Incisal Index PDF

Restoring the Incisal Edge
Douglas A. Terry, D.D.S.

Abstract
The clinical significance is that anterior tooth fractures can
Restorative dentistry evolves with each development of
be predictably restored using contemporary small particle
new material and innovative technique. Selection of
hybrid composite resin systems with the aforementioned
improved restorative materials that simulate the physical
restorative techniques. These placement techniques when
properties and other characteristics of natural teeth, in
used with proper attention to preparation design, adhesive
combination with restorative techniques such as the prox-
protocol and finishing and polishing procedures, allow the
imal adaptation and incremental layering, provide the
clinician to successfully restore form, function and esthetics
framework that ensures the optimal development of an
to the single anterior tooth replacement.
esthetic restoration. These advanced placement techniques offer benefits such as enhanced chromatic integration, polychromatism, ideal anatomical form and function, optimal proximal contact, improved marginal integrity
and longer lasting directly placed composite restorations.
The purpose of this article is to give the reader a better
understanding of the complex restorative challenge in
achieving true harmonization of the primary parameters in
esthetics (that is, color, shape and texture) represented by
the replacement of a single anterior tooth. The case presented demonstrates the restoration of a Class IV fracture
integrating basic adhesive principles with these placement techniques and a recently developed nanoparticle
hybrid composite resin system (Premise, Kerr/Sybron,
Orange, CA). The clinical presentation describes preopera-
tive considerations, tooth preparation, development of the

body layer, internal characterization with tints, development of the artificial enamel layer, shaping and contouring,
and polishing of a Class IV composite restoration.
30 NYSDJ AUGUST/SEPTEMBER 2005
THE SINGLE ANTERIOR TOOTH replacement remains a complex

aesthetic challenge for technicians and clinicians in restorative
dentistry. This challenge exists in either composite restorative systems or porcelain systems while attempting to achieve true harmonization of the primary parameters in aesthetics (that is, color,
shape, texture). While porcelain designing relies on stone models,
photographs and the clinicians narrative description to the laboratory technician, direct restorative resin reconstruction relies on the
surrounding dentition for correlation. The proximate environment
commands the appearance of any restoration. Increased patient
demand for aesthetic dentistry with minimal invasive procedures
has resulted in the extensive use of freehand bonding of composite
resin to address this challenge.
Achieving a restorative result with optimal physical and
mechanical characteristics often required the use of a combination
of hybrid and microfill. The hybrid provided the strength and
sculptability, and the microfill furnished the polish and durability
of the restoration.An incremental layering technique with composite resin resulted in an optimal depth of cure while reducing the
effects of shrinkage and stress forces during the polymerization
process.1, 2 Yet, when different restorative composites of varying
refractive indexes, shades and opacities were stratified, clinicians
observed a polychromatic effect.3 However, by using an anatomic

stratification with successive layers of dentin, enamel and incisal
composite, a more realistic depth of color could be achieved, as well
as surface and optical characteristics that mimic nature.4-5
The development of the polychromatic restoration from the
inequities of the different composite resin systems (hybrid and
microfill) stimulated scientists, researchers, clinicians and manufacturers to explore and develop restorative materials that are not
only applied in relationship to the natural tissue anatomy, but also
have similar physical, mechanical and optical properties of the
tooth structure.
In the past decade, aesthetic dentistry has continued to evolve
through innovations in restorative materials, bonding systems,
function-based treatments, conservative preparation design and
adhesive placement techniques. Such advances have increased the
restorative opportunities available for discriminating patients, and
have provided solutions to many of the aesthetic challenges faced
by clinicians. Increased use of composite materials to restore the
anterior dentition has drawn increased attention to contemporary
technological advances in restorative and aesthetic dentistry.
Contemporary Technological
Advances: Nanotechnology
In composite resin technology, particle size and the amount of particles represent crucial information in determining how best to use
the composite materials.Alteration of the filler component remains
the most significant development in the evolution of composite
resins,7 because filler particle size, distribution and the quantity
incorporated dramatically affect the mechanical properties and the
clinical success of composite resins.8 In general, mechanical and
physical properties of composites improve in relationship to the
amount of filler added. Many of the mechanical properties depend
upon this filler phase, including compression strength and/or hardness, flexural strength, the elastic modulus, coefficient of thermal
expansion, water absorption and wear resistance.
Nanotechnology or molecular manufacturing9 may provide
composite resin with filler particle size that is dramatically smaller
in size, can be dissolved in higher concentrations and polymerized
into the resin system with molecules that can be designed to be compatible when coupled with a polymer, and provide unique characteristics (physical, mechanical and optical). In addition, optimizing
the adhesion of restorative biomaterials to the mineralized hard tissues of the tooth is a decisive factor in enhancing the mechanical
strength and marginal adaptation and seal, while improving the reliability and longevity of the adhesive restoration.
Currently, the particle sizes of conventional composites are so
dissimilar to the structural sizes of the hydroxyapatite crystal, dental tubule and enamel rod, there is a potential for compromises in
adhesion between the macroscopic (40 nm to 0.7 um) restorative
material and the nanoscopic (1 nm to 10 nm in size) tooth structure.10 However, nanotechnology has the potential to improve this
continuity between the tooth structure and the nano-sized filler
particle and provide a more stable and natural interface between
the mineralized hard tissues of the tooth and these advanced

restorative biomaterials.
The following clinical presentation describes the use of a nanoparticle hybrid composite resin system (Premise, Kerr/Sybron, Orange, CA).
Preoperative Considerations
Prior to initiating the restorative procedure, an occlusal analysis of

the anatomical morphology of the tooth is performed and transferred to a hand-drawn diagram. This diagram acts as a restorative
roadmap for the clinician and can include such information as:
dentin and enamel intercolor contrasts; translucency patterns;
crazing; hypocalcification spots; incisal and gingival blending; and
stain patterns. Also, a preoperative selection of composite resins
and tints and modifiers with their shade and orientation is recorded. Shade selection should be accomplished prior to rubber dam
placement to prevent improper color matching as a result of dehydration and elevated values.11 When teeth dehydrate, the air
replaces the water between the enamel rods, changing the refractive
index that makes the enamel appear opaque and white.12
In addition, the preoperative occlusal stops and excursive
guiding planes can be recorded with articulation paper and can be
transferred to a hand-drawn occlusal diagram, recorded on an
intraoral or digital camera or indicated and reviewed on a stone
model. This initial registration is valuable in preparation design
when determining placement of centric stops beyond or within the
confines of the restoration, in determining the proper restorative
material thickness of the artificial enamel and artificial dentin, and
in minimizing finishing procedures.13
Restoration of Anterior Fracture:
Class IV Restoration
A 35-year-old male patient presented with a fractured maxillary

left central incisor (Figure 1). Upon self-assessment the patient
requested the most conservative and aesthetic restorative procedure available. Shade determination was accomplished by custom
fabricated shade comparison (Figure 2) and instrumental shade
analysis (ShadeScan, Cynovad, Montreal, Canada), and a previsualized
Figure 1. Preoperative facial view of fractured

maxillary left central incisor.
Figure 2. Custom-fabricated
shade tabs were developed
from composite material and
compared to existing tooth
structure.
NYSDJ AUGUST/SEPTEMBER 2005 31
A
Figure 3. Chamfer
0.3 mm in depth was
placed 2 mm long
around entire margin.
Figure 4. 0.5 mm
scalloped bevel was
placed with long,
tapered diamond bur.
Figure 5.
Preparation was
cleaned with 2%
chlorhexidine.
Figure 6. Preparation was etched for

15 seconds with 37.5%
phosphoric acid (Gel
Etchant, Kerr/Sybron,
Orange, CA).
color mapping (hand-drawn diagram and computer diagram) were

developed to anticipate the final result as previously indicated in
the preoperative considerations.
To facilitate access to the cervical region of the tooth, the field
was first isolated with a rubber dam using a modified technique.
This process involved creation of an elongated hole that allowed
placement of the rubber dam over the retainers to achieve adequate
field control.14,15 Once the extent of the preparation was determined,
a cervical chamfer 0.3 mm in depth was placed 2 mm long around
the entire margin to increase the enameladhesive surface and to
provide a sufficient bulk of material at the margins.16
A scalloped bevel on the chamfer was placed to break up the
straight chamfer line with a long tapered diamond (6850, Brasseler
USA, Savannah, GA) (Figure 3). Since the margin was on enamel, a 0.5
mm bevel was placed on the gingival margin to reduce microleakage with a needle-shaped fine diamond (DET-9, Brasseler, USA,
Savannah, GA) (Figure 4). The lingual aspect of the chamfer was
extended 2 mm onto the lingual surface, but not onto the occlusal
contact area. The margin should not end on the occlusal contact
area unless relocating it to a contact free area would require excessive reduction of healthy tooth structure.
The preparation was completed with a finishing disk and polished with rubber cups that contained a premixed slurry of pumice
and 2% chlorhexidine (Consepsis, Ultradent, South Jordan, UT) (Figure 5).
The preparation was rinsed and lightly air dried, and a soft metal
strip was placed interproximally to isolate the prepared tooth from
the adjacent dentition.
The total etch technique was used because of its ability to
minimize the potential of microleakage and to enhance bond
strength to dentin and enamel.17-19 The preparation was etched for
15 seconds with 37.5% phosphoric acid semi-gel (GEL-Etchant,
Kerr/Sybron, Orange, CA), rinsed for five seconds and gently air dried for
five seconds (Figure 6). Once a hydrophilic adhesive agent (Optibond
Solo Plus, Kerr/Sybron, Orange, CA) was applied for 20 seconds with a
Microbrush (Microbrush, Grafton, WI) disposable applicator using continuous motion, the excess was removed with the same applicator,
and the agent was light cured for 20 seconds (Figures 7 A-C).
Although a small amount of excess adhesive can be applied over the
Figure 7. (A) Single component adhesive (OptiBond SOLO plus,

