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BALKAN JOURNAL
OF STOMATOLOGY
Official publication of the BALKAN STOMATOLOGICAL SOCIETY

Volume 16 No 2 July 2012

ISSN 1107 - 1141

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Ljubomir TODOROVIĆ, DDS, MSc, PhD

Editor-in-Chief
Faculty of Dentistry
University of Belgrade
Dr Subotića 8
11000 Belgrade
Serbia

Editorial board
ALBANIA
Ruzhdie QAFMOLLA - Editor Address:
Emil KUVARATI Dental University Clinic
Besnik GAVAZI Tirana, Albania
BOSNIA AND HERZEGOVINA
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Naida HADŽIABDIĆ Faculty of Dentistry
Mihael STANOJEVIĆ Bolnička 4a
71000 Sarajevo, BIH
BULGARIA
Nikolai POPOV - Editor Address:
Nikola ATANASSOV Faculty of Dentistry
Nikolai SHARKOV G. Sofiiski str. 1
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FYROM
Julijana GJORGOVA - Editor Address:
Ana STAVREVSKA Faculty of Dentistry
Ljuben GUGUČEVSKI Vodnjanska 17, Skopje
Republika Makedonija
GREECE
Anastasios MARKOPOULOS - Editor Address:
Haralambos PETRIDIS Aristotle University
Lambros ZOULOUMIS Dental School
Thessaloniki, Greece
ROMANIA
Alexandru-Andrei ILIESCU - Editor Address:
Victor NAMIGEAN Faculty of Dentistry
Cinel MALITA Calea Plevnei 19, sect. 1
70754 Bucuresti, Romania
SERBIA
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Slavoljub ŽIVKOVIĆ Faculty of Dentistry
Zoran STAJČIĆ Dr Subotića 8
11000 Beograd, Serbia
TURKEY
Ender KAZAZOGLU - Editor Address:
Pinar KURSOGLU Yeditepe University
Arzu CIVELEK Faculty of Dentistry
Bagdat Cad. No 238
Göztepe 81006
Istanbul, Turkey
CYPRUS
George PANTELAS - Editor Address:
Huseyn BIÇAK Gen. Hospital Nicosia
Aikaterine KOSTEA No 10 Pallados St.
Nicosia, Cyprus

International Editorial (Advisory) Board

Christoph HÄMMERLE - Switzerland George SANDOR - Canada
Barrie Kenney - USA Ario SANTINI - Great Britain
Predrag Charles LEKIC - Canada Riita SUURONEN - Finland
Kyösti OIKARINEN - Finland Michael WEINLAENDER - Austria
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M. Ganibegović N. Forna
Past President: Prof. P. Koidis S. Kostadinović A. Bucur
President Elect: Prof. N. Sharkov A. Filchev M. Carević
Vice President: Prof. D. Stamenković D. Stancheva Zaburkova M. Barjaktarević
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BALKAN JOURNAL
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Official publication of the BALKAN STOMATOLOGICAL SOCIETY

Volume 16 No 2 July 2012

ISSN 1107 - 1141

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VOLUME 16 NUMBER 2 july 2012 PAGES 65-128

Contents

LR P. Papadopoulos Langerhans Cell Histiocytosis: 69

Its Oral and Maxillofacial Dimension

OP M. Pandilova Effects of Local Application of Ascorbic Acid and 74

A. Ugrinska Glutathione by Iontophoresis on Gingival Inflammation
S. Georgieva
M. Popovska
L. Kanurkova
K. Smilevska

OP L. Gavriliuc Salivary Glutathione-Dependent Enzymes in Patients with 79

E. Stepco Dental Fluorosis Treated by Complex Antioxidant Therapy
I. Lupan
N. Sevcenco
I. Spinei

OP A. Dimkov Release of Antimicrobial Agents from 84

E. Gjorgievska Glass Ionomer Cements
A. Fildishevski

OP E. Boteva Efficacy of Working Length Detection and 90

D. Yovchev Irrigation during Preparation of Curved Root Canals

OP T.T. Akbay Salivary Thromboplastic Activity May Indicate 94

M. Guvercin Wound Healing after Tooth Extraction
O. Gonul
A. Yarat
S. Akyuz
R. Pisiriciler
K. Göker

OP D. Veleski Biophysical Principles of the AcryLock Attachments Use in 98

B. Pejkovska Contemporary Prosthetic Dentistry
M. Antanasova

CR K. Tolidis Intraoral Ceramic Restoration Repair Techniques: Report of 3 Cases 103

P. Gerasimou
C. Boutsiouki

CR B. Vanlıoğlu A Multidiscipline Approach to Improve Aesthetics in a Patient with 109
Y. Özkan High Lip Line: A Clinical Report
Y. Kulak-Özkan
Balk J Stom, Vol 16, 2012 67

CR L. Mavriqi The Use of Advanced Technology to Avoid Injury of the 112

E. Baca Inferior Alveolar Nerve during Implant Surgery
A. Vjeshta

CR S. Karamanis Bony Lid Approach in Dentoalveolar Surgery: Report of 2 Cases 116

D. Tsoukalas
A. Traskas
N. Parissis

CR S. Dalampiras Technique of Frenectomy of Labial Fraenum with 122
C. Boutsiouki Combined Osteotomy at Intermaxillary Suture

CR B. Evrosimovska Fracture of the Maxillary Tuberosity: A Case Report 125

B. Velickovski
Z. Menceva
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Langerhans Cell Histiocytosis:

Its Oral and Maxillofacial Dimension

SUMMARY Petros Papadopoulos

This paper reviews clinical, histological and pathological characteristics Private Practice
of Langerhans Cell Histiocytosis (LCH) in relation to its oral and maxillofacial
interest. For purposes of better examination, LCH is differentiated into 3
syndromes: Hand-Sculler-Cristian (HSC) disease, Letterer-Siwe (LS) disease
and Eosinophilic Granuloma (EG). Abnormal proliferation of histiocytic cells
with Birbeck granules is found in all 3 of them.
The cause of LCH is related to abnormal proliferation of Langerhans
Cells (LCs) which are mononuclear phagocyte system cells concentrated
in oral gingival sulcular and junctional epithelium. LCH appears to attack
patients of any age, especially young children. Its predilection sites are
the maxilla and the mandible. In LS disease, ulceration of oral mucosa,
premature loss of teeth, suppuration or haemorrhage, all are common
symptoms. Moreover, in HSC soreness, generalized stomatitis and bone
destruction are found. EG preserves all the above characteristics and
underlines a delayed healing after extraction and pathologic fractures.
The diagnosis is served by radiographic images, which show solitary
intraosseous lesions, defined periphery and multiplicity of alveolar bone
lesions, bone sclerosis or root resorption. Early diagnosis improves the
prognosis and effectiveness of the treatment. The weapons against LCH are:
surgery, corticosteroids and alkylating agents.
Keywords: Langerhans Cell Histiocytosis; Hand-Sculler-Cristian Disease; Letterer-Siwe LITERATURE REVIEW (LR)
Disease; Eosinophilic Granuloma; Alveolar Bone; Bone Destruction Balk J Stom, 2012; 16:69-73

Introduction Its dental interest derives from its special histo­

The term Histiocytosis X was introduced by Lichten­
stein in 1953 for a group of diseases that produce 3
syndromes with similar clinical and histopathological
features1: Hand-Sculler-Cristian (HSC) disease, Letterer-
Siwe (LS) syndrome and Eosinophilic Granuloma (EG).
Since all 3 diseases have an abnormal proliferation of
histiocytic cells with characteristic Birbeck granules, a
differentiation between them has been abandoned and the
term “Langerhans Cell Histiocytosis” (LCH) is commonly
used nowadays2.
LCH develops in childhood as well as in adulthood3.
It can involve many organ systems but primarily affects
bone, skin, lymph nodes, lung, liver and spleen, endocrine
glands and nervous system4.
pathological characteristics referring to the oral and
maxillofacial region, as well as its relationship to certain
dental pathologies. This comprises the reason of a review
of all the aforementioned syndromes, which can be proven
useful either for general dentists or for specialized ones.
Role of Langerhans Cells in Oral
Pathology
Langerhans Cells (LCs) are bone marrow derived
cells that belong to the mononuclear phagocyte system
and (or) dendritic system5. In gingiva they are present in
3 areas: (1) the oral gingival epithelium; (2) the sulcular
70 Petros Papadopoulos
epithelium; (3) the junctional epithelium. They are located
in the suprabasal and spinous layers of the oral gingival and
sulcular epithelium. In the junctional epithelium, 2 types
of Langerhans cells can be observed. The first type with
a spherical morphology possesses a few short dendrites
and is weakly stained for Castleman’s Disease (CD) 1a
Thymocyte (T) 6 antigen. The other type exhibits dendrites
of moderate length and number with varied fluorescence
intensity against CD1a T6 antigen6. These heterogeneities
could represent different stages of a dynamic process
leading to an accumulation in number of LCs7.
Much experimental evidence has shown that there
are differences both in LC numbers and in surface
antigen expression between healthy and diseased
gingiva. Consequently, LC could represent “key” cells in
pathogenesis and development of periodontal disease8.
Moreover, the relationship between an increased number
of LCs and plaque accumulation was demonstrated in men
during experimental gingivitis. More LCs were found in
the inflamed gingiva in comparison to healthy gingiva
from the same patients. Many studies also suggested an
increase of the LCs in moderate gingival inflammation,
but a decreased number of LCs in periodontitis compared
with the controls. The numerical diminution of LCs
in the passage from gingivitis to periodontitis reveals
an important role of these cells in the pathogenesis of
gingival disease.
In contrast to gingivitis and periodontitis, a
satisfactory explanation of the proliferation of LCs in the
lesions of LCH is still missing, although its appearance is
definitely related to this proliferation9.
Histology (Microscopy)
For purposes of a better examination of the histology
of the disease, its differentiation into the 3 syndromes
we mentioned in the introduction could be critical.
Consequently:
1. Hand-Schuller-Cristian disease (chronic disseminated)
comprises of multiple lesions in the bones and soft
tissues initially, with some visceral lesions developing
later8. Except of the skin lesions, which are typical
nodules in flexures, a crusted scalp rash mimicking
seborrheic dermatitis may also be seen. Oral lesions
include gingivitis, ulcerations and destructive
granulomas involving the mandible and the maxilla.
Gingival tissue shows a dense infiltrate (histiocytic)
throughout most of the connective tissue. The nuclei
of the histiocytes are, for the most part, regular with
some vacuolisation. There is a significant number of
eosinophils scattered throughout much of the infiltrate.
2. Letterer-Siwe disease (acute disseminated): It
demonstrates an excessive proliferation of histiocytes
that accumulates in tissues. It can also include
Balk J Stom, Vol 16, 2012
nodular foci. Oral manifestations such as gingivitis
and ulcers as well as oral bleeding and eventual loss
of teeth are present10.
3. Eosinophilic granuloma of bone (chronic focal): It
can be solitary or multifocal11.
LCs are associated with eosinophils and often other
types of granulocytes in variable number. LCs have
pale, vesiculated, weakly eosinophilic cytoplasm and
nuclei that appear folded or lobulated. Mitotic activity
is typically absent. Eosinophils may be scattered among
the LCs or histiocytes. By electron microscopy, Birbeck
granules may be seen in LCs. They appear as lamellar
plates with a central striated line. They occasionally have
a terminal vesicular dilatation giving them a racquet
shape.
Incidence and Dental Predominant
Sites
LCH is considered a childhood disease, but the
diagnosis is often made in adults as a likely evolution of
the juvenile form12. It seems to be more frequent in males
than in females, with a reported ratio ranging from 1:1
to 4:113. In adults, there is a much greater variation with
a slight predominance of female patients12. It is very
interesting to notice that in a review of 1120 patients,
Hartman reported oral involvement in 10% of the cases.
a. LS disease: There is no special information about the
incidence of the LS disease. It particularly affects
infants or young children, under the age of 2 years,
predilection sites being the alveolar parts of the
maxilla and the mandible;
b. HSC disease occurs mainly in children or adults. The
maxilla and the mandible may be the first structures
to show signs of this condition14. It commonly affects
older children, between ages of 5 and 10, but may be
seen in any group;
c. EG constitutes about 50% to 60% of all Histiocytosis
X cases15. It is a disease with an incidence of 1 new
case/350000-2 million per year16, 17.
Approximately 75% of all patients are below 20
years of age2. Predominant locations are the flat bones,
with frequent involvement of the mandible in patients
less than 20 years old. Individuals over the age of 50 are
uncommonly affected.
Oral Manifestations
In case of the LCH, the first manifestations and
symptoms occur in the mouth5 and identification is
necessary for the diagnosis of the disease. The leading
Balk J Stom, Vol 16, 2012
symptom of the LCH within mandibular and maxillary
bones is pain, which sometimes is misdiagnosed as a
marginal infection2. There is also loosening of teeth,
as common presenting complains of the patients, as
well as necrotising and ulcerating defects of the mucosa
and jaw swelling5. The ulcerations are accompanied
by granulomatous exophytic tissue in the areas of the
attached gingiva in the maxilla, extending to the palate
anteriorly and posteriorly18.
In clinical cases without bone involvement, palatal,
lingual and vestibular bilateral ulcerations were recorded
in molar maxillary and mandibular regions. Submucosal
nodules were also recorded in the superior and inferior
frontal gums19. Except from pain,, a burning sensation
and spontaneous and mechanically induced bleeding
during oral hygiene procedures were noticed. The upper
and lower third molar regions were more inflamed and
painful19.
More specifically referring to each entity of the
disease separately, we can look into the following
signs and symptoms of oral involvement of the LCH:
(1) The LS syndrome -ulcerations of oral mucosa,
diffuse destruction of bone, premature loss of teeth,
haemorrhage, foul breath, suppuration; (2) The HSC
disease - generalised stomatitis, soreness, haemorrhage
from the gums, ulceration and necrosis of the oral mucosa,
progressive bone destruction of the alveolar process,
loosening and premature loss of teeth, facial asymmetry;
(3) The EO - periodontitis localised in an otherwise
healthy dentition, loss of alveolar bone with the area of
destruction replaced by soft tissue, delayed healing after
extraction teeth, premature loss of teeth, foul breath,
solitary soft tissue involvement may affect the tongue and
may also be confused with traumatic granuloma20.
In the EO, pathologic fractures may occur especially
in the long bones15. It is also useful to underline the fact
that in the HSC disease, typical lesions of the disease
involve the cranial bones, the eyes (exophthalmia) and
the pituitary gland (diabetes insipidus), whereas in the
LS disease, the syndrome is characterised by lymph
node, spleen and liver involvement, with a severe clinical
course12.
Diagnosis - Radiographic Image
An effort to find out the diagnosis of LCH would
be surely incomplete and insecure without taking into
consideration the radiographic image of the disease. LCH
presents as localised punched out radiolucencies with no
calcification and no sign of sclerosis or reaction at the
borders. There may be severe alveolar bone resorption
producing an appearance of teeth “floating in space”.
Panoramic radiograph and computerised tomography is
used for this purpose21. Moreover, in the EO of the jaws,
Langerhans Cell Histiocytosis 71
the borders of the lesions are mostly well delineated,
whereas in the HSC disease the lesions appear as round,
oval or irregular areas with sharp margins. In the jaws,
these areas look like cysts.
Concentrically, several studies showed at least 7
radiographic characteristics occurred frequently with LCH
of the jaws, such as the solitary intraosseous lesions that
are located outside the alveolar process, the multiplicity of
“alveolar bone” lesions or the well defined periphery. The
periphery of the lesions of LCH in the jaws is considered
to be well defined but uncorticated.
Another radiographic characteristic is the scooped
out shape. This occurs because bone destruction starts
below the crest of the alveolar process. Usually, a portion
of the superior aspect of the crest of the alveolar bone is
maintained at the mesial and distal margins of the area
of destruction and produces the scooped out appearance.
Bone sclerosis is a common observation in inflammatory
lesions of the jaws, and the fact that it appears frequently
in the alveolar bone lesions might be explained by
communication of the lesions with the oral cavity, that
results in a superimposed infection. Periosteal new bone is
observed in intraosseous lesions. The identification of the
presence of this thin layer of bone is highly dependent on
the projections available for study. Finally, root resorption
associated with lesions of the LCH is always very slight22.
It is necessary to notice the need of biopsies along
with immunohistochemistry to confirm the diagnosis of
the LCH and ascertain the nature of cells involved in the
lesions detected18. The infiltration cells in LCH are S-100,
CD1, CD4 and Human Leukocyte Antigen (HLA)-DR
positive. Electron microscopy will also detect the presence
of Birbeck granules23.
Differential Diagnosis
The puzzle of a successful diagnosis is completed by
the fulfilment of the differential one: clinically, the LCH
is difficult to be distinguished from bone metastases,
osteomyelitis or even malignant tumours. The final
diagnosis of the LCH can be made only by histology.
Morphologically, the cells are characterised by lobulated
nuclei, basophilic nuclei and eosinophilic cell plasma.
By immunohistochemistry, tumour cells usually express
S-100 and CD-1a. The detection of cytoplasmic inclusion
bodies known as Birbeck-Breatuach granules is a typical
characteristic of the LCH24. Besides histopathologic
diagnosis, a bone scintigraphy is mandatory to exclude
or to detect additional lesions. A common extraosseus
manifestation can be found in the lungs25.
The clinical appearance and course of the presenting
lesions usually suggest a differential diagnosis including
other causes of chronic ulceration, such as trauma,
necrotizing sialometaplasia, tuberculosis or deep fungal
72 Petros Papadopoulos
infection. Although T-cell lymphoma might manifest
as an ulcer, growth is very rapid and progressive, with
destruction of underlying bone. In contrast, in the LCH,
the ulcer may maintain the same appearance for months.
Another differential diagnostic possibility is
melanoma, although the presence or not of pigmentation
allows clinically to distinguish it from the LCH.
As mentioned above immunohistochemistry is very
useful to confirm diagnosis. S-100 positivity might prove
sufficient, in the appropriate light microscopic setting and
with negative immunohistochemical studies for Human
Melanoma Black (HMB)-45, leukocyte common antigen
(LCA) or CD3026.
Prognosis
Generally, the prognosis for patients with the various
forms of LCH has improved steadily with the advent of
an early and successful diagnosis and the evolution of a
more effective treatment. However, clinical prognosis
of patients will become worse with the growing number
of involved organs, with growing number of oral
dysfunctions27, with rapid disease progression, with
limited treatment response and decreasing age of the first
disease manifestation22.
Early onset is associated with bad prognosis.
In younger children, before the age of 3, the disease
progresses rapidly and is fatal. Late onset is associated
with milder forms of the disease. Prognosis is excellent
in isolated EO of bone, which may heal spontaneously.
There is a 90-95% recovery. Prognosis is also good to
very good in multiple EO’s restricted to bone15. Moreover,
soft tissue involvement is associated with bad prognosis.
In bone and soft tissue involvement, the mortality
rate is 50%. In HSC disease the mortality rate has been
estimated to be 30%. In LS disease the outcome is usually
fatal. Death usually ensues within 1-3 years from bone
marrow depletion, toxicity, septicaemia haemorrhage
and exhaustion. In HSC death usually ensues from
opportunistic infections, intracranial extension and
anaemia. Long survival is an exception in LS disease. In
infants, it is very acute and rapidly fatal.
Treatment
The treatment of LCH is dependent on the lesion
size and the degree of tissue involvement, and thus differs
from unifocal or multifocal (monostotic or polyostotic)
presentations26. Surgery, in particular for solitary bone
lesions, is still the treatment of choice. Following
radiation therapy, patients frequently experience pain
relief; however a complete remission is seldom achieved2.
Balk J Stom, Vol 16, 2012
In some large or multifocal lesions, it is necessary to
follow surgical curettage with radiation therapy.
Oral lesions are treated by topical corticosteroids
(betamethasone dipropionate 0.05% and sometimes in
combination with topical antifungals (miconazole oral gel)
to avoid oral Candida infections. The patient undergoes
frequent oral professional hygiene sessions to minimize
mucosal and periodontal damage.
Particularly, in the LS disease with a poor prognosis,
therapy consists of steroids used in conjunction with
a cytotoxic drug. Alkylating agents provide a more
definite suppressing action. Vinblastin has proved to
be a medication of value. Moreover, in recent years,
drug treatment, especially in cases of multiorgan
involvement, gains more and more importance. Such
drugs are 2-deoxycoformin, etoposide, vinblastin28-30,
mercaptopurine, methotrexate, predisolone, interferon31
and interleukin14.
Concluding Remarks
As it is well understood, the most important
parameter in the analysis of a disease as a scientific issue
is its cure. Generally speaking about cure of the LCH, not
only in jaws but as a multi-system threat, very interesting
questions are born such as: is LCH a malignant or an
inflammatory disorder? Should all LCH patients receive
therapy?
Concerning the first question, clinical data is
ambigual. Clonal expansion of LC, but not lesional
T-cells, was defined by the human androgen receptor
(HUMARA) DNA assay as well as T-cell receptor
analysis32. These findings have led many aficionados of
LCH to strongly state that it is a malignant proliferation.
Given certain CGH/LOH results from clonal versus
nonclonal LCH, the controversy on the malignant nature
of the LCH seems far from settled33,34.
About the second question (whether should all
LCH patients receive therapy), the studies show distinct
conclusions. The simple answer is no when including
single skull lesions in the frontal, parietal or occipital
areas and other skeletal lesions. However, it would be a
mistake to say that LCH is a slowly progressive disease
in which a “wait and see” approach should be adopted.
This is especially true of pulmonary, jaw and skin disease
of adults. Smoking cessation may be effective in some
patients with lung disease, but they need to be monitored
carefully since the insidious progression of cystic changes
and fibrosis can rob the patients of vital lung function.
Heroic surgery for jaw disease results in
disfigurement and loss of teeth, whereas a 6 month
course of viblastine and prednisone can cure the disease
and allow reformation of the bone with no loss of
dentition. Finally, painful and disturbing perineal ulcers
Balk J Stom, Vol 16, 2012
of LCH in women are best treated with chemotherapy or
thalidomide, not radiation.
This whole description reveals the importance of the
existence of such questions as the above. These prove to
be the basis of further evolution of scientific studies about
certain subjects of great medical concern35.
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23. Odam RB, James WD, Berger TG. Andrews’ Disease of the
skin. 9th ed. Philadelphia: WB Saunders Co, 2000; pp 913-917.
24. Chu T, Taffe R. The normal Langerhans cell and the
Langerhans cell histiocytosis cell. J Cancer, 1994; 23:4-9.
25. Malpas TS, Norton AJ. Langerhans cell histiocutosis in the
adult. J Med Pediatr Oncol, 1996; 27:540-546.
26. Milian MA, Bagan JV, Jimenez Y. Langerhans cell
histiocytosis restricted to the oral mucosa. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod, 2001; 91:76-79.
27. Giona F, Caruso R, Testi AM, et al. Langerhans cell
histiocytosis in adults. A clinical and therapeutic analysis
of eleven patients from a single institution. J Cancer, 1997;
80:1786-1791.
28. Basade MM, Nair CN, Kurkure PA, et al. Etoposide in
Langerhans cell histiocytosis in children: a preliminary
experience. Med Pediatr Oncol, 1996; 13:159-162.
29. Gadner H, Heitger A, Grois N, et al. Treatment strategy for
disseminated Langerhans cell histiocytosis. Med Pediatr
Oncol, 1994; 23:72-80.
30. Ladisch S, Gadner H, Aric M, et al. LCH-I: a randomized
trial of etoposide vs. vinblastine in disseminated Langerhans
cell histiocytosis. The Histiocyte Society. Med Pediatr
Oncol, 1994; 23:107-110.
31. Hirose M, Saito S, Yoshimoto T, et al. Interleukin – 2 therapy
of Langerhans cell histiocytosis. Acta Paediatr, 1995;
84:1204-1206.
32. William CL, Busque L, Griffith BB, et al. Langerhans
cell histiocytosis (histiocytosis X) - a clonal proliferative
disease. N Engl J Med, 1994; 331:154-160.
33. Murakami I, Gogusev J, Fournet JC, et al. Detection of
molecular cytogenetic aberrations in Langerhans cell
histiocytosis of bone. Hum Pathol, 2002; 33:555-560
34. Dacic S, Trusky C, Bakker A, et al. Genotypic analysis of
pulmonary Langerhans cell histiocytosis. Hum Pathol,
2003; 34:1345-1349.
35. Mc Clain KL, Natkunam Y, Swerdlow SH. Atypical cellular
disorders. Hematology, 2004; pp 283-296.
Correspondence and request for offprints to:
Petros Papadopoulos
Th. Sakellaridi 25a
542 48 Thessaloniki, Greece
E-mail: peterpap77@yahoo.gr
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BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141

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Effects of Local Application of Ascorbic Acid and

Glutathione by Iontophoresis on Gingival Inflammation

SUMMARY Maja Pandilova1, Ana Ugrinska2,

Management of gingival inflammation is always a priority in dental Silvana Georgieva1, Mirjana Popovska1,
Lidija Kanurkova1, Katerina Smilevska1
practice, regardless the possible involvement of other periodontal tissues.
1University Dental Clinical Centre “St.
Besides the use of systemic medical therapy, such as antibiotics, vitamins are
Pantelejmon”
also recommended as a complementary therapy. Nutritional vitamin intake 2Faculty of Medicine,
has been proven effective on gingival inflammation. The aim of this study Institute of Pathophysiology and
was to evaluate the effects of local application of glutathione and ascorbic Nuclear Medicine “Akademik Isak Tadzer”
acid by iontophoresis on gingival tissue inflammation. Skopje, FYROM
60 patients with periodontal disease were divided into 2 groups: the
control group was treated by conservative treatment of periodontal disease
only, and the study group was treated by ascorbic and glutathione, applied
with iontophoresis in 10 sessions, besides conservative treatment. Values for
gingival inflammation and gingival bleeding on probing were noted.
The obtained results showed significant differences for both gingival
inflammation and gingival bleeding between the examined groups, with
significant decrease in index values for gingival bleeding after 3 months in
the study group. ORIGINAL PAPER (OP)
Keywords: Gingival Inflammation; Iontophoresis; Ascorbic Acid; Glutathione Balk J Stom, 2012, 16:74-78

Introduction when taken in natural forms, like fruits and vegetables14.

