infraorbital artery. The distribution was confirmed on computed tomographic (CT) scan (Fig 6).

The patient was admitted to the facility and given methylprednisolone,

aspirin, low molecular weight heparin, and prophylactic antibiotics for 48 hours. The aspirin and steroids were continued for another 5 days. After a week the patient still had
chronic pain over the left anterior maxillary region, which
showed more bruising, while the left hard palate mucosa remained pale. Several areas of superficial ulceration were
seen along the margins of the palatal gingiva. After 1 month
the ulcerations healed and the patient was beginning to
have sensation return in the distribution of the infraorbital
nerve. He still has chronic debilitating pain in the left maxilla that has probably triggered his reactionary depression.
Discussion.Calcium hydroxide paste has a pH of 12,
so its exposure to blood causes crystalline precipitation because of the drastically divergent pH values. It is not a totally
biocompatible material. Clinicians must be aware that communication can form between the molar root apex and the
adjacent artery, and instrumentation may provide enough
trauma to allow material to pass into the artery. The syringe
technique used with calcium hydroxide generates pressures greater than the pressure in the artery, causing retrograde flow along the artery. Orthograde flow begins when
the material is displaced into the stem artery, carrying the
calcium hydroxide distally. Arterial obstruction alone did
not produce the necrosis seen in these cases. It is likely
that the calcium hydroxide reached the capillary bed and

was directly toxic to the tissues. Treatment includes aspirin,

heparin, steroids, and prophylactic antibiotics. The aspirin
and heparin should adequately prevent the propagation
of any thrombus; the steroid therapy diminishes inflammatory damage and neuronal injury, including pain; and the
antibiotics prevent any infection of the deep necrotic tissue.
These cases demonstrate the need to use caution with injectable systems for endodontic calcium hydroxide.

Clinical Significance.Calcium hydroxide is

not biocompatible. Its use in dentistry is so common we may forget its truly caustic nature. Because of its ease, application by syringe
injection into root canals is common. Presented
are two cases of what can happen when calcium
hydroxide is inadvertently extruded beyond the
apical foramen.

Sharma S, Hackett R, Webb R, et al: Severe tissue necrosis following

intra-arterial injection of endodontic calcium hydroxide: A case series. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 105:666-669,
2008
Reprints available from R Hackett, Dept of Oral & Maxillofacial
Surgery, Royal West Sussex Hosp NHS Trust, Spitalfields Ln,
Chichester, West Sussex, PO19 6SE, UK; e-mail: rob_hackett@
hotmail.co.uk

Esthetic Dentistry
Mock-ups help with demanding patients
Background.Elective restorative procedures should
not be undertaken until the dentist clearly understands
the patients expectations and the patient understands
the limitations of treatment. Before undertaking an irreversible procedure, the final result should be presented visually and as realistically as possible. Mock-ups prepared
when porcelain laminate veneers are chosen to obtain esthetics and function are objective and effective tools enabling the dentist, patient, and laboratory technician to
communicate clearly. With mock-ups everyone can see
a 3-dimensional representation of the result intraorally
over an extended time. This is better than the 2-dimensional images on a chairside screen. A series of diagnostic
mock-ups served as a means to evaluate esthetic demands
and provide restorations acceptable to a patient whose
esthetic sense was demanding.
Case Report.Woman, 21, was unhappy with her existing acrylic resin veneer provisional restorations (Fig 1) and

Fig 1.Preoperative photograph. (Courtesy of Reshad M, Cascione

D, Magne P: Diagnostic mock-ups as an objective tool for predictable
outcomes with porcelain laminate veneers in esthetically demanding
patients: A clinical report. J Prosthet Dent 99:333-339, 2008.)

Volume 54

Issue 1

2009

13

Fig 2.Tooth preparations by previous dentist showing large

open contacts between maxillary lateral incisors and canines.
(Courtesy of Reshad M, Cascione D, Magne P: Diagnostic mockups as an objective tool for predictable outcomes with porcelain
laminate veneers in esthetically demanding patients: A clinical
report. J Prosthet Dent 99:333-339, 2008.)

Fig 3.Stone cast of first diagnostic arrangement. (Courtesy of

Reshad M, Cascione D, Magne P: Diagnostic mock-ups as an objective tool for predictable outcomes with porcelain laminate veneers
in esthetically demanding patients: A clinical report. J Prosthet Dent
99:333-339, 2008.)

Fig 4.A, Silicone index adapted to preparations. B, Excess polymerized acrylic resin. C, Intraoral anterior view of mock-up. D, Removal of
excess polymerized resin with blade. (Courtesy of Reshad M, Cascione D, Magne P: Diagnostic mock-ups as an objective tool for predictable
outcomes with porcelain laminate veneers in esthetically demanding patients: A clinical report. J Prosthet Dent 99:333-339, 2008.)

14

Dental Abstracts

Fig 9.A, Intraoral anterior view of definitive restorations. B, Intraoral lateral view of definitive restorations. C, Patient smiling with definitive
restorations. D, Patient is satisfied with definitive restorations. (Courtesy of Reshad M, Cascione D, Magne P: Diagnostic mock-ups as an objective tool for predictable outcomes with porcelain laminate veneers in esthetically demanding patients: A clinical report. J Prosthet Dent
99:333-339, 2008.)

wanted the definitive restorations to be better. Her maxillary anterior teeth had been prepared for porcelain laminate veneers, but she was dissatisfied with the provisional
result and referred for final restoration procedures. She
had undergone extensive orthodontic treatment that was
unsuccessful (Fig 2), with large open contacts in the maxillary anterior dentition remaining after the procedure.

