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Theekakul C, Banomyong D, Osiri S, Sutam N, Ongchavalit L, Jantarat J. Mahidol Study 2: Treatment Outcomes and Prognostic Factors of Regenerative Endodontic Procedures in Immature Permanent Teeth. J Endod 2024:S0099-2399(24)00479-5. [PMID: 39216625 DOI: 10.1016/j.joen.2024.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/21/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Studies on the clinical outcomes and prognostic factors of regenerative endodontic procedures (REPs) in a large population and long-term recall period have been limited. Therefore, the aims of this study were to evaluate treatment outcomes and prognostic factors of REPs. METHODS Immature permanent teeth treated with REPs with a minimum one-year follow-up period were included. Treatment outcomes (functional retention, healed rate, root development and sensibility test response) and any prognostic factors were analyzed with multivariable Cox regression, linear regression, and risk-ratio regression. RESULTS One-hundred-twenty REPs teeth with a mean 41.7-month recall period were included with a functional retention rate of 97.5%. The healed, healing and diseased rates of REPs were 80%, 9.2%, and 10.8%, respectively. Significant prognostic factors for healed were age (<12 years old) and root development stage (stages 4 and 5). Changes in the apical diameter, root length, root width, and radiographic root area after REPs were 56.8%, 8.3%, 23.2%, and 21.7%, respectively. A significant prognostic factor for continued root development was etiology of pulpal disease (from caries or dens evaginatus). The sensibility test response rate was 41.7% with significant positive factors of EDTA irrigation and capping material level below the cemento-enamel junction. CONCLUSION REPs demonstrated high functional retention and healed rates. Patients <12 years old presented a higher healed rate and continued root development (excluding root length). Dental caries or anomalies had higher continued root development compared with dental trauma. The sensibility test response was related to EDTA irrigation and low-level capping material.
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Affiliation(s)
- Chayanun Theekakul
- Departments of Operative Dentistry and Endodontics, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | | | - Sittichoke Osiri
- Departments of Operative Dentistry and Endodontics, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Nithinun Sutam
- The Dental Department of Chulaborn hospital, Bangkok, Thailand
| | - Lalida Ongchavalit
- Departments of Operative Dentistry and Endodontics, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
| | - Jeeraphat Jantarat
- Departments of Operative Dentistry and Endodontics, Faculty of Dentistry, Mahidol University, Bangkok, Thailand.
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Kahler B, Lu J, Taha NA. Regenerative endodontic treatment and traumatic dental injuries. Dent Traumatol 2024. [PMID: 38989999 DOI: 10.1111/edt.12979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 07/12/2024]
Abstract
Pulp necrosis is the most common complication following dental trauma and is often associated with apical periodontitis. The management of these teeth is challenging in terms of large root canals, open apices, thin dentinal walls, and short roots. Over decades the conventional treatment for these teeth was calcium hydroxide apexification, a time-consuming procedure despite high success rates. Subsequently after the introduction of mineral trioxide aggregate and hydraulic calcium silicate materials single visit apical plug procedures became increasingly practiced with comparable success rates to the conventional apexification. The search continued afterward for a clinical procedure that may stimulate further root development and apical closure to avoid the long-term complication of root fracture after apexification. Regenerative procedures using stem cells derived from the apical papilla and blood clots as scaffolds were then introduced for the management of immature teeth, with variable protocols and success rates. This review will cover the evidence available and current position of regenerative endodontic procedures in traumatized immature teeth with apical periodontitis, in terms of clinical protocols, outcome, and potential prognostic factors.
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Affiliation(s)
- Bill Kahler
- Department of Restorative and Reconstructive Dentistry, School of Dentistry, University of Sydney, Camperdown, New South Wales, Australia
| | - Jing Lu
- Fujian Key Laboratory of Oral Diseases, School and Hospital of Stomatology, Fujian Medical University, Fuzhou, China
| | - Nessrin A Taha
- Conservative Dentistry Department, Jordan University of Science and Technology, Irbid, Jordan
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Nogueira APA, Grazziotin-Soares R, Leal AMM, Freitas Júnior SAG, Gonçalves BLL, Bauer J, Ferreira MC, Carvalho CN. Root Canal Dentin Microhardness after Contact with Antibiotic Medications: An In Vitro Study. Dent J (Basel) 2024; 12:201. [PMID: 39056988 PMCID: PMC11276266 DOI: 10.3390/dj12070201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/19/2024] [Accepted: 05/21/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Antibiotic pastes used as intracanal medication in cases of revascularization therapy might cause negative effects on tooth properties, such as a reduction in dentin microhardness. This in vitro study investigated dentin microhardness in three different locations distancing from the canal lumen after 20 days of treatment with a tri-antibiotic paste (ciprofloxacin, metronidazole, and minocycline), and with a double-antibiotic paste (ciprofloxacin and metronidazole), with calcium hydroxide [Ca(OH)2] UltracalTM XS-treated dentin as comparison. Material and Methods: Human mandibular premolars (n = 48) had the root canals cleaned and shaped and were used to produce dentin slices. Dentin slices remained immersed in the medications for 20 days. The Knoop microhardness (KHN) test was performed before (baseline/Day-0) and after treatment (Day-20) with the medications. Indentations were made at 25 µm, 50 µm, and 100 µm distances from the root canal lumen. The KHN was compared intra-group using Wilcoxon's test. Independent groups were compared using Mann-Whitney's and Kruskal-Wallis' tests, at α = 5%. Results: The microhardness in all the tested groups was reduced at Day-20 in comparison with Day-0 (p < 0.001) (intra-group comparison/same distances). The Day-0 values were similar, and the Day-20 values were higher for the Ca(OH)2 group (p < 0.05) (comparison between groups/same distances). Conclusions: Calcium hydroxide for 20 days would be preferred rather than antibiotic pastes to minimize the expected reduction in dentin microhardness during regenerative procedures.
