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Annual r e vi e w of s el ect ed dent al l i t erat ure: Report of the

Commi t t ee on Sci enti fi c I nves t i gat i on of the Ameri can
Academy of Res t orat i ve Dent i s t ry
Malcolm D. Jendresen, DDS, PhD,* Edward P. Allen, DDS, PhD,
Stephen C. Bayne, MS, PhD, Terence E. Donovan, DDS,
Tore L. Hansson, DDS, Odont Dr, Judson Klooster, DDS, and
John C. Kois, DMD, MSD
San Francisco, Calif.
Ea c h year t he Commi t t ee on Scientific Invest i ga-
t i on for t he Academy of Rest orat i ve Dent i st r y publ i shes
t hi s review of t he l i t er at ur e presumed to be of i nt erest to
our Academy members. The aut hors of t hi s review base
t hei r comment s on t he maj or medi cal and dent al j ournal
art i cl es of 1994 t hat were publ i shed and di st r i but ed to
heal t h science l i brari es in t he Uni t ed St at es before t he end
of t he cal endar year. The sel ect ed references are of pub-
l i shed art i cl es t hat we t hi nk reflect t he best exampl es of
wel l -conduct ed research and some exampl es i l l ust rat i ve of
poorl y conduct ed research. We at t empt ed to exclude
r edundant work, but i ncl uded confirming st udi es and rel-
evant review articles. Again, t hi s year' s l i t erat ure review
feat ures edi t ori al comment . The commi t t ee agai n reviewed
several hundr ed art i cl es t hi s year and chose less t han 350
in t hi s report .
Ther e was some unusual emphasi s in t he l i t erat ure t hi s
year. Ther e was concern for scientific ethics. 1 There was
at t ent i on being pl aced on more formal adherence to scien-
tific met hods at uni versi t i es. 2 Specifications of dent al ma-
t eri al s cont i nue to evolve qui ckl y as t he Eur opean Common
Mar ket at t empt s to set st andar ds for doing business. 3
Ther e was i ncreasi ng pressure to devise more meani ngful
bi ocompat i bi l i t y tests. 4' 5
If t here was one st ri ki ng feat ure about t he l i t erat ure in
1994, it was t hat numerous excel l ent reviews were pub-
lished. Thi s i ncl uded i nformat i on on pul p biology, 6-7 mi-
crobiologic predi ct ors of caries risk, S composites, 9 est het -
ics, 1~ dent i ne bondi ng systems, 11 dent i n permeabi l i t y, 12
amal gam bondi ng recommendat i ons, 13 amal gam t oxi ci t y
issues, 14 glass i onomer appl i cat i ons, 15,16 calcium hydroxi de
liners, 17 bi ocompat i bi l i t y of composites, Is and l i t erat ure
analysis.19, 20
Presented at the American Academy of Restorative Dentistry
meeting, Chicago, Ill., February 1995.
*Committee Chairman. Other authors of this article are Commit-
tee members.
J PROSTHET DENT 1995;74:60-99.
Copyright | 1995 by The Editorial Council of THE JOURNAL OF
0022-3913/95/$3.00 + 0. 10/ 1/ 64436
Once agai n i t is necessary to r epeat t hat t hi s is a review
of t he past year' s dent al l i t erat ure. Thi s is not i nt ended as
a comprehensi ve report on any one i nvest i gat i on or pub-
lished work. Each year we hear from some di sgrunt l ed in-
vest i gat or / aut hor whose work was not i ncl uded or was not
report ed in t he det ai l t hey hoped to realize. The i nt ent of
t he r epor t is to guide our academy members t owards t he
areas of i nvest i gat i on t hey wish to pursue in great er dept h.
The caries preval ence in U.S. school chi l dren remai ns
low; however it cont i nues to be recognized t hat a di spro-
port i onat e di st ri but i on of chi l dren bear t he br unt of t he
disease. Hi cks and Fl ai t z 21 In t hei r review concl uded t hat
17 % of Ameri can chi l dren and adol escent s exhi bi t ed 67 %
of t he t ot al caries experience. Si mi l arl y, Capl an and Wei n-
t r aub 22 found t hat 25 % of t he count ry' s chi l dren have 75 %
of t he disease. These reviewers also concl uded t hat mi nor-
ities, rural i nhabi t ant s, t hose wi t h mi ni mal fluoride expo-
sure, and t hose from less educat ed and less affluent fami -
lies have a hi gher caries incidence. Caries experience is also
low in ot her i ndust ri al i zed countries; however, report s from
t he Net her l ands 23 and Engl and and Wal es 24 i ndi cat e t hat
caries in t hei r young chi l dren has stabilized. Whet her a
si mi l ar t r end is occurring in U.S. school chi l dren needs to
be addressed.
The current epi demi ol ogi c pi ct ure of dent al caries illus-
t rat es t hat t he risk of occlusal caries has ext ended into t he
late- and post -t eenage years. St ahl and Katz, 25 reviewing
t he dent al records of 17- to 23-year-ol d st udent s at t he U.S.
Coast Guar d Academy, found t hat occlusal caries, in t he
absence of proxi mal caries, was fairly common (11.9%) in
molars. For eman 26 found t hat one t hi rd of U.S. Air Force
personnel younger t han 26 had occlusal caries. Bot h art i -
cles st ressed t he need for seal ant s in this older age group.
The epi demi ol ogy of caries in mat ur e adul t s and seniors
cont i nues to be st udi ed, wi t h report s of coronal caries in-
cidence in bl ack and white Nor t h Carol i ni ans 27 and root
caries preval ence in New Engl anders. 2s
The di spr opor t i onat e di st r i but i on of dent al caries indi-
cates t he need for rel i abl e screeni ng predi ct i ve met hods to
identify individuals at a higher caries risk. Studies of pos-
sible caries predictive methods for coronal caries in pre-
school, 2931 and school-age children 32, and root caries in
adults 33 have been reported. Although dietary factors, sal-
ivary mutans streptococci and lactobacilli, and various fa-
milial factors have been studied, the variable of greatest
predictive value appears to be the past caries history. 3133
Van Houte, s in a review (102 references) of microbiological
factors, specifically mutans streptococci and lactobacilli, as
predictors of caries risk, concluded that they are not reli-
able caries risk indicators for individuals but might be
promising for evaluating the caries risk of groups, s Studies
continue to demonstrate the reliability of the clinician's
ability to identify caries risk subjects without the use of
saliva tests but with just the information normally avail-
able at a dental examination. 34
With the changes in the epidemiology of dental caries,
the ability to arrest initial lesions, and the increasing use
of sealants, the need to properly diagnose lesions, especially
at an early stage, is essential. To this end, several review
articles have addressed the issue of caries detection in oc-
clusal surfaces, 35 approximal and occlusal coronal surfac-
es, 36 and root surfaces, s7 Standard and new methods of
caries detection methods have been studied, usually with
extracted teeth that can be sectioned to histologically ver-
ify the presence of caries. Lussi 3s showed that common
methods of detecting fissure caries, including visual-tactile
examinations, fail to accurately detect lesions that do not
exhibit definite macroscopic cavitation. Espelid et al. 39
showed that radiographs were of value for detecting oc-
clusal caries that extended into dentin, but that there was
great variation in the diagnostic ability of individual den-
tists who were confronted with the same set of radiographs.
Electrical resistance measurements (ERM) and visual in-
spection were compared with radiographic evaluation of
occlusal surfaces of third molars in another studyJ ~ ERM
had the highest sensitivity (ability to identify disease when
it exists), and visual inspection had the highest specificity
(ability to not wrongly identify disease when it does not
exist). A meta-analysis of 10 published studies of occlusal
caries detection found that ERM and fiberoptic illumina-
tion showed good sensitivity and specificity performance,
whereas the performance of xeroradiography was poor. 41
Considering the generally low caries rates, the value of a
conservative radiographic diagnostic approach has been
assessed. In one study, 4~ 14-year-old patients with a low
caries experience received a clinical and a radiographic ex-
amination with conventional and digital bitewing radio-
graphs. Two to three times more lesions were detected with
the radiographs than with the clinical examination alone.
However, the number of lesions extending into the dentin,
and therefore requiring restorative care, was low. Less than
2 % of the lesions requiring restoration were detected by
the inclusion of radiographs, and it was recommended that
in children with low caries risk, bitewings should be used
only when lesions are suspected. A study 43 of 490 adult
dental school patients compared a full-mouth radiographic
survey and the Food and Drug Administration's (FDA)
recommended survey, which uses fewer radiographs. For-
ty-four percent (1244 teeth) of the carious teeth were de-
tected by the radiographic examination alone. However,
the shorter FDA series missed detection of 93 lesions, of
which 36 extended into the dentin and required restorative
The use of pit-and-fissure sealants remains the newest
caries prevention method; however, the use of fluoride var-
nishes, although not new internationally, is the most recent
caries prevention method introduced to American dentists.
Both caries preventive approaches have been studied in
recent clinical trials. In a 3-year program, a glass-ionomer
sealant showed a caries reduction of 66.5 % but required
reapplication because of poor retention. 44 A glass-ionomer
and a resin-based sealant were evaluated in a 2-year half-
mouth comparison. Twenty-six percent of the glass-iono-
mer and 82% of the resin-based sealant were totally
present at the end of the study, confirming the low reten-
tion of glass-ionomer sealants. However, the caries reduc-
tion achieved was the same for both sealants. This may
have been because of the different mechanism of caries
prevention for the two products, because the glass-ionomer
sealant releases fluoride, or it may have resulted from the
generally low caries experience of the subjectsJ 5
Although a resin-based sodium fluoride varnish has been
proved effective in inhibiting caries in numerous clinical
trials, its fluoride concentration, 22,300 ppm, is the highest
of any of the professionally applied topical fluoride agents.
In a 2-year clinical trial t6 the caries inhibition of a standard
concentration fluoride varnish was compared with one with
half the fluoride concentration. The subjects received three
annual treatments. There was no significant difference in
the 3-year caries increment of the two treatment groups,
suggesting that a lower concentration fluoride varnish
might be feasible.
In addition to the several reviews already cited, several
other reviews dealing with the use and success of caries
prevention methods, the epidemiology of root and coronal
caries, and caries detection and prediction have been pub-
lished (see especially the Journal of Dent al Research,
March 1994; the Int ernat i onal Dent al Journal, suppl. 1,
December 1993; Advances in Dent al Research, July 1993;
Journal of the American Dent al Association, Suppl., Au-
gust 1994). Of special interest are three reviews that
address issues of genetics and dental caries. Russell 47
reviewed the application of molecular genetics, the in vitro
manipulation of DNA, to the oral microbiota, especially
Streptococci mutans. Sofaer's review 4s focuses on the
ability of host genes to influence caries susceptibility in in-
dividuals, and Mandel's review 49 summarizes the evidence
supporting a relationship between caries susceptibility and
human genetic factors, possibly mediated through saliva.
All three reviews offer unique perspectives on caries infec-
tion and host relationships.
J U L Y 1 9 9 5 6 1
Pulp biology
Again this year, the theme emphasized in pulp biology
research has been in vitro studies on extracted teeth deal-
ing with bonding systems and dentin permeability. Be-
cause of the diverse designs of these studies in recent years,
and the varied conclusions they appeared to support,
Stanley 6 authored a review article. He outlined the com-
mon outcomes resulting from current and recent research,
many of which coincide with, and thus validate, the
subjective observations of practitioners. These studies
have shown that high-speed cutting techniques are supe-
rior to low-speed techniques even when both incorporate
air and water coolant sprays, pressure in condensing
restorative materials intensifies pulpal responses induced
by the cutting procedure, and that chemically self-cured
resin composites requiring the application of a matrix to
enhance adaptation intensify pulpal response as compared
with visible light-cured equivalents applied incrementally,
fully cured throughout, and not requiring the pressure of
a matrix.
Stanley 7 offered further understanding of current re-
search in another review article. He reminds readers that
only a few millimicrons of the dentin surface need to be al-
tered in the surface preparation for bonding agents; there-
fore techniques should be used that merely remove or
modify the smear layer without removing the dentin plugs.
Active rubbing and scrubbing of the surface "appear to be
contraindicated; passive soaking of the conditioning solu-
tion on the dentin surface is adequate." This review also
offers some cogent observations concerning hypersensitiv-
ity of restored teeth.
White et al. 5~ reported a study to observe the degree of
pulpal healing after pretreatment of vital dentin before
placement of two composites (All-Bond and Scotchbond).
The authors noted no statistically significant differences in
pulpal response between teeth when All-Bond was used as
a dentin bonding agent, whether used on damp or air-dried
dentin, or in comparison with Scotchbond composite. They
considered all materials and treatment procedures used in
this in vivo animal study biologically acceptable under
ADA, FDI, and ISO guidelines.
Paul and Scharer 51 called attention to the failure of many
current research projects to include the consideration of
intrapulpal pressure as a factor contributing to fluid seep-
ing out of the dentinal tubules. This study of shear bond
strengths of 10 commonly used (and one experimental)
dentin bonding agents was designed to recognize this fac-
tor and to replicate in vitro the wetting effect of such den-
tidal fluid seepage. The bond strengths reported from this
project were lower than those reported from other studies.
One obvious value of this study was the development and
application of a research design to replicate intrapulpal
pressure toward the treated cavity surface in a laboratory
Mukai et al. 52 studied 22 permanent teeth (11 vital and
11 nonvital) to compare the fluoride level differences in
pulpal dentin. With the use of an abrasive microsampting
technique, a carefully controlled design was used to ensure
that specimens would not have been exposed to the mouth,
to isolate the role of pulpal circulation, to convey fluoride
ions to pulpal dentin. In this study teeth were obtained
from patients 20 to 73 years of age. The authors reported
that "fliuoride levels were significantly higher in vital than
non-vital teeth for each age group" and observed increases
of fluoride level with age. There was little difference of flu-
oride level between vital and noavital teeth. Hatton et al. 53
studied the effect of handpiece pressure and speed on the
intrapulpal temperature rise during finishing of class V
amalgam restorations. Finishing was done dry with a brown
rubber point; remaining dentin thickness was standardized
at 2.0 ram. Handpiece speeds varied from 7000 to 15,000
rpm. Reinforcing an old theme with this recent study, the
authors concluded that "to minimize pulpal damage, con-
tinuous contact time of finishing should be kept to less than
15 seconds and low to moderate pressure applied."
Pr e ve nt i ve de nt i s t r y
Emphasis in 1994 literature centered on the use and
evaluation of antimicrobial mouth rinses instead of analy-
ses of oral hygiene strategies, systemic uptake of fluoride,
and local application of fluorides and other caries inhibi-
tors. One might speculate that this shift of emphasis results
from the established levels of acceptance and efficacy of
fluoridation and from the proven outcomes of sealant
Mandrel 54 reminds us that "the antimicrobial era began
with Joseph Lister and Louis Past eur"--i t is not a new
theme. His article is an excellent review and update
concerning the use of antimicrobial mouth rinses. He notes
that limitations on mechanical plaque control compel our
attention to antibacterial agents that "supplement the
purely patient-dependent mechanical regimen." Although
mouth rinses were long considered to have an effect too
transitory to be taken seriously, the establishment in 1985
of formal standards and testing requirements by the ADA
Council on Dental Therapeutics for the testing and accep-
tance of antiplaque/antigingivitis agents brought a marked
change in this perspective. "The ADA Guidelines require
at least two 6-month, double-blind clinical studies to
establish a statistically significant reduction in plaque and
gingivitis, microbial monitoring to ensure that neither re-
sistant nor pathogenic opportunistic organisms emerged,
and that all the ingredients were safe to use."
Mandrel 54 describes the basic categories of mouth rinses,
notes their recognition or lack of it by the ADA Seal of Ac-
ceptance program, and discusses the relative effectiveness
of each. The use of additives that increase substantivity
(bioadhesives) may also increase the efficacy of mouth
rinses. In citing our need to learn more about the molecu-
lar mechanisms involved in plaque initiation and growth,
he notes that "the target organisms still are not fully
defined" and encourages further study.
Fine 55 observes that mechanisms of microbial action
have been studied in in vitro projects that may find valid
extrapolation to the oral environment. He discusses the
desirable characteristics of substantivity (binding to tissue
surfaces to produce sustained activity over time), penetra-
bility, and selectivity (ability of a drug to focus specifically
on target bacteria). He concludes by noting that the ulti-
mate test is to determine the effect of the agent in the oral
In an editorial piece, an English author, Abbrey
Sheiham, 56 says that "the recent sharp fall in the preva-
lence of the two main dental diseases in industrialized
countries calls for a radical revision of preventive dentist-
ry." He reviews various indices of improved health status,
but suggests that no evidence exists that better treatment,
preventive care, or increased dental manpower have con-
tributed significantly to those improvements. He suggests
that in the future, dentists should do fewer restorations and
observe what he calls a "central tenet of modern preventive
dentistry"--to avoid intervening before prevention has
been given a chance to work. He further recommends that
dentists' preventive practice should be confined to super-
vising auxiliaries who apply fissure sealants to selected
children and carry out simple preventive procedures. One
might ask how he validates this recommendation after
having castigated all previous preventive efforts as being
ineffective and unrelated to the improved status of oral
health he cites. Still, his comments are worthy of some note
because they were published in a medical journal where
they may have some influence on future health policy for-
mulations. The schema of delegating most or all procedural
treatment to dental auxiliaries may sound attractive, but
the political constraints of the profession and its regulatory
agencies quite possibly may regard this as an idea who time
has not come!
Cellaret et al. 57 report a study to test the dose-response
effect of topical application of delmopinol HC1 on the sal-
ivary microbiology. Forty-eight healthy subjects were en-
rolled in an oral hygiene program to upgrade their oral
health. After professional tooth-cleaning, they abstained
from all oral hygiene but applied 2 ml of a placebo passively
with a soft paintbrush twice daily for 2 weeks. Then each
was given another tooth cleaning, and the study group was
divided into three treatment groups of 16 individuals each.
They applied 2 ml of 0.1%, 0.5 %, and 1% delmopinol HC1
respectively, twice daily for the next 2 weeks. At the end of
this period, saliva samples were obtained and cultivated,
degree of gingivitis was measured, the stainable buccal
plaque extension was analyzed planimetrically, and the
bacterial morphotypes of plaque adjacent to the gingival
margin were analyzed. From the results of this study, the
authors concluded that "the short-term use of delmopinol
promotes healing of preestablished gingivitis, reduces
plaque formation, and delays plaque maturation without
detectable changes in the salivary microflora."
Chlorhexidine (CHI) has demonstrated its efficacy as an
antimicrobial mouthwash; reports on its use began to ap-
pear in the late 1960s and early 1970s. Use in the United
States has been approved by the Food and Drug Adminis-
tration and the ADA Council on Dental Therapeutics; it is
available by prescription in a 0.12% formulation. Some
dentists and periodontists have conjectured how its use-
fulness might be more widespread if it were available to the
U.S. public on an over-the-counter basis. Albandar et al. 5s
report the use of CHI in Norway, where it has been avail-
able without prescription in a 0.2 % mouthwash and a 1%
gel for nearly 20 years.
Approximately 10% of all dentists registered in Norway
were selected randomly after the population was stratified
by age, gender, specialty field, and place and type of prac-
tice. Responses were received from 354 dentists (78% of
459 sampled); 14% of these reported they never recom-
mend CHI to their patients. Of those responding, 85 % re-
ported using it often (in most patients) or routinely (in all
patients) after surgical periodontal procedures, 74 % when
treating acute gingivitis, and 35 % during nonsurgical pe-
riodontal therapy. It was also used in other treatment pro-
tocols, such as oral surgery (57 % of dentists use it routine-
ly), stomatitis (73 % reported using it frequently), and in
treating herpes simplex infections (54%).
Seventy-seven per cent of the dentists commented on the
staining of teeth, restorations, and tongue as a "major"
disadvantage. However only 27 % of the dentists reported
that they had "often seen', staining of the teeth. Other re-
ported disadvantages included dentists who cited the bit-
ter taste (12 % ) and those who reported that patients com-
plained of other disturbances such as dryness of the mouth
and the development of oral ulcerations. Dentists identi-
fied four areas in which CHI appears most useful: short-
term plaque control, long-term plaque control, control of
fungal infection (stomatitis), and treatment of acute gingi-
vitis. Nearly half of all dentists sampled used CHI for a
short course of plaque control lasting 1 to 2 weeks.
The large majority (94%) of the dentists surveyed
recommended CHI as a mouthwash; only 6% commonly
recommended the gel form. Only 4% of the dentists
recommended their patients to dilute the mouthwash to
obtain a 0.1% concentration; 96% recommended the stan-
dard commercially available 0.2 % formulation. The author
comments that the incidence of local side effects is thought
to be concentration-dependent and therefore suggests that
the USA regimen "may achievetherapeutic effects compa-
rable to those achieved with higher concentrations, never-
theless inducing less pronounced side effects."
Epstein et al. 59 cite the difficulties in maintaining ade-
quate oral hygiene levels among hospitalized patients, par-
ticularly those who are medically compromised or immu-
nocompromised. These problems have caused frequent
neglect of the institutionalized or hospitalized patient.
Foam brushes have been recommended to address this
need, but the foam brush has not been shown to be the
equivalent of a more conventional toothbrush. These
J ULY 1995 63
authors report the study of a daily hygiene protocol that
combines the use of the foam brush with the use of chlo-
rhexidine. The study involved 27 persons on the hospital
dental staff who volunteered to participate in a 2-week
randomized, crossover study to compare the use of a
toothbrush and a foam brush soaked with chlorhexidine.
The authors report that their results indicate that the foam
brush with chlorhexidine was equally as effective as an or-
dinary toothbrush in maintaining a low measure of gingi-
vitis and plaque levels. They recommend, as a sequel to this
study, that controlled studies be done among hospitalized
and immunocompromised patients.
Epi de mi ol ogy
Specific risk indicators associated with either suscepti-
bility or resistance to severe forms of periodontal disease
were evaluated in a cross section of 1426 subjects, 25 to 74
years of age residing in Erie County, New York, and sur-
rounding areas. 6~ The results showed that age, smoking,
diabetes mellitus, and the presence of Porphyromonas
gingivalis (Pg) and Bacteroides forsythias (Bf) were risk
indicators for loss of clinical attachment level (CAL). These
associations remained valid after controll for gender,
socioeconomic status, income, education, and oral hygiene
A prospective study was conducted among 700 ambula-
tory HIV-infected individuals seeking dental care. 61 The
prevalence rate of necrotizing ulcerative periodontitis
(NUP) was 6.3 %. The findings of a lower incidence of this
lesion among patients taking antibiotic medication, such as
Bactrim, and the effectiveness of local debridement, oral
rinses with chlorhexidene (CHI) and oral administration of
metronidazole (M) indicate a microbial etiology. The pre-
dictive value of a CD4+ cell count below 200 cells/mm 3 in
patients with this lesion was 95.1%. A cumulative proba-
bility of death within 24 months of a NUP diagnosis was
72.9%. Thus, the presence of NUP in HIV-infected indi-
viduals is a predictable marker for immune system deteri-
oration and disease progression.
In a retrospective study over a 3-year period, 23 cases of
localized juvenile periodontitis (LJP) were diagnosed from
a group of 5480 subjects with different forms of periodon-
tal disease in Saudi Arabia. 62 The overall prevalence of LJP
was 0.42% and the female to male ratio was 1.88:1. It is not
possible to hypothesize that this study is truly representa-
tive of the general population of Saudi Arabia, because the
determination of disease prevalence was performed on a
population specifically referred for treatment of disease.
However, the results are similar to the 0.53% prevalence of
LJP recently reported in U.S. adolescents.
Et i ol ogy a nd r i s k f a c t or s
Although putative periodontal pathogens are often iso-
lated from individuals with severe periodontitis, they also
frequently inhabit the subgingival environment and are not
always associated with advanced disease. However, through
prospective studies, results that directly implicate specific
bacteria with progressive periodontitis under certain envi-
ronmental conditions are starting to accumulate. Longitu-
dinal data indicate that individuals with Pg, when com-
pared with those without this species in their subgingival
plaque, are more at risk of losing CAL. 63 A number of other
specific bacteria may also be considered significant risk
factors for periodontitis. These species include PrevoteUa
intermedia (Pi), ActinobaciUus actinomycetemcomitans
(Aa), Eikenella corrodens, Fusobacterium nucleatum, Bf,
Campylobacter rectus, and Treponema species.
The distribution of Aa infection in patients with period-
ontitis was determined by culture of plaque samples from
all teeth in 46 subjects including 16 adult patients with pe-
riodontitis, 14 patients with early onset periodontitis
(EON), and 16 periodontally healthy subjects. 64 By sam-
pling all teeth, this is one of the first studies to describe the
distribution of Aa throughout the dentition. The findings
indicated that Aa occurred in the highest frequency and
proportions at molar and incisor sites irrespective of di-
sease category, although the Aa colonization was broader
in the adult periodontitis patients than the EOP patients.
The basis for this distribution has been suggested to result
from the temporal nature of the molars and incisors erupt-
ing earliest into the infected oral cavity.
The microbiota was assessed at sites with progressive
attachment loss in periodontitis-susceptible subjects. 65
The approach taken in this investigation was to identify
subjects with advanced periodontitis who exhibited active
progressing loss of CAL >2 mm at multiple sites during two
consecutive 12 month-intervals. These subjects were dif-
ferentiated from those in whom advanced periodontal dis-
ease was present at baseline but progression could not be
detected. This was accomplished by a comprehensive clin-
ical monitoring of 300 subjects at six sites per tooth at an-
nual examinations. A group of eight individuals who
fulfilled the criteria for progressive disease was thus iden-
tified as were 11 age- and sex-matched control subjects who
presented with advanced disease at baseline but were sta-
ble at all sites at all three examination intervals.In this
analysis, no difference could be observed in the subgingi-
val microbiota in the subjects who exhibited disease
progression when compared with the subjects with perio-
dontal disease but stable conditions. In addition, no
marked difference could be noted between progressive and
nonprogressive sites in the disease progression subjects.
To date no specific host genetic risk factors have been
identified for adult chronic periodontitis. 66 However, par-
ticipation of hereditary components in EOP was suggested
by a study of the frequency of human leukocyte antigen
(HLA) class II serotype and the variation of HLA class IIB
in 70 Japanese patients with periodontitis and 26 individ-
uals with periodontal health. 67 The results suggested that
intronic gene variations may be useful as gene markers for
a subpopulation of EOP patients and may affect immune
reactions such as antigen recognition.
In previous cross-sectional studies, it has been shown
that poorly controlled insulin dependent diabetics (IDD)
and non-insulin dependent diabetics (NIDD) with elevated
blood glucose and glycosylated hemoglobin (HBA1) levels
exhibit more loss of CAL and alveolar bone than controlled
diabetics. In a 2- year longitudinal study, a poorly con-
trolled IDD group had more sites with loss of proximal al-
veolar bone than the controlled IDD group. 6s The results
of this study also suggested that periodontal therapy did
not significantly improve the HBA1 or blood glucose levels
in the poorly controlled IDD group. The association of pe-
riodontal disease and diabetes was evaluated in a cross-
sectional study of 100 NIDD patients divided into four
groups according to age and years since diagnosis of diabe-
tes. 69 It was concluded that years since diagnosis of diabe-
tes is more significant than age for severity of periodontal
disease in NIDD patients.
Current knowledge about tobacco and periodontal dis-
ease, based on more than 10 years of research, strongly
suggests that tobacco and tobacco smoking is associated
with both an increased risk of developing disease and an
increased risk of not responding favorably to therapy. Al-
though the mechanism of action is not known, information
available to date indicates that tobacco primarily has a
systemic influence affecting host response or susceptibili-
ty. 70 The relationship between cigarette smoking and peri-
odontal disease was assessed in 82 regular dental patients,
21 smokers, and 61 nonsmokers. 71 Plaque levels were equal
for both groups but smokers had significantly more sites
with loss of CAL. A group of 273 subjects was followed up
for 10 years to determine the relationship of smoking and
tooth loss. 72 Age, plaque, and smoking seemed to have ma-
jor impacts on tooth loss. People with poor oral hygiene lost
more teeth if they smoked than if they did not smoke.
Among younger male smokers, the association between
smoking and tooth loss was strong. The findings of this
study suggest that smokers, especially those under 50 years
of age, are a high-risk group for tooth loss.
The incidence and severity of cyclosporin A (CsA)
induced gingival overgrowth (OG) was assessed in a longi-
tudinal study conducted during the first 6 months after
transplant surgery in 100 heart, liver, or kidney transplant
patients. 73 OG developed in 43 % of the patients. The find-
ings from this study suggested that the basic factor influ-
encing OG is CsA blood concentration followed by plaque
and/or gingivitis level. It was suggested that an oral hygiene
program before transplantation should be recommended as
a preventive measure. The occurrence of OG was evaluated
in two samples of patients with chronic progressive multi-
ple sclerosis (MS) in a 2-year double blind test of CsA
therapy. 74 The results showed an OG occurrence of 35% in
the MS patients treated with CsA for at least 1 year,
whereas the placebo group had an OG occurrence of 14 %.
Thus a true CsA- related OG occurrence was calculated as
21%. When patients with CsA trough levels <400 mg/ml
were considered, the occurrence of OG was identical to that
of the placebo group. This finding supports previous
observations that reducing CsA dosage can be an effective
way to lessen the severity of CsA-induced OG.
Evidence from three cases suggests that amlodipine, a
calcium channel blocker used in the management of angina
and hypertension, can be included in the list of dihydropy-
ridines that cause OG. 75 Other than nifedipine, dihydro-
pyridines that have been implicated in OG include nitren-
dipine, oxodipine, and felodipine. The dihydrodipines are
more frequently cited as a cause of drug-induced OG than
other types of calcium channel blockers, but this may be a
reflection on the usage of these drugs. In the three patients
described, gingival changes were observed as early as 3
months after drug use. The drug was detected in the crev-
icular fluid of the three patients, but the significance of this
finding in the pathogenesis of OG remains to be deter-
The results of combined cross-sectional and longitudinal
analyses on 225 adults with a high standard of oral hygiene
demonstrated that buccal gingival recession was a frequent
finding. 76 The proportion of subjects with recession in-
creased with age and sites with recession were susceptible
for additional recession. The development of gingival re-
cession leads to exposure of the root surface, which may
have undesirable consequences in terms of esthetics, root
sensitivity, and root caries. The observations in this study
suggest that teeth with recession should be considered as
susceptible to additional recession and that attention
should be paid to the tissue trauma caused by mechanical
tooth-cleaning procedures. In a curious cross-sectional
study, the width of radiologically defined attached gingiva
(RAG) was assessed over the permanent teeth of 123 sub-
jects aged 6, 10, and 12 years. 77 The width of RAG over
permanent teeth was measured from panoramic radio-
graphs as the midfacial distance from the cementoenamel
junction (CEJ) to the mucogingival junction (MGJ), which
was marked with a metal wire. A significant increase in the
RAG width was observed over permanent incisors and first
molars between the 6-year-old and 12-year-old age groups.
It was concluded that the RAG width increases during the
mixed dentition period; however, this study simply tracks
the CEJ relative to the MGJ and provides no actual soft
tissue measurements for comparison.
Di agnos i s
Microbiological testing with commercially available tests
and culture methods continues to be evaluated as an ad-
junct to the clinical diagnosis of periodontal disease. The
limitations of these tests in practice as well as their impor-
tance were described. Pg, as identified by enzyme-linked
immunosorbent assay (ELISA), had the highest degree of
sensitivity (0.90) and specificity (0.82) to clinical indicators
of adult periodontitis. 7s This study also showed that there
are significant differences in the detection abilities of the
J U L Y 1 9 9 5 6 5
DNA probe and ELISA methods, depending on the organ-
ism to be identified, because of the cross-reactivity seen
with the DNA probe. These differences have a direct im-
pact on the perceived association of the test microorgan-
isms with clinical indicators of adult periodontitis.
