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Editorial BoardChief Patron : Prof. A. D. N. BajpaiVice Chancellor-HP University, Shimla

Editor in Chief : Dr. Vikas JindalDirector-Professor,Department of PeriodonticsHimachal Dental college,Sundernagar,HP,India

Patron : Dr. V.K. GuptaChairman,Dr Puran Chand Medical Trust

Assistant Editor : Dr. Amrinder TuliSenior Lecturer,Dept of PeriodonticsHDC, Sundernagar, HP, India

Co-Editors

Dr. Anil SinglaDirector, Prof and Head, Deptt of Orthodontics, HDC, Sundernagar, HP, India

Dr. Bharat BhushanPrincipal, Prof and Head, Deptt of Pedodontics DAV Dental College, Solan

Dr. R.P. LuthraPrincipal, Prof.and Head,Deptt of Prosthodontics Govt. Dental College, Shimla, HP

Dr. Gaurav GuptaDirector,Prof and Head,Deptt of ProsthodonticsHIDS,Paonta Sahib,HP

Dr. Vinod SachdevPrincipal, Prof and Head, Deptt of Pedodontics, HDC, Sundernagar, HP, India

Dr. Rajan GuptaPrincipal, Prof.and Head,Deptt of Periodontics HIDS, Paonta Sahib, HP

Dr. Jagmohan LalPrincipal, Prof and Head, Deptt of ProsthodonticsBhojia Dental College, Nalagarh, HP

Editorial Board

Dr. K.S.NageshPrincipal, D.A.Pandu MemorialR.V.Dental College, Bangalore

Dr. R L JainPrincipal, Prof and Head, Deptt of Pedodontics Guru Nanak DentalCollege, Sunam, PB, India

Dr. Usha. H.LPrincipal,V. S. Dental College, Bangalore

Dr. Sumeet Sandhu Prof and Head,Deptt of Oral surgery,SGRD, Sri Amritsar, PB, India

Dr. SC Gupta Prof and Head, deptt of Community dentistry, HDC, Sundernagar, HP, India

Dr. KundabalaProf and Head,Manipal College of dental Surgery, Mangalore, Karnataka, India

Dr. D S KalsiPrincipal, Prof and Head, Deptt of Periodontics, BJS Dental College, Ludhiana, PB, India

Dr. Ravi KapoorPrinicipalMM Mullana Dental College, Ambala

Dr. S G DamleVice ChancellorMM Mullana Dental College, Ambala

Dr. D K Gautam Prof and Head, Deptt of Periodontics, HDC, Sundernagar, HP. India

Dr. Eswar NagrajProf and Head, Deptt of Oral Medicine,SRM Dental College, Chennai, TN, India Dr. Himanshu AeranDirector PG studies, Seema DentalCollege, Rishikesh, Uttranchal

Dr. Sameer KauraAssociate Prof, BJS Dental College, Ludhiana, PB, India

Dr. Navneet GrewalProf and Head,Deptt of Pedodontics, GDC, Amritsar, PB,India

Prof. H.S. BanyalDean of Studies,Himachal Pradesh University

Dr (Ms) Jaishree SharmaDirector, Medical Education & Research,Himachal Pradesh

Dr. Mahesh VermaDirector-Principal, Maulana AzadInstitute of Dental Sciences, New Delhi Dr A S GillDirector-Principal, Genesis Institute ofDental Sciences and Research,Ferozepur Punjab Dr. Satheesh ReddyProfessor, Department of Orthodontics &Dentofacial Orthopaedics, Sri Sai Collegeof Dental Surgery and Research, Vikarabad.

Dr. Vimil SikriPrincipal, Prof and Head Endodontics, Govt. Dental College, Amritsar, PB, India Dr. C S Bal Principal, Prof and HeadEndodontics, Sri Guru Ram Dass Dental College, Sri Amritsar, PB, India

Dr. Abi Thomas Principal, Prof and Head, Deptt ofPedodontics CDC, CMC, Ludhiana, PB, India

International Editorial Board

Dr. Manish ValiathanAssistant Professor, Department of Orthodontics School of Dental Medicine Case Western Reserve University, Cleveland, Ohio

Dr. DEEPAK G K, DDSOral and Maxillofacial SurgeonAssistant Professor of SurgeryUniversity of Cincinnati, Ohio, USA

Dr. RAJESH GUTTA, MSOral and Maxillofacial SurgeonAssistant Professor of SurgeryUniversity of Cincinnati, Ohio, USA

Advisors

Dr. I K PanditDr. Ashu BhardwajDr. Rajinder SinghDr. N C RaoDr. T P SinghDr. Rajiv AggarwalDr. Kalwa PavankumarDr. Mukesh Singhal

Dr. Vijay WadhwanCol (Dr.) B R CheetalDr. Vinod KapoorDr. Jaidev S DhillonDr. Malkiat SinghDr. Pradeep ShuklaDr. S.P.S. Sodhi

Dr. Ashwani DhobalDr. A K DubeyDr. S K KhindriaDr. Sanjay TiwariDr. Bhupinder PaddaDr. Ashu GuptaDr. Abhiney Puri

Official Journal of HP University, Shimla

Indian Journal of Dental SciencesE ISSN NO. 2231-2293 P ISSN NO. 0976-4003

a

©Indian Journal of Dental Sciences. ( , Issue: , Vol.: ) All rights are reserved.March 2013 1 5 b



©Indian Journal of Dental Sciences. (March 2013, Issue:1, Vol.:5) All rights are reserved. c



Editorial

©Indian Journal of Dental Sciences. ( , Issue: , Vol.: ) All rights are reserved.March 2013 1 5 d

Dear Readers,

This time I want to enrich your knowledge related to a very important topic of my own profession, as a periodontist, which can also help you all in your practice while formulating a diagnosis and treatment plan of a patient having gum problems.

From the earliest times, the human race has been plagued by a variety of gum problems and the main culprit considered were the "BACTERIA". I still remember when as a child I used to visit the dentist, I was always told to brush properly and keep my teeth clean. But with time, as the knowledge related to the pathogenesis of the disease process got magnified, new therapeutic modalities evolved in parallel with it. As a periodontist, I have seen tremendous changes in the therapeutic modes used to treat dental problems especially problems related to gums.

Initially, it was thought that periodontal diseases are initiated by bacteria that colonize the tooth surface and gingival sulcus. But now, the host response is considered equally important to play an essential role in the breakdown of connective tissue and bone, which are the key features of the

disease process. A new concept of host modulation has evolved which was routinely used by most physicians for the management of number of chronic progressive disorders like arthritis and osteoporosis.

In whole of this mechanism of bacterial stimulation and tissue destruction lies an intermediate mechanism of the production of cytokines, which stimulates in?ammatory events that activate effector mechanisms. Cells of the immune system communicate with each other, and respond to abnormal conditions by releasing soluble proteins, named cytokines. Cytokines play crucial roles in the maintenance of tissue homeostasis, a process which requires a delicate balance between anabolic and catabolic activities. The balance between periodontal breakdown and periodontal stability is maintained by the balance between anti-inflammatory cytokines or protective mediators such as Il-4 and Il-10 and pro-inflammatory mediators destructive mediators like Il-1, IL-6. Cytokines play an important role in numerous biological activities including proliferation, development, differentiation, homeostasis, regeneration, repair, and inflammation

I have often observed in patients coming with gum problems that the amount of destruction caused to the gums are inconsistent with the local factors present. For such situations, we used to focus our diagnosis towards aggressive periodontitis after correlating it with

radiographic findings or tried to correlate it with systemic factors. But emergence of the concept of host modulation has diversified our vision. We can now think of other etiological factors thereby not restricting ourselves towards dental plaque only. By saying this I don't mean to say that we have to negate the factor of dental plaque which is basic for occurrence of periodontal disease. The requirement is only to think beyond it also so that appropriate treatment plan can be choosen which will be beneficial for the patient. Through knowledge of cytokines, as I discussed above, we can monitor cytokine production or its profile may allow us to diagnose an individual's periodontal disease status and/or susceptibility to the disease and at the earliest we can halt the progression of the disease thereby providing benefit to the patient which is our ultimate goal.

Dr Vikas Jindal

Editor in Chief

Dr. Vikas Jindal

Editor in Chief

Indian Journal of Dental Sciences. March 2013 Issue:1, Vol.:5All rights are reserved

www.ijds.inOriginal Article

of Dental SciencesIndian Journal

E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Himanshu Aeran2 Pradeep Kumar3 Rubina Gupta4 Anubha Agarwal

the planar mean of the curvature of these surfaces. A plane is determined by at least three reference points that are not in a straight line.

Anteriorly, occlusal plane mainly helps in achieving esthetics and phonetics while posteriorly, it forms a milling surface. Thus, incorrect record of the occlusal plane would hamper esthetics, phonetics, and mastication. It may also affect the stability of a complete denture and ultimately result in alveolar bone resorption.

Functionally, the inclination of the occlusal plane is one of the key factors governing occlusal balance. The movement of the mouth during chewing shows a harmonious relationship between the tongue, the mandibular posterior teeth, and the buccinator muscle. The incorrect location of occlusal plane, results in malfunctions. Where the occlusal plane is too high, the tongue and buccinator muscle are not able to position the food bolus on the occlusal plane and hold it there during

IntroductionThe desire to look good & feel healthy is not limited by age. Today, esthetics is the primary concern of a patient seeking Prosthodontic treatment. For good esthetics, selecting the anterior teeth of correct size, shape & color is salient & for good functional ability, arranging the teeth in correct plane of occlusion is pivotal.

The occlusal plane, lost in patients rendered edentulous, should be relocated if complete dentures are to be a e s t h e t i c a l l y a n d f u n c t i o n a l l y satisfactory. The orientation of the occlusal plane forms the basis for teeth arrangement conducive to satisfactory esthetics & proper function. Thus it is one of the most important clinical procedures in prosthodontic rehabilitation.

T h e G L O S S A R Y O F PROSTHODONTIC TERMS (July 2005) defines occlusal plane as "the average plane established by the incisal and occlusal surfaces of the teeth". Generally, it is not a plane but represents

001©Indian Journal of Dental Sciences. (March 2013 Issue:1, Vol.:5) All rights are reserved.

1 Director PG Studies, Professor & Head, Department of Prosthodontics2 Professor & Head, Department of Pedodontics Seema Dental College & Hospital, Rishikesh,Uttarakhand3 Asstt. Professor, Department of Dental Surgery Muzaffarnagar Medical College, Muzaffarnagar, U.P.4 Chief Medical Administrative officer, Nirmal Ashram Eye Institute, Rishikesh, Uttarakhand

Relationship Of Labial & Lingual Frenum To

The Height Of Mandibular Central Incisors

Address For Correspondence:Dr. Himanshu AeranDirector PG Studies, Professor & HeadDepartment of ProsthodonticsSeema Dental College & HospitalVeerbhadra Road, Pashulok, Rishkesh -249203Ph- 09837063005E-mail: [email protected]

th Submission : 13 August 2012th Accepted : 19 January 2013

Quick Response Code

mastication. There is also a tendency for accumulation of food in the buccal and lingual sulci. An occlusal plane that is too low could lead to tongue and cheek biting.

One of the aims of prosthetic rehabilitation is to restore esthetics. The incisors & canines take on a fundamental role in fulfilling these functions. The amount of visible anterior teeth, with lip at rest or during function, is an important esthetic factor in determining the outcome of prosthodontic care. An acceptable amount of incisal edge display at rest depicts patient’s age.

Accurate determination of occlusal plane is also a pre-requisite for correct phonation. An incorrect occlusal plane can lead to speech difficulties in the form of incorrect pronunciations of certain sounds like ‘f’, ‘v’, ‘s’ etc. This inturn can

AbstractPurpose: To evaluate the reliability of the measurement of the distance between the lingual frenum & the labial frenum to the incisal edges of the mandibular central incisor respectively, as pre-extraction records for determining the vertical position of the mandibular incisors in complete dentures.Methods: The study comprised of 90 dentulous subjects (30 of each Angle’s class). Three mandibular casts were made from irreversible hydrocolloid impression for each subject. Labial & lingual frenii were recorded in function. The vertical distance between the frenii and incisal edges of mandibular central incisors was measured. Means and standard deviations were calculated and statistically analyzed.Results: Within limitations of this study, it was revealed that the standard deviation & coefficient of variance of the distance between the labial frenum & incisal edges of mandibular centrals is quite high & hence not reliable, While between that of lingual frenum & incisal edges of mandibular incisors is clinically insignificant & hence reliable.Interpretation and conclusions: It was concluded that: The distance between the labial frenum & the incisal edges of mandibular central incisors is not a reliable guide for determining the position of mandibular anterior teeth while the lingual frenum when recorded in function is a relatively stable landmark & hence, can be used as a pre-extraction record for determining the original position of the occlusal plane

Key WordsOcclusal plane, anterior attachment of the lingual frenum, alveolar attachment of the labial frenum, pre-extraction diagnostic records, vertical dimensions of occlusion.

lead to psychological disturbances in the patient.

Thus, it can be said that, for the success of complete denture prosthesis, arranging the teeth in correct plane of occlusion is pivotal. Changes in the plane of occlusion modify the physical & functional relationship of the oral musculature leading to an alteration in function, comfort & also the esthetic value. Considering the importance of the accurate establishment of the location and the effect of the inclination of the established occlusal plane on function, esthetics and speech, a method to conform it to the occlusal plane that existed in the natural teeth seems necessary.

Many authors have suggested the use of pre-extraction records like pre-extraction

[1]diagnostic casts (PEDCs) , instruments [2] [3](the Dakometer , profile template ,

[4] [5]Willis gauge , Sorenson profile scale , [6]and orofacial device ), measurements

[7](between tattoo points , of the closest [ 8 ]s p e a k i n g s p a c e , a n d o f t h e

[ 9 ]phys io log ica l r e s t pos i t i on ) , [10] [11]photographs , and radiographs . The

review of the literature indicated that PERs provided a useful guide in determining the edentulous patient’s original VDO and arranging the

[12]maxillary anterior teeth .

In the maxilla, the incisive papilla is a [13]stable anatomic landmark and it can be

used to determine the edentulous patient’s vertical relation. Unfortunately, there is no stable anatomic landmark in the mandible.

The purpose of this study was to evaluate the reliability of the measurement of the distance between the lingual frenum and the incisal edges of the mandibular central incisor & the labial frenum and the incisal edges of the mandibular central incisor as pre-extraction records for determining the vertical position of the mandibular incisors in complete dentures.

Aims & Objectives1. To measure the distance between the

mandibular labial frenum & incisal edge of mandibular central incisors so as to evaluate its importance for determining the plane of occlusion.

2. To evaluate the accuracy of distance between lingual frenum & incisal


edges of mandibular incisors as pre – extraction record for determining the plane of occlusion.

3. To compare the accuracy of labial & lingual frenum for determining the occlusal plane in Angle’s class I, II & III subjects

Review Of LiteratureNumerous authors have advocated different methods for the orientation of the occlusal plane. Most important & accurate of these is pre-extraction record, eg: profile photographs, lead wire, acrylic face mask, dentulous casts etc. Unfortunately, these records are generally not available. P. F. Foley & G.

[ 1 4 ]H. Latta through their study determined that there is a fairly constant relationship between the parotid papilla and the occlusal plane. An additional finding was that this relationship may not be the same on each side of the mouth. Race and sex differences were not

[15]significant. Majid Bissasu,1999 used the location of lingual frenum in determining the original vertical position of mandibular anterior teeth. He concluded that when recorded during function, lingual frenum is a relatively

[16]stable landmark. J. Mamootil (1994) gave a new concept of the plane of occlusion based on anatomical landmarks. The posterior end of the plane was set by the centres of the retromolar pads, and the anterior end of the plane was at the upper lip line. Sheldon Winkler

[17](2000) said that the maxillary occlusal rim in anterior region should be 1 - 2mm below the relaxed lip. For the mandibular rim the mandibular lower canine & 1st premolar should lie at or very near the commissure of the lips at rest. J. F.

[18]McCord and A. A. Grant (2000) in their article says that ideally, the incisal level of the upper rim is 2 mm inferior to the resting upper lip; the clinician should temper this by deciding what is appropriate for each patient. In younger patients it may 4–5 mm beneath the resting lip, In a old patient it might at level with the resting lip, or possibly 1 mm above this. Donald F. Reikie

[19](2001) said that stable occlusal plane can be correlated with the desired incisal display with lips at rest (generally averaging 2 mm in males and 3.5 mm in females and decreasing with age). Ideally, 1 to 1.5 mm of mandibular incisal length is visible when lips are at rest (repose), The clinically established ideal maxillary central incisor position allows

to establish the optimum posterior occlusal plane. K.-H Utz & F. Muller et al

[20](2004) measured the horizontal and vertical tooth positions of functionally and aesthetically pleasing dentures to pre-shape the rims of functional impression trays in the maxillary and the mandibular jaw. For the maxillary denture, they found the distance from the maxillary incisor to the incisive papilla to be12.7 ± 2.8, from the maxillary molar to the maxillary alveolar ridge to be 8.7 ± 2 .5 & from the top of maxillary flange to the maxillary incisor to be 23.1 ± 2.9. In case of mandibular dentures, the distances were: Mandibular incisor to mandibular alveolar ridge was 12.2 ± 2.7, Mandibular right molar to mandibular alveolar ridge was13 ± 3.4, Level of incisal edges of right mandibular lateral incisor and canine to mandibular flange was 15.1 ± 2.1. K Shigli, B.R.Chetal, J.

[21]Jabade studied the relation of various soft tissue landmarks like retromolar pad, parotid papilla, commissure of the lips, buccinator groove etc. to the occlusal plane. They found that: the mean values of all readings of buccinator groove was 0.94 mm below the mandibular occlusal plane & the commissure of the lip was inferior to the mandibular occlusal plane

[22]by 1.37 mm. Irfan Ahmad (2005) in his article on anterior esthetics said that there are two lip positions: static (at rest) & dynamic (smile). He studied the maxillary lip length in relation to anterior tooth exposure. He said that for a short lip length of 10 – 15mm, the exposure of maxillary central incisor is 3.92mm while for mandibular central is 0.64mm, for a medium lip of 16 – 20mm; they are 3.44mm & 0.77mm respectively. For a long lip (26 – 30mm) the maxillary incisor shows about 0.93mm & mandibular incisor shows 1.95mm.

It is evident that the various concepts reported in the literature allow variation in the location of occlusal plane. But, pre-extraction records remain the most important & accurate of these concepts.

Material And MethodsThe study was carried out on 90 completely dentulous patients between the age group of 20 – 35 yrs. The subjects were selected & divided into three groups on the basis of the Angles class I, II & III.

Selection CriteriaThe selected subjects showed all healthy permanent incisors with no gingival or

periodontal conditions or therapy that would undermine a healthy tooth-to-tissue relationship.Subjects with Abraded or attrited incisors, Ankyloglossia, Restorations that grossly altered the height of central incisors, Periodontally compromised or supraerupted teeth were rejected. There was no history of Orthodontic treatment or any Facial trauma or surgery

Procedure


The subjects were selected & divided into three groups on the basis of ANGEL’S class I, II & III. Three impressions of the mandibular arch of each patient were made with irreversible hydrocolloid impression material (alginate – Zelgan 2002.Dentsply). Both the labial & lingual frenii were recorded in their functional position. The labial frenum was recorded by pulling the lower lip upwards & outwards. The lingual frenum was recorded by asking the subject to touch the posterior part of the hard palate with his tongue.

The impressions were poured in class III dental stone (Kalstone). The bases were poured in class II type of plaster of paris (Fig.: 1). The cast was then mounted on Ney surveyor (Dentsply). The tilt was adjusted such that the analyzing rod touches the

alveolar attachment of the labial frenum & the anterior attachment of the lingual frenum at the same inclination (Fig.: 2). Tripodization of the cast was then done.The analyzing rod was then placed at the labial frenum & the level of the incisal surface of the mandibular central incisors was then marked on the analyzing rod using a permanent marker (Fig.: 3). Digital vernier calipers, with an accuracy of .001mm, were used to check the distance between the tip of the analyzing rod & the mark on the rod. This distance was recorded (Fig.: 4). Similar procedure was then carried out for the lingual frenum.

Same procedure was then repeated on the rest of the two casts of the subject. The mean & standard deviation of the three readings was calculated & statistically analyzed.

ResultsThe means and Standard Deviation of all

Fig - 1Fig - 2

Fig - 3

Fig - 4

TABLE: I

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Mean

Standard

Deviation

11.43

10.72

14.91

15.12

13.11

11.32

13.39

12.74

10.57

9.78

11.74

14.11

13.25

13.55

11.61

15

12.76

14.32

11.11

10.9

13.65

11.52

12.22

11.9

12.52

10.99

13.74

14.01

11.65

13.11

12.56

1.63

17.67

17.8

18.98

19.33

18.18

18.55

17.93

18.63

18.27

19.19

19.02

18.21

17.65

17.22

18.95

17.99

18.86

18.43

17.98

19.07

18.79

19

17.45

18.21

18.67

19.18

17.86

18.48

19.11

17.72

18.41

0.35

11.2

12.28

11.73

13.44

13.96

14.61

11.23

13.95

13.13

11.56

13.11

10.98

12.27

11.44

12.14

13.64

11.71

11.68

12.59

10.94

14.14

12

14.55

13.38

13.29

12.78

11.91

11.19

15.1

11.31

12.57

1.45

20.04

18.98

19.23

19.9

19.12

19.76

19.89

18.8

18.91

19.75

19.4

20.01

18.88

19.91

19.72

19.56

18.96

20.14

18.99

19.28

18.9

19.5

18.99

18.87

20.01

19.3

19.86

18.85

20.15

19.47

19.43

0.38

12.83

10.34

11.56

12.02

14.56

11.87

11.23

13.84

10.91

13.13

13.01

12.2

12.57

14.62

11.34

11.98

13.23

10.65

13.55

11.44

11.61

12.78

11.23

10.83

13.95

14.61

13.44

12.28

11.77

13.65

12.43

1.51

19.84

20.97

21.02

20.63

20.96

19.77

20.47

19.94

20.21

19.83

20

21.02

20.86

20.95

20.3

19.9

21.02

20.81

21

21.06

19.98

20.35

20.64

20.5

19.81

20.66

21.03

20.86

20.59

19.99

20.49

0.27

LingualFrenum

LingualFrenum

LingualFrenum

LingualFrenum

LingualFrenum

LingualFrenum

CLASS I CLASS II CLASS IIISUBJECT

the subjects are presented in (Table I). The Standard Deviation on labial frenum in class I, II & III subjects is quite high i.e. 1.63, 1.45 & 1.51mm respectively (Fig.: 5). Hence, labial frenum cannot be considered as a reliable pre-extraction record landmark. This is further supported by the t-test results which revealed that the relationship of labial frenum in the three classes is almost same


& hence clinically insignificant.

The Standard Deviation on lingual frenum in class I, II & III subjects is low i.e. 0.35, 0.38 & 0.27mm respectively (Fig.: 6). Hence, it can be considered as a reliable landmark. This is further supported by the t-test results which revealed that the relationship of lingual frenum is varying, & hence is significant.

Thus, this study revealed that the standard deviation & coefficient of variance of the distance between the labial frenum & incisal edges of mandibular centrals is quite high, While between that of lingual frenum incisal edges of mandibular incisors is clinically insignificant.

Hence, the lingual frenum can be used as pre-extraction record for the orientation of occlusal plane in complete dentures.

DiscussionCorrect registrat ion of vertical dimensions of occlusion is of stellar importance in fabrication of complete dentures. When artificial teeth are set in proper positions, the foundation is correctly laid for natural speech, pleasing appearances, and normal function. Alteration in the dimensions can lead to impaired esthetics, can induce speech difficulties & muscle discomfort.

According to Priest, for prosthesis to be successful, it should basically fulfill four levels of patients needs - first comfort, then function followed by esthetics &

[23]lastly self esteem . A person cannot rise to the upper level until the lower level is achieved.

Incorrect location of occlusal plane disturbs the harmonious relationship between the oral & perioral musculature & the teeth. The muscles will not be able to rest against the teeth, resulting in fatigue & discomfort. Hence, the first level of hierarchy is disturbed.

If the occlusal plane is too high, normal chewing is impaired, as the food cannot be properly placed back on the occlusal surfaces by the tongue lingually &buccinator buccally. If too low, then the tongue & cheek can overlap the lower teeth, causing tongue or cheek biting. Thus, the second level is also disturbed.The amount of visible anterior teeth, with lip at rest or during function, plays an important role in facial aesthetics. Improper occlusal plane, either in location or inclination, can lead to esthetic problems, disturbing the third level of hierarchy. This also in turn affects the patient’s self-esteem.

Unfortunately, there is no precise method for determining the correct vertical dimensions of occlusion. The various concepts & landmarks reported in the

Fig - 5

Fig - 6

literature by numerous authors for determination of occlusal plane in complete dentures unfortunately allow variations in the orientation. Thus, the only way to record the VDO of an edentulous patient more accurately would be to record the VDO before the extraction of the remaining teeth.

The results of this study indicate that the standard deviation between the anterior attachment of the lingual frenum when recorded during function & the incisal edges of the mandibular teeth is clinically low in all the three classes. On the other hand, the standard deviation between the anterior attachment of the labial frenum when recorded during function & the incisal edges of the mandibular teeth is high in all the three classes. Thus, it can be said that the distance between the labial frenum & the incisal edges of mandibular central incisors is not a reliable guide for determining the position of mandibular anterior teeth while the anterior attachment of the lingual frenum when recorded during function can be used as a reliable pre-extraction record for the orientation of occlusal plane.

The results of this study indicate that the distance between the anterior attachment of the lingual frenum and the incisal edges of mandibular central incisors was reliable when the frenum was recorded during function. Consequently, when measurements are made on pre-extraction diagnostic casts from the anterior attachment of the lingual frenum when recorded during function to the incisal edges of mandibular central incisors, then the vertical height of mandibular wax occlusion rims are adjusted anteriorly to correspond with these measurements. The vertical position of the mandibular incisors can then be copied in the complete dentures. Thus, the VDO of the edentulous patient can be preserved.

ConclusionWithin the limits of this study, it was concluded that:Ÿ The distance between the labial

frenum & the incisal edges of mandibular central incisors is not a reliable guide for determining the


position of mandibular anterior teeth.Ÿ The lingual frenum when recorded in

function is a relatively stable landmark & hence, can be used as a pre-extraction record for determining the original position of the occlusal plane.

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3. Crabtree DG, Ward JE, McCasland JP. A pre-extraction profile record. J Prosthet Dent 1981;45:479-83.

4. Willis FM. Features of the face involved in full denture prosthesis. Dent Cosmos 1935;77:851-4.

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6. Aboul-Ela LM, Razek MKA. Pre-extraction records of occlusal plane and vertical dimension. J Prosthet Dent 1977;38:490-3.

7. Silverman MM. Pre-extraction records to avoid premature aging of the denture patient. J Prosthet Dent 1955;5:465-76.

8. Silverman MM. Speaking method in measuring vertical dimension. J Prosthet Dent 1953;3:193-9.

9. Gillis RR. Establishing vertical d i m e n s i o n i n f u l l d e n t u r e construction. J Am Dent Assoc 1941;28:430-6.

10. Wright WH. Use of intra-oral jaw relation wax records in complete denture prosthesis. J Am Dent Assoc 1939;26:542-5.

11. Sharry JJ. Complete denture prosthodontics. McGraw-Hill; 1974

12. Bissasuv M.: Pre-extraction records for complete denture fabrication: A literature review. J Prosthet Dent 2004;91:55-8

13. Harper RN.: The incisive papilla - the basis of a technic to reproduce the p o s i t i o n s o f k e y t e e t h i n prosthodontia. J.D. Res. 1948; 27(6): 661 – 668.

14. Foley PF, Latta GH.: A study of the position of the parotid papilla relative to the occlusal plane. J. Prosthet.

Dent. 1985 Jan; 53(1): 124-6.15. Bissasu M.: Use of lingual frenum in

determining the original vertical position of mandibular anterior teeth. J. Prosthet. Dent. 1999; 82: 177-81.

16. Mamootil JA.: Plane of occlusion--a new concept. Aust Dent J. 1994 Oct; 39(5): 306-9.

17. Sheldon Winkler: Essentials of complete denture prosthodontics. S e c o n d e d i t i o n , I s h i y a k u EuroAmerica Inc. & AITBS Publishers: 2000.

18. M c C o r d J F. & G r a n t A A . : Registration: Stage I —Creating and outlining the form of the upper denture. British Dental J. 2000; 188 (10): 529 – 36.

19. Reikie DF.: Orthodontically Assisted Restorative Dentistry. J Can Dent Assoc 2001; 67(9): 516-20.

20. Utz KH., Muller F., Kettner N., Reppert G. & Koeck B.: Functional impression and jaw registration: a single session procedure for the construction of complete dentures. J. Oral Rehab. 2004; 31: 554–561

21. Shigli K, Chetal BR, Jabade J.: Validity of soft tissue landmarks in determining the occlusal plane. J Indian Prosthodont Soc 2005; 5: 139-145.

22. I. Ahmad.: Anterior dental aesthetics: dentofacial perspective. BDJ 2005’ July; 199 (2): 81 – 88.

23. Ronald E. Goldstein: Esthetics in dentistry, second edition, B. C. Decker Inc.: 1998.

Source of Support : Nill, Conflict of Interest : None declared




E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Saroj Thakur2 Abhay Kamra3 Pradnya Bansode4 Rambhika Thakur

[5]on the tactile sensation of the clinician. However, various factors such as, cervical constriction, canal length, canal taper, canal curvature, canal content, canal wall irregularities and the instrument used for determining the initial working width, may influence the

[3]tactile discrimination. Studies have shown that the enlargement of the coronal and middle third of the root canal allows a more accurate assessment of the

[5]initial apical canal diameter.

Cervical preflaring can be performed by different instruments. While Gates-Glidden drills have been used for pre-enlarging the coronal two thirds of the root canals since ages; contemporary nickel titanium (NiTi) rotary systems have specially designed files for cervical pref lar ing. Their character is t ic instrument design influences the coronal

[5], [6]preflaring of the canal. ProFile instruments were one of the first NiTi

[7]instruments, while K3 is one of the newer rotary NiTi instrument systems

[8]hence we are taking these systems .

Introduction:Cleaning and shaping of the root canal system is one of the important phases of

[1]root canal treatment procedure. It includes mechanical debridement, creation of space for medicament delivery, and forming optimized canal

[2]geometries for adequate obturation. In the course of cleaning and shaping the root canal system, the clinician needs to determine three clinical parameters. These are length of the canal, the taper of the preparation and the horizontal dimension of the preparation at its most apical extent also called the initial apical

[3]file size.

For cleaning and shaping of a root canal, most clinicians start by selecting a first file that they believe fits at the apex and

[4]enlarge in relation to that file diameter. It has been suggested that the amount of apical enlargement to be achieved during shaping of the canal should be three file sizes greater than the first file that fits at

[3]the apex. Determination of the first file that binds at the working length is based


1 Senior Lecturer, Dept. Conservative Dentistry & Endodontics Government Dental College, Shimla2 Professor & Head, Dept. Conservetive Dentistry & Endodontics C.S.M.S.S. Dental College & Hospital, Aurangabad.3 Associate Professor & Head Of Department, Dept. Conservative Dentistry & Endodontics Govt. Dental College &hospital, Aurangabad.4 Senior Lecturer, Dept. of Periodontics M.N.D.A.V. Dental College,Tatul, Solan

Influence Of Cervical Preflaring On Apical File

Size Determination: An In-vitro Study

Address For Correspondence:Dr. Saroj ThakurDepartment of Conservative Dentistry & Endodontics,Government Dental College,Shimla Himachal Pradesh

th Submission : 28 July 2012th Accepted : 16 January 2013

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This in vitro study is an attempt to evaluate the influence of cervical preflaring of root canals performed with Gates-Glidden drills, ProFile orifice openers and K3 body shaper files, on the accurate determination of initial apical canal diameter using stereomicroscope.

Material and Methods:Selection and preparation of samplesSixty recently extracted human maxillary permanent molars with relatively straight, non-fused, divergent roots were used in this study using all universal aseptic precautions. Conventional endodontic access cavities were prepared and the teeth were checked for patency and for the presence of a single root canal per root. The selected teeth were stored in normal saline at room temperature until further use.

Procedure:The root canal of each root was explored using a size 10 K-file until the apical foramen was reached and the tip of the

AbstractAim : To evaluate the influence of cervical preflaring of root canals with different rotary instruments on the selection of the first file that binds at the working length. Material and

Methods : Sixty recently extracted human maxillary permanent molars were randomly assigned to four groups. In the first group, root canals were not flared. Root canals of the group2, 3 and4 were preflared using Gates-Glidden Drills, ProFile orifice openers and K3 body shaper file respectively. The tooth length was determined by inserting an ISO 10 K-file to the apical foramen. Transversal sections of the working length (WL) regions were examined under stereomicroscope to assess discrepancy in the diameter of the root canal and the initial apical file at WL.Statistical Analysis : All the data was processed using SPSS statistical software.

Results : Canals preflared with K3 body shaper files presented the lowest discrepancy values between the file size and anatomical diameter while ProFile orifice openers were found second and Gates Glidden drills third best with statistically significant results. (p<0.05)

Conclusion : Preflaring with larger tapered instruments leads to a more accurate apical sizing, and this information is crucial concerning the appropriate final diameter for complete apical shaping.

Key WordsApical diameter, apical shaping, cervical preflaring, initial apical file, working width.

Figure 1: Comparison of mean discrepancy between file and canal diameter between groups.

file was visible. The actual canal length was determined and working length was established by deducting 1 mm. Cusp tips were used as reference points because the study is In-vitro. Both the working length and the reference point of each individual canal were recorded. All the canals in each tooth were included in the study. A total of 180 canals were eventually utilized. Each tooth was stored in an individually labelled, capped plastic vial containing normal saline.

Sizing of Canals.Each canal in all the selected teeth was sized with stainless steel K-files in random order. Handles of files were painted black in order to avoid the identification. Files were inserted passively into the canal with a light 'watch-winding' action and care was taken to avoid any force during sizing. File size was increased until binding sensation was felt at the working length. Measurement was undertaken starting from ISO size 10 and the biggest file size that reached the correct working length was recorded. The size of file was recorded as first file fitting at the apex (FFFA) before flaring (FFFAb). After this, samples were divided into four experimental groups of fifteen teeth each.In Group Ino cervical preflaring of root canals was performed, while in group II, group III and group IV cervical preflaring was achieved by using experimental instruments. The procedure of cervical flaring for each group was as follows:

Group I- Without cervical preflaringThis group received the initial apical instrument without previous preflaring of the root canal.

Group II- Cervical preflaring with Gates-Glidden drillsIn this group root canals were preflared with Gates-Glidden drills using endodontic electronic torque control motor X- SMART as per manufacturer's

[6]instructions. Flaring began with Gates-Glidden #4 and continued with a Gates-Glidden #3, 2, 1 extending the shaping further apically till resistance felt.Canal patency was checked and irrigation continued.

Group III- Cervical preflaring with ProFile orifice openersCervical flaring was done with ProFile instruments using a crown-down approach according to manufacturer's

[7]instructions. Flaring began with ProFile


orifice opener 3 (#40, 0.06 taper),and continued with aProFile orifice opener 2 (#30, 0.06 taper), ProFile orifice opener 1(#20, 0.06 taper) extending the shaping further apically till resistance felt.

Group IV- Cervical preflaring with K3 body shaper filesIn this group cervicalflaring was done with the K3 enhanced-tapered body shapers using a crown-down approach as

[8]per manufacturer's instructions. Flaring began with size 25(0.12 taper) taper orifice shaper and continued with a successively smaller tapered body shapers size 25 (0.10 taper) and 25 (0.08 taper) until the light resistance was felt. Thus, each smaller tapered file advanced further apically ensuring a crown down sequence.

During the preflaring of canals in group II, group III and group IV, 15% EDTA gel was used as a lubricant with each instrument. After each instrument use, canal was irrigated with 2 ml of 3% sodium hypochlorite (Vishal Dentocare Pvt. Ltd.) using a 27 gauge needle-syringe then recapitulated with a #10 file and re-irrigated.

Following this again sizing of each canal was done as descr ibed above. Measurement was undertaken starting from ISO size 10 and the biggest file size that reached the correct working length was recorded. This file was recorded as first file fitting at apex after flaring (FFFAa). The file corresponding to the initial apical file (IAF) after preflaring i.e. FFFAa was fixed into the canal at the working length (WL) with cyanoacrylate

adhesive. After this, roots of each sample were sectioned transversely 1 mm from the apex using diamond disc. Sectioned apical region was then observed under stereomicroscope (Olympus SZ 4045) at 30 X magnification. Root canal and file maximum diameters were measured directly using a calibrated ocular scale for each sample.

The di fferences between these measurements were submitted to s tat is t ical analysis . A mult iple comparison, one variable test (ANOVA) with post-hoc tukey's testwas performed to examine the effect of the four different preflaring techniques on the diameter differences found between root canals and binding instruments. Comparison of the first file that fits to the apex in each canal before and after flaring was performed by the Student- t- test. Mean values and standard deviations were calculated using a paired- t- test and ANOVA. Statistical analysis was performed at the 0.05 level of significance.

Results:A paired t-test of intragroup values indicated a significant difference (p, 0.001) of file size before and the after flaring for all early flaring groups (Table no. 1).

FFFA- First file fitting at apexFFFAb- First file fitting at apex before preflaringFFFAa- First file fitting at apex after preflaringThe increase in mean apical file diameter was approximately one file size for group

Table No. 1: Showing mean difference of file size before and after preflaring

Group I (Without preflaring)

Group II (GG drills)

Group III (Profile orifice openers)

Group IV (K3 body shapers)

FFFAb - FFAAa

FFFAb - FFAAa

FFFAb - FFAAa

FFFAb - FFAAa

Mean

0

-.0633

-.1089

-.1133

Std.

Deviation

0

.03471

.01991

.02477

Std. Error

Mean

0

.00517

.00297

.00369

95% Confidence

Interval of the Difference

Lower

0

-.1038

-.1049

-.1208

Upper

0

-.0829

-.0929

-.1059

t

0

-18.040

-33.316

-30.691

Df

44

44

44

44

'p value'

1

.0001

.0001

.0001

Paired Differences

Table No. 2: Showing discrepancies measured between canal diameter at working length and binding file with

different preflaring techniques

GROUPS

1. No preflaring

2. Gates Glidden drills

3. Profile orifice openers

4. K3 body shapers

Range of discrepancy

0.13-0.28

0.03 - 0.27

0.04- 0.19

0.01-0.14

Discrepency (Mean ± SD)

0.19 ± 0.036

0.14 ± 0.047

0.09 ± 0.039

0.05 ± 0.032

II, while it was two file sizes for group III and group IV.

Discrepancies measured between canal diameter at working length and FFFAa with different preflaring techniques by using stereomicroscope at 30 X magnification are presented in (Table 2) and (Fig.1).

The major discrepancy was found in group I, where no cervical preflaring was performed (0.19 mm average, Fig. 2). The K3 body shaper files produced the smallest differences between anatomical diameter and first file to bind (0.05 mm average, Fig. 3). ProFile orifice openers were found second and Gates Glidden drills third best with statistically significant results (0.09 mm, Fig. 4 and 0.14 mm, Fig. 5 respectively).

Discussion:The biomechanical preparation of the apical region is an essential and critical

[9]operative step of endodontic therapy. Many in vitro studies have recorded the scales and average sizes of root canals, but there have been few clinical attempts to determine the working width. The horizontal dimension of the root canal system is not only more complicated than the vertical dimension (root canal length or working length) but also more difficult to investigate because the horizontal dimension varies greatly at each vertical

[3]level of the canal.

Apical access by cervical preflaring has been increasingly investigated , the procedure aims to remove cervical interferences from the root canal entrances which represent an obstacle to free access of endodontic instruments to the apical portion of the root canals, which in turn enhances canal shaping at

[10]the apical third. Preflaring can be done with either manual or rotary instruments. Rotary flaring is more rapid than hand and reduces the treatment time; in addit ion f lare, smoothness and uniformity of the canal preparation are also better. Early flaring, regardless of the method used, removes these contacts, opens the space and reduces file contact, thus a file progresses more easily toward the apex and comes to a stop only when the diameter of the canal begins to apply pressure against the instrument. This better sense of apical diameter provides information that should result in better

[ 4 ]biomechanical preparation. The findings of the present study showed the


increase in mean apical file diameter after preflaring was approximately one file size for group II, whereas it was two file sizes for group III and group IV. This can be attributed to differences in design features of the instruments used in terms of their ISO size and taper resulting in different amount of removal of cervical

[11]interferences in each group.

There was a statistically significant difference (p <0.05) amongst groups, concerning the discrepancy between anatomical diameter at working length and the first file to bind in the canal. From all the rotary instruments evaluated in this study (Gates-Glidden drills, ProFile orifice openers and K3 body shaper files), canals preflared with K3 body shaper files (Group IV) presented the lowest discrepancy values between the file size and anatomical diameter whichcan be attributed to modified design ofK3 body shapers which include enhanced taper which allow complete removal of

[8], [10], [12]cervical interferences.

Groups preflared with ProFile orifice openers (Group III) and Gates Glidden drills (Group II) were found second and third best respectively with statistically significant results. The performance of ProFile orifice openers is due to their U-file radial-landed flute design that provides optimal cutting efficiency and a l lows for grea ter removal of

[7], [13]interferences in the cervical third.

The Gates Glidden drills straightened the coronal two- thirds of the root canals in an attempt to reduce binding in the coronal region which provided direct access to both the cervical and middle thirds of root canals, reducing the contact area of the instrument in these regions. When used adequately GG instruments are inexpensive, safe and clinically beneficial tools, nevertheless, these instruments did not allow for accurate

[5], determination of the initial apical file. [9], [12]

Conclusion:The findings of our study clearly suggest that cervical preflaring of canals is necessary for the better cleaning and shaping of the root canal as it facilitates more accurate determination of initial apical file size. The preflaring was best with K3 body shaper files as it lead to minimal discrepancy between initial apical file size diameter and canal diameter at working length.

Figure 2: Stereomicroscopic image of a Group I specimen

Figure 3: Stereomicroscopic image of a Group IV specimen

Figure 4: Stereomicroscopic image of a Group III specimen

Figure 5: Stereomicroscopic image of a Group II specimen


maxillary lateral incisors.Braz Dent J 2007; 18: 102-106.

11. Tennert C, Herbert J, Altenburger MJ, Wrbas KT.The effect of cervical preflaring using different rotary nickel-titanium systems on the accuracy of apical f i le size determination.J Endod 2010; 36: 1669-72.

12. Vanni JR, Santos R, Limongi O. Influence of cervical preflaring on determination of apical file size in maxillary molars: SEM analysis. Braz Dent J2005; 16: 181-186.

13. Tan BT and Messer HH.The effect of instrument type and preflaring on apical file size determination. Int Endod J 2002; 35: 752-758.

preflaring on apical file size determination.Int Endod J 2005; 38: 430-435.

6. Peter O and Peters C.Cleaning and shaping of root canal system. Cohen inPathways of the pulp. Ninth edition Mosby, Inc. 179-218.

7. Hsu YY, Kim S. The ProFile system. Dent Clin North Am 2004; 48:323- 35.

8. Mounce RE.The K3 rotary nickel-titanium file system. Dent Clin North Am 2004; 48: 137-157.

9. Schmitz MS, Santos R, Capelli A. Influence of cervical preflaring on determination of apical file size in mandibular molars: SEM analysis. Braz Dent J2008; 19: 245-251.

10. Ibelli GS, Barroso JM, Capelli A.Influence of cervical preflaring on apical file size determination in

References:1. Nagy CD, Bartha K, Bernath M,

Verdes E andSzabo J. A comparative study of seven instruments in shaping the root canal in vitro.Int Endod J 1997; 30: 124-32.

2. Ove PA.Current challenges and concepts in the preparation of root canal systems: A Review.J Endod 2004; 30:559-567.

3. Jou YT, Karabucak B, Levin J,Liu D. Endodontic working width: current concepts and techniques. Dent Clin North Am 2004; 48:69-85.

4. Contreras MAL, Zinman EH and Kaplan SG. Comparison of the first file that fits at the apex, before and after early flaring. J Endod 2001; 27:113-116.

5. Pecora JD, Capelli A, Guerisoli DMZ. Inf luence of cervical





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Pancham Aggarwal2 Sanjeev Soni3 Vinay S Dua

[9]malocclusion . DAI is integrated into the International Collaboration Study of Oral Health Outcomes by the World Health Organization as an international index, links clinical and aesthetic components mathematically to produce a single

[10]score . As dental auxiliaries can use the DAI to determine which patients to refer to a specialist, this can reduce the number of initial consultations by dentists or orthodontists, an important advantage in

[11],[12]public health programmes . DAI scores have also been found to be significantly associated with the perception of treatment need by students and parents (Cons et al. , 1987; Spencer et al. , 1992), and these are good predictors of the acceptance of future fixed orthodontic therapy (Jenny and Cons,

[12]1996b) .

The DAI has proven to be reliable and [13],[14]valid index . It is generally agreed

that DAI is quick, relatively simple to use [15]and universally acceptable . Besides,

the DAI has been adopted by the World Health Organization (WHO) as a cross-

IntroductionSpecial needs individuals are children or adults who are prevented by a physical or mental condition from full participation in the normal range of activities of their

[1],[2]age groups . The designation is useful for getting needed services, setting appropr ia te goa l s and ga in ing understanding for a child and stressed

[3]family . They usually exhibit high orthodontic treatment needs because of an increased prevalence and severity of

[4],[5],[6]malocclusions . Although their parents are highly motivated to improve the children's quality of life, by improving the appearance and the oral function, they are also the least likely to

[2]receive orthodontic treatment . Careful attention to malocclusion in children with special needs leads to a considerable

[7]improvement in the quality of life .

The Dental Aesthetic Index (DAI), developed in the United States of

[8]America predicts the clinical judgments o f o r thodon t i s t s in separa t ing handicapping from non-handicapping


1 Senior Lecturer, Dept. of Orthodontics & Dentofacial Orthopedics Shaheed K S S D College & Hospital, Sarabha.2 Reader, Dept. of Orthodontics & Dentofacial Orthopedics Desh Bhagat Dental College & Hospital, Muktsar.3 Professor & HOD, Dept. of Orthodontics & Dentofacial Orthopedics M.M. College of Dental Sciences & Research, Mullana (Ambala), Haryana

Malocclusion And Orthodontic Treatment

Need In Children With Special Needs

Evaluated Through Dental Aesthetic Index

Address For Correspondence:Dr. Pancham Aggarwal, Senior Lecturer,Dept. of Orthodontics & Dentofacial Orthopedics,Shaheed Kartar Singh Sarabha Dental College & Hospital,Sarabha, Punjab, India.E mail: [email protected]


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cultural index and has been applied among diverse ethnic groups without modification. All these reasons made it a suitable epidemiological index for using in developing countries, which lack a specifically developed orthodontic

[16]treatment need index . The DAI satisfies this need and can be used in epidemiological surveys to assess unmet

[15],[17]treatment need .

The purpose of this study was to evaluate the var ious malocclus ions and understand the orthodontic treatment need among 12-15 years children with special needs from special schools using Dental Aesthetic Index, so that better treatment services can be planned in future in the field of dentistry to treat the malocclusions.

Materials and MethodsA cross-sectional prospective study was performed among 78 children with special needs (52 boys and 26 girls) from special schools in Chandigarh and its surrounding areas aged between 12 to 15 years. These children were suffering

AbstractAim: To assess the severity of malocclusion and orthodontic treatment need in children with special needs.Method: A cross-sectional prospective study was performed among 78 children with special needs attending special schools, 12–15 years of age in Chandigarh and its surrounding areas. The Dental Aesthetic Index (DAI) was used in order to estimate the orthodontic treatment need. Data consisting of DAI components were recorded in WHO Oral Health Assessment Form (1997). The collected data were subjected to statistical analysis using Statistical Package for Social Sciences (SPSS Inc., Chicago IL, version 15.0 for Windows). The reliability between the

2two examiners was calculated by Cronbach’s Alpha. The Chi-square test (X ) and Fisher’s exact test were used to compare proportions.Results: Among the 78 children with special needs examined, 52 (66.7%) were boys and 26

_(33.3%) were girls. Out of these 43.6% children had DAI scores < 25 with no or minor malocclusion requiring no or little treatment, 17.9% had DAI scores of 26–30 with definite malocclusion requiring elective treatment, 17.9% had DAI scores of 31–35 with severe

_malocclusion requiring highly desirable treatment, and 20.5% had DAI scores > 36 with handicapping malocclusion requiring mandatory treatment.Conclusion: This study suggests that a large proportion of the children with special needs had very severe malocclusion where treatment is considered mandatory. Mentally disabled children have more orthodontic treatment need than the treatment need for sensory impaired children.

Key WordsChildren with special needs, Dental Aesthetic Index, Malocclusion and Treatment need.

from various developmental, physical and mental disabilities [Table 1]. This age group was chosen as this is the age when the malocclusion is expressed fully and the need for orthodontic treatment can be estimated so that the early intervention is possible.

Students were excluded from the study if they wore an orthodontic appliance or reported a history of previous orthodontic treatment, who were not cooperative for oral examination, children below the age of 12 years and children above the age of 15 years. The study was approved by the Ethical Committee and prior consent to conduct the study was obtained from the respective school authorities and from the parents or guardians of the children.The dental examinations and diagnostic criteria followed the World Health Organization recommendations for oral

[18]health surveys . Clinical examinations for evaluating DAI were made by two calibrated examiners. Thorough methodology t ra in ing for DAI measurements was done prior to the data collection at the Department of O r t h o d o n t i c s a n d D e n t o f a c i a l Orthopedics, M. M. College of Dental Sciences and Research, Mullana, Haryana. Twenty five of the children were re-examined 1 month after their initial examination to check the reliability of two examiners. The reliability of two examiners was calculated by Cronbach's Alpha.

The students were examined in natural daylight in one of the brightest rooms of their school using the Community Periodontal Index (CPI) probe, metal millimeter ruler and mouth mirror. Clinical examinations for evaluating DAI were made and the data was collected in WHO Oral Health Assessment Form (1997). Scores for each component were then multiplied by its corresponding regression coefficient using the rounded weights. The products were added, and summed up with the regression constant to give the DAI score [Table 2].

The result was then grouped according to various malocclusion severity levels:1. < 26: little or no treatment need2. 26 to 30: treatment elective3. 31to 35: treatment highly desirable 4. > 35: treatment mandatory

The statistical analysis was carried out using Statistical Package for Social


Sciences (SPSS Inc., Chicago, IL, version 15.0 for Windows). Qualitative or categorical variables were described as frequencies and proportions. Proportions were compared using Chi square or Fisher's exact test whichever was applicable. All statistical tests were two-sided and performed at a significance level of α=0.05.

ResultsThe reliability between two examiners was 0.903 which is more than 0.7 it indicated that values of two observers were reliable and the correlation coefficient between examiner 1 and examiner 2 was 0.824 which is excellent correlation.

Among the total 78 children with special needs, 52 (66.7%) were boys and 26 (33.3%) were girls. From these 10 (12.8%) of the children were suffering from autism, 4 (5.1%) were suffering from Down Syndrome, 11 (14.1%) were hearing impaired, 2 (2.6%) were

suffering from learning disability, 43 (55.1%) were suffering from mental retardation, 2 (2.6%) were suffering from orthopaedic disability, 1 (1.3%) were suffering from spastic paraplegia and 5 (6.4%) were visually impaired. The DAI scores calculated for all the disabled children are shown in Table 1. No statistically significant differences were observed with in the study group for

DISABILITY

Autism

Down Syndrome

Hearing Impaired

Learning Disability

Mental Retardation

Orthopaedic Disability

Spastic Paraplegia

Visually Impaired

Total

n (%)

10 (12.8)

4 (5.1)

11 (14.1)

2 (2.6)

43 (55.1)

2 (2.6)

1 (1.3)

5 (6.4)

78 (100)

DAI scores

<_ 25 n (%)

5 (14.7)

0 (0)

7 (20.6)

0 (0)

15 (44.1)

1 (2.9)

1 (2.9)

5 (14.7)

34 (100)

26–30 n (%)

1 (7.1)

2 (14.3)

1 (7.1)

1 (7.1)

8 (57.1)

1 (7.1)

0 (0)

0 (0)

14 (100)

31–35 n (%)

2 (14.3)

2 (14.3)

3 (21.4)

1 (7.1)

6 (42.9)

0 (0)

0 (0)

0 (0)

14 (100)

>_ 36 n (%)

2 (12.5)

0 (0)

0 (0)

0 (0)

14 (87.5)

0 (0)

0 (0)

0 (0)

16 (100)

2X = 29.349 (a), df= 21, P= 0.106

Table 1. Disability wise distribution of DAI scores.

DAI Components

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

Rounded weights

1

1

3

1

1

2

4

4

3

13

6No. of missing incisor, canine or premolar

teeth in maxillay and mandibular arches

Crowding in the incisal segment

(no. of segments crowded)

Spacing in the incisal segments

(no. of segments spaced)

Mid line diastema in millimeters

Largest anterior maxillary irregularity in millimeters

Largest anterior mandibular irregularity in millimeters

Anterior maxillary overjet in millimeters

Anterior mandibular overjet in millimeters

Vertical anterior open bite in millimeters

Antero-posterior molar relation; largest deviation

from normal either left or right , 0=normal,

1=1/2 cusp either mesial or distal, 2=1 full

cusp or more either mesial or distal

Constant

Table 2. Standard Dental Aesthetic Index (DAI) scoringDAI components Boys n (%) Girls n (%) Total n (%)

2X , P

Missing anterior teeth

Incisal segment crowding

43 (82.7)

9 (17.3)

25 (96.2)

1 (3.8)

68 (87.2)

10 (12.8)

2X = 2.810 (b)

P= 0.094

0

1–2 segments

13 (25.0)

39 (75.0)

32 (61.5)

20 (38.5)

39 (75.0)

13 (25.0)

25 (48.1)

27 (51.9)

17 (32.7)

35 (67.3)

30 (57.7)

22 (42.3)

45 (86.5)

7 (13.5)

51 (98.1)

1 (1.9)

28 (53.8)

19 (36.5)

5 (9.6)

10 (38.5)

16 (61.5)

23 (29.5)

55 (70.5)

2X = 1.511 (b)

P= 0.219

Incisal segment spacing

0

1–2 segments

0–2 mm

>2 mm

Normal

Half cusp deviation

Full cusp deviation

12 (46.2)

14 (53.8)

22 (84.6)

4 (15.4)

16 (61.5)

10 (38.5)

10 (38.5)

16 (61.5)

9 (34.6)

17 (65.4)

23 (88.5)

3 (11.5)

25 (96.2)

1 (3.8)

12 (46.2)

9 (34.6)

5 (19.2)

44 (56.4)

34 (43.6)

61 (78.2)

17 (21.8)

41 (52.6)

37 (47.4)

27 (34.6)

51 (65.4)

39 (50.0)

39 (50.0)

68 (87.2)

10 (12.8)

76 (97.4)

2 (2.6)

40 (51.3)

28 (35.9)

10 (12.8)

2X = 1.668 (b)

P= 0.196

2X = 0.940 (b)

P= 0.332

2X = 1.260 (b)

P= 0.262

2X = 1.177 (a)

P= 0.555

2X = 3.692 (b)

P= 0.055

2X = 0.057 (b)

P= 0.811

2X = 0.257 (b)

P= 0.612

2X = 1.468 (a)

P= 0.480

Midline Diastema

Maxillary anterior irregularity

Mandibular anterior irregularity

Anterior maxillary overjet

Anterior mandibular overjet

Vertical anterior open bite

Antero-posterior molar relation

Table 4. Distribution of DAI components.

0

>_ 1 mm

0

>_ 1 mm

0

>_ 1 mm

0

>_ 1 mm

0

>_ 1 mm

0

>_ 1 mm

2different disabilities (X =29.349, p=0.106). Among the 78 children, 21 (26.9%) belonged to 12 years of age group, 17 (21.8%) belonged to 13 years of age group, 19 (24.4%) belonged to 14 years of age group and 21 (26.9%) belonged to 15 years of age group. No statistically significant differences were observed with in the study group for

2different age groups (X =7.495, p=0.586). [Table 3]

Out of the 78 examined school children, 68 (87.2%) had no missing anterior teeth while 10 (12.8%) had 1 or more missing anterior teeth. Among the 52 examined boys, 43 (82.7%) had no missing anterior teeth, and 9 (17.3%) had 1 or more missing anterior teeth. Among the 26 examined girls, 25 (96.2%) had no missing anterior teeth, and 1 (3.8%) had 1 or more missing anterior teeth. A total of 23 (29.5%) school children had no incisal segment crowding and 55 (70.5%) had 1- or 2-segments crowding. A total of 44 (56.4%) school children had no incisal segment spacing and 34 (43.6%) had 1- or 2-segments spacing. Of 78 school children examined, 61 (78.2%) had no midline diastema and 17 (21.8%) had diastema of 1-4 mm. [Table 4]

41 (52.6%) of the children had no


maxillary anterior teeth irregularity and 37 (47.4%) had more than 1 mm maxillary anterior irregularity. A total of 27 (34.6%) of the children had no mandibular anterior teeth irregularity and 51 (65.4%) had more than 1 mm mandibular anterior irregularity. [Table 4]

In the present study, 39 (50.0%) school children had an anterior maxillary overjet of 0 to 2 mm, and 39 (50.0%) had an overjet of >2 mm. Of the boys, 30 (57.7%) had an anterior maxillary overjet of 0 to 2 mm, and 22 (42.3%) had an overjet of >2mm. 9 (34.6%) of the girls had an anterior maxillary overjet of 0 to 2 mm and 17 (65.4%) had an overjet of >2mm. Of the 78 examined school children, 68 (87.2%) had no mandibular overjet and 10 (12.8%) had a mandibular overjet of 1-5 mm. Of the 78 examined school children, 76 (97.4%) had no anterior open bite and 2 (2.6%) had an anterior open bite of 1-2 mm. Of the 78 examined school children, 40 (51.3%) had normal molar relationship, 28 (35.9%) had half-cusp deviation, and 10 (12.8%) had full-cusp deviation. However, for all 10 components of DAI, there were no statistically significant differences observed between boys and girls. [Table 4]

In the present study, the distribution of DAI scores and orthodontic treatment needs showed, 34 (43.6%) had DAI scores <_ 25 with no abnormality or little malocclusion requiring no or slight treatment, 14 (17.9%) had DAI scores of 26-30 with definite malocclusion requiring elective orthodontic treatment, 14 (17.9%) had DAI scores of 31-35 with severe type of malocclusion requiring highly desirable orthodontic treatment, 16 (20.5%) had DAI scores >_ 36 with v e r y s e v e r e o r h a n d i c a p p i n g malocclusion requiring mandatory type of orthodontic treatment. [Table 5]

Among the students who were having DAI scores <_ 25, 23 (67.6%) were boys and 11 (32.4%) were girls. Students having DAI scores of 26-30, comprised 10 (71.4%) boys and 4 (28.6%) girls. Students having DAI scores of 31-35, comprised 8 (57.1%) boys and 6 (42.9%) girls. Students having DAI scores >_ 36 comprised 11 (68.7%) boys and 5 (31.3%) girls. No statistically significant differences were found with in the study group between the boys and girls.

2(X =0.760, p=0.859). [Table 6]

DiscussionThe results of this study indicated that 43.6% of the disabled children had a dental appearance that required no or thodont ic t rea tment . This i s comparable to the study of Onyeaso CO for mentally handicapped children in Ibadan, Nigeria which reported about

[19]42% not requiring treatment .This result is, however, lower than that reported by Shivakumar and Chandu in a study of same age group of normal Indian

[20]children . In this latter study, over 79.9% of the normal children had DAI scores of 25 or less with slight or no treatment need. Furthermore, the results of our study indicated that the children with special needs had a higher DAI score of >_ 36 than the normal Indian children. It came out to be 20.5% in our study, which is very high in comparison to 0.5% as reported by Shivakumar and

[20]Chandu . It shows that children with special needs had a high frequency of v e r y s e v e r e o r h a n d i c a p p i n g malocclusion indicating mandatory treatment need as compared to normal children.

A large proportion of the children had severe to very severe malocclusion with treatment considered mandatory based on the decision points on the DAI scale.

DAI Components

Age

12

13

14

15

Total

n (%)

21 (26.9)

17 (21.8)

19 (24.4)

21 (26.9)

78 (100)

<_ 25 n (%)

No/slight need

10 (29.4)

7 (20.6)

9 (26.5)

8 (23.5)

34 (100)

26–30 n (%)

Elective treatment

3 (21.4)

4 (28.6)

5 (35.7)

2 (14.3)

14 (100)

31–35 n (%)

Highly desirable

5 (35.7)

3 (21.4)

3 (21.4)

3 (21.4)

14 (100)

>_ 36 n (%)

Mandatory treatment

3 (18.8)

3 (18.8)

2 (12.5)

8 (50.0)

16 (100)2X = 7.495 (a), df= 9, P=0.586

Table 3. Age wise distribution of DAI scores and orthodontic treatment needs.

n (%)

34 (43.6)

14 (17.9)

14 (17.9)

16 (20.5)

DAI scores

<_ 25

26–30

31–35

>_ 36

Severity of malocclusion

No abnormality or minor malocclusion

Definite malocclusion

Severe malocclusion

Very severe or handicapping

Treatment need

No or slight need

Elective

Highly desirable

Mandatory

Table 5. Prevalence of malocclusion and orthodontic treatment needs of study population.

Gender

Boys

Girls

Total

n (%)

52 (66.7)

26 (33.3)

78 (100)

<_ 25 n (%)

23 (67.6)

11 (32.4)

34 (100)

26–30 n (%)

10 (71.4)

4 (28.6)

14 (100)

31–35 n (%)

8 (57.1)

6 (42.9)

14 (100)

>_ 36 n (%)

11 (68.7)

5 (31.3)

16 (100)

DAI scores

2X = 0.760 (a), df= 3, P= 0.859

Table 6. Gender wise distribution of DAI scores.


5. Establish a good doctor-patient relationship, to gain the child's and parents' trust and to improve their confidence.

References1. Becker A, Shapira J,Chaushu S:

Orthodontic treatment for disabled children-A survey of patient and appliance management.Jour of Orthodontics/vol.28/2001/39-44.

2. Becker A, Chaushu S, Shapira J: Orthodontic treatment for the special needs child. Seminars in orthodontics Dec 2004; vol. 10(4): 281-292.

3. Soni S, Aggarwal P, Dua V: The Use of Index of Orthodontic Treatment Need (IOTN) in Children with S p e c i a l N e e d s . I n t J C o n t Dentistry.June 2011;2(3):72-79.

4. Shah N, Mathur V, Logani A: Guide l ines fo r Ora l Hea l th Promotion & Intervention for Disabled Population. Developed under GOI - WHO Collaborative Program (Biennium 08-09).

5. Koidin MB: Orthodontic care for the person with special needs: an overview. Exceptional Parent. May 2002: 1-2.

6. Winter K, Baccaglini L, Tomar S: A review of malocclusion among individuals with mental and physical disabilities. Special Care in Dent. 2008; 28(1):19-26

7. Oliveira A, Paiva S: Prevalence and determinant factors of malocclusion in children with special needs.Ejo. oxfordjournals.org/ content/ early/ 2010/ 10/18/ejo.cjq094.abstract.

8. Huwaizi A, Rasheed T: Assessment of orthodontic treatment needs of Iraqi Kurdish teenagers using the Dental A e s t h e t i c I n d e x . E a s t e r n Mediterranean Health Journal. 2009; vol 15(6): 1535-41.

9. Jenny J, Cons NC:Predicting handicapping malocclusion using the Dental Aesthetic Index (DAI). Int Dent J. 1993 Apr;43(2):128-32.

10. Danaei S, Amirrad F: Orthodontic treatment needs of 12-15-year-old students in Shiraz, Islamic Republic of Iran. Le Rev de S de la Medi or.2007; vol 13 (2): 326-334.

11. Cons NC, Jenny J: Comparing ethnic group-specific DAI equations with the standard DAI.Int Dent J. 1994 Apr;44(2):153-8.

12. Hamamci N, Basaran G: Dental Aes the t ic Index scores and perception of personal dental a p p e a r a n c e a m o n g Tu r k i s h

relationship discrepancies which is higher than that reported in the normal population 9.9% by Shivakumar and

[20]Chandu .

Utomi and Onyeaso found 36.2% of mentally handicapped children having severe and very severe malocclusion indicating treatment highly desirable and

[15]mandatory using DAI . In our study, 46.51% of children with mental retardation fall in this category which is slightly higher than their study. This means mentally handicapped children are really suffered from malocclusions requiring very much need for orthodontic treatment. Luppanapornlarp and Leelataweewud found 37.5% of autistic children having severe and very severe malocclusion indicating treatment highly

[14]desirable and mandatory using DAI . In our study, 40% of children with autism came out for this category which is nearly similar to their study.

Although, DAI is a relatively simple, reproducible, valid and appears to be the easiest tool to use, but it does not take into account buccal crossbite, posterior open bite, central line discrepancies, or a deep overbite, factors which may have considerable impact on treatment complexity and, therefore, weaken the index.

Conclusion1. A large proportion of the children

with specials needs had very severe malocclusion where treatment is considered mandatory.

2. The children with special needs had higher frequencies of all the malocclusion traits than normal children. Hence children with special needs have more orthodontic treatment needs than the treatment needs for normal children.

3. The mentally disabled children had higher frequencies of all the malocclusion traits than sensory impaired children. Hence mentally disabled children have more orthodontic treatment needs than the treatment needs for sensory impaired children.

4. Malocclusion is not a single entity but rather a collection of situations, each in itself constituting a problem, and any of these situations can be complicated by a multitude of genetic and environmental causes, so further studies in future can help in exploring more.

Unfortunately, the orthodontic treatment need of these children may not be met due to environmental factors and individual characteristics. Those with disabilities often lack the ability to recognize health problems and when they do recognize the need for services, many environmental and individual barriers prevent them from receiving necessary care. Constraints in a developing country like India are such that access to dental services including orthodontic care is impeded by several factors. These include the relatively low dental awareness, low number of orthodontic specialists, high cost of treatment, socio economic status of the patients and the lean budgetary allocation to oral health care.

Concerning the different malocclusion traits, hypodontia was found to occur in 12.8% of the study population which is comparable to that (7%) previously reported by Onyeaso CO among the

[ 2 1 ]handicapped children . Spacing occurred quite frequently among the disabled children. The higher prevalence of spacing in the disabled was a reflection of the higher frequency of missing teeth noted in such subjects, which our present study confirms.

About one-half of the study population noted with increased overjet is very high when compared to 6.7% observed in the normal population by Shivakumar and

[20]Chandu . This is of orthodontic concern, as in a previous report by Franklin and Luther children with cerebral palsy have a significantly increased overjet when compared with

[22]normal children . Children with mental retardation formed a large proportion of the study population. This may, therefore, explain the higher percentage of malocclusion in this study population when compared with the normal population. Anterior open bite was observed in 2.6% of the study population which was very less than that 25.5% noted by Utomi and Onyeaso in the

[15]mentally handicapped children . It is, however, comparable to that 2.4% reported by Shivakumar and Chandu in

[20]normal subjects . Oral dysfunctions and parafunctions of the masticatory system has been suggested as being responsible for the increased prevalence of malocclusion in mentally handicapped

[23]children by Oreland and Heijbel .

48.7% of the population had molar

University students. Eur J Ortho. 31(2009): 168-173.

13. Joanna J, Naham C: Comparing and contrasting two orthodontic indices, the Index of Orthodontic Treatment Need and the Dental Aesthetic Index. A m J O r t h o d D e n t o f a c Orthop.1996;110:410-6.

14. Luppanapornlarp S, Leelataweewud P : P e r i o d o n t a l S t a t u s a n d Orthodontic Treatment Need of Autistic children. World Journal of Orthodontics. 2010; vol.11, no.3: 256-261.

15. U t o m i I L , O n y e a s o C O : Malocclusion and orthodontic t r ea tment need of menta l ly handicapped children in Lagos, Nigeria: Pesq Bras Odontoped Clin Integr, João Pessoa. 2009; 9(1):7-11.

16. Naham C, Joanna J: Utility of the


D e n t a l A e s t h e t i c I n d e x i n Industrialized and Developing Countries. Journal of Public Health Dentistry.June 1989; Volume 49, Issue 3, pages 163-166.

