incisal index.pdf

Restoring the Incisal Edge Douglas A. Terry, D.D.S. Abstract

The clinical significance is that anterior tooth fractures can

Restorative dentistry evolves with each development of

be predictably restored using contemporary small particle

new material and innovative technique. Selection of

hybrid composite resin systems with the aforementioned

improved restorative materials that simulate the physical

restorative techniques. These placement techniques when

properties and other characteristics of natural teeth, in

used with proper attention to preparation design, adhesive

combination with restorative techniques such as the prox-

protocol and finishing and polishing procedures, allow the

imal adaptation and incremental layering, provide the

clinician to successfully restore form, function and esthetics

framework that ensures the optimal development of an

to the single anterior tooth replacement.

esthetic restoration. These advanced placement techniques offer benefits such as enhanced chromatic integration, polychromatism, ideal anatomical form and function, optimal proximal contact, improved marginal integrity and longer lasting directly placed composite restorations. The purpose of this article is to give the reader a better understanding of the complex restorative challenge in achieving true harmonization of the primary parameters in esthetics (that is, color, shape and texture) represented by the replacement of a single anterior tooth. The case presented demonstrates the restoration of a Class IV fracture integrating basic adhesive principles with these placement techniques and a recently developed nanoparticle hybrid composite resin system (Premise, Kerr/Sybron, Orange, CA). The clinical presentation describes preopera-

tive considerations, tooth preparation, development of the body layer, internal characterization with tints, development of the artificial enamel layer, shaping and contouring, and polishing of a Class IV composite restoration. 30 NYSDJ • AUGUST/SEPTEMBER 2005

THE SINGLE ANTERIOR TOOTH replacement remains a complex aesthetic challenge for technicians and clinicians in restorative dentistry. This challenge exists in either composite restorative systems or porcelain systems while attempting to achieve true harmonization of the primary parameters in aesthetics (that is, color, shape, texture). While porcelain designing relies on stone models, photographs and the clinician’s narrative description to the laboratory technician, direct restorative resin reconstruction relies on the surrounding dentition for correlation. The proximate environment commands the appearance of any restoration. Increased patient demand for aesthetic dentistry with minimal invasive procedures has resulted in the extensive use of freehand bonding of composite resin to address this challenge. Achieving a restorative result with optimal physical and mechanical characteristics often required the use of a combination of hybrid and microfill. The hybrid provided the strength and sculptability, and the microfill furnished the polish and durability of the restoration.An incremental layering technique with composite resin resulted in an optimal depth of cure while reducing the effects of shrinkage and stress forces during the polymerization process.1, 2 Yet, when different restorative composites of varying refractive indexes, shades and opacities were stratified, clinicians

observed a “polychromatic effect.”3 However, by using an anatomic stratification with successive layers of dentin, enamel and incisal composite, a more realistic depth of color could be achieved, as well as surface and optical characteristics that mimic nature.4-5 The development of the polychromatic restoration from the inequities of the different composite resin systems (hybrid and microfill) stimulated scientists, researchers, clinicians and manufacturers to explore and develop restorative materials that are not only applied in relationship to the natural tissue anatomy, but also have similar physical, mechanical and optical properties of the tooth structure. In the past decade, aesthetic dentistry has continued to evolve through innovations in restorative materials, bonding systems, function-based treatments, conservative preparation design and adhesive placement techniques. Such advances have increased the restorative opportunities available for discriminating patients, and have provided solutions to many of the aesthetic challenges faced by clinicians. Increased use of composite materials to restore the anterior dentition has drawn increased attention to contemporary technological advances in restorative and aesthetic dentistry. Contemporary Technological Advances: Nanotechnology

In composite resin technology, particle size and the amount of particles represent crucial information in determining how best to use the composite materials.Alteration of the filler component remains the most significant development in the evolution of composite resins,7 because filler particle size, distribution and the quantity incorporated dramatically affect the mechanical properties and the clinical success of composite resins.8 In general, mechanical and physical properties of composites improve in relationship to the amount of filler added. Many of the mechanical properties depend upon this filler phase, including compression strength and/or hardness, flexural strength, the elastic modulus, coefficient of thermal expansion, water absorption and wear resistance. Nanotechnology or molecular manufacturing9 may provide composite resin with filler particle size that is dramatically smaller in size, can be dissolved in higher concentrations and polymerized into the resin system with molecules that can be designed to be compatible when coupled with a polymer, and provide unique characteristics (physical, mechanical and optical). In addition, optimizing the adhesion of restorative biomaterials to the mineralized hard tissues of the tooth is a decisive factor in enhancing the mechanical strength and marginal adaptation and seal, while improving the reliability and longevity of the adhesive restoration. Currently, the particle sizes of conventional composites are so dissimilar to the structural sizes of the hydroxyapatite crystal, dental tubule and enamel rod, there is a potential for compromises in adhesion between the macroscopic (40 nm to 0.7 um) restorative material and the nanoscopic (1 nm to 10 nm in size) tooth structure.10 However, nanotechnology has the potential to improve this continuity between the tooth structure and the nano-sized filler particle and provide a more stable and natural interface between

the mineralized hard tissues of the tooth and these advanced restorative biomaterials. The following clinical presentation describes the use of a nanoparticle hybrid composite resin system (Premise, Kerr/Sybron, Orange, CA). Preoperative Considerations

Prior to initiating the restorative procedure, an occlusal analysis of the anatomical morphology of the tooth is performed and transferred to a hand-drawn diagram. This diagram acts as a restorative roadmap for the clinician and can include such information as: dentin and enamel intercolor contrasts; translucency patterns; crazing; hypocalcification spots; incisal and gingival blending; and stain patterns. Also, a preoperative selection of composite resins and tints and modifiers with their shade and orientation is recorded. Shade selection should be accomplished prior to rubber dam placement to prevent improper color matching as a result of dehydration and elevated values.11 When teeth dehydrate, the air replaces the water between the enamel rods, changing the refractive index that makes the enamel appear opaque and white.12 In addition, the preoperative occlusal stops and excursive guiding planes can be recorded with articulation paper and can be transferred to a hand-drawn occlusal diagram, recorded on an intraoral or digital camera or indicated and reviewed on a stone model. This initial registration is valuable in preparation design when determining placement of centric stops beyond or within the confines of the restoration, in determining the proper restorative material thickness of the artificial enamel and artificial dentin, and in minimizing finishing procedures.13 Restoration of Anterior Fracture: Class IV Restoration

A 35-year-old male patient presented with a fractured maxillary left central incisor (Figure 1). Upon self-assessment the patient requested the most conservative and aesthetic restorative procedure available. Shade determination was accomplished by custom fabricated shade comparison (Figure 2) and instrumental shade analysis (ShadeScan, Cynovad, Montreal, Canada), and a previsualized

Figure 1. Preoperative facial view of fractured maxillary left central incisor.

Figure 2. Custom-fabricated shade tabs were developed from composite material and compared to existing tooth structure.

NYSDJ • AUGUST/SEPTEMBER 2005 31

A Figure 3. Chamfer 0.3 mm in depth was placed 2 mm long around entire margin.

Figure 4. 0.5 mm scalloped bevel was placed with long, tapered diamond bur.

Figure 5. Preparation was cleaned with 2% chlorhexidine.

Figure 6. Preparation was etched for 15 seconds with 37.5% phosphoric acid (Gel Etchant, Kerr/Sybron, Orange, CA).

color mapping (hand-drawn diagram and computer diagram) were developed to anticipate the final result as previously indicated in the preoperative considerations. To facilitate access to the cervical region of the tooth, the field was first isolated with a rubber dam using a modified technique. This process involved creation of an elongated hole that allowed placement of the rubber dam over the retainers to achieve adequate field control.14,15 Once the extent of the preparation was determined, a cervical chamfer 0.3 mm in depth was placed 2 mm long around the entire margin to increase the enamel–adhesive surface and to provide a sufficient bulk of material at the margins.16 A “scalloped” bevel on the chamfer was placed to break up the straight chamfer line with a long tapered diamond (6850, Brasseler USA, Savannah, GA) (Figure 3). Since the margin was on enamel, a 0.5 mm bevel was placed on the gingival margin to reduce microleakage with a needle-shaped fine diamond (DET-9, Brasseler, USA, Savannah, GA) (Figure 4). The lingual aspect of the chamfer was extended 2 mm onto the lingual surface, but not onto the occlusal contact area. The margin should not end on the occlusal contact area unless relocating it to a contact free area would require excessive reduction of healthy tooth structure. The preparation was completed with a finishing disk and polished with rubber cups that contained a premixed slurry of pumice and 2% chlorhexidine (Consepsis, Ultradent, South Jordan, UT) (Figure 5). The preparation was rinsed and lightly air dried, and a soft metal strip was placed interproximally to isolate the prepared tooth from the adjacent dentition. The “total etch” technique was used because of its ability to minimize the potential of microleakage and to enhance bond strength to dentin and enamel.17-19 The preparation was etched for 15 seconds with 37.5% phosphoric acid semi-gel (GEL-Etchant, Kerr/Sybron, Orange, CA), rinsed for five seconds and gently air dried for five seconds (Figure 6). Once a hydrophilic adhesive agent (Optibond Solo Plus, Kerr/Sybron, Orange, CA) was applied for 20 seconds with a Microbrush (Microbrush, Grafton, WI) disposable applicator using continuous motion, the excess was removed with the same applicator, and the agent was light cured for 20 seconds (Figures 7 A-C). Although a small amount of excess adhesive can be applied over the 32 NYSDJ • AUGUST/SEPTEMBER 2005

B

C

Figure 7. (A) Single component adhesive (OptiBond SOLO plus, Kerr/Sybron, Orange, CA) was applied in continuous motion for 20 seconds. (B) Air thinned for 5 seconds. (C) Light cured for 20 seconds.

margins to improve sealing, this excess should be removed during finishing procedures to avoid adverse periodontal sequellae. Proximal Adaptation Technique