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Affiliation(s)
- Amanda Palmeira Arruda Nogueira
- School of Dentistry, CEUMA University, São Luís 65075-120, MA, Brazil; (A.P.A.N.); (A.M.M.L.); (S.A.G.F.J.); (B.L.L.G.); (M.C.F.)
| | - Renata Grazziotin-Soares
- Department of Oral Biological Medical Sciences, Faculty of Dentistry, University of British Columbia UBC, Vancouver, BC V6T 1Z4, Canada;
| | - Adriana Marques Mesquita Leal
- School of Dentistry, CEUMA University, São Luís 65075-120, MA, Brazil; (A.P.A.N.); (A.M.M.L.); (S.A.G.F.J.); (B.L.L.G.); (M.C.F.)
| | | | - Bruna Laís Lins Gonçalves
- School of Dentistry, CEUMA University, São Luís 65075-120, MA, Brazil; (A.P.A.N.); (A.M.M.L.); (S.A.G.F.J.); (B.L.L.G.); (M.C.F.)
| | - José Bauer
- Dental Materials Laboratory, School of Dentistry, University Federal of Maranhão (UFMA), São Luís 5085-582, MA, Brazil;
| | - Meire Coelho Ferreira
- School of Dentistry, CEUMA University, São Luís 65075-120, MA, Brazil; (A.P.A.N.); (A.M.M.L.); (S.A.G.F.J.); (B.L.L.G.); (M.C.F.)
| | - Ceci Nunes Carvalho
- School of Dentistry, CEUMA University, São Luís 65075-120, MA, Brazil; (A.P.A.N.); (A.M.M.L.); (S.A.G.F.J.); (B.L.L.G.); (M.C.F.)
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Anna B, Craig D, Gordon L, Eric S. Current Trends in Regenerative Endodontics: A Web-based Survey. J Endod 2024; 50:181-188. [PMID: 38013150 DOI: 10.1016/j.joen.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/18/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION The aim of this study was to ascertain the current trends in regenerative endodontic procedures (REPs) among clinicians, including case selection criteria and clinical protocols. METHODS An online questionnaire consisting of provider demographics, case selection criteria for REPs, and clinical protocols was made available to members of the American Association of Endodontists and members of the Endolit website. Data were analyzed using the Fisher exact test. RESULTS Two hundred seventy-two responses were analyzed (64.6% were men and 34.7% were women). Of those, 44.5% of respondents practiced in the United States, and 55.5% practiced outside of the Unites States. Most respondents (85.4%) reported performing REPs in their practice, and 92.2% were using sodium hypochlorite as one of their disinfecting irrigants. Calcium hydroxide was the most commonly used intracanal medicament (68.4%), and the majority of respondents use a blood clot alone as the scaffold (73.5%). Most (93%) of the providers reported using a bioceramic material for coronal capping. Practitioners outside the United States were found to be more likely to use adjunctive irrigation activation (P = .003). Younger practitioners preferred REPs over apexification (P = .01). Practitioners outside the United States were more likely to perform an REP in 1 visit (P = .006). Men were found to be more likely to always instrument the canal walls (P = .031). Women were found to be more likely to use manual irrigant activation, whereas men were more likely to use sonic activation (P = .043). CONCLUSIONS There is significant heterogeneity within REPs regarding case selection and clinical protocol. Notable differences were observed from the reported findings of REPs from 5 years ago.
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Affiliation(s)
- Bowers Anna
- Department of Endodontics, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California
| | - Dunlap Craig
- Department of Endodontics, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California.
