The effect of air-polishing abrasives on wear of direct restoration materials and sealants

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The effect of air-polishing abrasives on wear of direct restoration materials and sealants Matthias Anton Pelka, Katharina Altmaier, Anselm Petschelt and Ulrich Lohbauer JADA 2010;141(1):63-70 10.14219/jada.archive.2010.0022 The following resources related to this article are available online at jada.ada.org (this information is current as of August 19, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/141/1/63

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The effect of air-polishing abrasives on wear of direct restoration materials and sealants Matthias Anton Pelka, Priv.-Doz., Dr. med. dent., Dr. med. dent. habil.; Katharina Altmaier, Dr. med. dent.; Anselm Petschelt, Prof., Dr. med. dent., Dr. med. dent. habil.; Ulrich Lohbauer, Priv.-Doz., Dr. Ing.

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Background. Air-polishing devices (APDs) effectively remove supragingival staining. However, the use of APDs on restorative surfaces may result in clinN C U U A ING ED 3 ically relevant surface damage and material loss. RT ICLE Methods. The authors made plane specimens (N = 180) of dental restorative materials (Tetric EvoCeram [Ivoclar Vivadent, Schaan, Liechtenstein], Tetric Flow [Ivoclar Vivadent ], Grandio Flow [VOCO, Cuxhaven, Germany], Admira Seal [VOCO], Grandio Seal [VOCO]) and Ionofil Molar [VOCO]). The authors treated the specimens with standardized air abrasion, using three abrasives (Acclean Air Preventive Powder [Henry Schein, Langen, Germany], AirFlow Prophylaxis Powder [EMS, Nyon, Switzerland] and ClinPro Prophy Powder [3M ESPE, Seefeld, Germany]) for 10 seconds each. The authors used profilometric scanning to quantify defect depth and volume loss. Results. The abrasive ClinPro Prophy Powder produced the smallest defect depth and volume loss. Tetric EvoCeram experienced the smallest defect depth, whereas the flowable composites showed the greatest defect depths and volume losses. Sealants showed defects comparable with those the authors found in the glass ionomer, which were significantly smaller than those found in flowable composites. Conclusions. Air polishing of sealants and restorative materials always results in substance loss and surface damage. The sealants performed better in terms of abrasion resistance than did the flowable composites tested. Among the air-polishing abrasives, ClinPro Prophy Powder caused the least abrasive damage. Clinical Implications. Clinicians should use low-abrasion powder for frequent cleaning of discolored restorations with APDs to avoid excessive abrasion of restorative materials. Key Words. Dental restoration wear; dental sealants; dental prophylaxis; air abrasion; restorative material. JADA 2010;141(1):63-70. T

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ABSTRACT CON

emoval of supragingival and subgingival plaque and staining is crucial for maintenance of gingival and periodontal health.1 Dental care personnel usually remove supragingival stain and plaque by means of methods such as scaling, polishing with rubber cups and using polishing paste.2,3 Airpolishing devices (APDs) have come into increased use for easy, fast and complete removal of supragingival stain and plaque.4,5 Local factors, such as the surface roughness of enamel, cement and restorative materials in the cervical region, accelerate plaque accumulation and can cause esthetic and gingival problems.6,7 During air polishing, not only enamel and dentin but also restorative materials experience material loss. While enamel has the capacity for sustainable remineralization, the abraded and deteriorated surfaces of composite restorations stay generally unchanged.8 However, all surfaces of a restoration must be polished to reduce plaque retention. One in vivo study suggested a threshold surface roughness for bacterial retention (roughness average = 0.2 micrometers) below which no further reduction in bacterial accumulation could be expected through further polishing.9

Dr. Pelka is an associate professor, Dental Clinic 1, Operative Dentistry and Periodontology, University Hospital Erlangen, Glückstrasse 11 Erlangen, Bavaria 91054, Germany, e-mail “[email protected]”. Address reprint requests to Dr. Pelka. Dr. Altmaier maintains a private practice in general dentistry in Bamberg, Germany. Dr. Petschelt is a professor and the head/chair, Dental Clinic 1, Operative Dentistry and Periodontology, University Hospital Erlangen, Erlangen, Bavaria, Germany. Dr. Lohbauer is an associate professor, Dental Clinic 1, Operative Dentistry and Periodontology, University Hospital Erlangen, Erlangen, Bavaria, Germany.

