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BALKAN JOURNAL OF STOMATOLOGY
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ISSN 1107 - 1141
Ljubomir TODOROVI Ć , DDS, MSc, PhD
Faculty of Dentistry
University of Belgrade
Serbia
ALBANIA
Ruzhdie QAFMOLLA - Editor
Emil KUVARATI
Besnik GAVAZI
Address:
Dental University Clinic
Tirana, Albania
BOSNIA AND HERZEGOVINA
Maida GANIBEGOVI
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Naida HADŽIABDI Ć Faculty of Dentistry
Mihael STANOJEVI
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Nikola ATANASSOV
Nikolai SHARKOV
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Faculty of Dentistry
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Ana STAVREVSKA
Ljuben GUGU Č EVSKI
Address:
Faculty of Dentistry
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Anastasios MARKOPOULOS - Editor Address:
Haralambos PETRIDIS Aristotle University
Lambros ZOULOUMIS Dental School
Thessaloniki, Greece
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Victor NAMIGEAN
Cinel MALITA
Faculty of Dentistry
Calea Plevnei 19, sect. 1
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Slavoljub ŽIVKOVI
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Pinar KURSOGLU
Arzu CIVELEK
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Aikaterine KOSTEA
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BALKAN STOMATOLOGICAL SOCIETY
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BALKAN JOURNAL OF STOMATOLOGY
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OP C.E. Cubukcu
A.M. Gunes
Dental Health Status of Children with Acute Lymphoblastic
Leukaemia and Data from a Hospital-Based Paediatric Dental Unit
116
OP Ş.B. Türker
T. Bişkin
Effect of Bleaching Agents on the Colour of Different
Aesthetic Restorative Materials
OP K. Tolidis
P. Gerasimou
C. Boutsiouki
Effect of Composite Resin Shade and LED
Light Intensity on Microhardness
OP H.P. Papanagiotou
D. Pakou
P. Kamposiora
G. Papavasiliou
M. Mpriakou
S. Silvestros
OP Yu.M. Pogosyan
T.V. Khanamiryan
A.Yu. Pogosyan
E.K. Avetisyan
S.S. Burnazyan
The Use of Antimicrobial Agents for Treating
Soft Tissues for Final Impression Procedures
Study of Biodegradable Properties of Beeswax
Membrane in the Focus of Ectopic Implantation
OP E. Koliniotou-Koumpia
D. Dionysopoulos
E. Koumpia
G. Giannelis
Pulp Chamber Temperature Rise during
Resin Composite Polymerization
OP A.a Atanasovska-Stojanovska
Clinical Evaluation of the Effectiveness of Fidelis III
M. Popovska
Nd:Yag Laser as an Adjunct to Conventional
Periodontal Treatment of Chronic Periodontitis
OP B. Dzipunova
N. Tosheska
L. Kanurkova
J. Gjorgova
Facial Morphology in Class II Division 1 Malocclusion Cases
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133
142
150
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Balk J Stom, Vol 15, 2011
CR N. Economides
T. Vouzara
CR G. Milesis
T. Mechterides
A. Kyrgidis
A. Cheva
K. Antoniades
Non-Surgical Endodontic Retreatment after
Unsuccessful Apicectomy: A Case Report
Chondroblastic Osteosarcoma of the Mandible:
Case Report and Treatment Considerations
166
171
115
Errata
We wish to apologize for the error that occurred in the first issue of the BJS concerning the name of the 3 rd author of the article “Variation of Skeletal Cephalometric Variables in Class II Division 2 Patients with Age”
(pp. 35-40). The name of the 3rd author should be Helen Markovitsi instead of Eleni Markoviski.

BALKAN JOURNAL OF STOMATOLOGY
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SUMMARY
Background.
Minimal data about dental health from children with leukaemia and haemophilia are available in the southern part of Marmara,
Turkey.
Aim.
To determine possible differences in the status of dental health from children with acute lymphoblast leukaemia (ALL, n=67) and haemophilia (n=75) with children without systemic or general illnesses
(controls, n=218) in order to provide a novel data for the region.
Design.
In this retrospective study, the prevalence of caries, caries experiences, restoration index and treatment needs were determined.
Results.
The prevalence rates and experiences of the whole sample were found high. Children with ALL had significantly higher scores of caries experience, requiring more than 1-surface filling in both primary and permanent dentitions comparing to the haemophiliac cases and controls
(p<0.01; p<0.05).
Conclusions.
It was strongly suggested that dental supervision should be included into the medical care of children with ALL and haemophilia.
In order to improve dental health of both healthy and systemically compromised children, new goals should be integrated to hospitals in this region.
Keywords: Dental Health; Acute Lymphoblastic Leukaemia; Haemophilia; children
Cigdem Elbek Cubukcu
1
,
Adalet Meral Gunes 2
Uludağ University, Faculty of Medicine
1 Paediatric Dental Care Unit
2 Department of
Paediatric Haematology
Bursa, Turkey
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:116-120
Introduction
At a global level, rapid changes in the pattern of oral disease have been observed during the past decade.
In most developed countries, the occurrence of dental caries in children has declined dramatically, both in terms of lower prevalence and reduction of mean dental caries experience
4,11 . In contrast, reports are available on growing dental health problems in a number of developing countries, such as Turkey. The prevalence of dental caries among children in our country ranges between moderate to high, as classified by the World Health Organization criteria 9
. A recent epidemiological study showed that the prevalence of dental caries was over 90% at age 6 and approximately 80% in children aged 12
18
. According to the report, dmf/t and DMF/T values increase with age.
For both age groups, the D/d component constituted most of the caries indices, indicating the need for dental care.
Although minimal data about dental health from children with leukaemia and haemophilia are available, current findings are similar as in the general child population 8,17 .
Chemotherapy has been widely used for the treatment of leukaemia and may have adverse effects on the oral cavity
12
. Various reports indicated the relationship between dental caries prevalence and chemotherapy 5,14-16 .
These studies suggested that leukemic children had more carious teeth comparing to healthy subjects. Oral mucositis, xerostomia, oral fungal infections, gingival

Balk J Stom, Vol 15, 2011 Dental Status of Children with ALL and Haemophilia 117 bleeding, and dental abnormalities are also frequent 2,10,12 .
Therefore, children with leukaemia are considered to be a high risk group for dental care.
Although there have been several reports dealing with surgical management of haemophilia, there are few data for the dental health of children 3,21 . All the data indicated lower caries prevalence in haemophiliacs compared to healthy children since they receive more vigorous dental prevention programme than the general population when they attend a dental department.
Children receive treatment of haematological diseases at the Faculty of Medicine, which is the unique tertiary referral centre in the southern part of Marmara region in which no dental faculty exists. Therefore, the Paediatric Dental Unit located at the Faculty of
Medicine is the only tertiary referral centre in which the data on dental health has been recorded since its establishment in 2002. In this unit, a trained paediatric dentist works for systemically compromised children, as well as the healthy ones in close connection with the paediatricians.
The aim
of the present study was to determine possible differences in the dental health status of children with ALL and haemophilia compared to children without systemic or general illnesses in order to provide a novel data for the southern part of Marmara region.
experience-indices for decayed-missed-filled-teeth in permanent dentition (DMF/T) and primary dentition
(dmf/t) and restoration index (the filling teeth/ DMF/T or dmf/t ratio), were collected by a calibrated paediatric dentist with a No.4 plain mirror and compressed air where necessary. Inactive and non-cavitated carious lesions were included in the d/D component for recording the dmf/t and
DMF/T indices. The subjects were re-examined and the scores were controlled by a blind and calibrated dentist at the same visit. Any radiographic examinations were included. Mean DMF/T and dmf/t scores for each child were calculated from the data of regular examinations.
The method for calculating treatment needs was validated by classification of the cavities as no treatment, filling
1-surface, 2-surface, or 3-surfaces. All the carious teeth in each child were treated during the study period, and the treatment needs for both dentitions were calculated. There was no difference for the restorative procedures between primary teeth and permanent teeth.
The data was analyzed using SPSS (13.0). Parametric and/or non-parametric tests were chosen by using
Kolmogorov-Smirnov and Shapiro-Wilk tests. Statistical comparisons were performed using Mann Whitney-U and t-tests. Categorical data were compared using the chi-square test. A probability value less than 0.05 were considered significant
13
.
Material and Methods
This randomized descriptive study consisted of
360 consecutive child patients (mean age was 8.47±0.18 years; male/female ratio 198/162) admitted and referred to the Paediatric Dental Unit in the period 2002-2009.
Informed written consent was obtained from each family.
The study was also approved by the ethics committee of the Uludağ University, Faculty of Medicine, Bursa,
Turkey.
Children were divided into 3 groups based on the child’s medical history: (1) Group I (n=67) - children who were completed intensive chemotherapy period for
ALL; (2) Group II (n=75) - children with haemophilia; and (3) Group III (Controls; n=218) - children without systemic or general illnesses. Children from groups I and
II had dental symptoms and were referred to the Paediatric
Dental Unit; children in group III were admitted to the unit for routine dental examination or treatment.
All the subjects were examined 2 times in a year on a regular basis. The examinations took place in the dental unit. The visual dental findings, including caries
Results
Table 1. Dental caries experience - DMF/T and dmf/t scores of study groups at the end of a 2-year follow-up
Caries
Experience dt mt ft dmf/t
DT
MT
FT
DMF/T
N.S. = p>0.05.
ALL
(N=67)
0.0 ± 0.0
5.7 ± 0.7
3.3 ± 0.6
Hemophilia
(N=75)
0.1 ± 0.0
5.1 ± 0.5
1.1 ± 0.2
Controls
(N=218)
Mean ± SD Mean ± SD Mean ± SD
5.7 ± 0.7
0.0 ± 0.0
4.9 ± 0.5
0.1 ± 0.0
4.7 ± 0.3
0.1 ± 0.0
p
N.S
N.S.
0.1 ± 0.0
5.2 ± 0.3
N.S.
N.S.
1.6 ± 0.1
<0.01
0.3 ± 0.0
0.3 ± 0.2
3.9 ± 0.7
0.0 ± 0.0
0.1 ± 0.0
1.2 ± 0.2
0.0 ± 0.0
<0.05
0.2 ± 0.0
N.S.
1.8 ± 0.1
<0.01

118 Cigdem Elbek Cubukcu, Adalet Meral Gunes Balk J Stom, Vol 15, 2011
The prevalence of caries in ALL, haemophilia and controls was found 88%, 77%, and 87%, respectively.
No significant difference (p>0.05) was found in terms of caries prevalence among the groups. Caries experience indices were high in all groups regardless of the children’s medical condition (Tab. 1). The highest score of both
DMF/T and dmf/t indices was obtained in the decayed teeth component (DT/dt) in all groups. However, children with ALL had significantly higher scores of DT,
MT and DMFT (p<0.05; p<0.01; p<0.01) compared to haemophiliacs and controls.
The percentages of restoration index in permanent dentition were 13.04% in ALL group, 9.3% in haemophiliacs, and 17.94% in controls, whereas this finding in primary dentition was 0%, 2.08%, and 8.86%, respectively. The results were not significantly different.
The mean restoration index level in all groups was very low for both primary (3.6%) and permanent dentitions
(13.42%), which was also non-significant among groups
(p>0.05).
The mean numbers of teeth requiring treatment in each group, according to primary and permanent dentition, were displayed in table 2. Children with
ALL had significantly profound and wider caries in both dentitions, requiring more than 1 surface filling compared to other groups. They had either 2 or 3 surface fillings in primary dentition but, 1 and 2 surface fillings in permanent dentition. Children with ALL also had significantly (p<0.05) more inactive carious lesions on permanent teeth requiring no treatment versus haemophiliacs and controls.
Primary Teeth
No Treatment
Filling 1 surface
Filling 2 surface
Filling 3 surface
Permanent Teeth
No Treatment
Filling 1 surface
Filling 2 surface
Filling 3 surface
N.S. = p>0.05
N: The total number of subjects n: The total number of teeth
Table 2. Treatment needs of the study groups in primary and permanent dentitions
ALL
(N=67)
Mean ± SD n=43
15.1 ± 0.6
2.0 ± 0.3
1.4 ± 0.2
0.5 ± 0.1
n=44
24.6 ± 0.6
2.5 ± 0.5
0.4 ± 0.1
0.1 ± 0.05
Hemophilia
(N=75)
Mean ± SD n=67
16.2 ± 0.4
1.7 ± 0.3
0.7 ± 0.1
0.02 ± 0.02
n=52
26.6 ± 0.3
0.9 ± 0.2
0.1 ± 0.06
0.01 ± 0.01
Controls
(N=218)
Mean ± SD n=197
15.8 ± 0.2
1.8 ± 0.1
1.0 ± 0.1
0.1 ± 0.05
n=149
26.2 ± 0.1
1.3 ± 0.1
0.1 ± 0.04
0.04 ± 0.01
p
N.S.
N.S.
<0.05
<0.001
<0.05
<0.01
<0.001
N.S.
Discussion
The current study results clearly demonstrated that prevalence of caries and experiences in all groups were prominently high, indicating that the general children population in our region received low level of dental care and did not have benefit of advice how to prevent caries. As our unit is the only referral centre for paediatric dentistry in this region, it can be assumed that the results of this data represent the paediatric population living in this part of the country.
In the present study, children with ALL had the highest dmf/t and DMF/T scores, 3.84 and 5.76, respectively. This can be explained by dental complications of intensive ALL therapy, complexity and quality of the oral flora during chemotherapy, which can make the teeth

Balk J Stom, Vol 15, 2011 Dental Status of Children with ALL and Haemophilia 119 more susceptible to caries
1,20 . Similar or higher prevalence of dental diseases is reported for ALL compared to healthy children
1,19 . Another study from Turkey also reported higher caries experiences in children with ALL/lymphoma compared to children without systemic or general disease 6 .
Haemophiliacs had 1-2 carious teeth in their permanent dentition and 5-6 caries in primary dentition
(Tab. 1). Number of carious permanent teeth was similar with the controls but significantly lower than in children with ALL (p<0.01). This suggested that leukaemia as a disease itself deteriorates dental tissues more than haemophilia. Children with haemophilia in our country do not receive regular dental recalls 8,17 .
Therefore, the number of carious primary teeth was found similar with the other subjects (Tab. 1). However, this situation is different in developed countries where all paediatric haemophiliacs attend for dental care during their haematological visit and receive a more vigorous dental prevention programme than the entire population. Therefore, haemophiliac children have lower caries prevalence compared to healthy subjects in those countries
3,21 .
The restoration index in the present study was quite low in all groups for primary and permanent dentitions due to the insufficient and limited access to dental care.
However, leukaemia children had significantly profound and wider caries in both, primary and permanent teeth, requiring more than 1 surface fillings for primary teeth and 1 and 2-surface fillings for permanent teeth (Tab. 2).
The similar or higher degree of treatment need in children with cancer is reported comparing to healthy children in various reports 6,7,15,19 . Carious lesions on permanent teeth requiring no treatment in the same group were also significantly high (p<0.05). These findings indicated harsh effects of the chemotherapy on dental tissues, such as enamel demineralization and alteration in chemical structure and viscosity of saliva.
The results of this baseline study indicate that dental caries is a major problem in this region of Turkey and therefore an active and effective programme of caries prevention and dental care is necessary both for the children with ALL and haemophilia, as well as for the healthy population. Caries prevention should be added before dental care and also the importance of caries prevention rather than dental care should be emphasized regarding the risks that arise in the case of profound and untreated caries along with ALL and haemophilia. New dental health goals and alternative models of dental care delivery for all children living in this area should be integrated to the professional resources of the hospitals. Such goals for dental health both in Turkey and other developing countries will assist local health care planners to establish preventive programmes that target at general population, as well as the high risk groups such as leukaemia and haemophilia.
It is crucial to evaluate regular dental health surveys and eliminate potential sources of infection in mouth of children with ALL and haemophilia combined with their medical therapy.
References
1. Alaskan G, Alaskan C, Gagmen H, Bogus A, Steiner S,
Cárdenas C . Disturbances in oral and dental structures in patients with paediatric lymphoma after chemotherapy: a preliminary report. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod , 1999; 87:317-321.
2. Bonnaure-Mallet M, Bunetel L, Tricot-Doleux S, Guerin J,
Bergeron C, LeGall E . Oral complications during treatment of malignant diseases in childhood: effects of toothbrushing.
Eur J Cancer , 1998; 34:1588-1591.
3. Boyd D, Kinirons M . Dental experience of children with haemophilia in Northern Ireland. Int J Paed Dent , 1997;
7:149-153.
4. Burt BA . Trends in caries prevalence in North American children. Int Dent J , 1994; 44:403-413.
5. Clarkson JE, Eden OB . Dental health in children with cancer. Arch Disease Child , 1998; 78:560-561.
6. Dogan C, Haytac C, Antmen B, Sasmaz I, Tanyeli A . Oral health status in children with acute lymphoblastic leukemia and lymphoma. Turk J Haematol , 2001; 18:179-183.
7. Duggal MS, Curzon MEJ, Bailey CC, Lewis IJ, Prendergast
M . Dental parameters in the long term survivors of childhood cancer compared with siblings. Oral Oncol , 1997;
33:348-353.
8. Ermiş G, Kavaklı K, Polat A, et al . Dental care and current therapy in Turkish hemophiliacs. XXIII international congress of the world federation of hemophilia. The Hague, the Netherlands. 1998; 3:305 (Abs. 596).
9. Global oral health data bank. World Health Organization,
Geneva: WHO, 2000.
10. Kaste SC, Hopkins KP, Bowman LC, Santana VM . Dental abnormalities in children treated for neuroblastoma. Med
Pediatr Oncol , 1998; 30:22-27.
11. Marthaler TM, O’Mullane D, Vrbric V . The prevalence of dental caries in Europe, 1990-95. Caries Res , 1996; 30:237-
255.
12. Minicucci EM, Lopes LF, Crocci AJ . Dental abnormalities in children after chemotherapy treatment for acute lymphoblastic leukemia. Leukemia Res , 2003; 27:45-50.
13. Möller IJ, Poulsen S . A standardized system for diagnosing, recording and analyzing dental caries data. Scand J Dent
Res , 1973; 81:1-11.
14. Pajari U, Larmas M, Lanning M . Caries incidence and prevalence in children receiving antineoplastic therapy.
Caries Res , 1988; 22:318-320.
15. Pajari U, Ollila P, Lanning M . Incidence of dental caries in children with acute lymphoblastic leukemia is related to the therapy used. ASDC J Dent Child , 1995; 2:349-352.
16. Purdell-Lewis DJ, Stalman MS, Leeuw JA, Homphrey GB,
Kalsbeek H . Long term results of chemotherapy on the developing dentition: caries risk and developmental aspects.
Community Dent Oral Epidemiol , 1988; 16:68-71.

120 Cigdem Elbek Cubukcu, Adalet Meral Gunes Balk J Stom, Vol 15, 2011
17. Saraç A, Koca H, Çetingül E, Ertuğrul F, İlgenli T . Hemofili hastalarında diş sağlığının korunması ve tedavisi. Türkiye
Klinikleri- Dahili Tıp Bilimleri Hematoloji , 2006; 2:65-69.
18. Saydam G, Oktay I, Möller IG . A situation analysis of oral health in Turkey. Tur-Oral-Health (WHO). Printed in
Turkey, 1990.
19. Sepet E, Aytepe Z, Ozerken AG, et al . Acute lymphoblastic leukemia: dental health of children in maintenance therapy.
J Clin Pediatr Dent , 1998; 22:257-260.
20. Sixou JL, De Mederios-Batista O, Gandemer V, Bonaure-
Mallet M . The effect of chemotherapy on the supragingival plaque of pediatric cancer patients. Oral Oncol , 1998;
34:476-483.
21. Sonbol H, Pelargidou M, Lucas VS, Gelnier MJ,
Mason C, Roberts GJ . Dental health indices and cariesrelated microflora in children with severe haemophilia.
Haemophilia , 2001; 7:468-474.
Correspondence and request for offprints to:
Cigdem Elbek Çubukçu
Dental Care Unit
Faculty of Medicine
Uludag University, Bursa, Turkey
E-mail: dcelbek@yahoo.com

BALKAN JOURNAL OF STOMATOLOGY
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SUMMARY
The aim of this study was to compare the effects of 3 proprietary carbamide peroxide bleaching agents on the colour of 3 dental aesthetic restorative materials. 90 specimens made from feldspathic porcelain, microfilled composite and light-polymerized modified glass ionomer cement were prepared. Colorimeter was used for colour measurements, and 1-way Anova was used to evaluate the colour measurements (α<0.05).
The modified glass ionomer cement group was the only restorative material group that showed significant colour change (ΔE>3.3). No significant difference was found between bleaching agents, and no significant changes in the colour of feldspathic porcelain and micro-filled composite were observed.
Keywords:
Bleaching Agents; Aesthetic Restorative Material; Colour
Şebnem Begüm Türker, Turan Bişkin
Marmara University, Faculty of Dentistry,
Department of Prosthodontics, Istanbul, Turkey
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:121-126
Introduction
Tooth bleaching was reported in the literature as an aesthetic treatment option as early as 1898 1
. The night-guard bleaching technique has been in routine use since 1989, following the publication of Haywood and
Heymann 2
. The night-guard vital bleaching agents are commercially available as various products that have different carbamide peroxide content. The basic clinical technique involves the use of a soft, plastic, night-guardstyled prosthesis 3
. Carbamide peroxide (CP) solutions are very unstable and immediately dissociate into their constituent parts on contact with tissue or saliva. The
10-16% CP solution dissociates into 3-5% hydrogen peroxide and 7-10% urea. The hydrogen peroxide further degrades into oxygen and water, while the urea degrades into ammonia and carbon dioxide
1,3,4 . Treatment times for the night-guard vital bleaching technique vary extensively, and much depends on how much time per day that the patient spends for applying the technique
1
.
There are several reports on the effect of bleaching agents on the colour of restorative materials. Swift
5 and
Haywood
1
reported that night-guard vital bleaching technique has no significant effect on the colour of porcelain or other ceramic material, as well as amalgam and gold. Monaghan et al 6
reported that Rembrandt
Lighten and White and Brite bleaching agents created slight colour changes in the composite resin restorative material. Monaghan et al
7
also observed significant colour differences when the tested composite materials were exposed to the superoxyl bleaching solution after treatment with 37% H
3
O
4.
Cullen et al 8
found that microfilled composite colour changes occurred during the bleaching procedure but, bleached composite resins returned to their original colour after a week.
al 9
Fay et
reported that bleaching agents remove stains from composite and hybrid ionomer. Canay and Çehreli
10 claimed that 10% hydrogen peroxide (HP) was more likely to cause colour change of composites compared with 10% CP.
Aesthetic restorative materials have gained great popularity due to the patient’s cosmetic demands.
Feldspathic porcelain is one of several porcelains used for Class I and Class II cavities for inlay, onlay and full coverage restorations 11,12 . Micro-filled composite resins are used for Class III and Class IV restorations
13 and modified glass ionomer cement usually for Class V cavities 13,14 , both materials being used as an alternative to amalgam and gold restorations.

