Current Challenges in Color

Picture the scene: A new patient has been referred to your office for an esthetic treatment consultation. The patient’s mouth is an Easter egg basket of assorted colors and issues: some veneers here, an implant there, a post and core–treated tooth next to that, and a few missing papillae sprinkled—or not sprinkled—on top. None of it matches, and the patient understandably desires a more cohesive esthetic appearance. Enter you. How do you proceed?

If you’ve ever watched a home-remodeling television show, you know the first step is usually to tear everything out but the walls and roof in order to start fresh and work toward a beautiful, modern end result. Unfortunately, the human mouth is not quite as resilient. Patients often show up with a guestbook in their mouth signed by every dentist they’ve ever visited, and even the most advanced technician can have trouble matching color between different materials and thicknesses. Drs Stephen J. Chu, Rade D. Paravina, and Irena Sailer and master ceramist Adam J. Mieleszko confront these issues and more in their new book, Color in Dentistry: A Clinical Guide to Predictable Esthetics.

Color Matching with Discolored Substrates

One case described in the book involves the replacement of three crowns on nonvital anterior maxillary teeth previously treated with metal post-and-core buildups. The stumps were significantly discolored due to the large posts and translucent restoration materials.

“In a specific situation like this,” Dr Sailer explains, “the old post-and-core buildups were not removed because there was a risk of catastrophic root fracture upon removal and no indication to renew the endodontic treatment. Current material options made it possible to mask the metallic substructure and achieve an esthetic result.”

The old crowns were removed and displayed big metal posts that led to a strong discoloration of the composite cores. The team discussed removing the post-and-core buildups but decided not to do so because of the high risk for fracture of the roots. Because the patient was financially limited, the team offered him less costly monolithic chairside restorations based on a resin-based hybrid material (Lava Ultimate, 3M ESPE). Unfortunately, the raw and unpolished “biscuit try-in” of the monolithic crowns were not esthetic at all, and it became clear that even using a stain and glaze kit offered by the manufacturer, the desired esthetic outcome would not be reached. After discussing this esthetic limitation with the patient, he agreed to the extra cost for a small cutback and buccal veneering of the crowns to better match the natural reference tooth. (Case rehabilitation performed in collaboration with Vincent Fehmer, MDT.)

In this and similar cases, clinicians can often modify the treatment in order to achieve successful esthetic results using white resin, ceramic, and glass-ceramic materials. But what about cases where the discoloration is too strong to be masked with such translucent materials?

In the book, the authors describe a case involving the replacement of crowns on both of the patient’s maxillary central incisors where the left was nonvital and discolored and the right was vital and nondiscolored. Complicating the treatment planning and material selection was the patient’s insistence on all-ceramic restorations rather than metal-ceramic—the two original 20- to 30-year-old metal-ceramic crowns were opaque and not natural-looking, not to mention unsuccessful at masking the cervical discoloration of the tooth root. However, even after placing opaque zirconia frameworks, the technician was not able to fully mask the discolored left central incisor. Luckily, the technician had also made a pair of metal-ceramic crowns that the team compared at try-in, and the patient ended up agreeing with the team that the metal-ceramic crowns were better after all. The metal-ceramic crowns allowed the technician to start with the same gray framework color on both teeth, while also allowing for a thinner framework with a stronger value of opacity and larger ceramic shoulders to better reflect the veneering ceramic.

In this case, metal-ceramic crowns allowed the technician to start from the same gray framework color on both crowns, whereas zirconia frameworks failed to adequately mask the stump discoloration. (Case rehabilitation performed in collaboration with Walter Gebhardt, DT.)

Restoring Esthetics Using Pink Restorative Materials

Patients’ teeth are not the only reason they may be displeased with previous dental treatment. One of the newest and most exciting mediums of esthetic dentistry is the use of pink restorative materials, which is opening up a new range of treatment possibilities for soft tissue defects. Previously, the standard options for missing papillae were surgical soft tissue augmentation or forced orthodontic eruption. These options are time-consuming and costly and in some cases may not be possible or recommended due to unmet biologic parameters. Advances in both materials and techniques are making the use of pink restorative materials a reliable solution.

“Pink restorative materials can be used in patient situations where there are contraindications for surgery or when the patient simply does not want surgery,” Dr Sailer, who has used pink restorative materials in her practice for over a decade, explains. “They can also be done in complicated clinical situations with huge vertical and horizontal defects. The ceramic is smooth and polished at the surface—exactly like tooth-colored veneering ceramic. We design the pink porcelain to be cleanable and instruct patients on how to perform oral hygiene around reconstructions.” Pink restorative materials can also be used to restore missing papillae, which are especially common after single-implant therapy.

In a case where the patient presented with multiple adjacent implants placed from maxillary right canine to left central incisor and with inverted tooth axes, insufficient overjet and overbite, a reverse smile line, and lack of interproximal papillae, the presenting restorations “possessed all the dilemmas associated with not using pink restorative materials and only using white ceramics to compensate for esthetic deficiencies,” according to the authors. A treatment plan was devised that included ceramic veneers on the right second premolar and left first premolar, single crowns on the right first premolar and left lateral incisor, and an all-ceramic fixed dental prosthesis for the right canine to left central incisor. Importantly, pink restorative material was included on all but the two veneers. This tapered approach allowed the team to redefine the patient’s entire smile in a way that without the use of pink restorative materials would have required more invasive procedures such as orthognathic surgery.

Putting Everything Together

A final example involves matching dissimilar restoration and material types with pink ceramics. The patient, a 28-year-old woman, presented with multiple congenitally missing maxillary teeth (right canine and left lateral incisor), an impacted maxillary left canine, and existing composite direct veneer restorations on the maxillary right first premolar to central incisor and left primary lateral incisor to first premolar placed more than two decades ago. Several esthetic issues were present, including a canted transverse plane with lack of maxillary incisal tooth exposure. The maxillary restorative arch form was constricted due to the lack of intra-arch width development without the eruption of the permanent dentition, and previous composite bonding of the maxillary right first premolar to the left first premolar was disharmonious.

