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DENTAL TRIBUNEThe Worlds Dental Newspaper U.S. Edition
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Direct splintingCase study using this procedure or maintenanceo perio-compromised teeth.
Apical microsurgeryThe conclusion o this six-part series discussessutures and suturing technique.
Las Vegas or Santa Barbara?I youre going to AMED or AADOM, weve gotthe highlights o each or you.
g DT page 2A, ADA
ADA conerence seeks
solutions or older adults
g DT page 2A, GUM DISEASE
Oral squamous cell carcinoma (OSCC) is the most common malignancy o theoral cavity and has several known variants. The papillary variant o OSCCaecting the palate is rare compared to more common sites o involvementthat include the larynx, pharynx and nasopharynx. g See page 5A
Papillary squamous cell carcinomaGum disease a signifcantpublic health concern
The American Dental Associa-tion (ADA) is extending invitationsto those concerned about the oralhealth o vulnerable older adults andpeople with disabilities to attend anational conerence and help shapethe uture o oral health care or thisunderserved and growing popula-tion.
The national coalition conerence,titled Oral Health o Vulnerable OlderAdults and Persons with Disabilities,is scheduled or Thursday, Nov. 18, at
the JW Marriott in Washington, D.C.We look upon this conerence as
the rst step in building a consen-sus among a multi-disciplinary groupo proessionals in seeking solutionsabout oral health care or the vulner-able older adult and the disabled,said Dr. Raymond F. Gist, ADA presi-dent.
We are looking or attendeesideas, collaboration and support in
The prevalence o periodontal dis-ease in the United States may be signi-icantly higher than originally estimat-
ed. Research published in the Journalo Dental Research rom the Centersor Disease Control and Prevention(CDC) and the American Academy oPeriodontology (AAP) suggests that theprevalence o periodontal disease mayhave been underestimated by as muchas 50 percent. The implication is thatmore American adults may suer rommoderate to severe gum disease thanpreviously thought.
In a National Health and NutritionExamination Survey (NHANES) pilotstudy, unded by the CDCs Divisiono Oral Health, a ull-mouth, compre-hensive periodontal examination wasconducted on over 450 adults over the
age o 35. Periodontal disease was clas-sied according to denitions deter-mined by the CDC in collaboration
with the AAP.The prevalence rates were then
compared against the results o pre- vious NHANES studies, which useda partial-mouth periodontal examina-tion. Historically, NHANES has servedas the main source or determiningprevalence o periodontal disease inU.S. adults. The pilot study nds thatthe original partial-mouth study meth-odology may have underestimatedtrue disease prevalence by up to 50percent.
Several research studies have asso-ciated gum disease with other chronic
infammatory diseases, such as diabe-tes, cardiovascular disease and rheu-matoid arthritis.
This study shows that periodontal
disease is a bigger problem than weall thought. It is a call to action oranyone who cares about his or her oralhealth, said Samuel Low, DDS, MS,associate dean and proessor o peri-odontology at the University o FloridaCollege o Dentistry and president othe AAP.
Given what we know about therelationship between gum disease andother diseases, taking care o your oralhealth isnt just about a pretty smile.It has bigger implications or overallhealth, and is thereore a more sig-nicant public health problem, Lowadded.
Low explained that the increasedprevalence o periodontal disease
makes it essential to maintain healthyteeth and gums. Not only should you
CosmetiC tRiBUNeth Wrld Cc Dnry Nwpapr U.s. edn
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Dr. Joel BergDr. L. Stephen BuchananDr. Arnaldo CastellucciDr. Gorden ChristensenDr. Rella ChristensenDr. William DickersonHugh DohertyDr. James DoundoulakisDr. David GarberDr. Fay GoldstepDr. Howard GlazerDr. Harold HeymannDr. Karl Leinelder
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Asthmatickids andtooth decay
In the past, there have beensuggestions that asthma and toothdecay were linked, especially orchildren. But according to a newreport rom the American DentalAssociation, that is apparently notthe case. A critical review o the lit-erature examined 27 separate stud-ies published in 29 dierent papersbetween 1976 and March 2010.
The studies looked into possibleconnections between asthma anddental caries.
Gerardo Maupom, proessor opreventive and community dentistryat the Indiana University School o
Dentistry and author o the newstudy, said: We ound little evi-dence to suggest that asthma causestooth decay. In act, the two larg-est studies we reviewed ound thatchildren with asthma appear to haveewer cavities than others. This maybe because their parents are used totaking them to health-care provid-ers, and routinely bring them to thedentist.
The notion that there is a linkbetween asthma and tooth decaymay have its origin in anecdotalstatements by emergency room
workers who see children withpoorly managed asthma, Maupom
said. These children could also bemore likely to have poorly man-aged dental conditions, and there-ore tooth decay. Its reasonable tobelieve that poor clinical manage-ment may be associated with bothconditions, not the asthma that iscausing the cavities.
The study does acknowledge thatit is dicult to explicitly determinei there is a connection betweenasthma and dental decay predom-inately because o the large num-ber o variables related to asthma,including the wide range o treat-ments or the illness and the severityo asthma symptoms. Yet, research-ers suggest there is no need or
parents with asthmatic children tobe concerned.
However, children who use nebu-lizers to control their asthma may beincreasing their exposure to sugars,as nebulizers oten contain ructose.Frequent intake o sugar can lead totooth decay as the sugar reacts withthe plaque on teeth and orms anacid that gradually dissolves the pro-tective enamel coating on the teeth.
Dr. Nigel Carter, chie executiveo the British Dental Health Founda-tion, advises the best way to protectchildrens teeth rom decay is tomake sure they brush twice a day
with a fuoride toothpaste. It is also
important to cut down how otensugar occurs in a childs diet.
Carter said: It is vital that chil-dren brush their teeth both morn-ing and night or two minutes with
f DT page 1A, GUM DISEASE
g DT page 4A
helping rame the conerences rec-ommendations that could be used bymany sectors, including educationalinstitutions, proessional organiza-tions and policy makers.
Proessionals concerned aboutoral health or vulnerable olderadults and people with disabilities,including dentists and dental hygien-ists, geriatricians, nurses, oral healthadvocates, aging and disability advo-cates, long-term care providers andpolicy makers and legislative sta,are encouraged to register or theconerence.
Dental experts will present top-ics o critical importance in meet-ing the oral health needs o specialpopulations, including collabora-tion between disciplines, oral healthdelivery systems, policy implications,medical dental considerations and
coalition building.Responding to each presentation
will be an expert rom outside den-tistry, representing geriatric medi-cine, long-term care, aging advocacy,state health and policymakers.
Active audience participation willollow as attendees have the oppor-tunity to provide input as they discussthe presentations.
The conerence is a uniqueopportunity to help shape the utureo oral health care and improve thequality o lie or vulnerable olderadults and those with disabilities,said Gist. We highly encourage thoseinterested proessionals to attend. DT
(Source: American DentalAssociation)
take good care o your periodontalhealth with daily tooth brushing andfossing, you should expect to get acomprehensive periodontal evaluationevery year, he advised.
