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October 2010 www.dental-tribune.com Vol. 5, No. 21

ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
CHosmetiC
YGIENE TtRIBUNE
the
RiBUNe
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World’sCosmetic Dentistry
Dental Hygiene Newspaper
Newspaper · U.s.
· U.S. edition
Edition

Las Vegas or Santa Barbara? Apical microsurgery Direct splinting

If you’re going to AMED or AADOM, we’ve got The conclusion of this six-part series discusses Case study using this procedure for maintenance
the highlights of each for you. u pages 8A–10A sutures and suturing technique. u page 1B of perio-compromised teeth. upage 1C

Gum disease a significant Papillary squamous cell carcinoma

public health concern
The prevalence of periodontal dis-
ease in the United States may be signif-
icantly higher than originally estimat-
ed. Research published in the Journal
of Dental Research from the Centers
for Disease Control and Prevention
(CDC) and the American Academy of
Periodontology (AAP) suggests that the
prevalence of periodontal disease may
have been underestimated by as much
as 50 percent. The implication is that
more American adults may suffer from
moderate to severe gum disease than
previously thought.
In a National Health and Nutrition
Examination Survey (NHANES) pilot
study, funded by the CDC’s Division
of Oral Health, a full-mouth, compre-
hensive periodontal examination was
conducted on over 450 adults over the
age of 35. Periodontal disease was clas-
sified according to definitions deter-
mined by the CDC in collaboration
with the AAP.
The prevalence rates were then
compared against the results of pre-
vious NHANES studies, which used
a partial-mouth periodontal examina-
tion. Historically, NHANES has served
as the main source for determining
prevalence of periodontal disease in
U.S. adults. The pilot study finds that
the original partial-mouth study meth-
odology may have underestimated
true disease prevalence by up to 50
percent.
Several research studies have asso-
ciated gum disease with other chronic
inflammatory diseases, such as diabe-
(Photo/Molka, Dreamstime.com)
disease is a bigger problem than we
all thought. It is a call to action for
anyone who cares about his or her oral
health,” said Samuel Low, DDS, MS,
associate dean and professor of peri-
odontology at the University of Florida
College of Dentistry and president of
the AAP.
“Given what we know about the
relationship between gum disease and
other diseases, taking care of your oral
health isn’t just about a pretty smile.
It has bigger implications for overall
health, and is therefore a more sig-
nificant public health problem,” Low
added.
Low explained that the increased
prevalence of periodontal disease
makes it essential to maintain healthy
Oral squamous cell carcinoma (OSCC) is the most common malignancy of the
oral cavity and has several known variants. The papillary variant of OSCC
affecting the palate is rare compared to more common sites of involvement
that include the larynx, pharynx and nasopharynx.
g See page 5A
ADA conference seeks
solutions for older adults
The American Dental Associa- the JW Marriott in Washington, D.C.
tion (ADA) is extending invitations “We look upon this conference as
to those concerned about the oral the first step in building a consen-
health of vulnerable older adults and sus among a multi-disciplinary group
people with disabilities to attend a of professionals in seeking solutions
national conference and help shape about oral health care for the vulner-
the future of oral health care for this able older adult and the disabled,”
underserved and growing popula- said Dr. Raymond F. Gist, ADA presi-
tion. dent.
The national coalition conference, “We are looking for attendees’
titled Oral Health of Vulnerable Older ideas, collaboration and support in
Adults and Persons with Disabilities,
is scheduled for Thursday, Nov. 18, at g DT page 2A, ADA
AD

tes, cardiovascular disease and rheu- teeth and gums. “Not only should you
matoid arthritis.
“This study shows that periodontal g DT page 2A, GUM DISEASE