Restorative challenges were clearly communicated to her,

including the apical and mesial position of the gingival margin of the right maxillary lateral incisor (Fig 3) and the asymmetry in the gingival zenith between the maxillary laterals.
The edge-to-edge position of the laterals and canines also
complicated the scenario, but the patient had committed
herself to treatment and was highly motivated to proceed.

Her complaint focused on the shape of the overcontoured provisional restorations and the asymmetry and
lack of harmony between her maxillary central incisors.
Most people can perceive an angulation of the maxillary
central incisor crown (cant) of 2 mm or more; this patient
recognized a cant of 1 mm, so was classified as exacting.
She had no desire to undergo further orthodontic treatment. Assessment of her physiological and psychological
needs yielded a categorization of the problem as Class III,
meaning that although she was exacting, her dental needs
could be met using a mock-up and provisional restorations
for an objective communication tool. Porcelain laminate veneers were determined to be the best approach for restoring her maxillary anterior teeth after other options were
presented, discussed, and rejected by the patient.

A freehand diagnostic wax pattern served as the baseline

for the initial diagnostic assessment. The diagnostic cast
with wax pattern was converted to stone so the patient
could better assess the outcome. The diagnostic cast was
used to make an impression. The laboratory technician
was included in the planning interview, and knowing the patients personality helped the technician define the preliminary restorative goal. The direct communication between
technician and patient was a key component of accurate information transfer.
The initial diagnostic arrangement was translated into
a diagnostic direct mock-up over the existing preparations
in a specific sequence of steps (Fig 4).The mock-up was
enhanced by using light-polymerizing stains. The patient

Volume 54

Issue 1

2009

15

was quite accepting of the outcome with the direct mockup, but was encouraged to wear the mock-up for a week
so that her friends and family could give her feedback.
She remained satisfied overall, but had several modifications to make to the mock-up. The modified mock-up
was then translated into stone and the patients approval
was again sought. At this point, tooth preparation was resumed. The clinician was able to produce just what the patient wanted esthetically in the final restoration (Fig 9).
Discussion.Use of the mock-ups and allowing the patient to be fully informed and directly participating in the
process removed several barriers to providing a restoration
with appropriate esthetics. The patients attitude and psychological status were considered at each step. The clinical
procedure was achieved through direct communication between patient, dentist, and laboratory technician.

Clinical Significance.Communication between patient and doctor about what is desired

and what is possible is essential to success
with complex cases. Presented is a way of demonstrating what can be done and what it will
look like before cutting teeth.

Reshad M, Cascione D, Magne P: Diagnostic mock-ups as an objective tool for predictable outcomes with porcelain laminate veneers
in esthetically demanding patients: A clinical report. J Prosthet Dent
99:333-339, 2008
Reprints available from M Reshad, Dept of Advanced Graduate Prosthodontics, School of Dentistry, Univ of Southern California, 925 W
34th St, Los Angeles, CA 90089-0641; fax: 213-740-1209; e-mail:
reshad@usc.edu

Implants
Endoscopic transnasal removal of implant
Background.Dental implants and other foreign bodies may migrate and require removal. An endoscopic transnasal approach was used for a woman whose implant
became displaced.
Case Report.Woman, 46, complained of an unattractive smile because of a missing upper premolar tooth and an
edentulous space left when an upper molar was extracted.
Examination revealed several teeth had been extracted, creating an unesthetic gap between the upper left first premolar and the upper left first molar. The approach chosen to
resolve the problem included an implant-supported fixed
restoration in the area of the second left upper premolar
and the right upper second molar. Surface-roughened, titanium dental implants were placed. The patient desired an
esthetic result as quickly as possible, so the premolar-site
implant, which had good initial stability, had a temporary
restoration placed immediately. Routine follow-up after
7 days showed no problems.
Three weeks later the patient complained that the tooth
had fallen out and she now had mild pain on the left side
of her face. The premolar-site implant could not be found
on clinical examination, so an orthopantomogram was obtained (Fig 1). The implant had become dislodged into
the posterior area of the left maxillary sinus. The patient
eventually admitted that she had lost the temporary crown
2 weeks previously and had been chewing on the exposed
area of the implant. A maxillofacial surgeon was consulted
to perform surgical removal of the implant. An endoscopic
transnasal approach was chosen. The endoscopic

16

Dental Abstracts

Fig 1.Orthopantomogram showing dental implant in left maxillary sinus. (Courtesy of Lubbe DE, Aniruth S, Peck T, et al: Endoscopic transnasal removal of migrated dental implants. Br Dent
J 204:435-436, 2008.)

uncinectomy and middle meatal antrostomy located the implant in the posteromedial aspect of the maxillary sinus.
The implant was removed atraumatically using a curved forceps under 30-degree endoscopic guidance.
Discussion.The classic Caldwell-Luc procedure
would have been much more invasive than the endoscopic
transnasal approach for this patient. An otolaryngologist
should be consulted when there is a maxillary antrum lesion
to determine if endoscopic transnasal removal is feasible.