Annual review of selected scientific

literature: Report of the Commit tee on

Scientific Investigation of the American
Academy of Restorative Dentistry
Terence E. Donovan, DDS,a Maxwell Anderson, DDS, MS,
MEd,b William Becker, DDS,c David R. Cagna, DMD, MS,d
Thomas J. Hilton, DDS, MS,e and Jeffrey Rouse, BS, DDSf
University of North Carolina, Chapel Hill, NC; University of
Southern California, Los Angeles, Los Angeles, Calif; University of
Tennessee Health Science Center, Memphis, Tenn; University of
Oregon Health and Science University, Portland, Ore; University
of Texas Health Science Center at San Antonio, San Antonio, Tex
In the past decade, there has been trolled clinical trials (RCTs) to answer CARIES AND PULP
an explosion in the volume of dental the primary question posed by the re- PATHOLOGY
literature. New journals have been view.
introduced on a regular basis and The primary purpose of this re- A number of studies were pub-
are competing with many of the es- view is to assist practicing dentists in lished last year on pulp capping,
tablished journals with a long history clinical decision making and to guide particularly on the effect of different
of publication. Dentists are urged to them to the best scientific evidence materials on pulp capping outcomes.
practice evidence-based dentistry at published in 2008. The Committee One such study evaluated the expres-
a time when commercialization of the on Scientific Investigation has care- sion of fibronectin and type III col-
profession has become rampant and fully reviewed and selected articles lagen in human pulps following pulp
materials are routinely brought to the published in 2008 because they be- capping with calcium hydroxide (cal-
marketplace with little or no clinical lieve the resultant data contributes cium hydroxide powder followed by
documentation. to the advancement of the practice of placement of Dycal; Dentsply Caulk,
While the volume of scientific lit- evidence-based dentistry. Comments Milford, Del) or a 2-step, etch-and-
erature has increased dramatically, on study design, statistical analysis, rinse adhesive (Single Bond; 3M ESPE,
the quality of the evidence produced and the relative strengths of the find- St. Paul, Minn).1 Fibronectin is con-
leaves much to be desired. Many ar- ings are included to aid the reader in sidered to be a marker for reparative
ticles are simply clinical reports that, interpretation of the results. dentin, and type III collagen is synthe-
while they may be of interest to clini- The analysis of the scientific lit- sized during the initial healing phase
cians, are low in the desired hierarchy erature published in 2008 is divided of tissue repair. Forty-six healthy pre-
of evidence. Many clinical trials are into 6 sections: (1) caries and pulp molars indicated for orthodontic ex-
neither randomized nor controlled, pathology; (2) periodontics; (3) traction were randomly assigned to 1
and also are underpowered by virtue dental materials; (4) occlusion, tem- of 3 groups: (1) control, no pulp cap;
of relatively small samples sizes. Most poromandibular disorders, and sleep- (2) pulps exposed and capped with
authors of systematic reviews lament disordered breathing; (5) prostho- adhesive; or (3) pulps exposed and
the fact that there are not enough dontics; and (6) implant dentistry. capped with calcium hydroxide. Pulp
properly conducted randomized con- caps were covered with resin-modi-

a
Chair, Committee on Scientific Investigation, AARD; Professor and Section Head for Biomaterials, Department of Operative Den-
tistry, University of North Carolina.
b
Private practice, Sequim, Wash.
c
Clinical Professor, Advanced Education in Prosthodontics, University of Southern California, Los Angeles; private practice, Tucson,
Ariz.
d
Professor and Director, Advanced Prosthodontics, University of Tennessee Health Science Center, College of Dentistry.
e
Alumni Centennial Professor in Operative Dentistry, Oregon Health and Science University.
f
Private practice; San Antonio, Tex.
(J Prosthet Dent 2009;102:10-45)
The Journal of Prosthetic Dentistry Donovan et al
July 2009
fied glass ionomer and restored with
composite resin. Teeth were extracted
7 or 30 days after treatment.
The results showed that calcium
hydroxide-capped pulps had similar
type III collagen and fibronectin ex-
pression as the control (noncapped)
pulps, and both of these were signifi-
cantly greater than the expression in
the adhesive-capped pulps. Further-
more, the adhesive-capped pulps
showed persistent inflammatory
process throughout the study period.
This study demonstrated that healthy
pulps, even in the absence of bacte-
rial contamination, did not produce
extracellular matrix elements when
capped with a 2-step, etch-and-rinse
adhesive.
Another study evaluated the re-
sponse of human pulps when capped
with a self-etch adhesive system.2
Thirty-four healthy human premolars
scheduled to be extracted for orth-
odontic reasons had the pulps inten-
tionally exposed and capped with 1
of 2 self-etch adhesives (Liner Bond
2V; Kuraray Co, Ltd, Osaka, Japan, or
Clearfil SE Bond; Kuraray Co, Ltd) or
calcium hydroxide (Dycal; Dentsply
Caulk). All teeth were restored with
self-etch adhesive and composite res-
in. Teeth were extracted at 30 or 90
days and assessed histologically. The
results showed significantly more den-
tin bridge formation and significantly
less inflammation in teeth capped
with calcium hydroxide compared
to those capped with the self-etch
adhesive. There was no difference in
the performance of the 2 adhesives.
These results occurred despite there
being little to no bacterial contamina-
tion of the specimens.
The use of mineral trioxide aggre-
gate (MTA) (ProRoot MTA; Dentsply
Tulsa Dental Specialties, Tulsa, Okla)
has captured the attention of the pro-
fession. Its use, initially for sealing
root ends after surgery, has expanded
and now includes pulp capping. A
number of studies using MTA for pulp
capping have been published recently.
One such study observed 40 subjects
with 53 direct pulp caps due to car-
Donovan et al
ies (49 recalled) over periods of 1 to
9 years (mean, 3.94 years).3 No teeth
exhibited abnormal radiographic or
periodontal findings, and no teeth
had pain in response to percussion.
Bleeding was controlled with sodium
hypochlorite; MTA was placed over
the exposure and sealed in place with
a moist cotton pellet for 5-10 days be-
fore final restoration with a bonded
composite resin restoration. Recall
data were based on self-reports from
patients, periapical radiographs, and
testing with a cold stimulus. The over-
all survival rate was 98%. The authors
note that the outcomes suggest that
MTA is a more predictable pulp-cap-
ping material than calcium hydroxide.
However, calcium hydroxide was not
evaluated in this study, there was no
control group (or any other group
pulp capped with any other material),
the subjects were not randomized to
groups, all clinical procedures were
accomplished by a single operator,
and no histological evaluation was in-
cluded. Therefore, the results provide
a low level of evidence, and no clear
justification for this statement.
Several other studies compared the
outcomes of pulp capping with MTA
or calcium hydroxide. Most of these
studies were performed using healthy
teeth, typically premolars scheduled
for extraction for orthodontics. In-
vestigators in 1 study intentionally
exposed the pulps of 40 premolars,
controlled hemorrhage with saline,
and capped the exposures with either
MTA or calcium hydroxide powder
and calcium hydroxide cement (Life;
Kerr Corp, Orange, Calif ).4 The au-
thors restored the preparations with a
reinforced zinc-oxide eugenol cement
(IRM; Dentsply Caulk), extracted the
teeth after 30 or 60 days, and evaluat-
ed the pulps histologically. There were
no significant differences between the
2 groups in terms of inflammation or
dentin bridge formation, although
there was a trend towards superior
performance in the calcium hydrox-
ide specimens in terms of dentin
bridge formation after 30 days, and
a tendency towards less inflamma-
11
tion in the MTA groups after 30 and
60 days.
Another study by the same lead
investigator used a methodology
similar to the previous study.5 Again,
40 healthy premolars had the pulps
intentionally exposed, hemorrhage
was controlled with saline, and expo-
sures were capped with either MTA or
calcium hydroxide. In this study, the
calcium hydroxide group was directly
pulp capped with calcium hydroxide
cement (Life; Kerr Corp) without the
intervening layer of calcium hydroxide
powder. The capping materials were
sealed with resin-modified glass iono-
mer (Vitrebond; 3M ESPE), bonded
with a 3-step, etch-and-rinse adhe-
sive (Scotchbond Multi-Purpose; 3M
ESPE), and restored with composite
resin (Z100; 3M ESPE). Teeth were
extracted after 30 or 60 days and
evaluated histologically. In this study,
the MTA showed significantly better
dentin bridge formation and other
pulpal findings (particles of capping
materials in pulp tissue) at 30 days
compared to calcium hydroxide, but
these differences disappeared after
60 days. There were no significant
differences in the other assessed cat-
egory of pulpal inflammation.
In a study that evaluated the effect
of MTA and calcium hydroxide on re-
parative dentin bridge formation fol-
lowing pulp capping, the researchers
evaluated markers for odontoblast
differentiation (dentin sialoprotein,
DSP) and cellular protection (heme
oxygenase, HO-1).6 Intentional pulp
exposures were made in 20 healthy
third molars, bleeding was controlled
with saline, pulp capping was per-
formed with MTA or calcium hydrox-
ide cement (Dycal; Dentsply Caulk),
resin-modified glass ionomer (Fuji II
LC; GC America, Alsip, Ill) was used
for sealing, and the preparations
were restored with bonded compos-
ite resin. Teeth were extracted after 2
months and subjected to histological
evaluation and immunochemistry.
There were no differences between
the 2 groups in terms of inflamma-
tion, but the MTA group showed a
12
significantly thicker dentin bridge.
The authors attributed this to the
fact that the MTA-capped pulps also
exhibited significantly greater expres-
sion of HO-1 and DSP, resulting in
a better healing environment in the
early stages of pulp repair.
Pulp capping in primary molars
was also investigated in a study pub-
lished in 2008.7 Twenty-five subjects
with symmetrical pairs of primary
molars with carious pulp exposures
received 1 pulp cap with MTA and 1
pulp cap with calcium hydroxide (Dy-
cal; Dentsply Caulk), followed by a
zinc-oxide eugenol (ZOE) base (Kal-
zinol; Dentsply DeTrey GmbH, Kon-
stanz, Germany) and an amalgam
restoration. The patients were fol-
lowed clinically and radiographically
for 24 months. During this time, no
teeth exhibited failure, showing equal
outcomes as a result of pulp capping
primary molars with either MTA or
calcium hydroxide.
While some differences in the per-
formance of pulps capped with MTA
versus calcium hydroxide do appear in
some studies, the trend appears to be
towards similar performance of teeth
following pulp capping with either
MTA or calcium hydroxide. The ratio-
nale for this may be explained in part
by a study that characterized the hy-
dration products of MTA.8 MTA was
evaluated using radiographic diffrac-
tion analysis. Both unhydrated and
hydrated specimens were evaluated,
and chemical analysis of the products
released into solution was performed.
The results showed that the primary
hydration product of MTA is calcium
hydroxide. Prior research by this same
author has demonstrated that the
high concentration of calcium hydrox-
ide eluted from MTA resulted in cell
proliferation, accounting for MTA’s
biocompatibility. Since MTA is a
source of calcium hydroxide, it seems
reasonable that MTA and calcium hy-
droxide would provide similar clinical
outcomes in regard to pulp capping.
Dental caries continue to receive
attention from researchers in the ar-
The Journal of Prosthetic Dentistry
eas of incidence and prevalence, di-
agnosis, prevention, treatment, and
microbiology.
Incidence and prevalence
A number of authors investigated
the incidence and prevalence of den-
tal caries in countries throughout the
world. Most studies were stratified by
age or focused on a unique age group-
ing and by what is seen as the emerg-
ing needs of a population. Caries
prevalence in children has continued
to decline in many countries, while
the disease disproportionately af-
fects smaller segments of society and
is ever further sequestered to occlusal
surfaces.9 Emerging countries, where
cariogenic diets are being introduced,
are exceptions to this decreasing car-
ies trend. Research on the emerging
elder populations shows seniors are
increasingly retaining their teeth and,
as a consequence, have more teeth at
risk for root caries and periodontal
diseases. Higher socioeconomic sta-
tus and independent living both pro-
mote better oral and overall health.10
Dementia and other cognitive impair-
ment conditions have demonstrated
a high association with both coronal
and root caries.11 Interesting tech-
niques for the uniform gathering of
incidence and prevalence data are
also emerging, including the use of
teledentistry. In a study of Early Head
Start children, investigators used im-
ages made with an intraoral camera
by telehealth assistants to provide
visual information to a calibrated pe-
diatric dentist.12 They concluded that
this is a viable technique for efficiently
screening preschool children for early
signs of caries. These data make it
clear that researchers throughout the
world are engaged in understanding
the distribution of dental caries and
the early identification of those who
need interceptive and preventive ser-
vices.
Diagnosis
Research focused on diagnosing
Volume 102 Issue 1
dental caries, especially pit and fissure
caries, continues to reflect the cur-
rent state of uncertainty concerning
whether a demineralized pit or fissure
is, in fact, active or inactive. Research-
ers continue to make progress in this
quest for objectivity and this year have
reported use of lasers, visible light,
fluidic probes, neural nets, radiovisi-
ography, bio-impedance, digital cam-
eras, infrared phothermography, the
use of a Raman spectrascope, bacte-
rial acid production, and cone-beam
and x-ray fluorescence as tools to help
objectify clinical decision making.
Laser fluorescence (LF) studies
continue to show mixed results. Re-
searchers performed a clinical study
comparing LF with a visual examina-
tion system.13 The visual system used
was that of Ekstrand and colleagues,14
which has demonstrated a reasonable
degree of accuracy when compared
to histologic findings. The method
is also reportedly training intensive,
which limits its utility for nonresearch
clinicians. These kinds of surrogate
comparisons, while interesting, beg
the question as to whether or not the
LF system improves diagnostic accu-
racy with respect to the true condition
of the tooth. The authors note that
accurate occlusal caries diagnosis is
difficult, with false-positive and false-
negative findings occurring frequently,
and then use surrogate visual scores
as the comparative reference for the
LF. Despite these limitations, results
are consistent with the findings of
other investigators, which show that
LF is significantly better at identifying
healthy surfaces than those judged to
be carious and that LF is not particu-
larly valuable for diagnosing early car-
ious lesions.15 A positive finding was
found for detection of interproximal
caries with LF.16 However, the clinical
utility is questionable in an area that
is not normally considered diagnosti-
cally difficult.
The application of the science
from a number of developing allied
fields to caries diagnosis continued
to be demonstrated in 2008. Whether
any of these will become clinically use-
Donovan et al
July 2009
ful adjuncts to diagnosis for a clinical
practice is uncertain. It does, however,
demonstrate that the well-recognized
problems associated with diagnosis
of caries in specific locations and de-
grees of demineralization remain clini-
cal problems of importance. One such
investigation was the application of
fluidic probes measuring impedance
variation between sound and cari-
ous tooth structure.17 The researchers
successfully applied this technology
to the measurement of both pit and
fissure and interproximal lesions in a
prototype model.
A neural net (artificial intelligence)
to improve radiographic interpreta-
tion was successfully used to enhance
the diagnostic accuracy of the best
of 25 test examiners from a receiver
operating characteristic (ROC) curve
value of 0.717 to an ROC of 0.884
when measured against the histology
of sectioned teeth viewed through a
microscope. ROC is a useful metric.
The calculations were developed in
World War II as a way to optimize the
models for radar detection of enemy
targets. ROC has subsequently been
applied to other fields and is increas-
ingly used in medicine and dentistry
to optimize models and discard those
that are suboptimal. In this case, the
researchers used this methodology to
optimize a neural net (the model sys-
tem) for the radiographic diagnosis
of caries on the basis of its accuracy
compared to microscopic examina-
tion of the tooth after sectioning. The
neural net improved the diagnostic
accuracy by a substantial 39.4% com-
pared to all examiners. The diagnostic
improvement when combined with
the previously discussed teledentistry
may be a sign of future practices.
Of clinical interest to dentists is a
study of the early detection of white
spot lesions with digital radiography
conducted in Australia.18 This investi-
gation reported both an in vitro and a
clinical study that investigated the use
of digital photography and a software
program on remineralization therapy,
demonstrating that the studied remin-
eralization protocol was, in fact, use-
Donovan et al
ful. The message for the nonresearch
clinician is that digital photography
is useful in documenting white spot
situations and the results of in-office
or take-home remineralizing medica-
ments.
In keeping with emerging medical
trends, researchers in Japan examined
a caries activity test (Cariostat; Dent-
sply-Sankin, Tokyo, Japan) combined
with a questionnaire to determine
the prognostic capacity in Japanese
children over a 3.5-year period.19 The
group clinically examined 1206 chil-
dren, born in 2000, at 18 months, 2
years, and 3.5 years of age. The clini-
cal findings were correlated to the
Cariostat test and the responses to
the questionnaire. The caries activity
test was successfully able to predict
the direction of caries incidence at
the examination time intervals. If this
is a repeatable experimental result in
other populations, this “prognostic”
may provide a mechanism for direct-
ing scarce resources to those at great-
est risk for adverse outcomes (caries
requiring restoration).
Finally, there is information for
those considering purchasing a cone-
beam computed tomography scan for
detection of dental caries. The 2 cone-
beam units tested against both digital
and conventional radiographic cap-
ture showed lower diagnostic accura-
cy for caries detection by cone beam
than electronic capture or film.20
Prevention
Traditional methods for caries pre-
vention continued to receive research
attention in 2008. These included
fluoride, chlorhexidine, pit and fissure
sealants, xylitol, arginine, and calcium
phosphate applications. Recently, in-
vestigators examined the effective-
ness of 3 preventive approaches in a
2-year trial comparing school-based
application of chlorhexidine varnish
or sodium fluoride gel versus dental
health education alone in “high-risk
adolescents.”21 The inclusion criteria
for “high-risk adolescents” were chil-
dren aged 11 to 13 years with a de-
13
cayed, missing, filled surfaces (DMFS)
index of 0. As might be expected, the
study did not show differences be-
tween treatment groups.
Fluorides
Guidelines for the use of fluorides
in children were published in the Jour-
nal of Clinical Pediatric Dentistry.22
This article extends the 2006 work
of the American Dental Association
(ADA) Council on Scientific Affairs23
by offering clinical recommendations
for professionally applied fluorides.
The application sequence recommen-
dation is that the teeth receive either
a tooth brush or prophylaxis with a
rubber cup before application of a
fluoride varnish to dried teeth, fol-
lowed by no tooth brushing and a
soft diet for 12 hours. This is reason-
ably consistent with the ADA Coun-
cil’s findings. It should be noted that
the evidence for the 12-hour hiatus is
not strong.
It is clear from an Australian sys-
tematic review that when considering
populations, fluoridation of water
supplies remains the most effective
and socially equitable mechanism
available when compared to incor-
poration in milk or salt.24 A well-done
systematic review of fluoride varnish25
in concert with similar reviews of pit
and fissure sealants was published.
The findings of the review are that for
those considered at high risk for den-
tal caries (including previous caries,
low socioeconomic status) a twice-
yearly application of unit-dosed fluo-
ride varnish should be used with as
many other proven preventive strate-
gies such as possible. The use of non-
dental personnel to apply varnishes
at well-baby visits showed a 35%
decrease in DMFS for babies receiv-
ing 4 or more treatments between 9
and 30 months.26 While most fluoride
studies were conducted in young co-
horts, 1 study investigated 3 different
fluoride strategies for frail individuals
older than 75.27 They found that fluo-
ride varnishes applied by a hygienist
or 5000-ppm fluoride dentifrice used
14
twice daily significantly reduced root
caries progression compared to an
untreated cohort or to those brushing
twice daily with a 1450-ppm fluoride
toothpaste. Given the aging of the
world’s populations with increasing
retention of teeth, studies such as this
are useful for clinicians and care facil-
ity administrators in preventive plan-
ning and policy/guideline making.
Chlorhexidine
The use of chlorhexidine for caries
control continues to be controversial.
One review28 concludes that the data
are suggestive but incomplete when
examining the literature relative to
rinses, gels, and chlorhexidine varnish-
es. The review also notes that many
studies use the surrogate outcome
measure of S. mutans count reduction
rather than actual caries incidence
measures. As noted later in this re-
view, S. mutans is not the only putative
pathogen for dental caries. This use
of a bacterial surrogate is a reflection
of the cost of longitudinal caries trials
and continues to be a research issue.
The results of this report confirm the
findings of a number of previous sys-
tematic reviews that found a lack of
well-conducted research that would
verify chlorhexidine’s effectiveness.29-
31
The results do not indicate that the
preventive and management methods
reviewed are not efficacious; rather,
they demonstrate that not enough
is known through well-performed
studies to determine their efficacy.
Chlorhexidine’s side effects: taste al-
teration, staining, and sore mouth
and/or throat, were evaluated. 32,33
In uncontrolled diabetic patients in
the Veteran’s Administration system
with a glycosylated hemoglobin test
value of hemoglobin A1c ≥8.5%, 31%
of those enrolled in a clinical trial
reported 1 or more of these adverse
events. These effects were transient
and resolved with the discontinuation
of the chlorhexidine rinse.
