Vol. 5 n° 1 2006
Transcript
Vol. 5 n° 1 2006
MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology QUARTERLY OF MAXILLO ODONTOSTOMATOLOGY FOUNDED IN 2002 BY MAURO OREFICI OFFICIAL JOURNAL OF ITALIAN MAXILLO ODONTOSTOMATOLOGIC SOCIETY Honorary President Giovanni Dolci Editor in Chief Luigi Mastroianni Scientific Director Mauro Orefici Editorial Office Romano Amato President Advisory Board F. Nardi (Anatomia Patologica), C. Ciarla, E. Cipriani (Anestesiologia Maxillo Odontostomatologica), M. Bobò, M. Cipollone, V. Contreas, G. Iannetti, A. Moro (Chirurgia Maxillo Odontostomatologica), B. Condorelli, C. Maggiore, M. Procaccini, M. Ripari (Clinica Odontostomatologica), A. Schindler (Fisiopatologia della Deglutizione), V. De Cicco, C. Di Paolo (Gnatologia), A. Lacarbonara, R. Marasca (Laserterapia), F. Chiarenza (Management Sanitario), C. Angioni, A. Di Corato (Maxillo Odontostomatologia Forense), A.M. Fornabaio (Odontoiatria Preventiva), F. Ambrosi, F. Cianfriglia, R. Morello, G. Spriano (Oncologia), E. Accivile, M. Fraccon (Ortodontia), F. Ottaviani (Patologia delle Ghiandole Salivari), M. Capogreco, U. Romeo, F. Spadari (Patologia Odontostomatologica), M. De Luca (Parodontologia), V. Lacarbonara, R. Gatto (Pedodonzia), A. Barlattani, C. Braconi, F. Di Carlo, P. Palattella, M. Quaranta (Protesi), A. Paoletti, P. Zotti (Radiologia), A. D’Epiro, M. Donvito, (Sanità Militare), A. D’Alessandro (Scienza dell’Alimentazione), M. Angelino, E. Ortolani, P. Vallogini (Urgenze Maxillo Odontostomatologiche) NATIONAL REFERENCES S.I.M.O. Northern Italy Central Italy Southern Italy Walter Ghinzani Maurizio Ripari Domenico Cicciù Cuba U.K. France F. Basulta Valela C. Scully R. Cavesian, J. Dichamp J. F. Chassagne, P. B. Tardieu O. Fromovich, O. Nahlieli W. Chen, M.L. Urken F. Marchall INTERNATIONAL REFERENCES Israel USA Switzerland Co-Directors: Pasquale Capaccio, Giovanni Davide Galeota Co-Editors in Chief: Giovanni Ballarani, Antonio Manieri Administrative Secretary: Andrea Sileo Scientific Secretary: Vincenzo Palazzo Technical Director: Massimo Stanzione Asclepion (Formazione continua in Sanità) Via Cipro 4H - 00136+ Roma - Tel. 06.3251700 C.O.d.A. (Cenacolo Odontostomatologico dell’Adriatico) Via Parioli, 41 - 00197 Roma - Tel. 06.8091721 CRAL Ospedale G. Eastman, Roma Corso P. Umberto, 35 - 65122 Pescara - Tel. 085.373328 Santa Apollonia Managing Editor Maurizio Vergnani Direction, Editorial Office, Graphic Office, Advertising Office, Administration: Piazza Confienza 3, 00185 Roma, tel. 06.44.40.040 - fax 06. 23.32.48.671 e-mail: [email protected] Web Site: www.simo-santapollonia.it Pubblicazione Scientifica Trimestrale aut. 461 del 5 agosto 2002 Tribunale di Roma Publisher: B&C s.r.l. - Strada Teverina km 3,600 - 01100 Viterbo Vol. 5 - N° 1 CORRESPONDING ASSOCIATIONS AIAS (Associazione Italiana Assistenza Spastici) Esperanto Viale Regina Elena, 387/b - 00161 Roma - Tel. 06.84483 Lega Italiana Lotta Contro i Tumori Via dell’Esperanto, 58 - 90144 Roma - Tel. 06.5921972 Scuola Viva Via A. Torlonia, 15 - 00161 Roma - Tel. 06.4425971 Vaclav Vojta (Centro di Riabilitazione) Via Crespina, 35 - Roma - Tel. 06.5515909 Via S. Pincherle, 186 - Roma - Tel. 06.5413733 Pagination and printing: Arti Grafiche Nobili Sud Viale delle Scienze, 14 - N.I. S. Rufina - Cittaducale (Ri) Annual subscription of 4 numbers with postal expedition: Italia 20 euro; enti 40 euro; estero 50 euro; enti 70 euro; 1 fascicolo 5 euro, i fascicoli arretrati vengono maggiorati del 50% Payment: assegno bancario non trasferibile intestato a S.I.M.O. o bonifico bancario a San Paolo, Filiale 05123 - Viale Parioli 45/B 00197 Roma - CIN C - ABI 01025 - CAB 03321 - C/C 074002180139 o CCP n° 37816899 intestato a S.I.M.O. For any further information mail to: [email protected] The journal is available in italian language on: www.simo-santapollonia.it MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology I The International Journal of Maxillo INSTRUCTIONS TO AUTHORS The authors are not recommended to Title page. The page must contain: ded material is not insured against Academic or professional affiliation Odontostomatology, official journal of the send the original manuscript. The sen- ty, is devoted to the publication of original damages or loss. and addresses, 3) Address of the author Odontostomatology. Manuscripts are accep- writings on articles published in the sent with e-mail and fax number, if that the same works have not been or will director manager. Italian Maxillo-Odontostomatologic Socie- contributions in the field of Maxillo ted for reviewing with the understanding not be published nor is presently submitted elsewhere, and that all persons listed as authors have given their approval for the This magazine also publishes signed available, 4) Acknowledgements, 5) RULES FOR THE MANUSCRIPT Title. The page 1bis must only contain 1. Editorial the publication: of the author’s experience. Such an arti- 1 . Editorial 2 . Original scientific experimental or non experimental researches of maxillo odontostomatologic interest 3 . Scientific updating and critical researches 4 . Interesting, unusual clinical cases 5 . Reportage on practical cases 6 . 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This section e) References Vol. 5 - N° 1 Summary or abstract and key words. c) Summary or Abstract and key words b) Title Piazza Confienza 3, 00185 ROMA - e- web site: www.simo-santapollonia.it. the title of the research. the target of the research. d) Text: introduction, materials and methods, mail:[email protected] Whatever economic support. a) Title page the supplement, and the must be sent, by S.I.M.O. Regional Referents, to “S.I.M.O.”, to whom correspondence should be review, if not censured by the scientific submission of the paper. The following articles are evaluated for 1)Title, 2) Author’s full names, results, discussion, conclusion f) Tables and Illustrations g) Figure legends. must contain the methods of the research. Results. They must be introduced with logical sequence . MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology II Discussion. It must contain the innovating and important conclusions of the research. References. They should be listed at the end of the paper and should be numbered consecutively as they are cited. In the text, references are identified by Arabic numerals set in superscript type within brackets. References first cited in tables or figure legends must be numbered so that they will be in sequence with references cited in the text. The reference section should be typed double-spaced at the end of the text, following the sample formats given below. For abbreviations of journal names, refer to List of Journal Indexed in Index Medicus. Provide all authors’ names when fewer than seven; when seven or more, list the first three and add et al. Provide article titles and inclusive pages. “Unpublished observations” and “personal communications” do not qualify as references and should be placed parenthetically in the text. Accuracy of reference data is the responsibility of the author. Journal article Capaccio P, Minetti AM, Manzo R, Palazzo V, Ottaviani F. The role of sialoendoscopy in the evaluation of obstructive salivary disease. Int J Maxillo Odontostomatol 2003; 2:9-12. Orsini M, Orsini G, Benlloch D, et al. Comparison of calcium sulfate and autogenous bone graft to bioabsorbable membranes plus autogenous bone graft in the treatment of intrabony periodontal defects: a split-mouth study. J Periodontol 2001; 72:296-302. Vol. 5 - N° 1 INSTRUCTIONS TO AUTHORS Book McNeill C. Current controversies in temporo-mandibular disorders. Chicago: Quintessence, 1992:52-65. Chapter in Book Roth R. Gnathologic concepts and orthodontic treatment goals. In: Jarabak JR, ed. Technique and treatment with light wire appliances. St. Louis: CV Mosby, 1970:1160-1223. Tables and Illustrations. They must be cited consecutively in the text, using arabic numerals. Each table should be titled, appropriately numbered and typed on a separate sheet. Units of measurement should be indicated and all abbreviations defined. All the illustrations/graphs drawings and photographs) should be referred to in the text as Figures. These should be good quality glossy photographs. Legends to figures should be typed on a separated sheet. Figure Legends. The caption of the pictures must be included in an additional paper with the same numeration of the text. 3. Review articles They should not be more than 5.000 words, 100 references, 6 illustrations. 4. Clinical cases They must be concise, supported by data and provided with reference to the case concerning literature. They should be start with a short introduction followed by the description of the case, discussion and references. 5 . Brief communications Brief descriptions (no larger than a typewritten-page) of practical advices. 6. Communications to the management direction Open letter to the director. Observations on the published scientific paper. Drafts: only short corrections permitted. Photos: 24x36 original colour slides. 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In brief, the introduction must clarify the aim of the research. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology III INSTRUCTIONS TO AUTHORS Materials and methods The aim consists in describing in detail how the research has been carried on mentioning the materials, the tools, the clinical case and the experimental procedures. If the used methods are original, they must be described in detail; if not the authors must refer to the original article they were taken from. In this section the authors must mention possible statistic analysis. Results The results must follow a short logical clearly sequence. They may be visualized by means of indexes, graphics, grids, photos, to facilitate the reader’s immediate understanding. Such a material must support the written text. Discussion The section must answer the question on the possible implications of the described experimental data. It must clarify the significant contribution and the limits by confronting them with other research contained in others arti- cles, coming to the same or contrasting conclusions. The section must contain a deep analysis of the validity of the given results. Conclusion The conclusion is a brief outline of the Vol. 5 - N° 1 discussion section. It must be clear and brief. Riassunto In italian language References They are intended to provide the reader with useful extra reference for further information on the topic. The bibliography will be reduced to a minimum, including only the reference material quoted in the article concerning the authors transfer the copyright to the Maxillo-odontostomatologic review. They declare having respected the declaration of Helsinki and the general principles regulating research on animals. The managery staff will anonymously examine all the received material, answe- ring by e-mail, fax or mail for acceptan- ce. 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Text files with 3 copy manuscripts, including visual material, floppy or compact disk will be euro; Institutions 70 euro; An issue 5 How to pay: by non-transferable bank cheque to S.I.M.O. or by bank draft to the Ca.Ris.Bo.