| | - Lai Gordon
- Department of Endodontics, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California
| | - Salmon Eric
- Outcome Assessment Liaison, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California
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Lu J, Kahler B, Jiang X, Lu Z, Lu Y. Treatment outcomes of regenerative endodontic procedures in nonvital mature permanent teeth: a retrospective study. Clin Oral Investig 2023; 27:7531-7543. [PMID: 37875745 DOI: 10.1007/s00784-023-05343-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/14/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVES This retrospective study was undertaken to clinically and radiographically evaluate the long-term outcomes of regenerative endodontic procedures (REPs) for nonvital mature permanent teeth, to analyze predictors influencing treatment outcomes. METHODS Nonvital mature permanent teeth treated by REPs with a minimum follow-up period of 6 months were included from 2015 to 2017. Treatment outcomes were categorized as success and failure. The periapical status and lesion healing were assessed in terms of the periapical index (PAI) and the percentage changes in periapical radiolucency (PARL) area. The clinical and radiographic outcomes of REPs were assessed by Mann-Whitney test at different follow-up period. Kaplan-Meier curves and Univariate Cox regression analysis were conducted to assess the success and identify potential predictors affecting outcomes, respectively. RESULTS A total of 37 mature teeth with an average follow-up of 4.3 years satisfied the criteria, and 89.2% of the teeth had a successful outcome. Significant differences in PAI scores were found between each period with respect to the baseline (p < .05). Among different periods, there was a significant difference between intervals of 3-6 months and 7-12 months (p = .039) and no significant difference between each interval of more than 12 months (p > .05). Eighty-seven percent of teeth with preoperative PARL presented completely healed. REPs significantly decreased the PARL area at the interval of 7-12 months compared to 3-6 months (p = .025), with no significant difference between each interval of more than 12 months (p > .05). No significant predictor was found for the success of outcome (p > .05). Thirteen teeth (35.1%) regained pulp sensibility, and 40.5% of the teeth exhibited intracanal calcification. CONCLUSIONS Within the limitations of this study, REPs provided a high long-term success rate and promoted the resolution of PARL as a biologically-based alternative treatment option for nonvital mature teeth. CLINICAL RELEVANCE REPs provide a high long-term success rate and promoted healing of apical periodontitis comparable with reported outcomes for root canal therapy of mature teeth.
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Affiliation(s)
- Jing Lu
- Fujian Key Laboratory of Oral Diseases, School and Hospital of Stomatology, Fujian Medical University, 246 Yangqiao Zhong Road, Fuzhou, 350002, Fujian, China
| | - Bill Kahler
- School of Dentistry, University of Sydney, Camperdown, Australia
| | - Xing Jiang
- Fujian Key Laboratory of Oral Diseases, School and Hospital of Stomatology, Fujian Medical University, 246 Yangqiao Zhong Road, Fuzhou, 350002, Fujian, China
| | - Zhaojie Lu
- Fujian Key Laboratory of Oral Diseases, School and Hospital of Stomatology, Fujian Medical University, 246 Yangqiao Zhong Road, Fuzhou, 350002, Fujian, China
| | - Youguang Lu
- Fujian Key Laboratory of Oral Diseases, School and Hospital of Stomatology, Fujian Medical University, 246 Yangqiao Zhong Road, Fuzhou, 350002, Fujian, China.
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Wang N, Liu H, Shen Y. Endodontic microsurgery for failed regenerative endodontic procedures. Asian J Surg 2023; 46:6093-6094. [PMID: 37775387 DOI: 10.1016/j.asjsur.2023.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023] Open
Affiliation(s)
- Nan Wang
- Department of Stomatology, Affiliated Hospital of Jining Medical University, Jining, China
| | - He Liu
- Division of Endodontics, Department of Oral Biological & Medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, Canada.
| | - Ya Shen
- Division of Endodontics, Department of Oral Biological & Medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, Canada
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Demircan B, Demir P. 3D finite element analysis of stress distribution as a result of oblique and horizontal forces after regenerative endodontic treatment part II: comparison of material thickness. BMC Oral Health 2023; 23:869. [PMID: 37974115 PMCID: PMC10655308 DOI: 10.1186/s12903-023-03559-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023] Open
Abstract
AIM This study aimed to evaluate the stress distribution caused by secondary trauma forces after regenerative endodontic treatment (RET) using different thicknesses of coronary barrier material with three-dimensional finite element analysis(FEA). METHOD A control model was created using the tomography image of the immature maxillary central tooth with computer software.Study models were created with the modulus of elasticity and Poisson's ratio of the materials used in RET.Enamel, dentin, cementum, periodontal ligament, cortical, and cancellous bone were modeled. Coronary barrier materials were applied in 3 mm and 5 mm thicknesses (Model 1: control model, model 2:3 mm/Calcium Enriched Mixture(CEM), model 3:3 mm/Mineral Trioxide Aggregate(MTA), model 4:3 mm/Biodentin, model 5:5 mm/CEM, model 6:5 mm/MTA, model 7:5 mm/Biodentin). For the trauma force simulation, 300 N force in the horizontal direction was applied to the buccal surface of the tooth in the first scenario. For the second scenario, maximum bite force simulation, a force of 240 N in the oblique direction was applied to the palatal surface of the tooth. FEA was performed with Algor Fempro. The resulting stresses were recorded as Von Mises, maximum, and minimum principal stresses. RESULTS Lower stress values were obtained in 5 mm models compared to 3 mm models. However, the difference between them was insignificant. Lower stress values were obtained in all RET models compared to the control model. The lowest stress values in dental tissues and bone tissue were obtained in the CEM models. CONCLUSION This is the first study in which the stress caused by different thicknesses of CEM on dental tissues was evaluated with FEA. RET strengthens immature teeth biomechanically. CEM and Biodentin are more successful materials in stress distribution than MTA. Considering the cost of treatment, 3 mm material thickness is ideal for RET since there is no significant difference between the stress values resulting from the use of 5 mm and 3 mm coronary barrier material.