Since composite does not have hydroxyapatite crystals, enamel rods and dentinal tubules, the final composite restoration requires the clinician to develop an illusion of the way light is reflected, refracted, transmitted and absorbed by these microstructures of the dentin and enamel. Therefore, in recreating the proximal surface, a similar orientation of enamel and dentin is required. Since a silhouette of the cavity form is highlighted by the darkness of the oral cavity, which is described as “shine through,” it is necessary to use an opacious dentin replacement with higher color saturation. This ensures that when light strikes the optically denser dentin with more color saturation, more light is reflected back to the eyes. To reproduce the optical effects of the enamel, a translucent composite encapsulates the inner dentin core and alters the quantity and quality of the light as it is reflected back to the eyes. An infinitesimal amount of glycerin was applied to the mesial surface of the maxillary right central with unwaxed floss (Figure 8). The proximal adaptation technique was used because it allows optimal adaptation of the initial composite layer to the adjacent tooth without using a mylar plastic strip. Although studies indicate a smooth surface can be attained with the mylar strip, improper proximal adaptation can result in inadequate contact, improper anatomical form and shape, and surface defects. Opacious dentin replacement was selected for strength and color, and the most suitable restorative materials for the core of these restorations were the hybrids and the microhybrids. Because these small-particle hybrids have refractive properties and a variety of color selections similar to that of dentin, they imitate the natural tooth structure extremely well and have enough resistance for most occlusal stress-bearing regions in the anterior segment. (Premise, Kerr/Sybron, Orange, CA; Venus, Heraeus Kulzer, Armonk, NY; Gradia, GC America, Alsip, IL; Vitalescence, Ultradent, Salt Lake City, UT; Filtek Supreme, 3M ESPE, St Paul, MN; Point 4, Kerr/Sybron, Orange, CA).

“Artificial Dentin” Layer

The initial artificial dentin body layer of opacious B-1 shaded hybrid composite resin (PremiseTM Kerr/ Sybron, Orange CA) was applied, adapted and contoured to the proximal surface of the contralateral central incisor with a long-bladed interproximal instrument, smoothed out with a sable brush and light cured for 40 seconds, which allowed placement of subsequent increments without deforming the underlying composite layer (Figure 9). An elliptical increment of opacious B-1 shaded hybrid composite resin was placed from the incisolingual aspect to form an incisal matrix. While the material was still soft, vertical and horizontal invaginations were placed with a long-bladed composite instrument, smoothed with a sable brush, and light cured for 40 seconds from the facial and lingual aspects (Figure 10). It was crucial to maintain a smooth internal surface, since surface irregularities could have interfered with placement of the tints for internal characterization. In addition, these invaginations created translucency and provided regions for placement of tints. In order to prevent overbuilding of the artificial dentin layer, it is imperative to monitor the composite from the incisal aspect to provide adequate space for the final “artificial enamel layer.”

Figure 8. Glycerin was applied to proximal surface of maxillary right central using un-waxed floss as separating medium.

Figure 9. First layer of artificial dentin body, opacious B-1 shaded hybrid composite was applied and contoured to proximal surface of contralateral central incisor with longbladed instrument.

Figure 10. Increment of composite was added to incisoligual aspect and contoured, followed by placement of vertical and horizontal invaginations. Restoration was then light cured for 40 seconds.

Figure 11. Diluted white tint was applied in vertical and horizontal invaginations and placed along interface to disguise fracture line.

Figure 12. Diluted gray tint was applied vertically corresponding to contralateral central and to create illusion of translucency.

ization technique uses color variation to emphasize the nuances of color in the incisal edge and instill the restoration with a threedimensional effect. “Artificial Enamel” Layer

The enamel or artificial enamel layer is the principal determinant of the value of tooth or the restoration;21 this can be varied by the thickness of this layer. The enamel is colorless, but through its network of rods acts as a fiber optic conduit and projects the underlying color found in the dentin. The nanoparticle hybrid (Premise, Kerr/Sybron, Orange, CA) used in developing this restoration has four translucent shades: super clear, clear, amber and gray. A super clear translucent-shaded hybrid composite was applied and contoured with a long-bladed composite instrument. A precut mylar strip was placed and adapted over the facial surface and light cured from the facial and the lingual aspects for 40-second intervals, respectively (Figures 13 A,B). Developing the restoration in increments and considering the occlusal morphology and occlusal stops allows the clinician to minimize finishing procedures and results in a restoration with improved physical and mechanical characteristics with less microfracture. After placing the last layer of composite and prior to final cure, an oxygen inhibitor, Glycerin (Insure, Cosmedent, Chicago, IL) or DeOxTM (Ultradent, South Jordan, UT), is applied in a thin layer with a brush to the surface of the restoration and light cured for a twominute post cure.22

Internal Color Characterization

A thin layer of resin can be applied and cured to create a “light diffusion layer” and provide an illusion of depth for restorations of limited thickness. This translucent layer will cause an internal diffusion of light and control luminosity within the internal aspect of the restoration.20 A white tint (Kolor Plus, Kerr/Sybron, Orange, CA) was placed along the fracture line and on specific regions in the vertical invaginations corresponding to the schematic color mapping diagram of the contralateral central and light cured for 40 seconds (Figure 11). A gray tint (Kolor Plus, Kerr/Sybron, Orange, CA) was placed on specific regions in the vertical invaginations corresponding to the schematic color mapping diagram of the contralateral central and light cured for 40 seconds (Figure 12). This internal character-

A

B

Figure 13. (A) Super-clear translucent shaded hybrid was placed at the incisal third of tooth. (B) Precut mylar strip was placed and adapted over facial surface to achieve smooth surface and light cured. NYSDJ • AUGUST/SEPTEMBER 2005 33

A Figure 14. To reproduce natural form and texture, initial contouring was performed with #30 fluted, needle-shaped finishing bur.

Figure 15. Contouring and finishing of lingual aspect were accomplished with #30 fluted, egg shaped finishing bur.

Figure 16. Interproximal region was finished with aluminum oxide finishing strips that were used sequentially according to grit and ranged from coarse to extra fine.

Figure 17. Final polish was performed with silicone points to eliminate surface defects.

B

Figure 18. (A) Definitive polish and high luster were accomplished with soft goat hair bush with composite polishing paste. (B) With cloth wheel using staccato motion.

Finishing and Polishing Procedure

Finishing focuses on contouring, adjusting, shaping and smoothing the restoration, while polishing concentrates on producing a smooth surface luster and highly light-reflective surface.23 The final restorative phase was achieved by contouring and finishing the restoration, which remains critical to the enhancement of esthetics and the longevity of the restored teeth.24,25 To reproduce the shape, color and gloss of the natural dentition, while enhancing the esthetics and longevity of the restoration, the following protocol was implemented. Surface texture of composite restorations is relatively hard to achieve, demanding intensive training and meticulous attention to technique coupled with very attentive observation of natural teeth. In this case,particular attention was given not only to the relationship between the expanse and direction of the marginal ridge, lingual fossa and the anatomic variations of the teeth that will be adjacent to the restoration, but also to the light refraction and surface reflection resulting from microstructure of the tooth surface.26 The initial contouring was performed with a series of finishing burs to replicate form and texture. The facial contouring was initiated with #30 fluted, needle-shaped burs (BluWhite Diamonds and Carbides, #7714, Kerr/Sybron, Orange, CA) (Figure 14). The lingual surfaces were contoured with #30 fluted, football-shaped burs (BluWhite Diamonds and Carbides, #9406, Kerr/Sybron, Orange, CA) (Figure 15). Finishing the proximal, facial and incisal angles was performed with aluminum oxide disks and finishing strips (Figure 16). These were used sequentially according to grit, and ranged from coarse to extra fine. For characterization, finishing burs, diamonds, and rubber wheels and points were used to create indentations, lobes and ridges (Figure 17). The definitive polish and high luster was accomplished with a soft white goat hair brush with composite polishing paste (Diamond Polishing Paste, Kerr/Sybron, CA) and a cloth wheel using staccato motion (Figures 18 A,B). The contact was tested with unwaxed floss to ensure the absence of sealant in the contact zone, to verify adequate contact and the absence of a gingival overhang, and to inspect the margins. 34 NYSDJ • AUGUST/SEPTEMBER 2005

The rubber dam was removed, and the patient was asked to perform closure without force and then centric, protrusive and lateral excursions.Any necessary occlusal equilibration was accomplished with a 30-micron, egg-shaped finishing diamond bur, and the final polish was repeated. The surface quality of the composite is influenced not only by the polishing instruments and polishing pastes, but also by the composition and filler characteristics of the composite.27 The newer formulations of nanocomposites with smaller particle size, shape and orientation, and increased filler concentration provide improved physical, mechanical and optical characteristics.Although clinical evidence of polishability with these new nanoparticle hybrids appears promising, the long-term durability of the polish will need to be evaluated in future clinical trials. The completed restoration reveals the harmonious integration of composite with natural tooth structure that can be achieved while developing an optimal proximal contact and marginal integrity in the interproximal zone through the use of incremental layering of composite resin and the proximal adaptation technique (Figures 19 A, B). Conclusion

This article has reviewed the advances in composite resin technology and provided a detailed description of the preparation design, restoration and finishing protocol for a Class IV fracture on a maxillary left central incisor using a nanoparticle composite resin system, Premise.

A

B

Figures 19 A, B. Postoperative facial view of restored central incisor. Note harmonious integration of composite with natural tooth structure in interproximal zone.

