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The Journal of Implant & Advanced Clinical Dentistry

Volume 10, No. 5 July 2018

Fibrous Dysplasia

Florid Cemento-Osseous Dysplasia

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The Journal of Implant & Advanced Clinical DentistryVolume 10, No. 5 • July 2018

Table of Contents

6 Fibrous Dysplasia of the Mandible: A Case Report Dr. Dhaval P Pandya, Dr. Anil Varshney, Dr. Purvi D Pandya, Dr. Prashant D Shirke

12 Florid Cemento-Osseous Dysplasia of the Jaws: Report of a Rare Case Dhaval P Pandya, Prachi Chaubal

2 • Vol. 10, No. 5 • July 2018

The Journal of Implant & Advanced Clinical Dentistry • 3


Table of Contents

20 Analysis of the Mechanical Behavior of Components of Osseointegrated Implants Submitted to Maximum Compression Dr. Nathalia Benevides de Moraes, Dr. Eduardo José de Moraes, Carlos Nelson Elias, Luis Eduardo Benevides de Moraes

26 Developing a Long-Term Rela-tionship with Patients: The Role of the Dental Hygienist Nafiseh Soolari, Soulayman Diallo, Ahmad Soolari


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Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

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Pandya et al

Fibrous dysplasia is a skeletal develop-mental disorder of the bone forming mes-enchyme that manifests as a defect in

osteoblastic differentiation and maturation. It is a lesion of unknown etiology, uncertain pathogen-esis, and diverse histopathology. Fibrous dyspla-

sia represents about 2.5% of all bone tumours and over 7% of all benign tumours. The aim of this article is to present a rare case report of monostotic fibrous dysplasia of posterior mandi-ble in a forty seven year old asymptomatic Indian female and its interdisciplinary management.

Fibrous Dysplasia of the Mandible: A Case Report

Dr. Dhaval P Pandya1 • Dr. Anil Varshney2 • Dr. Purvi D Pandya3

Dr. Prashant D Shirke4

1. Private practice limited to periodontics and implantology at Mumbai, India.

2. Senior consultant Orthodontist at Mumbai, India.

3. Private practice limited to conservative dentistry, endodontics and esthetic dentistry at Mumbai, India.

4. Consultant oral and maxillofacial radiologist at Mumbai, India.

Abstract

KEY WORDS: Fibrous Dysplasia, Mandible, Interdisciplinary planning

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Pandya et al

INTRODUCTION Fibrous dysplasia (FD) is a benign fibro-osse-ous pathologic condition characterized by the replacement of bone with fibrous tissue.1

It is a bone development anomaly character-ized by hamartoma proliferation of fibrous tis-sue within the medullary bone, with secondary bony metaplasia, producing immature, newly formed and weakly calcified bone, without maturation of the osteoblast which appears radiographically as the classically described ground-glass appearance.2 The lesion was first described by Lichtenstein.3 If fibrous dyspla-sia affects only one bone, it is called mono-static FD, but multiple bones may also be affected and this form is called polyostotic

FD. The monostotic form of fibrous dysplasia is the most common, comprising 70% of cases. A typical monostotic lesion, usually presented unilateral, will involve the femur, tibia or ribs, with 25% occurring in the bones of the skull. Affection of the craniofacial bone is observed with 10% of the patients suffering from mono-stotic FD. Twenty-five percent of fibrous dyspla-sia involves two or more bones. These lesions may be localized to one region of the body or they may be disseminated. There is a female predilection in polyostotic fibrous dysplasia, and up to 50% may involve bones in the head and neck. A special form of FD is McCune-Albright syndrome, which is characterized by endocrine dysfunction including acromegaly, Cushings syndrome, hyperthyroidism and vita-min D resistant rickets. The most common fea-tures of this syndrome are; precocious puberty in girls and brownish pigmentations of the skin (café-au-lait spots) with irregular borders.4

CASE REPORTA 47 year old asymptomatic Indian female requested for a second opinion regarding her dental condition. Her chief complaint was replacement of her lower left second molar with a dental implant supported prosthesis. Intra oral examination revealed missing lower left sec-ond molar along with extruded maxillary left sec-ond molar reducing the inter occlusal distance from cusp to the bone for a restoration, maloc-clusion, few poorly contoured dental fillings and food lodgement with the lower right molar area.

Extra oral examination revealed nothing abnor-mal. An interdisciplinary treatment plan was for-mulated and with the help of the basic diagnostic aids like dental models and panoramic Xray, a treatment plan was formulated with inputs from the endodontist, periodontist and an orthodon-tist. An Ortho-Perio-Endo treatment plan con-sisted of fixed orthodontic therapy including placing of mini orthodontic implant at the lower left posterior region interdentally between the second premolar and the molar region and pala-tally in the upper arch for anchorage and intru-sion of the maxillary left second molar to increase the inter occlusion restorative space. Poorly con-toured dental fillings as well as the poorly fab-ricated crown with lower right first molar were re-done by the endodontist and the intra bony defect which seemed one of the cause of the food lodgement with the mandibular left second pre-molar and molar and area was treatment planned orthodontically with movement of the teeth so as to fill with the bone deposition interdentally with the orthodontic teeth movement. Periodon-tal treatment consisted of non surgical therapy.

The edentulous site at the mandibular left second molar region was left as it is because of

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the nature of the lesion and limited inter occlu-sal restorative space after intrusion. Extraction of a root piece with relation to the mandibular left first molar was not carried out and the patient was kept on a clinical and radiologic recall and fol-low up to evaluate any changes in the bone and the risk it carries. Since the patient was asymp-tomatic and showed no signs of swelling, facial asymmetry, pain etc a conservative approach was formulated with no surgical biopsy intervention.

RADIOLOGICAL FINDINGS A single hyperdense lesion was noted in the left posterior mandible. The lesion extended from the left retromolar region to the mesial of the left first premolar. The borders were well demar-cated mesially and distally, but along the course blending into the native bone and presenting a

dense granular appearance. There was slight expansion of the lingual as well as buccal cor-tices along with thinning, while maintaining the overall shape of the bone. Laminae durae were not distinct in the course of the lesion. Root resorption was absent. The cortex of the infe-rior alveolar canal could not be distinctly traced. The overall picture was suggestive of Fibrous Dysplasia, a differential of Pagets disease may be considered; but the unilateral involvement would be more in favour of Fibrous Dysplasia.

Figure 1: Panoramic radiograph with markings of areas of suspected FD.


Pandya et al

HEMATOLOGICAL AND OTHER BIOCHEMICAL

INVESTIGATIONSHaematological, endocrine including thyroid and parathyroid hormone and other biochemi-cal investigation including serum alkaline phos-phatase was reported to be in normal range.

