Revista Romana de STOMATOLOGIE Supliment 2008

Revista Romn de
STOMATOLOGIE
Volumul LIV Nr. 3, Supliment An 2008
ISSN 1843-0805 Cod CNCSIS 756
Redactor ef: Prof. Univ. Dr. Em. HUTU Redactor ef Adjunct: Conf. Univ. Dr. M.V. CONSTANTINESCU Secretar General de Redacie: ef Lucr. Dr. Elena-Gabriela DESPA Dr. E. POPA Redactor Responsabil de numr: ef Lucr. Dr. Liana STANCIU Redactori verificare articole: Conf. Univ. Dr. Cornelia BCLEANU ef Lucr. Dr. Tudor IONESCU, ef Lucr. Dr. Dnu CHIRU Dr. Ingrid PINTILIE Redactori Relaii Internaionale: ef Lucr. Dr. Alina DAN Dr. Simona MUNTEAN
CONSILIUL TIINIFIC:
Prof. Dr. D. BORZEA Cluj-Napoca Dr. C. BRUSCAGIN Italia Prof. Dr. A. BUCUR Bucureti Prof. Dr. V. BURLU Iai Dr. Ugo CAPURSO Italia Prof. Dr. V. CRLIGERIU Timi Prof. Dr. Elvira COCRL Cluj-Napoca Prof. Dr. M. CRIOIU Craiova Conf. Dr. B. DIMITRIU Bucureti Prof. Dr. H. DUMITRIU Bucureti Prof. Dr. L. ENE Bucureti Prof. Dr. Norina FORNA Iai Prof. Dr. A. GARFUNKEL Israel Prof. Dr. N. GANUTA Bucureti Dr. I.B.T. GEORGESCU Bucureti Prof. Dr. Ov. GRIVU Arad Prof. Dr. A. ILIESCU Bucureti Prof. Dr. Ecaterina IONESCU Bucureti Conf. Univ. Dr. Ileana IONESCU Bucureti Prof. Dr. S. IONI Bucureti Conf. Dr. D.A. MARI Constana G-ral Prof. Dr. T.A. MIHAI Bucureti Prof. Dr. S. SANDHAUS Elveia Prof. Dr. Valentina SCNTEI-DOROB Iai Prof. Dr. A. SCHNEIDER Germania Dr. Eugenia ROCA Italia Prof. Dr. Mihaela PUNA Bucureti Conf. Dr. Al. PETRE Bucureti Prof. Dr. Mariana Brndua POPA Bucureti Prof. Dr. S. POPA Cluj Dr. Ion RNDAU Bucureti Prof. Dr. Dan Dumitru SLVESCU Bucureti Conf. Dr. C. VRLAN Bucureti Prof. Dr. Maria VORONEANU Iai Prof. Dr. Theodor TRISTARU Bucureti Conf. Dr. Irina ZETU Iai Conf. Dr. Liviu ZETU Iai
Universitatea de Medicin i Farmacie Carol Davila, Facultatea de Medicin Dentar, Bucureti
Prof. Dr. Drago STANCIU Decan Prof. Dr. Rodica LUCA Prodecan Conf. Dr. Radu erban OVARU Prodecan Conf. Dr. Codru SARAFOLEANU Prodecan Prof. Dr. Victor NIMIGEAN Secretar tiinific
Universitatea Titu Maiorescu, Facultatea de Stomatologie, Bucureti
Prof. Dr. D. SLVESCU Decan Prof. Dr. V. CHERLEA Prodecan Prof. Dr. Mircea IFRIM Prodecan Conf. Dr. Cornelia BCLEANU Secretar tiinific
Universitatea de Vest Vasile Goldi, Facultatea de Medicin General i Medicin Dentar, Arad
Prof. Dr. Maria NEGUCIOIU Prof. Dr. Voicu SEBEAN Prof. Dr. Emil URTIL Conf. Dr. Valeria COVRIG Conf. Dr. Mugur POPESCU Conf. Dr. Emanuel BRATU
Editura Medical AMALTEA

Editori: Dr. M.C. Popescu Dr. Cristian Crstoiu Director executiv: George Stanca Redactori: Oana Cristina Plcint, Alina-Nicoleta Ilie Prepress: AMALTEA TehnoPlus Tehnoredactor: Gabriela Cpitnescu DTP: Petronella Andrei Producie: Mihaela Conea Distribuie: Mihaela Stanca ________________ CONTACT: AMR@medica.ro ABONAMENTE: redactia@amaltea.ro
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Revista este realizat n colaborare cu Facultatea de Medicin Dentar a Universitii Titu Maiorescu, Bucureti
Cuprins
ODONTOLOGIE 1. Cornelia Bcleanu Administrarea de fluor pe cale general i local ____________________________________ 2 . Cornel Boitor, Anca Fril Sensibilitatea dentinar dup restaurri coronare adezive: cauze i mijloace de prevenie _____________________________________________________________________ 3 . Cornelia Bcleanu Posibiliti terapeutice n distrucii coronare ntinse ___________________________________ PARODONTOLOGIE 4. Theresa E. Madden, Brock Herriges, Linda Boyd, Gayle Laughlin, Gary T. Chlodo, David I. Rosenstein Alterations in HbA1c Following Minimal or Enhanced Non-surgical, Non-antibiotic Treatment of Gingivitis or Mild Periodontitis in Type 2 Diabetic Patients: A Pilot Trial _____________________________________________________ MATERIALE DENTARE 5. Maurizio Sedda, Andrea Casarotto, Aune Rausita, Andrea Borracchini Effect of Storage Time on the Accuracy of Casts Made from Different Irreversible Hydrocolloids ________________________________________________________ CHIRURGIE ORO-MAXILO-FACIAL 6. Mirela-Jeni Comancianu Eludrilul i implicaiile lui n cazul extraciei molarului de minte superior ________________ 7. Mehtap Muglali, Ayse Pinar Sumer Squamous Cell Carcinoma Arising in a Residual Cyst: A Case Report ___________________ OCLUZOLOGIE 8. Andre L.F. Costa, Anelyssa DAbreu, Fernandon Cendes Temporomandibular Joint Internal Derangement: Association with Headache, Joint Effusion, Bruxism, and Joint Pain __________________________________________________________ PROTETIC DENTAR 9. Anca Fril, Cornel Boitor Rolul zonei de nchidere velopalatinal n prevenirea eecurilor protezei mobile ___________ 10. Elena-Gabriela Despa Rezultatele studiului clinic i statistic asupra cmpului protetic edentat total ______________ 11. Elena-Gabriela Despa, Gabriela Moise Aspecte ale micrilor mandibulare la edentatul total _________________________________
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General and Local Fluorine Administration
ODONTOLOGIE
ADMINISTRAREA DE FLUOR PE CALE GENERAL I LOCAL

Conf. Dr. Cornelia Bcleanu Disciplina Odontoterapie restauratoare, Facultatea de Medicin Dentar, Universitatea Titu Maiorescu, Bucureti
METODE DE ADMINISTRARE GENERAL A FLUORULUI

n urma unor studii ample, s-a determinat c fluorul este singurul element mineral unanim corelat cu rezistena la carie a dinilor. Prevenirea cariei dentare prin administrarea de fluor reprezint modalitatea prin care s-au obinut cele mai importante rezultate. Ca urmare, administrarea fluorului se poate realiza pe cale general i pe cale local. Dintre modalitile de administrare a fluorului, pe cale general, cea mai indicat, (n special ca raport cost/eficien) este prin consumul de ap fluorizat. S-au fcut numeroase studii privind concentraia optim a fluorului n ap, toate demonstrnd ca reducerea cea mai spectaculoas a incidenei cariei se produce pn la o concentraie de 1 ppm, concentraie la care leziunile distrofice de fluoroz sunt rare i de minim gravitate. O sintez a 95 de studii din 20 de ri, realizate n condiii diferite privind eficacitatea prevenirii cariei dentare la copii prin fluorizarea apei, arat o reducere cu peste 40% a cariilor dinilor permaneni (Naylor i Murray-1976). De asemenea fluorul prezint o aciune benefic i asupra persoanelor adulte rezidente permanent ntr-o localitate cu ap fluorizat. La acestea s-a constatat o reducere cu 45% a numrului de suprafee cariate comparativ cu o populaie ce consum ap cu un coninut sczut de fluor. Astfel se poate concluziona c fluorizarea apei are un efect protectiv substanial i de durat. Fluorizarea apei, combinat cu celelalte msuri preventive a redus prevalena cariei cu circa 75% n general, iar pentru suprafeele aproximale chiar cu 90%.
La adulii cu vrsta ntre 20-44 ani s-a estimat n urma consumului de ap fluorizat o reducere cu 20-30% a cariilor coronare i o reducere cuprins ntre 20-40% a cariilor radiculare. De asemenea, s-a demonstrat c fluorul prezint efectul cariopreventiv cel mai mare pe suprafeele libere 86%, apoi pe suprafeele aproximale 75%, iar cel mai mic efect cariopreventiv l prezint la nivelul anurilor i fosetelor ocluzale 31%. Toate aceste date i-au permis lui Horowitz s afirme c fluorizarea apei asigur beneficii tuturor persoanelor dentate de-a lungul ntregii viei. O alt metod de administrare general a fluorului este prin fluorizarea srii de buctrie ce se realizeaz cu 200-250 mg fluorur de Na la 1kg de sare, asigurndu-se astfel un aport de pn la 2 mg Fluor la un consum mediu de 6g sare/zi. Fluorizarea srii de buctrie nu necesit dect 3% din cantitatea de fluor necesar pentru fluorizarea apei ns efectul carioprotectiv este ceva mai sczut dect cel care se ntlnete n urma fluorizrii apei potabile. Fluorizarea laptelui i a buturilor rcoritoare are de asemenea efecte carioprotective ns mai sczute dect cele obinute n urma fluorizrii apei potabile. Stephen (1981) a artat c un consum zilnic n coal de 200 ml lapte cu coninut de 1,5 mg de fluor pe timp de 4 ani a redus incidena cariei la primii molari permaneni cu 34% comparativ cu lotul martor. De asemenea GEDALIA (1981) a raportat o reducere cu 28% a indicelui DMF S la copiii de 6-9 ani care au consumat la coal 100 g suc de portocale coninnd 1 mg F (10 ppm) pe o perioad de 3 ani.
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n ceea ce privete fluorizarea alimentelor, aceasta prezint dezavantajul unui dozaj relativ prin diferenele cantitative de ingestie alimentar ntre indivizi, iar compoziia deosebit a meniurilor face imposibil stabilirea unui echilibru de dozare a fluorului. O alt metod de administrare a fluorului pe cale general este prin administrarea tabletelor i soluiilor ce conin fluor. n literatura de specialitate au aprut mai multe articole ce se refer la eficacitatea administrrii tabletelor sau soluiilor, articole ce au fost sintetizate de ctre DRISCOL 1974 i BINDER 1978. Aceste cercetri pot fi mprite n trei grupe dup modul de administrare: 1. prenatal; 2. nainte de vrsta colar; 3. la coal i numai n timpul colii. 1. Administrarea de fluor prenatal este benefic n profilaxia cariei la copii, n special pentru dentiia temporar dar cele mai bune rezultate se obin dac este continuat prin administrare de fluor la copil ct mai curnd dup natere. 2. Potrivit diferitelor studii se arat c efectele carioprotective mari (circa 50-80%) s-au obinut dac administrarea fluorului s-a nceput nainte de vrsta de 2 ani. Efectele cele mai bune s-au obinut unde dozele de fluor au fost corelate cu concentraia fluorului din ap i cu vrsta copilului (HENON 1977). Studiile privind efectul administrrii fluorului sub form de tablete sau soluii asupra dinilor permaneni arat o reducere important a cariilor mai ales dac administrarea s-a fcut de la natere cel puin 7 ani (ntre 39 i 80%). 3. Administrarea tabletelor sau soluiilor cu fluor n coal ncepnd cu clasa I (6-7 ani), cu o durat de minimum 5 ani s-a dovedit cariopreventiv n medie de 30% (DRISCOL 1978). Aceste cercetri arat fr nici un dubiu c folosirea tabletelor sau soluiilor este eficient n prevenirea cariilor dentare att la dinii temporari ct i la cei permaneni. Dup vrsta de 2 ani este de preferat s se administreze fluorul sub form de tablete, copilul fiind instruit s le sug seara, nainte de culcare, pentru a combina efectul general cu cel local asupra dinilor temporari. Se folosesc tablete de fluor: Concaden; Zymafluor; Law. Cu o cantitate de fluor de: 0,25 mg; 0,50 mg; 0,75 mg; 1 mg
Cantitatea de fluor administrat trebuie corelat cu: concentraia fluorului din apa potabil; vrsta copilului; zona climatic. Pentru zona de clim temperat, dac fluorul din apa potabil nu depete 0,4 ppm, se administreaz n funcie de greutatea copilului: de la natere pn la 10 kg 0,25 mg F/zi; de la 10 kg la 15 kg 0,5 mg F/zi; de la 15 kg la 20 kg 0,75 mg F/zi; peste 25 kg 1 mg F/zi. Pentru obinerea efectului cariostatic este necesar aportul minim de 1,3 mg de fluor zilnic pe cale general. Suplimentarea, indiferent de metod, se raporteaz la: concentraia din apa potabil; cantitatea de ap potabil consumat n medie pe zi; aportul mediu oferit prin alimente; concentraia din atmosfer, pentru zonele cu poluare fluorurat. Pentru a fi eficace metodele de administrare general trebuie: s foloseasc faza I (amelogenez i mineralizare); s se prelungeasc n faza a II-a (de maturare preeruptiv); s se prelungeasc chiar i la nceputul fazei a III-a (posteruptiv) cnd se completeaz maturarea superficial a smalului. Programul complet ncepe prin administrarea zilnic de fluor la femeia gravid ncepnd cu luna a IV-a de sarcin i pn la natere, se continu administrarea la copil ncepnd ct mai aproape de momentul naterii, zilnic, pn la vrsta de 12-14 ani, fr ntrerupere. Administrarea numai n prima faz (0-6 ani) sau numai n a II-a faz (6-12 ani) reduce mult eficacitatea cu perspectiva de a se pierde efectul n timp. Dac se respect programul complet (cel puin de la 0 la 12 ani) n toate metodele se obin rezultate egale. Diferenele sunt doar n privina costului, uurina de administrare i posibilitile de abordare a unor colectiviti ct mai mari.
METODE DE FLUORIZARE LOCAL

Fluorizarea local se poate realiza profesional dar i personal.
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Fluorizarea local profesional se poate realiza cu ajutorul soluiilor simple de NaF sau SnF, soluiilor sau gelurilor cu un pH acid, pastelor profilactice cu fluor i lacurilor cu fluor. Dintre soluiile cu fluor utilizate n fluorizarea profesional local, se folosesc: a. Fluorura de sodiu 2% ce este cea mai uzual soluie pentru aplicaii topice pe dinii curai (fr plac bacterian) de 2-4 ori pe an. b. Fluorura de staniu este de 3 ori mai eficient n scderea solubilitii smalului la acizii slabi comparativ cu soluia de NaF. Gelurile de fluor utilizate n fluorizarea local profesional s-au obinut prin adugarea n soluii a unor ageni de gelificare, cum ar fi metil, hidroximetil celuloz. Din aceast categorie fac parte gelul de fluorortofosfat ce este uor de utilizat ntr-un conformator individual, nu provoac salivaie sau senzaie de vom pentru c nu se rspndete n cavitatea bucal i are proprieti tixotropice, adic, se transform n soluie sub aciunea presiunii, ptrunznd astfel n anuri i fosete. n cazul aplicrilor bianuale reducerea cariilor este de 20-40%. Alturi de acesta, se mai utilizeaz i gelul de fluorur de amin ce reduce solubilitatea smalului i uureaz prin proprietile lui tensioactive, fixarea de fluor la suprafeele dentare. Un astfel de gel este gelul ELMEX ce se aplic o dat pe sptmn pe suprafeele dinilor, cu ajutorul unei canule adaptate la sering, lsnduse 2-3 minute n contact cu dinii, dup care se realizeaz periajul. Lacurile cu fluor au fost realizate pentru a reduce timpul de aplicare, pentru a simplifica tehnica i pentru a crete timpul de contact al fluorului cu suprafeele dinilor. Produsele cele mai cunoscute sunt: DURAPHAT ce conine 2,26% F sub form de NaF, ntr-o soluie alcoolic de rini naturale, el adernd uor pe suprafeele umede ale dinilor; ELMEX PROTECTOR ce conine aminofluoruri ncorporate ntr-un lac de poliuretan autopolimerizabil; EPOZYLATE ce este un lac protector de lung durat i are ncorporat monofluor disodic ntr-un lac de poliuretan autopolimerizabil.
n ceea ce privete eficiena acestora, s-a constatat c, aplicate pe o perioad mai mare de timp i prin aplicri mai frecvente se obine o reducere a incidenei cariei ntre 30 i 38%, fiind la fel de eficiente ca i soluiile i gelurile fluorurate. Aplicaiile topice prin ionoforez reprezint cea mai eficace metod de prevenire prin aplicaii topice de fluor prin faptul c prin aciunea curentului de joas tensiune, ionul de fluor este forat s ptrund n cantitate mare i la o adncime mai mare, inclusiv pe feele aproximale, n structura smalului. n acest fel se aplic soluiile de fluorur de sodiu 1% sau de fluorortofosfat 1,4% n ine sau n gutiere standard sau individuale, conectate la o instalaie simpl cu baterii electrice, ns metoda este costisitoare i dificil de aplicat n colectiviti. Fluorizarea local personal se realizeaz de ctre pacient cu ajutorul pastelor de dini fluorurate i cu aminofluoruri i prin cltiri bucale. Exist ns rezerve n ceea ce privete folosirea pastelor de dini cu coninut ridicat de fluor la copii n cursul mineralizrii i maturrii smalului dinilor permaneni, n special n zonele fr deficit de fluor n apa potabil, din cauza posibilitii de apariie a fluorozei. n ceea ce privete cltirile bucale, acestea se realizeaz cu ajutorul unor: soluii de NaF neutrale n concentraii de la 500 ppm la 3 000 ppm; soluii acidulate de NaF; soluii cu fluoruri de staniu, amoniu, fier, aluminiu. Cercettorii care au testat mai multe soluii cu fluor (TAVEL i ERICSON1965) au ajuns la concluzia c se obin rezultate pozitive cu oricare din aceste combinaii, eficacitatea depinznd de concentraia n ion de fluor, i timpul de contact cu suprafeele dentare. n general se obine o reducere de peste 30% n aplicaii zilnice timp de mai muli ani, ns nu se recomand la copii sub 5 ani care pot nghii o cantitate din soluie cu posibilitatea de supradozare a fluorului ingerat. n tabelul urmtor sunt reprezentate substanele pe baz de fluor care sunt utilizate pentru aplicaii profesionale sau la domiciliu.
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Adres de coresponden: Conf. Dr. Bcleanu Florentina Cornelia, Facultatea de Medicin Dentar, Universitatea Titu Maiorescu, Strada Gheorghe Petracu, Nr. 67A, Sector 3, Cod Potal 031593, Bucureti email: corneliabicle@yahoo.com
ODONTOLOGIE
SENSIBILITATEA DENTINAR DUP RESTAURRI CORONARE ADEZIVE: CAUZE I MIJLOACE DE PREVENIE