During the “tear-out” phase of this oral renovation, the old composite restorations were removed. The team also extracted the primary left lateral incisor and the impacted canine. The right incisors required esthetic crown lengthening to restore the proper length relative to width. The definitive restorations included preparationless veneers on the second premolars, metal-ceramic implant restorations on the right canine and left lateral incisor and canine, single metal-ceramic full-coverage crowns on the first premolars, and extended all-ceramic layered feldspathic veneer restorations on the right incisors and left central incisor.

This case involved esthetic integration with regard to individual tooth proportion, arch form, and color matching between dissimilar materials (metal-ceramics vs all-ceramics) and restoration types (full-coverage crowns versus veneers). Pink-colored ceramics replaced the height of the lost interproximal papilla between the left lateral incisor and canine. The definitive restorations also blended with the patient’s mandibular dentition, on which she had performed minor vital bleaching. The end result is a harmonious, well-proportioned smile with improved function that, most importantly, the patient was very happy with.

A Guide to Success

Many restorative dentists and laboratory technicians can fabricate a beautiful restoration in an ideal clinical situation. However, successful esthetic results are much more elusive when the patient has soft tissue defects or when the case involves previous nonesthetic restorations. Color in Dentistry: A Clinical Guide to Predictable Esthetics guides clinicians through that renovation process and provides insight on all things color. You may not be the last entry in your patient’s dental guestbook, but with results like these you can be the most memorable and effective.


Stephen J. Chu, DDS, MSD, CDT, MDT, is an associate clinical professor in the Ashman Department of Periodontology and Implant Dentistry and the Department of Prosthodontics as well as the director of esthetic education at the New York University College of Dentistry. He has published more than 40 articles and given lectures nationally and internationally on the subjects of esthetic, restorative, and implant dentistry. Dr Chu is a coauthor of the book Fundamentals of Color: Shade Matching and Communication in Esthetic Dentistry, Second Edition (Quintessence, 2011) and is on the editorial review board of several peer-reviewed dental journals. He is the recipient of the Peter Scharer Distinguished Lecturer Award from the European Academy of Esthetic Dentistry and the Lloyd L. Miller Distinguished Lecturer Award from the Society for Color and Appearance in Dentistry. Dr Chu maintains a private practice limited to fixed prosthodontics, esthetic dentistry, and implant dentistry in New York City.

Rade D. Paravina, DDS, MS, PhD, is a tenured Professor at the University of Texas School of Dentistry at Houston and Director of the Houston Center for Biomaterials and Biomimetics. He is founder and past president of the Society for Color and Appearance in Dentistry (SCAD) and received the 2011 E. B. Clark Award from SCAD in 2011. He is the 2014 recipient of the Jerome M. and Dorothy Schweitzer Research Award of the Greater New York Academy of Prosthodontics. Dr Paravina is a fellow of the American Academy of Esthetic Dentistry, the American Association for Dental Research, and SCAD. Dr Paravina coauthored Fundamentals of Color: Shade Matching and Communication in Esthetic Dentistry, Second Edition (Quintessence, 2011) and Esthetic Color Training in Dentistry (Elsevier, 2004) and has contributed to 15 book chapters, 2 software programs, 1 educational CD, and more than 220 peer-reviewed publications. He serves as associate editor of the Journal of Esthetic and Restorative Dentistry and editorial review board member of several other peer-reviewed dental journals. Dr Paravina lectures nationally and internationally on various topics associated with color and appearance in esthetic dentistry.

Irena Sailer, Prof Dr Med Dent, is professor and chair of the Division of Fixed Prosthodontics and Biomaterials at the University of Geneva in Switzerland. She has served as a visiting scholar in the Department of Biomaterials and Biomimetics of the New York University College of Dentistry and currently holds an adjunct associate professorship of restorative dentistry at the University of Pennsylvania School of Dental Medicine. Dr Sailer is certified as a specialist in prosthodontics by the Swiss Society for Reconstructive Dentistry and in dental implantology by the Swiss Society for Dentistry.

Adam J. Mieleszko, CDT, graduated in 1997 from New York City Technical College with a degree in dental laboratory technology and received certification in dental ceramics in 2000. Since then he has worked in close collaboration with leading prosthodontists in the field. Mr Mieleszko is a coauthor of the book Fundamentals of Color: Shade Matching and Communication in Esthetic Dentistry, Second Edition (Quintessence, 2011) and has contributed to numerous clinical and technical articles in industry journals. He is a master ceramist based in New York City.

Posted in Books, Dental Technology, Esthetic Dentistry, Feature, Implant Dentistry, Prosthodontics, Restorative Dentistry | Tagged , , , , , , , , | Leave a comment

Quintessence Roundup: July

Quintessence 2017 Catalog

Monthly Special


Seltzer and Bender’s Dental Pulp, Second Edition

Edited by Kenneth M. Hargreaves, Harold E. Goodis, and Franklin R. Tay

This comprehensive update of a classic text presents the latest research on the dental pulp and its interaction with other tissues, highlighting its central role in both local and systemic health. The second edition has been completely revised to incorporate new chapters featuring the most topical issues in research and clinical practice, including developments in stem cell research and pulpodentin regeneration, the effects of the aging process on the pulp, and the interdependent relationship of the pulp and restorative dental procedures. New contributors bring fresh perspective to topics such as pulpal infections, odontalgia, and the relationship between the pulp and periodontal disease. Each chapter provides an introduction to its major themes for the busy clinician or dental student as well as up-to-date, biologically based clinical recommendations for restorative and endodontic procedures. Practicing clinicians will find this information to be essential to providing accurate diagnoses and effective treatment.

512 pp; 707 illus; ©2012; ISBN 978-0-86715-480-1 (B4801); Special price! $75

New Titles in Books


Color in Dentistry:
A Clinical Guide to Predictable Esthetics

Stephen J. Chu, Rade D. Paravina, Irena Sailer, and Adam J. Mieleszko

Predictable shade matching in dentistry remains a significant challenge for clinicians in daily practice. Color is an important aspect in the esthetics of teeth and dental restoration fabrication, and color discrepancy can mar restorative results, even when other aspects (marginal fit, occlusion, and morphology) are adequate. This book provides step-by-step protocols to help dental professionals accurately match, communicate, and reproduce the color of teeth and gingiva. These authors demonstrate how to implement color science in simple problem-solving instructions for predictable esthetics in both clinical protocols and laboratory techniques. An extensive presentation of clinical cases is included to illustrate the use of recommended protocols in general practice. An outstanding contribution to the practice and theory of color management in contemporary dentistry.

