Revista Românå de

STOMATOLOGIE
Volumul LIV
Nr. 3, Supliment
An 2008

ISSN 1843-0805
Cod CNCSIS 756

Redactor ªef:
Prof. Univ. Dr. Em. HUTU
Redactor ªef Adjunct:
Conf. Univ. Dr. M.V. CONSTANTINESCU
Secretar General de Redac¡ie:
ªef Lucr. Dr. Elena-Gabriela DESPA
Dr. E. POPA
Redactor Responsabil de numår:
ªef Lucr. Dr. Liana STANCIU
Redactori verificare articole:
Conf. Univ. Dr. Cornelia BÎCLEªANU
ªef Lucr. Dr. Tudor IONESCU, ªef Lucr. Dr. Dånu¡ CHIRU
Dr. Ingrid PINTILIE
Redactori Rela¡ii Interna¡ionale:
ªef Lucr. Dr. Alina DAN
Dr. Simona MUNTEAN

CONSILIUL ªTIINºIFIC:

Prof. Dr. D. BORZEA – Cluj-Napoca Prof. Dr. S. IONIºÅ – Bucure¿ti

Dr. C. BRUSCAGIN – Italia
Prof. Dr. A. BUCUR – Bucure¿ti
Prof. Dr. V. BURLU– Ia¿i
Dr. Ugo CAPURSO – Italia
Prof. Dr. V. CÂRLIGERIU – Timi¿
Prof. Dr. Elvira COCÂRLÅ – Cluj-Napoca
Prof. Dr. M. CRÅIºOIU – Craiova
Conf. Dr. B. DIMITRIU – Bucure¿ti
Prof. Dr. H. DUMITRIU – Bucure¿ti
Prof. Dr. L. ENE – Bucure¿ti
Prof. Dr. Norina FORNA – Ia¿i
Prof. Dr. A. GARFUNKEL – Israel
Prof. Dr. N. GANUTA – Bucure¿ti
Dr. I.B.T. GEORGESCU – Bucure¿ti
Prof. Dr. Ov. GRIVU – Arad
Prof. Dr. A. ILIESCU – Bucure¿ti
Prof. Dr. Ecaterina IONESCU – Bucure¿ti
Conf. Univ. Dr. Ileana IONESCU – Bucure¿ti
Conf. Dr. D.A. MARIª – Constan¡a
G-ral Prof. Dr. T.A. MIHAI – Bucure¿ti
Prof. Dr. S. SANDHAUS – Elve¡ia
Prof. Dr. Valentina SCÂNTEI-DOROBź – Ia¿i
Prof. Dr. A. SCHNEIDER – Germania
Dr. Eugenia ROªCA – Italia
Prof. Dr. Mihaela PÅUNA – Bucure¿ti
Conf. Dr. Al. PETRE – Bucure¿ti
Prof. Dr. Mariana Brându¿a POPA – Bucure¿ti
Prof. Dr. S. POPA – Cluj
Dr. Ion RÂNDAªU – Bucure¿ti
Prof. Dr. Dan Dumitru SLÅVESCU – Bucure¿ti
Conf. Dr. C. VÂRLAN – Bucure¿ti
Prof. Dr. Maria VORONEANU – Ia¿i
Prof. Dr. Theodor TRÅISTARU – Bucure¿ti
Conf. Dr. Irina ZETU – Ia¿i
Conf. Dr. Liviu ZETU – Ia¿i
 Universitatea de Medicinå ¿i Farmacie „Carol Davila“,
Facultatea de Medicinå Dentarå, Bucure¿ti
Prof. Dr. Drago¿ STANCIU – Decan
Prof. Dr. Rodica LUCA – Prodecan
Conf. Dr. Radu ªerban ºOVARU – Prodecan
Conf. Dr. Codru¡ SARAFOLEANU – Prodecan
Prof. Dr. Victor NIMIGEAN – Secretar ªtiin¡ific

Universitatea „Titu Maiorescu“, Facultatea de Stomatologie, Bucure¿ti

Prof. Dr. D. SLÅVESCU – Decan
Prof. Dr. V. CHERLEA – Prodecan
Prof. Dr. Mircea IFRIM – Prodecan
Conf. Dr. Cornelia BÎCLEªANU – Secretar ªtiin¡ific

Universitatea de Vest „Vasile Goldi¿“,

Facultatea de Medicinå Generalå ¿i Medicinå Dentarå, Arad
Prof. Dr. Maria NEGUCIOIU
Prof. Dr. Voicu SEBEªAN
Prof. Dr. Emil URTILÅ
Conf. Dr. Valeria COVRIG
Conf. Dr. Mugur POPESCU
Conf. Dr. Emanuel BRATU

Editura Medicalå AMALTEA

Editori: Dr. M.C. Popescu
Dr. Cristian Cârstoiu
Director executiv: George Stanca
Redactori: Oana Cristina Plåcintå, Alina-Nicoleta Ilie
Prepress: AMALTEA TehnoPlus
Tehnoredactor: Gabriela Cåpitånescu
DTP: Petronella Andrei
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TIPAR:
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Revista este realizatå în colaborare cu

Facultatea de Medicinå Dentarå
a Universitå¡ii „Titu Maiorescu“,
Bucure¿ti
 Cuprins

ODONTOLOGIE
1. Cornelia Bîcle¿anu
Administrarea de fluor pe cale generalå ¿i localå ____________________________________

2. Cornel Boitor, Anca Frå¡ilå

Sensibilitatea dentinarå dupå restauråri coronare adezive: cauze ¿i mijloace
de preven¡ie _____________________________________________________________________

3. Cornelia Bîcle¿anu
Posibilitå¡i terapeutice în distruc¡ii coronare întinse ___________________________________

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-FACIALÅ
6. Mirela-Jeni Comancianu
Eludrilul ¿i implica¡iile lui în cazul extrac¡iei 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 D’Abreu, Fernandon Cendes
Temporomandibular Joint Internal Derangement: Association with Headache, Joint Effusion,
Bruxism, and Joint Pain __________________________________________________________

PROTETICÅ DENTARÅ
9. Anca Frå¡ilå, Cornel Boitor
Rolul zonei de închidere velopalatinalå în prevenirea e¿ecurilor protezei mobile ___________

10. Elena-Gabriela Despa

Rezultatele studiului clinic ¿i statistic asupra câmpului protetic edentat total ______________

11. Elena-Gabriela Despa, Gabriela Moise

Aspecte ale mi¿cårilor mandibulare la edentatul total _________________________________
 1 ODONTOLOGIE
ADMINISTRAREA DE FLUOR PE CALE
GENERALÅ ªI LOCALÅ
General and Local Fluorine Administration
Conf. Dr. Cornelia Bîcle¿anu
Disciplina Odontoterapie restauratoare, Facultatea de Medicinå Dentarå,
Universitatea Titu Maiorescu, Bucure¿ti
METODE DE ADMINISTRARE GENERALÅ A
FLUORULUI
În urma unor studii ample, s-a determinat cå
fluorul este singurul element mineral unanim
corelat cu rezisten¡a la carie a din¡ilor.
Prevenirea cariei dentare prin administrarea de
fluor reprezintå modalitatea prin care s-au ob¡inut
cele mai importante rezultate.
Ca urmare, administrarea fluorului se poate
realiza pe cale generalå ¿i pe cale localå.
Dintre modalitå¡ile de administrare a fluorului, pe
cale generalå, cea mai indicatå, (în special ca raport
cost/eficien¡å) este prin consumul de apå fluorizatå.
S-au fåcut numeroase studii privind concen-
tra¡ia optimå a fluorului în apå, toate demonstrând
ca reducerea cea mai spectaculoaså a inciden¡ei
cariei se produce pânå la o concentra¡ie de 1 ppm,
concentra¡ie la care leziunile distrofice de fluorozå
sunt rare ¿i de minimå gravitate.
O sintezå a 95 de studii din 20 de ¡åri, realizate
în condi¡ii diferite privind eficacitatea prevenirii
cariei dentare la copii prin fluorizarea apei, aratå
o reducere cu peste 40% a cariilor din¡ilor per-
manen¡i (Naylor ¿i Murray-1976).
De asemenea fluorul prezintå o ac¡iune beneficå
¿i asupra persoanelor adulte rezidente permanent
într-o localitate cu apå fluorizatå. La acestea s-a
constatat o reducere cu 45% a numårului de su-
prafe¡e cariate comparativ cu o popula¡ie ce con-
sumå apå cu un con¡inut scåzut de fluor.
Astfel se poate concluziona cå fluorizarea apei
are un efect protectiv substan¡ial ¿i de duratå.
Fluorizarea apei, combinatå cu celelalte måsuri
preventive a redus prevalen¡a cariei cu circa 75%
în general, iar pentru suprafe¡ele aproximale chiar
cu 90%.
156 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
La adul¡ii cu vârsta între 20-44 ani s-a estimat
în urma consumului de apå fluorizatå o reducere
cu 20-30% a cariilor coronare ¿i o reducere
cuprinså între 20-40% a cariilor radiculare.
De asemenea, s-a demonstrat cå fluorul pre-
zintå efectul cariopreventiv cel mai mare pe
suprafe¡ele libere – 86%, apoi pe suprafe¡ele
aproximale – 75%, iar cel mai mic efect cario-
preventiv îl prezintå la nivelul ¿an¡urilor ¿i fo-
setelor ocluzale – 31%.
Toate aceste date i-au permis lui Horowitz så
afirme cå fluorizarea apei asigurå beneficii tuturor
persoanelor dentate de-a lungul întregii vie¡i.
O altå metodå de administrare generalå a
fluorului este prin fluorizarea sårii de bucåtårie ce
se realizeazå cu 200-250 mg fluorurå de Na la
1kg de sare, asigurându-se astfel un aport de pânå
la 2 mg Fluor la un consum mediu de 6g sare/zi.
Fluorizarea sårii de bucåtårie nu necesitå decât
3% din cantitatea de fluor necesarå pentru fluori-
zarea apei înså efectul carioprotectiv este ceva mai
scåzut decât cel care se întâlne¿te în urma fluori-
zårii apei potabile.
Fluorizarea laptelui ¿i a båuturilor råcoritoare
are de asemenea efecte carioprotective înså mai
scåzute decât cele ob¡inute în urma fluorizårii apei
potabile.
Stephen (1981) a aråtat cå un consum zilnic în
¿coalå de 200 ml lapte cu con¡inut de 1,5 mg de
fluor pe timp de 4 ani a redus inciden¡a cariei la
primii molari permanen¡i 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 ¿coalå 100 g suc de
portocale con¡inând 1 mg F (10 ppm) pe o perioadå
de 3 ani.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
În ceea ce prive¿te fluorizarea alimentelor,
aceasta prezintå dezavantajul unui dozaj relativ
prin diferen¡ele cantitative de ingestie alimentarå
între indivizi, iar compozi¡ia deosebitå a meniurilor
face imposibilå stabilirea unui echilibru de dozare
a fluorului.
O altå metodå de administrare a fluorului pe
cale generalå este prin administrarea tabletelor ¿i
solu¡iilor ce con¡in fluor.
În literatura de specialitate au apårut mai multe
articole ce se referå la eficacitatea administrårii
tabletelor sau solu¡iilor, articole ce au fost sinteti-
zate de cåtre DRISCOL – 1974 ¿i BINDER – 1978.
Aceste cercetåri pot fi împår¡ite în trei grupe
dupå modul de administrare:
1. prenatalå;
2. înainte de vârsta ¿colarå;
3. la ¿coalå ¿i numai în timpul ¿colii.
1. Administrarea de fluor prenatal este beneficå
în profilaxia cariei la copii, în special pentru denti¡ia
temporarå dar cele mai bune rezultate se ob¡in dacå
este continuatå prin administrare de fluor la copil
cât mai curând dupå na¿tere.
2. Potrivit diferitelor studii se aratå cå efectele
carioprotective mari (circa 50-80%) s-au ob¡inut
dacå administrarea fluorului s-a început înainte de
vârsta de 2 ani.
Efectele cele mai bune s-au ob¡inut unde dozele
de fluor au fost corelate cu concentra¡ia fluorului
din apå ¿i cu vârsta copilului (HENON – 1977).
Studiile privind efectul administrårii fluorului
sub formå de tablete sau solu¡ii asupra din¡ilor per-
manen¡i aratå o reducere importantå a cariilor mai
ales dacå administrarea s-a fåcut de la na¿tere cel
pu¡in 7 ani (între 39 ¿i 80%).
3. Administrarea tabletelor sau solu¡iilor cu
fluor în ¿coalå începând cu clasa I (6-7 ani), cu o
duratå de minimum 5 ani s-a dovedit cario-
preventivå în medie de 30% (DRISCOL – 1978).
Aceste cercetåri aratå fårå nici un dubiu cå
folosirea tabletelor sau solu¡iilor este eficientå în
prevenirea cariilor dentare atât la din¡ii temporari
cât ¿i la cei permanen¡i.
Dupå vârsta de 2 ani este de preferat så se
administreze fluorul sub formå de tablete, copilul
fiind instruit så le sugå seara, înainte de culcare,
pentru a combina efectul general cu cel local
asupra din¡ilor 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
157
Cantitatea de fluor administratå trebuie corelatå
cu:
– concentra¡ia fluorului din apa potabilå;
– vârsta copilului;
– zona climaticå.
Pentru zona de climå temperatå, dacå fluorul
din apa potabilå nu depå¿e¿te 0,4 ppm, se admi-
nistreazå în func¡ie de greutatea copilului:
– de la na¿tere pânå 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 ob¡inerea efectului cariostatic este ne-
cesar aportul minim de 1,3 mg de fluor zilnic pe
cale generalå.
Suplimentarea, indiferent de metodå, se rapor-
teazå la:
– concentra¡ia din apa potabilå;
– cantitatea de apå potabilå consumatå în
medie pe zi;
– aportul mediu oferit prin alimente;
– concentra¡ia din atmosferå, pentru zonele cu
poluare fluoruratå.
Pentru a fi eficace metodele de administrare ge-
neralå trebuie:
– så foloseascå faza I (amelogenezå ¿i mine-
ralizare);
– så se prelungeascå în faza a II-a (de maturare
preeruptivå);
– så se prelungeascå chiar ¿i la începutul fazei
a III-a (posteruptivå) când se completeazå
maturarea superficialå a smal¡ului.
Programul complet începe prin administrarea
zilnicå de fluor la femeia gravidå începând cu luna
a IV-a de sarcinå ¿i pânå la na¿tere, se continuå
administrarea la copil începând cât mai aproape
de momentul na¿terii, zilnic, pânå la vârsta de 12-14
ani, fårå întrerupere.
Administrarea numai în prima fazå (0-6 ani)
sau numai în a II-a fazå (6-12 ani) reduce mult
eficacitatea cu perspectiva de a se pierde efectul
în timp.
Dacå se respectå programul complet (cel pu¡in
de la 0 la 12 ani) în toate metodele se ob¡in rezul-
tate egale.
Diferen¡ele sunt doar în privin¡a costului, u¿u-
rin¡a de administrare ¿i posibilitå¡ile de abordare a
unor colectivitå¡i cât mai mari.
METODE DE FLUORIZARE LOCALÅ
Fluorizarea localå se poate realiza profesional
dar ¿i personal.
158 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
Fluorizarea localå profesionalå se poate
realiza cu ajutorul solu¡iilor simple de NaF sau SnF,
solu¡iilor sau gelurilor cu un pH acid, pastelor
profilactice cu fluor ¿i lacurilor cu fluor.
Dintre solu¡iile cu fluor utilizate în fluorizarea
profesionalå localå, se folosesc:
a. Fluorura de sodiu 2% – ce este cea mai
uzualå solu¡ie pentru aplica¡ii topice pe din¡ii cura¡i
(fårå placå bacterianå) de 2-4 ori pe an.
b. Fluorura de staniu – este de 3 ori mai
eficientå în scåderea solubilitå¡ii smal¡ului la acizii
slabi comparativ cu solu¡ia de NaF.
Gelurile de fluor utilizate în fluorizarea localå
profesionalå s-au ob¡inut prin adåugarea în solu¡ii
a unor agen¡i de gelificare, cum ar fi metil, hidro-
ximetil celulozå.
Din aceastå categorie fac parte gelul de fluoro-
rtofosfat ce este u¿or de utilizat într-un confor-
mator individual, nu provoacå saliva¡ie sau sen-
za¡ie de vomå pentru cå nu se råspânde¿te în cavi-
tatea bucalå ¿i are proprietå¡i tixotropice, adicå,
se transformå în solu¡ie sub ac¡iunea presiunii,
påtrunzând astfel în ¿an¡uri ¿i fosete.
În cazul aplicårilor bianuale reducerea cariilor
este de 20-40%.
Alåturi de acesta, se mai utilizeazå ¿i gelul de
fluorurå de aminå ce reduce solubilitatea smal¡ului
¿i u¿ureazå prin proprietå¡ile lui tensioactive,
fixarea de fluor la suprafe¡ele dentare.
Un astfel de gel este gelul ELMEX ce se aplicå
o datå pe såptåmânå pe suprafe¡ele din¡ilor, cu
ajutorul unei canule adaptate la seringå, låsându-
se 2-3 minute în contact cu din¡ii, dupå care se
realizeazå periajul.
Lacurile cu fluor au fost realizate pentru a re-
duce timpul de aplicare, pentru a simplifica tehnica
¿i pentru a cre¿te timpul de contact al fluorului cu
suprafe¡ele din¡ilor.
Produsele cele mai cunoscute sunt:
– DURAPHAT – ce con¡ine 2,26% F sub
formå de NaF, într-o solu¡ie alcoolicå de
rå¿ini naturale, el aderând u¿or pe supra-
fe¡ele umede ale din¡ilor;
– ELMEX PROTECTOR – ce con¡ine
aminofluoruri încorporate într-un lac de
poliuretan autopolimerizabil;
– EPOZYLATE – ce este un lac protector de
lungå duratå ¿i are încorporat monofluor
disodic într-un lac de poliuretan auto-
polimerizabil.
În ceea ce prive¿te eficien¡a acestora, s-a
constatat cå, aplicate pe o perioadå mai mare de
timp ¿i prin aplicåri mai frecvente se ob¡ine o
reducere a inciden¡ei cariei între 30 ¿i 38%, fiind
la fel de eficiente ca ¿i solu¡iile ¿i gelurile fluoru-
rate.
Aplica¡iile topice prin ionoforezå reprezintå cea
mai eficace metodå de prevenire prin aplica¡ii
topice de fluor prin faptul cå prin ac¡iunea curen-
tului de joaså tensiune, ionul de fluor este for¡at
så påtrundå în cantitate mare ¿i la o adâncime mai
mare, inclusiv pe fe¡ele aproximale, în structura
smal¡ului.
În acest fel se aplicå solu¡iile de fluorurå de
sodiu 1% sau de fluorortofosfat 1,4% în ¿ine sau
în gutiere standard sau individuale, conectate la o
instala¡ie simplå cu baterii electrice, înså metoda
este costisitoare ¿i dificil de aplicat în colectivitå¡i.
Fluorizarea localå personalå se realizeazå de
cåtre pacient cu ajutorul pastelor de din¡i fluorurate
¿i cu aminofluoruri ¿i prin clåtiri bucale.
Existå înså rezerve în ceea ce prive¿te folosirea
pastelor de din¡i cu con¡inut ridicat de fluor la copii
în cursul mineralizårii ¿i maturårii smal¡ului din¡ilor
permanen¡i, în special în zonele fårå deficit de
fluor în apa potabilå, din cauza posibilitå¡ii de
apari¡ie a fluorozei.
În ceea ce prive¿te clåtirile bucale, acestea se
realizeazå cu ajutorul unor:
– solu¡ii de NaF neutrale în concentra¡ii de la
500 ppm la 3 000 ppm;
– solu¡ii acidulate de NaF;
– solu¡ii cu fluoruri de staniu, amoniu, fier,
aluminiu.
Cercetåtorii care au testat mai multe solu¡ii cu
fluor (TAVEL ¿i ERICSON–1965) au ajuns la
concluzia cå se ob¡in rezultate pozitive cu oricare
din aceste combina¡ii, eficacitatea depinzând de
concentra¡ia în ion de fluor, ¿i timpul de contact
cu suprafe¡ele dentare.
În general se ob¡ine o reducere de peste 30%
în aplica¡ii zilnice timp de mai mul¡i ani, înså nu
se recomandå la copii sub 5 ani care pot înghi¡i o
cantitate din solu¡ie cu posibilitatea de supradozare
a fluorului ingerat.
În tabelul urmåtor sunt reprezentate substan¡ele
pe bazå de fluor care sunt utilizate pentru aplica¡ii
profesionale sau la domiciliu.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 159
160 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