Dentinal Sensibility After Adhesive Coronal Restorations: Causes and Prevention Methods
ef Lucr. Dr. Cornel Boitor, ef Lucr. Dr. Anca Frail Facutatea de Medicin Victor Papilian, Sibiu
REZUMAT
Dei n vitro adeziunea dintre esuturile dentare i materialul de obturaie adeziv ndeplinete caliti remarcabile, n practica cotidian se constat ntr-un proces important de cazuri apariia unei sensibiliti dentinare postoperatorii. Aceast sensibilitate depinde de factorii locali ai pacientului dar i de calitatea sau modul de utilizare al materialelor compozite folosite. Cuvinte cheie: adeziune compozit-dinte, contracie de polimerizare, sensibilitate dentinar, prevenie.
ABSTRACT
Althuoght in vitro the adhesion between the dental tissue and adhesive felling materials is very, strong freqently in practice we there a past operatory dentinal sensibility. This sensibility depend an local pacient factors but also on the qualitz of the materials that has been used. Key words: the dental-composite adhesion, polimerisation contraction, dental sensibility, prevention.
Pentru a putea considera apariia sensibilitii dentinare ca un eec al restaurrilor adezive, trebuie s eliminm a priori printr-un diagnostic diferenial toate celelalte cauze posibile, precum: fracturi, fisuri, leziuni carioase, parodontite apicale, eroziuni cuneiforme, abrazii. Dei mecanismele fiziopatologice de producere a sensibilitii dentinare nu sunt complet elucidate, ipoteza hidrodinamica a lui Brannstrom este mprtit de un numr foarte mare de studii recente (1,2). Din punct de vedere clinic, manifestrile de sensibilitate post operatorie, dup restaurri adezive, apar ntr-o relaie evident cu pierderea etaneitii marginale. Principalele cauze ale acestei sensibiliti pot fi grupate n umtoarele patru grupe de cauze: 1. Cauze legate de materialul de obturaie compozit n cazul compozitelor, principala cauz care poate duce la apariia sensibilitii postoperatorii este contracia de polimerizare, care poate varia ntre 1.5-5% n volum (3,4). Contracia compozitelor poate avea urmatoarele efecte:
Tensiuni la nivelul esuturilor dentare, care pot antrena flexiuni ale cuspizilor, slbirea prismelor de smal i poate merge pan la fisuri sau fracturi. Pierderea adaptrii marginale cu apariia unor hiatusuri ce favorizeaz percolaia marginal. Aceasta se manifest clinic sub form de sensibilitate postopeatorie, carii secundare marginale sau inflamaii pulpare. Contracii interne ale materialului de obturaie care poate produce fracturi in masa compozitului. Diminuarea rezistenei mecanice a compozitului. Posibilitile de prevenire constau n reducerea efectelor nedorite ale contraciei de polimerizare pe baza urmtoarelor proceduri: Folosirea unui adeziv cu ncrctur mineral mare. Aplicarea compozitului n straturi succesive n funcie de configuraia cavitii Adoptarea tehnicii de obturaie sandwich cu utilizarea unei baze intermediare din
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ciment ionomer de sticl modificat (fotopolimerizabil) Utilizarea unui strat intern de compozit fluid care permite diminuarea stresului de contracie cu circa 20-50% (4) Utilizarea unui compozit pe baz de siloran (Filtec Siloran -2M ESPE), care are un coeficient redus de contracie de ordinul 0.8% (relativ insuficient confirmat de studiile clinice). 2. Cauze legate de mrimea cavitii Restaurrile directe din materiale compozite au ca prim indicaie cavitile coronare de mrime mic i mijlocie. n cazul unor caviti de mrime mare, cu toate msurile de prevenie pe care le putem lua, apare totui o contracie a materialului de obturaie. Posibilitile de prevenire eficiente se bazeaz pe recurgerea la metode indirecte de restaurare de tip onlay, cimentat sau colat pe dinte (5). 3. Cauze legate de adezivul folosit Adezivii de generaia a 5-a, care conin ntr-un singur flacon primerul, rina adeziv i solventul sunt foarte uor de aplicat n practic, scurtand timpul de lucru. Cerina acestui adeziv este s fie aplicat pe o dentin cu un anumit grad de umiditate. Dificultatea tehnica a medicului practician, const tocmai n realizarea acestei umiditi care s favorizeze ptrunderea optim n dentin a adezivului. Aplicarea greit poate duce la compromiterea etaneitii marginale, sensibilitate dureroas, coloraii marginale inestetice sau chiar leziuni curioase secundare. Posibilitile de prevenire constau n recurgerea la sisteme adezive cu autogravare, care reduc considerabil riscul de aplicare pe o dentin cu umiditate nepotrivit (se nlatur etapa de uscare i splare a dentinei). n plus, acest sistem de autogravare nu nlatur detritusul dentinar remanent din canaliculii dentinari (cepurile canaliculare), ci l blocheaz i stabilizeaz pe loc, ceea ce previne deplasarea fluidului prin canaliculii dentinari. Aceasta explic n bun parte rata sczut a sensibilitatii dentinare, observat clinic la adezivii de acest tip (6,7). 4. Cauze legate de polimerizare Folosirea unei surse de lumin pentru polimerizarea compozitului determin o conrtacie de polimerizare a materialului, n direcia sursei luminoase (6,8). Aceast etap considerat de multe ori consumatoare de timp, a dus la apariia unor lampi cu timpi de expunere tot mai sczui.
Studiile recente asupra fotopolimerizrii compozitelor au artat ca retraciile de polimerizare nu sunt ntr-o legtur liniar direct cu timpul de expunere i cu intensitea luminoas. n consecin, un timp de expunere mai lung i o intensitate mai sczut, determin o rat de polimerizare mai mare decat un timp scurt cu o intenistate mare a luminii. Polimerizarea progresiv are repercursiuni benefice asupra calitii legturii compozit-esut dentar (7). Modalitile de prevenire a unor erori legate de fotopolimerizare au obiectivul de a realiza o cat mai bun legtur dinte-material de obturaie i pot fi obinute prin: Straturi de compozit cu grosime de cel mult 2 mm (care permite reacia de polimerizare n condiii optime). Obturaiile de volum mediu i mare trebuie efectuate n straturi succesive plasate oblic fa de perei, astfel ncat vectorul de contracie s aib o rezultant favorabil adeziuni la esuturi(figura 1. A-D) (8).
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Concluzii Sensibilitatea dentinar aprut, dup efectuarea restaurrilor adezive din compozit este considerat un eec al tratamentului. El este pus n legtur direct cu pierderea nchiderii marginale datorit contraciilor din timpul polimerizrii sau unor greeli tehnice de utilizare a materialelor adezive. Prin aplicarea unor msuri stricte privind protocolul de polimerizare, sensibilitatea dentinar post operatorie poate fi prevenit. C
D
Figura 1. A-D Modaliti de plasare i polimerizare a materialului de obturaie n cavitile medii i mari cu scopul de a obine un vector de polimerizare favorabil adeziunii la esuturi (8).
BIBLIOGRAFIE
1. 2. 3. 4. 5. Branstrom M et all Sutdy of the mechanism of pain elicited from the dentin. Arch Oral Biol 1967; 12: 209-216 Pashley DH Dynamics of the pulpodentin complex. Crit Rev Oral Biol Med, 1996; 23:104-109 Peutzfeld A et all Rezin compozite propertis and energy density of light cure. J Dent Res 2005;84:659-662. Roth F Les composites, Ed Masson 2002. Kemp-Scholte CM et all Marginal integrity related to bond strenght and strain capacity of composite resin restorative systems. J Prosthet Dent 1990;64:658-664. 6. 7. Peutzfeldt A et all Adhesive systems :effect on bond strength of incorrect use. J Adhes Dent 2002:233-242. Opdam NJ et all Class 1 oclusal composite resin restoration in vivo postoperative sensitivity, wall adaptation and microleakage. Am J Dent 1998; 1:229-234. Lehmann N Les sensibilites postoperatoires. Causes et solutions preventives. Clinic, Les echecs. Hors Serie, Iunie 2008, 19-24.
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Adres de coresponden: ef Lucr. Dr. Fril Anca, Facultatea de Medicin Victor Papilian, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Cod Potal 550166 email: fratila.anca@yahoo.com
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POSIBILITI TERAPEUTICE N DISTRUCII CORONARE NTINSE
ODONTOLOGIE
Therapeutic Possibilities in Flat Coronal Lesions

Conf. Dr. Bcleanu Cornelia Facultatea de Medicin Dentar, UTM, Bucureti
REZUMAT
Tratamentul cariei dentare este strict conservator i vizeaz att eliminarea leziunii propriu-zise, ct i a efectelor secundare ale acesteia asupra esuturilor din vecintate. Scopul final al acestui tratament este refacerea corect a morfologiei coronare dentare astfel nct s nu se produc suferine ocluzo-articulare sau n timp, suferine ale organului pulpar, precum i recidiva de carie. Scop: Aceasta lucrare ii propune s prezinte tratamentul leziunilor coronare ntinse, att restaurrile directe cu materiale adezive dar i tratamentele utilizate atunci cnd nu se mai pot aplica tehnici conservative i este nevoie de restaurri coronare prin ancorri cu dispozitive radiculare, dup tratamentul endodontic Material i metod: Studiul s-a realizat pe un lot de 20 pacieni (12 femei, 8 brbai) cu vrste cuprinse ntre 25 si 55 ani, care s-au prezentat pentru rezolvarea unor distrucii coronare mari situate n zona frontal (13) i zona lateral (7). Rezultate i discuii: Sunt prezentate cteva cazuri clinice care reflect modaliti de restaurare a cariilor extinse. Concluzii: Aplicarea unor tehnici pot remedia neajunsurile ce pot aprea n restaurarea leziunilor carioase ntinse. Cuvinte cheie: leziuni carioase ntinse, factor C, contracie de polimerizare
ABSTRACT
The treatment of dental caries is strictly conservative, aiming the elimination both of the wound itself and its side effects on the neighbouring tissues. The goal of this treatment is the proper restoration of the tooth morphology without damaging the integrity of the dental pulp. Purpose: This paper aims to present the treatment of the flat coronary lesions through both of direct restorations and by using radicular pin after endodontic treatment. Material and method: The study was conducted on a lot of 20 patients (12 women, 8 men) aged between 25 and 55 years, which presented large coronary caries located in the frontal (13) and lateral area (7)of the arcades. Results and Discussion: Are presented several clinical cases which reflect different ways for the restoration of extensive cavities. Conclusions: The application of described techniques can remedy the shortcomings that may arise in the restoring of the flat caries. Key words: flat carious lesions, Factor C, contraction polymerization
INTRODUCERE
Tratamentul cariei dentare este strict conservator i vizeaz att eliminarea leziunii propriu-zise, ct i a efectelor secundare ale acesteia asupra esuturilor din vecintate. Scopul final al acestui tratament este refacerea corect a morfologiei coronare dentare astfel nct s nu se produc suferine ocluzo-articulare sau n timp, suferine ale organului pulpar, precum i recidiva de carie.
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SCOP
Aceasta lucrare ii propune s prezinte tratamentul leziunilor coronare ntinse, att restaurrile directe cu materiale adezive dar i tratamentele utilizate atunci cnd nu se mai pot aplica tehnici conservative i este nevoie de restaurri coronare prin ancorri cu dispozitive radiculare, dup tratamentul endodontic
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MATERIAL I METOD
Studiul s-a realizat pe un lot de 20 pacieni (12 femei, 8 brbai) cu vrste cuprinse ntre 25 i 55 ani, care s-au prezentat pentru rezolvarea unor distrucii coronare mari situate n zona frontal (13) i zona lateral (7) fig. 1
dontic i restaurare prin ancorare n canalul radicular pentru creterea retentivitii (fig. 3).
Figura 3 Repartiie lot dup material de restaurare Figura 1 Repartiia lotului pe zone
Etiologia leziunilor coronare/grupe de vrst este prezentat n fig. 2
CAZURI CLINICE
Caz 1 Pacient n vrst de 25 ani prezint fractur coronar la nivelul lui 12, cu interesarea pulpei dentare. Tratamentul a constat din restaurare direct, dup depulpare, cu pin intraradicular i restaurare coronar cu material compozit. Protocol terapeutic 1. Tratament endodontic i obturaie canal 2. Dezobturarea canalului cu freza Gates (Antaeos, VDW GmbH, Munchen, Germany) pe 2/3 din lungime 3. Demineralizarea canalui cu acid fosforic 37%, splare, uscare cu conuri de hrtie. 4. Aplicara a 2 straturi de agent bonding (Single Bond 2, 3M ESPE), fotopolimerizare 20 sec. 5. Aplicarea pinului cu 2R 1,2mm in canal si proba sa (Stick Tech Ltd, Turku, Finland) 6. Cimentare cu rasina de cimentare aplicata cu Lentullo (Rely X Unicem, 3M ESPE, Seefeld, Germany), fotopolimerizare 7. Reconstructie coronara prin aplicare in straturi a compozitului (Gradia Direct, GC Corporation, Tokyo, Japan) 8. Reechilibrare ocluzala pentru indepartarea contactelor premature
Figura 2 Etiologia leziunilor/grupe vrst
Restaurrile s-au realizat cu materiale compozite, 8 cazuri, 4 au fost restaurate cu amalgam, iar 8 dintre cazuri au necesitat tratament endo-
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9. Finisare (kit Soflex, 3M ESPE, St Paul, MN, USA)
Figura 7 Aspect final
Figura 4 Aspect iniial
Caz 2 Pacienta prezint o leziune carioas extins cervical. Restaurarea s-a realizat cu materiale compozite dup o tehnic special. Pentru o mai bun vizualizare tehnica este exemplificat pe un dinte extras. Tehnica: se aplic primul strat de compozit apoi se se fac dou incizii diagonale de 1,5 mm prin toat grosimea materialului mprindu-l astfel n patru pri cu forme triunghiulare, plane. se fotopolimerizeaz 40 sec dinspre vestibular. urmtorul strat se aplic ntr-o 1/2 incizie diagonal i se fotopolimerizeaz. urmtorul strat se aplic n cea de-a doua incizie i se fotopolimerizeaz, etc. se aplic alt strat orizontal, se fac tieturi diagonale i aa pn la umplerea complet a cavitii Aceast tehnic reduce factorul C i contracia de polimerizare Factorul C este definit ca fiind relaia dintre suprafeele care au fcut priz i cele care nu au fcut priz n urma bonding-ului. Dac raportul este mare n favoarea suprafeelor care nu au fcut priz denot o presiune mare datorit polimerizrii. Supraf. cu bonding Factorul C= Supraf. fr bonding Factorul C calculat ca fiind 5 nainte de incizii, obinut atunci cnd stratul e n contact cu podeaua cavitii si cu cei patru perei nconjurtori, a fost
Figura 5 Cimentare pin
Figura 6 Aplicare compozit
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redus la 0,5 cnd fiecare parte triunghiular era n contact (ader) cu un singur perete i o ptrime din podeaua cavitii.
urmtorul strat acoper taieturile diagonale, etc (Fig. 8-14).
Figura 8 Factorul C n cele dou tehnici
Aceeai tehnic de aplicare n straturi pe care se fac tieturi n diagonal combinat cu o stratificare a culorilor, pentru a reduce factorul C i contracia de polimerizare se poate aplica i pentru restaurarea unei caviti de cls a 2 a . (demonstraie pe dinte extras) Tehnica de lucru dup terminarea preparaiei, se aplic o matrice cu ajutorul unei spatule de plastic se aplic primul strat de compozit (nuanta A1, smal) pe suprafaa intern a benzii conformatoare i exteriorul pereilor vestibular, oral i gingival, urmate de fotopolimerizare dinspre ocluzal 40 sec. ndeprtarea matricei, lsarea icului i completarea fotopolimerizarii dinspre V i oral restul peretelui proximal a fost restaurat prin aplicarea a 2 sau 3 straturi de compozit la nivelul peretelui parapulpar (nu mai gros de 1,5 mm) urmate de fotopolimerizare dinspre ocluzal 40 sec. n cavitatea proximal, fiecare strat orizontal de compozit, a fost mprtit de o diagonal, n 2 portiuni naintea fotopolimerizrii. n acest fel, fiecare poriune de strat mprit a luat contact cu 1/2 din peretele gingival. se adaug urmtorul strat i se fotopolimerizeaz dinspre ocluzal 40 sec. pn se ajunge la nivelul peretelui pulpar al poriunii orizontale urmtorul strat se aplic pe peretele pulpar al poriunii orizontale i se practic o tiatur n diagonal delimitandu-se 4 poriuni triunghiulare care vin n contact doar cu 2 perei ai cavitii, reducndu-se astfel factorul C, se fotopolimerizeaz dinspre ocluzal
Figura 9 Aplicare matrice
Figura 10 Formarea peretelui proximal
Figura 11 Aplicare strat orizontal
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Figura 12 Realizare tieturi diagonale
Figura 14 Realizare tieturi diagonale 2
Figura 13 Aplicare strat orizontal 2
Figura 15 Aspect final
CONCLUZII
Evoluia cariei dentare are ca rezultat pierderi mari de substan dur dentar care produc contacte dentare nefuncionale, cu consecine grave pentru ntreg aparatul dentomaxilar. Aceste dezechilibre ocluzale genereaz suprasolicitarea dinilor antrenai n proces i influeneaz negativ funcionalitatea arcadelor dentare, a sistemului muscular i a ATM. Restaurarea se poate face prin tehnici directe, utliliznd materiale adezive sau prin utilizarea unor mijloace suplimentare de retenie prin ancorarea n canalul radicular dup tratamentul endodontic. n scopul realizrii unei interfee flexibile dinte/restaurare, compozitul de restaurare trebuie plasat de aa manier nct contracia de polimerizare s fie redus la minim. n felul acesta se evit formarea hiatusului marginal i apariia microinfiltraiilor marginale. Aplicarea compozitului n straturi i realizarea unor tieturi n diagonal reduce factorul C i deci, contracia de polimerizare.
REVISTA ROMN DE STOMATOLOGIE VOL. LIV, NR. 3, SUPLIMENT, AN 2008 BIBLIOGRAFIE

1. Ferracane JL, Mitchem JC Relationship between composite contraction stress and leakage in Class V cavities. Am J Dent 2003; 16:239-243. Giachetti L, Scaminaci Russo D, Bambi C, Grandini R A review of polymerization shrinkage stress: Current techniques for posterior direct resin restorations. J Contemp Dent Pract 2006; 4:079-088. 3.
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Khamis Hassan, Salwa Khier Composite resin restorations of large Class II cavities using split-increment horizontal placement technique, Operative Dentistry, may-june 2006 Khamis Hassan, Salwa Khier Split-increment Technique:An Alternative Approach for Large Cervical Composite Resin Restorations, J Contemporary Dental Practice, 2007, 8(2)
Adres de coresponden: Conf. Dr. Bcleanu Florentina Cornelia, Facultatea de Medicin Dentar, Universitatea Titu Maiorescu, Strada Gheorghe Petracu, Nr. 67A, Sector 3, Cod Potal 031593, Bucureti email: corneliabicle@yahoo.com
PARODONTOLOGIE
ALTERATIONS IN HBA1C FOLLOWING MINIMAL OR ENHANCED NON-SURGICAL, NON-ANTIBIOTIC TREATMENT OF GINGIVITIS OR MILD PERIODONTITIS IN TYPE 2 DIABETIC PATIENTS: A PILOT TRIAL
Theresa E. Madden, DDS, MS, PhD, FACD; Brock Herriges, DMD; Linda Boyd, RDH, MS, EdD; Gayle Laughlin, DDS, PhD; Gary T. Chlodo, DMD, FACD; David I. Rosenstein, DMD, MPH
ABSTRACT
Aim: The purpose of this pilot study was to determine and compare the effects of two protocols aimed at reducing periodontal inflammation, upon the metabolic control of the diabetic condition in subjects with elevated baseline glycosylated hemoglobin (HbA1c). Methods and Materials: Forty-two non-smoking type 2 diabetes subjects with mildly elevated HbA1c (>7 but < 9%) and severely elevated (>9%) were randomized to one of two non-surgical periodontal therapy protocols. Patients in the minimal therapy (MT) group received scaling, root planning, and oral hygiene instructions on two occasions six months apart. Participants randomized to the frequent therapy (FT) protocol received scaling, root planing, and oral hygiene instructions at two-month intervals and were provided a 0.12% chlorhexidine rinse for home use twice daily. Neither systemic nor local antibiotics were provided to either group. Subjects were asked to report any changes in diabetic medications, nutrition, and physical activity. Data analyses (ANOVA, t-test, Mann-Whitney) grouped subjects according to baseline HbA1c (>7 and < 9%, or > 9%), treatment protocol (minimal or frequent), and +/- medication change. Results: In both MT and FT groups the clinical attachment level (CAL) remained unchanged but the other measures [gingival index (GI) and pocket dept (PD)] of periodontal health improved. Mean reductions in plaque showed improvement but calculus was worse in the FT group, likely due to the use of chlorhexidine. At six months, the largest reduction of HbA1c was 3.7; experienced by a subject receiving FT but no changes in diabetic medication. Among the MT and no medication change subjects, the maximum reduction was 1.6. Overall mean reduction in HbA1c of 27 subjects with baseline HbA1c >9.0 and no medication change was 0.6 with no statistical difference between the MT and FT groups. Among the medication-change subjects with baseline HbA1c >9.0, mean reduction of 1.38 was seen with FT compared to 1.10 with MT. Conclusion: Overall, modest improvements in HbA1c were detected with a trend towards FT being better than MT. Although this pilot trial was under-powered to detect small between-group differences, the magnitude of our findings (0.6 mean improvement in HbA1c) matches closely findings from the only meta-analysis conducted on this topic to date. Larger scale studies must be undertaken on diabetic patients with periodontal problems. Clinical Significance: Preventive periodontal regimens for diabetic patients should be sufficiently intense and sustained to eliminate periodontal inflammation and should be closely coordinated with the patients overall clinical diabetic management. Key words: Diabetes, periodontal disease, HbA1c
INTRODUCTION
Oral Health and Glycemic Control For the diabetic patient, tremendous improvements in health and quality of life are the rewards of maintaining life-long normoglycemia. (1-2) The American Diabetes Association Standards of Medical Care (2006) recommend diabetic patients strive to maintain the HbA1c <7, ideally between 4 and 6. (3-8) While many diabetic
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patients have difficulty maintaining this level of glycemic control, those achieving intermediate and/or intermittent control experience far fewer complications such as retinopathy, nephropathy, neuropathy, fatigue, weakness, memory loss, cardiovascular disease, need for amputations, tooth loss, and periodontal infection. (1-5,9-28) Using a proportional hazards model and stringent controls of potential confounders, it has been shown the risk of diabetic nephropathy and cardiac
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mortality in Pima Indians is elevated 3.2 fold (95% CI 1.1-9.3) in those with severe periodontal disease. (23) Excellent glycemic control is achieved with strict regimens of diet, exercise, weight loss, avoidance of infections, fastidious self-care, avoidance of tobacco, medication adjustments, frequent medical attention, and self-monitoring of blood glucose levels using home glucometers. Emerging evidence suggests the reduction of periodontal inflammation may be one additional strategy in reducing HbA1c. (29-31) When a series of studies of various sizes were subjected to a systematic review and meta-analysis, periodontal intervention reduced HbA1c by 0.66 in type 2 diabetic patients. (31) For this pilot study, a small number of diabetic patients with elevated HbA1c were recruited. Because subjects with moderate and severe periodontitis were excluded, the use of antibiotics during this short-term intervention was avoided. Chlorhexidine gluconate was the sole chemotherapeutic agents tested because it has been shown to be effective in managing gingivitis. (32-35)
METHODS AND MATERIALS