Although the long-term benefits of this material remain to be determined, the use of an optimized particle composite in the aforementioned patient demonstrated enhanced sculptability, the polishability of a microfill, the strength of a hybrid and the ability to simulate the optical properties of the natural tooth. While the evening news may fail to report the technological advancements that led to the development of the optimized particle composite, another milestone in the practice of dentistry has occurred in the endless quest for the ideal composite. ■ REFERENCES 1. Tjan AHL, Glancy JF. Effects of four lubricants used during incremental insertion of two types of visible light-activated composites. J Prosthet Dent 1988;60:189-194. 2. Kovarik RE, Ergle JW. Fracture toughness of posterior composite resins fabricated by incremental layering. J Prosthet Dent 1993;69:557-560. 3. Dietshi D. Free-hand composite resin restorations: a key to anterior aesthetics. Pract Periodont Aesthet Dent 1995;7(7):15-25. 4. Jefferies SR The art and science of abrasive finishing and polishing in restorative dentistry. Dent Clinic North America 1998;32(4):613-627. 5. Donly KJ, Browning R. Class IV preparation design for microfilled and macrofilled composite resin. Pediatric Dentistry January/February 1992;14(1): 34-36. 6. Kim HS, Um CM. Color differences between resin composite and shade guides. Quint Int August 1996;27(8):559-567. 7. Roulet JF. Degradation of Dental Polymers. 1st ed. Basel, Switzerland: S. Karger AG, 1987. 8. Leinfelder KF. Composite resins: properties and clinical performance. In: O’Brien WJ, and Powers, JM, ed. Dental Materials: Properties and Selection. Chicago, IL: Quintessence Publishing Co. 1989:139-57. 9. Kirk RE, Othmer DF, Kroschwitz J, Howe-Grant. Encyclopedia of Chemical Technology. 4th ed. New York: Wiley. 1991:397. 10. Muselmann M. Composites make large difference in “small” medical, dental applications. Comp Tech December 2003:24-27.

11. Fahl N Jr., Denehy GE, Jackson RD. Protocol for predictable restoration of anterior teeth with composite resins. Pract Perio Aesthet Dent 1995;7(8):13-21. 12. Winter R.Visualizing the natural dentition. J Esthet Dent 1993;5(3):102-117. 13. Liebenberg WH. Successive cusp build-up: an improved placement technique for posterior direct resin restorations. J Canad Dent Assoc 1996;62(6):501-507. 14. Liebenberg WH. General field isolation and the cementation of indirect restorations: Part 1. J Dent Assoc of South Afr 1994; 49(7): 349-353. 15. Croll TP. Alternative methods for use of the rubber dam. Quint Int 1985;16:387-392. 16. Bichacho N. Direct composite resin restorations of the anterior single tooth: clinical implication and practical applications. Compend 1996;17(7): 796-802. 17. Kanca, J III. Improving bond strength through etching of dentin and bonding to wet dentin surfaces. J Am Dent Assoc 1992(123):35-43. 18. Nakabayashi N, Nakamura M,Yasuda, N. Hybrid layer as a dentin-bonding mechanism. J Esthet Dent 1991;3(4):133-138. 19. Kanca J III. Resin bonding to wet substrate. II. Bonding to enamel. Quint Int. 1992;23(9):625-627. 20. Vanini L. Light and color in anterior composite restorations. Pract Periodont Aesthet Dent 1996;8(7):673-682. 21. Muia PJ. Esthetic Restorations: Improved Dentist-Laboratory Communication. Carol Stream, IL: Quintessence Publishing 1993: 86-87. 22. Sturdevant CM, Roberson TM, Heymann HO, et al. The Art and Science of Operative Dentistry. 3rd Ed. St. Louis: Mosby-Year 1995: 592. 23. Schwartz RS, Summitt JB, Robbins JW. Finishing and Polishing. In: Fundamentals of Operative Dentistry: A Contemporary Approach. Carol Stream, IL:Quintessence Publishing Co. Inc. 1996:201-205. 24. Jefferies SR, Barkmerier M, Gwinnett AJ. Three composite finishing systems: a multisite in vitro evaluation. J Esthet Dent 1992;4(6):181-185. 25. Goldstein RE. Finishing of composites and laminates. Dent Clin North Am 1999; 33(2): 305-318. 26. Hegenbarth EA. Teeth and Esthetics. In: Creative Ceramic Color: A Practical System. Chicago, IL: Quintessence 1989:9-36. 27. Jefferies Sr, Smith RL, Barkmeier WW, et al. Comparison of surface smoothness of restorative resin materials. J Esthet Dent 1989; 1(5): 169-175.

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The Unilateral Posterior Functional Crossbite An Opportunity to Restore Form and Function Elliott M. Moskowitz, D.D.S., M.Sd Abstract The unilateral posterior crossbite (UPXB) with functional shift of the mandible is commonly encountered in young children and adolescents. Differential diagnosis and the impact this type of malocclusion might have upon the growth and development of dental and facial components are discussed. Impaired function and compromised facial esthetics may be consequences of untreated UPXBs with functional shifts. Appropriate treatment protocols and specific orthodontic appliances intended to correct these problems are presented.

POSTERIOR CROSSBITES in the mixed or permanent dentition represent deviations from normal bucco-lingual occlusal relationships. Posterior crossbites can be caused by malpositions of individual or groups of posterior teeth (dental crossbites), malpositions of posterior teeth accompanied by a functional shift of the mandible (functional crossbites), or transverse disharmonies of the maxilla and mandible (skeletal crossbites). Frequently, posterior crossbite relationships may be caused by a combination of the aforementioned factors. Posterior crossbites are frequently observed as lingual crossbites (Figure 1), but may also be found in buccal crossbite relationships (Figure 2). 36 NYSDJ • AUGUST/SEPTEMBER 2005

There is a wide range of reported incidences of unilateral posterior crossbite (UPXB) in the primary and mixed dentition. The incidence of UPXB has ranged from 7% to 23%.1-7 Posterior crossbites have been reported to develop between 19 months and 5 years of age, with approximately 80% of UPXBs being accompanied by functional shifts of the mandible.8 The posterior crossbite with functional shift of the mandible should be differentiated from posterior dental crossbites without functional shifts. Figure 3 is a posterior dental crossbite caused by an individual tooth malposition of the maxillary left molar. Note that the maxillary and mandibular dental midlines coincide. This type of crossbite can be treated by moving the tooth (or teeth) in crossbite into normal position. However, the situation in Figure 4 is quite different. The observed crossbite relationship in the maximum intercuspation position appears to be identical to the dental crossbite anomaly. A closer look, however, reveals a notable disparity between the maxillary and mandibular dental midlines. The mandible has shifted (to the side of the observed crossbite) as it encountered prematurities upon closure. If we were to place the mandible in its normal transverse position (lining up the true maxillary and mandibular dental midlines), we would observe the actual transverse relationship between the maxillary and mandibular posterior teeth (Figure 5). It becomes apparent that both the right and left sides of the maxillary posterior segments are lingually displaced. Consequently, the functional crossbite (even though it resembles the dental posterior crossbite in the maximum intercuspation position) is a result of a

Figure 1. Most posterior crossbites are observed as lingual crossbites. Maxillary left molar is situated lingual to its normal position.

Figure 2. Although less frequently encountered, some posterior crossbites are buccal crossbites. Maxillary molar is positioned buccally, and mandibular molar is positioned lingually.

Figure 3. Posterior dental crossbite: definite occlusal stop in position of maximum intercuspation. Normal buccolingual inclinations of opposing molars on right side. Abnormal tipping on left side. Maxillary and mandibular dental midlines coincide.

Figure 4. Posterior functional crossbite: with teeth in maximum intercuspation, unilateral crossbite is seen. Opposite side appears to occlude normally. Mandibular midline is shifted toward crossbite side.

Figure 5. Functional crossbite on left displays mandibular transverse shift to patient’s left side as result of occlusal prematurities. Lining up true upper and lower dental midlines (by shifting mandible to patient’s right side) reveals actual transverse relationship between maxillary and mandibular dental arches. Maxillary dental arch is now seen as being constricted bilaterally.

Figure 8. Patient R.G. displays facial asymmetry as result of transverse shift of mandible upon closure.

Figure 6. Patient R.G. has unilateral posterior crossbite with functional shift of mandible (to patient’s left side). Upper and lower dental midlines are characteristically disparate. Figure 7. Diagrammatic depiction of transverse shifting of mandible associated with unilateral posterior crossbites.

bilateral constriction or narrowness of the maxillary dental arch and, therefore, requires bilateral posterior expansion. The young patient, R.G., in the composite intraoral photograph (Figure 6) has UPXB in the mixed dentition with functional shift of the mandible. Note that the left side is observed in crossbite and the right side appears “normal” in the maximum intercuspation position. The maxillary and mandibular dental midlines are significantly disparate. In cases of functional crossbites, the mandible shifts to the side of the observed crossbite (Figure 7). Facial asymmetries can be either subtle or significant. Figure 8 reveals patient R.G.’s facial asymmetry, caused by a lateral or transverse shift of the mandible. Need for Orthodontic Treatment

Posterior crossbites with functional mandibular shifts should be treated earlier rather than later.9 In general, the mixed dentition stage is an ideal time to treat UPXBs with functional shifts; however, they may be treated in the primary dentition as well. The dentitional status (presence of permanent maxillary and lateral incisors and first permanent molars) and important management considerations are usually favorable during the mixed dentition. From a practical perspective, few patients in the primary dentition are seen by most orthodontists on a routine basis. There is ample empirical and evidenced-based information to support the need for treatment while skeletal and dental growth and development are relatively active. Pinto, et. al.10 found both positional and morphological changes in young patients with posterior functional crossbites. Condylar position and length of the

mandibular skeletal structures, particularly the mandibular ramus, differed when bilateral structures were compared. Interestingly, it was also found that compensatory growth during and after maxillary expansion eliminated positional and morphological asymmetries observed before treatment. Simply stated, both form and function were restored via maxillary expansion and elimination of the functional shift of the mandible. Sonneson, et al.11 measured the bite force of patients with and without posterior functional crossbites with pressure transducers. They found a significant increase in muscle tenderness and other TMD symptomology in the crossbite sample. Additionally, bite force was also decreased in patients with crossbites. These investigators concluded, “The early treatment of unilateral posterior crossbites was advisable to optimize conditions for function.” Figure 9 shows a composite photograph of an adult patient, G.W., with a longstanding left side crossbite relationship and functional shift of the mandible to the left side. The facial asymmetry is notable. The anteroposterior cephalometric radiograph (Figure 10) confirms the asymmetric mandibular skeletal structures as a result of continued differential growth and development while the mandible was positioned in an abnormal transverse relationship. Several viable treatment options were offered to the patient. These options included a combined orthodontic/orthognathic surgical protocol (which might have fully corrected the skeletal disharmonies) and a sole conventional orthodontic treatment intended to merely “improve” the mandibular asymmetry by allowing the mandible to assume a more normal transverse position after funcNYSDJ • AUGUST/SEPTEMBER 2005 37

Figure 9. Adult patient, G.W., displays facial asymmetry as result of longstanding functional crossbite that persisted during growth.