DISCUSSIONFibrous dysplasia of the cranium is a rare disor-der of unknown etiology in which normal bone is replaced by abnormal fibro-connective tissue pro-liferation. In 36.3% of the cases of FD the clinical beginning is hidden, there are no clear symptoms. The rest of the patients (63.6%) are with diverse symptoms depending on location, swelling, defor-

mation and presence of pain. Polyostotic fibrous dysplasia affects multitude skeletal bones usu-ally unilateral.2 There is some evidence that the etiology of FD may be local infection or trauma.1 In most cases, the radiographic and clinical find-ings are sufficient to allow the practitioner to diag-nose without a biopsy.5 The differential diagnosis with similar radiographic appearance such as ameloblastoma, ameloblastic fibroma, ameloblas-tic odontoma, ameloblastic fibroodontoma, central giant cell granuloma, odontogenic cyst, ossify-ing fibroma, osseous dysplasia, chronic scleros-ing osteomyelitis and osteosarcoma should be considered.6 FD is a rare but severe bone dis-ease which may cause fractures in long bones, deformities and bone pain. Although most lesions appear to stabilize when approaching bone matu-

Figure 2: Computed tomography scan showing areas of ground glass appearance.

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rity, some cases can reach severe asymmetry, visual impairment, diplopia, pain, paraesthesia, proptosis, hearing loss, anosmia, nasal obstruc-tion, epistaxis and epiphora. The patients gener-ally complain of swelling (94)% and pain (15%).7

If FD is asymptomatic, it can be noticed inci-dentally in CBCT, CT scans and radiographs. If there is no symptom or evidence of progression during follow-up, surgical treatment isn’t consid-ered.8 This was demonstrated in our reported case. Recurrence of FD is rare when the lesion has occurred in adults but it is seen more com-monly in growth period.9. Concentration of serum

alkaline phosphatase (ALP) may be important marker for detection of the recurrence of the lesion. The patients who had FD, have higher ALP, this may be a reliable marker for estimating tumour progress and a sudden rise in ALP was corre-lated with the regrowth of FD by Park et al.10 In general, conservative dental therapy can be per-formed safe in patients with FD. Regular clinical check-ups are recommended as the disease is associated with enamel hypoplasia, dentin dys-plasia, taurodontism, an increased caries index score, and malocclusion.11 Orthodontic therapy is described in the literature as more prolonged, but this is not a contraindication.12 In the current sci-entific literature, only case reports exist for implant placement in affected areas.13,14 Recent litera-ture search shows successful oral rehabilitation by dental implants with guided bone regenera-tion for teeth involved in Fibrous Dysplasia of the maxilla,15 but in our case we chose to be conser-vative in our approach for treatment. The patient was asymptomatic and did not exhibit any signs of swelling, facial asymmetry and pain. Our case also showed limitation in the interocclusal restor-ative space at the edentulous site even after orth-odontic intrusion of the maxillary left second molar. A long term occlusal wired splint has helped in maintaining any relapse of the molar extrusion .The patient is kept on a periodic recall and fol-low up to evaluate any changes in the lesion.

CONCLUSIONThis case report demonstrates monostotic fibrous dysplasia of the mandible. The clinical and radiologic features are notable. Monostotic fibrous dysplasia of the mandible in a middle aged asymptomatic patient poses a challenge

Figure 3: Lateral cephalogram image showing areas of suspected FD.


Pandya et al

Correspondence:Dr. Dhaval Pandya Email: [email protected]

DisclosureThe authors report no conflicts of interest with anything reported in this article.

References1. Canitezer G, Gunduz.K (2013) et al. Monostotic

Fibrous Dysplasia: A case report Dentistry 2012: Vol 3 No 2.

2. Cholakova R, Kanasirska, et al Fibrous Dysplasia in the maxilla mandibular region – A case report J IMAB – Annual proceedings: Vol 16, book 4; 2010.

3. Lichtenstein L (1938) Polyostotic Fibrous Dysplasia Arch Surg 36 : 874-898

4. Delilbasi, Deniz, Ekisi et al Monostotic Fibrous Dysplasia of the mandible OHDM Vol 13 No 2 June 2014.

5. White SC, Pharoah MJ, (2009) Oral radiology: Principles and interpretation ( 6th Ed) Elseiver

6. O’Connell KJ (1981) Bony enlargement of the left maxilla. J Am Denta Assoc 102: 340-342.

7. McDonald- Jankowski D (1999) Fibrous Dysplasia in the jaws of a Hong Kong population :Radiographic presentation and systemic review :DentoMaxillofac Rad 28:195-202.

8. Ozek C, Gundogan H et al Craniomaxillofac Fibrous Dysplasia J craniomaxillofac surg 13: 382-389.

9. Alvares LC, Capelozza AL et al (2009) Monostotic Fibrous Dysplasia :A 23 year recall follow up of a patient with spontaneous bone remodelling Oral Surg O Med O Pathol Oral Radiol Endod 107:229-234.

10. Park BY, Cheon Yw et al (2010) Prognosis for craniofacial Fibrous Dysplasia after incomplete resection :age and serum alkaline phosphatise :Int J Oral Maxillofac Surg 39: 221-226.

11. Akintoye SO, Lee JS et al (20013) Dental characteristics of Fibrous Dysplasia and Mc-Cune Albright syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 96 : 275-282.

12. Akintoye SO, Boyce AM, Collins MT (2013) Dental perspectives in Fibrous Dysplasia and Mc-Cune Albright sundrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 116:149-155.

13. Bajwa MS, Ethunandan M, Foold TR (2003) Oral rehabilitation with endosseous implants in a patient with with Fibrous Dysplasia (MC-Cune Albright syndrome) –A case report. J Oral Maxiilofac Surg 66:2605-2608.

14. Petroceli M, Kretschmer W(2014) Conservative treatment and implant rehabilitation of the mandible in a case of craniofacial Fibrous Dysplasia: A case report. J oral Maxillofac Surg 72:901-906.

15. Monje, Suarez, Garcia et al Oral rehabilitation by dental implants for teeth involved in a maxillary Fibrous Dysplasia J Periodontol 2012.

Figure 4: Final panoramic radiograph

to the dental clinician. Therapy should always be determined by the progression of the dis-ease and requires close interdisciplinary co-operation with a regular follow up and recall. l

Pandya et al

Florid Cemento-Osseous Dysplasia (FCOD) is a rare “fibro-osseous” lesion that charac-teristically affects the jaw bones in middle

aged individuals. The condition is usually asymp-tomatic and needs no treatment. The diagnosis of FCOD is made typically on the basis of clini-

cal and radiological features and biopsy is gen-erally not recommended due to the risk of post operative secondary infection. This article reports a rare case of FCOD affecting the maxilla and mandible as an incidental finding in a sixty three year old asymptomatic Indian female patient.