Kerr/Sybron, Orange, CA) was applied in continuous motion for 20
seconds. (B) Air thinned for 5 seconds. (C) Light cured for 20 seconds.
margins to improve sealing, this excess should be removed during

finishing procedures to avoid adverse periodontal sequellae.
Proximal Adaptation Technique
Since composite does not have hydroxyapatite crystals, enamel

rods and dentinal tubules, the final composite restoration
requires the clinician to develop an illusion of the way light is
reflected, refracted, transmitted and absorbed by these microstructures of the dentin and enamel. Therefore, in recreating the
proximal surface, a similar orientation of enamel and dentin is
required. Since a silhouette of the cavity form is highlighted by
the darkness of the oral cavity, which is described as shine
through, it is necessary to use an opacious dentin replacement
with higher color saturation. This ensures that when light strikes
the optically denser dentin with more color saturation, more light
is reflected back to the eyes. To reproduce the optical effects of the
enamel, a translucent composite encapsulates the inner dentin
core and alters the quantity and quality of the light as it is reflected back to the eyes.
An infinitesimal amount of glycerin was applied to the mesial
surface of the maxillary right central with unwaxed floss (Figure 8).
The proximal adaptation technique was used because it allows
optimal adaptation of the initial composite layer to the adjacent
tooth without using a mylar plastic strip. Although studies indicate
a smooth surface can be attained with the mylar strip, improper
proximal adaptation can result in inadequate contact, improper
anatomical form and shape, and surface defects.
Opacious dentin replacement was selected for strength and
color, and the most suitable restorative materials for the core of
these restorations were the hybrids and the microhybrids.
Because these small-particle hybrids have refractive properties
and a variety of color selections similar to that of dentin, they
imitate the natural tooth structure extremely well and have
enough resistance for most occlusal stress-bearing regions in
the anterior segment. (Premise, Kerr/Sybron, Orange, CA; Venus, Heraeus
Kulzer, Armonk, NY; Gradia, GC America, Alsip, IL; Vitalescence, Ultradent, Salt
Lake City, UT; Filtek Supreme, 3M ESPE, St Paul, MN; Point 4, Kerr/Sybron,
Orange, CA).
Artificial Dentin Layer
The initial artificial dentin body layer of opacious B-1 shaded

hybrid composite resin (PremiseTM Kerr/ Sybron, Orange CA) was applied,
adapted and contoured to the proximal surface of the contralateral
central incisor with a long-bladed interproximal instrument,
smoothed out with a sable brush and light cured for 40 seconds,
which allowed placement of subsequent increments without
deforming the underlying composite layer (Figure 9). An elliptical
increment of opacious B-1 shaded hybrid composite resin was
placed from the incisolingual aspect to form an incisal matrix.
While the material was still soft, vertical and horizontal invaginations were placed with a long-bladed composite instrument,
smoothed with a sable brush, and light cured for 40 seconds from
the facial and lingual aspects (Figure 10). It was crucial to maintain
a smooth internal surface, since surface irregularities could have
interfered with placement of the tints for internal characterization.
In addition, these invaginations created translucency and provided
regions for placement of tints. In order to prevent overbuilding of
the artificial dentin layer, it is imperative to monitor the composite
from the incisal aspect to provide adequate space for the final artificial enamel layer.
Figure 8. Glycerin
was applied to proximal
surface of maxillary
right central using
un-waxed floss as
separating medium.
Figure 9. First layer

of artificial dentin
body, opacious B-1
shaded hybrid composite was applied
and contoured to
proximal surface of
contralateral central
incisor with longbladed instrument.
Figure 10. Increment

of composite was
added to incisoligual
aspect and contoured,
followed by placement
of vertical and horizontal invaginations.
Restoration was
then light cured
for 40 seconds.
Figure 11. Diluted white tint was applied in vertical

and horizontal invaginations and placed along
interface to disguise fracture line.
Figure 12. Diluted gray

tint was applied vertically
corresponding to contralateral central and to create
illusion of translucency.
ization technique uses color variation to emphasize the nuances of

color in the incisal edge and instill the restoration with a threedimensional effect.
Artificial Enamel Layer
The enamel or artificial enamel layer is the principal determinant

of the value of tooth or the restoration;21 this can be varied by the
thickness of this layer. The enamel is colorless, but through its network of rods acts as a fiber optic conduit and projects the underlying color found in the dentin. The nanoparticle hybrid (Premise,
Kerr/Sybron, Orange, CA) used in developing this restoration has four
translucent shades: super clear, clear, amber and gray.
A super clear translucent-shaded hybrid composite was
applied and contoured with a long-bladed composite instrument.
A precut mylar strip was placed and adapted over the facial surface
and light cured from the facial and the lingual aspects for 40-second intervals, respectively (Figures 13 A,B). Developing the restoration in increments and considering the occlusal morphology and
occlusal stops allows the clinician to minimize finishing procedures
and results in a restoration with improved physical and mechanical
characteristics with less microfracture.
After placing the last layer of composite and prior to final cure,
an oxygen inhibitor, Glycerin (Insure, Cosmedent, Chicago, IL) or DeOxTM (Ultradent, South Jordan, UT), is applied in a thin layer with a
brush to the surface of the restoration and light cured for a twominute post cure.22
Internal Color Characterization
A thin layer of resin can be applied and cured to create a light diffusion layer and provide an illusion of depth for restorations of
limited thickness. This translucent layer will cause an internal diffusion of light and control luminosity within the internal aspect of
the restoration.20 A white tint (Kolor Plus, Kerr/Sybron, Orange, CA) was
placed along the fracture line and on specific regions in the vertical
invaginations corresponding to the schematic color mapping diagram of the contralateral central and light cured for 40 seconds
(Figure 11). A gray tint (Kolor Plus, Kerr/Sybron, Orange, CA) was placed
on specific regions in the vertical invaginations corresponding to
the schematic color mapping diagram of the contralateral central
and light cured for 40 seconds (Figure 12). This internal character-
Figure 13. (A) Super-clear translucent shaded hybrid was placed at the incisal
third of tooth. (B) Precut mylar strip was placed and adapted over facial surface
to achieve smooth surface and light cured.
A
Figure 14. To reproduce natural form
and texture, initial
contouring was
performed with #30
fluted, needle-shaped
finishing bur.
Figure 15. Contouring and finishing of

lingual aspect were
accomplished with
#30 fluted, egg
shaped finishing bur.
Figure 16. Interproximal region was

finished with aluminum
oxide finishing strips
that were used
sequentially according
to grit and ranged from
coarse to extra fine.
Figure 17. Final

polish was performed
with silicone points
to eliminate surface
defects.
Figure 18. (A) Definitive polish and high luster were accomplished
with soft goat hair bush with composite polishing paste. (B) With
cloth wheel using staccato motion.
Finishing and Polishing Procedure
Finishing focuses on contouring, adjusting, shaping and smoothing the restoration, while polishing concentrates on producing a
smooth surface luster and highly light-reflective surface.23 The
final restorative phase was achieved by contouring and finishing
the restoration, which remains critical to the enhancement of
esthetics and the longevity of the restored teeth.24,25 To reproduce
the shape, color and gloss of the natural dentition, while enhancing the esthetics and longevity of the restoration, the following
protocol was implemented.
Surface texture of composite restorations is relatively hard to
achieve, demanding intensive training and meticulous attention to
technique coupled with very attentive observation of natural teeth.
In this case,particular attention was given not only to the relationship
between the expanse and direction of the marginal ridge, lingual
fossa and the anatomic variations of the teeth that will be adjacent
to the restoration, but also to the light refraction and surface reflection resulting from microstructure of the tooth surface.26
The initial contouring was performed with a series of finishing
burs to replicate form and texture. The facial contouring was initiated with #30 fluted, needle-shaped burs (BluWhite Diamonds and
Carbides, #7714, Kerr/Sybron, Orange, CA) (Figure 14). The lingual surfaces
were contoured with #30 fluted, football-shaped burs (BluWhite
Diamonds and Carbides, #9406, Kerr/Sybron, Orange, CA) (Figure 15).
Finishing the proximal, facial and incisal angles was performed
with aluminum oxide disks and finishing strips (Figure 16). These
were used sequentially according to grit, and ranged from coarse to
extra fine. For characterization, finishing burs, diamonds, and rubber wheels and points were used to create indentations, lobes and
ridges (Figure 17). The definitive polish and high luster was accomplished with a soft white goat hair brush with composite polishing
paste (Diamond Polishing Paste, Kerr/Sybron, CA) and a cloth wheel using
staccato motion (Figures 18 A,B).
The contact was tested with unwaxed floss to ensure the
absence of sealant in the contact zone, to verify adequate contact
and the absence of a gingival overhang, and to inspect the margins.
The rubber dam was removed, and the patient was asked to perform closure without force and then centric, protrusive and lateral
excursions.Any necessary occlusal equilibration was accomplished
with a 30-micron, egg-shaped finishing diamond bur, and the final
polish was repeated.
The surface quality of the composite is influenced not only by
the polishing instruments and polishing pastes, but also by the
composition and filler characteristics of the composite.27 The newer
formulations of nanocomposites with smaller particle size, shape
and orientation, and increased filler concentration provide
improved physical, mechanical and optical characteristics.Although
clinical evidence of polishability with these new nanoparticle
hybrids appears promising, the long-term durability of the polish
will need to be evaluated in future clinical trials.
The completed restoration reveals the harmonious integration
of composite with natural tooth structure that can be achieved
while developing an optimal proximal contact and marginal
integrity in the interproximal zone through the use of incremental
layering of composite resin and the proximal adaptation technique
(Figures 19 A, B).
Conclusion
This article has reviewed the advances in composite resin technology and provided a detailed description of the preparation design,
restoration and finishing protocol for a Class IV fracture on a maxillary left central incisor using a nanoparticle composite resin system, Premise.
Figures 19 A, B. Postoperative facial view of restored central incisor. Note harmonious integration of composite with natural tooth structure in interproximal zone.
Although the long-term benefits of this material remain to be

determined, the use of an optimized particle composite in the
aforementioned patient demonstrated enhanced sculptability, the
polishability of a microfill, the strength of a hybrid and the ability
to simulate the optical properties of the natural tooth.
While the evening news may fail to report the technological
advancements that led to the development of the optimized particle composite, another milestone in the practice of dentistry has
occurred in the endless quest for the ideal composite.
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with composite resins. Pract Perio Aesthet Dent 1995;7(8):13-21.
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13. Liebenberg WH. Successive cusp build-up: an improved placement technique for posterior direct resin restorations. J Canad Dent Assoc 1996;62(6):501-507.
14. Liebenberg WH. General field isolation and the cementation of indirect restorations:
Part 1. J Dent Assoc of South Afr 1994; 49(7): 349-353.
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16. Bichacho N. Direct composite resin restorations of the anterior single tooth: clinical
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20. Vanini L. Light and color in anterior composite restorations. Pract Periodont Aesthet
Dent 1996;8(7):673-682.
21. Muia PJ. Esthetic Restorations: Improved Dentist-Laboratory Communication. Carol
Stream, IL: Quintessence Publishing 1993: 86-87.
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23. Schwartz RS, Summitt JB, Robbins JW. Finishing and Polishing. In: Fundamentals of
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25. Goldstein RE. Finishing of composites and laminates. Dent Clin North Am 1999;
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The Unilateral Posterior Functional Crossbite