According to Paul Eke, MPH, PhD,epidemiologist at the CDC and leadauthor o the study, the ndings havesignicant public health implications.The study suggests we have like-ly underestimated the prevalence operiodontal disease in the adult U.S.population, he said. We are current-ly utilizing a ull-mouth periodontalexamination in the 2009/10 NHANESto better understand the ull extent andcharacteristics o periodontal diseasein our adult population.
Eke added, Research suggestsa connection between periodontalhealth and systemic health. In lighto these ndings, understanding the
relationships between periodontal dis-ease and other systemic diseases in theadult U.S population is more crucialthan ever.
Patients can assess their risk orperiodontal disease and learn more by
visitingperio.org. DT
(Source: AAP)
About the AAPThe American Academy o Periodon-tology (AAP) is the proessional orga-nization or periodontists. Periodon-tists are also dentistrys experts inthe treatment o oral infammation.They receive three additional years o
specialized training ollowing dentalschool. The AAP has 8,000 membersworldwide.
Do you have general comments or criticism you would like to share? Isthere a particular topic you would like to see more articles about? Let usknow by e-mailing us [email protected]. I you would liketo make any change to your subscription (name, address or to opt out)please send us an e-mail at [email protected] and be sureto include which publication you are reerring to. Also, please note thatsubscription changes can take up to 6 weeks to process.
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By Stuart J. Oberman, Esq.
Dental practice auditsDental audits were rare at one time.
Now, however, with insurance com-panies and third-party payers auditingmore routinely, it is much more likelythat a dental practice will ace an audit.Most dental practices that are con-tracted with dental plans are auditedat least once during the course o theirpractice.
Many o these dentists are let won-dering why audits are becoming amore routine exercise o third partypayers. The answer: alarming statis-tics. The FBI estimates that 10 percento the money expended on health careis due to raudulent activity. Insurance
companies estimate that raudulenthealth-care billing represents up to$10 billion each year.
In addition, Medicare raud isbecoming more rampant. The UnitedStates General Accounting Oce esti-mated that out o every $7 spent onMedicare, $1 is lost to Medicare raud.Fraud is adding enormous costs to thenations health-care system. As moreraudulent health-care charges rack upor insurance companies to pay, insur-
ance companies are becoming seriousabout auditing health-care practices.
With a thorough understanding o theaudit process, dentists will be betterprepared or what appears to be theinevitable.
Why me?Ater receiving notice o an impendingaudit, dentists oten wonder why theirpractice has been targeted. Generally,the audits conducted by dental plansand third-party payers are a methodo showing state regulators that thepatients are receiving quality care. Athird-party payer is an organizationother than the patient (which wouldbe the rst party) or health-care pro-
vider (also known as the second party)
involved in the nancing o healthcare services.
The audits are typically meant tocheck the status o a dental plan andare not meant to be a check on thespecic dental practice. The selec-tion process third parties undertake
to audit a given dental practice var-ies. Third parties may randomly pickdental practices based on how likelythe practice is to have discrepanciesonce audited. The third partys goal isto recoup lost dollars, and so this strat-egy is chosen to allow a third party toobtain the largest return.
A dental practice is most likely tobe audited ater submitting atypicalclaims online. A third-party payer ana-lyzes each claim submitted. The audi-tors fag abnormal or atypical chargesas these may suggest provider abuse.Additionally, third parties track inor-mation on practice charges by analyz-ing the average cost per claim, average
cost per person and how oten certaintreatments are perormed. With thisinormation, the third parties targetspecic dental practices or an audit.
An auditors goalsAuditors typically share commongoals. By conducting audits, third partypayers are attempting to prevent abuseo the payment system. By perormingaudits on practices, dentists are orcedto understand the importance o keep-ing records and submitting only hon-est and accurate claims.
Also, dentists are more likely tokeep accurate records and submittruthul claims when they know anaudit may be lurking than i they
assume their dental practice willnever ace an audit.
A second goal ties in with the rst,and that is to help dentists under-stand and ollow the third-partypayers guidelines. Finally, the audi-tors are trying to nd instances ooverpayments to dental practition-ers or claims the dental practice hassubmitted.
The audit process: frst contact
Many dentists want to know what toexpect i their practice is hit with anaudit. First, the dentist will most likelybe notied o the impending audit by aletter, however, the third-party payermay make initial contact with the den-tal practice by telephone. When a tele-phone call takes place, a day and timeor the audit will be arranged, and thedentist should ascertain what type oaudit will be conducted.
It is also advisable to ask why theaudit is being perormed. The answermay be that it was simply a randomselection, but a dental practitionershould make certain that it was notbecause o a claim submission that the
third-party payer fagged as abnormal.
Auditors and fle accessWhen auditing the dental practice, theinsurance plan will most likely sendrepresentatives to the dental practiceto ensure that billing claims matchdocumentation in patient les. Audi-tors will analyze whether amountspaid to the practice were or an actu-al member o their insurance plan,
whether the services rendered wereactually provided according to treat-ment plans and whether the servic-es provided by the dentists were inaccord with ederal law.
Additionally, auditors may analyze
patient les. Auditors may be inter-ested in reviewing patient medical his-tories, dental histories, documentationo oral examinations, treatment notes,diagnosis, procedures completed, theoutcome o each procedure and ol-low-up care. It is also possible thatdocumentation supporting submittedclaims will be requested during anaudit.
Problems encountered duringaudits are most likely due to improp-er documentation o records ratherthan by raudulent billings. The den-tist is typically without recourse i therecords in the patient le do not matchup with the claims billed.
Various state laws and the HIPAA
(Health Insurance Portability andAccountability Act) privacy rule per-mit third-party payers to access andreview the health records o their ownmembers. However, third-party pay-ers are no longer permitted to accessthe records o patients who are notenrolled in their plans like they werein the past. Thereore, third-party pay-ers are no longer able to compare
Practice Matters DENTAL TRIBUNE | OctOber20104A
fuoride toothpaste and visit theirdentist as oten as recommended.
Sugary oods and drinks can dam-age the teeth. Instead, replace these
with healthy snacks such as cheese,raw vegetables, seeds, bread, crack-ers, breadsticks and ruit, and try toencourage children to drink moremilk and water. Parents should try
AD
and reduce the number o snackattacks to no more than three mealsand two snacks a day.
These simple changes to a childs
diet and oral health routine can real-ly help decrease risks o tooth decayand other oral health problems,Carter said. DT
(Source: British Dental HealthFoundation)
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signicant decreases in death ratesrom heart disease, cerebrovascu-lar disease and inections over theprevious 50 years or many orms ocancer, death rates remain essen-tially unchanged during that sametime period.1
Squamous cell carcinoma (SCC)is the most common malignant neo-plasm aecting the head and neck.Mucosal cases account or more
than 90 percent o all malignantneoplasms aecting oropharyngealstructures, with oral squamous cellcarcinoma (OSCC) being the mostcommon oral malignancy.2
Several variants o OSCC existand histopathologic classicationsor variants o OSCC include papil-lary, spindle cell, adenosquamous,
their enrollees records and charges with those o patients not enrolledunder their plans.
Beyond patient flesAside rom auditing the patient les,the third-party payer may also accessthe quality o the acility, the main-tenance o the equipment, the levelo diculty patients on their planencounter in obtaining appointmenttimes, and the level o compliance withederal regulations during the courseo the audit.
