673 Revista Română de Anatomie funcţională şi clinică, macro- şi microscopică şi de Antropologie Vol. XIV – Nr. 4 – 2015 CLINICAL ANATOMY BILATERAL SINUS LIFT WITH THE SIMULTANEOUS INSERTION OF IMPLANTS: A CASE REPORT Mihaela Mitrea 1 , Anca Rusu 3 , Dorelia Lucia Călin 2 “Grigore T. Popa” University of Medicine şi Pharmacy, Iaşi 1. Discipline of Anatomy 2. Discipline of Cariology and Restorative Odontotherapy 3. Private Dental Office “dr. Anca Rusu”, Bucureşti Primary dentist BIlATeRAl SInUS lIfT wITh The SIMUlTAneOUS InSeRTIOn Of IMPlAnTS: A CASe RePORT (Abstract): Sinus floor augmentation is a technique that is used to improve long- term retention of the implants.The purpose of this case report is to present the clinical results of bilateral sinus lifting procedure with simultaneous insertion of implants through the antrostomy with a single lateral window in the right sinus and double window antrostomy in the left sinus. Bone addition material was Cerabone (Botiss Biomaterials) and 5 implant Sky Classic from Bredent. Results: All the implants (five in number) which were inserted immediately, simultaneously with the bilateral sinus lift procedure were osseointegrated correctly and it was possible to move to the prosthetic stage. There were no clinical signs of postoperative sinusitis.Conclusions: Bilateral sinus lift procedure with immediate insertion of implants proved to be successful leading to os- seointegration and stability of implants, went without postoperative complications and showed good acceptance by the patient. Key words: BIlATeRAl SInUS lIfT, IMPlAnT, DOUBle wIn- DOw AnTROSTOMy INTRODUCTION edentulous maxillary posterior region pre- sents difficulties concerning the insertion of implants as compared to other areas of the oral cavity. After the loss of teeth, anatomical and functional changes occur in the maxilla, the mandible position modifies as well as the aes- thetic profile, malocclusion, difficulties in mas- tication and speech arise etc. Maxillary alveolar process is resorbed grad- ually in vertical and horizontal senses (1). This reduction interests especially the vertical dimen- sion of bone, between the top of the alveolar ridge and the floor of the maxillary sinus, called by Misch (2) subsinusal vertical dimension. loss of teeth in the posterior maxilla can induce expansion of the maxillary sinus as a result of pneumatization, through a positive air pressure created during breathing. It is not uncommon for maxillary sinus floor to be present close to the alveolar ridge. The tendency towards sinus pneumatization is sig- nificantly higher after molar extraction com- pared to that generated by the extraction of premolars (3). Moreover, the residual alveolar ridge is reduced due to centripetal resorption of the alveolar bone at the level of maxilla, especially in the buccal area. ANATOMICAL CONSIDERATIONS REGARDING THE POSTERIOR REGION OF THE MAXILLA The use of oral implants in the posterior region of the maxilla has become a routine practice in dentistry. The frequency of oral implant place- ment has raised the number of neurosensory disorders and hemorrhages, it is therefore im- portant for surgeons to detect the neurovascular structures from the level of maxilla. The maxillary sinus and nasal cavity occupy a large space in the middle of the face, and expansion of the sinus cavity towards alveolar processes occurs due to loss of teeth. The max- illary sinus is constantly expanding with age.