Mechanicsburg, PA New York, NY 10001

Permit # 306 Suite #801
PAID 213 West 35th Street
U.S. Postage Dental Tribune America
PRSRT STD
2A News Dental Tribune | October 2010
f DT page 1A, GUM DISEASE
take good care of your periodontal
health with daily tooth brushing and
flossing, you should expect to get a
comprehensive periodontal evaluation
every year,” he advised.
According to Paul Eke, MPH, PhD,
epidemiologist at the CDC and lead
author of the study, the findings have
significant public health implications.
“The study suggests we have like-
ly underestimated the prevalence of
periodontal disease in the adult U.S.
population,” he said. “We are current-
ly utilizing a full-mouth periodontal
examination in the 2009/10 NHANES
to better understand the full extent and
characteristics of periodontal disease
in our adult population.”
Eke added, “Research suggests
a connection between periodontal
health and systemic health. In light
of these findings, understanding the
relationships between periodontal dis-
ease and other systemic diseases in the
adult U.S population is more crucial
than ever.”
Patients can assess their risk for
periodontal disease and learn more by
visiting perio.org. DT
(Source: AAP)
About the AAP
The American Academy of Periodon-
tology (AAP) is the professional orga-
nization for periodontists. Periodon-
tists are also dentistry’s experts in
the treatment of oral inflammation.
They receive three additional years of
specialized training following dental
school. The AAP has 8,000 members
worldwide.
Tell us what you think!
Do you have general comments or criticism you would like to share? Is
there a particular topic you would like to see more articles about? Let us
know by e-mailing us at feedback@dental-tribune.com. If you would like
to make any change to your subscription (name, address or to opt out)
please send us an e-mail at database@dental-tribune.com and be sure
to include which publication you are referring to. Also, please note that
subscription changes can take up to 6 weeks to process.
AD
f DT page 1A, ADA
helping frame the conference’s rec-
ommendations that could be used by
many sectors, including educational
institutions, professional organiza-
tions and policy makers.”
Professionals concerned about
oral health for vulnerable older
adults and people with disabilities,
including dentists and dental hygien-
ists, geriatricians, nurses, oral health
advocates, aging and disability advo-
cates, long-term care providers and
policy makers and legislative staff,
are encouraged to register for the
conference.
Dental experts will present top-
ics of critical importance in meet-
ing the oral health needs of special
populations, including collabora-
tion between disciplines, oral health
delivery systems, policy implications,
medical dental considerations and
coalition building.
Responding to each presentation
will be an expert from outside den-
tistry, representing geriatric medi-
cine, long-term care, aging advocacy,
state health and policymakers.
Active audience participation will
follow as attendees have the oppor-
tunity to provide input as they discuss
the presentations.
“The conference is a unique
opportunity to help shape the future
of oral health care and improve the
quality of life for vulnerable older
adults and those with disabilities,”
said Gist. “We highly encourage those
interested professionals to attend.” DT
(Source: American Dental
Association)
Asthmatic
kids and
tooth decay
In the past, there have been
suggestions that asthma and tooth
decay were linked, especially for
children. But according to a new
report from the American Dental
Association, that is apparently not
the case. A critical review of the lit-
erature examined 27 separate stud-
ies published in 29 different papers
between 1976 and March 2010.
The studies looked into possible
connections between asthma and
dental caries.
Gerardo Maupomé, professor of
preventive and community dentistry
at the Indiana University School of
Dentistry and author of the new
study, said: “We found little evi-
dence to suggest that asthma causes
tooth decay. In fact, the two larg-
est studies we reviewed found that
children with asthma appear to have
fewer cavities than others. This may
be because their parents are used to
taking them to health-care provid-
ers, and routinely bring them to the
dentist.”
“The notion that there is a link
between asthma and tooth decay
may have its origin in anecdotal
statements by emergency room
workers who see children with
poorly managed asthma,” Maupomé
said. “These children could also be
more likely to have poorly man-
aged dental conditions, and there-
fore tooth decay. It’s reasonable to
believe that poor clinical manage-
ment may be associated with both
conditions, not the asthma that is
causing the cavities.”
The study does acknowledge that
it is difficult to explicitly determine
if there is a connection between
asthma and dental decay — predom-
inately because of the large num-
ber of variables related to asthma,
including the wide range of treat-
ments for the illness and the severity
of asthma symptoms. Yet, research-
ers suggest there is no need for
parents with asthmatic children to
be concerned.
However, children who use nebu-
lizers to control their asthma may be
increasing their exposure to sugars,
as nebulizers often contain fructose.
Frequent intake of sugar can lead to
tooth decay as the sugar reacts with
the plaque on teeth and forms an
acid that gradually dissolves the pro-
tective enamel coating on the teeth.
Dr. Nigel Carter, chief executive
of the British Dental Health Founda-
tion, advises the best way to protect
children’s teeth from decay is to
make sure they brush twice a day
with a fluoride toothpaste. It is also
important to cut down how often
sugar occurs in a child’s diet.
Carter said: “It is vital that chil-
dren brush their teeth both morn-
ing and night for two minutes with
g DT page 4A
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contact Group Editor Robin Goodman at
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Dental Tribune cannot assume respon-
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for product names or statements made
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Editorial Board
Dr. Joel Berg
Dr. L. Stephen Buchanan
Dr. Arnaldo Castellucci
Dr. Gorden Christensen
Dr. Rella Christensen
Dr. William Dickerson
Hugh Doherty
Dr. James Doundoulakis
Dr. David Garber
Dr. Fay Goldstep
Dr. Howard Glazer
Dr. Harold Heymann
Dr. Karl Leinfelder
Dr. Roger Levin
Dr. Carl E. Misch
Dr. Dan Nathanson
Dr. Chester Redhead
Dr. Irwin Smigel
Dr. Jon Suzuki
Dr. Dennis Tartakow
Dr. Dan Ward
4A Practice Matters Dental Tribune | October 2010
Dental practice audits
By Stuart J. Oberman, Esq.
Dental audits were rare at one time.
Now, however, with insurance com-
panies and third-party payers auditing
more routinely, it is much more likely
that a dental practice will face an audit.
Most dental practices that are con-
tracted with dental plans are audited
at least once during the course of their
practice.
Many of these dentists are left won-
dering why audits are becoming a
more routine exercise of third party
payers. The answer: alarming statis-
tics. The FBI estimates that 10 percent
of the money expended on health care
is due to fraudulent activity. Insurance
companies estimate that fraudulent
health-care billing represents up to
$10 billion each year.
In addition, Medicare fraud is
becoming more rampant. The United
States General Accounting Office esti-
mated that out of every $7 spent on
Medicare, $1 is lost to Medicare fraud.
Fraud is adding enormous costs to the
nation’s health-care system. As more
fraudulent health-care charges rack up
for insurance companies to pay, insur-
AD
(Photo/Elenathewise, Dreamstime.com)
ance companies are becoming serious
about auditing health-care practices.
With a thorough understanding of the
audit process, dentists will be better
prepared for what appears to be the
inevitable.
Why me?
After receiving notice of an impending
audit, dentists often wonder why their
practice has been targeted. Generally,
the audits conducted by dental plans
and third-party payers are a method
of showing state regulators that the
patients are receiving quality care. A
third-party payer is an organization
other than the patient (which would
be the first party) or health-care pro-
vider (also known as the second party)
involved in the financing of health
care services.
The audits are typically meant to
check the status of a dental plan and
are not meant to be a check on the
specific dental practice. The selec-
tion process third parties undertake
to audit a given dental practice var-
ies. Third parties may randomly pick
dental practices based on how likely
the practice is to have discrepancies
once audited. The third party’s goal is
to recoup lost dollars, and so this strat-
egy is chosen to allow a third party to
obtain the largest return.
A dental practice is most likely to
be audited after submitting atypical
claims online. A third-party payer ana-
lyzes each claim submitted. The audi-
tors flag abnormal or atypical charges
as these may suggest provider abuse.
Additionally, third parties track infor-
mation on practice charges by analyz-
ing the average cost per claim, average
cost per person and how often certain
treatments are performed. With this
information, the third parties target
specific dental practices for an audit.
An auditor’s goals
Auditors typically share common
goals. By conducting audits, third party
payers are attempting to prevent abuse
of the payment system. By performing
audits on practices, dentists are forced
to understand the importance of keep-
ing records and submitting only hon-
est and accurate claims.
Also, dentists are more likely to
keep accurate records and submit
truthful claims when they know an
audit may be lurking than if they
assume their dental practice will
never face an audit.
A second goal ties in with the first,
and that is to help dentists under-
stand and follow the third-party
payer’s guidelines. Finally, the audi-
tors are trying to find instances of
overpayments to dental practition-
ers for claims the dental practice has
submitted.
f DT page 2A
fluoride toothpaste and visit their
dentist as often as recommended.
Sugary foods and drinks can dam-
age the teeth. Instead, replace these
with healthy snacks such as cheese,
raw vegetables, seeds, bread, crack-
ers, breadsticks and fruit, and try to
encourage children to drink more
milk and water. Parents should try
The audit process: first contact
Many dentists want to know what to
expect if their practice is hit with an
audit. First, the dentist will most likely
be notified of the impending audit by a
letter, however, the third-party payer
may make initial contact with the den-
tal practice by telephone. When a tele-
phone call takes place, a day and time
for the audit will be arranged, and the
dentist should ascertain what type of
audit will be conducted.
It is also advisable to ask why the
audit is being performed. The answer
may be that it was simply a random
selection, but a dental practitioner
should make certain that it was not
because of a claim submission that the
third-party payer flagged as abnormal.
Auditors and file access
When auditing the dental practice, the
insurance plan will most likely send
representatives to the dental practice
to ensure that billing claims match
documentation in patient files. Audi-
tors will analyze whether amounts
paid to the practice were for an actu-
al member of their insurance plan,
whether the services rendered were
actually provided according to treat-
ment plans and whether the servic-
es provided by the dentists were in
accord with federal law.
Additionally, auditors may analyze
patient files. Auditors may be inter-
ested in reviewing patient medical his-
tories, dental histories, documentation
of oral examinations, treatment notes,
diagnosis, procedures completed, the
outcome of each procedure and fol-
low-up care. It is also possible that
documentation supporting submitted
claims will be requested during an
audit.
Problems encountered during
audits are most likely due to improp-
er documentation of records rather
than by fraudulent billings. The den-
tist is typically without recourse if the
records in the patient file do not match
up with the claims billed.
Various state laws and the HIPAA
(Health Insurance Portability and
Accountability Act) privacy rule per-
mit third-party payers to access and
review the health records of their own
members. However, third-party pay-
ers are no longer permitted to access
the records of patients who are not
enrolled in their plans like they were
in the past. Therefore, third-party pay-
ers are no longer able to compare
and reduce the number of ‘snack
attacks’ to no more than three meals
and two snacks a day.”
“These simple changes to a child’s
diet and oral health routine can real-
ly help decrease risks of tooth decay
and other oral health problems,”
Carter said. DT
(Source: British Dental Health
Foundation)
Dental Tribune | October 2010 Clinical 5A

Papillary squamous cell

their enrollees’ records and charges
with those of patients not enrolled
under their plans.