The Journal of Prosthetic Dentistry
Arginine
For a number of years it has been
reported that the generation of alkali
products by oral biofilm bacteria fed
a suitable metabolic substrate is a
factor in the homeostasis of the pH of
the oral biofilm.34 The semi-essential
amino acid, L-arginine, when me-
tabolized by specific intraoral bacte-
rial species, creates a pH rise that is
thought to offset the pH fall caused
by acid-producing bacteria.35 Re-
search to leverage this reaction in a
commercial product was reported
in 2008.36 This 1-year study of 200
children examined the development
of caries in the primary molars and
first permanent molars in 10.5- to 11-
year-old children exhibiting previous
clinical signs of caries. Two groups
were tested. One received a sugarless
mint (control group) and the other a
sugarless mint containing an arginine
bicarbonate calcium carbonate mix-
ture (treatment group). Based on the
DMFS scores, the treatment group
showed a reduction of 75.6% at 6
months with a 50.7% reduction at 12
months. The combined DMFS and
decayed, exfoliated, filled surfaces
(DEFS) primary teeth reductions were
76.2% at 6 months and 74.8% at 12
months. These mints appear to be un-
dergoing the Food and Drug Admin-
istration (FDA) approval process in
the United States and, therefore, are
not yet commercially available. Other
arginine-containing products are be-
ing developed by dental manufactur-
ers and merit watching as clinical tri-
als are reported.
Calcium phosphate
The use of calcium phosphate as
a remineralizing agent has been stud-
ied in vitro, in situ, and in vivo for a
number of years. The 2008 literature
describing the efficacy of various cal-
cium phosphate agents shows mixed
results, with a tendency toward suc-
cessful remineralization of demineral-
ized enamel. Two reviews on the use of
casein phosphopeptide amorphous
Volume 102 Issue 1
calcium phosphate (CPP-ACP) ar-
rive at different conclusions.37,38 One
of the studies concludes that while 7
of 9 clinical studies reviewed (involv-
ing delivery by sugar-free pellet or
slab chewing gum, lozenges, milk, or
mouth rinse) demonstrated efficacy
in preventing dental caries by remin-
eralizing subsurface carious lesions in
situ in a dose-response fashion, there
was not sufficient strength of evidence
to form a conclusion regarding long-
term effectiveness.37 The other study
found that reviewed literature of a dif-
ferent delivery system (Tooth Mousse;
GC Corp, Tokyo, Japan) showed good
remineralization effect, especially
when applied after the use of a fluo-
ridated toothpaste.38
Two in situ trials39,40 showed ef-
ficacy for CPP-ACP in remineralizing
artificial caries lesions, while a clini-
cal trial41 of 2720 adolescents inves-
tigated sugar-free gum containing
CPP-ACP and demonstrated an 18%
less progression of clinical interproxi-
mal lesions than in those chewing the
same gum without the casein deriva-
tive over 24 months.
Treatment
With the advent of minimally in-
vasive dentistry, the concurrent ad-
vancement of materials science and
better designed clinical trials create
the potential to treat dental caries by
traditional surgical techniques and
nonsurgical or minimally invasive
methods and materials. Two reports
of the use of an “infiltrating” resin
technology and protocol appeared in
2008.42,43 In these in vitro studies, ei-
ther artificially induced demineraliza-
tion or naturally occurring uncavitated
smooth surface lesions were treated
for 2 minutes with 15% HCl to remove
an intact surface layer of enamel, in
an approach similar to the abrasive
techniques for white spot treatment.
After water rinsing, reagent-grade
ethanol was applied as a desiccant.
Following ethanol evaporation, res-
ins of varying penetration coefficients
were applied. The resins were then
Donovan et al
July 2009
visible light polymerized. The higher
penetration coefficient formulations
were successful in penetrating well
into the demineralized areas. This
is an extension of earlier work inves-
tigating the surface sealing of these
types of early lesions.44 If the clinical
trials of these penetrating resins dem-
onstrate reasoned efficacy without
undue work-burden, these new mate-
rials and techniques have significant
practice implications. Since no irre-
versible procedure is performed, most
practice acts in the United States
would permit a hygienist or other in-
dividual with conformant training to
place these restorations. Additionally,
while not reported in these research
efforts, the use of similar methodol-
ogy for pits and fissures and for what
is currently termed preventive resin res-
torations45 would seem highly probable
as this technology evolves.
A similar strategy for treating root
caries seems likely. In 2008, a group
tested the concept of surface seal-
ing of roots with all-in-one bonding
agents to limit the adherence of an S.
mutans-containing biofilm.46 A fluo-
ride-containing bonding agent proved
superior to nonfluoride-containing
agents in this short-term test.
One additional clinical trial testing
materials and methods for minimally
invasive dentistry (MID) was reported
in 2008.47 This study showed no dif-
ference in retention and acceptance
criteria for teeth minimally restored
with glass ionomer using a chemome-
chanical preparation technique ver-
sus a standard atraumatic restorative
technique (ART); the point being that
neither technique used rotary instru-
ments.
At the other end of the depth of
preparation spectrum, 1 author re-
viewed the materials choices for vital
pulp therapy in primary teeth for di-
rect and indirect pulp caps and pul-
potomies.48 Formocreosol remains
the most frequently used medicament
for pulpotomies, while mineral triox-
ide aggregate and ferric sulfate were
found to be viable alternatives.
Donovan et al
Microbiology of caries
The 2008 research continued
to support the concept of bacterial
communities being integral to dental
health or dental caries initiation and
progression. Research demonstrates
that the bacterial community is not
identical for all dental caries.49 The
investigators demonstrated that the
microbial flora they identified using
16S rRNA varied based on the state
of progression of a lesion, from white-
spot to advanced dentinal caries, as
well as variations in microbial flora be-
tween individuals in the same disease
state. This is consistent with previous
studies that show differences between
enamel and dentin caries flora. The
weakness of this type of study is that
it does not record longitudinal history
of the ecology. Rather, it takes indi-
vidual pictures or snapshots at points
in time. These snapshots provide no
information as to whether the lesion
is actively progressing at the time of
sampling or quiescent. Therefore, the
association of specific bacteria and
disease progression is lacking. A study
of preschool children using similar
analyses showed direct correlations
between caries status and the concen-
trations of S. mutans and S. sobrinus.50
A study examining the effect of
Listerine (Johnson and Johnson
Healthcare Products, Skillman, NJ) or
chlorhexidine on the dental biofilm51
noted that the variance in bacterial
biofilm members between examined
subjects elicited changes in the mi-
crobial response to the studied an-
tiseptics. Resistance of S. mutans to
antimicrobial agents was further ex-
plored in a study that examined the
susceptibility of S. mutans to antimi-
crobial agents in the presence of vary-
ing concentrations of sucrose. The
investigators found that antimicro-
bial susceptibility decreased with in-
creasing availability of sucrose.52 Ad-
vising patients to lower the frequency
of sucrose consumption continues
to be a viable suggestion, albeit for
more than just the reduction of acid
production. Investigators also exam-
15
ined exposing S. mutans to increased
levels of one of its own quorum-sens-
ing signals, competence-stimulating
peptide (CSP),53 and found that sig-
nificant overexpression of the signal
resulted in growth arrest and eventual
S. mutans cell death, thus paving the
way for CSP-mediated targeted killing
of S. mutans. This concept of modula-
tion of the dental biofilm by selective
killing or enrichment seems to hold
promise for more effective control of
the caries process.
PERIODONTICS
In periodontics and implant den-
tistry, there is continued interest in
the relationships between systemic
diseases and periodontal diseases as
well as gingival augmentation and
socket preservation. This review will
attempt to evaluate these interesting
and sometimes controversial sub-
jects in an objective manner. Most
papers reviewed were not the result
of randomized, controlled clinical tri-
als. Most are clinical series, clinical
reports, and studies performed on a
limited number of animals.
Periodontal disease and systemic dis-
ease relationships
Periodontal diseases are inflam-
matory conditions that were once
thought to have manifestations lo-
calized to the oral cavity alone, and
were considered the concern of only
dentists and other oral health profes-
sionals.54 Emerging evidence suggests
that periodontal diseases may have a
role in numerous conditions that im-
pact systemic well being, including
diabetes mellitus. Periodontal inflam-
mation is associated with an elevated
systemic inflammatory state and an
increased risk of major cardiovascular
events such as myocardial infarction
and stroke, adverse pregnancy out-
comes such as preeclampsia, low birth
weight, and preterm birth, and altered
glycemic control in people with dia-
betes. Intervention trials suggest that
periodontal therapy, which decreases
16
the intraoral bacterial bioburden and
reduces periodontal inflammation,
can have a significant impact on sys-
temic inflammatory status. Evidence
suggests that periodontal therapy is
associated with improved glycemic
control in many patients with both di-
abetes and periodontal diseases. Rec-
ognition of the bilateral relationships
between oral and systemic health will
challenge physicians and dentists to
work together closely when managing
patients with diabetes and periodon-
tal disease.
Bacterial plaque is the main etio-
logic agent related to periodontal tis-
sue destruction. Diabetes is consid-
ered an important risk factor, not only
for the onset but also for progression
of the disease. The aim of 1 study55 was
to analyze structural changes in the
rat gingival epithelium and connective
tissue in response to the experimental
periodontal disease induced by the
ligature technique, under the influ-
ence of diabetes. The results showed
that experimental periodontal disease
is characterized by marked inflamma-
tion, affecting both the epithelial and
connective tissues, causing degenera-
tion of the dermal papilla, increase
in the number of inflammatory cells,
destruction of reticulin fibers, and ac-
cumulation of dense collagen fibers.
These changes were worsened by dia-
betes, apparently by hampering the
inflammatory response and affecting
tissue repair of the affected tissues.
A MEDLINE-PubMed Central
search for evidence of an association
between diabetes and periodontal
and periimplant conditions and the
impact of periodontal therapy in sub-
jects with diabetes was performed.56
The search included articles published
up to December 2007. Evidence on
the association between diabetes
and periodontitis supports the con-
cept of increased severity but not ex-
tent of periodontitis in subjects with
poorly controlled diabetes. Subjects
with controlled diabetes do not show
an increase in extent and severity of
periodontitis. Periodontitis is associ-
ated with poor glycemic control and
The Journal of Prosthetic Dentistry
diabetes-related complications. It is
inconclusive that periodontal therapy
with or without the use of antibiotics
results in improvements of glycemic
control and of markers of systemic
inflammation. Evidence is lacking to
indicate that implant therapy in sub-
jects with diabetes yields long-term
outcomes comparable with those of
nondiabetic subjects. Poorly con-
trolled diabetes may be considered
a risk factor for increased severity of
periodontitis. The effects of periodon-
tal therapy on glycemic control and
systemic inflammation are not proven
and require confirmation in large-
scale randomized controlled clinical
trials. Large variations in study design
and study populations contribute to
the inconsistencies of findings related
to the effect of glycemic control.
The effect of nonsurgical peri-
odontal treatment, with or without
systemic administration of doxycy-
cline, on the metabolic control of pa-
tients with type 1 diabetes was stud-
ied.57 Sixty type 1 diabetic subjects
with moderate to severe periodon-
titis were recruited. Periodontal pa-
rameters were measured, and blood
specimens were obtained to evaluate
glycosylated hemoglobin.58,59 Group 1
(30 patients) was treated with scaling,
root planing, and chlorhexidine rinses
for 3 months in conjunction with sys-
temic administration of doxycycline
(100  mg once per day for 15  days).
Group 2 (30 patients) received the
same periodontal treatment but with-
out the use of doxycycline. The paired
Student t test was used to detect dif-
ferences between glycosylated hemo-
globin means before and 3  months
after periodontal treatment in group
1 and group 2, separately. Changes
in mean HbA1c after treatment were
0.07% in group 1 and -0.06% in group
2, which were not statistically sig-
nificant after 3  months. Significant
changes were not found even in pa-
tients with the best response to peri-
odontal treatment. Periodontal treat-
ment in type 1 diabetic patients after
a 3-month follow-up did not improve
metabolic control of diabetes as mea-
Volume 102 Issue 1
sured by glycosylated hemoglobin.
Extraction socket healing
Extraction socket healing has
become the focus for many animal
and clinical studies. Previous studies
indicate that there are dimensional
changes in bone and soft tissue after
tooth extraction.60-63 Five dogs were
used to study dimensional altera-
tions of the alveolar ridge that occur
following implant placement in fresh
extraction sockets.60 Following flap
elevation in mandibular posterior re-
gions, the distal roots of molars were
removed. In the right jaw quadrants,
implants with an airborne-particle-
abraded and acid-etched surface were
placed in the fresh extraction sockets,
while in the left jaws, the correspond-
ing sockets were left for spontaneous
healing. The mesial roots were re-
tained as surgical control teeth. After
3 months, the animals were examined
clinically, sacrificed, and tissue blocks
containing the implant sites, the ad-
jacent tooth sites (mesial root), and
the edentulous socket sites were dis-
sected, prepared for ground section-
ing, and examined with a microscope.
Results at implant sites revealed the
level of bone-to-implant contact
(BC) was located 2.6 ±0.4 mm (buc-
cal aspect) and 0.2 ±0.5 mm (lingual
aspect) apical of the implant level. At
the edentulous sites, the mean verti-
cal distance between the marginal
termination of the buccal and lingual
bone walls was 2.2 ±0.9 mm. Marked
dimensional alterations occurred in
the edentulous ridge after 3 months
of healing following the extraction of
the distal root of mandibular premo-
lars. The placement of an implant in
the fresh extraction site failed to pre-
vent the remodeling that occurred in
the walls of the socket. The resulting
height of the buccal and lingual walls
at 3 months was similar for implants
and edentulous sites, and vertical
bone loss was more pronounced at
the buccal than at the lingual aspect
of the residual ridge. It is suggested
that the resorption of the socket walls
Donovan et al
July 2009
that occurs following tooth removal
must be considered in conjunction
with implant placement in fresh ex-
traction sockets.
Implants placed immediately af-
ter tooth extraction offer several ad-
vantages, but authors have reported
problems in filling the residual gap
between the implant and the socket
walls.64 Barrier and grafting tech-
niques have been evaluated and yield
varying results, so it has been sug-
gested that the timing of implant
placement may be important for suc-
cess. Bone healing and coronal bone
remodeling around 35 implants, 20
placed immediately after tooth re-
moval and 15 placed 6 to 8 weeks
after extraction, were evaluated.64 All
implants were submerged and placed
within the alveolar confines, leaving
circumferential defects because the
implants did not contact the bone
at the coronal aspects. All implants
were stable. After implant placement
the mean distance from buccal bone
to lingual bone was 10 mm (SD 2.47)
for immediate implants and 8.86 mm
(SD 2.36) for delayed implants. No
membrane or filling materials were
used. Primary flap closure was accom-
plished in all instances. At second-
stage surgery, all periimplant defects
were filled, and the mean distance
from buccal bone to lingual bone
was 8.1 mm (SD 1.3) for immediate
implants and 5.8 mm (SD 1.3) for
delayed implants. This pattern of cor-
onal bone remodeling showed a nar-
rowing of the buccolingual width and
was clinically similar for the 2 groups.
It was noted that the delayed implants
exhibited smaller buccolingual bone
width at the first measurement. This
study suggests that circumferential
defects could heal clinically without
any guided bone regeneration (GBR)
in both experimental groups, and that
the procedure was free from compli-
cations in the postoperative period,
probably because of the absence of
barrier membranes and/or grafting
materials. Histologically, periimplant
defects of over 1.5 mm heal by con-
nective tissue apposition, rather than
Donovan et al
by direct bone-to-implant contact,
but clinically this healing may be suc-
cessful. No histological analysis was
performed in the study, but even the
largest residual gaps were filled with
hard tissue that could not be probed.
The effect on hard tissue modeling
and remodeling of the placement of
a xenograft in fresh extraction sockets
in dogs was evaluated.65 Five mongrel
dogs were used. Two mandibular pre-
molars were hemisected in each dog,
and the distal roots were carefully
removed. In one socket, a graft (Bio-
Oss Collagen; Geistlich Pharma AG,
Wolhusen, Switzerland) was placed,
whereas the contralateral site was
left without grafting. After 3 months
of healing, the dogs were euthanized
and biopsy specimens were obtained.
From each experimental site, 4 ground
sections (2 from the mesial root and
2 from the healed socket) were pre-
pared, stained, and examined un-
der the microscope. The presence of
Bio-Oss Collagen failed to inhibit the
processes of modeling and remodel-
ing that occurred in the socket walls
following tooth extraction. However,
it apparently promoted de novo hard
tissue formation, particularly in the
cortical region of the extraction site.
Thus, the dimension of the hard tissue
was maintained and the profile of the
residual ridge was better preserved.
The placement of a biomaterial in an
extraction socket may promote bone
modeling and compensate, at least
temporarily, for marginal ridge con-
traction.
A recent study offered somewhat
conflicting results as compared to
studies that demonstrated extraction
socket healing occurs uneventfully
without augmentation or grafting.66
The authors evaluated whether tooth
extraction without the elevation of
a mucoperiosteal flap has advanta-
geous effects on the resorption rate
after tooth extraction. In 5 beagle
dogs, polyether impressions were
made before the surgery. The roots of
the first and second premolars were
extracted and the sites were assigned
to one of the following groups: treat-
17
ment group (Tx) 1, no treatment;
Tx 2, surgical trauma (flap elevation
and repositioning); Tx 3, the extrac-
tion socket was filled with Bio-Oss
Collagen (Geistlich Pharma AG) and
closed with a free soft-tissue graft; Tx
4, after flap elevation and reposition-
ing, the extraction socket was treated
with Bio-Oss Collagen and a free soft-
tissue graft. Impressions were made 2
and 4 months after surgery. The casts
were scanned, matched together with
baseline casts, and evaluated with dig-
ital image analysis. Results indicated
that the group without flap elevation
demonstrated significantly lower re-
sorption rates both with and without
socket-preservation techniques. Fur-
thermore, socket-preservation tech-
niques yielded better results com-
pared with no treatment of the socket.
The results demonstrated that leav-
ing the periosteum in place decreases
the resorption rate of the extraction
socket. Also, the treatment of the ex-
traction socket with Bio-Oss Collagen
and a free gingival graft seems benefi-
cial in limiting the resorption process
after tooth extraction.
Another study assessed contour
changes after socket preservation
techniques.67 The distal root of the
third and fourth mandibular premo-
lars were extracted in 5 beagle dogs.
The following treatments were ran-
domly assigned for the extraction
socket. Tx 1: placement of Bio-Oss
Collagen (Geistlich Pharma AG); Tx
2: placement of Bio-Oss Collagen
and a free soft tissue graft; Tx 3: no
treatment; and Tx 4: the internal buc-
cal aspect was covered with an ex-
perimental collagen membrane, the
extraction socket was filled with Bio-
Oss Collagen, and the membrane was
folded on top of the graft. Impres-
sions were obtained at baseline and 2
and 4 months after surgery. Buccolin-
gual measurements were performed
using digital imaging analysis. All
groups displayed contour shrinkage
at the buccal aspect. The differences
between the 2 test groups (Tx 1, Tx
2) and the control group (Tx 3) were
only significant at the buccal aspect
18
(P≤.001). It was concluded that the
preservation techniques used were
not able to entirely compensate for
the alterations after tooth extraction.
However, incorporation of Bio-Oss
Collagen seems to have the potential
to limit but not avoid the postopera-
tive contour shrinkage.
Another study investigated the
clinical regeneration of extraction
sockets using high-density polytetra-
fluoroethylene (dPTFE) membranes
without the use of a graft material.68
A total of 276 extraction sockets were
evaluated in 276 subjects (151 males
and 125 females; mean age, 50.2
years; age range: 24 to 73 years). Af-
ter extraction, flaps were elevated and
a dPTFE membrane was placed over
the extraction site. The flaps were re-
positioned and sutured into place.
Primary closure was not obtained over
the membranes. The cemento-enamel
junctions of the adjacent teeth were
used as reference points. Measure-
ments were made postextraction and
12 months after surgery in the same
areas with the help of a guide and
were defined as the distance from the
reference points to the bone level.
Hard tissue biopsies were made from
10 representative subjects during
implant placement 12 months after
socket preservation. The bone core
samples were submitted for histologic
evaluation. A stringent plaque-control
regimen was enforced in all subjects
during the 12-month observation pe-
riod. A significant regeneration of the
volume of sockets could be noted by
histologic evaluation, indicating that
the newly formed tissue in extraction
sites was mainly bone. No influence of
gender, smoking, age, or clinical bone
level before treatment was found on
the percentage of bone gain. It was
concluded that use of dPTFE mem-
branes predictably resulted in the
preservation of soft and hard tissue in
extraction sites.
