Sunteți pe pagina 1din 63

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 Conf. Dr. D.A. MARIª – Constan¡a
Prof. Dr. A. BUCUR – Bucure¿ti G-ral Prof. Dr. T.A. MIHAI – Bucure¿ti
Prof. Dr. V. BURLU– Ia¿i Prof. Dr. S. SANDHAUS – Elve¡ia
Dr. Ugo CAPURSO – Italia Prof. Dr. Valentina SCÂNTEI-DOROBź – Ia¿i
Prof. Dr. V. CÂRLIGERIU – Timi¿ Prof. Dr. A. SCHNEIDER – Germania
Prof. Dr. Elvira COCÂRLÅ – Cluj-Napoca Dr. Eugenia ROªCA – Italia
Prof. Dr. M. CRÅIºOIU – Craiova Prof. Dr. Mihaela PÅUNA – Bucure¿ti
Conf. Dr. B. DIMITRIU – Bucure¿ti Conf. Dr. Al. PETRE – Bucure¿ti
Prof. Dr. H. DUMITRIU – Bucure¿ti Prof. Dr. Mariana Brându¿a POPA – Bucure¿ti
Prof. Dr. L. ENE – Bucure¿ti Prof. Dr. S. POPA – Cluj
Prof. Dr. Norina FORNA – Ia¿i Dr. Ion RÂNDAªU – Bucure¿ti
Prof. Dr. A. GARFUNKEL – Israel Prof. Dr. Dan Dumitru SLÅVESCU – Bucure¿ti
Prof. Dr. N. GANUTA – Bucure¿ti Conf. Dr. C. VÂRLAN – Bucure¿ti
Dr. I.B.T. GEORGESCU – Bucure¿ti Prof. Dr. Maria VORONEANU – Ia¿i
Prof. Dr. Ov. GRIVU – Arad Prof. Dr. Theodor TRÅISTARU – Bucure¿ti
Prof. Dr. A. ILIESCU – Bucure¿ti Conf. Dr. Irina ZETU – Ia¿i
Prof. Dr. Ecaterina IONESCU – Bucure¿ti Conf. Dr. Liviu ZETU – Ia¿i
Conf. Univ. Dr. Ileana IONESCU – Bucure¿ti
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
Produc¡ie: Mihaela Conea
Distribu¡ie: Mihaela Stanca
________________
CONTACT: AMR@medica.ro
ABONAMENTE: redactia@amaltea.ro

TIPAR:
EMPIRE Print – RomExpo, Pavilion T, Bucure¿ti
tel.: 021 / 316 96 40, 031 / 405 99 99
email: office@empireprint.ro

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 La adul¡ii cu vârsta între 20-44 ani s-a estimat
FLUORULUI în urma consumului de apå fluorizatå o reducere
cu 20-30% a cariilor coronare ¿i o reducere
În urma unor studii ample, s-a determinat cå cuprinså între 20-40% a cariilor radiculare.
fluorul este singurul element mineral unanim De asemenea, s-a demonstrat cå fluorul pre-
corelat cu rezisten¡a la carie a din¡ilor. zintå efectul cariopreventiv cel mai mare pe
Prevenirea cariei dentare prin administrarea de suprafe¡ele libere – 86%, apoi pe suprafe¡ele
fluor reprezintå modalitatea prin care s-au ob¡inut aproximale – 75%, iar cel mai mic efect cario-
cele mai importante rezultate. preventiv îl prezintå la nivelul ¿an¡urilor ¿i fo-
Ca urmare, administrarea fluorului se poate setelor ocluzale – 31%.
realiza pe cale generalå ¿i pe cale localå. Toate aceste date i-au permis lui Horowitz så
Dintre modalitå¡ile de administrare a fluorului, pe afirme cå fluorizarea apei asigurå beneficii tuturor
cale generalå, cea mai indicatå, (în special ca raport persoanelor dentate de-a lungul întregii vie¡i.
cost/eficien¡å) este prin consumul de apå fluorizatå. O altå metodå de administrare generalå a
S-au fåcut numeroase studii privind concen- fluorului este prin fluorizarea sårii de bucåtårie ce
tra¡ia optimå a fluorului în apå, toate demonstrând se realizeazå cu 200-250 mg fluorurå de Na la
ca reducerea cea mai spectaculoaså a inciden¡ei 1kg de sare, asigurându-se astfel un aport de pânå
cariei se produce pânå la o concentra¡ie de 1 ppm, la 2 mg Fluor la un consum mediu de 6g sare/zi.
concentra¡ie la care leziunile distrofice de fluorozå Fluorizarea sårii de bucåtårie nu necesitå decât
sunt rare ¿i de minimå gravitate. 3% din cantitatea de fluor necesarå pentru fluori-
O sintezå a 95 de studii din 20 de ¡åri, realizate zarea apei înså efectul carioprotectiv este ceva mai
în condi¡ii diferite privind eficacitatea prevenirii scåzut decât cel care se întâlne¿te în urma fluori-
cariei dentare la copii prin fluorizarea apei, aratå zårii apei potabile.
o reducere cu peste 40% a cariilor din¡ilor per- Fluorizarea laptelui ¿i a båuturilor råcoritoare
manen¡i (Naylor ¿i Murray-1976). are de asemenea efecte carioprotective înså mai
De asemenea fluorul prezintå o ac¡iune beneficå scåzute decât cele ob¡inute în urma fluorizårii apei
¿i asupra persoanelor adulte rezidente permanent potabile.
într-o localitate cu apå fluorizatå. La acestea s-a Stephen (1981) a aråtat cå un consum zilnic în
constatat o reducere cu 45% a numårului de su- ¿coalå de 200 ml lapte cu con¡inut de 1,5 mg de
prafe¡e cariate comparativ cu o popula¡ie ce con- fluor pe timp de 4 ani a redus inciden¡a cariei la
sumå apå cu un con¡inut scåzut de fluor. primii molari permanen¡i cu 34% comparativ cu
Astfel se poate concluziona cå fluorizarea apei lotul martor.
are un efect protectiv substan¡ial ¿i de duratå. De asemenea GEDALIA (1981) a raportat o
Fluorizarea apei, combinatå cu celelalte måsuri reducere cu 28% a indicelui DMF – S la copiii de
preventive a redus prevalen¡a cariei cu circa 75% 6-9 ani care au consumat la ¿coalå 100 g suc de
în general, iar pentru suprafe¡ele aproximale chiar portocale con¡inând 1 mg F (10 ppm) pe o perioadå
cu 90%. de 3 ani.

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


REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 157

În ceea ce prive¿te fluorizarea alimentelor, Cantitatea de fluor administratå trebuie corelatå


aceasta prezintå dezavantajul unui dozaj relativ cu:
prin diferen¡ele cantitative de ingestie alimentarå – concentra¡ia fluorului din apa potabilå;
între indivizi, iar compozi¡ia deosebitå a meniurilor – vârsta copilului;
face imposibilå stabilirea unui echilibru de dozare – zona climaticå.
a fluorului. Pentru zona de climå temperatå, dacå fluorul
O altå metodå de administrare a fluorului pe din apa potabilå nu depå¿e¿te 0,4 ppm, se admi-
cale generalå este prin administrarea tabletelor ¿i nistreazå în func¡ie de greutatea copilului:
solu¡iilor ce con¡in fluor. – de la na¿tere pânå la 10 kg – 0,25 mg F/zi;
În literatura de specialitate au apårut mai multe – de la 10 kg la 15 kg – 0,5 mg F/zi;
articole ce se referå la eficacitatea administrårii – de la 15 kg la 20 kg – 0,75 mg F/zi;
tabletelor sau solu¡iilor, articole ce au fost sinteti- – peste 25 kg – 1 mg F/zi.
zate de cåtre DRISCOL – 1974 ¿i BINDER – 1978. Pentru ob¡inerea efectului cariostatic este ne-
Aceste cercetåri pot fi împår¡ite în trei grupe cesar aportul minim de 1,3 mg de fluor zilnic pe
dupå modul de administrare: cale generalå.
1. prenatalå; Suplimentarea, indiferent de metodå, se rapor-
2. înainte de vârsta ¿colarå; teazå la:
3. la ¿coalå ¿i numai în timpul ¿colii. – concentra¡ia din apa potabilå;
– cantitatea de apå potabilå consumatå în
1. Administrarea de fluor prenatal este beneficå medie pe zi;
în profilaxia cariei la copii, în special pentru denti¡ia – aportul mediu oferit prin alimente;
temporarå dar cele mai bune rezultate se ob¡in dacå – concentra¡ia din atmosferå, pentru zonele cu
este continuatå prin administrare de fluor la copil poluare fluoruratå.
cât mai curând dupå na¿tere. Pentru a fi eficace metodele de administrare ge-
2. Potrivit diferitelor studii se aratå cå efectele neralå trebuie:
carioprotective mari (circa 50-80%) s-au ob¡inut – så foloseascå faza I (amelogenezå ¿i mine-
dacå administrarea fluorului s-a început înainte de ralizare);
vârsta de 2 ani. – så se prelungeascå în faza a II-a (de maturare
Efectele cele mai bune s-au ob¡inut unde dozele preeruptivå);
de fluor au fost corelate cu concentra¡ia fluorului – så se prelungeascå chiar ¿i la începutul fazei
din apå ¿i cu vârsta copilului (HENON – 1977). a III-a (posteruptivå) când se completeazå
Studiile privind efectul administrårii fluorului maturarea superficialå a smal¡ului.
sub formå de tablete sau solu¡ii asupra din¡ilor per- Programul complet începe prin administrarea
manen¡i aratå o reducere importantå a cariilor mai zilnicå de fluor la femeia gravidå începând cu luna
ales dacå administrarea s-a fåcut de la na¿tere cel a IV-a de sarcinå ¿i pânå la na¿tere, se continuå
pu¡in 7 ani (între 39 ¿i 80%). administrarea la copil începând cât mai aproape
3. Administrarea tabletelor sau solu¡iilor cu de momentul na¿terii, zilnic, pânå la vârsta de 12-14
fluor în ¿coalå începând cu clasa I (6-7 ani), cu o ani, fårå întrerupere.
duratå de minimum 5 ani s-a dovedit cario- Administrarea numai în prima fazå (0-6 ani)
preventivå în medie de 30% (DRISCOL – 1978). sau numai în a II-a fazå (6-12 ani) reduce mult
Aceste cercetåri aratå fårå nici un dubiu cå eficacitatea cu perspectiva de a se pierde efectul
folosirea tabletelor sau solu¡iilor este eficientå în în timp.
prevenirea cariilor dentare atât la din¡ii temporari Dacå se respectå programul complet (cel pu¡in
cât ¿i la cei permanen¡i. de la 0 la 12 ani) în toate metodele se ob¡in rezul-
Dupå vârsta de 2 ani este de preferat så se tate egale.
administreze fluorul sub formå de tablete, copilul Diferen¡ele sunt doar în privin¡a costului, u¿u-
fiind instruit så le sugå seara, înainte de culcare, rin¡a de administrare ¿i posibilitå¡ile de abordare a
pentru a combina efectul general cu cel local unor colectivitå¡i cât mai mari.
asupra din¡ilor temporari.
Se folosesc tablete de fluor: Concaden; METODE DE FLUORIZARE LOCALÅ
Zymafluor; Law.
Cu o cantitate de fluor de: 0,25 mg; 0,50 mg; Fluorizarea localå se poate realiza profesional
0,75 mg; 1 mg dar ¿i personal.
158 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

Fluorizarea localå profesionalå se poate În ceea ce prive¿te eficien¡a acestora, s-a


realiza cu ajutorul solu¡iilor simple de NaF sau SnF, constatat cå, aplicate pe o perioadå mai mare de
solu¡iilor sau gelurilor cu un pH acid, pastelor timp ¿i prin aplicåri mai frecvente se ob¡ine o
profilactice cu fluor ¿i lacurilor cu fluor. reducere a inciden¡ei cariei între 30 ¿i 38%, fiind
Dintre solu¡iile cu fluor utilizate în fluorizarea la fel de eficiente ca ¿i solu¡iile ¿i gelurile fluoru-
profesionalå localå, se folosesc: rate.
a. Fluorura de sodiu 2% – ce este cea mai Aplica¡iile topice prin ionoforezå reprezintå cea
uzualå solu¡ie pentru aplica¡ii topice pe din¡ii cura¡i mai eficace metodå de prevenire prin aplica¡ii
(fårå placå bacterianå) de 2-4 ori pe an. topice de fluor prin faptul cå prin ac¡iunea curen-
b. Fluorura de staniu – este de 3 ori mai tului de joaså tensiune, ionul de fluor este for¡at
eficientå în scåderea solubilitå¡ii smal¡ului la acizii så påtrundå în cantitate mare ¿i la o adâncime mai
slabi comparativ cu solu¡ia de NaF. mare, inclusiv pe fe¡ele aproximale, în structura
Gelurile de fluor utilizate în fluorizarea localå smal¡ului.
profesionalå s-au ob¡inut prin adåugarea în solu¡ii În acest fel se aplicå solu¡iile de fluorurå de
a unor agen¡i de gelificare, cum ar fi metil, hidro- sodiu 1% sau de fluorortofosfat 1,4% în ¿ine sau
ximetil celulozå. în gutiere standard sau individuale, conectate la o
Din aceastå categorie fac parte gelul de fluoro- instala¡ie simplå cu baterii electrice, înså metoda
rtofosfat ce este u¿or de utilizat într-un confor- este costisitoare ¿i dificil de aplicat în colectivitå¡i.
mator individual, nu provoacå saliva¡ie sau sen- Fluorizarea localå personalå se realizeazå de
za¡ie de vomå pentru cå nu se råspânde¿te în cavi- cåtre pacient cu ajutorul pastelor de din¡i fluorurate
tatea bucalå ¿i are proprietå¡i tixotropice, adicå, ¿i cu aminofluoruri ¿i prin clåtiri bucale.
se transformå în solu¡ie sub ac¡iunea presiunii, Existå înså rezerve în ceea ce prive¿te folosirea
påtrunzând astfel în ¿an¡uri ¿i fosete. pastelor de din¡i cu con¡inut ridicat de fluor la copii
În cazul aplicårilor bianuale reducerea cariilor în cursul mineralizårii ¿i maturårii smal¡ului din¡ilor
este de 20-40%. permanen¡i, în special în zonele fårå deficit de
Alåturi de acesta, se mai utilizeazå ¿i gelul de fluor în apa potabilå, din cauza posibilitå¡ii de
fluorurå de aminå ce reduce solubilitatea smal¡ului apari¡ie a fluorozei.
¿i u¿ureazå prin proprietå¡ile lui tensioactive, În ceea ce prive¿te clåtirile bucale, acestea se
fixarea de fluor la suprafe¡ele dentare. realizeazå cu ajutorul unor:
Un astfel de gel este gelul ELMEX ce se aplicå – solu¡ii de NaF neutrale în concentra¡ii de la
o datå pe såptåmânå pe suprafe¡ele din¡ilor, cu 500 ppm la 3 000 ppm;
ajutorul unei canule adaptate la seringå, låsându- – solu¡ii acidulate de NaF;
se 2-3 minute în contact cu din¡ii, dupå care se – solu¡ii cu fluoruri de staniu, amoniu, fier,
realizeazå periajul. aluminiu.
Lacurile cu fluor au fost realizate pentru a re- Cercetåtorii care au testat mai multe solu¡ii cu
duce timpul de aplicare, pentru a simplifica tehnica fluor (TAVEL ¿i ERICSON–1965) au ajuns la
¿i pentru a cre¿te timpul de contact al fluorului cu concluzia cå se ob¡in rezultate pozitive cu oricare
suprafe¡ele din¡ilor. din aceste combina¡ii, eficacitatea depinzând de
Produsele cele mai cunoscute sunt: concentra¡ia în ion de fluor, ¿i timpul de contact
– DURAPHAT – ce con¡ine 2,26% F sub cu suprafe¡ele dentare.
formå de NaF, într-o solu¡ie alcoolicå de În general se ob¡ine o reducere de peste 30%
rå¿ini naturale, el aderând u¿or pe supra- în aplica¡ii zilnice timp de mai mul¡i ani, înså nu
fe¡ele umede ale din¡ilor; se recomandå la copii sub 5 ani care pot înghi¡i o
– ELMEX PROTECTOR – ce con¡ine cantitate din solu¡ie cu posibilitatea de supradozare
aminofluoruri încorporate într-un lac de a fluorului ingerat.
poliuretan autopolimerizabil; În tabelul urmåtor sunt reprezentate substan¡ele
– EPOZYLATE – ce este un lac protector de pe bazå de fluor care sunt utilizate pentru aplica¡ii
lungå duratå ¿i are încorporat monofluor profesionale sau la domiciliu.
disodic într-un lac de poliuretan auto-
polimerizabil.
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 – Tensiuni la nivelul ¡esuturilor dentare, care
dentinare ca un e¿ec al restaurårilor adezive, tre- pot antrena flexiuni ale cuspizilor, slåbirea
buie så eliminåm a priori printr-un diagnostic prismelor de smal¡ ¿i poate merge panå la
diferen¡ial toate celelalte cauze posibile, precum: fisuri sau fracturi.
fracturi, fisuri, leziuni carioase, parodontite apicale, – Pierderea adaptårii marginale cu apari¡ia
eroziuni cuneiforme, abrazii. unor hiatusuri ce favorizeazå percola¡ia mar-
De¿i mecanismele fiziopatologice de producere ginalå. Aceasta se manifestå clinic sub formå
a sensibilitå¡ii dentinare nu sunt complet elucidate, de sensibilitate postopeatorie, carii secun-
ipoteza hidrodinamica a lui Brannstrom este împår- dare marginale sau inflama¡ii pulpare.
tå¿itå de un numår foarte mare de studii recente – Contrac¡ii interne ale materialului de obtu-
(1,2). ra¡ie care poate produce fracturi in masa
Din punct de vedere clinic, manifestårile de compozitului.
sensibilitate post operatorie, dupå restauråri adezive, – Diminuarea rezisten¡ei mecanice a compo-
apar într-o rela¡ie evidentå cu pierderea etan¿eitå¡ii zitului.
marginale. Principalele cauze ale acestei sensibilitå¡i Posibilitå¡ile de prevenire constau în reducerea
pot fi grupate în umåtoarele patru grupe de cauze: efectelor nedorite ale contrac¡iei de polimerizare
1. Cauze legate de materialul de obtura¡ie pe baza urmåtoarelor proceduri:
compozit – Folosirea unui adeziv cu încårcåturå
În cazul compozitelor, principala cauzå care mineralå mare.
poate duce la apari¡ia sensibilitå¡ii postoperatorii – Aplicarea compozitului în straturi succesive
este contrac¡ia de polimerizare, care poate varia în func¡ie de configura¡ia cavitå¡ii
între 1.5-5% în volum (3,4). Contrac¡ia compozi- – Adoptarea tehnicii de obtura¡ie „sandwich“
telor poate avea urmatoarele efecte: 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 SCOP
Tratamentul cariei dentare este strict conservator Aceasta lucrare i¿i propune så prezinte
¿i vizeazå atât eliminarea leziunii propriu-zise, cât tratamentul leziunilor coronare întinse, atât
¿i a efectelor secundare ale acesteia asupra ¡esutu- restaurårile directe cu materiale adezive dar ¿i trata-
rilor din vecinåtate. mentele utilizate atunci când nu se mai pot aplica
Scopul final al acestui tratament este refacerea tehnici conservative ¿i este nevoie de restauråri
corectå a morfologiei coronare dentare astfel încât coronare prin ancoråri cu dispozitive radiculare,
så nu se producå suferin¡e ocluzo-articulare sau dupå tratamentul endodontic
în timp, suferin¡e ale organului pulpar, precum ¿i
recidiva de carie.