With approval from the Oregon Health and Science University Institutional Review Board, eligible subjects were recruited using flyers and advertisements in newspapers in the greater Portland area. A screening oral examination, medical history review, and blood sample to determine HbA1c were carried out to confirm eligibility (see Table 1 for inclusion and exclusion criteria) and to answer participant questions about the study. Fifty eligible, consenting subjects were randomized (by flip of a coin) to either the minimal therapy (MT) or frequent therapy (FT) groups. The treatment groups were balanced for gender only. Following the pre-treatment assessment, all subjects were provided with oral home care instructions, oral prophylaxes including scaling, and root planing was limited to the inflamed periodontal pockets with clinical attachment loss. These services were provided in one appointment which varied in time between 60 and 90 minutes. Control subjects were recalled for oral hygiene instructions and oral prophylaxes with scaling and localized root planing at one six-month interval. FT subjects were recalled for oral prophylaxes with localized scaling. Localized root planing and oral hygiene instruction every two months (four
sessions total) were provided at no cost and 0.12% chlorhexidine gluconate rinse (Peridex, Zila Pharmaceuticals) was given for twice daily, 30 second, oral rinsing. All treatment provided in this protocol was delivered by the research dental hygienist, and all periodontal evaluations were performed by a graduate periodontology resident who was blinded to the subjects group assignment. The weight and medical history of each participant was updated at each appointment to identify factors that might impact glycemic control within the six weeks preceding the serological and periodontal data collection. These specific factors included: weight gain or loss, infections, illnesses, the use of antibiotics, steroids, or any other new medications that are known to interfere with blood glucose control. All subjects were also interviewed to gather information on exercise levels and frequency of glucose monitoring and medications. HbA1c was measured at baseline, six months, and eight months following randomization and represented the primary endpoint in this investigation. The study also evaluated the severity of periodontal disease in subjects using several indices of oral health at baseline, six months, and eight months. Inflammation (GI), clinical attachment loss (CAL), probing depth (PD), plaque index (PI), and calculus index (CI) all were quantified. PI and CI scores were quantified using indices in which the four smooth surfaces of all existing teeth are scored and a percentage of surfaces with plaque or calculus are recorded. The Le and Silness GI36 (Table 2) was used to assess inflammation of the gingiva on the mesial, distal, buccal, and lingual surfaces of the Ramfjord index teeth (#3, 9, 12, 19, 25, and 28).37 The GI procedure consisted of inserting a calibrated periodontal probe no more than 2 mm into the gingival sulcus, starting just distal to the midpoint of the buccal surface, then moving the probe tip gently into the mesial interproximal area. CAL and PD were measured at six sites for the index teeth using the Michigan Probe calibrated in 2 mm increments. Because PD recordings can vary significantly according to positions of the probe tip, all probing and recession measurements were completed and then repeated for a second set of measurements. Where there was a difference between these two readings, the two numbers were averaged. In the FT group mouth rinse compliance was evaluated by questioning the participants and by measuring remaining rinse in the bottles returned at the follow-up appointments.
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Table 1. Inclusion and exclusion criteria.
Table 2. Gingival Index.36
test whether there were effects due to treatment group, time of examination, or interaction of these two independent variables. Using the upper limit of the average HbA1c level in type 2 diabetes in the United States (9.0) as a defining value, subjects in each group were divided into those who had baseline levels above 9.0 from those below 9.0. This data was analyzed for improvement in HbA1c at six and eight months. Those subjects undergoing physicianadvised diabetic medication changes during the study period were grouped separately. Obviously improvements in HbA1c cannot be attributed solely to the periodontal intervention in these subjects.
ANALYTICAL AND STATISTICAL METHODS

Data from baseline, six month, and eight month follow-up evaluations were summarized for each oral health variable by calculating means and standard deviations. Significant differences in oral health indices between the FT, enhanced oral treatment regimen, and the control regimen over time were calculated by using the Students t-test analysis for continuous data (PD, CAL) and the Mann-Whitney test for non-parametric data (PI, CI, GI, and HbA1c). The main point of interest, the influence of dental treatment on the metabolic indicator, was analyzed using a mixed between within subjects analysis of variance (ANOVA) to
RESULTS
The study enrolled 50 subjects who met the inclusion/exclusion criteria at baseline and randomized 25 to the control treatment group and 25 to the FT group. Two subjects passed-away for reasons unrelated to the study. Six subjects were withdrawn from the study due to violations in the inclusion/exclusion criteria, such as smoking. Of the 42 remaining subjects who completed the study, 15 had their diabetes medications changed at the advice of their physicians. There were 27 subjects who did not have diabetic medication changes. No subjects needed to be omitted from the analysis because of significant changes in diet, weight, or exercise habits.
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Figure 1 and Table 3 demonstrate the changes that were observed in the oral health variables. With the exception of CAL, all oral health measurements demonstrated significant (p<.05) improvement in both the MT and FT subjects at six months. FT subjects showed greater improvements in PI at eight months (FT 81% v. MT 74% less plaque), PD (FT 17% v. MT 16% shallower probing depths), and GI (FT 63% v. MT 57% less gingival inflammation). MT subjects demonstrated more improvement in CI (FT 67% v. MT 79% less calculus). Tables 4 and 5 and Figures 2 and 3 show the changes observed in HbA1c over the course of the study. Because the groups were so small, we can assert no statistically significant main effects for either treatment group or time of examination. Although the most dramatic HbA1c reductions (Table 5) of 1.38 (FT) and 1.10 (MT) were
observed in subjects with HbA1c > 9, it must be assumed the medication change influenced these results. In the HbA1c > 9 subjects with no medication change about half as much improvement in HbA1c was seen at six months. Mean reductions of 0.58 (FT) and 0.64 (MT) were encouraging but do not indicate more periodontal therapy is better as had been expected.
DISCUSSION
As expected, the periodontal health of all subjects improved; the FT subjects demonstrated greater improvements in PD, PI, and GI compared to MT subjects, and no changes in CAL occurred because very few (n=3) baseline pocket depths were greater than 3 mm. Increased levels of calculus in the FT groups is certainly explained by their use of chlorhexidine. (35)
Figure 1. Observed changes in oral health variables.
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Table 3. Oral health variables.
Diabetic subjects entering the study with HbA1c levels above 9.0 experienced a trend toward greater HbA1c reductions than those with levels below 9.0 at baseline, regardless of the study condition to which they were exposed. These subjects experienced 0.6 reduction in HbA1c, which is similar to other periodontal interventions of this nature. (38-40) However, because of the small samples sizes, the differences between groups did NOT reach statistical significance. At the eighth month follow-up, mean HbA1c in all groups gravitated toward return to baseline levels as has been seen in other periodontal and diabetes studies. (30,4,42) Sample size presented the major flaw in this study and was exacerbated by the need to accommodate statistically for 15 subjects (nine in the FT and six in the MT groups) undergoing changes in their diabetes medications. In addition, as this study was being completed, results of a systematic review of like studies indicate much larger samples sizes
are needed to determine what intensity and duration of periodontal therapy is needed to answer the question, particularly when the severity of periodontitis is mild. (31) Other modest limitations of this study include failure to have a non-treatment control group, failure to provide placebo rinse to the MT group, measuring GI and CAL only on the six Ramfjord teeth (39) instead of the entire dentition, and inherent difficulties blinding an examiner when chlorhexidine stain is present. As in all universitybased studies, the results may not be as generalizable to real world patients as would be the results from practice-based and communitybased studies. With the limitations noted, a reduction of 0.6 (or 6%) HbA1c should be considered clinically desirable in a given patient with mild periodontal inflammation. As little as a 1% decrease in HbA1c has been shown to reduce myocardial infarctions by 14%, (46) and a 1% elevation in HbA1c results
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Table 4. Effect of periodontal treatment on HbA1c. (Subjects with no medication change.)
Table 5. Effect of periodontal treatment in subjects requiring medication change.
Figure 2. No significant difference was found between experimental and control HbA1C levels (p>.05) at baseline, six months, and eight months.
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Figure 3. Comparison of changes in HbA1C over time for test subjects and those excluded because of medication change during trial period, grouped according to initial levels. There were no significant differences within each group over time but significant (p<.05) differences between subjects with <9% and >9% HbA1C entry levels are shown (*). The reduction in baseline to six months for the medication change groups >9% can be seen to be about wice that noted for the test groups >9% (downward arrows).
in a 25% increase in complications. (45) Large scale (medical, non-dental) studies in the US and UK of intensive medical treatment regimens resulted in an average HbA1c reduction of 1.86 (or approximately 19%). (1-2,10,21) These reductions are comparable to periodontal intervention studies of severe periodontitis patients which yield HbA1c reduction (up to 17.1%) when using antibiotics with special populations more severely affected by periodontitis and diabetes, such as Pima Indians and US Veterans. (23,30) Clearly, the modest, short-term improvement in metabolic control achieved with a group of diabetic patients with fairly good oral health points to the need to perform a larger-scale, longerterm study with diabetic patients who have more serious inflammatory and infectious oral diseases. While it is likely practicing dentists and physicians are intuitively aware that alleviation of oral disease and the associated infection has a beneficial effect on metabolic control of diabetes, the magnitude
of this effect and its long-term sequelae need additional documentation.
CONCLUSION
Overall, modest improvements in HbA1c were detected with a trend towards FT being better than MT. Although this pilot trial was under-powered to detect small between-group differences, the magnitude of our findings (0.6 mean improvement in HbA1c) matches closely findings from the only meta-analysis conducted on this topic to date. Larger scale studies must be undertaken on diabetic patients with periodontal problems.
CLINICAL SIGNIFICANCE
Preventive periodontal regimens for diabetic patients should be sufficiently intense and sustained to eliminate periodontal inflammation and should be closely coordinated with the patients overall clinical diabetic management.
Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 5, July 1, 2008
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Torre MA, Shrestha B, Vargas CM Improving the oral health of Alaska natives. Am J Public Health. 2005; 95(5):769-73. Jones JA, Miller DR, Wehler CJ, Rich S, Krall E, Christiansen CL, Rothendler JA, Garcia RI Study design, recruitment, and baseline characteristics: the Department of Veterans Affairs Dental Diabetes Study. J Clin Periodontol. 2006 Oct 13;.[Epub ahead of print]. Ainamo J, Lahtinen A, Uitto VJ Rapid periodontal destruction in adult humans with poorly controlled diabetes: a report of two cases. J Clin Periodontol. 1990; 17:22-8. Shlossman M, Knowler WC, Pettitt D, Arevalo A, Genco RJ Type II diabetes and periodontal disease (Abs). J Dent Res. 1987; 66:256. Saremi A, Nelson RG, Tulloch-Reid M, Hanson RL, Sievers ML, Taylor GW, Shlossman M, Bennett PH, Genco R, Knowler WC Periodontal disease and mortality in type 2 diabetes. Diabetes Care. 2005; 28(1):27-32. Faria-Almeida R, Navarro A, Bascones A Clinical and metabolic changes after conventional treatment of type 2 diabetic patients with chronic periodontitis. J Periodontol. 2006; 77(4):591-8. Grossi SG, Skrepcinski FB, DeCaro T, Robertson DC, Ho AW, Dunford RG, Genco RJ Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol. 1997; 68:713-9. Janket SJ, Wightman A, Baird AE, Van Dyke TE, Jones JA Does periodontal treatment improve glycemic control in diabetic patients? A meta-analysis of intervention studies. J Dent Res. 2005; 84(12):1154-19. Lindhe J, Nyman S Long-term maintenance of patients treated for advanced periodontal disease. J Clin Periodontol. 1984; 11:504-14. Wennstrom J, Lindhe J The effect of mouthrinses on parameters characterizing human periodontal disease. J Clin Periodontol. 1986; 13:86-93. Schaeken MJ, Keltjens HM, Van der Hoeven JS Effects of fluoride and chlorhexidine on the microflora of dental root surfaces and progression of root-surface caries. J Dent Res. 1991; 70:150-3. Lang NP, Grec MC Chlorhexidine digluconate - an agent for chemical plaque control and prevention of gingival inflammation. J Periodontal Res. 1986; suppl:74-89. Loe H, Silness J Periodontal disease in pregnancy. I - Prevalence and severity. Acta Odont Scand. 1963; 21:533-51. Ramfjord, SP Indices for prevalence and incidence of periodontal disease. J Peridontol. 1959; 30:51-9. Iwamoto Y, Nishimura F, Nakagawa M, Sugimoto H, Shikata K, Makino H, Fukuda T, Tsuji T, Iwamoto M, Murayama Y The effect of antimicrobial periodontal treatment on circulating tumor necrosis factor-alpha and glycated hemoglobin level in patients with type 2 diabetes. J Periodontol. 2001 Jun; 72(6):774-8. Stewart JE, Wager KA, Friedlander AH, Zadeh HH The effect of periodontal treatment on glycemic control in patients with type 2 diabetes mellitus. J Clin Periodontol. 2001 Apr; 28(4):306-10. Seppala B, Seppala M, Ainamo J A longitudinal study on insulin-dependent diabetes mellitus and periodontal disease. J Clin Periodontol 1993; 20:161-5. Miller LS, Manwell MA, Newbold D, Reding ME The relationship between reduction in periodontal inflammation and diabetes control: A report of 9 cases. J Periodontal. 1992; 63:843-8. Sastrowijoto SH, van der Velden U, van Steenbergen TJM, Hillemans, P, Hart AAM, de Graaff J, Abraham-Inpijn L Improved metabolic control, clinical periodontal status and subgingival microbiology in insulin-dependent diabetes mellitus: a prospective study. J Clin Periodontol. 1990; 17:233-242. Beck JD, Caplan DJ, Preisser JS, Moss K Reducing the bias of probing depth and attachment level estimates using random partialmouth recording. Community Dent Oral Epi. 2006; 34(1):1-10. Fisher M Prevention of macrovascular complications. European Heart J Supplements. 2003; 5 (Suppl B):B21-B26. Schellhase KG, Koepsell TD, Weiss NS Glycemic control and the risk of multiple microvascular diabetic complications. Fam Med. 2005; 37(2):125-30.
MATERIALE DENTARE
EFFECT OF STORAGE TIME ON THE ACCURACY OF CASTS MADE FROM DIFFERENT IRREVERSIBLE HYDROCOLLOIDS
Maurizio Sedda, CDT, DDS, MSc; Andrea Casarotto; Aune Rausita, DDS, PhD; Andrea Borracchini, MD, DDS
ABSTRACT
Aim: Several new irreversible hydrocolloid formulations have recently become available with claims of an improved dimensional stability by the manufacturers. The aim of this study was to evaluate the accuracy of casts made from alginate impression materials poured immediately and after specific storage periods. Methods and Materials: Five alginates were tested: CA 37 (Cavex); Jeltrate (Dentsply Caulk); Jeltrate Plus (Dentsply Latin America); Hydrogum 5 (Zhermack); and Alginoplast (Heraeus Kulzer). A master model was mounted on a special device and used to obtain the impressions. These impressions were stored at 23C and 100% relative humidity, then poured with gypsum immediately, and again after 24, 72 and 120 hours. The casts were measured and the data were analyzed by one way analysis of variance (ANOVA) and Tukey test at p<0.05. Results: The dimensional stability of the alginate impressions was both material and time dependent (p<0.05). After 24 hours of storage, only Alginoplast and Hydrogum 5 comply with the master model (p>0.05). After 72 and 120 hours, only Hydrogum 5 was dimensionally stable (p>0.05). Conclusion: The dimensional stability of the alginate impressions is influenced by the selected material and the storage time. Clinical Significance: Alginate impressions should generally be poured immediately. However, some new types of alginate may have the pouring delayed. Key words: Alginate, hydrocolloid, impression, dimensional stability
INTRODUCTION
Alginate-based impression materials have been used in dentistry since 1947. (1) Originally used as precision impression materials in fixed prosthodontics1 they are more commonly used for the initial impression to obtain a preliminary model used for diagnostic purposes, treatment planning, and for the fabrication of a provisional prosthesis or custom tray. The dimensional stability of alginate-based impression materials has been studied since the 1970s.2 In particular, the phenomena of syneresis has received a great amount of attention. (3-47) Syneresis is intended as the expression of fluid onto the surface of gel structures. (48) The clinical consequence is the shrinkage of the material due to the loss of water by evaporation. (48) The actual ISO 156349 states the requirements for the alginate-based impression materials, however, no information is provided on the methodological test valid for the evaluation of their dimensional stability. In recent years different tests have been developed for analyzing this
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property. (4-6,36,42,50-54) The most common one consists of taking the impression from a master cast (usually made of acrylic or stainless steel) and measuring the discrepancy between the latter and the obtained cast. Although the measurement of a single die can be performed with greater accuracy, (6) the distance between various dies is an important variable that should be considered in order to perform the test in clinically relevant conditions. Shrinkage occurring in the palatal zone of the impression might reduce the distance between the teeth of different semi-arches. The aim of this study was to verify the dimensional stability of five different alginatebased impression materials stored in a 100% relative humidity environment after different periods of time. The null hypotheses tested were: (1) there is no difference in dimensional stability among different alginate-based materials and (2) the dimensional stability is not affected by storage time.
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With the aim to reproduce the clinical conditions a new stainless steel testing device (TST) was developed (Figures 1 and 2). The TST consists of three parts: the base, the master model, and the carrier. The base is a quadrangular block on which three pins are entirely engaged into three holes on the stainless steel standard tray. The device may be assembled and dissembled with precision by means of an accuracy engagement feature. On the base, four studs allow the master model to slide. The master model consists in a quadrangular plate to which four cylinders are welded. The head of each cylinder was well-rounded and a truncated cone with a global tapered shape of 6 was obtained to simulate a clinical die. The lower corner of the truncated cone was considered to be the finish line of the die. An acrylic resin model was prepared and fixed on the plate allowing the exposure of the head of the cylinder to simulate an upper arch with four dies in FDI World Dental Federation (FDI) tooth number positions 13, 23, 17, and 27 (Figure 2). To leave a thickness of approximately 3 mm of alginate between the top of the dies and the tray, four stainless steel spacers were machined and positioned on the studs of the base. The carrier is a quadrangular plate on which four trapezoidal grooves are realized. The grooves are aimed at maintaining the cast obtained from the impression in a fixed and stable position.
A total of 200 stainless steel standard nonperforated rimlock trays were prepared for the experiment. In each tray three holes were drilled with a numerical control machine (accuracy 0.01 mm). Each tray was measured, and a performance test was rendered to ensure a full engagement. Five alginates were selected: CA 37 (Cavex, Haarlem, Nederland) Jeltrate (Dentsply Caulk, Milford, DE, USA) Jeltrate Plus (Dentsply Latin America, Rio de Janeiro, Brazil) Hydrogum 5 (Zhermack Spa, Badia Polesine, Italy) Alginoplast (Heraeus Kulzer, Hanau, Germany) The alginate powder was stored for three days at 231C and 5010% relative humidity in a temperature controlled-room. All the procedures were carried out in the same conditions. Four different storage times (0, 24, 72 and 120 hours) were tested by taking ten impressions for each period of time. A total of 20 groups were obtained (Table 1). The master model was used as a control group.
IMPRESSION PROCEDURE
The tray was locked on the base, and an aerosol universal adhesive (Fix Adhesive, Dentsply DeTrey GmbH, Konstanz, Germany) was sprayed on the tray and left to dry for 5 minutes according to Leung et al. (9) A quantity of 30 g of powder was weighed (HP 5000 CE, Micron, Cavaria, Varese, Italy). The corresponding amount of distilled water was calculated as indicated by the manufacturer and introduced inside the cup (55) of an electronic vacuum mixing machine (Twister Evolution, Renfert, Hilzingen, Germany). The powder was added and immediately mixed by hand for 5 seconds. The mechanical mixing was then performed under vacuum at 250 rpm for 30 seconds with a rotation sense inverted every 5 seconds. The resulting alginate was immediately placed in the locked tray, and the impression of the master model was taken within the setting time indicated by the manufacturer at 23C. Once set, the alginate was trimmed at the border of the tray before the removal to allow boxing of the impression during pouring. The master model was gently separated from the impression and the latter from the base. To simulate clinical conditions the impression was then immediately stored in a hermetic nylon bag in which a paper sheet (weight 5 g) wetted with 30 g of distilled water had been inserted 10 minutes before, according to Schleier et al. (6) The paper was positioned to avoid direct contact with
Figure 1 The master model mounted on the base.
Figure 2 The acrylic master model containing four stainless steel dies.
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the tray and the alginate. (55) The bag was immediately introduced in a 3500 mL plastic storage box in which another paper sheet (weight10 g approximately) wetted with 60 g of distilled water had been inserted 10 minutes previously, (6) then stored at 231C for the time indicated in Table 1 prior to pouring with gypsum. For the storage time indicated as 0 hours, the casts were poured immediately after the removal from the master model.
Table 1. Groups of tested materials and storage time in hours (h).
CAST FORMATION
When the predetermined storage time had elapsed, the impression was removed from the plastic bag and locked again on the TST base. Then 150 g of Type III gypsum powder (Elite Model Type III) was mixed with 75 g of distilled water using an electronic vacuum mixing machine (Twister Evolution) at 250 rpm for 30 seconds and poured into the impression. The TST carrier was
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then placed and maintained in position for the setting time indicated by the gypsum manufacturer. After final setting of the gypsum, the carrier was gently removed and the cast was carefully separated from the impression. The material was stored for 48 hours at 23C and 50% relative humidity prior to measuring.
RESULTS
The results of the statistical analysis are shown in Tables 2 and 3. In order to simplify the interpretation of the achieved results, a summary is provided in Table 4. Groups 1, 5, 9, 13, 14, 15, 16, 17, and 18 showed no statistically significant difference from the control group (p > 0.05). When the impressions were poured immediately, all the tested alginates were able to reproduce the master model without any statistically significant difference (p > 0.05) in all the tested measurements. After 24 hours of storage, only Alginoplast and Hydrogum 5 fit all the measurements (p > 0.05). The only casts able to comply with the control group in all the measurements after 72 and 120 hours were obtained from Hydrogum 5 (p > 0.05).
MEASUREMENT AND STATISTICAL ANALYSIS

