journal of the oxford dental college squamous … 2 issue 2 may- aug...figure 4:iopa of 11,12,13,21....

1 2 3 4Dr. Ahad.M.Hussain , Dr. A.V.Ramesh Dr.Shoba.C , Dr.Sunil Kumar ,5Dr.C.D.Dwarakanath

,

SQUAMOUS CELL CARCINOMA OF THE GINGIVA

ABSTRACT

Keywords : Oral cancer, squamous cell carcinoma, gingival

neoplasms.

Squamous cell carcinoma is a malignant epithelial

neoplasm characterized by variable clinical manifestations.

When located in the gingiva, this neoplasm may mimic

common inflammatory lesions. This is a case report of

squamous cell carcinoma of the gingiva, where the patient

had no known risk factors for the development of this

neoplasm.

Case Report

Dept of PeriodonticsThe Oxford Dental College, Hospital and Research Center, Bangalore.

1Reader2Professor

3Reader4Private Practice

5Professor& HOD

INTRODUCTION

1A neoplasm, as defined by Willis is an abnormal

mass of tissue, the growth of which exceeds and is

uncoordinated with that of normal tissues and persists

in the same excessive manner after cessation of the

stimuli which evoked the change. The term Oral

Cancer encompasses all neoplasms that originate in

the oral tissues. Oral Squamous Cell Carcinoma is a

serious health concern, and is one of the leading 2cancers in India and South east Asia. Many unique

features of gingival squamous cell carcinoma clearly

delineate it from Oral Squamous Cell Carcinomas

(OSCC) arising in other sites.

Except for carcinoma of the lip vermilion, the

most common sites of oral OSCC are the tongue and

floor of mouth, followed at a lower frequency by the 5 soft palate, gingiva and buccal mucosa. This neoplasm

is more frequent in males than in females, but this is 3, 4 not observed in cases of OSCC located in the gingiva.

Gingival OSCC can mimic a multitude of oral lesions

Journal Of The Oxford Dental College

Email for [email protected].

especially those of inflammatory origin, in addition

predisposing and presenting factors are different from

those of other OSCC. Squamous cell carcinoma (SCC), 3however, comprises 90-95% of all oral malignancies.

In general, OSCC affects subjects after their 4fifth decade of life . The etiology of OSCC remains

unknown, but predisposing factors such as smoking 3associated with heavy alcohol use are well known.

Other habits have also been associated with OSCC,

such as chewing betel leaves and reverse smoking, 6practices commonly observed in India .

CASE REPORT

A male patient aged 26 years reported to the

Department of Periodontics, The Oxford Dental

College and Hospital with a complaint of a swelling in

relation to the upper right front “gums” since two

months. The swelling was painless however, he

complained of mild pain associated with food

lodgment and bleeding on brushing. The patient had

been to a dentist earlier for which antibiotics and

| 114 | JTODC, 2 (2), 2011

analgesics were prescribed for the same. The patient

did not have any tobacco related habits Medical, family

and occupational histories were non-contributory.

GENERAL EXAMINATION

A diffuse swelling was noticed in the right

submandibular region. The submandibular, jugulo--

digastric and jugulo-omohyoid lymph nodes were

palpable, non tender, firm and movable.

ORAL EXAMINATION

There was a localized diffuse enlargement

present on the gingiva in relation to 11, 12, 13 and 14,

measuring about 4 cm in length and 3cm in width. On

the labial surface the lesion extended anteriorly upto

the mid labial region of the central incisor, posteriorly

upto the disto buccal line angle of the canine (Figure

1). Superiorly the lesion extends into the vestibule and

inferiorly it extents upto the gingival margin (Figure 1).

Palatally the lesion does not cross the mid line and

extends anteriorly upto the mid palatal region of the

central incisor and posteriorly upto the mid palatal

region of the first premolar. Superiorly it extends close

to the mid line but does not cross it and inferiorly it

extents upto the marginal gingival (Figure 3). The

surface was reddish and ulcerated and the lesion easily

bled on probing. The margins of the lesion were rolled

(Figure 2). On periodontal examination there were

deep probing depths measuring 8-10 mm and Grade I

mobility was present in relation to 11, 12 and 13. There

was no recession seen as shown in Figure 1. However

all the other teeth were periodontally sound and

showed no signs of disease. Trauma from occlusion

was also ruled out as there were no signs of a

traumatic bite.

RADIOGRAPHIC EXAMINATION

The radiograph showed a well circumscribed

radiolucency extending up to the apical third with loss

of lamina dura and interdental bone in relation to 11,

12, 13 and 21.

Figure 1: Facial view of the lesion

showing the extent of the lesion

Figure 2: The lesion shows a

rolled margin and an ulcerated surface.

Figure 3: This view shows the palatal extension

of the lesion. Note the ulcerated surface.

Figure 4:IOPA of 11,12,13,21. Note the well

circumscribed radiolucency extending upto

the apical third of the roots with complete

loss of interdental bone.

Figure 5:Occlusal

radiograph.Note

the lesion with

well defined

borders extending

from 13-21,

with bone loss

extending upto

the apices.

JTODC, 2 (2), 2011 | 115 |

Based on the clinical and radiographic

examination a Provisional diagnosis of Pyogenic

Granuloma was made. However a differential

diagnosis of Exophytic squamous cell carcinoma,

Keratoacanthoma, Papilloma, Exophytic verrucous

carcinoma was made. An incisional biopsy of the lesion

and a FNAC of right submandibular lymph node were

taken to ascertain the final diagnosis.

CYTOPATHOLOGICAL EXAMINATION

Site: Submandibular Lymph Node

The cytosmears show numerous malignant

epithelial cells with a good number of mitosis. The

cytological features are suggested of a metastatic

epithelial malignancy probably a squamous cell

carcinoma.

The lesion presented squamous epithelial cells

invading the connective tissue in the form of cords and

islands. The cells resembled normal keratinocytes with

a few islands showing keratin pearl formation.

Inflammatory cell infiltrate was seen in the connective

tissue.

Figure 6: Note bone loss localized

only to the region of the lesion

Figure 7: Note numerous malignant epithelial cells

HYPERCHROMATIC NUCLEI

Figure 8:Note multiple hyperchromatic nuclei.

EPITHELIAL INFILTRATION

LIGHT MICROSCOPE

Figure 9:Connective tissue infiltration is seen

KERATIN PEARLS

Figure 10:Keratin pearls

seen within the connective tissue

Figure 11: Islands of epithelial cells clearly

seen infiltrating the connective tissue

MALIGNANT EPITHELIAL CELLS

| 116 | JTODC, 2 (2), 2011

DIAGNOSIS

A final diagnosis of Squamous cell carcinoma of

gingiva in relation to 11,12,13,21 was made based on

the histopathological report.

DISCUSSION

Squamous cell carcinoma is the most frequent

malignant neoplasm of the mouth, corresponding to

96% of all malignant tumors in this region. In general,

Squamous cell carcinoma mainly affects males older 7than 40 years and is extremely rare in young patients.

The most affected sites in the mouth are, in decreasing

order, the lower lip, lateral border of the tongue, retro 5molar region, floor of the mouth, and gingiva.

Although the clinical presentation of the Squamous cell

carcinoma varies according to the affected site, the

degree of differentiation and the invasiveness or the

exophytic characteristics of most lesions are noticed in

the ulcerative stage.

Squamous cell carcinoma of the gingiva more 5 frequently involves the mandible than the maxilla and

4is mainly observed in female older than 50 years.

However, some investigators have reported a higher 6 8 incidence in males. According to Yoon et al and Meleti

7et al . Gingival Squamous cell carcinoma does not

show a strong association with classical risk factors

such as tobacco use, either smoked or chewed in its

various forms especially when associated with

excessive consumption of alcohol. In the present case,

the patient had never consumed alcohol or used any

other tobacco products.

Carcinoma of the gingiva usually is manifested as

an area of ulceration which may be a purely erosive

lesion or may exhibit an exophytic granular or verrucous

type of growth. It may or may not be painful. The

attached gingiva is more frequently involved than the

free gingiva. On the gingiva an exophytic carcinoma may

assume a serpiginous form. Similar corroborative

features are found in the present case.

