Download e-copy - Smile Dental Journal

Download e-copy - Smile Dental Journal

Smile Dental Journal - December 2011 - Volume 6, Issue 4 - - Distributed free of charge

Dental Journal

Adhesion of Candida

Albicans to Denture

Base and Denture

Liners with Different

Surface Roughness

An In-vitro Study

Solving TMJ Problems

with Orthodontic Treatment

and Cosmetic Mouth


Case Series

Dental Implants’


Are they Educative?

A Cross-Sectional Study

The Diagnosis and

Management of


Maxillary Canines

Outcomes Following


A Retrospective Study

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Smile Dental Journal

December 2011

Volume 6, Issue 4

Quarterly Issued

Distributed Free of Charge

+962 7 96367954

Amman, Jordan

+961 70 32 32 75



Dr. Ma’moon A. Salhab

Director in Charge &

Chief Editor

Dr. Issa S. Bader

Editorial Director

Dr. Hassan A. Maghaireh

Marketing Director

Solange R. Sfeir

Art & Design

Solange R. Sfeir

Cover Design

Stephanie S. Moufarrej

Published by MENA Co. for

Dental Services

Jordanian National Library

Registration # 3954/2008/P

ISSN 2072-473X

Printed By:

Ad-Dustour Commercial Printing Press

Amman, Jordan

Mission Statement

Bridging the gap between advanced upto-date

peer-reviewed dental literature and

the dental practitioners enabling them to

do their jobs better- is our ultimate target.

Besides, Smile provides readers with

information regarding the available dental

products, armamentarium, news

and proceedings of dental symposia,

workshops and conferences.


Smile Dental Journal makes every

effort to report clinical information and

manufacturers’ product news accurately, but

cannot assume responsibility for the validity

of product claims or typographical errors.

Opinions or interpretations expressed by the

authors are their own and do not necessarily

reflect nor hold Smile team responsible for

the validity of the content.

Editorial Review Board

• Prof. Dr. Marco Esposito / Italy

DDS, PhD Implant Dentistry & Periodontics

• Prof. Louis Hardan / Lebanon

DDS, DEA, PhD, Restorative & Esthetic Dentistry

• Dr. Maher Abdeljawad / Jordan

BDS, MDentSci, Restorative Dentistry

• Dr. Hani Abudiak / UK

BDS, MFDS RCSFRCD, PhD Paediatric Dentistry

• Dr. Eyas Abu-Hijleh / UAE

DDS, PhD, Orthodontics & Dentofacial Orthopedics

• Dr. Layla Abu-Naba’a / Jordan

BDS, MFD, RCS, PhD, Prosthodontics

• Dr. Ali Abu Nemeh / Jordan

BDS, NDB, MSc, Endodontics

• Dr. Hazem Al-Ahmad / Jordan

BDS, MSc, FDSRCS, Maxillo-Facial Surgery

• Dr. Muna Al-Ali / Australia


• Dr. Suhail H. Al-Amad / UAE

D.Clin.Dent (Melb), FRACDS-Oral Med, GradDip

ForOdont (Melb), JMC-Oral Med

• Dr. Zaid Al-Bitar / Jordan

BDS, MSc, MOrth, RCS, Orthodontics

• Dr. Wesam Aleid / UK


Oral, facial, and Head & Neck Surgeon

• Dr. Raed Al-Jallad / Palestine

BDS, MSc, FFDRCS, FDSRCS, Oral & Maxillofacial Surgery

• Dr. Hani Al Kadi / KSA

BDS, Dip ODONT, MDS, Endodontics

• Dr. Alan Al-Qassab / Erbil-Iraq

BDS, HDD (Ortho), MSc, MOMS RCPS(Glasg), Oral &

Maxillofacial Surgery

• Dr. Mohammad Al-Rabab’ah / Jordan

BDS, MFD RCSIre, MRD(Pros), RCSEd, JB(Cons) PhD

• Dr. Hatem Al-Rashdan/ Jordan

BDS, MSc, Jordanian Board of Maxillofacial Surgery

• Dr. Majd Al-Saleh / Jordan

BDS, DDS, MSc, Pediatric Dentistry

• Dr. Ahmad Al-Tarawneh / Jordan

DDS, M.Clin.Dent, Jordanian Board of Orthodontics

• Dr. Hayder Al-Waeli / Jordan

BDS, MSc, Jordanian Board of Periodontology

• Dr. Muayad Assaf / Jordan

BDS, MSc Endodontics

• Dr. Manal Azzeh / Jordan

BDS, MSc, Jordanian Board of Periodontology

• Dr. Lama Jarrah / Jordan

BDS, MSc, Jordanian Board of Orthodontics

• Dr. Ghada Karien / Jordan

BDS, JDB, Pediatric Dentistry

• Dr. Edgard El Chaar / USA

DDS, MS. Periodontology & Implantology

• Dr. Ahmad Kutkut / USA

DDS, MS, Prosthodontics, USA

• Dr. Yousef Sadik Marafie / Kuwait

BDS, MSD, Prosthodontics

• Dr. Hakam Mousa / Jordan

BDS, MSD, Operative Dentistry

• Dr. Jumana Sabbarini / Jordan

BDS, MSc, Jordanian Board of Pediatric Dentistry

• Dr. Samer Sunna / Jordan

BDS, MSc, M.Orth, RCS, Orthodontics

• Dr. Marwan Qasem / Palestine

DDS, PG Fellowship Imlpantology

• Dr. Thamer Theeb / Jordan

BDS, MSc, Prosthodontics

• Dr. Leema Yaghmour / Jordan

BDS, DUA, DUB, Pediatric & Community Dentistry

International Advisory Board

• Prof. Abdullah Al-Shammery / KSA

BDS, MS Restorative Dentistry / Rector, Riyadh Colleges of

Dentistry & Pharmacy

• Prof. Magid Amin Ahmed / Egypt

Oral & Maxillo-Facial Surgery / Vice President MSA University

Dean, Faculty of Dentistry MSA University

• Prof. Jamal Aqrabawi / Jordan

DDS, DSc, DMD Endodontics / Dental Faculty, University of Jordan

• Prof. Nabil Barakat / Lebanon

DDS, MSc, FICD Maxillo-Facial Surgery / President of LAO & EMAO

• Prof. Stephen Cohen / USA

MA, DDS, FICD, FACD, Diplomate, American Board of Endodontics

• Prof. Azmi Darwazeh / Jordan

BDS, MSc, PhD Oral Pathology Oral Medicine / Former Dean, Faculty

of Dentistry JUST / Examiner, Faculty of Dentistry RCS Ireland

• Prof. Mohamed Sherine Elattar / Egypt

BDS, MSc, PhD Prosthodontics / Former Dean, Faculty of Dentistry,

Pharos University / President of AOIA

• Prof. Fouad Kadim / Jordan

BDS, MSc, PhD Conservative Dentistry / Vice Dean, Faculty of

Dentistry, University of Jordan

• Prof. Howard Lieb / USA

DMD General Dentistry & Management Sciences / College of

Dentistry, New York University

• Prof. Edward Lynch / UK

PhD (Lon), MA, BDentSc, TCD, FDSRCS (Ed), FADFE, FDSRCS (Lon)

Head of Dental Education and Research Warwick University

• Prof. Lamis D. Rajab / Jordan

DDS, PhD, Pediatric Dentistry / Former Dean, Faculty of Dentistry,

University of Jordan

• Prof. Issam Shaaban / Syria

BDS, PhD, Maxillo-Facial Surgery / Former Dean, Faculty of

Dentistry Damascus University / President of Syrian OMFS Society

• Prof. Yousef Talic / KSA

BDS, MSc, DASO, FICOI, FICD, Consultant in Prosthodontics &

Implantology, College of Dentistry, King Saud University

• Prof. Abbas Zaher / Egypt

BDS, MS, PhD Orthodontics, Professor of Orthodontics / Vice-

Dean, Alexandria University / Vice-President, World Federation of


• Prof. Carina Mehanna Zogheib / Lebanon

DDS, PhD Restorative and Esthetic Dentistry, FICD

Head of Restorative and Esthetic Dentistry Department, Saint-

Joseph University

• Dr. Nadim Abou-Jaoude / Lebanon

CES, DU, FICD Prosthodontics, Lecturer, Lebanese University /

Clinical Associate, American University of Beirut

• Dr. Hasanen H. Al-Khafagy / UAE

BDS, MSc, PhD Conservative Dentistry, Ajman University of Science

& Technology

• Dr. Jaser Al-Ma’itah / Jordan

BDS, MSc Oral Surgery, Head of Dental Department, Jordanian

Royal Medical Services

• Dr. Maher Almasri / UK

DDS, MSc, PhD, FADFE, Director of Oral Surgery Courses, Bone

Graft Modules Leader, Warwick University / President of the Syrian

Section of IADR

• Dr. Abdelsalam Elaskary / Egypt

BDS, FICOI, President of ASOI

• Dr. Yasin El-Husban / Jordan

DDS, MSc Prosthodontics, Former Minister of Health

Former Head of Dental Department & King Hussein Hospital

• Dr. Zbys Fedorowicz / Bahrain

Director, The Bahrain Branch of the UK Cochrane Centre

• Dr. Wolfgang Richter / UK

DDS, PhD, Restorative Dentistry, President of ESCD

• Dr. Mohammad Sartawi / Jordan


Senior Consultant Maxillo-Facial Surgery



Dental Implants’ Homepages: Are they Educative?

A Cross-Sectional Study

By Layla Abdel-Aziz Abu-Naba’a


Solving TMJ Problems with Orthodontic Treatment and Cosmetic

Mouth Rehabilitation: Case Series


By Leonid Rubinov



Outcomes Following Zygomatic: A Retrospective Study

By Majed Hani Khreisat


40 The Diagnosis and Management of Impacted Maxillary Canines

By Eyas Abuhijleh, Dalal Masri, Nadia Farawana, Mariam Nmari


Adhesion of Candida Albicans to Denture Base and Denture

Liners with Different Surface Roughness: An In-vitro Study


By Zahraa Nazar Al-Wahab

Debate in Focus





Summaries in


Endodontic or Dental

Implant Therapy: The

Factors Affecting Treatment


Effect of Teeth with

Periradicular Lesions on

Adjacent Dental Implants

The Effects of Smoking on

Fracture Healing


Ask the Experts

Flash News

Two Minutes with


Affiliation & Distributors

• Bahrain:

Bahrain Dental Society +973 17723767,

• Egypt:

Alexandria Oral Implantology Association +203 5451277

• Iran:

Shayan Simin Teb Co. +98 21 66380364/5,

Iranian General Dental Association +98 2188287794/5,

• Iraq:

Iraqi Dental Association +964 015379267,

Kurdistan Dental Association +964 7504510315,

Pro Health Line Company +964 7504544479,

Emirates Scientific Bureau +964 771 0131978,

• Jordan:

Jordanian Dental Association (JDA) +962 6 5665520,

Basamat Medical (Pharmadent) +962 6 5605395,

• Kuwait:

Kuwait Dental Association +965 5325094,

• Lebanon:

Lebanese Dental Association +961 1 611555,

Lebanese Dental Laboratory Association (OPDL) +961 5955 151

Richa Dental Store +961 5 452555,

• Oman:

Oman Dental Society +968 95769039,

• Palestine:

Palestinian Association of Implant Dentistry (PADI)

+970 2 2954545,

• Qatar:

Qatar Dental Society +974 4393144,

Ali Bin Ali Medical The i-partner +974 4867871 ext. 247

• Saudi Arabia:

Saudi Dental Society +966 1 4677743,

• Sudan:

Sudanese Dental Association +249 83 779769,

• Syria:

Najjar Trading Est. +963 (11) 2244140,

• United Arab Emirates:

Noble Medical Equipment +971 4 3255046

Dubai Medical Equipment L.L.C. +971 6 554 0206

Editorial Policy

• Our objective is to publish a dental journal of consistent high quality and help to increase the exposure of literature written by dental professionals from our region at a global level.

• Literature review, original research, clinical case reports, case series, short communication, randomized clinical trials, and book reviews are among our scope of published

material, where the clinical aspect of dentistry is presented in a scientific way, starting each article with an abstract, backed up by references in accordance with

the Vancouver citation style.

• The journal encourages the submission of papers with a clinical approach, practical or management oriented, besides papers that bridge the gap between dental

research and clinical application.

• Received manuscripts are first revised by the editor to check if it is appropriate for publishing in Smile and that it complies with the author›s guidelines. The manuscript is

then forwarded to two or more professional reviewers. Anonymity of both the author and reviewer is preserved (double blinded peer-review process).

• Our editorial policy which controls the quality of articles and assures their accuracy, clarity, and smooth readability through high level enthusiast regional and

international team of experts is our golden key for success.

• Finally, we believe that a controlled content of advertisements could be informative and beneficial especially in dentistry, where the armamentarium and pharmaceuticals

are a major and integral part of the dental science.

The Smile...

Past - Present - Future

If we take a look at the pathway of Dentistry over the past century, we would notice that

The Smile was certainly not the primary focus of the dentist`s awareness and concern until

recently. Dental Aesthetics is one of the revolutions in dentistry since World War II with the

others being the technology and equipment of the 1950s, the emphasis of prevention for

teeth conservation in the 1960s and lately implant dentistry in the 1980s. In fact providing

aesthetic dentistry to patients became an economic necessity for dentists.

In 1989, while chairing the scientific committee at the Lebanese University-School of Dentistry, we organized the 1 st

meeting worldwide on “The Smile” for 2 days that included the contributions of all dental and oro-facial specialties.

Our editorial at the time focused not only on the relationship between health and aesthetics but stressed on the interlink

established between a society of consumption constantly influenced by the mass media, a medical industry catering for

marketing, a dental profession exploring new horizons and a patient constantly seeking for beauty. Such vicious circle

could expose medicine to lose its nobility and with it its true identity.

Today, 22 years later, our opinion has not only not changed but all our apprehension and fear of aesthetic abuses has been

justified specially when considering all the disasters resulting and/or hidden behind the so called “Hollywood Smile”.

Nowadays, the smile still plays a major role in communication and is considered as one of the main tools in advertising.

However, are we really attracted to teeth that are falsely so white and chalky without any natural transparency or

translucency and look so fake? Are we satisfied as dentists to look at magazines covers only to find smiles that all look the

same, in which one size fits everybody and encourage our patients to request copycats because it is the smile of their idols?

Are we not responsible to control and guide the mass media in educating the public and spreading the correct information

rather than adverts not evidence based. Finally shouldn’t we even prepare guidelines about the Ethics of Aesthetics!

With such observations, Aesthetics should be revisited and we would have to pay Mother Nature more respect. Aesthetics

should be viewed in term of rejuvenation with a custom made approach and some consideration to the individual

characteristics. It would have to make people look younger but not cloned to such extent that they loose their personality.

The smile is part of the body and not a wear that changes with years along with fashion.

According to the philosopher Kant, Beauty is defined as “What Attracts Universally and Without any Concept”.

Concerning the smile, we have to go back to our basics:

1. The color is not the only variable in tooth aesthetics, we have to consider position, volume, texture... It is Microaesthetics

2. The tooth is only one variable in the smile components that include the periodontium, lips, smile reveal... It is Macroaesthetics

3. The smile is part of the Facial Harmony that involves the eyes, nose, and chin

The ideal smile team would include an Orthodontist, a Periodontist and a Prosthodontist or a General Dentist in order to

have a multi disciplinary approach and take the best from every specialty. A Maxillo–Facial Surgeon could be consulted in

certain conditions.

Taking all these data into consideration, we have to admit that the time factor plays a major role when a multidisciplinary

approach is indicated for a long lasting result. This time, essential for therapy, that the patient wants to be always shorter

and faster, becomes in fact the only judge for success.

Finally, communication is an issue that we should not overlook if we want to meet our patients’ expectations. Since they

usually pay up front for a series of procedures with an outcome they envision quite differently than we do.

In such circumstances we might fall into Charles Revlon thought:

“In the Factory we Make Cosmetics and in the Store we Sell… Hope”

Prof. Jean-Marie Megarbane DCD, CAGS, FAIDS, FICD

Masters Dental Clinic, Beirut-Lebanon

| 4 | Smile Dental Journal | Volume 6, Issue 34 - 2011

International Events

6 - 8 February

14 th King Saud University &

23 rd Saudi Dental Society

International Dental


Riyadh, KSA

12 - 15 March

3 rd International Conference

of King Abdulaziz University

Jeddah, KSA

30 - 31 March

2 nd Iraqi Dental Reunion IDR Annual

Conference 2012

Erbil, Iraq

3 - 4 May


th CAD/CAM &

Computerized Dentistry

International Conference

Dubai, UAE


3 - 5 February

1 st Annual Conference of The Arabian

Academy of Esthetic Dentistry

Cairo, Egypt

26 - 28 April

Sky Meeting 2012 (AOIA)

Alexandria, Egypt

12 - 13 April

8 th Gulf Dental Association

Conference & 2 nd Qatar

Internationl Dental

Association Conference

Doha, Qatar

17 - 19 May

7 th Lebanese Dental

Laboratory Seminar


Beirut, Lebanon

25 - 26 May

Tarnow Alumni & Friends

Venice, Italy

For more dental events please visit or our page on Facebook

Smile Dental Journal | Volume 6, Issue 4 - 2011| 5 |

Smile Message

1 st Smile Dental Symposium; the First Step in Long Term

Evidence Based Dental Program

Dentistry is a continually developing science. Over the past 20 years or so there have

been changes of opinion and practice: some techniques and opinions previously

advocated are not so today; controversies and conflicts surrounding the practice of dentistry have arisen; and a full

circle of opinions have been travelled by dentists over a period of time.

Smile Dental Journal was proud to launch its Smile Dental Symposia with the theme of “Dental Implants: Is Quicker

Always Better?”. The 1 st Smile Dental Symposium aimed to look into one of the interesting branches of dentistry; Dental

Implantology. The science of dental implantology is not only regarded as one of the major innovations in dentistry, but

also has come a long way in a relatively short period of time.

The one-day event featured a high-quality scientific program along with an up to date and advanced dental show.

The majority of the delegates agreed that this symposium had provided them with evidence based and clinical tips

which they can apply in their day to day dental implant practice.

The symposium social event – “Smile Dental Journal 5 th Anniversary Gala dinner” – took place at the glamorous

five star Land Mark hotel in Amman, under the patronage of the president of the Jordan Dental Association; Dr.

Qadoomi. The symposium was organized in co-operation with the Scientific Committee in the Jordan Dental

Association and was also well supported by the dental and local private companies who have sponsored the prizes

for the quiz show during the Gala dinner.

This successful symposium was not the end. It is not even the beginning of the end. But it is, perhaps, the end of

the beginning, as we promise the dental community in the Middle East more of these advanced and well structured

dental symposia covering different dental specialties in various countries, aiming to bridge the gap between evidence

based and clinical practice in the whole area.

For the full symposium report and photos, please refer to the Event section.

Behind the scenes we are very fortunate to have a small and dedicated team who work hard to ensure the Smile

Dental Journal functions smoothly. Thank you to all the directors, Dr. Mamoon Salhab Tamimi, Dr. Issa Bader and

Miss. Solange Sfeir.

Finally, I would like to thank all Smile Dental Journal reviewers, the international advisory board and our beloved

readers for their support and encouragement over the last year.

New Authors Guidelines are Well Received

Since we have updated our authors’ guidelines for submitting manuscripts to Smile Dental Journal to meet the

international requirements for reporting on health research are continuously evolving, we have started to receive a

better quality articles from authors all around the world. We made it clear that the key point is to focus on quality

rather than quantity, and I think that we are on the right track.

Even better, I am now delighted to announce that we are now been recognized by a number of high standards

dental schools as one of the esteemed indexed journals where staff and students can publish their studies and reports

as a mean for granting promotion. If anything, this recognition is a great proof that in a short time, Smile Dental

Journal has managed to prove that we are a peer reviewed, evidence based dental journal which aims to improve

the quality of dental care provided to dental patient in this area.

While we promise to continue this thousand mile journey, we urge our readers to support us by continuing to submit

high quality dental articles which are of interest to practitioners in all areas of dental practice, including general

practice, community and hospital dentistry, the armed forces, corporate bodies.

Dr. Hassan Maghaireh

Editorial Director

Smile Dental Journal

| 6 | Smile Dental Journal | Volume 6, Issue 14 - 2011

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1 Amornchat C et al. (2004) Mahidol Dent J 24(2): 103-111

2 Fine DH et al. (2006) J Am Dent Assoc 137: 1406-1413

3 Panagakos and FS et al. teeth (2005) J Clin Dent recommend 16 (Suppl): S1-S20 Colgate Total

4 Garcia-Godoy F et al. (1990) Am J Dent 3 (Spec Issue): S15-26





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4 Garcia-Godoy F et al. (1990) Am J Dent 3 (Spec Issue): S15-26

5 Banoczy and J et al. (1995) teeth Am J Dent 8(4): recommend 205-208 Colgate Total


and teeth recommend Colgate Total


6 Hu D et al. (2003) Compend Contin Educ Dent 24 (9 Suppl): 34-41

7 Marinho et al. The Cochrane Library. Issue I. John Wiley & Sons, 2006

1 Amornchat C et al. (2004) Mahidol Dent J 24(2): 103-111

2 Fine DH et al. (2006) J Am Dent Assoc 137: 1406-1413

3 Panagakos FS et al. (2005) J Clin Dent 16 (Suppl): S1-S20

4 Garcia-Godoy F et al. (1990) Am J Dent 3 (Spec Issue): S15-26

5 Banoczy J et al. (1995) Am J Dent 8(4): 205-208

6 Hu D et al. (2003) Compend Contin Educ Dent 24 (9 Suppl): 34-41

71 Marinho Amornchat et al. C et The al. Cochrane (2004) Mahidol Library. Dent Issue J 24(2): I. John 103-111 Wiley & Sons, 2006

2 Fine DH et al. (2006) J Am Dent Assoc 137: 1406-1413

3 Panagakos FS et al. (2005) J Clin Dent 16 (Suppl): S1-S20

4 Garcia-Godoy F et al. (1990) Am J Dent 3 (Spec Issue): S15-26

5 Banoczy J et al. (1995) Am J Dent 8(4): 205-208

6 Hu D et al. (2003) Compend Contin Educ Dent 24 (9 Suppl): 34-41

71 Marinho Amornchat et al. C et The al. Cochrane (2004) Mahidol Library. Dent Issue J 24(2): I. John 103-111 Wiley & Sons, 2006

2 Fine DH et al. (2006) J Am Dent Assoc 137: 1406-1413

3 Panagakos FS et al. (2005) J Clin Dent 16 (Suppl): S1-S20

4 Garcia-Godoy F et al. (1990) Am J Dent 3 (Spec Issue): S15-26

5 Banoczy J et al. (1995) Am J Dent 8(4): 205-208

6 Hu D et al. (2003) Compend Contin Educ Dent 24 (9 Suppl): 34-41

7 Marinho et al. The Cochrane Library. Issue I. John Wiley & Sons, 2006




Neutral Zone in Complete Dentures:

Systematic Analysis of Evidence and Technique

• Ahmad A. Jum’ah, BDS(Hons), MSc/PhD (Clin) Student-Second year

Restorative Dentistry Department, Leeds Dental Institute, University of Leeds, UK

• Peter J. Nixon, Senior Consultant in Restorative Dentistry, Leeds Dental Hospital,

Leeds Teaching Hospitals Trust (LTHT), England, UK


Neutral zone technique is a physiologic and functional approach that is widely and concisely described as a treatment

modality for unstable lower complete denture cases. It serves as a guide of where to set teeth and how to contour the

polished surface of the denture to ensure optimal stability, retention, facial support and aesthetics. In patients with

compromised support and poor denture adaptability, this technique is considered as a valuable tool in the prosthodontist’s

armoury especially where dental implants are contraindicated or unfeasible. The aim of this article is to describe the concept

and technique of neutral zone, discuss rationale, indications and to evaluate this technique from evidence-based perspective.

Abbreviations: NZ: Neutral zone, CD: complete denture, VDO: Vertical dimension at occlusion.


Stability of lower CDs is well recognized as a potentially

difficult treatment aim to achieve. Looseness and discomfort

are the most frequent complaints reported by patients and

they are quite often difficult to manage by dentists.