17. Jenny J, Cons NC: Establishing malocclusion severity levels on the Dental Aesthetic Index (DAI) scale. Aust Dent J. 1996 Feb;41(1):43-6.

18. World Health Organization: Oral Health Surveys-Basic Methods 4th edition. Geneva 1997; ISBN: 9241544937.

19. ONYEASO CO: Orthodont ic t r ea tment need of menta l ly handicapped children in Ibadan, Nigeria, according to the dental aesthetic index. Journal of dentistry for children. 2003; vol. 70(2), pp. 159-163.

20. Shivakumar KM, Chandu GN:

Severity of malocclusion and orthodontic treatment needs among 12-to-15-year-old school children of Davangere District, Karnataka, India. Eur J Dent. 2010; vol 4: 298-307.

21. Onyeaso CO: Malocclusion pattern among the handicapped children in Ibadan, Nigeria. Nig J Clin Pract. 2002; 5(1): 52-60.

22. Franklin DL, Luther F: The prevalence of malocclusion in children with Cerebral palsy. Eur J Ortho. 1996; vol 18: 637-643.

23. Oreland A, Heijbel J: Oral function in the physically handicapped with or without severe mental retardation. ASDC J Dent Child. 1989 Jan-Feb; 56(1): 17-25.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Ritu Jindal2 Rohini Dua3 Eera Bunger

There are multiple approaches to measuring childhood temperament including temperament scales, maternal reports, naturalistic measures and laboratory observations. The use of temperament questionnaires has gained acceptance by parents who consider that it enhances the understanding and management of their children. When associated with inappropriate feeding habits, ECC results in demineralization of the primary dentition, starting from maxillary anterior teeth and followed by maxillary and mandibular primary

[10]molars.Keeping this in mind, we conducted a study to determine if a relationship exists between a mother's perception of her child's temperament and child's risk factors for ECC.

Materials and MethodsTwo hundred children of 2-6 years age reporting to the Department of Pedodontics and Preventive dentistry, National Dental College, Dera Bassi, Mohali were evaluated between March 2011 to October 2011. The eligibility criteria for this study included healthy child status (ASA I) and the presence of

IntroductionEarly childhood caries (ECC) is a unique3.6ttern of dental decay afflicting

[6]infants and young children. As we enter the next millennium, dental caries remains a significant problem. The increased prevalence, high cost associated with ECC has lead some researchers to look beyond biological factors and explore behavioral factors to understand ECC's development and

[11]prevention.

Infant temperament, in particular has received considerable attention as a tendency to crying and as an early

[4],[2]predictor of clinical problems. Temperament refers to an infant's style of interaction with the environment, and appears heritable and stable across time, but modifiable by later environmental influences[3]. Studies have shown that children with "difficult" temperament were more likely than those with "easy"

[13],[14]ones to develop behavior disorders.Both feeding and temperament have seldom been considered together, nor have they been distinguished from other potential ly important variables, especially in nonclinical populations.


1,2 Professor3 Pg Student Dept. Of Pedodontics & Preventive Dentistry National Dental College And Hoapital, Dera Bassi

Is Child’s Temperament a cause of Early

Childhood Caries (ECC)?

Address For Correspondence:Dr. Ritu JindalHouse No - 279Urban Estate Phase II, Jalandhar Punjab

th Submission : 10 July 2012st Accepted : 1 February 2013

Quick Response Code

all four maxillary primary anteriors and maxillary first primary molars. Informed consent was taken from the parents explaining the aim, importance of the study.First, a Demographic survey data regarding the child's age, gender, and educational status of the mother, parent's occupation and mother's perception of her child's temperament was collected. The questionnaire consisted of a printed form which included series of questions regarding child's feeding practices, oral hygiene practices, and mother's perception of her child's temperament. It was made in English, Hindi and regional language (Punjabi). It was designed to be as simple as possible and included all the i m p o r t a n t e t i o l o g i c a l f a c t o r s . Questionnaire form was filled by the mothers. Children were then examined in the presence of mother.All eligible children were clinically examined in a dental chair using light source, mirror to diagnose caries using

[16]d d caries criteria. (Table 1) No 1 2-3

attempt was made to probe or radiograph the teeth. Dental examinations were carried out by one dentist.Using EAS Temperament scale for children as a standard reference,

[3]questionnaire was set. (Table 2)

AbstractBackground: Early childhood caries (ECC) is a significant pediatric problem. In recent years, ECC has begun to be associated to numerous social and psychosocial environmental conditions, one of which is child’s temperament.Aim: The purpose of this study was to determine if a relationship existed between mother’s perception of her child’s temperament and risk factors for Early Childhood Caries (ECC). Methods and Materials: The study sample consisted of 200 children aged 2-6 years. Informed consent was taken. Questionnaire was given to mothers regarding child’s feeding practices, oral hygiene practices and her perception of child’s temperament.Results: Data collected was processed and analyzed using SPSS statistical software program. “Easy” children were significantly more likely to be breast fed to sleep (72%). “Difficult” children were mostly bottle fed to sleep (77%) and had more carious involvement (79%). Child’s temperament perceived by mothers may be related to important ECC risk factors. Males were more likely to be perceived by their mothers as “difficult” than females (59%). “Easy” children had their teeth brushed twice daily (14.5%).Conclusion: Mother’s perception of child’s temperament may be related to important early childhood caries risk factors.

Key WordsTemperament, Risk Factors, Early Childhood Caries, Feeding.


Responses were divided into either "easy" or "difficult" according to mother's perception for the purpose of statistical analysis. The data were subsequently processed and analyzed using the SPSS statistical Software program. Chi - Square test was employed

to evaluate the results. All tests had 0.05 level of statistical significance. This study was approved by the Institutional Review Board.

ResultsData was collected from 200 records of children ages from 2 to 6years. Ninety nine subjects were males (41%) and one hundred and one were females (59%). A significant relationship was found between temperament reported by mothers and child's gender where males were more likely to be perceived as "difficult" than females, the difference being statistically significant(p=0.016). 110(55%) of the subjects were reported by their mothers as "easy" and 90(45%) were reported as "difficult". Relationship between perceived temperament of child and the child's feeding habits was found to be varying significantly (Table 3). As for brushing habits, significant relationship was found between "difficult" and "easy" children regarding their oral hygiene practices (Table 4). Perceived temperament and past dental status of child also shown to have statistically significant results (Table 5). Lastly, "difficult" children were found to have carious lesion significantly more often than "easy" children (Table 6).

DiscussionThe present study is an effort to link child's temperament using EAS Temperament scale and ECC. The results revealed that children perceived as "easy" were more likely to be breast fed to sleep. The scientific literature available on breast-feeding and its relationship to dental caries is meager as

[11]that related to bottle-feeding. Valaitis et al was unable to draw conclusions regarding the relationship between ECC and breast-feeding. This is because of inconsistencies in the methodology and differences in definitions of ECC and

[15]breast feeding. Unlike other studies, this research correlates chi ld 's temperament with breast-feeding or oral

Table 1 . Caries Diagnosis Criteria

Smooth Surfaces

Appearance/colour

Surface

Tactile

Location

Pits & fissures

Appearance/colour

Surface

Tactile

Undermining

d1 lesions

Chalky white

Intact

Normal

Adjacent to soft tissue

Chalky white margin

Intact

Normal

Not present

d2-3 lesions

Chalky white with darker centre

Cavitated- definite loss of tooth

structure

Soft

Adjacent to soft tissue margin

Stained light to dark brown

Cavitated- definite loss of tooth

structure

Soft

Evident

Table 2. Sample questions using EAS Temperament scale

a) How active is your child?

Very energetic

Little lazy

b) How emotional is your child?

Gets upset easily

Easy going

c) How your child does behave socially?

Takes long time to mix with strangers

Likes to be with people

d) Does your child get along with people?

Tends to be shy

Makes friends easily

Table 3. Relationship Between Perceived Temperament And Feeding Habits (n=200)

Manner of feeding

Breast

Bottle

Both

Duration of breast feeding

>12 months

Duration of bottle feeding

25-36 months

Breast fed to sleep

Yes

No

Bottle fed to sleep

Yes

No

Breast fed on demand

Yes

No

Pacifier usage

Yes

No

Easy (%)

(n=110)

63(57.2%)

7(6.4%)

40(36.4%)

89(81%)

18(16.4%)

79(72.0%)

31(28.0%)

52(47.0%)

58(53.0%)

90(82.0%)

20(18.0%)

(n=110)

32(29.0%)

78(71.0%)

Difficult (%)

(n=90)

22(24.4%)

18(20.0%)

50(55.6%)

48(54%)

18(20%)

52(58.0%)

38(42.0%)

69(77.0%)

21(23.0%)

62(69.0%)

28(31.0%)

(n=90)

42(47.0%)

48(53.0%)

p value

<.001*

<.001*

<.001*

.038*

<.0001**

.033*

.010*

*Chi-square test statistic; significance= p<.05

Table 4. Relationship Between Perceived Temperament And Oral Hygiene Practices(n=200)

Frequency of brushing

Once daily

Twice daily

Supervision of tooth brushing

Child alone

Parent

Child under supervision

Tooth Cleaning Aids

Tooth paste & brush

Tooth paste & finger

Any other means

Brushing at night

Yes

No

Easy (%)

(n=110)

84(85.5%)

26(14.5%)

64(58.2%)

24(21.8%)

22(20.0%)

96(87.3%)

14(12.7%)

0(0%)

22(20.0%)

88(80.0%)

Difficult (%)

(n=90)

79(87.8%)

11(12.2%)

45(50.0%)

15(16.7%)

30(33.3%)

85(94.4%)

0(0%)

5(5.6%)

18(20.0%)

72(80.0%)

p value

.038*

.097

<.001*

1

Table 5. Relationship Between Perceived Temperament And Past Dental Status(n=200)

Ever Visited Dentist

Yes

No

If yes, Last visit to Dentist

<6 months

<6 months

Easy (%)

(n=110)

62(56.0%)

48(44.0%)

(n=62)

35(56.0%)

27(44.0%)

Difficult (%)

(n=90)

38(42.0%)

52(58.0%)

(n=38)

13(34.0%)

25(66.0%)

p value

.046*

.030*

Table 6. Relationship Between Perceived Temperament And Caries (n=200)

Carious Lesion

Yes

No

Easy (%)

(n=110)

56(50.9%)

54(49.1%)

Difficult (%)

(n=90)

71(79.0%)

19(21.0%)

p value

<.001***

*Chi-square test statistic; significance= p<.05

hygiene habits.Literature has shown that if child maintains low sugar diet and good oral hygiene, caries incidence is less in breast

[1],[12],[17]fed children. Current study suggested that children perceived as "difficult" took bottle to bed more often and were at higher risk for caries development. This corroborates the

[5],[6]earlier findings.Besides feeding duration; timing, frequency and content of feeding may also be related to temperament10. In our study, "easy" children were breast fed beyond 12 months and "difficult" children were bottle fed up to 25-36 months. Also stated in literature that children who were breast fed had less caries as compared to those who were

[5]bottle fed.Maziade et al and Prior et al, reporteda greater proportion of boys to have a difficult temperament, harder for their mothers to manage and showed more

[7],[9]behavior problems. . Our results are in confirmation to the available data. Males were more likely to be perceived as "difficult" than females. This might be because of our social set up; boys are believed to be of active temperament as compared to girls.Majority of the children, irrespective of "easy" or "difficult" group used tooth brush and paste as a tooth cleansing aid.This study has showed that "easy" children had their teeth brushed twice daily because they possibly did not protes t as much as "diff icul t" children.Most of the children were found to brush their teeth once daily. Non significant results were found for brushing under supervision and night brushing."Easy" children had reported to visit dentist significantly more often than "difficult" children. Moreover, last visit to dentist within 6 months was more often for "easy" children. "Difficult" children were found to have more caries as compared to "easy" children.Using simple method of child's temperament assessment, our results showed relationships between mother's perceptions of child's temperament and ECC. It is of paramount importance that the caregiver/parent be aware of the potential ramifications of each etiological factor and correct it at the earliest.By identifying child's temperament, parents can be educated on what attempts can be made to modify child's behavior.


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17. Winter GB, Rule DC, Mailer GP, James PMC, Gordon PH. The prevalence of dental caries in preschool children aged 1 to 4 years. Br Dent J 1971;130:271.

York, NY: John Wiley; 1989:537-556.

Besides these, clinician may suggest alternative methods of parental management when the child, the environment and the parent are not interacting in an effective way. Proper anticipatory guidance, periodic dental checkups and adequate preventive and corrective treatment for the diseased can avoid the severity of dental caries in children in "easy" and "difficult" groups.

ConclusionResults of the present study concluded that:Ÿ Children perceived as "easy" were

more likely to be breast fed, have their teeth brushed twice daily.

Ÿ Children perceived as "difficult" were more likely to be males and were bottle fed, had their teeth brushed once daily and had higher incidence of carious lesions.

Ÿ Maternal reported child temperament may be related to important early childhood caries risk factors.

References1. Alaluusua S, Myllarniemi S, Kallio

M, Salmenpera L, Tainio VM. Prevalence of caries and salivary levels of mutans streptococci in 5-year-old children in relation to duration of breast feeding. Scand J Dent Res 1990;98:193-196.

2. Bates JE. The concept of difficult temperament. Merrill-Palmer Q. 1982;26:289-319.

3. Buss A, Plomin R: Temperament: Early developing personality traits. Hillsdale NJ: Erlbaum, 1984.

4. Carey WB. Maternal anxiety and infantile colic. Is there a relationship? Clin Pediatr . 1968;7:590-595.

5. Holt RD, Joels D, Bulman J, et al. A third study of caries in preschool aged children in Camden. Br Dent J. 1988;165:87-91.

6. Marino RV, Bomze K, Scholl TO, Anhalt H. Nursing bottle caries: characteristics of children at risk. Clin Pediatr (Phila).1989;28(3):129-31.

7. Maziade M, Cote R, Boudreault M, Thivierge J, Caperaa P. The New York longitudinal studies model of temperament: Gender differences and demographic correlate in a French-





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Nitasha Gandhi2 Rajashekhar Sangur3 H.R. Dayakare4 Sumir Gandhi

properties. Zakaria et al reported some benefit from using two agents," liquid dispersing agent and microcrystal

[3]additive," but the composition of these components was not specified. The addition of a mixture of Gum Arabic and Calcium Hydroxide to Types II and Type I I I gypsum produc t s has a l so

[4]demonstrated the same effect .It is stated that incorporation of Gum Arabic and Calcium Hydroxide in different proportions like 1% of Gum Arabic and 0.132% of Calcium Hydroxide, 2% of Gum Arabic and 0.2% Calcium Hydroxide will improve the

[5]hardness . But there is no specific evidence in the dental literature stating how much percentage of Gum Arabic and Calcium Hydroxide will provide the better hardness to gypsum products.The present study was planned to compare the surface hardness of Type I, Type II and Type III gypsum products in relation to addition of Gum Arabic and Calcium Hydroxide in different proportions.Materials and methodsArmamentariums used in this study are-1. Electronic precision balance2. Vibrator3. Volumetric beaker4. Rubber bowl

IntroductionGypsum products probably serve the dental profession more adequately than any other material used in dentistry. Dental plaster, dental stone, high strength dental stone and casting investment material constitute this group of products which are closely related. Dental gypsum products are most widely used among other cast and die materials because of ease of manipulation and other reasonable properties dimensional stability, compatibility with different materials etc.It is important that cast and die material must have adequate surface hardness to resist abrasion, unfortunately currently available Type I, Type II and Type III do not fill the ideal requirement in relation to hardness which many times results in failure of prosthesis. It has been found possible to produce gypsum products with adequate hardness by incorporation of additives. One method of improving

[1]hardness is to impregnate epoxy resin on gypsum although hardening solution

[2]may be beneficial but their application involves extra step in cast or die preparation. Studies to reduce the water requirement of dental gypsum products have been conducted to produce set materials with less porosity, greater density and enhanced mechanical


1 Prof. & Head , Department of Prosthodontics Christian Dental College2 Professor & Head , Department of Prosthodontics Rama Dental College, Kanpur3 Professor & Head , Department of Prosthodontics College of Dental Sciences, Davengere4 Professor & Head , Department of Oral Surgery Christian Dental College, Ludhiana

Effects of Gum Arabic and Calcium Hydroxide

on the surface hardness of Type I, Type II and

Type III Gypsum Products— A Comparative

Study

Address For Correspondence:Dr. Nitasha GandhiDept of ProsthodonticsChristian Dental CollegeCMC Brown Road Ludhiana (Pb)

rd Submission : 23 April 2012th Accepted : 25 February 2013

Quick Response Code

5. Straight stainless steel mixing spatula6. Vicker's hardness testing machine7. Micrometer microscope

Materials used in this study are-1. Type I Impression Plaster. [ Ramen

research Industry, Kolkata, India]2. Type II model plaster [Asian

Chemicals]3. Type III dental stone [Asian

Chemicals]4. G u m A r a b i c [ S w a s t i k

Pharmaceuticals Mumbai]5. Calcium Hydroxide [Deepti Dental

Products, Ratnagiri, Karnatak]6. Water

The study was conducted in two phases-I) Preparation of samplesII) Evaluation of surface hardness.Standardized rubber moulds ( synthetic rubber-33077 Vulcoform) measuring 1.5 cm height and 1 cm diameter in dimensions were fabricated in a private firm to prepare the uniform size samples for the present study. Selected gypsum products were taken in specified quantity with the help of an electronic precision

AbstractObjective Gypsum products are used frequently in dentistry. Presently available Type I (Impression plaster), Type II (Dental plaster) and Type III (Dental stone) gypsum products do not fulfill the ideal requirements in relation to hardness. Methods Surface hardness of Type I, Type II and Type III gypsum products with the addition of Gum Arabic and Calcium Hydroxide in different concentrations were measured with Vicker’s hardness testing machine and results were compared with control group. Results It has been noted that the surface hardness was increased significantly for dental plaster and dental stone but there was minimal change in hardness of impression material. Type III gypsum product with the proportion of 2% Gum Arabic + 0.2% Calcium Hydroxide showed the highest value. Significance Addition of Gum Arabic and Calcium hydroxide in different proportions increase the surface hardness of Gypsum products. The process is easy, cheap and does not require any extra step in the process.

Key WordsGum Arabic, Calcium Hydroxide, Surface hardness, Gypsum products.

balance. Water was taken in specified volume according to ADA specification No 25 in a volumetric beaker.

I) Preparation of samples-A. Control Group-Type I, Type II, and Type III gypsum products and water were taken in a specified quantity of water: powder ratio according to ADA specification No 25 in a clean rubber bowl and manually manipulated to a homogenous mix and vibrated on a vibrator at control speed to remove air bubbles and then poured into the standardized rubber mould. Overall six samples were made. Poured gypsum products were allowed to set for 45 minutes before they were separated from the mould.

B. Preparation of study samples-Gum Arabic and Calcium Hydroxide (gypsum hardeners were taken in two different proportions for the study purpose-1. 1% Gum Arabic and 0.132% Calcium

Hydroxide ) percent by weight in 100 gms of gypsum powder)

2. 2% Gum Arabic and 0.2% Calcium Hydroxide ) percent by weight in 100 gms of gypsum powder)

The gypsum hardeners were added according to the different proportions in the selected gypsum product after 100% mesh screening. Six samples of each gypsum product were made for each of the two different proportions of gypsum hardeners. Water: powder ratio was taken similar to the control group.Overall, 18 samples of the control and 36 samples of the study were made and numbered accordingly.

II) Evaluation of surface hardness-The surface hardness was evaluated after 24 hours of pouring the gypsum products by an experienced engineer who was blinded to the samples. The surface hardness of samples were tested by using Vicker's hardness testing machine (Avery Denison Model 6408, England). This tester consists of a 136 degree diamond pyramid indenter, which contacts and penetrates the surface of a sample under a


definite load application. The indenter produces a pyramidal indentation, the diagnoses of which were measured with a micrometer microscope. The weight applied was 10 Kg for 10 seconds and weight applied and time applied were kept constant for all the samples.The values obtained were compared and subjected to statistical analysis.

ResultsMean and standard deviation of surface hardness of gypsum products Type I, II and III with the addition of Gum Arabic and Calcium Hydroxide in two different proportions are presented in [Table 1]. In all three types of gypsum products the addition of 2% Gum Arabic and 0.2% Calcium Hydroxide showed the highest hardness value followed by 1% Gum Arabic and 0.132% Calcium Hydroxide and the least value was shown by the control group.One way ANOVA and Student-Newman-Keul's test was used to compare the hardness of Type I, II and III gypsum products in three experimental groups (Table 2). There was a statistically significant difference between type I, II and III in all the three groups as expected. The critical value of F being 3.68 (for all groups) for p=0.05.One way ANOVA and Student-Newman-Keul's test was used to compare the hardness produced by different concentration of Gum Arabic and Calcium Hydroxide in each type of gypsum. These showed a statistically significant difference in hardness caused b y t h e a d d i t i o n o f d i f f e r e n t concentrations of Gum Arabic and Calcium Hydroxide within each type. The addition of 2% Gum Arabic and 0.2% Calcium Hydroxide showed the highest value among all the three types (Table 3). The critical value of F being 3.68 (for all groups) for p=0.05.Since all the three gypsum products as well as two proportions of additives showed significant difference in surface hardness, interaction between the products and proportions were also checked by 2-way ANOVA analysis. It revealed that there was a statistically

significant difference in hardness resulting from interaction between type if gypsum and the proportion of Calcium Hydroxide and Gum Arabic added. This was contributing to the difference in hardness caused by type of gypsum product and the concentration of additives.Type III gypsum products with the proportion of 2% Gum Arabic and 0.2% Calcium Hydroxide showed the highest value and least value was shown by Type I control group.

DiscussionSurface hardness is the result of interaction of numerous properties. Among the properties that influence the hardness of the material are its strength, proportion limit, malleability and

Table 1 : Comparison of surface hardness of Gypsum Products with different concentrations of Gum Arabic and Calcium Hydroxide

Mean

SD

Control

2.59

0.29

1% Gum

Arabic+0.132%

Ca(OH)2

3.17

0.00

2% Gum

Arabic+0.2%

Ca(OH)2

3.59

0.17

Control

6.39

0.56

1% Gum

Arabic+0.132%

Ca(OH)2

12.45

0.46

2%

Gum Arabic+0.2%

Ca(OH)2

14.05

0.23

Control

11.38

0.43

1% Gum

Arabic+0.132%

Ca(OH)2

23.88

0.78

2% Gum

Arabic+0.2%

Ca(OH)2

27.65

0.15

Surface Hardness of Type I (In VHN) Surface Hardness of Type II (In VHN) Surface Hardness of Type III (In VHN)

Table - 2 : Comparison Of Surface Hardness Between Three Types Of Gypsum Products Within The Three Experimental

Groups

Concentration

Control

1% Gum

Arabic+0.132%

Ca(OH)2

2% Gum+

Arabic+0.2%

Ca(OH)2

Type

I

II

III

I

II

III

I

II

III

Mean±SD

2.59±0.29

6.39±0.56

11.38±0.43

3.17±0.0

12.45±0.46

23.88±0.78

3.59±0.17

14.05±0.23

27.65±0.15

F* Value

1598.9

2352.4

24474.6

Q** Value

0.86

1.04

0.40

*One Way ANOVA **Student-Newman-Keul's Test

Table-3 : Comparison of Surface hardness between the experimental groups in Type I, Type II and Type III Gypsum

products

Type

I

II

III

Concentration

Control

1% Gum+ Arabic+0.132% Ca(OH)2


Control



Control



Mean±SD

2.59±0.29

3.17±0.0

3.59±0.17

6.39±0.56

12.45±0.46

14.05±0.23

11.38±0.43

23.88±0.78

27.65±0.15

F* Value

39.9

504.8

1594.3

Q** Value

0.40

0.87

1.02

*One Way ANOVA **Student-Newman-Keul's Test

Table 4 : Results of 2-way ANOVA testing effect of type of gypsum product, concentration of additive and their

interaction on surface hardness.

2 Way-ANOVA

Type of Gypsum

Concentration of

Gum Arabic and

Ca(OH)2

Interaction

Residual

Total

SS

2882.5

681.0

388.7

7.6

3959.8

Df

2

2

4

45

53

MSS

1441.2

340.5

97.2

0.2

F

8564.8

2023.5

577.5

-

P

<0.01

<0.01

<0.01

-

resistance to abrasion. Numerous factors influence the hardness, so the term is difficult to define.According to Skinner, hardness is

[6]"resistance to indentation" . Surface hardness of gypsum indicates to what extent the forces applied during work on the gypsum cast can be resisted. But studies have shown that surface hardness of these materials is less and not enough to resist the abrasion, so loss of surface details during fabrication leads to error in prosthesis. To overcome this, several methods have been proposed to increase the surface hardness satisfactorily.Various studies are done by using chemical substitute like epoxy resin1,

[7]commercially available model sealants , [8] [9]cyanoacrylate and lignosulphonates

etc. to increase the surface hardness of [2]gypsum products. Toreskorg et al

proved that liquid hardeners increase the surface hardness, Hollenbaek and

[10]Sullivan found no such increase with the liquid hardener. However, they reported a dimensional increase in connection with the employment of gypsum hardeners.

[11]Masson described a technique for impregnating stone die with acrylic resin;

[12]but Eshleman reported that with acrylic resin there is an increased average die

[2]size of 11.7 mm .[5]Alsadi Sally stated the use of gypsum

hardening solution that are applied to the set material may be beneficial but their application takes an extra step in cast or die preparation. So, he opted another method of improving surface hardness by addition of Gum Arabic and Calcium Hydroxide in gypsum products.Gum Arabic is a carbohydrate, Gum hydrolyzing to arabinose and hexoses, found naturally in union with Calcium, potassium, magnesium ions. Calcium oxide when comes in contact with water or moisture, it gives rise to Calcium Hydroxide.Mixture of Gum Arabic and Calcium oxide markedly reduces the water requirement when used correctly and it is consequently possible to use then in a process for producing ultra hard cast

[13],[14]system , when small amount of surface active materials like Gum Arabic and Calcium Hydroxide are added to hemihydrates, water requirement of plaster and dental stone are reduced while

[6],[15]mechanical properties are improved .Calcium sulfate hemihydrates is ionic in nature, it would be expected that polar-non polar substances would be absorbed by the polar end, the less polar parts being


left exposed to the liquid. Surface active materials have a number of hydrophilic groups, which are active in reducing the water requirement. Large molecules with many polar groups may increase the consistency by being simultaneously adsorbed on the two particles of hemihydrates and hence increasing

[13], [14]adhesion .

ConclusionFrom the results obtained by the present study, it has been proved that there is significant increase in the surface hardness by the addition of Gum Arabic and Calcium Hydroxide. All these materials including gypsum hardeners are cheap and easy to manipulate. There is no extra step for die or cast preparation as with other materials like a polysterene, epoxy resins etc. As gypsum hardeners were added directly to gypsum products. All the used materials including gypsum hardeners are cheap and easy to manipulate. The used gypsum hardeners decreases the water requirement, so that the reduction of water-calcined gypsum ratio provides the most practicable means of producing harder casts, the enhanced hardness being due to increased density. Even it has been noted that the surface hardness was increased significantly for dental plaster and dental stone but there was minimal change in hardness of impression plaster. Type III gypsum product with the proportion of 2% Gum Arabic +0.2% Calcium Hydroxide showed the highest value and least value was shown by Type I control group.To conclude, Gum Arabic and Calcium Hydrox ide dec rease the wa te r requirement, so that the reduction of water-calcined gypsum ratio provides the most practicable means of producing harder cast. Moreover, further studies are required to know the effect of hardeners on the various physical properties of the gypsum products and also to know the correct water proportions.

References1. Sanad ME, Combe EC, Grant AA:

Hardening of model and die materials by an epoxy resin. J Dent 1980 Jun; 8(2):158-62.

2. Toreskog S, Phillips RW, Schnel R: Properties of die material: A comparative study. J Prosthet Dent 1966; 16:119-31.

3. Zakaia MR, Johnston WM, Reisbick

MH, Campagni WV. The effects of a liquid dispersing agent and a microcrystalline additive on the physical properties of type IV gypsum. J Prosthet Dent 1988 Nov; 60(5):630-7.

4. Sanad ME, Combe EC, Grant AA: The use of additives to improve the mechanical properties of gypsum products. J Dent Res 1981; 61:808-810.

5. Alsadi S, Combe EC, Cheng YS.: Properties of gypsum with the addition of gum Arabic and calcium hydroxide. J Prosthet Dent 1996 Nov; 76(5):530-4.

6. Anusavice JK, Brantley AW. Physical properties of Dental Materials. In, Anusavice KJ (ed). The science of Dental materials, 11th edition. London, Saunders, 2004; 96.

7. Sanad ME, Combe EC, Grant AA: The effect of model sealant solution on the properties of gypsum. J Dent 1980 Jun; 8(2):152-7

8. Fukui H, Lacy AM, Jendresen MD: Effectiveness of hardening films on d i e s tone . J P ros the t Den t 1980:44:57-63.

9. Combe EC, Smith DC: Improved stone for construction of models and dies. J Dent Res 1971 Jul-Aug; 50(4):897-901.

10. Hollenbaek GM, Sullivan M. Water substitutes for mixing gypsums. J South Calif Dent Assoc 1964; 32, 199-203.

11. Mason HJ. Impregnation of stone dies with acrylic resin. J Prosthet Dent.1970 Jan; 23(1):96-8.

12. Eshleman JR. Surface hardness and dimensional accuracy of stone dies impregnated with acrylic resin. J Dent Res 1971 Mar-Apr; 50(2):507.

13. Ridge MJ, Boell GR: the water requirement of calcined gypsum. Commonwealth scientific and Industrial research organization. 1962: report F1-7:1-11.

14. Ridge MJ, Boell GR: the water requirement of calcined gypsum. Commonwealth scientific and Industrial research organization. 1962: report F1-9:1-21.

15. Craig RG. Gypsum Products and Investments. In, Craig RG (ed). Restorative dental material, 9th edition. London, Mosby, 1993; 349.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Neha Vadhera2 Sameer Makkar3 Rajan Dhawan4 Simranjeet Kaur

verify that within any portion of root canal there will be sufficient space for rotary instrument to follow. In 2004,

[5]Berutti et al recommended manual preflaring of the root canal to create a glide path before using NiTi rotary instrumentation. They advocate that the root canal diameter should be atleast one size larger as the tip of the first rotary instrument to be used in that root canal. They also reported that a reduction in torsional stress increased the average lifespan of instrument almost six-fold with a reduced risk of instrument fracture.

The adoption of new treatments, techniques or concepts depends not only on their effectiveness or biological rationale but also on operator's preference for and satisfaction in performing such procedures (Granados

[6]et al. 1997). Some clinical procedures are not widely implemented for simple reason that they are too difficult or too inconvenient to perform, even though they have strong biological rationale. Undoubtedly, biological principles of endodontic treatment are violated when

IntroductionEndodonticpost graduate programs include a wide gamut of subjects varying from the ones which are daily practiced to the ones which are not often imbibed by the budding endodontists in their daily p r a c t i c e b e s i d e s t h e i r importance.Endodontic Glidepath preparationfalls into the latter category.

[ 1 ]According to West(2010), the endodontic Glidepath is a smooth radicular tunnel from canal orifice to physiologic terminus (foraminal constriction). Its minimal size should be a "super loose No. 10" endondontic file. The Glidepath must be discovered if already present in the endodontic anatomy or prepared if it is not present. The Glidepath can be short or long, narrow or wide, essentially straight or curved.

[2]According to Ronald et al (2002) and [3]Peters et al (2003) , the risk of

instrument fracture can be reduced by performing coronal enlargement of the

[4]root canal. Blum et al (2003) suggested that a glide path should be created with small stainless steel hand files to create or


1 Post Graduate Student2 Professor And Head Of Department3 Professor4 Post Graduate Student Department Of Conservative Dentistry And Endodontics National Dental College, Derabassi, Punjab

Indian Endodontic Postgraduates’ Perceptions

Of Preparing Glide Path During Root Canal

Treatment

Address For Correspondence:Dr. Neha VadheraD/o Sh. Anil Vadhera, Punia Colony,Street no. 7, Haripura road, Sangrur, Punjab

rd Submission : 3 June 2012th Accepted : 10 February 2013

Quick Response Code

rubber dam is not used, yet a majority of practitioners continue to practice in such

[7]manner (Whitworth et al 2000, Slaus & [8]Bottenberg 2002). From a public health

care point of view, the issue of treatment efficiency and cost is also important because resources in the society are limited in a developing nation as ours. Hence they should be directed to the most effective and the most efficient treatment regimen. Decisions making by clinicians a p p e a r s t o b e c o m p l e x a n d multidimensional. So a study was planned and conducted to assess certain endodontic practices like preparation of g l i d e p a t h a m o n g e n d o d o n t i c postgraduate students in India.

This questionnaire based study aimed at gauging awareness and practice of preparing glide path among endodontic post graduate students throughout the nation.

Materials And MethodsA questionnaire survey was used to tabulate opinions and awareness of the postgraduate endodontic students in India concerning the preparation of the

AbstractThis questionnaire based study aimed at gauging the awareness and practice of preparing glide path among endodontic post graduate students throughout the nation. By surveying a substantial majority of post graduate students in India, a broadly national perspective on the issue was sought. A questionnaire survey was used to tabulate opinions and awareness of the postgraduate endodontic students in India concerning the preparation of the glide path while performing root canal treatment. 320 survey forms were mailed electronically to Postgraduate students and 180 were distributed at a national conference. The respond rate was 75% by former and 80% by latter that is a total of 444 filled survey forms out of 500 were finally evaluated in the study. Most of the students prepare it occasionally (60%) with 10 no. file (50%) with combination of irrigant solutions (60%) and watch winding motion (58%). It was concluded that most of the endodontic post graduate students in India are still not preparing the glide path always so the professional bodies in endodontics should embark on training programs, seminars and workshops aimed at improving the knowledge and skills of the endodontic post graduate students in India.

Key Wordssurvey; questionnaire; glide path; irrigant

Table 2. Go to Length Immediately or Early Coronal Enlargement

Frequency

Go To Length Immediately

Early Coronal Enlargement

Number Of Respondents

178

266

glide path while performing root canal treatment. 320 survey forms were mailed electronically to Post graduate students and 180 were distributed at a national conference. The respond rate was 75% by former and 80% by latter method i.e. a total of 444 filled survey forms were f inally evaluated in the study. Questionnaire comprised of 8 questions in all. The questions were framed to cover all the possible aspect concerning the preparation of glide path. (Table 1).

Table 1. Sample Of Glidepath Survey Letter To Endodontists.

1. Do you know what is glide path?Ÿ Yes, i always prepare.Ÿ Yes, i prepare it occassionallyŸ Yes, but I don't prepare...Ÿ I don't have any idea

2. What size hand file do you prefer for your Glidepath(choose one) ? Ÿ #10 sizeŸ #15 sizeŸ #20 sizeŸ more than 20

3. Do you use straight manual files or do you precurve them(choose one) ?Ÿ StraightŸ PreCurved

4. Do you "go to length immediately" or d o y o u d o " e a r l y c o r o n a l enlargement" (choose one)?Ÿ Immediately if I can.Ÿ Early coronal enlargement

5. What is your preferred irrigating solution(choose one) ?Ÿ Sodium hypochloriteŸ EDTAŸ Viscous irrigators like RC-Prep,

GlydeŸ Combination of above

6. How do you determine your Glidepath length (choose one)?Ÿ Apex locatorŸ RadiographicallyŸ TactileŸ Combination of above

7. Which radiographic technique would you use ?Ÿ RVGŸ Simple radiograph

8. When making the Glidepath, what hand motion do you use (ie, "watch/wind”,"push/pull," or other) ? Ÿ Watch-windingŸ Push-pullŸ BothŸ Others

Results


Figure 1. Hand File Size Preference.

Figure 2. Irrigation Solution Preference.

Figure 3- determination of glide path length

Only 30 % of respondents always prepare a glide path in their practice. Most of them (60%) prepare it occasionally, 20% never prepared it and 10 % did not have any idea of glide path preparation. 55% of respondents precurve the file before inserting into canal whereas 45 % preferred to use it straight. (Figure 1 and Table 2), (Figure 2 and 3).

Most of post graduate students preferred prefer "watch/wind." (Figure 4)

DiscussionMany clinicians instrument the curve in the canal exclusively by hand and only use rotaries for the straight part of the canal. There are also some clinicians who use hand instruments greater than a No. 10 to make a glide path (50 % of respondents use greater than a No. 10 file to make a glide path ). Neither of these approaches is advisable because hand instruments greater than No. 10 in the canal may cause an iatrogenic event. Even if a No. 15 hand file passes through a severely curved canal initially, very often it will not be able to negotiate the curve a second time. The only hand instrument that should be used in a severely curved canal is a No. 8 or a No. 10 reamer, which will follow the curve without any need to pre-bend (50 % of respondents use No. 10 file for preparing glide path according to this survey). Just like a tooth with a severe curve must be loosened with either proximators, luxators, elevators, or periotomes before the extraction forceps are employed so that the root does not fracture during the extraction process, so too a well-defined glide path must be made to prepare the curved canal for instrumentation and


[9]shaping. Melvyn Segal in 2008 has found through experimenting on extracted teeth with curved canals that hand instruments above No. 10 can easily create a ledge or transport or zip the apex. Often, a zip or transportation may not even be apparent on a radiograph. The clinician will believe that he or she performed the perfect root canal on a curved root, when in reality the canal was transported or zipped.

When preparing a straight canal, any system will work. But when it comes to a severely curved canal, the curve has to be well-prepared by precurving the instrument (55 % of post graduate students precurve their instruments according to this survey) before using any of the systems to prevent an iatrogenic event.

60 % of post graduate students prefer to do early coronal enlargement before going to apex. Slightly more post graduate students prefer early coronal enlargement, primarily due to the presence of restrictive dentin which restricts finesse and mastery of the first Glidepath file.

Most of the post graduate students prefer to use combination of NaOCl, EDTA and viscous chelators for preparing glide path. Sodium hypochlorite and a viscous chelator (or a combination of the 2) enable digestion of necrotic pulp and the ability to emulsify vital pulp.

Working length determination is one of the most critical steps in endodontics, as it facilitates biomechanical preparation and obturation of the root canal system.

Failure to accurately determine the length of the root canal often results in apical perforation, over instrumentation and other mishaps which leads to root canal failure.

A majority of the respondents (34 %) were using the radiographs to determine the working length. This method has inherent inaccuracies, as the apical foramen may not be detectable on radiographs. Electronic apex locator has the advantage of being able to locate the apical foramen. Nevertheless, electronic apex locator is not the substitute for radiographs since the latter provide valuable information about root canal morphology as well. So combination of these methods should be preferred. 40 % of respondents preferred to use combination of radiograph and electronic apex locator. The combination of apex locator and radiographic terminus, is the clinician's choice. Canal length accuracy is excellent when both methods of length determination validate each other. The important thing to remember is that the length is dynamic and becomes shorter, especially in the early stages of rotary shaping, due to canal shortening.

[10]In 2006, West recommended using a K-file with an initial watch winding motion to remove restricted dentin in very narrow canals, followed by a vertical in and out motion with a 1mm amplitude as the dentin wall wears away and the file advances apically. Most endodontists prefer "watch/wind." Only 9% chose "other." These motions make endodontic files efficient when the dentist learns how, when, and why to use what motion. Glidepath demands that the dentist "thinks" and is "deeply present," resisting all distractions.

ConclusionWithout the endodontic Glidepath, the rationale of endodontics cannot be achieved. A nonsurgical seal requires first the creation of a radicular path that can be cleaned of viable and nonviable bacteria, vital and nonvital pulp tissue, biofilm, and smear layer; then shaped to a continuously tapering funnel that can be predictably and easily obturated. Moreover, Glidepath is necessary for quality control. Sustainable excellent endodontic obturations are not possible without it.

The preparation of glide path is important

Figure 4. Hand Motion Preference.

in endodontics so the professional bodies in endodontics should embark on training programs, seminars and workshops aimed at improving the knowledge and skills of the endodontists. Appropriately structured continuing education courses and journals may be able to meet the demands and needs of endodontists in India.

References1. West J. The Endodontic Glidepath:

Secrets to rotary success. Dentistry Today 2010; 29(9): 90-9343.

2. Roland DD, Andelin WE, Browning DF, Hsu GR, Torabinejad M. The effect of preflaring on the rates of separation for 0.04 taper nickel-titanium rotary intruments. J Endod 2002; 28(7): 543-545

3. Peters OA, Peters CI, Schonenberg K, Barbakow F. ProTaper rotary root


canal preparation: assessment of torque and force in relation to canal anatomy. Int Endod J 2003; 36: 93-99.

4. Blum JY, Machtou P, Ruddle CJ, Micallef JP. The analysis of mechanical preparations in extracted t ee th us ing p ro taper ro ta ry instruments: value of the safety quotient. J Endod 2003; 29: 567-575

5. Berutti E, Negro AR, Lendini M, Pasqualini D. Influence of manual preflaring and torque on the failure rate of Protaper instruments. J Endod 2004; 30: 228-30

6. Granados A, Jonsson E, Banta HD et al. EUR-ASSESS Project Subgroup Report on dissemination and impact. International Journal of Technology Assessment in Health Care 1997; 13: 220-86.

7. Whitworth JM, Seccombe GV,

Shoker K, Steele JG. Use of rubber dam and irrigant selection in UK general dental practice. International Endodontic Journal 2000; 33: 435-41.

8. Slaus G, Bottenberg P. A survey of endodontic practice amongst Flemish dentists. International Endodontic Journal 2002; 35: 759-67.

9. Melvyn Segal. Managing Curved Canals: the Straight-Away and Super Glide Path Technique. Inside Dentistry April 2008, Volume 4, Issue 4

10. West J. Endodontic update . J Esthet Restor Dent. 2006;18:280-300.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Somik Bose2 Gayatri Gundannavar3 Anirban Chatterjee4 Rosh Radhika Mohan5 Ramesh Alampalli Viswanath6 Sonia Shetty

the rapid formation of biofilm. Periodontal wounds appear to heal faster in sites with fewer plaque score (Mengel et al). In fact the First European Workshop stated that post operative plaque control is the determining factor for the successful outcome of flap surgery.As early as 1920, Ward advocated the use of periodontal dressing for routine periodontal surgical procedures in order to reduce pain, infection, root sensitivity & minimise caseous deposits within the wound site. But studies using split mouth design (Stahl et al, Greensmith & Wade, Jones et al) have demonstrated surgical sites with dressing resulted in more amount of plaque accumulation compared to sites without a dressing and concluded that dressing aids little to the healing process. Also, Addy et al found advantage in using 0.2%CHX rinse when c o m p a r e d t o p e r i o d o n t a l

[3],[4],[5],[6],[7]dressing.Three categories of some common periodontal dressings in the dental market are classified as solid and non-

IntroductionWounds in the oral cavity feature extremely good healing capacities, however, some situations requires the isolation of wounds from the oral milieu, ranging from extractions to flap surger ies . Per iodonta l surg ica l procedures are routinely carried out for the management of diseased periodontal tissues. Several factors contribute to uneventful and healthy post-operative

[1],[2]healing.Wound healing following periodontal flap surgery is influenced by the factors like bacterial contamination, innate wound-healing potential, local site characteristics, surgical procedure / t e c h n i q u e a n d s y s t e m i c a n d environmental factors (e.g diabetes & smoking).The inhibitory effect of bacterial contamination and infection on post-surgical wound healing has been well documented (Burke et al; Herrera et al). Following surgery, the healing process develops by an inflammatory response and in turn the inflammation promotes


1 PG Student2 Reader3 Professor4 Senior Lecturer5 Principal, Professor and Head6 PG Student Department of Periodontics, The Oxford Dental College Hospital & Research Center.

Comparison Of The Early Wound Healing

Following Periodontal Flap Surgery In

Periodontitis Patients With And Without

Periodontal Dressing

Address For Correspondence:Dr. Somik Bose, Department of Periodontics,The Oxford Dental College Hospital & Research Center,Bommanahalli, Hosur Road, Bangalore- 560068.E-mail ID:[email protected]


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soluble, soft and non-soluble, and soft and soluble materials. The most common and widely used non-soluble dressing is the non-eugenol dressing in the Coe-pakTM (Coe l abora to r i e s , GC international Inc, UK) which is supplied as two pastes or as an auto-mixing system contained in a syringe. GCF flow is an important determinant in the ecology of periodontal pocket or sulcus. It creates a flushing action and an isolation effect. In addition, it probably determines the growth level of subgingival microorganisms and is a potential marker for periodontal disease activity. GCF flow (or flow rate) is the process of fluid moving into and out of the gingival crevice or pocket. It is a small stream, usually only a few microliters per hour. It is approximately 10.2 µl/hr in health and in advanced periodontitis, it is as high as 137 µl/hr. 5-24 ml of GCF is secreted daily. The gingival flow however, is expected to increase dramatically as inflammation

AbstractBackground and Objectives: Periodontal dressings are routinely used following periodontal surgical procedures and several studies have shown that it results in more plaque accumulation and hence pronounced inflammation immediate post-surgically; which delay the healing of the tissues. Also the bulky periodontal dressing can result in considerable patient discomfort. The aim of the study was to compare the early wound healing events and patient comfort following periodontal flap surgery with and without a dressing.Materials and Methods: A total number of fifteen patients indicated for periodontal flap surgery was randomly allotted to dressing or non-dressing group and a split mouth study design was followed.Assessment of early wound healing done by swelling of soft tissue & the colour of gingiva, volumetric measurement ofGCF and patient VAS questionnaire.Results: A higher trend for mean pain scores and swelling of face was reported by the patients in the dressing group compared to non- dressing group. Clinical evaluation revealed more pronounced swelling and colour changes of the gingiva in patients with dressing. Also, the mean percentage increase of GCF flow was found to be higher with the same.Conclusion: Based on the results of our study, we can conclude that periodontal dressing results in more inflammation immediate post-surgically which may in turn delay the wound healing response as compared to patients with a dressing.

Key WordsCoe- Pak, GCF, Periodontal flap surgery, Wound healing, Periotron.

1 PG Student2 Reader3 Professor4 Senior Lecturer5 Principal, Professor and Head6 PG Student Department of Periodontics, The Oxford Dental College Hospital & Research Center.

becomes more severe and vascular permeability increases. It has also been stated that increase in GCF flow is one of the f i r s t change occur r ing a s inflammation progresses before any other visible signs of inflammation and that its value is more correlated to the status of the underlying gingival tissues than any other signs or indices of gingival inflammation.Various studies have shown that GCF flow consistently increases following surgery till 2-3 weeks, decreasing to baseline or lower values following then in 6 weeks or so and that the percentage increase is directly proportional to the inflammatory component of the underlying healing tissues (Arnold et al 1966, Suppipat et al in 1978).Griffiths and Sterne et al (1992) found thatwhile the initial volume of GCF showed no association with any clinical measurement, there was an association between flow rate of GCF and gingival colour. The volume of GCF collected in the final, 5th sample was associated with the Gingival Index. The sample site strongly influenced all measures of GCF volume. It is proposed that the flow rate of GCF may be a better indicator of gingival inflammation than the more imprecise clinical assessments of inflammation, since GCF flow rates more precisely reflect changes in tissue

[8],[9],[10]permeability.Greensmith Al et al in 1947 studied the differences between dressing (Coe-pak) and non- dressing wound after reverse bevel flap procedures. The results showed that both the groups had comparable clinical parameters and gingival fluid level. However, it was found that 45% of patients preferred no closure of the wound by periodontal dressing, while 37.5% had no preferences and 16.6% preferred a dressing.Jones TM et al in 1979, compared clinical and histological results after access flap surgery with and without non-eugenol dressing and evaluated fluid Index, inflammatory index, pocket depth and patient comfort upto 16 weeks postoperatively. Results showed no difference in these parameters between quadrants where periodontal dressings were or were not used following surgery. The patients reported severe pain and discomfort postoperatively when the dressing was used. The results of this study suggest that a surgical dressing serves no useful purpose following a

[6]periodontal flap surgery.Its an accepted fact that there will be more a m o u n t o f p l a q u e a n d d e b r i s


accumulation underneath a periodontal dressing as compared to sutures alone; however, whether it leads to delayed wound healing response is something which needs to be sorted out. (PHOTOS 1,2,3 AND 4).

Thus the aim of this study was:1. To assess the early wound healing

outcomes of patients with a periodontal dressing and to compare with a non-dressed site.

2. To assess patient comfort as evaluated by the patient assessment questionnaire.

Materials and methods: This was a randomized case controlled clinical trial with split mouth design study which was conducted on patients reporting to the Department of Periodontics, The Oxford Dental College and Hospital, Bangalore. Patients who were systemically healthy, non-smokers, not under any medication, diagnosed with periodontitis, indicated for periodontal flap surgery were included in the study. It was made clear that participation is entirely voluntary. Patients were explained about the nature of the study, the need for surgery and the outcome of it, followed by which a verbal & written consent was obtained. A total number of 15 patients having at least 2 sextants indicated for surgery were randomly allotted to either Dressing group (Coe-PakTM) or Non-dressing group and a split mouth design was followed. Access flap surgery was done and patients were given dressing or left without it following the surgery.Comprehensive medical and dental history was recorded and routine blood investigations were carried out. The patients were then given an explanation of the study and an informed consent was obtained and was also asked to fill a self reported questionnaire.On the day of surgery (baseline) PeriotronTM score was recorded at the deepest site of the selected area for surgery. All periodontal surgical procedures were performed on an outpatient basis under aseptic conditions using the conventional techniques of Kirkland's access flap surgery.All subjects answered a questionnaire [Pain (0-10);Swelling of mucosa (0-3);Swelling of face (0-3);Bleeding post operatively (yes or no);Mean no of analgesics taken] at each day following surgery till one week, which was provided to them as a VAS chart, to evaluate post-operative symptoms.

Photo: 1 - Coe- Pak Placement At Baseline

Photo: 2 - Deposits Underneath The Coe- Pak After One Week

Photo: 3 - Non-Dressing Site At Baseline

Photo: 4 - Plaque Deposits On The Suture Threads After One Week

All the patients were subjected to evaluation of swelling of soft tissues and colour of gingiva at one week after surgery.Volumetric measurement of GCF was done at baseline (at the day of surgery) and two weeks following surgery by using filter paper strips which was subjected to quantitative analysis on the Periotron 8000TM.Statistical analysis was done by unpaired and paired Student t test. Significance is assessed at 5 % level of significance. The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the data.

Results:Graph 1, Graph 2, Graph 3, Graph 4, Graph 5, Graph 6

DiscussionPeriodontal dressings are routinely used fo l lowing per iodonta l su rg ica l procedures. This study compared clinically the use of dressing following periodontal flap surgery versus non-dressing, in a randomized clinical trial;considering the hypothesis that it results in more plaque accumulation and hence pronounced inflammation immediate post-surgically; which delay the healing of the tissues. Also the bulky periodontal dressing can result in considerable patient discomfort. The results of the present clinical experiment has demonstrated thatthe useof dressings resulted in increased inflammation immediate post-surgically based on the clinical parameters and increased patient discomfort based on the self reported questionnaire by the patient.Smeekens JP et al 1992, studied the histological evaluation of tissue response 7 days after surgery using dressing materials like Barricaid, Ward's wonder pak and carboxyl methyl cellulose and control. No significant differences between the 2 different dressings. The control areas showed an overall lesser degree of inflammation. After 14 days, no difference between test and control were noted.Allen DR et al in 1983, Studied the clinical effects of a periodontal dressing after Modified Widman flap surgery. The patients were studied for 2 months after surgery (at 2 weeks, 1 month, and 2 months) with respect to gingival crevicular fluid, gingival inflammation, attachment level and pocket depth. The patients were also given a questionnaire. Result showed no significant differences


Results in our study revealed that both the groups show similar mean pain score in all the 7 days, however with statistically significant (p<0.001) rise in the dressing group in the first day.

GRAPH 1: PAIN- Post operative pain experience (0= no pain, 1= mild pain, 2= moderate pain, 3= severe pain) noticed at each day following surgery till one week.

Our study revealed that all the cases had swelling of face as perceived by the patient in the first day with significantly increased number of cases having swelling in the following days in the dressing group. Whereas only an insignificant number of cases reported swelling of face in the non- dressing group. This difference between the groups also reached statistical significance in all the days of the week (p<0.001).

GRAPH 2: SWELLING OF FACE- Post- operative swelling of face (YES/ NO) noticed at each day following surgery till one week.

Post- operative oozing of blood following the procedure was seen in both the groups for the first day; the non-dressing group demonstrating higher mean score on the first day (40% in non- dressing group versus 20% in the dressing group) but it did not reach statistical significance. 20 % of the cases reported oozing on the 2nd day in the non- dressing group.

GRAPH 3: BLEEDING POST-OPERATIVELY- Post- operative oozing of blood (YES/ NO) noticed at each day following surgery till one week.


operated half received a noneugenol dressing and the other half had no dressing. GCF, gingival index, pocket depths and patient comfort were studied up to 16 weeks. Results indicated that there was no difference in clinical

Results indicated a trend towards similar number of mean analgesics taken in both the groups in the following 5 days after surgery.

GRAPH 4: MEAN NUMBER OF ANALGESICS TAKEN- Number of analgesics taken every day following surgery till one week is noted in the two groups.

The GCF flow consistently increased at the 2nd week in all the patients in our study; however the dressing group showed very high mean percentage increase GCF flow (186%) compared to the non- dressing group (66%). (PHOTOS 7 AND 8).

GRAPH 6: GCF FLOW- Measured at baseline (at the day of surgery) and 2 weeks and the percentage rise in GCF flow is noted in the two groups.

Swelling of soft tissues and the colour of gingiva changes seen in our current study was significantly higher in the dressing group (Mean 1.6 and 1.4 respectively) as compared to the non- dressing group (Mean 0.6 and 0.6 respectively). This difference also reached statistical significance (p<0.001). (PHOTOS 5 AND 6).

GRAPH 5: CLINICAL EVALUATION AT ONE WEEK- Swelling of soft tissues and colour of gingiva was evaluated after one week as absent (0), moderate(1) or pronounced(2) in the two groups.

Photo: 5 - Clinical Picture Of Gingiva After One Week Under Coe- Pak

Photo: 6 - Clinical Picture Of Gingiva After One Week Without Dressing

Photo: 7 - Paper Strip Placement For Gcf Evaluation

Photo: 8 - Periotron Score

humans.Clinical and histological results after periodontal flap surgery with and without dressing were evaluated and subjectively postoperative comfort was evaluated. Out of the 20 quadrants

between the dressed and undressed [5],[11],[12]sites.

Jones TM, Cassingham RM in 1979 compared healing following periodontal surgery with and without dressing in

parameters. Patients reported more pain and discomfort when dressing was used.Checchi L, Trombelli L in 1993 evaluated postoperative pain and discomfort with and without periodontal dressing in conjunction with 0.2% chlorhexidine mouthwash after apically positioned flap procedure. 24 patients requiring bilateral comparable procedures was taken up in a split mouth design. Results indicated a similar trend for mean pain scores as assessed by patients for both sides during the 7-day postoperative period. No significant differences were found between the 2 treatments with respect to frequency distribution of patients who did or did not take analgesics. Although patients with dressing frequently experienced eating difficulty, most stated a psychological feeling of protection and well-being with its use.

However, in our study results indicated a higher trend for mean pain scores and swelling of face as assessed by patients in the dressing group compared to the non- dressing group during the 7-day postoperative period. This can be attributed to the hardness on setting, non-adhesiveness and non-solubility of the Coe- PakTM dressing and comparative bulkiness of the dressing as compared to when it is left undressed, although it mainly depends on the nature and duration of surgical procedure.Mild post-procedural oozing of blood was found to be more in patients without a dressing as compared to the Coe-Pak group. This mainly implies that a periodontal dressing is more helpful in controlling post-operative oozing of blood following flap surgery, if any; and should be advocated in cases where hemostasis could not be achieved properly.Clinical evaluation after one week revealed more pronounced swelling and colour changes of the gingiva in patients with a Coe- Pak dressing. These differences could be attributed due to the higher amount of plaque accumulation and hence higher inflammation seen underneath Coe- Pak as compared to the non-dressing sites.Also, the mean percentage increase of GCF flow from baseline to 2 weeks was found to be higher with the same. GCF is a reflection of the inflammatory status at the base of the gingival sulcus, thus this difference reflects that Coe- pak resulted in pronounced inflammation at the base of the sulcus whereas it was minimal when no dressing was placed.Patients with dressing frequently


experienced eating difficulty and most of them preferred the usage of no dressings (60%), although most (20%) stated a psychological feeling of protection and well-being with its use and the rest had no preference (20%).

ConclusionAt this time, there is a great deal of debate over the value and usefulness of periodontal dressings. Experimental evidence has not fully resolved this issue.Based on the results of our study, we can conclude that periodontal dressing with C o e - P a k T M r e s u l t s i n m o r e inflammation immediate post-surgically which may in turn delay the wound healing response as compared to patients without a dressing following periodontal flap surgery, permitting the cellular oxidation and exchange of tissue fluids which are essential for the events in wound healing process.Thus a periodontal dressing should only be advocated in certain cases where it is definitely indicated e.g., apically displaced flap to prevent its displacement coronally (Tyrell et al), or to provide support to stabilize a free gingival graft (Farnoush et al). It is indicated in other cases where good adaptation of the flap is not achievable (Allen et al). In most other cases, it should be left on the preference of the operator and the patients.So, instead of regular use of a dressing following flap surgeries, we can limit our use only to certain indications and in patients who prefer the feeling of being well protected psychologically.

Acknowledgements:1. I would like to thank Dr. A. V.

R a m e s h , T h e H e a d o f T h e Department of Periodontics,The Oxford Dental College, Hospital and Research Center;

2. I would also like to extend my support to Mr. K.P. Suresh, for helping me in carrying out the statistical analysis; and

3. And last but not the least, I would like to thank the Management, The Oxford Dental College, Hospital and Research Center,for providing me with the materials for carrying out the study.

References1. Burke, J. F. (1971) Effects of

inflammation on wound repair. J Dent Res 50, 296-301.

2. Flores de Jacoby, L. & Mengel, R. (1995) Conventional surgical

procedures. Periodontol 2000 9, 38-54.

3. Sandalli. P. & Wade, A. B. (1969) Alterations in crevicular fluid flow d u r i n g h e a l i n g f o l l o w i n g gingivcctomy and flap procedures. J Periodontol Res 4, 314-318.

4. Stahl. S. S.. Witkin. G. Heller A. & Brown. R. (1969) Gingival Healing III. The effects of periodontal dressings on gingivectomy repair .J Periodontol 40, 34- 37.

5. Allen, D. R. and Caffesse, R. G. (1983): Comparison of results following modified Widman flap surgery with and without surgical dressing. J. Periodontol. 54, 470-475.

6. Jones, T. M. and Cassingham, R. J. (1979): Comparison of healing following periodontal surgery with and without dressing in humans. J. Periodontol. 50, 387-393.

7. C h e c c h i L , T r o m b e l l i L . Postoperative pain and discomfort with and without periodontal dressing in conjunction with 0.2% chlorhexidine mouthwash after apically positioned flap procedure. J Periodontol. 1993;64(12):1238-42.

8. Arnold R, Lunstad G, Bissada N. Alteration in crevicular fluid flowduring healing following gingival surgery. J Periodont Res1966; 1: 303-308.

9. G r i f f i t h s G S , S t e r n e J A C . Association between volume and flow rate of GCF and clinical m e a s u r e m e n t s o f g i n g i v a l inflammation in a population of British male adolescents. J Clin Periodontol 1992; 19: 464- 470.

10. Cheshire, P. D., Griffiths, G. S., Griffiths, B. M. and Newman, H. N. (1996): Evaluation of the healing response following placement of Coe-pak and an experimental pack after periodontal flap surgery. J. Clin. Periodontol. 23, 188-193.

11. Eber, R. M., Shuler, C. F., Buchanan, W., Beck, F. M. and Horton, J. E. (1989): Effects of periodontal dressings on human gingival fibroblasts in vitro. J. Periodontol. 60, 429-434.

12. Smeekens JP, Maltha JC, Renggli HH. Histological evaluation of surgically treated oral tissues after application of a photocuring periodontal dressing material. An animal study. J Clin Periodontol. 1992;19 (9 Pt 1):641-5.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Garima Gupta2 Subraya Mogra3 V. Surendra Shetty4 Siddarth Shetty5 Sachin Goyal6 Sakshi Garg

[10]Rajgopal and Kansal evaluated MP3 stages and found a significant correlation with the six CVMI stages. Mir et al[11] in a study on Canadian population found correlation values of 0.72 between Fishman maturation prediction method (FMP) and the cervical vertebral maturation (CVM) method.

[12]Gandini et al in their study on 30 individuals compared the skeletal maturation as measured by hand-wrist bone analysis and by cervical vertebral analysis and they found that cervical vertebrae stages are highly correlated to skeletal maturity as assessed by hand wrist radiographs and thus CVM method is an efficient way of assessing skeletal maturity without additional radiation exposure to the patient.Thus, this study was carried out with the aim of finding and proving the efficacy of the cervical maturation status as a suitable alternative to hand wrist radiographsfor the assessment of skeletal maturity and thereby, protecting our patients from unjustified radiation exposure.

Material And MethodsThis study was a retrospective cross - sectional study and lateral cephalograms and hand wrist radiographs of 160 children including 83 males and 77 females, age group 8 to 15 years, who were registered as patients at the dental institute, were evaluated. All the radiographs evaluated were taken as

IntroductionIn orthodontics and dentofacial orthopedics it is becoming increasingly evident that the timing of treatment onset is as critical as the selection of the specific treatment protocol. By beginning the treatment at the individual's optimal maturational stage, the most favorable response with the least potential side effects can be obtained. Individual skeletal maturity can be assessed by means of several biologic

[1],[2]indicators: increase in body height , skeletal maturation of the hand and

[3], [4], [5]wrist, dental development and [4],[6]eruption , sexual indicators like

[5],[7]menarche or voice changes and [8],[9]

cervical vertebrae maturation . Use of hand wrist radiographs has been proved to be a reliable method for the assessment of somatic maturity of an individual. However with the proven association of radiation as causative agent of cancer and various other defects and anomalies,the routine use of hand wrist radiographs has lately been questioned from the radiation safety point of view. Thus, it has become imperative that skeletal maturity indicators easily observed on routine pretreatment orthodontic records should be used. One such methodis cervical vertebrae maturational (CVM) status, assessed from lateral cephalograms which is routinely taken as pretreatment orthodontic record.


1 Reader, Dept. of Orthodontics and Dentofacial Orthopedics, Bhojia Dental College & Hospital, Budh, Baddi, H.P.2 Professor and Head,3 Professor4 Associate Professor Dept. of Orthodontics and Dentofacial Orthopedics, Manipal College of Dental Sciences, Mangalore,5 Reader, Dept. of Periodontology, Bhojia Dental College & Hospital, Budh, Baddi6 Senior Lecturer, Dept. of Periodontics, Rayat & Bahra Dental College& Hospital, Mohali.

Hand Wrist Radiographs - Are They Really

Required As Maturation Indicators????

Address For Correspondence:Dr. Garima GuptaSenior LecturerDept. of Orthodontics & Dentofacial OrthopedicsBhojia Dental College & Hospital, Budh,Baddi, Himachal Pradesh. IndiaTelephone: +91-9780459804Email:[email protected]

th Submission : 3 June 2012th Accepted : 9 December 2012

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routine pretreatment records for orthodontic purpose.

The selection criteria included:

The subjects were all Indians, and free of any known serious illness.

The subjects had not undergone any previous orthodontic treatment or extraction of any permanent teeth.

The subjects had normal dental conditions, i.e. no impaction or transposition of teeth.

There was no previous history of trauma or injury to the face and the hand and wrist regions and all the records assessed were of good quality.

AbstractObjective: To find the suitable alternative for hand wrist radiographs as skeletal maturity indicators to avoid unjustified radiation exposure to patients.Material and Methods: Sample consisted of 160 subjects, including 83 males and 77 females. Hand wrist assessment using Bjork, Grave and Brown, cervical vertebrae assessment with Modified Cervical Vertebrae stages was done. Results: Results showed a highly significant correlation between hand wrist stages and cervical vertebrae maturation stages with a very high Spearman's correlation coefficient (ρ= 0.82)Conclusion: Cervical vertebrae assessment proved to be a suitable alternative to hand wrist method for skeletal maturity determination.

Key Wordscervical vertebrae, Hand wrist radiograph, Skeletal maturity

Both the radiographs for an individual were taken on the same appointment.

Left hand wrist radiographs were evaluated by direct reading(Figure -3) of radiographs using Bjork Grave and

[13]Brown method to evaluate the skeletal maturational status.Lateral cephalograms were traced (Figure -2) for cervical vertebrae 2, 3 and 4, on acetate tracing sheet and evaluated using modified CVM method as given by

[14]Baccetti et al (Figure -1) to assess the level of cervical vertebrae maturation.

Statistical Analysis was performed


using the Statistical Package for Social Sciences (SPSS) version 13.Correlation among various methods was determined using x2 test and significance was established with P value set at 0.05.Correlation values for various variables were calculated by using Spearman Correlation Coefficient (p).Percentage distributions for different variables were evaluated

ResultsTables Igive the correlation values of CVM methods and hand wrist method. As the descriptive data of various stages was similar for males and females, the

Figure 2 - Radiograph showing patient in CS 3 with corresponding tracing.

Figure 3 - Hand wrist radiograph showing stage 8 of skeletal maturity.

Figure 1 - Lateral head films showing various stages of cervical vertebrae maturation- CS 1 to CS 6

HW1

HW2

HW3

HW4

HW5

HW6

HW7

HW8

HW9

TOTAL

1

13

38.20%

12

35.30%

6

17.60%

2

5.90%

0

0%

1

3%

0

0%

0

0%

0

0%

34

100%

2

2

4.30%

10

21.70%

24

52.20%

5

10.90%

5

10.90%

0

0%

0

0%

0

0%

0

0%

46

100%

3

0

0%

2

7.70%

11

42.30%

4

15.40%

6

23.10%

3

11.50%

0

0%

0

0%

0

0%

26

100%

4

0

0%

0

0%

3

11.10%

1

3.70%

19

70.40%

3

11.10%

1

3.70%

0

0%

0

0%

27

100%

5

0

0%

0

0%

0

0%

0

0%

1

10%

4

40%

2

20%

3

30%

0

0%

10

100%

6

0

0%

0

0%

0

0%

0

0%

2

11.80%

0

0%

2

11.80%

9

52.90%

4

23.50%

17

100%

15

9.40%

24

15%

44

27.50%

12

7.50%

33

20.60%

11

6.90%

5

3.10%

12

7.50%

4

2.50%

160

100%

CV STAGETOTAL

HAND WRIST

STAGE

Table II – Percentage distribution of cervical vertebrae stages among hand wrist

stages for overall sample

Sample

Total sample

Males

Females

N

160

83

77

Spearman’s correlation

coefficient(?)

0.842

0.678

0.842

P value

0.05

0.05

0.05

significance

Highly significant

Highly significant

Highly significant

Table I-Correlation coefficient between hand wrist maturation and cervical

vertebrae stages

percentage distribution of cervical vertebrae stages among various hand wrist stages is combined and shown for the total sample in Table II.The spearman correlation coefficients were highly significant for comparisons among hand wrist stages and cervical vertebrae stages for both females and males. Females showed a higher correlation with of cervical vertebrae maturation with hand wrist stages (0.842) than males (0.678). The correlation between hand wrist stages and cervical vertebrae maturation for the total sample was 0.821.The highest percentage distribution was shown by CS 4 in HW 5 (70.4%) as shown by Table II.

DiscussionVarious biologic indicators have been used to assess an individual's skeletal maturity. Hand wrist evaluation has proved to be a reliable indicator of somatic maturity. However, the routine use of hand wrist radiographs has lately been questioned due to radiation safety point of view. Thus, the use of maturity indicators observed routinely on pretreatment orthodontic records has become imperative. One such indicator available at disposal of an orthodontist is cervical vertebrae maturation status as seen on a lateral cephalogram. The aim of this study was to correlate hand wrist method and cervical vertebrae evaluation as skeletal maturity indicators and prove the efficacy of the cervical maturation status as a suitable alternative to hand wrist radiographs and thereby, protecting our patients from unjustified radiation exposure.