The carrier was compiled in a HB 350 measuring machine (Starrett Sigma, North Yorkshire, England), and the posterior corner was set parallel to the axis movement of the machine. The cast was placed on it and maintained in position by means of the four reference grooves. Six measurements (mm) were recorded for each model (Figure 3): D1.3: diameter of die 1.3 D2.3: diameter of die 2.3 d3: internal distance between dies 1.3 and 2.3 D1.7: diameter of die 1.7 D2.7: diameter of die 2.7 d7: internal distance between dies 1.7 and 2.7
DISCUSSION
The five alginates tested in this study yielded different results, showing the dimensional stability of the impression is directly related to the type of material used. Thus, the first null hypothesis, there is no difference in dimensional stability among different alginate-based materials is rejected. Immediate pouring of the impression has been traditionally suggested as a means to counteract the well-known dimensional instability of conventional alginate-based materials. However, if the impression could be stored for a reasonable time prior to pouring, this could improve the management of chair side procedures, offering a potential advantage for the clinician. In this study the impressions were stored at 100% relative humidity and pouring was delayed up to five days (i.e., 120 hours). Different results recorded for the tested alginate-based materials could be related to differences in chemical composition of the alginate materials. However, little information is provided in manufacturer instruction sheets and there is no recent literature on the influence of individual chemical components on the dimensional stability of these impression materials. Water evaporation may induce the shrinkage of hydrocolloids materials, (48) and the powder/ water mixing ratio may have some influence on the dimensional stability of the impression. In the present study the same amount of alginate powder was used for each impression (30 g). Hydrogum 5, the most stable among the five tested materials, was mixed with a weight ratio of 2.143 (64.3 g of
Figure 3 Measurements analyzed in the master model and in the obtained casts
All measurements were carried out three times, 1 mm below the finish line of each die. The results were statistically analyzed with SPSS 12.0 (SPSS, Inc., Chicago, IL, USA). The Levene Test was used to verify the homogeneity of variances, followed by one way analysis of variance (ANOVA), and a Tukey Test for post-hoc comparison between the groups. The level of significance was set at p<0.05.
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distilled water), while the mixing ratio of Jeltrate Plus, Alginoplast, and Jeltrate were 2.375, 2.381, and 2.714 (71.3, 71.4, and 81.4 g of distilled water), respectively. However, the mixing ratio
Table 2 Measurements of D1.3, D2.3, and d3.
and the dimensional stability did not seem to influence the results since CA 37 had the same mixing ratio as Hydrogum 5 but showed less dimensional change. Furthermore, no recent
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Table 3 Measurements of D1.7, D2.7, and d7.
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Table 4 Summary of obtained results.
literature was found regarding the influence of the powder/water ratio on the dimensional stability. This is probably more related to the ability of the material to keep water inside the mass than to the global amount of water present in each impression. By analyzing the measurements for each alginate material it was shown the dimensional stability of the tested alginate impression materials changes with storage time. This warrants the rejection of the second null hypothesis, the dimensional stability is not affected by storage time. Dies became wider and distances between
them become smaller with time. These findings are in agreement with Schleier et al. (6) and may be related to the shrinkage of the mass due to syneresis. The widening of the dies could be explained as follows: the master model reproduced an upper jaw with the dies positioned on the arch. During the impression procedure the arch leaves a semicircular void in the impression and the material is mainly pushed in the palatal and vestibular zone of the impression tray. As the result of the shrinkage, the impression material around the die was subjected to centrifugal tensile forces,
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so its diameter was increased (dies became wider). Furthermore, as usually occurs in clinical situations, the greatest amount of alginate was visibly located in the palatal zone and the shrinkage of this area may explain why the distance between dies decreased. Some limitations of this study can be identified. First, the acrylic master model used to take the impressions was prepared with the least number of undercuts, to prevent the distortion of the material during the removal of the impression. In clinical situations the impression is usually less easy to remove from the patients mouth and the material could be more subjected to distortion. Second, the impressions were not subjected to disinfection procedures. However, if a proper decontamination protocol is followed, the influence of disinfection procedures on dimensional stability is not clinically relevant. (4,56) Taylor et al.4 found in some cases disinfected impressions can even have an overall improvement in dimensional accuracy. One hypothesis advanced by the investigators to account for this improvement is the initial syneresis may be counteracted by imbibition during disinfection.
CONCLUSION
Within the limits of this study, the following conclusions can be drawn: The dimensional stability of the alginate impression was influenced by either the type of alginate or the storage time prior to pouring. Impressions recorded with CA 37 (Cavex), Jeltrate (Dentsply Caulk), and Jeltrate Plus (Dentsply Latin America) should be poured immediately. The impressions recorded with Alginoplast (Heraeus Kulzer) can be poured after 24 hours if correctly stored. The impressions recorded with Hydrogum 5 (Zhermack) can be poured after five days if correctly stored.
When alginate materials are used, an immediate pouring of the cast is still recommended. However, the results suggest pouring may be delayed, provided a stable alginate is used and the impression is correctly stored.
REFERENCES
Hansson O, Eklund J A historical review of hydrocolloids and an investigation of the dimensional accuracy of the new alginates for crown and bridge impressions when using stock trays. Swed Dent J 1984;8:81-95. 2. Sawyer HF, Sandrik JL, Neiman R Accuracy of casts produced from alginate and hydrocolloid impression materials. J Am Dent Assoc 1976;93:806-8. 3. Frank RP, Thielke SM, Johnson GH The influence of tray type and other variables on the palatal depth of casts made from irreversible hydrocolloid impressions. J Prosthet Dent 2002;87:15-22. 4. Taylor RL, Wright PS, Maryan C Disinfection procedures: their effect on the dimensional accuracy and surface quality of irreversible hydrocolloid impression materials and gypsum casts. Dent Mater 2002;18:103-10. 5. Bayindir F, Yanikoglu N, Duymus Z Thermal and pH changes, and dimensional stability in irreversible hydrocolloid impression material during setting. Dent Mater J 2002;21:200-9. 6. Schleier PE, Gardner FM, Nelson SK, Pashley DH The effect of storage time on the accuracy and dimensional stability of reversible hydrocolloid impression material. J Prosthet Dent 2001;86:244-50. 7. Boden J, Likeman P, Clark R Some effects of disinfecting solutions on the properties of alginate impression material and dental stone. Eur J Prosthodont Restor Dent 2001;9:131-5. 8. Nishi Y, Tsuru K, Kishita C, Hamano T, Kawahata N, Nagaoka E Impression pressures against teeth in a partially edentulous model with a mobile tooth: influence of impression tray design. J Oral Rehabil 2000;27:380-6. 9. Leung KC, Chow TW, Woo EC, Clark RK Effect of adhesive drying time on the bond strength of irreversible hydrocolloid to stainless steel. J Prosthet Dent 1999;81:586-90. 10. Inoue K, Song YX, Fujii K, Kadokawa A, Kanie T Consistency of alginate impression materials and their evaluation. J Oral Rehabil 1999;26:203-7. 1. 11. Leung KC, Chow TW, Woo CW, Clark RK Tensile, shear and cleavage bond strengths of alginate adhesive. J Dent 1998;26:617-22. 12. Johnson GH, Chellis KD, Gordon GE, Lepe X Dimensional stability and detail reproduction of irreversible hydrocolloid and elastomeric impressions disinfected by immersion. J Prosthet Dent 1998;79:446-53. 13. Saito S, Ichimaru T, Araki Y Factors affecting dimensional instability of alginate impressions during immersion in the fixing and disinfectant solutions. Dent Mater J 1998;17:294-300. 14. Haywood VB, Powe A Using double-poured alginate impressions to fabricate bleaching trays. Oper Dent 1998;23:128-31. 15. Eriksson A, Ockert-Eriksson G, Lockowandt P Accuracy of irreversible hydrocolloids (alginates) for fixed prosthodontics. A comparison between irreversible hydrocolloid, reversible hydrocolloid, and addition silicone for use in the syringe-tray technique. Eur J Oral Sci 1998;106:651-60. 16. al-Omari WM, Jones JC, Wood DJ The effect of disinfecting alginate and addition cured silicone rubber impression materials on the physical properties of impressions and resultant casts. Eur J Prosthodont Restor Dent 1998;6:103-10. 17. Hondrum SO, Fernandez R Jr Effects of long-term storage on properties of an alginate impression material. J Prosthet Dent 1997;77:601-6. 18. Shigeto N, Yamada Y, Iwanaga H, Subianto A, Hamada T Setting properties of alginate impression materials in dynamic viscoelasticity. J Oral Rehabil 1997;24:761-5. 19. Poulos JG, Antonoff LR Disinfection of impressions. Methods and effects on accuracy. NY State Dent J 1997;63:34-6. 20. Federick DR, Caputo A Comparing the accuracy of reversible hydrocolloid and elastomeric impression materials. J Am Dent Assoc 1997;128:183-8. 21. Schwartz RS, Hensley DH, Bradley DV Jr Immersion disinfection of irreversible hydrocolloid impression in pH-adjusted
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39. Lewinstein I, Craig RG Accuracy of impression materials measured with a vertical height gauge. J Oral Rehabil 1990;17:303-10. 40. Peutzfeldt A, Asmussen E Accuracy of alginate and elastomeric impression materials. Scand J Dent Res 1989;97:375-9. 41. Peutzfeldt A, Asmussen E Effect of disinfecting solutions on accuracy of alginate and elastomeric impressions. Scand J Dent Res 1989;97:470-5. 42. Jones ML, Newcombe RG, Barry G, Bellis H, Bottomley J A Reflex Plotter investigation into the dimensional stability of alginate impressions following disinfection by varying regimes employing 2.2 per cent glutaraldehyde. Br J Orthod 1988;15:185-92. 43. Durr DP, Novak EV Dimensional stability of alginate impressions immersed in disinfecting solutions. ASDC J Dent Child 1987;54:45-8. 44. Mendez AJ The influence of impression trays on the accuracy of stone casts poured from irreversible hydrocolloid impressions. J Prosthet Dent 1985;54:383-8. 45. Dahl BL, Dymbe B, Valderhaug J Bonding properties and dimensional stability of hydrocolloid impression systems in fixed prosthodontics. J Prosthet Dent 1985;53:796-800. 46. Bergman B, Bergman M, Olsson S Alginate impression materials, dimensional stability and surface detail sharpness following treatment with disinfectant solutions. Swed Dent J 1985;9:255-62. 47. Miller MW Syneresis in alginate impression materials. Br Dent J 1975;139:425-30. 48. Anusavice KJ Phillips Science of Dental Materials, 11th Edition. Saunders, Elsevier Science 2003;206,234. 49. International Organization for Standardization. ISO 1563:1990 Dental Alginate Impression Material. 50. Hiraguchi H, Nakagawa H, Wakashima M, Miyanaga K, Sakaguchi S, Nishiyama M Effect of storage period of alginate impressions following spray with disinfectant solutions on the dimensional accuracy and deformation of stone models. Dent Mater J 2005;24:36-42. 51. Jagger DC, Al Jabra O, Harrison A, Vowles RW, McNally L The effect of a range of disinfectants on the dimensional accuracy of some impression materials. Eur J Prosthodont Restor Dent 2004;12:154-60. 52. Hiraguchi H, Nakagawa H, Uchida H, Tanabe N Effect of rinsing alginate impressions using acidic electrolyzed water on dimensional change and deformation of stone models. Dent Mater J 2003;22:494-506. 53. Smith SJ, McCord JF, Macfarlane TV Factors that affect the adhesion of two irreversible hydrocolloid materials to two custom tray materials. J Prosthet Dent 2002;88:423-30. 54. Brosky ME, Pesun IJ, Lowder PD, Delong R, Hodges JS Laser digitization of casts to determine the effect of tray selection and cast formation technique on accuracy. J Prosthet Dent 2002;87:204-9. 55. Anusavice KJ Phillips Science of Dental Materials, 11th Edition. Saunders, Elsevier Science 2003;243. 56. Lu JX, Zhang FM, Chen YM, Qian M [The effect of disinfection on dimension stability of impressions]. Shanghai Kou Qiang Yi Xue 2004;13:290-2.
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Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 4, May 1, 2008
CHIRURGIE ORO-MAXIMOFACIAL
ELUDRILUL I IMPLICAIILE LUI N CAZUL EXTRACIEI MOLARULUI DE MINTE SUPERIOR

Eludril and Its Implications in the Maxillary Third Molar Extraction
Dr. Mirela-Jeni Comancianu Medic dentist (specialist-stomatologie general), Clinica Alexa Dentistry, Bucureti
REZUMAT
Un studiu statistic efectuat pe 320 de pacieni ce conine aciunea antimicrobian, antiinflamatorie, analgezic i cicatrizant a Eludrilului. Acest studiu a fost fcut pe durata a doi ani de zile n Clinica Alexa Dentistry, Bucureti, Romnia.
ABSTRACT
A statistic study performed on 320 patients regarding the antimicrobial, anti-inflammatory, analgesic and cicatrisant action of Eludril. This has been a two year study at Alexa Dentistry Clinique, Bucharest, Romania.
INTRODUCERE
Extracia, considerat o intervenie chirurgical de necesitate este normal s fie precedat de un examen general i local minuios, care s ofere date precise asupra modului n care va fi efectuat actul operator i condus ulterior tratamentul postextractional. Al treilea molar se mai numete i masea de minte, iar tiinific Dens sapientiae sau Dens serotinus i prezint o varietate extrem de mare de forme att ale coroanei, ct i ale radcinilor (tabelul 1). Molarul superior are trei rdcini care pot fi fuzionate complet sau parial, astfel nct apare ca
avnd dou rdcini prin unirea celor vestibulare, sau o singur radacin prin unirea celor trei. Uneori, din corpul radicular principal se detaeaz lateral mici rdcini accesorii. Forma rdcinilor este neregulat, cu curburi variabile i poriuni apexiene efilate.
PACIENTI I METODE
Am realizat un studiu pe 320 pacieni situai ca vrst n intervalul 18-55 ani, deci cu o medie de vrst de 36,5 ani, att de sex feminin (224), ct i masculin (96), domiciliai n mediul urban i rural. Aceast statistic nu vizeaz indicaiile de extracie ale molarului de minte superior i nici
Tabelul 1
Adres de coresponden: Doctor Comancianu Mirela-Jeni, Clinica Alexa Dentistry, Aleea Mgura Vulturului, Nr. 9, Bl. 435, Sc. B, Ap. 44, Sector 2, Bucureti email: mirelacomancianu@yahoo.com
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accidentele i complicaiile survenite ca urmare a unor evaluri greite a situaiei clinice. Studiul a fost fcut pe durata a doi ani de zile din cazuistica Clinicii Alexa Dentistry din Bucureti. Studiul in vivo s-a desfurat pe dou grupe de pacieni: 50% dintre ei (112 femei i 48 brbai) au folosit Eludril i restul de 50% nu, fiind grupul de control. nainte i dup efectuarea extraciei pacienii inclui n studiu (50% dintre ei) au fost rugai si clteasc uor gura, fr for cu soluii reci de Eludril (clorhexidina 0,10% + clorbutanol 0,50%), peste alveola aplicndu-se un tampon de comprese sterile, uor compresiv, urmnd ca de a doua zi s nceap a se spla pe dini i a se clti uor cu Eludril diluat n proporie de 1/3, aplicat de dou ori pe zi timp de un minut pe suprafaa extraciei. Pacienii din grupul de control dup extracie, au primit doar indicaiile postextractionale obinuite.
CONCLUZII
n chirurgia oral clorhexidina este utilizat nu doar pentru calitile sale bacteriostatice i bactericide, ci i datorit beneficiilor oferite n vindecarea plgilor. Astfel, soluia de Eludril folosit nainte i dup efectuarea interveniei
chirurgicale, a sczut riscul de infecie cu 70% i a facilitat procesul de regenerare tisular cu 68% fa de grupul de control. Eludrilul stimulnd refacerea mucoasei bucale prin multiplicarea fibroblatilor i diferenierea Keratinocitelor epiteliale, avnd astfel aciune cicatrizant. Aciunea analgezic postchirurgical a fost prezent la 96% dintre pacieni, Eludrilul avnd i o aciune rezidual foarte bun rmne n cavitatea oral cel puin 30% la 8 ore de la cltire (figura 1). Pacienii au fost nregistrai la fiecare or, pentru 8 ore de la extracie cu o scar ntre: 0 = nu exist durere 10 = durere medie 15 = durere intolerabil. n figura 1 apare durerea n timpul primelor ore de la extracie. La 2 i 4 ore dup extracie diferena este marcant. Dei este eficient asupra microorganismelor gram negative i gram pozitive, respectiv asupra levurilor, clorhexidina nu determin dismicrobisme, pstrnd echilibrul n microflora normal a cavitii bucale. Aciunea antiinflamatorie a clorhexidinei se datoreaz i efectului de curare al mucoasei prin eliminarea resturilor alimentare (vezi figura 2).
Figura 1
BIBLIOGRAFIE
1. 2. 3. 4. Asanami J Third molar. Extraction, Quintessence Publishing Co. Inc., 19 Boboc Gheorghe Aparatul dentomaxilar-formare i dezvoltare, Ed. II, Editura Medical, 1996, pag. 110-116 Burlibaa Corneliu i colab. Chirurgie oral i maxilofacial, Ed., II, Editura Medical, 1999, pag. 115 Gman Mirela-Jeni, Herescu Costic Accidente la extracia molarului de minte superior, Lucrare de Diplom, U.M.F. Dr. Carol Davila, 1999 Nimigean V, Podoleanu L Noiuni de anatomie topografic a capului i gtului i de anatomie oral Editura Cerma,1993, pag. 83-107
Figura 2 Pacient care a folosit Eludril dup extracii
5.
CHIRURGIE ORO-MAXIMOFACIAL
SQUAMOUS CELL CARCINOMA ARISING IN A RESIDUAL CYST: A CASE REPORT

Mehtap Muglali, DDS, PhD; Ayse Pinar Sumer, DDS, PhD
ABSTRACT
Aim: The purpose of this report is to present a case of squamous cell carcinoma (SCC) arising from a mandibular residual cyst. Background: Although rare, SCC may arise in the epithelial lining of odontogenic cysts. The diagnosis of the development of carcinoma from the cyst lining can only be established by histopatologic examination. Report: A case of SCC arising from a mandibular residual cyst in a 55-year-old man is presented along with a discussion of the critical elements needed for accurate diagnosis and treatment. Summary: The development of SCC from residual cysts is rare but should always be considered in the differential diagnosis. This case report clearly demonstrates the importance of clinician awareness of the malignant potential of apparently innocuous cystic lesions. It also underscores the importance of a careful histological examination and the necessity of obtaining biopsy materials from various areas to prevent a misdiagnosis of large-sized cysts. Citation: Muglali M, Sumer AP. Squamous Cell Carcinoma Arising in a Residual Cyst: A Case Report. J Contemp Dent Pract 2008 September; (9)6:115-121. Key words: Residual cyst, squamous cell carcinoma, SCC, odontogenic cyst
INTRODUCTION
Although rare, the epithelial lining of an odontogenic cyst may undergo malignant transformation. The incidence of carcinomas arising in odontogenic cysts was reported to be approximately 1-2/1000. (1) The pathogenesis is unknown, but long-standing inflammation and continuous intracystic pressure were suggested as possible causative factors. (2) Differential diagnosis of odontogenic cyst and malignant tumor arising in the cyst may be difficult due to the nonspecific clinical and radiological presentation. (2) The definitive diagnosis must be made by histological examination. (3,4) Among the odontogenic cysts, malignant transformation of the keratocyst and dentigerous cyst is high. (2,5) Although squamous cell carcinoma (SCC) arising in various developmental and inflammatory odontogenic cysts has been well established, to the best of the authors knowledge, there has been only four reports in the English literature on the development of SCC from residual cysts. (4,6-8) This report presents an additional case of SCC arising from a mandibular residual cyst. Diagnosis
CASE REPORT
A 55-year-old man presented complaining of a swelling in the right mandibular molar region. The dental history revealed he had his right mandibular second premolar extracted two months earlier. A painless swelling in the extraction area was noted by the patient four weeks after the extraction. He reported a slight paraesthesia in the right lip. Extraoral examination revealed a slight swelling on the right mandibular region. Buccal expansion of the alveolar ridge posterior to the right mandibular first premolar was observed on intraoral examination. The mucosa covering the alveolar ridge, floor of the mouth, and the buccal vestibule was intact with no ulceration. The panoramic radiography showed a welldefined radiolucent lesion extending from the right canine to the angle of the mandible measuring 6.5 x 3 cm (Figure 1). There was no cervical lymphadenopathy. Because of the large size of the lesion, marsupialisation was performed and the specimen was submitted for microscopic examination. Histopathologic examination showed a full
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The thin mandible was fractured in the corpus region during the enucleation process and had to be stabilized by intermaxillary fixation. The specimen was then sent for histopathological examination. This time the lesion was reported to be SCC (Figure 3).
Figure 1 Panoramic radiograph demonstrating a unilocular radiolucency extending from the right premolar teeth to the angle of the mandible.
thickness of the epithelium was composed of large squamous cells. Loss of the normal cell polarity and maturation was noted. Abnormal mitotic figures could be seen over the basal layer of the epithelium. There was no invasion of the basal layer of the epithelium (Figure 2). In the light of these histological features a diagnosis of residual cyst with dysplastic features in the lining epithelium was established.
Figure 3 Histopathology of the resection specimen revealed SCC (HE x100).
As a result, a hemimandibulectomy was performed together with a neck dissection of 32 lymph nodes along the right posterior cervical lymph chain. The surgical site was reconstructed with a tibial bone graft. Histological examination of the resected mandible revealed the tumor invaded the surrounding bone and one of the cervical lymph nodes. The patient is under a close post-surgical follow-up regimen.
DISCUSSION
Figure 2 High power appearance of the cyst epithelium showed nuclear atypia and irregularity in maturation and organization (HE x400).
TREATMENT
The decision was made to totally enucleate the lesion followed by close follow-up examinations since the lesion was confined only to the epithelium without any connective tissue invasion. Enucleation of the lesion was performed under general anaesthesia using an intraoral approach. During the enucleation it was noted the wall of the lesion was adherent to the surrounding bone. Both the lingual and buccal cortex of the mandible was thin owing to the expansion of the lesion and the neurovascular bundle was pushed inferiorly.
Neoplastic transformation in the epithelial lining of an odontogenic cyst is a rare but a well-described phenomenon. The neoplasms associated with epithelial lining of the cyst include ameloblastoma, SCC, and mucoepidermoid carcinoma. (9-13) Malignant squamous epithelium within an odontogenic cyst may represent (a) an invasion of the cyst from an adjacent primary carcinoma of the jaw, (b) a cystic change in a primary carcinoma, or (c) a malignant change within the cyst wall. (11-14) The histopathologic criterion employed to document malignant transformation of the cyst lining is the identification of a transition from the normal lining epithelium to dysplasia and to carcinoma. (2,11,15) As in the case presented in this report, this sequence was followed. The most probable reason for the development of
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carcinoma seems to be due to malignant transformation in the residual cyst wall. In a study concerning the malignant transformation of odontogenic cysts keratinization of cystic epithelium and chronic inflammation lesions were found to be the main risk factors. (16) In the present case there was no keratinization of cystic epithelium, only dense chronic inflammation. Therefore, a malignant lesion was not considered and enucleation was done following marsupialisation. In general, odontogenic cysts grow by bone expansion and the expansion is mostly to the buccal/labial vestibule. Intraosseous tumors, on the other hand, expand on both the buccal and lingual sides of the jaws. (17) Therefore, the existence of a buccolingual expansion should remind clinicians of the possibility of a tumor; most probably an ameloblastoma or an intraosseos carcinoma. The probability of a malignant lesion was never of concern in the present case because of the absence of lingual expansion. Reported clinical signs of malignant lesions generally include the presence of cervical lympadenopathy. There was no palpable lympadenopathy present in the present case, although a metastasis in a nodule was determined following neck dissection. Lack of a clinically palpable lympadenopathy was misleading. When cysts reach a large size, parestehesia of the mental nerve may occur. However, the existence of paraesthesia should serve as a reminder of the possibility of an intraosseous carcinoma. In the present case, although paraesthesia of the lip together with buccal expansion should have raised the suspicion of carcinoma, the benign radiological presentation also served to mislead clinicians. Keratocysts appear as well-defined radiolucent areas, either more or less rounded with a scalloped margin or multiloculated. Keratocyst may be confused radiographically with a ameloblastoma or with dentigerous cysts. (18) Ameloblastomas have a honeycomb pattern and a single, well-defined cavity indistinguishable from a radicular or, rarely, a dentigerous cyst. (19)
Multylocular areas in the present case were evaluated as perforations in the buccal and lingual cortex arising from the enlarging dimensions of the residual cyst. Enucleation is the preferred treatment of odontogenic cysts. However, when the lesion is large, marsupialisation can be performed due to the risk of fracture during the removal of the lesion by enucleation. In the present case marsupialisation was the initial treatment planned due to the large size of the lesion. However, enucleation was carried out later because the lesion had dysplastic features. As anticipated, the mandible was fractured during the procedure despite careful manipulation. However, this case shows marsupialisation may lead to false negative results. Enucleation should be considered regardless of the risk of fracture. If marsupialisation is selected as a treatment choice, then a biopsy should be taken from different regions of the lesion. To decide on the mode of therapy based on only one biopsy from such a large lesion was a wrong approach. An initial surgical approach through a buccal window would provide specimens with a lower probability of compromising tissue by the inflammatory process caused by potential exposure to the oral cavity. The patient indicated his face swelled after the extraction of the mobile teeth. That would support the possibility a malignant change could result from a communication with the oral cavity and concurrent exposure to the pathogenic mechanisms that affect the oral mucosa.
SUMMARY
The development of SCC from residual cysts is rare, however, it should always be considered in the differential diagnosis. This case report clearly demonstrates the importance of clinician awareness of the malignant potential of apparently innocuous cystic lesions. It also underscores the importance of a careful histological examination and the necessityof obtaining biopsy materials from various areas to prevent a misdiagnosis of large-sized cysts.
REFERENCES
1. Stoelinga PJW, Bronkhorst FB The incidence, multiple presentation and recurrence of aggressive cysts of the jaws. J Cranio Maxillofac Surg 1988; 16:184-195. Bradley N, Thomas DM, Antoniades K, Anavi Y Squamous cell carcinoma arising in an odontogenic cyst. Int J Oral Maxillofac Surg 1988; 17:260-263. 3. Makowski GJ, McGuff S, Van Sickels JE Squamous cell carcinoma in a maxillary odontogenic keratocyst. J Oral Maxillofac Surg 2001; 59:76-80. van der Wal KG, de Visscher JG, Eggink HF Squamous cell carcinoma arising in a residual cyst. A case report. Int J Oral Maxillofac Surg 1993; 22:350-352.
2.
4.
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5.