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673
Revista Română de Anatomie funcţională şi clinică, macro- şi microscopică şi de Antropologie
Vol. XIV – Nr. 4 – 2015 CLINICAL ANATOMY
BILATerAL SINuS LIfT wITh The SIMuLTANeOuS INSerTION Of IMpLANTS: A CASe repOrT
Mihaela Mitrea1, Anca rusu3, Dorelia Lucia Călin2
“Grigore T. Popa” University of Medicine şi Pharmacy, Iaşi1. Discipline of Anatomy
2. Discipline of Cariology and Restorative Odontotherapy3. Private Dental Office “dr. Anca Rusu”, Bucureşti
Primary dentist
BIlATeRAl SInUS lIfT wITh The SIMUlTAneOUS InSeRTIOn Of IMPlAnTS: A CASe RePORT (Abstract): Sinus floor augmentation is a technique that is used to improve long-term retention of the implants.The purpose of this case report is to present the clinical results of bilateral sinus lifting procedure with simultaneous insertion of implants through the antrostomy with a single lateral window in the right sinus and double window antrostomy in the left sinus. Bone addition material was Cerabone (Botiss Biomaterials) and 5 implant Sky Classic from Bredent. Results: All the implants (five in number) which were inserted immediately, simultaneously with the bilateral sinus lift procedure were osseointegrated correctly and it was possible to move to the prosthetic stage. There were no clinical signs of postoperative sinusitis.Conclusions: Bilateral sinus lift procedure with immediate insertion of implants proved to be successful leading to os-seointegration and stability of implants, went without postoperative complications and showed good acceptance by the patient. Key words: BIlATeRAl SInUS lIfT, IMPlAnT, DOUBle wIn-DOw AnTROSTOMy
INTrODuCTIONedentulous maxillary posterior region pre-
sents difficulties concerning the insertion of implants as compared to other areas of the oral cavity. After the loss of teeth, anatomical and functional changes occur in the maxilla, the mandible position modifies as well as the aes-thetic profile, malocclusion, difficulties in mas-tication and speech arise etc.
Maxillary alveolar process is resorbed grad-ually in vertical and horizontal senses (1). This reduction interests especially the vertical dimen-sion of bone, between the top of the alveolar ridge and the floor of the maxillary sinus, called by Misch (2) subsinusal vertical dimension.
loss of teeth in the posterior maxilla can induce expansion of the maxillary sinus as a result of pneumatization, through a positive air pressure created during breathing.
It is not uncommon for maxillary sinus floor to be present close to the alveolar ridge. The tendency towards sinus pneumatization is sig-
nificantly higher after molar extraction com-pared to that generated by the extraction of premolars (3). Moreover, the residual alveolar ridge is reduced due to centripetal resorption of the alveolar bone at the level of maxilla, especially in the buccal area.
ANATOMICAL CONSIDerATIONS regArDINg The pOSTerIOr regION Of The MAxILLAThe use of oral implants in the posterior region
of the maxilla has become a routine practice in dentistry. The frequency of oral implant place-ment has raised the number of neurosensory disorders and hemorrhages, it is there fore im-portant for surgeons to detect the neurovascular structures from the level of maxilla.
The maxillary sinus and nasal cavity occupy a large space in the middle of the face, and expansion of the sinus cavity towards alveolar processes occurs due to loss of teeth. The max-illary sinus is constantly expanding with age.
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Its expansion is noticed especially after extrac-tion of molars and premolars. edentation has as result a very thin bony wall that separates the oral cavity from the maxillary sinus.
The maxillary sinus is a large solitary cav-ity, but sometimes it can be divided into small-er cavities which are separated by septa. These would have their origins in the development of the maxillary sinus and tooth eruption, being known as primary septa. Sometimes they are acquired structures, resulting from pneumatiza-tion of the maxillary sinus after tooth loss, a situation in which are called secondary septa (4).
Maxilla has a dense vascular network. The maxillary sinus is vascularized by maxillary artery branches via infraorbital artery, the great palatine artery and facial artery. The venous system is collected either by a single trunk, which is a continuation of the spheno-palatine vein, or by three venous plexus: the anterior and posterior pterygoid plexus, and the alveolar plexus. The anterior and posterior pterygoid plexus converge through the lateral pterygoid muscle and connects with the alveolar plexus which drains partly into the maxillary vein and partly into the facial vein. The innervation of the maxillary sinus is ensured by the maxillary nerve (V2): the second branch of the trigemi-nal nerve and its collateral branches (5).
Insertion of implants in the posterior max-illa can be problematic due to small amounts of subsinusal bone as a result of resorption, pro-gressive pneumatization of the maxillary sinus and reduced bone density. Maxilla consists mainly of cancellous bone, being one of the least dense bone structures of the oral cavity.
Available bone volume and bone quality de-termine the type of the implant and the used surgical technique, having a vital role in the success of treatment (6). Sinus floor augmenta-tion is a technique for reconstruction of bone anatomy and is used to develop a sufficient bone volume in order to improve long-term retention of the implant (7).