It is prudent that the dentist remainswith the auditor at all times. It is worththe time to clear the calendar on theday o the audit and to stay with theauditor as patient and billing recordsare reviewed. Also, the sta o the den-tal practice should be prepared or theaudit, and the dentist should discussthe procedures to be ollowed beorethe day it is conducted.
Because dental audits are becom-ing a routine part o doing business,dentists must protect their practice bypreparing their oce or an audit.
To prevent audit problems, den-tists should make themselves aware oterms o any third-party contracts, keepthe plan manuals in a sae place so thedentist can reer back to them, ensureeach procedure perormed matchesthe procedure billed and ensure thatall patient records are organized andcontain all relevant inormation oneach patient.
Also, when claims are led online,ensure that the correct price is sent tothe third-party insurer.
With a more thorough understand-ing o third-party audits and the third-party payers motivation or conduct-ing them, dentists will be more likely toavoid costly mistakes. DT
Approximately one in threeAmericans will develop a malig-nancy in their lietime.1 The chanceso developing certain malignanciesincrease with age and several con-tributing risk actors such as tobac-co and alcohol use. Notwithstanding
DENTAL TRIBUNE | OctOber2010 Clinical 5A
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About the author
Stuart J. Oberman, Esq., hasextensive experience in repre-senting dentists during dentalpartnership agreements, part-nership buy-ins, dental MSOs,commercial leasing, entity or-mation (proessional corpora-tions, limited liability compa-nies), real estate transactions,employment law, dental boarddeense, estate planning, and
other business transactions thata dentist will ace during his orher career.
For questions or commentsregarding this article, visitwww.gadentalattorney.com.
Papillary squamous cellcarcinoma o the hard palate
By Paul C. Lee, BA; Justin Olsen,BS; Joshua Adcox, BS and Parish P.Sedghizadeh, DDS, MS
Report of a rare case affecting the oral cavity
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and basaloid carcinoma; it is alsopossible to categorize types o OSCCbased on clinical descriptors such asulcerative, fat, polypoid and verru-coid.2 OSCC variants can have dier-ent growth patterns, ranging romsmall mucosal thickenings to largemasses, and can appear endophyticor exophytic.
These tumors are erythematous to
white to tan, requently eeling rm
on palpation. Conventional OSCCis composed o variable degrees osquamous dierentiation, with well-dierentiated cells closely recapitu-lating normal squamous epitheliumbut demonstrating some degree obasement membrane violation bynests o tumor cells, to poorly dier-entiated cells with more anaplastic-like appearances.
As a result o its complex exo-phytic papillary architecture, the
papillary variant o SCC can be achallenge to accurately diagnoseand histologic assessment o under-lying invasion can be very dicult.3Risk actors and pathogenesis orpapillary SCC are unclear althoughhuman papilloma virus subtypes arethought to play a role in some cases. 3
The purpose o this paper is to(a) present a rare case o papil-lary OSCC aecting the hard palate,and (b) describe the clinical andhistologic eatures o this tumor insupporting the dentists role in earlydetection.
Case reportA 63-year-old emale presentedto the dental clinic at the HermanOstrow School o Dentistry, Univer-sity o Southern Caliornia with thechie complaint o a growth appear-ing on the roo o her mouth approx-imately two months prior to her pre-
sentation to our clinic. The patientspast medical history included typeII diabetes mellitus controlled withdiet and exercise, and denial o anyalcohol or tobacco use.
The remainder o her medicaland social history was non-contribu-tory; she was not taking any medica-tions and a review o systems wasunremarkable. Intraoral examina-tion revealed a 3.5 cm exophyticmass in the anterior midline region
o the hard palate (Fig. 1). Thelesion appeared vascularized withill-dened borders and no evidenceo ulceration or erosion.
The patient had mild sensitivityupon palpation o the lesion. No cer-
vical or submandibular lymphade-nopathy was observed during theextraoral examination o the headand neck. Panoramic radiographyrevealed no abnormalities o thepalatal area.
The patient was inormed thata biopsy must be taken to obtain adenitive diagnosis; inormed con-sent was obtained or incisionalbiopsy with local anesthesia. Duringthe administration o local anes-thesia, the cortical bone under thetumor elt intact with the end o theneedle. A representative wedge otissue was removed and placed in10 percent ormalin or microscopicevaluation.
The biopsy site was cauterized toobtain postoperative hemostasis dueto the high degree o vascularity.The biopsy site was closed with our3.0 chromic gut interrupted sutures.Hemostasis was achieved, postop-erative instructions were given andthe patients postoperative condition
was good.The gross examination o the
specimen consisted o a sot, tanpapillary and riable mass. The his-
Clinical DENTAL TRIBUNE | OctOber20106A
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Fig. 1: Clinical image o the palate o a 63-year-old emale showing anerythematous exophytic mass with a cauliower-like or papillary suracearchitecture. (Photos/Provided by Paul Lee)
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non-movable mass.1However, OSCC oten begin
as white or red plaques o sur-
ace mucosa, making early clinicaldetection possible. I a leukoplakicor erythroplakic lesion appears inthe oral cavity and does not heal
within a ew weeks, biopsy is rec-ommended or denitive diagnosis,
which may represent levels o histo-logically normal tissue (e.g., kerato-sis) to atypia, dysplasia, carcinomain situ or overt carcinoma.1
Papillary OSCC, such as the casepresented here, is a variant o SCCas classied by the World HealthOrganization4 and can present aseither in situ or invasive lesions.5Male predominance exists in OSCCcases, and the sites most commonly
aected in order o prevalence arethe larynx, nasal cavity and oralcavity.2, 5
The clinical appearance o papil-lary OSCC oten mimics other vari-ants such as verrucous carcinoma,
which is included in a dierentialdiagnosis until conrmation withmicroscopic examination and diag-nosis.3
Microscopically, OSCC can showinvasive and disorganized growth
with the ollowing: dyskeratosis,keratin pearls and intercellularbridges, increased nuclear-to-cyto-plasmic ratios, nuclear chromatinirregularities, prominent eosino-philic nucleoli and increased mitot-
ic gures with atypical ormation.Perineural invasion can be seen insome lesions, presenting a positivecorrelation to metastatic potential.1In this case presentation, many othe aorementioned microscopiceatures o OSCC were evident with-out evidence o perineural invasion.
Early detection o OSCC, spe-cically stage I or II diagnosis, isusually associated with a avorableprognosis. Papillary OSCC in gen-eral has a 70 percent, ve-year sur-
vival rate at any stage, and at T1 itcarries a 100 percent survival rate6compared to other variants, such asbasaloid (40 percent, two-year sur-
vival), adenosquamous (55 percent,two-year survival), and spindle cell(80 percent, ve-year) carcinomas.2Most reported cases o papillary SCCexhibit a mean diameter o 1 to 1.5cm2. Our patient presented with arelatively large lesion measuring
topathologic evaluation revealedan exophytic, papillary proliera-tion o surace mucosa showing
marked maturational perturbations.It included cellular and nuclearpleomorphism, prominent nucleo-li, hyperchromatism, acantholysis,increased mitotic activity and abnor-mal mitotic gures, dyskeratosis andkeratin pearls, and increased nucle-ar-to-cytoplasmic ratios.