Managing gingival inflammation is one of the first
challenges that every peridontologist faces, no matter if
the process is located only in the gingival tissue, or severe
periodontal destruction had taken place. Furthermore,
control of infection and gingival inflammation is
necessary regardless the following course of periodontal
therapy, conservative or surgical. Keeping inflammation
under control is even more important in the maintenance
period.
The methods used for dealing with gingival
inflammation are various, such as: removal of local
irritations, training the patients to maintain optimal plaque
control, and applying different kinds of medication.
Besides the antibiotic therapy, which in certain cases is
applied, for control of inflammation and creating better
conditions for managing microorganism challenge,
vitamins are often used as a supplemental therapy. The
effects of vitamins on the gingival tissue are confirmed
Receiving vitamins as supplements in a chemical way
(pills, tablets), according to our previous examinations15
did not show measurable results.
Therefore the aim of this study was to verify the
effects, if any, of topical appliance of ascorbic acid and
glutathione delivered by iontophoresis in the gingival
tissue, on gingival inflammation.
Material and Methods
For realization of our goal 60 patients with
periodontal disease, randomly selected, participated in the
study. The selected patients met the following criteria:
●● None of the patients had attachment lost on probing
greater then 5 mm;
●● None of the patients had any systematic disease, or
was receiving any drugs;
Balk J Stom, Vol 16, 2012 Application of Ascorbic Acid and Glutathione by Iontophoresis 75

●● All patients had forefeel the conditions for Table 2. Average index values for gingival bleeding for the
iontophoresis (patients with heart disease and control group
pregnant women were excluded from the study);
X Sd Se t p
●● All patients were between 35 and 45 years of age;
●● All patients, according to their history, brushed their Before therapy 2.76
teeth twice a day and occasionally used additional After therapy 1.56 0.55 0.11 11.39 <0.001
products for inter-dental cleaning. 3 months after therapy 2.20 0.72 0.09 4.26 <0.001
●● Patients were separated in 2 different groups, 30
patients each: The study group also had a significant decrease
●● The control group, treated only with conservative of gingival inflammation and gingival bleeding after
treatment; the performed therapy (inflammation went from 2.30
●● The study group, treated by iontophoresis with to 0.93 and gingival bleeding went from 2.66 to 0.77).
ascorbic acid and glutathione beside the conservative Nevertheless, the index values after the 3-month period
treatment. showed bigger stability for the study group compared with
Ascorbic acid was applied by all standard procedu­ the control group (Tabs. 3 and 4).
res, depending on the individual patients’ sensitivity of
current strength and the transportability of molecules of Table 3. Average index values for gingival inflammation for the
the applied solution. After a 30 min break, to each patient study group
of the study group, glutathione was applied as solution on
the electrodes covered with sterile gaze soaked in solution X Sd Se t p
of distilled water and 0.9% NaCl. The iontophoresis of Before therapy 2.30
glutathione was performed from the active electrode After therapy 0.93 0.61 0.11 12.17 <0.001
with negative charge for a period of 15 minutes. Both 3 months after therapy 1.01 0.70 0.09 10.30 <0.001
glutathione and ascorbic acid were applied every day
during period of 10 days.
All patients were trained to maintain oral hygiene Table 4. Average index values for gingival bleeding for the
and were called 3 months later for a control visit. examined group
Gingival inflammation and gingival bleeding were
X Sd Se t p
noted according to the criteria proposed by Silness and
Loe22, for each patient on his/her first visit, after the Before therapy 2.66
treatment, and on the recall visit after 3 months. Data After therapy 0.70 0.66 0.11 16.10 <0.001
were statistically processed by the computer programme 3 months after therapy 0.86 0.61 0.09 16.15 <0.001
Statistics 5.

Discussion
Results
The general idea of our study was to administrate
After processing the data we gained the following ascorbic acid and glutathione directly in gingival
results: both groups expressed excellent results during tissue in order to accomplish favourable ratio between
therapy according to the given criteria. The control group over-generated reactive oxygen species (ROS) and
had a significant decrease of gingival inflammation index antioxidants. ROS are highly reactive molecules which
and gingival bleeding after initial therapy: inflammation in their last electron circle have the ability to gain or
went from 2.46 to 0.83 and gingival bleeding from 2.76 lose 1 electron. This kind of structure makes them
to 1.56. However, on the control visit after 3 months, highly unstable, so they persist only a very short period
gingival inflammation was 1.40, while gingival bleeding of time (a nanosecond or less). Even so, they can cause
was almost at the start point (Tabs. 1 and 2). serious damages on the cellular level. They are taught to
be responsible for autoimmune diseases, atherosclerotic
changes and cancerous growth.
Table 1. Average index values for gingival inflammation for the
Once created, ROS can interact among themselves,
control group
which is most preferred outcome, yet less likely to
X Sd Se t p happen considering their brief life time. As long as the
production of ROS is in physiological range, the organism
Before therapy 2.46 ties them up in order to make them stable. But when
After therapy 0.83 0.80 0.11 11.06 <0.001 their production is increased or when the antioxidant
3 months after therapy 1.40 0.86 0.09 6.71 <0.001
system is exhausted, then the increased presence of ROS
76 Maja Pandilova et al.
start a chain reaction of creating more free radicals, even
more reactive and damageable from the initial one. The
chain reaction will run until the one of the antioxidant
mechanisms stops it.
ROS production is inevitable in all aerobic
organisms, including humans, who necessarily posses a
complex system of antioxidant defence8,21. If homeostasis
is interrupted in favour of ROS, an oxidative stress
situation is created21. Oxidative stress processes and
alterations in the immune system are closely related and
have been described in different diseases, thus both the
aspects also seem to be linked to the pathogenesis of
periodontal disease, and can also be detected in plasma
of patients with periodontal disease8,16,21. However, the
extent to which ROS over-generation influences the
initiation and progression of periodontal diseases is still
unknown.
The strong evidence linking ROS to the pathological
destruction of the connective tissue during periodontal
disease rests on the presence of neutrophil infiltration
as the main event in the host's response to bacterial
invasion1,2,10,19. The hydroxyl radical is able to initiate
a classical chain reaction, known as lipid peroxidation,
leading to vasodilatation and rat bone reabsorption8. An
example of the damage caused by hydrogen peroxide is
stimulation of phosphorylation of the NFkB-kB complex,
activating the NK-kB and facilitating nuclear translocation
and downstream of pro-inflammatory cytokines, including
IL-2, IL-6, IL-8, β-interferon and TNF-α, that are very
important in the pathogenesis of periodontal disease9.
Experiments concerning the effects of ROS
are generally focused on the effects of gingival
inflammation. Such experiments, conducted on lab
animals treated with pesticides, and given food with
lowered elementary antioxidant, showed desquamation
of the epithelium, swelling, elasticity loose and breaking
of the collagen, bone resorption and lowered speed of C
prolin incorporation, thickening of the blood vessels and
thrombosis with all it’s consequences5. On the contrary, in
another study, the lab animals were treated with ascorbic
acid, tocopherol and biophlavonides. In this experiment,
less inflammatory-destructive process was noticed12.
Mentioned data raises the questions on developing
pharmaco-prophylactic measures with bio antioxidants
and other bio-regulatives as an addition to the primary and
preventive treatment of periodontal disease.
The chain of inhibition of ROS: glutathione
- ascorbic acid - tocopherol, with transportation of
electrons from pironucleotides (NAD NADF) towards
ROS, guarantees permanent low level of free radicals in
the cells. Applying glutathione at periodontal disease has
proven to be effective in the early stages of the disease.
Beside glutathione, other antioxidants can be used with
good results such as: tocopherol or ascorbic acid12,13.
Glutathione (GSH) is a tripeptide of glutamine,
glycine, and cysteine. It is not an essential nutrient, since
Balk J Stom, Vol 16, 2012
it can be synthesized in the body from the amino acids
L-cysteine, L-glutamic acid, and glycine, and acts directly
as a generic ROS scavenger of the so-called Phase II
reactions17. GSH has multiple functions: it is the major
endogenous antioxidant produced by cells, participating
directly in neutralization of free radicals and reactive
oxygen compounds, as well as maintaining exogenous
antioxidants, such as vitamins C and E, in their reduced
active forms20. It is used in metabolic and biochemical
reactions, such as DNA synthesis and repair, protein
synthesis, prostaglandin synthesis, amino acid transport,
and enzyme activation.
Some periodonto-pathogenic bacteria deplete
GSH, and this may explain why the amount of this
antioxidant was not elevated in the gingival tissue of
patients with periodontal disease1,2,10. A similar result
was obtained in gingival tissue and blood, and lower
levels of GSH were detected in the crevicular gingival
fluid of patients with chronic periodontal disease, when
compared to normal subjects1,2. Systemic depletion of
antioxidants clearly indicates that in chronic periodontal
disease the antioxidant system is affected by a relatively
strong oxidation insult, which can deplete nutritional
antioxidants, such as vitamin E and C in plasma, and also
vitamin E in red cell membrane16.
According to the literature data on the positive effect
of this kind of additional therapy with vitamins, and in
our previous studies, we confirmed that individuals which
on regular daily base use citrus and citrus like fruits have
less gingival inflammation and gingival bleeding from
those who never use it, or use it occasionally14. But in
our further studies we got to the conclusion that if the
vitamins are received chemically (as pills) the significant
results were not achieved15.
In order to be able to get better topic apply of
antioxidants, directly in the gingival tissue, we decided to
use permeability of the oral mucosa and enhance the drug
appliance by electric current using iontophoresis. The
permeability barrier in oral mucosa is believed to be the
result of intercellular material derived from the so-called
‘membrane coating granules’ (MCG)6. MCG start forming
through cell differentiation and at the apical cell surfaces
they fuse with plasma membrane. This barrier is present in
the outermost 200 µm of the superficial layer. Permeation
studies have been performed using a number of very large
molecular weight tracers, such as horseradish peroxidase
and lanthanum nitrate3. After being applied to the outer
surface of the epithelium, these tracers penetrate only
through outermost layer of cells. When applied to the
submucosal surface, they permeate up to the top cell
layers of the epithelium. While the basement membrane
may present some resistance to permeation, the outer
epithelium is considered to be the rate limiting step to
mucosal penetration11.
There are 2 permeation pathways for passive
drug transport across the oral mucosa: paracellular
Balk J Stom, Vol 16, 2012
and transcellular routes4. These 2 routes can be used
simultaneously, but 1 route is usually preferred over the
other, depending on the physicochemical properties of
the drug. Since the intercellular spaces and cytoplasm
are hydrophilic in character, lipophilic compounds
would have low solubility in this environment. The cell
membrane is lipophilic in nature and hydrophilic solutions
will have difficulty permeating24.
Iontophoresis is a procedure based on the use of
galvanic electricity and provides easy, fast and effective
absorption of different kinds of substances in the tissue.
Iontophoresis accomplishes faster metabolism of cells
by movement of ions in the bodily fluids and opening on
canals in the cell’s membrane which create possibilities
for easer absorption of different liquid substances in
the tissue. Iontophoresis enhances drug delivery by 3
mechanisms: ion-electric field interaction provides an
additional force that drives ions through the tissue, the
flow of electric current increases the permeability of
the mucosa, and electro-osmosis produces bulk motion
of solvent that carries ions or neutral species with the
solvent stream. Electro-osmotic flow occurs in a variety
of membranes and is in the same direction as the flow of
counter-ions. It may assist or hinder drug transport18,23.
Iontophoresis can also enhance mucosa delivery by
a possibly dependant pore formation in the upper stratum
cell layer, attributed to a “flip-flop” gating mechanism that
occurs due to restructuring of the polypeptide helices on
application of electric current. Iontophoretic transport is
capable of producing a 100 fold enhancement relative to
passive diffusion7,23.
The achieved effects from our study were expected.
Inflammation and gingival bleeding showed significant
decrease of the average index values for both groups
after the therapy without noticeable difference between
the groups. Noticeable data were achieved for the
average index value for gingival bleeding after 3 months
had passed. Since our study design didn’t include
methods of tracing the given medicaments into the
tissue, the concentration they achieve and length of their
permeability, the prolonged improvement of clinical
parameters may convince us that we had created better
host environment.
It is worth mentioning that during our study same
problems occurred. Convincing the patients from the
study group to undertake the procedure was an issue,
since applied at the way we did the procedure, it was
rather time consuming for both patient and doctor. So
further work might be focused towards developing a
hydro-gel containing these or some other drugs and, using
iontophoretic enhancers, the time of appliance could be
shortened.
Discoloration of the mucosa did not appear in any of
the patients, since both agents are used in dermatology as
blanching agents.
Application of Ascorbic Acid and Glutathione by Iontophoresis 77
The achieved results of this study speak in favour of
applying ascorbic acid and glutathione by iontophoresis
in everyday clinical practice, especially for a long term
maintenance on once achieved results of periodontal
therapy.
References
1. Chapple ILC, Brock G, Eftimiadi C, Matthews JB.
Glutathione in gingival crevicular fluid and its relation to
local antioxidant capacity in periodontal health and disease.
J Clin Pathol, 2002; 55(6):367-373.
2. Chapple ILC. Role of free radicals and antioxidants in the
pathogenesis of the inflammatory periodontal diseases. J
Clin Pathol, 1996; 49:247-255.
3. Collins LMC. The Surface Area of the Adult Human Mouth
and Thickness of the Salivary Film Covering the Teeth and
Oral Mucosa. J Dent Res, 1987; 66:1300.
4. DeVries ME, Verhoef JC, Junginger HE. Developments in
buccal drug delivery. Crit Rev Ther Drug Carr Sys, 1991;
8:271.
5. Enwonwu C. Cellular and molecular effects of malnutrition
and their relevance to periodontal diseases. J Clin
Periodontol, 1994; 21:643-657.
6. Gandhi RE. Indirect atomic absorption determination of
atropine, diphenhydramine, tolazoline, and levamisole
based on formation of ion-associates with potassium
tetraiodometrcurate. Ind J Pharm Sci, 1988; 50:142.
7. Gangarosa LP, Sr. Iontophoresis in dental practice.
Chicago: Quintessence Publ Co Inc, 1983; p 40-52. 
8. Halliwell B, Gutteridge JMC. Free Radicals in Biology and
Medicine. Oxford: Clarendon Press, 1998; pp 617-783.
9. Honda T, Domon H, Okui T, Kajita K, Amanuma R,
Yamazaki K. Balance of inflammatory response in stable
gingivitis and progressive periodontitis lesions. Clin Exp
Immunol, 2006; 144(1):35-40.
10. Katsuragi H, Ohtake M, Kurasawa I, Saito K. Intracellular
production and extracellular release of oxygen radicals by
PMNs and oxidative stress on PMNs during phagocytosis of
periodontopathic bacteria. Odontology, 2003; 91(1):13-18.
11. Lee JW, JHP, Robinson JR. Bioadhesive-based dosage
forms: The next generation. J Pharm Sci, 2000; 89:850.
12. Meydani SN, Meydani M, Blumberg JB, Leka LS, Siber
G, Loszewski R, Thompson C, Pedrosa MC, Diamond
RD, Stollar BD. Vitamin E supplementation and in vivo
immune response in healthy elderly subjects. A randomized
controlled trial. JAMA, 1997; 277(17):1380-1386.
13. Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M,
Genco RJ. Dietary vitamin C and the risk for periodontal
disease. J Periodontol, 2000; 71(8):1215-1223.
14. Pandilova M, Ivanovski K, Ugrinska A, Minovska A,
Radojkova V, Ristoska S. The effect of nutritional vitamin
intake on periodontal health. Abstract Book of the 9th
Congress of the Balkan Stomatological Society, Ohrid
2004; p 97.
15. Pandilova M, Ugrinska A, Ivanovski K. Effects of nutritional
tocopherol intake on periodontal health. Mak Stom Pregl,
2009; 33(1-2):95-101.
78 Maja Pandilova et al.
16. Panjamurthy K, Manoharan S, Ramachandran CR.
Lipid peroxidation and antioxidant status in patients with
periodontitis. Cell Molec Biol Letters, 2005; 10(2):255-264.
17. Pompella A, Visvikis A, Paolicchi A, De Tata V, Casini AF.
The changing faces of glutathione, a cellular protagonist.
Biochemical Pharmacology, 2003; 66(8):1499-1503.
18. Rai R, Srinivas CR. Iontophoresis in dermatology. Ind J
Dermatol Vener Leprol, 2005; 71:236-241.
19. Sakallioğlu U, Aliyev E, Eren Z, Akşimşek G, Keskiner
I, Yavuz Ü. Reactive oxygen species scavenging activity
during periodontal mucoperiosteal healing: an experimental
study in dogs. Arch Oral Biol, 2005; 50(12):1040-1046.
20. Scholz RW. Graham KS, Gumpricht E, Reddy CC.
Mechanism of interaction of vitamin E and glutathione in
the protection against membrane lipid peroxidation. Ann NY
Acad Sci, 1989; 570:514-517.
21. Sculley DV, Langley-Evans SC. Salivary antioxidants
and periodontal disease status. Proc Nutr Soc, 2002;
61(1):137-143.
Balk J Stom, Vol 16, 2012
22. Silness P, Loe H. Periodontal disease in pregnancy. Acta
Odontol Scand, 1964; 22:121.
23. Semalty A, Semalty M, Singh R, Saraf SK, Saraf S.
Iontophoretic drug delivery system: A review. Technology
and Health Care, 2007; 15(4):237-245.
24. Wertz PW. The physical, chemical and functional properties
of lipids in the skin. Chemistry and Physics of Lipids, 1998;
91:85.
Correspondence and request for offprins to:
Pandilova Maja
University Dental Clinical Centre „St. Panteleimon”
Department of Oral Pathology and Periodontology
Skopje
FYR Macedonia
E-mail: mpandilova@yahoo.com
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Salivary Glutathione-Dependent Enzymes in

Patients with Dental Fluorosis Treated by
Complex Antioxidant Therapy

SUMMARY Ludmila Gavriliuc1, Elena Stepco2,

Introduction. Fluorosis, caused by long-term intake of high levels Ion Lupan2, Nina Sevcenco2, Iurii Spinei2
of fluoride, is characterized by clinical manifestations in teeth. Although State University of Medicine and Pharmacy
fluorosis is irreversible, it could be prevented by appropriate and timely “Nicolae Testemitanu”, Chisinau
intervention through understanding the process at biochemical and Republic of Moldova
1Biochemistry and Clinical Biochemistry
molecular levels. Increased production of reactive oxygen species (ROS)
Department
and lipid peroxidation has been considered to play an important role in the 2Department of Oral-maxillofacial Surgery and
pathogenesis of chronic fluoride toxicity. Saliva as a biological liquid of the Orthodontics of Children Dentistry
human organism may be a reflection of the metabolic state, and salivary
parameters are clinical-diagnostic means.
Aim. The aim was to examine comparatively activities of glutathione-
dependent enzymes, glutathione reductase and glutathione-S-transferase,
and contents of glutathione, calcium and protein in the saliva of adult
patients with dental fluorosis, before and after complex antioxidant therapy.
Material and Methods. 26 patients (19-30 years old) with mild and
moderate dental fluorosis (Dean’s classification: 3 and 4) and 20 healthy
subjects (20-30 years old) were examined. Patients were treated with
complex therapy, which included “Opalescente Whitening gel” (Ultradent
products, USA), calcium gluconate and vitamins-antioxidants A, E, D and C.
The activities of glutathione-dependent enzymes and contents of glutathione,
calcium and protein were determined in the saliva of the patients using
spectrophotometric methods.
Results. Chronic fluoride intoxication led to the imbalance of anti-
oxidative glutathione-dependent defense system in the patients with dental
fluorosis. The results reflected dose-dependent fluoride intoxication and
metabolic imbalance. The results suggest that complex antioxidant therapy
was effective and partially restored imbalance of the anti-oxidative defense
of saliva in patients with fluorosis.
Conclusion. Non-invasive methods of the glutathione-dependent
enzymes examination may be used in dental practice for estimation of the
degree of metabolic disturbances in patients with dental fluorosis. ORIGINAL PAPER (OP)
Keywords: Glutathione; Glutathione reductase; Glutathione-S-transferase; Fluorosis Balk J Stom, 2012; 16:79-83