256 pp; 890 illus; ISBN 978-0-86715-745-1 (B7451); Special preorder price! US $86

Anesthesia Considerations for the Oral and Maxillofacial Surgeon

Edited by Matthew Mizukawa, Samuel J. McKenna, and Luis G. Vega

Although office-based anesthesia administration has been essential in the evolution of outpatient surgery, it is becoming more complex as people live longer and with more comorbid diseases. The purpose of this book is to strengthen the margin of safety of office-based anesthesia administration by helping practitioners determine whether the patients they treat are good candidates for office-based anesthesia. This book is organized into three sections. The first section provides a review of the principles of anesthesia, including the pharmacology of anesthetic agents, local anesthesia, patient monitoring, preoperative evaluation, the airway, and management of emergencies and complications. The major organ systems of the body are reviewed in section two, and the most common comorbid conditions that affect these systems are described in terms of their pathophysiology, diagnosis, management, and anesthesia-related considerations. Section three reviews patient groups that warrant special consideration in the administration of office-based anesthesia, such as geriatric, pediatric, pregnant, and obese patients. Spiral-bound and featuring tabs for quick and easy reference, this important book belongs on the shelf of every clinician who provides anesthesia in the office setting.

482 pp; 101 illus; ISBN 978-0- 86715-713- 0 (B7130); Special preorder price! $134

The Bicon Short Implant: A Thirty-Year Perspective

Edited by Vincent Morgan

This book is a succinct and accessible compilation of over 30 years of knowledge concerning the Bicon system. It offers not only a history of dental implants and the science of osseointegration but also a vast collection of clinical examples that demonstrate Bicon’s capabilities. Bicon implants provide versatile, reliable treatment for a wide variety of clinical situations; they can successfully be placed in atrophic jaws, in sites that would require extensive bone grafting with longer implants, in tissue that has been compromised by medical conditions, and even in adolescent jaws that are still developing. With its proven track record of success, the Bicon system provides treatment opportunities for the benefit of clinicians, technicians, and patients by offering simple, predictable, and effective techniques. With everything from historical and theoretical origins to detailed step-by-step surgical and restorative guides, this book is a must-read for anyone interested in implantology.

336 pp; 1,800 illus; ISBN 978-0-86715-728-4 (B7284); Special preorder price!US $154

Advanced CBCT for Endodontics:
Technical Considerations, Perception, and Decision-Making

John A. Khademi, with contributions by Gary B. Carr, Richard S. Schwartz, and Michael Trudeau

This book encourages endodontists to develop a sound technical and theoretical understanding of CBCT. The authors compare the capabilities of modern CBCT imaging with traditional radiography and also present vital information about image interpretation and perception to increase competence and confidence in CBCT interpretation and minimize overdiagnosis and subsequent overtreatment.

352 pp; 688 illus; ISBN 978-0-86715-720-8 (B7208); Now available! US $148

How You See It and How You Don’t: How the Principles of Human Perception Affect CBCT Interpretation

New Issues in Journals


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Featured article: Interpositional Augmentation Technique in the Treatment of Posterior Mandibular Atrophies: A Retrospective Study Comparing 129 Autogenous and Heterologous Bone Blocks with 2 to 7 Years Follow-Up
Pietro Felice, Carlo Barausse, Antonio Barone, Giovanni Zucchelli, Maurizio Piattelli, Roberto Pistilli, Daniela Rita Ippolito, and Massimo Simion

Human Histologic Evidence of Reosseointegration Around an Implant Affected with Peri-implantitis Following Decontamination with Sterile Saline and Antiseptics: A Case History Report
Paul Fletcher, Daniel Deluiz, Eduardo M.B. Tinoco, John L. Ricci, Dennis P. Tarnow, and Justine Monnerat Tinoco

Combining Esthetic Layering and Lithium Disilicate Sintering Technique on Zirconia Frameworks: A Veneering Option to Prevent Ceramic Chipping
Reza Saeidi Pour, Daniel Edelhoff, Caroline Freitas Rafael, Otto Prandtner, Stefan Frei, Claudia Angela Maziero Volpato, and Anja Liebermann

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Bone Quality and Quantity and Dental Implant Failure: A Systematic Review and Meta-analysis
Bruno Ramos Chrcanovic, Tomas Albrektsson, and Ann Wennerberg

CAD/CAM Ceramic Overlays to Restore Reduced Vertical Dimension of Occlusion Resulting from Worn Dentitions: A Case History Report
Jiang Ting, Han Shuhui, and Hongqiang

Support Ratio Between Abutment and Soft Tissue Under Overdentures: A Comparison Between Use of Two and Four Abutments
Manami Abe, Tsung-Chieh Yang, Yoshionobu Maeda, Takanori Ando, and Masahiro Wada

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Featured Article: Cortical and Trabecular Bone Healing Patterns and Quantification for Three Different Dental Implant Systems
Heloisa F. Marão, Ryo Jimbo, Rodrigo Neiva, Luiz Fernando Gil, Michelle Bowers, Estevam A. Bonfante, Nick Tovar, Malvin N. Janal, and Paulo G. Coelho

Challenging Paradigms: Update on the Use of Dental Implant Therapy for Patients with Diabetes Mellitus
Thomas W. Oates

Zirconia Implants as an Alternative to Titanium: A Systematic Review and Meta-Analysis
Basel Elnayef, Aida Lázaro, Fernando Suárez-López del Amo, Pablo Galindo-Moreno, Hom-Lay Wang, Jordi Gargallo-Albiol, and Federico Hernández-Alfaro

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What Can Epigenetics Tell Us About Periodontitis?
Pamela Leong, Yuk Jing Loke, and Jeffrey M. Craig

Does Use of Alcohol-Containing Mouthrinse Increase Risk for Oral Cancer?
Ann Eshenaur Spolarich

Gingival Trauma: Tooth Brushing and Oral Piercings
Nienke L. Hennequin-Hoenderdos, Fridus A. van der Weijden, and Dagmar E. Slot