122 Şebnem Begüm Türker, Turan Bişkin Balk J Stom, Vol 15, 2011
In the literature, different techniques have been used to evaluate the colour of dental materials. Shade guides
15
, visual evaluation 16
or photographs
15,17-19 are useful for colour evaluation; however, these rely on subjective options, which have been shown to be unreliable.
The colorimetric instruments, such as colorimeters or spectrophotometers, yield numeric values and better reliability than the others
6,20-22 .
The aim
of this study was to determine the effects of 3 different proprietary carbamide peroxide bleaching agents (Nite-White, Opalescence and Rembrandt) on the colour of 3 dental aesthetic restorative materials: feldspatic porcelain, micro-filled composite and modified glass ionomer.
Material and Methods
3 bleaching products and 3 restorative materials were chosen for this study. The materials, product names, manufacturers, and pH values as measured with a universal indicator (pH=0-14; E Merck,
Dormstadt, Germany) are listed in table 1. For the colour measurements, a CR-200 colorimeter (Minolta
Co, Ramsey, NJ) was used. Although the manufacturer’s instructions for Remrandt Lighten Gel and Opalescence recommend the use of proprietary toothpaste, none were used to eliminate any mechanical abrasive effects 6
so that only the effect of the bleaching agents was investigated.
Material
Feldspathic porcelain
Product Name
Manufacturer
Duceram
Ducera Dental, Rosbah,
Germany
Modified glass ionomer cement
Fuji II LC GC Corp,Tokyo, Japan,
Composite Resin
10% Carbamide peroxide,
Carbapol pH=6
3M Silux Plus
3M ESPE, St. Paul,
Minn
Opalesence
Ultradent Products, Inc.
South Jordan, Utah
10% Carbamide peroxide pH=6-7
Rembrandt
Den-Mat Corp, Santa
Maria, Calif
16% Carbamide peroxide pH=5.5
Table 1. The used materials
Nite White
Discus Dental, Inc,
Beverly Hills, Calif
To prepare the porcelain specimens, a stainless steel mould consisted of 2 6mm-thick stainless steel plates, held together by welding. Before welding 4 holes, 1 cm in diameter, were drilled in of the plates to obtain flatbottom specimens. The metal mould was boxed, and silicon duplicating impression material (Flexil Dublicating
Silicone, Davis Schottlander & Davis Ltd, Letchworth
Herts, United Kingdom) was mixed in accordance with the manufacturer’s directions and poured into the boxed mould to duplicate the holes. Refractory material in a powder:liquid ratio of 3:1 was mixed by use of a vacuum mixer (Vop, Botevgrad, Bulgaria) and poured into the silicone mould by use of a vibrator (Vibraboy SL BEGO,
Bremen, Germany). When the material had set, the duplicated mould made of investment was removed from the silicon impression. This procedure was repeated until
30 investment moulds were produced.
A calibrated porcelain oven (Programat 90;
Ivoclar Vivadent, Schaan, Lichtenstein) was used to fire the porcelain specimens in accordance with the manufacturer’s instructions. 30 porcelain specimens were fired on the investment moulds. Investment material was cleaned from the sintered porcelain specimens by air-borne particle abraded with 250µm. aluminium oxide powder (Korax 250, BEGO). The specimens were then trimmed with a thin cylindrical diamond bur (D-Z
Labor, Drendel ans Zweilling GmbH & Co, Berlin,
Germany) and further air-borne particle abraded by use of 50µm. aluminium-oxide powders. After the selfglazing procedure 23,24 was completed in accordance with the manufacturer’s directions, specimens were cleaned in distilled water in an ultrasonic cleaner (Whaledent
Biosonic Coltène/ Whaledent Inc, Cuyohoga Falls, Ohio) for 5 minutes.
Holes 1cm in diameter were drilled in a 6mm-thick poytetrafluoroetylene plate to form composite and modified resin glass ionomer cement specimens.
These restorative materials were placed into the mould separately and sandwiched between 2 glass plates by use of titanium-coated instruments (Brilliant Esthetic
Line Composite Instrument Coltène AG, Altstatten,
Switzerland). In accordance with the manufacturer’s directions, specimens were polymerized for 40 seconds with a wide-tipped prismatic light-polymerizing unit (3M
ESPE, St. Paul, Minn) at 420mW. 30 specimens of each restorative material were prepared. The specimens were polished with medium, fine and superfine Sof-Lex disks
(3M ESPE) on a slow-speed handpiece in accordance with the manufacturer’s directions and further cleaned in distilled water in an ultrasonic cleaner (Whaledent
Biosonic Coltène/ Whaledent Inc) for 5 minutes.
Each restorative material group was divided into 3 bleaching subgroups (n=10). 2 specimens were selected from each of these subgroups to form the control groups.
All specimens were stored in distilled water in screw-top vials (Isolab, Wetheim, Germany) at room temperature for 24 hours before any test procedure. The bleaching procedure was performed over a period of 30 days. The specimens were immersed in the bleaching gels for an

Balk J Stom, Vol 15, 2011 Effect of Bleaching Agents on Restorative Materials 123 average of 8 hours per day. At the end of the bleaching procedure, the treated specimens were removed and washed under running distilled water for 30 seconds and placed in fresh distilled water until the next daily application
4,19,25,26 . The control specimens were kept in distilled water, and the distilled water was changed daily.
The colour measurements were repeated at intervals of 24 and 48 hours, and 1, 2, 3 and 4 weeks (30 days).
The specimens were positioned on the calibration plate of CR-200 as a standard background and 3 measurements for each specimen were performed in the same room and lighting. The mean of the readings was calculated. Then, the colour change of the specimens was determined by calculating the ΔE from the L*a*b* values obtained with the colorimeter. A ΔE of more than 1 is clinically noticeable under optimal viewing conditions by trained observers
27
. The following formula was used
27 :
ΔE= [(L *)
2
+ (a
F
*- a
I
*)
2
+ (b
F
*- a
I
*)
2 ]
1/2
F
*- L
I
In this system, L * represents lightness, a * rednessgreenness, and b * yellowness-blueness; the subscript I stands for the initial value and the subscript F stands for the final value
1-way analysis of variance (ANOVA) was used to evaluate the colour measurements. Significant results were evaluated again with Fisher and Duncan’s multiple range test (α<0.05).
Results
Mean colour change values and standard deviations for each combination of bleaching and restorative material group are given in table 2.
Statistical comparisons in ΔE were made: (1) with respect to bleaching time within bleaching agentrestorative material combination groups (Tab. 3 ); (2) between the bleaching agents with respect to time
(Tab. 4); and (3) between the bleaching agents for the statistically significant group at t=30 days.
The modified glass ionomer cement group was the only restorative material group that showed significant colour change (ΔE>3.3) with tested bleaching agents. The micro-filled composite group’s colour changes were not significant statistically; only Rembrandt bleaching agent created slight colour changes after 3 weeks of immersion
(ΔE>1).
Table 2. Mean ΔE values for all the materials tested
24 Hours- Inıtial
48 Hours-Initial
1 week-Initial 2 weeks-Initial
Mean * SD **
Mean SD Mean SD Mean SD
Feld. porcelain
NiteWhite
Opalescence
Rembrandt
Control
Glass Ionomer
NiteWhite
Opalescence
Rembrandt
Control
Microfilled
Comp.
NiteWhite
Opalescence
Rembrandt
Control
*: Mean ΔE value
**: Standard deviation
0.5
0.44
0.47
0.37
0.46
0.27
0.33
0.39
2.94
2.4
4.08
0.45
0.21
0.12
8.79
0.13
0.56
0.92
1.45
0.22
0.15
0.22
0.18
0.11
0.47
0.37
0.31
0.38
3.6
3
3.81
0.69
0.63
0.49
0.75
0.36
0.26
0.15
0.11
0.12
0.56
1.18
1.67
0.46
0.53
0.67
0.96
0.1
0.44
0.37
0.31
0.4
4.7
4.3
5.23
1.29
0.71
0.63
0.88
0.36
0.2
0.14
9.78
0.13
0.89
0.76
1.56
0.91
0.24
0.37
0.27
0.17
0.45
0.35
0.3
0.39
5.43
5.52
5.45
1.39
0.76
0.83
0.96
0.39
0.22
0.55
0.13
0.36
0.93
1.54
1.48
0.68
0.3
0.26
0.18
0.11
3 weeks-Initial 4 weeks-Initial
Mean SD Mean SD
0.47
0.66
0.48
0.59
5.62
6.91
7.97
1.35
0.74
0.87
1.04
0.41
0.2
0.17
0.15
0.16
0.72
0.81
1.51
0.89
0.4
0.33
0.39
0.15
0.45
0.34
0.19
0.1
0.38
0.12
0.39
0.16
5.4
6.65
8.06
1.62
0.76
0.86
1.04
0.39
0.78
0.92
1.57
0.7
0.45
0.43
0.22
0.15

124 Şebnem Begüm Türker, Turan Bişkin
Time
Time
Time
Time
Time
Time
Time
Time
Source of variation
Time
Time
Time
Time
Experimental group
PN
PO
PR
PCon
GlN
GlO
GlR
GlCon
CoN
CoO
CoR
CoCon
PN: Feldspathic porcelain- NiteWhite
PO: Feldspathic porcelain- Opalescence
PR: Feldspathic porcelain- Rembrandt
PCon: Feldspathic porcelain- Control
GIN: Glass ionomer- Nite White
GIO: Glass ionomer- Opalescence
Balk J Stom, Vol 15, 2011
Table 3. 1-way ANOVA results df Sum of Squares
5
5.466667E-03
5
5
5
5.77/6677E-02
3.741042E-02
1.86875E-03
5
5
5
5
5
5
5
5
48.91732
139.9323
137.2577
4.382835
0.4086917
1.478519
1.927867
9.810417E-03
Mean Square
1.093333E-.03
1.154333E-02
7.482084E-03
3.7375E-04
9.783464
27.98645
27.45155
0.8765671
8.173833E-02
0.2957037
0.3855733
1.962083E-03
GIR: Glass ionomer- Rembrandt
GICon: Glass ionomer- Control
CoN: Microfilled composite- Nite White
CoO: Microfilled composite- Opalescence
CoR: Microfilled composite- Rembrandt
CoCon: Microfilled composite- Control
F ratio
0.02
0.57
0.48
0.01
17.12
25.02
11.49
1.62
0.60
1.79
1.82
0.04
Probability
1.000
0.720
0.778
1.000
0.000
0.000
0.000
0.175
0.698
0.136
0.130
0.999
Nite White
Opalescence
Rembrandt
Control
Table 4. Relation between ANOVA result and mean colour value of glass ionomer cement
(values with same letter were not significant statistically)
24h-i
2.9a
2.4a
4.08
.45
48 h-i
3.6b
3.04bc
3.08c
.68
1 w-i
4.7d
4.3de
5.2e
1.3
2 w-i
5.4f
5.5fg
5.45g
1.3.9
3 w-i
5.6
6.9h
7.97h
1.35
4 w-i
5.4
6.65
8.06
1.62
Discussion
In the literature, with the development of cosmetic dentistry, bleaching techniques have gained a worldwide popularity among dentists as a treatment method.
Since the aesthetic demands have increased currently, porcelain inlay and onlay restorations, and glass ionomer restorations in appropriate indications have been used as alternatives to amalgam and composites.
There are several studies on the effects of bleaching agents on the existing restorations. Haywood
1 reported that porcelain, amalgam and gold alloy restorations were not affected by bleaching regarding the colour and composition. It was showed that bleaching solutions moved enamel through dentin and as this effect continued, colour of composite and porcelain restorations might seem lighter 3
. Swift
5
showed that vital bleaching procedure had not a significant influence on the colour and physical properties of porcelain and the other ceramics. In the current study, it was found that bleaching agents had no statistically and clinically significant effect on the colour of porcelain restorations, which was consistent with the findings of Haywood
1 and Swift
5
.

Balk J Stom, Vol 15, 2011 Effect of Bleaching Agents on Restorative Materials 125
There are several reports on the effect of bleaching agents on the colour of composite resins
7-10
. 2 of them used 30% HP and the others used CP as bleaching agents.
The authors 8,10 observed significant colour difference with the use of 30% HP that HP bleaching agents caused more colour change of composite compared with 10% CP. Monaghan et al
7 and
Cullen et al
This
8 investigation.
notified that bleaching agents, including
CP, create slight colour changes with the composite resin restorative materials; these changes were no different than exposure to water and bleached composite resins resume their colour after a week. Tested composite restorative material group’s colour changes occurred only with
Rembrandt bleaching agent, with a concentration of 10%, after the third week (ΔE>1). Unfortunately, it was not clinically significant. The result of this study is similar to those of Monaghan et al
7 and Cullen et al 8
. Unfortunately, in the presented study, Nite-White, with a concentration of 16% and Opalescence, with a concentration of 10%, did not cause any colour difference. Turker and Biskin
28
, reported a decrease of silica and silicon content (4.03%) on the surface of the micro-filled resins after treatment with 10% Rembrandt bleaching agents. This diminution suggested that Rembrandt bleaching agent caused erosion on the surface of composite matrix so, the slight colour changes of the Rembrandt bleaching agents could be related with this surface alterations.
In the presented study, statistically and clinically significant changes were found in the colour of glass ionomer restorative material treated with bleaching agents tested. There are no colour studies for modified glass ionomer cement to compare to the results of this study.
Nevertheless, this study found no significant differences in colour between any of the bleaching agents; the colour of the modified glass ionomer cement continued to increase during the period of bleaching procedure. Further studies are needed to determine the mechanism of colour change in aesthetics restorative materials when exposed to the bleaching agents, which was not a part of this
Conclusion in vitro as a bleaching agent, and they claimed
study suggests that the bleaching procedure had no colour changing effect on feldspathic porcelain and micro-filled composite restorations. Colour changes for the modified glass ionomer cement continued during bleaching procedure.
Acknowledgments
. We thank to SEM Ltd Şti for giving permission to use the colorimeter, to 3M San ve Ticaret
AŞ, Degussa Ticaret Ltd Şti, Orlu Dış Ticaret Ltd Şti,
Den-Mat Coo and to Discus Dental Coo, for supplying the tested materials.
References
1. Haywood VB . History, safety, and effectiveness of current bleaching techniques and applications of the nightguard vital bleaching technique. Quintessence Int , 1992;
23:471-488.
2. Haywood VB, Heymann HO . Nightguard vital bleaching.
Quintessence Int , 1989; 20:173-176.
3. Haywood VB, Heymann HO . Nightguard vital bleaching: how safe is it? Quintessence Int , 1991; 22:515-525.
4. Denehy GE, Swift EJ Jr . Single-tooth home bleaching.
Quintessence Int , 1992; 23:595-598.
5. Swift Jr EJ . Restorative considerations vital tooth bleaching.
J Am Dent Assoc , 1997; 128:60-64. Special supplements.
6. Monaghan P, Lim E, Lautenschlager E . Effects of home bleaching preparations on composite resin color. J Prosthet
Dent , 1992; 68:575-578.
7. Monaghan P, Trowbridge T, Lautenschlager E . Composite resin color change after vital tooth bleaching. J Prosthet
Dent , 1992; 67:778-781.
8. Cullen DR, Nelson JA, Sandrik JL . Peroxide bleaches:
Effect on tensile strength of composite resins. J Prosthet
Dent , 1993; 69:247-249.
9. Fay M, Servos T, Powers JM . Color of restorative materials after staining and bleaching. Oper Dent , 1999; 24:292-296.
10. Canay Ş, Çehreli MC . The effect of current bleaching agents on the color of light-polymerized composites in vitro. J
Prosthet Dent , 2003; 89:474-478.
11. Roulet J, Herder S . Bonded ceramic inlays. Chicago:
Quintessence. 1991; pp 9-17.
12. Schwartz S, Summitt JB, Robbins JW . Fundamentals of operative dentistry: a contemporary approach. Chicago:
Quintessence. 1996; pp 229-241.
13. Anusavice KJ . Phillip’s science of dental materials. 10 th
ed.
Philadelphia: WB Saunders. 1996; pp 530, 590, 595-597.
14. Lutz F, Setcos JC, Philips RW . Dental restorative resins.
Dental Clin North Am , 1983; 27:697-712.
15. Reinhardt JW, Eivins SE, Swift E . A clinical study of vital bleaching. Quintessence Int , 1993; 24:379-384.
16. Rosenstiel SF, Gegauff AG, Johnston WM . Duration of tooth color change after bleaching. J Am Dent Assoc , 1991;
123:54-59.
17. Lee CQ, Cabb CM, Zargartalebi F, et al . Effect of bleaching on microhardness, morphology and color of enamel. Gen
Dent , 1995; 158-162.
18. Haywood VB, Heymann HO . Nightguard vital bleaching.
Quintessence Int , 1989; 20:173-176.
19. Quellet D, Los S, Case H . Double-blind whitening nightguard study using ten percent carbamide peroxide. J Esthet
Dent , 1992; 4:79-83.
20. Mulla FA, Weiner S . Effects of temperature on color stability of porcelain stains. J Prosthet Dent , 1991; 65:507-512.
21. Rosenstiel SF, Porter SS, Johnston WM . Color measurements of all ceramic crown systems. J Oral Rehabil ,
1989; 16:491-501.
22. Seghi RR . Effects of instruments measuring geometry on colorimetric assessments of dental porcelains. J Dent Res ,
1990, 69:1180-1183.
23. Raimondo RL, Richardson JT, Wiedner B . Polished versus autoglazed dental porcelain. J Prosthet Dent , 1990;
64:553-557.

126 Şebnem Begüm Türker, Turan Bişkin Balk J Stom, Vol 15, 2011
24. Brewer JD, Garlapo DA, Chipps EA . Clinical discrimination between autoglazed and polished porcelain surfaces. J
Prosthet Dent , 1990; 64:631-635.
25. Gegauff AG, Rosenstiel SF, Langhout KJ . Evaluating tooth color change from carbamide peroxide gel. J Am Dent
Assoc , 1993; 124:65-72.
26. Kıhn PW, Barnes DM, Romberg E . A clinical evaluation of 10 percent vs 15 percent carbamide peroxide toothwhitening agents. J Am Dent Assoc , 2000; 131:1478-1484.
27. CIE Recommendations on uniform color spaces - color difference equations psychometric color terms. Suppl. No.2 to CIE publication no:15 (E-1.3.1) 1971/(TC-1.3). 1978.
28. Turker SB, Biskin T . Effect of three bleaching agents on the surface properties of three different esthetic restorative materials. J Prosthet Dent , 2003; 89:466-473.
Correspondence and request for offprints to:
Dr. Ş. Begüm Türker
Marmara University
Department of Prostodontics
Faculty of Dentistry
Büyük Çiftlik Sok. No:6
34365 Nişantaşı
Istanbul- TÜRKİYE
E-mail: begumturker@hotmail.com

BALKAN JOURNAL OF STOMATOLOGY
STOMA
TO
LO
GI
C
A
L
S
ISSN 1107 - 1141
SUMMARY
Clinical performance of light cured dental composites is greatly influenced by light intensity of the light curing unit and the shade of the resin composite used, affecting microhardness values. The purpose of the present study was to control those variables through Vickers microhardness.
A nanohybrid resin composite in shades A3, B2 and C2 was used along with higher and lower light intensity modes from LED curing devices. Data were analyzed with ANOVA and Tukey-Kramer test.
No significant differences were found for A3 shade. Shade B2 on the top, exhibited no significant difference in comparison between Elipar S10 and Valo standard mode (p>0.05) and within Valo modes (p>0.05). Shade
B2 at the bottom surface exhibited extremely significant difference for Radii and Elipar S10 (p<0.001), Elipar S10 and Valo standard mode (p<0.001).
Shade C2 at the top surface exhibited significant differences (p<0.05). Top surfaces exhibited greater microhardness values compared to bottom, as expected. A3 was acceptably polymerized. Higher power LEDs resulted in lower microhardness values when curing shade C2. But there was no difference between Valo modes, which represent the lowest and highest light intensity of this experiment. Elipar S10, with an average light intensity, polymerized efficiently all shades.
Keywords:
Microhardness; Composite Resin Shade; Light Curing, intensity
Kosmas Tolidis 1
, Paris Gerasimou
1
,
Christina Boutsiouki 2
Aristotle University of Thessaloniki
School of Dentistry
1
Dept of Operative Dentistry
2
Undergraduate Student
Thessaloniki, Greece
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:127-132
Introduction
Polymerization is a chemical reaction that converts small, individual monomer molecules into long, giant molecular chains 14
. Adequate polymerization is the key to successful clinical performance of the restoration and results in good physical properties
3,6,8,21 , so that changes in hardness, strength, stiffness, solubility, water absorption, colour stability and biocompatibility are avoided 3,9,16,31,37,43,45 . Sufficient photo-polymerization can be achieved when the proper output energy intensity, the effectual electromagnetic wavelength and the correct duration of time are combined
48
. Factors affecting polymerization can be divided into 2 groups: those concerning the material (organic matrix, filler loading, type and size, concentration of the initiator, shade, thickness of the restoration) and those related to the light curing unit (spectral distribution, intensity, exposure time, curing mode, position, type and distance of the light guide tip) 20,30,34,35 . However, under-curing has been noticed even when a proper technique and light curing device
(LCU) were used
32
.
Sufficient light in the proper wavelength must reach all areas and depth of a light-activated restoration to polymerize it totally 27,28,32 . Microhardness determines the sufficiency in polymerization and is affected by depth of cure and degree of conversion of C=C bonds
2
.
Depth of cure is termed as the decrement in cure due to penetration of light through the mass of the restorative
3,38
and can practically be measured by material differences in microhardness values between the top and bottom of specimen. However, microhardness and depth of cure profiles are generally not linear
49
, as low hardness values may be related to low filler content
52
.
Degree of conversion, which indicates the percentage

128 Kosmas Tolidis et al. Balk J Stom, Vol 15, 2011 of non-reacted C=C bonds, is affected by light intensity and exposure time
46 . Resin composite properties tend to improve as degree of conversion increases 15,16,53 . This is due to the increased cohesion of the organic matrix, when the percentage of non reacted C=C bonds is low
53
. On the other hand, high percentage of non reacted bonds, affects the initial strength of the restorative material, meaning that greater stress values could be elastically endured without harming the restoration
53
.
This study evaluated microhardness values, as it is an indirect way of evaluating depth of cure and degree of conversion 7,19 . The effect of different LCUs and composite resin shades, on the Vickers hardness scale was evaluated.
Material and Methods
A microhybrid resin composite (Filtek Z250,
3M-ESPE) in shades A3, B2 and C2 was used, with higher and lower light intensity modes from LED LCU.
This particular product contains Bis-GMA, UDMA and
Bis-EMA as monomers, zirconia/ silica as fillers, with average size 0.6μm and 60% by volume or 82% by weight filler concentration. The following LCUs were used: Radii
Plus (SDI), Elipar S10 (3M ESPE) and Valo (Ultradent), in standard and plasma mode (Tab. 1).
DEVICES
Radii Plus
Elipar S10
Valo Plasma
Valo Standard
MANUFACTURER
SDI
3M-ESPE
Ultradent
Ultradent
Table 1. Light Curing Units
LIGHT INTENSITY
1500mW
1200 mW (+/- 10%)
3200 mW
1000mW
WAVELENGTH
400-520nm
430-480nm
395-480nm
395-480nm
CURING TIME
25 sec
20 sec
4 sec
20 sec evaluated with Vickers microhardness (100gr for 15 seconds), both at the top and the bottom surface to assess microhardness values. Data were analyzed with ANOVA and Tukey-Kramer test. Hardness ratio was also calculated using the following formula: Hardness Ratio = Bottom
Surface Microhardness / Top Surface Microhardness. If that mean exceeded 80%, specimens were considered adequately polymerized 24,41,51 .
Results
Figure 1.
4 groups were formed for each shade and 5 specimens were made for each group, which were
4mm thick using a brass mould (Fig. 1). Specimens were covered with cellulose strip and polymerized with each LCU, with the LCU tip in contact with the strip. Specimens were kept for 24 hours in darkness and
Mean and standard deviation values are shown in table 2, and hardness ratios in Table 3.
No significant differences were found for A3 shade at the top surface and at the bottom surface for most of the curing modes used. Shade B2 on the top exhibited no significant difference in comparison between Elipar
S10 and Valo standard mode (p>0.05), and within Valo modes (p>0.05). Shade B2 at the bottom surface exhibited extremely significant difference for Radii and Elipar
S10 (p<0.001), and for Elipar S10 and Valo standard mode (p<0.001). Shade C2 at the top surface exhibited significant differences (p<0.05) in comparison between
Radii and Elipar S10, and for every curing unit at the bottom, except for Valo modes (p>0.05).