Adreså de coresponden¡å:
Conf. Dr. Bîcle¿anu Florentina Cornelia, Facultatea de Medicinå Dentarå, Universitatea „Titu Maiorescu“, Strada Gheorghe
Petra¿cu, Nr. 67A, Sector 3, Cod Po¿tal 031593, Bucure¿ti
email: corneliabicle@yahoo.com
 ODONTOLOGIE
2
SENSIBILITATEA DENTINARÅ DUPÅ
RESTAURÅRI CORONARE ADEZIVE: CAUZE
ªI MIJLOACE DE PREVENºIE
Dentinal Sensibility After Adhesive Coronal Restorations:
Causes and Prevention Methods
ªef Lucr. Dr. Cornel Boitor, ªef Lucr. Dr. Anca Fra¡ilå
Facutatea de Medicinå „Victor Papilian“, Sibiu

REZUMAT
De¿i în vitro adeziunea dintre ¡esuturile dentare ¿i materialul de obtura¡ie adeziv îndepline¿te calitå¡i remarcabile, în practica
cotidianå se constatå într-un proces important de cazuri apari¡ia unei sensibilitå¡i dentinare postoperatorii.
Aceastå sensibilitate depinde de factorii locali ai pacientului dar ¿i de calitatea sau modul de utilizare al materialelor compozite
folosite.

Cuvinte cheie: adeziune compozit-dinte, contrac¡ie de polimerizare, sensibilitate dentinarå, preven¡ie.

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 apari¡ia sensibilitå¡ii
dentinare ca un e¿ec al restaurårilor adezive, tre-
buie så eliminåm a priori printr-un diagnostic
diferen¡ial toate celelalte cauze posibile, precum:
fracturi, fisuri, leziuni carioase, parodontite apicale,
eroziuni cuneiforme, abrazii.
De¿i mecanismele fiziopatologice de producere
a sensibilitå¡ii dentinare nu sunt complet elucidate,
ipoteza hidrodinamica a lui Brannstrom este împår-
tå¿itå de un numår foarte mare de studii recente
(1,2).
Din punct de vedere clinic, manifestårile de
sensibilitate post operatorie, dupå restauråri adezive,
apar într-o rela¡ie evidentå cu pierderea etan¿eitå¡ii
marginale. Principalele cauze ale acestei sensibilitå¡i
pot fi grupate în umåtoarele patru grupe de cauze:
1. Cauze legate de materialul de obtura¡ie
compozit
În cazul compozitelor, principala cauzå care
poate duce la apari¡ia sensibilitå¡ii postoperatorii
este contrac¡ia de polimerizare, care poate varia
între 1.5-5% în volum (3,4). Contrac¡ia compozi-
telor poate avea urmatoarele efecte:
– Tensiuni la nivelul ¡esuturilor dentare, care
pot antrena flexiuni ale cuspizilor, slåbirea
prismelor de smal¡ ¿i poate merge panå la
fisuri sau fracturi.
– Pierderea adaptårii marginale cu apari¡ia
unor hiatusuri ce favorizeazå percola¡ia mar-
ginalå. Aceasta se manifestå clinic sub formå
de sensibilitate postopeatorie, carii secun-
dare marginale sau inflama¡ii pulpare.
– Contrac¡ii interne ale materialului de obtu-
ra¡ie care poate produce fracturi in masa
compozitului.
– Diminuarea rezisten¡ei mecanice a compo-
zitului.
Posibilitå¡ile de prevenire constau în reducerea
efectelor nedorite ale contrac¡iei de polimerizare
pe baza urmåtoarelor proceduri:
– Folosirea unui adeziv cu încårcåturå
mineralå mare.
– Aplicarea compozitului în straturi succesive
în func¡ie de configura¡ia cavitå¡ii
– Adoptarea tehnicii de obtura¡ie „sandwich“
cu utilizarea unei baze intermediare din

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 161

162 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

ciment ionomer de sticlå modificat Studiile recente asupra fotopolimerizårii com-

(fotopolimerizabil) pozitelor au aråtat ca retrac¡iile de polimerizare
– Utilizarea unui strat intern de compozit fluid nu sunt într-o legåturå liniarå directå cu timpul de
care permite diminuarea stresului de expunere ¿i cu intensitea luminoaså. În consecin¡å,
contrac¡ie cu circa 20-50% (4) un timp de expunere mai lung ¿i o intensitate mai
– Utilizarea unui compozit pe bazå de siloran scåzutå, determinå o ratå de polimerizare mai mare
(Filtec Siloran -2M ESPE), care are un decat un timp scurt cu o intenistate mare a luminii.
coeficient redus de contrac¡ie de ordinul Polimerizarea progresivå are repercursiuni bene-
0.8% (relativ insuficient confirmat de studiile fice asupra calitå¡ii legåturii compozit-¡esut dentar
clinice). (7).
2. Cauze legate de mårimea cavitå¡ii Modalitå¡ile de prevenire a unor erori legate
Restaurårile directe din materiale compozite au de fotopolimerizare au obiectivul de a realiza o
ca primå indica¡ie cavitå¡ile coronare de mårime cat mai bunå legåturå dinte-material de obtura¡ie
¿i pot fi ob¡inute prin:
micå ¿i mijlocie. În cazul unor cavitå¡i de mårime
– Straturi de compozit cu grosime de cel mult
mare, cu toate måsurile de preven¡ie pe care le
2 mm (care permite reac¡ia de polimerizare
putem lua, apare totu¿i o contrac¡ie a materialului
în condi¡ii optime).
de obtura¡ie.
– Obtura¡iile de volum mediu ¿i mare trebuie
Posibilitå¡ile de prevenire eficiente se bazeazå efectuate în straturi succesive plasate oblic
pe recurgerea la metode indirecte de restaurare de fa¡å de pere¡i, astfel încat vectorul de
tip onlay, cimentat sau colat pe dinte (5). contrac¡ie så aibå o rezultantå favorabilå
3. Cauze legate de adezivul folosit adeziuni la ¡esuturi(figura 1. A-D) (8).
Adezivii de genera¡ia a 5-a, care con¡in într-un
singur flacon primerul, rå¿ina adezivå ¿i solventul
sunt foarte u¿or de aplicat în practicå, scurtand
timpul de lucru. Cerin¡a acestui adeziv este så fie
aplicat pe o dentinå cu un anumit grad de umi-
ditate. Dificultatea tehnica a medicului practician,
constå tocmai în realizarea acestei „umiditå¡i“ care
så favorizeze påtrunderea optimå în dentinå a
adezivului. Aplicarea gre¿itå poate duce la com-
promiterea etan¿eitå¡ii marginale, sensibilitate
dureroaså, colora¡ii marginale inestetice sau chiar
leziuni curioase secundare.
Posibilitå¡ile de prevenire constau în recurgerea
la sisteme adezive cu autogravare, care reduc
considerabil riscul de aplicare pe o dentinå cu umi-
ditate nepotrivitå (se înlaturå etapa de uscare ¿i
A
spålare a dentinei). În plus, acest sistem de auto-
gravare nu înlaturå detritusul dentinar remanent
din canaliculii dentinari (cepurile canaliculare), ci
îl blocheazå ¿i stabilizeazå pe loc, ceea ce previne
deplasarea fluidului prin canaliculii dentinari.
Aceasta explicå în bunå parte rata scåzutå a sensi-
bilitatii dentinare, observatå clinic la adezivii de
acest tip (6,7).
4. Cauze legate de polimerizare
Folosirea unei surse de luminå pentru poli-
merizarea compozitului determinå o conrtac¡ie de
polimerizare a materialului, în direc¡ia sursei
luminoase (6,8). Aceastå etapå consideratå de
multe ori consumatoare de timp, a dus la apari¡ia
unor lampi cu timpi de expunere tot mai scåzu¡i. B
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 163

Concluzii
Sensibilitatea dentinarå apårutå, dupå efectuarea
restaurårilor adezive din compozit este consideratå
un e¿ec al tratamentului.
El este pus în legåturå directå cu pierderea
închiderii marginale datoritå contrac¡iilor din
timpul polimerizårii sau unor gre¿eli tehnice de
utilizare a materialelor adezive.
Prin aplicarea unor måsuri stricte privind
protocolul de polimerizare, sensibilitatea dentinarå
post operatorie poate fi prevenitå.

D
Figura 1. A-D
Modalitå¡i de plasare ¿i polimerizare a materialului de
obtura¡ie în cavitå¡ile medii ¿i mari cu scopul de a
ob¡ine un vector de polimerizare favorabil adeziunii la
¡esuturi (8).

BIBLIOGRAFIE
1. Branstrom M et all – Sutdy of the mechanism of pain elicited from 6. Peutzfeldt A et all – Adhesive systems :effect on bond strength of
the dentin. Arch Oral Biol 1967; 12: 209-216 incorrect use. J Adhes Dent 2002:233-242.
2. Pashley DH – Dynamics of the pulpodentin complex. Crit Rev Oral 7. Opdam NJ et all – Class 1 oclusal composite resin restoration in
Biol Med, 1996; 23:104-109 vivo postoperative sensitivity, wall adaptation and microleakage. Am
3. Peutzfeld A et all – Rezin compozite propertis and energy density J Dent 1998; 1:229-234.
of light cure. J Dent Res 2005;84:659-662. 8. Lehmann N – Les sensibilites postoperatoires. Causes et solutions
4. Roth F – Les composites, Ed Masson – 2002. preventives. Clinic, Les echecs. Hors Serie, Iunie 2008, 19-24.
5. 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.

Adreså de coresponden¡å:
ªef Lucr. Dr. Frå¡ilå Anca, Facultatea de Medicinå „Victor Papilian“, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Cod Po¿tal 550166
email: fratila.anca@yahoo.com
 3 ODONTOLOGIE

POSIBILITźI TERAPEUTICE ÎN
DISTRUCºII CORONARE ÎNTINSE
Therapeutic Possibilities in Flat Coronal Lesions
Conf. Dr. Bîcle¿anu Cornelia
Facultatea de Medicinå Dentarå, UTM, Bucure¿ti

REZUMAT
Tratamentul cariei dentare este strict conservator ¿i vizeazå atât eliminarea leziunii propriu-zise, cât ¿i a efectelor secundare ale
acesteia asupra ¡esuturilor din vecinåtate.
Scopul final al acestui tratament este refacerea corectå a morfologiei coronare dentare astfel încât så nu se producå suferin¡e
ocluzo-articulare sau în timp, suferin¡e ale organului pulpar, precum ¿i recidiva de carie.
Scop: Aceasta lucrare i¿i propune så prezinte tratamentul leziunilor coronare întinse, atât restaurårile directe cu materiale
adezive dar ¿i tratamentele utilizate atunci când nu se mai pot aplica tehnici conservative ¿i este nevoie de restauråri coronare prin
ancoråri cu dispozitive radiculare, dupå tratamentul endodontic
Material ¿i metodå: Studiul s-a realizat pe un lot de 20 pacien¡i (12 femei, 8 bårba¡i) cu vârste cuprinse între 25 si 55 ani, care s-au
prezentat pentru rezolvarea unor distruc¡ii coronare mari situate în zona frontalå (13) ¿i zona lateralå (7).
Rezultate ¿i discu¡ii: Sunt prezentate câteva cazuri clinice care reflectå modalitå¡i de restaurare a cariilor extinse.
Concluzii: Aplicarea unor tehnici pot remedia neajunsurile ce pot apårea în restaurarea leziunilor carioase întinse.