In the maxilla, gingival carcinoma often invades

into the maxillary sinus, or it may extend onto the

palate or into the tonsillar pillar. In most cases, the

metastasis to either the submandibular or the cervical

nodes eventually occurs in over 50% of the cases.

Histologically, the oral squamous cell carcinoma

is described as a tumour consisting of irregular rests,

columns or strands of malignant epithelial cells

infiltrating subepithelially.

This patient can be categorized as Stage III with

T N M . The prognosis is not particularly good, at this 2 1 0

stage of the disease 5 year survival rates are

approximately between 50% and 80%. The treatment

will comprise of surgery or radiotherapy or both. The

patient opted to get treatment at Tata Memorial

Cancer Institute in Mumbai.

CONCLUSION

Carcinoma of the gingiva is rare, but occasionally

the clinician may come across such cases, hence the

clinician must have the expertise to diagnose and

recommend appropriate treatment to the patient.

BIBLIOGRAPHY

1. Kumar et al.Robbin's basic pathology. Elsevier,

2003; 165-167.

2. Indira.A.P, Priscilla David, Roopashri G, Vaishali

M.R. Gingival Carcinoma in a non-tobacco user.

Journal of Dental Sciences & Research 1:2: 67-

74.

3. Wallace ML, Neville BW. Squamous cell

carcinoma of the gingiva with an atypical

appearance. J Periodontol. 1996 Nov;

67(11):1245-8.

4. Barasch A, Gofa A, Krutchkoff DJ, Eisenberg E.

Squamous cell carcinoma of the gingiva. A case

series analysis. Oral Surg Oral Med Oral Pathol

Oral Radiol Endod. 1995 Aug; 80(2):183-7.

5. Torabinejad M, Rick GM. Squamous cell carcinoma

of the gingiva. J Am Dent Assoc. 1980 Jun;

100(6):870-2.

6. Misra S, Chaturvedi A, Misra NC. Management of

gingivobuccal complex cancer. Ann R Coll Surg

Engl. 2008 Oct; 90(7):546-53.

7. Meleti M, Corcione L, Sesenna E, Vescovi P.

Unusual presentation of primary squamous cell

carcinoma involving the interdental papilla in a

young woman. Br J Oral Maxillofac Surg. 2007

Jul; 45(5):420-2.

8. Yoon TY, Bhattacharyya I, Katz J, Towle HJ, Islam

MN. Squamous cell carcinoma of the gingiva

presenting as localized periodontal disease.

Quintessence Int. 2007 Feb; 38(2):97-102.

JTODC, 2 (2), 2011 | 117 |

1 2 3Dr. Smitha B Kulkarni , Dr. Sachin. Naik , Dr Naganandini S

DENTAL CARIES VACCINE- PROSPECTS AND CONCERN

ABSTRACT

A cell-surface protein (PAc) and Glucosyltransferases

(GTFs) are two important virulence factors of the cariogenic

organism Streptococcus mutans.

In humans perioral immunization has led to an

increased salivary antibody activity in some studies but not in

others. There is no conclusive evidence which shows that

antibodies against S. mutans can influence dental caries

activity in man. Collaborative studies ought to be organized.

By such studies key information about the possible role of

antibodies in the development of dental caries in man could

be obtained within a reasonable period of time.

Keywords :

Most (but not all) of the

experimental dental caries vaccine approaches attempted to

modify initial infection with S. mutans. Translating this

approach to humans required that, we know when children

first become infected with S. mutans and from whom they got

the infection. Secretory IgA (SIgA) is the principal immune

component of major and minor gland salivary secretions and

thus would be considered to be the primary mediator of

adaptive immunity in the salivary milieu. The need to

understand the rate and characteristics of salivary immune

development triggered a series of studies that now support

the rationale for caries vaccine applications in early

childhood.

Dental caries. Streptococcus mutans,

Glucosyltransferase

Review Article

Department of Public Health Dentistry,

1Reader2Post Graduate Student

3Professor and HOD

The Oxford Dental College, Hospital and Research Center, Bangalore.

INTRODUCTION

Dental caries is an irreversible microbial disease

of the calcified tissues of teeth, characterized by

demineralization of the inorganic portion and

destruction of the organic substance of the tooth, (1) which often leads to cavitation. Mutans streptococci


Email for [email protected]

are the primary etiological agents, and within this

group, Streptococcus mutans and Streptococcus

sobrinus are the two most prevalent isolates from the

human oral cavity, Studies performed in numerous

laboratories over several decades have demonstrated

the feasibility of immunizing experimental rodents or

primates with protein antigens derived from

| 136 | JTODC, 2 (2), 2011

Streptococcus mutans or Streptococcus sobrinus

against oral colonization by mutans streptococci and

the development of dental caries. Protection has been

attributed to salivary IgA antibodies which can inhibit

sucrose-independent or sucrose-dependent

mechanisms of streptococcal accumulation on tooth surfaces according to the choice of vaccine antigen.

Strategies of mucosal immunization have been

developed to induce high levels of salivary antibodies

that can persist for prolonged periods and to establish (2) immune memory. Research efforts towards

developing an effective and safe caries vaccine have

been facilitated by progress in molecular biology, with

the cloning and functional characterization of virulence

factors from mutans streptococci, the principal

causative agent of dental caries, and advancements in

mucosal immunology, including the development of

sophisticated antigen delivery systems and adjuvants

that st imulate the induct ion of sal ivary (3) immunoglobulin A antibody responses. The

mechanisms of action of salivary IgA antibodies

against mutans streptococci include interference with

their sucrose-independent and sucrose-dependent

attachment to, and accumulation on, tooth surfaces,

as well as possible inhibition of their metabolic

activities [Russell et al., 1999]. This review describes

current strategies for anti-caries vaccination efforts

with regard to important bacterial targets, routes,

adjuvants and delivery systems for active and passive

immunization. Progress towards practical vaccine

development requires evaluation of candidate

vaccines in clinical trials. Promising strategies of

passive immunization also require further clinical (4)evaluation.

VACCINES

Vaccines are an immuno-biological substance

designed to produce specific protection against a

given disease. It stimulates the production of a

protective antibody and other immune mechanisms.

Vaccines are prepared from live modified organisms,

inactivated or killed organisms, extracted cellular (5)fractions, toxoids, or a combination thereof.

PREVENTING CARIES WITH A VACCINE

A vaccine painted on teeth has been shown to

protect against dental caries inducing Streptococcus

mutans, according to an article in the May issue of

Nature Medicine. Researchers at Guy's Hospital in

London conducted a study to compare an antibody

generated in transgenic plants such as tobacco or

potatoes with its parent immunoglobulin G antibody.

As part of the study, they grew a colorless, liquid S.

mutans vaccine in genetically altered tobacco plants.

To test the effectiveness of their vaccine against its

parent IgG antibody, they treated test subjects who

harbored S. mutans with topical chlorhexidine

gluconate for nine days to deplete the oral flora and

eliminate S. mutans. Then they applied the vaccine

directly to the volunteers' teeth two times a week for

three weeks. At days 21, 58, 88 and 118 after the trial

began, researchers collected dental plaque and saliva

samples to monitor the recolonization of S. mutans.

They found that the vaccine reduced the levels of S.

mutans to below detectable limits in both the plaque

and saliva in the subjects for at least four months.

Among control subjects who received a parent IgG

preparation, recolonization of S. mutans in plaque and

saliva began at day 21. Researchers hope their

findings will lead to the use of this approach to develop

vaccines that combat other microbial infections (6)affecting mucosal sites.

Glucosyltransferases- Growth of mutans

streptococci in the presence of antibody to GTF

significantly diminishes the amount of biofilm on glass

surfaces. Thus it was not surprising that immunization

studies using intact GTF vaccines successfully

protected animals infected with S. mutans. Passive

administration of antibody to GTF in the diet was also (7)protective.

CARIES VACCINE TESTED

Researchers at the Indiana University School of

Dentistry tested a mucosal vaccine against dental

caries. The researchers theorized that a mucosal

vaccine against Streptococcus mutans' surface

structures would protect against tooth decay by

inducing antibodies in saliva that would reduce

bacterial acid production and adhesion to the tooth

surface. The researchers studied experimental rats

that had been infected with S. mutans. The rats were

divided into one test group and two control groups.