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Figure 1. Plane specimen before air-abrasion testing.

Surface defects and retention areas of dental structures generally are congenital or iatrogenic. An iatrogenic surface defect may be a result of restorative application and periodontal scaling procedures on a tooth surface, crown or restorative material. Air-polishing systems are used widely for effective removal of staining. APDs can remove plaque but leave the exposed surfaces rougher than before treatment.6,10,11 Treating supragingival root surfaces with abrasive sodium bicarbonate powder may cause substantial substance loss, especially when one considers the cumulative damage resulting from several supportive periodontal treatments per year.12 The use of APDs on root surfaces should be limited owing to the weak resistance to abrasion of root cement and dentin, the accessibility of the subgingival region and the possible risk of an air emphysema caused by the high air pressure created during treatment with an APD.13 In vitro studies showed that a specially developed low-abrasion glycine powder reduced root surface deterioration by limiting the ability to remove supragingival staining. This glycine powder is suitable for removing biofilm on root surfaces up to 4 to 5 millimeters subgingivally.14,15 The purpose of the in vitro study we describe here was to evaluate the influence of different air abrasives on the surface damage and substance loss experienced by different dental restorative materials generally used in the cervical region or as pit-and-fissure sealants. MATERIALS AND METHODS

We manufactured 180 plane specimens (Figure 1) from six different dental restorative materials: 64

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dTetric EvoCeram (Ivoclar Vivadent, Schaan, Liechtenstein); dTetric Flow (Ivoclar Vivadent); dGrandio Flow (VOCO, Cuxhaven, Germany); dAdmira Seal (VOCO); dGrandio Seal (VOCO); dIonofil Molar (VOCO). We prepared the specimens—30 of each restorative material—according to the respective manufacturers’ recommendations16,17 (Table 1) and stored them for 14 days at 100 percent humidity. We then performed parallel grinding using a lapping machine that provided as much as 1,000-grit surface roughness. We mounted the specimens in a sample holder and then treated them with an APD (Prophyflex 3, KaVo Dental, Biberach, Germany) at a working distance of 5 mm for 10 seconds and at a 90˚ angulation. The APD was fixed and could not be moved during abrasion. We used three abrasives: Acclean Air Preventive Powder (sodium bicarbonate powder, Henry Schein, Langen, Germany), Air-Flow Prophylaxis Powder (sodium bicarbonate powder, EMS, Nyon, Switzerland) and ClinPro Prophy Powder (glycine powder, 3M ESPE, Seefeld, Germany). We performed profilometric scanning to quantify the resulting defect depths and volumes of the plane specimens. We carried out the threedimensional (3-D) measurements with a profilometer (Perthometer S3P, Mahr, Göttingen, Germany). We mounted the samples on an X Y cross table, which could be moved in the Y direction with a computer-controlled microstepper motor (step width, 1.25 μm). For each specimen, we scanned 200 tracks (X resolution, 25 μm; Y resolution, 25 μm; Z resolution, 0.5 μm). We added each recorded track (vertical data) to a data file with construction and software we developed (Xpert 5.0.2, Dental Clinic 1, Erlangen, Bavaria, Germany). This file could be displayed as a grey-level picture. We marked the worn area by using a computer mouse, and the program calculated a compensation plane by using the nonworn area. We computed the volume and the maximum defect depth of the treated area of each specimen in relation to this plane. After the wear test, we gold-sputtered specimens in each treatment and material group and judged them qualiABBREVIATION KEY. APDs: Air-polishing devices. SEM: Scanning electron microscope. 3-D: Threedimensional.