-branch number 123, Roma Parioli, Viale Parioli, 45 D cc. 2180139, ABI 6385 CAB 3205 or by included. post office current account n° 37816899 authors have to declare, under their For further information please send All the material must be original. The responsibility it has never been publis- hed before in any other review. The headed to S.I.M.O. your e.mail to: [email protected] MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology IV MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology VOLUME 5 JANUARY- FEBRUARY- MARCH 2006 S.I.M.O. NUMBER 1 Santa Apollonia SIMO IND E X B O O K Instructions to Authors Page I-IV ORIGINAL ARTICLES FOOD-RELATED ORAL DISEASES IN PREGNANT WOMEN Antonio D’Alessandro, Antonella Barone, Annalisa Aggio, Mario Capogreco, Mario Giannoni Page 11-14 Survey S.I.M.O. THE ROTARY INSTRUMENTS IN ORAL SURGERY: THEIR FEATURES AND SPECIFIC INDICATIONS Francesco Briguglio, Manuela Lapi, Enrico Briguglio, Roberto Briguglio Forthcoming events IMAGE GUIDED NAVIGATIONAL IMPLANTOLOGY: A NEW REHABILITATION PROCEDURE Alessandro Quaranta, Lorenzo Benedetti, Giovanni Ballarani, Marlene Fabrizi, Giorgio Pompa Page 3-8 Page 9-10 Page 15-17 Page 19-23 COMPUTER GUIDED IMPLANTOLOGY. INTRODUCTION TO THE SAFE SYSTEM® AND A CLINICAL CASE Philippe B. Tardieu, Luc Vrielinck, Nico Roose Page 25-32 Vol. 5 - N° 1 MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 1 Asclepion formazione continua in sanità REGIONE LAZIO ASL RM A CONVEGNO NAZIONALE Società Italiana Maxillo O d o n t o stomatologica MAURO OREFICI P R E S I D E N T E G I O VA N N I D O L C I P R E S I D E N T E DEL CONVEGNO La Maxillo Odontostomatologia nel Servizio Sanitario ROMA DUEMILA SETTE - 8 9 10 11 Esiste una Scuola Odontoiatrica Italiana che Ł patrimonio di tutti. Esiste anche una Gloriosa Tradizione Ospedaliera: ambizione della SIMO Ł di esserne la voce. Survey St. Apollonia 2006: S.I.M.O. 4° National Meeting by Emerenziana Veneziano On February, 9th, 10th and 11th 2006, close by historic G. Eastman Hospital, 4° National Meeting was set. On Thursday, opening day, in front of G. Eastman large square, third Mobile Dental Surgery was showed to the Authorities. It has been conceived and strongly desired by Society Chairman, Prof. Mauro Orefici who has been already planned and made possible, thanks to Regione Lazio, the achievement, in 2004, of the first two Mobile Dental Surgeries, an absolutely novelty in Italy, in Europe and maybe in all the world. This last “creature”, dental hospital on wheel, it has been supplied with an orthopantomographic system, thanks to this we can have a complete diagnosis of treated patients at home, and this will save them of having to come necessarily in pubblic or private radiological consulting rooms. Ceremony has continued inside assembly 3° Mobile Dental Surgery blessing Mr Luigi Mastroianni, S.I.M.O. Vice-Chairman, opening speech 600 van Mobile Unit blessing Ribbon cutting by Regione Lazio Equal Chances Chairman, H. Mrs Tibaldi Alessandra Vol. 5 - N° 1 room where long-standing wood of furnishings, of walls and of floor, of the walnut wood in primis which makes the environment precious, light up and heat the background even when the thermometer goes down like in these days. Authorities have listened, to with interest, the programmes outlined by the Society, even if everybody has noticed the absence of hospital sanitary managements and the administrative ones. So we have had the doubt that, maybe S.I.M.O. aims, they have not been completely understood or not well explained by Society Board and by all active members. They sacrifice their time and their energies for a praiseworthy reason, that is to say to simplify different ways to weak classes patients and particularly vulnerable ones allowing them to treat odontostomagnatic apparatus like all people want care its oral health without come to that terrible MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 3 Survey situations that can be resolved only with extensive drainage, with an enormous damage to patients’ mouth and to Pubblic finances. The day’s ended with the award, to memory of “Virgo Fidelis” Arma dei Carabinieri chorus performance 4° National Meeting Opening, authorities desk Mr Mauro Orefici, S.I.M.O. Chairman, consigns, in memory of Prof. Mario Martignoni, name-plate and title to his sons Massimiliano and Marco Prof. Mario Martignoni, of S.I.M.O. great title for his career with the delivery, to his sons Massimiliano and Marco, of a memento name-plate. Then, like culmination, Virgo Fidelis chorus performance has given great emotion and enthusiasm to the audience. Archibishop Alberto Tricarico, Apostolic Nuncio, Rome Vice-Major Mrs M. Pia Garavaglia, Prisoners’ Rights Guarantor Mr Marroni Angiolo, Mr Claudio Mastrocola, Quality Department Chief of Health Service Ministry, Mrs Alessandra Tibaldi Work, Equal Chances and Youth Policies Chairman, Mr Michele Donvito Military Health Service General Manager, Mrs Ileana Argentin Rome Major Delegate for Disabled People, Mrs Silvia Castorina Ziparo Health Vol. 5 - N° 1 Service Ministry Physician Manager and Mr Giovanni Dolci Dental Department of La Sapienza University in Rome are present. Friday the Board of Directors has shown the report of achieved aims after one year, thanks to Regione Lazio S.I.M.O. pilot project Mobile Dental Surgery, either about disabled people services, or about oncological prevention in square markets, with about 3000 treated patients. Then, interesting reports and intermeeting courses, like results of G. Eastman hospital physicians, nurses, dental mechanics, x-ray technicians experiences, are carried out. On Saturday, are present: Mr Alberto Barlattani, dentistry course Chairman at Tor Vergata University in Rome, Mr Giorgio Iannetti Maxillo-Facial Surgery School Principal at La Sapienza University in Rome, Mr Vito Contreas Military Health Service Vice-General Director, Mr Francois Chassagne Maxillo-Facial Surgery, Face Plastic Surgery and Stomatology Consultant Physician in University hospital in Nancy (France). So, the most significant annual event of a scientific society’s ended. Its most of great protagonists are hospital experts, achieved private self-employees and distinguished university ones, but first of all are all young members Those present at the Meeting Italian National anthem performance MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 4 Survey Those present at the Meeting with willingness also which want and they can emerge in spite of their surnames are not binded to famous people. This is for this reason that S.I.M.O. is great, because it gives, to everybody wants, possibility to express itself and to carry on its voice in national and international dental world through meetings, courses and pubblications. I wish good work to everybody and I want to thank the Board of Directors to wake up again in all people the same spirit with which George Eastman has created the dental hospital in Rome. Mrs Ileana Argentin, Rome Major Delegate for Disabled People Mobile Dental Surgeries, a very-good reciprocity between science and social life Press Office, Work, Youthful and Equal Chances Policies’ Chamber Today, Santa Apollonia Day - dentists and suffering from toothache Patron Saint - Regione Lazio Chairman of Work, Youthful and Equal Chances Policies, MRS Alessandra Tibaldi, has inaugurated the third Mobile Dental Surgery: a four-wheeled dental hospital. The Chairman has been enthusiast about Regione Lazio S.I.M.O. Pilot Project; a project that means, in a year, prevention at home for 2923 patients, of whom 2450 among disabled people, and thanks to this success it will be presented in Regione Lombardia and in Regione Sicilia also as soon as possible. This first experience has showed an important aspect: first one is about social character and concerns the easiness of access to service and to mouth care of these patients and Vol. 5 - N° 1 their families, with the consequent reduction of psychosocial effects like suffering and hardship caused by disease; the second one is about economic field merely: a real saving in terms of service and social expenditure. In fact, oral diseases individuation, in early phase, it permits to avoid future higher direct expenses (i. e. hospitalization, surgical expense. etc.) and, on the other hand, it permits to save even indirectly, eliminating secundary costs at family and social expenses (transfer, leaves, etc.). Like Mrs Tibaldi, lawyer Angelo Marroni, Prisoners’ Surety, is enthusiast because thanks to Mobile Dental Surgery this another “weak” class will take advantage of preventive dental services. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 5 Survey And something remains by Maurizio Ortu Sport like instrument of Disabled People Social Integration is the subject of a Lions District Meeting set in L’Aquila on March, 4th 2006 c/o Dompé Meeting Room. In the symposium new methods, new discoveries and new experiments are showed; they permit to the authorized personnel, a best professional approach to citizen exigencies. Present athletes’ proves, Mr Luigi Mastroianni, Mr Maurizio Ortu, Mr Giorgio Mataloni, Mr G. Davide Galeota, Mr Mauro Orefici, during Lions recognition name plate donation to S.I.M.O. guys who are sportsmen at high level because they are competitors for their national teams at Para Olympic Games, they practise sports like sailing, basketball and positively parashutting, paragliding, skiing and much more, have transmitted to those present the extraordinary energy they conceal, the desire to have fun and to compete we find in all guys of the world. If the others do anything why do not I? this is the question made by one of them to those present. Images showed by neo-graduate women of Motor Sciences Faculty are the best answer to this question. In this faculty, indeed, it works daily to improve everybody limits, that is to say to permit guy to stand up, round his pereambulator and to start to push it. Various experts and physicians contribution, world-famous also, has agreed to the idea to pay attention on individual ones, on that people daily search the door, rightly, in a world that only in the last years, recognized their merits and the necessity of no-self-sufficients social defence, making possible their treatment. At the meeting end, outdoor, many people on Mobile Dental Surgery represented, so, the only one messagge. It was a very great pleasure for the Lions, as from Mr Giorgio Mataloni, District Governor, to give it hospitality making the Authorities curious and the partecipants also with this unique and hypertechnological mean of transport and of treatment. Mr Gabriele De Cata, Mr Maurizio Ortu, Mr G. Davide Galeota, Mr Fausto Appia, Mr Luigi Zugaro, Mr Mauro Orefici, Archibishop in L’Aquila Giuseppe Molinari, Chief of Police in L’Aquila Mr Sergio Visone, Mr Luigi Mastroianni, Mr Giovanni Paqua Vol. 5 - N° 1 MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 6 Survey Here comes the Mobile Dental Surgery, the new frontier of prevention.The idea of S.I.M.O. chairman, Maxillo Odontostomatology Italian Society, Prof. Mauro Orefici by Andrea Lowelok (from “Professionisti Newspaper” Wednesday, January, 4 th