Hand wrist and cervical vertebrae evaluationThe results of this study (Table I) showed a highly significant correlation between hand wrist and cervical vertebrae maturation with the spearman correlation coefficient (p), of 0.84 for females (p<0.001) and 0.67 for males (p<0.001), and overall correlation coefficient of 0.82 (p<0.001) .This was in accordance with

[15]the results of Roman et al who showed higher correlation coefficients for females. Thus, the use of cervical vertebrae as an indicator of skeletal maturity was found to be more reliable in females as compared to males.The high level of correlation among hand wrist and cervical vertebrae maturation


shown in this study was in accordance [10] [16]with Mir et al , Kucukkeles et al and

[17]Garcia et al . The value of correlation coefficients differed among these and the present study, probably due to the use of different methods of evaluation of hand wrist and cervical vertebrae. Gandiniet

[12]al also showed the concordance of 83.3% in Bjork intervals and the improved cervical vertebrae maturation method. Descriptive analysis (Table II) of the present study showed results to be in accordance with the results of Gandini et

[12]al .CS 1 consisted of hand wrist stages 1, 2 and 3 (38.2%, 35.3% and 17.6% resp.) For CS 2 more than 50% individuals were in hand wrist stage 3 followed by hand wrist stage 2 (21.7%).Thus, 83.7% of individuals (67 out of 80) belonging either to CS 1 or 2 were in hand wrist stages 1, 2 or 3, as shown by Gandini et al[12]where CVMS 1 (CS1 and CS2 combined of present study) consisted of Bjork's hand wrist stages 1, 2 and 3.CS 3 of the present study showed a varied distribution among hand wrist stages 3, 4, 5 and 6 with majority in stage 3 (42.3%), which is in contrast to the results of

[12]Gandini et al where the equivalent cervical stage was related to hand wrist stage 4.CS 4 had 70.4% individuals belonging to hand wrist stage 5 and relatively lesser percentage (11.1%) in stage 6.CS 5 showed distribution among hand wrist stage 6 (40%), 7 (20%) and 8 (30%).CS 6 represented a combination of hand wrist stages 8 (52.9%) and 9 (23.5%). The highly significant correlation (p<0.001) of cervical vertebrae maturation stages to the hand wrist maturity stages makes it a reliable indicator of an individual's skeletal maturity. The specific distribution of hand wrist stages among the various cervical stages makes the cervical vertebrae maturation method a clinically reliable method of determining ones skeletal maturity, to assess the status of an individual's pubertal growth spurt in relation to his/her own growth cycle, with the use of a single routine pretreatment lateral cephalogram.

ConclusionModified Cervical Vertebrae Maturation stages can be used as a reliable indicator of an individual's skeletal maturity as they showed very high correlation with

hand wrist stages and the specific distribution of hand wrist stages among the various cervical vertebrae stages provide the means to assess the status of an individual's pubertal growth spurt in relation to his/her own growth cycle, with the use of a single routine pretreatment lateral cephalogram. Thereby providing us with the means to protect our patients from unwarranted radiation exposure by eliminating the use of hand wrist radiographs.

AcknowledgementI would like to acknowledge Dr. Pramod Philip and Dr.NavneetArora for the support and guidance provided by them in carrying out this study.

References1. Nanda R. The rates of growth of

several facial components measured f r o m s e r i a l c e p h a l o m e t r i c roentgenograms. Am J Orthod 1955; 41:658-673

2. Hunter CJ. The correlation of facial growth with body height and skeletal maturation at adolescence. Angle Orthod. 1966; 36:44-54.

3. Greulich W, Pyle S. Radiographic Atlas of Skeletal Development of Hand and Wrist. Stanford, California: Stanford University Press; 1959

4. Bjork A, Helm S. Prediction of the age of maximum pubertal growth in body height. Angle Orthod. 1967; 37:134-143.

5. Tofani M. Mandibular growth at puberty. Am J Orthod. 1972; 62: 176-194.

6. Lewis AB, Garn SM. The relationship between tooth formation and other maturational factors. Angle Orthod. 1960;30:70-77

7. Hagg U, Taranger J. Maturation indicators and the pubertal growth spurt. Am J Orthod. 1982; 82:299-309.

8. Lamparsk i D . Ske le ta l Age Assessment Utilizing Cervical Vertebrae. [Master ' s thesis] . Pittsburgh, Pa: University of Pittsburgh; 1972. As cited by O'Reilly MT, Yanniello GJ. Angle Orthod. 1988; 58:179-184.

9. O'Reilly MT, Yanniello GJ. Mandibular growth changes and maturation of cervical vertebrae-a longitudinal cephalometric study. Angle Orthod. 1988; 58:179-184.

10. Rajagopal R, Kansal S. A comparison of modified MP3 stages and cervical

vertebrae as growth indicators. J ClinOrthod 2002;36:398-406

11. Carlos Flores-Mir, Corr A. Burgess, Mitchell Champney, Robert J. Jensen, Micheal R. Pitcher, Paul W. Major. Correlation of Skeletal Maturation Stages Determined byCervical Vertebrae and Hand-wrist Evaluations.Angle Orthod 2006; 76:1-5.

12. Gandini P, Mancini M, Federico. A comparison of hand wrist bone and cervical vertebral analyses in measuring skeletal maturation. Angle Orthod 2006; 76:984-989

13. Grave KC, Brown T. Skeletal ossification and the adolescent


growth spurt. Am J Orthod. 1976; 69:611-619

14. Baccetti T, Franchi L, and James A. McNamara. The Cervical Vertebral Maturation (CVM) Method for the Assessment of OptimalTreatment Timing in Dentofacial Orthopedics. SeminOrthod 2005;11:119-129.

15. San Roman P, Palma JC, Oteo MD, Nevado E. Skeletal maturation determined by cervical vertebrae development. Eur J Orthod. 2002; 24:303-311

16. Kucukkeles N, Acar A, Arun T. comparisons between cervical vertebrae and hand wrist maturation for the assessment of skeletal

maturity. J ClinPediatr Dent 1999; 24:47-52. As cited by Grave K, Townsend G AustOrthod J. 2003; 19:33-45.

17. Garcia-Fernandez P, Torre H, Flores L, Rea J. The cervical vertebrae as m a t u r a t i o n a l i n d i c a t o r . J ClinOrthod1998; 32:221-225.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Manish Sen kinra2 Ramit Verma3 Archna Nagpal4 P .R. Verma5 Amit Kalra6 Monica Kinra

[3]For getting successful treatment dentist must (1) Understand the histology and pathology of the living tissue that make up the basal seat (2) Use a clinical technique in making impression that selectively distribute pressure( selective pressure theory ) to the basal seat . These biologic principles, objectives and theories enhance the retention, stability and support of the denture, which are all interrelated. Dentist should always remember the two most important factors in making satisfactory impressions for complete denture patients , that is accurately fitting custom impression tray and proper positioning of the special

[3]impression tray .

The number of variable factors associated with impression techniques is so many that a single standard technique is not possible for all completely edentulous situations. The variable factors are number of impression materials each having their own manipulative qualities, individual patient having variable anatomy and operator's

[2]skill and experience .

This article presents impression technique which is substitute for conventional impression technique using incremental border molding , this single stage border moulding using putty silicone impression material technique is easy to practice , has rapid approach and

IntroductionImpression making for complete denture Prosthodontics has matured from the art of carving wooden or ivory blocks that accommodate the intra oral contours to the more sophisticated methods in use

[1]today . A complete denture impression is a negative registration of the entire denture bearing, stabilizing, and border seal areas present in edentulous mouth. The art and science of impression making is an ancient endeavor. Since 20 th century onwards so much has been written and published about impression techniques for completely edentulous

[2]situations . This subject has still remained confused among dentists, reason behind is that all research works and subsequent publications were theoretically based, not scientifically approved in the research laboratory. No true research work was done and subsequently published to prove or d i s a p p r o v e t h e a d v a n t a g e s , disadvantages and limitations of various impression techniques. Impression techniques must adhere to biologic principles, objectives and theories dictated by the anatomic (gross and microscopic) and the physiology of the eden tu lous mou th . Impre s s ion techniques for compete denture should never violate important biological principles, if they are violated, denture lose retention, stability, create soreness or cause resorbtion of the underlying bone.


1 Associate Professor2 Assistant Professor3 Professor and H.O.D.4 Professor Department of Prosthodontics Himachal Dental College, Sunder Nagar, H. P.5 Assistant Professor, Department of Prosthodontics, Genesis Dental College, Ferozpur, Punjab .6 Dental Surgeon, Jaipur Dental Clinic, Abohar,Punjab.

Inovative Impression Technique For Complete

Denture Patients

Address For Correspondence:Dr. Manish Sen kinraAssociate ProfessorDepartment of Prosthodontics,Himachal Dental College, Sunder Nagar, H. P.


Quick Response Code

is much accurate.

1 - Single Stage Border Molding Using Putty Silicone Material As Alternate Substitute For Incremental Border Molding Technique.This technique has some advantages over conventional impression technique i.e. stage by stage border molding using low fusing impression compound. It is preferable that border molding material is placed continuously along the entire border of a special impression tray and that the border molding procedure is completed in a single stage to record the width and depth of entire length of the

[4]sulcus . Border molding material should possess a homogenous consistency so that it can offer uniform resistance to displacement by the vestibular tissues. This is not possible with low fusing impression compound. It is usual practice to soften the low fusing impression compound on an open flame, and later to temper in warm water before it is placed

AbstractPurpose of this article is to achieve uniform border moulding with putty silicone impression material in single stage border moulding technique .This single stage border moulding technique is an alternative substitute for incremental border moulding in which low fusing impression compound is routinely used. Since several years it has been practice to use low fusing impression compound for incremental border moulding. This technique has many limitations. Thus in this article authors have described elaborately single stage border moulding technique with putty silicone impression material. This technique is easy to practice, has rapid approach and is much accurate.

Key Wordscomplete denture impression technique , single stage border molding , heavy body putty silicone , low fusing impression compound ,light body silicone impression material.

in patient's mouth . The softening and hardening rate of low fusing impression compound varies from one portion of the special impression tray to another depending on the application of external heat .Thus the viscosity of softened low fusing impression compound may differ from one area to another. As a result, that part of the special impression tray having softened low fusing impression compound of higher viscosity may offer greater resistance to displacement by the tissues than that part having low viscosity

[4]material . As Low fusing impression compound lacks thixotropicity, this material when unsupported for more than 2mm cannot maintain its height when bulk is added along the borders . One of the limitations of using low fusing impression compound for border molding is its short manipulation time. It hardens quickly in patients mouth and does not remain in a plastic stage till the functional movements of the vestibular and alveo - lingual sulcular tissues are completed .Thus stage by stage border molding using low fusing impression compound is a questionable . Preferably border molding should be completed in a single stage .The heavy body putty silicone appears to be a good material for

[4]single stage border molding .Ideal material which will allow simultaneous molding of all borders has two general advantages, the number of insertions of the special impression trays for maxillary and mandibular border molding could be reduced to two, is a

[3],[5]great time and motion advantage . The d e v e l o p m e n t o f a l l b o r d e r s simultaneously avoids propagation of errors caused by a mistake in one section, affecting the borders contours in another

[3],[5]section .In view of these limitations of low fusing impression compound the heavy body putty silicone has been tried. The ideal requirement of a material to be used for simultaneously molding of all borders are that it should have sufficient body to allow it to remain in position on the borders during loading of the tray , allow some time for preshaping of forms of the borders without adhering to the fingers, have a setting time of 3- 5 minutes , retain adequate flow while seating in the mouth , allow finger placement of the material into deficient parts after seating the tray and be readily trimmed and shaped so that excess material can be carved out to shape the borders before the final

[5]impression is made .


The advent of heavy body putty silicone for single step border molding presents an important advancement in impression technique 3,4. Heavy body putty silicone materials have many advantages over low fusing impression compound these include(1) Elimination of the water bath ( 2) Ease of manipulation as it is viscous and knead able (3) Accurate placement to the borders as slumping does not take place while recording functional width and depth of the sulcus (4) Elimination of the multiple insertions and removal of the special impression tray while border molding as heavy body putty silicone has long setting time 2-4 minutes (5) Homogenous consistency and (6) Superior accuracy in recording borders .

Border Moulding The Special Impression TrayMake primary cast in the usual manner. Block out undercuts on the cast with base plate wax(D.P.I- modeling wax ; Dental product of India Mumbai, India). One thickness of base plate wax relief (Sharry's design) was provided over the cast , no relief wax was placed on the sulcus areas except where undercuts were present . Total four tissue stops were placed two in the canine region and two in

[6]the molar region . Autopolymerising acrylic resin custom impression trays ( D.P.I -RR cold cure ; Dental Product of India ; Mumbai , India) was constructed over the relieved primary casts . The extension of the custom impression tray

was checked intra orally, borders were [5]kept 2mm short of the periphery . The

extension of the posterior palatal seal area was marked with indelible pencil.

Putty base and catalyst was taken out as per requirements and kneaded as per manufacturer's instructions for 1 minute with the help of fingers and than a roll of 3-5 mm width ,after that the putty was placed on the entire periphery of special impression tray including the posterior palatal seal area. The material was placed on the borders , making certain a minimal width of 5mm exist on the special impression tray. The material was reshaped quickly to proper contours with fingers . Later special impression tray was immediately inserted in the patients mouth .All borders were inspected to make certain that sufficient heavy body putty silicone material was present in the vestibule. Desired movements were done for 3 - 4 minutes to record functional depth and width of the sulcus .

When the fingernail fails to make indentation into the material it was assumed that material had finally set[5]. Molded special impression tray was removed from the mouth and border molding was inspected , any deficient sites can be corrected with the small mix of putty material , if there is any over extension than it can be detected as the molded tray will show through the heavy body silicone putty border molding material [Fig -1].

Fig -1 Border molded special impression tray using heavy body Putty silicone impression material.

Preparation Of The Maxillary Special Impression Tray To Secure The Final ImpressionBorders were reduced on the special impression tray which show through the heavy body putty silicone material, as they indicate overextension or pressure spots . scalpel was used to remove any of the material that extends internally within the tray more than 6 mm . 8- The wax spacer (D.P.I - modeling wax) was removed from the special impression tray and any heavy body putty silicone material extending into an undercut was also removed so that the special impression t ray can be seated comfortably in place . Thickness of the flange was reduced all over its borders to approximately 2.5 to 3 mm .

Making Of Final Impression[7]In the final impression tray holes were

made as prescribed by Boucher and tray adhesive ( 3 M ) was applied on the tissue surface of special impression tray , 5-6 mm inside the border and 3mm outside the special impression tray for chemical adhesion between special impression tray and light body silicone impression material[3]. Light body silicone impression material (3M ESPE Express TM XT Light body) was squeezed out from auto mixing gun and directly placed on tissue surface area and on the outer border of special impression tray , loaded


custom impression tray was placed in the patient mouth . The desired movements were performed to record the functional sulculas depth . When final impression material has set, impression was removed and thoroughly washed under running tap

[3]water and then it was inspected [Fig 2 ].A technique of completing border molding in single stage, open mouth impression method using heavy body silicone putty (3 M) followed by final wash impression using light body silicone impression material is described above 3. Dentist can also use this technique in making single stage, close

[4] mouth impression technique .

Summary And ConclusionThis article outlines single stage border molding technique and materials required to achieve predictable complete denture final impression using selective pressure philosophy. It is recommended that regardless of the material selected for the use , the clinician select a method and

[8]use it consistently. Functioning of the complete denture depends on the impression technique . Several

impression techniques have been described in the literature since the turn of the century when Green brothers introduced the first scientific system of recording dental impression. Advocates of each technique have their own claim of

[4]superiority over the other. Since several years it has been the practice to use low fusing impression compound for border molding, the technique of border molding with this material has many limitation thus putty silicone was used for single stage border molding.

References1. Zinner I D , Sherman H : An analysis

of the development of the complete denture impression techniques . J Prosthet Dent 1981;46: 3:242 -249

2. Solomon EGR : A critical analysis of complete denture impression procedures : Contribution of early Prosthodontists in India - part I . J.I.P.S 2011 ;11(3) :172-182

3. Hickey JC , Zarb GA , Bolender CL , (eds) Boucher's Prosthodontic treatment for edentulous patient (ed9) . CBS , MO :Mosby ,1990, pp . 220-221

4. Solomon EGR : Single stage silicone border molded closed mouth impression technique - part II . J.I.P.S ;11 (3) :183-188

5. Smith D E , Toolson L B , Blender C L , Lord J L : One step border molding of the complete denture impression using a polyether impression material . J Prosthet Dent 1979 ;41 :3 :347 -351

6. Shetty S, Nag PVR, Shenoy KK : A review of the techniques and presentation of an alternate custom tray design. J.I.P.S 2007; 7: 8-11

7. Frank R P : Analysis of the pressure dur ing maxi l lary edentulous impression procedures . J Prosthet Dent 1996 ; 22 ;4 :400 - 13

8. Felton D A , Cooper L F , Scurria M S : Predictable impression procedures for complete dentures . Den Clin North Am 1996 ; 40; 1: 39- 51


Fig -2 Final impression made using Light body silicone impression material.




E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Priyanka Ghalaut2 Sundeep Bhagwath3 Susmita Saxena

The last few decades have seen the development of the lip prints as another skin impression, which may be useful in forensic identification.Lip prints are unique to every individual;

[5]MacDonnell reported that two identical twins which were indistinguishable by other means had different lip prints. Some of the great work on lip prints has been done by Japanese doctors Suzuki and Tsuchihashi which includes formulation of the widely used lip prints

[6]classification . They reported that Lip prints of the twins and their parents were not identical, and that their lip groove pattern could be influenced by hereditary

[7]factors . This finding was important due to the fact that both uni-ovular twins contain the same DNA but not the same fingerprints and lip prints. The only other analysis of lip prints connected with families found was reported by Hirth,

[8](1975) in which they suggested a genetic basis of lip prints Lip print patterns of parents and children and those of siblings have shown some similarities.

IntroductionLip prints have been used since long for criminal identification but have a limited role in forensic identification. Lip prints are normal line and fissures in the form of wrinkles and grooves present in the zone of transition of lips between inner labial

[1]mucosa & outer skin . Examination of lip prints is called as cheiloscopy. Lip prints are unique and do not change during the life of a person. It has been verified that they recover after undergoing alterations like trauma,

[2]inflammation and diseases like herpes . The disposition and form of the furrows does not change with environmental

[3]factors .Lip prints are similar to fingerprints, palm prints and footprints in that it is an individual characteristic. Evidence of lips prints left at the crime scene is similar to finger prints. Lip prints provide us important information regarding identification of suspects and have became an important tool in forensic

[4]identification .


1 Post Graduate Student2 Professor and Head3 Ex-Head Department Of Oral Pathology And Microbiology, Subharti Dental College Meerut (UP).

An Assessment Of Inheritance Pattern Of Lip

Prints In North Indian Population

Address For Correspondence:Dr. Priyanka GhalautPost Graduate Student,Department Of Oral Pathology and Microbiology,Subharti Dental College MeerutE mail - [email protected] : 09837175914


Quick Response Code

Lip prints are unique to each person but basic lip prints patterns (as given by Tsuchihashi) could still have similarities within the family.If established that there is a hereditary pattern in lip prints patterns, it can be an important tool in personal identification and determining familial lineage of a person. Therefore, present study was carried out to ascertain whether there is any hereditary pattern in lip prints patterns, and thereby, to investigate the potential role of lip prints in personal identification.

Materials And MethodThe subjects for the investigation included 90 individuals of 30 families from north Indian origin population. Father, mother, and a son or daughter of each family were selected. A written informed consent was taken from each subjects, In case of minor subject consent was taken from either of the parent. Following materials were used in recording lip prints.Ÿ red colored lipsticks and lipstick

brushes.Ÿ a cellophane tape.Ÿ white colored bond papers.

AbstractIntroduction- Lip prints are normal line and fissures in the form of wrinkles and grooves present on the lips. Lip prints are similar to fingerprints and have an individual characteristic. Lip prints provide us important information and have became an important tool in forensic identification.Lip prints are unique to each person but basic lip prints patterns could still have similarities within the family. If established that there is a hereditary pattern in lip prints patterns, can be an important tool in personal identification and determining familial lineage of a person.Aim And Objectives- Therefore, present study was carried out to ascertain whether there is any hereditary pattern in lip prints patterns between parents and offspring's. Methodology- The subjects for the investigation included 90 individuals of 30 families from north Indian origin population. Father, mother and a son or daughter of each family was selected The lip prints of either son or a daughter along with their father and mother from each family were recorded. Each lip of the 30 offspring was compared with the corresponding lip of his or her parents. The middle segments of each lip of the offspring that matched with either of the parents was noted and recorded. The results were evaluated by two way Anova and Karl-Pearson correlation coefficient tests.Results- Among 30 families, in 25 families the lip print patterns of child were similar to either of parents. Karl-Pearson correlation coefficient showed a strong positive & significant correlation between parents and their offspring's (p<0.05). Conclusions-There was statistically significant resemblance of offspring lip prints with parents lip prints. Our result indicates the role of heredity in lip prints. Comparison of lip prints within members of the family might give valuable indications for the identification of the suspect and help in determining family lineage of a person.

Key Wordsinheritance, wrinkles, grooves, population, lip prints

1 Post Graduate Student2 Professor and Head3 Ex-Head Department Of Oral Pathology And Microbiology, Subharti Dental College Meerut (UP).

Ÿ a magnifying lensŸ a scissor, pencil, cottonŸ Gloves, a wall mirror

Criteria for sample selection:The subjects had no congenital facial defects, no lesions on the lips and no known hypersensitivity to any of the above material used. To ascertain the inheritance of lip prints, and 30 families with offspring's were studied. The lip prints of either son or a daughter along with their father and mother from each family were recorded. Each lip of the 30 offspring was compared with the corresponding lip of his or her parents. The middle segments of each lip of the offspring that matched with either of the parents was noted and recorded.

MethodThe subjects were asked to sit at relaxed position on dental chair, and the lips of the subjects were cleaned with the help of wet cotton. Then a portion of red colored lipstick was cut from the top of the lipstick with the help of bard parker knife and this portion was put into the dappen dish, and the lipstick was taken from the dappen dish and applied on the lips with the lip brush. The subjects were asked to rub both the lips to spread uniformly the applied lipstick. Over the lipstick, the glued portion of the cellophane tape strip was placed and a lip impression was made by dabbing it in the center first and then pressing it uniformly towards the corners of the lips. The cellophane strip was then stuck to the white bond paper for permanent record purpose and then lip impress ions were subsequent ly visualized with the use of a magnifying lens, and recorded In this study, the classification of patterns of the lines on the lips proposed by Sujuki &

[6]Tsuchihashi , was followed as ;

Type I: Clear-cut vertical grooves that run across the entire lips.

Type I': Similar to type I, but do not cover the entire lip.

Type II: Branched grooves (branching Y- shaped pattern).

Type III: Intersected grooves. Criss-cross pattern, reticular grooves.

Type IV: Reticular grooves.Type V: Grooves do not fall into any of

the type I-IV and cannot be differentiated morphologically. (Undetermined).

Results


TOTAL LIP PRINTS AND THEIR PATTERNS

TOTAL SAMPLE =90Family =30

In off springs there was 83.33 % resemblance with parents lip prints out of 30 families. Among 30 families, in 25 families the lip print patterns of child were similar to either of parents. Two way anova test revealed a significant difference in type of lip prints found in different families (p>0.05).when compared within same family there was no significant difference between parents and offsprings.Karl-Pearson correlation coefficient also showed a strong positive & significant correlation between parents and their offspring's (p >0.05).A m o n g 2 5 f a m i l i e s s h o w i n g resemblance, in 14 family's father's lip prints resembled Childs lip prints while in 11 families mother's lip prints resembled Childs lip prints (Figure 1 a & b ).Z-test was applied to test the resemblance of lip prints to mother and father separately in the family. Z-test showed positive correlation with both parents. The resemblance of patterns of lip prints between father and offspring was found to be statistically significant (z=1.978, p<0.05). Similerly the resemblance of patterns of lip prints between mother and offspring was also found to be significant (and z=2.466, P<0.05).

DiscussionMost of the studies on lip prints had yielded varying results for different populations. In our population vertical lip prints were most predominant while

[7]Tsuchihashi Y (1974) in his study on Japanese population found that intersected lip pattern was the most frequent. Vahanwalla and Parekh

[9](2000) in their study in Mumbai found that vertical lip pattern was most common. Sivapathasundharam et al

[10](2001) studied the lip prints of Indo-Dravidian population and noted that intersected lip pattern was predominant. These studies indicate that there exists lot of regional variation among different populations.Our study showed 83.3 % resemblance between parents and Childrens. The offspring's lip prints in our population showed strong resemblance with parents as there was no statistically significant

difference between the offspring's and parents lip print patterns(p-value = 1, p> 0.05 Table 3)this is in accordance with

[11]study of J.Augustine et al(2008) . Both mother and father showed strong positive & significant correlation between parents and their offspring's indicating that lip print patterns do have a family linkage.This study indicates that there might be

Figure 1(A) Lip prints pattern seen in two families.Father (Branched),Mother (Branched),

Daughter (Branched)

Figure 1(B) Lip prints pattern seen in two families.Father (Intersected),Mother (Vertical),

Daughter (Intersected)

Table 1

Types

Type I

Type II

Type III

Type IV

Type V

Father

12

08

04

05

01

30

Mother

10

07

08

05

0

30

Lip Print Patterns

In Son / Daughter

11

08

08

03

0

30

Lip Prints Patterns

In Childs Matching

With Either Of Parents ( 25 )

09

07

06

03

0

25

Son\Daughter

an inheritance pattern for lip prints from parents to offspring's. A strong inheritance phenomenon of lip patterns has also been proved by studies of Hirth

[8] [12]et al (1975) and Schnuth et al (1992) , who found that heredity plays important role in lip print development as similarities were found between parents and children.Hence, in accordance with previous studies, our results also provide further evidence to the role of heredity in lip prints. Our study indicates that lip print patterns of childrens shows a marked similarity with parents and can be used for comparison of lip prints within members of the family. Lip print patterns can also be used in determining the family roots of person. However non resemblance of lip print patterns cannot be ruled out as negating parent child relationship therefore further detailed study is required to draw final conclusions.

Conclusions1. In north indian population vertical lip

pattern was most common than any other type of lip pattern.

2. There was statistically significant


resemblance of offspring lip prints with parents lip prints.

3. Male offsprings showed more resembelence with mothers while female offsprings showed more resembelence with father.

References1. Synder L.M. Textbook of Homicide

investigation. Identification f dead bodies. 1950; 65.

2. S a n t o s M . c h e i l o s c o p y - A Supplementary stomatological means of identification. 1967; 2.

3. Suzuki K. Recent history of forensic odontology in Japan. The intern. Microfilm J. Leg. Med. 1967; 2: 2.

4. Suzuki K., Tsuchihashi Y and Suzuki H. A trail of personal. Identification by means of lip prints I. Jap. J. Leg. Med. 1968; 22; 392.

5. Dr. Anil Aggrawal. The importance of lip prints (Forensic Files) Web Mystery Magazine 2004; Vol.II No. 2 , http://lifeloom.com//II2Aggrawal.htm Visited 06 - 09 - 2005.

6. Suzuki K. and Tsuchihashi Y. Personal identification by means of lip print. J. of Forensic Medicine.

1970; 17(2): 52-57.7. Tsuchihashi Y. Studies on personal

identification by means of lip prints. Forensic Science International 1974;3:233-48.

8. Hirth L, Gottsche H.et al. Lip prints - v a r i a b i l i t y a n d G e n e t i c s . Humangenetik 1975;30: 47-62

9. Vahanwahal S.P. and Dr. Parekh D.K. Study of lip prints as an aid to forensic methodology. 2000; 71: 269-271. J. of Indian Dental Association

10. Sivapathasundharam B, Prakash PA, S i v a k u m a r G . L i p p r i n t s (cheiloscopy). Indian J Dent Res 2001;149:129-32.

11. J. Augustine, S.R. Barpande, J.V. Tupkari. Cheiloscopy As An Adjunct To Forensic Identification: A Study Of 600 Individuals J Forensic Odontostomatol 2008;27:2:44-52).

12. Schnuth M.L. Advantages of lip print analysis in criminal investigations. The FBI law Enforcement Bulletin 1992 Nov.

Table 2. The Karl -Pearson's correlation coefficient shows strong positive & high significant association b/w mother &

children* (P<.05) and Father & children* (p<.05) respectively at α=.05 level of significance

S. No.

1

2

Paires Of Family Members

Mother & Children

Father & Children

Corelation Cofficients

.9730*

.9143*

P- Value / Significance

P<.05 (Significant)

P<.05 (Significant)

Table 3. Anova: Two-factor Without Replication Showing Strong Association Between Parents And Childrens

Source of Variation

Among the Type of LIP Prints

Persons (Father/Mother & Children)

Error

Total

SS

185.3333333

0

12.66666667

198

Df

4

2

8

MS

46.33333333

0

1.583333333

F

29.26315789

0

P-value

0.000079*

1

Significance

P<.05 *(Significant)

P >.05(N.S.)

F crit

3.837853355

4.458970108





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Vinit Singh2 Anil Singla3 Vivek Mahajan4 Hs. Jaj5 Tahira Bawa

from their parents and teachers. The criteria for sample selection were the following-1. The mandibular permanent incisors,

the mandibular and maxillary permanent canines , and the mandibular and maxillary premolars were fully erupted.

2. There was no obvious loss of tooth material mesiodistally as a result of caries, fractures, congenital defects, or interproximal attrition.

3. The dental impressions and study casts were high quality and free of distortions.

4. The subjects had no previous history of orthodontic treatment.

5. All subjects had a similar ethnic background.

The teeth measured were the mandibular central and lateral permanent incisors, the mandibular and maxillary permanent canines, and the first and second premolars of both arches. The values obtained for the right and left canine-premolar segments in each arch were averaged, so that there would be one value for the mandibular canine-premolar segment and one value for the maxillary canine-premolar segment for

IntroductionMixed dentition space analyses forms an essential part of diagnostic procedures. These analyses help to assess the amount of space required for the alignment of unerupted permanent teeth in a dental

[1]arch . Inappropriate mixed dentition space analyses results could lead to extraction decisions that negatively alter

[2]a patient's soft tissue facial profile .The applicability of this method to populations of other ethnic groups has

[3], [4], [5], [6], [7]been studied and doubted

So the purpose of this study is to formulate the new prediction aids (probability tables and prediction equations) that can enable a more accurate mixed dentition space analysis in Himachal population.

Materials and MethodThis study was conducted in the Department o f Orthodont ics , H i m a c h a l D e n t a l C o l l e g e , Sundernagar, H.P. Dental study casts of 100 male and 100 female subjects were selected for this study. The casts were made from dental impressions of children in various schools of Himachal Pradesh state in India, after approval was obtained


1 PG Student2 Prof. And Head3 Senior Lecturar4 Reader Deptt Of Orthopedic & Dentofacial Orthopedics Himachal Dental College, Sundarnagar5 BDS Dr. Hsj Institude Of Dental Science And Hospital, Chandigarh, Punjab

Development Of A Prediction Equation For The

Mixed Dentition In A Himachal Population.

Address For Correspondence:Dr. Vinit SinghPG StudentDeptt Of Orthopedic & Dentofacial OrthopedicsHimachal Dental College, Sundarnagar


Quick Response Code

each value of the combined mandibular incisors.

Measurements of the mesiodistal crown widths of the mandibular and maxillary teeth were made by using a digital caliper with a vernier scale, calibrated to the nearest 0.03 mm, the tips of the calipers were precision engineered to ensure the greatest accuracy while measuring the various tooth groups (Fig 1). A standardized method proposed by

[12]Moorrees and Reed was used to

AbstractIntroduction: The determination of a tooth-size to arch-length discrepancy in mixed dentition requires an accurate prediction of the mesiodistal widths of the unerupted permanent teeth. The purposes of this study were to evaluate the applicability of Moyer's probability tables in Himachal population and to formulate more accurate mixed dentition prediction aids. Materials and Methods: Dental study casts of 100 male and 100 female subjects were selected from Himachal population, who had fully erupted mandibular permanent incisors and maxillary and mandibular canine and premolars. We measured the mesiodistal crown width with digital calipers and the values were then subjected to statistical and regression analysis. Result:Mandibular segment group showed significant differences (P?0.001) between mesiodistal width of males and females.Regression equation for the maxillary arch (male- Y=9.79+0.99x, Female Y=8.99+0.81x) and the mandibular arch (male-Y=12.97+0.82x, Female Y =11.4+.50x) were used to develop new predictability tables on Moyers pattern. Significant differences were found between our predicted width and Moyers tables at the recommended 75% level. Conclusion:The equations and charts commonly used for North American children (75th percentile) did not accurately predict for our sample. The regression equations and the tables developed in this study can be used for orthodontic treatment planning for children in Himachal population.

Key WordsRegression equation, Unerupted, Mixed dentition

Fig 1: Vernier Callipers Used For Measuring The Mesiodistal-widths


measure the mesiodistal crown widths. The greatest mesiodistal crown width of each tooth was measured between its contact points, with the sliding caliper placed parallel to the occlusal and vestibular surfaces (Fig 2). This method was reported to be highly repeatable and accurate for measuring mesiodistal

[10]crown widths by Doris et al .

ResultsDescriptive statistics, including the mean, standard deviation,and minimum and maximum values were calculated. The coefficient of co-relation was calculated to find the co-relation between the sums of canine and premolars in both arches with that of sum of mandibular incisors (Table II). A student's unpaired t test was calculated to compare tooth dimensions between male and female subjects. It showed highly significant difference in mandibular group with males having larger teeth.

These data were then used to develop regression equations

Y= a+b(x)a and b are regression co-efficient

Y = summed width of mandibular incisors

x = summed width of canine and premolars

Male: Maxilla- Y=9.79+0.99x Mandible -Y=12.97+0.82x

Female: Maxilla- Y=8.99+0.81xMandible- Y =11.4+.50x

The co-efficient of determination r2 was calculated to determine the accuracy of the formulated regression equation. The standard error of estimate was calculated to determine the validity of the proposed equation and compared with reports of various investigators. This regression analysis was used to formulate new prediction equations that can be used clinically to predict the mesiodistal crown widths of the unerupted canine premolar segments (Y) when the combined mesiodistal crown widths of the 4 mandibular permanent incisors are known (X). The regression equations derived in this study were used to prepare new probability tables on the Moyer's pattern and are presented in Table III, Table IV and Table VIII.

Fig2: Measuring The Mesiodistal Dimensions Of Teeth

Table I – Descriptive statistics for the combined mesio-distal width of the 3 tooth groups.

Tooth Group

Mandibular incisors

Maxillary

canine premolar

segment(UCPM)

Mandibular

canine premolar

segment(LCPM)

Sex

M

F

M

F

M

F

Range

21.04 - 25.91

21.22 - 25.67

17.27 - 24.51

17.70 - 22.36

17.27 - 23.38

17.26 - 23.22

Mean±S.D

23.47 ± 1.08

23.05 ± 0.97

20.73 ± 1.03

20.61 ± 0.85

20.73 ± 1.17

20.33 ± 1.03

T-value

2.89**

0.29

2.57*

Table II- Regression parameters for prediction of mesiodistal widths of canine-premolar segments

Tooth groups

UCPM

LCPM

sex

M

F

M

F

r

0.10

0.082

0.083

0.051

regression

a

9.795

8.999

12.97

11.4

constants

b

0.99

0.818

0.82

0.50

r2

. 010

0.007

0.007

0.003

SEE

(mm)

1.08

0.97

1.08

0 .97

r , Correlation; a and b, regression constants; r², coefficient of determination;SEE - standard error of estimate.

Table III- Actual and Predicted values at 35th, 50th and 75thpercentile of Moyers chart for Males in the mandibular

arch

LI

19.5

20.0

20.5

21.0

21.5

22.0

22.5

23.0

23.5

24.0

24.5

25.0

25.5

35th

Percentile

19.2

19.4

19.5

19.7

19.8

19.9

20.1

20.2

20.4

20.5

20.6

20.8

20.9

50th

percentile

19.6

19.8

19.9

20.1

20.2

20.3

20.5

20.6

20.8

20.9

21.0

21.2

21.3

75th

percentile

20.4

20.5

20.6

20.8

20.9

21.0

21.2

21.3

21.5

21.6

21.8

21.9

22.1

present75th

20.8

20.7

21.3

20.4

21.8

21.2

21.3

21.7

22.1

20.7

19.3

20.5

22.3

Table IV- Actual and Predicted values at 35th, 50th and 75th percentile of Moyers chart for females in the mandibular

arch

LI

19.5

20.0

20.5

21.0

21.5

22.0

22.5

23.0

23.5

24.0

24.5

25.0

25.5

35th

percentile

19.2

19.4

19.5

19.7

19.8

19.9

20.1

20.2

20.4

20.5

20.6

20.8

20.9

50th

percentile

19.6

19.8

19.9

20.1

20.2

20.3

20.5

20.6

20.8

20.9

21.0

21.2

21.3

75th

percentile

20.4

20.5

20.6

20.8

20.9

21.0

21.2

21.3

21.5

21.6

21.8

21.9

22.1

present75th

20.5

20.7

21.3

21.5

20.7

20.7

20.8

20.8

20.8

20.3

21.2

22.5

22.3

Table V- Actual and Predicted values at 35th, 50th and 75th percentile of Moyers chart for Males in the maxillary arch

LI

19.5

20.0

20.5

21.0

21.5

22.0

22.5

23.0

23.5

24.0

24.5

25.0

25.5

35th

percentile

19.2

19.4

19.5

19.7

19.8

19.9

20.1

20.2

20.4

20.5

20.6

20.8

20.9

50th

percentile

19.6

19.8

19.9

20.1

20.2

20.3

20.5

20.6

20.8

20.9

21.0

21.2

21.3

75th

percentile

20.4

20.5

20.6

20.8

20.9

21.0

21.2

21.3

21.5

21.6

21.8

21.9

22.1

present75th

21.6

20.7

21.5

20.3

21.5

21.1

21.3

21.1

21.5

21.9

21.4

20.9

21.5

Table VI- Actual and Predicted values at 35th, 50th and 75th percentile of Moyers chart for Females in the maxillary arch

LI

19.5

20.0

20.5

21.0

21.5

22.0

22.5

23.0

23.5

24.0

24.5

25.0

25.5

35th

percentile

19.2

19.4

19.5

19.7

19.8

19.9

20.1

20.2

20.4

20.5

20.6

20.8

20.9

50th

percentile

19.6

19.8

19.9

20.1

20.2

20.3

20.5

20.6

20.8

20.9

21.0

21.2

21.3

75th

percentile

20.4

20.5

20.6

20.8

20.9

21.0

21.2

21.3

21.5

21.6

21.8

21.9

22.1

present75th

21.3

20.7

21.1

19.9

21.0

21.1

20.9

21.7

21.9

21.2

21.2

21.5

21.5

DiscussionThe size of the teeth is related to genetics (e.g., gender and ethnicity) and environment. There are definite racial and ethnic differences evident with

[5],[9], [10], [11], [12], [13], [14], [15]regard to tooth size and this is clearly reflected by the differences seen in the data from the regression equations between the present

[16]study and the data of Moyers .


Accurate treatment planning in management of mixed dentition cases is of great importance. But if predicted values of the width of the canines and premolars itself is wrong, the whole treatment may be a failure. A difference of 2mm per arch between the predicted width and the actual width is clinically significant as it effects extraction decision in patients with moderate crowding (4-7mm) in mixed dentition. Permanent teeth may be either inappropriately retained or extracted on the basis of such an inaccurate tooth width prediction and the whole treatment plan may be a failure.

The use of digital calipers with a standard error of +0.03 mm have been shown to be more accurate methods of measuring mesiodistal tooth dimension on dental study models. Hence, they were chosen

[ 1 7 ]for this study . The excellent measurement accuracy reduced the possibility of introducing systemic and random errors in measurements.

Table I shows that the male subjects have statistically larger mesiodistal tooth dimension in the mandibular arch than the female subjects. The difference in the mesiodistal tooth dimension of the canines and premolars between both the genders in the maxillary arch is not statistically significant. Our results were similar to the study conducted by

[16]Schirmer , but many other authors do not differentiate the genders when predicting the mesiodistal diameter of

[3],[5]these teeth .

Table II shows males show the highest r2 (0.10) value for the maxillary buccal segment. This shows that the prediction equation of the maxillary arch for male subjects is more precise. Female subjects

[2]show the lowestr (0.007) value for the maxillary buccalsegment. This shows that the prediction equation of the maxillary arch for female subjects is less

[13]precise. Jaroontham J et al obtained lower r2 values (0.29 for maxillary teeth and 0.34 for mandibular teeth in males; 0.39 for maxillary teeth and 0.42 for mandibular arch in females). In another similar study conducted on subjects in Southern Thailand, r2 values were 0.46 and 0.47 for maxillary and mandibular teeth, respectively. The difference in the sets of r2 of these studies might be attributable to the effect of different sample sizes and the ethnic mixes.

The new mixed dentition prediction aids (regression equations and probability tables) developed in this study are presented in Tables III, Tables IV, Tables V, Tables VI and Tables VIII. The use of these prediction aids for estimation of unerupted canine premolar widths could result in a more accurate mixed dentition space analysis in Himachal population.

Significant differences (P 0.05) were found between the predicted mesiodistal tooth widths of our study and that of the Moyers probability tables at almost all percentile confidence levels (Table VII). It can be generally stated that the Moyers tables tend to underestimate the mesiodistal canine-premolar widths of this population group, including at the recommended 75% level. Probability tables on the Moyers pattern have also

[14]been derived by Priya and Munshi [16](South Indians) and Schirmer (black

[14]South Africans). Priya and Munshi also concluded that the Moyers probability tables underestimated the tooth sizes of

[16]South Indian children. Schirmer tested the applicability of the Moyers tables in black South Africans and found highly significant differences (P 0.001) at all percentile confidence levels, in the arches of both male and female subjects, except at the 75%, 85%, and 95% levels in the maxillary arch of females. Al-Khadra6 found that the recommended 75% confidence level of the Moyers probability tables overestimated the sizes of canines and premolars of a Saudi Arab population.

[18]Moyers' mixed dentition analysis is based on the correlation of tooth sizes between the sum of the mandibular permanent incisors and unerupted canines and premolars. Moyers recommended using the 75th percentile level of probability in his tables. In agreement with previous studies concluding that Moyers' regression equations are not an accurate method for the prediction of the size of unerupted permanent teeth in different populations [6],[13],[16]. Weshowed in this study that Moyers' tables cannot be used at the recommended 75% probability, since significant differences were observed for the actual widths of the canine and premolars segment and those predicted by Moyers' probability tables. Our results confirm that the Moyers probability tables underestimate tooth sizes of

Table VII. Differences between the regression values of this study and those in the Moyers probability tables at various

percentile levels

Percentile

5

15

25

35

50

65

75

85

90

Male

-.71900

-.77564*

-.84650*

-1.04393**

-.92425**

-.83845**

-.88650**

-.85278**

-.57200

Female

.61910*

.26758

.14175

.07563

-.33400

-.17690

-.17250

-.39738

-.66560*

Male

.068000

-.313250

-.379870

-.594290

-.784000*

-1.012610**

-.839120

-.569320

-1.038000

Female

.768150

.357480

.217260

.062250

-.059000

-.108890

-.344990

-.092860

-.369070

Difference Y1-Y2 (mm)

Maxillary canine-premolar

segments (Y1-Y2)

Difference Y1-Y2 (mm)

Mandibular canine-premolar

segments (Y1-Y2)

Y1, Predicted mesiodistal width of canine-premolar segments in thisstudy; Y2, predicted mesiodistal width of canine-premolar segmentsin the Moyers study.*P 0.05; (statistical tool:Wilcoxon signed rank sum test).P*- Significant value;P**-Highly significant value

Table VIII : Prediction equations from various studies at the 50th percentile

Study

(Himachal pradesh , India)

Punjab , India

Diagne et al

(Senegalese)

Jaroontham and Godfrey

(Thai)

Lee-Chan et al

(Asian Americans)

Moyers

(North American whites)

Sex

M

F

M

F

M

F

M

F

M

F

M

F

Arches

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

MAXILLARY

MANDIBULAR

Prediction equation Y

9.79+0.99(x)

12.97+0.82(x)

8.99+0.81(x)

11.4+.50(x)

7.15+ 1 0.67(X)

7.15+ 1 0.67(X)

7.44 +1 0.65(X)

6.15+ 1 0.67(X)

9.60+ 1 0.55(X)

5.54+ 1 0.72(X)

13.77 +1 0.35(X)

8.74+ 1 0.56(X)

13.36+ 1 0.41(X)

11.92 +1 0.43(X)

11.16 +1 0.49(X)

9.49 +1 0.53(X)

8.19 +1 0.63(X)

7.46 +1 0.62(X)

9.73+ 1 0.51(X)

10.79+ 1 0.45(X)

14.17+ 1 0.28(X)

8.85 +1 0.52(X)

Himachal population. Developing new probability tables on the Moyers pattern, specifically for different population groups, can aid in achieving more accurate estimation of unerupted tooth sizes.

ConclusionThe following conclusions were drawn from this study -1. There is statistically significant

sexual dimorphism in tooth sizes in Himachal population, highlighting the importance of developing separate mixed dentition prediction aids for male and female patients.

2. Moyers prediction tables were not accurate when applied to our sample. The differences noted between predicted values of the Moyers tables and those of present investigation are the result of racial and ethnic diversity.

3. M o y e r s p r o b a b i l i t y t a b l e s underestimate tooth sizes of Himachal population.

References1. Ballard ML, and Wylie W. Mixed

dentition case analysis estimating size of un-erupted permanent teeth. AmericanJournal of Orthodontics 1947; 33: 754-59.

2. Huckaba G.W. Arch size analysis and tooth size perdition. Dental Clinics of North America1964; 8: 431-440

3. Durgekar SG, Naik V. Evaluation of Moyers mixed dentition analysis in school children. Indian J Dent Res 2009; 20:26-30

4. Fonsenca CC. Predicting the mesio-distal crown width of the canine-


premolar segment of maxillary dental arches. M.S. Thesis, University of Tennessee, School of Dentistry, Memphis, 1961.

5. Ferguson FS, Marco DJ, Sonnenburg EM and Shakun M.L. The use of regression constants in estimating t o o t h s i z e i n t h e N e g r o population.American Journalof Orthodontics1978; 73(1): 68-72.

6. Al-Khadra BH. Prediction of the size of un-erupted canines and premolars in a Saudi Arab population.American Journal of Orthodontics and DentofacialOrthopedics 1993; 104(4): 369-372.

7. Yuen KK, Tang EL and So LL. Mixed dentition analysis for Hong Kong C h i n e s e . T h e A n g l e Orthodontist1998; 68(1): 21-28.

8. Smith HP, King DL and Valencia R. A comparison of three methods of mixed dentition analyses. The Journal ofPedodontics1979; 3(4): 291-302.

9. M o o r r e e s C FA a n d R e e d RB.Correlation among crown diameters of human teeth.Archives of OralBiology 1964; 9 : 685-697.

10. Doris JM, BernardBW, Kuftinec MM, Stom D.A biometric study of tooth size and dental crowding.Am J Orthod 1981;79:326-35.

11. Lavelle CLB. Maxillary and mandibular tooth size in different racial groups and in different occlusal categories. Am J Orthod1972;61:29-37.

12. Bishara SE, JakobsenJR,Abdallah E M , F e r n a n d e z G a r c i a A . Comparisons of mesiodistal and buccolingual crown dimensions of

the permanent teeth in three populations from Egypt, Mexico, and the United States. Am J Orthod Dentofacial Orthop 1989;96:416-22.

13. Jaroontham J, Godfrey K. Mixed dentition space analysis in a Thai p o p u l a t i o n . E u r J O r t h o d 2000;22:127-34.

14. Priya S, Munshi AK. Formulation of a prediction chart for mixed dentition analysis. J Indian SocPedodPrev Dent 1994;12:7-11.

15. Lee-Chan S, Jacobson BN, Chwa KH, Jacobson RS. Mixed dentition analysis for Asian-Americans.Am J O r t h o d D e n t o f a c i a l O r t h o p 1998;113:293-9.

16. Schirmer UR, Wiltshire WA. Orthodontic probability tables for black patients of African descent: mixed dentition analysis. Am J O r t h o d D e n t o f a c i a l O r t h o p 1997;112:545-51.

17. Diagne F, Diop-Ba K, Ngom PI, Mbow K. Mixed dentition analysis in a Senegalese population: elaboration of prediction tables. Am J Orthod Dentofacial Orthop 2003;124:178-83.

18. M o y e r s R E . H a n d b o o k o f orthodontics. 4th ed. Chicago: Year Book Medical Publishers; 1988:p. 577.

19. Crosby DR, Alexaander CG. The o c c u r r e n c e o f t o o t h s i z e discrepancies among different malocclusion groups.Am J Orthod Dentofacial Orthop; 1989;95:457-61.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Rosaiah K2 Aruna K

suggests a specific bacterial etiology in many forms of periodontal diseases. The association of a limited number of bacterial species i.e. Haemophillus Actinobacillus) actinomycetemcomitans (Zamban 1985), P. gingivalis (Slots 1985, Loesche et al 1985) T,(B) forsythia, Wolinella recta (Dznk et al 1985) and spirochetes (Loesche et al 1985) with various forms of periodontal disease allows for the development of diagnostic tools that are based upon the detection of

[1]one or more of these in plaque samples . The detection and enumeration of these specific organisms by cultural or microscopic methods is time-consuming and labor intensive. An ideal approach would be the development of a diagnostic test for the presence and level of these organisms that is simple, inexpensive and reliable.

P.gingivalis and capnocytophaga species phenotypically similar to C.gingivalis,

IntroductionClinical manifestation of periodontal disease depicts past destructive activity which may have caused significant irreparable loss. It would be a nice approach to be able to detect causative periodontal pathogens, intercept and prevent the disease process through practical and rapid tests rather than cure. The knowledge about the microbiologic and immunologic factors responsible for the pathogenesis of periodontal disease has greatly advanced in the last few years and has improved our understanding of the disease process, leading to the development of certain indicators for the identification of persons and/or sites with higher susceptibility to periodontal breakdown. Recognition and assessment of this susceptibility enhances the p red ic tab i l i ty and ou tcome of periodontal therapy.

Evidence has been presented which


1 Professor & HOD. Dept of Periodontics,2 Reader, Conservative Dentistry, Peoples Dental Academy, Bhopal,Madhya Pradesh.

The Detection Of Bana Hydrolysis Activity In

Chronic Periodontitis

Address For Correspondence:Dr. Rosaiah K,Professor & HOD.Dept of Periodontics,Peoples Dental Academy, Bhopal, Madhya PradeshHIG-3, PDA Staff quarters,Peoples Campus, Bhanpur,Bhopal.Mobile:9893050554Email id: [email protected]

th Submission : 18 September 2012th Accepted : 10 February 2013

Quick Response Code

T.denticola, a small spirochete (Laughan et al 1982) and T.forsythia Tanner et al 1985) possess a trypsin like enzyme which can be detected by a biochemical

[2],[3]chromogenic reaction . Previous studies (Loesche et al 1987) have demonstrated that the hydrolysis of the trypsin substrate N benzyl-Dl-arginase- 2- naphthalamide (BANA) by sub-gingival plaque obtained from a single site correlates best with the numbers and proportions of spirochaetes in plaque samples and may serve as an indicator of

[4].[21],[25]clinical disease

Early detection of periodontal disease using BANA hydrolysis provides a rationale for implementing treatment, and allows the operator to intercept the disease at a primary level. The testing of innocuous sites in healthy and diseased individuals would help to clarify their true nature at a cellular level and expose vulnerable areas. This quality would also indirectly enable the clinician to monitor sites for the development of active periodontal disease and even predict future attachment loss. Chair side microbial and enzyme diagnoses offer important advantages by simple, rapid

AbstractIntroduction: Studies (Loesche et al 19(7) have demonstrated that the hydrolysis of the trypsin substrate N benzyl-Dl-arginase- 2- naphthalamide (BANA) by sub-gingival plaque correlates best with the numbers and proportions of periodontopathogens in plaque samples and may serve as an indicator of clinical disease.Micro-organisms associated with chronic periodontitis such as P.gingivalis (Slots, Loesche et al 1985) T.denticola (Laughan et al 1982) and T (Bacteroid).forsythia (Tanner et al ) possess a trypsin like enzyme which can be detected by a biochemical chromogenic reaction.This indicates that the detection of BANA enzyme in plaque samples could serve as a marker of periodontal disease.Aim of the study: 1. To determine the efficacy of BANA hydrolysis by sub-gingival plaque micro-organisms as a

diagnostic tool in periodontal disease.2. To correlate the test reaction with the clinical diagnosis in healthy patients and patients

suffering from chronic periodontitis.Methodology: 55 Subjects from a periodontally defined population were evaluated for the ability of their sub-gingival plaque samples to hydrolyze a 0.67 mmol solution of BANA and correlate it with its clinical diagnosis. They were divided into 2 groups.25 periodontally healthy patients were placed under group I (control) and 30 periodontally diseased patients were placed under group II(diseased).After the clinical assessments were made and the findings recorded, 4 to 6 sub-gingival plaque samples were obtained from the buccal interdental areas around the first molar tooth in each quadrant. After dispersion in 0.6 ml of Sorensen phosphate buffer, 50 microlitres were incubated with 0.1 ml of BANA solution at 370C for 18 hrs. The outcome of the hydrolysis was recorded with the help of a colour reaction Results obtained were tabulated and subjected to statistical analysis.Conclusion: The outcome of BANA test was highly significant in periodontally diseased subjects. It can be used as a reliable indicator of BANA positive species in sub-gingival plaque.

Key WordsChronic Periodontitis, BANA Test, Microorganisms, enzymes, plaque.

and reliable in-office tests. Based on this data, an attempt is made to detect the B A N A p o s i t i v e o rg a n i s m s i n periodontally healthy and diseased sites

[5],[6],[7],[8],[9],[21],[22]with varying pocket depths

[10],[11],[12],[13]Materials & Methods 1. Mouth Mirror2. Periodontal probe - Williams

graduated periodontal probe3. Tweezer4. Sterile Cotton Rolls5. Sterile curettes - HU FREID Posterior

numbers 11/12, 13/146. Vortex Mixer7. Micropipettes from PIPETMAN8. 0 . 1 5 m o l / L M o n o p o t a s s i u m

Phosphate9. 0.15mol/L disodium Phosphate(The above two solutions are mixed in

required proportions to obtain a Sorensen phosphate buffer of pH 7.2)

10. 44mg BANA 11. 1ml dimethyl sulfoxide (DMSO).12. 99 ml Sorerisen buffer to give u

working solution of 0.67 m mol BANA

13. 1 drop of fast garnet indicator dye (0.1 %)

14. Isopropyl Alcohol.[14],[15]15. Incubator at 37°C

[16],[17]Criteria For Selection :1. 55 subjects were between the age

group of 35-50 years 2. Women who were pregnant or with

any hormonal disturbances were not selected.

3. Subjects without any relevant systemic disease were selected.

4. The patient should not have a history of any antibiotic therapy during the past 3 months and should not have undergone periodontal therapy for the past one year.

5. Untreated patients with a clinical diagnosis of chronic periodontitis were selected in addition to subjects with healthy periodontium.

6. All subjects had a full complement of teeth

Patient Categorization:Group I : (Control Group) 25 periodontally healthy individuals showing sulcus depth less than or equal to 3 mm served as the control group.

Group II (Chronic Periodontitis)30 patients suffering from chronic periodontitis with a pocket depth of atleast 6 mm were selected, examined


and grouped on the day of sampling as they presented themselves at the out-patient section of the department of periodontics. A brief case history was taken and recorded. Each selected site was diagnosed as clinically healthy or diseased depending on the evaluation of the periodontium. All patients were informed of the nature of the study to be undertaken and were willing and co-operative.

Selection of sites:For the purpose of standardization, the first molar-tooth in each quadrant was chosen. The mesial and distal areas on the buccal aspect in each subject were examined.

Recording of pocket depth :Probing pocket depth was noted at the selected sites using a William's graduated pocket marking probe. Probing method was standardized by inserting the probe into the mesial and distal areas in the posterior region directed towards the contact point. Weight of the handle was transferred to the tip of the probe to standardize the probing force. However, only the deepest pocket was recorded and the reading made to the nearest millimeter.

Recording of Index:The following index was recorded for each subject which helped to categorize them into various groups.

Periodontal lndex (PI) by Russel (1956)This Index was used to estimate the extent of periodontal disease by measuring the presence or absence of the gingival inflammation and its severity, pocket formation and masticatory function.The criteria were used to assess all of the gingival tissue circumscribing a tooth.A PI score per individual is determined by adding scores of all the teeth and divided by the number of teeth examined.

SCORE CRITERIA0 Negative - There is neither overt

inflammation in the investing tissues nor loss of function due to destruction of supporting tissues

1 Mild gingivitis-There is an overt area of inflammation in the free gingiva, but this area does not circumscribe the tooth.

2 G i n g i v i t i s i n f l a m m a t i o n completely circumscribes the tooth,

but there is no apparent break in the epithelial attachment

3 Used when radiographs are available

4 Gingivitis with pocket formation. Tooth is firm with normal function.

5 Advanced destruction with loss of masticatory function. The tooth may be loose, may have drifted, may sound dull on percussion with a metallic instrument, or may be depressed in its socket.

Sampling Procedures:The first molar tooth in each quadrant was selected for sampling of sub-gingival plaque. The buccal inter-dental areas were chosen and kept as constant. The sample site was isolated with cotton and air-dried. The supra-gingival plaque was removed using a sterile scaler in an apical to coronal direction in order to avoid pushing supragingival plaque into subgingival space.

The area was then instrumented with a sterile curette separately in each of these sites from an apical-most position. The plaque mass obtained on the instrument tip was immediately transferred to a test tube containing 0.6 ml of Sorensen buffer. A minimum of 4 to 6 samples were collected.

Dispersion of the plaque was by vigorous vibration for 20 seconds in a vortex mixer until a homogenous plaque suspension was obtained. 50 microliters of this suspension was then removed with the help of a micropipette and transferred to another test-tube for further analysis.

Enzymatic Procedures:For the analysis of plaque samples a S o r e n s e n b u f f e r ( 0 . 1 5 m o l / I ) monopotassium phosphate, 0.15 mol/l disodium Phosphate) at pH 7.2 was used. This solution is required to preserve and maintain the enzymatic activity of the sample.

BANA (Sigma Chemical Company, St. Louis , Missour i , U.S .A. ) i s a commercially available colourless synthetic peptide in a powder form. It has a strong affinity to proteolytic enzymes like trypsin. It was obtained from Sigma Chemical Company for the purpose of this study.

A stock solution BANA (44 mg) and 1 ml dimethyl sulfoxide (DMSO) was diluted

in 100 ml of buffer to give a working solution of 0.67 m mol/l BANA at pH 7 which is said to give the best results for the enzyme assay.100 microlitres (0.1 ml) of this working solution was added to 50 microlitres of the plaque suspension and incubated overnight at 37°C. The period of incubation ranged from 18-20 hours. A drop of 0.1%fast Garnet indicator dye was then added, and the intensity of the chromogenic reaction was read visually and scored as

[14],[15].follows

1. Yellow-Negative2. Yellowish Orange- Weakly Positive3. Orange red-Positive4. Red-Strongly Positive

The results for the patients were noted after 5-15 minutes and recorded in a tabular form according to the respective group. They were then subjected to statistical analysis.

ResultsThe study includes 55 patients, 25 of control group and 30 from chronic periodontitis group. The BANA test results were compared between healthy and diseased sites. Standard statistical techniques like analysis of variance, and chi-square test were used.

Mean values of plaque, gingival and bleeding index and periodontal index of different groups that were included in this study are presented in Table I.

Plaque Index:Comparison of mean values of Plaque index are presented in Table 1 & Graph 1. Mean Plaque index in Group A (Control) was 0.79. Group B showed a Mean value of 1.53.

Gingival Index:The mean values of gingival index in Group I(healthy) was 0.62. It was 1.36 in Group II.

Bleeding Index:Comparison of mean values of bleeding index in Group I (healthy) was 0.39, Group II revealed l.38.Comparison between healthy and diseased sites revealed a higher mean value in diseased sites - than in healthy sites.

BANA Results:The BANA results were evaluated at


control and diseased sites. The results obtained by the BANA test were categorized as :-Negative - YellowWeekly Positive - Yellowish OrangePositive - Orangish RedStrongly Positive - Red

In healthy group 16 sites showed negative, 6 sites showed weakly positive, and 3 as positive.In diseased group 8 showed negative, 4 sites showed weak positive, 18 sites showed positive results.Assessment of validity of BANA test reflected a sensitivity of (true positivity) of 70%, & specificity (true-negativity) of 66% and overall accuracy of 69%.

DiscussionRecent research in periodontology has been devoted to the description of microbial composition of plaque taken from both healthy and diseased subjects and has indicated that a definite number of bacterial species are associated with periodontal disease.This has generated the hypothesis that periodontal disease is essentially an infection due to one or m o r e o f t h e p u t a t i v e

[1],[18],[19],[20],[24]periodontopathogens

The bacterial species most frequently associated with periodontitis are anaerobic organisms that can use proteins and peptide as energy sources. Only certain putative periodontopathic bacteria possess a trypsin - like enzyme, that can cleave a variety of synthetic substrates that have arginine attached to a chromophore. When these substrates are incubated with plaque, a color reaction occurs. The hydrolysis of Benzoyl DL Arginase Naphthylamide (BANA) by sub gingival plaque samples was the first of these substrates to be suggested as being of possible diagnostic value in periodontal disease.

The unique nature of BANA hydrolase is the identity of the bacterial species which possess it. Thus far, porphyromonas gingivalis,Tannerella (Bacteroid) forsythia and Treponema denticola are the only bacterial species of over 60 species tested that exhibit strong and consistent BANA hydrolase activity. Apart from these three BANA positive species, Capnocytophaga is also associated with BANA hydrolase

[2],[3] [21], [22],[23], [25].activity However, the capnocytophaga species were identified

Table 1

S. No.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Mean

SD

PI

0.2

1

0.5

J.0

1

1

0.5

1

0.5

1

1

0.5

1

0.5

1

1

0.5

1

0.5

1

1

1

0.2

1

1

-

-

-

-

-

0.79

0.861

GI

0.5

1

0.5

0.2

1

0.5

0.5

0.2

0.5

1

0.5

0.5

1

0.5

0.5

0.5

1

1

0.2

1.2

0.5

0.2

0.5

0.5

1

-

-

-

-

-

0.62

0.73

BI

0.2

0.5

0.2

0.5

0.5

0.5

0.2

0.5

0.2

0.5

0.2

0.2

0.5

0.2

0.5

0.5

0.2

0.5

0.5

0.5

0.5

0.2

0.5

0.2

0.5

-

-

-

-

-

0.39

0.55

PI

0.2

0.2

0.4

0.2

0.2

0.4

0.2

0.2

0.4

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.2

0.4

0.4

0.2

0.2

0.2

-

-

-

-

-

2.4

0.81

PI

1

1

1

1.2

1

2

1

1

2

1

1.5

2

2

1.5

2

2

1

2

1.2

1

2

2

2

2

1

2

1.5

2

1.5

1.5

1.53

1.6

GI

2

1

2

1

1

1

1.5

1

2

1

1

2

1

1

2

2

1

2

1

1.5

2

1

1

2

1

1

1.5

1.5

1

1

1.36

1.45

BI

2

2

2

1

1

1

1.5

1

2

1

1.5

1.5

1

1

2

1.5

0.5

2

1

1.5

1.5

1

2

2

1

1

1.2

1.5

1

1

1.38

1.42

PI

4

4.8

4.2

4.8

4.2

4.5

6.5

4.6

4

4.2

3.8

4.5

4

3.2

2.2

6

5

6.5

6

4

6

8

8.4

6.5

1

4

5.5

4.2

3.8

6.2

5.02

3.71

Group - A Group - B

PI : Plaque IndexGI : Gingival IndexBI : Bleeding IndexPDI : Periodontal IndexS.D. : Standard Deviation

Table : 2 : Comparison Of Bana Results Between Healthy And Diseased Sites

Groups

Healthy

Diseased

No.

16

3

%

64

10

No.

6

5

%

24

16.6

No.

3

22

%

12

73.3

Total

25

30

Negative Weak Positive Positive

BANA RESULTS

Chi Square x2 = 7.72P 0.56 Significant

Table : 3 : Specificity And Sensitivity Of Bana Results

6

3

T

Sensitivity : 70%Specificity : 66%Overall Accuracy : 69%

Positive

22

9

31

Negative

8

16

24

30

25

in low proportions in both the BANA positive and negative results.

The detection of BANA hydrolase positive organisms was done by time consuming procedures like bacterial culture method and immunological assay. For the rapid detection of these organisms in vitro BANA test was first utilized in the dental field by Loesche in 1986.

The following instances are examples of when or where the BANA test could be applied in periodontal therapy. (a) At initial diagnosis, in conjunction

with clinical parameters, so as to establish treatment tactics.

(b) To determine whether initial treatment has been adequate or whether additional modalities are called for.

(c) At recall visits, to determine whether treatment is necessary.

(d) To p r e d i c t p o s s i b l e f u t u r e deve lopment o f pe r iodon ta l inf lammation or per iodontal breakdown.

Loesche et al (1987) have shown that BANA hydrolysis by plaque samples has


the potential to be a marker of periodontal morbidity as assessed by probing depth measurements and by plaque proportions spirochetes.Syed et al (1984) have shown that BANA hydrolysis can he used to measure the efficacy of anti-microbial treatment in the experimental gingivitis model.Gusberti et al (1986) have shown that BANA hydrolysis along with other enzyme markers can be used to diagnose and to monitor treatment efficacy in refractory patients. Thus the clinical management of patients with periodontal disease can be based on criteria given by both bacterial and clinical parameters that can be compared at different time intervals, as was suggested by Listgarten (1986).The substrate BANA has been used over others as studies have shown that it has a consistent and distinctive ability to reflect the presence of all three pathogens under consideration, did not need the presence of' expensive equipment or expert handling and demonstrated a high degree of sensitivity, specificity, predictivity and accuracy.

The plaque sample is often contaminated

with (GCF and or blood, but neither blood, saliva nor GCF are found to be able to hydrolyze BANA.

Limitation of BANA test is, it does not identify which of the three BANA positive species is present in plaque. However, as all three species are anaerobes, it allows the clinician to determine that an anaerobic infection is present.

Research directions regarding the use of the BANA test may include:- 1. Studies to monitor the efficacy of

selected clinical or anti-microbial procedures.

2. To assess patient's compliance towards anti-microbial agents.

3. Cost-effectiveness and cost-benefit analysis of the BANA test.

4. Prospective cohort studies, where risk indicators such as a positive test r e s u l t a n d t h e s u b s e q u e n t development of clinical disease could he followed throughout time.

5. School-based screening programmes to identify risk groups for periodontal diseases at an early age.

6. It could also be available for screening of populations or in a manner suitable for epidemiological surveys.

7. It may he applied to assess the microbial status before and after periodontal therapy and also to compare it with other micro-biological diagnostic procedures like bacterial culture, ELISA, and DNA probe.

A tooth site with a BANA positive plaque [6]is indicative of 5 x 10 or more of the

anaerobic bacteria detected by the BANA test Generally, a weak positive result in a clinically symptom-free patient without a history of periodontal disease confirms the presence of low levels of anaerobic bacteria which are consistent with the absence of periodontal disease for the patient. However, a weak positive result in a symptom-free patient with a history periodontal disease which is now in maintenance phase may be indicative of re-colonization with pathogenic bacteria. Hence, additional preventive measures may be indicated for such a patient. On the other hand a negative BANA

[6]response indicates less than 1 x 10 of the anaerobic bacteria detected by the test

[21]exhibiting clinical judgment of health.

Graph - I(Group - A)

Graph - II(Group - A)

Similarly the presence of BANA positive plaque around the tooth site at the conclusion of initial periodontal treatment indicates still presence of higher proportions of anaerobic bacteria in the periodontal pocket as a residual infection. This is also indicative of future attachment loss which is having potentially greater clinical significance. Hence, further anti-microbial therapy or surgical intervention or both are essential for the treatment of these.

It has been shown that conversion of BANA positive plaque to BANA negative plaque may lead to a reduction in the need for surgical intervention. And this may be significantly modified by certain host factors. These host factors are host immune responses or patient's ability to maintain the oral hygiene at an optimum level. All these intrinsic and extrinsic host factors determine the tooth's sites specific response to a certain extent.

