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Smile Dental Journal - December 2011 - Volume 6, Issue 4 - www.smiledentaljournal.com - 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 

Rehabilitation 

Case Series 

Dental Implants’ 

Homepages: 

Are they Educative? 

A Cross-Sectional Study 

The Diagnosis and 

Management of 

Impacted 

Maxillary Canines 

Outcomes Following 

Zygomatic 

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 

Lebanon 

sola@smiledentaljournal.com 

www.smiledentaljournal.com 

Director 

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. 

Disclaimer 

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 

BDS, MFDS 

• 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 

BDS, MBBS, MRCSEd, FFDRCSI(OSOM), FRCS(OMFS) 

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 

Orthodontists 

• 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 

BSc, BDS, MSc, FFDRCSI (OSOM) 

Senior Consultant Maxillo-Facial Surgery

14 

Implantology 

Dental Implants’ Homepages: Are they Educative? 


By Layla Abdel-Aziz Abu-Naba’a 

Orthodontics 

Solving TMJ Problems with Orthodontic Treatment and Cosmetic 

Mouth Rehabilitation: Case Series 

26 

By Leonid Rubinov 

32 

Maxillofacial 

Outcomes Following Zygomatic: A Retrospective Study 

By Majed Hani Khreisat 

Multidisciplinary 

40 The Diagnosis and Management of Impacted Maxillary Canines 

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

Prosthodontics 

Adhesion of Candida Albicans to Denture Base and Denture 

Liners with Different Surface Roughness: An In-vitro Study 

46 

By Zahraa Nazar Al-Wahab 

Debate in Focus 

08 

54 

60 

Research 

Summaries in 

Focus 

Endodontic or Dental 

Implant Therapy: The 

Factors Affecting Treatment 

Planning 

Effect of Teeth with 

Periradicular Lesions on 

Adjacent Dental Implants 

The Effects of Smoking on 

Fracture Healing 

66 

Ask the Experts 

Flash News 

Two Minutes with 

78 

Affiliation & Distributors 

• Bahrain: 

Bahrain Dental Society +973 17723767, bahds@batelco.com.bh 

• Egypt: 

Alexandria Oral Implantology Association +203 5451277 

www.aoiaegypt.com 

• Iran: 

Shayan Simin Teb Co. +98 21 66380364/5, info@shayansiminteb.com 

Iranian General Dental Association +98 2188287794/5, info@igda.ir 

• Iraq: 

Iraqi Dental Association +964 015379267, info@iraqidental.org 

Kurdistan Dental Association +964 7504510315, 

dara_saeed@yahoo.com 

Pro Health Line Company +964 7504544479, www.prohealthline.com 

Emirates Scientific Bureau +964 771 0131978, www.prohealthline.com 

• Jordan: 

Jordanian Dental Association (JDA) +962 6 5665520, info@jda.org.jo 

Basamat Medical (Pharmadent) +962 6 5605395, www.basamat.com 

• Kuwait: 

Kuwait Dental Association +965 5325094, www.kda.org.kw 

• Lebanon: 

Lebanese Dental Association +961 1 611555, www.lda.org.lb 

Lebanese Dental Laboratory Association (OPDL) +961 5955 151 

www.opdlb.com 

Richa Dental Store +961 5 452555, www.richadental.com 

• Oman: 

Oman Dental Society +968 95769039, omandent@omantel.net.om 

• Palestine: 

Palestinian Association of Implant Dentistry (PADI) 

+970 2 2954545, www.implant.ps 

• Qatar: 

Qatar Dental Society +974 4393144, www.qatardentalsociety.org 

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

www.alibinali.com 

• Saudi Arabia: 

Saudi Dental Society +966 1 4677743, www.sds.org.sa 

• Sudan: 

Sudanese Dental Association +249 83 779769, sdaassnan@hotmail.com 

• Syria: 

Najjar Trading Est. +963 (11) 2244140, najjest@scs-net.org 

• United Arab Emirates: 