Beyond patient files

Aside from auditing the patient files,
the third-party payer may also access
the quality of the facility, the main-
tenance of the equipment, the level
of difficulty patients on their plan
encounter in obtaining appointment
times, and the level of compliance with
federal regulations during the course
of the audit.
It is prudent that the dentist remains
with the auditor at all times. It is worth
the time to clear the calendar on the
day of the audit and to stay with the
auditor as patient and billing records
are reviewed. Also, the staff of the den-
tal practice should be prepared for the
audit, and the dentist should discuss
the procedures to be followed before
the day it is conducted.
carcinoma of the hard palate
Report of a rare case affecting the oral cavity
By Paul C. Lee, BA; Justin Olsen,
BS; Joshua Adcox, BS and Parish P.
Sedghizadeh, DDS, MS
Approximately one in three
Americans will develop a malig-
nancy in their lifetime.1 The chances
of developing certain malignancies
increase with age and several con-
tributing risk factors such as tobac-
co and alcohol use. Notwithstanding
significant decreases in death rates
from heart disease, cerebrovascu-
lar disease and infections over the
previous 50 years for many forms of
cancer, death rates remain essen-
tially unchanged during that same
time period.1
Squamous cell carcinoma (SCC)
is the most common malignant neo-
plasm affecting the head and neck.
Mucosal cases account for more
than 90 percent of all malignant
neoplasms affecting oropharyngeal
structures, with oral squamous cell
carcinoma (OSCC) being the most
common oral malignancy.2
Several variants of OSCC exist
and histopathologic classifications
for variants of OSCC include papil-
lary, spindle cell, adenosquamous,
g DT page 6A
AD

Because dental audits are becom-

ing a routine part of doing business,
dentists must protect their practice by
preparing their office for an audit.
To prevent audit problems, den-
tists should make themselves aware of
terms of any third-party contracts, keep
the plan manuals in a safe place so the
dentist can refer back to them, ensure
each procedure performed matches
the procedure billed and ensure that
all patient records are organized and
contain all relevant information on
each patient.
Also, when claims are filed online,
ensure that the correct price is sent to
the third-party insurer.
With a more thorough understand-
ing of third-party audits and the third-
party payer’s motivation for conduct-
ing them, dentists will be more likely to
avoid costly mistakes. DT