Recognizing the variation in results
following extraction socket healing,
another study was designed to evalu-
ate healing in all tissue compartments
during healing of extraction sockets.69
The Journal of Prosthetic Dentistry
The purpose of the study was to moni-
tor, during a 6-month period, the heal-
ing of human extraction sockets and
include a semiquantitative analysis of
tissues and cell populations involved
in various stages of the processes of
modeling/remodeling. Twenty-seven
biopsies, representative of the early,
intermediate (6-8 weeks, n=6), and
late phase (12-24 weeks, n=11) of
healing, were collected and analyzed.
Granulation tissue that was present
in comparatively large amounts in the
early healing phase of socket healing
was, in the interval between the early
and intermediate observation phase,
replaced with provisional matrix and
woven bone. The density of vascular
structures and macrophages slowly
decreased from 2 to 4 weeks over
time. The presence of osteoblasts
peaked at 6-8 weeks and remained al-
most stable thereafter; a small num-
ber of osteoclasts were present in a
few specimens at each observation
interval. The study findings demon-
strated that great variability exists in
humans with respect to hard tissue
formation within extraction sockets.
Thus, whereas a provisional connec-
tive tissue consistently forms within
the first weeks of healing, the interval
during which mineralized bone is laid
down is much less predictable.
Soft tissue augmentation
Soft tissue augmentation for peri-
odontal situations as well as dental
implants is always of interest and
occasionally controversial. Soft tis-
sue augmentation frequently involves
treatment of recession defects; there-
fore, it is important to understand
the classification of these defects.70
In Miller Classification Class I defects,
the marginal recession does not ex-
tend beyond the mucogingival junc-
tion. For Class II defects, the marginal
tissue extends to or beyond the mu-
cogingival junction with no loss of in-
terdental bone or soft tissue. In Class
III defects, the recession extends to or
beyond the mucogingival junction,
and there is bone or tissue loss api-
Volume 102 Issue 1
cal to the cemento-enamel junction.
For Class IV defects, marginal tissue
recession extends beyond the muco-
gingival junction. Loss of interdental
bone extends to a level apical to the
extent of marginal tissue recession.
New techniques as well as mate-
rials offer clinicians and patients a
myriad of treatment choices. It is not
clear whether 1 method or material is
superior to another. This review will
attempt to answer this question.
An electronic search (MEDLINE,
EMBASE, and PubMed Central) for
randomized controlled clinical trials
with at least 6 months of follow-up
comparing subepithelial connective
tissue grafts (SCTG) with other pro-
cedures for the treatment of gingival
recession was performed for articles
published up to December 2007.71
To be eligible to be included in this
review, patients had to present a di-
agnosis of gingival recession with the
following characteristics: (1) reces-
sion areas selected for treatment,
classified as Miller Class I or Class II,
of at least 2 mm; (2) recession areas
containing teeth with no caries or res-
torations; and (3) at least 10 partici-
pants per group at final examination.
From a total of 568 references, 23
studies were considered relevant. The
results indicated a statistically signifi-
cantly greater reduction in gingival
recession for SCTG, when compared
to acellular dermal matrix grafts and
guided tissue regeneration with re-
sorbable membranes (GTR rm). For
clinical attachment level changes, dif-
ferences between all groups were not
significant. For changes in the kerati-
nized tissue (KT), the results showed
a statistically significant gain in the
width of KT for SCTG when compared
to GTR rm. The results of this review
show that subepithelial connective
tissue grafts provided significant root
coverage, clinical attachment, and
keratinized tissue gain. Overall com-
parisons allow the conclusion to be
drawn that subepithelial connective
tissue grafts are the gold-standard
procedure in the treatment of reces-
sion-type defects.
Donovan et al
July 2009
The decision whether to leave con-
nective tissue grafts exposed or to
cover them with coronally positioned
flaps is a surgical dilemma. A study
was designed to evaluate changes in
gingival dimensions and root cover-
age using the same procedure but
varying the amount of connective tis-
sue graft left uncovered.72 Twenty-five
Miller Class I or II recession defects in
20 healthy subjects were randomly as-
signed to test (exposed connective tis-
sue group; E group) or control (fully
covered connective tissue group; FC
group) groups and treated with a
connective tissue graft procedure. In
the E group, 1 to 2 mm of the graft
was left uncovered at the completion
of the surgery, whereas the FC group
had the graft completely covered by
the flap. Clinical parameters assessed
included probing depth, recession
depth, and clinical attachment level,
width of keratinized tissue, mobility,
and plaque score. At 12 weeks, the
mean root coverage percentages for
FC and E groups were 93% and 88%,
respectively. The difference between
the groups was not statistically signifi-
cant (P=.48). Complete root coverage
was observed in 79% and 64% of the
subjects in FC and E groups, respec-
tively. There was greater increase in
the width of keratinized tissue in the
E group (1.5 ±1.1 mm) than the FC
group (0.9 ±0.9 mm), although this
difference did not reach statistical
significance (P=.16). There were no
statistically significant differences be-
tween the groups for the changes in
other parameters. Both procedures
resulted in successful root coverage
with an increase in the width of kera-
tinized tissue. Leaving a portion of the
graft exposed resulted in a greater in-
crease of keratinized tissue, and com-
plete coverage of the graft resulted in
greater root coverage. However, these
differences did not reach statistical
significance.
Platelet-rich plasma (PRP) applied
at the time of gingival augmentation
may promote periodontal regenera-
tion at the grafted site. The aim of
one study was to compare connective
Donovan et al
tissue graft (CTG) plus PRP with CTG
alone in the treatment of gingival re-
cession.73 Forty patients with Miller
Class I or II recessions were included.
Each recession was randomly treated
with either CTG plus PRP or CTG
alone. Clinical variables were recorded
at baseline and at 6 weeks and 6 and
12 months. Root coverage (RC) and
attachment gain (AG) were also cal-
culated. Study results indicated that
probing depth, recession depth, clini-
cal attachment level, keratinized tis-
sue width, and recession width (RW)
were improved in both study groups.
However, no difference was observed
between groups, except in recession
width. Recession in the control group
was statistically lower than the test
group at all follow-up periods. Treat-
ment of recession with CTG or a CTG-
PRP combination resulted in favorable
clinical outcomes. However, no differ-
ence could be found between CTG
and CTG plus PRP. Whether much
longer follow-up studies with higher
statistical power may provide differ-
ing results remains questionable.
With root coverage procedures,
it has been speculated that the time
required for additional gain in the
amount of keratinized tissue may be
greater for the acellular dermal matrix
than for the connective tissue. Differ-
ent techniques have been proposed
for the treatment of gingival reces-
sion. This study compared the clini-
cal results of gingival recession treat-
ment using a subepithelial connective
tissue graft and an acellular dermal
matrix allograft.74 Seven patients with
bilateral Miller Class I or II gingival
recession were selected. Twenty-six
recessions were treated and randomly
assigned to the test group. In each
subject, the contralateral recession
was assigned to the control group. In
the control group, a connective tissue
graft in combination with a coronally
positioned flap was used; in the test
group, an acellular dermal matrix al-
lograft was used as a substitute for
palatal donor tissue. Probing depth,
clinical attachment level, gingival re-
cession, and width of keratinized tis-
19
sue were measured 2 weeks prior to
surgery and at 6 and 12 months post-
surgery. There were no statistically
significant differences between the
groups in terms of recession reduc-
tion, clinical attachment gain, prob-
ing pocket depth, and increase in the
width of the keratinized tissue after 6
or 12 months. There was no statisti-
cally significant increase in the width
of keratinized tissue between 6 and
12 months for either group. Within
the limitations of this study, it can be
suggested that the acellular dermal
matrix allograft may be a substitute
for palatal donor tissue in root pro-
cedures.
The primary purpose of a random-
ized, controlled, masked clinical trial
was to compare the percentage of
root coverage obtained with a coro-
nally positioned flap plus acellular
dermal matrix (ADM) allograft to
that of a tunnel technique plus ADM
4 months postsurgically.75 Twenty-
four subjects with 1 site with 3 mm
or greater Miller Class I or II reces-
sion were treated and followed for 4
months. Twelve patients received a
coronally positioned flap plus ADM
and were considered the positive con-
trol group. The test group consisted
of 12 subjects treated with a coronal-
ly positioned tunnel technique plus
ADM (TUN). Subjects were randomly
selected by a coin toss to receive the
test or control treatment. The mean
facial recession defect at the initial
examination for the TUN group was
3.1 ±0.3 mm; this was reduced to 0.7
±0.9 mm at the 4-month examina-
tion, for a gain of 2.4 ±1.0 mm or 78%
defect coverage (P<.05). The mean fa-
cial recession defect at the initial ex-
amination for the CPF group was 3.4
±0.8 mm; it was reduced to 0.2 ±0.3
mm at the 4-month examination, for
a gain of 3.2 ±0.9 mm or 95% de-
fect coverage (P<.05). There was no
statistically significant difference be-
tween groups (P>.05). The coronally
positioned flap plus ADM produced a
defect coverage of 95%, whereas the
tunnel technique plus ADM produced
only 78% coverage. This difference
20
was considered clinically significant
but was not statistically significant.
Another study evaluated the safety
and effectiveness of a tissue-engi-
neered skin product composed of via-
ble neonatal keratinocytes and fibro-
blasts isolated from human foreskin
and compared it to a free gingival graft
(FGG) in a procedure to enhance ker-
atinized tissue (KT) and wound heal-
ing around teeth that do not require
root coverage.76 Twenty-five subjects
were enrolled who had at least 2 non-
adjacent teeth in contralateral quad-
rants exhibiting an insufficient zone
of attached gingiva requiring soft tis-
sue grafting where root coverage was
not desired. One tooth was random-
ized to receive an FGG, and the other
was randomized to receive bilayered
cell therapy (BCT). The amount of KT
was measured at baseline and 3 and
6 months, and the texture and color
of the grafted tissue were compared
to the surrounding tissue at 1, 3, and
6 months. A questionnaire was used
to determine subject preference at
6 months. Biopsies and persistence
studies were performed on a sub-
set of the subjects. The FGG group
generated statistically significantly
(P<.001) more KT than the test de-
vice (BCT) (4.5 ±0.80 mm versus 2.4
±1.02 mm); no significant difference
in recession or clinical attachment
level was detected between treatment
groups (P=.212 and P=.448, respec-
tively), and no significant differences
were detected at any time point for
bleeding on probing (BOP), resis-
tance to muscle pull, or inflamma-
tion. The BCT group had significantly
better color and texture match with
surrounding tissue (P<.001), and
subject preference was significantly
greater for the BCT group (P=.041).
No device-related adverse events
or safety issues occurred during the
course of the study. The tissue-engi-
neered graft BCT was safe and capa-
ble of generating de novo KT without
the morbidity and potential clinical
difficulties associated with donor-site
surgery. The amount of KT generated
with FGG was greater than that gen-
The Journal of Prosthetic Dentistry
erated with BCT. Several points must
be mentioned concerning this study.
One issue is whether the treated sites
were diseased. There was no evidence
of continued attachment loss for ei-
ther test or control groups. It appears
the greatest improvement, other than
color match, was for the free gingival
graft sites.
DENTAL MATERIALS
Sealants
Sealants have been a proven pre-
ventive approach for several decades.
However, a number of aspects regard-
ing sealants remain unknown or con-
troversial. Several articles addressed
some of these issues. Two articles
reported on practice-based data ob-
tained in Finland that dealt with the
issue of generalized versus targeted
sealant application. One study77
retrospectively compared the cost-
effectiveness in 2 community dental
practices, 1 in which sealants were
routinely placed versus 1 in which
sealants were targeted to patients at
high risk for caries. The study popula-
tion consisted of 3816 children in the
2 communities, assessed at the age
of 12. Sealants were applied shortly
after tooth eruption. In both groups,
sealants were not placed in children
who failed to make their routine seal-
ing appointments. Additionally, in the
targeted-placement group, sealants
were not placed on the teeth of those
patients designated as being at low
risk for caries. Preventive measures,
such as oral hygiene instructions,
dietary counseling, and fluoride var-
nish, were similar in both communi-
ties, except for supervised xylitol gum
use in the targeted group, which was
accounted for in the statistical analy-
sis. Caries risk analysis was assessed
on the basis of dental caries and pres-
ence of S. mutans in dental plaque at
age 2. The applied sealant (Delton,
Light Cure-Clear; Dentsply Intl, York,
Pa) was the same for all subjects. Cost
effectiveness was calculated using the
cost of sealants and restorations on
Volume 102 Issue 1
permanent first molars, based upon
a standardized fee schedule. The cu-
mulative cost of treatment (sealants
plus restorations plus preventive mea-
sures) was 184.20€ (251.26 USD)
per subject in the targeted group,
and 234.30€ (319.60 USD) per sub-
ject in the all-sealed group. Almost
all of this difference was due to the
considerably higher cost of restoring
nonsealed teeth in the nontargeted
community versus the targeted com-
munity, emphasizing the need to di-
rect sealant placement to those indi-
viduals at greater risk for caries. The
weakness of this study, as with most
practice-based research, is that it was
not possible to completely account
for all confounding factors.
Using additional data from the
previous study, a survival analysis
was performed on the effectiveness
and timing of restorative treatment
in sealed versus nonsealed teeth.78 A
survival analysis was conducted, in
which survival was defined as the time
during which the mandibular first
permanent molars survived without
caries or restorative treatment. The
mean survival time of sealed molars
was significantly (P<.001) longer than
that of the nonsealed teeth in the
blanket sealant group, whereas the
nonsealed teeth in the targeted group
actually showed the best survival time
of all groups. Only 60% of nonsealed
molars in the blanket treatment group
survived without restoration, while
80% of nonsealed permanent man-
dibular first molars in the targeted
group survived without restoration.
To assist clinicians in the clini-
cal decision-making process, the
American Dental Association (ADA)
published its evidence-based clinical
recommendations for pit and fissure
sealants.79 The ADA recognizes the
effectiveness of dental sealants, but
also the confusion and controver-
sies that are associated with sealant
placement. The Council on Scientific
Affairs undertook a critical evaluation
of the published scientific evidence re-
garding sealants, weighed their find-
ings on strength of the evidence, and
Donovan et al
July 2009
graded their clinical recommenda-
tions (A-D) on the basis of this weight-
ing. Among some of their higher rated
recommendations (A, B) were the fol-
lowing: sealants should be placed on
permanent teeth when the tooth or
patient is determined to be at risk for
experiencing caries; sealants should
be placed on early (noncavitated) le-
sions to limit lesion progression; resin
sealants are the first choice material
for sealants; use of a primer/adhesive
after acid etching will enhance seal-
ant retention; routine mechanical
preparation before acid etching is not
recommended. This review also rein-
forced the concept that use of sharp
explorers is not necessary for the de-
tection of early lesions, and forceful
use of explorers can damage tooth
surfaces.
A group of authors, in conjunc-
tion with the Center for Disease Con-
trol Dental Sealant Systematic Review
Work Group, undertook an analysis
to evaluate lesion progression under
sealants.80 This paper reported on a
meta-analysis designed to examine
the effectiveness of sealants on pre-
venting pit and fissure caries lesion
progression of permanent teeth. The
review was limited to randomized
and nonrandomized controlled trials
and cohort studies that evaluated the
percentage of lesions that progressed.
From an initial group of 1872 records
and associated references, 311 ar-
ticles were reviewed, 6 of which had
information on the percentage of le-
sions progression compared to a con-
current control group. This represent-
ed 384 persons, 840 teeth, and 1090
surfaces. The studies included both
resin and glass ionomer sealants. Ap-
proximately 90% of the lesions were
noncavitated. The median annualized
lesion progression rate was 5.0% for
sealed lesions, compared to 16.1%
for unsealed lesions. Overall, sealants
prevented progression in 73.2% to
75.0% of the lesions evaluated in the
data. The consistency and direction
of the findings across the studies was
consistent. An interesting finding was
that while the probability of a sealed,
Donovan et al
noncavitated lesion progressing was
2.6%, the probability of a nonsealed,
noncavitated lesion progressing was
only 12.6%. The authors suggested
that this indicated that immediate
surgical intervention in noncavitated
lesions may not be indicated. The
overall conclusion was that the evi-
dence supports placing sealants over
noncavitated caries lesions in the
permanent teeth of children, adoles-
cents, and young adults.
An area of concern that has resur-
faced is the potential adverse health
effects of bisphenol-A (BPA). In a sys-
tematic review,81 the authors noted
that BPA is used as a plasticizer in
many products, such as polycarbon-
ate plastic food-storage containers.
In dentistry, BPA is used in the man-
ufacture of dental resins for dental
composite resins and sealants. This
review found that none of the 7 ADA-
approved sealants released detect-
able amounts of BPA. The authors
recommended that clinicians use 1
of the following procedures following
the placement of a sealant to remove
the air-inhibited layer and reduce the
potential leaching of BPA from this
unpolymerized surface layer: (1) use
a mild abrasive such as pumice with
a prophy cup or on a cotton tip ap-
plicator; (2) have the patient gargle
with tepid water for 30 seconds; (3)
use an air-water spray to rinse the
surface of the sealant for 30 seconds
while suctioning fluids from the pa-
tient’s mouth. Another group of re-
searchers82 evaluated degradation
products over a 2-week period from
an experimental composite using
liquid chromatography mass spec-
trometry. They found no BPA in any
of the specimens analyzed. In the pre-
viously mentioned American Dental
Association evidence-based clinical
recommendations for pit and fissure
sealants,79 the reviewers noted that
some studies found trace amounts of
BPA in the saliva of patients immedi-
ately after sealant administration, but
that no systemic levels of BPA were
detected, and there was no evidence
of estrogenicity with such low levels of
21
BPA exposure.
Amalgam
Much of the scientific research ef-
fort pertaining to amalgam revolves
around health concerns. An interesting
controlled clinical trial83 was designed
to assess the effectiveness of 3 treat-
ment strategies applied to patients
with subjective health complaints
who attributed their health problems
to dental amalgam restorations. Sub-
jects between the ages of 20 and 50
who reported at least 10 symptoms,
and who did not exhibit relevant ex-
clusionary criteria, including mental
disorders and drug or alcohol abuse,
were randomized to 1 of 3 treatments:
(1) all amalgam restorations were re-
moved and replaced with ceramic,
gold, or composite resin restorations;
(2) in addition to having all amalgam
restorations removed and replaced,
this group also received high doses of
vitamins and trace elements (recom-
mended by the International Associa-
tion of Holistic Dental Medicine) de-
signed to enhance mercury excretion;
(3) no amalgam restorations were re-
moved and the subjects participated
in a health promotion program to aid
in developing self-management skills
for a healthy lifestyle. The primary
outcome was the difference in com-
plaints at baseline and 12 months
later. There was no significant differ-
ence in the primary outcomes among
the 3 groups, despite the fact that the
amalgam removal groups showed sig-
nificantly lower levels of blood and
urine mercury compared to the no-
removal group, demonstrating that a
low mercury level was not a prerequi-
site for subjective improvement.
The New England Children’s Amal-
gam Trial84 evaluated the psychosocial
health of children who received amal-
gam restorations versus those who
received composite resin restorations.
A total of 534 children between the
ages of 6 and 10 with at least 2 car-
ies lesions were randomly assigned to
have their caries restored with either
amalgam or composite resin. After 5
22
years, the psychosocial scores on the
Child Behavior Checklist were com-
pared to the baseline scores. In most
measured areas, there were no signifi-
cant differences between the groups.
Several areas (internalizing and total
problem behaviors, activities, anx-
ious/depressed and delinquent be-
havior) showed significantly greater
improvement in the amalgam group
compared to the composite resin
group.
Two more articles were published
from the comprehensive study accom-
plished by the Universities of Washing-
ton and Lisbon assessing the effects
of amalgam restorations on various
health parameters in children. In the
first report,85 507 children between
the ages of 8 and 12 with at least 1
posterior caries lesion were randomly
assigned to receive either amalgam
or composite resin restorations. The
results of systematic neurological ex-
aminations carried out at baseline
and over 7 years of follow-up were
reported. Individuals in the amalgam
group averaged between 7.7 and 10.7
restored surfaces. The neurological
examination was standardized, and
assessed measures of neurological
hard signs (NHSs) such as mental sta-
tus, cranial nerve function, plantar re-
sponses, cerebellar functions, touch,
joint position, vibration senses, in-
voluntary movements, and tremor;
as well as neurological soft signs
(NSSs) such as mirror movements,
synkinesias, fine finger movements,
heel-to-toe walking, motor impersis-
tence, restlessness, or hyperactivity.
While there was an increase in NHSs
over the course of the study, there
were no significant differences in the
outcomes between the groups in any
year of the study. The second article86
evaluated a subset of the above pop-
ulation to determine if amalgam res-
torations had an impact on mercury-
and antibiotic-resistant bacteria from
baseline levels compared to compos-
ite resin restorations. The concern is
that mercury released from amalgam
could cause an increase in bacteria
resistant to antibiotics, thereby in-
The Journal of Prosthetic Dentistry
creasing the susceptibility to bacterial
diseases resistant to usual drug ther-
apy. One hundred and fifty children
were cultured at baseline, after den-
tal treatment, and annually over the
7-year period of the study. Both oral
and urine specimens were analyzed.