Figure 12. E.H. is 8-year-old female displaying “classic” UPXB in mixed dentition.

Figure 10. Anterior-posterior cephalometric radiograph confirms mandibular asymmetry.

Figure 13. Facial asymmetry of E.H. as result of functional shift of mandible.

tional interferences were removed. The patient rejected orthognathic surgery and opted for conventional orthodontic treatment, which entailed maxillary dental expansion and the use of fixed orthodontic appliances to improve inter- and intradental relationships. Figure 11 is a post-treatment composite showing significant inter- and intradental arch corrections. The facial asymmetry has been reduced as the mandible assumed a more normal transverse relationship. The remaining asymmetry is due to unchanged bilateral morphological mandibular structural differences that naturally would not be expected to fully correct without the assistance of a surgical procedure. Treatment

The treatment of posterior crossbites with functional shifts generally entails use of an orthodontic appliance that is capable of effecting bilateral expansion of the maxillary dental arch and/or expansion of the palate via sutural disjunction. The clinician should assess the level of orthodontic correction that is needed beyond the mere elimination of the functional shift using the same criteria that are appropriate for the diagnosis, treatment planning, choice of appliance(s) and retention requirements of any prospective orthodontic patient. E.H. is an 8-year-old female with UPXB with functional shift in the mixed dentition (Figure 12). The right side displays a complete 38 NYSDJ • AUGUST/SEPTEMBER 2005

Figure 11. Post-orthodontic treatment composite illustrating dental and facial improvement.

Figure 14. Fixed palatal expansion device used in treatment of E.H’s functional crossbite.

crossbite relationship from the maxillary right primary canine to the maxillary right first permanent molar. The mandible has shifted to the patient’s right side as a result of prematurities caused by the malpositions of the teeth and constriction of the maxillary dental arch. The maxillary and mandibular dental midlines do not coincide. The early effects of the transverse malpositioning of the mandible in the lower third of the face can be seen in Figure 13. A fixed palatal expander (Figure 14) was placed, and the parent was instructed to activate the expansion screw with a “key” once a day. This early or “phase I” treatment extended approximately nine months. Figure 15 shows the composite post-treatment outcome. Note the elimination of crossbites, dental midline coincidence and improvement in facial symmetry (Figure 16). The 9-year-old patient in Figure 17 has UPXB with functional shift (to the patient’s right side) in the mixed dentition. The dental midlines do not coincide.A removable expansion appliance was prescribed (Figure 18) to effect bilateral dental expansion. The patient or parent activated the expansion screw placed in the palatal portion of the appliance. Note that the occlusal acrylic portion of the removable appliance covers the buccal surfaces of the posterior teeth to minimize occlusal interferences and unwanted tipping of the buccal segments. The crossbite and functional shift were corrected in less than six months. Figure 19 shows the correction as the patient continues to develop into the permanent dentition.

Figure 15. Post “phase I” treatment demonstrating return to dentofacial harmony in mixed dentition.

Figure 16. Facial asymmetry of E.H. eliminated.

Figure 18. Removable dental expansion appliance with occlusal coverage.

Figure 17. UPXB with functional shift in mixed dentition.

Figure 19. Correction of UPXB.

Figure 21. Bonded palatal expanding device with occlusal coverage. Figure 20. Patient P.C. with UPXB and functional shift in permanent dentition.

Figure 22. Correction of functional crossbite and improvement in inter- and intradental relationships.

P.C. is a 16-year-old female in the permanent dentition with UPXB and functional shift of the mandible to the right side (Figure 20). A fixed palatal expander with occlusal acrylic coverage was bonded to the maxillary dental arch (Figure 21). This type of fixed expander can eliminate occlusal interferences during treatment, minimize unwanted vertical changes that sometimes accompany palatal expansion, and obviate the need for separation and banding of posterior teeth. Treatment extended approximately 16 months and included a brief period of conventional fixed orthodontic appliances to coordinate inter- and intradental relationships. Figure 22 shows the posttreatment outcome, in which the functional crossbite was eliminated. Conclusions

UPXB with functional shift of the mandible is a type of malocclusion that can impair both form and function in growing individuals. Pediatric dentists and other clinicians who choose to treat children and adolescents should be keenly aware of the diagnostic features of UPXB with functional shifts and recommend orthodontic corrective procedures earlier rather than later. The mixed dentition is an ideal stage to consider beginning orthodontic treatment in these types of cases. The successful resolution of UPXB with functional shift represents a valuable and conservative dental health service for individual patients with this type of malocclusion. ■

REFERENCES 1. Kutin G, Hawes RR. Posterior crossbites in the deciduous and mixed dentition. AM J Orthod 1969;56:491-504. 2. Day AJ, Foster TD. An investigation into the prevalence of molar crossbite and some associated etiological conditions. Dent Pract. 1971;21:402-10. 3. Infante PF. An epidemiologic study of finger habits in preschool children as related to malocclusion, socioecononomic status, race, sex, and size of community. J Dent Child 1976;1:33-8. 4. de Vis H, de Boever JA, van Cauwenberge P. Epidemiologic survey of functional conditions of the masticatory system in Belgian children aged 3-6 years. Comm Dent Oral Epidemiol 1984;12:203-207. 5. Heikinheimo K, Salmi K. Need for orthodontic intervention in five-year-old Finnish children. Proc Finn Dent Soc 1987;83:165-9. 6. Hannuksela A, Laurin A, Lehmus V, Kouri R. Treatment of crossbite in early mixed dentition. Proc. Finn Dent Soc. 1988;84:175-82. 7. Kurol J, Bergland L. Longitudinal study and cost-benefit analysis of the effect of early treatment of posterior crossbites in the primary dentition. Eur J Orthod 1992;14:173-9. 8. Thilander B,Wahlund S, Lennartsson B.The effect of early interceptive treatment in children with posterior crossbite. Eur J Orthod 1984;6:25-34. 9. Gottlieb Eugene, Moderator, JCO Roundtable, Early Orthodontic Treatment, Part 2. J Clinical Orthod March, Volume XXXVIII, Number 3:135-154. 10. Pinto,AS, Buschang, PH, Throckmorton GS, Chen P. Morphological and positional asymmetries of young children with functional unilateral posterior crossbite. Am. J. Orthod. 2001;20:513-520. 11. Sonnesen L, Bakke M, Solow B. Bite force in pre-orthodontic children and unilateral crossbite Eur. J. Orthod. 2001;23:741-749. 12. Moskowitz E. Orthodontics in the Progressive Dental Practice. In Essential Dental Handbook. Tulsa, OK: PennWell Corp. 2003:387-430.

NYSDJ • AUGUST/SEPTEMBER 2005 39

TONGUE PIERCING Risk Factor to Periodontal Health Jennifer Choe, D.D.S.; Khalid Almas, B.D.S., M.Sc., FRACDS, FDSRCS, FICD; Robert Schoor, D.D.S. Abstract Body piercing has grown in popularity among teenagers and young adults. Dating back to antiquity, piercing is a cultural practice used in ceremonial or religious rites; however, today, it is commonly exercised as a method of selfexpression. Different complications and side effects are associated with intraoral piercing, including pain, swelling, infection, gingival trauma, chipped or fractured teeth, increased salivary flow, calculus buildup, and interference with speech and swallowing. We present a case report of periodontal treatment of traumatized gingival tissue caused by a tongue stud. The step-by-step periodontal surgical management of the case has been elaborated. The role of oral and dental health care professionals in managing the growing problem of tongue piercing as a periodontal risk factor has also been highlighted. 40 NYSDJ • AUGUST/SEPTEMBER 2005

ALTHOUGH ORAL PIERCING IS POPULAR among certain cultures and in some developing countries, only recently has it gained partial acceptance in Western society.1-3 Body beautification, decoration and body art are ancient practices that have been exercised by humans across cultures for centuries. Intentional, irreversible changes to the human body have been practiced by older, as well as modern, civilizations for a variety of reasons. The most common of these are expressing spiritual devotion or dedication to magic, fulfilling social demands, making a personal statement or enhancing individual sex appeal. A multitude of body beautification procedures were in use by older civilizations and are commonly seen today, especially in developing countries. Among these are skin tattooing, branding and piercing of ear lobes and the nose.4 Oral body art, as it is referred to, usually involves piercing of the tongue, cheeks, lips or uvula. The lip is the most commonly pierced site, but tongue piercing is becoming more prevalent.With the growing number of oral piercings being performed,it is vital that dentists are aware of the risks, complications and dental implications associated with such procedures.1 This article includes a case report on tongue piercing, periodontal trauma and its surgical management. And it presents the topic of oral piercing with special emphasis on complications and ethical considerations for dental professionals.

Figure 1. Metallic tongue stud opposing lingual aspect of tooth #25.

Figure 2. Occlusal view of tooth #25 with gingival cleft on lingual aspect.

Figure 3. V-shaped cleft (gingival recession).