About the author

Stuart J. Oberman, Esq., has

extensive experience in repre-
senting dentists during dental
partnership agreements, part-
nership buy-ins, dental MSOs,
commercial leasing, entity for-
mation (professional corpora-
tions, limited liability compa-
nies), real estate transactions,
employment law, dental board
defense, estate planning, and
other business transactions that
a dentist will face during his or
her career.
For questions or comments
regarding this article, visit
www.gadentalattorney.com.
6A Clinical Dental Tribune | October 2010
papillary variant of SCC can be a
challenge to accurately diagnose
and histologic assessment of under-
lying invasion can be very difficult.3
Risk factors and pathogenesis for
papillary SCC are unclear although
human papilloma virus subtypes are
thought to play a role in some cases.3
The purpose of this paper is to
(a) present a rare case of papil-
lary OSCC affecting the hard palate,
and (b) describe the clinical and
histologic features of this tumor in
supporting the dentist’s role in early
detection.
Case report
A 63-year-old female presented
to the dental clinic at the Herman
Fig. 1: Clinical image of the palate of a 63-year-old female showing an Ostrow School of Dentistry, Univer-
erythematous exophytic mass with a cauliflower-like or papillary surface sity of Southern California with the
architecture. (Photos/Provided by Paul Lee) chief complaint of a growth appear-
ing on the roof of her mouth approx-
white to tan, frequently feeling firm imately two months prior to her pre-
f DT page 5A on palpation. Conventional OSCC sentation to our clinic. The patient’s
is composed of variable degrees of past medical history included type
and basaloid carcinoma; it is also squamous differentiation, with well- II diabetes mellitus controlled with
possible to categorize types of OSCC differentiated cells closely recapitu- diet and exercise, and denial of any
based on clinical descriptors such as lating normal squamous epithelium alcohol or tobacco use.
ulcerative, flat, polypoid and verru- but demonstrating some degree of The remainder of her medical
coid.2 OSCC variants can have differ- basement membrane violation by and social history was non-contribu-
ent growth patterns, ranging from nests of tumor cells, to poorly differ- tory; she was not taking any medica-
small mucosal thickenings to large entiated cells with more anaplastic- tions and a review of systems was
masses, and can appear endophytic like appearances. unremarkable. Intraoral examina-
or exophytic. As a result of its complex exo- tion revealed a 3.5 cm exophytic
These tumors are erythematous to phytic papillary architecture, the mass in the anterior midline region
AD
of the hard palate (Fig. 1). The
lesion appeared vascularized with
ill-defined borders and no evidence
of ulceration or erosion.
The patient had mild sensitivity
upon palpation of the lesion. No cer-
vical or submandibular lymphade-
nopathy was observed during the
extraoral examination of the head
and neck. Panoramic radiography
revealed no abnormalities of the
palatal area.
The patient was informed that
a biopsy must be taken to obtain a
definitive diagnosis; informed con-
sent was obtained for incisional
biopsy with local anesthesia. During
the administration of local anes-
thesia, the cortical bone under the
tumor felt intact with the end of the
needle. A representative wedge of
tissue was removed and placed in
10 percent formalin for microscopic
evaluation.
The biopsy site was cauterized to
obtain postoperative hemostasis due
to the high degree of vascularity.
The biopsy site was closed with four
3.0 chromic gut interrupted sutures.
Hemostasis was achieved, postop-
erative instructions were given and
the patient’s postoperative condition
was good.
The gross examination of the
specimen consisted of a soft, tan
papillary and friable mass. The his-
Dental Tribune | October 2010 Clinical
Fig. 2: Histopathologic evaluation
demonstrates abnormal mucosa
with a micropapillary surface mor-
phology and marked maturational
perturbations in association with
acute and chronic inflammatory
cells (H&E, 20x original magnifica-
tion).
topathologic evaluation revealed
an exophytic, papillary prolifera-
tion of surface mucosa showing
marked maturational perturbations.
It included cellular and nuclear
pleomorphism, prominent nucleo-
li, hyperchromatism, acantholysis,
increased mitotic activity and abnor-
mal mitotic figures, dyskeratosis and
keratin pearls, and increased nucle-
ar-to-cytoplasmic ratios.
Invasive cords and islands of
malignant mucosa were visualized
and the associated connective tis-
sue contained an influx of acute
and chronic inflammatory cells. To
evaluate whether the inflammatory
infiltrates observed in the cancerous
tissue were in response to super-
imposed fungal infection (because
organisms such as Candida albi-
cans are common oral inhabitants),
periodic-acid Schiff staining was
conducted and determined to be
negative with appropriate staining of
control tissue.
The patient was referred to the
head and neck oncology group at the
University of Southern California,
Los Angeles County Hospital and
Keck School of Medicine. Clinical
work-up for staging was performed
and computerized tomography
scans of the head, neck and chest
were determined to be negative for
metastatic disease; the lesion was
staged at T2N0M0.
The patient underwent tumor
resection with 1 cm margins and
suprahyoid neck dissection, with
no radiation or chemotherapy. Her
postoperative course was unevent-
ful, and histopathologic analysis
confirmed a diagnosis of papillary
OSCC.
The dissected lymph nodes
showed no metastatic involvement,
confirming that the surgical mar-
gins were tumor free. There was no
clinical evidence of recurrence at
6-months follow-up.
Discussion
The typical presentation for OSCC
can be either a symptomatic or
asymptomatic mucosal ulcer. These
superficial ulcers often progress into
symptomatic or asymptomatic exo-
phytic or endophytic nodules with
eroded or ulcerated surfaces, and
can progress to direct invasion of the
deeper structures resulting in a firm,
7A
so in only 40.11 percent of their 406
patients. This difference was statisti-
cally significant (P < .001).8
OSCC is a major public health
problem that is not just limited to
certain risk groups, such as those
who smoke and drink as in this case
report. Early detection and identifi-
cation of OSCC is critical to patient
treatment and survival. DT
A complete list of references is
Fig. 3: Histopathologic evaluation Fig. 4: Histopathologic evaluation available from the publisher
reveals invasive islands and cords of of invasive cords of mucosa at