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Affiliation(s)
- Beril Demircan
- Department of Pediatric Dentistry, Faculty of Dentistry, Nuh Naci Yazgan University, Kayseri, 38170, Kocasinan, Türkiye.
| | - Pınar Demir
- Department of Pediatric Dentistry, Faculty of Dentistry, Nuh Naci Yazgan University, Kayseri, 38170, Kocasinan, Türkiye
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Jiang X, Liu H. Analysis of the achievement of primary and secondary goals and influencing factors in single-rooted immature permanent teeth after regenerative endodontic procedures: a retrospective study. BMC Oral Health 2023; 23:851. [PMID: 37951858 PMCID: PMC10640728 DOI: 10.1186/s12903-023-03553-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/19/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE This study explored the achievement of primary and secondary goals and factors influencing their achievement in regenerative endodontic procedures (REPs) for immature permanent teeth. METHODS Dental records of all patients who received REPs for immature permanent teeth at the Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology between January 2012 and January 2023 were retrieved. The evaluation of the primary goal was based on medical and radiographic records. The achievement of the primary goal was defined as the absence of clinical signs and symptoms, such as pain, swelling, or sinus tract and the absence of periapical radiolucency, as assessed on postoperative periapical radiographs. The achievement of secondary goal represented increased root wall thickness and/or increased root length, that is, continued root development. Periapical radiographs before and after treatment were used to evaluate the achievement of the secondary goal. The secondary goal was required to be achieved alongside the achievement of primary goal. RESULTS A total of 436 teeth (136 anterior and 300 posterior teeth) were included in this study, 96.1% of which demonstrated achievement of the primary goal. Signs of failure (17 teeth) included crown fracture and uncontrolled and recurrent periapical lesions. In addition, 77.8% of teeth demonstrated achievement of the secondary goal, and more than half of the teeth exhibited a complete root development. Evaluation factors included patients' age, sex, tooth type, etiology, preoperative periapical lesion, duration of clinical signs and symptoms, follow-up period, and stage of root development. The achievement of the primary and secondary goals were significantly related to age and tooth type (p < 0.05). CONCLUSIONS Children with a younger initial visit age are more likely to achieve primary and secondary goals. Additionally, posterior teeth had an advantage over anterior teeth in achieving primary and secondary goals.
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Affiliation(s)
- Xijun Jiang
- Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology & National Center for Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental Materials, Beijing, China
| | - He Liu
- Department of Pediatric Dentistry, Peking University School and Hospital of Stomatology & National Center for Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health & NMPA Key Laboratory for Dental Materials, Beijing, China.
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Li J, Cheng J, Yang F, Yu J, Song G. Treatment outcomes of immature permanent necrotic evaginated teeth: A retrospective study comparing regenerative endodontic procedures with apexification. Int J Paediatr Dent 2023; 33:595-606. [PMID: 37158340 DOI: 10.1111/ipd.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 03/21/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Few studies have compared the outcomes of regenerative endodontic procedures (REPs) and calcium hydroxide apexification focusing on necrotic teeth with dens evaginatus. AIM To qualitatively and quantitatively compare the treatment outcomes of REPs and calcium hydroxide apexification in teeth with dens evaginatus. DESIGN Immature permanent necrotic evaginated teeth treated with REPs or calcium hydroxide apexification for a follow-up period of at least 12 months were included. Tooth success and survival rates were analyzed. Changes in radiographic root length, apical diameter, and radiographic root area (RRA) were quantified. Prognostic factors that might influence RRA were identified via multivariate linear regression analysis. RESULTS A total of 112 teeth (50 REP cases and 62 apexification cases) with a median follow-up period of 26.5 months were included. Regenerative endodontic procedures and calcium hydroxide apexification exhibited similar satisfactory success and survival rates (p > .05). Additionally, 88 teeth were quantitatively analyzed. The REP group presented a significantly greater percentage increase in RRA and less decrease in apical diameter than the calcium hydroxide apexification group (p < .05). Teeth treated with REPs and with Stages 7 and 8 of root development showed a better gain in RRA (p < .05). CONCLUSION While REP and calcium hydroxide apexification had similar success and survival rates, teeth with REPs showed an increase in RRA, indicating that REP is the preferred choice.