Case Report

A 26-year-old Caucasian male patient was referred to the New York University College of Dentistry Department of Periodontics for evaluation of the lingual aspect of tooth #25. An initial clinical and radiographic evaluation was performed.A periapical radiograph revealed localized horizontal bone loss associated with tooth #25. Clinical evaluation of the midlingual aspect of the tooth illustrated isolated 5 mm of gingival recession, a probing pocket depth of 4 mm and localized inflammation. No other sites displayed any loss of attachment. The patient had scaling and root planing performed by his dentist one week before visiting the department, and there was no evidence of supragingival plaque or calculus. There was no mobility associated with any of the teeth, and there was an absence of occlusal interferences. The localized gingival defect was directly opposed to the location of the patient’s tongue stud (Figures 1-4). In general, the patient’s oral hygiene was good. Periodontal Treatment

After a complete intraoral examination and periodontal charting, a treatment plan was formulated that included removal of the tongue stud and a subepithelial connective tissue graft on the lingual aspect of tooth #25. As the probing pocket depths ranged from 1 mm to 3 mm in other areas of the mouth, and the patient had maintenance prophylaxis prior to his examination, supragingival scaling was not performed.

Figure 4. Tooth #25 with circumferential osseous defect.

Figure 5. Local anesthesia infiltration given.

Surgical Procedure

Following local anesthesia on the lingual aspect of teeth #22-27 and on the palatal aspect of teeth #12-15, using two carpules of lidocaine with 1:100,000 epinephrine, the area affected by the tongue stud was accessed by a lingual full thickness mucoperiosteal flap reflection using sulcular incisions. Care was taken to conserve the papilla between the adjacent teeth (Figures 5-7). Apical to the 5 mm of gingival recession on the lingual aspect of tooth #25, a split thickness flap was reflected to accommodate a connective tissue graft from the palatal site. Approximately 80% of the attachment loss was localized to the lingual aspect of tooth #25. The circumferential osseous defect was consistent with the inferior ball of the tongue stud, extending more than 6 mm apical to the cemento-enamel junction (CEJ). The connective tissue graft was harvested from the palatal aspect of tooth #14, using an 8 mm long

Figures 6 & 7. Lingual full thickness flap reflection from tooth #25.

Figure 6.

Figure 7.

NYSDJ • AUGUST/SEPTEMBER 2005 41

Figure 8. Palatal donor site of connective tissue graft.

Figure 9. Connective tissue (8 x 5 mm) placed at defect site.

horizontal incision at a perpendicular angle to the palatal vault. A second horizontal incision was placed parallel to the palatal vault to dissect the connective tissue from the donor site. An 8 x 5 mm piece of connective tissue with approximately 1 mm band of epithelium was yielded from the site (Figure 8). The lingual surface of tooth #25 was swabbed with 10% tetracycline solution, and the area was rinsed with sterile saline after one minute. The enamel matrix derivative (Emdogain 0.3 ml, Straumann Biologics Co., Waltham, MA 02451) was placed on the lingual aspect of tooth #25, and the connective tissue graft was placed over the exposed root surface. The epithelial aspect of the donor graft was placed at the level of the CEJ. The connective tissue was sutured with 5.0 vicryl interrupted sutures placed on mesial and distal sides of tooth #25. The epithelial flap was also sutured with 5.0 vicryl interrupted sutures to the mesial and distal of tooth #25. The area was inspected for flap stability and adequate tension relief. Additional Emdogain was placed over the flap and the donor site. The metal tongue stud was removed. The donor site was also sutured with the same material (Figures 9, 10). Postop Instructions and Follow-up

Figure 10. Connective tissue graft sutured with 5.O vicryl sutures.

Postoperative instructions included 500 mg Amoxicillin tablets three times daily for one week, 800 mg Motrin (analgesic) as needed for pain, and rinsing with Chlorhexidine mouthrinse twice a day for two weeks. The 10-day postoperative evaluation revealed remarkable healing. The patient said he had minimal postoperative discomfort (Figure 11).At our 4-month follow-up visit, the patient’s oral hygiene had improved and attachment loss appeared to have stabilized (Figure 12 ). Discussion

Figure 11. Postoperative healing after 10 days.

Figure 12. Postoperative healing after four months.

42 NYSDJ • AUGUST/SEPTEMBER 2005

The patient in this case report represents a situation that will occur more frequently as the popularity of tongue piercing increases. And while tongue piercing is gaining in popularity, it does not appear to be a harmless fad. On the contrary, there is a risk of infection and edema, which could cause a hazard to the airway.2 Consequently, warnings have appeared in the popular press. And, according to a recent report, experts from the Academy of General Dentistry have warned that implanting jewelry in the tongue may lead to numbness, loss of taste and mobility, and even a life-threatening blood clot.5 According to a recent report, common complications and possible adverse consequences of oral piercing can be summarized as follows:1 ● Oral pain ● Edema ● Infection ● Disease transmission ● Airway obstruction secondary to swelling ● Prolonged bleeding ● Chipped or fractured teeth

● ● ● ● ● ● ● ● ● ● ●

Mucosal or gingival trauma Interference with mastication and swallowing Speech impediment Hypersalivation Hyperplastic or scar tissue formation Nerve damage and paraesthesia Aspiration of specific piercing jewelry Foreign body incorporation into site of piercing Obstruction of radiographic images Calculus formation on metal surfaces Metal hypersensitivity The presence of a piercing in the oral cavity should be evaluated with its surrounding structures as a regular parameter when performing an initial examination. The question about intraoral piercing should also be incorporated into a questionnaire provided for new patients in the dental practice. In the patient described here,the trauma to the periodontal structure on the lingual surface of tooth #25 appeared to be directly caused by the lower ball of a lingual stud, as no other patterns of attachment loss were present in any other areas of the oral cavity. These findings strongly implicate the piercing as the primary factor in this localized traumatic periodontitis. It was recommended to our patient that he remove the tongue stud as part of the treatment plan. The patient agreed as he was well informed of the situation. Oral hygiene instructions were provided for long-term maintenance of the tooth and mouth in general. Of primary interest to the dentist are perioral and intraoral piercings.These expressions of body art became a dental concern over the past few years because of the increased frequency of their use and their influence on the health,function and esthetics of oral tissues.Management of the consequences,either direct or indirect, of oral piercing represents a basic function in modern dental practices. Hence, an integral part of emergency procedures is to treat postoperative and latent complications and to perform comprehensive treatment planning, including restorative treatment and periodontal follow-up care.4 The ADA opposes the practice of intraoral/ perioral piercing and supports legislation requiring parental consent of minors who want to be pierced because of the potential for numerous negative sequelae.6 Each state has the opportunity to consider legislation regarding the issue of minors and the regulation of piercing parlors, which would mandate the use of sterile equipment as well as submission to OSHA guidelines and inspections. The process starts at the local level with dental professionals who can educate their patients about the risks of piercing.7

Conclusion

Determination of the periodontal treatment for a localized mucosal or gingival defect resulting from disease or trauma in a mouth is case dependent. Generally, the goals of periodontal treatment are to restore the function and esthetics of periodontium and long-term maintenance of teeth and gingival tissues. The periodontal surgical procedure with connective tissue graft has predictable outcome in the absence of causal trauma. Dental professionals should be aware of oral and perioral piercing and should be able to talk with their patients about these issues and provide sound advice and comprehensive care for soft and hard tissue damage caused by oral piercing jewelry. ■ REFERENCES 1 . Farah CS, Harmon DM. Tongue piercing: case report and review of current practice.Aus Dent J 1998; 43: 387-389. 2. Scully C, Chen M.Tongue piercing (oral body art).Br J Oral Maxillofac Surg 1994; 32:37-38. 3. Maibaum WW, Margherita VA. Tongue piercing: a concern for the dentist. Gen Dent 1997; 45: 495-497. 4. Bassiouny MA, Deem LP., Deem TE. Tongue piercing: a restorative perspective. Quintessence Int 2001; 32: 477-481. 5. Jones HE. Are they just skin deep? RDH 1996;16:38-44. 6. American Dental Association. ADA statement on intraoral/perioral piercing. Available at: http://www.ada.org/prof/resources/positions/statements/piercing.asp. January 2003. 7. Dunn WJ, Reeves TE. Tongue piercing: case report and ethical overview. General Dentistry May-June 2004; 244-247.

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Use of Interdisciplinary Team Approach in Establishing Esthetic Restorative Dentistry Dov M. Almog, D.M.D.; Sean W. Meitner, D.D.S.; Neer Even-Hen, D.D.S.; Joshua P. Grant, D.D.S.; James L. Soltys, D.D.S. Abstract Managing crown lengthening in cases of attrition (wear or loss of tooth substance) and achieving desired esthetic outcomes, especially in the esthetic zone, is challenging. This case report presents an interdisciplinary approach to case management. Concomitant use of digital imaging, along with model wax-ups and surgical guide, were used to enhance patient acceptance during treatment planning and to facilitate communication and treatment implementation among dental professionals and laboratory technicians. Resulting surgical template was used for crown lengthening to apically position the gingival zenith (margin) to a predetermined level, crown preps and final restorations, respectively, ultimately improving esthetics and patient satisfaction. Supplementing esthetic treatment planning with digital imaging, model wax-ups and a surgical template allows a dentist to carry information into the mouth and incorporate it into the surgical procedure, crown preps, temps and, ultimately, the final restoration. 44 NYSDJ • AUGUST/SEPTEMBER 2005

AN INTERDISCIPLINARY APPROACH taken by a restoring dentist, periodontist, dental laboratory and digital imaging technicians to re-establish esthetics in a case of severe occlusal wear is presented. Digital imaging is used during treatment planning to increase patient acceptance and to facilitate communication among the restorative and surgical dentists and dental laboratory.1 Using digital simulations, the planned prosthesis can be viewed in the context of the surrounding soft tissues in a life-like manner. The rationale for selecting digital imaging as a consultation tool was to better describe the proposed treatment, making it easier to visualize the proposed goals and enhancing the ability to share the anticipated results with friends and family. Often, crown-lengthening procedures are necessary for reestablishing esthetics. The rationale for a crown-lengthening procedure is to increase the apico-coronal height of the clinical crown for a clinically acceptable prosthetic restoration.2-4 For a successful treatment outcome, the dimension of the attachment apparatus needs to be considered. To achieve stable soft-tissue levels and gingiva that is healthy in appearance, it is important to respect the attachment apparatus. Unfortunately, it is common to violate the attachment apparatus with restorative materials.5-9 After the crown-lengthening procedure, the surgical site may be closed with a variety of suture techniques, such as single interrupted and continuous suture. The surgical approach that is presented in this case report includes use of subsidiary tacks to stabilize and position the tissues without the use of sutures. Tacks have been used previously in surgical techniques for membrane stabilization and have been shown to be biologically compatible.10-11

A

B Figure 1. Before (A) and computer-simulated after (B) close-up photographs.