Noble Medical Equipment +971 4 3255046 

imad.kafity@noblemedical.ae 

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

www.mamut-dental.com 

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 

info@mastersdentalclinic.com 

www.mastersdentalclinic.com 

| 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 

Conference 

Riyadh, KSA 

www.sds.org.sa 

12 - 15 March 

3 rd International Conference 

of King Abdulaziz University 

Jeddah, KSA 

www.kau.edu.sa 

30 - 31 March 

2 nd Iraqi Dental Reunion IDR Annual 

Conference 2012 

Erbil, Iraq 

www.cappmea.com/idr2012 

3 - 4 May 

6 

th CAD/CAM & 

Computerized Dentistry 

International Conference 

Dubai, UAE 

www.cappmea.com/ 

cadcam6 

3 - 5 February 

1 st Annual Conference of The Arabian 

Academy of Esthetic Dentistry 

Cairo, Egypt 

www.araed-org.com 

26 - 28 April 

Sky Meeting 2012 (AOIA) 

Alexandria, Egypt 

www.aoiaegypt.com 

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 

(LDLS) 

Beirut, Lebanon 

www.opdlb.org 

25 - 26 May 

Tarnow Alumni & Friends 

Venice, Italy 

www.tarnowalumni.com 

For more dental events please visit www.smiledentaljournal.com 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 


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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 

dnaahj@leeds.ac.uk 

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

Leeds Teaching Hospitals Trust (LTHT), England, UK 

Abstract 

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. 

Introduction 

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 


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 

Rationale 

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 

Indications 

• 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 

Polyether 

Hard relining material 


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

technique 

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 

Discussion 

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 


(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 

Conclusion 

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. 

Acknowledgement 

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. 

References 

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Press,Ltd;1948. 

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

Dent. 1956;6:450-64. 


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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. 

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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. 

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

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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. 

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

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

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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. 

2007;18(1):83-6. 

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

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

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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. 

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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. 

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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. 

1978;6(2):147-60. 

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. 

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Dental Implants’ Homepages: 

Are they Educative? 


Layla Abdel-Aziz Abu-Naba’a 

BDS, PhD, MFDRCS 

• Department of Substitutive 

oral sciences, college of 

dentistry, Taibah University, 

AlMadinah AlMonawwarah 

KSA 

• Formerly Prosthodontic 

Department, Jordan 

University of Science and 

Technology, Jordan 

laylanabaa@hotmail.com 

Abstract 

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. 

Introduction 

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- 


ADA.org: 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. 

Aim 

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 

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E-Publications/E-mail 

Journal of the ADA 

Subscribe 

Professional Product 

Review 

DENTAL CAREERS AND 

JOB LISTINGS 

EVIDENCE BASED 

DENTISTRY 

PODCASTS 

ADA POLICIES & POSITIONS 

STANDARDS 

Licensure | Catalog | Member Directory | Contact 

DENTAL BUYING GUIDE 

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 DENTAL IMPLANT, Houston, TX 

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 

Page 

placing 

1 of 

the 

2 

simplest 

URL address (~.com) and relevant to dental implants. 

Once placed in the address bar, the URL address 

could either remain the same, or it could automatically 

27-Dec-11 

Monday, December 26th 2011 3:41PM EST CONTACT US | LAB ONLINE STORE 

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HOME OVERVIEW PRODUCTS CASES VIDEOS COURSES CALENDAR MANUALS DOWNLOADS NEWS 

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Clinically proven since 1985, Bicon’s unique dental implants and its revolutionary clinical techniques have not only passed the test of time, but also 

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continue to lead implant dentistry. We welcome your joining Bicon clinicians from around the world, so that both you and your patients may also 

enjoy the many clinical benefits of Bicon implants. 

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Search 

UPCOMING COURSES 

2/1-3 Surgical and Prosthetic 

Principles Course • Boston, MA 

2/8 Intro Live Surgery Tutorial 

1 • London, UK 

2/17 Hands-On Practical Course • 

Boston, MA 

2/21 Treatment Planning Tutorial 

2• Lndon, UK 

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s 

i 

(Fig. 2) 

Sample of one of 

the comprehensive 

webpages 

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 

apparent 

s 

Information for Patients 

Since 1985 dentists have been offering patients 

the benefits of the Bicon Dental Implant System. 