Balk J Stom, Vol 15, 2011
SDI top
SDI bottom
S10 top
S10 bottom
Valo Plasma top
Valo Plasma bottom
Valo Standard top
Valo Standard bottom
SDI
S10
Valo Plasma
Valo Standard
Factors Influencing Microhardness of Dental Composites 129
Table 2. Mean values and Standard Deviations
A3 B2
70.5
43.72
70.16
47.42
62.56
33.56
70.08
50.40
2.915
6.212
3.181
3.529
2.795
3.660
2.807
4.799
64.12
46.56
70.44
56.18
70.54
47.3
72.76
47.44
3.075
0.466
2.747
1.504
1.932
2.728
1.246
3.570
68.36
51.18
74.00
57.00
69.02
39.34
71.34
44.26
C2
2.150
2.102
2.715
3.713
2.518
0.841
3.125
3.948
Table 3. Hardness Ratios
A3
71%
71%
64%
47%
57%
50%
51%
80%
79%
74%
59%
69%
67%
61%
63%
72%
51%
70%
69%
54%
B2
74%
70%
49%
52%
69%
73%
64%
60%
72%
68%
59%
67%
66%
68%
85%
79%
74%
73%
71%
89%
C2
83%
90%
49%
55%
58%
58%
58%
47%
57%
62%
67%
73%
69%
80%
69%
74%
81%
69%
77%
81%

130 Kosmas Tolidis et al. Balk J Stom, Vol 15, 2011
Discussion
Microhardness is an important parameter for physical and mechanical behaviour of composite resin restorations. Adequate polymerization is required for clinically successful restorations. Light intensity and shade play an important role in the top, as well as in the bottom microhardness values, as stated in the literature.
Therefore the influence of composite resin shade and
LCU with varying light intensities was evaluated in the present study.
One shade from each colour group was chosen, in order to study all colour groups - A, B and C.
Composite resin was placed with bulk technique into the mould, in order to eliminate other parameters affecting microhardness. Our variables were composite resin shade and light intensity. Cellulose strip was placed before polymerization in order to eliminate oxygen-inhibited layer. Specimens were kept for 24 hours in darkness, as no contribution of environmental light to post-irradiation polymerization was needed. It is also mentioned that post irradiation microhardness, which is related with polymerization kinetics, increases rapidly within the first hour after polymerization, but the increase does
24,30 . Optimal microhardness not continue after 24 hours can be achieved after 1 hour
18
, after 1 day
25
, and up to
1 month 49
. Polymerization time was longer than the manufacturer recommended, as it is mentioned that time needs to be extended to reach the desirable microhardness values, especially when light intensity is reduced by any factor 29,30 .
For all composite resin shades and LCUs, microhardness was greater at the top surface, which can be attributed to polymerization distance. Bottom surfaces are harder to polymerize, as light is absorbed and scattered through the material, and light intensity can be reduced up to 94% in 2mm depth 10,11,19,37,38,42,44,50 . As a result, the top surface microhardness is not an adequate indicator of complete polymerization 33,40 .
Differences in polymerization depth were observed depending on the shade of resin composite used. A2, A4, B1 and D3 shades meet or exceed the
ISO requirement of 1.5mm polymerization depth, but in some commercially available resins, these shades behave differently and can meet the ISO expectations 22
, but double time of polymerization is recommended 13
. However, curing time seems to affect more polymerization of shade C and light intensity seems to affect more shade B, for both the top and the bottom surfaces, as mean values of our results indicate
(Tab. 2). As for shade A, no significant difference was noted between light intensities or polymerization time.
Sharkey et al 39 and Park et al 29 agree that microhardness interval between the top and the bottom surface in shade
A is relatively small, due to effective light penetration through the material. It is generally stated, that more transparent shades achieve higher microhardness values than other chromatic shades 1
.
Successful polymerization of a certain composite resin and consequently acceptable microhardness value seems to depend on the combination of light intensity, wavelength output and duration of time.
Overall brightness and light intensity of the LCU do not totally predict the curing performance, but generally high light intensity leads to increased depth of cure 17,26 . Higher power LEDs generally resulted in lower microhardness values when curing shade
C2 but, on the other hand, there was no difference between Valo modes, which represent the lowest and highest light intensity in this experiment. In order to improve immediate depth of cure, Dennison et al
12 recommends high intensity LCU for polymerization.
But high intensities and short curing times, as Valo in plasma mode, have raised many concerns as they are thought to result in reduced degree of polymerization by terminating the polymer chains in the pre-gel period earlier. Moreover, greater polymerization shrinkage values are noted in such cases 5,23,47 .
Polymerization with Elipar S10, with an average light intensity, results in acceptable microhardness values for all shades. Energy density received by the material is the light intensity multiplied by polymerization time 35
. Not receiving the appropriate energy density can result in the reduced microhardness. Valo in plasma mode has the lowest energy density, despite the highest light intensity in the present study.
Differences in microhardness values between SDI,
S10 and Valo in standard mode can be explained in terms of homogenous light distribution and emission wavelength. Degree of polymerization depends on homogeneity, as differences in light intensity from location to location across the light guide tip may lead to insufficient polymerization, which in turn results in diminished microhardness values. However, Arikawa et al 2
showed that light emission from LED was the least non-homogenous. Wavelength range of light emitted by
LCUs needs to be as close as possible to the absorption peak of the composite resin’s photoinitiator (468nm for camphoroquinone). Differences in spectral emission, wavelength range and peaks may result in differences in polymerization and thus in microhardness values, even if both LCUs have the same light intensity. This is noted in our study, as LCUs emit at various wavelength ranges
(Tab. 1).
Bottom microhardness should ideally reach 80-90% of the hardness of the top surface 24,41,51 . Very few specimens exhibited such microhardness ratio values
(Tab. 3, in bold). But specimens’ thickness was 4mm and bulk technique was used. On the other hand, curing with
LED LCUs, results in microhardness values of 80% or more of the maximum hardness of the composites 36 .

Balk J Stom, Vol 15, 2011 Factors Influencing Microhardness of Dental Composites 131
Conclusions
Top surfaces exhibited greater microhardness values compared to bottom surfaces, as expected. A3 exhibited acceptable microhardness values with all the
LED curing devices. Higher power LEDs generally result in lower microhardness values when curing shade
C2. But there is no difference between Valo modes, which represent the lowest and highest light intensity of this experiment. Elipar S10, with an average light intensity, seems to polymerize efficiently all shades. As for microhardness ratio, very few specimens exhibited values greater than 80%.
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Correspondence and request for offprints to:
Tolidis Kosmas
51 Tsimiski Str.
54623, Thessaloniki, Greece
Email: ktolidis@dent.auth.gr

BALKAN JOURNAL OF STOMATOLOGY
STOMA
TO
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ISSN 1107 - 1141
SUMMARY
Background . The response of periodontal tissues to prosthetic restorations, either temporary or permanent, has been an issue of major concern. Temporary restorations induce o slight to moderate inflammatory response of the adjacent soft tissues that could affect the quality of final impressions for fixed prostheses. The aim of this double-blind, randomized,
3 group parallel-designed clinical trial was to evaluate and compare the efficacy of 2 mouthrinses and a placebo on inhibiting inflammation around teeth bearing provisional restorations. A secondary objective was to evaluate if C31G could cause staining of the restorations and/or changes in taste perception.
Material and Methods . The 2 mouthrinses used, were chlorhexidine digluconate and 0.3% C31G in an aqueous base. 28 patients underwent periodontal examination at baseline, which included assessment of the plaque index, bleeding on probing and discoloration index. 110 teeth prepared to receive fixed prosthetic restorations and provisional restorations were evaluated prior to final impression procedures. All patients were randomly assigned to 3 groups: the first group received 0.3% C31G in an aqueous base, the second group received chlorhexidine digluconate, and the third group received placebo. Statistical Analysis was performed by using both Multivariate Analysis of Variance (MANOVA) and Univariate
Analysis of Variance (ANOVA) with repeated measures. The 4 dependent variables were plaque index, gingival index, surface coloration index and coloration severity index. The experimental factors were the administrated agent (between-subjects factor) and the intervals of consecutive measurements (within-subjects factor). Interaction between the experimental factors (therapeutic agent - repeated measures) was also examined. The level of statistical significance was set to 5%.
Results . Both agents improved plaque index and bleeding on probing.
The placebo had no efficacy in plaque control; 0.3% C31G in an aqueous base appeared to have positive control in plaque accumulation, superior than chlorhexidine digluconate. It was free of side effects, did not cause any staining of the teeth or induced an intrinsic bad taste.
Conclusion . Within the limitations of this study, the results suggested that both mouthrinses were able to improve the condition of the periodontal tissues adjacent to teeth that bear provisional restorations, in order to prepare them for the final impression. C31G in an aqueous base had no side effects like staining of teeth.
Keywords:
Final Impressions; Antimicrobial Agent; Staining
Harry P. Papanagiotou, Dafni Pakou, Phophi
Kamposiora, George Papavasiliou, Myrto
Mpriakou, Spiros Silvestros
University of Athens, Dental School
Department of Prosthodontics, Athens, Greece
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:133-141

134 Harry P. Papanagiotou et al. Balk J Stom, Vol 15, 2011
Introduction
According to the glossary of Prosthodontic Terms
1
, impression is a negative likeness or copy in reverse of the surface of an object, an imprint of the teeth and adjacent structures for use in dentistry. The purpose is to fabricate an accurate positive replica of the oral structures, namely a cast. The most important factors for a precise and successful impression, regardless the impression material and the impression technique that was used are healthy soft and hard tissues in the oral cavity. This can be achieved by the completion of necessary dental treatment, including periodontal, endodontic and orthodontic therapy
2
, and a high oral hygiene status. Interim prosthesis is called a fixed or removable dental or maxillofacial prosthesis, designed to enhance aesthetics, stabilization and/or function for a limited period of time, after which it is to be replaced by a definitive prosthesis. In fixed prosthodontics, provisional restorations are fabricated using various techniques 3-6 and should fulfill given biological, mechanical and aesthetic requirements. They can either enhance the oral tissues health 7 or may induce a slight inflammatory response of the adjacent soft tissues.
According to Trushkowsky, 6 provisional restorations should fulfil several requirements in order to avoid plaque accumulation and consequently periodontal inflammation:
1. They should isolate the prepared teeth from the oral environment;
2. They should have an adequate anatomical shape, form and marginal fit;
3. They should be able to maintain the prepared teeth in position, providing contact points with adjacent teeth and antagonists.
Even when provisional restorations are made following the above mentioned standards, they can induce a mild inflammatory response at the surrounding soft tissues. This is usually due to the nature of the materials used and may affect the quality of final impressions.
Antimicrobial agents have an important effect to periodontal health, as microbial plaque is the major etiologic factor of periodontal disease
8
. Consequently, the reduction or even elimination of the perio-pathogenic microorganisms is the most significant part of the periodontal therapy 9
. There are various antimicrobial agents that can be used, which can be divided in 5 categories according to Mandel 9 :
1.
Antiseptics;
2.
Antibiotics;
3. Enzymes;
4. Non-enzymatic agents;
5. Agents able to destroy the adherence between some bacteria or between the bacteria and the tooth surfaces.
The most known antimicrobial agents are: (1) Listerin that reduces plaque accumulation by 35% and gingival inflammation
10
, although it doesn’t seem to have any influence on microflora constitution
10
; (2) Triclozan , which consists of a combination of diphenol and a germicidal agent with low toxicity and wide antibacterial action - studies showed moderate effectiveness in the reduction of plaque accumulation, mostly because of its rapid release
9 ;
(3) Chlorhexidine , which is considered to be one of the most effective antimicrobial agents in the reduction of plaque accumulation and the control of gingivitis, even in lack of oral hygiene
11 ; it also has an auxiliary effect in periodontal treatment through control of inflammation and subgingival plaque accumulation
12
. It is adsorbed in tooth surfaces, which is one of its most important properties, even when these surfaces are covered with hymenium, and it is released slowly, preventing microbe proliferation 10,13-15 . It shows low toxicity and infrequent side effects, which appear mainly after long term use, such as brown discoloration of tooth surfaces and restorative materials
16 , alteration in taste perception 11,17 , an increase of calculus formation
18
, and soft tissue delamination and teeth hypersensitivity; (4) C31G , a 0.3% solution in an aqueous base, which affects bacterium glycolysis and has wide germicidal action against Gram + and Gram - bacteria
19 ; in vitro , C31G in concentration of 0.5% is as effective as chlorhexidine 20
. It is chemically sticky and binds itself to sites within the periodontal pocket, so it continues to be effective for prolonged periods of time.
The combined use of mechanical and chemical means in oral hygiene is the most effective way to control plaque accumulation and therefore keep the periodontal tissues healthy. The aim
of this study was to evaluate the efficacy of C31G on inhibiting inflammation around teeth bearing provisional restorations prior to final impressions for fixed prostheses and compare its efficacy with that of chlorhexidine and a placebo. Secondary objective of the study was to estimate the degree of discoloration on provisional restorations
21-23
, as well as changes in taste perception, caused by the use of C31G in comparison with chlorhexidine and placebo (mouthrinse without an active agent).
Materials and Methods
This study was a randomized, double-blind clinical trial. 28 consecutive patients participated, who presented for treatment in the Graduate Prosthodontics Clinic at the
School of Dentistry of the University of Athens, Greece.
The inclusion criteria for the patients were as follows:
●
Patients had to be at least 18 years old and participate in the trial voluntarily;
● They had to have free medical history;
● They should not have been on antibiotic or antiinflammatory treatment;
● They should not have been heavy smokers (not more than 8 cigarettes per day);

Balk J Stom, Vol 15, 2011 Antimicrobial Mouthrinses for Treating Soft Tissues 135
● They had to have completed their periodontal treatment;
● Dimensions and location of the restorations to be placed should have been the same, as far as possible.
The patients were randomly assigned to 3 groups according to the applied treatment, by means of a table of random numbers:
Group A. Patients received 0.3% solution of C31G
(Therasol®, Ora Tec Corp., Herndon, VA, USA);
Group B. Patients received solution of chlorhexidine
0.12% (Peridex®, Procter and Gamble, Cincinnati, Ohio, USA);
Group C, (control group). Patients received a placebo.
All patients were instructed to use their mouthrinse twice a day. Using a medium toothbrush, Oral B
Advantage Plus, (Procter and Gamble, USA), they had to “dip” the brush into a cup full of mouthrinse and brush the buccal and lingual surfaces of the teeth covered by provisional restorations. Subsequently, they should have not eaten or drunk anything for 30 minutes. They were instructed not to change their nutrition preferences and oral hygiene habits and not to use other mouth rinses than the recommended, until the trial was completed.
Measurements were performed at a total of one hundred and ten teeth.
During the initial examination the patients were randomly divided into the 3 groups by a team member who did not participate in any other part of the trial procedure. A second researcher prior to the preparation of the teeth carried out the measurements and estimated the plaque index , the bleeding on probing
and the discoloration index (severity and area). Measurements for plaque index were performed separately for each tooth on
4 surfaces (mesial, distal, buccal, lingual)
24 ; bleeding on probing index was based on the number of tooth surfaces without bleeding
24
; discoloration index was measured according to the areas that had stains and also according to the severity of the stains and discolorations
24
.
The abutment teeth were prepared using diamond burs, with rounded shoulder or deep chamfer finish lines that ended 1 mm subgingivally. Provisional restorations were fabricated of auto-polymerizing Jet acrylic resin
(Lang Dental, Chicago, USA) by means of the direct technique. They were cemented using TempBond NE
(Kerr Corporation, Orange, CA, USA.)
The second examination took place 2 weeks after the tooth preparation and the cementation of the provisional restorations. The same set of measurements was repeated.
All patients were questioned about possible problems such as discomfort, pain etc. Patients were given a specific mouthwash, without knowing the type or brand name of the antimicrobial solution. All antimicrobial agents were placed in identical bottles.
4 weeks later, the same measurements were repeated and information on possible side effects was accumulated.
Final impressions were made at the same appointment, for the fabrication of permanent restorations.
The experimental planning was done with multivariate analysis of variance (MANOVA), with repeated measurements. The aim of the analysis of variance was to test assumptions that were based on differences of averages. In order to construct a scale with equal distances and quantities, a linear transformation of the indexes was performed, that included percentage measurements. So 0 remained the same, 25% was transformed into 1, 50% was transformed into 2, 75% into
3 and 100% into 4.
Results
As shown in table 1, the experimental design resulted statistically significant differences for both between-subject (Pillai’s Trace = 0.750; p<0.001) or within-subjects effects (Pillai’s Trace = 0.807; p<0.001).
More specifically, measurements concerning dependent variables differed significantly depending either on the administrated therapeutic agent or on the intervals of consecutive measurements. Interaction between the experimental factors (therapeutic agent - repeated measures) also showed statistically significant differences
(Pillai’s Trace = 1.281; p<0.001).
Consecutively, a Mauchly test of Sphericity was performed (Tab. 2). The test of sphericity presented statistically significant results (p<0.001) concerning all dependent variables. Therefore the fundamental prerequisite of applying this analysis was fulfilled without adjusting the degrees of freedom according to epsilon correction factors.
As could be seen in table 3, all dependent variables, plaque index, bleeding on probing and the discoloration index (severity and area), presented significant changes
(p<0.001) in both the univariate level (measurements in different time intervals - repeated measurements) and the interaction level between therapeutic agent and repeated measurements. Hence, data showed statistical significance in all the dependent variables, either in univariate or in
2-way interaction level.
Table 4 shows that the therapeutic agent, by itself, exhibited significant high differentiation in measurements concerning all 4 dependent variables.