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tatively by using a scanning electron microscope (SEM) (Leitz ISI SR 50, Akashi, Tokyo) at different magnifications to determine the mode of wear patterns and the surface morphology. We performed a statistical analysis by using SPSS for Windows 16.0 (SPSS, Chicago). To determine the influences of the abrasives and the dental restorative materials on substance loss, we performed an analysis of variance (ANOVA) of volume loss and defect depth (ANOVA, Bonferroni modified least significant difference [LSD], P < .05). We calculated homogeneous subsets for the materials and the different powders (Tukey B test, P < .05).

TABLE 1

Characteristics of test restorative materials. BRAND NAME

MANUFACTURER

SHADE

LOT NO.

FILLER COMPOSITION

TYPE

Tetric EvoCeram

Ivoclar Vivadent (Schaan, Liechtenstein)

A3

H 35663

75.5 percent weight/54.0 percent volume; d50 *= 0.6 µm†

Nanofilled hybrid composite, prepolymerized fillers

Tetric Flow

Ivoclar Vivadent

A3

J00218

64.6 percent weight/39.7 percent volume; d50 = 0.6 µm

Nanofilled flowable composite

Grandio Flow

VOCO (Cuxhaven, Germany)

A3, A5

610353

80.0 percent weight/65.6 percent volume; d50 = 6 µm

Nanofilled flowable composite

Admira Seal

VOCO

NA‡

602082

55.0 percent weight/43 percent volume

Sealant

Grandio Seal

VOCO

NA

V30667

70.0 percent weight/57.4 percent volume

Sealant

Ionofil Molar

VOCO

A3

610719

50 percent weight; d50 = 6 µm

Glass ionomer cement

* d50: Median diameter. † µm: Micrometer. ‡ NA: Not applicable.

RESULTS

Table 2 presents the results of the 3-D measurements, the volume losses and the maximum defect depths. Table 3 displays the calculated P values (ANOVA, modified LSD) of the defect volumes for the restorative materials in the different air-powder groups. Among the tested materials, Tetric EvoCeram had the smallest defect depth and volume loss. In contrast, Tetric Flow and Grandio Flow had the greatest defect volumes (Table 3, Figure 2, Table 4; page 67). When we compared the abrasive powders, we found that the two sodium bicarbonate powders (Acclean and Air-Flow) caused comparable defect depth and volume loss in the restorative materials. However, ClinPro produced significantly less surface damage than did the other two powders (P < .01) (Table 5, page 68). ClinPro produced a defect depth less than that produced by the sodium bicarbonate powders in Admira Seal (37 to 43 percent less) and in Grandio Flow (74 to 76 percent less). With the two sodium bicarbonate abrasives, the restorative materials all had comparable rankings regarding maximum defect depth and volume loss. Admira Seal exhibited sig-

nificantly less defect depth and volume loss than did the glass ionomer cement and the two flowable composites we tested (Figure 2). When we used the glycine abrasive (ClinPro), the wear ranking of the materials was slightly different. Admira Seal, rather than Tetric EvoCeram, showed the fewest volume defects. The flowable composite Grandio Flow exhibited surface deterioration comparable with that of the glass ionomer cement Ionofil Molar (Figure 2). SEM analysis. Figure 3 (page 69) exhibits the worn surface structures of the materials tested. The SEM investigation at ×1,000 magnification revealed the differences in surface morphologies and showed rough surfaces with exposed or disintegrated fillers, depending on the respective matrix/filler compositions. Tetric EvoCeram (Figure 3A) showed an inhomogeneous surface structure with small disintegrated filler particles but large prepolymerized fillers (20-50 µm) still embedded in the matrix. Grandio Flow (Figure 3C) showed large exposed or disintegrated glass fillers (10 µm) with remaining holes in the composite matrix (arrows). The surface of Admira Seal (Figure 3D) showed some air blisters (arrow) in a mostly homogeneous structure. Grandio Seal (Figure 3E) exhibited small irregular filler particles of up to 5 µm in diameter, and the glassJADA, Vol. 141