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Affiliation(s)
- Jiahui Li
- Department of Paediatric Dentistry, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Jing Cheng
- Department of Paediatric Dentistry, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Fengjiao Yang
- Department of Paediatric Dentistry, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Jingjing Yu
- Department of Paediatric Dentistry, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
| | - Guangtai Song
- Department of Paediatric Dentistry, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Wuhan, China
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Balbinot GS, Leitune VCB, Zatta KC, Benin T, Guterres SS, Collares FM. Controlled drug delivery from metronidazole-containing bioactive endodontic cements. Dent Mater 2023; 39:839-845. [PMID: 37500315 DOI: 10.1016/j.dental.2023.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES This study aims to formulate metronidazole liquid nanocapsules (MTZLNC) and evaluate their effect on the physicochemical and biological properties of calcium silicate-based bioactive endodontic cements, in vitro. METHODS A MTZLNC suspension was formulated by deposition of the preformed polymer and characterized by laser diffraction and high-performance liquid chromatography (HPLC). Calcium silicate (CS) was mixed with a radiopaque agent (calcium tungstate - CaWO4), at 10 wt%, to produce the cement powder. Cements liquids were used with two concentrations of MTZLNC suspension: 0.3 mg/ml and 0.15 mg/ml. Cements prepared with distilled water were used as the control. The radiopacity, setting time, and flow were evaluated following ISO 6876:2012. The compressive strength analysis was conducted according to ISO 9917:2007. pH and mineral deposition were evaluated after immersion in simulated body fluid (SBF). Cell behavior was evaluated by the viability of pre-osteoblastic cells and pulp fibroblasts by SRB and MTT and the antibacterial activity against Enterococcus faecalis was analyzed immediately and after nine months of water storage. RESULTS MTZLNCs were formulated with a median diameter of 148 nm and 83.44 % load efficiency. Increased flow and reduced strength were observed for both MTZLNCs concentrations. The incorporation of MTZLNCs maintained the ability of cements to increase pH media and promote mineral deposition over the samples, without promoting cytotoxicity. A 2 log10 reduction in E. faecalis CFU was observed immediately and after nine months in water storage. CONCLUSION The formulation of MTZLNCs allowed the development of antibacterial calcium silicate-based-cements with suitable physicochemical properties and bioactivity, with a reduction in mechanical strength. The 0.3 mg/ml concentration in cements liquid promoted effective and sustainable antibacterial activity.
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Affiliation(s)
- Gabriela Souza Balbinot
- Department of Dental Materials, School of Dentistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Vicente Castelo Branco Leitune
- Department of Dental Materials, School of Dentistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Kelly Cristina Zatta
- Cosmetology and Pharmaceutical Nanotechnology Laboratory, School of Pharmaceutical Sciences, Universidade Federal do Rio Grande do Sul, Av. Ipiranga 2752, 90610-000 Porto Alegre, RS, Brazil
| | - Tainara Benin
- Pharmaceutical Nanotechnology Laboratory, School of Pharmaceutical Sciences, Universidade Federal do Rio Grande do Sul, Av. Ipiranga 2752, 90610-000 Porto Alegre, RS, Brazil
| | - Silvia Stanisçauski Guterres
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Fabricio Mezzomo Collares
- Department of Dental Materials, School of Dentistry, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Van Gorp G, Declerck D. Long-term Outcome of Endodontically Treated Traumatized Immature Upper Incisors. J Endod 2023; 49:1106-1119. [PMID: 37385539 DOI: 10.1016/j.joen.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION In a growing child, preservation of traumatized immature permanent upper incisors is challenging. This study aimed to evaluate the long-term outcome of endodontically treated traumatized immature upper incisors and associated variables. METHODS A total of 183 traumatized immature upper incisors treated with pulpotomy, apexification, or regenerative endodontic procedure (REP), with follow-up between 4 and 15 years, were assessed for presence of pulpal responses or periodontal/bone responses using standardized clinical and radiologic criteria. Logistic regression, including stage of root development, type and complexity of traumatic event, type of endodontic intervention, and history of orthodontic management, were used to estimate impact on tooth survival and occurrence of tissue responses. Study approved by Ethics Committee Research UZ/KU Leuven (S60597). RESULTS After a median follow-up of 7.3 years (interquartile range, 6.1-9.2), 159 teeth (86.9%) were still functional. From these teeth, 58 (36.5%) developed tissue responses. This was significantly associated with stage of root development at moment of trauma (root length <¾) and type of endodontic intervention (REP presenting worst outcome). Tooth loss (24 teeth, 13.1%) occurred after a mean time span of 3.2 years (±1.5) and was significantly associated with type and complexity of the traumatic event and type of endodontic intervention, with apexification showing better results than REP (odds ratio, 0.30; 95% confidence interval, 0.11-0.79). CONCLUSIONS A large number of endodontically treated traumatized immature teeth could be kept functional. Very immature teeth, teeth with periodontal tissue damage, and teeth treated with REP were at highest risk for an unfavorable outcome.
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Affiliation(s)
- Gertrude Van Gorp
- Unit of Paediatric Dentistry and Special Dental Care, KU Leuven Department of Oral Health Sciences and Department of Dentistry, University Hospitals Leuven, Leuven, Belgium.
| | - Dominique Declerck
- Unit of Paediatric Dentistry and Special Dental Care, KU Leuven Department of Oral Health Sciences and Department of Dentistry, University Hospitals Leuven, Leuven, Belgium
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Tang Y, Xu K, Chen Y, Lu L. Evaluating the efficacy of endodontic microsurgery for teeth with an undeveloped root apex and periapical periodontitis after nonsurgical treatment failure. BMC Oral Health 2023; 23:414. [PMID: 37349753 PMCID: PMC10288790 DOI: 10.1186/s12903-023-03117-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023] Open
Abstract
AIM To determine the efficacy of endodontic microsurgery for teeth with an undeveloped root apex and periapical periodontitis caused by an abnormal central cusp fracture after failed nonsurgical treatment. METHODOLOGY Eighty teeth in 78 patients were subjected to endodontic microsurgery. All patients were clinically and radiologically examined 1 year postoperatively. The data were statistically analyzed using SPSS 27.0 software. RESULTS Of the 80 teeth in 78 patients, periapical lesions had disappeared in 77 teeth at 1-year postoperative follow-up, with a success rate of approximately 96.3% (77/80). The efficacy of endodontic microsurgery was not affected by sex, age, extent of periapical lesions, and presence of the sinus tract. Between-group differences were not statistically significant (P > 0.05). CONCLUSIONS Endodontic microsurgery can be an effective alternative treatment option for teeth with an undeveloped root apex and periapical periodontitis caused by an abnormal central cusp fracture after nonsurgical treatment failure.