Invasive cords and islands omalignant mucosa were visualizedand the associated connective tis-sue contained an infux o acuteand chronic infammatory cells. Toevaluate whether the infammatoryinltrates observed in the canceroustissue were in response to super-imposed ungal inection (because
organisms such as Candida albi-cans are common oral inhabitants),periodic-acid Schi staining wasconducted and determined to benegative with appropriate staining ocontrol tissue.
The patient was reerred to thehead and neck oncology group at theUniversity o Southern Caliornia,Los Angeles County Hospital andKeck School o Medicine. Clinical
work-up or staging was perormedand computerized tomographyscans o the head, neck and chest
were determined to be negative ormetastatic disease; the lesion wasstaged at T2N0M0.
The patient underwent tumor
resection with 1 cm margins andsuprahyoid neck dissection, withno radiation or chemotherapy. Herpostoperative course was unevent-ul, and histopathologic analysisconrmed a diagnosis o papillaryOSCC.
The dissected lymph nodesshowed no metastatic involvement,conrming that the surgical mar-gins were tumor ree. There was noclinical evidence o recurrence at6-months ollow-up.
DiscussionThe typical presentation or OSCCcan be either a symptomatic or
asymptomatic mucosal ulcer. Thesesupercial ulcers oten progress intosymptomatic or asymptomatic exo-phytic or endophytic nodules witheroded or ulcerated suraces, andcan progress to direct invasion o thedeeper structures resulting in a rm,
over 3 cm in diameter.Dentists have a critical role in
early identication o and eectivecare during OSCC progression rompremalignant lesion to malignan-cy.7 A study conducted to evaluatethe eectiveness o dentists in theearly detection, treatment and post-operative care o OSCC in a centralEuropean population revealed theollowing results: Dentists identi-ed 72.5 percent o the tumors inthe 608 patients they saw as malig-nant, while amily physicians did
DENTAL TRIBUNE | OctOber2010 Clinical 7A
so in only 40.11 percent o their 406patients. This dierence was statisti-cally signicant (P < .001).8
OSCC is a major public healthproblem that is not just limited tocertain risk groups, such as those
who smoke and drink as in this casereport. Early detection and identi-cation o OSCC is critical to patienttreatment and survival. DT
A complete list o reerences isavailable rom the publisher
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About the authors
Paul C. Lee, BA; Justin Olsen,
BS; and Joshua Adcox, BS, are den-
tal students at the Herman Ostrow
School o Dentistry o USC, Universi-
ty o Southern Caliornia, Los Ange-
les. Parish P. Sedghizadeh, DDS,
MS, is an assistant proessor at the
Herman Ostrow School o Dentistryo USC, University o Southern Cali-
ornia, Los Angeles.
For correspondence:
Paul C. Lee
925 West 34th Street, DEN 4110
University o Southern Caliornia,
School o Dentistry
Los Angeles, Cali. 90089-0641
E-mail: [email protected]
Fig. 2: Histopathologic evaluationdemonstrates abnormal mucosawith a micropapillary surace mor-
phology and marked maturationalperturbations in association withacute and chronic inammatorycells (H&E, 20x original magnifca-tion).
Fig. 3: Histopathologic evaluationreveals invasive islands and cords omalignant epithelium in addition todyskeratosis and early keratin pearl
ormation (H&E, 20x original mag-nifcation).
Fig. 4: Histopathologic evaluationo invasive cords o mucosa athigh power magnifcation showscellular and nuclear pleomor-
phism, hyperchromatism, acan-tholysis, dyskeratosis, prominentnucleoli and increased nuclear-to-cytoplasmic ratios (H&E, 40xoriginal magnifcation).
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Santa Barbara hosts a dentists
look through the microscopeon courses at education acilitiesalong the Pacic coast.
I you have not registered orthe meeting yet, you may reg-ister online and view the com-plete schedule at www.microscopedentistry.com. Your pre-registra-tion helps AMED plan and prepareso please make your registration assoon as possible.
During the meeting there willalso be special events that accom-
The Academy o MicroscopeEnhanded Dentistrys 9th AnnualMeeting and Scientic Session willbe held Nov. 46 in Santa Barbara,Cali., at Fess Parkers Double TreeResort. The theme is The Intersec-tion o Macro & Micro Dentistry.
The meeting will eature lec-tures rom top clinicians in everydiscipline as well as master classes,corporate orums and pre- and postsession, comprehensive, hands-
panying guests will be sure toenjoy. Call (800) 564-4333 to make
your hotel reservations. You may also become an
AMED an on Facebook atw w w . a c e b o o k . c o m / m i c r odentistry. See you in Santa Barbara!
The daily schedule or the eventollows.
Thursday, Nov. 4 7 a.m., registration and exhib-
its open 9:30 a.m.1:30 p.m., spouse/
guest event, Lotus land garden tour(there is a ee or this event)
8 a.m.12:45 p.m., general ses-sion
~ John West, DDS, MSD, Presi-dents Welcome
~ Cli Ruddle, DDS, My End-odontic Practice: A 35-year Retro-spective Analysis
~ Terrel Pannkuk, DDS, MScD,The Endo/Perio Dierential Diag-nosis
~ Paul Anstey, DDS, The Power
o 3-D Imaging in Endodontics andBeyond
~ Tetsuya Hirata, DDS, PhD,What I Learned During EightYears o Research Study in Image
Enhanced Dentistry~ Cherylin Sheets, DDS, Quanti-
tative Percussion Diagnostics and Magnifcation: A Synergistic Com-bination
12:451 p.m., members busi-ness meeting
12:452 p.m., luncheon buffet 25 p.m., Endo Master Class~ Carlos Murgel, DDS, Small
FOV CBCT or Endodontics: Anoth-er Gadget or a Paradigm Shit?
~ Terrel Pannkuk, DDS, MScD,Outcome Study Science and Art: Canthe Value o an Endodontic Tech-nique or Technology Be Adequately
Assessed?~ Morlo Okaguchi, DDS, Micro-
scope Assisted Precision Dentistry II~ Eudes Gondim, DDS, PhD,
Beyond the Microscope: What ElseCan Make the Dierence?
~ John West, DDS, MSD, speak-ers panel moderator
25 p.m., Perio Master Class~ Markus Hrzeler, DMD, PhD,
Minimally Invasive Implant Sur- gery Supported by MicrosurgicalTechniques
~ Adriana McGregor, DDS, The
Hidden Secrets o Outstanding Results in Sot-tissue ManagementAround Implants: From Planning toPlacement to Restoration
~ Te-Fu Li, DDS, Micro-invasiveTreatment o Periodontal Pockets
~ Katsuhiko Akiyama, DDS, Papilla Reconstruction Using thePatch Technique
~ Bryan Pearson, DDS, MS,speakers panel moderator
25 p.m., Restorative MasterClass
~ Kunio Matsumoto, DDS, Pre-Treatment in Esthetic Restoration
~ Masayuki Okawa, DDS Mini-mally Invasive Interventions and
Interdisciplinary Approach or Esthetic Dentistry
~ Jos Roberto Moura, DDS, Artand Precision with Direct Compos-ites
~ Claudia Cia Worschech, DDS, PhD, Obtaining Clinical Success
AMED Meeting Preview DENTAL TRIBUNE | OctOber20108A
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with Micro Laminate PorcelainVeneers
~ Assad F. Mora, DDS, MSD,FACP, speakers panel moderator
711 p.m., Social Event: Wel-come reception, entertainment anddance
Friday, Nov. 5 8 a.m., registration and exhib-
its open 8 a.m.5 p.m., Test Drive the
Latest Technology 9 a.m.12:45 p.m., general ses-
sion~ Larry Rikin, DDS, Facial
Esthetics~ Glenn vanAs, DDS, Lasers and
the Operating Microscope: Seeingthe Light!
