Immediate Implant Placement

The Journal of Implant & Advanced Clinical Dentistry
Volume 6, No. 4 July 2014
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The Journal of Implant & Advanced Clinical Dentistry • 1
The Journal of Implant & Advanced Clinical Dentistry
Volume 6, No. 4 • July 2014
Table of Contents
5 Immediate Implant Placement
with One Year Follow-up:
A Case Report
Dr. Abdulgani Azzaldeen, Dr. Bajali Musa,
Dr. Abu-Hussein Muhamad
13 Immediate Placement of Dental
Implants in Molar Sites:
A Case Series
Dr. Mohit B. Zamad, Dr. Aakanksha
Zamad. Dr. Akshay Daga, Dr. Pankaj Ahare
23 Microleakage of Pit and Fissure
Sealants Comparing Air
Abrasion and Acid Etch
Techniques – An in Vitro Study
Dr. Raman Deep Kaur, Neeraj Mahahjan
35 The Application of Extraoral
Infraorbital Nerve Block
Compared to the Intraoral
Approach
Dr. Shady A. M. Negm

The Journal of Implant Advanced Clinical Dentistry
Volume 6, No. 4 • July 2014
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2 • Vol. 6, No. 4 • July 2014

The Journal of Implant Advanced Clinical Dentistry • 3
Tara Aghaloo, DDS, MD
Faizan Alawi, DDS
Michael Apa, DDS
Alan M. Atlas, DMD
Charles Babbush, DMD, MS
Thomas Balshi, DDS
Barry Bartee, DDS, MD
Lorin Berland, DDS
Peter Bertrand, DDS
Michael Block, DMD
Chris Bonacci, DDS, MD
Hugo Bonilla, DDS, MS
Gary F. Bouloux, MD, DDS
Ronald Brown, DDS, MS
Bobby Butler, DDS
Nicholas Caplanis, DMD, MS
Daniele Cardaropoli, DDS
Giuseppe Cardaropoli DDS, PhD
John Cavallaro, DDS
Jennifer Cha, DMD, MS
Leon Chen, DMD, MS
Stepehn Chu, DMD, MSD
David Clark, DDS
Charles Cobb, DDS, PhD
Spyridon Condos, DDS
Sally Cram, DDS
Tomell DeBose, DDS
Massimo Del Fabbro, PhD
Douglas Deporter, DDS, PhD
Alex Ehrlich, DDS, MS
Nicolas Elian, DDS
Paul Fugazzotto, DDS
David Garber, DMD
Arun K. Garg, DMD
Ronald Goldstein, DDS
David Guichet, DDS
Kenneth Hamlett, DDS
Istvan Hargitai, DDS, MS
Michael Herndon, DDS
Robert Horowitz, DDS
Michael Huber, DDS
Richard Hughes, DDS
Miguel Angel Iglesia, DDS
Mian Iqbal, DMD, MS
James Jacobs, DMD
Ziad N. Jalbout, DDS
John Johnson, DDS, MS
Sascha Jovanovic, DDS, MS
John Kois, DMD, MSD
Jack T Krauser, DMD
Gregori Kurtzman, DDS
Burton Langer, DMD
Aldo Leopardi, DDS, MS
Edward Lowe, DMD
Miles Madison, DDS
Lanka Mahesh, BDS
Carlo Maiorana, MD, DDS
Jay Malmquist, DMD
Louis Mandel, DDS
Michael Martin, DDS, PhD
Ziv Mazor, DMD
Dale Miles, DDS, MS
Robert Miller, DDS
John Minichetti, DMD
Uwe Mohr, MDT
Dwight Moss, DMD, MS
Peter K. Moy, DMD
Mel Mupparapu, DMD
Ross Nash, DDS
Gregory Naylor, DDS
Marcel Noujeim, DDS, MS
Sammy Noumbissi, DDS, MS
Charles Orth, DDS
Adriano Piattelli, MD, DDS
Michael Pikos, DDS
George Priest, DMD
Giulio Rasperini, DDS
Michele Ravenel, DMD, MS
Terry Rees, DDS
Laurence Rifkin, DDS
Georgios E. Romanos, DDS, PhD
Paul Rosen, DMD, MS
Joel Rosenlicht, DMD
Larry Rosenthal, DDS
Steven Roser, DMD, MD
Salvatore Ruggiero, DMD, MD
Henry Salama, DMD
Maurice Salama, DMD
Anthony Sclar, DMD
Frank Setzer, DDS
Maurizio Silvestri, DDS, MD
Dennis Smiler, DDS, MScD
Dong-Seok Sohn, DDS, PhD
Muna Soltan, DDS
Michael Sonick, DMD
Ahmad Soolari, DMD
Neil L. Starr, DDS
Eric Stoopler, DMD
Scott Synnott, DMD
Haim Tal, DMD, PhD
Gregory Tarantola, DDS
Dennis Tarnow, DDS
Geza Terezhalmy, DDS, MA
Tiziano Testori, MD, DDS
Michael Tischler, DDS
Tolga Tozum, DDS, PhD
Leonardo Trombelli, DDS, PhD
Ilser Turkyilmaz, DDS, PhD
Dean Vafiadis, DDS
Emil Verban, DDS
Hom-Lay Wang, DDS, PhD
Benjamin O. Watkins, III, DDS
Alan Winter, DDS
Glenn Wolfinger, DDS
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Azzaldeen et al
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Azzaldeen et al
Background: This case report describes
extraction of a fractured left maxillary central
incisor tooth, followed by immediate place-
ment of a dental implant in the prepared socket
and temporization by a bonded restoration.
Methods: The tooth was extracted with mini-
mal hard and soft tissue trauma and without
flap reflection. The socket was prepared to the
required depth and a dental was inserted. An
impression was made 4 months after implant
insertion, and a definitive restoration was placed.
Results: The atraumatic operating tech-
nique and the immediate insertion of the
Implant resulted in the preservation of
the hard and soft tissues at the extrac-
tion site. The patient exhibited no clini-
cal or radiologic complications through 12
months of clinical monitoring after loading.
Conclusion: The dental implant and provi-
sional restoration provided the patient with
immediate esthetics, function, comfort and
most importantly preservation of tissues.
Immediate Implant Placement with
One Year Follow-up: A Case Report
Dr. Abdulgani Azzaldeen1
• Dr. Bajali Musa2
• Dr. Abu-Hussein Muhamad3
1. Assistant Professor, Al Quds University, Jerusalem, Palestine
2. Assistant Professor, Al Quds University, Jerusalem, Palestine
3. Visiting Professor, Napoli University, Athens, Greece
Abstract
KEY WORDS: Dental implant, immediate placement, temporization, prosthetics

