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Introduction: The aim of this case-control study was to examine the relationship between type 2 diabetes mellitus (DM) and the occurrence of VRFs. The crack extension, dentin sclerosis, and chemical characteristics of root dentin in teeth with VRF from patients with/without DM were also compared., Methods: One hundred and thirty-two patients diagnosed with VRF in crowned root filled posterior teeth were selected. The study was conducted in 2 parts. In Part-1: The cases were matched with control teeth (1:1) for age (±5 years), sex, tooth type, apical extent of root filling, time period after root filling to a diagnosis of VRF, presence or absence of intracanal post and abutment status. The presence or absence of type 2 DM (HbA1c > 6.5) was recorded. In Part-2: The extracted teeth with VRF from the case control study were used to evaluate the extension of VRF, presence of sclerotic dentin and isthmus using a microscopic analysis; while the levels of pentosidine, collagen cross-linking ratio and mineral-collagen ratio were determined by Fourier-transform infrared spectroscopy. The distribution of DM between cases and controls was analyzed using Pearson Chi-Square test and Odds Ratio estimated. Chemical composition data was analyzed using Mann-Whitney test. The extent of sclerotic dentin was analyzed using Pearson Chi-Square test., Results: When compared to patients without DM, patients with DM had 2.67 (95% CI: 1.6-4.45) folds higher odds for occurrence of VRF. Pentosidine (P = .014), collagen cross-linking ratio(P = .047), mineral-collagen ratio (P = .009) and sclerotic dentin extent (P = .0009) were significantly higher in patients with DM and VRF., Conclusions: Type 2 DM was more often associated with VRFs in root canal treated teeth with crowns. Root dentin from patients with type 2 DM and VRF had higher levels of pentosidine, collagen cross-linking ratio, mineral to collagen ratio and sclerotic dentin., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

A vertical root fracture (VRF) is a complex condition in which the fracture lines can be partial or complete and extend along the long axis of the tooth. Considering the nature of the damage and the low likelihood of a successful outcome, such fractures can be difficult to manage. Their management typically involves complex endodontic or surgical procedures, which can be technically challenging for general dentists. Recent advancements introduce promising techniques, such as intentional replantation, adhesive methodologies, and regenerative procedures, showcasing potential in salvaging teeth affected by VRFs. Nonetheless, the imprecise nature of symptoms necessitates meticulous case evaluation by clinicians. Comprehensive patient counseling regarding diverse treatment options and potential ramifications remains crucial to preserving the affected tooth. Preserving a vertically fractured tooth aids in improving both function and aesthetics while safeguarding the arch's integrity by maintaining the height of the alveolar bone. It is important to note that the success of the treatment procedures depends on the extent and location of the fracture, the condition of the tooth and fragment, and the skill of the dental professional performing the treatment. This review highlights the complexity of VRF management, emphasizing the necessity for precise evaluation, patient education, and the exploration of innovative techniques. It aims to review the treatment of VRFs, ranging from classical to contemporary methods, with a focus on tooth preservation. The establishment of standardized protocols and conduct of further research to ascertain long-term efficacy are imperative in optimizing outcomes and retaining natural dentition in cases of VRFs.

Acute dental trauma is unscheduled and presents infrequently to the majority of practitioners. Therefore, a consistent, logical and systematic process for examination, prioritisation and management is imperative for all sustained injuries to have an optimal outcome. Fractures are a frequent sequela to dental trauma and can involve any aspect of the tooth structure or supporting alveolar bone. While some minor crown fractures may initially seem inconsequential, they may be a subtle indication to a more serious underlying root fracture. Concomitant injuries and injuries that have been initially missed are generally associated with poorer outcomes. The time sensitive management of traumatic dental injuries aims to preserve pulpal and periodontal health where possible. The follow up period for tooth or alveolar fractures are important to allow for early intervention if pathology develops., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Introduction: The aim of this study was to identify specific clinical signs or symptoms and potential risk factors which are most likely associated with the presence of a vertical root fracture (VRF) in endodontically treated teeth (ETT)., Methods: Electronic databases (MEDLINE via PubMed, EMBASE via Ovid, Scopus, and Web of Science) were searched by 2 reviewers in October 2022 for clinical studies, in which at least either the clinical presentation or potential risk factors associated with a VRF were assessed. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of odds ratios (ORs) were performed separately for several signs or symptoms and risk factors., Results: Fourteen sources reporting on 2877 teeth (489 with VRF and 2388 without VRF) were included in the meta-analyses. Regarding the clinical presentation, the presence of sinus tracts (OR = 4.87; 95% confidence interval [CI], 1.58-15.0), increased periodontal probing depths (OR = 13.24; 95% CI, 5.44-32.22), swelling/abscess (OR = 2.86; 95% CI, 1.74-4.70), and tenderness to percussion (OR = 1.76; 95% CI, 1.18-2.61) were significantly associated with the presence of a VRF (P adj. value < .05). None of the assessed risk factors (sex, type of teeth, tooth location, posts, indirect restoration, and apical extension of the root canal filling) were found to be significantly associated with the presence of a VRF (P adj. value > .05)., Conclusions: Four clinical presentations were identified to be the most significant signs or symptoms for a VRF in ETT: presence of sinus tracts, increased probing depths, swelling/abscess, and tenderness to percussion. None of the assessed risk factors pointed out to be significantly associated with a VRF., Registration: CRD42022354108 (PROSPERO)., (Copyright © 2023 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

The present study reported a method for inducing incomplete root fracture in human extracted teeth for the purpose of evaluating the merits of different diagnostic imaging techniques. Thirty-five single-rooted teeth were inspected under magnification and transillumination to exclude previously fractured teeth. Tooth crowns were removed, and the root canals were prepared up to the ProTaper Next X4 (40.06) file. Each root was lined with wax and embedded in a polystyrene resin block. The setup was attached to a universal testing machine for pressing a customized conical wedge (diameter at tip: 0.6 mm; taper: 0.2 mm/mm) into the instrumented canal with a 2 kN load at 5 mm/min. The machine was programmed to stop after a sudden 10% drop in loading force. Each specimen was removed from the resin block and inspected under × 20 magnification and transillumination to identify the fracture characteristics (pattern, surfaces and root-third affected). The gap width of each specimen was measured at different locations along the fracture line. The protocol induced incomplete vertical root fractures in all specimens. Fracture widths were < 100 μm in all specimens (mean gap width: 34.9 μm). The proposed methodology was successful in inducing incomplete vertical root fractures with characteristics that resemble the clinical presentation of these conditions. The method is easy to execute, highly reproducible and helps to minimize bias in laboratory studies that aims to mimic vertical root fractures., (© 2023. The Author(s), under exclusive licence to The Society of The Nippon Dental University.)