The rats in test group A were intranasally vaccinated

JTODC, 2 (2), 2011 | 137 |

with a mixture of surface structures from S. mutans

combined with cholera toxin B subunit, or CTB, and

free cholera toxin, or CT, which are commonly used to

help the body absorb vaccines and to induce a greater

amount of antibodies in saliva and serum. The rats in

control group B were not vaccinated. The rats in

control group C were vaccinated intranasally with only

CTB and CT. At the end of the study, the rats in group A

had salivary and serum antibody response levels more

than twice as high as those of the rats in groups B and

C. The researchers concluded that the vaccine was (8)successful in reducing the amount of tooth decay.

NEW VACCINE STRATEGIES

ACTIVE IMMUNIZATION

Synthetic Streptococcus mutans peptides

S.mutans antigen coupled to cholera toxin subunits

S.mutans genes fused to a virulent salmonella

Liposome-coated delivery systems

PASSIVE IMMUNIZATION

Monoclonal antibodies applied topically

Immune bovine milk and whey

Egg yolk antibody

Transgenic plant antibody

Primary oral immunization of mice with a

bacterial protein antigen genetically coupled to the A2

and B subunits of cholera toxin induced specific

secretory immunoglobu l in A and serum

immunoglobulin G antibodies that persisted at

substantial levels for at least 11 months. A subsequent

single booster immunization did not further enhance

the antibody responses. Long-term antibody

persistence may be especially important in infections

caused by common pathogens for which continuous (9)immunity would be advantageous.

Recent attention to mucosal immunization

strategies has been focused on the nasal route for

vaccine delivery. This study was designed to determine

the effectiveness of a liposome-protein vaccine

compared to that of a protein-only vaccine in inducing

immune responses in humans. Healthy subjects were

randomly assigned to two groups and immunized

intranasally with a crude antigen preparation rich in

glucosyltransferase (C-GTF) from Streptococcus

mutans, alone or in liposomes. Parotid saliva, nasal

wash, and serum were collected prior to and at weekly

intervals following immunization and were analyzed

for anti-C-GTF activity by enzyme linked

immunosorbent assay. The levels of immunoglobulin A

(IgA) anti-C-GTF activity in the nasal wash from both

groups after immunization increased to a mean peak

of fivefold over the baseline level on day 28. Salivary

IgA anti-C-GTF responses were induced to a lesser

extent. IgG and IgA anti-C-GTF responses in serum

were detected on day 14. The IgA responses were

predominantly of the IgA1 subclass. These results

show that C-GTF vaccines were more effective in

inducing a local secretory IgA antibody response than

a salivary or serum response when they were given

intranasally. The IgA1 anti-C-GTF response in nasal

wash samples for liposomal antigen versus antigen

only was the only response which was significantly

different (P < 0.04). This suggests that the form of the

antigen affects the magnitude of the local mucosal

response but not that of a disseminated response.

These results provide evidence for the effective use of

a nasal protein vaccine in humans for the induction of (10)mucosal and systemic responses.

Passive immunization: There is increasingly active

research in passive immunization-the direct

introduction of specific pre targeted antibodies into the

mouth-as a means of protecting against caries.

Bypassing both the systemic and the mucosal immune

systems would raise far less concern about any

potential side effects of the immunization procedure.

An attenuated, recombinant Salmonella

typhimurium mutant, x4072(pYA2905), expressing

the surface protein antigen A (SpaA) of Streptococcus

sobrinus was investigated for its effectiveness in

inducing protective immune responses against S.

sobrinus-induced dental caries in an experimental

caries model. Fischer rats were orally immunized with

either 108 or 109 CFU of S. typhimurium

x4072(pYA2905). Persistence of salmonellae in

Peyer's patches and spleens and the induction of

immune responses were determined. Maximum

numbers of salmonellae were recovered from Peyer's

| 138 | JTODC, 2 (2), 2011

patches of rats within the first week of immunization,

with higher numbers recovered from rats given 109

CFU than from those given 108 CFU. Serum anti-

Salmonella and anti-SpaA responses increased more

rapidly in rats given 109 CFU than in rats given 108

CFU. The salivary antibody response to SpaA increased

with time, but the response varied in the two groups.

In a separate study, rats were orally immunized with

the recombinant Salmonella mutant and then

challenged with cariogenic S. sobrinus. The levels of

serum and salivary antibody and caries activity were

assessed at the termination of the experiment. Higher

levels of salivary immunoglobulin A antibody to SpaA

and Salmonella carrier were detected in rats given 109

CFU than in those given 108 CFU, and these responses

were higher than those in nonimmunized controls.

Mandibular molars from immunized rats had lower

numbers of recoverable streptococci and less

extensive carious lesions than those from

nonimmunized, control rats. These data indicate that

oral immunization with an attenuated recombinant S.

typhimurium expressing SpaA of S. sobrinus induces

the production of antigen-specific mucosal antibody (11)and confers protection against dental caries.

Several other approaches to passive

immunization are being investigated. Systemic

immunization of cows with a vaccine from whole

mutans streptococcal cells generated IgG antibodies in

both the serum and the milk whey. When added to a

caries promoting diet in a rat model, this immune whey

resulted in a substantial degree of caries protection."

In a preliminary human experiment, 14 days' use of a

bovine-milk-whey mouthrinse containing antibodies to

mutans streptococci resulted in a lower percentage of

plaque S. mutans than both that in pre-test plaque and

that in the control group's plaque several studies have

investigated yolk from the eggs of chickens immunized

with S. mutans as a source of antibodies. Formalin-

killed whole cells of S. mutans were used as the

antigen in one study' and cell associated

glucosyltransferase in the other. Caries reduction in

the rat experimental model was shown in both (12)studies.

ROUTES TO PROTECTIVE RESPONSES

Mucosal applications of dental caries vaccines are

generally preferred for the induction of secretory IgA

antibody in the salivary compartment, since this

immunoglobulin constitutes the major immune

component of major and minor salivary gland

secretions. Many investigators have shown that

exposure of antigen to mucosally associated lymphoid

tissue in the gut, nasal, bronchial, or rectal site can

give rise to immune responses not only in the region of

induction, but also in remote locations. Several

mucosal routes have been used to induce protective

immune responses to dental caries vaccine antigens.

ORAL

Many of the earlier studies relied on oral

induction of immunity in the gut-associated lymphoid

tissues (GALT) to elicit protective salivary IgA antibody ”responses. System. Experiments in humans of the

ingestion of S. mutans in gelatins capsules resulted in

an increase in secretory IgA antibodies in saliva,

although for a limited time only. The oral route is not

ideal for reasons including the detrimental effects of

stomach acidity on antigen, or because inductive sites (13)were relatively distant.

INTRANASAL

Intranasal installation of antigen, which targets

the nasal-associated lymphoid tissue (NALT)

(Brandtzaeg and Haneberg, 1997) Conventional

Sprague-Dawley rats, infected with S. mutans at 18 to

20 days of age, were intranasally immunized with a

mixture of S. mutans surface proteins, enriched for

fimbriae and conjugated with cholera toxin B subunit

(CTB) plus free cholera toxin (CT) at 13, 15, 22, 29,

and 36 days of age (group A). Control rats were either

not immunized (group B) or immunized with adjuvant

alone (CTB and CT [group C]). At the termination of

the study (when rats were 46 days of age), immunized

animals (group A) had significantly (P < 0.05) higher

salivary IgA and serum IgG antibody responses to the

mixture of surface proteins and to whole bacterial cells

than did the other two groups (B and C). No significant

differences were found in the average numbers of

recovered S. mutans cells among groups. Therefore, a

mixture of S. mutans surface proteins, enriched with

fimbria components, appears to be a promising

immunogen candidate for a mucosal vaccine against ( 14)dental caries.

JTODC, 2 (2), 2011 | 139 |

TONSILLAR

Tonsillar tissue contains the required elements of

immune induction of secretory IgA responses (van

Kempen et al., 2000), although IgG, rather than IgA,

response characteristics are dominant in this tissue

(Boyaka et al., 2000). The palatine tonsils, and

especially the nasopharyngeal tonsils, have been

suggested to contribute percursor cells to mucosal

effector sites (Brandtzaeg, 1996), such as the salivary

glands.the experiments have shown that topical

application of formalin-killed Streptococcus

sobrinuscells in rabbits can induce a salivary immune

response, which can significantly decrease the

consequences of infection with cariogenic

Streptococcus sobrinus. Interestingly, repeated

tonsillar application of a particulate antigen can induce

the appearance of IgA antibodies producing cells in

both the major and minor salivary glands of the (15)rabbit.