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


REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 165

MATERIAL ªI METODÅ dontic ¿i restaurare prin ancorare în canalul ra-


dicular pentru cre¿terea retentivitå¡ii (fig. 3).
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 3
Reparti¡ie lot dupå material de restaurare

Figura 1
Reparti¡ia lotului pe zone

Etiologia leziunilor coronare/grupe de vârstå


este prezentatå în fig. 2

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
Figura 2 3. Demineralizarea canalui cu acid fosforic
Etiologia leziunilor/grupe vârstå 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
Restaurårile s-au realizat cu materiale com- Corporation, Tokyo, Japan)
pozite, 8 cazuri, 4 au fost restaurate cu amalgam, 8. Reechilibrare ocluzala pentru indepartarea
iar 8 dintre cazuri au necesitat tratament endo- 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 reten¡ie prin ancorarea în canalul radicular
mari de substan¡å durå dentarå care produc dupå tratamentul endodontic.
contacte dentare nefunc¡ionale, cu conse- – În scopul realizårii unei interfe¡e flexibile
cin¡e grave pentru întreg aparatul dento- dinte/restaurare, compozitul de restaurare
maxilar. Aceste dezechilibre ocluzale gene- trebuie plasat de a¿a manierå încât contrac¡ia
reazå suprasolicitarea din¡ilor antrena¡i în de polimerizare så fie reduså la minim. În
proces ¿i influen¡eazå negativ func¡iona- felul acesta se evitâ formarea hiatusului mar-
litatea arcadelor dentare, a sistemului mus- ginal ¿i apari¡ia microinfiltra¡iilor marginale.
cular ¿i a ATM. – Aplicarea compozitului în straturi ¿i reali-
– Restaurarea se poate face prin tehnici zarea unor tåieturi în diagonalå reduce
directe, utlilizând materiale adezive sau prin factorul C ¿i deci, contrac¡ia de polimerizare.
utilizarea unor mijloace suplimentare de
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


glycemic control, those achieving intermediate
Oral Health and Glycemic Control and/or intermittent control experience far fewer
For the diabetic patient, tremendous impro- complications such as retinopathy, nephropathy,
vements in health and quality of life are the neuropathy, fatigue, weakness, memory loss,
rewards of maintaining life-long normoglycemia. cardiovascular disease, need for amputations, tooth
(1-2) The American Diabetes Association Stan- loss, and periodontal infection. (1-5,9-28) Using
dards of Medical Care (2006) recommend diabetic a proportional hazards model and stringent
patients strive to maintain the HbA1c <7, ideally controls of potential confounders, it has been
between 4 and 6. (3-8) While many diabetic 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 171

mortality in Pima Indians is elevated 3.2 fold (95% sessions total) were provided at no cost and 0.12%
CI 1.1-9.3) in those with severe periodontal chlorhexidine gluconate rinse (Peridex™, Zila
disease. (23) Pharmaceuticals) was given for twice daily, 30
Excellent glycemic control is achieved with second, oral rinsing. All treatment provided in this
strict regimens of diet, exercise, weight loss, protocol was delivered by the research dental
avoidance of infections, fastidious self-care, hygienist, and all periodontal evaluations were
avoidance of tobacco, medication adjustments, performed by a graduate periodontology resident
frequent medical attention, and self-monitoring of who was blinded to the subjects’ group assignment.
blood glucose levels using home glucometers. The weight and medical history of each par-
Emerging evidence suggests the reduction of ticipant was updated at each appointment to
periodontal inflammation may be one additional identify factors that might impact glycemic control
strategy in reducing HbA1c. (29-31) When a series within the six weeks preceding the serological and
of studies of various sizes were subjected to a periodontal data collection. These specific factors
systematic review and meta-analysis, periodontal included: weight gain or loss, infections, illnesses,
intervention reduced HbA1c by 0.66 in type 2 the use of antibiotics, steroids, or any other new
diabetic patients. (31) medications that are known to interfere with blood
For this pilot study, a small number of diabetic glucose control. All subjects were also interviewed
patients with elevated HbA1c were recruited. to gather information on exercise levels and
Because subjects with moderate and severe perio- frequency of glucose monitoring and medications.
dontitis were excluded, the use of antibiotics during HbA1c was measured at baseline, six months, and
this short-term intervention was avoided. Chlor- eight months following randomization and repre-
hexidine gluconate was the sole chemotherapeutic sented the primary endpoint in this investigation.
agents tested because it has been shown to be The study also evaluated the severity of perio-
effective in managing gingivitis. (32-35) dontal disease in subjects using several indices of
oral health at baseline, six months, and eight
METHODS AND MATERIALS months. Inflammation (GI), clinical attachment
loss (CAL), probing depth (PD), plaque index (PI),
With approval from the Oregon Health and and calculus index (CI) all were quantified. PI and
Science University Institutional Review Board, CI scores were quantified using indices in which
eligible subjects were recruited using flyers and the four smooth surfaces of all existing teeth are
advertisements in newspapers in the greater scored and a percentage of surfaces with plaque
Portland area. A screening oral examination, me- or calculus are recorded. The Löe and Silness GI36
dical history review, and blood sample to deter- (Table 2) was used to assess inflammation of the
mine HbA1c were carried out to confirm eligibility gingiva on the mesial, distal, buccal, and lingual
(see Table 1 for inclusion and exclusion criteria) surfaces of the Ramfjord index teeth (#3, 9, 12,
and to answer participant questions about the 19, 25, and 28).37
study. Fifty eligible, consenting subjects were The GI procedure consisted of inserting a
randomized (by flip of a coin) to either the minimal calibrated periodontal probe no more than 2 mm
therapy (MT) or frequent therapy (FT) groups. The into the gingival sulcus, starting just distal to the
treatment groups were balanced for gender only. midpoint of the buccal surface, then moving the
Following the pre-treatment assessment, all probe tip gently into the mesial interproximal area.
subjects were provided with oral home care CAL and PD were measured at six sites for the
instructions, oral prophylaxes including scaling, index teeth using the Michigan Probe™ calibrated
and root planing was limited to the inflamed in 2 mm increments. Because PD recordings can
periodontal pockets with clinical attachment loss. vary significantly according to positions of the
These services were provided in one appointment probe tip, all probing and recession measurements
which varied in time between 60 and 90 minutes. were completed and then repeated for a second
Control subjects were recalled for oral hygiene set of measurements. Where there was a difference
instructions and oral prophylaxes with scaling and between these two readings, the two numbers were
localized root planing at one six-month interval. averaged.
FT subjects were recalled for oral prophylaxes with In the FT group mouth rinse compliance was
localized scaling. Localized root planing and oral evaluated by questioning the participants and by
hygiene instruction every two months (four 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.

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
Table 2. subjects.
Gingival Index.36

RESULTS
ANALYTICAL AND STATISTICAL METHODS
The study enrolled 50 subjects who met the
Data from baseline, six month, and eight month inclusion/exclusion criteria at baseline and
follow-up evaluations were summarized for each randomized 25 to the control treatment group and
oral health variable by calculating means and 25 to the FT group. Two subjects passed-away
standard deviations. Significant differences in oral for reasons unrelated to the study. Six subjects were
health indices between the FT, enhanced oral withdrawn from the study due to violations in the
treatment regimen, and the control regimen over inclusion/exclusion criteria, such as smoking. Of
time were calculated by using the Student’s t-test the 42 remaining subjects who completed the
analysis for continuous data (PD, CAL) and the study, 15 had their diabetes medications changed
Mann-Whitney test for non-parametric data (PI, at the advice of their physicians. There were 27
CI, GI, and HbA1c). The main point of interest, subjects who did not have diabetic medication
the influence of dental treatment on the metabolic changes. No subjects needed to be omitted from
indicator, was analyzed using a mixed between the analysis because of significant changes in diet,
within subjects analysis of variance (ANOVA) to weight, or exercise habits.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 173

Figure 1 and Table 3 demonstrate the changes observed in subjects with HbA1c > 9, it must be
that were observed in the oral health variables. assumed the medication change influenced these
With the exception of CAL, all oral health results. In the HbA1c > 9 subjects with no medi-
measurements demonstrated significant (p<.05) cation change about half as much improvement
improvement in both the MT and FT subjects at in HbA1c was seen at six months. Mean reduc-
six months. FT subjects showed greater impro- tions of 0.58 (FT) and 0.64 (MT) were encouraging
vements in PI at eight months (FT 81% v. MT 74% but do not indicate “more periodontal therapy is
less plaque), PD (FT 17% v. MT 16% shallower better” as had been expected.
probing depths), and GI (FT 63% v. MT 57% less
gingival inflammation). MT subjects demonstrated DISCUSSION
more improvement in CI (FT 67% v. MT 79% less
calculus). As expected, the periodontal health of all
Tables 4 and 5 and Figures 2 and 3 show the subjects improved; the FT subjects demonstrated
changes observed in HbA1c over the course of greater improvements in PD, PI, and GI compared
the study. Because the groups were so small, we to MT subjects, and no changes in CAL occurred
can assert no statistically significant main effects because very few (n=3) baseline pocket depths
for either treatment group or time of examination. were greater than 3 mm. Increased levels of
Although the most dramatic HbA1c reductions calculus in the FT groups is certainly explained
(Table 5) of 1.38 (FT) and 1.10 (MT) were 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 are needed to determine what intensity and duration
HbA1c levels above 9.0 experienced a trend of periodontal therapy is needed to answer the
toward greater HbA1c reductions than those with question, particularly when the severity of
levels below 9.0 at baseline, regardless of the study periodontitis is mild. (31)
condition to which they were exposed. These sub- Other modest limitations of this study include
jects experienced 0.6 reduction in HbA1c, which failure to have a non-treatment control group,
is similar to other periodontal interventions of this failure to provide placebo rinse to the MT group,
nature. (38-40) However, because of the small measuring GI and CAL only on the six Ramfjord
samples sizes, the differences between groups did teeth (39) instead of the entire dentition, and
NOT reach statistical significance. At the eighth inherent difficulties blinding an examiner when
month follow-up, mean HbA1c in all groups gravi- chlorhexidine stain is present. As in all
tated toward return to baseline levels as has been universitybased studies, the results may not be as
seen in other periodontal and diabetes studies. generalizable to “real world patients” as would be
(30,4,42) the results from practice-based and community-
Sample size presented the major flaw in this based studies.
study and was exacerbated by the need to accom- With the limitations noted, a reduction of 0.6
modate statistically for 15 subjects (nine in the FT (or 6%) HbA1c should be considered clinically
and six in the MT groups) undergoing changes in desirable in a given patient with mild periodontal
their diabetes medications. In addition, as this study inflammation. As little as a 1% decrease in HbA1c
was being completed, results of a systematic review has been shown to reduce myocardial infarctions
of like studies indicate much larger samples sizes 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 of this effect and its long-term sequelae need
scale (medical, non-dental) studies in the US and additional documentation.
UK of intensive medical treatment regimens
resulted in an average HbA1c reduction of 1.86 CONCLUSION
(or approximately 19%). (1-2,10,21) These
reductions are comparable to periodontal Overall, modest improvements in HbA1c were
intervention studies of severe periodontitis patients detected with a trend towards FT being better than
which yield HbA1c reduction (up to 17.1%) when MT. Although this pilot trial was under-powered
using antibiotics with special populations more to detect small between-group differences, the
severely affected by periodontitis and diabetes, magnitude of our findings (0.6 mean improvement
such as Pima Indians and US Veterans. (23,30) in HbA1c) matches closely findings from the only
meta-analysis conducted on this topic to date.
Clearly, the modest, short-term improvement
Larger scale studies must be undertaken on
in metabolic control achieved with a group of
diabetic patients with periodontal problems.
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 CLINICAL SIGNIFICANCE
inflammatory and infectious oral diseases. While Preventive periodontal regimens for diabetic
it is likely practicing dentists and physicians are patients should be sufficiently intense and sustained
intuitively aware that alleviation of oral disease to eliminate periodontal inflammation and should
and the associated infection has a beneficial effect be closely coordinated with the patient’s overall
on metabolic control of diabetes, the magnitude 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 177

REFERENCES
1. Testa MA, Simonson DC – Health economic benefits and quality Torre MA, Shrestha B, Vargas CM – Improving the oral health of
of life during improved glycemic control in patients with type 2 Alaska natives. Am J Public Health. 2005; 95(5):769-73.
diabetes mellitus. JAMA. 1998; 280(17):1490-6. 25. Jones JA, Miller DR, Wehler CJ, Rich S, Krall E, Christiansen
2. UK Prospective Diabetes Study Group. Intensive blood-glucose CL, Rothendler JA, Garcia RI – Study design, recruitment, and
control with sulphonylureas or insulin compared with conventional baseline characteristics: the Department of Veterans Affairs Dental
treatment and risk of complications in patients with type 2 diabetes Diabetes Study. J Clin Periodontol. 2006 Oct 13;.[Epub ahead of
(UKPDS 33). Lancet. 1998; 352(9131):837-53. print].
3. American Diabetes Association. Standards of Medical Care in 26. Ainamo J, Lahtinen A, Uitto VJ – Rapid periodontal destruction
Diabetes-2006. Diabetes Care. 2006; 29(Suppl 1):S4-S42. in adult humans with poorly controlled diabetes: a report of two
4. The Diabetes Control and Complications Group. Retinopathy and cases. J Clin Periodontol. 1990; 17:22-8.
nephropathy in patients with type 1 diabetes four years after a trial 27. Shlossman M, Knowler WC, Pettitt D, Arevalo A, Genco RJ –
of intensive therapy. N Engl J Med. 2000; 342(6):381-9. Type II diabetes and periodontal disease (Abs). J Dent Res. 1987;
5. Reichard P, Nilsson BY, Rosenqvist U – The effect of long-term 66:256.
intensified insulin treatment on the development of microvascular 28. Saremi A, Nelson RG, Tulloch-Reid M, Hanson RL, Sievers
complications of diabetes mellitus. N Engl J Med. 1993; 329:304-9. ML, Taylor GW, Shlossman M, Bennett PH, Genco R, Knowler
6. Cohen MP – Non-enzymatic glycosylation: A central mechanism in WC – Periodontal disease and mortality in type 2 diabetes. Diabetes
diabetic microvasulopathy? J Diabet Complications. 1988; 2(4):214-7. Care. 2005; 28(1):27-32.
7. Fitzgibbons JF, Koler RD, Jones RT – Red cell age-related 29. Faria-Almeida R, Navarro A, Bascones A – Clinical and
changes of hemoglobins A1a+b and A1c in normal and diabetic metabolic changes after conventional treatment of type 2 diabetic
subjects. J Clin Invest. 1976; (58):820-4. patients with chronic periodontitis. J Periodontol. 2006; 77(4):591-8.
8. The Expert Committee on the Diagnosis and Classification of 30. Grossi SG, Skrepcinski FB, DeCaro T, Robertson DC, Ho AW,
Diabetes Mellitus. Report os the Expert Committee on the Dunford RG, Genco RJ – Treatment of periodontal disease in
Diagnosis and Classification of Diabetes Mellitus. Diab Care. 1998; diabetics reduces glycated hemoglobin. J Periodontol. 1997; 68:713-9.
21(S1):s5-s19. 31. Janket SJ, Wightman A, Baird AE, Van Dyke TE, Jones JA –
9. The Diabetes Control and Complications Group. Diabetes control Does periodontal treatment improve glycemic control in diabetic
and complications trial (DCCT): results of feasibility study. Diabetes patients? A meta-analysis of intervention studies. J Dent Res. 2005;
Care. 1987; 10:1-19. 84(12):1154-19.
10. The Diabetes Control and Complications Trial Research Group. The 32. Lindhe J, Nyman S – Long-term maintenance of patients treated for
effect of intensivetreatment of diabetes on the development and advanced periodontal disease. J Clin Periodontol. 1984; 11:504-14.
progression of long-term complications in insulin-dependent diabetes 33. Wennstrom J, Lindhe J – The effect of mouthrinses on
mellitus. N Engl J Med. 1993; 329:977-86. parameters characterizing human periodontal disease. J Clin
11. Tervonen T, Knuuttila M – Relation of diabetes control to Periodontol. 1986; 13:86-93.
periodontal pocketing and alveolar bone level. Oral Surg. 1986; 34. Schaeken MJ, Keltjens HM, Van der Hoeven JS – Effects of
61:346-9. fluoride and chlorhexidine on the microflora of dental root surfaces
12. Emrich LJ, Schlossman M, Genco RJ – Periodontal disease in and progression of root-surface caries. J Dent Res. 1991; 70:150-3.
non-insulin dependent diabetes mellitus. J Periodontol. 1991; 35. Lang NP, Grec MC – Chlorhexidine digluconate - an agent for
62:123-30. chemical plaque control and prevention of gingival inflammation. J
13. Hugoson A, Thorstennson H, Falk J, Kuylenstierna J – Periodontal Res. 1986; suppl:74-89.
Periodontal conditions in insulin dependent diabetes. J Clin 36. Loe H, Silness J – Periodontal disease in pregnancy. I - Prevalence
Periodontol. 1989; 16:215-23. and severity. Acta Odont Scand. 1963; 21:533-51.
14. Safkan-Seppala B, Ainamo J – Periodontal conditions in insulin 37. Ramfjord, SP – Indices for prevalence and incidence of periodontal
dependent diabetes mellitus. J Clin Periodontol. 1992; 19:24-9.
disease. J Peridontol. 1959; 30:51-9.
15. Tervonen T, Oliver R – Long-term control of diabetes mellitus and
38. Iwamoto Y, Nishimura F, Nakagawa M, Sugimoto H, Shikata K,
periodontitis. J Clin Periodontol. 1993; 20:431-5.
Makino H, Fukuda T, Tsuji T, Iwamoto M, Murayama Y – The
16. Harrison R, Bowen WH – Periodontal health, dental caries, and
effect of antimicrobial periodontal treatment on circulating tumor
metabolic control in insulin-dependent diabetic children and
necrosis factor-alpha and glycated hemoglobin level in patients with
adolescents. Ped Dent. 1987; 9:283-6.
type 2 diabetes. J Periodontol. 2001 Jun; 72(6):774-8.
17. Gislen G, Nilsson KO, Matsson L – Gingival inflammation in
39. Stewart JE, Wager KA, Friedlander AH, Zadeh HH – The effect
diabetic children related to degree of metabolic control. Acta
of periodontal treatment on glycemic control in patients with type 2
Odontologica Scand. 1980; 38:241-6.
diabetes mellitus. J Clin Periodontol. 2001 Apr; 28(4):306-10.
18. Cohen DW, Friedman LA, Shapiro J, Kyle GC, Franklin S –
40. Seppala B, Seppala M, Ainamo J – A longitudinal study on
Diabetes mellitus and periodontal disease: Two-year longitudinal
insulin-dependent diabetes mellitus and periodontal disease. J Clin
observations, Part I. J Periodontol. 1970; 41:709-12.
Periodontol 1993; 20:161-5.
19. National Institute for Dental Research. Oral health of United States
41. Miller LS, Manwell MA, Newbold D, Reding ME – The
Adults. The National Survey of Oral Health in U.S. Employed Adults
relationship between reduction in periodontal inflammation and
and Senior: 1985-1986 National Findings. Bethesda, MD, U.S.
diabetes control: A report of 9 cases. J Periodontal. 1992; 63:843-8.
Govt. Printing Office, 1987 (DHEW NIH publ. no. 87-2868).
20. Tervonen T, Karjalainen K, Knuuttila M, Huumonen S – 42. Sastrowijoto SH, van der Velden U, van Steenbergen TJM,
Alveolar bone loss in type 1 diabetic subjects. J Clin Periodontol. Hillemans, P, Hart AAM, de Graaff J, Abraham-Inpijn L –
2000 Aug;27(8):567-1. Improved metabolic control, clinical periodontal status and
21. UK Prospective Diabetes Study Group. Effect of intensive blood- subgingival microbiology in insulin-dependent diabetes mellitus: a
glucose control with metformin on complications in patients with type prospective study. J Clin Periodontol. 1990; 17:233-242.
2 diabetes (UKPDS 34). Lancet. 1998; 352(9131):654-65. 43. Beck JD, Caplan DJ, Preisser JS, Moss K – Reducing the bias of
22. Finestone AJ, Boorujy SR – Diabetes mellitus and periodontal probing depth and attachment level estimates using random partial-
disease. Diabetes. 1967; 16:336-40. mouth recording. Community Dent Oral Epi. 2006; 34(1):1-10.
23. Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad MF, 44. Fisher M – Prevention of macrovascular complications. European
Genco RJ, Knowler WC – Periodontal disease and NIDDM in Heart J Supplements. 2003; 5 (Suppl B):B21-B26.
Pima Indians. Diabetes Care. 1990; 13(8):836-40. 45. Schellhase KG, Koepsell TD, Weiss NS – Glycemic control and
24. Campbell D, Pollick HF, Lituri KM, Horowitz AM, Brown J, the risk of multiple microvascular diabetic complications. Fam Med.
Janssen JA, Yoder K, Garcia RI, Deinard A, Hemphill S, de la 2005; 37(2):125-30.
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