~ Marc Alexander, DDS, Treat-ment Planning or Esthetics
~ Paul Piontkowski, The PerectCAD/CAM Restoration
25 p.m, short presentations~ Randy Shoup, DDS, Minimally
Invasive Restorative Dentistry: Live Demonstration o Principals, Tech-niques, Equipment and Materials
~ Junya Okawara, DDS, Peri-odontal Microsurgery: AchievingGingival Level Alignment with Con-netive Tissue Grat
~ Cami Ferris, DDS, Heroic End-odontics in an Age o Implants
~ Masahiro Nakazawa, DDS,Utility o All-on-4 with Socket Pres-ervation
~ Kazuo Kurihara, DDS, Tissue Management Around Implants inEsthetic Zones
~ Stephane Browet, DDS, TheMatrix Revisited 25 p.m., corporate forums~ BioClear Composites Hands-on
Course (there is an additional costor this course)
~ Global Surgical~ AMD Lasers~ Crystal Mark & GC America:
Air Abrasion 23:30 p.m., spouse/guest
event: Land shark tour (there is aee or this event)
711 p.m., social event: presi-dents dinner and awards
Saturday, Nov. 6 8 a.m. registration and exhibits
open 9 a.m.1:30 p.m., Test Drive the
Latest Technology 9 a.m.1:30 p.m., general ses-
sion~ Dennis Shanelec, DDS, A Ret-
rospective o Clinical PeriodontalMicrosurgery
~ Je Hamilton, DDS, Oral Med-icine and the Clinical Operating
Microscope~ Eric Herbranson, DDS, The
Latest in Photographic Documenta-tion
~ Peter J. Jannetta, MD, Neuro-genic Face Pain in the Dental Ofce
~ Malcolm Snead, DDS, PhD,
Thinking the Unthinkable: Regener-ating the Whole Tooth
1:30 p.m., adjourn~ O-site hands-on courses~ Pre & post session hands-on
courses will be held at the Micro-surgery Training Institute
DENTAL TRIBUNE | OctOber2010 AMED Meeting Preview 9A
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Social events and tours Santa Barbara Back-CountryWine Tour, Nov. 10, a.m.4:30 p.m,
Enjoy lush valley views, breath-taking scenery and stops at our othe regions best wineries or tast-ings and a gourmet picnic lunch atone o the vineyards.
Journey back to Santa Barbarathrough oak-shaded canyons anddirt trails, past the ormer Rea-gan Ranch and along the beautiulPacic. Spouse/guest event: LotusLand
garden tour with lunch,Nov. 4, 9:30a.m.1:30 p.m.
You are invited to visit Lotus-land, a unique 37-acre estate andbotanic garden situated in the oot-hills o Montecito to the east o thecity o Santa Barbara. Visit www.
lotusland.orgor more inormation. Welcome reception, entertainmentand dancing, Nov. 4, 711 p.m.
This event is an opportunity ormembers and guests rom aroundthe world to meet ace to ace.Enjoy a Santa Barbara themed din-ner, entertainment and dancing.Attire is Caliornia casual. Spouse/guest event: Santa Bar-baras land shark tour, Nov. 5,
23:30 p.mClimb aboard Santa Barbaras
original amphibious tour vehicleor a personally narrated 90-min-ute land and sea adventure. Enjoyexquisite views o the Santa Bar-bara coastline, the Riviera and theSanta Ynez mountains as seen onlyrom our boat at sea. Presidents dinner and awards,
Nov. 5, 79:30 p.mEnjoy an elegant evening during
AMEDs annual Presidents Dinnerand short awards presentation cer-emony. Attire or this event is semi-ormal. DT
AMED Program Co-chairs: Drs.William Lannan and John West
AMED Scientifc Session Commit-tee: Drs. Terry Pannkuk, Adriana
McGregor and Tetsuya Hirata
Contact inormation:Academy o Microscope EnhancedDentistryP.O. Box 15834Fort Wayne, Ind. 46885Phone: (260) 249-1028www.microscopedentistry.com
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What you learn in Vegas doesnthave to stay in Vegas, AADOM saysBy Fred Michmershuizen, Online Editor
can implement Monday morning. 10:45 a.m.12:45 p.m.: Tips for
Going Green in the Dental Ofce, byKevin Henry
Going green doesnt mean giv-ing up electricity or reverting backto the Stone Age. It does, however,mean a new way o thinking andawareness in the dental oce. Inthis lecture, participants will learnhow to help save the environmentby taking small steps in each roomo the dental oce.
2:304:30 p.m.: Writers Work-shop or Dental Ofce Managers,
Kevin HenryHave you ever dreamed o being
published? Do you have a wealtho knowledge that you would love
to share but are unsure how? JoinKevin Henry, managing editor oDental Economics and editor oDental Assisting Digest, or thisinteractive workshop.
2:304:30 p.m: How to Start a
Local Study Club: S.T.A.R.T.S. Meth-od, Judy Kay Mausol
One o the big questions beingasked today is, How do I start alocal study club? Judy Kay, theStudy Club S.T.A.R.T.S. expert, canshow how you can take your passionand ideas and transorm them intoa thriving and successul study clubtoday. Learn the six step S.T.A.R.T.S.method to study club success.
The AADOM is gearing up or its6th Annual Dental Oce Manag-ers Conerence, to be held Oct. 22and 23 at the Las Vegas Hilton, andplenty o education is on the menu.The ollowing educational programs
will be oered in Las Vegas.
Friday, Oct. 22 10:15 a.m.12:15 p.m.: Conict,
Gossip & Tension Resolution or the Dental Ofce Manager, Judy KayMausol
Discover how to elevate you com-
munication to a level that resolvesconfict, gossip and tension and takesa team rom good to great everytime. Learn how to create an envi-ronment where everyone ocuses onthe positive (what is right) instead othe negative (what is wrong).
10:15 a.m.12:15 p.m. and
repeating 2:304:30 p.m.: The Practice Promise: How To CreateYour Brand, Fred Joyal, ounder o1-800-DENTIST, with special guest
Rita Zamora, social media expert; acilitator is Kim McQueen, market-ing manager, Patterson Ofce Sup-
pliesI you are an oce manager who
wants to learn how to navigate amarketing plan with options gearedtoward the specics o your loca-tion, specialty, oerings and overallpractice promise, this session isor you. Participants will gain thetools they need to build a marketingplan or the upcoming year.