136 Harry P. Papanagiotou et al.
Effect between-subject within-subjects
Interaction between experimental factors a Exact statistic
Balk J Stom, Vol 15, 2011
Table 1. Multivariate Analysis of Variance, Pillais’s Trace
Intercept
Agent measurement
Value F
Pillai’s Trace .985
1660.524(a)
Pillai’s Trace .750
15.738
Pillai’s Trace .807
52.373(a)
Hypothesis df Error df Sig.
4.000
8.000
8.000
104.000
210.000
100.000
.000
.000
.000
measurement Agent
Pillai’s Trace 1.281
22.486
16.000
202.000
.000
Table 2. Mauchly’s Test of Sphericity
Within Subjects
Effect
Measure df Sig.
Epsilon
Μeasurement
Color color_severity
.608
.576
52.723
58.553
2
2
.000
.000
Greenhouse-
Geisser
.718
.702
Huynh-Feldt Lower-bound
.739
.722
.500
.500
Gingival .847
17.614
2
.000
.867
.897
.500
Hygiene
.666
43.057
2
.000
.750
.772
.500
Tests the null hypothesis that the error covariance matrix of the orthonormalized transformed dependent variables is proportional to an identity matrix.
Source Measure
Table 3. Univariate statistical tests within subject measurements measurement color color_severiy
Gingival
Hygiene measurement * Agent
Color color_severiy
Gingival
Error(measurement)
Hygiene
Color color_severiy
Gingival
Hygiene
Transformed Variable: Average
Type III Sum of
Squares
26.789
18.742
30.287
33.637
26.242
25.867
15.396
12.631
64.261
42.988
55.652
62.260
df
2
2
2
2
4
4
4
4
214
214
214
214
Mean Square
6.561
6.467
3.849
3.158
.300
13.394
9.371
15.143
16.818
.201
.260
.291
F
44.606
46.651
58.231
57.809
21.848
32.192
14.801
10.854
Sig.
.000
.000
.000
.000
.000
.000
.000
.000

Balk J Stom, Vol 15, 2011
Source
Intercept
Agent
Error
Measure
Color color_severity
Gingival
Hygiene
Color color_severity
Gingival
Hygiene
Color color_severity
Gingival
Hygiene
Antimicrobial Mouthrinses for Treating Soft Tissues 137
Table 4. Univariate statistical tests between subjects factor
Type III Sum of Squares
315.415
243.547
310.283
3125.306
66.615
46.858
20.281
7.623
80.382
48.960
85.843
120.332
2
2
107
1
2
2
107
107
107
1
1 df
1
Mean Square
315.415
243.547
310.283
3125.306
33.307
23.429
10.141
3.811
.751
.458
.802
1.125
F
419.861
532.264
386.755
2779.051
44.337
51.204
12.640
3.389
.000
.000
.000
.037
Sig.
.000
.000
.000
.000
Concerning plaque index, significant differences could be observed regarding either measurements at different time intervals or the therapeutic agent used. In figure 1, it was confirmed that dental hygiene, in general terms, showed an improvement (amelioration) from the first measurement (mean 2.66) to the second (mean 3.36) and a slight decrease (mean 3.29) at the last measurement.
A possible explanation was that solely the fact of
“approaching” a dentist, can mobilize the patient towards practices which ensured a better oral hygiene.
In figure 2, it could be noted that both therapeutic agents (Peridex® and Therasol®) showed better results compared to the placebo. More explicitly, patients who used Therasol®, showed a better result (higher mean) independently of the time of measurement (mean
Therasol® 3.32; mean Peridex® 3.03).
As could be seen in figure 3, interaction between time of measurement and therapeutic agent showed
Therasol® to give a better outcome. Patients that used placebo, although they also presented amelioration between the first and the second measurement, finally returned to their starting point.
Gingival Index showed a constant decrease
(Fig. 4) as treatment proceeded (first measurement - mean 1.38; second measurement - mean 0.91; third measurement - mean 0.64). Concerning the therapeutic agent (Fig. 5), either Peridex® or Therasol® showed a significant amelioration of patient’s condition compared to the placebo, independently of the measurement time.
Between them, a significant difference was not observed.
Figure 6 shows interaction between different measurements during the treatment and the administrated therapeutic agents. Placebo patients presented neither amelioration nor deterioration of their condition according to the given variable, as expected. On the contrary, both therapeutic agents showed therapeutic activity since both groups presented a decrease in measurement of gingival index, thus an amelioration of patients’ condition, without noticing significant differences between them.
As could be seen in figure 7, second measurement
(independently of the therapeutic agent used) presented the lowest mean value concerning surface coloration index (mean value 0.58). In contrast, in figure 8, it can be seen that the best mean value regarding surface coloration index was attributed to the group that used Therasol®
(mean value 0.38)
Regarding interaction between time intervals of measurement and therapeutic agent used (Fig. 9), results illustrated that the C31G’s action was significantly better compared to that of chlorhexidine (F=53.95; p<0.01) in what regarded the Surface Coloration Factor.
Chlorhexidine’s results seemed to be inferior even compared to those of the placebo.
Results regarding the coloration severity index were similar to those of the surface coloration index. With this

138 Harry P. Papanagiotou et al. index, the second measurement also (independently of the therapeutic agent used) presented the lowest mean values
(Fig. 10).
The best mean value regarding coloration severity index was attributed to the use of Therasol® (Fig. 11).
Once again, chlorhexidine’s performance was worse than using a placebo. Concerning time of measurement
(Fig. 12), Therasol® presented better clinical results compared to those of chlorhexidine (F=100.37; p<0.01).
Balk J Stom, Vol 15, 2011
Figure 3. Interaction between different measurements and antimicrobial agents according to the plaque index (F=10.854; p<0.01)
Figure 1. Plaque index means in different measurements (F=57.89; p<0.01)
Figure 4. Gingival index means in different measurements (F=58.23; p<0.01)
Figure 2. Plaque index means according to the antimicrobial agent used
(F=3.39; p<0.05)
Figure 5. Gingival index means according to the antimicrobial agent used (F=12.64; p<0.01)

Balk J Stom, Vol 15, 2011 Antimicrobial Mouthrinses for Treating Soft Tissues 139
Figure 6. Interaction between different measurements and antimicrobial agents according to the gingival index (F=14.821; p<0.01)
Figure 9. Interaction between different measurements and antimicrobial agents according to the coloration index (F=21.848; p<0.01)
Figure 7. Coloration index means in different measurements (F=58.2; p<0.01)
Figure 10. Coloration severity index means in different measurements
(F=46.65; p<0.01)
Figure 8. Coloration index means according to the antimicrobial agent used (F=44.33; p<0.01)
1.25
Coloration 1.00
severity index means
0.75
0.50
0.25
1.262
0.957
0.378
CXD PLACEBO
ANTIMICROBIAL AGENTS
THERASOL
Figure 11. Coloration severity index means according to the antimicrobial agent used (F=51.25; p<0.01)

140 Harry P. Papanagiotou et al. Balk J Stom, Vol 15, 2011
Figure 12. Interaction between different measurements and antimicrobial agents according to the coloration severity index means
(F=32.192; p<0.01)
Discussion
The use of antimicrobial agents provides important help in the control of plaque accumulation and therefore in the inhibition of periodontal disease
25
. However, acceptance of a recommended product by the patient usually depends on its flavour and cost, especially for daily use. Another significant factor is the absence of side effects, like undesirable staining, alterations in taste and soft tissue delamination.
The use of several agents has been studied in the past regarding their antimicrobial capability. The aim of this study was to estimate the impact of the 0.3% solution of
C31G in an aqueous base in inhibiting inflammation of the periodontal tissues adjacent to teeth with provisional restorations prior to final impression making procedures, and compare that impact with chlorhexidine and placebo.
A limitation of this study was the size of the sample.
However the results were statistically significant and represented real measurements. The fact that plaque index and bleeding on probing improved with the 2 antimicrobial agents was also significant, while no improvement was observed with the placebo. 0.3% solution of C31G in an aqueous base seemed to give better results for the plaque index” as the trial proceeded, despite the fact that the 2 agents had similar baseline measurements. In terms of the area and the severity of discoloration, the antimicrobial agents showed greater differences, with C31G yielding better results. The discoloration index decreased in the second measurement because no mouth rinse had yet been used. However, in the third measurement C31G was the only one that showed decreased of discoloration index, while use of either chlorhexidine or the placebo lead to an increase of the staining. It should be noted that discoloration is a proven side effect of chlorhexidine 16, 26 .
These observations are very important for clinical practice, because it is proved, as in many other studies in the past, that the use of chlorhexidine increased the severity of discoloration 16,26 , while in the same period of time, the use of C31G did not induce staining on the surfaces of the provisional restorations. Moreover, the improvement of both, bleeding on probing and plaque index, improves the condition of the soft tissues prior to final impression procedures.
Many times, residual inflammation on periodontaly treated patients makes impression procedures difficult.
Inflammation in such cases is attributed to the presence of interim restorations, mainly due to the properties of the material used. Reducing the inflammation can be proved critical for impression making procedures. As it was shown in this study, the use of antimicrobial agents directly on the areas to be restored, led to a significant improvement of the periodontal indexes in these areas.
Discoloration of teeth to be restored could influence the aesthetic outcome of the prosthesis. Any agent leading to such staining should be avoided, especially in aesthetic areas. The results of this study indicated that the use of chlorhexidine, although inhibiting residual inflammation, lead to severe staining of provisional restorations.
Therefore, especially in aesthetic areas, a non-staining agent like C31G could give better overall results.
In the future it should be studied whether the mean of applying the antimicrobial agent played a role in the outcome. The observation time period of this study lasted
4 weeks. It would be interesting in future studies to study the results from the use of these antimicrobial agents for longer periods of time, when implants are going to be placed, and for the preparation of the peri-implant tissues for impression procedures as well.
Conclusions
1. C31G and chlorhexidine improved the plaque index and bleeding on probing;
2. C31G yielded better results;
3. C31G did not cause discoloration on the tooth surfaces, while chlorhexidine did;
4. C31G improved the condition of the periodontal tissues adjacent to teeth that bearded provisional restorations, in order to prepare them for final impression procedures.
Acknowledgements
. We would like to express our deep appreciation to Ms. Chrisopoulou, Intertrade-Dental AE
Co, for the valuable help and support.

Balk J Stom, Vol 15, 2011 Antimicrobial Mouthrinses for Treating Soft Tissues 141
References
5. The Glossary of Prosthodontic Terms. J Prosthet Dent ,
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6. Vanarsdall RL . Orthodontics. Provisional restorations and appliances. Dent Clin North Am , 1989; 33:479-496.
7. Galindo D, Soltys JL, Graser GN . Long-term reinforced fixed provisional restorations. J Prosthet Dent , 1998;
79:698-701.
8. Luthardt RG, Stossel M, Hinz M, Vollandt R . Clinical performance and periodontal outcome of temporary crowns and fixed partial dentures: A randomized clinical trial. J
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9. Biggs WF, Litvak AL, Jr . Immediate provisional restorations to aid in gingival healing and optimal contours for implant patients. J Prosthet Dent , 2001; 86:177-180.
10. Trushkowsky RD . Fabrication of a fixed provisional restoration utilizing a light-curing acrylic resin.
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11. Sorensen JA, Doherty FM, Newman MG, Flemmig TF .
Gingival enhancement in fixed prosthodontics. Part I:
Clinical findings. J Prosthet Dent , 1991; 65:100-107.
12. Konig J, Storcks V, Kocher T, Bossmann K, Plagmann HC .
Anti-plaque effect of tempered 0.2% chlorhexidine rinse: an in vivo study. J Clin Periodontol , 2002; 29:207-210.
13. Mandel ID . Antimicrobial mouthrinses: overview and update. J Am Dent Assoc , 1994; 125(Suppl 2):2S-10S
14. Fischman SL . A clinician’s perspective on antimicrobial mouthrinses. J Am Dent Assoc , 1994; 125(Suppl 2):20S-
22S.
15. Gent JF, Frank ME, Hettinger TP . Taste confusions following chlorhexidine treatment. Chem Senses , 2002;
27:73-80.
16. Eaton KA, Rimini FM, Zak E, Brookman DJ, Hopkins LM,
Cannell PJ, et al . The effects of a 0.12% chlorhexidinedigluconate-containing mouthrinse versus a placebo on plaque and gingival inflammation over a 3-month period. A multicentre study carried out in general dental practices. J
Clin Periodontol , 1997; 24:189-197.
17. Christensen GJ . Provisional restorations for fixed prosthodontics. J Am Dent Assoc , 1996; 127:249-252.
18. Ernst CP, Prockl K, Willershausen B . The effectiveness and side effects of 0.1% and 0.2% chlorhexidine mouthrinses: a clinical study. Quintessence Int , 1998; 29:443-448.
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D . Clinical study of a C31G containing mouthrinse: effect on salivary microorganisms. J Clin Dent , 1990; 2:34-38.
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Correspodence and request for offprints to:
Harry P. Papanagiotou
124B Vas. Sofias Av.
11526 Athens
Greece
Email: hpapanag@hotmail.com

BALKAN JOURNAL OF STOMATOLOGY
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ISSN 1107 - 1141
SUMMARY
The aim of this study was to investigate the response of muscular tissues upon implantation of beeswax membrane into the muscles of the anterior abdominal wall in 50 rats, and the way of its dissolution.
The beeswax membrane was an inert to surrounding muscles and did not produce inflammation in the focus of ectopic implantation, promoting normal regeneration of the tissues. Dissolution time of beeswax membrane of 35-40µ width lasted 5-6 months. The data obtained point out a possibility of using beeswax membrane as a membrane for guided tissue regeneration.
Keywords:
Beeswax; Ectopic Implantation; Tissue Response
Yu.M. Pogosyan, T.V. Khanamiryan, A.Yu.
Pogosyan, E.K. Avetisyan, S.S. Burnazyan
Department of Plastic and Maxillofacial Surgery
National Health Institute, and
Department of Oral and Maxillofacial Surgery of
State Medical University, Yerevan, Armenia
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:142-149
Introduction
At present, there are over 3 dozens of various membranes that are used for bone defect isolation from penetrating unwanted cells during the regeneration period. There are several studies that investigate various types of membranes 1,5,6,12,13,16,20,23,24,26,27 . A number of researches reveal negative influence of bacteria contaminating the membrane, and the decrease of bone tissue augmentation
4,9,18,19,21,25 . Bacterial contamination of the regenerating wound significantly leads to a compromised outcome. Bacterial species, bacterial count and the area of bacterial contamination present on the guided tissue regeneration (GTR) membrane are some of the factors that may affect GTR outcome 7,11,22 .
Comparing various membrane types, the researchers came to the opinion that the effect of their use significantly depends on treatment planning concerning indication for reconstructive procedure and its performing, as well as local conditions
15,24 . The point of insufficient efficacy of the membranes due to infection in the wound remains disputable 28
. For the reduction of bacterial contamination and prevention of wound infection, some authors recommend the use of antibiotic-lead membranes 7,11,22 .
Numerous experimental and clinical investigations proved a significant improvement if membranes and transplanting materials are used
2,3,8,10,12,14 .
The aim of this study was to investigate the response of muscular tissues upon implantation of beeswax membrane into the muscles of the anterior abdominal wall in 50 rats, and the way of its dissolution.
Materials and Methods
Beeswax is a tough wax, formed from a mixture of several compounds. Beeswax has a high melting point range, 62-64°C (144-147°F). Its main components are palmitate, palmitoleate, oleate esters, aliphatic alcohols, hydroxypalmitate and pro-vitamin A.
Beeswax has antiinflammatory, bactericidal and anti-oxidative features, stimulates regeneration and growth of tissues. Beeswax is an ingredient in surgical bone wax.
The experiments were carried out on 50 white mongrel rats with average body mass of 150g. The animals were divided into 2 groups: group 1 - controls and group 2 - animals with ectopically implanted beeswax membrane (BWM). Under ether anesthesia, a pocket 1x0.5 cm in size was formed in the oblique muscles of the anterior abdominal wall with blunt tool corresponding to BWM size - 1x0.5cm and thickness -
32-40 mk (Fig. 1). In the 1 st
group of animals the pockets remained empty, and in the second, BWMs were packed up in sterile condition, with one membrane in each pocket. The BWMs were sterilized by gamma-irradiation.
The wounds were completely sutured, layer by layer, and treated by 5% iodine solution (Fig. 1). The animals were

Balk J Stom, Vol 15, 2011 Response to Beeswax Membrane Implantation 143 withdrawn from the experiment by the excessive dose of ether in the 7 th
, 15 th
, 30 th
, 60 th
, 90 th 120 th and 180 th days. The tissues obtained in these terms were fixed in 10% formalin neutral solution and filled in paraffin blocks. The slides sized about 7-8µ were dyed with haematoxylin-eosin (HE).
Figure 1. The stages of bee wax membrane implantation into the anterior abdominal wall in rats. 1) beeswax membranes; 2) pocket formation corresponding to the membrane size; 3) membrane implantation into the formed pocket; 4) layer-by-layer suturing of the wound.
Results and Discussion
On the first day and the following days of observation of animals, no significant deviations of wound healing processes after surgery were observed.
In all the animals wounds healed uneventfully, by first intention.
At the 7 th
day after surgery, exploring the area of surgical intervention in control animals, some haemorrhagic foci and disturbance of blood vessel bed in the surgical area was observed in the anterior abdominal wall (Fig. 2.1). In the experimental group animals the contours of bee wax membrane were obviously determined (Fig. 3.1). In both groups a certain decrease in translucency of the anterior abdominal wall was observed in the area adjacent to the zone of surgical intervention, probably due to developing post-operative oedema.
Microscopically, regenerative-granular processes were expressed in the control group as a reactive-inflammatory response, with newly generated vessels. Defibrillated areas of the muscular fibres were penetrated by plasmatic cells and connective, presented by polymorph cells, including endothelial cells, fibroblasts, histocytes, as well as accumulation of neutrophils and macrophages, and the net of fibres located between the vessels (Fig. 4.1). In the preparations of the experimental group, no macrophage response was revealed; the observed connective tissue elements were mainly fibroblastic, though wide lucidity areas between the muscular bundles were found out, defining the presence of the membrane (Fig. 5.1).

144 Yu.M. Pogosyan et al. Balk J Stom, Vol 15, 2011
Figure 2. Macroscopic picture of surgical intervention in the oblique muscles of the anterior abdominal wall of the control group animals
(explanation in the text)
At the 15 th
day after the surgery, findings hardly differ from those obtained on the 7 th
day. Macroscopically, transparency increased in the anterior abdominal wall, and signs of tissue oedema disappeared. However, surgical area in the control group animals was more transparent.
In micro-preparations, a moderate reactive inflammatory process with densely located mononuclear cells of the same type and partly preserved infiltrations of plasmatic type was observed, including the presence of thin-walled capillaries type. Rough fibrous connective tissue strips were formed in the junction points of the torn fibres, with muscular fibre regulation (Fig. 4.2). In the experimental group of animals, the formation of fibrous-granular tissue around the main vacuolar cavities was observed (Fig.
5.2). The latter could be the evidence of triggering BWM biodegradation process, so that the BWM is fragmented into separate parts and wrapped by fibroblastic elements.
th
day after membrane implantation in
At the 30 the muscular bed, macroscopically, the membrane edges became more transparent and irregular, resembling mosaic (Fig 3.2). The muscles surrounding the membrane had the structure typical of the crossstriated ones. Microscopically, homogenization of the affected myofibrils and bordering areas of the muscles was observed, with continuation new blood vessels and capillaries formation (Fig. 5.4). In histograms of experimental animals, the fibroblast number continued progressively to increase, enlarging the granular tissue area and decreasing size of the space occupied by the membrane, i.e., meaning dissolution of BWM and its replacement with fibrous-reticular tissue (Fig. 5.4).
Increase in the amount of collagen fibres and formation of dense rough fibrous connective tissue with the developed capillary net was also observed.
At the 60 th
day after membrane implantation in the muscular bed, macroscopically, the area of surgical intervention was practically invisible in the control group, and vascular bed was restored almost completely
(Fig. 2.2). In the experimental group, the membrane resembled mosaic picture with dark and lighter areas.
The membrane edges were irregular and ragged
(Fig. 3.4). Microscopically, vessel infiltration with cellular elements was observed here and there, which confirms the angiogenesis process. The spaces occupied by the membrane varied in shape and size, and were surrounded by the connective tissue with capillaries, including collagen and elastic fibres accumulated in bundles. The absence of connective-tissue capsule in the zone of the implanted membrane represents the evidence of the material biocompatibility and complete dissolution of the BWM.
At the 90 th
day of study, the intrusion zone in the control group animals macroscopically could not be revealed and capillary bed restored completely (Fig. 2.3).

Balk J Stom, Vol 15, 2011 Response to Beeswax Membrane Implantation 145
Figure 3. Macroscopic picture of the intervention area in the oblique muscles of the anterior abdominal wall in the experimental group animals
(explanation in the text)

146 Yu.M. Pogosyan et al. Balk J Stom, Vol 15, 2011
Figure 4. Morphological picture of intervention in the control animals (staining by hematoxillin-eosine , x60 magnification, explanation in the text)
In the histograms, only in some preparations, junction lines of the muscular bundles were traced. (Figs. 4.3 and 4.4). In the experimental group, macroscopically, the picture was almost the same as at the 60 th
day of the study. The process of collagen and elastic fibre formation actively continued though the decrease in the amount of fibroblasts and fibro-granular tissue.
By the 4 th
month of observation, the membrane thinned fragments with ragged and uneven edges were observed. In the surgery zone, vascular bed was practically restored (Fig. 3.5). Microscopically, an unordered location of muscular fibres and, here and there, preserved micro-cavities with uneven edges, with penetration of fibrous cord and a delicate net of connective tissue, were observed in the experimental group of animals (Fig. 5.5).
By the end of the experiment, at the 180 th
day after surgical intervention, the presence of the membrane in the muscular bed in the experimental animals was not observed, which indicated a complete dissolution of the membrane. The vascular bed and the transparency of the abdominal wall completely restored (Fig. 3.6).
Microscopically, in all the preparations, a restored tissue with cross-striated orientation of the fibres and the vascular system with fibrous tissue net areas, including muscular fibre fragments, was present (Fig.
5.6). Microscopically, muscular fibres, a delicate net of fibrous tissue with the areas of rough fibrous tissue were observed, which means that cicatricle tissue has been completely formed in the intervention zone.
Thus, based on the results of the presented research, we concluded that the BWM prepared by us is not only an inert material for implantation; it did not cause inflammatory reaction, but promoted normal regeneration.
It should be noted that bee wax is a biologically active product possessing high bactericidal properties. Due to the presence of pro-vitamin A and other biologically active substances, it is able to stimulate regeneration processes, which results in quick healing of the affected tissues.

Balk J Stom, Vol 15, 2011 Response to Beeswax Membrane Implantation 147
Figure 5. Morphological picture after beeswax membrane ectopic implantation (stained by hematoxillin-eosine, 1.3.4.5.6. x60 magn., 2 – x200 magn, explanation in the text)
The membrane dissolution terms are such that it could be applied as an alternative to other known membranes for isolation of bone defects and bone augmentation; it creates favourable conditions for successful formation, reliable preservation and normal transformation of various substitutes of bone tissue and blood clot in the area of bone defect. Summarizing the research data on regeneration processes after BWM ectopic transplantation, the results indicate that the applied BWM is involved into the biodegradation process by the 15 th
day after the implantation and, by gradual fragmentation and dissolution, it is substituted with connective tissue of various degree of maturity.
The dissolution terms of the BWM 32-45 µ thick vary from 5 to 6 months, which is acceptable to be used as a membrane for guided tissue regeneration.