Examining the nature of stress distribution within the intact tooth can aid in understanding how natural tooth structures are able to resist mechanical forces during masticatory function. Identification of potential fractures in teeth on clinical examination is essential for correct diagnosis, particularly if there is pulpal involvement. This discussion will consider the different types of fracture, their identification and management. This paper will highlight management of tooth fractures, including identifying prognostic indicators, which are largely dependent on the extent of the fracture within the tooth structure.

Autotransplantation of teeth is a considerable option for tooth replacement in adults who are to undergo orthodontic treatment. Being compared with dental implantation, this procedure is more preferable as a grafted tooth functions as a normal one. In this case report, we describe successful autotransplantation of the third molar with complete root formation. To provide better adaptation of the donor tooth, we used its preoperatively printed replica. The donor tooth was immediately placed to the recipient site and splinted for 28 days. Endodontic treatment was initiated 2 weeks after transplantation. Clinical and radiographic findings at 6 and 12 months of follow-up are compared with the results described in the literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Traumatic oral injuries in children involve trauma to the dentition and the surrounding oral soft tissue structures. They usually present as an emergency hence their management poses a challenge globally. Treatment of a tooth fracture, displacement or loss is determined by the type and severity of the injury independent of the etiology. It necessitates the experience for behavior management in a child, ascertaining a patient centered diagnosis, formulating a definitive treatment plan, explanation and consent of oral care to the parents or carer with optimal operator skills. This article provides an overview on the types of oral injury in a child patient, their recognition, diagnosis and management based on credible, practical and readily understandable evidence.

Background: Root fractures are not a common injury, but a thorough understanding of their etiology, healing responses, diagnosis, management, and prognosis is essential., Review: The prognosis is largely related to the patient's age; degree of displacement, if any, of the coronal fragment; and the location and orientation of the fracture. The more apical the fracture is located, the better the prognosis. Teeth with root fractures located supracrestally may have the worst prognosis, but their management and outcome depend on many factors, with the most influential factor being the ability to restore the tooth because the coronal fragment usually needs to be removed. In contrast, root fractures located in the apical and middle thirds and those subcrestally in the coronal third of the root have a good prognosis and usually require little, if any, treatment apart from immediate repositioning (if the coronal fragment has been displaced) and stabilization. Monitoring of root-fractured teeth over time is essential to determine the healing response and to assess whether the pulp survives or not. In some cases, the pulp in the coronal fragment may necrose and become infected, thus requiring root canal treatment, but this should only be done to the fracture line. Pulp necrosis and infection typically occur within the first 3-4 months if it is a direct result of the trauma. However, pulp necrosis and infection can also occur many years later, in which case it is likely to be a result of bacterial penetration via cracks or breakdown of restorations., Conclusion: Overall, root fractures should be managed conservatively unless they are located supracrestally., (© 2019 John Wiley & Sons A/S and American Association of Endodontists.)

Periapical and bitewing radiographs lack the sensitivity to reliably diagnose horizontal root fractures, and, therefore, asymptomatic teeth with root fractures may remain undetected for years. This article reports a case in which a patient presented with a mucogingival defect on tooth No. 24 with no apparent history of dental trauma. During a free gingival graft procedure, a horizontal root fracture was observed in the apical third of the aforementioned tooth. After the clinician communicated this finding to the patient, the patient recollected two instances of trauma that had occurred to this area more than 30 years earlier. The presence of the horizontal root fracture did not affect the postoperative healing from the mucogingival procedure, and the tooth remained stable at the 1-year follow-up.

A 23 year old male patient was submitted to surgical assisted rapid maxillary expansion (SARME). There were any postoperative complications until the finish of orthodontic expansion process. However, in the 30th postoperative day, patient mentioned pain in upper central incisor. Periapical radiography evidenced a root fracture of central upper right incisor. After endodontic treatment, the fractured apex was removed. After 3 years of follow-up, the patient finished orthodontics, and the damaged tooth was in good aspect. Apical fracture is an unexpected complication of SARME. However, follow-up and correct treatment lead to a good prognosis for tooth maintenance.