In 10 Aa positive patients, subgingival microbial samples
were obtained from the proximal aspects of every tooth
before and 1 month after deep scaling and root planing. 79
Aa was present in 40 % of the samples taken before treat-
ment and 23% taken after. Several tests with different
thresholds of detection are commercially available to indi-
cate presence of Aa. This study showed that the threshold
of detection influences the outcome of such tests. The de-
tection frequency of Aa is substantially decreased when
only Samples yielding 105 CFU/ml are considered positive.
This affects the number of random samples required to di-
agnose the presence of Aa. In this study, at a sensitivity of
105 CFU/ml, six of 10 patients would have been considered
free of Aa after treatment, and in the remaining four pa-
tients, more than 10 random samples would have been re-
quired to detect Aa with 95 % confidence. If elimination of
Aa is the goal of therapy, such insensitive tests are clearly
not the appropriate tool for diagnosis and evaluation of
treatment outcomes. Because the relationship between the
frequency of Aa before and after treatment was found to be
highly significant, it was concluded that multiple positive
results obtained before periodontal treatment indicate a
higher chance for persistence of the organism after thera-
py.S0 Detection of multiple positive sites obviously has a
great diagnostic impact. This may be more important than
the mere knowledge of presence or absence determined by
a single site test.
The effect of periodontal therapy on clinical and micro-
biological parameters was evaluated in 23 subjects with se-
vere generalized EON. sl Levels of Aa were not significantly
affected by scaling and root planing but were reduced by
open flap debridement. Conversely, Pg was virtually elim-
inated by scaling and root planing, demonstrating that the
two bacterial types respond differently to periodontal
therapy. These changes in microbiological parameters were
similar to those found in studies of LJP subjects where
surgery or antibiotics have been shown to be necessary to
reduce levels of Aa. It therefore appears that the nature of
the subgingival infection instead of solely the clinical pat-
tern of periodontal destruction might be important in de-
termining appropriate periodontal therapy. The impor-
tance of microbial analyses was illustrated in a report of
three clinical cases, s2 Each case demonstrated a continued
lack of response to conventional periodontal therapy over
a 3- to 4-year period. The patients were termed refractory
to treatment and subjected to extensive microbiological
analyses and sensitivity testing. After institution of the
appropriate antibiotic and conservative mechanical ther-
apy, each case demonstrated a dramatic remission, which
was maintained for a minimum of 21/2 years. These cases
illustrated the limitations of fluorescent antibody identifi-
cation and DNA probe analysis because of the limited
number of pathogens that can be identified and inability to
determine antibiotic sensitivity. Although anecdotal in
nature, these cases support the usefulness of microbial
identification along with antibiotic sensitivity as an ad-
junct to clinical diagnosis in special cases. This report does
not indicate that culture and sensitivity should be re-
quested routinely in the diagnosis and treatment of routine
The accuracy, consistency, time, comfort, and cost of
probing with a conventional hand probe (CP) with 3 mm
banded markings (Hu Friedy Manufacturing Co., Chicago,
Ill.), a manual pressure-regulated probe (MP) (True Pres-
sure Sensitive Pocket Searcher, Ivoclar Vivadent, Inc.,
Amherst, N.Y.) and two electronic probes, IP (Interprobe,
Bausch and Lomb, Oral Care Division, Inc., Tucker, Ga.)
and FP (Florida Probe, Florida Probe Corp., Gainesville,
Fla.) were evaluated, s3 Although some statistically signif-
icant differences were found between probes, no differ-
ences were considered to be of clinical significance. The use
of pressure-sensitive probes is well accepted in periodontal
research but in nonresearch settings, where the detection
of subtle clinical changes may not be necessary, the data
indicated that manual probes are equally reliable, less ex-
pensive, and less time-consuming to use.
To determine whether elastase levels in gingival crevic-
ular fluid (GCF) could serve as a marker for the progression
of periodontitis, GCF elastase and periodontal status were
evaluated in 31 periodontitis patients and 32 healthy vol-
unteers over a 6- month period, s4 The results indicated that
sites with high levels of elastase were at significantly
greater risk for progressive bone loss as determined by
subtraction radiography. The finding of a correlation
between a positive elastase test and increased risk of future
bone loss suggests that such a test may be helpful in iden-
tifying sites that require additional treatment.
As risk assessment tests are refined and developed for
detection of periodontitis, it is probable that they will not
be used alone, but instead in conjunction with the tradi-
tional clinical examination with a periodontal probe.
Pha r ma c ol ogi c t he r a py
Considerable research continues in an effort to enhance
the treatment of periodontal disease with antimicrobial
agents. Interest has recently centered on local antimicro-
bial delivery systems and agents.
A 6-month multicenter evaluation of tetracycline (TTC)
fiber (Actisite, ALZA Corp., Palo Alto, Calif.) therapy used
in conjunction with scaling and root planing was performed
on 113 maintenance patients, s5 Sites that were 5 to 8 mm
deep and had a history of bleeding on probing (BOP) were
randomly assigned to receive either scaling and root plan-
ing (SRP) alone (control) or SRP plus TTC fiber therapy
(experimental). This study demonstrated that TTC fiber
therapy significantly enhanced the clinical benefits ob-
tained by SRP in recurrent periodontitis in maintenance
6 6 V O L U ME 74 N U MB E R 1
patients. The positive effect was still apparent at 6 months
after application of the fibers. This study focused on the
benefits of TTC fiber therapy in periodontal maintenance
patients with individual sites of recurrent disease after
conventional therapy. TTC fibers were used as a supple-
ment to initial mechanical therapy in a variety of clinical
presentations in a series of six clinical cases followed for up
to 18 months, s6 Optimal results were obtained when TTC
fibers were combined with mechanical root debridement
and stringent home care protocols, and their use was not
advised for patients with poor home care or who were un-
able to comply with a regular maintenance program. Out-
comes included suppression of periodontal pathogens, re-
duction of BOP, decrease in probing pocket depth (PPD),
and increase in clinical attachment level (CAL).
A randomized controlled design was used in an attempt
to compare the clinical efficacy of minocycline (MC) in a
biodegradable controlled-release system with clinically
matched controls, s7 The MC was evaluated alone or as an
adjunct to SRP (MC + SRP) compared with SRP alone or
no treatment in 51 adult patients with PPD of 7 mm, dem-
onstrating the presence of Pg, Pi, or Aa. At 1 month, all
three treatment groups showed a mean decrease in gingi-
val index that was significantly different from the no-
treatment group; however, by 3 months the MC groups had
rebounded and only the SRP group was significantly
different from the no- treatment group. The decrease in
PPD for the MC + SRP group was significantly greater
than for all other groups at 1 month and significantly dif-
ferent from the SRP and no-treatment groups at 6 months.
Although MC as an adjunct to SRP produced results supe-
rior to those for SRP alone in terms of PPD reduction, the
effect was transient and did not improve the CAL response
beyond that seen with SRP alone.
The clinical effects of 1% chlorhexidine (CHI) gel (Cor-
sodyl Dental Gel, ICI Dental, UK) or 40 % TTC in white
petrolatum placed subgingivally in periodontal pockets >4
mm were evaluated in 22 adult periodontitis patients, ss
The effect of SRP and subgingival application of either the
CHI gel or the TTC paste was little different from SRP
alone. The clinical and microbiologic effects of root condi-
tioning with a TTC-containing gel and a gel with a mixture
of TTC and citric acid (CA) after SRP was investigated, s9
In this study the gel was actively burnished into the root
surfaces for 5 minutes instead of passively placed in the
pocket. The results indicated that both gels provided some
additional improvement in gingival health and on the
composition of the subgingival microflora compared with
SRP alone. The results of this study must be interpreted
with caution because of its limited sample size and short
observation period.
A controlled clinical study evaluated the survival rates of
Aa, Pg, and P/ i n periodontal pockets after SRP and in-
trapocket irrigation with either 2 mm of 0.12 % CHI (Peri-
dex, Procter & Gamble, Cincinnati, Ohio) compared with
saline and no-irrigation controls in seven adult periodon-
titis patients. 9~ This study was conducted in only 48 sites
in seven patients and thus must be interpreted with cau-
tion. Although a larger sample size may have revealed dif-
ferences, the results of this short-term clinical trial indicate
that extensive SRP appears to be effective in eliminating
or reducing the target species in the majority of tested sites
detectable by DNA probe technology. The addition of a
single professional pocket antimicrobial irrigation did not
appear to augment either the clinical or microbiologic re-
sults. The clinical effects of a single application of 5 %
metronidazole (M) in a collagen local delivery system were
evaluated in association with SRP under local anesthesia
in 28 patients with pockets >5 mm. 91 Comparison was
made to a control group that received SRP alone. Both
groups had decreased PPD, BOP, and gingival index (GI),
but results were slightly better in the MZ group.
Systemically administered antibiotics were assessed in
20 patients with periodontal abscesses. 92 The abscesses,
treated by drainage and supragingival scaling in addition
to systemic TTC, demonstrated reduced PPD and BOP
and a gain of CAL after 6 months. All abscesses except two
harbored Pg and/or Pi at baseline, and these bacteria were
significantly reduced in number and proportion during the
6-month follow-up period. TTC was used for its effective-
ness against both Aa and black pigmented anaerobes and
for its ability to inhibit collagenolytic activity. It is possi-
ble that another broad-spectrum antibiotic such as amox-
icillin or an antibiotic mainly directed against anaerobes
such as M would have had the same antimicrobial effect. It
was concluded that Pg and Pi play an important role in pe-
riodontal abscess formation and that drainage of the
abscess combined with systemic antibiotic administration,
without subgingival scaling, favors resolution and reattach-
Nonsteroidal anti-inflammatory drugs (NSAIDs) have
been researched as an adjunct in the control of periodon-
titis. A double-blind parallel group study investigated the
effect of systemic flurbiprofen (FBP), 100 mg daily, com-
bined with toothbrushing on the resolution of experimen-
tal gingivitis in 47 subjects. 93 The results indicated that,
when taken for 7 days, FBP had a statistically significant,
but clinically insignificant, effect on resolution of gingival
inflammation. This study was a short-term evaluation and
thus long-term effects cannot be ascertained. However, the
chronicity of periodontal infections may preclude the
long-term systemic administration of NSAIDs.
In an attempt to facilitate calculus removal, a prescaling
gel has recently been marketed, SofScale (Ash Instrument
Division, Dentsply Ltd., Weybridge, UK). This product
contains EDTA and sodium lauryl sulfate and is claimed to
soften calculus, Two different double-blind, split-mouth
placebo-controlled clinical studies 94 ,95 evaluated this prod-
uct. There was no difference in scaling time between prod-
uct and placebo. The operator did not consider the gel to
facilitate calculus removal and patients did not find calcu-
lus removal more comfortable when SofScale gel was used.
J ULY 1 9 9 5 67
The r es ul t s of t hes e s t udi es do not s uppor t t he use of Sof-
Scal e gel as an a dj unc t t o scal i ng.
S u r g i c a l r e g e n e r a t i v e t h e r a p y
Res ear ch on t he effect s of ba r r i e r me mbr a ne s , bot h non-
r es or babl e a nd r es or babl e, for gui ded t i ssue r egener at i on
( GTR) has c ont i nue d t o e xpa nd as new pr oduc t s a nd new
a ppl i c a t i ons ar e eval uat ed. Ma n y si gni f i cant advances were
r e por t e d t hi s pa s t year.
The use of GTR was e va l ua t e d i n t he t r e a t me n t of 19
pai r s of mol a r cl ass I I f ur cat i on def ect s i n 13 pat i ent s . 96
One def ect f r om each pai r of f ur cas was t r e a t e d wi t h a
Gor e - Te x me mb r a n e ( GTPM, W. L. Gor e a nd Associ at es,
Fl agst af f , Ari z. ) a nd t he ot he r was t r e a t e d by open fl ap de-
b r i d e me n t ( OFDB) . The r es ul t s i ndi cat ed t h a t t he GTR
pr oc e dur e was cl i ni cal l y si gni f i cant l y s uper i or t o OFDB as
de t e r mi ne d by r e duc t i on i n PPD and gai n i n ver t i cal and
hor i zont al open pr obi ng a t t a c h me n t at 6 mont hs af t er sur -
gery. Ce r t a i n cl i ni cal p a r a me t e r s for success were empi r i -
cal l y de t e r mi ne d: (1) a mol ar wi t h a l ong r oot t r u n k has a
gr eat er pot e nt i a l for success t ha n one wi t h a s hor t r oot
t r unk; (2) t he pr esence of enamel pr oj ect i ons i nhi bi t s suc-
cess; (3) t r e a t me n t of ma n d i b u l a r f ur cat i ons is mor e suc-
cessful t ha n t h a t of ma xi l l a r y f ur cat i ons; and (4) i na bi l i t y
t o cover t he ba r r i e r me mb r a n e ent i r el y wi t h t he fl ap ma y
l i mi t success. The effect of GTR wi t h GT P M was e va l ua t e d
i n t he t r e a t me n t of 88 t e e t h wi t h advanced pe r i odont i t i s i n
23 pat i ent s . 97 The mean i ni t i al def ect size was 8.8 mm f r om
t he CEJ t o t he bone. At t he t i me of me mbr a ne r emoval , t he
mean t i ssue l evel was 3.0 mm as me a s ur e d f r om t he CEJ t o
t he cor onal mar gi n of t he r egener at ed t i ssue, r e pr e s e nt i ng
a me a n gai n of CAL of 5.8 mm. Re e nt r y at 9 t o 12 mont hs
r eveal ed a me a n di s t ance f r om t he CEJ t o t he bone mar gi n
of 6.1 mm, r e pr e s e nt i ng a me a n gai n of 2.7 mm of mi ner -
al i zed t i ssue. The decr eas ed a mount of mi ner al i zed t i ssue
at r e e nt r y i n r el at i on t o t he t i ssue gai n at me mb r a n e
r emoval was s pe c ul a t e d t o be t he r es ul t of f or ma t i on of a
l ong connect i ve t i ssue a t t a c h me n t a nd sur gi cal di f f i cul t i es
i n compl et e cover age of t he newl y f or med t i ssue.
The heal i ng r es ul t s wer e c ompa r e d af t er t r e a t me n t of
buccal cl ass I I ma n d i b u l a r f ur cat i on def ect s wi t h ei t her
GTR usi ng GT P M or a cor onal l y pos i t i oned fl ap ( CPF)
t echni que. 9s The f i ndi ngs of t hi s s t udy showed no si gni fi -
cant di f f er ence bet ween t he t wo t r e a t me n t met hods . The r e
was a si gni f i cant di f f er ence i n me a n PPD bet ween t he
gr oups at basel i ne, whi ch ma de i nt e r pr e t a t i on of r es ul t s
di ffi cul t . I n vi ew of t he s mal l numbe r of pa t i e nt t r e a t me n t s
eval uat ed, t hi s i nves t i gat i on s houl d be cons i der ed a pi l ot
s t udy. I n a s i mi l ar s t udy, 26 ma n d i b u l a r cl ass I I I f ur cat i on
def ect s wer e t r e a t e d i n 26 s ubj ect s by use of a r egener at i ve
t e c hni que t h a t i nc l ude d CA r oot - condi t i oni ng, pl a c e me nt
of de mi ne r a l i z e d f r eeze- dr i ed bone al l ogr af t ( DFDBA) ,
a nd cor onal l y pos i t i one d f l aps secur ed by c r own- a t t a c he d
sut ur es. 99 I n a ddi t i on t o t hi s t he r a py, GT P M was pl aced i n
14 of t he 26 def ect s and r es ul t s were c ompa r e d at 12 t o 14
mo n t h s a f t e r oper at i on. Li t t l e di f f er ence was obs er ved
bet ween def ect s t r e a t e d wi t h or wi t hout GTPM. I t was
cons i der ed pos s i bl e t h a t t he me mb r a n e s and cor onal l y po-
s i t i oned f l aps pr ovi de d t he s ame benef i t s of wound pr ot ec-
t i on and cl ot s t abi l i zat i on. For bot h t r e a t me nt s , me a n i m-
pr ove me nt was obs er ved for f ur cal CAL, f ur cal bone l evel s,
and def ect vol umes. However , onl y a few def ect s i mpr ove d
t o t he e xt e nt t h a t t hese t hr ough- a nd- t hr ough def ect s
showed sof t a nd ha r d t i ssue cl osure. The r esul t s of t hi s
s t udy a nd pr evi ous s t udi es on ma n d i b u l a r cl ass I I I f ur ca-
t i on def ect s show t h a t pr e s e nt l y avai l abl e met hods do not
pr ovi de s at i s f act or y r es ul t s for mos t of t hese sever e defect s.
A numbe r of newl y devel oped r es or babl e me mbr a ne s
were i nves t i gat ed. One s t udy e va l ua t e d t he use of t wo
newl y devel oped bi oabs or babl e me mbr a ne s ( Resol ut Re-
gener at i ve Ma t e r i a l , W. L. Gor e a nd Associ at es) dur i ng
heal i ng of sur gi cal l y cr eat ed def ect s i n dogs. 1~176 Hi st ol ogi c
and hi s t omet r i c eval uat i ons de mons t r a t e d t hat , i n s pi t e of
ear l y me mbr a ne r es or pt i on as s oci at ed wi t h a mi ni ma l i n-
f l a mma t or y r eact i on, t her e was r ef or mat i on of a connect i ve
t i ssue a t t a c hme nt . New c e me nt um wi t h i nser t i ng col l agen
fi bers was obs er ved on t he pr evi ous l y de nude d r oot sur -
faces. Me mb r a n e r es or pt i on was s t a r t e d by 4 weeks a nd was
near l y compl et e at 6 mont hs . Th e r es or pt i on pr ocess was
Dot seen t o i nt er f er e wi t h t he r egener at i on achi eved. The
pe r i odont a l t i ssue r esponse t o t he Gui dor ma t r i x ba r r i e r
( Gui dor AB, Huddi nge, Sweden) was eval uat ed af t er GTR
t r e a t me n t of ar t i f i ci al dehi scence def ect s on 45 t e e t h i n 15
monkeys. 1~ Dur i ng i ni t i al heal i ng, t he mat r i x ba r r i e r was
i nt e gr a t e d wi t h t he s ur r oundi ng t i ssues. The ba r r i e r f unc-
t i on was ma i n t a i n e d for 6 weeks af t er pl a c e me nt and i t s
s ubs equent r e s or pt i on di d not i nt er f er e wi t h t he r egener -
at i ve heal i ng pr ocess. New a t t a c h me n t and bone were
f ound af t er 6 weeks of heal i ng. Bi or es or pt i on of t he mat e-
r i al and t i ssue r eor gani zat i on was c ompl e t e d 6 t o 12 mont hs
af t er t r e a t me nt . Ne i t he r of t hes e t wo ani mal s t udi es used
cont r ol gr oups.
I n a cl i ni cal s t udy, 10 cl ass I I f ur cat i ons and 47 i nt r a bony
def ect s i n 59 pa t i e nt s were t r e a t e d by GTR wi t h a Gui dor
me mbr a ne a nd assessed at 12 mont hs af t er surgery. 1~ The
f ur cat i on def ect s ha d a mean r e duc t i on i n PPD of 3.7 _+ 1.4
mm wi t h a me a n gai n i n ver t i cal CAL of 3.4 + 1.5 mm and
hor i zont al CAL gai n of 3.3 + 1.4 mm r es ul t i ng i n compl et e
cl osur e i n 9 of 19 defect s. At t he i nt r a bony defect s, me a n
PPD r educt i on was 5.4 _+ 2.3 mm a nd mean gai n of CAL
was 4.9 _+ 2.2 mm. Mean gi ngi val r ecessi on (REC) was 0.2
mm for f ur cat i on def ect s and 0.5 mm for i nt r a bony def ect s.
I t shoul d be not e d t h a t t hi s is a r e por t of cases wi t hout
cont r ol gr oups a nd shoul d be e va l ua t e d as such. Cont r ol l ed
cl i ni cal s t udi es ar e needed t o ver i f y t he ef f ect i veness of t hi s
bi or es or babl e me mb r a n e i n GTR t he r a py.
The efficacy of a r es or babl e s ynt he t i c mat er i al , Vi cr yl
( Et hi con Inc. , Sommer vi l l e, N. J. ), us ed ext ensi vel y i n
gener al sur ger y for wound s u p p o r t was assessed in 40 pa-
t i ent s wi t h cl ass I I f ur cat i on def ect s. 1~ An e xpe r i me nt a l
gr oup of 20 pa t i e nt s r ecei ved OFDB pl us t he me mbr a ne
and a cont r ol gr oup of 20 pa t i e nt s r ecei ved OFDB al one. At
~ 8 V O L U ME 7 4 N U MB E R 1
6 mont hs af t er s ur ger y t he r e duc t i on i n PPD was 4.3 mm
in t he t es t gr oup a nd 2.0 mm i n t he cont r ol gr oup. Gai n i n
CAL was 4.4 mm i n t he t e s t si t es c ompa r e d wi t h 0.8 mm for
cont r ol si t es. Conver si on f r om cl ass I I t o cl ass I f ur cat i on
gr ade was not e d i n 15 of 20 t e s t si t es a nd 1 of 20 cont r ol
si t es. Bas el i ne p a r a me t e r s wer e si gni f i cant l y di f f er ent for
t he t wo gr oups, t hus af f ect i ng i nt e r pr e t a t i on of r esul t s.
However , t hi s s t udy showed t h a t t he r es or babl e s ynt het i c
me mb r a n e r e s ul t e d i n si gni f i cant i mpr ove me nt i n f ur ca-
t i on def ect s c ompa r a bl e t o t h a t seen i n ot her s t udi es wi t h
nonr es or babl e bar r i er s . A t ype I bovi ne col l agen me mbr a ne
( Bi omend, Cal ci t ek Inc. , Car l s bad, Cal i f. ) was eval uat ed i n
GTR t r e a t me n t of 12 pa t i e nt s wi t h bi l a t e r a l ma ndi bul a r
cl ass I I f ur cat i on def ect s wi t h l oss of CAL 6 mm) ~ Te e t h
were r a n d o ml y assi gned t o ei t her a t es t gr oup t ha t was
t r e a t e d by OFDB pl us t he me mb r a n e or a cont r ol gr oup
t r e a t e d by OFDB al one. The r esul t s seen at 12 mont h re-
e nt r y i ndi c a t e d t h a t t he bovi ne col l agen me mbr a ne pr o-
duced si gni f i cant l y gr eat er def ect fill, 2.5 mm vs. 1.5 mm,
and ver t i cal bone fill, 2.8 mm vs. 1.5 mm, t ha n t he cont r ol
si t es. Th e me a n r e duc t i on i n PPD a nd gai n i n CAL f or t he
me mb r a n e si t es was 2.85 mm and 1.67 mm, r espect i vel y,
c ompa r e d wi t h 1.92 mm a nd 0.67 mm for t he cont r ol si t es.
A l i mi t a t i on of t hi s s t udy was t he smal l s ampl e size; how-
ever, t he s t udy suggest s t h a t t he use of an a bs or ba bl e col-
l agen me mb r a n e ma y have benef i ci al effect s i n t he t r e a t -
me nt of ma n d i b u l a r cl ass I I f ur cat i on def ect s.
The effi cacy of t hr e e t ype s of bi odegr adabl e, hi gh mol ec-
ul ar wei ght pol yl act i c aci d ( PLA) me mbr a ne s cont ai ni ng
0%, 10%, or 30% l ow mol ecul ar wei ght ol i gomer s was
eval uat ed i n e xpe r i me nt a l buccal pe r i odont a l def ect s cre-
a t e d sur gi cal l y i n 6 a dul t beagl e dogs. 1~ I t a p p e a r e d t h a t
a s at i s f act or y r egener at i on of pe r i odont a l t i ssues coul d be
obt a i ne d by al l t hr e e t ype s of PLA me mbr a ne s a nd s t at i s -
t i cal l y si gni f i cant di f f er ences coul d be obs er ved for epi t he-
l i al a t t a c hme nt , al veol ar bone r egr owt h, connect i ve t i ssue
a t t a c hme nt , a nd new c e me nt um f or ma t i on i n t he exper i -
me nt a l gr oups c ompa r e d wi t h t he cont r ol s.
An a bs or ba bl e col l agen me mb r a n e ( Per i obar r i er , Col l a-
Tec, Inc. , Pl ai ns bor o, N. J. ) was c ompa r e d wi t h t he nonr e-
s or babl e bar r i er , GTPM, i n t he sur gi cal t r e a t me n t of cl ass
I I mol ar f ur cat i on def ect s. 1~ A s pl i t mout h desi gn was used
for t r e a t me n t of t wo c ompa r a bl e def ect s i n 13 pa t i e nt s . The
GT P M was r emoved 6 weeks af t er pl a c e me nt a nd mea-
s ur e me nt s wer e r e pe a t e d at 6 mont hs af t er sur ger y. The r e
were no si gni f i cant di f f er ences i n any of t he cl i ni cal
p a r a me t e r s bet ween t r e a t me n t gr oups. On t he basi s of t he
r es ul t s of t hi s s hor t - t e r m cl i ni cal t r i al , t he a bs or ba bl e
me mb r a n e was as effect i ve as t he GTPM.
The r e were t wo r e por t s on t he use of r ubbe r da m ma t e -
r i al as a ba r r i e r me mbr a ne . The ma t e r i a l was s el ect ed for
i t s pr ope r t i e s of i mp e r me a b i l i t y a nd el as t i ci t y, whi ch pr o-
vi ded a c ompl e t e i s ol at i on of def ect s wi t h a t i ght seal
a r ound t he r oot s a nd s uppor t for t he over l yi ng fl ap. I n a
r e por t of 10 p a t i e n t s wi t h ext ens i ve mul t i pl e pe r i odont a l
osseous def ect s i n at l eas t one qua dr a nt , t he me a n gai n i n
CAL at 4 mo n t h s af t er s ur ger y was 3.84 mm. 1~ Re e n t r y 6
t o 7 mont hs af t er s ur ger y r eveal ed a me a n osseous fill of
4. 25 mm. Thr e e pa t i e nt s e xhi bi t e d 1.0 t o 3.5 mm of s upr a-
cr est al osseous r egener at i on a nd t he r emai ni ng pa t i e nt s
ha d an osseous def ect fill of 80% t o 95%. Res ul t s of a r ub-
ber da m GTR s t udy i n f our pa t i e nt s i ndi c a t e d a 12- mont h
gai n of CAL r angi ng f r om 3 t o 5 mm, c ompa r a bl e t o CAL
gai n wi t h ot he r bar r i er me mbr a ne s , l~ Re e nt r y a t 12
mont hs r eveal ed a c ombi na t i on of fi l l i ng of t he api cal por -
t i on of t he osseous def ect s wi t h mar gi nal bone r es or pt i on,
r es ul t i ng i n compl et e bone r es ol ut i on i n f our of t he five
si t es. Al t hough t he r ubbe r da m ma t e r i a l a ppe a r s t o be ap-
pl i cabl e t o GTR i n pe r i odont a l t he r a py, f ur t her t e s t i ng is
necessar y bef or e t hi s ma t e r i a l can be r e c omme nde d for
cl i ni cal use.
Fa c t o r s i nf l ue nc i ng GTR s u c c e s s
A si gni f i cant r e por t cat egor i zed t he obs er ved cl i ni cal and
r adi ogr aphi c r es pons es i n over 1000 i nt r abone, f ur cat i on,
and dehi scence def ect s t r e a t e d wi t h combi ned r egener at i ve
t h e r a p y usi ng DFDBA, GTPM, ci t r i c aci d (CA) r oot con-
di t i oni ng, and cor onal l y pos i t i one d fl aps when ne e de d for
me mb r a n e cover age, i n an a t t e mp t t o del i neat e t he r ange of
heal i ng ot her wi se mas ked by s t at i s t i cal anal ysi s of t her a-
peut i c r esul t s. 1~ Four p a t t e r n s of heal i ng were cat egor i zed:
(1) r api d, 13%; (2) t ypi cal , 76%; (3) del ayed, 8%; a nd (4)
adver se, 3 %. Ra p i d heal i ng was char act er i zed by cont i nu-
ous fl ap cover age of t he me mb r a n e unt i l r emoval at 6 t o 8
weeks af t er pl a c e me nt and t he need t o peel t he me mb r a n e
f r om t he unde r l yi ng t i ssue, whi ch ha d a bonel i ke a ppe a r -
ance. Typi c a l heal i ng had ear l y me mbr a ne exposur e, easy
me mbr a ne r emoval , an unde r l yi ng r ubbe r l i ke or gr anul a-
t i on t i ssue t h a t was r e s i s t a nt t o pr obi ng, a nd del ay of r a-
di ogr aphi c a ppe a r a nc e of bone fill up t o 12 mont hs . De-
l ayed heal i ng was char act er i zed by ear l y me mbr a ne expo-
sure, wi t h t i s s ue i nf l ammat i on a nd possi bl e exudat i on,
i mma t ur e gr a nul a t i on t i ssue at me mb r a n e r emoval , and
del ay of r a di ogr a phi c bone ma t u r a t i o n up t o 24 mont hs .
The adver se gr oup was char act er i zed by abscess f or ma t i on
and a di f f i cul t pos t ope r a t i ve cour se wi t h fragi l e t i s s ue and
sur f ace necrosi s. The a ppe a r a nc e of t he new t i ssue at t he
t i me of me mb r a n e r emoval was cons i der ed t he si ngl e mos t
i mp o r t a n t cons i der at i on for heal i ng p a t t e r n de t e r mi na -
t i on. The f i ndi ng of bone or a p i n k sur f ace wi t h a r ubbe r -
l i ke cons i s t ency was a good i ndi c a t i on of success. The fi nd-
i ng of bone at me mbr a ne r emoval was obs er ved onl y in
cases t r e a t e d by DFDBA and a t t e s t s t o t he os t eoi nduct i ve
pot e nt i a l of t hi s mat er i al . Sof t a nd ha r d t i ssue r epai r wi t h
GTR wi t h a nd wi t hout DFDBA was eval uat ed at r e e nt r y
i n ma ndi bul a r cl ass I I mol ar f ur cat i on i nvas i ons J 1~ Bot h
t r e a t me n t gr oups ha d a si gni f i cant decr ease i n ver t i cal and
hor i zont al de pt hs but i t a p p e a r e d t h a t t he t r e a t me n t wi t h
DFDBA had a mor e posi t i ve ef f ect on gai ni ng CAL.
The si gni f i cance of space pr ovi s i on for r egener at i on of
al veol ar bone a nd c e me nt um i n pe r i odont a l def ect s was
assessed i n five beagl e dogs. II-1 A t i t a ni um- r e i nf or c e d
JULY 1995 69
Gore-Tex membrane (GTAM, W.L. Gore and Associates)
was shaped to enhance space in supra-alveolar periodontal
defects. The finding of dramatic improvement in bone and
cementum regeneration compared with controls reflects
the biologic significance of space provision for regeneration
of periodontal structures. Meaningful regeneration was
observed only in sites without complications from mem-
brane exposure or collapse. When membranes were ex-
posed, an acute inflammatory infiltrate occupied the space
under the membrane and regeneration was not observed.
A double-blind, controlled regenerative trial assessed the
clinical, microbiologic, and histologic factors associated
with successful GTR in human mandibular class II buccal
furcation defects. 112 GTPM placed in 30 subjects was
retrieved at 6 weeks and examined histologically. At 12
months after surgery, clinical measurements and reentry
surgical measurements were repeated. Reduction in PPD
(2.6 mm), gain in horizontal CAL (2.6 ram), and gain in
vertical CAL (0.95 mm) were all significantly better than
baseline values. Deep initial pockets, good oral hygiene,
absence of gingival inflammation and Aa infection, and
presence of connective tissue cells on the inner surface of
the retrieved membrane all were associated with enhanced
periodontal regeneration. Monitoring these factors and in-
tervening as appropriate might increase the predictability
and success of GTR. An additional noteworthy observation
from this study was the finding of no discernible difference
between subjects for whom SRP was deferred to the time
of surgery compared with subjects who received SRP as
part of the hygienic phase of therapy. Thus the concept of
deferring definitive SRP of the treatment site until the
time of surgery was not supported by this study.