12. Johnson LM, Sapp JP, McIntire DN Squamous cell carcinoma arising in a dentigerous cyst. J Oral Maxillofac Surg 1994; 52:987990. 13. Manganaro AM, Cross SE, Startzell JM Carcinoma arising in a dentigerous cyst with neck metastasis. Head Neck 1997; 19:436439. 14. Browne RM, Gough NG Malignant change in the epithelium lining odontogenic cyst. Cancer 1972; 29:1199-1207. 15. Berenholz L, Gottlieb RD, Cho YS, Lowry LD Squamous cell carcinoma arising in a dentigerous cyst. Ear Nose Throat Journal 1988; 67:764-772 16. Timosca GC, Cotutiu C, Gavrilita L Malignant transformation of odontogenic cysts. Rev Stomatology Chir Maxillofacial 1995; 96:88-95. 17. Thomas G, Sreelatha KT, Balan A, Ambika K Primary intraosseous carcinoma of the mandible- a case report and review of the literature. Eur J Surg Oncol 2000; 26:82-86. 18. Cawson RA, Odell EW, Poeter S Cawsons Essentials of Oral Pathology and Oral Medicine. 7th edn. UK: Churchill Livingstone, 2002 19. Regezi JA, Sciubba JJ, Jordan RCK Oral pathology. Clinical Pathologic Correlations. 4th edn. USA: Saunders, 2003
Yoshida H, Onizawa K, Yusa H Squamous cell carsinoma arising in association with an orthokeratinized odontogenic keratocyst: report of a case. J Oral Maxillofac Surg 1996; 54:647651. 6. Martinelli C, Melhado RM, Callestini EA Squamous-cell carcinoma in a residual mandibular cyst. Oral Surg Oral Med Oral Pathol 1977; 44:274-278. 7. Schwimmer AM, Aydin F, Morrison SN Squamous cell carcinoma arising in residual odontogenic cyst. Report of a case and review of literature. Oral Surg Oral Med Oral Pathol 1991; 72:218221. 8. Swinson BD, Jerjes W, Thomas GJ Squamous cell carcinoma arising in a residual odontogenic cyst: Case report. J Oral Maxillofac Surg 2005; 63:1231-1233. 9. Copete MA, Cleveland DB, Orban RE JR, Chen SY Squamous carcinoma arising from a dentigerous cyst: report of a case. Compend Contin Educ Dent 1996;17:202-204. 10. Eversole LR, Sabes WR, Rovin S Aggressive growth and neoplastic potential of odontogenic cyst. Cancer 1975; 35:270-281. 11. Gardner AF A survey of odontogenic cyst and their relationship to squamous cell carcinoma. J Canad Dent Assoc 1975; 41:161167.
Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 6, September 1, 2008
OCLUZOLOGIE
TEMPOROMANDIBULAR JOINT INTERNAL DERANGEMENT: ASSOCIATION WITH HEADACHE, JOINT EFFUSION, BRUXISM, AND JOINT PAIN
Andre L.F. Costa, DDS, MS; Anelyssa DAbreu, MD; Fernandon Cendes, MD, PhD
ABSTRACT
Aim: The aim of the present study was to assess the correlation of temporomandibular joint internal derangement (TMJ ID) in patients with the presence of headache, bruxism, and joint pain using magnetic resonance imaging (MRI). Methods and Materials: This study evaluated 42 joints in 42 patients; 21 patients diagnosed with unilateral TMJ ID and a history of headaches and 21 patients diagnosed with unilateral TMD ID without a history of headaches. Signs of headache, bruxism, and joint pain were diagnosed clinically and were also obtained from the patients history. Sixteen joints in 16 patients without signs or symptoms of TMD or headache were included as a control group. All patients underwent bilateral MRI of the TMJ to evaluate the disc position and the presence of joint effusion. Data were analyzed using Chi-square and Fischers exact tests. Results: Bruxing behavior was most frequently reported by patients with headaches (p<0.0125). Eightyfive percent of subjects with headaches also reported joint pain. A significant association was found between headache and TMJ effusion (p<0.0125). Patients with more severe disc displacement also had a higher frequency of effusion (p=0.001). Conclusion: The results suggest joint effusion may have a role in the pathogenesis of headache in TMJ ID. Clinical Significance: Temporomandibular joint effusion on MRI may serve as a biological marker of headache associated with TMD and could be helpful for diagnostic classification and treatment follow up. Citation: Costa ALF, DAbreu A, Cendes F. Temporomandibular Joint Internal Derangement: Association with Headache, Joint Effusion, Bruxism, and Joint Pain. J Contemp Dent Pract 2008 September; (9)6:009-016. Key words: Temporomandibular joint internal derangement, Temporomandibular disorders, TMD, TMJ, headache, joint effusion, bruxism, joint pain
INTRODUCTION
Temporomandibular disorders (TMD) are frequent and widespread in the general population. The chief complaint is usually pain, which can manifest itself in different ways: headache, jaw ache, ear ache, and facial pain. (1-5) Seventy percent of TMD patients report headaches. (6,7) Headaches are, however, a common complaint in the adult population,7 and the International Headache Society recognizes thirteen major headache categories with more than one hundred subdivisions. (8) Several studies have shown an association between TMD and headaches, although a causal relationship has not been fully established. Some patients with headaches have signs and symptoms of TMD, while other patients with TMD report having headaches. (6,9-11) In addition, recurrent
headaches are independent of the neurological diagnosis of the headache syndrome. (11) A possible explanation is TMD has common parafunctional habits, such as bruxing behavior, which could account for the headaches observed in those patients. (12,13) TMJ internal derangement (TMJ ID) is the most frequent type of TMD and is characterized by several stages of dysfunction involving the condyle-disk relationship. (14,15) TMJ ID is considered to be a basic mechanism in the pathogenesis of TMJ dysfunction. Two types of derangements of the condyle-disk complex are commonly identified in sagittal magnetic resonance imaging (MRI): anterior disk displacement with reduction or anterior disk displacement without reduction. MRI studies have suggested headaches due to ID of the TMJ appear to be primarily inflammatory in origin due to
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stretching of the collateral diskal ligaments with subsequent anterior disk displacement. (16) Some studies also found a strong association between joint effusion and joint pain (11,17) and observed joint effusion is more often observed in more advanced stages of ID. (13,18) The aim of the present study was to determine the correlation of TMJ ID in patients with the presence of headache, bruxism, and joint pain using MRI.
corrected to the horizontal angulation of the long axis of the condyle. T1-weighted SE sagittal images (TR = 650 msec, TE = 22 msec, matrix = 316 x 240, flip 160, slice thickness = 1.5 mm, field of view = 10 x 10, NEX 1) were acquired in open and closed mouth position. T2-weighted FSE sagittal images (TR = 5300 msec, TE = 90 msec, matrix = 216 x 216, flip 160, slice thickness = 1.5 mm, field of view = 12 x 12, NEX 2) were acquired in closed mouth position.

Subjects Forty-two consecutive patients with TMJ ID and joint pain gave written informed consent to participate in this study which was approved by the Institutional Review Board of the University Hospital at UNICAMP. No subject in either the TMJ ID or control group refused to participate. The study evaluated 42 joints in 42 patients (35 females, 7 males, age range 16-83 years) referred to the TMJ outpatient clinic of the Dentistry Service of the University Hospital at UNICAMP for evaluation of TMJ pain. Patients were divided into two groups: 21 patients with TMJ ID and headaches and 21 patients with TMJ ID without headaches. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was used to diagnose unilateral TMJ related TMD group II (disk displacement). (19) Examiners were dentists, trained and calibrated in these procedures, who assessed the presence of joint pain and bruxism. Patients were included with side-related TMJ pain and absence of splint therapy and/or history of facial trauma. Patients with headaches were evaluated by a neurologist, who reviewed the headache history, performed a neurological examination, and established the diagnosis. (8) No set time frame was established in regard to the presence of headaches. Instead, patients were asked if headaches interfered with their current lives or if they were using any analgesic medication regularly for headaches. The control group was comprised of 16 TMJs of 16 subjects (11 women, 5 men, age range 2637 years) who had no current or previous TMD symptoms and denied having headaches.
IMAGING ASSESSMENT OF ARTICULAR DISC AND JOINT EFFUSION

A radiologist (ALFC) without prior knowledge of each subjects condition established the radiological diagnosis. The position of the disc was determined according to previous established criteria20 using sagittal images in closed and open mouth position to evaluate disk reduction (anterior disk displacement with reduction or anterior disk displacement without reduction). Joint effusion was identified as an area of high signal intensity in the region of the upper and lower joint spaces on T2 weighted images. (17)
DATA ANALYSIS
The primary objective was to establish if MRI diagnostic findings correlated with the presence of headaches. A chi-square test or, when necessary, a Fishers exact test was used to determine the association between the clinical and imaging findings. Significance level was established as p<0.05. A secondary analysis was conducted in patients with headaches and the presence of bruxing behavior, joint pain, and effusion. Due to multiple sequential comparisons, in this case, the p level was adjusted downwards to p<0.0125.
RESULTS
Forty-two joints were evaluated. The headache diagnosis in the 21 affected patients were: 18 had migraine without aura; one had migraine without aura, but with a clear correlation between headache and TMD symptoms; and two had tensiontype headaches. All patients with headaches had a normal neurological examination. None was in regular follow up with a neurologist or using preventive medicine. The only medications reported were over-the-counter analgesics. Headache patients more frequently reported TMJ pain in their clinical history than TMJ patients
DATA ACQUISITION
All subjects underwent MRI of the TMJ obtained by a 2 Tesla scanner (Elscint Prestige, Haifa, Israel) with surface coils. MRIs were
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without headaches. Eighteen (85%) patients with headaches reported joint pain, while only three (14.1%) patients did not (p<0.0125). Meanwhile, only nine (42.8%) patients without headaches had joint pain (Table 1). Bruxing behavior was also more frequently reported by patients with headaches. The frequency of bruxing among headache subjects was 71.4% ( p <0.0125), three times higher than the headache free group (Table 2).
Table 1 Relation between headache and joint pain in TMD patients
Table 4 Relation between MRI diagnoses of ID and headache in patients group
*P values were obtained using Fischers exact test (P significant <0.0125). Table 5 Relation between joint effusion and headache in TMD patients
*P values were obtained using chi-square test (P significant <0.0125). Numbers in parentheses represent the percent of each row. Table 2 Relation between headache and bruxism behavior in TMD patients
*P values were obtained using Fischers exact test (P significant <0.0126). Numbers in parentheses represent the percent of total (n=42). Table 6 Relation between joint pain and joint effusion in TMD patients
*P values were obtained using Fischers test (P significant <0.0125). Numbers in parentheses represent the percent of each row.
Patients with headaches exhibited significantly more ID in the MRI than the control group (p<0.0125) (Table 3). Headaches occurred more frequently in patients with more severe TMJ ID and anterior disk displacement without reduction (Table 4). Joint effusion was more prevalent in headache patients, with 16 patients with headaches and joint effusion (p<0.0125) (Table 5). Patients with joint effusion had a higher prevalence of joint pain (p<0.005) (Table 6). Patients with more severe disc displacement also had a higher frequency of joint effusion (p<0.005) (Table 7). In the control group only three subjects had ID of the disc and just one had associated joint effusion.
Table 3 Relation between MRI diagnoses of joints in study group and controls
*P values were obtained using Fischers exact test (P significant <0.0126). Numbers in parentheses represent the percent of total (n=42). Table 7 Relation between MRI diagnosis of ID and joint effusion in TMJ ID patients and controls
ID: Internal corangement ADDR: Anterior disk displacement with reduction ADDWR: Anterior disk displacement without reduction *P values were obtained using Fischers exact test (P significant <0.0125).
DISCUSSION
The principal findings of this study are: 1. Bruxing behavior seems to be a risk factor for the development of headaches in TMJ 2. Headaches in TMD ID are associated with joint pain 3. Patients with joint pain had a higher prevalence of joint effusion in the MRI 4. Headaches were most frequently reported in patients with joint effusion and patients with more severe radiological diagnosis
*P values were obtained using Fischers exact test (P significant <0.0125). Numbers in parentheses represent the percent of total (n=58).
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TMD is widely accepted as a multifactorial disorder, while headaches are a nearly universal human experience representing the final common expression of a wide variety of assaults upon the human nervous system. (21) In this investigation the main objective was to understand the pathophysiology of TMJ ID in patients with headaches. Therefore, a control group free of signs and symptoms of TMD and headaches was selected to avoid the presence of heterogeneous pathology and confounding factors. Previous studies of TMD and headaches reported tension-type headaches as the most frequent headaches associated with TMD. (22) In this sample, however, a much higher incidence of migraines was observed. This result may be due to the inclusion of a neurological assessment in the present study which in previous studies was not reported and may have led to misdiagnosis of the condition. Additionally, a hospital-based population was used in the present investigation which may have introduced a selection bias in this sample. Migraine is a primary headache, hence, it is not a symptom produced by another disorder but is in itself a disorder. (23,24) Nevertheless, recent evidence suggests patients with migraines have a higher prevalence of TMJ ID. (25) Headaches related to dental occlusion and dental parafunctions are able to mimic primary migraine headaches, (24) and treatment of the causative disorder can improve the headache. (24) Results of a previous study (11) suggested patients with unexplained headaches should be considered for evaluation of the presence of ID and inflammation of the TMJ. There is a general agreement TMJ effusion represents an inflammatory response to a dysfunctional diskcondyle relationship (26-28) and more recurrent in painful non-reducing joints. (13) This study found joint effusion was more frequent in patients with anterior disk displacement without reduction. The present findings confirmed effusion is more frequently encountered in anterior disk displacement without reduction (26) and is associated with joint pain. (13) TMJ pain and dysfunction may be caused by bruxism (13) and indirectly related to headaches. (16) It is well known minor changes in jaw position could result in large increases in the activity of masticatory muscles. (29) This modification causes articular pain and abnormal mechanical stresses within the joint, resulting in
accumulation of irritating agents in the tissue fluid13 and inflammatory changes in the retrodiskal tissue and synovial membrane leading to subsequent joint effusion. (30) Effusion appeared in just one subject of the control group. In this study only the presence of effusion characterized by an area of high signal intensity along the articular surface was identified with no measure of the grade of this collection. It can be theorized the increase in levels of effusion leads to a susceptibility to headaches from accumulation of inflammatory mediators within the joint. Arthroscopic analysis of synovial fluids in the articular joint demonstrated they are constituted by prostanoids, (31) proinflammatory cytokines, (32) and nitric oxide. (33) Takahashi and coworkers demonstrated nitric oxide concentration in ID is significantly higher than in normal joints. (34) Nitric oxide functions as a modulator of apoptosis (35,36) and apoptosis caused by oxidative stress is involved in inflammatory articular diseases. (37,38) It is also known to regulate blood pressure and vascular tone, as well as function in neural signaling. (39) High concentrations of nitric oxide may lead to a headache attack. One can hypothesize if joint effusion is present, the possibility of pain to be present is greater. If peripheral sensitization (pain in the joint) is present in chronic pain with central sensitization and migraine, this could be a trigger of the headache.
CONCLUSION
The results of this study suggest more severe pathology of the TMJ ID noted by MRI might increase the risk of headache in patients presenting to a dental clinic for the evaluation of TMJ symptoms. An interesting follow up study to confirm these findings would be to assess patients with primary headaches for TMD, including MRI, and assess how treatment of TMD in primary headache patients would affect the control of subsequent attacks in those patients.
Temporomandibular joint effusion on MRI may serve as a biological marker of headache associated with TMD and could be helpful for diagnostic classification and treatment follow up.
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Magnusson T, Carlsson GE Recurrent headaches in relation temporomandibular joint paindysfunction. Acta Odontol Scand. 1978; 36:333338. Dalkinz M, Pakdemirli E, Beydemir B Evaluation of Temporomandibular Joint Dysfunction by Magnetic Resonance Imaging Tr J Med Sci. 2001; 31:337343. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgia and facial pain, 2nd edn. Cephalalgia; 2004; 24(Suppl. 1):1 160. Schokker RP, Hansson TL, Ansink BJ, Habets LL Craniomandibular in headache patients. J Craniomandib Disord. 1989; 3:714. Schokker RP, Hansson TL, Ansink BJ, Habets LL Craniomandibular in patients with different types of headache. J Craniomandib Disord. 1990; 4:4751. Schellhas KP, Wilkes CH, Baker CC Facial pain, headache, and temporomandibular joint inflammation. Headache. 1989. 29:22932. Ciancaglini R, Radaelli G The relationship between headache and symptoms of temporomandibular disorder in the general population. J Dent. 2001; 29:938. Guler N, Yatmaz PI, Ataoglu H, Emlik D, Uckan S Temporomandibular internal derangement: correlation of MRI findings with clinical symptoms of pain and joint sounds in patients with bruxing behaviour. Dentomaxillofac Radiol. 2003; 32:30410. Rasmussen OC Description of population and progress of symptoms in a longitudinal study of temporomandibular joint arthropathy, Scand J Dent Res. 1981; 89:196203. Okeson JP Diagnosis of temporomandibular disorders. In: J.P. Okeson, Editor, Management of temporomandibular disorder and occlusion (5th ed.), Mosby, St Louis (2003), pp. 321364. Kreisberg MK Headache as a symptom of craniomandibular disorders I: Pathophysiology Cranio. 1986; 4:13542. Westensson PL, Brooks S Temporomandibular joint: relationship between MR evidence of effusion and the presence of pain and disk displacement. AJR Am J Roentgenol. 1992; 159:559 63. Sano T, Westesson PL Magnetic resonance imaging of temporomandibular joint. Increased T2 signal in the retrodiscal tissue of painful joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995; 79:511516. Dworkin SF, LeResche L Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord. 1992; 6:301355. Katzberg RW Temporomandibular joint imaging. Radiology. 1989; 170:297307. Cady R, Schreiber C, Farmer K, Sheftell F Primary Headaches: A Convergence Hypothesis. Headache. 2002; 42(3),204216. 22. Reik L The temporomandibular joint pain-dysfunction syndrome: a frequent cause of headache. Headache. 1981; 21:151-156. 23. Tepper SJ Treatment of headache pain with botulinum neurotoxins. Pain Pract. 2004 Mar; 4:38-46. 24. Melis M, Secci S Migraine with aura and dental occlusion: a case report. J Mass Dent Soc. 2006; 54:28-30. 25. DeRossi SS, Stoopler ET, Sollecito TP Temporomandibular Disorders And Migraine Headache: Comorbid Conditions?: The Internet Journal of Dental Science. 2005; 2:1. 26. Sano T, Westesson PL Magnetic resonance imaging of temporomandibular joint. Increased T2 signal in the retrodiscal tissue of painful joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995; 79:511516. 27. Segami N, Suzuki T, Sato J, Miyamaru M, Nishimura M, Yoshimura H Does joint effusion on T2 magnetic resonance images reflect synovitis? Part 3. Comparison of histologic findings of arthroscopically obtained synovium in internal derangements of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 95:7616. 28. Emshoff R, Gerhard S, Ennemoser T, Rudisch A Magnetic resonance imaging findings of internal derangement, osteoarthrosis, effusion, and bone marrow edema before and after performance of arthrocentesis and hydraulic distension of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006; 101:78490. 29. Rugh JD, Drago DJ Vertical dimension: a study of clinical rest position and jaw muscle activity. J Prosth Dent. 1981; 45:670675. 30. Guler N, Uckan S, Imirzaliogu P, Acikgozoglu S Temporomandibular joint internal derangement: relationship between joint pain and MR grading of effusion and total protein concentration in the joint fluid. Dentomaxillofac Radiol. 2005; 34:17581. 31. Kubota E, Kubota T, Matsumoto J, Shibata T, Murakami KI Synovial fluid cytokines and proteinases as markers of temporomandibular joint disease. J Oral Maxillofac Surg. 1998; 56:192198. 32. Segami N, Miyamaru M, Nishimura M, Suzuki T, Kanayame K, Murakami KI Does joint effusion on T2 magnetic resonance images reflect synovitis? Part 2. Comparison of concentration levels of proinflammatory cytokines and total protein in synovial fluid of the temporomandibular joint with internal derangements and osteoarthrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002; 94:515521. 33. Suenaga S, Abeyama K, Hamasaki A, Mimura T, Noikura T Temporomandibular disorders: relationship between joint pain and effusion and nitric oxide concentration in the joint fluid. Dentomaxillofac Radiol. 2001; 30:214218. 34. Takahashi T, Kondon T, Kamei K, Seki H, Fukuda RW, Nagai H, Takano H, Yamazaki Y Elevated leves of nitric oxide in synovial fluid from patients with temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996; 82:505-509. 35. Brockhaus F, Brune B p53 accumulation in apoptotic macrophages is an energy demanding process that precedes cytochrome c release in response to nitric oxide. Oncogene. 1999; 18:640310. 36. Brune B, von Knethen A, Sandau KB Nitric oxide (NO): An effector of apoptosis. Cell Death Differ. 1999; 6:96975. 37. Hashimoto S, Takahashi K, Amiel D, Coutts RD, Lotz M Chondrocyte apoptosis and nitric oxide production during experimentally induced osteoarthritis. Arthritis Rheum. 1998; 41:126674. 38. Nagai H, Kumamoto H, Fukuda M, Takahashi T Inducible nitric oxide synthase and apoptosisrelated factors in the synovial tissues of temporomandibular joints with internal derangement and osteoarthritis J Oral Maxillofac Surg. 2003; 61:801807. 39. Langrer JM, Rosemary A, Hoffman JR, Lancaster JRJ, Simmons RL Nitric oxide, a new endogenous immunomodulator. Transplantation. 1993; 55:12051212.
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Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 6, September 1, 2008
PROTETIC DENTAR
ROLUL ZONEI DE NCHIDERE VELOPALATINAL N PREVENIREA EECURILOR PROTEZEI MOBILE