With Bicon Dental Implants, your dentist has the 

ability to provide you with secure implant 

restorations often without the need for 

additional grafting procedures. The restorations 

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LATEST VIDEOS 

» REGISTER for Upcoming Webcast 

» Webcast Replays 

» Introductory Videos 

» Technique Videos 

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» Case Study Videos 

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UPCOMING EVENTS 

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Congress • Boston, MA 

2/23-25 Chicago Midwinter 

Meeting • Chicago, IL 

3/1-3 AO Annual Meeting • 

Phoenix, AZ 

SHORT® Implants 

THE BICON DESIGN is driven by 

simplicity. One of the cornerstones of 

that simplicity is the innovation of 

SHORT® Implants. When the Bicon 

system was first introduced in 1985, its 

8.0mm length implants were considered 


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 

Including “SCIENTIFIC ACTIVITIES”, “MATERIALS”, 

“CAREER DEVELOPMENT”, “CLINICAL SKILL 

DEVELOPMENT”, “DENTAL TECHNICIAN” and “PATIENT 

GUIDED INFORMATION” 

Labels and the sum of Information materials provided 

Including: “INTRODUCTORY”, “DISTRIBUTION”, 

“CORPORATION”, “HONORARIES” and “IMPLANTS’ 

OVERVIEW INFORMATION” 

Labels and the sum of Services and support 

materials provided 

Including “PRODUCTS”, “NETWORK OF USERS”, 

“SUPPORT”, “SERVICES”, “COMMUNICATION”, and 

“SIGN-UPS” 

Target audience 

The paper describes the targeted audience besides 

conventional users of implant related webpages, 

including higher dental specialties, other professions and 

other users. 

Results 

Sample selection 

Twelve webpages were accessed from the ADA list of 

total 39 companies present in its dental buying guide 

“IMPLANTS AND ACCESSORIES CATEGORY”. The list 

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 

subjects 

Scientific Activities: 

“COURSES” and “UPCOMING COURSE” blogs were 

the only icons leading to webpages about courses in two 

homepages. 

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 

had “MANUALS”, “DOWNLOADS” and “INTERNATIONAL 

DOWNLOADS” for 12 languages. One webpage had 

recourse materials reached by icons embedded in a 

drop-down list called “CLINICAL RESOURCES”, and 

contained “ARTICLES”, “BIBLIOGRAPHY”, “BROCHURES”, 

“LITERATURE” and “FAQ” icons. 

Professional and career Development 

Icons leading to relevant developments were labeled: 

“DENTAL PROFESSIONALS”, “PROFESSIONAL 

EDUCATION”, “CONTINUING EDUCATION”, 

“COURSES”, “CALENDAR” “EDUCATION”, 

“EDUCATION CALENDAR”, “EDUCATION AND 

EVENTS”, “ONLINE TRAINING”, “CONGRESS” and 

“SEMINAR TOURS”. 

One webpage had a very rich “CONTINUING 

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


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

residencies. 

Clinical Skills Development 

Icons used were: “VIDEOS”, “MARGINAL BONE 

MAINTENANCE”, “CASE PRESENTATION”, and 

“IMPLANT ABUTMENT SELECTION GUIDE”. One 

webpage provided to icons “DIGITAL DENTISTRY” and 

a specific “NAME-IMAGING TECHNIQUE”. Another 

had “DIGITAL DENTISTRY” and “INDIVIDUALIZED 

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”, 

“TECHNICAL TIPS” and “TECHNICAL BULLETINS” icons. 

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 

QUESTIONS” “FIND A DOCTOR, OR DENTIST”, “ALL 

ABOUT IMPLANTS”, “TESTIMONIALS”, “PATIENT 

STORIES”, ”PATIENTS GUIDE TO IMPLANTS”, ” 

HOW IMPLANTS CHANGE YOUR LIFE”, “DENTAL 

GLOSSARY”, “PATIENT EDUCATION”, “GUM DISEASE”, 

”RESTORATIONS”, “PATIENTS’ SITE”, ” BEFORE AND 

AFTER”, and ”PATIENT VIDEOS”. 

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” 

and “WORLD WIDE”. 

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 

“COMPANY”, “CORPORATE”, OR “CORPORATE 

HEADQUARTERS”, “INCORPORATION”, “INC” and 

“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” 

Honoraries 

One homepage offered a research prize. 


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 

Services 

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 

0 


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 

Polls 

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 

Process 

0 Testimonials 2 

Compatibility with Other Implant 

Systems 

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. 

Surveys 

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 (~.com) 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” 


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”, 

“PROCEDURES”, “PRODUCT CATALOGUE” and “HOW 

TO ORDER”. 

A second homepage linked “PRODUCTS” to a 

webpage containing images and an overview of one 

implant, more icons for “PRODUCT INFORMATION”, 

“CASE STUDIES”, “IMPLANTS”, “ABUTMENTS” 

“KITS”, “INSTRUMENTATION”, ” GRAFT MATERIAL”, 

“TRANSITIONAL IMPLANTS”, ” EDUCATIONAL 

MATERIALS”, “REFERENCES”, “FAQ” and “DOWNLOAD 

PDF CATALOGUE”. 