Cuvinte cheie: leziuni carioase întinse, factor C, contrac¡ie 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 vizeazå atât eliminarea leziunii propriu-zise, cât
¿i a efectelor secundare ale acesteia asupra ¡esutu-
rilor din vecinåtate.
Scopul final al acestui tratament este refacerea
corectå a morfologiei coronare dentare astfel încât
så nu se producå suferin¡e ocluzo-articulare sau
în timp, suferin¡e ale organului pulpar, precum ¿i
recidiva de carie.
SCOP
Aceasta lucrare i¿i propune så prezinte
tratamentul leziunilor coronare întinse, atât
restaurårile directe cu materiale adezive dar ¿i trata-
mentele utilizate atunci când nu se mai pot aplica
tehnici conservative ¿i este nevoie de restauråri
coronare prin ancoråri cu dispozitive radiculare,
dupå tratamentul endodontic

164 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
MATERIAL ªI METODÅ
Studiul s-a realizat pe un lot de 20 pacien¡i (12
femei, 8 bårba¡i) cu vârste cuprinse între 25 ¿i 55
ani, care s-au prezentat pentru rezolvarea unor
distruc¡ii coronare mari situate în zona frontalå (13)
¿i zona lateralå (7) fig. 1
Figura 1
Reparti¡ia lotului pe zone
Etiologia leziunilor coronare/grupe de vârstå
este prezentatå în fig. 2
Figura 2
Etiologia leziunilor/grupe vârstå
Restaurårile s-au realizat cu materiale com-
pozite, 8 cazuri, 4 au fost restaurate cu amalgam,
iar 8 dintre cazuri au necesitat tratament endo-
165
dontic ¿i restaurare prin ancorare în canalul ra-
dicular pentru cre¿terea retentivitå¡ii (fig. 3).
Figura 3
Reparti¡ie lot dupå material de restaurare
CAZURI CLINICE
Caz 1
Pacient în vârstå de 25 ani prezintå fracturå co-
ronarå la nivelul lui 12, cu interesarea pulpei den-
tare.
Tratamentul a constat din restaurare directå,
dupå depulpare, cu pin intraradicular ¿i restaurare
coronarå cu material compozit.
Protocol terapeutic
1. Tratament endodontic ¿i obtura¡ie canal
2. Dezobturarea canalului cu freza Gates
(Antaeos, VDW GmbH, Munchen, Germany)
pe 2/3 din lungime
3. Demineralizarea canalui cu acid fosforic
37%, spålare, uscare cu conuri de hârtie.
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
166 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

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

USA)

Figura 7
Aspect final

Figura 4
Aspect ini¡ial
Caz 2
Pacienta prezintå o leziune carioaså extinså cer-
vicalå. Restaurarea s-a realizat cu materiale com-
pozite dupå o tehnicå specialå. Pentru o mai bunå
vizualizare tehnica este exemplificatå pe un dinte
extras.
Tehnica:
– se aplicå primul strat de compozit apoi se se
fac douå incizii diagonale de 1,5 mm prin toatå
grosimea materialului împår¡indu-l astfel în
patru pår¡i cu forme triunghiulare, plane.
– se fotopolimerizeazå 40 sec dinspre vesti-
bular.
– urmåtorul strat se aplicå într-o 1/2 incizie
diagonalå ¿i se fotopolimerizeazå.
– urmåtorul strat se aplicå în cea de-a doua
Figura 5 incizie ¿i se fotopolimerizeazå, etc.
Cimentare pin – se aplicå alt strat orizontal, se fac tåieturi
diagonale ¿i a¿a pânå la umplerea completå
a cavitå¡ii
Aceastå tehnicå reduce factorul C ¿i contrac¡ia
de polimerizare
– Factorul C este definit ca fiind rela¡ia dintre
suprafe¡ele care au fåcut prizå ¿i cele care
nu au fåcut prizå în urma bonding-ului.
– Dacå raportul este mare în favoarea supra-
fe¡elor care nu au fåcut prizå denotå o
presiune mare datoritå polimerizårii.

Supraf. cu bonding
Factorul C= —————————————
Supraf. fårå bonding

Factorul C calculat ca fiind 5 înainte de incizii,

Figura 6 ob¡inut atunci când stratul e în contact cu podeaua
Aplicare compozit cavitå¡ii si cu cei patru pere¡i înconjuråtori, a fost
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 167

redus la 0,5 când fiecare parte triunghiularå era în – urmåtorul strat acoperå taieturile diagonale,
contact (aderå) cu un singur perete ¿i o påtrime etc (Fig. 8-14).
din podeaua cavitå¡ii.

Figura 8
Factorul C în cele douå tehnici

Aceea¿i tehnicå de aplicare în straturi pe care Figura 9

se fac tåieturi în diagonalå combinatå cu o Aplicare matrice
stratificare a culorilor, pentru a reduce factorul C
¿i contrac¡ia de polimerizare se poate aplica ¿i
pentru restaurarea unei cavitå¡i de cls a 2 a .
(demonstra¡ie pe dinte extras)

Tehnica de lucru
– dupå terminarea prepara¡iei, se aplicå o matrice
– cu ajutorul unei spatule de plastic se aplicå primul
strat de compozit (nuanta A1, smal¡) pe suprafa¡a
internå a benzii conformatoare ¿i exteriorul
pere¡ilor vestibular, oral ¿i gingival, urmate de
fotopolimerizare dinspre ocluzal 40 sec.
– îndepårtarea matricei, låsarea icului ¿i com-
pletarea fotopolimerizarii dinspre V ¿i oral
– restul peretelui proximal a fost restaurat prin Figura 10
aplicarea a 2 sau 3 straturi de compozit la Formarea peretelui proximal
nivelul peretelui parapulpar (nu mai gros de
1,5 mm) urmate de fotopolimerizare dinspre
ocluzal 40 sec.
– în cavitatea proximalå, fiecare strat orizontal
de compozit, a fost împårtit de o diagonalå,
în 2 portiuni înaintea fotopolimerizårii. În
acest fel, fiecare por¡iune de strat împår¡it a
luat contact cu 1/2 din peretele gingival.
– se adaugå urmåtorul strat ¿i se fotopoli-
merizeazå dinspre ocluzal 40 sec. pânå se
ajunge la nivelul peretelui pulpar al por¡iunii
orizontale
– urmåtorul strat se aplicå pe peretele pulpar
al por¡iunii orizontale ¿i se practicå o tåiaturå
în diagonalå delimitandu-se 4 por¡iuni triun-
ghiulare care vin în contact doar cu 2 pere¡i
ai cavitå¡ii, reducându-se astfel factorul C, Figura 11
se fotopolimerizeazå dinspre ocluzal Aplicare strat orizontal
168 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

Figura 14
Realizare tåieturi diagonale 2
Figura 12
Realizare tåieturi diagonale

Figura 15
Figura 13
Aspect final
Aplicare strat orizontal 2

CONCLUZII
– Evolu¡ia cariei dentare are ca rezultat pierderi
mari de substan¡å durå dentarå care produc
contacte dentare nefunc¡ionale, cu conse-
cin¡e grave pentru întreg aparatul dento-
maxilar. Aceste dezechilibre ocluzale gene-
reazå suprasolicitarea din¡ilor antrena¡i în
proces ¿i influen¡eazå negativ func¡iona-
litatea arcadelor dentare, a sistemului mus-
cular ¿i a ATM.
– Restaurarea se poate face prin tehnici
directe, utlilizând materiale adezive sau prin
utilizarea unor mijloace suplimentare de
reten¡ie prin ancorarea în canalul radicular
dupå tratamentul endodontic.
– În scopul realizårii unei interfe¡e flexibile
dinte/restaurare, compozitul de restaurare
trebuie plasat de a¿a manierå încât contrac¡ia
de polimerizare så fie reduså la minim. În
felul acesta se evitâ formarea hiatusului mar-
ginal ¿i apari¡ia microinfiltra¡iilor marginale.
– Aplicarea compozitului în straturi ¿i reali-
zarea unor tåieturi în diagonalå reduce
factorul C ¿i deci, contrac¡ia de polimerizare.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 169

BIBLIOGRAFIE
1. Ferracane JL, Mitchem JC – Relationship between composite 3. Khamis Hassan, Salwa Khier – Composite resin restorations of
contraction stress and leakage in Class V cavities. Am J Dent 2003; large Class II cavities using split-increment horizontal placement
16:239-243. technique, Operative Dentistry, may-june 2006
2. Giachetti L, Scaminaci Russo D, Bambi C, Grandini R – A 4. Khamis Hassan, Salwa Khier – Split-increment Technique:An
review of polymerization shrinkage stress: Current techniques for Alternative Approach for Large Cervical Composite Resin
posterior direct resin restorations. J Contemp Dent Pract 2006; Restorations, J Contemporary Dental Practice, 2007, 8(2)
4:079-088.

Adreså de coresponden¡å:
Conf. Dr. Bîcle¿anu Florentina Cornelia, Facultatea de Medicinå Dentarå, Universitatea „Titu Maiorescu“, Strada Gheorghe
Petra¿cu, Nr. 67A, Sector 3, Cod Po¿tal 031593, Bucure¿ti
email: corneliabicle@yahoo.com
 4 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 patient’s overall clinical diabetic management.

Key words: Diabetes, periodontal disease, HbA1c

INTRODUCTION patients have difficulty maintaining this level of

Oral Health and Glycemic Control
For the diabetic patient, tremendous impro-
vements in health and quality of life are the
rewards of maintaining life-long normoglycemia.
(1-2) The American Diabetes Association Stan-
dards of Medical Care (2006) recommend diabetic
patients strive to maintain the HbA1c <7, ideally
between 4 and 6. (3-8) While many diabetic
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

170 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 perio-
dontitis were excluded, the use of antibiotics during
this short-term intervention was avoided. Chlor-
hexidine 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, me-
dical history review, and blood sample to deter-
mine 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
171
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 par-
ticipant 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 repre-
sented the primary endpoint in this investigation.
The study also evaluated the severity of perio-
dontal 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 Löe 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.
172 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
Table 1.
Inclusion and exclusion criteria.
Table 2.
Gingival Index.36
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 Student’s 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
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.
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.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 impro-
vements 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
173
observed in subjects with HbA1c > 9, it must be
assumed the medication change influenced these
results. In the HbA1c > 9 subjects with no medi-
cation change about half as much improvement
in HbA1c was seen at six months. Mean reduc-
tions 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.
174 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 sub-
jects 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 gravi-
tated 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 accom-
modate 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 community-
based 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
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 175

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.
176 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

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 patient’s overall
clinical diabetic management.

Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 5, July 1, 2008
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 5 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 23°C 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 property. (4-6,36,42,50-54) The most common

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
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 alginate-
based 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.

178 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
METHODS AND MATERIALS
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.
Figure 1
The master model mounted on the base.
Figure 2
The acrylic master model containing four stainless steel dies.
179
A total of 200 stainless steel standard non-
perforated 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
23±1°C and 50±10% 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 23°C. 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
180 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
the tray and the alginate. (55) The bag was
immediately introduced in a ±3500 mL plastic
storage box in which another paper sheet
(weight±10 g approximately) wetted with 60 g of
distilled water had been inserted 10 minutes
previously, (6) then stored at 23±1°C 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
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
then placed and maintained in position for the
setting time indicated by the gypsum manu-
facturer. After final setting of the gypsum, the
carrier was gently removed and the cast was care-
fully separated from the impression. The material
was stored for 48 hours at 23°C and 50% relative
humidity prior to measuring.
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
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 varian-
ces, followed by one way analysis of variance
(ANOVA), and a Tukey Test for post-hoc com-
parison between the groups. The level of signi-
ficance was set at p<0.05.
181
RESULTS
The results of the statistical analysis are shown
in Tables 2 and 3. In order to simplify the inter-
pretation 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).
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
182 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

distilled water), while the mixing ratio of Jeltrate and the dimensional stability did not seem to
Plus, Alginoplast, and Jeltrate were 2.375, 2.381, influence the results since CA 37 had the same
and 2.714 (71.3, 71.4, and 81.4 g of distilled mixing ratio as Hydrogum 5 but showed less
water), respectively. However, the mixing ratio dimensional change. Furthermore, no recent

Table 2
Measurements of D1.3, D2.3, and d3.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 183

Table 3
Measurements of D1.7, D2.7, and d7.
184 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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,
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 patient’s 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 influ-
ence 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.
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2. Sawyer HF, Sandrik JL, Neiman R – Accuracy of casts produced
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5. Bayindir F, Yanikoglu N, Duymus Z – Thermal and pH changes,
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185
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.
CLINICAL SIGNIFICANCE
When alginate materials are used, an immediate
pouring of the cast is still recommended. However,
the results suggest pouring may be delayed, pro-
vided a stable alginate is used and the impression
is correctly stored.
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
186 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
sodium hypochlorite. Part 1: Microbiology. Int J Prosthodont
1996;9:217-22.
22. Hutchings ML, Vandewalle KS, Schwartz RS, Charlton DG –
Immersion disinfection of irreversible hydrocolloid impressions in pH-
adjusted sodium hypochlorite. Part 2: Effect on gypsum casts. Int J
Prosthodont 1996;9:223-9.
23. Cohen BI, Pagnillo M, Deutsch AS, Musikant BL – Dimensional
accuracy of three different alginate impression materials. J
Prosthodont 1995;4:195-9.
24. Anastassiadou V, Dolopoulou V, Kaloyannides A – The
relation between thermal and pH changes in alginate impression
materials. Dent Mater 1995;11:182-5.
25. Anastassiadou V, Dolopoulou V, Kaloyannides A –
Relationship between pH changes and dimensional stability in
irreversible hydrocolloid impression material during setting. Int J
Prosthodont 1995;8:535-40.
26. Vandewalle KS, Charlton DG, Schwartz RS, Reagan SE,
Koeppen RG – Immersion disinfection of irreversible hydrocolloid
impressions with sodium hypochlorite. Part II: Effect on gypsum. Int
J Prosthodont 1994;7:315-22.
27. Schwartz RS, Bradley DV Jr, Hilton TJ, Kruse SK – Immersion
disinfection of irreversible hydrocolloid impressions. Part 1:
Microbiology. Int J Prosthodont 1994;7:418-23.
28. Hilton TJ, Schwartz RS, Bradley DV Jr – Immersion disinfection
of irreversible hydrocolloid impressions. Part 2: Effects on gypsum
casts. Int J Prosthodont 1994;7:424-33.
29. Beyerle MP, Hensley DM, Bradley DV Jr., Schwartz RS, Hilton
TJ – Immersion disinfection of irreversible hydrocolloid impressions
with sodium hypochlorite. Part I: Microbiology. Int J Prosthodont
1994;7:234-8.
30. Tan HK, Wolfaardt JF, Hooper PM, Busby B – Effects of
disinfecting irreversible hydrocolloid impressions on the resultant
gypsum casts: Part I–Surface quality. J Prosthet Dent 1993;69:250-
7.
31. Tan HK, Hooper PM, Buttar IA, Wolfaardt JF – Effects of
disinfecting irreversible hydrocolloid impressions on the resultant
gypsum casts: Part III—Dimensional changes. J Prosthet Dent
1993;70:532-7.
32. Ramer MS, Gerhardt DE, McNally K – Accuracy of irreversible
hydrocolloid impression material mixed with disinfectant solutions. J
Prosthodont 1993;2:156-8.
33. Peters MC – Accuracy and dimensional stability of a combined
hydrocolloid impression system. J Prosthet Dent 1992;67:873-8.
34. Touyz LZ, Rosen M – Disinfection of alginate impression material
using disinfectants as mixing and soak solutions. J Dent
1991;19:255-7.
35. Rosen M, Touyz LZ – Influence of mixing disinfectant solutions into
alginate on working time and accuracy. J Dent 1991;19:186-8.
36. Jones ML, Newcombe RG, Bellis H, Bottomley J – The
dimensional stability of self-disinfecting alginate impressions compared
to various immersion regimes. Angle Orthod 1990;60:123-8.
37. Ralph WJ, Gin SS, Cheadle DA, Harcourt JK – The effects of
disinfectants on the dimensional stability of alginate impression
materials. Aust Dent J 1990;35:514-7.
38. Peutzfeldt A, Asmussen E – Effect of disinfecting solutions on
surface texture of alginate and elastomeric impressions. Scand J
Dent Res 1990;98:74-81.
Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 4, May 1, 2008
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.
 CHIRURGIE ORO-MAXIMOFACIALÅ
6
ELUDRILUL ªI IMPLICAºIILE LUI ÎN CAZUL
EXTRACºIEI MOLARULUI DE MINTE
SUPERIOR
Eludril and Its Implications in the Maxillary
Third Molar Extraction
Dr. Mirela-Jeni Comancianu
Medic dentist (specialist-stomatologie generalå), Clinica Alexa Dentistry, Bucure¿ti

REZUMAT
Un studiu statistic efectuat pe 320 de pacien¡i ce con¡ine ac¡iunea antimicrobianå, antiinflamatorie, analgezicå ¿i cicatrizantå a
Eludrilului. Acest studiu a fost fåcut pe durata a doi ani de zile în Clinica Alexa Dentistry, Bucure¿ti, România.