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A Retrospective Study on Possible Predictive Factors for Long-term Temporomandibular Joint Degeneration and Impaired Mobility in Juvenile Arthritis Patients
Stanimira I. Kalaykova, Adriaan T. Klitsie, Corine M. Visscher, Machiel Naeije, and Frank Lobbezoo

Prevalence of Temporomandibular Disorders in the Northern Finland Birth Cohort 1966
Päivi Jussila, Heikki Kiviahde, Ritva Näpänkangas, Jari Päkkilä, Paula Pesonen, Kirsi Sipilä, Pertti Pirttiniemi, and Aune Raustia

A Rare Case of Misdiagnosed Silent Lung Cancer with Solitary Metastasis to the Temporomandibular Joint Condyle
Luca Guarda-Nardini, Edoardo Stellini, Adolfo Di Fiore, and Daniele Manfredini

Dental Meetings Quintessence Will Attend in July


AGD2017: Booth #210
hosted by the Academy of General Dentistry, July 15–17 in Las Vegas, Nevada

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How One Surgeon Changed the Lives of Patients with Crouzon Syndrome Worldwide

When Martin Chin, DDS, had his first encounter with Crouzon syndrome, he was a 21-year-old dental student spending his free time in Dr Egil Harvold’s craniofacial anomalies clinic. That first encounter sparked a journey of discovery and innovation that would change the face of dentistry.

“A young child, maybe 3 years old, was brought in by his father,” Dr Chin recalls. “The child’s eyes protruded and he was having trouble breathing. Dr Harvold confirmed the child had Crouzon syndrome and explained this to the father. The father responded by saying he didn’t understand our concern. ‘All of my children look like that,’ he said. I went out into the waiting area. Sure enough, there were four children sitting out there, all with Crouzon faces.”

Photos of people affected by Crouzon syndrome from the Children’s Craniofacial Association.

Crouzon syndrome is a genetic disorder that affects the first pharyngeal arch during fetal development. In a person with Crouzon syndrome, the skull and facial bones fuse early, preventing normal bone growth. Because of this, the midface of a Crouzon patient remains much smaller than average during development. The face does not extend outward. Organs such as the eyes and airway are severely compressed, complications which only become more pronounced as the child continues to outgrow his or her disordered bone structure. Severe breathing issues such as sleep apnea can develop, requiring continuous positive airway pressure (CPAP) machines or even tracheostomies. Children with less drastic physical symptoms still suffer emotional effects due to discrimination and abuse from their peers.

When Dr Chin began learning about Crouzon syndrome, most oral and maxillofacial surgeons treating these patients were performing the intracranial monobloc procedure as developed by Dr Paul Tessier. (The modern evolution of Dr Tessier’s procedure is the Monobloc Frontofacial Advancement procedure, which is still commonly performed today on Crouzon patients.) Unfortunately, due to the young age of most patients at the time they required surgery, the limitations of pediatric anesthesia, and the inherent trauma of the operation, the operation had only a 50% success rate.

“The operation is done through what’s called a coronal flap,” Dr Chin explains. “You make an incision at the top of the head, almost like a headband, and you peel the forehead down. The problem is that these children do not have normal skulls. When you’re reflecting this flap down, the brain is often exposed in small areas. You have to separate the forehead tissue from the dura. Each time you do this procedure you increase the chance of directly damaging the brain with your instruments or exposing the brain to infection.

“When I was a student, Dr Tessier came to our hospital to demonstrate the monobloc surgery. They took four children to surgery. Two died during the surgery and two lived. These were high-risk surgeries, but these children and parents were desperate.”

The Start of a New Paradigm

According to Dr Chin, the idea of coming upon major scientific discoveries by accident doesn’t work. We’ve all heard the story of Alexander Fleming’s accidental discovery of penicillin. But Dr Chin stresses that when you are confronted with a problem that is impossible to treat, there is a logical way to approach it.

“Carefully analyze the problem and then determine which technologies can be used in this situation,” he advises. “Those technologies will almost always have to be taken from another medical specialty and adapted. You must be willing to look to another type of doctor or scientist and adapt their technology to your problem. After you do that, you have to figure out how to use it to solve your problem.”

The problem was Crouzon syndrome—a skull too small, a skull that couldn’t grow. The problem was a surgery that gave some children a chance at life but also left far too many dead.

Years after meeting those first five siblings with Crouzon, Dr Chin had a realization while performing a Le Fort III with internal fixation on a young girl with a severe form of Crouzon called klebatschaldel (German for cloverleaf head). As he and the lead surgeon placed the plates and screws that would hold her puzzle of a skull in place, Dr Chin realized something. “Do you know that this is not working?” he asked. The lead surgeon said, “Of course it’s working.”

What Dr Chin had discovered is that the procedure was not actually achieving any length of expansion. Previously, postoperative radiographs were not taken, so he began taking cephalometric radiographs before and after the surgery and discovered that there were no benefits. These traumatic, high-risk surgeries were actually not working.

“At best,” Dr Chin explains, “you could only achieve about a 20% correction with conventional surgery, which means you either have to repeat the procedure multiple times or settle for less. In some cases, when I looked back at what other people had done—they actually got 0%. You could take the radiographs from before and after and they were exactly the same. Twelve hours of surgery—no treatment. If you were aggressive and good at it, you could maybe get 6 mm of movement. But most patients require anywhere from 15 to 30 mm to correct the eye sockets and midface to adult-sized levels so you don’t have to go back later and reoperate. And the mortality rate goes up with each repeated surgery.”

An Ilizarov apparatus treating a fractured tibia and fibula.

But if conventional surgery wasn’t working, how could he get those 15 to 30 mm? And how much could he gain in a single operation? Dr Chin thought back to a lecture he’d attended as a dental student from a Ukranian doctor who had studied under the orthopedic surgeon Gavriil Ilizarov before escaping from the Soviet Union. He had brought several patient records from the hospital in Kurgan where Ilizarov developed his famous bone-lengthening procedure. The procedure uses an external device to slowly distract, or pull apart, two pieces of severed bone in order to lengthen them through osteogenesis. In a way, the theories were similar: Crouzon patients needed a skull that was “longer,” or deeper.

Le Fort III Advancement with Gradual Distraction Using Internal Devices

Around the time Dr Chin was rethinking the conventional surgical protocol, he met a 6-year-old patient whose radiographs before and after the 12-hour surgery showed no advancement. Her mother asked Dr Chin if he had any ideas.