Neuromuscular control is said to be the key determinant

of stability of lower CD as the area available for support is

far less than maxillary support area. Size and position of

prosthetic teeth and the contours of polished surface have

a crucial role in lower CD stability as they are subjected to

destabilizing forces from the tongue, lips and cheeks if they

are placed in hindrance with function of these structures. 1

Throughout time, many concepts and theories emerged

to describe where prosthetic teeth of CD should

be positioned. Some of them adopted mechanical

principles, 2,3 others used biometric guides 4 and a minority

advocated mathematical formulas based on natural teeth

position and dimensions. 5 These dogmatic or arbitrary

approaches have been challenged and found insufficient,

in fact not only by rigorous research, but also by failure

to restore function, aesthetic and comfort in patients with

severely atrophic mandibular ridges (Class V Atwood’s 6 ),

patients with enlarged tongue and cases of marginal or

segmental mandibulectomy. To overcome such problem,

the neutral zone technique was advocated.

The neutral zone, zone of minimal conflict, 7 zone of

equilibrium, 8 potential denture space 9 and the dead

space 10 are all terms used to describe the potential area

where forces generated in an outward direction from the

tongue are being neutralized or balanced by the inward

forces generated by lips and cheeks during functional

activities. Setting teeth and contouring polished surface

of lower CD within this zone, makes the prosthesis less

subjected to dislodging forces and adds more to stability. 11

Analysis of functional forces

Understanding the unique and synergistic interplay

and complex movements of muscles of cheeks, lips

and tongue is the first step in construction of lower

CD that is stabilized rather than being dislodged by

movements of these structures. 11,12 Description of forces

applied to the lower CD purely on the basis of direction

is an oversimplification, yet, it is quite useful for better

understanding of the concept. 12

The outward forces are principally generated by the

tongue and lingual frenum into which, genioglossus

muscle is inserted. Teeth should be set and flanges should

be contoured in harmony with tongue size, position and

shape during rest and function. In rest position, the tongue

rests on lingual cusps of posterior teeth and lingual

flanges posteriorly and anteriorly. The tongue space

determined by position of teeth is far more important

during function. Setting teeth too lingualy will encroach

on this space and the tongue tends to dislodge denture

in function. The height of posterior teeth is of a great

importance in stability of lower CD as well. Having the

tongue resting on lingual cusps will reduce the horizontal

(outward) force and apply force with vertical (downward)

component which enhances stability and retention. 11

Inward forces are generated by cheeks resulting from

contraction of the buccinator muscle that pushes food

bullous on top of occlusal surfaces of posterior teeth.

Flanges contoured and teeth set too buccal are at

increased risk of being dislodged by the action of this

muscle. Anteriorly, lip muscles (mentalis and orbicularis

oris) are the source of inward forces generated during

speaking and swallowing. Contraction of these muscles

to attain seal during these activities can destabilize lower

CD with teeth and flanges placed too far labially. The

modiolus is a knot-like structure found in corners of the

| 8 | Smile Dental Journal | Volume 6, Issue 4 - 2011

mouth where several muscles are inserted. Movement of

this structure narrows the space available for flanges and

teeth. The modiolus produces quite strong inward forces

in premolar region. Thus, contouring flanges in harmony

with its’ functional movement is essential. 11,12


The rationale of using neutral zone technique is to

fabricate a lower CD that is optimally situated and in

harmony with the structures and forces discussed above.

By doing so, these forces are more likely to be stabilizing

rather than unseating. 11 The need for such a technique

that is based on physiologic concepts is significantly

increasing as emergence of several factors (discussed

below) render a high proportion of conventionally made

lower CDs unsatisfactory.

Increased access to dental care has led to patients losing

their teeth at a later stage of life. 13 Compounded by

increased life expectancy, this has led to the majority

of CD wearers to be elderly and has increased the

proportion of those who have poor neuromuscular

control, poor adaptive capacity, severely atrophic

ridges 14 and atypical denture support area as a result

of surgical interventions, poor planning for transition

from partially dentate to edentulous state, 15 untreated

edentulism for long period of time ,16,17 trauma or

systemic diseases. Occasionally, patients with one or

a combination of these conditions can be successfully

treated by CD constructed by conventional techniques. 11


• In general, neutral zone technique is indicated when

stability and patient’s acceptance of lower CD are in

question. Searching the literature, this technique is

found to be used in the following clinical situations:

• Severely atrophic mandibular ridge 12,13,18-22 (Atwood’s V).

• Patients with prominent and highly attached mentalis

muscle, lateral spreading of tongue as a result of poor

transition from dentate to edentulous state and severe

resorption. 13

• Patients with diminished neuromuscular control such as

those with a history of stroke, 13 Parkinson’s disease 13,23

or patients with impaired motor innervation to oral and

facial muscles as a result of brain surgery. 18

• Patients with atypical shape or consistency of oral

and perioral structures. For example, patients who

have scleroderma, 13 marginal 21,24 or segmental 25,26

mandibulectomy and partial glossectomy. 27

• NZ technique can be used to locate optimal position

for implants in cases of implant-supported or -retained

overdentures, which enhances the overall outcome of

treatment. 28

Clinical technique

Primary and secondary impressions are taken for

maxillary and mandibular denture bearing areas as in

standard complete denture treatment. Bite registration

is then performed as in conventional treatment. Master

casts with record blocks should be mounted on an

articulator. In the lab, the lower occlusal rim is removed

from baseplate and substituted with a baseplate with

acrylic pillars 29 in the premolar regions and/or wire

loops 13 on the remaining areas of the baseplate. The

pillars preserve the VDO recorded in bite registration

stage. It is essential the the pillars are relatively thin

bucco-lingually and are positioned directly over the

ridge. The base plate is then fitted in the patient’s mouth

and VDO and extensions are checked. Then impression

material such as compound 11 , plaster 22 , wax 30 , silicone 31 ,

polyether 32 or tissue conditioner 13,33 is applied to the

baseplate and retained by the wire loops and/or acrylic

pillars. Before setting of material, patient is asked to

perform functional movement such as, licking lips,

swallowing, pronouncing some words or combination

of these. Care should be taken that the patient should

continue performing functional movements until the full

setting of material; otherwise material might flow back

and give inaccurate recording of the neutral zone. It is

useful if the chosen material has relatively long working

time to allow the required movements to be carried out

before the material becomes rigid. Also, it is worthwhile

to mention that it is better to perform the NZ record

while the upper occlusal rim or finished denture is fitted

in the patient mouth as it may help to control recording

material and prevent it from being displaced in a labioocclusal

direction. 29

In the lab, the baseplate carrying recording material is

fitted on the master cast again and VDO is checked. A

putty or plaster index is made around the NZ record.

Placement of three orientation grooves is recommended

as these help in repositioning the index on the master cast.

Impression material is then removed and replaced

by wax; the use of the index will make sure that wax

replicates the neutral zone record. Subsequently, teeth

should be set and flanges contoured according to the

index that represents NZ.

NZ impression technique has various modifications, not

only in terms of materials used or retention provided by

baseplate, but also in terms of the functional movements

performed and refinement of the procedure. A further

more defined NZ record can also be achieved in try-in

stage. The wax below the teeth and covering the flanges

can be cut back and tissue conditioning material or

medium-bodied silicone applied. The patient is asked

again to perform functional movements. The dentures

are processed as usual. The same procedure has also

(Table 1) Materials Used for NZ Impression

Impression plaster

Impression waxes

Impression compound

Regular bodied silicone

Tissue conditioner


Hard relining material

Smile Dental Journal | Volume 6, Issue 4 - 2011| 9 |

(Table 2) Summary of clinical and laboratory stages of NZ


Clinic 1: Upper & lower primary impressions using stock trays

Lab1: Casting primary models and construction of special trays

Clinic 2: Upper & lower secondary impressions

Lab 2: Casting master models and construction of record blocks

Clinic 3: Bite registration

Lab 3: Mounting master casts using CR record on semi-adjustable

or average value articulator. Removal of lower wax rim and fabrication

of baseplate for NZ impression

Clinic 4: NZ impression

Lab 4: NZ impression record mounted on lower master cast, orientation

grooves placed on master cast, putty index adapted around

NZ record and impression material removed and poured in wax

Finally, setting of teeth completed

Clinic 5: Try-in stage. Afterwards, NZ impression refined by tissue

conditioner applied to lower try-in denture

Lab 5: Processing, finishing and polishing

Clinic 6: Insertion of finished dentures

been described after insertion of the denture but using

hard relining material. 27,31


Many approaches to set teeth have been advocated and

used in complete denture treatment. 20 However, there

is substantial debate on which of these provide optimal

position in the facio-lingual dimension and guarantee a

favourable outcome in terms of stability, facial support,

chewing efficiency, aesthetics and patient comfort. Some

of these approaches utilized biometric measurements and

location of relatively stable anatomical landmarks to set

teeth; 4 others relied on difference in resorption patterns

to set denture teeth where their natural predecessors

were thought to have been. 34 Some authors adopted a

mechanical concept and advocated setting teeth directly in

the centre of denture support area where the least amount

of leverage is present which in turn enhances the stability

of lower CD. 35 All of these approaches were and are still

being used and each of them proved to have advantages

and disadvantages when compared to others. Furthermore,

these approaches seem to work best when used with

patients who have; their oral and peri-oral musculature

unaltered for any reason, adequate neuromuscular control

and acceptable amount of residual ridge for support.

Unfortunately, the proportion of patients with these features

is dramatically decreasing and so the NZ concept has

become increasingly significant. These observations are

strongly supported by studies investigating the effect of

period of edentulism on position of neutral zone. It has

been found that NZ is closely related to the crest of residual

(Fig. 1) NZ baseplate with

acrylic pillars and wire loop

(Fig. 2) A: NZ impression taken with silicon. B: Putty index

adapted around master cast

ridge in patients who have been edentulous for less than

two years and significantly differs in those who were

edentulous for a period more than that. 16,17

Realizing the importance of the forces generated

by various oral structures on the teeth and polished

surfaces of CDs and their effect on the stability of CD

sheds light on the NZ technique. 1,10 It has been shown

that compromised retention, poor stability, phonetic

problems, inadequate facial support, inefficient

tongue posture/function and increased gagging are

all associated with functionally inappropriate setting of

denture teeth and physiologically inadequate contours

or volume of the denture base. 20

NZ technique has been criticized based on claims that

it is supported by empirical evidence. However, other

authors maintain that this is inaccurate as NZ technique

is based on significant clinical observations on the role

of destabilizing forces the muscles apply to CDs during

functional movements. Furthermore, the large number of

case reports accumulated in a short period of time and

clinical studies conducted by Stromberg & Hickey 36 and

Fahmy & Kharat 37 undermine this criticism and add to

the validity of NZ technique. Stromberg & Hickey 36 found

better patient adaptability to physiologically formed

denture bases when compared to conventional ones.

Fahmy & Kharat 37 found improved comfort and speech

clarity reported by patients upon wearing CD fabricated

using NZ technique when compared to conventional

CD. Moreover, Barrenas and Odman found less post

insertion problems and better patient acceptance in

NZ dentures when compared to conventional ones. 38

(Table 3) Summary of NZ impression clinical technique

Baseplate with acrylic pillars and/or wire loop is fitted in patient’s

mouth and checked for proper extensions and VDO

Baseplate is coated by adhesive and loaded with regular bodied

silicone impression material

While the patient is setting upright and comfortable the baseplate is

inserted in patient’s mouth

Patient is then asked to swallow few time, moisten lips, use tongue to

clear buccal sulci, smile, grin and purse lips

Before final setting of material, patient is asked to read loudly a

vocal passage

Once set, NZ impression removed and inspected for deficiencies

which can be corrected by addition of impression material

Impression disinfected and sent to lab

| 10 | Smile Dental Journal | Volume 6, Issue 4 - 2011

(Fig. 3) Setting of teeth according to NZ record. Note the class II

arrangement of teeth

Recently, Raja and Saleem 19 published results of clinical

trial in which they compared patient acceptance of NZ

dentures and conventional dentures in 128 patients. The

authors concluded that there is no significant difference

in terms of patient’s acceptance between the two groups

as far as patients who have been edentulous for less

than two years are concerned. However, in patients who

have been edentulous for more than two years, better

results and patient acceptance were reported with NZ

dentures. Unfortunately, the aforementioned studies can

be criticized in terms of design or information about

blinding and randomization which affects the quality of

evidence taken from these studies.

The principle of the NZ concept has remained the

same since it has been first described by Beresin and

Schiesser. However, the technique has been subjected to

various modifications. Type of retention incorporated in

the baseplate (acrylic pillars or wire loops 13 ), recording

materials used and further refinement to the initial

record are among the variations between clinicians.

The authors’ preference is to use combination of thin

acrylic pillars in premolar region connected by a wire

loop which maintains the VDO and provides maximum

retention at the same time. Medium or regular bodied

silicone impression material used along with adhesive

for the initial record that is refined in the try-in stage by

tissue conditioning material is the personal preference of

the authors for purposes of NZ recording.

(Fig. 4) Refined NZ record using tissue conditioner on try-in denture

The effect of various functional movements patients

perform during recording NZ on the location and

dimensions of NZ has been investigated by Makzoumi 39 .

This investigation concluded that NZ recorded whilst

patients perform a phonetic exercise is significantly

narrower when compared with a NZ record produced

during swallowing. This finding may be of a clinical

significance from two perspectives; first, the author used

modelling compound for the swallowing and used tissue

conditioner for phonetic technique which may indicate

that one of these materials is less reliable than the other

in recording NZ. Second, dentures fabricated utilizing

one functional exercise to shape the NZ may be unstable

during other functions. The authors’ preference is to as

patients to perform multiple tasks including swallowing,

using the tongue to moisten lips and finishing with

reading a speech articulation passage loudly.

From biomechanical perspective, NZ technique has

one disadvantage as teeth may be set far from the

denture support area. For example, in a case of

excessive resorption of the anterior area of the mandible

accompanied by prominent and highly attached mentalis

muscle, this will shift the NZ more lingually away from

the crest of the ridge. This horizontal discrepancy can

increase the leverage forces on the denture and may

destabilize it. 21 However, there is an agreement that

these leverage forces are well counterbalanced by

favourable and seating forces resulting from optimal

placement of teeth and polished surfaces of denture

being in harmony with the tongue, lips and cheeks. 1,11,40


NZ concept is considered as exceptionally important

when considering treatment options for patients

complaining from unstable lower CD particularly

if implant treatment is not feasible. It aims to place

lower CD where forces generated by lips, cheeks and

tongue have a stabilizing rather than dislodging effect.

The principle technique used to record neutral zone

is extensively recorded; yet it needs to be backed up

with high quality clinical trials to push it further up on

the hierarchy of evidence. It is not a widely practiced

procedure while the proportion of patients that may

befit from is significant. This may be attributed to a lack

of experience and exposure to this technique during

undergraduate training and the associated increase in

chair time and laboratory costs.


The authors would like to acknowledge with gratitude Dr.

Brian Nattress for his continuous support and cheif dental

technician, Carol Scholfield, for the skilled lab work.


1. Fish E. Principles of Full Denture Prosthesis. 7 th Ed. London: Staple


2. Wright Cr, Swartz Wh, Godwin Wc. Mandibular Denture Stability: A New

Concept. Overbeck;1961.

3. Lammie G. Aging Changes and the Complete Lower Denture. J Prosthet

Dent. 1956;6:450-64.

Smile Dental Journal | Volume 6, Issue 4 - 2011| 11 |

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Stand No. 18

4. Pound E. Esthetic Dentures and Their Phonetic Values. J Prosthet Dent.


5. El-Gheriani As. A New Guide for Positioning of Maxillary Posterior Denture

Teeth. Journal of Oral Rehabilitation. 1992;19(5):535-8.

6. Atwood Da. Postextraction Changes in the Adult Mandible as Illustrated

by Microradiographs of Midsagittal Sections and Serial Cephalometric

Roentgenograms. The Journal of Prosthetic Dentistry. 1963/10//;13(5):810-24.

7. Matthews E. Br Dent J. 1961;111(The Polished Surfaces) :407-11.

8. Grant Aa, Johnson W. An Introduction to Removable Denture Prosthetics. C.

Livingstone; 1983.

9. Roberts A. The Effects of Outline and Form Upon Denture Stability And

Retention. Dent Clin North Am. 1960;4:293-303.

10. Fish E. Using The Muscles To Stabilize The Full Lower Denture. J Am Dent

Assoc. 1933;20:2163-9.

11. Beresin Ve, Schiesser Fj. The Neutral Zone in Complete Dentures. The Journal

of Prosthetic Dentistry. 1976;36(4):356-67.

12. Gahan Mj, Walmsley Ad. The Neutral Zone Impression Revisited. Br Dent J.


13. C.D Lynch Pfa. Overcoming the Unstable Mandibular Complete Denture: The

Neutral Zone Impression Technique. Dental Update. 2006;33:21-6.

14. Miller Wp, Monteith B, Heath Mr. The Effect of Variation of The Lingual Shape

of Mandibular Complete Dentures on Lingual Resistance to Lifting Forces.

Gerodontology. 1998;15(2):113-9.

15. Allen Pf, Wilson Nhf. Teeth for Life for Older Adults. Quintessence;2002.

16. F.M F. The Position of the Neutral Zone in Relation to the Alveolar Ridge. The

Journal of Prosthetic Dentistry. 1992;67(6):805-9.

17. Raja Hz Sm. Relationship of Neutral Zone and Alveolar Ridge with Edentulous

Period. J Coll Physicians Surg Pak. 2010;20(6):395-9.

18. Memarian Lsfgsfam. Using Neutral Zone Concept in Prosthodontic Treatment

of a Patient with Brain Surgery: A Clinical Report Journal of Prosthodontic

Research. 2011;55(2):117-20.

19. Hina Z. Raja Mns. Neutral Zone Dentures Versus Conventional Dentures in

Diverse Edentulous Periods Biomedic. 2009;25:136-45.

20. Cagna Dr, Massad Jj, Schiesser Fj. The Neutral Zone Revisited: From

Historical Concepts to Modern Application. The Journal of Prosthetic Dentistry.


21. Wee Ag, Cwynar Rb, Cheng Ac. Utilization Of The Neutral Zone Technique

For A Maxillofacial Patient. Journal of Prosthodontics. 2000;9(1):2-7.

22. Johnson A Ns. The Unstable Lower Full Denture-A Practical and Simple

Solution. Restor Dent. 1989;5:82-90.

23. Makzoume J. Complete Denture Prosthodontics for a Patient with Parkinson’s

Disease Using the Neutral Zone Concept: A Clinical Report. Gen Dent.


24. G. P, C., Hekimoglu, N., Sahin. Rehabilitation of a Marginal Mandibulectomy

Patient Using a Modified Neutral Zone Technique: A Case Report. Braz Dent J.


25. Pravinkumar G. P. Conventional Complete Denture for a Left Segmental

Mandibulectomy Patient: A Clinical Report. Journal of Prosthodontic Research.


26. Kokubo Y, Fukushima S, Sato J, Seto K. Arrangement of Artificial Teeth in the

Neutral Zone after Surgical Reconstruction of the Mandible: A Clinical Report.

The Journal of Prosthetic Dentistry. 2002;88(2):125-7.

27. Ohkubo C, Hanatani S, Hosoi T, Mizuno Y. Neutral Zone Approach for

Denture Fabrication for a Partial Glossectomy Patient: A Clinical Report. The

Journal of Prosthetic Dentistry. 2000;84(4):390-3.

28. Yasunori Suzuki Coath. Implant Placement for Mandibular Overdentures

Using the Neutral Zone Concept. Prosthodont Res Pract. 2006;5:109-12.

29. Basker Rm, Davenport Jc, Thomason Jm. Prosthetic Treatment of the Edentulous

Patient. John Wiley & Sons; 2011.

30. Lott F, Levin B. Flange Technique: An Anatomic and Physiologic Approach to

Increased Retention, Function, Comfort, and Appearance of Dentures. The

Journal of Prosthetic Dentistry. 1966/6//;16(3):394-413.

31. Mccord Jf, Grant Aa. Prosthetics: Impression Making. Br Dent J. [10.1038/

Sj.Bdj.4800516]. 2000;188(9):484-92.

32. Agarwal S, Gangadhar P, Ahmad N, Bhardwaj A. A Simplified Approach

for Recording Neutral Zone. The Journal of Indian Prosthodontic Society.


33. P. K, N., Ari, S., Calikkocaoglu. Using Tissue Conditioner Material in Neutral

Zone Technique. N Y State Dent J. 2007;73(1):40-2.

34. David M W. Tooth Positions on Complete Dentures. Journal of Dentistry.


35. Sharry Jj. Complete Denture Prosthodontics. Mcgraw-Hill; 1974.

36. Stromberg Wr, Hickey Jc. Comparison of Physiologically and Manually

Formed Denture Bases. The Journal Of Prosthetic Dentistry.15(2):213-26.

37. Fahmy Fm, Kharat Du. A Study of the Importance of the Neutral Zone in

Complete Dentures. The Journal of Prosthetic Dentistry. 1990;64(4):459-62.

38. Barrenäs L, Ödman P. Myodynamic and Conventional Construction of

Complete Dentures: A Comparative Study of Comfort and Function. Journal

of Oral Rehabilitation. 1989;16(5):457-65.

39. Makzoume Je. Morphologic Comparison of Two Neutral Zone Impression

Techniques: A Pilot Study. The Journal of Prosthetic Dentistry. 2004;92(6):563-8.

40. Gt. Mcdonald H, Larsen. The Neutral Zone Space: A Clue to Denture Stability.

Gen Dent. 1984;32(6):510-1.


| 12 | Smile Dental Journal | Volume 6, Issue 4 - 2011


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Dental Implants’ Homepages:

Are they Educative?

A Cross-Sectional Study

Layla Abdel-Aziz Abu-Naba’a


• Department of Substitutive

oral sciences, college of

dentistry, Taibah University,

AlMadinah AlMonawwarah


• Formerly Prosthodontic

Department, Jordan

University of Science and

Technology, Jordan


Dental implant manufacturers’ web pages are presenting more links to educative

material targeting students, dental practitioners, technicians, and patients.

Aim: This cross-sectional study aims to describe the amount of links to educational and

scientific material in comparison with links to information, support services and other

web-based material using a standardized methodology.

Material and methods: A convenient sample of dental manufacturers’ web pages

was chosen. The ADA lists 39 companies in its dental buying guide “ IMPLANTS AND

ACCESSORIES CATEGORY “ in 2010. Icons present in the companies web pages are active

links, which linked the surfer to other web pages. The subsequent webpage was categorized

according to the material presented in it as: Educational and scientific materials,

Information materials, Services and support materials. Target audiences were described.

Results: This study shows that homepages focus on being directories, containing

variable numbers of clickable icons. Clicking them lead the reader to other web pages,

either containing the actual material of interest, or containing another directory of more

clickable icons. Types of material presented by the clickable icons on the homepages

of the sample, included a sum of 93 informative, 64 service related or supportive

and 85 lead to material described as educational. Three homepages represented a

comprehensive directory by including icons leading to all three materials’ categories(one

included a sum of 78 links, the second included 57 and the final had 42 links).

Conclusions: Within the limit of this cross sectional study, it is concluded that

educational material is considered as a major category of material presented by the

homepages of dental implant manufacturers.

Keywords: Dental Implants, Education, e-resources, Cross-sectional study, Internet.


Internet became a preferred tool for enquiries, information gathering and

communications for many. Clinical skills of health professionals were enhanced by this

new learning behavior that evolved with the expanding use of the net. It helped surfers

to answer patient related questions, pharmaceutical inquiries, and update and follow

clinical developments. 1

However, many experts involved in critical appraisals of internet-disseminated

materials, advocated professionals to perform informed searches and rely on evidence

derived from good research. 2 They disseminated this message by spreading the word

through the internet!

Dental bodies also promote evidence-based dentistry and set guides for the learners

on how to judge the hierarchy of evidence. More and more educative material are

distributed by the internet as an instructional method, which proved better than traditional

methods. 3 Now it is accepted to accumulate independent-study points from internet-

| 14 | Smile Dental Journal | Volume 6, Issue 4 - 2011 Dental Buying Guide

Page 1 of 2

based courses, as for continuation of dental practice

licensure. 4 Teledentistry, dental informatics and dental

portals, are subject which have developed into mature

branches of specialty, revolving around the internet

technology and the delivery of reliable knowledge. 5-8

Implant manufacturers developed their web pages,

accordingly, to become more educative. An increasing

number of homepages contain dedicated sections for

evidence and continual education. Some manufacturers

began investing in educational institutions which

prioritize research. Others have devoted funds, advisors

and publications which would help perform and later,

disseminate results of studies using their implant systems.

Educative material is presented to target a larger audience

of implant service receivers, providers and distributers.


