Post on 08-Aug-2020
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1I J C D C
588Indian Journal of Comprehensive Dental Care
CONTENTS
ORIGINAL ARTICLES
RETROSPECTIVE ANALYSIS OF FOCAL FIBROUS HYPERPLASIA 598* Adesh S Manchanda **Ramandeep S Narang ***Balwinder Singh ****Kashish Mahajan
PREVALENCE OF ORAL AND MAXILLOFACIAL LESIONS IN DISTRICT OF AMRITSAR 603: A RETROSPECTIVE STUDY*Preeti Chawla Arora **Ruhi Duggal ***Sargun Sarang ****Arshdeep Kaur *****Aman Arora
DENTAL CARIES STATUS OF FIRST PERMANENT MOLARS AMONG SCHOOL 609CHILDREN OF AMRITSAR DISTRICT*Satinder Singh **Amaninder Kaur ***Gurpreet Kaur ****Gagan Deep
CORRELATION OF SKELETAL MATURATION USING CVMI WITH DENTAL 612CALCIFICATION USING WILLEM'S METHOD*Kamaldeep Sharma **Sukhdeep Singh Kahlon ***Chetandev Singh Boparai ****Veneet Mehta *****Navjot Singh Jassal ******Amardeep Singh Sandhu
IMPLANTS IN FRESH AND HEALED EXTRACTION SOCKETS 617*Tejinder Kaur **Sumeet Sandhu ***Pradeep Goyal
CASE REPORTS
TEMPORAL HEMATOMA AFTER POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK 626- A CASE REPORT*Harpreet Singh **Ramandeep Singh Bhullar ***Amneet Kaur Sandhu
INTRARADICULAR REHABILITATION OF WEAKENED ANTERIOR TOOTH USING LIGHT 636-TRANSMITTING POST - A CASE REPORT*Ramneek Khatter **C.S.Bal ***Ripu Daman Singh ****Shilpa Walia
DENTIGEROUS CYST IN A YOUNG CHILD ASSOCIATED WITH MULTIPLE TOOTH BUDS 640: A PERPLEXITY*Sunil Gupta **Amit Dhawan ***Anjali
PERIODONTAL MANIFESTATIONS OF DERMATITIS HERPETIFORMIS: A CASE REPORT 643*Vandana **Supreet Kaur ***Navneet Kaur ****Vishakha Grover
VITAL BLEACHING: A REVIEW AND CASE REPORTS 647* Megha Majajan ** Roma Goyal ***Pardeep Mahajan ****Prashant Monga ****Nitika Bajaj
RESTORING ESTHETICS WITH MAGNET RETAINED CHEEK PLUMPERS 651*Sumant Saoji **Surendra Agrawal ***Anjali Bhoyar ****Swapnil Parlani
I J C D C
589Indian Journal of Comprehensive Dental Care
CONTENTS
REVIEW ARTICLES
DENTAL DILEMMA-9 680
IRON DEFICIENCY ANEMIA AND ORAL HEALTH PROSPECTIVE – A REVIEW 655*Navpreet Kaur **Gaurav Goyal ***Sarfaraz Padda ****Bhawandeep Kaur *****Sunidhi
VIRTUAL ARTICULATORS IN PROSTHODONTICS 661*Kavipal Singh **Kamleshwar Kaur ***Geetika Chawla
DENTAL PULP REGENERATION IN PAEDIATRIC DENTISTRY : ROLE OF STEM CELLS 665*Rashu Grover **Gunmeen Sadana ***Manjul Mehra ****Jasmeet Kaur
PROSTHETIC PLANES OF INTEREST FOR ESTABLISHIBG THE OCCLUSAL PLANE- A REVIEW 669*Seema B. Pattanaik **Sagar R. Bhule ****Amanpreet Kaur Gill ****Poonam V. Jaybhay
AN OVERVIEW OF MUSCULOSKELETAL DISORDERS AMONG ORAL HEALTH PROFESSIONALS: 675*Pankaj Mishra **Manas Gupta ***Neha Singh ****Kriti Shrivastava *****Pushpraj Singh
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1
I J C D C
590Indian Journal of Comprehensive Dental Care
DR SUKHDEEP SINGH KAHLON
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1
DR. RAJESH KHANNA
DR. SUMEET KAUR SANDHU (Principal S.G.R.D.)
DR. KAMALDEEP SHARMA
DR. ADESH MANCHANDA
Indian Journal of Comprehensive Dental Care
I J C D CI J C D C
591
About the Journal
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1
I J C D C
592Indian Journal of Comprehensive Dental Care
Manuscripts must be prepared in accordance with "Uniform validation. Up to 400 words and 4 references.requirements for Manuscripts submitted to Biomedical Announcements of conferences, meetings, courses, awards, Journal" developed by International Committee of Medical and other items likely to be of interest to the readers should be Journal Editors (October 2001). The uniform requirements submitted with the name and address of the person from and specific requirement of ' Indian Journal of Comprehensive whom additional information can be obtained. Up to 100 Dental Care' are summarized below. Before sending a words. manuscript contributors are requested to check for the latest
Authorship criteriainstructions available. All persons designated as authors should qualify for The Editorial Processauthorship, and all those who qualify should be listed. Each
The manuscripts will be reviewed for possible publication with author should have participated sufficiently in the work to the understanding that they are being submitted to one take public responsibility for appropriate portions of the journal at a time and have not been published, simultaneously content. The first author should take responsibility for the submitted, or already accepted for publication elsewhere. integrity of the work as a whole, from inception to published The Editors review all submitted manuscripts initially. article. Manuscripts with insufficient originality, serious scientific Authorship credit should be based only onflaws, or absence of importance of message are rejected. The
1. Substantial contributions to conception and design, journal will not return the unaccepted manuscripts. or acquisition of data, or analysis and interpretation of data;
Other manuscripts are sent to two or more expert reviewers 2. Drafting the article or revising it critically for without revealing the identity of the authors to the reviewers. important intellectual content; and Within a period of six to eight weeks, the contributors will be
3. Final approval of the version to be published. informed about the rev iewers ' comments and Conditions 1, 2, and 3 must all be met. Acquisition of funding, acceptance/rejection of manuscript. Articles accepted would the collection of data, or general supervision of the research be copy edited for grammar, punctuation, print style, and group, by themselves, do not justify authorship.format. Page proofs will be sent to the first author, which has
to be returned within five days. Correction received after that The order of authorship on the byline should be a joint period may not be included. All manuscripts received are duly decision of the co-authors. Authors should be prepared to acknowledged. explain the order in which authors are listed. Once submitted
the order cannot be changed without written consent of all Types of Manuscripts and word limitsthe authors.Original research articlesFor a study carried out in a single institute, the number of Randomized controlled trials, intervention studies, studies of authors should not exceed six. For a case-report and for a screening and diagnostic test, outcome studies, cost review article, the number of authors should not exceed four. effectiveness analyses, case-control series, and surveys with For short communication, the number of authors should not high response rate. Up to 2500 words excluding references be more than three. A justification should be included, if the and abstract.number of authors exceeds these limits.
Short CommunicationOnly those who have done substantial work in a particular
Up to 1000 words excluding references and abstract and up to field can write a review article. A short summary of the work 5 references. done by the authors (s) in the field of review should Case reports accompany the manuscript. The journal expects the authors
to give post-publication updates on the subject of review. The New / interesting / very rare cases can be reported. Cases with update should be brief, covering the advances in the field after clinical significance or implications will be given priority, Up to the publication of article and should be sent as letter to editor, 2000 words excluding references and abstract and up to 10 as and when major development occur in the field. references.Sending the Manuscript to the JournalReview articlesArtic les should be submitted onl ine at http:// Systemic critical assessments of literature and data sources. www.sgrdjournaldent.org. Up to 3500 words excluding references and abstract.1. First Page File: Prepare the title page, covering Letter to the Editorletter, acknowledgement, etc., using a word processor
Should be short, decisive observation. They should not be program. All information which can reveal your identity preliminary observations that need a later paper for
Instructions to Authors
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1
I J C D C
593Indian Journal of Comprehensive Dental Care
should be here. Do not zip the files. characters;
2. Article file: The main text of the article, beginning 4. Name of the authors (the way it should appear in the from Abstract till References (including tables) should be in journal), with his or her highest academic degree(s) and this file. Do not include any information such as institutional affiliation; acknowledgement, your names in page headers, etc., in this 5. The name of the department(s) and institution(s) to file. Do not zip the files. Limit the file size to 400 kb. Do not which the work should be attributed; incorporate images in the file. If the file size is large, graphs can
6. The name, address, phone numbers, facsimile be submitted as images separately without incorporating numbers, and e-mail address of the contributor responsible for them in the article file to reduce the size of the file. correspondence about the manuscript;
3. Images: Submit good quality color images. Size of 7. The total number of pages, total number of the image should be as less as possible. All image formats photographs and word counts separately for abstract and for the (jpeg, tiff, gif, bmp, png, eps, etc.) are acceptable; jpeg is most text (excluding the references and abstract). suitable. 8. Source(s) of support in the form of grants, equipment, 4. Legends: Legends for the figures/images should be drugs, or all of these; and included at the end of the article file. 9. If the manuscript was presented as part at a meeting, The authors' form and copyright transfer form has to be the organisation, place, and exact date on which it was read. submitted to the editorial office by post, in original with the Abstract Pagesignatures of all the authors within two weeks of online
submission. Images related to the articles should be sent in a The second page should carry the full title of the manuscript and 'compact disc' or as hard copies to the journal office at the an abstract (of no more than 150 words for case reports, brief time of acceptance of the manuscript. These images should of reports and 250 words for original articles). The abstract should high resolution and exceptional quality. be structured and state the Context (Background), Aims, Settings
and Design, Methods and Material, Statistical analysis used, Editorial officeResults and Conclusions. Below the abstract should provide 3 to DR SHANTUN MALHOTRA ( EDITOR-IN-CHIEF)10 key word.
SRI GURU RAM DAS INSTITUTE OF DENTAL SCIENCES & IntroductionRESEARCH, MALL MANDI, G.T.ROAD AMRITSAR-143006State the purpose of the article and summarize the rationale for PUNJABthe study or observation.
E-MAIL- drshantun@gmail.com Ph.no- 09317741818 Methods
Preparation of the ManuscriptDescribe the selection of the observational or experimental
Microsoft Word must be used to submit a subjects (patients or laboratory animals, including controls) manuscript. The text must be double spaced with 1" margins clearly. Identify the age, sex, and other important characteristics and justified to the left-hand margin. Avoid using "styles" or of the subjects. Identify the methods, apparatus (give the document templates. The "Normal" Word format is manufacturer's name and address in parentheses), and recommended. (Arial 12 pt text is preferred.) The manuscripts procedures in sufficient detail. Give references to established should be typed in A4 size (212 × 297 mm) paper, with margins methods, including statistical methods; provide references and of 25 mm (1 inch) from all the four sides . The language should brief descriptions for methods that have been published but are be British English. Please number all pages. not well known; describe new or substantially modified The text of observational and experimental articles should be methods, give reasons for using them, and evaluate their divided into sections with the headings: Introduction, limitations. Identify precisely all drugs and chemicals used, Methods, Results, Discussion, References, Tables, Figures, including generic name(s), dose(s), and route(s) of Figure legends, and Acknowledgment. Do not make administration. Reports of randomised clinical trials should subheadings in these sections. present information on all major study elements, including the
protocol, assignment of interventions (methods of Title Pagerandomisation, concealment of allocation to treatment groups),
The title page should carry and the method of masking (blinding)1. Type of manuscript Ethics2. The title of the article, which should be concise, but When reporting experiments on human subjects, indicate informative; whether the procedures followed were in accordance with the 3. Running title or short title not more than 50 ethical standards of the responsible committee on human
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1
I J C D C
594Indian Journal of Comprehensive Dental Care
experimentation (institutional or regional) and with the order). Identify references in text, tables, and legends by Arabic Helsinki Declaration of 1975, as revised in 2000 (available at numerals in superscript. References cited only in tables or figure http://www.wma.net/e/policy/17-c_e.html). Do not use legends should be numbered in accordance with the sequence patients' names, initials, or hospital numbers, especially in established by the first identification in the text of the particular illustrative material. When reporting experiments on animals, table or figure. Use the style of the examples below, which are indicate whether the institution's or a national research based on the formats used by the NLM in Index Medicus. The council's guide for, or any national law on the care and use of titles of journals should be abbreviated according to the style laboratory animals was followed. used in Index Medicus. Use complete name of the journal for
non-indexed journals. Avoid using abstracts as references. StatisticsInformation from manuscripts submitted but not accepted
When possible, quantify findings and present them with should be cited in the text as "unpublished observations" with appropriate indicators of measurement error or uncertainty written permission from the source. Avoid citing a "personal (such as confidence intervals). Report losses to observation communication" unless it provides essential information not (such as dropouts from a clinical trial). Put a general available from a public source, in which case the name of the description of methods in the Methods section. When data person and date of communication should be cited in are summarized in the Results section, specify the statistical parentheses in the text. For scientific articles, contributors methods used to analyse them. Avoid non-technical uses of should obtain written permission and confirmation of accuracy technical terms in statistics, such as 'random' (which implies a from the source of a personal communication. If the number of randomising device), 'normal', 'significant', 'correlations', and authors is more than six, list the first six authors followed by et al. 'sample'. Define statistical terms, abbreviations, and most
Journal referencessymbols. Use upper italics (P < 0.05). Standard journal articleResultsKulkarni SB, Chitre RG, Satoskar RS. Serum proteins in Present the results in logical sequence in the text, tables, and tuberculosis. J Postgrad Med 1960; 6:113-120. illustrations. Do not repeat in the text all the data in the tables
or illustrations; emphasise or summarise only important Volume with supplementobservations. Shen HM, Zhang QF. Risk assessment of nickel carcinogenicity Discussion and occupational lung cancer. Environ Health Perspect 1994; 102
Suppl 1:275-282. Emphasize the new and important aspects of the study and the conclusions that follow from them. Do not repeat in detail Issue with supplementdata or other material given in the Introduction or the Results Payne DK, Sullivan MD, Massie MJ. Women's psychological section. Include in the Discussion section the implications of reactions to breast cancer. Semin Oncol 1996; 23(1, Suppl 2):89-the findings and their limitations, including implications for 97. future research. Relate the observations to other relevant
Books and Other Monographsstudies. Personal author(s)In particular, contributors should avoid making statements on Ringsven MK, Bond D. Gerontology and leadership skills for economic benefits and costs unless their manuscript includes nurses. 2nd ed. Albany (NY): Delmar Publishers; 1996. economic data and analyses. Avoid claiming priority and
alluding to work that has not been completed. State new Editor(s), compiler(s) as authorhypotheses when warranted, but clearly label them as such.
Norman IJ, Redfern SJ, editors. Mental health care for elderly Recommendations, when appropriate, may be included.
people. New York: Churchill Livingstone; 1996.Acknowledgments
Chapter in a bookAs an appendix to the text, one or more statements should
Phillips SJ, Whisnant JP. Hypertension and stroke. In: Laragh JH, specify contributions that need acknowledging but do not
Brenner BM, editors. Hypertension: pathophysiology, diagnosis, justify authorship, such as general support by a departmental
and management. 2nd ed. New York: Raven Press; 1995. pp 465-chair; Acknowledgments of technical help; and
478. Acknowledgments of financial and material support, which
Tablesshould specify the nature of the support. This should be the last page of the manuscript. Tables should be self-explanatory and should not duplicate
textual material. References
Tables with more than 10 columns and 25 rows are not References should be numbered consecutively in the order in acceptable. which they are first mentioned in the text (not in alphabetic
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1I J C D C
595Indian Journal of Comprehensive Dental Care
Illustrations (Figures) Sending a revised manuscript
Figures should be numbered consecutively according to the While submitting a revised manuscript, contributors are order in which they have been first cited in the text. requested to include, along with single copy of the final
revised manuscript, a photocopy of the revised manuscript Symbols, arrows, or letters used in photomicrographs should with the changes underlined in red and copy of the comments contrast with the background and should marked neatly with with the point to point clarification to each comment. The transfer type or by tissue overlay and not by pen. manuscript number should be mentioned without fail.
Titles and detailed explanations belong in the legends for The authors' form and copyright transfer form has to be illustrations not on the illustrations themselves. submitted in original with the signatures of all the
When graphs, scatter-grams or histograms are submitted the contributors at the time of submission of revised copy.numerical data on which they are based should also be
Article printing chargessupplied. ReprintsThe photographs and figures should be trimmed to remove all
the unwanted areas. All authors will be sent reprints of journal issue free of cost and additional copies can be purchased at Rs 500/ per copy .If photographs of people are used, either the subjects must
not be identifiable or their pictures must be accompanied by Copyrightswritten permission to use the photograph. The whole of the literary matter is the copyright of the If a figure has been published, acknowledge the original Editorial Board. The Journal, however, grants to all users a source and submit written permission from the copyright free, irrevocable, worldwide, perpetual right of access to, and holder to reproduce the material. A credit line should appear a license to copy, use, distribute, perform and display the work in the legend for figures for such figures. (either in pre-print or post-print format) publicly and to make
and distribute derivative works in any digital medium for any The Journal reserves the right to crop, rotate, reduce, or reasonable non-commercial purpose, subject to proper enlarge the photographs to an acceptable size. attribution of authorship and ownership of the rights. The
Fo r o n l i n e s u b m i s s i o n Refe r to g u i d e l i n e at journal also grants the right to make small numbers of printed www.sgrdjournaldent.org copies for their personal non-commercial use. Legends for Illustrations Contributors' Form Available at www.sgrdjournaldent.org.Type or print out legends (maximum 40 words, excluding the credit line) for illustrations using double spacing, with Arabic numerals corresponding to the illustrations.
When symbols, arrows, numbers, or letters are used to identify parts of the illustrations, identify and explain each one clearly in the legend.
Explain the internal scale and identify the method of staining in photomicrographs.
Protection of Patients' Rights to Privacy.
Identifying information should not be published in written descriptions, photographs, sonograms, CT scans, etc., and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. When informed consent has been obtained, it should be indicated in the article and copy of the consent should be attached with the covering letter.
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1I J C D C
596Indian Journal of Comprehensive Dental Care
Greetings to all the subscribers of IJCDC . Newer research taking place in all branches of dentistry is leading
a path towards a more preservative and regenerative dentistry, thus fulfilling the desired goal of dentistry.
What was once just an idea , is now gaining structure and applicable form.
Another very important need of the hour is catering proper dental facilities to the ever growing poor
population of our country. It is the duty of every practitioner to have a philanthropist view and try to serve
our own poor. We should try our best to render effective and inexpensive treatment to those who can't
afford and reach out for a more noble cause .
Sometimes sincere blessings yield more fruits than wealth. This in turn would enable proper dentistry to
be available to all in a phased out manner, as our ultimate goal should be.
With these thoughts we bring you this issue of IJCDC.
Dr Sumeet Kaur Sandhu
Patron IJCDC
From the Patron's Desk ………
Indian Journal of Comprehensive
Dental Care
JAN - JUNE. 2015 • VOL 5 • ISSUE 1I J C D C
597Indian Journal of Comprehensive Dental Care
With the new issue, we at the IJCDC would like to contribute to sharing our knowledge and recent
treatment protocol with our peers and hope in reciprocation would get a chance to publish works not only
from each corner of our country but from our overseas esteemed professionals as well.
“To be yourself in a world that is constantly trying to make you something else is the greatest
accomplishment.” “
With these lines penned by Ralph Waldo Emerson, I would like to highlight the fact that often we demean
and underestimate the hidden potential of our visions and dreams and usually succumb to follow paths
already laid down by others. This is the trend which is seen in Indian dental researchers as well, we mostly
start projects by following criteria already printed by our peers in foreign lands.
I urge more and more people start believing in themselves and bring forth their own innovations in
dentistry as we do have the potential to carry the torch. To do so not only researchers need to come forth,
also more governmental and institutional authorities should start investing in deserving research work
done by indigenous researchers.
I hope this vision prevails and we take dentistry in our country to an envious height.
Dr Shantun Malhotra
Editor-in-chief
IJCDC
Editorial
RETROSPECTIVE ANALYSIS OF FOCAL
FIBROUS HYPERPLASIA
Abstract:
Introduction: Focal fibrous hyperplasia, also known as irritation or traumatic
fibroma, is a reactive, inflammatory lesion of connective tissue.
Aim: To perform a retrospective cross sectional clinico-epidemiological study
of focal fibrous hyperplasia.
Materials and Methods: We reviewed 117 cases of focal fibrous hyperplasia of
oral cavity from the archives of Department of Oral Pathology, SGRD Institute of
Dental Sciences and Research, Amritsar.
Settings and Design: Data with regard to age, gender, location, size of lesion,
pain, history of trauma, attachment to base, color of lesion and recurrence,
were collected and statistically analyzed.
Results: The most common affected site was the buccal mucosa (55.5%).
Almost two-third of the cases were concentrated from second to fifth decade
of life. Almost equal sex preponderance was seen. History of trauma was seen
in 61.5% of the patients. Pain was seen in 15.4% of FFHs. 94% of the cases were
sessile in nature. 3 recurrences were noted (2.5%).
Conclusion: The present study highlights the distribution of focal fibrous
hyperplasia and its presentation with emphasis on lesions which mimic it
clinically. Further studies are needed on the distribution of the lesions in
different ethnic and geographical populations.
Keywords: Fibrous hyperplasia, fibroma, soft tissue tumors
598
Corresponding author:Name: Dr. Ramandeep S NarangMDS (Oral Pathology & Microbiology)Address: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M) 9417551161 Email: narangraman@yahoo.com
1. Reader, Department of Oral Pathology & Microbiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
2. Professor & Head, Department of Oral Pathology & Microbiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
3. Senior lecturer, Department of Oral Medicine & Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
4. Ex-Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
INTRODUCTION an oral soft tissue tumor are diagnosis of the underlying
lump and its appropriate management. Oral mucosa is Soft tissue is defined as the supportive or connective tissue under constant irritation from chewing, trapped food and of the body and includes fibrous connective tissue, bone, debris, calculi, fractured teeth, and iatrogenic factors muscle, fat, etc. Benign soft tissue tumors are lumps and including overextended flanges of dentures and bumps that are non cancerous in nature and are relatively overhanging dental restorations. Mucosa may react to these common in general population. Benign tumors cannot irritants by developing an outgrowth called reactive spread to other parts of the body but they can continue to hyperplasia. These tumor like lesions are non neoplastic, but grow at the original site where they can cause a problem by indicate a chronic process in which an exaggerated repair pressing on the surrounding tissues and are cosmetically
2,31 (granulation tissue) follows injury.unsightly.
Various soft tissue tumors of oral cavity are pyogenic Oral soft tissue tumors are diverse in etiology and diagnostic granuloma (PG), peripheral ossifying fibroma (POF), epulis possibilities. Key management for a patient presenting with
Indian Journal of Comprehensive Dental Care
I J C D C1. Adesh S Manchanda
2. Ramandeep S Narang
3. Balwinder Singh
4. Kashish Mahajan
Date of Submission : 2/2/15 Date of Acceptance : 21/2/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Indian Journal of Comprehensive Dental Care 599
fissuratum, neurofibroma, chondroma, lipoma, myxoma, cases (61.5%). In 64 cases (54.7%) the tumor size was found
peripheral giant cell granuloma (PGCG), but the most to be <1cm (Figure 2). 110cases (94%) were clinically sessile.
common benign soft tissue neoplasm occurring in oral cavity The follow up period for patients ranged from one week to 4is focal fibrous hyperplasia (FFH). FFH is also known as about four years after the treatment and 3 recurrences were
traumatic fibroma as most cases present with history of found (2.5%).
trauma or local irritation. It is a reactive, inflammatory DISCUSSIONhyperplastic lesion of connective tissue and may present
Although tumors constitute only a small number of the clinically as a yellow white (in keratosis), red (when inflamed pathological conditions seen by dentist, they are of great and ulcerated), grayish brown (in blacks), or mucosal significance since they have the potential ability to coloured, mostly sessile, smooth surfaced nodule, which is jeopardize the health and longevity of the patient. Many of usually asymptomatic, mostly seen in females of middle
3,5 the great variety of oral tumors will seldom be seen by the age. Common sites of occurrence are along the occlusal line general practitioner of dentistry. Yet, it is of utmost of buccal mucosa, edentulous alveolar ridges, palate, lower importance that they be familiar with them so that when one lip, etc. and consistency may vary from firm & resilient to soft does present itself, they may either institute appropriate & spongy.
1treatment or refer the patient to the proper therapist. Histologically FFH consists of bundles of interlacing
The results of the present study show an almost equal gender collagenous fibers interspersed with varying numbers of predilection (M:F= 0.95:1) for FFH and this is contradictory to fibroblasts or fibrocytes and small blood vessels. Collagen
2,7previous studies in which a female predilection is seen. FFH fibers are arranged in radiating, circular or random pattern. may be present in a wide age range but in the current study it Hyperplasia is usually considered to be a self limiting process.
nd thwas common in the 2 -5 decade of life probably relating to Hyperplastic tissue sometimes, but not invariably, regresses specific features in this range of life, that include lip biting after the removal of stimulus or irritant. Treatment for habit, wearing dentures, and chronic cheek biting. Due to fibroma is conservative surgical excision usually and seldom
1,6 these habits of cheek biting buccal mucosa is the most does the lesion recurs. common site for FFH. Apart from this, it is possible that
MATERIALS AND METHODS female hormones contribute to an increased production and
A retrospective analysis of 216 cases of soft tissue tumors accumulation of collagen by fibroblasts in the presence of
was done from the departmental archives of Department of chronic injury. Interestingly, other reactive lesions also show
Oral Pathology, SGRD Institute of Dental Sciences and a great predilection for females and are detected in the first
Research, Amritsar and 117 cases which were diagnosed five decades of life, when hormonal changes are most 7-9histopathologically as FFH during the period between May predominant.
2010 to September 2014 were selected for the study. The Our findings as regards to the site, confirm the previous
cases with complete clinical history and histopathological 6,7,10reports that found a higher prevalence of FFH in the evidence of FFH were included in the study.
buccal mucosa along the bite line, but contrasted with the 2Data was statistically analyzed regarding age, gender, size, study by Zarei et al , where it was mostly found in the gingiva
colour, site of lesion, pain, history of trauma, tumor (Table 2). Regardless of the site, FFH characteristically
attachment with base and recurrence. In this cross sectional exhibits a limited growth potential and in this study 54.7%
study we have limited the analyses to description of variables cases of FFH presented with a size of < 1 cm. Definitive
such as proportions and means. diagnosis is based on histological interpretation to rule out
the possibility of lesions which pose a similar clinical RESULTSappearance.
Out of 117 cases of FFH 57 cases (48.7%) were males and 60 Histologically, FFH is characterized by an encapsulated, solid, cases (51.3%) were females. Most common site of nodular mass of dense and sometimes hyalinized fibrous occurrence was buccal mucosa (55.5%) followed by gingiva connective tissue (Figure 3). The surface epithelium is usually (11.9%), lips (10.2%), alveolar ridge (6.8%), tongue (5.9%), atrophic, but may show signs of continued trauma, such as hard palate (5.1%) and retromolar area (4.2%) [Table 1]. excess keratin, intracellular edema of the superficial layers or Almost two-third of the cases were concentrated from
4,7traumatic ulceration. About 1% of FH present with stellate second to fifth decade of life (Figure 1). Most of the cases 11and giant cells. Although PGCG, POF, PG, neurofibroma, reported with no pain [99 cases (84.6%)], pinkish red colour
myxoma presents with similar clinical features as that of FFH, [96 cases (82%)] and history of trauma were seen in only 72 but their histological aspects are different.
Indian Journal of Comprehensive Dental Care 600
0
5
10
15
20
25
30
0-10 11.-20. 21-30 31-40 41-50 51-60 61-70 71-80
no.of patients
FIGURES
Figure 1: Distribution of 117 cases of focal fibrous hyperplasia according to age of patients.
Figure 2: Distribution of 117 cases of focal fibrous
hyperplasia according to diameter of lesion
Figure 3: Histopathological section showing
a dense and hyalinized
fibrous connective tissue stroma with an
atrophic epithelium. (H & E, X 10)
< 1 cm (54.7%)
1-2cm (25.3%)
>2cm (20%)
7-9PGCG is a rather common lesion of oral cavity, arising mainly long standing PG. Neurofibroma exhibits considerable
from the connective tissue of the gingiva or the periosteum variation in histologic structure but is generally composed of
of the alveolar ridge due to the irritational trauma. The lesion a proliferation of delicate spindle cells with thin wavy nuclei
is characterized by a non-encapsulated highly cellular mass intermingled with neurites in an irregular pattern as well as
with abundant giant cells dispersed throughout. PG consist delicate, interwining connective tissue fibrils. Myxoma is
of prominent vascular spaces lined with endothelium in a composed of haphazardly arranged stellate, spindle-shaped,
loosely arranged fibrillary matrix, with moderate to severe and round cells in an abundant, loose myxoid stroma that 1chronic inflammation while in POF presence of contains only a few collagen fibrils.
mineralization areas – bone, cementum-like material or Immunohistochemical (IHC) staining for cytoplasmic
dystrophic calcifications with multinucleated giant cells is a filaments, including vimentin, desmin, GFAP, and
common finding. On account of their clinical and neurofilaments, can aid in the precise identification of
histopathological similarity, it is considered that at least 12connective tissue tumors, including sarcomas. IHC stain some cases of POF may arise as a result of maturation of a
shows that cells in FFH are only vimentin positive, suggesting
Indian Journal of Comprehensive Dental Care 601
TABLES
Table 1: Distribution of 117 Focal fibrous hyperplasia cases according to the site of involvement
SITE No. OF CASES RELATIVE
FREQUENCY
Buccal mucosa
65 55.5%
Tongue
Dorsal surface
Ventral surface
Lateral border
Apex
7
4
1
2
0
5.9%
3.4%
0.85%
1.7%
0
Lip
Upper lip
Lower lip
Commissure
12
3
8
1
10.2%
2.5%
6.8%
0.85%
Gingiva 14 11.9%
Hard palate 6 5.1%
Alveolar ridge 8 6.8%
Retromolar region 5 4.2%
2Table 2: Comparison of data from Zarei et al , 7Santos et al and the current study.
