canadian journal of journal canadien de restorative …...computerized dentistry 46...

ISSN

1916

-7520

Dental Materials /Matériaux dentaires

Gestion de cabinet /Practice Management

Computerized Dentistry /Dentisterie numérique

Prosthodontics /Prosthodontie

PEER-REVIEWED –JOURNAL - REVUE DES PAIRS

VOLUME 2-3SUMMER / ÉTÉ 2009

www.cardp.ca

Canadian Journal ofRestorative Dentistry & ProsthodonticsThe official publication of the Canadian Academy ofRestorative Dentistry and Prosthodontics

Publication officielle de l'Académie canadiennede dentisterie restauratrice et de prosthodontie

Journal canadien dedentisterie restauratrice et de prosthodontie

Canadian Journal ofRestorative Dentistry & ProsthodonticsThe official publication of the Canadian Academy ofRestorative Dentistry and Prosthodontics

Publication officielle de l'Académie canadiennede dentisterie restauratrice et de prosthodontie

Journal canadien dedentisterie restauratrice et de prosthodontie

www.andrewjohnpublishing.com

PUBLICATIONS AGREEMENT # 40025049

3Canadian Journal of Restorative Dentistry and Prosthondontics

VOL. 2, NO. 3 • SUMMER / ÉTÉ 2009

Official Publication of the CanadianAcademy of Restorative Dentistry andProsthodontics

Publication officielle de L’Académie canadienne dedentisterie restauratrice et de prosthodontie

EDITOR-IN-CHIEF/RÉDACTEUR EN CHEFHubert Gaucher

Québec City, Québec | [email protected]

ASSOCIATE EDITORS/RÉDACTEURS ASSOCIÉSEmmanuel J. Rajczak

Hamilton, Ontario | [email protected] Andrea

Chester, Nova Scotia | [email protected] Nimchuk

Vancouver, British Columbia | [email protected]

SECTION EDITORS/RÉDACTEURS DE SECTION

Occlusion and Temporo-Mandibular Dysfunctions/Occlusion et dysfonctions temporo-mandibulaires

John NasedkinVancouver, British Columbia | [email protected]

Implant Dentistry/Dentister ie implantaireDwayne Karateew

Vancouver, British Columbia | [email protected] Dentistry / Dentister ie esthétique

Paresh ShahWinnipeg, Manitoba | [email protected]

Dental Technology / French to comePaul Rotsaert

Hamilton, Ontario | [email protected]

MANAGING EDITOR/DIRECTEUR DE LA RÉDACTION

Scott [email protected]

CONTRIBUTORS/CONTRIBUTEURSBegüm Akkayan, Hubert Gaucher, Bruce Kleeberger

Jacques Marois, Domenic Morielli, Burcu Sahin

ART DIRECTOR/DESIGN /DIRECTEUR ARTISTIQUE/DESIGN

Binda [email protected]

SALES AND CIRCULATION COORDINATOR/COORDONATRICE DES VENTES ET DE LA DIFFUSION

Brenda [email protected]

TRANSLATION/TRADUCTIONSanaa Elkhattabi / Susan Collins, MA, Certified Translator

(ATIO) / Gladys St. Louis

ACCOUNTING / COMPTABILITÉSusan McClung

GROUP PUBLISHER / CHEF DE LA DIRECTIONJohn D. Birkby

[email protected]_____________________________________________

CJRDP/JCDRP is published four times annually by Andrew JohnPublishing Inc. with offices at 115 King StreetWest, Dundas, On, CanadaL9H 1V1. We welcome editorial submissions but cannot assume respon-sibility or commitment for unsolicited material. Any editorial material,including photographs that are accepted from an unsolicited contributor,will become the property of Andrew John Publishing Inc.FeedbackWewelcome your views and comments. Please send them to Andrew JohnPublishing Inc., 115 King Street West, Dundas, On, Canada L9H 1V1.Copyright 2009 by Andrew John Publishing Inc. All rights reserved.Reprinting in part or in whole is forbidden without express written con-sent from the publisher.Individual CopiesIndividual copies may be purchased for a price of $19.95 Canadian. Bulkorders may be purchased at a discounted price with a minimum orderof 25 copies. Please contact Ms. Brenda Robinson at (905) 628-4309 orbrobinson@ andrewjohnpublishing.com for more information and specif-ic pricing.

Publications Agreement Number 40025049ISSN 1916-7520

Return Undeliverable Canadian Addresses to:

AJPI 115 King Street West, Suite 220Dundas Ontario L9H 1V1

Ah, but! We soon learn that we arebeing closely watched from all sides!

Professional and government authorities,not to mention the public at large, expectus to be competent and up to date,among other virtues. Lifelong learningisn’t a new concept, by any means.Confucius, More, Dewey, Rousseau, andso many others, consider lifelong learningessential to the pursuit of happiness. Onecannot approach happiness withoutimproving oneself and one cannotimprove without change. And one cannotchange without … education.So even though buzzwords like globaliza-tion and specialization are incentive enoughto want to pursue one’s knowledge in anygiven field, such intangibles as openness,curiosity, self-improvement, and under-standing are the real deal clinchers.Today’s dental practitioner can expect todedicate at least 1,000 hours to continuingeducation (CE) in the course of his/her pro-fessional life. Countless CE activities andvenues are offered to us. Have you checkedthe Web lately? Why, we could conceivablystay home and let the so-called coursescome to us, if we wanted to. There’s noshortage of passive, path-of-least-resistancecontent being peddled out there.

But there comes a time when most of us feelthe need to reach out and get involved inour own development, interact with ourpeers, tweak our proficiencies. Study clubsare a case in point.For many, such worthy local endeavoursnaturally lead to the next level, whereby thepractitioner strives to share, contribute, andexchange knowledge with colleagues out-side the immediate clinical surroundings.This impulse to get involved on a widerscale reflects a desire to establish universalconsensus on clinical procedures, materialsand technologies and impact the professionper se.Professional associations, through theirscientific programs, offer such opportunitiesto their members, to pursue their ideals, totake from and give their respective expertiseto their colleagues.A Jobboom Internet survey1 (1,763 respon-dents) in the Province of Québec had thepublic identify the best 25 jobs. Dentistrywas their number one choice due to thefollowing criteria, by order of importance:(1) Professional development; (2)Autonomy; (3) Income; (4) Decision mak-ing participation; (5) Team work; and (6)Flexible schedules. Not bad! It is obviousthat our patients perceive dental profession-

MESSAGE FROM THE EDITOR-IN-CHIEFMESSAGE DU RÉDACTEUR EN CHEF

ContinuingEducation:

Perceptions and Rewards

School graduations are often the first occasions to hear about our own con-tinuing education. We haven’t even set foot outside university confines andthe dean is already telling us, in his allocution, that we owe it to our patientsand to ourselves to be perpetual students. Yet there we are, thinking thatwe’re out of the woods, eagerly expecting to navigate through life and careerwithout any further assistance.

MESSAGE FROM THE EDITOR-IN-CHIEF

als as enjoying a stimulating and interestingwork environment. If it weren’t for dentistsprojecting their continuing professionalenthusiasm through professional develop-ment, how else would the public know whata terrific profession ours is?Herein, you will read Mr. Jacques Marois’second practice management article ondental leadership describes the attributes ofthe Magician and Fairy archetypes, andtheir ongoing thirst for discovering andlearning. The author explains the pivotalrole each archetype plays in humanresource and management skills.Dr. Bruce Kleeberger's case reports in“Using Provisional Restorations to GuideTissue Healing for Predictable ProstheticAesthetics” details the efficient manner ofplanning and executing temporary restora-tions for varied clinical situations in orderto shape the gingival tissue for optimal

health and esthetics.Computer assisted implant surgeries arebecoming a common and widespread prac-tice standard. Dr. Domenic Morielli, usingcase reports, demonstrates the advantagesand the learning curve associated to thiscontemporary standard of care.In Dr. Begüm Akkayan et al’s dental materi-al in vitro study, “The Effect of DifferentSurface Treatments on the Bond Strength ofTwo Esthetic Post Systems,” quartz fiber-reinforced and zirconium posts are evaluat-ed in regards to bond strengths that variousavailable chairside surface treatments canprovide when using MPD containing resincement. Resulting SEM data from push-outtests are analyzed and de-bonding failurepatterns are compared.This issue invites you, members and guests,to our Annual Scientific Meeting and SocialProgram that will be held in vibrant

Montréal come September. Moreover, a wel-come initiative in the form of simultaneoustranslation has been made available on site.In addition to the academy’s top-notch sci-entific program, this Montréal meetingoffers a pre-meeting CAD/CAM course,numerous social and sport activities andindustry exhibits that are sure to make thisrestorative and prosthodontics meeting thecontinuing education experience of theyear! Be sure to stop by the CJRDP/JCDRPdesk to meet your editorial team.1 Le plus beau métier Dentiste; Le Journal

de Québec2008;XLI(357):1–4.

Dr. Hubert GaucherEditor-in-Chief

Journal canadien de dentisterie restauratrice et de prosthodontie Été 20094

CJRDP Editorial Board/Le comité de rédaction JCDRP

Editor-in-Chief/Rédacteur en chefHUBERT GAUCHERQuébec City, Québec

Associate Editors/Rédacteurs associés

EMMANUEL J. RAJCZAKHamilton, Ontario

MAUREEN ANDREAChester, Nova Scotia

DENNIS NIMCHUKVancouver, British Columbia

Section Editors/Section éditeursOcclusion andTemporo-MandibularDysfunctions/Occlusion et Dysfonctionstemporo-mandibulaire

JOHN NASEDKINVancouver,British Columbia

ImplantDentistry/DentisterieimplantaireDWAYNE KARATEEWVancouver,British Columbia

Esthetic Dentistry /Dentisterie esthétiquePARESH SHAHWinnipeg, Manitoba

Dental Technology /Technologie dentairePaul RotsaertHamilton, Ontario

V O L U M E 2 • I S S U E 3

Content/Sommaire

FEATURES/ARTICLES

3 Message from the Editor-in-Chief8 Message du rédacteur en chef

SUMMER / ÉTÉ 2009

INDICATES PEER REVIEWED/INDIQUE REVUE DES PAIRS

Dental Materials /Matériaux dentaires22 The Effect of Different Surface

Treatments on the Bond Strength ofTwo Esthetic Post SystemsBy Begüm Akkayan, DDS, PhD, Burcu Sahin, DDS,and Hubert Gaucher, DDS,MScD

Gestion de cabinet30 Dentiste et leader : Générez le

succèsPar Jacques Marois, MSc

Practice Management34 Dentist and Leader: Generate

SuccessBy Jacques Marois, MSc

Prosthodontics / Prosthodontie38 Using Provisional Restorations

to Guide Tissue Healing forPredictable Prosthetic EstheticsBy Bruce Kleeberger, DDS

Computerized Dentistry46 Computer-Assisted Implant

Surgery: Evolving Standards of CareBy Domenic Morielli, BSc, DDS, Certified Oral andMaxillo-Facial Surgeon

Dentisterie numérique52 Chirurgie d’implant assistée par

ordinateur: Des normes de soins enévolutionPar Domenic Morielli, BSc, DDS, Chirurgien buccalet maxillo-facial agrée

2246 38

About the CoverMarché Bonsecours, opened in 1847. It oncehoused Montreal City Hall between 1852 and1878 and also briefly accommodated theParliament of United Canada in 1849. Today,the market houses outdoor cafés, restaurantsand boutiques.

Au sujet de la page couvertureLe Marché Bonsecours a ouvert ses portesen 1847. Entre 1852 et 1878 il abritait l'Hôtelde ville de Montréal puis, brièvement, leParlement du Canada Uni en 1849.Aujourd'hui le site rassemble cafés, restau-rants et boutiques.

7Canadian Journal of Restorative Dentistry and Prosthondontics

13 INDUSTRY NEWS / NOUVELLES DE L'INDUSTRIE17 CARDP CONFERENCE INFORMATION

,

MESSAGE DU RÉDACTEUR EN CHEF

Hélas non! Nous ne tardonspas à reconnaître que nous

sommes surveillés de tous côtés.Les organismes professionnels etles instances gouvernementales,sans oublier le public, s’attendententre autres, à ce que nous puis-sions faire preuve de compétenceet être à jour dans nos connais-sances.L’éducation qui s’étend sur une vie

entière n’est pas un concept nou-veau. Pour Confucius, More,Dewey, Rousseau et bien d’autresencore, la formation continue estessentielle à la poursuite du bon-heur. On ne peut espérer le bon-heur sans s’améliorer soi-même eton ne peut s’améliorer sans change-ment. Et sans l’éducation…on nepeut changer.Même si les mots du jour, tels glob-alisation et spécialisation nous inci-tent à vouloir approfondir nos con-naissances dans un domaine donné,les aspects intangibles, comme l’ou-verture d’esprit, la curiosité, l’auto-amélioration et la compréhension,

en demeurent les vrais argumentsdécisifs.De nos jours, le praticien dentairepeut s’attendre à consacrer au moins1 000 heures en éducation continuedurant sa vie professionnelle. Denombreuses activités d’éducationcontinue nous sont offertes. Avez-vous navigué le Web récemment?Nous pouvons maintenant prendretoutes sortes de cours dans le con-fort de notre demeure si nous levoulons. Ce ne sont pas les cours demoindre effort qui manquent.Mais il vient un temps lorsque laplupart d’entre nous ressentons lebesoin de jouer un rôle actif dansnotre propre développement, d’in-teragir avec nos collègues et con-frères et de perfectionner nos com-pétences. Les cercles d’études ensont un exemple type.Pour plusieurs, de telles entreprisesméritoires mènent naturellement àun autre niveau, où le praticien viseà partager, collaborer et échangerses connaissances avec ses collèguesen dehors de son milieu clinique

immédiat. Cette motivation àvouloir s’impliquer reflète un désird’établir un consensus universel surles procédures cliniques, le matérielet les technologies, et aussi d’avoirun impact sur la profession propre-ment dite.Les associations professionnelles,par l’entremise de leurs programmesscientifiques, offrent la possibilité àleurs membres de poursuivre leuridéal, d’apprendre de leurs collègueset également de partager leurs con-naissances et compétences avec cesderniers.Dans un sondage sur l’Internet1

mené par Jobboom (1763 répon-dants) au Québec, on demandaitd’identifier les 25 meilleures profes-sions. La Médecine dentaire estarrivée au premier rang en raisondes critères suivants, par ordred’importance : (1) développementprofessionnel; (2) autonomie;(3) revenu; (4) participation à laprise de décision; (5) travaild’équipe; et (6) horaire flexible.Pas si mal! Il est évident que nospatients perçoivent que les profes-sionnels dentaires trouvent leurmilieu de travail intéressant et stim-ulant. Si ce n’était pas des dentistesqui projettent leur enthousiasmeconstant par le perfectionnementprofessionnel, comment le publicsaurait-il que notre profession est siformidable?Vous pourrez lire ci-après le deux-ième article de gestion de la pra-tique sur le leadership rédigé par

Éducation continue :Perceptions et récompenses

Bien souvent, c’est au cours de la remise des diplômes que l’onentend parler d’éducation continue. N’ayant pas encore exploré lemonde du travail, le Doyen de notre Faculté nous révèle déjàdans son allocution que nous devons continuer d’étudier pour lebienfait de nos patients et pour nous-mêmes. Nous sommes là,croyant que le pire est déjà passé, et que nous pourrons main-tenant poursuivre notre vie et notre carrière sans aide aucune.

8 Journal canadien de dentisterie restauratrice et de prosthodontie Été 2009

Canadian Journal of Restorative Dentistry and ProsthondonticsSummer 2009 Canadian Journal of Restorative Dentistry and Prosthondontics 9

MESSAGE DU RÉDACTEUR EN CHEF

Monsieur Jacques Marois. Il décrit les qual-ités des archétypes du magicien et de la féeet leur soif de découverte et d’acquisition dusavoir. L’auteur explique le rôle de base quechaque archétype joue dans les ressourceshumaines et les compétences en gestion.Les rapports de cas du Dr Bruce Kleebergerdans « L’utilisation des restaurations provi-soires pour guider la cicatrisation pour uneprosthodontie prévisible » discutent de lamanière efficace de planifier et d’effectuerdes restaurations temporaires pour diverscas cliniques afin de façonner le tissu gingi-val pour une santé optimale et unemeilleure esthétique.Les chirurgies implantaires assistées parordinateur sont de plus en plus courantes.Le Dr Domenic Morielli, en se servant derapports de cas, démontre les avantagesassociés à cette technologie contemporaine.

Dans l’étude in vitro sur le matériel dentaireintitulée « L’effet de différents traitements desurface sur la force de liaison de deux sys-tèmes de pivots esthétiques », le Dr BegümAkkayan et ses collaborateurs ont évaluédes pivots renforcés au quartz et en zirconi-um se rapportant à la force de liaison quedivers traitements de surface disponiblespeuvent fournir lorsqu’on utilise de la résinecontenant du MDP. Les données obtenuespar microscopie électronique à balayage(MEB) des épreuves de contrainte parexpulsion sont analysées et les essais ratésde liaison sont comparés.Nous profitons de l’occasion dans cenuméro pour convier les membres et leursinvités à assister à notre Congrès scien-tifique annuel ainsi qu’au programme socialqui auront lieu à Montréal en septembre. Deplus, les participants pourront profiter de la

traduction simultanée mise à leur disposi-tion.En plus du programme scientifique de pre-mier plan de l’Académie, un cours deCAO/FAO sera offert avant le Congrès àMontréal, en plus d’activités sociales etsportives et des expositions qui feront de cetévénement la meilleure expérience en for-mation continue de l’année! Ne manquezpas de venir rencontrer l’équipe de rédac-tion de CJRDP/JCDRP.