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Affiliation(s)
- Yumu Tang
- Department of Endodontics, Suzhou Stomatological Hospital, Suzhou, 215005, China
| | - Ke Xu
- Department of Endodontics, Suzhou Stomatological Hospital, Suzhou, 215005, China
| | - Yumao Chen
- Department of Orthodontics, Suzhou Stomatological Hospital, Suzhou, 215005, China
| | - Le Lu
- Department of Endodontics, Suzhou Stomatological Hospital, Suzhou, 215005, China.
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13
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Hu X, Wang Q, Ma C, Li Q, Zhao C, Xiang K. Is Etiology a Key Factor for Regenerative Endodontic Treatment Outcomes? J Endod 2023:S0099-2399(23)00293-5. [PMID: 37285935 DOI: 10.1016/j.joen.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/29/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION This study aimed to evaluate treatment outcomes of regenerative endodontic treatment (RET) in nonvital immature permanent teeth due to developmental malformation and trauma, and to analyze the influence of etiology on the prognosis. METHODS Fifty-five cases were included and divided into a malformation group (n=33) and a trauma group (n=22). Treatment outcomes were classified as healed, healing and failure. Root development was evaluated in terms of root morphology and the percentage changes in root length, root width and apical diameter during a follow-up period of 12 to 85 months (mean 30.8 months). RESULTS The mean age and the mean degree of root development in the trauma group were significantly younger than that in the malformation group. The success rate of RET was 93.9% (81.8% healed, 12.1% healing) in the malformation group and 90.9% (68.2% healed, 22.7% healing) in the trauma group, showing no statistically significant difference. The proportion of type I-III root morphology in the malformation group (97%, 32/33) was significantly higher than that in the trauma group (77.3%, 17/22) (P<0.05), whereas there was no significant difference in the percentage changes of root length, root width and apical diameter between the two groups. Six cases (6/55, 10.9%) showed no significant root development (type IV-V) (1 in the malformation group and 5 in the trauma group). Six cases (6/55, 10.9%) revealed intracanal calcification. CONCLUSIONS RET achieved reliable outcomes regarding the healing of apical periodontitis and continued root development. The etiology seems to influence the outcome of RET. Malformation cases presented with a better prognosis than trauma cases after RET.
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Affiliation(s)
- Xiaoyan Hu
- Stomatologic Hospital & College, Anhui Medical University, Key Lab. of Oral Diseases Research of Anhui Province, Hefei, 230032, China.
| | - Qingtong Wang
- Institute of Clinical Pharmacology, Anhui Medical University, Key Laboratory of Anti-inflammatory and Immune Medicine, Ministry of Education, Collaborative Innovation Center of Anti-inflammatory and Immune Medicine, Hefei, 230032, China
| | - Chenxue Ma
- Stomatologic Hospital & College, Anhui Medical University, Key Lab. of Oral Diseases Research of Anhui Province, Hefei, 230032, China
| | - Quanli Li
- Stomatologic Hospital & College, Anhui Medical University, Key Lab. of Oral Diseases Research of Anhui Province, Hefei, 230032, China
| | - Chunhui Zhao
- Stomatologic Hospital & College, Anhui Medical University, Key Lab. of Oral Diseases Research of Anhui Province, Hefei, 230032, China
| | - Kun Xiang
- Stomatologic Hospital & College, Anhui Medical University, Key Lab. of Oral Diseases Research of Anhui Province, Hefei, 230032, China
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Kumar JK, Surendranath P, Eswaramoorthy R. Regeneration of immature incisor using platelet rich fibrin: report of a novel clinical application. BMC Oral Health 2023; 23:69. [PMID: 36732777 PMCID: PMC9896711 DOI: 10.1186/s12903-023-02759-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/23/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endodontic treatment of young permanent teeth with necrotic pulp presents a clinical challenge for the dentist, and conventional endodontic treatment will result in tooth fracture along with a poor prognosis. Regenerative endodontics is a new protocol that has been advanced in the last decades for managing immature permanent teeth. Rare successful management of immature permanent incisors using platelet-rich fibrin is a technique-sensitive procedure. CASE PRESENTATION A 08 years 04 months old female reported the chief complaint of pain in the upper front tooth region for one week. A blunderbuss canal was identified on radiographic examination, and revascularization using platelet-rich fibrin was planned and adopted. After the treatment, apical closure and root lengthening were noted without complications during subsequent follow-ups. Complete periapical healing with greater than 1.5 cm of dentinal thickness was noted. CONCLUSION Revascularization can be considered a viable treatment option for immature nonvital permanent teeth; with advancements in regenerative medicine and clinical practices, revascularization therapies could be developed as a novel mode of treatment in non-vital and dental traumatic cases.