one consists of taking the impression from a
Alginate-based impression materials have been
master cast (usually made of acrylic or stainless
used in dentistry since 1947. (1) Originally used
steel) and measuring the discrepancy between the
as precision impression materials in fixed
prosthodontics1 they are more commonly used for latter and the obtained cast. Although the
the initial impression to obtain a preliminary model measurement of a single die can be performed with
used for diagnostic purposes, treatment planning, greater accuracy, (6) the distance between various
and for the fabrication of a provisional prosthesis dies is an important variable that should be
or custom tray. The dimensional stability of considered in order to perform the test in clinically
alginate-based impression materials has been relevant conditions. Shrinkage occurring in the
studied since the 1970s.2 In particular, the palatal zone of the impression might reduce the
phenomena of syneresis has received a great distance between the teeth of different semi-arches.
amount of attention. (3-47) Syneresis is intended The aim of this study was to verify the
as the expression of fluid onto the surface of gel dimensional stability of five different alginate-
structures. (48) The clinical consequence is the
based impression materials stored in a 100%
shrinkage of the material due to the loss of water
relative humidity environment after different
by evaporation. (48) The actual ISO 156349 states
the requirements for the alginate-based impression periods of time. The null hypotheses tested were:
materials, however, no information is provided on (1) there is no difference in dimensional stability
the methodological test valid for the evaluation of among different alginate-based materials and (2)
their dimensional stability. In recent years different the dimensional stability is not affected by storage
tests have been developed for analyzing this time.

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


REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 179

METHODS AND MATERIALS A total of 200 stainless steel standard non-


perforated rimlock trays were prepared for the
With the aim to reproduce the clinical conditions a experiment. In each tray three holes were drilled
new stainless steel testing device (TST) was developed with a numerical control machine (accuracy ±0.01
(Figures 1 and 2). The TST consists of three parts: the mm). Each tray was measured, and a performance
base, the master model, and the carrier. test was rendered to ensure a full engagement.
The base is a quadrangular block on which three Five alginates were selected:
pins are entirely engaged into three holes on the • CA 37 (Cavex, Haarlem, Nederland)
stainless steel standard tray. The device may be • Jeltrate (Dentsply Caulk, Milford, DE, USA)
assembled and dissembled with precision by • Jeltrate Plus (Dentsply Latin America, Rio
means of an accuracy engagement feature. On the de Janeiro, Brazil)
base, four studs allow the master model to slide. • Hydrogum 5 (Zhermack Spa, Badia
The master model consists in a quadrangular plate Polesine, Italy)
to which four cylinders are welded. The head of • Alginoplast (Heraeus Kulzer, Hanau, Germany)
each cylinder was well-rounded and a truncated The alginate powder was stored for three days at
cone with a global tapered shape of 6° was 23±1°C and 50±10% relative humidity in a
obtained to simulate a clinical die. The lower temperature controlled-room. All the procedures
corner of the truncated cone was considered to be were carried out in the same conditions. Four different
the finish line of the die. An acrylic resin model storage times (0, 24, 72 and 120 hours) were tested
was prepared and fixed on the plate allowing the by taking ten impressions for each period of time. A
exposure of the head of the cylinder to simulate total of 20 groups were obtained (Table 1). The master
an upper arch with four dies in FDI World Dental model was used as a control group.
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 IMPRESSION PROCEDURE
of the dies and the tray, four stainless steel spacers The tray was locked on the base, and an aerosol
were machined and positioned on the studs of the universal adhesive (Fix Adhesive, Dentsply DeTrey
base. The carrier is a quadrangular plate on which GmbH, Konstanz, Germany) was sprayed on the
four trapezoidal grooves are realized. The grooves tray and left to dry for 5 minutes according to Leung
are aimed at maintaining the cast obtained from et al. (9) A quantity of 30 g of powder was weighed
the impression in a fixed and stable position. (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
Figure 1 with a rotation sense inverted every 5 seconds.
The master model mounted on the base. 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
Figure 2 minutes before, according to Schleier et al. (6) The
The acrylic master model containing four stainless steel dies. 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 CAST FORMATION
immediately introduced in a ±3500 mL plastic
storage box in which another paper sheet When the predetermined storage time had
(weight±10 g approximately) wetted with 60 g of elapsed, the impression was removed from the
distilled water had been inserted 10 minutes plastic bag and locked again on the TST base.
previously, (6) then stored at 23±1°C for the time Then 150 g of Type III gypsum powder (Elite
indicated in Table 1 prior to pouring with gypsum. Model Type III) was mixed with 75 g of distilled
For the storage time indicated as “0 hours”, the water using an electronic vacuum mixing machine
casts were poured immediately after the removal (Twister Evolution) at 250 rpm for 30 seconds and
from the master model. poured into the impression. The TST carrier was
Table 1.
Groups of tested materials and storage time in hours (h).
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 181

then placed and maintained in position for the RESULTS


setting time indicated by the gypsum manu-
facturer. After final setting of the gypsum, the The results of the statistical analysis are shown
carrier was gently removed and the cast was care- in Tables 2 and 3. In order to simplify the inter-
fully separated from the impression. The material pretation of the achieved results, a summary is
was stored for 48 hours at 23°C and 50% relative provided in Table 4.
humidity prior to measuring. 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
MEASUREMENT AND STATISTICAL ANALYSIS were poured immediately, all the tested alginates
The carrier was compiled in a HB 350 measuring were able to reproduce the master model without
machine (Starrett Sigma, North Yorkshire, England), any statistically significant difference (p > 0.05)
and the posterior corner was set parallel to the axis in all the tested measurements. After 24 hours of
movement of the machine. The cast was placed storage, only Alginoplast and Hydrogum 5 fit all
on it and maintained in position by means of the the measurements (p > 0.05).
four reference grooves. The only casts able to comply with the control
Six measurements (mm) were recorded for each group in all the measurements after 72 and 120
model (Figure 3): hours were obtained from Hydrogum 5 (p > 0.05).
• D1.3: diameter of die 1.3
• D2.3: diameter of die 2.3 DISCUSSION
• d3: internal distance between dies 1.3 and
2.3 The five alginates tested in this study yielded
• D1.7: diameter of die 1.7 different results, showing the dimensional stability
• D2.7: diameter of die 2.7 of the impression is directly related to the type of
• d7: internal distance between dies 1.7 and material used. Thus, the first null hypothesis, ”there
2.7 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,
Figure 3 little information is provided in manufacturer
Measurements analyzed in the master model and in the instruction sheets and there is no recent literature
obtained casts on the influence of individual chemical
components on the dimensional stability of these
All measurements were carried out three times, impression materials.
1 mm below the finish line of each die. Water evaporation may induce the shrinkage
The results were statistically analyzed with SPSS of hydrocolloids materials, (48) and the powder/
12.0 (SPSS, Inc., Chicago, IL, USA). The Levene water mixing ratio may have some influence on
Test was used to verify the homogeneity of varian- the dimensional stability of the impression. In the
ces, followed by one way analysis of variance present study the same amount of alginate powder
(ANOVA), and a Tukey Test for post-hoc com- was used for each impression (30 g). Hydrogum
parison between the groups. The level of signi- 5, the most stable among the five tested materials,
ficance was set at p<0.05. 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 them become smaller with time. These findings
powder/water ratio on the dimensional stability. are in agreement with Schleier et al. (6) and may
This is probably more related to the ability of the be related to the shrinkage of the mass due to
material to keep water inside the mass than to the syneresis. The widening of the dies could be
global amount of water present in each impression. explained as follows: the master model reproduced
By analyzing the measurements for each an upper jaw with the dies positioned on the arch.
alginate material it was shown the dimensional During the impression procedure the arch leaves
stability of the tested alginate impression materials a semicircular void in the impression and the
changes with storage time. This warrants the material is mainly pushed in the palatal and
rejection of the second null hypothesis, “the vestibular zone of the impression tray. As the result
dimensional stability is not affected by storage of the shrinkage, the impression material around
time.” Dies became wider and distances between the die was subjected to centrifugal tensile forces,
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 185

so its diameter was increased (dies became wider). CONCLUSION


Furthermore, as usually occurs in clinical
situations, the greatest amount of alginate was Within the limits of this study, the following
visibly located in the palatal zone and the conclusions can be drawn:
shrinkage of this area may explain why the • The dimensional stability of the alginate
distance between dies decreased. impression was influenced by either the type
Some limitations of this study can be identified. of alginate or the storage time prior to pouring.
• Impressions recorded with CA 37 (Cavex),
First, the acrylic master model used to take the
Jeltrate (Dentsply Caulk), and Jeltrate Plus
impressions was prepared with the least number
(Dentsply Latin America) should be poured
of undercuts, to prevent the distortion of the
immediately.
material during the removal of the impression. In
• The impressions recorded with Alginoplast
clinical situations the impression is usually less
(Heraeus Kulzer) can be poured after 24
easy to remove from the patient’s mouth and the hours if correctly stored.
material could be more subjected to distortion. • The impressions recorded with Hydrogum
Second, the impressions were not subjected to 5 (Zhermack) can be poured after five days
disinfection procedures. However, if a proper if correctly stored.
decontamination protocol is followed, the influ-
ence of disinfection procedures on dimensional
stability is not clinically relevant. (4,56) Taylor et CLINICAL SIGNIFICANCE
al.4 found in some cases disinfected impressions When alginate materials are used, an immediate
can even have an overall improvement in pouring of the cast is still recommended. However,
dimensional accuracy. One hypothesis advanced the results suggest pouring may be delayed, pro-
by the investigators to account for this vided a stable alginate is used and the impression
improvement is the initial syneresis may be is correctly stored.
counteracted by imbibition during disinfection.