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 având douå rådåcini prin unirea celor vestibulare,

Extrac¡ia, consideratå o interven¡ie chirurgicalå
de necesitate este normal så fie precedatå de un
examen general ¿i local minu¡ios, care så ofere
date precise asupra modului în care va fi efectuat
actul operator ¿i condus ulterior tratamentul post-
extractional.
Al treilea molar se mai nume¿te ¿i „masea de
minte“, iar ¿tiin¡ific „Dens sapientiae“ sau „Dens
serotinus“ ¿i prezintå o varietate extrem de mare
de forme atât ale coroanei, cât ¿i ale radåcinilor
(tabelul 1).
Molarul superior are trei rådåcini care pot fi
fuzionate complet sau par¡ial, astfel încât apare ca
sau o singurå radacinå prin unirea celor trei.
Uneori, din corpul radicular principal se deta-
¿eazå lateral mici rådåcini accesorii. Forma rådå-
cinilor este neregulatå, cu curburi variabile ¿i
por¡iuni apexiene efilate.
PACIENTI ªI METODE
Am realizat un studiu pe 320 pacien¡i situa¡i ca
vârstå în intervalul 18-55 ani, deci cu o medie de
vârstå de 36,5 ani, atât de sex feminin (224), cât
¿i masculin (96), domicilia¡i în mediul urban ¿i
rural. Aceastå statisticå nu vizeazå indica¡iile de
extrac¡ie ale molarului de minte superior ¿i nici

Tabelul 1

Adreså de coresponden¡å:
Doctor Comancianu Mirela-Jeni, Clinica Alexa Dentistry, Aleea Mågura Vulturului, Nr. 9, Bl. 435, Sc. B, Ap. 44, Sector 2, Bucure¿ti
email: mirelacomancianu@yahoo.com

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 187

188 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
accidentele ¿i complica¡iile survenite ca urmare a
unor evaluåri gre¿ite a situa¡iei clinice. Studiul a
fost fåcut pe durata a doi ani de zile din cazuistica
Clinicii Alexa Dentistry din Bucure¿ti. Studiul in
vivo s-a desfå¿urat pe douå grupe de pacien¡i: 50%
dintre ei (112 femei ¿i 48 bårba¡i) au folosit Eludril
¿i restul de 50% nu, fiind grupul de control.
Înainte ¿i dupå efectuarea extrac¡iei pacien¡ii
inclu¿i în studiu (50% dintre ei) au fost ruga¡i så-
¿i clåteascå u¿or gura, fårå for¡å cu solu¡ii reci de
Eludril (clorhexidina 0,10% + clorbutanol 0,50%),
peste alveola aplicându-se un tampon de comprese
sterile, u¿or compresiv, urmând ca de a doua zi så
înceapå a se spåla pe din¡i ¿i a se clåti u¿or cu
Eludril diluat în propor¡ie de 1/3, aplicat de douå
ori pe zi timp de un minut pe suprafa¡a extrac¡iei.
Pacien¡ii din grupul de control dupå extrac¡ie, au
primit doar indica¡iile postextractionale obi¿nuite.
CONCLUZII
În chirurgia oralå clorhexidina este utilizatå nu
doar pentru calitå¡ile sale bacteriostatice ¿i
bactericide, ci ¿i datoritå beneficiilor oferite în
vindecarea plågilor. Astfel, solu¡ia de Eludril
folositå înainte ¿i dupå efectuarea interven¡iei
Figura 1
Figura 2
Pacient care a folosit Eludril dupå extrac¡ii
chirurgicale, a scåzut riscul de infec¡ie cu 70% ¿i
a facilitat procesul de regenerare tisularå cu 68%
fa¡å de grupul de control. Eludrilul stimulând
refacerea mucoasei bucale prin multiplicarea
fibrobla¿tilor ¿i diferen¡ierea Keratinocitelor
epiteliale, având astfel ac¡iune cicatrizantå.
Ac¡iunea analgezicå postchirurgicalå a fost
prezentå la 96% dintre pacien¡i, Eludrilul având ¿i
o ac¡iune rezidualå foarte bunå – råmâne în
cavitatea oralå cel pu¡in 30% la 8 ore de la clåtire
(figura 1).
Pacien¡ii au fost înregistra¡i la fiecare orå,
pentru 8 ore de la extrac¡ie cu o scarå între:
• 0 = nu existå durere
• 10 = durere medie
• 15 = durere intolerabilå.
În figura 1 apare durerea în timpul primelor
ore de la extrac¿ie. La 2 ¿i 4 ore dupå extrac¡ie
diferen¡a este marcantå.
De¿i este eficientå asupra microorganismelor gram
negative ¿i gram pozitive, respectiv asupra levurilor,
clorhexidina nu determinå dismicrobisme, påstrând
echilibrul în microflora normalå a cavitå¡ii bucale.
Ac¡iunea antiinflamatorie a clorhexidinei se
datoreazå ¿i efectului de curå¡are al mucoasei prin
eliminarea resturilor alimentare (vezi figura 2).
BIBLIOGRAFIE
1. Asanami J – „Third molar. Extraction“, Quintessence Publishing Co.
Inc., 19
2. Boboc Gheorghe – „Aparatul dentomaxilar-formare ¿i dezvoltare“,
Ed. II, Editura Medicalå, 1996, pag. 110-116
3. Burliba¿a Corneliu ¿i colab. – „Chirurgie oralå ¿i maxilofacialå“,
Ed., II, Editura Medicalå, 1999, pag. 115
4. Gåman Mirela-Jeni, Herescu Costicå – „Accidente la extrac¡ia
molarului de minte superior“, Lucrare de Diplomå, U.M.F. „Dr. Carol
Davila“, 1999
5. Nimigean V, Podoleanu L – „No¡iuni de anatomie topograficå a
capului ¿i gâtului ¿i de anatomie oralå“ Editura Cerma,1993, pag.
83-107
 CHIRURGIE ORO-MAXIMOFACIALÅ
7
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 CASE REPORT

Although rare, the epithelial lining of an
odontogenic cyst may undergo malignant trans-
formation. The incidence of carcinomas arising
in odontogenic cysts was reported to be approxi-
mately 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 trans-
formation 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
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 swel-
ling on the right mandibular region. Buccal expan-
sion of the alveolar ridge posterior to the right
mandibular first premolar was observed on intra-
oral 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 wellde-
fined 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 lympha-
denopathy.
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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190 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 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.
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 3
Histopathology of the resection specimen revealed
SCC (HE x100).
As a result, a hemimandibulectomy was per-
formed 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 in-
vaded the surrounding bone and one of the cer-
vical lymph nodes. The patient is under a close
post-surgical follow-up regimen.
DISCUSSION
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 car-
cinoma, or (c) a malignant change within the cyst
wall. (11-14) The histopathologic criterion em-
ployed 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
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 lympa-
denopathy. There was no palpable lympa-
denopathy 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 con-
fused 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)
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.
2. 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.
191
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 odon-
togenic 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.
3. Makowski GJ, McGuff S, Van Sickels JE – Squamous cell
carcinoma in a maxillary odontogenic keratocyst. J Oral Maxillofac
Surg 2001; 59:76-80.
4. 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.
192 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
5. 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; 54:647-
651.
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; 72:218-
221.
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; 41:161-
167.
Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 6, September 1, 2008
12. Johnson LM, Sapp JP, McIntire DN – Squamous cell carcinoma
arising in a dentigerous cyst. J Oral Maxillofac Surg 1994; 52:987-
990.
13. Manganaro AM, Cross SE, Startzell JM – Carcinoma arising in
a dentigerous cyst with neck metastasis. Head Neck 1997; 19:436-
439.
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 –Cawson’s 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
 OCLUZOLOGIE
8
TEMPOROMANDIBULAR JOINT INTERNAL
DERANGEMENT: ASSOCIATION WITH
HEADACHE, JOINT EFFUSION, BRUXISM,
AND JOINT PAIN
Andre L.F. Costa, DDS, MS; Anelyssa D’Abreu, 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 patient’s 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 Fischer’s 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, D’Abreu 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 headaches are independent of the neurological

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
diagnosis of the headache syndrome. (11) A
possible explanation is TMD has common para-
functional 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

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 193

194 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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.
METHODS AND MATERIALS
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 26-
37 years) who had no current or previous TMD
symptoms and denied having headaches.
DATA ACQUISITION
All subjects underwent MRI of the TMJ
obtained by a 2 Tesla scanner (Elscint Prestige,
Haifa, Israel) with surface coils. MRIs were
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 160º, 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 160º, slice thickness =
1.5 mm, field of view = 12 x 12, NEX 2) were
acquired in closed mouth position.
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
Fisher’s 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 head-
ache and TMD symptoms; and two had tension-
type 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 re-
ported were over-the-counter analgesics.
Headache patients more frequently reported
TMJ pain in their clinical history than TMJ patients
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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
*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 Fischer’s 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 Fischer’s exact test (P
significant <0.0125). Numbers in parentheses represent the
percent of total (n=58).
195
Table 4
Relation between MRI diagnoses of ID and
headache in patients’ group
*P values were obtained using Fischer’s exact test
(P significant <0.0125).
Table 5
Relation between joint effusion and headache
in TMD patients
*P values were obtained using Fischer’s 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 Fischer’s 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 Fischer’s 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 pre-
valence of joint effusion in the MRI
4. Headaches were most frequently reported
in patients with joint effusion and patients
with more severe radiological diagnosis
196 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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 charac-
terized 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 sus-
ceptibility 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 sym-
ptoms. 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.
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.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
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tissue of painful joints. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 1995; 79:511–516.
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; 95:761–6.
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;
101:784–90.
29. Rugh JD, Drago DJ – Vertical dimension: a study of clinical rest
position and jaw muscle activity. J Prosth Dent. 1981; 45:670–675.
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;
34:175–81.
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;
56:192–198.
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; 94:515–521.
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; 30:214–218.
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;
18:6403–10.
36. Brune B, von Knethen A, Sandau KB – Nitric oxide (NO): An
effector of apoptosis. Cell Death Differ. 1999; 6:969–75.
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Chondrocyte apoptosis and nitric oxide production during
experimentally induced osteoarthritis. Arthritis Rheum. 1998;
41:1266–74.
38. Nagai H, Kumamoto H, Fukuda M, Takahashi T – Inducible
nitric oxide synthase and apoptosisrelated factors in the synovial
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osteoarthritis J Oral Maxillofac Surg. 2003; 61:801–807.
39. Langrer JM, Rosemary A, Hoffman JR, Lancaster JRJ,
Simmons RL – Nitric oxide, a new endogenous immuno-
modulator. Transplantation. 1993; 55:1205–1212.
 9 PROTETICÅ DENTARÅ

ROLUL ZONEI DE ÎNCHIDERE

VELOPALATINALÅ ÎN PREVENIREA
EªECURILOR PROTEZEI MOBILE
The Importance of the Closing Vaultpalatine Zone in
Preventing Removable Prosthesis’s Failure
ªef Lucr. Dr. Anca Fratilå, ªef Lucr. Dr. Cornel Boitor
Facutatea de Medicinå „Victor Papilian“, Sibiu

REZUMAT
Zona de închidere velopalatinalå, respectiv închiderea marginalå posterioarå a protezei mobile maxilare are o importan¡å covår¿itoare
în restaurarea edenta¡iei totale. Aceasta zonå func¡ionalå distalå, înregistratå corect, de¡ine un rol primordial în men¡inerea,
sprijinul ¿i stabilitatea protezei mobile, prevenind e¿ecul terapeutic.

Cuvinte cheie: închidere velopalatinå, linia de vibra¡ie, proteza mobilå.

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 e¿ec în protezarea mobilå, poate fi conse-
cin¡a unor erori sau deficien¡e ce pot apare în cursul
uneia dintre urmåtoare etape: examenul clinic ¿i
planul de tratament; amprentå preliminarå ¿i ana-
liza ei; închiderea perifericå velopalatinalå la
maxilar; amprentå finala anatomo-func¡ionalå;
determinarea dimensiunii verticale de ocluzie ¿i a
rela¡iilor intermaxilare; montarea din¡ilor; confor-
marea suprafe¡ei lustruite a protezei; optimizarea
men¡inerii ¿i stabilitå¡ii bazei protezei.
ROLUL ZONEI DE ÎNCHIDERE VELOPALATINÅ
Aceasta zonå func¡ionalå distalå, înregistratå
corect, de¡ine un rol primordial în men¡inerea ,
sprijinul ¿i stabilitatea protezei totale maxilare.
Zona de închidere velopalatinå la proteza maxi-
larå trebuie så fie etan¿å în condi¡ii statice ¿i dina-
mice (fona¡ie, degluti¡ie), respectiv odatå cu mi¿-
cårile vålului palatin. Ea participå la stabilizare
opunându-se for¡elor de basculare, ¿i la sprijin prin
extensia distalå maximå ce permite cre¿terea ariei
de sus¡inere a protezei.
Închiderea velopalatinalå corespunzåtore evitå
infiltrarea alimentelor sub protezå, diminua
reflexul de vomå ¿i permite o tranzi¡ie între protezå
¿i palatul moale nesesizabilå pentru limbå.
BOLTA PALATINÅ
Prezintå 3 pår¡i distincte:
• palatul dur, osos;
• palatul moale sau vålul palatin care suportå
mari deplasåri în cadrul func¡iilor;
• partea aponevroticå a vålului care cores-
punde inser¡iei pe palatul dur.
Aceastå zonå aponevroticå „care vibreazå pe
loc“ odatå cu diferitele func¡ii este aceea în care
trebuie situatå închiderea palatinå. Zona e deli-
mitatå de linii de vibra¡ie anterioarå ¿i posterioarå
ale lui Silverman(1):
• linia de vibra¡ie posterioarå este puså în evi-
den¡å de pronun¡ia blândå ¿i prelungitå a
unui „Ah“ clar (fig.1);
• linia de vibra¡ie anterioarå este puså în
eviden¡å de pronun¡ia scurtå ¿i viguroaså a
fonemei „Ah“. Ea corespunde liniei de jonc-
¡iune palat dur-palat moale ce se poate
materializa când cerem pacientului så sufle
pe nas, cu nårile prinse (manevra Valsalva)