A Mobile Dental Surgery to approach again citizen-patient to sanitary prevention, with a sort of service at home from the original Lazio Region, to other Regions like idea to export. This is the project of S.I.M.O., Maxillo-Odontostomatology Italian Society, that has already received funds from Region Lazio. For S.I.M.O. Chairman, Prof. Mauro Orefici considerable increase of degenerative-chronic disease and of tumors, growing incidence of chronic diseases and their complications makes possible that financial burden of these pathologies to pass the buck to SSN change with considerable increase of chronic degenerative diseases and of tumors. Growing incidence of chronic diseases and their complications enables that financial weight of these pathologies relieves itself on National Health Service and on citizen budget, and in a decade it will be untenable. About chronic oral diseases, they are, for a large part, preventable and, this justifies necessity to define company prevention plan together with national one. All developped nations, just for chronic degenerative diseases expenses, are active to put into practice welfare, structural, sanitary reforms, so that to allow possibility of prevention application on a large scale. Financial Act 2005 foresees that one of Region aim, to obtain national sanitary fund 5% difference, is national prevention plan and national training plan start. To start a prevention plan and an encouragement of sanitary priorities, turning towards all citizens but in particular weak classes and vulnerable ones like children, old, disabled, excluded people, is a duty it can’t be disregarded. In Italy 45% of people doesn’t go to the dentist, so, only 55% of people with a risk factor submits to screening for diagnosis of oral tumors. It needs of a coordination that permits good oral health, uniformly, in all national and regional territory just to guarantee prevention and early diagnosis services and, then, to obtain good quality life with a cut of maxilloodontostomatological pathologies. Among Lazio Region strategies about maxillo-odontostomatological prevention, it emerges an experiment made by S.I.M.O., the only one in its field in Italy and in Europe. It is the first to think of carry out maxillo-odontostomatological prevention and training at home patients, in associations, home for the aged, in Rsa, in municipalities squares “clinical research applied on territory”. S.I.M.O., with respect for its institutional independence and Vol. 5 - N° 1 2006, Anno I n° 34) with respect for the laws in force, acts with collaboration spirit and solidarity with national and foreign institutions, with particular care to carried out researches spreading and achieved knowledges. It promotes, also, sanitary education and scientific and technic staff training and bringing up to date in specific field. Now it is important to confront and to coordinate different experiences and organization choices, in its own organization independence ambit. This research “mobile dental surgeries: clinical research and application on territory” maxillo-odontostomatologia international Journal of maxillo-odontostomatology vol. 4 n. 3 page 67-87 has passed, in advance, with good marks, experiment phase. Nowadays we are at second year of project that if involved all Lazio Region provinces is certainly a transition year. Success of achieved consents, carried out services, sanitary, economic and social saving, even if in general scepticism, have, really, kept to the letter of Ministerial instruction about necessity of citizen prevention and training at home use. S.I.M.O. and Lazio Region experimental study, with its successful outcome, aims to suppose the establishment of oral diseases prevention services with hospital at home because of National Health Service lack in prevention, diagnosis, treatment and rehabilitation of oral diseases specialized public structures. Mobile dental surgeries for weak classes patients and vulnerables ones. Now it is necessary to define a role and staff activity to put an end the whole experimental plan of S.I.M.O. and Lazio Region maxillo-odontostomatological prevention project at home: “hospital at home”: so, we must recognize priorities in different specific field above mentioned, From developping age, through schools to disabled people, from old aged one, with presence of family houses and excluded aged people institutes, prisoners to get the common citizen. All of this, Mr Orefici ends, through a well defined Operative Centre c/o George Eastman Hospital RM A Asl, Region Lazio leader company for maxillo-odontostomatological prevention at home thanks to Mobile Dental Surgeries planned by some doctors for this aim just into the most glorious hospital in Italy. For this aim during the 4° National Meeting it has been inaugurated the first qualification course for dental operators on Mobile Dental Surgeries: Mobile Units, just to create a model for an efficacious prevention at national level also. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 7 Survey IN ALL LAZIO REGION PRISONS HERE COME MOBILE DENTAL SURGERIES TO TREAT PRISONERS’ TEETH Initiative will carry out thanks to an Agreement Contract among Regional Prisoners’ Surety, Regional Director’s Office of Penitentiary Management and Maxillo-Odontostomatological Italian Society (S.I.M.O.) In Lazio prisons three S.I.M.O. (Maxillo-Odontostomatological Italian Society) Mobile Dental Surgeries will carry out clinical and therapeutical operations about prisoners to point out and to treat oral and teeth diseases. The initiative, the first and the unique one in Europe, starts thanks to an Agreement Contract signed by Mr Angiolo Marroni, Regional Surety of Prisoners’rights, by Mr Ettore Ziccone, Regional Director’s Office of Penitentiary Management and by Prof. Mauro Orefici, S.I.M.O. Chairman. Service, which will help to improve oral hygiene conditions, is appointed to create a favourable climate of opinion, to inform and to train to good health and to stamp out oral cavity pathologies of Lazio prisoners. To carry out this activity S.I.M.O. (no-profit Society founded in “George Eastman” Dental Hospital in Rome), with Lazio Region funds, will utilize doctors, dentists, dental nurses which, just from a long time, carry out prevention activity of oral cavity diseases among weak classes. Service, will be carried out by three Mobile Dental Surgeries, Mobile Units equipped with chair, turbine, hydraulic system, surgical operations kits, sterilizer and digital x-ray machine. In one of these there is a last generation orthopantomographic system to make digital orthopanoramics for clinical diagnosis. In prisons will take part beyond Mobile Dental Surgery, a team with doctor, nurse and driver. Screening will examine prisoner’s fitness to receive a dental hygiene treatment or dental one. “Among Surety’s priorities there is Prisoners” Health Right Defence-Mr Angiolo Marroni said- because this is one of the most violated in prisons. Oral cavity pathologies are at the third place for incidence in prison. An incidence, that thanks to the Contract and to Lazio Region funds we hope to depress. We are always looking for collaborations which can improve prisoners’ life quality, a fundamental aspect of prison life which passes by these measures of treatment and prevention also. We have very pleasure about the initiative in all Lazio prisons-Director, Mr Ettore Ziccone said- and it is in strict continuity with that one of last February with foresees the Vol. 5 - N° 1 possibility to have dental prosthesis free for Rebibbia Prisoners’. “Health Right is a duty which society must show for all citizens. Mr Mauro Orefici, S.I.M.O. Chairman saidcivilization level of a society is measured thanks to lavish care to defend everybody’s rights. Activity we show, we hope it will be soon established, is an important step toward clinical application on territory and dental hospital at home”. Signature moment Regional Surety of Prisoners’ rights Mr Angiolo Marroni, Regional Director’s Office of Penitentiary Management Mr Ettore Ziccone and Prof. Mauro Orefici, S.I.M.O. Chairman. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 8 FORTHCOMING EVENTS APRIL 05-08/04/2006 - Portland, Oregon (USA) ODA 2006 - OREGON DENTAL CONFERENCE Information: Oregon Dental Association 17898 SW McEwan Road Portland, Oregon 97224-7798, USA Exhibits Manager: Cindy Fletcher E-mail: [email protected] Tel: +1 503 6203230 ext. 102 Toll free: 800 4525628 ext.102 Fax: +1 503 6204169 Website: www.oregondental.org Exhibition Venue: Oregon Convention Center 05-08/04/2006 - Rome (Italy) EXPO DI PRIMAVERA AND 13TH NATIONAL CONGRESS OF THE "DENTISTRY TEACHING BODY" Information: Pro Odonto Congress srl Contact Person: Ms. Gallusi Via Monte delle Gioie 24, 00199 Roma Tel. +39 06 86211131 Fax. +39 06 86212026 08/4/2006 - ROME (Italy) MAXILLO-ODONTOSTOMATOLOGY IN EUROPE (13TH NATIONAL CONGRESS OF THE “DENTISTRY TEACHING BODY”) E-mail: segreteria@simo-santapollonia Website: www.simo-santapollonia.it 07-09/04/2006 - Singapore IDEM - 2006 INTERNATIONAL DENTAL EXHIBITION AND MEETING Information: KoelnMesse GmbH Messeplatz 1 50679 Cologne, Germany Tel. +49 221 821 2374 // 2314 Fax +49 221 821 3325 E-mail: [email protected] International Contact: Mr. Denis Steker E-mail: [email protected] Website: www.idem-singapore.com Exhibition Venue: Suntec Singapore International Convention & Exhibition Centre (Level 6) Vol. 5 - N° 1 15-18/04/2006 - Moscow (Russia) DENTAL CLINICA -1ST INTERNATIONAL EXHIBITION OF DENTAL SERVICES Information: Dental-Expo Ltd. Usievicha 8A - 125319 Moscow, Russia Tel/Fax +7-095 155-79-00, 155-79-03, 152-15-40 E-mail: [email protected] // [email protected] Website: www.dental-expo.ru Exhibition Venue: Crocus Expo 17-20/04/2006 - Moscow (Russia) DENTAL SALON 2006 - INTERNATIONAL EXHIBITION Information: Dental-Expo LTD Contact: Mr. Ilia Brodetski E-mail: [email protected] // [email protected] Usievicha 8A -125319 Moscow, Russia Phone/Fax +7 095 155 7900 // 155 7903 // 152 1540 Website: www.dental-expo.ru Exhibition venue: Crocus Expo 20-22/04/2006 - Washington (USA) 2006 NATION'S CAPITAL DENTAL MEETING & EXHIBITION Information: District of Columbia Dental Society 502 C Street, N.E. Washington, DC 20002-5810 USA Tel: +1 202 547 7613 Fax: +1 202 546 1482 E-Mail: [email protected] Website: www.dcdental.org 27-30/04/2006 - New Orleans, Louisiana (USA) AAOP 2006 ANNUAL CONFERENCE & EXHIBITION OROFACIAL PAIN Information: AAOP - American Academy of Orofacial Pain 19 Mantua Road, Mt. Royal New Jersey 08061 - 1006, USA Referent: Wendy Stevens Tel. +1 856 423 7222 262 E-mail: [email protected] Website: www.aaop.org Exhibition Venue: Sheraton New Orleans Hotel MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 9 FORTHCOMING EVENTS MAY 06/05/2006 - Narni-Terni-Umbria-Italy PUBLIC MAXILLO-ODONTOSTOMATOLOGY: PROTECTED CLASSES. WHICH FUTURE ? E-mail: segreteria@simo-santapollonia Website: www.simo-santapollonia.it 06-09/05/2006 - Las Vegas, Nevada (USA) 106TH AAO ANNUAL SESSION Information: AAO - American Association of Orthodontists Attn: AAO Senior Meetings and Exhibits Manager 401 North Lindbergh Boulevard St. Louis, Missouri USA 63141-7816 Tel: +1 314 993 1700 Fax: +1 314 997 1745 // 692 8178 Toll free: 800 424 2841 Website: www.aaortho.org Website: www.AAOmembers.org E-mail: [email protected] Exhibition Venue: Sands Expo, Halls B 11-13/05/2006 - Vienna (Austria) WID 2006 - INTERNATIONAL DENTAL EXHIBITION Information: Osterreichischer Dentalverband Eschenbachgasse 11 A-1010 Vienna, Austria Tel +43 1 587 363322 www.dentalverband.at www.wid-dental.at 13/05/2006 - Pescara (Italy) THE HOME-PREVENTION IN MAXILLO-ODONTOSTOMATOLOGY E-mail: segreteria@simo-santapollonia Website: www.simo-santapollonia.it 18-20/05/2006 - Birmingham (UK) BRITISH DENTAL CONFERENCE & EXHIBITION 2006 Information: BDA Events team Tel: +44 20 7563 4590 Fax: +44 20 7563 4591 Elise Cole E-mail: [email protected] Website: www.bda-events.org Vol. 5 - N° 1 18-20/05/2006 - Rimini (Italy) AMICI DI BRUGG - 49TH CONGRESS Information: Associazione Amici di Brugg Via A. Cantore, 45 16149 Genova Tel/Fax:+39 010 6451539 E-mail: [email protected] Website: http://www.amicidibrugg.it Exhibition Information: PROMUNIDI S.r.l., Mr. Luigi De Vecchi Tel: +39 02 70061221 Fax: +39 02 70006546 E-mail: [email protected] E-mail: [email protected] 27/05/2006 - Rome (Italy) ADVANCED TECHNOLOGY IN MAXILLO-ODONTOSTOMATOLOGY: LASER, ULTRASOUND, MICROSCOPY Centre: George Eastman Hospital - Rome E-mail: segreteria@simo-santapollonia Website: www.simo-santapollonia.it JUNE 10/06/2006 - Torino (Italy) ESSENTIAL MAXILLO-ODONTOSTOMATOLOGY E-mail: segreteria@simo-santapollonia Website: www.simo-santapollonia.it 21-24/06/2006 - Ponza (Italy) MORBI ORIS E-mail: segreteria@simo-santapollonia Website: www.simo-santapollonia.it MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 10 ORIGINAL ARTICLES FOOD-RELATED ORAL DISEASES IN PREGNANT WOMEN *Antonio D’Alessandro, MD,DDS, **Antonella Barone, PhD Oral Hygiene, *Annalisa Aggio, PhD Biology, **Mario Capogreco, MD,DDS, **Mario Giannoni, MD,DDS * ** SUMMARY Both pregnant women and Medical Doctor, Dentist, Dental Hygienist, Nutritionist and Obstetric know that maternal dental problems seem to be increased during gestation and lactation. This finding might explained as an aggravation of latent or pre-existing oral diseases, linked to the difficulty to carry out a correct oral hygiene, to early pregnant nausea and vomiting and to hormonal influence on oral tissues. Race, education and job seem to be very determinant. It is supposed that some obstetric problems of mothers and babies are a consequence of pregnant oral condition. Pregnant women oral health could be guarantee by an adequate assistance from the Dentist, the Nutritionist and the Dental Hygienist. It is to set out of the term of an effective management of public and private health services in the way to guarantee to the mother and to the babies the best health conditions. Key words: Pregnancy, Oral health, Nutrition. INTRODUCTION The pregnancy is a modified physiological condition able to induce, in whole woman body and in oral tissues in particular, a wide series of metabolic changes, with clinical conseCorresponding author: Antonio D’Alessandro, MD,DDS Dipartimento di Medicina Interna e Sanità Pubblica Via S.Sisto, 22 - I - 67100 L’Aquila Tel. +39 0862 432889 - Fax +39 0862 432858 e-mail: [email protected] Vol. 5 - N° 1 Università degli Studi di L’Aquila Dipartimento di Medicina Interna e Sanità Pubblica Università degli Studi di L’Aquila Dipartimento di Scienze Chirurgiche quences for the oral cavity, also linked to food habits and oral hygiene behavioural. Both pregnants and health operators well know as oral diseases might be increased during gestation and lactation. In spite of this, pregnancy is not a determinant factor under a pathogenetic point of view, but a natural condition which plays an important role in the aggravation of latent or preexisting oral diseases (1). In the offspring too, a correct development of the buccal sphere is strictly related to food habits and to maternal oral health situation. After the 5° month of gestation, pre-existing gingivitis or periodontal disturbances might be compound in consequence of the hormon-dependent modification hyper-vascularization mediated, linked to an increase of steroidal specific receptors. This condition inhibits the practice of a correct and constant oral hygiene, because of gingival bleeding and dentinal hypersensitivity. The pregnant gingivitis is widely diffuse in far eastern women, and it is related to the pregnancy month and sexual hormone (2). GI (Loe and Silness Gingival Index) and PPD (Probing Pocket Depth) appear increased in pregnants with hormonal changes during the early months. The evidence is probably linked both to the gingival bleeding after tooth brushing and to vomiting (3). The pregnant vomiting is linked to the increased sympathetic activity, to the loss in gastric secretion and motility, to the release of endometrium catabolism substances and to the psychologic factors. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 11 D’Alessandro A. et al. Nausea, vomiting and hypervascularization are linked to placental hormones -HCG and PRL release too; the estrogens cause thickness of oral epithelium and its exfoliation, oedema and mucosal bleeding (4). High progesteron serum concentration is related to decreased T lymphocyte activity, increased PGE synthesis, histamine release from mast cells and overgrowth of anaerobic subgingival bacteria. The clinical attachment loss is higher in jobless women and it is linked to the race too; the higher GI the lower level of education was found. Gingival inflammation is higher in elder women and in women with a low professional level. Pregnant gingivitis is linked to gingival hypertrophy; both them decrease at the late pregnancy, by eliminating local irritation factors (5). Pregnant’s epulis was found in a low percentage of subjects but, instead of this, deep periodontal lesions seemed to be as to not pregnant one, in groups of patients with similar characteristic. Because pregnancy aggravate pre-existing or latent oral disturbances, promoting oral health in pregnant women might contribute to primary prevention of the main oral disease and could have a particularly positive social impact. About hard oral tissues, there are not clinical evidences concerning what are usually believed about caries incidence during pregnancy (6). In fact, there is not any kind of mineral depletion in maternal dental tissues. So, health operators have to explain to the mothers that “the body can’t take calcium from the teeth to construct newborn’s bones” and as the true reasons of dental caries must be find in the increase of daily sugary snacks and in the change of oral hygiene behavioural, induced by vomiting, nausea and gingival bleeding. In fact, in the early pregnancy, the food snacks reduce the hormonal-induced gastric symptoms; afterwards they compensate the slower gastric empty time, the reduced gastric extension and filling linked to foetal growth and the glycemic level changes induced by the unforeseeable foetal energetic expenditure. Experiments on animals revealed as a marked calcium lack in food daily intake cannot inhibit offspring enamel mineralization, but it might delay it. On the contrary, very high calcium amounts, administered by special diets, are toxic for animal foetus which reveals low birth weight and lack of dental and bone calcification units. In these conditions, surviving calcification units start to expand later vs controls (7). Vol. 5 - N° 1 Moreover, higher caries risk is linked in pregnant women to a lower saliva buffer capacity induced by lower salivary flow rate, increased number of oral cariogenic microorganisms, decrease in salivary pH vomiting and estrogen-induced. Gastric acid reaches the oral cavity by vomiting and it predisposes to dental caries and erosions. Estrogens and androgens are known to regulate carbonic anhydrase VI (CA) gene expression in the saliva; CA protects the teeth by accelerating the neutralization of hydrogens ions in the enamel pellicle on dental surfaces, but more findings are necessary to confirm its true role in the caries development (8). Nevertheless, a proper nutrition and an adequate oral hygiene can minimize all these problems. In this way, telephone interviews to study the self-assessment of oral dental conditions, the hygiene behaviour and dental visiting habits of pregnant women seem to be useful to plan public pre-natal prevention programmes to improve the oral health of mother and babies (9). Under the point of view of the relationships between oral health and pregnancy, periodontal diseases might be a risk factor for systemic maternal or foetal diseases and for obstetric disturbances. In fact, the periodontal diseases seem to be linked to preterm labor, pre-term premature rupture of membranes, and pre-term low birth weight babies (10). Emerging evidence has shown as smoker malnourished women having less visits to the dentist are particularly susceptible to pre-eclampsia, and pregnancy granuloma. To prevent possible severe repercussions on pregnancy outcome, future mothers should receive a nutritional support and a regular professional oral hygiene. Without a professional help, simple self oral hygiene and correct nutrition seem to be difficult to carry out. In this way, a daily rinse with a solution of sodium fluoride 0.05% and clorexhedine 0.12% reduces significantly the presence of Streptococcus mutans in the oral cavity of the mother and in the oral cavity of the baby, until he will be two years old. Instead of this, 58% of american mothers had no dental and dietary assistance during pregnancy, and they were not informed about risks of active and passive cigarette smoking (11). For these reasons, a large part of them meet the dentist exclusively for acute dental pain. The factors able to induce the mothers to meet the dentist for periodic controls are individual (married, who met dentist also before pregnancy and with flossing habit), financial (dental insurance), and related to the level of education. On the other side, the dentist is sometimes worried to ope- MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 12 D’Alessandro A. et al. rate on pregnant, because of the fear of pre-term labor or legal outcome. The request of a nutritional counselling by the mother is very rare. Instead of this, a correct nutrition during pregnancy is important to determine a right amount of energy, protein, calcium, phosphorus and vitamin A, C, and D. It is able to correct both the nutritional deficiency and the food excess, and the related excess in body weight, with the metabolic and obstetric consequences both in the mother and in the baby. Moreover, a correct development of foetal oral tissues is linked to mother dietary habits, to geographical location, to occupation, and to cultural and ethnic factors (12). Dietary patterns of mothers have changed dramatically during the past two decades, because the trend of consumption of food for population in general and for mothers in particular is in the direction of unhealthier eating habits, as food rich in fat, cholesterol, refined sugar and salt and poor in fibre and polyunsaturated fatty acids. This food patterns and the sensible reduction