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TABLE 2

Means and standard deviations (SDs) of the maximum depth and volume for the restorative materials in the different air-powder groups. POWDER*

Acclean Air Preventive Powder

Air-Flow Prophylaxis Powder

ClinPro Prophy Powder

RESTORATIVE MATERIAL†

NO. OF SPECIMENS

MAXIMUM DEPTH (µm‡)

VOLUME (mm³§)

Mean

SD

Mean

SD

Tetric EvoCeram

10

153.4

31.2

0.19

0.05

Tetric Flow

10

239.5

50.6

0.40

0.11

Grandio Flow

10

304.2

33.7

0.65

0.11

Admira Seal

10

173.6

43.8

0.27

0.05

Grandio Seal

10

212.5

40.8

0.44

0.09

Ionofil Molar

10

198.5

47.9

0.39

0.10

Tetric EvoCeram

10

156.3

59.4

0.21

0.07

Tetric Flow

10

282.6

36.3

0.46

0.08

Grandio Flow

10

326.3

33.2

0.65

0.10

Admira Seal

10

190.8

23.6

0.32

0.05

Grandio Seal

10

232.7

29.8

0.47

0.07

Ionofil Molar

10

234.4

42.7

0.42

0.09

Tetric EvoCeram

10

42.8

13.4

0.05

0.05

Tetric Flow

10

139.2

27.1

0.19

0.02

Grandio Flow

10

78.9

32.0

0.10

0.06

Admira Seal

10

109.1

30.3

0.03

0.07

Grandio Seal

10

117.3

32.8

0.18

0.04

Ionofil Molar

10

85.9

18.7

0.13

0.04

* Acclean Air Preventive Powder is manufactured by Henry Schein, Langen, Germany. Air-Flow Prophylaxis Powder is manufactured by EMS, Nyon, Switzerland. ClinPro Prophy Powder is manufactured by 3M ESPE, Seefeld, Germany. † Manufacturers of restorative materials tested are listed in Table 1. ‡ µm: Micrometers. § mm3: Cubic millimeters.

ionomer Ionofil Molar (Figure 3F) showed embedded glass filler particles of up to 10 µm in diameter. The surface structures correspond to the compositions of the materials tested, which might account for the materials’ differences in resistance to air-powder abrasion. DISCUSSION

Air polishing of fissure sealants and restorative materials generally results in substance loss. The amount of substance loss and the size of the defect depths depend on the abrasive powder applied, the treatment distance, the treatment angulation and the treatment time.18,19 This study design kept the parameters of working distance, treatment angulation (90˚) and treatment time (10 seconds) constant, to allow us to focus on the influence of the restorative materials and applied abrasive powders. To avoid differences caused by dif-

TABLE 3

P values between the mean defect volumes of the restorative materials, according to air-powder groups.* RESTORATIVE MATERIAL TETRIC FLOW POWDER‡ Significance

A

B

C

GRANDIO FLOW A

B

.001 .001 .001 .001 .001

ADMIRA SEAL C

A

B

C

.03

.05

.01

.44

.001 .001 .001 .001 .001 .001

GRANDIO SEAL A

B

RESTORATIVE MATERIAL†

IONOFIL MOLAR C

A

B

C

.001 .001 .001 .001 .001 .001 Tetric EvoCeram .34

.82

.72

.68

.30

.001 .001 .004 .001 .001 .001 .001 .001 .001 .001 .001

.01

.01

.18

.21

.01

Tetric Flow

.23

Grandio Flow

.001 Admira Seal .02

Grandio Seal

* P values calculated by means of analysis of variance Bonferroni modified least significant difference. † Materials’ manufacturers are listed in Table 1. ‡ Powder A: Acclean Air Preventive Powder (Henry Schein, Langen, Germany). Powder B: Air-Flow Prophylaxis Powder (EMS, Nyon, Switzerland). Powder C: ClinPro Prophy Powder (3M ESPE, Seefeld, Germany).