198 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
(fig. 2) sau deplasând un fuloar în partea
posterioarå a boltei palatine pentru a repera
jonc¡iunea palat dur-palat moale. Banda de
flexiune a vålului, situatå între aceste douå
linii, este variabilå în formå ¿i întindere.
Figura 1(8)
Figura 2(8)
Mi¿cårile vålului palatin sunt complexe, varia-
bile de la un pacient la altul ¿i necesitå un studiu
individual din partea medicului pentru a putea fi
observate, în determinarea zonei de închidere velo-
palatinalå nu poate în nici un caz delegat tehni-
cianul dentar, care nu dispune de factori pri-
mordiali ce nu pot fi aprecia¡i decât clinic.
REALIZAREA PRACTICÅ A ÎNCHIDERII
VELOPALATINALE (2,8)
Fie cå e vorba de tehnicile care utilizeazå gra-
varea modelului, fie cå sunt tehnici func¡ionale
sau mixte, este indispensabil så reperåm punctele
¿i liniile de referin¡å (3,4):
• cro¿etele aripilor interne ale apofizelor
pterigoide;
• ¿an¡urile pterigomaxilare ¿i ligamentele
pterigomaxilare, ligamentul trebuie ocolit de
marginea protezei totale;
• zonele lui Schroder a cåror depresibilitate
trebuie apreciatå;
• foveele palatine care trebuiesc reperate;
• liniile de vibra¡ie anterioarå ¿i posterioarå a
vålului palatin.
199
TEHNICA CLASICÅ
Se repereazå ¿i se traseazå în gurå cu un creion
dermatograf, liniile de vibra¡ie posterioarå ¿i ante-
rioarå a vålului (fig.1 ¿i 2). Aceste douå linii
determinå zona de închidere velopalatinalå ¿i
trebuiesc transpuse pe modelul secundar (modelul
de lucru).
Pentru aceasta, macheta de cearå este introduså
în gurå, linia de vibra¡ie posterioarå marcatå cu
creionul dermatograf, se imprimå pe fa¡a mu-
cozalå. Macheta este atunci reduså pânå la aceastå
linie, apoi este replasatå pe modelul secundar pe
care aceastå linie se reproduce. Linia de vibra¡ie
anterioarå este apoi trasatå pe mucoaså ¿i în acela¿i
fel ca limita posterioarå, e transferatå pe model cu
ajutorul machetei.
Apoi, compresibilitatea tisularå a benzii de
flexiune e apreciatå cu ajutorul unui instrument
(fuloar).
La jumåtatea distan¡ei dintre cele 2 linii de
vibra¡ie, se traseazå o linie intermediarå pe model.
Adâncimea gravajului pe aceastå linie intermediara
este egalå cu 2/3 din compresibilitatea tisularå.
Adâncimea gravajului scade la jumåtate la nivelul
liniei posterioare de vibra¡ie pentru a avea un relief
rotunjit netraumatizant. Adâncimea gravajului
scade progresiv pentru a se anula la nivelul liniei
de vibra¡ie anterioarå (fig.3) (8).
Figura 3(8)
Macheta e repozi¡ionatå pe modelul secundar ¿i liniile
de vibra¡ie se traseazå pe gips. Adâncimea de gravaj
corespunde cu 2/3 din compresibilitatea tisularå
evaluatå în gurå cu fuloarul, la distan¡å egalå de cele
douå linii de vibra¡ie.
În mod clasic, pentru vålurile cu înclinare inter-
mediarå se då ca adâncime de gravaj:
• 1 mm la foveele palatine;
• 1,5 mm în dreptul zonelor Schroder;
• 0,5 mm la nivelul inser¡iei ligamentelor
pterigo-maxilare.
200 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

Închiderea velopalatinå poate så se reveleze
deficitarå imediat sau ulterior. Poate så fie incorectå
sau så aibå o compresie nepotrivitå (fie prea mare,
fie insuficientå) chiar dacå este situatå corect. O
compresie excesivå va declan¿a o scurgere hidricå
care va fi înso¡itå de modificåri ce vor duce la o
pierdere a aderen¡ei.
vålului (Fig.6). Apoi în cavitatea oralå se traseazå
cu creionul chimic linia de vibra¡ie posterioara,
care se va imprima pe fa¡a mucozalå a protezei.
Excesurile sunt eliminate pânå la linia posterioarå
de vibra¡ie (Fig.7).

Tehnica Devin în realizarea închiderii velopalatinale

(5,8)
Indica¡iile sunt de douå ordine:
• pentru a perfec¡iona închiderea velopala-
tinalå a unei proteze mobile existente;
• pentru a transforma o protezå existentå fårå
închiderea velopalatinalå în protezå de
tranzi¡ie, a¿teptând confec¡ionarea unei alte
proteze.
Figura 5(8)
Dupå ce s-a reperat în gurå linia de vibra¡ie
posterioarå a lui Silverman, se pot prezenta 2
cazuri:
• trebuie prelungitå posterior baza protezei,
apoi trebuie realizatå închiderea velopala-
tinalå;
• extensia distalå e suficientå, dar închiderea
velopalatinalå e deficitara sau inexistentå ¿i
trebuie amelioratå sau creatå.
Tehnica descriså e aceea a lui Devin (fig. 4-
10)(8).
Dacå baza protezei trebuie prelungitå posterior
se procedeazå astfel: se îndepårteazå un strat din Figura 6(8)
suprafa¡a mucozalå în regiunea posterioarå a pro-
tezei ¿i sunt create reten¡ii; 2 benzi de cearå sunt
apoi adåugate: una e fixatå pe fata externa a pro-
tezei, cealaltå din prelungirea fe¡ei mucozale.

Figura 7(8)

Se repereazå ¿i traseazå cu creionul chimic linia

Figura 4 (8)
Ceara e prescurtatå pânå la linia posterioarå de
vibra¡ie ¿i banda de spa¡iere este eliminatå.
Rå¿ina autopolimerizabilå e dispuså în reten¡ii
¿i pe banda de cearå care råmâne (Fig.5). Proteza
e aplicatå pe câmp cu o presiune digitalå puternicå,
rå¿ina e modelatå de mucoasa palatinå ¿i zona
de vibra¡ie anterioarå care se va imprima apoi pe
fa¡a mucozalå a protezei. Cu bandå adezivå se face
o îndiguire anterioarå pentru a evita refluarea de
rå¿inå. Grosimea ¿i configura¡ia acestei îndiguiri
sunt în func¡ie de compresibilitatea ¡esuturilor.
Rå¿ina e aplicatå în spatele îndiguirii ¡inând cont
de compresibilitatea tisularå, apoi proteza e
inseratå în gurå cu o puternicå presiune digitalå.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
Dupå polimerizare banda adezivå se îndepårteazå
iar proteza se prelucreazå.
Eficacitatea acestei închideri velopalatine
ob¡inute e controlatå printr-o presiune pe fa¡a
palatinalå a incisivilor maxilari.
Figura 8(8)
Figura 9(8)
BIBLIOGRAFIE
1. Silverman Sl – Dimensions and displacement patterns of the
posterior palatal seal. J Prosthet Dent 1971;25:470-488.
2. Begin M, Rohr M – Le joint velopalatin en prothese complete
maxillaire. Cah Prothese 1983;43:55-78.
3. Grant AA, Heath JR, McCord JF – Complete prosthodontics.
Problems, diagnosis and management. London Wolfe, 1994.
4. Lejoyeux J – Prothese complete. Examen clinique, materiaux et
techniques d’empreintes. Tome 1. Paris : Maloine, 1979.
Adreså de coresponden¡å:
ªef Lucr. Dr. Boitor Cornel, Facultatea de Medicinå „Victor Papilian“, Str. Pompeiu Onofreiu, Nr. 2-4, Sibiu, Cod Po¿tal 550166
201
Figura 10(8)
CONCLUZIE
Cunoa¿terea tehnicilor de înregistrare a zonei
de închidere velopalatinå este importantå, pentru
a preveni e¿ecurile date de absen¡a sau de
înregistrarea eronatå a acestei zone func¡ionalå
distalå (zona de închidere velopalatinalå) cu rol
primordial în reten¡ia ¿i în stabilitatea protezei
mobile maxilare.
5. Devin R – Adaptation et habilitation des protheses totales
defectueuses. Act Odonto-Stomatol 1969; 87:279-300.
6. Hue O, Berteretche MV – Prothese complete. Realite clinique,
solutions therapeutiques. Paris: Quintessence International, 2003.
7. Pompignoli M, Doukhan JY, Raux D – Prothese complete.
Clinique et laboratoire. Paris: Editions CdP, 1993.
8. 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.
 10 PROTETICÅ DENTARÅ

REZULTATELE STUDIULUI CLINIC ªI

STATISTIC ASUPRA CÂMPULUI PROTETIC
EDENTAT TOTAL
The Results of the Clinical and Statistical Study of Totally
Edentulous Prosthetic Field
ªef Lucr. Dr. Elena-Gabriela Despa
Catedra de Proteticå Dentarå Facultatea de Medicinå Dentarå
Universitatea „Titu Maiorescu“

REZUMAT
Analiza statisticå efectuatå pe cele douå loturi (diferite ca numår de pacien¡i), a încercat så stabileascå asemånåri ¿i/sau deosebiri
între aspectele clinice studiate, o corela¡ie între caracteristicile câmpului protetic edentat total ¿i pacientul examinat. Sinteza
rezultatelor studiului este absolut necesarå, permi¡ând eviden¡ierea legåturilor cauzale ¿i mecanismelor specifice de evolu¡ie a
câmpului protetic edentat total. Condi¡iile socio-economice, reprezintå un factor deosebit de important, care participå la marea
variabilitate a dimensiunii ¿i formelor substratului osos, dar în special asupra structurilor morfologice reprezentate de muco-
periost. Studiul clinic ¿i statistic a demonstrat cå fiecare câmp protetic edentat total este unic în felul såu, fiind influen¡at de statutul
socio-economic, condi¡iile culturale, obiceiurile igieno-sanitare.

Cuvinte cheie: studiu clinic, elementele câmpului protetic edentat total, statisticå sanitarå, curbå de distribu¡ie cu caracter normal,
distribu¡ie 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 study’s 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 edentate maxilare din punct de vedere al înål¡imii,

Câmpurile protetice constituie frecvent zona în
care se eviden¡ieazå calitå¡ile protezelor, fiindcå
datoritå neadaptårilor au produs la nivelul ¡esutu-
rilor moi (zonei de sprijin ¿i zonei de succiune)
modificåri morfo-histologice (microscopice ¿i ma-
croscopice).
Din acest punct de vedere (al pacien¡ilor exa-
mina¡i ¿i trata¡i în ultimii 3 ani), con¡inutul studiului
clinic poate så reprezinte un material documentar
sau didactic util pentru îmbogå¡irea no¡iunilor
despre variabilitatea câmpurilor protetice, a¿a cum
va fi prezentat în paginile urmåtoare.
În analizå (studiu clinic) am urmårit urmå-
toarele aspecte clinice: caracteristicile crestelor
atrofiei, lå¡imii; adâncimea bol¡ii palatine; existen¡a
sau nu a torusului palatine; forma bol¡ii palatine,
caracterul atrofiei; dimensiunea în sens antero-
posterior a bol¡ii palatine; caracteristicile substra-
tului mucos; caracteristicile crestei edentate man-
dibulare din punct de vedere al simetriei, înål¡imii,
atrofiei, direc¡iei fa¡å de planul sagital, forma;
caracteristicile tuberculului piriformi: direc¡ia fa¡å
de creastå, volumul.
Din punct de vedere teoretic ¿i practic aceste
aspecte au fost descrise ¿i de autori români: Ene ¿i
Popovici (4,5), Hutu (6), Preoteasa (9), Påuna (9),
Bratu (1).
Studiul clinic a solicitat timp, råbdare ¿i un spirit
de observa¡ie, care s-a format ¿i dezvoltat progresiv