An Opportunity to Restore Form and Function
Elliott M. Moskowitz, D.D.S., M.Sd
Abstract
The unilateral posterior crossbite (UPXB) with functional
shift of the mandible is commonly encountered in young
children and adolescents. Differential diagnosis and the
impact this type of malocclusion might have upon the
growth and development of dental and facial components
are discussed.
Impaired function and compromised facial esthetics may
be consequences of untreated UPXBs with functional shifts.
Appropriate treatment protocols and specific orthodontic
appliances intended to correct these problems are presented.
POSTERIOR CROSSBITES in the mixed or permanent dentition represent deviations from normal bucco-lingual occlusal relationships.
Posterior crossbites can be caused by malpositions of individual or
groups of posterior teeth (dental crossbites), malpositions of posterior
teeth accompanied by a functional shift of the mandible (functional
crossbites), or transverse disharmonies of the maxilla and mandible
(skeletal crossbites). Frequently, posterior crossbite relationships may
be caused by a combination of the aforementioned factors.
Posterior crossbites are frequently observed as lingual crossbites (Figure 1), but may also be found in buccal crossbite relationships (Figure 2).
There is a wide range of reported incidences of unilateral posterior crossbite (UPXB) in the primary and mixed dentition. The
incidence of UPXB has ranged from 7% to 23%.1-7 Posterior crossbites have been reported to develop between 19 months and 5 years
of age, with approximately 80% of UPXBs being accompanied by
functional shifts of the mandible.8
The posterior crossbite with functional shift of the mandible
should be differentiated from posterior dental crossbites without
functional shifts. Figure 3 is a posterior dental crossbite caused by
an individual tooth malposition of the maxillary left molar. Note
that the maxillary and mandibular dental midlines coincide. This
type of crossbite can be treated by moving the tooth (or teeth) in
crossbite into normal position.
However, the situation in Figure 4 is quite different. The
observed crossbite relationship in the maximum intercuspation
position appears to be identical to the dental crossbite anomaly. A
closer look, however, reveals a notable disparity between the maxillary and mandibular dental midlines. The mandible has shifted (to
the side of the observed crossbite) as it encountered prematurities
upon closure. If we were to place the mandible in its normal transverse position (lining up the true maxillary and mandibular dental
midlines), we would observe the actual transverse relationship
between the maxillary and mandibular posterior teeth (Figure 5). It
becomes apparent that both the right and left sides of the maxillary
posterior segments are lingually displaced. Consequently, the functional crossbite (even though it resembles the dental posterior
crossbite in the maximum intercuspation position) is a result of a
Figure 1. Most posterior

crossbites are observed
as lingual crossbites.
Maxillary left molar is
situated lingual to its
normal position.
Figure 2. Although less

frequently encountered,
some posterior crossbites
are buccal crossbites.
Maxillary molar is
positioned buccally,
and mandibular molar
is positioned lingually.
Figure 3. Posterior
dental crossbite: definite
occlusal stop in position
of maximum intercuspation. Normal buccolingual inclinations of
opposing molars on right
side. Abnormal tipping
on left side. Maxillary
and mandibular dental
midlines coincide.
Figure 4. Posterior
functional crossbite: with
teeth in maximum intercuspation, unilateral
crossbite is seen.
Opposite side appears
to occlude normally.
Mandibular midline is
shifted toward crossbite side.
Figure 5. Functional crossbite on left displays

mandibular transverse shift to patients left side as
result of occlusal prematurities. Lining up true upper
and lower dental midlines (by shifting mandible to
patients right side) reveals actual transverse relationship between maxillary and mandibular dental
arches. Maxillary dental arch is now seen as being
constricted bilaterally.
Figure 8.
Patient R.G.
displays facial
asymmetry as
result of transverse shift of
mandible upon
closure.
Figure 6. Patient R.G. has unilateral posterior crossbite with functional shift
of mandible (to patients left side). Upper and lower dental midlines are
characteristically disparate.
Figure 7. Diagrammatic
depiction of transverse shifting
of mandible associated with
unilateral posterior crossbites.
bilateral constriction or narrowness of the maxillary dental arch

and, therefore, requires bilateral posterior expansion.
The young patient, R.G., in the composite intraoral photograph
(Figure 6) has UPXB in the mixed dentition with functional shift of
the mandible. Note that the left side is observed in crossbite and the
right side appears normal in the maximum intercuspation position. The maxillary and mandibular dental midlines are significantly disparate. In cases of functional crossbites, the mandible shifts to
the side of the observed crossbite (Figure 7). Facial asymmetries can
be either subtle or significant. Figure 8 reveals patient R.G.s facial
asymmetry, caused by a lateral or transverse shift of the mandible.
Need for Orthodontic Treatment
Posterior crossbites with functional mandibular shifts should be

treated earlier rather than later.9 In general, the mixed dentition
stage is an ideal time to treat UPXBs with functional shifts; however, they may be treated in the primary dentition as well. The dentitional status (presence of permanent maxillary and lateral incisors
and first permanent molars) and important management considerations are usually favorable during the mixed dentition. From a
practical perspective, few patients in the primary dentition are seen
by most orthodontists on a routine basis.
There is ample empirical and evidenced-based information to
support the need for treatment while skeletal and dental growth
and development are relatively active. Pinto, et. al.10 found both
positional and morphological changes in young patients with posterior functional crossbites. Condylar position and length of the
mandibular skeletal structures, particularly the mandibular ramus,

differed when bilateral structures were compared. Interestingly, it
was also found that compensatory growth during and after maxillary expansion eliminated positional and morphological asymmetries observed before treatment. Simply stated, both form and function were restored via maxillary expansion and elimination of the
functional shift of the mandible.
Sonneson, et al.11 measured the bite force of patients with and
without posterior functional crossbites with pressure transducers.
They found a significant increase in muscle tenderness and other
TMD symptomology in the crossbite sample. Additionally, bite
force was also decreased in patients with crossbites. These investigators concluded, The early treatment of unilateral posterior crossbites was advisable to optimize conditions for function.
Figure 9 shows a composite photograph of an adult patient,
G.W., with a longstanding left side crossbite relationship and functional shift of the mandible to the left side. The facial asymmetry is
notable. The anteroposterior cephalometric radiograph (Figure 10)
confirms the asymmetric mandibular skeletal structures as a result
of continued differential growth and development while the mandible
was positioned in an abnormal transverse relationship.
Several viable treatment options were offered to the patient.
These options included a combined orthodontic/orthognathic surgical protocol (which might have fully corrected the skeletal disharmonies) and a sole conventional orthodontic treatment intended to
merely improve the mandibular asymmetry by allowing the
mandible to assume a more normal transverse position after funcNYSDJ AUGUST/SEPTEMBER 2005 37
Figure 9. Adult patient, G.W., displays facial

asymmetry as result of longstanding functional
crossbite that persisted during growth.
Figure 12. E.H. is 8-year-old female displaying

classic UPXB in mixed dentition.
Figure 10. Anterior-posterior

cephalometric radiograph confirms mandibular asymmetry.
Figure 13. Facial asymmetry of E.H. as

result of functional shift of mandible.
tional interferences were removed. The patient rejected orthognathic surgery and opted for conventional orthodontic treatment,
which entailed maxillary dental expansion and the use of fixed
orthodontic appliances to improve inter- and intradental relationships. Figure 11 is a post-treatment composite showing significant
inter- and intradental arch corrections. The facial asymmetry has
been reduced as the mandible assumed a more normal transverse
relationship. The remaining asymmetry is due to unchanged bilateral morphological mandibular structural differences that naturally would not be expected to fully correct without the assistance of a
surgical procedure.
Treatment
The treatment of posterior crossbites with functional shifts generally entails use of an orthodontic appliance that is capable of
effecting bilateral expansion of the maxillary dental arch and/or
expansion of the palate via sutural disjunction. The clinician
should assess the level of orthodontic correction that is needed
beyond the mere elimination of the functional shift using the same
criteria that are appropriate for the diagnosis, treatment planning,
choice of appliance(s) and retention requirements of any prospective orthodontic patient.
E.H. is an 8-year-old female with UPXB with functional shift in
the mixed dentition (Figure 12). The right side displays a complete
Figure 11. Post-orthodontic treatment composite illustrating dental and facial improvement.
Figure 14. Fixed palatal expansion device used in

treatment of E.Hs functional crossbite.
crossbite relationship from the maxillary right primary canine to

the maxillary right first permanent molar. The mandible has shifted to the patients right side as a result of prematurities caused by
the malpositions of the teeth and constriction of the maxillary dental arch. The maxillary and mandibular dental midlines do not
coincide. The early effects of the transverse malpositioning of the
mandible in the lower third of the face can be seen in Figure 13. A
fixed palatal expander (Figure 14) was placed, and the parent was
instructed to activate the expansion screw with a key once a day.
This early or phase I treatment extended approximately nine
months. Figure 15 shows the composite post-treatment outcome.
Note the elimination of crossbites, dental midline coincidence and
improvement in facial symmetry (Figure 16).
The 9-year-old patient in Figure 17 has UPXB with functional
shift (to the patients right side) in the mixed dentition. The dental
midlines do not coincide.A removable expansion appliance was prescribed (Figure 18) to effect bilateral dental expansion. The patient
or parent activated the expansion screw placed in the palatal portion
of the appliance. Note that the occlusal acrylic portion of the removable appliance covers the buccal surfaces of the posterior teeth to
minimize occlusal interferences and unwanted tipping of the buccal
segments. The crossbite and functional shift were corrected in less
than six months. Figure 19 shows the correction as the patient continues to develop into the permanent dentition.
Figure 15. Post phase I treatment demonstrating

return to dentofacial harmony in mixed dentition.
Figure 16. Facial asymmetry of

E.H. eliminated.
Figure 18. Removable dental

expansion appliance with
occlusal coverage.
Figure 17. UPXB with functional shift in mixed dentition.
Figure 19. Correction of UPXB.
Figure 21. Bonded

palatal expanding
device with occlusal
coverage.
Figure 20. Patient P.C. with UPXB and functional shift in permanent dentition.
Figure 22. Correction of functional crossbite and improvement in inter- and

intradental relationships.
P.C. is a 16-year-old female in the permanent dentition with