The microflora was examined in 11 barrier membranes
around teeth with furcation or intrabone defects and in 16
membranes around implants with bone defects. 113 The
main finding of this study was the inverse relationship be-
tween microbial counts and gain of CAL. Teeth with mem-
branes harboring greater than l0 s total counts either lost
attachment or gained 2 mm of CAL whereas 80 % of teeth
with less than 108 total viable counts gained 3 mm of CAL.
Ninety percent of implants with bacteria-free membranes
demonstrated complete bone fill, whereas 87 % of implants
with infected membranes revealed residual tissue defects.
Systemic doxycycline or penicillin and oral CHI rinses
prescribed concomitantly with membrane insertion did not
control several periodontal pathogens. This study suggests
that subgingival microorganisms interfere with optimal
healing in GTR. Black pigmented anaerobic rods, Aa, and
Peptostreptococcus micros seemed to be particularly
detrimental to healing. It was suggested that adjunctive
antimicrobial therapy in GTR should aim at eradicating
periodontal pathogens before membrane insertion and
maintaining a pathogen-free environment during the heal-
ing period. Administration of MC with a local drug deliv-
ery system (Periocline, Sunstar, Inc., Osaka, Japan) was
introduced as a part of initial periodontal therapy after
microbiological examinations in a case of postjuvenile pe-
riodontitis in a 28- year-old patient. 1~4 The lesions were
subsequently treated by GTR with GTPM, resulting in
considerable gain of CAL with minimal REC. This obser-
vation suggests that the local delivery of antibiotics before
regenerative therapy may be effective in treatment of
selected cases.
The effect of local application of M gel (Elyzol 25 %
Dental Gel, Dumex, Copenhagen, Denmark) along with
GTPM was evaluated in 12 patients with one pair of ver-
tical periodontal bone defects of comparable size. 115 The
control defects received no M gel. All membranes were re-
moved 6 weeks after surgery. At 6 months after membrane
removal, the median gain in CAL as a percentage of the
initial defect depth was 92 % for test defects and 50 % for
control defects. No statistically significant differences were
found between test and control sites for plaque, BOP, re-
duction in PPD, gain in bone height, or REC. The micro-
bial colonization of the healing defects in this clinical study
was also reported. 116 Between the presurgical and the
1-week examination, the median number of cultivable
bacteria in the test pockets was significantly reduced
whereas the control pockets showed an increase. Two weeks
after membrane and M gel placement and at all following
examinations no microbiological differences between test
and control sites were observed. Despite the good clinical
results in the test group, all membranes from both groups
were heavily colonized with bacteria at the time of removal.
Thus, although bacterial colonization of the healing wound
was delayed, it was not prevented.
The 1-year results of a GTR procedure in patients
treated with or without antibiotics was reported. 117 GTPM
was placed over mandibular molar class II furcation inva-
sions and retained for 4 weeks. Group 1 patients received
no antibiotics and group 2 patients received amoxicillin/
clavulanate potassium during the first 10 days after sur-
gery. The antibiotic use was found to have controlled ini-
tial inflammation, but 12 months later it had produced no
direct effect on bone regeneration or soft tissue attachment
of clinical significance. An overall defect decrease of 40 %
was noted in the absence of inflammation compared with
11% in the presence of postsurgical inflammation. The re-
sults suggested that the lack of maintenance care affected
the outcome of the regenerative procedure.
GTR i n a l ve ol a r r i dge a nd i mpl a nt
a ppl i c a t i ons
A surgical technique using the principles of GTR to pre-
vent localized ridge deformities at extraction sites deficient
in alveolar bone was described. 11s The objective was to fa-
cilitate vertical and horizontal bone regeneration in a
damaged alveolar socket to achieve adequate alveolar ridge
morphology for esthetic and/or functional purposes where
unassisted healing would likely result in poor ridge mor-
phology. A GTAM membrane was placed ove~ the deficient
extraction socket with the coronal aspect of the membrane
7 0 V O L U ME 7 4 N U MB E R 1
left exposed, which simplified the procedure and did not
adversely affect the outcome provided CHI was applied
twice daily to the membrane. The membrane was removed
6 to 10 weeks after surgery and the results obtained were
stable over a 2-year period. In contrast, results of a clinical
and microbiologic study suggests that exposure of GTAM
membranes in the treatment of fresh extraction sockets
with osseointegrated implants hinders the effectiveness of
GTR in peri-implant tissues. 119 The presence of a high
number of bacteria on the alveolar aspect of the membrane
corresponding to the areas exposed to the oral cavity con-
firmed that bacteria are able to pass through the material
regardless of its porosity.
Bone regeneration and osseointegration of hydroxyapa-
tite (HA) coated implants (Calcitek, Carlsbad, Calif.) and
titanium plasma-sprayed (TPS) implants (The Strau-
mann Co., Cambridge, Mass.) placed immediately after
extraction were evaluated in 36 adults. 12~ Ten HA and 12
TPS implants were grafted with DFDBA, covered with
GTAM, and the flap coronally positioned for primary clo-
sure in 20 patients. Ten additional HA and 11 TPS im-
plants were similarly placed except that DFDBA was not
used. Osseous structures were evaluated at initial place-
ment and at the 6-month reentry. Combining DFDBA with
the membrane led to a statistically greater bone regenera-
tion than the use of the GTAM alone. The DFDBA was
most effective at sites with deep wide osseous defects or
bony dehiscences.
Two different techniques were described to facilitate
primary closure in immediate placement of implants in
fresh extraction sockets. In a series of four cases, autoge-
nous gingival grafts were harvested from the palate or tu-
berosity and sutured in place to cover the exposed alveolus
and fixture. 121 It was suggested that survival of the graft for
2 to 4 weeks allowed time for tissue from the socket to sur-
round the implant without epithelial intervention. At stage
2 surgery, all implants had achieved complete osseointe-
gration as determined clinically and radiographically. No
histologic analysis was performed to confirm the clinical
observations. A technique to increase the quantity of gin-
giva around a tooth scheduled for extraction was de-
scribed. 122 When the tooth is reduced to a subgingival po-
sition, the surrounding gingiva will spontaneously cover
the condemned root, thereby simplifying subsequent im-
plant or socket retention procedures requiring primary flap
A staged ridge augmentation/implant placement ap-
proach was reported in four cases. 123 Extraction sites with
extensive damage to the alveolar ridge were first treated by
placement of DFDBA covered by GTAM. The DFDBA
functioned as a space maintainer for the desired ridge
morphology and provided osteoinduction and osteocon-
duction, and the membrane allowed GTR. Dental implants
were placed after 6 to 10 months of ridge healing. A new
surgical technique using absorbable orthopedic pins for
space maintenance in GTR treatment of localized alveolar
ridge defects was presented. 124 Three defects treated with
this procedure were completely resolved with new bone
formation. Bone biopsies taken at subsequent implant
placement surgery indicated that maintenance of space
beneath the membrane and a stabilized blood clot were
sufficient to promote bone formation without the use of
implanted materials. A GTR technique was tested for its
ability to promote vertical ridge augmentation in severely
atrophic partially edentulous ridges in a controlled study
in humans.125 Vertical bone formation was evaluated at
surgical sites where implants were left protruding 4 to 7 mm
from flat atrophic ridges. The implants were covered with
titanium- reinforced GTAM membranes, which were re-
moved at 9 months after surgery. This study demonstrated
that it was possible to gain up to 4 mm of vertical bone
augmentation. Most coronal portions of the implants pro-
truding more than 4 mm from the bone crest were sur-
rounded by a dense fibrous tissue. Histologic analysis
revealed osseointegration of the newly formed bone with
the titanium implants.
The bone-forming capacity of DFDBA and autologous
bone grafts were evaluated in extraction sockets. 126 Seven
paired extraction sites were grafted with either DFDBA or
autologous bone. The sites were reentered after 3 to 13
months for biopsy specimens of the grafted sites. Sockets
grafted with autologous bone healed uneventfully with vi-
able bone. By contrast, the DFDBA used in this study was
surrounded by but was not replaced by viable bone. The
authors speculated that retention of the nonviable particles
of bone may interfere with normal bone formation. Non-
grafted control sites were not used in this study. The results
of two sinus augmentation procedures, one grafted with
DFDBA and the other with autogenous iliac bone, before
implant placement, were reported. 127 After histologic anal-
ysis of bone cores obtained at the time of implant place-
ment it was determined that sites grafted with autogenous
bone contained more mineralized bone than sites grafted
with DFDBA, which still contained remnants of DFDBA
up to 16 months after placement. New bone formation was
limited and fibrous encapsulation of the allograft was com-
mon in the portion of the graft approximating the elevated
sinus membrane.
Gr owt h f a c t or s a nd GTR
Platelet-derived growth factor (PDGF) is a polypeptide
growth factor considered to have a role in the proliferation
and migration of fibroblasts at wound healing sites. The
effect of PDGF was evaluated with and without barrier
membranes in a standardized closed-wound surgical model
in mongrel dogs. 12s The data demonstrated that within this
model system, PDGF can stimulate the proliferation of fi-
broblasts when compared with control or GTPM speci-
mens. A similar study was performed on standardized pe-
riodontal defects in four beagle dogs. 129 Collagen sponges
impregnated with insulinlike growth factor II (IGF-II), fi-
broblast growth factor, and transforming growth factor
J ULY 1995 71
b e t a I wer e f i t t ed t o def ect s r andoml y. Cont r a l a t e r a l con-
t r ol def ect s r ecei ved t he col l agen wi t h vehi cl e onl y. Hi s t o-
met r i c anal ys i s showed no di f f er ences i n f i br obl a s t a nd
col l agen de ns i t y bet ween cont r ol and gr owt h f act or def ect s.
I n al l si t es si gni f i cant l y mor e bone f or med i n cont r ol s t ha n
i n cor r es pondi ng gr owt h f act or defect s. I n gener al , t hes e
r es ul t s i ndi cat e t h a t unde r t he e xpe r i me nt a l condi t i ons i n
t hi s s t a nda r di z e d pr ot ocol , pr ocedur al or bi ol ogi c var i a-
t i ons ma y exceed any heal i ng di f f er ence i nduced by t he
a ppl i c a t i on of t he gr owt h f act or combi nat i on used. Fu r t h e r
eval uat i ons ar e neces s ar y bef or e a pos s i bl e r ol e for t hes e
gr owt h f act or s i n pe r i odont a l wound heal i ng unde r cl i ni cal
condi t i ons can be as cer t ai ned a nd opt i ma l combi nat i ons
and de l i ve r y s ys t ems devel oped.
The c ommonl y used a ni ma l model s for eval uat i ng per i -
odont al r egener at i ve t h e r a p y ar e t he beagl e dog model wi t h
na t ur a l l y occur r i ng pe r i odont a l di sease and t he n o n h u ma n
pr i ma t e wi t h l i ga t ur e - i nduc e d a t t a c h me n t loss. The r es ul t s
of e xpe r i me nt s compar i ng t he heal i ng r esponse t o per i o-
dont a l s ur ger y wi t h a nd wi t hout concur r ent use of P DGF
and I GF - I i n t hes e model s was r epor t ed. 13~ At 1 mont h,
P DGF / I GF - I a dmi ni s t r a t i ons r es ul t ed i n 64.1% a nd 51.4%
i ncr eases i n new a t t a c h me n t f or ma t i on i n t he n o n h u ma n
pr i ma t e a nd dog, r espect i vel y, wher eas cont r ol s, s ur ger y
pl us pl acebo, ha d 34.1% a nd 8. 6%, r espect i vel y. Osseous
def ect fill was 21.6% a nd 65% i n t he P DGF / I GF - I pr i ma t e
a nd dog, r espect i vel y, c ompa r e d wi t h 8.5% a nd 14. 5%, re-
spect i vel y, i n t he cont r ol s. Thus t he osseous r es pons e was
gr eat er i n t he dog mode l wher eas new a t t a c h me n t f or ma-
t i on was gr eat er i n t he n o n h u ma n pr i ma t e model . I n bot h
model s, t he P DGF / I GF - I a p p e a r e d t o pr omot e per i odon-
t al r egener at i on.
P e r i o d o n t a l p l a s t i c s u r g e r y
The a r e a of pe r i odont a l sur ger y r el at ed t o r econs t r uct i on
pr i nc i pa l l y i nvol vi ng sof t t i ssues has r e c e nt l y been t e r me d
pe r i odont a l pl as t i c s ur ger y a nd i ncl udes ma n y of t he pr o-
cedur es f or mer l y r ef er r ed t o as mucogi ngi val sur ger y. A
n u mb e r of r e por t s of new t echni ques , sur gi cal r ef i nement s ,
a nd pr e di c t a bi l i t y of pe r i odont a l pl as t i c s ur ger y pr oce-
dur es a p p e a r e d t hi s pa s t year.
A modi f i ed cor onal l y pos i t i one d fl ap wi t h i nl ai d mar gi ns
was des cr i bed. 131 I n 20 i s ol at ed def ect s wi t h me a n REC 3.0
mm, c ompl e t e r oot cover age was achi eved i n 95 % of t he
si t es a nd me a n r oot cover age was 98. 8%. The pr oc e dur e
r e por t e dl y r e s ul t e d i n a decr ease i n s ens i t i vi t y a nd excel -
l ent est het i cs.
Sur gi cal modi f i cat i ons t o t he envel ope t echni que for sof t
t i ssue gr af t i ng wer e pr e s e nt e d t o ext end i t s use t o i ncl ude
mul t i pl e ' adj acent ar eas of REC whi l e pe r mi t t i ng conser -
vat i on of exi st i ng gi ngi va, mi ni ma l sur gi cal t r a u ma t o t he
r eci pi ent ar ea, a nd f i r m f i xat i on of t he connect i ve t i ssue
gr af t . 132 Res ul t s wi t h t hi s modi f i ed t echni que wer e re-
p o r t e d f or 23 si t es i n 12 pat i ent s . 133 Compl e t e r oot cover-
age was achi eved i n 61% of t he t r e a t e d si t es a nd me a n r oot
cover age was 84 %. Th e degr ee of r oot cover age was f ound
t o decr ease wi t h i ncr ease i n t he wi dt h a nd de pt h of t he
REC. Wh e n REC was 3 ram, me a n r oot cover age was 95 %,
wher eas 4 mm REC r es ul t ed i n a me a n r oot cover age of
The r es ul t s of t he t echni que usi ng connect i ve t i ssue wi t h
pa r t i a l t hi cknes s doubl e pedi cl e fl ap was r e por t e d f or 100
consecut i vel y t r e a t e d REC def ect s. 134 The pr ocedur e pr o-
duced a me a n r oot coverage of 97.7 % wi t h compl et e r oot
coverage i n 89% of t he si t es. Ne i t h e r def ect wi dt h nor
de pt h a p p e a r e d t o affect r oot coverage. Al l def ect s ha d a 2
mm de pt h wi t h a r ange of 2.0 t o 7.0 mm and a mean of 3.3
mm. The me a n wi dt h was 3.5 mm. Res ul t s were r e por t e d
1- year af t er s ur ger y for a connect i ve t i ssue gr af t cover ed by
a f ul l - t hi cknes s doubl e - pa pi l l a fl ap. 135 Mean REC for 15
si t es decr eas ed f r om 3.66 mm t o 1.09 mm for a me a n r oot
cover age of 70.5 %. The me a n di mens i on of ker at i ni zed t i s-
sue i ncr eas ed f r om 1.6 mm t o 4.3 mm. I t was not e d t ha t
connect i ve t i ssue gr af t ed be ne a t h t he al veol ar mucos a di d
not i nduce i t s t r a ns f or ma t i on i nt o ker at i ni zed gi ngi val t i s-
sue. The a ut hor s cons i der ed t he cani ne t oot h an unf avor -
abl e si t e for c ompl e t e r oot cover age due t o i t s r oot pr om-
i nence.
I n a c ompa r a t i ve s t udy, 30 cl ass I and I I REC def ect s i n
30 s ubj ect s were t r e a t e d wi t h a s ubepi t hel i al connect i ve
t i ssue gr af t pr ocedur e. 136 I n one gr oup of 15 si t es, t he ep-
i t hel i al col l ar of t he gr af t was r e t a i ne d and l ef t expos ed
( CTG gr oup) . I n t he ot her gr oup of 15 si t es, t he epi t hel i al
col l ar was r emoved, t he r oot s wer e condi t i oned wi t h CA,
and t he gr af t was compl et el y s ubme r ge d under a cor onal l y
pos i t i oned fl ap (CR gr oup) . Me a n r oot exposur e was
r educed f r om 4.53 mm t o 1.60 mm i n t he CTG gr oup, f or
a mean r oot cover age of 65 %, a nd f r om 4.20 mm t o 1.27 mm
i n t he CR gr oup, for a me a n r oot coverage of 70%.
Compl et e r oot cover age was achi eved i n 5 of 15 si t es i n t he
CTG gr oup a nd 3 of 15 si t es i n t he CR gr oup.
A t i t a ni um- r e i nf or c e d GT P M me mb r a n e was used t o
t r e a t si ngl e REC si t es i n 12 pa t i e nt s wi t h an a t t a c h me n t
loss of 4 t o 7 mm f r om t he CEJ t o t he most cor onal a t t a c h-
me nt wi t hi n t he sul cus. 137 A t r a pe z oi da l fl ap was r ai sed a nd
t he r oot sur f ace was t hor oughl y cl eaned wi t h cur et t es a nd
r ot ar y i ns t r ume nt s . The me mb r a n e was s haped t o cr eat e a
space bet ween i t a nd t he expos ed root , a d a p t e d over t he
r oot , a nd s ut ur e d at t he CEJ. Th e fl ap was cor onal l y posi -
t i oned t o obt a i n me mbr a ne coverage. Af t er 4 weeks, t he
me mbr a ne was r emoved, a nd a f ul l t hi cknes s fl ap was
r ai sed a nd pos i t i one d cor onal l y t o cover t he newl y r egen-
er at ed t i ssue. Me a n bas el i ne a t t a c h me n t l oss was 5.3 mm
and at 15 mont hs af t er s ur ger y i t was 1.4 mm for a me a n
r oot cover age of 73. 6%.
Use of a GT P M me mbr a ne c ombi ne d wi t h TTC r oot
condi t i oni ng a nd a f i br i n- f i br onect i n seal i ng s ys t em ( Ti s-
sucol, I mmu n o AG, Vi enna, Aus t r i a) was des cr i bed for
t r e a t me n t of REC i n 15 pa t i e nt s wi t h i sol at ed def ect s 4 t o
6 mm deep. 13s Th e me mbr a ne was r emoved af t er 6 weeks
and t he p a t i e n t s were eval uat ed 6 mont hs af t er me mb r a n e
r emoval . Me a n REC decr eas ed f r om 4.7 mm t o 1.1 mm,
r e pr e s e nt i ng a mean r oot cover age of 77 %. Compl e t e r oot
cover age was achi eved i n 6 of 15 si t es. The i nt e r pos i t i on of
a 2 t o 3 mm t hi c k fi l m of f i br i n- f i br onect i n bet ween t he
me mbr a ne a nd t he r oot sur f ace a ppe a r e d t o pr ovi de
enough space for r egener at i ng t i ssues.
I n a case r epor t , a ma n d i b u l a r i nci sor wi t h REC, an ab-
sence of a t t a c he d gi ngi va, a nd 5 t o 6 mm PPD on t he f aci al
and i nt e r pr oxi ma l sur f aces was t r e a t e d by GTR wi t h a
GT P M me mb r a n e and DF DBAJ 39 At 8 mont hs a f t e r sur-
gery, t he r e was a gai n of CAL on t he mesi al , faci al , and di s-
t al as pect s of 5.0 mm, 4.5 mm, a nd 4.0 mm, r espect i vel y.
Ke r a t i ni z e d gi ngi va i ncr eas ed f r om 1.0 t o 3.0 mm a nd 86 %
r oot cover age was achi eved.
P e r i o d o n t a l ma i n t e n a n c e t h e r a p y
The r es ul t s of pe r i odont a l ma i nt e na nc e t h e r a p y ( MT)
was e va l ua t e d i n young a dul t s wi t h sever e pe r i odont i t i s
( SP) who ha d pr evi ous l y r ecei ved pe r i odont a l t h e r a p y
consi st i ng of SRP f ol l owed by OFDB. 14~ Over al l PPD i n-
cr eased at a ye a r l y r at e of 0.19 mm, wher eas at per i odon-
t al l y i nvol ved si t es, P P D i ncr eas ed at a r at e of 0.65 mm.
Si t es i n whi ch Pg was de t e c t e d ha d a mean l oss of CAL of
0.72 mm af t er 3 mont hs and si t es havi ng no de t e c t a bl e Pg
exper i enced l i t t l e or no l oss of CAL. Aa was de t e c t e d i n 29
si t es f r om 12 s ubj ect s but was not as s oci at ed wi t h l oss of
CAL. The s e r es ul t s i ndi c a t e t h a t Pg, b u t not Aa, ma y be
pr edi ct i ve of f ut ur e l oss of CAL i n young a dul t s wi t h gen-
er al i zed SP a nd t h a t t he f r equency of pe r i odont a l di sease
pr ogr essi on ma y be hi gher i n SP pa t i e nt s t ha n i n ot he r pa-
t i e nt popul at i ons . Mi cr obi ol ogi cal moni t or i ng of pa t i e nt s
for Pg a nd mor e f r e que nt cl i ni cal moni t or i ng of SP pa t i e nt s
ma y be a p p r o p r i a t e dur i ng MT.
The effect of MT was e va l ua t e d over a 4- year pe r i od i n
39 pa t i e nt s who ha d been successf ul l y t r e a t e d for moder -
at e t o a dva nc e d per i odont i t i s . 141 The r esul t s doc ume nt e d
t h a t pa t i e nt s wi t h a hi gher me a n BOP pr eval ence had
hi gher r i sk for l oss of CAL at si ngl e si t es. On t he basi s of
t hi s l i mi t e d evi dence, i t was suggest ed t ha t i t woul d be ap-
pr opr i a t e t o use a t hr e s hol d BOP val ue as a ma r k e r for i n-
t ens i f yi ng t r e a t me n t dur i ng pe r i odont a l MT. A speci fi c
BOP t hr e s hol d was not suggest ed.
Ot her t ha n BOP a nd PPD, no cl i ni cal i ndi cat or s of di s-
ease have been shown t o be usef ul pr e di c t or s of f ut ur e di s-
ease act i vi t y. The i nf l uence of mol a r f ur cat i on i nvol vement
( FI ) a nd t oot h mobi l i t y ( MOB) on t he r esponse t o per i o-
dont a l t h e r a p y was e va l ua t e d i n 24 pa t i e nt s pl a c e d on a
3- mont h i nt er val over an 8- ye a r per i od of MT a f t e r per i -
odont al s ur ge r yJ 42 I t was concl uded t ha t mol ar s wi t h F I
l ose mor e CAL a nd ar e 2.5 t i me s mor e l i kel y t o be l ost t ha n
mol ar s wi t hout FI dur i ng MT. MOB al so r es ul t ed i n mor e
l oss of CAL i n mol ar t eet h, a nd mobi l e t e e t h wi t h F I were
f ound t o l ose mor e CAL t ha n mol ar s wi t h ei t her MOB or
FI al one. Mor e successf ul t r e a t me n t for mol ar t e e t h wi t h F I
af t er t h e r a p y ma y d e p e n d on de ve l opme nt of new i ns t r u-
me nt s or t echni ques t h a t coul d r emove or cont r ol t he l ocal
et i ol ogi c f act or s wi t hi n t he FI .
The r ol e of MT was assessed i n t he ma i nt e na nc e of CAL
gai ned by GTR i n deep i nt r a bone def ect s. 143 Af t er GTR
wi t h GT P M me mbr a ne s , 40 deep i nt r a bone def ect s i n 23
pa t i e nt s gai ned 4.1 mm of CAL af t er 1 year of s t r i nge nt
pl aque cont r ol . I n t he s ubs e que nt 3 year s, 15 pa t i e nt s wi t h
22 t r e a t e d si t es ( gr oup A) wer e r ecal l ed ever y 3 mont hs . I n
t hi s gr oup CAL r e ma i ne d st abl e. Conver sel y, ei ght pa t i e nt s
wi t h 18 si t es ( gr oup B), who r ecei ved onl y s por adi c care,
l ost 2.8 _+ 2.7 mm of t he CAL t h a t ha d been gai ned a t 1
year . Det ect i on of BOP, pl aque, Pg and, P/ was si gni fi -
cant l y mor e f r e que nt in r e ge ne r a t e d si t es of gr oup B
pat i ent s . I t was concl uded t h a t s t a bi l i t y of t he sur gi cal l y
gai ned CAL was as s oci at ed wi t h s t r i nge nt or al hygi ene t h a t
was mor e pr e di c t a bl y enf or ced by a r egul ar MT pr ogr am.
Nonpr e s c r i pt i on pr e br us hi ng r i nses t o f aci l i t at e de nt a l
pl aque r emoval have been a dve r t i s e d i n r ecent years. A new
ver si on of t he pr e br us hi ng s ol ut i on Pl a x ( Col gat e- Pal mo-
l i ve) was r ecent l y i nt r oduc e d wi t h t he a ddi t i on of 0.03 t r i -
cl osan a nd 0.025 s odi um f l uor i de t o i t s var i ous d e t e r g e n t
i ngr edi ent s. I n a doubl e - bl i nd eval uat i on, t he pr opor t i on of
pl aque r emoved af t er r i nsi ng wi t h Pl ax r i nse and t oot h-
br us hi ng was c ompa r e d wi t h r i nsi ng wi t h pl acebo and
t oot h- br us hi ng. 144 Anal ysi s of d a t a r eveal ed no benef i ci al
effect i n t e r ms of pl aque r emoval when Pl ax r i nse was used.
I n t e r d i s c i p l i n a r y c o n s i d e r a t i o n s
The na t ur a l l y occur r i ng di mens i ons of t he dent ogi ngi val
j unc t i on were e xa mi ne d i n 10 a dul t h u ma n cadaver j aws. 145
Th e connect i ve t i s s ue a t t a c h me n t ( CTA) , epi t hel i al at -
t a c h me n t (EA), a nd sul cus de pt h (SD) were me a s ur e d hi s-
t omor phome t r i c a l l y on 171 t oot h sur f aces wi t h mean mea-
s u r e me n t s of 0.77 + 0.32 mm, 1.14 +_ 0.49 mm, a nd
1.34 +_ 0.84 mm, r es pect i vel y. Th e CTA var i ed i n l engt h
b u t wi t h a mor e nar r ow r ange t ha n t he EA or SD. Whe n t he
me a s ur e me nt s for sur f aces wi t h subgi ngi val r es t or at i ons
were c ompa r e d wi t h t he di mens i ons for sur f aces wi t hout
r es t or at i ons , t her e was a si gni f i cant l y l onger EA for t he re-
s t or ed t eet h. No si gni f i cant di f f er ence was f ound for t he
ot he r di mensi ons. The hi s t or i cal concept of al l owi ng 1.0
mm f or t he CTA woul d a de qua t e l y i ncl ude t he di mens i ons
f ound i n t hi s s t udy.
The i nf l uence of over hangi ng ma r gi na l r es t or at i ons on
pe r i odont a l s t at us was eval uat ed i n a r et r os pect i ve s t udy
on a consecut i ve r ef er r al popul a t i on at t he De p a r t me n t of
Per i odont ol ogy, Skans t ul l , St ockhol m, Sweden. 146 Al l pa -
t i e nt s r ef er r ed t o a nd gi ven pe r i odont a l t r e a t me n t a t t he
cl i ni c over a 2- year per i od were i ncl uded; t hus t he s ampl e
is r e pr e s e nt a t i ve of a pe r i odont i t i s popul at i on. I t was f ound
t h a t pe r i odont a l pocket s at pr oxi ma l si t es wi t h mar gi nal
over hangs were si gni f i cant l y de e pe r t h a n si t es wi t h me t a l
r es t or at i ons wi t hout over hangs, a nd t he cl oser t he over -
hang was t o t he pe r i odont a l t i ssues, t he mor e pr onounc e d
was t he de t r i me nt a l effect .
Si nt e r e d met al s have r ecent l y been devel oped for t he
cons t r uct i on of me t a l cer ami c crowns. A r a ndomi z e d dou-
bl e - bl i nd s t udy c ompa r e d t he gi ngi val r esponses t o ar t i f i -
JULY 1995 73
cial crowns with sintered noble metal margins and cast no-
ble metal margins by measuring gingival crevicular fluid
(GCF) flow in highly motivated patients. 147 Significantly
elevated GCF flow rates were recorded for all artificial
crowns, compared with natural teeth, but there were no
variations recorded for the different types of crown mar-
gins. These results indicated that the subgingival sintered
copings caused no more gingival inflammation than tradi-
tional cast metal copings.
The effect of denture wearing habits was studied in 31
overdenture wearers, 17 day-and-night wearers and 14
day-only wearers, during a period of 5 years with controlled
oral hygiene. 14s During the study period, 20 % of the abut-
ment tooth surfaces showed loss of CAL and 40 carious le-
sions developed in the day-and-night wearers compared
with 8 % of tooth surfaces with CAL loss and three carious
lesions in the day-only wearers. These results indicate that
wearing overdentures day and night is a major risk factor
for periodontitis and caries in complete overdenture pa-
tients with controlled oral hygiene.
Electronic dental analgesia systems (EDA), which are
supposed to offer an alternative to local anesthetics, have
recently been introduced. The reliability of the ACS system
(Anesthesia Concept Systems, Synapse, Paris, France) was
investigated during periodontal therapy with a sonic scaler
(Sconiflex 2000-N, KAVO, Brussels, Belgium). 149 The
clinical trial was conducted as a randomized single-blind
split-mouth design. Results indicated no significant differ-
ences in subject pain assessment because similar results
were obtained in both the EDA and placebo trials. It was
concluded that the effect of EDA application during scal-
ing is of questionable value.
Temporomandibular joint sounds were defended in a
thesis by Spruijt and Wabeke. 15~ Examination of different
groups of subjects showed that TMJ sounds are fairly
common in nonpatients. Within the field of TMD, total
freedom from TMJ sounds can no longer be considered a
treatment goal. TMJ sounds are not indicative of disorder.
The sounds may or may not accompany pain and impaired
mobility of the TMJ, but they are, in themselves, not an
indication of TMD. Pain and functional limitations are in-
dicators of TMD. The authors concluded their thesis by
stating "it clicks, so what?"
Many articles stress the need for improvement in clini-
cal diagnostics. However, instrumental imaging analysis
gets priority in several studies, which mostly emphasize the
problem of TMJ disk displacement. One hundred patients
suspected to have disk displacement were evaluated and
compared clinically and by pseudodynamic MRI. 151 There
was a positive correlation between both diagnostic methods
in 66% of the joints. In 15% there was disagreement
between the two methods. MRI showed the possibility to
correct the clinical diagnosis in more than half of the
remaining joints. The other half of the joints became a
source of discussion and suggested that MRI has some dif-
ficulties in detecting the exact disk position, especially in
joints with an anterior disk displacement with early reduc-
tion. This is clinically easy to realize and to understand,
and this is also supported by the previously mentioned
study, underlining the pattern of TMJ clicking noises to
come and go. Overdiagnostics used in the interpretation of
MRI findings followed by extensive treatments regularly
crosses the mind of the critical clinician. One study on
clinical findings related to morphologic changes in TMJ
autopsy specimens found that the association between pain
and dysfunction and joint morphology is complex, and
gross morphologic alterations can be present in the absence
of TMJ pain and dysfunction. 152 Nineteen persons had
been clinically examined before death for signs and symp-
toms of TMD. The TMJs were later analyzed macroscop-
ically at autopsy and statistically associated with history
and clinical findings. The majority of joints showed differ-
ent forms of changes. In contradiction, signs and symptoms
of TMD had not been common for the persons when alive.