Thus, the ability of BANA to detect a particular threshold of anaerobic periodontopathic bacteria was found to be a valuable diagnostic tool for screening the individuals at risk for anaerobic infection. BANA test results showing positive or weak positive or negative reaction also has the potential of enabling the clinician to monitor the


adequacy of treatment procedures. These findings suggest that BANA hydrolysis by sub-gingival plaque can be used as a simple and objective test to identify those sites in individuals who might require treatment to reduce their pathogenic microflora.Results obtained from each patient were tabulated and analyzed. A glance at the results the results shows:

Groups-I (Control gp) :Negative : 16%Positive : 7-28%Strongly Positive : 0-8%

Group - II (Diseased)Negative : 3 : 9.99%Weakly Positive : 5 : 16.65%Positive : 14 : 46.62%Strongly Positive : 8 : 26.64%

The results reported in the study imply that BANA test has multiple utilities in identifying periodontal disease that would facilitate patient management. However, BANA hydrolysis is unable to detect an individual pathogen and their identification via the color reaction or their disappearance after therapy as it is as a group and not individually. Also species associated with active disease like Wolinella recta, E- Corrodens and P-intermedius are not detected. Inspite of these limitations BANA has been shown

to be a marker periodontal morbidity as assessed by probing depth measurements and by plaque proportions of spirochetes.

Summary And Conclusion55 Subjects from a periodontally defined population from the department of periodontics ,Government Dental College and Hospital, Hyderabad were evaluated for the ability of their sub-gingival plaque samples to hydrolyze a 0.67 mmol solution of BANA and correlate it with its clinical diagnosis. Two groups comprising healthy and diseased subjects were tested.After the clinical assessments were made and the findings recorded, 4 to 6 sub-gingival plaque samples were obtained from the buccal interdental areas around the first molar tooth in each quadrant. After dispersion in 0.6 ml of Sorensen phosphate buffer, 50 microlitres were incubated with 0.1 ml of BANA solution at 370C for 18 hrs. The outcome of the hydrolysis was recorded with the help of colour reaction obtained by the addition of drop of 0.1% solution of fast Garnet indicator dye. It was graded from 1-4 as yellow, yellowish - orange, organic red and red. The purpose of this study was to detect the BANA positive micro-organisms in periodontally healthy and diseased site.

It could be concluded that :i. BANA is an effective substrate for

hydrolysis by specific subgingival plaque micro organisms and can be used as a reliable indicator of BANA positive species in sub-gingival plaque.

ii. The outcome of BANA test was highly significant in periodontally diseased subjects.

iii. The BANA test can he used as a simple and objective means of determining diseased sites requiring periodontal treatment.

iv. It can be used to confirm the need for treatment in patients who have undergone periodontal treatment.

v. It may be used to assess the microbial status before and after periodontal therapy and also to compare it with other microbiological diagnostic procedures such as bacterial culture, ELISA and DNA probe.

Thus, the BANA test has the potential to be used as an objective indicator of future periodontal disease activity in healthy and treated individuals.

References:1. MOORE W.E., RANNEY R.R.

HOLDEMANL V. : Sub-gingival microflora in periodontal disease: Cultural studies. R..J. Genco and S.E. Mergenhagen (eds) , Host-parasite Interactions in Periodontal Disease, P-13, Washington, D.C., American Society of Microbiology, Cited from J. Periodontol 59: 50R-515, 19RR.

2. PEDERSSON E.D, MILLER J. W., MATHESON S., SIMONSON L.G., CHADWICK D.E. COVILL P.J.: Trypsin like activity levels of t r e p o n e m a d e n t i c o l a a n d porphyromonas gingivalis in adults wi th pe r iodon t i t i s . J . C l in . Peridontology, 1994 (R): 8;21;519-25.

3. RAMFJORD S.P., CAFFESSE R.G., MORRISON H.C, et al. : 4 modalities of periodontal treatment compared over 5 years. .J. Periodontol 14: 8;445-452, 1987

4. CHENG, S.L. AND CHAN E.C.S.,: The routine isolation, growth and maintenance of the intermediate size, anaerohic oral spirochaete from peridontal pockets. Periodontology. Res. 19: 362-368, 1983

5. LOESCHE W.J. BRETZ W.A., LOPATIN D., STOLL .I., RAU C.F, HILLENBURG K..L KII,LOY W..I., DRISKO C.L, WILLIAMS R., W E B E R H . P. , C L A R K W. , MAGNUSSON 1., WALKER C., and HUJOEL P.P. Multicenter clinical evaluation of a chair-side method for detecting certain periodontopathic bacteria in periodontal disease. J. Periodontology, 1990:61; 189-196.

6. LOESCHE W.J.: DNA probe and enzyme analysis in periodontal diagnostics. J. Periodontology 1992:63: 1102

7. LOESCHE W.J., LOPATIN D.E., GIORDANO J., ALEOFORADO G., HUJOEL P. : Comparison of BANA t e s t , D N A p r o b e s , a n d immunological reagents for ability to detect anaerohic periodontal infections due to P.g, T. d. B.f.J., Clin, Microbiol. 1YY2: 30(2) -127-33

8. LOESCHE W..J., SYED S.A. and STOLLS J. : Trypsin like activity in subgingival plaque - A diagnostic


marker for spirochaetes and peridontal disease. J. Periodontlogy, 1986: 5 266.

9. S M I T H A . J . WA D E W. G . , GREENMAN J., ADDYM : Analysis of cult ivable porphyromonas gingivalis with trypsin like protease enzyme activity and serum antibodies in chronic adult periodontitis. J. Oral Disease. 1995: 1 (2): 70-6

10. BRETZ W.A., W.J. LOESCHE: Characteristics of Trypsin-like activity in sub-gingival plaque samples. Dent. Res. 66: 1668-1672, 1987.

11. Bretz W.A., Lopatin D.E. Loesche W.J., Benzoyl: arginine napthylamide (BANA) hydrolysis by Treponema denticola and or Bacteroid gingivalis in periodontal plaques. Oral Microbiol Immunology. 275-279, 1990.

12. COXS, W. ELEY B.M. Trypase like activity in crevicular fluid from gingivitis and periodontitis: 1. Perio, Res. 1989: 2: 41-44.

13. DRAKE C. W., :: HUNT R.J., BECK J.D., ZAMRON J.J. : : The distribution and interrelationship of Aa, Pg, Pl, and BANA scores among older adults, J. Peridontology, 1993: 64(2): 89-94.

14. FEITOSA A.C. AMALFITANO J, LOESCHE W.J., : The effect of incubation temperature on the specificity of the BANA test J., Oral Microbiol. Immunology 1993: 8 (1): 57-61.

15. JOSEPH AMALFITANO, ANNA B., De FILIPPO BRETZ W.A. and LOESCHE W.J.: The effects of incubation length and temperature on the specificity and sensitivity of the N - B e n z o y l - D L - a r g i n i n e n a p h t h y l a m i d e ( B A N A ) J . Periodontology, 1993: 64:848-852.

16. BRETZ W.A., EKLUND S.A., RAD/CCH I R., SCHORK M.A. LOESCHE,. W.J. : The use of a rapid enzymatic assay in the field for the detection of infection associated with adult periodontitis. .J. Public Health Dent. 1993: 53(4): 235:40.

17. FERMIN A CARRANZA., MICHAL G . N E W M A N . : C l i n i c a l periodontology, W.B. Saunders

Company, 8th Edition, 1996 : 385.18. LOESCHE W.J., SYED S.A.

SCHMIDTHE., MORRISON : Bacterial profiles of sub-gingival p laques in per iodont i t i s . J . Periodontology, 1985: 56-447.

19. CHRISTERSSON, L.A. C.L. FRANSSON, R.G. DUNNFOR, J.J ZAMBON: Sub-gingival distribution o f p e r i o d o n t a l p a t h o g e n i c microorganisms in adult peridontitis of. Peridontology 63: -118--125, 1992.

20. G M U R R . S T R U B . J . R . GUGGENHEIM B. : Prevalence of bacteroid forsythus and B. Gingivalis i n s u b g i n g i v a l p l a q u e o f periodontally treated patients short recall. J. perio. Res. 1989: 2-1:113-120.

21. The ability of the BANA Test to detect different levels of P. gingivalis, T.denticola and T. forsythia .Braz O r a l R e s . 2 0 1 0 A p r - 2 2 4 Jun;24(2):224-30

22. The ability of the BANA Test to detect different levels of P. gingivalis, T. denticola and T. forsythia. The ability of the BANA Test to detect different levels of P. gingivalis, T. denticola and T. forsythia. J Am Geriatr Soc. 2005 Sep ;53:1532-7 . José Alexandre de Andrade, Magda F e r e s , Lu c i en e C r i s t i n a d e Figueiredo, Sérgio Luiz Salvador, Sheila Cavalca Cortelli

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www.ijds.inCase Report


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Priyadarshini Boral2 Sridhar Chowdhary3 Goutham Kumar

Patient with age 65 years old came to Panineeya dental collage with the teeth present unilaterally 13,14,15 and 34,35,36,37 Kennedy's class I and class II. Patient wanted a replacement of teeth by removable partial denture. As the patient was very old and medically compromised implant supported denture were not considered. As the teeth are very less in number and present unilaterally, the flexible denture with wrap around distal clasp was fabricated for the patient by engaging the undercut

Method1. Primary impression was made with

irreversible hydrocolloid impression material.

2. Custom tray was made with 2mm wax spacer.

3. Elastomeric impression material with light body and putty was made

4. Duplication of master cast was done with the die stone

5. Jaw relation was made 6. Teeth set-up :- no less than 1\3 of the

teeth neck be inserted into modelling wax. V-shaped channels were created on the tissue side of the tooth

7. The duplicated model was waxed up and cut with the special saw or disk as close to the wax as possible

8. Special flask with bolts was used .The lower half of the flask was filled with stone and covered the model

9. Sprues were connected to the wax pattern a) Sprues should be straight .b) A sprue should be thinner at the connector. c) Minimum 3 sprue

IntroductionFlexible denture can be used for the patient having few teeth or at-least two teeth in both side of arch .It can be used even in case with teeth present unilaterally in arch using extended clasp. The application of nylon like material for the fabrication of dental appliances replaces the acrylic and metal to build the framework of removable partial denture.

Thermoplastic materials for dental prosthesis , Valplast (Valpalst int. Corp USA) and Flexiplast (Bredent) were first introduced to dentistry in 1950. Both materials were similar grade of polyamides (nylon plastic) rapid injection systems ( Flexible company USA) originated in 1962. Valplast introduced a flexible same translucent thermoplastic resin to create flexible tissue born partial denture. Acetal was first proposed as an unbreakable thermoplastic resin for removable partial denture in 1971. In 1986 tooth coloured clasp was introduced. The clasp was flexible. In 1992 Flexite company developed the first preformed tooth coloured clasp.

Applications of thermoplastic resin are 1) Removable partial denture 2) Provisional crown and bridge 3) Obturator and speech therapy appliance 4) Orthodontic retainer and bracket 5) Impression trays 5) Border moulding material 6) occlusal splint 7) Implant abutments

Case


1,2 Professor3 Reader Department of Prosthodontics Panineeya Institute of Dental Sciences & Research Centre, Kamala Nagar, Road No 5, DilshukhNagar, Hyderabad - 500 060

Flexible Partial Denture For Unilateral

Remaining Teeth By Using Wrap Around Clasp

Address For Correspondence:Dr. Priyadarshini BoralProfessor (Department of Prosthodontics)Panineeya Institute of Dental Sciences & Research CentreKamala Nagar, Road No 5DilshukhNagar, Hyderabad - 500 060

th Submission : 18 April 2012th Accepted : 29 January 2013

Quick Response Code

AbstractValplast has got a high creep resistance , fatigue resistance, wear resistance and less porosity. Some patients are allergic to free monomer , in flexible denture free monomer content is negligible . In this case teeth were present in unilateral arch , it was not adequate to retain cast partial denture . Flexible denture was fabricated which had got a good retention and stability by using distal wrap around clasp

Key Wordsflexible denture, thermoplastic resin denture, tooth and tissue born denture, wrap around clasp denture

should be present one on each distal side and one in the middle of the connector

10. Flask was closed using bolts to allow opening it easily after dewaxing

11. Upper half of the flask was filled with stone through opening

12. Dewaxing was performed for 15 min in boiling water

13. The cartridge was heated at 285 degree Celsius and injected in to the flask with Valplast machine

14. Flask was Bench cooled, the denture was taken out, trim and polish it with polishing bur

Disscussion:Flexible dentures exhibit high creep resistance, fatigue resistance as well as excellent wear characteristic and solvent resistance .There is no free monomer and porosity with less odour and stain. It has got higher dimensional and colour stability. Thermoplastic nylon is a resin derived from diamine and dibasic acid monomer . Nylon exhibits high physical strength, heat resistance and chemical resistance .Because of its inherent


ConclusionWhenever there are unilateral teeth remaining with minimal undercuts, by using wrap around clasp we can fabricate a good flexible partial denture. As the patient was very old and medically compromised implan t was no t considered. In this case there was a good retention, light weight, better esthetics and comfortable to the patient comparable to cast partial denture.

Reference1. Lowe LG: Flexible denture flanges

for patients exhibiting undercuts, tuberosities and reduced width of buccal vestibule: a clinical report: J Prosthet Dent 2004;13(1);17-27

2. Keenan PL, Radford DR, Clark KF: Dimensional change in complete

flexibility, it is used primarily for flexible tissue born partial denture .It does not have enough strength to use for occlusal rest seat ,and won't maintain vertical dimension when used in direct occlusal forces .Thermoplastic nylon is injected at temperature from 274 to 293 degree Celsius and has a specific gravity of 1.14 ,mould shrinkage amount to 0.014 inch\inch ,tensile strength is 11000 psi and flexural strength is 16000psi. Nylon is little more difficult to trim and polish. The resin is semi translucent and provide excellent aesthetic for flexible tissue borne partial denture

Valplast is nearly unbreakable, is coloured pink like a gum, can be built quite thin, and can form not only the denture base, but the clasp as well. Since clasp are built to curl around the neck of the tooth, they are pract ical ly indistinguishable from gums that surrounds the teeth. Even though this denture dose not rest on the natural teeth like cast partial denture , the clasp rest on gum surrounding the natural teeth. This type of partial denture is extremely stable, retentive and elasticity of the clasp keeps them that way indefinitely. Flexite supreme's base component is co-polyamide. It is easy to adjust and polish. Flexite is used to fabricate removable partial denture, TMJ disfunction, bruxism, anti- snoring device, sport mouth guards, tooth coloured clasp. Flexible thermoplastic materials is available in three tissue shades. The material is monomer free, unbreakable, light weight and impervious to oral fluids. Flexite plus may also combine with a metal frame work to eliminate the display of metal labially

SummaryFlexible dentures fabricated by using Valplast nylon resin are derived from diamine and dibasic acid monomer. Valplast exhibits high physical strength, heat resistance and chemical resistance. It has got good stiffness and wear resistance but it cannot be used as an occlusal rest as in cast partial denture. It is used primarily as a tissue borne flexible partial denture. Valplast is slightly difficult to adjust and polish. In this case teeth are present unilaterally, so better option was flexible partial denture by using wrap around distal clasp . The denture had a better retention and stability.

Fig.1 Shows Kennedy's class II

Fig.2 Shows Kennedy's class I

Fig.3 Shows maxillary and mandibular edentulous arches

Fig.4 Shows flexible dentures on casts

Fig.5 Shows maxillary and mandibular flexible dentures

Fig.6 Shows maxillary denture in patient's mouth

Fig.7 Shows maxillary and mandibular dentures in patient's mouth

Fig.8 Shows maxillary and mandibular dentures in occlusion


cured by three denture base processing methods;J Prosthet Dent 1992;67;879-81

10. Wong DM, Cheng LY, Chow TW: Effect of processing method on dimentional accuracy and water sorption of acrylic resin denture : J Prosthet Dent 1999;81:300-4

11. Wostmann B, Butz-Jorgensen E, Jepson N, et al: Indication for removable partial denture: a literature r e v i e w : I n t . J P r o s t h o d o n t 2005;18(2):139-45

6. Nogueria SS, Ogle RE, Davis EL: Comparision of accuracy between compression and injection moulded complete dentures.J Prosthet Dent 1999;82:291-300

7. Parvizi A,Lindquist T, Schneider R et al: Comparison of dimensional accuracy of injection moulded denture base material to that of conventional pressure pack acrylic resin J Prosthodont 2004;13(2);83-9

8. Pardo-Mindan S, Ruiz-Villan Diego JC: A flexible lingual clasp as an esthetic alternative: a clinical report: J Prosthet Dent 1993;69:245-46

9. Salim S, Sadamori S, Hamanda T: The dimentional accuracy of rectangular acrylic resin specimens

denture fabricated by injection moulding and microwave processing : J Prosthet Dent 2003; 89(1);37-44

3. John J, Gangadhar SA, Shah I: Flexural strength of heat-polmerized polymethyl methacrelate denture, resin reinforced with glass, aramid or nylon fibres : J Prosthetic Dent 2001;86(4) 424-7

4. Anderson GC, Schulte JK, Arnold TG,: Dimensional stability of i n j e c t i o n a n d c o n v e n t i o n a l processing of denture base acrylic resin : J Prosthet Dent 1988;60:394-8

5. Beaumont AJ Jr.: An overview of esthetics with removable partial d e n t u r e Q u i n t e s s e n c e I n t . 2002;33(10):747-55





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Leena Verma2 Rupandeep Kaur Samra

differential diagnosis can be made [3]radiograpically. It is generally accepted

that fusion results from the cojoining of two separate pulp canals, while gemination originates when one tooth

[2],[4]bud attempts to split into two. In clinical situations, cases of fusion have the appearance of a congenitally missing tooth, while in gemination the number of teeth in the dentition is normal per quadrant, provided the double teeth is counted as one unit.

This paper reports a rare case of fusion of deciduous mandibular incisors along with bilateral fusion in succadeneous permanent teeth.

Case ReportA 3-year-old male child reported to Department of Pedodontics and Preventive Dentistry with a chief complaint of unusually large lower anterior teeth. Intraoral clinical examination revealed that patient was in a deciduous dentition period and the number of teeth present in mandibular arch were less than normal and the teeth (71,72 and 81,82) were fused together [Fig.1] . Periapical radiographic examination revealed the complete fusion of central and lateral incisors with one root and one pulp canal [Fig. 2] on both sides of mandible, along with the bilateral fusion of associated permanent

IntroductionThe phenomenon of tooth fusion arises through union of two normally separated tooth germs, and depending upon the stage of development of the teeth at the time of union, it may be either complete or incomplete. On some occasions, two independent pulp chambers and root canals can be seen. Fusion occurs during the morphodifferentiation of the dental germs and the outcome depends on the degree of development of the teeth

[1]involved. It is also caused by the persistence of the dental lamina between two or more tooth germs, or, by the attempt of a supernumerary tooth to develop from the remnants of the dental lamina after it has divided from a neighboring tooth germ. The union can be at enamel /dentin with common pulp chamber or separate pulp chambers. When it occurs precociously it may be that the two developing teeth unite to form what appears clinically as a single

[2]tooth of normal size. However, if it occurs at a more advanced stage of development the outcome is a tooth of double size or a tooth with bifid crown.

In addition to affecting two normal teeth fusion may also occur between normal tooth and a supernumerary tooth such as mesiodens and distomolar. This developmental anomaly is most often confused with gemination. However, a


1 Assitant Professor, Dept. of Pedodontics Dr HSJ Institute of Dental Sciences and Research, Chandigarh.2 Reader, Dept. of Prosthodontics Himachal Dental College, Sundernagar, H. P.

Bilateral Fusion In Deciduous Dentition

Associated With Bilateral Fusion In

Succadeneous Permanent Teeth – A Case

Report.Address For Correspondence:Dr. Leena Verma G.H-28, Flat No 132,M.D.C Sector 5, Panchkula (Haryana)


Quick Response Code

AbstractFusion is a developmental anomaly in which two dental germs have developed separately and then become united. The incisors are reported to be fused in primary and permanent dentition, but bilateral mandibular fusion of the primary incisors is a rare event, with a prevalence of less than 0.02%. When all four permanent successors are also bilaterally fused, this event becomes rarer still. This study describes a case report of bilateral fusion in deciduous dentition of a 3-year-old boy associated with bilateral fusion in succadeneous permanent teeth.

Key WordsFusion, deciduous dentition, gemination.

Figure 1: Intraoral View Showing Fusion Of Deciduous Incisors.

Figure 2: IOPA Showing Complete Fusion With One Root And One Pulp Canal.

successors of right and left central and lateral incisor which is an unusual dental anomaly. OPG was advised which confirmed this finding [Fig.3]. There was


successors of right and left central and lateral incisor which is an unusual dental anomaly.

References:1. Ten Cate AR. Oral Histology:

Development, Structure, and Function. St. Louis, MO: Mosby; 1998:81-102.

2. Turell IL, Zmener O. Endodontic therapy in a fused mandibular molar. J Endod 1999; 25: 208-9.

3. Camm HJ, Wood AJ. Gemination, fusion and supernumerary tooth in the primary dentition - report of case. ASDC J Dent Child 1989; 56: 60 -1.

4. Nunes E, de Moraes IG, de Novaes PM, de Sousa SM. Bilateral fusion of mandibular second molars with supernumerary teeth- A case report. Braz Dent J 2002; 13:137-41.

5. Neves AA, Neves ML. Bilateral connation of permanent mandibular incisors: a case report. Int J of Paediatr Dent 2002; 12:61-5.

6. Saxena A, Pandey RK, Kamboj M. Bilateral fusion of permanent mandibular incisors: a case report. J Indian Soc Pedod Prev Dent 2008; 26 Suppl 1:S32-3.

7. Milano M, Seybold SV, McCandless G, Cammarata R. Bilateral fusion of the mandibular primary incisors: report of case. ASDC J Dent Child 1999;66:280-2, 229.

8. Hagman FT. Anomalies of form and number, fused primary teeth, a correlation of the dentitions. ASDC J Dent Child 1988; 55:359-61.

9. Peyrano A, Zmener O. Endodontic management of mandibular lateral incisor fused with supernumerary tooth. Endod Dent Traumatol 1995; 11:196-8.

10. Aguiló L, Gandia JL, Cibrian R, Catala M. Primary double teeth. A retrospective clinical study of their morphological characteristics and associated anomalies. Int J Paediatr Dent 1999; 9:175-83.

11. Tomizawa M, Shimizu A, Hayashi S, Noda T. Bilateral maxillary fused primary incisors accompanied by succedaneous supernumerary teeth: report of a case. Int J Paediatr Dent 2002; 12:223-7.

[9]frequently in the primary dentition.

Four morphological types of fusion were identified by Aguiló L, Gandia JL,

[10]Cibrian R, Catala M : type I- bifid crown-single root; type II- large crown-large root; type III- two fused crowns-single root; type IV- two fused crowns-two fused roots. Type I was seen only in the maxilla and types II and III only in the mandible. Type IV was seen mostly in the maxilla. In this case, Type III fusion was observed.

Fused teeth are usually asymptomatic. Teeth with these abnormalities are unaesthetic due to their irregular morphology. They also present a high predilection to caries, periodontal disease and spacing problems. The main periodontal complications in fusion cases occur due to the presence of fissures or grooves in the union between the teeth

[2],[3]involved. In a preventive concern, the buccal and lingual vertical grooves of double primary teeth may be pronounced and difficult to clean, and are highly susceptible to caries. The placement of fissure sealants or composite restorations in these grooves should decrease the

[9]caries risk.

Several clinical problems in the permanent dentition follow fused primary teeth such as physiological root resorption of fused deciduous teeth being retarded due to greater root mass and increased area of root surface, leading to delayed or ectopic eruption of permanent successors.

A rare case of fusion between maxillary p r i m a r y c e n t r a l i n c i s o r s a n d supplemental teeth occurring bilaterally, a ccompan ied by succedaneous supernumerary teeth has also been cited by Tomizawa M, Shimizu A, Hayashi S, Noda T which involved extraction of the supernumerary teeth for eruption of permanent teeth and their careful

[11]monitoring. Porcelain veneers and crowns can enhance the esthetic appearance.

In this case there was complete fusion of deciduous central and lateral incisors on both side of mandible, along with the bilateral fusion of associated permanent

no history of pain or discomfort and incisors were caries free. The hair and skin of the patient appeared normal and no systemic abnormality or congenital disease was noted in the medical history of the patient and her family.

Treatment plan for the patient included follow up till the deciduous fused incisors are shed off and fused permanent incisors erupt. The fused permanent incisors will then be kept under observation for their abnormal morphology and excessive mesiodistal width which can cause problems with spacing, alignment and function.

DiscussionConnated teeth are the consequences of developmental anomalies leading to the eruption of joined elements. According to current definitions, gemination occurs when one tooth bud tries to divide, while

[5]fusion occurs if two buds unite.

Fusion is the union of two teeth by dentin and enamel. It has been thought that some forces or pressure produces impact of the developing tooth germs and subsequent union of enamel organ and the dental papilla resulting in union of enamel organ and the dental papilla resulting in fusion of teeth or genetic inheritance can be a

[6]possible etiology. If this contact occurs early at least before calcification begins, the two teeth may be completely united to form a single large tooth.

Bilateral mandibular fusion of the primary incisors is a rare event, occurring

[7]with a prevalence of less than 0.02% . When all four permanent successors are also bilaterally fused, this event becomes rarer still. Patients with fused incisors have less than a 20 percent chance of

[8]having a missing permanent tooth. Epidemiological studies showed that the prevalence of fused teeth was similar for girls and boys and occurred most

Figure 3: O.P.G Showing Fused Deciduous And Permanent Incisors.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Sharma Kirti

[3]or custom made . Stock prostheses are usually advocated when time is limited and cost is a consideration. No special materials are required for its fabrication; and the use of stock ocular prostheses of appropriate contour, size, and color can

[4]provide an acceptable esthetic result.

Case ReportThis is a case report of a 60 year old lady who reported with the chief complaint of missing left eye [Figure 1]. Patient gave a history of infection in the left eye 4-5 years back followed by enucleation of the same. Clinical examination revealed a healthy intraocular tissue bed with adequate depth between the upper and lower fornices for retention of the ocular prosthesis Patient was diagnosed of enucleated left eye socket and a custom ocular prosthesis was planned for her rehabilitation.

TechniqueThe impression material (non reversible hydrocolloid)) was injected into the left eye socket [Figure 2] and the patient was instructed to perform all the movements of the eye, before the impression material was set. The impression was poured with gypsum to obtain the primary cast. [Figure 3]. Thereafter, a wax spacer was adapted over the defect over which a perforated special tray was fabricated for

Introduction:Generally the first features to be noticed of the face to be noted are the eyes . The ill fated loss or absence of an eye may be caused by a congenital defect, irremediable trauma, tumor, a painful blind eye, sympathetic ophthalmia or the need for histological confirmation of a

[1]suspected diagnosis . The disfigurement associated with loss of an eye can cause significant physical and emotional problems. Most patients experience considerable stress, primarily due to adjusting to the functional disability caused by the loss and to public reactions to the facial impairment. Replacement of the lost eye as soon as possible is necessary to promote physical and psychological healing for the patient and to improve social acceptance.

One of the most effective methods to rehabilitate an ocular defect is by the fabrication of ocular prostheses. The main goals of the ocular prosthesis are to restore facial esthetics, prevent eyelid collapse and deformity, protect the socket against injuries caused by foreign bodies, dust and smoke, re-establish the correct route of the lachrymal secretion to prevent accumulation in the cavity, and preserve muscular tonus to avoid anti-

[2]symmetrical alterations . Ocular prostheses are either readymade (stock)


1 Sr lecturer, Dept of Prosthodontics, M.G.V 's K.B.H Dental College and hospital, Panchvati, Nashik

Prosthetic Management Of An Ocular Defect –

A Case Report.Address For Correspondence:Dr. Kirti Sharma,House no 907,Arun Vihar, Sector - 29, NoidaPh no - 09787031104Email - [email protected]

th Submission : 28 June 2012th Accepted : 8 February 2013

Quick Response Code

AbstractAmongst all the sensory organs, the eyes play the most significant role in our lives. Unfortunately, the eyes are the most sensitive of them all and the one most prone to be damaged. The disfigurement associated with the loss of an eye can cause significant physical and emotional problems. The management of an anoptholmic socket requires the combined effort of ophthalmologist and maxillofacial prosthodontist. The surgeon provides the basis for successful rehabilitation. The maxillofacial prosthodontist provide prosthetic treatment to the best of his ability. A thorough knowledge of the anatomy is necessary for successful treatment. The goal of any prosthetic treatment is to return the patient to society with a normal appearance. Various treatment modalities are available including stock or custom made prostheses. The present article describes the prosthetic management of an ocular defect with a custom-made ocular prosthesis.

Key Wordsocular prostheses , anophthalmic socket , custom made

Figure 1 - Preoperative Photograph Of Patient.


making the final impressions [Figure 4].

The final impressions were made by expressing alginate into the defect using a disposable syringe. Next the perforated acrylic resin tray was loaded and placed over the defect [Figure 5]. The impression was first recovered from the lower, shallower sulcus first, and then rotated out of the deeper, upper sulcus. The impression was boxed and poured in dental stone up to the height of contour of the impression. A separating agent was

Figure 2 - Primary Impression Of The Defect.

Figure 3 - Fabrication Of Primary Cast With Adaptation Of Wax Spacer.

Figure 4 - Perforated Special Tray.

Figure 5 - Final Impression.

Figure 6 - Two Piece Master Cast.

Figure 7 - Scleral Try- In .

Figure 8 - Horizontal And Vertical Reference Lines.

Figure 9 - Final Trial With The Attached Iris.

Figure 10 - Post Operative Photograph Of The Patient.

placed and the reminder of the impression is poured to obtain a two piece mold [Figure 6].

The wax pattern was made by pouring melted wax through the funnel shaped hole and into the assembled mold. The mold was stored in water for a few minutes prior to filling it with molten wax as it prevented the wax from adhering to the stone. After the wax had cooled, the wax pattern was recovered. Once the wax pattern had been smoothed and polished, it was ready to be tried in the eye socket. The wax pattern was inserted by lifting the upper lid, and the superior edge of the pattern being placed behind the lid and gently pushing it upward. While drawing the lower lid down, the inferior border of the pattern was seated in the inferior fornix, and then the lower lid was released. The eye contours were checked and it was trimmed precisely until it accurately fitted into the socket [Figure 7].

Before the final trial of wax pattern, certain guidelines were marked on the patient's face with an indelible pencil: a vertical midline was marked considering


the stable anatomical landmarks and prominent points on the face. The midline was marked passing through the forehead crease, glabella, tip of the nose, and chin. The distance from the right eye medial canthus to the midline and left eye medial canthus to the midline was measured .The patient was asked to gaze straight at an object kept 4 feet away. The vertical lines were then marked coinciding with the medial and distal extremities of the iris of natural eye. Similarly, the horizontal lines referring to the center, inferior, and superior limits of the iris were marked [Figure8]. The markings were transferred onto the sculpted scleral wax pattern, and the stock eye that matched the iris-pupil complex of the contra lateral natural eye was selected and attached to the wax pattern. A final wax trial was carried out and the patients satisfaction was confirmed [Figure 9].

The wax pattern was invested, dewaxed, and packed with heat-cured tooth colored acrylic resin and curing was carried out. After the flask was cooled, deflasking was done, prosthesis was separated from the investment and was polished. It was ensured that the polished prosthesis was

free of roughness that could irritate the eye socket and encourage secretions to accumulate for additional irritation.

Prior to the insertion of the polished prosthesis, it was disinfected in a solution of 0.5% chlorhexidine and 70% isopropyl alcohol for 5 min. After disinfection, the prosthesis was rinsed in sterile saline solution to avoid chemical irritation and finally the ocular prosthesis was delivered [Figure 10] and post delivery instructions were given.

References1. Artopoulou I, Mountgomery P, Wesly

P, Lemon J. Digital imaging in the fabrication of ocular prosthesis. J Prosthet Dent. 2006;95:327-30.

2. Taylor TD. Carol stream, Illinois: Quintessence publishing co, Inc; 2000. Cl inical maxi l lofacia l prosthetics; pp. 233-76.

3. Cain JR. Custom ocular prosthetics. J Prosthet Dent. 1982;48:690-4.

4. Mazaheri M. Prosthetics in cleft palate treatment and research. J Prosthet Dent. 1964;14:1146-58.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Suman Yadav2 Harish Yadav3 Sonia Arora

[8], [9] & home bleaching with carbamide [10]peroxided . While each technique with

its accompanying chemical agent has its place in an armamentarium of vital tooth stain removers, none meets the needs of

[11]all stains & patient situations. Macroabrasion is another technique which is not followed routinely.It has been suggested that an approach combining various techniques of bleaching can compensate for their individual shortcomings & extend the effectiveness of this conservative

[12],[13],[14],[15]approach to care . A combined technique can result in the successful treatment of some stains where previously only masking procedures with resin bonding, veneers & crowns were

[11]effective.

TechniquesMacroabrasion or Megabrasion:Some enamel defects or white spots on t e e t h t h a t d o n o t r e s p o n d t o microabrasion and bleaching may respond better to macroabrasion. It is an alternative technique for the removal of localized, superficial white spots & other stains or defects. The discolored enamel contains an increased amount of organic matrix, which is not an adequate substrate for adhesion of dental materials. When the lesion is generally restricted to enamel, its elimination will not result in exposure of dentin (Magne

[16]1997).

IntroductionOne of the greatest assets a person can have is a smile that shows beautiful, natural teeth. Esthetics is a prime consideration in today’s population, with an ever increasing demand for a sparkling smile. In fact today’s patient pays more attention to cosmetics than ever before & teeth are a key consideration in personal appearance. In today’s modern civilized cosmetic world, well contoured & well aligned white teeth set the standard for beauty.There are many methods to improve esthetics like bleaching, composite restorations, veneers, crowns, etc. Today’s esthetic dentistry seeks to improve the appearance of patients’ smiles with a minimally invasive approach. Tooth discoloration is one reason patients seek esthetic dental treatment. The etiology of dental

[1]discoloration is multifactorial.Discolorations are classified as being extrinsic (attached to the surface of the tooth) or intrinsic (incorporated into the tooth matrix). Although extrinsic discoloration can be removed with a prophylactic cleaning procedure, intrinsic staining necessitates chemical

[1]bleaching.Three treatments are currently popular for removing a variety of intrinsic stains from vital teeth. These are enamel

[2],[3],[4]microabrasion technique , office [5], [6], [7], bleaching with hydrogen peroxide


1 Head Of The Department, Dept. Of Conservative Dentistry & Endodontics2 Principal & HOD, Dept. Of Prosthodontics3 Senior Lecturer Dept. Conservative Dentistry & Endodontics, S.G.T. Dental College, Hospital & Research Institute, Gurgaon, Haryana

Removal Of Intrinsic Stains From Vital Teeth

By A Combination Therapy – Case Reports

Address For Correspondence:Dr. Suman Yadav, S.G.T. Dental College,Hospital & Research InstituteNear Sultanpur Bird Sanctuary,Gurgaon-Farukhnagar RoadVillage Budhera Gurgaon -123505.


Quick Response Code

Macroabrasion involves removing the outer layer of opaque enamel using a 12-fluted composite finishing bur or a fine grit finishing diamond in a high-speed handpiece with water-air spray. Light, intermittent pressure is used with careful monitoring of removal of tooth structure so as to avoid irreversible damage to the

[17]tooth.After removal of the defect or on termination of any further removal of tooth structure, a 30-fluted, composite finishing bur is used to remove any facets or striations created by the previous instruments. Final polishing is accomplished with an abrasive rubber point.This technique is advantageous in being considerably faster. Also it does not require the use of a rubber dam or special instrumentation. Gross removal of the defect can be easily accomplished with m a c r o a b r a s i o n . H i g h - s p e e d i n s t r u m e n t a t i o n a s u s e d i n macroabrasion is technique sensitive and can have catastrophic results if the clinician fails to use extreme caution. It also makes way for the active reagents of

AbstractThe goal of the cases reported here is to demonstrate how more than one chemical agent or technique can meet the needs of individual stains & patient situations and help achieve an esthetically pleasing smile. Materials and Methods: Patients with localized brown stains were treated with a combination therapy of macroabrasion and in-office bleaching. Macroabrasion, using a fine composite finishing diamond bur, removed the superficial discolorations. Further in-office bleaching with 35% hydrogen peroxide (Whiteness HP, FGM, SC, Brazil) aided in obtaining maximum stain removal. Results: Appreciable stain removal could be achieved by combining the two techniques i.e. macroabrasion and in-office bleaching. Conclusions: This combination therapy for removing intrinsic stains demonstrated effective stain removal and can be considered for most of the tooth discoloration cases and can help in enhancing esthetics.

Key Wordsintrinsic stains, bleaching, macroabrasion, fluorosis


Case ReportsPatient 1A 20 year old female patient was referred to the Department of Conservative Dentistry & Endodontics of S.G.T. Dental College, Hospital & Research Institute, with a chief complaint of presence of localized stains confined to permanent maxillary incisors (Figure 1).Clinical examination revealed brown bands on maxillary central incisors with yellowish brown discolorations on lateral incisors.These brown stains were diagnosed to be due to Fluorosis (Grade 3), as patient was a resident of Haryana, where fluoride levels of water are high.The treatment plan was to use a combination therapy of macroabrasion & bleaching. Macroabrasion was done to remove these typically superficial discolorations using mild abrasion of surface enamel using a fine composite finishing diamond bur, once complete oral prophylaxis had been done (Figure 2).The brown stains however, were not completely removed after the mild macroabrasion of surface enamel. The residual stain was judged to be seated deep in dentin. To further improve the appearance of these teeth, office bleaching with 35% hydrogen peroxide containing bleaching system (Whiteness HP, FGM, SC, Brazil) (Figure 3) was adopted to lighten the tooth structure adjacent to the white areas so that they would be less noticeable.Then with the marginal gingival barrier, the same 35% hydrogen peroxide containing gel was applied on the residual stains of maxillary incisors, according to the manufacturer ’s directions, to obtain maximum stain removal (Figure 4). Three applications w e r e d o n e a c c o r d i n g t o t h e manufacturer’s instructions each of 15 minutes.Additional 2 cycles of light curing of 10 seconds each was done for each tooth. (Figure 5)To allow complete stain removal & enhance the esthetics, a second appointment was given to the patient & office bleaching was again carried out. And the results came out to be appreciable (Figure 6).

Patient 2A 17 year old male patient, hailing from Gurgaon, Haryana, was referred to the Department of Conservative Dentistry &

bleaching system to penetrate.

Office bleaching:Office bleaching techniques rely on the use of 30 to 35% preparations of hydrogen peroxide. Such techniques have been used to remove stains and discolorations that reside in both enamel

[11]and the dentin. Its mechanism relies on an oxidation process to reduce large, pigmented molecules to smaller, less

[5]noticeable ones . Hydrogen peroxide is a caustic agent. The soft tissue may be protected, usually with a rubber dam. Hydrogen peroxide is capable of penetrating through the tooth to the pulp

[18]but with no long-term pulpal reaction . It is suitable for intrinsic stains that are either developmental or acquired in

[11]origin.Hydrogen peroxide is applicable to stains that reside deep in enamel and dentin as well as the superficial enamel. The techniques traditionally associated with office hydrogen peroxide have required several office visits. Nowadays gingival isolation is done via a Top Dam and a 30 to 35% hydrogen peroxide solution is applied to the teeth in liquid or gel form for about 15 minutes cycle.Another approach depends on activation of the hydrogen peroxide using a composite resin curing light. At the end of the bleaching session the bleach is rinsed from the teeth. The patient repeats the process, usually within 7 to 10 days if required.Office bleaching techniques can successfully remove many stains that acid abrasion can. They have an advantage of removing deep enamel & dentin retained stains without the loss of tooth s t ructure . I t has several disadvantages too. It usually requires several office visits, with consequent increases in overall cost. Additionally, the results of this approach are often unpredictable with relapse and retreatment a common complaint of dentists and patients alike. It does not remove white discolorations, although it can lessen the appearance of whiteness in the stains by lightening adjacent tooth structure. This office bleaching can provide a solution in case there is a lack of compliance with home bleaching.Following are the reports of few cases being presented to demonstrate how more than one chemical agent or technique can meet the needs of individual stains & patient situations.

Figure 1. Pretreatment view where brown stains were localized predominantly on the facial surface of these teeth.

Figure 2. Maxillary incisors after macroabrasion to remove superficial brown stains.

Figure 3. Whiteness HP, FGM (SC, Brazil)

Figure 4. Operative view of bleaching of maxillary incisors with Whiteness HP, FGM, with a marginal gingival barrier.

Figure 5. Teeth immediately after the treatment.


Endodontics, of S.G.T Dental College, for his complaint of brown discolored teeth since childhood.The clinical examination revealed presence of brown discolorations on maxillary central incisors. These brown stains were diagnosed to be due to Fluorosis (Grade 3), as patient was a resident of Haryana, where fluoride levels of water are high (Figure 7).The treatment plan was to use fine finishing diamond bur to mildly abrade the surface enamel, so as to remove the brown stains & as much of the white discoloration as possible from the superficial enamel of maxillary central incisors.Note the brown stains have been lightened to light brown on maxillary central incisors in (Figure 8).For further whitening of teeth, with the marginal gingival barrier, the same 35% hydrogen peroxide containing gel was applied on the residual stains of maxillary incisors, according to the manufacturer’s directions, to obtain maximum stain removal. (Figure 9) shows the operative view of bleaching of maxillary incisors with Whiteness HP, FGM (SC, Brazil) with a marginal gingival barrier.Three applications were done according to the manufacturer’s instructions each of 15 minutes with additional 2 cycles of light curing of 10 seconds each for each tooth. After the above procedure, brown stains on maxillary central incisors faded away & a better esthetic smile was achieved (Figure 10).

Patient 3The third patient was a 21 year old female, a resident of Haryana, complaining of presence of localized brown bands on upper front teeth (Figure 11). After the clinical examination, it was concluded that the root cause of the brown discoloration of maxillary incisors was due to Fluorosis.A combination therapy was again planned for the patient. With a fine finishing diamond bur, dark stains from surface enamel were abraded so as to lighten the stains as seen in the (Figure 12).Next procedure undertaken was office bleaching with Whiteness HP, FGM, containing 35% Hydrogen Peroxide, under marginal gingival barrier as described in previous cases. (Figure 13)Esthetic smile was achieved after the procedure (Figure 14).

DiscussionThe use of hydrogen peroxide to whiten teeth via an in-office bleaching technique was first reported in 1877. In 1918, Abbot introduced the chairside bleaching method, as it is known today, using 35% hydrogen peroxide with heat & light to

[1]boost the oxidation reaction. Even though hydrogen peroxide has been successfully used in dentistry for many years, the mechanism by which bleaching occurs is currently not clearly understood. Several reactions may account for bleaching efficiency, depending on the environmental conditions, such as temperature, pH, ultraviolet light and the presence of some ions. Under alkaline conditions, hydrogen peroxide can undergo an ionic dissociation to give rise to the formation of the perhydroxyl anion. The perhydroxyl anion (HO2-) can be, by

Figure 6. Maxillary incisors after office bleaching.

Figure 7. Pretreatment view of brown discoloration predominating the facial aspect of maxillary incisors.

Figure 8. Maxillary central incisors after macroabrasion to remove superficial brown stains.

Figure 9. Office bleaching.

Figure 10. Maxillary central incisors after Office bleaching.

Figure 11. Pretreatment view of discolored maxillary incisors with brown bands.

Figure 12. Maxillary incisors after macroabrasion.

Figure 13. Operative view

Figure 14. Post-operative view of the patient.

itself, the active species in the bleaching process but can also be an electron donor to initiate the formation of free radicals [19]. In addition to the anionic dissociation, hydrogen peroxide can undergo a homolytic cleavage. This reaction is mainly promoted by high temperature and UV light & can result in the appearance of a powerful oxidant agent

[19]called hydroxyl radical (HO.) . These free radicals are highly unstable and are therefore, strong oxidative agents which disintegrate the larger chromophores. It results in a shift of the visible absorption spectrum of the compound from a longer to a shorter wavelength, leading to the production of less chromatogenic

[20]compounds .Some enamel defects or white spots/opacities on teeth that don’t respond to microabrasion & bleaching may respond better to macroabrasion.Benbachir N. et al (2007) gave a report illustrated with clinical cases citing the limitations of microabrasion in patients with discolored anterior teeth. In cases with severe enamel defects, megabrasion combined with a minimally invasive adhesive resin composite restoration may present a valuable alternative to

[21]microabrasion . Amarlal D. et al (2006) also compiled case reports with relevant clinical photographs of discolored teeth where the treatment regimen included

[22]macroabrasion .Bodden MK et al (2003) treated a patient with a level 3 endemic dental fluorosis w a s t r e a t e d s e q u e n t i a l l y b y mac roab ra s ion t e chn iques and nightguard vital bleaching. This conservat ive treatment regimen produced results that were termed "excellent" by the patient and met the

[23]goals of the dentists .Macroabrasion removes superficial stains from surface enamel and makes way for the active reagents of bleaching system to penetrate.Heymann preferred in-office bleaching over home applied technique of bleaching. Although it uses very caustic chemicals it is totally under the dentist’s control, the soft tissue is generally protected from the process and it has the potential for bleaching teeth more

[17]rapidly .

ConclusionWhile macroabrasion, office bleaching, home bleaching and veneer ing techniques can each successfully solve the problems of many stained &


discolored teeth, using the techniques together can help solve many more. Matching the stain with the correct technique requires knowledge of the various intrinsic stains & their potential for stain removal with each chemical agent.Where stain removal is incomplete with one treatment technique or where multiple stains exist, it is possible to sequence together various techniques for a more efficient & successful result. This combination therapy of macroabrasion and in-office bleaching, for removing intrinsic stains demonstrated effective stain removal and can be considered for most of the tooth discoloration cases and can help in enhancing esthetics.

References1. Nacer Benbachir, Stefano Ardu, Ivo

K r e j c i . S t e c t r o p h o t o m e t r i c evaluation of the efficacy of a new in-o ff i ce b l each ing t echn ique . Quintessence International 2008; 39(4): 299-306.

2. McCloskey RJ. A technique for removal of fluorosis stains. J Am Dent Assoc 1984; 109: 63-64.

3. Croll TP, Cavanaugh RR. Enamel color modifications by controlled hydrochloric acid-pumice abrasions. I: Techniques and examples. Quintessence Int 1986; 17: 81-87.

4. Killian CM, Croll TP. Enamel microabrasion to improve enamel surface texture. J Esthet Dent 1990; 2: 125-128.

5. Bailey R, Christen A. Bleaching of vital teeth with endemic fluorosis. Oral Surg 1968; 26: 871-878.

6. Murr in JR, Barkmeier WM. Chemical treatment of vital teeth with intrinsic stain. Quintessence Int 1982; 13: 6-10.

7. J o r d o n R E , B o k s m a n L . Conservative vital bleaching treatment of discolored dentition. Compend Contin Educ Dent 1984; 5: 803-808.

8. Feinman RA, Goldstein RE, Garber DA. Bleaching teeth. Chicago: Quintessence. 1987.

9. Feinman RA, Madray G, Yarborough D. Chemical, optical and physiologic mechanisms of bleaching products: a review. Pract Periodont Aesthetic Dent 1991; 3: 32-36.

10. Haywood VB, Heyman HO. Nigh tguard v i t a l b leach ing .

Quintessence Int 1989; 20: 173-176.11. Susan A. McEvoy. Removing

intrinsic stains from vital teeth by microabrasion and bleaching. Journal of Esthetic Dentistry, 1995; 7(3): 104-109.

12. McEvoy SA. Chemical agents for removing intrinsic stains from vital teeth. II: Current techniques and their clinical application. Quintessence Int 1989; 20: 379-384.

13. Croll TP. Enamel microabrasion followed by dental bleaching. Case reports. J Esthet Dent 1992; 23: 317-321.

14. Cvitko E, Swift EJ, Denehy GE. Improved esthetics with a combined bleaching technique: a case report. Quintessence Int 1992; 23: 91-93.

15. Killian CM. Conservative color improvement for teeth with fluorosis type stain. J Am Dent Assoc 1993; 124: 72-74.

16. Bleaching techniques in Restorative Dentistry by Linda Greenwall. Pg 207-208.

17. Harald O. Heymann. Sturdevant’s Art & Science of Operative Dentistry. Fifth edition, Mosby, Elsevier; 2006

18. Bowles WH, Ugwuneri Z. Pulp chamber penetration by hydrogen peroxide following vital bleaching procedures. J Endod 1987; 8: 375-377.

19. Maryline Minoux, Rene Serfaty. Vital tooth bleaching: Biologic adverse effects—A review. Quintessence Int. 2008; 39(8): 645-59.

20. Seghi RR, Denry I. Effects of external bleaching on indentation and abrasion characteristics of human enamel in vitro. J Dent Res 1992; 71: 1340-1344.

21. Benbachir N, Ardu S, Krejci I. Indications and limitations of m i c r o a b r a s i o n t e c h n i q u e . Quintessence Int. 2007; 38(10): 811-15.

22. Deepti Amarlal, R. Rayen, M.S. Muthu. Macroabrasion in Pediatric Dentistry. Journal of Clinical Pediatric Dentistry 2006; 31(1): 9-13.

23. Bodden MK, Haywood VB. Treatment of endemic fluorosis and t e t r a c y c l i n e s t a i n i n g w i t h macroabrasion and nightguard vital b l e a c h i n g : a c a s e r e p o r t . Quintessence Int. 2003; 34(2): 87-91.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Deepa D2 Ambika Chawla3 Priyanka Srivastava

gingival hyperpigmentation including patient's comfort, operator's ease, complications, outcome and prognosis.

Case Report:A 27 years old male patient presented tothe department of Periodontology, Subharti dental collegeand hospital, with the chief complaintof "black" colored gums. Patientrequested for any kind of esthetic treatment whichcould make his "black" colored gums look better. Medical history was non-contributory. Intra- oral examination revealed that he had deeply pigmented gingiva (Fig.1). A complete medical, family history and blood investigations were carried out to rule out any contraindication for surgery. The entire procedure was explained to the patient and written consent was obtained. A split mouth design including three different depigmentation techniques were adopted. The depigmentation treatment procedure was carried out with conventional scalpel surgery on one side anddiode laser on contralateral side in upper anterior teeth and in lower anteriors depigmentation was done with electro surgicalelectrode.After adequate local anesthesia, maxillary right heavily pigmented gingiva up to the first premolar was de-epithelized with a scalpel blade (No.11) b y a s l i c i n g m e t h o d ( F i g . 2 ) . Depigmentation was carried out from mucogingival junction towards tip of interdental papilla. Care was taken to avoid pitting of gingival surface or to

Introduction:The harmony of the smile is determined not only by the shape, the position and the color of the teeth but also by the gingival tissues.Gingival health and appearance form an essential component of an

[1]attractive smile. Gingival pigmentation varies among different ethnic groups. Among same race, the depth of color depends on density of melanin and

[2]degree of melanoblastic activity. Melanin pigmentation results from melanin granules, which are produced by melanoblasts. Melanin hyperpigmentation of gingiva usually referred by patients as black gums is considered to be unaesthetic. This problem looks exaggerated in patients with a "gummy smile" or excessive gingival display whilesmiling. Gingival depigmentation is a periodontal plasticsurgical procedure whereby the gingival hyperpigmentation is removed or reduced by various techniques. The foremost indication for depigmentation therapy is the demand by a patient for

[ 3 ]improved esthetics. Techniques available for esthetic depigmentation includes abrasion with diamond bur, slicing with scalpel, cryosurgery, electro surgery, gingivectomy with free gingival autograft, acellular dermal matrix allografts, and various types of lasers have been used for cosmetic therapy of

[3]gingival melanin depigmentation.This case presents the comparison of conventional surgery by scalpel, electro surgery and diode laser for removal of


1 Professor2 Ex - Post Graduate Student3 Post - Graduate Student Department of Periodontology Subharti dental College and Hospital Meerut-250005, U.P, India

Gingival Depigmentation By Scalpel, Diode

Laser And Electrosurgery - A Case Report

Address For Correspondence:Dr. Deepa DProfessor, Department of PeriodontologySubharti Dental College and HospitalDelhi-Haridwar By-pass roadMeerut-250005, U.P, IndiaPh:09639923588e-mail: [email protected]

th Submission : 6 March 2012th Accepted : 18 November 2012

Quick Response Code

AbstractThe color of the gingiva depends on the ethnicity and varying degree of melanin deposition. Gingival and cutaneous melanin pigmentation is a common aesthetic problem. This problem is aggravated in patients with a gummy smile or excessive gingival display. The gumminess in cases of skeletal class II malocclusion, bimaxillary protrusionand fairer individuals would make a smile unpleasant. Various techniques of depigmentation have been explained in the literature to treat this entity. Here we present a case of hyperpigmentation treated with scalpel, diode laser and electrosurgical procedure in a split mouth design with a note on comparison of healing.

Key WordsGingival Depigmentation, Melanin, Diode Laser, Electosurgery, Healing, Hyperpigmentation

Fig.1: Pre-operative Photograph

Fig.2: Pre-operative Photograph With Scalpel


remove too much tissue. Care was also taken to remove all remnants of melanin pigment as thoroughly as possible.A semiconductor diode laser (980 nm wavelength, 2.5 W) was used for depigmentation on the contralateral side (Fig.3). Laser ablation was started from mucogingival junction towards tip of interdental papilla. The motion of ablation was performed as light brushing strokes and tip was kept in motion all the time. Remnants of the ablated tissue were removed using sterile gauze dampened with saline solution. The procedure was repeated until desired depth of tissue removal was achieved. Electrosurgical technique was performed with the loopelectrode (Fig.4). A blended cutting& coagulating (fully rectified) current wasused. In all the steps the electrode wasactivated and moved in a concise "shaving"motion. Extreme care was exercised toavoid contacting the tooth surface. Forhemostasis, the ball electrode was used (Fig.5). Periodontal Pack was placed and post-surgical instructions were given to thepatient along with the prescription of anti-inflammatory analgesics. The patient was advised 0.2% chlorhexidine gluconate mouth wash 12thhourly for one week.The patient was reviewed at the end of oneweek (Fig.6). The healing processwas uneventful onscalpel surgical area than compared todiode laser and electrosurgically treated sides.Areas of raw wound surface were visible on electrosurgical treated site.But, patient did notreport any discomfort. Patient was reviewed at the end of two weeks (Fig.7); slight pain was experienced by the patient in area treated with electrosurgical treated site. At the end of onemonth, re-epithelization was complete andhealing was found to be satisfactory on all the treated sites(Fig.8).

Discussion:Oral pigmentation occurs in all races ofman. There are no significant differences inoral pigmentation between males andfemales. The intensity and distribution ofpigmentation of the oral mucosa is variable,not only between races, but also betweendifferent areas of the same mouth.Melanin pigmentation is frequentlycaused by melanin deposition by activemelanocytes located mainly in the basallayer of the oral epithelium. Pigmentationcan be removed for esthetic

[3]reasons .Different treatment modalities have

[4]beenused for this purpose. Selection of atechnique for depigmentation of the gingivashould be based on clinical experience,patient's affordability and individualpreferences.Scalpel surgical technique is highlyrecommended in cons ide ra t ion o f theequ ipment constraints that may not befrequently available in clinics. It is knownthat the healing period for scalpel wounds isfaster

[5]than other techniques.Electrosurgery requires more expertise thanscalpel surgery. Prolonged or repeatedapplication of current to tissue induces heataccumulation and undesired t issuedestruct ion. Contact wi th periosteum or alveolar bone and vital

[6] teeth should be avoided. Semiconductor d i o d e l a s e r i s p r e f e r r e d f o r depigmentation as laser light at 800 to 980 nm is poorly absorbed in water, but highly absorbed in haemoglobin and other pigments, as compared to other

[7]lasers. In the present report it was associated with better healing response than electrosurgical treated site.

The healing period of scalpel wounds was shorter than with diode laser and electrosurgery.In area treated with scalpel, the tissue had not been subjected to the effects of thermocoagulation and carbonization from the laser irradiation or burn from electrosurgery.Also there is lack of bleeding and clot formation in theelectrosurgeryand laser wounds, which are present after use of scalpel and form the "first phase" of healing. Although healing of laser wound is slower than healing of scalpel wounds, a sterile inflammatory reaction occurs after procedure. Blood vessels in the surrounding tissue up to a diameter of 0.5 mm are sealed; thus, the primary advantage is haemostasis and a relatively

[6]dry operating field.There was an inherent delay in epithelial migration and a denatured zone is formed within the connective tissue after

Fig.3: Pre-operative Photograph With Diode Laser Tip

Fig.4: Operative Site With Electrosurgical Tip

Fig.5: Immediate Post-operative Photograph

Fig.7: Two Weeks Post-operative Photograph

Fig.6: One Week Post-operative Photograph

Fig.8: One Month Post-operative Photograph

electrosurgery probably due to lateral heat generated within the tissue by the active electrosurgery electrode. Prolonged or repeated application of current to t i ssue induces heat accumulation and undesired tissue destruction. Contact with periosteum or alveolar bone and vital teeth should be avoided.

Conclusion:The depigmentation procedure was successful and the patient was satisfied with the result. Hence we conclude that depigmentation of hyper pigmented gingiva by scalpel surgery is simple, easy to perform, cost effective and above all it causes less discomfort. Diode laser proved to be effective alternative for gingival depigmentation with benefits like ease if usage, convenience in dental clinics and decreased trauma to patient. While electrosurgical procedure provided blood free working area, contouring and festooning was easy with various electrodes. As far as healing was concerned, it was relatively better with


scalpel surgery compared to diode laser and electro surgery at the end of one week but no difference was found at the end of one month. However, further long term longitudinal studies are required to evaluate and confirm the results with assessment of repigmentation.

References:1. Lagdive S, Doshi Y, Marawar PP.

M a n a g e m e n t o f G i n g i v a l Hyperpigmentation using surgical blade and diode laser therapy: A comparative study ; J Oral Laser Application 2009;9:41-47

2. Bhusari BM, Kasat S. Comparison between scalpel technique and electrosurgery for depigmentation: A case series. J Indian SocPeriodontol 2011;15:402-5

3. Gokhale ST, Vatsala V, Gupta R, Gupta V. Treatment of gingival hyperpigmentation by scalpel surgery and electrosurgery: A split mouth design; Indian Journal of Dental Sciences2011;3:10-11

4. Pontes AE, Pontes CC, Sovza

SL,Novaes AB, Girsi M, Taba M. Evaluation of the efficacy of the acellular dermal matrix allograft with partial thickness flap in the elimination of gingival melanin pigmentation. A comparative clinical study with 12 months of follow-up. Journal of esthetic and restorative dentistry 2006;18(3):135-143

5. Almas K and Sadiq W. Surgical treatment of melanin pigmented gingiva. An esthetic approach. Indian Journa l of Denta l Research 2002;13(2):70-73

6. O z b a y r a k S , D u m l a A , Eracalik,Yalcinkaya S. Treatment of melanin pigmented gingiva and oral mucosa by CO2 laser. Oral Surgery Oral Medicine Oral pathology Oral Radiology and Endodontics2000; 90 (1):14-15

7. The Academy of Laser Dentistry Featured wavelength : diode- the diode laser in dentistry ; Wavelengths 2000;8:13





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Nivedita Rewal2 Vinod Sachdev3 Vimal Chander Kirtaniya4 Arun Singh Thakur

shaped (coniform) tooth with a normal root. Tuberculate (multicusped) supernumerary tooth is a short barrel shaped tooth with normal or invaginated crown but rudimentary root. A supplemental tooth refers to a supernumerary tooth of normal size and shape and resembles the normal series(duplication). Most of the supernumerary in the primary dentition are of the supplemental type. In the permanent dentition they are more common in the maxillary lateral incisor region.Odontome is a supernumerary having no regular shape of a tooth but it is usually multiple in nature.There are many complicationswhich h a v e b e e n a s s o c i a t e d w i t h supernumeraries,like impaction of adjacent teeth, delayed or ectopic eruption of relevant teeth, crowding, rotation and development of midline diastemaof permanent incisors. There are reports that a supernumerary may erupt into the floor of nasal cavity instead of oral cavity. A supernumerary may give rise to development of dentigerous

[9],[10]cyst.The aim of this report is to document two cases. First an interesting case of four impacted supernumeraries without any associated syndrome and a case of impacted supernumerary tooth resulting in the rotation of permanent left central incisor.

Introduction:Supernumerary teeth are developmental d i s t u rbances occu r r i ng du r ing odontogenesis resulting in the formation of teeth in excess of the normal series. They occur both in the deciduous and in the permanent dentition, but their occurrence is more in permanent dentition. In the primary dentition the incidence is 0.3-0.8% and in the permanent dentition it is 1.5-3.5% with a male to female occurrence ratio of

[1],[2]2:1. Supernumerary teeth may be single, multiple, unilateral or bilateral, erupted or unerupted and in one or both

[3]the jaws. Single supernumeraries occur i n 7 6 - 8 6 % o f c a s e s , d o u b l e supernumeraries occur in 12-23% of cases and multiple supernumeraries in

[4],[5],[6],[7]less than 1% of cases.These teeth can be classified in the following manner. Firstly, according to their location in the dental arch a supernumerary can either be classified as amesiodens, paramolar ordistomolar. Secondly, they can be classified according to their morphological forms as conical, tuberculate, supplemental or

[8]an odontome. A mesiodens is a supernumerary located in between the central incisors in the maxilla. A paramolar is one situated bucally or palatally to one of the maxillary molars. A distomolar is situated distal to the third molar.A conical supernumerary is a small peg


1 Senior Lecturer2 Professor and Head3 Professor Dept. of Pedodontics & Preventive Dentistry4 Senior Lecturer Dept. of Public Health Dentistry Himachal Dental College, Sundernagar-175002

Surgical Management Of Supernumerary

Teeth - Review Of Literature And Two Case

Reports.

Address For Correspondence:Dr. Arun Singh ThakurSenior lecturer, Dept. of Public Health DentistryHimachal Dental College, Sundernagar-175002Phone number: +919318615459Email Id: [email protected]

th Submission : 16 June 2012th Accepted : 8 January 2013

Quick Response Code

Case Report:An 11 year old female patient reported to the Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sundernagar, H.P with the chief complaint of malaligned front teeth. The patient had no significant medical historysuggesting the presence of any syndrome. The dental history did not suggest any trauma to the front teeth as well. Intra-oral examination revealed proclined maxillary permanent left central incisor with diastema in between central incisors (Figure 1). On palpation the supernumerary teeth could neither be

AbstractSupernumerary teeth may be defined as one that is additional to normal series of dentition and can be found in almost any region of the dental arch. These teeth particularly in the maxillary anterior region may prevent the eruption of adjacent permanent teeth, cause their ectopic eruption or diastema in the midline. This article will present the surgical management of i) multiple supernumerary teeth in the maxillary anterior region andii) another case of impacted supernumerary tooth in the maxillaresulting in rotation of permanent left central incisor.

Key WordsSupernumerary teeth, maxillary central incisor, rotation

Figure 1. Intra Oral Photograph Of Case 1 Radiograph


felt on labial nor on palatal sides of the incisors.The occlusal and intra-oral periapical radiographs revealed the presence of multiple supernumerary teeth in the mid line of maxilla (Figure 2,3).

The treatment plan comprised of surgery followed by the orthodontic intervention. After adequate anaesthesia was obtained, an incision in the alveolar ridge was made. Both buccal and palatal flaps were raised. With the help of an elevator all four supernumerary teeth were removed. The flaps were closed with sutures (Figure 4,5,6,7).

Prior to proceeding for surgical procedures routine blood and urine examinations were carried out and the results were found to be within the normal limit. A course of antibiotics and analgesics were prescribed to prevent any post-operative complications. The patient was advised to maintain a good oral hygiene. After sufficient bone was formed into the surgical wounds, the patient was referred to the department of orthodontics for alignment of teeth.

Case Report:A 12 year old male patient reported with the chief complaint of malalignedfront teeth. Intra oral examination revealed rotated permanent left central incisor ( F i g u r e 8 ) . A n i n t r a - o r a l periapicalradiograph as well as occlusal radiograph were taken immediately. Theyrevealed the presence of an impacted supernumerary tooth in relation to the left central incisor (Figure 9).

The anaesthesia was administered. The palatal mucoperiosteal flap was raised from upper right canine to left first premolar. The bone cutting was minimumas the supernumerary was lying just below the mucoperiosteum. With the help of an elevator the supernumerary was removed and the flap was closedafter thorough debridement and cleaning (Figure 10,11). The postoperative instructions and management were same as described before.

After proper healing of the wounds and filling of the bone cavity with new bone, we planned to go for the orthodontic correction of therotated permanent left central incisor (Figure 12,13,14).

Discussion

Figure 2: Occlusal

Figure 3: Intraoral Periapical Radiograph

Figure 4: Buccal And Palatal Flap Raised

Figure 5: All Teeth Removed

Figure 6: Four Supernumerary Removed

Figure 7: Post-operative Radiograph

Figure 8: Intra oral photograph

Figure 9: Occlusal and Intra oral of case 2periapical radiographs

Figure 10: Supernumerary Tooth Visible

Figure 11: Post-operative Radiograph On Raising The Palatal Flap

The etiology of supernumerary teeth remains unclear, but several theories have been been suggested. The hyperactivity of the dental lamina is the

[11]most accepted cause. According to this theory, remnants of dental lamina are thought to induce development of an extra tooth bud which results in a supernumerary. A second theory is the dichotomy theory, which suggests that the tooth bud is split to create two

[12]teeth. The supplemental teeth may explain the presence of this theory.Along with these two theories genetics has also been considered in the development of supernumerary teeth as multiple supernumeraries are associated with various syndromes.The multiple supernumerary teeth are u sua l ly a s soc i a t ed w i thDowns s y n d r o m e , G a r d n e r s syndrome,Cleidocranial dysplasia, Cleft lip and palate, Orodigito facial


[5],[6],[13],[14]dysostosis. The present case reveals the presence of multiple supernumerary teeth in a non syndromic patient. According to Munns, the earlier the offending tooth is removed the better

[15]is the prognosis. But there are some controversies regarding the removal of supernumerary teeth in the mixed dentition period. Most of the authors recommend surgical removal of supernumerary tooth as and when half of the root of the adjacent permanent incisors was formed. This is to minimize injury to the developing permanent tooth.The treatment therefore comprised of surgical removal of supernumerary tooth fo l lowed by or thodont ic intervention.In the second case the impacted supernumerary tooth resulted in rotation of left permanent central incisor along with presence of crowding.In this case there was lack of space for the accommodation of the rotated left central incisor. The rotation of left central incisor tooth was corrected with fixed appliance therapy. The tooth is now well aligned in the maxillary arch after about 9 months of active treatment (Figure 12,13,14). The retention of rotation cases should be done with fixed appliance and for a long period of time to prevent relapse.

References1. Mason C, Azam N, Holt RD and Rule

DC (2000). A retrospective study of unerupted maxil lary incisors associated with supernumerary teeth. Br J OralMaxillofacSurg, 38: 6

2. Sharma A. Familial occurrence of mesiodens: A Case report. J Indian SocPedoPrev Dent 2003;21:2.

3. RajendranR,Sivapathasundram B. S h a f e r ' s Te x t b o o k o f o r a l pathology,5th ed. Elsevier: New Delhi, India; 2006.

4. Scheiner MA, Sampson WJ. Supernumerary teeth: a review of the literature and four case reports. Aust Dent J .1997; 42:160-165.

5. R a j a b L D , HamdanMA.Supernumerary teeth: review of the literature and survey of 152 cases.Int J PaediatrDent 2002;12:244-254.

6. Zhu JF, Marcushamer M, King LD, Henry JR.Supernumerary and congenitally absent teeth:a literature review. J Cl inPedia t r Dent . 1996;20:87-95.

7. So LLY.Unusual supernumerary teeth.Angle Orthod.1990;60:289-292.

8. Mitchell L(1989). Supernumerary teeth. Dent Update 16:65-69.

9. Hattab FN, YassinOM,Rawashdeh MA. Supernumerary teeth :Report of three cases and review of the literature.J Dent Child 1994;61:382-93.

10. SolaresR.The complications of late diagnosis of anterior supernumerary teeth: Case report. J Dent Child 1990; 57:209-11.