There were no significant differences
between children with amalgam or
composite resin restorations in either
oral or urinary levels of antibiotic- or
mercury-resistant bacteria, providing
evidence that treating children with
amalgam restorations does not influ-
ence the level of antibiotic-resistant
bacteria.
Composite resin
An interesting clinical study evalu-
ated the efficacy of various minimal
intervention techniques to increase
the longevity of both amalgam and
composite resin restorations.87 Six-
ty-six patients having 271 defective
restorations (193 amalgam, 78 com-
posite resin) exhibiting marginal de-
ficiencies (marginal crevice, marginal
staining, but not caries) were assessed
for 7 Ryge criteria at baseline and at
2 years following 1 of 5 randomly as-
signed treatments: (1) repair: defec-
tive margins were prepared with car-
bide burs and restored with the same
material as the original restoration
(amalgam for amalgam restorations
or adhesive/composite resin for com-
posite resin restorations); (2) seal-
ing of margins: defective areas were
etched with 35% phosphoric acid and
had a resin-based sealant applied;
(3) refurbishing: defective areas were
smoothed and polished; (4) replace-
ment: the existing restoration was
completely removed and replaced
with a new amalgam or new com-
posite restorations; (5) untreated:
no additional treatment. While the
particular categories of change varied
among the various treatments, all of
the treatment groups showed signifi-
cant improvement from baseline to
the 2-year recall, while the untreated
group showed significant deteriora-
tion. The importance of this study
Volume 102 Issue 1
was to demonstrate that minimal in-
tervention techniques could provide
similar outcomes as total replacement
over 2 years, while reducing cost and
invasive intervention.
An area of interest in recent years
regarding composite resin has been
the use of composite resin that has
been warmed to reduce viscosity and
improve adaptation. One in vitro
study evaluated the use of preheated
composite resin on restoration micro-
leakage.88 Extracted third molars re-
ceived 2 Class II preparations with the
gingival margin on dentin, and were
randomly assigned to 1 of 4 groups:
(1) control: composite resin (Es-
thet-X; Dentsply Caulk) placed and
polymerized in 2-mm increments; (2)
preheated: composite resin warmed
to 130°F, then placed and polymer-
ized as for the control group; (3) de-
layed: composite resin warmed and
placed as for preheated group, but
polymerization was delayed for 15
seconds; (4) flowable: 1-mm-thick
layer of flowable composite resin (Es-
thet-X Flow; Dentsply Intl) was placed
and polymerized, then composite res-
in was placed and polymerized as for
the control group. All teeth were ther-
mal cycled, stored in dye for 24 hours,
sectioned, and evaluated for microle-
akage. There were no differences at
occlusal (enamel) margins among the
groups. At the gingival (dentin) mar-
gins, the preheated group, in which
the composite resin was immediately
polymerized after placement, showed
significantly reduced microleakage
compared to the other 3 groups, con-
firming previous findings.
Fracture is a major cause of fail-
ure in composite resin restorations. A
study evaluated whether the cervico-
occlusal shape of Class II composite
resin restorations affected marginal
ridge fracture strength.89 Standardized
Class II preparations were performed
in artificial mandibular first molars.
The preparations were restored with
an adhesive, and 3 different compos-
ite resins of varying filler composition
and resultant elastic modulus, using
2 different matrices: a straight ma-
Donovan et al
July 2009
trix (standard Tofflemire; Kerr Hawe,
Bioggio, Switzerland) or a contoured
matrix (Palodent; Dentsply Intl). The
marginal ridge was stressed with a
universal testing machine. The con-
toured proximal surfaces demonstrat-
ed significantly more resistance to
fracture than did the straight surfaces
for all tested composite resins. The
fracture resistance was not related to
the modulus of elasticity of the com-
posite resins. The authors conjectured
that the greater volume of composite
resin below the marginal ridge in the
contoured restorations explained the
outcome.
Clinicians are concerned with
which system is the best to polish res-
in restorations. The latest addition to
the dentist’s armamentarium for pol-
ishing composite resins is the 1-step
polishing systems. An in vitro study
evaluated 2 of these systems on nano-
filler-containing composites.90 Stan-
dardized composite specimens were
fabricated from 6 nanofiller-contain-
ing composite resins, and randomly
assigned to 1 of 4 groups: (1) control:
composite resin polymerized against
a Mylar strip (no finishing); (2) PoGo
(Dentsply Caulk): following abrasion
with 1200-grit silicon carbide paper,
the surface was finished for 30 sec-
onds with PoGo disc; (3) OptraPol
(Ivoclar Vivadent, Amherst, NY): same
procedure as PoGo group but using
OptraPol; (4) Sof-Lex (3M ESPE): af-
ter initial surface preparation as for
the previous 2 groups, the surface
was finished with medium, fine, and
superfine Sof-Lex discs for 30 seconds
each. The surface roughness for each
specimen was assessed with a profi-
lometer, and the Vickers hardness was
determined for each specimen. The
Mylar strip provided the smoothest
surface. While there were some sta-
tistical differences among the various
composites, in general, the two 1-step
systems provided a surface finish and
surface hardness that was comparable
to the multistep polishing system.
Another concern with respect to
composite resin restorations relates
to light-polymerization systems and
Donovan et al
techniques. Turbo tip light guides
are popular because of their abil-
ity to concentrate light emission. A
well-executed study evaluated the
influence of light guide type on light
emission and composite resin micro-
hardness.91 A laser beam analyzer was
used to evaluate light distribution
across the emission tip of standard
and turbo-style light guides. Two-
millimeter thick specimens of a hybrid
composite resin (Z100; 3M ESPE)
and microfill composite resin (Filtek
A110; 3M ESPE) were polymerized,
and the Knoop hardness was tested
across the top and bottom surfaces.
The results showed that the standard
light guide demonstrated significantly
more uniform light emission than did
the turbo light guide. While both light
tip guides provided a higher polymer-
ization at the center of the composite
resin specimen than at the periphery,
there was significantly less decrease
in polymerization from center to pe-
riphery with the standard light guide
as compared to the turbo light guide.
This lack of uniformity of the compos-
ite resin polymerization produced by
the turbo guide was more pronounced
on the bottom surface of the compos-
ite resin than on the top surface. This
study demonstrated that while the
turbo-style light guide may increase ir-
radiance, additional exposures might
be needed when polymerizing larger
restorations to compensate for the
reduced polymerization at the periph-
ery of the turbo-style guide.
Another study also evaluated the
impact of light guide geometry on
polymerization efficacy.92 Four light
guides of varying “R” value (entry
diameter/exit diameter ratio) were
used with 2 different LED curing
lights (FreeLight 2; 3M ESPE, and
L.E.Demetron 1; KerrHawe) to po-
lymerize composite resin specimens.
The initial polymerization regimen
was accomplished with the end of
the light guide against the composite
resin specimen. Subsequent compos-
ite resin specimens were polymerized
with the light guide moved away from
the composite resin surface in 1-mm
23
increments. The depth of polymeriza-
tion of the composite resin specimens
was assessed and statistically corre-
lated with the “R” value. The results
showed that when the light guide was
close to the composite resin surface,
the guide with the higher “R” value
(turbo-style) was more efficient at
polymerizing composite resin. How-
ever, as the distance from the end of
the light guide to the surface of the
composite resin increased past 4-5
mm, the standard-style guide was
more efficacious at polymerizing the
composite resin specimens. Consider-
ing the limitation on how close a light
guide would be able to come to the
bottom of a proximal box in a Class
II preparation, this study emphasizes
the shortcomings of the turbo tip
light guide as compared to the stan-
dard light guide.
Various polymerizing regimens
have been suggested to reduce po-
lymerization shrinkage stress of com-
posite resins in the belief that this
will promote enhanced marginal seal.
While some laboratory studies have
shown that reduced irradiance during
the initial stages of polymerization
can improve marginal integrity, clini-
cal verification of this has been lack-
ing, particularly in composite resin
restorations other than Class V resto-
rations. A recently published clinical
study addressed this shortcoming.93
Twenty patients each received at least
1 pair of Class I or II restorations. One
restoration of the pair was polymer-
ized with a plasma arc curing (PAC)
light (2000 mW/cm2 for 10 seconds
for each 1.5- to 2-mm increment),
and the other restoration was polym-
erized with a soft start regimen (200
mW/cm2 for 20 seconds for each 1.5-
to 2-mm internal increment, then
200 mW/cm2 for 3 seconds, a wait-
ing period of 3 minutes; 200 mW/
cm2 for 3 seconds, a waiting period
of 5 minutes; 600 mW/cm2 for 20
seconds from multiple angles, and a
waiting period of 3 minutes for the fi-
nal increment). Each restoration was
evaluated at intervals of 2 weeks and
3, 12, and 24 months for evidence
24
of “marginal stress” (cracked tooth
syndrome, postoperative sensitivity,
secondary caries, interfacial stain-
ing, marginal discrepancy). At the
end of the 2-year evaluation period,
there were no significant differences
between the groups. This reinforces
the belief that current polymerization
shrinkage stress reduction procedures
are not effective in clinically relevant
time regimens.
A critical review of the literature
was published on failure of dental
composite resin restorations, and
focused primarily on the effects of
laboratory variables and testing pro-
cedures on the mechanical properties
of these materials.94 This article also
reviewed the failures of composite
resins in clinical studies, and con-
cluded that failures in the first 5 years
after restoration placement were pri-
marily related to restoration factors
(technique or material selection),
while failures after this initial period
were usually due to secondary caries.
This review reemphasizes the need for
clinicians to incorporate appropriate
materials with proper technique and
patient selection to enhance clinical
success with composite resin restora-
tions.
Dental adhesives
The trend in recent years has been
towards simplification of adhesives,
as manufacturers have marketed sys-
tems that combine the etchant, prim-
er, and resin components to reduce
the number of application steps. Both
in vitro and in vivo research evidence
has suggested that there may be some
reduced efficacy with the simplified
systems. Two clinical studies reported
results comparing the performance
of simplified systems to the 3-step,
etch-and-rinse “gold-standard” ad-
hesive systems. In the first study,95 52
patients with 267 noncarious cervi-
cal lesions were randomly restored
with a 3-step etch-and-rinse adhe-
sive (OptiBond FL; Kerr Corp) or a
1-step self-etch system (GC G-Bond;
GC America), followed by a compos-
The Journal of Prosthetic Dentistry
ite resin restoration (Gradia Direct
Anterior; GC America). For each pa-
tient, half the lesions were treated
with the 3-step system, and half were
treated with the 1-step system. Dur-
ing restoration, teeth were isolated
with cotton rolls and saliva suction.
Baseline, 6-month, and 1-year evalu-
ations were performed by examiners
blinded to the adhesives used. After 1
year of service, lesions restored with
both adhesives provided comparable
results in terms of retention, second-
ary caries, and sensitivity. Both adhe-
sives showed an increase in marginal
defects from baseline to 1 year; how-
ever, those restorations done with the
1-step system showed a significantly
greater increase in marginal defects at
the enamel margin compared to the
etch-and-rinse system. The authors
suggested that this result may be due
to an inferior enamel etch for the
1-step self-etch system compared to
the 3-step, total-etch system. In addi-
tion, there was a slightly significant in-
crease in marginal discoloration with
the 1-step system compared to the
3-step system.
The second study was of similar
design,96 with 30 patients receiving a
total of 105 restorations, divided into
4 groups, for noncarious cervical le-
sions of varying degrees of sclerosis.
The 1-step adhesive (iBond; Heraeus
Kulzer, Armonk, NY) was used in 3
groups: restorations with no to mild
sclerosis, restorations with moderate
to significant sclerosis, and restora-
tions with moderate to significant
sclerosis that received acid etching pri-
or to adhesive application. The con-
trol was a 3-step, total-etch adhesive
(Gluma Solid Bond; Heraeus Kulzer)
used to restore lesions with no to mild
sclerosis. All lesions received the same
composite resin (Durafill VS; Heraeus
Kulzer), and teeth were isolated with
either cotton rolls or a rubber dam,
depending on access. Restorations
were evaluated at baseline, and at 6,
18, and 36 months after placement
using standardized Ryge criteria. No
significant differences were found
among the groups for retention rate,
Volume 102 Issue 1
secondary caries, or sensitivity. How-
ever, the quality of marginal seal as
measured by marginal adaptation
and/or marginal discoloration de-
creased over the 3-year study period
for all of the 1-step restorations, but
not for the 3-step restorations. While
not statistically significant when com-
pared to the 3-step adhesive, all of the
lost restorations came from the 1-step
adhesive groups. When the 3-year
marginal discoloration scores were
compared between the 1-step group
that received the additional etch prior
to application compared to the group
that did not, those restorations that
received the phosphoric acid etch
performed significantly better, al-
though still significantly worse than
the restorations that were placed with
the 3-step, total-etch adhesive.
Another study compared the clini-
cal performance of noncarious cer-
vical lesions restored using an etch-
and-rinse adhesive versus a self-etch
adhesive.97 Twenty-nine patients with
at least 2 pairs of similar sized non-
carious cervical lesions (116 resto-
rations) were restored with a 2-step
self-etch adhesive (Tyrian SPE; Bisco,
Inc, Schaumburg, Ill) or a 2-step etch-
and-rinse adhesive (One-Step Plus;
Bisco, Inc). With both systems, the
adhesives were divided into 2 groups:
those that were applied per manu-
facturer’s instructions (2 coats), and
those that received a double applica-
tion of the second-step component
(4 coats). All lesions were restored
with a microfilled composite resin
(Micronew; Bisco, Inc). Restorations
were evaluated at baseline, and af-
ter 6, 12, and 18 months of clinical
performance using modified Ryge
criteria. Of the 4 groups, only those
lesions restored with the etch-and-
rinse adhesive and the double ap-
plication did not show a significant
decrease in retention over the study
period. All other groups, including
both adhesives applied using manu-
facturer’s instructions, did not meet
ADA guidelines. The results suggest
that the combination of a phosphoric
acid etch and additional application
Donovan et al
July 2009
of the primer/adhesive component al-
lows better penetration and improved
resin concentration in the demineral-
ized dentin surface. In an additional
finding of note, the study found that
marginal discoloration was an early
indicator of restoration loss.
Taken together, these clinical
studies confirm that, in general, the
simplified adhesive system perfor-
mance is inferior when compared to
the etch-and-rinse, 3-step adhesive
systems. This appears to be particu-
larly true when the 3-step systems are
compared to the 1-step, all-in-one ad-
hesives.
Laboratory studies have also eval-
uated various parameters of adhesive
performance to determine if modifi-
cation of self-etch application proce-
dures can improve their performance.
One of the disadvantages associated
with self-etch systems is their inability,
relative to etch-and-rinse systems, to
adequately etch and adhere to enamel.
To address this shortcoming, 1 study
evaluated the shear bond strength to
enamel of an etch-and-rinse adhesive
to several self-etch systems, applied
following manufacturer instructions
and with prior phosphoric acid etch-
ing.98 The proximal surfaces of human
molars were ground flat and random-
ly divided into 2 groups: 1 group was
etched with 37% phosphoric acid and
the other was not. These 2 groups
were further divided among the 4
adhesives tested: an etch-and-rinse
adhesive (Syntac Classic; Ivoclar Viva-
dent), two 2-step self-etch adhesives
(AdheSE; Ivoclar Vivadent, and Xeno
III; Dentsply Intl), and a 1-step self-
etch adhesive (Futurabond NR; VOCO
America, Inc, Sunnyside, NY), which
were applied according to manufac-
turers’ instructions. Statistical analy-
sis of the shear bond strength testing
showed that phosphoric acid etching
of the enamel surface significantly im-
proved bond strength compared to
self-etching alone, regardless of the
system.
In a similar study comparing shear
bond strength of self-etch adhesives
applied with or without prior phos-
Donovan et al
phoric etching, the authors added a
thermal cycling step to assess the du-
rability of any bond strength increase
to enamel.99 Following bovine enamel
surface preparation, teeth were ran-
domly assigned to receive 37% phos-
phoric etching or no etching. Three
1-step systems (Absolute; Dentsply
Intl, or Clearfil Tri-S Bond; Kuraray
Co, Ltd, or GC G-Bond; GC America)
and two 2-step systems (Fluoro Bond
Shake One; Shofu, San Marcos, Calif,
or One-Up Bond F Plus; Tokuyama
America, Inc, Encinitas, Calif ) were
applied according to manufactur-
er instructions and stored for 24
hours. One half of the specimens in
each group were then tested in shear
mode, and the other half were ther-
mal cycled 10,000 times between 5°C
and 55°C before being tested in shear
mode. All of the adhesives showed an
increase in bond strength with prior
phosphoric acid etching, regardless
of whether thermal cycling was done,
and the increase was significant for 3
of the adhesives (Absolute, Clearfil
Tri-S Bond, and Fluoro Bond Shake
One). This confirms the previous
study results, and shows that there is
the potential that a phosphoric etch
prior to self-etch adhesive application
can provide a durable improvement
to enamel bond strength, with at least
some self-etch systems.
Other research focused on the ef-
fects of other modifications of appli-
cation technique on adhesive perfor-
mance. One such study evaluated the
impact of air stream temperature on
bond strength and microleakage of
2 etch-and-rinse adhesives that con-
tained different solvents.100 Flat den-
tin surfaces were prepared on human
teeth, and 2 etch-and-rinse adhesives
(Single Bond; 3M ESPE, and Prime
& Bond 2.1; Dentsply Intl) were ap-
plied. After each adhesive coat was
applied, the dentin surface was dried
with either a warm (60°C) or cool
(20°C) air stream. After light polym-
erizing the adhesive, composite resin
was added and polymerized in 1-mm
increments, and then sectioned into
sticks. Most sticks were subjected to
25
microtensile bond strength testing,
but 3-4 sticks from each tooth were
stored in silver nitrate and evaluated
for microleakage. Results of the bond
strength testing showed that the bond
strength was higher for both adhe-
sives when warm air drying had been
used; this difference was significant
for Single Bond. Likewise, microleak-
age was reduced for both adhesives
when warm air drying was done prior
to light polymerization. These results
confirmed the concept that it is essen-
tial to maximize solvent evaporation
to maximize bond strength.
The use of lasers for cavity prepa-
ration has received much attention in
recent years. This has prompted re-
search to determine if laser prepara-
tion has an effect on the bond of ad-
hesives to tooth structure compared
to preparations made with burs. One
such study evaluated the hybrid layer
in dentin following preparation with
a diamond rotary cutting instrument
or an Er:YAG laser at 2 different pulse
energies and 2 different frequencies.101
Flat dentin surfaces were prepared for
10 seconds, bonded with 1 of 4 differ-
ent adhesives: a 3-step etch-and-rinse
system (Scotchbond Multi-Purpose;
3M ESPE), two 2-step etch-and-rinse
systems (Single Bond 2; 3M ESPE,
and Prime & Bond 2.1; Dentsply
Intl), and one 1-step all-in-one system
(Xeno III; Dentsply Intl), and restored
with composite resin. The specimens
were sectioned, sputter coated, and
the hybrid layer was evaluated quan-
titatively (thickness) and qualitatively
(consistency) by scanning electron mi-
croscopy (SEM). The results showed
that the hybrid layer of the diamond
rotary cutting instrument-prepared
dentin was significantly thicker and
more regular than the hybrid layer of
the laser-prepared dentin, and there
were many laser-prepared specimens
in which no hybrid layer was found at
all.
Another investigation determined
the effect of laser preparation on den-
tin microtensile bond strength.102 Flat
dentin surfaces were created on bo-
vine incisors with a diamond saw, then
26
prepared with Er:YAG laser or a #245
carbide bur. A 2-step etch-and-rinse
adhesive (Single Bond; 3M ESPE) was
applied as called for by the manu-
facturer, and composite resin was
added incrementally and polymer-
ized. The specimens were assigned to
1 of 4 storage groups: 24-hour water
storage; or 500 thermal cycles/week
(5°C/55°C) and water storage for 1
week, 1 month, or 6 months. After
water storage/thermal cycling, speci-
mens were sectioned and subjected
to microtensile bond strength testing.
In general, the bur-prepared dentin
surfaces demonstrated higher bond
strengths than the laser-prepared sur-
faces, with the laser-prepared surfaces
subjected to 6-month thermal cycling
and water storage showing significant-
ly lower bond strength than any other
group. In addition, adhesive failure
was the predominant mode of failure
in the laser-treated groups (62.1%),
whereas mixed or cohesive failures ac-
counted for the major mode of failure
in the bur-prepared groups (77.1%).
SEM analysis of the specimens after
bond strength testing showed that
the bur-prepared dentin produced
more uniform, thicker hybrid layers
with less morphological changes even
after the simulated aging procedure
(water storage/thermal cycling) than
the laser-prepared dentin.