Introduction many parts of the world (India, China, Canada, USA,

France, Bulgaria, Romania, etc.) where drinking water
Dental fluorosis, caused by long-term intake of high contains more than 1 ppm of fluoride5. In certain regions
levels of fluoride, is characterized by clinical manifestations of the Republic of Moldova people use drinking water with
in teeth1. Fluorosis is a serious public health problem in high level fluoride, from 0.8 mg/L to 14.0 mg/L (Tab. 1).
80 Ludmila Gavriliuc et al.
Table 1. Fluoride concentration in drinking water in different
regions of Moldova
Regions C= mg/L Regions C= mg/L
Anenii Noi 1.7-3.0 Hincesti 2.0-5.5
Cimislia 1.78-3.2 Glodeni 2.0-8.16
Orhei 2.1-3.7 Ungheni 5.7
Floresti 3.21-3.7 Falesti 3.2-8.7
Chiadir-Lunga 2.6-4.7 Pirlita 9.0-14.0
Dental fluorosis is a developmental disturbance of
dental enamel caused by successive exposures to high
concentrations of fluoride during tooth development,
leading to enamel with lower mineral content and
increased porosity. This subsurface porosity or hypo-
mineralization is most likely caused by a delay in
hydrolysis and removal of enamel proteins, particularly
amelogenin, as the enamel matures4.
The severity of dental fluorosis depends on when
and for how long the overexposure to fluoride occurs,
the individual response, weight, physical activity,
nutritional factors and bone growth5,17,20. The risk period
for aesthetic changes in permanent teeth is between 20
and 30 months of age20. The recommended level for
daily fluoride intake is 0.05-0.07 mg F/kg/day, which is
considered of great help in preventing dental caries, acting
in remineralisation. A daily intake above this safe level
leads to an increased risk of dental fluorosis. The effects
of fluoride on enamel formation suggest that fluoride
affects the enamel-forming cells, the ameloblasts3.
Fluor is the most active halogen, which is
widespread. Intoxication by fluoride leads to chronic
oxidative stress and numerous pathological consequences:
DNA damage, inhibition of type I collagen synthesis,
altered activities of enzymes and metabolic lesions14,18.
Increased free radical generation and lipid peroxidation
(POL) are proposed to mediate the toxic effects of
fluoride on soft tissues and teeth. Oxidative stress
was evaluated by the assays of malondialdehyde and
antioxidants in patients with fluorosis. Increased POL and
altered levels of antioxidants were observed in the blood
of children with endemic skeletal fluorosis14. Many results
are about investigation of POL and antioxidant defense
system in human blood and urine. Data of examinations
of salivary components in patients with fluorosis are not
numerous and contradictory12,14.
Saliva, as a biological liquid of human organism,
may be a reflection of the metabolic state. Salivary
components (indices) have clinical-diagnostic means11,16.
Non-invasive methods of the salivary parameters
examination may be used in dental practice for estimation
of the degree of metabolic disturbances in patients with
dental fluorosis.
Balk J Stom, Vol 16, 2012
The aim of this investigation was to examine
comparatively activities of glutathione-dependent
enzymes, glutathione reductase and glutathione-S-
transferase, and the content of glutathione in saliva of
adult patients with dental fluorosis, before and after
complex antioxidant therapy.
Material and Methods
26 patients (19-30 years old) with mild and moderate
dental fluorosis (Dean’s classification: 3 and 4) and 20
healthy subjects (20-30 years old) were examined.
Patients were treated with complex therapy, which
included “Opalescente Whitening gel” (Ultradent
products, USA), calcium gluconate (1.5 g/day) and
vitamins-antioxidants A (retinol palmitate -100 000 U/
day), E (alfa-tocopherol acetate -100mg/day), D3 (600 U/
day) and C (ascorbate - 100mg/day). The first course of
antioxidant therapy (AOT) was during 30 days, the second
AOT course was repeated 1 year after the first AOT. The
salivary parameters (indices) were examined 3 times
during the treatment: before the therapeutic course and
twice after the AOT processes.
Saliva was collected in the morning, before breakfast
(8 am), and centrifuged at 600 g for 10 min. After
centrifugation saliva was examined using SP “Humalyzer
2000” (Germany). The contents of glutathione, protein,
calcium, activities of glutathione reductase and
glutathione-S-transferase were determined in saliva by
spectrophotometric methods. Glutathione reductase (GR,
E.C. 1.6.4.2) activity was determined with the method
already described9. Glutathione-S-transferase (GST,
E.C. 2.5.1.18) activity was determined with the method
described by Habig and Jacoby10. Glutathione’s content14,
calcium-ions (Ca2+) content2 were determined by
corresponding methods, and protein content by pyrogallol
photometric test19. The results were statistically analyzed
with Student’s t-test and Microstat: Microsoft Excel 2003
programme.
Results
Examination of patients with dental fluorosis showed
the sufficient difference between contents of their salivary
indices and the control group (healthy subjects). Results
of the comparative examination of the slivery parameters
are shown in figure 1. The content of protein determined
in saliva of patients with fluorosis before treatment was
1.40 g/L (152.5%; p<0.001) in comparison with the
healthy subjects (0.920 g/L). Concentration of salivary
calcium (Ca2+) in patients was 1.428 mmol/L (59.9%;
p<0.001) in comparison with healthy subjects (2.383 g/L).
Balk J Stom, Vol 16, 2012
Figure 1. Contents of protein (g/L and calcium (mmol/L) in the saliva of
patients with dental during complex antioxidant therapy (AOT) courses
(1 - protein, left - healthy, right - before treatment; 2 - protein, left - 1st
AOT, right - 2nd AOT; 3 and 4 - calcium)
The first AOT course decreased the protein content
to 1.065 g/L (116.0%; p>0.05) and increased calcium
content to 2.042 mmol/L (85.69%; p>0.05). The
second AOT decreased the protein content to 1.016 g/L
(110.7%; p>0.05) and increased calcium concentration
to 2.117 mmol/L (88.8 %; p>0.05).
Figure 2. The content of glutathione (1) in saliva of patients with dental
fluorosis after complex AOT, and activities of glutathione reductase (2),
glutathione-S transferase (3). The first column - before treatment, the
second - after the 1st AOT, the third - after the 2nd AOT
(healthy subjects - 100%)
The results of the activity of glutathione-dependent
enzymes and content of glutathione in saliva in patients
with dental fluorosis during antioxidant therapeutic
courses are shown in figure 2. Results are the evidence
that in patients before the treatment the salivary
glutathione content was 89 mcmol/L (37.08%; p<0.01 in
Complex Antioxidant Treatment of Dental Fluorosis 81
comparison with the healthy individuals - 240 mcmol/L).
After the first AOT, its content increased to 173 mcmol/L
(72.08%; p<0.05) and after the second course of AOT it
increased to 274 mcmol/L (114.17%, p>0.05). In saliva
of the patients with dental fluorosis the glutathione
reductase activity was 130.9 U/L (78.3%; p<0.01 in
comparison with the healthy individuals - 167.1 U/L).
After the first AOT, the activity of glutathione reductase
was 101.6 U/L (60.8%; p<0.01) and after the second
AOT course it increased to 121.6 U/L (72.8%; p<0.05).
Glutathione-S-transferase activity in saliva in patients
with fluorosis was increased before treatment (3598 U/L),
i.e. 122.9% (p<0.05 in comparison with healthy subjects
- 2927 U/L). After the first AOT course it decreased to
3450 U/L (117.87%; p<0.05), and even more after the
second AOT (2801 U/L), which is 95.7% of the values of
healthy subjects (p>0.05).
Discussion
The long-term intake of high levels of fluoride with
drinking water leads to dental fluorosis. Fluorosis is a
serious public health problem in many countries where
drinking water contains high level of fluorides. Treatment
of patients with fluorosis, which affects both young
and old alike, has posed a daunting task of the medical
fraternity. Children have been affected by fluorosis of
teeth that is one of the clinical manifestations of the
disease and metabolic disturbances.
Saliva as a biological liquid of the human organism
may be a reflection of the metabolic state. Also, salivary
components have clinical-diagnostic means. Our results
point out that parameters of saliva in patients with dental
fluorosis differ from the same parameters of the control
group (healthy persons). In saliva of our patients with
dental fluorosis the content of protein was increased,
which may confirm the dentinal-enamel porosity and
removal of enamel proteins to patients’ saliva. AOT
courses decreased its content in saliva of the patients.
Our yearly results of creatinine, urea, proline and
hydroxyproline determination in saliva of the patients
with dental fluorosis were also different from the same
parameters of healthy persons7. The described parameters
of saliva in the patients with dental fluorosis reflect
disturbance of the protein metabolism.
Mineral components of saliva constitute one third of
all salivary substances, which play an important role for
teeth, soft tissues and mouth enzymes. Calcium (Ca2+)
is one of the main elements necessary for bones and
teeth formation. It is also needed for many processes in
82 Ludmila Gavriliuc et al.
human organism: moving of nerve impulse, contraction
and tonus of muscles, blood clotting (the IV plasmatic
factor), stabilizer of α-amylase, etc. Determination of
Ca2+-ions concentration in saliva in the patients with
fluorosis showed its decreasing value. It is logical to
assume that all the above-mentioned processes with Ca2+-
ions participation may be changed in patients with dental
fluorosis as well6. Both courses including complex AOT
and calcium gluconate increased its concentration in
saliva of the patients.
Main biological role of glutathione reductase is
based on the reduction of oxidized glutathione (GSSG)
to its reduced form (GSH) with utilization of NADPH+.
Hydrophilic antioxidant glutathione is the main
component of redox-buffer system of the intracellular
medium. Glutathione-associated metabolism is a major
mechanism for cellular protection against agents which
generate oxidative stress and POL. Recent genetic and
biochemical evidence has demonstrated that glutathione
and glutathione-dependent enzymes play a central role
in the cellular defense against toxic agents. Enzyme
glutathione-S-transferase catalyzes the conjugation of
GSH with different toxic and mutagenic compounds,
which are generated during POL processes. Chronic
intoxication by fluoride leads to metabolic imbalance
of antioxidant enzymes and reflects the decrease of
glutathione content and activity of glutathione reductase
in saliva of patients with dental fluorosis. Also,
intoxication leads to the increase of of glutathione-S-
transferase activity in saliva of the patients. Complex
therapy, including AOT and calcium gluconate,
increased content of glutathione and decreased activity
of glutathione-S-transferase in saliva of patients with
dental fluorosis. We found negative correlation between
the content of glutathione and clinically manifested
characteristics of the disease in patients with dental
fluorosis8. There was a direct relationship between
the activity of glutathione-S-transferase and clinical
manifestations.
We found the direct correlation between clinical
characteristics, reflecting the level of the pathological
process, and metabolic imbalance, which can allow more
correct estimation of the intoxication degree caused by
fluoride intake (Invention G2 MD, 2006)8.
Conclusions
On the basis of our results, we can confirm that
in patients with dental fluorosis an imbalance between
salivary parameters/indices takes place as a result of
Balk J Stom, Vol 16, 2012
chronic intoxication with fluoride content in drinking
water. The imbalanced salivary components - calcium,
protein and glutathione-dependent enzymatic defense
system, including glutathione, glutathione reductase and
glutathione-S-transferase, were partially corrected by
complex antioxidant therapy. Moreover, 2 AOT courses
were more effective than only 1 course. In all fluoride-
endemic regions of different countries it is necessary to
carry out prophylactic actions, especially laying emphasis
on small schools, pregnant women and feeding mothers.
These prophylactic actions will decrease the risk of
chronic intoxication by fluorides.
References
1. Alvarez JA, Rezende KM, Marocho SM, Alves FB, Celiberti
P, Ciamponi AL. Dental fluorosis: exposure, prevention
and management. Med Oral Patol Oral Cir Bucal, 2009;
14(2):E103-107.
2. Barnett RN. Photometric test, CPC method. J Clin Pathol,
1973; 59:836.
3. Bronckers AL, Lyaruu DM, DenBesten PK. The impact
of fluoride on ameloblasts and the mechanisms of enamel
fluorosis. J Dent Res, 2009; 88(10):877-893.
4. DenBesten PK. Mechanism and timing of fluoride effects
on developing enamel. J Public Health Dent, 1999;
59(4):247-251.
5. Fluorides Environmental Health. Criteria 227. World Health
Organization. Geneva, 2002.
6. Gavriliuc L, Stepco E, Godoroja P, Hornet V. Imbalance
of certain components of saliva patients with fluorosis.
J Oral Health Dental Management Black Sea Countries
(Constanta, Romania), 2004; 3(4/10):15-19.
7. Gavriliuc LA, Stepco EA, Hornet VI, Mocan EI, Cheptanaru
CF, Godoroja PD. Imbalance of the biochemical parameters
in saliva of patients with fluorosis. Curierul Medical
(Chisinau, Moldova), 2005; 2(284):10-13.
8. Gavriliuc LA, Stepco EA, Spinei IuG, Godoroja PD. Method
of differential diagnostics of fluorosis. BOPI: MD 3163 G2,
(Chisinau, Moldova), 2006; 10:32.
9. Gerasimov AM, Koroleva LA, Brusov OS, Olfer’ev AM,
Antonenkov VD, Pancenko LF. Enzymatic mechanisms of
inhibition of peroxide oxidation in different regions of rat
brain. Vopr Med Khim (Mosk), 1976; 22(1):89-94.
10. Habig WH, Jacoby WB. Assays for differentiation of
glutathione S-transferase. Methods in Enzymology, 1981;
77:398-405.
11. Hofman LF. Human saliva as a diagnostic specimen. J Nutr,
2001; 131(5):1621-1625.
12. Huang Z, Li K, Hou G. Study on the correlation of the
biochemical indexes in fluoride workers. Zhonghua Lao
Dong Wei Sheng Zhi Ye Bing Za Zhi, 2002; 20(3):192-194.
13. Miao Q, Xu M, Liu B. In vivo and in vitro study on the
effect of excessive fluoride on type I collagen of rats. Wei
Sheng Ian Jiu, 2002; 31(3):145-147.
14. Shivarajashankara JM. Oxidative stress in children with
endemic skeletal fluorosis. Fluoride, 2001; 34:103-107.
Balk J Stom, Vol 16, 2012 Complex Antioxidant Treatment of Dental Fluorosis 83

15. Sedlak I, Lindsay RH. Estimation of total protein bound 20. Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington
and nonprotein sulfhydryl groups in tissue with Ellman’s HV, Marinho VC. Topical fluoride as a cause of dental
reagents. Anal Biochem, 1968; 25(2):192-198.
fluorosis in children. Cochrane Database Syst Rev, 2010;
16. Streckfus CF, Bigler LR. Saliva as a diagnostic fluid. Oral
Dis, 2002; 8(2):69-76. (1):CD007693.
17. Susheela AK, Bhatnagar M. Reversal of fluoride induced
cell injury through elimination of fluoride and consumption
of diet rich in essential nutrients and antioxidants. Mol Cell
Biochem, 2002; 234-235(1-2):335-340. Correspondence and request for offprints to:
18. Vani ML, Reddy KP. Effect of fluoride accumulation on
Prof. Ludmila Gavriliuc
some enzymes of brain and gastrocnemius muscle of mice.
State University of Medicine and Pharmacy “Nicolae Testemitanu”
Fluoride, 2000; 33:17-26.
19. Watanabe N, Kamei S, Ohkuto A. Urinary protein as Department of Biochemistry and Clinical Biochemistry
measured with a pyrogallol red-molybdate complex: Bul. Stefan cel Mare 165, Chisinau
Manually and in a Hitachi 726 automated analyzer. Clin MD 2004 Moldova
Chem, 1986; 32:1551-1554. e-mail: gavrlu@yahoo.com
 L SOCIETY
BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141

CA
GI
LO
TO
STOMA

Release of Antimicrobial Agents from

Glass Ionomer Cements

SUMMARY Aleksandar Dimkov, Elizabeta Gjorgievska,

Aleksandar Fildishevski
The aim of this study was to determine the level of antimicrobial
agents Benzalkonium Chloride and Cetylpyridinium Chloride released Faculty of Dentistry, Clinic for Pediatric and
from ChemFlex, a conventional glass ionomer cement (GIC). The main null Preventive Dentistry, Skopje, FYROM
hypothesis tested was that there is no release of antimicrobial agents into
the surrounding medium. 3 groups of the conventional ChemFlex GIC of
5 samples each, with Benzalconium Chloride and CPC incorporated, were
prepared - each group with a different percentage of the agents (1%, 2%,
and 3%). The determination of the quantity of the antimicrobial agents was
done by an UV- Spectrophotometer. The measurements were performed at
11 successive time intervals.
The results of the statistical analysis point out that it is possible to
incorporate these antimicrobial agents in conventional GIC, especially when
the added percentage of the antimicrobial agents is 3%. ORIGINAL PAPERS (OP)
Keywords: GIC; Antimicrobial Agents; UV-Spectrophotometry Balk J Stom, 2012; 16:84-89

Introduction application9. There are several studies dealing with

Because of the relatively frequent occurrence of
recurrent caries after a restorative treatment, and because
of the huge number of cariogenic microorganisms
existing in the oral cavity, which present a potential
risk factor regarding the development of new carious
lesions, attention has increasingly been directed toward
therapeutic antimicrobial effects of restorative materials.
The glass ionomer cements (GIC) distinguish
themselves as most acceptable restorative materials
possessing the positive characteristics of fluorine in the
processes of remineralization and antimicrobial action1-4.
Their usage is determined by their characteristic to release
fluorine and to participate in the mechanism of inhibition
of the secondary caries development5-7. At the same time
they also act upon the surrounding bacteria by reducing
the cariogenic microorganisms8.
In addition to the release of fluoride ions, GIC
can potentially be used as matrices for the release of
other active antimicrobial components. In regard to the
incorporation of antimicrobial agents, chlorhexidine
has been described as a golden standard for antibacterial
the effect of incorporating chlorhexidine in different
concentrations and its combinations in GIC to improve
their antimicrobial properties10-14.
There are only a few data in the literature referring
to the incorporation and release of other antimicrobial
components in GIC. Although a part of them have a
confirmed effect in the reduction of cariogenic salivary
flora when used in rinses or toothpastes, the results
regarding their incorporation in GIC are still scarce15-18.
Cetylpyridinium Chloride (CPC), as an active component
of oral antiseptics, has a broad antimicrobial spectrum
with a strong bactericidal effect on Gram positive
pathogens and a fungicidal effect. Its effectiveness
against gram negative pathogens and mycobacteria is
questionable19,20. The official US pharmacopoeia accepts
Benzalkonium Chloride as an auxiliary antimicrobial
agent15. It is the major antimicrobial agent in numerous
toothpastes and mouth rinses.
The objective of this study was to determine the
level of release of the antimicrobial agents Benzalkonium
Chloride and Cetylpyridinium Chloride from the
conventional GIK ChemFlex, previously incorporated
Balk J Stom, Vol 16, 2012
with various concentrations of antimicrobial agents.
The null hypothesis tested was that there is no release
of antimicrobial agents into the surrounding medium,
and that there are no differences due to the type of
antimicrobial agents and their represented percentages.
Materials and Methods
Material
The commercially available conventional GIC that
was used in the analyses was a material being widely
applied in restorative dentistry (ChemFlex, DENTSPLY
DeTrey, Konstanz, Germany). The composition of this
GIC is shown in table 1. The antimicrobial compounds
used in the study were: Cetylpyridinium Chloride (C0732
by Sigma - Aldrich Co.) and Benzalkonium Chloride
(12660 by Fluka Chemical Corporation Milwaukee, WI,
USA).
Table 1. The material used in the research
Material Classification Composition Manufacturer
Strontium,
aluminium, DENTSPLY
Conventional
fluoride, silicate, DeTrey,
ChemFlex glass-ionomer
tartaric acid, Konstanz,
cement
pigments, Germany
polyacrylic acid
3 groups of the conventional GIC ChemFlex of 5
samples each, with Benzalkonium Chloride incorporated,
were prepared - each group with a different percentage of
the agent (i.e. 1%, 2% and 3%); and another 3 5 sample
groups, but with Cetylpyridinium Chloride incorporated,
were also prepared - each group having the corresponding
percentage of the agent (1%, 2% and 3%).
Preparation of Samples
The antimicrobial compounds Benzalkonium
Chloride (BCH) and Cetylpyridinium Chloride (CPC)
were first incorporated into the GIC’s polyacrylic acid
by mixing, and then the powder was added gradually,
to the previously prepared acid and antimicrobial
compound mixture, and they were mixed together until
complete saturation. The antimicrobial agents were
added in strict portions of 1, 2 and 3% of the weight
of the cement. The determination of the concentration
(weight) of BCH and CPC was done by measuring the
given percentage of the antimicrobial agent with an
analytical balance. Preceding analyses had determined
the concentrations of 1, 2 and 3% of antimicrobial agents
to be equivalent to 0.0022 g, 0.0044 g and 0.0066 g, of
Antimicrobial Agents Release from GIC 85
the whole cement mass. The freshly mixed paste was
placed into 6 mm high metal moulds having 4 mm in
diameter. The moulds had been closed by metal plates
on both sides, placed in special clamps and then placed
in an incubator at 37oC for 1 hour (maturation time).
After their removal from the incubator, the specimens
were taken out from the clamps and moulds, and stored
individually in separate marked plastic tubes with 5 ml
de-ionized water at a temperature of 22–24oC and at an air
humidity of 40–50% . The sample tubes had been chosen to
allow minimal contact between the specimen and the tube
and therefore allow diffusion of antimicrobial agents from
all surfaces of the specimens into the surrounding aqueous
medium.
Determination of the Antimicrobial Agents
(UV-Spectrophotometric Analysis)
The determination of the quantity of the antimicrobial
agents was done by a so UV- Spectrophotometer, and the
results were expressed in Absorbance Units (AU). The
spectrophotometer was calibrated using BCH and CPC
solution with predetermined concentrations. The UV
spectrophotometer was set to a detection wavelength of
maximal absorption (214 nm) for BCH, and 259 nm for
CPC.
The measurements were performed at 11 successive
time intervals as follows: 15, 30, 45 min, 1, 2, 3, 4, 24 hr,
7, 14 and 30 days. During the entire period, the de-ionized
water where the samples were stored was not changed.
The statistical analysis of the results was performed
using the 1-way ANOVA, the Post-hoc-Tukey honest
significant difference (HSD), and the Mann-Whitney U
Test.
Results
The analysis of the variances (ANOVA) showed a
statistically significant difference between the average
values over the tested period in the group ChemFlex
+ BCH both for 1%, 2% and 3%, where p=0.000000
(Tab. 2). According to the post-hoc-Tukey honest
significant difference test (HSD), the difference was
statistically significant at 1% ChemFlex + BCH for
p=0.000 between the average values at 24 hr, 7, 14 and
30 days and in respect to all other average values. In the
case of 2% of the same compound, the difference was
statistically significant for p=0.000 between the average
values at 2, 3, 4 and 24 hr, 7, 14 and 30 days and in
respect to all other average values, whereas in the case of
3% it was statistically significant for p=0.000 between the
average values at 7, 14 and 30 days and in respect to all
other average values.
86 Aleksandar Dimkov et al. Balk J Stom, Vol 16, 2012

Table 2. The average values of ChemFlex + Benzalkonium Chloride for the 3 tested concentrations over the test period
(data obtained in AU)
ChemFlex + ChemFlex + ChemFlex +
Time Benzalkonium Chloride 1% Benzalkonium Chloride 2% Benzalkonium Chloride 3%
MEAN ± (SD) MEAN ± (SD) MEAN ± (SD)
15 min 0.01 (0.00) 0.01 (0.00) 0.03 (0.01)
30 min 0.02 (0.00) 0.01 (0.00) 0.03 (0.01)
45 min 0.02 (0.00) 0.01 (0.00) 0.03 (0.01)
1 hour 0.02 (0.00) 0.01 (0.00) 0.04 (0.02)
2 hours 0.05 (0.01) 0.04 (0.00) 0.05 (0.01)
3 hours 0.05 (0.01) 0.04 (0.00) 0.05 (0.01)
4 hours 0.05 (0.01) 0.08 (0.00) 0.05 (0.01)
24 hours 0.07 (0.02) 0.06 (0.01) 0.07 (0.02)
7 days 0.14 (0.02) 0.16 (0.01) 0.15 (0.02)
14 days 0.12 (0.04) 0.20 (0.00) 0.17 (0.03)
30 days 0.19 (0.03) 0.25 (0.00) 0.23 (0.03)
p 0.000000 0.00 0.000000

In the group ChemFlex + CPC the analysis of the
variances shows a statistically significant difference between
the average values over the tested period in the case of 1%
CPC for p=0.000000, in the case of 2% CPC for p=0.000000
and the case of 3% CPC for p=0.000103 (Tab. 3). According
to the post-hoc-Tukey honest significant difference test
(HSD), when the differences in the average values were
tested individually, in the case of 1% CPC it was statistically
significant for p=0.000 between the average values at 7, 14
and 30 days; in the case of 2% it was statistically significant
for p=0.000 between the average values at 7, 14 and 30 days
in respect to all other average values; in the case of 3% CPC,
it was statistically significant for p=0.04 between the average
values at 15, 30 min and 24 hr, and at 4 hr, 24 hr and 7 days.