148 Yu.M. Pogosyan et al. Balk J Stom, Vol 15, 2011
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R . Guided tissue regeneration therapy of 203 consecutively treated intrabony defects using a bioabsorbable matrix barrier. Clinical and radiographic findings. J Periodontol , 1997; 68(6):571-581.
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Correspondence and request for offprints to:
Anna Poghosyan, DMD
Department of Maxillofacial Surgery
YSMU #1 Hospital
Yerevan, Armenia
E-mail: asmida@arminco.com

BALKAN JOURNAL OF STOMATOLOGY
STOMA
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ISSN 1107 - 1141
SUMMARY
Objectives
:
To compare the pulp chamber temperature during illumination of resin-based composites using different light-curing units, and to assess the effects of a glass-ionomer (GI) base on the increase of pulp chamber temperature during polymerization.
Material and Method: Standard occlusal cavities were prepared and restored with the adhesive bonding agent Clearfil Liner Bond 2V and the composite resin Clearfil AP-X. The GI base, Aqua Ionobond, was preapplied. Groups were polymerized with a halogen-curing lamp (QTH) and with a LED lamp. Intrapulpal temperature rises were measured at 60sec intervals and data analyzed using ANOVA, Post-Hoc Scheffé and t-test.
Results
:
The smallest rise was recorded when a GI base was applied to the cavity floor and the halogen curing lamp used, while the highest rise occurred when the LED curing lamp used directly over the bonding agent.
Conclusion
:
Visible light-cure lamps varied greatly in the amount of heat emitted and judicious choice of lamps can minimize the potential for pulpal damage. The GI liner lowered the pulp chamber temperature rise occurring during the illumination of composite restoration significantly.
Keywords:
Light Curing; Composite Resin; Intrapulpal Temperature; Light-Curing Unit
Eugenia Koliniotou-Koumpia
1
,
Dimitrios Dionysopoulos 1 , Effimia Koumpia 2 ,
Georgios Giannelis
3
Aristotle University of Thessaloniki
Thessaloniki, Greece
1 Department of Operative Dentistry
2 Department of Orthodontics
3 Resident, University of British Columbia
Vancouver, Canada
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:150-154
Introduction
Dental pulp is a specialized tissue, which performs its vital functional mission within a specific temperature range. An intrapulpal temperature increase of 5.6ºC, resulting in a critical temperature of 42.5ºC, could cause irreversible damage to the pulpal tissue
33
. However, this threshold remains controversial in the light of most recent studies 3
.
Cavity preparation, polymerization of lining and restorative materials, with or without the use of light-curing systems, all serve as potential sources of temperature increase at the cavity floor level
24
.
Temperature increases during the curing of lightactivated resin-based composites are related both to the exothermic composite polymerization process and to the energy absorbed during irradiation with lightcuring units 13
. According to Lloyd et al
18
, the decisive factor in temperature increase during light-activated polymerization of resin composites is the energy absorbed during irradiation, whereas the exothermic composite polymerization process is of secondary importance in temperature increase. Nevertheless, contrary to them,
Hofmann et al
15
, found that a rise in temperature during polymerization was caused equally by radiation and by reaction heat.
Quartz-tungsten-halogen (QTH) lamps are the most frequently used sources for light curing. Typically, 500-
800 mW/cm
2
of light intensity for 30-40sec is necessary from QTH sources to polymerize composites to a depth of 2mm, but the amount of curing time also is a function of type, shade and thickness of the material. Newer QTH sources with intensities in excess of 1500 mW/cm
2
have been developed to cure thicker layers of composite in shorter periods of time. The wavelengths of their light

Balk J Stom, Vol 15, 2011 Pulp Chamber Temperature during Resin Polymerization 151 range from 400 to 500nm
30
. However, heat generation is their major disadvantage 26 .
A different type of light source is the blue Light-
Emitting-Diodes (LED) curing unit. It features very narrow spectral ranges. Specifically, the wavelength of their light is around 470 nm and this coincides with the camphor-quinone absorption peak 26,30 .
Several studies claim that all light sources might potentially generate injurious temperatures in the pulp
4,13,17,32 . The increase in temperature in the pulp chamber during illumination can be affected by several factors. The light-curing unit type, its power density, the duration of exposure, the distance between the tooth or composite surface and the light guide tip end, the composite shade, the thickness of the composite material, and the remaining dentin thickness
5,6,20,29,31 .
The placement of a cement base is often proposed as a thermal barrier to protect the pulp tissue from thermal shock
7,12 . However, the efficiency of the cement base, in providing thermal insulation, is dependent on its thickness 24
. The objectives of this in vitro study were:
(1) to measure the increase of pulp chamber temperature induced during light-curing with 2 different curing lamps, a QTH light unit and a LED light unit, and (2) to examine the effect of a previously applied glass ionomer
(GI) base on temperature rise in the pulp chamber during polymerization. chamber. The probe of the thermocouple thermometer was pushed through the apical foramen into the coronal pulp chamber until resistance was felt. The exact location of the probe was checked radiographically (Fig. 1).
The rise in temperature within the pulp chamber was recorded continuously and evaluated at a stabilized room temperature (20±0.1ºC) at 60sec interval, after the lightcuring had begun.
Material and Method
32 freshly extracted human upper premolars, free of caries and other defects, extracted for orthodontic purposes, were used in this study. Patient age range was
11-18 years. The teeth were stored in 0.2% thymol for not more than 4 months, and randomly assigned to 8 groups of 4 teeth each. Prior to the study the teeth were cleaned of all superficial debris using an ultrasonic scaler. The teeth were kept in distilled water at 37±1°C to ensure hydration of the dental tissues. The roots of the premolars were rejected below the dental-enamel junction (DEJ), so that the coronal pulp chamber was accessible and the pulp tissue was removed from the pulp chamber.
For each tooth, a class I cavity preparation was cut in the occlusal surface of the tooth. The approximate dimensions of the cavity preparations were 3mm mesiodistally, 1.5mm buccolingually, and 2mm depth.
The remaining dentin thickness between pulp chamber and occlusal cavity floor was approximately 1±0.1mm as assessed by radiographs
12,13 . For the cavity preparation, a high-speed handpiece and a new regular grit diamond bur
(#842, Komet, Lemgo, Germany) were used. The bur was changed after the preparation of every third cavity.
A thermocouple thermometer (SDT 358, Type K,
Korea) was used to measure the temperature in the pulp
Figure 1. The radiograph of the right position of the thermocouple probe into the coronal pulp chamber of the tooth
To measure the increase in temperature in the pulp chamber during illumination, the bonding agent Clearfil
Liner Bond 2V (Kuraray, Japan) and the composite resin
Clearfil AP-X, A3 shade (Kuraray, Japan) were used in all the experimental trials. Each cavity was filled with composite resin in 2 increments and each increment was light-cured immediately after application.
The light sources used in this study are sited in table 1. The curing radiometer Curing Light Meter 200
(Rolence Enterprise Inc, Chungli, Taiwan R.O.C.) was used to measure the intensity output of each light unit.

152 Eugenia Koliniotou-Koumpia et al. Balk J Stom, Vol 15, 2011
Material Brand
Power Density Manufacturer
Elipar 2500
810mW/cm2 3M ESPE, Seefeld,
Germany
Ledemetron 1
1220mW/cm2 Kerr Corp. Danbury,
USA
Both the resin-based composites and the lightcuring units were used according to the manufacturer’s instructions. In all trials, the lamp tip was positioned directly over the cavity.
The eight groups were:
Group A
(A
1 and A
2
) - measurement of the pulp chamber temperature during adhesive bonding agent polymerization for 20sec (Group
A
1
), and during composite polymerization for 40sec
(Group A
2
) with the LED curing lamp (Ledemetron 1).
The composite was applied in the cavity in 2 layers and each layer was cured in the standard programme for
40sec. For each curing, the temperature increase was measured for 60sec as mentioned above;
Group B
(B
1 and B
2
) - measurement of the pulp chamber temperature during adhesive bonding agent polymerization for 20sec
(Group B
1
) and during composite polymerization for
40sec (Group B
2
) with the QTH curing lamp (Elipar
2500). The application and the curing of the composite were the same as described for Group A;
Group C
(C
1 and C
2
) - measurement of the pulp chamber temperature during adhesive bonding agent polymerization for
20sec (Group C
1
) and during composite polymerization for 40sec (Group C
2
) with the LED curing lamp
(Ledemetron 1) in the standard programme, in cavities lined with a GI base (Aqua Ionobond, Voco), which had been previously applied. The thickness of the GI base was 1mm and it was radiographically checked. The application and the curing of the composite were the same as described for Group A;
Group D
(D
1
and D
2
)
- measurement of the pulp chamber temperature during adhesive bonding agent polymerization for 20sec (Group
D
1
) and during composite polymerization for 40sec
(Group D
2
) with the QTH curing lamp (Elipar 2500), in cavities lined with a pre-applied GI base (1mm). The application and the curing of the composite were the same as described for Group A.
The data were statistically analyzed using ANOVA,
Post-Hoc Scheffé and t-test, with p<0.05.
Results
Table 1. Light sources used in this study
Radiographs revealed that the end of the thermocouple probe was situated in the pulp just beneath the dentin. Table 2 shows mean values and standard deviations of temperature increases in adhesive and resin composites polymerized by different light sources. The mean pulp chamber temperature increase ranged between
3.4ºC and 11.4ºC, depending on the light curing unit and the placement of a GI base. The smallest temperature rise was recorded when a GI base was applied to the cavity floor and the QTH curing lamp was used (Group D
2
; p<0.05). The highest temperature rise was induced when the LED unit was used directly over the bonding agent
(Group A
1
; p<0.05). When a GI base was applied to the cavity floor, all the temperature rises were significantly lower (Groups C and D; p<0.05).
Table 2. Mean temperature rises, and standard deviation.
Groups
Group A (adhesive) (A1)
Group A (composite) (A 2 )
Group B (adhesive) ( B1)
Group B (composite) (B2 )
Group C (adhesive) (C1)
Group C (composite) (C2)
Group D (adhesive) (D1)
Group D (composite) (D2)
Discussion
Mean
5.0
4.1
3.9
3.4
11.4
7.1
7.6
5.1
S.D.
0.5
0.6
0.5
0.5
1.2
0.7
1.2
0.9
Curing lamps produce heat during their operation
13,25 . Manufacturers of composite resins recommend a specific curing time that it is unwise to exceed. For conventional halogen light sources this time is 40 sec 13
. However, new curing lamps like LED may require shorter curing times because of their high intensity output
13,19,23,25 be easier
5,7,11 appropriate
. The higher the radiation time and the irradiance are, the higher the increase in temperature is
The temperature of 20 ± 0.1º C was used as a baseline in this in vitro study. The same starting point was used as in other studies, so that comparison would
. Perhaps the temperature of 37º C (the normal intrapulpal temperature) might have been more
13,25 .
6,26 .
In the present study the highest rise in temperature was induced by the LED curing system. The mean values ranged from 7.1ºC (Group A
2
) to 11.4ºC (Group A
1
). The last temperature (11.4ºC) was significantly higher than all the others (p<0.05). It was also obvious that even if a GI base had previously been applied, the LED curing system still induced the highest temperature rises between the two groups (C and D), ranging from 4.1ºC (Group C
(Group C
1
2
) to 5.0ºC
). In agreement with the findings of previous studies, the higher intensity LED light produced a larger interpulpal temperature rise compared with the lower intensity halogen light
14,17 . This finding supports the work

Balk J Stom, Vol 15, 2011 Pulp Chamber Temperature during Resin Polymerization 153 of Hanning and Bott
13
, who found that light intensity rather than the type of light source was important.
The results of this study do not correspond with the low temperature rise induced by LED curing units revealed in other studies 26,27,32 . This could be due to the high intensity output of the LED lamp used in the present study (1220mW/cm²), whereas in other studies LED lamps with much lower output were used 1,22,26-28,32 .
Moreover, the LED curing units led to a lower degree of converse for resin-based composites, compared to conventional QTH lamps 8,26 . The less successful polymerization in addition to the relatively high temperature increase, which was found in the present study (11.4°C), indicate the need of further development of LED lamps
2
. Nevertheless, LED curing units have many advantages, such as their specific spectral emission, small size, long-lasting quality, and the fact that they are battery-powered and totally silent. They have all the features to rival the QTH light curing units
14
.
Concerning the application of the GI base to the cavity floor, the statistically significant lower intrapulpal temperature during composite curing is obvious, taking into account 2 curing lamps that were used in this study
(p<0.05). These results agree with those of 2 other studies
5,14 that the GI base seems to be a reasonably good thermal insulator.
Under the conditions of this study, the temperature increase during bonding agent curing (Groups A
D
1 curing (Groups A
2
1
, B
1
, C
1
,
) was higher than the increase during composite resin
, B
2
, C
2
, D
2
). This can be attributed to the thickness of the material, because adhesives form a very thin layer, whereas the resin-based composites form much thicker layers. This finding corresponds to that of an older in vitro
study 1
. As mentioned in the introduction, material thickness affects the temperature rise in the pulp chamber
6 . More specifically, temperature increases correspond with decreased material thickness
Moreover, the differences between Groups A
and B
2
1
and A
26 .
2
,
are statistically significant (p<0.05). On and B
1 the other hand, no statistically significant differences were found between Groups C
and C
2
, and D
1 1
and D
2 concerning temperature rises during curing, when a GI base had been applied previously to the cavity floor
(p>0.05). These findings seem to show that the preapplication of a cement base can change the participation of the material thickness in the temperature rise during polymerization.
Although it is accepted that iatrogenic increases in pulpal temperature are undesirable, the threshold above which significant damage occurs remains controversial.
Many papers investigating temperature rise within the pulp cite Zach and Cohen
33
as evidence that heat can seriously affect pulpal health. It should be noted that this study is very old and that the method can be criticized, and that other researchers have failed to demonstrate the loss of vitality experienced in the Zach and Cohen study. Nyborg and Brännström
21 reported that pathologic changes with aspiration and loss of odontoblasts occurred in all teeth subjected to heat.
3
reported no necrotic or reparative
Baldissara et al changes in teeth following intrapulpal temperature increases averaging 11.2
0
C. These discrepancies in the long-term outcome were attributed to the differences in the nature of heat application. A more recent work done by Eberhard et al 10
focused on the detection of inflammatory mediators produced in response to heat as a noxious stimulus. This study demonstrated a significant increase in the synthesis of leukotriene B
4 within the pulp cell cultures exposed to temperature increases of up to 7 o
C, similar to those deemed relevant to clinical practice mediator produced remains unknown. However, as leukotriene B
13
. The significance of the levels of
4
has the ability to induce inflammation, it seems logical that exposure to procedures that results in its synthesis should be limited.
With respect to clinical experience, even with the use of the high intensity LED lamps, which induced high temperature rises (11.4ºC) the pulp tissue seems to be able to recover from the high thermal irritation.
Conclusion
Clinicians should be aware of the possible thermal hazard to the pulp, as a result of the composite resin illumination process. Visible light-cure lamps varied greatly in the amount of heat emitted, and judicious choice of lamps can minimize the possibility of pulpal damage during placement of the composite system. Within the limits of the present study, the high intensity LED curing system seems to lead to the highest temperature increase.
On the other hand, the lower intensity QTH lamp seems to induce lower temperature rise.
The GI liner lowered the pulp chamber temperature rise occurring during the illumination of composite restorations significantly, regardless of the light source used.
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Correspondence and request for offprints to:
Dr Eugenia Koliniotou-Koumpia
Aristotle University of Thessaloniki
Dental School
Department of Operative Dentistry
54124 Thessaloniki
E-mail: jeny@dent.auth.gr

BALKAN JOURNAL OF STOMATOLOGY
STOMA
TO
LO
GI
C
A
L
S
ISSN 1107 - 1141
SUMMARY
Background : The primary goal of periodontal therapy is to arrest the inflammatory process by reducing microorganisms. Therefore laser therapy, used as an adjunct to conventional therapy, has been proposed as a novel treatment option.
Methods : The study had a split mouth design. We included 30 subjects aged 30-60 years with chronic periodontitis, according to AAP from 1999.
The control side, the left quadrant of the lower and the upper jaw, was treated only with scaling and root planning (SRP) + pocket curettage.
The test side, right quadrant of the lower and the upper jaw, was treated both with SRP + pocket curettage, and Fidelis III Nd:YAG laser (Fotona).
We used 2 treatment options of Nd:YAG laser: closed curettage and deep disinfection. The following clinical conditions were evaluated on the day
0 and the day 90: the plaque index (PI), gingival index (GI), bleeding on probing (BOP), pocket probing depth (PPD), and clinical attachment lost
(CAL).
Results : There were no statistically significant differences concerning clinical data between the test and control side on baseline. Both treatments enhanced the clinical situation compared to baseline. All above mentioned parameters significantly decreased after 3 months compared to baseline.
BOP significantly decreased at the test side compared to the control side, 3 months after the treatment (Z = -5.93; p<0.001).
Conclusion : SRP was effective in reducing levels of clinical outcomes in periodontitis (plaque, inflammation, BOP, PPD and CAL). Fidelis III
Nd:Yag laser had longer lasting effect in BOP.
Keywords: Chronic Periodontitis; Nd:Yag Laser; Periodontal Indexes; Bleeding on Probing
Aneta Atanasovska-Stojanovska,
Mirjana Popovska
University “Ss. Cyril and Methodius”, Faculty of Dentistry, University Dental Clinical Centre,
Department of Periodontology and Oral
Pathology, Skopje, FYROM
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:155-160
Introduction
The primary goal of periodontal therapy is to arrest inflammation by reducing microorganisms. Current approach is based on mechanical removal and the use of remedies (antibiotics and corticosteroids), which are used locally or systemically. There were 2 problems we faced with their uses. The first, there is some percent of patients with contraindications for chemotherapeutics. The second, because of the chronic nature of periodontal disease, repeated administration of some antibiotics may provoke bacterial resistance due to their mutation.
Therefore laser therapy, used as adjunct or as conventional therapy, has been proposed as a novel treatment option against bacterial invasion.
Delivery of laser light, locally on the inflamed periodontal pocket, causes disruption on cellular membrane of bacterial cells and do not causes resistance on host response. The use of a Nd:YAG laser in the treatment of chronic periodontitis is based on the purported benefits of subgingival curettage, which induces new attachment through regeneration of cementum,

156 Aneta Atanasovska-Stojanovska, Mirjana Popovska Balk J Stom, Vol 15, 2011 periodontal ligament, and forming of alveolar bone
1
.
There is limited evidence suggesting that lasers cause greater reduction of subgingival bacteria than reduction achieved by conservative periodontal therapy
2
. Laser therapy seems to have impact on the micro-flora, which in comparison to the use of antibiotics, does not has known side-effects. The minimal risk for bacterial resistance to laser therapy is a major advantage
3
. The effect of laser light against human tissue depend of wave length of energy that was emitted from the laser, power of density and time duration of laser light toward tissue. Primary rule with laser light management is the fact that the laser effect is bigger when energy absorbed by tissue is bigger.
Speed and efficiency of laser procedures are defined by laser parameters, size of the treated surface and speed of moving handpiece.
Periodontal disease in any form and clinical stadium may be treated by laser light. Limited research suggests that the use of lasers as an adjunct to scaling and root planning (SRP) may improve the effectiveness of this procedure
4-6 . Each laser has different wavelengths and power levels that can be used safely during different periodontal procedures. However, damage to periodontal tissues can be caused if an inappropriate wavelength and/ or power level is used during a periodontal procedure.
The aim
of this study was to examine whether laser therapy, as an adjunct to SRP + pocket curettage in subjects with chronic periodontitis, improves the treatment results compared to treatment with SRP + pocket curettage alone.
Material and Method
This split mouth study aimed to compare conservative technique in periodontal treatment
(SRP + pocket curettage) and combined treatment with (SRP + pocket curettage) and laser Nd:YAG as an adjunct. The study was conducted at the
Department of Oral Pathology and Periodontology,
Dental Clinical Center St. Pantelejmon - Skopje. All of the patients signed a written consent to participate in the study, which was approved by Ethical
Committee of the Faculty of Dentistry in Skopje.
30 subjects aged 30-60 with chronic periodontitis according to the AAP (American Academy of
Periodontology) from 1999
7
, were selected. Criteria for participation in the study were the following: the presence of at least 3 teeth in each quadrant of the jaw with periodontal probing depth ≥ 4 mm; patients without any systemic diseases; non-smokers in the past ten years.
When they joined the study each patient was marked with randomization number. 2 quadrants on the left side of the upper and lower jaw were treated by SRP + pocket curettage alone, and were named the control side
; another
2 quadrants on the right side of the upper and lower jaw were treated both with SRP + pocket curettage and Fidelis
III Nd:Yag laser (Fotona), and were named the test side .
Clinical condition was evaluated on baseline using clinical parameters (indexes) of all teeth with 1 or 2 roots, in each quadrant. Patients were instructed how to maintain basic oral hygiene by applying Bass method for brushing teeth, twice a day, and to use dental floss.
SRP was performed under local anesthesia with manual instruments (Greys’s curettes) on both sides. The whole study was performed by one operator.
24 hours after completing the required conservative treatment, the test side was treated with laser light. We used Fidelis III Nd:Yag laser 1064nm wave length, with chosen options for closed curettage and deep disinfection:
VSP (very short pulse), power 1.5W Hz, frequency 20 Hz, periodontal fibre handpiece 300μ, time 60 sec/pocket.
Optical periodontal fibre was inserted in the pocket and kept parallel with the root surface of the tooth, performing laterally movement along the pocket. The data were recorded in individual places, under the patient’s number.
Patients were scheduled for check up after 6 weeks from the treatment, during which period the oral hygiene was controlled, with given advices for maintaining it.
This was evaluated by removing dental calculi and dental plaque if necessary . Then the patients were scheduled for check up after 3 months from the initial treatment, and the same periodontal indexes were measured. The clinical outcomes were compared for both the examined sides (test and control) at the beginning (before treatment), and after
3 months.
Clinical outcomes were measured using plaque index (PI) - Silness & Loe, 1964
8
, and gingival index
(GI) - Loe & Silness 1963
9
. The indexes were determined on the buccal, lingual, mesial and distal side of each tooth, in each quadrant, for all 30 patients. Bleeding on probing (BOP) was graded 1, if it occurred within 30 sec. If not, it was graded 0. Pocket probing depth (PPD) was measured with periodontal probe from the gingival margin to the bottom of the periodontal pocket. Clinical attachment lost (CAL) was measured with periodontal probe from the enamel-cementum junction to the bottom of the periodontal pocket. For each tooth, maximal PPD and CAL derived by measuring 6 sites around each tooth, recording the maximum values.
The patients were scheduled for check up after
3 months from the baseline treatment, when same periodontal indexes were measured
Statistical analysis of data was made with the program STATISTICA 7.0, using descriptive statistics, test for normality, T-test, Wilcoxon matched pairs test
(Z) and Mann-Whitney U Test (Z), at the series with numerical distinctions. At the series with attributive distinctions, structural percentage was used.