MINOR SALIVARY GLAND

The minor salivary glands populate the lips,

cheeks, and soft palate. These glands have been

suggested as potential routes for mucosal induction of

salivary immune responses (Crawford et al., 1975;

Schroeder et al., 1983), given their short, broad

secretory ducts that facilitate retrograde access of

bacteria and their products (Nair and Schroeder,

1983), and given the lymphatic tissue aggregates that

are often found associated with these ducts.

Experiments in which Streptococcus sobrinus GTF was

topically administered onto the lower lips of young

adults have suggested that this route may have

potential for dental caries vaccine delivery. In these

experiments, those who received labial application of

GTF had a significantly lower proportion of indigenous

S. mutans/total Streptococcal flora in their whole

saliva during a 6-week period following a dental (13)prophylaxis, compared with a placebo group

RECTAL

More remote mucosal sites have also been

investigated for their inductive potential. For example,

rectal immunization with non-oral bacterial antigens

such as Helicobacter pylori (Kleanthous et al., 1998) or

Streptococcus pneumonia (Hvalbye et al., 1999),

presented in the context of toxin-based adjuvant, can

result in the appearance of secretory IgA antibody in

distant

Salivary sites. The colo-rectal region as an

inductive location for mucosal immune responses in

humans is suggested from the fact that this site has

the highest concentration of lymphoid follicles in the

lower intestinal tract. Preliminary studies have

indicated that this route could also be used to induce

salivary IgA responses to mutans streptococcal

antigens such as GTF (Lam et al., 2001). One could,

therefore, foresee the use of vaccine suppositories as

one alternative for children in whom respiratory (15)ailments preclude intranasal application of vaccine.

FUTURE DIRECTIONS

Efforts have been made to develop

immunotherapeutic agents against caries and

periodontal disease, it is a matter of great importance

to ensure safety along with effective protection.

Further, as a result of increased commercial demand

for safe therapeutic antibodies, there is a need for an

efficient and low-cost production process. Recent

advances in genetic engineering have allowed for the

development of new commercial products from plants

for food and ecological and medical applications

(Mason and Arntzen, 1995; Collins and Shepherd,

1996; Mason et al., 1998). For the development of

vaccines, tobacco and/or potato plants were

genetically transformed and expressed the genes

encoding the hepatitis B surface antigen (Mason et at.,

Production of antibodies in plants has been previously

reported (Conrad and Fiedler, 1998). However, full-

length antibodies are not readily assembled in

bacterial expression systems (Ma and Hein, 1996). An

important advantage of plants is their ability to

assemble H-chains with L-chains to form full-length

antibodies. In the biotechnology field, transgenic

plants are rapidly emerging as an important source for

the production of proteins of human origin. These

proteins are being targeted for medical and dental

therapeutic purposes and thus constitute strong (14) motivation for enhanced research in plant biology.

CONCLUSION

Streptococcus mutants play a key role for the

development of dental caries and that a vaccine

| 140 | JTODC, 2 (2), 2011

directed against this microorganism could be a

valuable adjunct to existing preventive measures in

some countries. Only a few studies, however, have

examined the efficacy of dental caries vaccines in

humans. Although several years have passed, active

immunization against caries remains a goal yet to be

achieved. The successful development of vaccines

against oral diseases requires a concerted effort by

industry, government, and academia and also it is a

matter of great importance to ensure safety along with

effective protection.

BIBLIOGRAPHY

th1. Shafer's text book of oral pathology 5 Edition

2. MichaelW. Russella Noel K. Childersb Suzanne M.

Michalekc Daniel J. Smithd Martin A. Taubmand,

A Caries Vaccine?, Caries Res 2004;38:230235

3. Hajishengallis and Michalek-1999-Current status

of a mucosal vaccine against dental caries.-Oral

Microbiol Immunol-14-1-20

4. Russell MW, Childers NK, Michalek SM, Smith DJ,

Taubman MA, A Caries Vaccine? The state of the

science of immunization against dental caries.

Caries Res. 2004 May-Jun;38(3):230-5.

5. Park's Text book of Preventive and Social thmedicine, 20 Edition

6. Question of the month, JADA, Vol. 129, June

1998 682

7. Daniel J. Smith, Caries Vaccines for the Twenty-

First Century. Journal of Dental Education,

Volume 67, Number 10

8. Irwin d. Ivandel, Caries prevention: current

strategies, new directions, , Am Dent Assoc

1996;127;1477-1488.

9. George Hajishengallis et al, Persistence of Serum

and Salivary Antibody Responses after Oral

Immunization with a Bacterial Protein Antigen

Genetically Linked to the A2/B Subunits of

Cholera Toxin, Infection and Immunity, Feb.

1996, Vol. 64, No. 2, p. 665667

10. Noel k. Childers et al, A Controlled Clinical Study

of the Effect of Nasal Immunization with a

Streptococcus mutans Antigen Alone or

Incorporated into Liposomes on Induction of

Immune Responses, Infection and Immunity.

Feb. 1999, p. 618623 Vol. 67, No. 2

11. Redman et al, Oral Immunization with

Recombinant Salmonel la typhimurium

Expressing Surface Protein Antigen A of

Streptococcus sobrinus: Dose Response and

Induction of Protective Humoral Responses in

rats Tamara k, Infection and Immunity, May

1995, p. 20042011 Vol. 63, No. 5.

12. Construction of a New Fusion Anti-caries DNA

Vaccine, Y. Niu, J. Sun, M. Fan, Q.-A. Xu, J. Guo,

R. Jia, and Y. Li, J Dent Res 88(5):455-460, 2009

13. KM Shivakumar, SK Vidya, GN Chandu, Dental

caries vaccine, Indian j Dent Res.20(1).2009

14. Y. Abiko passive immunization against dental

caries and periodontal disease: development of

recombinant and human monoclonal antibodies,

Crit Rev Oral Biol Med (2000) Crit Rev Oral Biol

Med 11(2):140-158 (2000)

15. Fontana, et al.-1999-Intranasal immunization

against dental caries with a Streptococcus

mutans-enriched fimbrial preparation.-Clin

Diagn Lab Immunol-6-405-9

JTODC, 2 (2), 2011 | 141 |

1 2 3Dr.SavithaA.N , Dr.MuthaD.P , Dr. DwarakanathC.D.

TREATMENT OF MANDIBULAR MOLAR WITH CLASS IV FURCATION INVOLVEMENT UTILIZING GLASS IONOMER CEMENT

ABSTRACT

Treatment of multirooted posterior teeth has

conventionally consisted of scaling and root planing followed

by attempts to preserve and conserve as much structure

possible by apically positioned flaps, tunnelling, root

amputation, root resection, guided tissue regeneration,

osseous grafting and combination of osseous grafting and

barrier membrane techniques. Successful treatment has

often been directed and measured by how well the clinician

obtains sufficient access to facilitate patient's hygiene effort.

Long term success has been determined by tooth retention

and arrest of further destruction within furcation areas.

This case report uses a glass ionomer cement

restoration as a barrier in the treatment of class IV furcation

defect. There was reduction in tooth mobility and plaque

count, no bleeding on probing and decrease in probing depth

with the use of glass ionomer cement. The study considers

this as a treatment modality for seemingly hopeless

mandibular molar.

Case Report

Department of periodontics

1Professor2Post Graduate Student

3Professor and HOD


INTRODUCTION

Treatment of class III and class IV furcation has

been historically less than predictable. Numerous

studies have shown that teeth with advanced furcation

defect have less survival rate than those with less 1,2,3severe bone loss . Various treatment modalities have

been attempted to retain multirooted teeth, but most

have met with limited degree of success.