REFERENCES
1. Hansson O, Eklund J – A historical review of hydrocolloids and an 11. Leung KC, Chow TW, Woo CW, Clark RK – Tensile, shear and
investigation of the dimensional accuracy of the new alginates for cleavage bond strengths of alginate adhesive. J Dent 1998;26:617-22.
crown and bridge impressions when using stock trays. Swed Dent J 12. Johnson GH, Chellis KD, Gordon GE, Lepe X – Dimensional
1984;8:81-95. stability and detail reproduction of irreversible hydrocolloid and
2. Sawyer HF, Sandrik JL, Neiman R – Accuracy of casts produced elastomeric impressions disinfected by immersion. J Prosthet Dent
from alginate and hydrocolloid impression materials. J Am Dent 1998;79:446-53.
Assoc 1976;93:806-8. 13. Saito S, Ichimaru T, Araki Y – Factors affecting dimensional
3. Frank RP, Thielke SM, Johnson GH – The influence of tray type instability of alginate impressions during immersion in the fixing and
and other variables on the palatal depth of casts made from disinfectant solutions. Dent Mater J 1998;17:294-300.
irreversible hydrocolloid impressions. J Prosthet Dent 2002;87:15-22. 14. Haywood VB, Powe A – Using double-poured alginate impressions
4. Taylor RL, Wright PS, Maryan C – Disinfection procedures: their to fabricate bleaching trays. Oper Dent 1998;23:128-31.
effect on the dimensional accuracy and surface quality of irreversible 15. Eriksson A, Ockert-Eriksson G, Lockowandt P – Accuracy of
hydrocolloid impression materials and gypsum casts. Dent Mater irreversible hydrocolloids (alginates) for fixed prosthodontics. A
2002;18:103-10. comparison between irreversible hydrocolloid, reversible hydrocolloid,
5. Bayindir F, Yanikoglu N, Duymus Z – Thermal and pH changes, and addition silicone for use in the syringe-tray technique. Eur J Oral
and dimensional stability in irreversible hydrocolloid impression Sci 1998;106:651-60.
material during setting. Dent Mater J 2002;21:200-9. 16. al-Omari WM, Jones JC, Wood DJ – The effect of disinfecting
6. Schleier PE, Gardner FM, Nelson SK, Pashley DH – The effect alginate and addition cured silicone rubber impression materials on
of storage time on the accuracy and dimensional stability of
the physical properties of impressions and resultant casts. Eur J
reversible hydrocolloid impression material. J Prosthet Dent
Prosthodont Restor Dent 1998;6:103-10.
2001;86:244-50.
17. Hondrum SO, Fernandez R Jr – Effects of long-term storage on
7. Boden J, Likeman P, Clark R – Some effects of disinfecting
solutions on the properties of alginate impression material and properties of an alginate impression material. J Prosthet Dent
dental stone. Eur J Prosthodont Restor Dent 2001;9:131-5. 1997;77:601-6.
8. Nishi Y, Tsuru K, Kishita C, Hamano T, Kawahata N, Nagaoka 18. Shigeto N, Yamada Y, Iwanaga H, Subianto A, Hamada T –
E – Impression pressures against teeth in a partially edentulous Setting properties of alginate impression materials in dynamic
model with a mobile tooth: influence of impression tray design. J viscoelasticity. J Oral Rehabil 1997;24:761-5.
Oral Rehabil 2000;27:380-6. 19. Poulos JG, Antonoff LR – Disinfection of impressions. Methods
9. Leung KC, Chow TW, Woo EC, Clark RK – Effect of adhesive and effects on accuracy. NY State Dent J 1997;63:34-6.
drying time on the bond strength of irreversible hydrocolloid to 20. Federick DR, Caputo A – Comparing the accuracy of reversible
stainless steel. J Prosthet Dent 1999;81:586-90. hydrocolloid and elastomeric impression materials. J Am Dent Assoc
10. Inoue K, Song YX, Fujii K, Kadokawa A, Kanie T – Consistency 1997;128:183-8.
of alginate impression materials and their evaluation. J Oral Rehabil 21. Schwartz RS, Hensley DH, Bradley DV Jr – Immersion
1999;26:203-7. 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 39. Lewinstein I, Craig RG – Accuracy of impression materials measured
1996;9:217-22. with a vertical height gauge. J Oral Rehabil 1990;17:303-10.
22. Hutchings ML, Vandewalle KS, Schwartz RS, Charlton DG – 40. Peutzfeldt A, Asmussen E – Accuracy of alginate and elastomeric
Immersion disinfection of irreversible hydrocolloid impressions in pH- impression materials. Scand J Dent Res 1989;97:375-9.
adjusted sodium hypochlorite. Part 2: Effect on gypsum casts. Int J 41. Peutzfeldt A, Asmussen E – Effect of disinfecting solutions on
Prosthodont 1996;9:223-9. accuracy of alginate and elastomeric impressions. Scand J Dent Res
23. Cohen BI, Pagnillo M, Deutsch AS, Musikant BL – Dimensional 1989;97:470-5.
accuracy of three different alginate impression materials. J 42. Jones ML, Newcombe RG, Barry G, Bellis H, Bottomley J – A
Prosthodont 1995;4:195-9. Reflex Plotter investigation into the dimensional stability of alginate
24. Anastassiadou V, Dolopoulou V, Kaloyannides A – The impressions following disinfection by varying regimes employing 2.2
relation between thermal and pH changes in alginate impression per cent glutaraldehyde. Br J Orthod 1988;15:185-92.
materials. Dent Mater 1995;11:182-5. 43. Durr DP, Novak EV – Dimensional stability of alginate impressions
25. Anastassiadou V, Dolopoulou V, Kaloyannides A – immersed in disinfecting solutions. ASDC J Dent Child 1987;54:45-8.
Relationship between pH changes and dimensional stability in 44. Mendez AJ – The influence of impression trays on the accuracy of
irreversible hydrocolloid impression material during setting. Int J stone casts poured from irreversible hydrocolloid impressions. J
Prosthodont 1995;8:535-40. Prosthet Dent 1985;54:383-8.
26. Vandewalle KS, Charlton DG, Schwartz RS, Reagan SE, 45. Dahl BL, Dymbe B, Valderhaug J – Bonding properties and
Koeppen RG – Immersion disinfection of irreversible hydrocolloid dimensional stability of hydrocolloid impression systems in fixed
impressions with sodium hypochlorite. Part II: Effect on gypsum. Int prosthodontics. J Prosthet Dent 1985;53:796-800.
J Prosthodont 1994;7:315-22. 46. Bergman B, Bergman M, Olsson S – Alginate impression
27. Schwartz RS, Bradley DV Jr, Hilton TJ, Kruse SK – Immersion materials, dimensional stability and surface detail sharpness
disinfection of irreversible hydrocolloid impressions. Part 1: following treatment with disinfectant solutions. Swed Dent J
Microbiology. Int J Prosthodont 1994;7:418-23. 1985;9:255-62.
28. Hilton TJ, Schwartz RS, Bradley DV Jr – Immersion disinfection 47. Miller MW – Syneresis in alginate impression materials. Br Dent J
of irreversible hydrocolloid impressions. Part 2: Effects on gypsum 1975;139:425-30.
casts. Int J Prosthodont 1994;7:424-33. 48. Anusavice KJ – Phillips’ Science of Dental Materials, 11th Edition.
29. Beyerle MP, Hensley DM, Bradley DV Jr., Schwartz RS, Hilton Saunders, Elsevier Science 2003;206,234.
TJ – Immersion disinfection of irreversible hydrocolloid impressions 49. International Organization for Standardization. ISO 1563:1990 -
with sodium hypochlorite. Part I: Microbiology. Int J Prosthodont Dental Alginate Impression Material.
1994;7:234-8. 50. Hiraguchi H, Nakagawa H, Wakashima M, Miyanaga K,
30. Tan HK, Wolfaardt JF, Hooper PM, Busby B – Effects of Sakaguchi S, Nishiyama M – Effect of storage period of alginate
disinfecting irreversible hydrocolloid impressions on the resultant impressions following spray with disinfectant solutions on the
gypsum casts: Part I–Surface quality. J Prosthet Dent 1993;69:250- dimensional accuracy and deformation of stone models. Dent Mater
7. J 2005;24:36-42.
31. Tan HK, Hooper PM, Buttar IA, Wolfaardt JF – Effects of 51. Jagger DC, Al Jabra O, Harrison A, Vowles RW, McNally L –
disinfecting irreversible hydrocolloid impressions on the resultant The effect of a range of disinfectants on the dimensional accuracy of
gypsum casts: Part III—Dimensional changes. J Prosthet Dent some impression materials. Eur J Prosthodont Restor Dent
1993;70:532-7. 2004;12:154-60.
32. Ramer MS, Gerhardt DE, McNally K – Accuracy of irreversible 52. Hiraguchi H, Nakagawa H, Uchida H, Tanabe N – Effect of
hydrocolloid impression material mixed with disinfectant solutions. J rinsing alginate impressions using acidic electrolyzed water on
Prosthodont 1993;2:156-8. dimensional change and deformation of stone models. Dent Mater J
33. Peters MC – Accuracy and dimensional stability of a combined 2003;22:494-506.
hydrocolloid impression system. J Prosthet Dent 1992;67:873-8. 53. Smith SJ, McCord JF, Macfarlane TV – Factors that affect the
34. Touyz LZ, Rosen M – Disinfection of alginate impression material adhesion of two irreversible hydrocolloid materials to two custom
using disinfectants as mixing and soak solutions. J Dent tray materials. J Prosthet Dent 2002;88:423-30.
1991;19:255-7. 54. Brosky ME, Pesun IJ, Lowder PD, Delong R, Hodges JS –
35. Rosen M, Touyz LZ – Influence of mixing disinfectant solutions into Laser digitization of casts to determine the effect of tray selection
alginate on working time and accuracy. J Dent 1991;19:186-8. and cast formation technique on accuracy. J Prosthet Dent
36. Jones ML, Newcombe RG, Bellis H, Bottomley J – The 2002;87:204-9.
dimensional stability of self-disinfecting alginate impressions compared 55. Anusavice KJ – Phillips’ Science of Dental Materials, 11th Edition.
to various immersion regimes. Angle Orthod 1990;60:123-8. Saunders, Elsevier Science 2003;243.
37. Ralph WJ, Gin SS, Cheadle DA, Harcourt JK – The effects of 56. Lu JX, Zhang FM, Chen YM, Qian M – [The effect of disinfection
disinfectants on the dimensional stability of alginate impression on dimension stability of impressions]. Shanghai Kou Qiang Yi Xue
materials. Aust Dent J 1990;35:514-7. 2004;13:290-2.
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
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,


sau o singurå radacinå prin unirea celor trei.
Extrac¡ia, consideratå o interven¡ie chirurgicalå Uneori, din corpul radicular principal se deta-
de necesitate este normal så fie precedatå de un ¿eazå lateral mici rådåcini accesorii. Forma rådå-
examen general ¿i local minu¡ios, care så ofere cinilor este neregulatå, cu curburi variabile ¿i
date precise asupra modului în care va fi efectuat por¡iuni apexiene efilate.
actul operator ¿i condus ulterior tratamentul post-
extractional.
Al treilea molar se mai nume¿te ¿i „masea de PACIENTI ªI METODE
minte“, iar ¿tiin¡ific „Dens sapientiae“ sau „Dens Am realizat un studiu pe 320 pacien¡i situa¡i ca
serotinus“ ¿i prezintå o varietate extrem de mare vârstå în intervalul 18-55 ani, deci cu o medie de
de forme atât ale coroanei, cât ¿i ale radåcinilor vârstå de 36,5 ani, atât de sex feminin (224), cât
(tabelul 1). ¿i masculin (96), domicilia¡i în mediul urban ¿i
Molarul superior are trei rådåcini care pot fi rural. Aceastå statisticå nu vizeazå indica¡iile de
fuzionate complet sau par¡ial, astfel încât apare ca 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 chirurgicale, a scåzut riscul de infec¡ie cu 70% ¿i


unor evaluåri gre¿ite a situa¡iei clinice. Studiul a a facilitat procesul de regenerare tisularå cu 68%
fost fåcut pe durata a doi ani de zile din cazuistica fa¡å de grupul de control. Eludrilul stimulând
Clinicii Alexa Dentistry din Bucure¿ti. Studiul in refacerea mucoasei bucale prin multiplicarea
vivo s-a desfå¿urat pe douå grupe de pacien¡i: 50% fibrobla¿tilor ¿i diferen¡ierea Keratinocitelor
dintre ei (112 femei ¿i 48 bårba¡i) au folosit Eludril epiteliale, având astfel ac¡iune cicatrizantå.
¿i restul de 50% nu, fiind grupul de control. Ac¡iunea analgezicå postchirurgicalå a fost
Înainte ¿i dupå efectuarea extrac¡iei pacien¡ii prezentå la 96% dintre pacien¡i, Eludrilul având ¿i
inclu¿i în studiu (50% dintre ei) au fost ruga¡i så- o ac¡iune rezidualå foarte bunå – råmâne în
¿i clåteascå u¿or gura, fårå for¡å cu solu¡ii reci de cavitatea oralå cel pu¡in 30% la 8 ore de la clåtire
Eludril (clorhexidina 0,10% + clorbutanol 0,50%), (figura 1).
peste alveola aplicându-se un tampon de comprese Pacien¡ii au fost înregistra¡i la fiecare orå,
sterile, u¿or compresiv, urmând ca de a doua zi så pentru 8 ore de la extrac¡ie cu o scarå între:
înceapå a se spåla pe din¡i ¿i a se clåti u¿or cu • 0 = nu existå durere
Eludril diluat în propor¡ie de 1/3, aplicat de douå • 10 = durere medie
ori pe zi timp de un minut pe suprafa¡a extrac¡iei. • 15 = durere intolerabilå.
Pacien¡ii din grupul de control dupå extrac¡ie, au În figura 1 apare durerea în timpul primelor
primit doar indica¡iile postextractionale obi¿nuite. ore de la extrac¿ie. La 2 ¿i 4 ore dupå extrac¡ie
diferen¡a este marcantå.
CONCLUZII De¿i este eficientå asupra microorganismelor gram
negative ¿i gram pozitive, respectiv asupra levurilor,
În chirurgia oralå clorhexidina este utilizatå nu clorhexidina nu determinå dismicrobisme, påstrând
doar pentru calitå¡ile sale bacteriostatice ¿i echilibrul în microflora normalå a cavitå¡ii bucale.
bactericide, ci ¿i datoritå beneficiilor oferite în Ac¡iunea antiinflamatorie a clorhexidinei se
vindecarea plågilor. Astfel, solu¡ia de Eludril datoreazå ¿i efectului de curå¡are al mucoasei prin
folositå înainte ¿i dupå efectuarea interven¡iei eliminarea resturilor alimentare (vezi figura 2).

Figura 1

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
Figura 2 capului ¿i gâtului ¿i de anatomie oralå“ Editura Cerma,1993, pag.
Pacient care a folosit Eludril dupå extrac¡ii 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


Diagnosis
Although rare, the epithelial lining of an
odontogenic cyst may undergo malignant trans- A 55-year-old man presented complaining of a
formation. The incidence of carcinomas arising swelling in the right mandibular molar region. The
in odontogenic cysts was reported to be approxi- dental history revealed he had his right mandibular
mately 1-2/1000. (1) The pathogenesis is second premolar extracted two months earlier. A
painless swelling in the extraction area was noted
unknown, but long-standing inflammation and
by the patient four weeks after the extraction. He
continuous intracystic pressure were suggested as
reported a slight paraesthesia in the right lip.
possible causative factors. (2)
Extraoral examination revealed a slight swel-
Differential diagnosis of odontogenic cyst and
ling on the right mandibular region. Buccal expan-
malignant tumor arising in the cyst may be difficult
sion of the alveolar ridge posterior to the right
due to the nonspecific clinical and radiological mandibular first premolar was observed on intra-
presentation. (2) The definitive diagnosis must be oral examination. The mucosa covering the
made by histological examination. (3,4) alveolar ridge, floor of the mouth, and the buccal
Among the odontogenic cysts, malignant trans- vestibule was intact with no ulceration.
formation of the keratocyst and dentigerous cyst is The panoramic radiography showed a wellde-
high. (2,5) Although squamous cell carcinoma fined radiolucent lesion extending from the right
(SCC) arising in various developmental and canine to the angle of the mandible measuring 6.5
inflammatory odontogenic cysts has been well x 3 cm (Figure 1). There was no cervical lympha-
established, to the best of the authors’ knowledge, denopathy.
there has been only four reports in the English Because of the large size of the lesion,
literature on the development of SCC from residual marsupialisation was performed and the specimen
cysts. (4,6-8) This report presents an additional case was submitted for microscopic examination.
of SCC arising from a mandibular residual cyst. Histopathologic examination showed a full

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 189


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

The thin mandible was fractured in the corpus


region during the enucleation process and had to
be stabilized by intermaxillary fixation. The
specimen was then sent for histopathological
examination. This time the lesion was reported to
be SCC (Figure 3).

Figure 1
Panoramic radiograph demonstrating a unilocular
radiolucency extending from the right premolar teeth to
the angle of the mandible.

thickness of the epithelium was composed of large


squamous cells. Loss of the normal cell polarity
and maturation was noted. Abnormal mitotic
figures could be seen over the basal layer of the
epithelium. There was no invasion of the basal
layer of the epithelium (Figure 2). In the light of
these histological features a diagnosis of residual Figure 3
cyst with dysplastic features in the lining Histopathology of the resection specimen revealed
SCC (HE x100).
epithelium was established.

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
Figure 2
High power appearance of the cyst epithelium showed
Neoplastic transformation in the epithelial lining
nuclear atypia and irregularity in maturation and of an odontogenic cyst is a rare but a well-described
organization (HE x400). phenomenon. The neoplasms associated with
epithelial lining of the cyst include ameloblastoma,
TREATMENT SCC, and mucoepidermoid carcinoma. (9-13)
Malignant squamous epithelium within an
The decision was made to totally enucleate the odontogenic cyst may represent (a) an invasion
lesion followed by close follow-up examinations of the cyst from an adjacent primary carcinoma
since the lesion was confined only to the of the jaw, (b) a cystic change in a primary car-
epithelium without any connective tissue invasion. cinoma, or (c) a malignant change within the cyst
Enucleation of the lesion was performed under wall. (11-14) The histopathologic criterion em-
general anaesthesia using an intraoral approach. ployed to document malignant transformation of
During the enucleation it was noted the wall of the cyst lining is the identification of a transition
the lesion was adherent to the surrounding bone. from the normal lining epithelium to dysplasia and
Both the lingual and buccal cortex of the mandible to carcinoma. (2,11,15) As in the case presented
was thin owing to the expansion of the lesion and in this report, this sequence was followed. The
the neurovascular bundle was pushed inferiorly. most probable reason for the development of
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 191

carcinoma seems to be due to malignant Multylocular areas in the present case were
transformation in the residual cyst wall. evaluated as perforations in the buccal and lingual
In a study concerning the malignant cortex arising from the enlarging dimensions of
transformation of odontogenic cysts keratinization the residual cyst.
of cystic epithelium and chronic inflammation Enucleation is the preferred treatment of odon-
lesions were found to be the main risk factors. (16) togenic cysts. However, when the lesion is large,
In the present case there was no keratinization marsupialisation can be performed due to the risk
of cystic epithelium, only dense chronic of fracture during the removal of the lesion by
inflammation. Therefore, a malignant lesion was enucleation. In the present case marsupialisation
not considered and enucleation was done following was the initial treatment planned due to the large
marsupialisation. size of the lesion. However, enucleation was
In general, odontogenic cysts grow by bone carried out later because the lesion had dysplastic
expansion and the expansion is mostly to the features. As anticipated, the mandible was
fractured during the procedure despite careful
buccal/labial vestibule. Intraosseous tumors, on the
manipulation. However, this case shows
other hand, expand on both the buccal and lingual
marsupialisation may lead to false negative results.
sides of the jaws. (17) Therefore, the existence of
Enucleation should be considered regardless of
a buccolingual expansion should remind clinicians the risk of fracture. If marsupialisation is selected
of the possibility of a tumor; most probably an as a treatment choice, then a biopsy should be
ameloblastoma or an intraosseos carcinoma. The taken from different regions of the lesion. To
probability of a malignant lesion was never of decide on the mode of therapy based on only one
concern in the present case because of the absence biopsy from such a large lesion was a wrong
of lingual expansion. approach. An initial surgical approach through a
Reported clinical signs of malignant lesions buccal window would provide specimens with a
generally include the presence of cervical lympa- lower probability of compromising tissue by the
denopathy. There was no palpable lympa- inflammatory process caused by potential
denopathy present in the present case, although a exposure to the oral cavity. The patient indicated
metastasis in a nodule was determined following his face swelled after the extraction of the mobile
neck dissection. Lack of a clinically palpable teeth. That would support the possibility a
lympadenopathy was misleading. When cysts malignant change could result from a
reach a large size, parestehesia of the mental nerve communication with the oral cavity and concurrent
may occur. However, the existence of paraesthesia exposure to the pathogenic mechanisms that affect
should serve as a reminder of the possibility of an the oral mucosa.
intraosseous carcinoma. In the present case,
although paraesthesia of the lip together with SUMMARY
buccal expansion should have raised the suspicion
of carcinoma, the benign radiological presentation The development of SCC from residual cysts
also served to mislead clinicians. is rare, however, it should always be considered
Keratocysts appear as well-defined radiolucent in the differential diagnosis.
areas, either more or less rounded with a scalloped This case report clearly demonstrates the
margin or multiloculated. Keratocyst may be con- importance of clinician awareness of the malignant
fused radiographically with a ameloblastoma or potential of apparently innocuous cystic lesions.
with dentigerous cysts. (18) It also underscores the importance of a careful
Ameloblastomas have a honeycomb pattern histological examination and the necessityof
and a single, well-defined cavity indistinguishable obtaining biopsy materials from various areas to
from a radicular or, rarely, a dentigerous cyst. (19) prevent a misdiagnosis of large-sized cysts.

