Passing of the Torch

EDITORIAL

Passing of the Torch Final Thoughts on the Past and the Future Photo by Timothy Raab, Northern Photo Service

THIS ISSUE marks the beginning of a new leged to work with during my rather long direction for The New York State Dental involvement in dental journalism. Journal. My five-year tenure as Journal Managing Editor Mary Stoll has been a Editor has ended. I congratulate my colstrong influence on the positive evoluleague and friend Kevin J. Hanley, who will tion of The Journal, a source of consesucceed me in this position. Dr. Hanley and quential guidance and a wonderful I have worked closely for the past five friend. She is, indeed, the “cement” that years, as he fulfilled his role as associate has bound all of our contributions into a editor of The NYSDJ. He has made significohesive, meaningful, serious and enjoycant contributions to our Journal, but able publication. She is representative of focused as well on helping to develop our the high-quality NYSDA staff. NYSDA News, the publication he oversaw Our editorial team (Moskowitz, as editor. Dr. Hanley’s editorial skills and Hanley and Stoll) started this journey his devotion to the dental profession will five years ago. We set our goals and, to a Elliot Moskowitz, right, with incoming Journal Editor Kevin Hanley. help bring The NYSDJ to new heights of large extent, we have met many of them. excellence. We believed that The Journal could be a Having forged professional and personal relationships with unique composite of relevant scientific and clinical manuscripts, many NYSDA staff, officers, Governors and, most importantly, important Association news, legal and ethical perspectives, and grassroots members, there is an understandable regret on my part reports of events within and beyond our NYSDA borders.We vowed over leaving this position. I will miss the daily communication I to make The Journal a meaningful NYSDA member benefit. have had with so many of you about The Journal, NYSDA, compoThe response from the national and international community nent concerns and the dental profession. I will even miss the of dentists, as evidenced by the many clinical and/or research manexpected (and required) critiques (both positive and negative) of uscripts we receive, has fueled our enthusiasm to expand the scope The Journal itself. And I will miss an important association with of The NYSDJ as a peer-reviewed publication. We were fortunate as one of the most gifted and enlightened editors I have been priviwell to be able to chronicle important changes in the way dentistry 4 NYSDJ • JANUARY 2009

NYSDA D

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OFFICERS

Michael R. Breault, President 1638 Union St., Schenectady, NY 12308

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Stephen B. Gold, Immediate Past President 8 Medical Dr., Port Jefferson Station, NY 11776

Robert J. Doherty, President Elect Mark J. Feldman, Interim Executive Director 280 Mamoroneck Ave., White Plains, NY 10605 20 Corporate Woods Boulevard, Albany, NY 12211 Chad P.Gehani, Vice President 35-40 82nd St., Jackson Heights, NY 11372 Richard F. Andolina, Secretary-Treasurer 74 Main St., Hornell, NY 14843

William R. Calnon, ADA Trustee 3220 Chili Ave., Rochester, NY 14624

BOARD OF GOVERNORS

is practiced in New York State. A mandatory fifth year in dental education (PG-Y1) as a licensure requirement and other forward-thinking NYSDA initiatives have served as models for the entire country. There has been a lot of concern expressed about the future of print media. No doubt, competing media formats will challenge all of us involved in dental journalism.Our Journal, however, will meet those challenges because of a singular strength that has defined both it and NYSDA. That strength is the powerful collective voice of the ADA member dentist in New York State. It is the voice of thousands of individual dentists who will continue to read The NYSDJ and support NYSDA. It is that voice that motivates your editorial team. Once again, I want to wish Dr. Hanley and Ms. Stoll the very best continued success. And to our NYSDA membership, thank you, for allowing me to be the editor of your publication, The New York State Dental Journal.

D.D.S. M.Sd

NY County-Lawrence A. Bailey 215 W. 125th St., New York, NY 10027 NY County-Steven DeCrescenzo 140 E. 56th St., Ste. 1B, New York, NY 10022 NY County-Matthew J. Neary 501 Madison Ave., Fl. 22, New York, NY 10022 2-Craig S. Ratner 7030 Hylan Blvd., Staten Island, NY 10304 2-James J. Sconzo 1666 Marine Parkway, Brooklyn, NY 11234 3-John P. Essepian 180 Old Loudon Rd, Latham, NY 12110 3-Douglas B. Smail 500 Federal St., Ste. 202, Troy, NY 12180 4-Mark A. Bauman 157 Lake Ave., Saratoga Springs, NY 12866 4-James E. Galati 1758 Parkwood Plaza, Clifton Park, NY 12065 5-Jonathan R. Gellert 7627 Park Ave., Lowville, NY 13367 5-John J. Liang 2813 Genesee St., Utica, NY 13501 6-Scott J. Farrell 39 Leroy St., Binghamton, NY 13905 6-Ronald J. Laux 419 Walnut St., Elmira, NY 14901 7-Robert J. Buhite, II 1295 Portland Ave., Rochester, NY 14621 7-Andrew G. Vorrasi 2005 Lyell Ave., Rochester, NY 14606

8-Frank C. Barnashuk 2158 Abbott Rd., Lackawanna, NY 14218 8-Kevin J. Hanley 959 Kenmore Ave., Buffalo, NY 14223 9-Edward M. Feinberg 14 Harwood Ct., Ste. 322, Scarsdale, NY 10583 9-Malcolm S. Graham 170 Maple Ave., Ste. 403, White Plains, NY 10601 9-Neal R. Riesner 111 Brook St., 3rd Fl., Scarsdale, NY 10583 N-Peter Blauzvern 366 N. Broadway, Jericho, NY 11753 N-David J. Miller 467 Newbridge Rd.,East Meadow, NY 11554 N-Frank J. Palmaccio 8243 Jericho Tpke, Woodbury, NY 11797 Q-Mitchell S. Greenberg 119-66 80th Rd, Kew Gardens, NY 11415 Q-Robert L. Shpuntoff 28 Beverly Rd., Great Neck, NY 11021 S-Paul R. Leary 80 Maple Ave., #206, Smithtown, NY 11787 S-Steven I. Snyder 264 Union Ave., Holbrook, NY 11741 B-Richard P. Herman 20 Squadron Blvd., New City, NY 10956 B-Robert Margolin 1 Fountain Ln., Ste.3L, Scarsdale, NY 10583

COUNCIL CHAIRPERSONS Annual Meetings Frederick W. Wetzel 1556 Union St. Schenectady, NY 12309

Governmental Affairs Alan L. Mazer PO Box 985, 140 Terryville Rd., Pt. Jefferson Station, NY 11776

Awards Brian T. Kennedy 4 Carla Lane Troy, NY 12180

Insurance Roland C. Emmanuele 4 Hinchcliffe Dr., Newburgh, NY 12550

Chemical Dependency Robert J. Herzog 16 Parker Ave., Buffalo, NY 14214

Membership & Communications Lidia M. Epel 165 N. Village Ave., #102, Rockville Center, NY 11570

Dental Benefit Programs Ian M. Lerner One Hanson Pl., #2900, Brooklyn, NY 11243 Dental Education & Licensure Paul R. Leary 80 Maple Ave., #206, Smithtown, NY 11787 Dental Health Planning & Hospital Dentistry Robert A. Seminara 281 Benedict Rd., Staten Island NY 10304 Dental Practice Steven L. Essig 33 Main St., Ravena, NY 12143 Ethics Adam A. Edwards 103 Main St., Altamont, NY 12009

New Dentist David C. Bray 18 Leroy St., Binghamton, NY 13905 Peer Review & Quality Assurance Steven Damelio 1794 Penfield Rd., Penfield, NY 14526 Relief Anthony V. Maresca 207 Hallock Rd., Stony Brook, NY 11790

OFFICE Suite 602 20 Corporate Woods Blvd. Albany, NY 12211 (518) 465-0044 (800) 255-2100 Mark J. Feldman Interim Executive Director Lance Plunkett General Counsel Beth M. Wanek Associate Executive Director Michael J. Herrmann Assistant Executive Director Finance-Administration Judith L. Shub Assistant Executive Director Health Affairs Sandra DiNoto Director Public Relations Mary Grates Stoll Managing Editor

NYSDJ • MARCH 2008 5 NYSDJ • JANUARY 2009 5

EDITORIAL

The Torch is Passed Building on a solid foundation.

IN 2002, SHERRY ALBERT announced his retirement as editor of The New York State Dental Journal. NYSDA immediately commenced a search for his replacement. There were many great candidates, and the search committee interviewed each of them. I was one of the lucky interviewees. The committee made its decision, and I was named associate editor of The Journal. The editor’s position went to Elliott Moskowitz. Following up on a Board directive, the committee limited his term to five years. Dr. Moskowitz has ably served The Journal and NYSDA for the past five years. He leaves The Journal with an international reputation for excellence and a drawer full of top-notch manuscripts ready for publication. Dr. Moskowitz has been a marvelous mentor to me during my tenure as associate editor. I have learned a great deal from him, lessons that will serve me well as I take over the helm of your Journal. I thank Elliott for his guidance and for the friend he has become. Elliott is a tremendous individual who leaves large shoes to fill. I will continue to rely heavily upon him and his advice as I take over this position. Behind the scenes, we have the best managing editor in the business. Mary Stoll has been overseeing production of The Journal for over 20 years. It’s doubtful it could be published without her guidance. I first met Mary when I became a member of the nowdefunct Council on Publications. Her knowledge is extensive; and I have learned to seek out her advice during my tenure as editor of the NYSDA News. I look forward to continuing to work with Mary. She has already kept me busy reading manuscripts. Our advertising manager, Jeanne Deguire, does an excellent job securing advertising for The Journal and the NYSDA News. Without this income, our publications would be a significant drain on the Association treasury. The Journal contracts with two art directors as well—Kathryn Sikule and Ed Stevens—both of whom do a superlative job. 6 NYSDJ • JANUARY 2009

When Elliott was editor, he stressed it was a team effort that went into publication of The Journal. He was absolutely right. We have an excellent team. We have excellent staff working at NYSDA, and I look forward to working closely with all of them. I will make good use of their expertise on a regular basis. Any mistakes made will be my own. My vision for The Journal is to keep it the well respected voice of NYSDA. This Journal is, as I noted earlier, internationally known. We receive manuscripts from around the world, from hopeful authors seeking publication. Our standards are high, and I will maintain them. I will rely upon the members of our Editorial Review Board for guidance as to the appropriateness of each article considered for publication. My desire is to publish cutting-edge research that will help you, the dentist, in your practice, wherever that may be, stay current with advances in dentistry. I hope to have an excellent mix of articles covering all aspects of dentistry. In turn, I look to you, the readers, to help me during my editorship. How, you ask? By letting me know how I am doing. By writing letters to the editor if you feel something is not being covered well or correctly. By calling me to discuss your concerns. I have spoken with many editors over the years. The number-one complaint I hear from these editors is that no one writes letters to their journals, so they don’t really know how they are doing. I look forward to being the editor of The New York State Dental Journal. This is an enormous responsibility that I won’t take lightly. I am here to serve you, the members. I promise to give this position all of my attention and to fulfill it to the best of my ability. I thank you for this opportunity. I am truly humbled by the trust and faith you have placed in me. I will not let you down.