VARIABLES ZAREI ET AL2
172 cases (%)
SANTOS ET AL7
193 cases (%)
CURRENT STUDY
117 cases (%)
Mean age
40.6
41.4
39.2
Sex
Female (54)
Female (70.5)
Female (51.3)
Site
Gingiva (48.8)
Buccal mucosa (61.7)
Buccal mucosa (55.5)
History of trauma
N.A.
90.7
61.5
Pain
N.A.
7.8
15.4
Size
<1cm (66)
<1cm (49.2)
<1cm (54.7)
Attachment to
base
N.A. N.A. Sessile- 94
Recurrence none 1.0 2.5
N.A. : Not available
a fibroblast phenotype. FFH is treated by conservative REFERENCES
surgical excision; recurrence is extremely rare. However, it is 1. Shafer WG, Hine MK, Levy BM. A textbook of oral important to submit the excised tissue for microscopic pathology, ed 6, Philadelphia, 1983, W. B. Saunders examination because other benign and malignant tumors Company, pp 80, 148, 198-99.may mimic the clinical appearance of fibroma.
2. Zarei MR, Chamani G, Amanpoor S. reactive CONCLUSION hyperplasia of the oral cavity in Iran: a review of 172
Soft tissue tumors in the head and neck region sometimes cases. Br J Oral Maxillofac Surg 2007; 45: 288-92.
display borderline pathological features regarding benign or 3. Neville B, Damm D, Allen CM, Bouquot JE. Oral and malignant behaviour. Problems of differential diagnosis ndmaxillofacial pathology, 2 ed Philadelphia: Saunders; concern a wide range of other diseases and immuno -
2002.p. 438-9, 447-52.histochemical analysis may be helpful in diagnosis. The
4. Robinson RA. Head and neck pathology: Atlas for present study highlights the distribution of FFH and its sthistologic and cytologic diagnosis, 1 ed. Philadelphia: presentation with emphasis on lesions which mimic it
Lippincot Williams and Wilkims; 2009.clinically. Further studies are needed on the distribution of
the lesions in different ethnic and geographical populations. 5. Regezi JA, Sciubba JJ, Jordan RCK. Oral pathology: thclinical pathologic correlations. 4 ed. Philadelphia:
Saunders; 2003.p. 158.
Indian Journal of Comprehensive Dental Care 602
6. Gonsalves WC, Chi AC, Neville BW. Common oral 11. Regezi JA, Courtney RM, Kerr DA. Fibrous lesions of the
lesions: Part II. Masses and neoplasia. AM Fam skin and mucous membranes which contain stellate
Physician 2007; 75: 509-12. and multinucleated cells. Oral Surg Oral Med Oral
Pathol 1975; 39: 605-14.7. Santos TS, Martins-Filho PRS, Piva MR, Andrade ES.
Focal fibrous hyperplasia: A review of 193 cases. J Oral 12. Jordan RCK, Daneils TE, Greenspan JS, Regezi JA.
Maxillofac Pathol 2014; 18(1): 86-89. Advanced diagnostic methods in oral and maxillofacial
pathology; Oral Surg Oral Med Oral Pathol Oral Radiol 8. Saravana GHL. Oral pyogenic granuloma: A review of Endod 2002; 93:56-74.137 cases. Br J Oral Maxillofac Surg 2009;47:318-9
9. Mishra MB, Bhishen KA, Mishra S. Peripheral ossifying
fibroma. Oral Maxillofac Pathol 2011; 15: 65-8.
10. Dayan D, Wolman M, Hammel I. Histochemical study of
the blue autofluorescence of collagen in oral irritation
fibroma: Effects of age of patients and of durations of
lesions. Histopathol 1994; 9: 11-13.
PREVALENCE OF ORAL AND MAXILLOFACIAL LESIONSIN DISTRICT OF AMRITSAR: A RETROSPECTIVE STUDY
ABSTRACT
AIMS & OBJECTIVES: The objective of the study was to determine the
prevalence of different oral and maxillofacial lesions of the oral cavity in the
district of Amritsar.
MATERIALS AND METHOD: Retrospective analysis was carried out to assess
the prevalence of pathological oral conditions in 68138 patients seeking dental
care in SGRD Institute of Dental sciences and Research from January 2013-
December 2014.
RESULTS: 68,138 patients were screened out of which 1145 (1.6%) had one or
more lesions. Most of the lesions were present in males and the pathologies
were mostly present in the older age group. Most commonly found lesion was
lichen planus (14.8%).
CONCLUSION: The results of the study have helped to determine the various
pathologies of oral cavity in the population of Amritsar. The prevalence of
individual lesions differed significantly by age and sex. This can serve as a
baseline for future studies with the goal of finding ways to improve oral health
in this population.
KEYWORDS: Amritsar, prevalence, oral and maxillofacial lesions, lichen planus
603
Corresponding author:Name:Dr. Preeti Chawla Arora. MDS Address: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M) 8146425170 Email: dr.preetsgmail.com
1. Reader, Department of Oral Medicine, Diagnosis and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
2. Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
3. Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
4. Reader, Department of Oral Medicine, Diagnosis and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
5. Reader, Department of Prosthodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
Indian Journal of Comprehensive Dental Care
I J C D C1. Preeti Chawla Arora
2. Ruhi Duggal
3. Sargun Sarang
4. Arshdeep Kaur
5. Aman Arora
Date of Submission : 7/1/15 Date of Acceptance : 18/2/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
INTRODUCTION: population of Punjab. Thus, it is essential to conduct clinical
research to find out the prevalence of oral lesions which can Identification of oral pathological conditions forms an serve as the basis for a larger nationwide survey. The aim of integral part of their treatment. Various oral mucosal the study was to determine the prevalence of different lesions may go unnoticed while doing clinical dental pathological oral lesions among the patients seeking dental examination of patients, thus it is important to not only see care in S.G.R.D Institute of Dental Sciences and Research, the teeth but also the various oral tissues as they may give Amritsar. information of the health status of the patient. “Mouth is the
mirror of body”, this statement aptly describes the MATERIALS & METHOD:
importance of oral mucosal examination. Different oral Retrospective study and analysis was carried out from the conditions can also reflect the socio-economic status, records of the Oral Medicine & Diagnosis Department of educational, cultural and behavioural traditions. SGRD, Institute of Dental sciences and Research from
Several studies have been carried out to evaluate the January 2013 to December 2014, over a period of 2 years.
prevalence of oral and maxillofacial conditions by clinical The population under study consisted of 68,138 patients,
examination and detailed history taking. Most of the out of which 34,821 (51.1%) were males and 33,317 (48.8%)
studies on oral mucosal lesions are on tobacco associated were females ranging from 1.5 months to 91years of age.
lesions and premalignant and malignant lesions. However, The mean age of the sample group was 44.5years.
very few of them have been conducted on various oral and A thorough intraoral clinical examination was performed by maxillofacial pathological conditions amongst the trained staff of the Department of Oral Diagnosis and
Indian Journal of Comprehensive Dental Care 604
Medicine using artificial light, dental mirror, dental explorer, cell carcinoma (SCC)(4.6%), mandibular fracture (3.5%),
gauze, latex gloves and other materials. Personal data recurrent herpes labialis (RHL)(3.4%).
including age, gender and chief complaint were recorded. DISCUSSION: Clinical diagnosis was established after proper history and
Infection, trauma, systemic conditions, adverse oral habits & clinical examination, along with appropriate radiographic hereditary conditions & immuno-pathological states can and pathological investigations. The lesions which were present with various oral mucosal lesions. Oral health survey indicated for biopsy were correlated with their histo-data are essential for proper health planning. Most of the pathological reports. The type and distribution of the oral conducted studies are of tobacco related/associated lesions mucosal conditions was recorded. The data obtained was or oral cancer. In addition, most of the conducted studies analysed from the records with special emphasis on oral were of tumors or ulcers and did not include all oral lesions in mucosal lesions. Various pathological oral mucosal changes
1adult populations. and conditions of the maxillofacial complex were included in
the study. Very few studies regarding prevalence of oral mucosal
abnormalities in the state of Punjab has been carried out. It is Exclusion criteria:very essential to establish base line data on the prevalence of
Dental caries, periodontal disease, periapical pathologies oral lesions as oral health survey data are essential for proper
were excluded from the study. Hairy tongue, fordyce's health planning programs. The pattern of disease is changing
granules, leukoedema, linea alba, fissured tongue, tori are due to increasing awareness, changes in lifestyle and
the most commonly occurring normal variants were increasing interest in oral health. Due to the cultural and
excluded from the study.religious beliefs, tobacco in any form is minimally used in the
The subjects were divided into 3 groups according to their state of Punjab. But in recent times, due to the changing
age trends and social influence, the use of tobacco has increased.
Group I: 0-20 years (young age and adolescents) Among 68,138 patients seeking dental care 1.6 (%) presented
with various pathological oral lesions. The prevalence of oral Group II: 21-40 years, (middle age)pathological conditions in our study was 1.6%. Here we have
Group III: more than 40 years (older age group) excluded the normal mucosal variations and certain other
physiological conditions which have been included in most of The prevalence of each pathological entity in relation to age 1the prevalence studies. Al-Mobeeriek A et.al in their study and sex was determined and the data was statistically
amongst Saudi patients have recorded the prevalence of analysed by Chi-square test.
15%. This can be attributed to the inclusion of normal RESULTS
physiological variations present in the oral cavity. Mehrotra 2The presence of pathological oral and maxillofacial et al have found a prevalence of oral lesions as 8.4 %.
3conditions and their distribution according to age and sex is Saraswathi T.R. et.al have found the prevalence of clinically represented in Table I. Amongst the 68,138 patients, 1145 significant oral lesions to be 4.1% in South India. patients (1.6%) had pathological oral lesions, out of which
In our study, the pathological oral mucosal changes were 649 (56.6%) were males and 496 (43.3%) were females.
more prevalent in males, however there was no significant Although the pathological oral conditions were more
difference in the prevalence of oral lesions between males prevalent in males, however there was no significant
1 4and females. However, Al-Mobeeriek A et.al , Narty N , difference in the prevalence of oral lesions between males 5Masadomi H et al , have observed that females have a higher (649/34,821 i.e. 1.86%) and females (496/33317 i.e. 1.48%)
prevalence rate. Also, there was no significant difference in (p<0.05 was significant)the prevalence of oral lesions between males and females as
6A statistically significant greater percentage of older patients seen by Ali M et al . So we can conclude that prevalence of i.e Group III (50.56%), had one or more oral lesion than oral lesions is an independent variable of sex.patients of Group I & II. The second most common
According to our study the pathological oral lesions were occurrence of oral and maxillofacial lesions was seen in most commonly observed in the older age group (Group III) Group II (40.08%) followed by the least occurrence in Group I followed by middle age group (Group II) and least in the (9.3%).
6young and adolescent stage (Group II). However Ali M et.al In our study, the most prevalent oral mucosal lesion was have observed that middle age group has higher prevalence lichen planus (14.8%).The other most common ones were of oral lesions followed by older age group and young age space infections (9.7%), tobacco pouch keratosis (6.4%), 1group (Group I) Al-Mobeeriek A et.al in their study have leukoplakia (6.4%), trigeminal neuralgia (6.3%), squamous
Indian Journal of Comprehensive Dental Care 605
TABLE I: Frequency of individual oral and maxillofacial conditions and their distribution according to age and sex.(p<0.05= significant)
ANUG-Acute Necrotising Ulcerative Gingivitis NS- Non Significant S- Significant
LESIONS MALES FEMALES FREQUENCY
(%)
SEX AGE
<20 21-40 >40
Lichen planus 64 105 14.8 S S 2 40 127
Melanosis 51 60 9.7 S S 22 57 32
Aphthous ulcer 52 32 7.3 NS NS 10 41 33
Tobacco Pouch Keratosis
12
11
6.4
S
S
5
49
19
Leukoplakia
70
3
6.4
S
S
1
41
31
Trigeminal neuralgia
35
37
6.3
NS
S
0
10
62
Traumatic ulcer
43
26
6.0
NS
S
2
16
51
Squamous Cell Carcinoma
45
6
4.6
S
S
0
15
36
Mandibular fracture
34
6
3.5
S
S
9
22
9
TMJ Arthritis
13
26
3.4
S
S
3
23
13
Recurrent Herpes
Labialis
15
24
3.4
S
NS
6
16
17
Oral Submucous Fibrosis
23
3
2.3
S
NS
1
15
10
Fibroma
12
14
2.3
NS
NS
2
10
14
Myofacial Pain Dysfunction Synd.
7
17
2.1
S
S
5
16
3
Burning mouth syndrome
4
19
2.0
S
S
0
2
21
Candidiasis
12
11
2.0
NS
NS
1
7
15
Melanotic macule
6
8
1.2
NS
S
1
11
2
Radicular cyst
5
6
1.0
NS
S
5
5
1
Maxillary fracture
10
0
0.9
S
NS
2
5
3
Angular cheilitis
6
4
0.9
NS
NS
0
4
6
Gingival Enlargement
5
5
0.9
NS
NS
3
4
3
Denture stomatitis
4
5
0.8
NS
NS
0
2
7
Osteomyelitis
6
3
0.8
NS
NS
0
4
5
Frictional Keratosis
6
3
0.8
NS
NS
0
3
6
Inflammatory hyperplasia
2
6
0.7
NS
NS
2
1
5
Atypical Facial pain
2
6
0.7
NS
NS
0
4
4
Epulis Fissuratum
3
4
0.6
NS
NS
0
1
6
Odontogenic Keratocyst
4
3
0.6
NS
NS
1
2
4
Ludwig’s
Angina
2
4
0.5
NS
NS
0
4
2
Ankyloglossia
3
3
0.5
NS
NS
0
3
3
S/NS
Indian Journal of Comprehensive Dental Care 606
Desquamative gingivitis 0 5 0.4 S NS 0 2 3
Herpes zoster 2 3 0.4 NS NS 1 2 2
Chemical Burn 4 1 0.4 NS S 0 5 0
Ameloblastoma 3 2 0.4 NS S 2 1 2
Oro antral fistula 1 4 0.4 NS NS 0 0 5
Lichenoid reaction 4 0 0.3 NS NS 0 2 2
Erythroplakia 3 1 0.3 NS NS 0 3 1
Smoker’s Palate 3 1 0.3 NS NS 0 2 2
Radiation Induced Xerostomia 2 2 0.3 NS NS 0 1 3
Ossifying fibroma 1 2 0.3 NS NS 1 1 1
Hemangioma 3 1 0.3 NS NS 0 1 3
Hematoma 2 1 0.3 NS S 2 0 1
Lipoma 3 0 0.3 NS NS 1 0 2
Sialolith 3 1 0.3 NS NS 0 3 1
Erythema Multiforme 0 3 0.3 NS NS 0 1 2
Verrucous carcinoma 4 0 0.3 NS NS 0 3 1
Geographic tongue (symptomatic) 1 3 0.3 NS NS 0 1 3
Subluxation TMJ 1 2 0.3 NS NS 0 3 0
Pyogenic granuloma 1 3 0.3 NS NS 0 3 1
Drug induced GE 1 2 0.3 NS S 2 1 0
Foliate pappilitis 1 2 0.3 NS NS 1 2 0
Amelogenesis imperfect 2 2 0.3 NS S 4 0 0
TMJ Ankylosis 2 1 0.3 NS S 3 0 0
Glossodynia 1 2 0.3 NS NS 1 1 1
Papilloma 1 1 0.2 NS NS 0 1 1
Parotid Abscess 2 0 0.2 NS NS 0 1 1
Pemphigus 2 0 0.2 NS NS 0 0 2
Adenomatoid Odontogenic Tumor 1 1 0.2 NS NS 1 0 1
Scleroderma 0 2 0.2 NS NS 0 1 1
Fibro osseous lesions 1 1 0.2 NS NS 0 2 0
Indian Journal of Comprehensive Dental Care 607
concluded that middle age was the most affected. Herpes simplex infections and recurrent aphthous ulcers are
rarely biopsied. Also many of the patients are not willing for In our study sample the most commonly occurring lesion was biopsy, and do not turn up for follow up. Most of the oral lichen planus (14.8%). Its overall prevalence was found to be pathological conditions listed in this study were confirmed by 0.24 %. According to the statistics, the lesion was found to be histo-pathological examination wherever necessary. Future significantly present in females and in Age Group III. Omal
7 studies with clinico-pathological co-relations, with habit, PM et al have found a prevalence of lichen planus 0.64% in
type, symptomatology and site of the lesion should be the population of South India.
performed.Leukoplakia, Squamous cell carcinoma (SCC), Oral Sub-
CONCLUSIONmucous Fibrosis (OSMF) were significantly present among
males which is in accordance with various studies around the The results of the present study provide important
world. information about the prevalence of pathological oral lesions
among patients seeking dental care in Amritsar. The These premalignant and malignant lesions were
information presented in this study adds to our predominantly seen in males as compared to females. In an
understanding of common oral pathological lesions Indian scenario, usage of tobacco is more among males than
occurring in general public. females. Pre malignant lesions (Leukoplakia, OSMF) were
mostly prevalent in the age Group II and SCC was seen mostly This information can help determine the epidemiology and
in age Group III. severity of oral lesions in Punjab and help identify risk factors
for oral lesions. It will also serve as a baseline for future Generally Lichen planus, TMJ associated inflammatory
studies with the goal of finding ways to improve oral health. conditions, burning mouth syndrome (BMS) are considered
to be stress related lesions and are frequently detected in REFERENCES:
female population. There was a similar observation in the 1. Al – Mobeeriek A, Al Dosari AM. Prevalence of oral Punjabi population, as stated by the study. lesions among Saudi Dental patients. Ann Saudi Med
This study does not represent all the lesions seen by dentists, 2009; 29 (5): 365-368.
since certain conditions may go unnoticed. Lesions such as 2. Mehrotra R, Thomas S, Nair P, Pandya S, Singh M,
Masseteric hypertrophy 1 1 0.2 NS NS 0 0 2
Mucocele 2 0 0.2 NS NS 1 1 0
Pemphigoid 1 0 0.1 NS NS 0 0 1
Odontome 0 1 0.1 NS S 1 0 0
Peripheral Giant Cell Granuloma 0 1 0.1 NS S 1 0 0
Central Giant Cell Granuloma 1 0 0.1 NS NS 0 1 0
Allergic stomatitis 1 0 0.1 NS NS 0 1 0
ANUG 0 1 0.1 NS NS 0 1 0
Adenoma 1 0 0.1 NS NS 0 0 1
Nasopalatine duct cyst 0 1 0.1 NS NS 0 0 1
A-V Malformations 1 0 0.1 NS S 1 0 0
Epidermolysis Bullosa 0 1 0.1 NS S 1 0 0
Osteoma 1 0 0.1 NS NS 0 1 0
Bell’s palsy 0 1 0.1 NS NS 0 1 0
TOTAL 649 496 107 459 578
Indian Journal of Comprehensive Dental Care 608
Nigam N et al. Prevalence of oral soft tissue lesions in 6. Ali M, Joseph B, Sundaram D. Prevalence of oral
Vidisha. BMC Research Notes 2010; 3: 23. mucosal lesions in patients of THE Kuwait University
Dental Center. The Saudi dental journal 2013; 25: 111-3. Saraswathi TR, Ranganathan K, Shanmugam S, 118.Sowmya R, Narsimhan PD, Gunaseelan R. Prevalence
of oral lesions in relation to habits: Cross sectional 7. Omal PM, Jacob V , Thomas NG. Prevalence of oral ,
study in South India. Indian J Dent Res 2006; 17 (3): skin, and oral and skin lesions of Lichen Planus in
121- 5. patients visiting a dental school in southern India.
Indian J Dermat 2012 ;57(2):107-109.4. Narty N, Masadomi H, Al – Gilani M, Al- Mobeereik A.
Localized inflammatory hyperplasia of the oral cavity:
a clinicopathological study of 164 cases. Saudi Dent J.
1994 ; 6 (3).
5. Masadomi H, Algilani M, Narty N, Alsaif N, Salem G, Jul
R, Schiodt T. Tumors, cyst, cyst-like and allied lesions of
the jaws and oral mucosa in Riyadh, KSA. Saudi Dent J.
1992 Jan;4 (S1) Actaodontol -scand 1984
Feb;42(1):41-5.
DENTAL CARIES STATUS OF FIRST PERMANENT
MOLARS AMONG SCHOOLCHILDREN OF
AMRITSAR DISTRICT
Abstract
Background: Schoolchildren in the age group of 8-12 years are the most
vulnerable group for various oral health problems; this is the time in which the
permanent molars erupt in the oral cavity and heralds the beginning of a time in
which there is a combination of primary and permanent teeth. This tooth is
often ignored by the child and parents as they are not aware of the importance
of it. Thus such a study can be used as a powerful aid for planning a proper oral
health care system at early ages.
Aim & objectives: The aim and objective of the study is to asses the status of
the first permanent molars among school children of Amritsar city in the age
group of 8-12 yrs.
Materials and Methods: The present study was an observational study done
among the 1389 subjects who were taken from 15 randomly selected schools in
Amritsar district. Dental caries status of the permanent first molar was
assessed according to WHO Oral Health Surveys: Basic Method (1997). OHI(S)
index was used for assessing oral hygiene and Loe and Silness was done to
assess gingivitis. The data regarding the oral hygiene practice was collected
using pretested proforma.
Results: 85.0% of boys claimed that they use toothbrush to clean their teeth
whereas in girls it was reported to be 91.1%. The mean DMFT of the boys was
0.58 + 1.11 whereas in girls it was 0.61+1.08. The mean OHI – S on the first
permanent molars of boys was 1.36 + 0.72 whereas in girls it was 1.22 + 0.84.
Conclusion: The results of this study would provide a base line data for
implementation of preventive oral care at the earliest age, then sustaining
these preventive measures in the later ages thus avoiding extensive expenses
on oral health care.
Key Words: First permanent molars, dental caries, oral hygiene practice.
609
Corresponding author:Name: Dr. Satinder Singh WaliaAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M) 08968584500.Email: drsatinder@hotmail.com
14. Associate Professor, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
2. Reader, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
3. Lecturer, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
4. Ex-intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
Indian Journal of Comprehensive Dental Care
I J C D C1. Satinder Singh Walia
2. Amaninder Kaur
3. Gurpreet Kaur
4. Gagan Deep
Date of Submission : 8/1/15 Date of Acceptance : 22/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
INTRODUCTION lesion to pulp exposure in a 6 - month period. The loss of first
molar due to extraction or removal leads to problem in The first permanent molar is very important tooth from both space management, tooth movement, mastication and functional and development point of view, its importance occlusion which can be traced throughout the life of that could be attributed to the earliest eruption, bearing of person. Promoting oral health during childhood establishes maximum occlusal load, maintain arch perimeter, key factor a foundation for life long oral health and general well being in occlusion, maximum surface area, provides the best
2thus establishing good oral health early. The aim of this anchorage, considered to be the growth centre in the oral 1 project was to study the caries status of first permanent cavity. A carious lesion may develop rapidly in the first
molars among schoolchildren of Amritsar district in the age permanent molar and occasionally progress from incipient group of 8-12 years.
Indian Journal of Comprehensive Dental Care 610
Materials and Method proforma also included some dental hygiene habits
questionnaires. Type iii method of examination was carried Based on the result of pilot study sample size of 1389 was out using plain mouth mirror, explorer, probe, WHO probe, estimated. In September 2014, as an epidemiologic survey, tweezer, cotton, cold sterilization and sunlight for natural this study was conducted on schoolchildren which were illumination. taken from 15 randomly selected schools in Amritsar district.
Permission to carry out the study among schoolchildren was Data Analysis: The collected data was entered in the
obtained from the principal's of the respective school. Dental microsoft excel sheet and analyzed using SPSS 11.5 version.
caries status of the permanent first molar (16. 26, 36, and 46) The descriptive statistics was used and significance was set at
was assessed according to WHO Oral Health Surveys: Basic P< 0.05. Results:
Method (1997). OHI(S) index was used for assessing oral Table:-1 show the study group comprised of 1389 hygiene and Loe and Silness was done to assess gingivitis. The schoolchildren, out of whom, 747 (53.8%) were boys and 642
Table-1: Distribution of the study subjects
according to oral hygiene practices
ORAL HYGIENE PRACTICES
GENDER
Boys (n=747)
Girls (n = 642)
Aid for cleaning teeth
Toothbrush
635(85.0)
585(91.1)
Finger
43(5.8)
12(1.9)
Datun
69(9.2)
45(7.0)
Frequency of cleaning TeethOnce in a day
484(64.8)
371(57.7)
Twice a day232
(31.2)261
(40.6)
Don’t clean every day29
(3.9)12
(1.7)
Table-2: Distribution of the study subjects
according to prevalence of dental caries
Gender
(n = 1389)
Mean
DMFT
Mean
OHI-S
Boys
(n = 747)
0.58 +
1.11
1.36 +
0.72
Girls
(n = 642)
0.61 + 1.08 1.22 + 0.84
TOTAL 0.59 + 1.10 1.29 + 0.78
Table-3: Age wise distribution of the study subjects according to
prevalence of dental caries.
Age in yrs (n=no. of schoolchildren)
Dental Caries
Caries Free (n=922)
Caries Affected (n=467)
Boys
(%)
Girls
(%)
Boys
(%)
Girls
(%)
8 yrs
(n =327)
121
(24.7)
106
(24.4)
58
(22.4)
42
(20.0)
9 yrs
(n =265)
112
(22.9)
101
(23.3)
34
(13.2)
18
(8.6)
10 yrs
(n =315)
113
(23.1)
87
(20.1)
50
(19.4)
65
(31.1)
11 yrs
(n =216)
82
(16.7)
79
(18.2)
42
(16.2)
13
(6.2)
12 yrs
(n =266)
61
(12.4)
60
(13.8)
74
(28.6)
71
(33.9)
Total
489
433
258
209
Indian Journal of Comprehensive Dental Care 611
(46.2%) were girls. The oral hygiene practice was assessed, and lifestyles. The results of this study would provide a base
85.0% of boys claimed that they use toothbrush to clean their line data for implementation of preventive oral care at the
teeth whereas in girls it was reported to be 91.1%. When earliest age, then sustaining these preventive measures in
asked about frequency of cleaning teeth, out of 747 boys, the later ages thus avoiding extensive expenses on oral
64.8% said that they clean their teeth once in a day and 31.2% health care.
said that they clean twice a day. Whereas in girls out of 642 Referencesgirls, 57.7% said they clean their teeth once in day and 40.6%
1. Arrow P. et. al Prevalence of development enamel said they clean twice a day. defects of the first permanent molars among school
Table:-2 show the summarization of the status of the first children in Western Austrailia. Aut. Dent. J. 2008, sep permanent molars in the study population. The girls had 53(3) 250-9. more dental caries on the first permanent molars as
2. E. S. Akpata and D. Jackson; “Caries vulnerability of first compared to the boys. In 10 yrs age group boys had 19.3% of and second permanent molar in the urban Nigerians”; dental caries whereas girls had 31.1%. Dental caries was Archies of Oral Radilogy Vol. 23, Issue 9, 1978 pg. 795-found more on the occlusal surface among both boys and the 800. girls in all the age groups. The mean DMFT of the boys was
0.58 + 1.11 whereas in girls it was 0.61+1.08. The girls had 3. Nazik Mostafa Nurelhuds et. al Oral health status of 12 better oral hygiene on the first permanent molars as year old school children in Khartoum State . The Sudan, a compared to the boys. The mean OHI – S on the first school based survey. BMC Oral Health 2009. 9115. permanent molars of boys was 1.36 + 0.72 whereas in girls it
4. Katherine Westwater “ A study of the relative caries was 1.22 + 0.84. (Table:-3)
prevalence in first and second molar of rural Zambian Discussion school children. Jol. of Dentistry Vol. 5 Issue 1, 1997.