10:45 a.m.12:45 p.m., repeating
2:304:30 p.m.: All Stressed Up & NoPlace to Go, Larry Wintersteen
Learn rom one o the best den-tal management consultants in thecountry, Larry Wintersteen, how tohandle the stress only a dental ocemanager can experience. Go home
with stress-eliminating ideas you
Saturday, Oct. 23 9:1510 a.m.: Keynote Session:
Lioness Leadership: Awaken the Instinctive Leader in You!, KatherineEitel
Lions are born leaders. Cubs areborn with instincts to hunt, propagate,lead and thrive, they just dont knowit. The primary goal o mature lion-esses is to awaken those instincts toensure the success o the pride. Likelions, you already have the instinctiveability to lead and lead powerullyrom whereever you are in lie. Mosto us just dont know it, or trust it, yet.
10:3011:30 a.m.: Your education.
Your proessional development. Yourway., Cindy Durley, MEd, MBA, and
Liz Koch
In this interactive workshop,attendees will be asked to share theirexpertise and strategic planning skillsas we work together to determine andthen prioritize the online educationneeds o dental oce managers.
2:304 p.m.: Practice Management
Expert PanelIn this one-hour Q&A, expert con-
sultants representing all elds opractice management will take to thestage to answer questions. Questions
will be submitted ahead o time toallow experts to prepare.
12:301:45 p.m.: My Ofce Man-ager is a Rock Star!
Do you know how important you
are to your practice? Learn rsthandrom a practicing dentist how truly
valuable you are. I you sometimeseel under-appreciated, you are notalone. How can you get the recogni-tion you deserve? Come nd out!
In addition to the educationalopportunities listed above, the ollow-ing pre-conerence programs will beoered on Thursday, Oct. 21:
10:30 a.m. Dental Spouse Business
RoundtableDental spouses will come together
to discuss the unique challenges aced when running a practice and beingmarried to the doctor.
2:305 p.m.: Best Practices Work-shop: The Ultimate Roundtable Experi-ence, Katherine Eitel
Attendees are invited to join thisinteractive workshop to share bestpractices with other oce managersrom around the country. A Q&A ses-sion eaturing a panel o AADOMsOce Managers o the Year will beollowed by roundtable discussions byspecialty. The session will conclude
with Train the Trainer, in whichEitel will teach attendees how to bring
what they have learned home. Key Opinion Leader Ofce Man-
ager CouncilAADOM is looking or the best den-
tal oce managers in the country tobe a part o this new event. Attendeescan meet with dental industry leadersrepresenting various businesses andshare with them how they can betterserve you, the dental oce manager.
What products, services and discountscan they provide to you to help you do
your job better? They value your opin-ion and want to hear rom you.
The AADOM Conerence DiamondSponsor is Patterson Dental.
More inormation about the eventis available at www.dentalmanagers.com/conerence. DT
(Source: AADOM)
AADOM Meeting Preview DENTAL TRIBUNE | OctOber201010A
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nozzles ensures that the powderis thoroughly washed out o thepocket, along with the removedbioilm, according to EMS. Thenozzle is simply itted onto thePerio-Flow handpiece, which hasa magnetic holding device and canthereore be removed lexibly.
The Air-Flow Master does notsimply take care o periodontalpockets, but also provides supra-gingival prophylaxis. Whetherplaque or hard deposits theAir-Flow handpiece strokesthe tooth suraces clean with theappropriate powder gently andselectively. In addition to the clas-
sic powder, EMS has developeda sot powder or more sensitiveteeth.
And recently, patients haveacquired a taste or this treat-ment: The classic powder is avail-able not only in a neutral lavor,but also in cherry, black currant,tropical, lemon and mint lavors.
Every lavor has its own color-coded ring, which is placed on thepowder chamber so that it is clearat a glance which lavor is being
With the new Air-Flow Masterrom EMS, prophylaxis is enter-ing a previously unexplored area.This instrument gives periodontalpockets a thorough cleaning by airpolishing.
The biokinetic energy, appliedin a powder-air-water mixture,removes the bioilm down to thebase o the pocket, brings abouta sustained reduction in bacteria,irms the gum and reduces thepocket depth.
The patient beneits twiceover because the procedure isnot only more eicient, but alsomore comortable than conven-
tional curettes or instruments thatscratch the tooth.
This subgingival deep divinguses a special single-use nozzle,combined with extra-ine grainAir-Flow Powder that is non-abra-sive on the tooth surace.
The lat and tapered, slightlybent nozzle has three openingsrom which the powder-air-watermixture emerges in the subgingi-
val area with gentle turbulence.The special construction o the
used at any time.The Air-Flow Master is oper-
ated exclusively through touchand thereore is very hygienic.The person providing treatmentplaces one inger on the touchpanel and controls the power andliquid unctions rom minimum tomaximum by gently stroking overthem. In addition, a ingertip isenough to switch between the Air-Flow and Perio-Flow applications.
The application currently inuse lights up in luorescent blue.Because o its smooth suraces,the instrument is easy and hygien-ic to clean and thereby guarantees
the highest hygienic standards,according to EMS.
More inormation is available atEMS Electro Medical SystemsCorp. DT
Electro Medical Systems Corp.11886 Greenville Ave., #120
Dallas, Texas 75243Tel.: (972) 690-8382
Fax: (972) [email protected]
www.ems-dent.com
DENTAL TRIBUNE | OctOber2010 Industry News 11A
EMS Air-Flow Master: prophylaxis nowalso available or periodontal pockets
Atlas Denture Comort provides alasting solutionDentists oten dont look or-
ward to having patients with den-tures, according to Paul Homoly,DDS, president o Homoly Com-munications.
When asked why, he repliedthat the procedure leaves bothdentist and patient eeling bereto lasting solutions: there is con-tinuous need or repeated visitsto the dentist or adjustments;
patients endure discomort and, worse yet, experience diiculty with everyday unctions such asspeaking, chewing, and smiling orlaughing.Even unwanted soundsmay also be heard coming romthe dentures, such as clicking or
whistling.All o this leaves people wear-
ing conventional dentures eelinginsecure and sel-conscious. Den-ture wearers o any age could indthemselves changing their dailyroutineeven choosing to avoideating because o discomort orembarrassment.
This is endured because the
one alternative they may have changing their conventional den-tures into implant supported den-tures has historically been outo their reach because o high pre-
vailing costs, painul and inconve-nient surgical procedures or limi-
tations in the width o their ridges.Atlas Denture Comort is a
simple solution that was developedby Dentatus USA. This aordable,one-hour, chairside procedure issoon to be the industry standardor securing and retaining either apatients new or existing dentures.
Atlas Implants, approved ormarketing by the FDA, are suit-able or retaining lower dentures
economically, regardless o thepatients age.
The Denture Comort procedureconsists o placing our Atlas nar-row-body titanium alloy implantsinto the edentulous jaw anteriorto the mental oremen. Then, Den-ture Comorts cushioning silicone Tu-Link is expelled intothe denture to it snugly over andaround the short, dome-shapedheads o the Atlas implants so thatthe denture can be securely andconidently retained.
The result is a comortable itand optimal retention all with-out surgery, without bleeding,
without bank-breaking expense!Atlas Denture Comort is the
only system on the market todaythat eliminates the hardware typi-cally associated with overdentures.The Atlas System uses no O-rings,no housings, no adhesives.
The unique Tu-Link siliconereline provides the retention tothe implants or a stress-ree den-ture, easy insertion, retention andremoval.