D.D.S.

Annual Meeting 2008 Congratulations and well wishes were frequently heard at Board of Governors Annual Meeting November 13 in Albany as NYSDA installed its new officers and shone the spotlight on recipients of Association’s top honors. Photosbyby Bill Cancellare Photos Tim Raab, Northern Jr. Photo Services

NYSDA 2009 officers strike formal pose following installation. They are, from left, President Michael Breault, President Elect Robert Doherty, Vice President Chad Gehani, Secretary-Treasurer Richard Andolina, Immediate Past President Stephen Gold.

2008 President Steve Gold receives NYSDA President’s Award from 2009 President Michael Breault.

G. Kirk Gleason, winner of 2008 NYSDA Distinguished Service Award, attended dinner with his family. They are, from left: wife, Dale; daughter, Cara Krebs; son, G. Christopher.

Governor and Second District President Craig Ratner, left, and NYSDA constitutional specialist Robert Peskin, right, with Roy Lasky. Mr. Lasky, recently retired, was attending his last Annual Meeting as executive director.

Michael Leifert, center, New York County, winner of NYSDA New Dentist Leadership Award, with wife, Ronniette, and father, Melvyn. The trio comprises a family of orthodontists. 20 NYSDJ • JANUARY 2009

is night to remember

Ninth District Governor Edward Feinberg, far right, gets together with colleagues from Queens County. The are, from left: Executive Director William Bayer; President Viren Jhaveri; Joseph Caruso, Governmental Affairs Council and EDPAC Component Chair; Chad Gehani, incoming NYSDA Vice President.

Cheryl Ennis, New York Dental Assistants Association, enjoys conversation between ADA Second District Trustee William Calnon, left, and NYSDA 2007 President Steven Gounardes.

Eighth District President Frank Barnashuk, Governor Kevin Hanley and Robert Herzog, chair, NYSDA Council on Chemical Dependency, share light moment at cocktail party preceding dinner and awards program.

New York County Governor Lawrence Bailey, left, with Brian Kennedy, NYSDA Past President, and Sue Comisi, New York Dental Assistants Association.

Third District Governor John Essepian greets his executive director, Kathy Moore, and President Elect Howard Bresin.

NYSDJ • JANUARY 2009 21

Annual Meeting 2008 is night to remember

Bronx County colleagues are, from left, Amarilis Jacobo, 2008 President Robert Margolin, EDPAC Component Chair Joel Friedman, and Madeline Ginzburg, 2008 chair, Council on Dental Education & Licensure.

Nassau County contingent enjoys the party. They are, from left: Governor Peter Blauzvern; Governor Frank Palmaccio; Governor David Miller; Executive Director Gabriele Libbey; Lidia Epel, chair, NYSDA Council Membership & Communications; Robert Peskin, NYSDA Council Dental Education & Licensure.

Ninth District is represented at Annual Meeting by, from left: Roland Emmanuele, chair, Council on Insurance; Governor Neal Riesner; District President Robert Tauber.

Seventh District Governor Andrew Vorrasi, second from left, is welcomed to Long Island fold by, from left, Suffolk County Governor Steven Snyder; Alan Mazer, Suffolk County, chair, Council on Governmental Affairs; Nassau County Governor Frank Palmaccio.

Pre-dinner conversation is enjoyed by, from left: New York County Governor Matthew Neary; Frederick Wetzel, co-chair, NYSDA-MLMIC Underwriting/Claims Review Committee; Ninth District Governor Malcolm Graham; New York County Governor Robert Raiber. 22 NYSDJ • JANUARY 2009

Photos by John Bollentin, Creative Photograph, Burnt Hills

2009

NYSDA President Michael Breault guides dental resident Don Evans in oral examination. Dr. Breault is popular teacher in general practice residency program at St. Clare’s/Ellis Hospital, Schenectady.

NYSDA PRESIDENT MICHAEL R. BREAULT Consensus Personality Ready to Lead Association in Transition Destiny may have had a role in selection of health care career.

G. Kirk Gleason, D.D.S. WILL THE REAL MICHAEL BREAULT PLEASE STAND UP! Is he the superb surgeon and successful periodontist? Is he the high-speed training instructor and Porsche car race driver? Is he the well-known lecturer? Is he the teacher and mentor at St. Clare’s Hospital? Is he the Tae-Kwon-Do world and national level black belt? Is he the husband, devoted family man and community activist? Is he the long-time local, state and national dental leader? Amazingly, Mike is all of the above, and, now, the new NYSDA President as well. Destined to be a Doctor

Mike was destined to be a doctor. His grandfather was a country physician, and Mike, just 5 years old, went on house calls with him. Mike’s father is a retired general surgeon, and the family grew up in a home/office in Schenectady. His uncle is a podiatrist, his sister a nurse. Grandfather Breault graduated from Albany Med in 1917; Mike’s father graduated from Albany Med in 1947; and Mike graduated from Georgetown in 1977—all 30 years apart. Mike’s father, the surgeon, had many friends who were dentists. Seeing their lifestyle, versus his, he encouraged his son to con30 NYSDJ • JANUARY 2009

sider dentistry so that Mike could have a “more normal life.” The dentistry part worked out great, but certainly not the “normal life.” You can double that thought after Mike’s last year as president elect of NYSDA and all the interesting challenges and changes within the Association during 2008. Mike’s father was worried about being called out in the middle of the night. Mike’s challenge has been thousands of cell phone minutes, conference calls and negotiations. However, the old saying, “if you need something done right, ask a busy person” seems to apply all too well. Mike’s early years were filled with variety. He worked at a hardware store, pumped gas, was a prep chef, was an orderly at Ellis Hospital in Schenectady and was a dental assistant in a periodontal office in Schenectady. That last position caused him to ultimately specialize in periodontics. Later, his mentors, John Queern and Lloyd Williams, offered him a position in their practice. Mike and his partner, Mike McGovern, eventually became the owners of the Schenectady practice. They have two other offices, one in Amsterdam and one in Glens Falls. In an interesting twist, their Schenectady periodontal office is located in the building in which Mike grew up. His parents still occupy the living quarters. Dr. Queern was a NYSDA Governor and ADA Delegate. He took Mike to his first dental meeting at the Queensbury Hotel in Glens

Falls. Mike subsequently got to know Sam Coppola of the Fourth District Dental Society when Sam was running for NYSDA President. Mike has been deeply involved in organized dentistry ever since. The Fourth District has contributed several well-known figures to the top NYSDA post, starting with Sam Coppola 26 years ago. Thirteen years later, Bob Westcott took over the helm. And, now, 13 years later, it’s Mike Breault who is president. Asked what the Fourth District has meant to him, Mike replied,“It’s a group of very dedicated dentists who want the best for the public and for organized dentistry. No contention. They try hard to work with each other, to smooth out problems and get things done.”

Mike and Linda Breault at home with sons David, left, and Nicholas.

Personal Challenges

A doctor is not exempt from personal medical problems. Mike had to endure a severe case of Bell’s palsy for five months during his second year of practice. And he was born with a congenital heart defect. It was not treatable at that time, and he was expected to die by the time he turned 18. However, his physician father closely followed research on the ailment being conducted worldwide and when a new surgical procedure was finally developed, Mike, then 16, was taken to Pittsburgh for what proved to be a successful operation. Now an excellent skier, with a black belt in tae-kwon-do and the reflexes of a race car driver, it is obvious Mike has overcome his setbacks. Perhaps surviving a serious physical ailment helps to calm a person—whether it is heading NYSDA, speaking to large groups, performing intricate surgery, or staying in control of a car racing at 150 MPH, Mike seems to have an inner resolve that makes you want to have him in charge.

Linda, Mike’s wife, is a well-known and active community volunteer. She is currently chair of the Ellis Hospital Foundation. She and Mike met in college while attending dances at Fordham. She was a student at Hunter College. They were married during Mike’s junior year at Georgetown. She taught high school math in Manhattan, Washington, D.C., and New Jersey while Mike completed his education. She recalls with fondness living in D.C. during the exciting Centennial year of 1976. She is a little less enthused about their time in New Jersey in 1978 while Mike was doing his periodontal residency at Farleigh Dickenson. There they endured long gas lines and Linda had an hour commute to her job. Mike and Linda have two sons. David, 27, graduated from Siena College, near Albany, and works in real estate in the Capital District. Nicholas, 23, graduated from Villanova University in Pennsylvania and works for a financial firm in New York City. David trained with his father in Korea in Tae-Kwon-Do. Both boys share with their father a love for car racing and skiing. Lectures and Honors

Family and Education

Mike grew up in Schenectady. He attended high school at Christian Brothers Academy in Albany. He then went to Fordham University for his B.S. degree and to Georgetown University for his D.D.S. He received his periodontal training at Farleigh Dickinson University in 1979 and TMD training at the University of Medicine and Dentistry of New Jersey in 1983. He was Board certified in periodontics in 1988 and received a Certificate of Training in Implantology from Harvard in 1989. Mike has also completed a course in public speaking and human relations at the Dale Carnegie Institute.

Mike is an accomplished public speaker whose venues have included local and regional dental meetings, national and international conferences, study clubs and civic organizations. He is a soughtafter lecturer on a range of topics, from implants, bisphosphonates and all phases of periodontal treatment, to race car driving. He has given well over 100 presentations and has contributed articles to numerous publications. Many of us have been privileged to hear Mike speak on different occasions and can attest that he does a great job on all topics. Mike has received many honors, but he is especially proud of the Robert A. Smith Award, the highest honor given by the Fourth NYSDJ • JANUARY 2009 31

District; the Spirit of Healing Award from St. Clare’s Hospital, recognizing him for enhancing the quality of life in his community through professional service, education, advocacy and leadership; his Award for Clinical Excellence in Teaching from St. Clare’s; and for repeatedly being named Teacher of the Year by the residents at St. Clare’s. Nearly 100 dental residents and thousands of patients have benefited from his clinical expertise and steadfast commitment to delivering excellence in patient care. Leadership

Mike is well trained for his leadership role as NYSDA President.He was vice president of his dental school class, president of the Upper New York State Society of Periodontists, president of the Schenectady County Dental An accomplished high-speed driver and instructor, Mike Breault is partial to Porsches. Here he is with his favorite, a Porsche 911GT3. Society, president of the Schenectady Dental Study Club, president of the Fourth District Dental Society, and he has served in all the chairs of NYSDA. He was a NYSDA Governor for eight years and an ADA Delegate for eight years. Mike’s service to dentistry is diverse. He has volunteered with the Medico Missionary Program in Honduras and has lectured widely on dentistry in underdeveloped countries. He holds leadership positions in the prestigious American College of Dentists and International College of Dentists, has headed study groups and reference committees at NYSDA, was on ADA reference committees, is on The New York State Dental Journal Editorial Review Board and is associate editor of the Fourth District Newsletter. Mike has been a presenter at the Fourth District Leadership Conference and is a presenter for the new NYSDA Ethics and Jurisprudence course. He is a tireless worker on all levels and doesn’t view any job as being too big or too small. While he was president of the Fourth District and running the Saratoga Dental Congress, he might also be seen tweaking the AV setup or helping a hygiene student with a table clinic. Even when he takes on new challenges, he continues to excel in every other area of his life. We are very lucky to have this talented person as our new president, especially now when we face the challenges of finding a new executive director and, possibly, instituting dramatic changes in the Association’s governance structure. Expect calm and decisive leadership, efficient and well-planned meetings, and a bringing together of diverse factions and groups for the betterment of the Association, dentistry and the public. Should be a good year! 32 NYSDJ • JANUARY 2009