1 Le plus beau métierDentiste; Le Journalde Québec2008;XLI(357):1–4.

Dr Hubert GaucherRédacteur en chef

3M ESPE Announces theElipar S10 LED Curing Light

Sleek, stainless steel model deliversquality and confidence

13Canadian Journal of Restorative Dentistry and ProsthondonticsSummer 2009

INDUSTRY NEWS /NOUVELLES DE L' INDUSTRIE

LONDON, ON. – 3M ESPE introduces the Elipar S10LED curing light featuring a one-piece stainless steelhousing that brings together form and function in arobust new face to the curing light market. Expandingupon 3M ESPE’s more than 30 years of experience indeveloping curing light technology, the Elipar S10 LEDcuring light has been designed to inspire confidence withits unmatched fea-tures for convenienceand versatility of use.The Elipar S10 LEDcuring light from 3MESPE possesses aunique, ergonomicV-shape body thatprovides a comfortable grip from various angles, allowingany user’s technique to be best accommodated. Alongwith superior aesthetic appeal, the small size offers anexcellent weight balance. The shield of the device servesas a flat surface rest for roll-off protection; and the wandis cordless, making handling and performing procedureseasier. In addition to the extraordinary steel design andimproved maneuverability, the Elipar S10 LED curinglight from 3M ESPE has an innovativemagnetic lightguide fixture for quick attachment and removal of thelight guide, allowing for easy insertion, removal and posi-tioning.With the capacity to operate in complete silence, theElipar S10 LED curing light from 3M ESPE includes aswitch-off option for timer and beep signals, and does nothouse a noisy fan. A unique timer on the device offers arange of five, 10, 15, 20, and 120 second cure modes, anda tack-cure mode. The tack-cure mode gives reproducible

one-second light pulses in response to pushing and hold-ing down the trigger button, making removal of excesscements easier, safer and more predictable.This first class wand features the latest in high powerLED technology, offering up to double the optical powerof other leading devices—1200 mW/cm² of intensity outof a wide, 10 mm tip. The tip offers easy positioning thatcovers up to an 80% larger surface area than the standardLED light guide. The optical set-up of the Elipar S10LED curing light, comprising 3M’s nano-reflector tech-nology, is optimized to deliver a more focused light out-put. Even at a distance of seven millimeters, the EliparS10 LED curing light from 3M ESPE offers up to threetimes more intensity than comparable devices, enablingan improved depth of cure. Used as directed, it is capableof performing a five second cure for shades A3 andlighter, and enables polymerization of compatible materi-als in half of the manufacturer’s recommended time.The Elipar S10 LED curing light from 3M ESPE operateswith a high-performance Lithium-ion battery that can beeasily inserted and removed, much resembling a flash-light. The battery allows light output to remain consistentthroughout its charge, and does not weaken during pro-longed curing procedures. This advanced battery tech-nology provides 60 minutes of cure time before recharg-ing is needed. Although heat management is typicallychallenging in high-power devices that do not have a fan,continuous runtime is a benefit of the Elipar S10 LEDcuring light from 3M ESPE, as it can run a remarkableseven minutes in a sealed housing.

www.3MESPE.ca

If you have a press release you would like us toconsider for Industry News, please forward them to

Scott Bryant, managing editor at:[email protected]

Si vous avez un communiqué de presse à soumettreaux Nouvelles de l’Industrie, veuillez le transmettre àScott Bryant, Gestion de la Rédaction:[email protected]

INDUSTRY NEWS / NOUVELLES DE L' INDUSTRIE

PRO-V COAT is the first-of-its-kind hydrogel separatingagent allowing the clinician to utilize the beneficialImmediate Dentin Sealing (IDS) Technique without therisk of the provisional material bonding to the toothstructure or contaminating the tooth substrate. Pro-VCoat promotes bond maturity and decreased sensitivity.Immediate Dentin Sealing Clinical Advantages:• Patient Comfort – less sensitivity during provision-

alization, limited need for anesthesia during finalcementation, and reduced post-op sensitivity

• Maximum Tooth Structure Preservation –

increased retention for short clinical crowns ortapered preps

• Separate Conditioning of Enamel and Dentin– wet bonding to dentin, and dry bonding toenamel at final placement

• Eliminates the need for use of temporarycements

Magne, Pascal, DMD, PhD, “Immediate DentinSealing: A Fundamental Procedure for IndirectBonded Restorations,” Inside Dentistry 2006;20–25.www.biscocanada.com

ProDrive Systems AnnouncesThree New Dealers to North

American Distribution ChannelProDrive Systems announces distribution among nine dealers

within the American Dental Cooperative.


Pro-V Coat is Now Available,Exclusively from Bisco Dental

Products Canada Inc.

Montreal, June 29, 2009 ProDriveSystems announced today the addition ofthree new dental suppliers to the coast-to-coast network of US distributors. A1Handpiece Specialists, Dailey Dental Supplyand Hewitt Dental represent the newestmembers of the American DentalCooperative to distribute ProDrive products(handpieces, burs and upgrade replacement

turbines for leading brand handpieces).The growing demand for ProDrive amongthe American Dental Cooperative (ADC)demonstrates the success and overwhelm-ingly positive response from customers.Richard St-Pierre, president and CEO ofProDrive Systems added, ProDrive contin-ues to surpass every benchmark since ourcommercial launch in January 2009. Not

only do we offer a game-changing productthat will revolutionize dentistry, we alsooffer our dealers extensive technical train-ing, sales support and a collaborative mar-keting program. The support of our dealernetwork is among the reasons whyProDrive has sustained extraordinarygrowth and success.

www.prodrivesystems.com

Canadian Journal of Restorative Dentistry and ProsthondonticsSummer 2009 17

LʼHôtel Le Westin, jeudi, le 24 septembre, 2009 – 13h00 à 17h00 (Places limitées) ; Les frais 295,00$

DENTAL MATERIALS / MATÉRIAUX DENTAIRES

The Effect of Different SurfaceTreatments on the Bond Strength

of Two Esthetic Post SystemsBy Begüm Akkayan, DDS, PhD, Burcu Sahin, DDS, and Hubert Gaucher, DDS,MScD

ABSTRACTThe purpose of this study was to evaluate the effect of different surface treatments on thebond strength of fibre-reinforced and zirconium posts cemented with MDP-containing resincement (methacryloyloxydecyl dihydrogen phosphate). Eighty intact,maxillary human canineswere selected for this study. The crowns of each root were sectioned 2 mm above the cemento-enamel junction. Following endodontic treatment, the roots were divided into two groups of 40teeth. Root canal preparations were performed for quartz fibre-reinforced posts, (DT Light Post)(n = 40) and zirconium posts (CosmoPost) (n = 40). The groups were further divided into foursubgroups in order to receive the following three different surface treatments: (1) Airborne par-ticle abrasion with Al2O3 of 50 µm diameter (AIRB), (2) Silane coupling agent application (SIL),(3) Tribochemical silica coating (TSC). The posts of the fourth subgroups received no treatmentand served as control groups. Following cementation, the roots were embedded into acrylicresin moulds and each root was cut horizontally to produce four 2-mm-thick sections throughpost-dentin specimens. Push-out tests were performed at a cross-head speed of 0.5 mm/min.Data analysis was made with one-way ANOVA and multiple comparison tests. Characteristicde-bonded failure surfaces were examined with a scanning electron microscope (SEM). Thehighest bond strength values were obtained with tribochemical silica coating (TSC groups) for


About the AuthorsBegüm Akkayan, DDS, PhD, is professor, Department of Fixed

Prosthodontics, Faculty of Dentistry, Istanbul University, Istanbul-Turkey. Her fields of interest are esthetic post systems, adhesives, andall-ceramic systems. She can be reached at: [email protected].

Burcu Sahin, DDS, is a PhD student, Department of FixedProsthodontics, Faculty of Dentistry, Istanbul University, Istanbul-

Turkey. She can be reached at: [email protected].

Hubert Gaucher, BA, DDS,MScD, is the scientific director of theCanadian Dental Research Institute (CDRI/ICRD). He can be reached

at: [email protected].

Begüm Akkayan,DDS, PhD

Burcu Sahin, DDS Hubert Gaucher,BA, DDS,MScD

,

,

,

Current esthetic post materials, such as fibre-reinforced resincomposite or zirconia, offer preferred optical properties for

highly esthetic restorations. Zirconia posts, made from fine-graindense tetragonal zirconium polycrystals (TZP), were developedin the late 1980s possessing high flexural strength and fracturetoughness.1–4 Glass- and quartz-fibre reinforced post systems,with elastic moduli comparable to that of dentin, were introducedlater.5–7 Fibre-reinforced post systems are mostly composed of ahighly cross-linked polymer resin matrix, inorganic fillers, andreinforcing fibres of carbon, glass, or quartz.8,9 Translucentquartz-fibre post systems were then introduced as a method to

AKKAYAN ET AL.


achieve optimal esthetic by allowing the use of adhesive systemsand light-polymerized luting agents.10

These non-metallic posts, are intended to be adhesively bondedto the root canal. It has been reported that the adhesive resin cementsystems have the ability to adhere to dentin and the post with a rein-forcing effect.11 The type of resin cement utilized had a significantinfluence on bond strengths to fibre reinforced posts.12 Chemicalaffinity between post and luting material is extremely important forachieving high bond strength.13 Different resin luting agents havebeen proposed for cementing tooth collared posts and can generallybe divided into conventional bisphenol A glycidyl methacrylate

both of the post systems tested. Airborne particle abrasion (AIRB group) resulted with the sec-ond highest bond strength value in quartz fibre-reinforced post groups. No significant differ-ences were recorded for the quartz fibre-reinforced post group which received silane couplingagent (group SIL) compared with the control group (p > .05). Within the limitations of this invitro study it can be concluded that different surface treatments and physical characteristics ofthe post systems have an effect on the bond strength of quartz fibre-reinforced and zirconiumposts cemented with adhesive resin cements. The results of this study could also serve as effec-tive measures for clinical applications.

RÉSUMÉLe but de cette étude est d’étudier l’effet des différents traitements de surface sur la force de laliaison renforcée par des fibres des tenons et les tenons de zirconium consolidés avec du liantde résine synthétique contenant du DPM (Dihydrogèno phosphate methacryloyloxydecylique).Quatre vingt supérieures canines humaines sont sélectionnées pour cette étude. Les couronnesde chaque racine sont sectionnées de 2 mm au dessus de la jonction amélo-cementaire. Suiteau traitement endodontique, les racines sont divisées en 2 groupes de 40 dents. Les prépara-tions des canaux radiculaires ont été faites pour recevoir des tenons quartz renforcés par desfibres, (DT Light Post) (n = 40) et des tenons de Zirconium (CosmoPost) (n = 40). Les groupes ontété encore divisés en quatre sous groupes afin de recevoir les trois différents traitements de sur-face suivants : (1) Abrasion aéroportée des particules avec le Al2O3 de 50 µmde diamètre (AIRB),(2) Application de l’agent de couplage Silane (SIL), (3) Revêtement en silice Tribochimique (RST).Les tenons du quatrième sous groupe n’ont pas reçu de traitement et ont servit comme groupede contrôle. Après scellement, les racines ont été enfouies dans des moules en résine acryliqueet chaque racine a été coupée horizontalement pour produire quatre sections d’épaisseur de 2-mm à travers des spécimens post dentines. Les épreuves de contraintes par expulsion ont étéréalisées à une vitesse de 0.5 mm/min. L’analyse des données a été réalisée avec ANOVA à sensunique et de multiples épreuves comparatives. Les caractéristiques des cautionnées surfacessont examinées avec un microscope électronique à balayage (MEB). Les valeurs les plus élevéesde la force des liaisons sont obtenues avec le revêtement en silice tribochimique (Groupe RST)pour les deux systèmes des tenons testés. L’abrasion aéroportée des particules (Le groupe AIRB)a obtenu la deuxième plus haute valeur de force de la liaison dans le groupe de tenons quartzrenforcés de fibres. Aucune différence significative n’a été enregistrée dans le groupe de tenonsquartz renforcés de fibres qui ont reçu l’agent de couplage silane (groupe SIL) comparativementau groupe de contrôle (p > .05). Malgré les limitations de cette étude in vitro, on peut conclureque les différents traitements de surface et les caractéristiques physiques des systèmes detenons ont un effet sur la force de la liaison renforcée par des fibres et les tenons de zirconiumconsolidés avec du liant de résine synthétique. Les résultats de cette étude peuvent aussi servircomme mesures efficaces pour les applications cliniques.

THE EFFECT OF DIFFERENT SURFACE TREATMENTS ON THE BOND STRENGTH OF TWO ESTHETIC POST SYSTEMS

(BIS-GMA)- based resin luting agents andso-called adhesive resin luting agents con-taining functional monomers such as 10-methacryloxydecy dihydrogen phosphate(10-MDP).14 The resin cements containingthe adhesive monomer MDP are reportedto demonstrate the ability to adhere to dif-ferent types of restorative materials, includ-ing fibre posts.14,15

Failure of posts mainly includes debond-ing of the post, fracture of the root, andfracture of the post. Considering thatdebonding is a frequent type of failure withrestorations of various post systems, thebond strength between posts and lutingagent should be considered an importantfactor. Many studies have focused attentionon different ways of improving the interfa-cial bond strength between posts and resin-based materials. The surface characteristicsof esthetic posts, which can be modifiedthrough various techniques, have beenreported to influence bonding of resin lut-ing agents.16–20

The air abrasion modification is basedon air-particle abrasion with different parti-cle sizes. Recent studies have shown thatairborne-particle abrasion with aluminaparticles changes the structure of the sur-face by plastic deformation and roughening,resulting in an increased surface area and avolume loss of material.21,22

The use of aluminum-trioxide particlesmodified with silica for airborne-particleabrasion was introduced in the late 1980s.23

This procedure resulted in the embeddingof the silica-coated alumina particles on thesurface, thereby welding a silicate layer ontothe surface by means of the high spot heatproduced by the blasting pressure. This sili-cate-coated surface is chemically more reac-tive to resin when an application of thesilane coupling agent is utilized. The CoJetsystem (3M ESPE, Seefeld, Germany) is achairside system with an intraoral airborne-particle-abrasion device (DentoPrep;Ronvig, Daugaard, Denmark); the systemincludes a tribochemical coating of the sur-face with silica-modified aluminum-oxideparticles (CoJet Sand; 3M ESPE) followedby silanization (ESPE Sil 3M ESPE). TheCojet treatment has been found to enhancethe bond strength of resin cement toesthetic post systems of different composi-tion.20,24–26

Silane coupling agents are hybridorganic-inorganic compounds and promotechemical bonding between dissimilarorganic and inorganic materials through

dual reactivity.27–29 Inorganic groups ofsilane molecule form covalent siloxanebonds with the silica of the ceramic materi-al; meanwhile, the organic functional partcan polymerize with the organic matrix ofthe composite resin material.30,31

3-Methacryloyloxpropyltrimethoxysilane(3-MPS) is a commonly used silane mole-cule in dental applications.32 The applicationof silane coupling agents also increase thesurface energy and wetting ability of thesurface.33

The purpose of this study was to evalu-ate the effect of different surface treatmentson the bond strength of quartz fibre-rein-forced and zirconium post systems cement-ed with MDP containing resin cement.

Material and MethodsEighty maxillary canines extracted for peri-odontal reasons, with similar root lengthand free of cracks, caries, and fractures wereselected and stored in 0.9% saline solution(Baxter Healthcare Corporation, Deerfield,IL). Teeth with excessive root curvaturewere not selected. All teeth were sectionedperpendicular to their long axes, 2 mmabove the cemento-enamel junction with alow-speed saw (Isomet, Buehler Ltd, LakeBluff, IL) utilizing water-cooling. The rootcanals were mechanically enlarged usingendodontic files (Hero 642, Micro Mega SA,Geneva, Switzerland) operated at 400 rpmunder a constant irrigation with 3% NaOCl.The enlarged canals were rinsed with dis-

tilled water, dried with paper points, andobturated with gutta-percha cones using lat-eral condensation (Gutta Percha Points,United Dental Mfgs, West Palm Beach, FL)using a eugenol-free sealer (AH 26,Dentsply DeTrey, Konstanz, Germany).The post spaces were prepared 24 hoursafter completing endodontic procedures.Gutta-percha was removed with a warmendodontic plugger (Kerr Sybron Corp,Romulus, MI, USA) leaving 3 mm of theendodontic filling in the apical portion.Subsequently, the post spaces were preparedin two main groups of 40 specimens withthe special preparation burs of each postsystem. The materials used in this study arepresented in Table 1.Size 3 quartz fibre posts were used forgroup 1 (n = 40) and zirconia posts of 1.70mm in diameter were used in group 2(n = 40) (Figure 1). Each group were fur-ther divided into four subgroups in order toreceive the following three different surfacetreatments; (1) Group AIRB, Airborne par-ticle abrasion with Al2O3 of 50 µm diame-ter at 2.8 bar pressure for 20 seconds from adistance of 10 mm, (2) Group SIL, Silanecoupling agent application. Silane wasapplied with a brush and allowed to air dryfor 5 minutes, (3) Group TSC, Tribochemicalsilica coating. The posts were abraded withan intra-oral airborne particle abrasiondevice using 30 μm silica modified Al203particles. The abrasive was applied perpen-dicular to the surface at 2.8 bar pressurefrom a distance of 10 mm for 20 seconds.

Journal canadien de dentisterie restauratrice et de prosthodontie24 Été 2009

Figure 1. Esthetic post systems used; CosmoPost (left) – D.T. Light Post (right).

25

AKKAYAN ET AL.

The post surfaces were then coated with thesilane coupling agent of the Cojet systemand allowed to air dry for 5 minutes. Theposts of the fourth subgroups received notreatment and served as control groups. Theexperimental groups with different surfacetreatments are listed in Table 2.All posts (n = 80) were marked at a distance

of 12 mm from their respective apical ends.A line was drawn around the post at thislevel in order to standardize the cementedpost lengths. All posts were cemented withthe same adhesive system (Clearfil LinerBond 2V, Kuraray Co Ltd, Osaka, Japan)and dual-polymerizing resin luting agent(Panavia F 2.0, Kuraray Co Ltd, Osaka,

Japan). One drop of each primer A and Bwas mixed and applied to the post spacewalls with a microbrush (Microbrush X;Microbrush Corp, Grafton, WI) for 30 sec-onds. Excess primer solution was removedwith paper points, and the primer was gen-tly air dried. Bond A was applied with amicrobrush, excess adhesive solution wasremoved with paper points, and the bond-ing agent was light polymerized for 20 sec-onds using a halogen light unit with 800mW/cm2 intensity (Optilux 501; Kerr/Demetron Research Corp, Danbury, CT)with the tip of the light unit directly in con-tact with the post space. For the cementa-tion of the posts, equal amounts of a dual-polymerized resin luting agent paste baseand catalyst were mixed and applied to thepost space walls with a lentulo spiral instru-ment (Dentsply Maillefer, Ballaigues,Switzerland). The posts were then seated tofull depth in the prepared spaces using fin-ger pressure. The excess luting agent wasimmediately removed with a small brush.After the initial chemical polymerization,the resin luting agent was light polymerizedfor 20 seconds by transilluminating theposts, keeping the tip of the light unit indirect contact with the coronal end of theposts. After the cementation procedures, all

Table 1.Materials selected for this study

Material Manufacturer Type CompositionCosmoPost Ivoclar Vivadent, Zirconia post ZrO2 90%,HfO2 4.5%, Y2O3

Schaan, Liechtenstein 5.4%, Al2O3 0.5%DT Light Post Bisco Inc., Schaumburg, IL Translucent quartz fibre post Quartz fibres 62%

Epoxy resin 38%Cojet Sand 3M ESPE, Seefeld, Germany Tribochemical silica-coating particles Silica modified Al2O3 particles

of 30 µmESPE Sil 3M ESPE, Seefeld, Germany Silane coupling agent 3-MPS, ethanolKorox 50 Bego, Bremen, Germany Sandblasting material Al2O3 particles of 50 µm 99.6%Clearfil Porcelain Kuraray Co Ltd, Osaka, Japan Silane coupling agent 3-MPS, bisphenol-a-Bond Activator polyethoxy-dimethacrylateClearfil Liner Bond 2V Kuraray Co Ltd, Osaka, Japan Self-etching primer Primer A and B:MDP, HEMA,

hydrophilic methacrylate,dl-camphorquinone,N-diethanol-p-toluidine, H2O

Clearfil Liner Bond 2V Kuraray Co Ltd, Osaka, Japan Light polymerizing bonding agent Bonding A: BIS-GMA,HEMA,dl-camphorquinone,N-diethanol-p-toluidine,silanated colloidal silica

Panavia F 2.0 Kuraray Co Ltd, Osaka, Japan Dual polymerizing resin luting agent Paste A: Silanated silica,microfiller,MDP, dimethacrylates,photo/chemical initiatorPaste B: Silanated barium glass,surface-treated NaF, dimethacrylates,chemical initiator

Table 2. Experimental groups with different surface treatments and estheticpost systems

Post Types Surface Treatments Luting AgentAIRB, airborneparticle abrasion (n = 10)

ZIRCONIA SIL, silane couplingagent ( n = 10)

n = 40 TSC, tribochemicalsilica coating ( n = 10)CONT, no surface PANAVIA F 2.0treatment (n = 10)AIRB, airborne particle n = 80abrasion (n = 10)

QUARTZ SIL, silane couplingFIBER agent (n = 10)

n = 40 TSC, tribochemicalsilica coating (n = 10)CONT, no surface treatment (n = 10)

Summer 2009 Canadian Journal of Restorative Dentistry and Prosthondontics

specimens were stored in distilled water for24 hours before testing.Every sixth root was embedded into anacrylic resin mould using a speciallydesigned rectangular shaped stainless steelsupporter. Each resin mould was thenattached to the arm of a low-speed diamondsaw (Isomet; Buehler Ltd, Lake Bluff, IL)and sectioned perpendicular to the longaxis under water-cooling. From each speci-men, four post/dentin sections wereobtained starting from the most cervicalpart of the root, each 2 mm thick. Due tothe different apical designs of the experi-mental posts, 4 mm of post segments at theapical end were left aside. The exact upperand lower diameters of the post segmentswere determined using a digital micrometer(Mitutoya, Tokyo, Japan) with 0.01 mmaccuracy according to this test design. Eachstudy group of 10 roots provided a total of40 test specimens.