Florid Cemento-Osseous Dysplasia of the Jaws: Report of a Rare Case

Dhaval P Pandya, MDS1 • Prachi Chaubal, MDS2

1. Private practice limited to periodontics and implantology at Mumbai, India

2. Chief oral and maxillofacial radiologist at Jhankaria Imaging Mumbai and Thane Ultrasound Centre, Thane, India

Abstract

KEY WORDS: Florrid Cemento-Osseous Dysplasia, oral pathology, mandible, maxilla, case report

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Pandya et al

CASE REPORT A sixty three year old Indian female patient was referred for treatment of her edentulous bilateral posterior mandible with dental implants. There was no significant medical history. Dental his-tory comprised of extractions of her mandibular right and left first and second molars long time back. She exhibited reduced vertical dimen-sion of her maxillo-mandibular relation and as a consequence demonstrated deep bite. There was significant attrition with respect to her man-dibular right and left premolars, canines, and incisors bilaterally. Since this was the baseline situation to start with, her centric records were taken and maxillary and mandibular impres-sions were poured and dental models were articulated on a semi adjustable articulator.

Drug history revealed that the patient was on anti hypertensive therapy since a few years. The patient was normal built having normal gait and posture. Her vitals were within normal lim-

its. She was well oriented to surroundings. There was no other medical history. Extra oral examina-tion revealed no abnormality. Digital periapical radiographs were taken of the edentulous sites of the mandible, along with other areas of the dentition of both the jaws. Dental CBCT of the mandible was performed on a Carestream 9300 machine. The dental CBCT showed multiple pre-dominantly radio-opaque, mixed density lesions in the periapical area of the mandibular anterior and bilateral third molar regions as well as in the edentulous mandibular right posterior region. The multi- quadrant involvement as well as the char-acteristic periapical location and appearance of these lesions was confirmatory of FCOD on imag-ing. The lesions in the edentulous could be resid-ual lesions. Routine haematological investigations were found to be normal. Dental implant reha-bilitation of the patient’s edentulous areas of the mandible was ruled out because of the risk of sec-ondary infection according to scientific literature.

Figure 1: Panoramic radiograph with markings showing FCOD lesions.

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DISCUSSION FCOD is a rare disease which is characterized by replacement of bone and connective tissue by cemento-osseous tissue affecting the jaw bones. They are mostly found in middle aged individu-als characterized by radio-opaque cementum like masses involving multi quadrant of dentition.1,2

On the basis of extent and radiographic appearances, the cemento-osseous dysplasia is classified into three types; 1) Periapical type - typ-ically surrounds the periapical region of the teeth and are generally bilateral (usually seen in mandib-ular anterior region); 2) Florid type - characterized by sclerotic symmetrical masses involving multiple areas or quadrants; 3) Focal type - generally found as a single lesion.3 The term “Florid” was coined by Melrose et al.1 Melrose et al denoted the term

Florid to describe wide spread and extensive nature of florid osseous dysplasia. However, the term “cemento-osseous dysplasia” was coined by Waldron due to close resemblance of the dense, sclerotic masses to cementum of tooth.4

The term florid cemento-osseous dys-plasia has been proposed in the sec-ond edition of International histological classification of odontogenic tumours5 to replace the term gigantiform cementoma given in the first edition’s, The WHO histological typ-ing of odontogenic tumours: a commentary.6

The World Health Organization has classi-fied cemento- osseous dysplasia on the basis of age, gender, location, histopathology, radiologic and clinical characteristics.5 The florid cement osseous dysplasia is prevalent in African Ameri-

Figure 2: Periapical radiograph of anterior mandible showing FCOD lesions.

Figure 3: Periapical radiograph of right posterior mandible showing FCOD lesions.


Pandya et al

can females in fourth to fifth decade of life with mean age occurrence of forty two years of age.7

The etiopathogenesis of FCOD is still not clear. Some authors agree on the concept that the proliferation of fibroblastic mesenchymal stem cells in the apical periodontal ligament which are considered as cemento blastic precur-sor stem cells leads to the formation of agglom-erated mass whereas others agreed on the view that FCOD may arise from the remnants of the cementum left after tooth extraction.8 The FCOD can reach up to size one to two centimeters and affects edentulous jaws and the tooth extrac-tion sockets like in this reported case; however it can be localized near teeth. FCOD can cause bony expansion and can be secondarily infected.6

Previously, the FCOD was reported under

variety of pathologies like multiple cemento- ossi-fying fibroma, sclerosing osteomyelitis, multiple enostosis and gigantiform cementoma.9 Many authors have coined FCOD as Paget’s disease of mandible and periapical cemental dysplasia.10

The focal COD arises at the previous extrac-tion site or at the apices of the molar region, rarely exceeding 2 cm in diameter, mimicking the radio-logical presentation of the periapical osseous dysplasia. The FCOD and periapical osseous dys-plasia involve a single area or multiple areas in a quadrant. The symmetrical presentation of pathol-ogy affecting more than one quadrant confirms the diagnosis.11 The FCOD are clinically asymptom-atic and may be found as incidental radiological finding presenting as multiple radiopaque masses within peripheral radiolucent rim located in two or

Figure 4: Periapical radiograph of left posterior mandible showing FCOD lesions.

Figure 5: Periapical radiograph of maxillary right canine showing FCOD lesions.

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Figure 7: CBCT cross-sectional view of anterior mandible showing FCOD lesions.

Figure 8: CBCT cross-sectional view of posterior mandible showing FCOD lesions.

Figure 9: CBCT axial view of mandible showing FCOD lesions.


Pandya et al

Figure 10: 3-dimensional reconstruction of right mandible showing FCOD lesions.