LET THE HEALING BEGIN The NYSDJ: The community dental health coordinator (CDHC) is a proposed new member of the dental team. If adopted, it would be a controversial addition. How do you feel about the CDHC, and where do you see such a person fitting into the delivery of dental care to patients? Dr. Breault: While the CDHC and its role in organized dentistry are controversial, I feel its implementation is almost inevitable. This is because of a number of forces taking hold in the profession, some of which we have no control over. The biggest factor to date has been the issue of accessibility, or the lack thereof. Certain segments of the population in this country have serious difficulty gaining access to quality oral health care. The CDHC model was borne out of an increasing awareness that we need to address this issue. Facilities such as nursing homes and elder-care institutions do not always have the resources to diagnose and treat individuals for oral health care problems, which can lead to greater physical difficulties. Similarly, both urban and rural areas may lack acceptable levels of care. The CDHC has been developed at the national level to begin to address these problems. As with many situations that are forced upon us, we can either embrace it as part of the solution or become intransigent and attempt to resist it. However, judging from the currents at the national level, it is something that will inevitably be thrust upon us, and I feel it is better to have a place at the table in its formulation and implementation. This may be difficult for some practitioners to accept, but it is better to have a hand in the issue than to be left out of the decision-making process. Ultimately, this type of practitioner should fill the void in underserved areas but only under the supervision of the oral health-care team leader, the dentist. The NYSDJ: What is the single most important issue facing NYSDA? Dr. Breault: At this particular point in our Association’s history as the leading advocate for its members and the patients they treat, I believe we need to continue to come together as an organization. We have had a few difficult years in the immediate past, and there were times when it appeared the State Dental Association might be coming apart. This could have had the effect of essentially destroying our organization and all the good it has stood for and accomplished over the last 150 years. In recent months, it appears we have begun to find common ground on most if not all issues. We cannot afford to spend more time and energy on the fractious questions that have divided us. Therefore, in terms of the single most important issue facing us now, I believe the reconstituting and reenergizing of our Association is paramount, so that we can move forward and deal with the other important concerns facing us. I’m thinking especially of the new governance system we may well embrace in the coming year. If adopted, it will bring about a restructuring of the entire Association governing structure, which will, in turn, bring about the involvement of more members in the direct administration of Association affairs NYSDJ • JANUARY 2009 33

were able to show them first hand the advantages of membership. This is a very positive activity that has been and could be emulated throughout the state to enable younger dentists to learn from their seasoned colleagues what organized dentistry can offer them. The NYSDJ: We hear much about access to care and dentistry’s role in improving it. How would you describe the access-to-care problem in New York State, and what can NYSDA do to ensure that people outside of the delivery system are reached? Dr. Breault: As I indicated previously, the access issue is one that has come to the forefront in recent years and will not be solved in the immediate future. Recognizing that this is an ever-increasing problem has taken a while but is now front and center for the dental community. One approach is, again, to utilize auxiliaries who are trained for this type of extended therapy for the aged and underserved populations. However, this has to always be under the From track to ski trail, Mike Breault indulges a passion for physical activity. As a youth, it wasn’t certain he purview of the dentist as the oral health-care would live to adulthood. team leader. There are models being develthrough an expanded House of Delegates and Board of oped nationally that will assist all oral health care providers with Trustees. This is a development whose time has come. the implementation of these models in the institutions and clinThe NYSDJ: NYSDA’s membership is aging, making memics that will best serve needy populations. bership recruitment and retention even more critical to the Another venue to consider is volunteerism. There are future of our dental organization. At the same time, younger approximately 14,000 to 16,000 dentists in New York State. If dentists are considering many factors before deciding where to each and every one of them voluntarily contributed one half day practice and whether to join organized dentistry. Do you have a month to work in an underserved area or a community health any thoughts on how to make New York State and organized center/clinic—or even to teach at a dental school or residency— dentistry more attractive and relevant to practicing dentists, the positive impact on the access problem would be far reachespecially new practitioners? ing. These are points that I feel need to be expressed to our Dr. Breault: Without new members adding to and reinvigodental community. And, we must constantly stay vigilant about rating an organization, that organization will eventually die. Ours state programs, such as Medicaid, to ensure that they fulfill is no different. Without an influx of new and younger members, necessary mandates and meet the needs of the underserved. our Association could very well expire. There are a few immediThe NYSDJ: Every year, the incoming NYSDA President ate issues that contribute to this situation. First, it is difficult to identifies his goal for the coming year. What is your number-one ask young people just out of dental school and shouldering goal, why and how do you propose to achieve it? enormous monetary debt to join the tripartite system with its Dr. Breault: Actually, the goal for my administration is twoattendant fees. A staggered dues structure that increases slowfold: 1. To mend this Association so that it is stronger and conly over time is proving to be a positive step. Second, awareness tinues to serve our members and the needs of their patients betof the tripartite structure and the benefits of joining that system ter than ever; and 2. To have a positive impact on the growing needs to be brought to the attention of our younger colleagues. requirement of all of the people of this state for access to the One of the single most influential programs I have been best oral health care team in the country. Neither of these interinvolved in recently occurred within our own district. We held an related issues is going to be easy to accomplish. But by having evening meeting at the State Dental Association headquarters the members of our Association come together on matters of to which, at the request of our executive director, all new, immediate concern, we can accomplish both of these goals. younger dentists were invited. Representatives from the State These are the two areas that I have been speaking to over Association and local dental leaders discussed the various posthe last year in my various visitations throughout the state. It is itive aspects of belonging to the tripartite system. Among the essential that we reach out to the many subgroups of practictopics discussed were peer review, legal matters and the assising dentists who are more comfortable in their cultural commutance offered by the Association, malpractice and continuing nities than in the State Association. Only by engaging them in education. By engaging these younger practitioners in a diadialogue and making it possible for their members to become logue about the benefits of belonging to organized dentistry, we the future leaders of tomorrow, will our Association thrive. ■ 34 NYSDJ • JANUARY 2009

Dental Health Certificate Program Elicits More Questions and Answers IMPLEMENTATION OF THE landmark dental health certificates law, requiring that school districts request a dental health certificate from children, continues to raise questions among both school districts and dental providers. Last September, The New York State Dental Journal carried information about the law and how it was to be carried out (Dental health certificates advance profession’s mission. NYSDJ 2008;74(5):44-45). There have been developments since that article appeared, including the awarding of a generous grant by the American Dental Association Public Advocacy Program to the New York State Dental Foundation (NYSDF) to ease implementation of the new law. What follows is an update of information previously presented on dental health certificates. Answers have been provided by NYSDF Executive Director Laura Leon and Milton L Lawney, D.D.S., public advocacy coordinator for the NYSDF. The NYSDJ: The ADA provided a generous grant to assist in implementing the legislation. Why? Ms. Leon: The ADA has always been proud that the dental profession stresses prevention and providing the best oral health care to all Americans. As soon as you start talking about providing care to all, you also need to talk about ensuring access to care. The ADA recognized that the New York legislation was innovative and that it has the ability to increase access to oral health care. The grant will enable the NYSDF to implement the legislation, work with stakeholders, provide mailings, create Web sites and develop programs that can be shared with other states. 36 NYSDJ • JANUARY 2009

The NYSDJ: What is meant by the term “comprehensive dental examination,” as used in the new law? Dr. Lawney: The dental examination is used to determine a child’s dental health condition. Therefore, it is defined for this purpose as an assessment performed by a dentist or a dental hygienist under the general supervision of a dentist (charting caries and periodontal conditions as an aid to diagnosis by the dentist) for purposes of determining the presence of any painful conditions, obvious swelling related to clinical evidence of open cavities, or any other condition that interferes with a student’s ability to chew, speak or focus on school activities. Radiographs are not expected to be part of this assessment. Rather, this is a visual caries assessment.And it does not have to be performed in a dental office. It proves that the child is not in pain, that the child can concentrate in class, and it is an important measurement tool in assisting state agencies to make sure that all children have a dental home. The NYSDJ: What is the dentist’s liability in providing a dental assessment? Dr. Lawney: NYSDA and the NYSDF have been sensitive to the patient liability issue when assessing children. The following is an integral part of the Dental Certificate form and must be agreed to by the child’s parent or guardian. “I understand by signing this form I am consenting for the child named above to receive a basic oral health assessment. I understand that this assessment is only a limited means of evaluation to assess

the student’s dental health, and I would need to secure the services of a dentist in order for my child to receive a complete dental examination with X-rays if necessary to maintain good oral health. “I also understand that receiving this preliminary oral health assessment does not establish any new, ongoing or continuing doctorpatient relationship. Further, I will not hold the dentist or those performing this assessment responsible for the consequences or results should I choose NOT to follow the recommendations listed below….” Some schools may have developed their own form. However, the official certificate that was approved by NYSDA, the New York State Education Department and Department of Health contains protections for the dentist regarding liability and obligation to the patient.We strongly suggest that you use only this form. Copies can be downloaded from the Foundation Web site at www.nysdentalfoundation.org. The NYSDJ: May dentists charge for the assessment? Dr. Lawney: The law requires that schools offer a list of dentists who offer free or reduced-fee screenings for children who do not have insurance, Medicaid, Child Health Plus, or who are unable to afford such screenings. The purpose of the legislation is to increase access and to find children a dental home. It is hoped that assessments will be provided at no cost for eligible children. The NYSDJ: What happens if a dentist declares that a child is not in fit dental health condition to permit him/her to attend the public schools? Dr. Lawney: The law does not require that a student be withheld from attending classes as a result of the findings on the dental health certificate. However, it is hoped that such a finding will cause parents or guardians to make arrangements for care.

does not provide the needed care. One program will be based upon governmental involvement and one will rely on volunteers. More information will follow regarding these programs. The NYSDJ: How do dentists get involved? How do they plan a schoolwide assessment? Ms. Leon: Dentists are encouraged to review the information on the NYSDF Web site, www.nysdentalfoundation.org. The Web site provides the ability to sign up electronically to provide assessments. The Foundation will forward members’ names and willingness to participate to the appropriate state agencies, to be included on the list of dentists who provide dental assessments for free or at reduced cost for eligible children. If you are not able to sign up electronically, please call the Dental Foundation at (800) 255-2100. Dental components will also be planning schoolwide and community assessments when necessary. Members should contact their components for further information. The NYSDJ: Is there anything dentists can do if they find that their school districts have insufficient information regarding dental health certificates? Dr. Lawney: It is very important that the dental certificate program be implemented consistently throughout the state. The certificate program went into effect on Sept. 1, 2008; however, the State Education Department did not provide implementing policies to the dental community until the middle of September. Also, the information provided to the public schools by the Education