A third homepage linked “PRODUCTS” to a webpage 

containing an overview of one implant then icons 

FOR “IMPLANTS”, “REGENERATIVE”, “SURGICAL”, 

“RESTORATIVE”, “SHOPPING CART”, “CATALOGUE”, 

“SURGICAL MANUAL” and “CLINICAL OVERVIEW”. 

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 

“INSTRUMENTS COMMON TO IMPLANTS”. 

The sixth homepage linked “PRODUCTS” to a 

webpage containing introductory paragraphs, 7 

icons for implants and implant related materials, and 

icons labeled “IMPLANT TRAINING”, “CONCEPTS”, 

“SOLUTIONS FOR INDICATION”, “CASES AND 

SOLUTIONS” “PRODUCTS”, “SCIENTIFIC EVIDENCE” 

“INDIVIDUALIZED PROSTHETICS”, “DIGITAL 

DENTISTRY”, “ EDUCATION AND EVENTS”, “SCIENCE 

AND ENOVATION” “CLINICAL MANUAL”, “SHOP 

ONLINE” “PRODUCT QUICK LINKS” and “DIGITAL 

PRECISION” ICONS. 

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 

“PATIENTS’ RESOURCES”, “FIND A DENTIST” in the drop 

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

drop down-list from “PROGRAMS” 

Support 

Labels used by icons leading to this material were 

“PRODUCTS AND SERVICES”, “COSTUMERS SUPPORT”, 

“COSTUMERS’ SERVICES”, “TECHNICAL HELP”, 

“TECHNICAL SERVICE”, “ENGINEERING SERVICES” icon for 

designers, “ADVISORY BOARD” and a “RETURN POLICY” 

Interaction 

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. 

Signups 

Membership applications were present by icons, as 

well as “SIGNUP FOR AN E-BULLETIN” and “E-NEWS 

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 


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. 

Discussion 

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 

include: 

• 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 

icons “NEWS”, “EVENTS”, “PRESS RELEASE” and 

“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 


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 

ASKED QUESTIONS” “DENTAL GLOSSARY”, “PATIENT 

EDUCATION”, “GUM DISEASE”, ”RESTORATIONS”, 

“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. 


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 

evidence. 

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. 

Conclusions 

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. 

Acknowledgement 

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. 

References 

1. Mattheos N, Stefanovic N, Apse P, Attstrom R, Buchanan J, Brown P, 

et al. Potential of information technology in dental education. Eur J 

Dent Educ. 2008;12:85-92. 

2. Bufano Ub, Branch-Mays G, Gilliam J, Romberg E. An Online 

Multimedia Treatment Planning Tool: Effect On Dental Students’ 

Knowledge In Using Standardized Clinical Data. J Dent Educ. 

2010;74:50-7. 

3. Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori 

VM. Internet-based learning in the health professions: a metaanalysis. 

JAMA. 2008;300:1181-96. 

4. Schleyer TK, Dodell D. Ajuwon, Grace A. Continuing dental 

education requirements for relicensure in the United States. J Am 

Dent Assoc. 2005;136:1450-6. 

5. Sanchez Dils E, Lefebvre C, Abeyta K. Teledentistry in the United 

States: a new horizon of dental care. Int J Dent Hyg. 2004;2:161-4. 

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. 

2008;133:S61-7. 

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. 

2008;133:S61-7. 

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. 

2010;74:65-78. 

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

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

2004;68:1245-57. 

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. 

2003;77:27-35. 

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. 

2003;7:103-10. 

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. 


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Solving TMJ Problems with Orthodontic 

Treatment and Cosmetic Mouth Rehabilitation 

Case Series 

Leonid Rubinov 

DDS, PhD 

• Instructor of the International 

Association for Orthodontics 

• Fellow of the American 

Association for Functional 

Orthopedics 

• Clinical Professor of the 

International Department of 

NYU’s College of Dentistry, 

USA 

drrubinov@yahoo.com 

Abstract 

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. 

Introduction 

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 


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 


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 

treatment. 

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 

Discussion 

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 


(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 

treatment 

(Fig. 18) Retracted view 

of left side occlusion after 

treatment 

(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 

treatment 


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. 

Conclusion 

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. 

References 

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. 