6 • Vol. 6, No. 4 • July 2014
INTRODUCTION
Immediate implants are defined as the place-
ment of implants in course of surgical extrac-
tion of the teeth to be replaced. The insertion
of implants immediately after extraction is not
new, and in the 1980s, the University of Tübin-
gen advocated the procedure as the tech-
nique of choice for Tübingen and München
ceramic implants.1,2
As a result of the suc-
cess of the protocol designed by Brånemark
and his team for their dental implant system,
other procedures were largely relegated for
many years. Initially, a healing period of 9-12
months was advised between tooth extrac-
tion and implant placement. Nevertheless, as a
result of continued research, a number of the
concepts contained in the Brånemark proto-
col and previously regarded as axiomatic; such
as the submerged technique concept, delayed
loading, machined titanium surface, etc.;
have since been revised and improved upon
even by actual creators of the procedure.2-4
Based on the time elapsed between extrac-
tion and implantation, the following classifica-
tion has been established relating the receptor
zone to the required therapeutic approach:
1. Immediate implantation, when the remnant
bone suffices to ensure primary stability
of the implant, which is inserted in the
course of surgical extraction of the tooth
to be replaced (primary immediate
implants).
2. Recent implantation, when approximately
6-8 weeks have elapsed from extrac-
tion to implantation, a time during which
the soft tissues heal, allowing adequate
mucogingival covering of the alveo-
lus (secondary immediate implants).
3. Delayed implantation, when the receptor
zone is not optimum for either immediate
or recent implantation. Bone promotion is
first carried out with bone grafts and/or
barrier membranes, followed approximately
6 months later by implant positioning
(delayed implants).
4. Mature implantation, when over 9 months
have elapsed from extraction to implantation.
Mature bone is found in such situations.3-7
The most frequently cited reasons for unde-
rutilization of endosseous implant therapy are
that treatment cost is perceived to be too high
and treatment takes too long (Branemark’s orig-
inal treatment protocols required up to a year or
more to complete treatment) An obvious area
of focus has been to decrease the amount of
time necessary to complete implant therapy.
Approaches to achieve this goal have domi-
nated clinical research and practice: delayed/
immediate implant loading, improving implant
surface technology (promotion of quicker heal-
ing and better osseointegration), and immedi-
ate placement of an endosseous implant after
extraction of a natural tooth.1
In this paper a
case presentation supporting the last of these
three approaches will be shown. The definition
for an immediate endosseous implant is extrac-
tion of a natural tooth followed by immediate
placement (within the same surgical procedure)
of an endosseous dental implant. Immediate
implants have become widely accepted despite
controversial beginnings and the available liter-
ature consistently cites high levels of success
ranging from 94-100% on average and immedi-
ate implants provide clinically recognizable ben-
efits. Broadly speaking, these benefits include
reduction of morbidity, reduction of alveolar
Azzaldeen et al

bone resorption. Controlled clinical studies
have demonstrated an average of 4.4mm of hor-
izontal and 1.2mm of vertical bone resorption
six months after tooth extraction preservation
of gingival tissues, preservation of the papilla
in the esthetic zone, and reduction of treat-
ment cost and time while the healing phase is
shorter in general and there is a reduction in the
number of procedures.1-5
With the extraction
socket as a guide, the surgeon can also more
easily determine the appropriate parallelism and
alignment relative to the adjacent and opposing
residual dentition. To maximize the advantage of
these benefits and to minimize implant failure,
case selection must be based on sound clinical
and research criteria. Immediate placement and
provisionalization for single tooth replacement
allows for minimal disruption of the marginal soft
tissues, providing immediate prosthetic support
for the peri-implant tissues through the use of
a carefully crafted provisional restoration. Pri-
mary implantation is fundamentally indicated for
replacing teeth with pathologies not amenable
to treatment, such as caries or fractures. Imme-
diate implants are also indicated simultaneous
to the removal of impacted canines.5,6
Immedi-
ate implantation can be carried out on extracting
teeth with chronic apical lesions which are not
likely to improve with endodontic treatment and
Figure1: Initial retracted view. Figure 2: Initial occlusal view.
Figure 3: Initial xray.
Azzaldeen et al

8 • Vol. 6, No. 4 • July 2014
apical surgery.7
The surgical requirements for
immediate implantation include extraction with
the least trauma possible, preservation of the
extraction socket walls and thorough alveolar
curettage to eliminate all pathological material.
Primary stability is an essential requirement, and
is achieved with an implant exceeding the alve-
olar apex by 3-5 mm, or by placing an implant
of greater diameter than the remnant alveo-
lus. Esthetic emergence in the anterior zone is
achieved by 1-3 mm sub-crestal implantation.6,7
There are contraindications to immedi-
ate placement of dental implants. The exis-
tence of an acute periapical inflammatory
process constitutes an absolute contraindi-
cation to immediate implantation.8,9
In the
case of socket-implant diameter discrepan-
cies in excess of 5 mm, which would leave
most of the implant without bone contact,
prior bone regeneration and delayed implan-
tation may be considered.10
Avoid teeth with
large or acute periapical infection; Teeth with
labial bony dehiscence or fenestration defects;
Insufficient bone apically to ensure primary
Figure 4: Coronal portion of tooth removed. Figure 5: Tooth removed atraumatically, the facial plate
was very thin.
Figure 6: Immediate post op view. Figure 7: Immediate post op view.
Azzaldeen et al

Figure 8: Xray of immediate implant placement.
Figure 9: Stock abutment.
Figure 10: Final crown retracted view.
stability of the implant; Systemic factors that
may impair healing (e.g. smoking); Large bul-
bous root morphology, Interproximal bone
loss (aesthetic zone), active periodontitis.11
CASE REPORT
A 53-year-old male patient presented with a
history of trauma and crown fracture at the
cervical area of tooth 8 (figures 1-3) and
requested an immediate solution. Clinical and
radiological evaluation revealed adequate
alveolar bone, absence of periapical pathol-
ogy but fracture line was below the crest of
alveolar bone and was limited to the tooth. So,
it was decided to extract and place endos-
seous implant immediately and place a pro-
visional restoration to avail the benefits like
preservation of bone and emergence profile.
After administering appropriate antibiotic
and analgesic, induction of local anesthesia
was carried out using lignocaine with adrena-
line. As preservation of alveolar bone is key to
success of immediate implants, extraction of
tooth has to be atraumatic, so using periotomes
and small periosteal elevators the fragment was
Azzaldeen et al

10 • Vol. 6, No. 4 • July 2014
luxated without excessive enlargement of the
socket, and using an innovative method where
endodontic file was used to engage the canal
wall and tooth fragment was slowly luxated and
removed from the socket using the file (figures
4, 5). The sockets were debrided with curettes
and a dental implant (BioHorizons, Birming-
ham, Alabama, USA) of dimensions 4 x 12mm
was planned. After checking for primary stability,
which was achieved by wrenching the implant into
the bone beyond the apex of the socket, xeno-
graft (Bio-Oss, Geistlicht, Princeton, New Jer-
sey, USA) was packed between the implant and
labial socket wall. The cover screw was placed
and interrupted sutures were placed. Intraoral
photography was taken to see the implant place-
ment (figures 6, 7). It was found to be satis-
factory. Postoperative instructions were given
to the patient and they were asked to report
back after 1 week. The sutures were removed
after 7 days and the patient received temporary
acrylic crown bonded to the adjacent teeth with
fiber-reinforced composite on the same day.
The patient was recalled after four months for
the prosthetic procedures and was given porce-
lain fused to metal crown over the implant. He
was recalled for prophylaxis and follow up every
three months. The clinical and radiographic
appearances at six months and after one year
show good aesthetic result and acceptable
osseointegration of the implant (figures 8-12).
CONCLUSION
The implant therapy must fulfill both func-
tional and esthetic requirements to be consid-
ered a primary treatment modality. Aiming to
reduce the process of alveolar bone resorp-
tion and treatment time, the immediate place-
ment of endosseous implants into extraction
sockets achieved high success rate of between
94-100%, compared to the delayed placement. ●
Figure 11: Occlusal view of final crown. Figure 12: Final restoration at 12 months.
Correspondence:
Dr. Abu-Hussein Muhammed
123 Argus Street
10441 Athens
Greece
abuhusseinmuhamad@gmail.com
Azzaldeen et al