The Importance of the Closing Vaultpalatine Zone in Preventing Removable Prosthesiss Failure
ef Lucr. Dr. Anca Fratil, ef Lucr. Dr. Cornel Boitor Facutatea de Medicin Victor Papilian, Sibiu
REZUMAT
Zona de nchidere velopalatinal, respectiv nchiderea marginal posterioar a protezei mobile maxilare are o importan covritoare n restaurarea edentaiei totale. Aceasta zon funcional distal, nregistrat corect, deine un rol primordial n meninerea, sprijinul i stabilitatea protezei mobile, prevenind eecul terapeutic. Cuvinte cheie: nchidere velopalatin, linia de vibraie, proteza mobil.
ABSTRACT
The closing vaultpalatine zone, respectively the closing marginal posterior of removable maxillary prosthesis is overwhelming important in the restoration of total edentation. This functional distal area, properly registered, has an essential role in the maintaining, support and stability of the removable maxillary prosthesis preventing the therapeutic failure. Key words: posterior damming, the vibrating line, removable prosthesis.
Un eec n protezarea mobil, poate fi consecina unor erori sau deficiene ce pot apare n cursul uneia dintre urmtoare etape: examenul clinic i planul de tratament; amprent preliminar i analiza ei; nchiderea periferic velopalatinal la maxilar; amprent finala anatomo-funcional; determinarea dimensiunii verticale de ocluzie i a relaiilor intermaxilare; montarea dinilor; conformarea suprafeei lustruite a protezei; optimizarea meninerii i stabilitii bazei protezei.
reflexul de vom i permite o tranziie ntre protez i palatul moale nesesizabil pentru limb.
BOLTA PALATIN
Prezint 3 pri distincte: palatul dur, osos; palatul moale sau vlul palatin care suport mari deplasri n cadrul funciilor; partea aponevrotic a vlului care corespunde inseriei pe palatul dur. Aceast zon aponevrotic care vibreaz pe loc odat cu diferitele funcii este aceea n care trebuie situat nchiderea palatin. Zona e delimitat de linii de vibraie anterioar i posterioar ale lui Silverman(1): linia de vibraie posterioar este pus n eviden de pronunia blnd i prelungit a unui Ah clar (fig.1); linia de vibraie anterioar este pus n eviden de pronunia scurt i viguroas a fonemei Ah. Ea corespunde liniei de jonciune palat dur-palat moale ce se poate materializa cnd cerem pacientului s sufle pe nas, cu nrile prinse (manevra Valsalva)
ROLUL ZONEI DE NCHIDERE VELOPALATIN

Aceasta zon funcional distal, nregistrat corect, deine un rol primordial n meninerea , sprijinul i stabilitatea protezei totale maxilare. Zona de nchidere velopalatin la proteza maxilar trebuie s fie etan n condiii statice i dinamice (fonaie, deglutiie), respectiv odat cu micrile vlului palatin. Ea particip la stabilizare opunndu-se forelor de basculare, i la sprijin prin extensia distal maxim ce permite creterea ariei de susinere a protezei. nchiderea velopalatinal corespunztore evit infiltrarea alimentelor sub protez, diminua
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(fig. 2) sau deplasnd un fuloar n partea posterioar a boltei palatine pentru a repera jonciunea palat dur-palat moale. Banda de flexiune a vlului, situat ntre aceste dou linii, este variabil n form i ntindere.
TEHNICA CLASIC
Se repereaz i se traseaz n gur cu un creion dermatograf, liniile de vibraie posterioar i anterioar a vlului (fig.1 i 2). Aceste dou linii determin zona de nchidere velopalatinal i trebuiesc transpuse pe modelul secundar (modelul de lucru). Pentru aceasta, macheta de cear este introdus n gur, linia de vibraie posterioar marcat cu creionul dermatograf, se imprim pe faa mucozal. Macheta este atunci redus pn la aceast linie, apoi este replasat pe modelul secundar pe care aceast linie se reproduce. Linia de vibraie anterioar este apoi trasat pe mucoas i n acelai fel ca limita posterioar, e transferat pe model cu ajutorul machetei. Apoi, compresibilitatea tisular a benzii de flexiune e apreciat cu ajutorul unui instrument (fuloar). La jumtatea distanei dintre cele 2 linii de vibraie, se traseaz o linie intermediar pe model. Adncimea gravajului pe aceast linie intermediara este egal cu 2/3 din compresibilitatea tisular. Adncimea gravajului scade la jumtate la nivelul liniei posterioare de vibraie pentru a avea un relief rotunjit netraumatizant. Adncimea gravajului scade progresiv pentru a se anula la nivelul liniei de vibraie anterioar (fig.3) (8).
Figura 1(8)
Figura 2(8)
Micrile vlului palatin sunt complexe, variabile de la un pacient la altul i necesit un studiu individual din partea medicului pentru a putea fi observate, n determinarea zonei de nchidere velopalatinal nu poate n nici un caz delegat tehnicianul dentar, care nu dispune de factori primordiali ce nu pot fi apreciai dect clinic.
REALIZAREA PRACTIC A NCHIDERII VELOPALATINALE (2,8)

Fie c e vorba de tehnicile care utilizeaz gravarea modelului, fie c sunt tehnici funcionale sau mixte, este indispensabil s reperm punctele i liniile de referin (3,4): croetele aripilor interne ale apofizelor pterigoide; anurile pterigomaxilare i ligamentele pterigomaxilare, ligamentul trebuie ocolit de marginea protezei totale; zonele lui Schroder a cror depresibilitate trebuie apreciat; foveele palatine care trebuiesc reperate; liniile de vibraie anterioar i posterioar a vlului palatin.
Figura 3(8) Macheta e repoziionat pe modelul secundar i liniile de vibraie se traseaz pe gips. Adncimea de gravaj corespunde cu 2/3 din compresibilitatea tisular evaluat n gur cu fuloarul, la distan egal de cele dou linii de vibraie.
n mod clasic, pentru vlurile cu nclinare intermediar se d ca adncime de gravaj: 1 mm la foveele palatine; 1,5 mm n dreptul zonelor Schroder; 0,5 mm la nivelul inseriei ligamentelor pterigo-maxilare.
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nchiderea velopalatin poate s se reveleze deficitar imediat sau ulterior. Poate s fie incorect sau s aib o compresie nepotrivit (fie prea mare, fie insuficient) chiar dac este situat corect. O compresie excesiv va declana o scurgere hidric care va fi nsoit de modificri ce vor duce la o pierdere a aderenei. Tehnica Devin n realizarea nchiderii velopalatinale (5,8) Indicaiile sunt de dou ordine: pentru a perfeciona nchiderea velopalatinal a unei proteze mobile existente; pentru a transforma o protez existent fr nchiderea velopalatinal n protez de tranziie, ateptnd confecionarea unei alte proteze. Dup ce s-a reperat n gur linia de vibraie posterioar a lui Silverman, se pot prezenta 2 cazuri: trebuie prelungit posterior baza protezei, apoi trebuie realizat nchiderea velopalatinal; extensia distal e suficient, dar nchiderea velopalatinal e deficitara sau inexistent i trebuie ameliorat sau creat. Tehnica descris e aceea a lui Devin (fig. 410)(8). Dac baza protezei trebuie prelungit posterior se procedeaz astfel: se ndeprteaz un strat din suprafaa mucozal n regiunea posterioar a protezei i sunt create retenii; 2 benzi de cear sunt apoi adugate: una e fixat pe fata externa a protezei, cealalt din prelungirea feei mucozale.
vlului (Fig.6). Apoi n cavitatea oral se traseaz cu creionul chimic linia de vibraie posterioara, care se va imprima pe faa mucozal a protezei. Excesurile sunt eliminate pn la linia posterioar de vibraie (Fig.7).
Figura 5(8)
Figura 6(8)
Figura 7(8)
Figura 4 (8) Ceara e prescurtat pn la linia posterioar de vibraie i banda de spaiere este eliminat.
Rina autopolimerizabil e dispus n retenii i pe banda de cear care rmne (Fig.5). Proteza e aplicat pe cmp cu o presiune digital puternic, rina e modelat de mucoasa palatin i zona
Se repereaz i traseaz cu creionul chimic linia de vibraie anterioar care se va imprima apoi pe faa mucozal a protezei. Cu band adeziv se face o ndiguire anterioar pentru a evita refluarea de rin. Grosimea i configuraia acestei ndiguiri sunt n funcie de compresibilitatea esuturilor. Rina e aplicat n spatele ndiguirii innd cont de compresibilitatea tisular, apoi proteza e inserat n gur cu o puternic presiune digital.
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Dup polimerizare banda adeziv se ndeprteaz iar proteza se prelucreaz. Eficacitatea acestei nchideri velopalatine obinute e controlat printr-o presiune pe faa palatinal a incisivilor maxilari.
Figura 10(8)
CONCLUZIE
Figura 8(8)
Cunoaterea tehnicilor de nregistrare a zonei de nchidere velopalatin este important, pentru a preveni eecurile date de absena sau de nregistrarea eronat a acestei zone funcional distal (zona de nchidere velopalatinal) cu rol primordial n retenia i n stabilitatea protezei mobile maxilare.
Figura 9(8)
BIBLIOGRAFIE
1. 2. 3. 4. Silverman Sl Dimensions and displacement patterns of the posterior palatal seal. J Prosthet Dent 1971;25:470-488. Begin M, Rohr M Le joint velopalatin en prothese complete maxillaire. Cah Prothese 1983;43:55-78. Grant AA, Heath JR, McCord JF Complete prosthodontics. Problems, diagnosis and management. London Wolfe, 1994. Lejoyeux J Prothese complete. Examen clinique, materiaux et techniques dempreintes. Tome 1. Paris : Maloine, 1979. 5. 6. 7. 8. Devin R Adaptation et habilitation des protheses totales defectueuses. Act Odonto-Stomatol 1969; 87:279-300. Hue O, Berteretche MV Prothese complete. Realite clinique, solutions therapeutiques. Paris: Quintessence International, 2003. Pompignoli M, Doukhan JY, Raux D Prothese complete. Clinique et laboratoire. Paris: Editions CdP, 1993. Begin M, Fouilloux I Roles du JVP et du JSL dans la prevention des echecs en PAC. Clinic, Les echecs. Hors Serie, Iunie 2008, 26-32.
Adres de coresponden: ef Lucr. Dr. Boitor Cornel, Facultatea de Medicin Victor Papilian, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Cod Potal 550166
10
PROTETIC DENTAR
REZULTATELE STUDIULUI CLINIC I STATISTIC ASUPRA CMPULUI PROTETIC EDENTAT TOTAL

The Results of the Clinical and Statistical Study of Totally Edentulous Prosthetic Field
ef Lucr. Dr. Elena-Gabriela Despa Catedra de Protetic Dentar Facultatea de Medicin Dentar Universitatea Titu Maiorescu
REZUMAT
Analiza statistic efectuat pe cele dou loturi (diferite ca numr de pacieni), a ncercat s stabileasc asemnri i/sau deosebiri ntre aspectele clinice studiate, o corelaie ntre caracteristicile cmpului protetic edentat total i pacientul examinat. Sinteza rezultatelor studiului este absolut necesar, permind evidenierea legturilor cauzale i mecanismelor specifice de evoluie a cmpului protetic edentat total. Condiiile socio-economice, reprezint un factor deosebit de important, care particip la marea variabilitate a dimensiunii i formelor substratului osos, dar n special asupra structurilor morfologice reprezentate de mucoperiost. Studiul clinic i statistic a demonstrat c fiecare cmp protetic edentat total este unic n felul su, fiind influenat de statutul socio-economic, condiiile culturale, obiceiurile igieno-sanitare. Cuvinte cheie: studiu clinic, elementele cmpului protetic edentat total, statistic sanitar, curb de distribuie cu caracter normal, distribuie de tip polinomial.
ABSTRACT
The statistic analyis carried out on the two groups ( different as number of patients), has tried to establish similarities and/or differences between the clinical aspects studied, a correlation between the characteristics of the prosthetic fields totally edentulous and the examined patient. The synthesis of the studys result is absolutely necessary, allowing to emphasise the causative connections and mechanisms specific to the evolution of the totally edentuluous prosthetic field. The socio-economic conditions are an important factor involved in the great variability of the shape and size of the osseous underlayer, but especially on morphological structures represented by mucous-periosteum. The statistic and clinical study has proved that each totally edentuluos prosthetic field is unique, being influenced by the socio-economical standard, cultural conditions and hygienic habits. Key words: clinical study, elements of the totally edentulous prostetic field, medical statistics, normal distribution curve, polynominal distribution.
INTRODUCERE
Cmpurile protetice constituie frecvent zona n care se evidenieaz calitile protezelor, fiindc datorit neadaptrilor au produs la nivelul esuturilor moi (zonei de sprijin i zonei de succiune) modificri morfo-histologice (microscopice i macroscopice). Din acest punct de vedere (al pacienilor examinai i tratai n ultimii 3 ani), coninutul studiului clinic poate s reprezinte un material documentar sau didactic util pentru mbogirea noiunilor despre variabilitatea cmpurilor protetice, aa cum va fi prezentat n paginile urmtoare. n analiz (studiu clinic) am urmrit urmtoarele aspecte clinice: caracteristicile crestelor
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edentate maxilare din punct de vedere al nlimii, atrofiei, limii; adncimea bolii palatine; existena sau nu a torusului palatine; forma bolii palatine, caracterul atrofiei; dimensiunea n sens anteroposterior a bolii palatine; caracteristicile substratului mucos; caracteristicile crestei edentate mandibulare din punct de vedere al simetriei, nlimii, atrofiei, direciei fa de planul sagital, forma; caracteristicile tuberculului piriformi: direcia fa de creast, volumul. Din punct de vedere teoretic i practic aceste aspecte au fost descrise i de autori romni: Ene i Popovici (4,5), Hutu (6), Preoteasa (9), Puna (9), Bratu (1). Studiul clinic a solicitat timp, rbdare i un spirit de observaie, care s-a format i dezvoltat progresiv
REVISTA ROMN DE STOMATOLOGIE VOL. LIV, NR. 2-3, AN 2008
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pentru a fi remarcate toate particularitile morfostructurale, specifice n momentul examinrii fiecrui pacient.
MATERIAL I METOD DE STUDIU

Studiul clinic (analiza cmpurilor protetice edentate total) a fost posibil fiindc l-am efectuat timp de aproximativ 8 ani, pe un numr de 506 pacieni. n ultimii trei ani numrul de pacieni edentai total s-a mrit foarte mult datorit celor care sunt asistai sociali de la sectorul 2 Bucureti. Aceti pacieni sunt lipsii de posibiliti materiale, ceea ce se reflect n starea de igien a protezelor pe care le posed de 5-10 ani, reparate de mai multe ori, sau transformate din cele pariale n proteze totale. Cazurile studiate le-am clasificat dup form, dimensiune, aspecte (simetrice-asimetrice) i structura muco-periostului n funcie de cauzele determinante fiind prezentate astfel: cazuri cu forme i dimensiuni diferite, foarte mari sau foarte mici care sunt constituionale; cazuri cu forme i dimensiuni dobndite n urma extraciilor sau al interveniilor chirurgicale; cazuri cu aspecte ale muco-periostului determinate de iatrogenoze-proteze care au produs leziuni datorit neadaptrilor (suprafeelor bazale, mucozale sau suprafeelor ocluzaleobservate suprapunerile IM cu RC). Dimensiunile bolii palatine au fost msurate i de Johnson D.L, Holt R.A, Duncanson J.R.M n 1986 (7), studiu publicat n J.A.D.A i citat de Bratu n 2005 (1). Autorul citat a realizat urmtoarele msurtori (fig.1) pe un lot de pacieni edentai total.
adncimea din zona medie a bolii palatine, pe seciune frontal (AZMP); adncimea din zona posterioar a bolii palatine, pe seciune frontal (AZPP); unghiul dintre linia median i creasta rezidual n zona median (UMCM); unghiul dintre linia median i creasta rezidual n zona posterioar (UMCP). Pacienii studiai sunt prezentai n dou loturi determinate de perioada n care au fost rezolvai (tabelul 1) i de aspectele tratamentelor protetice, care au fost vizibile la nivelul cmpurilor protetice i la nivelul protezelor.
Tabelul 1 Repartizarea pacienilor pe loturi i perioada de examinare
Figura 1 Diagrama msurtorilor lui Johnson: a) n plan sagital, b) n plan frontal (1,7)
linia medio-sagital era evaluat ntre papila incisiv i linia interhamular (LMS); adncimea antero-posterioar (AAP); unghiul antero-posterior (UAP); limea n zona medie a palatului (LZMP); limea n zona posterioar a palatului (LZPP);
n prima perioad (2000-2005), lotul a fost de 212 de pacieni i a fost analizat separat, cazuistica consultat a fost mai uniform nu a existat n mod evident particulariti care reprezint excepii, fiindc solicitau numai protezri, fr acuze speciale. Pacienii din acest lot aveau o situaie socioeconomic bun, cu o educaie stomatologic acceptabil; purtau proteze care erau nlocuite periodic la un interval de 3-4 ani, la cea mai mic modificare resimi n funcionalitatea aparatului dento-maxilar (masticaie, fizionomie, fonaie) solicitau examen de specialitate (2,3). Pacienii din al doilea lot (2005-2008) n numr mai mare de 294, datorit condiiilor materiale deosebit de modeste i a tratamentelor realizate incorect, asociate cu vechimea protezelor au constituit pentru studiu cazuri remarcabile, utile scopului propriu, s fie analizat varietatea cmpurilor protetice. Acest lot a fost deosebit de interesant fiindc s-au remarcat urmtoarele (2,3): tratamentele realizate reprezentate de protezele totale aveau multe deficiene clinico-tehnice; protezele erau foarte vechi, n medie de 8-10 ani, reparate, de mai multe ori, materialul mbtrnit; starea de igien locoregional n mod evident nu constituia o preocupare vizibil n mod deosebit la nivelul protezelor; cmpurile protetice prin aspectul muco-periostului materializa consecinele defectelor de adaptare mucozal i ocluzal a protezelor. Analiza fiind efectuat pe cele dou loturi (diferite ca numr de pacieni), am ncercat s gsesc
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asemnri i/sau deosebiri ntre aspectele clinice studiate, o corelaie ntre caracteristicile cmpului protetic edentat total i pacientul examinat.
METODOLOGIA STUDIULUI STATISTIC