The NYSDJ: If a child is not in fit dental health condition and is not able to afford dental treatment, what should the next steps be? Ms. Leon: First, the dentist should have the child’s parent or guardian ascertain if the child is eligible for Medicaid or Child Health Plus by referring the parent or guardian to the local department of social services. Child Health Plus just raised the financial threshold for children to become eligible. Second, if a child is not eligible for Medicaid or Child Health Plus, the parent or guardian may contact the department of social services for the locations of local Article 28 clinics or community health centers that provide reduced-fee or no-cost dentistry. Third, the parent or guardian may contact the local dental component to find out if there are any local charitable organizations or dentists that provide free or reduced-cost dentistry. The NYSDF is developing two trial programs to address treatment issues if the above protocol NYSDJ • JANUARY 2009 37

To become involved, sign up electronically and contact your local component. Let them know that you want to help. It is about kids. Department has been inconsistent and requires updating. NYSDA and the NYSDF will be meeting with State Education personnel in the near future to address this situation. Updates will be provided on the Foundation Web page. If your public school district requires more information regarding dental certificates, please have the district contact the New York State Education Department. They may also review the Foundation’s Web page, which has links to the appropriate state agencies. It is important that school districts be fully aware of all policies now so they can fully implement the certificate program this coming September. The NYSDJ: Have there been any group assessments in 2008, and what can be done locally? Ms. Leon: Assessments were provided at The New York State Fair with the assistance of the Fifth District Dental Society. The University at Buffalo School of Dental Medicine provided an assessment program in cooperation with the Eighth District Dental Society. The Fourth, Fifth, Sixth and Seventh districts will provide assessments at 45 Kinney Drug stores in February during Children’s Dental Health Month. Suffolk and Nassau County Dental societies are planning large group assessments as part of their Give Kids A Smile program. Also, many dentists have signed up electronically and have provided assessments in their offices. The success of the dental health certificate program will only come through the continued commitment and hard work of the components.All schools and children are local. They seek care from local dentists, and the components are tied into the resources of their communities. NYSDA, NYSDF and the components are committed to the success of dental health certificates. To become involved,sign up electronically and contact your local component. Let them know that you want to help. It is about kids. The NYSDJ: Where can dentists get more information? Ms. Leon: Please review the information regarding dental health certificates on the Foundation’s Web site. The State Education Department has the approved form and answers to frequently asked questions on its Web site, www.opnysed.gov/dentnews.htm. The Q&A is extensive and should be read thoroughly. Information can also be obtained by calling Dr. Lawney at NYSDF, (800) 255-2100, or writing to him at 20 Corporate Woods Blvd., Suite 602, Albany, NY 12211. ■ 38 NYSDJ • JANUARY 2009

Rationale and Technique for Achieving Occlusal Harmony Saul S. Kimmel, D.M.D. Abstract For a patient to function normally with natural or restored dentition, the occlusal contacts should be in harmony with the musculature and the temporomandibular joint. Many times, this harmonious relationship is altered by restorative treatment, periodontal disease or tooth loss. If the adaptive capacity of the patient is less than the forces placed upon the tooth or restoration, failure in one form or another often results. This article presents a rational method the dentist can use to recognize and understand the markings made with articulating paper so that harmonious contacts can be detected and contacts that disturb occlusal harmony eliminated.

THE MAJOR RESPONSIBILITY of the restorative dentist is to treat the dentition and its surrounding structures in such a manner that the contacting surface—occlusal or incisal—of the tooth or restoration is able to position itself against its antagonist—another occlusal or lingual surface or restoration—in a stable relationship. The dentist is equally intent on insuring that when mandibular movements occur away from the contacting position, they will be performed without interferences, thus, maintaining occlusal stability and orofacial harmony. To accomplish this appropriately and easily, the treating dentist must possess knowledge of the movements of the mandible during function and be aware of the nature of occlusal contacts that the mandibular teeth generate during their excursive paths when

contacting the maxillary dentition. However, it has been my experience that many dentists view occlusion and these occlusal relationships as difficult or virtually impossible to understand. This article will attempt to clarify the concepts of occlusal contacts and provide a simplified method for eliminating occlusal interferences. The movements of the mandible through its excursive pathways are guided and controlled by anterior and posterior anatomical structures. These are the temporomandibular joint (posterior) and the lingual surfaces of the maxillary anterior teeth, and, sometimes, the lingual surfaces of the maxillary buccal cusps (anterior). The posterior determinant is fixed or unalterable, while the anterior determinant may be altered by selective reshaping and restorative measures. The crucial factor to the placement of occlusally harmonious restorations and occlusal reshaping is to understand that with an Angle Class I maxillo-mandibular relationship, closing protrusive and lateral movements of the mandible will cause the dentition to contact only in definite areas. In other words, specific mandibular movements repeatedly produce the same contacts, or occlusal markings, only on specific areas of the teeth. Goals of Occlusal Harmonization

It should be understood from the outset that an asymptomatic occlusion that will not undergo restorative or prosthetic intervention should not be reshaped prophylactically. The purpose of our treatment is not to create an “ideal” occlusion, or one that has the characteristics of what we consider “perfect.” Rather, it is meant to create a “physiologic” occlusion, or one that is in sufficient harmony with the anatomic and physiologic controls of the mandible and musculature so as not to induce pathology within the tissues of the oral system. As treating dentists, we will observe that an occlusal disharmony may present itself as symptoms in our patients such as: NYSDJ • JANUARY 2009 39

1. headache; 2. facial pain; 3. neck and shoulder pain; 4. TMJ dysfunction; 5. pulpitis; 6. apical periodontitis; 7. uncomfortable prosthesis; 8. hearing impairment; and 9. referred pain. Signs of occlusal disharmony may also be evident as radiographic proliferative changes, such as: 1. condensing osteitis; 2. hypercementosis; 3. thickening of the lamina dura; 4. exostosis; and 5. bony apposition. It may produce and present itself as well as visible degenerative changes, such as: 1. premature wear; 2. cusp fracture; 3. bone resorption; 4. perforation of the condylar disc; 5. erosion of the condyle; and 6. osteoporosis of the TMJ fossa. The position and anatomical structuring of the mandible and temporomandibular joint cause this anatomic combination to function as a Class III lever that produces no mechanical advantage during function. It is when “interferences” are encountered in the natural or restored dentition during centric closure or during excursive movements, thus changing a Class III levering system (that produces no mechanical advantage) into a Class I or Class II levering system (that produces mechanical advantage), that the aforementioned signs or symptoms become evident. Another way of thinking of “harmonization” is to think of it as elimination of fulcrums by restorative measures or reshaping of the offending enamel. Objectives of Harmonization

The restorative dentist should strive to achieve the six goals listed here. ● Attain maximum distribution of force throughout the dentition in the intercuspal position. The force of closure and excursions should be borne by the long axis of the tooth, producing as little lateral stress as is possible. ● A “broad” surface contact should be changed to a minimal point contact. Eliminate all “grasping” contacts. ● Once centric relation and centric occlusion contact have been established for a tooth, never eliminate this supportive position by restoration or reshaping. ● There should be no impediment to all lateral and protrusive mandibular movement from full contact position. Anterior teeth should separate posterior teeth during protrusive movement without interference. The lateral movements should produce disclusion on the opposite side to which the mandible moves without interferences. ● The vertical dimension of occlusion must be maintained or created at a clinically acceptable level with an adequate amount of “freeway” space. ● Mandibular separation from full intercuspal position in all excursive pathways should be immediate. If excessive translation occurs from the intercuspal position to the discluding contact surfaces, interferences are more likely to be encountered. Restorative measures should be taken to create an “immediate disclusion.” 40 NYSDJ • JANUARY 2009

Figure 1. Centric occlusion contacts.

Centric Occlusion Contacts

Centric occlusion contacts may be thought of, for the purposes of this article, as the position of full closure, or when the teeth are in maximum intercuspation. We may see some light contact on the lingual surfaces of maxillary anterior teeth and the labio-incisal angle of mandibular anterior teeth. In the posterior segments, in this position, contacts will only occur on the lingual cusp tips, central fossae and marginal ridges of maxillary teeth, and the buccal cusp tips, central fossae and marginal ridges of mandibular teeth. In centric occlusion, these are the only areas that should contact; and these contact positions should be the primary focus of retention if occlusal reshaping is to be performed (Figure 1). Centric Relation Contacts

Ideally, centric relation contacts should coincide with centric occlusion contacts. However, this is usually not the norm. It has been this author’s experience that a .5 mm. discrepancy that produces an anterior displacement or “slide”produces no pathological effects on the dentition, musculature or TMJ. In the anterior teeth, centric relation contacts will be minimal or non-existent, and may coincide with centric occlusion contacts. In the maxillary posterior dentition, centric relation contacts may coincide with centric occlusion contacts on the cusp tips but be slightly distal to the centric relation contacts on the marginal ridges and fossae. In the mandibular posterior teeth, the cusp tip marks will again coincide and be slightly mesial to the centric occlusion marks on the marginal ridges and fossae (Figure 2). When there is a discrepancy between centric relation and centric occlusion producing a forward slide to maximum intercuspation,it is caused by premature contacts of mesial inclines of maxillary lingual cusps and distal inclines of mandibular buccal cusps (Figure 3). No other surface contact produces this movement.

Figure 2. Centric relation contacts.

Figure 3. Centric interferences causing forward slide.

Where there is a discrepancy between centric relation and centric occlusion producing a lateral slide, the slide producing contact is found between the centric relation contact and the working contact and non-working contact. To simplify identification, first eliminate all non-working contacts. With an anterior- or cuspid-protected occlusion,identification of the lateral producing slide is simplified,as any contacts in the posterior working area may be easily eliminated. If any residual slide is present, it is due to cuspid contact. This can be reduced by judicious reshaping without injudicious recontouring of lateral guidance surfaces. In dealing with a “group function”in lateral excursion, some of the working contacts may have to be reduced to eliminate the lateral slide. This will be the areas closest to the centric relation contacts. At no time should there be reduction of centric contacts. Working Contacts

The “working”movement may be described as the side to which the mandible moves during lateral function. Note that with the teeth in normal alignment, a working side movement will produce contact—or markings—only on the lingual inclines of the maxillary buccal cusps and sometimes on the lingual cusps and the buccal inclines of the mandibular buccal and sometimes on lingual cusps. If a group function exists, there may be contact on the incisors. No other movement will produce markings in these areas during a working movement (Figure 4). Non-working Contacts

There are contacts made on the opposite side to which the mandible has moved in lateral excursions, that is, if the mandible has moved to the right, non-working contacts would be found on the left side. The direction of the contact is from mesiolingual to distobuccal on the inner aspects of the supporting cusps of both arches. Almost all the

Figure 4. Working contacts.

contact areas are located on the mesial inner inclines of the upper supporting cusps and the distal inner inclines of lower supporting cusps; exceptions are the mesiolingual cusps of upper molars and the distobuccal cusps of lower molars. There will be no anterior contact, and no other movements will produce contacts in these areas. As elimination of these contacts will not jeopardize centric occlusion or centric relation contacts or reduce vertical dimension of occlusion, it is recommended that these contacts be eliminated initially (Figure 5). Protrusive Contacts

A protrusive movement is an anterior movement or protrusion of the mandible. This movement produces contact on the labio-incisal angle of the mandibular anterior teeth coincident with centric markings, and on the lingual surfaces of maxillary anterior teeth incisal to centric markings (Figure 6). Protrusive contacts in the natural dentition are undesirable and are considered “protrusive interferences.” When they occur, they are found on the distal inclines of maxillary lingual cusps and on the mesial inclines of mandibular buccal cusps. No other movement of the mandible will produce contacts in these areas (Figure 7). Technique

Prior to discussing the technique for obtaining occlusal harmonization by selective reshaping of restorative material or enamel, I wish to stress that it is both unwise and inappropriate to perform either service for a patient who displays longstanding symptoms in the TMJ or musculature. Performing either of these services in a symptomatic patient may not only accentuate the symptomatology, but it may further “lock” the patient into a pathology-producing position. Occlusal surfaces act as a “muscle programmer” that causes the mandible to move to a certain position. If this programming is NYSDJ • JANUARY 2009 41

Figure 5. Non-working contacts.