Acknowledgments
The authors would like to thank the following: Setergiou Bros Dental Laboratory,
Athens, Greece for the fabrication of the ceramic restorations.
Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
1. Wagenberg BD, Ginsburg TR. Immediate implant placement on removal of
the natural tooth: retrospective analysis of 1,081 implants. Compendium of
Continuing EducDent 22:399-404; 2001.
2. Cooper LF, Rahman A, Moriarty J, et al. Immediate mandibular rehabilitation with
endosseous implants: simultaneous extraction, implant placement, and loading.
Int JOral Maxillofac Implants 17:517-25; 2002.
3. Di Felice R, D’Amario M, De Dominicis A, Garocchio S, D’Arcangelo C, Giannoni
M. Immediate placement of bone level Sraumann implants: A case series. Int J
Periodontics Restorative Dent2011;31:57-65.
4. Gelb DA. Immediate implant surgery: ten-year clinical overview. Compendium of
Cont Educ Dent 20:1185- 92; 1999.
5. Barone A, Rispoli L, Vozza I, Quaranta A, Covani U. Immediate restoration
of single implants placed immediately after tooth extraction. J Periodontol
2006;77:1914-20.
6. Hoffmann O, Beaumont C, Zafiropoulos GG. Immediate implant placement: A
case series. J Oral Implantol 2006;32:182-9.
7. Zabalegui I, García M. En Gutiérrez JL, García M, eds. Integración de la
implantología en la práctica odontológica. Madrid: Ergon. p. 127-36; 2002
8. Romanos GE. Treatment of advanced periodontal destruction with immediately
loaded implants and simultaneous bone augmentation: A case report. J
Periodontol 2003;74:255-61.
9. Novaes-Junior AB, Novaes AB. Immediate implants placed into infected sites: a
clinical report. Int J Oral Maxillofac Implants10:609-13; 1995
10. Anitua E, Orive G. A new approach for atraumatic implant explantation and
immediate implant installation. Oral Surg Oral Med Oral Pathol Oral Radiol
2012;113:e19-25.
11. Strub JR, Kohal RJ, Klaus G, Ferraresso F. The re implant system for immediate
implant placement. J Esthet Dent 9:187-96;1997.
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Azzaldeen et al

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Zamad et al
C
ommonly, immediate implants have been
reserved for the single rooted anterior
tooth and single or bi-rooted premo-
lar tooth. Perhaps the most important aspect
of any implant surgery in accordance with the
successful procedure is implant stability and
bone to implant contact (BIC). Immediate den-
tal implant placement has been an acceptable
procedure for at least the past two decades.
Removal of molar teeth provides a chal-
lenging and intriguing dilemma due to multiple
root morphology. In the case of extraction
and immediate placement of dental implants
preserving alveolar bone proper, particularly
that of the labial and lingual plates of bone is
essential in providing the optimal environment
for maximizing BIC and implant stability. Also,
the position of the final restoration must be
considered, in relation to intra and inter arch
position, occlusion, function and esthetics.
Thus, minimal alveolar bone removal should be
considered and attained to aid in the above
factors in order to provide an acceptable surgi-
cal site for successful placement of the dental
implant. Finally, and perhaps most importantly
when considering immediate molar implant
placement, removal of the intra-alveolar sep-
tum should be avoided to aid in increas-
ing BIC and allowing the attainment of initial
implant stability at the time of placement.
Immediate Placement of Dental Implants
in Molar Sites: A Case Series
Dr. Mohit B. Zamad1
• Dr. Aakanksha Zamad2
Dr. Akshay Daga3
• Dr. Pankaj Ahare4
1. Oral maxillofacial surgeon, California, USA
2. Post-graduate student, VSPM Dental College research Centre, Nagpur, India
3. Oral maxillofacial surgeon
4. Department of Orthodontics, VSPM Dental college research Center, Nagpur, India
Abstract
KEY WORDS: Dental implants, immediate placement, molars

14 • Vol. 6, No. 4 • July 2014
INTRODUCTION
Immediate implant placement following tooth
extraction in appropriately selected cases can
be considered an optimal procedure for the fol-
lowing reasons: the natural healing process is
mobilized to the maximum, no bone resorp-
tion, drilling is reduced, number of sur-
gical stages are eliminated, design and
construction of prosthesis is simplified, and
positive psychological effect on the patient.1,2
As per previous studies, immediate implant
placement was carried out in single rooted
teeth more successfully. The posterior man-
dible can be considered for implant place-
ment because of the premature loss of molars
and it is always a challenging task to place
implant in multirooted teeth as there is dis-
crepancy between size of implant and
socket. However, their use is complicated by
the anatomic obstacles of the inferior alveo-
lar nerve and the presence of softer bone. 3, 4
The implant diameter is often smaller than
the diameter of the root of the extracted
tooth. In cases where the distance between
the implant and the extraction socket is less
than 2mm , spontaneous bone healing can
be expected without the necessity for addi-
tional grafting procedures.5,6,7
However,
if the gap is more, then augmentation pro-
cedures are carried out by using synthetic
bone graft followed by a non resorbable
expanded Poly Tetra Fluoro Ethylene (ePTFE)
membrane for soft tissue augmentation.8,9,10
Figure 1a: Pre-operative intraoral radiograph.
Figure 1b: Atraumatic extraction of mandibular first
molar.
Zamad et al

CASE REPORT 1
A 30 year old, non smoker visited the Depart-
ment of Oral Maxillofacial Surgery, VSPM Den-
tal College Research Centre, Nagpur. Tooth
#30 was vertically fractured (Fig.1a) and was
not associated with any infection. All the avail-
able treatment options were discussed with the
patient which involves the hemisection of lower
right 1st
molar with extraction of the distal root and
tooth segment and metal ceramic bridge fabrica-
tion ; extraction of lower right 1st
molar and fab-
rication of a metal ceramic bridge, extraction of
lower right 1st
molar, followed by a delayed implant
placement, or an immediate implant placement.
The patient opted for immediate implant
placement for which the patient consented. All
Figure 1c: Placement of barrier membrane. Figure 1d: Abutment at time of prosthesis placement.
Figure 1e: Prosthesis. Figure 1f: Intraoral radiograph after prosthesis placement.
Zamad et al

16 • Vol. 6, No. 4 • July 2014
the necessary blood investigations were car-
ried out and radiological investigations were
evaluated for the selection of implant size.
A crevicular incision extending to the adja-
cent teeth was made and a full thickness
envelope flap was reflected. Lower right first
molar was atraumatically extracted. The socket
was curetted and irrigated with saline
solution (Fig.1b). The dimension of the socket
was measured with a periodontal probe (UNC 15,
Hu Friedy, Germany) after tooth extraction. The
mesiodistal distance was 9 mm, buccolingual dis-
tance was 8 mm and the depth in the mesial side
was 8 mm. A dental implant 4.2 mm wide, length
11.5 was placed into the interradicular bone.
Pilot drill (2mm) was used for initial preparation.
This was followed by sequential drilling along the
implant axial line to allow the implant to have ade-
quate bone contact and implant placement done.
Synthetic bone graft was used to cover the
implant into the remaining socket and a non-
resorbable ePTFE membrane was then secured
over the socket for regeneration of soft tis-
sues and bony augmentation (Fig. 1c). The
patient was then prescribed an appropriate anti-
biotic and analgesic and chlorhexidine mouth-
wash. The membrane was removed 4 weeks after
surgery. Healing cap was placed 6 months
after surgery. After 2 weeks , healing cap
was removed and implant was loaded
with a single, ceramic crown (Figs. 1 d,e,f).
CASE REPORT 2
Another patient, a 17 year old female, reported
in our department. This patient came with the
complaint of overretained lower right decid-
uous (Fig.2a,b) molar and wanted to replace
it. All the treatment options as for Case
1 were given and patient opted for immedi-
ate implant placement. All the pre-operative
investigations were within normal limits. The
same surgical procedure was carried out for
implant placement as in the previous case
(Fig. 2c,d). In this case, no bone graft was
required as the gap between implant the
socket was wall was less than 2mm and the
primary stability immediately after implant
placement was good. Prosthesis for this
patient was given after 3 months (Figs. 2 e, f, g).
CASE REPORT 3
A 23 year old male patient reported in our
clinic for extraction of his carious tooth
with lower right mandibular first molar. The
patient opted for immediate implant place-
ment. The same procedure was carried out
and implant placement was done (Figs. 3 a, b).
OBSERVATIONS
Clinical evaluation was done at one, two and
three months preloading , then at one, three
and six months after loading including fol-
lowing parameters: Probing depth, bleeding
index and gingival index, except for case 1
in which preloading follow up was 6 months
as the primary stability was average. Radio-
graphic evaluation was done for all cases
at same follow up post loading periods
using periapical and panoramic radiographs
to assess marginal bone height and bone
density mesial and distal to implant fixture.
Postoperative follow up visits for all
three patients were made every week dur-
ing the first 4 weeks and then followed by
Zamad et al