REFERENCES
1. Stoelinga PJW, Bronkhorst FB – The incidence, multiple 3. Makowski GJ, McGuff S, Van Sickels JE – Squamous cell
presentation and recurrence of aggressive cysts of the jaws. J carcinoma in a maxillary odontogenic keratocyst. J Oral Maxillofac
Cranio Maxillofac Surg 1988; 16:184-195. Surg 2001; 59:76-80.
2. Bradley N, Thomas DM, Antoniades K, Anavi Y – Squamous 4. van der Wal KG, de Visscher JG, Eggink HF – Squamous cell
cell carcinoma arising in an odontogenic cyst. Int J Oral Maxillofac carcinoma arising in a residual cyst. A case report. Int J Oral
Surg 1988; 17:260-263. 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 12. Johnson LM, Sapp JP, McIntire DN – Squamous cell carcinoma
arising in association with an orthokeratinized odontogenic arising in a dentigerous cyst. J Oral Maxillofac Surg 1994; 52:987-
keratocyst: report of a case. J Oral Maxillofac Surg 1996; 54:647- 990.
651. 13. Manganaro AM, Cross SE, Startzell JM – Carcinoma arising in
6. Martinelli C, Melhado RM, Callestini EA – Squamous-cell a dentigerous cyst with neck metastasis. Head Neck 1997; 19:436-
carcinoma in a residual mandibular cyst. Oral Surg Oral Med Oral 439.
Pathol 1977; 44:274-278. 14. Browne RM, Gough NG – Malignant change in the epithelium
7. Schwimmer AM, Aydin F, Morrison SN – Squamous cell lining odontogenic cyst. Cancer 1972; 29:1199-1207.
carcinoma arising in residual odontogenic cyst. Report of a case and 15. Berenholz L, Gottlieb RD, Cho YS, Lowry LD – Squamous cell
review of literature. Oral Surg Oral Med Oral Pathol 1991; 72:218- carcinoma arising in a dentigerous cyst. Ear Nose Throat Journal
221. 1988; 67:764-772
8. Swinson BD, Jerjes W, Thomas GJ – Squamous cell carcinoma 16. Timosca GC, Cotutiu C, Gavrilita L – Malignant transformation
arising in a residual odontogenic cyst: Case report. J Oral Maxillofac of odontogenic cysts. Rev Stomatology Chir Maxillofacial 1995;
Surg 2005; 63:1231-1233. 96:88-95.
9. Copete MA, Cleveland DB, Orban RE JR, Chen SY – 17. Thomas G, Sreelatha KT, Balan A, Ambika K – Primary
Squamous carcinoma arising from a dentigerous cyst: report of a intraosseous carcinoma of the mandible- a case report and review
case. Compend Contin Educ Dent 1996;17:202-204. of the literature. Eur J Surg Oncol 2000; 26:82-86.
10. Eversole LR, Sabes WR, Rovin S – Aggressive growth and 18. Cawson RA, Odell EW, Poeter S –Cawson’s Essentials of Oral
neoplastic potential of odontogenic cyst. Cancer 1975; 35:270-281. Pathology and Oral Medicine. 7th edn. UK: Churchill Livingstone,
11. Gardner AF – A survey of odontogenic cyst and their relationship 2002
to squamous cell carcinoma. J Canad Dent Assoc 1975; 41:161- 19. Regezi JA, Sciubba JJ, Jordan RCK –Oral pathology. Clinical
167. Pathologic Correlations. 4th edn. USA: Saunders, 2003

Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 6, September 1, 2008
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


diagnosis of the headache syndrome. (11) A
Temporomandibular disorders (TMD) are possible explanation is TMD has common para-
frequent and widespread in the general population. functional habits, such as bruxing behavior, which
The chief complaint is usually pain, which can could account for the headaches observed in those
manifest itself in different ways: headache, jaw patients. (12,13)
ache, ear ache, and facial pain. (1-5) Seventy TMJ internal derangement (TMJ ID) is the most
percent of TMD patients report headaches. (6,7) frequent type of TMD and is characterized by
Headaches are, however, a common complaint in several stages of dysfunction involving the
the adult population,7 and the International condyle-disk relationship. (14,15) TMJ ID is
Headache Society recognizes thirteen major considered to be a basic mechanism in the
headache categories with more than one hundred pathogenesis of TMJ dysfunction. Two types of
subdivisions. (8) derangements of the condyle-disk complex are
Several studies have shown an association commonly identified in sagittal magnetic
between TMD and headaches, although a causal resonance imaging (MRI): anterior disk
relationship has not been fully established. Some displacement with reduction or anterior disk
patients with headaches have signs and symptoms displacement without reduction. MRI studies have
of TMD, while other patients with TMD report suggested headaches due to ID of the TMJ appear
having headaches. (6,9-11) In addition, recurrent 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 corrected to the horizontal angulation of the long
subsequent anterior disk displacement. (16) Some axis of the condyle. T1-weighted SE sagittal
studies also found a strong association between images (TR = 650 msec, TE = 22 msec, matrix =
joint effusion and joint pain (11,17) and observed 316 x 240, flip 160º, slice thickness = 1.5 mm,
joint effusion is more often observed in more field of view = 10 x 10, NEX 1) were acquired in
advanced stages of ID. (13,18) open and closed mouth position. T2-weighted FSE
The aim of the present study was to determine sagittal images (TR = 5300 msec, TE = 90 msec,
the correlation of TMJ ID in patients with the matrix = 216 x 216, flip 160º, slice thickness =
presence of headache, bruxism, and joint pain using 1.5 mm, field of view = 12 x 12, NEX 2) were
MRI. acquired in closed mouth position.

METHODS AND MATERIALS IMAGING ASSESSMENT OF ARTICULAR DISC


Subjects AND JOINT EFFUSION
Forty-two consecutive patients with TMJ ID A radiologist (ALFC) without prior knowledge
and joint pain gave written informed consent to of each subjects’ condition established the
participate in this study which was approved by radiological diagnosis. The position of the disc was
the Institutional Review Board of the University determined according to previous established
Hospital at UNICAMP. No subject in either the criteria20 using sagittal images in closed and open
TMJ ID or control group refused to participate. mouth position to evaluate disk reduction (anterior
The study evaluated 42 joints in 42 patients (35 disk displacement with reduction or anterior disk
females, 7 males, age range 16-83 years) referred displacement without reduction). Joint effusion
to the TMJ outpatient clinic of the Dentistry was identified as an area of high signal intensity
Service of the University Hospital at UNICAMP in the region of the upper and lower joint spaces
for evaluation of TMJ pain. Patients were divided on T2 weighted images. (17)
into two groups: 21 patients with TMJ ID and
headaches and 21 patients with TMJ ID without DATA ANALYSIS
headaches. The Research Diagnostic Criteria for
Temporomandibular Disorders (RDC/TMD) was The primary objective was to establish if MRI
used to diagnose unilateral TMJ related TMD diagnostic findings correlated with the presence of
group II (disk displacement). (19) Examiners were headaches. A chi-square test or, when necessary, a
dentists, trained and calibrated in these procedures, Fisher’s exact test was used to determine the
who assessed the presence of joint pain and association between the clinical and imaging
bruxism. Patients were included with side-related findings. Significance level was established as
TMJ pain and absence of splint therapy and/or p<0.05. A secondary analysis was conducted in
history of facial trauma. Patients with headaches patients with headaches and the presence of bruxing
were evaluated by a neurologist, who reviewed behavior, joint pain, and effusion. Due to multiple
the headache history, performed a neurological sequential comparisons, in this case, the p level was
examination, and established the diagnosis. (8) No adjusted downwards to p<0.0125.
set time frame was established in regard to the
presence of headaches. Instead, patients were
RESULTS
asked if headaches interfered with their current
lives or if they were using any analgesic Forty-two joints were evaluated. The headache
medication regularly for headaches. diagnosis in the 21 affected patients were: 18 had
The control group was comprised of 16 TMJs migraine without aura; one had migraine without
of 16 subjects (11 women, 5 men, age range 26- aura, but with a clear correlation between head-
37 years) who had no current or previous TMD ache and TMD symptoms; and two had tension-
symptoms and denied having headaches. type headaches. All patients with headaches had
a normal neurological examination. None was in
DATA ACQUISITION regular follow up with a neurologist or using
preventive medicine. The only medications re-
All subjects underwent MRI of the TMJ ported were over-the-counter analgesics.
obtained by a 2 Tesla scanner (Elscint Prestige, Headache patients more frequently reported
Haifa, Israel) with surface coils. MRIs were TMJ pain in their clinical history than TMJ patients
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 195

without headaches. Eighteen (85%) patients with Table 4


headaches reported joint pain, while only three Relation between MRI diagnoses of ID and
headache in patients’ group
(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 *P values were obtained using Fischer’s exact test
headache free group (Table 2). (P significant <0.0125).
Table 5
Table 1
Relation between joint effusion and headache
Relation between headache and joint pain
in TMD patients
in TMD patients

*P values were obtained using chi-square test (P significant *P values were obtained using Fischer’s exact test
<0.0125). Numbers in parentheses represent the percent of each row. (P significant <0.0126). Numbers in parentheses represent
the percent of total (n=42).
Table 2
Relation between headache and bruxism Table 6
behavior in TMD patients Relation between joint pain and joint effusion
in TMD patients

*P values were obtained using Fischer’s test (P significant <0.0125).


Numbers in parentheses represent the percent of each row. *P values were obtained using Fischer’s exact test
(P significant <0.0126). Numbers in parentheses represent
the percent of total (n=42).
Patients with headaches exhibited significantly
more ID in the MRI than the control group Table 7
(p<0.0125) (Table 3). Headaches occurred more Relation between MRI diagnosis of ID and joint
effusion in TMJ ID patients and controls
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 ID: Internal corangement
pain (p<0.005) (Table 6). Patients with more severe ADDR: Anterior disk displacement with reduction
disc displacement also had a higher frequency of ADDWR: Anterior disk displacement without reduction
*P values were obtained using Fischer’s exact test
joint effusion (p<0.005) (Table 7). (P significant <0.0125).
In the control group only three subjects had ID
of the disc and just one had associated joint effusion.
DISCUSSION
Table 3
Relation between MRI diagnoses of joints in study The principal findings of this study are:
group and controls 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
*P values were obtained using Fischer’s exact test (P 4. Headaches were most frequently reported
significant <0.0125). Numbers in parentheses represent the in patients with joint effusion and patients
percent of total (n=58).
with more severe radiological diagnosis
196 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

TMD is widely accepted as a multifactorial accumulation of irritating agents in the tissue


disorder, while headaches are a nearly universal fluid13 and inflammatory changes in the
human experience representing the final common retrodiskal tissue and synovial membrane leading
expression of a wide variety of assaults upon the to subsequent joint effusion. (30) Effusion
human nervous system. (21) In this investigation appeared in just one subject of the control group.
the main objective was to understand the In this study only the presence of effusion charac-
pathophysiology of TMJ ID in patients with terized by an area of high signal intensity along
headaches. Therefore, a control group free of signs the articular surface was identified with no measure
and symptoms of TMD and headaches was of the grade of this collection. It can be theorized
selected to avoid the presence of heterogeneous the increase in levels of effusion leads to a sus-
pathology and confounding factors. ceptibility to headaches from accumulation of
Previous studies of TMD and headaches inflammatory mediators within the joint.
reported tension-type headaches as the most Arthroscopic analysis of synovial fluids in the
frequent headaches associated with TMD. (22) In articular joint demonstrated they are constituted
this sample, however, a much higher incidence of by prostanoids, (31) proinflammatory cytokines,
migraines was observed. This result may be due (32) and nitric oxide. (33) Takahashi and coworkers
to the inclusion of a neurological assessment in demonstrated nitric oxide concentration in ID is
the present study which in previous studies was significantly higher than in normal joints. (34)
not reported and may have led to misdiagnosis of Nitric oxide functions as a modulator of apoptosis
the condition. Additionally, a hospital-based (35,36) and apoptosis caused by oxidative stress
population was used in the present investigation is involved in inflammatory articular diseases.
which may have introduced a selection bias in this (37,38) It is also known to regulate blood pressure
sample. Migraine is a primary headache, hence, it and vascular tone, as well as function in neural
is not a symptom produced by another disorder signaling. (39) High concentrations of nitric oxide
but is in itself a disorder. (23,24) Nevertheless, may lead to a headache attack. One can hypothesize
recent evidence suggests patients with migraines if joint effusion is present, the possibility of pain to
have a higher prevalence of TMJ ID. (25) be present is greater. If peripheral sensitization
Headaches related to dental occlusion and dental (pain in the joint) is present in chronic pain with
parafunctions are able to mimic primary migraine central sensitization and migraine, this could be a
headaches, (24) and treatment of the causative trigger of the headache.
disorder can improve the headache. (24)
Results of a previous study (11) suggested CONCLUSION
patients with unexplained headaches should be
considered for evaluation of the presence of ID and The results of this study suggest more severe
inflammation of the TMJ. There is a general pathology of the TMJ ID noted by MRI might
agreement TMJ effusion represents an inflammatory increase the risk of headache in patients presenting
response to a dysfunctional diskcondyle to a dental clinic for the evaluation of TMJ sym-
relationship (26-28) and more recurrent in painful ptoms. An interesting follow up study to confirm
non-reducing joints. (13) This study found joint these findings would be to assess patients with
effusion was more frequent in patients with anterior primary headaches for TMD, including MRI, and
disk displacement without reduction. The present assess how treatment of TMD in primary headache
findings confirmed effusion is more frequently patients would affect the control of subsequent
encountered in anterior disk displacement without attacks in those patients.
reduction (26) and is associated with joint pain. (13)
TMJ pain and dysfunction may be caused by CLINICAL SIGNIFICANCE
bruxism (13) and indirectly related to headaches.
(16) It is well known minor changes in jaw Temporomandibular joint effusion on MRI may
position could result in large increases in the serve as a biological marker of headache associated
activity of masticatory muscles. (29) This with TMD and could be helpful for diagnostic
modification causes articular pain and abnormal classification and treatment follow up.
mechanical stresses within the joint, resulting in
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 197

REFERENCES
1. McNeill C – Management of temporomandibular disorders: 22. Reik L – The temporomandibular joint pain-dysfunction syndrome:
concepts and controversies. J Prosthet Dent. 1997; 77:510–522. a frequent cause of headache. Headache. 1981; 21:151-156.
2. McNeill C, Mohl ND, Rugh JD, Tanaka TT – 23. Tepper SJ – Treatment of headache pain with botulinum
Temporomandibular disorders: diagnosis, management, education, neurotoxins. Pain Pract. 2004 Mar; 4:38-46.
and research. J Am Dent Assoc. 1990; 120:253, 255, 257. 24. Melis M, Secci S – Migraine with aura and dental occlusion: a
3. Okeson JP – Orofacial pain: guidelines for assessment, diagnosis, case report. J Mass Dent Soc. 2006; 54:28-30.
and management. Quintessence Publishing Co, Chicago 1996; p. 25. DeRossi SS, Stoopler ET, Sollecito TP – Temporomandibular
33–34. Disorders And Migraine Headache: Comorbid Conditions?: The
4. De Kanter RJ, Truin GJ, Burgersdijk RC, Van’t Hof MA, Internet Journal of Dental Science. 2005; 2:1.
Battistuzzi PG, Kalsbeek H, Käyser AFl – Prevalence in the 26. Sano T, Westesson PL – Magnetic resonance imaging of
Dutch adult population and a meta-analysis of signs and symptoms temporomandibular joint. Increased T2 signal in the retrodiscal
of temporomandibular disorders. J Dent Res. 1993; 72:150–918. tissue of painful joints. Oral Surg Oral Med Oral Pathol Oral Radiol
5. DeRossi SS, Greenberg MS, Sollecito TP, Detre JA – A Endod. 1995; 79:511–516.
prospective study evaluating and analyzing the presence of 27. Segami N, Suzuki T, Sato J, Miyamaru M, Nishimura M,
temporomandibular disorders (TMD) in a cohort of patients referred Yoshimura H – Does joint effusion on T2 magnetic resonance
to a neurology clinic for evaluation and treatment of headache. Oral images reflect synovitis? Part 3. Comparison of histologic findings
Surg Oral Med Oral Pathol Oral Radiol Endod. 2000; 89:443. of arthroscopically obtained synovium in internal derangements of
6. Magnusson T, Carlsson GE – Recurrent headaches in relation the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral
temporomandibular joint paindysfunction. Acta Odontol Scand. Radiol Endod. 2003; 95:761–6.
1978; 36:333–338. 28. Emshoff R, Gerhard S, Ennemoser T, Rudisch A – Magnetic
7. Dalkinz M, Pakdemirli E, Beydemir B – Evaluation of resonance imaging findings of internal derangement, osteoarthrosis,
Temporomandibular Joint Dysfunction by Magnetic Resonance effusion, and bone marrow edema before and after performance of
Imaging Tr J Med Sci. 2001; 31:337–343. arthrocentesis and hydraulic distension of the temporomandibular
8. Headache Classification Committee of the International Headache joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;
Society. Classification and diagnostic criteria for headache 101:784–90.
disorders, cranial neuralgia and facial pain, 2nd edn. Cephalalgia; 29. Rugh JD, Drago DJ – Vertical dimension: a study of clinical rest
2004; 24(Suppl. 1):1 160. position and jaw muscle activity. J Prosth Dent. 1981; 45:670–675.
9. Schokker RP, Hansson TL, Ansink BJ, Habets LL – 30. Guler N, Uckan S, Imirzaliogu P, Acikgozoglu S –
Craniomandibular in headache patients. J Craniomandib Disord. Temporomandibular joint internal derangement: relationship
1989; 3:71–4. between joint pain and MR grading of effusion and total protein
10. Schokker RP, Hansson TL, Ansink BJ, Habets LL – concentration in the joint fluid. Dentomaxillofac Radiol. 2005;
Craniomandibular in patients with different types of headache. J 34:175–81.
Craniomandib Disord. 1990; 4:47–51. 31. Kubota E, Kubota T, Matsumoto J, Shibata T, Murakami KI –
11. Schellhas KP, Wilkes CH, Baker CC – Facial pain, headache, Synovial fluid cytokines and proteinases as markers of
and temporomandibular joint inflammation. Headache. 1989. temporomandibular joint disease. J Oral Maxillofac Surg. 1998;
29:229–32. 56:192–198.
12. Ciancaglini R, Radaelli G – The relationship between headache 32. Segami N, Miyamaru M, Nishimura M, Suzuki T, Kanayame K,
and symptoms of temporomandibular disorder in the general Murakami KI – Does joint effusion on T2 magnetic resonance
population. J Dent. 2001; 29:93–8. images reflect synovitis? Part 2. Comparison of concentration levels
of proinflammatory cytokines and total protein in synovial fluid of
13. Guler N, Yatmaz PI, Ataoglu H, Emlik D, Uckan S –
the temporomandibular joint with internal derangements and
Temporomandibular internal derangement: correlation of MRI
osteoarthrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
findings with clinical symptoms of pain and joint sounds in patients
2002; 94:515–521.
with bruxing behaviour. Dentomaxillofac Radiol. 2003; 32:304–10.
33. Suenaga S, Abeyama K, Hamasaki A, Mimura T, Noikura T –
14. Rasmussen OC – Description of population and progress of
Temporomandibular disorders: relationship between joint pain and
symptoms in a longitudinal study of temporomandibular joint
effusion and nitric oxide concentration in the joint fluid.
arthropathy, Scand J Dent Res. 1981; 89:196–203.
Dentomaxillofac Radiol. 2001; 30:214–218.
15. Okeson JP – Diagnosis of temporomandibular disorders. In: J.P.
34. Takahashi T, Kondon T, Kamei K, Seki H, Fukuda RW, Nagai
Okeson, Editor, Management of temporomandibular disorder and
H, Takano H, Yamazaki Y – Elevated leves of nitric oxide in
occlusion (5th ed.), Mosby, St Louis (2003), pp. 321–364.
synovial fluid from patients with temporomandibular disorders. Oral
16. Kreisberg MK – Headache as a symptom of craniomandibular
Surg Oral Med Oral Pathol Oral Radiol Endod. 1996; 82:505-509.
disorders I: Pathophysiology Cranio. 1986; 4:135–42.
35. Brockhaus F, Brune B – p53 accumulation in apoptotic
17. Westensson PL, Brooks S – Temporomandibular joint:
macrophages is an energy demanding process that precedes
relationship between MR evidence of effusion and the presence of
cytochrome c release in response to nitric oxide. Oncogene. 1999;
pain and disk displacement. AJR Am J Roentgenol. 1992; 159:559–
18:6403–10.
63. 36. Brune B, von Knethen A, Sandau KB – Nitric oxide (NO): An
18. Sano T, Westesson PL – Magnetic resonance imaging of effector of apoptosis. Cell Death Differ. 1999; 6:969–75.
temporomandibular joint. Increased T2 signal in the retrodiscal 37. Hashimoto S, Takahashi K, Amiel D, Coutts RD, Lotz M –
tissue of painful joints. Oral Surg Oral Med Oral Pathol Oral Radiol Chondrocyte apoptosis and nitric oxide production during
Endod. 1995; 79:511–516. experimentally induced osteoarthritis. Arthritis Rheum. 1998;
19. Dworkin SF, LeResche L – Research diagnostic criteria for 41:1266–74.
temporomandibular disorders: review, criteria, examinations and 38. Nagai H, Kumamoto H, Fukuda M, Takahashi T – Inducible
specifications, critique. J Craniomandib Disord. 1992; 6:301–355. nitric oxide synthase and apoptosisrelated factors in the synovial
20. Katzberg RW – Temporomandibular joint imaging. Radiology. tissues of temporomandibular joints with internal derangement and
1989; 170:297–307. osteoarthritis J Oral Maxillofac Surg. 2003; 61:801–807.
21. Cady R, Schreiber C, Farmer K, Sheftell F – Primary 39. Langrer JM, Rosemary A, Hoffman JR, Lancaster JRJ,
Headaches: A Convergence Hypothesis. Headache. 2002; Simmons RL – Nitric oxide, a new endogenous immuno-
42(3),204–216. modulator. Transplantation. 1993; 55:1205–1212.