The technique of “sinus lift” consists in increasing vertically the alveolar ridge of max-illary posterior area by interposing different types of bone grafts between Schneider sinusal membrane and the floor of the maxillary sinus (8). The procedure is one of the most common preprosthetic surgical procedures performed in dentistry today.
Sinus floor augmentation was introduced by Tatum in 1976, modified by Boyne and James
in 1980 (8) and then changed again by Tatum in 1986 (9), this procedure is still used today. Sinus augmentation procedure is indicated when the penetration of the implant in antrum can not be avoided.
external lateral sinus lift technique (lateral antrostomy) can be conducted in a single surgical step (implants are placed simultaneosly with the elevation of Schneider membrane) or two surgical steps (implants are inserted in a few months after sinus augmentation). The choice of using one or another of described techniques is based on bone offer in vertical direction. Thus, if the height of the alveolar ridge is less than 4-5 mm is recommended to choose the two-stage technique in order to obtain a good stability for the implant and where the ridge height is greater than 5 mm the one-stage technique can be carried out. lateral sinus lift technique allows to obtain a bone height of 8 to 15 mm.
Open sinus lift surgery is performed under local anesthesia, an incision is practiced on the alveolar ridge and two vertical incisions. Crestal incision is made slightly to palatal in order to keep a wider band of keratinized attached gin-giva for a stronger wound closure and to prevent its dehiscence. The flap is detached, a window is carried out in the lateral wall of the sinus and with appropriate tools (antral curette, elevators) the Schneider membrane is rised from the walls of the maxillary sinus in order to create the necessary space for bone grafting. This new created space is filled with material for bone addition and will provide the platform for im-plant placement. It is very important for the graft material to be stable. The surgeon may opt to use a resorbable membrane to cover the material for bone addition. finally, the created window will be covered with an artificial mem-brane to protect the addition material, and the gingiva will be repositioned perfectly closing the operational site.
wallace and froum (11), have led a system-atic study about the the technique of lateral fenestration, concluding that it is advantageous to use graft particle simultaneously with the insertion of implants with rough surface and a barrier membrane covering the bone window to enhance the chances of success of the proce-dure. The use of membrane showed a success rate of 93.6% compared to 88.7% when not using it.
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when are carried out sinus lift technique should be considered the arterial blood supply of the maxillary sinus. when preparing the bone window can be encountered intraosseous or extraosseous branches. A very good knowl-edge of the arterial blood supply of the antero-lateral wall of the maxillary sinus is absolutely necessary to perform this surgical procedure. In the cortical bone of the lateral wall of the sinus is present an intra-osseous anastomosis between the dental branch of the posterior su-perior alveolar artery also called alveolar antral artery and the infraorbital artery (12). Alveolar antral artery from antero-lateral wall of the sinus can cause hemorrhages in about a fifth of the osteotomy with lateral window (13) and the more residual alveolar ridge is resorbed, the better the chances that this artery to be injured.
Antral alveolar artery is partly situated in-traosseous in the area where it is practiced the antrostomy, from the second premolar to the second molar, being very close to Schneider membrane and partially embedded in the lat-eral wall of the sinus (12).
hemorrhages can reduce visibility and can cause the increasing of surgical time (14). Thus appear difficulties in visualization and elevation of sinusal membrane, complicating the inser-tion of the material for bone addition. hemor-rhage caused by injury of this artery can dislo-cate the material for bone addition by the effect of “washing” caused by blood pressure, can cause hematomas of the cheek, thus creating an ideal environment for bacterial multiplication and infection.
The presence of maxillary sinus septa can complicate the luxation of window and the lift-ing of sinus membrane (15). Boyne and James (9) have recommended the cutting of the septum with a chisel and removal of it with a hemo-static forceps to place the graft into the cavity without interruption. Sometimes, if it is carried out a sinus lift technique in the presence of maxillary sinus septa will be necessary to change the design of lateral window to avoid sinus membrane perforation and fracture of septa (16,17). It is essential to identify radiological the presence of these structures because the lateral window design in sinus lifting technique is based on the presence and size of maxillary sinus septa.