Introduction: This study evaluated the image quality and the diagnosis of root fractures when using the Zoom Reconstruction tool (J Morita, Kyoto, Japan)., Methods: A utility wax phantom with a metal sample inside was used for objective evaluation, and a mandible with 27 single-rooted teeth (with and without obturation and with and without vertical or horizontal fractures) was used for diagnostic evaluation. The images were acquired in 3 protocols: protocol 1, field of view (FOV) of 4 × 4 cm and a voxel size of 0.08 mm; protocol 2, FOV of 10 × 10 cm and a voxel size of 0.2 mm; and protocol 3, Zoom Reconstruction of images from protocol 2 (FOV of 4 × 4 cm and a voxel size of 0.08 mm). The objective evaluation was achieved by measuring the image noise, and the diagnosis of fractures was performed by 3 evaluators. The area under the receiver operating characteristic curve was used to calculate accuracy, and analysis of variance compared the accuracy and image quality of the protocols., Results: Regarding quality, protocol 1 was superior to protocol 2 (P < .0001) and Zoom Reconstruction (P < .0001). Additionally, images of protocol 2 presented less noise than the Zoom Reconstruction image (P < .0001); however, for diagnosis, Zoom Reconstruction was superior in relation to protocol 2 (P = .011) and did not differ from protocol 1 (P = .228) for the diagnosis of a vertical root fracture in filled teeth., Conclusions: The Zoom Reconstruction tool allows better accuracy for vertical root fracture detection in filled teeth, making it possible to obtain a higher-resolution image from a lower-resolution examination without having to expose the patient to more radiation., (Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Objectives: The objective of this study was to determine which patient traits, behaviors, external tooth and/or crack characteristics correlate with the types of symptoms that teeth with visible cracks exhibit, namely pain on biting, pain due to cold stimuli, or spontaneous pain., Methods: Dentists in the National Dental Practice-Based Research Network enrolled a convenience sample of subjects each of whom had a single, vital posterior tooth with at least one observable external crack (cracked teeth); 2858 cracked teeth from 209 practitioners were enrolled. Data were collected at the patient-, tooth-, and crack-level. Generalized estimating equations were used to obtain significant (p < .05) independent odds ratios (OR) associated with teeth that were painful for 10 outcomes based on types of pain and combinations thereof., Results: Overall, 45% of cracked teeth had one or more symptoms. Pain to cold was the most common symptom, which occurred in 37% of cracked teeth. Pain on biting (16%) and spontaneous pain (11%) were less common. Sixty-five percent of symptomatic cracked teeth had only one type of symptom, of these 78% were painful only to cold. No patient-, tooth- or crack-level characteristic was significantly associated with pain to cold alone. Positive associations for various combinations of pain symptoms were present with cracks that: (1) were on molars; (2) were in occlusion; (3) had a wear facet through enamel; (4) had caries; (5) were evident on a radiograph; (6) ran in more than one direction; (7) blocked transilluminated light; (8) connected with another crack; (9) extended onto the root; (10) extended in more than one direction; or (11) were on the distal surface. Persons who were <65 yo or who clench, grind, or press their teeth together also were more likely to have pain symptoms. Pain was less likely in teeth with stained cracks or exposed roots, or in non-Hispanic whites., Conclusions: Although pain to cold was the most commonly noted pain associated with symptomatic cracked teeth, no patient-, tooth- or crack-level characteristic was significantly associated with pain to cold alone. Characteristics were only associated with pain on biting and/or spontaneous pain with or without pain to cold., Clinical Significance: Although often considered the most reliable diagnosis for a cracked tooth, pain on biting is not the most common symptom of a tooth with a visible crack, but rather pain to cold., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Spontaneously catastrophic fracture of intact unrestored molar teeth is not common. Nevertheless, cracks do occur that progress apically, resulting in the complete splitting of the tooth and root. This report describes a catastrophic fracture that occurred in an unrestored mandibular second molar resulting in a previously unreported combination of a longitudinal and horizontal root fracture, appearing radiographically as a single horizontal root fracture., Methods: Tooth fragments were examined clinically, stereoscopically, and by scanning electron microscopy. Fractographic analysis was used to investigate the dynamics involved in fracture initiation, structural resistances encountered during progression of the fracture, and reasons for direction changes culminating in the unusual radiographic appearance., Result: The uniqueness of this report is that it describes fractographic evidence of factors contributing to the initiation and progression of an in vivo crack. It shows fracture markings that are evidence of the energy dissipation mechanisms. The topographic location of these markings confirmed that cracks occur in vivo in stages with different rates of progression., Conclusion: This analysis helps to explain why split teeth are uncommon and highlights some of the multitude of factors that have to coincide for a tooth to catastrophically fracture. The report describes the mechanism of fracture and should stimulate clinicians and researchers to investigate cracking of teeth by undertaking fractographic analysis of extracted cracked teeth., (Copyright © 2017 American Association of Endodontists. All rights reserved.)

Diagnosing vertical root fracture (VRF) is difficult. Here, we retrospectively investigated the duration from initial symptoms to a definite diagnosis of VRF in dental offices. Data were collected on patients with VRF between July 2013 and June 2015. Initial symptoms were ascertained from clinical records. The focus was on the maxillary second premolars and mesial roots of the mandibular first molars, where VRF is most frequent. All VRF in the bilateral dentition was analyzed. Only cases in which the buccal-lingual plane of the root was fractured were included. Data from 31 dental offices revealed a total of 39 VRFs in the maxillary second premolars and 43 in the mandibular mesial roots of the first molars. The patients comprised 42 males and 40 females, and the average age was 59.7±11.6 years at initial onset of symptoms. The mean duration from initial symptoms to a definite diagnosis in the maxillary second premolars was 18.3±22.5 months, while that in the mandibular first molars was 16.1±17.8 months. The cumulative diagnostic rate was 48.7% at 12 months and 79.5% at 24 months in the maxillary second premolars, and 38.1% at 12 months and 86.0% at 24 months in the mandibular first molars. No significant difference was observed between tooth type. If VRF is suspected, doctors should explain the risks of tooth extraction and begin considering treatment options. The present results revealed that 80% of VRFs were diagnosed within 2 years of initial onset of symptoms.

Asymptomatic vertical enamel and dentin cracks can lead to multiple pathologic consequences ranging from caries to pulpal involvement, periodontal involvement, complete tooth fracture, and tooth loss if intervention is postponed. Early diagnosis, using magnification, tactile examination, transillumination, and dyes, and early restorative and occlusal treatments can be incorporated into daily practice to prevent further crack propagation before asymptomatic cracks become symptomatic and cause further damage to the dentition and surrounding tissues. This article reviews the rationales and presents a systematic approach for early diagnosis and treatment of asymptomatic vertical enamel and dentin cracks based on current evidence.