Figure 6. Protrusive contacts.

longstanding and present in an individual whose capacity for adaptation has been exceeded, symptomatology, pathology or both may be created. The musculature must be “deprogrammed” prior to intervention by the treating dentist. There are several methods and devices available to deprogram symptomatic musculature. I have found that use of a full-time disclusion appliance to relieve spasmodic musculature and “unload” the TMJ, is both predictable and reliable.1,2 After longstanding symptoms are eliminated, occlusal intervention may be instituted. The technique for selective reshaping is based upon the principle of knowing the normal from the abnormal and then eliminating the abnormal or pathology-producing interferences. The technique differs from previous techniques, as it is not predicated on determining centric relation position prior to selective reshaping of contacting surfaces.This concept is also predicated on the principle that the disclusion device has “deprogrammed”the musculature and that the longstanding muscular or TMJ symptoms have been eliminated. Once these symptoms have been eliminated and the musculature is not spasmodic, it is reasonable to assume that elimination of the occlusal contacts that generated the spasm will eliminate the centric closure interference. Once this interference is eliminated, a “physiologic centric position” will result. It is this author’s experience that a .5 mm protrusive slide from centric relation contact position to maximum intercuspation is both common and well tolerated. Centric closure interferences producing a lateral slide are less well tolerated and produce more symptomatology. These are more difficult to properly eliminate, as they are present on inclined planes adjacent to centric contacts. The difficulty lies in eliminating lateral slide-producing contacts without encroaching on centric stabilizing contacts. I believe it is appropriate and functional and stable to maintain to two centric contact position “stops” per tooth without compro42 NYSDJ • JANUARY 2009

Figure 7. Protrusive interferences.

mising individual dental stability. Therefore, as it is more important to eliminate the lateral-producing slide, it is acceptable to encroach upon a centric holding contact if we are able to maintain at least two contacts per tooth. If, in the operator’s judgment and observation, vertical occlusal stability is maintained, encroachment upon centric stops (vertical) is acceptable, both functionally and physiologically. How it’s Done With the patient reclined in a supine position, the maxillary and mandibular teeth are both air-dried and wiped dry with gauze. Full-arch articulating paper is placed on the maxillary arch (for convenience), and the patient is instructed to bite until full closure is attained. The patient is then instructed to move the mandible through all lateral and protrusive excursions, keeping mind to maintain full occlusal contact during these movements. The operator should now examine all the markings produced by the mandibular excursive movements and analyze them to determine if an anterior or lateral slide is present. The lateral slide is caused by premature contact on the inclined planes surrounding the intercuspal contact position or excessively heavy and/or premature cuspid contact (Figures 8,9). Eliminate posterior interferences by polishing away the areas adjacent to the centric occlusion contact markings without eliminating the centric contacts. If elimination of centric contacts is unavoidable, the operator should ensure that at least two centric stops per tooth are preserved. Eliminate cuspid interferences by deepening the lingual contour of the upper cuspid. Do not reduce the cusp height of mandibular cuspids. With knowledge of the location of appropriate contacts in all excursive movements, eliminate inappropriate contacts (interferences). Eliminate non-working interference by reducing the

Figure 8. Premature and heavy contacts.

Figure 9. Lateral view showing cause of protrusive and nonworking interferences.

inclined planes without reducing centric stops. Eliminate working interferences by reducing inclined planes without reducing cusp height. Eliminate protrusive contacts in the posterior dentition without reducing centric stops. Polish smooth any treated enamel or restorative surfaces. Topical fluoride should be applied to reduce/prevent sensitivity. If the markings displayed initially have extensive inappropriate contacts, make needed changes over several appointments to avoid occlusal “overawareness” by the patient. If a disclusion appliance was used prior to occlusal therapy, the patient should continue to use it during occlusal therapy. When the patient has adapted to the changes made, musculature is comfortable and symptoms are greatly reduced or completely absent, initiate restorative therapy. Elimination of “deflecting”contacts to full closure will yield an unimpeded arc of closure that produces a cusp-fossa-marginal ridge relationship in maximum intercuspation.If lateral excursions are “cuspid protected,” there should be no posterior contact during excursions (Figure 10). Should marginal ridges be prominent on anterior teeth, these will be the protrusive and lateral movements’ guiding surfaces. If the dentition is worn, protrusive and lateral guidance is more likely to occur in the central fossae of anterior teeth.Should a group function posterior relationship exist,the contacts should be light and evenly distributed. Conclusion

A simple concept and method have been presented that permit the treating dentist to easily recognize and eliminate interferences to harmonious functioning of the dentition during closure as well as protrusive and lateral excursive movements of the mandible by reshaping the enamel and/or restorative material. ■

Figure 10. Cuspid-protected occlusion markings.

REFERENCES 1. Kimmel SS. A disclusion appliance to eliminate occlusally generated TMD symptoms prior to and during fixed orthodontic therapy. J Gen Ortho 1994;5(3):5-11. 2. Kimmel SS. Temporomandibular disorders and occlusion: an appliance to treat occlusion generated symptoms of TMD in patients presenting deficient anterior guidance. Cranio: J Craniomandib Pract. 1994;13(4):234-40. 3. Guichet NF. Occlusion. Denar Corp:Anaheim, CA. 1977. 4. Smuckler H. Equilibration in the Restored and Natural Dentition. Quintessence:Chicago IL, 1991. 5. Ross IF. Occlusion: A Concept For the Clinician. CV Mosby: St. Louis, MO. 1977. 6. Abrams L. Occlusal Adjustment of the Natural and Restored Dentition. Quintessence: Chicago, IL. 1981. 7. Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems. 2nd ED.CV Mosby: St. Louis, MO. 1989. 8. Solberg WK; Clark GT.TMJ Problems: Biologic Diagnosis & Treatment.Quintessence:Chicago, IL. 1980. 9. Solnit A, Curnutte DC. Occlusal Correction: Principles and Practice. Quintessence:Chicago, IL. 1980. 10. Shore NA. TMJ Dysfunction & Occlusal Equilibration. JB Lippincott. 1976. 11. Hall WB,et al.Decision Making in Dental Treatment Planning.CV Mosby: Chicago,IL.1994. 12. Marcotte MR. Biomechanics in Orthodontics. BC Decker: Philadelphia, PA. 1990. 13. Mulligen TF. Common Sense Mechanics. CSM: Phoenix, AZ. 1982. 14. Ramfjord S; Ash M. Occlusion. WB Saunders:Philadelphia, PA. 1969. 15. Huffman RW; Regenos JW. Principles of Occlusion. H&R Press: Reynoldsburg, OH. 1989. 16. McNeil C. Science and Practice of Occlusion. Quintessence: Chicago, IL. 1997. 17. Celenza FW. Occlusal Morphology. Quintessence:Chicago, IL. 1980. 18. Fox CV; Fox F. Diagnostic Casts, Occlusal Evaluation and Equilibration. UB Press: Buffalo, NY 1995. 19. Neff PA. TMJ, Occlusion and Function. Georgetown University Press: Washington DC. 1975. 20. Continuum II: J LD Pankey Institute. Coral Gables, FL., 1981.

The “Read, Learn and Earn” home study program is a joint offering of The New York State Dental Journal and the New York State Dental Foundation. Readers are invited to visit the NYSDF Web site, wwwnysdflearning.org, to complete questions based on material in this Journal.You are advised to have the corresponding issue of The Journal with you when you take the exam. Each exam will be based on three articles in The Journal and will consist of 18 questions. Those who successfully complete the exam will be eligible for three home-study credits. To register and complete the online exam visit www.nysdflearning.org and follow the instructions. NYSDA members will be charged $60 per exam, nonmember dentists $120 and hygienists $40.

Queries about this article can be sent to Dr. Kimmel at [email protected] NYSDJ • JANUARY 2009 43

Is Bronchial Asthma a Risk Factor for Gingival Diseases? A Control Study Abhishek Mehta, M.D.S.; Peter Simon Sequeira, M.D.S.; Ramesh Chandra Sahoo, M.D.; Gurkiran Kaur, M.D.S.

Abstract Asthma is a serious global health problem. People of all ages in countries throughout the world are affected by this chronic airway disorder, which can be severe and sometimes fatal. The prevalence of asthma is increasing everywhere, especially among children. Several oral health conditions are documented among asthmatic patients, such as an increased rate of caries development and reduced salivary flow; an increased prevalence of oral mucosal changes, like oropharyngeal candidiasis and gingivitis; and orofacial abnormalities. The study presented here was conducted to find a relationship between increased levels of plaque and gingivitis and bronchial asthma. Around 80 asthmatic patients were examined for their plaque and gingival status. Their scores were compared with a control group matched for age, sex and socioeconomic status. Results showed a significant increase in plaque and gingival scores among asthmatics as compared to the control group. Hence, there is a need to educate this group of patients about their increased risk of gingival disease and the importance of proper plaque control. 44 NYSDJ • JANUARY 2009

ASTHMA IS A CHRONIC INFLAMMATORY DISORDER of the airways. According to the latest GINA (Global Initiative for Asthma) report, it is estimated that as many as 300 million people of all ages and all ethnic backgrounds suffer from asthma. In India, the prevalence of asthma is 3% of the total population.1 Individuals suffering from bronchial asthma were found to have more caries and gingivitis as compared to the general population. They also have an increased prevalence of oral mucosal changes, like oropharyngeal candidiasis, and orofacial abnormalities. Few studies have been conducted to find out the plaque and gingival status of asthmatic patients compared to a non-asthmatic control group. Results of these studies were conflicting, as some studies have shown an increase in plaque and gingivitis in asthmatic patients, while others failed to show any such association. Most of these studies were conducted in Scandinavian countries. The study presented here was conducted to assess the plaque and gingival status of asthmatic patients 11 to 25 years of age, and to examine the possible association of these conditions to various aspects of bronchial asthma and its management. Material and Methods