in physical activity consequent to the constant use of cars, elevators, mobile telephones, remote controls and so on, contribute to diet-related chronic diseases, such as obesity, diabetes, hypertension, hearth disease and dental caries. The best outcome of pregnancy, as lower mother and baby mortality and morbidity are observed when the baby weight is higher than 3.5 kg and lower than 4.0 kg. This condition is very rare when the mother is obese or diabetic: baby birth-weight is strictly related to pregnancy out of range increase of body weight and to mother pre-pregnancy Body Mass Index (kg/m2). On the contrary, when the mother BMI is lower of range at the begin of the pregnancy, higher amounts of energy are requested. The correct development of oral tissues is also linked to a correct mother nutrition. It is request a safety increase of 6.0 g of protein a day; further increases have no benefits and might be dangerous for the baby. All kind of lipid are important in pregnancy, but arachidonic acid and docohexanois acid are essential for foetal brain and retina develop and it might have a lack in the babies not breastfed. The vitamin D need is increased because the mineralization of foetus bones and oral tissues and its dietary recommended increase is 10mg a day. Vitamin C allowance (45 mg/die in not pregnant women) must be increased of 10 mg/die and of further 10mg/die in smoker mothers; folic acid allowance (200 mg/die) have to Vol. 5 - N° 1 be doubled to prevent spina bifida and anencephalia; an addition of vitamin B12 is necessary in vegetarian women; an addition of 400mg/die of calcium and phosphorus is necessary to prevent depletion of mother storings; no increases of sodium are needed (13). Because many mothers have not adequate storage of iron, in consequence of the difficulty to absorb iron from foods, it might be necessary drug supplementation (30 mg/die). The contribute of fluoride to the develop of foetal oral tissues is not clear. Maternal alcohol abuse might contribute to the newborn foetal alcohol syndrome (FAS), characterized by congenital facial anomalies traditionally associated with hearing disorders, and significant impairments in neurodevelopment and physical growth. Such disorders can contribute to the learning, behavioral, and emotional difficulties seen in FAS patients and warrant early, nutritional intervention (14). Instead of the nutritional supplement of polinsaturated fatty acids (PUFA) and vitamin E seem to protect foetus against mother alcohol abuse, this way seems to be difficult to carry out in alcohol-dependent mothers (15). All evidences seem to demonstrate as a correct diet and a adequate professional control of oral health during pregnancy represent an important way for global and dental health both in the mother and in the baby. In this way a nutrition educational programme to promote a healthy diet and to correct unsound food beliefs and habits and a dental continuous assistance, with a correct dental hygiene, are urgently needed from government or private health services. RIASSUNTO E ben noto come i problemi orali sembrino aumentati durante la gravidanza e l’allattamento. Ciò è legato all’aggravamento di condizioni patologiche pre-esistenti, all’obiettiva difficoltà nell’attuazione di una corretta igiene orale, alla nausea ed al vomito ed alle influenze ormonali sui tessuti orali. Razza, lavoro svolto e scolarità sembrano essere parimenti importanti. Inoltre, sembrerebbe che alcune complicanze ostetriche siano legate alle condizioni orali materne. Per questi motivi, la gestante ha bisogno dell’assistenza dell’Odontoiatra, del Nutrizionista e dell’Igienista Dentale. Il loro intervento dovrebbe essere proposto da strutture sanitarie pubbliche e private. Parole chiave: Gravidanza, Salute orale, Nutrizione. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 13 D’Alessandro A. et al. REFERENCES 1. Laine MA. Effect of pregnancy on periodontal and dental health. Acta Odontol Scand 2002; 60: 257-64. 2. Lieff S, Boggess KA, Murtha AP, Jared H, Madianos PN, Moss K, Beck J, Offenbacher S. The oral conditions and pregnancy study: periodontal status of cohort of pregnant women. J Periodontol 2004; 75: 116-26. 3. Meneghini C, Battaglia T, Piccoli A. Periodontal pathology during pregnancy. Clin Ter 2003; 154: 105-9. 4. Gajendra S, Kumar JV. Oral health and pregnancy: a review. NY State Dent J 2004; 70: 40-4. 5. Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet. 2005; 366:1809-20. 6. Lydon-Rochelle MT, Krakoviak P, Hujoel PP, Peters RM. Dental care use self-reported dental problems in relation to pregnancy. Am J Public Health 2004; 94: 765-71. 7. Mills LW, Moses DT. Oral health during pregnancy. MCN Am J Matern Child Nurs 2002; 27: 275-80. 8. Kivela J, Laine M, Rajaniemi H. Salivary carbonic anhydrase VI and its relation to salivary flow rate and buffer capacity in pregnant and non pregnant women. Arch Oral Biol 2003; 48: 547-51. Vol. 5 - N° 1 9. Christensen LB, Jeppe-Jensen D, Petersen PE. Self-reported gingival condition and self-care in the oral health of Danish women during pregnancy. Clin Periodontol 2003; 30: 949-53. 10. Carta G, Persia G, Falciglia K, Iovenitti P. Periodontal disease and poor obstetrical outcome. Clin Exp Obstet Gynecol 2004; 31: 47-9. 11. Breedlove G. Prioritinzing oral health in pregnancy. Kans Nurse 2004; 79: 4-6. 12. Sarlati F, Akhondi N, Jahanbakhsh N. Effect of general health and sociocultural variables on periodontal status of pregnant women. J Int Acad Periodontol 2004; 6: 95-100. 13. Tanaka K, Miyache Y, Sasaki S, Ohya Y, Miyamoto S, Matsunaga I, Yoshida T, Hirota Y, Oda H. Active and passive smoking and tooth loss in japanese women: baseline data the Osaka maternal and child health study. Ann Epidemiol 2005; 15: 358-64. 14. Taani DQ, Habashneh R, Hammad MM, Batieha A. The periodontal status of pregnant women and its rela- tionship with socio-demographic and clinical variables. Oral Rehabil 2003; 30: 440-5. 15. Sulik KK. Genesis of alcohol-induced craniofacial dysmorphism. Exp Biol Med 2005; 230: 366-75. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 14 THE ROTARY INSTRUMENTS IN ORAL SURGERY: THEIR FEATURES AND SPECIFIC INDICATIONS *Francesco Briguglio, DS, *Manuela Lapi, DDS, *Enrico Briguglio, MD,DDS, *Roberto Briguglio, MD,DDS * SUMMARY This study analyses the actual use of burs in oral surgery. They can be used in different surgical fields: teeth inclusion, cysts, periapical pathology, implants, guided bone regeneration, periodontal surgery and maxillary sinus augmentation. Essential factors in the selection of the right bur to use are construction material, surface, shape, speed and the requested handpiece. Besides the operative phases in which they can be used are indicated. At last a particular consideration is given to the characteristics of a new polivalent bur used for a clinical case now solved and here presented. Key words: Bur, Oral surgery, Osteotomy, Osteoplasty, Odontectomy Università di Messina Cattedra di Parodontologia 3) High speed Handpieces (until 400.000 gr./min.), utilized in odontectomy, odontoplasty and osteoplasty. Before using a bur it is essential to know its characteristics: shape, surface, size, resistance to fracture and building materials which are steel or tungsten carbide. Steel burs are cheaper and need low speed handpieces, but they lose their cutting edge quickly. Tungsten carbide burs are very expensive and resistant and need a high speed handpiece, but they do not lose their cutting edge even if they are used on hard tissues like enamel. As regards bur surface, they can be multiblade, generally used for osteotomy, and diamonded, used for odontectomy (Tables 1, 2). Burs shapes are connected with the result you need to get, the anatomical characteristics of the surgical site and the concerned tissue (Table 3). INTRODUCTION In dentistry burs are the most frequently used instruments in oral surgery where their applications concern sectors such as the extraction of included third molar or of other included teeth, cystectomy, periapical surgery, sinus lifting, implantology and periodontal surgery (1, 2, 3, 4, 5, 6). Since their utilization regards bone or dental tissue, we are going to analyse differences and indications of handpieces in these particular fields: 1) Low speed Handpieces (until 40.000 gr./min.), utilized in osteotomy like in the third molar extraction or in apicectomy: 2) Very low speed Handpieces (until 4.000 gr./min.), utilized in implantology. Lapi, DDS Via Vittorio Emanuele Orlando, 4 98028 Santa Teresa di Riva, Messina Tel/Fax +39090696777 Tel +393493646214 e-mail: [email protected] Table 1. Tungsten carbide burs: features and indications Corresponding author: Manuela Vol. 5 - N° 1 Table 2. Tungsten carbide burs: features and indications MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 15 Briguglio F. et al. Table 3. Tungsten carbide burs: features and indications About the last characteristic taken in consideration, that is bur dimension, we must consider that burs are produced according to codified standards (ISO-ADA). In some situations, however, the length of a bur can determine a successful operation which allows the surgeon a quicker work, that is to say less labour and stress both for the operator and for the patient, that involves a smaller trauma and a better postoperative course. MATERIALS AND METHODS After mentioning the main burs normally used, the present study presents a recently tested new polivalent bur (HXU 254, Fresissima). It consists of a single integral 30 mm long monoblock, with a 6,5 mm active end. Its troncoconical shape, thin stem and absence of any soldering explain its large versatility. We may shortly say that HXU 254 can be mainly used for: - Third molars surgery - Generally extractive surgery - Endodontic surgery: both osteotomy and apical section - Periodontal resective surgery - Roots surgery The cutting-crown operation is to be remembered as one of the non-surgical indications. In the case of a part of osteointegrated implant resection, a trephine bur is to be preferred because, being of different sizes, it is possible to get the most suitable one for the implant taken in consideration. Figure 1. Clinical aspect of the operating field Figure 2. The elevation of the flap and the exposition of the tooth crown CLINICAL CASE In the present clinical case the new bur HXU 254 was used to extract a third molar mandibular partially included. A clinical vision of the operating field is in the Figure 1. After producing anaesthesia, a total thickness marginal flap was elevated to obtain the exposition of the crown (Figure 2). Then using a new bur, an osteotomy and an osteoplasty was carried out till to allow the extraction of the tooth (Figure 3). Finally the flap was repositioned and sutured. DISCUSSION AND CONCLUSION The present study represents a contribution to dental surge- Vol. 5 - N° 1 Figure 3. The odontectomy using the HXU 254 bur MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 16 Briguglio F. et al. gery and provides a scheme for the utilization of burs. It is obviously necessary to make a reference about the use of high and low speed handpieces, the tissue which is to be removed and the shape of the above mentioned instruments. All their characteristics are related to the suitable operation. Finally the characteristics of the new polivalent bur are exposed together with the description of a clinical case. RIASSUNTO Questo studio analizza l’attuale utilizzo degli strumenti rotanti in chirurgia orale. Essi possono essere usati nei REFERENCES diversi settori della chirurgia: inclusioni dentarie, patologie periapicali, implantologia, rigenerazione ossea guidata, chirurgia parodontale, chirurgia del seno mascellare. Sono da considerarsi fattori essenziali nella scelta della giusta fresa: il materiale di costruzione, la superficie, la forma, la velocità e il manipolo necessario. In conclusione particolare attenzione viene data alle caratteristiche di una nuova fresa, usata per un caso clinico ora risolto e qui presentato. Parole chiave: Strumento rotante, Chirurgia orale, Osteotomia, Osteoplastica, Odontotomia. 