Figure 11: 3-dimensional reconstruction of left mandible showing FCOD lesions.

more quadrants usually in tooth bearing areas.12

Sometimes FCOD may be associated with symptoms of dull pain or drainage with exposure of sclerotic calcified masses in the oral cavity. This may occur as a progressive alveolar atrophy under a denture or after extraction of teeth in the affected areas.13 Broadly, on the basis of clini-cal findings FCOD is divided into sporadic and familial types. The sporadic cases have single site involvement; however, the familial forms appears to be inherited as an autosomal dominant trait with variable phenotypic expression which is character-ized by more expansile lesions and tend to occur in the younger subjects.14 Radiographically, these lesions appear radiolucent initially. With time, the lesion evolves to a mixed radiolucent radio opaque stage before progressing to a complete radio opaque stage. However there is absence of normal trabecular pattern of the bone in the lesion. The lesions are typically found in the tooth bearing areas of the jaws.15 The radiographic appearance of FOCD is very characteristic and very helpful in establishing the diagnosis. Com-

puted Tomography (CT) is the imaging modality of choice for differentiating FCOD from lesions exhibiting sclerotic appearance.16 The differen-tial diagnosis of FCOD includes Paget’s disease, chronic diffuse osteomyelitis, and Gardner’s syn-drome,17 enostosis or exostosis and odontogenic tumours, especially cemento ossifying fibroma.18

Several cases have been reported where misdi-agnosis and biopsy of the lesion has lead to second-ary infection/ osteomyelitis. It is therefore of prime importance to establish a firm diagnosis based on clinical and radiological features alone and to pre-vent any intervention in these lesions when asymp-tomatic. In our case, the radiological diagnosis of “this incidental finding was useful in prevent-ing implant placement and associated possible complications of secondary infection” was made.

Histopathology picture of an early lesion shows cellular fibrous tissue containing trabecu-lae of woven bone with cementum like califica-tion.11 With maturation, the ratio of fibrous tissue to mineralized materials are decreased and tra-beculae become more curvilinear structures19

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Table 1: Cases of florid osseous dysplasia reported in Indian population (J Clin Diagnostic Research 2017 Jan, Vol-11(1): ZD 21-ZD 24)

Secondary Author Age/Sex Site Symptoms osteomyelitis

Mangala M et al., 30/F, 38/F Bilateral posterior Present pain, swelling Absent mandible

Jerjes W et al., 27/F Bilateral posterior Absent Absent mandible

Shah V et al., 37/F Bilateral posterior Present pain, swelling Absent mandible

Bansal S et al., 14/M Bilateral Maxilla Absent Absent and mandible

Asnani U et al., 63/F Bilateral posterior Present swelling Absent maxilla

Premlatha BR et al., 37/F Bilateral posterior Absent Absent mandible

More CB et al., 60/F Bilateral Maxilla Present pain Absent and mandible

Mohammed RB et al., 52/F Bilaeral Maxilla Present pain, pus Present and mandible discharge (maxilla)

Mukherjee J et al., 42/F Bilateral posterior Absent Absent mandible

Das BK et al., 45/F Bilateral posterior Present pain Absent mandible

Grewal HK et al., 26/M Bilateral posterior Present pain, swelling Absent mandible

Shelly A et al., 64/F Bilateral Maxilla Present pain Absent and mandible

Mufeed A et al., 46/F Bilateral maxilla Present pain, pus Present and mandible discharge (maxilla)

Kunjir G et al., 35/F Bilateral maxilla Present swelling Absent and mandible

Chhabra N et al., 50/F Bilateral maxilla Absent Absent and mandible

Chattopadhyay et al., 41/M Bilateral maxilla Present pain, pus Present and mandible discharge (mandible)


Pandya et al

that progress to the radiopaque stage in which the cementum-like tissue coalesce to form large basophilic calcification with resting and reversal line.20 Lesions are composed of anastomosing bone trabeculae and layers of cementum like cal-cification embedded in fibroblastic background.21

Management of FOCD involves clinical and radio-graphic follow up. Until a definitive diagnosis is not obtained clinically and radiologically, any inva-sive dental treatment should not be considered.22

CONCLUSIONDiagnosis of FCOD mainly relies on clinical and radiological findings alone. A biopsy or surgi-cal intervention may lead to a risk of secondary infection such as osteomyelitis. The nature of the bone involved may show dysplastic change from the normal pattern and hence long term follow up with radiographic examination is recommended. There may be an associated risk of failure of osseointegration with a dental implant consider-ing the bony changes in these pathologies. l

Correspondence:Dr. Dhaval Pandya Email: [email protected]

DisclosureThe authors report no conflicts of interest with anything reported in this article.

References 1. MacDonald : a DS. Florid cemento osseous dysplasia: A systemic review.

Dentomaxillofac Radiol. 2003;32:141–9.

2. Das BK, Das SN, Gupta A, Nayak S. Florid cementoosseous dysplasia. Journal of Oral and Maxillofacial Pathology : JOMFP. India; 2013. p. 150.

3. Jerjes W, Banu B, Swinson B, Hopper C. Florid cemento-osseous dysplasia in a young Indian woman. A case report. Br Dent J. 2005;198(8):477–8.

4. Waldron CA. Fibro-osseous lesions of the jaws. J Oral Maxillofac Surg. 1993;51(8):828–35.

5. Pindborg J J, Kramer I R H TH. Histological typing of odontogenic tumours, jaw cysts and allied lesions. International histological classification of tumours. 1971. 32-3 p.

6. Kramer IRH, Pindborg JJ, Shear M. The WHO histological typing of odontogenic tumours: A commentary on the second edition. Cancer. 1992;70(12):2988–94.

7. Summerlin DJ, Tomich CE. Focal cemento-osseous dysplasia: a clinicopathologic study of 221 cases. Oral Surg Oral Med Oral Pathol. 1994;78(5):611–20.

8. Mehta RV KS. Floridcement-osseousdysplasia: A case report. Indian Dent Res Rev 2011. 2011;3:22–3.

9. Beylouni I, Farge P, Mazoyer JF, Coudert JL. Florid cemento-osseous dysplasia: Report of a case documented with computed tomography and 3D imaging. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics. 1998. p. 707–11.

10. Bencharit S, Schardt-Sacco D, Zuniga JR, Minsley GE. Surgical and prosthodontic rehabilitation for a patient with aggressive florid cemento-osseous dysplasia: A clinical report. J Prosthet Dent. 2003;90(3):220–4.

11. Speight PM, Carlos R. Maxillofacial fibro-osseous lesions. Current Diagnostic Pathology. 2006. p. 1–10.

12. Babaria U, Patel H, Pandya H, Dewan H, Bhavasar B, Thakkar D et al. Florid osseous dysplasia: A case repor. J Dent Sci 2011. 2011;2(10):1.

13. Said-al-Naief NA SE. Florid osseous dysplasia of the mandible: report of a case. Compend Contin Educ Dent. 1999;20:1017–9.

14. Young SK, Markowitz NR, Sullivan S, Seale TW, Hirschi R. Familial gigantiform cementoma: classification and presentation of a large pedigree. Oral surgery, oral medicine, and oral pathology. 1989. p. 740–7.

15. Singer SR, Mupparapu M, Rinaggio J. Florid cementoosseous dysplasia and chronic diffuse osteomyelitis Report of a simultaneous presentation and review of the literature. Journal of the American Dental Association (1939). 2005. p. 927–31.