Tetanus is a life-threatening clinical syndrome that commonly presents with muscular spasms, rigidity, and autonomic instability. It is considered rare in industrialized countries, and tetanus occurring secondary to dental abscesses, procedures, or infections has been infrequently reported. We describe the case of a patient inadequately immunized for tetanus, who presented to the emergency department with muscular spasms, rigidity, and autonomic instability in the setting of an odontogenic infection. A clinical diagnosis of tetanus was made and subsequently managed successfully.

Traumatic injuries to the primary dentition present special problems and the management is often different as compared with the permanent dentition. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialities were included in the task group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care for management of primary teeth injuries. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the guidelines, but believe that their application can maximize the chances of a positive outcome.

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

Aim: To investigate how the exposure parameters used when producing CBCT scans affect diagnostic accuracy when detecting simulated vertical root fractures and how various filling materials affect image quality., Methodology: A total of 160 extracted single-rooted human teeth were divided into four groups based on the materials within the root canals: unrestored, gutta-percha, metallic post and fibreglass post. Half of the sample of each group was selected for the induction of vertical root fractures. Each tooth was placed in an empty socket of a dry skull which was scanned on a CBCT unit (9000 3D scanner; Kodak Dental Systems, Carestream Health, Rochester, NY, USA) using the following exposure parameters: 74 kV/12 mA; 74 kV/10 mA; 74 kV/8 mA; 74 kV/6.3 mA; 70 kV/12 mA; 70 kV/10 mA; 70 kV/8 mA; 70 kV/6.3 mA. Two observers assessed all images using a 5-point confidence scale for fracture detection and a 4-point score for the presence of artefacts. Sensitivity, specificity, accuracy and area under ROC curve were compared by two-way anova and Tukey's test. Artefact formation was evaluated by descriptive statistics., Results: There were no significant differences in the sensitivity (P = 0.370), specificity (P = 0.660), accuracy (P = 0.084) and area under the ROC curve (P = 0.674) values amongst the various exposure parameters within the same group. There were some significant differences when the groups were compared for each intracanal material. The sensitivity and accuracy of the group containing metallic posts were significantly lower than the unrestored and fibreglass post groups (P ≤ 0.017)., Conclusion: The variations in exposure parameters did not interfere with the diagnosis of vertical root fractures, independent of the root canal restorative status. Metallic posts were associated with greater artefact formation and compromised the diagnostic performance. It is possible to decrease the kVp/mA settings to reduce the probability of biological effects due to radiation, without losing diagnostic accuracy., (© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Background: Cracked teeth are ubiquitous in the adult dentition. The objective of this study was to determine which patient traits and behaviors and external tooth and crack characteristics correlate with cracked teeth being symptomatic., Methods: Dentists in The National Dental Practice-Based Research Network enrolled a convenience sample of patients each with a single, vital posterior tooth with at least 1 observable external crack in this observational study; they enrolled 2,975 cracked teeth from 209 practitioners. The authors collected data at the patient level, tooth level, and crack level. They used generalized estimating equations to obtain significant (P < .05) independent odds ratios (OR) associated with teeth that were symptomatic for a crack., Results: Characteristics positively associated with cracked tooth symptoms, after adjusting for demographics, included patients who clenched, ground, or pressed their teeth together (OR, 1.30; 95% confidence interval [CI], 1.12-1.50), molars (OR, 1.58; 95% CI, 1.30-1.92), teeth with a wear facet through enamel (OR, 1.22; 95% CI, 1.01-1.40), carious lesions (OR, 1.31; 95% CI, 1.07-1.60), cracks that were on the distal surface of the tooth (OR, 1.31; 95% CI, 1.13-1.52), and cracks that blocked transilluminated light (OR, 1.31, 95% CI, 1.09-1.57). Teeth with stained cracks were negatively associated with having cracked tooth symptoms (OR, 0.68; 95% CI, 0.55-0.84)., Conclusions: The greatest likelihood of a cracked tooth being symptomatic was found when patients reported clenching or grinding their teeth and had a molar with a distal crack that blocked transilluminated light., Practical Implications: This information can help inform dentists in the decision-making process regarding the prognosis for a cracked tooth., (Copyright © 2017 American Dental Association. Published by Elsevier Inc. All rights reserved.)

A growing problem in dentistry is complications associated with failing amalgam restorations that have been in place for many years. At present, there is a wide variety of treatment options available in the clinician’s armamentarium when this situation arises, however, without the correct diagnosis, the prognosis for the tooth may quickly diminish, despite the clinician’s best efforts. A confusing array of symptoms and failures may confound even the most experienced dentist, which will inevitably lead to invasive and time consuming approaches in a desperate attempt to rectify the initial problem. This paper, the first part of a three-part series, discusses the possible aetiological factors responsible for restoration failure, including occlusal issues and cracks within the tooth structure. The second part of the series will focus on restorative options and root-treated teeth. The third, and final, part of the series will provide an overview of the previous papers and conclude with a case report. Clinical relevance: Failure of amalgam restorations is a commonly encountered clinical problem in general practice and no one case presents in the same way. A competent diagnosis regarding the occlusion and tooth structure, followed with implementation of the most appropriate, minimally invasive treatment option, requires an adequate knowledge of current literature.

The aim of this study was to nondestructively analyze enamel crack behavior on different areas of teeth using 3D swept source-optical coherence tomography (SS-OCT). Ten freshly extracted human teeth of each type on each arch ( n = 80 teeth) were inspected for enamel crack patterns on functional, contact and nonfunctional, or noncontact areas using 3D SS-OCT. The predominant crack pattern for each location on each specimen was noted and analyzed. The OCT observations were validated by direct observations of sectioned specimens under confocal laser scanning microscopy (CLSM). Cracks appeared as bright lines with SS-OCT, with 3 crack patterns identified: Type I - superficial horizontal cracks; Type II - vertically (occluso-gingival) oriented cracks; and Type III - hybrid or complicated cracks, a combination of a Type I and Type III cracks, which may or may not be confluent with each other. Type II cracks were predominant on noncontacting surfaces of incisors and canines and nonfunctional cusps of posterior teeth. Type I and III cracks were predominant on the contacting surfaces of incisors, cusps of canines, and functional cusps of posterior teeth. Cracks originating from the dental-enamel junction and enamel tufts, crack deflections, and the initiation of new cracks within the enamel (internal cracks) were observed as bright areas. CLSM observations corroborated the SS-OCT findings. We found that crack pattern, tooth type, and the location of the crack on the tooth exhibited a strong correlation. We show that the use of 3D SS-OCT permits for the nondestructive 3D imaging and analysis of enamel crack behavior in whole human teeth in vitro. 3D SS-OCT possesses potential for use in clinical studies for the analysis of enamel crack behavior.