More percentage of school girls in the age group of 8-12 yrs 5. A.M Acevedo et. al; “A longitudinal study of dental caries showed presence of dental caries on the first permanent in the first permanent molars of Venezuelan children” molars this could be due to the early eruption of the first
6. J.C. Carvalho , K. R. Ekstrand and A. Thylstry “ Dental permanent molars among the girls than the boys, similar to
plaque and caries on occlusal surfaces of first permanent 2the results of the studies of E.S. Akpate and D. Jackson , A.M.
molars in relation to stages of eruption J. Dent. Res. 1989 5 7Acevedo.et. al and Baca P, Junco P et. al. The occlusal caries
68:773. was more compared to other surfaces suggesting that
7. Baca P. Junco P et. al; “ Caries incidence in permanent occlusal surface of the first molars was most prone to dental first molars after discontinuation of a school based caries due to its morphology, thus suggesting early chlorhexidine thymol vanish program”; Comm. Dent. preventive measures on this surface. Oral Epidem. 2003 Jan 31(3):179-83.
It was surprise to note that the oral hygiene status was better 8. Erik T. Parner, Jeno M. “Heidmanetal Surface- specific among the girls than the boys even through the girls are more
caries incidence in permament molars in Danish affected by dental caries. Measurement of brushing children”; European J. of Oral Sciences Dec. 2007 vol frequency at the age of 8-12 years may not necessarily reflect 115, issue 6 491-496. the teeth hygiene habits at the time of tooth eruption and
the following years. Moreover, if a child has a pervious 9. World Health Organization. Oral Health Surveys. Basic, thhistory of extensive caries he or she may well respond methods , (WHO), Geneva 1997, 4
favourably to dental care. For this reason frequency at a given
period may not correlate well with the caries experience, a
factor representing a lifelong process.
Conclusion
The present study has provided a valid overview of the status
of the first permanent molars among school children of
Amritsar district. At the global level marked changes in oral
disease patterns have observed over the past decades. The
prevalence and severity of dental caries of school children
have declined and the trend parallels the implementation of
preventive oral care programs and changing living conditions
CORRELATION OF SKELETAL MATURATION
USING CVMI WITH DENTAL CALCIFICATION
USING WILLEM'S METHOD
Abstract
Aim : The aim of the study was to evaluate skeletal age using CVMI and dental
age using Willem's method , compare and correlate cervical vertebrae maturity
indicator and dental calcification stages with chronological age.
Method: A total sample of 100 patients (57 Male and 43 Female) ranging in age
from 9 to 16 years were selected and their skeletal and dental age were
evaluated and correlated with the chronological age.
Results: The data confirmed a strong and significant correlation between all the
parameters and highly significant correlation of the dental age using Willem's
method with the chronological age (r=0.801) followed by CVMI (r=0.618).
Conclusion: The present study indicates that (1) There is significant correlation
between skeletal and dental age with the chronological age. (2) Dental age
using Willem's method is more closely related to the chronological age
followed by CVMI. (3) Even on comparison dental age using Willem's method
found to be more comparable with the chronological age than CVMI.
Key Words : Skeletal maturation; Lateral cephalogram; Cervical vertebrae
maturation indicators; Panoramic radiograph; Willem's Method.
612
Corresponding author:Name: Dr. Kamaldeep SharmaAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, AmritsarPhone no: +919417846890Email: Kamal_dentist2002@yahoo.com
1. MDS, Reader, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
2. Professor and Head of Department, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
3. Senior Lecturer, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
4. Postgraduate student, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
5. Postgraduate student. Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
6. Lecturer, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
INTRODUCTION: inspection of the developing bones, their initial appearance
and their subsequent ossification-related changes in shape Growth is the result of biologic processes by means of which 5, 11and size. living matter normally gets larger and it is not uniform
thoroughly throughout the life. Dental maturity can be determined by the stage of tooth
eruption or the stage of tooth formation. The latter is It is important to know the stage of maturation of a patient. proposed as a more reliable criterion for determining dental Assessing maturational status and knowing whether the maturation. Dental age is of particular interest to the pubertal growth spurt of that patient has been reached or orthodontist in planning the treatment of different types of completed, can have a considerable influence on diagnosis,
9malocclusion in relation to maxillofacial growth.treatment goals, treatment planning, and the eventual
outcome of orthodontic treatment. Considerable variations
in the development among children of the same
chronological or calendar age have led to the concept of
biologic or physiologic age. Physiologic age is the registry of
the rate of progress toward maturity that can be estimated
by somatic, sexual, skeletal, and dental maturity. The
technique for assessing skeletal maturity consists of visual is association between skeletal maturity and different
The most useful method to evaluate biological maturity is
the estimation of the skeletal age due to the fact that the
changes that bones experience during their maturation
process are very similar in all individuals and each
ossification centre goes through a number of morphological
changes that can be easily identified.
There
Indian Journal of Comprehensive Dental Care
I J C D C1. Kamaldeep Sharma
2. Sukhdeep Singh Kahlon
3. Chetandev Singh Boparai
4. Veneet Mehta
5. Navjot Singh Jassal
6. Amardeep Singh Sandhu
Date of Submission : 13/11/14 Date of Acceptance : 29/12/14
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Indian Journal of Comprehensive Dental Care
stages of dental calcification, thus stages of dental Mean, Standard deviation was calculated of different ages.
calcification might be used as a first-level diagnostic tool to Correlation coefficient and paired t-Test was performed
estimate the timing of pubertal growth spurt. among cervical vertebrae maturation and dental calcification
age was made.
INTERPRETATION OF RESULT:
The data confirmed a strong and significant correlation
between all the parameters and highly significant correlation
of the dental age using Willem's method with the
chronological age (r=0.801) followed by CVMI (r=0.618) as
shown in Table II. On comparison dental age using Willem's
method was found to be more comparable than CVMI as
shown in Table III. The complete statistical descriptions has
been given in Table I.MATERIALS AND METHODS:
DISCUSSION:
Chronological age is not a valid predictor of skeletal growth
velocity or skeletal maturity. Sexual dimorphism is well
documented and there is a wide range of individual 9variability in timing of periods of increased growth velocity.
Pancherz and Szyska found that the cervical vertebral
maturation method has level of reliability comparable to the 7hand and wrist method.
Guy Willems in 2001 repeated Demirjian's study for the
Belgian Caucasian population.Statistical analysis of the
results led to creation of new tables for boys and girls with 8the maturity scores expressed in years.
Patel PS et al tested the applicability of Demirjian's and
Willem's dental age assessment methods as well as Greulich
and Pyle skeletal age assessment method in children residing
in Gandhinagar district in 180 subjects and they evaluated
that the Willem's dental age estimation method proved to be 15
the most accurate and consistent.
STATISTICAL ANALYSIS:
AIMS & OBJECTIVES:
The present study was conducted
(1) To evaluate skeletal age using lateral cephalogram for
cervical vertebrae and dental age using panoramic
radiograph.
(2) To compare and correlate cervical vertebrae maturity
indicator and dental calcification stages with chronological
age.
A total sample of 100 patients (57 Male and 43 Female)
ranging in age from 9 to 16 years were selected. Two
radiographs namely Lateral Cephalogram, Panoramic
radiograph were taken on the same date for selected
subjects after having their parents consent for the study as
shown in Fig1 and Fig 2 respectively.
The inclusion criteria were as follows:
- Chronological age ranging from 9 to 16 years
-No serious illness
- Normal overall growth and development
-Absence of abnormal dental conditions, such as impaction,
transposition, and congenitally missing teeth
Absence of previous history of trauma or disease to the face
and neck
-Absence of orthodontic treatment
-No permanent teeth extracted.
The system developed by Hassel and Farman for lateral Dental eruption is a fleeting event that is under greater 6cephalogram to determine the skeletal maturation environmental influence. In the present study, calcification
evaluation on each subject by classifying C2, C3, and C4stages of teeth, rather than eruption were preferred because
into six groups depending on their maturation patterns (Fig1) tooth formation is proposed as a more reliable criterion for 8and Willem's method for dental age assessment from determining
panoramic radiograph in which one of eight stages of 1Dental maturation . calcification (A to H) was assigned to each mandibular
The present study was aimed to assess the skeletal age using tooth(fromCVMI and dental age using Willem's method and to correlate
central incisor to the second molar on left quadrant) were the dental as well as skeletal age with the chronological age.
used .Both the radiographs were traced on 0.003 inch matte Dental mean age for males (12.629±1.64 yrs) and Females acetate with 0.5 mm diameter lead pencil using a (13.395±1.84 Yrs) and CVMI mean age for males (12.574 ± radiographic illuminator. After evaluating the different stages 0.58Yrs) and Females (12.685±0.97Yrs) were compared with of CVMI and of Dental Calcification, these were correlated the chronological mean age for males (12.367±1.38Yr) and with chronological age.Females (12.687±1.259Yrs).The p value was highly significant
in Females (P=0.001) and significant in males (p=0.041) while
613
Indian Journal of Comprehensive Dental Care 614
CVMI stages from I to VI Patient Positioning for recordingCVMI using Lateral Cephalogram
Fig.1.Assessment of skeletal maturity using CVMI from Lateral Cphalograph as an indicator
Development stage of permanent dentition Patient Positioning for recording
CVMI using Lateral Cephalogram
Fig.2.Assessment of Dental maturity using dental age(Willem's Method)
from Panoramic Radiograph as an indicator
Indian Journal of Comprehensive Dental Care 615
TABLE I
N Mean SD
Std.
Error
95% Confidence
Interval for Mean
Min Max
Lower
Bound
Upper
Bound
CHRONOLOGICAL AGE M 57 12.36702 1.3849 .18344 11.99954 12.734 9.060 15.06
F 43 12.68698 1.2598 .19212 12.29925 13.074 11.01 15.05
Total 100 12.50460 1.3355 .13355 12.23960 12.769 9.060 15.06
Dental Age(Willems ) M 57 12.62982 1.6454 .21794 12.19323 13.066 8.840 16.30
F 43 13.39535 1.8436 .28116 12.82794 13.962 8.400 15.79
Total 100 12.95900 1.7659 .17659 12.60859 13.309 8.400 16.30
CVMI Skeletal Age
M
57
12.57491 .58906
.07802
12.41861
12.731
10.83
15.06
F
43
12.68581 .97959
.14938
12.38434
12.987
10.83
14.46
Total
100
12.62260
.77873
.07787
12.46808
12.777
10.83
15.06
Dental Age CVMI age
Chronological age r =
p =
0.801
<0.001**
0.618
<0.001*
Dental Age r = p =
- 0.589 <0.001*
CVMI age
r =
p =
-
-
TABLE II Correlation
r : Pearson Correlation Coefficient; **p<0.001; Highly signify
Sex Chronologi
cal Age
Dental age
(Willem’s)
CVMI age Chr. Age vs
DA P value
C. Age vs CVMI
age P value
M 12.367 ±
1.385
12.629 ±
1.645
12.57491±
.589064
0.041* 0.190
F
12.687 ±
1.259
13.395 ±
1.844
12.68581±
.979597
<0.001**
0.993
TABLE III Correlation
*p<0.05; Significant; **p<0.001; highly significant
Indian Journal of Comprehensive Dental Care 616
comparing dental age with chronological age while it is non-
significant in case of CVMI and chronological mean age in
both sexes.
Pearson correlation coefficient between each parameter was
evaluated. Data confirmed a highly significant correlation
between all parameters and strong and highly significant
correlation between the dental age using Willem's method
with the chronological age as given by (r=0.801;p<0.001)
followed by CVMI (r=0.618;p<0.001)
Most of the studies in literature are based on the comparison
between skeletal age using CVMI, Dental age using Demirjian 8, 11stages with chronological age.
This is the first study which has compared the chronological
age with the CVMI and tooth calcification stages using
Willem's Method.
The unique and significant findings from the present study
imply that the tooth calcification stages evaluated by
Willem's method as observed on panoramic radiographs give
fairly accurate results and can be considered reliable
indicators of skeletal maturity with the methodology 8suggested by Willem.
4. Leonard S. Fishman .radiographic Evaluation of Skeletal
Amturation.AO 1982;52(2).
5. Anibal M.Silveria,Leonard S.Fishman,J.Daniel Subtelny,
Denise K.Kassebaum. Facial growth during adolescence
in early, average and late maturers. Angle
Orthod.1992;62:185-189.
6. Brent Hassel, and Allan G. Farman, Skeletal maturation
evaluation using cervical vertebrae ,AJODO 1995
7. Pancherz H, Szyska M. Analyse der Halswirbelkörper
statt der Handknochen zur Bestimmung der skelettalen
und somatischen Reife. IOK 2000;32:151-161.
8 .Guy Willems. A Review of most commonly used Dental
age estimation Techniques. JOFOS 2001;19(1).
9. Suleekorn Krailassiri,Niwat Anuwognukroh,Surachai
Dechkunakorn. Relationship between Dental
Calcification stages and skeletal Maturity Indicators in
Thai individuals.Angle Orthod.2002;72:155-166.
10. Sun-Mi Cho. Skeletal maturation evaluation using
mandibular third molar development in adolescents.
Korean J Orthod 2009;39(2):120-129.
11. Mandava Prasad,Venkata Suresh Kumar Ganji , Suja Ani CONCLUSION:George,Ashok Kumar,Talapaneni ,Sharath Kumar Shetty.
It was concluded that: A Comparison between Cervical Vertebrae and
Modified MP3 Stages for the assessment of skeletal (1)There is significant correlation between skeletal age,
Maturity.Journal of Natural Science, Biology and dental age and the chronological age.
Medicine 2013;4:74-80.(2)Dental age using Willem's method is more closely related
12. Rajshekar Patil et al.A Correlative Study between Hand-to the chronological age followed by CVMI.
Wrist Maturation and Cervical Vertebrae for the (3)On comparison dental age using Willem's method found
Assessment of Skeletal Age. JIAOMR April- June to be more comparable with the chronological age than
2013;25(2):99-103.CVMI.
13. Begum Mohammed et al. Dental age estimation using REFERENCES:
Willems method: A digital orthopantomographic study. 1. Nolla C. The development of the permanent teeth. ASDC Contemporary Clinical Dentistry 2014;5(3).
J Dent Child 1960;27:254-66.14. R.H.Kamble et al. Evaluation and comparison of skeletal
2. Haavikko K. The formation and the alveolar and clinical and dental maturity indicators in individuals with eruption of the permanent teeth. An orthopanto- different growth pattern. IOSR Journal of Dental and mographic study. Suom Hammaslaak Toim 1970;66: Medical Sciences 2014;13(12):4-8103-70.
15. Patel PS et al. Accuracy of two dental and one skeletal 3. Demirjian et al. A New system of dental age assessment. age estimation methods in 6-16 year old Gujarati
Human Biology 1973;45(2):211-227. children .J Forensic Dent Sci. 2015 Jan-Apr;7(1):18-27.
IMPLANTS IN FRESH AND HEALED EXTRACTION SOCKETS
ABSTRACT
The aim of this study is to assess the clinical and radiographic success of
endosseous implants placed in fresh extraction sockets and healed extraction
sockets.
Material and Method: The study was conducted in 6 patients divided into two
groups. In group I, the endosseous implants were placed in healed extraction
sockets and in group II, implants were placed in fresh extraction sockets. A
standard two stage surgical protocol of implant placement was used in both the
groups. All implants were assessed for esthetics, occlusion, stability and
complications.
Results and conclusion: Esthetic appearance of the replaced teeth was scored
as excellent at two sites in group I as compared to three sites in group II.
Occlusion was found to be satisfactory in both the groups throughout the
follow up period. Also, there was no implant failure in both the groups except
for minor complications.
Keywords: Endosseous implants, fresh extraction socket, healed socket.
617
Corresponding author:Name: Dr. Tejinder KaurAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M).:9814010528Email: tkgumber@gmail.com
1. Professor, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
2. Professor & Head, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
3. Consultant, Private Practice , Jalandhar
Indian Journal of Comprehensive Dental Care
I J C D C1. Tejinder Kaur
2. Sumeet Sandhu
3. Pradeep Goyal
Date of Submission : 2/12/14 Date of Acceptance : 28/12/14
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
INTRODUCTION recession and taking advantage of the healing socket.
Whereas, a healed socket provides a defect-less bone The missing tooth can be replaced by various effective without any pathology or soft tissue interference thus, methods (i.e. fixed partial denture, removable partial contributing to the success of the implant. In the present denture) but the use of dental implant for replacement of a study emphasis was given to determine the clinical & lost tooth is the best as it treats both hard and soft tissues radiographic success of endosseous implants placed in fresh and replaces missing teeth in a truly natural and esthetic extraction socket & healed extraction socket.manner.
MATERIAL AND METHODSCurrently, implants are not only used to replace the lost
tooth but also a well documented treatment modality for The present study was undertaken in six patients for
oral and maxillofacial reconstruction, anchorage during rehabilitation of single/multiple teeth in the out-patient
orthodontic treatment, and even formation of new bone in department of Oral and Maxillofacial Surgery at Sri Guru 1process of distraction osteogenesis. Ram Das Institute of Dental Sciences and Researh, Sri
Amritsar. The patients were divided into two groups. In Implants can be placed immediately after extraction of the
group I, the endosseous dental implants were placed in tooth in a fresh socket or after healing of the extraction
healed extraction sockets and in group II the implants were socket. The procedure of placement of an implant in a fresh
placed in fresh extraction sockets. A total number of eight extraction socket simplifies the treatment by performing a
internal hex type dental implants were placed, four in each single surgical procedure, decreasing treatment time,
group. Patients in the age group of 18-65 years and having minimizing shrinkage of hard tissue, minimizing soft tissue
Indian Journal of Comprehensive Dental Care 618
Table: 1 Age And Gender Distribution Of Patients
AGE
GROUP
(in years)
GENDER TOTAL NUMBER
OF IMPLANTS
Group I(n)
Group II(n) Group I Group II
Male
Female Male Female
15-30 1 0 1 1 1 4
31-45 1 1 0 0 2 0
46-60 1 0 0 0 1 0
61-75 0 0 0 0 0 0
Total 3 1 1 1 4 4
n- no of patients
Table: 2 Distribution According To
Site And Cause Of Tooth Loss
S. No. Site Cause of tooth
loss/replacement
Group I I Right mandibular first molar Caries
II Left mandibular second premolar Caries
III Left mandibular second premolar Periodontitis
IV Left mandibular first molar Caries
Group II I Right maxillary lateral incisor Trauma
II Right mandibular second premolar Caries
III Right mandibular first molar Caries
IV Right Maxillary Lateral incisor Caries
Table – 3 Site, Bone Quality, Bone Volume And Dimensions Of Implant Used In Group I And II
S.
No.
SITE OF IMPLANT
PLACEMENT
BONE
QUALITY
BONE VOLUME (in mm) IMPLANT
DIMENSION (in mm)
width
height
length
diameter Length
Group
I
I Right mandibular first molar
Class I
5.5
15.69
8.0
4.2
10
II Left mandibular second premolar
Class I
5.2
15.50
8.5
3.75
13
III Left mandibular second premolar
Class I
4.8
13.5
8.5
3.3
10
IV Left mandibular first molar Class I 6.5 16.0 12 4.2 13
Group
II
I Right maxillary lateral incisor
Class II
5.5
16.70
6.0
4.2
13
II Right mandibular second
premolar
Classs I
6.5
21.0
6.0
4.2
13
III Right mandibular first molar
Class I
9.5
15.0
11
4.2
13
IV Right Maxillary lateral incisor Class II 6.0 20.0 6.0 4.2 13
Class I – Evenly spaced trabeculae with small cancellated spaces.
Class II – Slightly larger cancellated spaces with less uniformity of the osseous pattern.
Indian Journal of Comprehensive Dental Care 619
Cases
Site
Osseointegration
Infection
Injury to adjacent structure
Radiographic evaluation Clinical evaluation
Radiolucency
around
fixture
Crestal
bone
loss (in
mm)
Evidence of
any
pathology
Suppuration
Mobility
Significant
probing
depth
Group
I
I Right mandibular first molar
A
0
A
A
A
A
A A
II Left mandibular second premolar P 1.5 A A A A A A
III Left mandibular second premolar
A
2.5
A
A
A
A
A A
IV Left mandibular first molar
P
2
A
A
A
A
A A
Group
II
I Right maxillary lateral incisor
A
2.5
A
A
A
A
A A
II Right mandibular second premolar
P
0
A
A
A
A
A A
III Right mandibular first molar A 1.5 A A A A A A
IV Right maxillary lateral incisor A 0 A A A A A A
Table 4 -Evaluation of implants at time of the second stage surgery
A- Absent, P- Present
S. No.
Site
Follow up
period (in
months)
Crestal bone
loss (in mm)
Esthetics
Occlusion
Implant stability Oral hygiene Gingival health
Suppuration
Bleeding on
probing
Probing depth
Plaque index
Bleeding
indexGingival
index Complications
Group
I
I Right mandibular first molar 24 2.5mm 2 Infra-occlusion
A A 5mm 1 1 0 Screw loosening
II Left mandibular second premolar
12
1.5mm
1
Class I
A
A
3mm
0
0 0 A
III Left mandibular second premolar
12
2.5mm
2
Class II
A
A
3mm
0
0 0 A
IV Left mandibular first molar
11
2mm
1
Class I
A
A
3mm
0
0 0 Cement washout
Group
II
I Right maxillary lateral incisor
13
3mm
1
Class I
A
A
2mm
0
0 0 A
II Right mandibular second premolar
11
1mm
1
Class I
A
A
1mm
1
1 0 A
III Right mandibular first molar
11
1.5mm
2
Class I
A
A
1mm
1
1 0 Cement washout
IV Right maxillary lateral incisor 13 1.5mm 1 Class I A A 1mm 1 0 0 A
Table 5-EVALUATION AT THE TIME OF FINAL FOLLOW UP
·Esthetics – (1-excellent, 2-good)
·Plaque index (0-no plaque, 1-a film of plaque adherent to the free gingival margin recognized only by running a probe
across the tooth surface)
·Bleeding index (0-no bleeding, 1-isolated bleeding spot visible)
·Gingival index (0-absence of inflammation)
·A-Absent,
Indian Journal of Comprehensive Dental Care 620
Implant Placement In Fresh Extraction Socket
Implant Placement In Healed Socket
Use of periotome for extraction oflateral incisor
The socket after extractionof the lateral incisor
Photograph of the implantimmediately after insertion at the
prepared site
Final seating of the implant 2mmbelow the crestal margin
Pre operative photograph Photograph after prosthesisplacement
Pre operative IOPA showingthe root stump of rightmaxillary lateral incisor
Post operative IOPAimmediately after implant
placement
Pre-Operative Drilling the hole for implantusing surgical stent
Photograph immediately afterimplant placement
Post operative Photograph
Pre-Operative IOPA Post operative IOPA Immediately afterimplant placement
0 No Bone loss detectable
1 Reduction of bone level not exceeding 1/3rd of implant length 2 Reduction of bone level exceeding 1/3 rd
but not ½ of implant
length
3
Reduction of bone level exceeding ½ of implant length
1 Excellent 2 Good 3
Moderate
4
Poor 5
Very poor
Table 6:- Four point scale for bone level assessment
Table 7:-VAS (Visual Analog Scale forasthitics
Indian Journal of Comprehensive Dental Care 621
edentulous spans with class I and II type bone ( Linkow's coded drills( according to the size of the selected implant) to 2classification 1970) were included in the study. They were the appropriate length. If bone was dense in an area, the
selected irrespective of sex, caste, creed and socio-economic threads were tapped with a bone tap. The implant was
status. removed from the sterile vial with the 4mm square head
insertion tip and hand ratcheted in place with the 4 mm PRE-OPERATIVE ASSESSMENT
square ratchet adapter. A titanium cover screw was inserted A detailed history including general, physical and clinical on the implant( to protect the internal threads and close the examination was carried out in all patients. Detailed clinical space) with the use of implant screw driver. Primary closure examination consisted of careful evaluation of soft and hard of the flap was obtained with 3-0 mersilk.tissue which provided necessary diagnostic information for
b) Surgical Protocol for Placement of Implant in Fresh proceeding with implant therapy. The available bone was
Extraction Socket: measured for width (buccolingual), length (mesiodistal) and
thickness of soft tissue. A full thickness mucoperiosteal flap was raised. Periotome
(Uniti) was used for atraumatic extraction of the tooth with Radiographic evaluation: Radiographs {intraoral periapical
maximum conservation of investing alveolar bone. Socket (IOPA) and orthopantomogram (OPG)} were evaluated for
was curetted & debrided to remove any soft tissue. The complete survey of teeth and adjacent bony structures.
surgical guide template was positioned and the socket was ·Bone height: The height of available bone was measured initially prepared with 2.0mm pilot drill through the hole in from the crest of edentulous ridge to the opposing the stent. The socket was then gradually enlarged with landmarks, such as maxillary sinus or mandibular canal in the standard color coded drills to the appropriate length. The posterior region and maxillary nares or inferior border of implant was removed from the sterile vial with the 4mm mandible in anterior region. Panoramic radiograph was used square head insertion tip and hand-ratcheted in place with for the estimation of bone height, taking account of a the use of 4mm square ratchet adapter. Implant was placed constant vertical magnification factor of 1.3 approximate 2mm apical to the tooth apex & countersunk 2
mm below the height of crestal bone. A titanium cover screw Actual available bone height= Distance from crest of the was inserted in the implant with the use of implant screw ridge to the opposing landmarks on OPG divided by 1.3driver. The primary closure of the flap was done with 3-0
Study casts were used to evaluate the centric relationship, mersilk. A radiograph was taken post-operatively to evaluate
interarch occlusal clearance, occlusal discrepancies and the position of implant in relation to adjacent structures such
dentition (opposite and adjacent), to measure the bony as nasal floor, inferior alveolar canal and adjacent teeth.
width and prepare a surgical stent. All patients were prescribed oral antibiotics and oral
SURGICAL PROCEDURE:analgesics for 5 days and 0.2% chlorhexidine gluconate
Surgical procedure was explained to patient and a written (Hexidine mouth wash; ICPA Health Product Private Limited, valid consent was obtained. Preoperatively, routine blood India) for 2 weeks. The patients were evaluated on weekly investigations and complete urine examination were carried basis until soft tissue healing was completed (3 weeks). Both out. All surgeries were carried out under strict aseptic the techniques of implant placement were evaluated for the conditions with local infiltration{using 2% lignocaine following parameters : hydrochloride with 1:200000 adrenaline( Xylocaine 2% with
·Osseointegration: adrenaline 1:200,000; Astra Zeneca Pharma India Limited,
§ Radiographic evalutionIndia)} given buccally and lingually/palatally to achieve
anesthesia. The oral cavity was rinsed with 0.2% § Radiolucency around fixture chlorhexidine gluconate for 30 seconds before surgery. The
Adequate bone level: was assessed according to four point surgical procedure comprised of two stages.
3scale (0-3) (table 6)STAGE I: Surgical insertion of implant in healed extraction
o Clinical evaluation socket
§ Suppuration The mucoperiosteal flap was elevated to an extent required
for placement of implant. The site was initially prepared with § Clinical mobility
2.0mm pilot drill at a speed of 1000 r.p.m. The paralleling pin § Significant probing depth around fixture. was placed in initial preparation and a radiograph (IOPA) was
· Infection taken to assess osteotomy depth, alignment and angulation.
The site was then gradually enlarged with standard color · Injury to adjacent anatomical structures
Indian Journal of Comprehensive Dental Care 622
STAGE II: SURGICAL EXPOSURE OF THE IMPLANT patients had class I bone structure. The buccolingual width
ranged from 4.8 mm to 6.5 mm, mesiodistal length ranged The goal of surgical uncovering was to attach the healing from 8.0 mm to 12 mm and available alveolar bone height abutment to the implant, preserve attached tissue and ranged from 13.5 mm to 16.0 mm. Depending upon bone recontour the tissue as necessary. For making single crown, volume, the diameter of implant placed ranged from 3.3 mm the open tray impression technique was used. The prepared to 4.2 mm and length ranged from 10 mm to 13 mm. In group crown was checked for its passive fit to the abutment and no II patients, 50% of patients had class I and 50% had class II interference with adjacent teeth. The crown was cemented bone structure. The buccolingual width ranged from 5.5 mm with zinc phosphate cement (Pyrex Polymers, India). to 9.5 mm, mesiodistal length ranged from 6.0 mm to 11 mm
1. Both the techniques of implant placement were and available alveolar bone height ranged from 15 mm to 21 evaluated for the following parameters : mm. The diameter of all implants placed in the fresh
extraction sockets (both in anterior and posterior region) was • Esthetics : of the dental rehabilitation was 4.2 mm and length 13 mm based on bone volume and root evaluated using VAS (visual analog scale) as graded by the
3 dimensions. (Table 3)patient : (Table7)
Table 4 shows evaluation of implants at the time of second 14stage surgery. In group I, apical radiolucency around the
implant was observed to be present in 50% of the cases as • Occlusion : compared to 25% cases in group II. However, in all patients,
the crestal bone loss at the time of second stage surgery was • Implant stability : found to be in the range of 0 to 2.5 mm in both the groups.