Table 3. The average values of ChemFlex + Cetylpyridinium Chloride for the 3 tested concentrations over the test period
(data obtained in AU)
ChemFlex + Cetylpyridinium ChemFlex + Cetylpyridinium ChemFlex + Cetylpyridinium
Time Chloride 1% Chloride 2% Chloride 3%
MEAN ± (SD) MEAN ± (SD) MEAN ± (SD)
15 min 0.01 (0.00) 0.03 (0.01) 0.06 (0.01)
30 min 0.02 (0.00) 0.02 (0.00) 0.05 (0.01)
45 min 0.02 (0.00) 0.03 (0.00) 0.06 (0.01)
1 hour 0.02 (0.00) 0.02 (0.00) 0.06 (0.01)
2 hours 0.02 (0.00) 0.03 (0.01) 0.06 (0.01)
3 hours 0.02 (0.00) 0.03 (0.01) 0.08 (0.01)
4 hours 0.02 (0.00) 0.03 (0.01) 0.09 (0.01)
24 hours 0.03 (0.00) 0.04 (0.01) 0.09 (0.01)
7 days 0.09 (0.01) 0.08 (0.00) 0.09 (0.00)
14 days 0.12 (0.02) 0.07 (0.00) 0.06 (0.01)
30 days 0.11 (0.06) 0.11 (0.01) 0.08 (0.01)
p 0.00000 0.00000 0.000103
Balk J Stom, Vol 16, 2012 Antimicrobial Agents Release from GIC 87

The difference in the average values obtained by
treatment with ChemFlex + BCH 1% and ChemFlex +
CPC 1% was statistically significant between the values
at 2, 3, 4, 24 hours and 7 days for p<0.05; the other
differences were statistically insignificant for p>0.05
(Tab. 4). The difference in the average values obtained
by treatment with ChemFlex + BCH 2% and ChemFlex +
CPC 2% was statistically significant between the values
at 15, 30, 45 min, 4 hr and 7,14 and 30 days for p<0.05;
the other differences were statistically insignificant for
p>0.05. The difference in the average values obtained
by treatment with ChemFlex + BCH 3% and ChemFlex
+ CPC 3% was statistically significant between the
values at 15, 30, 45 min, 1 and 4 hr and 7, 14 and 30
days for p<0.05; the other differences were statistically
insignificant for p>0.05.

Table 4. Mann-Whitney U Test for the average values between groups treated with ChemFlex + Benzalkonium Chloride and
ChemFlex + Cetylpyridiniun Chloride

ChemFlex + BCH 1% ChemFlex + BCH 2% ChemFlex + BCH 3%

Time ChemFlex + CPC 1% ChemFlex + CPC 2% ChemFlex + CPC 3%
p-level p-level p-level
15 min 0.174526 0.016294* 0.047203*
30 min 0.676104 0.009024* 0.047203*
45 min 0.250593 0.009024* 0.047203*
1 hour 0.117186 0.174526 0.047203*
2 hours 0.009024* 0.174526 0.117186
3 hours 0.016294* 0.174526 0.075801
4 hours 0.009024* 0.009024* 0.028281*
24 hours 0.009024* 0.075801 0.117186
7 days 0.016294* 0.009024* 0.009024*
14 days 0.464703 0.009024* 0.009024*
30 days 0.016294 0.009024* 0.009024*

* - Statistical significant

Discussion The finding that the specimens containing higher

This study is a part of a comprehensive study
dealing with the possibility to incorporate antimicrobial
components from the group of quaternary ammonium
compounds in conventional GIC.
The results show a continual release of the
antimicrobial compounds, starting at 15th minute, with
a tendency of increase at all periods of measurement.
The highest values were obtained at the end of the test
time period, i.e. after one month, and for the highest
tested concentration - 3%. The conclusion drawn from
the statistical analysis stresses that the addition of BCH
and CPC shows highly significant differences between
the average values over the tested period and between
the different percentages, and the incorporation of 3%
antimicrobial components into GIC as being the most
appropriate.
concentrations of antimicrobial agent (3% in this case)
released proportionally its higher amounts is in agreement
with the results of Ribeiro and Ericson21. In contrast to
our study the GIC used were ChemFil and AquaCem. The
concentrations of the antimicrobial agents used were also
different (7.5% and 8.2% w/w) chlorhexidine digluconate,
respectively, and 13.3% w/w of chlorhexidine diacetate. In
contrast to our study, the specimens used by the authors
of the aforementioned study had far lower dimensions
(3 mm diameter and 1.5 mm thickness). Chlorhexidine
digluconate was quickly released from AquaCem and after
5 days no measurable increase of concentration was seen.
This tendency was also seen with diacetate /AquaCem.
Similar to the previously mentioned results are those
obtained by investigating the use of an experimental GIC
as a carrier for the release of chlorhexidine acetate21.
The concentrations range was from 0.5% to 13.0% of
88 Aleksandar Dimkov et al.
chlorhexidine acetate by weight. In contrast to our study,
release into water was examined using high-performance
liquid chromatography. The specimens had an internal
diameter of 10 mm and a thickness of 1 mm. In this
case the release of the antimicrobial compound had also
occurred relatively soon, all measurable chlorhexidine
was released within 22 hr; however, that was less than
10% of the total mass incorporated in the specimens.
In both quoted papers, incorporation of the
antimicrobial compound was made in the GIC powder.
Contrary to this, in this study, incorporation of the 2
antimicrobial compounds was in the GIC liquid, because
of the chemical structure of the antimicrobial compounds
and the better distribution of the long chains of the
quaternary compounds in a liquid medium. The data that
an increased percentage of incorporated chlorhexidine
acetate gave an increased release into the water is in
correspondence with our results. The increasing amounts
of incorporated antimicrobial agents (chlorhexidine
diacetate) did not result in significant increases in eluted
concentrations, which is in contrast to our study and also
in contrast to the studies mentioned above14.
Attempts have been made to incorporate
antimicrobial compounds in other restorative materials by
investigating the ability of incorporation of antimicrobial
agent CPC in the resin matrix22. Among the antimicrobial
properties of the resin, the releasing of CPC into water was
investigated as well, using a UV-vis spectrophotometer
during the different time periods. The results revealed that
less than 0.11 AU of CPC was released into water for all
specimens. In our case, the release of CPC in water in the
amount of 0.11 AU+/–0.2 AU was noted on the 14th and
30th day on an average in 1% ChemFlex + CPC; on the
30th day on the average for 2%, and on the 30th day in one
specimen for 3% ChemFlex + CPC.
As for this study, there is a question of the
cumulative effect of the compounds in the medium
(de-ionized water). The increase of the level of released
compounds increase with time, which speaks of additional
dilutions of the compounds in the medium. In order
to see the anticariogenic effect of the compounds on
the oral flora, i.e. in order to make a parallel with the
effect that would have occurred inside the oral cavity, it
would be necessary to perform certain microbiological
analyses as well. Even though the majority of studies
analyze the release of the compounds in a fresh medium
before each measurement, the cumulative effect of the
leached antimicrobial compounds is very important,
above all in the cases of poor oral hygiene. An aspect of
no less importance, yet, is the effect that such modified
GIC could have towards the cavities in the course of
application, i.e. the effect of the antimicrobial compounds
being deposited at the junctures between the restoration
and the dentine, and their protective effect. In situations
of implementing a sound oral hygiene, the cumulative
effect of antimicrobial compounds would not be of such
Balk J Stom, Vol 16, 2012
importance because of frequent rinsing of the oral cavity.
Regarding such cases, an analysis should be made of the
release of antimicrobial compounds in the medium by
changing the latter in predefined time intervals.
Conclusions
1. The addition of BCH and CPC shows high
significant differences between the average values
over the tested period and between the different
percentages.
2. The incorporation of 3% antimicrobial components
(BCH and CPC) into GIC is the most appropriate.
Acknowledgments: This article was submitted in
partial fulfilment of a PhD degree at the School of
Science, University of Greenwich, UK and the Faculty
of Dentistry - Skopje, FYROM. I should like to thank to
Professor John W. Nicholson for the award of a Visiting
Fellowship which allowed complete experimental work
reported in this paper to be carried out at the University of
Greenwich, UK.
References
3. McLean JW, Nicholson JW, Wilson AD. Proposed
nomenclature for glass-ionomer dental cements and related
materials. Quintessence Int, 1994; 25:587-589.
4. Nicholson JW. Chemistry of glass-ionomer cements: a
review. Biomaterials, 1998; 19:485-494.
5. Nicholson JW. Adhesive dental materials and their
durability. Int J Adhesion Adhesives, 2000; 20:11-16.
6. Attar N, Onen A. Fluoride release and uptake characteristics
of aesthetic restorative materials. J Oral Rehab, 2002;
29:791-798.
7. Berg JH. The continuum of restorative materials in pediatric
dentistry - a review for the clinician. Pediatric Dentistry,
1998; 20:93-100.
8. Dionysopoulos P, Kotsanos N, Pataridou A. Fluoride release
and uptake by four new fluoride releasing restorative
materials. J Oral Rehab, 2003; 30:866-872.
9. Billington RW, Williams JA, Dorban A, Pearson GJ. Glass
ionomer cement: evidence pointing to fluorine release in the
form of monofluorophosphate in addition to fluoride ion.
Biomaterials, 2004; 25:3399-3402.
10. Hengtrakool C, Pearson GJ, Wilson M. Interaction between
GIC and S. sanguis biofilms: Antibacterial properties and
changes of surface hardness. J Dentistry, 2006; 34:588-597.
11. Leunga D, Spratt DA, Pratten J, Gulabivala K, Mordan NJ,
Young MN. Chlorhexidine-releasing methacrylate dental
composite materials. Biomaterials, 2005; 26:7145-7153.
12. Jedrychowski JR, Caputo AA, Kerper S. Antibacterial and
mechanical properties of restorative materials combined
with chlorhexidine. J Oral Rehabil, 1983; 10:373-381.
Balk J Stom, Vol 16, 2012
13. Patel MP, Cruchley AT, Coleman DC, Swai H, Braden M,
Williams DM. A polymeric system for the intra-oral delivery
of an anti-fungal agent. Biomaterials, 2001; 22:2319-2324.
14. Sanders BJ, Gregory RL, Moore K, Avery DR.
Antibacterial and physical properties of resin modified
glass-ionomers combined with chlorhexidine. J Oral
Rehab, 2002; 29:553-558.
15. Botelho MG. Inhibitory effects on selected oral bacteria of
antibacterial agents incorporated in glass ionomer cements.
Caries Research, 2003; 7:108-114.
16. Takahashi Y, Imazato S, Kaneshiro AV, Ebisu S, Frencken
JE, Tay FR. Antibacterial effects and physical properties
of glass-ionomer cements containing chlorhexidine for the
ART approach. Dent Mater, 2006; 22:647-652.
17. Block, SS. Disinfection, Sterilization and Preservation.
Fourth Edition. Philadelphia - London: Lea & Febiger,
1991; pp 225-242, 274-286.
18. Ciancio S. Expanded and future uses of mouth rinses. J Am
Dent Assoc, 1994; 25(Suppl 2):29S-32S.
19. DePaola LG, Minah GE, Overholser CD, Meiller TF,
Charles CH, Harper DS, McAlary M. Effect of an
antiseptic mouth rinse on salivary microbiota. Am J Dent,
1996; 9: 93-95.
20. Charles CH, Sharma NC, Galustians HJ, Qaqish J,
McGuire JA, Vincent JW. Comparative efficacy of an
antiseptic mouth rinse and an antiplaque/antigingivitis
dentifrice. A six-month clinical trial. J Am Dent Assoc,
2001; 32:670-675.
Antimicrobial Agents Release from GIC 89
21. Radford JR, Beighton D, Nugent Z, Jackson RJ. Effect of
use of 0.05% Cetylpyridinium Chloride mouthwash on
normal oral flora. J Dent, 1997; 25:35-40.
22. Pitten FA, Kramer A. Efficacy of Cetylpyridinium Chloride
used as oropharingeal antiseptic. Arzneimittelforschung,
2001; 51:588-595.
23. Ribeiro J, Ericson D. In vitro antibacterial effect of
chlorhexidine added to glass-ionomer cements. Scand J
Dent Res, 1991; 99:533-540.
24. Palmer G, Jones FH, Billington RW, Pearson GJ.
Chlorhexidine release from an experimental glass ionomer
cement. Biomaterials, 2004; 25:5423-5431.
25. Namaba N, Yoshida Y, Nagaoka N, Takashima S, Yoshimoto
KM, Maeda H, van Meerbeek B. Antibacterial effect of
bactericide immobilized in resin matrix. Dental Mat, 2009;
25:424-430.
Correspondence and request for offprints to:
Aleksandar Dimkov
Faculty of Dentistry, Clinic for Pediatric and Preventive Dentistry
Skopje, FYR Macedonia
E-mail: dimkovaleksandar@gmail.com
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BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141

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Efficacy of Working Length Detection and

Irrigation during Preparation of Curved Root Canals

SUMMARY Ekaterina Boteva1, Dimitar Yovchev2

Curved root canals are challenge for instrumentation, preparation,
Faculty of Dental Medicine, Sofia, Bulgaria
irrigation and obturation. The aim of the present study was to find the 1Department of Conservative Dentistry
working length (WL) and irrigation efficiency in root canals with curvatures 2Department of Imaging and Oral Diagnostics

30º-45º and in root canals with anatomical abnormalities 45º-90º.

68 human, matured, extracted molars with 201 root canals were
included in the study. Molars were placed in 3 groups in relation to the
angle between the root and the axis. The first group were teeth with straight
canals (25º-30º, a control group; 14 teeth - 45 root canals), the second
group were teeth with curved canals (30º-45º; 22 teeth – 66 root canals) and
third group were teeth with severely curved canals (45º-90º; 31 teeth with
96 root canals). Measurements: mesio-distal buccal size of the chamber in
its largest part and both bucco-lingual sizes - mesial as L1 and distal as L2.
Root canal preparation: removal of the root pulp with K endofiles number
6, 8 and 10, with Step-Down and Balance-force techniques. Canals length
was measured radiographically by intra-oral radiographs, preparation
continuous after X-ray analysis of the level of penetration of irrigants with
contrast solution of diluted Urograffin 66%. Regime of active irrigation:
same for all groups with 2% H2O2 and 1% NaOCl and paper points drying.
To follow up the results a fourth radiograph was made and a second one
with Urograffin. The applied criteria for WL and for penetration of the
irrigant was as follows: 3 - the whole WL; 2 - 1 mm shorter than WL; 1 - 2
mm shorter than WL; and 0 - more than 2 mm shorter than WL.
The active irrigation was more efficient in curved root canals, because
in straight canals most of the irrigant was lost, back in the mouth or
periapically. In straight root canals, only moisturizing (Miller pins) of the
canal can be effective and less dangerous. ORIGINAL PAPER (OP)
Keywords: Endodontics; Working Length; Root Canals, curved Balk J Stom, 2012; 16:90-93

Introduction found in our previous studies, are from 16-19% of all

Curved root canals are well known challenge for
instrumentation, preparation, irrigation and obturation.
Root curvatures with abnormalities over 45º are not
investigated from this point of view at all. Iatrogenic
errors are often associated with these teeth. In the last
15 years, between 1995 and 2010, only 13 articles are
related to this problem, excluding those with extreme
methodology as the use of 6.25% NaOCl.
All published articles are researches from in vitro
studies and surprisingly the curvatures are from 20º up
to 40º. Teeth with curvatures between 25º and 45º, as we
teeth, and those with curvature of 45º are more than 1.3%.
The number of experimental teeth in most of the studies
varies between 30 and 135, while the average numbers
are 59-621-14. In most studies, the preparation technique
was reported to be Step-Down1,2,5-9,11,12. Different
instrumentations with hand files6,13 and machine rotary
files10,11,14 were used.
Apical preparation size varied from № 10-25 to
№ 40-45, in relation to the degree of curvature. In these
papers, the differences are not only in the irrigation
regimes but in type of medication. NaOCl was used as
2.5-5%3,7,10 and in combination with EDTA5,6. In all
Balk J Stom, Vol 16, 2012 Working Length Detection of Curved Root Canals 91

H2О2 was used for irrigation. The followed up methods Irrigation measurements scale: The applied
were x-ray3, SEM8, bioluminiscense7,9, intra-operative criteria for working length (WL) and for penetration
microscopy2, stereomicroscopy13 and light microscopy6. of the irrigant were as follows: 3 - the whole WL, 2 - 1
In most of the cases, the results were predictable and mm shorter than WL, 1 - 2 mm shorter than WL, and 0 -
mostly a logical result from the design of the experiment. more than 2 mm shorter than WL. All measurements were
Summarizing the results, it can be concluded that the type performed by the same examiner, 3 times with at least 3
of preparation is a major factor for the degree of removal days intervals between.
of the smear layer and penetration of irrigants and
medicines. The highest efficiency was 70% in one group
in one article. In most articles, penetration of irrigants was
not complete among curvatures between 30-40º. Results
The aim of the present study was to find the
working length and irrigation efficacy in root canals 4 root canals from 207 were not found - 2%. 7
with curvatures 30º-45º and in those with anatomical instruments were fractured, 4 in group 2, 3 in group 3,
abnormalities 45º-90º. and none in the control group. In 7 canals, dentine debris
formed intracanal blockage, from them 3 in group 1
(control group), 1 in group 2 and 3 in group 3.
As is shown in table 1, most mistakes were made
Material and Methods in the control group, nearly in one third of the cases.
This fact can be explained in 3 different ways. The first
Teeth: 68 human matured extracted molars with 201 explanation could be frequent ramifications, the second
- difficulties related to the most accurate choice of the
root canals are included in the study. All teeth are from the
size of an instrument, and the third could be hyper-
same geographical region.
instrumentation, made more often in strait root canals. In
Groups: Molars are separated in 3 groups in relation
all in vitro studies there is a lack of data on age and sex
to the angle between the root and the axis. Molars with
of the teeth and anthropometrical data. In the experimental
straight roots (25º-30º) were a control group (14 teeth with
groups, this percentage was 10% and 9%, or 3 times less.
45 root canals), the second group were molars with curved
The same trend persisted when irrigants were tested.
roots (30º-45º; 22 teeth with 66 root canals), and the third
In the control group, in 50% of the cases the irrigant was
group were teeth with severely curved roots (45º-90º; 31
not present in the canal system (table 2). Still high but
teeth with 96 root canals). lower were cases in the experimental groups - 33% in
Measurements: Mesio-distal buccal size of the group 2 and 20% in group 3.
chamber in its largest part and both bucco-lingual sizes
- mesial as L1 and distal like L2, and the average of last
two as L. Table 1. Working length and number of samples of upper and
Root canal preparation: Started with opening the lower molars
orifices with manual Orifice Openers and removal of the
root pulp with K endofiles number 6, 8 and 10, using GROUPS 3 (the 2 (1mm 1 (2mm 0 (>2mm
Step-Down and Balance force techniques. Root canal whole WL) from WL) from WL) from WL)
length was measured radiographically with K files, and Controls (n=45) 26 7 - - 2 1 5 1
preparation continued after X-ray analysis of the level of
30º to 45º (n=66) 42 7 4 7 1 - 3 2
penetration of irrigants with contrast solution of diluted
Urograffin 66%. 45º to 90º (n=96) 42 36 - - 1 - 6 -
Regime of active irrigation: It was the same for all
groups - with 2% H2O2 and 1% NaOCl and paper points
drying. The aim of root canal preparation was even in Table 2. Penetration of the irrigant
roots with 90º curvatures the apical stop to be number
20-25, and for the rest of the teeth 30-40. To follow up the GROUPS WL3 WL2 WL1 WL0
results, a fourth radiograph was made and a second one
Controls n=45 17 3 - 21
with Urograffin. Instrument fractures and canal blockage
were registered too. 30º to 45ºn=66 43 1 9 13
X-ray regimes: Dental X-ray unit was Phot-XII
45º to 90ºn=96 65 9 8 14
(Takara Belmont Corp, Japan) and intraoral digital sensor
Eva (Dent-X Co.) was used. All radiographs were exposed
under the same conditions (exposure settings – 60 kv, Figures 1-3 depict X-rays of the WL detection, as
7mA and time 0.04s). well as irrigant penetration in different groups.
92 Ekaterina Boteva, Dimitar Yovchev Balk J Stom, Vol 16, 2012

a b
(a) Correct and incorrect working length (b) Correct and incorrect (non-sufficient) penetration of the irrigant
Figure 1. Group 1 - Straight root canals

a b
(a) Correct and incorrect working length (b) Correct and incorrect (non-sufficient) penetration of the irrigant
Figure 2. Group 2 - Curved root canals

a b
(a) Correct and incorrect working length (b) Correct and incorrect (non-sufficient) penetration of the irrigant
Figure 3. Group 3 - Root canals with severe curvatures and abnormalities

Discussion Non-effective irrigation could happen even in curved

Under the conditions of this study, designed on
the basis of realistic clinical approach to difficult teeth,
it is difficult to favours the role of irrigants in the root
canal preparation. In straight canals, especially in young
patients, the extrusion of the irrigant periapically is more
often. Clinically, this leads to toxic periodontitis and later
to creation of chronic periapical lesions.
In curved canals, penetration of irrigants is more
difficult, which has its positive and negative aspects.
Practically, more severe is the curvature more the
instrumentation is related to moisturizing the internal root
canal surface and the use of new flexible files with proper
sizes. This finding is similar as in some other studies3,7,10.
canals only with 24-28º7 and 30-33º3.
The separation of teeth in groups of lower and upper
teeth in this study was found to be useless.
Conclusions
X-ray WL detection of molars with root canal
curvatures is more accurate, compared to molars with
straight roots.
The active irrigation is more efficient in curved root
canals, because in straight canals most of the irrigant is
lost back in the mouth or periapically.
In straight root canals only moisturizing (Miller pins)
the canal can be effective and less dangerous.
Balk J Stom, Vol 16, 2012
References
1. Baugh D, Wallace J. The role of apical instrumentation in
root canal treatment: a review of the literature. JOE, 2005;
31:333-340.
2. Bing F, et al. Negotiation of C shaped canal system in
mandibular second molars. JOE, 2009; 35:1003-1008.
3. Bronnec F, Bouillaguet S, Machtou P. Ex vivo assessment
of irrigant penetration and renewal during the final irrigation
regimen. Int Endod J, 2010; 43:663-672.
4. Ding-Ming H, et al. Study of the progressive changes in
canal shape after using different instruments by hand in
simulated S shaped canals. JOE, 2007; 33:986-989.
5. Liu SB, et al. Cleaning effectiveness and shaping ability
of rotary ProTaper compared with rotary GT and manual
K-Flexofile. Am J Dent, 2006; Dec.19:353-358.
6. Lumley PJ. Cleaning efficiency of two apical preparation
regimes following shaping with hand files of greater taper.
Int Endod J, 2000; 33:262-265.
7. Nguy D, Sedgley C. The influence of canal curvature on the
mechanical efficiency of root canal irrigation in vitro using
real-time imaging of bioluminescent bacteria. JOE, 2006;
32:1077-1080.
8. Rodig T, Hulsmann M, Kahlmeier G. Comparison of root
canal preparation with two rotary NiTi instruments ProFile
04 and GT Rotary. Int Endod J, 2007; 40(7):553-562.
9. Sedgley CM, Applegate B, Nagel A, Hall D. Real time
imaging and quantification of bioluminescent bacteria in
root canals in vitro. JOE, 2004; 30:893-898.
Working Length Detection of Curved Root Canals 93
10. Schafer E, Vlosis M. Comparative investigation of two
rotary NiTi instruments: ProTaper versus RaCe. Part 2.
Cleaning effectiveness and shaping ability in severely
curved root canals of extracted teeth. Int Endod J, 2004;
37:239-248.
11. Schafer E, Erler M, Dammaschke T. Comparative study on
the shaping ability and cleaning efficiency of rotary Mtwo
instruments. Int Endod J, 2006; 39:203-212.
12. Schnaider SW. A comparison of canal preparations in
straight and curved canals. Oral Surg Oral Med Oral
Pathol, 1971; 32:271-275.
13. Wu MK, Wesselink PR. Efficacy of three techniques in
cleaning the apical portion of curved root canals. Oral Surg
Oral Med Oral Pathol Oral Radiol Endodont, 1995; 79:492-
496.
14. Yoshimine Y, Ono M, Akamine A. The shaping effects of
three NiTi Rotary instruments in simulated S shaped canals.
JOE, 2005; 31:333-340.
Correspondence and request for offprints to:
Dr. Ekaterina Boteva
Dept. of Conservative Dentistry
Faculty of Dental Medicine
1 Georgy Sofiisky str.
Sofia, Bulgaria
E-mail: e_boteva@abv.bg
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BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141

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Salivary Thromboplastic Activity May Indicate