Push-out testing was performed and thepush-out bond strength values were calcu-lated as per a previous study by Akgungörand Akkayan.34 The post segments wereloaded with a conical plunger, 1.1 mm indiameter, centered on the post (Figure 2).Loads were applied from an apical to cervi-cal direction with a universal testingmachine (Autograft AG-IS 5K-N Shimadzu,Kyoto, Japan) at a crosshead speed of 0.5mm/min. The peak force, at the point ofextrusion of the post segment from the testspecimen, was taken as the point of bondfailure and recorded in Newtons (N). Push-out bond strength values in MPa were thencalculated by dividing this force by thebonded area of the post segment. Mean val-ues were compared with one-way analysisof variance (ANOVA), followed by TukeyHSD test (p > .05) for post-hoc compar-isons. Student’s t-test was performed toassess the significance within groups.Adhesive, cohesive and mixed types of fail-ures, which occurred during de-bonding ofthe post sections at the post-resin-dentininterface, were determined and representa-tive SEM (JSM 6400; JOEL, Tokyo, Japan)micrographs were taken.

ResultsThe mean push-out bond strength valuesand standard deviations (SDs) of the dif-ferent groups are shown in Table 3 andFigure 3.Among the surface treatments tested, thetribochemical silica coating (group TSC)resulted in the highest bond strength valuesfor both of the post systems tested (21.24 ±

1.91 MPa zirconia / 24.62 ± 1.71 MPaquartz fibre). For quartz fibre reinforcedposts, the second highest bond strengthvalue was obtained with airborne particleabrasion (group AIRB) (20.08 ± 1.14 MPa)whereas the application of silane couplingagent (group SIL) had the second highest

significant effect for zirconia post group(17.02 ± 1.61 MPa). The application of air-borne particle abrasion (group AIRB) onzirconia posts (10.12 ± 1.23 MPa) and theapplication of silane coupling agent (groupSIL) on quartz fibre reinforced posts (14.28± 1.66 MPa) had no significant effect com-pared to untreated post groups (groupCONT) (10.68 ± 1.23 MPa zirconia / 13.96± 1.14 MPa quartz fibre).Group TSC, group AIRB, and group CONTdemonstrated statistically higher bondstrength values for quartz fibre reinforcedpost groups compared to zirconia postgroups within the post group comparisons(p < .001). Group SIL was the only groupthat resulted in statistically higher bondstrength values for the zirconia post groupaccording to within-group comparisons(p < .001).

DiscussionThe hypothesis of the present study wasconfirmed; i.e., the bond strengths to postswere significantly affected by the investigat-ed surface treatments and posts of differentcomposition.

Particle abrasion with alumina particlesis used for many types of restorations andresults in increased roughness of the surfaceand increased surface area.21,22 Physicalabrasion with alumina particles is a wellestablished technique which generates aclean surface and introduces surface rough-ness and porosity. Such physical action isreported to increase surface area and bond-ing strength to posts.33,35

In the present study, the effect of air-borne-particle abrasion on the bondstrength of zirconia posts to resin cementsrevealed no statistical significance com-pared to the control group (p > .05). A for-mer study reported that airborne particleabrasion or grinding may result in thedevelopment of flaws inside the microstruc-ture of the zirconia ceramic material.21,36

Bitter et al21 reported increased higher bondstrength values for zirconium posts after



Table 3.Mean push-out bond strengths and standard deviation (SD) of theexperimental groups

Surface Treatment Groups Mean (MPa) SDZirconia Quartz Fiber Zirconia Quartz Fiber

AIRB 10.12 C 20.08B 1.23 1.40SIL 17.02 B 14.28C 1.61 1.66TSC 21.24A 24.62A 1.91 1.71CONT 10.68C 13.96C 1.23 1.14Same letters show no significant difference (p>0.05)

Figure 2. The post segments were loadedwith a conical plunger for the push-out test.

Figure 3.Mean push-out bond strength val-ues and trust interval at 95% for all groups.


airborne particle abrasion. However air-borne particle abrasion was performed withalumina particles of 110 µm in their studywhereas, in other studies15,20 including thepresent study particles of 50 µm were used.This different finding may be explained bythe fact that the large particle size mayresult in more micromechanical retention.21

The representative SEM micrographs of thistest group, demonstrating mostly adhesivefailure at the dentin-resin interface, sup-ported the findings of the study (Figure 4).

The effect of airborne particle abrasionapplication has been rarely described forfibre posts. Sahafi et al.20 reported that alu-mina sandblasting increased the bondstrength to glass fibre posts. Similar resultswere obtained in the study by Cheleux etal.33 The results of the present study arecomparable with the above studies in whichairborne particle abrasion significantlyincreased the bond strength values inquartz fibre-reinforced post groups. Thisresult can be explained by the role of sand-blasting abrasion, mainly affecting the resinmatrix rather than the post fibres, therebyincreasing the post surface area.

Silane solutions are hybrid organic-inor-ganic compounds that can establish adhe-sion between organic and inorganic matri-ces by means of an intrinsic dual reactivity.37

A chemical coupling at the post-resincement interface is only possible betweenthe resin cement and exposed fibres or fillerparticles of the post. It has been reportedthat no bonding is expected to occurbetween the methacrylate based resin of thecements and the epoxy resin matrix ofquartz fibre reinforced posts due to the dif-ferences in chemistry.38 The effect of silaneapplication on the bond strength betweenfibre posts and resin cements revealed nostatistical significance in the present study.Perdigao et al.35 only applied silane with no

AKKAYAN ET AL.

prior surface preparation producing nonsignificant results as were obtained as in thepresent study. The representative SEMmicrographs of this test group demonstrat-ed mostly adhesive failure at the post-resininterface (Figure 5). It was conjectured thatthe silica fibre surfaces need to be freshlyexposed, preferably by physical abrasion inorder to benefit from the silane couplingeffects. The creation of strong siloxanebonds effectively increased the adhesionvalues. Recently published studies revealedpromising results in conditioning prefabri-cated epoxy resin-based fibre reinforcedposts with different solutions such as potas-sium permanganate and hydrogen peroxidefollowed by silanization.39

Zirconium-oxide posts are not silicabased; therefore, chemical silica-silanebonds cannot be established as the chemicalbonding to ceramic surface is based on thereaction between the silica content of theceramic material and the silane couplingagent.40 Moreover, the application of acidicagents such as phosphoric or hydrofluoricacid to zirconium posts will not create asufficiently roughened surface for enhancedmicromechanical retention.41 Kern andWegner24 evaluated different adhesionmethods and their durability after long-term storage of 150 days and repeated ther-mocycling. According to their study, silaneapplication resulted in an initial bond thatfailed spontaneously after simulated aging.There was a significant difference in themean bond strength values of zirconia postgroup which received silane coupling agentcompared with the control group (p < .001)whereas no significant differences wererecorded for the quartz fibre-reinforcedpost groups (p > .05) for the present study.This could be explained by better wettabilityof the silane coupling agent on the zirconiapost surface. Comparable results may be

achieved if durability of the bond strengthswere also evaluated.

Silica coating techniques are proposed toincrease the surface silica content and toestablish chemical silica-silane bonding.42

The surface of quartz fibre reinforced postwith a cross-linked polymer matrix isreported to be well polymerized and only asmall reactivity is left for free-radical poly-merization bonding. The fact that the poly-mer phase cannot be dissolved by adhesiveresin also avoids the possible inter-diffusionbonding mechanism. In agreement withpreviously reported studies of the adhesionbetween post and cement,18,20 this studyrevealed improved post-cement adhesionafter tribochemical silica-coating for two ofthe post systems tested. This system alsoserves as a micromechanical interlockingfor post retention.43 The failure analysisrevealed mostly cohesive failure withincement followed by mixed failure type forthe TSC group instead of adhesive failures(Figure 6 and 7).

It has been also reported that the type ofcement used significantly influences theretention values of the post systems of dif-ferent composition. Asmussen et al.44 relat-ed this finding by differences in the corre-

Figure 4. Representative SEM micrograph ofAIRB zirconia group, demonstrating adhesivefailure at the dentin-resin interface (x 25).

Figure 5. Representative SEM micrograph ofSIL quartz fibre group, demonstrating adhe-sive failure at the post-resin interface (x 25).

Figure 6. Representative SEM micrograph ofTSC quartz fibre group, demonstrating cohe-sive failure within resin cement (x 30).

Figure 7. Representative SEM micrograph ofTSC zirconia group, demonstrating mixed fail-ure at the dentin-resin interface (x 25).

of prefabricated posts on bonding of resincement. Oper Dent 2004;29:60–68.

16. Magni E,Mazzitelli C, Papacchini F, et al.Adhesion between fiber posts and resinluting agents: A microtensile bondstrength test and an SEM investigationfollowing different treatments of the postsurface. J Adhes Dent 2007;9:195–202.

17. Asmussen E, Peutzfeldt A, Sahafi A.Bonding of resin cements to post materi-als: influence of surface energy character-istics. J Adhes Dent 2005;7:231–34.

18. Ohlmann B, Fickenscher F, Dreyhaupt J, etal. The effect of two luting agents, pre-treatment of the post, and pretreatmentof the canal dentin on the retention offiber-reinforced composite posts. J Dent2008;36:87–92.

19. Balbosh A, Kern,M. Effect of surface treat-ment on retention of glass fiber endodon-tic posts. J Prosthet Dent 2006;95:218–23.

20. Sahafi A, Peutzfeldt A, Asmussen E,Gotfredsen K. Bond strength of resincement to dentin and to surface-treatedposts of titanium alloy, glass fiber, and zir-conia. J Adhes Dent 2003;5:153–62.

21. Bitter K, Priehn K,Martus P, Kielbassa AM.In vitro evaluation of push-out bondstrengths of various luting agents totooth-collared posts. J Prosthet Dent2006;95:302–10.

22. Kern M,Thompson VP. Sandblasting andsilica coating of glass-infiltrated aluminaceramic: volume loss,morphology andchanges in the surface composition. JProsthet Dent 1994;71:453–61.

23. Peutzfeldt A, Asmussen E. Silicoating:evaluation of a newmethod of bondingcomposite resin to metal. Scand J DentRes 1988;96:171–76.

24. Kern M,Wegner SM. Bonding to zirconiaceramic: adhesion methods and theirdurability. Dent Mater 1998;14:64–71.

25. Xible AA, Jesus Tavarez RR, Araujo CRP,BonachelaWC. Effect of silica coating andsilanization on flexural and composite-resin bond strengths of zirconia posts: Anin vitro study. J Prosthet Dent2006;95:224–29.

26. Valandro LF, Yoshiga S,Melo R, Galhano G.Microtensile bond strength between postand a resin cement: effect of post surfaceconditioning. J Adhes Dent 2006;8:105–111.

27. Kato H,Matsumura H, Ide T, Atsuta M.Improved bonding of adhesive resin tosintered porcelain with the combinationof acid etching and a two-liquid silaneconditioner. J Oral Rehabil 2001;28:102–108.

28. Shimada Y, Yamaguchi S, Tagami J.Microshear bond strength of dual curedresin cement to glass ceramics. DentMater 2002;18:380–88.

29. Taira Y, Yanagida H,Matsumura H, et al.



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spondence of surface energy characteristicsof the posts and cements. Previous studiesreported increased bond strengths of resincements containing functional phosphatemonomers.12,21,27,45 MDP monomer is able toform durable chemical bonds withZrO2,46,47 whereas the silane coupling agentacts to increase the wettability of post mate-rial.33,40 Sahafi et al.20 reported that MDPcontaining resin exhibited a comparableeffect on bond strength values for airborne-particle abrasion and the Cojet treatment.

Within the limitations of this in vitrostudy it can be proposed that different sur-face treatments and physical characteristicsof the post systems have an effect on thebond strength of quartz fibre-reinforcedand zirconium posts cemented with adhe-sive resin cements. Nevertheless, further invitro studies focusing on various combina-tions of surface treatments and differenttypes of adhesive bonding systems andcements should be conducted for providinglong term clinically effective results. Theresults of this study could also serve aseffective measures for clinical applications.

ConclusionWithin the limitation of this in-vitro study,the following conclusions may be drawn:1. The highest bond strength values were

obtained with tribochemical silicacoating (group TSC) for both of thepost systems tested.

2. Airborne particle abrasion (groupAIRB) resulted in having the secondhighest bond strength value in quartzfibre-reinforced post groups.

3. No significant differences wererecorded for the quartz fibre-rein-forced post group which received asilane coupling agent (group SIL)when compared with the controlgroup.

4. Significantly higher initial bondstrength values for the control groupswere obtained for quartz fibre-rein-forced posts compared to zirconiumposts according to the within groupanalysis.

5. It could be speculated from these vari-ous control groups that adhesivelycemented quartz fibre-reinforcedposts with no surface treatmentappear to be more retentive.

DisclosureThe authors declare no competing financialinterests.

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35. Perdiago J, Geraldeli S, Lee, IK. Push-out

bond strengths of tooth-collared postsbonded with different adhesive systems.Am J Dent 2004;17:422–26.

36. Lawn BR, Deng Y, Lloyd IK, et al. Materialsdesign of ceramic-based layer structuresfor crowns. J Dent Res 2002;81:433–38.

37. Matinlinna JP, Lassila LV, Özcan M,Yli-Urpo A. An introduction to silanes andtheir clinical applications in dentistry. Int JProsthodont 2004;17:155–64.

38. Monticelli F, Toledona M,Tay FR, Ferrari M.A simple etching technique for improvingthe retention of fiber posts to resin com-posites. J Endod 2006;32:44–47.

39. Monticelli F, Toledano M,Tay FR, et al. Postsurface conditioning improves interfacialadhesion in post/ core restorations. DentMater 2006;22:602–609.

40. Blatz MB, Sadan A, Kern M. Resin-ceramicbonding: a review of the literature. JProsthet Dent 2003;89:268–74.

41. Ozcan M,Vallittu PK. Effect of surface con-ditioning methods on the bond strengthof luting cement to ceramics. Dent Mater2003;19:725–31.

42. Amaral R, Ozcan M, Bottino MA,Valandro

LF.Microtensile bond strength of a resincement to glass infiltrated zirconia-rein-forced ceramic: the effect of surface con-ditioning. Dent Mater 2006;22:283–90.

43. Goracci C, Fabianelli A, Sadek FT, et al. Thecontribution of friction to the dislocationresistance of bonded fiber posts. JEndodont 2005;31:608–12.

44. Asmussen E, Attal J-P, Degrange M.Factors affecting the energy of adherenceof experimental cements bonded to anickel-chromium alloy. J Dent Res1995;74:715–20.

45. Boschian PL, Cavalli G, Bertani P, GaglianiM. Adhesive post endodontic restorationswith fiber posts: push-out tests and SEMobservations. Dent Mater 2002;18:596–602.

46. Luthy H, Loeffel O, Hammerle CH. Effect ofthermocycling on bond strength of lutingcements to zirconia ceramic. Dent Mater2006;22:195–200.

47. Wolfart M, Lehmann F,Wolfart S, Kern M.Durability of the resin bond strength tozirconia ceramic after using different sur-face conditioning methods. Dent Mater2007;23:45–50.

AKKAYAN ET AL.


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Sous le thème « Être dentiste etleader », cet article est le deuxièmed’une série de trois ayant pour objec-tif d’amener les dentistes à prendreconscience de l’importance dedevenir de meilleurs leaders, desleaders plus complets, aussi biendans leur clinique dentaire que dansleur vie.

Le premier article en brefComme la plupart des experts, beaucoup dedentistes agissent comme si leur succès nedépendait que de la qualité de leur expert-ise. Cette croyance est fausse! C’est, en effet,très important d’être un bon dentiste pourréussir, mais c’est encore plus importantd’être un bon leader.Un leader, c’est quelqu’un qui prend la têted’un groupe de personnes et qui les influ-ence à penser et à agir dans la directionqu’il leur propose. Dans votre centre den-taire, vous êtes un bon leader si vous réus-sissez à rallier votre équipe pour qu’elle tra-vaille efficacement à son plein potentiel àl’accomplissement de votre vision. Vous êteségalement un bon leader auprès de vospatients si vous réussissez à les influencer

afin qu’ils optent pour les meilleurs choix detraitement pour eux-mêmes.Le modèle de leadership que j’ai développédans mon livre1 et que j’ai introduit dans lepremier article comprend quatre dimen-sions, auxquelles correspondent quatrearchétypes des individus matures. Un arché-type, c’est une force qui anime universelle-ment les individus. Voici ce modèle :

VisionRoi / Reine

Réalité Leadership ÉthiqueMagicien / AmoureuxFée

CourageGuerrier / Mère

Schéma 1.Modèle intégré de leadership

Première dimension/archétype :Vision (Roi/Reinè)Le premier article a porté principalementsur la première dimension du leadership : lepouvoir de la vision qui correspond àl’archétype Roi/Reine. Un bon leader pro-pose une direction, montre le chemin auxautres et les mobilise à agir pour réaliser savision. C’est le volet idéaliste du leadership.

Le visionnaire propose aux autres de s’en-gager à créer un monde meilleur.En tant que leader visionnaire, votre leader-ship repose en premier sur votre capacité :• de communiquer aux membres de

votre équipe : votre vision, votre mis-sion, vos valeurs, vos standards (vosprotocoles) et vos objectifs

• de mobiliser votre équipe afin quetous travaillent efficacement ensembledans la direction que vous leur pro-posez

Avoir du leadership, ça commence parrépondre à la question : qu’est-ce que jeveux vraiment?Ce deuxième article aborde la deuxièmedimension du leadership qui porte sur lepouvoir de la connaissance, qui correspondà l’archétype Magicien/Fée.