While the data would indicate
that laser preparation has a negative
effect on dentin adhesion, it has been
suggested that such negative effects
would not be seen on enamel, par-
ticularly if an Er,Cr:YSGG laser (Wa-
terlase; Biolase, Irvine, Calif ) is used
rather than an Er:YAG laser. A study by
a Belgian research group evaluated the
micromorphological characteristics
and bond strength of laser-prepared
enamel.103 The enamel of human mo-
lars was flattened with a diamond
rotary cutting instrument; half of the
specimens were further prepared with
the Er,Cr:YSGG laser. One 3-step ad-
hesive (OptiBond FL; Kerr Corp), one
2-step self-etch adhesive (Clearfil SE
Bond; Kuraray Co, Ltd), and 2 all-in-
one adhesives (Adper Prompt L-Pop;
The Journal of Prosthetic Dentistry
3M ESPE, and Clearfil S3 Bond; Kura-
ray Co, Ltd) were applied per manu-
facturer’s instructions, then restored
with composite resin. After 24-hour
water storage, the specimens were
sectioned for microtensile strength
testing, following which several speci-
mens from each group were analyzed
with SEM. All adhesives showed lower
bond strength to the laser-prepared
enamel versus diamond rotary cut-
ting instrument-prepared enamel,
with all but one (Clearfil S3 Bond) of
these being significantly lower. Evalu-
ation of the bonding surfaces demon-
strated a higher incidence of adhesive
failures among the laser-prepared
enamel surfaces compared to the dia-
mond rotary cutting instrument-pre-
pared enamel surfaces, including the
presence of small pieces of enamel on
the composite resin side of the speci-
mens. The authors surmise that the
results were due to the ablative effects
of laser on the tooth surface, result-
ing in microcracks that weakened the
subsequent bond.
OCCLUSION, Mandibular impressions were made
TEMPOROMANDIBULAR
DISORDERS, AND
SLEEP-DISORDERED
BREATHING
Occlusion
Investigation into the art and sci-
ence of occlusion continues as the
profession strives to better under-
stand that which so fundamentally af-
fects oral function, oral dysfunction,
and any therapeutic efforts to suc-
cessfully restore oral health. Though
not addressed in detail in this review
of occlusion literature, readers are
encouraged to examine a recent sum-
mary of occlusal concepts in fixed
prosthodontics.104 The historical
development of important consid-
erations in this subject area, such as
gnathology and competing occlusal
concepts, centric relation, maximum
intercuspation, anterior guidance,
and occlusal vertical dimension, are
discussed. The authors of this report
Volume 102 Issue 1
acknowledge the need for higher-or-
der scientific research to validate the-
ories of occlusal restorative therapy.
The authors also state that the lack of
a universally accepted evidence-based
model should not diminish profes-
sionally responsible goals of precision
and excellence in the clinical delivery
of fixed prosthodontics.
Made challenging by expected vari-
ability in patients, functional condi-
tions, and developmental dynamics,
the organization of natural dentitions
remains of substantial interest to the
profession. A longitudinal report was
presented105 on development of the
curvature of the human occlusal plane
as viewed from a sagittal perspective,
a characteristic first described by Fer-
dinand Graf von Spee in the late 19th
century. Dental casts from 16 male
and 17 female participants were in-
vestigated. Casts originated in the
Iowa Facial Growth Study (subjects
were predominantly of Northern Eu-
ropean descent, with Class I occlu-
sions and normal faces, and were
followed from 3 to 26 years of age).
on young children through to age 26,
and mandibular dental casts were ob-
tained and analyzed at 7 approximate
time points: at 3.5 to 5 years of age,
the oldest casts with deciduous sec-
ond molars and incisors, the young-
est casts with permanent first molars
and incisors, the oldest casts prior to
second molar eruption, the youngest
casts with second molars, at 16 years
of age, and at 26 years of age.
A digital caliper mounted on a
dental surveyor was used to analyze
and measure each cast. Mandibular
casts were oriented parallel to a ref-
erence plane defined by the distal-
facial cusp tips of the most posterior
teeth and the incisal edge of the most
erupted central incisor. The occlusal
curvature was measured as the maxi-
mum perpendicular distance between
the reference plane and any of the fa-
cial cusp tips on that side of the den-
tal arch.
Findings did not reveal significant
differences in occlusal curvature be-
Donovan et al
July 2009
tween left and right sides in individu-
als studied, nor were there significant
gender differences. The deciduous
dentition was found to have a relative-
ly flat occlusal plane, with the largest
increase in curvature occurring after
eruption of the permanent first mo-
lars. Occlusal plane curvature again
increases with eruption of the perma-
nent second molars and then remains
relatively stable into early adulthood.
The authors suggested that character-
izations arising from this investigation
yield guidelines descriptive of the nor-
mal curve of Spee for reference dur-
ing orthodontic and comprehensive
restorative therapy.
The need for prosthodontic re-
placement of missing posterior teeth
has historically been the subject of
much debate. One consequence of
failure to replace missing teeth in a
timely manner is positional changes
in adjacent and opposing dentition
resulting in occlusal interferences.
One study was designed to identify
clinical parameters associated with
occlusal contacts in centric relation
and the development of occlusal in-
terferences associated with posterior
tooth loss.106
One hundred consecutive patients
with an unopposed posterior tooth
served as the experimental group.
“Unopposed” was defined as 20%
or less of the occlusal surface in con-
tact with opposing dentition in the
maximum intercuspal position for a
minimum of 5 years. One hundred
age- and gender-matched controls
also participated. Involvement of the
unopposed tooth in centric relation
contact, as well as in working, non-
working, and protrusive occlusal in-
terferences, was identified with 8-µm
articulating film. Occlusal contacts
were recorded with patients in the
supine position, following a period
of anterior deprogramming, and us-
ing bimanual manipulation guided
closures. Diagnostic dental casts
were analyzed to characterize the
malposition of the unopposed tooth.
Data analysis included examination
of means and distributions, scatter
Donovan et al
plots, box plots, relative risk tables,
and generalized linear modeling. In-
terexaminer reliability was evaluated
to be acceptable.
The general finding was that un-
opposed teeth were more likely to
be involved with functional occlusal
interferences than their matched con-
trols. The overall incidence of occlus-
al interferences in the experimental
groups was 53%, as compared to only
12% in the control group. Compar-
ing the presence of specific occlusal
interferences between experimental
and control groups, the following fre-
quencies were recorded: 30% and 2%
respectively for centric relation inter-
ferences, 22% and 3% respectively for
protrusive interferences, 19% and 1%
respectively for working interferences,
and 11% and 7% respectively for non-
working interferences. The data also
demonstrated associations between
characteristic movements of adja-
cent/opposing teeth and the presence
of occlusal interferences. Centric rela-
tion contacts were associated with the
extent of unopposed supraeruption.
Protrusive interferences were more
prevalent when the site of tooth loss
was bounded. Mesial tipping of teeth
distal to the edentulous site reduced
this effect. Working side interferences
were significantly associated with tip-
ping of teeth mesial to the edentulous
site.
The authors concluded that the
presence of multiple occlusal inter-
ferences resulting from missing teeth
and unopposed dentition may sig-
nificantly impact efforts to restore
healthy continuity to the dental arch.
Both functional and restorative con-
siderations must be given to occlusal
stability, direct occlusal trauma, and
the complexity of restoring both the
unopposed tooth and other teeth that
may share occlusal relationships.
Recently, a number of scientifically
valid investigations into complete
denture occlusion have appeared in
the professional literature. One group
studied the influence of bilateral bal-
anced occlusion and canine guidance
on initial patient satisfaction with
27
conventional complete dentures.107
Using a single-blind crossover study
design, 38 edentulous patients (24
women, 14 men, 50 to 87 years of age)
were each provided a single maxillary
complete denture and 2 nearly iden-
tical mandibular complete dentures.
The 2 mandibular dentures differed
only in that one possessed a bilateral
balanced occlusal arrangement, while
the other provided canine protected
articulation. Following adjustment
and placement of the dentures, pa-
tients alternated daily between the 2
mandibular dentures.
At 2 weeks, patient preference was
recorded using a standardized ques-
tionnaire. Next, all complete dentures
were subjected to laboratory remount
procedures. The canine protected ar-
ticulation mandibular dentures were
subtractively adjusted to yield bilat-
eral balanced occlusions. Simultane-
ously, acrylic resin was added to the
mandibular canines on the bilateral
balanced dentures to arrive at ca-
nine protected articulation. Patients,
uninformed about these alterations,
wore their dentures for an additional
2 weeks. Patient satisfaction was then
again surveyed.
Results indicated that a significant
number of patients preferred the bi-
lateral balanced dentures after the
initial 2 weeks of wear. Following the
second 2 weeks, most patients either
preferred the bilateral balanced den-
tures, or expressed no preference. Au-
thors concluded that the bilateral bal-
anced occlusal scheme appears to be
preferred by patients during the initial
adaptation phase following complete
denture therapy.
Compared to natural tooth res-
torations or implant-supported res-
torations, management of occlusal
contact precision during complete
denture therapy is complicated by
denture base instability. This is espe-
cially evident in edentulous mandi-
bles. Clinical experience suggests that
occlusal errors can contribute to func-
tional denture instability, subsequent
irritation of the denture foundation,
and patient discomfort. The ability to
28
provide an accurate prosthetic occlu-
sion is both necessary and challeng-
ing. Investigators evaluated available
complete denture occlusal refinement
procedures to ascertain the most ap-
propriate clinical approach for pro-
viding accurate complete denture
therapy.108
In this prospective clinical trial,
30 edentulous patients (21 female, 9
male, 50 to 84 years of age, reasonable
residual ridge anatomy, no TMJ prob-
lems) were provided new complete
dentures fabricated with balanced
articulations. Patients were divided
into 3 equal experimental groups:
group LCRO received prostheses sub-
jected to both laboratory and clinical
remount procedures for occlusal cor-
rection, group LRO received dentures
subjected to only laboratory remount
procedures, and group OOC received
complete dentures for which occlusal
corrections were accomplished exclu-
sively by intraoral procedures when
required. Routine denture placement
and intaglio surface adjustments were
provided. Recall examinations were
performed after 48 hours and after 1
week.
The objective of the study was to
identify the denture occlusal refine-
ment regimen associated with opti-
mal prosthesis comfort and the fewest
required postinsertion appointments.
At each postinsertion appointment
requested by patients, examinations
were accomplished, tissue irritations
were identified, necessary intaglio
surface adjustments were made, and
patient pain/comfort was graded on
a 5-point scale. Analysis for statisti-
cal differences between treatment
groups involved the chi-square test
and Kruskal-Wallis test at a 95% con-
fidence level.
Results revealed that the LCRO
group required significantly fewer
postinsertion adjustment appoint-
ments, experienced fewer soft tissue
irritations, had less pain during mas-
tication, and enjoyed more mastica-
tory comfort when compared to the
other experimental groups. When
considering postinsertion adjustment
The Journal of Prosthetic Dentistry
appointments and patient comfort as
indicators of treatment success, the
authors concluded that, within study
limitations, the combined use of lab-
oratory and clinical remount proce-
dures to effect occlusal refinement of
complete dentures is preferred to lab-
oratory remounts alone or intraoral
occlusal corrections.
Temporomandibular disorders
Literature appearing in the broad
subject area of temporomandibular
disorders (TMDs) was again volu-
minous in 2008. Of note were 2 re-
view/summation articles likely to be
of interest to those seeking detailed,
state-of-the-art information on tem-
poromandibular disorders (TMD).
The first addressed the relationship
between TMDs and bruxism in child-
hood and adolescence.109 This review
included 30 scientifically valid reports
published between 1970 and 2007.
Bruxism was identified as a possible
causal factor, via functional man-
dibular overload, in childhood TMD.
Though the relationship between
bruxism and TMD in young patients
remains unsettled in the literature,
this report provides an excellent,
comprehensive, up-to-date review for
interested readers.
A second article110 reviewed cur-
rent understandings of the unique
anatomy and physiology of the tem-
poromandibular joint (TMJ) and the
pathogenesis of joint degeneration.
The authors then probe future inno-
vations in TMJ diagnostics and thera-
peutics by reviewing novel tools avail-
able to the profession in the broad
fields of biomedicine, imaging, and
computer technology. Cone-beam
computed tomography has been
shown to be a dose-conservative,
cost-effective, and accurate alterna-
tive to more conventional 3-dimen-
sional imaging modalities. Identifica-
tion of biomarkers associated with
TMJ diseases using synovial lavage
and powerful new microarray tech-
nologies is a promising biomedi-
cal tool that may result in effective
Volume 102 Issue 1
therapeutic interventions. Since ge-
netic factors likely have a role in TMD
pronicity and severity, genotyping to
identify risk holds promise for future
diagnostic identification and sub-
sequent preventive and therapeutic
interventions. The development of
high-throughput genome sequenc-
ing will provide future clinicians with
ready access to individual patient in-
formation so that highly specific and
therapeutically targeted interventions
can be rendered.
Intraoral palpation of the lateral
pterygoid muscle area is often in-
cluded as a recommended element
in the clinical examination of myo-
fascial pain patients. However, ample
intraoral clinical access to effectively
accomplish this procedure has been
questioned, and the anatomic avail-
ability of the lateral pterygoid to
intraoral palpation is suspect. To
clarify this important diagnostic con-
sideration, investigators performed
a blind, controlled, clinical trial de-
signed to evaluate the validity of in-
traoral lateral pterygoid palpation as
a diagnostic instrument.111
Using the Research Diagnostic Cri-
teria for Temporomandibular Disor-
ders (RDC/TMD),112 44 women clas-
sified as RDC/TMD Diagnostic I were
selected into the study. Thirty-three
asymptomatic, age-matched women
served as controls. Subjects ranged
from 15 to 55 years of age. A single ex-
aminer, blinded to patient allocation,
performed all muscle palpations. In-
traoral palpations of the lateral ptery-
goid area were attempted by placing
the forefinger, or the little finger, over
the buccal area in the maxillary third
molar region and exerting posterior,
superior, and medially directed pres-
sure behind the maxillary tuberocity.
Patients’ indications of pain, or the
absence of pain, on palpation were
noted. Descriptive statistics were
used to compare the groups studied.
Sensitivity, specificity, and likelihood
ratios were calculated for the muscle
site palpations performed.
Results indicated that intraoral
palpation in the lateral pterygoid area
Donovan et al
July 2009
presented an unacceptably low speci-
ficity yielding an increased frequency
of false-positive palpation responses.
The authors pointed out the 22.73%
false-positive response rate may be
attributed to pain originating from
oral mucosal compression, buccina-
tor muscle compression, palpation of
the tendonous insertion of the tem-
poral muscle at the medial surface of
the coronoid process, or pressure to
medial pterygoid muscle fibers. The
authors concluded that intraoral pal-
pation in the lateral pterygoid region
should be discouraged due to ana-
tomic inaccessibility and a high level
of false-positive responses. Within the
study’s limitations, authors suggested
that intraoral palpation of the lateral
pterygoid area does not reach accept-
able values of specificity. Therefore,
caution in judging positive patient
responses to this examination tech-
nique is necessary.
Understanding functional biome-
chanics of the temporomandibular
joint is critical to managing patients
affected by joint dysfunction. In
healthy patients, normal movement
of the condyle-disc assembly within
joint spaces incurs low frictional load-
ing due to lubrication derived from
synovial fluid. However, in diseased
tissues and under excessive loading
conditions, the coefficient of friction
within joint spaces may increase due
to deterioration of the lubrication
mechanism or reduction of synovial
fluid viscosity. It has been suggested
that, from a biomechanical point of
view, prolonged clenching in the pres-
ence of increased TMJ friction might
contribute to anterior displacement of
the disc within the joint space. Inves-
tigators constructed a finite element
(FE) model to investigate possible
relationships between joint friction,
prolonged clenching, and TMJ disc
displacement.113
FE modeling of a glenoid fossa, ar-
ticular disc, and mandibular condyle
was performed using information de-
rived from magnetic resonance imag-
ing of a 23-year-old woman with no
history of TMJ disorders or parafunc-
Donovan et al
tional habits. The model consisted of
17,548 elements (1136 bone, 1273
disc, and 13,825 surrounding soft
tissue nodes). Frictional coefficients
used ranged from 0.001 to 0.1 µm,
covering values previously observed
in synovial joints. Joint loading was
simulated with forces derived from 4
unilateral muscles (masseter, tempo-
ralis, medial pterygoid, and lateral
pterygoid). Clenching was simulated
by simultaneous activation of all
muscles at 20% of their maximum. FE
analysis was accomplished during 10
minutes of clenching.
In general, results indicated that,
regardless of the frictional coefficient
used, the disc appeared to be loaded
predominantly in the intermediate
zone at the onset of clenching, with
steady-state levels reached at 2 min-
utes. After 10 minutes, the largest
stress appeared in the central inter-
mediate zone and the posterior band.
Maximum stress produced in the disc
(125.3 g/mm2) occurred when the
frictional coefficient was increased
to 0.1 µm. Upon tracking 5 distinct
points in the disc for movement, it
was demonstrated that all 5 points
were displaced forward during the
first 1 to 3 minutes of clench. Maxi-
mum forward disc movement of 0.32
mm was found after 10 minutes of
clench as the frictional coefficient in-
creased.
The authors concluded that,
based on evidence derived from this
FE model of the TMJ, habitual and
prolonged clenching might induce,
or contribute to, anterior disc move-
ment. Additionally, this forward disc
movement may be accentuated by
increases in the frictional coefficient
within the joint space.
In 1992, the Research Diagnostic
Criteria for Temporomandibular Dis-
orders (RDC/TMD)112 was introduced
as a standardized diagnostic instru-
ment for classifying TMD patients
during scientific research efforts. To
be useful, all clinical measures within
this instrument must be both reliable
and valid. To date, the validity of the
RDC/TMD examination has not been
29
scientifically demonstrated. Investiga-
tors sought to determine the relative
significance of various components of
the RDC/TMD clinical examination in
distinguishing healthy from diseased
joints and whether these components
possess predictive accuracy for distin-
guishing healthy from symptomatic
subjects.114
The experimental population con-
sisted of 149 patients with symptom-
atic temporomandibular joints (65%
female, mean 34.4 years of age) and
43 symptom-free controls (75% fe-
male, mean 38.5 years of age). All
subjects were examined by 2 calibrat-
ed examiners using RDC/TMD pro-
cedures and other tests. Assessments
included evaluations for joint sounds
and pain, standardized muscle palpa-
tions, range of mandibular motion
measurements, psychosocial assess-
ment, and dynamic and static com-
pression of the TMJs. Bilateral joint
MRIs were accomplished in both open
and closed positions. Images were as-
sessed in 2 diagnostic categories: disc
displacement with reduction, disc
displacement without reduction, or
no disc displacement; and arthrosis
or no arthrosis.
Sophisticated statistical manage-
ment involved random forest analysis
to evaluate the importance of differ-
ent variables in the classification pro-
cess. This statistical approach was
used because it effectively covers all
components of the clinical examina-
tion, weighing the contribution of
each to the diagnosis.
To distinguish between healthy
joints and joints with disc displace-
ment, forest plot analysis revealed
overjet measurement, somatization,
depression, opening pattern, and joint
sounds during opening under TMJ
compression to be important vari-
ables. To distinguish between anterior
disc displacement with and without
reduction, the following examination
variables were identified as impor-
tant: facial pain, tenderness of lateral
pterygoid area, overjet measurement,
maximum unassisted opening, maxi-
mum assisted opening, history of
30
locked jaw, joint sounds on opening,
joint sounds on protrusion, and joint
sounds on lateral excursions under
TMJ compression. Finally, to distin-
guish between arthrosis and no ar-
throsis, analysis demonstrated locked
jaw, joint sounds on lateral excursion
to ipsilateral side, and joint sounds
on protrusion to be significant. Of
particular importance in distinguish-
ing between all joint conditions were
a history of locked jaw, maximum as-
sisted opening, and maximum unas-
sisted opening.
Within the limitations of this study
as described by authors, the validity
of clinical TMJ examination proce-
dures might be enhanced by using the
16 variables of greatest importance
(listed above) identified in this study.
Sleep-disordered breathing
Sleep-disordered breathing (SDB)
is currently recognized as a significant
disease entity in both adults and chil-
dren. Obstructive sleep apnea is also
recognized as a significant chronic
disorder related to substantial end-or-
gan morbidity, increased health care
expenditures, compromised quality of
life, as well as significant cardiovascu-
lar, metabolic, and neurobehavioral
complications. Additionally, mount-
ing evidence points to an association
of this relatively newly identified dis-
ease with increases in mortality. The
social impact of SDB can be appreci-
ated in the rules requiring pilots and
commercial truck drivers to disclose
SDB diagnoses during state and fed-
eral certification processes.115
For those interested in this topic,
2008 saw the production of 2 out-
standing review publications that are
both must-reads. First, the journal
Proceedings of the American Thoracic So-
ciety hosted a virtual symposium to
thoroughly and critically review the
current knowledge in sleep-disordered
breathing and to provide insight and
guidance into important questions
that require further investigation.116
Seventeen separate but well-coordi-
nated articles117-133 were written by
The Journal of Prosthetic Dentistry
authorities in their subject areas and
account for over 140 pages within this
journal. Topics covered include epide-
miology, pathophysiology, diagnosis,
nonsurgical and surgical therapies,
and associated complications. A sec-
ond outstanding review publication
on sleep apnea and cardiovascular
disease resulted from an extensive col-
laborative effort.134 This article pro-
vides thorough background informa-
tion on cardiovascular involvement
in patients affected by sleep apnea.