Articol publicat cu acordul The Journal of Contemporary Dental Practice, Volume 9, No. 6, September 1, 2008
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- reflexul de vomå ¿i permite o tranzi¡ie între protezå
cin¡a unor erori sau deficien¡e ce pot apare în cursul ¿i palatul moale nesesizabilå pentru limbå.
uneia dintre urmåtoare etape: examenul clinic ¿i
planul de tratament; amprentå preliminarå ¿i ana- BOLTA PALATINÅ
liza ei; închiderea perifericå velopalatinalå la
maxilar; amprentå finala anatomo-func¡ionalå; Prezintå 3 pår¡i distincte:
determinarea dimensiunii verticale de ocluzie ¿i a • palatul dur, osos;
rela¡iilor intermaxilare; montarea din¡ilor; confor- • palatul moale sau vålul palatin care suportå
marea suprafe¡ei lustruite a protezei; optimizarea mari deplasåri în cadrul func¡iilor;
men¡inerii ¿i stabilitå¡ii bazei protezei. • partea aponevroticå a vålului care cores-
punde inser¡iei pe palatul dur.
ROLUL ZONEI DE ÎNCHIDERE VELOPALATINÅ Aceastå zonå aponevroticå „care vibreazå pe
loc“ odatå cu diferitele func¡ii este aceea în care
Aceasta zonå func¡ionalå distalå, înregistratå trebuie situatå închiderea palatinå. Zona e deli-
corect, de¡ine un rol primordial în men¡inerea , mitatå de linii de vibra¡ie anterioarå ¿i posterioarå
sprijinul ¿i stabilitatea protezei totale maxilare. ale lui Silverman(1):
Zona de închidere velopalatinå la proteza maxi- • linia de vibra¡ie posterioarå este puså în evi-
larå trebuie så fie etan¿å în condi¡ii statice ¿i dina- den¡å de pronun¡ia blândå ¿i prelungitå a
mice (fona¡ie, degluti¡ie), respectiv odatå cu mi¿- unui „Ah“ clar (fig.1);
cårile vålului palatin. Ea participå la stabilizare • linia de vibra¡ie anterioarå este puså în
opunându-se for¡elor de basculare, ¿i la sprijin prin eviden¡å de pronun¡ia scurtå ¿i viguroaså a
extensia distalå maximå ce permite cre¿terea ariei fonemei „Ah“. Ea corespunde liniei de jonc-
de sus¡inere a protezei. ¡iune palat dur-palat moale ce se poate
Închiderea velopalatinalå corespunzåtore evitå materializa când cerem pacientului så sufle
infiltrarea alimentelor sub protezå, diminua 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 199

(fig. 2) sau deplasând un fuloar în partea TEHNICA CLASICÅ


posterioarå a boltei palatine pentru a repera
jonc¡iunea palat dur-palat moale. Banda de Se repereazå ¿i se traseazå în gurå cu un creion
flexiune a vålului, situatå între aceste douå dermatograf, liniile de vibra¡ie posterioarå ¿i ante-
linii, este variabilå în formå ¿i întindere. 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
Figura 1(8)
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
Figura 2(8) rotunjit netraumatizant. Adâncimea gravajului
scade progresiv pentru a se anula la nivelul liniei
de vibra¡ie anterioarå (fig.3) (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 Figura 3(8)
sau mixte, este indispensabil så reperåm punctele Macheta e repozi¡ionatå pe modelul secundar ¿i liniile
de vibra¡ie se traseazå pe gips. Adâncimea de gravaj
¿i liniile de referin¡å (3,4):
corespunde cu 2/3 din compresibilitatea tisularå
• cro¿etele aripilor interne ale apofizelor evaluatå în gurå cu fuloarul, la distan¡å egalå de cele
pterigoide; douå linii de vibra¡ie.
• ¿an¡urile pterigomaxilare ¿i ligamentele
pterigomaxilare, ligamentul trebuie ocolit de
marginea protezei totale; În mod clasic, pentru vålurile cu înclinare inter-
• zonele lui Schroder a cåror depresibilitate mediarå se då ca adâncime de gravaj:
trebuie apreciatå; • 1 mm la foveele palatine;
• foveele palatine care trebuiesc reperate; • 1,5 mm în dreptul zonelor Schroder;
• liniile de vibra¡ie anterioarå ¿i posterioarå a • 0,5 mm la nivelul inser¡iei ligamentelor
vålului palatin. pterigo-maxilare.
200 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

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

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) de vibra¡ie anterioarå care se va imprima apoi pe
Ceara e prescurtatå pânå la linia posterioarå de fa¡a mucozalå a protezei. Cu bandå adezivå se face
vibra¡ie ¿i banda de spa¡iere este eliminatå. o îndiguire anterioarå pentru a evita refluarea de
rå¿inå. Grosimea ¿i configura¡ia acestei îndiguiri
Rå¿ina autopolimerizabilå e dispuså în reten¡ii sunt în func¡ie de compresibilitatea ¡esuturilor.
¿i pe banda de cearå care råmâne (Fig.5). Proteza Rå¿ina e aplicatå în spatele îndiguirii ¡inând cont
e aplicatå pe câmp cu o presiune digitalå puternicå, de compresibilitatea tisularå, apoi proteza e
rå¿ina e modelatå de mucoasa palatinå ¿i zona inseratå în gurå cu o puternicå presiune digitalå.
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 201

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 10(8)

CONCLUZIE
Figura 8(8)
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.

Figura 9(8)

BIBLIOGRAFIE
1. Silverman Sl – Dimensions and displacement patterns of the 5. Devin R – Adaptation et habilitation des protheses totales
posterior palatal seal. J Prosthet Dent 1971;25:470-488. defectueuses. Act Odonto-Stomatol 1969; 87:279-300.
2. Begin M, Rohr M – Le joint velopalatin en prothese complete 6. Hue O, Berteretche MV – Prothese complete. Realite clinique,
maxillaire. Cah Prothese 1983;43:55-78. solutions therapeutiques. Paris: Quintessence International, 2003.
3. Grant AA, Heath JR, McCord JF – Complete prosthodontics. 7. Pompignoli M, Doukhan JY, Raux D – Prothese complete.
Problems, diagnosis and management. London Wolfe, 1994. Clinique et laboratoire. Paris: Editions CdP, 1993.
4. Lejoyeux J – Prothese complete. Examen clinique, materiaux et 8. Begin M, Fouilloux I – Roles du JVP et du JSL dans la prevention
techniques d’empreintes. Tome 1. Paris : Maloine, 1979. des echecs en PAC. Clinic, Les echecs. Hors Serie, Iunie 2008, 26-32.

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
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,


atrofiei, lå¡imii; adâncimea bol¡ii palatine; existen¡a
Câmpurile protetice constituie frecvent zona în sau nu a torusului palatine; forma bol¡ii palatine,
care se eviden¡ieazå calitå¡ile protezelor, fiindcå caracterul atrofiei; dimensiunea în sens antero-
datoritå neadaptårilor au produs la nivelul ¡esutu- posterior a bol¡ii palatine; caracteristicile substra-
rilor moi (zonei de sprijin ¿i zonei de succiune) tului mucos; caracteristicile crestei edentate man-
modificåri morfo-histologice (microscopice ¿i ma- dibulare din punct de vedere al simetriei, înål¡imii,
croscopice). atrofiei, direc¡iei fa¡å de planul sagital, forma;
Din acest punct de vedere (al pacien¡ilor exa- caracteristicile tuberculului piriformi: direc¡ia fa¡å
mina¡i ¿i trata¡i în ultimii 3 ani), con¡inutul studiului de creastå, volumul.
clinic poate så reprezinte un material documentar Din punct de vedere teoretic ¿i practic aceste
sau didactic util pentru îmbogå¡irea no¡iunilor aspecte au fost descrise ¿i de autori români: Ene ¿i
despre variabilitatea câmpurilor protetice, a¿a cum Popovici (4,5), Hutu (6), Preoteasa (9), Påuna (9),
va fi prezentat în paginile urmåtoare. Bratu (1).
În analizå (studiu clinic) am urmårit urmå- Studiul clinic a solicitat timp, råbdare ¿i un spirit
toarele aspecte clinice: caracteristicile crestelor 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 203

pentru a fi remarcate toate particularitå¡ile morfo- • adâncimea din zona medie a bol¡ii palatine,
structurale, specifice în momentul examinårii pe sec¡iune frontalå (AZMP);
fiecårui pacient. • adâncimea din zona posterioarå a bol¡ii pa-
latine, pe sec¡iune frontalå (AZPP);
MATERIAL ªI METODÅ DE STUDIU • unghiul dintre linia medianå ¿i creasta rezi-
dualå în zona medianå (UMCM);
Studiul clinic (analiza câmpurilor protetice • unghiul dintre linia medianå ¿i creasta rezi-
edentate total) a fost posibil fiindcå l-am efectuat dualå în zona posterioarå (UMCP).
timp de aproximativ 8 ani, pe un numår de 506 Pacien¡ii studia¡i sunt prezenta¡i în douå loturi
pacien¡i. În ultimii trei ani numårul de pacien¡i determinate de perioada în care au fost rezolva¡i
edenta¡i total s-a mårit foarte mult datoritå celor (tabelul 1) ¿i de aspectele tratamentelor protetice,
care sunt asista¡i sociali de la sectorul 2 Bucure¿ti. care au fost vizibile la nivelul câmpurilor protetice
Ace¿ti pacien¡i sunt lipsi¡i de posibilitå¡i materiale, ¿i la nivelul protezelor.
ceea ce se reflectå în starea de igienå a protezelor Tabelul 1
pe care le posedå de 5-10 ani, reparate de mai Repartizarea pacien¡ilor pe loturi ¿i perioada
multe ori, sau transformate din cele par¡iale în de examinare
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; În prima perioadå (2000-2005), lotul a fost
– cazuri cu forme ¿i dimensiuni dobândite în de 212 de pacien¡i ¿i a fost analizat separat, cazuis-
urma extrac¡iilor sau al interven¡iilor chirur- tica consultatå a fost mai uniformå nu a existat în
gicale; mod evident particularitå¡i care reprezintå excep¡ii,
– cazuri cu aspecte ale muco-periostului deter- fiindcå solicitau numai protezåri, fårå acuze spe-
minate de iatrogenoze-proteze care au produs ciale. Pacien¡ii din acest lot aveau o situa¡ie socio-
leziuni datoritå neadaptårilor (suprafe¡elor economicå bunå, cu o educa¡ie stomatologicå
bazale, mucozale sau suprafe¡elor ocluzale- acceptabilå; purtau proteze care erau înlocuite
observate suprapunerile IM cu RC). periodic la un interval de 3-4 ani, la cea mai micå
Dimensiunile bol¡ii palatine au fost måsurate modificare resim¡i¡å în func¡ionalitatea aparatului
¿i de Johnson D.L, Holt R.A, Duncanson J.R.M dento-maxilar (mastica¡ie, fizionomie, fona¡ie)
în 1986 (7), studiu publicat în J.A.D.A ¿i citat de solicitau examen de specialitate (2,3).
Bratu în 2005 (1). Autorul citat a realizat urmå- Pacien¡ii din al doilea lot (2005-2008) în numår
toarele måsuråtori (fig.1) pe un lot de pacien¡i mai mare de 294, datoritå condi¡iilor materiale
edenta¡i total. 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
Figura 1 deficien¡e clinico-tehnice; protezele erau foarte
Diagrama måsuråtorilor lui Johnson: a) în plan sagital,
vechi, în medie de 8-10 ani, reparate, de mai multe
b) în plan frontal (1,7)
ori, materialul îmbåtrânit; starea de igienå loco-
• linia medio-sagitalå era evaluatå între papila regionalå în mod evident nu constituia o preocupare
incisivå ¿i linia interhamularå (LMS); vizibilå în mod deosebit la nivelul protezelor;
• adâncimea antero-posterioarå (AAP); câmpurile protetice prin aspectul muco-periostului
• unghiul antero-posterior (UAP); materializa consecin¡ele defectelor de adaptare
• lå¡imea în zona medie a palatului (LZMP); mucozalå ¿i ocluzalå a protezelor.
• lå¡imea în zona posterioarå a palatului Analiza fiind efectuatå pe cele douå loturi (di-
(LZPP); 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 fiind folositå în special pentru evaluarea gradului
studiate, o corela¡ie între caracteristicile câmpului de omogenitate a unei colectivitå¡i. De exemplu,
protetic edentat total ¿i pacientul examinat. o devia¡ie standard cu valoare mare aratå o dis-
persie mare, deci un grad mai scåzut de omoge-
METODOLOGIA STUDIULUI STATISTIC nitate a respectivului lot. Pentru calculul devia¡iei
standard prin metoda momentelor (M1 ¿i M2) se
Statistica sanitarå (8) este ¿tiin¡a care are ca folose¿te formula 1.
obiect cunoa¿terea detaliatå, dinamicå ¿i structuratå
a stårii de sånåtate în cadrul popula¡iei sau a unor (1)
anumite e¿antioane din aceasta, în corela¡ie cu fac-
torii sociali, economici, culturali, igienico-sanitari Momentul reprezintå o datå statisticå ce depinde
¿i medico-biologici determinan¡i. Scopul studiilor de media aritmeticå ponderatå. Formula de calcul
statistice este detectarea tendin¡elor evolutive ale stårii a momentului este:
de sånåtate în corela¡ie cu activitatea medico-sani-
tarå, a cårei eficien¡å este chematå så o aprecieze.
(2)
Având la bazå metode adecvate cunoa¿terii
proceselor ce se desfå¿oarå aleator, teoria proba-
X’ reprezentând diferen¡a fa¡å de media aritmeticå
bilitå¡ilor, studiile statistice reu¿esc så descifreze,
ponderatå, n frecven¡ele, iar N numårul de cazuri.
cu o eroare cunoscutå ¿i acceptabilå corela¡iile
Pe majoritatea loturilor statistice cu numero¿i
multiple dintre fenomenele studiate ¿i factorii deter-
minan¡i, în vederea stabilirii principalelor tendin¡e pacien¡i, calcularea momentelor necesitå un mare
ale acestora. În mod deosebit, studiile statistice ne consum de timp, în acest caz folosindu-se formula
ajutå så în¡elegem influen¡a condi¡iilor de via¡å, a simplificatå:
nivelului de trai cultural ¿i material asupra evolu¡iei
diferitelor fenomene patologice, inclusiv în sfera (3)
sånåtå¡ii oro-dentare. Concluziile ¿i rezultatele
studiilor clinice sunt întårite prin analiza ¿i sinteza
statisticå a respectivei cercetåri. b. Coeficientul de varia¡ie
Analiza cercetårii trebuie så înceapå cu veri- În loturile ce prezintå caracteristici diferite, ne-
ficarea aspectelor teoretice ale studiului, sco¡ând omogene, devia¡iile standard nu sunt comparabile.
în eviden¡å structura ¿i dinamica evolu¡iei carac- Din acest motiv se utilizeazå coeficientul de va-
teristicilor câmpului protetic edentat total. Am ria¡ie (cV), care nu este altceva decât devia¡ia stan-
urmårit eviden¡ierea legåturilor func¡ionale de dard exprimatå procentual, formula de calcul fiind:
cauzalitate, ritmul de apari¡ie ¿i dezvoltare, con-
centrarea sau dispersia anumitor caracteristici ale (4)
câmpului protetic edentat total. În cadrul analizei
am verificat exactitatea ¿i eficien¡a metodelor de Mp reprezentând media aritmeticå ponderatå. Un
cercetare folosite, alegând metodele adecvate pro- coeficient de varia¡ie mai mic de ± 10% indicå o
blemelor specifice.
dispersie micå, deci o omogenitate mare; o valoare
Pentru analiza statisticå am folosit metode ale
de ± 10 pânå la ± 20% indicå o variabilitate medie, iar
statisticii matematice: valorile medii, dispersia de
o valoare de peste ± 20% ne aratå lipsa omogenitå¡ii.
la valorile medii, eroarea medie, devia¡ia standard,
corela¡ia ¿i regresia valorilor ob¡inute, pentru a
c. Reparti¡ia normalå (curba normalå de frecven¡e)
putea compara cele douå loturi, precum ¿i distri-
bu¡ia pe grupe de vârstå, sex etc. De obicei, fenomenele biologice sunt carac-
Sinteza rezultatelor studiului este absolut nece- terizate prin variabile continue (variabile de tip
sarå, permi¡ând eviden¡ierea legåturilor cauzale ¿i dimensiune, vârstå etc.). Majoritatea acestor feno-
mecanismelor specifice de evolu¡ie a câmpului mene se caracterizeazå, în popula¡iile de dimen-
protetic edentat total. În final, analiza ¿i sinteza siuni mari printr-o distribu¡ie a valorilor ce urmeazå
statisticå ne permit o bunå aplicare practicå a con- a¿a-numita curbå normalå a reparti¡iei de frecven¡e
cluziilor ob¡inute în urma studiului. (curba sau „clopotul“ lui Gauss-Laplace). Aria curbei
distribu¡iei normale este definitå de medie ¿i de
a. Devia¡ia standard abaterea standard, formula sa fiind:
Devia¡ia standard (notatå cu s) måsoarå gradul
de dispersie de la medie a unei serii de valori, ea (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 207