202 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 2-3, AN 2008

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
pentru a fi remarcate toate particularitå¡ile morfo-
structurale, specifice în momentul examinårii
fiecårui pacient.
MATERIAL ªI METODÅ DE STUDIU
Studiul clinic (analiza câmpurilor protetice
edentate total) a fost posibil fiindcå l-am efectuat
timp de aproximativ 8 ani, pe un numår de 506
pacien¡i. În ultimii trei ani numårul de pacien¡i
edenta¡i total s-a mårit foarte mult datoritå celor
care sunt asista¡i sociali de la sectorul 2 Bucure¿ti.
Ace¿ti pacien¡i sunt lipsi¡i de posibilitå¡i materiale,
ceea ce se reflectå în starea de igienå a protezelor
pe care le posedå de 5-10 ani, reparate de mai
multe ori, sau transformate din cele par¡iale în
proteze totale.
Cazurile studiate le-am clasificat dupå formå,
dimensiune, aspecte (simetrice-asimetrice) ¿i struc-
tura muco-periostului în func¡ie de cauzele deter-
minante fiind prezentate astfel:
– cazuri cu forme ¿i dimensiuni diferite, foarte
mari sau foarte mici care sunt constitu¡io-
nale;
– cazuri cu forme ¿i dimensiuni dobândite în
urma extrac¡iilor sau al interven¡iilor chirur-
gicale;
– cazuri cu aspecte ale muco-periostului deter-
minate de iatrogenoze-proteze care au produs
leziuni datoritå neadaptårilor (suprafe¡elor
bazale, mucozale sau suprafe¡elor ocluzale-
observate suprapunerile IM cu RC).
Dimensiunile bol¡ii palatine au fost måsurate
¿i de Johnson D.L, Holt R.A, Duncanson J.R.M
în 1986 (7), studiu publicat în J.A.D.A ¿i citat de
Bratu în 2005 (1). Autorul citat a realizat urmå-
toarele måsuråtori (fig.1) pe un lot de pacien¡i
edenta¡i total.
Figura 1
Diagrama måsuråtorilor lui Johnson: a) în plan sagital,
b) în plan frontal (1,7)
• linia medio-sagitalå era evaluatå între papila
incisivå ¿i linia interhamularå (LMS);
• adâncimea antero-posterioarå (AAP);
• unghiul antero-posterior (UAP);
• lå¡imea în zona medie a palatului (LZMP);
• lå¡imea în zona posterioarå a palatului
(LZPP);
203
• adâncimea din zona medie a bol¡ii palatine,
pe sec¡iune frontalå (AZMP);
• adâncimea din zona posterioarå a bol¡ii pa-
latine, pe sec¡iune frontalå (AZPP);
• unghiul dintre linia medianå ¿i creasta rezi-
dualå în zona medianå (UMCM);
• unghiul dintre linia medianå ¿i creasta rezi-
dualå în zona posterioarå (UMCP).
Pacien¡ii studia¡i sunt prezenta¡i în douå loturi
determinate de perioada în care au fost rezolva¡i
(tabelul 1) ¿i de aspectele tratamentelor protetice,
care au fost vizibile la nivelul câmpurilor protetice
¿i la nivelul protezelor.
Tabelul 1
Repartizarea pacien¡ilor pe loturi ¿i perioada
de examinare
În prima perioadå (2000-2005), lotul a fost
de 212 de pacien¡i ¿i a fost analizat separat, cazuis-
tica consultatå a fost mai uniformå nu a existat în
mod evident particularitå¡i care reprezintå excep¡ii,
fiindcå solicitau numai protezåri, fårå acuze spe-
ciale. Pacien¡ii din acest lot aveau o situa¡ie socio-
economicå bunå, cu o educa¡ie stomatologicå
acceptabilå; purtau proteze care erau înlocuite
periodic la un interval de 3-4 ani, la cea mai micå
modificare resim¡i¡å în func¡ionalitatea aparatului
dento-maxilar (mastica¡ie, fizionomie, fona¡ie)
solicitau examen de specialitate (2,3).
Pacien¡ii din al doilea lot (2005-2008) în numår
mai mare de 294, datoritå condi¡iilor materiale
deosebit de modeste ¿i a tratamentelor realizate in-
corect, asociate cu vechimea protezelor au constituit
pentru studiu cazuri remarcabile, utile scopului
propriu, så fie analizatå varietatea câmpurilor pro-
tetice. Acest lot a fost deosebit de interesant fiindcå
s-au remarcat urmåtoarele (2,3): tratamentele reali-
zate reprezentate de protezele totale aveau multe
deficien¡e clinico-tehnice; protezele erau foarte
vechi, în medie de 8-10 ani, reparate, de mai multe
ori, materialul îmbåtrânit; starea de igienå loco-
regionalå în mod evident nu constituia o preocupare
vizibilå în mod deosebit la nivelul protezelor;
câmpurile protetice prin aspectul muco-periostului
materializa consecin¡ele defectelor de adaptare
mucozalå ¿i ocluzalå a protezelor.
Analiza fiind efectuatå pe cele douå loturi (di-
ferite ca numår de pacien¡i), am încercat så gåsesc
204 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
asemånåri ¿i/sau deosebiri între aspectele clinice
studiate, o corela¡ie între caracteristicile câmpului
protetic edentat total ¿i pacientul examinat.
METODOLOGIA STUDIULUI STATISTIC
Statistica sanitarå (8) este ¿tiin¡a care are ca
obiect cunoa¿terea detaliatå, dinamicå ¿i structuratå
a stårii de sånåtate în cadrul popula¡iei sau a unor
anumite e¿antioane din aceasta, în corela¡ie cu fac-
torii sociali, economici, culturali, igienico-sanitari
¿i medico-biologici determinan¡i. Scopul studiilor
statistice este detectarea tendin¡elor evolutive ale stårii
de sånåtate în corela¡ie cu activitatea medico-sani-
tarå, a cårei eficien¡å este chematå så o aprecieze.
Având la bazå metode adecvate cunoa¿terii
proceselor ce se desfå¿oarå aleator, teoria proba-
bilitå¡ilor, studiile statistice reu¿esc så descifreze,
cu o eroare cunoscutå ¿i acceptabilå corela¡iile
multiple dintre fenomenele studiate ¿i factorii deter-
minan¡i, în vederea stabilirii principalelor tendin¡e
ale acestora. În mod deosebit, studiile statistice ne
ajutå så în¡elegem influen¡a condi¡iilor de via¡å, a
nivelului de trai cultural ¿i material asupra evolu¡iei
diferitelor fenomene patologice, inclusiv în sfera
sånåtå¡ii oro-dentare. Concluziile ¿i rezultatele
studiilor clinice sunt întårite prin analiza ¿i sinteza
statisticå a respectivei cercetåri.
Analiza cercetårii trebuie så înceapå cu veri-
ficarea aspectelor teoretice ale studiului, sco¡ând
în eviden¡å structura ¿i dinamica evolu¡iei carac-
teristicilor câmpului protetic edentat total. Am
urmårit eviden¡ierea legåturilor func¡ionale de
cauzalitate, ritmul de apari¡ie ¿i dezvoltare, con-
centrarea sau dispersia anumitor caracteristici ale
câmpului protetic edentat total. În cadrul analizei
am verificat exactitatea ¿i eficien¡a metodelor de
cercetare folosite, alegând metodele adecvate pro-
blemelor specifice.
Pentru analiza statisticå am folosit metode ale
statisticii matematice: valorile medii, dispersia de
la valorile medii, eroarea medie, devia¡ia standard,
corela¡ia ¿i regresia valorilor ob¡inute, pentru a
putea compara cele douå loturi, precum ¿i distri-
bu¡ia pe grupe de vârstå, sex etc.
Sinteza rezultatelor studiului este absolut nece-
sarå, permi¡ând eviden¡ierea legåturilor cauzale ¿i
mecanismelor specifice de evolu¡ie a câmpului
protetic edentat total. În final, analiza ¿i sinteza
statisticå ne permit o bunå aplicare practicå a con-
cluziilor ob¡inute în urma studiului.
a. Devia¡ia standard
Devia¡ia standard (notatå cu s) måsoarå gradul
de dispersie de la medie a unei serii de valori, ea
fiind folositå în special pentru evaluarea gradului
de omogenitate a unei colectivitå¡i. De exemplu,
o devia¡ie standard cu valoare mare aratå o dis-
persie mare, deci un grad mai scåzut de omoge-
nitate a respectivului lot. Pentru calculul devia¡iei
standard prin metoda momentelor (M1 ¿i M2) se
folose¿te formula 1.
(1)
Momentul reprezintå o datå statisticå ce depinde
de media aritmeticå ponderatå. Formula de calcul
a momentului este:
(2)
X’ reprezentând diferen¡a fa¡å de media aritmeticå
ponderatå, n frecven¡ele, iar N numårul de cazuri.
Pe majoritatea loturilor statistice cu numero¿i
pacien¡i, calcularea momentelor necesitå un mare
consum de timp, în acest caz folosindu-se formula
simplificatå:
(3)
b. Coeficientul de varia¡ie
În loturile ce prezintå caracteristici diferite, ne-
omogene, devia¡iile standard nu sunt comparabile.
Din acest motiv se utilizeazå coeficientul de va-
ria¡ie (cV), care nu este altceva decât devia¡ia stan-
dard exprimatå procentual, formula de calcul fiind:
(4)
Mp reprezentând media aritmeticå ponderatå. Un
coeficient de varia¡ie mai mic de ± 10% indicå o
dispersie micå, deci o omogenitate mare; o valoare
de ± 10 pânå la ± 20% indicå o variabilitate medie, iar
o valoare de peste ± 20% ne aratå lipsa omogenitå¡ii.
c. Reparti¡ia normalå (curba normalå de frecven¡e)
De obicei, fenomenele biologice sunt carac-
terizate prin variabile continue (variabile de tip
dimensiune, vârstå etc.). Majoritatea acestor feno-
mene se caracterizeazå, în popula¡iile de dimen-
siuni mari printr-o distribu¡ie a valorilor ce urmeazå
a¿a-numita curbå normalå a reparti¡iei de frecven¡e
(curba sau „clopotul“ lui Gauss-Laplace). Aria curbei
distribu¡iei normale este definitå de medie ¿i de
abaterea standard, formula sa fiind:
(5)
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 205

Aplicarea ecua¡iei de calcul a curbei normale testul t fiind folosit pe e¿antioane cu mai pu¡in de
ne este de folos în stabilirea curbelor de tendin¡å. 50 de subiec¡i.
Formula de calcul a testului F este:
d. Testele de semnifica¡ie statisticå
Deciziile statistice se bazeazå pe teoria (6)
probabilitå¡ii, pe baza loturilor folosite putându-
se trage concluzii estimative asupra întregii po-
pula¡ii. În cazul a douå loturi selectate în mod Mp1 = media aritmeticå ponderatå a primului lot
asemånåtor teståm dacå diferen¡ele sunt sau nu s1 = devia¡ia standard a primului lot
semnificative. Se porne¿te de la ipoteza nulå (H0) N1 = numårul de pacien¡i al primului lot
cå cele douå loturi sunt asemånåtoare din punct Mp2 = media aritmeticå ponderatå a celui de-al
de vedere statistic, diferen¡ele datorându-se fluc- doilea lot
tua¡iei de selec¡ie din cadrul aceleia¿i popula¡ii. s 2 = devia¡ia standard a celui de-al doilea lot
Dacå rezultatele testelor de semnifica¡ie statisticå N2 = numårul de pacien¡i al celui de-al doilea lot
ne conduc la diferen¡e semnificative din punct de
vedere statistic, se respinge ipoteza nulå H 0 , Dupå stabilirea F calculat se cautå în tabelele de
acceptându-se ipoteza alternativå H1. reparti¡ie statisticå valoarea F teoretic (F tabelar) la
Testele de semnifica¡ie statisticå sunt supuse o probabilitate de 0,95 (prag de semnifica¡ie statis-
mai multor tipuri de erori: ticå 95%). Pentru stabilirea F tabelar se calculeazå
– eroarea de tip I (eroare a) reprezintå res- numårul de grade de libertate (f), conform formulei:
pingerea H0, de¿i ea ar trebui acceptatå, fiind
(7)
corectå;
– eroarea de tip II (eroare b) reprezintå accep-
tarea H0, de¿i ea ar trebui respinså, fiind in-
Coeficientul c se stabile¿te conform:
corectå.
Dacå probabilitatea de apari¡ie a erorii a cre¿te,
(8)
probabilitatea de apari¡ie a erorii b scade. Mini-
malizarea ambelor tipuri de eroare se face prin
cre¿terea mårimii e¿antionului, la valori reprezen-
tative. REZULTATE ªI DICUºII ALE STUDIULUI
Nivelul de semnifica¡ie statisticå este proba-
Rezultatele studiului clinic au fost centralizate în
bilitatea maximå de apari¡ie a unei erori a, el tre-
tabele pentru a eviden¡ia asemånåri sau diferen¡e între
buind stabilit la începutul studiului, pentru a nu
cele douå loturi de pacien¡i edenta¡i total studia¡i.
compromite rezultatele cercetårii.
Astfel în tabelul 2 au fost centralizate datele în
În studiul de fa¡å am stabilit un prag de semni-
ceea ce prive¿te tipul de edenta¡ie întâlnitå la pacien¡ii
fica¡ie statisticå de 95% (a = 0,05), prag acceptat
examina¡i, vârsta pacien¡ilor, sexul (bårba¡i, femei),
ca suficient de precis de majoritatea studiilor sta-
factorul etiologic ce a determinat edenta¡ia totalå.
tistice din domeniul medical. Testul de semni-
Cu toate cå, cele douå loturi sunt diferite ca
fica¡ie statisticå analizeazå diferen¡ele valorilor
numår de pacien¡i examina¡i au existat unele ase-
medii calculate teoretic fa¡å de valorile stabilite
månåri: edenta¡ia totalå bimaxilarå avea ponderea
prin måsurare, pe respetivele loturi. Dacå diferen¡a
cea mai mare; edenta¡iile unimaxilare, cel mai frec-
acestor valori este mai micå sau egalå decât a,
vent au apårut la nivelul maxilarului superior;
vorbim despre o diferen¡å care este nesemnificativå
edenta¡ia totalå a apårut cel mai frecvent la femei;
din punct de vedere statistic, ceea ce confirmå
caria ¿i complica¡iile ei, ca factor etiologic a apårut
ipoteza nulå.
în mai multe cazuri comparativ cu parodontopatia.
Un test de semnifica¡ie statisticå este considerat
Frecven¡a mai mare a edenta¡iei totale la femei
bun atunci când probabilitatea ca el så respingå decât la bårba¡i a fost citatå ¿i de Hutu (1998),
ipoteza nulå este micå, dar are o probabilitate mare ulterior de Bratu (2005).
de respingere a acestei ipoteze atunci când ea este În ceea ce prive¿te vârsta pacien¡ilor au existat
falså. Principalele teste de semnifica¡ie statisticå deosebiri între cele douå loturi:
folosite uzual sunt testul Student (t) ¿i testul Fisher – în primul lot frecven¡a cea mai mare a pa-
(F). Diferen¡a majorå între cele douå teste este cien¡ilor au avut vârsta cuprinså între 66-70
legatå de nivelul de reprezentativitate al lotului, de ani;
206 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

– în lotul doi frecven¡a cea mai mare apare la În cazul lotului 2, existå de asemenea diferen¡e
pacien¡ii cu vârsta cuprinså între 61-65 de ani. între numårul de pacien¡i raportate pe sexe, dar
Aceastå deosebire a apårut datoritå caracteris- curba de distribu¡ie are un caracter normal la
ticilor diferite între cele douå loturi. Pacien¡ii din ambele sexe, corespunzând pantei descendente a
primul lot manifestau un interes deosebit pentru „clopotului“ lui Gauss; afirma¡ia este întåritå de
protezare cu men¡inerea stårii de sånåtate a apara- coresponden¡a remarcabilå între curbele måsurate
tului dento-maxilar, fiind sus¡inu¡i ¿i de un statut ¿i curbele de calcul a tendin¡ei (grafic 2). Acest
socio-economic mai ridicat, în schimb pacien¡ii rezultat corespunde statutului socio-economic,
din lotul al doilea erau dintr-o categorie defa- cultural ¿i obiceiurilor igienico-sanitare precare ce
vorizatå, care nu au beneficiat de tratamente caracterizeazå lotul 2, edenta¡ia totalå evoluând
stomatologice constant ce le permitea men¡inerea natural sub ac¡iunea factorilor etio-patogenici.
stårii de sånåtate a aparatului dento-maxilar (pa-
cien¡i asista¡i sociali).
Cele douå loturi au fost comparate statistic folosind
testul Fisher (formula 6), rezultând un F calculat de
2,510, fa¡å de un F tabelar de 1,79. Deoarece F calculat
> F tabelar, respingem ipoteza nulå H0, cele douå loturi
fiind diferite, neomogene, din punct de vedere statistic.
Acest rezultat corespunde caracterului neomogen al
celor douå loturi, cei din primul lot beneficiind de
condi¡ii socio-economice ¿i culturale superioare celor
din cel de-al doilea lot.
Grafic 1
În cadrul ambelor loturi a fost studiatå curba
Vârsta pacien¡ilor lotul 1
de reparti¡ie a cazurilor pe grupe de vârstå,
studiindu-se coresponden¡a cu curbele de calcul
ale tendin¡elor în popula¡ie, aceasta respectând
distribu¡ia de tip normal (formula 5).
În cazul lotului 1, de¿i existå diferen¡e între
numårul de pacien¡i raportate pe sexe, curba de
distribu¡ie nu are caracter normal (Gaussian), la
ambele sexe, lucru demonstrat ¿i de curbele de
tendin¡e calculate (grafic 1). Devierea de la dis-
tribu¡ia normalå se explicå, din nou, prin condi¡iile
socio-economice dar ¿i obiceiurile igienico-sani-
tare de bunå calitate, ce îndepårteazå ace¿ti pa- Grafic 2
cien¡i de evolu¡ia naturalå a edenta¡iei totale. Vârsta pacien¡ilor lotul 2