Authors also provided commentary
on future directions in therapy and
research. Authors cited over 400 ref-
erences in this publication.
Currently, SDB in adult popula-
tions has been shown to be indepen-
dently associated with a number of
clinically important outcomes. How-
ever, child populations have not been
subjected to similar scientific inquiry.
Investigators evaluated the associa-
tion between SDB and blood pressure
in a large representative random sam-
ple of children135 with mild to moder-
ate SDB, to establish the apnea-hypo-
pnea index in children that is clinically
associated with significantly elevated
blood pressure, and to determine the
relative contribution of potential risk
factors in this association. This report
on SDB in children represents the
largest published population-based
sample of 5- to 12-year olds in this
area of investigation.
The parents of 7312 elementary
school children received question-
naires previously validated to identify
children at high risk for SDB. A total
of 5740 questionnaires were returned
(78.5% response rate). Using a stratifi-
cation of grade, gender, and SDB risk,
700 children were randomly selected
and subjected to physical examina-
tion and 9-hour polysomnography,
maintaining the representativeness
of the original sample (70% response
rate). Physical examinations included
height, weight, waist and neck mea-
surements, blood pressure, visual ex-
amination of nose/throat, evaluation
of respiratory function, and blood
pressure measurement.
Volume 102 Issue 1
Sleep apnea and hypopnea were
defined using criteria commonly ac-
cepted in clinical practice. Apnea
indexes (AI) and apnea-hypopnea
indexes (AHI) were calculated. Indi-
viduals were defined as “without SDB”
if AHI<1, as “mild SDB” if 1≤AHI<5,
and as “moderate SDB” if AHI≥5. Us-
ing these criteria, 8 children (1.14%)
were affected with moderate SDB,
175 (25%) were classified as having
mild SDB, and 517 (73.86%) were
without SDB. Statistical comparison
of AHIs and blood pressure measure-
ments revealed that blood pressure
was strongly associated with AHI in
this population of children.
In this study, SDB appeared to be
an independent risk factor for elevat-
ed blood pressure in children aged
5 to 12 years. Authors noted that at
the threshold of AHI≥5, the effect on
blood pressure appears to warrant
therapeutic intervention for SDB. Ad-
ditionally, at a threshold of AHI≥3,
the critical assessment of blood pres-
sure and AHI at routine follow-up vis-
its seems warranted, although addi-
tional research is necessary to validate
this conclusion. Since high AHI in
children was found to independently
contribute to clinically significant el-
evation in blood pressure, the authors
suggested that its detection and man-
agement may lead to a reduction of
elevated blood pressure in children
and the subsequent reduction of car-
diovascular risk in these same individ-
uals as adults.
Though nasal continuous posi-
tive airway pressure (CPAP) remains
the gold standard of treatment for
obstructive sleep apnea syndrome
(OSAS), compliance with this treat-
ment modality is variable, and un-
comfortable side effects limit ad-
herence. Patients unable to tolerate
CPAP therapy and patients with mild
to moderate OSAS are candidates
for mandibular advancement de-
vice therapy. Unfortunately, there is
little data on the long-term success
of mandibular advancement devices.
To shed light on long-term outcomes,
investigators136 assessed the 10-year
Donovan et al
July 2009
compliance and therapeutic opinions
of patients treated with mandibular
advancement devices. The authors
hypothesized that mandibular ad-
vancement devices are an acceptable
form of long-term treatment for pa-
tients with problem snoring and mild
to moderate OSAS.
One hundred and eighty patients
were provided mandibular advance-
ment devices in 1996. All devices were
of the same design. At the outset, the
severity of OSAS in this patient pop-
ulation was as follows: all patients
snored; 72 patients were considered
normal with AHI<5; 52 had mild dis-
ease (5≤AHI≤14); 34 had moderate
disease (15≤AHI≤30); and 21 had
severe disease (AHI>30). In 2006,
questionnaires were provided to these
patients to survey device wear and
satisfaction, sleep quality/duration,
lifestyle, weight, height, and smok-
ing/alcohol habits. Seventy-two of
the 180 questionnaires were returned
(40% response rate, 56 males, 16 fe-
males).
Results indicated that 48 patients
(66%) were still wearing the mandibu-
lar advancement device at the time
of the survey. Of the 24 patients no
longer wearing the device, 12 claimed
it was very uncomfortable, 3 found it
slightly uncomfortable, and no infor-
mation was available on the remaining
7 patients. Data were then evaluated
for associations between success and
other factors, including body mass in-
dex, smoking, alcohol consumption,
sleep duration, and sleep quality.
Sleep quality was the only factor sig-
nificantly associated with successful
wear of the mandibular advancement
device. Side effects reported included
discomfort, excessive salivation, dry
mouth, loose fit, stained teeth, repo-
sitioned jaw, and excessive flatulence.
When asked to rate the overall suc-
cess of the device, 24% of the patients
stated “fair,” and 46% reported the
device provided “good” success.
Based on this data, authors ac-
cepted the original hypothesis that
mandibular advancement devices
are an acceptable form of treatment
Donovan et al
in the long term for patients with
problem snoring and mild to moder-
ate OSAS. A high level of treatment
success is suggested by the fact that
66% of the patients were still wear-
ing their devices and 70% rated their
devices as fair to good after 10 years
of practical use. Unfortunately, the
response rate for the present investi-
gation was only 40%. Although this
compares favorably to other similar
studies, a substantial amount of pa-
tient response data were not collected
and evaluated on the important issue
of continued therapeutic impact of
the mandibular advancement devices.
The authors concluded by stating that
the mandibular advancement device
appears to be an acceptable long-
term solution for a significant number
of patients with problem snoring and
those with mild to moderate OSAS.
Cur r ently,  poly somnography
serves as the gold-standard diagnos-
tic test for OSAS, providing informa-
tion on the severity of OSAS and the
degree of sleep fragmentation. How-
ever, polysomnography does not pro-
vide direct information regarding the
specific pathophysiology of this dis-
ease. It is known that the severity of
OSAS is generally correlated with the
degree of collapse of the pharyngeal
region at the base of the tongue. One
method of ascertaining critical infor-
mation on effects of the degree of
pharyngeal narrowing on SDB is the
application of nasopharyngoscopy
using the Muller maneuver. As this
approach has not been sufficiently in-
vestigated and reported, investigators
examined correlations between the
degree and shape of pharyngeal nar-
rowing at different anatomical levels
during the Muller maneuver and the
severity of SDB.137
Thirty-three patients (29 male, 4
female, mean age of 49 years, mean
body mass index (BMI) of 23.5) with
suspected SDB underwent polysom-
nography. Mean AHI, supine body
position AHI, and lateral body posi-
tion AHI were calculated. Fiberoptic
nasopharyngoscopy using the Muller
maneuver was performed for each pa-
31
tient in the supine position with the
head in a neutral position. Degree and
shape of pharyngeal narrowing was
evaluated at both retropalatal and
retroglossal levels, while the shape of
pharyngeal narrowing was evaluated
at the retropalatal level.
Results indicated that the mean
AHI for this patient population was
28 (range 1.1 to 74.8). Three subjects
were simple snorers, 9 had mild OSAS
(5≤AHI<15), 10 had moderate OSAS
(15≤AHI<30), and 11 had severe
OSAS (AHI≥30). A significant correla-
tion was identified between the degree
of retroglossal pharyngeal narrowing
and total and supine AHI. Additional-
ly, the degree of retropalatal pharyn-
geal narrowing demonstrated signifi-
cant positive correlation with lateral
AHI. These findings suggest that the
mechanism of airway narrowing at
the retroglossal level in supine SDB
patients is primarily posterior tongue
movement influenced by gravitational
force and/or reduced muscular activ-
ity compared to normal individuals.
The present study also showed that
lateral narrowing at the retropalatal
pharyngeal level is more significantly
positively correlated with mean total
AHI than anteroposterior narrowing.
Although currently available informa-
tion does not provide a clear rationale
for the deleterious effects of lateral
retropharyngeal narrowing on OSAS,
the authors suggested that lateral fat
deposition may have a role, even in
relatively nonobese individuals.
The authors concluded that the
anatomic pharyngeal level and the de-
gree and character of pharyngeal nar-
rowing, as observed during fiberoptic
nasopharyngoscopy using the Muller
maneuver, revealed significant corre-
lations with AHIs calculated in differ-
ent sleeping positions.
PROSTHODONTICS
A pilot study was conducted to
determine the position of the incisal
edges of maxillary canines and cen-
tral incisors relative to the maxillary
lip line in a reposed position.138 The
32
proposed benefit would be for estab-
lishing a proper incisal plane for eden-
tulous patients. Measurement of the
canine and central incisal edge display
was conducted on 104 Caucasian
dentate patients between the ages
of 30 and 59. Exclusions were made
for previous facial plastic surgery, or-
thodontics modifying the incisal edge
position, or moderate to severe wear
of the maxillary anterior teeth. The in-
vestigator did not control for aberrant
lip length or maxillary anterior den-
toalveloar extrusion, both of which
will impact the central exposure more
than the canine. The maxillary right
canine and right central incisal edge
displays were measured visually with
a millimeter ruler. The data were sepa-
rated by age and sex. Age was brack-
eted into 3 groups: ages 30 to 39, 40
to 49, and 50 to 59 years. Exposure
of the central incisors in repose dem-
onstrated wide variation. In the 30 to
39 age group, women averaged 4.1
mm (0- to 8-mm range) and men av-
eraged 3.2 mm (0- to 7-mm range).
For women aged 40 to 49, the average
display was 2.8 mm (-1 to +6 mm),
and for men, it was 2.4 mm (-3 to
+5 mm). In the 50 to 59 age group,
women averaged 1.8 mm (-1 to +5
mm) and the men averaged 1.4 mm
(-3 to +5) central incisor display. The
canine measurements had less de-
viation for each age bracket. For the
30- to 39-year olds, the women aver-
aged 1 mm (-1 to +2 mm), and men
averaged 0.9 mm (-1 to +2 mm). For
the women aged 40 to 49, the average
canine display was 0.4 mm (-1 to +2
mm), and for men it was 0.2 mm (-1
to +2 mm). Finally, in the group aged
50 to 59 years, the average for women
was -0.5 mm (-2 to +1 mm), and for
men, -0.9 mm (-2 to +1 mm). While it
is more difficult to measure teeth that
fall below the lip line in repose, the
author concludes that the position
of the canines is more predictable
than the position of the central inci-
sors. In future investigations, control
over anatomic and dental variations
at the midline would provide more
The Journal of Prosthetic Dentistry
conclusive insight into the norms for
positioning edentulous and dentate
incisal edges in repose.
Luting agents
Self-etching cements are a rela-
tively new category of luting agents.
While the chemistry varies, they are
essentially resin cements. One labo-
ratory study attempted to determine
whether self-etching cements pro-
duce performance equal to conven-
tional resin cements.139 The flexural
strength, modulus of elasticity, and
24-hour pH profile of 3 self-etching
luting agents in both translucent and
A3 shades (RelyX Unicem (3M ESPE),
Maxcem (Kerr Corp), and Embrace
WetBond (Pulpdent Corp, Water-
town, Mass)) were compared with
2 conventional resin cements (Re-
lyX ARC (3M ESPE), Linkmax (GC
America)), and 2 resin-modified glass
ionomer (RMGI) cements (Fuji PLUS
(GC America), RelyX Luting Plus (3M
ESPE)). Flexural strength was tested
on bar-shaped specimens (25 x 2 x
2 mm3) for each of the luting agents.
The self-etch specimens were either
autopolymerized or light polymerized
for the dual-polymerized mode. The
specimens were polished, measured,
and stored in water for 24 hours. A
3-point-bend test was preformed in a
universal testing machine at a cross-
head speed of 0.75 mm/min, and
the flexural strength was calculated.
Modulus of elasticity was determined
from the load deformation profiles
generated during the 3-point-bend
test. RMGIs had significantly lower
flexural strength than the other luting
agents. The resin cements and self-
etch cements possess comparable
flexural strengths within the same
mode of polymerization. The excep-
tion was the Embrace Wet bond au-
topolymerizing mode that was simi-
lar to the RMGIs. The modulus of
elasticity results demonstrated that
the autopolymerizing and dual-po-
lymerizing RelyX Unicem (translucent
and A3) and Maxcem clear dual-po-
lymerizing cements had significantly
Volume 102 Issue 1
higher modulus of elasticity than the
RMGIs and conventional resin ce-
ments. The other self-etch cements
were not significantly different than
the traditional cements. The 24-hour
pH change in each material was also
tested. Self-etching cements began
with the lowest pH and the conven-
tional resins began with the highest.
The self-etching pH changes over the
24-hour period varied significantly
between type of resin and mode of
polymerization. RelyX Unicem dis-
played the most dramatic rise in pH
over the first hour and had the high-
est final pH. Both Maxcem and Em-
brase showed little change in the acid-
ity over time in the autopolymerizing
mode. Embrase  dual-polymerizing
provided a more dramatic rise in pH.
An oxygen-inhibited layer was noted
with Embrase in both polymerization
modes, indicating a lack of complete
polymerization.  The  investigators
concluded that, while the self-etching
chemistry has significant advantages,
the cements evaluated could not be
considered a homogeneous group.
The flexural strengths were similar,
but the modulus of elasticity varied
dramatically depending on the type of
cement and the mode of polymeriza-
tion. The results demonstrated that
the pH profiles differed significantly,
again with the mode of polymeriza-
tion and type of cement. Prolonged
acidity, especially periods of time
when the acidity is below pH 3, may
have an impact on pulpal health and
postoperative sensitivity. All of the
self-etching resins worked best when
light polymerized, but the clinical effi-
cacy of a dual-polymerizing self-etch-
ing cement was not addressed.
Aprismatic cervical enamel has
been shown to be more acid resis-
tant and can negatively affect bond
strengths. Another in vitro study
of self-etching cements focused on
the bond quality of resin to cervi-
cal enamel with and without an acid
pretreatment.140 Forty proximal cer-
vical enamel surfaces were prepared
on extracted third molars. Half of the
specimens were etched for 30 seconds
Donovan et al
July 2009
with phosphoric acid, and the other
specimens were not. Self-etching ce-
ments (RelyX Unicem; 3M ESPE, and
Multilink; Ivoclar Vivadent) were com-
pared to a conventional resin cement
(RelyX ARC; 3M ESPE). Composite
resin specimens (Filtek Z250; 3M
ESPE) were luted to the etched and
unetched cervical enamel and light
polymerized. The teeth were sectioned
parallel to the adhesive surface, and
specimens underwent microtensile
testing. The results indicated that the
effects of enamel etching were depen-
dent on the resin cement tested. No
significant difference was found for
Multilink, but the etched specimens
of RelyX Unicem resulted in a signifi-
cant increase in bond strength. Under
field-emission scanning electron mi-
croscopy, the RelyX Unicem and RelyX
ARC resins had significantly deeper
penetration into the crystallites and
enamel rods produced after etching
than the Multilink, explaining the
greater bond strength.
Endodontic posts
A prospective clinical trial com-
pared the survival data for endodon-
tically treated teeth with and without
placement of a prefabricated metal
post at 17-year follow-up.141 Eighty-
seven patients with 98 restorations
were included in the evaluation.
Teeth included either did not require
a crown or the patient could not af-
ford the treatment, a reality of clinical
practice. The investigators did not es-
tablish a criteria for classifying a tooth
as not requiring a crown after endo-
dontics, or requiring a crown and not
receiving it. These teeth were not dif-
ferentiated in the data collection. The
article suggests that all of the teeth
had substantial dentin height. The au-
thors define adequate height to mean
that >75% of the circumferential den-
tin was at least 1 mm thick and 1 mm
above the free gingival margin. If more
detailed information delineating the
exact amount of clinical crown had
been reported, it might be possible to
know whether the long-term survival
Donovan et al
is more dependent on the post, post
filling material, or amount of remain-
ing clinical crown. The post and no-
post groups were determined by bal-
anced randomization. The posts were
metal, parallel-sided passive posts
luted with Panavia cement (Kuraray
Co, Ltd). At year 5, 87% of the teeth
were available for evaluation. This
decreased to 82% at 10 years, 67%
at 15 years, and 39% at 17 years. The
overall restoration survival rate was
53% ±14%, and the tooth survival rate
was 79% ±11%. Teeth with posts re-
quired more intervention, but not at
a significant rate. Interestingly, only 1
tooth with a post failed from a root
fracture. Crown placement was the
most common intervention for failed
restorations. Several factors weak-
ened this study, including a high num-
ber of operators, lack of calibration
and randomization. It does, however,
present interesting information on
the long-term prognosis of endodon-
tically treated teeth not provided with
cuspal coverage.
An in vitro study was conducted on
the residual dentin thickness of bifur-
cated first premolars after endodon-
tic treatment and post preparation.142
Extracted maxillary first premolars
were divided into 2 groups, depending
on the level of the bifurcation above
or below the middle third of the root
length. Endodontic canal preparation
was performed using a K-40-size file
at the apex in a step-back technique.
Post preparations were completed on
13 teeth with junctions of the bifurca-
tion located in the middle to coronal
third. Parallel-sided drills (ParaPost,
Nos. 3 and 4; Coltène/Whaledent,
Inc, Cuyahoga Falls, Ohio) were used
to finish the post preparation in both
canals. The residual dentin thickness
was measured for all teeth at 2, 4,
and 6 mm apical to the CEJ. The re-
sults indicated that a step-back tech-
nique removes more dentin in the
coronal than in the middle and api-
cal regions. The opposite is true for
post preparation with a parallel-sided
drill, which will remove more dentin
in the apical than in the middle and
33
coronal regions. Interestingly, the re-
sidual dentin thickness (RDT) of the
lingual aspect of the buccal root and
buccal aspect of the lingual root were
the most affected. The mean RDT of
the lingual aspect of the buccal root,
6 mm below the CEJ, was 0.82-0.9
mm after root canal and post prepa-
ration, making the root more suscep-
tible to root fracture or perforation.
The endodontic preparation reduced
the wall thickness to less than 1 mm
in 53% of the buccal roots and 38% of
the lingual roots. After post prepara-
tion, the values increased to 77% for
the buccal roots and 61% for the lin-
gual roots. The results suggest that,
due to the unique architecture of
the bifurcated maxillary first premo-
lar, parallel-sided post preparation
is contraindicated and unnecessary
reduction of RDT may be detrimen-
tal. Further study of other teeth with
tapering canals should be conducted
and may elicit similar findings.
An interesting push-out bond
strength and sealing ability study was
conducted on 5 adhesive cements
routinely used for fiber post bond-
ing.143 Fifty single-rooted teeth were
endodontically prepared and obtu-
rated. The post space was prepared
and the teeth were restored with a
carbon fiber post (Parapost Fiber Lux;
Coltène/Whaledent, Inc). The luting
agents were chosen by adhesive strat-
egy and polymerization mode: Pana-
via 21 (Kuraray Co, Ltd), self-etch,
autopolymerizing; Clearfil Esthetic
Cement (Kuraray Co, Ltd), self-etch,
dual polymerizing; Variolink II (Ivoclar
Vivadent), etch and rinse, dual po-
lymerizing; RelyX Unicem (3M ESPE),
self-adhesive, dual polymerizing; and
an experimental self-adhesive cement
(GC Corp), self-adhesive, dual polym-
erizing. The post was luted following
manufacturer’s instructions, includ-
ing light polymerization of the coro-
nal portion of the dual-polymerizing
cements. Three 2-mm-thick speci-
mens were cut from each tooth: coro-
nal, middle, and apical. Each section
was connected to a modified fluid-fil-
tration system to measure the sealing
34
ability at a constant hydrostatic pres-
sure. After the sealing test, the speci-
mens were subjected to a push-out
test using a universal testing machine
until the post was dislodged. The re-
sults indicate that the choice of bond-
ing agent has a significant impact on
the push-out bond strength. The low-
est bond strengths were recorded for
the middle and apical portions of the
root, except for RelyX Unicem. The
highest bond strength was detected
in the apical third. The highest bond
strength was recorded for Clearfil Es-
thetic Cement. It was not significantly
different than Panavia 21, but was sig-
nificantly different than the other ce-
ments. No significant differences were
found between the other cements ex-
cept for the GC experimental luting
agent, which was significantly lower
than all cements. The luting agent
also significantly affected the sealing
ability. No difference was detected by
region of the root. Both of the self-
adhesive cements (Rely X Unicem and
GC self-adhesive experimental ce-
ment) had significantly more micro-
leakage than any other cement tested.