Our study was conducted on 160 subjects 11 to 25 years old. They were divided into two equal groups of asthmatics and controls. The asthmatic group comprised 80 patients who were suffering from bronchial asthma and were receiving treatment at the Department of Chest Medicine and Allergy, KMC Hospital, Attavar (Mangalore). These patients were on asthmatic medication (both ␤2- agonists and corticosteroids) for at least six months and were using an inhaler device for delivery of at least one type of asthmatic medication.

and gingival status and to examine the possible association of these The control group consisted of individuals who were matched to conditions to various aspects of bronchial asthma and its managethe asthmatics by age, sex and socioeconomic status. The socioecoment. The results were compared with a control group that was nomic status of the subjects was obtained from Kumar’s modificamatched for age, sex and socioeconomic status. tion of Prasad’s social classification for Indian families, which is a 2,3 In our study, the asthmatic group had significantly more widely used socioeconomic scale in research studies in India. severe gingivitis as compared to the control group (p< 0.001). This Training and calibration of the examiner for different indices result is similar to the findings in studies conducted by Hyyppa TM to be used in the study was done before starting the study. A pilot et al7 and McDerra EJC et al.8 study was done on 20 asthmatic patients to check for feasibility of The possible reasons for increased prevalence of gingivitis in the study. The pilot study was also used to select the particular asthmatic patients are related to immunological factors and mouth social class for both of the groups. breathing habits. In periodontal disease, the host response via the Examination of subjects was done using a dental chair under immune defense system is considered important. Although the role standard illumination. Data was collected by means of a proforma, of allergy is not clear, IgE-mediated mechanisms are supposed to be which was designed to collect information on the patients’age and sex involved in the pathogenesis of gingival and periodontal diseases. In and their oral hygiene practices.Turesky S,Gilmore ND and Glickman patients having birch pollen allergy, an increased amount of gingiviF modification of Quigley -Hein plaque index4 and Modified Gingival tis was observed during the pollen season when compared with the Index5 was used to record plaque and gingival status, respectively. off season. Platelet-activating factor, one of the mediators of allergic Information regarding duration of asthma, type of medication and inflammatory reactions, is also present in inflamed gingival tissues. frequency of intake, and severity of asthma was collected from the medical records of the patients.Asthmatics were categorized into moderate and severe categories according to the classification given by the National Heart, Lung and TABLE 1 Blood Institute, USA, in 1997.6 Distribution of Subjects According to Age Groups The results were analyzed using a statistical packAsthmatics Mean Age (SD) Controls Mean Age (SD) age for social sciences (SPSS - version 11). Total

Results

In this study,80 asthmatic patients were examined for their plaque and gingival status and compared with the same number of control group subjects. The mean age was 17.4 (± 4.3) years for asthmatics and 17.2 (± 4.23) years for controls.There was no statistically significant difference in the age for the two groups or in any age group (Table 1). Neither was there a significant difference between their oral hygiene habits.Most of the subjects were using toothbrush and toothpaste for cleaning their teeth. When comparison was done between asthmatics and controls for mean Modified Quigley-Hein Plaque Index (MQHPI) scores, the mean MQHPI score for asthmatics was 1.94 (±0.73), as compared to 1.51 (± 0.37) for controls. The difference was statistically significant: independent sample t test, p < 0.001 (Table2). Table 3 describes the comparison between asthmatics and controls for mean Modified Gingival Index (MGI) scores. The mean MGI score for asthmatics was 1.42 (±0.31), as compared to 0.90 (±0.21) for controls. There was significant difference between the mean MGI score of the two groups: independent sample t test, p < 0.001. Discussion

The study presented here is a case-control study conducted on asthmatic patients to assess their plaque

t-test

80

17.4 (4.3)

p > 0.05

80

17.2 (4.23)

Not significant

TABLE 2 Comparison of Mean Modified Quigley-Hein Plaque Index (MQHPI) Scores Between Asthmatics and Controls Confidence Interval Mean MQHPI Score

Standard Standard Lower Deviation Error (SD) (SE)

Asthmatics

1.94

0.73

0.08

Controls

1.51

0.37

0.04

0.24

Upper

Significance [P]

0.60

0.001*

Independent sample t test * p value is statistically significant

TABLE 3 Comparison of Mean Modified Gingival Index (MGI) Scores Between Asthmatics and Controls Confidence Interval SD

SE

Asthmatics

Mean MGI Score 1.42

0.31

0.03

Controls

0.90

0.21

0.02

Significance [P] Lower

Upper

0.43

0.60

0.001*

Independent sample t test * p value is statistically significant

NYSDJ • JANUARY 2009 45

Interestingly, some of the cytokines, which mediate inflammatory processes in the mucous membranes of airways, are also found in inflamed periodontal tissues. Gingival mononuclear cells obtained from adult patients with chronic periodontitis can produce increased amounts of interleukin IL-5 and IL-6. Recently, it has been reported that there is a general defect in the mucosal permeability of asthmatics, independently of atopic status. Taken together, it seems that inflammatory processes in both asthma and periodontal diseases share partly similar pathophysiologic features, a fact that may to some degree explain the increased prevalence of periodontal inflammation in asthmatics.9 Asthmatics have more tendencies toward mouth breathing because of various dentofacial abnormalities associated with asthma. Studies have described increased upper anterior and total anterior facial height, high palatal vault, greater overjets and high prevalence of crossbites in children with chronic rhinitis. All these factors favor mouthbreathing, leading to dehydration of alveolar mucosa and an increase in gingival inflammation, especially in the maxillary anterior region.6 In the study presented here, asthmatics had significantly higher mean plaque scores as compared to controls. McDerra EJC et al.8 observed similar results, but Hyyppa TM et al.7 found asthmatics had lower plaque scores than controls. Ryberg M et al.9 reported no difference in plaque scores between asthmatics and controls. Higher plaque score can partially explain more gingivitis among asthmatic patients. It may be that the parents of asthmatic children are less likely to view teeth to be of great importance when compared to the asthma itself.8 Hence, there is an urgent need to educate asthmatic patients regarding their risk for various dental diseases. Also, dental professionals should regard these patients as a high-risk group and make them aware of their predisposition towards dental diseases. ■ Queries about this article can be sent to Dr. Mehta at [email protected]

REFERENCES 1. Masoli M, Fabian D, Holt S, Beasley R. Global burden of asthma. GINA report, 2004. Available from: www.ginasthma.com. 2. Prasad BG. Social classification of Indian families. J Indian Med Assoc 1968;37:250-251. 3. Kumar P. Social classification – need for constant updating. Indian J Community Med 1993;18:60-61. 4. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of vitamin C. J Periodontol 1970;41:41-3. 5. Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker LA. Modified Gingival Index for use in clinical trials. Clin Prev Dent 1986;8:3-6. 6. Steinbacher DM, Glick M. The dental patient with asthma – an update and oral health considerations. JADA 2001;132:1229- 1239. 7. Hyyppa TM, Koivikko A, Paunio KU. Studies on periodontal conditions in asthmatic children. Acta Odontol Scand 1979;37:15-20. 8. McDerra EJC, Pollard MA, Curzon MEJ. The dental status of asthmatic British school children. Pediatr Dent 1998;20:281-287. 9. Laurikainen K, Kuusisto P. Comparison of the oral health status and salivary flow rate of asthmatic patients with those of nonasthmatic adults—results of a pilot study. Allergy 1998;53:316-9. 46 NYSDJ • JANUARY 2009

Early Orthodontic Diagnosis and Correction of Transverse Skeletal Problems Antonino G. Secchi, D.M.D., M.S.; Rose Wadenya, B.D.S., M.S., D.M.D. Abstract Rapid maxillary expansion (RME) is an orthodontic treatment commonly used in children to correct skeletal transverse problems of the maxilla. This clinical report introduces an effective way to diagnose and treat skeletal transverse problems achieving an orthopedic response, thereby reducing dental tipping and the need to overcorrect. Two clinical cases are used to illustrate an accurate skeletal diagnosis of the transverse dimension, orthopedic treatment using RME and a rationale for early orthodontic intervention.

ORTHODONTIC DIAGNOSIS and treatment of transverse discrepancies continue to be sources of controversy among orthodontists and other practicing dentists.1 A major part of the confusion about the transverse dimension stems from the fact that most practitioners diagnose transverse problems based on the clinical appearance of teeth, without properly assessing the skeletal width of the maxilla and mandible. Compensatory buccal or lingual inclination of maxillary and/or mandibular

teeth can easily mask an underlying transverse skeletal discrepancy. Therefore, the presence or absence of maxillary crowding, posterior crossbite or constricted arches does not necessarily indicate a transverse skeletal problem or the severity of the discrepancy and should not be used to diagnose the skeletal width discrepancy between the upper and lower jaws. Established skeletal landmarks must be used to properly diagnose the skeletal width of the maxilla and mandible. Broadbent introduced lateral and posteroanterior (PA) cephalograms in the 1930s, which soon became the gold standard for orthodontic skeletal diagnosis in the sagittal and vertical dimensions. However, PA cephalograms were not considered an important part of routine orthodontic record and were mainly used to assess facial asymmetry. Consequently, skeletal diagnosis of the transverse dimension was greatly overlooked. More recently, Vanarsdall2 emphasized the use of PA cephalograms to diagnose the skeletal width of the maxilla and mandible based on skeletal landmarks (Figure 1) and norms (Table I) developed by Ricketts.3 It is important to emphasize that the skeletal diagnosis using a PA cephalogram will not only show the existence of a discrepancy in the width between the maxilla and mandible, it will also show the severity of such discrepancy. The severity of the transverse skeletal discrepancy and the age of the patients are the most important factors in

determining the appropriate treatment (orthodontics, orthopedics or surgery) and the prognosis. Clinical Management of Rapid Maxillary Expansion

Orthopedic expansion of the maxilla is based on application of forces of up to 120 Newton to open the palatal suture and achieve optimal skeletal correction.4 We recommend appliances such as Haas RME (Case One; Figures 2a to 2h) and “bonded” RME (Case Two; Figures 3a to 3h) that utilize the palatal contour for anchorage and produce orthopedic response, minimizing adverse dental tipping. The appliances should be cemented with glass ionomer cement because of its caries-protective effect through fluoride release. The activation is semi-rapid, requiring two turns of the screw daily (.5 mm. opening) for approximately two weeks. It is important to notice that the skeletal response to expansion can be different from one patient to another, depending on factors such age. The younger the patient is, the closer the relationship to 1:1 between expansion at the screw level and skeletal level will be. On the other hand, as the patient matures, the skeletal expansion obtained can be only one-third of the expansion produced at the screw level. Then, post-expansion PA cephalogram is useful to evaluate the amount of skeletal correction achieved. The appliance is left in place for about five months to provide stability and to NYSDJ • JANUARY 2009 47

allow the opened suture to heal through bone apposition. This approach differs from slow maxillary expansion, which does not favor orthopedic correction but, rather, produces buccal tooth movement, which is unstable, and may cause future relapse and potential periodontal problems. Figure 2a. Pre-treatment intraoral frontal photograph exhibiting right unilateral posterior crossbite and mandibular functional shift to patient’s right.