Deuxième dimension/archétype :Connaissance (Magicien/Fée)Cette deuxième dimension du leadershipfait un contrepoids à la première dimen-sion. C’est le volet pragmatique du leader-ship. C’est bien beau d’avoir un idéal, unevision, encore faut-il avoir les deux piedssur terre. Un bon leader doit ainsi bien con-naître la réalité.Le mot clé pour cette dimension du leader-ship, ce sont les faits. Le leader réaliste garde


GESTION DE CABINET

À propos de l’auteurJacques Marois est un stratège, un coach et un formateur expérimenté et enthousiaste. Il détient une maîtriseen économie et une formation poussée en coaching. En 1999, il a été cofondateur d’Inter Formation, une entre-prise offrant du coaching et de la formation aux leaders de PME et à leurs équipes. En 2006, il a choisi d’orien-ter son expertise vers les dentistes et les équipes dentaires. Pour vous procurer son livre « Dentiste et Leader »ou pour toute demande de renseignements sur les services offerts par Inter Formation : jacques.marois@inter-

formation.ca / 450-449-9700

Dentiste et leader :Générez le succès

Par Jacques Marois,MSc

le contact avec ce qui existe présentement.Pour un dentiste, être réaliste, c’est bien con-naître son marché, ses employés, la dentis-terie, ses forces et ses faiblesses. Tre réaliste,c’est se dire clairement la vérité. Tre réalistec’est également être en contact avec lesautres, avec leur réalité.Les perceptions ne sont pas des faits, maisc’est un fait que les personnes ont des per-ceptions et que ces perceptions influencentles gens. Il est donc important pour lui desavoir comment les autres le perçoivent. Ilcherche aussi à savoir comment ces percep-tions influencent leurs attitudes et leurscomportements avec lui et au sein del’équipe. Cette connaissance lui permet d’a-gir sur les facteurs qui influencent leurs per-ceptions, dans le but de générer de l’engage-ment, de l’efficacité et de l’enthousiasme.Ainsi, pour être compétent dans cette deux-ième dimension du leadership, le dentistedoit maîtriser deux formes deconnaissances :• La connaissance formelle de la réalité,

des choses concrètes; par exemple,(1) bien maîtriser les connaissancesreliées à son champ d’expertise(2) avoir de bons moniteurs poursuivre l’évolution de ses résultats

• La connaissance des êtres humains(des membres de son équipe, de sespatients et de lui-même), car c’est,avant tout, sur des êtres humains querepose la réalisation de son rêve

Cette deuxième dimension du leadershipcorrespond presque parfaitement aux arché-types du Magicien et de la Fée.

Le Magicien a le pouvoir de laconnaissance formelleLe fait d’introduire des personnages commeles magiciens et les fées peut vous semblerquelque peu ésotérique. Détrompez-vous,ce ne l’est pas! Le Magicien, c’est le meilleurconseiller du Roi! Croyez-vous vraimentque les magiciens et les fées ont des pou-voirs magiques? Les non-initiés pensent queoui, les magiciens et les fées savent très bienque ce n’est pas le cas. Leur pouvoir est celuide la connaissance.Le Magicien a le pouvoir de la connaissancerationnelle, de la connaissance formelle. Ilcomprend bien le monde matériel qui l’en-toure. C’est de cette connaissance qu’il tireson pouvoir. Il mélange savamment lesingrédients pour en tirer une poudre auxpouvoirs qui semblent magiques pour tous,

sauf pour lui qui sait exactement ce qui secache derrière cette apparente magie.Récemment, pendant que mon dentistereconstruisait l’une de mes dents, j’essayaisde m’imaginer ce qu’aurait pensé un patientqui aurait reçu de tels traitements auMoyen-Âge. J’ai ouvert la bouche et, sanssouffrance, je repartais, quatre-vingt-dixminutes plus tard, avec une belle dentneuve! Ce patient aurait certainement prismon dentiste pour un magicien. Le dentisteaurait probablement été éventuellementbrûlé sur un bûcher. Pourtant, ce n’était pasde la magie. Pour le dentiste, ce n’était quel’application minutieuse de connaissances etd’habiletés qu’il avait acquises, comme tousles magiciens, dans une tour du savoir,auprès de magiciens plus savants que lui!Vous êtes un dentiste, vous êtes donc unmagicien des dents! Vous accomplissez desprodiges qui, pour les non-initiés, relèventdu miracle. Le Magicien apprend sans cesse,car sa quête est celle de la connaissance, dela maîtrise de la réalité. Il a toujours soif dedécouvrir, d’apprendre. Les dentistes sontgénéralement compétents dans l’archétypedu Magicien, en ce qui a trait au volet den-tisterie. Pour ce qui est d’un autre volet de laréalité des dentistes, celui de la gestiond’une micro-entreprise, ils le sont souventbeaucoup moins.

La Fée utilise le pouvoir del’intuitionD’un seul coup de baguette magique, d’unseul mot, d’un seul regard, la méchante Féepeut vous transformer en crapaud et labonne Fée peut vous donner des pouvoirsextraordinaires. Comme le Magicien, la Féesait très bien qu’elle ne fait pas de magie.Son pouvoir est cependant plus proche de lamagie, car elle le puise dans le domaine del’intuition et de la connaissance profondedes êtres humains. La Fée connaît ce qui secache dans le cœur des gens et elle sait com-ment y accéder pour le libérer. C’est l’arché-type central au plan de la gestion desressources humaines.S’ils sont d’excellents magiciens des dents,les dentistes sont souvent, pour le moins,inconfortables avec l’archétype de la Fée.Plusieurs dentistes sont peu habiles avecleur baguette magique. J’en connais mêmequi, sans le vouloir vraiment, réussissentd’un seul regard ou en quelques mots, àtransformer leurs employées en crapauds!Ils possèdent le pouvoir de la Fée, ils ontune baguette magique, mais ils la maîtrisent

mal!En fait, les dentistes ne sont pas les seuls àmal maîtriser cette importante dimensiondu leadership. C’est le cas de la majorité desprofessionnels et des cadres dans les organi-sations de toutes tailles. C’est en effet beau-coup plus facile de gérer des choses que degérer des gens. De plus, dans un monde axésur la connaissance rationnelle, l’intuition etla connaissance profonde de l’être humainsont très peu valorisées.Pourtant, le leadership, c’est l’art d’influ-encer les autres. Comment pouvez-vousinfluencer efficacement les membres devotre équipe et influencer vos patients, sivous ne comprenez pas bien les forces quiles animent et si vous ne savez pas commentles canaliser?Même si le domaine des dynamiqueshumaines n’est surtout pas une scienceexacte, en dépit des prétentions de certainsexperts, vous pouvez faire des progrès rapi-des et significatifs, peu importe voshabiletés présentes. Vos devez cependantdécider d’en faire une priorité et d’y con-sacrer un peu de temps et d’efforts. Encoaching et dans le cadre de mes formationsavec les dentistes et les gestionnairesd’équipes dentaires, je propose à mes clientsplusieurs stratégies personnelles et interper-sonnelles qui permettent souvent de générerdes résultats plutôt remarquables.En voici trois qui illustrent bien commentvous pouvez avoir un fort impact positif survotre équipe, simplement en appliquant desstratégies accessibles à tous. Voici donc cestrois « secrets » que connaissent bien lesFées. Ils vous seront utiles aussi bien avecvotre équipe et vos patients, que dans votrevie.

Premier secret : faites attentionau CIA!Connaissez-vous les facteurs qui motivent leplus vos employées au travail? Est-ce l’ar-gent? Les conditions de travail? Le faitd’avoir du travail intéressant? La possibilitéde progresser dans leur carrière? La fidélitéde leur leader?Ce n’est aucune de ces réponses. De nom-breuses études, dont celle présentée dansl’excellent livre de Thomas G. Crane, TheHeart of Coaching,2 démontrent que les troisfacteurs qui influencent le plus la motiva-tion des employés au travail sont, :1. Se sentir Compris2. Se sentir Important et3. Se sentir AppréciéSi chacune de vos employées a la perception

MAROIS


DENTISTE ET LEADER

que vous la comprenez, qu’elle a de plus lacertitude d’être importante et si, en plus, elleest certaine que vous l’appréciez vraiment,chacune sera alors beaucoup plus motivée àvous donner son plein potentiel. C’est ceque j’appelle « Avoir le CIA de votre bord! ».Dans le cas contraire, si vos employées ne sesentent pas comprises et/ou importanteset/ou appréciées, vous aurez alors le CIAcontre vous et ça risque de vous coûtercher! En fait, même de généreuses augmen-tations de salaire n’auront alors qu’un effetpositif de très courte durée (moins d’unmois). Mais comment faire pour avoir leCIA de votre coté?Il y a plusieurs façons de le faire, mais,parmi toutes, il y a une arme redoutable.Connaissez-vous cette « arme ultime » faceau CIA? Cette arme d’une efficacité red-outable, c’est l’écoute! L’art d’écouter, c’est lesecret No 1 des Fées. C’est en écoutant avecempathie, avec le désir sincère de les com-prendre vraiment, qu’elles accèdent auxforces qui les animent. Même les méchantesFées sont, à leur façon, compétentes pourécouter. C’est en écoutant les autres qu’ellesdécouvrent précisément quoi dire pour lestransformer en crapaud! Dans le troisièmearticle, je reviendrai plus à fond sur l’écoutelorsque j’aborderai l’archétype del’Amoureux.

Deuxième secret : maîtrisez l’artd’apprécier!Voici quelques chiffres provenant d’une trèsvaste étude menée auprès de 200 000dirigeants et employés et présentée dans lelivre « The Carrot Principle » de Gostick etElton.3

• 65% des employés affirment qu’on neleur a témoigné aucune marque d’ap-préciation au cours de la dernièreannée

• 79% des gens quittent leur emploiprincipalement parce qu’ils ne ressen-tent pas qu’on apprécie leurs efforts

• 94% des employés les plus heureux autravail sont d’avis que leur patronreconnaît efficacement leur contribu-tion, alors que c’est le cas pour seule-ment 2% des employés qui se disentmalheureux au travail

• 66% des employés affirment que lestémoignages d’appréciation les incitentde façon très significative à améliorerleur rendement

Cette étude ne fait que confirmer ce que

plusieurs autres études ont déjà démontré :pour mobiliser votre équipe, apprenez àdémontrer systématiquement votre appréci-ation à chacun des membres qui la com-posent!D’ailleurs, après avoir, pendant des années,enseigné aux leaders d’équipe à travaillerauprès de leurs employés afin d’éliminerleurs faiblesses, les meilleurs consultantsleur enseignent maintenant à cultiver lesforces de leurs employés. C’est beaucoupplus efficace ainsi.En réalité, le problème, ce n’est pas tellementque les dentistes n’apprécient pas les mem-bres de leur équipe, mais c’est plutôt qu’ilsne savent pas comment le leur démontrerou pire, qu’ils ne voient pas l’importance dele faire. Régulièrement des dentistes me fontpart de leur inconfort et de leur incom-préhension face au besoin constant d’appré-ciation démontré par certains membres deleur équipe :« Je la paie bien pour qu’elle travaille bien. Jen’ai pas de temps à perdre à lui faire sanscesse des compliments. Je ne trouve pas çaadulte! »« Elle devrait pourtant bien le savoir que jel’apprécie, si je n’étais pas satisfait, je le luidirais (ou elle ne travaillerait pas dans maclinique.)»« Si je leur démontre trop que je les appré-cie, ça va me coûter cher d’augmentationsalariale.»« Je suis un dentiste, pas un thérapeute! »Voilà autant de citations qui démontrentque certains dentistes ne comprennent pasbien la réalité suivante : démontrer de l’ap-préciation, c’est au moins aussi payant pourle dentiste que pour l’employé! En fait, c’estpossiblement un acte plus payant à l’heure,que tous les autres actes que vous poserez àvotre chaise auprès de vos patients tout aulong de la journée.Voici une technique très efficace qui peutêtre utilisée avec toutes les personnes quevous appréciez (employés, clients, amis,conjoint, enfants). Pour en saisir tout l’im-pact, placez-vous dans la peau de la person-ne qui reçoit le témoignage d’appréciation. Ilest probable que vous n’ayez pas reçu sou-vent, tout au long de votre vie, des marquesaussi puissantes d’appréciation. Voici les 4étapes à suivre.Étape No 1 : Assurez-vous d’avoirl’attention de l’autreSi vous êtes certain que l’autre personne estdisponible pour vous écouter, vous pouvez

aller directement à la deuxième étape.Sinon, assurez-vous de capter son attentionen éveillant sa curiosité. Pour y arriver, jevous propose le choix de lui faire une trèsbrève déclaration d’introduction ou de luiposer une question d’introduction.Voici un exemple de déclaration d’intro-

duction: « Nicole, je veux te dire quelquechose d’important au sujet de ce qui vientde se passer avec ta patiente. »Voici maintenant un exemple dequestion d’introduction: « Nicole, j’aiquelques chose d’important à te dire main-tenant, est-ce que je peux te parler deuxminutes?»L’idée, c’est de capter l’attention de votreemployée, en éveillant sa curiosité. Aprèscette introduction, quand la curiosité estpiquée, nos sens se focalisent pour la satis-faire.Ne jouez pas de rôle, en prenant par exem-ple le ton de celui qui a un reproche à for-muler. Votre intention est de démontrervotre appréciation, alors allez-y en vous lais-sant déjà habiter par un sentiment d’appré-ciation, voire de gratitude envers elle. Sivotre employée est quelque peu inquiète rel-ativement à ce que vous allez lui dire, voussavez déjà que vous allez la rassurer dansquelques secondes.Étape No 2 : Lancer deux petitesflèches bien pointuesCommencer par émettre deux ou troispetites observations positives très précises.Ces petites flèches d’appréciation visent àsouligner les points précis que vous appré-ciez. Votre employée sera par la suite portéeà les répéter. Ces petits compliments trèspointus visent également à créer une brèche,une connexion émotionnelle positive pourla troisième étape. Plus vous serez précis etsincère lors de cette deuxième étape, mieuxce sera. Par exemple :« Nicole, j’ai trois choses à te dire. La pre-mière, c’est que j’ai trouvé ça vraiment superquand tu as pris la main de madame X etque tu lui as dit… Ça l’a vraiment rassurée.»Après avoir décoché votre première petiteflèche d’appréciation, attendez quelquesinstants, puis décochez votre deuxièmeflèche :« Je veux aussi te dire que j’apprécie vrai-ment les efforts que tu fais pour arriver àl’heure à la clinique, même si ce n’est pasfacile pour toi avec ta situation familiale. »Étape No 3 : Visez droit au cœurL’ouverture est créée, il est maintenanttemps de lancer droit au cœur votre mes-


sage global d’appréciation. Ce message neporte pas sur les comportements, ils portentsur la personne elle-même. Ainsi, aprèsavoir reconnu des comportements positifs,c’est le moment idéal pour reconnaître l’êtrehumain à la source de ces comportements.Votre message doit être complètementauthentique et bref. Vous devez le dire avecvotre cœur et non avec votre tête.N’exagérez rien, dites seulement ce que vouspensez en focalisant sur les qualitéshumaines à la base des comportementspositifs que vous avez observés (vos deuxpetites flèches). Par exemple :« Nicole, tu es une assistante très compé-tente, fiable et généreuse. Je me compte trèschanceux de t’avoir dans mon équipe. »Il est souhaitable que votre marque d’appré-ciation se termine par une brève déclarationdémontrant l’impact que son comportementa sur vous : « … Je me compte trèschanceux de t’avoir dans mon équipe ».Vous avez maintenant lancé toutes vosflèches. Passez à la dernière étape.Étape No 4 : Recevez avec ouver-tureC’est maintenant à votre tour de recevoir.Vous avez lancé votre dernière flèche droitau cœur et marqué profondément votreemployée. Ne parlez plus. Laissez les flèchesagir, elles portent une substance magiquetrès puissante : votre appréciation. Votreemployée a été touchée et ses réactions peu-vent être très variées. Il est possible qu’ellepleure, qu’elle soit gênée, heureuse. Il estpossible qu’elle garde le silence, qu’elle vousretourne l’ascenseur ou simplement qu’ellevous dise merci! Dans tous les cas, vousn’avez rien à réparer, rien à changer. Recevezsimplement son message, puis reprenez lecours de vos activités. Inutile de prolongerla situation. La substance magique pour-suivra son travail dans le coeur de votreemployée, et en vous.La fréquence des messages d’appréciationpeut varier selon les employés, mais danstous les cas, ils doivent être assez fréquentspour que vos employés ne doutent jamaisque vous les appréciez.

Troisième secret : appréciez aussivos patients!Quel dentiste ne voudrait pas avoir une pra-tique pleine, ne comprenant que despatients idéaux? Alors, quand vous avez unpatient idéal sur votre chaise, ne vous gênezpas pour le lui dire.

Vos patients ont, eux aussi, le besoin de sesentir Compris, Importants et Appréciés. Sivous réussissez avec eux également à mettrele CIA de votre bord, ils vous seront fidèleset ils auront davantage de chance de vousréférer des patients idéaux comme eux.

Influencer ou manipulerLa principale force des leaders, c’est leurcapacité d’influencer les autres. Comme ledémontrent ces exemples, l’art d’influencerpeut prendre des formes très subtiles.Dans le contexte du leadership, il y a uneimportante distinction à faire entre « influ-encer » et « manipuler » :Un leader manipule les autres quand ilutilise les autres afin de satisfaire ses propresintérêts. Il les influence quand il vise àservir ce qu’il perçoit être le meilleur intérêtde son patient.La distinction semble claire en théorie :Quand on manipule on se sert des autresVsQuand on influence on vise à les servir!Dans la réalité quotidienne de votre cliniquedentaire, cette distinction s’avère parfoisbeaucoup moins claire. Elle peut mêmedevenir très difficile à établir quand votreintérêt et celui de vos patients ou de vosemployés convergent.Par exemple, vous voulez présenter à votrepatient un plan de traitement complexe etdispendieux. C’est ce plan qui, à vos yeuxd’expert, est le plus approprié pour votrepatient. C’est également celui qui est le plusintéressant et le plus payant pour vous. Vousvoulez l’influencer, mais c’est vraiment con-tre vos valeurs de le manipuler. Au momentoù vous présenterez ce plan à votre patient,quel genre de leader serez-vous?Serez-vous celui qui influence et quigardera le cap en vue d’amener son patient àfaire le meilleur choix en fonction de sasanté et de ses autres priorités personnelles?Serez-vous celui qui manipule et quicherchera avant tout à servir ses propresintérêts, au détriment des autres priorités dupatient?Serez-vous celui qui abdique et qui renon-cera à son pouvoir d’influence, par craintede manipuler ou de déplaire à son patient?Comme vous le voyez, c’est quand votreintérêt et l’intérêt du client convergent, quela ligne de démarcation peut vous semblergrise dans votre tête! Influencer, c’estdemeurer intègre face à soi et face à l’autre.Suis-je en train de manipuler mon patient

pour servir mes propres intérêts ou de l’in-fluencer dans son meilleur intérêt?La ligne de démarcation c’est votre inten-tion. Quand vous proposez une solution àvotre patient : Est-ce que vous pensez enpremier à son intérêt? De plus, avez-voustoute l’information requise pour bien cernerquel est son meilleur intérêt, compte tenude ses autres priorités?Si la réponse est : OUI! Alors, allez-y, etagissez en bon leader : influencez-le! C’estl’éthique de chercher à influencer votreclient, en restant dans le cadre des limitesacceptables : ne pas mentir, ne pas faire despromesses irréalistes, ne pas cacher une par-tie de la réalité qui pourrait le faire reculer,ne pas faire de chantage émotionnel (de lapression).Quand vous renoncez à votre pouvoir d’in-fluencer votre patient par crainte de luidéplaire et éventuellement par crainte de leperdre comme patient, j’estime que vouscommencez à pencher du côté de la manip-ulation. En effet, ne pas dire « votre véritéd’expert » à votre patient, par crainte de leperdre et qu’il change de dentiste, ça se rap-proche de la manipulation.Par ailleurs, il arrive souvent que ce ne soitni urgent, ni le bon moment pour expliquervotre plan de traitement à votre patient.Alors, s’il n’est pas vraiment disponible pourvous écouter, limitez-vous à l’essentiel etattendez le bon moment.N’oubliez jamais que votre réalité de den-tiste n’est qu’un aspect de la réalité pour lepatient. Votre patient n’est pas que desdents. Il a sa vie, ses priorités, ses obliga-tions. C’est à partir de toutes les donnéesqui définissent son contexte qu’il fera seschoix. Plus vous découvrirez quelles sont sesautres priorités, plus vous serez en mesured’établir, avec lui, une stratégie de traitementqui concorde avec sa vie. Encore une foisici, la clé c’est l’écoute. Un leader compétentdans l’archétype Magicien/Fée sait poser lesbonnes questions et il sait aussi écouter ceque le patient cherche à lui faire compren-dre. Il sait que, pour influencer son patient,il doit bien le comprendre.