La ambele loturi a fost aplicat testul Fisher 1 ¿i asimetricå la cei din lotul 2; în ceea ce
(formula 6), pentru depistarea diferen¡elor semni- prive¿te forma, prezen¡a sau nu a torusului
ficative din punct de vedere statistic între sexul ¿i distan¡a antero-posterioarå au existat ase-
feminin ¿i cel masculin. månåri cu toate cå numårul de câmpuri stu-
Lotul 1 a prezentat un F calculat de 7,5086 fa¡å diate era diferit între cele douå loturi, astfel
de un F tabelar de 1,96, iar lotul 2 un F calculat de a dominat forma bol¡ii de „U“, fårå torus
6,623 fa¡å de un F tabelar de 1,83. La ambele loturi palatin ¿i cu o distan¡å antero-posterior în
F calculat > F tabelar, deci respingem ipoteza nulå medie de 4 cm;
H0, existând diferen¡e semnificative din punct de – tuberozitå¡ile maxilare la ambele loturi ca
vedere statistic între edenta¡ii de sex feminin ¿i frecven¡å erau medii, prezente; în ceea ce
cei de sex masculin, cauzele probabile fiind con- prive¿te retentivitatea cel mai frecvent erau
cordan¡e cu cele expuse anterior. retentive unilateral.
În tabelul 3 au fost centralizate datele în ceea La ambele loturi s-a efectuat analiza statisticå
ce prive¿te elementele câmpului protetic edentat a dimensiunii antero-posterioare a bol¡ii palatine,
total maxilar studiate. Astfel: studiindu-se curba de reparti¡ie a acesteia (formula
– creasta edentatå avea cel mai frecvent înål¡i- 5). Graficele 3 ¿i 4 aratå o distribu¡ie de tip normal,
mea de 5-6 mm în cazul lotului 1, iar în lotul 2 Gaussian, deoarece dimensiunea antero-poste-
de 3-4 mm; din punct de vedere al atrofiei în rioarå a bol¡ii palatine este singurul parametru al
ambele loturi creasta era atrofiatå neuniform; câmpului protetic edentat total maxilar care nu
iar ca lå¡ime, în lotul 1 cel mai frecvent creasta suferå modificåri în urma edenta¡iei, påstrându-se
era rotunjitå, iar în lotul 2 ascu¡itå; morfologia normalå.
– bolta palatinå cel mai frecvent a avut o adân- Un alt element morfologic al câmpului protetic
cime de 6-8 mm în cazul lotului 1 ¿i de 3-5 edentat total maxilar supus analizei statistice a fost
mm lotul 2; din punct de vedere al atrofiei, tuberozitatea maxilarå din punct de vedere al
avea o atrofie simetricå la pacien¡ii din lotul retentivitå¡ii.

Tabelul 3
Rezultatul studiului câmpului protetic edentat total maxilar
208 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

Grafic 3
Dimensiunea antero-posterioarå a bol¡ii palatine lotul 1
Grafic 5
Tipul retentivitå¡ii tuberozitå¡ii maxilare lotul 1

Grafic 4
Dimensiunea antero-posterioarå a bol¡ii palatine lotul 2

Grafic 6
Lotul 1 se caracterizeazå printr-o curbå de dis- Tipul retentivitå¡ii tuberozitå¡ii maxilare lotul 2
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- Astfel, între cele douå loturi examinate au apårut
nerea stårii de troficitate a suportului muco-osos urmåtoarele diferen¡e sau asemånåri:
prin protezåri corecte (transmit presiunile masti- – în lotul 1 cel mai frecvent creasta edentatå
catorii ce favorizeazå osteogeneza conform mandibularå era simetricå, iar în lotul 2 era
studiilor lui Jores), tuberozitatea maxilarå pås- asimetricå;
trându-¿i rolul de stâlp posterior, pterigo-maxilar – în ambele loturi cel mai frecvent creasta
în structura de rezisten¡å a viscerocraniului. edentatå a avut o înål¡ime medie, chiar dacå
În schimb, analiza statisticå a curbei de distri- cele douå loturi erau diferite ca numår de
bu¡ie pe lotul 2 aratå un tip polinomial (grafic 6), câmpuri edentate mandibular examinate; de
tuberozitatea maxilarå suferind modificåri aleatorii men¡ionat în lotul 2 existå o micå diferen¡å
ce o îndepårteazå de morfologia normalå a denta- între numårul crestelor de înål¡ime medie ¿i
¡ilor. Aceste modificåri osoase sunt determinate cele negative;
de utilizarea unor proteze incorecte, instabile pe – altå asemånare apare la direc¡ia crestei în
câmpul protetic ce transmit discontinuå presiunile plan sagital ¿i forma crestei, în ambele loturi
masticatorii, care conform studiilor lui Jores de- cel mai frecvent au apårut creste cu direc¡ie
clan¿eazå resorb¡ii osoase. orizontalå ¿i formå de “U”;
În tabelul 4 am centralizat datele referitoare la – în ceea ce prive¿te tuberculul piriform, în
elementele câmpului protetic edentat total ambele loturi au existat cel mai frecvent tu-
mandibular ce au fost examinate în cadrul studiului berculi piriformi în pozi¡ie orizontalå ¿i cu un
clinic. volum mediu (putând favoriza protezarea).
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 209

Tabelul 4
Rezultatul studiului câmpului protetic edentat total mandibular

CONCLUZII
având direc¡ia în plan sagital cel mai frec-
1. Studiul statistic a eviden¡iat în cazul acestor vent orizontalå (56% dintre cazuri);
loturi, diferite din punct de vedere a numårului de • tuberculul piriform în 58% dintre cazuri avea
pacien¡i examina¡i, unele asemånåri ¿i deosebiri. un volum mediu, iar direc¡ia fa¡å de creasta
Variabilitatea morfo-clinicå a câmpurilor protetice edentatå era orizontalå (65% dintre cazuri).
edentate total a fost demonstratå prin caracteristicile 3. Lotul 2 a fost reprezentat de pacien¡i a cåror
diferite ale celor douå loturi. vârstå frecvent era cuprinså între 61-65 de ani, 62%
2. Lotul 1 a fost reprezentat de pacien¡i a cåror erau femei, cel mai frecvent prezentau edenta¡ie
vârstå frecvent era cuprinså între 66-70 de ani, 54% bimaxilarå (64% din pacien¡i), iar factorul etiologic
erau femei, cel mai frecvent prezentau edenta¡ie în 57% dintre cazuri, prezenta cauze asociate.
bimaxilarå (64% dintre pacien¡i), iar factorul etiologic b. Câmpul protetic edentat total maxilar a fost
în 65% dintre cazuri, prezenta cauze asociate. caracterizat de urmåtoarele elemente:
a. Câmpul protetic edentat total maxilar a fost • creste edentate cu o înål¡ime de 3-4 mm (66%
caracterizat de urmåtoarele elemente: dintre cazuri), atrofiate neuniform (60%
• creste edentate cu o înål¡ime de 5-6 mm dintre cazuri), ascu¡ite (69% dintre cazuri);
(43% dintre cazuri), atrofiate uniform (59% • bolta palatinå cu o adâncime de 3-5 mm
dintre cazuri), rotunjite (65% dintre cazuri); (63% dintre cazuri), fårå torus palatin (95%
• bolta palatinå cu o adâncime de 6-8 mm dintre cazuri), atrofiate asimetric (59% dintre
(65% dintre cazuri), fårå torus palatin (95% cazuri), având forma literei U (44% dintre
dintre cazuri), atrofiate simetric (65% dintre cazuri), cu o dimensiune în sens antero-
cazuri), având forma literei U (63% dintre posterior de 4 cm (67% dintre cazuri);
cazuri), cu o dimensiune în sens antero-pos- • tuberozitå¡ile maxilare au fost cel mai frecvent
terior de 4 cm (64% dintre cazuri); în 43% dintre cazuri prezente, medii.
• tuberozitå¡ile maxilare au fost cel mai frec- c. Câmpul protetic edentat total mandibular a
vent în 51% dintre cazuri prezente, medii. fost caracterizat de urmåtoarele elemente:
b. Câmpul protetic edentat total mandibular a • creste edentate asimetrice (70% dintre ca-
fost caracterizat de urmåtoarele elemente: zuri), în formå de U (52% dintre cazuri), de
• creste edentate simetrice (77% dintre ca- înål¡ime medie (43% dintre cazuri), cu o re-
zuri), în formå de U (58% dintre cazuri), de sorb¡ie neuniformå, fårå torus mandibular,
înål¡ime medie (43% dintre cazuri), cu o având direc¡ia în plan sagital cel mai frec-
resorb¡ie neuniformå, fårå torus mandibular, vent orizontalå (54% dintre cazuri);
210 REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008

• tuberculul piriform în 54% dintre cazuri avea punde statutului socio-economic al pacien¡ilor din
un volum mediu, iar direc¡ia fa¡å de creasta acest lot).
edentatå era orizontalå (62% dintre cazuri). 6. Condi¡iile materiale, reprezintå un factor
4. Astfel, pacien¡ii din primul lot au fost carac- deosebit de important, care participå la marea
teriza¡i de câmpuri protetice cu elemente morfo- variabilitate a dimensiunii ¿i formelor substratului
logice specifice ce favorizeazå protezarea, iar men- osos, dar în special asupra structurilor morfologice
¡inerea troficitå¡ii muco-osoase cu påstrarea acestor
reprezentate de muco-periost.
elemente este determinatå de protezåri repetate,
7. Între cele douå loturi au fost câteva asemånåri,
corecte, proteze cu o igienå foarte bunå (corespunde
dar nu sunt concludente, loturile fiind diferite ca
statului socio-economic al pacien¡ilor studia¡i).
5. Câmpurile protetice la pacien¡ii din lotul doi numår de pacien¡i. Studiul clinic ¿i statistic a de-
au prezentat elemente ce pot influen¡a negativ pro- monstrat cå fiecare câmp protetic edentat total este
tezarea, modificåri frecvente la nivelul mucoasei unic în felul såu, fiind caracterizat de anumite ele-
acoperitoare (stomatopatii protetice), determinate mente morfologice specifice fiecårui pacient, ce
de lipsa unei protezåri corecte, folosirea unor pot fi influen¡ate de statutul socio-economic, con-
proteze vechi, cu o stare de igienå precarå (cores- di¡iile culturale, obiceiurile igieno-sanitare.

BIBLIOGRAFIE
1. Bratu D, colab – Bazele clinice ¿i tehnice ale protezårii edenta¡iei 5. Ene L – Edenta¡ia totalå, Ed. IMF Bucure¿ti, 1989.
totale, Ed. Medicalå, Bucure¿ti, 2005. 6. Hutu E – Edenta¡ia totalå, Ed. Na¡ional, Bucure¿ti, 2005.
2. Despa EG, Ionescu T, Hutu E – Studiul clinic asupra câmpului 7. Jonhson DL, Holt RA, Duncanson JRM – Contour of the
protetic edentat total (partea I) – Rev. Stomatologia – Vol I, Nr. 1, edentulos palate, JADA 1986, 113, 35.
Bucure¿ti, 2004. 8. Mure¿an P – Manual de metode matematice în analiza stårii de
3. Despa EG, Ionescu T, Hutu E – Studiul clinic asupra câmpului sånåtate, Ed. Medicalå, Bucure¿ti, 1989.
protetic edentat total (partea II), Rev. Stomatologia – Vol I, 9. Påuna M, Preoteasa E – Aspecte practice în protezarea edenta¡iei
Nr. 2-3, Bucure¿ti, 2004. totale, Ed. Cerma, Bucure¿ti, 2002.
4. Ene L, Popovici C – Edenta¡ia totalå-clinicå ¿i tratament, Curs [*| In-line.WMF *][*| In-line.WMF*]
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
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 plåtor în timpul mastica¡iei; mi¿cåri extreme con-
mandibulei la edentatul total reprezentate de afirma¡iile form schemei lui Posselt.
„nu sunt modificåri comparativ“ cu ale dentatului. Mi¿cårile din prima categorie, executate în mod
Cercetåtorii japonezi au demonstrat prin radio- automatizat sunt dominante în sens vertical, numai
metrie la dentat în cursul a 24 de ore din¡ii celor 10% în sens orizontal (laterale), cu scopul de a
douå arcade sunt în contact direct între ei aproxi- aplica resturile alimentare ¿i a le readuce pentru
mativ 1,30 ore (90 minute), în acest timp majo- tritrurare pe fe¡ele ocluzale.
ritatea contactelor sunt prezente în timpul degluti¡ie Mi¿cårile în sens orizontal pot fi provocate direct
(14, 20, 22). În cadrul ciclului masticator auto- sau indirect pe cale reflexå pentru evitarea obstacolului
matizat existå trei tipuri de mi¿cåri: mi¿cårile man- constituit de diferite contacte premature sau interferen¡e.
dibulei fårå contacte dentodentare care formeazå Acest tip de mi¿care, de¿i automatizate, sunt nocive,
marea majoritate a mi¿cårilor mandibulare auto- nu trebuie så fie prezente ¿i la edentatul total.
matizate; mi¿cårile mandibulare automatizate cu Din acelea¿i considerente Jankelson a afirmat
contacte dentare, din care func¡ional majoritatea în mod natural, tritrurarea alimentelor, în special
sunt realizate în timpul degluti¡iei ¿i numai întâm- 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 produse de absen¡a sensibilitå¡ii