16. Summerlin DJ, Tomich CE. Focal cemento-osseous dysplasia: a clinicopathologic study of 221 cases. Oral Surg Oral Med Oral Pathol. 1994;78(5):611–20.

17. J. H. Kim, B. C. Song, S. H. Kim, and Y. S. Park. Clinical, radiographic and histological findings of florid cemento-osseous dysplasia: a case report. Imaging Sci Dent. 2011;41:139–42.

18. Ariji Y, Ariji E, Higuchi Y, Kubo S, Nakayama E, Kanda S. Florid cemento-osseous dysplasia. Radiographic study with special emphasis on computed tomography. Oral Surg Oral Med Oral Pathol. 1994;78(3):391–6

19. Das BK, Das SN, Gupta A, Nayak S. Florid cementoosseous dysplasia. Journal of Oral and Maxillofacial Pathology : JOMFP. India; 2013. p. 150.

20. Brad WN, Douglass DD, Carl MA JE. Oral and maxillofacial pathology. 2nd ed. Philadelphia, Pennsylvania: saunders; 2002.

21. Gonçalves M, Píspico R, Alves FDA, Lugão CEB, Gonçalves A. Clinical, radiographic, biochemical and histological findings of florid cemento-osseous dysplasia and report of a case. Braz Dent J. 2005;16(3):247–50

22. Smith S, Patel K, Hoskinson AE. Periapical cemental dysplasia: a case of misdiagnosis. British dental journal. 1998. p. 122–3.

de Moraes et al

BACKGROUND: Adell et al. presented a longitu-dinal clinical study of the protocols proposed by Brånemark, where the clinical behavior of osseoin-tegrated implants was evaluated over 15 years. In this study, the authors confirmed the predictability and high success rate of this new modality of treat-ment, as well as analyzed its complications and fail-ures. Some authors have reported that overloading the implant-implant assembly can lead to biome-chanical failures, damage to biological structures and / or prosthetic components. The existence of dimensional tolerances, so that there is the coupling of the prosthetic components to the implants, allow the generation of micro-movements, which can lead to the fracture of the abutment fixing screws. Other authors carried out laboratory studies with maxi-mum compression tests to evaluate the behavior of implants with internal and external hexagon, found that the implants with internal anti-rotational pre-sented better fracture resistance of the abutment fixation screw. Therefore, the present work consists of an experimental study to analyze the mechani-cal behavior of two anti-rotational systems (inter-nal and external) and the fracture resistance of the osseointegrated implant abutment screw with vari-ous diameters using maximum compression tests

MATERIALS AND METHODS: Twelve angled abutments of 15° for cemented prosthesis were selected, nine with external anti-rotational and three with internal anti-rotational (Conexão Sistema de Prótese - São Paulo, Brazil). The abutments and the implants were acquired in the specialized trade,

being mixed and coupled to each implant in a random way. The implants were fixed in cylindrical bases of epoxy resin. To fix the abutments to the implants a manual torque wrench of the Dyna Torc brand was used, and a preload of 32 Ncm was applied to each bolt of abutments. The complete apparatus was placed on the EMIC test machine where an increasing load was applied, keeping the machine system moving at a speed of 1 cm / min. The load was applied on the long axis of the implant until the complete fracture of the abutment fixing screw. RESULTS: After the maximum compression tests it was observed that there was a plastic deforma-tion and fracture of the fixing screws of the abut-ments. In this way it was found macroscopically that the anti-rotational (hexagon) of both implant systems presented deformation. In a SEM analy-sis, it was possible to prove more details of the anti-rotational deformation. It is important to note that all fractured screws presented the fracture point between the first three threads.

CONCLUSIONS: 1. The abutment fixing bolts showed the fracture point on the first 3 threads; 2. The implants with internal anti-rotational showed a better resistance to fracture of the abutment fixing screw; 3. The implants with internal anti-rotational showed a greater defor-mation in the system in the abutment-implant coupling area, which suggests that this defor-mation occur before the fracture of the screw.

Analysis of the Mechanical Behavior of Components of Osseointegrated Implants Submitted to Maximum Compression

Dr. Nathalia Benevides de Moraes1 • Dr. Eduardo José de Moraes2 Carlos Nelson Elias3 • Luis Eduardo Benevides de Moraes4

1. Specialist in Prothses and Orla Implantology, IDM, Rio de Janeiro, Brazil

2. Oral Maxillofacial Sugeon and MSc in Oral Implantology, IDM, Rio de Janeiro, Brazil

3. MSc and Phd in Materials Science, IME, Rio de Janeiro, Brazil

4. Oral Maxillofacial Surgeon and Specialist in Oral Implantology, IDM, Rio de Janeiro, Brazil

Abstract

KEY WORDS: Dental implants, osseointegration, deformation, anti-rotation, stress

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de Moraes et al

INTRODUCTIONAdell et al.1 presented a longitudinal clinical study of the protocols proposed by Brånemark, where the clinical behavior of osseointegrated implants was evaluated over 15 years. In this study, the authors confirmed the predictability and high success rate of this new modality of treatment, as well as analyzed its complications and fail-ures. Among the problems observed over time, the mechanical complications associated with the fracture of components of the superstruc-ture were cited in the literature. Some authors2,3 have reported that overloading the implant-implant assembly can lead to biomechanical failures, dam-age to biological structures and/or prosthetic components. Haas et al.4 observed during the clinical follow-up of 56 unitary implants of the Brånemark system, after 1 year in function, that the most frequent complication was the pillar fixation screw fracture. McGlumphy et al.5 con-sidered that fracture of components of osseoin-tegrated implants is a clinical sign indicating that there are inappropriate forces on the superstruc-ture. The existence of dimensional tolerances, so that there is the coupling of the prosthetic components to the implants, allow the genera-tion of micro-movements, which can lead to the fracture of the abutment fixing screws. Several authors6,7,8 have verified that dimensional toler-ances in external hexagon implants vary in aver-age from 0.01 to 0.024 mm. The greater the mismatch in the coupling of the connections, the greater the instability of the system when sub-jected to the masticatory loads and favors the fail-ure of its components. Other authors9,10 carried out laboratory studies with maximum compres-sion tests to evaluate the behavior of implants with internal and external hexagon, found that the

implants with internal anti-rotational presented better fracture resistance of the abutment fixa-tion screw. Therefore, the present work consists of an experimental study to analyze the mechani-cal behavior of two anti-rotational systems (inter-nal and external) and the fracture resistance of the osseointegrated implant abutment screw with vari-ous diameters using maximum compression tests.