The results of another autopsy study underline the patho-
genesis of TMD to be functional. 153 Specimens from young
people were compared with specimens from elderly. The
results suggested that the frequency ofmorphologic changes
such as deviation in form, arthrosis, perforations, disk dis-
placement, disk deformation, and adhesions is higher in the
TMJs of elderly persons. Clinical follow up studies 154-156
proclaim the value of nonsurgical treatment modalities
that seem to be directed toward the causal function that is
the trigger for the intra-articular changes from adaptation.
The first study involved 195 patients treated conserva-
tively for 2 years. The results showed a statistically signif-
icant reduction of symptoms and continuing improvement.
An exponential mathematic model demonstrated that sta-
bilization of the effectiveness of conservative therapeutic
schemes for CMD was achieved between 6 months and 1
year after the initiation of treatment. Magnusson et al. 155
longitudinally followed up 84 subjects 15 to 25 years of age
concerning clinical signs of craniomandibular dysfunction.
Only 21 subjects (25 % ) were judged by the examiners to be
in need of some kind of functional treatment. A minor
treatment was suggested that in most cases, could be
incorporated into the subject's ordinary dental treatment.
Clinical signs of TMJ osteoarthrosis and internal derange-
ment 30 years after nonsurgical treatment were studied by
de Leeuw et al. 156 Ninety-nine patients and 35 control
subjects participated in the study. During the first years of
treatment, the main signs of TMJ osteoarthrosis and
internal derangement decreased significantly. In the next
three decades, very few changes were noticed underlining
the immediate response of treatment and long-lasting su-
periority of a correct initial diagnosis. The importance of
proper diagnostic criteria was stressed in the discussion of
the questionable effects of conservative treatment in 33
patients who later underwent TMJ surgery. 157 Patients
with ankylosis and anterior disk displacement without re-
duction were generally referred for consultation with a
surgeon earlier than normal.
New discoveries in the field of TMJ anatomy were made
that may enable more adequate conservative treatment
designj 5s Eight TMJs were removed from elderly human
cadavers. The histologic features of the retrodiscal tissues
of TMJs in the open and closed position were compared.
The primary role of these components was to provide a
volumetric compensatory mechanism for pressure equili-
bration. The mechanism was still functioning in joints that
demonstrated pathological changes. Elastin found in the
upper and lower strata of the retrodiscal tissues and in the
central zone was believed to provide the primary volume
compensatory mechanism for the joint. Angiography of the
temporomandibular joint autopsy specimens showed that
most of the vascular supply appears to come from the lat-
eral and medial aspects of the condyle head and from the
anterior and posterior disk attachments. 159 Twenty young
intact temporomandibular joints (mean age 26.2 years)
were examined at autopsy regarding the.histologic organi-
zation of the lateral pterygoid muscle interface with the
temporomandibular joint. 16~ At the insertion of the muscle
to the joint, no consistent divisions into separate anatomic
muscle heads were found. The muscle fibers attached to the
condyle immediately inferior to the articular surface in all
cases, and very few fibers inserted into the disk. Therefore,
it was hypothesized that the force exerted by these few fi-
bers inserting into the disk would not be responsible for an
anterior displacement of the disk. The observation of an
identifiable tendon inserting through fibrocartilage supe-
riorly, while the muscle fibers attached to the periosteum
inferiorly, is important in the interpretation of soft tissue
TMJ imaging. The distribution and arrangement of extra-
cellular matrix proteins were examined in the primate
temporomandibular joint disk and posterior attachment
with a combination of light microscopic, immunohisto-
chemical, and biochemical techniques. 161 The results of the
examination of the 22 juvenile and subadult macaques and
baboons indicate that the primate TMJ disk is a microhet-
erogenous tissue with distinct regional specializations. Ko-
rioth and Hannam ~62 studied the forces during simulated
tooth clenching. They described the articular loading and
the simultaneous forces on the dental arch with static bites
on a three-dimensional finite element model of the human
mandible. Five clenching tasks were modeled. Predictions
were confirmed that the human mandibular condyles are
load-bearing, with greater force magnitudes transmitted
bilaterally during intercuspal and incisal clenching and
through the balancing-side articulation during unilateral
biting. Higher forces were found on the lateral and latero-
posterior regions of the condyles during intercuspal clench-
ing. The medial condylar regions were more heavily loaded
during incisal clenching. The distribution of TMJ reaction
forces between working and balancing sides was described
in another article ~G3with a biomechanical model of the hu-
man mandible used in unilateral clench. The reaction
forces that act on the TMJ during unilateral clench do not
always load the balancing-side joint more than the work-
ing-side joint.
A series of studies on thermography was presented by
Gratt et al. 163-167 Thermographic characterization of inter-
nal derangement of the temporomandibular joint was as-
sessed in 30 patients with internal derangement verified by
temporomandibular joint arthrotomography with an
Agema 870 thermographic unit. The results indicated low
levels of thermal symmetry in patients with internal
derangement of TMJ. Characteristic thermal TMJ changes
suggested the technique has potential for clinical develop-
ment, although the results do not allow any differential di-
agnostic conclusions. The same technique was applied to
study the difference between 50 TMJ patients with inter-
nal derangement or osteoarthrosis and 30 normal TMJ
subjects. In differentiating between "abnormal" and "nor-
mal" TMJs by classification-tree analysis, correct classifi-
cations were made in 89 % of the cases and observer diag-
nostic accuracy was 84 %. In evaluating for specific diag-
noses, correct classifications were made in 73 % of the cases;
the observer evaluation was correct in 59 %. The three best
temperature measures found were the zone immediately
overlying the TMJ, the midfacial zone temperature, and
the spot temperature anterior to the external auditory me-
atus. The clinical procedure can be performed quickly and
is not invasive, painful, or unpleasant. Thus it seems to of-
fer socioeconomic advantages in the confusion of confir-
matory instruments in diagnostics. In the third study the
technique was used to identify inferior alveolar nerve def-
icits, a major complication in maxillofacial surgery. Six
such diagnosed patients were compared with 12 normal
subjects. The results indicated high levels of thermal sym-
metry of the chin in normal subjects and low levels of ther-
mal symmetry in the patients. The differences between the
groups were noticeable in the frontally projected facial
thermograms. Thermographic assessment of reversible in-
ferior alveolar nerve deficit was studied in 12 subjects in
whom a conduction defect of the inferior alveolar nerve was
induced by use of 2 % lidocaine. Changes in facial skin
temperature manifested the induced deficit earlier than
discriminative clinical tests. The prolonged elevation of
thermal asymmetry suggested that the technique has the
ability to detect subtle changes in nerve function that are
not discernible by physical neurosensory tests relying on
patient response. Thus clinical improvements are to be ex-
pected when the technique has been further evaluated.
An Italian study of 797 patients found that patients with
more severe arthropathy showed more ear, nose, and throat
symptoms36s The clinical criteria of severity encompassed
joint sounds, tenderness to temporomandibular palpation,
and pain severity in the temporomandibular joint region.
The severity of arthropathy was significantly associated
with ear, nose, and throat symptoms as a whole and specif-
ically with deafness and dizziness. However, tinnitus and
J U L Y 1 9 9 5 7 5
earache were not statistically significant in association.
Tinnitus remains in the gray area between the different
health professions.
A controlled clinical, electromyographic, and kinesio-
graphic assessment of craniomandibular disorders in
women compared 35 patients with 26 similarly aged wom-
en. 169 The patients showed higher prevalence of bruxism
than the controls but showed no significant differences in
the occlusal variables. The EMG assessment showed t hat
the rest activity of elevator muscles was significantly
higher. Only the maximum and average velocities during
fast and wide opening were significantly different between
the two groups. Dao et al.170 compared pain and quality of
life in bruxers and patients with myofascial pain of the
masticatory muscles. Self-reports of pain and quality of life
were recorded on 100 mm visual analogue and five-point
category scales from one group of 19 nocturnal bruxers and
61 patients with myofascial pain of the masticatory mus-
cles with no evidence of bruxism. Pain was more intense in
those bruxers who reported pain than among the myofas-
cial pain patients, even though pain was not the chief com-
plaint of bruxers. Pain from bruxism was worse in the
morning, and this suggests that it is possibly a form of pos-
texercise muscle soreness. Myofascial pain, which was
worse late in the day, is likely to have a different etiology.
The article leaves the reader to conclude that myofascial
pain may be the result of tooth clenching during the day.
If so, bruxism is defined as tooth grinding only. A separa-
tion of the two activities must be further emphasized in
future research. One study differentiated between muscu-
loligamentous, dentoalveolar, and neurologically based
craniofacial pain by using a diagnostic questionnaire. 171 It
was concluded t hat the questionnaire might be used for an
initial categorization of pain, but there is still no substitute
for a thorough history and clinical examination.
The influence of time, facial side, and location on pain-
pressure thresholds in 29 patients with chronic myogenous
temporomandibular disorder were studied and compared
with 11 controls. 172 No significant pain-pressure threshold
differences were found between the more and less painful
sides, as indicated by the patients, which lends support to
theories of centrally mediated pain. Against this back-
ground, the results of topical application of capsaicin (a
substance P depleter) in certain types of neurogenically
mediated pain conditions are confusing but interesting. 173
The cause and effect of mandibular and condylar asym-
metries were the focus of several studies. Prepubertal facial
t rauma seems to be related to radiographic evidence of
mandibular asymmetry. 174 In another study 11 patients
presenting with mandibular asymmetry were exposed to
MR imaging and arthrography of the temporomandibular
joints. 175 The results of this study indicate to the reader
t hat a condylar asymmetry was the main reason for the
clinically recognized mandibular asymmetry. The varia-
tion of condylar asymmetry with age in edentulous patients
with craniomandibular disorder of myogenous origin was
studied by Miller. 176 The asymmetry index was found to be
lower than that of dentate patients with craniomandibular
disorders. It was also found to be higher than t hat of a nor-
mal edentulous patient group. No correlation between age
and the asymmetry index was found. The results empha-
size t hat craniomandibular disorders have a functional eti-
ology and are not age dependant. The reasons for condylar
asymmetry are not fully known. Therefore the suggestive
article on the importance of disk position by Hall and
Nickerson 177 is an interesting contribution to the list of fu-
ture research proposals.
The increase of vertical dimension by 3.5 to 4.5 mm in-
terincisally was studied in eight subjects regarding its ef-
fect on mandibular postural rest position.17s Initial speech
difficulties and muscle discomfort decreased within 2
weeks. No difference was found in interocclusal rest space
after the occlusal vertical dimension was increased for
clinical rest position and for relaxed resting posture. This
suggests t hat the clinician may not need to be afraid of
changing vertical dimension when abraded teeth are to be
restored. A computerized system for reproducing a pa-
tient' s occlusion during mandibular movements was devel-
oped and described in a Japanese st udyJ 79 When the abil-
ity to visualize and analyze the occlusion was provided
through recording of occlusal form and mandibular move-
ments optically and digitally, the limitations of the artic-
ulator and the casts were eliminated. However there were
inadequacies in both accuracy and convenience. Future re-
search and development were suggested by the investiga-
Stability of disclusion time was studied in six women 1
year after occlusal adjustment, is~ Before adjustment, the
women had presented multiple symptoms of chronic my-
ofascial pain dysfunction syndrome. The short mean dis-
clusion time remained after 1 year and no symptoms were
observed. However, nocturnal bruxism appeared to recur
with chronic regularity. The results indicate t hat short
disclusion time is beneficial for the masticatory muscles. In
a second study the same author compared the disclusion
time between chronic myofascial pain dysfunction patients
and nonpatients, lsl In general, the mean disclusion time
was significantly longer in dysfunction patients. The dis-
clusion time was suggested to be of diagnostic importance
when the differing etiologic factors of chronic muscle dys-
function are evaluated. Against this background it is inter-
esting to note t hat the results from another study is2 on
lateral and protrusive contact schemes and occlusal wear
concluded "t hat the role of disclusive protection in the oc-
currence of occlusal wear may be questioned." That study
was performed on 80 dental students. Among other things,
the difference in age between the various components
should be considered before the clinical applications of the
results turn into new dogmas. The T-scan system was used
in a study on the quantitative analysis of occlusal balance
in intercuspal position, ls3 Sixty normal subjects demon-
strated bilateral balance and an anteroposterior center of
force in the first molar region. Patients with cranioman-
dibular disorder demonstrated marked differences from
the control group. However, only five patients were exam-
ined. The specific diagnosis of the craniomandibular disor-
der was not reported. Therefore, the conclusion that the
T-scan system proved useful in determining premature
contacts in CMD patients must be interpreted with utmost
caution; especially because the occlusal pattern in CMD
patients fluctuates rapidly.
The masticatory function was studied in edentulous pa-
tients treated with fixed complete dentures on osseointe-
grated implants during a 10-year period. 184 Twenty-three
patients participated in the study. Nine patients received
a maxillary fixed implant-supported complete denture
prosthesis after the initial placement of the mandibular
restoration. The maximal occlusal force did not differ be-
tween the two different groups. A dramatic long-lasting
improvement of masticatory function is achieved with the
mandibular fixed implant-supported prosthesis in com-
plete denture wearers.
In a Swedish article, Hallonsten 185 questions the quality
of care for children. Children have special needs and den-
tists who do not devote at least 50 % of their time to the care
of children are probably not going to possess the necessary
skills. From a critical review of the literature on craniom-
andibular disorders in children it is almost impossible to
get a clear picture of the magnitude of the disorder in a pe-
diatric population. 186 Forty epidemiologic studies were
evaluated. Eight symptoms and eight signs were chosen
and analyzed. The variation of reported frequencies was
considerable. Despite the interexaminer and intraexam-
iner variation, the other plausible reason is that the meth-
ods used in these studies originally were designed to fit the
needs of an adult population. The methods have been ap-
plied to children without consideration of age and cognitive
development of the child. The reader concludes that to
improve the clinical situation in the future, the profession
needs strict diagnostic criteria and standardized methods
for the age groups to be examined.
The proliferation of articles related to implant dentistry
continued unabated in 1994. However, for the first time in
recent years, case reports and opinion articles were not
predominant. The majority of articles were either clinical
or laboratory studies related to longevity or other specific
aspects of implant dentistry. Perhaps this may be an indi-
cation of the increasing maturity of the discipline. Most of
the articles could be placed in one of three groups: presur-
gical alteration of implant sites, clinical studies, and fail-
ures and complications.
Numerous articles addressed topics related to presurgi-
cal alteration of potential implant sites, especially as it
concerns the final esthetic result. The emphasis of these
articles was on thorough data collection and treatment
planning before placement of the implants.
Another large group of articles described clinical studies,
including many retrospective analyses of success/failure
rates and an encouraging number of prospective studies.
The other topic addressed by a large number of investi-
gations was that of failures and complications from implant
therapy. Often these failures occur in patients who have
developed unrealistic expectations. The importance of
skilled patient management and proper informed consent
before initiation of irreversible treatment cannot be over-
Pr e s ur gi e a l t r e a t me nt pl a nni ng/
a l t e r a t i on of pot e nt i a l i mpl a nt s i t e s
An interesting epidemiological study evaluated the num-
ber and location of potential implant sites in a population
of 579 Swedish adults between 20 and 80 years of age. ls7
The study used a radiological evaluation with implant
templates corrected for magnification and evaluated sites
anterior to the second molars. No attempt was made to
calculate the width of the alveolus, which reduces the
power of the study; however some interesting observations
were made. Seventy-eight per cent of the available sites
were in individuals between 60 and 80 years of age. Only 4 %
of these patients were interested in receiving implant ther-
apy! Thirteen per cent of patients from 40 to 60 years of age
were willing to consider implant therapy. The primary
conclusion of the study was that the number of totally
edentulous patients will clearly decrease in the future, and
the primary receiver of implant therapy will be partially
edentulous patients. It is not known how closely these
numbers can be extrapolated to the North American pop-
ulation, but it is likely that the trends will be similar.
Sophisticated diagnosis and treatment planning in par-
tially edentulous patients is critical, especially in the pos-
terior mandible. Accurate radiographic assessment of the
amount of remaining bone and the location of anatomical
structures, especially the mandibular canal, is essential. A
number of options are available for radiographic evalua-
tion, and one excellent study compared the accuracy of pe-
riapical, panoramic, and computerized tomographic radio-
graphs in locating the mandibular canal, lss The study used
a human cadaver mandible and a custom acrylic-resin
template with gutta-percha markers.
Periapical and panoramic radiography has obvious lim-
itations in that both are two-dimensional and do not per-
mit accurate determination of the buccolingual position of
the mandibular canal. Three-dimensional computerized
tomography can provide this valuable information, but the
dimensional accuracy of such surveys have not been deter-
mined. Data from this study determined that the average
distortion with periapical radiographs was 14 % (1.9 mm),
and the distances measured were always enlarged. The
distortions with panoramic radiography were greater
(23.5%-3.0 mm), and were generally found to be enlarged,
but in some cases were diminished.
Computerized tomography was very accurate, with dis-
J ULY 1995 77
tortion amounting to only 1.8% (0.2 ram), which would
likely have minimal clinical significance. It is believed that
longer implants are essential to withstand occlusal stresses
in the posterior mandible over the long term. Given that the
major impediment to placing such longer implants is the
position of the mandibular canal, it would seem imperative
that computerized tomography be utilized to determine
accurately both the amount of bone and position of the ca-
nal before determining the definitive treatment plan. Re-
lying on an inaccurate radiographic survey may well result
in placement of implants where inadequate bone exists or
implants that are shorter than they need to be, thus com-
promising the long-term prognosis. An even worse conse-
quence would be inadvertent penetration of the canal with
attendant paresthesia or dysesthesia.
Patients often present with moderate to severe resorp-
tion of the alveolus in the posterior mandible. The clinician
is~ faced with a difficult diagnostic decision in these pa-
tients, because of the number of surgical/restorative op-
tions. Ridge grafting and/or augmentation with exclusion
membranes is not entirely predictable, and in the case of
ridge grafting requires hospitalization and involves exten-
sive morbidity at the donor site. In addition, the new
osseous structure often creates restorative p~oblems by re-
ducing the interocclusal distance.
Placement of short implants, even with the advent of the
new wider fixtures, is rather unpredictable. One option is
to consider mandibular nerve transpositioning surgery.
This procedure permits placements of implants of suffi-
cient length along with bicortical stabilization at the same
surgical operation as the transposition of the neurovascu-
lar bundle. Three articles written on the subject of man-
dibular nerve repositioning illustrate the disparity in qual-
ity of articles related to implant dentistry. 189191
One article, which was essentially a case report, merely
described the surgical and restorative procedures that were
followed, ls9 Although the results of the procedures de-
scribed were excellent, panoramic radiography was the
only survey used, which is questionable at best. More im-
portantly, the only mention of possible complications was
that the patient was informed of possible transient numb-
ness of the lip and chin, and that the potential for long-term
sensory alteration was remote, but it did exist. No discus-
sion of the incidence or severity of long-term complications
was given for the reader, nor was there any in- depth dis-
cussion of the advantages and disadvantages of the proce-
dure or other more conservative options. The article also
failed to discuss what experiential qualifications should be
possessed by the surgeon. Such an article can clearly paint
an unrealistically optimistic picture of this procedure and
could result in performance of this sophisticated surgical
operation by individuals ill-equipped to render such a ser-
Another article described the results of 10 mandibular
nerve transpositions and concomitant implant placement
in six patients. 19~ In contrast to the previous citation, the
benefits and risks of this procedure were well described as
were the details of the surgical procedure. An objective
measure of sensory alteration (two-point discrimination
test) was used. All implants placed were functioning well at
1 year. At 3 months 40 % of the sites demonstrated altered
sensation. This was reduced to 20 % at 6 months and 10 %
(one site) at I year. In the latter two evaluations, the pa-
tients reported normal function, but the objective discrim-
ination test showed some minimal sensory deficit. On the
basis of this preliminary data, consideration of the use of
this modality can be cautiously recommended.
A third article in this group was basically a discussion by
four prominent oral and maxillofacial surgeons on the rel-
ative benefits and risks of transposition of the inferior al-
veolar nerve in conjunction with implant placement. 191
This article should be required reading for surgeons and
restorative dentists alike before they decide to recommend
such a procedure for their patients. The authors of this il-
luminating article discuss in depth the benefits and risks
involved with this surgery. Although anecdotal, their col-
lective experiences indicate that 3 % to 5 % of patients may
suffer with permanent paresthesia or dysesthesia as a com-
plication of the surgery. Of the two sequelae, dysesthesia
involving a burning sensation of the chin, lip, and gingiva
is the most serious, and patients suffering from this prob-
lem are often exceedingly bitter. It is also important to note
that the incidence of dysesthesia is as high or higher when
implants are placed in atrophied posterior mandibles
without transposition of the neurovascular bundle, and the
quality of implant placement in these cases is inherently
compromised. The main conclusions of the article are that
the procedure is extremely beneficial to implant placement
and stability, but that there are serious complications for
a small but defined number of patients. Such a procedure
should only be undertaken by experienced surgeons after
careful consideration of the alternatives. The patient
should be fully informed about the potential risks involved.
Restoration of severely resorbed maxillary ridges is ex-
ceedingly difficult. In most patients with this condition
there is insufficient quantity and quality of bone in which
to place endosseous implants. A recent retrospective study
reported excellent results with iliac crest grafts stabilized
with endosseous implants, subantral augmentation, and
placements of implants in the grafted material a minimum
of 5 months later. 192
Twenty patients were treated in this study. Of the 21
implant fixtures used to stabilize the grafted material, 90 %
survived and were used in the final prosthesis. One hundred
twenty-seven implants were placed in the grafted material,
and 99% were in place and functioning 26 to 97 months af-
ter restoration. The amount of bone loss around the
implants at i year was comparable to that reported in other
studies with maxillary implants placed in nongrafted bone.
The implants were eventually restored with either fixed
restorations or totally implant-supported overdentures.
Although this approach requires three surgical operations
and the difficulties inherent with the iliac crest surgery, the
success reported in this study provides hope for such
patients who are indeed true dental cripples.
The topic of placement of implants immediately in ex-
traction sockets continues to be controversial, and two in-
teresting prospective studies have evaluated results ob-
tained with the use of different approaches to eliminate
osseous defects inherent with immediate placement. 193,194
In the first study, e-PTFE barrier membranes were
placed covering the implants and bony defects. 193 The
membranes were covered at the initial surgical operation,
and if they did not become exposed in the interim, they
were removed at second-stage surgery. In 20 of the 49 im-
plants placed, the membranes became exposed and were
removed before the abutment connection surgery. Three of
the 49 implants placed were lost (93.9 % survival) at 1 year.
The average gain in bone formation was 4.8 mm for sites
where the membrane was retained and 4 mm when the
barrier was prematurely exposed. The average mesiodistal
bone loss 1 year after loading was 0.72 mm.
The second study, which at the time of reporting only
followed the implants up to the time of abutment connec-
tion, used autogenous bone grafting at the time of imme-
diate implant placement to correct the osseous defectsJ 94
A total of 54 implants were placed in 30 patients. The au-
togenous bone chips were harvested from bony ledges and
protuberances in the surgical area and combined with bone
material retrieved from the drill flutes. All implants were
retained and loaded, and the reduction in defect depth and
width at second-stage surgery compared favorably with the
previous study.
On the basis of these studies, placement of implants in
an extraction socket along with either method to reduce
local osseous defects can be quite predictable. However, it
is important to note that the number of implants placed in
these studies is rather small and these results are extremely
short term. The long term-response of the grafted and re-
generated bone to loading is not known, and cannot be
predicted from these reports.
Another interesting article discussed the disadvantages
of placement of implants in extraction sockets and sug-
gested that a superior approach might be localized ridge
augmentation and guided tissue regeneration after extrac-
tion and before implant placement at a subsequent oper-
ation. The disadvantages of immediate placement of
implants in fresh extraction sites include potential for
compromised fixture placement, reduced stabilization, risk
of failure because ofinfection, poor esthetics, and the prob-
lems related to inherent bone defects, dehiscences, and
Waiting 3 to 6 weeks after extraction to place the im-
plants also has significant disadvantages, and the authors
believe that treating the extracted alveolus with a bone
graft to act as a space maintainer and provide osteoinduc-
tion and osteoconduction is superior option. This proce-
dure is accomplished in conjunction with exclusion mem-
brane placement to allow for guided tissue regeneration.
Although this two-step procedure is more expensive and
involves additional surgery, it does permit uncompromised
fixture placement to maximize esthetics and function of the
final prosthesis. The surgical and restorative results
achieved with four patients are presented to support this
approach, again a very small sample size from which to
draw general conclusions.
Clearly the demand for "esthetic" implant restorations
has increased as the emphasis from the restoration of to-
tally edentulous mouths to that of partially edentulous pa-
tients has evolved. One thorough article discussed the ma-
jor differences between use of the nonsegmented abutment
(UCLA) and esthetic titanium abutments (EsthetiCone,
Nobelpharma USA, Westmont, Ill.) to achieve predictable
esthetic implant restorations. 195 Both approaches allow
subgingival restorations beginning 2 to 3 mm beneath the
mucosa, thus creating a natural and gradual emergence
The nonsegmented abutment connects directly to the
implant fixture and permits restoration with limited in-
terocclusal distance and improvement in esthetics. The
abutment can be used with an internal hexagon for single
units or without for multiple restorations. The abutment
can be fabricated by waxing directly to the implant analogs,
to prefabricated plastic burnout patterns, or to machined
prefabricated gold alloy abutments. Potential deficiencies
with this system, (aside from the general technique sensi-
tivity and difficulty in determining an accurate "passive"
subgingival fit, which is common to both described sys-
tems) include galvanism and corrosion at the implant/res-
toration junction as a result of dissimilar metals, oreover-
,the soft tissue attachment to the restorative alloy and/or
ceramic may not be equal to that achieved with titanium.
These two deficiencies have not proved to be of major clin-
ical concern at this juncture.
The major difficulty with the nonsegmented abutment is
that it is retained to the fixtures with titanium alloy screws
that are the same diameter as the conventional abutment
screws. Thus there is no "weak link" with this system. It is
postulated that adverse forces on such a restoration may
not result in screw failure, and therefore transmit such
forces to the implant and supporting bone. While there is
no documentation to support the hyposthesis, it is believed
by some that this could eventually result in bone loss, mo-
bility, and implant failure.
The EsthetiCone abutment is a tapered transmucosal
titanium abutment with 1, 2, or 3 mm collars at the base.
Galvanism is obviously of no concern and, especially with
use of the 3 mm collar for cases where the implant fixture
is a considerable distance below the mucosa, hemidesmo-
somal attachment of the soft tissue can be expected. A gold
alloy cylinder fits over the titanium abutment. The gold
alloy cylinder becomes part of the wax pattern and even-
tually the final restoration. It contacts the abutment only
at the base and is retained with small gold alloy screws.
J ULY 1 9 9 5 79
These screws constitute the desired "weak link" in the sys-
tem, and are expected to loosen or break under adverse
lateral forces. This, it is postulated, releases the deleterious
forces before the bone/implant interface can be adversely
affected. The broken gold screw is easily retrievable,be-
cause it comes out with the abutment screw. Again, it must
be stated that there is no objective documentation sup-
porting this theory either.
The disadvantages of the EsthetiCone approach include
similar difficulties attaining accurate "passive" fits and the
fact that they cannot be used with single units because of
the lack of an antirotational device. This approach does not
solve the problem of limited interocclusal distance, and re-
quires a minimum of 6.7 mm from the top of the implant
to the top of the gold cylinder. To quote the author: "The
compromise of fabricating the restorations is the same. The
main difference between the UCLA abutment and the Es-
thetiCone -@ is that while both provide similar esthetic re-
sults, the EsthetiCone -O also provides a weak link in case
adverse forces are produced by an unacceptable fit."
Although the use of the nonsegmented abutment or Es-
thetiCone system permits use of subgingival restorations
and allows the restorations to emerge from the soft tissue,
they inherently do not address the basic problem that the
diameter of most implants is not the same as the roots of
the teeth they are replacing. One excellent article described
an innovative, practical, yet elegant technique to help pre-
dict, develop, and evaluate the emergence profile of the fi-
nal restoration and soft tissue contours at the provisional
stage. 196 The interested reader is referred to the article it-
self for the specific details of the proposed technique. It
uses a combination of surgical expansion of the soft tissue
and gingivoplasty along with a customized acrylic resin
provisional restoration that is used as a healing matrix for
the soft tissue in a manner similar to that used with the
ovate pontic concept. The tissues are allowed to stabilize
before fabrication of the definitive prosthesis, and a matrix
is used to ensure duplication of the contours of the provi-
sional in the final prosthesis. Soft tissue casts are used to
transfer the soft tissue contours formed by the provisional
restoration to the laboratory technician.
Cl i ni c a l s t udi e s
Considerable interest in the use of implant-supported
single-tooth restorations continues to be expressed. One
marginal retrospective study reported on 93 single-tooth
replacements using the Bhnemark system with implants
placed between 1987-1990.197 The restorations had been in
place from 3 to 46 months (mean 18 months). One weak-
ness of the study was the distribution of the implants, with
72% placed in the anterior maxilla and only one implant
placed in molar area. Implant survival rate was excellent,
with only 2/93 implants lost. Data regarding bone loss was
difficult to assess because of the admitted poor quality of
the radiographs obtained. Eighty-one per cent of the im-
plants had no occlusal contact in maximum intercuspation.
In spite of this lack of occlusal contact, 43 % of the resto-
rations demonstrated loose abutment screws over the short
course of the study. Nine crowns that had been perma-
nently cemented had to be remade because the abutment
screws beneath became loose.
Clearly many of the difficulties experienced in this study
can be attributed to poor abutment design and to the fact
that single-tooth implants were in their infancy when the
study was initiated. The conclusion offered by the authors
that, "From this study of the first group of consecutive sin-
gle-tooth replacements provided in a specialist clinic, it can
be concluded that this treatment alternative offers prom-
ising results for the replacement of missing single teeth,"
is not supported by the data presented. The limited success
documented in this study cannot be extrapolated to single-
tooth implants in the molar regions.
A superior prospective multicenter study, again prima-
rily in premolars and anterior teeth, reported results sim-
ilar to the previous study. 19s This study reported on 3-year
results and had an overall survival rate of 97.2 % and min-
imal gingival changes, with bone loss less than 0.1 mm per
year. Screw loosening was also a problem with this group
of patients and appeared to lessen somewhat in the second
and third years of the study. The investigators in both this
and the previous study reported significantly less screw
loosening when gold screws were used instead of titanium
screws. Again, results of this study should not be extrapo-
lated to single-tooth implants in the molar area.