a maintenance program consisting of semi-
annual follow up appointments for 2 years.
RESULTS
The results of these three cases are reported
in Table 1. In the pre-loading clinical evalu-
ation, all three patients were followed up
at one, two and four months post opera-
tively. At the first week postoperative , some
discomfort was reported without any com-
plaint of severe pain or edema. All wounds
healed properly during follow up period.
The post-loading evaluation was done
one, three and six months post-load-
ing as implant mobility was tested using
the Miller Mobility Index (MI) scores. 11
Two
of our cases showed no mobility dur-
ing the follow up period. The remain-
ing one case showed decline in mobility
index scores through the follow up period.
Probing depth12
was measured for
each implant for the four surfaces col-
lectively (buccal, lingual, mesial and distal).
There was gradual decrease in probing
depth measurement during the study period.
Bleeding index12
were measured from
the four surfaces collectively around the
implant. At the three months follow-up
period the bleeding index value showed a
decline and a further decline was appar-
ent at the six months follow-up period.
Gingival index12
scores were measured
of the four surfaces collectively for all
implant surfaces. At three months fol-
Table 1: Results of the Study
Healing
Extracted Inter Labial period
Tooth and Radicular Peri Peri before
Implant Reason Bone Implant Implant final
Patient Age/ Replacement for After Socket Primary Socket prosthesis
No. Sex Site Extraction Extraction Gap Stability Grafting (in month)
Unrestorable -
Mandibular tooth structure
1 32/Male right secondary to Intact 2mm Average Yes 6 months
first molar vertical tooth
fracture
Mandibular -
over retained To replace
2 17/Female primary The missing Intact 2mm Good No 3 months
first molar tooth
Unrestorable -
Mandibular tooth
3 23/Male right secondary to Intact 2mm Good No 3 months
first molar caries
Zamad et al

18 • Vol. 6, No. 4 • July 2014
Figure 2a: Preoperative intraoral radiograph showing
retained primary molar.
Figure 2b: Preoperative clinical view showing retained
primary molar.
Figure 2c: Extraction socket.
Figure 2d: Implant placement immediately after
extraction.
low-up period a decline in the gingi-
val index score was noticed. At six
months follow up period, further
decline in gingival index score was shown.
Both marginal bone height and bone den-
sity were evaluated for all cases through-
out the post-loading follow up period. For the
marginal bone height measurements, there
Zamad et al

Figure 2e: Abutment at second stage. Figure 2f: Implant supported prosthesis.
Figure 2g: Panoramic radiograph after prosthesis placement.
Zamad et al

20 • Vol. 6, No. 4 • July 2014
was decrease in the marginal bone height
around all implants at the three months
post-loading period and then increase
in the six months post-loading period.
DISCUSSION
All the 3 patients were very pleased with
the functional outcomes of their treat-
ment. A main factor determining the suc-
cess of immediate placement is the initial
stability of the implant. The extraction site
must be evaluated to see whether it is
suitable for immediate implant placement.
Micromovements between implant and sur-
rounding bone should be avoided to allow
successful healing to occur. In the pres-
ent case reports, the interradicular septum
of extraction socket was used to anchor
the implant. Therefore, sufficient height and
width of the interradicular septum should
be considered serious selection criteria
for this treatment modality. Further selec-
tion criteria include the following: absence
of clinical signs of acute periodontal or end-
odontic abscess formation,2
establishment of
healthy periodontal conditions before sur-
gery; and patient compliance. It has been
suggested that the implant should be
placed into a minimum of 3 mm of solid
bone apical to the extraction site.13,14,15,,16
The observation of a crestal gap between
the implant shoulder and the socket wall is
a common finding and in such cases aug-
mentation procedures are indicated.17
All the
3 extraction sockets had intact socket walls
after extraction. Following placement of the
implants, primary stability of all cases were
good except in the first case where primary
stability was not achieved. All the cases had
good soft tissue architecture preservation at
one week post surgery with minimal edema
and there were no complaints of pain nor
discomfort during early post-operative healing
period. All the implants achieved success-
ful osseointegration after a healing period
of between 3 and 6 months. The residual
Figure 3a: Preoperative intraoral radiograph. Figure 3b: Intraoral radiograph after implant placement.
Zamad et al

peri implant socket spaces were found to
be well healed exhibiting no implant thread
exposure at the end of healing process.
In our study, two cases have showed no
mobility through-out the post-loading follow-up
period and one case showed gradual decline
in the Mobility Index scores and decrease in
Gingival bleeding indices as well as Probing
depth during the follow-up period. This indi-
cated healing of soft tissue attachment around
the implant and absence of peri-implant dis-
ease due to extensive oral hygiene instructed to
the patients. This is in agreement with Linkow
et al,18
who stated that periodontal indices
were not directly related to the success or fail-
ure of osseointegration of implants. They are
used for monitoring peri-implant soft tissue.
CONCLUSION
The above findings suggest that in cases
of immediate implant placement in molar
region, a sufficient interradicular bone width
can be utilised for primary retention of imme-
diate implant successfully. The long term
stability of immediate implant palce-
ment in the molar region has been dem-
onstrated previously; however, the existing
data is not sufficient for determination of
treatment guidelines. More extensive and
long term study is further motivated. ●
Correspondence:
Dr. Mohit B. Zamad
1, Bolero , Mission Veijo
CA 92692
Email – drmohitzamad@gmail.com
Disclosure
The author reports no conflicts of interest with anything mentioned in this article.
References
1. Zahnmed SM: Prevention of alveolar ridge resorption after teeth extraction. Int
J Oral Maxillofac Surg. 114: 328, 2004.
2. Esposito M, Grusovin MG, Kwan S, Worthington H V, Coulthard P: Intervention
for replacing missing teeth: bone augmentation techniques for dental implant
treatment. Aust Dent J. 70: 54, 2009.
3. Abubaker O, Benson K: Oral and Maxillofacial secrets, Hanley ,Beflus inc ;
Philadelphia. PP 309, 2000.
4. Coatoam G, Mariotti A: Immediate placement of anatomically shaped dental
Implants. J Oral Implantol. 26:170, 2000.
5. Chen ST, Darby IB, Reynolds EC, Clement JG. Immediate implant placement
postextraction without flap elevation. J Periodontol. 80 : 163-172, 2009
6. McAllister BS, Haghighat K. Bone augmentation techniques. J Periosdontol.
78 : 377-396, 2007.
7. Fugazzotto PA. Report of 302 consecutive ridge augmentation procedures
: technical considerations and clinical results . Int J Oral Maxillofac Implants.
13 : 358-368: 1998.
8. Simon M, Trisi P, Piattelli A: Vertical ridge augmentation using a membrane
technique associated with ossointegrated, implants. Int J Periodont Rest Dent.
14: 497, 1994.
9. Rominge J W,Triplett R G: The use of guided tissue regeneration to improve
implant osseointegraion. J Oral Maxillofac Surg. 52:106,1994.
10. Schliephake H, Dard M, Planck H, Hierlemann H, Jakob A.: Guided bone
regeneration around endosseious implants using a resorbable membrane VS
ePTFE membrane. Clin. Oral Impl .Res:11:230, 2000.
11. Miller SC. Textbook of Periodontia. 3rd
Edition, Blankiston Inc. Pub,
Philadephia. Pg 215, 1950.
12. Mohamed TN, Younis AES et al. Immediate implants in lower posterior
teeth with bone substitute and guided tissue membrane. Cairo Dental
Journal. Vol 25 , No 1; 2009 : 61-67.
13. Esposito M, Grusovin MG et al. The effectiveness of immediate, early and
conventional loading of dental implants : A Cochrane systematic review
of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2007;
22 : 893- 904.
14. Schwartz AD, Chaushu G. The ways and wherefores of immediate
placement of implants into fresh extraction sites : A literature review. J
Periodontol ;68:915-923: 1997.
15. Werbitt MJ , Goldberg PV. The immediate implant: Bone preservation and
bone regeneration. Int J Periodontics Restorative Dent. 1992;12:207-217.
16. Cochran DL, Schenk RK et al. Bone response to unloaded titanium
implants with sand blasted ad acid etched surface : A histometric study
in the canine mandible. J Biomed Mater Res. 1998;40:1-11.
17. Anson, D. The changing treatment planning paradigm: Save the Tooth or
Place and Implant. 2010. 30:506-5-17.
18. Linkow LI et al. Factors influencing long term implant success. J Prosth
Dent. 1990; 63:64.
Zamad et al