• Suppuration (Table 4)
• Bleeding on probing Also there was no signs of any infection during the healing
• Probing depth <3mm. phase and no injury to adjacent structures was observed.In
group I, at the time of final follow up, crestal bone loss ranged • Oral hygiene was assessed using: from 1.5 to 2.5mm which was observed to be stable from six
4• Plaque index (Loe 1967) months following placement of prosthesis. The esthetic 5 appearance of the restoration was scored to be excellent by • Bleeding index (Mombelli et al 1987) :
50% of the patients and good by remaining 50% whereas in • Gingival health :
group II, crestal bone loss ranged from 1 to 3mm and the 6• Gingival index (Loe & Silness 1963) : esthetic appearance was scored to be excellent by 75% and
good by 25% of the patients. (Table 5). I n g r o u p I , • Complications prosthesis loosening was observed in two patients as
compare to one patient in group II.OBSERVATIONS
DISCUSSION The results of the study have been compiled as follows :
An ideal implant treatment plan is based on the patient's The table 1 reveals number of implants according to age and needs, desires and financial commitment. The rehabilitation gender. In group I, out of four implants , 25% of implants were with the use of implants is considered successful if direct inserted in patients in the age group of 15-30 years, 50% of contact of bone and implant takes place at microscopic level implants were placed in patients in the age group of 31-45 (osseo-integration). For achievement of osseointegration, years, and 25% in 46-60 years age group. However, In group II, the implant must be sterile, made of a highly biocompatible all implants were placed in the age group of 15-30 years. material such as titanium, inserted with atraumatic surgical (Table 1) technique that avoids overheating of the bone during
preparation, placed with initial stability and not functionally In group I, all implants were placed in the mandibular loaded during the healing period of four to six months.posterior region. In group II, 50% of the implants were placed
in maxillary anterior region and 50% in mandibular posterior Adequate bone height, buccolingual width and mesiodistal region. In both the groups, in 75% of the cases, the cause of length is required at edentulous span/extraction socket for tooth replacement was caries. (Table 2) the optimal functional and esthetic results in the use of
endosseous dental implants for rehabilitation of lost teeth. Table 3 shows the distribution of site, bone quality, bone For assessing the optimal diameter of the implant to be used, volume and dimensions of implant used. In group I, all a minimum of 0.5mm bone should be available on each side
Indian Journal of Comprehensive Dental Care 623
16at the crestal level. the literature . In our study, suppuration and bleeding on
7 probing around the implant were found to be absent in both Guncu et al 2008 reported the use of dental
group I and group II at the time of second stage surgery and implants of 11.5 mm length and 4.0 mm diameter in
subsequent follow ups. While the probing depth was absent mandibular posterior region in healed extraction sockets.
8 at the time of second stage surgery but ranged from 3-5 mm While Schropp et al 2003 have advocated the use of dental
in group I and 1-2mm in group II at the time of final follow up. implants of diameter 3.25 to 6.0mm and length 8.5 to 15mm
In one patient, probing depth was observed 5mm on buccal in anterior and premolar region in both healed and fresh
side, 18 months after loading in group I. Similar results have extraction sockets of maxilla and mandible. Fugazzotto PA
179 also been reported by Mangano C and Bartolucci EG 2001
2008 reported the use and success of implants of diameter after 2 year of loading. Absence of suppuration has also been
4.1 mm and length 10 or 12mm in his study on immediate 7 18reported by Guncu et al 2008 and Covani et al 2004 .
implant placement at time of mandibular molar extraction 19Contrary to these findings, Barano et al 2006 and Chushu G which is in accordance with the present study in which all
20et al 2001 have reported suppuration at the implant site implants were 4.2 mm in diameter and 13 mm in length in which resulted in peri-implantitis. fresh extraction socket. In healed sockets, implant diameter
ranged from 3.3- 4.2 mm ( length 10-13 mm). Presence of connective tissue capsule surrounding the
10 implant leads to mobility. Implant becomes tender to Smith DE and Zarb GA 1989 reported complete peri-percussion or pressure with increase in mobility, thus implant radiolucency as a predictor for implant failure as it
10resulting in implant failure (Smith DE and Zarb GA 1989 ). indicates presence of soft tissue and probable implant Other factors responsible for implant mobility are: altered mobility. In present study, apical radiolucency was present in density of bone, anatomical location or improper implant site two cases of group I and one case of group II at second stage preparation. Absence of mobility after placement of of surgery. Radiolucency around the implant has been endosseous dental implant in healed and fresh extraction attributed to infection, presence of preexisting bone sockets is well documented in literature. In our study, no pathology, poor bone quality and fenestration of vestibular
11,12 mobility was observed in group I and group II at second stage alveolar bone . In our study although fenestration did not surgery and on follow up examinations after prosthesis occur during drilling but in both groups periapical
20placement. Contrary to our findings, Chaushu G et al 2001 radiolucency was caused by over-drilling at time of implant 19and Barone et al 2006 have reported presence of mobility insertion.
of implants placed in fresh extraction sockets, while Weng et 21 22Radiographically, the osseointegration can be determined by al 2003 and Mesa et al 2008 have reported mobility of the
evaluating evidence of crestal bone loss. In all patients implant placed in healed extraction sockets which they rdincluded in this study the crestal bone loss was less than 1/3 attributed to inadequate bony dimension, shorter implant
the implant length. In both group I and group II, the crestal length, poor bone quality and high functional loads.bone loss at time of second stage surgery was in range of 0 to
Esthetic outcome is one of the primary concerns in patients 2.5mm. After 6 1to 18 months follow up period from undergoing prosthetic rehabilitation. In our study, esthetic permanent prosthesis placement, the crestal bone loss appearance after prosthetic placement was scored as ranged from 1.5 to 2.5mm in group I and 1 to 3mm in group II, excellent by 50% patients. and as good by the rest in group I, which remained stable on subsequent follow up radiographs.
13 whereas in group II, 75% of patients scored the esthetic In a study by Zarona et al 2006 on use of dental implants in appearance of the replaced tooth as excellent and 25% healed extraction sockets, it was found that after 1 year of scored it as good. This is in accordance with the study by Yerit loading the bone loss was in range of 0.46 to 1.32mm which
3et al 2004 in which 76.9% implants were evaluated as increased by 0.1 to 0.2mm at 24 months of follow up. 14 excellent and 23.1% as good. Whereas, Cooper et al 2001 reported cortical bone loss of 0
to more than 2mm after 12 months of follow up. The mean Satisfactory occlusion is necessary for maintaining a
value of crestal bone loss of 1.5+_0.5mm (range 2-3mm) at harmony in masticatory apparatus. An implant is similar to
12 month follow up period has been reported by Covani et al ankylosed tooth. The cushion of the periodontal ligament is 152007 in their study on use of dental implants in fresh not present around the implant. Biting forces are transmitted
extraction sockets. through the implant to the surrounding bone. If occlusion is
not satisfactory, excessive or traumatic occlusal forces may Osseointegration can also be evaluated clinically by assessing cause non-infective bone loss. In our study, occlusion was the suppuration, probing depth and mobility. Implants with found to be satisfactory in both the groups throughout the absence of suppuration, bleeding on probing and probing follow up period. depth < 3mm are considered stable/healthy as reported in
Indian Journal of Comprehensive Dental Care 624
4At the time of follow up, the plaque index (Loe 1967) was 3. Yerit KC, Posch M, Hainich S, Turhani D, Klug C, Wanschitz
scored as 0 in 75% cases of group I and 25% cases of group II. F et al. Long time implant survival in the grafted maxilla :
Whereas the index was scored as 1 in 25% cases of group I results of a 2 year retrospective study. Clin Oral Impl Res
and 75% cases of group II. This is accordance with the results 2004 ;15 : 693-69913of Zaron et al 2006 . 4. Loe H. The gingival Index, the Plaque Index and the
Retention. J Periodontol 1967;38(6):610-6.At the time of follow up, bleeding index in 75% cases of group
I and 50% cases of group II were scored as 0 while 25% cases 5. Mombelli A, van Ossten MA, Schurch E Jr, Lang NP. The of group I and 50% cases of group II were scored as 1. The microbiota associated with successful or failing reason was probably due to poor maintenance of oral o s s e o i n t e g r a t e d t i t a n i u m i m p l a n t s . O r a l hygiene. Similar results have also been documented by MicrobiolImmuno 1989;1 2:145-151.
23Heydenruk et al 2003 in their study. 6. Loe H and Sillness J. Periodontal disease in pregnancy. I.
6Gingival index (Loe H and Silness J 1963) was used in present Prevalence and severity. ActaOdontologica Scand. study to assess gingival health. In our study, gingival index 1963;21:533-551.was scored 0 in both the groups at the time of follow up.
24 13 7. Guncu MB, Aslan Y, Tumer C, Guncu GN and Uysal S. In Gastaldo et al 2004 and Zarone et al 2006 assessed the
patient -comparison of immediate and conventional gingival health in patients with dental implants and reported
loaded implants in mandibular molar sites within 12 no gingival inflammation by ensuring proper maintenance of
months. Clin Oral Impl Res 2008;19:335-341.oral hygiene.
8. Schropp L, Kostopoulos L and Wenzel A. Bone healing Any form of treatment has its share of failure and
following immediate versus delayed placement of complication rate. In our study, prosthesis loosening was
titanium implants into extraction sockets: a prospective observed to be 50% in group I and 25% in group II. In group I,
clinical study. Int J Oral Maxillofac Implants two patients presented with prosthesis loosening one due to
2003;18:189-199.abutment screw loosening and the other due to cement
washout while in group II, one patient reported with 9. Fugazzotto Paul A. Immediate placement at the time of
prosthesis loosening due to cement washout. Screw mandibular molar extraction: description of technique
loosening in our study was probably due to two reasons: and preliminary results of 341 cases. J Periodontal
firstly, inadequate counter torque during tightening which 2008;79:337-347.
led to insufficient screw tightening and thus loosening later 10. Smith D.E and Zarb G.A. Criteria for success of on and secondly, due to excessive occlusal loading because of osseointegratedendosseous implants. J Prosthet Dent supra-eruption of the opposing molar. Other complication 1989;62:567-572.documented in our study was cement washout. This can
11. Ashley ET, Covington LL, Bishop BG, Breault LG. ailing occur as cements are soluble in the oral fluid or due to and failing endosseous implants: a literature review. J marginal gap greater than 75 m. Similar complications have
25 26 Contemp Dent Pract 2003;4:35-50.also been reported by Simon et al 2003 and Priest G 1999
with use of endosseous dental implants. 12. Tozum TF, Sencimen M, Ortakoglu K, Ozdemir A, Aydin
OC and Keles M. Diagnosis and treatment of a large CONCLUSIONS periapical implant lesion associated with adjacent
No dental implant failure was observed in both the groups till natural tooth : a case report. Oral Surg Oral Med Oral the final follow up period except for minor complications Pathol Oral Radiol and Endod 2006;101:e132-e138.(prosthesis loosening). However, in the present study success
13. Zarone F, Sorrentino R, Vaccaro F and Russo S. Prosthetic cannot be scored as 100% as the number of patients is too treatment of maxillary lateral incisor agenesis with small to come to any conclusion regarding success rate of osseointegratedimplants : a 24-39 month prospective dental implants. clinical study. Clin Oral Impl Res 2006;17:94-101.
BIBLIOGRAPHY14. Cooper L, Felton DA, Kugelberg CF, Ellner S, Chaffee N,
1. Jones AA and Cochran DL. Consequences of implant Molina A et al. A multicenter 12- month evaluation of a design. Dent Clin N Am2006 ;50:339–360. single- tooth implants restored 3 weeks after 1- stage
surgery. Int J Oral Maxillofac Implants 2001;16:182-192.2. Misch Carl E. Bone density. In :Scortecci G.M, Misch CE
and Benner Klaus - U, editors. Implants and restorative 15. Covani U, Marconcini S, Galassini G, Cornelini R, Santini S dentistry. London : Martin Dunitz Limited, 2001:79-87. and Barone A. Connective tissue graft used as a barrier
Indian Journal of Comprehensive Dental Care 625
to cover an immediate implant. J Periodontal 423.
2007;78:1644-1649. 22. Mesa F, Munoz R, Noguerol B, Luna JDD, Galindo P and
16. Lang NP and Lindhe J.Maintainence of the implant O'Valle F. Multivariate study of factors influencing
patient.In :Lindhe J, Karring T and Lang N., editors. primary dental implant stability. Clin Oral Impl Res
Clinical Periodontology and Implant Dentistry. 2008;19:196-200.
1997:1024-1030 23. Heydenrijk K, Raghoebar GM, Meijer HJA and Stegenga
17. Mangano C and Bartolucci EG. Single tooth B. Clinical and radiologic evaluation of 2 stage IMZ
replacememt by morse tapered connection implants : a implants placed in asingle- stage procedure: 2 year
retrospective study of 80 implants. Int J Oral maxillofac results of a prospective comparative study. IntJ
Implants 2001;16:675-680. OralMaxillofac Implants 2003;18:424-432.
18. Covani U, Crespi R, Cornelini R and Barone A.Immediate 24. Gastaldo JF, Cury PR and Sendyk WR. Effect of vertical
implants supporting single crown restoration : a 4-year and horizontal distances between adjacent implants
prospective study.J Periodontal 2004;75:982-988. and adjacent tooth and an implant on the incidence of
interproximal papilla. J Periodontal 2004;75:1242-1246.19. Barone A, Rispoli L, Vozza H, Quaranta A and Covani U.
Immediate restoration of a single implant placed after 25. Simon Robert L, Fullerton and Calif. Single implant-
tooth extraction. J Periodontal 2006;77:1914-1920. supported molar and premolar crowns: a ten year
retrospective clinical report. J Prosthet Dent 20. Chaushu G, Chaushu S, Tzohar A and Dayan D. 2003;90:517-521.Immediate loading of single- tooth implants:immediate
versus non-immediate implantation. A clinical report. 26. Priest George. Single- tooth implants and their role in
IntJ OralMaxillofac Implants 2001;16:267-272. preserving remaining teeth: a 10 year survival study.
IntJ Oral Maxillofac Implants 1999;14:181-188.21. Weng D, Jacobson Z, Tarnow D, Hurzeler MB, Faehn O,
Sanavi F et al. A prospective multicenter trial of 3i
machined-surface implants:resultsafter 6 years of
follow-up. IntJ Oral Maxillofac Implants 2003;18:417-
TEMPORAL HEMATOMA AFTER POSTERIOR
SUPERIOR ALVEOLAR NERVE BLOCK- A CASE REPORT
Abstract
Posterior superior alveolar (PSA) nerve block is among the most reliable nerve
blocks when recommended protocol is followed. However, clinicians may
choose to avoid this block because of high risk of hematoma formation caused
when needle inadvertently enters the pterygoid venous plexus or maxillary
artery or its branches. Hematoma apart from resulting in psychological effect
on patient due to unaesthetic discolouration of the face, also results in
pressure on tissues which decreases vascularity to the region which further
acts as a culture media thereby potentiating the development of the infection.
The aim of this article is to present a rare case of temporal hematoma after
administrating posterior superior alveolar nerve block.
Keywords: Posterior superior alveolar (PSA) nerve block, pterygoid venous
plexus, maxillary artery, infra temporal fossa.
626
Corresponding author:Name: Dr. Ramandeep Singh BhullarAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M) 9417065522Email: drbhullar07@gmail.com
1. Post graduate student, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
2. M.D.S, Professor, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
3. M.D.S, Reader, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
Indian Journal of Comprehensive Dental Care
I J C D C1. Harpreet Singh
2. Ramandeep Singh Bhullar
3. Amneet Kaur Sandhu
Date of Submission : 6/12/14 Date of Acceptance : 13/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
INTRODUCTION Case Report
Oral surgical and dental procedures are routinely A forty year old female patient reported to department of 1performed in outpatient settings. The most commonly oral and maxillofacial surgery after for the removal of root
anesthetized nerves in dentistry are branches or nerve stumps in relation to left maxillary posterior region (27).
trunks associated with the maxillary and mandibular Intraoral examination revealed edentulous maxillary and 2divisions of trigeminal nerve (cranial nerve V). mandibular arch with root stumps of left maxillary second
molar present. Patient gave history of extraction of all the Despite proper tissue preparation and appropriate
teeth within last 4 months without any complication. The anesthetic techniques, local and/or systemic complications
medical history was unremarkable The family history was associated with local anesthesia occasionally occur.
also non-significant. After positioning patient in a Posterior superior alveolar (PSA) nerve block is among the
comfortable recumbent position and under proper most reliable nerve blocks when recommended protocol is
sterilization protocol, left posterior superior alveolar nerve followed. However, clinicians may choose to avoid this block
block using 2% lignocaine with 1:2,00,000 adrenaline was because of high risk of hematoma formation caused when
administered with 27-gauge needle. The aspiration was needle inadvertently enters the pterygoid venous plexus or 3 done in two planes before administrating the anesthetic maxillary artery or its branches. The purpose of this article is
agent and it was negative. The needle was withdrawn safely to present a rare case of temporal hematoma after
after administrating 1.8ml of solution. An extraoral administrating posterior superior alveolar nerve block.
hematoma at the left temporal and cheek area was noted
Indian Journal of Comprehensive Dental Care 627
5immediately after the needle was withdrawn that increased zygomatic arch and medial surface of the skull.
slowly. The swelling was typically dumb-bell shaped, The posterior superior alveolar nerve is a branch of the
compressible and non tender (Fig. 1). Patient had no maxillary division of the trigeminal nerve. It originates from
complaint of pain and trismus. Further treatment was the main trunk in pterygopalatine fossa, passes inferiorly
terminated and extraoral as well as intra oral pressure was along the posterior wall of maxilla, and enters the bone
applied. Patient was advised to apply ice packs at the about 1 cm superior and posterior to the third molar tooth.
hematoma area. Tab. Augmentin 625 mg and Tab. Novagesic This nerve supplies the buccal gingivae, periodontium, and
forte three times a day was advised for 3 days. The patient 6 alveolus associated with the maxillary molar teeth. (Fig. 2)st th thwas called for follow up on 1 day, 4 day and 7 day. She had
The posterior superior alveolar (PSA) nerve block is no other complaint except for swelling which started th accomplished by depositing the anesthetic agent along the reducing in size over next 2 days and was normal by the 7
posterior surface of the maxilla. The needle must be day.advanced medially, superiorly and posteriorly at a 45 degree
DISCUSSION angle to the maxillary occlusal plane to reach the
Infra temporal fossa is an irregular non fascial lined space infratemporal fossa. This places the needle point in
lying medial to inner surface of vertical ramus of mandible immediate vicinity of the foramina through which the nerve 7and the zygomatic arch. It is bounded anteriorly by the enters the maxilla. The improperly positioned needle while
posterior surface of maxilla and the inferior orbital fissure, administrating posterior superior alveolar nerve block can 6posteriorly by mastoid and tympanic portions of temporal result in various complications. These may range from
bone and superiorly by inferior surfaces of greater wing of milder complications such as hematoma, trismus,
sphenoid and squamous portion of temporal bone. Laterally mandibular anaesthesia to more severe ocular complications
it is bounded by zygomatic arch and ascending ramus of including ophthalmoplegia, ptosis of eyelid, mydriasis, loss of
mandible. It communicates with the orbit through the vision, diplopia, dizziness and miosis. Neurological
inferior orbital fissure, with the middle cranial fossa through complications including facial nerve palsy and abducent 1,2,8,9the foramen ovale and spinosum and with the nerve palsy have also been reported.
pterygopalatine fossa through pterygopalatine fissure. The The injury of the blood vessels related to PSA nerve results in
contents of infratemporal fossa includes medial and lateral effusion of the blood into the infratemporal fossa which
pterygoid muscles, mandibular division of trigeminal nerve, accommodates a large volume of the blood from where it
chorda tympani branch of facial nerve, otic ganglion, internal progress inferiorly and anteriorly towards the lower region of
4maxillary artery and pterygoid venous plexus. the cheek resulting in the swelling and discoloration of the
The temporal fossa is superior to the infratemporal fossa, involved region. From infratemporal fossa, the effused blood
above the zygomatic arch. It is limited superficially by thick may traverse to temporal fossa superiorly through the gap
sheet of temporalis fascia arising from zygomatic arch and between zygomatic arch and medial surface of the skull,
extending upto superior temporal line. It communicates with thereby resulting in hematoma formation in temporal
the infratemporal fossa below through the gap between the region. The size of the hematoma depends upon the density
Fig. 1 Hematoma formation in cheek and temporal region Fig.2 Infra temporal fossa and its contents
Indian Journal of Comprehensive Dental Care 628
6of the tissues surrounding the blood vessel. complications associated with local anesthesia
administration in dentistry. Dent Clin N Am 54 (2010) Hematoma apart from resulting in psychological effect on
677-686.patient due to unaesthetic discolouration of the face, also
results in pressure on tissues which decreases vascularity to 3. Chisci G, Chisci C, Chisci V, Chisci E. Ocular
the region. This further acts as a culture media thereby complications after posterior superior alveolar nerve 10 block: a case of trochlear nerve palsy. Int J. Oral potentiating the development of the infection. The first step
Maxillofac. Surg. 2013; 42 : 1562-1565.in the management of hematoma formation should be
reassurance to the patient. The patient should be advised to 4. Arya S, Rane P, Cruz AD. Infratemporal fossa, avoid application of heat extraorally. Ice packs for 30 minutes masticatory space and parapharyngeal space: Can the per hour for the first 24 hours after surgery followed by radiologist and surgeon speak the same language? Int intermittent hot moist packs should be advised to resolve the J Otorhinolaryngol Clin 2012; 4(3) : 125-135.
11condition . Furthermore, analgesics and antibiotics should 5. Pillai AK, Kulkarni p et al. Infratemporal and temporal be prescribed for pain relief and preventing any infection.
abscess- Retrograde infection from mandibular Any dental treatment in the involved region should be 6 molars. IOSR Journal of Dental and Medical deferred until the signs and symptoms resolve.
Sciences2014; 13(11): 96-99.To minimize the risk of hematoma formation, dentist should
6. Gupta N, Singh K, Sharma S. Hematoma - A be well versed not only with the anatomy of infratemporal Complication of Posterior Superior Alveolar Nerve region but also with the technique of administration of the Block. J Dent Probl Solut 2(1): 109.local anesthesia. In addition to this, use of 27 gauge short
needle, minimum number of needle penetration into tissues, 7. C. Richard Bennet. Monheim's Local anesthesia and thmultiple aspirations while administrating the local anesthetic pain control in dental practice. Edition 7 . Page-84.
agent, aspiration in two planes, penetration of needle to a 8. Steenen AS, Dubois L et al. Ophthalmic complications
depth of 16 mm in adults whereas 10-14 mm in smaller after intraoral local anesthesia: Case report and
1,6,12adults and children should be considered. Further, certain review of literature. Oral Surg Oral Med Oral Pathol
studies advocate the use of infiltration instead of nerve block Oral Radiol 2012; 113: e1-e5.
as it provides equally acceptable anaesthesia for maxillary 9. Crean SJ, Powis A. Neurological complications of local molars with greater ease while overcoming difficulties and
1 anesthetics in dentistry. Dent update 1999; 26: 344-complications associated with block.349.
To conclude, the knowledge of anatomy of Infra temporal 10. Larry J Peterson. Contemporary oral and maxillofacial fossa is of utmost importance to the dentist and one should
surgery. Edition 4. Page 45.be thorough with the complications that may occur while
giving PSA nerve block. At the same time, prior information 11. Daniel M Laskin. Oral and maxillofacial surgery. to the patient should be given so as to minimize the Edition 2. Page 41.psychological ill- effects of the complications, if it occurs.
12. Stanley F. Malamed. Handbook of Local Anesthesia. BIBLIOGRAPHY
Edition 6. Page 96.1. Padhye M, Gupta S, Chandiramani G and Bali R. PSA
block for maxillary molar's aesthesia- an obsolete
technique? Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2011; 112: e39-e43.
2. Boynes SG, Echeverria Z, Abdulwahab M. Ocular
TREATMENT OF IMPACTED MAXILLARY CENTRAL INCISORS: AN ORTHO-SURGICAL APPROACH
Abstract
This case report describes the treatment of an 11 year old boy with both central
maxillary incisors impacted because of 2 supernumerary teeth. Therapeutic
management of the impacted teeth was combined with orthodontic
treatment. A sequential approach of surgical removal of the supernumerary
teeth with surgical exposure and orthodontic traction of the impacted teeth
resulted in proper incisor positioning. Close monitoring and multidisciplinary
cooperation during the various treatment phases led to a successful aesthetic
result, with good periodontal health and functional occlusion
Keywords: orthodontics, arch length, maloclusion
629
Corresponding author:Name: Dr. Kamaldeep SharmaAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar(M) +919417846890Email: kamal_dentist2002@yahoo.com
1. MDS, Reader, Sri Guru Ram Das Institute of Dental Sciences And Research, Amritsar.
2. MDS, Professor, Sri Guru Ram Das Institute of Dental Sciences And Research, Amritsar.
3. MDS, Reader, Sri Guru Ram Das Institute of Dental Sciences And Research, Amritsar
4. PG Student, Sri Guru Ram Das Institute of Dental Sciences And Research, Amritsar
5. PG Student, Sri Guru Ram Das Institute of Dental Sciences And Research, Amritsar
6. BDS, Lecturer, Sri Guru Ram Das Institute of Dental Sciences And Research, Amritsar
Indian Journal of Comprehensive Dental Care
I J C D C1. Kamaldeep Sharma
2. Sukhdeep Singh Kahlon
3. Amneet Kaur Sandhu
4. Manmeet Kaur Bagga
5. Shaunak Vyas
6. Princejit Kaur
Date of Submission : 13/11/14 Date of Acceptance : 29/12/14
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
INTRODUCTION which include tooth size, presence of supernumerary teeth,
mucosal or bony barrier, retained deciduous teeth and Impaction of maxillary permanent central incisor is quite an presence of a cystic mass. Various treatment modalities infrequent finding in dental practice, but its treatment is
1 exist to treat a case with impacted maxillary central incisors. challenging because of its importance to facial esthetics.
In the present case study, impacted maxillary central incisors The maxillary incisors are the most prominent teeth in an
were successfully aligned into occlusion by surgical individual's smile, they are also the teeth that are on
exposure and employing orthodontic measures.maximum display during speech in most individuals and the
normal eruption, position and morphology of these teeth CASE REPORT
are crucial to facial esthetics and phonetics. Normally, a An 11 year old male patient reported to the Department of tooth erupts into the oral cavity once two-thirds of root Orthodontics and Dentofacial Orthopaedics with chief formation is complete. An impacted tooth is one that fails to complaint of missing upper anterior teeth. After taking erupt into the dental arch within the expected time. Many detailed history, it was revealed that the child had no history patients with impacted maxillary central incisors are of trauma to the maxillary arch. Clinical examination referred to orthodontist by general practitioners or pediatric revealed that patient had Angle's Class I malocclusion with dentists because parents are concerned about the unerupted maxillary central incisors; proclined and impaction of an incisor in the early mixed dentition, even protruded maxillary lateral incisors and anterior deep bite.
2though its occurrence is less frequent. Mottling was also seen on the labial surfaces of the teeth.
Radiographic examination showed that patient had Tooth impaction may result from a number of local causes
Indian Journal of Comprehensive Dental Care 630
supernumerary teeth in relation to maxillary central incisor. The occurrence of unerupted maxillary incisors can be
associated with hereditary and environmental factors. The The proposed treatment plan was to extract the definition of impaction varies with different clinicians. supernumerary teeth and surgically expose the maxillary
3 Kuftinec and Shapira described impaction as a condition in central incisors followed by their alignment with fixed which an embedded tooth in the alveolus is prevented from orthodontic treatment.eruption or a tooth is locked in position by bone or by the
4Orthodontic Procedure: adjacent tooth. Suri et al states that if the eruption is delayed
in terms of both chronological and dental age, it is unlikely A 0.018 x 0.025 inch pre-adjusted edgewise fixed st that the permanent tooth will erupt without orthodontic mechanotherapy was used. Initially bands fabrication for 1
intervention. Both clinical and radiographic investigations permanent molars in both arches was done which was are required prior to formulating the treatment plan. There followed by bonding of the maxillary arch. 0.014 Niti was are other treatment options for the impacted central incisors placed in maxillary arch with wire sleeve with respect to both which include extraction of the impacted central incisor and central incisors to prevent laceration of inner surface of restoration with a bridge or an implant later when growth upper lip. Patient was given strict oral hygiene instructions, had ceased or extraction of the impacted central incisor and and an orthodontic toothbrush was prescribed for the same. closure of the space substituting the lateral incisor for the After 8 months of alignment and leveling with 0.016x0.022
5c e n t ra l i n c i s o r w i t h a c o m p o s i t e b u i l d - u p .stainless steel wire; surgical exposure of impacted central
incisors and extraction of supernumerary teeth were done.