With the concept of Ilizarov distraction in mind, Dr Chin set to work. He designed an internal distraction device that would push the osteotomy segments outward. “There were a number of deaths that were related just to the instruments themselves,” he explains. “Most surgeons are pretty detailed about how they killed the patient, so I had a lot of information on how you shouldn’t do these operations. I then designed the distraction procedure to try to get around where the catastrophic events were occurring.”

The Chin Midface distraction device.

Dr Chin at his personal Bridgeport milling machine.

But when he started looking for a manufacturer to make the device, everyone turned him down. Without evidence of it working, the device was too dangerous to make—the liability to the manufacturers was too much. So Dr Chin asked the manufacturers how they would make the implants, and they told him. He asked them to sell him a Bridgeport mill and send it to his house along with a book on how to use it, and they sent both. Then he manufactured the distraction device and specialty implants himself.

“It’s not normal,” he says, laughing. “When my office would set up these procedures, they would schedule 40 hours outside of the office for me to stand at the milling machine in my garage grinding the titanium implants for a single child.”

Compared with the 50% mortality rate of Dr Tessier’s early procedure, the operation Dr Chin designed has only a 3% to 5% mortality rate. “But still, to have 1 in 25 patients die is upsetting,” Dr Chin says. “Personally, I have never lost a patient on the table ever. We have not lost a single patient on the table to this procedure. We are very careful. I designed the procedure to minimize risk.”

Diagram of the Chin Midface device in the bone structure of a patient undergoing a modified Le Fort III osteotomy with midface advancement to treat midfacial hypoplasia caused by prior radiation treatment for pharyngeal rhabdomyosarcoma. The surgery is designed to open three bone-forming chambers. Point A is the pterygomaxillary junction, point B is the divided molar bone, and point C is the nasal aperture and orbital floor. The bone-forming chambers fill with structural bone without the benefit of grafting or growth factors.

The patient’s appearance before Le Fort III midfacial advancement and 1 year afterward.

An Unavoidable Risk

There is another risk that Dr Chin has learned to prioritize.

“When you work on children with craniofacial deformities, there is a sort of evolution as the child ages,” Dr Chin explains. “When the child is very young, it’s actually engaging to have everyone in the room come and look at them. They feel special. But then they get a little older and realize, ‘They’re looking at me because I look funny.’ Once the child’s peers and other people around them start to make comments, the child generates this idea that they’re not whole, they’re not okay, they’re not good. What you never want to do with a child is give them this idea that they’re so ugly they need to have an operation—that doesn’t do their mental health any good. You never want to tell the child that you’re going to make them beautiful. My patients ask me, ‘When you’re done, will I be beautiful?’ And I tell them, ‘The only thing I can guarantee you is that you’ll be different.'”

In an opinion piece for The New York Times, Ariel Henley writes about this aspect of Crouzon: the hidden effects, both from the disfigurement and from the treatment. Dr Chin performed his surgery on Ariel and her twin sister twice, once when they were 6 years old and again at 12 years old. “Even with the physically traumatic surgeries I was required to undergo,” she writes, “the physical aspect of my condition was nothing compared with the emotional toll of living with an appearance-altering condition. The everyday stares, comments, and subhuman treatment acted as a constant reminder of my painful medical history and my perceived shortcomings.”

Ariel Henley, radiographs and facial appearance before Le Fort III midfacial advancement with distraction and 14 days afterward. The midface-mobilizing device was used to mobilize the maxilla at the Le Fort III level along with the zygoma, inferior orbits, and nose. Internal distraction devices were used to transport the midface anteriorly, opening a 20-mm pterygomaxillary bone-forming chamber. The anterior fragment contained developing teeth that supply neuromuscular signaling to the bone-forming chamber. The pterygoid muscles attached to the intact pterygoid plates supplied neuromuscular signaling from the posterior aspect of the chamber. No bone grafting was necessary.

She continues: “Because salvaging my physical health was so crucial, the emotional aspect of living with a facial disfigurement was overlooked by health professionals. While my mother and father did their best to offer support, there was only so much they could do. I tried therapy, but therapists always seemed to ask the wrong questions and never seemed to understand what it was like to have my physical appearance change drastically time and time again. ‘It’s like in Freaky Friday,’ I would tell them. ‘Except I never get my body back. I never get my face back.’ Despite their best efforts, they simply could not relate.”

Dr Chin used to send all of his patients to a psychotherapist—a former patient who had undergone the surgery herself and was uniquely positioned to understand exactly what current patients were going through. After she relocated, Dr Chin began counseling patients himself. “I usually study my patients for 1 to 2 years before undertaking the surgery,” he explains. “In that time I am going to understand what you think so I will not disappoint you. Then I follow patients forever afterward.

“These patients require time to assimilate to their new appearances. With good support, they are usually fine. But I’ve also made mistakes, and the mistakes that I’ve made were devastating.” Dr Chin recalls a time when he missed a patient’s severe depression and ended up with a death. “After the patient left the hospital, they didn’t come back for the postoperative exam. At all. Their postoperative appointment was for 3 weeks later, but in the mean time they hung themself. A child.”

Putting the Patient First

When you grow up with a frequently changing face and a standing reservation in the operating room, a lot can feel out of your control. Dr Chin confronts this by giving his patients as much control as he can. In his appointments the parents sit behind the child, and he speaks directly to the child:

“I often ask, ‘Well, what do you think?’ And they say, ‘Well, I think my face looks pushed in. I don’t like it.’ And I say, ‘Well I can do an operation that can make this look more like this.’ And the patient will say, ‘Oh yeah, I would like that, I think.’ You don’t ever want to imply that the child is not okay the way they are. That impression doesn’t go away, even if you correct the problem. They still feel defective.”

Ariel agrees. “One thing I appreciated about Dr Chin was his willingness to be honest and straightforward with me,” she recalls. “He did a great job of working with my parents to help me feel like I always had a say in what was done. I can still remember sitting in my hospital bed waiting to go in for surgery and having Dr Chin go over the details with me. He would describe what he was going to do and how he was going to do it. Allowing me to be part of the process gave me a sense of control that I desperately needed.”