Balk J Stom, Vol 15, 2011 Nd:YAG Laser in Periodontal Treatment 157
Results
We included 30 subjects in the study, 15 males and 15 females. Table 1 shows descriptive statistics of examined patients’ age. Men were older (48.67±7.51) than women
(46.33±7.041), without statistically significant difference.
Table 2 shows clinical parameters of the test and control side determined at the baseline examination. There were no significant differences between control and test side for each of the examined parameters (Tab. 2).
On the 90 th
day of study (Tab. 3) there were no significant differences between control and test side for PI, GI, PPD and CAL.
For Z = -5.93 and p < 0.001
(p = 0.000000) there was a significant difference between the values of BOP test/BOP control (there was significantly increased bleeding on probing in the controlled side of the mouth).
Table 4 shows a comparison of clinical parameters received on baseline examination (before therapy) and day
90, conducted at the same side of the mouth. There was a significant difference of all the examined parameters on the test and control sides at the baseline examination and the 90 th
day of study, as well as between the groups.
Males
Females
N
15
15
Mean
48.67
46.33
Table 1. Age of the examined patients
Confidence
-95%
44.51
42.44
Confidence
+95%
52.82
50.23
Min.
35.00
37.00
Max.
60.00
59.00
SD
7.51
7.04
Parameter
PI
GI
BOP
CAL
PPD*
Table 2. Comparison of clinical parameters determined at the baseline examination of the test and control sides
Rank Sum test
* Descriptive Statistics for the PPD
868.50
875.50
944.50
920.00
Mean
5.33
Rank Sum control
961.50
954.50
885.50
910.00
Mean
5.35
U
403.50
410.50
420.50
445.00
t
-0.10
Z
-0.69
-0.58
0.44
0.074
df
58 p-level
0.49
0.56
0.66
0.94
p
0.92
Parameter
PI
GI
BOP
CAL
PPD
Table 3. Comparison of clinical parameters determined on the 90th day of the study of the test and control side
Rank Sum test
911.50
854.00
514.00
925.00
925.00
Rank Sum control
918.50
976.00
1316.00
905.00
905.00
U
446.50
389.00
49.00
440.00
440.00
Z
-0.05
-0.90
-5.93
0.15
0.15
p-level
0.96
0.37
0.000*
0.88
0.88

158 Aneta Atanasovska-Stojanovska, Mirjana Popovska Balk J Stom, Vol 15, 2011
PPD
Table 4. Comparison of clinical parameters determined on baseline and day 90 conducted at same side of mouth.
Parameter
PI test
PI control
GI test
GI control
BOP test
BOP control
CAL test
CAL control
PPD test
Valid
30
30
30
30
30
30
30
30
30
Mean
5.35
0.00
0.00
0.00
0.00
T
0.00
0.00
0.00
0.00
0.00
Mean
4.17
Z
4.78
4.78
4.78
4.78
4.78
4.11
4.015
4.015
4.622599
t
9.71
p-level
0.000002*
0.000002*
0.000002*
0.000002*
0.000002*
0.000040*
0.000060*
0.000060*
0.000004* p
0.00000*
Discussion
Usage of Nd:Yag laser in the treatment of chronic periodontitis was based on successful subgingival curettage, which lead to creation of the new attachment throw regeneration of cementum and periodontal ligament; it contributes to the creation of new alveolar bone, too.
These results were due to reduction of number of bacterial cells in periodontal pocket, coagulation of inflamed and necrotizing tissue and its bio-stimulating effect on osteoblasts
10
.
One of the first in vivo
studies reporting the reduction in pathogenic bacteria following irradiation with the
Nd:YAG laser showed decreases in Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), and
Actinobacillus Actinomicetemcomitans (Aa)
11
. A later study, also using the Nd:YAG laser, compared laser therapy to SRP and reported that both modalities reduced levels of microorganisms, but incompletely eliminated Aa.
Laser therapy resulted in a greater reduction in microbial flora against baseline levels 10 weeks after the beginning of the therapy
12
.
Another in vivo study compared SRP (1 episode) to SRP followed by irradiation with the Nd:Yag laser at a relatively high energy density of 124/cm
2
. Treated pockets were irradiated once per week for 3 weeks.
Levels of Pg, Pi and Aa were determined at 6 months after the treatment, and only levels of Pg were found to be significantly reduced compared to SRP
13
. In the study of Ambrosini et al
14
, no statistically significant difference was observed for adjunctive effect of laser therapy against
SRP alone. However, all patients received a prescription of 0.2% chlorhexidine for mouth rinse during the initial healing phase 14
. On the contrary, statistically significant differences in GI and CAL were reported for the laser treated sites compared to controls at 6 months in the study by Neill and Mellonig 15
.
In our study, the results clearly show that both treatment modalities were effective in decreasing the values of the clinical parameters used for evaluation of periodontitis. At the beginning, the mean PPD was 5.33 for the test side and 5.35 for the control side, and changed to 4.22 for the test side (SRP + laser) and 4.17 (SRP) after the treatment. These values corroborate those obtained by other authors
16,17 . It has been established that SRP is an efficient therapy
18
and that very few pockets do not show some sign of improvement after non-surgical treatment
19
.
In our study, initial mean CAL was 5.00 for the entire sample and changed to 4.79 for the test side (SRP
+ laser), and 4.75 (SRP) 3 months after the treatment.
Statistical analysis of data showed a significant difference between the values of CAL after periodontal treatment on both sides. There was a significant difference between the values of CAL on the control side and the test side, on baseline examination and 90 days thereafter. The only significant result from the analyses conducted on 90 th day is for (BOP) values between the test and control sides.
Significantly higher bleeding has been noticed on the control side than on the test side.
Evaluating outcomes of non-surgical periodontal therapy concerning CAL, this seems as gold standard.
Thus, if one calculates the average gain in CAL reported in studies for laser therapy with Nd:YAG versus SRP

Balk J Stom, Vol 15, 2011 Nd:YAG Laser in Periodontal Treatment 159 alone, it becomes evident that there is minimal benefit following sub-gingival laser therapy 20,21 .
Further analysis of these data shows that some of the studies reported essentially equivalent results between laser-treated groups and controls studies
24,25
3 studies
clearly favoured laser therapy against SRP.
26-28
22,23 , and some
reported little to no difference in PPD reduction when comparing laser treated site to control sites (SRP only) when using different kind of laser light
(Er:YAG, Nd:YAP and gallium arsenide diode laser) and one study 29 reported a greater mean decrease in PD in
SRP treated sites than in those treated by laser. However, these studies used different kind of laser light.
Lastly, when the Nd:YAG laser was combined with locally delivered monocycline, PD was significantly reduced compared to sites treated by laser alone 30
. Results for BOP and reduction of pathogenic bacteria were contradictory, too. 2 studies 31,32 reported no difference between test and control groups in levels of sub-gingival bacteria, and 2 studies reported significant decreases in laser treated sites 33. Due to these contradictory findings, it seems that there is a great need to develop an evidence based approach for usage of lasers to treat chronic periodontitis.
Conclusion
SRP + pocket curettage was effective in reducing levels of clinical outcomes in periodontitis (plaque, inflammation, BOP, PPD and CAL). Fidelis III Nd:Yag laser have longer lasting effect in BOP.
References
1. Myers TD . What lasers can do for dentistry and you. Dental
Management , 1989; 29:26-28.
2. Meral G, Tasar F, Kocagoz S, Sener C . Factors affecting the antibacterial effects of Nd:YAG laser in vivo. Laser in
Surgery and Medicine , 2003; 32:197-202.
3. Nussbaum EL, Lilge L, Mazzulli T . Effects of 810 nm laser irradiation on in vivo growth of bacteria: Comparison of continuous wave and frequency modulated light. Laser in
Surgery and Medicine , 2002; 31:343-351.
4. Aoki A, Miura M, Akiyama F, et al . In vitro evaluation of
Er:YAG laser scaling of subgingival calculus in comparison with ultrasound scaling. J Period Res , 2000; 35:266-277.
5. Eberhard J, Ehlers H, Falk W, Acil Y, Albers HK, Jepsen S .
Efficacy of subgingival calculus removal with Er:YAG laser compared to mechanical debridement: An in situ study. J
Clin Periodontol , 2003; 30:511-518.
6. Caton JG, Zander HA . The attachment between tooth and gingival tissues after periodic root planning and soft tissue curettage. J Periodontol , 1979; 50:462-466.
7. Gary C . Armitage Development of a Classification System for Periodontal Diseases and Conditions. Ann Periodontol ,
1999; 4:1-6.
8. Silness J, Loe H . Periodontal disease in pregnancy II.
Correlation between oral hygiene and periodontal condition.
Acta Odontol Scand , 1964; 22:121-135.
9. Loe H, Silness J . Periodontal disease in pregnancy I. Prevalence and severity. Acta Odontol Scand , 1963; 21:533-551.
10. Trylovich DJ, Cobb CM, Pippin DJ, Spencer P, Killow
WJ . The effects of Nd:YAG laser on in vitro fibroblast attachment to endotoxin-treated root surfaces. J Periodontol ,
1992; 63:633-636.
11. Cobb CM, McCawley TK, Killoy WJ . A preliminary in vivo study on the effects of the Nd:YAG laser on root surfaces and subgingival microflora. J Periodontol , 1992; 63:701-707.
12. Ben Hatit Y, Blum R, Severin C, Maquin M, Jabro MH . The effects of a pulsed Nd:YAG laser on subgingival bacterial flora and on cementum: An in vivo study. J Clin Laser Med
Surg , 1996; 14:137-143.
13. Gutkenecht N, Radufi P, Franzen R, Lampert F . Reduction of specific microorganisms in periodontal pockets with the aid of an Nd:YAG laser - An in vivo study. J Clin
Periodontol , 1995; 22:71-77.
14. Ambrosini P, Miller N, Briancon S, et al . Clinical and microbiological evaluation of the effectiveness of the
Nd:YAP laser for the initial treatment of adult periodontitis.
A randomised controlled study. J Clin Periodontol , 2005;
32:670-676.
15. Neill Me, Melonig JT . Clinical efficacy of the Nd:Yag laser for combination periodontics therapy. Practical
Periodontics and Aesthetic Dentistry , 1997: 9(6 Suppl):1-5.
16. Hill, RW, Ramfjord SP, Morrison E . Four types of periodontal treatment compared over two years. J
Periodontol , 1981; 52:655-662.
17. Kaldahal WB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE .
Evaluation of four modalities of periodontal therapy. Mean probing depth, probing attachment level and recession changes. J Periodontol , 1988; 59:783-793.
18. Cobb CM . Lasers in periodontics: A review of the literature.
J Periodontol , 2006; 77:545-564.
19. Badersten A, Nilveus R, Egelberg J . Effects of non surgical periodontal therapy. III. Single versus repeated instrumentation. J Clin Periodontol , 1984; 11:114-124.
20. Liu CM, Hou LT, Wong MY, Lan WH . Comparison of Ng:YAG laser versus scaling and root planning in periodontal therapy. J Periodontol , 1999; 70:1276-1282.
21. Miyazaki A, Yamaguchi T, Nishikata J, et al . Effects of
Nd:YAG and CO
2
laser treatment and ultrasonic scaling on periodontal pockets of chronic periodontitis patients. J
Periodontol , 2003; 74:175-180.
22. Borrajo JL, Varela LG, Castro GL, et al . Diode laser 980nm as adjuncts to scaling and root planning. Photomedical
Laser Surgery , 2004; 22:509-512.
23. Schwarz F, Sculean A, Georg T, Reich E . Periodontal treatment with an Er:YAG laser compared to scaling and root planning. A controlled clinical study. J Clin
Periodontol , 2001; 72:361-367.
24. Schwarz F, Sculean A, Beraktar M, et al . Clinical evaluation of an Er:YAG laser combined with scaling and root planning for non-surgical periodontal treatment. A controlled, prospective clinical study. J Clin Periodontol ,
2003; 30:26-34.

160 Aneta Atanasovska-Stojanovska, Mirjana Popovska Balk J Stom, Vol 15, 2011
25. Schwarz F, Sculean A, Beraktar M, et al . Periodontal treatment with an Er:YAG laser or scaling and root planning. A 2 year follow-up split-mouth study. J
Periodontol , 2003; 74:590-596.
26. Sculean A, Schwarz F, Berakdar M, et al . Periodontal treatment with an Er:YAG laser compared to ultrasonic instrumentation: A pilot study. J Periodontol , 2004;
75:966-973.
27. El Yazami H, Azehoui N, Ahariz M, Rey G, Sauvetre E .
Periodontal evaluation of an Nd:YAP laser combined with scaling and root planning for nonsurgical periodontal treatment. A clinical evaluation. Journal of Oral Laser
Appliance , 2004; 4:97-102.
28. Yilmaz S, Kuru B, Kuru L, et al . Effect of gallium arsenide diode laser on human periodontal disease: A microbiological and clinical study. Laser Surgical Medicine , 2002; 30:60-66.
29. Nogouchi T, Sanaoka A, Fukuda M, et al . Combined effects of Nd:YAG laser irradiation with local antibiotic application into periodontal pockets. J Int Acad
Periodontol , 2005; 7:8-15.
30. Radvar M, MacFarlane TW, MacKenzie D, et al . An evaluation of the Nd:YAG laser in periodontal pocket therapy. Br Dent J , 1996; 180:57-62.
31. Quadri T, Miranda L, Tuner J, Gustafsson A . The short term effects of low lasers as adjunct therapy in the treatment of periodontal inflammation. J Clin Periodontol ,
2005; 32:714-719.
32. Liu C-M, Hou L-T, Wong M-Y, Lan WH . Comparison of ND:YAG laser versus scaling and root planning in periodontal therapy. J Periodontol , 1999; 70:1276-1282.
33. Harris DM, Gregg RH, Mc Carthy DK, Colby LE, Tilt LV .
Laser assisted new attachment procedure in private practice.
Gen Dent, 2004; 52:396-403.
Correspondence and request for offprint to:
Prof. Aneta Atanasovska-Stojanovska
“Kozle “113
1000 Skopje, FYR Macedonia
E mail anetaivica@yahoo.com

BALKAN JOURNAL OF STOMATOLOGY
STOMA
TO
LO
GI
C
A
L
S
ISSN 1107 - 1141
SUMMARY
The aim of this study was to obtain the data for jaw skeletal variations and maxillary and mandibular position according to cranial base in individuals with Class II Division 1 malocclusion, as well as their length.
To accomplish that goal, 52 subjects aged 14 to 19, with Class II Division 1 malocclusion have been examined, and than compared with control group, consisting of 40 subjects with normal occlusion. A profile tele-roentgen film was taken of each patient and following parameters were analysed: angle SNA, angle SNB, angle ANB, Sna-Snp (maxillary length) and Go-Gn
(mandibular length). Patients were divided in 4 subgroups consisting of both genders: Subgroup A, with the ante-position of both jaws; Subgroup B with maxillary ante-position and mandibular retro-position; Subgroup C with maxillary normo-position and mandibular retro-position; Subgroup D with retro-position of both jaws.
The maxilla was in retro-position most frequently (53.97% in girls and 65.47% in boys), rarely in ante-position (34.5% and 23.0%), and nonfrequently in normo-position (11.53% in both sexes). The mandible was most frequently in retro-position (88.4% in girls and 92.27% in boys). The distance Sna-Snp decreased non-significantly in girls and boys, except in
A subgroup, where the distance was significantly increased (p<0.05). The distance Go-Gn in girls was decreased with different significance, except in subgroup with maxillary normo-position and mandibular retro-position. In boys, the decrease was significant in A and B subgroups (p<0.01), as well as in D subgroup (p<0.05).
It can be concluded that malocclusion Class II Division 1 is not a unique clinical entity, but spectrum of many combinations of components, with distinct dental and skeletal variations in length and position.
Keywords:
Facial Morphology; Skeletal Variations; Class II Division 1 Malocclusion
Biljana Dzipunova, Natasha Tosheska, Lidija
Kanurkova, Julijana Gjorgova
University “St. Ciril and Methodius”
Faculty of Dentistry, Department of Orthodontics
Skopje, FYROM
ORIGINAL PAPER (OP)
Balk J Stom, 2011; 15:161-165
Introduction
Malocclusion Class II Division 1, because of its frequency, was always challenging for examination.
There is universal agreement for its actual morphology, which is postnormal relationship of mandibular dentition to its maxillary opponent, and protrusion of maxillary frontal segment, frequently with deviations in dental arches, deviations in vertical and transversal relationship between jaws and coronal compression. Frequently the lower anterior segment shows supra-version, a tendency toward flattering and some irregularities. Maxillary arch sometimes shows demonstrable narrowing in the premolar region, which is responsible for “V” arch shape.
Other regular characteristic is abnormal muscle function.
With the increase of overjet, the lower lip cushions to the lingual aspect of these teeth. During swallowing, abnormal mental muscle activity and aberrant buccinator activity, together with compensatory tongue function and changed tongue position, tend to accentuate the narrowing of the maxillary arch, labial inclination of maxillary incisors and flattering of mandibular incisors 1,5,6,8,10,16 .
Aetiology is always in relationship with all prenatal and postnatal influences, which can alter normal physiological processes. But, fundamental cause for malocclusion is heredity. Other factors

162 Biljana Dzipunova et al. Balk J Stom, Vol 15, 2011 are: civilized live manner and habits, decreased masticatory function and interweave of different genetic characteristics from heterogeneous geographic, ethnic and race groups.
Many orthodontic authorities say that Class II
Division 1 malocclusion is more than irregular teeth and lack of space. There is no constancy in eruption of the upper first permanent molar and there is a great diversity in skeletal and dental basis. Research reports on distoocclusion are huge, but there is not a universal agreement for the actual morphology of this abnormality, many parameters tend to be changed differently.
Interestingly, there are different opinions about variations in jaws relationship according to anterior cranial base, and many authors elaborated different morphologic relationships
6,10,12,13 .
These differences among results and conclusions of various studies are possibly due to diversities among different skeletal Class II types. Because in malocclusion Class II Division 1 face morphologic characteristics depend on clinical form of the malocclusion, and as several skeletal combinations exist that cannot be evaluated only by clinical examination and gnathometric analysis, the aim of this study was to obtain the data for jaw skeletal variations and maxillary and mandibular position according to cranial base, as well as their length.
Material and Methods
Results and Discussion
Figure 1.
Table 1. All subgroups, according to sex, frequency and age
Frequency of all subgroups, according of sex and age malocclusion sII/1 sex frequency age subgroup A subgroup B
f
m
f
m
11,53 %
7,7 %
23,07 %
15,3 %
15,2
15,5
14,8
14,9 subgroup C subgroup D
f
m
f
m
11,53 %
11,53 %
53,87 %
65,47 %
16,6
15,0
16,0
14,7
52 subjects, aged 14-19 years, with Class II
Division 1 malocclusions have been examined, and than compared with the control group consisting of
40 subjects of the same age with normal occlusion. A profile tele-roentgen film was taken of each patient and following parameters were analysed: angle SNA, angle
SNB, angle ANB, distance Sna-Snp (maxillary length) and distance Go-Gn (mandibular length), as shown on figure 1.
According to angles of maxillary and mandibular prognathism, we formed 4 subgroups in the investigated group (Tab. 1):
● Subgroup A: anteposition of both jaws;
●
Subgroup B: maxillary anteposition and mandibular retroposition;
●
Subgroup C: maxillary normoposition and mandibular retroposition;
● Subgroup D: retroposition of both jaws.
The results for variations of sagittal jaw relationship according to cranial base, are in accordance with findings of other authors 1,6,10,12,13,17,22 , but the different frequency was established.
Maxillary and mandibular positions, in accordance to anterior cranial base and parameters in all subgroups, in females and males, are given on figures 2 and 3, and tables 2 and 3.
The results are in agreement with those of Renfroe
18
,
McNamara 12
, Rusich-Tasich
22
and Pancherz
14
, but not with results of Riedel
19 and Bishara 1
, who considered that there is no significant differences in maxillary A-P relation in Class I and Class II, and those of Rosenbloom
21
, who found that dominant type is maxillary anteposition.