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VOLUME (mm3)

ferent working pressures and powder emission rates, Acclean Prophy Powder we used only one airAir-Flow Prophylaxis Powder 0.80 polishing device (ProClinPro Prophy Powder phyflex 3, KaVo). Thus, the results reflect exclusively the influence of the dif0.60 ferent powders and the materials tested. Air polishing with abrasive powders is related to an abra0.40 sive mechanism different from that associated with common causes of intraoral abrasive wear. 0.20 Usually, investigators test wear resistance to food mastication or in direct contact with antagonistic 0.00 materials to evaluate AdmiraSeal Tetric Grandio Grandio Ionofil Tetric Flow EvoCeram Seal Flow Molar dental restorative RESTORATIVE MATERIAL materials.20-22 It is unknown and requires further investigation as to Figure 2. Box plots depicting the volume loss in cubic millimeters. Horizontal bars represent medians; boxes represent areas; error bars represent the 10th and 90th percentiles. Clearly visible whether standard wear are the differences in defect volumes between ClinPro Prophy Powder (3M ESPE, Seefeld, Germany) test results of dental and the other polishing powders. P values are listed in Tables 3 and 4. mm3: Cubic millimeters. restorative materials TABLE 4 obtained in two-body (chewing simulator) and three-body Statistical subgroups for the restorative (Academic Center for Dentistry Amsmaterials, according to the Tukey B test. terdam wear machine) wear measureRESTORATIVE MATERIALS ments can be correlated to the wear results obtained with air-powder abraMaterial* No. of Mean Volume/Mean Maximum Depth, † According to Homogeneous Subset Specimens sion.23 Investigators perform tests of air 1 2 3 4 5 abrasion caused by air-polishing powTetric 30 0.15/117.5 ders to test the powders’ abrasive EvoCeram effects on natural tooth substances 24 Admira Seal 30 0.21/157.8 such as enamel or root dentin. FurIonofil 30 —‡/172.9 0.31/— thermore, it is unclear whether the use Molar of polishing pastes with rotating rubber Tetric Flow 30 0.35/— 0.35/220.4 cups is clearly less invasive, because Grandio 30 —/187.5 0.37/— the surface roughness of restorative Seal materials may be increased after treatGrandio 30 —/236.5 0.47/— ment with prophylaxis paste, dependFlow 3,24,25 ing on the paste’s abrasiveness. The * Materials’ manufacturers are listed in Table 1. resulting surface roughness, at least on † Means for the groups are displayed on the basis of volume (cubic millimeters)/maximum depth (micrometers), Tukey B test, P = .05. polished surfaces, seems to be compa‡ Dashes indicate data that are not applicable. rable for air abrasive powders and polishing pastes.24,26 Our in vitro design caused 3-D defects, and it was problematic to and Grandio Seal) showed good results, only measure roughness on surfaces that were not flat. slightly inferior to those of Tetric EvoCeram. In our study, sealants with low wear resistance These results suggest that wear caused by air in the occlusal stress-bearing area (Admira Seal abrasion follows principles other than those for 16

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TABLE 5

Statistical subgroups for the air-polishing powders, according to the Tukey B test. AIR-POLISHING POWDERS Powder*

No. of Specimens

Mean Volume/Mean Maximum Depth, † According to Homogeneous Subset 1

ClinPro Prophy Powder

60

Acclean Air Preventive Powder

60

Air-Flow Prophylaxis Powder

60

2

3

0.12/95.5

0.39/213.6

0.42/237.2

* Powders’ manufacturers are listed in Table 2. † Means for the groups are displayed on the basis of volume (cubic millimeters)/maximum depth (micrometers), Tukey B test, with an error probability of P = .01.