UPXB and functional shift of the mandible to the right side (Figure
20). A fixed palatal expander with occlusal acrylic coverage was bonded to the maxillary dental arch (Figure 21). This type of fixed
expander can eliminate occlusal interferences during treatment, minimize unwanted vertical changes that sometimes accompany palatal
expansion, and obviate the need for separation and banding of posterior teeth. Treatment extended approximately 16 months and included a brief period of conventional fixed orthodontic appliances to coordinate inter- and intradental relationships. Figure 22 shows the posttreatment outcome, in which the functional crossbite was eliminated.
Conclusions
UPXB with functional shift of the mandible is a type of malocclusion that can impair both form and function in growing individuals. Pediatric dentists and other clinicians who choose to treat
children and adolescents should be keenly aware of the diagnostic features of UPXB with functional shifts and recommend orthodontic corrective procedures earlier rather than later. The mixed
dentition is an ideal stage to consider beginning orthodontic
treatment in these types of cases.
The successful resolution of UPXB with functional shift represents a valuable and conservative dental health service for
individual patients with this type of malocclusion.
REFERENCES
1. Kutin G, Hawes RR. Posterior crossbites in the deciduous and mixed dentition. AM J
Orthod 1969;56:491-504.
2. Day AJ, Foster TD. An investigation into the prevalence of molar crossbite and some
associated etiological conditions. Dent Pract. 1971;21:402-10.
3. Infante PF. An epidemiologic study of finger habits in preschool children as related to
malocclusion, socioecononomic status, race, sex, and size of community. J Dent Child
1976;1:33-8.
4. de Vis H, de Boever JA, van Cauwenberge P. Epidemiologic survey of functional conditions of the masticatory system in Belgian children aged 3-6 years. Comm Dent Oral
Epidemiol 1984;12:203-207.
5. Heikinheimo K, Salmi K. Need for orthodontic intervention in five-year-old Finnish
children. Proc Finn Dent Soc 1987;83:165-9.
6. Hannuksela A, Laurin A, Lehmus V, Kouri R. Treatment of crossbite in early mixed dentition. Proc. Finn Dent Soc. 1988;84:175-82.
7. Kurol J, Bergland L. Longitudinal study and cost-benefit analysis of the effect of early
treatment of posterior crossbites in the primary dentition. Eur J Orthod 1992;14:173-9.
8. Thilander B,Wahlund S, Lennartsson B.The effect of early interceptive treatment in children with posterior crossbite. Eur J Orthod 1984;6:25-34.
9. Gottlieb Eugene, Moderator, JCO Roundtable, Early Orthodontic Treatment, Part 2. J
Clinical Orthod March, Volume XXXVIII, Number 3:135-154.
10. Pinto,AS, Buschang, PH, Throckmorton GS, Chen P. Morphological and positional asymmetries of young children with functional unilateral posterior crossbite. Am. J. Orthod.
2001;20:513-520.
11. Sonnesen L, Bakke M, Solow B. Bite force in pre-orthodontic children and unilateral
crossbite Eur. J. Orthod. 2001;23:741-749.
12. Moskowitz E. Orthodontics in the Progressive Dental Practice. In Essential Dental
Handbook. Tulsa, OK: PennWell Corp. 2003:387-430.
TONGUE PIERCING
Risk Factor to Periodontal Health
Jennifer Choe, D.D.S.; Khalid Almas, B.D.S., M.Sc., FRACDS, FDSRCS, FICD; Robert Schoor, D.D.S.
Abstract
Body piercing has grown in popularity among teenagers
and young adults. Dating back to antiquity, piercing is a
cultural practice used in ceremonial or religious rites; however, today, it is commonly exercised as a method of selfexpression. Different complications and side effects are
associated with intraoral piercing, including pain, swelling,
infection, gingival trauma, chipped or fractured teeth,
increased salivary flow, calculus buildup, and interference
with speech and swallowing. We present a case report of
periodontal treatment of traumatized gingival tissue
caused by a tongue stud. The step-by-step periodontal
surgical management of the case has been elaborated.
The role of oral and dental health care professionals in
managing the growing problem of tongue piercing as a
periodontal risk factor has also been highlighted.
ALTHOUGH ORAL PIERCING IS POPULAR among certain cultures and in some developing countries, only recently has it gained
partial acceptance in Western society.1-3 Body beautification, decoration and body art are ancient practices that have been exercised
by humans across cultures for centuries. Intentional, irreversible
changes to the human body have been practiced by older, as well as
modern, civilizations for a variety of reasons. The most common of
these are expressing spiritual devotion or dedication to magic, fulfilling social demands, making a personal statement or enhancing
individual sex appeal. A multitude of body beautification procedures were in use by older civilizations and are commonly seen
today, especially in developing countries. Among these are skin tattooing, branding and piercing of ear lobes and the nose.4
Oral body art, as it is referred to, usually involves piercing of the
tongue, cheeks, lips or uvula. The lip is the most commonly pierced
site, but tongue piercing is becoming more prevalent.With the growing number of oral piercings being performed,it is vital that dentists
are aware of the risks, complications and dental implications associated with such procedures.1 This article includes a case report on
tongue piercing, periodontal trauma and its surgical management.
And it presents the topic of oral piercing with special emphasis on
complications and ethical considerations for dental professionals.
Figure 1. Metallic tongue stud opposing lingual

aspect of tooth #25.
Figure 2. Occlusal view of tooth #25 with gingival

cleft on lingual aspect.
Figure 3. V-shaped cleft (gingival recession).
Case Report
A 26-year-old Caucasian male patient was referred to the New York

University College of Dentistry Department of Periodontics for evaluation of the lingual aspect of tooth #25. An initial clinical and radiographic evaluation was performed.A periapical radiograph revealed
localized horizontal bone loss associated with tooth #25. Clinical
evaluation of the midlingual aspect of the tooth illustrated isolated 5
mm of gingival recession, a probing pocket depth of 4 mm and localized inflammation. No other sites displayed any loss of attachment.
The patient had scaling and root planing performed by his
dentist one week before visiting the department, and there was no
evidence of supragingival plaque or calculus. There was no mobility associated with any of the teeth, and there was an absence of
occlusal interferences. The localized gingival defect was directly
opposed to the location of the patients tongue stud (Figures 1-4). In
general, the patients oral hygiene was good.
Periodontal Treatment
After a complete intraoral examination and periodontal charting, a

treatment plan was formulated that included removal of the tongue
stud and a subepithelial connective tissue graft on the lingual
aspect of tooth #25. As the probing pocket depths ranged from
1 mm to 3 mm in other areas of the mouth, and the patient had
maintenance prophylaxis prior to his examination, supragingival
scaling was not performed.
Figure 4. Tooth #25

with circumferential
osseous defect.
Figure 5. Local anesthesia infiltration given.
Surgical Procedure
Following local anesthesia on the lingual aspect of teeth #22-27 and

on the palatal aspect of teeth #12-15, using two carpules of lidocaine with 1:100,000 epinephrine, the area affected by the tongue
stud was accessed by a lingual full thickness mucoperiosteal flap
reflection using sulcular incisions. Care was taken to conserve the
papilla between the adjacent teeth (Figures 5-7).
Apical to the 5 mm of gingival recession on the lingual aspect
of tooth #25, a split thickness flap was reflected to accommodate a
connective tissue graft from the palatal site. Approximately 80% of
the attachment loss was localized to the lingual aspect of tooth #25.
The circumferential osseous defect was consistent with the inferior
ball of the tongue stud, extending more than 6 mm apical to the
cemento-enamel junction (CEJ). The connective tissue graft was
harvested from the palatal aspect of tooth #14, using an 8 mm long
Figures 6 & 7.
Lingual full thickness
flap reflection from
tooth #25.
Figure 6.
Figure 7.
Figure 8. Palatal
donor site of connective
tissue graft.
Figure 9. Connective
tissue (8 x 5 mm)
placed at defect site.
horizontal incision at a perpendicular angle to the palatal vault. A

second horizontal incision was placed parallel to the palatal vault to
dissect the connective tissue from the donor site.
An 8 x 5 mm piece of connective tissue with approximately
1 mm band of epithelium was yielded from the site (Figure 8). The
lingual surface of tooth #25 was swabbed with 10% tetracycline
solution, and the area was rinsed with sterile saline after one
minute. The enamel matrix derivative (Emdogain 0.3 ml, Straumann
Biologics Co., Waltham, MA 02451) was placed on the lingual aspect of
tooth #25, and the connective tissue graft was placed over the
exposed root surface. The epithelial aspect of the donor graft was
placed at the level of the CEJ.
The connective tissue was sutured with 5.0 vicryl interrupted
sutures placed on mesial and distal sides of tooth #25. The epithelial
flap was also sutured with 5.0 vicryl interrupted sutures to the mesial
and distal of tooth #25. The area was inspected for flap stability and
adequate tension relief. Additional Emdogain was placed over the
flap and the donor site. The metal tongue stud was removed. The
donor site was also sutured with the same material (Figures 9, 10).
Postop Instructions and Follow-up
Figure 10. Connective