References1. Marois J. Dentiste et leader. Boucherville,

PQ: Inter Formation, 2008.2. Crane TG. The Heart Of Coaching. San

Diego: FTA Press, 2001.3. Gostick A and Chester E. The Carrot

Principle. Salt Lake City, UT: OC TannerCompany, 2007.

MAROIS



This article is the second in a seriesof three articles on the theme of“Dentist and Leader,” with the goalof encouraging dentists to reflectupon the importance of becomingbetter, more well-rounded leaders intheir dental clinics and in their lives.

Summary of the First ArticleLike most experts, many dentists act asthough their success depends solely on thequality of their expertise. This belief is mis-leading! Being a good dentist is indeed anecessary foundation for success, but it iseven more important to be a good leader.A person who has a goal and who heads upa group of people, influencing them to thinkand act to achieve that goal, is a leader. Inyour dental practice, you are a good leaderif you are able to rally your team membersto work effectively to their full potential inorder to accomplish your vision. You arealso a good leader to your patients if you areable to influence them to make the bestdecisions about treatment for themselves.The leadership model I developed in mybook,1 and which I introduced in the firstarticle, is made up of four dimensions, cor-

responding to the four archetypes of matureindividuals. Archetypes are strengths whichuniversally empower individuals. This iswhat the model looks like:

VISION

King – Queen

Reality Leadership EthicsMagician– LoverFairy

CourageWarrior–Mother

Diagram 1. Integrated leadership model.

First Dimension/Archetype: Vision(King/Queen)The first article mainly covered the firstdimension of leadership: the power of vision,corresponding to the King/Queen arche-type. Good leaders set a goal, show othersthe way and mobilize them to act to achievetheir vision. This is the idealist aspect ofleadership. A visionary calls on others to getinvolved in creating a better world.As a visionary leader, your leadership isbased first and foremost on your ability todo the following:• communicate to the members of your

team: your vision, mission, values,standards (protocols) and objectives,and

• mobilize your team so that they allwork effectively together towards thegoal you have set them.

Exercising leadership starts with answeringthe question:What do I really want?This second article deals with the seconddimension of leadership, the power ofknowledge, corresponding to theMagician/Fairy archetype.

Second Dimension/Archetype:Knowledge (Magician/Fairy)This second dimension of leadership coun-terbalances the first dimension. This is thepragmatic aspect of leadership. While it isgreat to have an ideal or vision, you alsohave to keep both feet on the ground. Thus,a good leader must also really know thereality.The facts are a key concept for this dimen-sion of leadership. A realistic leader stays intouch with the status quo. For a dentist,being realistic means really knowing yourmarket, your employees, dentistry, and yourstrengths and weaknesses. Being realisticmeans telling yourself the truth plainly.Being realistic also involves being in contactwith others and with their realities.

PRACTICE MANAGEMENT

About the authorJacques Marois, strategist, coach, and experienced and enthusiastic trainer, has a master’s degree in economyand extensive training in coaching. In 1999, he cofounded Inter Formation, a company offering coaching andtraining to SME leaders and their teams. In 2006, he decided to focus his expertise on dentists and dental

teams. To order his book,Dentiste et Leader, or for more information on the services offered by InterFormation, write to [email protected] or call 450-449-9700.

Dentist and Leader:Generate Success

By Jacques Marois,MSc

Perceptions are not facts; however, it is afact that people have perceptions and thatthose perceptions influence them.Therefore, it is important for dentists toknow how others perceive them. Dentistsmust also seek to know how those percep-tions influence people’s attitudes and behav-iours towards the dentist and within theteam. With that knowledge, dentists are ableto take action on the factors that influenceother people’s perceptions, in order to gen-erate commitment, effectiveness, and enthu-siasm.Thus, to be competent in this seconddimension of leadership, dentists must mas-ter the following forms of knowledge:• Formal knowledge of reality or con-

crete things, for example, (1) master-ing the knowledge related to theirfield of expertise, (2) having gooddashboards to track the progress ofresults;

• Knowledge of human beings (mem-bers of your team, your patients, andyourself), because achieving yourdream is based primarily on humanbeings.

This second dimension of leadership is analmost perfect match with the Magician andFairy archetypes.

The Magician Has the Power ofFormal KnowledgeIntroducing characters such as magiciansand fairies may seem slightly esoteric. Butyou are quite mistaken; that is not the case!The magician is the king’s best advisor! Doyou really believe that magicians and fairieshave magical powers? The uninitiated thinkso, but magicians and fairies know very wellthat is not true. Their power comes fromknowledge.The magician has the power of rational orformal knowledge. He has a clear under-standing of the material world around him.He draws his power from that knowledge.He skilfully mixes the ingredients to pro-duce a potion with powers which everyonethinks are magical, except him, because heknows exactly what is hidden behind theapparent magic.Recently, while my dentist was reconstruct-ing one of my teeth, I tried to imagine whata patient would have thought about receiv-ing similar treatment in the Middle Ages. Iopened my mouth and, with no pain, I leftagain 90 minutes later with a beautiful newtooth! That patient would certainly have

taken my dentist for a magician and thedentist would probably have eventuallybeen burned at the stake. Yet, it was notmagic. For the dentist, it was merely themeticulous application of knowledge andskills that he had acquired, like all magi-cians, in a tower of knowledge, from magi-cians more knowledgeable than him!You are a dentist, so you are a tooth magi-cian! You accomplish wonders which, forthe uninitiated, are miraculous. A magiciannever stops learning, because his quest isthe quest for knowledge, for mastery ofreality. He is always driven to discover andlearn. Dentists are generally competent inthe magician archetype insofar as dentistryis involved. For another aspect of dentists’reality, managing a small business, they areoften much less competent.

The Fairy Uses the Power ofIntuitionWith a single wave of her magic wand, witha single word, a single look, the bad fairycan change you into a frog or the good fairycan give you extraordinary powers. Like themagician, the fairy knows full well that sheis not performing magic. However, herpower is more like magic because she getsher power from intuition and an in-depthknowledge of human beings. The fairyknows what is hidden in people’s hearts andshe knows how to access and release it. Thisis the central archetype for human resourcemanagement.Although they are excellent tooth magi-cians, dentists are often, to say the least,uncomfortable with the fairy archetype.Many dentists are not very handy with theirmagic wands. I even know some who, with-out really meaning to, with a single look ora few words, manage to change theiremployees into frogs! They have the fairy’spower, they have a magic wand, but theyhave not mastered it!Dentists are not the only ones who have notmastered this important dimension of lead-ership. This is true of the majority of profes-sionals and managers in organizations of allsizes. It is much easier to manage thingsthan people. Besides, in a world focused onrational knowledge, intuition, and an in-depth knowledge of human beings are notvery highly valued.And yet, leadership is the art of influencingothers. How can you effectively influencethe members of your team and influenceyour patients, if you do not have a clear

understanding of the strengths that empow-er them and if you do not know how tochannel those strengths?Although the field of human dynamics isreally not an exact science, despite theclaims of some experts, you can make rapid,significant progress, no matter what yourcurrent skill level is. However, you mustresolve to make it a priority and devote timeand effort to it. When I am coaching ortraining dentists and dental team managers,I offer my clients several personal and inter-personal strategies which often producequite remarkable results.The following are three strategies whichclearly illustrate how you can have a majorpositive impact on your team, simply byapplying strategies which are accessible toall. So, these are three “secrets” that thefairies know well. They will be helpful toyou with your team and your patients, andin your life.

First Secret: Pay Attention to theUIA!Do you know the factors that most motivateyour employees at work? Is it money?Working conditions? Having an interestingjob? Career advancement opportunities?The loyalty of their leader?None of these are the answer. Many studies,including the one presented in the excellentbook by Thomas G. Crane, “The Heart ofCoaching”2 show that the three factors thatmost influence employee motivation are:1. Feeling Understood,2. Feeling Important, and3. Feeling Appreciated.If all your employees perceive that youunderstand them, if they are satisfied thatthey are important, and if, in addition, theyare sure that you truly appreciate them, theywill then be much more motivated to giveyou their full potential. This is what I call“Having the UIA on your side!”Conversely, if your employees do not feelunderstood and/or important and/or appre-ciated, then you will have the UIA againstyou and that could well prove expensive! Asa matter of fact, even generous salaryincreases will only have a very short-termpositive effect (less than a month). But whatcan you do to keep the UIA on your side?There are several ways to accomplish thisbut, of them all, there is one formidableweapon. Do you know the “ultimateweapon” for the UIA? This absolutely for-

MAROIS

Canadian Journal of Restorative Dentistry and ProsthondonticsSummer 2009 35

Été 2009Journal canadien de dentisterie restauratrice et de prosthodontie

you already know that you are going toreassure him or her in a few seconds.Step No 2: Launch Two VeryTargeted Little ArrowsStart by offering two or three very specific,positive little observations. The purpose ofthese appreciative little arrows is to high-light the specific points that you appreciate.Your employee will then be likely to repeatthem. These very targeted little compli-ments are also intended to create an open-ing, a positive emotional connection for thethird step. The more specific and sincereyou are in this second step, the better, forexample:“Nicole, I have three things to say. The firstis that I thought it was really great whenyou held Mrs. X’s hand and you told her …That really reassured her.”After releasing your first little arrow ofappreciation, wait a few seconds, thenrelease your second one:“I also want to tell you that I really appreci-ate the effort you make to get to the clinicon time, even though it’s not easy for youwith your family situation.”Step No 3: Get Right To the Heart ofThingsThe opening has been created and now it istime to get right to the heart of your overallmessage of appreciation. This message isnot about behaviour; it is about the personthemselves. After recognizing positivebehaviour, this is the ideal time to recognizethe human being behind that behaviour.Your message must be absolutely genuineand brief. You must say it with your heart,not your head. Do not exaggerate anything,just say what you think, focusing on thehuman qualities behind the positive behav-iour you have observed (your two littlearrows), for example:“Nicole, you are a very competent, reliableand considerate assistant. I consider myselfvery lucky to have you on my team.”Ideally, your sign of appreciation will end ina short statement showing the impact of theperson’s behaviour on you: “… I considermyself very lucky to have you on my team.”Now you have sent all your arrows. Go onto the next step.Step No 4: Receive OpenlyNow it is your turn to receive. You sent yourlast arrow right to the heart and profoundlyaffected your employee. Do not say any-thing else. Let the arrows do their work;they contain a very powerful magical sub-

don’t have any time to waste paying hercompliments all the time. I don’t think that’svery mature!”“But she ought to know that I appreciateher; if I wasn’t satisfied, I’d tell her (or shewouldn’t be working in my clinic).”“If I show them too much that I appreciatethem, it’ll cost me in salary increases.”“I’m a dentist, not a therapist!”These are all quotes which show that somedentists do not really understand the fol-lowing reality: showing appreciation is atleast as profitable for the dentist as for theemployee! In fact, on an hourly basis, itmight well be an action which is more prof-itable than all the other actions you will takefor patients in your chair in the course of aday.The following is a very effective techniquewhich can be used with everybody youappreciate (employees, clients, friends, part-ner, children). In order to really feel theimpact, place yourself in the position of theperson receiving the message of apprecia-tion. Probably you have not often received,in your entire lifetime, such powerful signsof appreciation. There are four steps to fol-low.Step No 1: Make Sure You Have theOther Person’s AttentionIf you are sure that the other person is avail-able to listen to you, you may go directly tothe second step. Otherwise, make sure youattract the person’s attention by piquing hisor her curiosity. To do so, I suggest youeither make a very short introductory state-ment or ask an introductory question.This is an example of an introductory state-ment: “Nicole, I want to say somethingimportant about what just happened withyour patient.”And this is an example of an introductoryquestion: “Nicole, I have something impor-tant I’d like to say now, may I speak to youfor a couple of minutes?”The idea is to attract your employee’s atten-tion by piquing his or her curiosity. Afterthat introduction, when the curiosity ispiqued, our senses are focused on satisfyingthat curiosity.Do not play a role, for example, by sound-ing like somebody with a criticism to make.Your intention is to demonstrate yourappreciation, so start off by already having afeeling of appreciation or gratitude towardsthe person. Even if your employee is slightlyworried about what you are going to say,

midable weapon is … listening! The art oflistening is the fairies number one secret. Bylistening with empathy, with a sincere desireto truly understand others, fairies can accessthe strengths that empower them. Even badfairies are competent at listening, in theirown way. By listening to others, they dis-cover exactly what to say to change theminto frogs! In the third article, I will go intomore detail about listening when I intro-duce the archetype of the lover.

Second Secret: Master the Art ofAppreciation!The following figures are from a very exten-sive study conducted on 200,000 managersand employees, which is presented in thebook The Carrot Principle by Gostick andElton3:• 65% of employees report that they

have been shown no sign of apprecia-tion during the previous year;

• 79% of people leave their jobs mainlybecause they do not feel that theirefforts are appreciated;

• 94% of the employees who are happi-est at work believe that their bosseffectively recognizes their contribu-tion, while only 2% of employees whosay they are unhappy at work have thesame belief;

• 66% of employees report that signs ofappreciation provide very significantencouragement for them to improvetheir performance.

This study only confirms what several otherstudies have already shown: to mobilizeyour team, you must learn to systematicallyshow your appreciation to each and everyteam member!Moreover, having spent years teaching teamleaders to work with their employees toeliminate their weaknesses, the best consult-ants are now teaching them to cultivatetheir employees’ strengths. This is muchmore effective.In actual fact, the problem is not so muchthat dentists do not appreciate the membersof their team, but rather that they do notknow how to show them their appreciationor, even worse, they do not see the impor-tance of doing so. On a regular basis, den-tists tell me about their discomfort with andinability to understand the constant needfor appreciation shown by some membersof their teams:“I pay her well so that she works well. I

DENTIST AND LEADER

36

Summer 2009 Canadian Journal of Restorative Dentistry and Prosthondontics

MAROIS

It is ethical to try to influence your client,while staying within acceptable limits. Donot tell lies, do not make unrealistic promis-es, do not hide any part of the reality whichmight make your patient pull back, do notexert emotional blackmail (pressure).When you relinquish your power to influ-ence your patient for fear of displeasing thepatient and possibly for fear of losing thepatient from your clinic, I believe that youare starting to lean towards manipulation.Not telling the patient “your truth as anexpert,” for fear of losing the patient toanother dentist, is getting close to manipu-lation.Furthermore, it often happens that it is nei-ther urgent or the right time to explain yourtreatment plan to your patient. So, if thepatient is really not available to hear you,limit yourself to the basic points and waitfor the right time.Always remember that your reality as adentist is only one aspect of reality for yourpatients, who are more than just their teeth.Each patient has a life, priorities and obliga-tions. Decisions are made based on all theinformation defining your patient’s context.The more you find out about your patient’sother priorities, the more you will be able toestablish, with your patient, a treatmentstrategy that suits his or her life. Here again,listening is the key. Leaders who are compe-tent in the magician/fairy archetype knowhow to ask the right questions and alsoknow how to hear what patients are tryingto make them understand. They know that,in order to influence their patients, theymust really understand them.

References1. Marois J. Dentiste et leader. Boucherville,

PQ: Inter Formation, 2008.2. Gostick A and Chester E. The Carrot

Principle. Salt Lake City, UT: OC TannerCompany, 2007.

3. Crane TG. The Heart Of Coaching. SanDiego: FTA Press, 2001.

When you manipulate, you are usingothersVs.When you influence, you aim to serveothers!In the daily reality of your dental clinic, thisdistinction is sometimes much less clear. Itmay even become very difficult to establishwhen your interests and the interests ofyour patients or your employees converge.For example, you want to present yourpatient with a complex, costly treatmentplan. In your opinion as the expert, thatplan is the most appropriate one for yourpatient. It is also the one that is most valu-able and profitable for you. You want toinfluence your patient, but it is reallyagainst your values to manipulate thepatient. When you present this plan to yourpatient, what kind of leader will you be?Will you be a leader who influences, whosegoal is to lead your patient to make the bestdecision based on your patient’s health andother personal priorities?Will you be a leader who manipulates, seek-ing first and foremost to serve your owninterests, at the expense of the patient’sother priorities?Will you be a leader who abdicates, relin-quishing your power to influence, for fear ofmanipulating or displeasing your patient?As you can see, when your interests and theclient’s interests converge, the boundary linemay appear grey in your mind! Influencingmeans remaining honest to yourself and toothers.Am I manipulating my patient to serve myown interests or influencing my patient inhis or her best interests?The boundary line represents your inten-tion. When you suggest a solution to yourpatient, are you thinking first about yourpatient’s interests? And do you have all thenecessary information to really figure outwhat is in your patient’s best interests, con-sidering the patient’s other priorities?If the answer is: YES! Then go ahead, andact like a good leader; influence the patient!

stance: your appreciation. Your employeehas been touched and his or her reactionsmay be very varied. It is possible that theremay be tears, or your employee might beembarrassed or pleased. Your employeemay stay silent, may repay the compliment,or may simply say thank you! In any case,you do not have to fix or change anything.Simply receive your employee’s messagethen go back to your activities. There is noneed to prolong the situation. The magicalsubstance will continue working in youremployee’s heart, and in you.The frequency for messages of appreciationmay vary by employee, but in all cases, mes-sages must be frequent enough that youremployees are never in any doubt that youappreciate them.

Third Secret: Also Appreciate YourPatients!What dentist would not want to have a fullpractice with nothing but ideal patients? So,when you have an ideal patient in yourchair, do not hesitate to say so.Your patients also need to feel Understood,Important, and Appreciated. If you manageto get the UIA on your side with them aswell, they will be loyal to you and they willbe more likely to refer ideal patients likethemselves to your practice.

Influencing or ManipulatingThe greatest strength of leaders is their abil-ity to influence others. As these examplesshow, the art of influencing may take verysubtle forms.In the context of leadership, there is animportant distinction between influencingand manipulating.Leadersmanipulate others when they usethem to satisfy their own interests. Theyinfluence others when they aim to servewhat they perceive to be in the patient‘s bestinterests.The distinction seems clear in theory:

37


Using Provisional Restorationsto Guide Tissue Healing for Predictable

Prosthetic Esthetics

By Bruce Kleeberger, DDS

ABSTRACTProvisional restorations can be used to guide soft tissue healing following surgical intervention.Interdisciplinary treatment planning for predictable outcomes is critical and involves co-ordinating the various specialist services. Five cases are presented to demonstrate the use ofbis-acryl (“composite”) materials at various stages of the restorative process. Some of theseinvolve fixed tooth supported restorations and others are supported by osseointegratedimplants.The development of multi-opacity, repairable and polishable bis-acryl materials has improvedour ability to durable long term provisionals. They can be manipulated easily chairside toprovide a matrix which supports the tissue or generates a force to direct gingival tissuehealing. In addition, these provisional restorations are highly esthetic.

RÉSUMÉLes restaurations provisoires peuvent être utilisées pour guider la guérison des tissus mousaprès une intervention chirurgicale. La planification des traitements interdisciplinaires pourprévoir les résultats est essentielle et implique la coordination des services de plusieurs spé-cialistes. Cinq cas sont présentés pour montrer l’utilisation des matériaux bis-acrylique (“ Lecomposite”) à des stades variés du processus de restauration. Certains comprennent des restau-rations de dents fixes et autres sont soutenues par des implants osseointegrés.