The method for prevention of the epithelial

migration along the cemental wall of the pocket that

has gained wide attention is Guided tissue

regeneration (GTR). GTR method derives from the

classic studies of Nyman, Lindhe, Karring and Gottlow

and is based on assumption that only the periodontal

ligament cells have the potential for the regeneration

of the attachment apparatus of the tooth. Guided

tissue regeneration is a procedure that uses a physical

JTODC, 2 (2), 2011 | 127 |

barrier to allow selective repopulation of the

periodontal defect during wound healing. Melcher

proposed that cells from the periodontal ligament play

an important role in healing of osseous defects

involving alveolar bone and cell derived from the 4 periodontal ligaments. In recent years there have

been varieties of barriers used for GTR. Studies using a

nonresorbable expanded polytetrafluroethelene

(ePTFE) membrane have been extensively studied in

animal models and human beings for the treatment of 5 furcation defects. There are some disadvantages of a

nonresorbable membrane: they require a second

procedure to remove the membrane, require more

postoperative visits and have the potential for more

postsurgical complications.

Except for a small number of studies, most

success regarding regeneration of furcations apply to

class II mandibular furcation only. Failure to treat class

III and IV furcations are attributed to various factors

like root proximity that prevents adequate bone

quantity to gain the necessary regenerative cells, also

trying to adapt the membrane could be difficult and

stabilizing membrane around the multirooted teeth is

also a problem faced. Once the procedure is

completed, then maintenance and home care of the

surgical site becomes a concern, adding to higher

failure rates.

6 A study by CR Andergg using a resin ionomer

restoration as a barrier in the treatment of a class III

furcation defect found that there was reduction in

tooth mobility and plaque count, no bleeding on

probing and decrease in a probing depth with the use

of resin ionomer.

A recent study by CR Andergg and DG Metzler

have shown that teeth with hopeless prognosis might

be retained by decreasing bleeding on probing and

tooth mobility when furcation area are sealed with the 7resin iononer.

Dragoo et al demonstrated the use of subgingival 8 resin restoration. He placed a modified resin glass

ionomer resin subgingivally to restore the teeth that

were previously considered as hopeless or

nonrestorable. The clinical and histological evidence of

epithelium and connective tissue attachment to the

resin ionomer restoration material was observed

during healing process.

A study conducted by Schever W. has shown that

glass ionomer material is insoluble in oral fluid; shows

increased adhesion to tooth structure and other dental 9substrate and is biocompatible

The purpose of this study is to present case using

a combination of glass ionomer restoration as a barrier

along with resorbable barrier membrane in the

treatment of class IV mandibular furcation.

CASE REPORT:

A 35 year old patient diagnosed with Generalised

aggressive periodontitis presented with the class IV

furcation defect involving 36. Tooth had poor to

hopeless prognosis based on clinical parameters of

grade II mobility, probing depth (> 7mm), grade IV

furcation involvement and associated inflammation.

The tooth was vital with no periapical radiographic

changes. After explaining treatment option to the

patients including extraction as the next option,

patient elected to have glass ionomer placed as an

occlusive barrier over his furcation defect.

Following administration of local anaesthesia

using inferior alveolar nerve block and long buccal

nerve block of 2% lidocaine with a concentration of

1:200000 epinephrine, sulcular incisions were made

from mesiofacial surface of 35 to distofacial surface of

38 and a full thickness flap was reflected to expose the

furcation entrance.

The area was debrided using curettes, scaled and

root planed using ultrasonic scalers. Osseous

topography was assessed, and bioresorbable

membrane (Perioguide) was placed in buccal furcation

area. On lingual furcation due to extent of furcation

and associated recession no regenerative procedure

could be tried and therefore occlusive barrier using a

glass ionomer was used to fill-in the furcation defect

and prevent the recurrence of bacteria and the debris

into the furcation. The glass ionomer was placed using

plastic instruments in the furcation defect.

The flaps were replaced and sutured using 3-0

direct interrupted silk suture. The patient was adviced

to use 0.2% chlorhexidine gluconate mouth rinse

| 128 | JTODC, 2 (2), 2011

twice daily for 2 weeks. The patient was provided with

the postoperative home care instructions and was

prescribed with the antibiotic (Amoxicillin 500 mg,

three times daily for seven days) to reduce the risk of

postoperative infection. Sutures were removed after

10 days. Patient was recalled weekly for the first

month for postsurgical evaluation and reinforcement

of plaque control. The patient was further followed up

at three and six month intervals for supportive

periodontal therapy.

After 1 year postoperatively, the tooth was

revaluated for the following parameters: tooth

mobility, probing depth, bleeding on probing and

plaque level. There was only grade I mobility,

< 4mm probing depth, no bleeding on probing and

plaque record of only 10%. Moreover, the patient was

asymptomatic, tooth was in function and the patient

did not experience any discomfort.

a) Probing depth of 7mm irt 36

b) Ccrevicular incision given from 34-38

a

b

c) Full thickness flap reflected

c

d

d) Presence of Grade IV furcation

e) Bioresorbable membrane placed irt buccal furcation

e

f

f) GIC placed irt lingual furcation

g) Direct interrupted sutures given

g

h

h) 10 days post-operative photograph

JTODC, 2 (2), 2011 | 129 |

DISCUSSION:

The mandibular molar that received glass

ionomer restoration was functional and asymptomatic,

and patient experienced no adverse problem even 1

year after the restoration was placed. The buccal

surface in relation to which membrane was used, was

found to be associated with recession and exposure of

the buccal furcation.

The result of this case report states that long

term prognosis of the traditionally hopeless

mandibular molar class IV furcation can be improved

by using an occlusive barrier, such as glass ionomer

restoration cement. Not only does the barrier seal the

furcation entrance from the epithelial, bacterial and

food debris invasion but may enable easier home care

due to the reduced surface area of the furcation left to

clean.

The use of glass ionomer cement to regenerate

the attachment apparatus in the treatment of

advanced furcation involvement was not the goal of

the treatment. There was no intention to regenerate

the tissue on lingual side. The goal of selecting this

therapy was simply to retain the hopeless mandibular

molar with advanced furcation involvement in its

position and function.

CONCLUSION:

Potential advantages of an occlusive barrier such

as glass ionomer includes ease of placement, does not

require suture for stability, does not require complete

coverage by gingival flap, and long junctional epithelial

attachment to the glass ionomer, is bacteriostatic due

to fluoride release and finally it is of lower cost.

To potentially determine a greater clinical

significance, studies with a larger sample size and

control must be done. Within limitations of this case

report, it can be concluded that glass ionomer

restorative material may be effective as occlusive

barrier when treating mandibular molar class IV

furcation defects.

BIBLIOGRAPHY

1. Hamp SE,Nyman S , Lindhe J. Periodontal

treatment of multirooted teeth.Results after 5

years.J Clin Periodontol 1975;2:126-135.

i

Buccal aspect

Lingual aspect

j

i,j) 1 year postoperative photographs

l

l) preoperative radiograph

k) 1 year post operative radiograph

k

| 130 | JTODC, 2 (2), 2011

2. Pearlman BA. Long term periodontal care: A

comparative retrospective survey. J Periodontol

1993;64:723-729.

3. Hirsfield J, Wasserman B. A long term survey of

tooth loss in 600 treated periodontal patients. J

Periodontol 1978;49:225-237.

4. Melcher AH. On repair potential of periodontal

tissues. J Periodontol 1976;47:256-260.

5. Gottlow J, Nyman S, Lindhe J, Karring T,

Wennstrom J.New attachment formation in human

periodontium by guided tissue regeneration. J Clin

Periodontal 1986; 13:604-616

6. Anderegg CR. Treatment of class III maxillary

furcations using a resin ionomer. A case report. J

Periodontal 1998;69:948-950

7. Anderegg CR, Metzler DG. Relation of

multirooted teeth with class III furcation utilizing

resin. Report of 17 cases. J Periodontal

2000;71:1043-1047.

8. DragooM. Resin ionomer and hybrid ionomer

cement. Human clinical and histologival wound

healing responses in special periodontal

condition.Int J Periodontics Restorative Dent

1997;17:75-87.

9. Schever W,Dragoo M. Geriostore: new clinical

application for resin ionomer.Practical

Periodontic Aesthetic Dent 1995: Jan-Feb 144.