Overall, the results of the push-out
bond strength appear to be inversely
correlated to the sealing effectiveness
of the cement.
Complete dentures
The association between periodon-
tal pathogens and various systemic
diseases is more widely known. Sev-
eral studies evaluated the plaque and
biofilm in dentate subjects, but rela-
tively little is known about the bacteri-
al flora of an edentulous patient. The
assumption is that when the teeth are
removed, the periodontal pathogens
are no longer present. Several investi-
gators tested that theory in a unique
research project.144 Sixty-one subjects,
edentulous for at least 1 year, wearing
complete maxillary and mandibular
dentures on a daily basis, were tested.
Microbial specimens were obtained
from 8 separate locations: tongue
(dorsum, ventral, lateral), buccal mu-
cosa, vestibule, hard palate, floor of
The Journal of Prosthetic Dentistry
mouth, and anterior attached gingiva.
The dentures were also sampled from
the cameo surface, the teeth, and the
junction between the cameo and inta-
glio surfaces. In addition, unstimulat-
ed saliva specimens were obtained for
evaluation. All specimens were ana-
lyzed with a checkerboard DNA-DNA
hybridization to determine the levels
of 41 bacterial species often found in
the plaque and soft tissue biofilms in
dentate subjects. The denture acrylic
resin biofilm was high in Actinomyces
species, V. parvula, and Streptococcus
species. Interestingly, the periodon-
tal pathogens A. actinomycetemcomi-
tans and P. gingivalis were also present
intraorally. The specimens from the
dorsum of the tongue had the high-
est bacterial counts, followed by the
attached gingiva. The lowest counts
occurred in the vestibule and buccal
mucosa. The concentration of bacte-
rial colonization varied between loca-
tions and species. S. mitis and S. ora-
lis, for example, were found in higher
concentrations on soft tissue as op-
posed to the denture acrylic resin or
saliva. The periodontal pathogens
isolated in this research project were
believed to have been eliminated with
the extraction of all natural teeth.
They were, however, seen in signifi-
cant numbers in the edentulous sub-
ject. The researchers stressed an in-
creased emphasis on the oral hygiene
of edentulous patients to reduce the
risk of systemic disease.
An in vitro examination of the di-
mensional accuracy of different den-
ture relining methods and materials
was conducted.145 Fifty identical den-
tures were fabricated on 50 casts from
a stainless steel master cast. Denture
bases were produced to create 1.5
mm of relief space for the reline. Five
relining methods and materials were
tested: laboratory heat polymerized,
laboratory heat/pressure polymer-
ized, laboratory autopolymerized,
chairside autopolymerized, and chair-
side light polymerized. The labora-
tory methods and materials followed
manufacturer specifications for a re-
line. The chairside material was mixed
Volume 102 Issue 1
and placed under a static load of 2 kg.
The dimensional change of the relined
denture was determined with a repli-
ca technique. A low-viscosity silicone
impression material was injected in
the intaglio of the denture and placed
on the master cast under a 2-kg static
load. The wash was removed from the
denture and embedded between 2 lay-
ers of heavy-viscosity vinyl polysilox-
ane. Each block of silicone was sliced
on the posterior palatal border, and
the replicated thickness of the gap
was measured. Statistically significant
differences were found between the
groups. The chairside autopolymeriz-
ing reline showed the greatest dimen-
sional accuracy, while the laboratory
heat-polymerized conventional tech-
nique produced the greatest error. Re-
searchers noted that there appears to
be a close correlation between the de-
gree of heat and the amount of shrink-
age during processing. As the heat is
low, the degree of change is due to
polymerization shrinkage alone. The
chairside materials had large stan-
dard deviations, probably due to the
difficulty in repositioning the denture
base. The authors concluded that the
use of a chairside material along with
a reline jig and pressure tank may pro-
vide the advantage of low shrinkage
with added control over placement
and production of a posterior seal.
The issue of the long-term poor physi-
cal properties of the chairside materi-
als was not addressed.
Maxillofacial prosthodontics
Obturators have traditionally been
fabricated with silicone or polymethyl
methacylate (PMMA). These materi-
als have the inherent risk of bacterial
colonization, increasing the risk of lo-
cal and systemic infections. A study
was conducted to compare the mi-
croorganisms present on traditional
and titanium obturators.146 Thirty-
six patients with existing obturators,
17 titanium and 19 polymer, were
evaluated. Microbial specimens were
collected from the posterior surface
of the obturators and the adjacent
Donovan et al
July 2009
soft tissue. The PMMA obturators
were sectioned to obtain a section
of acrylic resin from the interior to
evaluate bacterial penetration. Mi-
crobiological analysis and quantifica-
tion of colony-forming units was con-
ducted. The research confirmed that
obturators harbor microorganisms
that are different than normal flora.
One hundred percent of the PMMA
surfaces were colonized by abnormal
bacterial species, while only 29.4% of
the titanium surfaces were colonized.
The tissue adjacent to PMMA obtura-
tors was contaminated in 94.7% of
the patients and in 47.1% of the pa-
tients with titanium. Penetration of
microbes was discovered in 68.4% of
the PMMA acrylic resin specimens.
The results showed that titanium can
provide a light, accurate casting that
may provide a healthier alternative to
PMMA in maxillofacial prostheses.
The difficulty in casting makes the use
of titanium more costly, and titanium
is more difficult to reline and adjust.
Color and shade matching
A clinical project focusing on
matching the color of a metal ce-
ramic crown to the natural dentition
was conducted.147 The study com-
pared the shade matching accuracy
of the final crowns produced using a
conventional visual shade matching
technique (individual dentists using a
shade guide to describe or map tooth
color for the laboratory) versus a cali-
brated spectrophotometer. The spec-
trophotometer provides the techni-
cian a color photograph of the tooth
and a digital mapping color calibrat-
ed to any shade guide. Metal ceramic
crowns for 36 single maxillary central
incisors were fabricated. Two crowns
were fabricated for each subject: one
with each shade mapping technique.
The color match of each crown was
analyzed both visually and with the
spectrophotometer. Twenty-two per-
cent of the crowns fabricated with the
conventional method and 77.8% of
the spectrophotometer crowns were
deemed acceptable. The color differ-
Donovan et al
ence between the target teeth and the
crowns was significantly lower in all
areas of the crown when measured
with the spectrophotometer as com-
pared to the visual method. The study
did not report whether the differences
were more related to chroma or value,
but simply grouped the data into a
color category. This project confirms
that the technique used by clinicians
of mapping color and drawing pic-
tures for the laboratory is a poor sub-
stitute for a photograph. The true in-
fluence of the digital shade guide data
cannot be distinguished in this study,
since the difference in final crowns,
comparing between a color-corrected
photograph and a spectrophotom-
eter, was not tested.
Historically, shade mapping has
used the clinicians’ color perception
of the tooth with respect to a shade
guide. Use of spectrophotometers
in shade matching can provide color
communication in any shade guide.
The ability of a ceramic system to cor-
rectly reproduce the spectrophotom-
eters’ selected shade was tested in an
in vitro study.148 The VITA Omega 900
dental ceramic system (VITA Zahn-
fabrik; Bad Säckingen, Germany) was
used in the study since it is marketed
to match the VITA Classical and VITA
3D-Master shade guides. Metal ce-
ramic specimens were fabricated to
match an A3 shade Classical and 2M3
shade for the 3D-Master. Specimens
were prepared using 3 different lay-
ering patterns to a standardized 1.3-
mm thickness. The specimens were
evaluated with a stand-alone clinical
spectrophotometer. The analysis indi-
cated that, regardless of layering pat-
tern, the color match between the ce-
ramic discs and the 3D-Master shade
guide were significantly better than
with the VITA Classical shade guide.
While this study is limited to a single
ceramic shade and porcelain system,
color correspondence appears to be
related to the shade guide chosen.
Ceramics
The veneering of an opaque zirco-
35
nium core has provided a new esthetic
challenge to ceramists. Recently, col-
ored zirconium frameworks have been
introduced in an attempt to address
this problem. The impact on core
strength caused by alterations in the
chemistry of colored zirconium and
the bond strength between the veneer
ceramic and the zirconia framework
were evaluated in a unique labora-
tory study.149 Five commercially avail-
able zirconium framework materials
(Cercon white and yellow (DeguDent
GmbH, Hanau, Germany), Lava white
and yellow (3M ESPE), and Procera
Zirconia (Nobel Biocare AB, Göte-
borg, Sweden)) were investigated. The
ceramic cores were grouped by surface
treatment before addition of the ve-
neering ceramic: unaltered, airborne-
particle abraded, or airborne-particle
abraded and coated with a liner ma-
terial. The specimens were tested for
microtensile bond strength (MTBS).
The analysis revealed a significant
difference between the surface treat-
ments and color. The airborne-parti-
cle-abraded pretreatment provided
an increase in the bond strength for
white specimens. However, the yellow
frameworks had significantly lower
strength. The liner material was ben-
eficial for all specimens but increased
the percentage of interfacial failure
compared to the airborne-particle-
abraded specimens. Significant differ-
ences were noted between white and
colored zirconium. Researchers noted
that the addition of coloring pigments
to the zirconium frameworks changed
the grain structure of the material.
Loss of material from airborne-par-
ticle abrasion is greater with colored
zirconium compared to white. The re-
sults indicate that this added surface
roughness and sharpness increases
interfacial failure. While each of the
zirconia materials are fabricated dif-
ferently, the impact of surface treat-
ments remained relatively constant.
In an attempt to match adjacent
restorations, laboratories may at-
tempt to use zirconium veneering ce-
ramic for porcelain laminate veneers.
Veneer ceramics are bonded to tooth
36
structure with micromechanical reten-
tion of the resin and an acid-etched
roughened ceramic surface. An in vit-
ro study of the bond strength of 3 zir-
conium veneering ceramics: Cerabien
CZR (Noritake, Aichi, Japan), Lava Ce-
ram (3M ESPE), and Zirox (Wieland
Dental Systems, Inc, Danbury, Conn),
and 4 traditional veneering ceramics:
Creation (Jensen Industries, North
Haven, Conn), IPS d.Sign (Ivoclar
Vivadent), Noritake EX-3 (Noritake),
and Reflex (Wieland Dental Systems,
Inc) was conducted to determine if
conventional ceramic and zirconium
veneering ceramic react similarly to
acid etching.150 Specimens of each of
the ceramics were etched with hydro-
fluoric acid following manufacturers’
specifications. The etched specimens
were microscopically evaluated. The
investigators found a significant dif-
ference in the surface roughness of all
tested groups. Two of the traditional
ceramics (Cerabien CZR and Reflex)
produced a surface roughness signifi-
cantly higher than the zirconia speci-
mens. Zirox was slightly rougher than
zirconium and IPS d.Sign created the
same roughness as the zirconium
specimens. The zirconium ceram-
ics all demonstrated similar surface
roughness after etching. The results
showed that they produced smooth
surfaces with some grooves. A silane
solution was applied for 60 seconds,
air dried, and then an adhesive bond-
ing agent was added. The ceramic
specimens were bonded to prepared
enamel specimens using a light-po-
lymerized resin cement. Shear load
was applied in a universal testing ma-
chine until failure. The average bond
strengths were reported. The highest
mean shear bond strength was from
the traditional ceramics Cerabien
CZR and Reflex, which were 50-60%
greater than the weakest mean bond
strength from a zirconium veneering
ceramic. While the etch patterns on
zirconia produced a smoother sur-
face, some of the zirconium ceram-
ics matched the bond strength of the
weakest conventional ceramic, IPS
d.Sign. The authors concluded that
The Journal of Prosthetic Dentistry
the bond strength of some of the zir-
conium ceramics was too weak to be
indicated for use in bonded ceramics,
and laboratories must choose the zir-
conium veneering ceramic carefully to
ensure a proper bond.
The impact of repeated firings
on the value and color of a restora-
tion fabricated with lithium disilicate
glass ceramic (IPS e.max Press; Ivoclar
Vivadent) and zirconium oxide (DC-
Zirkon; DCS Dental AG, Allschwil,
Switzerland) was tested.151 Thirty
4-mm discs with a core thickness of
1 mm were fabricated. An A1-colored
veneer ceramic with a thickness of
0.5, 1.0, or 1.5 mm was fired to the
discs. The firings were performed ei-
ther 3, 5, 7, or 9 times. At each inter-
val, the color and value were evalu-
ated with a spectrophotometer and
compared to the other specimens.
The results showed that an increase in
firings yielded an increase in value for
both cores. As the veneering ceramic
increased in thickness, the bright-
ness decreased for both cores, result-
ing in darker specimens. The chroma
increased for the 0.5-mm IPS e.max
Press specimens but not for the 1-mm
specimen. At 1.5 mm, only the blue-
yellow chroma increased. For the
zirconium specimens, the red-green
value decreased with repeated firings,
except for the 1.5-mm specimens, for
which it increased. The blue-yellow
value increased for the 0.5-mm-thick
and 1.5-mm-thick zirconium speci-
mens, but there was no change in this
value in the 1.0-mm-thick specimens.
The mean color change for repeated
firings and different ceramic thick-
nesses for a zirconium framework was
below the color change units rated
as a match in the oral environment.
However, the color change was higher
for IPS e.max Press, indicating that
extended firings could compromise a
successful intraoral color match. In-
vestigators did not provide detail on
the color of the core ceramics. This is
important, given that most zirconium
specimens are opaque white, and
lithium disilicate glass ceramic can be
heat pressed in multiple shades. Fi-
Volume 102 Issue 1
nally, without a control of a fired, un-
veneered core specimen, the true influ-
ence of the core on the color change
cannot be determined.
Removable partial dentures
Component removable partial
dentures are fabricated in segments
and assembled on a final cast. The
possible advantage of a passive fit
has always been countered by the dif-
ficulty in maintaining passivity and
strength when joining the units. Two
studies addressed these issues. An in
vitro analysis was undertaken to mea-
sure distortions in cobalt-chromium
frameworks after laser welding.152 A
Kennedy Class III mandibular arch
was reproduced in a refractory final
cast from which 5 frameworks were
cast. Measuring points were defined
on a measuring base and the fit of the
casting was evaluated with an optical
microscope in 3 axes. Each casting
was cut in the middle of both eden-
tulous spans and reseated. The seg-
ments were joined with acrylic resin
(GC Pattern Resin; GC America), and
a welding cast was poured against the
framework. The joint was prepared
and laser welded. The specimens
were returned to the final cast for fi-
nal optical measurements. The results
indicate that the use of laser welding
can maintain an accurate fit of the
framework. The authors highlighted
the significant increase in cost associ-
ated with the laser welding procedure
as compared to casting alone.
The torsional strength, ductility,
and fracture behavior of titanium al-
loy, commercially pure titanium, and
cobalt-chromium after laser welding
was compared in an interesting in vit-
ro investigation.153 Fifteen dumbbell-
shaped specimens of each metal were
cast. The specimens were divided into
3 groups: unwelded, welded with
200V of laser voltage, and welded with
260V of laser voltage. The laser weld-
ing was conducted with a Nd:YAG
unit. The welded specimens were cut
in half and then laser welded at the
appropriate voltage. All of the speci-
Donovan et al
July 2009
mens were then tested with a multiax-
is hydraulic unit until failure. The frac-
tured specimens were observed under
a scanning electron microscope for
fracture characteristics. The results
indicated that the welded joints in
both titanium groups were as strong
as in the unwelded group. The Co-Cr
welded groups abruptly failed at the
weld joint, resulting in significantly
lower torsional strength compared to
that of the unwelded casting. All of
the titanium castings broke outside of
the weld. The Co-CR castings failed
within the welded joint. These failures
demonstrated a brittle fracture char-
acteristic under SEM.
Impression materials
Poor impression quality is a con-
cern for both restorative dentists and
dental laboratories. A randomized
controlled clinical trial was conduct-
ed on the reproduction of finish lines
during clinical impression making with
polyether monophase, 1-step vinyl
polysiloxane (VPS), and 2-step putty-
wash VPS impression materials.154 Im-
pressions on 48 patients requiring a
posterior single crown or short-span
fixed prosthesis were evaluated for ac-
curacy of the finish line reproduction.
Plaque index, probing depth, bleed-
ing on probing, and gingival index
were recorded as independent param-
eters for evaluation. The same inves-
tigator made all of the impressions.
A dual-cord technique was used with
aluminum chloride chemical astrin-
gent. Three impressions were made of
each tooth with the materials used in
random order for each subject. None
of the impressions were repeated, re-
gardless of the quality. Investigators
recorded bleeding during impression
making and blood in the impression.
If investigators control the field to be
impressed more carefully, it may be
possible to determine if the choice of
impression technique or sulcus con-
trol is the key to providing a clinically
acceptable reproduction of the finish
line. Definitive casts were prepared
from the impressions and the prepared
Donovan et al
tooth and adjacent teeth digitally
scanned. The finish line reproduction
was the only outcome measured. The
cast from the 1-stage VPS impression
was chosen as the reference, and 3-D
deviations from it were evaluated. The
results showed that the 1-stage VPS
impression is the most accurate. The
monophase polyether reproduced fin-
ish lines significantly more accurately
than the 2-stage putty-wash VPS tech-
nique. Several factors weakened this
study, the greatest of which was that
the 1-stage impression was chosen as
the control. The study may only com-
pare the results of the other materials
against a 1-stage technique, and pro-
vides no proof that any impression
adequately reproduced the intraoral
finish line. The study does, however,
bring into question the accuracy of a
2-stage putty-wash technique, given
the comparatively poor detail repro-
duction. As expected, blood in the
field or in the impression affected the
accuracy.
Another project investigated the
depth of reproduction with sulcus
width and material mixing techniques
as variables.155 Researchers created
a steel master die with an adjustable
artificial sulcus from reversible hy-
drocolloid. The sulcus depth was a
constant 2 mm. Sulcus widths tested
varied: 50, 100, or 200 µm. Impres-
sions with 1 vinyl polysiloxane (VPS)
(Flexitime; Heraeus Kulzer), 2 poly-
ether (PE) (Impregum; 3M ESPE, and
P2 Polyether; Heraeus Kulzer) and 1
hybrid VPS/PE elastomer (FUS) (Fu-
sion; GC Corp) were made using a
single-mix or double-mix technique.
The single-mix was made with the
light-body or monophase pastes only.
The double-mix was produced with
a light-body wash and a monophase
or heavy-body tray material. Repro-
duction of the sulcus depth and de-
tail was determined by 3-dimensional
laser topography of the impressions.
Analysis by a 3-way ANOVA indicated
that the impression material, impres-
sion technique, sulcus width, and
their interactions were all significantly
different. At a 200-µm width, VPS
37
and Impregum reproduced the total
depth of the sulcus equally as well
and significantly better than FUS and
P2 Polyether, which were not signifi-
cantly different. The impression mix
techniques provided only a small sig-
nificant difference between VPS and
FUS. For a sulcus width of 100 µm,
all of the variables were significantly
different. Impregum reproduced the
sulcus depth better than VPS and
FUS, which were both significantly
better than P2 Polyether. The depth
of reproduction was also impacted by
the mixing technique. A double-mix
technique was better for all materi-
als. Finally, at the 50-µm-wide sulci,
the materials, techniques, and their
interactions were significantly differ-
ent. Impregum reproduced detail to
a greater depth than FUS and VPS.
The P2 Polyether showed the poorest
reproduction. The double-mix tech-
nique was again superior to either sin-
gle-mix technique. All materials pro-
duced poorer reproduction and more
variation with smaller sulcus widths.
The results demonstrated that with
a suitable retraction technique that
opens the sulcus to a width of 0.2
mm or greater, a clinically acceptable
impression may be fabricated, irre-
spective of the material or technique.
The investigators concluded that the
accuracy of the impressions is more
dependent on the impression mate-
rial and the mixing technique when
there is insufficient retraction or when
time delay after removal of the retrac-
tion cord has caused the sulcus to col-
lapse.
Fixed prosthodontics
A clinical study investigated the
internal fit and marginal accuracy
of zirconium 4-unit all-ceramic fixed
partial denture (FPD) frameworks.156
Twenty-four posterior 4-unit FPDs
were fabricated from a semisintered
blank zirconia material using com-
mercially available computer-aided
design/computer-aided manufac-
turing (CAD/CAM) methods. The
frameworks were veneered with Lava
38
Ceram (3M ESPE). After intraoral
adjustment, the resultant internal
space was documented by replica
technique. A light-bodied silicone was
applied as a disclosing medium and
loaded from the occlusal with 20-N
force. After removal, a heavy-bodied
silicone was added to the retainers to
stabilize the film in the abutment. The
replicas were sectioned and cross-
sections were measured at x50 mag-
nification at 4 landmarks: marginal
discrepancy, midaxial discrepancy,
axio-occlusal transition, and centro-
occlusally. The investigator random
error was 8.9%, or twice the amount
of other similar studies. The 4-unit
FPDs demonstrated a mean mar-
ginal discrepancy of 91 µm (SD ±58
µm) and a median of 77 µm. At the
midaxial landmark, the mean discrep-
ancy was 98 µm (SD ±45 µm) with a
median of 87 µm. The mean of the
axio-occlusal transition was 207 µm
(SD ±215 µm) with a median of 167
µm. At the centro-occlusal landmark,
a mean of 202 µm (SD ±181 µm) was
measured, with a median of 170 µm.