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Outcomes Following Zygomatic 

Complex Fractures 

A Retrospective Study 

Majed Hani Khreisat 

BDS, MSc, JBO 

• MSc UK 

• JBO in Oral & Maxillofacial 

surgery, Amman - Jordan 

majed_khreisat@hotmail.com 

Abstract 

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

Introduction 

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. 

Results 

The results of this study were described in sequence of 

the objectives. Detailed description of separate results is 

shown in figures and tables. 

Discussion 

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. 

Age 

Range 

Number 

of patient 

Male Female Total 

% 

Number 

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 

% 

Total 

number of 

patient 

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 

Over 

48 

2 4 2 4 4 8 

Total 38 76 12 24 50 100 

(Table 1) Age and sex of study group 

16 

14 

12 

10 

8 

6 

4 

2 

0 

14-18 

19-23 

24-28 

29-33 

34-38 

39-43 

(Fig. 1) Aetiology by age distribution 

44-48 

Over 48 

% 

Total 

Others 

Industrial 

Road Trafic 

Accident 

Sport 

Fall 

Assault 


Time from presentation to treatment 

4-7 days 

8-13 days 

14+ days 

8-13 days 

38.00% 

n=19 

Number of cases 

20 

18 

16 

14 

12 

10 

8 

6 

4-7 days 

16.00% 

n=8 

14+ 

days 

46.00% 

n=23 

4 

2 

0 

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 

intervention) 

(Fig. 4) Types of zygomatic-complex fractures 

40 

50 

45 

30 

32 

40 

35 

Number of of cases 

20 

10 

5 

0 3 3 3 2 

Assault Fall Sport RTA Other 

Aetiology 

Site of the fracture 

Site of the fracture 

Left 

Right 

Aetiology 

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

Frequency 

30 

25 

20 

15 

10 

5 

0 

Oedema 

Circum-orbital ecchymosis 

Subconjunctival haemorrhage 

Flattening of the cheek 

Limitation of mandibular 

movement 

Step deformity (infra-orbital 

rim) 

Deformity of Z-F suture 

Infra-orbital paraesthesia 

Diplopia 

Limitation of Orbial movement 

Epistaxis 

being commonly injured due to assault (32 patients, 

64%) (p

25 

20 

Orbital floor exploration 

Subciliary incision 

Transconjuctival incision 

Lateral brow incision 

15 

10 

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 

incision 

27% 

n=4 

Subciliary 

incision 

0 

Closed Reduction 

Open Reduction 

& Internal fixation 

Orbital floor 

Explanation 

Waiting & Observation 

Transconjuctival 

incision 13% 

n=2 

60% 

n=9 

(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 

PDS 

Medpore 

Vicrly mesh 

None 

None 

33% 

n=5 

(Fig. 8) Repair of orbital floor defects 

PDS 

20% 

n=3 

Medpore 

7% 

n=1 

Vicrly mesh 

40% 

n=6 

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. 


60 

55 

50 

45 

40 

35 

30 

Frequency 25 

Percentage 20 

15 

10 

5 

0 

Asymmetry 

(Cheek Flattening) 

Limitation mandibular 

movement 

Deformity of 

orbital rim 

Deformity of 

Z-F Suture 

Infra-orbital 

paraesthesia 

(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). 

Conclusion 

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. 

References 

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

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

1999;37:448-50. 

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

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

Diplopia 

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. 

2002;55:1-7. 

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

2003;73:49-54. 

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. 

1985;43(6):417-28. 

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. 

1978;12(1):59-63. 

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. 

1990;30(5):380-3. 

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. 

1961;13:325-39. 

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 reconstructions. 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. 


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The Diagnosis and Management of 

Impacted Maxillary Canines 

Eyas Abuhijleh 

BDS, PhD 

• Specialist Orthodontist and 

Assistant Professor, Tawam 

Hospital, Dental Center 

Al Ain - UAE 

eabuhijleh@tawamhospital.ae 

Dalal Masri 

BDS 

• General Dental Practitioner 

Tawam Hospital, Dental 

Center, Al Ain - UAE 

dmasri@tawamhospital.ae 

Nadia Farawana 

MDSc 

• German Board of 

Orthodontics, Tawam 

Hospital Dental Center, 

Al Ain - UAE 

nfarawana@tawamhospital.ae 

Mariam Nmari 

DDS 

• General Dental Practitioner 

Yas Medical Center 

Al Buraimi - Oman 

mariam.nmari@yahoo.com 

Abstract 

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. 