malignant epithelium in addition to high power magnification shows About the authors
dyskeratosis and early keratin pearl cellular and nuclear pleomor-
formation (H&E, 20x original mag- phism, hyperchromatism, acan-
nification). tholysis, dyskeratosis, prominent Paul C. Lee, BA; Justin Olsen,
nucleoli and increased nuclear- BS; and Joshua Adcox, BS, are den-
to-cytoplasmic ratios (H&E, 40x
tal students at the Herman Ostrow
original magnification).
School of Dentistry of USC, Universi-
non-movable mass.1 ty of Southern California, Los Ange-
However, OSCC often begin over 3 cm in diameter. les. Parish P. Sedghizadeh, DDS,
as white or red plaques of sur- Dentists have a critical role in MS, is an assistant professor at the
face mucosa, making early clinical early identification of and effective Herman Ostrow School of Dentistry
detection possible. If a leukoplakic care during OSCC progression from of USC, University of Southern Cali-
or erythroplakic lesion appears in premalignant lesion to malignan- fornia, Los Angeles.
the oral cavity and does not heal cy.7 A study conducted to evaluate
within a few weeks, biopsy is rec- the effectiveness of dentists in the For correspondence:
ommended for definitive diagnosis, early detection, treatment and post- Paul C. Lee
which may represent levels of histo- operative care of OSCC in a central 925 West 34th Street, DEN 4110
logically normal tissue (e.g., kerato- European population revealed the University of Southern California,
sis) to atypia, dysplasia, carcinoma following results: Dentists identi- School of Dentistry
in situ or overt carcinoma.1 fied 72.5 percent of the tumors in Los Angeles, Calif. 90089-0641
Papillary OSCC, such as the case the 608 patients they saw as malig- E-mail: chong.lee@usc.edu
presented here, is a variant of SCC nant, while family physicians did
as classified by the World Health
Organization4 and can present as
AD
either in situ or invasive lesions.5
Male predominance exists in OSCC
cases, and the sites most commonly
affected in order of prevalence are
the larynx, nasal cavity and oral
cavity.2, 5
The clinical appearance of papil-
lary OSCC often mimics other vari-
ants such as verrucous carcinoma,
which is included in a differential
diagnosis until confirmation with
microscopic examination and diag-
nosis.3
Microscopically, OSCC can show
invasive and disorganized growth
with the following: dyskeratosis,
keratin pearls and intercellular
bridges, increased nuclear-to-cyto-
plasmic ratios, nuclear chromatin
irregularities, prominent eosino-
philic nucleoli and increased mitot-
ic figures with atypical formation.
Perineural invasion can be seen in
some lesions, presenting a positive
correlation to metastatic potential.1
In this case presentation, many of
the aforementioned microscopic
features of OSCC were evident with-
out evidence of perineural invasion.
Early detection of OSCC, spe-
cifically stage I or II diagnosis, is
usually associated with a favorable
prognosis. Papillary OSCC in gen-
eral has a 70 percent, five-year sur-
vival rate at any stage, and at T1 it
carries a 100 percent survival rate6
compared to other variants, such as
basaloid (40 percent, two-year sur-
vival), adenosquamous (55 percent,
two-year survival), and spindle cell
(80 percent, five-year) carcinomas.2
Most reported cases of papillary SCC
exhibit a mean diameter of 1 to 1.5
cm2. Our patient presented with a
relatively large lesion measuring
8A AMED Meeting Preview Dental Tribune | October 2010
Santa Barbara hosts a dentist’s
look through the microscope
The Academy of Microscope
Enhanded Dentistry’s 9th Annual
Meeting and Scientific Session will
be held Nov. 4–6 in Santa Barbara,
Calif., at Fess Parker’s Double Tree
Resort. The theme is “The Intersec-
tion of Macro & Micro Dentistry.
The meeting will feature lec-
tures from top clinicians in every
discipline as well as master classes,
corporate forums and pre- and post
session, comprehensive, hands-
AD
on courses at education facilities
along the Pacific coast.
If you have not registered for
the meeting yet, you may reg-
ister online and view the com-
plete schedule at www.microscope
dentistry.com. Your pre-registra-
tion helps AMED plan and prepare
so please make your registration as
soon as possible.
During the meeting there will
also be special events that accom-
panying guests will be sure to
enjoy. Call (800) 564-4333 to make
your hotel reservations.
You may also become an
AMED fan on Facebook at
www.facebook.com/micro
dentistry. See you in Santa Barbara!
The daily schedule for the event
follows.
Thursday, Nov. 4
• 7 a.m., registration and exhib-
its open
• 9:30 a.m.–1:30 p.m., spouse/
guest event, Lotus land garden tour
(there is a fee for this event)
• 8 a.m.–12:45 p.m., general ses-
sion
~ John West, DDS, MSD, Presi-
dent’s Welcome
~ Cliff Ruddle, DDS, My End-
odontic Practice: A 35-year Retro-
spective Analysis
~ Terrel Pannkuk, DDS, MScD,
The Endo/Perio Differential Diag-
nosis
~ Paul Anstey, DDS, The Power
of 3-D Imaging in Endodontics and
Beyond
~ Tetsuya Hirata, DDS, PhD,
What I Learned During Eight
Years of Research Study in Image
Enhanced Dentistry
~ Cherylin Sheets, DDS, Quanti-
tative Percussion Diagnostics and
Magnification: A Synergistic Com-
bination
• 12:45–1 p.m., members’ busi-
ness meeting
• 12:45–2 p.m., luncheon buffet
• 2–5 p.m., Endo Master Class
~ Carlos Murgel, DDS, Small
FOV CBCT for Endodontics: Anoth-
er Gadget or a Paradigm Shift?
~ Terrel Pannkuk, DDS, MScD,
Outcome Study Science and Art: Can
the Value of an Endodontic Tech-
nique or Technology Be Adequately
Assessed?
~ Morlo Okaguchi, DDS, Micro-
scope Assisted Precision Dentistry II
~ Eudes Gondim, DDS, PhD,
Beyond the Microscope: What Else
Can Make the Difference?
~ John West, DDS, MSD, speak-
ers’ panel moderator
• 2–5 p.m., Perio Master Class
~ Markus Hürzeler, DMD, PhD,
Minimally Invasive Implant Sur-
gery Supported by Microsurgical
Techniques
~ Adriana McGregor, DDS, The
Hidden Secrets of Outstanding
Results in Soft-tissue Management
Around Implants: From Planning to
Placement to Restoration
~ Te-Fu Li, DDS, Micro-invasive
Treatment of Periodontal Pockets
~ Katsuhiko Akiyama, DDS,
Papilla Reconstruction Using the
Patch Technique
~ Bryan Pearson, DDS, MS,
speakers’ panel moderator
• 2–5 p.m., Restorative Master
Class
~ Kunio Matsumoto, DDS, Pre-
Treatment in Esthetic Restoration
~ Masayuki Okawa, DDS Mini-
mally Invasive Interventions and
Interdisciplinary Approach for
Esthetic Dentistry
~ José Roberto Moura, DDS, Art
and Precision with Direct Compos-
ites
~ Claudia Cia Worschech, DDS,
PhD, Obtaining Clinical Success
Dental Tribune | October 2010 AMED Meeting Preview 9A