tissue graft sutured with
5.O vicryl sutures.
Postoperative instructions included 500 mg Amoxicillin tablets

three times daily for one week, 800 mg Motrin (analgesic) as needed for pain, and rinsing with Chlorhexidine mouthrinse twice a day
for two weeks. The 10-day postoperative evaluation revealed
remarkable healing. The patient said he had minimal postoperative
discomfort (Figure 11).At our 4-month follow-up visit, the patients
oral hygiene had improved and attachment loss appeared to have
stabilized (Figure 12 ).
Discussion
Figure 11. Postoperative healing

after 10 days.
Figure 12. Postoperative healing

after four months.
The patient in this case report represents a situation that will occur
more frequently as the popularity of tongue piercing increases. And
while tongue piercing is gaining in popularity, it does not appear to
be a harmless fad. On the contrary, there is a risk of infection and
edema, which could cause a hazard to the airway.2 Consequently,
warnings have appeared in the popular press. And, according to a
recent report, experts from the Academy of General Dentistry have
warned that implanting jewelry in the tongue may lead to numbness,
loss of taste and mobility, and even a life-threatening blood clot.5
According to a recent report, common complications and
possible adverse consequences of oral piercing can be summarized as follows:1
Oral pain
Edema
Infection
Disease transmission
Airway obstruction secondary to swelling
Prolonged bleeding
Chipped or fractured teeth
Mucosal or gingival trauma

Interference with mastication and swallowing
Speech impediment
Hypersalivation
Hyperplastic or scar tissue formation
Nerve damage and paraesthesia
Aspiration of specific piercing jewelry
Foreign body incorporation into site of piercing
Obstruction of radiographic images
Calculus formation on metal surfaces
Metal hypersensitivity
The presence of a piercing in the oral cavity should be evaluated with its surrounding structures as a regular parameter when
performing an initial examination. The question about intraoral
piercing should also be incorporated into a questionnaire provided
for new patients in the dental practice.
In the patient described here,the trauma to the periodontal structure on the lingual surface of tooth #25 appeared to be directly caused
by the lower ball of a lingual stud, as no other patterns of attachment
loss were present in any other areas of the oral cavity. These findings
strongly implicate the piercing as the primary factor in this localized
traumatic periodontitis. It was recommended to our patient that he
remove the tongue stud as part of the treatment plan. The patient
agreed as he was well informed of the situation. Oral hygiene instructions were provided for long-term maintenance of
the tooth and mouth in general.
Of primary interest to the dentist are perioral
and intraoral piercings.These expressions of body art
became a dental concern over the past few years
because of the increased frequency of their use and
their influence on the health,function and esthetics of
oral tissues.Management of the consequences,either
direct or indirect, of oral piercing represents a basic
function in modern dental practices. Hence, an integral part of emergency procedures is to treat postoperative and latent complications and to perform comprehensive treatment planning, including restorative
treatment and periodontal follow-up care.4
The ADA opposes the practice of intraoral/
perioral piercing and supports legislation requiring parental consent of minors who want to be
pierced because of the potential for numerous negative sequelae.6 Each state has the opportunity to
consider legislation regarding the issue of minors
and the regulation of piercing parlors, which
would mandate the use of sterile equipment as
well as submission to OSHA guidelines and
inspections. The process starts at the local level
with dental professionals who can educate their
patients about the risks of piercing.7
Conclusion
Determination of the periodontal treatment for a localized mucosal or gingival defect resulting from disease or trauma in a mouth is
case dependent. Generally, the goals of periodontal treatment are to
restore the function and esthetics of periodontium and long-term
maintenance of teeth and gingival tissues.
The periodontal surgical procedure with connective tissue
graft has predictable outcome in the absence of causal trauma.
Dental professionals should be aware of oral and perioral piercing
and should be able to talk with their patients about these issues and
provide sound advice and comprehensive care for soft and hard tissue damage caused by oral piercing jewelry.
REFERENCES
1 . Farah CS, Harmon DM. Tongue piercing: case report and review of current practice.Aus
Dent J 1998; 43: 387-389.
2. Scully C, Chen M.Tongue piercing (oral body art).Br J Oral Maxillofac Surg 1994; 32:37-38.
3. Maibaum WW, Margherita VA. Tongue piercing: a concern for the dentist. Gen Dent
1997; 45: 495-497.
4. Bassiouny MA, Deem LP., Deem TE. Tongue piercing: a restorative perspective.
Quintessence Int 2001; 32: 477-481.
5. Jones HE. Are they just skin deep? RDH 1996;16:38-44.
6. American Dental Association. ADA statement on intraoral/perioral piercing. Available
at: http://www.ada.org/prof/resources/positions/statements/piercing.asp. January 2003.
7. Dunn WJ, Reeves TE. Tongue piercing: case report and ethical overview. General
Dentistry May-June 2004; 244-247.
Use of Interdisciplinary Team Approach

in Establishing Esthetic Restorative Dentistry
Dov M. Almog, D.M.D.; Sean W. Meitner, D.D.S.; Neer Even-Hen, D.D.S.;
Joshua P. Grant, D.D.S.; James L. Soltys, D.D.S.
Abstract
Managing crown lengthening in cases of attrition (wear or
loss of tooth substance) and achieving desired esthetic
outcomes, especially in the esthetic zone, is challenging.
This case report presents an interdisciplinary approach to
case management.
Concomitant use of digital imaging, along with model
wax-ups and surgical guide, were used to enhance patient
acceptance during treatment planning and to facilitate
communication and treatment implementation among dental professionals and laboratory technicians.
Resulting surgical template was used for crown
lengthening to apically position the gingival zenith (margin) to a predetermined level, crown preps and final
restorations, respectively, ultimately improving esthetics
and patient satisfaction.
Supplementing esthetic treatment planning with digital
imaging, model wax-ups and a surgical template allows a
dentist to carry information into the mouth and incorporate
it into the surgical procedure, crown preps, temps and,
ultimately, the final restoration.
AN INTERDISCIPLINARY APPROACH taken by a restoring dentist,

periodontist, dental laboratory and digital imaging technicians to
re-establish esthetics in a case of severe occlusal wear is presented.
Digital imaging is used during treatment planning to increase
patient acceptance and to facilitate communication among the
restorative and surgical dentists and dental laboratory.1 Using digital simulations, the planned prosthesis can be viewed in the context
of the surrounding soft tissues in a life-like manner. The rationale
for selecting digital imaging as a consultation tool was to better
describe the proposed treatment, making it easier to visualize the
proposed goals and enhancing the ability to share the anticipated
results with friends and family.
Often, crown-lengthening procedures are necessary for reestablishing esthetics. The rationale for a crown-lengthening procedure is to increase the apico-coronal height of the clinical crown
for a clinically acceptable prosthetic restoration.2-4 For a successful
treatment outcome, the dimension of the attachment apparatus
needs to be considered. To achieve stable soft-tissue levels and gingiva that is healthy in appearance, it is important to respect the
attachment apparatus. Unfortunately, it is common to violate the
attachment apparatus with restorative materials.5-9
After the crown-lengthening procedure, the surgical site may
be closed with a variety of suture techniques, such as single interrupted and continuous suture. The surgical approach that is presented in this case report includes use of subsidiary tacks to stabilize and position the tissues without the use of sutures. Tacks have
been used previously in surgical techniques for membrane stabilization and have been shown to be biologically compatible.10-11
B
Figure 1. Before (A) and computer-simulated after (B) close-up photographs.
This article and case study illustrate a multidisciplinary team

approach to the esthetic and prosthetic rehabilitation of the maxillary anterior region, using consultation adjuncts like digital imaging, model waxups and surgical templates,including subsidiary use of surgical tacks.
Case Report
A 53-year-old Caucasian male patient was evaluated for esthetics

concerns involving severe anterior occlusal wear. His chief complaint was that we fix his short front teeth.
His medical history revealed myocardial infarction five years ago;
the patient is taking medications to control hypertension and elevated
serum cholesterol.Following a full-mouth radiographic survey,an intraoral exam revealed dental restorations on all posterior teeth, including a
fixed partial denture from teeth #3-6 (of five years duration), and an
implant-supported crown on tooth #12 (of three years duration). All
anterior teeth from canine to canine in both the mandible and maxilla
presented with extreme wear to the incisal edges. Canine guidance did
not exist, as all anterior teeth contacted during excursive movements.
With the exception of marginal redness and swelling around teeth # 6
and 9, the patients gingiva was pink, firm and healthy in appearance
(Figure 1A).No radiographic evidence of bone loss was visible.
In order to obtain optimum therapeutic results and to execute
interdisciplinary care for this complex esthetic abnormality case, a
team of providers gathered to develop a consistent treatment philosophy, including diagnostic and treatment planning procedures.
Digital Imaging
Following a preoperative consultation among a team made up of a