Wilcko et al
Aim: To investigate the degree of dye penetra-
tion as an estimation of marginal adaptation
of pit and fissure sealants after preparation
with air abrasion and acid etching techniques.
Method: Sixty freshly extracted human premo-
lars were taken and divided into three groups
of twenty teeth each. Fissures of samples
of Group I were opened using Air abrasion.
Samples of Group II were prepared using
combination of Air abrasion and Acid Etching
while that of Group III were prepared by Con-
ventional Bur preparation and Acid Etching. To
all the prepared samples single layer of bond-
ing agent was applied and then the fissures
were closed using light cured pit and fis-
sure sealant. Specimens were then subjected
to thermocycling and dye penetration in Sil-
ver Nitrate solution. Finally the teeth were sec-
tioned buccolingually. The sectioned samples
were then assessed under stereomicroscope
to measure the extent of dye penetration.
The measured scores were analyzed statistically.
Results: All the three groups ( Air abra-
sion, Air abrasion + Acid Etching, Bur prep-
aration + Acid Etching) tested showed
microleakage at tooth sealant interface.
The degree of microleakage among the three
groups was greatest for Air Abrasion. Least
degree of microleakage was found in proce-
dure done with air abrasion and acid etching.
Conclusion: This study suggests that
the Air abrasive technique in combina-
tion with Acid etching can be consid-
ered as a method of choice for dental
enamel priming before sealant placement.
Microleakage of Pit and Fissure Sealants
Comparing Air Abrasion and Acid Etch
Techniques – An in Vitro Study
Raman Deep Kaur, BDS, MDS1
• Neeraj Mahahjan, BDS, MDS2
1. Senior Lecturer, GNDDC, Sunam, Punjab, India
2. Professor and Department Head, GNDDC, Sunam, Punjab, India
Abstract
KEY WORDS: Air abrasion, acid etching, microleakage, sealants

24 • Vol. 6, No. 4 • July 2014
Kaur et al
INTRODUCTION
In 1895, Greene Vardiman Black introduced
revolutionary concepts of restorative treat-
ment, turning the empirical dentistry at
that time into a scientifically based sci-
ence. Extension of preparations was incorpo-
rated to prevent marginal and recurrent caries.
Mechanical retention was required to secure
the restorative material. In the past few
years, the emerging techniques of opera-
tive dentistry dedicated to minimal invasion
and minimal sacrifice of sound tooth struc-
ture have been explored and documented,
and they have become part of mainstream
dentistry. Microdentistry, the dental science
of diagnosing, intercepting, and treating
dental decay on the microscopic level, is
now emerging as an operative tool in sci-
ence - based microdentistry,37
and thus a new
term “Prevention of Extension” is introduced.
Pit and fissure caries has the highest
prevalence of all dental caries. The pits
and fissures which are actually the grooves
and the fossa with non-coalesced enamel
provides an excellent mechanical shelter for
microorganisms. The dental battle against
decay in pits and fissures has a long and
creative past that includes such preven-
tive innovations as early physical blocking
of fissures with Zinc phosphate cement,
mechanical fissure eradication, and chemi-
cal treatment with silver nitrate.15
An invasive
operative procedure, the prophylactic odon-
totomy introduced in the 1920s, remained
the treatment of choice for many clinicians
well into the 1970s. But with Buon-
ocore’s visionary procedure came the
ability, as he predicted in 1955, to suc-
cessfully prevent caries by sealing pits and
fissures with a bonded resin material.40
The prevention of pit and fissure caries
through the use of occlusal sealants con-
tinues to be focus in pediatric population.
The morphological configuration of occlusal
pits and fissures (narrow, ‘deep gaps) facili-
tates retention of bacteria, nutrients and
debris.27
If the fissures are sealed com-
pletely and microleakage is prevented, they
act as a physical barrier to external carious
agents, thus preventing the onset of caries.13
Marginal microleakage following seal-
ant placement allows bacteria and bacte-
rial byproducts to penetrate beneath the
sealant, potentially initiating and perpetuat-
ing the caries formation process.40
Removal
of enamel surface contaminants and obtain-
ing a properly acid etched surface prior
to sealant placement are important factors
for successful retention and caries preven-
tion.4
Etching produces a wettable surface and
a retentive pattern.6
Acid etching is however
a technique sensitive process involving sev-
eral time consuming steps. Therefore, sev-
eral methods of preparing fissures such
as enameloplasty, an air polishing sys-
tem or laser treatment have been advo-
cated by researchers for sealant retention.
Bonding techniques developed by Buono-
core (1951), Bowen (1970) and others pro-
vide an alternative to mechanical retention.
The course towards enamel conservation
has prompted a second look at air -abra-
sive cavity preparation.17
Air abrasion was
first introduced in dentistry in 1943, when
Dr Robert Black patented the micro – sand-
blaster for dental applications.28
The kinetic

Kaur et al
cavity preparation technique was pioneered
in 1940s and was integrated into some
dental practices in the mid – 1950s, only
to be supplanted by the widespread adop-
tion of the air rotor high speed hand piece.
Air abrasive technology has been
reported to prepare enamel and dentin for
bonding in a similar way to acid etching.17,18
With the improved restorative materials avail-
able today, a more conservative cavity
preparation is acceptable, making air abra-
sion a potential alternative to conventional
handpieces.25
Air abrasion works by spray-
ing a particular area of the tooth with a
thin stream of air and a fine abrasive pow-
der made of alumina, avoiding the odors,
noises, vibrations, microcracks and, in most
cases, the apprehension associated with
the drill. It is designed to provide patient
–friendly care, which is especially impor-
tant for the treatment of children’s dental
problems. Some authors have also stated
that air abrasion may serve as an alterna-
tive to acid etching of enamel, coining the
phrase “ air – abrasion etching ”.35
A num-
ber of studies have examined the influence
of tooth preparation on microleakage of pit
and fissure sealants. There have been
very few studies directly comparing the
degree of microleakage of sealants follow-
ing preparation of pits and fissures with
bur preparation, acid etching and air abra-
sion. Hence, this study was done to inves-
tigate the degree of dye penetration as
an estimation of marginal adaptation of pit
and fissure sealants after preparation with
air abrasion and acid etching techniques.
MATERIALS AND METHODS
Sixty noncarious human premolars extracted
for orthodontic purpose were collected. After
extraction the teeth were cleaned of the
debris and blood clots in running water
and were examined by transillumination
to exclude teeth exhibiting enamel frac-
tures as these might allow dye penetra-
tion. The teeth were stored in distilled water
at room temperature. The teeth were randomly
divided into three equal groups. In Group I
(Air Abrasion Group) the occlusal sur-
faces were prepared with the hand
piece of Air Abrasive system (Prep
Start, Danville), using 27 micron diameter
Aluminum oxide particles through 0.015”
nozzle opening at 80 psi pressure. The
nozzle tip was held at 2 mm from tooth
surface and slightly offset from perpendicu-
lar. A quick, steady, sweeping motion was
used along the surface to achieve a uniform,
frosty appearance. The excess particles
were then removed with a moisture – free
air stream, and the surface was not rinsed.
In Group II (Air abrasion + Acid etch
group), the occlusal surfaces were again
prepared with Air Abrasive system. The
prepared surfaces were then etched using
37% Phosphoric acid gel (Actino Etchant
Gel) for 15 seconds. The specimens
were then rinsed with water for 15 sec-
onds, ensuring that all the etchant has been
removed. Each specimen was dried with
oil free compressed air until a chalky white
appearance was obtained. In Group III (Bur
preparation + Acid etch Group), the occlu-
sal surfaces were prepared using a round
diamond bur at high speed with air–water spray.