If the impacted tooth is extracted there is a risk of resorption Surgical Procedure:
of alveolar bone and this can lead to alveolus becoming All surgical procedures were performed after obtaining the thinner and deficient. To avoid these disadvantages it is consent of the patient. Extraction of supernumerary teeth always beneficial to facilitate the eruption of the impacted and surgical exposure of maxillary central incisors was done tooth. Surgical exposure followed by orthodontic traction after elevating the full thickness muco-periosteal flap under and alignment are preferred for such kind of scenarios. local anaesthesia (2% lignocaine hydrochloride with Previous studies have shown that an impacted tooth can be 1:200000 epinephrine). After surgical exposure brackets brought into proper alignment in the dental arch by surgical were placed on both central incisors. The muco-periosteal exposure and orthodontic traction. A comprehensive flaps were replaced and sutured with 4-0 black silk suture. evaluation of the case is of prime consideration prior to The Patient was given amoxicillin 500 mg t.i.d. and diclofenac initiating a treatment. Factors such as position and level of sodium and serratiopeptidase B.D. for 5 days root completion, root angulation, space available to postoperatively. The patient returned two weeks later, after accommodate the impacted tooth are to be evaluated. It is soft tissue healing, and the ligature wire was tied to the always beneficial for esthetics of the patient, if labial surgically exposed central incisors. The patient was recalled epithelial attachment on the impacted incisor is preserved every three weeks. during surgical exposure so that the aligned tooth can have
good gingival contour and attached gingiva. Other treatment Post-operatively after 3 weeks; step bends were placed in alternatives for impacted central incisors 0.016 x 0.022 stainless steel wire to allow eruption of the
surgically exposed central incisors. Subsequently, both CONCLUSION central incisors were tied to 0.016 x 0.022 inch stainless steel
Impacted permanent central incisors can be successfully wire with ligature wire for allowing eruption of both central
aligned into occlusion by surgical exposure and employing incisors. Alignment and leveling of both central incisors was
orthodontic measures. This can be a treatment of choice accomplished within next 7 months.
preferred over extractions, as this treatment plan gives good DISCUSSION results and there is, as such no major side effects associated.
1 Frontal Smiling Pretreatment 1 OPG 3 Surgery 4 Frontal Smiling Final
Indian Journal of Comprehensive Dental Care 631
REFERENCES 6. Becker A. Early treatment for impacted maxillary
incisors. Am J Orthod Dentofacial Orthop. 2002; 1. R.M. Shetty, UDixit, H. Reddy, Shivaprakash P. K., B. Kaur 121:586–587. K. NagarajImpaction of the Maxillary Central Incisor Associated
with Supernumerary Tooth:Surgical and Orthodontic 7. Madhur Upadhyay ,Sumit Yadav Impacted maxillary
Treatment People's Journal of Scientific Research Vol. central incisor, canine, and second molar with 2
4(1), Jan. 2011 NR Thosar supernumerary teeth and an odontoma AJODO
Volume 135, Issue 3, March 2009, Pages 390–399 2. P Vibhute Surgical and orthodontic treatment of an Teresa Pinhoimpacted permanent central incisor: A case report
Contemp Clin Dent. 2012 Apr; 3(Suppl1): S37–S40 8. Manuel Neves, Célia Alves Impacted maxillary central
Yehoshua Shapira incisor: Surgical exposure and orthodontic treatment
AJODO August 2011 vol. 140, Issue 2, Pages 256-2653. D.M.D., Mladen M. Kuftinec Early diagnosis and
interception of potential maxillary canine impaction 9. Dalia smailience Antanas sidlauskas Impaction of
antral maxillary incisor associated with supernumerary 4. Suri l, Gagari E, Vastardis H, Delayed tooth eruption: teeth: initial position and spontaneous erupting Pathogenesis, diagnosis, and treatment. A literature timing. Baltic stomatologia dental and maxillofacial review. Am J Orthod Dentofacial Orthop 2004;126:432-journal 103-107, 2006 45)
10. Chiara pavuni, Manmela mucedero Impacted maxillary 5. Lin YT. Treatment of an impacted dilacerated maxillary incisors: Diagnosis and predictive measurements central incisor. Am J Orthod Dentofacial Orthop 1999; Annalidi Stmatologia 2012:III(3/4):100-105 115: 406-9.
GINGIVAL RECESSION COVERAGE WITH PLATELET-
RICH FIBRIN IN CORONALLY ADVANCED FLAP :
A CASE REPORT
ABSTRACT:
Gingival recession is the exposure of root surface due to apical migration of
gingival tissue margin. It presents with destruction of both soft and hard
tissues. Treatment of gingival recession has become an important therapeutic
procedure . Many periodontal plastic procedures have been developed to
obtain predictable root coverage. A recent innovation in dentistry is the
preparation and use of Platelet Rich Fibrin (PRF), a second generation platelet
concentrate. The growth factors present in PRF help in wound healing and are
also regarded as promoters of tissue regeneration. The aim of this case report
was to determine the clinical outcome of Miller's Class I recession using
coronally advanced flap with platelet rich fibrin clot (PRF) membrane in a 40-
year-old male who presented with hypersensitivity in relation to left lower
posterior region of teeth. The clinical outcome of the surgical procedure
accounted for successful coverage of the recession defect and an enhanced
gingival biotype.
Keywords: Platelet – rich fibrin, coronally advanced flap , gingival recession.
632
Corresponding author:Name:Dr. Navkiran (Professor and Head) Dept. of Periodontology and Oral ImplantologySri Guru Ram Das Institute of Dental Sciences and Research Amritsar(M) 09356001062E-mail: n.kiran97@yahoo.co.uk
1. M.D.S.,Professor and Head, Department of Periodontology & Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
2. M.D.S. student, Department of Periodontology & Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
3. M.D.S, Reader Department of Periodontology & Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
4. M.D.S., Sr. Lecturer, Department of Periodontology & Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
Indian Journal of Comprehensive Dental Care
I J C D C1. Navkiran
2. Aneet Kaur
3. Ashish Verma
4. Sahib Tej Singh
Date of Submission : 30/11/14 Date of Acceptance : 3/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
th INTRODUCTION: Since mid 20 century , different techniques have been
developed to cover the denuded roots. Free autogenous Gingival recession is the exposure of root surface due to grafts and pedicle grafts including rotational flaps, advanced apical migration of junctional epithelium. It is associated flaps and semilunar flaps have been advocated. with thermal and tactile sensitivity, esthetic complaints, Combination grafts with either autogenous grafts or root caries and tooth loss at times. There are two types of allograft and with GTR membranes were developed later to gingival recessions, one due to periodontitis and the other
6 correct mucogingival defects. A recent innovation in primarily related to the mechanical factors, especially faulty 1 dentistry is the use of Platelet-rich fibrin (PRF), a tooth brushing. In general, complete coverage of facial
concentrated suspension of growth factors found in recession defects can be achieved when there is no loss of platelets. These growth factors are involved in wound interproximal bone. Other factors that can predispose to healing and are postulated as promoters of tissue gingival recession include tooth malpositioning, bone
7regeneration. dehiscence, thin marginal soft tissue, high frenulum
attachment, dental restorative, orthodontic, or periodontal Platelet-rich fibrin (PRF), which is a second-generation 2-6 treatments. Periodontal reconstructive surgery consists of platelet concentrate, was defined as an autologous
8,9various mucogingival procedures. The primary goal of these leukocyte and PRF biomaterial by Choukroun.
procedures is to benefit periodontal health through the Platelet concentrates contain PDGF, TGF and many other
reconstruction of lost hard and soft tissues, or by preventing growth factors that modulate and upregulate one growth
its additional loss, and also in enhancing the esthetic factors function in the presence of second or third growth
appearance.
Indian Journal of Comprehensive Dental Care 633
10 factor. This specific feature influenced the decision to use RBCs at the bottom
platelet concentrates as the material of choice . Because of the absence of an anticoagulant, blood began to
In the case described in the article, platelet rich derivative coagulate as soon as it came in contact with the glass surface.
(PRF) was combined with coronally displaced flap technique Therefore, for successful preparation of PRF, speedy blood
for recession coverage. collection and immediate centrifugation, before the clotting 9cascade is initiated, is absolutely essential. After CASE REPORT :
centrifugation, PRF was obtained in the form of a membrane A 40 year-old male patient reported to the Department of by squeezing out the fluids in the fibrin clot. PRF was easily Periodontology and Oral Implantology with the chief separated from the red corpuscles base by using sterile complaint of hypersensitivity to chilled drinks, in relation to tweezers and scissors just after the removal of PPP and then the left lower back teeth region. He had no significant transferred onto a sterile dappen dish (Figure 3). At the medical history and dental history. On clinical examination, recipient site, the PRF membrane was placed over the multiple adjacent recessions were identified on the left gingival recession site. The flap was coronally advanced to anterior and posterior mandibular teeth (Figure 1). Miller's cover the membrane as well as the defect and then sutured.Class I recession defect, was measured by calculating the
Surgical Procedure:distance between the cementoenamel junction (CEJ) and the
gingival margin. It was recorded as 3 mm on the left lower The use of coronally advanced flap to cover areas with
second premolar (35). Phase 1 therapy was completed and localized recession was first described by Prino Prato et al. in
oral hygiene instructions were reinforced. The surgical 1999. This technique involved the reflection of a full
procedure was explained to the patient and informed thickness flap adjacent to the defect and the mucosal flap
consent was obtained. The parameters recorded before and beyond the mucogingival junction, which was stretched in
after surgery were: Pocket depth, Recession depth and coronal direction to cover the defect. After proper isolation
Clinical Attachment Level (CAL) of the surgical field, the operative site i.e. 35 was
anesthetized using 2% Xylocaine with adrenaline Preparation of platelet-rich fibrin membrane:(1:200,000). Two vertical incisions were given at the line
PRF was prepared in accordance with the protocol developed angles of two adjacent teeth to the operating tooth, 8,9 by Choukroun et al. After the recipient site preparation was extending beyond the mucogingival junction. Sulcular
completed, 5 ml of venous blood was drawn in test tubes incision was given which connected the two vertical incisions without anticoagulant, and centrifuged immediately. It was (Figure 4). A full thickness flap followed by a partial thickness
centrifuged for 15 minutes at 2700 rpm. The resultant flap was reflected. The exposed root surfaces were scaled product consisted of the following three layers (Figure 2): and root planed. The PRF membrane was placed over the site
and stabilized (Figure 5). The flap was then slided to Topmost layer consisting of Acellular Platelet-Poor Plasma completely cover the membrane and secured using sling (PPP)sutures (Figure 6).Periodontal dressing was given thereafter
PRF clot in the middle(Figure 7).
Figure 1 Figure 2 Figure 3 Figure 4
Figure 5 Figure 6 Figure 7 Figure 8
Indian Journal of Comprehensive Dental Care 634
Post Operative Instructions: stem cells. The scientific rationale behind the use of platelet
preparations lies in the fact that the platelet granules are a Suitable antibiotics and analgesics were prescribed along reservoir of many growth factors that are known to play a with chlorhexidinedigluconate mouth rinses (0.2%) twice
12crucial role in hard and soft tissue repair mechanism. PRF daily for 2 weeks. include Epidermal growth factor (EGF), Transforming growth
Periodontal dressing and sutures were removed 1 week after factor beta (TGF-ß), vascular endothelial growth factor the operation. (VEGF), Platelet-derived growth factors (PDGFs) and Insulin
like growth factor-1 (IGF-1). There are many factors to affect Proper oral hygiene maintenance by gentle brushing was the release of these growth factors like PRF preparation and advised.manipulation. The present paper evaluates the clinical
Healing:efficacy of PRF in the treatment of Millers Class I gingival
Post operative follow up was done for upto three months. In recession. There are many studies to support the excellent this case, there was no post operative complication and the ability of autologous PRF to enhance periodontal wound healing was found to be satisfactory. healing.
13 Results : Su et al. evaluated that preparing the PRF immediately
before using it to allow for continuous release of growth Post-operative follow up was done at 1 month and healing factors over the subsequent 300 minutes (5 hours). So it is was found to be satisfactory. Re-examination at 3 month beneficial that the preparation of surgical site is done at the after the root coverage surgery revealed reduction in the same time as during the PRF preparation. So that after the gingival recession (Figure 8).preparation of PRF, it can be immediately placed on the
DISCUSSION:surgical site.
The ultimate goal of any therapeutic intervention aimed at Pradeep et al. evaluated improvement in the hard tissue
root coverage should be to restore the gingival margin at CEJ 14regeneration in mandibular grade II furcation.and to achieve attachment of tissues at root surface so that a
15 Aroca et al. evaluated the soft tissue regeneration in the normal healthy gingival sulcus with no bleeding on probing, 10 treatment of multiple adjacent gingival recession sites. PRF is and a minimal probing depth is present. Various surgical
also involved in the healing process by the progressive procedures have been described to treat gingival recession, release of cytokines during fibrin matrix remodeling. Slow but these have been demonstrated to heal with long fibrin polymerization during PRF processing leads to the junctional epithelium. Now a days, there are many intrinsic incorporation of platelet cytokines and glycan chains regenerative materials that are used, like; enamel matrix in the fibrin meshes.derivative, platelet derived growth factor, bone
morphogenic protein, platelet-rich plasma, PRF, fibroblast PRF affects the blood activation process and induce an growth factor, parathyroid hormone which played role in increased leukocyte degranulation and cytokine release from regeneration and healing by angiogenesis, cementogenesis, proinflammatory mediators, such as interleukin (IL)-1ß, IL-6,
11 mitosis, chemotaxis, etc. Although the bilaminar technique and tumor necrosis factor-a, anti-inflammatory cytokines, using subepithelial connective tissue graft holds a promising such as IL-4.results in root coverage, histological studies show
PRF provides a dense fibrin scaffold with a large number of unpredictable healing. The use of PRF membrane in our case
leukocytes concentrated in one part of the clot.report alleviated the need for donor site for the
After surgery, PRF release growth factors (e.g., transforming procurement of connective tissue graft. This has encouraged
growth factor-β, platelet derived growth factor-a β, and investigations of a more regenerative nature. Platelet-rich
vascular endothelial growth factor) and glycoproteins (e.g., fibrin is a second generation platelet concentrate and is
thrombospondin-1) over 1 week.defined as an autologous leukocyte and platelet-rich fibrin 9biomaterial. It was first developed by Choukroun et al. PRF preparation is very simple, fast, easy and cost-free and
without the use of any anticoagulant. It causes sustained It has been used extensively in combination with bone graft 8release of growth factors.materials for periodontal regeneration, ridge augmentation,
sinus lift procedures for implant placement and for coverage However, some studies reported inferior root coverage of of recession defects in the form of a membrane. This about 80.7% at the test site (CAF+ PRF) as compared to about membrane consists of a fibrin 3-D polymerized matrix in a 91.5% achieved at control site (CAF), but an additional gain in specific structure, with the incorporation of platelets, gingival/ mucosal thickness compared to conventional leukocytes, growth factors, and the presence of circulating therapy and the thickness of the keratinized tissues is
Indian Journal of Comprehensive Dental Care 635
16increased as reported in both studies . 8. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate. Part PRF membrane used in this case report had the advantage of
III: Leucocyte activation: A new feature for platelet absence of an anticoagulant, therefore blood began to
concentrates? Oral Surg Oral Med Oral Pathol Oral coagulate as soon as it came in contact with the glass surface.
Radiol Endod 2006;101:e51-e55. Therefore, for successful preparation of PRF, speedy blood
collection and immediate centrifugation, before the clotting 9. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin
cascade is initiated, is absolutely essential. (PRF): A second-generation platelet concentrate. Part II:
Platelet-related biologic features. Oral Surg Oral Med CONCLUSION:
Oral Pathol Oral Radiol Endod 2006;101:e45-e50. PRF contains regenerative properties and has a great
10. Griffin TJ, Cheung WS. Treatment of gingival recession potential for surgical wound healing. So, PRF is effective in
with a platelet concentrate graft. A report of two cases. the management of gingival recession and gain in clinical
Int Journal of Periodont Restorat Dent. 2004;24:589-95.attachments as regenerative material. Furthermore, PRF is
cost effective. Further studies are necessary to assess the 11. Giannobile WV, Somerman MJ. Growth and
histology of the regenerated tissue and mechanisms to amelogenin-like factors in periodontal wound healing.
maximize the growth factor delivery while using PRF. So, this A systematic review. Ann Periodontol 2003;8:193-204.
case report reflects the success of this biomaterial for 12. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, coverage of gingival recession defects and the ability to Strauss JE, Georgeff KR. Platelet-rich plasma: growth increase the thickness of the keratinised gingival tissue. factor enhancement for bone grafts. Oral Surg Oral Med
REFERENCES: Oral Pathol Oral Radiol Endod 1998; 85: 638-46.
1. Löe H, Anerud A, Boysen H. The natural history of 13. Su C Y, Kuo YP, Tseng YH, Su CH, Burnouf T. In vitro
periodontal disease in man: Prevalence, severity, and release of growth factors from platelet-rich fibrin (PRF):
extent of gingival recession. J Periodontol 1992;63:489- a proposal to optimize the clinical applications of PRF.
95. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;
108: 56-61. 2. Baker D, Seymour G. The possible pathogenesis of
gingival recession. J Clin Periodontol 1976;3:208-19. 14. Sharma A, Pradeep AR. Autologous platelet-rich fibrin in
the treatment of mandibular degree II furcation 3. Gartrell JR, Mathews D. Gingival recession. The
defects: A randomized clinical trial. J Periodontol condition, process, and treatment. Dent Clin North Am
2011;82:1396-1403. 1976;20:199-21
15. Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical 4. Hoag P. Isolated areas of gingival recession: Etiology and
evaluation of a modified coronally advanced flap alone treatment. CDS Rev 1979;72:27-34.
or in combination with a platelet-rich fibrin membrane 5. Smith RG. Gingival recession. Reappraisal of an for the treatment of adjacent multiple gingival
enigmatic condition and a new index for monitoring. J recessions: A 6-month study. J Periodontol Clin Periodontol 1997;24:201-5. 2009;80:244-252.
6. Pini Prato GP, Rotundo R, Magnani C, Ficarra G. Viral 16. Wang HL, Greenwell H. Surgical periodontal therapy. etiology of gingival recession: A case report. J Periodontol 2001;25:89-99. Periodontol 2002;73:110-4.
7. Tozum TF, Demiralp B. Platelet- Rich Plasma: A
promising innovation in dentistry . J Can Dent
Assoc.2003;69:664.
INTRARADICULAR REHABILITATION OF WEAKENED ANTERIOR TOOTH USING LIGHT-TRANSMITTING POST- A CASE REPORT
ABSTRACT:
Composite resins have been advocated as a reinforcing material for badly
damaged endodontically treated teeth with flared canals. Light-transmitting
plastic posts allow the transmission of light into the root canal and enable
intraradicular composite resin reconstitution and reinforcement of weakened
roots. At the same time, the light-transmitting plastic post forms an optimal
post canal in the rehabilitated root and can be used to fabricate custom cast
post and core or matching retentive prefabricated post. These light-
transmitting posts are a useful addition to the dental armamentarium
Keywords: composite resin, light transmitting post, reinforcement
636
Corresponding author:Name: Dr. Ramneek KhatterAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M) .: 9855106630Email: doctorramneek@hotmail.com
1. Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
2. Prof Head & Principal Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
3. Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.
4. Senior Lecturer, Guru Nanak Dev Dental College Sunam.
Indian Journal of Comprehensive Dental Care
I J C D C1. Ramneek Khatter
2. C.S.Bal
3. Ripu Daman Singh
4. Shilpa Walia
Date of Submission : 11/11/14 Date of Acceptance : 3/12/14
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Introduction continued function of the tooth.
The crux of endodontically treated tooth revolves around A technique employing acid etching of dentin in
restoration and reinforcement. The flared canal, arising as a combination with autocuring composite resin was
result of carious extension, trauma to an immature tooth, introduced to rehabilitate such a weakened root in 3pulpal pathosis, iatrogenic endodontic misadventure, or conjunction with the preparation of a post canal.
4-6idiopathic causes, can present a difficult restorative Numerous studies have advocated and demonstrated the
problem to the dental surgeon. In such cases placement of adequacy of composite resins in dowel and core systems for
retentive pins is impossible because of the lack of dentinal the restoration of endodontically treated teeth. Composite
structure at the coronal portion of the root. Further the use resin is thus accepted today as a sufficiently strong
of conventional, tapered, cast posts would concentrate reinforcing build-up material.
wedging forces, further stressing the critically weakened A further development was the introduction of the
1, 2coronal end of the post canal. However, the introduction 7chemically adhesive glass-cermet cement. it has also been of materials capable of bonding to dentinal structure has
reported as a possible reinforcing material in flared canals created potential for the reconstitution and rehabilitation
of weakened endodontically treated roots. Despite their of lost dentinal tissues to salvage severely damaged teeth
many desirable properties, glass-cermet cements still lack that would otherwise be extracted. When the weakened
the physical and mechanical strengths of composite resins. root is internally rebuilt with suitable adhesive dental
However, autocuring composite resins, on the other hand, materials, the root is dimensionally and structurally
are considered an acceptable alternative to cast dowel and reinforced to support and retain a post and core for
Indian Journal of Comprehensive Dental Care 637
core systems, because it has been reported that there is no subsequently been endodontically treated, was
significant difference between the composite resin dowel found.(Fig1,Fig2). 8and core systems tested and cast dowel and core. The introduction of transilluminating plastic posts (Luminex,
Unfortunately, after mixing is completed, control of the Weissman Technology) has enabled the transmission of light chemically curing composite resin is difficult, especially in into the root canal to polymerize composite resin placed deep portions of the root canals. Polymerization of light- within it. The affected tooth was isolated with split dam curing composite resins can be a problem when they are technique and clamps were modified to adapt to the placed in the deeper parts of root canals. location (Fig3).The apical portion of the obturated root canal
A light-transmitting post was introduced to transmit light to is first prepared with suitable reamers to the desired size and
polymerize composite resins placed deeply as a dentinal depth to fit a corresponding-sized light-transmitting plastic
substitute to internally rehabilitate weakened roots. The post. The matched post is removed and the internal root
posts allow reconstitution of the root as well as preparation dentin is etched and primed using self etch adhesive (Adper
of the post canal, rendering the defective endodontically Prompt, 3M-ESPE) is used according to the manufacturer's
treated root capable of supporting a post and core and instructions. The dentinal primer is applied with a micro
thereby ensuring the continued function of the badly brush over the dentinal surfaces and dried with oil-free air.
damaged tooth. This case report describes a intraradicular The adhesive is then similarly applied over the primed
reinforcement of flared canal involving composite resin dentin. After the light-transmitting post is reinserted, the
polymerization with these transilluminating posts. adhesive is cured for 10 seconds with a suitable light-curing
unit. The light-transmitting post is again removed.Materials and Methods
For reconstituting and rehabilitating the root a visible light-A 22 years old patient reported to the Department of
curing hybrid composite resin (Z250,3M-ESPE) is carried and Conservative Dentistry and Endodontics, Sri Guru Ram Das
packed with suitable plastic instruments into the canal. The institute of Dental Sciences and Reaserch, Sri Amritsar with
light- transmitting post is reseated to its full depth to ensure the chief complaint of decayed upper front tooth. Patient
the desired post canal length is achieved and, at the same gave the history of trauma 12 years back and got the root
time, through the pressure exerted, to facilitate good canal treatment done from private practitioner. However
adaptation of the composite resin against the canal walls. the coronal portion further discolored with time and was
Following removal of excess material from the coronal root unaesthetic and patient wanted the restoration of the same.
face, a light-curing unit is applied to the end of the plastic On clinical examination, there was a large deep coronal root
post to transilluminate light along its entire length to defect caused by gross intraradicular extension of caries into
polymerize the surrounding composite resin (Fig4). The post a previously traumatized central incisor that had
is then removed with a hemostat, leaving a reinforced root
Fig1: Preoperative radiograp Fig2: Preoperative photograph of the large defect at coronal root end of maxillary left incisor is caused by carious extension into a previously
traumatized immature incisor.
Fig3: Rubber dam isolation using split dam technique
Fig4: Light is transmitted into the root canal using light transmitting post to
polymerize the intracanal composite resin.
Fig5: A matching post canal is created in conjunction with
reinforcement of defective root
Fig6: Post operative radiograph of reinforced root and restoration
with cast post and core
Fig 7: Post operative photograph
Indian Journal of Comprehensive Dental Care 638
with a patent, size matched post canal (Fig5). the defective portion, thereby reinforcing the weakened
root.With the root now rehabilitated, the damaged tooth is
brought to function and esthetics using custom made cast The use of light-transmitting posts in conjunction with light-
metal post and core. Wax pattern was made in direct curing composite resins within a post canal space eliminates
technique and invested later to obtain the cast post and core the difficulty in control experienced with a rapidly
(Fig 6). Finally, the clinical technique is completed with the polymerizing auto curing composite resin and ensures
cementation cast post and core followed by esthetic crown complete polymerization in a light-curing composite resin.
(Fig 7). Besides internally rehabilitating and rebuilding the
weakened root, the light-transmitting plastic post can at the Clinical applicationssame time form an optimal post canal. Because posts are
There are many clinical situations in which an internally intended to provide retention and resistance to damaged root can be endodontically treated and displacement of the core, the post canal should be as small rehabilitated in conjunction with preparation of the post as the apical dentin portion of the root canal would fit the canal. Generally in these cases, the defect assumes a flared smallest acceptable size post. This would ensure that the configuration at the coronal portion of the root canal, while diametral dimension of the composite resin reinforcement is
9the apical portion has adequate dentinal support. The entire effectively increased to better resist fracture to the root. external root surface is also essentially intact and adequately
A tooth with a flared canal in an otherwise intact arch supported by periodontal tissues. It is therefore presents the dentist with a restorative problem, previously, fundamentally sound to reconstitute the weakened coronal such a tooth, even in the maxillary anterior region, would be portion so that the rehabilitated root is rendered capable of deemed unrestorable and would usually be extracted. supporting a restoration and thereby continuing the Today, with rapid advancement in adhesive techniques and usefulness of the tooth.materials, restorative dentistry has shifted to conservation
Discussion of even badly damaged teeth and their restoration to
function and esthetics so as to best serve the needs of the The depth of cure of visible light-curing composite resin patient, through reconstitution of the intraradicular defect, achieved at best in the conventional manner is 2 to 3 mm, the compromised tooth is reinforced and rehabilitated to because of the limited transillumination of light through the retain a post and core and support a functional esthetic composite resin. With the introduction of light-transmitting crown. The reconstitution and reinforcement can be easily plastic posts, it is possible to transilluminate light through and successfully achieved by using light-curing composite the bulk of deeper, intra-radicularly placed composite resin, resins polymerized with the aid of light-transmitting plastic because light is transmitted along the entire length of the posts. Flared canals resulting from damage caused by caries, plastic post. Complete polymerization of the composite trauma, congenital disorder, internal resorption, or resin along the entire length and circumference of the flared iatrogenic or other idiopathic causes can thus be adequately root canal is thus possible. Following polymerization and reinforced by using the technique described.removal of plastic post, a patent, accurate and retentive post
canal is immediately established. This technique thereby Conclusionensures that retention and resistance requirements of post
Successful treatment of weakened teeth with pulpal disease and core systems can be conveniently and easily met.depends not only on good endodontic therapy, but also on
For a flared canal, the use of a cast post can concentrate good prosthetic reconstruction. A wide range of techniques wedging forces at the weakened coronal portion of the root. of varying complexity are available and selecting the The use of a prefabricated post, however, entails the optimum restorative modality to compensate for the loss of obturation of the large defect with a cementing medium, coronal tooth structure is considered key to restorative creating a very weak area the entire post-core-crown-tooth success.complex. Therefore, it is practical to reinforce this weakened
Referencesintraradicular portion by rebuilding the lost dentin with a
strong dentinal substitute. Many clinicians have advocated 1. Zmener O. Adaptation of threaded dowelS to dentin. (4, 6)the use of composite resin as a reinforcing material. Good Prosthet Dent 1980:43:530-535.
bonding of composite resins to dentin is now possible 2. Davy DT. Dilley GL. Krejci RF. Determination of stress pal- because of the advances in dentinal adhesives. In a flared terns in root-tilled teeth incorporating various dowel canal, the composite resin bonded to the root- dentinal designs, J Dent Res 1981; 60:1301-1310.surfaces would dimensionally and structurally reconstitute
3. Lui JL. A technique to reinforce weakened roots with
Indian Journal of Comprehensive Dental Care 639
post canals. Endod DentTraumatol 1987; 3:310-314. 8. Plasnians PHM. Welle PR, Vrijhoef MMA. In vitro
resistance of composite resin dowel and cores J Endod 4. Spalten RG. Composite resins to restore mutilated 1988;14:300-304.teeth. JProst Dent 1971;25:323-326.
9. Gutmann J. Preparation of endodontically treated teeth 5. Landwerlen JR, The composite resin post and core, J to receive post-core restoration, J Prosthet Dent 1977; Prosthet Dent 1972; 28:500-503.38:413-419.
6. Baraban DJ. Immediate restoration of pulpless teeth, J
Prosthet Dent 1972; 28:607-612.
7. McLean JW, Gasser O. Glass-cermet cements.
Quintessence Int. 1985; 16:333-343.
DENTIGEROUS CYST IN A YOUNG CHILD ASSOCIATED WITH MULTIPLE TOOTH BUDS: A PERPLEXITY
Abstract
A dentigerous cyst or follicular cyst is an odontogenic cyst — thought to be of
developmental origin — associated with the crown of an unerupted tooth.Such
cyst may remain completely asymptomatic unless when infected or discovered
accidently on radiographs.The purpose of this case report is to describe the
diagnosis and management of dentigerous cyst in a 9-year-old boy. The chosen
treatment was cyst enucleation and tooth extraction followed by replacement
of missing teeth with removable partial denture.