Introduction 

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 

Diagnosis 

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. 


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 

Creation 

Monitor Eruption of Canine 

Extract Deciduous Canines / Space Creation 

Canine not Erupting in 1 year 

Radiographic Localization: Beneficial Change in Position 

YES 

NO 

Canine Buccally or Palatally Impacted 

Surgical Exposure & Orthodontic Alignment 

NO 

Surgical Removal or Auto-Transplantation 

NO 

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 

Management 

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 

Auto-transplantation 

• 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 

References 

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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Adhesion of Candida Albicans to Denture 

Base and Denture Liners with Different 

Surface Roughness 

An In-vitro Study 

Zahraa Nazar Al-Wahab 

BDS, MSc 

• Lecturer, Department of 

Dental Technologies, College 

of Health and Medical 

Technologies, Foundation of 

Technical Education 

Baghdad, Iraq 

zahraawahab@yahoo.com 

Abstract 

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 

no.12 

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

ISO 1567, type II class I ADA 

no.12 

Heat-polymerized acrylic resin-based resilient liner 

Vertex Soft (V) 

Vertex-Dental BV, Zeist, 

The Netherlands 

100001 

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

Detax, GmbH & Co. KG, 

Germany 

03008 

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. 


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 


(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 

1273.7± 

220.82 

1580.8 

±117.46 

1588.77 ± 

152.12 

1590.36 ± 

452.17 

HC1 

CC1 

(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 

V1 

M1 

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 

VHS P

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 

Conclusion 

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. 

References 

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. 

2004;20:167-75. 

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. 

2006;96:205-11. 

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. 

2010;29(2):206-12. 

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. 

2002;282:1423-31. 

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. 

1997;77:535-9. 

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. 

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December Expert Panel 

Hassan Maghaireh 

BDS, MFDS, MSc 

• BDS, Cairo University 

• MFDS, RCS Edinburgh 

• MSc Implants University of 

Manchester 

• Honorary Clinical Teacher, 

University of Manchester 

• Editorial Board; European 

Journal of Oral Implantology 

• Implant Referral Practice, 

Leeds - UK 

• maghaireh@smile-mag.com 

Wesam Aleid 

• BDS, MBBS, MRCSEd 

(Surgery-in-General), 

FFDRCSI (OSOM), FRCSEd 

(OMFS) 

• Oral, Maxillofacial, and 

Head & Neck Surgeon, UK 

• eidwisam@yahoo.com 

Alexandre Khairallah 

BDS, PGD 

• PGD, Oral and Maxillo- facial 

Imaging, Lebanese Univ. 

• Fellow of the European 

Academy of Maxillo-Facial 

Radiologist 

• 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@ 

hotmail.com 

Ali Abu Nema 

BDS, NDB, MSc 

• BDS, Jordan University of 

Science and Technology 

• NDB, American Dental 

Association 

• MSc, Endodontics University 

of Manchester, UK 

• Private Endoodontic Referral 

Practice, Amman-Jordan 

• abunema_ali@hotmail.com 

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. 


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 

aesthetics. 

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 

fixation? 

Answer: Dr. Wesam Aleid 

Background 

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 

Evidence 

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 

management. 

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. 

Confusion 

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. 

2-4) 

• 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 


(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 

reality? 

(Fig. 2) 

Cut for choosing 

implant 

(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. 

References 

1. Loukota RA et al. Subclassification 

of fractures of the condylar process 

of the mandible. British Journal 

of Oral and Maxillofacial Surgery. 

2005;43:72-3. 

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 

measurements 

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. 

C 

M 

Y 

CM 

MY 

CY 

CMY 

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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. 

CHX 

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 

C 

microbial cell walls, which alters 

M 

the cells osmotic equilibrium. This 

Y 

CM 

(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. 

Substantivity 

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 

phosphate 

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. 

MY 

CY 

IDA 

CMY 

K 

Annual Conference 2012 

30 - 31 March 2012 

Saad Palace, Erbil - Iraq 

2 nd Iraqi Dental Reunion 

“Breaking New Opportunities” 


DO YOU SUFFER FROM 

BLEEDING GUMS? 

BLEEDING GUMS CAN BE THE FIRST SIGN OF GUM DISEASE, 

WHICH IS THE NO. 1 CAUSE OF TOOTH LOSS. 