This cross sectional study aims to develop a standardized

methodology to describe webpage contents in Dental

Implant manufacturers’ webpages. Links present were

to be categorized to educational (scientific material) in

comparison with links to information, support services

and other web-based material present in. Then a

comparison of a sample of homepages for 12 valid

and current implant manufacturers was done using this

standardized methodology.

Materials and Methods

Bicon Definitions Dental Implants

Selection of manufacturers’ homepages

A valid and current manufacturer means; that the

company is consistent in its ownership, still managing



About ADA Publishing

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Professional Product









Licensure | Catalog | Member Directory | Contact


Introduction Listing in the Buying Guide

Buying Guide Search Contact the Buying Guide

New Dentist Resources

Product Category Search Results for 'Implants and Accessories'

3i, Palm Beach Garden, FL

Ace Surgical Supply Co Inc., Brockton, MA

AIT Dental, Inc, Beverly Hills, CA

Aseptico Inc, Woodinville, WA

Asteto Dent Labs, Maplewood, NJ

Astra Tech, Inc., Lexington, MA

Attachments International, San Mateo, CA

Bicon Dental Implants, Boston, MA

Bien Air USA, Irvine, CA

Bio-Lok International, Inc., Deerfield Beach, FL

Butler Company, John O., Chicago, IL

De' Plaque Inc., Victor, NY

Dental Arts Laboratories Inc, Peoria, IL

Dentatus USA Ltd., New York, NY

Dentsply International, York, PA

Drake Precision Dental Lab, Charlotte, NC

Essential Dental Systems, South Hackensack, NJ


Euro Teknika, Houston, TX

Florida Dental & Medical Supply, Miami, FL

G & H Dental Arts, Inc., Torrance, CA

Hartzell & Son, G., Concord, CA

Implamed, Attleboro, MA

IMTEC Corp, Ardmore, OK

ITL Dental, Santa Ana, CA

Keller Laboratories Inc., St. Louis, MO

Lifecore Biomedical, Chaska, MN

Nobel Biocare USA, Inc., Yorba Linda, CA

Paragon Implant Company, Encino, CA

(Fig. 1) The Sample of study was derived from the ADA Dental

buying guide, (Implants and Accessories) product category

accessed on the 7 th February 2010

Polymedia Inc., Canton, MA

and maintaining PracticeWares the active Dental Supply, website Rancho Cordova, CA related to dental

Procera, Yorba Linda, CA

implants. Homepages Prowest Dental Lab, of San these Francisco, CAcompanies are listed by

Recigno Laboratories Inc, Willow Grove, PA

the ADA webpage (fig. 1). Being current means that the

Steri-Oss, Yorba Linda, CA

Sterngold, Attleboro, MA

manufacturer was still distributing the implant system.

The mhtml:file://H:\D\LAYLA\KSA\Research\Implants\D homepage is defined here Jafar-website as the first research-\implant English pop...

internet webpage appearing after



1 of




URL address ( and relevant to dental implants.

Once placed in the address bar, the URL address

could either remain the same, or it could automatically


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(Fig. 2)

Sample of one of

the comprehensive


containing icons

for the three main

categories (e:

educative materials,

i: informative

materials, s: service

provisions). Flashes

and animations

are not active in

this still image nor

are embedded lists



Information for Patients

Since 1985 dentists have been offering patients

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8.0mm length implants were considered

Smile Dental Journal | Volume 6, Issue 4 - 2011| 15 |

edirect to another URL. If the webpage is not relevant to

implants, it becomes mandatory to choose the implant

product line. Then the subsequent page is considered the

homepage. Some webpages mandate the selection of

the region first. Once selected, the subsequent page is

considered the homepage.

Sample selection

A convenient sample of dental manufacturers’

webpages was chosen. The ADA lists 39 companies in

its dental buying guide “IMPLANTS AND ACCESSORIES

CATEGORY”. The list provided, at the time of research,

contains links to subsequent webpages per each company.

Only 12 companies were valid and current implant

manufacturers and their webpages were accessed, while

the rest provided webpages for companies dealing with

implant related materials and devices.

Icon Definition

An icon is defined here as an active link, where a web

component can be clicked by mouse navigation or enter

controls. The webpages provided clickable icons: in the

form of buttons, images, or texts. The total number of

these icons are counted either if directly seen on the home

page or embedded in drop-down lists or in active flashes.

Once clicked, these icons linked the surfer to other

webpages. The labels used on these icons are put in

parenthesis “ “. The subsequent webpage was categorized

according to the material presented in it (fig. 2). Variations

of content are reported in terms of:

Labels and the sum of Educational and scientific

materials provided





Labels and the sum of Information materials provided




Labels and the sum of Services and support

materials provided




Target audience

The paper describes the targeted audience besides

conventional users of implant related webpages,

including higher dental specialties, other professions and

other users.


Sample selection

Twelve webpages were accessed from the ADA list of

total 39 companies present in its dental buying guide


provided, contains links to subsequent webpages per

each company. These were considered sufficient to

develop a standardized methodology of researching the

contents of home pages.

Seven webpages changed their web content slightly

between two points of search (7 th February 2010, 20 th

march 2010). Changes mainly were in blog areas

called: highlights, news blog, upcoming courses and

upcoming events blogs. One changed a congress

announcement, added a “NEWS” icon and updated its

copy right statement. Another announced redistribution

of one of its implants. The next added a “LAB” icon,

updated the flash presenting current events and changed

language names into flags. Finally, one changed some

icons in its footer quick link bar.

Icon Identification on homepage

Results of materials gained by clicking icons are briefed

in table 1, “HOME” is an icon that leads to the homepage

itself. This is useful as the header and footer links are fixed

in subsequent webpages and could help redirect the reader

back to the original webpage. Other material include.

Educational and scientific material: labels and


Scientific Activities:

“COURSES” and “UPCOMING COURSE” blogs were

the only icons leading to webpages about courses in two


Other activities as Meetings, symposia, scientific days,

forums, congresses were announced and linked to, by

labels “NEWS” and “EVENTS” present in homepages as

blog sections or icons.

Recourse Materials

Multiple labels were used, “DOCUMENTATION”,

“ARCHIVES”, “STUDIES”, and “LIBRARY”. One webpage


DOWNLOADS” for 12 languages. One webpage had

recourse materials reached by icons embedded in a

drop-down list called “CLINICAL RESOURCES”, and


“LITERATURE” and “FAQ” icons.

Professional and career Development

Icons leading to relevant developments were labeled:







One webpage had a very rich “CONTINUING

EDUCATION” icon. It contained a drop-down list of

| 16 | Smile Dental Journal | Volume 6, Issue 4 - 2011

icons, labeled by name, for 4 seminars, 3 courses, and 2


Clinical Skills Development

Icons used were: “VIDEOS”, “MARGINAL BONE



webpage provided to icons “DIGITAL DENTISTRY” and

a specific “NAME-IMAGING TECHNIQUE”. Another


PROSTHETICS”. One had country selections in dropdown

lists from “CAD CAM” and “CARE” a specific

service for customized prosthetics.

Dental technician guided educative material

Icons used were labeled: “LAB”, “LABORATORIES”,


Patient guided educative material

Icons used were labeled: “PATIENTS”, and “CONSUMER

SITE”. Two webpages had a service, selecting country

and region in a drop-down list, changing the language

for the patients.

Three webpages were rich, providing multiple patient

materials. Icons were listed in sections or in drop-down

lists from a “PATIENTS” icon; “FREQUENTLY ASKED








Information material: labels and subjects

Introductory information

Introductions were in the form of full paragraphs.

This was the only section containing paragraphs.

These paragraphs either described the company, or

their implant system. Some webpages labeled those

paragraphs as “WELCOME NOTES”.

Distribution information

One homepage had a “GLOBAL HOME” icon which

lead to a new webpage with a map asking to locate the

region, in which the reader is living.

One homepage used both labels “GLOBAL WEBSITES”


Another used “INT’l” and “EUROPE” leading to

webpages describing regional offices.

One webpage had local distributors in a drop-down list

from the icon “PRODUCTS”.

Two webpages announced distributor change for one of

their implants.

Corporation information

Labels expected to be used as synonyms were



“MANUFACTURER”. But some homepages used them as

separate icons, each leading to different material.

One webpage used both “MANUFACTURER” and

“COMPANY”, two webpages used both “HEAD

QUARTERS” and “CORPORATE”, and one used both

“CORPORATE” and “OUR COMPANY”. Each of the

coupled icons, led to a different webpage.

News information

“NEWS” and “EVENTS” are another example of icons

which seem to be equal but were used as separate labels:

One homepage used “EVENTS” icon to lead to a

webpage listing scientific events. The “NEWS” and

“PRESS ROOM” blog were about products.

In another homepage, “NEWS” linked to an e-bulletin

mixing product news, offers, technique resources, and

scientific events. The “CALENDAR” icon led to a list of

scientific events. An icon “SUBSCRIBE TO BULLETIN” was

also present that webpage.

The next homepage had “NEWS AND EVENTS” in one

icon and led to the following: press releases, to sign-in

for an e-newsletter, product news, and scientific events.

Another homepage included labels “NEWS” which linked

to an announcement page, “EVENTS” led to a list of

trade shows and courses.

Icon ”NEWS AND EVENTS” in the next homepage, led to

company and financial news.

The next homepage, “EVENTS” icon led scientific

courses, while “NEWS” led to company news, product

news and tradeshows.

Another homepage had ”CORPORATION ***-NEWS”

linking to corporation events and speaks at multiple forums.

The next homepage had “EDUCATION AND EVENTS”

linked to scientific news, “MEDIA” led to both scientific

and corporate news.

The later had a news blog related to product news and

company activities, and “MEDIA RELATIONS” icon for

referred those seeking news.

The final homepage, had “TRADESHOWS”, “E-NEWS”

icons and an “EDUCATION CALENDAR” were dedicated

to scientific events. Icons “PRESS RELEASE” and “E-NEWS

LINKING” led to webpages about product news and

clinical techniques, while its “HIGHLIGHTS BLOG” was

dedicated to product news and scientific events. Two

webpages had no icons termed “NEWS” or “EVENTS”


One homepage offered a research prize.

Smile Dental Journal | Volume 6, Issue 4 - 2011| 17 |

Information Services and Support Educational and Scientific

Introductory Information Products Activities

Introductory Paragraphs 6 Products 9 Upcoming Courses Blog 1

Welcome Notes 2 On-Line Stores or E-Shop 6 Courses 1

About Us 2 My Cart 1 Materials

General Information 1 My Order 1 Documentation 1

Overview 2 My Account 1 Manuals 1

Prefaces, Who Are We?, What Is …?. 0 Consumer Site 1 International Downloads 1

Distribution Information Great Offers 1 Archives 1

Regional Offices Store 1 Studies 1

Global Home 2 Other Equipment 1 Library 1

Home 7

Product Catalogs, Online, PDF,

Ordered to Mail or Email Address, 0 Brochures 1

Restricted (Registering or Subscribing)

Global Websites 1 Finding A Network Of Local Users Bibliography 1

World Wide 2 Locate a Doctor or Find a Dentist 2 Literature 1

Int’l 1 Laboratories 1 FAQ 1

Europe 1 Support Articles 1

Distributors 2 Products and Services 1 Downloads 1

Global Network, Distributors 1

Costumers Support, and Costumers


2 Clinical Resources 1

Representatives, Trade Links, Regional

Homepages, Put on a Map

0 Technical Help and Technical Service 2

Presentation Briefings, Multimedia, Publications,

Abstracts, Case Reports, Books

Corporation Information Engineering Services 1 Professional and Career Development

Manufacturer 1 Advisory Board 1 Dental Professionals 2

Company and Our Company 8 Return Policy 1 Calendar 1

Head Quarters 1 Interaction Courses 1

Corporate 3 Comment and Make an Inquiry 2 Education 3

Name- Inc. 1 Help 1 Professional Education 1

Company Logos- Sentence 4 Contact 5 Continuing Education 1

President’s Message 1 Contact Us, 5 Education Calendar 1

Executive Profile 1 Email Us 1 Education and Events 1

Company News 1 Search Boxes 7 Congress 1

Jobs and/or Careers 5 Search 1 Seminar Tours 1

Investors and/or Investor Relation 2 Sitemap 3 Online Training 1

Carriers Regional Sales Managers 1 Signups Name- Residency 2

Company Activities Platinum Name- Course 3

Trade Shows and Appearances 3 Login Name- Seminar 4

Events 3 Extranet Login Clinical Skill Development:

News 4 Signup for an E-Bulletin 1 Videos 2

News and Events 2 E-News Letter 1 Manuals 1

E-News 1 Signup Forms for E-News 2 Cases 1

Sign-In for an E-News Letter 1 Pod Casts 1 Case Presentation

Subscribe to Bulletin 1 Web Casts 1 Digital Dentistry 2

Corporation Name-News 1 Syndications as RSS 0 Name of Imaging Technique 2

Education and Events 1 Individualized Prosthetics 1

Media 1 Implant Abutment Selection Guide 1

Highlights Blog 1 CAD CAM and CARE 1

Press Room Blog 1 On Marginal Bone Maintenance 1

News Blog 1 Dental Technician Guided Information

Media Relations 1 Laboratories 2


| 18 | Smile Dental Journal | Volume 6, Issue 4 - 2011

Information Services and Support Educational and Scientific

Introductory Information Products Activities

Press Release 1 Technical Tips 1

Company History, Corporation Structure,

Staff Info.

0 Technical Bulletins 1

Legal and Webpage Issues Lab 1

Site Requirements 1 Patient Guided Information

Copyright Declarations 10 Patients’ Resource 1

Legal Notices/ Terms/ Information 4 Patients 9

Privacy Policy/ Statement 7 Patients’ Site 1

Disclaimer 1 Patient Education 1

Trade Marks 1 Consumer Site 1

Conditions/Terms of Use 3 Frequently Asked Questions 1

Imprint 1 Find a Doctor, or Dentist 1

Honoraries All About Implants 1

Research Prize 1 Patients Guide to Implants 1

Surveys 3 Patient Videos 1

Honors, Voted, Prizes (Products or

Company) Quality Assurance Approvals,

0 Before and After 1


Implants’ Overviews Dental Glossary 1

Implant History 1 Restorations 1

Image of the Abutment/ Implant 3 Single Tooth Restoration 1

Implant Fixtures 1 Multiple Teeth Restoration 1

Healing Abutments 1 Over Dentures 1

Implants and Abutments 1 Partial Dentures 1

Innovation, Advancements, Latest,

What's Hot, New!

0 Gum Disease 1

Past Products, Deceased Lines, Manufacturing


0 Testimonials 2

Compatibility with Other Implant


0 Patient Stories 1

How Implants Change Your Life 1

(Table 1) Icons and content numbers are reported, for those included in dental implant manufacturers’ home page.

Note: (“ ”) designate icons labels, (/ )separates possible synonyms, “INT”L” = international, FAQ = frequently asked questions (labels

are quoted exactly as they appear in the webpage), and finally, “name- ******” indicates that the label uses trade names for the

incorporation or a product line in the label. These are not reported here to preserve the identity of webpage. Repeated icon names in

different categories indicate that these icons lead to different webpages addressing each separately, although having the same label.


One homepage provided 3 icons to different surveys.

Implants’ overviews

Some of this information was present in subsequent

webpages from “NEWS” and “EVENTS” icons, as

advancements. More information will be displayed in the

“PRODUCTS” icon explained later. Other information

were contained in icons ”IMPLANT FIXTURES” and

“HEALING ABUTMENTS”. One webpage provided an

icon indicating the compatibility of their abutment with

other implant systems.

Services and support material: labels and subjects.

Products: homepages provided information about

products using the label “PRODUCTS” in the form of

icons, flashes, and videos.

Three homepages studied were redirected to implant

webpages, as the first simple ( webpage had no

information on implants but featured other products.

Once reaching the implant related webpage, now

considered the homepage, one of them had a dropdown

list from “PRODUCTS” icon listing 4 implants and

3 implant related materials. The other two listed the

implants and related products on the webpage itself.

Icon “PRODUCTS”, is another example of how a

label is variably used and leads to different webpage

materials. One homepage used the label “PRODUCTS”

Smile Dental Journal | Volume 6, Issue 4 - 2011| 19 |

that led to other products which were not implants or

implant related. Another homepage had a drop-down

list embedded in the “PRODUCTS” icon, hiding further

icons for 8 implant products, 5 prosthetic products, and

11 surgical regenerative materials, related to implant

therapy. One homepage had “PRODUCTS” icon leading

to 2 implant lines and 5 implant related material.

The next description of the label “PRODUCTS” is more

complex as more material lie one click away, even not

related to implant products.

One homepage used “PRODUCTS” icon to lead to

a webpage containing introductory paragraphs and

further icons for implants, implant related materials

and software. It also had icons labeled “MANUALS”,



A second homepage linked “PRODUCTS” to a

webpage containing images and an overview of one

implant, more icons for “PRODUCT INFORMATION”,






A third homepage linked “PRODUCTS” to a webpage

containing an overview of one implant then icons




A fourth webpage homepage linked “PRODUCTS” to a

webpage containing a list of further icons for “IMPLANT

PRODUCTS” and 6 products not related to dental

implants. It also had the contact address.

The fifth homepage linked “PRODUCTS” to a webpage

containing introductory paragraphs, 5 implants

icons, and icons labeled “NEW PRODUCTS” and


The sixth homepage linked “PRODUCTS” to a

webpage containing introductory paragraphs, 7

icons for implants and implant related materials, and









The final webpage homepage linked “PRODUCTS” to a

webpage containing an introductory paragraph, a drop

down-list of countries, to locate choose local markets

and one icon leading to “CAD CAM”

Finding a network of local users

Three homepages provided this service by icons labeled

as “LOCATE A DOCTOR” icon in a drop-down list from


down-list from “PATIENTS”, and “LABORATORIES” in the

drop down-list from “PROGRAMS”


Labels used by icons leading to this material were






Homepages provided some interaction with the

consumers by asking for Feedback and interaction in

icons labeled “COMMENT” and “MAKE AN INQUIRY”,

“HELP”, and “ADVISED CONTACTS” icons. Search boxes

and Sitemaps helped online interaction with the web

content of subsequent pages.


Membership applications were present by icons, as


LETTER”. One homepage had “POD CASTS” and

multiple “WEB CASTS” to sign up for.

Sum of links per Category

Webpages obtained in this sample, contained a sum of

93 informative icons, 64 services and support icons and

85 educative icons, after excluding the icons related to

legal and copyright notes, not relevant to the study.

Three webpages could be described as comprehensive,

including icons leading to all categories under study.

They linked to 78, 57 and 42 different webpages

respectively. One webpage (117 icon links) lacked icons

for the essential educational category on its homepage.

Interested groups which may find relevant material

Patients, general dental practitioners and technicians

could be considered conventional users of these

webpages. They would seem to benefit the most as the

majority of the icons, relevant to the three categories

under study, were directed to this group.

However, some icons and content of the homepages

were found to meet the interest of: Periodontists,

Surgeons, Prosthodontists, CAD CAM users, Esthetic

dentists, and Radiologist. These included a few, highly

specific, line of products or highly specialized techniques.

Other dental professions as researchers, reviewers of

systematic reviews, evidence seekers, academicians and

| 20 | Smile Dental Journal | Volume 6, Issue 4 - 2011

students could find a share of the interest, but indirectly; as

there are no dedicated icons addressing their specific needs.

Unusual interests were met, but with a few number

of icons, for the general public, dental administrative

workers, treatment seekers or tourists, investors, the

press, internet link seekers, internet bloggers, web page

developers, designers and inventors.


The methodology developed in this study

This study is the first – within the knowledge of the

author- which studies the dental implant manufacturers’

webpages from this angle. The necessity for categorizing

materials linked from the webpages and presenting

this work comes from a previous study where there

was a need to scan all available lists of dental implant

manufacturers to compare implant–abutment interfaces

and its mechanics. The researchers were faced by the

huge variability of webpages and the confusion in the

labels of icons, leading to different materials each time.

Of a total of 150 webpages, the gathered experience

was sufficient to develop the methodology for this study,

and be presented to the reader who will face such

confusion when doing any search for multiple implant

systems for any reason.

Educative material was the focus of this study as

educating possible users increase their confidence and

provide them with sufficient evidence as required for high

quality treatments. This methodology can be repeated to

study any dental or medical product or service providers’

webpages to describe and develop recommendations for

their content.

The role of implant manufacturers’ webpages

Implant manufacturers’ have developed their webpages

to become a rich niche. Attracting the users or potential

users to longer sessions of webpage viewing and surfing

would indirectly help making the implant system familiar

to visual and comprehension senses. These methods


• Developing more interactions by clickable and

navigation-activated icons, makes it less boring.

• Additions of whole page flashes are still limited in the

sample of study, but partial flashes make the webpage

appear lively.

• The addition of larger numbers of icons embedded

in drop-down lists and pop-out windows increase the

chance of including a term, thatmeets an interest or need.

The efficiency of searching sessions in targeting needed

information is reached as more searches are done,

more subsequent webpages are explored and refined

and using correct tools as search boxes and site maps.

It is guided by how the learner is motivated. 9 The use

of a search box, for even the experienced, is the next

immediate option, if the relevant icon of interest is not

perceived directly from the homepage. So having such

tool is essential. Searches usually include an average of

two terms. If well studied, the webpage developers of

the site would annually accumulate these search terms

placed in their search boxes and add or rename their

homepage icons to reflect those terms, most in demand.

Customizing the contents, either to regions, languages,

individual accounts, logins, memberships and icons

labeled “my-*****”, may increase pertinence. Finally,

including multiple links to a single target increases the

chance of clicking an icon.

The previous were general methods used by most

webpages of the study. Three webpages were considered

comprehensive as they used more methods to attract

the surfer. They used multiple icon formats, leading to a

single page as a way of overcoming variability present

in internet experience of surfers. Attracting casual users

by images, flashes, and videos seems logic and was

used. Also including quick link bars in the header,

footer, and the side, would increase the chance of hitting

relevant information. Repeating those quick link bars

in subsequent pages makes the surfer oriented. Having

a site map has also this effect. Assigning sections in

the webpage, for each of the conventional users, and

concentrating their relevant links in that area, are even

more methods used.

Are the implant manufacturers’ webpages informative?

Looking at the homepage only, the direct answer to this,

is no!. There is a very limited number of paragraphs that

could add to the information of the surfer. These are

limited to welcome notes, very short sentences displaying

the company’s logo, or introductory paragraphs either to

the company or implant system used.

But when clicking icons for educative, informative, and

supportive or service providing materials, opening each

single webpage which is present one-click away could

answer some of that need. The action of webpages acting

as good directories should also be balanced with the

limitation that most users have, which is that they click no

more than only two pages away. So it is essential to have

the actual information, one or two-clicks away, at best.

Examples of this suggested confusion were for the


“PRODUCTS”. The subsequent pages were variable.

Some did not include enough information, but only

adding a new list of icons to be searched. Others include

icons which may seem to be essential, but hidden from

the homepage. If taking the classification of categories

used in this study as a reference, some information in the

subsequent pages was under un-expected icons labels,

mixing the needs, and adding to the confusion of surfer.

Opening the subsequent page was essential for another

reason. Many of the terms used in the labels of icons

Smile Dental Journal | Volume 6, Issue 4 - 2011| 21 |

were not clear, and only after opening the next page,

was the meaning explored. Many icon labels, which

seemed to be synonyms, were not used as such. So there

is a need for a standardized labeling method.

Are the implant manufacturers’ webpages educative?

To answer this critical question, levels of education are

separated, in the following discussion.

Patients’ education material

Retention of dental information is enhanced by the net 10

and consumers look for health care information online. 11

using the net by patients was to change dentists,

travel, discuss treatment with their dentists, ask for

more explanations, which may be considered by some

clinicians to be a burden on valuable clinical time. But

this had, in some occasions, led to patients demanding

inappropriate care or more complex treatment, if the

information is not validated. 12

Educating this group is essential, by providing an

abundance of scientifically valid material in reliable

resources, rather than the subjective material, limited

in experience and disseminated in chat rooms and

unspecialized forums.

Implant webpages provide material for patients in many

forms. Introductory into implants, implant treatment

options, what is expected from the treatment and

brochures and leaflets. Customization of the material

is done in a few webpages, where language is selected

by the patient. Services follow, leading patients to

doctors who use their system, testimonials and stories

of who had a chance to get them done, ” BEFORE AND

AFTER” images, and ”PATIENT VIDEOS”. All of these are

minimally educative-informative icons. Better educative

resources are expected in labeled icons: “FREQUENTLY



“PATIENTS’ SITE”, and these are present as icons in

more comprehensive webpages. These were present in a

limited number of webpages.