Ariel has a unique perspective on the emotional toll of Crouzon treatment. “I didn’t experience these surgeries and recovery periods alone,” she says. “I witnessed my twin sister go through them, too. This is part of the reason why I’m so vocal about my experiences, because I know what it’s like both as a patient and as a witness. It’s hard to make sense of these experiences, but trying to process my own situation while watching my sister—someone I love more than life—recover from such major operations as well was often traumatic.”

Continuing to Advance

In her piece for The New York Times, Ariel stresses the emotional toll both of living with facial disfigurement and of treatment and recovery. “Since my article came out a few months ago,” she says, “I’ve received dozens of emails from doctors and surgeons all over the country telling me they’ve only recently begun paying attention to the mental and emotional effects of procedures on patients. Some even apologized for not realizing sooner. I think this is an excellent step in the right direction—it’s important for surgeons to recognize the importance of treating the whole patient. If mental health can be addressed by specialists, I think physical and emotional recovery will be less traumatic. I strongly believe counseling and therapy should be required both prior to and after surgery. Almost every single adult I’ve met with Crouzon syndrome has at one point struggled with depression and/or PTSD symptoms. Many didn’t seek professional help until they reached adulthood and then had trouble finding a specialist who understood the struggles they faced.”

She offers a framework for professionals to improve: “Hospitals with craniofacial departments should offer support groups for patients to meet other individuals with similar experiences and connect current patients with previous patients to establish a mentor/mentee relationship. I also think all craniofacial surgeons should be required to sit in on a panel of previous and current patients to learn about the patient perspective. I believe this should happen once per year as part of ongoing training. Consulting with patients to understand the patient side of the condition will allow for greater empathy and well-rounded care. Many patients feel isolated in their experiences: Connecting them with a person or a group of individuals who have had similar experiences can help them feel less alone.

“The surgeries I had as a child changed my life. These procedures allowed me to live a rich and normal life. They boosted my self-confidence and improved my quality of life. This is an easier conclusion to reach now that I’m an adult—now that I’m no longer in the depth of recovery. During recovery, I had a hard time understanding the benefits because all I could focus on was the physical and emotional pain. These procedures were hard. They were really, really hard. They were excruciating—physically and emotionally.”

An illustration of the osteotomy Dr Chin performed on Ariel Henley showing the segment of her skull that was separated and then projected outward by the midfacial advancement distraction.

Her final piece of advice? “For surgeons performing these procedures and treating individuals with Crouzon or other craniofacial disorders, I would say be present. Treat each patient and each family as if they are your own. This always made me feel safe and allowed me to worry less about the procedure and more about healing and feeling better.”

As for Dr Chin, he continues to search for unconventional surgical solutions to oral and maxillofacial surgery’s most challenging problems. His book, Surgical Design for Dental Reconstruction with Implants: A New Paradigm (Quintessence, 2015), offers solutions for cases where conventional surgery has failed. Cases described in the text include using Sharpey’s fibers from the periodontal ligaments of developing teeth to generate bone in deficient areas, substituting bone morphogenetic protein (BMP) when conventional bone grafting is likely to fail, and combining osteotomies with distraction principles and the body’s own generative processes to fill congenital defect regions such as cleft palates without bone grafting. Like his revolutionary Crouzon surgery, the procedures have been designed to minimize trauma and risk to the patient by working around the events where conventional surgery would fail. More importantly, these advanced concepts can be applied to routine surgeries to avoid complications, increase reliability of results, and streamline the use of costly materials such as BMP or growth factors by “hacking” the biologic processes at the cellular level.

Some would say all of this happened by chance. But if the image of Dr Chin spending hours on end milling custom titanium implants for his patients and the writings of Ariel on facial equality and patient-centered health care say anything, it’s that change can only occur when determination to alter the current paradigm exists.


Martin Chin, DDS, is an oral and maxillofacial surgeon who maintains a private practice at California Pacific Medical Center in San Francisco. His private practice focuses on orthognathic, craniofacial, and dental implant surgery. He is also an attending surgeon at the University of California Children’s Hospital in Oakland. Dr Chin has developed many devices and techniques for distraction osteogenesis of the orbit, midface, and alveolar processes. Multiple US and international patents have been issued for these innovations, and Dr Chin has written and lectured internationally on these topics. He maintains an active research program for the development of instruments and processes to improve the practice of maxillofacial surgery. He is also the founder and director of the Beyond Faces Foundation, which supports treatment of children with craniofacial disorders. Dr Chin is a diplomate of the American Board of Oral and Maxillofacial Surgery and a fellow of the American College of Dentists. His book, Surgical Design for Dental Reconstruction with Implants: A New Paradigm, bridges the gap between the routine practice of maxillofacial surgery and theoretical laboratory science to establish a working model that can be applied to real problems affecting real patients.

Ariel Henley, is a writer with a bachelor’s degree in English and political science from the University of Vermont. She is passionate about writing as a form of activism. Much of her work explores her experiences growing up with a facial disfigurement as a result of Crouzon syndrome. Ms Henley writes to explore issues related to beauty, equality, human connection, and understanding trauma through the lens of her own experiences. She shares her story in an effort to help eliminate stigma, educate others about the importance of facial equality, and promote mainstream inclusion for individuals with physical differences. Ms Henley’s work has appeared in The New York Times, The Washington Post, Vice, The Rumpus, and Narratively. She is a 2017 San Francisco Writers’ Grotto Fellow and is currently working on a memoir.

Posted in Books, Implant Dentistry, Misc, Oral and Maxillofacial Surgery, Research, Restorative Dentistry | Tagged , , , , , , , , | Leave a comment

Quintessence Roundup: June


Quintessence 2017 Catalog

New Titles in Books


Advanced CBCT for Endodontics:
Technical Considerations, Perception, and Decision-Making

John A. Khademi, with contributions by Gary B. Carr, Richard S. Schwartz, and Michael Trudeau

This book encourages endodontists to develop a sound technical and theoretical understanding of CBCT. The authors compare the capabilities of modern CBCT imaging with traditional radiography and also present vital information about image interpretation and perception to increase competence and confidence in CBCT interpretation and minimize overdiagnosis and subsequent overtreatment.