This article and case study illustrate a multidisciplinary team approach to the esthetic and prosthetic rehabilitation of the maxillary anterior region, using consultation adjuncts like digital imaging, model waxups and surgical templates,including subsidiary use of surgical tacks. Case Report

A 53-year-old Caucasian male patient was evaluated for esthetics concerns involving severe anterior occlusal wear. His chief complaint was that we “fix his short front teeth.” His medical history revealed myocardial infarction five years ago; the patient is taking medications to control hypertension and elevated serum cholesterol.Following a full-mouth radiographic survey,an intraoral exam revealed dental restorations on all posterior teeth, including a fixed partial denture from teeth #3-6 (of five years duration), and an implant-supported crown on tooth #12 (of three years duration). All anterior teeth from canine to canine in both the mandible and maxilla presented with extreme wear to the incisal edges. Canine guidance did not exist, as all anterior teeth contacted during excursive movements. With the exception of marginal redness and swelling around teeth # 6 and 9, the patient’s gingiva was pink, firm and healthy in appearance (Figure 1A).No radiographic evidence of bone loss was visible. In order to obtain optimum therapeutic results and to execute interdisciplinary care for this complex esthetic abnormality case, a team of providers gathered to develop a consistent treatment philosophy, including diagnostic and treatment planning procedures. Digital Imaging

Following a preoperative consultation among a team made up of a NYSDJ • AUGUST/SEPTEMBER 2005 45

prosthodontist, periodontist and laboratory technician, it was determined by the team that the patient would benefit from digital imaging simulations. After a detailed treatment plan was prescribed, preoperative facial and close-up digital photographs were acquired with a digital camera (DX4900 Dental Digital Camera Kit, Eastman Kodak Co., Rochester, NY).

Figure 2. A .020-inch vacuum plastic form was made over the stone cast duplicate of the diagnostic wax-up, then trimmed to the scalloped outline of the gingival zenith on the teeth.

Facial and close-up digital images of the patient were downloaded to a computer. Simulation of esthetic values of crown width and height was achieved using a specialized dental imaging software (PracticeWorks/DICOMTM Cosmetic Imaging Software, Version 1.73, Eastman Kodak, Atlanta, GA). Before and after 8-inch x 11-inch print outputs were produced using a desktop printer (Kodak Personal Picture Maker 200 by Lexmark, Eastman Kodak, Co., Rochester, NY) and glossy photographic paper (Kodak Desktop Medical Imaging Paper, Eastman Kodak, Co., Rochester, NY). The consultation adjunct output included a personalized before and after facial and close-up digital photograph (Figure 1). Diagnostic Wax-up/Surgical Template

A

B Figure 3. A) Surgical template is placed over epically positioned flap to confirm desired gingival margin. B) Surgical tacks are used to stabilize soft tissues.

Figure 4. Intraoral anterior view of maxillary anterior dentition 6 weeks after final restorations have been delivered. 46 NYSDJ • AUGUST/SEPTEMBER 2005

Impressions were made of both arches using stock trays and irreversible hydrocolloid. These were then cast in stone. The casts were articulated in a semi-adjustable articulator (Hanau H2, Waterpik Technologies, Fort Collins, CO). Concomitant with the digital imaging output, using average values of crown width and height, the gingiva was scalloped on the casts to achieve desired crown length. A diagnostic wax-up was then completed to visualize the final outcome. It is important to stress that the extra length was achieved in a gingival direction almost exclusively, with only 1 mm added to the incisal edge. This is done both for esthetic reasons and to avoid excessive restorative materials from interfering during function. The diagnostic wax-up was duplicated and poured in dental stone. A .020-inch vacuum plastic form was made over this cast, then trimmed to the scalloped outline of the gingival zenith on the teeth scheduled to have crown-lengthening surgery (Figure 2). This vacuum-formed tray was designed to serve as a surgical guide template during the crown-lengthening procedure. Tooth #6 was not included, as this was part of a fixed partial denture that was not being replaced. During the surgical visit, the mucoperiosteal flap was elevated beyond the mucogingival junction, allowing apical displacement of the gingiva. The surgical guide was then placed over the teeth and used to position the gingival tissues to the apical margin of the planned prosthesis (Figure 3A). Subsidiary surgical tacks, 5 mm in length, were then driven through the marginal gingival tissues into the interproximal bone to stabilize the marginal tissue at the desired level as indicated by the surgical guide (Figure 3B). After four weeks of tissue maturation, teeth #7-11 were prepared for full coverage porcelain-fused-to-metal crowns. Full arch Impergum-polyether impressions were taken (3M-ESPE, St. Paul, MN)

and poured in die stone. Acrylic temporaries were fabricated (Coldpack, Motloid of Chicago, IL) using the diagnostic wax-up as a template. The patient returned four weeks later for crown placement with provisional cement (Zone Non Eugenol, CADCO-VanR, Oxnard, CA). After six weeks the crowns were cemented with a resinreinforced glass ionomer (FujiPlus, GC Corp., Tokyo, Japan)(Figure 4). Discussion

Good team communication is critical to patient satisfaction in esthetic dentistry. This article and case study illustrate a multidisciplinary team’s role in the prosthetic and esthetic rehabilitation of the maxillary anterior region. Digital imaging and diagnostic waxup enable both clinicians and patients to view the desired final outcome of their teeth and soft tissue at the preoperative stage. In more complex treatment plans, the dentist can convey a treatment concept to the patient more easily and realistically when using digital imaging.1, 12-14 Additionally, esthetics is subjective and can vary considerably between individuals. It is important to illustrate the planned outcome to the treating team members and to the patient, and to receive feedback. The surgical guide template in particular enabled the team to transfer information into the mouth and incorporate it into the surgical procedure, crown preps, temps and, ultimately, the desired final restoration. This case study also illustrates the subsidiary use of surgical tacks (IMTEC Tac System, New York, NY). Crown lengthening for an esthetic procedure requires stabilization of the soft tissues for the most predictable results, and the ability to achieve adequate extension of the clinical crown is often difficult.15 The purpose of the tack is to provide immediate stabilization at a predictable level. Tacks were originally developed in Europe for the stabilization of membranes in ridge preservation and ridge augmentation procedures.10,11 If sutures alone are used to stabilize the flaps, by pulling the flaps up against the teeth, their final position is not as predictable, as the tissues may still shift. Periodontal pack is often used with sutures to stabilize the tissues. The tacks must be placed in the interproximal bone between adjacent teeth to avoid contact with the roots. The tacks can be covered with periodontal pack if there is any question or fear of them being lost and swallowed during the healing period. Although the gratifying esthetic outcome in this particular case presentation tends to support an interdisciplinary approach and the use of treatment planning adjuncts, the authors strongly encourage conducting more comprehensive investigations with larger study populations and numerical data to support success-to-failure ratio following the concomitant use of digital imaging, model wax-ups and surgical templates during esthetic procedures. ■

REFERENCES 1. Goldstein C, Goldstein RE, Garber DA. Computer imaging: an aid to treatment planning. J Calif Dent Assoc 1991;19:47-51. 2. Kois JC. Altering gingival levels: the restorative connection, part 1: biologic variables. J Esthet Dent 1994;6:3-9. 3. Garguilo AW. Dimensions and relationships of the dentogingival junction in humans. J Periodontol 1961;32:261-7. 4. Ingber JS, Rose LF, Coslet JG. The “biologic width”- a concept in periodontics and restorative dentistry. Alpha Omegan 1977;70(3):62-5. 5. Maynard JG, Wilson RD. Physiologic dimensions of the periodontium fundamental to successful restorative dentistry. J Periodontol 1979;50:107. 6. Nevins M, Skurow HM. The intracrevicular restorative margin, the biologic width, and the maintenance of the gingival margin. Int J Periodont Rest Dent 1984;4(3):31-49. 7. Kaldahl WB, Becker CM, Wentz FM. Periodontal surgical preparation for specific problems in restorative dentistry. J Prosthet Dent 1984;51(1):36-41. 8. Parma-Benfenati S, Fugazzotto PA, Ruben MP. The effect of restorative margins on the postsurgical development and nature of the periodontium. Part I. Int J Periodont Rest Dent 1985;5(6):31. 9. Oakley E, Rhyu IC, Karatzas S, Gandini-Santiago L, Nevins M, Caton J. Formation of the biologic width following crown lengthening in nonhuman primates. Int J Periodontics Restorative Dent 1999 Dec;19(6):529-41. 10. Block MS. Preserving alveolar ridge anatomy following tooth removal in conjunction with delayed implant placement.Atlas Oral Maxillofac Surg Clin North Am 1999;7(2):61-77. 11. Guided Tissue Regeneration, The Final Mechanical Stabilizer. http://www.imtec.com/ demo/gtr_product.php (last viewed 10/13/04). 12. Grubb JE, Smith T, Sinclair P. Clinical and scientific applications/advances in video imaging. Angle Orthod 1996; 66: 407-16. 13. Papasotiriou OS, Nathanson D, Goldstein RE. Computer imaging versus conventional esthetic consultation: a prospective clinical study. J Esthet Dent 2000;12(2):72-7. 14. Almog DM, Sanchez Marin C, Proskin HM, Cohen MJ, Kyrkanides S, Malmstrom H. Choice for utilization of esthetic services following four different esthetic consultation methods: pilot study. J Dent Res 2003, Vol. 82, Special Issue A. 15. Herrero F, Scott JB, Maropis PS, Yukna RA. Clinical comparison of desired versus actual amount of surgical crown lengthening. J Periodontol 1995;66:568-571.

This study was supported by the divisions of Prosthodontics and Periodontics at the University of Rochester Eastman Dental Center.