Undergraduate dental surgeons, hygienists,

assistants, and technician students

For this group, internet is now promoted to be an

education recourse and assistant to conventional methods.

Students had responded by accepting it, retaining

more information by it, and considering it an essential

adjunctive to conventional methods. 13,14 Providing the

material through a central location for e-resources, and

be connected to wider geographical distributions as by

podcasts, significantly increased their interest. 15

Student preferences were then announced by many

studies about what should the material look like on the

net, to consider it educative. Material is preferred to be

accessed off-campus, 16 standardized in terms of labels

and format, outlined in an e-syllabus, 17 and visually

perceived. Illustration methods are preferred in the forms

of “SLIDE GALLERIES”, “SLIDE SERIES” and streaming

videos. High quality images or videos were preferred if

supported by the DSL connection, contained sound and

text subtitles, short, and embedded in the text. 18 Online

quizzes produced variable response. Such inclusions

produced greater interaction, motivation and knowledge

retention. 19-21

As previous experience with online material is confounding

factor to this group, 22 material provided should have simple

interactions to reach needed information.

The introduction of dental implants into the curriculum

of these undergraduate courses has been reliant on

text books and lecture notes. The role of dental implant

webpages in providing educative material to these

groups is anticipated but not met directly as the student

is faced with no icons relevant to their needs. They could

access some of the patient materials, but would not

be able to comprehend all the professional terms and

specialized techniques for technician and professional

sections. Simple terminologies, more illustrated

techniques and well labeled icons could be areas of

further advancement towards being more educative.

Schools that adopt teaching comprehensive treatment

planning and team approach therapies, in final years,

are faced with bit more difficulty. The reliance on

experienced educators increases, to guide the students

through their pile of accumulating study materials. The

level of depth varies, in these approaches, according

to the dental school plans. The educators may face the

problem of introducing the current systems, using any of

the material provided by the implant webpage as they

are insufficiently directed from the homepage icons,

and may lack comparative clinical studies leading to

conclusions from the experience.

Dental education

Professional development materials are present in

many dental implant manufacturer webpages. Different

levels of specialty are also present but the problem is

faced where many of the intended material is present

in subsequent webpages, which may not be clear and

explored by the homepage icons. If the item is not

present, then facilities as site maps and search boxes

are the next choice. Some users often go straight to the

search feature on a site when it is present even before

searching the icons of the homepage. 23

This richness meets the definitions of a dental portal but also

the definition of power searching; process of finding good

quality information from the web as quickly and as easily

as possible. 24 But scientific validity and level of evidence

produced in these webpages warrant more research.

| 22 | Smile Dental Journal | Volume 6, Issue 4 - 2011

A side missing from these webpages is the retrieval

of implants in cases of failure. 25 Only one webpage

provided a return policy. Presence of such material

or through communication with a suggested list of

experienced clinicians, can aid in reducing the more

stressful aspects of implant dentistry.

Limitations of the study

1. It is a study of only the first homepage as it is

considered here as the first window which should

guide the browser to their specific knowledge needs.

2. The use of synonyms could not be concluded. There

are no references for the number and use synonyms

that may indicate a single subject. These are

collectively added to the lists but those that were felt to

be different were separated.

3. This research should mandatory be repeated, using

this methodology, but studying the webpages one or

two pages away from all homepage icons. This would

give a better insight to the answer of this study’s

question. e.g products may lead to a catalogue,

download material can lead to scientific literature

or catalogues. So even the lack of the icons leading

to some category materials, may not necessarily be

inferring their lack from the whole page.

4. The scientific validity of educative material and the

level of evidence provided by them have not been

verified. The material could be highly reliable if

produced from systematic reviews and randomized

clinical trials, or less reliable if concluded from case

studies, non-controlled short term studies. Better

scientific referencing of information is required.

5. It is recommended for quality assurance bodies to

mark presented materials according to the level of


6. There is lack in educative materials for students

although they could share the regular interest on

sections of FAQ or introduction to but labeling a

section for students would seem reasonable.


Richness in the webpages provided by dental implant

manufacturers meets the need for many. However,

scientific validity and level of evidence produced in these

webpages warrant more research. Better referencing

of educative material is required. Student educative

materials are lacking.


The author would like to acknowledge the Deanship of

Research in Jordan University of Science and technology

for funding multiple Dental Implant researches, from

which the experience had accumulated to perform this

study. And would thank colleagues at the faculty of

Dentistry for in depth discussions and cooperation.


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6. Schleyer TK, Corby P, Gregg AL. A preliminary analysis of the dental

informatics literature. Adv Dent Res. 2003;17:20-4.

7. Song M, Spallek H, Polk D, Schleyer T, Wali T. How information

systems should support the information needs of general dentists

in clinical settings: suggestions from a qualitative study. BMC Med

Inform Decis Mak. 2010;10:7.

8. Schleyer T, Spallek H. An evaluation of five dental Internet portals. J

Am Dent Assoc. 2002;133:204-12.

9. Grimes EB. Student perceptions of an online dental terminology

course. J Dent Educ. 2002;66:100-7.

10. Patel JH, Moles DR, Cunningham SJ. Factors affecting information

retention in orthodontic patients. Am J Orthod Dentofacial Orthop.


11. Schleyer TK, Spallek H, Torres-Urquidy MH. A profile of current

Internet users in dentistry. J Am Dent Assoc. 1998;129:1748-53.

12. Ní Ríordáin R, McCreary C. Dental patients’ use of the Internet. Br

Dent J. 2009;207:583-675.

13. Patel JH, Moles DR, Cunningham SJ. Factors affecting information

retention in orthodontic patients. Am J Orthod Dentofacial Orthop.


14. Al-Jewair TS, Azarpazhooh A, Suri S, Shah PS. Computer-assisted

learning in orthodontic education: a systematic review and metaanalysis.

J Dent Educ. 2009;73:730-9.

15. Barley SR. Computer-based distance education: why and why not.

The Educational Digest 1999;65:55-9.

16. Grimes EB. Student perceptions of an online dental terminology

course. J Dent Educ. 2002;66:100-7.

17. McCann AL, Schneiderman ED, Hinton RJ. E-teaching and learning

preferences of dental and dental hygiene students. J Dent Educ.


18. Boberick KG. Creating a web-enhanced interactive preclinic

technique manual: case report and student response. J Dent Educ.


19. Fleming DE, Mauriello SM, McKaig RG, Ludlow JB. A comparison

of slide/audiotape and Web-based instructional formats for

teaching normal intraoral radiographic anatomy. J Dent Hyg.


20. Pilcher ES. Students’ evaluation of online course materials in fixed

prosthodontics: a case study. Eur J Dent Educ. 2001;5:53-9.

21. Eynon R, Perryer G, Walmsley AD. Dental undergraduate

expectations and opinions of Web-based courseware to

supplement traditional teaching methods. Eur J Dent Educ.


22. Gallagher JE, Dobrosielski-Vergona KA, Wingard RG, Williams

TM.Web-based vs. traditional classroom instruction in gerontology:

a pilot study. J Dent Hyg. 2005;79:7.

23. Ross NCM, Wolfram D. End User Searching on the Internet: An

Analysis of Term air Topics Submitted to the Excite Search Engine. J

Amer Soc Inform Sci. 2000;51:949-58.

24. Spink A, Wolfram D, Jansen MBJ, Saracevic TJ. Searching The

Web: The Public and Their Queries. Amer Soc Inform Sci Tech.

2001;52: 226-34.

25. Toffler M. A dose of implant reality. State Dent J. 1999;65:28-32.

Smile Dental Journal | Volume 6, Issue 4 - 2011| 23 |




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Solving TMJ Problems with Orthodontic

Treatment and Cosmetic Mouth Rehabilitation

Case Series

Leonid Rubinov


• Instructor of the International

Association for Orthodontics

• Fellow of the American

Association for Functional


• Clinical Professor of the

International Department of

NYU’s College of Dentistry,



TMJ disorder is considered a gray area of dentistry. Treatment of these types of

problems with TMJ splints is often a temporary solution. Achieving a permanent

correction is usually difficult, because it requires changing the position of mandibular

condyles inside a TM joint. In many cases this goal is unattainable using only one

treatment modality. The unique treatment philosophy described in this article requires

a multidisciplinary approach. It starts with orthodontic treatment which enhances the

relationship inside the TM joint, alleviates TMJ symptoms and sets the stage for further

full mouth rehabilitation, if necessary. Orthodontic treatment in these cases is performed

with special attention to dentofacial orthopedics. The end result of this treatment

creates improved position of condyles inside TMJ, proper three dimensional orthopedic

relationships between the patient’s jaws and correct occlusion. This produces greatly

improved facial proportions, enhanced facial appearance and youthful look of the

patient while laying the groundwork for more successful restorative procedures.

Keywords: TMJ, Orthodontic treatment, Cosmetic rehabilitation, Dentofacial orthopedics.


TMJ disorder is considered a gray area of dentistry. According to LeResche, 1 “Overall,

it is estimated that approximately 10% of population over the age of 18 years have

pain in the TMJ region”. 1 There are a lot of uncertainty and different opinions what

is causing the TMD, how to treat it and even if any treatment required at all. After

reviewing literature Luter, 2 Luter and others 3 did not find enough evidence to support

or refute the use of orthodontic therapy for the treatment of temporomandibular

disorders (TMD). Meanwhile, it has been suggested that an internal derangement and

TMJ symptoms may be caused by the mandible being trapped and retracted behind

maxillary front teeth, forcing the TM disc anteriorly due to the condyles having been

forced posteriorly. 4 Treatment of TMD with different types of TMJ splints is a temporary

solution. It is suggested that a permanent occlusal orthodontic treatment to be used

after a change in the position of the mandible after repositioning-stabilization splints. 5

In his articles Brenkert, 6,7 described different choices for orthodontic treatment for the

anterior repositioned splint stabilized patients following anterior disk (s) displacement.

He outlined of how to properly treat these patients to consistent stabilized occlusion

compatible with the TMJ splint position. DeSteno 8 discussed stabilization and

rehabilitation principles of the therapy of the patients after TMJ splints, emphasizing

prosthodontic and orthodontic perspective.

The goal of this article is to lay out the framework for a unique treatment philosophy.

An interdisciplinary approach, starting with dentofacial orthopedic and orthodontic

treatment, allows the dentist to focus on proper arrangements inside TMJ. Changing

the size of the Maxilla is giving the dentist an opportunity to advance Mandible down

and forward, thus improving position of condyles and alleviating the majority of TMJ

symptoms. It is also is setting up condition for a much better restorative phase of the

treatment and usually improving facial appearance of the patient too.

The cases presented in this article can be seen as an illustration of how the

interdisciplinary approach can help in solving TMJ issues. Orthodontic treatment in

| 26 | Smile Dental Journal | Volume 6, Issue 4 - 2011

the beginning, with special attention to dentofacial

orthopedics, will place teeth and jaws in a position that

ensures the improved relationships inside TMJ and the

successful completion of the subsequent prosthetic phase

of the patient’s full mouth rehabilitation and greatly

improve the overall esthetic result.

Case 1

Patient O., 40 years old presented with several concerns

about her smile (figs. 1, 2): her front teeth are too

vertical, gummy smile, cosmetically unpleasant prosthetic

restorations (fig. 3).

She also had numerous TMJ symptoms such as: “tension”

headaches, headaches in right and left temple areas and

back of her head. She had frequent neck aches, difficulty

of opening her mouth wide, clicking sounds in her joints

and ringing sounds in her ears. She was grinding her

teeth at night and had pain in her TM joints.

Clinical and X ray evaluations showed, that patient had

Class II malocclusion, with her front maxillary teeth in

vertical, almost retrusive position, trapping her mandible

distally (fig. 4).

Distally displaced position of the mandible pushed

patient’s condyles into posterior/ superior position, thus

causing abovementioned TMJ symptoms.

(Figs. 1 & 2) Facial view & Natural smile of the patient O.

before treatment

(Fig. 3) Retracted view of the patient smile before treatment

The objective of the treatment plan for this patient

was to advance her mandible down and forward,

thus improving her appearance and eliminating TMJ

problems. Expansion of Maxilla along with protrusion

of maxillary incisors forward was necessary in order to

achieve required advancement of mandible.

These objectives were accomplished in 4 months of

treatment by using 3-Way Sagittal Removable Appliance

(fig. 5).

Upper and lower braces were placed in order to move teeth

into best possible positions for future restorative treatment.

At the end of this stage of the treatment skeletal changes

in patient’s face and jaws were obvious (fig. 6).

Positions of the condyles inside TMJ also changed,

helping alleviate and eliminate most of her TMJ

symptoms (figs. 7, 8).

(Fig. 4) Cephalometric X ray before treatment

Restorative part of the treatment was performed after

completion of orthodontic phase. Zirconia crowns were

placed on teeth #7, #10, #12, #13, #14, #19, #20,

#21, #28 and #29. Porcelain veneers were place on

teeth #4, #5, #6, #8, #9 and #11. (figs 9-11)

The final results of the treatment may be described as

a triple effect:

First: Patient’s TMJ symptoms have completely disappeared,

allowing her pain free and symptoms free existence.

(Fig. 5) Retracted view after treatment with removable appliance

Smile Dental Journal | Volume 6, Issue 4 - 2011| 27 |

Second: Patient’s facial appearance improved

dramatically, providing her with much more balanced,

proportional and youthful look.

Third: Her smile got better with new esthetically pleasing

restorations, better functional occlusion and eliminations

of gummy smile.

Case 2

Patient I., 33 years old, (fig. 12) came to the office with

several TMJ symptoms such as: “tension” headaches,

headaches in front of her head. She had frequent neck

aches, stiff neck, clenched her teeth during day and

night and was grinding her teeth at night.

Clinical evaluation showed, that patient had Class II

malocclusion with deep overbite and large overjet, placing

her condyles in superior/posterior position (figs. 13, 14).

(Fig. 6) Cephalometric X ray after the treatment

The objective of the treatment plan for this patient was, like

with patient in case 1, to advance her mandible down and

forward, thus improving her appearance and eliminating

TMJ problems. Expansion of maxilla was necessary to

achieve required advancement of mandible. This goal

(fig.15) was achieved by using fixed orthopedic appliance.

(Fig. 7) Transcranial X-ray of

left TMJ before treatment

(Fig. 8) Transcranial X-ray of

left TMJ after treatment

Further orthodontic treatment, using braces and

functional appliances, allowed advancing mandible

down and forward, effectively placing condyles in proper

position inside TMJ.

Fabrication of two 3-unit Zirconia bridges to replace

missing first mandibular molars and support newly

established occlusion complete the restorative part of the


The final result of the treatment of this patient was

similar to the patient in case 1: Patient’s TMJ symptoms

were eradicated, patient’s facial appearance changed

pretty drastically (fig. 16) and her occlusion improved by

eliminating overbite and overjet (figs. 17, 18).

(Figs. 9 & 10) Facial view & Natural smile after treatment

(Fig. 11) Retracted view of the patient smile after restorative phase


The interdisciplinary treatment of the patients with

TMJ problems is difficult to accomplish due to the

complexity of maintaining acquired mandible position,

which is achieved through its anterior reposition. The

prevailing treatment philosophy in general dentistry and

orthodontics is based on assumption of immovability of

the alveolar bone after the development of dentoalveolar

complex is completed and the permanent teeth have

erupted. This kind of approach is making the goal of

permanently repositioning the mandible downward and

forward is impossible to achieve in many TMJ cases due

to size and position of maxilla. To the contrary, the new

treatment philosophy with special attention to dentofacial

orthopedic, described in this article, results in an

accomplishment of above-mentioned reposition of the

mandible. The new orthopedically improved occlusion

| 28 | Smile Dental Journal | Volume 6, Issue 4 - 2011

(Fig. 12) Facial view of

patient I. before treatment

(Fig. 16) Facial view of

patient I. after treatment

(Fig. 13) Retracted view before treatment

(Fig. 17) Retracted view after treatment

(Fig. 14) Retracted view

of left side occlusion before


(Fig. 18) Retracted view

of left side occlusion after


(Fig. 15) Maxillary models before and after orthodontic phase

of treatment

is creating proper relationships inside TMJ, subsequently

eliminating the majority of TMJ issues.

a dentofacial orthopedics approach regardless of age

of the patient. The changes undergone by patient’s

faces, the size of the jaws and the occlusion and teeth

position cannot be explained by simple tooth movement

but rather by response of the alveolar bone as a

“whole”. Orthopedic changes in patient’s jaws and

their relationships are generally responsible for overall

improvement in facial appearance, correlations of the

condyles and discs inside TMJ and the creation of much

better groundwork for subsequent restorative procedures.

The scientific evidence for the new dentofacial orthopedic

approach is coming from work of Melsen, 9,10 and

Cacciafesta, 11 who advocate that the dentoalveolar

complex is much more malleable than previously believed.

Michael O. Williams and Neal C. Murphy have introduced

the concept of “whole bone” perspective to the alveolar

bone response to continuous low orthopedic force. 12

The cases presented in this article show that the

remodeling and redevelopment of the patient’s facial

and dentoalveolar structures can be performed using

(Fig. 19) Patient’s O. CT scan: maxillary transverse view after


Smile Dental Journal | Volume 6, Issue 4 - 2011| 29 |

Patient O. from case 1 has undergone CT scan examinations

several months after the completion of the treatment. The

goal of this research was to evaluate the long term effect of

the completed interdisciplinary treatment on the condition

and integrity of the alveolar bone and on the position and

stability of the roots of the teeth within the bone. An image

from this examination can be seen in fig. 19.

The assessments of this and other images for this patient

are consistent with the picture of normal alveolar bone

with roots of the teeth positioned proportionally within

the boundaries of the bone. There is no visible damage,

dehiscences or fenestrations in the buccal alveolar plate and

no bone loss can be observed.

These CT scans illustrate the “whole bone” remodeling

response to successfully performed orthopedic and

orthodontic treatment.


The addition of the orthodontic treatment to interdisciplinary

approach to solve TMD can result in permanent resolution of

the patient’s TMJ issues. The final outcome of this treatment

results in much improved position inside TM joints, significant

enhancement of the patient’s overall facial appearance,

occlusion, function and esthetic aspects of the smile. This

treatment philosophy gives the dentist an opportunity to

assess patients in a different way. The ensuing orthodontic

treatment with special attention paid to dentofacial

orthopedics allows for the remodeling of a patient’s alveolar

bone and whole dentoalveolar complex. The bone movement

creates a proper orthopedic relationship between the jaws

with stable results and healthier TMJ. The implementation

of this phase of the treatment places teeth and jaws in the

position that dramatically improves the dentist’s ability

to perform its restorative part. The overall results of the

treatment are elimination of the majority of TMJ problems,

much improved facial appearance, youthful look and proper

occlusion allowing for better patient’s functional ability and

esthetically attractive smile.


1. LeResche L. Epidemiology of temporomandibular disorders: implications for the

investigation of etiologic factors. Crit Rev Oral Biol Med. 1997;8:291-305.

2. Luter F. TMD and occlusion part I. Damned if we do? Occlusion: the interface

of dentistry and orthodontics. British Dental Journal. 2007;202:E2.

3. Luter F, Layton S, McDonald F. Orthodontics for treating temporomandibular

joint(TMJ) disorders (Review). 2010 The Cochrane Collaboration.

4. Wyatt W.E. Preventing adverse effects on the temporomandibular joint through

orthodontic treatment. Am J Orthod Dentofacial Orthop. 1987;91:493-9.

5. Capurso U, Marni I. Orthodontic treatment of TMJ disc displacement with

pain: an 18 year follow-up. Prog Orthod. 2007;8(2):240-50.

6. Dennis R. Brenkert. Orthodontic treatment for the TMJ patient following splint

therapy to stabilize a displaced disk(s): a systemized approach. Part I, TMJ

orthodontic diagnosis. Cranio: The Journal of Craniomandibular Practice.

28.3 (July 2010) p.193.

7. Dennis R. Brenkert. Orthodontic treatment for the TMJ patient following

splint therapy to stabilize a displaced disk(s): a systemized approach. Part II.

Cranio: The Journal of Craniomandibular Practice. 28.4 (Oct. 2010) p.260.

8. Desteno C V, et al.: Phase II rehabilitation of the temporomandibular joint

dysfunction patient. Clin Prey Dent. 1989; 11(5):29-32.

9. Birte Melsen. Biological reaction of alveolar bone to orthodontic tooth

movement. The Angle orthodontist. 1999;69(2):151-6.

10. Birte Melsen. Tissue reaction to orthodontic tooth movement - a new

paradigm. European Journal of Orthodontics. 2001;23:671-81.

11. Cacciafesta V. Dr. Birte Melsen on adult orthodontic treatment. J Clin

Orthod. 2006;12:703-16.

12. Michael O. Williams and Neal C. Murphy. Beyond the Ligament: A Whole-

Bone Periodontal View of Dentofacial Orthopedics and Falsification of

Universal Alveolar Immutability. Seminars in Orthodontics, Vol. 14, No 4

(December), 2008;246-59.

| 30 | Smile Dental Journal | Volume 6, Issue 4 - 2011

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Outcomes Following Zygomatic

Complex Fractures

A Retrospective Study

Majed Hani Khreisat


• MSc UK

• JBO in Oral & Maxillofacial

surgery, Amman - Jordan


Purpose: This is a descriptive analytic study evaluated the cause, type, incidence,

complications and treatment modality of zygomatic complex fractures at Manchester

Royal Infirmary in Manchester, United Kingdom over a period of six months from 10-1-

2005 to 20-7-2005.

Patients and Methods: This study was undertaken to investigate the outcomes following

zygomatic complex fractures in the unit of Oral and Maxillofacial Surgery at Manchester

Royal Infirmary, over a six month period. Information for the study was gathered from

patient records and a self-administrated patient questionnaire over a period of six months

from 10-1-2005 to 20-7-2005. Fifty patients, who had sustained zygomatic-complex

fractures were examined clinically, radiographicaly, and also underwent orthoptic

investigations. Ethical approval was gained from the local research ethics committee.

Results: The age of the patients ranged from 17 to 75 years. Seventy six percent of

patients were male, and the mean and median ages were (32.3; 30.5) for males,

and (33.4; 30.5) for females respectively. The male to female ratio was 3:1. Assault

was the major cause of zygomatic complex fractures, (35 patients [70%]), followed by

sport (8 patients [16%]). The majority of assault cases were in the 24-28 age groups.

The vast majority of patients (68.0%) with zygomatic complex injuries presented within

24 of their injury to the Accident & Emergency department, 15 cases (30%) presented

between 1-3 days, and only one case (2%) attended between 4-7 days. Patients

presented with circum-orbital ecchymosis as the most common sign, which was evident

in 41 patients (82%). Infra-orbital paraesthesia was present in 38 patients (76%). Subconjunctival

haemorrhage was seen in 33 patients (66%). Flattening of the cheek was

present in 28 patients (56%). Epistaxis occurred in 23 (46%) of patients. Step deformity

of the infra-orbital rim and deformity at Z-F suture were present in 36%, and 38%

of patients, respectively. Thirty-six percent of patients had limitation of mandibular

movements. Nine cases out of fifty (18%) presented with diplopia. Surgical treatment

was provided for 36 patients (72%). Fourteen (28%) of patient were observed and

treated conservatively. Closed reduction was performed for 42% of the treatment group

and 19 fractures were reduced by the Gillies temporal approach and 2 fractures via a

buccal approach; 30% of the fractures were reduced by open reduction and internal

fixation and the orbital floor was investigated in 15 patients. Ten patients required

orbital floor reconstruction and the preferred alloplastic material in this patient group

was Vicryl mesh (40%). The most common incision to explore the orbital floor is the

subciliary incision which was utilised in 9 patients the lateral brow incision was utilised

in 4 patients (27%). And two patients (11.8%) had the trans-conjunctival approach.

Statistically analysis revealed a significant difference between assault as the aetiology

and the types of zygoma fracture (p


Zygomatic or Malar bone fractures are (2 nd most

common) after nasal bone fractures among facial

skeletal Injures. 1,2 The high incidence of these fractures

may probably be attributed to the fact that Zygoma’s

occupy an anatomically prominent position within the

facial skeleton which frequently exposes it to traumatic

forces. The prominent convex shape of the zygoma

makes it vulnerable to traumatic injury. Even minimally

displaced zygomatic-complex fractures can result in

functional and aesthetic deformities. All traumas to the

face, particularly above the level of the mouth, require

a careful ocular examination including an estimation

of visual acuity of each eye, and zygomatic-complex

fractures are frequently complicated by injury to the orbit

and eye adnexae, which are the most serious negative

outcomes of zygomatic complex fractures. 3

Patients and Methods

Information for the study was gathered from patient

records and a self-administrated patient questionnaire

over a period of six months from 10-1-2005 to 20-

7-2005. Fifty patients, who had sustained zygomaticcomplex

fractures were examined clinically, radiographicaly,

and also underwent orthoptic investigations.