Another prospective multicenter study evaluated 521
Bhnemark implants in 197 free-standing prostheses 3 years
after loading. 199 Cumulative success rates were 94.8% for
prostheses and 93.9% for implants. Most of the lost pros-
theses were supported by only two implants. The most
common complication was loosening of gold screw, which
occurred most often when there were only two supporting
implants. Data from this study support the concept of us-
ing as many implants as possible in partially edentulous
Economic considerations make the use of totally im-
plant-supported fixed prostheses out of the question for a
large segment of the population. Many of these patients
could receive tremendous benefits with the placement of
two implants and construction of a mandibular overden-
ture, and the costs of such therapy would likely be within
their means. A timely prospective study presented prelim-
inary data on implant-retained overdentnres in 36 pa-
tients. 2~176 In 12 of the patients the overdenture was attached
to the implants with magnets. Twelve dentures were
attached with ball attachments and 12 more with a bar and
clip system. The implants were under loading for times
ranging from 3 to 24 months (mean 12.4 months). There
were no failures in the study and no differences in clinical
performance of the prostheses, although more mainte-
nance appointments were required with the magnet and
ball attachment groups than with the groups with the bar
and clip system. This increased maintenance notwith-
standing, in the short term, the mode of attachment did not
seem to influence clinical success. It must be stressed that
these are short-term results and differences may become
apparent when long-term data become available. Implant-
retained mandibular overdentures do appear to offer a
predictable cost-effective service for most edentulous pa-
One interesting unexpected result of overdenture treat-
ment with many of these patients was a unique occupa-
tional opportunity. One of these patients found part-time
employment as a paper-punch, and several were research-
ing similar opportunities at the time of writing. While the
hours are long and little is known regarding occupational
hazards such as TMD, constipation, and so forth, the rates
of remuneration are high and may allow the patient to re-
turn at a future date for the placement of more implants
and a hybrid prosthesis. It is incumbent on the surgeon to
identify individuals who may wish to take advantage of this
unique opportunity. In these patients, very precise fixture
placement exactly 6.37 mm apart (center to center) is es-
sential to fit most commercially available binders.
The placement of osseointegrated implants in adolescent
patients remains controversial. Twenty-seven B~nemark
implants were placed in 15 patients aged 13 through 19
years and evaluated yearly for 3 years. 2~ All of the implants
osseointegrated, but in patients who demonstrated resid-
ual craniofacial growth, the implant-supported restora-
tions were in infraocclusion at 3 years. The relative posi-
tional change of the implants was determined to be the re-
sult jaw growth instead of tooth eruption or implant
intrusion. Basically this study agrees with previous animal
studies that revealed that implants placed in growing jaws
became ankylosed and did not move with jaw growth. Thus,
implants can be placed in adolescents, providing that all
teeth have fully erupted and that growth and skeletal de-
velopment is complete. The dental and skeletal maturity
instead of the chronologic age of the patient determines
whether the restored implant(s) will eventually be in infra-
occlusion. The study also demonstrated some interproxi-
mal bone loss on natural teeth adjacent to implants. The
author suggested that provision of sufficient mesiodistal
space before fixture placement is critical to avoid such bone
At the other end of the spectrum from adolescents are the
elderly patients who are candidates for implant placement.
One extensive article extracted data related to elderly pa-
tients from data gathered in previous studies. 2~ The arti-
cle tried to answer two main questions. First, can osseointe-
grated implants be prescribed for elderly patients? This
question was clearly answered in the affirmative as data
showed that of 207 implants placed in elderly patients, only
10 failed to integrate (success rate 95.2 %). This is compa-
rable to success rates in younger age groups. The second
question; can successful osseointegration be maintained as
these patient~ age? Again the answer is affirmative, because
only 1.5% of integrated implants were lost after loading in
the aforementioned group. The authors' state, "Our clini-
cal studies support the conclusion that neither advanced
age itself nor the diminished levels of oral hygiene that of-
ten accompany it are alone contraindications to a prescrip-
tion for treatment with osseointegration."
One specialized function that has been suggested for os-
seointegrated implants has received little scientific study,
that is anchorage for orthodontic movement of teeth in
partially edentulous adult patients. One well-conducted
investigation evaluated 23 implants used as anchorage in
nine patients aged 17 through 64 years. 2~ The implants
served to permit a wide range of orthodontic movements
for times ranging from 4 to 33 months. Cephalometric ra-
diographs were used to demonstrate that the implants re-
mained stationary and did not move during the duration of
the orthodontic treatment. After orthodontic treatment
was completed, the fixtures served as abutments for defin-
itive prostheses.
One of the major benefits of overdenture therapy, re-
taining natural tooth roots, is the maintenance of discreet
proprioception because of the presence of tactile receptors
in the periodontal ligament. Although implant-retained
overdentures fulfill many of the functions of tooth-retained
overdentures such as improved retention and stability and
bone preservation, it is not known what level of proprio-
ception is retained, because the periodontal ligament is
obviously absent. A recent study compared the ability of
patients with tooth- retained overdentures and implant-
retained overdentures to detect subtle differences in the
thicknesses of thin foils placed between the teeth. 2~ Ten
different thicknesses of foil (10 to 100 micrometers) were
used. Active oral tactile sensibility was significantly better
with natural teeth than with implant-supported overden-
tures. Thus it appears that the presence of a residual
periodontal ligament in the mandible influences the prop-
rioception of overdenture wearers. Implants supporting
overdentures do not appear to contribute to improved tac-
tile sensibility. However, they do contribute significantly to
improving the stability of overdentures, which may well be
more important for masticatory efficiency and comfort
than is tactile sensibility.
Compl i c a t i ons of i mpl a nt t he r a py
Several reviewed studies and a number that were not re-
viewed identified screw loosening as a significant problem,
especially with some of the early single-tooth implant res-
torations. As a result of the high incidence of loosening,
several articles were written that addressed different as-
pects of this vexing complication.
There are a number of potential causes of screw loosen-
ing, including lack of accurate "passive" fit of the restora-
tion, cyclical stresses, and excessive occlusal load. Another
potential factor is that the screw was simply not adequately
tightened at the time of placement. It appears from the lit-
erature that a certain minimum applied torque is essential
to prevent loosening, but excessive torque could exceed the
J U L Y 1 9 9 5 8 1
yield strength of the screw, resulting in permanent defor-
mation and loss of mechanical properties of the screw. One
study evaluated the ability of practitioners to impart the
desired torque with handheld screwdrivers. 2~ These au-
thors also examined the magnitude and variability of
torque generated by manual and electronic torque devices
currently on the market.
In part I of the study, 16 experienced surgeons and
prosthodontists were asked to place a 10, 20, and 32 Ncm
torque on an appropriate B~nemark implant component by
using handheld screwdrivers. The oral and maxillofacial
surgeons were consistently well below the desired values
(23 % to 48 %), whereas the prosthodontists placed torques
that were within 15 % of the desired values. These results
were obtained in a laboratory setting where the clinicians
did not have to contend with saliva, restricted access, and
poor visibility, all of which would make accurate applica-
tion of the proper torque more difficult.
In part II of the study, one clinician tested a number of
commercially available torquing devices to evaluate torque
delivered at specific target values. Although there was some
variability between the devices, they all consistently pro-
duced torques within 10 % of the desired target values.
Given the high incidence of screw loosening reported in
the literature, optimum tightening of screw components is
critical. The importance of being able to apply a desired
torque consistently to ensure that the components are nei-
ther overtightened or undertightened cannot be over-
stated. From the data presented in this study, it would ap-
pear that more consistent torque and preload can be
obtained with use of a calibrated torquing device.
A scholarly treatise, however, on tightening aspects of
screw joints in osseointegrated implants, along with the
principles of tightening methods and assessments of their
accuracy, casts some doubt on the validity of the preced-
ing conclusion. 2~ The use of engineering principles regard-
ing the significance of tightening abutment screws was dis-
cussed along with the difference between optimum torque
and design torque. It was concluded that the proprietary
literature loosely uses the term "optimum torque" :nap-
propriately, and that "design torque" is the more correct
term. Methods currently advocated for screw tightening in
implant dentistry were analyzed and found to be of limited
value. The authors conclude that an adequate torquing de-
vice would not only deliver the optimum torque required
but also detect misfits between the components. Undetec-
ted misfits often are responsible for screw loosening even
when the optimum torque is applied. Such devices are not
currently commercially available. The authors have de-
signed a prototype of such a device based on torque/angle
control methods instead of simple torque control.
One interesting case report described a patient who had
received a mandibular prosthesis fully supported with five
B~nemark implants. 2~ The implants and prosthesis had
functioned successfully for several years until the patient
was placed on a regimen of sodium diphenylhydantoinate
(Dilantin) as an antiaconvulsive agent subsequent to sur-
gery for a brain tumor. Eleven months after prescription of
the medication, the patient presented with firm, fibrotic,
hyperplastic peri-implant tissue that totally obliterated
the space between the ridge and the prosthesis. The tissue
mass was excised and t'ound histologically to be consistent
with a diagnosis of phenytoin hyperplasia. Because bacte-
rial plaque has been identified as an etiologic agent in Di-
lantin hyperplasia, the patient was placed on a strict oral
hygiene regimen with 3-month recall. There has been no
recurrence of the hyperplastic tissue at 1 year after ex-
One final citation was selected from outside the main-
stream implant literature because of the potential this
technology may have to improve the prognosis of implant
therapy. 2~ The research group presented a number of pro-
vocative studies on regeneration of both cartilage and bone
in animal models. The concept required the development
of synthetic biodegradable polymer materials that act as
scaffolds for the regenerating tissues. These scaffolds,
which consist of polymer strands, are seeded with either
bovine chondrocytes or fibroblasts from periosteum, de-
pending upon whether cartilage or bone is desired. The
scaffolds and seeded progenitor cells are then implanted
subcutaneously in mice. Twelve weeks after implantation,
new hyaline cartilage or bone is found at the surgical site:
The investigation described use of polymeric scaffold
material that was presurgically formed to one of four spe-
cific shapes. Twelve weeks after implantation, the newly
generated tissues were examined and found to have the
same shape and dimensions as the original construct. There
were no signs of resorption or overgrowth, and histologic
evaluation confirmed the presence of normal, mature
tissue. The results suggest that such ossified tissue can be
created in predetermined shapes and dimensions by the
use of cell transplantation on appropriate polymer tern-
plates. Such technology has great potential for ridge aug-
mentation before implant placement and would eliminate
the morbidity currently experienced with iliac crest grafts.
Further study is indeed indicated.
Implant dentistry continues to be a popular topic in the
literature. Data from long-term retrospective and prospec-
tive studies that were initiated in the infancy of the disc:-
pline are now becoming available and document the high
success rate regarding implant retention that was initially
reported. The trend of therapy continues to be toward so-
phisticated diagnosis and treatment planning, with the
emphasis placed on precise fixture placement for improved
esthetics and function. A number of important preplace-
ment modal:ties have been described, advocated, and, most
importantly, are beginning to be evaluated with objective
Complications of implant treatment continue to be a re-
ality, but can clearly be minimized with careful diagnosis
and t r e a t me nt pl anni ng, al ong wi t h met i cul ous del i very of
t he surgical, rest orat i ve, and fol l ow-up mai nt enance t her -
A maj or cri t i ci sm of t he dent al mat er i al s research area is
t ha t very few i nvest i gat ors are t r ul y seeking st r uct ur e-
pr oper t y rel at i onshi ps or at t empt i ng t o under s t and un-
der l yi ng mechani sms. Dur i ng t he pas t year t her e was liter-
ally an expl osi on of articles rel at ed t o bondi ng and adhe-
sive mat eri al s. However, al most all of t hese focused on
t est i ng commerci al pr oduct s, wi t h little if any t r ue scien-
tific focus. I ndi vi dual research r epor t s r epr esent ed qui t e a
br oad s pect r um of scientific value. At one ext reme, some
exper i ment s in ver y i mpor t ant areas were very poor l y de-
signed, l acki ng cont rol s, sufficient repl i cat i ons, and st at i s-
tical anal ysi s i n a meani ngf ul way. A si mi l ar ext reme was
t he case of exper i ment s t ha t were done well, whi ch shoul d
have never been done at all. Ther e are still a large numbe r
of uni mpor t a nt exper i ment s bei ng r out i nel y conduct ed.
Wh y is it val uabl e t o measur e bond st r engt hs in MPa t o t wo
deci mal pl aces? Wha t is t he real meani ng of a bond
st r engt h di fference t hat is onl y 1 MP a when most i ndi vi d-
ual s do not accur at el y follow t he manuf act ur er ' s i nst r uc-
t i ons for usi ng a pr oduct ? I n ever y one of t hese cases t he
exper i ment s i nvol ved numer ous cofact ors t ha t were ei t her
uncont r ol l ed and/ or ignored.
De n t a l a ma l g a m
Each year t her e is i ncreasi ng awareness t ha t dent al
amal gam is used less and less in devel oped count ri es, not
because of pot ent i al t oxi ci t y pr obl ems for pat i ent s, but be-
cause of i ncreasi ng envi r onment al regul at i ons and con-
cerns. Despi t e t he rising pressure f r om envi r onment al
forces, t her e are ma ny who resi st ed t hi s t ransi t i on. Cor bi n
and Kohn 2~ ar gued st r ongl y t ha t amal gam mus t cont i nue
t o be used because of t he enor mous economi c benefi t for
t he publ i c heal t h care syst em of t he Uni t ed St at es. Thei r
poi nt was t ha t even if t her e were some di sadvant ages, t hese
were offset by t he large benefi t deri ved by society. Ther e-
fore, t hese ot her risks shoul d be accept ed. Others, 21~ Ber r y
et al., st ressed t he need for amal gam use on t he basis of its
hi st ori c l ongevi t y in st ress bear i ng si t uat i ons. Still ot hers
cont i nued t o r ef ut e any pot ent i al t oxi c effects. Jones 14
summar i zed t he science of amal gam and t oxi ci t y issues in
an el egant article.
For t he t i me being, t her e is a maj or focus on i ncreasi ng
caut i ons f or mer cur y cont ai nment i n t he dent al operat ory.
Fer r acane et al. 211 r epor t ed t ha t mer cur y vapor levels
chai rsi de af t er amal gam pl acement or removal r et ur ned t o
backgr ound levels wi t hi n 20 t o 30 mi nut es even in poorl y
vent i l at ed operat ori es. Fi l t er i ng devi ces were capabl e of
r educi ng t he vapor levels by 25 % but coul d not reduce t he
exposur e t o backgr ound levels any faster. Powell et al. 212
det er mi ned vi a clinical si mul at i ons t ha t i nsert i on or re-
moval of dent al amal gam never el evat ed t he mer cur y vapor
concent r at i ons above 0.05 mg/ m 3 in t est s per f or med wi t h
Val i ant , Di spersal l oy, and I ndi sper se mat eri al s. The gr oup
also not ed t ha t i ndi um cont ai ni ng amal gams di d not seem
t o pr oduce r educed mer cur y levels. However, Okabe et
al.213 was able t o pr oduce lower mer cur y levels in i ndi um
cont ai ni ng syst ems but t he mechani sm of t he effect was
unknown. Mahl er 2~4 i nvest i gat ed t he effect of Sn on
r educi ng Hg vapor levels and demons t r at ed t ha t t here was
a st r ong correl at i on of Sn cont ent in t he gamma- one phase
wi t h r educed Hg vapor.
Al t er nat i ves t o mer cur y- cont ai ni ng syst ems are ones
wi t h i ncreased r epl acement of mer cur y wi t h i ndi um, gal-
lium, or bot h. However, t her e has been some concern t ha t
t hese subst i t ut es mi ght be as toxic. Chandl er et al. 215 dem-
onst r at ed t ha t gal l i um ni t r at e or i ndi um ni t r at e as dis-
solved salts were rel at i vel y nont oxi c in t i ssue cul t ure t est s
versus mer cur y ni t rat e.
Anot her pat i ent issue cont i nued t o be s ympt oms of some
pat i ent s t ha t were bl amed on dent al amal gam rest orat i ons.
Ther e is cont i nui ng review of t hese cases but onl y a l i mi t ed
number s of clinical studies. A t r eat ment r ecommended by
some ant i amal gami st s is t he pr escr i pt i on of met al com-
pl exi ng compounds such as EDTA or DMSA. Sandor ough
et al. 216 exami ned numer ous pat i ent s i n a pl acebo-con-
t rol l ed s t udy and concl uded t ha t t her e was no gr ound for
DMSA use.
Despi t e its decreasi ng usage, dent al amal gam cont i nues
t o pr ovi de l ong- t er m service. J oks t ad et al. 217 r epor t ed t hat
in a cross-sect i onal s t udy of al most 10,000 rest orat i ons i n
service, t he medi an r epl acement age f or amal gams, com-
posites, and gold r est or at i ons was 12 t o 14, 7 t o 8, and 20
years, respect i vel y.
Ad h e s i o n a n d b o n d i n g
Slowly, t her e is shi ft i ng concer n away from bond
st r engt hs t owar d t r yi ng t o under s t and t he energy-absorb-
ing charact eri st i cs of t he bonded i nt erface. Wi t h t ha t con-
cern has been an i ncreasi ng i nt erest i n measur i ng fat i gue
st r engt h, t oughness, and failure pat t er ns i nst ead of bond
st rengt hs. Er i ckson and Glasspoole 2~s comment ed at t he
end of t hei r review of composi t e resin syst ems t hat single-
cycle bond st r engt h has not been a good i ndi cat or of clin-
ical per f or mance. However, for t he moment , dent i n bond-
ing s t r engt h remai ns t he focus of al most every research
Char l t on and Beat t y 219 compar ed t wo dent i n bondi ng
syst ems ( Scot chbond Mul t i pur pose and Opt i bond) and
saw no difference i n bond st r engt h for bondi ng t o wet ver-
sus dr y dent i n subst rat es. Vargas and Swi ft 22~ saw no dif-
ference bet ween wet and dr y dent i n bondi ng for two bond-
i ng syst ems. However, for ma ny ot hers t hi s difference was
rel at i vel y i mpor t ant . El habas hy and Swi ft 221 exami ned
Tenur e sol ut i on bondi ng and demons t r at ed t ha t hi gher
shear bond st r engt hs were achi eved wi t h wet dent i n under
J ULY 1995 8 3
physi ol ogi c pr es s ur e t ha n for dr y dent i n. Gwi nne t t 222
d e mo n s t r a t e d t h a t dr i e d de nt i n coul d be r e we t t e d ade-
qua t e l y t o pr oduc e effect i ve bondi ng.
Nume r ous ma t e r i a l s wer e de mons t r a t e d t o i nt er f er e
wi t h enamel a n d / o r de nt i n bondi ng. Di s hma n et al. 223
showed t h a t bl eachi ng t r e a t me n t s af f ect ed enamel sur f aces
and i nt e r f e r e d wi t h t he pol yme r i z a t i on r eact i on, l i mi t i ng
bondi ng. Ha v e ma n and Cha r l t on 224 showed t h a t oxal at e
sol ut i ons, whi ch ar e r out i ne l y used t o seal de nt i n t o cont r ol
s ens i t i vi t y, i nt e r f e r e d wi t h de nt i n bondi ng when used i n
cavi t y pr e pa r a t i ons . Per i gao et al.225 i nves t i gat ed chl or hex-
i di ne use wi t h d e n t i n bondi ng syst ems. Al t hough chl or hex-
i di ne t r e a t me n t s pr oduc e d a de t e c t a bl e f i l m on dent i n, i t
di d not i nt er f er e wi t h bondi ng of Al l - Bond 2 de nt i n bond-
i ng agent . Fi l l e r et al. 226 not e d t he same r es ul t s for
chl or hexi di ne on enamel . However , ot her t hi ngs coul d
af f ect d e n t i n del et er i ous l y. Pe r di ga o et al. 227 not e d t h a t
de nt i n bondi ng was l ess effect i ve t o de mi ne r a l i z e d or
hype r mi ne r a l i z e d dent i n. Pe r di ga o et al. 22s e xa mi ne d t he
pot e nt i a l c ont a mi na t i on of si l i ca f r om aci d condi t i oni ng
gels. Al t hough si l i ca coul d be det ect ed, i t di d not seem t o
i nt er f er e wi t h bondi ng. Sal i va c ont a mi na t i on pr oduc e d
some r e duc t i on i n bond s t r e ngt h 229 but no s t a t i s t i c a l l y sig-
ni f i cant changes. Scl er ot i c d e n t i n pr oduces gr eat er chal -
l enges for d e n t i n bondi ng. Van Me e r be e k et al. 230 con-
cl uded t h a t i t is mor e di f f i cul t t o f or m hybr i d l ayer s when
scl er ot i c de nt i n is i nvol ved. I t mi ght be be t t e r t o use a bur
t o r oughen or r emove t he scl er ot i c out er l ayer of dent i n.
The mos t i mp o r t a n t st age i n bondi ng seems t o be get t i ng
t he bondi ng ma t e r i a l s t o wet de nt i n and p e n e t r a t e i nt o t he
sur f ace of t he i nt e r t ubul a r dent i n. Fi nger et al. 231 me a s ur e d
t he s ol ubi l i t y p a r a me t e r of r esi ns and not e d t h a t t hose wi t h
val ues gr eat er t h a n 30 MJ(1/2)/m (3/2) pr oduc e d s i gni f i cant l y
hi gher s he a r bond s t r e ngt hs becaus e of t he good wet t i ng.
Al l of t he des i r abl e pr ope r t i e s of t he bonde d i nt er f ace seem
t o d e p e n d on t he ext ent of t hi s wet t i ng. Ta m and Pi l l i ar 232
me a s ur e d t he i nt er r aci al f r act ur e t oughnes s for bondi ng
s ys t ems a nd showed t h a t condi t i oned and wet de nt i n mor e
easi l y pr oduc e d good bondi ng t ha n condi t i oned but dr y
de nt i n or unc ondi t i one d dent i n.
A cont i nui ng ques t i on for i nves t i gat or s has been t he
t he or e t i c a l l i mi t for de nt i n bondi ng st r engt h. Cha ppe l l and
Ei ck 233 e xa mi ne d si x c ur r e nt de nt i n bondi ng s ys t ems and
me a s ur e d bond s t r engt hs for most , and 15 t o 16 MPa wi t h
Sc ot c hbond Mul t i pur pos e was t he gr eat est . Gwi nnet t , 234
usi ng a new me t h o d t o meas ur e cohesi ve s t r engt h, r e por t e d
t h a t t he s hear bond s t r e ngt h for de nt i n was 36 MPa . How-
ever, Sano et al. 235 car ef ul l y col l ect ed mi cr os peci mens of
de nt i n f r om h u ma n and bovi ne t e e t h for mechani cal pr op-
er t y me a s ur e me nt s . Th e y r e por t e d ul t i ma t e t ens i l e
s t r engt hs for d e n t i n of a ppr oxi ma t e l y 100 MPa . Gener al l y
t he t ens i l e s t r e ngt h val ues ar e as s umed t o be appr oxi -
ma t e l y hal f of t he s hear s t r e ngt h val ues. Re t i e f et al. 236
l ooked at mi cr ol eakage ver sus bond s t r e ngt h a nd con-
cl uded t h a t as one a ppr oa c he d 21 MPa , t he mi cr ol eakage
val ues d r o p p e d cl ose t o zero. Ther ef or e, t ha t ma y be t he
pr act i cal l i mi t for cl i ni cal bond s t r engt h.
At t he mo me n t mos t cl i ni cal s t udi es of de nt i n bondi ng
s ys t ems have been conduct ed for onl y s hor t t i mes. Van
Me e r be e k et al.237 s umma r i z e d s t udi es i nvol vi ng mor e t ha n
1177 cl ass V adhes i ve r es t or at i ons as meet i ng t he ADA re-
qui r e me nt for pr ovi s i onal accept ance of no mor e t h a n 5 %
f ai l ur e at 1 year . Ot her s have ha d l ess success wi t h con-
t e mp o r a r y syst ems. 23s Duke et al.239 r e por t e d excel l ent re-
sul t s for Pr i s ma Uni ver s al Bond 3 adhesi ve af t er 2 year s of
cl i ni cal eval uat i on. Tyas, 24~ i n a s t udy wi t h Te nur e adhe-
sive, r e por t e d 11% f ai l ur e at 3 year s wi t h a sl i ght i ncr ease
i n mar gi n s t ai ni ng on average. Cl ear l y, mor e l ong- t er m
cl i ni cal t r i al s need t o be done t o cl ar i f y t he meani ng of l ab-
or at or y d a t a pr e s e nt l y bei ng gener at ed.
Al t hough t he r e is gener al consensus t ha t a hybr i d l ayer
is necessar y for good bondi ng, t he det ai l s of t he bondi ng
zone ar e st i l l not wel l under s t ood. The act ual bondi ng zone
can a p p a r e n t l y be qui t e het er ogeneous. The pr opos e d
me c ha ni s m f or de nt i n adhes i on i s by mi cr omechani cal i n-
t er l ocki ng of r esi n wi t h r e mn a n t col l agen i n t he decal ci f i ed
i nt e r t ubul a r dent i n. Some r esi n pe ne t r a t e s de nt i na l t u-
bul es, but t he e xt e nt of t h a t c ont r i but i on t o bondi ng is st i l l
not well under s t ood. Fe r r a r i et al. 241 r e por t e d de nt i na l t u-
bul e t ags of up t o 100 mi cr ons i n nonvi t al t eet h and up t o
10 mi cr ons i n vi t al t eet h, and t hes e few were conf i ned t o t he
fl oor of t he cavi t y pr e pa r a t i on. However , mos t t ubul e t ags
ar e r el at i vel y shor t . Ta y et al. 242 c onduc t e d SEM and TEM
i nves t i gat i ons of t he hybr i d l ayer zone but t hose ar e hi ghl y
s pecul at i ve i nt e r pr e t a t i ons of t he views. Ot her i nvest i ga-
t i ve t ool s ar e j us t begi nni ng t o be a ppl i e d t o t hi s pr obl em.
Cassi nel l i a nd Mo r r a 243 used at omi c force mi cr os copy t o
show t he a ppe a r a nc e of Gl uma on dent i n. Thi s t echni que
has gr eat a dva nt a ge because i t can pr oduce at omi c r esol u-
t i on.
I n a ddi t i on t o t he nor mal act i on of bondi ng agent
pr oduci ng an occl udi ng film, some mat er i al s cont ai n r eac-
t a nt s t h a t can i nt e r a c t wi t h t he s me a r l ayer. Di j kma n et
al. 244 eval uat ed gl ut a r di a l de hyde t r e a t me nt s of t he s mear
l ayer and r e p o r t e d suffi ci ent f i xat i on t o keep 50 % of t he
t ubul e openi ngs cover ed dur i ng condi t i oni ng t r e a t me nt s .
As de nt i n bondi ng s ys t ems become mor e wi del y used,
some cl i ni ci ans ar e r el yi ng on t he seal i ng abi l i t y and el i m-
i nat i ng t he use of l i ner s and bases. Whi t e et al. 245 t e s t e d
Al l - Bond 2 a nd Sc ot c hbond 2 bondi ng syst ems af t er aci d
et chi ng of vi t al de nt i n near t he pul p at t he bot t om of deep
Cl ass V cavi t i es. Aci d et chi ng di d not i mpa i r nor ma l heal -
Ama l g a m b o n d i n g
Dent i n bondi ng use wi t h a ma l ga m r es t or at i ons pr oduces
be t t e r seal i ng t h a n t r a di t i ona l l i ner s and has t he pot e nt i a l
for s t r engt heni ng t he t oot h at t he s ame t i me. Eakl e et al. 246
r e por t e d t h a t Ty t i n and gal l i um al l oys coul d be bonde d
wel l enough wi t h Pa na vi a ma t e r i a l t h a t t he c ombi na t i on
exceeded the advantages of traditional undercuts for
retention. However, the experience with amalgam bonding
has been quite varied. There is increasing evidence that for
amalgam bonding to work properly the adhesive must be
able to mix along the interface with freshly condensed
amalgam material and produce mechanical interlocking.
Ideal conditions for this are poorly understood. In many
cases, the use of thickening agents or multiple coats of
dentin bonding agent seem to produce much stronger den-
tin bonding. Boyer and Roth z47 examined the fracture re-
sistance of teeth with bonded amalgams using C + B Me-
tabond, Amalgambond, and Panavia EX systems. The
tooth reinforcement was similar or less than with compos-
ite systems. Vargas et al. 24s tested Amalgambond Plus ma-
terial with HPA (high performance resin additive) and
demonstrated much stronger bonding than for Optibond,
Imperva Dual, Clearfill, or All-Bond 2 adhesives. Most
likely the other systems had not produced a thick enough
film to achieve micromechanical interlocking with the
amalgam. Santos and Meiers 249 tested the fracture resis-
tance of premolars with MOD amalgam bonded and
unbonded restorations without observing any effect. Again
this could occur if the amalgam had not become interlocked
with the adhesive. Bagley et al. 25~ reported much higher
bonding strengths for resin filled amalgam bonding agents
versus conventional ones. Kawakami et al. 251 demonstrated
that the range under these circumstances could be from 1
to 14 MPa. Souza et al. 252 only found low bond strengths
for Clearfil Photobond and Panavia systems under normal
circumstances. Barkmeier et al. 253 reported much greater
bonding strengths when the HPA was added to either
Amalgambond or Amalgambond Plus materials, presum-
ably to thicken each system. To date there have been very
few SEM analyses of the nature of the interface of amal-
gam bonded systems. Garcia-Bargero et al. 254 presented
excellent photomicrographs, but did not interpret the in-
terpenetration of bonding agent and amalgam in those
views as the mechanism of adhesion, even though that was
most likely the case. The mechanism of action of amalgam
bonding agent appears to be mechanical and not chemical.
Therefore, one would not expect very good bonding of new
amalgam to old amalgam via this mechanism. Nuckles et
al. 255 did not note any increase in strength of new to old
amalgam because of the use of amalgam bonding agent.
The final properties realized for dental composites
depend strongly on the degree of conversion of the mono-
mer to polymer during polymerization. This, in turn,
depends on the efficiency of the curing system chemistry,
potential light activation, and the intensity of the light.
More and more work is now being conducted to ensure op-
timal light-curing conditions of composites. Under most
circumstances the degree of conversion ranges from 60 % to
75%. Lee and Greener 256 determined that the minimum
intensity for curing composite and/or dentin bonding com-
ponents effectively was 250 mW/cm 2. Rueggeberg et al. 257
developed a mathematical model for curing to take many
of the light energy related variables into account. Thick-
ness of composite was most important. Duration and
intensity of the light were next most important. No more
than 2 mm increments should ever be cured and i mm was
more ideal. Watts and Cash 259 have provided an excellent
explanation of the physics of the process and light curing
efficiency values.
The clinical challenges for excellent curing are adequate
access for curing and light sources of adequate intensity.
Most light curing devices now have built-in radiometers for
this purpose. Peutzfeldt 26~ showed a linear correlation be-
tween the degree of cure achieved and ODe type of radiom-
eter's readings. Adequate access in many situations is the
real challenge. Light-curing wedges were invented to direct
the light to interproximal areas. However, Ciamponi et
al. 261 reported that complete polymerization could never be
achieved with light reflective wedges.
To circumvent these problems, chemical approaches to
improve ~degree of conversion are being explored. Peu-
tzfeldt 262 determined that the addition of diacetyl-con-
taining monomers to composites could increase the degree
of cure. Finally, a novel approach has been to eliminate ef-
fects of oxygen inhibition during curing by flooding the
curing zone with nitrogen. For bonding agents, this pro-
duced an increase in bond strength of 20 to 80 %. The ef-
fect on composites has not yet been reported.
One of the poorly understood events associated with
composite resin use was the possibility of monomer diffu-
sion out of unset materials and/or monomer production
from degrading restorations. Gerzina and Hume 264 moni-
tored the diffusion of TEGDMA monomer, which has been
used routinely as composite matrix diluent. They com-
pared direct release on the surface of the composite to that
that was diffusible from that surface through dentin. Less
than 1% of the direct release rate was diffused through
dentin in i day and only 60 % after 3 days, establishing that
dentin was performing as a protective barrier for the pulp.