JTODC, 2 (2), 2011 | 131 |

1 2 3Dr. Bipin Chandra Reddy , Dr.Kishan Panicker G , Dr. Mahendra P , 4 5 6 7Dr.Sanjay Mohanchandra , Dr.Ramakrishna T ,Dr. Nikhil Singvi ,Dr. Jyotsna Rao J.

PILOMATRICOMA OF THE CHEEK

ABSTRACT

Keywords :

Pilomatricomas, formerly known as pilomatrixomas, are

superficial, benign skin tumors that are typically located in

the Head and neck region and most often occur before the

age of 20 years. In 1880, Malherbe and Chenantais described

calcifying epithelioma as a benign subcutaneous tumor 1arising from sebaceous glands . In 1922, Dubreuilh and

Cazenave described the unique histopathologic

characteristics of this neoplasm, including islands of epithelial

cells and shadow cells. In 1961, Forbis and Helwig proposed

the term pilomatrixoma to describe the condition to avoid a

connotation of malignancy and to denote its origin from hair 3matrix cells. Despite being better defined, pilomatricomas

continue to be frequently misdiagnosed and are not usually

considered in differential diagnoses. They typically present as

a superficial, firm, solitary, slow growing, painless mass of

the dermis. The overlying skin may exhibit a bluish

discoloration or ulceration. Treatment consists of surgical

excision. Recurrence is rare after complete resection.

Malignant Pilomatricomas have rarely been reported.

Calcifying epithelioma, Pilomatricoma,

Osteoma Cutis , Calcified Dermoid cysts, Calcified Hematoma

or lipoma, Dystrophic calcification.

Case Report

Dept of Oral and Maxillofacial Surgery

4Professor5Professor

6P.G. Student


1Reader2Reader3Reader

7Reader

CASE REPORT :

A 45 year old female patient reported our

department with a chief complaint of a hard swelling in

her left cheek region which had progressed gradually

to the present size since 39 year. On eliciting history of

this illness there was a negative family history with no

signs and symptoms of pain. No other positive history

was elicited except for the discomfort. Patient had no



history of trauma in childhood with respect to the

region of occurrence of the lesion.

On general physical examination all the vitals

parameters of the patient were within normal limits.

On examination, a solitary well-defined swelling was

seen on the left cheek region measuring around

1.5cms in diameter, roughly oval in shape extending

from 2cms from the corner of the mouth to around

| 118 | JTODC, 2 (2), 2011

3cms from the pinna of left ear. Surface over the

swelling shows a glossy appearance. Color of swelling

is similar to the surrounding skin, the edges of the

swelling are clearly defined.

On palpation the swelling is bony hard in

consistency with well defined edges, its non fluctuant,

non reducible, non compressible. The skin is fixed to

the underlying swelling but swelling is not fixed to the 8underlying structures. Graham and Merwin described

the “tent sign” elicited by stretching the skin over the

pilomatrixoma tumor to feel the irregular surface of

the mass.

The swelling was provisionally diagnosed as

Osteoma Cutis (A type of calcinosis cutis).In the

differential diagnosis, it is necessary to rule out:

Calcified Dermoid cysts, Calcified Hematoma or

lipoma, Dystrophic calcification.

Prior to any surgical intervention, Routine Blood

investigations were carried out. Elevated serum

phosphorous levels were found, remaining parameters

were within normal limits. PA view skull showed a

Radio-Opacity in the Left cheek region very superficial

to the overlying skin.

A total excision of the lesion was performed

under local anesthesia with the overlying skin,

followed by primary closure with vicryl and prolene

sutures.

The histopathological examination revealed

Shadow or ghost cells, with a central unstained area

representing a shadow of a lost nucleus. Basaloid cells

had a round basophilic nucleus and scant cytoplasm at

the periphery of epithelial islands. Pilomatrixomas are

of ectodermal origin and arise from the outer root

sheath cell of the hair follicle. They arise in the lower

dermis and form a connective tissue capsule. Calcium

PA view-

JTODC, 2 (2), 2011 | 119 |

deposition and a foreign body reaction commonly

occur, and ossification has been reported.

DISCUSSION:

Pilomatricoma are ectodermic tumors originated

in the outermost cells of the sheath of the hair follicle 8 root which have been described in eyelids and eye

brows for over 40 years. They can appear at any age,

with greater prevalence in the first and sixth decade of

life, with very little frequency in youngsters and adults,

and more predominant in men than women .The

appearance of pilomatricoma in patients with

myotonic dystrophy is more frequent than in the

general populat ion. However, in general

pilomatricoma is not hereditary. The pathogenic

mechanism of its development is associated to 2mutations in the betacatenine gene (CTNNB1) and it

has been confirmed that this mutation does not only

occur in pilomatricoma but in hair follicle carcinomas

too, directly involving the betacatenine dysfunction as 5the main cause of tumor growth in the hair follicle.

The location of 94% of cases is the scalp, face, 5 7 neck and upper limbs as well as the periorbitary

region which is involved in 21the% of cases. It has

been suggested that the distribution of pilomatricoma

matches the density of hair follicles in a given area.

H is topatho log ica l ly, p i lomatr icoma is

characterized by a mass made up by basaloid cells,

ghost cells and calcification and sometimes

ossification. The ghost cells represent necrosis areas

of previously vital basaloid cells. The calcification and

ossification areas appear progresively in the necrosis

areas. There is also an increase of small sized vessels

and the overlying dermis and epidermis are atrophic.

In general, the clinical development is benign,

although malign transformations have been

described. Treatment is surgical excision and, if done

adequately, recurrence is exceptional.

REFERENCES:

1) Friedrich W. Moehlenbeck; Pilomatrixoma ,Arch

Dermatol/Vol 108,Oct 1973

2) Ashraf M. Hassanein, Steven M. Glanz,Harvey P.

Kessler, Thomas A. Eskin, - Catenin Is Expressed

Aberrantly in Tumors Expressing Shadow Cells -

Pilomatricoma, Craniopharyngioma, and

Calcifying Odontogenic CystAm J Clin Pathol

2003;120:732-736

3) Ming-Ying Lan,; Ming-Chin Lan,; Ching-Yin Ho,

Wing-Yin Li,; Ching-Zong Lin, Pilomatricoma of

the Head and Neck -A Retrospective Review of

179 Cases: Arch Otolaryngol Head Neck

Surg. 2003;129:1327-1330

4) Angelique Danielson-Cohen, Samuel J. Lin, C.

Anthony Hughes,Young H. An, John

Maddalozzo; Head and Neck Pilomatrixoma in

Children, Arch Otolaryngol Head Neck S u r g .

2001;127:1481-1483

5) Kusama K, Katayama Y, Oba K, Ishige T, Kebusa Y,

Okazawa J,Fukushima T, Yoshino A. Expression

of Hard a-Keratins in Pilomatrixoma,

Craniopharyngioma, and Calcifying Odontogenic

Cyst. Am J Clin Pathol. 2005 Mar;123(3):376-81

6) MigrirovL,FridmanE, Talmi YP, Pilomatrixoma of

the retroauricular area and arm, J P e d i a t r

Surg 2002; 37:20

7) Samet Yalcin, Burak Veli, Omer Parlak, Cagatay

S i sman , Ave ry ra re l o ca l i z a t i on o f

pilomatrixoma: Bratisl Lek Listy 2010;

111(2),108-109

8) Izquierdo-rodríguez c1, Mencía-gutiérrez e1,

Gutiérrez-díaz e1, suárez-gauthier An

unusual presentation of a pilomatrixoma in the

eyelid, Arch Soc Esp Oftalmol 2006; 81: 483-486

| 120 | JTODC, 2 (2), 2011

1 2 4 5Dr Gayatri R.G , Dr A.V. Ramesh , Dr Aditi Dhage , Dr C.D.Dwarakanath 3Dr Rosh R.M ,

DOUBLE PAPILLA FLAP FOR ROOT COVERAGE

ABSTRACT

Keywords : G

Gingival recession with exposure of root surface is

routinely encountered in clinical practice. It may cause

aesthetic problems and hypersensitivity. There are several

periodontal plastic procedures available to treat these

defects. The present case series attempts to evaluate the

efficacy of double papilla procedure in managing isolated

recession.

ingival recession, hypersensitivity, root

coverage and double papilla flap.