Wound Healing after Tooth Extraction

SUMMARY T. Tunali Akbay1, M. Guvercin2, O. Gonul2,

A. Yarat1, S. Akyuz3, R. Pisiriciler4, K. Göker2
Oral mucosa is susceptible to tissue injury from many causes, including
infection, autoimmune disorders, surgical and accidental trauma, and Marmara University, Faculty of Dentistry
1Department of Biochemistry
gingival and periodontal inflammation; however, little is known about the 2Department of Maxillofacial Surgery
events that influence wound healing in the mouth. This study investigated the 3Department of Paediatric Dentistry
4Department of Histology and Embriology
changes in salivary thromboplastic activity prior to and after primary tooth
Istanbul, Turkey
extraction. Cytological smears and biochemical tests were also used in this
study.
Salivary pH and salivary flow rate did not significantly change
after primary tooth extraction. Salivary thromboplastic activity was not
significantly higher after extraction than prior to extraction (p=0.068).
Epithelial cells significantly decreased and leukocyte cells significantly
increased in saliva after primary tooth extraction (p<0.001). In conclusion:
oral cavity may aid the process of haemostasis and perhaps wound
healing in the extraction area by increasing salivary leukocyte cells and
thromboplastic activity. Thromboplastic activity may be a novel indicator of
wound healing completion.
Keywords: Salivary Cells; Salivary Flow Rate; Salivary pH; Salivary Thromboplastic ORIGINAL PAPER (OP)
Activity; Tooth Extraction Balk J Stom, 2012; 16:94-97

Introduction extrinsic coagulation pathway. Activated monocytes and

Wound healing is a dynamic, multi-faceted
physiological process that involves a wide range of
biological mediators1. Although primary tooth extraction is
a simple intervention, some complications can occur. Oral
mucosa is susceptible to tissue injury from many causes,
including infection, autoimmune disorders, surgical
and accidental trauma, and gingival and periodontal
inflammation; however, little is known about the events
that influence wound healing in the mouth15. Normally
tooth extraction induces some changes in the oral cavity2.
Saliva is important in maintaining oral health and much
of this protective activity is mediated by the variety of
different salivary proteins3.
Damaged tissue release a lipoprotein known as
thromboplastin (tissue factor, FIII), which activates the
endothelial cells also express this thromboplastin in their
surface and participate in coagulation4. Thromboplastin
initiates the coagulation system and is a component of cell
membrane, but not found active in the blood5,6. Like body
fluids, saliva has also been known to have thromboplastic
activity7-10. Thromboplastin in saliva is thought to supply
haemostasis when injury takes place in the mouth and
it facilitates the barrier function of buccal mucosa7,11.
Thromboplastin is related to cells and cell fragments in
saliva12,13. In the adult vertebrate body, physical integrity
is continuously maintained by a tissue repair mechanism
consisting of the vascular endothelium, tissue factor and
circulating factors VII, IX and X that governs localized
thrombin elevations. The cellular effects of these
thrombin elevations explain all aspects of tissue repair and
maintenance14.
Balk J Stom, Vol 16, 2012
It has been shown that oral cavity is also affected
from the disturbances of the haemostatic system in
which spontaneous bleeding of dental tissues, petechiae
of oral soft tissues and ecchymoses are common in
routine oral examination15. Post operative examinations
show that minor oral surgery can also cause bleeding.
Salivary thromboplastin may establish the hemostasis
after oral traumas7,11. Thromboplastin also contributes to
wound healing, inflammatory response, tumour growth,
metastasis and angiogenesis16,17. The disturbance of
hemostatic balance in the oral cavity is an indicator of an
acquired or congenital defect of the coagulation system18.
There is no study in the literature involving the
relationship between the wound healing after primary
tooth extraction and salivary thromboplastic activity.
In this study; wound healing in oral cavity is followed
by the salivary thromboplastic activity after primary
tooth extraction. Salivary pH and salivary flow rate were
also determined and saliva imprint samples were also
evaluated cytologically.
Material and Methods
This study was performed on 25 healthy children
with the age range of 7-12 years. Healthy children
were randomly selected from individuals who attended
Marmara University Faculty of Dentistry. Oral dental
examinations and restorative treatments were conducted
by a paedodontist. Among the group, 80% of the children
had experienced dental extractions before. Thereafter,
they were sent to the Oral and Maxillofacial Surgery
Department for tooth extraction as they had caries
and pulpal pathology. Children had standard breakfast
1 hour before tooth extraction. 3 primary canines, 1
primary incisor, 21 primary molars were extracted from
25 children. Informed consent was obtained from each
subject’s family before saliva collection.
All saliva samples were collected in the resting
position in the surgery department. Firstly, subjects rinsed
the mouth with distilled water 3 times. Unstimulated
mixed saliva samples were collected by spitting into a
funnel prior to and 1 hour after primary tooth extraction.
Collection time was recorded and saliva volume was
measured by pipetting the saliva into a new tube. Then
the tubes were stored at -200C. Salivary flow rate was
calculated by dividing the saliva volume to the collection
time. Saliva samples were analyzed for pH by using
pH-paper (Neutralit-pH 5.5-9.0; Merck-pH indicate
paper).
Thromboplastic activity of saliva samples was
evaluated according to Quick’s 1-stage method using
normal plasma19. This was performed by mixing 0.1
ml of saliva with 0.1 ml of 0.02 M CaCl2, with the
clotting reaction being started on addition of 0.1 ml of
Wound Healing and Thromboplastic Activity 95
plasma. All reagents were at the reaction temperature
(37oC) before admixture. Since the clotting time is
inversely proportional to the thromboplastic activity,
the lengthening of the clotting time was counted as a
manifestation of the decreased thromboplastic activity.
For cytological examinations, saliva samples were
smeared over a glass microscope slide and fixed with air.
They were stained with Giemsa-stain20. All slides were
examined microscopically (x100) for the presence of
epithelium, erythrocyte, leukocyte and yeast cell.
The results were evaluated using Student t-test,
Wilcoxon test, Pearson correlation analysis and Spearman
correlation analysis; the Unistat 5.0 statistical package
programme was used.
Results
Mean age and body mass index of 25 children were
9.88±1.39 and 16.70±2.23, respectively. Salivary pH
values and salivary flow rates did not significantly change
after primary tooth extraction. Salivary thromboplastic
activity was moderately higher after the extraction than
prior to extraction (Tab. 1).
No significant difference of yeast cells was found
in the values prior to and after the extraction in saliva
imprint samples (p>0.1). Erythrocytes were not found in
saliva samples. Epithelial cells significantly decreased and
leukocyte cells significantly increased in saliva imprint
samples after primary tooth extraction (Tab. 2).
Significant negative correlation was found between
salivary flow rate and thromboplastic activity before
primary tooth extraction (r= -0.413; p=0.04). No
significant differences were found in any parameter were
found in accordance with gender.
Table 1. Comparison of salivary flow rate, pH and
thromboplastic activity prior to and after primary tooth
extraction
Pre-extraction Post-extraction p
(n=25) (n=25) ( t-test)
Salivary flow 0.21 ± 0.11 0.21 ± 0.08 0.782
rate (ml/min)
Salivary pH 7.22 ± 0.45 7.34 ± 0.40 0.136
Salivary
Thromboplastic 72.64 ± 27.59 60.08 ± 26.23 0.068
Activity (sec)
Values are given as mean ± standard deviation. Since the clotting
time is inversely proportional to the thromboplastic activity, the
lengthening of the clotting time is a manifestation of decreased
thromboplastic activity.
96 T. Tunali Akbay et al. Balk J Stom, Vol 16, 2012

Table 2: Cytological examination of saliva samples Thromboplastin is related to the cells and cell
fragments of saliva; consequently, high cell content
Pre-extraction Post-extraction p Wilcoxon of saliva (epithelial cells and leukocytes) increases
(n=25) (n=25) thromboplastic activity7,10,11. Normally, leukocytes do
Epithelial cells not have thromboplastic activity, they can only secrete
(1) 16 % 64 % thromboplastin when they are exposed to vein media or
(2) 28 % 36 % 0.001 collagene23-25. Clot formation and wound healing process
(3) 56 % 0% following tooth extraction are initiated by saliva. In the
Leukocyte cells present study, leukocyte cell count increased 1 hour after
(0) 56 % 4% tooth extraction. There was no significant difference in
(1) 32 % 16 % 0.001 STA between pre and post tooth-extraction time, possibly
(2) 4% 56 % due to the decrease in epithelial cell count or inhibition
(3) 8% 24 % of thromboplastic activity by specific inhibitor, like
Yeast cells tissue factor pathway inhibitor. Saliva as well as blood
(0) 68 % 68 % 1.000 coagulation system can play preventive role in oral cavity
(1) 32 % 32 % damages. Thromboplastin also plays an important role in
wound healing, inflammatory response, tumour growth,
Epithelial cells - 1: 0-15 cells (normal) 2: 16-30 cells (medium)
metastasis and angiogenesis16,17.
3: more than 30 cells (too much)
Leukocyte cells - 0: nonexistent 1: 3-5 cells 2: 6-15 cells 3: The relationship between salivary pH and salivary
more than 16 cells flow rate is well known12,13. Fluctuations in salivary pH
Yeast cells - 0: nonexistent 1: present may change the secretion of thromboplastin from the
cells present in saliva. Salivary pH and thromboplastic
activity can also be affected by the changes of salivary
flow rate. In the present study, salivary pH and flow rate
did not change after primary tooth extraction. Absence of
Discussion significant difference in STA between groups may indicate
undisturbed wound healing after tooth extraction.
Wound healing process seem to be strictly regulated Negative correlation between salivary thromboplastic
by multiple growth factors and cytokines released at activity and salivary flow rate has been shown in healthy
the wound site18. In this study, possible new marker subjects10. In the present study, there was also negative
- thromboplastin was monitored in saliva after tooth correlation between thromboplastic activity and salivary
extraction, as alterations that disrupt controlled timely flow rate before tooth extraction (r= -0.413; p=0.04);
healing process would extend tissue damage and prolong interestingly this correlation was not seen after tooth
repair18. extraction. This finding may support the secretion of
Whole saliva is the most frequently used type of thromboplastin from the leukocytes 60 minutes following
saliva for the diagnosis of systemic diseases, since it is tooth extraction. Thromboplastic activity may be a novel
readily collected and contains serum constituents. These indicator of wound healing completion.
constituents derive from the local vascular bed of salivary
glands and reach the oral cavity via the flow of gingival
fluid. Analysis of saliva may be useful for the diagnosis
of hereditary disorders, autoimmune diseases, malignant References
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1. McGrory K, Flaitz CM, Klein JR. Chemokine changes
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and the monitoring of illicit drug use21,22. Salivary 2004; 324:317-320.Simon E, Matee M. Post-extraction
thromboplastin may establish haemostasis following complications seen at a referral dental clinic in Dar Es
oral trauma and facilitates barrier functions of oral Salaam, Tanzania. Int Dent J, 2001; 51:273-276.
mucosa7,11. As thromboplastic activity has been measured 2. Kaufman E, Lamster IB. The Diagnostic Applications of Saliva
by PT test, shortened clot formation time shows increased - A Review. Crit Rev Oral Biol Med, 2002; 13:197-212.
thromboplastic activity19. Salivary thromboplastic activity 3. Li J, Chen J, Kirsner R. Pathophysiology of acute wound
was moderately increased after a single tooth extraction. healing. Clin Dermatol, 2007; 25:9-18.
4. Bachli E. History of tissue factor. Br J Haematol, 2000;
Our preliminary assays (data not shown) showed a
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significant increase in salivary thromboplastic activity 5. Selighson U. Disseminated intravascular coagulation (DIC).
after 2 teeth extraction. According to this finding, we In: Beutler E, Lichtman MA, Coller BS, Kipps TJ, Seligsohn
consider that the size of an extraction area and the quality URI (eds). Williams Hematology. USA: McGraw-Hill
of the extraction may affect the thromboplastic activity. Companies Inc, 2001; pp 1677-1695.
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6. Zacharski LR, Rosenstein R. Reduction of salivary tissue
factor (thromboplastin) activity by warfarin therapy. Blood,
1979; 53:366-374.
7. Lwaleed BA, Francis JL, Chrisholm M. Urinary tissue factor
levels in neoplastic disease. Ann Saudi Med, 2000; 20:197-201.
8. Tutuarima JA, Hische EAH, Trotsenburg L, Helm
HJ. Thromboplastic activity of cerebrospinal fluid in
neurological disease. Clin Chem, 1985; 31:99-100.
9. Yarat A, Tunali T, Pisiriciler R, Akyuz S, Ipbuker A, Emekli
N. Salivary thromboplastic activity in diabetics and healthy
controls. Clin Oral Invest, 2004; 8:36-39.
10. Belikov PP. Blood coagulation factors in saliva in injury
of oral mucous membrane. Stomatologia (Moskva), 1971;
50:72-74.
11. Flink H, Tegelberg A, Lagerlof F. Influence of the time
of measurement of unstimulated human whole saliva on
the diagnosis of hyposalivation. Arch Oral Biol, 2005;
50:553-559.
12. Fenoll-Palomares C, Munoz Montagud JV, Sanchiz
V, Herreros B, Hernandez V, Minguez M, Benages A.
Unstimulated salivary flow rate, pH and buffer capacity of
saliva in healthy volunteers. Rev Esp Enferm Dig, 2004;
96:773-783.
13. Coleman LS. A hypothesis: Factor VII governs clot
formation, tissue repair and apoptosis. Med Hypoth, 2007,
69:903-907.
14. Whelton H. The anatomy and physiology of the salivary
glands. In: Edgar WM, O’Mullane DM (eds). Saliva and
Oral Health. Great Britain: Thanet Press Lim, 1996; pp 1-8.
15. Rickles FR, Shoji M, Abe K. The role of hemostatic system
in tumor growth, metastasis and angiogenesis: tissue factor
is a bifunctional molecule capable of inducing both fibrin
deposition and angiogenesis and cancer. Int J Hematol,
2001; 73:145-150.
16. Rickles FR, Patierno S, Fernandez PM. Tissue factor,
thrombin and cancer. Chest, 2003; 124:58-68.
17. Sindet-Pederson S. Haemostasis in oral surgery the possible
pathogenetic implications of oral fibrinolysis on bleeding.
Experimental and clinical studies of the haemostatic balance
in the oral cavity, with particular reference to patients with
acquired and congenital defects of the coagulation system.
Dan Medl Bull, 1991; 38:427-443.
Wound Healing and Thromboplastic Activity 97
18. Ingram GI, Hills M. Reference method for the one-stage
prothrombin-time test on human blood. Thromb Haemost,
1976; 36:237-238.
19. Atay Z, Topalidis T. Cytodiagnostik der Serösen Höhlen.
Atlas und Lehrbuch. Hannover: Wolfgang Pabst Verlag,
1994; pp 356.
20. Humphrey SP, Williamson RT. A review of saliva: Normal
composition, flow and function. J Prosth Dent, 2001;
85:162-169.
21. Jansen Van Rensburg BG. Saliva. In: Oral Biology. Berlin:
Quinstessence Publishing Co Inc, 1995; pp 469-478.
22. Butenas S, Bouchard BA, Brummel-Ziedins KE, Parhami-
Seren B, Mann KG. Tissue factor activity in whole blood.
Blood, 2005; 105:2764-2770.
23. Day SM, Reeve JL, Pedersen B, Farris DM, Myers DD,
Im M. Macrovascular thrombosis is driven by tissue factor
derived primarily from the blood vessel wall. Blood, 2005;
105:192-198.
24. Roberts HR, Monroel DM, Hoffman M. Molecular biology
and biochemistry of the coagulation factors and pathways of
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TJ, Seligsohn URI (eds). Williams Hematology. USA:
McGraw-Hill Companies Inc, 2001; pp1409-1425.
Correspondence and request for offprints to:
Aysen Yarat
Marmara University, Faculty of Dentistry
Department of Biochemistry
Guzelbahce, Buyukciftlik sok. No:6
34365 Nisantasi-Istanbul-Turkey
e-mail : ayarat@marmara.edu.tr
ttunali@marmara.edu.tr
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Biophysical Principles of the AcryLock Attachments

Use in Contemporary Prosthetic Dentistry

SUMMARY D. Veleski, B. Pejkovska, M. Antanasova

Introduction. There are many choices and different protocols when University of “St. Cyril and Methodius”, Faculty
determining treatment of partially edentulous patients. In this article we are of Stomatology, Clinic of Mobile Prosthetic
reviewing the dental treatment throughout the use of partial dentures with Dentistry, Skopje, FYROM
AcryLock attachments in patients who previously have been treated with
different types of fixed-mobile appliances.
Material and Methods. We have accomplished fixed-mobile dental
appliances with the use of AcryLock attachments in 7 patients who
previously have worn appliances with Lecodent attachments. Comparative
analysis has been carried out with the methods used in biophysics. The
patients have been followed-up for a year.
Results. After the fixed-mobile prosthetic rehabilitation has been
accomplished with the use of attachments from the AcryLock system,
exceptional functional and aesthetic results have been noticed.
Conclusion. The AcryLock attachments serve the patient extremely
well as a treatment modality option with removable partial dentures for
several reasons. Primarily, they are designed very close to the abutment
tooth centre, allowing the direction of the force vectors straight down along
the long axis of the tooth. Attachments shown in this survey illustrate good
functional and aesthetic aspects. Consequently, it is realistic to expect
greater longevity in the use of these elements, in comparison to the previous
methods in treatment of partially edentulous patients. ORIGINAL PAPER (OP)
Keywords: Partial Dentures; Attachments; AcryLock Balk J Stom, 2012; 16:98-102

Introduction

There are many possibilities for the selection of

different protocols to determine the treatment plan for
partially edentulous patients. In this article, the dental
treatment has been reviewed through the application of
partial dentures with attachments in patients who were
previously treated with other kinds of fixed-mobile
allowances. Partial dentures throughout the application
of attachments are categorized as a culmination of
knowledge and art in dental removable prosthetics.
Primarily, they seem very complex, but attachments bond
the fixed and the mobile part of the allowance in a simple Figure 1. The metal skeleton of a lower partial denture, with a green
manner in an incredibly functional whole (Fig. 1). patrice on the left side of the patient’s fixed-mobile construction
Balk J Stom, Vol 16, 2012 The Use of AcryLock Attachments 99

A huge variety exists in partial dentures with is placed in the house of the metal skeleton of the partial
attachments, not only in shape but also in the way denture.
of manufacturing, the material from which they are The matrices are available in 3 different sizes for
developed and, certainly, the indications. They belong setting different withdrawal forces: (1) green matrix -
to the group of complex partial dentures. Attachments normal friction; (2) yellow matrix - medium friction
represent polyvalent precision combining elements who (Fig. 2); (3) red matrix - high friction.
serve to combine (attach) the fixed with the mobile part
of complex fixed-mobile appliances. They have become
from the need to hide the visible retention elements of
removable partial dentures with which their aesthetic
value has extremely increased.
Attachments in most of the cases consist of 2 basic
parts:
-- Patrix, the primary or male part;
-- Matrix, the secondary or female part.
The parts of the attachments are constructed in a
manner that, with their combining, a functional whole
is accomplished of the attachment system and dental
appliances. With the use of attachments in partial
dentures, one part is incorporated in the fixed and the
other in the mobile dental appliance.
In this article attachments are being reviewed
from the group of vertical slide attachments. They are
represented by a system of double elements for retention, Figure 2. Presentation of a fixed and mobile part of a prosthetic
restoration with yellow matrices
or cylinder assembly in a miniature shape.
That system is consisted of:
1. Patrix, primary or inner part of the system, or
positive;
2. Matrix, secondary or outer part of the system, or
negative.
From the industrially produces sliders, in this The new matrix design with a single retention point
article the emphasis will be given on the AcryLock slide allows the matrix to be easily exchanged without time-
attachments. They belong to the group of extra-coronary consuming reduction and fitting of the friction insert.
attachments. They are made out of plastics, which burns Only alloys with a 0.2 proof stress of over 500 N/mm2
out with no residual parts. The size of the non-residual should be used to ensure stability.
burnout patrix is 0.04 mm to ensure a defined dimension The complexity with designing fixed-mobile dental
for the plastic matrix after preparation and polishing. appliances throughout the use of AcryLock attachments
This slider consists of patrix and matrix. The system is should be analyzed with the methods of biophysics.
specific because it consists of an extra-coronary part of With the help of these useful methods, the forces of
the crown, which is consisted of a guide and a patrix. the chewing pressure (while using these attachments) are
The guide is applied to the approximal side of the wax directed down the long axis of the tooth, minimizing the
model of the application crown (special purpose crown) torque and the lateral forces, and therefore improving the
in the 0 position of the paralelometer. The role of the chances for success of the restoration.
guide is for the patrix to be on an acceptable distance
from the interdental papilla. On the guide then the patrix Material and Method
is applied and in accordance with the position and shape
of the alveolar reef, it is positioned. A few millings are Complex fixed-mobile restorations have been
possible on the guide and the patrix with the purpose of accomplished with the application of Acrylock
improving the adaptation to the interdental papilla and the attachments in 7 patients who have previously been
alveolar reef. The patrix with the wax is tied to the guide treated with different types of treatment modalities.
and together with the wax model on the fixed construction In this article a review has been made by representing
with specific laboratory procedures is replaced with characteristic cases that have been treated with paying
precious or base alloys. meticulous attention to details. The patients have been
The matrix of the Acrylock attachments is made treated with these appliances and with the methods of
out of hard plastics and with the responding instrument biophysics in the clinic for removable dental prosthetics.
100 D. Veleski et al.
Before beginning with the prosthetic approach,
the patients needed pre-prosthetic preparation due to the
presence of mouth and periodontal diseases, and also at
the clinic for oral surgery. With the team approach, the
rest of the teeth were prepared for further development of
application crowns, use of the AcryLock attachments and
the development of the skeletal partial denture.
Presentation of cases
The first patient was completely edentulous in the
upper jaw and partially (subtotal) edentulous in the lower
jaw. This patient has worn total acrylic denture in the
upper jaw, and a bridge with Lecodent bars and a lower
skeletal denture. Both dentures needed to be replaced
with new prosthetic restorations. New total prosthesis
was made in the upper jaw; in the lower jaw, 2 remaining
canines were endodontically treated and the prosthetic
preparation impression was taken for the production of
a new dental bridge with the elements of the AcryLock
attachments (Fig. 3). The patrix is incorporated in the
Figure 3. Metal ceramic bridge with the Patrice incorporated from the
system of AcryLock attachments
Figure 5. The completed fixed-mobile complex construction
Balk J Stom, Vol 16, 2012
bridge construction while the matrix is applied in the
lower skeletal prosthesis (Figs. 4 and 5).
The second patient previously possessed a dental
bridge construction with attachments of the type
Lecodent, and a skeletal denture in the upper jaw. As
local conditions enabled construction of fixed-mobile
restorations with the system of AcryLock attachments
(Fig. 6), it was performed as well (Figs. 7 and 8).
The third patient came to the clinic for removable
dental prosthetics, with worn out fixed-mobile dental
appliances having Lecodent bars that needed to be
replaced. The upper left premolar had to be extracted;
furthermore, the supporting tissue complex had to be
treated for the presence of periodontal pockets. The upper
right canine was suitably treated endodontically and
enhanced with metal posts and cores (Fig. 9).
Our patients were followed in a period of time of one
year in which many aspects were notified concerning the
choice of these attachments in the complete prosthetic
rehabilitation.
Figure 4. A lower partial denture with the incorporated matrix from the
system of Acrylock attachments
Figure 6. The remaining 2 teeth were endodontically treated and
prepared for crowns
Balk J Stom, Vol 16, 2012 The Use of AcryLock Attachments 101

Figure 7. Fixed-mobile construction before cementation of the bridge in Figure 8. The completed prosthetic restoration
the mouth - palatal view

Figure 9. Intraoral view of the teeth after the pre-prosthetic treatment Figure 10. The finished fixed-mobile construction - palatal view of the
and preparation of the teeth attachments of the AcryLock type