Balk J Stom, Vol 15, 2011 Facial Morphology in Class II Division 1 Patients 163
Figure 2. Frequency of maxillary position in accordance to anterior cranial base, in females and males
Figure 3. Frequency of mandibular position in accordance to anterior cranial base, in females and males
Table 2. Values of investigated parameters in all subgroups, for females subgroup A subgroup B angle SNA angle SNB
88.00* * *
82.170* * *
84.00* *
76.250 *
Angle ANB
Sna-Snp
5.830* *
56.83
6.90* * *
56.92
Go-Gn 72.83* 73.58
(* low significance, ** high significance, *** very high significance) subgroup C
82.00
76.50*
5.50* *
56
77.5
subgroup D
78.390* *
72.10* * *
6.40 * * *
57.53
72.75* * normal occlusion
80.140
77.880
2.430
57.59
76.0
Table 3. Values of investigated parameters in all subgroups, for males subgroup A subgroup B angle SNA angle SNB
87.00 ***
81.00 ***
83.750 ***
75.630 *
Angle ANB
Sna-Snp
6.00 ***
60.0 *
6.630 **
55.5
Go-Gn 80.75 ** 78.5
(* low significance, ** high significance, *** very high significance) subgroup C
82.00*
75.830*
5.50**
56
77.5
subgroup D
79.460
72.770 ***
6.470 ***
55.75
72.65 * normal occlusion
80.330
77.470
2.580
56.38
76.79
Studies of longitudinal growth of untreated individuals, done by Riolo et al
20 and Broadbent et al 2
, have revealed that the relationship of the maxillary complex to upper facial structures stays relatively constant during growth as shown by angle SNA. In this study, the position of maxillary complex in Class II individuals was variable. Most frequently, maxilla was in retroposition relative to cranial base structures. Maxillary skeletal retrusion was usually found in conjunction with excessive vertical development. Solow and Kreiborg
23 suggest that a lowering of the mandible is usually prompted by altered respiratory function, which may induce a stretching of the

164 Biljana Dzipunova et al. Balk J Stom, Vol 15, 2011 facial soft tissue layer. These tissues can than inhibit the forward development of the naso-maxillary complex. The results of this study seem to support that hypothesis.
The distance Sna-Snp is decreased non-significantly in girls and boys, except in A subgroup, where the distance was significantly increased (p<0.05).
The change in size and proportion of the upper face during growth and development is familiar to us from several biometric studies. The maxillary growth in length is directed towards the palatine bone, and it is accompanied by periosteal apposition at the maxillary tuberosity. The growth in height takes place at the sutures
- articulations of the frontal and zygomatic processes, and by periosteal apposition on the lower border of the alveolar process. The direction of tooth eruption is predominantly vertical, but if there is a large component of forward eruption (heredity or habits), the alveolar prognatism will be increased and the alveolar arch elongated forwards.
Results are compatible with those of Renfroe
18
,
Hitchoch 8
, Moyers
11
, McNamara
12
, Deguchi
4
, Karlsen
9
,
Rusich-Tasich
22
, Pancherz
14 and Bischara 1
, but they are not in agreement only with those of Cassidy
3 and
Rosenbloom 21
, who state that mandible is mostly in normal position. These results indicate that retrusion of the mandible most commonly occur as contributing factor to Class II malocclusion. This is not surprising in view of its developmental characteristics. Embriologically, the mandible is not derived from the primary cartilaginous skeleton; for the most part, it develops independently, lateral to Meckel’s cartilage. The cartilage of the mandibular condyle has been shown to be distinct from other growth cartilages of both the craniofacial region and the appendicular skeleton
5,10,16 . Many experimental studies of condylar growth adaptations to alterations in biomechanical and biophysical environment of the craniofacial region in rhesus monkeys and other animal species, indicate that mandibular growth can be increased or decreased by changing the mandibular postural position
11,15 . These studies suggest that growth of the condylar cartilage may be in part adaptive, so condylar response to alterations in the environment may more closely resemble that of periosteum than that of the epiphyseal cartilages of long bones. Since growth of the mandible can be influenced by alterations in the functional environment, it seems to us that abnormal muscle function, altered occlusal inter-digitation and other factors may affect the size and shape of the mandible in the growing Class II individuals.
Many orthodontics consider that there are 2 ways in which the mandible can be situated posteriorly: structurally (various dimensions of the mandible, e.g. body length, ramus height, gonial angle; or the glenoid fossa can be placed further back than in neutrocclusion) and functionally (acquired muscle contraction patterns may cause the mandible to assume a posterior position as a result of sucking habit or by congenital origin).
The distance Go-Gn in girls is decreased with different significance except in subgroup with maxillary normoposition and mandibular retroposition. In boys, the decrease is significant with p<0.01 in A and B subroups, and p<0.05 in D subgroup. Literature shows abundant data with opposite opinions for this parameter. Renfroe
18
,
Cassidy 3
and Rusic-Tasic and Tijanic
22
are of the opinion that the mandible is not insufficient in this malocclusion and that the problem is not in its length. Gilmore
7
, Fisk 6 ,
Rakosi 17
, Karlsen
9 and Bishara 1
, as we did, established a decrease of the mandibular length.
Growth of the jaws usually correlates with the physiologic events of puberty. In both the maxilla and the mandible, growth in the width is completed first, then growth in length and finally growth in height. Growth in width of both jaws, including the width of the dental arches, tends to be completed before the adolescent growth spurt. Growth in length of both jaws continues throughout the period of puberty. Growth in vertical height of the jaws and face continues longer in both genders than growth in length 16 .
Malocclusion arises throughout variation in the normal developmental process, so orthodontic treatment often involves manipulation of skeletal growth or camouflage, but always rests on a precise diagnosis.
The key decision in treatment planning for patients with skeletal malocclusion is to select the best approach: growth modification, if possible, provides the ideal results; camouflage represents a compromise that may be quite acceptable in moderate skeletal discrepancies; surgical correction is reserved for the most severe problems.
Conclusions
We establish existence of 4 subgroups, in both sexes. They are: Subgroup A, with the anteposition of both jaws; Subgroup B with maxillary anteposition and mandibular retroposition; Subgroup C with maxillary normoposition and mandibular retroposition; Subgroup
D with retroposition of both jaws. Class II Division 1 malocclusion is not a unique clinical entity, but spectrum of many combinations of components, with many dental and skeletal variations in lenght and position. Most frequently, the maxilla is in retroposition, rarely in anteposition, and sometimes in normoposition. The most frequently, the mandible is in retroposition.
The distance Sna-Snp was decreased nonsignificantly in girls and boys, except in A subgroup, where the distance was significantly increased (p<0.05).
The distance Go-Gn in girls was decreased with

Balk J Stom, Vol 15, 2011 Facial Morphology in Class II Division 1 Patients 165 different significance, except in subgroup with maxillary normoposition and mandibular retroposition. In boys, the decrease was significant with p<0.01 in A and B subroups, and p<0.05 in D subgroup.
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II malocclusion. Am J Orthod , 1980; 78(5):477-494.
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15. Petrovic A . Mechanisms and regulation of mandibular condylar growth. Acta Morphol Scand ; 1972; 10:25-34.
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17. Rakosi T . Differential diagnosis and planning in treatment of Class II malocclusions in mixed dentition. In: Graber
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18. Renfroe EW . A study of the facial patterns associated with Class I, Class II division 1 and Class II Division 2 malocclusions. Angle Orthod , 1948; 18:12-15.
19. Riedel R . The relation of maxillary structures to cranium in malocclusion and in normal occlusion. Angle Orthod , 1952;
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20. Riolo M, Moyers RE, McNamara JA Jr, Hunter WS . An atlas of craniofacial growth. Craniofacial growth series,
Center for human growth and development. The University of Michigan, Ann Arbor, 1974.
21. Rosenbloom RE . Class II malocclusion: mandibular retrusion or maxillary protrusion? Angle Orthod , 1995;
65(1):49-62.
22. Rusic-Tasic V, Tijanic Lj . Tip lica kod osoba sa malokluzijom II/1 klase. Bilten UOJ , 1996; 29(1-2):221-
233. (in Serb)
23. Solow B, Kreiborg S . Soft-tissue stretching: a possible control factor in craniofacial morphogenesis. Scand J Dent
Res , 1977; 85:505-507.
Correspondence and request for offprints:
Ass. Dr. Biljana Dzipunova
“Jurij Gagarin” 26/3
Skopje, FYR Macedonia e-mail: bibidzipun@yahoo.com

BALKAN JOURNAL OF STOMATOLOGY
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ISSN 1107 - 1141
SUMMARY
Introduction
:
Endodontic failure may arise mainly from persistent intra-radicular infection from remaining bacteria in the root canal. As a result, retreatment is the most appropriate way of dealing with failed cases.
However, many clinicians choose to perform periapical surgery, on the grounds that it is simpler and has immediate results. The resected teeth with insufficient root canal treatment may fail again. In this case, orthograde retreatment can have favourable results. The aim of the present study was to describe a case, where an orthograde retreatment was applied in symptomatic upper premolars that had already resected.
Methods
:
This case report describes the orthograde retreatment of upper premolars after unsuccessful apicectomy. A 32-year old female patient presented complaining of extra-oral fistula and intra-oral swelling associated with the upper left premolars. Radiographic examination showed that the premolars had received inadequate endodontic treatment and presented periapical radiolucency. An orthograde retreatment was performed in both of them.
Results
:
After 15 days, the teeth were asymptomatic and the intra-oral swelling had disappeared. In addition, no exudate was found in the root canals and the extra-oral fistula was no more active. At a 3-year recall the region appeared normal.
Conclusions
:
Orthograde retreatment is a treatment option in teeth with unsuccessful apicectomy and poor endodontic treatment.
Keywords:
Orthograde Retreatment; Apicectomy, unsuccessful
N. Economides, T. Vouzara
Aristotle University, Dental School
Department of Endodontology
Thessaloniki, Greece
CASE REPORT (CR)
Balk J Stom, 2011; 15:166-170
Introduction
Root canal treatment is an effective way of tooth preservation. Success rate of initial endodontic treatment has been found to reach even 97%
1
. Yet, endodontic failures are not uncommon in daily dental practice. Endodontically treated teeth may fail mainly because of intra-radicular or extra-radicular infection
2
.
Another reason for failure, which cannot be related to microorganisms, is foreign-body reaction
2
.
Intra-radicular infection is the most common cause for endodontic failure
2
. It can occur due to insufficient root canal cleaning and persistence of bacteria at the time of root filling
3
, or due to re-infection caused by coronal leakage 4
. The most frequent microorganism, isolated in failed cases is Enterococcus faecalis , which is a species scarcely found in untreated root canals
5
. It is suggested that
E. faecalis
is inserted into the canal during root canal treatment
3,6,7 . In addition, E. faecalis can withstand intra-canal medication, even calcium hydroxide
8 and luck of symbiotic bacteria 3,9 . Therefore it is difficult to be eradicated after its settlement in the canal 2,3 . As far as coronal leakage is concerned, it can be attributed to coronal decay, tooth fracture, restoration fracture, restoration loss and late replacement of the temporary restoration by the permanent one
2,10 .
A low percentage of endodontic failures happen because of extra-radicular infection
2
. Extra-radicular infection derives from bacteria that have entered periapical tissues and evaded host defence mechanisms
2
.
The presence of these microorganisms cannot be detected

by the clinician or eliminated by intra-canal medicaments, as they are situated away from the apex
2
.
In case of failure of the primary endodontic treatment, there are 2 possible choices: non-surgical retreatment or peri-radicular surgery. Sometimes, periapical surgery is preferred owing to the fact that it seems to be a simpler and quicker solution compared with retreatment. Unlike surgery, retreatment may involve a considerable difficulty in removing the coronal restoration or regaining access to the apex. As a consequence, many clinicians decide to perform an apicectomy instead of a retreatment.
However, a number of cases have been reported in the literature, where endodontic failures after being treated by peri-radicular surgery, failed again and the problem was resolved by non-surgical retreatment of the resected teeth
11-16 . These cases strengthen the generally accepted aspect that endodontic failure results mainly from remaining bacteria in the root canal 2
. Thus, the efficient disinfection of the root canal with orthograde retreatment is a prerequisite for healing
2
.
The following case report aims to present a case where a secondary orthograde treatment was performed in infected upper premolars that had been previously treated by apicectomy and retrofilled with amalgam.
Figure 1. The maxillary left premolars present poor endodontic treatments and periapical radiolucencies, while their apexes have received apicectomied had been retro-filled with amalgam.
Case Report
A 32-year-old female patient presented complaining of persistent extra-oral fistula and episodic intra-oral swelling in the area of her maxillary first and second left premolars. The patient’s medical history did not reveal anything remarkable. The patient also reported that endodontic therapies had been performed in her first and second premolars by a general practitioner 5 years ago.
Nevertheless, episodic pain and intra-oral swelling made her to visit her dentist a year later. He suggested her to undergo an apicectomy in order to cure the periapical disease. After the periapical surgery, teeth remained asymptomatic for 4 years. When the symptoms returned, the patient was referred to the endodontist.
Clinical examination showed an active extra-oral fistula corresponding with the area of upper left premolars and an intra-oral swelling apically to the premolars.
Moreover, both teeth were tender to percussion.
Radiographic examination revealed that there was a periapical radiolucency associated with the previously resected and retrofilled with amalgam apices of upper premolars. The quality of the initial endodontic treatments was poor (Fig. 1). The absence of sufficient intra-canal endodontic treatment in both teeth led to the decision of performing an orthograde retreatment in the both. Besides, the roots had already been shortened due to the previous apicectomy and the periodontal condition was not favourable so as to support a further periapical surgery.
Figure 2. Radiographic appearance of premolars after the orthograde retreatment and the root canal obturation
A rubber dam was used to isolate the premolars.
The coronal restorations of the premolars were removed so as the gutta-percha fillings to be exposed. The guttapercha filling material was debrided with Gates-glidden burs, K-files and ProTaper micro-instruments by using a crown-down technique. The same equipment was used in the mechanical preparation of the palatal and buccal canal of the first premolar. As irrigation solutions, 2.5% NaOCl and 15% EDTA were used. During instrumentation, careful manipulation of micro-instruments averted the extrusion of amalgam retrofill into periapical tissues.

168 N. Economides, T. Vouzara Balk J Stom, Vol 15, 2011
When chemo-mechanical preparation was completed and root canal cleanliness ensured for both teeth, the canals were dried with paper points and filled with Ca(OH)
2 paste by using a Lentulo-spiral paste filler. The access cavities were temporarily sealed with cotton pellets and zinc oxide eugenol temporary filling material. Finally, the patient was rescheduled for a next appointment.
After 15 days, the teeth were asymptomatic and the intra-oral swelling had disappeared. In addition, no exudate was found in the root canals and the extra-oral fistula was no more active. Thereby, root canals were obturated with gutta-percha and AH26 root canal sealer by using a lateral condensation technique (Fig. 2). The crowns were sealed with resin. At a 3-year recall there was a complete bone healing (Fig. 3) and the teeth had been permanently restored by fixed prosthodontics, and were in normal function.
Figure 3. At a three-year recall the bone healing has almost been completed
Discussion
Generally, the success rate of retreatment is considered to be lower than the success rate of primary
17
. Yet, it is also deemed that if endodontic treatment access to the apical foramen is not inhibited by canal blocks, retreatment can have a similar result with
17
. More specifically, primary endodontic treatment the outcome of secondary endodontic treatment has been reported to be successful in 74-77% of cases 3,17 .
Negative prognostic factors are the pre-existence of a periapical lesion, the quality of previous treatment 17,18 , the quality of the coronal restoration
17 and the occurrence of iatrogenic errors
18
. Positive prognostic factor is the use of sophisticated equipment, like a dental operative
18
. microscope
Furthermore, the success rate of periapical surgery fluctuates between 40% and 92.5% according to the results of several studies
18-21
. The outcome of endodontic surgery is negatively affected by the size of the lesion
18
, whereas it is enhanced by the use of modern instruments and materials, such as dental operative microscope, ultrasonic and MTA
18
. On top of that, endodontic surgery has better results in cases where a non-surgical retreatment precedes than in cases where periapical surgery is the first choice
18
. Moreover, re-surgery presents lower success rate than the first-time surgery 18,22 .
Although it is speculated that periapical surgery may have higher initial success rate compared with retreatment, this result is reversed during the elapse of time. It means that periapical surgery is more successful than retreatment on the short-term (1-4 years follow-up) 18,21 , whilst retreatment is equally
21 or more successful
18
than periapical surgery on the long-term (>4 years follow-up). This could be explained by the fact that retreatment is a conservative way of treatment, which needs more time to cause healing than periapical surgery does, or by the assumption that lesions may relapse a long time after surgery
21
.
It was previously mentioned that intra-radicular infection is responsible for the majority of endodontic failures
2
. Taking into consideration that intra-radicular infection is caused by remaining bacteria in the root canal, it can be inferred that the first choice should be the non-surgical retreatment
2,21 . Certainly, there is a low possibility that failure may occur because of extraradicular infection
2
. In this case, the suggested treatment is periapical surgery, as intra-canal medication cannot be
2,21 . Nonetheless, extra-radicular infection cannot effective be diagnosed without the means of surgery
2
. Thus, taking into account that intra-radicular infection is the most common cause for failure and extra-radicular infection cannot be easily detected, it is proposed that clinicians ought to begin with retreatment in case of an endodontic failure
2
. Periapical surgery should be implemented when retreatment fails, primary treatment or retreatment cannot

Balk J Stom, Vol 15, 2011 Retreatment after Unsuccessful Apicectomy 169 be performed, retreatment has unfavourable prognosis, and a biopsy is necessary 2
.
The present case report describes a case of upper premolars with failed periapical surgery, which were successfully treated with orthograde retreatment. To the authors’ best knowledge, several similar cases have been published during the last 30 years
11-16 . Kleier
11 reported a non-surgical retreatment of maxillary central incisors, which had been previously resected and retrofilled with amalgam. The case was considered to be successful, though the follow-up period was short (18 months).
Chalfin et al
12
stated 3 cases where periapical surgery was not successful, because undiscovered root canals had caused endodontic failure. Retreatment, which included the previously undetected canals, was the treatment of choice in this case. Recall time was soon in this case as well (6-12 months).
The importance of apical stop in the success of endodontic retreatment was pointed out by Fava in 2001
13
.
A maxillary premolar which had already undergone 2 conservative and 2 surgical failures was cured with nonsurgical retreatment and calcium hydroxide apexification.
Calcium hydroxide was used not only to disinfect the root canal, but also in order to promote the formation of an apical barrier before the final root canal obturation. This procedure targeted to fix the open apex, exposed dentinal tubules and root resorption caused by periapical surgery.
A sufficient recall period (>2 years) ensured the success of this case. Similarly, Sedgley and Wagner
14 mentioned the orthograde retreatment and apexification of the mesial canals of a mandibular molar, which had formerly received unsuccessful endodontic treatment, retreatment and apicectomy. Review time was adequate in this case, too (5 years).
Caliskan 15
retreated 90 failed teeth with periapical radiolucencies. 11 teeth had received periapical surgery in the past and 5 of them were submitted in an apexification procedure. 5 cases out of 11 presented complete healing, and 2 out of 11 showed partial healing after 8-20 months.
Finally, Kusgoz et al 16 described a case where an orthograde retreatment was performed in a mandibular lateral incisor, which had earlier been resected. The tooth did not respond to conventional intra-canal medication with calcium hydroxide and needed to be treated with an intra-canal triple antibiotic paste. What is more, MTA was used to obdurate the apical part of the canal in order to eliminate the possibility of extrusion of the filling material through the resected apex. A 30-month follow-up time interval confirmed the success of the case.
In the present case, there was clear evidence that intra-canal infection was the reason for failure, as both premolars had received inadequate initial treatment.
Consequently, orthograde retreatment was thought to be the treatment of choice. The appliance of strict endodontic protocol safeguarded the efficient disinfection of the root canals. In addition, the radiographic assessment showed that the quality of the retrograde filling was satisfying and therefore it was decided that it could be retained in the root apexes and used as an apical barrier for the orthograde filling material. This element is crucial for the success of orthograde retreatment, as it creates an apical stop and ensures that the instrumentation and obturation do not exceed the working length. It should be added that a 3-year follow-up is believed to be a safe time period regarding evaluation of the success of the case.
It is obvious that if peri-radicular surgery is performed instead of retreatment, while there is solid evidence of intra-radicular infection, unfavourable results are expected. On the contrary, surgically treated cases that fail because of persistent bacteria in the root canal can be successfully treated by non-surgical retreatment.
However, Ricucci and Siqueira
23
reported a case where endodontic treatment, apicectomy and orthograde retreatment did not manage to cure the responsible teeth due to complex root canal anatomy. Eventually, a second peri-radicular surgery after the orthograde retreatment promoted healing. Hence, considerable preservations are expressed whether a sole orthograde retreatment after failed apicectomy can always be effective. It is claimed that in cases with intricate root canal anatomy, non-surgical retreatment may need to be combined with a further surgical treatment in order to be successful
23
.
Besides, retreatment can improve the outcome of the following peri-radicular surgery
Conclusions
References
18,23 .
Orthograde retreatment can be an efficient therapeutic option in case of failed peri-radicular surgery, provoked by remaining intra-canal microorganisms.
Nevertheless, careful case selection should take place before the final decision.
1. Friedman S, Mor C . The success of endodontic therapy - healing and functionality. Journal of the Californian Dental
Association , 2004; 32 (6):493-503.
2. Siqueira JF Jr . Aetiology of root canal treatment failure: why well treated teeth can fail. Int Endod J , 2001; 34:1-10.
3. Sundqvist G, Figdor D, Persson S, Sjogren U .
Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod , 1998;
85:86-93.
4. Saunders WP, Saunders EM . Coronal leakage as a cause of failure in root canal therapy : a review. Endod Dent
Traumatol , 1994; 10:105-108.