Keywords: dentigerous cyst, surgical, enucleation
640
Corresponding author:Name: Dr. Sunil Gupta, MDSProfessor, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, AmritsarEmail: sunilpedo@gmail.com
1. Professor, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar.
2. Reader, Department of Oral and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar.
3. Post Graduate Student, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar.
Indian Journal of Comprehensive Dental Care
I J C D C1. Sunil Gupta2. Amit Dhawan3. Anjali
Date of Submission : 30/11/14 Date of Acceptance : 3/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Introduction The aim of this article is to present a case of 9 yr old child
who presented with a large dentigerous cyst associated right Dentigerous cyst is defined as a cyst that originates by mandibular permanent premolars and canine tooth buds. separation of the follicle around the crown of an unerupted
tooth. It is the most common type of developmental Clinical case
odontogenic cyst. It encloses the crown of an unerupted A nine year old male patient reported to the department of tooth and is attached to the tooth at the cementoenamel Paediatric and Preventive Dentistry, Sri Guru Ram Das junction. The pathogenesis of this cyst is uncertain, but institute of Dental Sciences. The patient was accompanied apparently it develops by accumulation of fluid between the by his parents who complained about a hard swelling on the
1reduced enamel epithelium and the tooth crown. lower right side of the face of child since 2-3 months. Patient
It represents about 20% of all jaw cysts and is recognised as gave history of extractions with respect to 84 and 85 around
one of the most frequently diagnosed lesion of the jaw a week back. There was no history of systemic pathologies or 4 previous trauma in the affected area.[Daley et al., 1994; Ochsenius et al., 2007].
On clinical examination extra- orally slight facial asymmetry Dentigerous cyst may be asymptomatic clinically and
was noticed on right side of the face near the lower border of discovered accidentally by routine panoramic radiographic
mandible. On palapation a hard, nonmobile, non-tender the examination or may present as a painless swelling of the
mass was felt in the region of mandibular right premolars. involved area. Radiographically, it usually presents as a
On intra- oral examination buccal vestibule was found to be unilocular and pericoronal radiolucent lesion of an
obliterated in relation to right mandibular missing unerupted or impacted tooth in the jaws.
Indian Journal of Comprehensive Dental Care 641
deciduous molars. (fig 1) Recall visit
Orthopantomograph findings revealed a well delimited After 10 days the wound was checked and sutures were
unilocular radiolucent area, measuring approximately 30 removed. Orthopantomograph showed complete removal of
mm in its largest diameter, with well-defined sclerotic the cyst. (fig 4) On 1 month recall the wound healed perfectly
margins, completely enclosing the developing tooth buds of and the patient was asymptomatic. Patient was then
43, 44 and 45 permanent teeth and associated with root of recalled after 9 months, OPG showed complete bone
83. (fig 2)Volume CT scan examination of mandible bone formation in area of the cyst. (fig 7)
revealed a well-defined expansile unilocular fluid densiort Replacing the missing canine and premolarscystic lesion of size 2.6 1.7 cm in the mandible on the right
After 3 months. The edentulous space was replaced by a side causing thinning of the overlying cortex. There was no removable partial denture (fig 5, 6) so as to aid the patient in break in cortex nor any soft tissue mass was seen. Provisional
stchewing and preventing drifting of 1 permanent molar into diagnosis of dentigerous cyst was concluded.the edentulous space.
Patient was referred to the department of Oral and DiscussionMaxillofacial Surgery, Sri Guru Ram Das institute of Dental
Sciences. The cyst was enucleated under general anaesthesia The word dentigerous means “tooth bearing” which after relevant medical tests. The enucleated mass included describes the cyst appropriately.Dentigerous cysts are cyst, 83 and tooth buds of 43, 44 and 45. (fig 3) developmental cysts of odontogenic origin and at age 0–9
years the mandibular second premolar is the most involved The enucleated mass was sent for histopathological tooth and between the ages of 10–19 years the permanent examination. The patient was prescribed antibiotics and maxillary canines are the most represented teeth [Bernick, analgesics and was asked to report after 1 week. 1949; Ericsson et al., 2002]. In the second and third decades
Histopathological reportof life it is most often associated with impacted mandibular
4Macroscopic appearance was described as multiple soft third molars [Shear, 1983].
tissue bits together measuring 3cm 2cm in dimension. The Patients with dentigerous cyst may experience pain or show
specimen was creamish brown in colour and firm in inflammatory signs if the cyst is infected. It may be associated
consistency.with unerupted permanent teeth, supernumerary teeth or
On microscopic examination the given section showed a odontomas.
cystic cavity which was lined by 2-4 cell layered epithelium The radiographic picture alone is insufficient for the definite
with flat or cuboidal cells which at places exhibit arcading diagnoses of dentigerous cyst, because the similar
pattern. The cystic capsule was delicate to dense at placed radiographic pictures can be found in other odontogenic
and was moderately infiltrated with chronic inflammatory lesions such as odontogenic keratocyst, unicystic
cells. Few odontogenic rests were also evident in the ameloblastoma or adenomatoid odontogenic tumor.
connective tissue capsule. The diagnosis of dentigerous cyst Therefore, the final pathological diagnosis is based on
was confirmed.
Fig.1 Fig.2 Fig.3 Fig.4
Fig.5 Fig.6 Fig.7
Indian Journal of Comprehensive Dental Care 642
microscopic examination of biopsy or surgical excision emphasised that in order not to disturb normal configuration
specimens. It is also difficult to distinguish between a small and growth of bone structures and eruption of developing
dentigerous cyst and a large dental follicle. Daley and teeth, surgical treatment with minimal injury to bone 4 Wysocki had pointed out that the only reliable way for structures is crucial. The prognosis is excellent when the cyst
distinguishing between a small dentigerous cyst and a large is enucleated in toto and recurrence is rare. As the lining
dental follicle is the identification of a cystic cavity at the time epithelium has the pluripotential capacity, these lesions may 2of surgery. progress to ameloblastoma, mucoepidermoid carcinoma
and squamous cell carcinoma warranting early diagnosis and Histologically, dentigerous cysts may be inflamed or 5treatment.uninflamed. When uninflamed, they are characterized by a
wall of relatively loose connective tissue, and an epithelial Conclusion
lining consisting of two to four layers of cuboidal cells. When Dentigerous cyst development associate with an unerupted
inflamed, the fibrous wall is more collagenized, with a permanent tooth is not uncommon but as they are
chronic inflammatory infiltrate. The epithelial lining is asymptomatic, they can attain considerable size without the
hyperplastic, and a keratinized surface is sometimes notice of the patient, a thorough radiographic evaluation
observed. The exact histogenesis of dentigerous cysts is still must be carried out all unerupted teeth that have well past
unknown, but most authors agree they are of developmental their expected eruption date. Serial panoramic films are a
origin. common and reliable tool for the diagnosis and assessment
It has been suggested that two types of dentigerous cysts of progress in healing of space occupying lesions of jaw
exist. The first are developmental cysts of the permanent bones.
dentition, and are usually the result of an impacted tooth. Importance of the article:
These cysts occur in the second or third decade of life and are · Healing and bone regeneration is excellent in pediatric discovered on routine radiographs. The second type are
patients.inflammatory cysts that occur in immature teeth, as a result
of periapical inflammation, generally due to a nonvital · Early diagnosis and being able to differentiate a deciduous tooth or to dissemination of an inflammatory developmental cyst from inflammatory cyst is crucial in process affecting the follicle of a permanent tooth. These pediatric patients for subsequent treatment planning to cysts are diagnosed in the first or second decade of life. It has reduce potential morbidity.also been suggested that concomitant use of cyclosporin and
Bibliographycalcium channel blockers may have an influence on the
1. Neville, Damm and Allen (2002).Oral and maxillofacial formation of maxillary cysts. These drugs may alter ndpathology (2 ed.)mechanisms that regulate gingival stromal tissue
reabsorption, thus causing gingival hypertrophy, which may 2. Lin HP, Wang YP, Chen HM, Cheng SJ, Sun A, Chiang CP. A obstruct tooth eruption and, consequently, facilitate cyst clinicopathological study of 338 dentigerous cysts. J Oral development. Pathol Med. 2013 Jul;42(6):462-7.
The role of the p53 protein in the development of 3. Piattelli A1, Fioroni M, Santinelli A, Rubini C. P53 protein odontogenic cysts through alterations in cell proliferation expression in odontogenic cysts. J Endod. 2001 was studied by Piattelli et al, who found that p53- positive Jul;27(7):459-61.tissues appear to exhibit greater proliferative activity; of the
4. Berdén J1, Koch G, Ullbro C. Case series: Treatment of 24 cases of dentigerous cysts studied, 9.1% were positive for
large dentigerous cysts in children. Eur Arch Paediatr 3this protein.Dent. 2010 Jun;11(3):140-5.
There are two principal surgical approaches to treatment of 5. Mishra R, Tripathi AM, Rathore M. Dentigerous Cyst
dentigerous cysts – enucleation and decompression [Ziccardi associated with Horizontally Impacted Mandibular
et al., 1997; Martinez-Pérez and Varela-Morales, 2001; Second Premolar. Int J Clin Pediatr Dent. 2014
Motamedi and Tales, 2005; Fujii et al., 2008]. The different Jan;7(1):54-7.
techniques have mostly been presented as case reports
[Ziccardi et al., 1997; Martinez-Pérez and Varela- Morales,
2001; Ertas and Yavus, 2003; Delbem et al., 2006, Chew and
Aghabeigi, 2008]. The treatment of young patients with large
dentigerous cysts covered with only a thin layer of bone
tissue and displaced tooth germs is challenging. It has to be
PERIODONTAL MANIFESTATIONS OF DERMATITIS HERPETIFORMIS: A CASE REPORT
ABSTRACT
Dermatitis herpetiformis (DH) is an autoimmune blistering disorder with a
multifactorial etiology associated with a gluten-sensitive enteropathy. In this
article, a case of dermatitis herpetiformis, with oral lesions and skin lesions, is
described. Evaluation of laboratory findings, clinical picture, and response to
sulfones is essential to the final diagnosis and is emphasized.
Keywords: Dermatitis herpetiformis, gluten-sensitive enteropathy, bullous skin
disease
643
Corresponding author:Name:Dr. VandanaReader, Department of Periodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, AmritsarEmail address. – dr.vandana6@gmail.com(M) 91-9464278294
1. Reader, Deptt. Of Periodontology and Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar.
2. Reader, Deptt. Of Periodontology and Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar.
3. Post Graduate student Deptt. Of Periodontology and Oral Implantology, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar
4. Associate Professor, Department of Periodontics, Dr. H.S. Judge Institute of Dental Sciences and Research, Chandigarh
Indian Journal of Comprehensive Dental Care
I J C D C1. Vandana2. Supreet Kaur3. Navneet Kaur4. Vishakha Grover
Date of Submission : 29/11/14 Date of Acceptance : 2/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
4INTRODUCTION haemorrhagic.
Dermatitis herpetiformis (DH) was first described in 1884 by In addition to the lesions in the skin and small intestine, 1Dr. Louis Duhring at the University of Pennsylvania. It is an patients with DH may have oral involvement, or atleast they
autoimmune blistering disorder associated with a gluten- often show IgA deposits in apparently normal oral mucosa 5 sensitive enteropathy. The etiology is multifactorial with when examined during direct immunoflorescence (IFL).
2 strong genetic and autoimmune influences. Several authors have recently recognized a bullous skin
disease clinically closely resembling either DH or bullous Dermatitis herpetiformis usually presents in the third decade, 3 pemphigoid, but with linear IgA deposition in the basement
although individuals of any age can be affected. Males are 6,7 membrane zone. A disease entity or not, the term linear IgA affected twice as common as females. Primary lesions take the
disease is becoming more popular for patients who may also form of erythematous papules, urticarial-like plaques or have oral lesions.vesicles. It can be asymptomatic or cause severe burning and
itching. The prodrome of localised stinging, burning, or itching CASE REPORT
sensation may occur 8-12 hours before the lesions appear. A 60 years old female patient reported to the department of Herpetiform grouping is often present. Sometimes crusted Periodontology and Oral Implantology of Sri Guru Ram Das lesions are present. They are symmetrically distributed over Institute of Dental Sciences and Reasearch Sri Amritsar. the extensor surfaces (buttock, knees, sacral area, elbows and Patient presented with the chief complaint of bleeding from shoulders), face and facial hair line, scalp and posterior nuchal gums and multiple missing teeth. area. Vesicles may be found on palms and are sometimes
Indian Journal of Comprehensive Dental Care 644
Medical history instructions. After the completion of active periodontal
treatment, patient was kept on maintainance phase and Patient's mental development was normal. Patient had supportive periodontal therapy was performed to prevent severe problem of acidity and regurgitation and painful recurrence of ulcers. Patient was advised warm saline rinses burning sensation in the abdomen.three times a day and alcohol free mouthwash was
Physical examination prescribed in order to prevent any burning sensation. After
the completion of periodontal treatment, patient was Patient had healed lesions on forehead, hands and arms. referred to the department of prosthodontics for (Figure1) Healed lesions were also seen on joints viz. knees, replacement of missing teeth. elbows and hips. (Figure 2) Lesions were also present inside
the ear and on eyelids. These lesions caused itching with Patient was already on dapsone 100 mg daily and healing of formation of vesicles. Patient also complained of painful lesions was observed after its intake. Restricted wheat diet burning sensation stinging and variations in the intensity of was continued and patient was referred to physician for itching. Vesicles healed on their own. Soles of palms and feet, consultation and for tapering off of steroids. abdomen and back were spared of the lesions.
DISCUSSIONDiet history
Recent studies have distinguished linear IgA disease from DH Patient was on restricted wheat diet and steroids for the last suggesting that it is a separate disease entity not associated
6, 7two years with gluten-sensitive enteropathy. In contrast to DH, linear IgA disease seems to have a high incidence of mucous Oral examination
membrane lesions, and a relationship with cicatricial (benign She had severe burning sensation on tongue and dryness of
mucous membrane) pemphigoid has recently been oral mucosa with white patches on labial mucosa. Patient
8 suggested. Further characterization of these immunologic also complained of chelosis at angles of mouth with
diseases which also involve oral mucosa warrants IEM occasional apthous ulcers. Patient expressed her inability to
studies to localize the target structures for antibody eat and drink anything due to extreme pain. Patient had poor
deposition. Previous IEM studies in cicatricial pemphigoid oral hygiene with abundant plaque and calculus because of
9, 10 have localized IgG and IgA deposition in the lamina lucida her inability to brush teeth due to pain and bleeding.
These studies have shown that IgA is deposited along the 11 Differential diagnosis elastic fibers in case of dermatitis herpetiformis.
The differential diagnosis includes dermatitis herpetiformis, Therefore, diagnosis of dermatitis herpetiformis is based on Grover's disease, Pemphigus foliaceus or erythematosus, certain investigations such as:bullous lupus erythematosus and other immunobullous
Histology: In early non-vesicular skin lesions, histology is lesions.
characterised by neutrophilic micorabscesses in dermal Management papillae. There are neutrophilic fragments and eosinophils.
Papillary dermis is separated from the overlying epidermis. Patient was given complete oral prophylaxis and oral hygiene
Figure1: Healed lesions on forehead Figure 2: Lesions on hands and arms Figure 3: Oral examination
Indian Journal of Comprehensive Dental Care 645Indian Journal of Comprehensive Dental Care
There is perivascular neutrophilic, eosinophilic and DH. No new eruption develops after one to two days of
lymphohistiocytic infiltrate around upper and mid-dermal treatment, but there may be exacerbation on withdrawal of 4blood vessels. drug.
Direct IMF: The granular IgA deposits at dermal papillae is Sulfapyridine 1-1.5 gm daily is an alternative for patients
classical. IgA is unevenly distributed throughout the skin; intolerant to dapsone, the elderly, and those with cardio-12 pulmonary problems. Non-steroid anti-inflammatory drugs being more dense near the active lesion. The preferred
can cause exacerbation of DH even during dapsone biopsy site for immunopathologic diagnosis in DH is the
treatment in these patients. Combination Therapy (Diet and normal appearing skin adjacent to an active lesion.3 IgA1 is
sulphone) has the advantage of reducing the maintenance the predominant subclass found. The IgA deposits are
dosage or even complete withdrawal of the drug, provided unaffected by drug treatment but decrease with adhesion to 4
gluten free diet. that the patient strictly adheres to the gluten free diet.
Site of blister It was thought that blistering occurred below CONCLUSION
lamina densa. Recent study using immunomapping Although DH is a chronic disease, patients can have technique instead of electron microscopy demonstrated that exceptional control over clinical symptoms after they have the cleavage took place above lamina densa within the made the necessary lifestyle modifications; specifically, strict lamina lucida. It has been proposed that neutrophils infiltrate adherence to a gluten-free diet and if possible. In addition, dermal papilla and release lysosomal enzymes resulting in medical management may be necessary as dictated by the papillary edema. Further recruitment of neutrophils and patient's symptoms. Although medications prescribed release of enzymes cause enzymatic damage of the lower strictly for the treatment of DH; namely, dapsone and/or lamina lucida, leading to vesicle formation within the lower sulfapyridine, have no effect on the underlying
13lamina lucida above lamina densa. gastrointestinal disease, they offer the advantage of rapid
symptomatic relief and improvement in skin manifestations. Cytokine Various cytokines have been shown to be involved
DH patients can be reassured that although this is a chronic in the pathogenesis of DH. ELAM (endothelial leucocyte
and sometimes unpredictable disease, lifestyle adjustments adhesion molecules) expression was increased in the deep
and medical treatment can be highly successful.Till date very dermis. Interleukin-8 was elevated in basal keratinocytes.
few cases have been reported about the possible association Granulocyte Macrophage-Colony Stimulating Factor was
between periodontitis and DH. Further research is needed to raised in the dermo-epidermal junction. These cytokines
establish any possible association. promote neutrophilic activation and infiltration. GM-CSF
stimulated expression of IgA-Fc receptors on polymorphs. REFERENCESThey account for the neutrophilic infiltration and activation,
14 1. Duhring LA. Landmark article, aug 30, 1884: Dermatitis enzymes release and vesicles formation.herpet- iformis. by Louis A. Duhring. JAMA. 1983 Jul 8;
Indirect IMF The anti-gliadin antibodies are non-specific. The 250:212-6. IgG anti-gliadin antibody is present in pemphigus, while IgA
15,16 2. Bolotin D, Petronic-Rosic V. Dermatitis herpetiformis. anti-gliadin antibody can be found in pemphigoid.Part I. epidemiology, pathogenesis, and clinical
Anti-reticulin IgA is disease-specific while the anti- reticulin presentation. J Am Acad Dermatol. 2011 Jun; 64:1017, IgG is not. Anti-endomysial IgA is most specific for DH and 24; quiz 1025-6.GSE, and it correlates with the disease activity of GSE. The
3. Fry L. Dermatitis herpetiformis: problems progress and titre decreases with gluten free diet and is useful in 4 prospects. Eur J Dermatol 2002; 12: 523–531.monitoring the disease progress and compliance to diet.
4. Katz SI. Dermatitis Herpetiformis. In: Fitzpatrick TB, HLA association HLA B8 is detected in 77-87% of DH. In 17 Eisen AZ, Wolff K, Freedberg IM, Austen KF, editors.
addition, HLA DR3, Dqw2 are also associated the disease. Dermatology in General Medicine. 4th edition. McGraw
DH can be managed by taking gluten free diet. Gluten free Hill 1993; 1: 56; 636-40.diet is effective but takes five months to one year for its effect
5. Harrison PV, Scott DG, Cobden I. Buccal mucosa to become apparent. Other treatment modalitites like
immunofluorescence in coeliac disease and dermatitis sulphones and combination therapy of diet and sulphones
herpetiformis. Br J Dermatol 1980; 102: 687-8.can be used. Sulphone drugs (e.g. dapsone with a dosage of
6. Lawley TJ, Strober W, Yaoita H, Katz SI. Small intestinal 100-150mg daily) cause rapid improvement of symptoms
biopsies and HLA types in dermatitis herpetiformis and signs, usually around three hours to few days after the
patients with granular and linear IgA skin deposits. J first dose. This rapid response aids in making the diagnosis of
Indian Journal of Comprehensive Dental Care 646
Invesl Dermatol 1980; 74: 9-12. dermatitis herpetiformis within the lamina lucida. J Am
Acad Dermatol 1992; 27:209-13. 7. Leonard JN, Haffenden GP, Ring NP, et al. Linear IgA
disease in adults. Br J Dermatol 1982; 107: 301-16. 14. raeber M, Baker BS, Garioch JJ, et al. The role of
cytokines in the generation of skin lesion in dermatitis 8. Leonard JN, Wright P, Williams DM, et al. The herpetiformis. Br J Dermatol 1993; 129: 530-2. relationship between linear IgA disease and benign
mucous membrane pemphigoid. BrJ Dermatol 1984; 15. Peters MS, McEvoy MT. Ig A antiendomysial antibodies in
110: 307-14. dermatitis herpetiformis. J Am Acad Dermatol 1989; 21:
1225- 31.9. Fine J-D, Neises GR, Katz SI. Immunonuorescence and
immunoeleetron microscopic studies in cicatricial 16. Kuman V, Zane H, Kaul N. Serologic markers of Gluten-
pemphigoid. J Invest Dermatol 1984; 82: 39-43. sensitive enteropathy in Bullous disease. Arch Dermatol
1992; 128: 1474-8. 10 Hietanen J, Rantala I, Reunala T: Benign mucous
membrane pemphigoid with linear IgA deposits in oral 17. Chan SH, Wee GB, Srinivasan N, et al. HLA antigens in
mucosa. Scand J Dent Res: in press. three common populations in South East Asia: Chinese,
Malay and Filipino. Tissue Antigens 1979; 13: 361-8.11. Yaoita H. Identification of IgA binding structures in skin
of patients with dermatitis herpetiformis. J/nmi
Dermato/ 1978; 71: 213- 6.
12 Zone JJ, Meyer LJ, Peterson MJ. Deposition of granular
IgA relative to clinical lesions in dermatitis
herpetiformis. Arch Dermatol 1996; 132(8): 912-8.
13 Smith JB, Taylor, Zone JJ. The site of blister formation in
VITAL BLEACHING: A REVIEW AND CASE REPORTS
Abstract:
The importance of tooth whitening for patients has shown a dramatic increase
in the number of products and procedures over recent years. Vital tooth
bleaching refers to chair-side clinical application of a chemical solution to a
tooth surface in order to achieve whitening effect of the teeth. Vital bleaching
has found to be very effective but it also has its drawbacks. The current article
gives knowledge of vital tooth whitening with respect to external bleaching
methods. The external bleaching of vital teeth focuses on patient selection,
mechanisms, bleaching procedure and various in office bleaching systems and
techniques and their disadvantages.
Keywords: vital bleaching, tooth whitening, external bleaching, office
bleaching
647
Corresponding author:Name: Prashant MongaReader, Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur.
1. Consultant Cosmetic Dentist2. Consultant Endodontist3. Professor and Head, Conservative Dentistry and
Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur.
4. Reader, Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur.
5. Reader, Department of Pedodontics, Genesis Institute of Dental Sciences and Research, Ferozepur.
Indian Journal of Comprehensive Dental Care
I J C D C1. Megha Majajan
2. Roma Goyal
3. Pardeep Mahajan
4. Prashant Monga
5. Nitika Bajaj
Date of Submission : 2/2/15 Date of Acceptance : 4/3/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Introduction application of 17-50% of hydrogen peroxide formulation to
thetooth surface. Proponents of power bleaching claimto The desire to have white teeth and thus a morepleasant reduce the total in office bleaching timenecessary by smile has become an important esthetic need of patients energizing the bleach material usingvarious light sources, today. Although a wide arena ofesthetic restorative such as laser, plasma arc light,LED light, helogen[4].materials are available to us today for the management of
discolored teeth,bleaching still remains a viable option in Bleaching is a conservative and effective method tolighten
certain cases. Vital tooth bleaching is a popular discolored teeth and has been practiced indentistry for
treatmentmodality in dentistry[1]. There are a number many centuries. There are a number ofmethods and
ofmethods and approaches avai lable for vital approaches that have been describedin the literature for the
teethbleaching utilizing different bleach agents, bleaching of vital teeth. Forexamples, methods utilizing
c o n e n t rat i o n s , t i m e o f a p p l i c at i o n , p ro d u c t different bleachagents, concentrations, times of
format,application mode and light activation[2]. application,product format, application mode and
lightactivation[5].The advantage of an in office bleaching over an athome
bleaching technique include dentist control,avoidance of The mechanism by which teeth are whitened byoxidizing
soft tissue exposure and materialingestion, reduced total materials such as hydrogen peroxide andcarbamide
treatment time and greaterpotential for immediate result peroxide are currently not fullyunderstood. Considering the
that may enhancepatient satisfaction and motivation[3]. available literature,evidence points towards the initial
The typical inoffice bleaching regimen involves the diffusion ofperoxide into and through the enamel to reach
Indian Journal of Comprehensive Dental Care 648
theenamel dentine junction and dentine regions[6]. days. Patients were recalled after oneweek and two more
Asperoxide diffuses into the tooth, it produces freeradicals cycles of bleaching were done (fig.7).
and attack the complex ring structure ofstain molecules and Case report 2:oxidize and convert them intomore simple chain structures
A 25-year-old male patient visited our clinic with a complaint thus altering thereflective index of the tooth so that it about his tooth color. He was a healthy patient without any appearslighter[7].systemic medical disorder and was a non-smoker. During
The safety of hydrogenperoxide has been substantiated in examination, it was observed that there was no positional numerous scientific reports . Clinical findings, includinglong- disorder, morphologic malformation, periodontal or term trials and post-treatment monitoringstudies endodontic infections.Shade determination was made using demonstrate that vital tooth bleaching iswell-tolerated, with a shade guide(Figure 8).mild and transient toothsensitivity representing the most
The decision was made to perform an inoffice bleaching common.treatment to whiten the teeth in a conservative manner and
Case reports- to improve the aesthetics. At the beginning the patient was
Case repot 1 informed about the benefits and potential risks and
complications of the bleaching treatment. Also, the A patients aged 22 yearscame tothedepatment of interactions and possible positive (effectiveness and short Conservative and Endodontics,Genesis Institute of Dental application time) or negative (possible hypersensitivity due Sciences and Research,Ferozepurwith the chief complain of to the bleaching treatment, chemical irritations on the tissue discoloured teeth. During examination, it was observed that surfaces due to possible contact of the bleaching gel to patient had generalizedfluorosis stains with no tooth loss, mucosa) outcomes were explained to the patient in positional disorder, morphologic malformation, periodontal understandable terms.Firstly, the superficial stains on the or endodontic infection or persistent structural staining at teeth were removed by using pumice (Figure 9). the anterior region (Figure 1). The decision was made to
perform an in office bleaching treatment to whiten the teeth A bleaching gel (opalescence boost, Ultradent products
in a conservative manner and to improve the aesthetics GmbH, Germany) with 35% H O content was selected for this 2 2
treatment.Dry teeth and apply Gingival Barrier to both After all the relevant explanations,options, limitations and arches, slightly overlapping enamel and interproximal prognosis were discussed with the patients. A preoperative spaces. Light cure in a fanning motion for 10-20 seconds until photograph with the shade tab was taken under standarized Gingival Barrier is cured.(Figure 10). The two components of lightingthe bleaching gel were mixed as described by the
Conditions (fig 2). Oral prophylaxis was done to manufacturer using the system component syringes (Figure removeextrinsic stains. (fig 3) 11). The mixture was applied onto the teeth at a thickness of
about 1 mm according to the manufacturers' instructions.Patient's oral mucosa wasprotected by application of
Vaseline to prevent anyirritation due to the bleaching agent. The gel application and irradiation cycle was performed Teeth wereisolated with liquid rubber dam and light cured three times during the treatment process. After the (fig 4). Lipand check retractor was placed in position. treatment, the bleaching gel was suctioned and washed Bleaching agent (Pola office+, SDI Limited, Victoria, Australia) away. The final shade determination was made using the was mixed according tomanufacturer recommendations and same shade guide and the final shade of the teeth was applied on the surface of stained teeth (fig.5). Teeth were identified as A1 (Figure 12). The patient was happy about the irradiated with the Er:YAG laser (Phillips zoomlight) (fig.6) for final color and the teeth were not sensitive during or after the eight minutes (as directed by manufacturer). Patients were procedure. The gum protection gel was removed and the asked to report any sensitivity by raising their hand. After the patient was advised to avoid foods with colorants.cycle of eight minutes was completed, bleaching agent was
Discussion-removed with a damp cotton pellet and fresh lymixed
bleaching agent was reapplied. Same cycle was repeated for The exact mechanism behind tooth bleaching isunclear,
three more times, lastly surface of teeth were rinsed and however, it is generally believed that freeradicals produced
dried. by H O may be responsible for bleaching effects[8]. H O 2 2 2 2
Areas of damage were washed copiously diffuses through the enamel and dentin, producing free with water. Patients were asked to avoid food or beverages radicals that react with pigment molecules breaking their that can cause staining of teeth and to avoid habits likes double bonds .The change in pigment molecule moking. Patients were prescribed fluoride mouthwash for 15 configurationand/or size may result in changes in their
Mouth was checked for any irritations from the
bleaching agent.