Tabelul 2
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
La ambele loturi a fost aplicat testul Fisher
(formula 6), pentru depistarea diferen¡elor semni-
ficative din punct de vedere statistic între sexul
feminin ¿i cel masculin.
Lotul 1 a prezentat un F calculat de 7,5086 fa¡å
de un F tabelar de 1,96, iar lotul 2 un F calculat de
6,623 fa¡å de un F tabelar de 1,83. La ambele loturi
F calculat > F tabelar, deci respingem ipoteza nulå
H0, existând diferen¡e semnificative din punct de
vedere statistic între edenta¡ii de sex feminin ¿i
cei de sex masculin, cauzele probabile fiind con-
cordan¡e cu cele expuse anterior.
În tabelul 3 au fost centralizate datele în ceea
ce prive¿te elementele câmpului protetic edentat
total maxilar studiate. Astfel:
– creasta edentatå avea cel mai frecvent înål¡i-
mea de 5-6 mm în cazul lotului 1, iar în lotul 2
de 3-4 mm; din punct de vedere al atrofiei în
ambele loturi creasta era atrofiatå neuniform;
iar ca lå¡ime, în lotul 1 cel mai frecvent creasta
era rotunjitå, iar în lotul 2 ascu¡itå;
– bolta palatinå cel mai frecvent a avut o adân-
cime de 6-8 mm în cazul lotului 1 ¿i de 3-5
mm lotul 2; din punct de vedere al atrofiei,
avea o atrofie simetricå la pacien¡ii din lotul
Rezultatul studiului câmpului protetic edentat total maxilar
207
1 ¿i asimetricå la cei din lotul 2; în ceea ce
prive¿te forma, prezen¡a sau nu a torusului
¿i distan¡a antero-posterioarå au existat ase-
månåri cu toate cå numårul de câmpuri stu-
diate era diferit între cele douå loturi, astfel
a dominat forma bol¡ii de „U“, fårå torus
palatin ¿i cu o distan¡å antero-posterior în
medie de 4 cm;
– tuberozitå¡ile maxilare la ambele loturi ca
frecven¡å erau medii, prezente; în ceea ce
prive¿te retentivitatea cel mai frecvent erau
retentive unilateral.
La ambele loturi s-a efectuat analiza statisticå
a dimensiunii antero-posterioare a bol¡ii palatine,
studiindu-se curba de reparti¡ie a acesteia (formula
5). Graficele 3 ¿i 4 aratå o distribu¡ie de tip normal,
Gaussian, deoarece dimensiunea antero-poste-
rioarå a bol¡ii palatine este singurul parametru al
câmpului protetic edentat total maxilar care nu
suferå modificåri în urma edenta¡iei, påstrându-se
morfologia normalå.
Un alt element morfologic al câmpului protetic
edentat total maxilar supus analizei statistice a fost
tuberozitatea maxilarå din punct de vedere al
retentivitå¡ii.
Tabelul 3
208 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
Grafic 3
Dimensiunea antero-posterioarå a bol¡ii palatine lotul 1
Grafic 4
Dimensiunea antero-posterioarå a bol¡ii palatine lotul 2
Lotul 1 se caracterizeazå printr-o curbå de dis-
tribu¡ie de tip normal (grafic 5), identicå cu cea a
pacien¡ilor denta¡i. Påstrarea acestei caracteristici
la edenta¡ii totali din lotul 1 se explicå prin men¡i-
nerea stårii de troficitate a suportului muco-osos
prin protezåri corecte (transmit presiunile masti-
catorii ce favorizeazå osteogeneza conform
studiilor lui Jores), tuberozitatea maxilarå pås-
trându-¿i rolul de stâlp posterior, pterigo-maxilar
în structura de rezisten¡å a viscerocraniului.
În schimb, analiza statisticå a curbei de distri-
bu¡ie pe lotul 2 aratå un tip polinomial (grafic 6),
tuberozitatea maxilarå suferind modificåri aleatorii
ce o îndepårteazå de morfologia normalå a denta-
¡ilor. Aceste modificåri osoase sunt determinate
de utilizarea unor proteze incorecte, instabile pe
câmpul protetic ce transmit discontinuå presiunile
masticatorii, care conform studiilor lui Jores de-
clan¿eazå resorb¡ii osoase.
În tabelul 4 am centralizat datele referitoare la
elementele câmpului protetic edentat total
mandibular ce au fost examinate în cadrul studiului
clinic.
Grafic 5
Tipul retentivitå¡ii tuberozitå¡ii maxilare lotul 1
Grafic 6
Tipul retentivitå¡ii tuberozitå¡ii maxilare lotul 2
Astfel, între cele douå loturi examinate au apårut
urmåtoarele diferen¡e sau asemånåri:
– în lotul 1 cel mai frecvent creasta edentatå
mandibularå era simetricå, iar în lotul 2 era
asimetricå;
– în ambele loturi cel mai frecvent creasta
edentatå a avut o înål¡ime medie, chiar dacå
cele douå loturi erau diferite ca numår de
câmpuri edentate mandibular examinate; de
men¡ionat în lotul 2 existå o micå diferen¡å
între numårul crestelor de înål¡ime medie ¿i
cele negative;
– altå asemånare apare la direc¡ia crestei în
plan sagital ¿i forma crestei, în ambele loturi
cel mai frecvent au apårut creste cu direc¡ie
orizontalå ¿i formå de “U”;
– în ceea ce prive¿te tuberculul piriform, în
ambele loturi au existat cel mai frecvent tu-
berculi piriformi în pozi¡ie orizontalå ¿i cu un
volum mediu (putând favoriza protezarea).
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
Rezultatul studiului câmpului protetic edentat total mandibular
CONCLUZII
1. Studiul statistic a eviden¡iat în cazul acestor
loturi, diferite din punct de vedere a numårului de
pacien¡i examina¡i, unele asemånåri ¿i deosebiri.
Variabilitatea morfo-clinicå a câmpurilor protetice
edentate total a fost demonstratå prin caracteristicile
diferite ale celor douå loturi.
2. Lotul 1 a fost reprezentat de pacien¡i a cåror
vârstå frecvent era cuprinså între 66-70 de ani, 54%
erau femei, cel mai frecvent prezentau edenta¡ie
bimaxilarå (64% dintre pacien¡i), iar factorul etiologic
în 65% dintre cazuri, prezenta cauze asociate.
a. Câmpul protetic edentat total maxilar a fost
caracterizat de urmåtoarele elemente:
• creste edentate cu o înål¡ime de 5-6 mm
(43% dintre cazuri), atrofiate uniform (59%
dintre cazuri), rotunjite (65% dintre cazuri);
• bolta palatinå cu o adâncime de 6-8 mm
(65% dintre cazuri), fårå torus palatin (95%
dintre cazuri), atrofiate simetric (65% dintre
cazuri), având forma literei U (63% dintre
cazuri), cu o dimensiune în sens antero-pos-
terior de 4 cm (64% dintre cazuri);
• tuberozitå¡ile maxilare au fost cel mai frec-
vent în 51% dintre cazuri prezente, medii.
b. Câmpul protetic edentat total mandibular a
fost caracterizat de urmåtoarele elemente:
• creste edentate simetrice (77% dintre ca-
zuri), în formå de U (58% dintre cazuri), de
înål¡ime medie (43% dintre cazuri), cu o
resorb¡ie neuniformå, fårå torus mandibular,
209
Tabelul 4
având direc¡ia în plan sagital cel mai frec-
vent orizontalå (56% dintre cazuri);
• tuberculul piriform în 58% dintre cazuri avea
un volum mediu, iar direc¡ia fa¡å de creasta
edentatå era orizontalå (65% dintre cazuri).
3. Lotul 2 a fost reprezentat de pacien¡i a cåror
vârstå frecvent era cuprinså între 61-65 de ani, 62%
erau femei, cel mai frecvent prezentau edenta¡ie
bimaxilarå (64% din pacien¡i), iar factorul etiologic
în 57% dintre cazuri, prezenta cauze asociate.
b. Câmpul protetic edentat total maxilar a fost
caracterizat de urmåtoarele elemente:
• creste edentate cu o înål¡ime de 3-4 mm (66%
dintre cazuri), atrofiate neuniform (60%
dintre cazuri), ascu¡ite (69% dintre cazuri);
• bolta palatinå cu o adâncime de 3-5 mm
(63% dintre cazuri), fårå torus palatin (95%
dintre cazuri), atrofiate asimetric (59% dintre
cazuri), având forma literei U (44% dintre
cazuri), cu o dimensiune în sens antero-
posterior de 4 cm (67% dintre cazuri);
• tuberozitå¡ile maxilare au fost cel mai frecvent
în 43% dintre cazuri prezente, medii.
c. Câmpul protetic edentat total mandibular a
fost caracterizat de urmåtoarele elemente:
• creste edentate asimetrice (70% dintre ca-
zuri), în formå de U (52% dintre cazuri), de
înål¡ime medie (43% dintre cazuri), cu o re-
sorb¡ie neuniformå, fårå torus mandibular,
având direc¡ia în plan sagital cel mai frec-
vent orizontalå (54% dintre cazuri);
210 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
• tuberculul piriform în 54% dintre cazuri avea
un volum mediu, iar direc¡ia fa¡å de creasta
edentatå era orizontalå (62% dintre cazuri).
4. Astfel, pacien¡ii din primul lot au fost carac-
teriza¡i de câmpuri protetice cu elemente morfo-
logice specifice ce favorizeazå protezarea, iar men-
¡inerea troficitå¡ii muco-osoase cu påstrarea acestor
elemente este determinatå de protezåri repetate,
corecte, proteze cu o igienå foarte bunå (corespunde
statului socio-economic al pacien¡ilor studia¡i).
5. Câmpurile protetice la pacien¡ii din lotul doi
au prezentat elemente ce pot influen¡a negativ pro-
tezarea, modificåri frecvente la nivelul mucoasei
acoperitoare (stomatopatii protetice), determinate
de lipsa unei protezåri corecte, folosirea unor
proteze vechi, cu o stare de igienå precarå (cores-
BIBLIOGRAFIE
1. Bratu D, colab – Bazele clinice ¿i tehnice ale protezårii edenta¡iei
totale, Ed. Medicalå, Bucure¿ti, 2005.
2. Despa EG, Ionescu T, Hutu E – Studiul clinic asupra câmpului
protetic edentat total (partea I) – Rev. Stomatologia – Vol I, Nr. 1,
Bucure¿ti, 2004.
3. Despa EG, Ionescu T, Hutu E – Studiul clinic asupra câmpului
protetic edentat total (partea II), Rev. Stomatologia – Vol I,
Nr. 2-3, Bucure¿ti, 2004.
4. Ene L, Popovici C – Edenta¡ia totalå-clinicå ¿i tratament, Curs
pentru studen¡i, Litografia I.M.F., Bucure¿ti, 1988.
Adreså de coresponden¡å:
ªef Lucr. Dr. Elena Gabriela Despa, Facultatea de Medicinå Dentarå, Universitatea „Titu Maiorescu“, Str. Dionisie Lupu, Nr. 70,
Sector 1, Bucure¿ti
email: gabidespa@gmail.com
punde statutului socio-economic al pacien¡ilor din
acest lot).
6. Condi¡iile materiale, reprezintå un factor
deosebit de important, care participå la marea
variabilitate a dimensiunii ¿i formelor substratului
osos, dar în special asupra structurilor morfologice
reprezentate de muco-periost.
7. Între cele douå loturi au fost câteva asemånåri,
dar nu sunt concludente, loturile fiind diferite ca
numår de pacien¡i. Studiul clinic ¿i statistic a de-
monstrat cå fiecare câmp protetic edentat total este
unic în felul såu, fiind caracterizat de anumite ele-
mente morfologice specifice fiecårui pacient, ce
pot fi influen¡ate de statutul socio-economic, con-
di¡iile culturale, obiceiurile igieno-sanitare.
5. Ene L – Edenta¡ia totalå, Ed. IMF Bucure¿ti, 1989.
6. Hutu E – Edenta¡ia totalå, Ed. Na¡ional, Bucure¿ti, 2005.
7. Jonhson DL, Holt RA, Duncanson JRM – Contour of the
edentulos palate, JADA 1986, 113, 35.
8. Mure¿an P – Manual de metode matematice în analiza stårii de
sånåtate, Ed. Medicalå, Bucure¿ti, 1989.
9. Påuna M, Preoteasa E – Aspecte practice în protezarea edenta¡iei
totale, Ed. Cerma, Bucure¿ti, 2002.
[*| In-line.WMF *][*| In-line.WMF*]
 PROTETICÅ DENTARÅ
11
ASPECTE ALE MIªCÅRILOR
MANDIBULARE LA EDENTATUL TOTAL
Aspects of the Mandible Movements in the Totally
Edentulous Patients
ªef Lucr. Dr. Elena-Gabriela Despa, Ddr. Gabriela Moise
Catedra de Proteticå Dentarå Facultatea de Medicinå Dentarå Universitatea
„Titu Maiorescu“

REZUMAT
Prin apari¡ia stårii de edenta¡ie totalå se modificå foarte mult condi¡iile anatomice ¿i neuro-musculare care declan¿au, reglau ¿i
influen¡au mi¿cårile mandibulare. Edenta¡ia totalå, instalatå brusc sau lent (treptat) este caracterizatå de o engramå proprie, fiind
dificil de apreciat propor¡ia, råmaså din starea de dentat sau din engramele care sau format în fazele de edenta¡ie par¡ialå.
Rela¡iile intermaxilare la edentatul total sunt analizate pentru a se decela dacå existå modificåri ¿i valoarea lor. Determinarea ¿i
restaurarea rela¡iilor intermaxilare sunt ob¡inute fårå dificultate ¿i se realizeazå o suprapunere a intercuspidårii maxime cu rela¡ia
centricå ceea ce constituie idealul.
Absen¡a suprapunerii intercuspidårii maxime cu rela¡ia centricå, constituie o mare eroare capabilå så determine grave tulburåri în
mi¿cårile mandibulare fiindcå ocluzia-contactele dentare produc alunecåri (derapaje).

Cuvinte cheie: mi¿cåri func¡ionale, mi¿cåri automatizate, mi¿cåri nefunc¡ionale, engrama mi¿cårilor mandibulare, suprapunerea
intercuspidare maximå cu rela¡ia centricå (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).

În trecut au existat ipoteze referitor la mi¿cårile
mandibulei la edentatul total reprezentate de afirma¡iile
„nu sunt modificåri comparativ“ cu ale dentatului.
Cercetåtorii japonezi au demonstrat prin radio-
metrie la dentat în cursul a 24 de ore din¡ii celor
douå arcade sunt în contact direct între ei aproxi-
mativ 1,30 ore (90 minute), în acest timp majo-
ritatea contactelor sunt prezente în timpul degluti¡ie
(14, 20, 22). În cadrul ciclului masticator auto-
matizat existå trei tipuri de mi¿cåri: mi¿cårile man-
dibulei fårå contacte dentodentare care formeazå
marea majoritate a mi¿cårilor mandibulare auto-
matizate; mi¿cårile mandibulare automatizate cu
contacte dentare, din care func¡ional majoritatea
sunt realizate în timpul degluti¡iei ¿i numai întâm-
plåtor în timpul mastica¡iei; mi¿cåri extreme con-
form schemei lui Posselt.
Mi¿cårile din prima categorie, executate în mod
automatizat sunt dominante în sens vertical, numai
10% în sens orizontal (laterale), cu scopul de a
aplica resturile alimentare ¿i a le readuce pentru
tritrurare pe fe¡ele ocluzale.
Mi¿cårile în sens orizontal pot fi provocate direct
sau indirect pe cale reflexå pentru evitarea obstacolului
constituit de diferite contacte premature sau interferen¡e.
Acest tip de mi¿care, de¿i automatizate, sunt nocive,
nu trebuie så fie prezente ¿i la edentatul total.
Din acelea¿i considerente Jankelson a afirmat
în mod natural, tritrurarea alimentelor, în special
la edentatul total este ob¡inutå prin mi¿cårile man-