Double window antrostomy has been pro-posed in the presence septa (16, 18,19,20), with a window located anterior and one poste-
rior of septum. This technique allows better access to instruments and the risk of puncturing the membrane is much smaller, the vasculariza-tion is better preserved in the area and improves the integration and stability of implants and bone graft (21).
An important complication of antrostomy with lateral window is sinus membrane perfora-tion. If the perforation is small it can be covered with a resorbable collagen membrane, and if is large a suture is necessary to prevent the entry of graft particles in the maxillary sinus and the emergence of complications such as maxillary sinusitis. The perforations of membrane, ac-cording to the scientific literature, are strongly associated with the occurrence of postoperative complications and consist of acute or chronic sinus infection, bacterial invasion, swelling, bleeding, wound dehiscence, loss of graft mate-rial and an interruption of the normal sinus physiological function (22,23).
for sinus augmentation have been used bone grafts in the form of particles or block, coming from various sources. It has been reported that bone grafts using particles have greater chanc-es of success than those in block. Cerabone (Botiss Biomaterials) is derived from the min-eral phase of bovine bone, which shows strong resemblance to the human bone with regard to chemical composition, porosity and surface struc-ture. The unique manufacturing process based on high-temperature heating removes all or-ganic and potentially antigenic components, making the material absolutely safe and free of proteins. Its three-dimensional porous network enables a fast penetration and adsorption of blood and serum proteins and serves as a res-ervoir for proteins and growth factors. After the material has been sterilized, it can be used for bone additions, without causing the occur-rence of an immune response from the host. In general, this type of biomaterial is osteoinduc-tive, and while it goes through physiological remodeling and becomes incorporated into the surrounding bone.
The amount of material required for the ad-dition of bone depends on the type of proce-dure. Bilateral sinus lift for the rehabilitation of molars and premolars region will require a greater amount of material compared to a uni-lateral procedure.
Currently, the lateral approach of maxillary sinus augmentation has become a routine tech-
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nique which allows to obtain a long-term sur-vival rates of implants over 96% in the poste-rior maxilla (24,25).
The possibility of inserting all implants in a procedure with a single step is perhaps more demanding technically than two-step method, because it relies on residual bone volume, but it is more advantageous to the patient because it reduces the number of procedures and the time required to complete the implant support-ed prosthesis (26).
The purpose of this case report is to present the clinical results of bilateral sinus lifting pro-cedure with simultaneous insertion of implants through the antrostomy with a single lateral window in the right sinus and double window antrostomy in the left sinus.
CASe repOrTThe CP patient, aged 42 years presented to
the Dr. Anca Rusu Private Dental Office in Bucharest having neuromuscular, mastication, phonation disorders, changes in position of the mandible and profile, reduced vertical dimen-sion as a result of a posterior maxillary Ken-nedy class II division edentation.
It was absolutely necessary to evaluate pre-operatively the medical and dental history of the patient. The patient was carefully evaluated from a medical, clinical, radiological point of view in order to assess the current health status and to identify any conditions that would re-quire preliminary treatment or contraindica-tions to implant therapy.
were performed the following laboratory tests: complete blood count (red cells, white cells, globular value, leukocytes, platelets, hemo-globin), bleeding and coagulation time, clot retraction time, hematocrit, coagulogram.
Odontal and periodontal clinical examina-tion was performed in the vicinity of maxillary sinus to detect any lesion that could cause od-ontogenic maxillary sinusitis. edentulous area is characterized by an atrophic alveolar ridge, low in height which makes impossible the placement of implants without bone addition procedures.
OPT radiographic examination and a preop-erative CT scan were performed for the evalu-ation of possible anatomical deformations (par-tial or total sinus septa) or the existence of sinus pathology (rhinosinusitis, sinusitis of odonto-genic origin, cysts, pseudocysts, polyposis, tu-mors).
It was found that the volume of residual bone at the level alveolar process is sufficient in quality and quantity to ensure primary initial stability of implants that will be inserted simul-taneously with sinus floor augmentation (fig.2).
It was decided to perform a bilateral sinus lift intervention through lateral approach, in quadrants 1 and 2 for the reconstruction of the alveolar ridge by apposition and interposition and simultaneous insertion of dental implants. Patient received detailed explanations on surgi-cal procedures that will be performed and in-formed consent was obtained from him.