PROSTHODONTICS / PROSTHODONTIE

About the AuthorDr. Bruce Kleeberger graduated from the University of Alberta, Faculty of Dentistry in 1978 and has been infull time practice for 30 years. He is a charter member of the Canadian Academy of Computerized Dentistryand of the Canadian Academy for Esthetic Dentistry. He holds a certificate of proficiency in the diode laser

from the American Academy of Laser Dentistry.Dr. Kleeberger has lectured on dental materials selection, dental techniques and treatment planning andconducted hands on training for graduate dentists. He has published in national and international peerreviewed professional publications. He reviews for the Academy of General Dentistry publication General

Dentistry and the Journal of the Canadian Dental Association.Correspondence may be directed to Dr. Bruce Kleeberger, BSc, DDS at [email protected].

Dental patients have heightened aware-ness of the esthetic potential of their

dental treatment. They demand beautifuland durable restorations. The restoringdentist is obligated to provide a high levelof interdisciplinary care and must be ableto coordinate the various specialties ofdentistry to meet these requirements. It isimperative that each case be plannedcarefully; beginning with the end in mindand with the patients’ expressed wants asa consideration during the planningphase but also through the entire courseof treatment. The restoring dentist mustbe the “quarterback” for the entire gameplan in order that the patient (the “ownerof the team”) receives the result heexpects. The dentist must understand thediagnosis, and be able to create an envi-ronment in which the outcome is pre-dictable. Soft tissue management is a keyto the success of dental prosthetic out-comes.Fortunately there continue to be advancesin dental science, technology and the clini-cians’ understanding of the relevant biology.Grafting of bone and soft tissue are com-mon regenerative procedures. The tissuesmust be carefully managed post-surgically

throughout the surgical and restorativephases to meet the functional and estheticrequirements of the case. By providing asuitable provisional restoration during thehealing period, soft tissue can be mouldedand guided in a predictable manner.The growth of periodontal tissue graftingtechnologies has been remarkable in therecent years. Autogenous, allograft,xenograft, and synthetic bone materials arefrequently used to augment the tissue if theclinical situation requires it. Connective tis-sue grafts, including pedicle grafts, likethose demonstrated by Dr. Stig Osterberg,Port Angeles, WA, allow the regeneration ofan acceptable volume of soft tissue.Previously the absence of adequate soft tis-sue would have been camouflaged withpink porcelain. It is not only possible, butconsidered standard of care, that patients beoffered these services as part of the compre-hensive treatment planning in the estheticzone. A sequence of considerations forinterdisciplinary treatment planning themanagement of soft tissue during the surgi-cal and restorative phases of fixed dentalprosthetics, with and without implants ispresented in Figure 1.Although acrylic resins such as SNAP

(Parkell Inc, Farmingdale, NY) have beenused traditionally as provisional restorativematerials, they are difficult to manipulate.The advent of bis-acryl resins in variousconsistencies, shades, opacities (translucen-cies), and filler particle sizes has made theman ideal material for short- and long-termprovisionalization. They can self-cure bybase/catalyst reactions in the absence oflight, on demand with a curing light or acombination of self cure and light cure. Animproved bis-acryl provisional restorationcan be fabricated in the laboratory byenhancing light, pressure, and in a vacuumto increase the percentage of cured resinand decreasing porosity, thereby increasingstrength. This makes it possible to repair,reline, make additions to, and tint the provi-sional restoration. The provisional can becustomized to mimic natural teeth at leastas well as porcelain, which is especiallyimportant in the anterior esthetic zone.

Pontic Site Tissue GuidanceWhen there is adequate gingival tissue vol-ume overlying an edentulous ridge it is pos-sible to create a soft tissue receptor sitedesigned for the pontic to rest in and creat-

KLEEBERGER


Le développement de matériaux bis-acryliques multi-opaques, réparables et polissables aamélioré la durabilité des provisoires de longue durée. Elles peuvent être manipulées facile-ment sur place pour fournir une matrice qui soutient le tissu ou produit une force pour dirigerla guérison du tissu gingival. En plus, ces restaurations provisoires sont hautement esthétiques.

Tooth requires replacement

Tooth in situ

Implant therapy

Adequate tissue

Treatment plan

Yes

Provisionalat 1ststage

surgery

Augmentsoft/

oseoustissue

•Provisional

at 1st or2nd stage

surgery

Ovatepontic attime of

extraction

Augmentsoft

tissue•

Ovateponticwithtoothprep

Provisionalwith allimplantsurgery

Augmentsoft/

oseoustissue

•Implantsurgery

•Provisional

at 1st or2nd stage

surgery

Ovatepontic

with toothprep

Augmentsoft

tissue•

Ovateponticwithtoothprep

Yes No

Yes

Yes

No

Yes No Yes No Yes No

Yes No

No

Figure 1. Interdisciplinary treatment planning for the management of soft tissue with provisionalization.

USING PROVISIONAL RESTORATIONS TO GUIDE TISSUE HEALING FOR PREDICTABLE PROSTHETIC ESTHETICS

ing the illusion of a natural tooth eruptingfrom intact periodontal tissues This ponticdesign is termed an “ovate pontic” and theprepared ridge is called an ovate ponticreceptor site.The site may be prepared at the time oftooth preparation by indenting the crest andlabial of the residual ridge with a large, eggshaped diamond bur, sculpting with electro-surgery, or ablating with the diode laser.The provisional restoration is contoured inan “egg shaped” fashion and when it isplaced onto the tissue it exerts slight pres-sure so that is blanches the tissue for nomore than 5 minutes. The pontic should besmooth and polished.The guidance of gingival tissue to create apontic receptor site can also begin followingtooth extraction if provisionalization canbegin immediately. This requires the sur-gery to be co-ordinated with the prosthetictreatment. The provisional restoration iscontoured in an ovate fashion and when itis cemented, it extends slightly into thefresh extraction site. The provisionalrestoration is checked for adequate contourand tissue support at 2-, 6-, and 12-weekintervals.In either case, when the patient returns forthe final restoration, the site is healed andthe final restoration should again exertslight pressure with blanching of the tissue,on the ridge. The blanching will disappearwithin 5 minutes if this is done correctly.This creates a very natural emergence pro-file for the restoration.

Case 1: Mature RidgeRecontouringThe patient presented with the upper rightlateral incisor missing but replaced with aremovable partial denture (Figure 2). Aspart of her phased treatment plan she want-ed to begin with the replacement of thetooth but planned to proceed with restora-tion of the remaining maxillary anteriorteeth as time and finances allowed. As shewanted whiter teeth, the definitive restora-tion would need to be a different shade thanthe unrestored teeth. She declined implanttherapy to replace the tooth because she didnot want the bone augmentation procedurethat would have been necessary before pre-dictable implant restoration. The ridge hadhealed with adequate soft tissue in thebucco-lingual and apico-occlusal dimen-sions. At the time of tooth preparation forthe fixed restoration, the soft tissue wascontoured with a large coarse diamond and

a bis-acryl provisional was contoured topress into the soft tissue preparation andencourage favourable healing (Figure. 3).When the final restoration was tried in itblanched the tissue (Figure 4). After 5 min-utes the blanching disappeared and thepontic had the illusion of a tooth emergingfrom periodontal tissue (Figure 5).

Case 2: Gingival Augmentation toCreate a Soft Tissue RidgeThe patient presented with an implant inthe upper right central incisor location. Hewanted a comprehensive dental restoration.The implant was placed at the time of toothextraction and had been placed too far api-cally and facially. As part of the comprehen-sive treatment plan, the remaining incisorswere to be restored and would serve well asabutments for a bridge supporting the pon-tic in the right central incisor position.When it was first examined, the implanthad a healing abutment screwed to theimplant in the upper right central incisorposition and a pontic bonded to the adja-cent teeth (Figure 6). Soft tissue augmenta-tion to create coverage of the facial surfaceof the implant had been attempted but wasunsuccessful. When the healing abutmentwas removed, however, there was adequatespace and blood supply for a ridge augmen-tation using a pedicle graft from the palate.This was accomplished with success. Theridge could then be prepared at the time ofprovisionalization to create a pontic recep-tor site, as was done in case 1. The provi-sional was fabricated directly in the mouthand then allowed to guide the soft tissuematuration for several months (Figure 7).The timing of the soft tissue surgery andanterior provisionalization coincided withthe posterior provisionalization. The poste-rior provisionalization was required inorder to evaluate long-term occlusal stabili-ty in this bite opening case as is taught byDawson.1 In the definitive restoration thepontic gives the illusion of a tooth emergingfrom periodontal tissue (Figures 8 and 9).

Case 3: Planning the Intrusion ofthe Anterior Segment with SoftTissue ManagementThe patient attended with mobility of theupper central incisors and inadequate peri-odontal support of all maxillary incisors. Hehad an angle class II skeletal pattern anddental class II, division 2 occlusion with


Figure 2. The right lateral incisor was extract-ed years earlier, and then replaced by aremovable partial denture. There is inade-quate bone for an implant without augmen-tation but adequate soft tissue remains foran esthetic restoration.

Figure 3. Two weeks after tooth preparation,tissue contouring and cementation of a bis-acryl provisional the tissue has healingfavourable to an ovate pontic.

Figure 4.When the definitive restoration istried in and fully seated the soft tissue willblanch for only 5 minutes.

typical2 severe overbite and maxillary ante-rior crowding (Figures 10 and 11). Themaxillary teeth have supra-erupted, alongwith their soft tissue support (Figure 12).He has excessive display of teeth and softtissue upon smiling. Although there was tobe posterior restorative treatment as part ofthe comprehensive treatment plan, therewas no need to increase vertical dimensionin order to create posterior restorative room(Figures 13 and 14).The treatment plan required an increase inthe anterior vertical dimension for restora-tion of function and aesthetics. This can beaccomplished in one or a combination ofways3,4 including the following:• Orthodontic: intrusion/relative extru-

sion• Periodontal: Repositioning of the gin-

gival margin (surgical crown length-ening

• Restorative: increasing posteriorrestorative vertical dimension (“biteraising”)

• Surgical: segmental osteotomy andintrusion of the anterior segment

Interdisciplinary treatment planning of thecase resulted in the decision to intrude themaxillary anterior by use of a combinationapproach to treatment. The incisor teethwere extracted (as they were periodontallycompromised) and the soft tissue healingdirected by use of a long term bis-acryl lab-oratory processed provisional restoration.This created the illusion that the periodon-tal apparatus was moved apically.The case was planned in the same way as adenture set-up is planned. The teeth wereremoved from the model and the ideal loca-tion of the central incisors determined,using the “neutral zone” as taught byDawson1 as a guide (Figure 15). A full con-tour waxup was completed for the case(Figure 16). Laboratory processed bis-acrylprovisional restorations (Radica Dentsply,York, PA) were fabricated (Figures 17 and18). When the teeth were extracted the softtissue was reflected sufficiently to allowosseous recontouring as guided by the sur-gical stent fabricated from the waxup. Theadjacent teeth were prepared as abutmentsfor the anterior bridge The provisionalrestoration was relined with flowable bis-acryl material (Integrity, Dentsply, York,PA) (Figures 19 and 20) and cemented withtemporary cement (Figure 21). Over thesubsequent 4 months, the provisionals,which can easily be augmented and pol-ished (Figures 22 and 23), were used to

KLEEBERGER


Figure 5. To relieve the patient from wearinga removable prosthesis, the cantilever bridgewas placed. The shade is the final shade forthe comprehensive restoration planned tocontinue in the future and to include theremaining anterior teeth. Note the labialemergence profile of the restoration.

Figure 6. The implant had been placed too farapically and labially to be restorable. Theresulting soft tissue defect is an estheticchallenge. An acrylic pontic has been bondedto the adjacent teeth to serve as a provisionalrestoration.

Figure 7. The healing abutment was removedand gingival augmentation surgery (pediclegraft) created adequate soft tissue volume.The provisional restoration helped guide thesoft tissue during maturation following sur-gery. This working model demonstrates theresulting soft tissue contours achieved fromadequate provisionalization.

Figure 8. Lateral view of the definitiverestoration. Note absence of scaring in thearea of the soft tissue augmentation aroundright central incisor pontic and the normalemergence profile.

Figure 9. Anterior retracted view of the defin-itive restoration at 3-years post treatment.

Figure 10. The patients chief concerns werehis failing posterior teeth and his loose max-illary anterior teeth.



Figure 11 Retracted anterior view. Note thesevere overbite and crowding of the maxil-lary anterior teeth which is typical of theclass II, division 2 occlusal pattern.

Figure 12. The anterior teeth, lacking contactwith lower incisors have supra-erupted. Thesoft tissue margins of the incisors, except forthe right central are incisal of their ideal loca-tion relative to the gingival margins of thecuspids bilaterally.

Figure 13. Lateral view demonstrating restora-tive needs.

Figure 14. In this lateral view, sufficient verti-cal room without bite raising for restorationis apparent.

Figure 17. Anterior view of the second labora-tory processed Radica provisional restora-tions.

Figure 19. The bis-acryl provisionals arerelined using the same technique used tobond to composite direct restorations includ-ing priming/bonding and application of flow-able bis-acryl resin.

Figure 20. The relined restorations are seatedin the mouth, allowed to self cure and thenremoved to trim to precise margins.

Figure 21. On the day of surgery the provi-sional restoration is seated, exerting pressurewhere necessary to direct the soft tissue tothe contours planned on the diagnosticmodel.

Figure 18. Close-up and reflected view of theprovisional restorations showing the highdegree of esthetic possible.

Figure 15. Adjustment of the model to deter-mine final position of the incisal edge wasplanned for the “neutral zone.”

Figure 16. Full contour waxup of the finalrestoration for diagnosis and to create thecontours of the provisional restoration.

guide the soft tissue healing. Differentialpressure along the edentulous ridge fromthe pontics guided the soft tissue to heal ina more apical direction and symmetrically.After 4 months the process of soft tissuemanagement with the provisional is com-pleted (Figures 24 and 25). The definitiverestoration creates the illusion of a toothemerging from healthy periodontal tissue(Figures 26–29).Peri-Implant Tissue GuidanceIn the absence of other limiting factors, theearlier that a provisional restoration can beplaced on a dental implant the more likely itis that the resulting soft tissue will be aes-thetically acceptable. Although somechanges are possible at the time of secondstage surgery (cover screw removal), theideal time is at the time of implant place-ment. If the implant is placed into a freshextraction site it may be even more pre-dictable. In the absence of infection and thepresence of adequate bone and soft tissue,the transition to an inconspicuous implantborne restoration is most predictable if thesoft tissue is supported adequately by a pro-visional prosthesis beginning at the time thetooth is lost.

Case 4: Provisional Placement attime of Extraction and ImplantPlacementThis patient had injured his right centralincisor and it had been restored with acrown and post (Figures 30 and 31).Fracture of the root necessitated extractionbut the associated tissues were adequatelyhealthy to permit the immediate placementof an implant at the time of tooth extrac-tion. The same day that the tooth wasextracted and the implant placed, thepatient received a custom composite provi-sional restorations designed to mimic thenatural tooth contours (Figures 32–35) inorder that the soft tissue would be support-ed and guided during healing. The proce-dure for fabricating this restoration hasbeen previously described5 and it is accom-plished with layering restorative bis-acrylcomposite with hybrid filler particles isshown by Fahl.6,7 Following removal of theprovisional at 6 months the natural appear-ance of the periodontal tissues is evident(Figure 36). The final restoration (Figure37) predictably maintains the soft tissuecontours.

KLEEBERGER


Figure 22. The provisionals are removed atintervals of 2, 4, 8, and 16 weeks and checkedfor adequate soft tissue surface contour. Theyare relined to continue pressure in areaswhere required.

Figure 23. The bis-acryl provisionals can bepolished with any composite polishing sys-tem or glazed with unfilled resin.

Figure 24. The soft tissue healing is complete.The provisionals have been relined as neededto crate ideal contours as predicted in thediagnostic phase.

Figure 27. The final restoration, retracted viewdemonstrating the gingival contours.

Figure 25. The ovate pontic receptor sites seenon the crest of the ridge were created by therelining of the bis-acryl provisionals.

Figure 28. The final restoration demonstrat-ing the illusion of teeth emerging fromhealthy periodontal tissue (right lateralview).

Figure 26. The final restoration demonstrat-ing the improved gingival tissue display.

Figure 29. The final restoration demonstrat-ing the illusion of teeth emerging fromhealthy periodontal tissue (left lateral view).


Case 5: Provisional Placement atTime of Second Stage ImplantSurgeryThis patient was congenitally missing themaxillary lateral incisors. At age 13 yearsthe teeth were replaced with bonded fixedrestorations (Figure 38). The restorationswere removed (Figure 39) in order thatimplants could be placed in the spaces pre-served by the bonded restorations at age 18years. At the time of 2nd stage surgery thesoft tissue was guided by a provisionalrestoration made of hybrid composite lay-ered onto a provisional abutment as was

done in case 4 (Figure 40).In this case, the left lateral incisor had ade-quate soft tissue volume for an ideal resultwithout soft tissue augmentation. At thetime of 2nd stage implant surgery, there wasfound to be minimal soft tissue volume forthe right lateral incisor; however. The con-nective tissue pedicle graft extending fromthe palate could have been used to createadequate soft tissue thickness in order that aprovisional restoration could be used toguide the soft tissue healing followingimplant exposure (2nd stage surgery). Thepatient, however, refused the additional sur-gery deciding that the benefit of the surgery

would be minimal.The composite provisional can be easilyreshaped to create contours for tissue sup-port and guidance. It can be augmented andreshaped by air abrading the surface, sila-nating and bonding to the old composite. Ifsufficient soft tissue thickness is present, byincreasing the profile of the emergence, thesoft tissue moves apically, and by reducingthe profile the soft tissue moves in anocclusal direction. These adjustments aremade in the provisional in order that thecontours can be finalized prior to the finalimpression. The resulting soft tissue con-tours are captured in the final impression


Figure 30. Initial presentation of the failingright central incisor.

Figure 33. Provisional restoration (lingualview).

Figure 31. Initial presentation radiograph.

Figure 34. Provisional restoration (apicalview).

Figure 35. Correct mesial and distal contoursof the provisional restoration.

Figure 32. Provisional restoration (labial view).It is important in creating the provisionalrestoration that the anatomy of the tooth beduplicated. Interdental tissue support is cre-ated by mesial and distal contours and dis-tinct line angles and height of labial of softtissue is maintained by correct emergenceprofile.

Figure 36. After 6 months the provisionalrestoration has created excellent soft tissuecontours for the final prosthesis.

using a rigid material, such as flowable lightcure resin which is injected around theimpression coping immediately afterremoval of the provisional, and then dupli-cated in the final restoration (Figure 41).The final restoration predictably achievesesthetic soft tissue profiles if there is ade-quate soft tissue to manipulate with the pro-visional restoration.

ConclusionPatients demand that we provide improvedesthetic services in restorative dentistry.With improved understanding of the biolo-gy, materials, and techniques to manage softtissue during provisionalization it is possibleto create a restoration that appears natural.The treatment planning for these proce-dures requires the coordination of specialistservices.The five cases presented demonstrate themanagement with provisionals, of soft tis-sue in cases which involve implants andthose which do not, and in which the clini-cal situation permits management from thetime of tooth loss and those which involvemanagement until after the ridge is healed.All use bis-acryl composite technologies forthe provisionalization procedures.

AcknowledgementsThe author wishes to thank Dr. JenniferCote, DDS, MSC DipPerio, for her assis-tance with Cases 2 and 4 and Dr. Ron

KLEEBERGER


Figure 41. Final restoration of the maxillarylateral incisors. The provisional restorationswere used to manipulate the soft tissue mar-gins by adjusting the contour of the emer-gence profile. On the left incisor, where therewas sufficient soft tissue, the tissue is ideal,on the right where there was inadequatelabial soft tissue, the gingival margin place-ment is more incisal than the idea.