26 • Vol. 6, No. 4 • July 2014
Kaur et al
After surface preparations of all the
specimens of Group I, Group II and
Group III, a uniform layer of single com-
ponent bonding system (Prime and Bond,
Dentsply), was applied, air thinned and
light cured for 30 seconds using a vis-
ible light curing unit (3M ESPE, Cur-
ing Light 2500, 3 M Dental Products). A
light cure pit and fissure sealant (Clinpro,
3 M Dental Products), was applied to all
the conditioned surfaces and light cured for
20 seconds using visible light curing unit.
The samples were then stored in distilled
water at room temperature for future use.
The restored teeth were subjected to
thermocycling regimen (Perkin Almer Ther-
mocycling Machine Model No. 9700 (Perkin
Almer Biocare Systems, United Kingdom) in
distilled water at 50
C and 550
C for 500
cycles , with a dwell time of 10 seconds. All
the specimens were then immersed in 50 %
Silver Nitrate dye solution for 2 hours in a
dark environment. After staining these teeth
were individually rinsed with distilled water
for one minute and were placed in photo
developing solution under fluorescent light
for 8 hours to precipitate the Silver Nitrate.
After removal from the developing solu-
tion, the teeth were washed in distilled
water to remove the excess surface dye.
Finally the teeth were sectioned longitudinally
in a buccolingual direction at low speed with
a water cooled diamond disk held in straight
hand piece. Microscopic evaluation of each
sectioned sample was examined using a Ste-
reomicroscope (Olympus SZ – PT, Japan)
under 10 x magnification. The extent of dye
penetration was determined at buccal and
lingual / palatal wall from the occlusal por-
tion of the restoration to base of the cavity
along the tooth restoration interface. All the
measurements were taken from the junction of
tooth sealant interface to the first point of ter-
mination. The scoring method as described
by Ovenbo and Raadal (1990) was used:
Table 1: Microleakage Scores
Microleakage Scores
Group 0.00 1.00 2.00 3.00 Total
I 5 11 2 2 20
II 17 3 20
III 13 4 3 20
Total 35 18 5 2 60

Kaur et al
● Score 0 = No microleakage (no dye
penetration).
● Score 1 = Microleakage less than half
the distance of the sealant border (dye
penetration less than half the distance
of one side of the fissure sealant and
enamel border).
● Score 2 = Microleakage one half the
distance of the sealant border (dye pen-
etration half the distance of one side of
the fissure sealant and enamel border).
● Score 3 = Microleakage along the
whole sealant / enamel border (dye pen-
etration along the whole fissure sealant
and enamel border).
The data collected was subjected to
Statistical Analysis with Kruskal Wallis,
ANOVA test and Mann – Whitney U tests.
RESULTS
The degree of dye penetration in the occlusal cav-
ity walls was assessed separately under a Ste-
reomicroscope at 10X magnification. The extent
of dye penetration was determined at buc-
cal and lingual / palatal wall from the occlu-
sal portion of the restoration to base of the
cavity along the tooth restoration interface.
Microleakage along the buccal and lin-
gual walls was measured on an Ordinal
scale with scores 0 to 3 in increasing order of
Figure 1:
■ Score 0 = No microleakage.
■ Score 1 = Microleakage less than half the distance of the
sealant border.
■ Score 2 = Microleakage one half the distance of the
sealant border.
■ Score 3 = Microleakage along the whole sealant /
enamel border.

28 • Vol. 6, No. 4 • July 2014
Kaur et al
Table 2: Comparison of Techniques
Group Buccal Lingual Overall
Mean .9500 .7000 1.0500
N 20 20 20
Std. Deviation .8870 .6569 .8870
Range 0-3 0-2 0-3
Std Error of Mean .1983 .1469 .1983
Mean .1500 5.00E-02 .1500
N 20 20 20
Std. Deviation .3663 .2236 .3663
Range 0-1 0-1 0-1
Std Error of Mean .8.19E-02 5.000E-02 8.19E-02
Mean .4500 .2000 .5000
N 20 20 20
Std. Deviation .7592 .4104 .7609
Range 0-2 0-1 0-2
Std Error of Mean .1698 9.177E-02 .1701
Mean .5167 .3167 .5667
N 60 60 60
Std. Deviation .7700 .5365 .7890
Range 0-3 0-2 0-3
Std Error of Mean 9.941E-02 6.926E-02 .1019
I
Air
Abrasion
II
Air
Abrasion
+
Acid Etching
III
Bur
Preparation
+
Acid Etching
Total

Kaur et al
penetration of dye. It was found that microleak-
age in buccal and lingual / palatal walls of all
the twenty samples prepared with Air abra-
sion (Group I) values range from minimum
zero to maximum three. In Group II Microleak-
age scores range from minimum score of 0
to maximum 2. In Group III microleakage scores
of the samples prepared by conventional
bur and Acid Etching ranges from 0 to 2.
The overall mean dye penetration for
Group I (Air abrasion) is 1.0500 + 0.8870.
For Group II (Air abrasion + Acid etch-
ing) the mean dye penetration value is 0.1500
+ 0.3663. For Group III (Bur prepara-
tion + acid etching) it is 0.5000 + 0.7609.
The results showed statistically significant
difference (p 0.05) in the microleakage
scores among the samples of Group I (Air
abrasion) and Group II (Air abrasion + Acid
etching . Intergroup comparison between group
I (Air abrasion) and Group III (Bur preparation
+ Acid etching) also showed the statistically
significant difference (p 0.05) among the
microleakage scores. The comparison between
Group II (Air abrasion + Acid etching) and
Group III (Bur preparation + Acid etching)
showed statistically insignificant difference
(p 0.05) among the microleakage scores .
So the results showed the maximum dye
penetration for the samples of Group I (Air
Figure 2:
GROUP I : Air Abrasion
GROUP II : Air Abrasion + Acid Etching
GROUP III : Bur preparation + Acid Etching
From the above graph its clear that Group I exhibits
maximum value of mean dye penetration (1.05 + .8870),
while the least values of mean dye penetration are shown
by Group II (0.15 + 0.3663).