The ceramo-metal prosthesis was removed (fig.3) and the right second premolar extrac-tion was performed.
Antibiotic prophylaxis was performed 1 hour before the beginning of the procedure with a dose of 1000 mg Amoxiklav, and then the local anesthesia.
After local anesthesia a crestal incision was made, supplemented by two vertical incisions and the detachment of a trapezoidal vestibular flap in order to expose the lateral wall of the sinus.
The osteotomy was practiced with the achie-vement of a lateral window to open the sinus using globular atraumatic burs at the right first molar level (fig.5).
It is fractured the well-defined bone fragment and pushed very carefully inward and superior in order to not perforate the sinus Schneider membrane, that covers the sinus floor.
The Schneider membrane was carefully de-tached from the walls of the maxillary sinus and sinus floor using elevators without perforat-ing it. The sinus membrane is not bone form-ing, so raising them will not produce the amount of bone to fill the cavity. It is very important to maintain intact the sinus membrane what is coming in contact with the bone graft material to prevent infection of the sinus.
The sinus membrane was carefully lifted and the implant was placed in the crestal bone at the level of first premolar. Bredent classic SKy implant was the length of 12 mm and diameter of 4 mm.
It was then inserted the implant SKy classic Bredent in the first molar having a length of 10 mm and a diameter of 4.5 mm, that entered into the sinus cavity below the membrane. The bone addition material (xenograft with natural bone substitutes Cerabone, bovine bone) was
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fig. 5. The achievement of lateral bone window in antero-lateral wall of right sinus, detachment of
sinus membrane and prepairing for insertion of bone addition material
fig. 6. Application of resorbable membrane at right sinus and the implant inserted at level of
first premolar
fig. 7. Bone augmentation in the right sinus and insertion of implants
fig. 8. Coating with collagen membrane
fig. 9. Suture in first quadrant fig. 10. Initial clinical appearance in second quadrant
placed under sinus mucous membrane, around the exposed implant tip and in the antral space along existing bone (fig.7).
lateral window was covered with a resorb-able collagen membrane (Jason membrane Bot-iss) (fig.8) and after was performed soft tissue suture (fig.9).
for the second quadrant was used “double window” technique because of the presence of sinus septum, with the achievement of a bone window situated posterior and one anterior from septum. This technique allows a better access
to instruments and the risk of puncturing the membrane is much smaller. Osteotomy has been practiced with the realization of two lateral windows using atraumatic globular burs (fig.11). Carefully was detached the Schneider membrane from the walls and the floor of the maxillary sinus using elevators without perforating it.
Osteotomy was performed to insert implants to the length determined by radiography. In order to ensure the parallelism of the implants have been used the parallelization pins (fig. 12). If the implants are not parallel they could desta-
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Bilateral Sinus Lift with the Simultaneous Insertion of Implants: A Case Report
bilize each other after insertion of dentures due to masticatory forces.
The implants were screwed into the openings of the alveolar bone, taking care not to exert excessive forces on bone. for the canine has been used an implant length of 12 mm and diameter of 3.5 mm, for the first premolar was used an implant with a length of 12 mm and a diameter of 4 mm, and for the first molar was used an implant with the a length of 10 mm, and diameter of 4.5 mm (SKy Classic Bredent). After placing the implants were screwed into them the healing caps.
Addition bone material was placed under the sinus mucous membrane through the two bone windows around the exposed part of implants at the level of premolar and molar and in the antral area over the existing bone.
The inserted bone particles through those two osseous windows in the sinus cavity were protected using resorbable collagen membranes (Jason membrane, Botiss) (fig.13,14) and after the gingiva was sutured.
Antiseptic solutions for oral irrigation with
Chlorhexidine 0.12% were indicated to reduce the plaque accumulation of in the area of im-plantation after surgery.
It were recommended anti-inflammatory pills, analgesics, nasal decongestant to improve per-meability osteo-meatal complex, cold water com-presses, antibiotics. The patient was instructed not to blow his nose for 7 days after surgery, to cough with open mouth to avoid increased pressure in the operated sinuses and to sleep upright.