Statistica sanitar (8) este tiina care are ca obiect cunoaterea detaliat, dinamic i structurat a strii de sntate n cadrul populaiei sau a unor anumite eantioane din aceasta, n corelaie cu factorii sociali, economici, culturali, igienico-sanitari i medico-biologici determinani. Scopul studiilor statistice este detectarea tendinelor evolutive ale strii de sntate n corelaie cu activitatea medico-sanitar, a crei eficien este chemat s o aprecieze. Avnd la baz metode adecvate cunoaterii proceselor ce se desfoar aleator, teoria probabilitilor, studiile statistice reuesc s descifreze, cu o eroare cunoscut i acceptabil corelaiile multiple dintre fenomenele studiate i factorii determinani, n vederea stabilirii principalelor tendine ale acestora. n mod deosebit, studiile statistice ne ajut s nelegem influena condiiilor de via, a nivelului de trai cultural i material asupra evoluiei diferitelor fenomene patologice, inclusiv n sfera sntii oro-dentare. Concluziile i rezultatele studiilor clinice sunt ntrite prin analiza i sinteza statistic a respectivei cercetri. Analiza cercetrii trebuie s nceap cu verificarea aspectelor teoretice ale studiului, scond n eviden structura i dinamica evoluiei caracteristicilor cmpului protetic edentat total. Am urmrit evidenierea legturilor funcionale de cauzalitate, ritmul de apariie i dezvoltare, concentrarea sau dispersia anumitor caracteristici ale cmpului protetic edentat total. n cadrul analizei am verificat exactitatea i eficiena metodelor de cercetare folosite, alegnd metodele adecvate problemelor specifice. Pentru analiza statistic am folosit metode ale statisticii matematice: valorile medii, dispersia de la valorile medii, eroarea medie, deviaia standard, corelaia i regresia valorilor obinute, pentru a putea compara cele dou loturi, precum i distribuia pe grupe de vrst, sex etc. Sinteza rezultatelor studiului este absolut necesar, permind evidenierea legturilor cauzale i mecanismelor specifice de evoluie a cmpului protetic edentat total. n final, analiza i sinteza statistic ne permit o bun aplicare practic a concluziilor obinute n urma studiului. a. Deviaia standard Deviaia standard (notat cu s) msoar gradul de dispersie de la medie a unei serii de valori, ea
fiind folosit n special pentru evaluarea gradului de omogenitate a unei colectiviti. De exemplu, o deviaie standard cu valoare mare arat o dispersie mare, deci un grad mai sczut de omogenitate a respectivului lot. Pentru calculul deviaiei standard prin metoda momentelor (M1 i M2) se folosete formula 1. (1) Momentul reprezint o dat statistic ce depinde de media aritmetic ponderat. Formula de calcul a momentului este: (2) X reprezentnd diferena fa de media aritmetic ponderat, n frecvenele, iar N numrul de cazuri. Pe majoritatea loturilor statistice cu numeroi pacieni, calcularea momentelor necesit un mare consum de timp, n acest caz folosindu-se formula simplificat: (3) b. Coeficientul de variaie n loturile ce prezint caracteristici diferite, neomogene, deviaiile standard nu sunt comparabile. Din acest motiv se utilizeaz coeficientul de variaie (cV), care nu este altceva dect deviaia standard exprimat procentual, formula de calcul fiind: (4) Mp reprezentnd media aritmetic ponderat. Un coeficient de variaie mai mic de 10% indic o dispersie mic, deci o omogenitate mare; o valoare de 10 pn la 20% indic o variabilitate medie, iar o valoare de peste 20% ne arat lipsa omogenitii. c. Repartiia normal (curba normal de frecvene) De obicei, fenomenele biologice sunt caracterizate prin variabile continue (variabile de tip dimensiune, vrst etc.). Majoritatea acestor fenomene se caracterizeaz, n populaiile de dimensiuni mari printr-o distribuie a valorilor ce urmeaz aa-numita curb normal a repartiiei de frecvene (curba sau clopotul lui Gauss-Laplace). Aria curbei distribuiei normale este definit de medie i de abaterea standard, formula sa fiind: (5)
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Aplicarea ecuaiei de calcul a curbei normale ne este de folos n stabilirea curbelor de tendin. d. Testele de semnificaie statistic Deciziile statistice se bazeaz pe teoria probabilitii, pe baza loturilor folosite putnduse trage concluzii estimative asupra ntregii populaii. n cazul a dou loturi selectate n mod asemntor testm dac diferenele sunt sau nu semnificative. Se pornete de la ipoteza nul (H0) c cele dou loturi sunt asemntoare din punct de vedere statistic, diferenele datorndu-se fluctuaiei de selecie din cadrul aceleiai populaii. Dac rezultatele testelor de semnificaie statistic ne conduc la diferene semnificative din punct de vedere statistic, se respinge ipoteza nul H 0 , acceptndu-se ipoteza alternativ H1. Testele de semnificaie statistic sunt supuse mai multor tipuri de erori: eroarea de tip I (eroare a) reprezint respingerea H0, dei ea ar trebui acceptat, fiind corect; eroarea de tip II (eroare b) reprezint acceptarea H0, dei ea ar trebui respins, fiind incorect. Dac probabilitatea de apariie a erorii a crete, probabilitatea de apariie a erorii b scade. Minimalizarea ambelor tipuri de eroare se face prin creterea mrimii eantionului, la valori reprezentative. Nivelul de semnificaie statistic este probabilitatea maxim de apariie a unei erori a, el trebuind stabilit la nceputul studiului, pentru a nu compromite rezultatele cercetrii. n studiul de fa am stabilit un prag de semnificaie statistic de 95% (a = 0,05), prag acceptat ca suficient de precis de majoritatea studiilor statistice din domeniul medical. Testul de semnificaie statistic analizeaz diferenele valorilor medii calculate teoretic fa de valorile stabilite prin msurare, pe respetivele loturi. Dac diferena acestor valori este mai mic sau egal dect a, vorbim despre o diferen care este nesemnificativ din punct de vedere statistic, ceea ce confirm ipoteza nul. Un test de semnificaie statistic este considerat bun atunci cnd probabilitatea ca el s resping ipoteza nul este mic, dar are o probabilitate mare de respingere a acestei ipoteze atunci cnd ea este fals. Principalele teste de semnificaie statistic folosite uzual sunt testul Student (t) i testul Fisher (F). Diferena major ntre cele dou teste este legat de nivelul de reprezentativitate al lotului,
testul t fiind folosit pe eantioane cu mai puin de 50 de subieci. Formula de calcul a testului F este: (6)
Mp1 = media aritmetic ponderat a primului lot s1 = deviaia standard a primului lot N1 = numrul de pacieni al primului lot Mp2 = media aritmetic ponderat a celui de-al doilea lot s 2 = deviaia standard a celui de-al doilea lot N2 = numrul de pacieni al celui de-al doilea lot Dup stabilirea F calculat se caut n tabelele de repartiie statistic valoarea F teoretic (F tabelar) la o probabilitate de 0,95 (prag de semnificaie statistic 95%). Pentru stabilirea F tabelar se calculeaz numrul de grade de libertate (f), conform formulei: (7)
Coeficientul c se stabilete conform: (8)
REZULTATE I DICUII ALE STUDIULUI

Rezultatele studiului clinic au fost centralizate n tabele pentru a evidenia asemnri sau diferene ntre cele dou loturi de pacieni edentai total studiai. Astfel n tabelul 2 au fost centralizate datele n ceea ce privete tipul de edentaie ntlnit la pacienii examinai, vrsta pacienilor, sexul (brbai, femei), factorul etiologic ce a determinat edentaia total. Cu toate c, cele dou loturi sunt diferite ca numr de pacieni examinai au existat unele asemnri: edentaia total bimaxilar avea ponderea cea mai mare; edentaiile unimaxilare, cel mai frecvent au aprut la nivelul maxilarului superior; edentaia total a aprut cel mai frecvent la femei; caria i complicaiile ei, ca factor etiologic a aprut n mai multe cazuri comparativ cu parodontopatia. Frecvena mai mare a edentaiei totale la femei dect la brbai a fost citat i de Hutu (1998), ulterior de Bratu (2005). n ceea ce privete vrsta pacienilor au existat deosebiri ntre cele dou loturi: n primul lot frecvena cea mai mare a pacienilor au avut vrsta cuprins ntre 66-70 de ani;
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n lotul doi frecvena cea mai mare apare la pacienii cu vrsta cuprins ntre 61-65 de ani. Aceast deosebire a aprut datorit caracteristicilor diferite ntre cele dou loturi. Pacienii din primul lot manifestau un interes deosebit pentru protezare cu meninerea strii de sntate a aparatului dento-maxilar, fiind susinui i de un statut socio-economic mai ridicat, n schimb pacienii din lotul al doilea erau dintr-o categorie defavorizat, care nu au beneficiat de tratamente stomatologice constant ce le permitea meninerea strii de sntate a aparatului dento-maxilar (pacieni asistai sociali). Cele dou loturi au fost comparate statistic folosind testul Fisher (formula 6), rezultnd un F calculat de 2,510, fa de un F tabelar de 1,79. Deoarece F calculat > F tabelar, respingem ipoteza nul H0, cele dou loturi fiind diferite, neomogene, din punct de vedere statistic. Acest rezultat corespunde caracterului neomogen al celor dou loturi, cei din primul lot beneficiind de condiii socio-economice i culturale superioare celor din cel de-al doilea lot. n cadrul ambelor loturi a fost studiat curba de repartiie a cazurilor pe grupe de vrst, studiindu-se corespondena cu curbele de calcul ale tendinelor n populaie, aceasta respectnd distribuia de tip normal (formula 5). n cazul lotului 1, dei exist diferene ntre numrul de pacieni raportate pe sexe, curba de distribuie nu are caracter normal (Gaussian), la ambele sexe, lucru demonstrat i de curbele de tendine calculate (grafic 1). Devierea de la distribuia normal se explic, din nou, prin condiiile socio-economice dar i obiceiurile igienico-sanitare de bun calitate, ce ndeprteaz aceti pacieni de evoluia natural a edentaiei totale.
Tabelul 2
n cazul lotului 2, exist de asemenea diferene ntre numrul de pacieni raportate pe sexe, dar curba de distribuie are un caracter normal la ambele sexe, corespunznd pantei descendente a clopotului lui Gauss; afirmaia este ntrit de corespondena remarcabil ntre curbele msurate i curbele de calcul a tendinei (grafic 2). Acest rezultat corespunde statutului socio-economic, cultural i obiceiurilor igienico-sanitare precare ce caracterizeaz lotul 2, edentaia total evolund natural sub aciunea factorilor etio-patogenici.
Grafic 1 Vrsta pacienilor lotul 1
Grafic 2 Vrsta pacienilor lotul 2
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La ambele loturi a fost aplicat testul Fisher (formula 6), pentru depistarea diferenelor semnificative din punct de vedere statistic ntre sexul feminin i cel masculin. Lotul 1 a prezentat un F calculat de 7,5086 fa de un F tabelar de 1,96, iar lotul 2 un F calculat de 6,623 fa de un F tabelar de 1,83. La ambele loturi F calculat > F tabelar, deci respingem ipoteza nul H0, existnd diferene semnificative din punct de vedere statistic ntre edentaii de sex feminin i cei de sex masculin, cauzele probabile fiind concordane cu cele expuse anterior. n tabelul 3 au fost centralizate datele n ceea ce privete elementele cmpului protetic edentat total maxilar studiate. Astfel: creasta edentat avea cel mai frecvent nlimea de 5-6 mm n cazul lotului 1, iar n lotul 2 de 3-4 mm; din punct de vedere al atrofiei n ambele loturi creasta era atrofiat neuniform; iar ca lime, n lotul 1 cel mai frecvent creasta era rotunjit, iar n lotul 2 ascuit; bolta palatin cel mai frecvent a avut o adncime de 6-8 mm n cazul lotului 1 i de 3-5 mm lotul 2; din punct de vedere al atrofiei, avea o atrofie simetric la pacienii din lotul
1 i asimetric la cei din lotul 2; n ceea ce privete forma, prezena sau nu a torusului i distana antero-posterioar au existat asemnri cu toate c numrul de cmpuri studiate era diferit ntre cele dou loturi, astfel a dominat forma bolii de U, fr torus palatin i cu o distan antero-posterior n medie de 4 cm; tuberozitile maxilare la ambele loturi ca frecven erau medii, prezente; n ceea ce privete retentivitatea cel mai frecvent erau retentive unilateral. La ambele loturi s-a efectuat analiza statistic a dimensiunii antero-posterioare a bolii palatine, studiindu-se curba de repartiie a acesteia (formula 5). Graficele 3 i 4 arat o distribuie de tip normal, Gaussian, deoarece dimensiunea antero-posterioar a bolii palatine este singurul parametru al cmpului protetic edentat total maxilar care nu sufer modificri n urma edentaiei, pstrndu-se morfologia normal. Un alt element morfologic al cmpului protetic edentat total maxilar supus analizei statistice a fost tuberozitatea maxilar din punct de vedere al retentivitii.
Tabelul 3 Rezultatul studiului cmpului protetic edentat total maxilar
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Grafic 3 Dimensiunea antero-posterioar a bolii palatine lotul 1 Grafic 5 Tipul retentivitii tuberozitii maxilare lotul 1
Grafic 4 Dimensiunea antero-posterioar a bolii palatine lotul 2 Grafic 6 Tipul retentivitii tuberozitii maxilare lotul 2
Lotul 1 se caracterizeaz printr-o curb de distribuie de tip normal (grafic 5), identic cu cea a pacienilor dentai. Pstrarea acestei caracteristici la edentaii totali din lotul 1 se explic prin meninerea strii de troficitate a suportului muco-osos prin protezri corecte (transmit presiunile masticatorii ce favorizeaz osteogeneza conform studiilor lui Jores), tuberozitatea maxilar pstrndu-i rolul de stlp posterior, pterigo-maxilar n structura de rezisten a viscerocraniului. n schimb, analiza statistic a curbei de distribuie pe lotul 2 arat un tip polinomial (grafic 6), tuberozitatea maxilar suferind modificri aleatorii ce o ndeprteaz de morfologia normal a dentailor. Aceste modificri osoase sunt determinate de utilizarea unor proteze incorecte, instabile pe cmpul protetic ce transmit discontinu presiunile masticatorii, care conform studiilor lui Jores declaneaz resorbii osoase. n tabelul 4 am centralizat datele referitoare la elementele cmpului protetic edentat total mandibular ce au fost examinate n cadrul studiului clinic.
Astfel, ntre cele dou loturi examinate au aprut urmtoarele diferene sau asemnri: n lotul 1 cel mai frecvent creasta edentat mandibular era simetric, iar n lotul 2 era asimetric; n ambele loturi cel mai frecvent creasta edentat a avut o nlime medie, chiar dac cele dou loturi erau diferite ca numr de cmpuri edentate mandibular examinate; de menionat n lotul 2 exist o mic diferen ntre numrul crestelor de nlime medie i cele negative; alt asemnare apare la direcia crestei n plan sagital i forma crestei, n ambele loturi cel mai frecvent au aprut creste cu direcie orizontal i form de U; n ceea ce privete tuberculul piriform, n ambele loturi au existat cel mai frecvent tuberculi piriformi n poziie orizontal i cu un volum mediu (putnd favoriza protezarea).
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Tabelul 4 Rezultatul studiului cmpului protetic edentat total mandibular
CONCLUZII
1. Studiul statistic a evideniat n cazul acestor loturi, diferite din punct de vedere a numrului de pacieni examinai, unele asemnri i deosebiri. Variabilitatea morfo-clinic a cmpurilor protetice edentate total a fost demonstrat prin caracteristicile diferite ale celor dou loturi. 2. Lotul 1 a fost reprezentat de pacieni a cror vrst frecvent era cuprins ntre 66-70 de ani, 54% erau femei, cel mai frecvent prezentau edentaie bimaxilar (64% dintre pacieni), iar factorul etiologic n 65% dintre cazuri, prezenta cauze asociate. a. Cmpul protetic edentat total maxilar a fost caracterizat de urmtoarele elemente: creste edentate cu o nlime de 5-6 mm (43% dintre cazuri), atrofiate uniform (59% dintre cazuri), rotunjite (65% dintre cazuri); bolta palatin cu o adncime de 6-8 mm (65% dintre cazuri), fr torus palatin (95% dintre cazuri), atrofiate simetric (65% dintre cazuri), avnd forma literei U (63% dintre cazuri), cu o dimensiune n sens antero-posterior de 4 cm (64% dintre cazuri); tuberozitile maxilare au fost cel mai frecvent n 51% dintre cazuri prezente, medii. b. Cmpul protetic edentat total mandibular a fost caracterizat de urmtoarele elemente: creste edentate simetrice (77% dintre cazuri), n form de U (58% dintre cazuri), de nlime medie (43% dintre cazuri), cu o resorbie neuniform, fr torus mandibular, avnd direcia n plan sagital cel mai frecvent orizontal (56% dintre cazuri); tuberculul piriform n 58% dintre cazuri avea un volum mediu, iar direcia fa de creasta edentat era orizontal (65% dintre cazuri). 3. Lotul 2 a fost reprezentat de pacieni a cror vrst frecvent era cuprins ntre 61-65 de ani, 62% erau femei, cel mai frecvent prezentau edentaie bimaxilar (64% din pacieni), iar factorul etiologic n 57% dintre cazuri, prezenta cauze asociate. b. Cmpul protetic edentat total maxilar a fost caracterizat de urmtoarele elemente: creste edentate cu o nlime de 3-4 mm (66% dintre cazuri), atrofiate neuniform (60% dintre cazuri), ascuite (69% dintre cazuri); bolta palatin cu o adncime de 3-5 mm (63% dintre cazuri), fr torus palatin (95% dintre cazuri), atrofiate asimetric (59% dintre cazuri), avnd forma literei U (44% dintre cazuri), cu o dimensiune n sens anteroposterior de 4 cm (67% dintre cazuri); tuberozitile maxilare au fost cel mai frecvent n 43% dintre cazuri prezente, medii. c. Cmpul protetic edentat total mandibular a fost caracterizat de urmtoarele elemente: creste edentate asimetrice (70% dintre cazuri), n form de U (52% dintre cazuri), de nlime medie (43% dintre cazuri), cu o resorbie neuniform, fr torus mandibular, avnd direcia n plan sagital cel mai frecvent orizontal (54% dintre cazuri);
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tuberculul piriform n 54% dintre cazuri avea un volum mediu, iar direcia fa de creasta edentat era orizontal (62% dintre cazuri). 4. Astfel, pacienii din primul lot au fost caracterizai de cmpuri protetice cu elemente morfologice specifice ce favorizeaz protezarea, iar meninerea troficitii muco-osoase cu pstrarea acestor elemente este determinat de protezri repetate, corecte, proteze cu o igien foarte bun (corespunde statului socio-economic al pacienilor studiai). 5. Cmpurile protetice la pacienii din lotul doi au prezentat elemente ce pot influena negativ protezarea, modificri frecvente la nivelul mucoasei acoperitoare (stomatopatii protetice), determinate de lipsa unei protezri corecte, folosirea unor proteze vechi, cu o stare de igien precar (cores-
punde statutului socio-economic al pacienilor din acest lot). 6. Condiiile materiale, reprezint un factor deosebit de important, care particip la marea variabilitate a dimensiunii i formelor substratului osos, dar n special asupra structurilor morfologice reprezentate de muco-periost. 7. ntre cele dou loturi au fost cteva asemnri, dar nu sunt concludente, loturile fiind diferite ca numr de pacieni. Studiul clinic i statistic a demonstrat c fiecare cmp protetic edentat total este unic n felul su, fiind caracterizat de anumite elemente morfologice specifice fiecrui pacient, ce pot fi influenate de statutul socio-economic, condiiile culturale, obiceiurile igieno-sanitare.
BIBLIOGRAFIE
1. 2. Bratu D, colab Bazele clinice i tehnice ale protezrii edentaiei totale, Ed. Medical, Bucureti, 2005. Despa EG, Ionescu T, Hutu E Studiul clinic asupra cmpului protetic edentat total (partea I) Rev. Stomatologia Vol I, Nr. 1, Bucureti, 2004. Despa EG, Ionescu T, Hutu E Studiul clinic asupra cmpului protetic edentat total (partea II), Rev. Stomatologia Vol I, Nr. 2-3, Bucureti, 2004. Ene L, Popovici C Edentaia total-clinic i tratament, Curs pentru studeni, Litografia I.M.F., Bucureti, 1988. 5. 6. 7. 8. 9. Ene L Edentaia total, Ed. IMF Bucureti, 1989. Hutu E Edentaia total, Ed. Naional, Bucureti, 2005. Jonhson DL, Holt RA, Duncanson JRM Contour of the edentulos palate, JADA 1986, 113, 35. Murean P Manual de metode matematice n analiza strii de sntate, Ed. Medical, Bucureti, 1989. Puna M, Preoteasa E Aspecte practice n protezarea edentaiei totale, Ed. Cerma, Bucureti, 2002. [*| In-line.WMF *][*| In-line.WMF*]
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4.
Adres de coresponden: ef Lucr. Dr. Elena Gabriela Despa, Facultatea de Medicin Dentar, Universitatea Titu Maiorescu, Str. Dionisie Lupu, Nr. 70, Sector 1, Bucureti email: gabidespa@gmail.com
PROTETIC DENTAR
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ASPECTE ALE MICRILOR MANDIBULARE LA EDENTATUL TOTAL