A written informed consent was obtained from the

patient or attendant. The treatment of fractures was done

by standard methods of reduction and fixation. Data

was analyzed in statistical program for social sciences

(SPSS) version 11.0. The frequency and percentage

was computed for qualitative variables, like gender,

etiologies, pattern and management modalities. Mean±

standard deviation was computed for qualitative

Variables, like age. Ethical approval was gained from the

local research ethics.


The results of this study were described in sequence of

the objectives. Detailed description of separate results is

shown in figures and tables.


The zygomatic complex gives the cheek prominence, and

it is the second most common mid-facial bone fractured

after the nasal bone and, overall, represents 13% of

craniofacial fractures. 4 Zygomatic complex fractures are

almost always associated with fractures of the floor of the

orbit. Typically, a fracture line extends from the inferior

orbital fissure antero-medially along the orbital process

of the maxilla, toward the infra-orbital rim.

Fifty patients attended with zygomatic complex fractures

over a six months period. The age of the patients ranged

from 17 to 75 years. Seventy six percent of patients were

male, and the mean and median ages were (32.3; 30.5)

for males, and (33.4; 30.5) for females respectively. The

male to female ratio was 3:1 as shown in table 1.




of patient

Male Female Total



of patient

Assault was the major cause of zygomatic complex

fractures, (35 patients [70%]), and the second most

common cause was sport (8 patients [16%]). The

majority of assault cases were in the 24-28 age groups.

This corresponds with results in comparable studies 5-8 as

shown in figure 1.

Of the patients who required surgical intervention,

8 (16%) were treated within 4-7 days and 19 (38%)

in 8-13 days. In 23 patients (46%) surgery was not

undertaken until 14 days. The reasons for this may

include allowing the oedema and ecchymosis to settle

and for the general condition of the patients to improve 9

as shown in figure 2.

We also evaluated the site of injury to whether it was

left-side or right, and compared this to aetiology of the

fracture. There was a statistically significant difference

between aetiologies and sites of injuries with left side



number of


14-18 4 8 0 0 4 8

19-23 2 4 2 4 4 8

24-28 12 24 4 8 16 32

29-33 5 10 1 2 6 12

34-38 6 12 2 4 8 16

39-43 4 8 1 2 5 10

44-48 3 6 0 0 3 6



2 4 2 4 4 8

Total 38 76 12 24 50 100

(Table 1) Age and sex of study group
















(Fig. 1) Aetiology by age distribution


Over 48





Road Trafic





Smile Dental Journal | Volume 6, Issue 4 - 2011| 33 |

Time from presentation to treatment

4-7 days

8-13 days

14+ days

8-13 days



Number of cases









4-7 days










Fracture of zygomatt

No significant displ

Comminuted fractures

Orbital wall fracture

Displacement en bloc

Rotation around Ion

Rotation around vert

(Fig. 2) Time from presentation to treatment (Time of Surgical


(Fig. 4) Types of zygomatic-complex fractures








Number of of cases




0 3 3 3 2

Assault Fall Sport RTA Other


Site of the fracture

Site of the fracture




(Fig. 3) Site of zygomatic complex fracture according to aetiology










Circum-orbital ecchymosis

Subconjunctival haemorrhage

Flattening of the cheek

Limitation of mandibular


Step deformity (infra-orbital


Deformity of Z-F suture

Infra-orbital paraesthesia


Limitation of Orbial movement


being commonly injured due to assault (32 patients,

64%) (p



Orbital floor exploration

Subciliary incision

Transconjuctival incision

Lateral brow incision



No Treatment

Lateral Brow Incision

Transconjunctival Approach

Subciliary Approach

Both Treatments (IOR & ZFS)

Zygomatico-Frontal Suture

Infra-orbital Rim

Buccal Sulcus Approach

Gillis Temporal Approach

Lateral brow







Closed Reduction

Open Reduction

& Internal fixation

Orbital floor


Waiting & Observation


incision 13%




(Fig. 6) Surgical approaches to zygomatic-complex fractures

(IOR: Infra-Orbital rim; ZFS: Zygomatic-frontal Suture)

reported by. 19 Thirty-six percent of patients had limitation

of mandibular movements, which is similar to finding

in other comparable studies. Nine cases out of fifty

(18%) presented with diplo. 20 Studies in the literature

report similar figures. 21,22 Some studies reported a lower

incidence 23 as shown in figure 5.

The treatment of zygomatic-complex fractures varies from

surgeon to surgeon and depends on the type of fracture

and given circumstance. Surgical treatment was provided

for 36 patients (72%). Fourteen (28%) of patient were

observed and treated conservatively. Forty-two percent of

patients underwent closed reduction by both extra oral

(Gillies temporal approach) and intra-oral approach

(Buccal sulcus approach). This surgical approach is

comparable and well reported in several studies. 24

Orbital floor exploration was undertaken in 15 (30%) of

patient and our figures compared well with 25,26 who have

relatively similar figures of 41.2% and 43.6% respectively.

Open reduction and internal fixation was undertaken in

15 cases (30%). Previously wiring at the infra-orbital rim

and zygomatico-frontal suture was undertaken but with

advent of plating, the majority of fractures are now with

titanium plates as shown in figure 6.

It was stated that adequate soft tissue access is of

paramount importance for orbital floor exploration,

and exposure of the fracture to stable bone for proper

anatomic reduction. 27 The most common incision to

explore the orbital floor is the subciliary incision which

was utilised in 9 patients (60%). 28, 29 stated similar figures

of 42% and 47% respectively. Some surgeons prefer the

lateral brow incision as this avoid fixation at the infraorbital

rim which is thin and sometimes less suitable

for plating. The lateral brow incision is utilised to plate

at the zygomatic-frontal suture and also for orbital

floor exploration. In our study group the lateral brow

incision was utilised in 4 patients (27%). Two patients

(11.8%) had the trans-conjunctival approach. The most

commonly stated criticism of this technique is the lack of

(Fig. 7) Orbital floor exploration in zygomatic complex fracture

Type of fixation



Vicrly mesh





(Fig. 8) Repair of orbital floor defects







Vicrly mesh



access to the operative field, although it provides good

cosmetic results with no visible scar but can carry a low

incidence of postoperative ectropion. 30 None of the

patients presented with early complication as a result of

the surgical approaches utilised as shown in figure 7.

Several of materials have been employed by

the surgeons in Manchester Royal Infirmary for

reconstruction of orbital floor defects. The convenience,

stability, lack of donor site morbidity, and reduced

anaesthetic and operating time has persuaded many

surgeons to use alloplastic materials for reconstruction

of orbital floor defects. The following materials were

utilised for reconstruction of the orbital floor: Vicryl mesh

(6 patients, 40%): PDS was utilised in 3 patients (20%)

and one patient had Medpore placed in the defect (7%).

For 5 patients (33%), the orbital defect was not repaired

following exploration. The early or late complications of

alloplastic implant materials include infection, extrusion,

migration, residual diplopia, lower eyelid oedema,

ectropion and tissue reaction. 31 None of the latter

complications were noted in patients in this study as

shown in figure 8.

Smile Dental Journal | Volume 6, Issue 4 - 2011| 35 |








Frequency 25

Percentage 20






(Cheek Flattening)

Limitation mandibular


Deformity of

orbital rim

Deformity of

Z-F Suture



(Fig. 9) Persistent complications of zygomatic-complex fractures

The most frequent complication of zygomatic complex

fractures was infra-orbital paraesthesia in 27 cases

(54%). This was followed by 3 cases (6%) in asymmetry

(cheek flattening). Two cases (4%) had limitation of

mandibular movement. Persistent diplopia and changes

of visual acuity was seen in one case (2%) (fig. 9).


This study presents information that can be

valuable in describing the pattern and spectrum

of zygomaticomaxillary complex fractures in local

population. Since the assault, the leading cause of facial

trauma, are usually associated with greater severity of

injuries, treatment approach needs to be comparatively

aggressive e.g. exposure of fracture sites and internal

fixations, for better aesthetic and functional restoration.

However, the four most important considerations

in treating zygomatic complex fractures are proper

reduction, adequate stabilization, adequate orbital

floor reconstruction (when necessary), and adequate

handling/positioning of periorbital soft tissue which will

provides the most accurate and satisfactory postoperative

results. Variance in treatment may exist because therapy

depends upon the type and severity of fracture, the time

since injury, and the surgeon’s personal experience. The

prognosis of zygomatic complex fractures is influenced

by delay between time of injury and treatment. The

timing of surgery is dependent on the general health

of the patient and the presenting signs and symptoms.

Ideally management of zygomatic complex injuries

should be undertaken after residual oedema has

subsided and a thorough pre-operative ophthalmic

assessment has been performed. As revealed in this

study, only 72% of patients received surgical intervention

to treat their injury.


1. Hollows P, D’Sa A, McAndrew PG. Life-threatening heamorrhage

after elevation of a fractured zygoma. Br J Oral Maxillofac Surg.


2. Israr N, Shah AA. Retrospective study of zygomatic complex

fractures in Sheffield England. Pak Oral Dent J. 2001;21:50-9.


Loss of

Visual Acuity

3. Mackinnon CA, David DJ, Cooter RD. Blindness and sever visual

impairment in facial fractures: An 11-year review. Br J Plast Surg.


4. Tadji Armin MB, Kimble Frank W. Fractured Zygomas. ANS. J. Surg.


5. Rowe, N.L, Killey, H.C. Fractures of the facial skeleton. Edinburgh,

E & S. Livingston. Ed.1. 1955;328-59.

6. Haider Z. Fractures of the zygomatic complex in the south-east

region of Scotland. Br. J. Oral. Surg. 1977;15:265-7.

7. Balle V, Christensen PH, Greisen O, Jorgensen PS. Treatment

of zygomatic fractures: a follow-up study of 105 patients.

Otolaryngolog. 1982;7:411-6.

8. Telfer MR, Jones GM, Shepherd JP (1991).Trends in the aetiology of

maxillofacial fractures in United Kingdom. (1977-1987). British. J.

Oral & Max-Fac. Surg. 1982;29:250-5.

9. Ogden GR. The Gillies method for fractured zygoma: an analysis

of 105 cases. J. Oral. Max-Fac.Surg. 1991;49:23-5.

10. Ellis E 3rd, el-Attar A, Moos KF. An analysis of 2,067 cases

of zygomatic orbital fractures. J. Oral Max-Fac. Surg.


11. Cramer, L.Tooze, F., Lerman, S. Blow-out fractures of orbit. Br. J.

Plast. Surg. 1965;18:171-9.

12. Kristeensen S, Tvetrs K. Zygomati Fractures: Classsification and

Complications. Clin. Otolarng. 1986;11:123-9.

13. Larsen OD, Thomsen M (): Zygomatic Fractures. II. A Followup

study of 137 patients. Scand. J. Plast. Reconstr. Surg.


14. Hollier, Larry H, M.D, Thornton James, M.D; Pazimiono, Pat M.D.;

Stal, Samuel M.D. The Management of Orbito-zygomatic fractures.

Plast Reconstr. Surgery. 2003;111(7):2386-93.

15. Wiesenbaugh Josph M. Diagnostic evaluation of zygomatic

complex fractures. Journal of oral surgery. 1970;28:204-8.

16. Kaasted E, Freng A.Zygomatico-maxillary fractures. J.

Craniomaxillo-facial Surgery. 1989;17:210.

17. Carr RM, Mathog RH. Early and delayed repair of orbito-zygomatic

fractures. J. Oral. Max-Fac. Surg. 1997;55:253-9.

18. Zachariades N, Papavassiliou D, Papadenetrion I. The alteration

in sensitivity of the infraorbital nerve following of the zygomatic

maxillary complex. Journal Cranio-Max-Fac. Surg, 18:315-318.

19. Kovacs and M. Ghahremani (2001). Minimization of zygomatic

complex fracture treatment. Int Journal. Oral Max-Fac Surgery.


20. Covington DS, Wainwright. DJ, Teichgraeber JF et al. Changing

patterns in the epidemiology and treatment of zygoma fractures:

10-year review. Journal of Trauma. 1994;37:243.

21. Knight, J.S. & North, J.F. The classification of Malar Fractures: An

analysis of Displacement as a Guide to Treatment. Br. J. Plast Surg.


22. Folkestad Lena, MD, Granstrom Gosta, MD. A prospective study of

orbital fracture squeals after change of surgical routines. J. Oral.

Max-Fac, Surg. 2003;61:1038-44.

23. Barclay TL. Diplopia in association with fractures involving the

zygomatic bone. Br. J. Plast Surg. 1958;11:47.

24. Zing M, Laedrach K, Chen J et al. Classification and treatment of

zygomatic fractures: A review of 1,025 cases. J. Oral. Max-Fac.

Surg. 1992;50:778.

25. Chen CT. Chen YR. Endoscopically assisted repair of orbital floor

fractures. Plast Reconstr. Surg. 2001;108:2011-8.

26. Manson PN, Iliff N, Bradely R. Trapdoor fractures of the orbit in

pediatric population. Plast Reconstr. Surg. 2002;109:490-5.

27. Manolidis S, Weeks BH, Kirby M, M. Hollier. Classification and

surgical management of orbital fractures: Experience with 111

orbital reconstru- ctions. J. Craniofacial Surg. 2002;13: 726-37.

28. Wray RC, Holtman B, Ribaudo JM, et al. A comparisons of

conjunctival and subciliary incisions for orbital fractures.Br. J. Plast.

Surg. 1977;30(2):142-5.

29. Pospisil OA, Fernando TD (1984). Review of the lower

blepharoplasty incision as a surgical approach to zygomaticoorbital

fractures Br. N J. Oral. Max-Fac.

30. Holtman B, Wray RC, Little G. A randomized comparison of four

incisions for orbital fractures. Plast Reconstr. Surg. 1981;67:731-5.

31. Jordan DR, Allen LH, White J, Harvey J, Pashby R, Esmaeli B.

Intervention within days for some orbital floor fractures: the whiteeyed

blow-out. Opthal. Plast Reconstr Surg. 1998;14:379-90.

| 36 | Smile Dental Journal | Volume 6, Issue 4 - 2011



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The Diagnosis and Management of

Impacted Maxillary Canines

Eyas Abuhijleh


• Specialist Orthodontist and

Assistant Professor, Tawam

Hospital, Dental Center

Al Ain - UAE

Dalal Masri


• General Dental Practitioner

Tawam Hospital, Dental

Center, Al Ain - UAE

Nadia Farawana


• German Board of

Orthodontics, Tawam

Hospital Dental Center,

Al Ain - UAE

Mariam Nmari


• General Dental Practitioner

Yas Medical Center

Al Buraimi - Oman


General dental practitioners and orthodontists will commonly encounter this problem

(impacted maxillary canines) and need to be fully aware of managing this situation.

Failure to diagnose and manage the ectopic upper canine efficiently can result in more

complex remedial treatment becoming necessary, which would be costly in terms of

clinical time for both the practitioner and patient. There is also the risk of damage to

the adjacent teeth which may lead to their loss and eventually to costly litigation claims.

The aims of this article are to:

1. Present evidence based recommendations to assist Dental Clinicians (Dental

Surgeon, Orthodontist, Pediatric Dental Specialist, Oral Surgeon) in the timely

detection and management of the ectopic maxillary canine.

2. Detect and manage impacted maxillary canines early.

3. Learn the complications associated with an impacted maxillary canine.

Keywords: Impacted canines, Surgical exposure, Orthodontic treatment.


Canines play a vital role in facial appearance, dental esthetics, arch development and

functional occlusion. Canine impaction is a common occurrence, because it develops

deep within the maxilla and has the longest path to travel compared with any other tooth

in the oral cavity. It is only with interdisciplinary care of general dentists and specialists by

early detection, timely interception, and well-managed surgical and orthodontic treatment

that impacted maxillary canines can be erupted and guided to an appropriate location in

the dental arch. 2


Clinical signs

• Over-retention of the primary canine. 2

• Delayed eruption of the permanent canine. 2

• Absence of a labial bulge in a 10- or 11- year-old patient. 2,3

• Presence of a palatal bulge. 2

• Distal crown tipping of the lateral incisor. 2,3

Radiographic investigation

The examination usually involves taking two radiographs and using the principle of

horizontal or vertical parallax, the horizontal parallax technique being the more reliable

in localizing impacted canines: 1

1. Horizontal parallax involves taking either:

• Two periapicals with different angulations and follow the (SLOB = same lingual

opposite buccal) rule 1-4 or

• An upper occlusal and a periapical.

| 40 | Smile Dental Journal | Volume 6, Issue 4 - 2011

Flow chart of the sequence of management of impacted maxillary canines

Clinical Examination at Age 10

Absence of Buccal Bulge and Presence of Palatal Bulge

Radiographic Localization

Line of Arch

Buccally Ectopic

Palatally Ectopic

Monitor Eruption

of Canine / Space


Monitor Eruption of Canine

Extract Deciduous Canines / Space Creation

Canine not Erupting in 1 year

Radiographic Localization: Beneficial Change in Position



Canine Buccally or Palatally Impacted

Surgical Exposure & Orthodontic Alignment


Surgical Removal or Auto-Transplantation


No Treatment and continuous Monitoring

2. Vertical parallax involves taking either:

• An upper occlusal (70–75°) and an

orthopantomogram (OPG) or

• A periapical and an orthopantomogram (OPG). 1,4

3. Advanced three-dimensional (3D) imaging

techniques: Cone-beam computed tomography

(CBCT) 1-4

Radiographic features

• Either non-vertical or no resorption of the deciduous

canine root. 3

• Canine crown overlapping adjacent incisor roots. 3

• Resorption of adjacent incisor roots. 2,3

• Magnification of the permanent maxillary canine

crown on a panoramic radiograph. 3


Interceptive treatment by extraction of the

deciduous canine

• The patient should be aged between 10-13 years. 1,4

• Better results are achieved in the absence of

crowding. 1,4

• Position of the canine in the dental arch and in

its relationship to the adjacent lateral decides the

outcome of the interceptive treatment. 1,4

• The need to maintain space (or even create additional

space) requires consideration. 1,4

• If radiographic examination reveals no improvement

in the impacted canine’s position 12 months after

extraction of the deciduous canine, alternative

treatment should be considered. 1,4

Surgical exposure and orthodontic alignment

• The patient should be well motivated and willing to

wear fixed orthodontic appliances. 1,4

• The patient should have good medical and oral health,

and maintain proper oral hygiene. 1,4

• The patient is considered to be unsuitable for

interceptive treatment. 1,4

• The degree of malposition of the impacted canine

should not be too great to preclude orthodontic

alignment. 1,4

• Exposure and alignment of the impacted canine is

indicated in cases when severe root resorption of an

incisor tooth has occurred necessitating its extraction. 4

• The optimal time for surgical exposure and orthodontic

alignment is during adolescence. 4

• Open communication between the orthodontist and

oral surgeon is essential for the choice of appropriate

surgical techniques.

• Careful selection of surgical and orthodontic

techniques is essential for the successful alignment of

impacted maxillary canines.

• Measured orthodontic forces in a favorable direction

leads to successful alignment.

Surgical removal of the palatally impacted

permanent canine

• This treatment option should be considered if the

patient declines active treatment and/or is happy with

their dental appearance. 1,4

• Surgical removal of the impacted canine should be

considered if there is radiographic evidence of early

root resorption of the adjacent incisor. 1,4

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• The best results are achieved if there is good contact

between the lateral incisor and first premolar. 1,4

• It is indicated in patients willing to undergo

orthodontic treatment to substitute the first premolar

for the canine. 1,4

• The possible risk of damaging the roots of adjacent

teeth during the surgical removal of the impacted

canine should be assessed and discussed with the

patient. 1


• This treatment option should be considered

if the patient is unwilling to wear orthodontic

appliances. 1,4

• Transplantation is indicated where interceptive

extraction of the deciduous canine has failed or

is unsuitable, and exposure and alignment of the

impacted canine is not possible. 1,4

• There should be adequate space available for the

canine and sufficient alveolar bone to accept the

transplanted tooth. 1,4

• The prognosis should be good if the canine to be

transplanted shows no evidence of ankylosis. 1

• The best results are achieved if the impacted canine

can be removed atraumatically. 1,4

• Depending on the stage of root formation (more

than 3/4 of the root formed) the transplanted canine

may require root canal therapy to be commenced

within ten days following transplantation. 1

No treatment and continuous monitoring

• The patient does not want treatment or is happy with

their dental appearance. 1,4

• There should be no evidence of root resorption of

adjacent teeth or other pathology. 1

• There should be good contact between the lateral

incisor and first premolar or the deciduous canine

should have a good prognosis. 1,4

• Severely displaced palatally impacted canines with no

evidence of pathology may be left in-situ, particularly if

the canine is remote from the dentition. 1

• Impacted canines left in-situ necessitate

radiographic monitoring to check for cystic changes

or root resorption. 1,4

• Regular review to ensure that the impacted canine

does not pose any risk to the adjacent structures. 1,4


1. Management of the palatally ectopic maxillary canine, Husain

J. et al., Publication of the Royal College of Surgeons, Faculty of

Dental Surgery, online publication, updated March 2010.

2. A review of the diagnosis and management of impacted

maxillary canines, Bedoya M. and Park J., The Journal of the

American Dental association (JADA). 2009;140:12:1485-93.

3. Managing the maxillary canine: 1. Diagnosis, localization

and interceptive treatment, McIntyre G., Orthodontic Update,

January 2008;1:7-15.

4. Clinical Practice Guidelines, The management of the palatally

ectopic canine, Ministry of Health Malaysia, September 2004.

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| 42 | Smile Dental Journal | Volume 6, Issue 4 - 2011


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and retreatment

Adhesion of Candida Albicans to Denture

Base and Denture Liners with Different

Surface Roughness

An In-vitro Study

Zahraa Nazar Al-Wahab


• Lecturer, Department of

Dental Technologies, College

of Health and Medical

Technologies, Foundation of

Technical Education

Baghdad, Iraq


This study investigated adherence of Candida albicans to denture base acrylic resins

and denture soft liners with varying surface roughness.

Materials and Methods: Two denture base acrylic resins (heat cured resin and cold

cured resin) and two commercial soft liners (one is heat polymerized acrylic resin

based and one is room temperature polymerized silicon based) having dimensions of

10X10X1.5mm for each specimen. Each material was divided into two groups: one is

processed against glass slide surface and the other is processed against dental stone

(10 samples for each group). Surface roughness measurements were made using a

profilometer where a stylus traverses across the layer of the surface. Human saliva

was collected from volunteers and the specimens were stored in human saliva which

was contaminated with yeast suspension of approximately 106 Candida albicans per

milliliter and incubated for 24hrs at 37C˚. After incubation, fixation of the attached

cells was done by treating the specimens with 100% ethanol for 3s and left to dry in

sterile plates. Specimens were stained using sterilized, fixated Methylene Blue stain for

1min and subsequently evaluated under optical microscope (Olympus, Japan) at X400

magnification. Visible measurement field was calculated in mm 2 and the obtained data

were expressed in cell/mm 2 .

Results: The materials processed against glass surface showed a very high significant

difference in surface roughness values than those processed against dental stone

surface (student t – test, P

(Table 1) Materials used in this study

Type of Material Trade Name Manufacturer Batch Number

Heat polymerized denture base acrylic resin Major base 2 (HC) Italy

ISO 1567, type I class I ADA


Room temperature polymerized denture base acrylic resin Major repair 2 (CC) Italy

ISO 1567, type II class I ADA


Heat-polymerized acrylic resin-based resilient liner

Vertex Soft (V)

Vertex-Dental BV, Zeist,

The Netherlands


Room temperature polymerized silicone-based resilient liner Mollosil (M)

Detax, GmbH & Co. KG,



The presence of Candida albicans on the upper fitting

surface of the denture is a major causative factor

in denture-associated chronic atrophic candidosis

(denture stomatitis), the most common form of oral

candidosis. 2 Candida albicans is a dimorphic fungus that

is commensal in the gastrointestinal and reproductive

tracts of healthy individuals. Under certain predisposing

conditions, Candida albicans can convert into a

pathogen capable of causing a variety of oral infections

including pseudomembranous candidiasis, erythematous

candidiasis and hyperplastic candidiasis, as well as

Candida-associated denture stomatitis, Candida

associated angular cheilitis, rhomboid glossitis and

chronic mucocutaneous candidiasis. 4

Denture stomatitis is an erythematous pathogenic

condition of the denture bearing mucosa and is mainly

caused by microbial factors, especially Candida albicans. 5

The etiology is multifactorial consisting of either ill-fitting

prostheses leading to mechanical irritation or poor

hygiene leading to chronic infection, regardless of the

initiating process Candida ablicans is the main cause of

fungal origin in denture stomatitis. 6

The first step implicated in denture stomatitis is adherence

of Candida to acrylic or to salivary pellicles adsorbed on

the surface of dental prosthesis. This is considered the

most important event in the ability of Candida albicans to

colonize dentures in the mouth. 4 The aim of this study is

to assess the ability of Candida albicans adherence to two

types of acrylic resin and two types of soft lining materials

with different surface roughness.