Indian Journal of Comprehensive Dental Care 649
opticalproperties, and consequently, the perception of andcould be lessened by reducing the duration of
alighter color by human eyes[9].The rate of chemical lightirradiation, increasing the thickness of appliedwhitening
reactions can be increased byincreasing the temperature, agent or increasing the absorption oflight by the beach
Different types ofenergy can be used in this procedure, with thereby increasing thetransmission of light energy through
the mostcommon being halogen, LED, or plasma arc. Use of the tooth[13].
UV light is dangerous to eyes and skin[10]. The idealsource of A number of factors, relating to the patient (e.g. ageand energy should be high energy to excite theperoxide initial tooth color), the bleaching material used(e.g. type of molecules without overheating the pulp ofthe tooth. Lights peroxide compound, peroxideconcentration, other are typically within the blue lightspectrum as this has been ingredients), and applicationmethod (e.g. contact time, found to contain the mosteffective wavelengths for initiating application frequency,enamel prophylaxis prior to bleaching the hydrogenperoxide reaction.The light source can activate treatment,activation method), may contribute to the peroxide to acceleratethe chemical redox reactions of the bleachingefficacy and the subsequent stability of bleachingprocess[11]. In addition, it has been speculated thebleaching achieved[14].The type of intrinsic stain and the thatthe light source can energise the tooth stain to aidthe initial toothcolour can play a significant part in the overall acceleration of the bleaching process[12].Successful u l t imateoutcome of tooth b leaching. Mi ld to vital bleaching requiregood whitening effect without moderatetetracycline staining tends to respond to extended excessive heating ofthe tooth. Theoretically, the pulpal bleaching regimes. However, it is documentedthat severe temperatureincrease is associated with light application tetracycline staining is more difficult tobleach[15].
Figure 1Preoperative
Figure 2Shade Evaluation
Figure 3Pumice Application
Figure 5Bleaching Gel Applied
Figure 6Laser Application
Figure 7Postoperative
Figure 4Gingival Barrier
Figure 8Preoperative
Figure 9Pumice Application
Figure 10Gingival Barrier Application
Figure 11Bleaching Gel Applied
Figure 12Postoperative
Indian Journal of Comprehensive Dental Care 650
The safety of 35% hydrogen peroxide for power bleaching has 7. Nathoo S, Stewart B, Petrone ME, ChaknisP,Zhang YP, De
been extensively researched in a recent study which VizioW,et al.(2003). Comparativeclinical investigation of
investigated the abrasion, erosion, hardness and structural the tooth whiteningefficacy of two tooth whitening gels.
changes on both enamel and dentine; the conclusion of the Journalof Clinical Dentistry 2003, 14, 64–9.
study was that 35% HP had no deleterious effects on either 8. Sulieman M, Addy M, MacDonal E, Rees JS.(2004). The enamel or dentine . effect of hydrogen peroxide concentration onthe
Mild to moderate, transient tooth sensitivity oftenoccurs outcome of tooth whitening: an in vitrostudy.Journal of
during the early stages of treatment andusually persists for 2- Dentistry, 32,295–9.
3 days. It has beensuggested as an indication of possible pulp 9. Sun, G.(2000). “The role of lasers in cosmeticdentistry”, alinflammation. Topical fluoride application and Dental Clinics of North America 44(4),831–850.desensitizing toothpastes or mouthwashes may be
10. Reyto, R.(1998).“Laser tooth whitening,” Dent ClinNorth prescribed to alleviate the symptoms[16]. Am 42, 755–762.
Conclusion:11. Kwon, Y.H., Huo, M.S., Kim, K.H., Kim, S.K. andKim,
For better effect of bleaching more than one visit would be Y.J.(2002).“Effects of hydrogen peroxide on thelight required, the results vary from patient to patient. For many, reflectance and morphology of bovineenamel,” Journal one visit would be enough to satisfy the aesthetic needs of of Oral Rehabilitation, 29(5), 473- 477.the patients and a second visit wouldn't be necessary.In
12. Jelinkova H, Dostalova T, Nemec M, SulcJ,Koranda P, office techniques with easier and simpler isolation methods HousovaD, et al.(2004).Laser radiation tooth and improved bleaching gels and improved whitening lights bleaching.Laser Physics Letters,1,617–20. have made bleaching results very efficient
13. Tavares, M., Stultz, J., Newman, M., Smith, V.,Kent, R., References –Carpino, E. and Goodson, J.M.(2003). “Lightaugments
1. Goldstein RE, Garber DA.(1995). Complete dental tooth whitening with peroxide,” JAm Dent Assoc 134(2), bleaching.Chicago: Quintessence Publishing Co. 167–175.
2. Greenwall L. (2001). Bleaching techniques inrestorative 14. Zalkind M, Arwaz JR, Goldman A, Rotstein dentistry—an illustrated guide. London: Martin Dunitz I.(1996).Surface morphology changes in humanenamel, Ltd. dentin and cementumfollowingbleaching, a scanning
3. Sulieman M. (2004).An overview of bleaching electron microscopystudy.Endodontics and Dental
techniques.1. History, chemistry, safety and Legal Traumatology, 12, 82–8.
aspects: Dental Updates ,31,608–16. 15. Titley K, Torneck CD, Smith D.(1988).The effect
4. Hannig C, Zech R, Henze E, Dorr-Tolui R, AttinT.(2003). ofconcentrated hydrogen peroxide solutions onthe
Determination of peroxides in saliva—kinetics of surface morphology of human toothenamel. Journal of
peroxide releaseintosaliva during home-bleaching Endodontics. 14, 69–74.
withWhitestrips and Vivastyle. Archives of OralBiology, 16 Sulieman M, Addy M, Macdonald E, Rees JS.(2004). As 48,559–66. afety study in vitro for the effects of an inofficebleaching
5. Joiner A, Thakker G.(2004) In vitro evaluation of anovel system on the integrity of enamel and dentine.Journal
6% hydrogen peroxide tooth whiteningproduct.Journal of Dentistry, 32,581–90.
of Dentistry,32(Suppl.1),19–25.
6. Kihn PW, Barnes DM, Romberg E, Peterson K. (2000).A
clinical evaluation of 10 percent vs 15percent carbamide
peroxide tooth-whiteningagents.Journal of the
American Dental Association, 131, 1478–84.
RESTORING ESTHETICS WITH MAGNET
RETAINED CHEEK PLUMPERS
Abstract
Since the mouth is one of the focal points of the face, it comes as no surprise
that esthetic of face plays a major role in how we perceive ourselves in society.
The whole face needs to be considered in totality when trying to work on dental
esthetics because the final picture should be a merger wherein the various
features of the face, smile, teeth, cheek and gums complement each other
naturally and completely. But due to ageing, edentulism cause many
consequences which includes sunken appearance of cheeks and lips. It has a
greater impact on esthetics as well as on psychology of the individual. This
clinical report make a focus on technique for fabrication of an intraoral
detachable magnet retained cheek plumpers using stainless steel coated close
field magnets. This technique of using detachable magnet retained cheek
plumping appliance is a modification from conventional technique. This
plumper's act by supporting the slumped tissue and also aid in improving
aesthetic.Esthetics plays an important role in complete denture treatment. In
this case report magnet retained cheek plumpers have helped us to attain this
goal. Thus patient's esthetics was improved along with providing function and
making him socially more acceptable and confident.
Keywords: sunken cheeks, cheek lifting appliance, magnet retained cheek
plumpers, improved aesthetics
651
Corresponding author:Name: Dr. Sumant SaojiPost Graduate Resident (Prosthodontics Crown Bridge and Implantology) Peoples College of Dental Sciences & Research Centre, Bhopal, India.
1. Post Graduate Resident (Prosthodontics Crown Bridge and Implantology) Peoples College of Dental Sciences & Research Centre, Bhopal, India.
2. Professor & Head Department of Prosthodontics Crown Bridge and Implantology. Peoples College of Dental Sciences & Research Centre, Bhopal, India
3. Professor Prosthodontics Crown Bridge and Implantology, Peoples College of Dental Sciences & Research Centre, Bhopal, India.
4. Reader (Prosthodontics Crown Bridge and Implantology) Professor, Peoples College of Dental Sciences & Research Centre, Bhopal, India.
Indian Journal of Comprehensive Dental Care
I J C D C1. Sumant Saoji
2. Surendra Agrawal
3. Anjali Bhoyar
4. Swapnil Parlani
Date of Submission : 22/12/14 Date of Acceptance : 16/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Introduction needed to improve the appearance of the patient. This
plumpers reduces the sagging of cheeks and improve In modern era esthetics have much more importance in muscle tone.person's professional and social life. Eyes, nose, cheeks, lips
and facial musculature due to their extreme visibility are an Cheek plumper is also known as the cheek lifting appliance.
important factor in determining facial esthetics. Slumping, It is basically prosthesis for supporting and lifting the cheek
sagging or hollowing of cheeks can increase person's age in that provide required support and esthetic that will increase
appearance and hence have a negative psychological effect the self confidence of the patient. A conventional cheek
on the patient. plumper is single unit prosthesis with extensions on either
side in the region of the polished buccal surfaces of the Lips and cheeks get support from the natural dentition and denture and are continuous with the rest of the denture.dental ridges or dentures which maintain the external form
of the lips and cheeks. Due to edentulism or facial deformity Limitations of single unit design are:
the lips and cheeks were remain unsupported. It weakens It causes muscle fatigue. Increased weight hampers the muscles and hampers their function. It leads to wrinkling retention of the maxillary denture. It is difficult to insert the of skin and sagging of lips and cheeks. In many cases support denture in patients with limited mouth opening. Muscle provided by denture flanges to circum oral muscles is not movements destabilize the maxillary denture. Plumpers sufficient so adequate support by cheek lifting appliance is
Indian Journal of Comprehensive Dental Care 652
Figure 2 Maxillary And Mandibular Final ImpressionsFigure 1 Preprosthetic View
Figure 3 Male Part Of Magnet On
The Maxillary Trail Denture
Figure 4 Impressions Of The Tissue Surface
Of The Magnet Retained Cheek Plumper
Figure 5 Attached Magnet Retained
Cheek Plumper Before Acrylization
Figure 6 Wax Pattern Of Dettachable
Cheek Plumber
Figure 7 Magnet Retained Cheek
Plumber In Position: Intraoral
Figure 8 Magnet Retained Cheek
Plumber In Position: Extraoral
Figure 9 .1
Pre Operative
Complete Denture
Figure 9.2
Complete Denture Without
Cheek Plumpers
Figure 9.3
Complete Denture With
Cheek Plumpers
Indian Journal of Comprehensive Dental Care 653
interfere with the action of masseter muscle and coronoid in the disto-superior aspect of the maxillary buccal flanges
process of the mandible. right and left side respectively. The cotton rolls acted as
template for further modeling wax addition to the sectional To overcome these problems denture with detachable form magnet retained wax cheek plumpers. Clinical magnets being of cheek plumper are preferred.beyond the affordability of the patient, a decision was made
Property of detachment and reattachment provide some to use stereo/radio magnets that are known for their merits like prevention of muscle fatigue, easy insertion in powerful magnetic attraction. The chances of corrosion and limited mouth opening patients thus increasing efficiency of loss of magnetic properties were explained to the patient. denture. Magnets were then placed into each of the hollowed buccal
extension on the right and left side approximately in the Case report cervical region of molars and male part of magnet was
A seventy two year old completely edentulous male patient attached [Figure 3]. The maxillary and mandibular trial
reported to the Department of Prosthodontics with the chief dentures were waxed up, flasked and dewaxed. Heat cure
complaint ill-fitting dentures and very poor esthetics. His acrylic resin was packed by taking care not to dislodge the
prior concern for the denture was functional purpose. It was magnets. Final finishing polishing and laboratory remounting
noticed that the patient was socially demoralized and was done.At the next appointment wax cheek plumper with
unhappy due to esthetic problems of sunken and sagging the female magnets was adjusted according to the desired
cheeks. History revealed that the patient was edentulous for cheek fullness & impression of tissues surface was taken with
the past ten years and was wearing complete denture light body [Figure 4]. Attached cheek plumpers [figure 5] and
prosthesis since then. The general health status of the wax pattern of detached plumpers [Figure 6] before
patient was quite satisfactory without significant history of acrylization shown in fig. Cheek plumpers were processed
systemic disorders. separately with high strength heat cure resin. Final finished
Extra oral examination revels poor esthetics, unsupported polished denture and the cheek plumper were inserted and oral musculature, sunken and slumped cheeks [Figure 1]. any adjustments required were done by slightly re-There were gliding movements in TMJ that prevented contouring the cheek plumper and refinishing was done mandible in proper opening and closing. Intra oral [Figure 7]. examination showed low well rounded ridge in maxillary arch
The patient was given routine post-insertion instructions and and uneven mandibular ridge. Inter arch space was sufficient
was motivated to make efforts to learn to adapt to the new with average mouth opening. The old existing dentures had
dentures and the magnet retained cheek plumper. Within a compromised retention and stability due to under extended
week, the patient expressed satisfaction in mastication and borders with severe occlusal wear. The patient needed
phonetics and his esthetic dilemma was reduced with use of complete denture and original form of cheeks which suited
detachable magnet retained cheek plumper [Figure 8].his face. Based on patient's needs a treatment plan was
Discussion formulated. Therefore, new complete denture was planned
with magnet retained cheek plumpers to provide adequate We greet the world with our faces. The face is the most visible support on both side of the cheeks to lift the sunken cheeks part of human anatomy, and it is the face which helps to to enhance facial esthetics and appearance. The ridges were determine our social acceptance. Facial appearance is of resorbed which precluded the use of conventional cheek great concern to everyone, for it is a significant part of the self plumper as the weight of the prosthesis would result in loss image. Denture esthetics have advanced ahead than mere of retention and stability of the maxillary denture with buccal selection of teeth on the factors of form, shape, color, extension to support the cheeks. The new design was to arrangement and sex, it is more of harmonization of artificial support the cheeks as well as not add to the weight of the with natural. Teeth loss in posterior region results in loss of prosthesis and prevent the insertion and removal of the support to cheeks, which tend to move medially to meet prosthesis. laterally expanding tongue. Cheek contour change as a result
of loss of vertical dimension of occlusion due to anterior All the conventional steps of complete denture fabrication teeth loss. Loss of subcutaneous fat, buccal pad of fat and were completed [Figure 2]. The occlusal scheme was decided elasticity of connective tissue produce the slumped cheeks, keeping in mind deviated movement of TMJ. Hence non seen in aged.anatomic teeth were used to decrease and transfer harmful
stresses to the resorbed mandibular ridge. At the try in Corrections of slumping of cheeks can be accomplished by appointment treatment modality for the loss of buccal pad of various methods like reconstructive plastic surgery, injecting fat in the cheek region was decided. Cotton rolls were placed the botulinum toxin (BOTOX) in the facial muscles and
Indian Journal of Comprehensive Dental Care 654
different types of prosthesis. The plastic surgery is a REFERENCES
traumatic procedure which leaves behind the post-surgical 1. Riley MA, Walmsley AD, Harris IR. Magnets in prosthetic scar, sometimes contra-indicated in old patients suffering dentistry. J Prosthet Dent 2001 :86:137–42 from systemic diseases. The conventional cheek plumper has
2. Verma N, Chitre V, Aras M . Enhancing appearance in the major problem of retention and stability of maxillary complete dentures using magnet retained cheek denture due increased size and weight of the denture. It can plumpers. J Indian Prostho Soc 2004:35-8. also lead to muscle fatigue due to continuous use. Magnet
has generated great interest within dentistry and their 3 Riley M, Williams A, Speight J, Walmsley A, Harris I. application are numerous. The reasons for their popularity Investigations into the failure of dental magnets. The are related to their small size and strong attractive forces. International journal of prosthodontics. 1999;12:249-Despite their advantage, magnets have poor corrosive 52.resistance within oral fluids and therefore require
4. Mukohyama H, Kadota C, Ohyama T, Ta-niguchi H. Lip encapsulation with relatively inert alloy such as stainless
plumper prosthesis for a patient with a marginal steel or titanium. In this case, stainless steel was used instead
mandibulectomy: a clinical report. J Prosthet Dent. 2004 of clinical magnets due to affordability of the patient. To
Jul;9:23-6.combat the major demerits of the conventional cheek
5. Bains JW, Elia JP. The role of facial skelet-al augmentation plumper this innovative intraoral detachable magnet and dental restoration in fa-cial rejuvenation. Aesthetic retained cheek plumper provides multiple advantages Plast Surg. 1994including smaller size, easy to insert in two separate portions,
easily detachable providing patient the allowance of its use
which in turn reduces the chances of muscle fatigue and
most importantly maintenance of the appliance becomes
easier.
Conclusion
The dentist's ability to understand and recognize the
problems of edentulous patients, to select the proper course
of required treatment and reassure them has proven to be
greatest clinical value. This case report describes a new
prosthetic aid that not only provides esthetics but also
improves the psychological profile of the patient.
No conflict of interest
IRON DEFICIENCY ANEMIA AND ORAL HEALTH PROSPECTIVE – A REVIEW
Abstract
According to the World Health Organization, a normal hemoglobin level for an
adult male is between 13.8 g/dl and for an adult woman is between 12.1 g/dl.
Anemia is not a diagnosis. It is a symptom of some underlying condition or
health even. Anemia is a global public health problem affecting both
developing and developed countries with major consequences for human
health as well as social and economic development. It occurs at all stages of the
life cycle, but is more prevalent in pregnant women and young children. Of
significance is the fact that India is among the countries with highest
prevalence of anemia in the world. As such, the country accounts for the largest
number of anemic persons in the world. Overall India contributes to about 50%
of global maternal deaths due to anemia. The present review is an attempt to
provide an overview of etiology, signs and symptoms of various types of
anemias with emphasis on the oral manifestations, and their influence on the
treatment plan of the dental health professional.
Keywords:- Anemia, Oral Health, Iron Deficiency, Oral Manifestations
655
Corresponding author:Name: Dr. Gaurav GoyalSr. lecturer, Department of Oral Medicine and Radiology, Genesis Institute Of Dental Sciences and Research, Ferozepur, Punjab, India E-mail dr.gaurav867@gmail.com
1. Sr. lecturer, Department of Oral Medicine and Radiology, Genesis Institute Of Dental Sciences and Research, Ferozepur, Punjab, India
2. Prof and Head, Department of Oral Medicine and Radiology, Genesis Institute Of Dental Sciences and Research, Ferozepur, Punjab, India
3. Reader , Department of Oral Medicine and Radiology, Genesis Institute Of Dental Sciences and Research, Ferozepur, Punjab, India
4. Sr. lecturer, Department of Oral Medicine and Radiology, Genesis Institute Of Dental Sciences and Research, Ferozepur, Punjab, India
5. BDS,Sri Guru Ram Das Institute of Dental Sciences and Research Amritsar, Punjab, India
Indian Journal of Comprehensive Dental Care
I J C D C1. Navpreet Kaur
2. Gaurav Goyal
3. Sarfaraz Padda
4. Bhawandeep Kaur
5. Sunidhi
Date of Submission : 22/12/14 Date of Acceptance : 19/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Introduction the maternal deaths are attributed to anemia during 3pregnancy. Iron deficiency anemia is the most common cause of anemia
in the India and throughout the world. This form of anemia Prevalence of Iron Deficiency Anemia in South Asia (%)
develops when the amount of iron available to the body In India, the prevalence of anemia is high because of
cannot complete the need of iron for the production of red 3Low dietary intake, which is less than 20 mg /day. blood cells. Iron deficiency anemia is a global public health
4problem, as compelling and harmful as the epidemics of Poor bio-availability of iron in Indian diet infectious diseases.
Adolescence is a crucial phase of growth in the life cycle of According to WHO report, 2002, iron deficiency anemia was an individual. Due to rapid growth there is increase in iron considered to be the most important contributing factors to requirement in both adolescent boys and girls. Though the
1the global burden of anemia. exact prevalence has not been determined, at least 75-85%
adolescent girls in India are anemic. According to WHO report, 2009, with a global population of
6,700 million, 2000 million suffer from iron deficiency The rates of low birth weight, prematurity, neonatal and anemia. Children and women in reproductive ages are more infant mortality among children born to undernourished
2at risk factor for developing iron deficiency anemia. adolescent women is high. In order to prevent high maternal
mortality and high incidence of low birth weight children in According to Maternal Mortality in India, 2008, 20% of all
Indian Journal of Comprehensive Dental Care 656
Table No. 1
Country children < 5yrs Women 15 -49 yrs
Pregnant women
Maternal deaths from anemia/yr
Afghanistan 65 61 - -
Bangladesh 55 36 74 2800 Bhutan 81 55 68 < 100
INDIA 75 51 87 22000
Nepal 65 62 63 760
Pakistan 56 59 - -
World total 50,000
Table no. 2 : Diagnosis of Iron Deficiency Anemia
Table No. 3 Characteristics of anemia associated with other disorders
Reduced haemoglobin Men <13.5 g/dl, women < 11.5 g/dl
Reduced MCV < 76 femtoliters (76–95 femtoliters)
Reduced MCH 29.5 ± 2.5 pg (27.0–32.0 pg)
Reduced MCHC 32.5 ± 2.5 g/dl (32.0–36.0 g/dl)
Blood film Microcytic hypochromic red cells
Reduced serum ferritin Men <10 µg/L, premenopausal women <5 µg/L
postmenopausal women <10 µg/L
Elevated percentage of hypochromic red cells
> 2%
Iron defi ciency
Chronic disorders Thalassaemia trait (α or β)
Degree of anaemia Any Seldom < 9.0 g/dl Mild
MCV
Serum ferritin N
sTfR N
Marrow iron Absent Present Present
Indian Journal of Comprehensive Dental Care 657
Once absorbed from the bowel, iron is transported across the
mucosal cell to the blood, where it is carried by the protein
transferrin to develop red blood cells in the bone marrow.
Iron stores ferritin. Ferritin is a labile and readily accessible
source of iron. In a day, about 1·mg of iron is excreted from
the body in urine, feces and sweat. Menstrual losses
accounts to an additional 20·mg per month. In pregnancy,
the increased requirement of iron of around 500–1000·mg
per month, contribute to the higher incidence of iron 7,8deficiency in women of reproductive age.
Risk Factors of Iron Deficiency Anemia
1. Age: Adolescents, postmenopausal womenIndia, there is a need to combat anemia during adolescence.
3 2. Sex: Increased risk in womenThis is the motive behind the 12 by 12 initiative by WHO.
3 3. Reproduction: Menorrhagia12 By 12 Initiative
4. Renal: HaematuriaA multi-pronged 12 × 12 initiative has been launched in the
country for addressing the problem of anemia. The target 5. Gastrointestinal tract: Appetite or weight changes, groups are the adolescents across the country. The aim is to changes in bowel habits, bleeding from rectum, achieve hemoglobin level of 12 gm% by the age of 12 years by melaena, gastric or bowel surgery2012. The initiative comprises of health and nutrition
6. Drug history: Aspirin and non-steroidal anti-education, weekly supplementation with iron folic acid
inflammatory drugstablet, parasite control through periodic de-worming and
7. Social history: Diet, especially vegetariansappropriate immunization along with measures for capacity
building. This initiative has been launched with the support 8. Physiological: Pregnancy, infancy, adolescence, of the Government of India, the Indian Council of Medical breastfeedingResearch, World Health Organization, UNICEF, Federation of
Clinical Features of Iron Deficiency AnemiaObstetrics and Gynecological Societies of India and other
Iron in hemoglobin binds with oxygen and carries it professional bodies.throughout the body to vital organs. When there is
Causes:inadequate iron, there is inadequate oxygen. Oxygen-
Iron deficiency anemia develops under 4 conditions. deprived organs cannot function properly and may even fail if 9deprived of oxygen rich blood for a prolonged length of time.1. Excessive blood loss.
Headache, dizziness, drowsiness, shortness of breath, and 2. Increased demands for red blood cells.syncope occur when too little oxygen is available to the heart
3. Decreased intake of iron.and the brain. This lack of oxygen can also cause tachycardia
94. Decreased absorption of iron. and chest pain.4,5,6Iron Metabolism Fatigue and weakness is a common experience for people
with iron deficiency anemia. Weakness is due to the body Iron has a pivotal role in many metabolic processes. The straining to acquire more oxygen and muscles being stressed average adult contains 3–5 grams of iron, of which two-thirds to function without sufficient blood flow. Then they become is in the oxygen carrying molecule hemoglobin. A normal diet progressively weaker and eventually may begin to spasm. provides about 15·mg of iron daily, of which 5–10% is Twitching, flinching, or an uncontrollable urge to move the absorbed, mainly in the duodenum and upper jejunum. The legs, a condition called as Restless Legs Syndrome, are acidic conditions help the absorption of iron in the ferrous common symptoms of iron deficiency anemia. Restless legs form. Absorption is helped by the presence of other reducing syndrome is a prevalent disorder affecting between 5 to 15 substances, such as hydrochloric acid and ascorbic acid. The percent of the adult population.body has the capacity to increase its iron absorption in the
face of increased demand, for example, in pregnancy, Pallor or pale skin is often observed in a person with anemia. lactation, growth spurts and iron deficiency. The person may have a ghostly pale appearance. The areas
that will be pale include the conjunctiva, cheeks, tongue,
Indian Journal of Comprehensive Dental Care 658
fingernail beds, and the palms of the hands. Paleness occurs capacity, i.e TIBC, were used in the diagnosis of iron
as the body diverts oxygen-rich blood from less vital areas to deficiency anemia.
the heart, lungs, and brain Serum Ferritin Level - Haematinic assays demonstrate
On examination, skin, nail and other epithelial changes may reduced serum ferritin concentration in straight forward iron
be seen in chronic iron deficiency. Atrophy of the skin occurs deficiency. As an acute phase, however, the serum ferritin
in about one third of patients and nail changes such as spoon- concentration may be normal or even raised in inflammatory 10shaped nails. This is known as koilonychia, which may result or malignant disease.
in brittle, flattened nails. A prime example of this is found in rheumatoid disease, in
Although uncommon, oesophageal and pharyngeal webs can which the active disease may result in a spuriously raised
also be a feature of iron deficiency anemia. serum ferritin concentration masking an underlying iron
deficiency caused by gastrointestinal bleeding after non-Pica, or the desire to eat nonfood items such as glue, hair, steroidal analgesic treatment. In cases where ferritin paint, clay, or dirt, is a symptom of iron deficiency that can be estimation is likely to be misleading, the soluble transferrin seen in any age. Pica is most often seen in children.
11receptor (sTfR) assay may aid the diagnosis. Transferrin Oral Manifestations receptors are found on the surface of red cells in greater
numbers in iron deficiency. Unlike serum ferritin, the level of Oral manifestations of iron deficiency anemia includes
sTfR does not rise in inflammatory disorders, and hence can angular chelitis, atrophic glossitis or generalized oral mucosal
help to differentiate between the anemia due to atrophy. The glossitis has been described as a diffuse or 10inflammation and iron deficiency.patchy atrophy of dorsal tongue papillae, giving a smooth,
glazed appearance of the tongue. This is often accompanied Bone Marrow Samplingby tenderness or a burning sensation.
Bone marrow aspirate may be carried out to demonstrate Some investigators have suggested that iron deficiency absent bone marrow stores. predisposes the patient to candidal infection, which results in
Effective management of iron deficiency relies on:changes seen at the corners of the mouth and on tongue.
(i) Appropriate management of the underlying cause, for Lactoferrin is a protein contained in body fluids such as saliva, example, gastrointestinal or menstrual blood loss tears, and vaginal secretions. Lactoferrin provides a defense
function because it binds with iron and withholds the iron (ii) Iron replacement therapy.
from pathogens such as Candida. When lactoferrin levels are Oral iron replacement therapy, with gradual replenishment
low, Candida can proliferate on the free iron. This is one of the of iron stores and restoration of hemoglobin, is the preferred
reasons for the soreness of the tongue.treatment.
8Laboratory InvestigationsOral ferrous salts are the treatment of choice and usually take
A full blood count and film should be assessed. These will the form of ferrous sulphate 200·mg three times daily.
confirm the anemia. Recognizing the indices of iron Alternative preparations include ferrous gluconate and
deficiency are usually straightforward. The following findings ferrous fumarate. All three compounds, however, are
are seen: associated with a high incidence of side effects, including
nausea, constipation and diarrhoea. These side effects may · Reduced haemoglobin concentrationbe reduced by taking the tablets after meals. Modified
· Reduced mean cell volume release preparations have been developed to reduce side
effects, but in practice these prove expensive and often · Reduced mean cell haemoglobin 9,11 release the iron beyond the sites of optimal absorption.