Results and Discussion

Figure 11. The completed rehabilitation with complex denture - frontal
dental bride and 2 applicable crowns
In patients who previously worn fixed-mobile dental
appliances with bars of the Lecodent type, comparative
analysis was carried out throughout the methods of the
biophysics. This method emphasizes the meaning of the
vectors that are gained when a force acts along the teeth,
or, in these cases, along the teeth covered with dental
crowns. That force is represented schematically with a
vector that touches the tooth and divides in a vertical and
in a horizontal component. The closer the direction of the
vectors along the long axis of the tooth, the better they are
from the aspect of minimizing the harmful lateral forces
that would devastate the entire final restoration. The
vertical forces physiologically burden the teeth optimally
102 D. Veleski et al.
when acting along their long vertical axis. Horizontal
forces, while they are in the physiological values, are
neutralized with the compensatory mechanism. If they
overcome the individual tolerance of the teeth, traumatic
forces prevail and in the process of bone remodelling
there is a predomination of degradation processes.
Our experience is that teeth can react painfully when
forces of 20 N act in horizontal direction, while in vertical
forces may cause pain in the apical region with intensity
of over 200 N. All of these facts should be considered
while making a treatment plan and choosing attachments.
In attachments from the type AcryLock there is a higher
“verticalisation” in directing the forces of the chew
pressure in comparison with sliders like Lecodent.
After the successfully accomplished fixed-mobile
prosthetic rehabilitation throughout the use of attachments
of the system Acrylock, exceptional functional and
aesthetic results were notified. Concerning the functional
aspect, subjective approach should be taken into
consideration (surveys taken from the patients at the
regular controls); methods from the biophysics should be
used as an objective method.
Our patients in the period of time of a year responded
positively and in comparison they accept the AcryLock
devices rather than the old ones (Lecodent bars). The
patients stated that they feel the new skeletal devices to
be more stable than the old ones and they felt safer while
talking and using them in the act of mastication. Patients
also acceptet the new therapy plan from the aesthetic point
of view.
Throughout the measures of the biophysics, the
functional value could be proved in addition to the axial
transmission of the chew pressure, with minimizing lateral
forces to the periodontium of the supportive teeth.
With analysis of the vectors of the forces
schematically shown as a comparative method by
analyzing the Lecodent with the AcryLock attachments;
using AcryLock attachments there was a higher vertical
transmission of chewing forces, since they are referred
as vertical sliders. In Lecodent bars, there is a minimal
tendency of anterior-posterior moves on the removable
dentures, especially if distal teeth are missing, and
because they are horizontal sliders.
Conclusion
The functional and the aesthetic demands that are
expected from the dentists can be pleased with a suitable
Balk J Stom, Vol 16, 2012
choice of materials, correct applications of procedures,
as well as the construction with strict holding on to the
biophysical principles. Attachments from the type of
AcryLock shown in this article throughout the case of
studies illustrate that they efficiently serve patients from
aspect of function and aesthetics.
Primarily, they are designed very close to the centre
of the teeth carriers of the dental bridge construction,
which enables the direction of the vector forces along the
vertical long axis of the tooth. From the results which we
have come to, it is realistic to expect longevity in the use
of these elements, in comparison to the previous methods
of treatment of partially edentulous patients.
References
1. Veleski D. Klinika i tehnika na parcijalnite protezi. Skopje:
Stomatološki fakultet, 2010.
2. Veleski D. Klinika i tehnika na skeletiranite parcijalni
protezi. Skopje: Stomatološki fakultet, 2011.
3. Veleski D. Evaluacija na vrednosta na dzvakopritisokot
i reakcija na potpornite tkiva kaj subtotalni protezi. PhD
Thesis, Skopje: Stomatološki fakultet, 1988.
4. Broadbent JM, Williams KB, Thomson WM, Williams SM.
Dental restorations: a risk factor for periodontal attachment
loss? J Clin Periodontol, 2006; 33:803-810.
5. Bambara GE. Attachment dentistry. A rationale for
reflection and treatment planning. N Y State Dent J, 2003;
69:28-30.
6. Dawson PE. Evaluation, Diagnosis, and Treatment of
Occlusal Problems. 2nd ed. St. Louis: CV Mosby Co, 1989;
pp 470-471.
7. Donovan TE, Derbabian K, Kaneko L, Wright R. Esthetic
considerations in removable prosthodontics. J Esthet Restor
Dent, 2001; 13:241-253.
8. Donovan TE, Cho GC. Esthetical considerations with
removable partial dentures. J Calif Dent Assoc, 2003;
31:551-557.
9. Ku YC, Shen YF, Chan CP. Extracoronal resilient
attachments in distal-extension removable partial
dentures. Quintessence Int, 2000; 31:311-317.
10. Porter JA, von Fraunhofer JA. Success or failure of
dental implants? A literature review with treatment
considerations. Gen Dent, 2005; 53:423-432.
11. Stamenkoviæ D. Stomatološka protetika, parcijalne proteze.
Beograd: Interprint, 2006; pp 286-287.
Correspondence and request for offprints to:
D. Veleski,
University of “St. Cyril and Methodius”
Faculty of Stomatology, Clinic of Mobile Prosthetic Dentistry
Skopje, FYROM
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Intraoral Ceramic Restoration Repair Techniques:

Report of 3 Cases

SUMMARY Kosmas Tolidis1, Paris Gerasimou1,

The authors’ intention was to present ceramic restoration repair as a Christina Boutsiouki2
reliable, low-cost and low-risk procedure, by demonstrating 3 cases in the
1Aristotle University of Thessaloniki, School of
aesthetic zone. Intraoral ceramic repair was chosen for the small porcelain
fracture of the maxillary left central incisor and for the large porcelain Dentistry, Dept of Operative Dentistry
surface detachment of the maxillary left lateral incisor, since patients did Thessaloniki, Greece
2Undergraduate Student, Aristotle University of
not want to replace the fixed denture. The third case presented an easy way
to correct orthodontic treatment relapse when ceramic restoration have Thessaloniki, School of Dentistry, Thessaloniki,
already been placed. Gaps formed between maxillary left lateral incisor and Greece
canine were closed using the same adhesion protocol.
The sequence of treatment is demonstrated altering the basic repair
protocol according to the needs of each case. The final outcome of the repair
with composite resin was an aesthetic alternative and the patients were fully
satisfied. CASE REPORT (CR)

Keywords: Ceramic, repair; Adhesion; Silane; Sandblasting Balk J Stom, 2012; 16:103-108

Introduction Removing the glazed ceramic layer is suggested in

Ceramic restorations have been part of dental
prosthetics for many years as they are characterized by
superior aesthetics, functionality and biocompatibility.
Feldspathic porcelain with a metallic framework, ultra-low
fusing porcelains and reinforced ceramics evolved over
decades21. Metal-ceramic fixed restorations, probably the
most frequently used, can survive up to 25 years3. But the
inherent brittleness of porcelain and the kind of cements
used for insertion might result in fracture and consequently
failure. Fractures are caused by trauma, acute accidents,
chronic habits (bruxism), flaws and contamination in
the original porcelain fabrication, or inadequate tooth
thickness during tooth preparation15. In these situations,
ceramic restoration repair is a reliable, low-cost and low-
risk procedure. Moreover, the same protocol can be used
for interdental gap closure between already placed ceramic
restorations.
Case Reports
Description of the Technique
-- Treatment of ceramic and metal surface
order to allow the exposure of the underlying ceramic
layer, which is more reactive and has greater contact
surface area. This can be made mechanically (roughening
with diamond burs), chemically (sandblasting, acid
etching), or with the combination of both.
Roughening with diamond burs should be performed
at high-speed to avoid production of cracks and fissures
in ceramic margins from the vibration of low-speed
handpieces. Diamond bur roughening should be combined
with other surface treatment methods in order to attain
higher adhesion values18.
Sandblasting is usually performed with a high-speed
stream of purified aluminium oxide particles (30-250
μm) delivered by air pressure (2-3 bars or 30-42 psi) for
approximately 15 seconds. Treatment of metal surface,
if showing, is done by sandblasting, in order to improve
retention by eliminating oxides and greasy materials
and by increasing surface area. Particles could also be
30 μm silica coated (SiOx). This results in deposition of
a molecular coating of alumina coated with silicic acid
on the alloy surface, providing a reliable mechanical
retention and physicochemical bond between the alloy and
the composite (CoJet-Sand, CoJet System, 3M-ESPE).
Allow drying for 5 minutes and do not use a water-syringe
104 Kosmas Tolidis et al. Balk J Stom, Vol 16, 2012

because of possible water or oil contamination. Rubber -- Application of opaquer

dam isolation and high power suction systems prevent soft Resin composites systems which offer opaque and
tissue injuries and control the emission and spread of the translucent resins should preferably be used to re-establish
aluminium oxide particles over the operative area15,20,22,28. aesthetics after ceramic repair15,18,22. Flowable resin in
Acid etching yields a clean surface and produces opaque shade seems to be very practical.
micro-retentions that increase bond strength of the etched Application of composite resin shades according to
substrate, as in composite resin adhesion protocol. Metal manufacturer’s recommendations, occlusal adjustment
is cleaned but not affected in another way. The following and polish.
acid formulations can be used: Case 1 (Incisal and Cervical Porcelain Fracture)
a) 37% phosphoric acid - it does not produce any A 47-year old male patient with a 4-unit metal-
type of alterations on the ceramic morphology, but it can ceramic fixed partial denture presented with a fracture on
be used to clean the ceramic surface after mechanical the incisal edge and cervical margin of the maxillary left
roughening. It is also used where tooth structure is central incisor and on the joint between the maxillary left
associated, as a part of the standard adhesion protocol25. central incisor and maxillary right central incisor palatally
b) hydrofluoric acid - it creates surface irregularities (Fig.1). Intraoral ceramic restoration repair was selected as
acting on the silicon dioxide (SiO2) of the porcelain the treatment of choice. Cotton rolls were used for isolation
vitreous phase. Concentration varies between 5-10% and and roughening of the ceramic surface was done with high
etching time between 20 seconds-10 minutes, depending speed bur. 10% hydrofluoric acid was applied for 2 min
on ceramic type. Manufacturer’s instructions are followed. on the ceramic and metal surface, followed by thorough
rinsing for 30s and drying (Fig. 2), application of metal
Hydrofluoric acid however is very aggressive to soft
primer for 1 min, silanization by silane application for 1
tissues and care should be taken. No consensus has yet
min, and application of unfilled resin and polymerization
been reached regarding its use, as similar results are
with a LED curing unit (Elipar S10, 3M-ESPE). Flowable
obtained with other surface treatment methods too13,25,27. opaquer was applied in 2 thin layers (Fig. 3) following by
c) 1.23% acidulated phosphate fluoride - its effect on incremental placement of dentin and enamel A3 composite
ceramics is similar to that of hydrofluoric acid, requiring resin shades (Fig. 4). Occlusal adjustment was made and
more time but without the aggressiveness towards soft finishing and polishing were done with the appropriate tips
tissues, attacking glass probably due to selective release (Fig. 5).
of sodium ions, interrupting the silica network. Etching
time varies from 5-15 minutes. The etched porcelain
does not have a frosted appearance after etching, as with
hydrofluoric acid27.
-- Metal surface treatment
Besides sandblasting, metal primer must be applied
on the showing metal surface in order to bond the resin
onto the metal. If metal is high-noble or noble, bond
strengths can be enhanced by tin plating the exposed
metal. If the metal is determined to be base metal, tin
plating is not necessary. The type of metal primer is
specified by the type of alloy and its ingredients14.
-- Silanization
Figure 1. Initial aspect of the small fracture in the distal angle of the
Ceramic primers containing silane are applied prior maxillary left central incisor
to the adhesive agent and used in order to improve the
chemical bond between porcelain and composite resin.
Silane consists of a carbon chain that presents a SiO2
group in a functional end. As a result, the functional end
is joined with the porcelain, thus maintaining the carbon
chain free for bonding to the resin. Silanization should
be used in conjunction with other surface treatments
(roughening with diamond burs, sandblasting, acid
etching) and the resin adhesive system. There are no
reports of disadvantages in the use of silane agents except
for the short shelf life, being 12-18 months9,18,22,25.
-- Application of unfilled resin
If the patient has the fractured piece of porcelain,
it can be re-bonded to the crown after using the etchant,
silane and unfilled resin on the piece too22. Figure 2. Etching with 10% hydrofluoric acid
Balk J Stom, Vol 16, 2012 Intraoral Ceramic Restoration Repair 105

(Fig. 8). Metal primer was applied for 1min, followed by

silanization by silane application for 1 min and application
of unfilled resin and polymerization with a LED curing
unit (Elipar S10, 3M-ESPE). Opaquer was applied in 2
thin layers (Fig. 9) following by incremental placement
of dentin and enamel A3 composite resin shades. Occlusal
adjustment was made and finishing and polishing were
done with the appropriate tips (Fig. 10).

Figure 3. Application of flowable opaquer

Figure 6. Initial aspect of the large porcelain surface detachment of the

buccal surface of the maxillary left lateral incisor

Figure 4. Incremental placement of composite resin

Figure 5. Final aspect of the ceramic repair Figure 7. Etching with 10% hydrofluoric acid

Case Report 2: Large Porcelain Surface Detachment

A 50-year old female patient with a 6-unit metal-
ceramic fixed partial denture presented with total
buccal surface detachment of maxillary left lateral
incisor (Fig. 6). Intraoral ceramic restoration repair
was selected as the treatment of choice. Light cured
rubber dam and lip retractor were used for isolation. 10%
hydrofluoric acid was applied for 2 min on the ceramic
and metal surface (Fig. 7), followed by thorough rinsing
for 30s and drying. Sandblasting with 30μm silica oxide
particles (CoJet Sand, 3M-ESPE) for 15s using a chairside
air-abrasion device (CoJet System, 3M-ESPE) was done Figure 8. Sandblasting with CoJet System (3M-ESPE)
106 Kosmas Tolidis et al. Balk J Stom, Vol 16, 2012

Figure 9. Application of flowable opaquer Figure 11. Initial aspect of the gap between the maxillary left lateral
incisor and canine

Figure 10. Final aspect of the ceramic repair Figure 12. Roughening ceramic surface with diamond bur

Case Report 3: Gap Closure between Porcelain

Restorations
A 42-year old male patient underwent orthodontic
treatment and placed all-ceramic crowns in maxillary
teeth. But orthodontic treatment relapsed and a small
gap was formed between the maxillary left lateral
incisor and canine (Fig. 11). Intraoral composite resin
addition on ceramic was selected as the treatment of Figure 13. Etching with 10% hydrofluoric acid

choice for the repair. Ceramic surface was roughened

with high speed diamond bur (Fig. 12). Light cured
rubber dam and lip retractor were used for isolation. 10%
hydrofluoric acid was applied for 2 min on the ceramic
surface (Fig. 13), followed by thorough rinsing for 30s
and drying. Silanization was achieved through silane
application for 1 min and application of unfilled resin
followed, polymerized with a LED curing unit (Elipar
S10, 3M-ESPE). A1 shade of composite resin was placed
incrementally (Fig. 14) until the desired shape of incisor
and canine was formed and polymerized with a LED
curing unit (Elipar S10, 3M-ESPE). Occlusal adjustment
was made and finishing and polishing were done with the
appropriate tips (Fig. 15). Figure 14. Incremental placement of composite resin
Balk J Stom, Vol 16, 2012
Figure 15. Final aspect of the ceramic repair
Discussion
Fracture can extend to ceramic only with or without
metal showing, or include metal framework. The simplest
repair is if the fracture is limited in the porcelain. If
tooth structure is revealed, the process should be slightly
altered, as clinical usage of hydrofluoric acid on dentine
should be avoided25. Likewise, a stable and durable bond
to ceramics that contain minimal or even no silica, such
as aluminium or zirconium oxide ceramics, requires
other surface pre-treatment techniques or modified
luting cements7, although it seems that silane coating or
silanization improve the longevity of repaired zirconia
crowns1. With similar procedures, fractures in all-
ceramic and in Cerec restorations can be fixed, but since
there are no clinical trials of these restorations of more
than 5 years3,29, it is questionable whether a repair or
a replacement should be decided. Generally the basic
protocol steps should be individualized to meet the needs
of each special repair case, as demonstrated in the cases
described.
Within the limitation of the studies, it seems that
acid etching and silanization create high bond strengths
between feldspathic porcelain and resin composite
cement11,24. Surface conditioning with hydrofluoric
acid and silanization or silane coating with the use of
CoJet and silanization, used as different options in the 2
cases described, exhibited no differences in shear bond
strength12. On the contrary, Ozcan et al17 showed that the
repair method based on silane coating and silanization was
superior to other repair strategies without silane coating
application. Combination of silane primer and unfilled
resin, shows the greatest magnitude of bond strength
in comparison with silane only, or unfilled resin only6.
Others, however, state that use of adhesive resin does not
improve resin adhesion to etched and silanized ceramic
after long term thermocycling and water storage19.
Research shows that sandblasting with aluminium oxide
particles is a better method of preparing the surface than
Intraoral Ceramic Restoration Repair 107
roughening with diamond burs30, but some state that it is
not superior to other kits without it10. Acid etching time
and type of bonding agent influence bond strength, and
self-etching bonding agents should be avoided5. Acid
etching, sandblasting with aluminium oxide or silica
coated particles, show no differences in fracture loads on
repaired surfaces; however, addition of a layer of glass
fibre-reinforced composite increased the load level16.
CoJet system sandblasting offers the highest bond strength
values for the metal substrate, in comparison to bonding
agents4. However, it is also stated that micro-mechanical
cohesion is not enough and that macro-mechanical
retention should be prepared where possible10. Bond
strengths between composite and porcelain resulting
from silanization seem to increase over time, as an effect
of water storage (Berry et al. 1999) and pre-polymerized
resin structures obtain higher shear bond strength values,
compared to in situ resin polymerization26.
Intraoral ceramic repairs present a variety of
difficulties and possible failures. The most important
issue is to explain to the patient the cause of the initial
restoration failure, to proceed in possible changes and
include the challenge of anticipating longevity of the
repair. The adhesive protocol needs to be abided by the
practitioner and physical and mechanical behaviour of
the very different materials used should be associated.
Metameric effect between dental porcelain and resin
composite8 and colour stability of repairing materials
over time23, should also be considered but hybrid resin
composites are best chosen for the repair procedure, as
they are best suited due to their physical, mechanical and
optical properties. Additionally, soft tissues should be
protected by the use of high-speed burs and acid etchants
in the operation field21. Moreover, function and thermal
changes are detrimental to all bonded restorations22.
Conclusion
When attempting to repair a fractured ceramic
restoration, it is important to determine the reason for
failure and eliminate it, or else the repair will probably
fair no better than the original restoration. The patient
has to be informed for the possible risks and alternative
solutions. Repairing ceramic restoration fractures with
composite resins has some major advantages, as it
preserves the main body of the restoration and avoids
extra unnecessary cut of the tooth, making the treatment
inexpensive and easy when no replacement or fabrication
of an over-casting is possible. Dental practitioners
should be familiar with the technique, as it can be used
in aesthetic restorations as shown, but keeping in mind
the fact that all clinical procedures have advantages and
disadvantages.
108 Kosmas Tolidis et al.
References
1. Attia A. Influence of surface treatment and cyclic loading on
the durability of repaired all-ceramic crowns. J Appl Oral
Sci, 2010; 18(2):194-200.
2. Berry T, Barghi N, Chung K. Effect of water storage on the
silanization in porcelain repair strength. J Oral Rehab, 1999;
26:459-463.
3. Blatz MB. Long-term clinical success of all-ceramic
posterior restorations. Quintessence Int, 2002; 33:415-426.
4. Gomes J, Fonseca R, Adabo G, Alberto C. Shear bond
strength of metal-ceramic repair systems. J Prosthet Dent,
2006; 96:165-173.
5. Guler AU, Yilmaz F, Yenisey M, Guler E, Ural C. Effect of
acid etching time and a self-etching adhesive on the shear
bond strength of composite resin to porcelain. J Adhes Dent,
2006; 8:21-25.
6. Hisamatsu N, Atsuta M, Matsumura H. Effect of silane
primers and unfilled resin bonding agents on repair bond
strength of a prosthodontic microfilled composite. J Oral
Rehab, 2002; 29:644-648.
7. Kern M, Wegner SM. Bonding to zirconia ceramic:
Adhesion methods and their durability. Dent Mater, 1998;
14:64-71.
8. Kim SH, Lee YK, Lim BS, Rhee SH, Yang HC. Metameric
effect between dental porcelain and porcelain repairing resin
composite. Dent Mater, 2007; 23:374-379.
9. Kupiec KA, Wuertz KM, Barkmeier WW, Wilwerding TM.
Evaluation of porcelain surface treatments and agents
for composite-to-porcelain repair. J Prosth Dent, 1996;
76(2):119-124.
10. Leibrock A, Degenhart M, Behr M, Rosentritt M, Handel G.
In vitro study of the effect of thermo- and load-cycling on
the bond strength of porcelain repair systems. J Oral Rehab,
1999; 26:130-137.
11. Lu R, Hartcourt JK, Tyas MJ, Alexander B. An investigation
of the composite resin/porcelain interface. Aust Dent J,
1992; 37:12-19.
12. Melo RM, Valandro LF, Bottino MA. Microtensile bond
strength of a repair composite to leucite-reinforced
feldspathic ceramic. Braz Dent J, 2007; 18(4):314-319.
13. Oh WS, Shen C. Effect of surface topography on the bond
strength of a composite to three different types of ceramic. J
Prosthet Dent, 2003; 90(3):241-246.
14. Okuya N, Minami H, Kurashige H, Murahara S, Suzuki S,
Tanaka T. Effects of metal primers on bonding of adhesive
resin cement to noble alloys for porcelain fusing. Dent
Mater, 2010; 29(2):177-187.
15. Ozcan M, Niedermeier W. Clinical study on the reasons for
and location of failures of metal-ceramic restorations and
survival of repairs. Int J Prosth, 2002; 15(3):299-302.
16. Ozcan M, Van der Sleen JM, Kurunmaki H, Vallittu PK.
Comparison of repair methods for ceramic-fused-to-metal
crowns. J Prosthod, 2006; 15(5):283-288.
Balk J Stom, Vol 16, 2012
17. Ozcan M, Valandro LF, Amaral R, Leite F, Bottino
MA. Bond strength durability of a resin composite on a
reinforced ceramic using various repair systems. Dent
Mater, 2009; 25:1477-1483.
18. Pameijer CH, Louw NP, Fisher D. Repairing fractured
porcelain: How surface preparation affects shear force
resistance. J Am Dent Assoc, 1996; 127(2):203-209.
19. Passos SP, Valandro LF, Amaral R, Ozcan M, Bottino MA,
Kimpara ET. Does adhesive resin application contribute to
resin bond durability on etched and silanized feldspathic
ceramic? J Adhes Dent, 2008; 10(6):455-460.
20. Reston EG, Closs LQ, Sato CT. Customized and low-cost
aspirator device for intra-oral sandblasting. Oper Dent,
2004; 29(3):354-356.
21. Reston EG, Filho SC, Arossi G, Cogo RB, Rocha CS,
Closs LQ. Repairing ceramic restorations: final solution or
alternative procedure? Oper Dent, 2008; 33(4):461-466.
22. Robbins JW. Intraoral repair of the fractured porcelain
restoration. Oper Dent, 1998; 23:203-207.
23. Saygili G, Sahmali S, Demirel F. Color stability of porcelain
repair materials with accelerated ageing. J Oral Rehab,
2006; 33:387-392.
24. Sorensen JA, Kang SK, Avera SP. Porcelain-composite
interface microleakage with various porcelain surface
treatments. Dent Mater, 1991; 7:118-123.
25. Szep S, Gerhardt T, Gockel HW, Ruppel M, Metzeltin D,
Heidemann D. In vitro dentinal surface reaction of 9.5%
buffered hydrofluoric acid in repair of ceramic restorations:
A scanning electron microscopy investigation. J Prosthet
Dent, 2000; 83(6):668-674.
26. Tulunoglu IF, Beydemir B. Resin shear bond strength to
porcelain and a base metal alloy using two polymerization
schemes. J Prosthet Dent, 2000; 83(2):181-186.
27. Tylka DF, Stewart GP. Comparison of acidulated phosphate
fluoride gel and hydrofluoric acid etchants for porcelain-
composite repair. J Prosthet Dent, 1994; 72(2):121-127.
28. Van der Veen JH, Jonglebloed WL, Dijk F. SEM study of six
retention systems for resin-to-metal bonding. Dent Mater,
1988; 4:266-271.
29. Van der Vyver PJ, Marais JT, de Wet FA. Repair of Cerec
porcelain with seven different systems. J Dent Assoc S Afr,
1996; 51(8):525-530 [abstract].
30. Yesil ZD, Karaoglanoglu S, Akgul N, Ozdabak N, Ilday
NO. Effect of different surfaces and surface applications on
bonding strength of porcelain repair material. NYSDJ, 2007;
73(3):28-32.
Correspondence and request foorr offprints to:
Kosmas Tolidis
51 Tsimiski Str.
54623, Thessaloniki
Greece
Email: ktolidis@dent.auth.gr
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BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141