While molar and premolar abutments
did not differ significantly from each
other, it should be noted that molars
showed greater inaccuracies than the
premolars. The investigators con-
cluded that the fit of zirconium 4-unit
fixed partial dentures compares fa-
vorably to the median fit of a 3-unit
metal ceramic FPD and 3-unit zirco-
nium FPDs. While this clinical study
provides an evaluation of a novel use
for a zirconium prosthesis, the large
discrepancies in fit and significant
standard deviations call into question
the recommendation. Extreme values
were possibly due to the larger milled
framework and shrinkage that occurs
in the sintering process, making the
clinical reliability of fit questionable.
While the zirconium framework occa-
sionally meets the 100-µm marginal
level of clinical acceptability, large
internal gap widths and variations in
the internal discrepancies may impact
the stability of this all-ceramic resto-
ration.
The Journal of Prosthetic Dentistry
IMPLANT DENTISTRY
There were numerous articles re-
lated to implant dentistry published in
the peer-reviewed literature in 2008. A
cursory search of PubMed referenced
1106 articles on this subject that were
published in the past year. The major-
ity of these publications were opinion
or technique articles, clinical reports,
or in vitro studies. There were numer-
ous short-term (1 or 2 years) clinical
studies, most of which had relatively
small sample sizes and no controls.
As has been the trend in recent years,
a number of systematic reviews were
published, some which are included in
this review. While these systematic re-
views often provide good information
regarding specific questions related
to the discipline of implant dentistry,
they almost universally indicate signif-
icant deficiencies in research design of
available clinical trials, which limit the
ability of the reviewers to form defini-
tive conclusions.
One such example was a system-
atic review that attempted to deter-
mine the relative efficacy of various
treatment modalities that have been
advocated for the treatment of peri-
implantitis.157 Periimplantitis is de-
fined as plaque-induced progressive
bone loss around osseointegrated im-
plants observed on radiographs and
coupled with clinical signs of infection
of the periimplant soft tissues. The in-
cidence of periimplantitis is generally
underreported; it may be as high as
16% for machined implants in service
more than 10 years and may be higher
with rough-surfaced implants.
An initial search of the literature
yielded 1304 possibly relevant titles;
13 of these publications were rigor-
ously evaluated, and only 5 studies
were deemed acceptable for the re-
view. Sample size calculations were
not done for any of the selected ran-
domized clinical trials (RCTs) and all
had relatively small sample sizes. It
was concluded that the risk for bias
was high for all included studies. As a
result of the substantial methodologi-
cal discrepancies amongst the stud-
Volume 102 Issue 1
ies, it was not feasible to conduct a
meta-analysis.
The data were not sufficient to
establish a gold-standard approach
for the treatment of periimplantitis.
The authors concluded that submu-
cosal debridement alone may not be
adequate for removal of the bacterial
load from the surfaces of implants
with periimplant pockets of 5 mm
or more. Mechanical debridement
coupled with the use of minocycline
appeared to have an improved treat-
ment outcome compared to debride-
ment along with chlorhexidine in the
short term. Guided bone regenera-
tion or use of a bone substitute can be
efficacious, but more data are needed
to determine optimum regenerative
techniques.
Another systematic review was
conducted with the objective to iden-
tify the most effective interventions
for treating periimplantitis around os-
seointegrated dental implants.158 The
authors evaluated data from 7 clinical
trials. Six of the 7 trials were consid-
ered to be at high risk for bias. It was
concluded that while most currently
used protocols for the treatment of
periimplantitis may be effective in the
short term, there is little reliable evi-
dence suggesting which intervention
might be the most efficacious.
In implant sites with 50% or great-
er bone loss, the addition of topical
antibiotic therapy to mechanical deb-
ridement resulted in a reduced pocket
probing depth (PPD) of 0.6 mm over
4 months. Four of the evaluated trials
demonstrated that mechanical debri-
dement alone, which is the simplest
approach, provided results that were
equivalent to more complex and ex-
pensive therapies. However, in all of
these studies, sample sizes were small
and follow-up times were short, so
the conclusions need to be consid-
ered with caution.
Results of implant therapy in pa-
tients with a history of periodontitis
have been of interest to clinicians. A
systematic review was done to deter-
mine the outcome of implant therapy
in periodontitis-susceptible patients
Donovan et al
July 2009
compared to patients with no history
of periodontal disease.159 Only trials
with a follow-up of 1 year or more
were considered for inclusion in the
review.
It was determined that there was
no statistically significant difference
in the survival of implant superstruc-
tures or implants in periodontitis-sus-
ceptible or nonperiodontitis subjects
evaluated at several different time
frames. More subjects in the perio-
dontitis-susceptible group developed
periimplantitis than in the nonperio-
dontitis group. Furthermore, the in-
cidence of periimplantitis was higher
in patients with aggressive periodon-
titis as opposed to those with chronic
periodontitis. Greater periimplant
bone loss was seen in the periodonti-
tis-susceptible group.
The author concluded that implant
treatment in periodontitis-susceptible
patients is not contraindicated. How-
ever, the higher demonstrated inci-
dence of periimplantitis may reduce
the potential longevity of the implant
treatment. When treating periodon-
titis-susceptible patients, it is recom-
mended that all severely compro-
mised teeth be extracted some time
before implant placement and that
treatment for the periodontitis should
be completed prior to implant place-
ment.
Another systematic review was
completed to determine implant out-
comes in partially dentate patients
who had been treated for periodontitis
compared with periodontally healthy
patients.160 Trials with a follow-up of
6 months or more were considered
for inclusion. Results from 9 clinical
trials were evaluated. Almost all stud-
ies were rated at a high risk for bias.
Higher survival and success rates
were recorded for nonperiodontitis
subjects than for subjects previously
treated for periodontitis. The non-
periodontitis group also had less peri-
implant bone loss and a lower inci-
dence of periimplantitis. The authors
suggest that all periodontal therapy
be completed prior to initiating im-
plant therapy and that these patients
Donovan et al
require continuous monitoring and
maintenance, but present limited
data in support of those recommen-
dations.
Interpretation of the data in the
preceding systematic reviews is con-
founded by the lack of data available
on the smoking habits of the subjects
in the included trials. Because smok-
ing is strongly associated with perio-
dontitis, implant failure, and periim-
plantitis, and because there was little
information on smoking patterns of
the subjects, the relative roles of peri-
odontitis and of smoking in the find-
ings is unknown.
There continues to be consider-
able interest in protocols involving
immediate and early loading of dental
implants. Outcomes with traditional
delayed loading (2.5-6 months) have
been excellent, but this approach re-
sults in prolonged treatment times
and frustration for many patients.
One RCT compared outcomes
with wide-bodied implants in the mo-
lar area that were restored with imme-
diate and delayed loading.161 Fifteen
implants were placed in each group.
The delayed group implants were re-
stored 3 to 4 months after implant
placement. The immediate loading
group received provisional restora-
tions loaded in maximum intercuspa-
tion position (MIP) with no contact in
lateral or protrusive excursions within
24 hours of implant placement.
Bone levels were evaluated radio-
graphically at the time of implant
placement and at 1 year. Immediately
loaded implants had an average loss
of 0.77 mm at 1 year, while the de-
layed loading group of implants had
a mean bone loss of 1.2 mm after 1
year. The difference was statistically
significant (P=.22) No implants were
lost at 1 year in the delayed loading
group, while 1 implant was lost in the
early loading group.
The authors concluded that imme-
diate loading of wide-bodied implants
in the mandibular molar region was a
viable option. Readers are cautioned
that this study has a small sample size
(n=15) and short time of observation
39
(1 year).
A prospective multicenter study
evaluated outcomes with 170 1-stage
smooth-surfaced mandibular im-
plants restored with early loading.162
The definitive prostheses were placed
within 6 weeks after implant place-
ment. All implants were placed in the
anterior mandible. One hundred and
twenty implants in 30 patients were
restored with mandibular overden-
tures, and 50 implants in 10 patients
were restored with fixed prostheses.
Prostheses and implants were evalu-
ated clinically and radiographically at
1, 3, and 5 years.
Twelve implants failed in 6 pa-
tients, and the cumulative implant
survival rate was 92.9% at 5 years.
Three implants were mobile but func-
tioning at 5 years, resulting in a cumu-
lative success rate of 91%. Mean bone
remodeling was less than 0.1 mm per
year after the first year of loading, and
the mean marginal bone level apical
to the implant collar was 0.66 mm.
The authors concluded that early
loading of implants in the anterior
mandible was successful for the ma-
jority of patients, and stable periim-
plant conditions resulted. They spec-
ulated that the slightly higher failure
rate compared to that achieved with
traditional loading protocols was due
to generous inclusion criteria and
the learning curve associated with a
novel treatment procedure. Unfortu-
nately, because the study had no con-
trol group, any speculation regarding
these results is merely speculation.
Immediate or early loading of den-
tal implants can be recommended for
implants placed in the anterior mandi-
ble, but the efficacy of such protocols
in the maxilla is not well documented
in the long term. One RCT compared
results of early and delayed loading
with implant-supported complete-
arch prostheses in the maxilla.163 An
early-loading protocol (within 9 to 18
days of placement) was used with 16
subjects, and a delayed protocol (2.5
to 5.1 months after placement) was
used with 8 subjects. Smokers were
excluded from the study.
40
A total of 142 implants were
placed, 95 in the early loading group
and 47 in the delayed loading group.
Either 5 or 6 implants were used in
each subject to support a complete-
arch prosthesis. Subjects were recalled
after 1, 3, and 5 years of loading for
clinical and radiographic evaluation.
In the early loading group, 5.3%
(5) of the implants were lost at 5
years. Also at 5 years, 4.3% (2) of the
implants were lost in the delayed load-
ing group. There were no differences
in implant stability. The early load-
ing group had more bone loss (0.8
mm versus 0.3 mm) than the delayed
loading group. The main technical
complications were tooth fractures
from the acrylic resin denture base. It
was concluded that this RCT showed
no important differences in treatment
outcome between early and delayed
loading of implants in the edentulous
maxilla after 5 years of function.
An interesting case-control study
evaluated tooth and implant loss in
refractory periodontal patients over
a mean period of 13.4 years (range,
8 to 19 years).164 The control group
was composed of matched age/gen-
der patients from the same specialty
practice.
Individuals who continue to suffer
from progressive periodontal deterio-
ration in spite of regular maintenance
are classified as having refractory
periodontal disease. Only 2.2% (27)
of patients in the specialty practice
conducting the study met the criteria
for inclusion in the refractory group.
Predictive factors for the refractory
group were heavy smoking (>20 ciga-
rettes/day), stress, and having a fam-
ily history of periodontitis.
Each refractory subject lost a mean
of 10.4 teeth (range, 4 to 16) over the
term of the study. This represented
50% of the teeth present at baseline.
Refractory subjects lost 0.78 teeth
per year, which was 35 times greater
than tooth loss in the control group.
Implants were placed in 14 of the
refractory subjects, and 9 of these
(64%) lost at least 1 implant. In total,
17 (25%) of the implants placed in the
The Journal of Prosthetic Dentistry
refractory group were lost. Fourteen
of these failed to integrate. Another
5 implants developed periimplanti-
tis and 3 of these implants were lost.
None of the implants placed in the
control group were lost. While this
case-control study includes a relative-
ly small sample size, results indicate
that implant therapy should be pro-
vided with caution for patients diag-
nosed with progressive periodontitis
associated with continued tooth loss.
There continues to be consider-
able interest and confusion related
to any type of dental surgery in pa-
tients taking bisphosphonates. There
appears to be some evidence that
patients taking intravenous bisphos-
phonates are at higher risk of devel-
oping osteonecrosis of the jaw (ONJ)
after oral surgery, but a direct causal
relationship has yet to be determined.
One retrospective study attempted to
determine outcomes of bone graft-
ing and implant placement in a group
of subjects taking oral bisphospho-
nates.165
A group of 42 subjects who had
taken oral bisphosphonate medica-
tion prior to receiving implants or
bone grafts were identified. The sub-
jects received 100 implants and 68
bone grafts. The subjects had been
taking oral bisphosphonate medica-
tion from 6 months to 11 years prior
to surgery, and most continued to
take the medication through the fol-
low-up period, which ranged from 4
months to over 7 years.
Of the 100 implants placed, 5
failed, yielding a success rate of 95%,
which was comparable to success
rates achieved in many studies. Three
of the failures were in the posterior
maxilla and 1 was in a heavy smoker.
All failures occurred before functional
loading. No patients showed any signs
or symptoms of ONJ. All of the usual
periodontal parameters were within
normal limits. Although the sample
size in this study is relatively small, it
does lend credence to the commonly
held concept that patients taking oral
bisphosphonates are not at high risk
for developing ONJ and that such pa-
Volume 102 Issue 1
tients can be the recipients of success-
ful implant and bone graft surgery.
Another retrospective analysis of
implant placement outcomes in pa-
tients taking oral bisphosphonates
was conducted.166 A total of 468 im-
plants were placed in 115 subjects
who were taking oral bisphospho-
nates. Only 2 of the implants failed
to integrate, yielding a success rate
of 99.6%. There was no evidence of
bisphosphonate-associated ONJ in
any of the patients. The authors con-
cluded that guidelines for treatment
of dental patients receiving intrave-
nous bisphosphonate treatments
should be different than for patients
taking the oral formulations of these
medications. Given the small sample
sizes in both of the last 2 studies, cli-
nicians would be wise to proceed with
caution when treating patients taking
oral bisphosphonates and in need of
implants and/or bone grafts. Clearly
treatment can be accomplished suc-
cessfully, but many questions remain
unanswered. It is possible that the
duration of bisphosphonate therapy
may influence results or that there are
confounding variables, such as smok-
ing or concomitant prednisone ther-
apy, which also may have an effect.
Clearly this subject requires more
investigation before clear, unambiva-
lent guidelines can be suggested.
One interesting systematic review
asked the question: “Does systemic
prophylactic antibiotic administra-
tion improve the outcome of implant
therapy versus no antibiotic/placebo
administration”?167 Only 2 acceptable
RCTs were identified. One of these
RCTs compared a protocol of 2 g of
preoperative amoxicillin versus a pla-
cebo (316 subjects). The other RCT
compared a protocol of 2 g of amoxi-
cillin preoperatively plus 500 mg of
amoxicillin 4 times/day for 2 days
postoperatively, versus no antibiotics
(80 subjects).
The meta-analysis of the 2 tri-
als demonstrated a statistically sig-
nificantly higher number of subjects
experiencing implant failures in the
group not receiving antibiotics. There
Donovan et al
July 2009
were no differences in the other out-
comes evaluated.
The authors concluded that there
is some evidence that 2 g of amoxi-
cillin given orally preoperatively sig-
nificantly reduces failures of dental
implants. It remains unclear whether
postoperative antibiotics are ben-
eficial, and which antibiotic might be
the most effective.
Another systematic review evalu-
ated the incidence of abutment screw
loosening in single implant restora-
tions.168 After initially identifying 1526
articles, the review was conducted us-
ing 27 studies. Internal and external
connection groups were examined
separately. The external connection
group consisted of 12 studies and 586
single implant restorations for a mean
follow-up time of between 3 and 5
years. The number of complication-
free single implant restorations after
3 years was 97.3%.
The internal connection group
comprised 15 studies with 1113 sin-
gle implant restorations for a mean
follow-up time of 3 to 10 years. The
percentage of complication-free sin-
gle implant restorations after 3 years
was 97.6%. The results between the
groups were not statistically signifi-
cant.
It was concluded that abutment
screw loosening is a rare event in sin-
gle implant restorations, regardless
of the implant-abutment connection,
provided that proper antirotational
features and torque are used.
Given that achieving accurate de-
livery of torque to implant screws
is important to prevent screw loos-
ening, one timely study evaluated
the accuracy of 2 different types of
torque drivers.169 Five new mechani-
cal torque-limiting devices (MTLDs)
were obtained from 6 different manu-
facturers, and forces were applied to
the precalibrated torque values. Three
of the devices were of the friction style
and the other 3 were spring loaded.
The peak torque value registered by
a digital torque gauge was recorded,
and the procedure was repeated 50
times for each MTLD.
Donovan et al
Statistical analysis used repeated-
measures ANOVA (α=.05) to assess
the accuracy of the MTLDs in deliv-
ering target torque values. Both the
mean absolute difference and the
mean percentage deviation between
measured torque values and target
torque values differed significantly
for the friction-style MTLDs and the
spring-style MTLDs. The data revealed
that the spring-style MTLDs were sig-
nificantly more accurate than friction-
style MTLDs in achieving their target
torque values.
A systematic review was conducted
to determine if there is a certain num-
ber of implants necessary to retain an
overdenture.170 The literature was ex-
tensively searched, and, using specific
inclusion and exclusion criteria for the
studies, 11 studies were selected for
inclusion in the review. Three of these
studies concerned maxillary overden-
tures and 8 involved mandibular over-
dentures.
Considering  the  fundamental
truth that no single treatment modal-
ity for tooth replacement can meet
all patient requirements, the review
concluded that in the maxilla, patient
satisfaction with implant-supported
overdentures was not significantly
higher than with new conventional
complete dentures. Overdentures in
the maxilla should only be used when
anatomical or physiological condi-
tions compromise the retention and
stability of a conventional complete
denture. The review also concluded
that if an overdenture is fabricated
in the maxilla, it should be implant-
retained or implant-supported, and 4
implants should be placed.
In the mandible, success rates of
implants and prostheses and patient
satisfaction are not dependent on
the number of implants used. Con-
sidering economic and maintenance
factors, the use of 2 implants and a
connecting bar seems to be the best
option for mandibular implant-re-
tained overdentures.
An excellent systematic review was
conducted to determine the 5-year
survival rate of implant-supported
41
single crowns (SCs) and to determine
the incidence of both biological and
technical complications.171 Ultimate-
ly, data from 26 clinical studies were
used to conduct a meta-analysis.
Five-year survival of implants sup-
porting single crowns was 96.8%,
while the survival rate of single crowns
supported by implants after 5 years
was 94.5%. The survival rate of metal
ceramic crowns at 5 years (95.4%)
was significantly superior to the sur-
vival rate of all-ceramic crowns, which
was 91.2%.
The incidence of periimplantitis
at 5 years was 9.7%, and 6.3% of im-
plants had bone loss exceeding 2 mm.
For other complications, implant
fracture rate was 0.14%, screw or
abutment loosening was 12.7%, and
the incidence of ceramic or veneer
fractures was 4.5%. Clearly, survival
rates for both implants and implant-
supported SCs were high at 5 years,
but both biological and technical
complications occur frequently.
A 20-year follow-up was published
on a group of 48 consecutive patients
treated with implants in the early
1980s.172 Nineteen of the patients
had died, and 21 patients with 23 im-
plant-supported prostheses could be
examined clinically and radiographi-
cally. All patients had been treated
ad modem Brånemark with a 2-stage
surgical procedure. Implant connec-
tions were made 3 to 4 months after
placement in the mandible and after a
minimum of 6 months in the maxilla.
Prostheses were fabricated with gold
alloy and acrylic resin denture teeth.
A total of 123 implants (27 in the
maxilla, 96 in the mandible) had been
placed in these 21 patients. Only 1
implant was lost, yielding a 20-year
survival rate of 99.2%. Mean bone
loss at 20 years was 0.53 mm. The
incidence of periimplantitis and other
complications was low. These results
are outstanding, but readers are cau-
tioned that they may not be extrapo-
lated to the abbreviated surgical and
loading protocols currently used. The
implants used with these patients also
had machined surfaces, which may
42
have contributed to the low incidence
of periimplantitis.
In summary, the discipline of im-
plant dentistry continued to grow in
2008. In general, the results of prop-
erly delivered implant therapy tend to
be positive. Long-term data are begin-
ning to be available. It is clear, howev-
er, that the designs of most published
studies tend to be less than optimal
and, thus, it is difficult to definitively
answer many of the important ques-
tions that clinicians would like to have
resolved.
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Corresponding author:
Dr Terence E. Donovan
Department of Operative Dentistry
University of North Carolina
School of Dentistry
437 Brauer Hall, Campus Box 7450
Chapel Hill, NC 27599
Fax: 919-966-5660
E-mail: Terry_Donovan@dentistry.unc.edu
Copyright © 2009 by the Editorial Council for
The Journal of Prosthetic Dentistry.