This minimally invasive tech-nique is easy or dentists to learnand implement, and will changethe lives o your patients. Checkout dentatus.com or upcominghands-on workshops.
Included in the tuition are a
patient education model, completepatient start-up kit and marketingtools to help you get started. DT
Dentatus USA192 Lexington Ave., #901
New York, N.Y. 10016Tel.: (800) 323-3136Tel.: (212) 481-1010
Fax: (212) 532-9026www.dentatus.com
For deep periodontal pockets: ThePerio-Flow handpiece, the nozzleand the Perio Air-Flow Powder
The new Air-Flow Master rom EMS:the subgingival practice unit.
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COSMETIC TRIBUNEThe Worlds Cosmetic Dentistry Newspaper U.S. Edition
By Dr. Ajay Kakar, India
Fig. 3: The fbre in place and poly-merised ater being coated with
owable composite.
g CT page 2C
OctOber2010 www.dental-tribune.com VOl. 3, NO. 10
Periodontal disease is initiatedin the main as gingivitis, whichin a smaller subset o individualsprogresses to the more advancedorm reerred to as periodonti-tis. Gingivitis is restricted to themarginal gingival area and doesnot lead to destruction o osseoustissue.
Gingi vitis is the progression toperiodontitis, which encompassesextensive loss o bone surround-
ing the tooth. Modern-day therapycan generally ensure the arresto the progression o periodontaldestruction and, in avourablesituations, even the regenera-tion o all the components o theperiodontal apparatus, albeit to amuch lesser extent than the origi-nal. O the periodontal structures,the loss o sot tissue makes theprocess o complete regenerationmuch more diicult.
In such circumstances, whereinthe inlammation and inectionhas been controlled and the dis-ease activity has been curbed, itbecomes imperative that the den-tition, which is deinitely compro-
mised owing to the pre-existingdamage, be supported and addi-tional aids provided to create theoptimum unction, coupled withaesthetics.
One o the key issues in suchdentitions is the mobility o theteeth. Such mobility may belocalised to certain teeth and ina speciic path o motion or maybe much more generalised andalict many teeth. In either case,the beneits o immobilisation aremultiple. The comort level o thepatient is suicient reason to usethis treatment option or mobileteeth.
Additionally, this also leadsto tremendous patient motiva-tion and compliance in maintain-ing oral hygiene, which directlytranslates into better periodontalhealth. Furthermore, an immo-bile tooth will heal much aster
and better than a mobile one. Anyregenerative therapy carried outaround alicted mobile teeth willhave better results than wouldhave been the case had the teethbeen immobilised (Figs. 14).
Another critical maniesta-tion o periodontal disease, whencoupled with imbalanced occlusalloads, is the sequel o migrationthat results rom such a clinicalsituation. Migration, an extremelyslowly developing phenomenon,leads to drastic consequences thatcan usually be optimally corrected
only by using orthodontic appli-ances.
But even this correctionrequires a permanent splintingprocedure to ensure that the con-cerned teeth remain in place anddo not migrate away once again.
Maintenance o periodontallycompromised teeth withdirect splinting: current
materials and options
Fig. 4: The completed splint withdirect bonding composite build-up to achieve a pleasing aestheticresult.
Fig. 5: A case o migration o thecentral incisors.
Fig. 6: A splint done ollowed byrecontouring o the tooth anddirect bonding composite build-ups.
Fig. 2: Grooves prepared on thebuccal surace o the incisors at theincisal third to enable placement othe fbre.
Fig. 1: A common periodontal situ-ation with mobile anterior max-illary teeth causing discomort.(Photos/Provided by Dr. Kakar)
This same technique can be usedroutinely by orthodontists to placepermanent non-invasive quartzsplints.
Another possible use o quartzglass ibre splints is in cases oalveolar ractures. The advent obonding dentistry and the easy-to-use quartz splint ibre make ita very strong contender or thestabilisation and immobilisation oanterior alveolar ractures.
A key actor towards achievingthe end point o a good and long-lasting splint is the base mate-
rial used in conjunction with thecomposite restorative material orbuilding and applying the splint.
It is very important that thesplint unctions like a monoblocand bonds optimally to the enameland dentine. In order to provide
this monobloc eect, the substruc-ture has to chemically bond and bein unison with composite restor-ative material.
In order to provide near-opti-mum bonding, the substructureand the entire monobloc, whichhas to be built up, have to be veryclosely adapted to the teeth aroundall the curves, right into the inter-proximal spaces. This means thatthe ibre material should havephysical properties that allowcurving and very easy manipula-tion into any shape (Figs. 5, 6).
The required materials orachieving a high quality unctionaland aesthetic splint are:
a pre-impregnated glass fibre-
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COSMETIC TRIBUNEThe Worlds Dental Newspaper US Edition
Do you have general comments or criti-
cism you would like to share? Is therea particular topic you would like to see
articles about in Cosmetic Tribune?
Let us know by e-mailing feedback@
dental-tribune.com. We look forward to
hearing from you!
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Published by Dental Tribune America 2010 Dental Tribune America, LLC
All rights reserved.
Cosmetic Tribune strives to maintainutmost accuracy in its news and clini-cal reports. I you nd a actual error orcontent that requires clarication, please
contact Group Editor Robin Goodman [email protected].
Cosmetic Tribune cannot assume respon-sibility or the validity o product claimsor or typographical errors. The pub-lisher also does not assume responsibilityor product names or statements madeby advertisers. Opinions expressed byauthors are their own and may not refectthose o Dental Tribune America.
fCT page 1C
2C Clinical COSMETIC TRIBUNE | OctOber2010
based splinting material; a restorative micro/nano-
illed composite material; a flowable composite mate-
rial; and a bonding agent.
The above only highlights thematerials required and does notlist the armamentarium, which
would consist o a number o spe-cial hand instruments to achievea high quality result and in-ish. Amongst the materials, thebonding agent and the compositerestorative material are depen-dent on the clinicians preerence.
The micro- or nano-illed rangeo products rom any o the indus-try leaders in restorative materialsare most appropriate. A good low-able material is also required tocreate a close it o the splint mate-rial to the tooth surace, while asixth or seventh generation bond-
ing agent would be able to achievethe desired bond strength.
The most critical aspect inachieving the ideal splint outcomeis the selection o the ibre usedas the substructure. There are anumber o options available onthe market. I have tested dier-ent splinting ibres throughout mycareer and quite a number o themhas given very good results andlasted or years.
Available materials have someavourable properties at the costo some other undesirable ele-ments and at times the clinicianhas to choose between sacriicing
several o the desired elements inorder to gain the others. The idealsubstructure ibre material hasthe ollowing properties:
high strength subsequent topolymerisation;
chemically bondable with
composite resin material; available in a pre-impregnat-
ed state; no thicker than 0.2 mm; available in varying widths; easy to trim and cut; and no memory as regards its
orm.
O the above, the last propertyis a critical one. Because o thediicult handling properties o theibre splint, splinting has beena very technique-sensitive proce-dure thus ar.
Unless the clinician wasextremely conversant with all therequisite steps and also extremelyskilul and dexterous in the han-dling o the ibre and composite,the likelihood o a long-term suc-cess would be reduced.