Case One

J.A. (7 years 10 months), a Caucasian male, was referred by his pediatric dentist for an orthodontic evaluation because of a posterior crossbite. His medical history was normal; and he had normal growth and dental development. Clinical examination revealed a unilateral posterior crossbite with a functional shift of the mandible to the patient’s right. As part of the routine orthodontic records, a PA cephalogram was taken to evaluate the skeletal width of the maxilla and mandible. PA cephalogram analysis showed a narrow maxilla (Mx-Mx) 56/61 mm. (patient/norm for his age) and a wide mandible (Ag-Ag) 78/73 mm. The recommended treatment was orthopedic expansion of the maxilla to normalize the skeletal transverse discrepancy. A Haas RME was fabricated and cemented with glass ionomer (Multi-Cure Glass Ionomer Band Cement from Unitek, 3M) to the first permanent molar and the first primary molar. The RME screw was turned twice a day for 14 days. Post-expansion PA cephalogram analysis showed a 5 mm. increase of the skeletal width of the maxilla, from 56 mm. to 61 mm.; and the expander was left in place for five months. Post-treatment intraoral photographs show the correction of the unilateral posteri-

Figure 1. Posteroanterior cephalogram showing skeletal landmarks used to evaluate width of maxilla and mandible. Maxillare (Mx), or J point, located at depth of concavity of lateral maxillae contours, where maxilla intersects zygomatic buttress. Mx-Mx: distance between left and right Mx (mm) that represents skeletal width of maxilla. Antegonion (Ag), or antegonial notch of mandible; defined as innermost height of contour along curved outline of inferior mandibular border, low and medial to gonial angle. Ag-Ag: distance between left and right Ag (mm); represents skeletal width of mandible.

or crossbite and the functional shift of the mandible. In addition, maxillary and mandibular midline alignment was also corrected.No further retention was needed after the RME was removed (Figures 2a to 2h). Case Two

Figure 2c. Intraoral frontal photograph after active orthopedic expansion was concluded. Posterior unilateral crossbite has been corrected and mandible is now centered on facial midline.

L.B. (7 years 3 months), an AfricanAmerican female, was referred by her pediatric dentist for an orthodontic evaluation because of an anterior crossbite. Medical history was within normal range. Intraoral examination showed a pseudo Class III relationship with an anterior crossbite. Upon closing, the upper and lower incisors

TABLE I. Rocky Mountain Norms of Maxillary and Mandibular Widths by Age Age (year)

Maxillary Width (mm)

Mandibular Width (mm)

Difference (mm)

Ratio

9 10 11 12 13 14 15 16

62 62.6 63.2 63.8 64.4 65 65.6 66.2

76 77.4 78.8 80.2 81.6 83 84.4 85.8

14 14.8 15.6 16.4 17.2 18 18.8 19.6

81.60% 80.90% 80.20% 79.50% 78.90% 78.30% 77.70% 77.40%

Rocky Mountain Skeletal Transverse Norms. Widths of maxilla and mandible, as well as difference between them, are expressed in mm. and by patient age. 48 NYSDJ • JANUARY 2009

Figure 2b. Pre-treatment intraoral maxillary occlusal photograph.

Figure 2d. Intraoral maxillary occlusal photograph after active expansion was concluded. Observe opening of Haas RME and diastema between central incisors.

Figure 2e. Post-treatment intraoral frontal photograph showing corrected buccolingual relationships, diastema between central incisors closed and midlines coincident.

Figure 2f. Post-expansion intraoral maxillary occlusal photograph one week after removing RME.

Figure 2g. Pre-expansion PA cephalogram. Maxillary width (Mx-Mx) of 56 mm. (61 mm. norm) and mandibular width (Ag-Ag) of 78 mm. (73 mm. norm).

Figure 2h. Post-expansion PA cephalogram showing increase in maxillary width of 5 mm., from 56 mm. to 61 mm.

made contact at the incisal edge, resulting in a forward movement of the mandible into an anterior crossbite relationship. As part of the routine orthodontic records,a PA cephalogram was taken to evaluate the skeletal width of the maxilla and mandible. PA cephalogram analysis showed a wide maxilla (Mx-Mx) 64/61 mm. (1SD wider than norm) and a wide mandible (AgAg) 80/73 mm. (3SD wider than norm). Though the maxilla was skeletally wider than the norm for the patient’s age,it was not wide enough to harmonize with the mandible.

The normal difference between the skeletal width of the upper and lower jaw at this age is 12 mm.; the patient’s was 16 mm. Therefore, to normalize the transverse skeletal relationship, orthopedic expansion of the maxilla was performed using “bonded” RME. This appliance allows opening of the bite to facilitate labial movement of the upper incisors. The expander was cemented using a fluoride-releasing bonding material (Excel Regular Set Kit from Reliance Orthodontic Products). The RME screw was turned twice daily for 12 days.

A post-expansion PA cephalogram showed a 5 mm. skeletal expansion of the maxilla, from 64 mm. to 69 mm. With the “bonded” RME, the bite was open, thus eliminating anterior interferences, along with the forward functional shift of the mandible. The anterior crossbite was corrected. The RME was kept in place for five months (Figures 3a to 3h). Discussion

Early orthopedic correction of the transverse dimension of the maxilla is valuable because

NYSDJ • JANUARY 2009 49

Figure 3a. Pre-treatment intraoral frontal photograph showing anterior crossbite.

of three factors: growth; function; and periodontal health. The transverse growth of the maxilla is completed earlier than in most of the other maxillofacial structures.5 The greatest growth of the maxilla occurs from 7 to 11 years in males and from 6 to 11 in females, with greater than 95% of total growth attained by 12 years of age.6 It has been reported that children with a functional unilateral posterior crossbite (FUPXB) could develop asymmetric muscle function and growth of the mandible because of the functional shift of the mandible.7 This growth pattern can be intercepted early by orthopedic expansion of the maxilla, allowing the mandible to grow normally.7 Using PA cephalograms and clinical examination, Herberger8 evaluated 55 patients 7 to 10 years post-treatment. These patients had orthopedic expansion between ages 8 and 13.He found significant skeletal expansion of the maxilla when compared to controls. However, when compared with patients who had the expansion done early (before age 10), the older patients (treatment at age 11 to 13) revealed considerable gingival recession in the premolar and molar areas. This occurrence can be explained by the fact that as the palatal suture begins to fuse, there is less skeletal expansion and more dental movement.As teeth move in a buccal direction through the alveolar bone, cortical bone thins out and produces dehiscences with subsequent gingival recession. Therefore, we encourage early correction of transverse problems based on a skeletal diagnosis obtained through PA cephalograms. The future is promising in this regard since new technologies such as the CBCT will allow us to better diagnose and 50 NYSDJ • JANUARY 2009

Figure 3b. Pre-treatment intraoral maxillary occlusal photograph. Notice palatal inclination of central incisors resulting from traumatic occlusal interference with lower incisors.

Figure 3c. Intraoral frontal photograph after active expansion was concluded. Bite is open due to “bonded” RME acrylic’s occlusal thickness. Opening bite allows for labial movement of maxillary incisors, which facilitates correction of anterior crossbite.

evaluate treatment through high-resolution 3D images. Conclusion

A proper skeletal diagnosis of the transverse dimension using specific landmarks on a PA cephalogram is useful to determine the severity of the dysplasia and select the proper treatment. Because of the transverse growth of the maxilla,the potential to correct a transverse skeletal dysplasia is much greater for a 7-year-old patient than for a 12year-old. Early correction of skeletal transverse discrepancies has been shown to help reduce susceptibility to functional and periodontal problems; therefore, early orthodontic diagnosis and correction of transverse skeletal problems should be considered. ■

Figure 3d. Intraoral maxillary occlusal photograph immediately after active expansion was concluded. Notice opening of “bonded” RME. This RME design covers palatal contours with acrylic, both soft tissue palate and occlusal and buccal surfaces of teeth.

Figure 3e. Post-treatment intraoral frontal photograph showing good buccolingual relationships and correction of anterior crossbite.

Queries about this article can be sent to Dr. Secchi at [email protected]

REFERENCES 1. Schiffman PH, Tuncay OC. Maxillary expansion: a meta analysis. Clin Orthod Res 2001;4(2):86-96. 2. Vanarsdall RL, Jr. Transverse dimension and long-term stability. Semin Orthod 1999;5(3):171-80. 3. Ricketts RM. Perspectives in the clinical application of cephalometrics. The first fifty years. Angle Orthod 1981;51(2):115-50. 4. Holberg C,Holberg N,Schwenzer K,Wichelhaus A,RudzkiJanson I.Biomechanical analysis of maxillary expansion in CLP patients.Angle Orthod 2007;77(2):280-7. 5. Edwards CB, Marshall SD, Qian F, Southard KA, Franciscus RG, Southard TE. Longitudinal study of facial skeletal growth completion in 3 dimensions. Am J Orthod Dentofacial Orthop 2007;132(6):762-8. 6. Snodell SF, Nanda RS, Currier GF. A longitudinal cephalometric study of transverse and vertical craniofacial growth. Am J Orthod Dentofacial Orthop 1993;104(5):471-83. 7. Pinto AS, Buschang PH, Throckmorton GS, Chen P. Morphological and positional asymmetries of young children with functional unilateral posterior crossbite. Am J Orthod Dentofacial Orthop 2001;120(5):513-20. 8. Herberger T. Rapid palatal expansion: Long term stability and periodontal implications. Unpublished Thesis, Department of Orthodontics, University of Pennsylvania 1987.

Figure 3f. Post-treatment intraoral maxillary occlusal photograph immediately after removal of RME. Redness of gingiva around teeth on palate is expected and returns to normal in less than week.

Figure 3g. Pre-expansion PA cephalogram. Maxillary width (Mx-Mx) of 64 mm. (61 mm. norm) and mandibular width (Ag-Ag) of 80 mm. (73 mm. norm). Skeletal width of maxilla is 1SD wider than norm. However, skeletal width of mandible is 3SD wider than norm.

Figure 3h. Postexpansion PA cephalogram exhibiting increase in maxillary width of 5 mm., from 64 mm. to 69 mm.

A Multi-Disciplinary Approach to Congenitally Missing Anterior Teeth David Galler, D.M.D.; Caroline Quiong D.D.S.; Jeffrey Galler, D.D.S. Abstract Congenitally missing teeth are not an unusual occurrence. What makes this case study unique is the combination of restorative challenges offered. The patient presented with the permanent upper right cuspid and lower anterior right and left central incisors congenitally missing, and with an underdeveloped upper right lateral incisor.

OFTEN, PATIENTS WHO PRESENT with difficult prosthetic and cosmetic concerns can benefit from a combination of different dental disciplines. Instead of trying to solve cases with a single method of treatment and simply making “the best of it,” dentists today can use several different treatment modalities to help achieve maximum success. This case demonstrates how an adult patient who disliked his three over-retained primary teeth required pre-prosthetic orthodontic intervention prior to restoration with implant, prosthetic and cosmetic dentistry.