Figure 39. Bonded bridges are removed andthe ridges are ready for implants

Figure 40. Provisional bis-acryl crowns wereplaced on implants following 2nd stageimplant surgery. Note the gingival margin ismore incisal than ideal on the lateral incisors.

Figure 37. Final restoration.

Fulton, DMD, MSc, DipPerio, for Case 5.Also special thanks to Mr. Barry Morleyand his team at Fine Arts DentalLaboratories, Vancouver, for laboratoryservices for all the cases presented.

DisclosureThe author delclares no competing financialinterests.

References1. Dawson PE. Functional Occlusion From

TMJ to Smile Design.Mosby Elsevier: St.Louis,MO, 2007.

2. ProfitWR Contemporary Orthodontics,2nd Ed.Mosby Elsevier: St. Louis,MO,1993.

3. Spear F. Occlusion in Clinical Practice.Seattle Institute for Advanced DentalEducation: Seattle,WA, 2003.

4. Spear FM, Kokich VG. A multidiscplinaryapproach to esthetic dentistry. Dent ClinN Amer 2007;51:487–505.

5. Kleeberger BG. Single tooth replacement:the ultimate aesthetic challenge. OralHealth 2009;109–115.

6. Fahl N. A Polychromatic composite layer-ing approach for solving a complex classIV/direct veneer-diastema combination:Part I. Pract Proced Aesthet Dent2006;18(10):641–45.

7. Fahl N. A Polychromatic composite layer-ing approach for solving a complex classIV/direct veneer-diastema combination:Part II. Pract Proced Aesthet Dent2007;19(1):17–22.

Figure 38. Bonded bridges replace the rightand left lateral incisors.


Computer-Assisted ImplantSurgery:

Evolving Standards of Care

By Domenic Morielli, BSc, DDS, Certified Oral and Maxillo-Facial Surgeon

ABSTRACTHistorically, surgical and prosthetic considerations in implant treatment did not always inter-sect. This sometimes resulted in situations where a great deal of effort and imagination wererequired on the part of the restorative dentist to complete certain cases. Surgeons did notalways have a good grasp of the prosthetic imperatives when placing implants. In addition,implant position and distribution were often decided at the time of surgery. Restorative den-tists on the other hand sometimes had limited understanding of the surgical difficulties ofplacing implants in atrophic ridges or compromised sites. These problems were graduallyaddressed by the emergence of teams of surgeons and prosthodontists working in close col-laboration, eventually resulting in more predictable outcomes. However, the developments ofnew materials and techniques have required a great deal of coordination and communicationbetween surgeon and restorative dentist, a difficult task when those involved are not in thesame office or at least close by. These, as well as many other concerns, are addressed by NobelBiocare’s NobelGuide system (NobelBiocare, Toronto, Ontario).

COMPUTERIZED DENTISTRY

About the AuthorDr.Morielli is a graduate of McGill where he obtained a BSc in physiology as well as a DDS. After completing

a multidisciplinary residency at St. Mary’s Hospital, he went on to pursue his training in maxillofacialsurgery at Laval University where he is a clinical professor in oral and maxillofacial surgery. In addition tomaintaining a private practice, Dr.Morielli has lectured extensively on implant surgery and traumatic

neuropathies of the trigeminal nerve.

The amalgamation of 3-D imaging,computer-assisted planning, and

stereolithographic surgical guide produc-tion for guided surgery is the basis for theNobelGuide concept.1–3 Data resultingfrom a computed tomography (CT) scanare used to produce a computer-generated3-D image of the patient’s maxilla ormandible as well as that of a precise radi-ographic guide reflecting idealized toothposition. A double-scan technique is usedwhereby one scan is taken with thepatient wearing the radiographic guideaccurately positioned in place with aradiotranslucent bite registration wafer. Asecond scan is then taken of the guidealone. Gutta percha points inserted in theguide allow the computer to align it withthe image of the patient’s bone. The oper-ator can then remove and replace theguide at will, as well as manipulate the 3-D image in various ways. I usually begin

the general evaluation of the patient’sbone at this time looking for obviousanomalies, ridge defects, residual roots,etc. I do this in the planning windowusing the left screen for gross evaluation,and I then quickly scroll through theentire jaw with the perpendicular re-slicefunction on the right screen (Figure 1). Ithen place the prosthesis on the imageand once again scroll through thepatient’s jaw evaluating gross relationshipbetween the residual crest and proposedtooth position (Figure 2). Various viewoptions then permit a site-by-site analysisafter placing implants based on preferredimplant distribution (Figures 3–5). Thiscomprises the first level of application ofthe NobelGuide concept (its use as a diag-nostic tool). Bone volume and morpholo-gy relative to tooth position can bedeemed inadequate and augmentationprocedures can be planned if needed.

Graft volume, material, and technique canthen be determined. If, on the other hand,a large amount of bone is available, it maybe decided to proceed to surgery by con-ventional techniques after converting theradiographic guide into a surgical guide.In my experience, implant inclination anddepth must often be altered to achievecomplete bone coverage, and accuratelyreproducing these inclinations on theradiographic guide is not an easy task.The next level of the NobelGuide conceptcan then begin if prosthetic requirements asdetermined by the restorative dentist havebeen met. This condition can be verified intwo ways. An image-capture function canbe used to transmit images to the restorativedentist, or the whole case-planning file canbe downloaded to a server that the restora-tive dentist can access and view the appro-priate file. At this point, final implant posi-tion, type, and dimensions are determined.This information is then transferred via theInternet to NobelBiocare where a surgicalguide is stereolithographically producedand returned to the operator (Figure 6).This guide is then placed on the patient’smounted casts and a bite registration waferis fabricated to allow precise placement inthe mouth at time of surgery. After verify-ing fit and adaptation, the guide is fixedtrans-mucosally to the patient’s bone by theuse of guide pins whose positions are alsodetermined during the planning phase. Theguide is at this point precisely related inthree dimensions to the underlying bone asvisualized on the 3-D computer image(Figures 7 and 8).Surgery can be undertaken as a flapless pro-cedure when appropriate conditions exist.These include of course adequate bone vol-ume and the presence of healthy immobilemucosa at the proposed implant sites. It isbeyond the scope of this article to debatethe necessity of having keratinized tissuesurrounding the trans-mucosal componentsof the implants, although I believe this to bedesirable. A flapless approach for implantplacement has already been described else-where.4,5 The first step in the surgical proce-dure consists of using a special drill whosefunction is to remove the mucosa overlyingthe implant sites while at the same timecountersinking the crestal bone to accom-modate the implant shoulder. This is donedirectly through the guide rings in the sur-gical guide contrary to the rest of thedrilling sequence which uses drill-guides ofdiameters corresponding to the drills indi-cated for each site. I prefer using a tissue

MORIELLI


Historically, surgical and prosthetic considerations in implant treatment didnot always intersect. This sometimes resulted in situations where a great dealof effort and imagination were required on the part of the restorative dentistto complete certain cases. Surgeons did not always have a good grasp of theprosthetic imperatives when placing implants. In addition, implant positionand distribution were often decided at the time of surgery. “I put them wherethe bone was,” is a phrase often heard in the past but no longer acceptabletoday. Restorative dentists on the other hand sometimes had limited under-standing of the surgical difficulties of placing implants in atrophic ridges orcompromised sites. Surgical guides, when provided, did not always consideranatomical limitations, therefore obliging the surgeon to make preoperativedecisions based on his or her understanding of the prosthodontics involved.These problems were gradually addressed by the emergence of teams of sur-geons and prosthodontists working in close collaboration, eventually resultingin more predictable outcomes. The development of a wide range of prostheticcomponents, regenerative materials, and grafting techniques eventuallyallowed these teams to treat most situations. The advent of modern imagingtechnologies and anatomical radiographic guides further enhanced pre-dictability by allowing implants to be placed relative to tooth position while atthe same time respecting anatomical structures, that is, prosthetic-drivenimplant placement. All this, however, required a great deal of coordinationand communication between surgeon and restorative dentist, a difficult taskwhen those involved are not in the same office or at least close by. These, aswell as many other concerns, are addressed by Nobel Biocare’s NobelGuidesystem (NobelBiocare, Toronto, Ontario).

COMPUTER-ASSISTED IMPLANT SURGERY: EVOLVING STANDARDS OF CARE

punch of appropriate diameter prior to thisstep to make tissue removal easier and morecomplete. The drill guides are insertedsequentially into the guide rings, and thedrills are therefore guided through the bonein precisely the same axis as in the virtualimage of the patient’s jaw. The position andinclination of the implants are thus assured,while depth is limited by placing drill-stopson the drills prior to commencing. Notethat the guide rings are embedded in theguide such that the platform of the implantis precisely 10 mm from the occlusal surface

of these rings. All of the instrumentationinvolved is designed to fulfill this condition.After completing the drilling sequence, animplant mount is fixed to the implants,which are then inserted through the guiderings without removing the guide. Theimplants are deemed to have attained prop-er depth when the shoulder of the implantmount comes into contact with the top ofthe guide rings. Because absolute congruen-cy between the prepared sites and angle ofimplant insertion is impossible even withthe NobelGuide technique, friction between

the guide rings and the implant mounts canlead the operator to believe that the under-lying bone is much denser than it is in reali-ty. This can be very significant especiallywhen the treatment plan involves theimmediate placement of a fixed prosthesis,and one or more unstable implants maymake this impossible. It has already beenshown that immediate placement of a fixedprosthesis on stable implants is a validoption even in fully edentulous cases (seeFigures 1–3, 6 and 7). After the implants areplaced, I once again use a tissue punch


Figure 1. Planning window with 3-D view on left and 2-D view on right.

Figure 2. Perpendicular re-slice plane can be scrolled through the 3-D image and viewed on theright screen.

Figure 3. Perpendicular re-slice plane posi-tioned at left canine site with guide in place.

Figure 4. Implant positioned on right screen.

expandable abutments that compensate forthe slight incongruence between the trueand planned position of the implants(Figure 12). When existing keratinizedmucosa is insufficient, I have found it to bepossible to use very conservative flaps inthe maxilla to reposition palatal mucosasince the surgical guide allows me to placethe implants without having to visuallyverify whether full bone coverage is possi-ble.The posterior mandible is one area whereNobelGuide is of unquestionable value.

MORIELLI

Canadian Journal of Restorative Dentistry and ProsthondonticsSummer 2009

Figure 5. Implant can be seen to protrude through bone and should berepositioned.

Figure 6. Surgical guide with six guide rings and three guide pin chan-nels.

through the guide rings after carefullyremoving the implant mounts, then with-draw the surgical guide and remove any softtissue debris overlying the head of theimplants. It thus becomes much easier toplace temporary abutments when indicated(Figure 9). This step is especially importantif the third level of the NobelGuide conceptis applied, that is, immediate fixation of ascrew-retained prosthesis (Figures 10 and11), as complete seating may be hamperedby the presence residual soft tissue. Theprosthesis is fixed by means of special

Figure 7. Surgical guide positioned by means of a bite registration pro-duced on mounted models and secured by three guide pins.

Figure 8. An even blanching of the tissue beneath the guide isobserved.

Several parameters are involved in deter-mining the feasibility of restoring this zonewith implant-supported restorations. Thefirst, and most important of course, isbone height above the inferior alveolarnerve canal. Damage to this structure by adrill or an implant can have dramatic con-sequences. Using NobelGuide to visualizethe inferior alveolar nerve (IAN) and thendrill and place the implants using guidedsurgery can minimize the risk to thepatient. The nerve can be visualized andmarked in various ways allowing an accu-

49


COMPUTER-ASSISTED IMPLANT SURGERY: EVOLVING STANDARDS OF CARE

rate evaluation of the available bone aboveit before placing the implants in theplanned positions. Other than IAN posi-tion, lingual concavities as well as crestalthickness and inclination can also be eval-uated (Figures 13 and 14).As with any new technique or procedure,there is a learning curve associated withNobelGuide. The steepness of this curvewill depend on a number of factors includ-ing the operator’s comfort with computers,as well as previous experience with implantsurgery and restoration. The software por-tion can be quite a challenge for some, but alarge part of the process can easily be dele-gated. In my practice, for example, my

implant coordinator inputs patient CT scandata, examines the resulting images, andverifies that the radiographic guide was welladapted to the subjacent tissues during thescan. This having been done, I can use mytime for diagnosis and placing implants onthe 3-D image. This is actually quitestraightforward as the implants can bemoved or changed as often as one wishesuntil a satisfactory position is achieved orthe treatment plan is altered.Only basic experience with computers isrequired to perform this virtual surgery. Acertain amount of surgical experience ishowever necessary because, as with anyother procedure, unexpected situations may

arise. It may, for example, not be possible toachieve primary stability for one or moreimplants. The operator must be able to dealwith this or any other complication associ-ated with conventional implant surgery andmust always have a rescue plan for both thesurgical and the prosthetic portion of thetreatment. I have had to replace an implantwith one with a larger diameter on twooccasions and alter the position of animplant on one occasion after a buccal platefracture during implant insertion. Hadthese cases involved an immediate prosthe-sis, it might have been impossible to deliverit if I did not have sufficient understandingof the prosthetics involved. Problems canarise even before planning begins. One thatI have encountered on a few occasions isthat the radiographic guide does not seatproperly in the mouth. This, of course, isvery serious since every subsequent step inthe process will be skewed. I believe that itis imperative to take very accurate impres-sions and pour the cast as though it were amaster cast for a multi-unit bridge. Alginateand plaster are not adequate materials forthis situation.In addition to its application as a diagnosticand planning tool, I also depend onNobelGuide to more easily convey topatients what their particular situationinvolves. When a patient can actually see a3-D image of his or her residual ridge witha large portion of an implant surface pro-truding through it, explaining why a graftor augmentation procedure is requiredbecomes much easier. The same is truewhen explaining the risk to the inferioralveolar nerve if the patient can see it cours-

Figure 9. After surgery is completed, the guide is removed and tempo-rary abutments are placed if no immediate prosthesis was planned.

Figure 10. Immediate prosthesis (occlusal view).

Figure 11. Immediate prosthesis (lateral view).


ing through the mandible and the implantspositioned above.

ConclusionAfter using NobelGuide to the first, second,or third level in over 200 cases from singletooth to complete upper and lower edenta-tion, I have found that it not only makesresults more predictable but decreases thesurgical time, minimizes the invasive natureof the surgery, and diminishes the risk toanatomic structures such as the IAN resultwith significantly reduced post-operativepain and morbidity for the patient.Although the cost for the radiographicguide, CT scan, and surgical guide can beclose to 2,000 dollars, not a single patienthas refused to proceed once the advantageswere explained. Furthermore, as surgicalcomponent dimensions are determined atthe planning stage, staff can place orders onan as-needed basis, minimizing the need fora large inventory. Because of the aforemen-tioned reasons, I believe NobelGuide will

quickly become the new standard of care inthe planning and execution of implantcases, and it has become an indispensabletool in my practice.

DisclosureThe author declares no competing financialinterests.

References1. van Steenberghe D, Naert I, Andersson M,

et al. A custom template and definitiveprosthesis allowing immediate implantloading in the maxilla: A clinical report.Int J Oral Maxillofac Implant2002;17(5):663–70

2. van Steenberghe D, Ericsson I, VanCleynenbreugel J, et al. High precisionplanning for oral implants based on 3-DCT scanning. A new surgical technique forimmediate and delayed loading. ApplOsseointegration Res 2004;4:27–31.

3. van Steenberghe D, Glauser R, BlombäckU, et al. A computed tomographic scan-

derived customized surgical template andfixed prosthesis for flapless surgery andimmediate loading of implants in fullyedentulous maxillae. A prospective multi-center study. Clin Implant Dent Relat Res2005;7(Suppl 1):S111–120.

4. Campelo LD, Camara JR. Flapless implantsurgery: a 10-year clinical retrospectiveanalysis. Int J Oral Maxillofac Implants2002;17(2):271–6.

5. BeckerW,Goldstein M, Becker BE, et al.Minimally invasive flapless implant sur-gery: a prospective multicenter study. ClinImplant Dent Relat Res 2005;7(Suppl1):S21–7.

6. Brånemark PI, Engstrand P, Ohrnell LO etal. Brånemark Novum. A new treatmentconcept for rehabilitation of the edentu-lous mandible. Preliminary results from aprospective clinical follow-up study. ClinImplant Dent Relat Res 1999;1:2–16.

7. Henry PJ, van Steenberghe D, Blomback U,et al. Prospective multicenter study onimmediate rehabilitation of edentulouslower jaws according to the BranemarkNovum protocol. Clin Implant Dent RelatRes 2003;5:137–42.

MORIELLI

Figure 13. Transparency mode showing theinferior alveolar nerve coursing through themandible.

Figure 14. Perpendicular re-slice from Figure13 showing implant position relative to theinferior alveolar nerve, residual crest, pro-posed tooth position, and lingual concavity.

Figure 12. Expandable abutment: as the abut-ment-screw is tightened, the four “wings” ofthe abutment’s collar expand and engage theprosthesis thereby securing it to theimplants.

Chirurgie d’implant assistéepar ordinateur:

Des normes de soins en évolutionPar Domenic Morielli, BSc, DDS, Chirurgien buccal et maxillo-facial agrée

RÉSUMÉA travers l’histoire, les considérations chirurgicales et prothétiques dans le traitement parimplant n’ont pas toujours convergé. Ceci aboutissait des fois à des situations qui exigeaientbeaucoup d’efforts et beaucoup d’imagination du dentiste restaurateur pour finir certains cas.Les chirurgiens n’ont pas toujours eu une bonne perception des impératifs prothétiques quandils mettaient en place des implants. En plus, la décision quant à la position de l’implant et à sadistribution était souvent prise au cours de l’intervention. Les dentistes restaurateurs, à l’op-posé, avaient parfois une compréhension limitée des difficultés chirurgicales de la mise enplace d’implants dans des crêtes atrophiques ou des sites fragilisés. Ces problèmes ont étégraduellement résolus avec l’émergence d’équipes de chirurgiens et de prosthodontistes qui, entravaillant en étroite collaboration, ont éventuellement rendus possible des résultats prévisi-bles. Néanmoins, le développement de matériaux nouveaux et de techniques nouvelles a exigéune grande demande de coordination et communication entre le chirurgien et le dentisterestaurateur, difficile quand les personnes impliquées n’opèrent pas dans le même cabinet oumême à proximité. Le système NobelGuide de Nobel Biocare (NobelBiocare, Toronto, Ontario)répond à ces préoccupations ainsi qu’à d’autres.

DENTISTERIE NUMÉRIQUE

L’auteurDr Morielli est promu de McGill University ayant obtenu un B.Sc. en physiologie ainsi qu’un D.D.S.

Après avoir complété une résidence multidisciplinaire à St-Mary’s Hospital, il poursuivit des études enchirurgie buccale et maxillofaciale à l’Université Laval, où il est professeur de la matière. En plus de main-tenir une pratique privée, le Dr Morielli a donné de nombreuses conférences sur la chirurgie implantaire et

les neuropathies traumatiques du nerf trijumeau.