Background: Vertical root fracture (VRF) requires root removal. Diagnostics for proper identification are critical. The author conducted a study to relate subjective, objective, and radiographic findings for VRF identification. They noted visual changes of root and overlying bone patterns after flap reflection., Methods: The author examined a case series of roots with suspected VRF after flap reflection and root or root-end removal; 42 roots were identified with a fracture. Before reflection, the author obtained diagnostic and periapical radiographic data that included symptoms, soft-tissue changes, percussion, mobility, probing patterns, and radiographic findings. After flap reflection, the author evaluated bony changes and root surfaces. VRF was visually confirmed after tooth or root removal., Results: Signs and symptoms diagnostic of VRF were inconsistent. All patients had endodontic therapy, many with posts, and for all patients, the pain was none to mild. In addition, the author found a history or presence of swelling (77%) or sinus tract (31%), that probing patterns differed (narrow-rectangular 66%), and that there was no defect in some patients (21%). Radiographic patterns varied from no change to extensive bone loss, and mobility ranged from none (55%) to slight or moderate (45%). Flap reflection revealed a "punched-out" bony lesion with granulomatous tissue (100%), and patterns were fenestration (21%) or dehiscence (79%). A fracture was visible on roots or resected root ends., Conclusions: The author found no consistent signs, symptoms, or radiographic changes of VRF. Flap reflection was found to be predictably useful; fractured roots had bony defects filled with granulomatous tissue., Practical Implications: VRF may be suspected from clinical findings; however, flap reflection is usually required for identification. Characteristic bony pattern and root visualization reveals the fracture, although root-end resection and examination is occasionally required., (Copyright © 2017 American Dental Association. Published by Elsevier Inc. All rights reserved.)

The goal of this study was to investigate length of time between full pulpotomy and a definitive diagnosis of vertical root fracture (VRF), as well as the age at which this was made. The participants comprised 63 dental patients (40 men and 23 women) with a mean age of 65.7±10.4 years in whom a definitive diagnosis of VRF had been made between July 2013 and June 2015, and who had also undergone a full pulpotomy. The data on all these cases were obtained from 22 dental clinics belonging to a clinical study group. The mean duration between a full pulpotomy and a definitive diagnosis of VRF was 141.0±88.9 months. The results showed no differences in terms of sex, mandible/maxilla, or tooth type. No relationship was observed between age at which the diagnosis was made and length of time between full pulpotomy and diagnosis (Pearson correlation coefficient = 0.162) (p>0.05). Most diagnoses of VRF were made in patients aged over 50 years, irrespective of length of time between full pulpotomy and the diagnosis. These results suggest that age is a stronger indicator of VRF than length of time between full pulpotomy and a definitive diagnosis.

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

Traumatic injuries to the primary dentition present special problems and the management is often different as compared with the permanent dentition. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialities were included in the task group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care for management of primary teeth injuries. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the guidelines, but believe that their application can maximize the chances of a positive outcome.

Introduction: The purpose of this study was to examine different patient- and treatment-related factors associated with the time of presentation of vertical root fractures (VRFs) in endodontically treated teeth restored with crowns., Methods: One hundred ninety-seven root-filled, crowned teeth with no post and suspected of VRFs were included in the study. Patient details with relevance to endodontic treatment and clinical signs/symptoms were documented, and radiographs were taken. A diagnosis of a VRF was confirmed after surgical flap elevation. Frequency distributions were determined, and statistical analyses were performed using Pearson chi-square analysis, Fisher exact test, cross tabulation, Pearson correlation, and multiple logistic regression., Results: Mandibular molars (34%) and maxillary premolars (22.8%) were the most frequently affected teeth. The postoperative time to the diagnosis of a VRF was 4.35 (±1.96) years. Female patients, posterior teeth, overfilled canals, and patients older than 40 years were associated with the presentation of VRFs within 5 years of the postoperative period. Clinical findings most frequently observed were pain on percussion (60%), pain on palpation (62%), presence of a deep narrow pocket (81%), and sinus tract/swelling (67%). "Halo"-type radiolucency (48.7%) was the most common radiographic feature related to VRFs., Conclusions: Pain on palpation/percussion, deep narrow pocket, sinus tract, and halo-type radiolucency are characteristic features of VRFs. Posterior teeth, overfilled canals, female patients, and older patients (>40 years) presenting with the previously described clinical features in endodontically treated teeth restored with crowns are more likely to present with VRFs within 5 years postoperatively., (Copyright © 2016 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Statement of Problem: Conventional dental diagnostic aids based upon imagery and patient symptoms are at best only partially effective for the detection of fine structural defects such as cracks in teeth., Purpose: The purpose of this clinical study was to determine whether quantitative percussion diagnostics (QPD) provided knowledge of the structural instability of teeth before restorative work begins. QPD is a mechanics-based methodology that tests the structural integrity of teeth noninvasively., Material and Methods: Eight human participants with 60 sites needing restoration were enrolled in an institutional review board-approved clinical study. Comprehensive examinations were performed in each human participant, including QPD testing. Each site was disassembled and microscopically video documented, and the results were recorded on a defect assessment sheet. Each restored site was then tested using QPD. The normal fit error (NFE), which corresponds to the localized defect severity, was correlated with any pretreatment structural pathology., Results: QPD agreed with clinical disassembly in 55 of 60 comparisons (92% agreement). Moreover, the method achieved 98% specificity and 100% sensitivity for detecting structural pathologies found later upon clinical disassembly. Overall, the NFE was found to be highly predictive of advanced structural pathology., Conclusions: The data from the present in vivo study support the hypothesis that QPD can provide the clinician with advance knowledge of the structural instability of teeth before restorative work begins., (Copyright © 2016 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.)