prosthodontist, periodontist and laboratory technician, it was

determined by the team that the patient would benefit from digital
imaging simulations. After a detailed treatment plan was prescribed, preoperative facial and close-up digital photographs were
acquired with a digital camera (DX4900 Dental Digital Camera Kit,
Eastman Kodak Co., Rochester, NY).
Figure 2. A .020-inch vacuum plastic form was made over the stone cast duplicate
of the diagnostic wax-up, then trimmed to the scalloped outline of the gingival zenith
on the teeth.
Facial and close-up digital images of the patient were downloaded to a computer. Simulation of esthetic values of crown width
and height was achieved using a specialized dental imaging software (PracticeWorks/DICOMTM Cosmetic Imaging Software, Version 1.73,
Eastman Kodak, Atlanta, GA). Before and after 8-inch x 11-inch print
outputs were produced using a desktop printer (Kodak Personal Picture
Maker 200 by Lexmark, Eastman Kodak, Co., Rochester, NY) and glossy photographic paper (Kodak Desktop Medical Imaging Paper, Eastman Kodak, Co.,
Rochester, NY). The consultation adjunct output included a personalized before and after facial and close-up digital photograph
(Figure 1).
Diagnostic Wax-up/Surgical Template
B
Figure 3. A) Surgical template is placed over epically positioned flap to confirm
desired gingival margin. B) Surgical tacks are used to stabilize soft tissues.
Figure 4. Intraoral anterior view of maxillary anterior dentition 6 weeks after final
restorations have been delivered.
Impressions were made of both arches using stock trays and irreversible hydrocolloid. These were then cast in stone. The casts
were articulated in a semi-adjustable articulator (Hanau H2,
Waterpik Technologies, Fort Collins, CO). Concomitant with the digital
imaging output, using average values of crown width and height,
the gingiva was scalloped on the casts to achieve desired crown
length. A diagnostic wax-up was then completed to visualize the
final outcome. It is important to stress that the extra length was
achieved in a gingival direction almost exclusively, with only 1
mm added to the incisal edge. This is done both for esthetic reasons and to avoid excessive restorative materials from interfering
during function.
The diagnostic wax-up was duplicated and poured in dental
stone. A .020-inch vacuum plastic form was made over this cast,
then trimmed to the scalloped outline of the gingival zenith on the
teeth scheduled to have crown-lengthening surgery (Figure 2). This
vacuum-formed tray was designed to serve as a surgical guide template during the crown-lengthening procedure. Tooth #6 was not
included, as this was part of a fixed partial denture that was not
being replaced.
During the surgical visit, the mucoperiosteal flap was elevated beyond the mucogingival junction, allowing apical displacement of the gingiva. The surgical guide was then placed over the
teeth and used to position the gingival tissues to the apical margin of the planned prosthesis (Figure 3A). Subsidiary surgical
tacks, 5 mm in length, were then driven through the marginal
gingival tissues into the interproximal bone to stabilize the marginal tissue at the desired level as indicated by the surgical guide
(Figure 3B).
After four weeks of tissue maturation, teeth #7-11 were prepared for full coverage porcelain-fused-to-metal crowns. Full arch
Impergum-polyether impressions were taken (3M-ESPE, St. Paul, MN)
and poured in die stone. Acrylic temporaries were fabricated

(Coldpack, Motloid of Chicago, IL) using the diagnostic wax-up as a template. The patient returned four weeks later for crown placement
with provisional cement (Zone Non Eugenol, CADCO-VanR, Oxnard, CA).
After six weeks the crowns were cemented with a resinreinforced glass ionomer (FujiPlus, GC Corp., Tokyo, Japan)(Figure 4).
Discussion
Good team communication is critical to patient satisfaction in

esthetic dentistry. This article and case study illustrate a multidisciplinary teams role in the prosthetic and esthetic rehabilitation of
the maxillary anterior region. Digital imaging and diagnostic waxup enable both clinicians and patients to view the desired final outcome of their teeth and soft tissue at the preoperative stage. In more
complex treatment plans, the dentist can convey a treatment concept to the patient more easily and realistically when using digital
imaging.1, 12-14
Additionally, esthetics is subjective and can vary considerably
between individuals. It is important to illustrate the planned outcome to the treating team members and to the patient, and to
receive feedback. The surgical guide template in particular enabled
the team to transfer information into the mouth and incorporate it
into the surgical procedure, crown preps, temps and, ultimately, the
desired final restoration.
This case study also illustrates the subsidiary use of surgical
tacks (IMTEC Tac System, New York, NY). Crown lengthening for an
esthetic procedure requires stabilization of the soft tissues for the
most predictable results, and the ability to achieve adequate extension of the clinical crown is often difficult.15 The purpose of the tack
is to provide immediate stabilization at a predictable level. Tacks
were originally developed in Europe for the stabilization of membranes in ridge preservation and ridge augmentation procedures.10,11 If sutures alone are used to stabilize the flaps, by pulling
the flaps up against the teeth, their final position is not as predictable, as the tissues may still shift. Periodontal pack is often used
with sutures to stabilize the tissues. The tacks must be placed in the
interproximal bone between adjacent teeth to avoid contact with
the roots. The tacks can be covered with periodontal pack if there is
any question or fear of them being lost and swallowed during the
healing period.
Although the gratifying esthetic outcome in this particular case
presentation tends to support an interdisciplinary approach and the
use of treatment planning adjuncts, the authors strongly encourage
conducting more comprehensive investigations with larger study
populations and numerical data to support success-to-failure ratio
following the concomitant use of digital imaging, model wax-ups
and surgical templates during esthetic procedures.
REFERENCES
1. Goldstein C, Goldstein RE, Garber DA. Computer imaging: an aid to treatment planning.
J Calif Dent Assoc 1991;19:47-51.
2. Kois JC. Altering gingival levels: the restorative connection, part 1: biologic variables. J
Esthet Dent 1994;6:3-9.
3. Garguilo AW. Dimensions and relationships of the dentogingival junction in humans. J
Periodontol 1961;32:261-7.
4. Ingber JS, Rose LF, Coslet JG. The biologic width- a concept in periodontics and
restorative dentistry. Alpha Omegan 1977;70(3):62-5.
5. Maynard JG, Wilson RD. Physiologic dimensions of the periodontium fundamental to
successful restorative dentistry. J Periodontol 1979;50:107.
6. Nevins M, Skurow HM. The intracrevicular restorative margin, the biologic width, and
the maintenance of the gingival margin. Int J Periodont Rest Dent 1984;4(3):31-49.
7. Kaldahl WB, Becker CM, Wentz FM. Periodontal surgical preparation for specific problems in restorative dentistry. J Prosthet Dent 1984;51(1):36-41.
8. Parma-Benfenati S, Fugazzotto PA, Ruben MP. The effect of restorative margins on the
postsurgical development and nature of the periodontium. Part I. Int J Periodont Rest
Dent 1985;5(6):31.
9. Oakley E, Rhyu IC, Karatzas S, Gandini-Santiago L, Nevins M, Caton J. Formation of the
biologic width following crown lengthening in nonhuman primates. Int J Periodontics
Restorative Dent 1999 Dec;19(6):529-41.
10. Block MS. Preserving alveolar ridge anatomy following tooth removal in conjunction with
delayed implant placement.Atlas Oral Maxillofac Surg Clin North Am 1999;7(2):61-77.
11. Guided Tissue Regeneration, The Final Mechanical Stabilizer. http://www.imtec.com/
demo/gtr_product.php (last viewed 10/13/04).
12. Grubb JE, Smith T, Sinclair P. Clinical and scientific applications/advances in video
imaging. Angle Orthod 1996; 66: 407-16.
13. Papasotiriou OS, Nathanson D, Goldstein RE. Computer imaging versus conventional
esthetic consultation: a prospective clinical study. J Esthet Dent 2000;12(2):72-7.
14. Almog DM, Sanchez Marin C, Proskin HM, Cohen MJ, Kyrkanides S, Malmstrom H.
Choice for utilization of esthetic services following four different esthetic consultation
methods: pilot study. J Dent Res 2003, Vol. 82, Special Issue A.
15. Herrero F, Scott JB, Maropis PS, Yukna RA. Clinical comparison of desired versus actual
amount of surgical crown lengthening. J Periodontol 1995;66:568-571.
This study was supported by the divisions of Prosthodontics and Periodontics at the University of
Rochester Eastman Dental Center.
Soft Tissue Plasmacytosis

A Case Report
Ins Vlez, D.D.S., M.S.; Sheldon M. Mintz, D.D.S., M.S.
Abstract
Plasma cell gingivitis was identified during the early 1970s
as an allergic reaction to a component in a chewing gum.
The clinical picture was described as bright erythema of
the entire gingiva, loss of stippling and generalized swelling.
Today, many allergens appear to be responsible for this
problem. This report presents an unusual case of softtissue plasmacytosis in a totally edentulous patient, which
may have been related to the use of a household and
kitchen cleaning solution on the prostheses.
THE CONDITION called plasma cell gingivitis may also be known as

atypical gingivostomatitis, soft tissue plasmacytosis, allergic gingivostomatitis, stomatitis venenata or irritant contact stomatitis. The
etiology is often found to be a hypersensitivity reaction to a flavoring
agent in food or chewing gum, such as cinnamon or mint.1,2 Other
cases have been traced to the use of red peppers in cooking.3 Still others have been deemed idiopathic, with no allergen identified.4
It is important to diagnose this condition properly. The appearance of the gingiva may be similar to that of a neoplastic process
such as multiple myeloma5 or leukemia. Other conditions, such as
discoid lupus, lichen planus, cicatricial pemphigoid or HIV-related
gingivitis, should also be considered.3
Plasma cell gingivitis has been described in the literature since

the late 1960s.1,4,6 It has a unique histopathologic presentation with
a dense chronic inflammatory infiltrate, predominantly plasma
cells.5 The clinical appearance is typically seen as a generalized
enlargement of the free and attached gingiva with bright erythema
and loss of normal stippling. In some cases, the condition also
includes the tongue, buccal and labial mucosa, and vermilion border of the lip. Patients are often symptomatic, complaining of a
rapid onset of soreness, bleeding gums and cracked lips.
Several well-studied cases have shown a true hypersensitivity reaction leading to the plasmacytosis of the gingiva. Kerr et al.,
in 1971, described eight cases of habitual gum chewers whose
signs and symptoms resolved once the allergen (the gum) was
removed. They used various laboratory tests, including complete
blood counts, blood chemistry, smears, blood agar aerobic and
anaerobic cultures, viral cultures, cultures for Candida and biopsy with tissue fixed for electron microscopic studies. Serio et al.,
in 1991, reported a case related to the use of fresh and dried red
peppers and chili peppers in cooking. Once these allergens were
removed from the patients diet, the lesions improved. Lubow et
al., in 1984, presented a case well shown to be caused by the use of
mint candies.
This report presents an unusual case of soft tissue plasmacytosis in a totally edentulous patient, which may have been
related to the use of a household and kitchen cleaning solution
on the prostheses.
The personal history of the patient disclosed the

habit of cleaning her dentures every day with a
household and kitchen cleaner.
Case Report
In January 1996, a 57-year-old white female was admitted to the