NYSDJ • AUGUST/SEPTEMBER 2005 47

Soft Tissue Plasmacytosis A Case Report Inés Vélez, D.D.S., M.S.; Sheldon M. Mintz, D.D.S., M.S. Abstract Plasma cell gingivitis was identified during the early 1970s as an allergic reaction to a component in a chewing gum. The clinical picture was described as bright erythema of the entire gingiva, loss of stippling and generalized swelling. Today, many allergens appear to be responsible for this problem. This report presents an unusual case of softtissue plasmacytosis in a totally edentulous patient, which may have been related to the use of a household and kitchen cleaning solution on the prostheses.

THE CONDITION called plasma cell gingivitis may also be known as atypical gingivostomatitis, soft tissue plasmacytosis, allergic gingivostomatitis, stomatitis venenata or irritant contact stomatitis. The etiology is often found to be a hypersensitivity reaction to a flavoring agent in food or chewing gum, such as cinnamon or mint.1,2 Other cases have been traced to the use of red peppers in cooking.3 Still others have been deemed idiopathic, with no allergen identified.4 It is important to diagnose this condition properly. The appearance of the gingiva may be similar to that of a neoplastic process such as multiple myeloma5 or leukemia. Other conditions, such as discoid lupus, lichen planus, cicatricial pemphigoid or HIV-related gingivitis, should also be considered.3 48 NYSDJ • AUGUST/SEPTEMBER 2005

Plasma cell gingivitis has been described in the literature since the late 1960s.1,4,6 It has a unique histopathologic presentation with a dense chronic inflammatory infiltrate, predominantly plasma cells.5 The clinical appearance is typically seen as a generalized enlargement of the free and attached gingiva with bright erythema and loss of normal stippling. In some cases, the condition also includes the tongue, buccal and labial mucosa, and vermilion border of the lip. Patients are often symptomatic, complaining of a rapid onset of soreness, bleeding gums and cracked lips. Several well-studied cases have shown a true hypersensitivity reaction leading to the plasmacytosis of the gingiva. Kerr et al., in 1971, described eight cases of habitual gum chewers whose signs and symptoms resolved once the allergen (the gum) was removed. They used various laboratory tests, including complete blood counts, blood chemistry, smears, blood agar aerobic and anaerobic cultures, viral cultures, cultures for Candida and biopsy with tissue fixed for electron microscopic studies. Serio et al., in 1991, reported a case related to the use of fresh and dried red peppers and chili peppers in cooking. Once these allergens were removed from the patient’s diet, the lesions improved. Lubow et al., in 1984, presented a case well shown to be caused by the use of mint candies. This report presents an unusual case of soft tissue plasmacytosis in a totally edentulous patient, which may have been related to the use of a household and kitchen cleaning solution on the prostheses.

The personal history of the patient disclosed the habit of cleaning her dentures every day with a household and kitchen cleaner.

Case Report

In January 1996, a 57-year-old white female was admitted to the Oral and Maxillofacial Surgery Department at ICHILOV Hospital in Tel Aviv, Israel, for evaluation of a sore mouth. Her medical history was unremarkable except for hypertension, which was controlled with diuretics and calcium channel blockers. Physical examination was within normal limits. The personal history of the patient disclosed the habit of cleaning her dentures every day with a household and kitchen cleaner. Oral examination revealed an edentulous patient using full, illfitting dentures. A diffuse erythema, fissuring and scaling of the vermillion border of the upper and lower lips with pronounced angular cheilitis were present. The inner surface of the upper lip also presented an erythematous, exophytic lesion covered by an irregular and pebbled surface, showing fissures, nodules and ulceration with focal white areas. The dorsal surface of the tongue appeared brilliantly erythematous with diffuse atrophy of the papillae. Fissures and papules were also noted. The buccal mucosa presented an edematous and erythematous lesion with a ragged white surface suggestive of a lupus-like reaction. The edentulous alveolar ridge was normal. Several incisional biopsies were taken. Microscopic examination revealed H & E sections showing superficial squamous epithelium with hyperparakeratosis, elongated thin rete ridges, exocytosis and microabscesses. The principal feature of the tissue was an intense inflammatory infiltrate of predominantly plasma cells immediately subjacent to the epithelium and extending downward into the reticular dermis. Numerous dilated blood vessels were present. Candida was not identified. To rule out the possibility of a plasma cell neoplasm, the clonality of the plasma cell infiltrate was investigated. B-lymphocytes with differentiation toward plasma cells have immunoglobulin molecules in their cytoplasm. Each normal plasma cell produces immunoglobulin of a single light chain type: Kappa (K) or Lambda (L). Normally, populations of human B cells carry K or L light chains in approximately a 2:1 ratio. Neoplastic populations arising from a single progenitor cell should contain only a single light chain: K or L. Polyclonal light chain population is indicative of nonneoplastic disease. Using tonsil tissue as a control, immuno-stains, anti Kappa and anti Lambda chains were performed, and a polyclonal population

Figure 1. Diffuse erythema, fissuring and scaling of vermillion border of lips and pronounced angular cheilitis. Atrophy of lingual papillae and fissures of dorsal tongue are also seen.

Figure 2. Edematous and erythematous buccal mucosa with white areas and fissures.

Figure 3. Exophytic lesion of upper labial mucosa, fissures, nodules and ulceration. NYSDJ • AUGUST/SEPTEMBER 2005 49

A Figure 4. Biopsy specimen showing hyperparakeratosis, exocytosis and microabscesses. Intense inflammatory infiltrate, basically composed of plasma cells, is present down into connective tissue (H & E stain).

B

Figures 5A and B. Biopsy specimens with special stains (A) anti-kappa light chain and (B) anti-lambda light chain, demonstrating polyclonal population of plasma cells.

was identified. In this way the non-tumoral nature of the lesions was confirmed. Discussion

The prevalence of contact dermatitis (both allergic and irritant) has been estimated at between 1% and 10% of the population.7 Many cases are probably unreported. As mentioned above, many agents placed in the mouth can be allergens, e.g., various foods, spices and flavorings. Chemicals in

oral care products, nicotine, thermal injury or metals may be chemical or mechanical irritants.7 In the case presented here, the condition resolved completely in approximately three weeks after cessation of using the household cleaning product. There may have been some mechanical injury to the mucosa because of the poor-fitting prostheses, but the most exuberant lesion was found on the upper labial mucosa. Speculation as to the allergen includes sodium hypochlorite, sodium lauryl sulfate, some coloring agent or a fragrance. The household cleaner was not analyzed. Conclusion

This case presents a plasma cell infiltration of the soft tissue throughout the oral cavity except for the edentulous alveolar ridge. If an allergic reaction is suspected, then it is important to investigate the patient’s diet and habits to determine the possible causes. A diary should be kept listing all things that enter the mouth, including foods, dentifrice, mouthwash, tobacco, alcohol, chewing gum, candy and medications (prescription and over-the-counter).5 Any habits such as chewing fingernails, pens or pencils may introduce other allergens.8 Sometimes even careful patch testing by a dermatologist may not reveal the allergen. Occasionally, topical or systemic steroids may be helpful for improving symptoms. ■ REFERENCES 1. Sollecito TP, Greenberg MS. Plasma cell gingivitis; Report of two cases. Oral Surg Oral Med Oral Pathol 1992;73:690-693. 2. Lubow RM, Cooley RL, Hartman KS, McDaniel RK. Plasma-cell gingivitis; Report of a case. J Periodontol 1984;55:235-241. 3. Serio FG, Siegel MA, Slade B. Plasma cell gingivitis of unusual origin. A case report. J Periodontol 1991;62:390-393. 4. Silverman S Jr, Lozada F. An epilogue to plasma-cell gingivostomatitis (allergic gingivostomatitis). Oral Surg Oral Med Oral Pathol 1977;43:211-217. 5. Neville B, Damm D,Allen C, Bouquot J, editors. Oral and Maxillofacial Pathology, 1st Ed. Philadelphia: W.B.Saunders. 1995; pp.126-127. 6. Kerr DA, McClatchey KD, Regezi JA. Idiopathic gingivostomatitis: cheilitis, glossitis, gingivitis syndrome, atypical gingivostomatitis, plasma cell gingivitis, plasmacytosis of gingiva. Oral Surg Oral Med Oral Pathol 1971;32:402-423. 7. Davis CC, Squier CA, Lilly GE. Irritant contact stomatitis: a review of the condition. J Periodontol 1998;69:620-631. 8. Millard HD, Mason D, editors. Perspectives on the World Workshop on Oral Medicine III, 1998. Ann Arbor: University of Michigan. 2000; pp 52-57. 9. Henry K, Farrer-Brown G. A Color Atlas of Thymus and Lymph Node Histopathology. London: Wolfe Medical Publications Ltd. 1981; pp. 263-276. 50 NYSDJ • AUGUST/SEPTEMBER 2005

Hospital Dentistry and GPRs A Relationship with a Past H. Barry Waldman, D.D.S., M.P.H., Ph.D. Abstract Dental programs have evolved from an occasional com-

services in private dental offices. And the average income of dentists was almost $13,000.(1)2

ponent of hospitals to fully recognized departments within

Early Years of Hospital Dentistry

the structure of most institutions. A review is presented of

Dental departments first appeared in some hospitals in the 1920s. Efforts were made to provide services that “were commensurate with the needs, facilities and personnel of the local communities.”2 In the late 1930s and early 1940s, a number of dental services were available in many government, voluntary and for-profit hospitals.

some of these developments, including the initiation of general practice residency (GPR) programs and training in a residency program as a substitute for the standard licensing examination.