HELPS STOP BLEEDING GUMS 

A DAILY TOOTHPASTE WITH MINERAL SALTS AND 6 NATURAL HERB EXTRACTS

AEEDC 2012 

Booth 312 

SISTEMA DIGITALE (DR) PER 

L’ACQUISIZIONE E L’ELABORAZIONE 

DI IMMAGINI INTRAORALI 

INTRAORAL IMAGES ACQUISITION AND 

PROCESSING DIGITAL SYSTEM (DR) 

SISTEMA INTRAORALE ALTA FREQUENZA 

HIGH FREQUENCY INTRAORAL SYSTEM 

DIAGNOSTICA DIGITALE DENTALE 

DENTAL DIGITAL DIAGNOSTIC 

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

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 

hani@clarendondentalspa.co.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 

Background 

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. 

Methods 

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. 

Results 

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). 

Conclusions 

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 


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: BAID@live.co.uk, www.baid.org.uk

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 

Introduction 

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. 


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. 

Results 

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. 


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 


6 thth 

CAD/CAM & Computerized Dentistry 


3 - 4 May 2012 

The Ritz-Carlton Hotel 

Dubai, UAE 

Dubai International 

Financial Center

www.aedsc.org

Meet us at 

AEEDC 2012 

Booth Booth 389+390 303 

mlutfi@m-lutfi.com

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. 


EPTA: CRITIC’s TEST 

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 

EPTA: THE ORIGINAL 

dentalArt_ love of details 

dentalArt spa 

Montecchio Precalcino 

Vicenza . Italy 

tel. +39 0445 802000 

www.dental-art.it 

Visit the “Dental Art Installations” on our 

website and discover latest Epta line 

compositions 


Mahmoud Lutfi 


Tel: +962 6 5656404/5 

Mobile: +962 7 95536867 

Email: mlutfi@m-lutfi.com

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. 

www.richadental.com 

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 

Excellence 

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 

www.castellini.com 

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. 

www.defend.com 


Don’t miss the 

SOARIC at AEEDC 

Hall 6 

Booth 178,179, 202, 203

Silfradent Optimizes Tissue 

Regeneration 

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 

Factors). 

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 

angiogenesis. 

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. 

www.silfradent.com 


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 

www.dentsplymea.com 

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 www.leaderitalia.it 

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. 

www.silfradent.com 


HIGH PERFORMANCE 

REMARKABLE BALANCE 

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. 

INSTRUMENT 

MANAGEMENT 

ENDODONTIC 

INSTRUMENTS 

RUBBERDAM 

CLAMPS 

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 

balance. 

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 

vision. 

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 

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Two Minutes with 

Prof. M. Sherine 

Elattar 

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 

Profile 

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? 

kofta 

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 

regularly? 

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 

you 


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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. 


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 

website: www.bidm-lda.com 


Come visit us at AEEDC 2012 at our Piro Trading booth # 206 - 212 & 221 - 227

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Building Smiles From The Bottom Up

27 October 2011 | Dubai, UAE 

2011 

3 

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 

3232 

rd nd Dental - Facial Cosmetic 


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 

atmosphere. 

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.

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Jan 31 st – Feb 2 nd 2012 

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25 - 28 October 2011, Cairo - Egypt 

15 

th 

International 

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 

1 

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. 


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. 


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) 

• CAPP MEA 

• Dara for Computers 

• Milano Sport 

• Budy Pendant 


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Quality 

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 

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Materials & Technologies 

The high-quality materials + 

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Production Cycle 

ImPlasa Höchst company specialists 

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Microscopy 

The surface of implants is prepared 

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minimal traumatizing in the area of 

implant installation, and such way 

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osseointegration process. 

The Sole Representative in the 

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E: dr.munther@implasa.de 

KSA 

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Tel: +96638898714 

professor_agha@yahoo.com.ca 

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Tel: +961 6 426462 

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Quality 

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. 

Microscopy 

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 

E: dr.munther@implasa.de 

KSA 

Saudi Swiss 

Consultant Dental Center 

Tel: +96638898714 

professor_agha@yahoo.com.ca 

Lebanon 



Tel: +961 6 426462 

kingdom_est@hotmail.com 

Syria 



Tel: +963 21 5732052 

majedajami01@hotmail.com 

Turkey 

ASYA DENTAL 

Tel: +902164957287 

gulcan_celebi@mynet.com 

UAE Dubai 

Bright Smile 

Medical Equipment 

Tel.: +971 4 4508423 

brightsmile.me@gmail.com

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