Oral and Maxillofacial Surgery Department at ICHILOV Hospital in
Tel Aviv, Israel, for evaluation of a sore mouth. Her medical history
was unremarkable except for hypertension, which was controlled
with diuretics and calcium channel blockers. Physical examination
was within normal limits. The personal history of the patient disclosed the habit of cleaning her dentures every day with a household and kitchen cleaner.
Oral examination revealed an edentulous patient using full, illfitting dentures. A diffuse erythema, fissuring and scaling of the
vermillion border of the upper and lower lips with pronounced
angular cheilitis were present. The inner surface of the upper lip
also presented an erythematous, exophytic lesion covered by an
irregular and pebbled surface, showing fissures, nodules and ulceration with focal white areas.
The dorsal surface of the tongue appeared brilliantly erythematous with diffuse atrophy of the papillae. Fissures and papules
were also noted.
The buccal mucosa presented an edematous and erythematous
lesion with a ragged white surface suggestive of a lupus-like reaction. The edentulous alveolar ridge was normal.
Several incisional biopsies were taken. Microscopic examination revealed H & E sections showing superficial squamous epithelium with hyperparakeratosis, elongated thin rete ridges, exocytosis
and microabscesses. The principal feature of the tissue was an
intense inflammatory infiltrate of predominantly plasma cells
immediately subjacent to the epithelium and extending downward
into the reticular dermis. Numerous dilated blood vessels were present. Candida was not identified.
To rule out the possibility of a plasma cell neoplasm, the clonality of the plasma cell infiltrate was investigated. B-lymphocytes
with differentiation toward plasma cells have immunoglobulin
molecules in their cytoplasm. Each normal plasma cell produces
immunoglobulin of a single light chain type: Kappa (K) or Lambda
(L). Normally, populations of human B cells carry K or L light
chains in approximately a 2:1 ratio. Neoplastic populations arising
from a single progenitor cell should contain only a single light
chain: K or L. Polyclonal light chain population is indicative of nonneoplastic disease.
Using tonsil tissue as a control, immuno-stains, anti Kappa and
anti Lambda chains were performed, and a polyclonal population
Figure 1. Diffuse erythema, fissuring and scaling of

vermillion border of lips and pronounced angular cheilitis.
Atrophy of lingual papillae and fissures of dorsal tongue
are also seen.
Figure 2. Edematous and erythematous buccal mucosa

with white areas and fissures.
Figure 3. Exophytic lesion of upper labial mucosa,

fissures, nodules and ulceration.
A
Figure 4. Biopsy specimen showing hyperparakeratosis, exocytosis and microabscesses. Intense
inflammatory infiltrate, basically composed of
plasma cells, is present down into connective
tissue (H & E stain).
Figures 5A and B. Biopsy specimens with special stains (A) anti-kappa light chain and (B) anti-lambda light
chain, demonstrating polyclonal population of plasma cells.
was identified. In this way the non-tumoral nature of the lesions

was confirmed.
Discussion
The prevalence of contact dermatitis (both allergic and irritant)

has been estimated at between 1% and 10% of the population.7
Many cases are probably unreported.
As mentioned above, many agents placed in the mouth can be
allergens, e.g., various foods, spices and flavorings. Chemicals in
oral care products, nicotine, thermal injury or metals may be chemical or mechanical irritants.7 In the case presented here, the condition resolved completely in approximately three weeks after cessation of using the household cleaning product.
There may have been some mechanical injury to the mucosa
because of the poor-fitting prostheses, but the most exuberant lesion
was found on the upper labial mucosa. Speculation as to the allergen
includes sodium hypochlorite, sodium lauryl sulfate, some coloring
agent or a fragrance. The household cleaner was not analyzed.
Conclusion
This case presents a plasma cell infiltration of the soft tissue

throughout the oral cavity except for the edentulous alveolar ridge.
If an allergic reaction is suspected, then it is important to investigate the patients diet and habits to determine the possible causes.
A diary should be kept listing all things that enter the mouth,
including foods, dentifrice, mouthwash, tobacco, alcohol, chewing
gum, candy and medications (prescription and over-the-counter).5
Any habits such as chewing fingernails, pens or pencils may introduce other allergens.8 Sometimes even careful patch testing by a
dermatologist may not reveal the allergen. Occasionally, topical or
systemic steroids may be helpful for improving symptoms.
REFERENCES
1. Sollecito TP, Greenberg MS. Plasma cell gingivitis; Report of two cases. Oral Surg Oral
Med Oral Pathol 1992;73:690-693.
2. Lubow RM, Cooley RL, Hartman KS, McDaniel RK. Plasma-cell gingivitis; Report of a
case. J Periodontol 1984;55:235-241.
3. Serio FG, Siegel MA, Slade B. Plasma cell gingivitis of unusual origin. A case report. J
Periodontol 1991;62:390-393.
4. Silverman S Jr, Lozada F. An epilogue to plasma-cell gingivostomatitis (allergic gingivostomatitis). Oral Surg Oral Med Oral Pathol 1977;43:211-217.
5. Neville B, Damm D,Allen C, Bouquot J, editors. Oral and Maxillofacial Pathology, 1st Ed.
Philadelphia: W.B.Saunders. 1995; pp.126-127.
6. Kerr DA, McClatchey KD, Regezi JA. Idiopathic gingivostomatitis: cheilitis, glossitis, gingivitis syndrome, atypical gingivostomatitis, plasma cell gingivitis, plasmacytosis of
gingiva. Oral Surg Oral Med Oral Pathol 1971;32:402-423.
7. Davis CC, Squier CA, Lilly GE. Irritant contact stomatitis: a review of the condition. J
Periodontol 1998;69:620-631.
8. Millard HD, Mason D, editors. Perspectives on the World Workshop on Oral Medicine III,
1998. Ann Arbor: University of Michigan. 2000; pp 52-57.
9. Henry K, Farrer-Brown G. A Color Atlas of Thymus and Lymph Node Histopathology.
London: Wolfe Medical Publications Ltd. 1981; pp. 263-276.
Hospital Dentistry and GPRs

A Relationship with a Past
H. Barry Waldman, D.D.S., M.P.H., Ph.D.
Abstract
Dental programs have evolved from an occasional com-
services in private dental offices. And the average income of dentists was almost $13,000.(1)2
ponent of hospitals to fully recognized departments within
Early Years of Hospital Dentistry
the structure of most institutions. A review is presented of
Dental departments first appeared in some hospitals in the 1920s.

Efforts were made to provide services that were commensurate
with the needs, facilities and personnel of the local communities.2
In the late 1930s and early 1940s, a number of dental services were
available in many government, voluntary and for-profit hospitals.
some of these developments, including the initiation of

general practice residency (GPR) programs and training
in a residency program as a substitute for the standard
licensing examination.
TRY TO IMAGINE THE SETTING in which hospital dentistry existed when I began my dental education more than 50 years ago.
Dentists (virtually all of whom were white males) stood while using
belt-driven drills that ran about 7,500 rpm. Discs were used to prepare crowns, because the steel burs couldnt cut through enamel.
The dental office staff answered phones and cleaned up between
patients; they seldom worked at chairside. More than 55% of dental
offices had only one full-time auxiliary staff member. (New York
State had the smallest proportion of dentists who used auxiliaries;
it was somehow related to the fact that the average age of New York
dentists was the highest in the nation.) Gloves were used only during surgical procedures. Third party insurance schemes were
extremely limited. Medicaid was off somewhere in the distant
future. Dental care in hospitals often was a sporadic reality in many
facilities. All too often, hospital dental care consisted of emergency
and surgical care for the poor, who were unable to secure needed
Hospital Dentistry in the 1950s

By the late 1950s, most dental schools had hospital affiliations.
Dental students received as much as 50 hours of training and experience in ward walking, history taking, operating room procedures
and hospital decorum. In general, the dental schools of the far west
and the eastern regions offered more extensive programs than did
schools in other sections of the country.
Dental internship and residency programs were available in
only about half of the hospitals that had received approval by the
Council on Hospital Dental Services of the ADA for such programs.
The number may have been so small, because there had not
been a great demand for dental internships.2
1
2
Unless otherwise stated, all material on the history of hospital dentistry was
drawn from the publication, Survey of Dentistry2
The median number of dentists (including both house and attending staff)
in hospitals with a dental staff was: 2 dentists in governmental (nonfederal)
hospitals; 6 dentists in federal hospitals; 9 dentists in voluntary hospitals; 3
dentists in proprietary hospitals.2
the most striking example of professional insularity

today is the practice of dentistrythe dentist practices
as an individual in the four walls of his office. He is not
integrated into the hospital, the institution which represents
the centricity in our society in the delivery of health care.
The dentist too often looks at the mouth as if there
were no man. In the hospital, too often is the man
looked at as if there were no mouth. 1960 1
About one-third(2,323) of the 6,818 hospitals listed by the
American Hospital Association had dental services. There was a
wide range in the reported number of staff dentists, but the largest
number (18%) of hospitals had only one dentist.(2)
Eighty-five percent of the hospitals with a dental staff had no
dental interns. Most of the hospitals with interns had 500 or more
beds. There were an average 0.3 dental interns per hospital in the
United States.
Among nonsalaried dentists, half of dental specialists reported having a hospital staff appointment (ranging from 98% of
oral surgeons to 26% of orthodontists) and 31% of general practitioners. The proportion of dentists with hospital staff appoint-
ments was highest in New England (49%) and lowest in the