Case Report

Department of Periodontics

2Professor


1Reader

3Senior Lecturer4Private practice

5Professor & HOD

CASE REPORT :

Gingival recession is defined as the displacement

of the gingival margin apical to the CEJ. Inflammation

related to plaque, improper tooth brushing, frenal pull,

iatrogenic dental care including tooth preparation,

margin placement, excessive orthodontic forces etc.

can be etiology to gingival recession along with

predisposing factors like minimal attached gingiva, 1tooth mal-position and abnormal root bone angle.

A requirement for root surface coverage arises

when gingival recession has esthetic implications,

where exposure has resulted in root sensitivity, or

where recession complicates routine home care

procedures.

There are four basic techniques for root coverage

namely 1) Pedicle grafts, 2) Free mucosal graft

3) Subepithelial connective tissue graft and 4)

Membrane barrier guided tissue regeneration

technique. Variations in these techniques have been

introduced by different authors. Although the



predictability of these treatment modalities varies,

several have been found to provide complete root

coverage in a high percentage of cases. The decision

to apply a technique involves evaluation of various

parameters such as width and depth of recession,

number of recessions, width of attached gingiva

present, width of adjacent interdental papilla and

thickness of recipient site tissue. Every technique can

produce a successful outcome if used in the correct 2,3site under the right circumstances.

Grupe and Warren proposed the technique of

laterally positioned flap operation for coverage of

isolated recessions. This procedure is indicated when

the site adjacent to the recession has adequate length,

width and thickness of gingiva. The disadvantage of

this procedure is possible occurrence of bone loss and

gingival recession at the donor site. Many methods

have been introduced to modify this technique to avoid

recession at the donor site. Partial thickness flap by

Steffilino, submarginal incision by Grupe and full

thickness flap by Pfeifer and Heller are a few

modifications which avoid recession at the donor 4,5,6,7site.

JTODC, 2 (2), 2011 | 121 |

The Double papilla flap introduced by Cohen and

Ross in 1968 is another variation of the laterally

repositioned flap. It is designed to achieve an

adequate zone of attached gingiva and/or coverage of

a denuded root surface by joining two interdental

papillae.This procedure has limited usefulness. Its

relatively poor predictability limits its application to

those areas of localized root exposure where the

available donor tissue is inadequate for laterally

positioned or obliquely positioned pedicle grafts. The

double papillae pedicle flap is most appropriate in

those cases where esthetics demands a close tissue

colour match and where the papillae are large and 8have a shallow gingival groove.

This article presents a case series where three

patients were treated with Double papilla flap

procedure to evaluate its effectiveness as a root

coverage procedure.

Methodology :

Three patients visiting the department of

Periodontics, The Oxford dental college with a

complaint of recession and associated sensitivity were

treated with Double papilla flap procedure. All these

patients had Miller's class I recession. The patients

were systemically healthy and had not undergone any

periodontal treatment in the past one year. The width

and depth of recession, width of attached gingiva was

recorded before the surgery and during the follow up

period. Following a detailed case history, the patients

were briefed about the procedure and then oral

hygiene instructions were given and this was followed

by thorough scaling and root planing.

Surgical technique:

A horizontal incision was given on either side of

the recession defects at the level of the CEJ. At the

proximal line angle of adjacent teeth, vertical releasing

incisions were given extending beyond the

mucogingival junction. At the margin of the defect, an

internal bevel incision along with a 'v' shaped incision

was given. A partial thickness flap was reflected

beyond the mucogingival line. The exposed root was

thoroughly planed with a curette. The papillae were

sutured together with a resorbable 5-0 suture starting

from the base. A periodontal dressing was placed on

the surgical site to avoid injury. Post surgical

instructions were given; patients were asked to avoid

brushing at the site of surgery and were instructed to

use 0.2% chlorhexidine for two weeks. The

periodontal dressing was removed after 2 weeks. The

patients were placed on regularly supportive

periodontal therapy. The clinical measurements were 9repeated every 3 months.

Case description:

Case 1:

A 23 year old male patient reported to the

Department of Periodontics with a chief complaint of

sensitivity in relation with lower left first premolar i.e.

34. On clinical examination the recession depth and

width were 2 mm. The width of attached gingiva was 1

mm and sulcus depth 1mm. Following initial therapy

Double papilla flap procedure was done. At the end of

2 weeks complete coverage was observed at the

treated site. The patient was recalled at regular

intervals for scaling. There was reduction in sensitivity

and the complete coverage was maintained at the end

of one year.

Case 1

a) Class I recession w.r.t 34 2mm

(b) Incisions placed

| 122 | JTODC, 2 (2), 2011

Case 2:

A 23 year old male patient with chief complaint of

hypersensitivity reported to the department. On

clinical examination the upper right lateral incisor (12)

had a recession defect with a depth of 3mm, width of

2mm, attached gingiva of 3mm and sulcus depth of

1mm. The double papilla flap procedure was done

after a thorough scaling and root planing. In this

patient a full thickness flap was reflected instead of a

split thickness as described in the original technique.

Complete root coverage and elimination of

hypersensitivity was achieved and this was maintained

at the end of 3 and 6 months respectively.

(c) Partial thickness flap reflected

(d) Papillae approximated

(e) Sutures Placed

(f) Periodontal pack placed

(h) 1 year follow up

Case 2

(a) Class I recession 3mm i.r.t 12


JTODC, 2 (2), 2011 | 123 |

Case 3:

A 32 year old male patient with chief complaint of

sensitivity in relation to 41 reported to the department

of Periodontics. On clinical examination the depth and

width of recession was 3 mm and 2mm. The width of

attached gingiva was 2mm and sulcus depth was 1

mm. The patient was subjected to scaling and root

planing followed by which the Double papilla flap

procedure was done. Complete coverage was

achieved at end of 2 weeks. This result has been

maintained upto 3 months.

(c) Incisions placed

(d) Full thickness flap reflected

(e) Papillae approximated

(f) Sutures placed

(g) 2 weeks post operative

(g) (h) 3 months follow up

(g)6 months follow up

| 124 | JTODC, 2 (2), 2011

Case 3

(a) Class I recession wrt 41 3mm


(c) Split thickness flap reflected

(d) Papillae approximated

Sutures placed

(f) Periodontal pack placed

1 month follow up

(g)(h) 3 months follow up

JTODC, 2 (2), 2011 | 125 |

DISCUSSION:

Root coverage is a successful and predictable

procedure in Periodontics, employing a variety of

techniques. The surgical technique of choice depends

on several factors, each having their advantages and

disadvantages.

The various techniques used over the years are

Rotational flaps, Advanced flaps, Subepithelial

connective tissue graft and Guided tissue regeneration

techniques. The mean percentages of root coverage

reported in various studies are 66%, 77%, 83% and

74% respectively. Cohen and Ross have reported a

success rate of 85% for the Double papilla procedure.

In this case report three patients presenting with

recession and a complaint of hypersensitivity were

treated with Double papilla flap procedure. This

decision was made because the teeth involved in all

the 3 cases had Millers class I recession which were

shallow and narrow, there was sufficiently wide inter

dental papillae present with the teeth adjacent to the

recession and presence of adequate thickness of

gingiva of the recipient site. The surgical technique

done was similar to the one described by Cohen and

Ross, except in one case where a full thickness flap

was reflected instead of a split thickness. To overcome

the difficulty of suturing two papillae, 5-0 resorbable

sutures were used to approximate them delicately.

Although double papilla flap procedure is known

to be technique sensitive, good results can be

achieved if the case selection is done appropriately.

The three cases presented here had complete

coverage that was maintained from 3 months to upto a

year. Similar results were found in other investigations.

Harris reported on the results of 100 consecutively

treated recessions done with a partial thickness double

papilla pedicle graft. The procedure produced 100 %

root coverage 89% of the time. Tetracycline root

conditioning was used and no initial preparation was .10done

Borghetti and Louise also used double papilla

technique over connective tissue for root coverage.

Unlike Harris who used tetracycline for root

biomodification, they used neither citric acid or

tetracycline, although they did “ vigorously” plane the

roots with curettes and burs. Whereas Harris used

partial thickness double papilla flap, Borghetti and

Louise used full thickness flap. An evaluation of the 15

graft sites one year later revealed 79.9% mean root

coverage.