Materials and Methods

Two commercially available denture base acrylic resins

were used, one is heat cured (HC) and the other is

cold cured (CC). Two liners were used, one is heat

polymerized acrylic resin based (V) and the other is room

temperature polymerized silicone based (M). All of these

materials were listed in Table 1.

Preparation of the specimens

Pink modeling wax forms (10X10X1.5) mm were

punched from a sheet of wax. Stone was mixed

according to the manufacturer’s instruction in the lower

half of the flask. Two types of mold were prepared in

such a manner that in the first type, one part of the mold

was dental stone and the other is glass surface, while

in the second type, both parts of the mold were dental

stone. To produce the specimens against the glass,

a glass microscope slide was pressed onto the stone

mixture in the lower part of the flask. After the stone has

set, wax specimens were placed on the top of the glass

slide surface. The upper part of the flask was placed in

position and the dental stone was poured over the wax

specimens. The flasks were separated and boiled out,

and the cover glass was degreased with liquid detergent.

The surface of the investing dental stone was lubricated

with separating media before packing of the materials.

All the tested materials were processed according to the

manufacturer’s instructions.

Sample grouping

HC1: Heat cured denture base acrylic resin processed

against glass

CC1: Cold cured denture base acrylic resin processed

against glass

V1: Heat polymerized acrylic resin-based resilient liner

processed against glass

M1: Room temperature polymerized silicone-based

resilient liner processed against glass

HC2: Heat cured denture base acrylic resin processed

against dental stone

CC2: Cold cured denture base acrylic resin processed

against dental stone

V2: Heat polymerized acrylic resin-based resilient liner

processed against dental stone

M2: Room temperature polymerized silicone-based

resilient liner processed against dental stone

Estimation of surface roughness of the specimens

The surface roughness of the specimens was measured

with profilometer (Talysurf 4, Taylor Hasbon, UK), where

a stylus traverses across the layer of the surface. Three

readings were taken for every specimens and the

average was calculated. The average surface roughness

values for all tested specimens are presented in Table 2.

Methods of saliva collection

Whole unstimulated saliva samples were collected and

pooled from 5 healthy male volunteers to eliminate

sample variation, 4 aged 18 – 22, (mean 20 years). The

Smile Dental Journal | Volume 6, Issue 4 - 2011| 47 |

(Table 2) Mean surface roughness values (Ra) and standard

deviation (SD) of all tested groups (in µm)

Mean and SD Group Mean ± SD Group

2.5±0.253 HC2 1.31 ± 0.166 HC1

5.59± 0.272 CC2 1.57±0.125 CC1

4.11±0.272 V2 1.4±0.221 V1

7.48±0.345 M2 1.5±0.290 M1

(Table 3) Mean and Standard deviation of Candida albicans

adhesion to all groups in cells/mm 2

Mean and SD Group Mean ± SD Group

3426.7 ±118.3 HC2

5371.8±223.45 CC2

5189.9±127.87 V2

7916.5±306.68 M2





1588.77 ±


1590.36 ±




(Table 4) Student–test comparing the mean surface roughness

values for each material according to the type of surface processing

Groups t – value P – value Group

saliva was collected between 9.00 and 10.00 am and

the volunteers had not eaten that morning. They were

not taking any drugs or medications known to affect

saliva production, composition, or flow within the last

three months. They were not taking any antibiotics or

antifungal agents. 8,7,4 Saliva was centrifuged at 14000g

for 15min and then it was used immediately. 8

Obtaining Candida albicans

Candida albicans strain ATCC 2091 was obtained as a

stock culture (from Pathological Analysis Department of the

College of Health and Medical Technologies, Baghdad,

Iraq), and incubated on Sabouraud dextrose agar slope

at 37°C for 48 h . Standard amounts of this culture were

inoculated into 2ml of liquid Sabouraud dextrose agar

and incubated at 37°C for 24 h . The culture was then

centrifuged (Function Line, Labofuge 400 R, Hereaus



HC1 & HC2 2.9748 P

(Table 6) One-way ANOVA test comparing Candida albicans

adhesion among materials processed against dental stone surface

Significance P-value F-value Group


adhesion on hydrophobic material was low. This result

also agrees with 16 and 19 , these studies stated that silicon

soft liner are more susceptible to Candida albicans

adhesion than acrylic resin since surface porosity, texture

and biologic and physical / chemical affinity between the

materials and microbial cells may be an important factor.

The results of the present study showed that molosil

soft liner processed against dental stone showed

significantly higher adhesion than vertex soft liner and

this agrees with 20 , a study stated that heat polymerized

soft liner showed lower adhesion than room temperature

polymerized soft liner. This finding is in agreement with 3 ,

a study which explained this result due to the presence

of porosities inside the matrix of the room temperature

polymerized material which facilitates the penetration

of blastospores. This finding agrees with 5,3 and 19 .

This finding also agrees with 9 , a study found that the

adherence of Candida albicans on room temperature

polymerized surfaces is related to the polymerization

method of the material tested.

In this study, there was no statistically significant

difference in Candida albicans adhesion between

cold cured denture base acrylic resin (CC2) and heat

polymerized acrylic resin based liner (V2) polymerized

against dental stone surface. This is because the

chemical composition of (V2) is similar to that of the

polymethyl methacrylate of cold cured denture base

acrylic resin polymer. 21


Rough surfaces of the denture base and soft liner

promote the adhesion of Candida albicans in vitro and

the surfaces that are as smooth as possible are more

desirable in terms of cleanability and prevention of

fungal disease. The selection of appropriate material

for a given function and their fabrication may affect the

performance of the material.


1. Radford DR, Watson TF, Walter JD Stephen J. Challacombe SJ. The

effects of surface machining on heat cured acrylic resin and two soft

denture base materials: a scanning electron microscope and confocal

microscope evaluation. J Prosthet Dent. 1997;78(2):200-8.

2. Waters MGJ, Williams DW, Jagger RG, Lewis MAO. Adherence of

Candida albicans to experimental denture soft lining materials. J

Prosthet Dent. 1997;77(3):306-12.

3. Bulad K, Taylor R, Verran J, Mc Cord F. Colonization and penetration

and denture doft lining materials by cardida. albicans Dent Mater.


4. Elguezabell N, Maza JL, Dorronsoro S, Pontou J. Whole saliva has a

dual role on the adherence and C. albicans to polyethyl methacrylate.

The open Dentistry J. 2008;2:1-4.

5. Nikawa H, Jintc Hamad A, Smak RA, Kumage H, Murat H. The

interactions between thermal cycled resilient denture lining materials

salivary and serum pellicles and Candida albicans in vitro: part II

Effects on fungal colonization. J Oral Rehab. 2000;27:124-30.

6. Kulak – Ozkan Y, Kazazoglu E, Arikan A. Oral hygiene habits,

denture cleanliness, presence and yeasts and stomatitis in elderly

people. J Oral Rehabel. 2002;29(3):300-4.

7. Moura JS, da Silva WJ, Pereira T, Bel Cury AAD, Rodrigues Garcia

RCM. Influence of acrylic resin polymerization methods and

saliva on the adherence of four Candida species. J Prosthet Dent.


8. Radford DR, Sweet SP, Challacombe SJ, WalterJD. Adherence of

Candida albicans to denture-base materials with different surface

finishes. Journal of Dentistry. 1998;26:577-83.

9. Vurual C, Ozdemir G, Kurtulmus H, Kumbuloglu O, Ozcan M.

Comparative effects of two different artificial body fluids on

Candida albicans adhesion to soft lining materials. Dent Mater J.


10. Douglass LJ. Candida biofilm and their role in infection. Trends

Microbiol. 2003;11:30-6.

11. Grubb BR, Chadburn JL, Boucher CR. Cr. In vitro microdialysis

for determination and nasal liquid composition, Am J Physiol.


12. Nevzatoğlu EU, Özcan M, Kulak-Ozkan Y, Kadir T. Adherence

of Candida albicans to denture base acrylics and silicone-based

resilient liner materials with different surface finishes. Clin Oral

Invest. 2007;11:231-6.

13. Verran J Maryan CJ. Retention of Candida abicans on acrylic resins

and silicon and different surface topography. J Prosthet Dent.


14. Taylor R, Maryan CH, Verran J. Retention of oral microorganisms

on cobalt – chromium and dental acrylic resin with different surface

finishes. J Prosthet Dent. 1998;80(5):592-7.

15. Henriques M, Azeredo J, Oliveira R. Adhesion of Candida albicans

and Candida dubliniensis to acrylic and hydroxyapatite. Colloids

and Surfaces B:Biointerffaces. 2004;33(3-4):235-41.

16. Pereira T, Cury AADB, Cenci Ms, Rodrigues – Garcia RCM. In vitro

Candida colonization on acrylic resins and denture linors: Influence

and surface frequencu, roughness, saliva and adhering bacteria. Int

J prosthodnt. 2007;20:308-10.

17. Hammoudi IM. Evaluation of the effect of polishing techniques on

surface roughness and adhesion of Candida albicans to the acrylic

complete denture. A thesis submitted to the College of Dentistry

in partial fulfillment of the requirements of Master of Science in

Prosthodontics, 2006.

18. Periera – Cenci T, Del bdcury A, Crielard W Tencate JM.

Development and Candida – associated denture stomtitis: New in

sights. J App Oral sci. 2008;16(2):86-94.

19. Bal BT, Yavuzyilmaz H, Yucel M. A pilot study to evaluate the

adhesion oral microorganisms to temporary soft lining materials. J

Oral Sci. 2008;50(1):1-8.

20. Gedik H, Ozkan YK. The effect of surface roughness of siliconebased

resilient liner materials on the adherence of Candida albicans

and inhibition of Candida albicans with different disinfectants.Oral

Health Prev Dent. 2009;7(4):347-53.

21. Mese A, Guzel KG. Effect of storage duration on the hardness and

tensile bond strength of silicone- and acrylic resin-based resilient

denture liners to a processed denture base acrylic resin. J Prosthet

Dent. 2008;99:153-9.

8 th Gulf Dental Association Conference

& 2 nd Qatar Internationl Dental Association Conference

| 50 | Smile Dental Journal | Volume 6, Issue 4 - 2011

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December Expert Panel

Hassan Maghaireh


• BDS, Cairo University

• MFDS, RCS Edinburgh

• MSc Implants University of


• Honorary Clinical Teacher,

University of Manchester

• Editorial Board; European

Journal of Oral Implantology

• Implant Referral Practice,

Leeds - UK


Wesam Aleid





• Oral, Maxillofacial, and

Head & Neck Surgeon, UK


Alexandre Khairallah


• PGD, Oral and Maxillo- facial

Imaging, Lebanese Univ.

• Fellow of the European

Academy of Maxillo-Facial


• Chef de Service, Oral and

Maxillo-facial Imaging Dept,

Dental School, Lebanese Univ.

• Founder and owner of

CLIR, Centre de Lecture et

d’Interpretation Radiologique

• alexandrekhairallah@

Ali Abu Nema


• BDS, Jordan University of

Science and Technology

• NDB, American Dental


• MSc, Endodontics University

of Manchester, UK

• Private Endoodontic Referral

Practice, Amman-Jordan


What is the up to date

evidence comparing flapless

implant placement to

conventional placement with

flap elevation ?

Answer: Dr. Hassan Maghaireh

Flapless implant surgery is

considered by some clinical reports

to offer advantages over the

traditional flap access approach.

Clinicians supporting this view

claim that flapless implants offer

minimized bleeding, decreased

surgical times and minimal

patient discomfort, other less

supported reports also claim that

with flapless placement, you can

get less marginal bone loss and

better aesthetics. On the other

hand, the view supporting open

flap implant placement argue that

with conventional flaps, clinicians

will have better visualization for

the adjacent vital structures, bone

fenestratins and dehiscences,

adjacent teeth and soft tissue

thickness, making it easier for

the clinicians to place the dental

implant(s) in the optimum way, in

addition to allowing the clinician to

carry out guided bone regeneration

procesure simultaneously with

implant placement which in return

allows for better aesthetic results.

While the dental literature is full

of descriptive studies and clinical

case reports promoting flapless

implant placement as a modern

technique, there is very little properly

conducted random controlled

clinical studies comparing flapless

placement with conventional flaps

in implant dentistry. The systematic

review conducted by Esposito et al.

(2007) has only managed to identify

five well conducted trials on this

topic and has concluded that while

flapless implant placement is feasible

and has been shown to reduce

patient postoperative discomfort

in adequately selected patients, no

effect was found on marginal bone

level or final aesthetic results.

| 54 | Smile Dental Journal | Volume 6, Issue 4 - 2011

A recent well conducted random

controlled trial by Cannizzaro et

al. (2010), compared flapless

versus open flap implant surgery

in partially edentulous patients,

in a split mouth design involving

40 patients and 143 implants,

reported no statistically significant

difference between the two groups

when looking into implants and

prosthetic success and post operative

complications. However, the same

study reported that placement of

flapless implants required statistically

significant less time than placement

after flap elevation with their patients

reporting less post operative swelling

and requiring less analgesics.

However, what’s interesting is that

this well conducted study which was

the first to look in to the effect of

flapless implants on marginal bone

levels in comparison to open flap

surgery, has reported no statistically

significant differences between the

two groups at baseline and 1 year

after loading.

To conclude, Flapless implant

placement is becoming a popular

topic in implant dentistry, and

with the evolution in radiological

imaging and introduction of new

techniques like the Nobel Guide

protocol, it became a more precise

and predictable procedure in

well selected patients. We should,

however, be aware that flapless

surgery does not automatically

contribute to a better direct

postoperative quality of life or better


Recommended reading list:

• Interventions for replacing missing

teeth: management of soft tissues for

dental implants, Esposito M, Grusovin

MG, Maghaireh H, Coulthard P,

Worthington HV. Chichester, UK:

Cochrane Database of Systematic

Reviews 2007 John Wiley & Sons, Ltd.

• Flapless versus open flap implant

surgery in partially edentulous

patients subjected to immediate

loading: one-year results from a splitmouth

randomised controlled trial.

Cannizzaro G, Esposito M, EJOI 2011.

• A comparison of two implant

techniques on patient-based outcome

measures: a report of flapless

vs. conventional flapped implant

placement, Jerome A. Lindeboom,

Arjen J. van Wijk, Clin. Oral Impl. Res.

21, 2010.

In condylar Fractures,

is open reduction and

internal fixation better than

functional intermaxillary


Answer: Dr. Wesam Aleid


Treatment of condylar fractures

has always been and continues to

be an area of hot debate, as to

whether conservative treatment with

Functional intermaxillary fixation

(IMF) is as good as the open

reduction and internal fixation (ORIF).

Several classification systems

emerged e.g. Spiessel and Schroll,

Neff, and SORG. The most widely

used classification in the United

Kingdom is the one described by

Richard Loukota in 2005 1 which was

revised in 2009. 2


Several clinical trials have been

conducted over the past two decades

to objectively measure the difference

in outcome between IMF and ORIF.

In 1998 JOOS compared the

outcome in a group of 122 patients

with 138 fractures, he concluded

that simple conservative treatment

had comparable results to ORIF

and therefore should be first line


In 2003 Luc treated 60 patients

with 71 fractures conservatively

and despite that 35% of his patients

developed symptoms of TMJ

dysfunction, he still concluded that

it is reasonable to manage condylar

fractures conservatively unless the

overlap between fragments is more

than 8mm, which is an indication for

ORIF in his view.

In 2006 Eckelt and Loukota 3

published a prospective randomised

multi-centre study which they refined

in 2008. 4 The study included 66

patients with 79 fractures, which

has shown a significantly improved

outcome for patients treated with

ORIF when the Fracture angulation

was more than 10 degrees, when

the ramus shortening (overlap)

was more than 2mm, or when the

fracture was bilateral.


What about growing children?

How I do it:

At any age if no malocclusion is

present then treatment is only with

soft diet. Even minimal malocclusion

should be allowed a week before

any intervention as it may be a

consequence of joint effusion,

tissue oedema or pain rather than

displacement of the fracture (Fig. 1).

(Fig. 1) Right side of a PA mandible showing

minimally displaced right condylar fracture.

In Adults, the absolute indications

for ORIF are:

• Inability to obtain adequate

occlusion by closed treatment

• Lateral extracapsular displacement

of the condyle

• Displacement of the condyle into

the external auditory meatus or the

middle cranial fossa

• Presence of foreign body or gross

contamination of the joint

Relative indications for ORIF:

• Bilateral condylar fractures in

edentulous Jaw

• Bilateral condylar fracture in

presence of midface comminution

• IMF contraindicated for medical

reasons (like COPD, Epilepsy, etc...)

• Ramus shortening (fragment

overlap) of more than 2mm (Figs.


• Fragments angulation of more than

10 degrees (Figs. 2-4)

Children less than 12 years old:

Always IMF as first line, starting with

rigid fixation for seven to ten days

Smile Dental Journal | Volume 6, Issue 4 - 2011| 55 |

(Fig. 2) Coronal CT of left condylar fracture

with comminution angulation, and overlap

the mandibular condylar process–a

prospective randomized multi-centre

study. Journal of Cranio-Maxillofacial

Surgery. 2006;34:306-14.

4. Matthias Schneider et al. Open

Reduction and Internal Fixation

Versus Closed Treatment and

Mandibulomaxillary Fixation of

Fractures of the Mandibular Condylar

Process: A Randomized, Prospective,

Multicentre Study With Special

Evaluation of Fracture Level. J Oral

Maxillofac Surg. 2008;66:2537-44.

(Fig. 1) Drawing of the line

What are the causes

of differences in height

between measurements on

para axial cuts issued from

a Dentascan and the clinical


(Fig. 2)

Cut for choosing


(Fig. 3) PA mandible of left condylar fracture

(same patient in figure1)

(Fig. 4) PA mandible of left condylar fracture

following ORIF (same patient in figure1)

followed by functional (elastics) IMF

for three to four weeks due to risk of

ankylosis of the joint.

Children 12 to 17 years old:

Treat with IMF for two to three

weeks. If Malocclusion persists

consider ORIF.


1. Loukota RA et al. Subclassification

of fractures of the condylar process

of the mandible. British Journal

of Oral and Maxillofacial Surgery.


2. Loukota R.A. et al. Nomenclature/

classification of fractures of the

mandibular condylar head. British

Journal of Oral and Maxillofacial

Surgery. 2010; 48:477-8.

3. ECKELT U et al. Open versus

closed treatment of fractures of

Answer: Dr. Alexandre Khairallah

The dentascan exam consists of a

series of axial acquisitions parallel

to the palate in the upper jaw and

the inferior border of the mandible

in the lower jaw; these are fixed

teeth free references. After choosing

a specific axial cut (fig. 1) passing

by the apices of teeth for instance

or parallel to the inferior alveolar

nerve,or the floor of the sinus,the

operator will draw a line with his

mouse on this particular cut.

The computer will automatically

generate a series of para axial

cuts perpendicular to this specific

line.Usually all measurements are

done on para axial cuts in order to

choose the exact implant’s length

and width (fig. 2). As mentioned

above, para axial cuts are

perpendicular to the line and not

to the maxilla or mandible (fig. 1).

Special attention must be drawn in

designing this specific line, it must

be parallel to the outer aspect of

the mandible or maxilla in order to

get theexact length and width of the

remaining bone (fig. 3); otherwise

measurements are calculated on

an oblique cut (fig. 4) and usually

this will lead to overestimated

measurements since the hypotenuse

of a rectangular triangle is bigger

than the adjacent segments

according to the Pythagoras theorem

in trigonometry (c2=a2+b2).

(Fig. 3) Parallel line will give exact measurements

(Fig. 4) Non parallel line will give wrong


For further informations you may

consult these references:

• Liang-Kuang C, Cheng-Tau Su,

Yuh-Feng T. Spiral Dental CT: Use in

Evaluating DentalImplantation. Chin J

Radiol. 2006;26:209-14.

• Danforth R, Dus I, Mah J. 3-D Volume

Imaging for Dentistry: A New Dimension.

CDA Journal. 2003;31:817-23.

• Covino SW, Mitnick RJ, Shprintzen

RJ, Cisneros GJ. The accuracy of

measurements of three-dimensional

computed tomography reconstructions. J

Oral MaxillofacSurg. 1996;54:982-90.









| 56 | Smile Dental Journal | Volume 6, Issue 4 - 2011

What are the advatnages

and disadvantages of using

Chlorhexidine as a root

canal irrigant?

Answer: Dr. Ali Abu Nema

Bacteria and their

byproducts are

considered to be one of

the main causes of root

canal treatment failure.

Hence, a major objective

in root canal treatment is

to disinfect the entire root

canal system.

Chlorhexidine digluconate

(CHX) is widely used in

disinfection because of

its excellent antimicrobial

activity. Its cationic structure

provides a unique property

named substantivity;

however, it lacks tissue

dissolving ability.


Mechanism of action

CHX is a positively charged

hydrophobic-lipophilic molecule

that interacts with phospholipids

and lipopolysaccharides on the

cell membrane of bacteria and

enters the cell through some type

of active or passive transport

mechanism. Its efficacy is due to the

interaction of the positive charge

of the molecule with the negatively

charged phosphate groups on


microbial cell walls, which alters


the cells osmotic equilibrium. This



(Fig. 1)

d) Cell Lysis

increases the permeability of the cell

wall, allowing the CHX molecule to

penetrate into the bacteria (fig. 1).

Antibacterial activity

2% CHX was found to be the

only solution able to eliminate

Actinomyces israelii. Oncag et al.

evaluated the antibacterial properties

against Enterococcus faecalis of

5.25% NaOCl and 2% CHX. The 2%

CHX was significantly more effective

against E faecalis. Also it has shown

Mechanisms of CHX

Active (or) Positive

Transport Mechanism

a) +ve Charged CHX Molecules

b) -ve charged phoshate

groups on microbial cell wall

c) CHX interacts with phosphate group of

microbial cell which after the cells osmotic equilibrium

to be that 2% CHX is very effective

against Staphylococcus aureus and

Candida albicans.


The antimicrobial substantivity of a

2% CHX solution as an endodontic

irrigant was reported to be 72

hours. It has been found that 5 min

application of 2% CHX solution

induced substantivity for up to 4

weeks. Another study found that the

substantivity of 2% CHX solution for

10 min application was for 12 weeks.

Leakage of

adenosine tri


Nucleic Acid

(Fig. 2)

Interaction between CHX

and NaOCl

A suggested clinical

protocol consists of

irrigation with NaOCl

to dissolve the organic

components, irrigation

with EDTA to eliminate the

smear layer and irrigation

with CHX to increase the

antimicrobial activity and

to induce substantivity. Such

a combination of irrigants

may enhance the overall

antimicrobial effectiveness,

however, some studies have

reported the occurrence

of color change and

precipitation when NaOCl

and CHX are combined

and shown to be toxic. Furthermore,

the color change may have some

clinical relevance because of staining

and that the precipitate might interfere

with the seal of the root filling (fig. 2).

Please find below two recommended

articles discussing the above topic:

• Mohammadi Z, Abbott PV. The

properties and applications of

chlorhexidine in endodontics. Int Endod

J. 2009;42(4):288-302.

• Kanisavaran ZM. Chlorhexidine

gluconate in endodontics: an update

review. Int Dent J. 2008;58(5):247-57.