MATERIALS AND METHODS Twelve angled abutments of 15° for cemented prosthesis were selected, nine with external anti-rotational and three with internal anti-rotational (Conexão Sistema de Prótese, São Paulo, Brazil). The abutments were coupled to implants as fol-lows: Three implants of 3.3 mm diameter per 10 mm length (anti-rotational external), Three implants 4.0 mm in diameter per 10 mm length (anti-rota-tional external), Three implants 5.0 mm in diameter per 10 mm length (anti-rotational external), Three implants 5.0 mm in diameter per 10 mm length (internal anti-rotational). The abutments and the implants were acquired in the specialized trade, being mixed and coupled to each implant in a random way. The implants were fixed in cylindri-cal bases of epoxy resin (1109 resin) with polym-erization time of 3 hours at room temperature. This material was selected because it presented the modulus of elasticity close to that of the 13.7 GPa bone. Initially the resins were cast in PVC tubes and after polymerization of the resin. The cylindrical base was cut in a lathe keeping at the following measures: 24 mm in diameter and 38 mm in height. Then, in the center of each resin base, perforations in the diameters of 3.3.4.0, 5.0 mm and 10 mm depth were realized with an angle of 90°. The implants were placed in the open cavity and fixed to the base with resin fol-

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lowing the curing specifications previously men-tioned for the preparation of the specimens. To fix the abutments to the implants a manual torque wrench of the Dyna Torc brand was used, and a preload of 32 Ncm was applied to each bolt of abutments. The complete apparatus was placed on the EMIC test machine where an increasing load was applied, keeping the machine system moving at a speed of 1 cm/min. The load was applied on the long axis of the implant until the complete fracture of the abutment fixing screw.

RESULTSThe samples were divided into 4 groups, and the groups 1 to 3 were composed of implants with external anti-rotational and group 4 for implants with internal anti-rotational system (Con-exão Sistema de Prótese, São Paulo, Brazil). As shown in Table 1, the implants of group 1 pre-sented a failure at an average value of 107.6 kgf, while the implants of group 2 had an average value of 158.9 kgf. In groups 3 and 4 composed

of implants of 5.0 mm in diameter, the implants with internal anti-rotational presented an aver-age value of 182.3 kgf, whereas those of exter-nal anti-rotational ones presented 160.00 kgf. In the analysis of average torque the best results were also of implants with internal anti-rotational, which presented an average value of 2005.3 kgf.

After the maximum compression tests it was observed that there was a plastic defor-mation and fracture of the fixing screws of the abutments. In this way it was found mac-roscopically that the anti-rotational (hexagon) of both implant systems presented deforma-tion. In a SEM analysis, it was possible to prove more details of the anti-rotational deforma-tion, as shown in figures 1 to 4. It is important to note that all fractured screws presented the fracture point between the first three threads.

Table 1: Results of the Maximum Compression Test

Height or Maximum Media Antirotational Depth of Strength Torque Samples System Antirotational (kgf) (kgf.mm)

Group 1 External 1.0mm 107.6 1183.6



Group 4 Internal 1.5mm 182.3 2005.3


de Moraes et al

DISCUSSIONThe mechanical problem most frequently men-tioned in the literature11,12,13,14 which involves the components of the osseointegrated implants, is related to the fixation screws of the superstruc-tures. Several authors11,12,13,14 considered that a large number of complications and failures pre-sented by implant-supported rehabilitations,

when submitted to masticatory loads, are due to the loosening of the fixation screws of the supra-structures, subsequently promoting fracture of the component. However, De Moraes et al.15 stated that the application of a preload of 32 Ncm to the abutment fixing screw is enough to prevent loos-ening of the screw and consequently to prevent its fracture. Binon16 analyzed several types of anti-

Figure 1: Implant with anti-rotational internal implant showing in higher magnification.

Figure 2: Internal anti-rotational showing deformation after maximum compression test.

Figure 3: Implant with deformed external anti-rotational system after maximum load test.

Figure 4: External anti-rotational showing deformation, in higher increase.

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rotational systems manufactured today, consid-ered the region of coupling of the abutment with the implant, as a critical area for the success of the rehabilitation, in function of the tensions generated in this region during the masticatory process. The author reviewed concepts regard-ing anti-rotational systems, and suggested modifications. An increase in the height of the external anti-rotations and the widening of the external hexagonal base, to promote a friction between the abutment and the hexagon reduces the microgaps between the connections. In the present work, the occurrence of deformation in the anti-rotational system of all the samples was verified through the MEV observations of the samples of the maximum load test. This cor-relation suggests that the overload in the abut-ment -implant complex promotes deformation of the hexagonal and precedes the fracture of the abutment fixation screw. Binon16 stated that anti-rotational devices, besides prevent-ing rotation in unitary prostheses, are extremely important for the stability of the suprastructure and, consequently, for the success of reha-bilitation. It should be remembered that in the present work it was considered that the loss of hexagonal integrity, contributed to the frac-ture of the screw of the pillar of sample 1, compatible with the conclusion of this author.

It is important to note that the maximum com-pression tests performed in this study were aimed at evaluating the strength of the abut-ment screw, as well as the behavior of the abut-ment-implant joint. The applied methodology was based on studies previously performed by other authors 10,17 who used the maximum load tests to analyze the mechanical behavior of implants

CONCLUSIONSWithin the limitations of this work and the need for similar conclusive studies to be car-ried out one can conclude the following:1. The abutment fixing bolts showed the

fracture point on the first 3 threads.2. The implants with internal anti-rotational

showed a better resistance to frac-ture of the abutment fixing screw.

3. The implants with internal anti-rotational showed a greater deformation in the sys-tem in the abutment-implant coupling area, which suggests that this deformation occur before the fracture of the screw. l

Correspondence:Dr. Eduardo Jose de MoraesAdress: Rua Figueiredo Magalhães, 437 apto 701 – Copacabana – Rio de Janeiro- BrazilZip code: 22031-011e-mail: [email protected]


de Moraes et al

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Adell, R., Lekholm, U., Branemark, P. I. A 15-year study of osseointegrated

implants in the treatment of edentulous jaw. Int. J Oral Surg 1981; 10: 387- 416.

2. Rangert, B., Krough, H. J., Langer, B., Roekel, N. V. Bending overload and implant fracture: a retrospective clinical analysis. Int. J. Oral Maxillofac Implants, 1995; 10: 326-334.

3. Skalak, R. Stress transfer at the implant interface. J Oral Implantol, 1988; 13: 581-593

4. Haas, R., Mendorf-Pouilly, N., Mailath, G.. Brånemark, P-I. The single tooth implants: a preliminary report of 76 implants. J Prosthet Dent 1995; 73: 274-279.