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Affiliation(s)
- Jishnu Krishna Kumar
- Department of Public Health Dentistry, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Chennai, India.
| | | | - Rajalakshmanan Eswaramoorthy
- Department of Applied Chemistry, School of Applied Natural Science, Adama Science and Technology University (ASTU), PO. 18888, Adama, Ethiopia.
- Department of Biomaterials, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Chennai, India.
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de Oliveira RA, Weissheimer T, Só GB, da Rosa RA, Souza MA, Ribeiro RG, Só MVR. Dentinal tubule penetration of sodium hypochlorite in root canals with and without mechanical preparation and different irrigant activation methods. Restor Dent Endod 2023; 48:e1. [PMID: 36875814 PMCID: PMC9982243 DOI: 10.5395/rde.2023.48.e1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/13/2022] [Accepted: 10/04/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives This study evaluated the dentinal penetration depth of 2.5% sodium hypochlorite (NaOCl) in root canals with and without preparation and different irrigant activation protocols. Materials and Methods Sixty-three bovine mandibular incisors were randomly allocated to 6 groups (n = 10): G1, preparation + conventional needle irrigation (CNI); G2, preparation + passive ultrasonic irrigation (PUI); G3, preparation + Odous Clean (OC); G4, no preparation + CNI; G5, no preparation + PUI; G6, no preparation + OC; and CG (negative control; n = 3). Samples were filled with crystal violet for 72 hours. Irrigant activation was performed. Samples were sectioned perpendicularly along the long axis, 3 mm and 7 mm from the apex. Images of the root thirds of each block were captured with a stereomicroscope and analyzed with an image analysis software. One-way analysis of variance, followed by the Tukey post hoc test, and the Student's t-test were used for data analysis, with a significance level of 5%. Results The NaOCl penetration depth was similar when preparation was performed, regardless of the method of irrigation activation (p > 0.05). In the groups without preparation, G6 showed greater NaOCl penetration depth (p < 0.05). The groups without preparation had a greater NaOCl penetration depth than those with preparation (p = 0.0019). Conclusions The NaOCl penetration depth was similar in groups with root canal preparation. Without root canal preparation, OC allowed deeper NaOCl penetration. The groups without preparation had greater NaOCl penetration than those undergoing root canal preparation.
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Affiliation(s)
- Renata Aqel de Oliveira
- Department of Conservative Dentistry, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Theodoro Weissheimer
- Department of Conservative Dentistry, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Gabriel Barcelos Só
- Department of Conservative Dentistry, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Ricardo Abreu da Rosa
- Department of Conservative Dentistry, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Matheus Albino Souza
- Department of Endodontics, School of Dentistry, University of Passo Fundo (UPF), Passo Fundo, RS, Brazil
| | - Rodrigo Gonçalves Ribeiro
- Department of Endodontics, School of Dentistry, State University of Western Paraná (UNIOESTE), Cascavel, PR, Brazil
| | - Marcus Vinicius Reis Só
- Department of Conservative Dentistry, School of Dentistry, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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Rahul M, Lokade A, Tewari N, Mathur V, Agarwal D, Goel S, Keshari P, Sharma S, Bansal K. Effect of Intracanal Scaffolds on the Success Outcomes of Regenerative Endodontic Therapy - A Systematic Review and Network Meta-analysis. J Endod 2023; 49:110-128. [PMID: 36410623 DOI: 10.1016/j.joen.2022.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/12/2022] [Accepted: 11/12/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The scaffolds used in regenerative endodontic therapy (RET) provide structural support for cells so that they can adhere to the scaffolds and also are crucial for cellular proliferation and differentiation. The objective of this network meta-analysis was to compare effects of different intracanal scaffolds on success outcomes of RET. METHODS PubMed/Medline, EMBASE, Cochrane, CINAHL, Scopus, and Web of Science databases were searched. Studies evaluating and/or comparing clinical and/or radiographic success of RET using different scaffolds with a minimum of 12 months follow-up were included. The Cochrane Collaboration risk of bias (ROB) tool and appropriate tools from Joanna Briggs Institute were used for the assessment of ROB. A network meta-analysis was performed to compare the primary outcome (clinical success) and other success outcomes (root maturation, and pulpal sensibility) using different scaffolds. RESULTS Twenty-seven studies fulfilled the desired inclusion criteria of which 25 had a low ROB whereas 2 had a moderate ROB. Clinical success of RET using platelet-rich plasma (PRP), blood clot (BC), and platelet-rich fibrin (PRF) scaffolds ranged between 91.66%-100%, 84.61%-100%, and 77%-100% respectively. The different scaffolds did not show any statistically significant difference in clinical success (PRF vs BC [P = 1.000], PRP vs BC [P = 1.000], and PRF vs PRP [P = .999]), apical root closure (PRF vs BC [P = 1.000], PRP vs BC [P = .835], PRF vs PRP [P = .956]), and pulp sensibility (PRF vs BC [P = .980], PRP versus BC [P = .520], and PRF vs PRP [P = .990]). CONCLUSION The intracanal scaffolds used during RET did not result in significant differences in regard to clinical success, root maturation, and pulpal sensibility.