Annual Conference 2012

30 - 31 March 2012

Saad Palace, Erbil - Iraq

2 nd Iraqi Dental Reunion

“Breaking New Opportunities”

Smile Dental Journal | Volume 6, Issue 4 - 2011| 57 |







AEEDC 2012

Booth 312










ViVi s.r.L. - Via Dei Lavoratori, 3/K - Buccinasco Italy - Tel. (+39) 02 45703068 - Fax (+39) 02 45703463 - -

Summarized & Presented by:

Hani Abudiak

BDS, MFDS RCSFRCD, PhD Paediatric Dentistry, Leeds University

• Canadian Fellowship in Paediatric Dentistry

• Senior Dental Officer in Paediatric, Bradford Teaching Hospital, England

• Private Paediatric Referral Practice, Leeds, England, UK

Endodontic or Dental Implant Therapy

The Factors Affecting Treatment Planning

JADA, Vol. 13, July 2006

Mahmoud Torabinejad, DMD, MSD, PhD; Charles J. Goodacre, DDS, MSD


For decades, all disciplines of dentistry have strived to prevent and treat caries and periodontal disease, as well

as to restore function and esthetics to patients affected by oral diseases or traumatic injuries. Despite these efforts,

many non-restorable teeth and teeth with severe periodontal involvement have been extracted, and traditionally

they have been replaced with fixed or removable prostheses. Advances in implant dentistry have provided

thousands of completely and partially edentulous patients with a more functional and attractive alternative to fixed

and removable prostheses.

Nowadays, clinicians are confronted with difficult choices regarding whether a tooth with pulpal and/or periapical

disease should be saved through endodontic treatment or be extracted and replaced with an implant.


The authors examined publications (research, literature reviews and systematic reviews) related to the factors

affecting decision making for patients who have oral diseases or traumatic injuries.


The factors to be considered included patient-related issues (systemic and oral health, as well as comfort and

treatment perceptions), tooth- and periodontium-related factors (pulpal and periodontal conditions, color

characteristics of the teeth, quantity and quality of bone, and soft-tissue anatomy) and treatment-related factors (the

potential for procedural complications, required adjunctive procedures and treatment outcomes).


The decision by the clinician and patient to retain or remove teeth should be based on a thorough assessment of

information related to risk factors affecting the long-term prognosis for endodontic and dental implant treatment.

The clinician should consider several factors when determining whether to save a tooth through endodontic therapy

or extract it and place an implant. These factors pertain to the patient’s health status, the condition of the tooth and

periodontium, and treatment-related considerations.

Patient-related factors include systemic and oral health, as well as patients’ comfort and perceptions about

treatment. Tooth- and periodontium-related factors include pulpal and periodontal conditions, biological

environmental considerations, color characteristics of the teeth, quantity and quality of bone, and soft-tissue

anatomy. Treatment-related factors include an assessment of potential procedural complications, required

adjunctive procedures and treatment outcomes data.

The British Academy in Implant Dentistry (BAID)

is Delighted to Announce

the 2012 Dates for the Diploma Examination

BAID Diploma

Exam : Part 1

Jordan Setting UK Setting

Date 22 July 2012 10 August 2012

Location Amman London

Fee £360 £360

Closing date 28 May 2012 25 June 2012

| 60 | Smile Dental Journal | Volume 6, Issue 4 - 2011

BAID Diploma

Exam : Part 2

UK Setting

Iraq Setting

Date 10-11 August 2012 24-25 September 2012

Location London Erbil

Fee £950 £950

Closing date 30 June 2012 30 July 2012

For more information:,

Effect of Teeth with Periradicular Lesions

on Adjacent Dental Implants

Shabahang S., Bohsali K, Boyne P., Caplanis N., Lozada J., Torabinejad M. September 2003

Oral Surg - Oral Med - Oral Pathol - Oral Radiol - Endod. Vol. 96 No. 3 pp 321-326


There are a number of factors that may cause areas of inflammation in the bone surrounding a root form implant,

such as overheating the bone during surgery, fenestration of the osteotomy site, remaining root particles or foreign

bodies and contamination of the implant surface with saliva or bacterial plaque during insertion. Whilst these factors

can largely be avoided, with the increased use of implants placed amongst a natural dentition there is an increased

risk of periradicular infections that may come into close contact with an adjacent implant. If such a lesion is capable of

contaminating the implant surface with endotoxins then decontamination or biological repair, particularly of roughened

surfaces, may be difficult and therefore osseointegration may be compromised along with long-term success.

It was the purpose of this study to determine in a animal model the effect of periradicular lesions on the

osseointegration of dental implants with or without treatment of the adjacent root and implant surface.

Materials and Methods

The second and third maxillary and mandibular premolars were extracted bilaterally in five adult beagle dogs and

a total of 40 implants placed at an angle with their apices in close proximity (1-2mm separation) to the root apices

of the remaining 1st and 4th premolars. The implants were Calcitek solid core or HA-coated with dimensions of

3.75mm x 10mm. After a healing interval of 2 months, the implants were randomly allo cated to one of four groups

each comprising 10 implants at which time they were surgically exposed and healing abutments placed. Each

animal received weekly chlorhexidine applica tion and monthly prophylaxis during the experimental period in order

to maintain healthy periimplant tissues. In group A the adjacent teeth were left untouched to serve as a negative

control. In group B and C periradicular lesions were induced by opening the teeth to the oral environment for 7 days

and then sealing the cavity for a further 8 weeks. The induced lesions were considered complete when there was no

evidence of bone radiographically between the root and the implant apices. Each of the lesions group B and C were

treated with conventional 2-visit endodontic procedures with intermediate calcium hydroxide dressings, however for

group C the periradicular lesions were also surgically debrided and the implant surface cleaned with an air/powder

abrasive unit (Prophy Jet, Dentsply) for 30 seconds and completed with a further 60 seconds of supersaturated citric

acid application. The premolar teeth forming group D had periradicular lesions induced in the same manner as

groups B and C, 5.5 months after implant placement. All animals were sacrificed at 7.5 months for histology. This

was carried out blind and involved analysis of the apical 4mm of each opposing implant or tooth surface for the

percentage osseointegration. Differences in the amount of osseointegration between groups, jaws and animals was

evaluated using one-way analysis of variance (ANOVA) and the Pearson correlation coefficient to determine any

significant differences between any of the various tooth and implants sites.


Only one implant was lost to the study after an early failure. The average percentage integration for the groups was

54%(A), 74%(B), 56%(C) and 68%(D). ANOVA revealed no differences between the four groups (P=0.518). After root

treatment of the adja cent premolar the group B implants showed resolution of the bony defect in 87% of the sites

whilst the surgical debridement group C this was reduced to 68%. No healing was observed in group D which had

formed the positive controls.

Discussion and Conclusions

Within the limitations of this prospective study and the relatively small sample size, the surgically debrided sites

appeared to do slightly less well than those only receiving conventional orthograde endodontics, the differences

however were clinically insignificant with no tangible benefits from the detoxification process. Future studies could also

determine whether or not bacterial contamination or endotoxins are present in the lesions adjacent to the implants.

Smile Dental Journal | Volume 6, Issue 4 - 2011| 61 |

The Effects of Smoking on Fracture Healing

Sloan A., Hussein I., Maqsood M., Eremin O., El-Sheemy M. April 2010

The Surgeon, Vol. 8 No. 2 pp 111-116

Apart from premature death; smoking has been implicated in increased morbidity and can affect the dynamics of

bone healing from a surgical viewpoint. The harmful effects of tobacco smoke would appear to be dose-related

and smoking cessation has been recommended to reverse the damaging nature of the habit. This current review

assesses the role of tobacco smoking in cellular activity and bone repair.

Whether or not smoke is inhaled or released into the surrounding air, 95% of it is made up of volatile acids. Around

500 gases are released including carbon monoxide, carbon dioxide, ammonia, hydrogen cyanide and benzene.

The particulate phase accounts for the remaining 5% and approximately 3500 chemicals are produced including

nicotine, anatabine and anabasine. The particulate phase also consists of tar, which contains the carcinogens.

Depending on brand, around 2-3mg of nicotine and 20-30ml of carbon monoxide are inhaled from each

cigarette. Nicotine is thought to be the addictive component in tobacco and causes increased platelet aggregation,

decreased microvascular protacyclin levels and inhibition of the biological function of fibroblasts. The peripheral

vasoconstriction caused by nicotine leads to decreased blood flow to the extremities and the chemical also has

effects on plasma hormone levels with vasopressin, B-endorphin, adenocorticotrophic hormone (ACTH) and cortisol,

all showing raised levels. Carbon monoxide arises from incomplete paper and tobacco combustion and displays

a greater affinity (200-fold) for hemoglobin binding when compared to oxygen. The ensuing carboxyhemoglobin

formed leads to hypoxia with 10 minutes of smoking leading to tissue-hypoxia for about 1 hour.

Smoking is thought to affect the fracture healing process due to a reduced blood supply to the injury site although

many theories exist relating to the role of free radicals, antioxidants and the attenuating effects of nicotine.

High doses of nicotine have also been shown to be toxic to osteoblasts and calcitonin. In addition it is thought

that other components in cigarette smoke can possess osteoblast-damaging properties. Clinical studies have

highlighted the negative effects of smoking on lumbar fusion procedures and the union of open tibial fractures

to a statistically significant degree. Surgical fixation has also been recommended for all fractures that are not

amenable to closed reduction.

Perioperative smoking cessation is generally advised although guidelines are vague, ranging from 1-28 days

pre-operatively and 5-28 days post-operatively. A minimum of 12 hours cessation pre-operatively is necessary for

the time required to clear CO levels from the human body. Although it is claimed that smoking causes irreversible

systemic and local tissue damage, surgical treatment should not be denied to those who do not stop smoking,

since cessation in itself cannot reverse all of the negative effects.

Discussion and Conclusions

This review suggests that many human and animal studies have demonstrated the negative effects of smoking on

wound and fracture healing. It is thought that the effects are mediated by the vasoconstrictive, platelet-activating

and aggregating properties of nicotine. In addition, at the cellular level, carbon monoxide has a hypoxic effect

and hydrogen cyanide inhibits oxidative metabolism. Tobacco smoking has been strongly implicated in delayed

healing and non-union of fractures. An evaluation of smoking history and cessation prior to surgery are advised

so that the risks, complications and harmful effects of the habit can be suitably discussed and addressed.

thth CAD/CAM & Computerized Dentistry

International Conference

6 thth

CAD/CAM & Computerized Dentistry

| 62 | Smile Dental Journal | Volume 6, Issue 4 - 2011

3 - 4 May 2012

The Ritz-Carlton Hotel

Dubai, UAE

Dubai International

Financial Center

Meet us at

AEEDC 2012

Booth Booth 389+390 303

British Academy of Implant Dentistry in Iraq

The British Academy of Implant Dentistry (BAID) has launched its scientific activities in the Middle East by starting the one year implant

course “Comprehensive Evidence Based and Clinical Implantology Course” in Iraq. This course came to light following the hard work

and great co-operation between BAID and the Iraqi Dental Association. Dr. Aljobory, the president of the dental association confirmed

that this intensive eight module clinical implant course (six academic modules & two

clinical modules) has been recognized by the Ministry of Health in Iraq as one of

the post graduate diplomas, the Iraqi dentists can register as one of their degrees.

On the other side, Dr. Maghaireh; the head of the international section in BAID has

confirmed that this well structured implant course meets the General Dental Council-

UK requirement in implant training in Britain and qualifies the course delegates to gain

accredited CPD hours by the British Academy of Implant Dentistry upon finishing the

course academic and clinical requirements and passing the course written exam.

This course will also exempt the successful delegates from the first part of the Diploma

in Implant Dentistry exams by the British Academy Of Implant Dentistry, and qualifies

them to apply for the 2 nd and final part of these exams, which are run by a group

of eminent implant clinicians and researchers such as Dr. Ibsy Hussain; the current

president of the British Academy of Implant Dentistry and Prof. Marco Esposito, who is

an internationally renowned researcher in implant dentistry.

This course in its first version attracted 108 dentists from all

around Iraq and was hosted in Erbil, the quiet but fascinating

city who is famous with its very friendly and helpful people.

The first module which took place on 25 th and 26 th November,

featured prominent speakers from the University of

Manchester, Nottingham Medical Centre and Eastman Dental

Institute and focused on the importance of treatment planning

in implant dentistry, role of medical screening for implant

patients and principled of surgical planning in implant therapy.

Finally, it is worth mentioning that this course has received

a very positive feedback from all of the delegates as well as

the Ministry of Health observers, who commended the British

academy of Implant Dentistry for delivering lectures high

standard lectures.

| 66 | Smile Dental Journal | Volume 6, Issue 4 - 2011


You could look at Epta for hours and still not unveil the secrets

invisibly and mysteriously concealed in its faultless details.

Meticulous design and simply beautiful materials.

A brilliant confl uence of technology and art that enhances your

talent and elevates your constant striving for perfection.

Epta. Technology and design. Beyond semblance.

AEEDC 2012

Booth 308 - 311


dentalArt_ love of details

dentalArt spa

Montecchio Precalcino

Vicenza . Italy

tel. +39 0445 802000

Visit the “Dental Art Installations” on our

website and discover latest Epta line


Middle East Area Manager

Mahmoud Lutfi

P.O.Box 641 11941 Amman Jordan

Tel: +962 6 5656404/5

Mobile: +962 7 95536867


Richa Dental Store

Organizes its 3 rd Implantology

training trip to Milan, Italy

From 15 th till 18 th of December 2011 RICHA DENTAL

STORE have organized a trip to NOVAXA LEADER

Course Center, Milano, Italy for 12 dentists from

Lebanon accompanied by Dr. Chadi Richa where a

large number of participants gathered from different

countries to attend this course.

The advanced course was held by Dr. Stefano Palmieri

with the participation of our guest Dr. Mohamad

Sartawi; well-known speaker and opinion leader in the

Middle East Area.

The Dentists who participated in this trip were:

Dr. Pascale Habr, Dr. Georges Hallage, Dr. Rosy Brax,

Dr. August Badawi, Dr. Alexandre Khairallah, Dr. Joseph

Abi Nasr, Dr. Houssam Abou Hamdan, Dr. Mohamad

El Masri, Dr. Jihad El Husseiny, Dr. Imad Mahfouz, Dr.

Machhour Moumneh and Dr. Abed El Salam Baalbacky.

The group also spent an enjoyable time discovering

different Italian cities such as Milan, Venice and Rome.

MYDENT International

Introduces New Ortho Boxes

Mydent International has introduced Retainer and Denture

Ortho Boxes, the latest in its line of DEFEND products.

DEFEND Retainer Boxes, #OB-2000, are crush proof

and feature a solid locking mechanism. These boxes

are easy to clean and come in 5 assorted colors. The

dimensions of these Retainer Boxes are 3” x 2½“ x 1”

deep. They are packed 12 per box.

Skema 8 – the Hallmark of


Skema 8 is the complete Castellini treatment centre.

Equipped with a selection of integrated specialist instruments

and exclusive technologies, the unit offers both the freedom

and flexibility of an all-inclusive concept and the solid values

of Castellini design.

Whatever the specialisation, from conservative dentistry

to oral surgery, dental surgeons can turn to Skema 8 for

immediate answers: a brushless micromotor capable of

extensive torque values, the LAEC system for maximum

efficiency and clinical safety in endodontic treatments,

Autosteril for total hygiene and the latest Castellini surgical

ultrasound handpiece.

In terms of comfort and ergonomics, the hydraulic patient

chair is an unrivalled example of design excellence, ensuring

far more than simply synchronised movements. In all clinical

situations, Skema 8 represents the peak of quality, working

comfort and advanced performance - a thoroughbred.

The Skema range of treatment centres, to which Skema

8 belongs, is the result of innovation aimed at constantly

raising the standards and quality of the unit to the advantage

of the dental professional. Practicality is crucial in making

advanced technologies immediately accessible. Each part of

the Skema unit demonstrates Castellini’s ability to provide

the surgeon with cutting-edge technology to ensure solutions

which are as advanced as they are highly practical.

Visit us at AEEDC Dubai 2012 / Booth 364 -Hall 7

DEFEND Denture Boxes, #OB-1000, feature high-impact plastic, 1 piece construction and contoured corners for ease of

cleaning. The tight fitting lid holds 1 or 2 dentures, with dimensions of 3” x 2½” x 2” deep. DEFEND Denture Boxes are

packed 12 per box in 4 assorted colors.

These high quality DEFEND Ortho Boxes close completely and securely, have a durable hinge and keep contents safe. They

are available through most dental dealers.

Mydent International is dedicated to fully maintaining its brand promise: "To provide the healthcare professional with the

highest quality infection control products, disposables, preventatives and impression material systems at affordable prices,

supported by superior service and 100% Customer Satisfaction." DEFEND: Works Better. Lasts Longer. Costs Less.

| 70 | Smile Dental Journal | Volume 6, Issue 4 - 2011

Don’t miss the


Hall 6

Booth 178,179, 202, 203

Silfradent Optimizes Tissue


Platelets: a Reservoir of

Endogenous Growth Factors

C.G.F.: Concentrated Growth Factors

L.F. Rodella , M. Labanca, R. Rezzani

An interesting clinical

option for optimizing tissue

regeneration is the use of

platelet concentrate. Platelets,

in fact, contain high quantities

of growth factors, such as

platelet-derived growth factor

(PDGF), transforming growth

factor TGF-ß1 and TGF-ß2,

fibroblast growth factor (FGF),

vascular endothelial growth

factor (VEGF) and insulin-like

growth factor (IGF), which

stimulate cell proliferation,

matrix remodeling and

angiogenic processes during

tissue regeneration.

To date, numerous

techniques using platelet

concentrate have been

developed in order to obtain

different ratios of platelets,

growth factors and fibrin

matrix, among these PRP

(Platelet Rich Plasma), PRF

(Platelet Rich Fibrin) and

CGF (Concentrated Growth


CGF is an innovative

method for producing a new

generation of platelet concentrates that is characterized by a

high concentration of autologous growth factors.

It is produced by processing blood samples with a special

blood phase separator (Medifuge MF200, Silfradent srl,

Forlì, Italy) without the addition of anticoagulant factors. In

particular, the potential of CGF is a solid consistency: in fact,

it is a rich and dense fibrin matrix in which multiple platelet

cell elements were “trapped” and some growth factors,

i.e. TGF-ß1 and VEGF, were expressed. Moreover, it seems

to be a potential source of CD34 positive cells, which are

known to be recruited from blood to injured tissue and play

a role in vascular maintenance, neovascularisation and


Regarding its applications, CGF was reported to have a

good regenerative capacity and a high versatility on sinus

and alveolar ridge augmentation. Nevertheless, these

characteristics make CGF functional for different clinical

applications in the field of tissue regeneration.

| 72 | Smile Dental Journal | Volume 6, Issue 4 - 2011

Brings simplicity to Endodontics

WaveOne, from DENTSPLY Maillefer, is the new

endodontic system designed to provide simplicity and

efficiency to the root canal shaping procedure.

The WaveOne motor works in a reciprocating mode with

a large rotating angle in the cutting direction providing

high efficiency, whereas a smaller angle in the reverse

direction allows the WaveOne file to safely progress

along the canal path, respecting the root canal anatomy.

The optimised angles also reduce the risk of a screwing

effect and file breakage.

Single file technique

The reciprocating technique makes it possible to shape

most root canals using only one single WaveOne

Nickel-Titanium (NiTi) file. No time is wasted changing

NiTi instruments during the root canal shaping procedure

and the global shaping time is decreased by up to 40%

versus a traditional continuous rotary technique, whilst still

providing premium quality root canal treatments.

The WaveOne file geometry was conceived specifically to

benefit from the optimised pre-programmed reciprocating

movement of the WaveOne motor. The proprietary

DENTSPLY M-Wire Nickel-Titanium technology provides

additional flexibility and greater resistance to cyclic fatigue,

the leading cause of file separation.

Single patient use

DENTSPLY Maillefer advocates single patient use as a

new standard of care, by proposing the WaveOne

reciprocating NiTi files exclusively in presterilized blister

packs and fitted with a non autoclavable handle. The

advantages are:

• Simplicity

• No risk of cross contamination

• Optimal cutting efficiency

• Better control of file breakage

TIXOS: Manufactured by Direct

Laser Metal Forming Technique

TIxos implants line has been developed after years of

research in cooperation with important National and

International Universities and Research Centers. Tixos

implants, manufactured through the exclusive and original

technique of Direct Laser Metal Forming, are designed

in 3D: around a very compact core an isoelastic surface

is created, which replicates the bone spongy geometry;

such a structure is highly mimetic, thus accelerating

bone healing and enhancing faster osseointegration,

as demonstrated by different in vitro and in vivo human

studies*. The tridimensional geometry constituted by

micro and macro-cavities of well defined sizes and form,

interconnected by micro-pores, promotes bone formation.

* References available on

New Procedures for the

Construction of the Implant Tunnel

using the new PEC Piezo

Expansion-Crest technique

Luca Lancieri, freelancer in Genoa -Italy

In recent years, the imperative of modern

surgery has become minimal invasiveness and

low biological impact. Piezo-electric surgical techniques fall

perfectly into this category. In developing these procedures, I

have devised a personal manoeuvre, which can be identified

using the acronym PEC, Piezo Expansion-Crest. With this

procedure, in one surgical session, it is possible to achieve

the bone thickness necessary in order to insert one or more

implants in crests which are atrophied due to post-extraction or

post-traumatic infections.

Today, patients are coming to our surgeries with two priority

needs: dental reconstruction with a high level of aesthetic

importance and the rapid morphological and functional

restoration of missing teeth. It is obvious that it becomes a

priority to have surgical procedures that make it possible to

replace missing teeth with implants. For this purpose, it is

possible to use piezo expansion-crest procedures.

Let us now analyse this technique in detail: the expansion-crest

makes it possible to create a permanent dilation suitable for

accepting the implants, thereby making the surgical intervention

quicker and more predictable. It is very important not to confuse

the expansion-crest with the split-crest, two procedures which

are apparently similar but totally different in terms of substance

and results. The split-crest is performed by opening a partialthickness

flap and using greenstick fracture of the crest and elastic

deformation under tension of the disjointed bone gaps. The

expansion-crest, however, is performed with a full-thickness flap and

takes advantage of the viscoelastic properties of the bone, allowing

a gradual separation of bone segments with permanent dilation

and plastic deformation devoid of tension. The lack of tension on the

implants is the key feature that makes it easier to stabilise the bone,

reducing the risk of absorption and allowing a more predictable

therapeutic outcome in the short, medium and long term.

Operational difficulties in the execution of the separation of bone

segments, especially in the jaw, are easily overcome by using the

new PEC technique. As a matter of fact, the inserts that I have

developed in cooperation with Silfradent, which provided the

technical support necessary for their creation, make it possible

to create the appropriate plastic dilation with minimum effort in

the progression in depth and with the maximum preservation

of the adjoining bone walls. The result is a kind of new implant

tunnel site that is both a passive stabilisation and active bone

proliferation site, extremely vibrant from a biological point of view

for the construction of the new implant site.

To this end, I have made a kit consisting of piezoelectric inserts

with increasing diameter, calibrated for the most common implant

procedures, with a non-working apex in order to avoid iatrogenic

fenestrations and at the same time enable the tips to behave in

a self-centring manner. The clinical case presented highlights the

easy management of this procedure which, even in extremely

critical clinical conditions, allows less experienced operators to

easily insert fixtures in crests with marked atrophy which, with the

usual procedures, would first require bone increase and then, at a

later date, the implant could be performed.

Today, using mini PEC procedures, it is possible to create

implant tunnels without rotary cutters, creating biological

conditions which are conducive to faster and more effective

healing from both an aesthetic and functional point of view,

improving the quality of the intra-operative stage and its course,

satisfying today’s contextual demand for minimally invasive

surgery with low biological impact.

| 74 | Smile Dental Journal | Volume 6, Issue 4 - 2011



Hu-Friedy’s outstanding combination of advanced technology

and innovative design gives practitioners clinical precision and

efficiency for a flawless performance, every time.

Hu-Friedy’s superior standards for instrument quality and

ongoing partnerships with industry thought leaders result in

specialized instruments that help the endodontist perform with

ever- increasing precision, efficiency and efficacy.







Hygiene must be the top priority

in your practice for the health of

your patients and assistants.

Our seamless and traceable

hygienic chain prevents infection

and protects both your assistants

and your patients by cleaning

instruments safely in the Hu-Friedy

instrument cassette. Unnecessary

handling is now in the past.

Hu-Friedy products are

individually handcrafted for high

performance and remarkable


Made from a specially blended

steel alloy for maximum durability

and resiliency, our instruments

have uniform tapers for smooth

condensing and spreading action

and exceptional strength throughout

the working ends.