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 2-3, AN 2008 211

212 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
dibulei în sens vertical, inclusiv la pacien¡ii care
în starea de dentat au avut componente orizontale
ale mi¿cårilor mandibulare.
Mi¿cårile automatizate în sens orizontal, fårå
contacte interdentare, apar în fona¡ie ¿i în mimica
specificå a individului.
Propulsia din timpul fona¡iei nu este posibil så
fie controlatå voluntar; de aceea montarea din¡ilor
frontali la protezele totale trebuie så permitå com-
pleta libertate de propulsie a mandibulei în timpul
fona¡iei (1,3,9,19,21). În acest scop, între incisivii
inferiori ¿i superiori se creeazå o inocluzie ori-
zontalå în sens sagital. Nerespectarea acestui spa¡iu
pentru propulsia mandibulei va reprezenta o con-
di¡ie favorizantå så se producå contacte la nivelul
din¡ilor frontali în fona¡ie, ceea ce determinå insta-
bilitatea protezelor ¿i întreruperea fona¡iei pentru
stabilizarea protezelor.
Mi¿cårile func¡ionale ale mandibulei în sens
vertical, sunt caracterizate de contacte dento-
dentare, care trebuie så fie prezente în timpul de-
gluti¡iei. Intercuspidarea maximå trebuie så se
suprapunå cu rela¡ia centricå la edentatul total
corect protezat (2,8,9,13,15).
Mi¿cårile din categoria a treia – reprezentate de
mi¿cårile extreme – propulsia maximå ¿i mi¿cårile
nefunc¡ionale indirect sunt sau nu cu contacte dento-
dentare. Mi¿cårile voluntare extreme nu apar niciodatå
în ciclul automatizat al mi¿cårilor de mastica¡ie.
Mi¿cårile extreme efectuate de mandibulå formeazå
aria mi¿cårilor limitå fa¡å de care aria mi¿cårilor
fundamentale la dentat, este mult mai micå.
La edentatul total protezat, aria acestor mi¿cåri
func¡ionale se råstrânge ¿i mai mult, în func¡ie de
stabilitatea ¿i men¡inerea protezelor. Prin apari¡ia
stårii de edenta¡ie totalå se modificå foarte mult
condi¡iile anatomice ¿i neuro-musculare care de-
clan¿au, reglau ¿i influen¡au mi¿cårile mandibulare.
Dintre determinan¡ii mi¿cårilor mandibulare
dispare în primul rând ghidajul anterior (11,18, 21)
care nu poate så fie refåcut protetic fårå riscul de a
destabiliza protezele.
Determinantul posterior, articula¡ia temporo-
mandibularå în func¡ie de modificårile morfo-func¡ionale,
prezintå, uneori multe leziuni structurale dar rela¡ia
centricå råmâne nemodificatå, fiind un reper fundamental,
care este deosebit de necesar pentru realizarea rapoartelor
intermaxilare func¡ionale la edentatul total.
Musculatura sau determinantul mijlociu, dupå
unele teorii, î¿i men¡in reflexele contrac¡iilor auto-
matizate, elementare dar cu multe modificåri
produse de absen¡a sensibilitå¡ii
proprioreceptorilor care existau la nivelul
parodon¡iului din¡ilor. De la suprafa¡a mucoasei
cavitå¡ii orale ¿i a limbii sunt transmise semnale
exteroreceptive. Toate particularitå¡ile structurilor
edentatului total produc tulburåri ale mecanismului
de reglare a contrac¡iilor automatizate mu¿chilor,
existente la nivelul engramei, de mastica¡ie, a
fiecårui individ.
În prima perioadå de la aplicarea protezelor apar
stimuli care produc organizarea unui tip deosebit
de mi¿cåri mandibulare automatizate influen¡ate
de urmåtorii factori biologici:
– engrama mi¿cårilor mandibulare deja exis-
tente în faza de dentat;
– determinantul posterior, respectiv mi¿cårile
permise de articula¡ia temporo-mandibularå ¿i
în special de pozi¡ia de rela¡ie centricå-care este
cunoscut, råmâne constantå ¿i reproductibilå;
– rela¡iile noi intermaxilare stabilite de protezele
totale, care cuprind: dimensiunea verticalå de
ocluzie, spa¡iul de inocluzie fiziologicå din
pozi¡ia de posturå, intercuspidarea maximå ¿i
raportul stabilit fa¡å de rela¡ia centricå, raportul
din¡ilor din zona frontalå ¿i lateralå fa¡å de
¡esuturile moi (buze, obraji ¿i limba) la care se
poate adåuga gradul de men¡inere ¿i de
stabilitate ale protezelor pe câmpurile protetice.
Fiziopatologia mecanismelor, care modificå
engrama mi¿cårilor mandibulare
Engrama mi¿cårilor automatizate se modificå
în raport cu tipul de edenta¡ie, topografia ¿i nu-
mårul din¡ilor prezen¡i pe arcadå (numårul sto-
purilor ocluzale prezente ¿i absente) (4,5,11,12).
Edenta¡ia totalå, instalatå brusc sau lent (treptat)
este caracterizatå de o engramå proprie, fiind dificil
de apreciat propor¡ia, råmaså din starea de dentat
sau din engramele care sau format în fazele de
edenta¡ie par¡ialå. Este cunoscut, engramele fixate
la nivelul sistemului nervos central sunt modificate
în raport cu evolu¡ia normalå sau patologicå a
diferitelor structuri ale aparatului dento-maxilar,
ale celorlalte organe ¿i sisteme. În faza de edentat
total individul mai påstreazå, unele elemente ale
engramei din starea de dentat (8,9,17,18).
Protezele, executate corect dacå sunt necesare
unele „retu¿uri“ ale engramelor de mastica¡ie
existente anterior, la majoritatea pacien¡ilor se
produce adaptarea sistemului neuro-muscular så
se ob¡inå reflexele necesare. Astfel se realizeazå
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
o selectare în final, automatizatå a mi¿cårilor
mandibulare, care sunt favorabile pentru adaptarea
pacientului la proteze (4,5,6,7).
Perioada de timp în care se produce automati-
zarea mi¿cårilor, determinate de contrac¡iile mus-
culare este variabilå în func¡ie de vârstå, de capa-
citatea biologicå ¿i reactivitatea fiecårui pacient.
La vârstele mai tinere, capacitatea de adaptare
este mai mare, comparativ cu cea a pacien¡ilor
foarte vârstnici. Ipoteza ¿i tendin¡a care a existat
în trecut în cadrul tehnologiei protezei totale, så
redea la edentatul total prin montarea din¡ilor
acelea¿i caracteristici la nivelul arcadelor dentare,
care au fost prezente în starea de dentat, a creat o
concep¡ie eronatå despre construc¡ia protezelor.
Anvelopa mi¿cårilor func¡ionale reflexe la dentat
delimiteazå o arie mult mai reduså fa¡å de mi¿cårile
limitå, s-a imaginat pentru protezele totale så se
reproducå mi¿cårile maxime dacå protezele sunt
men¡inute în mod corespunzåtor pe câmpurile protetice.
Mi¿cårile maxime au fost efectuate în timpul
amprentårii, la unele tehnici, ceea ce au avut ca
rezultat final, o reducere a suprafe¡ei zonei de
sprijin a câmpului protetic. For¡a de adeziune, fiind
mult mai reduså ¿i presiunile ocluzale au fost exer-
citate cu valori mai mari pe unitatea de suprafa¡å.
Rezultatul a fost nefavorabil din urmåtoarele
puncte de vedere: instabilitatea protezelor ¿i atrofia
structurilor biologice ale câmpurilor protetice.
Rela¡iile intermaxilare la edentatul total sunt
analizate pentru a se decela dacå existå modificåri
¿i valoarea lor. Astfel: la edentatul total, dupå
abla¡ia ¿i extrac¡iile protezelor fixe pluridentare
posibil så prezinte urmåtoarele aspecte:
a. dacå planul de ocluzie a prezentat elemente
favorabile så fie men¡inute rapoartele mandibulo-
maxilare încât intercuspidarea maximå så se
suprapunå cu rela¡ia centricå;
Determinarea ¿i restaurarea rela¡iilor inter-
maxilare sunt ob¡inute fårå dificultate ¿i se reali-
zeazå o suprapunere a intercuspidårii maxime cu
rela¡ia centricå ceea ce constituie idealul. Prog-
nosticul tratamentului de cele mai multe ori este
favorabil când sunt asigurate men¡inerea ¿i
stabilitatea în faza clinicå de amprentare.
b. dacå au fost denivelåri ale planului de
ocluzie, înso¡ite de puncte premature de contact
¿i interferen¡e în dinamica mandibularå care så
determine, ocluzie de necesitate ¿i de obi¿nuin¡å,
cu modificåri la nivelul articula¡iei temporo-man-
dibulare ¿i ale grupelor musculare.
213
Aceste situa¡ii clinice, nu reprezintå cazuri
izolate, unicate. Activitatea practicå ¿i documen-
tarea din literatura de specialitate, aratå un procent
suficient de mare, care trebuie så reprezinte un
semnal necesar ¿i util pentru fiecare medic dentist
solicitat så rezolve astfel de cazuri.
Dificultatea î¿i are debutul în faza de determi-
nare a rela¡iei centrice care de¿i se sus¡ine, este
conservatå permanent, stereotipurile contrac¡iilor
musculare instalate în perioade mai mari de timp,
î¿i men¡in activitatea ¿i în faza când se pozi¡ioneazå
mandibula în rela¡ie centricå, se manifestå
nefavorabil, asupra arcadei dentare a protezei
mandibulare în momentul conducerii în RC.
Existå tendin¡a la ace¿ti pacien¡i så-¿i pozi¡ioneze
mandibula în laterodevia¡ie stânga, dreapta sau
lateropulsie. Numai un exerci¡iu, care constå în
solicitarea intenså a mu¿chilor ridicåtori, în scopul
modificårii tonusului (obosealå) ¿i conducerea
mandibulei în pozi¡ie înaltå, posterioarå, simetricå
dupå tehnica lui Dawson sau Ramfiord creeazå
posibilitatea så se ob¡inå suprapunerea între
intercuspidarea maximå ¿i rela¡ia centricå (6,7,8,9,15).
Evolu¡ia ulterioarå: la proba machetelor po-
sibil så aparå tendin¡a de latero-devia¡ie când
trebuie så se ob¡inå intercuspidarea maximå, fårå
så se suprapunå cu rela¡ia centricå; iar la inser¡ia
protezelor så se manifeste acelea¿i tendin¡e.
Rezultatele favorabile adicå suprapunerea inter-
cuspidårii maxime cu rela¡ia centricå sunt ob¡inute dacå,
medicul dentist este dotat cu mult tact ¿i råbdare så
explice purtåtorului de proteze în fa¡a oglinzii cum så-
¿i dirijeze con¿tient mandibula, aceste explica¡ii sunt
utile pentru cei care au capacitatea så în¡eleagå
explica¡iile ¿i au dorin¡a så aplice ceea ce i se recomandå.
La edentatul total protezat majoritatea mi¿-
cårilor sunt necesare så fie realizate în axa balama
terminalå, distan¡area mandibulei (arcadei infe-
rioare fa¡å de cea superioarå) så fie numai de 20
mm-25 mm). Amplitudinea deschiderii gurii
trebuie så fie reduså. Consecin¡ele modificårilor
dimensionale ale dimensiunii verticale de ocluzie,
în plus sau în minus sunt cunoscute. Deasemenea
consecin¡ele care includ func¡ionalitatea prote-
zelor, prognosticul tratamentului din punct de
vedere curativ ¿i profilactic. În general se mai
adaugå modificårile structurilor anatomice com-
ponente ale aparatului dento-maxilar. Aceste mo-
dificåri este posibil så determine ¿i tulburåri în
echilibrul sistemului nervos central ¿i periferic.
Absen¡a suprapunerii intercuspidårii maxime
214 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008
cu rela¡ia centricå, constituie o mare eroare ca-
pabilå så determine grave tulburåri în mi¿cårile
mandibulare fiindcå ocluzia-contactele dentare
produc alunecåri (derapaje).
Primul contact dento-dentar între arcadele pro-
tezelor, creeazå senza¡ii de nesiguran¡å. Este insta-
latå o neconcordan¡å, nepotrivire între contactele
dentare. Reflex, se produc alte contacte mai ferme,
mai stabile în plan orizontal, ceea ce determinå
devierea mandibulei de la stereotipul creat pentru
mastica¡ie. Proteza este deplasatå de pe câmpul
protetic, progresiv ¿i dacå la inser¡ie a prezentat
men¡inere ¿i stabilitate foarte bunå determinate de
succiune ¿i adeziune. Acest mecanism, complex
neuro-muscular ¿i mecanic (IM) produce modificåri
la nivelul structurilor câmpului protetic- mucoaså
¿i os- atrofia osului ¿i hipertrofie localizatå în unele
zone ale mucoasei sau atrofie în altele.
Instabilitatea protezelor exercitatå de derapajul
ocluzal determinå anumite contrac¡ii (ticuri) ale
musculaturii oro-faciale ¿i ale mu¿chilor limbii cu
tendin¡a så stabilizeze proteza care nu sunt eficiente.
Concomitent, apar ¿i contrac¡ii ale mu¿chilor
mobilizatori ai mandibulei a cåror manifeståri sunt
urmate de consecin¡e asupra mecanismului care este
necesar pentru instalarea contrac¡iilor automatizate.
Spasmele musculare instalate, prezintå carac-
teristice disfunc¡iei, determinå cicluri masticatorii
atipice, cu componente orizontale importante, care
produc mai intens mobilizarea protezelor cu efecte
¿i asupra modificårilor de troficitate la nivelul
structurilor câmpului protetic.
Dacå între intercuspidarea maximå ¿i rela¡ia centricå
sunt diferen¡e foarte reduse, exprimate în milimetrii,
existå long centric ¿i din¡ii sunt din acrilat, fenomenul
de abraziune care se produce uneori, este favorabil så
se ob¡inå, rela¡ii ocluzale corespunzåtoare pentru
ocluzia de obi¿nuin¡å. Aceastå ocluzie, creeazå
condi¡iile necesare pentru automatizarea, mi¿cårilor
de mastica¡ie ¿i de intercuspidare maximå. La aceste
cazuri clinice dispar, consecin¡ele care se pot instala
asupra cinematicii mandibulare ¿i asupra ¡esuturilor
câmpului protetic.
Dacå diferen¡ele dintre intercuspidarea maximå ¿i
rela¡ia centricå sunt în jur de 0,5mm, localizate numai
la un grup de din¡i, depistate cu hârtia de articula¡ie
prin ¿lefuire apare posibilå instalarea coinciden¡elor
dintre contactele dentare ¿i rela¡ia centricå.
Pozi¡iile din¡ilor artificiali, dacå sunt în alte raporturi
cu buzele ¿i limba, pot så modifice mi¿cårile mandibulei
prin urmåtoarele mecanisme fiziopatologice:
instabilizeazå proteza în mod diferit, fie limba dacå este
în oro-pozi¡ie, fie buzele dacå sunt în vestibulo-pozi¡ie
¿i senza¡ii de disconfort pentru limbå în fona¡ie (de
încorsetare) ¿i de plasare a buzelor în alte pozi¡ii când
intrå în ac¡iune tonusul mu¿chilor orbiculari.
Modificårile mari de pozi¡ie ale din¡ilor sunt
urmate de instabilitatea protezelor, corectarea este
remediatå prin remontarea din¡ilor. Dacå pozi¡iile
din¡ilor sunt modificate, fårå consecin¡e mari
asupra stabilitå¡ii protezelor este recomandabil så
se temporizeze interven¡ia fiindcå existå posibili-
tatea unei adaptåri, în mod progresiv deoarece la
multe cazuri clinice se instaleazå lent.
Erori evidente la protezele totale pot så aparå
în urmåtoarele situa¡ii morfo-clinice (8,9,10,15):
– spa¡iul minim de vorbire al lui Silverman nu este
prezent sau are dimensiuni foarte reduse;
disfunc¡iile fonatorii, produc tulburåri în vorbire
cu repercursiuni psiho-nervoase, manifestate
sub formå de stres nervos, care sunt nefavorabile
pentru perioada de adaptare la proteze;
– spa¡iul func¡ional, util pentru limbå a lui
Scheirnemakers, când nu este prezent, are douå
consecin¡e: mobilizarea protezei inferioare,
senza¡ia de încorsetare a limbii;
– spa¡iul func¡ional util limbii nu este prezent
dacå: regula lui Pound nu s-a aplicat la mon-
tarea grupului din¡ilor laterali inferiori, versantul
lingual al protezei este gros, 1-4 mm (supra-
dimensionat) sau nu este concav.
Dacå spa¡iul func¡ional util pentru limbå nu este
prezent, mi¿cårile automatizate ale mandibulei sunt
întrerupte, de contrac¡iile mu¿chilor, care sunt nece-
sare så stabilizeze protezele. Contrac¡iile musculare
pentru stabilizare se produc la nivelul mu¿chilor
ridicåtori ai mandibulei, între cele douå arcade se
ob¡in contacte ocluzale care pozi¡ioneazå baza pro-
tezei pe câmpul protetic. Men¡inerea ¿i stabilitatea
protezelor pe câmpurilor protetice sunt determinate
de fidelitatea (corectitudinea amprentei) ¿i de rela¡iile
ocluzale dintre cele douå arcade dentare static ¿i
dinamic împreunå cu pozi¡iile din¡ilor (8,9,16).
Ace¿tia sunt factori deosebi¡i de importan¡i care
creeazå condi¡iile pentru func¡ionalitatea protezelor
sau pentru imposibilitatea utilizårii lor.
Instabilitatea creatå de neadaptarea bazelor la
zona de sprijin, „absen¡a“ succiunii, adeziunii, re-
la¡iile ocluzale necorespunzåtoare, reprezintå fac-
tori deosebi¡i de nocivi pentru men¡inerea stårii
de troficitate a ¡esuturilor aparatului dento-maxilar,
muco-periost, os ¿i a structurilor reprezentate de:
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 215

mu¿chii mobilizatori, oro-faciali ¿i elementele ocluzal ¿i dimensiunii verticale de ocluzie mai micå,
articula¡iei temporo-mandibulare. aduc mari dezavantaje câmpurilor protetice, pentru
Protezele instabile pe câmpurile protetice care momentul unei alte interven¡ii de protezare.
prezintå defecte la nivelul arcadelor dentare, a reliefului

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Adreså de coresponden¡å:
ªef Lucr. Dr. Elena Gabriela Despa, Facultatea de Medicinå Dentarå, Universitatea „Titu Maiorescu“, Str. Dionisie Lupu, Nr. 70,
Sector 1, Bucure¿ti
email: gabidespa@gmail.com