The management of adult dental trauma can be a daunting challenge for practitioners at any level. Like medical emergencies, initial management can have a large influence on prognosis. It is important that practitioners understand the basic principles of managing the acute presentations of dental trauma. This article aims to illustrate a step-by-step approach in order to improve the management within general dental practice for better outcomes for patients.

The aim of this review was to evaluate whether CBCT is reliable for the detection of root fractures in teeth without root fillings, and whether the voxel size has an impact on diagnostic accuracy. The studies published in PubMed, Web of Science, ScienceDirect, Cochrane Library, Embase, Scopus, CNKI and Wanfang up to May 2014 were the data source. Studies on nonroot filled teeth with the i-CAT (n = 8) and 3D Accuitomo CBCT (n = 5) units were eventually selected. In the studies on i-CAT, the pooled sensitivity was 0.83 and the pooled specificity was 0.91; in the 3D Accuitomo studies, the pooled sensitivity was 0.95 and pooled specificity was 0.96. The i-CAT group comprised 5 voxel size subgroups and the 3D Accuitomo group contained 2 subgroups. For the i-CAT group, there was a significant difference amongst the five subgroups (0.125, 0.2, 0.25, 0.3 and 0.4 mm; P = 0.000). Pairwise comparison revealed that 0.125 mm voxel subgroup was significantly different from those of 0.2, 0.25 and 0.3 mm voxel subgroups, but not from the 0.4 mm voxel subgroup. There were no significant differences amongst any other two subgroups (by α' = 0.005). No significant difference was found between 0.08 mm and 0.125 mm voxel subgroups (P = 0.320) for the 3D Accuitomo group. The present review confirms the detection accuracy of root fractures in CBCT images, but does not support the concept that voxel size may play a role in improving the detection accuracy of root fractures in nonroot filled teeth., (© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Introduction: This study aimed to report a possible effect of the presence of an adjacent implant on the development of a vertical root fracture (VRF) in endodontically treated teeth., Methods: A series of 8 cases in 7 patients with teeth diagnosed with VRF after the placement of implants in the adjacent area is described and analyzed. In addition, a comprehensive literature search with strict inclusion and exclusion criteria was undertaken to identify additional clinical studies that assessed this clinical scenario., Results: The case series analysis revealed that the time from implant placement to the diagnosis of VRF was between 5 and 28 months (average = 11 months). The majority of cases occurred in female patients who received 2 or more implants. Six of the 7 patients were older than 40 years, with an average age of 54 years. The majority of teeth with VRF were premolar or mandibular molar teeth (6/8 teeth). All fractured teeth had been restored with a crown and had a post present, and the quality of the root canal filling was determined to be adequate. The systematic review revealed that implant-associated VRF has not been investigated or reported in the literature yet., Conclusions: Based on a systematic review of the literature, this case series, although limited in its extent, is the first clinical report of a possible serious adverse event of implant-associated VRF in adjacent endodontically treated teeth. Additional clinical studies are indicated to shed light on this potential phenomenon., (Copyright © 2016 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Aim: To evaluate the influence of an artefact reduction algorithm (ARA) and several root filling materials on the detection of root fractures on cone-beam computed tomography (CBCT) images., Methodology: Forty-four teeth were divided into control and fractured groups and scanned on a Picasso Trio CBCT device under four conditions: unrestored, filled with gutta-percha cones, cast-gold or fibreglass posts; either with or without applying the ARA. Three calibrated examiners assessed the images. ROC analysis, anova and pairwise Tukey LSD test were performed., Results: No significant difference between the groups with and without the ARA was observed. There was no significant interaction between the algorithm and root condition. On the other hand, there was a significant difference in the mean values of sensitivity (Sn) and accuracy (Ac) amongst the different root filling groups (P ≤ 0.001)., Conclusions: The application of the ARA did not influence the diagnosis of root fractures, and its effects did not depend on root conditions. In relation to the filling materials, gold posts reduced the overall CBCT diagnostic ability, regardless of the use of the ARA., (© 2015 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Background: The aim of this study was to investigate dental disorders of brown howler monkeys maintained in captivity. The hypothesis is that the identification and diagnosis of the lesions may contribute to control and prevention., Methods: Sixteen intact brown howler monkeys (Alouatta guariba clamitans), eight females and eight males, weighing from 3.9 to 6.8 kg, were studied. Under general anesthesia, the teeth were evaluated by visual inspection, probing, palpation, and intra-oral radiographic exam. The findings were registered on a dental chart specific for primates., Result: Of the 16 monkeys evaluated in the present study, 94% (n = 15) had some type of dental disorder. The lesions observed were dental calculus (88%), dental wear (81%), missing teeth (38%), gingivitis (19%), gingival recession (6%), dental fracture (19%), pulp exposure (19%), and dental staining (25%)., Conclusions: Alouatta guariba clamitans maintained in captivity have a high rate of dental problems., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The ability to accurately detect tooth cracks and quantify their depth would allow the prediction of crack progression and treatment success. The aim of this in vitro study was to determine the capabilities of quantitative light-induced fluorescence (QLF) technology in the detection of enamel cracks., Methods: Ninety-six extracted human teeth were selected for examining naturally existing or suspected cracked teeth surfaces using a photocuring unit. QLF performed with a digital camera (QLF-D) images were used to assess the ability to detect enamel cracks based on the maximum fluorescence loss value (ΔFmax, %), which was then analyzed using the QLF-D software. A histologic evaluation was then performed in which the samples were sectioned and observed with the aid of a polarized light microscope. The relationship between ΔFmax and the histology findings was assessed based on the Spearman rank correlation. The sensitivity and specificity were calculated to evaluate the validity of using QLF-D to analyze enamel inner-half cracks and cracks extending to the dentin-enamel junction., Results: There was a strong correlation between the results of histologic evaluations of enamel cracks and the ΔFmax value, with a correlation coefficient of 0.84. The diagnostic accuracy of QLF-D had a sensitivity of 0.87 and a specificity of 0.98 for enamel inner-half cracks and a sensitivity of 0.90 and a specificity of 1.0 for cracks extending to the dentin-enamel junction., Conclusions: These results indicate that QLF technology would be a useful clinical tool for diagnosing enamel cracks, especially given that this is a nondestructive method., (Copyright © 2016 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