Matte-finish Satin Steel clamps

reduce glare and improve field of


Our Satin Steel rubber dam clamps

are created with a very bright

beginning - each one is carefully

designed and handcrafted for

superior strength and corrosion

resistance. The dull, matte-finish

comes next.

For more information on our products please

visit our website WWW.HU-FRIEDY.EU

or contact us by e-mail: INFO@HU-FRIEDY.EU

How the best perform

©2011 Hu-Friedy Mfg. Co., LLC. All rights reserved.

Denar ® Mark 300

Series Articulators

Whip Mix Restorative

Oral Health Division is

pleased to announce the

introduction of the next

generation articulators,

the Denar ® Mark 300

Series Articulators. The

Mark 300 Series offers

interchangeability among this

series of instruments and are

factory set to within 20 microns of accuracy. The Mark

300 Series is comprised of the Mark 330, Mark 320 and

Mark 310 articulators.

The features of these new articulators include:

• Mark 330 is semi-adjustable with adjustable condylar

inclination, progressive side shift, and immediate side shift

• Mark 320 is semi-adjustable with adjustable condylar

inclination and fixed progressive side shift

• Mark 310 is fixed settings for condylar inclination and

progressive side shift

• All are compatible with the DenarSlidematicfacebow

• All have positive centric latch that allows the upper and

lower members to be separated or positively locked

together in centric relation

• All have built-in magnetic mounting system

• All have unobstructed lingual access

Jet Carbides

from Beavers

For over 100 years Beavers Dental has been providing the

quality and performance you’ve come to expect. All Jet

Carbides are manufactured using a high grade Tungsten

Carbide with the tolerance on each shank adjusted to ensure

a positive non-slip fit into any handpiece. Jet Carbides are

produced in our Rotary Technology Innovation Center using

the very latest in equipment and are subjected to vigorous

quality control to comply to the most exacting standards. The

unique blade geometry of the Jet Carbide means you’ll get a

smoother cut and cleaner preparation every time!

Whitening Lamp 2

from WHITEsmile

The new WHITEsmile ® Whitening

LAMP is designed for even more

advanced in-office tooth whitening. The Blue

LED technology with high intensity spectrum

light 465nm wavelength and an output of

30.000 mW/cm² (3 LED’s, total of 30 W)

allows safe and effective tooth whitening

treatments. No harmful ultraviolet light and

heat development ensures patient safety and

comfort and therefore decreases the risk of

developing tooth sensitivity.


CrosstexSecureFit masks meet FDA requirements for ASTM*

F2100-11 Performance Class Specifications. ASTM material

testing standards include mask performance requirements for

fluid resistance, filtration value, breathability and flammability

of mask materials. ASTM classifications include three levels of

protection, with each level relating to the ability of the material

to provide fluid resistance and barrier protection for the wearer.

Crosstex offers a wide variety of mask designs, fit and filtration

to match the protection needs for each procedure or risk level,

including ASTM Level 1 (Isofluid ® ), Level 2 (Procedural) and

Level 3 (Ultra). All Crosstex ASTM rated masks are fluidresistant,

odorless, latex-free, fiberglass-free, with comfortable

outside attached earloops, downward pleated outer folds, and

offer a soft tear-resistant white inner layer.


NEW rotary NiTi glide path


Glide path development is an essential but time-consuming

step in endodontic treatment.

G-Files are based on an innovative design to help the

clinician safely save time in endodontic procedures. The

superior cross-section of the G-Files combines efficiency

and innovation. Along the length of the instrument, the

G-File has cutting edges on three different radiuses leaving

a large and efficient area for upward debris removal.

Used after hand files have measured working length,

G-Files safely enlarge the glide path in preparation for RCT

with rotary instrumentation system.


• Superior flexibility due to their small instrument diameters

(n° 12 and n° 17) and their slight .03 taper

• Non-working (safety) tip

• Electro-polished to optimize their efficiency in apical

progression while aiding in upward debris removal.

• Enhanced circulation of the irrigation solution beginning

from the initial phase of treatment

• Quickly and safely enlarge the canal passageway to the apex

| 76 | Smile Dental Journal | Volume 6, Issue 4 - 2011


Oral Care System from Germany

Special protection against:

• Bleeding gums

• Gum problems

• Periodontal disease



Pro Health Line

Iraq - Erbil City

Dr. Raman M. Asad

+964 (0) 750 454 4479

Emirates Scientific Drug Bureau

Iraq - Baghdad City

Dr. Mustafa Abdul Rasool

+964 (0) 771 33 1978

Two Minutes with

Prof. M. Sherine


Mohamed Sherine Ibrahim Elattar was born in Alexandria Egypt, April 18 th ,

1955. He went to the British boys school, followed by Ramleh secondary school,

then the Faculty of Dentistry at Alexandria University. Prof. Elattar has only one

brother; Shamel. His late father was the first graduate from Alexandria Dental

School, where the class at that time comprised of only two students. He saw in his

late father an inspiration and always wanted to accomplish what he didn’t do as

a dentist. He was appointed as a clinical instructor at Alexandria Dental School,

and then got married to his wife Nermine, while going through his master’s

degree. He believed that each of us should try his utmost to be unique in his field;

therefore he went further to gain higher clinical training program in Pittsburgh,

PA, USA. Nowadays, he is in the process of putting the final fine touches on his

new book : “ HOW TO BECOME A UNIQUE DENTIST” which includes lots of

inspirational tips & hints to young dentists in addition to sharing his clinical up to


date experience skills with the readers

Prof. Mohamed Sherine Ibrahim Elattar

BDS, MSc, PhD Prosthodontics

• President of AOIA

• Diplomat, ICOI, Section Manager, ICOI Middle-East

• Ex-Dean, Faculty of Dentistry, Pharos University

• Chapter Author: Dental Implantation and

Technology, Nova Publishers, USA, 2009

Why did you choose to be an implant dentist?

I fell in love with implants, while doing my first case at my

school in Pittsburgh…I saw how much implants changed

my patient’s life

What are the best/worst aspects of your job?

Stress, as you do your best to satisfy your patients, and try

to do a perfect job all the time. It’s never easy to reach

perfection, and it would be great if you are close

Where do you live?

Alexandria, Egypt

What do you drive?

A beautiful (and I mean it) Chinese car

What drives you?

Love to all my surroundings

What’s your favorite food?


What’s your hobby?

Dentistry and football

What’s your favorite film?

Mr. Bean (going for a holiday)

Favorite holiday destination?

Elgona, hurgada, Egypt

What inspires you?

A real smile of appreciation from a student, colleague or

a patient

What really annoys you?

A bad case that I did leading to an unsatisfied patient

What keeps you awake at night?

A treatment plan for a tough case

What makes you smile?

A family gathering with my wife, daughters and their husbands

What is your best characteristic?

My mother always tells me that I am an unusual person. I take

the best part of everybody and everything, ignoring the bad

parts… easily satisfied

Worst fault?

Worrying too much about other people

Can you describe yourself in three words?

Simple, loving and sincere

What do you do to relax?

Stay alone, watch a funny movie

If you weren’t a dentist, what would you have liked to

have been?

Restaurant owner

Do you read and recommend Smile Dental Journal


II honestly SMILE when I receive each new edition

What would be your motto in life?

Don’t look for money, just do your work and money will look for


| 78 | Smile Dental Journal | Volume 6, Issue 4 - 2011

Getting to the root of the problem.

As a world leader in the micro-design of Endo instruments, precision is our business. Our

Revo-S NiTi rotary system takes precision to new levels. With an easy 1-2-3 sequence,

the Revo-S NiTi system features a finely crafted, asymmetrical cross-section for increased

flexibility. The snake-like movement of the instrument within the canal reduces the stress

on the file and minimizes the risk of separation. Easy, effective and unlike anything else.


Join the REVOlution at

Revo-S is a registered trademark and “Your Endo Specialist” is a trademark of MIcro-Mega Ltd.

21 - 24 September 2011 | Dbayeh, Lebanon

BIDM & DGZI 2011

Prepared by Dr. Ronald Younes

The Beirut International Dental Meeting 2011 (21

st Annual

Scientific Congress of the Lebanese Dental Association) was

held in Beirut, Lebanon at the Congress Palace – Dbayeh

from 21 till 24 September 2011. The LDA also collaborated

with the German Association of Dental Implantology (DGZI)

for this global congress and merged the 8th Arab-German

Implantology meeting with the BIDM 2011, therefore

holding it simultaneously in the same venue.

The BIDM 2011 featured more than 120 scientific sessions

facilitated by nearly 100 speakers, hailing from American,

European and Arab countries, in addition to Lebanese

lecturers, covering a wide array of specialized subjects

within the numerous dental disciplines.

The four-day Scientific Program, entitled

“Exploring the

evidence”, focused on treatment planning as a means

of addressing the challenges commonly faced by dental

clinicians – how to reach

“a patient’s wish” and “the perfect

result”. The world-renowned speakers offered pragmatic

solutions and shed light on state-of-the-art techniques for

issues ranging from simple day-to-day clinical obstacles to

complex specialized demanding cases, making this congress

the most scientifically advanced in the Middle-East.

8 Pre-congress ‘step-by-step’ courses and hands-on

workshops took place on Wednesday September 21 st at

the Congress Palace during which the participants got to

experience first-hand some of the latest innovations in the

world of dentistry.

More than 2300 delegates and 4.000 visitors from around

the world attended the 2011 Beirut International Dental

Meeting, benefiting from 4 parallel ongoing conferences in 4

different halls at any given time, a wide range of attractions

including multiple oral sessions, 4 live video transmissions,

research sessions in Clinical and Basic Research, a young

podium where post-grad students got to present their cases.

More than 200 international and local exhibitors occupied

a commercial exhibition space of more than 3000 square

meters in total throughout the period of the congress with

products covering most of the dentists’ needs.

| 80 | Smile Dental Journal | Volume 6, Issue 4 - 2011

The LDA announced the dates for the BIDM

2012 (very promising scientific program),

which will be held in collaboration with the

French Dental Association and the FDI World

Dental Federation from the 19 th till the 22 nd

of September 2012 at the Congress Palace –

Dbayeh, Beirut, LEBANON

For more info, please visit the BIDM official


Smile Dental Journal | Volume 6, Issue 4 - 2011| 81 |

Come visit us at AEEDC 2012 at our Piro Trading booth # 206 - 212 & 221 - 227

CHOICE 2 Veneer Cement

Choice 2 is a light-cured veneer luting cement designed

specifically for superior color stability and esthetics.

the only color stable system available on the market

highly filled to enhance the strength of the restoration

offered in a range of shades which mimics the natural dentition





The Choice 2 system provides all the necessary materials to build a

solid restorative foundation from the bottom up and provide optimal

esthetics from the top down.


Zirconia - Alumnia -Metal Primer

Z-PRIME Plus significantly enhances

bond strengths to Zirconia, Alumina,

and Metal substrates more than any

other surface primer on the market!

For more information email or visit

Building Smiles From The Bottom Up

27 October 2011 | Dubai, UAE



rd Aesthetic Dentistry

MENA Awards

The Aesthetic Dentistry MENA Awards 2011 is one unique completion in which dentists from 12 countries compete

with their professional treatment achievements. 96 clinical cases have been submitted and judged by independent Jury

panel form 6 countries.

Dr. Ajay Juneja from UAE won two categories as best case in Cosmetic Aesthetic and Multidisciplinary, while Dr.

Thamer Theeb of Jordan won the “I Love My Dentist” award, this award was chosen by the public out of six finalists

from a total of 222 dentists representing 21 countries. The six finalists were chosen by the public who casted 5,800 votes.

“These awards are the highlights of the work of the dental profession in the Middle East and other countries,” explained

CAPP managing director Dr. Dobrina Mollova, organizer of the 3rd Dental-Facial Cosmetic International Conference.

Dr. Aisha Sultan, head of the Dental Department of the Ministry of Health and president of Emirates Dental Society,

commented: “The MENA award is the first award in the region and the world that aims to appreciate and recognize

the skills of dental practitioners. Today and for the third year in a row, this award has become a very well known event

amongst dentists in Asia, Africa and the Middle East.”

28 - 29 October 2011 | Dubai, UAE


rd nd Dental - Facial Cosmetic

International Conference

The organizers, CAPP and Emirates Dental Society achieved for the 3

rd time great record of attendance during the DFCIC 2011, and

established a reputation as the industry’s leading international conference. Jumeirah Beach Hotel hosted 756 participants in an elegant


Bringing together industrial leaders and professional practitioners, the conference not only delivered extensive scientific knowledge

from across the globe but gave way for an excellent opportunity to present the latest advancements and developments within the Facial

Cosmetics practice.

The 3

rd dental Facial not only opens the door to discussion and learning for this knowledge hungry region but allows the participants

to build their skills and use the opportunity for networking and sharing experiences in the application of technology throughout the

learning cycle - from primary and secondary education through to professional development and lifelong learning.

The international event brought together the best experts, speakers and specialists in the different fields of dental and facial cosmetic

from Middle East, UK, France, Germany, Switzerland, Italy, Norway and Austria. Participants were extremely happy with an excellent

program and highly reputable speakers. This was proven from participants’ feedback that the sessions they attended were greatly

appreciated. This was based on the evaluation forms from all participants, showing an average score of 4.1 out of 5 for informative

program and Lectures.

A Dental Technician Parallel Session was organized at the same time of the conference, where 47 participants joined the conference

from the Lebanese Dental Laboratories Association.

The conference hosted as well the first “Arab Dental Laboratory Union” Meeting to discuss future plans.

AUSGABE 1.2010

Meet us at AEEDC

Hall 7 booth 56

Bovine Bone

Straight Implant

SLS-Straight Implant

Synthetic Bone

Tapered Implant

Pericardium Membrane

Sinus-Lift Implant

Collagen Membrane

Soft-Bone Implant

Soft Tissue Graft

Dental implants

Collagen Fleece

Collagen Cone


Connecting the pieces

Looking for

Distributors in Middle East

Dentegris Deutschland GmbH

Grafschafter Straße 136 | DE-47199 Duisburg

Mail: |



Translucent quartz fiber


The smartest post you could envision






D.T. LIGHT-POST X-RO Radiopacity

Courtesy of Dr Cheleux University of Toulouse

X-RO ®

50 % more radiopaque

20 % stronger

30 % more retentive

The first and unique dental implant

in the world fabricated with

Direct Laser Metal Forming technique

by fusion of titanium microparticles !

Laser forming methods allow the

fabrication of implants with a very

compact core and an isoelastic

surface, which replicates the bone

spongy geometry.

The tridimensional network

of the surface, constituted by

interconnected cavities, promotes

faster bone formation*.

*References available upon request

The 16 th UAE International Dental Conference

& Arab Dental Exhibition

See you in Dubai

booth n. 318

Jan 31 st – Feb 2 nd 2012

Dubai International Convention & Exhibition Centre (DICEC)

LEADER ITALIA srl via Aquileja 49, 20092 Cinisello B. MI ITALY

ph +39 (0)2 618651 - fax +39 (0)2 61290676 -

25 - 28 October 2011, Cairo - Egypt




EDA Congress

The 15

th International EDA Congress has ended on a very high note. It has exceeded all

our expectations and reached a very high level of participation and attendance with over

120 Lecturers and over 6200 attendants.

This being the first Dental Congress to be held after the Egyptian revolution last January,

and amidst the turbulent and unsettled atmosphere prevailing since, it was feared

that many participants would be reluctant to make the trip and take the risk in such

circumstances, but fortunately, this has proved not to be the case, and those who came

never regretted making the trip.

All 17 workshops, pre-congress, during the congress and post-congress were fully booked

and attended. The attendants were fully satisfied and full of praise for the organizing teams.

For the first time in Egyptian Dental Congresses, there has been a live transmission

Via Satellite of a surgical operation in the Main Hall, which was highly attended and

enthusiastically received.

The accompanying trade exhibition was again a very successful one, and the exhibition

area in the Intercontinental City Stars Hotel (3800m

2 ) was a very spacious one and

enabled all traders to be with us.

The next EDA International Dental Congress will be held on the 6

th of November 2013,

when we hope to see you all again as well as many more who did not attend this

Congress. Thank you all very much indeed, and see you in two years time.

17 November 2011, Amman - Jordan


st Smile Dental Symposium

Dental Implants: Is Quicker Always Better?”

Smile Dental Journal in co-operation with the scientific committee in the Jordan Dental Association launched its

1 st Smile Dental Symposium on Thursday 17

th November 2011 in Amman-Jordan. This symposium aimed to look

into one of the advanced topics in dental implantology: The Ttiming in Implant Dentistry. This scientific event hosted

a group of prominent implant speakers with each of them presenting the up-to-date evidence based and clinical

tips and hints on implant placement in post extractive sockets and timing of loading dental implants; Dr. Hassan

Maghaireh from the University of Manchester, Prof. Marco Esposito, the Editor-in-Chief of The European Journal

of Oral Implantology, Prof. Alexandre Khairallah from the Lebanese University and Prof. M. Sherine Elattar, the

President of The Alexandria Oral Implantology Association.

This one-day event featured a high-quality scientific program along with an up-to-date and advanced dental show.

91% of delegates rated the symposium ‘excellent’, 97% of delegates agreed that this symposium had provided them

with evidence based and clinical tips which they can apply in their day to day dental implant practice. All of the

delegates confirmed that they would recommend this symposium to their friends and colleagues.

The day started with Dr. Maghaireh

who highlighted different clinical

scenarios where the timing of the

implant insertion and the incorporation

of the superstructure play an essential

role for the overall treatment outcome.

He also illustrated clinical philosophies,

protocols, tips and hints aiming to

help dentists to achieve predictable

highly aesthetic results in implant dentistry. Delegates were

shown how to turn time into an ally rather than an enemy.

Dr. Maghaireh also covered the clinical pros and cons of

immediate, early and delayed immediate placement in his

second lecture and went on his third lecture to present the

various loading protocols in implant dentistry, illustrating

various clinical cases on each technique.

Prof. Esposito, in return presented

the most up to date systematic reviews

he conducted on placing dental

implants in fresh extraction sockets

(Immediate, Immediate-Delayed

and Delayed Implants) and timing of

restoring the dental implants with the

final prosthesis. He discussed in his

two lectures the significant difference

between various clinical approaches in connection with the

implant treatment. Delegates had the opportunity to discuss

the random controlled trials conducted in the last three to five

years on timing and loading of dental implants.

Prof. Khairallah presented his lecture:

“The Importance of 3D Radiographic Input

in Planning Advanced Cases” which was

specially prepared for this symposium and

presented for the first time at this advanced

implant symposium. Pof. Khairallah

presented a series of radiological and

technological enhancement showing

all the benefits that a clinician can get

during planning for immediate implant(s) placement surgery

and furthermore, in making a decision on the timing of fitting

prosthetic superstructure. Delegates were also given a unique

opportunity to develop their skills in reading and analyzing Cone

Beam CT scans and the various 3D planning software.

Last, but not least was with Prof. Elattar,

who is the author of several articles

addressing the timing of implant insertion

and loading and the founder of a new

definition: ”Early Osteotomy “. In his lecture,

Prof. Elattar focused on the prosthetic

challenges which might face the dentist

while restoring an immediate loading

case in the aesthetic region. He presented

clinical situations that would frequently face most practitioners,

and would ultimately achieve better aesthetics if treated with

immediate loaded implants. Prof. Elattar, who is in the final stages

of publishing his new book; “ HOW TO BECOME A UNIQUE

DENTIST” gave our course delegates some of his inspirational

clinical and practice management tips in addition to sharing his

clinical up to date experience skills which were very well received.

| 92 | Smile Dental Journal | Volume 6, Issue 4 - 2011

In the evening, the symposium delegates celebrated the

social event – “Smile Dental Journal 5 th anniversary” at the

Gala dinner party which took place at the Landmark hotel

in Amman. We are proud at Smile Dental Journal that this

anniversary celebration took place under the patronage of

the president of the Jordan Dental Association; Dr. Azem

Qadoomi, who has exchanged trophies and certificates

with the speakers and the editorial team of Smile Dental

Journal. Smile Dental Journal is also delighted to have

the president of the scientific committee in the Jordanian

Dental Association; Dr. Mohammad Sartawi, and the

president of the Palestinian Dental Implant Society; Dr.

Marwan Al-Qasem among our honorary guests. The

symposium was also well supported by dental and local

private companies who have sponsored the prizes for the

quiz show during the Gala dinner. So many presents were

awarded to the course delegates during our 5 th anniversary

celebration, some which were tickets to the 6 th CAD/CAM

congress in Dubai in May 2012.

Smile Dental Journal | Volume 6, Issue 4 - 2011| 93 |

Finally, we would like to thank the following

companies for their support during

organizing and planning our 1 st Dental

Implant Symposium:

• Ferrari Dental Clinics & Labs (Inman Aligner)

• Eastern Medical Laser w.l.r

• Leader Italia srl (Tixos Implants)

• Basamat Pharmadent

• Bronze Medical Supplies Co. (BMSC)

• Al-Shumukh (ImPLASA Implants)


• Dara for Computers

• Milano Sport

• Budy Pendant

| 94 | Smile Dental Journal | Volume 6, Issue 4 - 2011

implant maintenance made

easy, efficient & effective!


TiTanium TipS

• Same material as abutments

• Safely glide over surfaces

• Easily remove debris

• 7 Familiar pattern designs

Visit us

• Sterilize by any method

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Booth #209

AEEDC 2012

Booth 329

Middle East Area Manager

Mahmoud Lutfi

P.O.Box 641 11941 Amman Jordan

Tel: +962 6 5656404/5

Mobile: +962 7 95536867


AEEDC 2009

Stand # 309-407

IDS 2009

Booth Hall No. 11.2303

Stand # R-040 - S-041

Aisle R

AEEDC 2012

Middle East Area Manager



East Area



Tel: +962 6 5656404/5

Mahmoud Lutfi

Fax: +962 6 5656402

Tel: +962 6 5656404

Mob: +962 7 95536867

Mob: +962 7 95536867





Dealers Welcome


Soft Tissue


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Dimensions length 195mm (with battery)

Diameter 18 mm

Weight < 200g, with battery attached

Laser Diode Wavelength 810±10 nm

Output Power 4w (Auto power)

Operation Mode, continuous wave (CW)

Fibre Tip Diameter 400 um / 200um

Aiming Beam diode 650 nm, < 1mW output

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Quality and guarantee of

effectiveness and trouble-free

process of prosthetics is the main

duty of Implasa Höchst company.

Research & Development

Is there a limit in development of

dental practice? The answer to this

question opens by itself, if we take a

look to the way which the Implasa

Höchst company passed for 10 years

in the field of the newest technologies

of the cure and prosthetics of teeth.

Materials & Technologies

The high-quality materials +

constantly improving technologies =

the guarantee of our quality and

your success

Production Cycle

ImPlasa Höchst company specialists

diligently control the quality of the

released production at all the stages

of technological process

and production.


The surface of implants is prepared

by unique technology of ImPlasa

Höchst company, named

ImPlapore, which allows to reach

minimal traumatizing in the area of

implant installation, and such way

maximally eases the

osseointegration process.

The Sole Representative in the

Middle East and Africa



Saudi Swiss

Consultant Dental Center

Tel: +96638898714


Kingdom Medical &

Dental Instruments

Tel: +961 6 426462


Kingdom Medical &

Dental Instruments

Tel: +963 21 5732052



Tel: +902164957287

UAE Dubai

Bright Smile

Medical Equipment

Tel.: +971 4 4508423


Quality and guarantee of

effectiveness and trouble-free

process of prosthetics is the main

duty of Implasa Höchst company.

Research & Development

Is there a limit in development of

dental practice? The answer to this

question opens by itself, if we take a

look to the way which the Implasa

Höchst company passed for 10 years

in the field of the newest technologies

of the cure and prosthetics of teeth.

Materials & Technologies

The high-quality materials +

constantly improving technologies =

the guarantee of our quality and

your success

Production Cycle

ImPlasa Höchst company specialists

diligently control the quality of the

released production at all the stages

of technological process

and production.


The surface of implants is prepared

by unique technology of ImPlasa

Höchst company, named

ImPlapore, which allows to reach

minimal traumatizing in the area of

implant installation, and such way

maximally eases the

osseointegration process.

The Sole Representative in the

Middle East and Africa



Saudi Swiss

Consultant Dental Center

Tel: +96638898714


Kingdom Medical &

Dental Instruments

Tel: +961 6 426462


Kingdom Medical &

Dental Instruments

Tel: +963 21 5732052



Tel: +902164957287

UAE Dubai

Bright Smile

Medical Equipment

Tel.: +971 4 4508423

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