with Micro Laminate Porcelain
Veneers
~ Assad F. Mora, DDS, MSD,
FACP, speakers’ panel moderator
• 7–11 p.m., Social Event: Wel-
come reception, entertainment and
dance
Friday, Nov. 5
• 8 a.m., registration and exhib-
its open
• 8 a.m.–5 p.m., Test Drive the
Latest Technology
• 9 a.m.–12:45 p.m., general ses-
sion
~ Larry Rifkin, DDS, Facial
Esthetics
~ Glenn vanAs, DDS, Lasers and
the Operating Microscope: Seeing
the Light!
~ Marc Alexander, DDS, Treat-
ment Planning for Esthetics
~ Paul Piontkowski, The Perfect
CAD/CAM Restoration
Social events and tours
• Santa Barbara Back-Country
Wine Tour, Nov. 10, a.m.–4:30 p.m,
Enjoy lush valley views, breath-
taking scenery and stops at four of
the region’s best wineries for tast-
ings and a gourmet picnic lunch at
one of the vineyards.
Journey back to Santa Barbara
through oak-shaded canyons and
dirt trails, past the former Rea-
gan Ranch and along the beautiful
Pacific.
• Spouse/guest event: LotusLand
garden tour with lunch, Nov. 4, 9:30
a.m.–1:30 p.m.
You are invited to visit Lotus-
land, a unique 37-acre estate and
botanic garden situated in the foot-
hills of Montecito to the east of the
city of Santa Barbara. Visit www.
lotusland.org for more information.
• Welcome reception, entertainment
and dancing, Nov. 4, 7–11 p.m.
This event is an opportunity for
members and guests from around
the world to meet face to face.
Enjoy a Santa Barbara themed din-
ner, entertainment and dancing.
Attire is California casual.
• Spouse/guest event: Santa Bar-
bara’s land shark tour, Nov. 5,
2–3:30 p.m
Climb aboard Santa Barbara’s
original amphibious tour vehicle
for a personally narrated 90-min-
ute land and sea adventure. Enjoy
exquisite views of the Santa Bar-
bara coastline, the Riviera and the
Santa Ynez mountains as seen only
from our boat at sea.
• President’s dinner and awards,
Nov. 5, 7–9:30 p.m
Enjoy an elegant evening during
AMED’s annual President’s Dinner
and short awards presentation cer-
emony. Attire for this event is semi-
formal. DT
AMED Program Co-chairs: Drs.
William Lannan and John West
AMED Scientific Session Commit-
tee: Drs. Terry Pannkuk, Adriana
McGregor and Tetsuya Hirata
Contact information:
Academy of Microscope Enhanced
Dentistry
P.O. Box 15834
Fort Wayne, Ind. 46885
Phone: (260) 249-1028
www.microscopedentistry.com
AD

• 2–5 p.m, short presentations

~ Randy Shoup, DDS, Minimally
Invasive Restorative Dentistry: Live
Demonstration of Principals, Tech-
niques, Equipment and Materials
~ Junya Okawara, DDS, Peri-
odontal Microsurgery: Achieving
Gingival Level Alignment with Con-
netive Tissue Graft
~ Cami Ferris, DDS, Heroic End-
odontics in an Age of Implants
~ Masahiro Nakazawa, DDS,
Utility of All-on-4 with Socket Pres-
ervation
~ Kazuo Kurihara, DDS, Tissue
Management Around Implants in
Esthetic Zones
~ Stephane Browet, DDS, The
Matrix Revisited
• 2–5 p.m., corporate forums
~ BioClear Composites Hands-on
Course (there is an additional cost
for this course)
~ Global Surgical
~ AMD Lasers
~ Crystal Mark & GC America:
Air Abrasion
• 2–3:30 p.m., spouse/guest
event: Land shark tour (there is a
fee for this event)
• 7–11 p.m., social event: presi-
dent’s dinner and awards