4. Lindhe J. 1. Bartolucci EG, Young Cho J. Atlante di chirurgia parodontale. Parodontologia. 2. Brusati R, et al. 5. Panzoni E. PICCIN, 1986:81-88. MASSON, 1985:48-56. Edi ERMES, 1998:439-460. I.C.A., 1992:45-55. Chirurgia endodontica. Trattato di tecnica chirurgica. 3. Calandriello M, Carnevale G, Ricci G. Parodontologia. Edizioni Martina, Bologna, 1996:444-528. Vol. 5 - N° 1 6. Sailer HF, Pajarola GF. Chirurgia orale. Masson, 1997:178-190. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 17 C AZIENDA Unita Sanitaria Locale ROMA A PATROCINI RICHIESTI A.S.P. - Azienda di Sanit Pubblica Ordine Provinciale di Roma dei Medici Chirurghi e degli Odontoiatri O.C.I. - Odontoiatri Cattolici Italiani Collegio dei Docenti di Odontoiatria REGIONE LAZIO Asclepion formazione continua in sanità S.I.M .O SOCIET ITALIANA MAXILLO ODONTOSTOMATOLOGI CA Presidente Onorario G iovanni D olci Presidente onvegno 1 Corso precongressuale Academy of laser dentistry introductor course Coordinatore R oberto M arasca 2 Corso precongressuale TecnologiCAD CAM: rapidit di esecuzion avanzate in e perfezione estetica Maxillo Odontostomatolog ROMA ia: Coordinatore G iulio D e C inti Roma, 26 maggio Ospedale G. Eastman Ospedale G. Eastman AULA MAGNA AULA MAGNA ventisette maggio 200 6 Esiste una Scuola Odontoiatrica Italiana che è patrimonio di tutti. Esiste anche una Gloriosa Tradizione Ospedaliera: BIBLIOTECA ambizione della SIMO è di esserne la voce. IMAGE GUIDED NAVIGATIONAL IMPLANTOLOGY: A NEW REHABILITATION PROCEDURE *Alessandro Quaranta, MD,DDS, **Lorenzo Benedetti, MD *Giovanni Ballarani, MD,DDS, *Marlene Fabrizi, DDS, *Giorgio Pompa, MD,DDS * ** SUMMARY Recently, computerized guided image methods combining a pre-operative 3D plan for inserting dental implants with a dental navigation system were introduced. This procedure allows the visualization of image based diagnostic data of patient’s jaws and makes it possible to use a dental implant navigation system (DenX’s, IGI System®). The surgeon can plan, using the system’s clinical planning tool, the drilling position, orientation and depth of each implant. The aim of this study is to describe the Den-X system that can help the clinician during the pre-operative planning and also during the intra-operative procedure. During the period of March-May 2005, 7 healthy no-smoking patients (age 40-55 years) were rehabilitated with a total of 13 fixtures (Imtec Implants® U.S.A.) using the DenX System (Moshav Ora, Israel), that tracks the actual position of the handpiece in real-time. The tracking method used by this system is an optical three linear camera tracker Flashpoint 5000 system (Image Guided Technologies. Boulder®, Colorado USA) upgraded by DenX for greater accuracy and reliability. All the surgical procedures were performed flapless, and the clinician was guided by the video data on position, angulation and depth for each implant. All the radiographic control examinations performed after 4 weeks showed the correct implants position and the absence of complications due to incorrect fixture placement. In conclusion, we can say that adoption of image-viewing software and motion tracking devices to guide the surgeon during the implant placement allows the correct insertion of fixtures improving the functional and aesthetic results, minimizing intra-operative risks and prosthetic complications. Università degli Studi La Sapienza, Roma Dipartimento di Protesi DenX’s IGI System, Italia INTRODUCTION Implant placement guided by prosthetic-driven procedures allows to resolve part of the surgical and prosthetic complications and limits (1). The CT Scan data can be used during the surgical stage through a stent provided with drill guides (2, 3). The main limitation of this procedure is due to the lack of control during the implant placement and to the fact that guides can’t be modified during the procedure (3, 4, 5, 6). Recent developments allowed to move data from TC Scan to the surgical site in real time obtaining a system of navigation based on transfer magnetic devices, but it still lacks of satisfactory accuracy (7, 8). More recently, computerized guided image methods combining a pre-operative 3D plan for inserting dental implants with a dental navigation system were introduced. The system we adopted allows the visualization of image based diagnostic data of patient’s jaws and makes it possible to use a dental implant navigation system (DenX’s, IGI System®). The surgeon can plan, using the system’s clinical planning tool, the drilling position, orientation and depth of each implant (Figure 1). Key words: Image Guided Navigational Implantology, CT Scan, Implants, System accuracy Corresponding author: Alessandro Via Ariosto, 24 00185 Rome, Italy Tel +390677200498 e-mail: [email protected] Vol. 5 - N° 1 Quaranta Figure 1. Confident® clinical planning tool showing the drilling position, orientation and depth MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 19 Quaranta A. et al. The system uses marker-based referencing methods to transfer the tool coordinate system to the patient (Figure 2). Figure 2. The system splint providede with ceramic spheres enclosed fits in patient’s cross arch Figure 3. The handle handpiece is provided with a set of IR LEDs A visual and audio guide helps the clinician during the surgical procedure, and the surgeon can move the drill in the correct position with the support of the navigation system. The DenX system helps the clinician during the pre-operative planning and also during the intra-operative procedure. An accuracy of 0.2-0.3 mm has proved to be attainable regarding intra-operative navigation systems (9, 10) and the system manufacturer claims a total system accuracy of about 0.1 mm. MATERIALS AND METHODS During the period of March-May 2005, 7 healthy no-smoking patients (age 40-55 years) were rehabilitated with a total of 13 fixtures (Imtec Implants® U.S.A.) using the DenX System (Moshav Ora, Israel), that tracks the actual position of the handpiece in real-time. The tracking method used by this system is an optical three linear camera tracker Flash-point 5000 system (Image Guided Technologies. Boulder®, Colorado USA) upgraded by DenX for greater accuracy and reliability. The system located the Handpiece’s 3D position by tracking a set of IR LEDs, linked to the handle handpiece (Figure 3). Implant size, position and orientation was based on CT data developed with IGI Software from DenX Ltd. The CT scan protocol was a Dentascan CT protocol (0.5 mm slice thickness, 0.5 mm table feed, fast incremental scanning, 120 kV, 33 mAs, 512*512 matrix) (Figure 4). Patient’s maxilla or mandible position were recorded by special ceramic spheres enclosed in an acrylic splint placed in patient’s cross arch. Vol. 5 - N° 1 Figure 4. Patient fits the acriylic splint during the CT Scan Exam The splint was fit by each patient during the CT Scan process, and was also mounted by the patient in the surgical phase. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 20 Quaranta A. et al. Figure 7. Patient 1: two fixtures placed on th left side Figure 8. Patient 2: three fixtures placed on the left side Figures 5, 6. Video and audio guide during the surgical procedure This allowed to set an interface between the scan and the real position of patient’s jaw. Pre-operative procedures started recording the handpiece with the ceramic spheres on the acrylic surgical stent. The surgical protocol started with local anaesthesia in the implant sites, following the operator placed the acrylic splint in patient’s mouth and registered the handpiece and jaws position. All the surgical procedures were performed flapless, and the clinician was guided by the video data on position, angulation and depth for each implant (Figures 5, 6). No suture was needed (Figures 7, 8, 9) and postoperative Vol. 5 - N° 1 Figure 9. Patient 2: two fixtures placed on the right side MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 21 Quaranta A. et al. medications included a light non-sterhoyd anti-inflammatory drug and antibiotics for 1 week. RESULTS No intra or post-operative injuries or accidents were reported. All the radiographic control examinations performed after 4 weeks showed the correct implant position and the absence of complications due to incorrect fixture placement (Figure 10, 11). The distance between implants and vital structures (i.e. mental foramen, alveolar nerve, maxillary sinus) were safe. All the patients reported complete satisfaction and minimal swelling, absence of pain and discomfort in the immediate and 1 week post-operative interviews. All the fixtures showed normal osseointegration and were restored with a delayed loading protocol (Figure 12). Figure 12. Patient 1: Implant-supported bridge loaded after 6 weeks DISCUSSION AND CONCLUSIONS Figure 10. Patient 1: X-Ray control exam performed at 1 month Successful placement of dental implants depends on surgery planning and an optimal performed surgical procedure that comes after the treatment plan (11, 12). Adoption of imageviewing software and motion tracking devices to guide the surgeon during the implant placement allows the correct insertion of fixtures improving the functional and aesthetic results, minimizing intra-operative risks and prosthetic complications. RIASSUNTO Figure 11. Patient 2: Ortopanthomograph control exam performed at 1 month Vol. 5 - N° 1 Recentemente, sono stati introdotti metodi di immagine computerizzata guidata che in associazione ad uno studio pre-operatorio si mostrano adatti all’inserimento di impianti dentali attraverso un sistema di navigazione in 3D. Questa procedura permette la visualizzazione dell’immagine ottenuta in base ai dati diagnostici relativi ai mascellari del paziente, rendendo così possibile l’uso del sistema di navigazione impiantare (DenX’s, IGI System®). Utilizzando il sistema di progettazione clinica, il chirurgo può impostare la posizione della fresa e l’orientamento tridimensionale nonché la profondità d’inserimento di ciascun impianto. Lo scopo del presente lavoro è quello di descrivere il sistema DenX, che può aiutare il chirurgo sia durante la fase pre-operatoria che intra-operatoria. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 22 Quaranta A. et al. Tra Marzo e Maggio 2005 sono stati riabilitati 7 pazienti non fumatori (di età compresa tra i 40 e i 55 anni) per un totale di 13 impianti (Imtec Implants® USA) utilizzando il sistema DenX (Moshav Oral, Israel), che segue in tempo reale la posizione della mano dell’operatore. Il meccanismo su cui si basa il sistema è rappresentato da una telecamera a fibre ottiche lineari Flashpoint 5000 (Image Guided Technologies. Boulder®, Colorado USA) consigliata dalla DenX per la sua precisione ed attendibilità. Tutte le fasi chirurgiche sono eseguite senza l’esecuzione di un lembo, e per quanto riguarda la posizione, l’angolazione e la profondità di ciascun impianto, l’operatore è guidato dalle immagini che appaiono sul video. I controlli radiografici eseguiti dopo 4 mesi hanno evidenziato il REFERENCES 1. Vannier MW, Hildeboldt CF, Cononver G, Knapp RH, Yokoyama-Crothers N, Wang G. Three-dimentional dental imaginig by spiral CT. Oral Surg Med Oral Pathol, Oral Radiol Endodont 84: 561-570, 1997. 2. Schiroli G, Di Carlo F, Quaranta A. Sistema di posizionamento stereoguidato degli impianti. Casi Clinici. Dental Cadmos 2/2005:33-41. 3. Sarment D, Al-Shammari K, Kazor CE. Stereolithographic surgical templates for placement of dental implants in complex cases. Int J Period Res Dent 2003 23 (3):287-95. 4. Fortin T, Coudert JL, Chapleboux G, Lavallee S. Computer-Assisted dental implant surgery using computed tomography. J Image Guide Surg 1: 53 – 58, 1995. 5. Sarment DP, Misch CE. Scannographic templates for novel pre-implant planning methods. Int Magaz Oral Impl 2002;1-3:16-22. 6. Birkfellner W, Watzingere F, Wanschitz F, et al. Systematic distortions in magnetic position digitizer. Medical Physics 25: 2242-2248, 1998. 7. Randelzhofer P. et al. Navigazione tridimensionale in implantologia orale: uno studio preliminare. Int J Periodontics Rest Dent 2001;6:617-25. Vol. 5 - N° 1 corretto posizionamento degli impianti e assenza di complicanze. Concludendo, si può affermare che l’uso del software descritto, che si basa su un sistema di navigazione guidata, offre al chirurgo un valido aiuto durante il posizionamento d’impianti, permettendone il corretto inserimento; consente, inoltre, di ottenere risultati funzionali ed estetici senz’altro migliori, minimizzando i rischi intra-operatori e le complicazioni legate alle fase protesica. Parole Chiave: Sistema di implantologia guidata, TC Denta-scan, Impianti, Precisione del sistema 8. Birkfellner W, Solar P, Bergmann H, Watzingere F, Wanschitz F, et al. In vitro assessment of a registration protocol for image guided implant dentistry. Clin Oral Impl Res 12: 69-78 2001. 9. Brief J, Hassfeld S, Redlich T, Ziegler C, Muenchenberg J, Daueber S, Pernozzoli A, Krempien R, Slacik P, Opalek M, Boesecke R, Mühling J. Robot Assisted Insertion of Dental Implants A clinical evaluation, CAR 2000, 932 – 937. 10. Hassfeld St, Brief J, Stein W, Ziegler C, Redlich T, Raczkowsky J, Krempien R, Mühling J. Navigationsverfahren in der Implantologie - Stand der Technik und Perspektiven. Implantologie 4: 373-390 (2000). 11. Münchenberg J, Brief J, Hassfeld S, Raczkowsky J, Rembold U, Wörn H. Expert Sup-ported Operation Planning in the Maxillofacial Sur-gery (1998), Proceedings of Computer Assisted Radiology and Surgery (CAR'98). June, 1998, Tokyo, Japan. 12. Stein W, Hassfeld S, Brief J, Bertovic I, Krempien R, Mühling J. CT-Based 3D-Planning For Dental Implantology. Proceedings of Medicine Meets Virtual Reality (MMVR'98), San Diego, 1998. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 23 S. I. M.O. SOCIETÀ ITALIANA MAXILL OODONTOSTOMATOLOGICA Presidente Onorario GIOVANNI DOLCI Presidente MAURO OREFICI PATROCINI PIEMONTE ReferenteG iancarlo C ortese CONVEGNO REGIONALE SIMO Presidenti M. Giordano , W. hinzani G Coordinatori Scientifici E. ePgazzano , G. ortese C MAXILLO ODONTOSTOMATOLOGIA ESSENZIALE TORINO OSPEDALE MARTINI 10 giugno 2006 Nell ambito del Covegno sar presente l odontoambulanza E s i s t e u n a S c u o l a O d o n t o i a t r i c a I t a l i a n a c h e è p a t r i m o n i o d i t u t t i . E s i s t e a n c h e u n a G l o r i o s a Tr a d i z i o n e O s p e d a l i e r a : ambizione della SIMO è di esserne la voce. COMPUTER GUIDED IMPLANTOLOGY. INTRODUCTION TO THE SAFE SYSTEM® AND A CLINICAL CASE *Philippe B. Tardieu, DDS, **Luc Vrielinck, MD,DDS, ***Nico Roose, MSC * ** *** SUMMARY The SAFE System constitutes a new approach to dental implant placement by allowing transfer to the mouth of an implant plan based on CT scan data. The system consists of dedicated tools for guided implant treatment, one single SurgiGuide is used for drilling guidance and implant placement. SAFE is an acronym for Secure, Accurate, Flexible and Ergonomic. The ease of execution, security of intervention and obtained accuracy are important positive aspects that lead us to believe that the SAFE System is likely to have a profound positive impact on our practice. Key words: Implantology, Safe System®, CT Scan data INTRODUCTION Since the 1990s, many medical teams have approached the problem of implant case planning with the assistance of computer applications. Thanks to the tools created by Materialise, we were able to establish the basics of a complete therapeutic protocol including not only case planning in 2 and 3 dimensions based on CT scan data, but also the transfer of projects into the mouth through the realization of customized surgical guides by means of stereolithography. We rapidly became aware that the tools of “classical” implantology were not adapted to this new approach and since greater accuracy, security and ease of use are now required during implant placement, new tools should be designed. This realization was a major step toward the conception of the SAFE System. Corresponding author: Philippe B. Tardieu, DDS 49, avenue Alsace-Lorraine - 38000 Grenoble Tel. 0476469721 - Fax 0476469710 e-mail: [email protected] Vol. 5 - N° 1 Paris VII University, PG in Implantology Nice-Sophia Antipolis University, Adjunct Associate Professor New York University Maxillo-facial Surgery, Dpt: Mond-Kaak en Aangezichtsheelkunde, Ziekenhuis Oost-Limburg (ZOL), Campus St Jan, Belgium Medical Research Engineer, Medical Production Manager Materialise N.V. Medical Department Technologielaan, Leuven, Belgium MATERIALS AND METHODS Implant planning requires time as well as minute attention to detail, as it determines the entire surgical phase. For this reason, the SimPlant programmes is used (1) . The position, inclination, depth, diameter and length of each implant can be changed as needed. Once the planning has been performed, it can be sent to Materialise for the fabrication of the surgical guides (2, 3). An order form allows the surgeon to request a customized guide according to his indications. He remains the designer of the surgical device. The guide is produced by means of the stereolithography process. The SAFE System assists the surgeon only during the surgical procedure (4). Prosthetic realization can afterwards be implemented conventionally. Description of the SAFE System® The SAFE System consists of dedicated tools for guided treatment of patients with implants. By using only one single surgical guide, one can guide position, angulation and depth for the drilling of the osteotomies as well as for the actual implant placement. It is a universal system that is not limited to the use of stereolithographic guides and it may be adjusted to any type of surgical guide. Moreover, all types of stereolithographic guides are compatible with the system: tooth-supported, bone-supported, mucosa-supported, mixed supported and even implant-supported. Drilling To prepare implant osteotomies using “classical” methods, a series of 5 different drills is used: a round burr, a drill with a primary diameter of about 2mm, a two-staged pilot drill, a twist drill with final diameter of about 3mm, and a countersink. Utilizing the SAFE System, only 2 drills are needed: a pilot drill and a calibrating drill (e.g. the pilot drill and the final drill). Because of the guiding of the drills, a round burr to prepare the site can be excluded. The pilot drill creates a MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 25 Tardieu P. B. et al. primary osteotomy of 2mm in diameter over the first 4mm of its cutting length. Additionally, due to its stepped design it simultaneously increases this diameter to 3mm. The final drill regulates the osteotomy to 3.15mm in diameter. The drill is designed to have this final diameter only over the first 4mm of its cutting length, and a reduced diameter over the rest to prevent overheating during its rotation in the bone by not having friction over the entire cutting length. The thread, gouge drawing and surface processing of these drills were modified in order to increase their cutting capacity; to prevent overheating during the osteotomy, irrigation with a cool saline solution is necessary. Because of the stepped design of both drills, both drills can be guided through one and the same drilling tube. As an extra feature, the two drills in the SAFE System have depth control stops. Seven different drill lengths are available: 10, 13, 15, 18, 20, 23, and 25mm. The most used are 13, 15 and 18mm. In order to control the depth for each osteotomy, the depth control is added to the surgical guide in the design phase. By adjusting the height position of the tubes in the surgical guide, each possible depth can be accounted for. Implant Placement In classical implantology, implant holders or fixture mounts are used to control manual and visual implant placement. Since at this stage the most serious position errors can still occur, guidance of the actual implant placement is essential. Indeed, during manual placement the implant may sometimes deviate from the drilling axis, because self-tapping implants will choose the way of minimal resistance, e.g. when the density gradient between dense cortical bone and a rather soft, spongy bone is too large. In certain cases, the surgeon may attempt to compensate for this problem by creating a conical hole with a countersink. In the SAFE System, the implant is directed to its planned position without the need for visual control, thanks to the use of a dedicated implant holder that passes through a guiding cylinder. This implant holder also has a depth control stop consisting of a flange located at its proximal end. Currently, several lengths of implant holders are available: 4, 5, 6, 7, 8, 9, 10 and 15mm. The most used are 7 and 9mm. Using the SAFE System® To illustrate the surgical steps, we have chosen an implant placement case in which a bone-supported surgical guide with SAFE System was used. During the first step, an incision is made in the mucosa and the underlying bone surface is exposed, clearing it of any fibrous remnants (Figure 1). The next step consists of applying the stereolithographic guide on the bone surface and securing it into position, if Vol. 5 - N° 1 Figure 1. Incision in the mucosa for exposing the bone surface. needed with the use of osteosynthesis screws. The guide is equipped with titanium guiding cylinders in which drilling tubes are screwed, made of surgical grade stainless steel. Screwing is