Many splint materials have atendency to a memory, that isthe property o returning to orig-inal shape i deormed underload. This memory o a material
makes it resistant to being shapedaround curves, especially curvesthat double-back, or example theinterproximal areas around thelinguals o lower anterior teeth oraround the curvature o a maxil-lary premolar.
I the material can be abri-cated in such a way that it bendsand adapts around curves withoutbouncing back, it makes adapt-ing and placing the splint in theoral cavity a ar simpler and moreaccurate task.
Glass-based ibres have aninherent tendency to maintaintheir longitudinal direction. This
can easily be observed in any uni-directional ibre splint material.The only way to negate this prop-erty o the ibre is to interweavethe ibres in a cross-stitch pattern.This creates a kind o mesh rame-
work, thereby making the mate-
rial almost ree o memory. Theterm zero memory can then beapplied to such a material, which
will only minimally maintain anyorm to which it is subjected (Figs.710).
Although the material does pos-sess a certain amount o memory,it becomes practically insignii-cant as regards clinical applica-tion. For all practical purposes,the material would then have zeromemory.
My best experience thus arhas been with a very new entry inthe splinting ibre market: QuartzSplint (Recherches TechniquesDentaires). The basic raw mate-rial used in this product is quartzglass, unlike regular glass ibre.This is the same quartz used todevelop endodontic posts, whichdemonstrate cyclic atigue resis-
tance values that are much higherthan desired in the oral cavity.
Quartz glass is also homog-enous with the Bis-GMA rangeo unilled resin, which makesit ideal or use with restorativecomposite material, allowing it
Figs. 1114:The near zero memory propertyo the rope quartz splint demon-strated by distortion intovarious shapes; the materialmaintains its distorted positionwithout any polymerisation.
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Figs. 710: The clinical zero memory eect o the woven quartz splint dem-onstrated by adaptation around the entire curvature o the crown o anextracted molar. The material is not polymerised but stays in the newlyadapted position.
Fig. 8
Fig. 9
Fig. 7
Fig. 10
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3CCOSMETIC TRIBUNE| OctOber2010 Clinical
to become a monobloc with thecomposite. The quartz splint isdeveloped as a woven ibre usingextremely thin strands o glassibres.
The weave pattern imbibescertain physical attributes to thematerial. It allows orce distri-bution in such a manner that itcreate the previously mentioned
clinical zero memory eect andnot resist and inhibit crack propa-gation.
All o the above-mentionedeects are achieved without anycompromise to the strength othe material. In act, the quartzibre will enhance and strengthenthe monobloc that is created withthe amalgamation o the unilledresin, quartz ibre, lowable com-posite, and micro-/nano-illedcomposite material.
Since the material is availablepre-impregnated and is soaked inunilled resin, it becomes all themore easier to use the splint rightout o the box. The zero memory
allows it to be adapted extremelyeasily around a curved arch with-out polymerisation. Once idealadaptation has been achieved, itcan be polymerised in that posi-tion and then layered with micro/nano composite to complete thesplint (Figs. 1114).
Another critical actor in the variety o situations or which asplint is indicated is the widthand thickness o the material. Toothick a material can be an encum-brance or placement and inalpositioning. An ideal thickness isbetween 0.1 and 0.25 mm.
The thinner the material
becomes, the lower its ability toreinorce and strengthen will be.The quartz splint is in the 0.2 mmthickness range, making it useulin almost all clinical situations.
The quartz splint is available ina variety o patterns and widths.
The recommended pattern orintra-oral splinting is the wovenpattern. This is available in widthso 1.5 mm, 2.5 mm and 4 mm. Othese three, the 1 mm design ismost suited or use as a retentionsplint in post-orthodontic casesin which the teeth are neitherextremely mobile nor do theyexhibit gingival recession and loss
o the supporting structures.The 2 mm ibres are most ide-ally suited or teeth alicted withprevious periodontal disease.
When the teeth are large in sizeand exhibit clinical crowns largerthan the anatomical crowns, the 3mm ibre may be used in lieu othe 2 mm ibre.
The quartz splint has a uniquedesign much like a braided rope giving it extremely high lexur-al strength values ater completepolymerisation. The design o thematerial requires it to be between1 and 2 mm in diameter.
A deep groove has to be cut intothe teeth where the splint is being
placed to enable it to be adapt-ed optimally. This design can beutilised when in cases in which anocclusal splint design is used tostabilise maxillary or mandibularpremolars.
Other than the woven and ropepatterns, the quartz splint is avail-able as a unidirectional ibre. Thisis not to be applied in clinical situ-ations, but rather as a laboratoryreinorcement material used todevelop poly-ceramic prostheses.The quartz splint also has a 4 cmx 4 cm mesh that can be applied indenture repairs, or example.
With material beneits aid-
ing and improving the unctionalaspect o splints, there has been anewer approach possible owing tothe enhancement o bonding den-tistry technology. Shade match-ing, polishability, enhanced bondstrength and much longer-lasting
composites have all contributedto a much greater usage o directbonding procedures in everydaydentistry.
The emphasis this has givento aesthetic procedures has beentremendous. Similarly, the quartzibre-based composite splint in a
dentition with pre-existing peri-odontal damage can be enhancedto achieve a much better aestheticresult (Figs. 1519).
Although unction has been theparamount and most critical issue
when placing a periodontal splint,aesthetics now also play an impor-tant role. The patient and theclinician may not be completelysatisied with unction.
It is quite easy to apply standardbonding principles o a diastemaclosure to ensure that the basicsubstructure is appropriatelylocated and thereby enable anexcellent aesthetic outcome withlongevity.
This modiication o a unction-al splint to an aesthetic splint canbe easily applied or anterior teethexhibiting extensive mobility ormigration. Several o these casescan be seen in Figures 1524, in
which the maxillary anterior teethpresented with diastemas and pro-
Fig. 21: Preparations done onthe palatal surace; the areawhere the splint is to be placedhas been grooved.
Fig. 22: A tin oil template placedon the grooved area to measurethe size o the required splint.
Fig. 23: The woven quartz splintplaced in the prepared area onthe palatal surace o the maxil-lary anteriors.
Fig. 24: The completed splint.
Dr. Ajay Kakar is in private practice spe-cialising in periodontics and implantology inMumbai in India. He is the secretary o boththe International Academy o Periodontology
and the Indian Academy o Aesthetic & Cos-metic Dentistry.
He lectures extensively in India and abroadand runs a web portal or Indian dentistry atwww.bitein.com. Kakar can be contacted [email protected] or at +91 98210 15579.
About the author
Fig. 16: Lingual view o thesame patient with mobile lowercentral incisors.
Fig. 15: Buccal view o a patientwith mobile lower central inci-sors.
Fig. 18: Buccal view o the splintdone with the woven quartzsplint.
Fig. 17: A tin oil templateused to measure the size o therequired splint.
Fig. 20_A case requiringpost-orthodontic retentiono the upper incisors; the splint isto be placed on the palatal sur-
ace o the maxillary anteriors.
Fig. 19: Lingual view o thesplint done with the wovenquartz splint.
clinations coupled with mobility.The results have been very satis-actory.
This article has only touched onthe undamental concepts osplints and the new improvisa-tions available in terms o materi-al technology. CT
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