5. McGlumphy, E. A.; Mendel, D.A.; Hollonay, J.A. Implant screw mechanics Dental implants, 1998; 42:71-89.

6. Binon, P.P. Evaluacion de Tres Sistemas de Implantes Dentales con Hexagonos Externos. Implant Dent 1996; 5: 235-248.

7. Elias, C.N; Vieira, L.H. ; Lima, J.H.C.. Tolerâncias Dimensionais em Implantes Dentários. Revista Brasileira de Odontologia 1999; 5: 234-238.

8. Ma, T.; Nicholls, J.I.; Rubenstein, J.E.. Tolerance Measurements of Various Implant Components. Int J.Oral Maxillofac Implants, 1997; 12 : 371-375.

9. Balfour, A. ; O’brein,G.R. Comparative Study of Antirotational Single Tooth Abutments.J Prosthet Dent 1995; 73: 36-43

10. Mollersten, L; Lockowandt, P. ; Linden, L-A. Comparison of Strength and Failure Mode of Seven Implant Systems: An in vitro Test. J Prosthet Dent. 1997; 78: 582-591.

11. Jemt, T., Linden, B., Lekholm, U. failures and complications in 127 consecutively placed fixed partial prostheses supported by Brånemark implants: from prosthetic treatment to first annual check-up. Int. J. Oral Maxillofac Implants 1992; 7: 40-44.

12. Jemt, T.,.; Petterson, PA., A 3-year follow-up study on single treatment. J Dent, 1993; 21: 203-208.

13. Kallus, T.,; Bessing, C.Loose gold screws frequently occur in full-arch prostheses supported by osseointegrated implants after 5-years. Int.J.Oral Maxillofac Implants, 1994; 9: 169-178.

14. Laney, W. R., Jemt, T., Harris, D.. Osseointegrated implants for single-tooth replacement: progress report from a multicenter prospective study after 3 years. Int. J. Oral Maxillofac Implants, 1994; 9: 49-54.

15. De Moraes, E.J; Elias, C.N.; De Moraes, M.C.C.S.B. Fadiga de Componentes protéticos de implantes osseointegrados.Revista Brasileira de Odontologia. 2006; 63:138-140.

16. Binon, P.P Implants and Components : Entering the New Millenium. Int.J.Oral Maxillofac Implants 2000; 15: 76-94 .

17. Patterson, E. A; Bureguette, R.L., Thoi, H.. Distribution of load in an oral prosthesis system: an in vitro study. Int. J Oral Maxillofac Implants, 1995; 10: 552-560

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Soolari et al

Dental insurance policies typically include two free cleanings per year, a service performed by dental hygien-

ists; these professionals, therefore, bring new patients to the dental practice. Since most patients desire and can probably afford a teeth-cleaning session, they are likely to schedule one (chrisad.com). The patients’ self-driven moti-

vation is a valuable opportunity for an office to invest in a strong dental hygiene program, and proper planning and staffing will make such a program an investment yielding high returns. The following article examines the role of dental hygienists in developing long term relationships with patients that can benefit dental practices.

Developing a Long-Term Relationship with Patients: The Role of the Dental Hygienist

Nafiseh Soolari, RDH, BA1 • Soulayman Diallo, MS2

Ahmad Soolari, DMD, MS3

1. Registered Dental Hygienist. Soolari Dentistry. Silver Spring, Maryland, USA

2. Founder, 5Focus Management. Washington DC, USA

3. Private practice. Soolari Dentistry. Silver Spring, Maryland, USA

Abstract

KEY WORDS: Dental hygiene, dental practice, practice management

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Soolari et al

Dental insurance policies typically include two free cleanings per year, a service performed by dental hygienists; these professionals, there-fore, bring new patients to the dental practice. Since most patients desire and can probably afford a teeth-cleaning session, they are likely to schedule one (chrisad.com). The patients’ self-driven motivation is a valuable opportunity for an office to invest in a strong dental hygiene program, and proper planning and staffing will make such a program an investment yielding high returns. The value in any dental practice is related to the number of active dental hygiene patients,1 and a full 40–60% of the office’s pro-duction comes from dental hygiene services.2

The dental hygiene program is the backbone of any practice because during teeth-cleaning sessions, a comprehensive evaluation can be performed to address all oral health problems. In addition, the office that offers extended hours of operation on evenings and weekends for teeth-cleaning sessions will enjoy patient loyalty and new and repeat business. If patients like what they see (office) and feel (degree of cleanliness), they will return for additional treatments when needed. One way to market a practice is to have a strong dental hygiene program; through the program, the patient will come to see the office as a trustworthy practice that provides personal-ized care. The practice that offers a free clean-ing to new patients may lose money on the first appointment, but impressing the patient favor-ably will almost always guarantee a return visit for repeat or other treatments. In contrast with appointments for periodontal surgery, which is perceived by most patients as stressful and anx-iety-producing, the hygiene patients look forward to their appointment. The hygiene appointment

costs less than the periodontal surgery appoint-ment, and is typically kept by the patient, while it is common for surgery patients to change or can-cel appointments because of financial consider-ations or the stress and anxiety associated with surgery. Surgery patients expect pain and swell-ing following treatment, in contrast with hygiene patients, who usually feel good after treatment. The patients’ expectations affect their percep-tions and attitudes toward the office visit, as well as their attendance rates and levels of post-treat-ment compliance. The dental hygienist’s approach to the patient-hygienist interaction can promote patient commitment to self-care,3 as the treatment approach is preventive rather than corrective.

Tooth loss is mainly attributable to caries or periodontal disease, and both causes are related to microorganismal conditions in the oral cavity. These conditions are generally associated with patients’ diet, behavior, manner in which food and beverages are consumed, the diet’s sugar content, activities prior to brushing, smoking, frequency of dental visits, fluoridation, suscep-tibility to infection, and effective home care. As periodontal appointments—whether surgical or non-surgical—can be stressful to patients, they are not the best time to engage in nutritional counsel-ing, but the hygiene appointment is. Patients are more relaxed during teeth-cleaning sessions, and patient education on smoking cessation, dietary changes, and occlusal guard consideration is more likely to be effective. Treatment accep-tance is more likely when the patient feels good about the treatment plan offered, the office envi-ronment, and communication with the staff, and has received information on the proposed pro-cedures and care.4 During the hygiene appoint-ment, the interaction between patients and dental

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hygienists can yield an overall treatment plan that patients accept and have a hand in designing. The dental hygienist is well-positioned to pro-mote preventive interventions such as offering toothpaste recommendations, teaching children to floss, and advising adult patients to use fluo-ride rinses.5 In addition, dental hygienists should be trained and empowered to detect chronic health problems, such as obstructive sleep apnea, and educate the patients on ways to resolve these issues.6 Dental hygienists who are given the time, equipment, and technology resources to educate patients on the value and benefits of treatments build patients’ trust and loyalty.2