170 N. Economides, T. Vouzara Balk J Stom, Vol 15, 2011
5. Weiger R, Mannche B, Werner H, Lost C . Microbial flora of sinus tracts and root canals of non-vital teeth. Endod Dent
Traumatol , 1995; 11:15-19.
6. Siren EK, Haapasalo MPP, Ranta K, Salmi P, Kerosuo
ENG . Microbiological findings and clinical treatment procedures in endodontic cases selected for microbiological investigation. Int Endod J , 1997; 30:91-95.
7. Sjogren U, Figdor D, Spangberg L, Sundqvist G . The antimicrobial effect of calcium hydroxide as a short-tem intracanal dressing. Int Endod J, 1991; 24:119-125.
8. Siqueira JF Jr, Lopes HP . Mechanisms of antimicrobial activity of calcium hydroxide: a critical review. Int Endod J ,
1999; 32:361-369.
9. Fabricious L, Dahlen G, Holm SE, Moller AJR . Influence of combinations of oral bacteria on periapical tissues of monkeys. Scand J Dent Res , 1982; 90:200-206.
10. Siqueira JF Jr, Rocas IN, Lopes HP, Uzeda M . Coronal leakage of two root canal sealers containing calcium hydroxide after exposure to human saliva. J Endod , 1999;
25:14-16.
11. Kleier DJ . Non-surgical retreatment of a postsurgical endodontic failure. J Endod , 1984; 10:577-579.
12. Chalfin H, Kellert M, Weseley P . Postsurgical Endodontics.
J Endod , 1993; 19:307-311.
13. Fava LRG . Calcium hydroxide in endodontic retreatmentafter two non-surgical and two surgical failures : report of a case. Int Endod J , 2001; 34:72-80.
14. Sedgley CM, Wagner R . Orthograde retreatment and apexification after unsuccessful endodontic treatment, retreatment and apicectomy. Int Endod J , 2003; 36:780-786.
15. Caliskan MK . Non-surgical retreatment of teeth with periapical lesions previously managed by either endodontic or surgical intervention. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod , 2005; 100:242-248.
16. Kusgoz A, Yildirim T, Er K, Arslan I . Retreatment of a resected tooth associated with a large periradicular lesion by using a triple antibiotic paste and Mineral Trioxide
Aggregate: a case report with a thirty-month follow-up. J
Endod , 2009; 35:1603-1606.
17. Ng YL, Mann V, Gulabivala K . Outcome of secondary root canal treatment: a systematic review of the literature. Int
Endod J , 2008; 41:1026-1046.
18. Torabinejad M, Corr R, Handysides R, Shababang S .
Outcomes of non-surgical retreatment and endodontic surgery: a systematic review. J Endod , 2009; 35:930-937.
19. August DS . Long-Term, postsurgical results on teeth wit periapical radiolucencies. J Endod , 1996; 22:380-383.
20. Maddalone M, Gagliani M . Periapical endodontic surgery: a three-year follow-up study. Int Endod J , 2003; 36:193-198.
21. Fabro M, Taschieri S, Testori T, Francetti L, Weinstein
RL . Surgical versus non-surgical endodontic retreatment for periradicular lesions (Review). The Cochrane Library ,
2008; 4:1-17.
22. Peterson J, Gutmann JL . The outcome of endodontic resurgery: a systematic review. Int Endod J , 2001;
34:169-175.
23. Ricucci D, Siqueira JF Jr . Anatomic and microbiologic challenges to achieving success with endodontic treatment: a case report. J Endod , 2008; 34:1249-1254.
Correspondence and request for offprints to:
Economides Nicolaos
Aristotle University
Dental School
Department of Endodontology
Thessaloniki, Greece

BALKAN JOURNAL OF STOMATOLOGY
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ISSN 1107 - 1141
SUMMARY
Background
:
Osteosarcomas (OS) are the most common primary malignant neoplasms of the bone. OS of the head and neck are extremely rare.
Case Report: A male patient, age 33, presented to the Oral and
Maxillofacial Surgery Clinic with severe swelling in the left mandibular region a month after initial resection of a chondroblastic OS of the left mandible. Hemi-mandibulectomy up to the region of the canine, supraomohyoid neck dissection and temporalis muscle reconstruction was performed. The patient was administered adjuvant chemotherapy and radiation therapy further to head and neck tumour board counselling.
Discussion
:
Negative surgical margins appear to be the only significant predictor of overall and disease-specific survival. Radiation therapy is more frequently employed in the OS of the head and neck when compared to OS of long bones, especially in patients with high grade tumour or in those where wide surgical margins cannot be obtained. In the latter patients neoadjuvant chemotherapy has been suggested to be beneficial. A multidisciplinary approach is justified, but the head and neck surgeon has the leading role. Review of the literature and case-wise counselling by the head and neck tumour board is recommended for every new case diagnosed.
Keywords:
Osteosarcoma; Jaw; Surgery; Chemotherapy; Radiotherapy
George Milesis
1 , Theodoros Mechterides 1
,
Athanassios Kyrgidis 1 , Angeliki Cheva 2 ,
Konstantinos Antoniades
1
1
Aristotle University of Thessaloniki
Faculty of Dentistry
Department of Oral and Maxillofacial Surgery G.
2
Papanikolaou General Hospital
Department of Histopathology
G. Papanikolaou General Hospital
Thessaloniki, Greece
CASE REPORT (CR)
Balk J Stom, 2011; 15:171-176
Background
Osteosarcomas (OS) are the most common primary malignant neoplasms of bone
1-4
. They are usually found in long bones, especially around the knee
1
. Their incidence in the head and neck region is extremely rare and they are mainly located in the maxillofacial region
1-8
. Local swelling with or without pain is the most frequent early clinical manifestation of the OS in the head and neck 5, 8 . The mean age of patients with OS of the jaw is between 30-40 years
1,4,5,8-10 . OS may be described as central, periosteal, parosteal or extra skeletal, depending on their origin.
According to their predominant histological differentiation,
OS are classified as osteoblastic, chondroblastic or fibroblastic
5
. Histologically OS are characterized by a malignant, undifferentiated stroma, which is producing neoplastic osteoid or bone. For the diagnosis of OS, the presence of osteoid formation is critical
5
.
OS of the head and neck (OSHN) are rare tumours and have been reported to constitute <10% of all cases of
1-7, 11 . OSHN typically occur in the 3rd or 4th decade
OS of life and with equal gender distribution, whereas OS of the long bones occur mostly in the 2nd decade of life and have a slight male preponderance 7,12 .
The aim of this paper was to present a case of a large chondroblastic OS of the mandible, which was treated after local recurrence. Given the lack of a specific treatment protocol for the OS of the jaw, together with the large tumour size, the prognosis could not be certain, thus particular reference is given to the treatment followed.
Case Report
A 33-year-old male patient presented to the Oral and Maxillofacial Surgery Clinic with severe swelling

172 George Milesis et al. Balk J Stom, Vol 15, 2011 in the left mandibular region. On clinical examination, the buccal mucosa of the region was found reddish, but its texture was normal and painless. His history revealed previous local surgical resection in the ENT department of a district general hospital, a month before referring to our clinic. Histology of the first operation reported chondroblastic OS of the left mandible resected in close surgical margins. On admission (same with referral day), a clinically evident recurrent lesion existed. Routine laboratory tests were normal with the exception of serum alkaline phosphatase, which was increased to 181 IU/L
(35-145 nl).
MRI and CT scan demonstrated an osteolytic destructive process located at the left mandibular angle and body, extending to the left mandibular ramus, with presence of bone trabeculae, and an accompanying soft tissue mass that was extending into the subcutaneous tissue with abnormal enhancement, which was extending into the left medial and lateral pterygoid muscles (Fig. 1, a-c). Whole-body bone scintigraphy showed increased pathological osteoblastic activity at the entire left side of the mandible. No other pathological loci where found in any other site of the body (Fig. 1d). Thoracic x-ray and CT scan revealed no pathologic findings that would indicate distant metastasis of the tumour.
The tumour was resected with hemi-mandibulectomy up to the region of the canine (#43), including intraoral preparation, dislocation of the left condyle, and en block removal of the tumour with the body of the mandible, and supra-omohyoid neck dissection. The temporalis muscle was prepared and sutured intra-orally via
semicoronary incision (left side) at the site of the defect. The tumour measured 13 cm in its larger diameter. Routine laboratory tests performed the first day after surgery showed that the patient’s serum alkaline phosphatase levels declined to normal (109 IU/L). a
Figure 1a and 1b. Facial (1a) and axial (1b) MRI sections from a 33-year-old male with recurrent OS of the mandible b
Histopathology reported a malignant neoplastic lesion of spindle-shaped neoplastic cells, with intermediate or severe nuclear atypia and increased mitotic activity (Figs. 2a and 2b). The cellular arrangement was diffused and in bundles, with focal formation of osteoid and osseous tissue (Fig. 2c). The cells also showed focal cartilage differentiation (Fig.
2d). Areas of coagulation necrosis were also found.
These characteristics are compatible with those of a chondroblastic OS. At least 1.5 cm of tumour free margins were reported all around tumour periphery.
The head and neck tumour board counselled adjuvant chemotherapy and radiation therapy in order to prevent further relapse. 1 month after operation the patient underwent chemotherapy (6 cycles for a period of 4 months). The regimen included ifosfamide (5gr day1-day3) and epirubicin (130mg day1) for the first
3 cycles, and ifosfamide only (5gr day1-day3) for the remaining 3 cycles. Supportive regimen with antiemetics, antihistamines and Mesna (for the prevention of the ifosfamide toxic effect) was also administered. Concurrent radiation therapy was administered; the left mandibular

Balk J Stom, Vol 15, 2011 area was irradiated using a 6MV photon beam produced by a linear accelerator and an estimated total dose of 6400
Gy (200 Gy fractionation).
The patient was followed-up for 20 months postoperatively and did not develop any clinical signs of the disease. Upper abdominal CT scans exhibited no evidence of metastasis.
Chondroblastic Osteosarcoma of the Mandible 173 a c
Figure 1c. Axial CT section from a 33-year-old male with recurrent OS of the mandible; b
Figure 2a and 2b. Presence of spindle-shaped neoplastic cells, with intermediate or severe nuclear atypia and increased mitotic activity; d
Figure 1d. Whole body scintigraphy shows no evidence of distant or regional metastasis, and a marked peri-tumoural inflammation c
Figure 2c. diffused cellular arrangement with focal formation of osteoid and osseous tissue;

174 George Milesis et al. Balk J Stom, Vol 15, 2011
Figure 2d. focal cartilage differentiation
Discussion d
OS, on the basis of the predominant matrix, are classified into osteoblastic, chondroblastic and fibroblastic
13
. Osteoblastic OS shows the predominant bone and/or osteoid matrix
13
. Fibroblastic OS shows a spindle-cell malignancy with only minimal amounts of osseous matrix 13
. Chondroblastic OS contains chondroid matrix dominantly 13
. There is disagreement in the literature with regard to the predominant histologic subtype of the OSHN. The chondroblastic has been described to be the predominant type in head and neck region
2-5,10,14 . However other authors reported the osteoblastic type to be more frequent 7-8, 15 .
Concerning the radiographic appearance, the presence of a widening of the periodontal ligament space, with or without an irregular absence or attenuation of the lamina dura, is estimated based on the panoramic and intraoral radiographs, as noted by Garrington et.al
8,16 .
Another sign is the presence of the “classic” sunburst or sunray appearance caused by osteophytic bone production on the surface of the lesion
2
. An additional significant sign analyzed on CT is the pattern of osteogenesis and bone destruction. However, in a recent studies, Nakayama et. al
13,16 showed that there was no significant association between the histological subtype and these CT findings.
It has been reported that with OSHN, there is a predominance of high grade tumors 5,7,14 . On the other hand, others reported that the majority of the cases belong to the intermediate grade of malignancy 5,10 . In our case, the tumour was of intermediate grade. Distant metastasis of the OSHN is rare, compared with the OS of the long bones, and mainly occurs in the lungs as a late stage event
5
. The main reason of failure in OSHN is local recurrence 5
.
The majority of studies could not correlate the histological type with the prognosis of OSHN.
Specifically Clark et. al. reported that patients with chondroblastic OSHN had a better overall survival rate when compared to patients with osteoblastic or fibroblastic tumours
4
. Takahama et.al
5
found similar results, whereas other authors consider the chondroblastic subtype of OSHN as an unfavourable prognostic factor 16 .
This could be clearer in the future with studies on larger groups of cases. Current studies report that factors influencing prognosis are the size of the tumour, the site and the incision margins.
The median of the tumour size in OSHN is 4-6cm in greatest dimension
5-6 . It has been reported that tumours bigger than 4cm in size are associated with negative prognosis since they showed significantly increased risk of local recurrence, which is the main reason of treatment failure 5-6 . Compared with other reports the tumour was unusually large (13cm).
with OSHN 2,3,5,6
5-6,17 , in our case
Negative surgical margins appear to be the only significant predictor of overall and disease-specific survival. For this reason complete surgical excision of the tumour is the mainstay of the treatment in patients
. However, only a few studies included information regarding surgical margins clearance.
Specifically, van Es et al
18
reported that 40% of their patients had positive surgical margins and their rates of local recurrence and distant metastases where 33% and
21%, respectively. These results are in accordance with other publications
6 . An important factor in the surgical treatment alone protocol is the amenability to radical resection with clear margins
2
. Clear margins may be difficult to achieve, particularly in the maxilla and scull base, where frequent positive margin rates of 31% to
54% have been reported, a condition that is associated with worse prognosis in the maxilla 2,6 . Nakayama et al
13,16 report that patients with OS of the maxilla had a good outcome, in contrast to that of the mandible, which had a poor outcome, and the difference was significant.
On the other hand there are few studies regarding the differences of the prognosis between the mandible and the maxilla, and therefore, further studies are needed. In the present case, given the previous excision in close surgical margins, extended effort has been put to ensure the widest possible clear free margins.
All these factors associated with negative prognosis, in addition to the lack of specific treatment protocol in
OSHN, make choosing the optimal treatment not easy.
The benefits of the use of multimodality treatment are not yet scientifically established in OSHN, in contrast to the OS of the long bones. However, an increasing number of studies report improved results with adjuvant chemotherapy and radiation therapy, as well as neoadjuvant chemotherapy, although the results were not statistically significant 2,3,6,7,19 .

Balk J Stom, Vol 15, 2011 Chondroblastic Osteosarcoma of the Mandible 175
Radiation therapy is more frequently employed in the OSHN than in those of the long bones, especially for patients with high grade tumour or in cases where wide surgical margins cannot be obtained
7
. OS are relatively radio-resistant, requiring more than 6000 cGy to be effective in an area of several vital structures 3,7 .
However, many researchers have incorporated the use of radiation therapy in the multimodality treatment of OS, taking advantage of the modern radiation techniques (3D conformal radiation therapy, intensity-modulated radiation therapy)
3
.
Regarding the use of chemotherapy, Smeele et al 19
reported the improved survival in OSHN patients treated with adjuvant chemotherapy irrespective of the completeness of surgical resection, which was statistically significant. Another meta-analysis by Kassir et al
20
found no benefit for chemotherapy in the treatment of OSHN and actually reported a worse outcome for patients treated with adjuvant chemotherapy, while other researchers reported better survival with chemotherapy 2,3,67,19,20 .
Many authors have suggested that neo-adjuvant chemotherapy may offer benefit via
a decrease in cellular viability at the tumour periphery, whereby better surgical
21,22
speculate that margins can be obtained
7,10 . Salvati et al application of neo-adjuvant chemotherapy in OSHN may decrease the risk of local relapse, decrease the number of eventual pulmonary metastases, and increase the time interval from surgery to the appearance of pulmonary metastases. However, larger numbers of patients will be required to answer the question of whether neo-adjuvant chemotherapy favourably impacts the disease-free or overall survival of patients with OSHN or not 7,21,22 .
Randomized clinical trials reported improved diseasefree survival using neo-adjuvant chemotherapy protocols indicating, however, the difficulty in assessing this response clinically or radiologically
3,6,23 . Specifically, they report that despite the lack of demonstrable overall benefit of neo-adjuvant chemotherapy, a favourable histological response to neo-adjuvant chemotherapy is an important prognostic variable and predictor of longterm treatment outcome. Recent studies support this view without being powered enough to report a statistically significant difference 3,6 .
Conclusively, OSHN is not as rare as one would anticipate. There is a considerable number of patients suffering from the malady. Choosing the optimal treatment for each one of them can be a tricky task. A multidisciplinary head and neck tumour board approach is justified, while the maxillofacial surgeon has the leading role. Ample knowledge of the craniofacial surgery complexities is a requisite to obtain negative surgical margins, which are the single predictor of survival.
Review of the literature and case-wise counselling by the head and neck tumour board is recommended for every new case diagnosed.
References
1. Gadwal SR, Gannon FH, Fanburg-Smith JC, Becoskie EM,
Thompson LD . Primary osteosarcoma of the head and neck in pediatric patients: a clinicopathologic study of 22 cases with a review of the literature. Cancer , 2001; 91:598-605.
2. Fernandes R, Nikitakis NG, Pazoki A, Ord RA . Osteogenic sarcoma of the jaw: a 10-year experience. J Oral Maxillofac
Surg , 2007; 65:1286-1291.
3. Laskar S, Basu A, Muckaden MA, D’Cruz A, Pai S,
Jambhekar N, et al . Osteosarcoma of the head and neck region: lessons learned from a single-institution experience of 50 patients. Head Neck , 2008; 30:1020-1026.
4. Clark JL, Unni KK, Dahlin DC, Devine KD . Osteosarcoma of the jaw. Cancer , 1983; 51:2311-2316.
5. Ademar Takahama J, Fábio de Abreu A, Clóvis Antonio
Lopes P, André Lopes C, Luiz Paulo K, Márcio Ajudarte
L . Clinicopathological and immunohistochemical analysis of twenty-five head and neck osteosarcomas. Oral Oncol ,
2003; 39:521-530.
6. Patel SG, Meyers P, Huvos AG, Wolden S, Singh B, Shaha
AR, et al . Improved outcomes in patients with osteogenic sarcoma of the head and neck. Cancer , 2002; 95:1495-1503.
7. Oda D, Bavisotto LM, Schmidt RA, McNutt M, Bruckner JD,
Conrad EU 3rd, et al . Head and neck osteosarcoma at the
University of Washington. Head Neck , 1997; 19:513-523.
8. Garrington GE, Scofield HH, Cornyn J, Hooker SP .
Osteosarcoma of the jaws. Analysis of 56 cases. Cancer ,
1967; 20:377-391.
9. Mark RJ, Sercarz JA, Tran L, Dodd LG, Selch M,
Calcaterra TC . Osteogenic sarcoma of the head and neck.
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1991; 117:761-766.
10. Delgado R, Maafs E, Alfeiran A, Mohar A, Barrera JL,
Zinser J, et al . Osteosarcoma of the jaw. Head Neck , 1994;
16:246-252.
11. Modarressi Ghavami SA, Lombardi T, Becker M, Richter M .
Chondroblastic osteosarcoma of the mandible: a case report with 14 years follow-up. Rev Stomatol Chir Maxillofac ,
2006; 107:380-385.
12. Ogunlewe MO, Ajayi OF, Adeyemo WL, Ladeinde AL, James
O . Osteogenic sarcoma of the jaw bones: a single institution experience over a 21-year period. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod , 2006; 101:76-81.
13. Nakayama E, Sugiura K, Kobayashi I, Oobu K, Ishibashi
H, Kanda S . The association between the computed tomography findings, histologic features, and outcome of osteosarcoma of the jaw. J Oral Maxillofac Surg , 2005;
63:311-318.
14. Mardinger O, Givol N, Talmi YP, Taicher S . Osteosarcoma of the jaw. The Chaim Sheba Medical Center experience.
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The Istituto Rizzoli-Beretta experience with osteosarcoma of the jaw. Cancer , 1991; 68:1555-1563.
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176 George Milesis et al. Balk J Stom, Vol 15, 2011
17. Kawasaki T, Ono N, Watanabe K, Hoshi K . Chondroblastic osteosarcoma of the mandible: report of a case. J Oral
Maxillofac Surg , 1996; 54:1123-1127.
18. van Es RJ, Keus RB, van der Waal I, Koole R, Vermey A .
Osteosarcoma of the jaw bones. Long-term follow up of 48 cases. Int J Oral Maxillofac Surg , 1997; 26:191-197.
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Clinical remarks on 19 cases. Cancer , 1993; 71:2210-2216.
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Correspondence and request for offprints to:
Kyrgidis Athanassios, MD, DDS, MSc
3 Papazoli St,
Thessaloniki, 546 30
Greece
E-mail: akyrgidi@gmail.com

BALKAN JOURNAL OF STOMATOLOGY
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ISSN 1107 - 1141
The BALKAN JOURNAL OF STOMATOLOGY provides contributors with an opportunity to publish review and original papers, preliminary (short) communications and case reports.
Review papers (RP) should present an analytic evaluation of certain problems in stomatology based on a critical approach to personal experience and to the published results of other authors.
Original papers (OP) should be related to the results of scientific, clinical and experimental research. They should investigate a certain stomatological problem using adequate scientific methods and comment the obtained results in accordance to the previously published observations of other authors.
Preliminary (short) communications (PC) should concern the preliminary results of current research.
Case reports (CR) should be related to uncommon and rare clinical cases, interesting from diagnostic and therapeutic viewpoints. Case reports may be related to innovations of surgical techniques as well.
Contributors from Balkan countries should send their manu scripts to domestic National Editorial Boards (addresses are cited on the second page of the Journal) for reviewing. Contributors from non-Balkan countries should send their manuscripts to the Editor-in-Chief (Prof. Ljubomir Todorovia, Faculty of Stomatology, Clinic of Oral Surgery, Dr Suboti}a 8, 11000 Belgrade,
Serbia, fax: +381 11 685 361).
No fees are awarded for the submitted papers. Original copies of papers, as well as illustrations, will not be returned.
Following acceptance of a manuscript for publication, the author will receive a page proof for checking. The proofs should be returned with the least possible delay, preferable bu e-mail
(ljubatod@eunet.yu) or the regular mail.
Offprints can be obtained on the author's request, the cost being paid by the author.
Preparation of manuscripts
All manuscripts should be submitted in correct English, typed on one side of the standardized paper, in single spacing, with ample margins of not less than 2.5 cm, and the pages numbered.
Papers submitted for publication should be accompanied by a statement, signed by all authors, that they have not already been published, and are not under consideration by any other publication.
One copy of the manuscript with one set of figures and tables is required. Every article should also be submitted as a MS
Word file on CD. The manuscript and the e-file must be identical, and the CD should contain no other file. The disk should be clearly labeled with the title of the article and the name(s) of the author(s).
The manuscripts should be set out as follows: title page, summary, text, acknowledgements if any, references, tables and captions of illustrations.
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The title page should give the following information: 1) title of the paper, 2) initials, surname and the institution address of each author, 3) name, address, telephone and
E-mail of the author responsible for correspondence and to whom requests for offprints should be sent and 4) sources of support in the form of grants if any.
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Key word should be included, according to Index Medicus.
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The complete title should preceed the text (but without authors and institution names). Headings should be appropriate to the nature of the paper. Normally, only two categories of headings should be used: major ones should be typed in capital letters in the centre of the page and bolded; minor ones should be typed in lower case (with an initial capital letter) at the left hand margin and bolded.
All illustrations, labeled as figures (such as photographs, line drawings, charts or tracings) should be submitted as highcontrast prints, black and white, suitable for publications. They must be marked on the back with the title of the paper, numbered with arabic numerals in the same order as they are cited in the text, and the top edge indicated with an arrow. Photomicrographs should have the magnifications and details of staining techniques shown. Short explanatory captions of all illustrations should be typed on a separate sheet.
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References.
References in the text should use superscript numerals as they appear in the list of references, with or without the name(s) of the author(s). The list of references at the end of the paper should be typed on a separate sheet, arranged alphabetically and numbered, and should include all references cited in the text. For review papers, references can be arranged consecutively and numbered (by Arabic numerals) as they are cited.
The accuracy of references is the responsibility of the author.
Titles of journals should be abbreviated as used by Index
Medicus. The format for references should be: year-volume-first and last page. References to monographs should also include place and the name of the publisher, and the page(s) referred to.
Examples:
1. Brown JS, Browne RM. Factors influencing the patterns of invasion of the mandible by squamous cell carcinoma. Int J Oral
Maxillofac Surg, 1995; 24:417-426.
2. Sternbach RA. Pain patients - traits and treatment. New York,
London, Toronto, Sydney, San Francisko: Academic Press, 1974; pp 20-30.
3. Koulourides T, Feagin F, Pigman W. Experimental changes in enamel mineral density. In: Harris RS (ed). Art and Science of
Dental Caries Research. New York: Academic Press, 1968, pp
355-378.