30 • Vol. 6, No. 4 • July 2014
Kaur et al
Group N Mean Rank
1.00 20 39.78
2.00 20 23.05
3.00 20 28.67
Total 60
1.00 20 40.25
2.00 20 23.45
3.00 20 27.80
Total 60
1.00 20 40.53
2.00 20 21.98
3.00 20 29.00
Total 60
Buccal Lingual Overall
Chi-Square 12.791 16.175 14.860
df 2 2 2
Asymp. Sig .002 .000 .001
Significant Significant Significant
Kruskal Wallis analysis to show the comparison of microleakage among Group I (Air abrasion), Group II (Air abrasion +
Acid etching), Group III (Bur preparation + Acid etching).
Table 3: Comparison of Microleakage Among Groups 1-3
Buccal
Lingual
Overall

Kaur et al
Figure 3: The above figure represents the statistically significant difference (p 0.05) in microleakage scores along the buccal
walls (0.003), lingual walls (0.00) and the total (0.001) microleakage scores among the three preparation groups. From the
above graph its clear that Group I exhibits maximum value of mean dye penetration (1.05 + .8870), while the least values of
mean dye penetration are shown by Group II (0.15 + 0.3663).
abrasion) with statistically significant difference
with the Group II and Group III, while the
least dye penetration is seen among the spec-
imens of Group II (Air abrasion + Acid etch-
ing) though statistically insignificant difference
was observed among Group II and Group III .
Hence, the degree of microleakage among the
three groups can be ranked in following order :
Air abrasion Bur preparation + acid
etching Air abrasion + acid etching
DISCUSSION
The focus of this study was chiefly the
preparation of enamel before applying the
pit and fissure sealant. Pit and fissure seal-
ants have become the most effective treat-
ment to prevent or arrest caries. While the
authors had previously attempted to find
conservative ways of treating occlusal
pits and fissures such as Wilson who used
Zinc Phosphate cement, Bodecker who pro-
posed enamel fissure eradication and Kline
and Knutson who used ammonical sil-
ver nitrate to treat pits and fissures, none
achieved any great measure of success.41
An invasive operative procedure, prophy-
lactic odontotomy introduced in the 1920’s
remained the treatment of choice for many
clinicians well into the 1970’s. Buonocore
introduced the acid etch technique to alter

32 • Vol. 6, No. 4 • July 2014
Kaur et al
the existing enamel in order to improve the
retention of acrylic restorative materials.
Alternative methods such as bur prepara-
tion, laser and air abrasion have been pro-
posed to better clean pits and fissures of
debris. Air abrasion has also been suggested as
a pretreatment method to mechanically roughen
enamel in a conservative and time efficient man-
ner and remove residual organic material in
the fissures to aid in sealant bonding. How-
ever marginal leakage studies have shown
that air abrasion alone is not as effective
as air abrasion coupled with acid etching
in preventing microleakage. So, this study
was done to compare the air abrasion and
acid etching techniques for enamel prepara-
tion before the placement of fissure seal-
ants using the dye penetration method.
The results of this study showed that
Air abrasion alone exhibited maximum micro-
leakage value as compared to other groups
(1.0500 + 0.8870). Tooth preparation by air
abrasion is reported to offer improved com-
fort by eliminating the vibration, pressure and
noise associated with rotational methods.
Air abrasion creates a roughened enamel
surface which make it more conducive to
bonding. Some studies have suggested that
this may eliminate the need for acid etch-
ing when applying pit and fissure sealants.45
Laurell et al found that air abra-
sion of the surface revealed a uniform
roughness of the enamel and that the
enamel prisms and dentinal tubules were
not identifiable. In addition enamel rod
prisms are not evident after air abrasion.25
The combination of air abrasion and acid
etching exhibited the least mean value of dye
penetration (0.1500 + 0.3663). The recom-
mended use of phosphoric acid is 30 – 50 %.
Thirty seven percent percent phospshoric acid
was used in this study as found by Silverstone,
that the application of 30% to 40% phos-
phoric acid resulted in very retentive enamel
surfaces. 37% phosphoric acid results in the
formation of monocalcium phosphate mono-
hydrate precipitate than can be rinsed off.
Ellis et al. reported that the enamel sur-
faces conditioned with a combination of air
abrasion and acid etch revealed a more
detailed pattern than surfaces treated with
either treatment alone.25
Its believed that
air abrasion may induce a more retentive
pattern and enhance etchant penetration to
deep fissures, as this system widens the
pits and fissures, eliminates organic material
and exposes more reactive tooth enamel.
The mean dye penetration for con-
ventional bur preparation and acid etch-
ing was 0.500 + 0.7609. For Opening
the fissures with a round diamond bur is
a conventional method of fissure prep-
aration. Etching with phosphoric acid
removes the enamel prisms, thus creat-
ing the micromechanical retention for the
sealant by the formation of resin tags.
In the present study the conventional
bur preparation and acid etching tech-
nique led to significantly less microleakage
than the air abrasion technique alone from
the microleakage point of view (p 0.05).
This finding suggested that removing the
debris was not sufficient to produce good
mechanical retention of the sealant mate-
rial and further treatment of enamel was
needed.45
However, found no statisti-

Kaur et al
cal significant difference in microleakage
between acid etched and air abraded teeth
prior to sealant or composite placements
Eakle et al. found that air abrasion pro-
duced a roughened surface but lacked the
seal obtained with acid etching; Brown and
Barkmeier, Ellis et al. showed that air abra-
sion alone was not sufficient in promoting
high bond strength of a sealant to enamel.
A study by Ferdianakis and Guirguis et al.
produced similar results. A clinical study
showed that sealants placed on occlusal
surfaces had similar retention rates after six
months for acid etched and air abraded
surfaces, but that sealants failed when
placed on buccal and distolingual surfaces
prepared by air abrasion alone. Therefore
from the literature, it appears that the etch-
ing technique is still considered to be the
treatment of choice over air abrasion alone.
The use of burs, however , has been
controversial and acid etching is always rec-
ommended after ameloplasty performed
with a bur. In our study the occlusal
surfaces of the Group III have been pre-
pared by round diamond bur followed by
acid etching. Various studies have compared
the microleakage produced by surfaces
prepared with burs with that of surfaces
prepared by acid etching or air abra-
sion techniques. Hatibovic - Kofman et al.,
found them to be superior, others found
them to be no superior, still others found
them to be no different or even worse.
The results of this present study found
that air abrasion followed by acid etch-
ing produced superior bonding surfaces
than those produced by air abrasion alone.
The lowest microleakage values of intact
enamel surfaces were achieved using air
abrasion with aluminum oxide followed by
acid conditioning with phosphoric acid.
The results of our study coincides
with that of A. Mentes and N. Gescoglu
who found that air abrasion of enamel fol-
lowed by acid etching produced the low-
est microleakage scores, which however
were not significantly lower than those
produced by the conventional method
of acid etching. Borsatto demonstrated
that the application of an aluminum oxide
jet in association with acid etching con-
ditioning of enamel presented shear bond
strength resistance values statistically simi-
lar to those obtained by acid conditioning.
Such findings suggest that the acid
etching step cannot be omitted if air abra-
sion technology is chosen to promote
bonding of pit and fissure sealants. Thus
the results of the present study indicate
that the combination of air abrasion and
acid etching technique can be considered
as a method of choice for enamel prep-
aration before the sealant placement. ●
Correspondence:
Dr. Raman Deep Kaur
28 S.J.S Avenue
Anjala Road
Amritsar- 143001
Punjab, India
9815472335
docraman@gmail.com

34 • Vol. 6, No. 4 • July 2014
Kaur et al
Disclosure
The authors report no conflicts of interest with
anything mentioned in this article.
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Kaur et al