After positioning the implants it was made a temporary prosthesis which has replaced missing teeth during implant osseointegration process (6 months).
reSuLTSThere were no clinical signs of postoperative
sinusitis.At an interval of 10-14 days the sutures were
removed.Postoperative assessment was done at one
month, two months and three months after the insertion of implants to notice any pain, gingi-val inflammation, swelling and increasing the
fig. 11. Achievement of bone windows for sinus lift
fig. 12. Parallelization pins at the level of the left canine and first premolar
fig. 13. Application of collagen membrane at the first window of the sinus
fig. 14. Application of collagen membrane in the other window of the sinus
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fig. 15. Control panoramic radiography of patient after bilateral sinus lift intervention with lateral approach. final radiological appearance
fig. 16. Abutments appearance before prosthesis cementation
fig. 17. The final aspect of the patient. Zirconia dental prosthesis fixed on prosthetic abutments
and implants
height of the bone and implants stability. In all implants a bone-implant contact was clearly visible. There were no radiolucencies around implants.
All the implants which were inserted im-mediately, simultaneously with the bilateral sinus lift procedure were osseointegrated cor-rectly and it was possible to move to the pros-thetic stage.
A zirconia dental prosthesis fixed on pros-thetic abutments and implants (fig.16,17) was achieved.
DISCuSSIONRestoration of partial edentulism with dental
implant therapy requires careful planning. This applies especially in the posterior maxillary area when pneumatization of sinuses could lim-it the amount of alveolar bone for implant inser-tion (27). Careful preoperative planning will reduce the incidence of complications and ana-
tomical and pathological unforeseen situations.Surgical procedures in the posterior maxil-
lary region require detailed knowledge about the maxillary sinus anatomy and possible ana-tomic variations (presence of sinus septa).
Maxillary sinus floor augmentation became a routine treatment preprosthetic in recent years. Sinus floor elevation with autogenous bone grafts and/or bone substitutes is a generally accepted procedure that allows the insertion of implants (28).
This allows the insertion of dental implants through simultaneously or in stages procedures in the posterior maxillary area, which in the past was considered inappropriate for insertion of implants due to insufficient bone volume. It is necessary to achieve a good initial primary stability to perform simultaneous implant inser-tion and sinus bone grafting (29).
numerous studies in the literature have reported long-term survival rates of implants
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Bilateral Sinus Lift with the Simultaneous Insertion of Implants: A Case Report
inserted in the augmented maxillary sinuses (30).
The most frequent surgical access continues to be lateral antrostomy, this involves the use of the thinnest areas of the anterolateral wall of the maxillary sinus. lateral antrostomy allows greater bone augmentation in the atrophic max-illa, but requires greater surgical access.
In the technique of double window antros-tomy proposed in the presence of sinus septa (34), the approach is through the anterior wall of the maxillary sinus, where bone is thinner, the use of instruments is simpler and therefore there is less chance of perforating the mem-brane (21).
Sinus lift is considered a safe procedure with a low prevalence of complications.
CONCLuSIONSBilateral sinus lift procedure with immediate
insertion of implants proved to be successful leading to osseointegration and stability of im-plants, went without postoperative complica-tions and showed good acceptance by the pa-tient.
Cerabone addition bone material (Botiss) demonstrated excellent osteoconductive proper-ties in grafted sinuses and allowed the survival of the implants. The barrier membrane
improved vital bone formation.
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Romanian Journal of Oral Rehabilitation
Vol. 7, No. 2, April - June 2015
12
THE MANAGEMENT OF PERIAPICAL MAXILLARY CYST
BY USING THE A-PRF (PLATELET RICH ADVANCED FIBRIN):
A CASE REPORT
Mihaela Mitrea1*
, Anca Rusu2, Dorelia Lucia Călin
3
1“Grigore T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry,
Department of Anatomy 2Specialist in dentoalveolar surgery, implantology at Private Dental Office “Dr. Anca Rusu”,
București 3“Grigore T. Popa" University of Medicine and Pharmacy - Iași, Romania, Faculty of Dentistry,
Department of Cariology and Restorative Odontotherapy
*Corresponding author: Mihaela Mitrea, DMD
“Grigore T. Popa" University of Medicine and Pharmacy