Saturday, Nov. 6
• 8 a.m. registration and exhibits
open
• 9 a.m.–1:30 p.m., Test Drive the
Latest Technology
• 9 a.m.–1:30 p.m., general ses-
sion
~ Dennis Shanelec, DDS, A Ret-
rospective of Clinical Periodontal
Microsurgery
~ Jeff Hamilton, DDS, Oral Med-
icine and the Clinical Operating
Microscope
~ Eric Herbranson, DDS, The
Latest in Photographic Documenta-
tion
~ Peter J. Jannetta, MD, Neuro-
genic Face Pain in the Dental Office
~ Malcolm Snead, DDS, PhD,
Thinking the Unthinkable: Regener-
ating the Whole Tooth
• 1:30 p.m., adjourn
~ Off-site hands-on courses
~ Pre & post session hands-on
courses will be held at the Micro-
surgery Training Institute
10A AADOM Meeting Preview Dental Tribune | October 2010
‘What you learn in Vegas doesn’t
have to stay in Vegas,’ AADOM says
By Fred Michmershuizen, Online Editor
The AADOM is gearing up for its
6th Annual Dental Office Manag-
ers Conference, to be held Oct. 22
and 23 at the Las Vegas Hilton, and
plenty of education is on the menu.
The following educational programs
will be offered in Las Vegas.
Friday, Oct. 22
• 10:15 a.m.–12:15 p.m.: Conflict,
Gossip & Tension Resolution for the
Dental Office Manager, Judy Kay
Mausolf
Discover how to elevate you com-
munication to a level that resolves
conflict, gossip and tension and takes
a team from good to great every
time. Learn how to create an envi-
ronment where everyone focuses on
the positive (what is right) instead of
the negative (what is wrong).
• 10:15 a.m.–12:15 p.m. and
repeating 2:30–4:30 p.m.: The
Practice Promise: How To Create
Your Brand, Fred Joyal, founder of
1-800-DENTIST, with special guest
Rita Zamora, social media expert;
facilitator is Kim McQueen, market-
ing manager, Patterson Office Sup-
plies
If you are an office manager who
wants to learn how to navigate a
marketing plan with options geared
toward the specifics of your loca-
tion, specialty, offerings and overall
“practice promise,” this session is
for you. Participants will gain the
tools they need to build a marketing
plan for the upcoming year.
• 10:45 a.m.–12:45 p.m., repeating
2:30–4:30 p.m.: All Stressed Up & No
Place to Go, Larry Wintersteen
Learn from one of the best den-
tal management consultants in the
country, Larry Wintersteen, how to
handle the stress only a dental office
manager can experience. Go home
with stress-eliminating ideas you
AD
can implement Monday morning.
• 10:45 a.m.–12:45 p.m.: Tips for
Going Green in the Dental Office, by
Kevin Henry
“Going green” doesn’t mean giv-
ing up electricity or reverting back
to the Stone Age. It does, however,
mean a new way of thinking and
awareness in the dental office. In
this lecture, participants will learn
how to help save the environment
by taking small steps in each room
of the dental office.
• 2:30–4:30 p.m.: Writers Work-
shop for Dental Office Managers,
Kevin Henry
Have you ever dreamed of being
published? Do you have a wealth
of knowledge that you would love
to share but are unsure how? Join
Kevin Henry, managing editor of
Dental Economics and editor of
Dental Assisting Digest, for this
interactive workshop.
• 2:30–4:30 p.m: How to Start a
Local Study Club: S.T.A.R.T.S. Meth-
od, Judy Kay Mausolf
One of the big questions being
asked today is, “How do I start a
local study club?” Judy Kay, the
Study Club S.T.A.R.T.S. expert, can
show how you can take your passion
and ideas and transform them into
a thriving and successful study club
today. Learn the six step S.T.A.R.T.S.
method to study club success.
(Photo/Provided by AADOM)
Saturday, Oct. 23
• 9:15–10 a.m.: Keynote Session:
Lioness Leadership: Awaken the
Instinctive Leader in You!, Katherine
Eitel
Lions are born leaders. Cubs are
born with instincts to hunt, propagate,
lead and thrive, they just don’t know
it. The primary goal of mature lion-
esses is to awaken those instincts to
ensure the success of the pride. Like
lions, you already have the instinctive
ability to lead and lead powerfully
from whereever you are in life. Most
of us just don’t know it, or trust it, yet.
• 10:30–11:30 a.m.: Your education.
Your professional development. Your
way., Cindy Durley, MEd, MBA, and
Liz Koch
In this interactive workshop,
attendees will be asked to share their
expertise and strategic planning skills
as we work together to determine and
then prioritize the online education
needs of dental office managers.
• 2:30–4 p.m.: Practice Management
Expert Panel
In this one-hour Q&A, expert con-
sultants representing all fields of
practice management will take to the
stage to answer questions. Questions
will be submitted ahead of time to
allow experts to prepare.
• 12:30–1:45 p.m.: My Office Man-
ager is a Rock Star!
Do you know how important you
are to your practice? Learn firsthand
from a practicing dentist how truly
valuable you are. If you sometimes
feel under-appreciated, you are not
alone. How can you get the recogni-
tion you deserve? Come find out!
In addition to the educational
opportunities listed above, the follow-
ing pre-conference programs will be
offered on Thursday, Oct. 21:
• 10:30 a.m. Dental Spouse Business
Roundtable
Dental spouses will come together
to discuss the unique challenges faced
when running a practice and being
married to the doctor.
• 2:30–5 p.m.: Best Practices’ Work-
shop: The Ultimate Roundtable Experi-
ence, Katherine Eitel
Attendees are invited to join this
interactive workshop to share best
practices with other office managers
from around the country. A Q&A ses-
sion featuring a panel of AADOM’s
Office Managers of the Year will be
followed by roundtable discussions by
specialty. The session will conclude
with “Train the Trainer,” in which
Eitel will teach attendees how to bring
what they have learned home.
• Key Opinion Leader Office Man-
ager Council
AADOM is looking for the best den-
tal office managers in the country to
be a part of this new event. Attendees
can meet with dental industry leaders
representing various businesses and
share with them how they can better
serve you, the dental office manager.
What products, services and discounts
can they provide to you to help you do
your job better? They value your opin-
ion and want to hear from you.
The AADOM Conference Diamond
Sponsor is Patterson Dental.
More information about the event
is available at www.dentalmanagers.
com/conference. DT
(Source: AADOM)
Dental Tribune | October 2010 Industry News 11A
EMS Air-Flow Master: prophylaxis now
also available for periodontal pockets
With the new Air-Flow Master
from EMS, prophylaxis is enter-
ing a previously unexplored area.
This instrument gives periodontal
pockets a thorough cleaning by air
polishing.
The biokinetic energy, applied
in a powder-air-water mixture,
removes the biofilm down to the
base of the pocket, brings about
a sustained reduction in bacteria,
firms the gum and reduces the
pocket depth.
The patient benefits twice
over because the procedure is
not only more efficient, but also
more comfortable than conven-
tional curettes or instruments that
scratch the tooth.
This “subgingival deep diving”
uses a special single-use nozzle,
combined with extra-fine grain
Air-Flow Powder that is non-abra-
sive on the tooth surface.
The flat and tapered, slightly
bent nozzle has three openings
from which the powder-air-water
mixture emerges in the subgingi-
val area with gentle turbulence.
The special construction of the
Atlas Denture Comfort provides a
lasting solution
Dentists often don’t look for-
ward to having patients with den-
tures, according to Paul Homoly,
DDS, president of Homoly Com-
munications.
When asked why, he replied
that the procedure leaves both
dentist and patient feeling bereft
of lasting solutions: there is con-
tinuous need for repeated visits
to the dentist for adjustments;
patients endure discomfort and,
worse yet, experience difficulty
with everyday functions such as
speaking, chewing, and smiling or
laughing.Even unwanted sounds
may also be heard coming from
the dentures, such as clicking or
whistling.
All of this leaves people wear-
ing conventional dentures feeling
insecure and self-conscious. Den-
ture wearers of any age could find
themselves changing their daily
routine—even choosing to avoid
eating because of discomfort or
embarrassment.
This is endured because the
one alternative they may have —
changing their conventional den-
tures into implant supported den-
tures — has historically been out
of their reach because of high pre-
vailing costs, painful and inconve-
nient surgical procedures or limi-
nozzles ensures that the powder
is thoroughly washed out of the
pocket, along with the removed
biofilm, according to EMS. The
nozzle is simply fitted onto the
Perio-Flow handpiece, which has
a magnetic holding device and can
therefore be removed flexibly.
The Air-Flow Master does not
simply take care of periodontal
pockets, but also provides supra-
gingival prophylaxis. Whether
plaque or hard deposits — the
Air-Flow handpiece “strokes”
the tooth surfaces clean with the
appropriate powder gently and
selectively. In addition to the clas-
sic powder, EMS has developed
a soft powder for more sensitive
teeth.
And recently, patients have
acquired a taste for this treat-
ment: The classic powder is avail-
able not only in a “neutral” flavor,
but also in cherry, black currant,
tropical, lemon and mint flavors.
Every flavor has its own color-
coded ring, which is placed on the
powder chamber so that it is clear
at a glance which flavor is being
tations in the width of their ridges.
Atlas® Denture Comfort™ is a
simple solution that was developed
by Dentatus USA. This affordable,
one-hour, chairside procedure is
soon to be the industry standard
for securing and retaining either a
patient’s new or existing dentures.
Atlas Implants, approved for
marketing by the FDA, are suit-
able for retaining lower dentures
economically, regardless of the
patient’s age.
The Denture Comfort procedure
consists of placing four Atlas nar-
row-body titanium alloy implants
into the edentulous jaw anterior
to the mental foremen. Then, Den-
ture Comfort’s cushioning silicone
— Tuf-Link® — is expelled into
the denture to fit snugly over and
around the short, dome-shaped
heads of the Atlas implants so that
the denture can be securely and
confidently retained.
The result is a comfortable fit
and optimal retention — all with-
out surgery, without bleeding,
without bank-breaking expense!
Atlas Denture Comfort is the
only system on the market today
that eliminates the hardware typi-
cally associated with overdentures.
The Atlas System uses no O-rings,
no housings, no adhesives.
used at any time.
The Air-Flow Master is oper-
ated exclusively through touch
and therefore is very hygienic.
The person providing treatment
places one finger on the touch
panel and controls the power and
liquid functions from minimum to
maximum by gently stroking over
them. In addition, a fingertip is
enough to switch between the Air- For deep periodontal pockets: The
Flow and Perio-Flow applications. Perio-Flow handpiece, the nozzle
The application currently in and the Perio Air-Flow Powder
use lights up in fluorescent blue.
Because of its smooth surfaces,
the instrument is easy and hygien-
ic to clean and thereby guarantees
the highest hygienic standards,
according to EMS.
More information is available at
EMS Electro Medical Systems
Corp. DT
Electro Medical Systems Corp.
11886 Greenville Ave., #120
Dallas, Texas 75243
Tel.: (972) 690-8382 The new Air-Flow Master from EMS:
Fax: (972) 690-8981 the subgingival practice unit.
info@ems-na.com
www.ems-dent.com
The unique Tuf-Link silicone patient education model, complete
reline provides the retention to patient start-up kit and marketing
the implants for a stress-free den- tools to help you get started. DT
ture, easy insertion, retention and
removal.
This minimally invasive tech- Dentatus USA
nique is easy for dentists to learn 192 Lexington Ave., #901
and implement, and will change New York, N.Y. 10016
the lives of your patients. Check Tel.: (800) 323-3136
out dentatus.com for upcoming Tel.: (212) 481-1010
hands-on workshops. Fax: (212) 532-9026
Included in the tuition are a www.dentatus.com
 Cosmetic TRIBUNE
The World’s Cosmetic Dentistry Newspaper · U.S. Edition