11. P r i m o s c h R E . A n t e r i o r supernumerary teeth-assessment and s u r g i c a l i n t e r v e n t i o n i n children.Pediatr Dent 1981;3:204-15.

12. Sedano HO, Gorlin RJ. Familial occurrence of mesiodens.OralSurg Oral Med Oral Pathol 1969;27:360-1.

13. Bohn A. Dental anomalies in harelip and cleft palate.ActaOdontol Scand.1963;21:1-114.

14. Kantor ML, Bailey CS, Burkes EJ. Duplication of the premolar dentition.OralSurg Oral Med Oral Pathol. 1988;66: 62-64.

15. Munns D. Unerupted incisors. Br J Orthod. 1981;8:39-42.

Figure 13: Partial Correction Of 21 In Progress

Figure 14: Correction Done





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Samriti Bansal2 Rattan Lal Jain3 Harsimrit Kaur4 Nidhi Mahajan

i n t e r f e rence du r ing too th bud d i f f e r e n t i a t i o n , t r a u m a t i c o r

[6], [8], [9], [10]inflammatory causes.The purpose of this paper was to report the case of a 12-year-old boy who presented with trauma-induced fusion of a supernumerary tooth and permanent maxillary right central incisor and describe its management.

Case ReportA 12-year old male patient reported to our institution with the chief complaint of extra tooth in the upper front region leading to an unaesthetic appearance. There was no associated history of pain or discomfort. Detailed anamnesis revealed a history of trauma in the upper front tooth region when the child was around 18 months of age, which led the milk tooth in the same region to get intruded. At that time, the patient visited a dental clinic and was recommended a 'wait and watch' approach, and one year

IntroductionSupernumerary tooth develops from an extra tooth bud arising from the hyperactivity of the dental lamina near the permanent tooth bud, or possibly from dichotomy or splitting of the

[1]permanent tooth bud itself. Several pathologies may arise because of them like impaction, malposed teeth, midline diastemma, ectopic eruption, and formation of primordial or follicular

[2]cyst. However, fusion of a normal permanent tooth and a supernumerary

[3]tooth is unusual.Fusion is the union of two developing dental germs resulting in a single large

[4]dental structure. It is defined, according to the classification of Wedl and as supplemented by Busch, as the organic dentinal union of two or more individual teeth. De Jonge (1955) proposed the term 'Synodontia' to describe teeth, which originate by the inability of adjacent

[5]tooth germs to retain their individuality. Fusion between supernumerary and permanent teeth occurs less frequently than fusion between other types of

[6]teeth. The overall prevalence is estimated in the literature to be 0.5% in the deciduous and 0.1% in the permanent

[7],[8],[9].dentition.The aetiology of fusion is still unknown, although many theories have been proposed, including genetic factors, racial differences, local metabolic


1 Associate Professor, Dept. of Pedodontics and Preventive Dentistry,2 Director, Guru Nanak Dev Dental College & Research Institute, Sunam, Punjab, India.3 Professor & Head, Dept. of Pedodontics and Preventive Dentistry Lakshmi Bai Dental College, Patiala, Punjab, India.4 Assistant Professor, Dept. of Pedodontics and Preventive Dentistry Krishna Dental College and Research Institute, U.P.,

Trauma - Induced Anomaly - Esthetic And Vital

Treatment Of An Unusual Case

Address For Correspondence:Dr. Samriti Bansal, C/O Dr. Amit Jindal,Street No.-7, Prem Basti, Sangrur,Punjab- 148001, India.Mobile no.- 09463217299E-mail: [email protected].

th Submission : 7 August 2012th Accepted : 4 February 2013

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later the intruded tooth was extracted. There was no relevant past medical history or any hereditary conditions and h i s phys i ca l examina t ion was unremarkable.On intra-oral examination (Fig 1), an erupted conical-shaped extra tooth was seen labial to the permanent maxillary right central incisor [tooth no. 11] causing slight lingual tipping of the permanent tooth. A dental floss was passed through the crowns of the two closely placed teeth, but this failed indicating a fusion between the two with deep grooves on the complex. There was

AbstractFusion of a normal permanent tooth and a supernumerary tooth is unusual. The overall prevalence is 0.5% in deciduous and 0.1% in permanent dentition. The purpose of this paper was to report the case of a 12-year-old boy who presented with trauma-induced fusion of a supernumerary tooth and permanent maxillary central incisor leading to unaesthetic appearance and describe its management. An erupted conical mesiodens was fused to permanent maxillary right central incisor in enamel and cementum only with unusually no dentinal involvement. Surgical sectioning and extraction of supernumerary tooth were done under local anesthesia after raising mucoperiosteal flap. Odontoplasty was performed on permanent incisor, followed by esthetic rehabilitation. After one year, the permanent central incisor presents no pathological feature. This case shows that presentation of fused teeth highly varies, thus requires diverse treatment protocols and necessitates proper diagnosis and multidisciplinary approach to achieve functional and esthetic success.Key Wordsesthetic rehabilitation, fusion, mesiodens, supernumerary tooth, surgical sectioning, synodontia, trauma, trauma-induced

Figure1- Intra-oral photograph: mesiodens fused to labial surface of tooth 11

Figure2- Pre-treatment radiograph: fused teeth with different roots and pulp cavities

presence of midline diastema arousing a suspicion of another unerupted supernumerary in the same area.Radiographic examination (Fig 2) revealed the presence of only one


central incisor was done with composite resin (Beautiful II, Shofu, Inc) (Fig 6). After one year of successful treatment, the permanent central incisor remains vital, no pathological feature has been observed, and the patient has experienced no discomfort. Postoperative radiograph exhibits normal periodontal and periapical tissues (Fig 7).

DiscussionMany theories have been proposed describing the aetiology of fusion, trauma to the predecessors being one of the causes; however, such cases are not well documented in the literature. Shafer, Hine, and Levy opined that the two normally separated tooth germs fuse when some physical force or pressure

[1]causes contact between them. Lowell and Soloman believe that fused teeth result from some physical action that causes the young tooth germs to come into contact, producing necrosis of the intervening tissue, thus allowing the enamel organ and dental papilla to fuse

[11]together. Spouge proposed that crowding of adjacent tooth germs may

[12]result in fusion.Thus, in the present case, the intrusive trauma to the predecessor incisor might have caused space lack in the area which was already crowded by the presence of a supernumerary tooth, thus, bringing a close contact between the two tooth buds, and hence, fusion ensued.Fusion may be classified as partial or total, i.e., fusio-totalis, partialis-

[8],[13]coronaries or partialis-radicularis. This process involves epithelial and mesenchymal germ layers resulting in

[10]irregular tooth morphology. The pulp chambers and canals may occur either separately or together according to the formation stage at the moment of the union. If this union occurs precociously, the crowns will be together with separate roots resulting in a big dental structure. If the union happens after the crown formation, the roots will probably be

[14]together. The two teeth may join at dentinal and/or enamel level - merging at

[15]enamel level alone being infrequent.However, unusually in the present case, both, the crowns as well as the roots were fused; but there was no communication between the pulp chambers and canals. Also, the union was limited to the level of enamel and cementum only with no involvement of dentin.Most cases of fused teeth are asymptomatic, and do not require

supernumerary tooth that was seen erupted. However, the fusion between the roots of the supernumerary and the permanent tooth was not evident radiographically. The root canal morphology was assessed using Clark's tube-shift technique that revealed two separate pulp chambers and canals.Thus, a diagnosis of trauma-induced fusion between erupted conical mesiodens and permanent maxillary right central incisor was made that presented with two separate pulp cavities.Treatment. Surgical sectioning and extraction of the supernumerary tooth were planned, and written consent was obtained after explaining the treatment plan to the patient and the parents. Following local anesthesia, a full thickness muco-periosteal flap was raised (Fig 3). This revealed the extension of fusion beyond the cervix of the crown extending to the root. So, the buccal cortical plate was removed with a surgical handpiece under water coolant, fo l lowed by sect ioning of the supernumerary tooth with a high-speed dental handpiece and diamond bur (104R, Shofu Inc., Kyoto, Japan) under a water coolant to separate the permanent central incisor and the supernumerary tooth (Fig 4). The teeth were separated such that the anatomy of the permanent tooth was not much disturbed. Also, the dentin of crown was not involved, leaving behind a layer of enamel, thus excluding the chances of sensitivity. Odontoplasty was performed on the root of permanent central incisor to establish a normal anatomy. There was no communication found between the pulps of the two involved teeth, confirming the radiographic diagnosis, thus, no endodontic treatment was required for the conserved central Incisor. It was expected that the involved permanent tooth would achieve reattachment of the cementum to bone as careful sectioning was done to avoid exposure of dentin, [which otherwise would have required restoration of the root to avoid dentin hyperesthesia]. Bonegraft (Ostofom, Zimmer Inc. Warsaw, IN, US) was placed and the mucosal flap was carefully repositioned and sutured using 4-0 interrupted silk suture. One week following the surgical removal, patient returned back to report no discomfort, mobility or sensitivity, and the tooth was vital (Fig 5). Sutures were removed and esthetic rehabilitation of permanent right

Figure3- Per-operative: reflected muco-periosteal flap revealing fusion extending to the root

Figure4- Sectioning: of supernumerary tooth followed by odontoplasty

Figure5- Post-operative photograph: depression on labial enamel of tooth 11

Figure6- Esthetic rehabilitation: with composite resin

Figure7- Post-operative radiograph: after 1 year, exhibiting normal periodontal and periapical tissues

treatment; nevertheless, fusion might cause clinical problems related to function; loss of space in the dental arch; carious lesions in the grooves, particularly in the fusion zone; periodontal problems associated with the grooves that extend subgingivally; asymmetries when fusion occurs in the anterior segment; malocclusions, especially when supernumeraries are involved; causes deviations; sometimes delays the eruption of other teeth; and endodontic complications. In the anterior region, this anomaly also causes an unpleasant aesthetic tooth shape due to

[6],[8],[9],[10]the irregular morphology. Various treatment modalities have been described in the literature with respect to the different presentations, locations and morphological variations of fused teeth. These include endodontics, restorations, selective grinding, surgical separation or extraction followed by prosthesis, per iodonta l and/or or thodont ic

[9],[10]treatment. Most of these cases require surgical removal because of their abnormal morphology excessive mesiodistal width, causing crowding, tooth malalignment and occlusal dysfunction; however, many authors have reported salvaging the fused teeth by acquiring a multi-disciplinary

[8],[10],[16]approach.

[17] [18]Ferreira-Junior et al , Cetinbas et al [3]and, Tsujino and Shintani reported

sectioning of the fused teeth and extraction of the supernumerary tooth.

[19] [10]Ghoddusi et al , Nunes et al and Song [ 2 0 ]et al assumed a non-surgical

endodontic approach for treatment of fused teeth, while surgical endodontic approach has also been successfully

[15],[21]adopted and documented. Tuna recommended extra-oral hemi-section and immediate replantation as an

[9]alternative treatment. Good and [22] [6]Berson , and Rani et al reported the

management of fused teeth with combined multidisciplinary approach.In the present case, treatment was recommended in order to improve the esthetic status of the patient, and to prevent periodontal disease and development of dental caries. The treatment required surgical separation and extraction of the supernumerary tooth followed by esthetic rehabilitation of the permanent tooth to achieve the desired result. Also, utmost care was taken to conserve the tooth structure and prevent exposure of dentin.


ConclusionThis case shows that presentation of fused teeth can be complex, thus requires diverse treatment protocols and necessitates proper diagnosis and multidisciplinary approach to achieve functional and esthetic success. Efforts must be directed to understand the tooth morphology and root canal anatomy in order to avoid treatment complications.

References1. Shafer WG, Hine MK, Levy BM. A

textbook of oral pathology. 4th ed., Philadelphia: W B Saunders Co., 2005:2-85.

2. R a j a b L D , H a m d a n M A . Supernumerary teeth: review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-254.

3. Tsu j ino K and Sh in t an i S . Management of a supernumerary tooth fused to a permanent maxillary central incisor. Pediatr Dent 2010;32(3):785-8.

4. Regezi JA, Sciubba JJ, Jordan RCK. Oral pathology: clinical pathologic correlations. 4th ed., Philadelphia: W B Saunders Co., 2003:367-384.

5. Schulze C. Developmental anomalies of the teeth and the jaws. In Gorlin RJ, Goldman HM (eds). Thoma's Oral Pathology, 6th ed., St. Louis: CV Mosby Co., 1970:96-183.

6. Rani KA, Metgud S, Yakub SS, Pai U, Toshniwal NG, Bawaskar N. Endodontic and esthetic management of maxillary lateral incisor fused to a supernumerary tooth associated with a talon cusp by using spiral computed tomography as a diagnostic aid: a case report. J Endod 2010;36:345-349.

7. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2nd ed., New Delhi: Elsevier, 2005:49-106.

8. Hulsmann M, Bahr R, Grohmann U. Hemisection and vital treatment of a fused tooth: literature review and case report. Endod Dent Traumatol 1997;13:253-8.

9. Tuna EB, Yildirim M, Seymen F, Gencay K, Ozgen M. Fused teeth: a review of the treatment options. J Dent Child 2009;76(2):109-16.

10. Nunes E, de Moraes IG, Novaes PMO, de Sousa SMG. Bilateral fusion of mandibular second molars with supernumerary teeth: case report. Braz Dent J 2002;13(2):137-141.

11. Lowell RJ, Soloman AL. Fused teeth. J Am Dent Assoc 1964, 68(5): 762-763.

12. Spouge JD. Oral Pathology. St. Louis: CV Mosby Co., 1973:135-6.

13. Peyrano A, Zmener O. Endodontic management of mandibular lateral incisor fused with supernumerary tooth. Endod Dent Traumatol 1995,11(4):196-198.

14. Morris DO. Fusion of mandibular third and supernumerary fourth m o l a r s . D e n t U p d a t e 1992;19(4):177-178.

15. Oliván-Rosas G, López-Jiménez J, Giménez-Prats MJ, Piqueras-Hernández M. Considerations and differences in the treatment of a fused tooth. Med Oral Patol Oral Cir Bucal 2004;9(3):224-8.

16. Delany GM, Goldblatt LI. Fused teeth: a multidisciplinary approach to treatment. J Am Dent Assoc 1981;103(5):732-734.

17. Osny Ferreira-Junior, Luciana Dorigatt i de Ávila, Marcelo Bonifácio da Silva Sampieri, Eduardo Dias-Ribeiro, Wei- liang Chen, Song Fan. Impacted lower t h i r d m o l a r f u s e d w i t h a supernumerary tooth-diagnosis and treatment planning using cone-beam computed tomography. Int J Oral Sci 2009;1(4):224-228.

18. Cetinbas H, Halil S, Akcam MO, Sari S, Cetiner S. Hemisection of a fused tooth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Oct 2007;104(4):120-4.

19. Ghoddusi J, Zarei M, Jafarzadeh H. Endododnt ic t rea tment of a supernumerary tooth fused to mandibular second molar: a case report. J Oral Sci 2006;48(1):39-41.

20. Song CK, Chang HS, Min KS. E n d o d o n t i c m a n a g e m e n t o f supernumerary tooth fused with maxillary first molar by using cone-beam computed tomography. J Endod Nov 2010;36(11):1901-04.

21. Ozant O, Umit C, Fatih A. Comprehensive therapy of a fusion between a mandibular lateral incisor and supernumerary tooth: a case report. Int Dent J 2005;55(4):213-216.

22. G o o d D L , B e r s o n R B . A supernumerary tooth fused to a maxillary permanent central incisor. Pediatr Dent 1980;2(4):294-6.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Tarun Singh Phull2 Ankit Gaur3 Tarun Sharma4 Shishir Singh5 Pradeep Raghav

2003 for the treatment of Class II malocclusion has been shown to be less effective in overjet reduction when compared to the results achieved by using

[ 4 ]Twin-block. According to the classification by Proffit and Fields, Twin-block is a passive tooth-borne appliance. The Twin-block myofunct ional appliance was first described by William

[5]Clark.

Diagnosis and Case SelectionAn 11 years old boy reported to the Department of Orthodontics and Dentofacial Orthopedics, Subharti Dental College, Meerut with the complaint of forwardly placed upper front teeth. The extra oral findings included a convex profile; incompetent lips with a lip trap and deep mento-labial

IntroductionDiagnosis in dentistry is as important as the treatment and its application at the correct age in dentofacial orthopedics becomes more crucial. Class II malocclusions can manifest in various skeletal and dental configurations. Most Class II patients have a deficiency in the anteroposter ior posi t ion of the

[1]mandible. Several treatment options are available for managing Class II p r o b l e m s , a n d a p p l i a n c e s f o r improvement of profile along with correction of forces by the facial musculature which have been classified as removable/ fixed myofunctional appliances have been used with great success in patients who are positively motivated for the treatment. Several varieties of functional appliances are currently in use that aim to improve skeletal imbalances. Modulation of maxillary growth along with possible improvement in mandibular growth and position, and changes in dental and muscular relationships are the expected effects of these functional appliances.

Norman Kingsley introduced the "bite-jumping" appliance (1879). The Balter's

[2] [3]bionator and Twin-block are two of the popular appliances used today of which the latter has been recommended for 24 hour wear for faster and better results. The dynamax appliance developed in


1 Senior Lecturer Dept of Orthodontics & Dentofacial Orthopedics, Seema Dental College & Hospital,Uttarakhand2 Private Practitioner, Gaur Dental Care Mayur Vihar, Phase -II, Patpatganj, New Delhi3 Senior Lecturer, Dept. of Orthodontics & Dentofacial Orthopedics, Seema Dental College & Hospital, Uttarakhand4 Reader,5 Professor & Head, Dept. of Orthodontics & Dentofacial Orthopedics, Subharti Dental College, Meerut, India

Dentofacial Orthopedics : Improving Esthetics

And Enhancing Mandibular Growth - Using A

Functional Appliance

Address For Correspondence:Dr. Tarun Singh Phull, Senior Lecturer,Dept. of Orthodontics & Dentofacial Orthopedics,Seema Dental College & Hospital, Virbhadra Road,Rishikesh,Uttarakhand-249203 , IndiaE-Mail: [email protected]: 08979415014.

th Submission : 11 July 2012th Accepted : 29 December 2012

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sulcus. The overbite of 7mm (100%) with a scissors bite in relation to 14, 44 & 24, 34 could be attributed to the retruded mandible. Intra-oral examination revealed a molar relation which according to Angle's classification was Class II; a canine relation of Class II; an overjet of 12 mm (Figs. 1 and 2). The

AbstractManagement of Class II dysplasias has always been a theme of interest to the orthodontist. Correction of skeletal problems during growth has been a topic of debate and controversy as related to the specialization of dentofacial orthopedics. Keeping the treatment goals and the psychological impact of early treatment in mind, it becomes imperative to correct the underlying discrepancy before or at the time of pubertal growth. Use of removable appliances like Twin-block or bionator helps not only in enhancing the profile but also reducing the list of treatment objectives in the second phase of therapy. A proper patient education for compliance of removable appliance should, therefore, be the first step in treatment. The following clinical case reports the importance and effectiveness of such a removable appliance i.e. Twin-block.

Key Wordsmandibular growth, Twin-block, profile.

Fig. 1 Pre-treatment Extra-oral photographs


overall diagnosis could be classified as Class II div 1 malocclusion.

The presence of a retrognathic mandible, the age of the child with a promising growth potential, a favorable mandibular growth pattern, absence of any dental crowding and a positive Visualized treatment objective (VTO) on bringing the mandible forwards by the patient himself, all indiacted that the extra-oral profile and intra-oral developing problems could be treated preeminently using a myofunctional therapy with a preference to the Twin-block appliance. It has been a proven fact that Twin-block is more efficient than the bionator in preventing forward movement of the

[6]maxillary molars.

Treatment plan and progressBite RegistrationFor Class II problems, the proper construction bite was taken and the models were articulated with mandibular protrusion. The mandibular advancement was kept 6mm sagitally with a 4mm of interocclusal clearance in the first

[7]premolar region. The interocclusal clearance was increased at the region of deep overbite and bite-blocks were designed to allow the free eruption of the lower molars to reduce the overbite by increasing the lower facial height.

The first phase of active twin-block therapy took almost 11 months due to breakages of the lower block. Deep overbite was reduced by selective trimming of the upper block as

[9]recommended.

ResultsThe ANB value changed from 11 degrees to 5 degrees due to increase of SNB from 69° to 74° (and a very slight decrease in SNA). Y-axis increased from 66° to 69° due to simultaneous effects of growth changes and selective eruption of lower posterior teeth (Fig. 6 to Fig. 10, Table I ). There were dento-alveolar changes other than the skeletal ones observed (Table II). The upper molars had distalized and lower molars mesialized (Fig. 10). The overall changes in facial profile and nose-lips-chin relation could be well appreciated (Fig. 4 and Fig. 5, Table III).

Other relevant cephalometric changesChanges during the active phase of treatment include the following:

Fig. 2 Intra -oral photographs showing molar and canine relation

Fig.3 Patient with the Appliance

Fig.4 Comparison of extra-oral features after first phase of orthopedic therapy i.e. after retention phase of removal appliance

Fig.5 Profile changes by enhancing mandibular growth helps in improvement of smile esthetics

Fig.6 Intra-oral changes: a leveling of curve of spee in lower arch improved the overbite. The deep bite is to be corrected by intrusion of upper incisors in 2-nd phase (fixed therapy)

Fig.7 Intra-oral changes: correction of molar, canine relation and overjet correction. Correction of developing scissors bite can be appreciated.

Table III : Composite Analysis showing soft tissue changes

*P

S- line

U- lip

S line

L-lip

PRE TT

5 mm

3 mm

POST TT

3 mm

4 mm

Table II : Composite Analysis comparing dental changes

*P

U1 to NA

U1 to NA

L1 to NB

L1 to NB

PRE TT

8mm

31°

6mm

28°

POST TT

5mm

22.5°

7mm

31°


1. Reduction in the anteroposterior apical base discrepancy on angular assessment of ANB angle

2. Increase in effective mandibular length (articulare to gnathion)

3. Increase in facial height (nasion to menton). The majority of patients in the control sample had deep overbite and the aims of treatment were consistent with increasing facial height.

4. Reduction in facial convexity (A point to facial plane)

5. Reduction in the distance from the distal outline of the upper first molar to the pterygoid vertical.

DiscussionIn many respects the occlusal inclined plane is a significant improvement on existing appliance mechanisms in the functional guidance of facial growth and development. Significant changes in facial appearances are seen within 2 or 3 months of starting treatment with twin blocks as a result of altered muscle balance and continuous wear, even during eating. Rapid soft-tissue adaptation occurs in response to an improved occlusal relationship.The most prominent dentoalveolar effect was proclination of the mandibular incisors as a result of the mesial force induced by protrusion of the mandible.The effect of functional appliance therapy on mandibular growth is a major controversy. Many researchers have claimed that extra mandibular growth

[8]occurs with the Twin-block. Soft-tissue compensation occurs to assist the primary functions of mastication and swallowing, which require an effective anterior oral seal.

Fig.8 Intra-oral occlusal changes

Fig.9 Comparison of pre - treatment lateral cephalogram and OPG with stage radiographs

Fig.10 Ricketts superimposition showing skeletal and dental changes by growth modulation

Table I : Composite Analysis comparing skeletal changes

*P

SNA

SNB

ANB

GoGn to SN

Y- Axis angle

PRE - TT

80°

69°

11°

27.5°

66°

POST- TT

79°

74°

5°

29°

69°

The twin block appliance positions the mandible downward and forward, increasing the intermaxillary space. As a result it is difficult to form an anterior oral seal by contact between the tongue and the lower lip, and patients spontaneously adopt a natural lip seal for deglutition without exercises when twin blocks are

[9]fitted. The lip seal is maintained throughout treatment and improved facial balance is evident within a few months of starting treatment.

ConclusionOrthodontic treatment with the Twin-block functional appliance appears to be e f f e c t i v e i n c o r r e c t i n g m o l a r relationships and reducing overjet in children with Class II div 1 malocclusion. The following conclusions can be drawn:1. Twin-bock appliance induced

mandibular growth by utilization of remaining growth in a child having mixed dentition, therefore, timing of this orthopedic approach was crucial.

2. The appliance was also effective in restricting forward movement of the maxillary molars.

3. The appliance helped dramatically in


system. Am J Orthod Dentofacial Orthop 1988; 93:1-18.

6. Jena AK, Duggal R and Prakash H. Skeletal and dentoalveolar effects of Twin-block and bionator appliances in the treatment of Class II malocclusion: A comparative study. Am J Orthod Dentofacial Orthop 2006;130:594-602.

7. De Vicenzo .O. J.P. & Winn. M.W. Orthopaedic and orthodontic effects resulting from the use of functional appliance with different amounts of protrusive activations. Am J Orthod Dentofacial Orthop 1989; 96: 181- 190 .

8. O'Brien K, Wright J, Conboy F, Chadwick S et al. Effectiveness of early orthodontic treatment with the twin-block appliance: a multicenter, randomized, controlled trial Part I: dental and skeletal effects. Am J O r t h o d D e n t o f a c i a l O r t h o p 2003;124:234-243.

9. Clark WJ. Twin block functional therapy. London: Mosby-Wolfe; 1995.

correction of the molar relationship.4. Forward movement of the maxillary

incisors was restricted.5. There was an apparent forward

movement of the mandibular incisors.

References1. McNamara JA Jr. Components of

Class II malocclusion in children 8-10 years of age. Angle Orthod 1981;51:177-202.

2. Ascher F. The bionator. In: Graber T M , N e w m a n n B , e d i t o r s . Removable orthodontic appliances. Philadelphia: W. B. Saunders; 1977. p. 229-246.

3. Clark WJ. The Twin-block traction technique. Eur J Orthod 1982;4:129-138.

4. Thiruvenkatachari B, Sandler J, Murray A, Walsh T and O'Brien K. Comparison of Twin-block and Dynamax appliances for the treatment of Class II malocclusion in adolescents: A randomized controlled trial. Am J Orthod Dentofacial Orthop 2010;138:144-145.

5. Clark WJ. The Twin Block technique: a functional orthopedic appliance





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Gupta Ashok K2 Sandhu Rupinder3 Prabhu Vivek4 Narayan Jayprakash

significant bone destruction and root [5]resorption of the permanent teeth.

Such multiple supernumerary teeth are usually associated with developmental disorders or syndromes like cleidocranial

[6]dysplasia and Gardner's syndrome. Occurrence of multiple supernumerary teeth in the absence of any associated syndrome or condit ion is very uncommon.

Case ReportA 22-year old male patient reported to dental clinic with the chief complaint of pain in the right lower back tooth region since 4 days. Patient gave the history of pain which was intermittent, mild in nature, increased after taking food, localized to the distal of lower right second molar, and got relieved on medication. Pain was not associated with any other symptom.

On clinical examination patient showed bilateral absence of 3rd molars in both the jaws with 28 teeth completely erupted in the oral cavity. It was also observed that patient had 3 partially erupted supernumerary teeth in the oral cavity, one tooth each erupting palatally i.r.t 16-17 and 26-27 (Figure 1) and one tooth erupting lingually i.r.t 46-47 (Figure 2).The area of chief complaint and the areas of teeth eruption were in different regions of the oral cavity, patient was advised for a orthopantomogram (OPG). The OPG

IntroductionSupernumerary teeth are present in addition to the normal complement of teeth in permanent / deciduous

[1]dentitions. These teeth may closely resemble the teeth of the group to which it belongs, i.e. molars, premolars or anterior teeth, or it may bear little resemblance in size or shape to which it is associated.

The incidence of supernumerary teeth is high in permanent dentition, affecting both the sexes, more common in males,

[2]with the male to female ratio of 2:1 and with a frequency of 0.14% - 0.64% of the

[3]general population. Supernumerary teeth can occur as singles, multiples, unilateral or bilateral, and in the maxilla, mandible or both. Supernumerary teeth are estimated to occur in the maxilla 8.2 to 10 times as frequently as in the mandible and most commonly affect the

[2]premaxilla. Supplemental premolars constitute approximately 10% of the total supernumerary cases, and almost 75% of

[4]those are present in the mandible.

Supernumeraries generally cause problems of malocclusion of local nature like tipping of adjacent teeth, rotation, bodily displacement, delayed eruption or prevent eruption of tooth of normal series. They lead to esthetic disharmony, functional distortion and may also cause formation of follicular cysts with


1 Assistant Professor, Dept of Oral & Maxillofacial Surgery,2 Assistant Professor , Dept of Prosthodontics,3 Senior Lecturer, Dept of Periodontics,4 Senior Lecturer, Dept of Prosthodontics, Institute Of Dental Education And Advanced Studies, Hospital & Research Centre, Gwalior, MP, India

Multiple Supernumerary Teeth In A Non-

syndromic Individual - A Case Report With

Seven Supplemental Premolars.

Address For Correspondence:Dr. Ashok Gupta,Sanjeevani Multispeciality Dental Clinic,111, Saugat Appartments, Near Millenium Plaza, University Road, Govindpuri, Gwalior.MP.Mobile no. +919301922853E-mail: [email protected], [email protected]


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AbstractSupernumerary teeth are rare occurring from 0.14% to 0.64% of the general population. Such multiple supernumerary teeth are usually associated with developmental disorders or syndromes like cleidocranial dysplasia and Gardner's syndrome. However, their occurrence in the absence of any associated syndrome or condition is very uncommon. In such non-syndromic cases, mandibular premolar region is the preferred site of occurrence. The presented case had seven supernumerary teeth out of which five were in the mandibular premolar region.

Key WordsSupernumerary teeth, supplemental teeth, syndrome

Figure 1: Palatally erupted supermumerary teeth between 16-17 and 26-27.

Figure 2: Lingually erupted supermumerary tooth between 46-47.

showed a total of 39 teeth in both the jaws (Figure 3). It was noted that all the quadrants had impacted 3rd molars. It was also observed that the patient had a total of seven supernumerary teeth, five of which were in the mandible and two in the maxilla.

As the OPG showed only faint images of the supernumerary teeth, intraoral periapical radiographs (IOPA) were taken to confirm the findings of the OPG in all the regions. IOPA i.r.t 14-18 showed presence of one supernumerary tooth between 16-17 (Figure 4). IOPA i.r.t 24-2 7 s h o w e d p r e s e n c e o f o n e supernumerary tooth between 26-27 (Figure 5). IOPA i.r.t 34-37 showed presence of two supernumerary teeth one in between 35-36 and the other overlapping the roots of 36 (Figure 6). IOPA i.r.t 45-48 showed presence of three supernumerary teeth between 45-46 and 46-47 and distally inclined to 47 (Figure 7). All supernumerary teeth, both impacted and partially erupted in oral cavity, resembled premolars in shape and size. Patient was examined for presence of any other associated dental, skeletal or medical condition.

Based on the dental findings and the absence of any associated disorder, the case was diagnosed as non-syndromic multiple supernumerary teeth and the patient was informed of the diagnosis.

DiscussionSupernumerary teeth may occur with or without more than 20 syndromes and developmental conditions, however, non-syndromic multiple supernumerary

[7]teeth are rarely encountered.

The etiology of supernumerary teeth is not known, but several hypotheses have

[8]been proposed :1. Disruption of normal embryonic

processes. a. Epithelial cell remnants b. Dichotomy of tooth germs. c. Proliferation of dental lamina.

2. Progress zone of dental lamina at the end of every tooth series or class gives rise to supernumerary teeth.

3. Atavism - This theory states that supernumeraries are a return to primitive dentition.

4. Hereditary - While an autosomal dominant inheritance is suggested, there is an increased incidence in male to female ratio indicating the


possibility of sex - linked hereditary. 5. Mutant genes can also account for

supernumeraries.

Many complications can be associated with supernumeraries, like impaction, delayed eruption or ectopic eruption of adjacent normal teeth, crowding, development of median diastema and formation of follicular cysts around supernumerary teeth with significant bone destruction, root resorption, pulp necrosis, pulp canal obliteration and

[5]ankylosis of the permanent teeth.

Supernumerary teeth are classified based on their morphology and location in the dental arch. In the presented case, six of the seven supernumerary teeth seen in the radiographs were in the premolar region. Supernumerary premolars are usually asymptomatic and most cases are diagnosed coincidentally during inspection of radiographs prior to the commencement of or tho-dont ic

[9], [10]treatment.The primary step of management is the localization and identification of the c o m p l i c a t i o n a s s o c i a t e d w i t h supernumeraries. Routine checkup should be scheduled for a supernumerary tooth. The need for surgical extraction does not arise till the tooth erupts spontaneously, without any signs of complications. However, surgical intervention should be considered if there are signs of complications, such as cystic changes, root resorption, or eruption disturbance of adjacent teeth. Treatment depends on the type and position of the supernumerary tooth and its effects on the adjacent tissues.

In this case the chief complaint of the patient was treated by extraction of the impacted third molar in the fourth quadrant. Interestingly during extraction, the socket d id not reveal the supernumerary tooth seen in the OPG and IOPA i.r.t 47-48. So the treatment for the supernumerary teeth was planned to be done at a later stage which included extraction of partially erupted three supernumerary teeth and observation for rest of the five impacted supernumerary teeth. Hence it was decided to follow up the presented case with regular visits and radiographs to check for the development of any complications.

ConclusionEarly diagnosis and treatment of patients

Figure 3: Orthopantomogram.

Figure 4: IOPA Radiograph i.r.t.14-18.




with supernumerary teeth are important to prevent or minimize complications. Routine checkup should be scheduled for a supernumerary tooth. The need for surgical extraction does not arise till the tooth erupts spontaneously, without any signs of complications. However, surgical intervention should be considered if there are signs of complications, such as cystic changes, root resorption, or eruption disturbance of adjacent teeth. Treatment depends on t h e t y p e a n d p o s i t i o n o f t h e supernumerary tooth and its effects on the adjacent tissues.

References1. S h a f e r W G . D e v e l o p m e n t a l

disturbance in shape of teeth in Shafer W.G, Hine M.K, Levy B.M.: A textbook of oral pathology, 4th ed. W. B. Sunders: Tokyo; 1983. p. 42-4.

2. R a j a b L D , H a m d a n M A . Supernumerary teeth: review of the


Med Oral Patol Oral Cir Bucal. 2009;14:E146-52.

8. Koul M, Koul R. An impacted supplemental premolar in the mandible. J Indian Soc Pedod Prev Dent 2006;24:38-40

9. S o l a r e s R , R o m e r o M I . Supernumerary premolars : a literature review. Pediatr Dent. 2004;26:450-8.

10. Yagüe-García J, Berini-Aytés L, Gay-Escoda C. Multiple supernumerary teeth not associated with complex syndromes: a retrospective study. Med Oral Patol Oral Cir Bucal. 2009;14:E331-6

literature and a survey of 152 cases. I n t J P a e d i a t r D e n t . 2 0 0 2 Jul;12(4):244-54.

3. Piattelli M, Piattelli A. Multiple impacted and erupted supernumerary premolars. Acta Stomatol Belg. 1995 Jun;92(2):75-6

4. Stafne EC: Supernumerary teeth. Dent Cosmos 74:653, 1932.

5. Hattab FN, Yassin OM, Rawashdeh MA. Supernumerary teeth: Report of three cases and review of the literature. J Dent Child 1994;61:382-93.

6. Hong-Keun Hyun, Byung-Duk Ahn, Min-Suk Heo, Min-Suk He. Nonsyndromic multiple mandibular supernumerary premolars. J Oral M a x i l l o f a c S u r g . 2 0 0 8 Jul;66(7):1366-9.

7. Ferrés-Padró E, Prats-Armengol J, Ferrés-Amat E. A descriptive study of 113 unerupted supernumerary teeth in 79 pediatric patients in Barcelona.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Gurmeet Singh Sachdeva2 Liza Thakur Sacheva3 Munish Goel4 Suma Ballal5 Deivanayagam Kandaswamy

mandibular first premolar with three distinct roots and three separate root canals has never been reported in literature so far.

This case report presents a successful, non-surgical endodontic management of bilaterally occurring three rooted mandibular first premolars.

Case ReportA 38 year old female patient was referred to our department for emergency endodontic management of Tooth # 21 (mandibular left first premolar) and tooth # 28 (mandibular right first premolar) following iatrogenic pulpal exposure during crown preparation. Medical history was non-contributory. Dental history revealed that she had undergone extraction of her lower six anteriors two years back due to non restorable lesions and had now decided to go in for a fixed

IntroductionCurrently, success in endodontic treatment is rated to be as high as 95%. In order to achieve endodontic success it is critical that, the entire root canal system must be debrided, disinfected and

[1]obturated .

Literature search reveals that the mandibular premolars exhibit highest incidence of variations in root canal

[1]anatomy . Hence, additional root canals must be detected in all cases otherwise treatment failure is extremely possible [2],[3],[4].

Variations in root canal morphology reportedly occur more frequently in mandibular first premolars than in the

[ 5 ] , [ 6 ] , [ 7 ]second premolars . Racial differences in root canal morphology of these teeth has also been well established [6],[8].

[9]A study conducted by Cleghorn et al reported that 98% of mandibular first premolars had a single root, 1.8% had two roots, and 0.2% had three roots. Four roots were extremely rare and were found to be less than 0.1% of teeth studied.

[10]Fisher et al and Chang et al have also reported cases of mandibular first premolars with three roots and three root c a n a l s . H o w e v e r e n d o d o n t i c management of bilaterally occurring


1 Reader, Dept. of Conservative Dentistry & Endodontics,2 Reader, Dept. of Oral Pathology.3 Professor & Head, Dept. of Conservative Dentistry & Endodontics, Himachal Dental College & Hospital, Sundernagar4 Professor, Dept. of Conservative Dentistry & Endodontics, Meenakshi Ammal Dental College, Chennai.5 Professor & Head, Dept. of Conservative Dentistry & Endodontics, Sri Ramachandra Dental College & Hospital, Chennai

Endodontic Management Of Bilaterally

Occurring Three-rooted Mandibular First

Premolars: A Case Report

Address For Correspondence:Dr. Gurmeet Singh Sachdeva, Dept. of Conservative Dentistry & Endodontics,Himachal Dental College & Hospital,Sundernagar, Distt Mandi Himachal PradeshE mail: [email protected]

th Submission : 4 September 2012th Accepted : 19 January 2013

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prosthesis in relation to it. The referring dentist had planned to use teeth # 20, # 21, # 28, # 29 as abutments for the fixed prosthesis and crown preparation was done in relation to them.

Pre-operative photographs (Fig. 1) and radiographs (Fig. 2A-D) provided by the

AbstractIt is important to accurately diagnose the morphology of the entire root canal system for successful completion of the endodontic treatment. Text book description of mandibular first premolar is typically of a single rooted tooth. The incidence of these teeth having two roots is quite high. Three and four rooted mandibular first premolars have also been reported but are extremely rare. Diagnostic aids such as preoperative radiograph followed by careful inspection of the pulp chamber floor aid in the location of root canal orifices. This case report describes successful non surgical management of bilaterally occurring mandibular first premolars with three separate roots and three root canals.

Key WordsAnatomic variations; bilateral; endodontic management; three rooted mandibular first premolar

Figure 1

Figure 2 A


locator (Root ZX, Morita, Tokyo, Japan), which was later confirmed with a radiograph (Fig. 3B and Fig. 4B).

The canals were cleaned and shaped with P ro tape r (Den t sp ly, Ma i l l e f e r, Bal laiques, Switzerland) rotary instruments under copious irrigation with 2.5 % Sodium hypochlorite and 17 % ethylenediaminetetraacetic acid (EDTA). The finishing of canals was performed until Protaper F2 reached the full working length. Root canals were dried with sterile paper points (Dentsply, Maillefer, Ballaiques, Switzerland). Calcium hydroxide paste (Calcicur ; VOCO, Cuxhaven, Germany) was applied and access temporarily sealed with Cavit (3M ESPE AG, Seefeld, Germany). The patient returned after one week. Both teeth were completely asymptomatic. Calcium hydroxide paste was removed and roots canals were obturated by cold lateral compaction of gutta percha using zinc oxide and eugenol (ZOE) sealer (Kemdent, Associated Dental Products Ltd, Wiltshire, UK). A post operative radiograph was taken (Fig. 3C and Fig. 4C) and the access was restored permanently with universal composite resin restorative material (3M ESPE Dental Products, St Paul, MN). One year recall radiographs of both the teeth revealed a healthy periapical bone (Fig. 3D and Fig. 4D).

DiscussionVariations in root canal anatomy of mandibular premolars occur far more

[12]often than one can expect. Hess , [13] [14] [15] [16]Mueller , Amos , Ring and Green

reported the presence of two canals in 2-17.9% of the teeth studied, with no reports on the presence of three canals.

[17]Pineda and Kuttler reported 0.9% of these teeth with three root canals whereas

[5]studies by Zillich and Dowson reported three root canals in 0.4% to 0.5% of the teeth investigated.

Like the number of root canals the number of roots may also vary. Anatomic

[9]studies by Cleghorn et al on 4,462 teeth revealed that 97% of mandibular first premolars had only a single root. Two roots were found in 1.8% of the teeth studied. The incidence of three roots was 0.2% and four roots were present in less

[18]than 0.1% of the teeth studied. Iyer et al have reported the incidence of three roots

[19]as 0.2% and Geider et al reported it to

referring dentist revealed normal coronal morphology of the tooth # 21 and tooth # 28 but the root canal anatomy of these teeth was quite unusual.

On clinical examination, the patient's oral hygiene was found to be moderate, and lower six anteriors were missing. Crown preparations were observed on tooth # 20, # 21, and tooth # 28, # 29 with pulpal exposure evident on the mesioocclusal aspect of tooth # 21 and # 28.

The involved teeth were tender on percussion. No periodontal pockets were present on either of them and thermal and electrical pulp testing elicited a positive response.

Radiographic evaluation revealed an unusual, bilateral complex root canal anatomy of the tooth # 21 and tooth # 28 (Fig. 2A-D). Vague outlines of the two roots could be identified on the radiographs. Additional radiographs taken at different angulations revealed the presence of an additional root. Crown preparation was also observed in relation to # 20, # 21 (Fig. 2B) and # 28 and # 29 (Fig. 2D) with almost negligible remaining dentin thickness on the mesioocclusal aspect of tooth # 21, # 28 suggestive of a pulpal exposure.

On the basis of the clinical and radiographic findings, a diagnosis of iatrogenic pulpal exposure of tooth # 21 and tooth # 28 was made. Once the confirmatory diagnosis was made, endodontic management of the involved teeth were planned.

After administration of local anaesthesia, coronal build up of the involved teeth was done with universal composite resin restorative material (3M ESPE Dental Products, St Paul, MN) for application of rubber dam clamps. The teeth were then isolated with rubber dam and the access opening was done keeping in mind the probable location of the orifices of the three root canals. (Fig. 3A and Fig. 4A)

On careful inspection of the pulp chamber floor with the operating microscope, three separate root canal orifices were observed (one mesial, one distobuccal, and one distolingual) both in tooth # 21 and # 28. Coronal flaring for all the three canals was carried out with Gates Glidden drills and working length was determined with the help of apex

Figure 2 B

Figure 2 C

Figure 2 D

Figure 3 A

Figure 3 B


revo lu t ion i sed the p rac t i ce o f endodontics. According to Saunders and

[ 2 3 ]Saunders , by using operating m i c r o s c o p e f o r c o n v e n t i o n a l endodontics, enhanced visualization of root canal intricacies is possible. This would help the clinician to diagnose, clean and shape the entire root canal system more effectively.

A wide range of opinions are reported in literature regarding the number of root

[9]canals , but there are very few reports on [11], the variations in the numbers of roots

[18] that occur in mandibular first premolars. Endodontic management of bilaterally occurring three rooted mandibular first premolars had never been reported in literature so far.

ConclusionSuccessful non surgical endodontic management of bilaterally occurring mandibular first premolars with three separate roots and root canals has been presented. To achieve predictable results, thorough debridement of the entire root canal system is imperative. During the course of endodontic treatment, the possibility of extra roots and root canals must be considered especially if the tooth in question is a mandibular premolar. The endodontist should always look for a second, third or even fourth root canal so that the entire root canal system can be debrided and success ensured. Enhanced visualization with the operating microscope must also be considered in the diagnosis and management of these teeth with extremely complex and highly variable root canal anatomy.

References1. Ingle JI, Bakland LK. Endodontics

(2003).5th ed, BC Decker, Inc. Elsevier.

2. Slowey RR (1979);Root canal anatomy: road map to successful endodontics. Dental Clinics of North America 23, 555-73.

3. Weine FS (1995) Non surgical re-treatment of endodontic failures. Compend Cont Educ Dent 16, 326-35.

4. Hoen MM, Pink FE (2002) C o n t e m p o r a r y e n d o d o n t i c retreatments: an analysis based on clinical treatment findings. Journal of Endodontics 28, 834-6.

5. Zillich R, Dowson J (1973) Root canal morphology of mandibular first and second premolars. Oral Surgery,

be 2.4%. Four rooted varieties have also [9]been reported, but are less than 0.1%.

Racial differences in root canal morphology have also been reported. The frequency of premolars with two and three root canals appears to be higher in

[20]the Asian population

Considering the fact that so much of aberrations exist in these teeth, it becomes mandatory for the clinicians to look for extra canals during the course of endodontic treatment.

[4]Hoen and pink reported 42% incidence of missed roots or canals in these teeth that needed retreatment. A study at the University of Washington which assessed the failure rate of endodontic therapy reported that, the mandibular first premolar had the highest failure rate

[1]at 11.45% . Numerous other incidences of failures and flare ups have been

[ 1 ]r e p o r t e d d u r i n g e n d o d o n t i c management of these teeth. This could possibly be due to the highly variable and extremely complex root canal anatomy of these teeth.

Radiographs produce only a two d imens iona l image of a th ree dimensional object resulting in superimposition of images. Hence, they are of rather limited value in cases with c o m p l e x r o o t c a n a l a n a t o m y. Interpretation and appraisal based upon a two dimensional radiograph may alert the clinician to the presence of aberrant anatomy but would not be able to c o n f i r m a t i v e l y d i a g n o s e t h e morphological structure of root canals

[21]and their interrelations .

In such cases the use of operating microscope may be of tremendous advantage in confirming the presence of

[22]extra root canals. According to Carr introduction of operating microscope has

Figure 3 C

Figure 3 D

Figure 4 A

Figure 4 B

Figure 4 C

Figure 4 D

Oral Medicine Oral Pathology.36, 738-44.

6. Trope M, Elfenbein L, Tronstad L 1986 Mandibular premolars with more than one root canal in different race groups. Journal of Endodontics 12, 343-5.

7. Vertucci FJ (1978). Root canal m o r p h o l o g y o f m a n d i b u l a r premolars. Journal of American Dental Association 97, 47-50.

8. Walker RT (1988) Root canal anatomy of mandibular f irst premolars in a southern Chinese population. Endodontics and Dental Traumatology 4, 226-8

9. Cleghorn BM, Christie WH, Dong CC (2007) The root and root canal m o r p h o l o g y o f t h e h u m a n mandibular first premolar: A li terature review. Journal of Endodontics 33, 509-16

10. Fischer GM, Evans CE (1992) A three-rooted mandibular second premolar. General Dentistry 40, 139-40.

11. Chan K, Yew SC, Chao SY (1992) Mandibular premolar with three root


Medicine Oral Pathology 33, 101-10. 18. Iyer VH, Indira R, Ramachandran S,

Srinivasan MR (2006) Anatomic variations in mandibular premolars in Chennai population. Indian Journal of Dental Research 17, 7-10

19. Geider P, Perrin C, Fontaine M (1989) [Endodontic anatomy of lower premolars- apropos of 669 cases]. J Odontol Conserv 11-5

20. De Moor RJ, Calberson FL (2005) Root canal treatment in a mandibular second premolar with three root canals Journal of Endodontics 31, 310-3.

21. Holtzman L (1998). Root canal treatment of mandibular second premolar with four root canals: a case report International Endodontic Journal 31, 364-6.

22. Carr GB (1992). Microscopes in Endodontics. Journal of California Dental Association 20, 55-61

23. Saunders W, Saunders E (1997) Conventional endodontics and the operating microscopes.

c a n a l s - t w o c a s e r e p o r t s . International Endodontic Journal 25, 261-4

12. Hess W (1925) The anatomy of the root-canals of the teeth of the permanent dentition, Part 1. New York:William Wood and Co.,

13. Mueller AH (1933) Anatomy of the root canals of the incisors, cuspids, and bicuspids of the permanent teeth. Journal of American Dental Association 20, 1361-8.

14. Amos ER (1955) Incidence of bifurcated root canals in mandibular bicuspids. Journal of American Dental Association 50, 70-1

15. Ring AL (1969) Rontgenologisch-anatomische Untersuchungen zur Mehr-wurzeligkeit von Eckzahnen und Pramolaren. Zahnarztliche Praxis 20, 169-73

16. Green D (1973) Double canals in single roots. Oral Surgery, Oral Medicine Oral Pathology 35, 689-96.

17. Pineda F, Kut t ler Y (1972) Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surgery, Oral





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Swati Gupta

left front teeth region that started a month before reporting (picture 1). Patient had a history of trauma 6 months back. His medical history was noncontributory. On the clinical examination of the anterior maxillary region, it was noted that the maxillary central incisor was painful during biting and percussion. The tooth was unresponsive to sensitivity testing with cold or an electric pulp tester (Parkell, Farmingdale, NY, USA). Radiographic examination demonstrated an apparent radiolucency in the middle third of the root canal (picture 2). There was clinically obvious pinkish color in tooth especially on the lingual side. There was bleeding sign on probing and recession of 3mm distobuccally, 2mm bucally and 2mm mesiobucally was calculated (picture 3). Clinical and radiographic examination indicated pulp necrosis with resorption causing lingual perforation. Grade II mobility was present. The patient was given a detailed explanation concerning the planned treatment procedure and prognosis. The tooth anesthetized followed by a conventional access cavity preparation and the cavities were widened with an Endo-Z bur (Dentsply Maillefer, Tulsa, OK) to enhance the visibility of the root canal. Irrigation of the canal was done several t imes with 5% sodium hypochlorite, and the last irrigation solution was left in the canal for 15 minutes to dissolve organic material. The canal was filled with calcium hydroxide, cotton and zinc oxide eugenol. At the next visit, determination of the working length was done using an electronic apex locator

IntroductionInternal resorption is a clinical term used to describe a relatively uncommon, insidious, and often aggressive form of resorption .It is characterized by an oval-shaped enlargement of root canal space (Well demarcated ballooning area). Lesion appears close to the canal even if angulations of radiographs changes. Outline of the canal is distorted. Pink spot is present. Internal resorption may extend to the external surface leading to primary endodontic and secondary periodontal lesion. Internal root resorption leading to communication between pulp space & periodontal ligament produces a complicated situation and a challenge to the clinician for its management. The most recent and promising material used to seal this communication is Mineral Trioxide Aggregate (MTA). It is seen in most cases as a late complication of traumatic injuries of the teeth, but it may also occur after orthodontic movement, orthognatic and other dentoalveolar surgery, periodontal treatment, bleaching of teeth, and a wide variety of traumatic conditions. Mineral trioxide aggregate or MTA (MTA; Pro-Root®, Dentsply Tulsa, Tulsa) is reported to show good sealing ability, a high degree of biocompatibility, and potential to be repair material for internal resoption. In this case report, the internal resoption was repaired with MTA and the rest of the canal was filled with gutta percha points.

Case ReportA 44-year-old male patient presented with a complaint of acute pain in upper


1 Sr Lecturer, D.A.V Dental College, YamunanagarUse Of Mineral Trioxide Aggregate In

Treatment Of Internal Resorption: A Case

Report

Address For Correspondence:Dr. Swati GuptaSr Lecturer,D.A.V Dental College, YamunanagarE-mail : [email protected]


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AbstractMineral trioxide aggregate (MTA) has shown potential as a repair material for internal resorption. This clinical case demonstrates that when MTA was used as a repair material for internal resorption, the tooth was well in function for 12 months. Both clinical and radiographic follow-up showed a stable condition without any probing defect, ongoing root resorption, apical pathosis and good amount of bone formation.

Key WordsMineral Trioxide aggregate, Internal root resorption

Picture 1

Picture 2

Picture 3

(Root ZX, J Morita Corporation. Kyoto, Japan). Canal enlargement was done with hand k-files. At the third visit, which was one week after initial visit, local anesthesia was administered, and mucoperiosteal flap was raised (picture


4) and the lesion was exposed (picture 5). Lesion on the root surface was located with a periodontal probe as shown in picture 6. A 15no k-file is shown passing through the access opening to the external surface of the lesion (picture 7). MTA was mixed with sterile water to a paste consistency following the manufacturer's instructions. MTA was then applied into the resorption defect with a small sized plastic filling instrument (picture 8). The remaining root canal was filled with gutta-percha points and sealer (AH26, Dentsplay, Konstanz, Germany) using a lateral condensation technique. Bone graft material hydroxyappatite crystals were applied on the MTA filled resorption lesion over the root surface (picture 9).A gingival tissue regeneration membrane was then placed (picture10) and the flap was then sutured (picture 11). A periodontal pack was placed on the sutured gingival (picture 12). The patient was recalled after 8-9 days, the pack was removed and sutures were removed. On clinical examination mobility reduced but recession increased to 4 mm (picture 13). Patient was regularly examined at an interval of 1 month (picture 14), 6 months, and then 1 year follow up radiographically. (picture 15).

DiscussionMTA has an excellent sealing ability in the presence of moisture in a root canal. This property is especially important in teeth with perforation and resorption because the material may be exposed to oral fluids. Local anesthesia was administered because the operator wanted to relieve the pain that the patient may experience when the filling material was packed against the tissue. The surgical intervention of perforation and resorption repair with MTA were reported to be successful. Formation of a physiological gingival crevice, function regeneration and maturation of the gingival connective tissue requires 3 to 5 weeks and surgical intervention would be more difficult if the defect was located on the lingual aspect of the root. In this case, 5% sodium hypochlorite was left in the canal for 15 minutes to dissolve the tissue. Sodium hypochlorite is well known to be effective in removing the smear layer from the canal walls and reducing the microorganisms and inf lammatory react ion with i ts availability in the clinic. Both clinical and radiographic follow-up showed a stable

Picture 4

Picture 5

Picture 6

Picture 7

Picture 8

Picture 9

Picture 10

Picture 11


condition without any probing defect, ongoing root resorption, or apical pathosis. MTA causes formation of cemetal layer over the sealed area. MTA preferent ia l ly induced a lkal ine phosphatase expression and activity in both periodontal ligament and gingival fibroblast. It helps in the bone regeneration adjacent to sealed area. Most of the cell studies showed good cell growth over MTA with the formation of a cell monolayer over the material. MTA allows overgrowth of cementum & periodontal ligament . Presence of cementum on the surface of MTA was a frequent finding. MTA actively promotes hard tissue formation rather than being inert or an irritant. The condensation of fibronectin around the formed apatite crystals permits cellular adhesion and differentiation seen as cementoblast in the periodontium. MTA supported almost c o m p l e t e r e g e n e r a t i o n o f t h e periradicular periodontium. MTA had antibacterial effects against facultative anaerobes but not agianst obligate anaerobes. Osteocalcin levels were also increased in the presence of MTA. MTA (ProRoot) also preferentially induced alkaline phosphatase expression and activity in both periodontal ligament and gingival fibroblast. To this case report confirms that the pocket depth in the resorption area sealed with MTA was reduced due to regeneration of cementum, periodontal ligaments as well as bone over the resorption area. MTA is the ideal material for repair of resorption lesions especially the internal resortion extending to the outer surface of the root leading to Endo-perio lesion.

References:1. Heithersay GS. Invasive cervical

resorption: an analysis of potential predisposing factors. Quintessence Int. 1999 Feb;30(2):83-95.

2. Gonzales JR, Rodekirchen H. Endodont ic and per iodonta l treatment of an external cervical resorption. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Jul;104(1):e70-7.

3. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993 Dec;19(12):591-5.

4. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide

aggregate for repair of lateral root perforat ions. J Endod. 1993 Nov;19(11):541-4.

5. Arens DE, Torabinejad M. Repair of furcal perforations with mineral trioxide aggregate: two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Jul;82(1):84-8.

6. Baratto-Filho F, Limongi O, Araújo Cde J, Neto MD, Maia SM, Santana D. Treatment of invasive cervical resorption with MTA: case report. Aust Endod J. 2005 Aug;31(2):76-80.

7. Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: results from a case series. Int Endod J. 2007 Jun;40(6):478-84.

8. Hsien HC, Cheng YA, Lee YL, Lan WH, Lin CP. Repair of perforating internal resorption with mineral trioxide aggregate: a case report. J Endod. 2003 Aug;29(8):538-9.

9. Ford HE, Ford TR. Surgical repair of a resorptive defect in an anterior tooth of an adolescent: a case report. Int J Paediatr Dent. 1998 Sep;8(3):219-22.

10. Ramfjord SP, Engler WO, Hiniker JJ. A radioautographic study of healing following simple gingivectomy. II. The connective tissue. J Periodontol. 1966 May-Jun;37(3):179-89.

11. Hunt PR. Safety aspects of mandibular lingual surgery. J Periodontol. 1976 Apr;47(4):224-9.

12. Heithersay GS. Treatment of invasive cervical resorption: an analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int. 1999 Feb;30(2):96-110.

13. Teixeira CS, Felippe MC, Felippe WT. The effect of application time of EDTA and NaOCl on intracanal smear layer removal: an SEM analysis. Int Endod J. 2005 May;38(5):285-90.

14. Jiménez-Rubio A, Segura JJ, Llamas R, Jiménez-Planas A, Guerrero JM, Calvo JR. In vitro study of the effect of sodium hypochlor i te and g lu ta ra ldehyde on subs t ra te adherence capacity of macrophages. J Endod. 1997 Sep;23(9):562-4.

15. Ercan E, Ozekinci T, Atakul F, Gül K. Antibacterial activity of 2% chlorhexidine gluconate and 5.25% sodium hypochlorite in infected root canal: in vivo study. J Endod. 2004 Feb;30(2):84-7.

Picture 12

Picture 13

Picture 14

Picture 15 Source of Support : Nill, Conflict of Interest : None declared




E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Rooposhi Saha2 Shobhit Sachdeva

systemic diseases, any history of trauma, or infections to the anterior region. Family history revealed no such finding in any members of the family.

Case 1: A 3 year old boy presented with a chief complaint of decayed teeth. On intraoral examination lower primary lateral incisors were bilaterally absent. Panaromic examination confirmed bilateral agenesis of deciduous mandibular lateral incisors (Figure 1, Figure 2).

IntroductionTooth agenesis is the most prevalent craniofacial congenital malformation in humans. Up to 25% of the population may have a missing third molar. Agenesis of other permanent teeth, excluding third molars, ranges from 1.6 to 9.6%, depending on the population studied. Primary dentition may also be affected, but with lower prevalence (from 0.5 to

[1]0.9%) (Vastardis, 2000) . The majority of persons with hypodontia (80%) lack only one or two teeth, permanent second premolars and upper lateral incisors being predominantly affected (Symons et

[2]al, 1993) . However, about 1% (0.08-1.1%) of the population suffers from oligodontia-the agenesis of more than 6

[3]teeth (Stockton et al, 2000 ; Gabris et al, [4]2001 ). Loss of all teeth is known as

anodontia. How tooth loss comes about is thus an important question.

Case ReportThese are the series of cases which reported to the Department of Pediatric and Preventive Dentistry, ITS Dental College, Muradnagar.

T h e c h i l d w a s b o r n t o nonconsanguineous parents. The pregnancy and delivery were uneventful. There was no history of any severe


1 Senior Lecturer2 Post Graduate Student Department of Pedodontics & Preventive Dentistry ITS Center for Dental Studies & Research, India

Hypodontia And Its Etiology: Clinical Cases &

Literature Review

Address For Correspondence:Dr. Rooposhi Saha24/5 Prabhat Nagar, Meerut 250001, U.P., IndiaTelephone number: +919557380153E-mail: [email protected]


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Case 2: A 15 year old girl presented with a chief complaint of dirty teeth. Intraoral examination revealed presence of a number of retained deciduous teeth. Henceforth panaromic examination was done to view the status of permanent teeth. OPG of the patient revealed the congenital absence of upper lateral incisors, canines, 1st and 2nd premolars bilaterally. In the lower arch second premolars were found missing bilaterally

AbstractThe smile is a unique facial expression distinct to primates. The main physical component of the smile is a complete dentition set comprising four different types of teeth. Vertebrate comparative histology has indicated that the continued evolution of teeth throughout the emergence of modern man is due to increased fitness they have offered us. Our modern lifestyle also has a special attachment to a complete set of dentition aside from their use as merely mastigatory appendages for food. For this reason, naturalists, biologists and dentists have for a long time been trying to unravel the cause for the congenital loss of teeth leading to several clinical phenotypes such as hypodontia, oligodontia and anodontia. This paper attempts to present the possible etiology and treatment options for congenitaly missing teeth through a series of case reports.

Key WordsHypodontia, Etiology, primates, vertebrate, mastigatory

Figure 1: Intraoral photograph showing bilaterally missing lateral incisors

Figure 2: Panoramic radiograph showing the missing teeth (primary dentition)

(Figure 3).

Case 3: A 14 year old boy presented with a chief complaint of forwardly placed upper anterior teeth. On examination lower lateral incisors and second premolars were missing bilaterally. To confirm the diagnosis OPG was taken which substantiated the finding of congenital bilateral absence of lower lateral incisors and second premolars.

Case 4: A 11 year old girl presented with chief complaint of spacing in lower front tooth. On clinical intraoral examination congenital absence of lower lateral incisors was suspected. Patient gave no history of trauma or avulsion of teeth. OPG was taken which confirmed agenesis of mandibular lateral incisors bilaterally.

Case 5: A 14 year old girl presented with a chief complaint of dirty teeth. Intraoral examination revealed extrinsic stains in


DiscussionThere appears to be a multifactorial aetiology to hypodontia, with both genetic and environmental factors p l a y i n g i m p o r t a n t r o l e s . T h e pathogenesis of hypodontia cannot be explained by genetic factors alone since monozygotic twins show discordant expression at a certain frequency with respect to hypodontia. Hypodontia is thought to involve environmental factors including infections e.g. Rubella, drugs such as thalidomide and irradiation as well as the developmental relationships between the nerves, maxilla, mandible, oral mucosa, supporting tissues and hard tissues.

Attempts were made to explain them with evolutionary and anatomic models such as Butler's field theory, odontogenic polar i ty, or Sofaer ' s model of compensatory tooth size interactions.

According to Butler's theory (1939), mammalian dentition can be divided into 3 morphologic fields corresponding to incisors, canines, and premolars/molars. Within each field, one "key" tooth is presumed to be stable; flanking teeth within the field become progressively less stable. Based on Butler's theory, the third molar and the first premolar would be predicted to be most variable in size and shape.

Clayton hypothesized that the teeth most often missing were "vestigial organs" with little practical value for modern man. In the evolutionary process, these teeth provide no selective advantage for the species and hence have been lost.

Sofaer et al speculated that agenesis occurs when there is insufficient primordia for tooth germ initiation.

Kjaer has explained the location of tooth agenesis by neural developmental fields i n t h e j a w s ( i n c i s o r f i e l d , canine/premolar, and molar field). The region within a single field where innervation occurs last is more likely to manifest tooth agenesis.

In the majority of cases, hypodontia has a genetic basis. To date, the mutation spectra of non-syndromic tooth agenesis in humans have revealed defects in two such genes that encode transcription factors, MSX1 and PAX9. Both Msx1 and Pax9 interact during the tooth-bud-

all teeth. The central incisors were not present bilaterally. Patient gave no history of trauma. IOPA and OPG were taken which confirmed the clinical finding.

Case 6: A 12 year old boy presented with a chief complaint of decayed lower left and right posterior teeth. IOPA and OPG of the patient revealed bilaterally absent second premolars in the lower arch and their was no sign of any presence of crypt formation.

Case 7: A 11 year old girl presented with a chief complaint of pain in lower left back tooth region. Intraoral examination revealed decayed lower first permanent molar and deciduous primary second molar on both the sides. IOPA and OPG of the patient were taken that suggested the absence of right second premolar while a crypt was appreciated of the left second premolar.

to-cap transition. In the mouse, in the absence of either Msx1 or Pax9, tooth development is arrested at the bud stage. The mode of inheritance of MSX1-caused hypodontia is predominantly

[5]autosomal-dominant, (Kim et al, 2006) . PAX9 has been found to be the gene causing isolated molar oligodontia, an autosomal-dominant disorder with agenesis of most permanent molars, sometimes in combination with other types of teeth.

Beyond these genetic disorders, tooth loss is triggered by a variety of oral diseases, such as periodontitis and dental caries, and by traumatic and age-related alterations. Hypodontia does not represent a life threatening condition; however, i t i s connected wi th masticatory, speech, and esthetic problems.

Clinical Treatment Of Tooth AgenesisMultiple treatment options are currently available for persons with tooth agenesis. Synthetic dental implants are a widespread standard procedure to replace missing teeth, and its success has increased in recent decades. Different fixtures-such as implant, crown, bridge, fixed or removable, complete and partial dentures-have been shown to be sufficient over the long term (Bartlett,

[6]2007) . The negative outcomes include possible infection causing failure of the implant to integrate with the bone, resulting in implant loss and possible

[7]bone loss (Callan, 2007) . Implants placed into developing alveolar ridges have been shown to inhibit ridge formation.

Tooth Engineering: A New Target In Tooth Loss TherapyThe re-organization of tissues in scaffolds to form new tissues/organs is one recent approach. This technique was successfully applied in periodontal

[8]regeneration (Duailibi et al, 2004 ) and has been tested in tooth engineering. So far, embryonic cells from fetuses have been used to form a new tooth de novo. The experiments support mammalian cell plasticity and suggest the existence

©Indian Journal of Dental Sciences. (March 2013 Issue:1, Vol.:5) All rights are reserved.

PAX9 is associated with oligodontia. Nat Genet 2000; 24:18-19.

4. Gabris K, Tarjan I, Csiki P, Konrad F, Szadeczky B, Rozsa N. [Prevalence of congenital hypodontia in the permanent dent i t ion and i ts treatment.] Fogorv Sz 2001; 94:137-140 (article in Hungarian).

5. Kim JW, Simmer JP, Lin BP, Hu JC. Novel MSX1 frameshift causes autosomal-dominant oligodontia. J Dent Res 2006; 85:267-271.

6. Bartlett D. Implants for life? A critical review of implant-supported restorations. J Dent 2007; 35:768-772.

7. Callan DP. Dental implant design and oral and systemic health. Compend Contin Educ Dent 2007; 28:482-492.

8. Duailibi MT, Duailibi SE, Young CS, Bartlett JD, Vacanti JP, Yelick PC. Bioengineered teeth from cultured rat tooth bud cells. J Dent Res 2004; 83:523-528

9. Hu B, Nadiri A, Kuchler-Bopp S, Perrin-Schmitt F, Peters H, Lesot H. Tissue engineering of tooth crown, root, and periodontium. Tissue Eng 2006; 12:2069-2075.

10. Ohazama A, Modino SA, Miletich I, Sharpe PT. Stem-cell-based tissue engineering of murine teeth. J Dent Res 2004; 83:518-522.

of a cell-specific developmental program, even after tissue dissociation and growth in culture conditions.

However, much more attractive is the challenge to form a mineralized tooth without any scaffold. Tooth germs can develop successful ly fol lowing dissociation and re-association without a

[9]scaffold support (Hu et al, 2006 ). This technique would enable one to collect an individual´s cells from any stem cell niche, grow these in the culture, induce them to progress along a tooth-developmental pathway, and create a de novo tooth. Great steps have already been made in this direction, a tooth having been created where the mesenchymal parts were stem-cell-derived (Ohazama

[10]et al, 2004 ). Therefore, the only non-stem-cell-derived parts of the resulting tooth crown were the ameloblasts.

ConclusionWith the increase in prevalence of hypodontia observed over the 20th century, the identification of its causative factors is essential for providing treatment to those afflicted in the future. Modern molecular genetic techniques have allowed us to start to identify the genetic factors responsible for tooth agenesis but more work is required to discover how malfunction in these factors disrupt tooth development. To achieve this, dental professionals need to collaborate with human geneticists for investigative research to increase the known population of mutations affecting the dentition.

References1. Vastardis. The genetics of human

tooth agenesis: New discoveries forunderstanding dental anomalies. American Journal of Orthodontics and Dentofacial Orthopedics2000; 117(6): 650-6

2. Symons AL, Stritzel F, Stamation J (1993). Anomalies associated with hypodontia of the permanent lateral incisor and second premolar. J Clin Pediatr Dent 17:109-111.