352 pp; 688 illus; ISBN 978-0-86715-720-8 (B7208); Special preorder price! US $118

How You See It and How You Don’t: How the Principles of Human Perception Affect CBCT Interpretation

 

Color in Dentistry:
A Clinical Guide to Predictable Esthetics

Stephen J. Chu, Rade D. Paravina, Irena Sailer, and Adam J. Mieleszko

Predictable shade matching in dentistry remains a significant challenge for clinicians in daily practice. Color is an important aspect in the esthetics of teeth and dental restoration fabrication, and color discrepancy can mar restorative results, even when other aspects (marginal fit, occlusion, and morphology) are adequate. This book provides step-by-step protocols to help dental professionals accurately match, communicate, and reproduce the color of teeth and gingiva. These authors demonstrate how to implement color science in simple problem-solving instructions for predictable esthetics in both clinical protocols and laboratory techniques. An extensive presentation of clinical cases is included to illustrate the use of recommended protocols in general practice. An outstanding contribution to the practice and theory of color management in contemporary dentistry.

256 pp; 890 illus; ISBN 978-0-86715-745-1 (B7451); Special preorder price! US $86

 

Nonsurgical Periodontal Therapy:
Indications, Limits, and Clinical Protocols with the Adjunctive Use of a Diode Laser

Marisa Roncati

This book outlines the author’s clinically proven protocols for specific cause-related nonsurgical periodontal therapy, including diagnosis, treatment planning, and therapeutic interventions tailored to individual patient needs. With a focus on improved clinical outcomes, the author describes the most effective way to use manual instruments, the adjunctive use of the diode laser, and guidelines for periodontal maintenance.

416 pp; 1388 illus; ISBN: 978-8-87492-045-7 (B9535); US $130

 

New Issues in Journals


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Featured article: Mandibular Regional Anatomical Landmarks and Clinical Implications for Ridge Augmentation
Istvan A. Urbán, Alberto Monje, Hom-Lay Wang, Jaime Lozada, Gabor Gerber, and Gabor Baksa

A Novel Approach to Bone Reconstruction: The Wafer Technique
Mauro Merli, Marco Moscatelli, Giorgia Mariotti, Alessandro Motroni, Annalisa Mazzoni, Simona Mazzoni, Lorenzo Breschi, and Michele Nieri

Survival Rates and Bone and Soft Tissue Level Changes Around One-Piece Dental Implants Placed with a Flapless or Flap Protocol: 8.5-Year Results
Stuart J. Froum and Ismael Khouly

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Bone Quality and Quantity and Dental Implant Failure: A Systematic Review and Meta-analysis
Bruno Ramos Chrcanovic, Tomas Albrektsson, and Ann Wennerberg

CAD/CAM Ceramic Overlays to Restore Reduced Vertical Dimension of Occlusion Resulting from Worn Dentitions: A Case History Report
Jiang Ting, Han Shuhui, and Hongqiang

Support Ratio Between Abutment and Soft Tissue Under Overdentures: A Comparison Between Use of Two and Four Abutments
Manami Abe, Tsung-Chieh Yang, Yoshionobu Maeda, Takanori Ando, and Masahiro Wada

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Featured Article: Cortical and Trabecular Bone Healing Patterns and Quantification for Three Different Dental Implant Systems
Heloisa F. Marão, Ryo Jimbo, Rodrigo Neiva, Luiz Fernando Gil, Michelle Bowers, Estevam A. Bonfante, Nick Tovar, Malvin N. Janal, andPaulo G. Coelho

Challenging Paradigms: Update on the Use of Dental Implant Therapy for Patients with Diabetes Mellitus
Thomas W. Oates

Zirconia Implants as an Alternative to Titanium: A Systematic Review and Meta-Analysis
Basel Elnayef, Aida Lázaro, Fernando Suárez-López del Amo, Pablo Galindo-Moreno, Hom-Lay Wang, Jordi Gargallo-Albiol, and Federico Hernández-Alfaro

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Interprofessional Education and Collaboration as an Approach to Overcoming Perceived Barriers in Improving Oral Health
Lorinda Coan and Amanda R. Reddington

Quality Resources for Clinical Decision Making: Part 4. Understanding the Flossing Controversy
JoAnn R. Gurenlian and Jane L. Forrest

Critical Thinking in Action: Consideration of Alternative Hypotheses
Donald M. Brunette

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A Retrospective Study on Possible Predictive Factors for Long-term Temporomandibular Joint Degeneration and Impaired Mobility in Juvenile Arthritis Patients
Stanimira I. Kalaykova, Adriaan T. Klitsie, Corine M. Visscher, Machiel Naeije, and Frank Lobbezoo

Prevalence of Temporomandibular Disorders in the Northern Finland Birth Cohort 1966
Päivi Jussila, Heikki Kiviahde, Ritva Näpänkangas, Jari Päkkilä, Paula Pesonen, Kirsi Sipilä, Pertti Pirttiniemi, and Aune Raustia

A Rare Case of Misdiagnosed Silent Lung Cancer with Solitary Metastasis to the Temporomandibular Joint Condyle
Luca Guarda-Nardini, Edoardo Stellini, Adolfo Di Fiore, and Daniele Manfredini

 

Dental Meetings Quintessence Will Attend in June


Partners in Synergy
hosted by Pikos and Salama, June 8–10 in Orlando, Florida

Multidisciplinary Treatment Solutions for Peri-implantitis Symposium
hosted by Geistlich Biomaterials, June 9–11 in Chicago, Illinois

Pacific Northwest Dental Conference: Booth #503
hosted by the Washington State Dental Association, June 15–16 in Bellevue, Washington

2nd Biennial Meeting of the International Academy for Adhesive Dentistry
hosted by Penn Dental Medicine, June 16–17 in Philadelphia, Pennsylvania

 

Upcoming Quintessence Symposia


Posted in Books, Endodontics, Esthetic Dentistry, Implant Dentistry, International Journal of Evidence-Based Practice for the Dental Hygienist, Journal of Oral & Facial Pain and Headache (formerly Journal of Orofacial Pain), Journals, Periodontics, Promotions, Prosthodontics, Restorative Dentistry, Roundup, Special Offer, The International Journal of Oral & Maxillofacial Implants, The International Journal of Periodontics & Restorative Dentistry, The International Journal of Prosthodontics, What's New | Tagged , , , , , , , , , | Leave a comment

How You See It and How You Don’t: How the Principles of Human Perception Affect CBCT Interpretation

(a) Try to find the dog in this image. (b) Can you make out any forms from the splotches in this image? (c) Though it may be hard to tell, both of the smaller rectangles are the same shade of gray. (d) This image appears to be a gradient gray bar over a similar gradient background. However, if you cover the background you will see that the bar is a uniform shade of gray.