Reinders et al.7 reported that the major-ity of dentists they polled appeared to favor an extended scope for dental hygienists, although dentists may not perceive the true breadth of hygienists’ role in patient care.8 While performing oral examinations and health assessments is part of the educational preparation of dental hygien-ists, the scope of their work is not standardized in private practice.9 Some dental practices may be under-utilizing a valuable resource, and this unintentional lapse can directly affect the office’s financial bottom line. Empowering the hygien-ist benefits the dental practice directly. Train-ing hygienists to administer local anesthesia, for example, has been shown to positively affect both patient satisfaction and the quality of care.10

The key to the dental hygienist’s success, however, is consistent and standardized train-ing. Dental hygienists’ knowledge of caries risk assessment has been shown to require improve-ment.11 Clovis et al.12 found that hygienists’ opinions on treatment protocols varied widely, owing to lack of understanding or misinforma-tion regarding current recommendations in the

field. Optimizing the effectiveness of the den-tal hygienist will therefore require modifica-tion of the standard approaches in hygienist training programs and continuing education.12

The success of a dental practice rests on patients’ acceptance of treatment plans.13 Prac-tices can maximize production and patient accep-tance by adopting the following protocols: 1) Set the next dental hygiene appointment imme-diately after the treatment, while the patient is still in the office; the hygiene reappointment rate has been shown to be associated with the prac-tice’s annual revenue;14 2) Confirm the appoint-ment 48 hours in advance by phone, text, or email;1 3) Write and rehearse patient-education scripts, so that patients feel fully informed and accept the proposed treatment plan; 4) Offer financing options;13 5) Offer extended hours for dental hygiene appointments, including eve-nings and weekends; 6) Accept a wide range of dental insurance plans; 7) Ensure the clean-liness of the office and a friendly, comfortable environment; 8) Train and empower your den-tal hygienists to perform comprehensive patient assessments and to make treatment recom-mendations without high-pressure sales tactics. In addition, it is important to develop a proto-col for filling voids in the hygienist’s schedule.2

The dental hygienist is an integral mem-ber of the practice team. The hygiene appoint-ment is a practice-builder, and should form the core of preventive care. The overall treatment plan will be accepted by patients if they like their experience at the practice: Atmosphere, cleanli-ness, friendly and professional front-desk staff, a hygienist who listens and responds to their concerns, and the tangible benefits they derive from their hygiene appointment. Investing in the


Soolari et al

practice’s hygiene program reduces the need for corrective periodontal surgery, while simul-taneously building a flourishing practice with a strong, motivated, and loyal patient following. l

Correspondence:Dr. Ahmad [email protected]

AcknowledgmentsThe authors would like to thank Dean Meyer, PhD, ELS for providing writing support.

DisclosureThe authors report no conflicts of interest with anything in this article.

References1. Levin R. Data bite: Survey finds improving dental

hygiene recall rates a primary growth opportunity for practices in 2017. Dentistry IQ. 2017. http://www.dentistryiq.com/articles/apex360/2017/02/data-bite-survey-finds-improving-hygiene-recall-rate-a-primary-opportunity-for-dental-practice-growth-in-2017.html. Accessed February 9, 2018.

2. Jameson C. Scheduling for higher efficiency, production and profit. Dentrix Magazine. 2017;29(3):14-18.

3. Calley KH, Rogo E, Miller DL, Hess G, Eisenhauer L. A proposed client self-care commitment model. J Dent Hyg. 2000;74(1):24-35.

4. Soolari A, Soolari N, Shams H, Albandar JM. Factors Influencing Patients’ Acceptance of Treatment Plans at a Private Periodontal Practice. J Implant Adv Clin Dent. 2015;7(8):39-46.

5. Widström E, Tillberg A, Byrkjeflot LI, Skudutyte-Rysstad R. Chair-side preventive interventions in the Public Dental Service in Norway. Br Dent J. 2016;Aug 26;221(4):179-85. doi: 10.1038/sj.bdj.2016.601.

6. Kornegay EC, Brame JL. Obstructive Sleep Apnea and the Role of Dental Hygienists. J Dent Hyg. 2015;89(5):286-92.

7. Reinders JJ, Krijnen WP, Onclin P, van der Schans CP, Stegenga B. Attitudes among dentists and dental hygienists towards extended scope and independent practice of dental hygienists. Int Dent J. 2017;67(1):46-58. doi: 10.1111/idj.12254.

8. Pritzel SJ, Green TG. Working relationship between dentists and dental hygienists: their perceptions. J Dent Hyg. 1990;64(6):269-72.

9. Gibson-Howell JC, Hicks M. Dental hygienists’ role in patient assessments and clinical examinations in U.S. dental practices: a review of the literature. J Allied Health. 2010;39(1):e1-6.

10. DeAngelis S, Goral V. Utilization of local anesthesia by Arkansas dental hygienists, and dentists’ delegation/satisfaction relative to this function. J Dent Hyg. 2000;74(3):196-204.

11. Francisco EM, Johnson TL, Freudenthal JJ, Louis G. Dental hygienists’ knowledge, attitudes and practice behaviors regarding caries risk assessment and management. J Dent Hyg. 2013;87(6):353-61.

12. Clovis JB, Horowitz AM, Kleinman DV, Wang MQ, Massey M. Maryland dental hygienists’ knowledge, opinions and practices regarding dental caries prevention and early detection. J Dent Hyg. 2012;86(4):292-305.

13. Levin R. Research Report: Case acceptance. Dental Economics. 2015;105(7). http://www.dentaleconomics.com/articles/print/volume-105/issue-7/practice/research-report-case-acceptance.html. Accessed February 9, 2018.

14. Smith A. There’s a hole in your hygiene: How reappointment rates dramatically affect dental practice growth. Dentistry IQ. 2016. http://www.dentistryiq.com/articles/apex360/2016/09/there-s-a-hole-in-your-hygiene-how-reappointment-rates-dramatically-affect-dental-practice-growth.html. Accessed February 9, 2016.

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Volume 9, No. 4 may/JuNe 2017

Xenograft Socket Preservation

The MIMS Technique for Gingival Grafting


Volume 9, No. 2 February 2017

Updated Primer on Amnion-Chorion Allografts

Computer Guided Full Arch Immediately Loaded

Dental Implants


Volume 9, No. 6 August 2017

Impacted Canine Replacement

6 Year Multi-Center Study onOsseofuse Dental Implants


Volume 9, No. 7 September 2017

Biotype Tissue Change at Second Stage Implant Surgery

Immediate vs. Early Loading of Short Implants

fibrous dysplasia - jiacd · fd. the monostotic form of fibrous dysplasia is the most common,...

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