3. Stockton DW, Das P, Goldenberg M, D'Souza RN, Patel PI. Mutation of


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E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 G.S Mamatha Reddy2 Bela Mahajan3 Rajiv S. Desai

both the mesiodens was evident in maxillary occlusal radiograph (Figure 2). Intraoral examination of the second twin revealed palatally placed single conical erupted mesiodens in the maxilla and slight overlapping of central insicors (Figure 3) . Intraoral periapical radiograph showed complete root formation of the mesiodens (Figure 4). Radiographs revealed no associated pathologies.Both the twins were referred to dental college for further treatment. Mesiodens were extracted in both the cases and the first twin was treated orthodontically for mal-aligned teeth.

DiscussionMesiodens is one of the developmental anomalies commonly seen in dental clinics and can cause esthetic or pathologic problems. Therefore, early detection is the most important measure

[2]for prevention of complications. The etiology of mesiodens is not well understood but several theories have been postulated regarding the causes of supernumerary teeth, including atavism, dichotomy of the tooth bud, and

[1],[2]hyperactivity of the dental lamina. Genetics is thought to contribute to the development of mesiodens as such teeth have been diagnosed in twins, siblings,

[7]and sequential generations of a family and this could be the possible etiology in the present case report. Supernumerary teeth may occur in isolation or as a part of syndrome, such as, cleidocranial, gardener's and cleft lip & palate

[1]syndrome.

IntroductionBy definition, supernumerary teeth are extra teeth in comparison to normal dentition. The most common type of supernumerary tooth as indicated by

[1], [2]Alberti et al, is mesiodens. They may be single or multiple, unilateral or bilateral, inverted, erupted or impacted

[1],[3],[4]and in one or both the jaws. A combination of numerous genetic and environmental influences also may have an effect on tooth number and

[5]morphology. Several reported cases show a familial incidence of mesiodens. In some cases, more than one sibling has

[6]been affected.This paper presents mesiodens in twins, one twin presenting with erupted double mesiodens in the midline and the other shows palata l ly erupted s ingle mesiodens.

Case ReportAn oral health survey in a primary school was conducted by the department of Oral Pathology. During examination of the students, we came across monozygotic twin brothers 14 years old with mesiodens. The twins were of similar facial appearance with many shared physical features. Their medical history was non- contributory and there was no history of similar anomalies in their family.Intra oral examination of first twin revealed permanent dentition with mal-aligned teeth. Two conical shaped mesiodens were erupted labially displacing the maxillary central incisors (Figure 1). Complete root formation of


1 Senior Lecturer2 Post Graduate Student Department of Oral Pathology & Microbiology Dr. D.Y.Patil Dental College and Hospital,Pune,India.3 Head of the Department, Department of Oral Pathology and Microbiology Nair Dental Hospital and College,Mumbai, India.

Mesiodens In Twins: A Case Report

Address For Correspondence:Dr. G.S. Mamatha Reddy.Senior lecturer, Department of Oral PathologyDr. D.Y.Patil Dental College and HospitalPimpri, Pune-18, India.Phone number: Mobile - 09922967325Residence- 020-27502024e-mail: [email protected]


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The reported prevalence of mesiodens in general population ranges between 0.15-

[1]1.9%. They are more common in males [1],[3],[7]than in females.

AbstractMesiodens are the most common supernumerary teeth occurring in 0.15-1.9% of the general population. Mesiodens in twins is an unusual and not a rare event. This report describes 14 year old monozygotic twin boys who both presented with erupted mesiodens. First twin showed double mesiodens and second twin showed single. All the three erupted mesiodens were of conical variety. Mesiodens were extracted in both the twins and further orthodontic treatment was carried out to correct mal-alignment of the teeth in the first twin.

Key WordsSupernumerary teeth; Conical mesiodens; Monozygotic twins

Fig. 1: Intraoral photograph showing labially placed erupted double mesiodens in first twin .

Fig. 2: Intraoral occlusal radiograph showing complete root formation of both the mesiodens in first twin.

Mesiodens has been reported commonly in maxilla specifically in pre maxillary

[1]region. Earlier studies have shown predominantly, a palatal position for the

[2]mesiodens. A study by Rajab LD and Hamdan MAM showed approximately 25% of mesiodens are located in the

[8]midline. Mesiodens can significantly alter both occlusion and appearance by altering the eruption path and the position

[2]of the permanent incisors. The site and location of the mesiodens in the present report is similar to earlier reported studies.Mesiodens can occur individually or as multiples (mesiodentes), may appear unilaterally or bilaterally, and often do not erupt. According to the shape and size, two subclasses are considered in the classification of mesiodens; namely, eumorphic and dysmorphic. The eumorphic (supplemental) subclass is usually similar to a normal-sized central incisor, whereas the dysmorphic teeth have different shapes and sizes and are categorized into conical, tuberculate,

[1],[4]supplemental and odontomes, of which the conical form is the most

[4]common type. Conical mesiodentes usually occur singly. They are generally


the early mixed dentition in order to facilitate spontaneous eruption and

[1]alignment of the incisors. In order to promote eruption and proper alignment of adjacent teeth, it is recommended to extract mesiodens in the early mixed dentition, which may reduce the need for

[1]orthodontic treatment. The later the extraction of the mesiodens, the greater the chance that the permanent tooth either will not spontaneously erupt or will be

[4]mal-aligned when it does erupt.

References1. Meighani G, Pakdaman A . Diagnosis

and Management of Supernumerary (Mesiodens): A Review of the Literature. Journal of Dentistry, Tehran University of Medical Sciences 2010; 7: 41-49.

2. Hyun HK, Lee SJ, Lee SH, Hahn SH, Kim JW. Clinical Characteristics and Complications Associated With Mesiodentes. J Oral Maxillofac Surg 2009; 67: 2639-2643.

3. Roychoudhury A, Gupta Y, Parkash H. Mesiodens: A retrospective study of fifty teeth. J Indian Soc Pedo Prev Dent 2000; 18:144-146.

4. Russell KA, Folwarczna MA. Mes iodens - Diagnos i s and M a n a g e m e n t o f a C o m m o n Supernumerary Tooth. J Can Dent Assoc 2003; 69:362-366.

5. Seddon RP, Johnstone SC, Smith PB. Mesiodens in twins: a case report and review of the literature. Int J of Pediat Dent 1997; 7:177-184.

6. Sedano HO, Gorlin RJ. Familial occurrence of mesiodens. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1969;27: 360-362.

7. Pavithra S, Babu A. Mesiodens with an unusual morphology and multiple impacted supernumerary teeth in a non-syndromic patient. Indian J Dent Res 2007; 18: 137-140.

8. R a j a b L D , H a m d a n M A M . Supernumerary teeth: review of the literature and a survey of 152 cases. Int J of Pediat Dent 2002; 12:244-254.

9. Scheiner MA, Sampson WJ. Supernumerary teeth: A review of the literature and four case reports. Aust Dent J 2007;42:160-65.

peg-shaped and are usually located palatally between the maxillary central incisors, tending to displace the erupting permanent central incisors. They often have a completely formed root and can

[4]erupt into the oral cavity. Foster and Taylor examined this relationship and found tuberculate types more commonly produced delayed eruption, whereas, conical types more commonly produced

[9]displacement of the adjacent dentition.The present paper reported mesiodens in monozygotic twins. The occurrence of mesiodens in twins is, therefore, of interest which is an unusual and not a rare event. Such cases may shed some light on the etiology of this common anomaly which has been supposed to have a genetic basis, possibly inherited as autosomal dominant gene with

[5]incomplete penetrance. Seddon RP, Johnstone SC and Smith PB reported a case of unerupted mesiodens in monozygotic twins. They also reviewed 8 cases and stated that monozygotic predominate dizygotic twins. Of the eight cases reported, two had described monozygous twins with bilateral mesiodens. Schon in 1974, described German twin boys with bilateral unerupted mesiodens and Choi et al in 1990 described monozygous Chinese twin boys both with an inverted mesiodens on the right side and a normally oriented mesiodens on the left side. In one twin the normally oriented

[5]mesiodens had erupted. In our case report, first twin had double mesiodens and second twin had single. All three were erupted, being of conical variety.The complications associated with mesiodens include delayed eruption in children with mixed dentition or permanent dentition, midline diastema, displacement or rotation of adjacent permanent incisors, cyst formation or c y s t i c c h a n g e s , r e s o r p t i o n o r dilacerations of the adjacent roots and

[2],[3]nasal eruption.Early diagnosis and proper line of treatment is necessary to prevent associated complications.There are two methods for extraction of mesiodens; early extraction before root formation of the permanent incisors and late extraction after root formation of the permanent incisors. Some authors recommend extraction of mesiodens in

Fig. 3: Intraoral photograph showing single palatally erupted mesiodens in the second twin.

Fig. 4: Intraoral periapical radiograph showing complete root formation of the mesiodens in the second twin.





E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Jeevanand Deshmukh2 Vinaya Kumar Kulkarni3 Girish Katti4 Sachin Deshpande

from poor oral hygiene, dental plaque and calculus or overhanging restorations may

[8]be precipitation factors in many cases . The growth is typically seen in young adults; however it may occur in any age, especially in individuals with poor oral hygiene. Females are far more susceptible than males because of the hormonal changes that occur in women during puberty, pregnancy, and

[9], [10]menopause. A preferences for children's has been reported by some

[6]investigators.

Pyogenic granuloma of the oral cavity is known to involve gingiva commonly

[12](75% of all cases), uncommonly it can occur on the lips, tongue, buccal mucosa,

[7],[12]palate and so on. Microscopically pyogenic granuloma is characterized by marked vascular proliferation amidst granulat ion t i ssue and chronic inflammatory infiltrate. When ulcerated, the surface of the lesion is covered with fibrin. Older lesions may present as

[13]fibrosis. In view of its clinical characteristics, similar to some commonly occurring lesions in the oral cavity, the differential diagnosis of pyogenic granuloma includes Peripheral giant cell granuloma, Peripheral ossifying fibroma, Metastasis of malignant tumors, Haemangioma, Conventional granulation tissue, Inflammatory gingival hyperplasia, Kaposi sarcoma, Angiosarcoma and Non

[7]Hodgkins lymphoma. Final diagnosis

Introduction:Pyogenic granuloma (PG) or granuloma pyogenicum is a common tumor-like mucocutaneous overgrowth that occurs in the oral cavity or on the skin. It is considered to be non-neoplastic in nature, but a kind of inflammatory hyperplasia. The term pyogenic is used erroneously since this condition does not

[1]produce any pus. Pyogenic granuloma is also known as pregnancy granuloma or pregnancy tumor when occurring in pregnant women, or as vascular eupulis, b e n i g n v a s c u l a r t u m o r a n d

[2]haemangiomatous granuloma.

"Hullihen S. P" in 1844 reported the first case of pyogenic granuloma which is probably the first case in the English

[3]literature . It was again described in 1897 by two French surgeons, Poncet and Dor, who named this lesion otyomycosis

[4]hominis. "Hartzell M. B in 1904 introduced the term "Pyogenic g r a n u l o m a " o r " G r a n u l o m a

[5]pyogenicum"

Zafarzadeh et al (2006) defined pyogenic granuloma as an inf lammatory overgrowth of the oral mucosa caused by

[6]minor trauma or irritation. According to [7]Neville et al (1998) , these injuries might

be caused in the mouth by gingival inflammation due to poor oral hygiene, trauma or local infection, representing an exuberant tissue response. Gingival irritation and inflammation that results


1 Professor & Head, Dept. of Periodontics Al Badar Dental College & Hospital, Gulbarga.2 Asstt. Professor, Dept. of Pedodontics & Preventive Dentistry, People's College of Dental Sciences & Research Centre, Bhopal (Madhya Pradesh)3 Prof. & Head, Dept. of Oral medicine & Radiology Al Badar Dental college & Hospital, Gulbarga.4 Professor & Head, Dept. of Pedodontics &Preventive Dentistry, Al-Ameen Dental College and Hospital, Bijapur

Pyogenic Granuloma, An Unusual Presentation

In Pediatric Patient - A Case Report.

Address For Correspondence:Dr. Jeevanand DeshmukhH.No. 1-1495/105/3/17Rukmini Pandurang KrupaBhagawati Nagar, Gulbarga. 585102Mob: 9740344521E-mail: [email protected]


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of the lesion is mainly by biopsy and histopathological examination.[7] Treatment of Pyogenic granuloma consists of surgical excision along with elimination of irritating local factors. We report an unusual case of pyogenic granuloma occurring in healthy pediatric patient.

Case ReportA 9 year old male patient was referred from department of pedodontics to the department of periodontics, Al Badar dental college and hospital for gingival swelling. The chief complaint of patient was discomfort in eating and unable to close the mouth completely. The lesion was of negligible size when the patient first noticed it (20 days back), but had grown over the past 20 days to attain the present size. No pain was associated with the lesion.

AbstractA number of pathological changes can produce enlargement of soft tissues in oral cavity presenting us with a diagnostic dilemma. These may include inflammatory reactions, neoplastic changes, cysts, developmental defects or variation in normal anatomic structures. Pyogenic granuloma is a reactive inflammatory hyperplasia seen in oral cavity and manifests as either sessile or pedunculated, erythmatous, exophytic papule or nodule with a smooth or lobulated surface that bleeds easily. We report an unusual case of pyogenic granuloma occurring in otherwise healthy nine year old pediatric patient, which was treated by conventional surgery with no recurrence for six months.

Key WordsPyogenic granuloma, Gingiva, Pediatric patient.

Extra oral examination did not reveal any facial asymmetry but lips were incompetent because of the extensive swelling. No abnormality was detected in temporomandibular joint and lymph nodes were not palpable. Intraoral clinical examination revealed solitary exophytic, sessile lesion, red in color, soft in consistency, with lobulations and bled easily on touch, extending from mandibular right central incisor to left canine involving both facial and lingual surfaces and from mucogingival junction to incisal plane (Fig - 1, 2). The size of the lesion was not in commensurate with the amount of local irritating factors present. There was grade I mobility in relation to 31 and 41. Intraoral periapical radiograph of that region showed minimal horizontal bone loss. Based on the overall clinical findings it was provisionally diagnosed as pyogenic granuloma or peripheral giant cell granuloma. The hemogram of the patient was within normal limits. Supragingival scaling was done and oral hygiene instructions were given. Excisional biopsy was done under local anesthesia. The biopsy specimen was sen t fo r the h i s topa tho log ica l examination. After complete hemostasis, periodontal pack was given and patient was recalled after one week. On recall visit periodontal pack was removed and satisfactory post operative healing was observed (Fig 3, 4).

Histopathological findings in the photomicrograph (Fig 5) shows stratified s q u m a o u s e p i t h e l i u m w i t h pseudoepitheliomatous hyperplastic connective tissue with proliferating endothelial cells and fibroplasts. Neovascularization is prominent (Fig 6). Intense inflammatory infiltrate is seen comprising of lymphocytes, plasma cells and neutrophils, extravasated RBC's and necrotic tissue is also seen. The above histopathological findings are suggestive of pyogenic granuloma and final diagnosis of pyogenic granuloma was made.

Discussion:Hyper plastic reactive lesions represent as a group the most common oral lesions, excluding caries, periodontal and periapical inflammatory disease. This group includes inflammatory gingival hyperplasia, oral pyogenic granuloma, peripheral giant cell lesion and peripheral

[14]cemento-ossifying fibroma . In an analysis of 244 cases of gingival lesions


in south Indian population, Shamim et al. found that these non neoplastic lesions accounted for 75.5% of cases with oral pyogenic granuloma being most frequent

[15]lesion, accounting for 52.71% cases .

There is consensus among many reviewers that pyogenic granuloma is reactional lesion formed in response to minor trauma or chronic irritation with reports of occurrences after low intensity

[1],[2],[7],[11],[12], [13]traumatic injuries. Gingival irritation as a result of calculus, overhanging edges or rough restorations might be the predisposing factor for the development of gingival pyogenic granuloma. It is possible that micro ulceration from these irritants in an already inflamed gingiva allows the ingress into the gingival connective tissue of low virulent oral microflora. This evokes an exaggerated vascular hyperplastic response in the connective tissue resulting in the formation of

[16]pyogenic granuloma . The other etiological factors considered are use of immunosuppressant drugs as reported by

Fig 1: Intraoral view showing facial extension of pyogenic granuloma.

Fig 2: Occlusal view of pyogenic granuloma showing facial and ligual extensions.

Fig 3: Postoperative intraoral facial view.

Fig 4: Postoperative occlusal view.

Fig 5: Histological photomicrograph showing stratified squmaous epithelium with pseudoepitheliomatous

hyperplastic connective tissue.

Fig 6: Histological photomicrograph showing Neovascularization.

[17] [18]Bachymer et al and Lee et al in patients of graft versus host disease who were under cyclosporine. Development of Pyogenic granuloma as result of using Dried Freezed Demineralized Bone Graft and Extended Polytetraflouroethylene in regenerative periodontal surgical

[19]procedure was reported. Kuo yuon et al have reported that imbalance between angiogenesis enhancers like Vascular endothelial growth factor, Basic f i b r o p l a s t g r o w t h f a c t o r a n d angiogenesis inhibitors like Angiostatin

[20]may play a role.

Although pyogenic granuloma may [21]occur in all ages, It is predominant in

the second decade of life in young adult females, possibly because of the vascular

[9], [10]effects of female hormones Studies [1] [22]done in Jordanian and Singaporian

population is in agreement with this. Some authors believe that patients are mostly males less than 18 years of age, females in the age range 18 to 39, and older patients with an equal gender

[23]distribution. In contrast to this, recent study by Epivationos et al reported that average age of the patient was 52 years with a peak incidence of occurrence in 6th decade of life and predominantly in

[24]women (1: 1.5). With regard to site, gingival pyogenic granuloma is more common in the maxilla than in the mandible and in the anterior region than

[18],[25]in the posterior regions of both jaws. Also, these lesions are more common on facial aspect than lingual, some extend between the teeth and involve both facial and lingual surfaces similar to the presented case. According to Villman et

[26]al majority of pyogenic granuloma occur on marginal gingiva with only 15% accounting for alveolar part. In this case, lesion involved the alveolar part. Clinically, pyogenic granuloma is a smooth or lobulated exophytic lesion manifesting as small, red erythematous papule on a pedunculated or sometimes with sessile base, which is usually hemorrhagic and compressible. The size varies in diameter from a few millimeters

[9], [10]to several centimeters . Rarely does PG exceed 2.5 cm in size and it usually reaches its full size within weeks or months , remaining indef in i te ly

[27]thereafter . Clinical development of the lesion is slow, asymptomatic and

[9], [10]painless, but it may also grow [14]rapidly, as reported in the present case.

The surface is characteristically


[28]ulcerated and friable which may be covered by a yellow, fibrinous

[17]membrane and its color ranges from pink to red to purple, depending on the age of the lesion. Young pyogenic granulomas are highly vascular in

[9]appearance because they are composed p redominan t ly o f hype rp la s t i c granulation tissue in which capillaries are prominent. Thus minor trauma to the lesion may cause considerable bleeding,

[9], [17]due to its pronounced vascularity , whereas older lesions tend to become

[9]more collagenized and pink . Rarely, PG may cause significant bone loss, as reported by Goodman-Topper and

[29]Bimstein . In the presented case, there was a slight bone loss and the initial mobility of central incisors came back to normal after surgery.

Under histopathological examination pyogenic granuloma shows increased vascularity with increased endothelial cell proliferation resembling granulation

[30]tissue and chronic inflammatory infiltrate dominated by plasma cells,

[31]lymphocytes and neutrophils . Bhaskar [32]SN, Jacoway JR observed in their study

that pyogenic granuloma is partly or completely covered by parakeratotic or non keratinized stratified squmaous epithelium. Major bulk of the lesion is formed by a non lobulated mass of angiomatous tissue. Usually lobulated lesions are composed of solid endothelial proliferation or proliferation of capillary sized blood vessels. Collagen in the connective tissue is sparse. The natural history of the lesion follows three distinct phases. In cellular phase, the lobules are compact and cellular with little lumen formation. In the capillary phase the lobules become highly vascular with abundant intraluminal red blood cells. In the involutionary phase there is tendency for intra and perilobular fibrosis with

[27]increased venular differentiation .

Pyogenic granuloma is a benign lesion; therefore, surgical excision is the treatment of choice although it may leave some visible scar. Although conservative surgical excision and removal of causative irritants (plaque, calculus, foreign materials, and source of trauma)

[9], [10], [33]are the usual treatments for gingival lesions, the excision should extend down to the periosteum and the adjacent teeth should be thoroughly scaled to remove the source of continuing

[9]irritation . Recently conservative surgical approaches to conventional surgery have been proposed, they include

[34] [35]NdYag laser , Co2 laser , Flashlamp [36] [37]pulsed dye laser and Cryosurgery .

These conservative treatments are usually adequate; however they can often result in visible scarring. Alternatively

[38]injections of absolute alcholol and s o d i u m t e t r a d e c y l s u l p h a t e

[39]sclerotherapy are simple and effective in treating pyogenic granuloma without scarring but require multiple sessions. Series of intralesional injections of corticosteroids are effective for highly

[40]recurrent cases of pyogenic granuloma . In the current case no recurrence was observed on follow up for 6 months.

Conclusion:The current case was unusual in the sense it was occurring in a pediatric patient. There was rapid growth of the lesion involving both facial and lingual surfaces covering the entire central incisors and extending up to alveolar mucosa. There are few case reports in the literature with above findings. We were not able to elucidate history of trauma as patient was pediatric and parents were not able to recollect the history of trauma.

References:1. Al-Khateeb T, Ababneh K. Oral

pyogenic granuloma in Jordanians: a retrospective analysis of 108 cases. J Oral Maxillofac Surg. 2003; 61:1285-1288.

2. Graham RM. Pyogenic granuloma: an unusual presentation. Dent Update. 1996; 23:240-241.

3. Hullihen SP (1844). Case of aneurism by anastomosis of the superior maxilla. AM J Dent Sc 4, 160 - 162.

4. Sanjay Venugopal et al. Pyogenic granuloma a case report. J Dent Sc & Res 1; 1: 80 - 85.

5. Hartzell MB (1904) Granuloma pyogenicum. J Cutan Dis Syph 22, 520-525.

6. Hamid Jafarzadeh. Oral pyogenic granuloma: A review. J Oral science 2006 ;48(4):167-175.

7. Neville BW, Damm DD, Allen CM. Patologia e oral maxillofacial. Rio D Janiero. Guanabara, Koogan, 1998.

8. Ange lopou lus AP. Pyogen ic granuloma of oral cavity: Statistical analysis of its clinical features. J. Oral Surgery 1971; 29: 840-845.

9. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral & maxillofacial

pathology. 2nd ed, Philadelphia: WB Saunders; 2002. p. 437-495.

10. Regezi JA, Sciubba JJ, Jordan RCK. Oral pathology: clinical pathologic considerations. 4th ed, Philadelphia: WB Saunders; 2003. p. 115-116.

11. Lin RL, Janniger CK. Pyogenic granuloma. Cutis. 2004;74:229 - 233.

12. Damm DD, Fantasia JE. Elevated and ulcerated nodule of lip. Pyogenic granuloma. Gen Dent. 2002;50:466-468.

13. Regezi JA, Sciuba JJ. Oral pathology, clinical pathological correlations. Philadelphia: Saunders; 1989.

14. Esmeili T, Lozada-Nur F, Epstein J. Common benign oral soft tissue masses. Dent Clin North Am. 2005 ; 49: 223-240.

15. Shamim T, Varghese VI, Shameena PM, Sudha S. A retrospective analysis of gingival biopsied lesions in south Indian population:2001-2006. Med O r a l P a t h o l O r a l C i r Bucal.2008;13(7): 414-418.

16. Bragado R, Bello E, Requena L, Renedo G, Texeiro E, Alvarez MV, Castilla MA, Caramelo C. Increased expression of vascular endothelial g r o w t h f a c t o r i n p y o g e n i c granulomas. Acta Derm Venereol 1999;79: 422-5.

17. Bachymeyer C, Devergie A, Mansour is Set a l . Pyogenic granuloma of the tongue in chronic graft vs host disease. Ann Dermatol venerol 1996; 123: 552 - 554(in french).

18. Lee L et al. Intraoral pyogenic granuloma after allogenic bone marrow transplant, report of three cases. Oral surg, Oral med, Oral pathol 1994; 78: 607 - 610.

19. Fowler FB et al. Pyogenic granuloma associated with GTR: A case report. J Periodontol 1996; 67: 1011 - 1015.

20. Kuo Yuon, Ying - Tai Jin, Ming T. lin The detection and comparison of angiogenesis - associated factors in P y o g e n i c g r a n u l o m a b y i m m u n o h i s t o c h e m i s t r y . J Periodontol 2000; 71: 701 - 709.

21. Lawoyin JO, Arotiba JT, Dosumic OO. Oral pyogenic granuloma: A review of 38 cases from Jhadan,


Nigeria. Br J Oral Maxillofac Surg 1997; 35:185-189.

22. Zan RB, Khoo SP, Yeo JF (1995) Oral Pyogenic granuloma (excluding pregnancy tumor) - a clinical analysis of 304 cases. Singapore Dent J 20, 8 - 10.

23. Pilch BZ. Head and neck surgical pathology. Lippincot Williams & Wilkins, Philadelphia 2001; 389 - 390.

24. Epivat ianos e t a l . Pyogenic granuloma of the oral cavity: C o m p a r i t i v e s t u d y o f i t s c l i n i c o p a t h o l o g i c a l a n d immunohistochemical features. Pathol int 55, 2005 : 391 - 397.

25. Bragado R, Bello E, Requena L, Renedo G, Texeiro E, Alvarez MV, Castilla MA, Caramelo C. Increased expression of vascular endothelial g r o w t h f a c t o r i n p y o g e n i c granulomas. Acta Derm Venereol 1999;79: 422- 425.

26. Vilmann A, Vilmann P, Vilmann H. pyogenic granuloma: evaluation of oral conditions. Br J Oral Maxillofac Surgery 1986; 24: 376 - 382.

27. Sternberg SS, Antonioli DA, Carter D, Mills SE Oberman H. Diagnostic s u rg i c a l p a t h o l o g y 3 r d E d Philadelphia: Lippincott Williams & Wilkins; 1999.p. 69, 174.

28. Greenberg MS, Glick M. Burkett's oral medicine: diagnosis and treatment. 10th ed, Hamilton: BC Decker; 2003. p. 141-142.

29. Goodman-Topper ED, Bimstein E. Pyogenic granuloma as a cause of bone loss in a twelve-yearold child: report of case. ASDC J Dent Child 1994;61:65-67.

30. Kerr DA. Granuloma pyogenicum. Oral surg Oral med Oral Pathol 1951; 4:158-176.

31. Eduardo Sanches Et al. Pyogenic granuloma on the upper lip: An unusual location. J App Oral Sci 2010; 18(5) 538 - 541.

32. Bhaskar SN, Jecoway JR. Pyogenic granuloma c l in ica l fea tures , incidence, histology and result of treatment. Report of 242 cases. J Oral surgery 1966; 24: 391-398.

33. Eversole LR. Clinical outline of oral

pathology: diagnosis and treatment. 3rd ed, Hamilton: BC Decker; 2002 p. 113-114.

34. Powell JL, Bailey CL, Coopland AT et al. Nd Yag laser excision of a giant gingival pyogenic granuloma of pregnancy. Lasers surg Med 1994; 14 : 178 - 183.

35. White JM, Chaudhary SI, Kudler et al. Nd Yag and Co2 laser therapy of oral mucosal lesions. J Clin Laser Med Surg 1998; 16: 299 - 304.

36. Meffert JJ, Cagna DR, Meffert RM. Treatment Of oral granulation tissue with Flashlamp pulsed dye laser. Dermatol Surg 1998; 845 - 848.

37. Ishida CE & Ramos C Silva. Cryosurgery in oral lesions. Int J Dermatol 1998; 37: 283 - 285.

38. I c h i m i y a M , Yo s h i k a w a Y, Hamamoto Y et al. Successful treatment of pyogenic granuloma with injection of absolute ethanol. J dermatol 2004; 31: 342 - 344.

39. Moon SE, Hwang EJ, Cho KH. Treatment of pyogenic granuloma by s o d i u m t e t r a d e c y l s u l p h a t e sclerotherapy. Arch dermatol 2005; 141: 644 - 646.

40. Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with corticosteroids. Oral Dis 2006; 12: 70 - 72.



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Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Amanish Singh Shinh2 Harjupinder Kaur Shinh3 Junaid Ahmad Shaik4 Guneet Guram5 Pritesh Singla

the disease.

T h e f o l l o w i n g c l i n i c a l o r a l manifestations sometimes give first indications of the disease.Ÿ Xerostomia (Dry Mouth)Ÿ Acetone BreathŸ Oral CandidiasisŸ Burning Mouth (Glossopyrosis)Ÿ Impaired wound healing.Ÿ Recurrent Oral Infections

Any patient suspected of having such symptoms should be sent for medical evaluation. Technically speaking , d e c r e a s e d P o l y m o r p h o n u c l e a r Leucocyte function, abnormal collagen metabolism and prolonged healing time, all possibly contributes to the oral complications.

The Polymorphonuclear Leucocytes (Neutrophils) show impaired chemotaxis and macrophagic function i.e. do not bind to the bacterial byproducts and plasma proteins and hence lead to the impaired healing.

The impaired use of glucose leads to the increased collagen breakdown in

IntroductionDiabetes mellitus is characterized by increased levels of blood sugar levels. Hyperglycemia causes delayed healing as a side effect. Orthodontic treatment involves tooth movement which is brought about by the iatrogenic

forces applied by orthodontists and an inflammatory reaction in response to these forces .The diabetic patient might not experience a physiologic healing process as a normal patient and might end up in an inadvertent break down of the supporting dental apparatus i.e. the periodontal ligament. DM is diagnosed based on the blood glucose concentration of or Glycosylated hemoglobin concentration.

Oral ManifestationsRoutine medical checkups not being a part of the Indian health system, more than half of the patients of DM actually go undiagnosed. Knowledge of the oral manifestations many a times leads to the discovery of diabetes in dental offices .The dental practitioner therefore should be aware of the oral manifestations of DM in order to spot initial symptoms of


1 Professor and Head Department Of Orthodontics Adesh Institute Of Dental Sciences, Bathinda.2 Private Practioner. Bathinda, Punjab3,4,5 Reader Department Of Orthodontics Adesh Institute Of Dental Sciences, Bathinda.

Diabetes Mellitus and Orthodontic Treatment:

A review

Address For Correspondence:Dr. Amanish Singh ShinhProfessor and Head, Department of OrthodonticsAdesh Institute of dental sciences, Bathinda 151001.E mail id [email protected]


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connective tissues, in addition altered protein metabolism might add to the

[2]impaired healing response in diabetics.

The caries and periodontal disease succeptibility increase in diabetics. Decreased salivary flow causes failure of self cleansing mechanism further

[3]increasing the caries succeptibility . Elevated salivary glucose levels results in increased bacterial substrate and hence increased exposure to bacteria.

Studies have shown that gingivitis is more severe in children with diabetes, and becomes even more severe with

[4], [5], [6], increasing blood glucose levels ref [7].

Even well controlled DM patients have more gingival inflammation, probably because of impaired neutrophil function. Periodontal disease tends to be more common due to vascular changes in DM

[8]related microangiopathies .

AbstractHospitals in India remark that they do not observe juvenile diabetes in their hospitals and clinics, leading to gross underestimation of the magnitude of the problem. Hospital records and/or clinic data over the last 3 decades indicate that young diabetics (diabetes onset before 15 years) constitute 1-5% of the total diabetic subjects enrolled. Providing orthodontic care for chronic childhood disease like diabetes is a major economic and psychological burden on the family members.DM is of two types, Type 1 or Insulin Dependent Diabetes, which accounts for the majority of childhood onset diabetes mellitus (onset before 20 years of age) is caused due to total deficiency in insulin secretion. Type 2 DM is caused due to a combination of resistance to insulin action and inadequate compensatory insulin secretion.The most common effect of diabetes mellitus is delayed healing and an increased tendency for periodontal disease. Since orthodontic treatment involves inflammatory histo -pathologic changes around the tooth .There might arise an untoward reaction even to the normal orthodontic forces in diabetics. The orthodontist must be aware of the implications of this chronic metabolic disorder. This review aims at understanding the consequences of disease in relation to orthodontic treatment.

Key WordsDiabetes Mellitus, Orthodontic treatment.type_I,type II diabetes Insulin related metabolic disorders, Glycosylated hemoglobin, Periodontal breakdown.


[12] the researchers found that certain diabetic changes in periodontium are more pronounced after orthodontic tooth movement.

Mechanical devices like tooth brush, interdentally brushes should be used ,but if are not enough then chlorehexidine mouth rinses can be used as an adjunct .however there should be an interval of at least 30 minutes between tooth brushing

[13], [14]and chlorehexidine rinse to minimize the neutralizing effect of the

[15], [16]tooth paste on the chlorehexidine molecule Chlorehexidine is cationic in form and tends to form salts with anions such as sodium lauryl sulphate widely used as a detergent in tooth pastes.

Type 2 DM patients can be considered more stable however type 1 are sensitive and should be handled with utmost care . T h e y a l s o e x p e r i e n c e m o r e hypoglycemic episodes .Most of the type 1 patients are young adults, morning appointments are preferable, if a long appointment ie lasting for more than an hour is required, patient should be advised to eat a usual meal and take the medication as usual.

To avoid any hypoglycemic episode in the office the dental staff should make sure that all the recommendations are met.

ConclusionsTo look good is every one's fundamental right. In today's world every child has the right to look the best and undergo any treatment to get there. General diseases should not be a handicap to achieve the optimum of beauty. When diabetes mellitus is a part of the patient's history, the orthodontic practitioner should have the basic knowledge and understanding of this disease and its impact on the oral cavity, and should understand the consequences of DM in relation to the orthodontic treatment.

Type 1 DM especially uncontrolled can have deleterious effects on the treatment outcome. Hyperglycemia may cause complications in treatment in form of delayed healing, increased periodontal breakdown, odontolgia, Non vital teeth, gingivitis etc. Hypoglycemic reaction on the other hand can be a life threatening emergency.

Patient's medical history is very crucial in

clinical examination and patients suspected of having DM should be referred for the medical evaluation.

Wel l con t ro l l ed DM i s no t a contraindication for orthodontic treatment.

In type 1 DM patients who are considered to be more brittle, oral cavity should be monitored regularly. And look for Candida infections, gingivitis, and periodontal breakdown. If type 1 DM patient suffers from a hypoglycemic reaction it should be assumed that diabetic state is not in well control.

If during orthodontic treatment signs of deterioration of glycemic control are noticed , the orthodontist should be advised to consult his/her physician.

References1. P.S.N. Menon, A. Virmani, P. Shah M.

Joshi, R. Raju, S. Setia, A. Sethi, N. K o c h u p i l l a i , M . M . S . A h u j a .Childhood onset diabetes mellitus in north India ,clinical trial and immunological studies. Department of Pediatrics and Endocrinology-Diabetes, Al1 India Institute of Medical Sciences, New Delhi-110029, India.

2. Saodoun A .Diabetes and periodontal disease. A review and update. J west soc Periodontol Periodontol Abstr 1980 ; 28:116-39.

3. Rothwell B, Richard E .Diabetes Mellitus: Medical and dental considerations .Spec Care Dent 1984; 4:58-65.

4. Gislen G, Nilsson KO, Matsson L, Gingival inflammation in diabetic children related to degree of metabolic control. Acta Odontol Scand 1980:38:241-6.

5. Ringelberg ML ,Dixon DO, Fancis AO, Plummer RW.Comparison of gingival health and gingival crevicular fluid flow in children with and without diabetes.J Dent Res 1977;56:108-11.

6. Gusberti FA , Seyd SA, Bacon G, Grossman N, Loesche W Puberty gingivitis in insulin- dependent diabetic children.I cross-sectional observations.J periodontal.

7. Katz PP, Wirthlin MR Jr, Szpunar SM,Selby JV, Sepe SJ.Showstack JA, Epidemiology and prevention of periodontal disease in individuals with diabetes. Diabetes care 1991;

Rylander et al reported that significantly more gingival inflammation in young DM patients with retinopathy compared

[9]with those without complications . .

Orthodontic Considerations1. First and of the foremost importance

to successfully treat a diabetic patient orthodontically is to have a good medical control. Patients with uncontrolled diabetes should not be considered for the treatment. If the patient is not in good metabolic control (HbA 1c>90%) every effort should be made to improve blood glucose levels before starting the treatment.

2. In patients with good medical control, all orthodontic/dental procedures can be performed without special precautions specially if there are no complications of DM.

3. Both removable or fixed appliances can be used.

4. When fixed appliances are used it is important to stress on good oral hygiene.

5. Prophylaxis should be performed regularly to avoid accumulation of deposits and avoid decay and periodontal disease progression.

6. Fluoride/chlorehexidine mouth rinse can provide further preventive benefits.

7. Diabetes related microangiopathy can occasionally occur in periapical vascular supply, resulting in unexplained dental pain, percussion sensitivity, pulpitis, or even loss of

[10], [11]vitality in sound teeth .The vitality of the teeth should be regularly checked .Use of optimum orthodontic forces to move the teeth remains the golden rule.

8. All adult diabetic patients should go for a complete periodontal diagnostic checkup including probing, plaque and gingivitis scores, and the evaluation for the periodontal treatment need. Any periodontal disease must be brought in control before instituting orthodontic treatment. It is recommended that all patients of diabetes controlled or uncontrolled should be marked as periodontal patients in orthodontic treatment plan. And considerations should be accordingly made .Retarded osseous regeneration, weakening of the periodontal ligament and microangiopathies in the gingival area have been reported


12. Holtgrave EA, Donath K. Periodontal reactions to orthodontic forces in the diabetic metabolic state. Fortschr Kieferorthop 1989; 50:326-37.

13. Barkvoll P, Rolla G, Svendsen AK. Interaction between chlorehexidine digluconate and sodium lauryl sulfate in vivo. J Clin Periodontol 1989:16; 593-5.

14. Owens J, Addy M, Faulkner J, Lockwood C, Adair R.A short term clinical study design to investigate the chemical plaque inhibitory properties of mouthrinses when used as adjuncts to tooth pastes: applied to chlorehexidine .

15. Anderson G, Bowden J. Morrisson

E,Caffesse R.Clinical effects of chlorehexidine mouthwashes on patients undergoing orthodontic treatment.Am J Orthod Dentofacial Orthop 1997;111:606-12.

16. Gehlen I, Netuschi L Berg R, Reich E, Katsaros C. The influence of a 0.2% Chlorehexidine mouth rinse on plaque re-growth in orthodontic patients randomized prospective study .Part I: clinical parameters' Orofac Orthop 2006; 61:54-62.


14:375-85.8. Tervonen T, Oliver RC. Long term

control of diabetes mellitus and periodontitis.J Clin periodontal 1993; 20;431-5.

9. Rylander H, Ramberg P,Blohme G, Lindhe J.prevelence of periodontal diseases in young diabetics.J Clin Periodontol 1987;14:38-43.

10. Firkin D Fergusen .Diabetes Mellitus and the dental patient.NZ Dent J 1985; 81:7-11

11. Geza T, Rose L. Dental correlations for diabetes mellitus. In Rose LF Kaye D, Editors, Internal medicine for dentistry. 2nded St Louis: C.V.Mosby; 1990.p.1153.


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Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Rika Singh2 Shrikar R. Desai

gram negative facultative anaerobes present on a biofilm on tooth surface. The periodontal diseases range from the relatively benign form of gingivitis to aggressive periodontitis. Many of these conditions are not only a threat to the dentition, but may also be a threat to general health. There are reports suggesting increased prevalence of diabetes, atherosclerosis, myocardial infarction, and stroke in patients with

[3], [4], [5]periodontal disease. Thus, the likelihood of periodontal disease being associated with systemic diseases is becoming established fact.In addition, a number of other chronic conditions of altered connective tissue metabolism, hormone imbalances and altered immune function have like-wise been associated with increased risk of

[ 6 ]periodontal disease. Of these, rheumatoid arthritis is of particular interest since it is a chronic inflammatory disease which demonstrates remarkably similar pattern of soft and hard tissue destruction to that noted in chronic

[7]periodontitis. Although the etiologies of these diseases are distinctly separate, the underlying pathological process has sufficient similarity and warrant consideration of the hypothesis that individuals at risk of developing rheumatoid arthritis may also be at risk of developing periodontitis and vice - versa.

Materials And MethodsA medline and manual search was conducted to identify studies concerned

IntroductionOver the past 10 years, several studies have been published pointing towards an association between periodontal diseases and various systemic disorders or diseases. Of these the possible associations between rheumatoid arthritis and periodontitis have been discussed. To date only few studies have examined the extent of association between Rheumatoid arthritis and periodontal disease and results have been conflicting. There is a unidentified disablement or dysregulation of common pathologic mechanisms operating in these two chronic inflammatory diseases.Rheumatoid arthritis is a chronic multisystem disease of unknown cause. Although there are a variety of systemic manifestations, the characteristic feature of rheumatoid arthritis is persistent inf lammatory synovi t is usual ly involving peripheral joints in a

[1]symmetric distribution.Rheumatoid arthritis was first described clinically in an 1800 doctoral thesis by Landre - Beaurais, a French medical student who called it the "Primary aesthetic Gout." Later in 1859 Sir Alfred Garred established the distinction between rheumatoid arthritis and gout and he called the condition as rheumatoid

[2]arthritis.P e r i o d o n t a l d i s e a s e i s a n a l l encompassing term relating to the destructive inflammatory disorders of the hard and soft tissues surrounding teeth. It is associated with bacteria predominantly


1 Post Graduate Student2 Professor & Guide Department of Periodontology, H.K.E. Society‘s S. Nijalingappa Institute of Dental Sciences and Research, Gulbarga

Rheumatoid Arthritis And Periodontitis

Address For Correspondence:Dr. Rika Singh, Post Graduate Student,H.K.E. Society‘s S. Nijalingappa Institute of DentalSciences and Research, Gulbarga, Karnataka, India


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with etiopathogenesis of rheumatoid a r t h r i t i s , p e r i o d o n t i t i s o r interrelationships between the two. The following search terms were used: 'rheumatoid arthritis', 'periodontitis' and 'rheumatoid arthritis and periodontitis' In addition, a manual search of the following journals was performed: Journal of American dental association, Arthritis and rheumatism, Journal of associations of physicians of India, Journal of rheumatology, British journal of rheumatology, Australian dental j o u r n a l , A m e r i c a n s o c i e t y o f microbiology, Community Dentistry and Oral Epidemiology, Journal of clinical immunology. A further manual search w a s c o n d u c t e d t h r o u g h t h e bibliographies of all relevant papers and review articles.

Possible Associations Between R h e u m a t o i d A r t h r i t i s A n d PeriodontitisDisease ProgressionThree distinct subpopulations in periodontal disease progression can be seen: 1) no progression of periodontal disease, in which around 10% of the population manifest very little or no disease which is of no particular consequence to the dentition; 2) moderate progression, affecting around 80% of the population and representing a

AbstractThe relationship between periodontitis and other chronic inflammatory destructive diseases such as rheumatoid arthritis has been discussed since long. Inspite of having different etiologies, similar mechanisms of tissue destructions have been seen in both.Purpose- The purpose of this study was to evaluate the possible interrelationship between rheumatoid arthritis and periodontitis on the basis of information available for the same.Materials and Methods- A medline and manual search was conducted to identify studies concerned with etiopathogenesis of rheumatoid arthritis, periodontitis or interrelationships between the two.Results- The studies shows that two diseases could be very closely related through common underlying dysfunction of fundamental inflammatory mechanisms. A common nucleus of activity in their pathogeneses provides novel paradigms of therapeutic targeting forreciprocal benefit.Key WordsRheumatoid arthritis, periodontitis, inflammation, therapy.

very slowly progressing form of disease that generally can be easily managed via routine therapies; and 3) rapid progression, affecting approximately 8% of individuals whereby extensive periodontal destruction occurs which can

[8]be very difficult to control.Similarly atleast three types of disease manifestation can be observed in RA populations: 1) self-limited: in these cases individuals originally presenting for RA have no evidence of disease 3 to 5

[9]years later; 2) easily controlled: the disease is relatively easily controlled w i t h o n l y N o n s t e r o i d a l a n t i -

[10]inflammatory drugs (NSAIDs); 3) progressive: these patients generally require second-line drugs, which often

[10], [11]still do not fully control the disease.

Can Bacteria Be A Common Etiologic Link Between Periodontitis And Rheumatoid Arthritis?There are a number of shared features between microorganisms that can induce RA in a genetically susceptible host and the recognized periodontal pathogens. Nonetheless, RA is still not largely recognized as a disease resulting solely from bacterial challenge. On the other hand, technological and conceptual a d v a n c e s h a v e p e r m i t t e d t h e identification of bacteria or groups of bacteria associated with specific

[12]periodontal diseases. Close inspection of the virulence factors of periodontal pathogens would suggest that such a response could be feasible. Thus, the possibility that ongoing periodontitis could trigger RA in genetically susceptible individuals is plausible. Notwithstanding the above, these concepts remain speculative until the causative agent for RA can be definitively identified. It is important to recognize that, based on current information, it cannot be proposed that periodontal pathogens cause, or are associated with, RA. The main focus of attention is directed not towards causality but rather associations between two chronic inflammatory conditions that may have common under ly ing pathogenic mechanisms.

Clinical Features Of Rheumatoid Arthritis And PeriodontitisPain, swelling and deformity of joints are the prominent features of RA. The most common joints affected include the joints of the hands, wrist and feet. Other organ systems can also be affected as a result of


microvessel vasculitis leading to the formation of nodules, pleural effusions, pulmonary fibrosis, cardiac disease and

[13]ocular disease. As a response to inflammation, muscles and tendons around an inflamed joint may shorten and undergo spasms. In the severe stages of the disease, synovitis and pannus denude the surface of cartilage and erode juxta-articular bone, creating incompatible articular surfaces. With the complete disappearance of cartilage, the opposing bone sur faces may fuse when

[14]immobilized.The periodontal tissues in health exist in steady-state equilibrium of tissue degradation and repair. With constant mechanical and chemical assaults, the periodontium for the most part manages to maintain its structural and functional integrity. However, if the balance between host response and bacterial virulence is disturbed, disease and consequent tissue destruction will

[15]occur. With developing inflammation; there is a marked accumulation of lymphocytes and monocytes within the connective tissue resulting in tissue swelling and matrix degradation.In contrast to RA, the development of periodontitis is not associated with pain. The clinical consequences of periodontal tissue destruction are gingival bleeding on probing, increased pocket probing depth due to apical migration of the junctional epithelium, periodontal bone loss and increased tooth mobility and ultimately, tooth loss if, disease activity

[16]continues.

ImmunogeneticsIn humans, many of the genes that regulate monocytic cytokine responses have been mapped to the HLA-DR region of chromosome 5 in the area of the TNF-β

[17],[18]genes. Both RA and progressive periodontitis are found to be associated

[19],[20]with this HLA complex , which suggests a genetic basis for the observed monocyte trait, linking RA, progressive periodontitis and other systemic diseases. It is reasonable to suggest that the inter-individual differences in the severity of RA and periodontal disease are partly due to intrinsic differences in the monocyte/T cell response traits. In both diseases, antigenic challenge (e.g. LPS) to the monocytic/lymphocytic axis would result in the secretion of catabolic cytokines and inflammatory mediators, of which PGE2, IL-1, TNF-a and IL-6 would appear to dominate

Mechanisms Of Tissue DestructionIn both RA and periodontitis, tissue destruction is not unidirectional, but an iterative process that is constantly being adjusted by the host response to inciting agents. The destruction of extracellular matrix in both diseases is determined by the balance of MMPs and their inhibitors. Bone destruction in periodontitis and RA is a result of the uncoupling of the normally coupled processes of bone resorption and bone formation, with PGE2, IL-1, and TNF-α, IL-6 as mediators of bone destruction. It is evident in both diseases that the host's immune response is controlled by genes that regulate differences in the monocyte/T cell response traits to different antigens that determine both the nature of the protective antibody response and the magnitude of tissue-destructive inflammatory response.

Osteoclast Activation and Vascular DamageMost recently, studies have begun to investigate the co distribution of cytokines involved in vascular damage and bone resorption in biopsies from graded rheumatoid arthritis and periodontitis lesions. Since the tumor necrosis factor (TNF)-like molecules and their receptors have been shown to be involved in both processes, studies are based on receptor activator of nFkappa B ligand (RANKL), osteopretogerin (OPG), and TNF-related apoptosis inducing ligand (TRAIL) to determine at least one molecular mechanism common to both conditions.The cell surface TNF-like molecule, RANKL and its receptor, RANK have been shown to be key factors regulating

[21],[22]osteoclast formation and activation. It has been shown that when RANKL binds to RANK on the surface of osteoclast precursors, these cells differentiate to form mature osteoclasts. It is now clear that RANKL, together with macrophage-colony stimulating factor (M-CSF), is required for osteoclast formation. The soluble TNF ''receptor-like'' molecule, OPG, is a natural

[23]inhibitor of RANKL. OPG binds to RANKL and prevents its ligation to RANK. The importance of these molecules in regulating bone metabolism has been demonstrated by transgenic and

[24]gene knock-out studies in mice. Since these factors control physiologic osteoclast formation, it is reasonable to

propose that they may also be key regulators of pathological bone

[25],[26]resorption. Although RANKL is normally provided by osteoblast-like

[26],[27]cells in bone, there are reports suggesting that lymphocytes present in rheumatoid tissues may be the main source of RANKL in inflammatory

[28]arthritis. Furthermore, CD3+ T cells from the human rheumatoid joint express RANKL and can promote osteoclasts formation from rodent spleen precursors. In addition to lymphocyte production of RANKL, inhibition of RANKL by OPG treatment in vivo reduces both bone and cartilage destruction in a model of

[29]adjuvant arthritis.Under certain conditions, human osteoclasts are derived from osteoclast precursor cells present in or near to the

[30],[31]tissues of arthritic joints. More [32],[33]recent reports in humans and

[29]animals show that RANK/RANKL interactions may be required for osteoclasts formation and bone resorption in the RA joint. Accordingly, it has been recently demonstrated that OPG and RANKL are expressed in biopsies of inflamed rheumatoid synovium and

[34]periodontitis lesions. In addition, it has been found that another ligand for OPG, TRAIL, is expressed in the both types of tissue (although not from the same patient). In these studies, it is noted that OPG decreases with inflammation, RANKL increases with inflammation, and TRAIL increases with inflammation. These findings may be of considerable significance in light of OPG's ability to block the activity of TRAIL (and vice versa) and TRAIL's anti-inflammatory

[35]properties.The production of OPG by endothelial cells may be significant for reasons other than its effects on bone metabolism, and there is now evidence to suggest that OPG might also regulate endothelial cell function. OPG has been reported to be required for endothelial cell survival and

[36]growth. In addition, OPG knock-out mice have been shown to develop arterial

[37],[38]calcification as well as severe osteoporosis, suggesting that vascular endothelial expression of OPG may have

[29]a role in vascular homeostasis. One of the most unexpected findings from recent studies of diseased periodontal and synovial tissues was the observation that endothelial cells produce large amounts of OPG. In response to proinflammatory cytokines TNF-α and IL-1β, OPG mRNA


expression was dramatically enhanced, resulting in secretion of newly synthesized OPG and a reduction in cell-associated OPG. Vascular damage due to apoptosis is thought to precede vascular

[39 ]calcification and contribute to [40]atherosclerosis. In addition; diabetic

endothelial cell dysfunction is associated with DNA damage induced by poly (ADPribose) polymerase activation. The exact cause of endothelial cell dysfunction is not known but it is possible that molecules such as TRAIL, expressed in nearby cells and tissues,

[26],[41]may be important. Studies confirm that OPG binds to TRAIL, although with less affinity than RANKL, in vitro, and blocks its activity. The final piece of compelling evidence for the role of OPG in vascular damage comes from the fact that OPG knock-out mice develop vascular calcification. It is significant to note that calcification cannot be reversed by systemic treatment with recombinant

[38]OPG postpartum. This supports the concept that OPG must be expressed within the endothelial cells, either in an appropriate form or associated with other molecules, and this only occurs following normal synthesis within the healthy endothelial cells.In light of the above, it can be proposed that at least one underlying common molecular pathway in common between rheumatoid arthritis and periodontitis may lie within the RANK/OPG/TRAIL axis whereby OPG decreases leading to decreased vascular protection. In addition, with an increase in RANKL and TRAIL within the tissues, not only is vascular damage possible, but significant activation of osteoclasts may result.

The Dual Purpose Therapies Based On Possible Links Between Ra And PeriodontitisTetracyclines And Its AnaloguesThe tetracyclines are a group of broad-spectrum antimicrobial agents. They are active against a number of gram-positive and gram-negative bacteria. In the 1980s, periodontal research revealed that tetracyclines also inhibited collagenase activity. Collagenases are a large family o f e n z y m e s t h a t b r e a k d o w n macromolecules in the connective tissue; they include matrix metalloproteinases (MMPs). Tetracyclines reduce the activity of MMPs by depriving them of divalent cations, which are cofactors necessary for their activity. They chelate these ions thereby reducing their protein

[42]degrading activity. This action of tetracyclines is observed at sub

[43]antimicrobial doses. Enhanced activity of the MMP has been demonstrated in synovial fluid and synovial fibroblasts of patients with rheumatoid arthritis and is partly responsible for joint destruction in

[44]these patients. Tetracyclines by virtue of their anti-MMP activity are useful in patients with rheumatoid arthritis. Several clinical trials have shown that minocycline administration in patients with rheumatoid arthritis was associated with significant reduction in disease

[45]activity.Soft and hard tissue destruction in periodontitis is partly due to bacterial virulence factors/enzymes and partly due

[46]to MMPs. Tetracyclines and their analogues have been shown to be useful in the treatment of patients with rapidly p r o g r e s s i v e a n d r e f r a c t o r y

[47]periodontitis. They act both by suppressing the growth of putative m i c r o o rg a n i s m s i m p l i c a t e d i n periodontitis and by decreasing the destruction of collagen in gingival, periodontal ligament and alveolar bone

[46]by inhibiting MMPs in these patients.

Nonsteroidal anti-inflammatory drugs (NSAIDs)The principal mechanism by which NSAIDs act is by inhibition of cycloxygenase-the enzyme responsible for the biosynthesis of prostaglandins. Studies have shown that periodontally d i s e a s e d t i s s u e s h a v e h i g h e r prostaglandin levels, especially prostaglandin E2, than in healthy

[48]tissue. In vivo studies have also shown that bone resorption in periodontitis is mediated in part by prostaglandins, showing that these may be important

[49]mediators of periodontal disease. If prostaglandins are important mediators of bone resorption in periodontitis, the use of NSAIDs should be effective in preventing inflammation-induced bone loss. Both animal and human studies have demonstrated that inhibiting prostaglandin E2 synthesis with NSAIDs has been associated with unequivocal therapeutic efficacy in patients with

[50]periodontitis.NSAIDs find their chief clinical application as and-inflammatory agents in the treatment of rheumatoid arthritis to reduce pain and inflammation. It has been documented that certain NSAIDs can directly inhibit the activation and

[51]function of neutrophils. They also

inhibit TNF-α release from monocytes [52]and non-killer (NK) cells. These

cycloxygenase independent effects may also contribute to the efficacy of NSAIDs in the treatment of rheumatoid arthritis.

BisphosphonatesOsteoclasts are responsible for the absorption and removal of bone. Agents that affect osteoclast function may be effective in the treatment of periodontitis and rheumatoid arthritis. A class of drugs known as bisphosphonates inhibits osteoclasts. They are incorporated into the bone and incapacitate osteoclasts thereby inhibiting lysosomal enzyme

[53]transport and secretion by osteoclasts. Focal bone damage and generalized bone loss are features of rheumatoid arthritis. Studies have shown that new-generation bisphosphonates, like zoledronic acid, reduced the development of new bony erosions in patients with rheumatoid arthritis suggesting a structural benefit with bisphosphonate therapy in these

[54]patients.Alveolar bone loss is an important complication of the inflammatory process in periodontitis. Markers of inflammation like TNF-α stimulate osteoclastic bone resorption in these patients. Bisphosphonate therapy is useful in them as they inhibit bone resorption and increase bone mass. Bisphosphonate treatment also improves the clinical outcome in patients with periodontitis and may be an important adjunctive treatment for periodontitis

[55]therapy for prevention of bone loss.

Emerging TherapiesOrnidazoleA synthetic nitroimidazole with potent antiprotozoal and antibacterial activity. Ornidazole has good activity against most of the periodontopathic bacteria and is a commonly used drug for the

[56]treatment of periodontitis. The usefulness of ornidazole has also been documented in patients with rheumatoid arthritis though its mechanism of action

[57]is not known. Ogrendik et al. showed that the administration of ornidazole in patients with active rheumatoid arthritis was associated with a significant reduction in pain, duration of morning stiffness, erythrocyte sedimentation rate (ESR) and C-reaction protein levels. An overall reduction in disease activity was observed. Ornidazole was well tolerated in these patients at a dosage of 500-1000 mg/day with few adverse effects, such as


headache, dry mouth, and nausea.

Chemically modified tetracyclines (CMTs)These are the drugs that were developed to eliminate the antimicrobial properties of tetracyclines while retaining their non antimicrobial properties by modifying the tetracyclic naphthacene carboxamide

[58]ring of tetracyclins. CMTs inhibit the [59]synthesis of MMPs. Non antibiotic

analogues of doxycyclin (CMT-3) and minocyclin (CMT-8) have been shown to be potent inhibitors of osteoclastogenesis

[60]in vitro. CMT-8 has also been shown to exert anti-inflammatory effects by inhibiting nitric oxide (NO) synthesis, and it can also modify cell viability by

[61]exerting a strong apoptotic activity. Such CMTs may reduce t issue breakdown and bone resorption in rheumatoid arthritis and periodontitis and might emerge as future disease-modify ing ant i rheumat ic drugs (DMARDs) in rheumatoid arthritis.

Osteoprotegrin (OPG)Recent evidence shows that the interaction between the receptor activation of nuclear factor kappa B ligand (RANKL) and its receptor activator (RANK) has an essential role in the activation of osteoclast and bone

[62]resorption. OPG is a naturally occurring high affinity soluble decoy receptor for RANKL. It inhibits RANKL interaction with RANK thereby inhibiting osteoclast activation as a result of this interaction. RANKL appears to be the important pathogenetic principle that is responsible for the destruction of bone matrix in patients with both rheumatoid

[63]arthritis and periodontitis. It has also been documented that OPG expression on synovial lining cells is deficient in patients with rheumatoid arthritis with active synovitis and in gingival cervical

[62] [64]fluid in patients with periodontitis. , In view of the ability of OPG to block RANK-RANKL interact ion and osteoclast activation, it may have a therapeutic role in conditions where bone destruction is a major sequel of chronic inflammation such as rheumatoid arthritis and periodontitis.

Conjugated linoleic acid (CLA)It has been found to be an important inhibitor of osteoclastogenesis. It acts by modulating the RANKL signalling pathway. CLA has also been shown to positively influence calcium and bone

metabolism. Thus, it may have important therapeutic implications in the treatment of inflammatory diseases associated with

[65]bone destruction.

Summary And ConclusionThere is no question that periodontitis and RA have many pathologic features in common. Emerging evidence suggests a strong relationship between the extent and severity of periodontal disease and RA. While this relationship is unlikely to be causal, it is clear that individuals with advanced RA are more likely to experience more significant periodontal problems compared to their non-RA counterparts, and vice versa. Hence, the possibility exists that both conditions result from a common underlying dysregulation of the host inflammatory response. The precise nature of this dysregulation remains to be established.It must be recognized that periodontitis differs in one significant way from RA through our understanding that the subgingival biofilm is a key etiologic factor. Unlike periodontal disease, no specific bacterial etiology has been identified for RA. Thus, while host modification of disease processes is possible for periodontitis, controlling the bacteria that cause periodontal infections remains a significant focus for periodontal treatment and prevention. At best, host modification can be only an adjunct treatment for periodontitis. However, until an etiologic factor can be found for RA, host modification remains the mainstay of treatment.There is accruing evidence to support the notion that both conditions manifest as a result of an imbalance between proinflammatory and anti-inflammatory cytokines. As a result, new treatment strategies will emerge for both diseases that may target the inhibition of proinf lammatory cytokines and destructive proteases. Through a better understanding of these two common chronic inflammatory conditions, it is hoped that areas of similarity can be exploited to determine the true relationship between these diseases and common areas of treatment. Already, it can be predicted that the periodontal status of patients with RA should be carefully screened.

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www.ijds.in

Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Jasjit Kaur2 Navneet Sharma3 Harpal Singh4 Amit Mahajan5 Prashanth Reddy

mandible resorbs at a rate about 4 times faster than the anterior edentulous mandible.Once the final prosthesis type has been determined, the next consideration is the required size, number, and location of endosseous implants necessary to satisfy the prosthodontic requirements. The primary criterion for proper implant support is the amount of available bone and is evaluated during the clinical e x a m i n a t i o n a n d r a d i o g r a p h i c assessment.

Material And MethodsAn exhaustive search was undertaken to identify published litereature related to evaluation of available bone by using key words .The search of MEDLINE database included all publications from 1983-2005. Selected articles were then obtained and reviewed.

DiscussionAvailable bone describes the volume of bone in the edentulous area considered for implant placement. It represents the external architecture of the bone. Evaluation of Available Bone The available bone for implant placement is evaluated in terms of the following parameters (Fig 1):I) Heightii) Widthiii) Lengthiv) Angulationv) Crown height / Bone Height (Implant

IntroductionLong term success in implant dentistry requires the evaluation of more than 50 dental criteria, many of which are unique

[1]to this discipline. The dentist should determine the prosthodontics needs and desires of the patient first, relative to the missing teeth. If natural teeth are in proper position to serve as potential abutment support, the traditional methods must be followed for restoring the dentition. If no teeth are present in the area of the abutment for the intended prosthesis, dentist determines the implant ideal and optional positions. The most important criteria for implant placement are available bone. Greenfield already appreciated the importance of available

[2]bone in implant region in 1913. The amount of available bone for implant, however, is difficult to evaluate exactly since the bone resorption process occurs soon after tooth extraction, particularly in the posterior maxilla region.Characteristic bone changes occurs after

[3],[4],[5]tooth loss .The amount of bone loss that occurs during the first year after tooth loss is almost 10 times greater than in the following years. A 25% decrease in bone width occurs within the first year

[6]and 40% within the first 1 to 3 years. As a result, the residual ridge shifts palatally in the maxilla and lingually in the mandible at the expense of the buccal cortical plate. Ratio of anterior maxillary bone loss to anterior mandibular bone loss is 1:4. The posterior edentulous


1 Assistant Professor, Department Of Prosthodontics2 Reader, Dept. of Oral Medicine & Radiology, Himachal Dental College, Sunder Nagar, H. P.3 Prof and Head, Department of Prosthodontics, Desh Bhagat Institute of Dental Sciences, Muktsar.4 Asst. Prof., Dept. of Oral & Maxillofacial Surgery, K. M. Shah Dental College & Hospital, Vadodra.5 Senior Lecturer, SJM Dental College And Hospital Chitradurga, Karnataka.

Available Bone - Key To Success In Implants

Address For Correspondence:Dr. Jasjit Kaur, Assistant ProfessorDepartment of Prosthodontics,Himachal Dental College, Sunder Nagar, H. P.Mobile: 09418421528Email - [email protected]


Quick Response Code

body) ratio

Available Bone HeightThe available bone height in an edentulous site is an important consideration because it governs the

AbstractWhen the remaining teeth cannot support the fixed partial denture, the traditional method of restoration has been the fabrication and insertion of removable partial denture.Well designed and fabricated removable partial denture can restore the oral function, but any patients cannot or will not adapt to such prosthesis. The use of osseointegrated implants alone or combination with teeth to support the fixed prosthesis has been accepted as an alternative to the removable partial denture. Osseo integrated endosseous implants that supports dental prosthesis have been used to restore the oral function and aesthetics of missing teeth with favourable results. Their success depends upon the maintenance of bone to implant interface to prevent mobility. Thus bone density becomes the key factor for success of endosseous implants which should be properly evaluated during diagnosis.

Key Wordsavailable bone, abundant bone, adequate bone, compromised bone,deficient bone, osteoplasty, augmentation, root form implants.

Fig 1 : available bone at the implant site is evaluated in terms of height (H), width (W), and length (L)

selection of the height (or length) of the implant fixture. It also influences the available crown height space and, consequently, force considerations and esthetics.The available bone height is measured from the crest of the edentulous ridge to the opposing limiting anatomical l a n d m a r k d u r i n g r a d i o g r a p h i c assessment (Fig 2). These limiting


structures include the inferior alveolar canal in the mandible and the floor of the nasal cavity and maxillary sinus in the maxilla. The anterior regions of the jaws have the greatest bone heights available. Specifically, the maxillary canine eminence region offers the greatest bone height in the maxilla and the mandibular first premolar region provides the most vertical column of bone in the mandible. [7]

In posterior regions, opposing landmarks such as the inferior alveolar canal and maxillary sinus prove to be more limiting for implant placement. This may necessitate use of narrower and shorter implants in these regions where greater forces are routinely generated. As a result, prognosis for implants placed in the posterior edentulous regions is regarded as being more guarded in comparison to anterior regions and the treatment plan may need to be modified to improve long term success. A 2-mm of bone height between a critical structure (inferior alveolar canal or maxillary sinus) and the implant is considered as a guideline to guard against surgical error. The height of implant also affects its total surface area. An implant 3mm longer provides more than 10% increase in surface area. The advantage of increased height does not express itself at the crestal bone interface but rather in initial stability of implant, the overall amount of bone implant interface, and a greater resistant to rotational torque during abutment screw tightening. The suggested minimum bone height for predictable long term endosteal implant survival is 9mm before 1981. The Branemark screw type implant body and osseointegrated approach was provided only in 3.75mm width and 9mm length and was used only in completely edentulous anterior maxilla and

[8]mandible. This height requirement is reduced in the very dense bone of the symphysis of an atrophic mandible when the prosthesis is overdenture or increased in the very porous type of bone of the

[9], [10]posterior maxilla. .

Available Bone WidthWidth of available bone is measured between the facial and lingual plates at the crest of potential implant site. The width of available bone represents the bucco-lingual dimension of available bone and determines the implant

diameter.The crest of the edentulous ridge is composed of dense cortical bone which permits immediate fixation of the implant. It normally has a triangular cross-section and is supported by a wider base. Hence, an osteoplasty will provide greater width of bone, although of reduced height. However, the anterior maxilla does not follow this rule because most edentulous ridges exhibit a labial concavity in the incisor area with an hourglass configuration. As a guideline, a minimum of 0.5-mm of bone should be available on each side of the implant at the crest to ensure sufficient bone thickness and blood supply around the implant. Hence, a 4-mm diameter implant usually requires more than 5-mm of crestal bone width (Fig 3).

Available Bone LengthThis refers to the mesio-distal length of available bone in the edentulous area and is limited by adjacent teeth or implants. As a guideline, the ideal mesiodistal distance between an implant and a tooth is 1.5 mm or more and 3-mm between each implant. This is because if bone loss occurs at the crest module of an implant or from periodontal disease with the adjacent tooth, the vertical defect will not spread to a horizontal defect and cause bone loss on the adjacent structure (Figs 4 and 5). Thus, a 4-mm diameter implant usually requires a minimum 7 mm of available bone length.Therefore in the narrower ridge with narrow diameter implant, placement of 2 or more implants often is indicated when possible to achieve sufficient implant bone surface area to compensate for the deficiency in width of implant.Ideal implant diameter corresponds to the width of the natural teeth 2mm below the CEJ. So that implant crown emergence through the soft tissue is similar to a

[11]natural teeth.

iv) Available Bone AngulationIdeally, the bone is perpendicular to the plane of occlusion; is aligned with the forces of occlusion; and is parallel to the long axis of the tooth or restoration. The available bone angulation represents the root trajectory in relation to the occlusal plane and, therefore, signifies the direction of forces applied to the implant body. The maxillary central incisors are teeth in the arch which can be loaded at 12

[12]degree angle only.