Lesions of nonendodontic origin, such as nasopalatine or globulomaxillary cysts, may mimic periapical radiolucencies associated with pulpal pathosis, and incorrect diagnosis may lead to unnecessary endodontic treatment. Horizontal root fractures most commonly affect the maxillary central and lateral incisors. Prognosis depends largely on the level of fracture; fractures in the apical third have the best prognosis, and those in the cervical third have the worst. This case report discusses surgical and restorative management of a patient who had a nasopalatine cyst that had been misdiagnosed and treated as an endodontic lesion of the maxillary right central incisor as well as a midroot horizontal fracture of the adjacent lateral incisor.

Background: Previous studies focused on the dental caries status of East African children and not on their overall dental needs. Urban children consume more sugar-rich foods., Objectives: To assess overall dental treatment needs of children living in an orphanage in Uganda., Study Design: Teeth were diagnosed as needing treatment by obvious frank carious lesions (WHO criteria), temporary fillings, staining, or very deep pit and/or fissures possibly requiring sealants. Calculus or crowding in the mandibular anterior region and evidence of tooth fractures were recorded, as were signs of wear on the mandibular molars and canines and the maxillary incisors., Results: Most of the primary teeth (64%) required no dental treatment, but almost all (98%) of the permanent teeth did. A mean (±standard deviation) of 4.81±1.92 permanent teeth required treatment. The mean number of missing teeth was 0.47. Thirty-one children (20.2%) had crowding, 52 (34%) had calculus, and 49 (32%) had signs of attrition on primary and permanent molar teeth (45 enamel only and 4 enamel and dentin)., Conclusions: Most of the primary teeth required no dental treatment, while the vast majority of permanent teeth did, possibly in association with high sugar cane consumption and poor brushing habits among older children.

Dental tooth restorative procedures may weaken the structural integrity of the tooth, with the possibility of leading to fracture. In this study we present findings of coronal dentin strength after different techniques of surface modification. The fracture strength of dentin beams after superficial material removal with a fine diamond bur high speed drill hand piece, Er:YAG (2.94 μm, 8 J/cm(2)), and Er,Cr:YSGG (2.78 μm, 7.8 J/cm(2)) laser irradiation slightly above the ablation threshold was measured by a four-point bending apparatus. Untreated dentin beams served as a control. A total of 58 dentin beams were manufactured from sterilized human extracted molars using the coronal part of the available dentin. Mean values of fracture strength were calculated as 82.0 ± 27.3 MPa for the control group (n = 10), 104.5 ± 26.3 MPa for high speed drill treatment (n = 10), 96.1 ± 28.1 MPa for Er,Cr:YSGG laser irradiation (n = 20), and 89.1 ± 36.3 MPa for Er:YAG laser irradiation (n = 18). Independent Student's t-tests showed no significant difference between each two groups (p > 0.05). Within the parameter settings and the limits of the experimental setup used in this study, both lasers systems as well as the high speed drill do not significantly weaken coronal dentin after surface treatment.

The timeliness of treatment after dental trauma is crucial to successful tooth preservation. This article focuses on the emergency treatment of common forms of dental trauma in athletes, both at the site of the injury and at the dental office. When dental injuries happen to young patients, saving the tooth is an absolute priority, because few long-term replacement solutions can be performed in a growing child. Preserving pulpal vitality of immature teeth is essential to allow continued root development.

Aim: To determine to which extent cavity preparation and each step of dentine removal in the process of root canal treatment (access cavity preparation and root canal enlargement) both individually and jointly contribute to the weakening of the tooth., Methods: Numerical analysis using finite element method (FEM) of separate and combined influence of two-surface Class II preparation and root canal treatment was undertaken to evaluate the decrease in tooth strength. The influence of the two stages in root canal treatment, access cavity preparation and root canal enlargement, was also analysed separately and jointly. After each of these phases, the crown was restored with composite resin, and the FEA was performed only on restored teeth. To estimate the influence of all these procedures on tooth fracture resistance numerically, a Failure Index based on the maximum principal stress criterion (MPCS) was applied. Compressive and tensile stresses were analysed separately and corresponding Failure Indices were calculated., Results: A two-surface resin composite restoration weakened the tooth by 23.25%. Nevertheless, the Failure Indices showed that this tooth was not likely to fracture even under high occlusal stress (710N). However, after access cavity preparation, the Failure Indices reached the point where, under high occlusal force that may occur in the posterior area, a tooth fracture occurred. The enlargement of root canals had an additional, but relatively small impact on tooth weakening, making the tooth even more susceptible to fracture. The combined influence of both cavity preparation and root canal enlargement led to weakening of 62.6% under a load of 710N, ultimately causing tooth fracture., Conclusion: The combined finite element method and the maximum principal stress analysis gave insight into the fracture mechanisms of teeth with two-surface composite restorations followed by root canal preparation. Removal of tooth tissue, despite its subsequent restoration with dental materials, weakened the tooth by changing the stress intensity and distribution through tooth structures. Access cavity preparation had the greatest influence on tooth strength whilst canal enlargement did not contribute to this process substantially., (© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd.)