Central region (25%).
More than 90% of the dental department was under a dentists direction.
Hospital Dentistry Post-1950
During the 1970s and 1980s, there were major increases in the
number of postdoctoral general dentistry programs and residents. The first effort to codify curricula for postgraduate general dentistry programs came in 1972 in the form of accreditation guidelines for general practice residency (GPR) programs
from the ADA Council on Dental Accreditation. During the
1970s, the number of programs and the number of residents
increased with funding from the Health Professions Education
Assistance Act and the Robert Wood Johnson Foundation.
Hospital sponsorship of the GPR programs (supported by federal graduate medical education [GME] funds) provided the
major impetus for the growth in graduate general dentistry programs during this period.
Since 1981, the major source of growth of postdoctoral education in general dentistry was in advanced education in general
dentistry (AEGD) programs sponsored by dental schools and
supported with federal GME funds.3,4
By the academic year 2001/02, there were 956 first-year resi-
dents enrolled in the 208 GPR programs. There were 898 graduates
from the 30 dental school-sponsored GPR and 178 hospitalsponsored GPR programs.5
Since 1987, hospitals have been allowed to receive GME funding for resident training in non-hospital settings. The Centers for
Medicare and Medicaid Services (CMS) (previously named the
Health Care Financing Administration) worked with dental schools,
hospitals and others to facilitate the creation of dental residency
programs in non-hospital settings that would qualify for GME
funds. However, in 2003, CMS took the position that GME funding
for dental residencies in non-hospital settings, which it had sanctioned and supported since 1997, was no longer appropriate.
Funding for these programs continued only for those residents who
had commenced their postdoctoral training prior to the ruling.6 As
a result, at many dental schools, efforts are being made to transfer
AEGD-sponsored programs to GPR arrangements and formats.
Types of Dental Services
The limited availability of hospital dental services in the past has

been replaced by a full range of needed services for the increasing
number of individuals with medically, physically and intellectually
compromised conditions, as well as individuals with limited financial resources who live in our communities. For example, the Web
page of one community hospital reports that it provides a full
range of dental care, including: restorative dentistry, gum (periodontal treatment), extractions, facial fractures, orthodontic care,
temporomandibular joint treatment, tumor, and correction of dental facial deformities.7
Program directors have reported a high level of inadequate
preparation among incoming dental residents, including, practice
management, care of medically compromised patients, pediatric
behavior management, quality assurance, oral diagnosis and treatment planning. In addition, there were concerns regarding the residents sense of professionalism and general attitudes.4,8-10
GPR directors reported increasing program curriculum content
to shore up incoming resident inadequacies. In addition, added
emphasis was placed in the care of HIV/AIDS patients, geriatric
patients and individuals requiring implantology and endodontics.4
Impact of GPR Programs
A series of studies of the activities of residents and graduates from

GPR programs demonstrate marked differences among these dentists and their colleagues who had completed an AEGD program or
who had no formal postdoctoral training. For example:
Half of former GPR residents held staff privileges in a hospital
or ambulatory setting, compared to a far smaller proportion of
practitioners without postdoctoral training.
Twice the proportion of former GPR residents, as compared to
practitioners without advanced training, provided consultations in a hospital or long-term care facility.
The practice characteristics of former GPR residents sug54 NYSDJ AUGUST/SEPTEMBER 2005
gested enhanced clinical skills in oral surgery, periodontics,

emergency dental care and oral medicine/pathology, as well
as continuing involvement in teaching.11
GPR residents reported more medically intensive,medically and
socially disadvantaged patients, as well as HIV/AIDS patients.
GPR-trained dentists reported significantly more biopsy procedures, conscious sedation, periodontal surgery and implants.
In addition, GPR-trained dentists were more likely to volunteer
time than other dentists.12
Female dentists reported fewer patients than male dentists, and
this difference was more significant for GPR-trained dentists.12
In addition, GPR and AEGD residents are less likely to seek
specialty training.13,14
Licensure
In January 2003, New York State initiated a new era in dental licensure. Dental school graduates who satisfactorily complete in its
entirety an accredited residency program of at least one years
duration may use that experience in lieu of Part III of the dental
licensing examination in order to obtain a dental license.15
The ability to substitute a residency program for the oneshot (Northeast Regional Board-NERB) examination15 not only
eliminates much of the controversy associated with the NERB
examination, but recognizes the value of GPR and other residency
programs as a critical step in the progressive training of dental
practitioners. (Note: As of January 2007, all applicants for initial
licensure in New York State will have to complete a CODA-approved
residency of at least one years duration.)
REFERENCES
1. Man and mouth. Editorial. Hospitals Jan. 16, 1960;34(2):37.
2. Hollinshead BS. Commission on the Survey of Dentistry in the United States. The Survey
of Dentistry. Washington, DC: American Council on Education, 1961.
3. Handelman SL, Meyerowitz C, Solomon E, et al. The growth of postdoctoral general dentistry programs. Spec Care Dent 1995;15(1):5-10.
4. Lefever KH, Atchison KA, Mito RS, et al. Curriculum emphasis and resident preparation
in postgraduate general dentistry programs. J Dent Edu 2002;66(6):747-756.
5. Survey Center. 2001/02 Survey of Advanced Dental Education. Chicago: American
Dental Association, 2003.
6. American Student Dental Association. Current Issues. Web site: sightmaker.umich.edu/
asda/current_asda_issues Accessed March 12, 2004.
7. Norwalk Hospital, CT. Web site: www.Norwalkhosp.org Accessed March 12, 2004.
8. Atchison KA, Bachand W, Buchanan CR, et al. Military and VA general dentistry training: a national resource. J Dent Edu 2002; 66(6):739-746.
9. Atchison KA, Cheffetz SE. Critical issues for dentistry: PGD program directors respond.
J Dent Edu 2002; 66(6):730-738.
10. Mito RS, Atchison KA, Lefever KH, et al. Characteristics of civilian postdoctoral general
dentistry programs. J Dent Edu 2002; 66(6):757-765.
11. Tejani A, Epstein JB, Gibson G, et al. A survey assessing the impact of a hospital-based
general practice residency program on dentists and dental practice. Spec Care Dent
2002; 22(1):16-22.
12. Atchison KA, Bibb CA, Lefever KH, et al. Gender difference in career and practice patterns of PGD-trained dentists. J Dent Edu 2002; 66(12):1358-1367.
13. Atchison KA, Mito RS, Rosenberg DJ, et al. PGD training and its impact on general dentist practice patterns. J Dent Edu 2002; 66(12):1348-1357.
14. Handelman S, Meyerowitz C, Iranpour B, et al. Evaluation of advanced general dentistry
education. Spec Care Dent 1993; 13(4 Suppl):177-185.
15. New York State Dental Association. NYSDA-initiated PGY1 legislation becomes law. July
30, 2002. Web site: www.nysdental.org Accessed March 12, 2004.
Four to Five Decades Later
Most dentists still practice (often with male and female partners
and associates) within the four walls of their offices (albeit the
office settings have changed dramatically, and practitioners now
sit). During these past decades, thousands of dental school graduates continued their training in a hospital environment and now
serve in our communitiesbetter prepared and capable of dealing in their private office or hospital setting with patients with
complex medical conditions, which increasingly are a reality in
many practices.
It must be noted that there have been declines in the number
of applicants to postgraduate general dentistry programs in the
last number of years.5,9 Preference for private practice and high
educational debts are suggested explanations. Based upon the
perceived limitations in the performance of incoming GPR residents, questions have been raised regarding the abilities of recent
graduates who without additional training enter private dental
practice arrangements.9
Whatever the future may hold for changes in the delivery of oral
health services to an increasingly diverse population in our communities, hospital and GPR programs have been and will continue to be
a critical step in eliminating our professional insularity.

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Restoring the Incisal Edge

Douglas A. Terry, D.D.S.

The clinical significance is that anterior tooth fractures can

Restorative dentistry evolves with each development of

be predictably restored using contemporary small particle

new material and innovative technique. Selection of

hybrid composite resin systems with the aforementioned

improved restorative materials that simulate the physical

restorative techniques. These placement techniques when

properties and other characteristics of natural teeth, in

used with proper attention to preparation design, adhesive

combination with restorative techniques such as the prox-

protocol and finishing and polishing procedures, allow the

imal adaptation and incremental layering, provide the

clinician to successfully restore form, function and esthetics

framework that ensures the optimal development of an

to the single anterior tooth replacement.

tive considerations, tooth preparation, development of the

THE SINGLE ANTERIOR TOOTH replacement remains a complex

observed a polychromatic effect.3 However, by using an anatomic

the mineralized hard tissues of the tooth and these advanced

Prior to initiating the restorative procedure, an occlusal analysis of

A 35-year-old male patient presented with a fractured maxillary

Figure 1. Preoperative facial view of fractured

NYSDJ AUGUST/SEPTEMBER 2005 31

Figure 6. Preparation was etched for

color mapping (hand-drawn diagram and computer diagram) were

Figure 7. (A) Single component adhesive (OptiBond SOLO plus,

margins to improve sealing, this excess should be removed during

Since composite does not have hydroxyapatite crystals, enamel

Artificial Dentin Layer

The initial artificial dentin body layer of opacious B-1 shaded

Figure 9. First layer

Figure 10. Increment

Figure 11. Diluted white tint was applied in vertical

Figure 12. Diluted gray

ization technique uses color variation to emphasize the nuances of

The enamel or artificial enamel layer is the principal determinant

Internal Color Characterization

Figure 15. Contouring and finishing of

Figure 16. Interproximal region was

Figure 17. Final

Finishing and Polishing Procedure

Although the long-term benefits of this material remain to be

NYSDJ AUGUST/SEPTEMBER 2005 35

The Unilateral Posterior Functional Crossbite

Figure 1. Most posterior

Figure 2. Although less

Figure 5. Functional crossbite on left displays

bilateral constriction or narrowness of the maxillary dental arch

Posterior crossbites with functional mandibular shifts should be

mandibular skeletal structures, particularly the mandibular ramus,

Figure 9. Adult patient, G.W., displays facial

Figure 12. E.H. is 8-year-old female displaying

Figure 10. Anterior-posterior

Figure 13. Facial asymmetry of E.H. as

Figure 14. Fixed palatal expansion device used in

crossbite relationship from the maxillary right primary canine to

Figure 15. Post phase I treatment demonstrating

Figure 16. Facial asymmetry of

Figure 18. Removable dental

Figure 17. UPXB with functional shift in mixed dentition.