Hanks et al. 265 monitored the diffusion rates through den-
tin. Water soluble molecules diffused at a rate inversely
proportional to the thickness of the dentin and related to
the molecular weight of the diffusing species. However,
nonaqueous materials did not diffuse sufficiently to be of
concern as a risk for the pulp. Therefore, some monomers
may not be a problem. Bean et al. e66 reported that there was
aqueous material extractable from many composites that
was produced by hydrolyzing dental polymer. The clinical
importance of these changes and released materials has yet
to be established. A good review of this situation was
reported by Wataha et al. 267
Some materials are being explored for intentional release
from set composites. Imazato and McCabe 26s compounded
MDPB antibacterial monomer into composite. The anti-
J ULY 1995 85
bacterial effect has yet to be demonstrated in situ, but small
additions of the materials did not adversely affect the
composite properties.
Although bonded composites tend to strengthen tooth
structure, setting may produce excessive tension along the
adhesive interfaces and either distort cusps or debond the
interface. Suliman et a l . 2 6 9 examined various composites
and the effect on cuspal deflection. Cusp deflection was less
than the shrinkage observed when the composite was
allowed to cure in an unrestricted situation. Hydrated
composite showed less deflection, presumably because the
absorbed water plasticized the system and produced some
volume expansion.
Changes that occur during intraoral service are not well
understood but are now being examined in terms of fatigue.
Braem et al. 27~ used a staircase approach for measuring
composite fatigue values and reported that there appeared
to be an endurance limit. Water absorption had a dramatic
effect on the results. Sarrett and Ray 271 showed that water
soaking for up to 12 months decreased wear resistance of
composites. Presumably similar matrix effects could limit
composite fatigue resistance. Braem et al. 272 has provided
an excellent review of key factors for fatigue testing and
considerations of testing effects for fatigue. Mair 273 con-
ducted compressive fatigue tests of composite cylinders
that were then Ag nitrate stained for cracks and noted dif-
ferences between microfill and coarse particle systems in
their response.
The key laboratory results of composite round robin
testing by the ADA of wear-resistant composites was sum-
marized by Ferracane and Mitchem.274 There was variation
in results among participants despite all attempts at stan-
dardization. However, the more important conclusion of
the authors was that in any experiment it is important to
include standard materials for reference for these other-
wise uncontrolled differences. This is rarely the case in
most dental materials research.
Actual clinical research on posterior composites has been
quite limited during the past two years. Bryant and
Hodge 275 reported 3-year clinical data on three composites.
Their coarse particle system showed more wear. The fine
particle and microfill systems showed more evidence of
margin fracture.
Despite numerous clinical trials of composites, most test
sites have differences in experimental designs, measure-
ment systems, reporting methods, or other variables that
prohibit simple comparisons of results between sites for
different materials. Taylor et al. 276 conducted a meta-
analysis of approximately 120 published studies and used
ranking methods to compare 2- and 3- year clinical wear
data for composites to rank-order 28 commercial products
with an extremely high level of concordance. This provided
a means of comparing the results of laboratory studies to
a standard reference.
Gl ass i onomers
New glass ionomers have been rapidly displacing more
traditional glass ionomer compositions. Burgess et al. 277
has provided an excellent overview of the properties of
many commercial products. The key concerns for perfor-
mance are long- term water resistance and extent of fluo-
ride release. Mitra and Kedrowski 27s demonstrated a slow
increase in compressive and diametral tensile strength for
most materials despite long-term storage in water. This is
encouraging and appears to represent both continuing re-
action and increased resistance to hydrolytic changes. Cat-
tani-Lorente et al. 279 monitored the mechanical behavior of
12 products for compressive, tensile, and flexural strength
up to 12 months and found no water degradation.
Fluoride release and anticaries effects cannot be readily
measured in clinical trials. Thus, laboratory studies are
used that measure resistance of dentin to demineralization
of adjacent tooth structure that has been subjected to car-
ies-simulating fluids or gels. Souto and Donly 2s~ demon-
strated this effect for two glass ionomers. Dionysopoulos et
al. 2sI showed that traditional glass ionomers and even flu-
oride-releasing amalgam created much more resistance
than any fluoride released from fluoride-containing com-
posites. Castro et al.2s2 demonstrated that protective coat-
ings on top of glass ionomers for initial protection from
water did not prevent fluoride release.
Unfortunately, despite the quality of fluoride release,
most glass ionomer compositions are not as strongly
bonded to dentin as composites with dentin bonding sys-
tems. Berry and Powers 2s3 reported relatively low bond
strengths for glass ionomers bonded to coronal and radic-
ular dentin. Mount 2s4 reviewed glass ionomers and future
research. Erickson 2s5 reviewed root surface use of glass
ionomers versus resin composites.
An interesting question raised by Andersson and Dahl 2s6
was whether A1 ion release from glass ionomers might re-
tard the remineralizatin of dentin below glass ionomer res-
torations. They measured more A1 release by conventional
glass ionomers than by resin hybrid systems.
While glass ionomers continue to evolve, there remains
a strong rift between supporters of traditional glass iono-
mer compositions and those promoting resin modified
compositions. One of the more interesting expressions of
this division was an article by McLean et al. 287 proposing
special nomenclature to emphasize this difference. In most
cases, nomenclature is proposed to clarify complicated sit-
uations. In this case the argument and new terms provided
seemed to muddy the waters. The authors proposed "res-
in-modified glass-polyalkenoate" cements as the new name
for hybrid glass ionomers.
Ce me nt s
Because of the relative success of chlorhexidine, it is be-
ing evaluated as an additive to many cement formulations
86 V O L U ME 74 N U MB E R 1
to create antibacterial activity. Brackett and Rosen 2ss
measured some antimicrobial effects when it was added to
zinc phosphate cement. There was no deleterious effect on
cement strength at low levels.
Esthetics and the ability to maintain the esthetic ap-
pearance over time are among the major attributes of por-
celain restorations. Recent progress in the technology and
research of new ceramic material has broadened the choices
for esthetic single crown restorations. However, the use of
porcelain restorations is fraught with problems that re-
quire the use of appropriate clinical technique. This year
research focused on the areas of color, ceramic alterations,
resistance to fracture, surface roughness, and fit compari-
sons with the CELAY system.
Research concerning the optimum form of optical geom-
etry for measuring color has given rise to various contro-
versies over the past 60 years. This year research data was
presented for a newly modified, noncontact spectropho-
tometer for clinical use. 289 The instrument is capable of
accurately measuring color within small areas (1 x 2 mm)
of a tooth. The measurement repeatability for opaque and
translucent porcelain samples provided a color difference
AE to be approximately 0.15 indicating a good color accu-
The fabrication of most porcelain restorations, either
with or without metal substructures, involves building dif-
ferent layers of opaque or body porcelain. Porcelain resto-
rations have double-layered color effects resulting from the
presence of these body and opaque layers. Those complex
layering procedures and processing variables influence the
color of the finished restorations. One study 29~ quantified
the color differences resulting when a defined l mm thick-
ness of body porcelain was fired on opaque porcelain of the
same brand and shade designation. Four brands of porce-
lain in six shades were evaluated in this study. All of the
porcelains tested(Ceramco, Vita, Jelenko, Will-Ceram)
showed clinically observable color differences (AEX) be-
tween the body-opaque double layer combinations and the
opaque porcelain alone. Spectrophotometrically matched
materials seem to be essential for a successful metal bond-
ing porcelain system. This study determined the magni-
tude of mismatch and indicated that the greater the mis-
match, the greater the shade variance with changes in body
porcelain thickness. This represents an important concern
in developing predictable color matching with our dental
laboratory support.
Color parameters of veneer porcelain systems are influ-
enced by various colored backings. The use of a colorime-
ter and the Kubelka-Munk Reflectance theory seems to
offer an accurate prediction for the resultant color. A1, D3,
and translucent porcelain samples were bonded to light and
dark substrates with universal, opaque, and untinted
shades of bonding resin, and the resultant reflectance val-
ues were compiled and compared. 291 Such data appears to
offer hope that a direct method of accurately predicting the
required porcelain that would result in a desired shade.
The color stability of high-fusing conventional porcelain
has been repeatedly discussed in the literature, but t he
newer, low-fusing porcelains such as Procera porcelain
have had only limited documentation. This lower-fusing
dental porcelain (755 C) was developed to be compatible
with the expansion coefficient of titanium restorative ma-
terial. One study compared the effect of accelerated aging
on the color stability of Ceramco and Procera dental por-
celains. 292 Both Procera and Ceramco porcelain exhibited
only "slight" color changes when they were subjected to 900
hours of accelerated aging.
Marginal precision relative to different porcelain sys-
tems and technique are well-documented. The ability to
maintain a high-quality margin in clinical as well as labo-
ratory settings has not been equally well-established. One
study ~9~ compared all-ceramic to porcelain-fused-to-ce-
ramic crowns by measuring the influence of three consec-
utive firing cycles on marginal opening. All-ceramic crowns
exhibited marginal openings that were more than three
times greater than that of metal-ceramic specimens. In-ce-
ram specimens exhibited a dramatic change after the first
firing, then appeared to stabilize. Conversely, Hi-ceram
and Willi- Glas crowns recorded more distortion with each
firing, and maximal distortion during the third firing.
Changes in the marginal integrity also occur as a result
of dental prophylactic procedures. The effects of ultrasonic
scaling and air-abrasive instrumentation for the removal of
calculus and stain at the labial porcelain margin interface
was also evaluated. 294 Although the standard deviations
were high relative to the mean surface roughness the results
were still significant. Surface roughness increased when
compared with untreated controls indicating compromises
especially when such procedures are indiscriminately used.
This study only evaluated PFC restorations with labial
margins at 90 degrees to the axial wall. Differences with
castable ceramics or bonded porcelain veneers were not
In-Ceram ceramic has been suggested as a core material
for resin-bonded fixed partial dentures. Etching of In-Ce-
ram with acids does not create a microretentive surface
compared with conventional ceramics so sandblasting has
been used to create a microretentive surface. One study
evaluated the effect of sandblasting and silica coating on
volume loss, morphology, and changes in the surface com-
position. 295 Volume loss through sand blasting was 36 times
less for In-Ceram compared with a feldspathic glass ce-
ramic (IPS-Empress), and did not change the surface com-
position of In-Ceram. Silica coating of In-Ceram with the
Rocatec system effectively increased the silica content,
providing a basis for silanes to enhance the resin bond
J ULY 1 9 9 5 87
clinically. However, the effect on bond strength was not
evaluated in this study and questions regarding clinically
relevant information persist.
The longevity of intraoral porcelain repair continues to
be a problem in dentistry. The factor often cited as most
clinically significant was etching of the porcelain surface
with hydrofluoric acid. Some investigators have suggested
that the greater porosity of the hydrofluoric acid etch pro-
duces a greater composite-to-porcelain bond. A new inves-
tigation tested this premise with two common fluoride
etchants. 296 Both etchants yielded bond strengths that
produced cohesive failure of all samples. This suggested
that the intraoral use of hydrofluoric acid is no more effec-
tive than the less dangerous acidulated phosphate fluoride
gel. In addition, the results reinforce previous studies that
contraindicate use of acidulated phosphate fluoride gels in
patients where ceramic restorations would be present.
Ceramic materials are brittle, have limited tensile
strength, and are subject to time-dependent stress failure.
These shortcomings are attributable to the presence of mi-
crodefects within the material and a degradation in aque-
ous environment resulting from subclinical crack growth.
Clinical porcelain crown strength is influenced by core
materials, the shape of the tooth preparation and method
of luting. One study compared the fracture strengths of
four types of all-ceramic premolar crowns (conventional
Vita-dur, In-Ceram, Dicor, IPS-Empress) after a pre-load
cycling in an aqueous atmosphere. 297 Fracture strength of
Vita-dur crowns was improved significantly by luting with
an adhesive resin cement. The average load to fracture of
ceramic crowns luted with any zinc phosphate cement af-
ter preload cycling in distilled water were: Vita-dur 770,
Dicor 840, IPS-Empress 891, and In-Ceram 1060. In-Ceram
fracture strength was significantly higher than the other
three materials, but had a large standard deviation created
by two distinct modes of failure: total fractures at 1276 and
fractures in which the core remained intact under loads of
808. It was interesting that within the parameters of this
study Vita-dur luted with adhesive resin was not signifi-
cantly different than In-Ceram. This study clearly demon-
strated the importance of fatigue loading and ideal tooth
preparation. Another study 29s compared the resistance to
fracturing of metal ceramic and all-ceramic crowns. All-ce-
ramic crowns (Hi-Ceram, In-Ceram and veneered glass ce-
ramic) exhibited overall (catastrophic) fracture. Metal-ce-
ramic showed multiple cracks with porcelain chipping. The
In-Ceram showed significantly higher average resistance to
fracture than the other all-ceramic specimens but were not
significantly different from the values obtained from the
metal-ceramic samples. Although the results offer more
encouragement for certain all-ceramic systems, the tests
were not run with fatigue-loaded samples in a moist envi-
ronment, which as seen from the previous study can dra-
matically impact the results. Therefore, clinical parallels
are not possible from this study.
For many years standard clinical and laboratory practice
and teaching has been that adjusted porcelain surfaces
should be reglazed to restore the surface finish. However,
reglazing is not always convenient or possible. Many tech-
niques for polishing porcelain have been evaluated and the
surface finishes compared favorably with glazed porcelain.
This study 299 investigated the wear effects of glazed,
unglazed, and polished porcelain against human enamel in
the laboratory. The rate of enamel wear produced by un-
glazed and glazed porcelain was similar. Polished porcelain
produced substantially less enamel wear. The data illus-
trates the potential damage porcelain can inflict upon
enamel, and suggests that porcelain be polished instead of
reglazed after chair side adjustment.
CAD-CAM ceramic restorations often require adjust-
ments that result in a need to reduce surface roughness.
Surface roughness resulting from five polishing systems on
two ceramics was assessed. 3~176 Disks of Ceramco II and Di-
cor MGC ceramic blocks were polished with five combina-
tions of 45, 25, and 10 micron diamonds, a 30 fluted carbide,
three silicon carbide impregnated rubber points, 4 and 1
micron diamond gels, and an aluminum oxide point and
two aluminum oxide pastes. Profilometer results indicated
that Dicor ceramic could be polished smoother than
Ceramco II ceramic. Finishing diamond points followed by
diamond gels produced the smoothest surface. A 30 fluted
carbide did not improve the smoothness in the combina-
I mpr e s s i on me t hods
This year research focused on custom tray material, ad-
hesive application parameters, accuracy concerns and dis-
infection procedures. All of these concerns have clinical
Any material used to make a custom impression tray
must be dimensionally stable over time and must not per-
manently deform when the filled impression tray is initially
placed intraorally, or when a completed impression is re-
moved from the oral cavity. The dimensional stability of
various tray systems have been the subject of several
investigations. In Part 13~ of a three part series, various
mechanical properties of five tray resins were compared.
The thermoplastic resins studied in this investigation ex-
hibited lower measured values for strength and elastic
modulus than the light-polymerizing polymethyl meth-
acrylate resin studied. Tray materials were evaluated
directly from the material. Previous researchers have
approached the problem of permanent tray deformation
indirectly by comparing measurements made on master
casts with those made on casts generated from impressions
of these master casts. It is important to note that here the
differences were not significant. In Part III 3~ a simple
mathematical model of a custom tray was developed to
predict stress distributions for the forces to which impres-
sion trays are subjected during dental procedures. The re-
8 8 VOL UME 74 N U MB E R 1
sults of this analysis indicated that these stresses would be
significantly lower than the yield stress for a commonly
used polymethyl methacrylate resin or a light-polymerized
resin. The stresses were also sufficiently low for us to con-
clude that thermoplastic resins would not permanently
deform. This information would account for the clinical
acceptability of these materials.
The effects of impression tray disinfection procedures on
the bond strength of impression-material adhesives to two
types of resin trays were evaluated with a tensile test. 3~
Differences were detected among materials and disinfec-
tion procedures. The type of tray material did not affect the
adhesive bond strength. The use of polyvinyl impression
materials with autopolymerizing resin trays and iodophor
disinfectant or light-cured resin trays with sodium hy-
pochlorite disinfectant should be avoided if maximum
bond strengths of adhesive to tray are to be realized.
The tensile bond strength of one addition silicone mate-
rial/adhesive system to three different custom tray mate-
rials at 10 minutes, 48 hours, and 7 days after adhesive ap-
plication was compared. 304 The Triad custom tray material
exhibited the highest mean adhesive tensile bond strengths
and Fastray material exhibited the lowest. The 10-minute
adhesive drying time exhibited the lowest tensile bond
strength whil~ the 48-hour adhesive drying time was the
highest for all custom impression tray materials. The
results from this investigation indicate that it may be ad-
vantageous to coat custom impression trays 24 hours before
the impression is to be completed, but that 10 minutes is
sufficient clinically. If the impression is not taken at this
point the results would indicate that there is no need to re-
apply the adhesive to the previously coated tray to achieve
adequate adhesive tensile bond strengths.
A dental impression material must have sufficient
strength to allow removal from a gingival sulcus without
tearing. It must also have sufficient elastic recovery. One
study 3~ examined the tear energy and permanent defor-
mation of polysulfide, polyether, and addition reaction sil-
icone impression materials. As expected, polysulfide mate-
rial had the highest tear energy. However the more relevant
clinical properties, such as tear at a point of minimal per-
manent deformation favored the addition-reaction sili-
cones followed by the polyethers.
Shear-thinning, the decrease in the apparent viscosity of
an impression material under a shear load, is characteris-
tic of many elastomeric impression materials and improves
handling properties. One study 3~ compared the apparent
viscosities of five elastomeric impression materials: three
polyvinyl siloxanes, one polyether, and one polysulfide.
One group of materials was manually spatulated and
injected through an impression syringe before being tested;
the other group was manually spatulated only before test-
ing. It was found the viscosities of those materials were not
affected by the shear load applied during syringing. One
other interesting study 307 evaluated the effects of the set-
ting stage on the accuracy of double-mix impressions made
with addition-curing silicone. The results indicated that
the double-mix impression was accurate independent of
the curing kinetics of the syringed material alone.
Displacement of the free gingiva before impression
making allows the unprepared tooth apical to the intra-
crevicular finish line to be recorded in the impression. An-
other study 3~ compared the dimensional accuracy of im-
pressions and dies made from a metal model having gingi-
val sulci of various widths. Impressions made from nar-
rower sulci showed greater distortions. It was observed that
the interproximal gingival sulcus closes to 0.2mm within 40
seconds. The smallest sulcular width enabling consistent
accuracy and defect-free was 0.22mm.
The Centers for Disease Control (CDC) and the Amer-
ican Dental Association (ADA) have made a series of rec-
ommendations regarding infection control procedures for
impressions entering the dental laboratory. Immersion
disinfection of irreversible hydrocolloid impressions with
sodium hypochlorite full strength (5.25 % ) for 10 minutes
was ineffective against all of the bacteria evaluated. 3~ To
prevent possible distortion of the impression, a disinfection
time of 10 minutes or less was used. Alcide LD was the only
disinfectant to achieve an average reduction of greater than
4log10 with all test organisms. 31~ Sodium hypochlorite was
the only disinfectant that produced gypsum specimen that
passed the ADA specification No. 18 test for detail repro-
duction. 3n No optimal combination of immersion time and
disinfection concentration was found with Microstone. 312
When considering both effectiveness and effects on the re-
sultant gypsum casts, the best results were obtained with
the chlorine-based disinfectants.
To further prevent cross-infection operatory-to-labora-
tory, two antimicrobial irreversible hydrocolloids were
evaluated. 313 Results indicated that antimicrobial irrevers-
ible hydrocolloids are more effective than non-antimicro-
bial ones in reducing surface growth of the oral bacteria
Lactobacillus and Streptococcus mutans. Finally, one
study 314 demonstrated that steam or ethylene oxide gas for
sterilization of addition silicone dental impressions made
in autopolymerizing acrylic resin custom trays can not be
recommended because of the potential for clinically signif-
icant dimensional changes in the resultant casts. The same
observation must be noted with respect to addition silicone
impressions in custom trays or stock metal rim lock trays
that were subjected to extended periods of immersion (12
hrs) in Cidex 7.
Ma r gi n i nt e gr i t y
Margin discrepancies have been measured by use of lab-
oratory and clinical methods. Laboratory methods are
usually more accurate than clinical examinations. This
year new alternatives have been offered to improve accu-
racy. One study 315 evaluated the effect of impression ma-
terials and techniques on the margin fit of metal castings.
J ULY 1995 89
Faciolingual sections of Ivorine teeth with cemented metal
castings were examined by scanning electron microscopy at
100 magnification. Measurements of the thickness of ce-
ment layers were calculated both manually and by use of
a recently developed computerized method. The differ-
ences in the giagival margin gaps between the elastomeric
and copper band/modeling compound impressions were
not clinically significant.
The fit of spark-eroded titanium and cast gold alloy cop-
ings was compared by assessment of retrieved cement film
analoguesY 6 The present study showed that the overall fit
of titanium copings was comparable to that of gold copings.
In margin areas, the space between the die and coping was
found to be larger for the spark-eroded when compared
with cast copings.
CELAY is a machinable ceramic system that is capable
of milling inlays, onlays, and veneers from prefabricated
industrial ceramic blocks. Direct intraoral or indirect pat-
terns may be used to make ceramic restorations. Scanning
electron microscopy was used to analyze the margin gap of
both methodsY 7 The direct fabrication technique yields
significantly better margin gap sizes for the interproximal
areas, while the indirect technique showed smaller margin
gaps at the occlusal borders.
Margin accuracy of provisional restorations fabricated
by different techniques was also evaluated. 31s Provisional
restorations were fabricated on a cast metal model and the
resultant margin discrepancies were measured. The mean
margin discrepancy with the removal technique for poly-
methlmethacrylate was significantly greater than control,
In Situ, Reline, and Indirect technique.
Another concern with the provisional restorations is
their lack of durability due to structural weakness. Reports
of improved mechanical properties for use in the medical
and aerospace industries have led to the incorporation of
Kevlar 49 fiber into orthodontic devices and provisional
restorations. One study 319 compared stainless steel wire
0.36 in. diameter with Kevlar 49 as a means of reinforcing
a four-unit posterior provisional restoration with two pon-
tics. Statistical analysis showed the bent wire configuration
had a significantly higher initial stiffness, no difference be-
tween designs for load at initial fracture, and higher signif-
icant unit toughness value for bent wire. On the basis of
manipulation ease alone, it seems that wire would be con-
sidered the material of choice for the reinforcement designs
used in this study.
Lut i ng a ge nt s
Complete and rapid seating of an artificial crown on a
fixed partial denture abutment should be accomplished
during the working time of the cement. In this study 32~ the
effect of cement space on cementation with an artificial
crown and machined die was investigated. Spacing was
varied in increments of 10 microns, and the dies were ce-
mented in the crowns by a force of 25 Newtons with either
zinc phosphate cement or a silicone fluid. The seating dis-
crepancy ranged from 368 microns without spacing to 29
microns with 50 microns spacing. Spacing of less than 40
microns prevented the crown from achieving the best seat-
ing that was possible with increased spacing before the set
of the zinc phosphate cement. An additional study 321 with
the same die system investigated the amount of cement
space necessary for optimal seating of crowns cemented
with resin luting cements. Panavia EX and C&B Metabond
required only 30 microns of axial space for complete seat-
ing. Both the ISO test and the ADA test recommend a
maximum zinc phosphate film thickness of 25 microns.
These widely used tests involve using two flat glass plates.
The cement film thickness is obtained from the separation
after 10 minutes. These tests, however, only place the ce-
ment in squeeze film flow, unlike the clinical situation in
which crown movement also acts to shear the cement. In
these studies, the more clinically relevant minimum film
thickness that allowed effective cement flow was deter-
Microleakage and margin openings are the important
causes of failure of dental restorations. This study ~22
investigated the relationship between margin opening and
microleakage. Standardized preparations were made on
human premolars, and copings were cast in a base metal
alloy by use of conventional techniques. The margin open-
ings between teeth and castings were measured, and mic-
roleakage was determined at the same points. No signifi-
cant correlation between margin opening and microleakage
was established for either pooled data or individual luting
agent groups of zinc phosphate cement, potycarboxylate
cement, glass ionomer, phosphate ester composite resin, or
composite resin with a NPG-GMA dentinal bonding agent.
A unique study 323 also evaluated In Vivo microleakage of
luting cements for cast crowns. Standardized tooth prepa-
rations were completed on previously intact human molars.
In vivo, and castings were made with a precious metal ce-
ramic alloy by conventional techniques. The casting were
randomly assigned by luting agents and cemented to peri-
odontally compromised molars. After six months the teeth
were carefully extracted, stained, embedded and sectioned,
and in vivo microleakage was measured. Comparison tests
revealed that the zinc phosphate group leaked significantly
more than the other cement groups.
Low film thickness is critical to seating of castings. Film
thickness is dependent on several parameters: material vis-
cosity, particle size, or to ambient conditions that include
temperature and humidity. The cement type had a greater
effect on film thickness than metal type. 324 A glass ionomer
cement produced lower overall film thicknesses than other
cement types, and noble metal ceramic alloy created lower
overall film thickness than other types of metal.
Long-term survival of cemented prostheses depends on
the integrity of the cement layer. Cement fractures permit
microleakage of bacteria or their by-products and changes
in stress distributions to supporting tissues. One study 325
used finite element analysis estimates of cement micro-
fracture under complete veneer crowns. There were mini-
mal effects for thickness of cement and margin configura-
Re mova bl e pr os t hodont i c s
This year the primary emphasis in removable prostho-
dontics focused on impressioning, processing, soft and re-
silient denture liners, denture stomatitis, cytotoxicity, and
repairs. In addition, a clinical trial compared two basic re-
movable partial denture designs.
Modeling compound has been the material of choice for
border molding since its introduction in 1911. During the
past two decades there had been a shift to other materials.
One study 326 compared two different impression proce-
dures to produce the maxillary tissue form of five edentu-
lous patients. One procedure used modeling plastic, the
second used tissue treatment material to border mold the
spaced trays. For both procedures the impression was
completed in polysulfide. Comparison of the cast profiles at
premolar and molar coronal sections showed no significant
differences between techniques.
Dimensional changes in acrylic resin have traditionally
been measured on maxillary dentures, with standardized
maxillary metal dies used as a master cast. This study 327
investigated the qualitative nature of the mandibular cur-
ing distortion and quantified the changes that occurred.
Measurements made before and after processing complete
mandibular dentures demonstrated that shrinkage oc-
curred in all dimensions, and the greatest shrinkage oc-
curred in an anterioposterior direction along the lingual
flanges. The final qualitative changes would appear as
pressure in the distolingual and anteriolabial regions.
Improving retention and stability of dentures is of
considerable interest in prosthetic dentistry. Although ad-
hesives are used by millions of denture wearers, and are
advocated as an over-the-counter product by many profes-
sionals, their use has not been generally accepted by the
dental profession as an adjunct to treatment. One study 32s
used quantitative methods to determine the effect of a
denture adhesive, Fixodent cream, on the retention and
stability of maxillary dentures in 20 patients. The results
of this study demonstrated the efficacy of a denture adhe-
sive in significantly improving denture retention and sta-
bility. The two critical issues related to the use of a denture
adhesive are efficacy in improving function and effect on
the health of the underlying oral tissues. The increase in
retention and stability created by the adhesive may pro-
mote better tissue health indirectly.
The use of soft denture liners is an important adjunct in
the treatment of complete and partial denture patients.
The desirable properties of resilient lining material could
be described as a cushioning effect upon the mucosa, per-
manent resilience and dimensional stability, adhesion to
without effect upon the denture base resin, minimal fluid
sorption and solubility, and an inhibition of fungal growth.
These materials often do not last more than a year or two
in service due to degradation caused by hardening, sorption
of odors, support of bacteria, color changes, and debonding
from the denture base. Water sorption and solubility can
dramatically affect the physical and mechanical properties
of the liner. The sorption and solubility of 12 soft denture
liners was evaluated. 329 A statistical analysis of the data
showed significant differences between materials. After one
year only Molloplast-B and Prolastic soft denture liners
had sorption values that met ADA specification 12.
The results of this study have clinical implications
because the sorption and solubility may affect the long-
term life expectancy of the soft denture liner. Observations
on the long-term use of a soft-lining material for mandib-
ular complete dentures was also evaluated. 33~ Data for
Molloplast-B soft-lining material in mandibular complete
dentures was compiled for 22 patients with a wearing time
of up to 9 years. Although some patients required mainte-
nance treatment, the soft-lining material outlasted the
acrylic teeth in many cases, and occlusal wear was the most
commonly cited reason for replacement.
The energy-absorbing behavior of four commercially
available soft denture liners was evaluated by use of a free
drop t es t y 1 As expected, the shock absorption of soft den-
ture liners is a function of the liner thickness. The Mollo-
plast-B and Molteno Soft materials showed excellent shock
Recently, a polyphosphazine fluoroelastomer material
(Novus) was announced as a permanent soft denture liner.
Initial clinical tests suggest that this liner exhibits clinical
behavior superior to the other most widely used resilient
liners. Two permanent resilient denture base liners, the
silicone based Molloplast-B and Novus were examined. 332
The compressibility- data indicated that Novus is more
compressible and required significantly less force for a
given strain than Molloplast-B. Novus also had the lowest
solubility and met the solubility limit required in ADA
Denture cleansers should reduce microbiological con-
tamination and have a minimum of effect on the physical
properties of the liner. The deterioration of six commercial
resilient denture lining materials immersed in seven groups
of denture cleansers was investigated. 333 The results sug-
gest that various components of denture cleansers and soft
denture liners, particularly peroxides, play important roles
in the deterioration of soft liners caused by cleansers. The
compatibility of denture cleansers with the soft liners was
summarized. Coe Comfort was the only liner that could be
used with all cleansers if replaced within 4 days. Only one
cleanser, Dentarent 567, was compatible with all liners for
at least 14 days.
Denture stomatitis is a term describing the inflamed
mucous membrane sometimes seen in the palate under a
maxillary denture. The significant causes include infection
with Candida species, and trauma. Different treatment
modalities focus on three major approaches. First, effective
cleansing of the denture by use of denture cleansers to
J ULY 1995 91
reach Candida organisms found on the inner surface of the
denture. Secondly, concentrating on the palate instead of
the denture because the yeast organism resides on the
denture bearing mucosa. Thirdly, making new dentures
with occlusal harmony to reduce trauma.
This study 334 investigated the effect of making new den-
tures, systemic fluconazole treatment, and systemic flu-
conazole treatment in conjunction with topical application
of 2 % chlorhexadine solution to the inner surface of the
denture. The study found that for generalized denture sto-
matitis treatment with systemic fluconzole in conjunction
with chlorhexadine produced greater improvement of pal-
atal inflammation. It is important to note here that the ef-
fect of chlorhexadine on the physical properties of the
denture were not evaluated. Concerns with staining as seen
with implant-supported prostheses could be a concern.
Further research would be necessary before clinical rec-
ommendations could be made.
Nystatin treatment resulted in a significant decrease in
surface hardness values compared with treatment with
Oral Safe or artificial saliva for both light or heat polymer-
ized denture resins. 335 Compromises to the surface of the
denture must be weighed in comparison to efficacy of
treatment of denture stomatitis by oral nystatin if the
denture is not going to be remade after treatment.
The institutionalized elderly could also benefit by use of
a fungicidal denture linerY 6 This could provide a more
predictable therapeutic modality independent of patient
compliance. Visco-gel and Lynol liners were impregnated
with various concentrations of Nystatin, and evaluated
over a 14-day period. The Visco-gel/Nystatin combination
exhibited great fungicidal activity. Initial rapid loss of po-
tency occurred between days 0 and 2. One million units of
Nystatin were required to maintain an adequate level of
antifungal activity.