accomplished with a mere quarter turn, thereby making it easier to perform the manipulation in the mouth (Figure 2). This device allows the transfer of the planned Figure 2. SAFE System surgical guide placement on the bone. implant project from the computer to the mouth of the patient with high accuracy (Figure 3) and, as in the presented example, to perform the placement of 3 implants of different lengths: 13, 10 and 7mm. In order to drill a 13mm hole, the pilot drill of 13mm is used (Figure 4). For an implant of 10mm, the pilot drill of 10mm is used for an implant of 7mm, the same drill is used (Figure 5). This is possible because the height of the guiding tube is adapted for the latter implant. In every case, drilling is performed until the drill is blocked by the depth control stop. MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 26 Tardieu P. B. et al. Figure 3. Clinical transfert of 3 implants planned with 13, 7 and 10 mm lengths Afterwards, the same operation is repeated using the final drills (Figure 6). Following drilling, the drilling tubes are unscrewed and removed from the stereolithographic guide (Figure 7). The guiding cylinders glued in the stereolithographic guide are then used for the implant placement. By using different lengths of implant holders for the different implants, also the depth of the implant placement can be securely controlled. As the depth control for drilling as well as implant placement is provided in the design of the stereolithographic guide, surgeons receive indications of which components drills and implant holders - to use for each implant to be positioned. As all the planning has been performed beforehand, the planning can be transferred to the operating room utilizing an easy to use dynamical surgical tray. All needed components can be positioned in a dynamic tray in an orde- Figure 4. Drilling with a pilot drill of 13mm for the 13mm implant Figure 6. Final Drillling Figure 5. A pilot drill of 10mm is used for both the 10mm implant for the 7mm implant Figure 7. Once the drilling has been finished, the drilling tubes are unscrewed and removed to get a direct access to Titanium guiding cylinders Vol. 5 - N° 1 MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 27 Tardieu P. B. et al. red way following the tooth positions of the implants to be placed (Figure 8). Implants are placed using guiding cylinders and appropriate implant mount (Figure 9). To finish the surgery, the surgeon can choose all possible options: screwing on of healing caps and covering the implants with the gingiva (Figure 10), placement of healing abutments during surgery (Figure 11), and immediate loading of implants with prosthetic elements in occlusal position (Figure 12). Various clinical studies or on cadavers or on dry models (5) show a deviation varying from 3.5mm for manual implant placement to 0.3mm using the SAFE System. A recent unpublished study on animals done by Dr. Luc Vrielinck shows an accuracy of 100 microns at the entry point of implants with the SAFE System. Figure 8. All needed components are in the dynamical surgical tray, in an ordered way following the tooth positions of the implants to be placed Figure 9. All the implants are placed during a single surgical step with the assistance of the SAFE System implant holders Vol. 5 - N° 1 Figure 10. The surgery can end with the placement of healing caps Figure 11. The surgery can end with the placement of healing abutments Figure 12. The system also allows immediate loading MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 28 Tardieu P. B. et al. CLINICAL CASE The Planning Phase The surgery planning is made using CT information within the SimPlant software (Figure 13). cal stop, depth control can be added in the design of the guide. By adapting the height of the tube within the SurgiGuide, compared to the actual platform of the planned implant, one can adapt the SurgiGuide for use of a certain length of drill and fixture mount for each implant individually. If all implants are positioned at the same level compared to the bone crest, and all implant lengths are within the same length range, this depth control makes it possible to drill all osteotomies with one and the same drill length. If the depth and length of the implants differs, more components might be needed to accomplish the surgery. Since the depth control is taken care of during the design of the SurgiGuide, the design decides which components are to be used for which implant positions. As such, every SurgiGuide will be accompanied with a Surgery Guideline explaining the different components to be used. Before Surgery Figure 13. Main SimPlant 9 screen. Implant position will be adapted using rotation and traslation tools. Number and size of implants will be decided Besides the bone quality and density, the ideal tooth set-up can be taken into account by having a radio-opaque scan prosthesis in the patient’s mouth during CT scan. This template is called a ScannoGuide ®. The position is defined by combining the ideal emergence of each implant with anatomical restrictions like bone quality. Also the length of each implant is defined at this point. To avoid problems for SurgiGuide design and/or design of the restorative bridge, it is checked whether the implants (and their restorative spaces) are sufficiently far from each other and from any remaining tooth. If implants are too close to remaining teeth, it might be impossible to position guiding tubes in the SurgiGuide at the lowest possible level above the supporting surface, because of the proximity of the neighbouring tooth. Using the surgery guideline, the dynamical surgical tray available in the SAFE Surgical Kit can be filled with the correct components for surgery (Figure 14). By positioning the needed drills and fixture mounts for each planned implant at the correct tooth position in the surgical tray, the transfer from the planning towards the actual surgery is simplified. If needed, titanium implant containers are available to accommodate the change from implant brand specific fixture mount to the SAFE fixture mount. The completely prepared surgical tray can be sterilised as a whole within the autoclave. As such, the complete surgery is prepared beforehand, and errors caused by making important decisions in a stressful environment like the surgery theatre are avoided. SurgiGuide Design After sending the treatment plan to Materialise, all planning aspects are transferred to the design of the SurgiGuide. As with regular SurgiGuides, SurgiGuides with the SAFE System also transfer position and angle of the different implants towards the surgery. Additionally, depth control is taken care of during design of the guides. Because all surgical components, like drills and fixture mounts, are available in different lengths and are equipped with collars as physi- Vol. 5 - N° 1 Figure 14. Dynamic tray MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 29 Tardieu P. B. et al. Surgery The teeth supported SurgiGuide is positioned in the patient’s mouth (Figure 15). Figure 17. Staged drill Figure 15. Teeth supported SurgiGuide in position After the SurgiGuide is secured, a trephine is used through the SurgiGuide to remove soft tissue and if needed to flatten the bone to the level where the implant platform is expected (Figure 16). Figure 18. Final drill Figure 16. Use of a trephine to punch the mucosa The drilling tubes are positioned in the SurgiGuide, and according to the planning and the surgery guideline, pilot drilling and final drilling are performed through one and the same drilling tube (Figure 17, 18). Before driving the implants into the jaw, it must be decided whether tapping is necessary or not, depending on the density of the bone at the implant sites. The implants are driven in position guided by the correct SAFE fixture mounts through the SurgiGuide (Figure 19). Vol. 5 - N° 1 Figure 19. Implant placement using SAFE implant mounts MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 30 Tardieu P. B. et al. To take into account mechanical considerations, the best option is to drive all implants partially into position before screwing the first implant completely down. Once all implants are driven into position, the implant holders and the SurgiGuide can be removed (Figure 20). The surgery can be finished in different ways, whether one Figure 20. After placing the implant mounts down to the flange,they are removed chooses to place healing caps (Figure 21) or to go for an immediately loaded temporary prosthesis. CONCLUSION The use of the SAFE System has many advantages over the current available systems. First of all, it is the only system available on the market to provide drilling and implant placement guidance in position, angulation and depth with only one surgical template. One drilling tube assures guidance of both (and all) drills. After unscrewing the drilling tubes, the implant placement can be guided through the titanium guiding tubes incorporated in the surgical template. Depth control is added by physical stops on drills as well as on the implant holders, combined with the height of the tubes in the design of the template. To accommodate the easy transfer of the implant planning towards the surgery theatre, an easy to use dynamical surgical tray is available. The current available system has been designed for standard external hex implants. Several implant manufacturers with internal retention implants are already adapting their components to make them compatible with the SAFE System. This system leads us to accurately control implant placement (6). This procedure opened the way to micro opening surgery, to trans-sinusal implant placements (6) and to the Immediate Smile® procedure (7) where the bridge is fabricated before implants placement, without taking an impression of implants. In this case the screw retained bridge is placed during the same appointment as implant placements. RIASSUNTO Il SAFE system costituisce un nuovo approccio per la locazione dell’impianto dentale permettendo un transfer alla bocca di un piano di impianto basato sul CT scannerizzazione dati. Il sistema consiste in strumenti atti al trattamento dell’impianto guidato, un singolo Surgiguide è usato per la trapanazione guidata e il posizionamento dell’impianto. Safe è un acronimo di Sicuro, Accurato, Flessibile ed Ergonomico. La facilità di esecuzione, la sicurezza di intervento e l’ottenuta accuratezza sono aspetti positivi importanti e ci portano a credere che il Safe System probabilmente avrà un profondo e positivo impatto sulla nostra attività pratica. Figure 21. Healing abutments placed for a painless transmucosal one stage surgery Vol. 5 - N° 1 Parole chiave: Implantologia, Safe System, Dentascan MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 31 Tardieu P. B. et al. REFERENCES 1. Kraut RA. Utilization of 3D/dental software for precise implant site 4. Tardieu PB, Vrielinck L, Escolano E. Computer-assisted Implant Placement. A Case Report: selection: clinical reports. Treatment of the Mandible. 2. Tardieu PB. 5. 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MAXILLO ODONTOSTOMATOLOGIA International Journal of Maxillo Odontostomatology 32