Aspects of the Mandible Movements in the Totally Edentulous Patients
ef Lucr. Dr. Elena-Gabriela Despa, Ddr. Gabriela Moise Catedra de Protetic Dentar Facultatea de Medicin Dentar Universitatea Titu Maiorescu
REZUMAT
Prin apariia strii de edentaie total se modific foarte mult condiiile anatomice i neuro-musculare care declanau, reglau i influenau micrile mandibulare. Edentaia total, instalat brusc sau lent (treptat) este caracterizat de o engram proprie, fiind dificil de apreciat proporia, rmas din starea de dentat sau din engramele care sau format n fazele de edentaie parial. Relaiile intermaxilare la edentatul total sunt analizate pentru a se decela dac exist modificri i valoarea lor. Determinarea i restaurarea relaiilor intermaxilare sunt obinute fr dificultate i se realizeaz o suprapunere a intercuspidrii maxime cu relaia centric ceea ce constituie idealul. Absena suprapunerii intercuspidrii maxime cu relaia centric, constituie o mare eroare capabil s determine grave tulburri n micrile mandibulare fiindc ocluzia-contactele dentare produc alunecri (derapaje). Cuvinte cheie: micri funcionale, micri automatizate, micri nefuncionale, engrama micrilor mandibulare, suprapunerea intercuspidare maxim cu relaia centric (point-centric).
ABSTRACT
When the totally edentulous status appears, the anatomical and neuro-muscular conditions that triggered, adjusted and influenced the mandible movements change tremenduously. Total edentation, set in suddenly or slowly ( gradually) is characterised by its own engrame being difficult to appreciate the proportion that remained from the dentulous status or the engrames formed during the partial edentulous phases. The relationship between jaws in the totally edentulous patient are analyse in order to see if there are changes and what their value is. Determination and restauration of the relationship between jaws are obtained easily and a superposition of the maximum intercuspidity with the centric relationship that is the ideal one is achieved. The lack of the maximum intercuspidity superposition with the centric relationship represents a great mistake that can cause severe disturbance in mandible movements because the occlusion-teeth contacts produce slides ( slips). Key words: functional movements, automaton movements, unfunctional movements, engrame of the mandible movements, maximum intercuspidation overlapping with the centric relationship (point-centric).
n trecut au existat ipoteze referitor la micrile mandibulei la edentatul total reprezentate de afirmaiile nu sunt modificri comparativ cu ale dentatului. Cercettorii japonezi au demonstrat prin radiometrie la dentat n cursul a 24 de ore dinii celor dou arcade sunt n contact direct ntre ei aproximativ 1,30 ore (90 minute), n acest timp majoritatea contactelor sunt prezente n timpul deglutiie (14, 20, 22). n cadrul ciclului masticator automatizat exist trei tipuri de micri: micrile mandibulei fr contacte dentodentare care formeaz marea majoritate a micrilor mandibulare automatizate; micrile mandibulare automatizate cu contacte dentare, din care funcional majoritatea sunt realizate n timpul deglutiiei i numai ntm-
pltor n timpul masticaiei; micri extreme conform schemei lui Posselt. Micrile din prima categorie, executate n mod automatizat sunt dominante n sens vertical, numai 10% n sens orizontal (laterale), cu scopul de a aplica resturile alimentare i a le readuce pentru tritrurare pe feele ocluzale. Micrile n sens orizontal pot fi provocate direct sau indirect pe cale reflex pentru evitarea obstacolului constituit de diferite contacte premature sau interferene. Acest tip de micare, dei automatizate, sunt nocive, nu trebuie s fie prezente i la edentatul total. Din aceleai considerente Jankelson a afirmat n mod natural, tritrurarea alimentelor, n special la edentatul total este obinut prin micrile man211
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dibulei n sens vertical, inclusiv la pacienii care n starea de dentat au avut componente orizontale ale micrilor mandibulare. Micrile automatizate n sens orizontal, fr contacte interdentare, apar n fonaie i n mimica specific a individului. Propulsia din timpul fonaiei nu este posibil s fie controlat voluntar; de aceea montarea dinilor frontali la protezele totale trebuie s permit completa libertate de propulsie a mandibulei n timpul fonaiei (1,3,9,19,21). n acest scop, ntre incisivii inferiori i superiori se creeaz o inocluzie orizontal n sens sagital. Nerespectarea acestui spaiu pentru propulsia mandibulei va reprezenta o condiie favorizant s se produc contacte la nivelul dinilor frontali n fonaie, ceea ce determin instabilitatea protezelor i ntreruperea fonaiei pentru stabilizarea protezelor. Micrile funcionale ale mandibulei n sens vertical, sunt caracterizate de contacte dentodentare, care trebuie s fie prezente n timpul deglutiiei. Intercuspidarea maxim trebuie s se suprapun cu relaia centric la edentatul total corect protezat (2,8,9,13,15). Micrile din categoria a treia reprezentate de micrile extreme propulsia maxim i micrile nefuncionale indirect sunt sau nu cu contacte dentodentare. Micrile voluntare extreme nu apar niciodat n ciclul automatizat al micrilor de masticaie. Micrile extreme efectuate de mandibul formeaz aria micrilor limit fa de care aria micrilor fundamentale la dentat, este mult mai mic. La edentatul total protezat, aria acestor micri funcionale se rstrnge i mai mult, n funcie de stabilitatea i meninerea protezelor. Prin apariia strii de edentaie total se modific foarte mult condiiile anatomice i neuro-musculare care declanau, reglau i influenau micrile mandibulare. Dintre determinanii micrilor mandibulare dispare n primul rnd ghidajul anterior (11,18, 21) care nu poate s fie refcut protetic fr riscul de a destabiliza protezele. Determinantul posterior, articulaia temporomandibular n funcie de modificrile morfo-funcionale, prezint, uneori multe leziuni structurale dar relaia centric rmne nemodificat, fiind un reper fundamental, care este deosebit de necesar pentru realizarea rapoartelor intermaxilare funcionale la edentatul total. Musculatura sau determinantul mijlociu, dup unele teorii, i menin reflexele contraciilor automatizate, elementare dar cu multe modificri
produse de absena sensibilitii proprioreceptorilor care existau la nivelul parodoniului dinilor. De la suprafaa mucoasei cavitii orale i a limbii sunt transmise semnale exteroreceptive. Toate particularitile structurilor edentatului total produc tulburri ale mecanismului de reglare a contraciilor automatizate muchilor, existente la nivelul engramei, de masticaie, a fiecrui individ. n prima perioad de la aplicarea protezelor apar stimuli care produc organizarea unui tip deosebit de micri mandibulare automatizate influenate de urmtorii factori biologici: engrama micrilor mandibulare deja existente n faza de dentat; determinantul posterior, respectiv micrile permise de articulaia temporo-mandibular i n special de poziia de relaie centric-care este cunoscut, rmne constant i reproductibil; relaiile noi intermaxilare stabilite de protezele totale, care cuprind: dimensiunea vertical de ocluzie, spaiul de inocluzie fiziologic din poziia de postur, intercuspidarea maxim i raportul stabilit fa de relaia centric, raportul dinilor din zona frontal i lateral fa de esuturile moi (buze, obraji i limba) la care se poate aduga gradul de meninere i de stabilitate ale protezelor pe cmpurile protetice. Fiziopatologia mecanismelor, care modific engrama micrilor mandibulare Engrama micrilor automatizate se modific n raport cu tipul de edentaie, topografia i numrul dinilor prezeni pe arcad (numrul stopurilor ocluzale prezente i absente) (4,5,11,12). Edentaia total, instalat brusc sau lent (treptat) este caracterizat de o engram proprie, fiind dificil de apreciat proporia, rmas din starea de dentat sau din engramele care sau format n fazele de edentaie parial. Este cunoscut, engramele fixate la nivelul sistemului nervos central sunt modificate n raport cu evoluia normal sau patologic a diferitelor structuri ale aparatului dento-maxilar, ale celorlalte organe i sisteme. n faza de edentat total individul mai pstreaz, unele elemente ale engramei din starea de dentat (8,9,17,18). Protezele, executate corect dac sunt necesare unele retuuri ale engramelor de masticaie existente anterior, la majoritatea pacienilor se produce adaptarea sistemului neuro-muscular s se obin reflexele necesare. Astfel se realizeaz
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o selectare n final, automatizat a micrilor mandibulare, care sunt favorabile pentru adaptarea pacientului la proteze (4,5,6,7). Perioada de timp n care se produce automatizarea micrilor, determinate de contraciile musculare este variabil n funcie de vrst, de capacitatea biologic i reactivitatea fiecrui pacient. La vrstele mai tinere, capacitatea de adaptare este mai mare, comparativ cu cea a pacienilor foarte vrstnici. Ipoteza i tendina care a existat n trecut n cadrul tehnologiei protezei totale, s redea la edentatul total prin montarea dinilor aceleai caracteristici la nivelul arcadelor dentare, care au fost prezente n starea de dentat, a creat o concepie eronat despre construcia protezelor. Anvelopa micrilor funcionale reflexe la dentat delimiteaz o arie mult mai redus fa de micrile limit, s-a imaginat pentru protezele totale s se reproduc micrile maxime dac protezele sunt meninute n mod corespunztor pe cmpurile protetice. Micrile maxime au fost efectuate n timpul amprentrii, la unele tehnici, ceea ce au avut ca rezultat final, o reducere a suprafeei zonei de sprijin a cmpului protetic. Fora de adeziune, fiind mult mai redus i presiunile ocluzale au fost exercitate cu valori mai mari pe unitatea de suprafa. Rezultatul a fost nefavorabil din urmtoarele puncte de vedere: instabilitatea protezelor i atrofia structurilor biologice ale cmpurilor protetice. Relaiile intermaxilare la edentatul total sunt analizate pentru a se decela dac exist modificri i valoarea lor. Astfel: la edentatul total, dup ablaia i extraciile protezelor fixe pluridentare posibil s prezinte urmtoarele aspecte: a. dac planul de ocluzie a prezentat elemente favorabile s fie meninute rapoartele mandibulomaxilare nct intercuspidarea maxim s se suprapun cu relaia centric; Determinarea i restaurarea relaiilor intermaxilare sunt obinute fr dificultate i se realizeaz o suprapunere a intercuspidrii maxime cu relaia centric ceea ce constituie idealul. Prognosticul tratamentului de cele mai multe ori este favorabil cnd sunt asigurate meninerea i stabilitatea n faza clinic de amprentare. b. dac au fost denivelri ale planului de ocluzie, nsoite de puncte premature de contact i interferene n dinamica mandibular care s determine, ocluzie de necesitate i de obinuin, cu modificri la nivelul articulaiei temporo-mandibulare i ale grupelor musculare.
Aceste situaii clinice, nu reprezint cazuri izolate, unicate. Activitatea practic i documentarea din literatura de specialitate, arat un procent suficient de mare, care trebuie s reprezinte un semnal necesar i util pentru fiecare medic dentist solicitat s rezolve astfel de cazuri. Dificultatea i are debutul n faza de determinare a relaiei centrice care dei se susine, este conservat permanent, stereotipurile contraciilor musculare instalate n perioade mai mari de timp, i menin activitatea i n faza cnd se poziioneaz mandibula n relaie centric, se manifest nefavorabil, asupra arcadei dentare a protezei mandibulare n momentul conducerii n RC. Exist tendina la aceti pacieni s-i poziioneze mandibula n laterodeviaie stnga, dreapta sau lateropulsie. Numai un exerciiu, care const n solicitarea intens a muchilor ridictori, n scopul modificrii tonusului (oboseal) i conducerea mandibulei n poziie nalt, posterioar, simetric dup tehnica lui Dawson sau Ramfiord creeaz posibilitatea s se obin suprapunerea ntre intercuspidarea maxim i relaia centric (6,7,8,9,15). Evoluia ulterioar: la proba machetelor posibil s apar tendina de latero-deviaie cnd trebuie s se obin intercuspidarea maxim, fr s se suprapun cu relaia centric; iar la inseria protezelor s se manifeste aceleai tendine. Rezultatele favorabile adic suprapunerea intercuspidrii maxime cu relaia centric sunt obinute dac, medicul dentist este dotat cu mult tact i rbdare s explice purttorului de proteze n faa oglinzii cum si dirijeze contient mandibula, aceste explicaii sunt utile pentru cei care au capacitatea s neleag explicaiile i au dorina s aplice ceea ce i se recomand. La edentatul total protezat majoritatea micrilor sunt necesare s fie realizate n axa balama terminal, distanarea mandibulei (arcadei inferioare fa de cea superioar) s fie numai de 20 mm-25 mm). Amplitudinea deschiderii gurii trebuie s fie redus. Consecinele modificrilor dimensionale ale dimensiunii verticale de ocluzie, n plus sau n minus sunt cunoscute. Deasemenea consecinele care includ funcionalitatea protezelor, prognosticul tratamentului din punct de vedere curativ i profilactic. n general se mai adaug modificrile structurilor anatomice componente ale aparatului dento-maxilar. Aceste modificri este posibil s determine i tulburri n echilibrul sistemului nervos central i periferic. Absena suprapunerii intercuspidrii maxime
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cu relaia centric, constituie o mare eroare capabil s determine grave tulburri n micrile mandibulare fiindc ocluzia-contactele dentare produc alunecri (derapaje). Primul contact dento-dentar ntre arcadele protezelor, creeaz senzaii de nesiguran. Este instalat o neconcordan, nepotrivire ntre contactele dentare. Reflex, se produc alte contacte mai ferme, mai stabile n plan orizontal, ceea ce determin devierea mandibulei de la stereotipul creat pentru masticaie. Proteza este deplasat de pe cmpul protetic, progresiv i dac la inserie a prezentat meninere i stabilitate foarte bun determinate de succiune i adeziune. Acest mecanism, complex neuro-muscular i mecanic (IM) produce modificri la nivelul structurilor cmpului protetic- mucoas i os- atrofia osului i hipertrofie localizat n unele zone ale mucoasei sau atrofie n altele. Instabilitatea protezelor exercitat de derapajul ocluzal determin anumite contracii (ticuri) ale musculaturii oro-faciale i ale muchilor limbii cu tendina s stabilizeze proteza care nu sunt eficiente. Concomitent, apar i contracii ale muchilor mobilizatori ai mandibulei a cror manifestri sunt urmate de consecine asupra mecanismului care este necesar pentru instalarea contraciilor automatizate. Spasmele musculare instalate, prezint caracteristice disfunciei, determin cicluri masticatorii atipice, cu componente orizontale importante, care produc mai intens mobilizarea protezelor cu efecte i asupra modificrilor de troficitate la nivelul structurilor cmpului protetic. Dac ntre intercuspidarea maxim i relaia centric sunt diferene foarte reduse, exprimate n milimetrii, exist long centric i dinii sunt din acrilat, fenomenul de abraziune care se produce uneori, este favorabil s se obin, relaii ocluzale corespunztoare pentru ocluzia de obinuin. Aceast ocluzie, creeaz condiiile necesare pentru automatizarea, micrilor de masticaie i de intercuspidare maxim. La aceste cazuri clinice dispar, consecinele care se pot instala asupra cinematicii mandibulare i asupra esuturilor cmpului protetic. Dac diferenele dintre intercuspidarea maxim i relaia centric sunt n jur de 0,5mm, localizate numai la un grup de dini, depistate cu hrtia de articulaie prin lefuire apare posibil instalarea coincidenelor dintre contactele dentare i relaia centric. Poziiile dinilor artificiali, dac sunt n alte raporturi cu buzele i limba, pot s modifice micrile mandibulei prin urmtoarele mecanisme fiziopatologice:
instabilizeaz proteza n mod diferit, fie limba dac este n oro-poziie, fie buzele dac sunt n vestibulo-poziie i senzaii de disconfort pentru limb n fonaie (de ncorsetare) i de plasare a buzelor n alte poziii cnd intr n aciune tonusul muchilor orbiculari. Modificrile mari de poziie ale dinilor sunt urmate de instabilitatea protezelor, corectarea este remediat prin remontarea dinilor. Dac poziiile dinilor sunt modificate, fr consecine mari asupra stabilitii protezelor este recomandabil s se temporizeze intervenia fiindc exist posibilitatea unei adaptri, n mod progresiv deoarece la multe cazuri clinice se instaleaz lent. Erori evidente la protezele totale pot s apar n urmtoarele situaii morfo-clinice (8,9,10,15): spaiul minim de vorbire al lui Silverman nu este prezent sau are dimensiuni foarte reduse; disfunciile fonatorii, produc tulburri n vorbire cu repercursiuni psiho-nervoase, manifestate sub form de stres nervos, care sunt nefavorabile pentru perioada de adaptare la proteze; spaiul funcional, util pentru limb a lui Scheirnemakers, cnd nu este prezent, are dou consecine: mobilizarea protezei inferioare, senzaia de ncorsetare a limbii; spaiul funcional util limbii nu este prezent dac: regula lui Pound nu s-a aplicat la montarea grupului dinilor laterali inferiori, versantul lingual al protezei este gros, 1-4 mm (supradimensionat) sau nu este concav. Dac spaiul funcional util pentru limb nu este prezent, micrile automatizate ale mandibulei sunt ntrerupte, de contraciile muchilor, care sunt necesare s stabilizeze protezele. Contraciile musculare pentru stabilizare se produc la nivelul muchilor ridictori ai mandibulei, ntre cele dou arcade se obin contacte ocluzale care poziioneaz baza protezei pe cmpul protetic. Meninerea i stabilitatea protezelor pe cmpurilor protetice sunt determinate de fidelitatea (corectitudinea amprentei) i de relaiile ocluzale dintre cele dou arcade dentare static i dinamic mpreun cu poziiile dinilor (8,9,16). Acetia sunt factori deosebii de importani care creeaz condiiile pentru funcionalitatea protezelor sau pentru imposibilitatea utilizrii lor. Instabilitatea creat de neadaptarea bazelor la zona de sprijin, absena succiunii, adeziunii, relaiile ocluzale necorespunztoare, reprezint factori deosebii de nocivi pentru meninerea strii de troficitate a esuturilor aparatului dento-maxilar, muco-periost, os i a structurilor reprezentate de:
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muchii mobilizatori, oro-faciali i elementele articulaiei temporo-mandibulare. Protezele instabile pe cmpurile protetice care prezint defecte la nivelul arcadelor dentare, a reliefului
ocluzal i dimensiunii verticale de ocluzie mai mic, aduc mari dezavantaje cmpurilor protetice, pentru momentul unei alte intervenii de protezare.
BIBLIOGRAFIE
1. 2. Allen N Dental Totale Prothesis, Br Dent J, 145, 169, 1990. Despa EG, Ionescu T Variabilitatea cmpului protetic edentat total, comunicare Congresul Internaional de Stomatologie 16-19 martie 2005, Bucureti. 3. Dyer M Prosthetic Dentistry, Ed Wright, London, 1999. 4. Ene L Ocluzia funcional, Stomatologia, 1982, 4; 271-280. 5. Ene L, Popovici C Micrile mandibulare la edentatul total, Stomatologia, 1982, 29, 1; 179-196. 6. Ene L, Popovici C Edentaia total-clinic i tratament, Curs pentru studeni, Litografia I.M.F., Bucureti, 1988. 7. Ene L Edentaia total, Ed IMF Bucureti, 1989. 8. Hutu E Edentaia total, Ed Didactic i Pedagogic, Bucureti, 1998. 9. Hutu E Edentaia total, Ed Naional, Bucureti, 2005. 10. Hutu E, Despa EG, Dan A, Giurescu R Edentatul total din Romnia-pacient european, Rev. Stomatologia Vol LIII, Nr. 2, Bucureti, 2007. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Ioni S Ocluzia dentar, Ed. Didactic i Pedagogic, Bucureti, 1996. Jensen K The Oclusion, J Oral Rehab, 26, 515, 1999. Katar H The Complete Denture, J Proth Dent, 2, 152, 1996. Kuwahara A The Deranjamnent of TMJ, J Am Dent Ass, 98, 112, 1990. Puna M, Preoteasa E Aspecte practice n protezarea edentaiei totale, Ed.Cerma, Bucureti, 2002. Poters K Dental materials, J Prosth Dent, 69, 282, 1997. Rndau Ion, Despa EG Reabilitri oro-dentare, Ed. Titu Maiorescu, Bucureti, 2005. Rndau Ion, Despa EG Tratamente protetice dentare complexe, Ed. Printech, Bucureti, 2008. Rndau Ion Proteze dentare, Ed. Medical, Bucureti, 1998. Sorria K The Occlusion Relations, J Dent Res, 17, 528, 1997. Thomson W Mastication, Ans Dent J, 58, 127, 1997. Tubert K Prothese Totale, Od Stom, 7, 618, 1995.
Adres de coresponden: ef Lucr. Dr. Elena Gabriela Despa, Facultatea de Medicin Dentar, Universitatea Titu Maiorescu, Str. Dionisie Lupu, Nr. 70, Sector 1, Bucureti email: gabidespa@gmail.com

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ADMINISTRAREA DE FLUOR PE CALE GENERAL I LOCAL

METODE DE ADMINISTRARE GENERAL A FLUORULUI

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METODE DE FLUORIZARE LOCAL

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SENSIBILITATEA DENTINAR DUP RESTAURRI CORONARE ADEZIVE: CAUZE I MIJLOACE DE PREVENIE

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Therapeutic Possibilities in Flat Coronal Lesions

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Etiologia leziunilor coronare/grupe de vrst este prezentat n fig. 2

Figura 2 Etiologia leziunilor/grupe vrst

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9. Finisare (kit Soflex, 3M ESPE, St Paul, MN, USA)

Figura 7 Aspect final

Figura 4 Aspect iniial

Figura 5 Cimentare pin

Figura 6 Aplicare compozit

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urmtorul strat acoper taieturile diagonale, etc (Fig. 8-14).

Figura 8 Factorul C n cele dou tehnici

Figura 9 Aplicare matrice

Figura 10 Formarea peretelui proximal

Figura 11 Aplicare strat orizontal

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Figura 12 Realizare tieturi diagonale

Figura 14 Realizare tieturi diagonale 2

Figura 13 Aplicare strat orizontal 2

Figura 15 Aspect final

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METHODS AND MATERIALS

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Table 1. Inclusion and exclusion criteria.

Table 2. Gingival Index.36

ANALYTICAL AND STATISTICAL METHODS

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Figure 1. Observed changes in oral health variables.

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Table 3. Oral health variables.

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Table 4. Effect of periodontal treatment on HbA1c. (Subjects with no medication change.)

Table 5. Effect of periodontal treatment in subjects requiring medication change.

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of this effect and its long-term sequelae need additional documentation.

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36. 37. 38.

14. 15. 16.

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METHODS AND MATERIALS

Figure 1 The master model mounted on the base.

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MEASUREMENT AND STATISTICAL ANALYSIS