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A Multidiscipline Approach to Improve Aesthetics in a

Patient with High Lip Line: A Clinical Report

SUMMARY Burçin Vanlıoğlu1, Yaşar Özkan2,

In the analysis of characteristics of a pleasant smile, a gummy smile Yasemin Kulak-Özkan1
has negative effects. A 25-year-old female patient was referred to the University of Marmara, Faculty of Dentistry
1Department of Prosthetic Dentistry
Marmara University, Faculty of Dentistry, Department of Prosthodontics.
2Department of Oral Surgery
On the basis of radiographic, cephalometric and oral examinations, the
Istanbul, Turkey
patient was diagnosed with Class II skeletal malocclusion, high angle facial
profile and partially edentulous. There was a severe aesthetic problem in
the anterior maxillary segment because of high lip line and an excessive
vertical growth of the maxillary anterior jaw. A surgical approach was
performed and excessive bone in the maxillary anterior region was removed
after extraction. 9 implants (SwissPlus, Zimmer Dental, Carlsbad, CA,
USA) were inserted in maxilla and 8 implants in the mandible. The stability
of the implants was evaluated by the resonance frequency analysis. After
prosthodontic treatment, the patient was recalled up to 5 years. The implants
were successful and patient satisfaction was high. CASE REPORT (CR)
Keywords: Implants; High Lip Line Balk J Stom, 2012; 16:109-111

Introduction Case Report

In the analysis of characteristics of a pleasant
smile, a gummy smile has negative components, which
most affects aesthetics of non-verbal communication.
The nature of a high smile line can be: dento-gingival,
connected to an abnormal dental eruption, which is
revealed by a short clinic crown; muscular, caused by
hyperactivity of the elevator muscle of the upper lip;
dento-alveolar (skeletal), due to an excessive protuberance
or vertical growth of the jawbone (maxillary); lastly,
a mixed nature, in the presence of more than 1 of the
above described factors1. Llocation of the lip during
speaking, smiling, and at rest is of key importance in
treatment planning for missing teeth in the aesthetic zone2.
Orthognathic surgery, orthodontic therapy, maxillary
and mandibular overlay removable partial dentures and
fixed partial dentures could be treatment alternatives for
patients with mixed dental and skeletal malocclusions3,4.
In this study, surgical approach was performed in a female
patient with gummy smile, and excessive bone in the
maxillary anterior region was removed. The patient was
treated with implant retained fixed partial dentures, and an
aesthetic outcome was improved.
25-year-old female patient was referred to our
clinic for evaluation. Her chief complaints were aesthetic
and functional deficiency. Cephalometric, panoramic
and periapical radiographs were taken and Rickett’s
cephalometric analysis was completed. There was severe
aesthetic problem in the anterior maxillary segment
because of the high lip line. On the basis of radiographic,
cephalometric and oral examinations, the patient was
diagnosed with Angle Class II occlusion and high angle
(Figs. 1 and 2). Intraoral examination revealed that several
teeth were lost as a result of poor endodontic therapy and
periodontal disease. There was an excessive protuberance
and vertical growth of the maxillary anterior jawbone. The
patient’s oral hygiene was poor. The temporomandibular
joint was asymptomatic and associated muscles were not
painful. The remaining dentition included 8 maxillary
teeth (right lateral incisor, right canine, right first
premolar, third molar, left canine, left first and second
premolars, left third molar) and 4 mandibular teeth (left
canine, left first premolar, left second and third molars).
Several different restorative options were discussed
with the patient, ranging from maintaining the existing
110 Burçin Vanlıoğlu et al.
dentition to extraction of the remaining maxillary and
mandibular teeth. The patient expressed a desire to keep
as many of the remaining teeth for as long as possible.
In the maxillary and mandibular arches, the use of a
fixed partial denture was contraindicated because of the
extensive tooth loss. Therefore a decision was made to
insert implants in the posterior edentulous parts.
Figure 1. Extraoral view before treatment at rest position
Figure 2. Intraoral view before treatment
The operation was done under general and local
anesthesia. 5 implants (SwissPlus, Zimmer Dental,
Carlsbad, CA, USA) were placed in the maxilla and 6
implants were placed in the mandible. The stability of
the implants was evaluated by the resonance frequency
analysis (Osstell, Integration Diagnostics, Savedalen,
Sweden) test during the osseointegration period of
8 weeks. The diagnostic models were examined in
the articulator and it was decided to make temporary
restorations in the ideal occlusion. All the teeth in
Balk J Stom, Vol 16, 2012
maxilla and mandible were prepared with a chamfer
finish line and provisional restorations were performed
and used for 2 weeks. The patient was unsatisfied with
the aesthetic outcome in the maxillary anterior region,
so it was decided to extract all the remaining maxillary
teeth. A surgical approach was performed and excessive
bone in the maxillary anterior region was removed after
extraction. 4 implants were inserted in the maxillary
anterior region in harmony with the lip line. The third
molars in the maxilla and left mandible were extracted
and the vertical dimension was decreased. Mandibular left
canine and left first premolar were extracted because of
periodontal tissue loss and 2 implants were placed.
The patient was referred for prosthetic rehabilitation
following 3 months to allow for osseointegration and full
maturation of the soft tissue. Diagnostic casts and record
bases were fabricated and then mounted in an articulator
(Artex; Girrbach Dental GmbH, Pforzheim, Germany).
Metal ceramic restorations (VMK-95 Metal Keramik; Vita
Zahnfabrik, Bad Sackingen, Germany) were fabricated
(Figs. 3 and 4) and cemented with glass ionomer cement.
After prosthodontic treatment, the patient was recalled 3,
6, 12 and 24 months later. The implants were evaluated
by clinical and radiographic parameters.
Figure 3. Extraoral view with provisional restorations at smile position
Figure 4. Location of implants at surgery
Balk J Stom, Vol 16, 2012
Figure 5. Extraoral view after treatment
The patient’s comfort with the decreased interocclusal
dimension and the patient satisfaction was high at 24
month evaluation. The patient was very satisfied with the
aesthetic outcome (Figs. 5 and 6). In this case there were
no complications after implant placement. Evaluation
of clinical parameters 5 years after final prosthodontic
treatment demonstrated stable attached gingiva around the
implants. Radiological evaluation demonstrated that peri-
implant bone loss was in the clinically acceptable levels.
Discussion
The diagnosis of gummy smile must be precocious
and based, with reference to specific parameters, upon
a careful analysis of the etiopathogenetic factors and
the degree of seriousness of the alteration. A correct
treatment plan must contemplate the possibility of an
orthodontic, orthopaedic and/or surgical therapeutic
solution considering the seriousness and complexity of the
gums exposures in connection with age of the subject1. In
this case, at first, the remaining teeth were not extracted
according to the wish and expectation of the patient, but
the aesthetic outcome with the provisional restorations
was not satisfactory; so, a surgical approach was preferred
- to remove the excessive bone in the anterior maxilla.
Improvement Aesthetics in a Patient with High Lip Line 111
Figure 6. Intraoral view after treatment
References
1. Monaco A, Streni O, Marci MC, Marzo G, Gatto R,
Giannoni M. Gummy smile: clinical parameters useful for
diagnosis and therapeutical approach. J Clin Pediatr Dent,
2004; 29(1):19-25.
2. del Castillo R, Drago C. Indexing and provisional
restoration of single implants. J Oral Maxillofac Surg, 2005;
63:11-21.
3. Fayz F, Eslami A. Determination of occlusal vertical
dimension: a literature review. J Prosthet Dent, 1988;
59:321-323.
4. Turner KA, Missirlian DM. Restoration of the extremely
worn dentition. J Prosthet Dent, 1984; 52:467-474.
Correspondence and request for offprints to:
Burçin Vanlıoğlu
University of Marmara
Department of Prosthodontics
Büyükçiftlik Sokak, No: 6 Güzelbahçe, 34365, Nişantaşı
Istanbul, Turkey
E-mail: drburcinakoglu@hotmail.com
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The Use of Advanced Technology to Avoid Injury of the

Inferior Alveolar Nerve during Implant Surgery

SUMMARY Luan Mavriqi, Egresa Baca, Anila Vjeshta

Introduction. The aim was to present and evaluate strategy of “Brianza Dent“, Tirana, Albania
avoidance the inferior alveolar nerve injury during implantation procedure
using the advanced technology (3D x-ray and piezosurgery) in cases of the
emphasized mandibular atrophy.
Cases Report. 3 healthy females and 9 males, aged 47-60 years, were
treated by implant supported dentures using the advanced technology.
Patients were treated successfully and signs of nerve injury were not noted.
They were advised to inform on the possible signs of prolonged paraesthesia
or anaesthesia after the procedure. 3 months later, they were rehabilitated
with implant supported bridges.
Conclusions. The use of piezosurgery reduces the overall surgical
time and allows better surgical control over the neurovascular bundle. The
use of 3D x-ray device provides us a full map of the nerve path and reduces
probability of nerve injury. CASE REPORT (CR)
Keywords: Piezosurgery; Implantation; Nerve Balk J Stom, 2012; 16:112-115

Introduction of the mental nerve and lower the risk of the IAN injury
(Fig. 4). An ultrasound bone-surgery device specifically
The aim was to present and evaluate strategy of engineered for simplified bone surgery (piezosurgery) was
avoidance the inferior alveolar nerve injury during developed to allow cutting of hard tissue without injuring
implantation procedure using the advanced technology the adjacent soft tissue. This article reports 12 cases where
(3D x-ray and piezosurgery) in cases of the emphasized this technique was used.
mandibular atrophy. Creating a small crestal bone
window10 by piezosurgery, an oral surgeon may avoid
overstretching the nerve or its injury inclining instruments
adequately in apico-coronal direction. Clinical evaluation
in a 36-month period found a return of normal sensation
in all the patients after a brief period of sensibility
disturbances.
The quantity of bone available in the mandible
posterior to the mental foramen is often reduced as a result
of alveolar resorption following tooth loss (Fig. 1). This
fact, as well as the high position of the inferior alveolar
nerve (IAN) can impede placing implants of the appropriate
length.
Among the therapeutic approaches for treating
severely atrophied mandible is IAN mobilization using the
piezosurgery1-4 and creating a small bone window (Figs.
2 and 3) to expose the bundle and reduce overstretching Figure 1. Intraoral situation before the treatment
Balk J Stom, Vol 16, 2012
Figure 2. Piezosurgery insertion allows removal of bone without
damaging the nerve
Figure 3. Osteotomy of cortical bone
Figure 4. After the surgery the nerve is free of tension because ostectomy
created more space for its accomodation
Avoidance of Inferior Alveolar Nerve Injury 113
Figure 5. Implant inserted to achieve bi-cortical fixation. The nerve
bundle is lateralized from the implant
Figure 6. Final intraoral view of the patient with implant-supported fixed
prosthesis
Cases Report
3 females and 9 males, aged 47-60 years, were
treated by implant supported dentures using the advanced
technology. 2 of the male patients were under treatment
for diabetes, and 3 other males were regularly taking
medicaments for hypertension. The rest of the patients
were healthy. 7 patients didn’t have posterior teeth in
the mandible and worn partial (skeletal) dentures, and 5
of them were edentulous in the mandible and worn total
dentures.
After the first panoramic x-ray (Fig. 7), an
emphasized atrophy of the posterior region of the
mandible, being less than 7 mm, was evidenced in
all the patients, similar as already reported5-8. To
gain more accurate information, all the patients were
3-dimensionally x-rayed (Fig. 8), so that the accurate
114 Luan Mavriqi et al.
values of the distance of the inferior alveolar nerve to
the alveolar ridge were obtained. The values were from
4.5 mm (min) to 6 mm (max). These values excluded
the probability of putting the implants classically, as
in that case vertical dimension of the bone should be
larger than 10 mm. The patients were informed about the
probability of the IAN bypass, which was provided by
3D radiography measurements11 during the intervention
(Figs. 9 and 10). The patients were informed about the
option of receiving a surgical transposition of the IAN
by ultrasound bone surgery device (piezosurgery). They
were also informed about the probability of any sensibility
disturbance.
Figure 7. Panoramic radiograph before the treatment
Figure 8. 3-dimensional radiography before the treatment
Figure 9. 3-D radiography after surgery
Balk J Stom, Vol 16, 2012
Figure 10. Panoramic radiography after insertion of fixed prosthesis
After application of articaine local anesthesia, a
crestal incision extending from the retromolar to the
premolar area was done, mucoperiosteal flap was raised
and, at the implantation site cortical bone was penetrated
by the millimetre pilot drill till the predefined depth. In
the premolar zone, a mucoperiosteal flap was reflected
exposing the mental foramen. After defining the correct
direction, we continued with the pilot cutter going along
the length of 10 mm. After the pilot cutter, we used the
anatomic cutter and finally inserted the implant (Fig. 5).
After the procedure, the 3D-radiogram was repeated (Fig.
9). Patients were prescribed antibiotics (amoxicillin) and
analgesic for 5 days, and advised to keep in touch about
the reaction after anesthesia. Only one out of 12 patients
showed a slight paraesthesia of the lip, which improved
after 2 weeks. The implant-supported bridges were done
after 3 months in all the patients (Fig. 6).
Discussion
Although IAN mobilization has been described in the
literature, it has not been widely used because of concerns
for injuring the IAN. The results of this case series
suggest that surgical transposition of the IAN by means
of ultrasound bone surgery is a safe option, since all the
treated patients with this technique did not manifest signs
of nerve injury; slight paraesthesia in 1 patient gone after
a short period of 2 weeks.
The IAN can be damaged during several phases of
the procedure: (1) during osteotomy to expose the nerve;
(2) during flap elevation; or (3) during insertion of the
implant. Better results, in terms of sensory alterations,
associated with IAN mobilization not involving the
mental foramen can be explained by the reduced need
to stretch the flap10. An osteotomy that is 20 mm long is
required to achieve sufficient elasticity of the IAN bundle
to avoid lengthening the bundle by more than 5% and
damaging it. The piezosurgical method helps to avoid this
problem.
Balk J Stom, Vol 16, 2012
The described technique brings up several risks;
primarily the temporary or permanent injury of the IAN,
but the use of 3D radiograms provide us a full map of
the nerve’s path and, during the intervention, enables a
reduction of the damage probability.
References
1. Atwood DA. Bone loss of edentulous alveolar ridges. J
Periodontol, 1979; 50:11-21.
2. Jensen O, Nock D. Inferior alveolar nerve repositioning in
conjunction with placement of osseointegrated implants: a
case report. Oral Surg Oral Med Oral Pathol, 1987; 63:263-
268.
3. Bovi M. Mobilization of the inferior alveolar nerve with
simultaneous implant insertion: a new technique. Case
report. Int J Periodontics Restorative Dent, 2005; 25:375-
383.
4. Misch CE, Judy KWM. Patient dental-medical, implant
evaluation form. Int Cong Oral Implant, 1987.
5. Atwood DA. Postextraction changes in the mandible as
illustrated by microradiographs of midsagittal sections and
serial cephalometric roentgenograms. J Prosthet Dent, 1963;
13:810-824.
6. Atwood DA. Reduction of residual ridges: a major oral
disease entity. J Prosthet Dent, 1971; 26:266-279.
Avoidance of Inferior Alveolar Nerve Injury 115
7. Tallgren A. The continuing reduction of the residual alveolar
ridges in complete denture wearers. A mixed longitudinal
study covering 25 years. J Prosthet Dent, 1972; 27:120-132.
8. Karagaclioglu L, Ozkan P. Changes in mandibular ridge
height in relation to aging the length of edentulism period.
Int J Prosthodont, 1994; 7:368-371.
9. Peleg M, Mazor Z, Chaushu, G Garg AK. Lateralization
of the inferior alveolar nerve with simultaneous implant
placement: A modified technique. Int J Oral Maxillofac
Implants, 2002; 17:101-106.
10. Vercelloti T, DePaoli S, Nevins M. The piezoelectric
bony window osteotomy and sinus membrane elevation:
introduction of a new technique for simplification of
the sinus augmentation procedure. Int J Periodontics
Restorative Dent, 2001; 21:561-567.
11. Nitsche T, Menzebach M, Wiltfang J. What are the
indications for the three-dimensional x-ray diagnostic
and image-based computerized navigation aids in dental
implantology? Systematic review consensus statements and
recommendations of the 1st DG Consensus Conference in
September 2010, Aerzen, Germany. Volume 4, Issue 5.
Correspondence and request for offprints to:
Luan Mavriqi
Brianza Dent
Rr: Bardhok Biba.P.Hodaj.Ap.A 9
Tirane, Albania
luanmavriqi@yahoo.com
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Bony Lid Approach in Dentoalveolar Surgery:

Report of 2 Cases

SUMMARY Stelios Karamanis1, Dimitrios Tsoukalas2, A.

Conventional surgical approach for cyst enucleation is removal of Traskas3, Nikolaos Parissis4
buccal compact bone plate, which often results in remarkable bone loss and Aristotle University of Thessaloniki,
subsequent mucosal recession. This report presents one case of residual School of Dentistry, Dpt. of Dentoalveolar and
mandibular cyst enucleation and one case of apicoectomized mandibular Implant Surgery and Radiology
molar, both treated with the bony lid approach. A window of buccal compact Thessaloniki, Greece
bone was precisely created using an electro-powered osteotome orientated
beyond the limits of cyst, followed by removal of the bone segment. After
the completion of the enucleation and apicoectomy, the bony lid was
relocated on its original position. The main advantage of this method over
conventional one is maintaining the buccal compact bone plate integrity and
minimizing the dimensions of the remaining bone cavity. CASE REPORT (CR)
Keywords: Bony Lid; Enucleation; Apicoectomy; Mandibular Molar Balk J Stom, 2012; 16:116-121

Introduction to these problems16. However, besides the possible risks

In most cases, conventional osteotomies in the
maxilla and the mandible are invasive surgical procedures
and result in remarkable bone loss. The created defects
very often can not be completely regenerated. They persist
for years causing problems for feature treatment and
impairing aesthetics13. Guided bone regeneration with
or without graft materials may offer solutions, but this
procedure requires more time and involves risk of wound
dehiscence and subsequent contamination3,4,16.
Jaw cysts remaining after tooth extraction, also called
residual cysts, and periapical cysts are frequent findings
in dentoalveolar surgery. The classic method for their
removal is conventional enucleation. According to this
procedure, the buccal bone plate is removed, the cystic
membrane is separated from the surrounding bone and
the enucleation follows as usual. In cases of periapical
cysts the whole procedure is combined with root apex
resection. The disadvantage of the classical method is
the bone defect that is often left after healing, which
usually results in mucosal recession that is likely to have
an impact on the adequate control of a conventional or
implant prosthesis, or even on the aesthetics of the area.
The use of autogenous bone graft, bone substitutes or
connective tissue graft, may give satisfactory solutions
mentioned above, some patients do not desire either to
undergo a second surgery, or to afford the financial cost
of such procedures. For these reasons, it is preferable
to avoid, where possible, creation of such defects from
the beginning, by utilizing more conservative surgical
techniques.
The bony lid technique has been described as
a bone-saving method and was originally applied in
cases of maxillary sinus surgery6,8,9,21. Subsequently, it
was expanded in cases of apicoectomy of mandibular
molars15,17,19,24 and enucleation of residual cysts5. Based
on previous experience, this paper describes 2 cases
where the bony lid approach was advocated, and explores
problems and concerns related to this treatment concept.
Case Reports
A female and a male patient of 63 and 25 years old
respectively presented to the clinic. The first patient
desired to wear a partial denture and was referred by the
department of prosthodontics. The second one mentioned
history of swelling in the region of second right lower
molar.
Balk J Stom, Vol 16, 2012 Bony Lid Approach in Dentoalveolar Surgery 117

Figure 1. Pre-operative panoramic radiography Figure 4. The bony lid

Figure 5. The cyst before removal

Figure 2. Pre-operative cross-sectional reconstruction of

CT scan images

Figure 6. The detached bony lid

Figure 3. Creation of the bony lid Figure 7. The bone cavity after cyst removal
118 Stelios Karamanis et al. Balk J Stom, Vol 16, 2012

Figure 8. Relocation of the bony lid Figure 11. Pre-operative panoramic reconstruction of CT scan images