The advantages of this technique include:

1) Alveolar bone loss is minimized because the

interdental bone is more resistant to loss than is

radicular bone.

2) The papillae usually supply a greater width of

attached gingiva as compared to that which is

gotten from the radicular surface of the bone.

3) Excellent colour match is achieved.

4) Second surgical site is avoided.

The challenge of the procedure is to join the two

delicate papillae as if they were one flap. Studies have

shown that the procedure is less predictable but these

studies have not been systematically evaluated. If the

case selection is done appropriately as shown in this

report good aesthetic results are attainable. Complete

root coverage was attained without causing recession

to the adjacent teeth.

REFERENCES

1) American Academy of Periodontology.

Consensus report on mucogingival therapy.

Proceedings of World Workshop in Periodontics.

Ann Periodontol 1996;1:702-706

2) American Academy of Periodontology. Oral

Reconstructive and Corrective Considerations in

Periodontal Therapy. J Periodontology 2005;

76:1588-1600

3) Wennstrom J.L Proceedings of 1996 World

Workshop in Periodontics. Ann Periodontol 1996;

1:667-701.

4) Grupe H.E, Warren RF. Repair of gingival defects

with sliding flap operation. J Periodontol

1956;27:92-5

5) Steffilino H.M. Management of gingival recession

and root exposure problems associated with

partial denture. DCNA 1964;8:111-20

6) Grupe H.E Modified technique for lateral sliding

flap operation. J Periodontol 1966;37:491-95

7) Pfeifer J.S, Heller R. Histologic evaluation of full

and partial thickness laterally repositioned flap:

A Pilot study. J Periodontol 1971;42:331-333

8) Cohen D, Ross S. The Double papilla repositioned

flap in periodontal therapy. J Periodontol

1968;39:65

9) Goldstein M, Brayer L and Schwartz Z. A Critical

evaluation of methods of root coverage. CROBM

1996;7:87-98

10) Harris R. The connective tissue and partial

thickness double papilla graft: A predictable

method of obtaining root coverage.

1992;63:477-86

| 126 | JTODC, 2 (2), 2011

1 2 Dr Venkatesh Garla , Dr Lokesh N.K. , 3Meenakshi Vishwanath

MANAGEMENT OF CLASS II DIVISION 2 MALOCCLUSION WITH SEVERE CROWDING USING T-LOOP

ABSTRACT

Keywords : G

In this Case Report, we report the successful treatment

of a patient, aged 19years, who had Angle's class II div 2

malocclusion with complete deep bite and severe upper and

lower anterior crowding. Segmental retraction of canine is

done using segmental T-loops followed by alignment of

upper and lower anteriors using PEA mechanics. The total

active treatment was 12 months. Both occlusion and facial

appearance were significantly improved. There were no

functional problems during or after treatment. Our results

suggest that segmental retraction of canine using T-loop in a

patient with severe crowding is most successful for

decrowding of upper and lower anteriors.

ingival recession, hypersensitivity, root

coverage and double papilla flap.

Case Report

Department of OrthodonticsThe Oxford Dental College, Hospital and Research Center, Bangalore.

1Reader2Senior Lecturer3Senior Lecturer

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technique has been designed to deliver relatively light

continuous forces with a good control over the anchor

unit.Therefore T-LOOP is the ideal choice for separate

retraction of canine with good anchor control.

CASE REPORT

A 19 yr. 0ld female patient by name Mangala

reported to the department of orthodontics with a

chief complaint of irregularly placed upper and lower

front teeth .No significant prenatal and postnatal

history elicited. Patient was moderately built and well

nourished for her age and sex. Extraoral examination

reveals mesocephalic, mesoprosppic, straight profile

with anterior divergence.

Intra oral examination reveals presence of Full

complement of teeth,good oral hygiene,squarish

| 132 | JTODC, 2 (2), 2011

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We planned for extraction line of treatment.

Segmental retraction of canine is done using T-loop

followed by alignment of maxillary and mandibular

teeth using MBT 0.18 SLOT PEA APPLIANCE.

TREATMENT PROGRESS

0.018” slot M.B.T. preadjusted edgewise

appliances were placed on right and left upper canine.

Segmental retraction of canine is done using T-loop

fabricated from 017” x .025” TMA wire.It is followed by

placement of brackets on upper anteriors and

continuous.016” Nickel Titanium wire is placed for

aligning upper anteriors. Once alignment of upper

teeth is completed, bracket placement is done on

lower arch. Segmental retraction is done using active

laceback, continuous.016” Nickel Titanium wire is

placed for alignment of lower teeth. It is followed by

.017” x .025” Nickel Titanium arch wires. It is followed

by 0.017” x .025” stainless steel arch wires in both

upper and lower arches. Space closure is done using

active tie backs and molar correction was done using

classII elastics. Finishing and detailing was done using

sectional .016 SS wire. The total active treatment time

was 12 months.

DISCUSSION

Some times because of anterior crowding space

must be made available for further decrowding of

anteriors by separate canine retraction. There are

various methods of segmental canine retraction,of

which T-LOOP is one of them.T-LOOP is fabricated out

of 17X25 inch TMA Wire.It was designed by

Burstone.It can also be used for enmass retraction.

Initially the M/F ratios are approximately 6-8

which produce controlled tipping. As the space closes

and the spring deactivates, the force level delivered by

the spring decreases at a much faster rate than the

movements. This cause both Ma/F and Mb/F ratios to

increase. These ratios soon become 10, where

Standard Form

(without preactivation bends)

With Preactivation Bends

for Equal and opposite movements

JTODC, 2 (2), 2011 | 133 |

translation will occur. Further deactivation increases

the M/F ratio to 12 and teeth might undergo root

movement. The T loop described in Biomechanics by

Nanda is designed for an activation upto 6 mm. At full

6mm activation tooth movement occurs in three

phases: tipping, translation and root movement. For a

symmetric centered spring an initial activation

produces a M/F ratio of 6/1 which results in tipping

movement of the teeth into the extraction space. With

2mm deactivation or spring activation = 4mm the

M/F ratio is 10/1 which results in translation of the

segments towards each other. With 1-2mm space

closure (spring activation =2mm) the M/F ration

increases to 12/1 and higher resulting in tooth

movement. Clinically the spring should not be re

activated till all three phases are complete.

The center position of the spring can be found

by:

distance = (interbracket distance activation)/ 2 where

distance = length of the anterior and posterior arms

(distance from the center of the T loop to either the

anterior or posterior tubes) interbracket

distance=distance between the canine and molar

brackets.

Activation= 6 millimeters of activation of the spring

TREATMENT RESULTS

The post treatment records show that both

skeletal disharmony and malocclusion were

significantly improved, and jaw movements during

mastication were in the normal range without signs or

symptoms of TMD.

CONCLUSION

We treated an Angle's class II div 2 malocclusion

with severe upper and lower crowding using

segmental T-loop mechanics. After treatment,

locclusion significantly improved, and jaw movements

during mastication remained in the normal range with

no TMD Signs or symptoms. Therefore, we suggest

that segmental T-loop mechanics is more useful in

patient with severe crowding to improve occlusion and

facial esthetics.

Figure 1: Pre treatment facial and

intra oral photographs

| 134 | JTODC, 2 (2), 2011

Figure 2: Pretreatment radiographs:

A, lateral cephalogram; B, panoramic radiograph

Figure 4: continuous mechanics

using 0.016 Nickle titanium wire

Figure 5: post treatment intra oral photographsFigure 3: segmental retraction of canine

using T-loop and Laceback

Figure 6: post treatment

radiographs: A, lateral

cephalogram;

B, panoramic radiograph

JTODC, 2 (2), 2011 | 135 |

REFERENCES

1. Burstone CJ:Rationale of the Segmented arch.

Am J Orthod 48:805-822,1962

2 Burstone CJ:The Mechanics of the Segmented

arch Techniques. Angle Orthod 36:99-120,1966.

3 Nanda R: Bio mechanical approaches to the

study of alterations of facial morphology. Am J

Orthod 78:213-226,1980.

journal of the oxford dental college squamous … 2 issue 2 may- aug...figure 4:iopa of 11,12,13,21....

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