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Affiliation(s)
- Morankar Rahul
- Division of pedodontics and preventive dentistry, Centre for Dental Education and Research, AIIMS, New Delhi, India.
| | - Amolkumar Lokade
- Division of pedodontics and preventive dentistry, Centre for Dental Education and Research, AIIMS, New Delhi, India
| | - Nitesh Tewari
- Division of pedodontics and preventive dentistry, Centre for Dental Education and Research, AIIMS, New Delhi, India
| | - Vijay Mathur
- Division of pedodontics and preventive dentistry, Centre for Dental Education and Research, AIIMS, New Delhi, India
| | - Deepali Agarwal
- Division of Public Health Dentistry, Centre for Dental Education and Research, AIIMS, New Delhi, India
| | - Shubhi Goel
- Department of Public Health Dentistry, Postgraduate Institute of Dental Sciences, Rohtak, Haryana, India
| | | | - Sidhartha Sharma
- Division of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, AIIMS, New Delhi, India
| | - Kalpana Bansal
- Division of pedodontics and preventive dentistry, Centre for Dental Education and Research, AIIMS, New Delhi, India
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Critical analysis using Kaplan-Meier survival to evaluate the influence of various factors on the failures of Regenerative Endodontic therapy. J Endod 2022; 49:96-97. [DOI: 10.1016/j.joen.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
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18
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Zeng Q, Zhang J, Guo J, Liu S, Yang M, Lin J. Preoperative factors analysis on root development after regenerative endodontic procedures: a retrospective study. BMC Oral Health 2022; 22:374. [PMID: 36058906 PMCID: PMC9442966 DOI: 10.1186/s12903-022-02412-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/26/2022] [Indexed: 12/22/2022] Open
Abstract
Background Regenerative endodontic procedures (REPs) have achieved clinical success on the immature permanent teeth with pulp necrosis, and can promote root development. However, preoperative factors and their effects on root development of REPs have not been definitely concluded. The aim of this study was to investigate the preoperative factors that may influence the root development of REPs. Methods A total of 116 teeth in 110 patients treated with REPs in the Paediatric Dentistry Department and Endodontics Department from 2013 to 2017 were included in this study. Preoperative factors including aetiology, age, diagnosis and initial root morphology were collected retrospectively, and the associations between these factors and root development after REPs were analysed by Fisher's exact test and multivariate logistic regression model. Results The overall rate of root development after REPs was 89.7%. The dens evaginatus group showed a higher rate (98.8%) in root development than the trauma group (67.6%) (P < 0.01). There was no significant difference among the different age groups (7–13 years old) or among different diagnoses groups (P > 0.05). And it showed in the trauma group that the teeth with apical foramen sizes larger than 3 mm significantly promoted root development than those smaller than 3 mm (P < 0.01). Multivariate logistic regression indicated that aetiology was significantly correlated with root development of REPs (OR: 0.07, 95% CI 0.007, 0.627, P < 0.05). Conclusions The REPs promoted more root developments in the dens evaginatus group than the trauma group, indicating that aetiology may be correlated with the root development of REPs. Supplementary Information The online version contains supplementary material available at 10.1186/s12903-022-02412-x.
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Affiliation(s)
- Qian Zeng
- Hospital of Stomatology, Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, 510055, China
| | - Jianying Zhang
- Xiangya Stomatological Hospital, Xiangya School of Stomatology, Central South University, Hunan Key Laboratory of Oral Health Research, Changsha, Hunan, China
| | - Jiang Guo
- Hospital of Stomatology, Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, 510055, China
| | - Shuya Liu
- Hospital of Stomatology, Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, 510055, China
| | - Maobin Yang
- Department of Endodontology, Kornberg School of Dentistry, Temple University, Philadelphia, PA, USA.
| | - Jiacheng Lin
- Hospital of Stomatology, Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, 510055, China.
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Aminoshariae A, Azarpazhooh A, Fouad AF, Glickman GN, He J, Kim SG, Kishen A, Letra AM, Levin L, Setzer FC, Tay FR, Hargreaves KM. Insights into the September 2022 Issue of the JOE. J Endod 2022; 48:1089-1091. [PMID: 36038197 DOI: 10.1016/j.joen.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Affiliation(s)
| | - Amir Azarpazhooh
- Faculty of Dentistry University of Toronto, Toronto, Ontario, Canada
| | - Ashraf F Fouad
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Jianing He
- Texas A&M College of Dentistry, College Station, Texas
| | - Sahng G Kim
- Columbia University College of Dental Medicine, New York, New York
| | - Anil Kishen
- Faculty of Dentistry University of Toronto, Toronto, Ontario, Canada
| | - Ariadne M Letra
- University of Pittsburgh, School of Dental Medicine, Department of Oral and Craniofacial Sciences, Center for Craniofacial and Dental Genetics, Pittsburgh, Pennsylvania
| | | | - Frank C Setzer
- University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
| | - Franklin R Tay
- The Dental College of Georgia, Augusta University, Augusta, Georgia
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