Substances leached from acrylic resin dentures can cause
adverse reactions in the oral mucosa adjacent to the den-
ture. Two independent studies evaluated leaching and cy-
totoxicity of formaldehyde and methylmethacrylate from
acrylic resin denture base materialsY 7, 33s Under in vivo
and in vitro conditions formaldehyde and methylmethacry-
late were significantly leached into human saliva. Preleach-
ing in water reduced subsequent leaching of both com-
ponents. The amount of the reduction depended on an in-
crease in the preleaching water temperature. Immersion of
acrylic resin dentures in hot water (50 degrees C) before
insertion was recommended to minimize risk of adverse
Fracture of dentures is a frustrating clinical finding in
practice. Management of the repair site interface is critical
to minimize adhesive or cohesive failure. One study 339 in-
vestigated repair of denture base resins with visible light-
cured materials. No interactions between base and repair
material was detected, which was attributed to poor adhe-
sive bonding, generating lower repair strength and tough-
ness. Visible light-cured resins can not be recommended as
repair materials until better bonding methods are devel-
Wetting the repair surface with methyl methacrylate
monomer was also studied. 34~ The results revealed that re-
paired test specimens were weaker than those not repaired.
The transverse strength of the test specimens increased as
the duration of methyl methacrylate wetting of the repair
surface increased. Wetting the surfaces for 3 minutes pro-
vided the largest increase in transverse strength and
diminished the number of adhesive failures.
There are almost no well-controlled clinical studies on
the effectiveness of removable partial denture (RPD)
design. Several longitudinal investigations and cross-sec-
tional surveys have established the long-term effects of
RPDs on periodontal health and caries incidence of abut-
ment teeth. A randomized clinical trial was undertaken to
compare the effectiveness of two partial denture designs,
one with an I-bar, the other with circumferential retainers,
in 134 patients with Kennedy Class I and class II edentu-
lous conditions. 341 The 5-year success rate demonstrated
that there was no significant differences between the two
designs in discernable changes in the nine measured com-
ponents of periodontal health of the abutment teeth. Con-
trary to the beliefs of some clinicians it would appear that
a well-constructed removable partial denture of either de-
sign, supported by favorable abutments and accompanied
by a regular hygiene recall program offers a satisfactory
treatment modality.
As a prOfession we grow by our continuous quest for new
knowledge. We must persist in asking and answering the
right questions.
We appreciate the assistance from Dr. Harold Stanley and Dr.
Louis Ripa for their support and input in the analysis of the 1994
literature and the preparation of this manuscript.
1. Frankel MS. Ethics in research. J Dent Res 1994;73:1759-65.
2. Moorhead JE, Rao PV, Anusavice KJ. Guidelines for experimental
studies. Dent Mater 1994;10:45-51.
3. . Mj or IA. Biological assessment of dental materials in Europe 1993-
recommendations and regulations. J Dent 1994;22(Suppl 2):$3-$5.
4. Pizzoferrato A, Ciapetti G, Stea S, Cenni E, Arciola CR, Granchi D,
Savarino L. Cell culture methods for testing biocompatibility. Clin
Mater 1994;15:173-90.
5. Polyzois GL. In vitro evaluation of dental materials. Clin Mater 1994;
6. Stanley HR. Dental iatrogenesis. Int Dent Journal 1994;44:3-18.
7. Stanley HR. Pulpal responses to conditioning and bonding agents. J
Esthet Dent 1993;5(5):208-14.
8. van Houte J. Microbiological predictors of caries risk. Adv Dent Res.
1993 Aug;7(2):87-96.
9. Bayne SC, Heymann HO, Swift EJ Jr. Update on dental composite
restorations. J Am Dent Assoc 1994;125:687-704.
10. Dietschi D, Magne P, Holz J. Recent trends in esthetic restorations for
posterior teeth. Quintessence Int 1994;25:659-78.
11. Eliades G. Clinical relevance of the formulation and testing of dentine
bonding systems. J Dent 1994;22:73-82.
12. Prati C. What is the clinical relevance of in vitro dentine permeability
tests? J Dent 1994;22:83-8.
13. Gwinnett A J, Baratieri LN, Monteiro S Jr, Ritter AV. Adhesive res-
torations with amalgam--guidelines for the clinician. Quintessence Int
14. Jones DW. The enigma of amalgam in dentistry. J Br Dent Assoc
15. McLean JW. Evolution of glass-ionomer cements: a personal view. J
Esther Dent 1994;6:195-206.
16. Mount GJ. Glass ionomer cements and future research. Am J Dent
17. Cox CF, Suzuki S. Re-evaluating pulp protection: calcium hydroxide
liners vs. cohesive hybridization. J Am Dent Assoc 1994;125:823-34.
18. Ferracane JL. Elution of leachable components from composites. J
Oral Rehabil 1994;21:441-52.
19. van Noort R. Dental materials: 1992 literature review. J Dent 1994;22:5-
20. Bayne SC, Swift EJ Jr. Review of the 1993 dental materials literature.
Dent Mater 1994;10:59-76.
21. Hicks M J, Flaitz CM. Epidemiology of dental caries in the pediatric
and adolescent population: a review of past and current trends. J Clin
Pediatr Dent 1993;18(1):43-9.
22. Caplan DJ, Weintraub JA. The oral health burden in the United
States: a summary of recent epidemiologic studies. J Dent Ed
23. Truin GJ, K6nig KG, Bronkhorst EM, Mulder J. Caries prevalence
amongst school children in the Hague between 1969 and 1993. Caries
Res 1994;28(3):176-80.
24. Downer MC. Changing trends in dental caries experience in Great
Britain. Adv Dent Res 1993;7(1):19-24.
25. Stahl JW, Katz RV. Occlusal dental caries incidence and implications
for sealant programs in U.S. college student population. J Public
Health Dent 1993 Fa11;53(4):212-8.
26. Foreman FJ. Sealant prevalence and indication in a young military
population. J Am Dent Assoc 1994 Feb;125(2):182-4, 186.
27. Drake CW, Hunt RJ, Beck JD, Koch GG. Eighteen-month coronal
caries incidence in North Carolina older adults. J Public Health Dent
1994 Win;54(1):24-30.
28. Joshi A, Douglass CW, Jette A, Feldman H. The distribution of root
caries in community-dwelling elders in New England. J Public Health
Dent 1994 Win; 54(1):15-23.
29. Schr6der U, Widenheim J, Peyron M, H/igg E. Prediction of caries in
1-year-old children. Swed Dent J 1994;18(3):95-104.
30. Boardman M, Cleaton-Jones P, Jones C, Hargreaves JA. Associations
of dental caries with salivary mutans streptococci and acid producing
bacteria in 5-year-old children from KwaZulu and Namibia. Int Dent
J 1994;44(2):174-80.
31. Holbrook WP, de Soet JJ, deGraff J. Prediction of dental caries in
pre-school children. Caries Res 1993;27(5):424-30.
32. Mattiasson-Robertson A, Twetman S. Prediction of caries incidence in
school children living in a high and low fluoride area. Community Dent
Oral Epidemiol 1993;21(6):365-9.
33. Scheinin A, Pienih~ikkinen K, Tiekso J, Holmberg S, Fukuda M, Su-
zuki A. Multifactorial modeling for root caries prediction: 3-year fol-
low-up results. Community Dent Oral Epidemiol 1994;22(2):126-9.
34. Alanen P, Hurskalnen K, Isokangas P, Pietil~i I, Lev~inen J, Saarini
UM, Tiekso J. Clinician's ability to identify caries risk subjects. Com-
munity Dent Oral Epidemiol 1994;22(2):86-9.
35. Kidd EA, Ricketts DN, Pitts NB. Occlusal caries diagnosis: a chang-
ing challenge for clinicians and epidemiologists. J Dent 1993
36. Angmar-M~nsson B, ten Bosch JJ. Advances in methods for diagnos-
ing coronal caries a review. Adv Dent Res 1993;7(2):70-9.
37. Banting DW. Diagnosis and prediction of root caries. Adv Dent Res
38. Lussi A. Comparison of different methods for the diagnosis of fissure
caries without cavitation. Caries Res 1993;27(5):409-16.
39. Espelid I, Tveit AB, Fjelltveit A. Variations among dentists in radio-
graphic detection of occlusal caries. Caries Res 1994;28(3):169-75.
40. Verdonschot EH, Wenzel A, Truin GJ, K6nig KG. Performance of
electrical resistance measurements adjunct to visual inspection in the
early diagnosis of occlusal caries. J Dent 1993;21(6):332-7.
41. Ie YL, Verdonschot EH. Performance of diagnostic systems in occlusal
caries detection compared. Community Dent Oral Epidemiol 1994;
42. Hintze H. Screening with conventional and digital bite-wing radiogra-
phy compared to clinical examination alone for caries detection in
low-risk children. Caries Res. 1993;27(6):499-504.
43. White SC, Atchison KA, Hewlett ER, Flack VF. Efficacy of FDA
guidelines for ordering radiographs for caries detection. Oral Surg Oral
Med Oral Path 1994;77(5):531-40.
44. Komatsu H, Shimokobe H, Kawakami S, Yoshimura M. Caries-
preventive effect of glass ionomer sealant reapplication: study presents
three-year results. J Am Dent Assoc 1994;125(5):543-9.
45. Forss H, Saarni UM, Seppii L. Comparison of glass-ionomer and res-
in-based fissure sealants: a 2-year clinical trial. Community Dent Oral
Epidemiol 1994;22(1):21-4.
46. Sepp~i L, P611iinen L, Hausen H. Caries-preventive effect of fluoride
varnish with different fluoride concentrations. Caries Res 1994;28(1):
47. Russell RR. The application of molecular genetics to the microbiology
of dental caries. Caries Res 1994;28(2):69-82.
48. Sofaer JA. Host genes and dental caries. Br Dent J 1993;175(11-
49. Mandel IW. Nature vs. nurture in dental caries. J Am Dent Assoc
50. White KC, Cox CF, Kanka J 3rd, Dixon DL, Farmer JB, Snuggs HM.
Pulpal response to adhesive resin systems applied to acid-etched vital
dentin: damp versus dry primer application. Quintessence Int 1994;
51. Paul S J, Scharer P. Intrapulpal pressure and thermal cycling: effect on
shear bond strength of eleven modern dentin bonding agents. J Esthet
Dent 1993;5(4):179-85.
52. Mukai M, Ikeda M, Yanagihara T, Hara G, Kato K, Ishiguro K, Na-
kagaki H, Robinson C. Fluoride distribution in dentine and cementum
in human permanent teeth with vital and non-vital pulps. Arch Oral
Biol 1994;39(3):191-6.
53. Hatton JF, Holtzmann D J, Ferrillo PJ Jr, Stewart GP. Effect of hand-
piece pressure and speed on intrapulpal temperature rise. Am J Dent
54. Mandel ID. Antimicrobial mouthrinses: overview and update. J Am
Dent Assoc 1994;125(Suppl 2):2S-10S.
55. FineD. Evaluationofantimicrobialmouthrinses and their bactericidal
effectiveness. J Am Dent Assoc 1994;125(Suppl 2):11S-9S.
56. Sheiham A. The future of preventive dentistry. BMJ 1994 Jul 23;
57. Collaert B, AttstrSm R, Edwardsson S, Hase JC, Astrom M, Movert R.
Short-term effect of topical application of delmopinol on salivary mi-
crobiology, plaque, and gingivitis. Scand J Dent Res 1994;102(1):17-23.
58. Albandar JM, Gjermo P, Preus HR. Chlorhexidine use after two de-
cades of over-the-counter availability. J Periodontol 1994;65(2):109-12.
59. Epstein J, Ransier A, Lunn R, Spinelli J. Enhancing the effect of oral
hygiene with the use of a foam brush with chlorhexidine. Oral Surg Oral
Med Oral Pathol 1994;77:242-7.
60. Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE,
Norderyd OM, Genco RJ. Assessment of risk for periodontol disease.
I, Risk indicators for attachment loss. J Periodontol 1994;65:260.
61. Glick M, Muzyka BC, Salkin LM, Lurie D. Necrotizing ulcerative pe-
riodontitis: a marker for immune deterioration and a predictor for the
diagnosis of AIDS. J Periodontol 1994;65:393.
62. Nassar MM, Afifi O, Deprez RD. The prevalence of localized juvenile
periodontitis in Saudi subjects. J Periodontol 1994;65:698.
63. Wolff L, Dahl~n G, Aeppli D. Bacteria as risk markers for periodon-
titis. J Periodontol 1994;64:498.
64. Ebersole JL, Cappelli D, Sandoval M-N. Subgingival distribution of A.
Actinomycetemeomitans in periodontitis. J Clin Periodontol
65. Liljenberg B, Lindhe J, Berglundh T, Dahl~n G, Jonsson R. Some mi-
crobiological, histopathological and immunohistochemical character-
istics of progressive periodontal disease. J Clin Periodonto11994;21:720.
66. Michalowicz BS. Genetic and heritable risk factors in periodontal dis-
ease. J Periodontol 1994;65:479.
67. Takashiba S, Noji S, Nishimura F, Ohyama H, Kurihara H, Nomura
Y, Taniguchi S, Murayama Y. Unique intronic variations of HLA-
DQss gene in early-onset periodontitis. J Periodontol 1994;65:379.
68. Sepp~il~i B, Ainama J. A site-by-site follow-up study on the effect of
controlled versus poorly controlled insulin-dependent diabetes melli-
tus. J Clin Periodontol 1994;21:161.
69. Cerda JG, de la Torre CV, Malacara JM, Nava LE. Periodontal disease
in non-insulin dependent diabetes mellitus (NIDDM). The effect of
age and time since diagnosis. J Periodontol 1994;65:991.
70. Bergstr6m J, Preber H. Tobacco use as a risk factor. J Periodontol
J ULY 1 9 9 5 9 3
71. Linden GJ, Mullally BH. Cigarete smoking and periodontal destruc-
tion in young adults. J Periodontol 1994;65:718.
72. Holm G. Smoking as an additional risk for tooth loss. J Periodontol
73. Somacarrera ML, Hernfindez, Acero J, Moskow BS. Factors related to
the incidence and severity of cyclosporin-induced gingival overgrowth
in transplant patients. A longitudinal study. J Periodonto11994;65:671.
74. Hefti AF, Eshenaur AE, Hassell TM, Stone C. Gingival overgrowth in
cyclosporine A treated multiple schlerosis patients. J Periodontol
75. Seymour RA, Ellis JS, Thomason JM, Monkman S, Idle JR. Amlo-
dipine-induced gingival overgrowth. J Clin Periodontol 1994;21:281.
76. Serino G, WennstrSm J, Lindhe J, Eneroth L. The prevalence and dis-
tribution of gingival recession in subjects with a high standard of oral
hygiene. J Clin Periodontol 1994;21:57.
77. Saario M, Ainamo A, Mattila K, Ainamo J. The width of radiological-
ly-defined attached gingiva over permanent teeth in children. J Clin
Periodontol 1994;21:666.
78. Melvin WL, Assad DA, Miller GA, Gher ME, Simonson L, York AK.
Comparison of DNA probe and ELISA microbial analysis methods and
their association with adult periodontitis. J Periodontol 1994;65:576.
79. Mombelli A, Gmiir, Gobbi C, Lang NP (a). Actinobacillus actino-
mycetemcomitans in adult periodontitis. I. Topographic distribution
before and after treatment. J Periodontol 1994;65:820.
80. Mombeni A, Gmfir, Gobbi C, Lang NP (b). Actinobacillus actino-
mycetemcomitans in adult periodontitis. II. Characterization of iso-
lated strains and effect of mechanical periodontal treatment. J Peri-
odontol 1994;65:827.
81. Gunsolley JC, Zambon JJ, Mellott CA, Brooks CN, Kaugars CC (a).
Periodontol therapy in young adults with severe generalized period-
ontitis. J Periodontol 1994;65:268.
82. Fine DH. Microbial identification and antibiotic sensitivity testing, an
aid for patients refractory to periodontal therapy. A report of 3 cases.
J Clin Periodontol 1994;21:98.
83. Perry DA, Taggart EJ, Leung A, Newbrun E. Comparison of a
conventional probe with electronic and manual pressure-regulated
probes. J Periodontol 1994;65:908.
84. Armitage GC, Jeffcoat MK, Chadwick DE, Taggart Jr. EJ, Numabe Y,
Landis JR, Weaver SL, Sharp TJ. Longitudinal evaluation of elastase
as a marker for the progression of periodontitis. J Periodontol 1994;
85. Newman MG, Kornman KS, Doherty FM. A 6-month multi-center
evaluation of adjunctive tetracycline fiber therapy used in conjunction
with scaling and root planing in maintenance patients: clinical results.
J Periodontol 1994;65:685.
86. Tonetti MS, Pini-Prato G, Cortellini P. Principles and clinical appli-
cations of periodontal controlled drug delivery with tetracycline fibers.
Int J Periodont Rester Dent 1994;14:421.
87. Jones AA, Kornman KS, Newbold DA, Manwell MA. Clinical and mi-
crobiological effects of controlled-release locally delivered minocycline
in periodontitis. J Periodontol 1994;65:1058.
88. Unsal E, Akkaya M, Walsh TF. Influence of a single application of
subgingival chlorhexidine gel or tetracycline paste on the clinical pa-
rameters of adult periodontitis patients. J Clin Periodonto11994;21:351.
89. Jeung S, Han S, Lee S, Magnusson I. Effects of tetracycline-contain-
ing gel and a mixture of tetracycline and citric acid-containing gel on
non-surgical periodontal therapy. J Periodontol 1994;65:840.
90. Shiloah J, Patters MR. DNA probe analyses of the survival of selected
periodontal pathogens following scaling, root planing, and intra-
pocket irrigation. J Periodontol 1994;65:568.
91. Hitzig C, Charbit Y, Bitten C, Fosse T, Teboul M, Hannoun L, Varone
R. Topical metronidazole as an adjunct to subgingival debridement in
the treatment of chronic periodontitis. J Clin Periodonto11994;21:146.
92. HafstrSm CA, WikstrSm MB, Renvert SN, Dahl~n GG. Effect of
treatment on some periodontopathogens and their antibody levels in
periodontal abscesses. J Periodontol 1994;65:1022.
93. Heasman PA, Seymour RA, Kelly PJ. The effect of systemically-ad-
ministered flurbiprofen as an adjunct to toothbrushing on the resolu-
tion of experimental gingivitis. J Clin Periodontol 1994;21:166.
94. Maynor GB, Wilder RS, Mitchell SC, Moriarty JD. Effectiveness of a
calculus scaling gel. J Clin Periodontol 1994;21:365.
95. Smith SR, Foyle DM, Daniels J. An evaluation ofa pre-scaling gel (Sof
Scale@) on the ease of supragingival calculus removal. J Clin Period-
ontol 1994;21:562.
96. Mellonig JT, Seamons BC, Gray JL, Towle HJ. Clinical evaluation of
guided tissue regeneration in the treatment of grade II molar furcation
invasions. Int J Periodont Rester Dent 1994;14:255.
97. Flor~s-de-Jacoby L, Zimmerman A, Tsalikis L. Experiences with
guided tissue regeneration in the treatment of advanced periodontal
disease. A clinical re-entry study, Part I. Vertical, horizontal and com-
bined vertical and horizontal periodontal defects. J Clin Periodontol
98. Andersson B, Bratthall G, Kullendorff B, GrSndahl K, Rohlin M,
AttstrSm R. Treatment of furcation defects. Guided tissue regenera-
tion versus coronaUy positioned flap in mandibular molars: a pilot
study. J Clin Periodontol 1994;21:211.
99. Garrett S, Gantes B, Zimmerman G, Egelberg J. Treatment of man-
dibular class III periodontal furcation defects. Ceronally positioned
flaps with and without expanded polytetrafluoroethylene membranes.
J Periodontol 1994;65:592.
100. Caffesse RG, Nasjleti CE, Morrison EC, Sanchez R. Guided tissue re-
generation: comparision of bioabsorbable and non-bioabsorbable mem-
branes. Histologic and histometric study in dogs. J Periodontol 1994;
101. Gottlow J, Laurell L, Lundgren D, Mathisen T, Nyman S, Rylander H,
Bogentoft C. Periodontal tissue response to a new bioresorbable guided
tissue regeneration device: a longitudinal study in monkeys. Int J Pe-
riodont Rester Dent 1994;14:437.
102. Laurell L, Falk H, Fornell J, Johard G, Gottlow J. Clinical use of a
bioresorbable matrix barrier in guided tissue regeneration therapy.
Case series. J Periodontol 1994;65:967.
103. Caton J, Greenstein G, Zappa U. Synthetic bioabsorbable barrier for
regeneration in human periodontal defects. J Periodento11994;65:1037.
104. Wang H, O'Neal RB, Thomas CL, Shyr Y, MacNeil RL. Evaluation of
an absorbable collagen membrane in treating class II furcation defects.
J Periodontol 1994;65:1029.
105. Robert PM and Frank RM. Periodontal guided tissue regeneration
with a new resorbable polylactic acid membrane. J Periodontol 1994;
106. Black BS, Gher ME, Sandifer JB, Fucini SE, Richardson AC.
Comparative study of collagen and expanded polytetrafluoroethylene
membranes in the treatment of human class II furcation defects. J Pe-
riodontol 1994;65:598.
107. Salama H, Rigotti F, Gianserra R, Seibert J. The utilization of rubber
dam as a barrier membrane for the simultaneous treatment of multi-
ple periodontal defects by the biologic principle of guided tissue
regeneration: Case reports. Int J Periodont Rester Dent 1994;14:17.
108. Cortellini P, Pini-Prato G. Guided tissue regeneration with a rubber
dam: a five-case report. Int J Periodont Rester Dent 1994;14:9.
109. Schallhorn RG, McClain PK. Clinical and radiographic healing pat-
tern observations with combine regenerative techniques. Int J Period-
ant Rester Dent 1994;14:391.
110. Wallace SC, Gellin RG, Miller MC, Mishkin DJ. Guided tissue regen-
eration with and without decalcified freeze-dried bone in mandibular
class II furcation invasions. J Periodontol 1994;65:244.
111. Sigurdsson TJ, Hardwick R, Bogle GC, Wikesj5 UME. Periodontal re-
pair in dogs: space provision by reinforced ePTFE membranes
enhances bone and cementum regeneration in large supraalveolar de-
fects. J Periodontol 1994;65:350.
112. Machtei EE, Cho MI, Dunford R, Norderyd J, Zambon JJ, Genco RJ.
Clinical, microbiological, and histological factors which influence the
success of regenerative periodontal therapy. J Periodonto11994;65:154.
113. Nowzari H, Slots J. Microorganisms in polytetrafluoroethylene barrier
membranes for guided tissue regeneration. J Clin Periodontol 1994;
114. Saito A, Hosaka Y, Nakagawa T, Seida K, Yamada S, Okuda K. Lo-
cally delivered minocycline and guided tissue regeneration to treat
post-juvenile periodontitis. A case report. J Periodontol 1994;65:835.
115. Sander L, Frandsen EVG, Arnbjerg D, Warrer K, Karring T. Effect of
local metronidazole application on periodontal healing following
guided tissue regeneration. Clinical findings. J Periodonto11994;65:914.
116. Frandsen EVG, Sander L, Arnbjerg D, Theflade E. Effect of local met-
ronidazole application on periodontal healing following guided tissue
regeneration. Microbiological findings. J Periodontol 1994;65:921.
117. Demolon IA, Persson GR, Ammons WF, Johnson RH. Effects of an-
tibiotic treatment on clinical conditions with guided tissue regenera-
tion: one-year results. J Periodontol 1994;65:713.
118. O'Brien TP, Hinrichs JE, Schaffer EM. The prevention of localized
9 4 V O L U M E 7 4 N U M B E R 1
ridge deformities using guided tissue regeneration. J Periodontol
119. Simion M, Baldoni M, Rossi P, Zaffe D. A comparative study of the ef-
fectiveness of e-PTFE membranes with and without early exposure
during the healing period. Int J Periodont Restor Dent 1994;14:167.
120. Gher ME, Quintero G, Assad D, Monaco E, Richardson AC. Bone
grafting and guided bone regeneration for immediate dental implants
in humans. J Periodontoi 1994;65:881.
121. Evian CI, Cutler S. Autogenous gingival grafts as epithelial barriers for
immediate implants: Case reports. J Periodontol 1994;65:201.
122. Langer B. Spontaneous in situ gingival augmentation. Int J Periodont
Restor Dent 1994;14:525-35.
123. Nevins M, Mellonig JT. The advantages of localized ridge augmenta-
tion prior to implant placement: a staged event. Int J Periodont Re-
stor Dent 1994;14:97.
124. Becker W, Becket BE, McGuire MK. Localized ridge augmentation
using absorbable pins and e-PTFE barrier membranes: a new surgical
technique. Case reports. Int J Periodont Restor Dent 1994;14:49.
125. Simion M, Trisi P, Piatelli A. Vertical ridge augmentation using a
membrane technique associated with osseointegrated implants. Int J
Periodont Restor Dent 1994;14:497.
126. Becker W, Becket BE, Caffesse R. A comparison of demineralized
freeze-dried bone and autologous bone to induce bone formation in
human extraction sockets. J Periodontol 1994;65:1128.
127. Nishibori M, Betts NJ, Salama H, Listgarten MA. Short-term healing
of autogenous and allogenic bone grafts after sinus augmentation: a
report of 2 cases. J Periodontol 1994;65:958.
128. Wang H, Pappert TD, Castelli WA, Chicgo Jr. D J, Shyr Y, Smith BA.
The effect of platelet-derived growth factor on the cellular response of
the periodontium: an autoradiographic study on dogs. J Periodontol
129. Seivig KA, Wikesj6 UME, Bogle GC, Finkelmann RD. Impaired early
bone formation in periodontal fenestration defects in dogs following
application of insulin-like growth factor II. Basic fibroblast growth
factor and transforming growth factor beta 1. J Clin Periodontol
130. Giannobile WV, Finkelman RD, Lynch SE. Comparison of canine and
non-human primate animal models for periodontal regenerative ther-
apy: results following a single administration of PDGF/IFG-I. J Peri-
odontol 1994;65:1158.
131. Harris RJ, Harris AW. The coronally positioned pedicle graft with in-
laid margins: a predictable method of obtaining root coverage of shal-
low defects. Int J Periodont Restor Dent 1994;14:229.
132. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for
root coverage. I. Rationale and technique. Int J Periodont Restor Dent
133. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for
root coverage. II. Clinical results. Int J Periodont Restor Dent 1994;
134. Harris RJ. The connective tissue with partial thickness double pedicle
graft: the results of 100 consecutively-treated defects. J Perlodontol
135. Borghetti A, Louise F. Controlled clinical evaluation of the subpedi-
cle connective tissue graft for the coverage of gingival recession. J Pe-
riodontol 1994;65:1107.
136. Bouchard P, Etienne D, Ouhayoun J, Nilv~us R. Subepithelial
connective tissue grafts in the treatment of gingival recessions. A com-
parative study of 2 procedures. J Periodontol 1994;65:929.
137. Tinti C. Vincenzi GP. Expanded polytetrafluoroethylene titanium-re-
inforced membranes for regeneration of mucogingival recession de-
fects. A 12-case report. J Periodontol 1994;65:1088.
138. Trombelli L, Schincaglia G, Checchi L, Calura G. Combined guided
tissue regeneration, root conditioning, and fibrin-fibronectin system
application in the treatment of gingival recession. A 15-case report. J
Periodontol 1994;65:796.
139. Shih SD, Allen EP. Use of guided tissue regeneration to treat a
mucogingival defect associated with interdental bone loss: a case
report. Int J Periodont Restor Dent 1994;14:553.
140. Gunsolley JC, Zambon JJ, Mellott CA, Brooks CN, Kaugars CC.
Maintenance therapy in young adults with severe generalized period-
ontitis. J Periodontol 1994;65:274.
141. Joss A, Adler R, Lang NP. Bleeding on probing. A parameter for mon-
itoring periodontal conditions in clinical practice. J Clin Periodontol
142. Wang H, Burgett FG, Shyr Y, Ramfjord S. The influence of molar fur-
cation involvement and mobility on future clinical periodontal attach-
ment loss. J Periodontol 1994;65:25.
143. Cortellini P, Pini-Prato G, Tonetti M. Periodontal regeneration of hu-
man infrabony defects (V). Effect of oral hygiene on long-term stabil-
ity. J Clin Periodontol 1994;21:606.
144. Vouras J, Sakellari D, Konstantinidis A. Effect of a new pre-brushing
rinse on dental plaque removal. J Clin Periodontol 1994;21:701.
145. Vacek JS, Gher ME, Assad DA, Richardson AC, Giambarresi LI. The
dimensions of the human dentogingival junction. Int J Periodont Re-
stor Dent 1994;14:155.
146. Jansson L, Ehnevid H, Lindskog S, BlomlSf L. Proximal restorations
and periodontal status. J Clin Periodontol 1994;21:577.
147. Setz J, Diehl J. Gingival reaction on crowns with cast and sintered
metal margins: A progressive report. J PROSTHET DENT 1994;71:442.
148. Budtz-Jiirgensen E. Effects of denture wearing habits on periodontal
health of abutment teeth in patients with overdentures. J Clin Peri-
odontol 1994;21:265.
149. Jacobs R, van Steenberghe D. The effect of electronic dental analgesia
during sonic scaling. J Clin Perlodontol 1994;21:728.
150. Spruijt RJ and Wabeke KB. On temporomandibular joint sounds
[Thesis]., Amsterdam, The Netherlands: University of Amsterdam,
151. De Mot B, Casselman J, De Boever J. Pseudodynamic magnetic res-
onance imaging in the diagnosis of temporomandibular joint dysfunc-
tion. J PROSTHET DENT 1994;72:309-13.
152. Pereira FJ, Lundh H, Westesson PL, Carlsson LE. Clinical findings
related to morphologic changes in TMJ autopsy specimens. Oral Surg
Oral Med Oral Pathol 1994;78:288-95.
153. Pereira FJ, Lundh H, Westesson PL. Morphoiogic changes in the
temporomandibular joint in different age groups. An autopsy investi-
gation. 0ral Surg Oral Med Oral Pathol 1994;78:279-81.
154. Garefis P, Grigoriadou E, Zarifi A, Koidis PT. Effectiveness of conser-
vative treatment for craniomandibular disorders: a 2-year longitudinal
study. J Orofacial Pain 1994;8:309-14.
155. Magnusson T, Carlsson GE, Egermark I. Changes in clinical signs of
craniomandibular disorders from the age of 15 to 25 years. J Orofacial
Pain 1994;8:207-215.
156. de Leeuw R, Boering G, Stegenga B, de Bont LGM. Clinical signs of
TMJ osteoarthrosis and internal derangement 30 years after nonsur-
gical treatment. J Orofacial Pain 1994;8:18-24.
157. Widmark G, Haraldsson T, Kahnberg KE. Effects of conservative
treatment in patients who later will be candidates for TMJ surgery.
Swed Dent J 1994;18:139-47.
158. Wilkinson TM, Crowley CM. A histologic study of retrodiscal tissues
of the human temporomandibular joint in the open and closed posi-
tion. J Orofacial Pain 1994;8:7-17.
159. Takagi R, Shimoda T, Westesson PL, Takahashi A, Morris TW, Sano
T, Moses JJ. Angiography of the temporomandibular joint. Oral Surg
Oral Med Oral Pathol 1994;78:539-43.
160. Bittar GT, Bibb CA, Pullinger AG. Histologic characteristics of the
lateral pterygoid muscle insertion to the temporomandibular joint. J
Orofacial Pain 1994;8:243-9.
161. Mills DK, Fiandaca DJ, Scapino RP. Morphologic, microscopic, and
immunohistochemical investigations into the function of the primate
TMJ disc. J Orofacial Pain 1994;8:136-154.
162. Korioth TWP, Hannam AG. Mandibular forces during simulated
tooth clenching. J Orofacial Pain 1994;8:178-89.