Fig 2 : height of available bone is measured from the crest of the edentulous ridge to the opposing landmark

Fig 3 : minimum bone width for a 4 -mm root-form implant is 5-mm in midfacial and lingual region

Fig 4 the ideal mesiodistal length between an implant and tooth is 1.5 mm or more and 3 mm between each implant

Fig 5 the ideal mesiodistal length between an implant and tooth is 1.5 mm or more and 3 mm between each implant

Table 1: Division A Dimensions

> 12 mm height

> 5 mm width

> 7 mm length

< 30 degrees of angulation

< 15 mm crown height

The bone angulation does not remain constant after tooth loss. A common example is the anterior maxilla. Here, labial undercuts and resorption after tooth loss often mandate a greater angulation of the implant or correction of the site before insertion. A similar protocol may be considered in the submandibular fossa region of the posterior mandible which may show a

[13], [14]deep lingual undercut .

iv) Crown Height / Implant body ratioThe available bone height influences the available crown height space. The crown height influences the esthetic appearance of the final restoration. Importantly, crown height may be considered a vertical cantilever and influences the amount of moment force exerted on the implant and surrounding crestal bone.As a guideline, the crown height/implant body ratio should be < 1 for improved implant prognosis. When this force multiplier is unfavorable (>1), the treatment plan may be modified to include a greater number of implants or wider implants to counteract the increase in stress. Limiting factor of angulation of force between the body and the abutment of an implant is correlated with the width of bone. The angled load to implant body increases the crestal stresses.

Classification System for Available Bone The dental implant approach to different bone volumes needs to be treatment plan oriented. In 1985, Misch and Judy proposed a classification system for the available bone with treatment options for each category. The basic four divisions have been expanded to following categories to extend this specific organized approach. Based on the Misch-Judy classification the bone volume divisions are: Ÿ Division AŸ Division B

i) Division B +ii) Division B - w (width)

Ÿ Division Ci) Division C - w (width)ii) Division C - h (height)


iii) Division C - a (angulation)Ÿ Division D

Division A (Abundant Bone)This category of bone volume is available soon after tooth loss and is abundant in all dimensions. Based on the available dimensions, use of Division A root-form implants with height > 12 mm and width > 4 mm is indicated in this category. Their advantages include: Ÿ Greatest surface areaŸ Improved stress distributionŸ Greatest range of prosthetic optionsŸ Less fracture of implant and

componentsŸ Less abutment screw loosening

Division A bone is mainly observed in the anterior regions Less bone height is available in the posterior mandible and maxilla due to limiting structures. In such situations, wider implants (5 to 6 mm) may be considered in the molar regions as suitable alternatives. Large diameter implants have less abutment screw loosening, and fracture

[15], [16]of the implant body or components. Osteoplasty may be performed to obtain the necessary bone width.

Prosthetic Options Available in Div A bone FP-1 restorations require Div A bone to allow ideal implant placement and natural appearance of the final prosthesis.FP-2 or FP-3 prosthesis may be considered depending on amount of bone loss and lip positions. RP-4 or RP-5 may need osteoplasty to gain sufficient interarch space to accommodate for the denture teeth, bulk o f ac ry l i c , supers t ruc tu re and overdenture attachments.

Division B (Adequate Bone)Slight to moderate atrophy is used to

[4]describe this clinical condition. Division B bone is characterized by reduced bone width in comparison to Division A bone and is mostly observed in the posterior regions. Two subtypes (B + and B - w) exist depending on the extent of resorption. The available mesio-distal bone length and angulation criteria also differ as a consequence of the reduced width of bone. Criteria of available bone height and crown height remain the same.

Fig 6 : A Division B ridge may be converted to Division A by osteoplasty

Fig 7 : an FP- 3 prosthesis is usually indicated due to extended crown heights

Table 2: Division B Dimensions

> 12 mm height

B +w 4 to 5 mm

B - w 2.5 to 4 mm

> 6 mm length

< 20 degrees of angulation

< 15 mm crown height

Treatment Options for Div B bone1) OsteoplastyThe most common approach followed is to modify the narrower Division B ridge into another bone division by osteoplasty. If the bone height attained after osteoplasty is greater than 12 mm, the division has been altered to a Division A with width > 5 mm (Fig 6). A FP-2 or FP-3 restoration is indicated in this scenario to compensate for the increased clinical crown height (Fig 7). However, the crown height/implant body ratio remains < 1 after the osteoplasty due to sufficient available bone height. Osteoplasty to


obtain a Division A ridge is mainly indicated in the anterior mandible because of the abundant available bone height and fewer esthetic concerns.If bone height attained after osteoplasty is less than 12 mm, the division has been altered to a Division C - h with the crown height/implant body ratio > 1. The treatment options will then follow those available in the Division C - h bone.

2) AugmentationThe Division B ridge may be converted to a Division A by augmentation (Fig 8). The augmentation requires a 4 to 6 months healing period before placement of endosteal implants. Augmentation is more predictable when the volume to augment is minimal and is for width rather than height due to the greater number of osseous walls in contact with the graft material. Augmentation is mainly indicated in the anterior maxilla for esthetics since it results in improved crown height/implant body ratios and more natural looking abutments.

3) Insert Division B implantsThe third option is to treat the available bone volume as it is and place narrower diameter implants. Division B implants have a smaller diameter of 2.7 to 3.5 mm. These root-form implants are indicated mainly for anterior single-tooth replacement for maxillary laterals or mandibular incisors.

[17], [18], [19]Their limitations are: The nearly 25% reduction in surface area results in almost twice the stress concentration at the crestal region.Lateral loads result in almost thrice the stress to the implant as compared to Division A implants. Hence, a greater risk of fatigue fracture is present. Due to the narrow diameter of the implant the emergence profile of the restoration is less esthetic (except for maxillary lateral or mandibular incisors)Hence, when Division B implants are indicated, it is advisable to increase the surface area by placing additional implants (wherever possible) and by surface treatments. In addition, the angle of load must be reduced to less than 20 degrees to compensate for the smaller

diameter.Narrower diameter implants have been found to be successful in the anterior region of the maxilla and are preferable where space is limited

Division C (Compromised Bone)Moderate to advanced atrophy is used to describe this clinical condition. The bone may be deficient in one or more dimensions. (Fig 9)

With continued resorption, the Division C - w bone changes to a Division C - h bone which is commonly observed in the posterior regions because the maxillary sinus or mandibular canal limits the vertical height sooner. Division C - a bone is found most often in the anterior maxilla and mandible with facial undercut regions, or the mandibular second molar with a severe lingual undercut. Implant-supported prostheses are more complex for this category due to the reduced bone volume but the patient usually is in greater need for increased prosthodontic support.

Treatment Options for Division C BoneA) Division C - w1) OsteoplastyThis converts the Division C - w bone to a Div C - h category since the crown height/implant body ratio is > 1. The treatment protocol of Division C - h bone is then followed.

2) AugmentationAugmentation of Division C - w bone is done when a fixed restoration is desired or when force factors necessitate so. The edentulism is then treated with the options available in the division of bone a t t a i n e d a f t e r a u g m e n t a t i o n . Augmentation is preferred in the posterior maxilla or mandible since osteoplasty may result in a Division D bone which represents the poorest prognosis. Bone grafting procedures are more difficult after height has been

[20], [21], [22]reduced. .

B) Division C - h1) Augmentation This is advocated in the posterior maxilla

Table 3: Division C Dimensions

< 12 mm height (C - h)

< 2.5 mm width (C - w)

> 30 degrees of angulation (C - a)

> 15 mm crown height

Table 4: Division D Dimensions

Basal bone loss

Flat maxilla

Pencil thin mandible

> 20 mm crown height

Fig 8 : Alternatively, augmentation may upgrade the Division B ridge to Division A

Fig 9 A : preoperative radiograph showing division C-h bone in the maxillary premolar region with Division D in the molar

region

Fig 10 : The posterior maxilla has been modified to Division A bone by sinus grafting

and mandible.

2) Root-form implants Additional implants are required to increase the overall implant-bone surface area to counteract the unfavorable force multiplier of increases crown height. For the same reason, in edentulous patients, RP-5 prosthesis may be considered to reduce the cantilever. Shorter textured implants may be suitable options in the posterior maxilla and mandible with compromised bone height as indicated by recent studies. Alternative to endosteal implants in the posterior edentulous division c-h arch the other implant systems are placed which

[23], [24], [25]are as follow: .

3) Other implant systemsŸ SubperiostealŸ Disk design Ÿ Ramus frameŸ Transosteal

C) Division C - a1) Augmentation to improve the

angulation 2) Subperiosteal implants

Division D (Deficient Bone)Severe atrophy is used to describe the clinical condition.

The completely edentulous Division D patient is the most difficult to treat. The surgical skill required is greater and the prosthetic outcome has a guarded prognosis. Fixed restorations are almost always contraindicated due to significant crown height. Idiopathic fractures during surgery or from implant failure or removal are likely complications.

Treatment Options for Division D BoneAugmentation Ÿ Autogenous bone grafts are indicated

to upgrade the division. (Fig 10)Ÿ Endosteal or subperiosteal implants

may be inserted depending on the division of bone attained.

Summary And ConclusionThe key determinant for clinical success of implants is available bone around that endosteal dental implant. The strength of bone is directly related to bone density. So available bone should be properly evaluated in terms of bone width, height,


length, angulation during diagnosis to determine the prognosis of implant placement.

References1. Adell R, Eriksson B, Lekholm U,

Branemark PI, Jemt T (1990) Long-t e r m f o l l o w - u p s t u d y o f osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 5:347-359.

2. Greeenfeld EJ (1913) Implantation of a r t i f i c ia l c rown and br idge abutments. Dent Cosmos 55:364-369.

3. Atwood DA (1963) Post extraction changes in the adult mandible are illustrated by microradiographs of midsagittal sections and serial cephalometrics roentgenogram. J Prosthet Dent 13:810-824.

4. Atwood DA (1971) Reduction of residual ridges: major oral disease entity. J Prosthet Dent 26:266-279.

5. Atwood DA, Coy WA (1971) C l i n i c a l , c e p h a l o m e t r i c , densitometric study of residual ridge. J Prosthet Dent 26:280-295.

6. Tallgreen A (1972) The continuing reduction of alveolar ridges in complete denture wearer: a mixed longitudinal study covering 25 years. J prosthet Dent 27:120-132.

7. Razavi R, Zena RB, Khan Z et al (1995) Anatomic site evaluation of edentulous maxilla for dental implant placement. J prosthet Dent 4:90-94.

8. B r a n e m a r k P I ( 1 9 8 3 ) . Osseontegration and its experimental background. J Prothet Dent 50:399-410.

9. Misch CE (1999) short versus long implant concept: functional surface areas. Dent Today 18(8):60-65.

10. Misch CE (1990) Density of Bone: effect on treatment plan, surgical approach, healing and progressive bone loading. Int J Oral Implant 6:23-31.

11. Hebel KS, Gajjar R (1997) Achieving superior esthetics results: parameter for implants and abutment selection. Int J Dent Symposia 4(1):42-47.

12. Lam RW (1960) Contour changes in a l v e o l a r p r o c e s s f o l l o w i n g extraction. J prosthet Dent 10:25-32.

13. Pietrovski J, Sorin S, Hirshfield Z (1976) The residual ridge in partial edentulous patients. J prosthet Dent

36:150-157.14. Pietrovski J,Massler M (1967)

Alveolar ridge resorption following tooth ext rac t ion . J pros the t Dent17:21-27.

15. Rangert B, Krogh P, Langer P, et al (1995) Bending overload and implant fracture: a retrospective clinical analysis. Int J Oral Maxillofac Implants 10:326-334.

16. Misch CE, Bidez MW (1997) Occ lus ion and c res ta l bone resorption: etiology and treatment planning strategies for implants in Mc Niell C, editor: science and practice of occlusion, quitenssence.

17. Misch CE, Bidez MW (1995) Maxillary anterior single tooth Implant health esthetic comproise. Int J Dent Symp 3:4-9.

18. Lum LB (1991) A biomechanical rationale for the use of short implants. J Oral Implantol 17:126-131.

19. Misch CE, Bidez MW (1994) Implants protected occlusion, a b i o m e c h a n i c a l r a t i o n a l e . Compendium 15; 1330-1342.

20. Misch CM, Misch CE, Resnik RR, et al (1992) Reconstruction of maxillary defects with mandibular symphysis g r a f t s f o r d e n t a l i m p l a n t s ' preliminary procedural report. Int J Oral Maxillofac Implants 3:330-366.

21. Misch CM, Misch CE (1995) The repair of severe localized ridge defects for implant placement using mandibular bone grafts, implant dent 4:261-267.

22. M i s c h C M ( 1 9 9 6 ) R i d g e augmentation using mandibular ramus grafts for the placement of dental implants: presentation a technique. Pract Periodontics Aesthet Dent 8:127135.

23. Scortecci GM (1999) Immediate function of cortically anchored disk design implant without bone augmentation in moderately to severely resorbed completely e d e n t u l o u s m a x i l l a e . O r a l implantol25:70-9.

24. Misch CE, Dietsh F (1992) The unilateral mandibular subperiosteal implant: indications and technique. Int J Oral Implantol 8(2, 3):21-29.

25. Misch CE (2005) Dental Implant Prosthetics.105-129.Elesvier Mosby .

Source of Support : Figures Courtesy-Dental Implant Prosthetics. Carl E Misch., Conflict of Interest : None declared


www.ijds.in

Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Pramod BJ2 Sujata S3 Dayananda BC4 Nagaraju K5 Saleem Shaikh

Nanobiotechnology plays an important role in the discovery of biomarkers of cancer. Several drugs in development for cancer are based on nanobiotechnology, and a few of these are already approved. Nanobiotechnology- based devices are in development as aids to cancer surgery. Finally, nanobiotechnology is playing an important role in personalized therapy for

[1]cancer.

This review focuses on the current concepts and the application of nanotechnology in by means of nano-systems in cancer diagnosis and treatment.

Historical BackgroundNanotechnology deals with structures that range from 1 to l00nm- about the size of a virus and 'Nano' derives its name

[2]from Greek word for "dwarf". The c o n c e p t u a l u n d e r p i n n i n g s o f nanotechnologies were first laid out in 1959 by the physicist Richard Feynman in his lecture, "There's plenty of room at the bottom". The term nanotechnology was not used until 1974, when Norio Taniguchi, a researcher at the University of Tokyo, used it to refer to the ability to engineer materials precisely at the nanometer level. The primary driving force for miniaturization at that time

IntroductionNanotechnology is the creation and utilization of materials, devices and systems through the control of matter on the nanometer-length scale, that is, at the level of atoms, molecules and s u p r a m o l e c u l a r s t r u c t u r e s . Nanobiotechnology is already starting to show the promise of an impact on health

[1]care.

Nanomedicine is defined as the application of nanobiotechnology to medicine and is based on the use of nanoscale materials and devices for diagnosis and drug delivery as well as for t h e d e v e l o p m e n t o f a d v a n c e d pharmaceut icals referred to as

[1]nanopharmaceuticals.

Nanobiotechnology is also being applied to refine surgery from microsurgery to nanosurgery. Examples include the construction of nanoscale robots, nanobots, for navigating the human body to detect as well as treat various diseases, and cell surgery using nanodevices and nanolasers. During the past few years, considerable progress has been made in the application of nanobiotechnology in cancer, that is, nano-oncology, which is recently the most important chapter of

[1]nanomedicine.


1 Reader,2 Sr Lect,3 Professor,4 Reader, Dept. of Oral Medicine & Radiology Seema Dental College and Hospital, Rishikesh5 Reader, Dept. of Oral & Maxillo-Facial Pathology ACPM Dental College, Dhule, Maharashtra, India

Nanosystems: Role In Oncology - An Overview

Address For Correspondence:Dr. Pramod BJ M.D.S Dept. of Oral & Maxillofacial Pathology & MicrobiologySeema Dental College and Hospital Rishikesh, UttarakhandEmail: [email protected],Mobile: +00 91 96396 43167


Quick Response Code

came from the electronics industry, which aimed to develop tools to create smaller electronic devices on silicon

[3]chips.

According to James R Baker Jr "Nanotechnology allows us to make materials that are thousands of times smaller than the smallest cell in the body". Because these materials are so small, they can easily get inside cells and

[4]change how they work.

Development Of NanotechnologyMihail (Mike) Roco of the U.S. National Nanotechnology Initiative has described four generations of nanotechnology development. The 1st generation, as Roco depicts it, is that of passive nanostructures, materials designed to perform one task. The 2nd generation introduces active nanostructures for multitasking; for example, actuators, drug delivery devices, and sensors. The 3rd generation features nano-systems

AbstractNanotechnology is the creation and utilization of materials, devices and systems through the control of matter on the nanometer-length scale, that is, at the level of atoms, molecules and supramolecular structures. Given the inherent nanoscale functional of living cells, it was inevitable that nanotechnology would be applied in biological settings, giving rise to the term nanobiotechnology; that is, the application of nanotechnology in the life sciences. Nanobiotechnology is also being applied to refine surgery from microsurgery to nanosurgery. During the past few years, considerable progress has been made in the application of nanobiotechnology in cancer, that is, nano-oncology, which is currently the most important chapter of nanomedicine. Nanobiotechnology plays an important role in the discovery of biomarkers of cancer. Several drugs in development for cancer are based on nanobiotechnology, and a few of these are already approved. Nanobiotechnology- based devices are in development as aids to cancer surgery. Finally, nanobiotechnology is playing an important role in personalized therapy for cancer.

Key Wordsbiomarkers, dendrimers, nano oncology, nanotechnology, quantum dots

wi th t housands o f i n t e r ac t ing components. A few years later, the first integrated nano-systems, functioning (according to Roco) much like a mammalian cell with hierarchical systems within systems, are expected to

[5]be developed.

Some experts may still insist that n a n o t e c h n o l o g y c a n r e f e r t o measurement or visualization at the scale of 1-100 nanometers, but a consensus seems to be forming around the idea that control and restructuring of matter at the nano-scale is a necessary element. As work progresses through the four generations of nanotechnology leading up to molecular nano-systems, which will include molecular manufacturing, we think it will become increasingly obvious that "engineering of functional systems at the molecular scale" is what

[5]nanotech is really all about.

Nanosystem's in cancer diagnosticsNano-biotechnology offers a novel set of tools for the detection of cancer and

[6]contributes to early detection of cancer.

Types of Nanosystem'sThese include as tabulated in [Table 1].

Application Of Nanotechnology In OncologyNanotechnology may have an impact on the key challenges in cancer diagnosis and therapy. Diagnosing, treating, and tracking the progress of therapy for each type of cancer has long been a dream among oncologists, and one that has grown closer to parallel revolutions in genomics, proteomics and cell bio1ogy. Nanotechnology's greatest advantage over conventional therapies may be the ability to combine more than one function. Recently, there is a lot of research going on to design novel 'Nanodevices' capable of detecting cancer at its earliest stages, pinpointing its location within the human body and delivering chemotherapeutic drugs against malignant cells. The major areas in which nanomedicine is being

[2]developed in oncology involve :Ÿ E a r l y d e t e c t i o n o f t u m o r

(developing "smart" collection platforms for simultaneous analysis of cancer-associated markers and designing contrast agents that improve the resolution of tumor area comparing with the nearby normal tissues), and


Ÿ Cancer treatment (creat ing nanodevices that can release

[2]chemotherapeutic agents) :

1. Detection of tumorEarly detection of tumor will greatly increase survival rates with the reasonable assumption that an in situ tumor will be easier to eradicate than one that has metastasized. Nanodevices and especially nanowires can detect cancer-related molecules, contributing to the early diagnosis of tumor. Nanowires having the unique properties of selectivity and specificity can be designed to sense molecular markers of malignant cells. They are laid down across a microfluidic channel and they allow cells or particles to flow through it. Nanowires can be coated with a probe such as an antibody or oligonucleotide. Proteins that bind to the antibody will change the nanowire's electrical conductance and this can be measured by a detector. As a result, proteins produced by cancer cells can be detected and earlier

[14]diagnosis of tumor can be achieved.

Nanoparticle contrast agents are being developed for tumor detection purposes. Labeled and non-labeled nanoparticles are already being tested as imaging agents in diagnostic procedures such as

[15]nuclear magnetic resonance imaging. There are two main groups of nanoparticles: 1) superparamagnetic iron oxides whose size is greater than 50 nm, 2) ultrasmall superparamagnetic iron

[16]oxides which are smaller than 50nm. Moreover, Quantum dots can be used to measure levels of cancer markers such as breast cancer marker Her-2, actin, microfibril proteins and nuclear

[17]antigens.

Nanotechnology for detection of cancer biomarkersAny specific molecular alteration of a cell on the DNA, RNA, metabolite or protein level may be referred to as a molecular biomarker. From a practical point of view, the biomarker would specifically and sensitively reflect a disease state and could be used for diagnosis as well as for disease monitoring during and following therapy. [18] Currently, available molecular diagnostic technologies have been used to detect biomarkers of various diseases such as cancer. Nanotechnology has further refined the detection of biomarkers. The physicochemical

characteristics and high surface areas of nanopart ic les make them ideal candidates for developing platforms for harvesting biomarkers. Some biomarkers also form the basis of innovative molecular diagnostic tests. A magnetic nanosensor technology is up to 1,000 times more sensitive than any technology now in clinical use, can detect biomarker proteins over a range of concentrations three times greater than any existing method and is accurate regardless of

[19]which bodily fluid is being analyzed. The nanosensor chip also can search for u p t o 6 4 d i f f e r e n t p r o t e i n s simultaneously and has been shown to be effective in early detection of tumors in mice, suggesting that it may open the door to significantly earlier detection of even the most elusive cancers in

[1]humans.

Investigating the potential for capturing circulating tumor cellsA method has been described for magnetically capturing circulating tumor cells in the bloodstream of mice followed

[20]by rapid photoacoustic detection. M a g n e t i c n a n o p a r t i c l e s a r e functionalized to target a receptor commonly found in breast cancer cells, which bind and capture circulating tumor cells under a magnet. The approach of integrating in-vivo multiplex targeting, m a g n e t i c e n r i c h m e n t , s i g n a l amplification and multicolor recognition, enables circulating tumor cells to be concentrated from a large volume in the vessels of tumor-bearing mice and has potential applications for the early diagnosis of cancer and the prevention of

[1]metastasis in humans.

Imaging applications of Nano-biotechnology in cancerHighly lymphotropic superparamagnetic iron oxide nanoparticles (SPIONs), measuring 2 to 3 nm on average have been used in conjunction with high-resolution MRI to reveal small and otherwise undetectable lymph node

[ 2 1 ]metastases. Quantum dots are attractive as optical imaging agents owing to their high brightness and photo- and biostability. Bioluminescence resonance energy transfer Quantum dots can improve the signal-to-background ratio for real-time imaging largely by

[22]suppressing background signal.

2. Tumour treatmentFrequent challenges encountered by


S. No TYPE OF NANOSYSTEM PHYSICAL PROPERTIES APPLICATIONS ADVANTAGES

LiposomesThese are the closed vesicle forms of hydrated

phospholipids.These are of 3 types based on size and number of bi-

layers. Ÿ Multilamellar vesiclesŸ Small unilamellar vesiclesŸ Large unilamellar vesicles

They are used in cancer therapy, carrier for antigens,

pulmonary delivery, leishmaniasis, ophthalmic drug

delivery.[7]

Ÿ Multilamellar vesiclesThese consist of several lipid bi-layers separated from one

another by aqueous spaces. These are heterogeneous in

size, ranging from few hundreds to thousands of nm in

diameter.Ÿ Small unilamellar vesicles (SUV’S) <100nmŸ Large unilamellar vesicles (LUV’S)>100nmThese consist of a single bi-layer surrounding the

entrapped aqueous space. Drug is either entrapped in the

aqueous space or intercalated into lipid bi-layer of

liposomes, depending on physicochemical characteristics

of the drug.

Ÿ Active and Passive delivery modeŸ FlexibleŸ Aqueous preparations

1.

Polymeric Nano Particles comprise of 1.Nanocapsules 2.Nanosphere.

Application of these particles in oncology has

exponentially increased with advent of biodegradable

polymers. Both natural (albumin, Chitosan, Heparin etc) and

Synthetic ( Poly-L- Lactide, Poly- [L-glutamate] Poly [D, L

Lactide-Coglycolide], [PEG, etc], biodegradable polymers

are being exercised as drug delivery systems.[4]

These are colloidal carrier, 10nm-1µm in size

consisting of synthetic or natural polymers. In these

polymers, drugs are physically dissolved, entrapped,

encapsulated or covalently attached to the polymer

matrix Ÿ Nanocapsules are systems in which drug is

confined to a cavity surrounded by unique polymeric

membraneŸ Nanospheres are systems in which the drug is

dispersed throughout the polymer matrix.[8]

BiodegradableŸ NaturalŸ Synthetic

2.

CantileversResearchers can read this change in real time and

provide not only information about the presence and

the absence but also the concentration of different

molecular expressions.

As a cancer cell secretes its molecular products, the

antibodies coated on the cantilever fingers selectively

bind to these secreted proteins, changing the physical

properties of the cantilever and signaling the presence of

cancer.

Ÿ Nanoscale cantilevers Are microscopic flexible beams resembling a row of

dividing boards – are built using semiconductor

lithographic techniques and are coated with molecules

capable of binding to the biomarkers of cancer like PSMA

(Prostate-Specific Membrane Antibody).

Ÿ Cantilever provide rapid and sensitive detection

of cancer-related molecules.[6]

3.

Quantum dots (QD)These are semi conducting materials consisting of a

semiconductor core coated by a shell to improve optical

properties.

These have a large impact on imaging, in-vitro and in-

vivo detection and analysis of biomolecules,

immunoassay, and DNA hybridization and in non-viral

vectors for gene therapy. It has main function in labeling

of cells and therapeutic tools for cancer treatment.[9]

Ÿ Their properties originate from their physical size

which ranges from 10-100A ° in radius. Ÿ The best characteristics of QDs and magnetic iron

oxide nanoparticles can be combined to create a single

nanoparticle probe that can yield clinically useful images

of both tumors and the molecules involved in cancer.[10]

Ÿ QDs are used as inorganic fluorophores, owing to

the fact that they offer significant advantages

over conventionally used fluorescent markers.

4.

DendrimersThey can be made more biocompatible compounds with

low cytotoxicity and high bio-permeability according to

the requirements

These can deliver bioactive substances like drugs,

vaccines, materials and genes to desired sites.[11]

Ÿ These are hyper branched, tree-like structures and

have compartmentalized chemical polymer.

Ÿ Low cytotoxicŸ High bio-permeability

5.

Carbon NanotubesThis technique can serve as an alternative to PCR and

identify multiple nucleotide polymorphic sites in large

strands on non-amplified DNA at relatively and low

cost.[4]

They scan down DNA and look for single nucleotide

polymorphism which make possible to detect whether an

individual has a high-risk or low-risk configuration for

developing the processes that lead to cancer.

Ÿ These are hexagonal networks of carbon atoms.

Length and diameter of these tubes are 1nm and

1-100nm in length.[12]

Ÿ EconomicŸ Identifies multiple nucleotide polymorphic sites

in large strands of non-amplified DNA

6.

Metallic Nano particlesNanoparticles of various metals have been made yet

silver and gold nanoparticles are of prime importance

for biomedical use.[5]

By attaching monoclonal antibodies (mAbs), which can

recognize a specific cancer cell, to gold nanoparticles or

nano-rods the “heating phenomenon” can be used in

cancer detection. This acoustic signal gives valuable

information about the presence of cancer cells

Ÿ Gold nanoparticles conjugated to anti-epidermal

growth factor receptor (anti- EGFR) mAbs

specifically and homogeneously bind to the surface

of the cancer cells with 600% greater affinity than

to the noncancerous cells. Ÿ This specific and homogeneous binding is found to

give a relatively sharper surface plasma resonance

(SPR) absorption

Ÿ Gold nanoparticles are not toxic to human cellsŸ Economic as it requires a simple, inexpensive

microscope and white light Ÿ The results are instantaneous Ÿ Highly sensitive.[13]

7.

Nanoshells Once the cancer cells take them up, by applying a near

infrared light that is absorbed by the nanoshells, it is

possible to create intense heat that selectively kills the

tumor cells and not the neighboring healthy cells.

Ÿ Nanoshells have a core of silica and a metallic

outer layer. These can be linked to antibodies that

can recognize tumor cells (PSMA).

Ÿ Increased efficacy of the therapeutic treatment Ÿ Minimal set of side effects.[6]

8.

NanowiresNano-sized sensing wires lie across a microfluidic

channel.

They can detect the presence of altered genes associated

with cancer and may help researchers pinpoint the exact

location of those changes.[6]

These are manmade constructs; made with carbon, silicon

and other materials that have the capability to monitor

the complexity of biological phenomenon.

Capability to monitor complexity of biological processes9.

current cancer therapies include nonspecific distribution of anti-tumour agent, inadequate drug concentrations reaching the tumor, and limited ability to monitor therapeutic responses. Poor drug delivering to the target site leads to significant complication, such as

[23]multidrug resistance. Current NT promises solutions to several of the current obstacles facing cancer therapies. Nanoparticles have size of 5nm to 200nm, allowing their unique interaction with biological systems at the molecular level. As a result of their materials composition, nanoparticles are capable of self-assembly and maintaining stability and specificity which are crucial t o d r u g e n c a p s u l a t i o n a n d

[4]biocompatibility. Nanoparticles can consist of a number of materials, including polymers, metals and ceramics. Many types of nanoparticles are under various stages of development as drug delivery systems, including liposomes and lipid based carriers (such as lipid emulsions and lipid -drug conjugates, polymer microspheres, micelles and various ligand - targeted

[2]products (such as immunoconjugates). As an example, a nanoparticle-based drug called "Abraxane", consisting of paclitaxel conjunctive to protein albumin particles, was approved by the Food and Drug Administration for breast cancer

[24]treatment a year ago. It is worthwhile to mention that selective delivery and targeting of nanoparticles to tumors may overcome the problem of toxicity and may increase the effectiveness of drug delivery. The barriers involving this procedure and that should be under consideration are a variety of physical and anatomical characteristics of solid tumors, such as the necrotic core with the surrounding hypoxic area, the elevated local temperature and the interstitial

[25], [26], [27]liquid pressure.

Several approaches have been used to target nanoparticles to tumor associated antigens, including direct conjugation of nanoparticles to monoclonal antibodies, modified plasma proteins or viral vectors. Recent progress has been made with targeted viral vectors for gene

[28]therapy applications.

In addition to this, laser-induced thermal effects around nanoparticles attached to specific targets have recently been used for the treatment of cancer. The basic concept for this application of


Nanotechnology is the fact that nanoparticles of different properties (magnetic, optical etc.), due to their size, can be delivered more easily to target cells than can larger particles, via conjugation with antibodies, conjugation t o v i r u s e s a n d p h y s i o l o g i c a l

[29]transportation.

After reaching target cells, these nanoparticles are then self-assembled into larger nanoclusters within cells. Afterwards, these nanoclusters can be ac t iva ted by laser i r rad ia t ion , microwaves or magnetic fields, depending on the nanoparticles synthesis. By this process and its photothermal effects, destruction of cancer can be achieved. More specifically, the nanoshell-assisted photo-thermal therapy (NAPT) is a non-invasive procedure for selective photo-thermal tumor destruction. It is based on nanoshells that absorb light in the near infrared (NIR) region, which is the wavelength that optimally penetrates tissues. The metal shell converts the absorbed light into heat with great efficacy. Further specificity can be engineered by attaching antigens on the nanoshells which are specifically recognized by the cancer cells. By supplying a light in NIR from a laser, the particles produce heat, which destroy the

[30]tumor.

In-vivo, Raoul Kopelman et al; have recently created three-component nanoparticles that target, image and destroy tumors in the brains of rats. The particles consist of an iron oxide core that serves as a magnetic resonance imaging (MRI) contrast agent. Attached to them are copies of a cancer-targeting peptide called F3, as well as a light-absorbing compound called photofrin that kills cells when hit with red light. When Kopelman's team used their combination particles to treat rats previously injected with cancer cells inside their brains, animals receiving the combination particles survived more than twice as long as control animals receiving the

[31]non-targeted photofrin compound.

Ultrasonic tumor imaging and t a r g e t e d c h e m o t h e r a p y b y nanobubblesDrug delivery in polymeric micelles combined with tumor irradiation by ultrasound results in effective drug targeting, but this technique requires

[32]prior tumor imaging. Multifunctional nanoparticles that are tumor-targeted drug carriers, long-lasting ultrasound contrast agents and enhancers of ultrasound-mediated drug delivery have been developed and deserve further

[1]exploration as cancer therapeutics.

Nanoparticle-based thermal ablation of cancerSeveral forms of energy have been used for the destruction of tumor cells that cannot be reached for conventional surgical excision. Thermal ablation therapy is the most promising of these methods but is limited by incomplete tumor destruction and damage to adjacent normal tissues. Use of nanoparticles has refined noninvasive thermal ablation of tumors, and several nanomaterials have been used for this p u r p o s e . T h e s e i n c l u d e g o l d nanomaterials, iron nanoparticles, magnetic nanoparticles and carbon nanotubes. Heating of the particles can be induced by magnets, lasers, ultrasound, photodynamic therapy and low-power X-

[33]rays.

Laser-induced thermal destruction of cancer using nanoparticlesSingle-walled carbon nanotubes (SWCNTs) show strong optical absorbance 700- to 1,100-nm NIR laser impulses. SWCNTs emit heat when they absorb energy from NIR light. Tissue is relatively transparent to NIR, which suggests that targeting SWCNTs to tumor cells, followed by noninvasive exposure to NIR light, will ablate tumors within the range of NIR. One s tudy has demonstrated the specific binding of mAb-coupled SWCNTs to tumor cells in vitro, followed by their highly specific

[34]ablation with NIR light. Only the specifically targeted cells were killed after exposure to NIR light. Selective cancer cell destruction can be achieved by functionalization of SWCNTs with a folate moiety, selective internalization of carbon nanotubes inside cells labeled with folate receptor tumor biomarkers, and NIR-triggered cell death, without

[1]harming receptor-free normal cells.

R o l e O f N a n o t e c h n o l o g y I n Personalized Therapy Of CancerPersonalized medicine simply means the prescription of specific therapeutics best suited for an individual. Personalized management is usually based on pharmacogenetic, pharmacogenomic,

p h a r m a c o p r o t e o m i c a n d pharmacometabolic information, but other individual variations in patients and environmental factors are also taken into

[35]consideration.

In cancer cases, the variation in behavior of cancer of the same histological type from one patient to another is also taken into consideration. Personalization of cancer therapies is based on a better understanding of the disease at the molecular level, and nanotechnology will

[36]play an important role in this area. With so many nanotechnologies available for drug delivery, it is recommended that computational mathematical tools be used to predict, which parameter's to be used for a multistage drug-delivery strategy. This would enable efficient localized delivery of chemotherapeutic drugs and lead to significant improvements in therapy efficacy as well as reduced systemic

[37]toxicity. Such an approach can be optimized for personalized oncology.

Advantages of NanotechnologyŸ Imaging agents and diagnostics that

will allow clinicians to detect cancer in its earliest stages

Ÿ Multifunctional, targeted devices capable of bypassing biological barrier to deliver multiple therapeutic agents directly to cancer cells

Ÿ Agents that can monitor predictive molecular changes and prevent precancerous cells from becoming malignant

Ÿ Novel methods to manage the symptoms of cancer that adversely impact quality of life

Ÿ Research tools that will enable rapid identification of new targets for clinical development and predict

[6]drug resistance.

Nanotechnology as a risk to human healthAlthough the benefits of nanotechnology are widely publicized, discussion of the potential effects of their widespread use in consumer and industrial products is just beginning. Both pioneers of nanotechnology and its opponents are finding it extremely hard to argue their case because of the limited information available to support one side or the other. Given the rapid rate of development in this area and the amount of publicity it is attracting, it is not surprising that concerns should have been raised relating


to the safety of nanomaterials in a variety [38], [39]of products. Although some

concerns may be ill-founded, it remains true that the toxicology of many nanomaterials has not yet been fully evaluated.

It has been shown that nanomaterials can enter the human body through several ports. Accidental or involuntary contact during production or use is most likely to occur via the lungs, from which a rapid translocation is possible to other vital organs through the bloodstream. On the cellular level, an ability to act as a gene vector has been demonstrated for nanoparticles.

Carbon black nanoparticles have been implicated in interfering with cell s igna l ing . There i s work tha t demonstrates uses of DNA for the size separation of carbon nanotubes. The DNA strand just wraps around it if the tube diameter is right. Though excellent for the purposes of separation, this tendency raises some concerns over the consequences of carbon nanotubes

[40], [41]entering the human body.

ConclusionsNanotechnology in modern medicine and nanomedicine is in infancy, having the potential to change medical research dramatically in the 21st century. Ÿ Nanomedical devices can be applied

for analytical, imaging, detection, diagnostic and therapeutic purposes and procedures, such as targeting cancer, drug delivery, improving cell-material interactions, scaffolds for tissue engineering, and gene delivery systems, and provide innovative opportunities in the fight against incurable diseases.

Ÿ There has been a huge progress on understanding the function of b i o l o g i c a l s t r u c t u r e s o f nanotechnology tools and techniques and their interaction and integration with several non-living systems, but there are still open issues to be answered, mainly related to biocompatibility of the materials and devices which are introduced into the body.

Ÿ Many promising novel nanoparticles and nanodevices are expected to be used, with an enormous positive impact on human health.

Ÿ The vision is to improve health by enhancing the efficacy and safety of

nanosystems and nanodevices.

In the coming years, nanotechnology will play a key role in the medicine of tomorrow providing revolutionary opportunities for early disease detection, diagnostic and therapeutic procedures to improve health and enhance human physical abilities, and thus enabling precise and effective therapy tailored to the mankind.

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www.ijds.in

Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Vishal Anand2 Minkle Gulati3 Bhargavi Anand

condition and history, together with the dentist's clinical expertise and the patient's treatment needs and prefernces [3]." The need of EBD is important for the dentist, especially with regards to patient safety, and for dentists to be able to keep up to date with developments in diagnosis, prevention and treatment of oral disease, and newly discovered causes of disease. Advances in dentistry are usually first reported in dental journals, and in order to keep up with new research, healthcare professionals need to feel confident that they can read and evaluate dental papers. EBD is founded on clinical research. The ultimate beneficiaries of EBD are members of the public, who will reap the rewards of better care. The internet allows patients, as well as professionals, access to health care information. The public, however, does not have the tools to evaluate the data adequately and must rely on their educated dentists to help sort fact from fiction. Patients will be more educated, more involved in their treatment decisions, and more appreciative of quality care. Dentists will also be benefitted from EBD. Instead of conducting free product testing for dental product manufacturers, practitioners will have at their disposal more valid research on which to predicate their clinical decisions. Researchers will benefit by being called upon to do the clinical testing necessary before new products are

IntroductionPeriodontology has a rich background of research and scholarship. The substantial and extensive periodontal information base, developed over the years, has provided a rational basis for choosing the best treatment for patients. Appraisal of this information has being an on-going and continuous effort by the American Academy of Periodontology (AAP) to ensure that the most accurate and efficacious concepts and technologies are used to provide care and stimulate

[1]innovation . Evidence-based dentistry (EBD) i s t he i n t eg ra t i on and interpretation of the available current research evidence, combined with personal experience. It allows dentists, as well as academics researchers, to keep update of the new developments and to make decisions that should improve their clinical practice. The term "Evidence-based Medicine" (EBM) from which evidence-based dentistry has followed, is relatively new (started in early 1900's) and is defined as "the integration of the best research evidence with clinical

[2]expertise and patient values ." The term was coined by the clinical epidemiology group at McMaster University in Canada. American Dental Association has defined EBD as: "an approach to oral health care that require the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical


1 Dept. of Periodontics, Faculty of Dental Sciences Chhatrapati Shahuji Maharaj Medical University Erstwhile King George's Medical College Lucknow, Uttar Pradesh2 Dept. of Periodontics Babu Banarasi Das College of Dental Sciences Chinhat, Lucknow, Uttar Pradesh3 Dept. of Prosthodontics Sardar Patel Post Graduate Institute of Medical & Dental Science, Lucknow, Uttar Pradesh

Evidence - Based Periodontology - A Review

Address For Correspondence:Dr. Vishal AnandB-103, Gautam Budhha HostelCSMMU/KGMCChowk, Lucknow, Uttar PradeshIndia, 226003Email - [email protected] no. - +91-9621280850


Quick Response Code

placed on the market.

Evidence-based periodontology aims to facilitate the efficient use of research data, accelerating the introduction of the best research into patient care. A useful definition of evidence-based health care has been proposed by Muir Gray: "An approach to decision making in which the clinician uses the best evidence available in consultation with the patient, to decide upon the options that suits that patient

[4]best ." It is a tool to support decision making and integrating the best evidence available with clinical practice, and is composed of various levels, which starts with the recognition of a knowledge gap. From the knowledge gap comes a focused question that leads on to a search

[5]for relevant information. .

Evidence-based periodontology is the application of evidence-based health care

AbstractPeriodontology has a rich history and a strong passion for science. The substantial and extensive periodontal information base, developed over the years, has provided a rational basis for choosing the best treatment for patients. When appropriately evaluated and carefully managed, the integration of emerging technology into practice can improve health and enhance the quality of life. Since the last AAP Workshop in 1996, great technological advances in the areas of data access, retrieval, and management have been made. Dentists need to make clinical decisions based on limited scientific evidence. In clinical practice, a clinician must weigh a myriad of evidences every day. Evidence-Based Periodontology aims to facilitate such an approach and it offers a bridge from science to clinical practice. This article will review the concepts of Evidence-Based Periodontology, introduce the systematic review as a research tool and examine how evidence can both inform and benefit healthcare in periodontology.

Key WordsEvidenced-Based Periodontal therapy, systematic reviews, critical appraisal, study designs


illness.

Bias: Bias is a systematic error. It leads to results which are consistently wrong in one/other direction. Bias leads to incorrect estimate of the effect of a risk factor/exposure.

Confounding: Describes the situation where an estimate of the association between an exposure and the disease is mixed up with the real effect of another exposure on the same disease, the two exposures being the same.

Confidence Interval: A method of statistical inference that allows statement to be made about the publication using data from the sample.

Odds ratio: Ratio of exposure among cases to exposure among controls.

Chance: Chance/sampling error plays a role in most studies of humans, since it is rarely if ever possible to include an entire population in an investigation. We therefore attempt to infer information about the population on the basis of information obtained from representative samples drawn from the population.

Naturalism: Qualitative methods seek to understand health and health-related behaviour in its every day or natural

[7]context .

The Development of Evidence Based PeriodontologyEvidence-based periodontology is built upon developments in clinical research design throughout the 18th, 19th and 20th

[8],[9],[10],[11]centuries . EBM has only been known for just over a decade One of the earliest to take up the challenge in periodontology (in fact in oral health research overall) was Alexia Antczak Bouckoms in Boston, USA. She and her colleagues challenged the methods and quality of periodontal clinical research in the mid-1980s and set up an Oral Health Group as part of the Cochrane Collaboration in 1994. The editorial base of the Oral Health group subsequently moved to Manchester University in 1997 with Bill Shaw and Helen Worthington as co-ordinating editors. The first Cochrane systematic review in periodontology was published in 2001 and researched the effect of guided tissue regeneration for

[11]infrabony defects . Periodontology held by the American Academy of

Periodontology included elements of evidence-based healthcare, supported by Michael Newman at UCLA. The 2002 European Workshop on Periodontology became the first international workshop to use rigorous systematic reviews to inform the consensus. The workshop was organized by the European Academy of Periodontology for the European Federation of Periodontology, under the chairmanship of Professor Klaus Lang. Most recently, the International Centre for Evidence-Based Oral Health was launched in 2003 to produce high quality evidence-based research with an emphasis on, but not limited to, periodontology and implants and to provide generic training in systematic

[5]reviews and research methods .

Clinical RelevanceOne of the barriers to the application of research findings in clinical practice is the way that results are often presented. Typically, a mean value will be published, based on a statistical analysis comparing experimental groups. Such a value in conjunction with its associated 95% confidence interval is useful to determine whether there is a statistically significant difference between groups and will often be a requirement of a study designed for regulatory approval. However, this type of analysis is not designed to provide information about the probability of achieving a certain outcome were the reader to apply it in practice. Such an outcome could include achieving a health benefit or preventing

[5]further disease . One approach to analysing and presenting data in a more clinically useful format is to calculate the number needed to treat (NNT). This is the number of patients that would need to be treated to achieve a stated benefit (NNTb) or to avoid a stated harm (NNTh) . I t i s der ived f rom a dichotomous outcome such as the proportion of sites achieving at least two mm gain in attachment. For the GTR meta-analysis, and using this benefit, the NNTb is eight. In other words, for every eight patients treated with GTR, you can expect one to have at least two mm more gain in clinical attachment than if you had used an access flap (95% confidence

[5]interval) .

Evidence-Based Periodontology v/s Traditional PeriodontologyEvidence-based periodontology uses a more t r an s pa ren t app roach t o

to periodontology. It is a tool to support decision making and integrating the best evidence available with clinical practice (Fig.1). Evidence based periodontology is an approach to patient-care and nothing more. It cannot provide answers if research data do not exist (other than using expert opinion) and it cannot substitute for highly developed clinical skills.

Advantages of evidence-based approach (EBA) compared with other assessment methods

[6]The EBA is: Ÿ Objective.Ÿ Scientifically sound.Ÿ Patient-focused.Ÿ Incorporates clinical experience.Ÿ Stresses good judgement.Ÿ Is thorough and comprehensive.Ÿ Uses transparent methodology.

Terminologies used in evidence-based [7]approach

Systematic review: Review of a clearly formulated question that attempts to minimize bias using systematic and explicit methods to identify, select, critically appraise and summarize relevant research.

Interpretation: It is the process by which qualitative methods seek to identify subjective meaning of a phenomenon.

Process: Qualitative methods used to identify the social processes that underlie healthcare.

Interaction: Encounter between physician and patient helps in bringing together conflicting views of health and

Fig. 1 Evidence Based Dentistry for Effective Practice


values.

The Components of Evidence-Based PeriodontologyEvidence-based periodontology starts with the recognition of a knowledge gap (Fig.2). From the knowledge gap comes a focussed question that leads on to a search for relevant information. Once the relevant information is located, the validity of the research needs to be considered in two broad areas. Firstly, is the science good (internal validity)? Internal validity focuses on the methodology of research. Secondly, can the findings be generalized outside of the study (external validity)? External validity might be affected by the way treatment was performed. After locating and appraising the research, the results then need to be applied clinically, or at least included in a range of options. Finally, the results in clinical practice need to be evaluated to reveal whether the adopted technique achieved the expected

[5]outcome . For rigorous systematic reviews, independent reviewers usually undertake quality appraisal in duplicate and checklists are frequently employed for this purpose. An example by Montenegro et al (2002) is shown in

[12]Table 2 .

Evidence-based approach (EBA) in periodontal therapy will be dealt under the following topics:Ÿ EBA and mechanical nonsurgical

pocket therapyŸ Effect of smoking on Non-surgical

pocket therapy (NST)Ÿ EBA in periodontal regenerationŸ EBA and mucogingival surgeryŸ EBP and open flap debridement

Evidence-based approach and mechanical nonsurgical pocket therapyA total of nine reviews were searched for

[14]the best evidence .Ÿ NST was found to have a positive

effect with the exception of pockets <3 µm.

Ÿ Patient, environmental, and operator factors affect therapy delivery.

Ÿ No difference was found between the effect of hand and machine-driven instruments.

Ÿ Machine-driven instruments were faster than hand-driven instruments.

Conclusions from 1996 world workshop on periodontics

[15]Chemical Plaque Control Ÿ The various antiplaque and/or

antigingivitis agents do not offer a substantial benefit for the treatment of periodontitis.

Ÿ They may however contribute to the control of gingival inflammation that exists with periodontitis.

Ÿ Supragingival irrigation may be used as an adjunct to tooth-brushing and has been shown to aid in the reduction of gingival inflammation.

Ÿ Even when subgingival irrigation is used, the evidence shows that there are no clear substantial long-term benefits for the treatment of periodontitis.

Antibiotic Therapy and PeriodonticsThe risk-benefit ratio indicates that systemic antibiotics should not be used for the treatment of gingivitis and common forms of adult periodontitis. But evidence suggests that systemic

acknowledge both the strengths and the limitations of the evidence. An appreciation of the level of uncertainty or imprecision of the data is essential in order to offer choices to the patient regarding treatment options. Evidence-based periodontology also attempts to gather all available data and to minimize bias in summarizing the data . F u r t h e r m o r e , e v i d e n c e - b a s e d periodontology acknowledges explicitly the type or level of research on which conclusions are drawn. However, one aspect that influences the reliability of the data is the control of bias. Bias is a collective term for factors that systematically distort the results of research away from the truth. Different research designs offer different possibilities for the control of bias and

[5]therefore vary in their reliability . The comparison between evidence based per iodonto logy and t rad i t iona l periodontology is shown in Table 1.

[12]The similarities between the two are: Ÿ High value of clinical skills and

experienceŸ Fundamen ta l impor t ance o f

integrating evidence with patient

Table 1: Comparison Of Evidence-based Periodontology V/s Traditional Periodontology

Evidence-based Periodontology

Uses best evidence available

Systematic appraisal of quality

of evidence

More objective, more transparent

and less biased process

Greater acceptance of levels

of uncertainty

Traditional Periodontology

Unclear basis of evidence

Unclear or absent of quality of

evidence

More subjective, more opaque and

more biased process

Greater tendency to black and

white conclusion

Fig. 2 Steps of Evidence-Based Periodontology

Table 2: Quality Assessment Checklist For Randomized Controlled Trials In Periodontology

Item

Randomization

Allocation

Classification

Adequate

Unclear

Inadequate

Adequate

Unclear

Inadequate

Definition

If generated by random number table (computer generated or not); tossed coins and shuffled cards.

Study refers to randomization but either does not adequately explain the method or no method was reported.

Methods include alternate assignment, hospital number, and odd/even birth date.

Methods include central concealment randomization (e.g. by telephone to a pharmacy or trial office), sequentially

numbered opaque numbers.

If the study referred to allocation concealment but either did not adequately explain the method or no method was reported.

Involved methods where randomization could not be concealed, such as alternate assignment, hospital number,

and odd / even birth date.

Blinding of patient, caregiver and examiner were

considered separately

Withdrawals and drop outs

Recorded as adequate, inadequate, unclear, or for examiner blinding, not applicable

if the study design precluded the possibility of blinding.

Were all patients who entered the trial properly accounted for at the end?

Where dropouts occurred, the use of analyses to allow for losses (such as intention to treat) was noted.


1. When compared with open flap debridement (OFD), guided tissue regeneration (GTR) showed increase in CAL, decrease in PPD, and defect fill.

2. When GTR with bone substitutes was compared with GTR alone, the results were similar.

3. No evidence was found for difference in use of ePTFE versus bioabsorbable membranes.

4. Long-term clinical outcomes/patient-centered outcomes could not be determined due to lack of available data. Heterogeneity was large and bias could not be eliminated.

Evidence on mucogingival therapy [19]Carlo Clauser in his meta-analysis

found that: Ÿ All the surgical procedures allow

complete root coverage.Ÿ Connective tissue grafting achieves

complete root coverage more frequently than does GTR.

Ÿ The probability of complete root coverage is high if the initial recession is shallow, irrespective of the surgical procedure employed.

Ÿ The probability of achieving complete root coverage decreases dramatically as the initial recession depth increases.

Evidence-based approach and open flap debridementSystematic reviews were conducted by

[20]Heitz Mayfield et al and Antczak et al [21].

Clinical implications of the whole review regarding open flap debridementIf pocket depth reduction is the main aim, surgical treatment is the treatment of choice. If increase in clinical attachment level gain is the main aim, nonsurgical therapy is of more benefit for shallow and moderate pockets and surgical therapy is the treatment of choice for deep pockets. Predictability of treatment outcome at sites with furcation involvement or angular defect is unclear.

Need for studies reporting individual [19]patient data

Individual patient data (IPD) is considered the gold standard for the following reasons:Ÿ Only IPD can provide the information

needed to investigate the role of various factors in different clinical situations.

Ÿ If data are only available on a trial level and not for individual sites, it is impossible to individually relate the baseline recession depth of a site to the treatment results of that specific site.

What is the significance of individual [19]patient data?

The clinical trial usually answers yes or no, but the rest of the information remains unused. The lost information would be very valuable in exploring data in order to raise few sensible questions and to design new trials. Therefore at least the following issues are relevant:Ÿ The possibility of exploring data from

different viewpoints.Ÿ The possibility of analysing the same

data in different ways.Ÿ The possibility of replicating the

study to reduce the margin of doubt that cannot be eliminated.

Ÿ The possibility of an in-depth check of the reliability of the data collection and analysis.

Ÿ The possibility of sizing new experiments in an economically sound way by saving or designing expensive pilot studies more rationally.

Ÿ The possibility of computing the confidence intervals of some statistics those are of interest to the reader.

[19]New pathway for scientific articles Ÿ Submittal of a 'conventional' paper

with summarized data.Ÿ Provisional acceptance: The author

could even choose be tween submitting the original set of data prior to publication or accept the challenge of confronting the editor's criticism of the published paper.

Ÿ The conventional paper is published in the journal. The original data and other elaborations by the authors are published on the journal's internet site.

Ÿ A forum to promote discussion of the article via email could be created and new ideas could certainly be a valuable by-product.

How to Critically Appraise?Ÿ It is necessary to consider those

factors that may affect the outcome of a study, will vary according to both the topic of research and the study designs employed, so it is not possible to devise a single system that

antibiotics may be useful in aggressive [15]forms of periodontitis .

Local Delivery of Antimicrobial [15]Agents

Ÿ There was modest gain in clinical attachment level and decrease in probing depth and gingival bleeding.

Ÿ A few side effects were demonstrated namely, transient discomfort, erythema, recession, allergy, and rarely candida infection.

Effect of smoking on nonsurgical therapy Systematic review of the effect of smoking on NST was conducted by

[16]Labriola et al. Search strategy included Medline, Embase and Central. Study design was controlled clinical trial.The outcomes were:Ÿ There was reduced pocket depth

reduction in smokers, compared with non-smokers.

Ÿ There was no significant difference in the change of Clinical Attachment Level (CAL) between smokers and non-smokers.

Ÿ The reason could be that the increased vasoconstriction in peripheral blood vessels of smokers leads to decrease in bleeding and edema. Also, smokers would have less potential for resolution of inflammation and edema within the marginal tissues and therefore less potential for gingival recession.

E v i d e n c e - b a s e d a p p ro a c h i n periodontal regeneration

Guided Tissue RegenerationThe study population included chronic periodontitis patients in subjects 21 years or older. The outcomes assessed were:

Short-term clinical outcomesIt included soft tissue changes such as increased CAL and decreased PPD.

Long-term clinical outcomesIt included disease recurrence and tooth loss.

Patient-centered outcomesIt included various factors such as ease of maintenance, change in esthetics, p/o complications, cost/benefit ratio, and patient well-being.

The meta-analysis done by Needleman et [17] [18]al and Murphy et al , revealed that:


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7. Evidence-based approach. Dent Clin North Am 2002; 46:54-62.

8. Mathews JR. Quantification and the Quest for Medical Certainty. Princeton: Princeton University Press, 1995.

9. Needleman IG. Introduction to evidence based dentistry. In: Clarkson, J, Harrison, JE, Ismail, AI, Needleman, IG, Worthington, H, eds. Evidence Based Dentistry for Effective Practice. London: Martin Dunitz, 2003; 1-17

10. Rangachari PK. Evidence-based medicine: old French wine with a new Canadian label? J R Soc Med 1997; 90:280-284.

11. Swales J. The troublesome search for evidence: three cultures in need of integration. J R Soc Med 2000; 93:402-407.

12. Montenegro R, Needleman I, Moles D, Tonneti M. Quality of RCTs in periodontology - a systematic review. J Dent Res 2002; 81:866-870.

13. Needleman IG, Giedrys-Leeper E, Tucker RJ, Worthington HV. Guided tissue regeneration for periodontal infra-bony defects (Cochrane Review). The Cochrane Library. O x f o r d : U p d a t e S o f t w a r e . h t t p : / / w w w . u p d a t e -software.com/clibhome/

14. Suvan JE . Effec t iveness o f mechanical nonsurgical pocket therapy. Periodontology 2000; 37:49-50.

15. Jeffcoat MK, McGuire M, Newman MG. Evidence based periodontal treatment: Highlights from the 1996 World Workshop in Periodontics. J Am Dent Assoc 1997; 128:713-23.

16. Labriola A, Needleman I, Moles DR. Systematic review of the effect of smoking on nonsurgical periodontal therapy. Periodontology 2000 2005;

37:124-37.17. Needleman IG, Giedrys-Leeper E.

Guided tissue regeneration for periodontal infra?bony defects. Cochrane Database Syst Rev 2001; 2:CD001724.

18. Murphy KG, Gunsolley JC. GTR for the treatment of periodontal intrabony and furcation defects: A systematic review. Ann Periodontol 2003; 8:266-302.

19. Clauser C, Nieri M, Franceschi D. Evidence-based mucogingival therapy, Part 2: Ordinary and individual patient data meta-analysis of surgical treatment of recession using complete root coverage as the outcome variable. J Periodontol 2003; 74:741-56.

20. Heitz-Mayfield L, Trombelli L, Heitz F. A systematic review of the effect of surgical debridement Vs non-surgical debridement for the treatment of chronic periodontitis. J Clin Periodontol 2002; 29:92-102.

21. Antizack A, Joshipura K, Burdick E. Meta-analysis of surgical Vs nonsurgical methods in the treatment of periodontal diseases. J Clin Periodontol 1993; 20:259-68.

22. A m e r i c a n A c a d e m y o f Periodontology. Proceedings of the 1 9 9 6 Wo r l d Wo r k s h o p i n Periodontics. Lansdowne, Virginia, July 13-17, 1996. Ann Periodontol 1996; 1:1-947.

23. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 17:1-12.

will be appropriate for every occasion.

Ÿ Some reviewers have attempted to devise composite scales that give scores for the various quality domains [22]. These scores are then summed to an overall summary measure for the study as a whole.

Ÿ An alternative approach is to appraise each quality component separately [23]. The results of the quality appraisal are used to assess the value of the evidence and to aid clinicians and reviewers in their efforts to place the evidence into context.

ConclusionsThe principles of evidence-based healthcare provide structure and guidance to facilitate the highest levels of patient care. There are numerous componen t s to ev idence-based periodontology including the production of best available evidence, the critical appraisal and interpretation of the evidence, the communication and discussion of the evidence to individuals seeking care and the integration of the evidence with clinical skills and patient values. Evidence-based healthcare is not an eas ie r approach to pa t i en t management, but should provide both clinicians and patients with greater confidence and trust in their mutual relationship.

References1. Micheal G Newman, Jack G Caton,

John C Gunsolley: The use of evidence-based approach in a periodontal therapy contemporary science workshop. Ann Periodontol 2003; 8:1-11.

2. Sackett DL, Strauss SE, Richardson WS, et al: Evidence-based medicine: how to practice and teach EBM, L o n d o n , 2 0 0 0 , C h u r c h i l l Livingstone.

3. Berthold M. Association moves on E B D . A v a i l a b l e a t : http://www.ada.org/prof/resources/topics/evidence based.asp. Accessed October 22, 2003.

4. G r a y J A M . E v i d e n c e - b a s e d Healthcare. Edinburgh: Churchill



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Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Meenakshi S2 Raghunath N

Generation Of OzoneOzone is very useful in the stratosphere by absorbing dangerous B and c ultraviolet radiations but is toxic for the pulmonary tract in the troposphere, particularly mixed with carbon monoxide(CO), N2O and traces of acids as it occurs in smog. It must be clear that if we want to use ozone in medicine, we must avoid its toxicity that can be controlled only if we operate cautiously by:1. Using precise ozone generator

equipped with a well-standardized photometer;

2. By collecting a precise gas volume with defined ozone concentration

3. By knowing the optimal dose for [4]

achieving a therapeutic effect.

There are three systems for generating [5]ozone gas:

Ultraviolet system: produces low concentrations of ozone, used in esthetics, and for air purification.Cold plasma system: used in air and water purificationCorona discharge system; produces high concentrations of ozone. It is the most common system used in the medical and dental field. It is easy to handle and it has a controlled ozone production rate.

Routes Of Administration:Parenteral, intravenous, intra-arterial, intramuscular, subcutaneous, intra-peritoneal, myofacial,intralesional,

[6]dental sulcus.

IntroductionOzone is a gas composed of three atoms of oxygen and present naturally in the upper layer of atmosphere in abundance. It has got the capacity to absorb the harmful ultra-violet rays present in the light spectrum from the sun. Ozone is an unstable gas and it quickly gives up nascent oxygen molecule to form oxygen gas. Due to the property of releasing nascent oxygen, it has been used in human medicine since long back to kill bacteria, fungi, to inactivate viruses and

[1]to control hemorrhages.

History Of OzoneOzone, the tri-atomic state of di-oxygen, symbol O3, has had a history in medical

[2]and dental usuage. In 1785 Van Marum noticed that air near his electrostatic machine acquired a characteristic odor when electric sparks were passed. In 1801, Cruickshank observed the same odor at the anode during electrolysis of water. Finally, in 1840, Shonbein named the substance which gave off this odor, ozone, from the greek word "ozein"- to smell. In 1857 werner Von Siemens designed an ozone generator that has since evolved into the present day, cylindrical dielectric type that makes up most of the commercially available ozone generators in use, and which has sometimes been called the "simens type" ozone generator. Ozone was first applied in Dentistry in 1932 bya a Swiss dental surgeon, Dr. Edwin Fisch.


1 Senior lecturer, Dept. of Prosthodontics,2 Associate Professor, Dept.Of Orthodontics & Dentofacial Orthopaedics, J.S.S. Dental College & Hospital, Mysore, Karnataka.

Ozone - A Healing Touch In Dentistry - A

Review

Address For Correspondence:Dr. Meenakshi SSenior lecturer, Dept .Of Prosthodontics,J.S.S.Dental College and Hospital,Mysore ,Karnataka, India.Email: [email protected] no. +919886494066

th Submission :6 July 2012th Accepted : 13 December 2012

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Usuage Of Ozone In Dentistry:In dentistry, ozone has got its role in various dental treatment modalities. Ozone therapy presents great advantages when used as a support for conventional

[1], [7]treatment.The main use of ozone in dentistry relies on its antimicrobial properties. It is proved to be effective against gram positive and gram negative bacteria,

[8]viruses and fungi.The influence of ozonized water on the epithelial wound healing process in the oral cavity was observed by filippi. It was found that ozonized water applied on the daily basis can accelerate the healing rate

[9]in oral mucosa. for dental extraction due to periodontitis or aggravated apical lesions the method of choice is ozonated water through its disinfectant effect. Before surgery it is recommended for disinfection to rinse the oral cavity with ozonated water and then is used for rinsing of abscess cavity after its

[10]opening.

Ozone Therapy In Prosthodontics:

AbstractOzone, an allotropic form of oxygen, is successfully used in the treatment of different diseases for more than a hundred years. The use of ozone in dentistry represents an absolutely new solution of acute problems in treatment of diseases of both therapeutic and surgical profile. Owing to the antiinflammatory, immunomodulating effects of ozone and its positive influence on the microcirculation, the ozone therapy is now widely used in dental field. This article focuses the ozone therapy and its application in dentistry.

Key Wordsozone, ozonated oilKey Wordsozone, ozonated oil

Microbial plaque accumulating on the dentures is composed of several microorganisms, mainly Candida albicans. Denture plaque control is essential for the prevention of denture stomatitis. In an attempt to solve this problem Arita et al, assessed the effect of ozonated water in combination with ultrasonication of C. albicans. Following exposure to flowing ozonated water (2-4mg/l) for one minute they found no viable C. Albicans suggesting the application of ozonated water in reducing the number of C. Albicans on denture

[11]bases.

Ozone Therapy In Endodontics:During cavity preparation of the tooth, ozonated water is used for disinfection. Ozonated physiological saline at ozone concentration of 2000mcg/l is used in the form of rinsing on the stage of tooth cleaning. The influence of ozonated water on the epithelial wound healing was observed by Filppi. It was found that ozonated water applied on the daily basis can accelerate the healing rate of oral mucosa as it has anti inflammatory and immune modulatory capacities. Ozone and ozonised oils can be used during root canal therapy to clean and sterilize the

[12], [13]canal systems.

Periodontal Pockets:Ozonated oils are made by strict manufacturing standards with medical grade oxygen. This oxygen is 99% pure, and is passed into a converter to from ozone. Ozone is then combined with pure

[14]vegetable oils and extracts.

Desentisitization Of Sensitive Tooth NecksQuick and prompt relief from root sensitivity has been documented after ozone spray for 60 seconds followed by mineral wash onto the exposed dentine in a repetitive manner. Ozone removes the smear layer opens up the dentinal tubules broadens the diameter and then calcium and fluoride ions flow into the tubules easily, deeply and effectively to plug the dentinal tubules, preventing the fluid exchange through the tubules. Thus ozone helps in terminating the root sensitivity problem within seconds and lasts for a long period than the

[15]conventional methods.

Contraindications1. Pregnancy2. Hyperthyroidism


3. Severe anemia4. Acute alcohol intoxication5. Ozone allergy in the event of ozone

intoxication the patient must e placed in the supine position, inhale humid oxygen, and take ascorbic acid,

[5],[15]vitamin E and n-acetylcysteine.

ConclusionThe future of ozone therapy must focus on the establishment of safe and well-defined parameters in accordance with randomized controlled trials to determine the precise indications and guidelines in order to treat various medical and dental pathologies. Scientific support, as suggested by demonstrated studies, for ozone therapy presents a potential for a traumatic, biologically-based treatment for conditions encountered in dental practice. Ozone therapy holds promising alternative dental treatment according to many case studies, but further research is needed to standardize indications and treatment procedures of ozone therapy.

References1. MullernP.,Guggenheim B: efficacy

of gasiform ozone and photodynamic therapy on a multispecies oral biodilm in vitro. Eur.J.Oral sci.2007, 115:77-80.

2. 2. Sunnan G.V. Ozone in medicine - overview and future directions. J.Adv.Med 1988,1(3):159-174.

3. Holmes J. Clinical reversal of root caries using ozone.Gerodontol.2003, 20(2);106-114.

4. Nogales C G. Ferrar i P.A. , Kantorovich E.O. Ozone Therapy in medicine and dentistry. J. Contemp Dent pract 2008,May;4(9)75-84

5. Priyamak A.A. Ozone - The revolution in dentistry. Copenhagen: Quintessance publishing,2004:155-164.

6. Seaverson K, Tschetter D. Patient guide to oxygen/ozone therapy. Health centered cosmetic dentistry. { o n l i n e } URL;http;/www.toothbythelake.net/ozone therapy.html.

7. Huth K.C. effect of aqueous ozone on

t h e N F - k B s y s t e m . .Dent.Res.2007:86(50); 451-456.

8. Flippi A. the influence of ozonised water on the epithelial wound healing process in the oral cavity. Clinic of oral surgery, Radiology and oral m e d i c i n e . A v a i l a b l e a t ; URL:http://www.oxyplus.net.

9. Nagayoshi M, Kitmmora C. the antimicrobial effect of ozonated water. J. Endod.2004.30;778-781.

10. Arita M, Nagayoshi M, Fukuizumi T. Microbicidal efficacy of ozonated water against Candida albicans adhering to acrylic denture plates: O r a l M i c r o b i o l o g y a n d immunology.2005: 20:206-10.

11. Baysan A, Beighton d. assessment of theozone - mediated killing of bacter ia in infected dent ine associated with non-cavitated occlusal carious lesions. Caries Res.2007; 41:337-341.

12. Baysan A, whiley r, Lynch E. anti microbial effects of a novel ozone generating device on microorganisms associated with primary root carious lesions. Caries Res. 2000; 34: 498-501.

13. Polydorov O, pelz K et al . Antimicrobial effect of ozone devices. Eur.J.Oral.Sci.2008:114; 349-353.

14. Garg R, tendon s. Ozone: A new face of dentistry. The internet Journal of DentalScience.2009; 7:2.



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Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Vineet Kumar2 (Major) Narinder Pahwa3 Yogesh Tokas4 Sunanda Roy Choudhury

and can be used for reproximation of teeth.

Design:It is a device made up of 19 gauge stainless steel wire with two loops on either ends to secure the metallic strip and a handle. This makes it convenient for the operator to work with and is comfortable for the patient.