Negm
Background: The application of infraorbital
nerve block is often to accomplish regional
anesthesia of the face. The procedure offers
several advantages over local tissue infiltra-
tion. A nerve block often achieves anesthe-
sia with a smaller amount of medication than
is required for local infiltration. In addition,
unlike local tissue infiltration, blocks can pro-
vide anesthesia without causing tissue distor-
tion. In this article I will discuss the structure
of anesthesia, approach of the technique, indi-
cation, contraindication and others. The aim
of this study was to describe a technique for
extraoral infraorbital nerve block using several
anatomical points for reference, simplifying
the procedure and enabling greater success
and a more rapid learning curve. Effective pain
control in Dentistry may be achieved by local
anesthetic techniques. The success of the
anesthetic technique for nerve block in anterior
region depends on the proximity of the needle
tip to the infraorbital foramen at the moment
of anesthetic injection into it. Two techniques
are available to reach the infraorbital nerve,
namely extraoral and intraoral; these tech-
niques differ in the place where we should start.
Methods: The application of extraoral infraor-
bital nerve block in implant for anterior region
has a superior effect rather than the intra-
oral approach. A nerve block often achieves
anesthesia with a smaller amount of medica-
tion than is required for local infiltration. In
addition, unlike local tissue infiltration, blocks
can provide anesthesia without causing tis-
sue distortion. And as we mention before that
successful infraorbital nerve block provides
anesthesia for the area between the lower
eyelid and the upper lip including the anterior
part of the alveolar ridge at the side of inner-
vation so we can perform the implant surgery
effectively with more comfort to the patients.
You should pay attention while using this tech-
nique because the needle is in very close prox-
imity to the facial artery. So that, avoid adding
vasoconstrictors to the anesthetic agent.
Results: The obtained data showed
100% success rate of anesthe-
sia injection for all cases we treated.
Conclusions: This method is potentially
effective for extraoral infraorbital nerve
block, especially in Geriatric Dentistry.
The Application of Extraoral Infraorbital Nerve
Block Compared to the Intraoral Approach
Dr. Shady A. M. Negm1
1. Dentist at Ministry of Health, Fellow of Alexandria Oral Implantology Association (A.O.I.A),
Fellow of Egyptian Society of Oral Implantology (E.S.O.I)
Abstract
KEY WORDS: Extraoral infraorbital nerve block, intraoral infraorbital nerve block, local anesthesia

36 • Vol. 6, No. 4 • July 2014
INTRODUCTION
In general, regional anesthesia is ideal when
the area of interest is innervated by a single
superficial nerve. The infraorbital nerve sup-
plies sensory innervation to the lower eyelid,
the side and ala of the nose, and the upper lip.
Since the infraorbital nerve provides a consid-
erably large area of sensory innervation, it is a
prime candidate for a regional nerve block. A
successful infraorbital nerve block provides
anesthesia for the area between the lower eye-
lid and the upper lip including the anterior part
of the alveolar ridge at the side of innervation.
The cranial nerve V (trigeminal nerve), pro-
vides sensory innervation to the face. The sec-
ond division, the maxillary nerve (V2), exits the
skull from the foramen rotundum. After giving off
numerous branches, the maxillary nerve even-
tually enters the face through the infraorbital
canal, where it ends as the infraorbital nerve.
The infraorbital nerve supplies sensory branches
to the lower eyelid, the side of the nose, and
the upper lip including the anterior part of
the alveolar ridge at the side of innervation.
Indications for infraorbital nerve blocks
include wound closure, pain relief, and
anesthesia for debridement. Contraindica-
tions for infraorbital nerve block include any
allergy or sensitivity to the anesthetic agent,
evidence of infection at the infection site,
distortion of anatomical landmarks, and unco-
operative patients. The disadvantage of the
infraorbital nerve block is that it is performed
by blind palpation of the infraorbital foramen.
Technique for extraoral infraorbital
nerve block
During the extraoral technique, the needle is in
very close proximity to the facial artery. Because
of this proximity, avoid adding vasoconstrictors
to the anesthetic agent. Use the landmarks to
locate the infraorbital foramen. Prepare the skin
overlying the infraorbital foramen with povidone
iodine (Betadine) and sterile gauze. Using ster-
ile technique, insert the needle through the skin,
the subcutaneous tissue, and the muscle. Aspi-
Figure 1: The chemical structure of local anesthetic agents.
Negm

rate to ensure the needle is not within a ves-
sel. The facial artery and vein are very close to
the needle in this position. Inject the anesthetic
solution. The infiltrated tissue appears swollen.
Firmly massage this area for 10-15 seconds.
Complications that may occur from the extraoral
infraorbital injection technique include bleed-
ing, hematoma, allergic or systemic reaction to
the anesthetic agent, infection, unintentional
injection into artery or vein, failure to anesthe-
tize, nerve damage, and swelling of the eye lid.
CASE PRESENTATION
These two Egyptian female patients came to my
clinic seeking for implant to restore the miss-
ing teeth in anterior segment of the alveolar
ridge. I decided to use the extraoral infraorbital
nerve block rather than infiltration intraorally.
The technique as I mention before is pain-
less and less traumatic. The anesthesia was
very effective and I complete the surgery with-
out any problems. The following figures show-
ing the application of the anesthesia: Figure
[2] showing the first patient with right extraoral
infraorbital injection; Figure [3] showing the
first patient with left extraoral infraorbital injec-
tion; Figure [4] showing the second patient
with left extraoral infraorbital injection; Fig-
ure [5] showing the upper anterior region of
first patient in where surgery was performed
during the implant surgical procedure; Fig-
ure [6] showing the upper left anterior region
of second patient in where surgery was per-
formed during the implant surgical procedure.
DISCUSSION
The majority of local anesthetic agents share
the same basic chemical structure, which con-
sists of an aromatic ring, linked to an interme-
diate chain (The intermediate chain between
the aromatic and hydrophilic segments is either
an ester or an amide), linked to a hydrophilic
amine segment as seen in Figure 1. The chemi-
cal structure of this intermediate group classi-
fies the agent into the amide group or the ester
group. This structural difference determines
Figure 2: The first patient with right extraoral
infraorbital injection.
Figure 3: The first patient with left extraoral
Negm

38 • Vol. 6, No. 4 • July 2014
Negm
Figure 4: The second patient with left extraoral
Figure 5: The upper anterior region of first
patient in where surgery was performed during
the implant surgical procedure.
Figure 6: The upper left anterior region of
second patient in where surgery was performed
during the implant surgical procedure.
the pathway by which the agent is metabolized
and its allergic potential. The toxicities associ-
ated with local anesthetics are cardiovascular
and neurologic. Methemoglobinemia can occur
with use of these agents, though it is rarely
clinically significant. An infraorbital nerve block
requires 1-3 mL of the chosen anesthetic agent.
Lidocaine (Xylocaine) is the most commonly
used agent. The onset of action for lidocaine
is approximately 4-6 minutes. The duration of
effect is approximately 75 minutes, which is suf-
ficient enough to complete the implant surgery
without needs of giving anesthesia again. ●
Correspondence:
Dr. Shady A. M. Negm
15 Elahwazy st., Elwardian
Alexandria, Egypt
+201002944111
smngm@msn.com
Disclosure
The author declare that he has no financial or personal relationship(s) that may
have inappropriately influenced him in writing this article
References
1. Gray H, Lewis WH. The trigeminal nerve. Gray’s Anatomy of the Human
Body. Bartleby.com. Accessed May 16, 2008.
2. Amsterdam JT, Kilgore KP. Regional anesthesia of the head and neck. In:
Roberts JR, Hedges JR, eds.Clinical Procedures in Emergency Medicine.
4th
ed. Philadelphia, Pa: WB Saunders Company; 2004:552-66.
3. Crystal CS, Blankenship RB. Local anesthetics and peripheral nerve
blocks in the emergency department.Emerg Med Clin North Am. May
2005;23(2):477-502.
4. Trott AT. Wounds and Lacerations: Emergency Care and Closure. 2nd
ed.
St. Louis, Mo: Mosby; 1997.
Negm

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