163. Ferrario VF, Sforza C. Biomechanical model of the human mandible
in unilateral clench: distribution of temporomandibular joint reaction
forces between working and balancing sides. J PROSTHET DENT 1994;
164. Gratt BM, Sickles EA, Wexler CE, Ross JB. Thermographic charac-
terization of internal derangement of the temporomandibular joint. J
Orofacial Pain 1994;8:197-206.
165. Gratt BM, Sickles EA, Ross JB, Wexler CE, Gornbein JA. Thermo-
graphic assessment of craniomandibular disorders: diagnostic inter-
pretation versus temperature measurement analysis. J Orofacial Pain
166. Gratt BM, Sickles EA, Shetty V. Thermography for the clinical
assessment of inferior alveolar nerve deficit: a pilot study. J Orofacial
Pain 1994;8:369-74.
167. ShettyV, Gratt BM, Flack V. Thermographicassessment ofreversible
inferior alveolar nerve deficit. J Orofacial Pain 1994;8:375-83.
J ULY 1995 9 5
168. Ciancaglini R, Loreti P, Radaelli G. Ear, nose and throat symptoms in
patients with TMD: the association of symptoms according to severity
of arthropathy. J Orofacial Pain 1994;8:293-7.
169. Tsolka P, Fenlon MR, McCullock AJ, Preiskel HW. A controlled clin-
ical, electromyographic, and kinesiographic assessment of cranioman-
dibular disorders in women. J Orofacial Pain 1994;8:80-9.
170. DaD TTT, Lund JP, Lavigne G. Comparison of pain and quality of life
in bruxers and patients with myofascial pain of the masticatory mus-
cles. J Orofacial Pain 1994;8:350-6.
171. Hapak L, Gordon A, Locker D, Shandling M, Mock D, Tenenbaum HC,
Differentiation between musculoligamentous, dentoalveolar, and neu-
rologically based craniofacial pain with a diagnostic questionnaire. J
Orofacial Pain 1994;8:357-68.
172. Reid KI, Gracely RH, Dubner RA. The influence of time, facial side,
and location on pain-pressure thresholds in chronic myogenous tem-
poromandibular disorder. J Orofacial Pain 1994;8:258-65.
173. Canavan D, Graff-Radford SB, Gratt BM. Traumatic dysesthesia of
the trigeminal nerve. J Orofacial Pain 1994:391-6.
174. Skolnick J, Iranpour B, Westesson PL, Adair S. Prepubertal trauma
and mandibular asymmetry in orthognathic surgery and orthodontic
patients. Am J Orthod Dentofac Orthop 1994;105:73-7.
175. Westesson PL, Tallents RH, Katzberg RW, Guay JA. Radiographic
assessment of asymmetry of the mandible. AJNR Am J Neuroradiol
176. Miller VJ. Variation of condylar asymmetry with age in edentulous
patients with a craniomandibular disorder of myogenous origin. J
PROSTHET DENT 1994:384-6.
177. Hall HD, Nickerson JW Jr. Is it time to pay more attention to disc po-
sition? J Orofacial Pain 1994;8:90-6.
178. Gross MD, Ormianer Z. A preliminary study on the effect of occlusal
vertical dimension increase on mandibular postural rest position. Int
J Prosthodont 1994;7:216-26.
179. Hayashi T, Saltoh A, Ishioka K, Miyakawa M. A computerized system
for analyzing occlusal relations during mandibular movements. Int J
Prosthodont 1994;7:108-14.
180. Kerstein RB. Disclusion time measurement studies: stability of
disclusion time--a 1-year follow up. J PROSTHET DENT 1994;72:164-8.
181. Kerstein RB. Disclusion time measurement studies: a comparison of
disclusion time between chronic myofascial pain dusfunction patients
and nonpatients: a population analysis. J PROSTHET DENT 1994;72:
182. Johansson A, Fareed K, Drear R. Lateral and protrusive contact
schemes and occlusal wear: a correlational study in a young adult Sandi
population. J PROSTHET DENT 1994;71:159-64.
183. Mizui M, Nabeshima F, Tosa J, Tanaka M, Kawazoe T. Quantitative
analysis of occlusal balance in intercuspal position using the T-Scan
system. Int J Prosthodont 1994;7:62-71.
184. Carlsson GE, Lindquist LW. Ten-year longitudinal study of mastica-
tory function in edentulous patients treated with fixed complete den-
tures on osseointegrated implants. Int J Prosthodont 1994;7:448-53.
185. Hallonsten AL. Separat barntandvhrdsorganisation effektivare. Tand-
l~ikartidningen 1994;86:1126-7.
186. Nydell A, Helkimo M, Koch G. Craniomandibular disorders in
children--a critical review of the literature. Swed Dent J 1994;18:191-
187. Bergendal T, Hugoson A, Kvint S, Lundgren D. A radiological inven-
tory of possible sites for cylinder implants in edentulous regions of the
jaws. Swed Dent J 1994;18:75-85.
188. Sonick M, Abrahams J, Faiella RA. A comparison of the accuracy of
periapical, panoramic, and computerized tomographic radiographs in
locating the mandibular canal. Int J Oral Maxillofac Implants
189. Dario L J, English R. Achieving implant reconstruction through bilat-
eral mandibular nerve repositioning. J Am Dent Assoc 1994;125:305-9.
190. Jensen J, Reiche-Fischel O, Sindet-Pedersen S. Nerve transposition
and implant placement in the atrophic posterior mandibular alveolar
ridge. J Oral Maxillofac Surg 1994;52:662-8.
191. Krogh PHJ, Worthington P, Davis WH, Keller EE. Does the risk of
complication make transpositioning the inferior alveolar nerve in con-
junction with implant placement a "last resort" surgical procedure?
Int J Oral Maxillofac Implants 1994;9:249-54.
192. Misch CE, Dietsh F. Endosteal implants and iliac crest grafts to restore
severely resorbed totally edentulous maxillae: a retrospective study. J
Oral Implantol 1994;20:100-10.
193. Becker W, Dahlin C, Becker BE, Lekholm U, van Steenberghe D,
Higuchi K, Kultje C. The use of e-PTFE barrier membranes for bone
promotion around titanium implants placed into extraction sockets: a
prospective multicenter study. Int J Oral Maxillofac Implants
194, Becket W, Becket BE, Polizzi G, Bergstrom C. Autogenous bone
grafting of bone defects adjacent to implants placed into immediate
extraction sockets in patients: a prospective study. Int J Oral Maxil-
lofac Implants 1994;9:389-96.
195. Lewis SG. Esthetic implant restorations. Compend Contin Educ Dent
196. Neale D, Chee WWL. Development of implanb soft tissue emergence
profile: a technique. J PROSTHET DENT 1994;71:364-8.
197. Ekfeldt A, Carlsson GE, Borjesson G. Clinical evaluation of single-
tooth restorations supported by osseointegrated implants: a retrospec-
tive study. Int J Oral Maxillofac Implants 1994;9:179-83.
198. Laney WR, Jemt T, Harris D, Henry PJ, et al. Osseointegrated
implants for single-tooth replacement: progress report from a multi-
center prospective study after 3 years. Int J Oral Maxillofac Implants
199. Gunne J, Jemt, T, Linden B. Implant treatment in partially edentu-
lous patients: a report on prostheses after 3 years. Int J Prosthodont
200. Naert L, Quirynen M, Hooghe M, van Steenberghe D. A comparative
prospective study of splinted and unsplinted Bhnemark implants in
mandibular overdenture therapy: a preliminary report. J PROSTHET
DENT 1994;7h486-92.
201. Thilander B, Odman J, Grondahl K, Friberg B. Osseointegrated
implants in adolescents: an alternative in replacing missing teeth?
Europ J Ortho 1994;16:84-95.
202. Zarb GA, Schmitt A. Osseointegration for elderly patients: The Tor-
onto study. J PROSTHET DENT 1994;72:559-68.
203. Odman J, Lekholm U, Jemt T, Thilander B. Osseointegrated implants
as orthodontic anchorage in the treatment of partially edentulous
adult patients. Europ J Ortho 1994;16:187-201.
204. Mericske-Stern R. Oral tactile sensibility recorded in overdenture
wearers with implants or natural roots: a comparative study. Part 2. Int
J Oral Maxillofac Implants 1994;9:63-70,
205. Goheen KL, Vermilyea SG, Vossoughi J, Agar JR. Torque generatedby
handheld screwdrivers and mechanical torquing devices for osseointe-
grated implants. Int J Oral Maxillofac Implants 1994;9:149-55.
206. Burguete RL, Johns RB, King T, Patterson EA. Tightening charac-
teristics for screwed joints in osseointegrated dental implants. J PROS-
THET DENT 1994;71:592-9.
207. Chee WWL, Jansen CE. Phenytoin hyperplasia occurring in relation
to titanium implants: a clinical report. Int J Oral Maxillofac Implants
208. Kim WS, Vacanti JP, Cima L, et al. Cartilage engineered in predeter-
mined shapes employing cell transplantation on synthetic biodegrad-
able polymers. Plast Reconstr Surg 1994;94:233-7.
209. Corbin SB, Kohn WG. The benefits and risks of dental amalgam: cur-
rent findings reviewed. J Am Dent Assoc 1994;125:381-8.
210. Berry TG, Nicholson J, Troendle K. Almost two centuries with amal-
gam: where are we today? J Am Dent Assoc 1994;125:392-9.
211. Ferracane JL, Engle JH, Okabe T, Mitchem JC. Reduction in opera-
tory mercury levels after contamination or amalgam removal. Am J
Dent 1994;7:103-7.
212. Powell LV, Johnson GH, Yashar N, Bales DJ. Mercury vapor release
during insertion and removal of dental amalgam. Oper Dent 1994;
213. Okabe T, Yamashita T, Nakajima H, Berglund A, Zhao I, Guo I, Fer-
racane JL. Reduced mercury vapor release from dental amalgams pre-
pared with binary Hg-In liquid alloys. J Dent Res 1994;73:1711-6.
214. Mahler DB, Adey JD, Fleming MA. Hg emission from dental amalgam
as related to the amount of Sn in the Ag-Hg (gamma one) phase. J Dent
Res 1994;73:1663-8.
215. Chandler JE, Messer HH, Ellender G. Cytotoxicity of gallium and in-
dium ions compared with mercuric ion. J Dent Res 1994;73:1554-9.
216. Sandborgh Englund G, Dahlqvist R, Lindelof B, Soderman E, Jonzon
B, Vesterberg O, Larsson KS. DMSA administration to patients with
alleged mercury poisoning from dental amalgams: a placebo-controlled
study. J Dent Res 1994;73:620-8.
217. Jokstad A, Mjor IA, Qvist V. The age of restorations in situ. Acta Odont
Scand 1994;52:234-42.
9 6 V O L U M E 7 4 N U M B E R 1
218. Erickson R, Glasspoole EA. Bonding to tooth structure: a comparison
of glass-ionomer and composite-resin systems. J Esthet Dent 1994;6:
219. Charlton DG, Beatty MW. The effect of dentin surface moisture on
bond strength to dentin bonding agents. Oper Dent 1994;19:154-8.
220. Vargas MA, Swift EJ Jr. Microleakage of resin composites with wet
versus dry bonding. Am J Dent 1994;7:187-9.
221. Elhabashy A, Swi f t EJ Jr. Bondi ng to etched, physiologically hydrat ed
dentin. Am J Dent 1994;7:50-2.
222. Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am
J Dent 1994;7:144-8.
223. Dishman MV, Covey DA, Baughan LW. The effects of peroxide
bleaching on composite to enamel bond strength. Dent Mater 1994;
224. Haveman CW, Charlton DG. Dentin treatment with an oxalate solu-
tion and glass ionomer bond strength. Am J Dent 1994;7"247-51.
225. Perdigao J, Swift EJ Jr, Denehy GE, Wefel JS, Donly KJ. In vitro bond
strengths and SEM evaluation of dentin bonding systems to different
dentin substrates. J Dent Res 1994;73:44-55.
226. Filler SJ, Lazarchik DA, Givan DA, Retief DH, Heaven TJ. Shear bond
strengths of composite to chlorhexidine-treated enamel. Am J Dent
227. Perdigao J, Denehy GE, Swift EJ Jr. Silica contamination of etched
dentin and enamel surfaces: a scanning electron microscopic and bond
strength study. Quintessence Int 1994;25:327-33.
228. Perdigao J, Denehy GE, Swift EJ Jr. Effects of chlorhexidine on den-
tin surfaces and shear bond strengths. Am J Dent 1994;7:81-4.
229. Johnson ME, Burgess JO, Hermesch CB, Buikema DJ. Saliva con-
tamination of dentin bonding agents. Oper Dent 1994;19:205-10.
230. Van Meerbeek B, Braem M, Lambrechts P, Vanherle G. Morpholog-
ical characterisation of the interface between resin and sclerotic den-
tine. J Dent 1994;22:141-6.
231. Finger WJ, Inoue M, Asmussen E. Effect of wettability of adhesvie
resins on bonding to dentin. Am J Dent 1994;7:35-8.
232. Tam LE, Pilliar RM, Effects of dentin surface treatments on the frac-
ture toughness and tensile bond strength of a dentin-composite adhe-
sive interface. J Dent Res 1994;73:1530-8.
233. Chappell RP, Eick JD. Shear bond strength and scanning electron mi-
croscopic observation of six current dentinal adhesives. Quintessence
Int 1994;25:359-68.
234. Gwinnett AJ. A new method to test the cohesive strength of dentin.
Quintessence Int 1994;25:215-8.
235. Sane H, Shone T, Takatsu T, Hosoda H. Microporous dentin zone be-
neath resin-impregnated layer. Oper Dent 1994;19:59-64.
236. Retief DH, Mandras RS, Russell CM. Shear bond strength required to
prevent microleakage at the dentin/restoration interface. Am J Dent
237. Van Meerbeek B, Peumans M, Vershueren M, Gladys S, Braem M,
Lambrechts P, Vanherle G. Clinical status of ten dentin adhesive sys-
tems. J Dent Res 1994;73:1690-702.
238. Tyas MJ. Clinical evaluation of five adhesive systems. Am J Dent
239. Duke ES, Robbins JW, Schwartz RS, Summitt JB, Conn LJ. Clinical
and interracial laboratory evaluation of a bonding agent in cervical
abrasions. Am J Dent 1994;7:307-11.
240. Tyas MJ. Three-year clinical evaluation of Tenure dent i ne bonding
agent. Aust Dent J 1994;39:188-9.
241. Ferrari M, Cadidiaco MC, Mason PN. Micromorphological relation-
ship between resin and dentin in Class II restorations: an in vivo and
in vitro investigation by scanning electron microscopy. Quintessence
Int 1994;25:861-6.
242. Tay FR, Gwinnett AJ, Pang KM, Wei SHY. Structure evidence of a
sealed tissue interface with a total-etch wet-bonding technique in rive.
J Dent Res 1994;73:629-36.
243. Cassinelli C, Morra M. Atomic force microscopy studies of the inter-
action of a dentin adhesive with tooth hard tissue. J Biomed Mater Res
244. Dijkman GEHM, Jongebloed WL, de Vries J, Ogaard B, Arends J.
Closing of dentinal tubules by glutardialdehyde treatment, a scanning
electron microscopy study. Scand J Dent Res 1994;102:144-50.
245. White KC, Cox CF, Kanca J, Dixon DL, Farmer JB, Snuggs HM. Pul-
pal response to adhesive resin systems applied to acid-etched vital
dentin: damp versus dry primer application. Quintessence Int 1994;
246. Eakle WS, Staninec M, Yip RL, Chavez MA. Mechanical retention
versus bonding of amalgam and gallium alloy restorations. J PROSTHET
DENT 1994;72: 351-4.
247. Boyer DB, Roth L. Fracture resistance of teeth with bonded amalgams.
Am J Dent 1994;7:91-4.
248. Vargas MA, Danehy GE, Ratananakin T. Amalgam shear bond
strength to dentin using different bonding agents. Oper Dent 1994;
249. Santos AC, Meiers JC. Fracture resistance of premolars with MOD
amalgam restorations lined with Amalgambond. Oper Dent 1994;
250. Bagley A, Wakefield CW, Robbins JW. In vitro comparison of filled
and unfilled universal bonding agents of amalgam to dentin. Oper Dent
251. Kawakami M, Staninec M, Imazato S, Torii M, Tsuchitani Y. Shear
bond strength of amalgam adhesives to dentin. Am J Dent 1994;7:53-6.
252. Souza MH, Retief DH, Russell CM, Denys FR. Laboratory evaluation
of phosphate ester bonding agents. Am J Dent 1994;7:67-73.
253. Barkmeier WW, Gendusa NJ, Thurmond JW, Triolo PT Jr. Labora-
tory evaluation of Amalgambond and Amalgambond Plus. Am J Dent
254. Garcia-Bargero AE, Barcia-Barbero J, Lopez-Calvo JA. Bonding of
amalgam to composite: tensile strength and morhpology study. Dent
Mater 1994;10:83-7.
255. Nuckles DB, Dranghn RA, Smith TI. Evaluation of an adhesive sys-
tem for amalgam repair: bond strength and porosity. Quintessence Int
256. Lee SY, Greener EH. Effect of excitation energy on dentine bond
strength and composite properties. J Dent 1994;22:175-81.
257. Rueggeberg FA, Caughman WF, Curtis JW Jr, Davis HC. A predictive
model for the polymerization of photo-activated resin composites. Int
J Prosthod 1994;7:159-66.
258. Rueggeberg FA, Caughman WF, Curtis JW Jr. Effect of light intensity
and exposure duration on cure of resin composite. Oper Dent 1994;
259. Watts DC, Cash AJ. Analysis of optical transmission by 400-500 nm
visible light into aesthetic dental biomaterials. J Dent 1994;22:
260. Peutzfeldt A. Correlation between recordings obtained with a light-
intensity tester and degree of conversion of a light-curing resin. Scand
J Dent Res 1994;102:73-5.
261. Ciamponi AL, Lujan VAP, Santos JFF. Effectiveness of reflective
wedges on the polymerization of composite resin. Quintessence Int
262. Peutzfeldt A. Quantity of remaining double bonds of diacetyl-con-
taining resins. J Dent Res 1994;73:511-5.
263. Rozmajzl WF Jr, Los SA, Albrechtsen LA, Barkmeier WW. Compos-
ite to dentin bond strength using a curing unit with nitrogen. Am J
Dent 1994;7:319-21.
264. Gerzina TM, Hume WR. Effect of dentine on release of TEGDMA
from resin composite in vitro. J Oral Rehabil 1994;21:463-8.
265. Hanks CT, Wataha JC, Parsell RR, Strawn SE, Fat JC. Permeability
of biological and synthetic molecules through dentine. J Oral Rehabil
266. Bean TA, Zhuang WC, Tong PY, Eick JD, Yourtee DM. Effect of es-
terase on methacrylates and methacrylate polymers in an enzyme
simulator for biodurability and biocompatibility testing. J Biomed
Mater Res 1994;28:59-64.
267. Wataha JC, Hanks CT, Strawn SE, Fat JC. Cytotoxicity of compo-
nents of resins and other dental restorative materials. J Oral Rehabil
268. Imazato S, McCabe JF. Influence of incorporation of antibacterial
monomer on curing behavior of a dental composite. J Dent Res
269. Suliman AH, Boyer DB, Lakes RS. Polymerization shrinkage of com-
posite resins: comparison with tooth deformation. J PROSTHET DENT
270. Braem MJA, Davidson CL, Lambrechts P, Vanherle G. In vitro flex-
ural fatigue limits of dental composites. J Biomed Mater Res 1994;
271. Sarrett DC, Ray S. The effect of water on polymer matrix and
composite wear. Dent Mater 1994;10:5-10.
272. Braem M, Lambrechts P, Vanherle G. Clinical relevance of laboratory
fatigue studies. J Dent 1994;22:97-102.
J ULY 1995 9 7
273. Mair LH. Subsurface compression fatigue in seven dental composites.
Dent Mater 1994;10:111-5.
274. Ferracane JL, Mitchem JC. Properties for posterior composites:
results of round robin testing for a specification. Dent Mater 1994;
275. Bryant RW, Hodge KLV. A clinical evaluation of posterior composite
resin restorations. Aust Dent J 1994;39:77-81.
276. Taylor DF, Bayne SC, Leinfelder KF, Davis S, Koch GG. Pooling of
long term clinical wear data for posterior composites. Am J Dent
277. Burgess J, Norling B, Summitt J. Resin ionomer restorative materials:
the new generation. J Esther Dent 1994;61207-15.
278. Mitra SB, Kedrowski BL. Long-term mechanical propert i es of glass
ionomers. Dent Mater 1994;10:78-82.
279. Cattani-Lorente MA, Godin C, Meyer JM. Mechanical behavior of
glass ionomer cements affected by long-term storage in water. Dent
Mater 1994;10137-44.
280. Souto M, Donly KJ. Caries inhibition of glass ionomers. Am J Dent
281. Dionysopoulos P, Kotsanos N, Koliniotou-Koubia E, Papadogiannis
Y. Secondary caries formation in vitro around fluoride-releasing res-
torations. Oper Dent 1994;19:183-8.
282. Castro GW, Gray SE, Buikema DJ, Reagan SE. The effect of various
surface coatings on fluoride release from glass-ionomer cement. Oper
Dent 1994;19:194-8.
283. Berry EA, Powers JM. Bond strength of glass ionomers to coronal and
radicu]ar dentin. Oper Dent 1994~19-122-6.
284. Mount GJ. Glass-ionomer cements, past, present, and future. Oper
Dent 1994;19:82-90.
285. Erickson RL. Root surface treatment with glass ionomers and resin
composites. Am J Dent 1994;7:279-85.
286. Andersson OH, Dahl JE. Aluminum release from glass ionomer
cements during early water exposure in vitro. Biomat 1994;15:882-8.
287. McLean JW, Nicholson JW, Wilson AD. Proposed nomenclature for
glass-ionomer dental cements and related materials. Quintessence Int
288. Brackett WW, Rosen S. The antimicrobial action of chlorhexidine-
containing zincphosphate cement. Oper Dent 1994;19:106-9.
289. Ishikawa-Nagai S, Sato R, Shiraishi A, Ishibashi K. Using a computer
color-matching system ia color reproduction of procelaia restorations.
Part III: a newly developed spectrophotometer designed for clinical
application. Int J Prosthodont 1994;7:50-5.
290. O'Brien W, Fan P, Groh C. Color difference coefficients of body-
opaque double layers. Int J Proshodont 1994;7156-61.
291. David B. Johnston W, Saba R. Kulbelka-Munk reflectance theory ap-
plied to veneer systems using a colorimeter. Int J Prosthodont 1994;
292. Razzoog M, Russel M. A comparison of the color stability of conven-
tional and titanium dental procelain. J PROSTHET DENT 1994;72:453-6.
293. Castellani D, Clauser C, Bernadini U. Thermal distoration of different
materials in crown construction. J PROSTHET DENT 1994;72:360-6.
294. Vermilyea S, Prosanna M, Agar J. Effect of ultrasonic cleaning and
airpolishing on porcelain labial margin restorations. J PROSTHET DENT
295. Kern M, Thompson V. Sandblasting and silica coating of glass -infil-
trated alumina ceramic: volume loss, morphology, and changes in the
surface composition. J PROSTHET DENT 1994;71:453-6L
296. Tylka D. Stewart G. Comparison of acidulated phosphate fluoride gel
and hydrofluoric acid etchants for porcelain composite repair. J PROS-
THET DENT 1994;72:121-7. 297.
297. Yoshinari M, Derand T. Fracture strength of all-ceramic crown. Int J
Prosthodont 1994;7:329-38.
298. Castellani D, Baccetti T, Giovanni A, Bernardini U. Resistance to
fracture of metal ceramic and all-ceramic crowns. Int J Prosthodont
299. Jagger D, Harrison A. An in vitro investigation into the wear effects of
unglazed, glazed, and polished porcelain on human enamel. J PROS-
THET DENT 1994;72:320-3.
300. Scurria M, Powers J. Surface roughness of two polished ceramic ma-
terials. J PROSTHET DENT 1994;711174-7.
301. Breeding L, Dixon D, Moseley J. Custom impression trays: Part
I--mechanical properties. J PROSTHET DENT 1994;71:31-4.
302. Moseley J. Dixon D, Breeding L. Custom impression trays. Part III: A
stress distribution model. J PROSTHET DENT 1994;71:532-8.
303. Thompson G, Vermilyea S. Agar J. Effects of disinfection of custom
tray materials on adhesive properties of several impression material
systems. J PROSTHET DENT 1994;72:651-6.
304. Dixon D. Breeding L, Brown J. The effect of custom tray material type
and adhesive drying time on the tensile bond strength of an impres-
sion material/adhesive system. Int J Prosthodont 1994;71129-33.
305~ Hondrum S. Tear and energy properties of three impression materi-
als. Int J Prosthodont 1994;7:517-2L
306. Chai J, Pang I. A study of the "thixotropic" property of elastomeric
impression materials. Iat J Prosthodont 1994;71155-8.
307. Takahashi H, Finger W. Effects of setting stage on the accurary of
double-mix impressions made with addition curing silicone. J PROS-
THET DENT 1994;72178-84.
308. Laufer B, Baharav H, Cardash H. The linear accuracy of impressions
and stone dies as affected by the thickness of the impression margin.
Int J Prosthodont 1994;7:247-52.
309. Beyerle M, Hensley D, Bradley D, Schwartz R, Hilton T. Immersion
disinfection of irreversible hydrocolloid impressions with sodium hy-
pochlorite. Part I: microbiology. Int J Prosthodont 1994;71234-8.
310. Schwartz R, Bradley D, Hilton T, Kruse S. Immersion disinfection of
irreversible hydrocolloid impressions. Part Ii microbiology. Int J
Prosthodont 1994;7:418-23.
311. Hilton T, Schwartz R, Bradley D. Immersion disinfection of irrevers-
ible hydrocolloid impressions. Part II: effects on gypsum casts. Int J
Prosthodont 1994;7:424-33.
312. Vandewalle K, Charlton D, Schwartz R, Reagan S, Koeppen R.
Immersion disinfection of irreversible hydrocolloid impressions with
sodium hypochlorite. Part II: effect on gypsum. Int J Prosthodont
313. Cserna A, Crist R, Adams A, Dunning D. Irreversible hydrocolloids: a
comparison of antimicrobial efficacy. J PROSTHET DENT 1994;71:387-9.
314. Olin P, Holtan J, Breitbach R, Rudney J. The effects of sterilization
on addition silicone impressions in custom and stock trays. J PROSTHET
DENT 1994;71:625-30.
315. Gelbard S, Aoskar Y, Zalkind M, Stern N. Effect of impression mate-
rials and techniques on marginal fit of castings. J PROSTHET DENT
316. Harris I, Wickens J. A comparison of the fit of spark-eroded titanium
copings and cast gold alloy copings. Int J prosthodont 1994;7:348-55.
317. Siervo S, Bandetti B, Siervo P, Falleni A, Siervo R. The CELAY sys-
tem: a comparison of the fit of direct and indirect fabrication tech-
niques. Int J Prosthodont 1994;7:434-9.
318. Moulding B, Loney R, Ritsco R. Marginal accuracy of provisional
restoraitons fabricated by different techniques. Int J Prosthodont
319. Powell D, Nicholls J, Yuodelis R, Strygler H. A comparison of wire and
Kevlar reinforced provisional restorations. Int J Prosthodont 1994;
320. Wilson P. Effect of increasing cement space on cementation of artif-
ical crowns. J PROSTHET DENT 1994;71:560-4.
321. WU J, Wilson P. Optimal cement space for resin luting cements. Int J
Prosthodont 1994;7:209-15.
322. White S, Ingles S, Kipnis V. Influence of marginal opening on
microleakage of cemented artificial crowns. J PROSTHET DENT 1994;
323. White S, Yu Z, Tom J, Sangsurasak S. In vivo microleakage of luting
cements for cast crowns. J PROSTHET DENT 1994;71:333-8.
324. Strutz J, White S, Yu Z, Kane C. Luting cement-metal surface phys-
iochemical interactions on film thickness. J PROSTHET DENT 1994;
325. Kamposiora P, Papavasilious G, Bayne S, Felton D. Finite element
analysis estimates of cement microfracture under complete veneer
crowns. J PROSTHET DENT 1994;71:435-41.
326. Abdel-Hakim A, A1-Dalgan A, AI-Bishre G. Displacement of border
tissues during final impression procedures. J PROSTHET DENT 1994;
327. Lechner S, Thomas G. Changes caused by processing complete man-
dibular dentures. J PROSTHET DENT 1994;72:606-13.
328. Grasso J, Rendell J, Gay T. Effect of denture adhesive on the retne-
tion and stability of maxillary dentures. J PROSTHET DENT 1994;
329. Kawano F, Dootz E, Koran A, Craig R. Sorption and solubility of 12
soft denture liners. J PROSTHET DENT 1994;72:393-8. --
330. Wright P. Observations on long-term use of a soft-lining material for
mandibular complete dentures. J PROSTHET DENT 1994;721385-92.
331. Kawano F, Kon M, Koran A, Matsumoto N. Shock-absorbing behav-
98 VOL UME 7 4 N U MB E R 1
ior of four processed soft dentrue liners. J PROSTHET DENT 1994;
332. Fraunhofer J, Sichina W. Characterization of the physical properties
of the resilient denture liners. Int J Prosthodont 1994;7:120-8.
333. Nikawa H, Iwanaga H, Hamada T, Yuhta S. Effect of denture cleans-
ers on direct soft denture lining materials. J PROSTHET DENT 1994;
334. Kulak Y, Arikan A, Delibalta N. Comparison of three different meth-
ods for generalized denture stomatits. J PROSTHET DENT 1994;72:283-8.
335. Aldana L, Marker V. Kolstad R, Iacopino A. Effects of Candida treat-
ment regimens on the physical properties of denture resins. Int J
Prosthodont 1994;7:473-8.
336. Truhlar M, Shay K, Sohnle P. Use of a new assay technique for quan-
tification of antifungal activity of nystatin incorporated in denture
liners. J PROSTHET DENT 1994;71:517-24.
337. Lefebvre C, Knoernschild K, Schuster G. Cytotoxicity of elutes from
lightpoymerized denture base resins. J PROSTHET DENT 1994;72:644-
338. Ts)a~hiya H, Hoshino Y, Tajima K, Takagi N. Leaching and cytotox-
icity of formaldehyde and methyl methacrylate from acrylic denture
resin base materials. J PROSTHET DENT 1994;71:618-24.
339. Andreopoulos A, Polyzois G. Repair of denture base resins using vis-
ible light-cured materials. J PROSTHET DENT 1994;72:462-8.
340. Vallittu P, Lassila V, Lappalainen R. Wetting the repair surface with
methyl methacyrylate affects the transverse strength of repaired heat-
polymerized resin. J PROSTHET DENT 1994;72:639-43.
341. Kapur K, Deupree R, Dent R, Hasse A. A randomized clinical trial of
two basic removable partial denture designs. Part I: comparisons of
five-year success rates and periodontal health. J PROSTHET DENT
The Glossary of Prosthodontic Terms, Si xth Edi t i on
The Glossary of Prosthodontic Terms is the ultimate resource for the professional.
This document, a collection of words/terms and their special connotation in the art
and science of prosthodontics, was created to provide a standard lexicon for the
The sixth edition of the Glossary (printed in the January 1994 issue of The Journal of
Prosthetic Dentistry) is now available from Mosby in your choice of formats:
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compatible computer, with a minimum of 640K RAM and DOS 3.1 or later.
The Glossary, which includes more than 2,500 entries, was prepared by The
Academy of Prosthodontics under the auspices of Dr. Clifford W. VanBlarcom,
chairman of the Academy' s Nomenclature Committee. A total of 18 organizations
participated in the development of the Glossary.
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