L’amalgamation de l’imagerie 3-D, laplanification assistée par ordinateur, et

le guide de production chirurgicale stere-olithographique pour des chirurgiesguidées sont les fondations du concept duNobelGuide.1–3 Les données résultant dubalayage tomodensitométrique sont util-isées pour produire une image généréepar ordinateur en 3-D du maxillaire oudu maxillaire inferieure du patient, aussibien que le guide radiographique précisréfléchissant la position idéale de la dent.Une technique à double scintigramme estutilisée, un scintigramme est pris dupatient ayant le guide radiographiqueplacé avec précision avec une plaquettemétallique enregistrant la morsure radiotransparente. Un deuxième scintigrammeest ensuite pris avec le guide seulement.Les points du Gutta percha insérés dans leguide permettent à l’ordinateur de s’align-er avec l’image de l’os du patient.L’operateur peut ensuite enlever et rem-placer le guide comme bon lui semble, etaussi manipuler l’image 3-D de plusieursfaçons. Je commence généralement l’éval-uation de l’os du patient à ce moment là,essayant de retrouver des anomalies évi-dentes, des défauts de crêtes, des racinesrésiduelles, etc. Je fais ceci dans la phasede planification en utilisant l’écran àgauche pour l’évaluation sommaire, etensuite je défile à travers toute la joueavec la fonction de vue anatomique per-pendiculaire sur l’écran à droite (Figure

1). Je place ensuite la prothèse sur l’imageet encore une fois je défile sur la joue dupatient(e) pour évaluer les relations som-maires entre la crête résiduelle et la posi-tion proposée de la dent (Figure 2). Desoptions variées de vue permettent ensuiteune analyse site par site après le place-ment d’implants en distribution préférée(Figures 3–5). Ceci compose le premierniveau d’application du conceptNobelGuide (son utilisation en tantqu’outil de diagnostic). Le volume de l’oset la morphologie relative à la position dela dent peuvent-être considérésinadéquats et des procédures d’augmenta-tion peuvent être planifiées le cas échéant.Le volume du greffon, la matière, et latechnique peuvent être déterminés.D’autre part, si une grande masse d’os estdisponible, la décision pourrait être prised’aller de l’avant avec l’intervention avecdes techniques classiques suite à la con-version du guide radiographique en guidechirurgical. Mon expérience m’a apprisque l’inclinaison et la profondeur de l’im-plant sont souvent altérées pour réussirune couverture complète de l’os, et repro-duire de manière précise ces inclinaisonsdans le guide radiographique n’est pasfacile.Le niveau suivant du concept duNobelGuide peut alors être entamé si lesexigences prosthétiques, telles déterminéespar le dentiste restaurateur, sont réunies.Cet état est constaté par deux moyens. Une

fonction de capture d’image est utilisée pourtransmettre les images au dentiste restaura-teur, le dossier complet de la planificationdu cas est téléchargé à un serveur auquel ledentiste restaurateur peut avoir accès etrevoir le dossier approprié. A ce stade, laposition de l’implant, son type et ses dimen-sions sont déterminées. Cette informationest ensuite transférée via l’internet àNobelBiocare ou un guide chirurgical estproduit stereolithographiquement et ren-voyé à l’operateur (Figure 6). Ce guide estensuite placé dans les modèles montés dupatient et une gaufrette d’enregistrement encire d’occlusion est fabriquée afin de perme-ttre un placement précis dans la bouche aucours de l’intervention. Après vérificationde l’ajustement et de l’adaptation, le guideest fixé à l’os du patient en utilisant lesergots du guide dont les positions sont aussidéterminées durant la phase de planifica-tion. Le guide est jusqu’ici lié précisémenten trois dimensions à l’os sous-jacentcomme on peut le voir sur l’image par ordi-nateur en 3-D (Figures 7 and 8).La chirurgie est prévue en tant que procédésans lambeaux quand les conditions appro-priées sont présentes. Ceci comprend biensur le volume de l’os et la présence demuqueuse saine et immobile aux sites pro-posés de l’implant. Ce n’est pas du champ dediscussion de cet article de débattre de lanécessité d’avoir du tissue kératinisé autourdes composants transmucosaux desimplants, toutefois je crois que ceci est

MORIELLI


A travers l’histoire, les considérations chirurgicales et prothétiques dans le traitement par implant n’ont pas toujoursconvergé. Ceci aboutissait des fois à des situations qui exigeaient beaucoup d’efforts et beaucoup d’imagination dudentiste restaurateur pour finir certains cas. Les chirurgiens n’ont pas toujours eu une bonne perception des impératifsprothétiques au moment de mettre en place des implants. En plus, la décision quant à la position de l’implant et à sadistribution était souvent prise au cours de l’intervention. “Je les place à l’endroit de l’os” est une phrase souvent enten-due dans le passé mais aujourd’hui inacceptable. Les dentistes restaurateurs, à l’opposé, avaient parfois une com-préhension limitée des difficultés chirurgicales de la mise en place d’implants dans des crêtes atrophiques ou des sitesfragilisés. Les guides chirurgicaux, quand ils sont disponibles, n’ont pas toujours pris en considération les limitationsanatomiques, obligeant le chirurgien à prendre des décisions préopératoires basées sur son ou sa perception de laprosthodontie impliquée. Ces problèmes ont été graduellement résolus avec l’émergence d’équipes de chirurgiens et deprosthodontistes qui, en travaillant en étroite collaboration, ont éventuellement rendus possible des résultats prévisi-bles. Le développement d’un large éventail de composants prothétiques, de matières régénératives, et de techniques degreffe, a éventuellement permis à ces équipes de traiter la plupart des situations. L’arrivée de technologies modernesd’imagerie et de guides radiographiques anatomiques a rehaussé la prévisibilité en permettant la mise en place d’im-plants relativement à la position de la dent tout en respectant les structures anatomiques, ceci étant, le placementd’implants dirigés par la prosthodontie. Toutefois, ceci exige une grande coordination et communication entrechirurgiens et dentistes restaurateurs, difficile et compliquée quand les personnes impliquées n’opèrent pas dans lemême cabinet ou à proximité. Le système NobelGuide de Nobel Biocare (NobelBiocare, Toronto, Ontario) répond aces préoccupations ainsi qu’à d’autres.

CHIRURGIE D’IMPLANT ASSISTÉE PAR ORDINATEUR: DES NORMES DE SOINS EN ÉVOLUTION

souhaitable. Une approche sans lambeauxpour le placement des implants a déjà étédécrite ailleurs.4,5 La première étape de laprocédure chirurgicale consiste a utiliser unforet spécial dont la fonction est d’enlever lamuqueuse sus-jacent les sites de l’implanttout en en contreperçant la crête de l’os pourpermettre l’épaulement de l’implant. Ceci estfait directement à travers les anneaux duguide dans le guide chirurgical contraire-ment au reste de la séquence du foret quiutilise les guides forets dont les diamètrescorrespondent aux forets correspondant à

chaque site. Je préfère utiliser un emporte-pièce de diamètre approprié avant cetteétape pour faciliter et mieux compléter l’ex-traction du tissue. Les guides des forets sontinsérés de façon séquentielle dans lesanneaux du guide, par conséquent les foretssont guidés à travers l’os précisément dans lemême axe que dans l’image virtuelle de lajoue du patient. La position et l’inclinaisondes implants sont ainsi assurées, tout enlimitant la profondeur en plaçant des arrêtsde forets avant d’avancer. Notez que lesanneaux du guide sont inclus dans le guide

de façon à ce que la plateforme de l’implantest précisément à 10 mm de la surfaceocclusale de ces anneaux. Toute l’instru-mentation impliquée est conçue pour rem-plir cette condition.Une fois la séquence de perforation com-plétée, une monture d’implant est fixée auximplants, qui sont ensuite insérés à traversles anneaux du guide sans ôter le guide. Lesimplants sont censés avoir la profondeurappropriée quand l’épaulement de la mon-ture de l’implant entre en contact avec lehaut des anneaux du guide. Étant donné


Figure 1. La fenêtre de planification avec vue en 3-D à gauche et vue en 2-D à droite.

Figure 2. Le plan de recoupe perpendiculaire défile à travers l’image en 3-D et vue sur l’écran àdroite.

Figure 3. Le plan de recoupe perpendiculaireest positionné à gauche du site de la canineavec le guide en place.

Figure 4. L’implant est positionné sur l’écran àdroite.

qu’une congruence absolue entre les sitespréparés et l’angle d’insertion de l’implantest impossible même avec la techniqueNobelGuide, les frictions entre les anneauxdu guide et les montures de l’implant peu-vent porter l’operateur à croire que l’os sus-jacent est plus dense que ce qu’il est en réal-ité. Ceci pourrait être très significatif spé-cialement quand le traitement implique leplacement immédiat d’une prothèse fixe, etun implant instable ou plus peut rendre ceciimpossible. On a déjà montré qu’un place-ment immédiat d’une prothèse fixe sur des

implants stables est une option valide mêmedans des cas complètement édentés (voirFigures 1–3, 6 et 7). Une fois les implantsplacés, j’utilise encore une fois un perfora-teur de tissue à travers les anneaux du guideaprès avoir extrait soigneusement les mon-tures d’implants, ensuite je retire le guidechirurgical et j’enlève tout débris de tissuemou sus-jacent le dessus des implants. Il estainsi plus facile de placer des piliers tempo-raires quand c’est indiqué (Figure 9). Cetteétape est spécialement importante si letroisième niveau du concept de NobelGuide

est appliqué, ceci étant, une fixation immé-diate d’une prothèse à vis inclus (Figures 10et 11), sachant qu’un appui complet peutêtre retardé par la présence de tissu mourésiduel. La prothèse est fixée par des piliersextensibles spéciaux qui compensent l’in-compatibilité légère entre la réalité et laposition planifiée des implants (Figure 12).En cas de muqueuse kératinisée insuff-isante, j’ai trouvé qu’il était possible d’utiliserdes lambeaux très conservateurs dans lamaxillaire pour repositionner la muqueusepalatine étant donné que le guide chirurgi-

MORIELLI


Figure 5. L’implant peut être vu en saillie à travers l’os et devrait êtrerepositionné.

Figure 6. Le guide chirurgical avec six anneaux du guide et trois ergotsdes canaux du guide.

Figure 7. Le guide chirurgical est positionne pour montrer l’enreg-istrement de la morsure produite sur des modèles montes et sécuriséspar trois ergots du guide.

Figure 8. Une perte régulière de coloration du tissue sous le guide estobservée.

CHIRURGIE D’IMPLANT ASSISTÉE PAR ORDINATEUR: DES NORMES DE SOINS EN ÉVOLUTION

cal me permet de placer les implants sansavoir à vérifier visuellement si la couverturetotale de l’os est possible.La mâchoire inferieure postérieure est unedes sections ou NobelGuide a une valeurinébranlable. Plusieurs paramètres sontimpliqués pour déterminer la faisabilité dela restauration de cette zone par des restau-rations soutenues d’implants. Le premier, etle plus important bien entendu, est la taillede l’os au-dessus du canal du nerf dentaireinferieur. Tout dommage infligé à cettestructure par une perforation ou un implantpeut avoir des conséquences dramatiques.L’utilisation de NobelGuide pour visualiserle nerf dentaire inferieur (NDI), ensuite laperforation et l’emplacement des implants àl’aide d’une chirurgie guidée minimisent lesrisques pour le patient ou la patiente. Le

nerf est visualisé et marqué de plusieursfaçons permettant une évaluation précise dul’os disponible au-dessus avant de placer lesimplants dans les positions planifiées. Enplus de la position du NDI, les concavitéslinguales, l’épaisseur des crêtes ainsi que l’in-clinaison sont évaluées (Figures 13 et 14).Comme pour toute technique ou interven-tion nouvelle, une période d’apprentissageest associée avec NobelGuide. La difficultéde cette période dépend de plusieurs fac-teurs dont le confort de l’operateur par rap-port aux ordinateurs, et aussi l’expérienceantérieure avec la chirurgie d’implants et larestauration. Le volet logiciel est tout undéfi pour certains, mais une bonne partiedu processus peut facilement être déléguée.Par exemple, dans mon cabinet, mon coor-dinateur ou ma coordinatrice d’implants

entre les données du scintigramme dupatient ou de la patiente, examine lesimages résultantes, et vérifie que le guideradiographique était bien adapté aux tissussous-jacents durant le balayage. Ceci étantfait, je peux utiliser mon temps pour lediagnostique et le placement des implantsdans l’image 3D. Ceci est plutôt simple étantdonné qu’on peut déplacer et changer lesimplants comme bon nous semble jusqu’àce qu’on arrive à une position satisfaisanteou que le plan de traitement est altéré.Seule une expérience de base avec les ordi-nateurs est exigée pour exécuter cettechirurgie virtuelle. Toutefois, une certaineexpérience en chirurgie est nécessaire dufait que, comme pour toute autre interven-tion, des situations inattendues peuvent sur-venir. Par exemple, il se peut qu’on n’arrivepas à une stabilité primaire pour un ouplusieurs implants. L’operateur doit êtrecapable de prendre des mesures dans ce casou dans toute autre complication associéeavec la chirurgie conventionnelle d’implantet doit toujours avoir un plan de secourspour les parties chirurgicales et prothé-tiques du traitement. J’ai eu à remplacer unimplant par un autre qui avait un plus granddiamètre à deux reprises et j’ai eu à altérer laposition d’un implant une fois après la frac-ture d’une plaque buccale durant l’insertiond’implant. Si ces cas avaient impliqué uneprothèse immédiate, il aurait été peut-êtreimpossible d’exécuter si je n’avais pas unecompréhension suffisante de la prothèseimpliquée. Les problèmes peuvent surveniravant même que la planification ne com-mence. Un problème auquel j’ai fait face àcertaines occasions est celui du guide radi-


Figure 9. Une fois la chirurgie complétée, le guide est retiré et despiliers temporaires sont placés, si aucune prothèse immédiate n’estplanifiée.

Figure 10. Prothèse immédiate (Vue occlusale).

Figure 11. Prothèse immédiate (Vue latérale).

ographique qui ne se pose pas de manièreappropriée dans la bouche. C’est trèssérieux, du fait que toute étape subséquentedans le processus sera asymétrique. Je croisqu’il est impératif de prendre des impres-sions très précises et verser le modèlecomme si c’était un modèle principal pourun pont avec piliers multiples.. L’alginate etle plâtre ne sont pas des matériaux appro-priés pour cette situation.En plus de son application comme outil dediagnostic et de planification, je me sersaussi du NobelGuide pour communiquerplus facilement aux patients les implicationsde leurs cas spéciaux. Quand un ou unepatiente voit effectivement sa crête résidu-elle en image 3-D avec une grande partie dela surface de l’implant en protrusion, expli-quer la nécessité d’une greffe ou d’une inter-vention d’addition devient plus aisé. Ceci estaussi vrai quand on explique les risquespour le nerf dentaire inferieur si le patientpeut le voir retrouver sa course à travers lamâchoire inferieure et les implants placésau-dessus.

ConclusionAprès avoir utilisé NobelGuide au premier,deuxième, ou troisième niveau dans plus de200 cas de la dent individuelle à l’édente-ment complet supérieur et inferieur, J’airéalisé que non seulement ça rend les résul-tats plus prévisibles mais diminue le temps

des chirurgies, minimise la nature invasivede l’intervention, et diminue les risquesanatomiques tel les résultats du NDI avec laréduction significative de la douleurpostopératoire et la morbidité chez le ou lapatiente. Même si le coût du guide radi-ographique, le scintigramme et le guidechirurgical peut avoisiner les 2000 dollars,pas un seul patient n’a refusé d’aller de l’a-vant une fois les avantages expliqués. Plusencore, étant donné que les dimensions descomposants chirurgicaux sont déterminéesdurant la phase de planification, le person-nel peut placer les commandes au besoin,minimisant ainsi les grands inventaires.Toutes les raisons citées ci haut, me fontcroire que NobelGuide va devenir très rapi-dement la nouvelle norme de soins dans laplanification et l’exécution des implants, etc’est aujourd’hui un outil indispensable dansmon cabinet.

DivulgationL’auteur affirme n’avoir aucun conflit d’in-térêt financier.

References1. van Steenberghe D, Naert I, Andersson M,

et al. Un gabarit personnalisé et une pro-thèse définitive permettant le charge-ment immédiat de l’implant dans la max-illaire: Un rapport clinique. Int J OralMaxillofac Implant 2002;17(5):663–70

2. van Steenberghe D, Ericsson I, Van

Cleynenbreugel J, et al. Planification dehaute précision pour les implants buc-caux se basant sur le balayage en 3-D.Une nouvelle technique chirurgicale pourle chargement immédiat et retardé. ApplOsseointegration Res 2004;4:27–31.

3. van Steenberghe D, Glauser R, BlombäckU, et al. Un modèle chirurgicale tomo-graphique personnalisé assisté par unbalayeur et une prothèse fixe pour leschirurgies sans volets et chargementimmédiat d’implants sur des maxillairescomplètement édentées. Une étudeprospective multicentrique. Clin ImplantDent Relat Res 2005;7(Suppl 1):S111–120.

4. Campelo LD, Camara JR. Chirurgie d’im-plant sans volet: une analyse rétrospec-tive sur 10- ans. Int J Oral MaxillofacImplants 2002; 17(2):271–6.

5. BeckerW,Goldstein M, Becker BE, et al.Chirurgie d’implant sans volets très peuinvasive: une étude multicentrique. ClinImplant Dent Relat Res 2005;7(Suppl1):S21–7.

6. Brånemark PI, Engstrand P, Ohrnell LO etal. Brånemark Novum. Un nouveau con-cept de réhabilitation pour les maxillairesédentés. Les résultats préliminaires d’uneétude de suivi prospective. Clin ImplantDent Relat Res 1999;1:2–16.

7. Henry PJ, van Steenberghe D, Blomback U,et al. Étude prospective multicentriquesur le sujet de la réhabilitation immédiatedes joues inférieures édentées en accor-dance avec le protocol de BranemarkNovum. Clin Implant Dent Relat Res2003;5:137–42

MORIELLI


Figure 13. Le mode transparent montre le nerfdentaire inferieur traversant la mandibule.

Figure 14. Coupe perpendiculaire de la Figure13 montrant la position de l’implant par rap-port au nerf dentaire inferieur, la crête résidu-elle, la position proposée de la dent et laconcavité linguale.

Figure 12. Piliers extensibles: comme le vis –pilier est serré, les quartes “ailes” du collierdu pilier s’étendent et impliquent les pro-thèses avoisinantes en les sécurisant auximplants.


Our Four MainObjectives

The Canadian Academy of RestorativeDentistry and Prosthodontics (CARDP)

is a not-for-profit,member-basedorganization that has Four Main

Objectives:

(1) To promote the improvement of the health of theCanadian public, through the advancement of the artand science of restorative and prosthetic dentistry.

(2) To promote the highest standard of professionalethics among its members and amongst the mem-bers of the dental profession.

(3) To encourage the quality and the quantity of teachingof restorative and prosthetic dentistry in Canadianuniversity dental schools.

(4) To provide continuing education in restorative andprosthetic dentistry for its members and for mem-bers of the dental profession in Canada.

The membership of CARDP consists of invited and pro-posed (sponsored) individuals who have earned peerrecognition for their aptitude in the practice or teachingof restorative dentistry and/or prosthetic dentistry.

Nos quatre butsprincipaux

L’Académie canadienne de dentisterierestauratrice et de prosthodontie

(ACDRP) est un organisme sans butlucratif dont les membres

poursuivent quatre objectifs principaux :

(1) Promouvoir l’amélioration de la santé des Canadienspar le biais de l’art et de la science de la dentisterierestauratrice et prothétique.

(2) Améliorer les normes d’éthique professionnelle parmises membres ainsi que les membres de la profession engénéral.

(3) Soutenir la qualité de l’enseignement de la dentisterierestauratrice et prothétique dans les facultés dentairescanadiennes.

(4) Offrir de l’éducation continue à ses membres ainsiqu’aux membres de la profession au Canada en dentis-terie restauratrice et prothétique.

Les membres de l’ACDRP sont des individus, invités ourecommandés (commandités) qui ont mérité l’approbationde leurs pairs pour leurs aptitudes dans la pratique ou l’en-seignement de la dentisterie restauratrice et/ou prothétique.

canadian journal of journal canadien de restorative …...computerized dentistry 46...

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