Distinctive existing occlusion and

Case Report

tooth alignment difficulties precluded

A healthy 33-year-old male presented with several dental concerns. He had three overretained primary teeth and was congenitally missing their permanent successors. The diminutive appearance of the primary upper right canine and primary lower anterior right and left central incisors had always bothered him (Figure 1). Furthermore, he was unhappy with the esthetic appearance of an underdeveloped upper right lateral incisor, “long” upper central

a simple approach of merely extracting the residual primary teeth and replacing the missing teeth prosthetically. Using orthodontics to create ideal interocclusal and interarch space was critical in preparing this case for prosthetic restoration.

Figure 1. Pretreatment mandibular occlusal.

Figure 2. Pretreatment, anterior view. NYSDJ • JANUARY 2009 51

Figure 3. Pretreatment, right lateral view.

incisors,and a space between the lower right canine and lateral incisor (Figure 2). Examination showed such a deep overbite that the incisal edges of the upper centrals were causing traumatic inflammation to the lower labial gingiva and almost total obscurity of the lower primary central incisors. The lower right canine was distally inclined and had extruded past the occlusal plane into the space of the opposing undersized upper right primary canine (Figure 3). Because there was minimal interocclusal space, the current position of the upper permanent central incisors left only enough interarch clearance for the existing primary central lower incisors; there was inadequate space to accommodate “adultsized” central incisors. The tilt of the lower right canine also prevented replacement of the upper primary right canine with an adultsized canine tooth (Figure 3). Treatment Plan

In order to make this case restorable, orthodontic treatment was imperative. The objectives were as follows: ● To reduce the amount of overbite and attain a more favorable overjet by intruding the upper central incisors and reducing their degree of angulation and proclining them. ● To improve the position of the upper right lateral incisor by moving it closer to the upper right central incisor but to avoid tipping it. This would increase spacing to accommodate a more idealsized canine implant and restoration. ● To upright the distally inclined lower 52 NYSDJ • JANUARY 2009

Figure 4. Post-Invisalign pre-implant stage.

Figure 5. Post-Invisalign pre-implant, interior view.

right cuspid so that it would no longer intrude into the space of the missing upper cuspid and to allow placement of an upper right canine implant and crown. Bone grafting would be necessary to provide sufficient bone for successful placement and integration of an implant in the lower anterior region. Treatment

Treatment objectives were realized through the use of a series of 26 Invisalign1 orthodontic aligners over 12 months. At the first aligner visit, the retained primary teeth were removed and resin pontics were placed into the corresponding spaces of the aligners. The pontics were replaced with each new aligner and provided a satisfactory provisional for the edentulous spaces throughout treatment. The aligners were worn 24 hours a day and were changed every two weeks. They were removed only for eating and for oral hygiene. The overbite was reduced; the overjet improved; and judicious use of interproximal reduction (IPR) improved the alignment of the upper incisors (Figure 5). Careful creation of .3 mm. of interproximal space between teeth #7 and #8 and between teeth #8 and #9 allowed for stable contacts without changing the curvature or anatomy of the teeth. This was accomplished by using Qwik-Strips,2 which allow for minimal tooth reduction precisely at the contact points without damaging the facial or incisal aspect of a tooth. “Ledging,” a common occurrence when performing IPR, is also avoided when using this method.

Figure 6. Post-Invisalign pre-implant crown, right lateral view.

Figure 7. Final result, mandibular, occlusal view.

The lower right canine was successfully tipped mesially to close the canine-lateral space and provide sufficient room for the opposing upper right canine implant and crown (Figure 6). Between weeks 50 and 52, the patient whitened his teeth, using the take-home Nite-White3 bleaching system. He was able to use his aligners as his whitening trays. The appearance of the underdeveloped upper right lateral incisor was improved with resin bonding. A synthetic bone substitute was placed in the lower anterior region. A single 3.75-

Figure 8. Final result, anterior view.

x-13 MIS4 implant was placed in the lower central incisor area (Figure 4) and a 3.75-x11.5 MIS implant was placed in the upper right canine edentulous area. A porcelainfused-to-gold crown was shaped to resemble two, individual central incisors and was used to restore the single lower central implant (Figure 8). A porcelain-fused-togold crown was used to restore the upper canine implant (Figure 9). After treatment, Invisalign retainers were worn at night to hold all teeth in their new position. Discussion

This case illustrates a successful,multi-disciplinary approach to a very complex restorative challenge. By using orthodontics, oral surgery,prosthetics and cosmetic dentistry,a highly satisfactory result was achieved. Comprehensive evaluation and thorough treatment planning were crucial. If the primary teeth were simply removed

and replaced with implants or removable prostheses, the case would have been doomed to failure because the pre-treatment occlusion did not allow for the proper clearance needed to restore this case. Using orthodontics first to create ideal interocclusal and interarch space was critical in preparing this case for prosthetic restoration. To that end, the Invisalign appliance served as an important and patient acceptable adjunctive appliance. The Invisalign appliance helped position the teeth and served as a provisional restoration, and aided in cosmetic whitening and retention once orthodontics was completed. ■ Queries about this article can be sent to Dr. David Galler at [email protected]

REFERENCES 1. 2. 3. 4.

Align Technology. California, USA. Axis Dental. Texas, USA. Discus Dental. California, USA. MIS Implants Technologies Ltd. Shlomi, Israel.

Figure 9. Final result, right lateral view.

NYSDJ • JANUARY 2009 53

Treatment of Gingival Recessions by Guided Tissue Regeneration and Coronally Advanced Flap Ali Banihashemrad, D.D.S., M.Sc.; Ershad Aghassizadeh, D.D.S.; Mehrdad Radvar, D.D.S., Ph.D. Abstract

depth; clinical attachment level; width of keratinized gingiva;

Gingival recession refers to the denudation of root surface

and width of recession.

caused by apical migration of the gingival margin as a

After six months, recession depth showed a mean

result of destruction of the covering gingival tissue of the

reduction of 67.88% and 57.42% in the “GTR + CAF” and

affected area. It is among the most frequent problems pre-

“CAF alone” groups, respectively. The mean difference

sented by periodontal patients and may have different eti-

between the groups was 1±0.33 mm (P=0.03).

ologies and sequels. So far, several techniques have been

The results of this study indicate that Miller’s Class I &

devised and tested to treat gingival recession. The aim of

II gingival recessions are amenable to treatment using the

this study was to assess the effectiveness of using a GTR

GTR technique with satisfactory outcome.

resorbable collagen membrane in conjunction with coronally advanced flap (CAF) as compared to CAF alone in the treatment of Miller’s Class I & II gingival recessions. Seven patients took part in the study, each providing either two or four facial recessions of 3 mm. to 6 mm., totaling 11 pairs of gingival recessions. The two paired sites within each patient were randomly assigned to one of the two treatments mentioned above. Prior to and six months after treatments, the following clinical parameters were measured and recorded: recession depth; probing pocket 54 NYSDJ • JANUARY 2009

GINGIVAL RECESSIONS have been treated successfully using several techniques. Evidence from human clinical studies indicate that, depending on the clinical conditions and the surgical approach, an outcome of 43% to 98% coverage could be achieved.1-12 All treatment techniques could be categorized in two main groups: free grafts and pedicle flaps. Pedicle flaps have been further divided into rotational and advanced flaps.2 Soft tissue free grafts, usually harvested from the patient’s palate, include connective tissue— epithelial and connective—grafts.3 The guided tissue regeneration (GTR) concept has been adopted for the treatment of gingival recessions.4-6 Treatment of denuded roots was first accomplished in monkeys using the GTR method.7 Since then, several clinical human studies have documented the use-

fulness of ePTFE barrier membranes in treatment of gingival recessions.8-9 The GTR principle in the treatment of this type of lesion includes attainment of new connective tissue attachment (CTA) and root coverage.10 Histological evidence indicated establishment of periodontal regeneration, including new CTA, new cementum and new bone formation on the previously exposed roots. The first clinical attempts to use the GTR technique using ePTFE membranes resulted in a modest success of 55% root coverage.8 However, through modification of the flap and more extensive root planing and bending of the membrane to provide space, a 72.7% root coverage was obtained.9 A non-resorbable membrane is less favorable than the bioabsorbable membranes, because a second surgical visit is required in the former.12 Bioabsorbable collagen membranes have been used in animal13 and human studies14 to regenerate periodontal defects. The aim of the study presented here was to evaluate a GTR treatment using a bioabsorbable membrane in conjunction with a coronally advanced flap (CAF) to treat gingival recession defects (Miller’s Class I and Class II defects).

horizontal periosteal-releasing incision and secured by orthodontic brackets and sutures. In the control group, the coronally advanced flap without the GTR membrane was used. Prior to surgery, at the mid-facial aspect of the teeth, the following clinical parameters were measured to the nearest millimeter using a William’s periodontal probe: ● Visible recession—distance between CEJ to gingival margin. ● Probing pocket depth. ● Keratinized gingiva width. ● Horizontal width of recession defect at the CEJ. ● Clinical attachment level. These measurements were repeated in both groups after six months. The same examiner conducted the examinations blindly. The examiner had been instructed to perform the probings using a calibrated periodontal probe with a gentle force of about 20 gr. Data analysis was performed using statistical software (Minitab, version 9.2). A paired t-test was used to elucidate significant differences in any of the aforementioned parameters after the GTR+CAF and CAF groups. Improvements after the two treatments were compared using the paired t-test.

Materials and Methods

This study was performed in the Periodontics Department of Mashhad Dental School in Iran in 1997. The participants were selected from patients referred to the department for treatment of facial gingival recessions. The study protocol had been approved by the Mashhad University Ethical Committee, and each patient signed an informed consent form prior to the study. A split-mouth design was used in the study. The patients were required to be nonsmokers, have a full-mouth plaque score of less than 15% and not have received any medication known to interact with periodontal treatment during the past six months. Another criterion for inclusion was to have a pair of bilateral facial gingival recessions of Class I or II, according to the Miller’s classification. The two recession defects were randomly assigned to receive either the test or control treatments using a coin toss. In each of the test patients, one recession defect was treated using a GTR collagen membrane (Paroguide, Coletica, Lyon, France) in conjunction with a coronally advanced flap (GTR+CAF).In each of the control patients, the recession defect was treated using the CAF alone. All of the patients received a full initial periodontal preparation consisting of oral hygiene instruction and scaling and root planing. If the width of keratinized tissue was judged to be inadequate, a free gingival graft was harvested from the palate and inserted on the study site. Four patients (cases No. 2, 7, 8 for both control and test sites and case No. 3 for the control site only) received the gingival augmentation procedure two months prior to the root coverage surgical procedure. The surgical technique in the GTR+CAF group consisted of reflection of a mucoperiosteal flap and reduction of the convexity of the root using a slow-speed handpiece when required. The bioabsorbable membrane was fitted and inserted on the defect and secured using sling sutures, and the flap was advanced coronally by

Results

After screening, a total of seven patients (one female and six males) were included in the study. Three patients had one pair of gingival

NYSDJ • JANUARY 2009 55

TABLE 1 Mean Recession (mm) and Standard Error of Mean (SEM) before and 6 Months after Treatments Treatment

Recession Height Presurgery Postsurgery

GTR +CAF

4.46±0.31

1.46±0.31

CAF alone

3.64±0.20

1.64±0.36

Group Difference

1.00±0.33 P=0.013*

Coverage

P value

3.00±0.36