Introduction: The purpose of this study was to determine the effect of alteration of the exposure parameters of a cone-beam computed tomographic (CBCT) scan on the detection of the presence or absence of simulated horizontal root fractures (HRFs)., Methods: CBCT scans of the lower incisor region of 5 human, dentate, dry mandibles were performed with 11 different exposure parameters. Ten teeth were extracted, and simulated HRFs were created near the apical thirds of the root. The fragments were reattached and the teeth replanted. The mandibles were rescanned over the same range of exposure parameters. Receiver operator characteristic analysis and kappa analyses were performed to assess diagnostic accuracy and intra- and interexaminer agreement for each scan setting., Results: The overall Az value (area under receiver operator curve) for the manufacturer's default setting was 0.95. The sensitivity was 0.94 and the specificity 0.96. A reduction in the tube current to 2 mA at 360° or 180° of rotation had no significant impact on the Az value, sensitivity, or specificity of CBCT imaging in the detection simulated HRFs. A reduction in the current to 1 mA at 360° or 180° of rotation significantly reduced the Az value (0.9 and 0.75, respectively) in comparison with the manufacturer's default setting (P < .05)., Conclusions: CBCT scans are an accurate and reliable technique to detect HRFs. Within the limitations of this study, it is possible to reduce the radiation dose by altering the exposure parameters without a significant reduction in the diagnostic quality of the CBCT scan generated for the detection of HRFs., (Copyright © 2015 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.)

The use of magnification by dental clinicians when carrying out examinations and treatments is becoming more commonplace. The best instrument for this purpose is the operating microscope which has been shown to enhance quality, longevity and outcome of clinical work as well as facilitating better ergonomics for both the dentist and dental nurse. This paper, the second of two, explores the potential uses for the operating microscope in general dental as well as specialist practice (such as endodontics) and discusses how the interested clinician can use such equipment in a practical manner. Clinical Relevance: The operating microscope enhances the dental surgeon's vision so improving treatment outcomes not only in specialist fields, such as endodontics, but also in many of the disciplines which general dental practice encompasses.

The aim of the study was to evaluate the knowledge of dental trauma management in the southern part of Hungary among parents, teachers, medical doctors and dentists. A cross-sectional study was performed among the mentioned groups, with a structured questionnaire. The participants consisted of 275 people, most of them were parents (185), the other groups were smaller (30-30). 73.62% of parents recognised that the maxillary incisor of a 9-year-old girl is probably a permanent tooth. In case of the coronal fracture of this tooth 65.03% responded correctly. The correct response rate for the management of an avulsed tooth was only 39.26%, but in case of loss of consciousness 92.64% would act correctly. The Chi-square test indicated that there was a significant association between the correct recognition of the type of incisor and higher education (p < 0.01), and the number of seen TDIs. The 76.7% of the parents was not satisfied with his knowledge about TDLs, and 74.9% was interested in more information. In our study the parents performed generally better compared to other studies, but compared to the other three groups their results were worse. The knowledge of the teachers and the doctors was almost equivalent. The dentist had the best results. The level of knowledge of dental trauma management was inadequate among parents, but the teachers and doctors should improve their knowledge too. We suggest that it's necessary to start educational campaigns among groups that could be the primary caregivers of traumatic dental injuries.

Statement of Problem: The detection of cracks and fractures in natural teeth is a diagnostic challenge. Cracks are often not visible clinically nor detectable in radiographs., Purpose: The purpose of this study was to evaluate the diagnostic parity of quantitative percussion diagnostics, transillumination, clinical microscopy, and dye penetration., Material and Methods: Three independent examiners provided blind testing for the study. Examiner 1 transilluminated 30 extracted teeth and 23 three-dimensional copy replica control teeth and documented any visible cracks. Each tooth was then mounted in acrylic resin with a periodontal ligament substitute. Examiner 2 examined each specimen aided by the clinical microscope and transillumination and documented visible tooth cracks and fractures. Examiners 1 and 3 then independently tested all specimens with a device developed for quantitative percussion diagnostics. All visible cracks/fractures were removed with a water-cooled fine diamond rotary instrument. Crack visibility was enhanced by the use of a clinical microscope, dye penetrant, and accessory transillumination. This disassembly process was video documented/photographed for each specimen. One more quantitative percussion diagnostics testing was administered when the disassembly was complete., Results: Quantitative percussion diagnostics crack detection agreed with the gold standard microscope and transillumination method in 52 of 53 comparisons (98% agreement). Moreover, the method achieved 96% specificity and 100% sensitivity for detecting cracks and fractures in natural teeth. When all tooth cracks were removed, quantitative percussion diagnostics indicated no further structural instability., Conclusions: Quantitative percussion diagnostics can nondestructively detect cracks and fractures in natural teeth with accuracy similar to that of the clinical microscope, transillumination, and dye penetrant. In addition, the method was able to reveal the presence of many cracks that were not detected by conventional transillumination., (Copyright © 2014 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.)

Various features of endodontic microbiology have been investigated using various methods. The aim of the present study was to review the existing literature on endodontic microbiology in dentinal tubules, and to present the features of two cases with endodontic pathology. An electronic search was performed with a search string created ad hoc. Ex vivo and in vitro studies were included, recording the method of detection and characteristics of analyzed teeth. Twenty studies fulfilled the inclusion criteria. Seven of them were in vitro laboratory studies on teeth inoculated after extraction, while 13 were ex vivo studies on extracted, infected teeth. Endodontic bacteria were detected in dentinal tubules, both as single units and as biofilm aggregates. Two similar in vitro cases presented here corroborate the latter findings. A number of techniques have been utilized to observe bacteria in the dentinal tubule ecosystem. Dentinal tubules are favorable niches for microbial survival, either in the form of monomicrobial or polymicrobial communities., (© 2014 Wiley Publishing Asia Pty Ltd.)