Figure 12. Pre-operative cross-sectional reconstruction of

CT scan images

Figure 9. Wound suturing

Figure 13. The bony lid

Figure 10. 3-months follow up CT scan image Figure 14. The resected apexes
Balk J Stom, Vol 16, 2012
Figure 15. Relocation of the bony lid
Figure 16. Wound suturing
Figure 17. 3-months follow up CT scan image
Bony Lid Approach in Dentoalveolar Surgery 119
Prior to surgery, both cases were evaluated
radiographically by conventional panoramic and CT
scan examination (Figs. 1, 2, 11 and 12). The first case
presented radiolucency in the region of lower right
molars, whilst the second one presented radiolucency
around the apices of the second right molar. Both
radiolucencies were well defined. The diagnoses were
residual and periapical cysts and the treatment plan
comprised enucleation and enucleation/apicoectomy
respectively using the technique of bony lid.
In both cases, after a full thickness mucoperiosteal
flap elevation, a parallelogram window of buccal compact
bone to the trabecular bone was precisely created using
an electro-powered MicroSaw (Dentsply Friadent,
Mannheim, Germany). The latter was first developed
in 1984 and consists of a thin diamond disk with a
diameter of 8mm. The disk is mounted on the hand piece
with a disk protector to prevent any injuries of the soft
tissues16. The sequence of osteotomies performed with
the diamond disk was, 2 proximal, 1 baso-horizontal
and 1 on the occlusal crestal site. The window was
orientated beyond the limits of the cyst (Figs. 3, 4 and
13). Subsequently, the removal of the bone lid took place
using a chisel. The detached bony lid (Fig. 6) was being
kept in physiological saline solution during the operation.
The enucleation of the cyst in the first case was performed
in the usual manner (Fig. 7). In the second case, the root
apex was removed by 2mm at least in order to eliminate
the apical canal delta. The apicoectomy was not followed
by retrograde filling due to the difficulty of access to the
surgical area (Fig. 14). Emphasis was given however
to the quality of root filling. The resection angle was
approximately equal to 100.
The procedures were completed with the relocation
of the bony lid on its original position (Figs. 8 and 15). In
both cases, the native bone graft was stabilized without
sutures since the bony lid was slightly bevelled, so that the
later be able to apply as an inlay autogenous bone graft.
After the operation was completed, the mucoperiosteal flap
was sutured with 4.0 mattress sutures (Figs. 9 and 16).
The patients were subscribed the routine
postoperative medication. 3 months later, in both cases no
clinical symptoms or signs were found and the follow-up
CT scan images revealed completely integration of the
bony lids (Figs. 10 and 17).
Discussion
The main advantage of the osteoplastic method
over the conventional approach is the maintenance of the
buccal compact bone plate integrity12. Replacement of
the buccal compact bone minimizes dimensions of the
remaining bone cavity. Filling of the cavity with any bone
graft material is not always necessary, and it depends on
120 Stelios Karamanis et al.
the size of the remained defect. In general, if the defect
size is estimated to be small, the latter may be left to
heal spontaneously, either a conventional prosthesis is to
be placed or an implant supported one. On the contrary,
if dimension of the remained defect is not negligible, the
use of autologous bone and bone substitute is proposed.
This is particularly important when the bone segment has
a small thickness14. Additional advantages are good vision
and access in the lower molar region, and creation of a
bone boundary which may be helpful in containing any
haematoma and allowing primary bone healing15.
There are some conditions that should be always
taken into consideration. The incision must be generous
and made from the canine tooth to the wisdom tooth area.
It also has to be fine and made through the compact bone
to the trabecular bone. Caution must be taken regarding
the possible buccal location of the mandibular canal.
The CT scan examination in such cases may be helpful.
The initial stability of the bony lid must be sufficient.
Since the bony lid must be chiseled, some patients under
regional anaesthesia may find it quite disagreeable15.
In the case of apicoectomy, the integrity of bony
window depends, apart from the aforementioned factors,
also on the quality of root filling and the absence of
unfilled canals or isthmuses. In this respect, the root apex
is supported to be removed by 2mm7. The necessity of
retrograde filling remains controversial. Some authors
prefer root canal filling and resection alone, without even
smoothing the exposed gutta-percha1,11. Some others find
that retrograde root filling improves apical sealing18,23. In
general, if the access for retrograde filling is limited but
root canal is completely filled, this may result in long
term clinical success. In case of retrograde filling the
cavity must be at least 3mm deep and the filling material
as bacteria-proof as possible10. The angle of resection
is supported to be 100approximately25. Finally, it is
supported that avoiding bacterial re-infection from the
root canal is far more important than complete curettage,
since remaining inflammatory tissue is intergraded in the
granulation tissue of the healing process. So, complete
curettage can be omitted if anatomical structures are at
risk20.
Bony lid approach is likely to present some
complications. The clinicians should be aware of possible
injury to adjacent anatomical elements (nerves, tooth
roots) due to poor preoperative planning. Furthermore,
fracture of the bone segment during reposition or
accidental drop into the bone cavity during the healing
period may occur. Infection and necrosis of the avascular
replanted bony lid is also a possible risk14,15.
Considering limitations of classic bony lid approach
exposed above, access to lower molar region was
proposed via trephining. If the distance between the roots
is small, a burr of 10-12mm in diameter should be used.
If the distance between the apexes is greater, trephination
must be performed twice, once mesial and once distal to
Balk J Stom, Vol 16, 2012
the apexes using burr diameter of 4-6mm. The advantages
of this modified technique are easier surgical procedure
compared to the traditional one, significant reduction of
post-operative pain due to the shorter and easier operation
and significantly quicker consolidation of graft material
in the bone defect. However, the risk of nerve damage
remains, and there is also the disadvantage of poorer view
of the surgical field compared to the traditional bony lid
method2.
Many studies have shown that the use of bony
lid method resulted in faster bone regeneration
without connective tissue ingrowth compared with the
conventional approach15,17,22. It is worth mentioning that
in less than 2% of patients wound dehiscence occurred
with contamination of the inlay bone graft and subsequent
wound revision15.
In both the presented cases, it was estimated
that the use of an electro-powered MicroSaw instead
of continuous drilling of the bone with burs offers
advantages as regards the accuracy of replacement
and stabilization of the bony lid. However, further
investigation is required to support the results of this
report despite the promising clinical outcome.
References
1. Bramwell JD, Hicks ML. Sealing ability of four retrofilling
techniques. J Endond, 1986; 12:95-100.
2. Buchter A, Kleinheiz J, Joos U. Wurzelspitzenresektion
unterer molaren über eine trepanbohrung. Quintessenz,
2002; 53:695-700.
3. Buser D, Dula K, Belser UC, Hirt H-P, Berthold H.
Localized ridge augmentation using guided bone
regeneration. I. Surgical procedure in the maxilla. Int
Periodontics Restorative Dent, 1993; 13:29-45.
4. Buser D, Dula K, Belser UC, Hirt H-P, Berthold H.
Localized ridge augmentation using guided bone
regeneration. II. Surgical procedure in the mandible. Int
Periodontics Restorative Dent, 1995; 15:11-29.
5. Drüke B. Osteoplastic procedure for cystic processes in
posterior mandibular region. ZWR, 1990; 99(12):957, 959-
960.
6. Gonzalez Ortin M, Argudo Marco F. Radiographic
advantages of the use of an osteoplastic technique in
classical surgery of the maxillary sinus. An Otorrinolaringol
Ibero Am, 1983; 10(2):107-113 (in Span)
7. Gutmann JL, Harrison JW. Posterior endondontic surgery:
anatomical considerations and clinical techniques. Int Endod
J, 1985; 18(1):8-34.
8. Feldmann H. Osteoplastic operation of maxillary sinus.
Laryngol Rhinol Otol (Stuttg), 1978; 57(5):373-378. (in
German)
9. Hardy JM, Montgomery WW. Osteoplastic frontal
sinusotomy: an analysis of 250 operations. Ann Otol Rhinol
Laryngol, 1976; 85(4 Pt 1):523-532.
Balk J Stom, Vol 16, 2012
10. Johnson BR. Considerations in the selection of a root-end
filling material. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod, 1999; 87:398-404.
11. Kaplan SD, Tanzilli JP, Raphael D, Moodnik RM.
A comparison of the marginal leakage of retrograde
techniques. Oral Surg Oral Med Oral Pathol, 1982; 54:583-
585.
12. Khoury F. A new technique for periapical curettage of lower
molars. Acta Odontol Stomatol, 1986; 154:181-186 (in
French)
13. Khoury F, Happe A. Soft tissue management in oral
implantology: a review of surgical techniques for shaping
an esthetic and functional peri-implant soft tissue structure.
Quintessence Int, 2000; 31:483-499.
14. Khoury F, Hemprich A, Sass T. Use of free bone graft in
various surgical procedures for the mandible. Dtch Z Mund-
Kiefer-Gesichtschir, 1985; 9:298-304 (in German) .
15. Khoury F, Hensher R. The bony lid approach for the apical
root resection of lower molars. Int J Oral Maxilofac Surg,
1987; 16:166-170.
16. Khoury F, Antoun H, Missika P. Bone Augmentation in Oral
Implantology. New Malden, UK: Quintessence Pub Co Ltd,
2007; pp 75-212, 299-320, 341-372.
17. Khoury F, Sass T. Methods and results of a replantable bone
lid in the apicectomy of lower molars. Dtch Z Mund-Kiefer-
Gesichtschir, 1986; 10:124-129 (in German)
18. King KT, Anderson RW, Pashley DH, Pantera EA
Jr. Longitudinal evaluation of the seal of endodontic
retrofillings. J Endod, 1990; 16:307-310.
Bony Lid Approach in Dentoalveolar Surgery 121
19. Lasaridis N, Zouloumis L, Antoniadis K. Bony lid approach
for apicoectomy of mandibular molars. Aust Dent J, 1991;
36(5):366-368.
20. Lin LM, Gaengler P, Langeland K. Periradicular curettage.
Int Endod J, 1996; 29:220-227.
21. Lindorff HH. Surgery of the endogenic-deseased maxillary
sinus: Technique and experiences with the bone cover
method. HNO, 1985; 33(9):416-421 (in German)
22. Schmidt J. Erfahrung mit der Knochendeckelmethode nach
Khoury zur Wurzelpitzenresextion unterer molaren in der
oralchirurghichen praxis. Quintessenz, 1990; 41:1263-1270.
23. Truggle ST, Anderson RW, Pantera EA Jr, Neaverth EJ.
A dye penetration study of retrofilling materials. J Endod,
1989; 15:122-124.
24. von Arx T. The tooth apex resection of molars. Schweiz
Monatsschr Zahnmed, 1999; 109(9):916-929.
25. Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in
periradicular surgery: a clinical prospective study. Int Endod
J, 1991; 33(2):91-98.
Correspondence and request foorr offprints to:
Stelios Karamanis
G.Papazoli 3
546 30 Thessaloniki
Greece
E-mail: karamaniss@yahoo.gr
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Technique of Frenectomy of Labial Fraenum with

Combined Osteotomy at Intermaxillary Suture

SUMMARY S. Dalampiras, C. Boutsiouki

Introduction: Maxillary midline diastema is often associated with School of Dentistry, Aristotle University of
an abnormal labial fraenum. Labial frenectomy is a common surgical Thessaloniki, Thessaloniki, Greece
procedure and is usually combined with orthodontic therapy for paediatric
patients.
Methods and Results: This case report describes the clinical condition
of a 14 year old patient with hypertrophied labial fraenum and maxillary
midline diastema. The treatment included frenectomy with osteotomy
combined with orthodontic therapy.
Conclusions: When an abnormal labial fraenum consists of fibrous
attachment inserting into the intermaxillary suture, frenectomy accompanied
by osteotomy seems to be the treatment of choice to prevent post-treatment
relapse. CASE REPORT (CR)
Keywords: Frenectomy; Osteotomy; Intermaxillary suture; Maxillary midline diastema Balk J Stom, 2012; 16:122-124

Introduction Case Report

Maxillary labial fraenum is a normal, triangular,
anatomic structure in oral cavity, extending from
maxillary midline gingival area into the vestibule and
mid-portion of the upper lip1. Sometimes it is present
as a thick, broad, fibrous attachment (called abnormal
fraenum). Depending on the level of gingival insertion2
and the extent of trans-septal fibres chain disruption3,
this situation may lead to maxillary midline diastema
preservation at a “space-prone dentition”3. The diastema is
termed “developmental” as it can often fully or partially
close after eruption of permanent lateral incisors and
canines4 in absence of pathological aetiology. But a
wider intermaxillary suture accompanying the abnormal
fraenum sometimes implicates aetiology of diastema
preservation1. If intermaxillary suture persists due to
insufficient compressive force during canine eruption,
or due to trans-septal fibres insertion5, or if fraenum
consists of dense collagen fibres3,6, diastema closure
will relapse. Initial diastema size, familial history and
spacing in dentition are mentioned as significant pre-
treatment factors for possible relapse7. In order to avoid
post-treatment complications7, frenectomy combined with
osteotomy is advised5.
A 14-year-old patient was referred by the
orthodontist for management of labial fraenum (Fig. 1,
left). Clinical examination revealed the presence of an
abnormal, hypertrophied labial fraenum and midline
diastema of about 2 mm (Fig. 1, left). Blanch test
was positive3. Radiographic examination exhibited a
V-shaped radiolucency in crestal bone between central
incisors7. The need for treatment was clearly guided by
orthodontist’s instructions for combination of frenectomy
with osteotomy. Surgical procedure was performed
under local anaesthesia (lidocaine with 1:200.000
epinephrine). Technique included gaining access to
intermaxillary suture by labial rhomboidal incision with
a scalpel, which combined removal of labial fraenum
by dissection of fibrous tissue attached to the upper lip
(Fig. 1, right). Interdental papilla was not included in the
incision in terms of better aesthetic results. Osteotomy
was performed at low speed with a cylindrical bur, under
continuous irrigation with sterile water. Labial and palatal
maxillary bone cortex was included, leaving palatal
periosteum intact. The surgical procedure resulted in
local separation of right and left maxilla at width of bur
(1.6 mm - 2 mm) and at 5 mm height, starting from crestal
Balk J Stom, Vol 16, 2012 Frenectomy with Combined Osteotomy 123

bone ridge and ending at cervical third of maxillary bone dressing (Septo-pack, Septodont). Analgesics and 0.2%
(Fig. 1, right). Therefore, trans-septal fibre attachment chlorhexidine mouthwash were prescribed for 5 days.
was destroyed. Sutures with 3-0 silk were made at upper After 10 days healing was uneventful, orthodontic
lip area, while gingival area was covered with gingival treatment started and is still ongoing.

Figure 1. Left: Clinical and radiographic examination. Clinical examination reveals abnormal fraenum and midline diastema preservation after
lateral incisors and canines eruption. Radiographic image before intervention, indicating width of intermaxillary suture and V-shaped radiolucency
between maxillary central incisors, possibly due to fraenum fibre insertion. The gap is broader at the cervical third of the suture
Right: Immediate inter-surgical view. Excision of the fraenum creates rhomboidal wound. Radiographic image shows the extent of bone
removal, which is clearly guided by the need to eliminate fibrous attachment into the intermaxillary suture

Discussion Diastema treatment with frenectomy, fixed

Management of maxillary midline diastema can be
treated with orthodontics, restorative dentistry, surgery
and with combinations of the above. The ideal treatment
should emphasize on the aetiology and on long-term
preservation of the therapeutic results, as it is noted that
relapses were twice as great in patients with abnormal
fraenum1.
orthodontic appliance and retainer, produces more stable
results, compared to treatment without frenectomy6,8.
Combination of frenectomy with osteotomy results in
stability in orthodontic closure of midline diastema5
as resistance against closure from alveolar bone is
eliminated9. Osteotomy results in de-cortication of
intermaxillary suture and elimination of possible trans-
septal fibres penetration5. However, trans-septal fibres can
124 S. Dalampiras, C. Boutsiouki
be reformed and create an elastic chain which preserves
tooth position and eliminates chance of displacement1,10.
Concerning gingival tissue aesthetics, in this case
interdental papilla was not violated and satisfying
aesthetic results are expected.
Conclusions
In cases of midline diastema combined with
abnormal labial fraenum and a radiographically diagnosed
persistent intermaxillary suture, frenectomy with
osteotomy seems to be the treatment of choice.
References
1. Edwards JG. The diastema, the frenum, the frenectomy. A
clinical study. Am J Orthod, 1977; 71:489-508.
2. Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema
and frenum morphology in the primary dentition. J Dent
Child (Chic), 2006; 73(1):11-14.
3. Ferguson MWJ. Pathogenesis of abnormal midlines spacing
of human central incisors. Br Dent J, 1983; 154:212-218.
Balk J Stom, Vol 16, 2012
4. Weyman J. The incidence of median diastemata during the
eruption of the permanent teeth. Dent Pract, 1967; 17:276-278.
5. Kraut RA, Payne J. Osteotomy of intermaxillary suture
for closure of median diastema. J Am Dent Assoc, 1983;
107:760-761.
6. Ziemba Z. Histomorphologic evaluation of upper lip frenum
in relation to the method of treating diastema. Ann Acad
Med Stetin, 2003; 49:353-365.
7. Shashua D, Artun J. Relapse after orthodontic correction
of maxillary median diastema: A follow-up evaluation of
consecutive cases. Angle Orthod, 1999; 69(3):257-263.
8. Antoni R, De Angelis D, Gravina GM, Accivile E. The
superior median frenulum. Surgical-orthodontic treatment of
a recurrence. Clin Ther, 1989; 130(2):95-100.
9. Bell WH. Surgical-orthodontic treatment of interincisal
diastemas. Am J Orthod, 1970; 57:158-163.
10. Stubley R. The influence of transseptal fibers on incisor
position and diastema formation. Am J Orthod, 1976;
70(6):645-652.
Correspondence and request for offprints to:
Boutsiouki Christina
Kallidopoulou 12, Faliro
54642, Thessaloniki, GREECE
E mail: bou_chri@yahoo.gr
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Fracture of the Maxillary Tuberosity: A Case Report

SUMMARY Biljana Evrosimovska, Boris Velickovski,

In everyday dental practice, during typical tooth extraction or Zaklina Menceva
oral surgery, sometimes unexpected complications happen. Concerning “St Cyril and Methody University”
extraction of maxillary molars, fracture of the maxillary tuberosity is among PHO University Dental Clinical Centre
the most delicate. This fracture is a serious complication; depending on its “St. Pantelejmon”, Faculty of Dentistry
Clinic for Oral Surgery
dimensions, it can present surgical, as well as prosthetic problem. From the
Skopje, FYROM
prosthetic point of view, anatomic area of maxillary tuberosity is especially
important for providing desired retention and stability of upper denture.
The aim of this paper is to show the surgical therapeutic approach to the
treatment of the maxillary tuberosity fracture occurred during extraction of
the maxillary second molar.
In particular case, after complete intraoral examination and X-ray
analysis, possible fracture of tuber maxillae could be predicted. Dentist
should mention this to the patient before starting the procedure and try to
avoid it with cautious and professional work. Otherwise, this can be a matter
of criminal act, with possible legal consequence. CASE REPORT (CR)
Keywords: Maxillary Tuberosity, fracture; Maxillary Molars, extraction Balk J Stom, 2012; 16:125-128

Introduction semi-impacted maxillary third molar, solitary maxillary

In everyday dental practice, during typical tooth
extraction or oral surgery, sometimes unexpected
complications happen. Peri-operative complications
can happen due to multiple causes, but unfortunately,
the main cause is still the iatrogenic factor. Some of
these complications happen relatively often, and some
extremely rarely.
During extraction of maxillary molars many
complications can happen, and fracture of the maxillary
tuberosity is among the most delicate. This fracture is
a serious complication; depending on its dimensions, it
can present surgical, as well as prosthetic problem. From
the prosthetic point of view, anatomic area of maxillary
tuberosity is especially important for providing desired
retention and stability of upper denture.
There are numerous circumstances that could
increase the risk of appearance of this peri-operative
complication1,8,11: weakness of the tuber maxillae as a
result of the strong maxillary sinus pneumatisation, low
resistance of bone in this area as a result of impacted or
molar, maxillary molar with extremely divergent or hyper-
cementotic roots or anomaly of the number of roots, and
tooth germination - fusion of second and third maxillary
molar.
As a result of smaller elasticity of bone tissue, the
risk of maxillary tuberosity fracture in older patients
increases. In addition, the risk of this complication
increases during ankylosis of maxillary molars, which
gives resistance to tooth luxation movements during
extraction2. In some particular cases, genesis of this
complication can indicate a therapeutic mistake (vitium
artis). Namely, as a result of the uncontrolled force,
as well as the use of inappropriate instrument during
extraction or inappropriate use of elevator, overly deep or
careless application of the forceps are possible factors of
additional risk for emergence of this complication4.
Diagnosis of the maxillary tuberosity fracture
assumes inspection, palpation and analysis of the
panoramic X-ray (orthopantomogram). Existence of
deformity is appointed with inspection during intraoral
examination. Orthopantomogram confirms the diagnosis
126 Biljana Evrosimovska et al. Balk J Stom, Vol 16, 2012

by finding of fracture line, which can be palpated from
the buccal or palatal side. Fracture of the maxillary
tuberosity can be confirmed since the time of performing
the extraction, because together with the forceps and
tooth, the whole tuber maxillae displaces. Oroantral
communication usually accompanies this complication6.
The aim of this paper is to show the surgical
therapeutic approach to the treatment of the maxillary
tuberosity fracture occurred during extraction of the
maxillary second molar.
As the fractured tuberosity could not be repositioned,
surgical removal of the fractured tuberosity together
with both teeth was performed (Fig. 2). During surgery,
the oroantral communication was confirmed due to the
fracture of the maxillary sinus walls (Fig. 3). Due to soft
tissue injury, the buccal adipose corpus could be seen
(Fig 4). In the same act, after levelling bone edges and
irrigation of the wound, it was completely sutured.

Case Report
A 45-year old female patient reported pain in the area
of second and third maxillary molar to her private dentist.
Beyond the clinical examination, without taking an X-ray,
extraction of the third maxillary molar was performed by
the dentist. However, after unsuccessful attempt of tooth
removal, the patient was sent to the Clinic of oral surgery
Figure 2. The removed fragment of the maxillary tuberosity, together
at the University dental clinical centre “Sts. Pantelejmon” with teeth
in Skopje. Patient had not been informed about the
previous nascent complication. Furthermore, the dentist
did not point out nor specify kind of complication.
Patient was accepted the same day at the Clinic for
oral surgery. From the dental history, we couldn’t find
out that fracture of the maxillary tuberosity happened
as the patient was not informed about that. However,
during intraoral examination mobility of the bone and
soft tissue in the area of the maxillary tuberosity could
be noted. Based on affirmative intraoral clinical finding,
the panoramic X-ray was made, which disclosed the
existence of a fracture line at the area of right maxillary
tuberosity, expanding to the space between second and
third maxillary molar (Fig. 1).

Figure 3. The created oroantral communication after the removal of

maxillary tuberosity

Figure 1. Orthopantomogram X-ray of the patient showing the fracture

line in the area of maxillary tuberosity, performed during the extraction
of third molar Figure 4. Intraoral view of the exposed buccal adipose corpus
Balk J Stom, Vol 16, 2012
After surgery, the usual postoperative instructions
were suggested, as well as the food regime. In addition,
antibiotic therapy (Neloren 600mg, twice a day for 5 days)
and corticosteroids (Dexamethason 4mg, once daily for 3
days) were ordered to the patient.
Postoperative period was characterised by intraoral
haematoma (Fig. 5) and extraoral presence of oedema
(Fig. 6), as a result of the tuberosity fracture and long
lasting of surgery.
Figure 5. Postoperative intraoral haematoma
Figure 6. Postoperative extraoral oedema
Discussion
The fracture of the maxillary tuberosity is one of
the worst peri-operative complications that may happen
during tooth extraction in the maxillary molar region5.
Several therapeutic procedures can be implemented
depending on different factors, such as patient’ general
health and age, the reason for tooth extraction, the
existence of oroantral communication, condition of the
Fracture of the Maxillary Tuberosity 127
alveolar process, the fracture line, the presence of the
antagonistic tooth, etc1,11.
In certain circumstances, after the detailed intraoral
examination and analysis of X-ray, the possibility for the
fracture of the maxillary tuberosity during tooth extraction
can be foreseen, and duty of the dentist is to inform the
patient in advance, but caution and professionalism during
the procedure must be maintained10. If the maxillary
tuberosity fracture nevertheless happens, the dentist
must diagnose the complication and inform the patient
about it. Otherwise, this managing could be considered
as a criminal act of the neglectful dentist, with low
consequences9.
There are several possibilities for treatment of the
maxillary tuberosity fracture. If the soft tissue is not
harmed, and the fractured tuberosity is still attached to the
periosteum, tooth could be carefully detached from the
bone and removed, and the bone fragment immobilized. If
the tooth was without any pathological changes (extraction
from orthodontic reasons), it can be maintained, and the
fractured tuberosity repositioned and immobilized. At the
same time, extraction should be postponed for 6-8 weeks,
and afterward extraction of the tooth should be performed
surgically circumstances7. If the fractured bone fragment
is detached from the soft tissue, it should be separated
and removed, the sharp edges smoothed, and soft tissue
sutured. Once oroantral communication is present, surgical
closure is obliged7. Regardless the procedure, antibiotic
cover is mandatory in order to prevent secondary infection.
Best therapeutic option is, certainly, prevention of
provoking such a complication, applying a detail clinical
examination, proper X-ray analysis, and the use of
adequate tooth extraction technique. If during the tooth
extraction certain degree of mobility of the maxillary
tuberosity is established visually and tactually, it is
especially important to stop with further extraction and try
to separate the roots, which should reduce the possibility
of this complication occurrence.
Fracture of the maxillary tuberosity is a serious
complication that creates difficulties for the subsequent
prosthetic rehabilitation. Moreover, it may provoke
serious secondary complications (bleeding, maxillary
sinus infection, etc). Dentist must estimate and predict
its possible creation and refer the patient for oral-surgery
intervention.
References
1. Altuğ HA, Sahin S, Sencimen M, Dogan N. Extraction
of upper first molar resulting in fracture of maxillary
tuberosity. Dent Traumatol, 2009; 25(1):1-2.
2. Chrcanovic BR, Freire-Maia B. Considerations of maxillary
tuberosity fractures during extraction of upper molars: a
literature review. Dental Traumatology, 2011; 27(5):393-398.
 128 Biljana Evrosimovska et al.
3. Fragiskos D. Oral Surgery. Berlin, Heidelberg, New York:
Springer, 2007; pp 183-184.
4. Jojić B, Perović J. Oralna hirurgija. Beograd: Naučna
knjiga, 1994; pp 169-170. (in Serb)
5. Lillich JD. Complications of dental surgery. Vet Clin North
Am Equine Pract, 1998; 14(2):399-410.
6. Miloro M. Peterson’s principles of oral and maxillofacial
surgery. 2nded. London: BC Decker Inc, 2004; pp 435-443.
7. Ngeow WC. Management of the fractured maxillary
tuberosity: an alternative method. Quintessence Int, 1998;
29(3):189-190.
8. Piščević A, Gavrić M, Sjerobabin I. Maksilofacijalna
hirurgija. Beograd: Draganić, 1995, pp 18-44. (in Serb
9. Puzović D, Čolić S. Sudskomedicinsko tumačenje preloma
tubera gornje vilice nastalog prilikom vađenja zuba.
Vojnosanit Pregl, 2010; 67(9):777-780. (in Serb)
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Balk J Stom, Vol 16, 2012
10. Shan N, Bridgman JB. An extraction complicated by lateral
and medial pterygoid tethering of a fractured maxillary
tuberosity. Br Dent J, 2005; 198(9):543-544.
11. Todorvić Lj, Petrović V, Jurišić M, Kafedžiska-Vračar V.
Oralna hirurgija. Beograd: Nauka, 2002. (in Serb)
Correspondence and request for offprints to:
Ass. d-r Biljana Evrosimovska mr. sci.
Faculty of dentistry, Department of oral surgery
Str. Vodjanska 17
1000 Skopje, FYR Macedonia
E-mail: tatijana_78@yahoo.com