occlusal contact or contact-free wear, in which a higher filler content enhances wear resistance.27-29 Tetric EvoCeram showed the best abrasion resistance, mainly owing to its incorporated inhomogenous fillers. Figure 3 shows large prepolymerized fillers (20-50 µm in diameter) that still are integrated after air abrasion, thus preventing extensive surface defects. However, large and insufficiently embedded filler particles generally cause a higher volume loss, as shown for Grandio Flow (Figure 3C). In contrast, the sealant Admira Seal had a lower content of small filler particles (43 percent volume) (Table 1) and showed superior resistance to air-powder abrasion. This might be due to an improved interfacial bonding of the fillers in the inorganic-organic hybrid polymer– based matrix material or to an improved wear resistance of the matrix itself, owing to its high elastic compliance.30,31 This could be one explanation for the improved air-powder abrasion resistance of Admira Seal compared with that of the two flowable composites we tested, Tetric Flow and Grandio Flow. We found the least surface deterioration throughout all restorative materials by using ClinPro Prophy Powder. ClinPro consists of pure glycine, which is an amino acid with a density of 1.59 grams per cubic centimeter32 and a grain size of 50 to 60 µm.33 Acclean Air Preventive Powder and Air-Flow Prophylaxis Powder consist of sodium bicarbonate, which is an inorganic salt of 68

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carbonic acid with a density of 2.22 g/cm3,32 and grain sizes of about 100 µm.34 The lower density and smaller grain size might be a major cause of ClinPro Prophy Powder’s reduced abrasivity. During the air-abrasion procedure, the powder particles are accelerated; owing to their grain size and density, which are smaller and lower, respectively, than those of particles in sodium bicarbonate powders, the glycine particles introduce a reduced kinetic energy on striking the tooth or restorative surface. Therefore, ClinPro’s ability to remove plaque and staining is limited, in contrast with that of the sodium bicarbonate powders, and thus it requires more time to achieve a clean tooth surface. The clinician should consider this increased time consumption (that is, lower efficiency) when comparing the surface damage caused by the different cleaning powders. To achieve supragingival cleaning of stained tooth and restoration surfaces with ClinPro comparable with that achieved with the sodium bicarbonate powders, the clinician must extend the treatment time. Our results showed that restorative materials used for tooth-colored restorations in the cervical, occlusal and anterior regions have different wear resistance to air-powder abrasion. Frequently, restorations are placed in the cervical region to treat noncarious lesions. These restorations might stain over time, and their margins might become discolored.35,36 Although such discolorations can be removed with air polishing, that may add to the localized treatment time and increase the risk of surface substance loss, depending on the restorative material used. One must estimate the risk of staining as clearly higher in the cervical region of the tooth than in the occlusal region. Flowable composites in the cervical region are exposed to a high wear stress because of the large restoration surface and the abrasion caused by air-polishing treatment. If one looks at the area in which clinicians apply sealants and flowable composites, the incidence of frequent air-polishing powder treatments clearly is higher in the cervical region and on vestibular surfaces of the front teeth than it is in the occlusal region. Discoloration more often appears on vestibular and cervical tooth surfaces. In consequence, flowable composites are exposed more frequently to air polishing than are sealants. Our results have shown that flowable composites may suffer from great substance loss as a result of airpolishing treatment with sodium bicarbonate

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A

B

C

D

E

F

Figure 3. Scanning electron microscopic images of the restorative materials tested. All materials showed an abraded rough surface structure that differed according to their composition. A. Tetric EvoCeram (TC) (Ivoclar Vivadent, Schaan, Liechtenstein). B. Tetric Flow (TF) (Ivoclar Vivadent). C. Grandio Flow (GF) (VOCO, Cuxhaven, Germany). The arrows point to large exposed or disintegrated glass fillers with holes in the matrix. D. Admira Seal (AS) (VOCO). The arrow points to an air blister. E. Grandio Seal (GS) (VOCO). F. Ionofil Molar (IM) (VOCO). μm: Micrometers.

abrasives. An abrasive powder based on glycine might be a better choice than a sodium bicarbonate abrasive in Class V restorations. CONCLUSION