în starea de dentat au avut componente orizontale proprioreceptorilor care existau la nivelul
ale mi¿cårilor mandibulare. parodon¡iului din¡ilor. De la suprafa¡a mucoasei
Mi¿cårile automatizate în sens orizontal, fårå cavitå¡ii orale ¿i a limbii sunt transmise semnale
contacte interdentare, apar în fona¡ie ¿i în mimica exteroreceptive. Toate particularitå¡ile structurilor
specificå a individului. edentatului total produc tulburåri ale mecanismului
Propulsia din timpul fona¡iei nu este posibil så de reglare a contrac¡iilor automatizate mu¿chilor,
fie controlatå voluntar; de aceea montarea din¡ilor existente la nivelul engramei, de mastica¡ie, a
frontali la protezele totale trebuie så permitå com- fiecårui individ.
pleta libertate de propulsie a mandibulei în timpul În prima perioadå de la aplicarea protezelor apar
fona¡iei (1,3,9,19,21). În acest scop, între incisivii stimuli care produc organizarea unui tip deosebit
inferiori ¿i superiori se creeazå o inocluzie ori- de mi¿cåri mandibulare automatizate influen¡ate
zontalå în sens sagital. Nerespectarea acestui spa¡iu de urmåtorii factori biologici:
pentru propulsia mandibulei va reprezenta o con- – engrama mi¿cårilor mandibulare deja exis-
di¡ie favorizantå så se producå contacte la nivelul tente în faza de dentat;
din¡ilor frontali în fona¡ie, ceea ce determinå insta- – determinantul posterior, respectiv mi¿cårile
bilitatea protezelor ¿i întreruperea fona¡iei pentru permise de articula¡ia temporo-mandibularå ¿i
stabilizarea protezelor. în special de pozi¡ia de rela¡ie centricå-care este
Mi¿cårile func¡ionale ale mandibulei în sens cunoscut, råmâne constantå ¿i reproductibilå;
vertical, sunt caracterizate de contacte dento- – rela¡iile noi intermaxilare stabilite de protezele
dentare, care trebuie så fie prezente în timpul de- totale, care cuprind: dimensiunea verticalå de
gluti¡iei. Intercuspidarea maximå trebuie så se ocluzie, spa¡iul de inocluzie fiziologicå din
suprapunå cu rela¡ia centricå la edentatul total pozi¡ia de posturå, intercuspidarea maximå ¿i
corect protezat (2,8,9,13,15). raportul stabilit fa¡å de rela¡ia centricå, raportul
Mi¿cårile din categoria a treia – reprezentate de din¡ilor din zona frontalå ¿i lateralå fa¡å de
mi¿cårile extreme – propulsia maximå ¿i mi¿cårile ¡esuturile moi (buze, obraji ¿i limba) la care se
nefunc¡ionale indirect sunt sau nu cu contacte dento- poate adåuga gradul de men¡inere ¿i de
dentare. Mi¿cårile voluntare extreme nu apar niciodatå stabilitate ale protezelor pe câmpurile protetice.
în ciclul automatizat al mi¿cårilor de mastica¡ie.
Mi¿cårile extreme efectuate de mandibulå formeazå Fiziopatologia mecanismelor, care modificå
aria mi¿cårilor limitå fa¡å de care aria mi¿cårilor engrama mi¿cårilor mandibulare
fundamentale la dentat, este mult mai micå. Engrama mi¿cårilor automatizate se modificå
La edentatul total protezat, aria acestor mi¿cåri în raport cu tipul de edenta¡ie, topografia ¿i nu-
func¡ionale se råstrânge ¿i mai mult, în func¡ie de mårul din¡ilor prezen¡i pe arcadå (numårul sto-
stabilitatea ¿i men¡inerea protezelor. Prin apari¡ia purilor ocluzale prezente ¿i absente) (4,5,11,12).
stårii de edenta¡ie totalå se modificå foarte mult Edenta¡ia totalå, instalatå brusc sau lent (treptat)
condi¡iile anatomice ¿i neuro-musculare care de- este caracterizatå de o engramå proprie, fiind dificil
clan¿au, reglau ¿i influen¡au mi¿cårile mandibulare. de apreciat propor¡ia, råmaså din starea de dentat
Dintre determinan¡ii mi¿cårilor mandibulare sau din engramele care sau format în fazele de
dispare în primul rând ghidajul anterior (11,18, 21) edenta¡ie par¡ialå. Este cunoscut, engramele fixate
care nu poate så fie refåcut protetic fårå riscul de a la nivelul sistemului nervos central sunt modificate
destabiliza protezele. în raport cu evolu¡ia normalå sau patologicå a
Determinantul posterior, articula¡ia temporo- diferitelor structuri ale aparatului dento-maxilar,
mandibularå în func¡ie de modificårile morfo-func¡ionale, ale celorlalte organe ¿i sisteme. În faza de edentat
prezintå, uneori multe leziuni structurale dar rela¡ia total individul mai påstreazå, unele elemente ale
centricå råmâne nemodificatå, fiind un reper fundamental, engramei din starea de dentat (8,9,17,18).
care este deosebit de necesar pentru realizarea rapoartelor Protezele, executate corect dacå sunt necesare
intermaxilare func¡ionale la edentatul total. unele „retu¿uri“ ale engramelor de mastica¡ie
Musculatura sau determinantul mijlociu, dupå existente anterior, la majoritatea pacien¡ilor se
unele teorii, î¿i men¡in reflexele contrac¡iilor auto- produce adaptarea sistemului neuro-muscular så
matizate, elementare dar cu multe modificåri se ob¡inå reflexele necesare. Astfel se realizeazå
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOL. LIV, NR. 3, SUPLIMENT, AN 2008 213

o selectare în final, automatizatå a mi¿cårilor Aceste situa¡ii clinice, nu reprezintå cazuri


mandibulare, care sunt favorabile pentru adaptarea izolate, unicate. Activitatea practicå ¿i documen-
pacientului la proteze (4,5,6,7). tarea din literatura de specialitate, aratå un procent
Perioada de timp în care se produce automati- suficient de mare, care trebuie så reprezinte un
zarea mi¿cårilor, determinate de contrac¡iile mus- semnal necesar ¿i util pentru fiecare medic dentist
culare este variabilå în func¡ie de vârstå, de capa- solicitat så rezolve astfel de cazuri.
citatea biologicå ¿i reactivitatea fiecårui pacient. Dificultatea î¿i are debutul în faza de determi-
La vârstele mai tinere, capacitatea de adaptare nare a rela¡iei centrice care de¿i se sus¡ine, este
este mai mare, comparativ cu cea a pacien¡ilor conservatå permanent, stereotipurile contrac¡iilor
foarte vârstnici. Ipoteza ¿i tendin¡a care a existat musculare instalate în perioade mai mari de timp,
în trecut în cadrul tehnologiei protezei totale, så î¿i men¡in activitatea ¿i în faza când se pozi¡ioneazå
redea la edentatul total prin montarea din¡ilor mandibula în rela¡ie centricå, se manifestå
acelea¿i caracteristici la nivelul arcadelor dentare, nefavorabil, asupra arcadei dentare a protezei
care au fost prezente în starea de dentat, a creat o mandibulare în momentul conducerii în RC.
concep¡ie eronatå despre construc¡ia protezelor. Existå tendin¡a la ace¿ti pacien¡i så-¿i pozi¡ioneze
Anvelopa mi¿cårilor func¡ionale reflexe la dentat mandibula în laterodevia¡ie stânga, dreapta sau
delimiteazå o arie mult mai reduså fa¡å de mi¿cårile lateropulsie. Numai un exerci¡iu, care constå în
limitå, s-a imaginat pentru protezele totale så se solicitarea intenså a mu¿chilor ridicåtori, în scopul
reproducå mi¿cårile maxime dacå protezele sunt modificårii tonusului (obosealå) ¿i conducerea
men¡inute în mod corespunzåtor pe câmpurile protetice. mandibulei în pozi¡ie înaltå, posterioarå, simetricå
Mi¿cårile maxime au fost efectuate în timpul dupå tehnica lui Dawson sau Ramfiord creeazå
amprentårii, la unele tehnici, ceea ce au avut ca posibilitatea så se ob¡inå suprapunerea între
rezultat final, o reducere a suprafe¡ei zonei de intercuspidarea maximå ¿i rela¡ia centricå (6,7,8,9,15).
sprijin a câmpului protetic. For¡a de adeziune, fiind Evolu¡ia ulterioarå: la proba machetelor po-
mult mai reduså ¿i presiunile ocluzale au fost exer- sibil så aparå tendin¡a de latero-devia¡ie când
citate cu valori mai mari pe unitatea de suprafa¡å. trebuie så se ob¡inå intercuspidarea maximå, fårå
Rezultatul a fost nefavorabil din urmåtoarele så se suprapunå cu rela¡ia centricå; iar la inser¡ia
puncte de vedere: instabilitatea protezelor ¿i atrofia protezelor så se manifeste acelea¿i tendin¡e.
structurilor biologice ale câmpurilor protetice. Rezultatele favorabile adicå suprapunerea inter-
Rela¡iile intermaxilare la edentatul total sunt cuspidårii maxime cu rela¡ia centricå sunt ob¡inute dacå,
analizate pentru a se decela dacå existå modificåri medicul dentist este dotat cu mult tact ¿i råbdare så
¿i valoarea lor. Astfel: la edentatul total, dupå explice purtåtorului de proteze în fa¡a oglinzii cum så-
abla¡ia ¿i extrac¡iile protezelor fixe pluridentare ¿i dirijeze con¿tient mandibula, aceste explica¡ii sunt
posibil så prezinte urmåtoarele aspecte: utile pentru cei care au capacitatea så în¡eleagå
a. dacå planul de ocluzie a prezentat elemente explica¡iile ¿i au dorin¡a så aplice ceea ce i se recomandå.
favorabile så fie men¡inute rapoartele mandibulo- La edentatul total protezat majoritatea mi¿-
maxilare încât intercuspidarea maximå så se cårilor sunt necesare så fie realizate în axa balama
suprapunå cu rela¡ia centricå; terminalå, distan¡area mandibulei (arcadei infe-
Determinarea ¿i restaurarea rela¡iilor inter- rioare fa¡å de cea superioarå) så fie numai de 20
maxilare sunt ob¡inute fårå dificultate ¿i se reali- mm-25 mm). Amplitudinea deschiderii gurii
zeazå o suprapunere a intercuspidårii maxime cu trebuie så fie reduså. Consecin¡ele modificårilor
rela¡ia centricå ceea ce constituie idealul. Prog- dimensionale ale dimensiunii verticale de ocluzie,
nosticul tratamentului de cele mai multe ori este în plus sau în minus sunt cunoscute. Deasemenea
favorabil când sunt asigurate men¡inerea ¿i consecin¡ele care includ func¡ionalitatea prote-
stabilitatea în faza clinicå de amprentare. zelor, prognosticul tratamentului din punct de
b. dacå au fost denivelåri ale planului de vedere curativ ¿i profilactic. În general se mai
ocluzie, înso¡ite de puncte premature de contact adaugå modificårile structurilor anatomice com-
¿i interferen¡e în dinamica mandibularå care så ponente ale aparatului dento-maxilar. Aceste mo-
determine, ocluzie de necesitate ¿i de obi¿nuin¡å, dificåri este posibil så determine ¿i tulburåri în
cu modificåri la nivelul articula¡iei temporo-man- echilibrul sistemului nervos central ¿i periferic.
dibulare ¿i ale grupelor musculare. 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- instabilizeazå proteza în mod diferit, fie limba dacå este
pabilå så determine grave tulburåri în mi¿cårile în oro-pozi¡ie, fie buzele dacå sunt în vestibulo-pozi¡ie
mandibulare fiindcå ocluzia-contactele dentare ¿i senza¡ii de disconfort pentru limbå în fona¡ie (de
produc alunecåri (derapaje). încorsetare) ¿i de plasare a buzelor în alte pozi¡ii când
Primul contact dento-dentar între arcadele pro- intrå în ac¡iune tonusul mu¿chilor orbiculari.
tezelor, creeazå senza¡ii de nesiguran¡å. Este insta- Modificårile mari de pozi¡ie ale din¡ilor sunt
latå o neconcordan¡å, nepotrivire între contactele urmate de instabilitatea protezelor, corectarea este
dentare. Reflex, se produc alte contacte mai ferme, remediatå prin remontarea din¡ilor. Dacå pozi¡iile
mai stabile în plan orizontal, ceea ce determinå din¡ilor sunt modificate, fårå consecin¡e mari
devierea mandibulei de la stereotipul creat pentru asupra stabilitå¡ii protezelor este recomandabil så
mastica¡ie. Proteza este deplasatå de pe câmpul se temporizeze interven¡ia fiindcå existå posibili-
protetic, progresiv ¿i dacå la inser¡ie a prezentat tatea unei adaptåri, în mod progresiv deoarece la
men¡inere ¿i stabilitate foarte bunå determinate de multe cazuri clinice se instaleazå lent.
succiune ¿i adeziune. Acest mecanism, complex Erori evidente la protezele totale pot så aparå
neuro-muscular ¿i mecanic (IM) produce modificåri în urmåtoarele situa¡ii morfo-clinice (8,9,10,15):
la nivelul structurilor câmpului protetic- mucoaså – spa¡iul minim de vorbire al lui Silverman nu este
¿i os- atrofia osului ¿i hipertrofie localizatå în unele prezent sau are dimensiuni foarte reduse;
zone ale mucoasei sau atrofie în altele. disfunc¡iile fonatorii, produc tulburåri în vorbire
Instabilitatea protezelor exercitatå de derapajul cu repercursiuni psiho-nervoase, manifestate
ocluzal determinå anumite contrac¡ii (ticuri) ale sub formå de stres nervos, care sunt nefavorabile
musculaturii oro-faciale ¿i ale mu¿chilor limbii cu pentru perioada de adaptare la proteze;
tendin¡a så stabilizeze proteza care nu sunt eficiente. – spa¡iul func¡ional, util pentru limbå a lui
Concomitent, apar ¿i contrac¡ii ale mu¿chilor Scheirnemakers, când nu este prezent, are douå
mobilizatori ai mandibulei a cåror manifeståri sunt consecin¡e: mobilizarea protezei inferioare,
urmate de consecin¡e asupra mecanismului care este senza¡ia de încorsetare a limbii;
necesar pentru instalarea contrac¡iilor automatizate. – spa¡iul func¡ional util limbii nu este prezent
Spasmele musculare instalate, prezintå carac- dacå: regula lui Pound nu s-a aplicat la mon-
teristice disfunc¡iei, determinå cicluri masticatorii tarea grupului din¡ilor laterali inferiori, versantul
atipice, cu componente orizontale importante, care lingual al protezei este gros, 1-4 mm (supra-
produc mai intens mobilizarea protezelor cu efecte dimensionat) sau nu este concav.
¿i asupra modificårilor de troficitate la nivelul Dacå spa¡iul func¡ional util pentru limbå nu este
structurilor câmpului protetic. prezent, mi¿cårile automatizate ale mandibulei sunt
Dacå între intercuspidarea maximå ¿i rela¡ia centricå întrerupte, de contrac¡iile mu¿chilor, care sunt nece-
sunt diferen¡e foarte reduse, exprimate în milimetrii, sare så stabilizeze protezele. Contrac¡iile musculare
existå long centric ¿i din¡ii sunt din acrilat, fenomenul pentru stabilizare se produc la nivelul mu¿chilor
de abraziune care se produce uneori, este favorabil så ridicåtori ai mandibulei, între cele douå arcade se
se ob¡inå, rela¡ii ocluzale corespunzåtoare pentru ob¡in contacte ocluzale care pozi¡ioneazå baza pro-
ocluzia de obi¿nuin¡å. Aceastå ocluzie, creeazå tezei pe câmpul protetic. Men¡inerea ¿i stabilitatea
condi¡iile necesare pentru automatizarea, mi¿cårilor protezelor pe câmpurilor protetice sunt determinate
de mastica¡ie ¿i de intercuspidare maximå. La aceste de fidelitatea (corectitudinea amprentei) ¿i de rela¡iile
cazuri clinice dispar, consecin¡ele care se pot instala ocluzale dintre cele douå arcade dentare static ¿i
asupra cinematicii mandibulare ¿i asupra ¡esuturilor dinamic împreunå cu pozi¡iile din¡ilor (8,9,16).
câmpului protetic. Ace¿tia sunt factori deosebi¡i de importan¡i care
Dacå diferen¡ele dintre intercuspidarea maximå ¿i creeazå condi¡iile pentru func¡ionalitatea protezelor
rela¡ia centricå sunt în jur de 0,5mm, localizate numai sau pentru imposibilitatea utilizårii lor.
la un grup de din¡i, depistate cu hârtia de articula¡ie Instabilitatea creatå de neadaptarea bazelor la
prin ¿lefuire apare posibilå instalarea coinciden¡elor zona de sprijin, „absen¡a“ succiunii, adeziunii, re-
dintre contactele dentare ¿i rela¡ia centricå. la¡iile ocluzale necorespunzåtoare, reprezintå fac-
Pozi¡iile din¡ilor artificiali, dacå sunt în alte raporturi tori deosebi¡i de nocivi pentru men¡inerea stårii
cu buzele ¿i limba, pot så modifice mi¿cårile mandibulei de troficitate a ¡esuturilor aparatului dento-maxilar,
prin urmåtoarele mecanisme fiziopatologice: 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

BIBLIOGRAFIE
1. Allen N – Dental Totale Prothesis, Br Dent J, 145, 169, 1990. 11. Ioni¡å S – Ocluzia dentarå, Ed. Didacticå ¿i Pedagogicå, Bucure¿ti, 1996.
2. Despa EG, Ionescu T – Variabilitatea câmpului protetic edentat 12. Jensen K – The Oclusion, J Oral Rehab, 26, 515, 1999.
total, comunicare Congresul Interna¡ional de Stomatologie 16-19 13. Katar H – The Complete Denture, J Proth Dent, 2, 152, 1996.
martie 2005, Bucure¿ti. 14. Kuwahara A – The Deranjamnent of TMJ, J Am Dent Ass, 98, 112,
3. Dyer M – Prosthetic Dentistry, Ed Wright, London, 1999. 1990.
4. Ene L – Ocluzia func¡ionalå, Stomatologia, 1982, 4; 271-280. 15. Påuna M, Preoteasa E – Aspecte practice în protezarea edenta¡iei
5. Ene L, Popovici C – Mi¿cårile mandibulare la edentatul total, totale, Ed.Cerma, Bucure¿ti, 2002.
Stomatologia, 1982, 29, 1; 179-196. 16. Poters K – Dental materials, J Prosth Dent, 69, 282, 1997.
6. Ene L, Popovici C – Edenta¡ia totalå-clinicå ¿i tratament, Curs 17. Rânda¿u Ion, Despa EG – Reabilitåri oro-dentare, Ed. Titu
pentru studen¡i, Litografia I.M.F., Bucure¿ti, 1988. Maiorescu, Bucure¿ti, 2005.
7. Ene L – Edenta¡ia totalå, Ed IMF Bucure¿ti, 1989. 18. Rânda¿u Ion, Despa EG – Tratamente protetice dentare
8. Hutu E – Edenta¡ia totalå, Ed Didacticå ¿i Pedagogicå, Bucure¿ti, 1998. complexe, Ed. Printech, Bucure¿ti, 2008.
9. Hutu E – Edenta¡ia totalå, Ed Na¡ional, Bucure¿ti, 2005. 19. Rânda¿u Ion – Proteze dentare, Ed. Medicalå, Bucure¿ti, 1998.
10. Hutu E, Despa EG, Dan A, Giurescu R – Edentatul total din 20. Sorria K – The Occlusion Relations, J Dent Res, 17, 528, 1997.
România-pacient european, Rev. Stomatologia – Vol LIII, Nr. 2, 21. Thomson W – Mastication, Ans Dent J, 58, 127, 1997.
Bucure¿ti, 2007. 22. Tubert K – Prothese Totale, Od Stom, 7, 618, 1995.

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