October 2010 www.dental-tribune.com Vol. 3, No. 10

Maintenance of periodontally
compromised teeth with
direct splinting: current
materials and options
By Dr. Ajay Kakar, India

Periodontal disease is initiated

in the main as gingivitis, which
in a smaller subset of indi­v iduals
progresses to the more advanced
form ­r eferred to as periodonti-
tis. Gingivitis is restricted to the
marginal gingival area and does
not lead to destruction of osseous
tissue.
Gingi­vitis is the progression to
periodontitis, which ­e ncompasses Fig. 1: A common periodontal situ- Fig. 2: Grooves prepared on the Fig. 3: The fibre in place and poly-
extensive loss of bone surround- ation with mobile anterior max- buccal surface of the incisors at the merised after being coated with
ing the tooth. Modern-day therapy illary teeth causing discomfort. incisal third to enable placement of flowable composite.
can generally ­ensure the arrest (Photos/Provided by Dr. Kakar) the fibre.
of the progression of peri­o dontal
destruction and, in favourable
situations, even the regenera-
tion of all the components of the
periodontal apparatus, albeit to a
much lesser extent than the origi-
nal. Of the periodontal structures,
the loss of soft tissue makes the
process of complete regeneration
much more ­difficult.
In such circumstances, wherein
the inflammation and infection Fig. 4: The completed splint with Fig. 5: A case of migration of the Fig. 6: A splint done followed by
has been controlled and the dis- direct bonding composite build- central incisors. recontouring of the tooth and
ease activity has been curbed, it up to achieve a pleasing aesthetic direct bonding composite build-
becomes imperative that the den- result. ups.
tition, which is definitely compro-
mised owing to the pre-existing
damage, be supported and addi-
tional aids provided to create the and better than a mobile one. Any This same technique can be used this monobloc effect, the substruc-
optimum function, coupled with regenerative therapy carried out routinely by orthodontists to place ture has to chemically bond and be
aesthetics. around afflicted mobile teeth will permanent non-invasive quartz in unison with composite restor-
One of the key issues in such have better results than would splints. ative material.
dentitions is the mobility of the have been the case had the teeth Another possible use of quartz In order to provide near-opti-
teeth. Such mobility may be been immobilised (Figs. 1–4). glass fibre splints is in cases of mum bonding, the substructure
localised to certain teeth and in Another critical manifesta- alveolar fractures. The advent of and the entire monobloc, which
a specific path of motion or may tion of periodontal disease, when bonding dentistry and the easy- has to be built up, have to be very
be much more generalised and coupled with imbalanced occlusal to-use quartz splint fibre make it closely adapted to the teeth around
afflict many teeth. In either case, loads, is the sequel of migration a very strong contender for the all the curves, right into the inter-
the benefits of immobilisation are that results from such a clinical stabilisation and immobili­sation of proximal spaces. This means that
multiple. The comfort level of the situation. Migration, an extremely anterior alveolar fractures. the fibre material should have
patient is sufficient reason to use slowly developing phenomenon, A key factor towards achieving physical properties that allow
this treatment option for mobile leads to drastic consequences that the end point of a good and long- curving and very easy manipula-
teeth. can usually be optimally corrected lasting splint is the base mate- tion into any shape (Figs. 5, 6).
Additionally, this also leads only by using orthodontic appli- rial used in conjunction with the The required materials for
to tremendous patient motiva- ances. composite restorative material for achieving a high quality functional
tion and compliance in maintain- But even this correction building and applying the splint. and aesthetic splint are:
ing oral hygiene, which directly requires a permanent splinting It is very important that the • a pre-impregnated glass fibre-
translates into better periodontal procedure to ensure that the con- splint functions like a monobloc
health. Furthermore, an immo- cerned teeth remain in place and and bonds optimally to the enamel
bile tooth will heal much faster do not migrate away once again. and dentine. In order to provide g CT page 2C
2C Clinical Cosmetic Tribune | October 2010
Fig. 7
Fig. 9
Figs. 7–10: The clinical zero memory effect of the woven quartz splint dem-
onstrated by adaptation around the entire curvature of the crown of an
extracted molar. The material is not polymerised but stays in the newly
adapted position.
f CT page 1C
based splinting material;
• a restorative micro/nano-
filled composite material;
• a flowable composite mate-
rial; and
• a bonding agent.
The above only highlights the
materials required and does not
list the armamentarium, which
would consist of a number of spe-
cial hand instruments to achieve
a high quality result and fin-
ish. Amongst the materials, the
bonding agent and the composite
restorative material are depen-
dent on the clinician’s preference.
The micro- or nano-filled range
of products from any of the indus-
try leaders in restorative materials
are most appropriate. A good flow-
able material is also ­r equired to
create a close fit of the splint mate-
rial to the tooth surface, while a
sixth or seventh ­g eneration bond-
ing agent would be able to achieve
the desired bond strength.
The most critical aspect in
achieving the ideal splint outcome
is the selection of the fibre used
as the substructure. There are a
number of options available on
the market. I have tested differ-
ent splinting fibres throughout my
career and quite a number of them
has given very good results and
lasted for years.
Available materials have some
favourable properties at the cost
of some other undesirable ele-
ments and at times the clinician
has to choose between sacrificing
several of the desired elements in
order to gain the others. The ideal
substructure fibre material has
the ­following properties:
• high strength subsequent to
polymerisation;
• chemically bondable with
Fig. 8
Fig. 10
composite resin material;
• available in a pre-impregnat-
ed state;
• no thicker than 0.2 mm;
• available in varying widths;
• easy to trim and cut; and
• no memory as regards its
form.
Of the above, the last property
is a critical one. Because of the
difficult handling properties of the
fibre splint, splinting has been
a very technique-sensitive proce-
dure thus far.
Unless the ­c linician was
extremely conversant with all the
requisite steps and also extremely
skilful and ­dexterous in the han-
dling of the fibre and composite,
the likelihood of a long-term suc-
cess would be reduced.
Many splint materials have a
tendency to a memory, that is
the property of returning to orig-
inal shape if deformed under
load. This memory of a material
makes it resistant to being shaped
around curves, especially curves
that double-back, for example the
interproximal areas around the
linguals of lower anterior teeth or
around the curvature of a maxil-
lary premolar.
If the material can be fabri-
cated in such a way that it bends
and adapts around curves without
bouncing back, it makes adapt-
ing and placing the splint in the
oral cavity a far simpler and more
accurate task.
Glass-based fibres have an
inherent tendency to maintain
their longitudinal direction. This
can easily be observed in any uni-
directional fibre splint material.
The only way to negate this prop-
erty of the fibre is to interweave
the fibres in a cross-stitch pattern.
This creates a kind of mesh frame-
work, thereby making the mate-
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Figs. 11–14:
The near zero memory property
of the rope quartz splint demon-
strated by distortion into
various shapes; the material
maintains its distorted position
without any polymerisation.
rial almost free of memory. The
term zero memory can then be
applied to such a material, which
will only minimally maintain any
form to which it is subjected (Figs.
7–10).
Although the material does pos-
sess a certain amount of memory,
it becomes practically insignifi-
cant as regards clinical applica-
tion. For all practical purposes,
the material would then have zero
memory.
My best experience thus far
has been with a very new entry in
the splinting fibre market: Quartz
Splint (Recherches Techniques
Dentaires). The basic raw mate-
rial used in this product is quartz
glass, unlike regular glass fibre.
This is the same quartz used to
develop endodontic posts, which
demonstrate cyclic fatigue resis-
tance values that are much higher
than desired in the oral cavity.
Quartz glass is also homog-
enous with the Bis-GMA range
of unfilled resin, which makes
it ideal for use with restorative
composite material, allowing it
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Cosmetic Tribune | October 2010 Clinical
Fig. 15: Buccal view of a patient
with mobile lower central inci-
sors.
Fig. 16: Lingual view of the
same patient with mobile lower
central incisors.
to become a monobloc with the
composite. The quartz splint is
developed as a woven ­f ibre using
extremely thin strands of glass
fibres.
The weave pattern imbibes
certain physical attributes to the
material. It allows force distri-
bution in such a manner that it
create the previously mentioned
clinical zero memory effect and
not resist and inhibit crack propa-
gation.
All of the above-mentioned
effects are achieved without any
compromise to the strength of
the material. In fact, the quartz
fibre will enhance and strengthen
the monobloc that is created with
the amalgamation of the unfilled
resin, quartz fibre, flowable com-
posite, and micro-/nano-filled
composite material.
Since the material is available
pre-impregnated and is soaked in
unfilled resin, it becomes all the
more easier to use the splint right
out of the box. The zero memory
allows it to be adapted extremely
easily around a curved arch with-
out polymerisation. Once ideal
adaptation has been achieved, it
can be polymerised in that posi-
tion and then layered with micro/
nano composite to complete the
splint (Figs. 11–14).
Another critical factor in the
variety of situations for which a
splint is indicated is the width
and thickness of the material. Too
thick a material can be an encum-
brance for placement and final
po­sitioning. An ideal thickness is
between 0.1 and 0.25 mm.
The thinner the material
becomes, the lower its ability to
reinforce and strengthen will be.
The quartz splint is in the 0.2 mm
thickness range, making it useful
in almost all clinical situations.
The quartz splint is available in
a variety of patterns and widths.
Fig. 17: A tin foil template
used to measure the size of the
required splint.
Fig. 18: Buccal view of the splint
done with the woven quartz
splint.
The recommended pattern for
intra-oral splinting is the woven
pattern. This is available in widths
of 1.5 mm, 2.5 mm and 4 mm. Of
these three, the 1 mm design is
most suited for use as a retention
splint in post-orthodontic cases
in which the teeth are neither
extremely mobile nor do they
exhibit gingival recession and loss
of the supporting structures.
The 2 mm fibres are most ide-
ally suited for teeth afflicted with
previous periodontal disease.
When the teeth are large in size
and exhibit clinical crowns larger
than the anatomical crowns, the 3
mm fibre may be used in lieu of
the 2 mm fibre.
The quartz splint has a unique
design — much like a braided rope
— giving it extremely high flexur-
al strength values after complete
polymerisation. The design of the
material requires it to be between
1 and 2 mm in diameter.
A deep groove has to be cut into
the teeth where the splint is being
placed to enable it to be adapt-
ed optimally. This design can be
utilised when in cases in which an
occlusal splint design is used to
stabilise maxillary or mandibular
premolars.
Other than the woven and rope
patterns, the quartz splint is avail-
able as a unidirectional fibre. This
is not to be applied in clinical situ-
ations, but rather as a laboratory
reinforcement material used to
develop poly-ceramic prostheses.
The quartz splint also has a 4 cm
x 4 cm mesh that can be applied in
­d enture repairs, for example.
With material benefits aid-
ing and improving the functional
aspect of splints, there has been a
newer approach possible owing to
the enhancement of bonding den-
tistry technology. Shade match-
ing, polishability, enhanced bond
strength and much longer-lasting
3C
Fig. 19: Lingual view of the Fig. 21: Preparations done on
splint done with the woven the palatal surface; the area
quartz splint. where the splint is to be placed
has been grooved.
Fig. 20_A case requiring
post-orthodontic retention
Fig. 22: A tin foil template placed
of the upper incisors; the splint is
on the grooved area to measure
to be placed on the palatal sur-
the size of the required splint.
face of the maxillary anteriors.
composites have all contributed
to a much greater usage of direct
bonding procedures in everyday
dentistry.
The emphasis this has given
to aesthetic procedures has been
tremendous. Similarly, the quartz
fibre-based composite splint in a Fig. 23: The woven quartz splint
dentition with pre-­existing peri- placed in the prepared area on
odontal damage can be enhanced the palatal surface of the maxil-
to achieve a much better aesthetic lary anteriors.
result (Figs. 15–19).
Although function has been the
paramount and most critical issue
when placing a periodontal splint,
aesthetics now also play an impor-
tant role. The patient and the
clinician may not be completely
satisfied with function.
It is quite easy to apply standard
bonding principles of a diastema
closure to ensure that the basic
substructure is appro­p riately Fig. 24: The completed splint.
located and thereby enable an
excellent ­aesthetic outcome with
longevity.
This modifi­cation of a function- clinations coupled with mobility.
al splint to an aesthetic splint can The results have been very satis-
be easily applied for anterior teeth factory.
exhibiting extensive mobility or This article has only touched on
migration. Several of these cases the fundamental concepts of
can be seen in Figures 15–24, in splints and the new improvisa-
which the maxillary anterior teeth tions available in terms of materi-
presented with diastemas and pro- al technology. CT
About the author
Dr. Ajay Kakar is in private practice spe-
cialising in periodontics and implantology in
Mumbai in India. He is the secretary of both
the International Academy of Periodontology
and the Indian Academy of Aesthetic & Cos-
metic Dentistry.
He lectures extensively in India and abroad
and runs a web portal for Indian dentistry at
www.bitein.com. Kakar can be contacted at
ajay@bitein.com or at +91 98210 15579.