The results of our study show that among the restorative materials we tested, flowable composites experienced the greatest surface defects as a result of use of air-polishing powders based on sodium bicarbonate. Repeated air-abrasive treatments of cervical restorations made of flowable composites enhance the risk of substance loss. ■ Disclosure. None of the authors reported any disclosures. 1. Westfelt E. Rationale of mechanical plaque control. J Clin Periodontol 1996;23(3, pt 2):263-267. 2. Schmidlin PR, Sener B, Lutz F. Cleaning and polishing efficacy of abrasive-bristle brushes and a prophylaxis paste on resin composite material in vitro. Quintessence Int 2002;33(9):691-699. 3. Roulet JF, Roulet-Mehrens TK. The surface roughness of restorative materials and dental tissues after polishing with prophylaxis and polishing pastes. J Periodontol 1982;53(4):257-266. 4. Gerbo LR, Barnes CM, Leinfelder KF. Applications of the airpowder polisher in clinical orthodontics. Am J Orthod Dentofacial Orthop 1993;103(1):71-73. 5. Weaks LM, Lescher NB, Barnes CM, Holroyd SV. Clinical evaluation of the Prophy-Jet as an instrument for routine removal of tooth stain and plaque. J Periodontol 1984;55(8):486-488. 6. Barnes CM, Hayes EF, Leinfelder KF. Effects of an air abrasive polishing system on restored surfaces. Gen Dent 1987;35(3):186-189. 7. Teughels W, Van Assche N, Sliepen I, Quirynen M. Effect of material characteristics and/or surface topography on biofilm develop-

ment. Clin Oral Implants Res 2006;17(suppl 2):68-81. 8. García-Godoy F, Hicks MJ. Maintaining the integrity of the enamel surface: the role of dental biofilm, saliva and preventive agents in enamel demineralization and remineralization. JADA 2008;139 (suppl 5):25S-34S. 9. Bollen CM, Lambrechts P, Quirynen M. Comparison of surface roughness of oral hard materials to the threshold surface roughness for bacterial plaque retention: a review of the literature. Dent Mater 1997; 13(4):258-269. 10. Kontturi-Narhi V, Markkanen S, Markkanen H. Effects of airpolishing on dental plaque removal and hard tissues as evaluated by scanning electron microscopy. J Periodontol 1990;61(6):334-338. 11. Eliades GC, Tzoutzas JG, Vougiouklakis GJ. Surface alterations on dental restorative materials subjected to an air-powder abrasive instrument. J Prosthet Dent 1991;65(1):27-33. 12. Petersilka GJ, Bell M, Mehl A, Hickel R, Flemmig TF. Root defects following air polishing. J Clin Periodontol 2003;30(2):165-170. 13. Mather AJ, Stoykewych AA, Curran JB. Cervicofacial and mediastinal emphysema complicating a dental procedure. J Can Dent Assoc 2006;72(6):565-568. 14. Petersilka GJ, Steinmann D, Häberlein I, Heinecke A, Flemmig TF. Subgingival plaque removal in buccal and lingual sites using a novel low abrasive air-polishing powder. J Clin Periodontol 2003;30(4): 328-333. 15. Petersilka GJ, Tunkel J, Barakos K, Heinecke A, Häberlein I, Flemmig TF. Subgingival plaque removal at interdental sites using a low abrasive air-polishing powder. J Periodontol 2003;74(3):307-311. 16. Helvatjoglu-Antoniades M, Papadogiannis Y, Lakes RS, Palaghias G, Papadogiannis D. The effect of temperature on viscoelastic properties of glass ionomer cements and compomers. J Biomed Mater Res B Appl Biomater 2007;80(2):460-467. 17. Lohbauer U, Frankenberger R, Krämer N, Petschelt A. Strength and fatigue performance versus filler fraction of different types of direct dental restoratives. J Biomed Mater Res B Appl Biomater 2006; 76(1):114-120. 18. Petersilka GJ, Schenck U, Flemmig TF. Powder emission rates of four air polishing devices. J Clin Periodontol 2002;29(8):694-698. 19. Petersilka GJ, Bell M, Mehl A, Hickel R, Flemmig TF. Root defects following air polishing. J Clin Periodontol 2003;30(2):165-170.

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