Everyone loves a good optical illusion. The world of social media was simultaneously thrilled and frustrated by the apparently color-changing dress that appeared in 2015 (discussed here, along with 11 other optical illusions). We enjoy optical illusions when they present as a fun trick to discuss with our friends. You may enjoy them less when they’re hiding in your patient’s CBCT scans, however.

“When digital radiography came out 20 years ago,” Dr John Khademi explains, “misinterpretation was rampant. Lots of fillings and crowns were inappropriately re-done by dentists who misinterpreted artifactual findings as recurrent decay. They took out the filling or cut off the crown and, lo-and-behold—no decay.”

“The problem with CBCT can be likened to the chicken and the egg,” he continues. “With periapical radiography, we all went to dental school and learned about how radiographs are made and how to interpret them: what decay looked like, crowns, fillings, etcetera. As specialists we went to endodontic school with people who had experience and we could interpret the radiography and get feedback from those with expertise: ‘This subtle finding means x, that finding means y.’ There was domain expertise and skill-set transfer. But CBCT was deployed into private practice completely devoid of any academic understanding of the image-generation process. There was an illusion of domain expertise as the medium looked familiar, but it wasn’t, leading to interpretive errors.”

Without that academic background in CBCT, clinicians are working backward to develop their expertise. Dr Khademi’s new book, Advanced CBCT for Endodontics: Technical Considerations, Perception, and Decision-Making, is a step toward filling the gaps in the industry’s current knowledge regarding CBCT interpretation. In it, he confronts and explains how the principles of human perception affect how we interpret CBCT imagery, much like how it affects what we see in those tricky optical illusions passed around via social media.

“Endodontists bring to the interpretive process a bias for interpretation that is influenced by other findings in the imaging,” Dr Khademi explains. “[In the figure to the right], the poorly done endodontics hits the endodontist immediately and biases the interpretation of the periapical area, increasing the chances that he or she will call an abnormal finding. This detection and recognition happens very quickly without effort and cannot be stopped. The clinician needs to then engage higher thinking and consider, ‘Are there any other explanations for these observations?’ The endodontist must recognize that all of the expertise he or she is bringing to the interpretive process is a double-edged sword.”

Use this attentional template to find the form hiding in image b at the top of this article.

The familiarity endodontists have with certain findings form attentional templates, similar to how we recognize familiar shapes or patterns in optical illusions. “We have an attentional template for recurrent decay underneath a crown from film radiography,” Dr Khademi says. “This attentional template hits us very fast with the perceptual process, and we mistake this familiarity and the speed with which we recognize this pattern for accuracy. However, this isn’t the film domain; it’s the digital domain, and a host of new artifactual imaging findings are possible.”

In the image to the right, we see what looks like recurrent decay and/or open margins. However, what is seen is actually an image-processing artifact called ringing artifact. This artifact mimics the attentional template for recurrent decay and open margins. The images below show this particular artifact simulated by software. Without knowledge of image processing and related artifacts specific to CBCT, the endodontist cannot differentiate between what is real and what is illusion, increasing the opportunity for inaccurate diagnoses.

How Do We Improve?

Clinicians must develop a new internal database not biased by the attentional templates developed through periapical radiography because the differences between the mediums mandate that much of that knowledge does not translate, and any attempt to make it translate may jeopardize success. Dr Khademi lays out the steps for building this knowledge:

“What endodontists must develop in terms of an internal database is the large number of artifactual findings that have no analog in PA radiography and can mimic pathologic findings, the very wide range of normal periapical findings at CBCT compared to projection radiography, and better language to describe imaging findings in a way that highlights inferences and uncertainty.”

All of these topics are covered in Dr Khademi’s book. However, he also emphasizes that endodontists must be open to feedback as well. “In private practice, we are generally alone and, because we aren’t the ones to extract teeth later, we don’t get feedback on our interpretive errors.”

In his book, Dr Khademi shares an example of a case (featured above) that he managed in 2010 right after installing a CS-9000 imager in his practice. The periapical projection radiography showed radiolucent findings possibly encompassing two or three roots and likely short root fillings of the mesiobuccal root, among other findings. The CBCT study showed radiolucent changes surrounding the palatal root, so Dr Khademi recommended extraction and replacement with an implant and referred the patient to a periodontist. The periodontist called back and said, “You may want to treat the necrotic lateral incisor.” While this particular case demonstrates the issue of satisfaction of search—the idea that once a meaningful interpretation is found, we stop looking—it also illustrates the importance of feedback.

“For us to experience failure we need to know that we have failed, and that requires feedback, Dr Khademi explains. “Here, in reference to my own interpretive failure on the necrotic lateral incisor, I would have never known that I had missed that finding had the periodontist not given me that feedback. Lacking feedback, there is some evidence that learning simply will not occur.”

When reading Dr Khademi’s book for the first time, some clinicians may find unsolicited feedback when they recognize artifacts explained in the text as findings they may have seen in their own patients’ imaging. However, as with the famous dress that some of us incorrectly saw as white and gold, the best part of finding out when you’re wrong is learning how to be right.


John A. Khademi, DDS, MS, is an adjunct assistant professor of endodontics at Saint Louis University. He received his dental degree from the University of California San Francisco and his certificate in endodontics and MS in digital imaging from the University of Iowa. He previously wrote software for laboratory automation, instrument control, and digital imaging. He lectures internationally about CBCT, clinical trial design, outcomes, and conventional endodontic techniques. As a Radiological Society of North America (RSNA) member for over 25 years, his background in medical radiology allows him a perspective shared by very few dental professionals. He maintains a private practice limited to endodontics in Durango, Colorado.

Posted in Books, Endodontics, Misc, What's New | Tagged , , , , , | 2 Comments