TRY TO IMAGINE THE SETTING in which hospital dentistry existed when I began my dental education more than 50 years ago. Dentists (virtually all of whom were white males) stood while using belt-driven drills that ran about 7,500 rpm. Discs were used to prepare crowns, because the steel burs couldn’t cut through enamel. The dental office staff answered phones and cleaned up between patients; they seldom worked at chairside. More than 55% of dental offices had only one full-time auxiliary staff member. (New York State had the smallest proportion of dentists who used auxiliaries; it was somehow related to the fact that the average age of New York dentists was the highest in the nation.) Gloves were used only during surgical procedures. Third party insurance schemes were extremely limited. Medicaid was off somewhere in the distant future. Dental care in hospitals often was a sporadic reality in many facilities. All too often, hospital dental care consisted of emergency and surgical care for the poor, who were unable to secure needed 52 NYSDJ • AUGUST/SEPTEMBER 2005

Hospital Dentistry in the 1950s By the late 1950s, most dental schools had hospital affiliations. Dental students received as much as 50 hours of training and experience in ward walking, history taking, operating room procedures and hospital decorum. In general, the dental schools of the far west and the eastern regions offered more extensive programs than did schools in other sections of the country. Dental internship and residency programs were available in only about half of the hospitals that had received approval by the Council on Hospital Dental Services of the ADA for such programs. The number may have been so small, “…because there had not been a great demand for dental internships.”2 1 2

Unless otherwise stated, all material on the history of hospital dentistry was drawn from the publication, Survey of Dentistry2 The median number of dentists (including both house and attending staff) in hospitals with a dental staff was: 2 dentists in governmental (nonfederal) hospitals; 6 dentists in federal hospitals; 9 dentists in voluntary hospitals; 3 dentists in proprietary hospitals.2

“…the most striking example of professional insularity today is the practice of dentistry…the dentist practices as an individual in the four walls of his office. He is not integrated into the hospital, the institution which represents the centricity in our society in the delivery of health care. …The dentist too often looks at the mouth as if there were no man. In the hospital, too often is the man looked at as if there were no mouth.” — 1960 1 About one-third(2,323) of the 6,818 hospitals listed by the American Hospital Association had dental services. There was a wide range in the reported number of staff dentists, but the largest number (18%) of hospitals had only one dentist.(2) Eighty-five percent of the hospitals with a dental staff had no dental interns. Most of the hospitals with interns had 500 or more beds. There were an average 0.3 dental interns per hospital in the United States. Among nonsalaried dentists, half of dental specialists reported having a hospital staff appointment (ranging from 98% of oral surgeons to 26% of orthodontists) and 31% of general practitioners. The proportion of dentists with hospital staff appoint-

ments was highest in New England (49%) and lowest in the Central region (25%). More than 90% of the dental department was under a dentist’s direction. Hospital Dentistry Post-1950 During the 1970s and 1980s, there were major increases in the number of postdoctoral general dentistry programs and residents. The first effort to codify curricula for postgraduate general dentistry programs came in 1972 in the form of accreditation guidelines for general practice residency (GPR) programs from the ADA Council on Dental Accreditation. During the 1970s, the number of programs and the number of residents increased with funding from the Health Professions Education Assistance Act and the Robert Wood Johnson Foundation. Hospital sponsorship of the GPR programs (supported by federal graduate medical education [GME] funds) provided the major impetus for the growth in graduate general dentistry programs during this period. Since 1981, the major source of growth of postdoctoral education in general dentistry was in advanced education in general dentistry (AEGD) programs sponsored by dental schools and supported with federal GME funds.3,4 By the academic year 2001/02, there were 956 first-year resi-

NYSDJ • AUGUST/SEPTEMBER 2005 53

dents enrolled in the 208 GPR programs. There were 898 graduates from the 30 dental school-sponsored GPR and 178 hospitalsponsored GPR programs.5 Since 1987, hospitals have been allowed to receive GME funding for resident training in non-hospital settings. The Centers for Medicare and Medicaid Services (CMS) (previously named the Health Care Financing Administration) worked with dental schools, hospitals and others to facilitate the creation of dental residency programs in non-hospital settings that would qualify for GME funds. However, in 2003, CMS took the position that GME funding for dental residencies in non-hospital settings, which it had sanctioned and supported since 1997, was no longer appropriate. Funding for these programs continued only for those residents who had commenced their postdoctoral training prior to the ruling.6 As a result, at many dental schools, efforts are being made to transfer AEGD-sponsored programs to GPR arrangements and formats. Types of Dental Services

The limited availability of hospital dental services in the past has been replaced by a full range of needed services for the increasing number of individuals with medically, physically and intellectually compromised conditions, as well as individuals with limited financial resources who live in our communities. For example, the Web page of one community hospital reports that it provides “…a full range of dental care, including: restorative dentistry, gum (periodontal treatment), extractions, facial fractures, orthodontic care, temporomandibular joint treatment, tumor, and correction of dental facial deformities.”7 Program directors have reported a high level of inadequate preparation among incoming dental residents, including, practice management, care of medically compromised patients, pediatric behavior management, quality assurance, oral diagnosis and treatment planning. In addition, there were concerns regarding the residents’ sense of professionalism and general attitudes.4,8-10 GPR directors reported increasing program curriculum content to shore up incoming resident inadequacies. In addition, added emphasis was placed in the care of HIV/AIDS patients, geriatric patients and individuals requiring implantology and endodontics.4 Impact of GPR Programs

A series of studies of the activities of residents and graduates from GPR programs demonstrate marked differences among these dentists and their colleagues who had completed an AEGD program or who had no formal postdoctoral training. For example: ● Half of former GPR residents held staff privileges in a hospital or ambulatory setting, compared to a far smaller proportion of practitioners without postdoctoral training. ● Twice the proportion of former GPR residents, as compared to practitioners without advanced training, provided consultations in a hospital or long-term care facility. ● The practice characteristics of former GPR residents sug54 NYSDJ • AUGUST/SEPTEMBER 2005

gested enhanced clinical skills in oral surgery, periodontics, emergency dental care and oral medicine/pathology, as well as continuing involvement in teaching.11 ● GPR residents reported more medically intensive,medically and socially disadvantaged patients, as well as HIV/AIDS patients. ● GPR-trained dentists reported significantly more biopsy procedures, conscious sedation, periodontal surgery and implants. In addition, GPR-trained dentists were more likely to volunteer time than other dentists.12 ● Female dentists reported fewer patients than male dentists, and this difference was more significant for GPR-trained dentists.12 In addition, GPR and AEGD residents are less likely to seek specialty training.13,14 Licensure

In January 2003, New York State initiated a new era in dental licensure. Dental school graduates who satisfactorily complete “…in its entirety an accredited residency program of at least one year’s duration… may use that experience in lieu of Part III of the dental licensing examination in order to obtain a dental license.”15 The ability to substitute a residency program for the “…oneshot (Northeast Regional Board-NERB) examination…”15 not only eliminates much of the controversy associated with the NERB examination, but recognizes the value of GPR and other residency programs as a critical step in the progressive training of dental practitioners. (Note: As of January 2007, all applicants for initial licensure in New York State will have to complete a CODA-approved residency of at least one year’s duration.)

REFERENCES 1. Man and mouth. Editorial. Hospitals Jan. 16, 1960;34(2):37. 2. Hollinshead BS. Commission on the Survey of Dentistry in the United States. The Survey of Dentistry. Washington, DC: American Council on Education, 1961. 3. Handelman SL, Meyerowitz C, Solomon E, et al. The growth of postdoctoral general dentistry programs. Spec Care Dent 1995;15(1):5-10. 4. Lefever KH, Atchison KA, Mito RS, et al. Curriculum emphasis and resident preparation in postgraduate general dentistry programs. J Dent Edu 2002;66(6):747-756. 5. Survey Center. 2001/02 Survey of Advanced Dental Education. Chicago: American Dental Association, 2003. 6. American Student Dental Association. Current Issues. Web site: sightmaker.umich.edu/ asda/current_asda_issues Accessed March 12, 2004. 7. Norwalk Hospital, CT. Web site: www.Norwalkhosp.org Accessed March 12, 2004. 8. Atchison KA, Bachand W, Buchanan CR, et al. Military and VA general dentistry training: a national resource. J Dent Edu 2002; 66(6):739-746. 9. Atchison KA, Cheffetz SE. Critical issues for dentistry: PGD program directors respond. J Dent Edu 2002; 66(6):730-738. 10. Mito RS, Atchison KA, Lefever KH, et al. Characteristics of civilian postdoctoral general dentistry programs. J Dent Edu 2002; 66(6):757-765. 11. Tejani A, Epstein JB, Gibson G, et al. A survey assessing the impact of a hospital-based general practice residency program on dentists and dental practice. Spec Care Dent 2002; 22(1):16-22. 12. Atchison KA, Bibb CA, Lefever KH, et al. Gender difference in career and practice patterns of PGD-trained dentists. J Dent Edu 2002; 66(12):1358-1367. 13. Atchison KA, Mito RS, Rosenberg DJ, et al. PGD training and its impact on general dentist practice patterns. J Dent Edu 2002; 66(12):1348-1357. 14. Handelman S, Meyerowitz C, Iranpour B, et al. Evaluation of advanced general dentistry education. Spec Care Dent 1993; 13(4 Suppl):177-185. 15. New York State Dental Association. NYSDA-initiated PGY1 legislation becomes law. July 30, 2002. Web site: www.nysdental.org Accessed March 12, 2004.

Four to Five Decades Later

Most dentists still practice (often with male and female partners and associates) within the four walls of their offices (albeit the office settings have changed dramatically, and practitioners now sit). During these past decades, thousands of dental school graduates continued their training in a hospital environment and now serve in our communities—better prepared and capable of dealing in their private office or hospital setting with patients with complex medical conditions, which increasingly are a reality in many practices. It must be noted that there have been declines in the number of applicants to postgraduate general dentistry programs in the last number of years.5,9 Preference for private practice and high educational debts are suggested explanations. Based upon the perceived limitations in the performance of incoming GPR residents, questions have been raised regarding the abilities of recent graduates who without additional training enter private dental practice arrangements.9 Whatever the future may hold for changes in the delivery of oral health services to an increasingly diverse population in our communities, hospital and GPR programs have been and will continue to be a critical step in eliminating our “professional insularity.” ■ NYSDJ • AUGUST/SEPTEMBER 2005 55