Fabrication:"C" interproximal strip holder can be easily fabricated with a universal plier. (A). It made up of 19 gauge stainless steel wire.1. Firstly 2 loops (6mm in length) are

formed at a distance of 6mm to each other in the same plane. (B)

2. Then wire is bent 900 just next to second loop to fabricate horizontal connecting arm and handle. ©

3. Handle should be fabricated 20 mm from the first 2 loops.

4. After forming handle the wire is c rossed over the hor izonta l connecting arm to fabricate the next 2 loops. (D)

5. Second set of loops should be of same dimensions and are formed parallel to first 2 loops.

6. Handle can be embedded in mix of cold cure acrylic for easy grip and smooth action

7. Up to 5mm width interproximal strip can be snugly fitted to all four loops like a 'C'. (E)

IntroductionInterproximal enamel reduction is a very simple clinical procedure at the hands of a well trained clinician. It involves the reduction, anatomic recontouring and protection of proximal enamel surfaces

[4]of permanent teeth . This procedure of enamel reduction is also known as proximal slicing, reapproximation and slenderization. This procedure is frequently carried out in cases of mild crowding usually in the lower anterior region and involves the removal of 2-4

[1]mm of enamel . Also proximal enamel reduction can be done to stabilize the occlusion after orthodontic treatment by creating more stable contact surfaces that he lp res i s t l ab io l ingual c rown displacement and it help to eliminate the

[3]need for lower incisor retention . Interproximal enamel reduction is a procedure which requires precision and control so that the actual morphology of the tooth is not altered also indiscriminate e n a m e l r e m o v a l m a y l e a d t o hypersensitivity and proximal caries. Therefore this procedure should be carried out with utmost care. Over the years different methods of interproximal enamel reduction have been developed. These include Airotor stripping by Sheridan1 and manually with the help of interproximal strip holders. This article will describe "C" interproximal strip holder which is an economical, easy to fabricate interproximal strip holder that can be fabricated by any general dentist


1 Reader2,3 Senior Lecturer4 Professor and Head Department of Orthodontics, S.B.B. Dental College, Ghaziabad, India.

'C' Interproximal Strip Holder

Address For Correspondence:Dr. Vineet Kumar29/103, East End apartments,Mayur vihar phase 1 ext.Delhi 110096Mobile no.09899347846Email: [email protected]


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8. Free end of strip is pulled from one side to make it taut.

Both safe sided and double sided strip can be snugly fitted. Although distance between the two sets of loops can be increased without compromising the tautness, it is made 20mm apart to prevent trauma to the tongue while moving it in a to and fro motion. (F)

Discussion:Interproximal enamel reduction is an i m p o r t a n t p r o c e d u r e u s e d b y orthodontists to relieve mild crowding in the lower anterior region. Peck and peck came up with an index in the 1970s. They advised stripping whenever the mesiodistal dimension of the mandibular incisor did not fall within acceptable

[5]figures as calculated from the index . The technique of interproximal reduction was revolutionised by Sheridan with the

[6]introduction of airotor stripping . Important indications for interproximal enamel reduction are tooth size discrepancy, interarch discrepancy, tooth shape and dental esthetics, macrodontia,

AbstractInterproximal reduction to remove proximal enamel is a procedure which is frequently carried out in cases of mild crowding usually in the lower anterior region and involves the removal of 2-4 mm

1of enamel . Radiographs are taken so that the clinician can determine the convexity of each 2proximal surface, thickness of enamel on each tooth and the disposition of the roots . Proximal

reproximation is also done when finishing a case. Flattening lower incisor contact points by slenderizing or stripping creates flat contact surfaces that help resist labiolingual crown

3displacement and it also helps to eliminate the need for lower incisor retention . Different modalities to carry out interproximal reduction of the enamel are given in the literature. This article will describe an economical, easy to fabricate interproximal strip holder that can be fabricated by any general dentist and can be used for reproximation of teeth.

Key WordsInterproximal, proximal, crown displacement, labiolingual, reproximation


[7]and to enhance retention and stability . However there are few contraindications to the procedure such as caries susceptibility, poor oral hygiene, severe

[7]crowding and hypersensitivity to cold .The amount of enamel that can be removed and the amount of space generated as suggested by Sheridan is if 50% of interproximal enamel is removed 6.4 mm of space can be generated from the 8 buccal contacts (0.8mm/ contact) and 2.5 mm of space can be created from 5 anterior contacts (0.5mm/ contact). So a total cumulative gain of 8.9 mm of the

[6]space is feasible .

'C' interproximal strip holder is a simple, easy to fabricate and sturdy device which can be used to perform the enamel reduction. Its use is easy to master and above all it can be sterilized in an autoclave and reused. It has got certain disadvantages such as it requires more time and abrasive strips have to be changed frequently. However it has got certain advantages such as the margin of error in the hands of a new operator is

much less as compared to Airotor stripping also the chances of altering tooth morphology and dentinal exposure are fewer with the "C" interproximal strip holder.

Proper treatment planning must be done before carrying out the procedure. Complete set of radiographs and models is needed. The orthodontist must decide how much enamel can be removed so that a sufficient amount of enamel is left to form a proper contact point and avoid

[7]root contact . When a tooth is rotated proximal surface should be reduced rather than the contact area.

Conclusion:Proper treatment planning should be done before carrying out the procedure as it requires precision. Sufficient amount of enamel should be left on the proximal surface to avoid dentinal exposure. When done properly enamel reduction with the 'C' interproximal strip holder will fulfil all these criteria.

References:1. John J. Sheridan: Air-Rotor Stripping

Update. J Clin Orthod 1987; 781 - 7882. Julien Philippe: A Method of Enamel

Reduction for Correction of Adult Arch-Length Discrepancy. J Clin Orthod 1991; 484 - 489

3. Raleigh Williams: Eliminating Lower Retention. J Clin Orthod 1985; 342 - 349

4. Peck H and Peck S: An index for assessing tooth shape deviations as applied to the mandbular incisors. Am J Orthod 1972; 61: 384-01.

5. Peck H and Peck S: crown dimensions and mandibular incisor alignment. Angle Orthod 1972; 42: 148-53.

6. Sheridan JJ. Airotor stripping. J Clin Orthod 1985; 19: 43-49.

7. Sandhya Jadhav et al: Interproximal enamel reduction in comprehensive orthodontic treatment: A review. Indian J Stomatol 2011; 2(4): 245-58.

Figure 1 A. Material Required And Steps In Fabrication Of Appliance.

Figure 1 B. Material Required And Steps In Fabrication Of Appliance.

Figure 1 C. Material Required And Steps In Fabrication Of Appliance.

Figure 1 D. Material Required And Steps In Fabrication Of Appliance.

Figure 1 E. Material Required And Steps In Fabrication Of Appliance.

Figure 1 F. Material Required And Steps In Fabrication Of Appliance.



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Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Deepti Varanasi2 S.R. Godbole3 R.U.Thombare

Light - Laser light used for dental procedures is a form of electromagnetic energy that has four characteristic features - monochromatic, collimation, coherency, and efficiency. Amplification - This electromagnetic energy is generated by excitation of an active medium like argon ,CO2, yttrium, aluminum, gallium ,neodymium, or erbium that provide the source of energy which is then amplified by mirrors and emerges as laser light.Stimulated Emission - The term 'stimulated emission' has its basis in the quantum theory of physics and is further conceptualized as relating to atomic architecture by Niels Bohr. The mirrors at each end of the active medium reflect the photons back and forth to allow further stimulated emission of the laser beam. Radiation - Radiation refers to the light waves produced by the laser as a specific

[2],[3]form of electromagnetic energy .

Laser-tissue interaction:Photobiological effects of laser light with tissue include absorption, transmission, scattering, and reflection. The amount of

Introduction :Laser technology has evolved in recent years and has been incorporated into most dental treatment modalities in different forms. Competition amongst the manufacturers of dental laser technologies has revolutionized the varied application and maneuverability of the laser handpiece for use during hard and soft tissue treatments. Lasers have transformed the working style and image of dentist clinician as a more precision oriented and efficient and updated clinician. However, the success of any procedure using laser is solely the result of knowledge, understanding and

[1],[8]adequate experience regarding lasers .

History :Though the credit for discovering the therapeutic use of lasers goes to Mainman et al (1960), lasers were brought to general dental practice in 1989 by Dr. William and Terry Myers, who modified an ophthalmic Nd:YAG laser

[3]for dental use . This unit pioneered the development of lasers dedicated to the field of dentistry. Since then, a number of laser wavelengths have been brought to the profession for various procedures.

Mechanism of Action:The word laser is an acronym for Light Amplification by Stimulated Emitted Radiation. It is a device that transforms light of various frequencies into an intense, small, and nearly non-divergent beam of monochromatic radiation,

[3]within the visible range .


1 Post Graduate Student2 Professor3 Vice Dean, Professor and H.O.D. Department Of Prosthodontics, Sharad Pawar Dental College, Wardha.

Application Of Lasers In Prosthetic Dentistry

Address For Correspondence:Dr. Deepti Varanasi, Department Of Prosthodontics,Sharad Pawar Dental College, Sawangi(Meghe), Wardha.Ph.no.: 0976460110/ 09960084785Email .: [email protected]

st Submission : 21 July 2012th Accepted : 13 January 2013

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energy that is absorbed by the tissue depends on the tissue characteristics,

[3]such as pigmentation and water content . Argon lasers are highly attenuated by hemoglobin, Diode and Nd:YAG by melanin. Lasers of CO2 and Erbium family are readily absorbed by hydroxyapatite and water, hence has great affinity for tooth structure and bone. Argon, diode and Nd:YAG lasers have greater penetration into the tissues as compared to CO2 and erbium lasers

[2]which act on the outer surface . These properties of lasers are exploited for performing hard and soft tissue procedures. The property of reflection is utilized in caries detection to measure the degree of sound tooth structure. The fourth effect is a scattering of the laser light, which is useful in facilitating the curing of composite resin. It is essential, therefore, for the clinician to choose the laser wavelength that will be absorbed maximally by the target tissue and to regulate the power parameters to create maximal surgical effect while not producing any unwanted collateral

[11]damage .

AbstractThe use of lasers in dentistry has burgeoned at an astounding rate over the past few years. Its introduction into the field of prosthodontics is soon replacing many conventional clinical and laboratory procedures.Once relegated to the use on soft tissue, now even hard tissue procedures can be done with lasers. Precision regarding the use of lasers and selection of the most appropriate laser wavelength and type for a given procedure is of utmost importance. This article reviews literature on lasers with the aim of providing a complete understanding of the fundamentals of lasers and their applications in the various aspects of prosthetic dentistry.

Key WordsLasers, prosthetic dentistry, hard and soft tissue procedures.

Fig.1: Laser Unit

Application of lasers in prosthodontics :1. Pre-prosthetic surgeries during

prosthetic reconstruction2. Laser tooth preparation3. Soft tissue management4. Laser scanning5. Implant recovery 6. Lasers used in dental lab procedures

[4]7. Laser sintering

Pre-Prosthetic Surgeries:The successful fabrication of removable full and partial dentures mainly depends on the preoperative evaluation and preparation of the supporting hard and soft tissue structures. Lasers can be used to per form mos t p repros the t ic

[11]surgeries .These procedures include -

-tuberosity reduction, -osseous recontouring of residual ridge and sockets ,-removal of bony spicules, tori and exostoses, - r e m o v a l o f i n f l a m e d a n d hyperplastic tissue or any soft tissue lesions,

[9]Wigdor et al described the advantages of lasers over conventional surgical procedures as follows:1. Dry and bloodless surgery2. Instant sterilization of the surgical

site3. Reduced bacteremia4. Reduced mechanical trauma5. Minimal postoperative swelling

scarring6. Minimal postoperative pain.


Laser Tooth Preparation :The new age dentistry and today's patient demands painless and stress free dental treatment, and lasers for tooth preparation is the answer to this. The procedure is as follows -1. Crown preparation is done at

maximum setting for cutting enamel (6 watts, 90% air, 10% water), defocused for 30 seconds to 1 minute to anaesthetize the tooth first.

2. Preparation is begun by starting on the buccal surface and making depth cuts of 2- 2.5mm , and then these reference points are connected .

3. The laser power is then further reduced to smoothen the surface of

[4]the prepared tooth .

Advantages of laser tooth preparation [5]include -

Ÿ No local anaesthesiaŸ Reduced clinical timeŸ More comfortable procedureŸ Heat generated is minimalŸ No vibrationŸ No smear layer formationŸ Precise , pin-point accuracyŸ Conservative preparation

Soft Management :The pivotal step of gingival retraction before making an impression for fixed prosthesis is made simple, easy , pain free, quick with the use of quartz fibre of 200-320um wavelength at sublative power levels - 100mJ per 10-20 pulses per second. The laser tip is placed below the height of the gingival crevice, and the tissue is 'ledged' to expose the margin of the preparation. This procedure is technique sensitive and must be done carefully to prevent inadvertent damage

[5],[10]to the tooth .Also, the use of soft tissue diode laser is advocated for gingival recontouring of ovate ponitc site / implant-supported fixed prosthesis to create an appropriate emergence profile. This helps improve aesthetics and increases the ease of postoperative oral hygiene maintenance. The laser (2 to 10pulses per second) is

used in the focused mode and aimed vertically down the tooth surface towards the tissue avoiding contact with the tooth

[11]surface .

Implant Recovery :The two staged implant placement method necessitates making of the final impression for the prosthesis after flap reflection. Instead, erbium/ holmium family of lasers can be used to perform dry mucosal ablation needed to expose the implant ensuring minimal bleeding, trauma to the flap reflected and minimal

[11]tissue shrinkage . One of the most interesting uses of lasers in implant dentistry is the possibility of salvaging ailing implants by decontaminating their surfaces with laser energy. Diode lasers were used in a study by Bach et al , who found a significant improvement in the 5-year survival rate when integrating laser decontamination into the approved

[7]treatment protocol .

Laser Scanner :Optical scanner is a hand held acquisition camera which uses highly visible blue light LED (light emitting diode) to capture digital impressions. These intra-oral scanners capture the 3D geometry of tooth preparation and other relevant structures with the help of a camera placed in a wand which is just 13mm w i d e , t h u s m a x i m i z i n g t h e

[8]maneuverability inside the mouth .

Laser Welding :Laser welding is an effective and routinely used method for various dental lab procedures against the conventional soldering. Advantages of laser welding:1. High bond strength and corrosion

resistance 2. Reduced oxidation when argon gas is

used for welding.3. Minimal heat generation and greater

precision in processing than with [6]soldering or other techniques .

Fig.2: Relative Absorption Levels Of Different Lasers

Fig.3: Pre-prosthetic Surgery Using Laser

Fig.5: 2nd Stage Surgery Using Laser

Laser Sintering :The face of the next generation maxillofacial prosthodontics is aptly described by laser sintering. This technology is a powder base layer-by-layer manufacturing technique in which a substrate is locally heated by laser radiation so that the particles solidify to form a 3D structure. This technology is being used nowadays for plastics, metals, metal alloys, and ceramics to fabricate

[12]any prosthesis . Laser sintering technology is pandora box that opens up more complex and high-tech tools like rapid prototyping and streolithography for making maxillofacial prosthesis,

[13]surgical and radiographic stents .

Conclusion :The potential for laser dentistry to improve dental procedures rests in the dentist's ability to control the power output and the duration of exposure on both hard and soft tissues, allowing for treatment of a highly specific area of focus without damaging surrounding tissues. Each wavelength and each device h a s s p e c i f i c a d v a n t a g e s a n d disadvantages.The clinician who understands these principles can take full advantage of the features of lasers and can provide safe and effective

[1]treatment .


References :1. Aesthetic dentistry :A clinical

approach to techniques and materials. - Ascheim and Dale ; 2nd edition.

2. Robert A. Convissar . 'The biologic rationale for the use of lasers in dentistry.' Dent Clin N am 2004; vol48, pg.771-794.

3. Donald J.Coluzzi . ' Fundamentals of denta l lasers : sc ience and instruments.' Dent Clin N am 2004; vol48, pg.751-770.

4. S t e v e n D . S p i t z . ' L a s e r i n Prosthodontics: Clinical Realities of a Dental Laser in a Prosthodontic Practice.'; Alpha Omegan , Vol101, number4, pg188-194.

5. Steven Parker. 'The use of lasers in fixed prosthodontics.' Dent Clin N am 2004; vol48, pg.971-998.

6. N.Baba, I.Wantanabe. ' Penetration depth into dental casting alloys by Nd :YAG Lase r. ' J ou rna l o f Biomaterials Materials Research (PartB) : Applied Biomaterials ; Vol72 B ; Issue 1, pg 64-68.

7. Emile Martin. 'Laser in dental implantology.'; Dent Clin N am 2004; vol48, pg.999-1015.

8. Timothy C.Adams. 'Lasers in aesthetic dentistry.' Dent Clin N am 2004; vol48, pg.833-860.

9. Gabi Kesler. 'Clinical Applications of laser during removable prosthetic reconstruction.' Dent Clin N am

2004; vol48, pg.963-969.10. B.Gokce, B.Ozpinar ,C.Artunc ,

G.Aksoy. 'Laser use vs. handpiece for tooth preparation : A preliminary in vitro study.'; Journal of Laser Applications, May 2009, Vol21, Issue 2, pg63-66.

11. Pick RM , Colvard MD. 'Current status of lasers in soft tissue dental surgery.' J Periodontol 1993, Vol64 , Issue 7, pg.589-602.

12. F.Klocke, C.Ader. 'Direct Laser Sintering of Ceramics.' ;Prod. Eng. Res. Develop. 2007, vol1, pg279-284.

13. Peter Regenfuss, Robby Ebert , Horst Exner . 'Laser Micro Sintering: a versat i le ins t rument for the generation of microparts.' ;Laser Technology Journal, Jan 2007, Vol 1; pg 26-31.

14. Lingfei Ji, Yijian Jiang . 'Laser sintering of transparent tantalum pentoxide dielectric ceramics.' Dental Materials, June 2006, Vol60, Issue 12, pg1502-1504.

15. Deppe H, Horch HH, Henke J, Donath K. 'Peri-implant care of ailing implants with carbon- dioxide layer.'; Int J Oral Maxillofac Implants 2001, Vol 16, Issue5 , 659-667.



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Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 S.Leena Sankari2 N. ARAVINDHA BABU3 Mahaboob Kadar Masthan4 Tathagata Bhattacharjee

[3]monocytes.Origin of mononuclear phagocyte system: Regarding formation of variety of blood cell from hematopoietic stem cell three models have been proposed. These are hierarchical model, stochastic

[2]model and sequential model.As per hierarchical model hematopoietic stem cell commits to a common myeloid precursor and a common lymphoid precursor. The common myeloid precursor generates precursors of m e g a k a r y o c y t e s , e r y t h r o c y t e s , g ranu locy tes and monocy tes / macrophages, whereas precursor for T- and B-cells and NK cells derived from

[2]common lymphoid precursor.Stochastic model suggests that the commitment decision of haematopoietic precursors is stochastic which can occur

[2]at any time. Sequential model shows that precursors derived from hematopoietic stem cells express the potential for megakaryocyte, erythrocyte, granulocyte, monocyte, B-cell, T-cell and NK cell development

[2]progressively.In foetus Haematopoietic stem cells originate from the yolk sac which migrate to the foetal liver and develop immature

[2]mononuclear phagocytes. On the other h a n d i n a d u l t s b o n e m a r r o w hematopoietic stem cells give rise to monoblast which differentiate into p r o m o n o c y t e , m o n o c y t e a n d macrophages which is short lived, nondividing terminating cells of mononuclear phagocyte system. Beside macrophages which are present during inf lammation there are cer ta in macrophages which are present under

Introduction:The mononuclear phagocyte system (MPS) is a part of the immune system that consists of cell family derived from progenitor cells in the bone marrow. These cells differentiate to form blood monocytes and circulate in the blood and at last they enter tissues to become

[1]resident tissue macrophages . In the last four decades there are several researches to detect the ontogeny of mononuclear phagocytes and it was found that there are several cellular similarities between the morphological, cytochemical and functional characteristics of monoblasts, pro-monocytes , monocytes and macrophages, so all these cells were recognized as members of a single cell family, collectively called mononuclear phagocytes and the concept of the mononuclear phagocyte system was

[2]developed.In the late 19th and early 20th centuries, eminent pathologist K.A.L. Aschoff along with several other pathologists, included macrophages (histiocytes) along with reticulum cells and phagocytic endothelia and proposed the concept of reticuloendothelial system, as all of these cells could internalize certain dyes. Later, however, it was found that endothelial cells are not phagocytes and the uptake of dyes is based on a completely different cellular mechanism. Hence they abandoned the term

[2] ,[3]'reticuloendothelial system'. In contrast van furth gave the concept of mononuclear phagocytic system and stated that all macrophages, either present in infection or residing in tissue at normal steady state derived from


1,2 Associate Professor3 Professor and Head4 Post Graduate Student Department of Oral Pathology & Microbiology, Sree Balaji Dental College & Hospital, Chennai.

The Mononuclear Phagocyte System In Health

And Disease

Address For Correspondence:Dr. S Leena Sankari, Associate Professor,Department of Oral Pathology and Microbiology.Sree Balaji Dental College & Hospital, Chennai-600100Tamil Nadu, Indiae-mail : [email protected]


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normal steady condition. These are microglia in brain, osteoclasts in bone and tissue macrophage such as kupffer cells in liver; histiocytes in connective tissue and skin; free macrophages in body cavities; free and fixed macrophages in spleen, lymph node, bone marrow and thymus; and macrophages in other

[3]various tissues.Current models states that blood monocytes, majority of macrophages and most dendritic cells originate in vivo from hematopoietic stem cell-derived progenitors which is having myeloid

[4]restricted differentiation potentiality.

Genetic control of generation of the MPS:Exact interaction between specific gene and transcription factors is very essential for specification of blood cell lineage. Colony stimulating factors (CSFs) are secreted glycoprotein. They bind to receptors which are located on surface of hematopoietic stem cells and activate intracellular signalling pathway to proliferate and differentiate blood cells, especially white blood cells. There are main three natural colony stimulating

AbstractThe mononuclear phagocyte system (MPS)) consist of cells which are derived from bone marrow hematopoietic stem cells, blood monocytes and cells which are associated with the connective tissue framework of the liver, spleen, and lymph nodes. Previously this system was known as reticuloendothelial system. Mononuclear phagocyte system is critical for immunity as well as homoeostasis. Any disturbance in this system leads to state of various diseases.

Key WordsPhagocyte, Macrophage, Monocyte, Immune.

factors. These are colony stimulating factor- 1 (CSF-1) , colony stimulating factor-2(CSF-2) and colony stimulating factor-3(CSF-3).CSF-1 is also called macrophage colony s t imulat ing factor(MCSF). They secret cytokine, which take major role in differentiation of macrophages from hematopoietic stem cells. In mononuclear phagocyte system colony stimulating factor-1(CSF-1) play the key role in proliferation and differentiation of all mononuclear phagocytic cells.CSF-1 binds to it receptor protein colony stimulating factor -1R (CSF-1R) on the cell surface and is encoded by c-fms proto oncogene

[2]for activation of cells. The expression of CSF-1R gene is dependent on the expression of transcription factor PU-1.Hence expression of PU-1 as well as CSF-1R is very critical for myelopoiesis, macrophage differentiation as well as generation of mononuclear phagocyte

[2]system.PU.1 is called master transcription factor. It is not only essential for development of myeloid lineages but it also prevents the activation of genes which plays major

[2]role to differentiate other pathways.

Cells of mononuclear phagocyte system :Monocytes - Monocytes are produced from its hematopoietic precursors stem cell monoblasts. They are the largest corpuscles in the blood. About one to three days monocytes circulate in the bloodstream and then move into tissues throughout the body. In the tissues they mature into different types of macrophages at different anatomical locations. Monocytes in tissues differentiate into tissue resident macrophages or dendritic cells. Monocytes, their macrophage and dendritic-cells serve mainly three functions in the immune system. These are phagocytosis, antigen presentation, and cytokine production. Monocytes migrate from blood to tissue during infection are equipped with pathogen recognition receptors and chemokines receptors.

Monoblasts & promonocytes -Monoblast develop from pluripotent hematopoietic stem cells which in turn mature into pro monocytes, monocytes and at last into macrophages.

Macrophages: Monocytes differentiate into macrophages in tissue and helps in


innate as well as adaptive immunity. They are resident phagocytes in lymphoid and non-lymphoid tissues and help in clearing of apoptotic cells and production of growth factor. A broad range of pathogen recognition receptors are attached with macrophages which make them efficient for phagocytosis and

[5]production of inflammatory cytokines.Dendritic cell: Dendritic cells are antigen presenting cells. They capture antigen, process them and present them on the cell surface. Along with regulation of adaptive immune response dendritic cells maintain B cell function and recall response. In human the dendritic cell originates from myeloid precursor consider as classical dendritic cell whereas plasmacytoid dendritic cells have lymphoid lineage.Classical Dendritic cells (cDCs): The main functions of these cells are antigen processing and its presentation. They show high phagocytic activity when they are immature whereas mature cells shows

[6],[7]high cytokine producing capacity. Classic dendritic cells are present in human circulation and move from tissues to the T-cell and B-cell zones of lymphoid organs via afferent lymphatics and high endothelial venules. They are generally short-lived, replaced by blood-borne precursors and T cell responses both in

[8],[9]the steady-state and during infection. Plasmacytoid Dendritic Cells (PDCs): These cells have lymphoid lineage and are relatively long lived compared to classical dendritic cells. These cells are present in bone marrow as well as all peripheral organs and produce massive type I interferons (IFN), as a result they respond well against viral infections. Plasmacytoid dendritic cells carry immunoglobulin as well as they act as antigen presenting cells and control T cell

[10].responses

Function of mononuclear phagocyte system:The main function of mononuclear phagocyte system is phagocytosis. It is mainly done by Macrophages.The antigens liberated by macrophages activate the B lymphocytes & helper T lymphocytes. Cells of this system Secrete IL-1, IL-6, and IL-12 in which IL-1 a c c e l e r a t e s t h e m a t u r a t i o n & proliferation of specific B lymphocytes & T lymphocytes, IL-6 causes growth of B lymphocytes & production of antibodies whereas IL-12 influences the T helper cells. These cells also Secret

TNF -alpha and TNF -beta. TNF-alpha causes necrosis of tumor & activates immune system on the other hand TNF-beta stimulates immune system & causes vascular response in addition. The cells secrets platelet derived growth factor (PDGF) which accelerates repair of damaged blood vessel & wound healing. Macrophages remove carbon particle & silicone; destroy senile red cells and hemoglobin. Macrophage also acts as an antigen presenting cell to sensitized T cell.

Disease associated with monocyte macrophage cell line-Numerous human disorders are associated with abnormalities of cells which are having macrophage like

[11]origin.These areŸ Mild blood monocytosis which may

be associated with infectious, inflammatory or collagen vascular diseases.

Ÿ N e o p l a s t i c p r o l i f e r a t i o n o f histiocytes which are seen in monocytic leukemia,malignant histiocytosis.

Ÿ Histiocytic proliferation of unknown o r i g i n s u c h a s s a r c o i d o s i s , g r a n u l o m a t o u s v a s c u l i t i d e s a n d We g e n e r granulomatosis.

Ÿ reactive proliferation secondary to infection as an example Tuberculosis.

Ÿ chemical exposure such as beryllium [11]and zirconium salts.

In monocyte - macrophage dysfunction syndrome there are subtle defect in macrophage function which impair host defence. These defects and its consequent situations areŸ Chemotaxis - present in NeoplasiaŸ Abnormal degranulation - Chediak

Higashi syndromeŸ Abnormal oxygen metabolism -

Chronic granulomatous diseaseŸ Suppressor monocytes - Miliary

tuberculosisŸ S u p p r e s s o r m o n o c y t e s -

Lepromatous leprosyŸ Chemotaxis,Suppressor monocytes -

Disseminated fungal infectionŸ Chemotaxis,Microbial killing -

Glucocorticoid treatmentŸ N e o p l a s t i c p r o l i f e r a t i o n o f

[11]macrophages - Hodgkin disease

A number of recent studies showed that there are macrophage dysfunctions in

neoplastic diseases.These dysfunctions can be considered in relation to cell maturation, migration and chemotaxis, phagocytosis, cytotoxicity and related phenomenon, lysozyme secretion and

[12]macrophages in malignant tumors.Scanning electron microscopic studies showed that the surface appearance of macrophages were more varied in

[12]lymphoma.It has also been demonstrated that patient with disseminated carcinoma had fewer macrophages whereas in localised carcinoma there were increased monocytic mobilisation.Increased phagocytic activity in monocyte/macrophages is related to untreated hodgkin's disease.On the other hand decreased phagocytic activity is related to stage III and IV hodgkin's

[12]disease.There are also lysozyme secretion disorder in malignancy. Favourable clinical condition showed enhanced lysozyme secretion whereas depressed lysozyme secretion is related to poorer prognosis.It has also been proved that presence of macrophages are more in non metastasizing tumour and less in

[12]metastasizing tumour.Alzheimer disease is also related to MPS disorder. Neurotoxicity in Alzheimer is related to higher brain A beta levels. Monocytes accumulate at sites of A-beta deposition is an initial attempt to clear these deposits and stop or delay their neurotoxic effects. Interaction of CCL2( A major monocyte chemokine), with its receptor CCR2 regulates mononuclear phagocyte accumulation and its clearance. CCR2 deficiency leads to l o w e r m o n o n u c l e a r p h a g o c y t e accumulation as a result, higher brain A-

[13]beta levels and neurotoxicity.

Conclusion:This article has first, briefly gives a review and current concept on re t icu loendothe l ia l sys tem and mononuclear phagocyte system.In particular, the review pointed out the cells of mononuclear phagocyte system, how these are developed and its genetic control. It has also described the essential role of macrophages between health and disease. Better understanding of mononuclear phagocyte system will provide us various scope of further investigation in the field of its clinical and basic research.


References1. Van Furth. R. Production and

migration of monocytes and kinetics of macrophages. In: Van Furth R. editor. Mononuclear Phagocytes B i o l o g y o f M o n o c y t e s a n d Macrophages. Dordrecht: Kluwer Academic Publishers;1992. p. 3-12.

2. Z o n g - L i a n g C h a n g . R e c e n t development of the mononuclear phagocyte system: in memory of Metchnikoff and Ehrlich on the 100th Anniversary of the 1908 Nobel Prize in Physiology or Medicine. Biology of the Cell. 2009; 101: 709-721.

3. Kiyoshi Takahashi. Development and differentiation of macrophages and related cells historical review and current concept. Journal of clinical a n d e x p e r i m e n t a l hematopathology.2001 May; Vol 41 no 1.

4. Frederic Geissmann, Markus G. Manz, Steffen Jung, Michael H. Sieweke, MiriamMerad, and Klaus Ley. Development of monocytes, macrophages and dendritic cells. S c i e n c e . 2 0 1 0 F e b r u a r y 5 ; 327(5966): 656-661.

5. Gordon S. Pattern recognition receptors: doubling up for the innate immune response. Cell. 2002 Dec 27;111(7):927-30.

6. Banchereau J, Steinman RM. Dendritic cells and the control of immunity. Nature 1998 Mar 19; 392:245-52.

7. Mellman I, Steinman RM. Dendritic cells: specialized and regulated antigen processing machines. Cell.2001 Aug 10; 106:255-8.

8. Liu K, Victora GD, Schwickert TA, Guermonprez P, Meredith MM, Yao K, Chu FF et al. In vivo analysis of dendritic cell development and homeostasis Science. 2009 Apr 17;324(5925):392-7. Epub 2009 Mar 12.

9. Claudia Waskow, Kang Liu, Guillaume Darrasse-Jèze, Pierre Guermonprez, Florent Ginhoux, Miriam Merad et al. The receptor tyrosine kinase Flt3 is required for dendritic cell development in peripheral lymphoid tissues. Nature Immunology.2008; 9: 676 - 683. Published online: 11 May 2008.

10. Colonna M, Trinchieri G, Liu YJ. Plasmacytoid dendritic cells in immunity.Nat Immunol.2004Dec;

5:1219-26.11. M o n o n u c l e a r p h a g o c y t e s :

Immunological functions and disease i m p l i c a t i o n s - M e d i c a l S t a f f Conference, University of California, San Francisco. West J Med.1979Feb; 130:153-157.

12. Rj sokol, G hudson. Disordered function of mononuclear phagocytes in malignant disease. J Clin Pathol. 1983;36:316-323.

13. H i c k m a n S E , E l K h o u r y J.Mechanisms of mononuclear phagocyte recruitment in Alzheimer's disease. CNS Neurol Disord Drug Targets. 2010 Apr;9(2):168-73.

14. Auffray C, Sieweke MH, Geissmann F. Blood Monocytes: Development, Heterogeneity, and Relationship with Dendritic Cells. Annu Rev Immunol. 2009;27:669.

15. S w i r s k i F K , M a t t h i a s Nahrendorf1,Martin Etzrodt, Moritz Wildgruber,Virna Cortez-Retamozo, Peter Panizzi, et al. Identification of Splenic Reservoir Monocytes and Their Deployment to Inflammatory Sites Science. 2009 31 July: 612-616.

16. Corcoran L, Ferrero I, Vremec D, Lucas K, Waithman J, O'Keeffe M et al. The lymphoid past of mouse plasmacytoid cells and thymic dendritic cells J Immunol.2003 May 15;170:4926-32.

17. Bonifer, C. and Hume, D.A. The transcriptional regulation of the colony-stimulating factor 1 receptor (csf1r) gene during hematopoiesis. Front. Biosci. 2008.13: 549-560.

18. Sasmono R.T., Oceandy D., Pollard J.W., Tong W., Pavli, P.Wainwright et al .A macrophage colony-stimulating factor receptor-green fluorescent protein transgene is expressed throughout the mononuclear phagocyte system of the mouse. Blood. 2003 Feb 1;101(3):1155-63. Epub 2002 Sep 12

19. DeKoter, R.P., Walsh, J.C. and Singh, H. PU.1 regulates both cytokine-dependent p ro l i fe ra t ion and d i f f e r e n t i a t i o n o f g r a n u l o c y t e / m a c r o p h a g e progenitors.EMBO J 1998; 17:4456-4468.

20. David A. Hume, Ian L. Ross, S. Roy Himes, R. Tedjo Sasmono, Christine A. Wells et al. The mononuclear phagocyte system revisited. J. Leukoc. Biol. 2002;72:621-627.



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Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Laxman Singh Kaira2 Vishal Katna3 Himanshu Kapoor4 Ramit Verma5 Manoj Rawat

surface tension, d) mechanical interlocking into under cuts d)intimate adaptation, e)peripheral seal, f) gravity, g ) a t m o s p h e r i c p r e s s u r e , h ) neuromuscular control

2) DiagnosisA thorough examination of edentulous mouth will provide information to make a diagnosis that will relate directly to the retention and stability of mandibular denture. Patients who have a normal tongue position possess a set of conditions that are conductive to retention of lower denture. Patients with a class 1 n 2 tongue position lack the ability to develop retention without some degree of training.

Normal tongue positionTongue fills the floor of the mouth and is confined by the mandibular teeth. The lateral borders rest on the occlusal surfaces of the posterior teeth and apex rests on the incisal edges of the anterior teeth.

Class 1 tongue positionRetracted . floor of the mouth is pulled downward is exposed back to the molar area. The lateral borders are raised above the occlusal plane and the apex is pulled down into the floor of the mouth.

Class 2 tongue positionRetracted and tongue is very tense and pulled backward and upward. The apex is pulled back into the body of tongue and almost disappears . the lateral borders rest above the mandibular occlusal plane. The

IntroductionStability is defined as resistance to h o r i z o n t a l d i s p l a c e m e n t o f prosthesis.Providing a stable mandibular denture has been challenging for prosthodontits. In particular it is more difficult to provide a stable denture in flat resorbed mandibular ridge. A stable m a n d i b u l a r d e n t u r e p r o v i d e s physiological comfort to the patient. This article first of all evaluates the factors necessary to develop stability in lower denture and then discusses the various techniques to improve mandibular denture stability in a resorbed mandibular ridge.

Evaluation of factors necessary to improve stabilityWright C R describes the following factors which are necessary to create and maintain stability in mandibular dentures.1. Retention2. Diagnosis3. Functions of mouth4. Denture base outline5. Occlusal plane6. Arch arrangement7. Patient education and motivation

1) RetentionDefined as the quality inherent in prosthesis acting to resist forces of dislodgement along the path of insertion. Retention resists adhesiveness of food, the forces of gravity, and the forces associated with opening of the jaws. Retention in turn depends upon a)adhesion b)cohesion c)interfacial


1 Assistant Proffessor VCSG Govt.medical College, Garhwal, Uttaranchal2,4 Senior Lecturer3,5 PG Student Deptt. Of Prosthodontics, Himachal Dental College, Sundernagar (H.P.)

Methods To Improve Stability In A Highly

Resorbed Mandibular Ridge - A Review Aricle

Address For Correspondence:Dr. Laxman Singh Kaira47 A Vijay Colony New Cantt Road Dehradoon Uttrakhand, Pin - 248001GSM : 91-8755902525Email Id : [email protected]


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floor of mouth is raised and tense.

3) Functions of mouthThe three important structures that are important to understand the functions of mouth are tongue, teeth, and medial roll of buccinators.

TongueThe tongue is the most accurate muscular organ of the body. It performs the functions of sucking, swallowing, receiving food in the mouth, mastication, vocalization and speech.

TeethThe primary functions of teeth is to deal with food. Incisors incise the food, canines tear the food and molars and 2nd premolars chew food. The Ist premolar neither tears nor chews the food. The buccal surface of first premolar forms a point of fixation for the medial roll of buccinators and other muscles at the corner of mouth.

Medial roll of buccinators

AbstractObtaining stability in resorbed mandibular ridge has long been a challenge for the prosthodontist. Stability of mandibular denture is usually the distinguishing factor between success and failure. This article intends to acquaint the various conservative techniques which can be employed to improve mandibular denture stability in case of a resorbed mandibular ridge.

Key WordsResorbed mandibular ridge, stability.

The medial roll of buccinator is a band of muscle f ibers within the large buccinators muscle. Main function of the medial roll is to form the buccal wall of food trough and to retrieve food that is forced into the buccal pouch. This mechanism is known as "shunting effect".

Food troughThe food is received by the tongue and placed on the molars to be chewed. The medial roll of buccinator moved inward towards the teeth the form the buccal wall of food trough, while the tip of tongue forms the lingual wall of the food trough.

4) Denture base outlineA properly form denture base outline develop a seal that can be maintained during most oral functions. The labial flange extends from one buccal frenum to other. The buccal flange extends from buccal frenum to retromolar pad. The posterior border extends to completely covers the retromolar pad. The lingual vestibule is divided into three areas: the anterior vestibule , called the sublingual crescent area or anterior sublingual fold; 2) the middle vestibule , called the mylohyoid area; and 3) the distolingual vestibule ,called the lateral throat form or retromylohyoid fossa.

5) Occlusal PlaneThe superior - inferior position of occlusal plane is an important factor which affects stability. An occlusal plane that is too high creates unnecessary trouble , while an occlusal plane that is slightly low causes no problem. An elevated plane not only prevents the tongue from reaching over the food table into buccal vestibule but also makes the control of food bolus and denture difficult.

6) Arch arrangementMeans the buccolingual relationship of teeth to the crest of ridge. The anterior teeth are set on the anterior part of the crest of the ridge with an incisal tilt of 20 degree and the posterior teeth are set over the crest of stress bearing area of the basal seat.

7) Patient education and motivationPatients with retracted tongue position should be trained and given the following exercises.Step 1- tongue is thrust in and out rapidly.Step 2 tongue is moved rapidly from side


to side.Step 3 tongue is extended fully and quickly retracted.Step 4 tongue is raised to its highest position well forward in the mouth as the sound "ee" is articulated and dropped down as sound "yup" is articulated. These exercises should be practiced thrice daily for a period of 15 minutes.

Now the treatment procedures to enhance lower denture stability(1) Overdentures(2) Neutral zone(3) Dynamic impression method(4) Metal denture bases(5) Neutrocentric concept(6) Linear occlusion concept(7) Implants

(1) OverdenturesThe anterior mandibular ridge can be preserved by maintaining one or more endodontically treated roots and fabrication of overdenture. Preservation of ridge can be attributed to the following factors (1)Masticatory force is transmitted to the root and periodontal ligament thus stimulating normal physiological function,(2) retained roots substantially increase lateral stability of denture thereby reducing trauma to the edentulous ridge, (3) better occlusal awareness , b i t ing forces and neuromuscular control,(4) increased horizontal stability .

(2) Neutral zoneThe potential space between lips and cheeks on one side and tongue on other ; that area where the forces between tongue and cheeks are equal. The aim of neutral zone is to construct a denture which is in harmony wi th i t s surroundings to provide optimum stability,retention and support. Sir W.Fish described a denture as having three surfaces: the impression surface, the occlusal surface and the polished surface. In case of highly resorbed ridge the area of impression surface decreases and the area of polished surface increases. Denture retention and stability are more dependent on accurate positioning of teeth and the contour of external surface of denture.

The Neutral Zone TechniqueThe usual sequence for complete denture is to make primary impressions, construct special trays, make final impressions, and then fabricate stabilized

bases . Occlusion rims are used to established the occlusal vertical dimensions and centric relation. With the neutral zone approach the procedure is reversed individual trays are made first . These are adjusted in the mouth to be sure that they are not overextended and remains stable during functional movements . Next tissue conditioner is used to fabricate occlusal rims. These rims , which are molded by muscle function ,locate the patients neutral zone . The mandibular neutral zone rim is indexed with putty placed on the buccal and lingual surfaces. Teeth are set up exactly following the index.

3) Dynamic impression methodsIn case of advanced mandibular residual ridge resorption, muscle attachments are located near the crest of residual ridge , and dislocating effect of the muscles is great. The range of muscle actions as well as the space into which denture can extend , can be recorded by dynamic impression method.

Dynamic impression methodA perforated individual tray is made on diagnostic cast . To obtain correct thickness of impression materials against denture bearing tissues, stops are made using green stick compound (3 stops,2 mm high ,one each in region of molars and one in incisors). Mandibular rests are placed in the region of molars on the occlusal surface of the tray. These rests are made using impression compound at a height corresponding to mandibular rest posit ion. Sufficient irreversible hydrocolloid is mixed and placed directly into the mouth to cover the mandibular ridge. A small amount is placed in the tray and the tray is placed in the patient mouth. The tray is pressed with digital pressure until stops are firmly seated on the residual ridge. Next ,the patient is asked to close his mouth firmly until the rests have obtained firm contact with the maxillae. The patient is asked to perform the tongue movements. the procedure develops a proper registration of the denture space. The tray is removed from the mouth after the impression material is set and the cast is poured immediately.

4) Metal denture basesIn 1957, Faber advocated using metal denture bases . however in a patient with atrophic residual Ridge the metal base may shift frequently and irritate the underlying tissues . A metal denture base

with soft liner often meets the needs of these patients. The denture base provides the weight necessary to facilitate stability while maintaining strength,and the soft l i ne r accommoda te s t he r i dge irregularities .

5) Neutrocentric occlusionDevan has suggested the two objectives of his occlusal scheme(1) neutralization of inclines ,(2) centralization of forces. The neutralization of inclines and centralization of forces aids in stability w i t h o u t i n t e r f e r i n g w i t h speech,appearance and chewing capacity. The 5 elements of this scheme are (a) Position - position of posterior teeth should be centralized so that the forces are perpendicular to the support areas.(b) Proportion- reduced the teeth width by 40% and this reduced the vertical stress on the ridge.(c) Pitch - this is the inclination of the occlusal plane. It is oriented parallel to the underlying ridge And midway between them. This directs the forces perpendicular to the mean osseous foundation plane.(d) Form - flat teeth with no deflective inclines were used so that there is no i n t e r f e r e n c e w i t h m a n d i b u l a r movements.(d) Number - the number of posterior teeth was reduced from 8 to 6 . this reduced the magnitude of occlusal forces.

6) Linear occlusion-William Goddard introduced the concept of linear occlusion. Frush described occlusion in geometric terms as one dimensional (linear), two dimensional (flat) and three dimensional (cusped). Linear occlusal scheme has the potential for creating the smallest lateral force component.it consists of following basic parameters.a) Zero degree teeth are opposed by

bladed (line contact) teeth in which the blade is a straight line over the crest of ridge.

b) Mandibular teeth are set to flat occlusal plane.

c) The arch which requires the greatest stability receives the blaed teeth

d) There is no anterior interference to protrusive or lateral movements.

e) This non interceptive occlusion provides a consistent vertical seating force in both centric and eccentric hence transe vectors are eliminated.


7) Implants -A dental implant is a prosthetic device made of an inert alloplastic material implanted into the oral tissues beneath the mucosa or/and periosteal layer , and support for fixed or removable dental prosthesis. The treatment options available for restoration of extremely resorbed mandible with implants can be categorized as:1) E n d o o s s e o u s i m p l a n t s i n

combination with fixed or removable prosthesis.

2) Augmentation of mandible by distraction osteogenesis ,followed by placement of endosseous implants in combination with fixed or removable prosthesis.

The choice between a mandibular implant supported overdentures and a mandibular full arch implant fixed prosthesis is dependent on(a) Anatomic factors( inter foramina

space, inter maxillary relationship).(b) Oral hygiene(c) Speech related factors(d) Patient preference (e) Cost

ConclusionStability of complete mandibular dentures has challenging dentists and patients alike. In particular ,a " resorbed mandibular ridge" is associated with difficulties in providing successful stable dentures. A lower denture which covers the entire supporting area available to it with its flange extensions in harmony with the surrounding musculature will certainly show improved stability.

References1. The glossary of Prosthodontic terms.

J Prosthet Dent 2005;94:10-92.2. Malachias A, Paranhos Hde F, da

Silva CH. Modified functional impression technique for complete denture. Braz Dent J 2005;16: 135-9.

3. J a c o b s o n T E , K r o l A J . A contemporary review of the factors in complete denture retention,stability and support. J Prosthet Dent. 1983;49:306-13.

4. Wright CR. Evaluation of the factors necessary to develop stability in mandibular dentures. J Prosthet Dent 2004;92:509-18.

5. Levin B. Impressions for complete dentures. Chicago : Quintessence Publishing Co. Inc ;1984.

6. Azzam MK, Yurktas AA, Kronman J. The sublingual crescent extension and its relation to the stability in mandibular complete dentures. J Prosthet Dent.1992; 67: 205-10.

7. Zarb bolender. Prosthodontic treatment of edentulous patients. 12 ed.

8. Jennigs DE. Treatment of mandibular compromised ridge. J Prosthet Dent 1989;61:575-9.

9. Gahan MJ, Walmsley AD . The neutral zone impression revisited. BR Dent J 2005;198: 269-72.

10. Makzoume J E. Morphological comparison of two neutral zone impression techniques: A pilot study . J Prosthet Dent 2004;92:563-8.

11. Fish E W . Principles of full denture prosthesis. 7 ed . London : staples press ,ltd :1948.

12. Beresin V E, Schiesser F J. the neutral zone in complete dentures. J Prosthet Dent.1976;36:357-67.

13. Tryde G, Olsson K, Jensen SA ,Cantor R, Tarsetano JJ , Brill N. Dynanic impression methods . J Prosthet Dent 1965; 15:1023-34.

14. Faber BL. Lower cast metal base dentures. J Prosthet Dent.1957;7:51-4.

15. Massad JJ. A metal based denture with soft liner to accommodate the severly resorbed mandibular alveolar ridge. J Prosthet Dent.

16. Devan MM. The concept of nuetrocentric occlusion as related to denture stability. J Am Dent Assoc 1954;48:165-9.

17. Wi l l i amson RS, Wi l l i amson A E , B o w l e y J . M a x i m i s i n g mandibular prosthesis stabilty utilizing linear occlusion,occlusal plane selection and centric recording. J Prosthodont 2004;13:55-61.

18. Frush linear occlusion .III Dent J.1966;35:788-94.

19. Stellingsma C, Vissink A, Meijer HJ, K u i p e r C , R a g h o e b a r G M . Implantology and the severly resorbed edentulous mandible. Crit Rev Oral Biol Med 2004;15:240-8.



www.ijds.in

Review Article


E ISSN NO. 2231-2293 P ISSN NO. 0976-4003

1 Rajesh H2 Anupama S Rao3 Vinita Boloor4 Sruthy Pratap

Progress of Periodontal Research and Practice in IndiaUntil 1960, the concept of specialist was not developed in India. With the commencement of postgraduate education in India in 1959, Orthodontics achieved a status of specialty as it was something new concerned with aesthetics. Periodontics as a specialty received very little attention during 1960-70s probably because little was known about the pathogenesis and management of periodontal diseases. The scientific advances made since then have constructively helped us to understand the disease and alter our treatment accordingly. The dental profession has now fully recognized the importance of

[3]periodontics as a clinical specialty.

Research Facilities and Activities.Research facilities and activities are absolutely essential for the progress of the dental health care system in India. Most of the research is carried out in dental institutions as a part of post graduate studies. The modern studies require sophisticated equipments. This requirement has resulted in a wide knowledge gap between the developed world and the institutions located in the less developed countries. Uniform modernization of laboratory facilities in all the institutions is an issue that has to be addressed at war footing. This will help

IntroductionResearch is a quest for knowledge through diligent search (or) investigation (or) experimentation aimed at the discovery and interpretation of new

[1 ]knowledge. Research inculcates scientific and inductive thinking and it promotes the development of logical habits of thinking and organization. Information technology is playing a major role in research in terms of data acqu is i t ion , in te rp re ta t ion and dissemination of results. It had r e v o l u t i o n i z e d t h e f i e l d o f bioinformatics. This has spurred increased research activities worldwide including India.

Research in India is still in its infancy. There is urgent need for reorganization of the valid research data in India. This will help in formulating national dental health care policies and evidence based clinical practice. Most of the research projects - be it epidemiological, preventive, experimental, clinical or non-clinical are of short-term nature and academic oriented. Fewer long term studies are

[2]available. Most of the multinational companies present in India carry out periodontal research to propagate their innovative products; however, their results may sometimes be biased. In this review an attempt made to analyze periodontal research and its effect on periodontal practice in India.


1,3 Reader2,4 Senior Lecturer Department of Periodontics, Yenepoya Dental College, Yenepoya University, Deralakatte, Mangalore, 575018

Trends In Periodontal Research In India - A

Review

Address For Correspondence:Dr. Anupama S RaoSenior Lecturer, Department of PeriodonticsYenepoya Dental College, Yenepoya University,Deralakatte, Mangalore, 575018, KarnatakaEmail Id- [email protected]


Quick Response Code

promote quality research all over the country.

Deficiency in skilled, trained, competent and willing technicians makes the maintenance and efficient use of facilities difficult. Most of the sophisticated instruments are imported and that spares and trained troubleshooters often have to fly in from overseas. This requirement

[2]has to be fulfilled. The migration of skilled researchers and technicians to well developed countries in search of lucrative jobs is another issue that the government of India need to address. National policies which make the entire dental practice and research lucrative should be formulated to prevent the brain drain. But care should be taken against spurious commercialization of research.Funding of research is another important issue. Several funding agencies are now available from department of public health. Indian medical council for research is one of the premier funding agencies with several institutes all over

[4]the country. .

AbstractPeriodontal diseases have affected mankind since the earliest of times. As there is a gradual decline in the trend of caries, prevalence of Periodontitis has considerably increased over a period of time. Periodontal research has progressed tremendously worldwide. In India in spite of increased periodontal research proper documentation and dissemination of information is lacking. This is a major setback in the current era of evidenced based clinical practice. Several Indian studies in the field of periodontology have been analysed and reviewed. This will aid in generating a data base of Indian periodontal research. Hence In this review, an attempt is made to analyze documented periodontal research and its relevance in present scenario in India.

Key WordsAntimicrobial therapy, epidemiological studies, periodontal research, regenerative therapy.

International Clinical Dental Research organization was established in 2008 with the objective of promoting dental research in India. It is dedicated to motivate clinicians & academicians to take more interest in clinical research. It also provides funds to support research

[5]studies / dissertations . The progress of the profession is very much dependent on the research activities. But the deficiency of technical knowledge of attaining funds among resea rchers has l ed to disappointment and loss of desired results. Health department has the responsibility to encourage the interested researchers by simplifying the funding regulations and reduction of outright rejections of research proposals. Basic training should be given to all health science faculties in writing a proposal, carrying out the research, fund management and publishing results.

Health Departments in most of the states give a low priority to dental research work. Meager funds are allotted to Dentistry. These funds do not fulfill the required objectives due to improper handling. A huge deficit exists between the amount of research work carried out and published work. This issue needs to

[5]be addressed . Inspite of deficiencies per iodonta l r esearch has been progressing steadily. Large number of dissertations has been written during the last four decades on various aspects of Periodontology (see Table 1).

Many multinational companies have excellent research facilities in India, but very little research work is published by them. Ayurvedic companies are also conducting research on their products and their works are not regularly published. Several in vitro studies and animal studies are also being conducted

[6]all over the country.

Research Activities in various fields of Periodontics - Most studies seem to have focused on research topic relevant to the Indian environment. Topics covered are mentioned in the Table no. 1

Etiological factors: Great deal of research work has established multifactorial nature of periodontal disease and mechanism leading to loss of attachment

[7],[8]apparatus.

Risk factors: Many risk factors modify the response to periodontal diseases


(Table 2).In India, there has been an explosion of interest and research in this area. Many dissertations & researches on risk factors in the Indian scenario have been

[9], [10], [11]conducted and published

Epidemio logy : Many sca t t e red epidemiological studies have been carried out in India. But results have been varied and conclusion cannot be drawn. (Refer Table 3, 4, 5)

Oral health in India:A muticentered oral health survey was conducted in India in the year 2004 under a co l labora t ive programme by Government of India and WHO. Few of well documented studies have been shown in the Table 5.

Plaque Control:The Indian system of medicine has given great importance to oral hygiene as an essential part of the general health. Many

people do not use tooth brushes but they use miswak sticks or fingers to clean their teeth (Refer table 6). However, in urban and semi-urban areas, tooth brushes are slowly replacing traditional methods. Effective employment of public health tools are required to improve the understanding and awareness of the results of research among general public. This could help translate research into practice.

Studies on indigenous herbs like neem, turmeric, miswak, pomegranate etc have gained importance in the recent years. Research on various interdental aids,dentifrices, mouth rinses & indigenous tooth cleansing methods are being conducted . This has resulted in development of quality indigenous products & has brought down the cost factor which is an important concern in developing countries.

Therapeutic treatment modalities

Table 1: Dissertation Topics from Indian Institutions.

No

1

2

3

4

5

6

7

8

Research Topics

Basic Science

Oral Hygiene

Epidemiology

Etiology

Systemic Factors

Preventive Periodontics

Treatment Modalities

Periodontal medicine

Table 2: List of risk factors

Risk Factors For Periodontal Disease

1.Tobacco Smoking

2.Diabetes

3.Microbial Deposits

4.Systemic Factors

5.Poor Oral Hygiene

Risk Determinants

1.Genetic Factors

2.Age

3.Gender

4.Socioeconomic Status

5.Stress

Risk Indicators

1.Hiv/aids

2.Osteoporosis

3.Infrequent Dental Visits

Risk Markers

1.Previous History Of Periodontal Disease

2.Bleeding On Probing

Table 4: Various Epidemiological Studies Conducted in India.

Sr No

1

2

3

4

5

6

7

8

9

10

11

12

Author

Desai

Shenoy

Shrinivas

Anil

Sunitha

Maity

Maity

Rao

Joseph Cheru

kurien

Shah

Maity

Year

1986

1989

1989

1990

1993

1994

1995

1995

1996

1996

1997

1998

Place

Gujarat

Bangalore

Andhra

Trivandrum

Varanasi

West Bengal

West Bengal

Varanasi

Trivandrum

karnataka

Ahmadabad

West Bengal

Age Group

-

15-64

-

10-15

35-44

35-44

65-74

15-19

35-44

65-74

15-19

35-44

65-74

15-44

15-64

15-19

35-44

65-74

15-19

35-44

30-44

45-64

>65

0

0.00

96

2

3

1

4.10

8.50

4.30

0.70

0.00

4.30

0.70

0.00

16

8.50

0.00

0.00

0.00

4.40

53

41

0

0

1

0.00

37

2

18

8

4.70

3.70

24.00

0.80

0.00

24.00

0.80

0.00

43

15.00

5.30

0.00

0.00

24

12

0.80

2

0

2

12.60

35

37

68

14

4.10

16

72.00

88.00

69.00

72.00

88.00

69.00

38

48

87.00

25.00

9.80

72

72

77

71

68

3

67.00

23

40

9

44

8.10

7.30

0.30

21.00

28.00

0.30

21.00

28.00

1.60

17

6.10

40

12

0.20

18

20

27

28

4

21.00

27

19

2

33

2.90

13.0

0.00

0.30

2.90

0.00

0.30

2.90

0.20

12

1.50

35

78

0.00

8.20

0.30

24

3.30

CPI score in percent


Table 3: Various Epidemiological Studies Conducted in India.1 [*M-Male], [*F-Female]

No

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Author

Marshall & Shourie

F.S. Mehta & Sanjana

J.C. Greene

S.P. Ramjford

O.P.Gupta

T.N. Chawla

M.K. Basu and Dutta

D.C. Miglani and Sharma

M.K.Basu and Dutta

Roy B.C.

S.L. Mangi

Boghani

Ramachandra

Thaha

YEAR

1947

1953

1960

1961

1964

1963

1963

1965

1965

1965

1966

1971

1974

1986

Place

Lahore

Bombay

Bombay - Urban Rural

Bombay - Urban Rural

Trivandrum

Lucknow

Calcutta

Government General Hospital, Madras

Calcutta

Kirke

Poona Industrial

Workers

Rural, Madhya Pradesh

Gujarat

Madras, Rural

Urban

Trivandrum, Urban, Rural

Sample Size

1054

2219

1613

1161

159

155

275

153

74

43

33

25

259

449

292

M 242

141

173

F 237

98

97

M103

153

99

F 41

36

26

775

947

1396

659

2040

1200

M 358

317

315

212

220

154

117

67

F 178

154

185

110

120

74

91

19

37

9837

6547

1536

6500

Age Group

09-17

18-55

11-17

11-17

19-30

11-20

21-30

31-40

41-50

51-60

61-70

71-80

12-17

18-23

24-30

12-17

12-17

18-23

24-30

12-17

18-23

15-20

21-25

26-30

15-20

21-25

26-30

12-17

18-23

24-30

19-55

19-55

19-55

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51-55

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51-58

>56

15-65

Gingivitis%

99.40

100.00

96.90

100

100

90.30

96.70

100.00

100.00

100.00

100.00

100.00

100.00

100.00

100.00

100.00

100.00

100.00

92.70

98.30

99.60

81.85

88.89

94.95

85.37

88.89

92.32

93.70

98.70

99.60

100.00

100.00

100.00

98.90

99.40

100.00

100.00

100.00

100.00

100.00

100.00

100.00

98.90

87.80

100.00

100.00

100.00

100.00

100.00

100.00

68

92.60

Periodontitis%

-

-

-

2.2

42.40

16.80

55.60

87.60

94.80

94.80

100.00

72.20

80.00

91.10

22.31

74.51

91.32

34.60

40.82

93.81

63.11

86.27

86.90

71.170

83.33

88.46

18.60

45.00

64.40

44

64

11.45

37.85

50.79

7.75

78.63

92.20

92.30

88.90

18.65

39.13

64.54

82.50

90.55

83.40

89.47

100.00

12.00

38.60

95.30

95.50

88.60

13Table 6: Indigenous Oral Hygiene Methods in India

(A) Plants and Their Parts1. Leaves:

Mango (Mangifera Indica)

Ixora Coccinea L

Cashew (Anacardium Occidentale)

2. Twigs and Stems:

Babul (Acacia Arabica)

Ixora Coccinea L

Neem (Azadirachta Indica)

Eugenia Corymbosa

Jatropha Carcas L

Banyan(Ficus Bengalensis)

3. Fruits:

Coconut and its parts

4. Barks:

Walnut (Juglans Regia)

(B) Charcoal and Modifications

1. Charcoal peices ground on stones

2. Charred paddy husk - Carbon from paddy husk (Activited Carbon)

3. Burnt charcoal shell powder

4. Carbon collected on vessels used for boiling water

5. Burnt tobacco and snuff

6. Modification of above mentioned materials with the addition of salt,

pepper powder etc.

(C) Miscellaneous

Sand

Brick Powder

Ash

Coal Powder

Common Salt

Table 7: Non surgical Therapy

Scaling and root planing

Elimination of Iatrogenic factors

Antimicrobial therapy- Systemic and local drug delivery system

Occlusal therapy

Photodynamic therapy

Ozone therapy

Table 8: Surgical Therapeutic Modalities – Objectives

Elimination of Gingival Inflammation

Elimination of Periodontal Pockets

Cessation of Bone Destruction

Re-establishment of Gingival Architecture

Regeneration of Periodontal Tissues

Lasers

Implants


Conventional treatment modalities for periodontal disease is shown in Table 7 & 8

Nonsurgical therapy;Antimicrobial Therapy: Administration of systemic antibiotics has been beneficial in periodontal treatment. But they have several problems associated with their use in the treatment of periodontal diseases. Three approaches to antimicrobial therapy have been studied. These include 1. Systemic administration: amoxicillin

,metronidazole combination & ciprofloxacin combination have been

[9]found to be effective.2. Topical administration: various

mouth rinses & herbal drugs are being studied. Conflict of interest cannot be completely ruled out.

3. Con t ro l l ed r e l ea se dev ices : Resorbable & non resorbable drug delivery system have been studied. Systematic review on the efficacy of local drug delivery system is presented in the [Table 9].

All the above studies reported reductions in gingival inflammation, plaque scores, and bleeding indices in both the control and the experimental groups. It was concluded that use of antimicrobial

12Table 5: Prevalance data of periodontitis from various studies done on Indian population.

Year

2000

2000

2004

2004

2004

2005

2005

2005

2005

2007

2007

2007

2007

2007

2007

2007

2007

2007

2008

2008

2008

2008

Author

Doifode et al

Jagdeeshan et al

Bali et al

Ranganathan et al

Ranganathan et al

Sood et al

Singh et al

Singh et al

Singh et al

Ranganathan et al

Vandana et al

WHO Arunachal pradesh

WHO Delhi

WHO Maharashtra

WHO Orissa

WHO

Puducherry

WHO Rajasthan

WHO uttar Pradesh

Parmar et al

Parmar et al

Rooban et al

Rooban et al

Sample size

5061

912

310

per region

1000

1000

1000

1000

500

500

136

1029

3200

3200

3200

3200

3200

3200

3200

168

197

100

100

Population

Urban

Field survey

rural women

Urban

Rural

Urban HIV males

Urban HIV females

Field survey

Field survey

Urban field survey

Rural field survey

Urban HIVpopulation

Periodontics OPD

Field survey

Field survey

Field survey

Field survey

Field survey

Field survey

Field survey

Dental OPD tobacco chewer

Dental OPD tobacco chewer

Dental OPD

Drug abuser

Age

0-60

>15

5-12

35-44

65-74

31-40

21-30

NA

>15 years

>15

>15

29.2± 4.9

15-74

12-15

35-44

65-74

12-15

35-44

65-74

12-15

35-44

65-74

12-15

35-44

65-74

12-15

35-44

65-74

12-15

35-44

65-74

12-15

35-44

65-74

32.7± 0.7

30.4± 0.8

18-48

18-48

Periodontitis definition

N.A.

N.A

CPITN

NA

NA

CPITN

CPITN

CPITN

CPITN

CPITN

CPITN

WHO

WHO

WHO

WHO

WHO

WHO

WHO

NA

NA

NA

NA

Prevalence of periodontitis in percentage

34.8

20.63 - moderate

25.6 - severe

17.5 - moderate

7.8 - severe

(35-44)

21.4 - moderate

18.1 - severe

(65-74)

31.6

22.6

29.1 - moderate

12.5 - severe

39.4 -moderate

16.9 - severe

43.5 moderate,22.9 severe

43.2 moderate

22.9 severe

86

27.2

15 moderate

2.6 severe(35-44)

18 moderate

0.6 severe(65-74)

34 moderate

1 severe(35-44)

1.7 moderate

1.7 severe(65-75)

48 moderate

2.9 severe(35-44)

55.2 moderate

4.5 severe(65-74)

35.7 moderate

9.7 severe(35-44)

32 moderate

15.6 severe (65-74)

26.3 moderate

4.7 severe (35-44)

48 moderate

2 severe

23.5 moderate

(35-44)

34.5 moderate

14 severe (65-74)

54.76

31

76.7

23.3

Table 9: Characteristics of the included studies by design 14and agent vehicle.

Reference

Mahendra

Mukthar

Kranty

Srinivas

Design/Duration

RCT split mouth

3 month

RCT split mouth

3 month

RCT split mouth

3 month

RCT split mouth

3 month

Intervention

SRP

SRP + Minocycline

Microsphere

SRP

SRP+10%Doxy Gel

SRP

SRP + Tetracycline

Hcl fibres

SRP

SRP + 2.5mg

Chlorhexidine gluconate

Sites

20

20

37

51

20

20

20

20

Outcome

PD,PI, BOP

PD,PI, BOP

PD,PI, BOP

PD,PI, BOP

Guided tissue regeneration- Resorbable and non resorbable membrane

Clot stabilization, wound protection and space closure

Root biomodification

Polypeptide growth factors

Enamel matrix proteins

Graft materials

Table 10: Various regenerative procedures

sustained-release systems as an adjunct to SRP does not result in significant patient-centered adverse events. Local drug delivery combined with Scaling and root planing appears to provide additional benefits in pocket depth reduction compared with Scaling and root planing alone. Systematic reviews of the data in Indian population is the need of the hour.

Lasers:Extensive studies are being carried out in different research institutes under the watchful eyes of the regulatory bodies like Indian Laser Association and laser institutions. Lasers have been used inNonsurgical therapy, surgical pocket therapy,Photodynamic therapy,Lasers for implant place ment, treatment of p e r i i m p l a n t i t i s , D e n t i n a l hypersensitivity, low level laser therapy, s o f t t i s s u e p r o c e d u r e s l i k e Depigmentation, frenectomy, frenotomy Systematic reviews and meta analysis of

[16]these studies are awaited.

Regenerative therapy:Several animal & human studies are being carried out on various regenerative approaches. Sri chitira research institute has been instrumental in bringing out quality indigenous allografts & GTR membranes(Periobone G, Periocol) . Extensive studies are being done on various regenerative materials at the institutional level and the research centers. But systematic reviews and meta analysis of studies being conducted in India is needed (Refer Table 10).

Periodontal Medicine:It is a new branch of Periodontology that has developed. It describes the bidirectional interrelationship between the systemic and periodontal diseases. It is a relatively new topic. It has gained momentum very quickly. Several studies are being conducted in various institutions in collaboration with hospitals. This is an encouraging development in periodontal research in India. ICMR has recently initiated research proposal to assess the relationship between periodontitis and preterm labor and low birth weight implants.

The available research data and future data should be subjected to intense scrutiny to separate sham research from original. These studies have to be


subjected to meta-analysis and published in accessible reputed journals. This strong data should form the foundation of public health education. There is no dearth of information among our clinician and researchers. But proper orientation through basic training could do a world of good. Attempts should be made to systematically document, analyze and interpret data. Screening of research for authenticity and appropriate utilization of funds will encourage periodontal research in India.

A collaborative approach between the P u b l i c h e a l t h d e n t i s t r y a n d Periodontology is required to improve the quality of dental care. A definite collaborative strategy could bring about radical changes in the public perception and understanding of periodontal research. This approach could help develop effective means of public health education and provision of advanced periodontal care to each and every citizen of our country and not to only the privileged few.

Conclusion:Scientific enquiry is one of the most challenging enterprises of mankind and the support it receives is the measure of strength, vitality and vision of the society. The approach and methods of research have slowly evolved to become more precise and efficient. The tendency is to explore the unknown. Periodontal research has gained a lot of momentum in the present decade. Funding of research has promoted many clinicians and academicians to indulge in active research. Various research centers of global standards are being set up in India. Bioinformatics is available at a mouse click. There is a need to conduct muticentered randomized controlled studies and systematic reviews because we are in an era of evidence based dentistry. There is a need to set up research database which can be easily accessed. Information sharing among various institution and research centers are required. Periodontal research in India has to create its own identity in the global scenario. The ultimate aim of the research should be to benefit the so called 'common man'.

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