· Reduced mean cell haemoglobin concentration. Effective iron replacement therapy should result in a rise in
Some modern analyzers determine the percentage of haemoglobin concentration of around 0.1·gram per deciliter. hypochromic red cells. The blood film shows microcytic But this varies from patient to patient. Once the hemoglobin hypochromic red cells. Hypochromic anemia occurs in other concentration is within the normal range, iron replacement
11disorders, such as anemia of chronic disorders, sideroblastic should continue for 3·months to replenish the iron stores.anemias and in globin synthesis disorders, such as
Failure to respond to oral iron therapy8thalassaemia.
The main reason for failure to respond to oral iron therapy is To differentiate the type, further haematinic assays may be
poor compliance. However, if the losses, for example, necessary. Historically, serum iron and total iron binding
Indian Journal of Comprehensive Dental Care 659
bleeding, exceed the amount of iron absorbed daily, the health professional for diagnosis and dental management of
haemoglobin concentration will not rise as expected. The patients with anemia. Bleeding disorders may be related to
presence of underlying inflammation or malignancy may also nutritional deficiencies which can lead to failure in normal
lead to poor response to therapy. Occasionally, haemostatic mechanisms. These disorders are usually the
malabsorption of iron, such as that seen in coeliac disease, result of abnormalities of platelets, blood vessels, plasma 9,11may lead to a failure to respond to the therapy. coagulation factor or the fibrinolytic system. These types of
anemia must be detected early and affected patients should Intravenous and Intramuscular Iron Preparations -
be referred promptly to a physician for diagnosis and Parenteral iron may be used when the patient cannot
treatment before invasive dental procedures are performed. tolerate oral supplements, for example, when patients have
severe gastrointestinal side effects or if the losses exceed the In conclusion, it is apparent that a thorough knowledge of
daily amount that can be absorbed orally. Intramuscular iron oral manifestations of anemia becomes important. For this, a
sorbitol injection was used as a parenteral iron replacement detailed history, clinical examination and screening tests play
for many years. Generally, around 10–20 deep intramuscular a vital role in the diagnosis of anemia.
injections were given over 2–3·weeks. However, side effects Hence, since the dental health professional may be the first were common and included pain, skin staining at the site of person to recognize the presence of anemia, his role in the injection and arthralgia. Newer intravenous iron multidisciplinary approach in the diagnosis and management preparations include iron hydroxide sucrose and iron of the various types of anemias cannot be underestimated.
9,11dextran, can be given intramuscularly. Reference
Prevention1) World Health Report (2002): Reducing Risks, Promoting
When absorption from the diet is likely to be matched or Healthy Life. Geneva: World Health Organization, pp (7-exceeded by losses, extra sources of iron should be 14).considered. Examples include prophylactic iron supplements
2) World Health Report (2009): Reducing Risks, Promoting in pregnancy or after gastrectomy, or encouragement of Healthy Life. Geneva: World Health Organization, pp breastfeeding.(20-54).
Dental Consideration3) Suneeta Mittal (2007). 12 by 12 initiative. WHO-CCR in
Dental patients presenting with symptoms of anemia or oral Human Reproduction.signs suggestive of this condition should have a complete
4) Provan D. Mechanisms and management of iron blood count, including differential blood count. If deficiency anemia (1999). British Journal of significantly lowered hemoglobin values are obtained, the Haematology; 105(Suppl 1): 19–26.patient should be referred to his or her physician for a more
thorough medical history, laboratory diagnosis, and 5) DeMaeyer E, Adiels-Tegman M. The prevalence of 12,13treatment. anaemia in the world (1985). World Health Statistics
Quarterly; 38: 302–16.Elective oral surgical or periodontal procedures should not
be performed on patients with marked anemia because of 6) Demir A, Yarali N, Fisgin T. Serum transferrin receptor
the potential for increased bleeding and impaired wound levels in beta-thalassemia trait (2004). Journal of
healing. When hemoglobin levels fall below 10 g/dL, the low Tropical Pediatrics; 50: 369 - 71.
oxygen tension affects the rheologic interactions between 7) Lozoff B, De Andraca I, Castillo M et al (2003).
the cellular components of blood, mainly platelets and Behavioral and developmental effects of preventing
12,13 endothelium, decreasing their ability to clot effectively. iron deficiency anemia in healthy full-term infants.
General anesthesia should not be administered unless the Pediatrics; 112: 846–54.
hemoglobin is at least 10 g/dL. The patient should never be 8) McIntyre AS, Long RG (1993). Prospective survey of treated with iron until the cause of the microcytic
investigations in outpatients referred with iron hypochromic anemia is found and corrected or until a deficiency anemia. Gut; 34: 1102–7.thorough search for the cause has proved unsuccessful.
9) Provan D. Mechanisms and management of iron Conclusiondeficiency anemia (1999). British Journal of
Various blood disorders, ranging from anemias to Haematology. 105(Suppl 1): 19–26.
malignancies, can have oral manifestations. Several types of 10) Punnonen K, Irjala K, Rajamaki A. Serum transferrin anemia present very characteristic oral, clinical and
receptor and its ratio to serum ferritin in the diagnosis radiological features. This signifies the role of the dental
Indian Journal of Comprehensive Dental Care 660
of iron deficiency (1997). Blood 89:1052–7. “Textbook of Oral Medicine, Diagnosis and Treatment”. th11 Edition : Hamilton, Ontrio11) Provan. Iron Deficiency Anaemia. ABC of Clinical
Haematology.2005
12) William Burket, ?Martin S. Greenberg. Burket's (2003).
“Textbook of Oral Medicine, Diagnosis and Treatment”. th10 Edition : Hamilton, Ontrio.
13) William Burket, ?Martin S. Greenberg. Burket's (2008).
VIRTUAL ARTICULATORS IN PROSTHODONTICS
Abstract
The future of dentistry is linked strongly to the use of computer technology
specifically virtual reality, which allows the dental surgeon to simulate true life
situations in patients. Virtual reality technologies in dentistry will be used to
provide better education and training by simulating complex contexts and
enhancing procedures that are traditionally limited, such as work with the
mechanical articulator. The virtual articulator has been designed for the
exhaustive analysis of static and dynamic occlusion. This tool incorporates
virtual reality applications into the world of dental practice with the purpose of
replacing mechanical articulators and thereby avoiding the errors and
limitations of the latter.
Key words
Virtual articulators, Dynamic occlusion, Jaw Motion Analyzer.
661
Corresponding author:Name: Dr. Kavipal SinghAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar(M) +9814417246Email: dr_kavipalsingh@yahoo.com
1. Professor and Head of Department of Prosthodontics and Crown & Bridge, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
2. Professor, Department of Prosthodontics and Crown & Bridge, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
3. Postgraduate student, Department of Prosthodontics and Crown & Bridge, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar
Indian Journal of Comprehensive Dental Care
I J C D C1. Kavipal Singh
2. Kamleshwar Kaur
3. Geetika Chawla
Date of Submission : 3/12/14 Date of Acceptance : 14/2/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Introduction reducing the limitations of mechanical articulators, due to a
series of advantages: full analysis of static and dynamic Virtual technologies in dentistry will be used to provide occlusion, of the inter-maxillary relationships, and the joint better education and training by simulating complex conditions, the possibility of selecting section planes which contexts and enhancing procedures that are traditionally
1 allowslimited, such as work with mechanical articulator . Virtual
articulators also known as “software articulators” are not detailed observation of regions of interest and great
concrete but exist only as a computer program. These potential in planning dental
articulators overcome many limitations associated with implants, since it affords greater precision and a lesser mechanical articulators such as simulation of mobility of duration of treatment.teeth which is not possible using plaster casts, simulation of
In addition,CAD/CAM techniques or tools for a virtual set up complex movement patterns of mandible which are of teeth could be linked and the quality of the networking dependent on effects of resilience of soft tissue and communication between dental practice and laboratory is muscles, representation of dynamic occlusion and problems improved. associated with dental materials and technical procedures
such as the deformation of registration material, the Advent of virtual articulators :stability of the articulator, the correct orientation of the cast
Szentpetery's virtual articulator: It was introduced by 2and expansion and contraction of plaster material .
Szentpetery in 1999. It is a mathematically simulated, fully
The virtual articulator offers the possibility of significantly adjustable 3D virtual dental articulator. It offers possibilities
Indian Journal of Comprehensive Dental Care 662
that are not offered by some of the mechanical articulators as animation of the jaw movement and delivers a dynamic and
curved Bennet angle movements which make it more tailored visualization of the collision
versatile but as it is a mathematical approach, if behaves as 6Points (Figure 2) .an average value articulator and so it is not possible to obtain
Virtual articulator based on mechanical dental articulator: easily the individualized movement paths of each patient( It was introduced by graphic design and engineering project Figure 1).developments, the University of the Basque Country in 2009.
Virtual articulator of Kordass and Gartner: Introduced by The main advantage of this approach is that the user can
Kordass and Gartner in 2003, this articulator is based on the 3choose the most suitable articulator to use in the simulation .exact registration of mandibular movement with the help of
Designing, programming and functioning of virtual jaw movement analyzer. This system requires digital 3D articulators : representation of the jaws as input data generates an
Figure 1- Szentpetery's virtual articulator
Figure 3 – Jaw Motion Analyser
Figure 2 – Virtual articulator of Kordass and Gartner
Figure 4- The virtual articulator planning process
Indian Journal of Comprehensive Dental Care 663
The programming and adjustment methods of the virtual trajectories in the sagittal and horizontal planes. This tool
articulator were described by Kordass and Gartner in 1999. allows us to observe the inter relationship between the
First a digital image is obtained of incisal guide and the condylar guide, and the effects of joint
mobility upon occlusion.the surfaces of each tooth, of the global dental arches, and of
the bite registries using a three-dimensional laser scanner. One of the most recent new developments in the virtual
This scanner projects a vertical laser beam onto the surface articulators is the 3D virtual articulation system (Zebris
of the object. A digital camera equipped with a charge company, D-Isny) which requires an input unit in the form of a
coupled device (CCD) registers the beam reflected from the 3D scanner, the software for prosthesis modelling and
object and transmits the digital signals to an electronic collision detection and the output module (a rapid
processing system where the processed image data are prototyping system). With this system, in addition to
stored as digital matrix brightness values, ready for use by the mandibular movement, masticatory movement can also be 3scanner software and for on-screen visualization and analyzed .
4computerized manipulation . Validation of this technology:
Functioning of the virtual articulator : The results of validation were recently presented. Comparing
After the articulator is modelled, the simulation is run and the model situation of a mechanical articulator (KaVo,
any possible interference on the designed prosthesis are Leutkirch, Germany) to the virtual articulator module,
checked out and if they are present corrected accordingly. DentCAM showed approximately the same number of
Ideally, the virtual articulator is equipped with a device for dynamic contacts in lateral movements to the left and right in
registering the specific mandibular movements of a given eight cases (mechanical articulator: 90, virtual articulator:
patient such as the Jaw Motion Analyser system ( Figure 3), 92). The results demonstrate the correspondence under
and can integrate the movements recorded in the animation. standardized conditions in relation to the detected number 6This system is based on measuring the velocity of ultrasonic of contacts in both situations .
impulses emitted from three transmitters attached to the In this same line, Proschel et al carried out a study of 57
lower sensor. Four receivers are attached to a face bow asymptomatic patients in order to determine the occlusal
opposite them. This positioning enables the detection of all errors appearing in the mechanical articulators. To this effect
rotative and translative components in all degrees of comparisons were made with the virtual articulator, yielding
freedom. A special digitizing sensor is used to determine the an error in the second molar of 200 µm in 16% of the patients
reference plane, which is composed of the hinge axis and of 300 µm in 6% of the subjects – this implying a low risk
infraorbital plane and special points of interest (eg: on the of error, though the acceptable limits in clinical practice could
5occlusal surface) . 7be exceeded .
If JMA tool is not available for registering the mandibular Likewise, other studies have compared the maximum
movements, specific movements must be defined by means number of contacts between the conventional method and
of parameters, in a way similar to the practice used with the virtual articulator – the occlusal contacts calculated from
mechanical articulators. After defining the movement the virtual models being shown to precisely reproduce the
parameters, collision detection is required in order to 8contacts obtained with the mechanical articulator .identify the movement restrictions. In these cases, it may be
Future work :of interest to leave a distance corresponding to the thickness
of the occlusion paper used in the mechanical articulators, In future, there is a need to develop a virtual articulator for calculating the points of occlusion on the basis of this software that integrates
6 distance ( Figure 4).the correcting software for CAD/CAM system directly into
Virtual reality dentcam : the process of construction of crowns and bridges. A digital
face-bow transfer is not possible. At present, the face bow To demonstrate virtual tools in dental articulation, the VR has to be mounted on the patient and then brought to the Dentcam was developed at University of Griefswald, dental mechanical articulator. Finally, it is important to Germany. It consists of three main windows, which show the remark that several improvements should be made up when same movement of the teeth from different aspects. The obtaining the patient's data. This is a main shortcoming latest software versions incorporate an orthodontic module which generates difficulties on the next step, this is, the use allowing theof the articulator and the design process. Therefore, a
creation of a virtual setup. The program has also been progress in this sense will bring important improvements on
equipped with the representation of the condylar 6the whole process .
Indian Journal of Comprehensive Dental Care 664
Haptic Based First Touch Enabled Virtual Articulator: References:
SensAble Dental Technologies has developed the newest 1. Virtual articulators in prosthodontics. International version of its Intellifit TE (Touch-Enabled) Digital Restoration journal of dental clinics 2011; 3(4): 39-41.System that offers dental labs even more choice,
2. The virtual articulator. International journal of performance and flexibility in digitally designing and computerized dentistry 2002; 5 : 101-106.fabricating a wide range of dental restorations. Intellifit's
unique 3D 'Virtual Touch' interface and integrated touch- 3. Virtual articulators : changing trends in prosthodontics. enabled articulator allow lab technicians to actually feel how Guident 2013 : 10-16.the teeth – including the new restoration they are producing
4. Virtual articulator for the analysis of dental occlusion : – will fit together in the patient's mouth. Articulators are
an update. Med Oral Patol Oral Cir Bucal 2012; 17 (1): essential to testing the occlusion of almost every type of
160-163.dental restoration and lab technicians have long used them,
as well as their sense of touch, to assess whether a
restoration will allow the patient to function with the correct
amount of contact and excursive movements. Intellifit's 6. Virtual Articulator: A Review Of Functioning And virtual articulator mimics the feel and function of a physical Designing.Indian Journal of Dental Sciences 2014; 6(5) : articulator, yet allows dynamic settings to meet patient 96-98. specifications and freedom of movement in three
7. Predicted incidence of excursive occlusal errors in dimensions. Touch-enabled, virtual articulator allows
common modes of articulator adjustment. Int J technicians to test occlusion of restoration – before it is
Prosthodont 2000;13: 303-310.9produced and enabling them to actually feel the fit .8. The Role of Virtual Articulator in Prosthetic and
Conclusion : Restorative Dentistry. Journal of Clinical and Diagnostic
The VR articulator is undoubtedly more than an entertaining Research 2014 ; 8(7): 25-28.novelty. The virtual articulator is a precise tool for the full
9. htt p : / / w w w. b u s i n e s s w i re . co m / n e ws / h o m e analysis of occlusion in a real patient, and can help the dental
/20110224005406/en/SensableDental-Debuts-professional in establishing a diagnosis and in planning the
Industry%E2%80%99s-Touch –Enabled –Virtual best treatment option. Another remarkable conclusion is the
–Articulator#. U7mUGfmSw20.flexibility and versatility offered by this type of Virtual
Articulator. The add-on modules will change conventional
ways of production and communication in dentistry and
begin to replace the mechanical tools.
5. Virtual prouction of dental prostheses using a dental
virtual articulator. Int J Interact Des Manuf 2014.
DENTAL PULP REGENERATION IN PAEDIATRIC DENTISTRY : ROLE OF STEM CELLS
ABSTRACT
Development in tissue engineering technologies have changed the traditional
knowledge and treatment possibilities with pulp affected immature
permanent teeth in young patients. Stem cells constitute the source of
differentiated cells for the generation of tissues suring development and for
regeneration of tissues that are diseased or injured postnatally. Post natal stem
cells which are capable of self-renewal, proliferation and differentiation into
multiple specialized cell lineages have been isolated and identified. Knowledge
regarding the regeneration abilities is important in exploring new therapeutic
possibilities for improving paediatric endodontic therapy.
Keywords: pulp, dental, regeneration stem cells.
665
Corresponding author:Name:Dr. Gunmeen Sadana, MDS, Professor and Head, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, AmritsarEmail: drgunmeen_sadana@yahoo.in
1. Reader, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar
2. Professor and Head, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar
3. Reader, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar
4. P.G., Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar
Indian Journal of Comprehensive Dental Care
I J C D C1. Rashu Grover
2. Gunmeen Sadana
3. Manjul Mehra
4. Jasmeet Kaur
Date of Submission : 31/11/14 Date of Acceptance : 5/1/15
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
INTRODUCTION is considered. However despite these advances, neither
MTA nor calcium hydroxide are currently able either to In the last decade, tremendous development has occurred 1 induce or stimulate pulp regeneration.
in the fields of regenerative medicine and dentistry. New
protocols for regenerative endodontic treatment along with With the development of new regeneration protocols,
parallel development of tissue engineering technologies discovery of stem cells of dental origin have recently
have changed traditional knowledge and treatment increased the intriguing possibility of using dental stem cells 5possibilities with pulp affected permanent immature teeth for tissue engineering. It has been noted that there is a
in young patients. population of post natal stem cells in human dental pulp.
The most striking feature of dental pulp stem cells (DPSCs) is Irreversible pulpal damage to immature permanent teeth their ability to regenerate a dentin-pulp like complex that is due to noxious infection or local trauma before normal composed of mineralized matrix within the tubules lined physiological closure of the apical structures poses a real
2 with odontoblasts and fibrous tissue containing blood clinical challenge. The completion of root development and
vessels in an arrangement similar to dentin-pulp stem closure of root apex of a permanent tooth occurs upto three
complex found in normal human teeth.3years after tooth eruption. In context to trauma or
The post-natal pulp contains several niches of potential infection, root canal development is interrupted and natural
progenitor/stem cells, which may have importance in apical closure cannot take place. In such situations the
mediating reparative dentine formation. Indeed , standard therapeutic approach to use synthetic
progenitor/stem cell niches are continually being identified biocompatible materials such as calcium hydroxide and MTA
Indian Journal of Comprehensive Dental Care 666
in all connective tissues of the body, where they play a (ii) stem cells from exfoliated deciduous teeth (SHED)
fundamental role in wound repair processes. This subset of (iii) stem cells from apical papilla (SCAP)undifferentiated cells can represent as little as 1% of the total
8,9(iv) periodontal ligament stem cells (PDLSCs).cell population. However, they produce multiple highly
differentiated progeny in response to specific extracellular Among them, all except SHED are from permanent teeth. signals. Central to the niche is the 'true' adult or 'mother' These dental stem cells are considered as mesenchymal stem cell which displays an infrequent, yet almost unlimited stem cells (MSCs) and possess different levels of capacities self renewal. At mitosis, these cells give rise to a renewed to become specific tissue forming cells.DPSCs and SHED are mother stem cell and a daughter transit amplifying from the pulp and SCAP is from the pulp precursor tissue, progenitor cell. These daughter progenitor cells possess a apical papilla. The exact nature location or origin of DPSC more limited capacity for self renewal, but are highly within the pulp is unclear; however they are found proliferative. They also appear to control multi potentiality, consistent with a perivascular niche ( Shi & Gronthos 2003). and are capable of following along several cell lineages to These ex vivo expanded cells can differentiate into ultimately produce terminally differentiated cells such as odontoblast-like cells and produce dentin-like tissue in both osteoblasts, odontoblasts, and, adipocytes, chondrocytes, in vitro and in vivo study systems. When grown in cultures
6and neural cells. and induced under specific conditions, DPSCs and SHED can
differentiate into neuronal and adipogenic cells in addition Tissue regeneration attempts to mimic the events of 10to dentinogenic cells. Studies have shown that SCAP development. Repopulating the open apex with immature
together with PDLSCs are able to form a root-like structure cells capable of being directed towards a specific cell fate and when seeded onto the hydroxyapatite-based scaffold and regenerating natural tissue may provide an alternative
3 implanted in pig jaws. These dental stem cells may treatment in teeth with open apex. The goal of this review potentially be utilized for dental tissue regeneration, i.e., article is to shed light on more recent clinical and molecular pulp/dentin and periodontal ligament. More importantly, advances described in the field of apical regeneration by the identification of these dental stem cells provided us a means of stem cell therapy.better understanding of the biology of pulp and periodontal
STEM CELLS ligament tissues and their regenerative potential after 5A stem cell is defined as a cell that can continuously produce tissue damage.
unaltered daughter cells and furthermore has the ability to Various experiments have been conducted to look for the
generate cells with different and more restricted properties.markers for dental stem cells that can be used in tissue
Stem cell biology has become an important field for the engineering approaches. DPSCs express specific stem cell
understanding of tissue regeneration, although much surface markers, including CD44, CD106, CD146, 3G5, and
knowledge in this area has been from the in vitro studies. In Stro-1, as well as matrix proteins associated with mineral
general, stem cells are defined by having two major tissue formation, such as alkaline phosphates, osteocalcin,
properties: (1) they are capable of self-renewal and (2) when and osteopontin. The periodontal ligament (PDL) displays a
they divide, some daughter cells give rise to cells that similar pattern of cell surface markers, proving that a
eventually become differentiated cells. Depending on the perivascular niche can also be obtained from adult pulp
type of stem cells and their ability and potency to become derived from outside the tooth [Shi et al., 2005; Sloan and
different tissues, the following categories of stem cells have Waddington, 2009]. DPSCs expressing specific cell-cycling
been established—(i) totipotent stem cells: each cell is mediators showed a higher rate of proliferation compared
capable of developing into an entire organism; (ii) to other DPSCs. DPSCs transplanted with the carrier
pluripotent stem cells: cells from embryos (embryonic stem hydroxyapatite/tricalcium phosphate produced a dentin-
cells) that when grown in the right environment in vivo are like structure lined with human odontoblast-like cells and
capable of forming all types of tissues; and (iii) multipotent surrounded by pulp like interstitial tissue that produced a 11stem cells: postnatal stem cells or commonly called adult bone-like tissue.
stem cells that are capable of giving rise to multiple lineages STEM CELLS AND PULP TISSUE REGENERATION
7of cells. Dental stem cells belong to the third category as At the beginning of 1990's , the concept of tissue engineering described below. was first introduced to refer to the biological techniques or
To date, four types of human dental stem cells have been processes to regenerate the living tissues. Three basic
isolated and characterized:biological elements required in dentin and pulp regeneration
2(i) dental pulp stem cells (DPSCs) : cells, a matrix or scaffold and signalling molecules.
Indian Journal of Comprehensive Dental Care 667
Two types of pulp regeneration can be considered based on clinical case of premolar showing periradicular radiolucency
the clinical situations: where canal instrumentation was not used throughout the
duration of the treatment. In summary the authors used only 1. Partial pulp regenerationirrigation with NaOCl and hydrogen peroxide and antibiotic
122. De novo synthesis of pulp. therapy with metronidiazole and ciprofloxacin with
secondary monitoring for thirty five months after finalization Ostby postulated the tissue reorganization in the canal space of the procedures. Complete apex formation and thickening filled with blood clot. It was observed that tissue formed in of the apical dentinal walls were reported a positive response the canal was not pulp but granulation or fibrous tissue and in to pulp vitality test. Banchs and Trope described another some cases the ingrowths of cementum and bone growth.It clinical case where a similar protocol was carried out on has been experimentally shown that apical part of pulp may premolar with periradicular bone damage and a positive remain vital and, after reimplantation, may proliferate
13 response to cold was obtained after 24 months of follow up. coronally, replacing the necrotized portion of pulp.These new but conservative therapeutic techniques have
Human tooth slices(1mm thick) were seeded with opened up to revascularization as an alternative method of
biodegradable scaffolds with SHED and transplanted into 17 treating immature permanent non vital teeth. The immunodeficient mice for 28 days. After this period, the
Regenerative Endodontics Committee of the American space once occupied by the scaffold was fully replaced for a
Association of Endodontists has tried to establish protocols dental pulp like tissue with morphologic characteristic similar
for revascularisation, as the success rates of these 8to a natural human dental pulp. 2,18experiments are important in animals This committee also CLINICAL APPLICATIONS OF STEM CELLS IN PAEDIATRIC supports the development of protocols for human pilot tests
2,19DENTISTRY
In paediatr ic dent istry stem cel ls can induce Stem cells and apexogenesis
revascularisation and apexogenesis. Severe damage due to Regeneration of tissue into the apex of an immature
trauma or infection can cause pulp necrosis and incomplete permanent teeth may come from stem cells already residing
root development in the immature tooth. In young patients, in the vital pulp tissue, the apical papilla, PDL or alveolar
some of the vital pulp tissue may be preserved to allow root bone. Also stem cells and growth factors seeded on scaffolds
development. If the infection spreads through the root canal, may be used as an alternative to regenerate tissue in vitro or
the residual pulp must be removed from the developing apex in vivo in near future. Mooney et al in 1996 first described an
to where it loses contact with the apical papilla. Ideally, the in vitro technique to engineer new pulp like tissues from
DPSCs and SCAPs should survive endodontic treatment, so 3cultured human pulpal fibroblasts. Development of 2,14,15 that they can support apexogenesis. The apical papilla
scaffolds and support structures to host the cells and growth and Hertwig's epithelial sheath play important roles in apical
factors which enable the sequence of biological events in 2,12development and regeneration. Although growth of the root regeneration to proceed are essential part of tissue
root will continue in the absence of these two components, it regeneration using bioengineering. In dental pulp will result in a relative periradicular thickening, due to the regeneration , the ideal matrix should ensure a good invasion of neighbouring cementum. In addition, Hertwig's 20 neurovascular supply to the new pulp tissue. Some authors epithelial root sheath stimulates the SCAPs to produce new
have exclusively aimed on regenerating soft pulp tissue ; they 2dentine deposits and to generate the rest of the apex. included the use of DPSCs seeded on a 3D polyglycolic acid
Revascularization and stem cells matrix and grown in vitro , the cells expanded and
proliferated to produce new tissue with a very similar In immature teeth trauma or infection causes irreversible cellularity to the original pulp. Biostructures obtained from pulp damage which hinders the development of root. It is natural compounds such as collagen offer good possible to conserve a portion of the vital pulp tissue for root biocompatibility such as those derived from polylactic acid, development to continue in young patients. It has been polyglycolic acid, sponges and hydrogels have predictable suggested in several clinical studies that DPSCs and SCAP can mechanical properties that offer greater control over survive the disinfection process as immature permanent degradation processes. The ideal scaffold or biostructure has teeth have a rich cellular and vascular supply. In spite of the not so far been determined although polymer and collagen traditional apex formation and apexification protocols , there derived scaffolds help calcium phosphate compounds have been recent reports of clinical modifications and other
21deriving from DPSCs and PDLSCs to survive and develop.alternatives which have been warmly welcomed in the field 16of paediatric dentistry. In 2001, Iwaya et al published the
Indian Journal of Comprehensive Dental Care 668
CONCLUSION: Res. 2002 Aug;81(8):531-5.
Reprogramming progenitor/stem cells into embryonic stem 11. Shi S Bartold PM, Miura M, Seo BM, Robey PG,
cells with broader regenerative potential has opened up new Gronthos S. The efficacy of mesenchymal stem cells to 2horizons into the possibilities of regenerative medicine. In regenerate and repair dental structures. Orthod
the recent years the knowledge regarding the dental pulp Craniofac Res. 2005 Aug;8(3):191-9.
biology has increased which offers more complex 12. Huang GT Apexification: the beginning of its end. Int understanding of the cellular and molecular processes Endod J. 2009 Oct;42(10):855-66. responsible for dental regeneration. In Paediatric Dentistry
13. Barrett AP Reade PC.Revascularization of mouse tooth the use of stem cells is strongly linked with apexogenesis and isografts and allografts using autoradiography and revascularisation. Along with an improved regimen of canal carbon-perfusion. Arch Oral Biol. 1981;26(7):541-5.disinfection, it seems to be the right time to establish a new
protocol for a paradigm shift in treating infected immature 14. Chueh LH Huang GT. Immature teeth with teeth. At the same time it is of utmost importance to provide periradicular periodontitis or abscess undergoing more evidence based research and conclusions in tissue apexogenesis:a paradigm shift. J Endod.2006 engineering and regenerative dentistry in order to provide Dec;32(12)patients the best possible treatment.
15. Stocum DL. Stem cells in regenerative biology and BIBLIOGRAPHY medicine. Wound Repair Regen. 2001 Nov-
Dec;9(6):429-42 1. Caruso S, Sgolastra F, Gatto R. Dental pulp regeneration
in paediatric dentistry: the role of stem cells. Eur J 16. Shin SY Albert JS, Mortman RE. One step pulp Paediatr Dent. 2014 Jun;15(2):904. revascularization treatment of an immature
permanent tooth with chronic apical abscess: a case 2. Iglesias-Linares A, Yáñez-Vico RM,Sánchez-Borrego E, report. Moreno-Fernández AM, Solano-Reina E, Mendoza-
Mendoza A. Stem cells in current paediatric dentistry 17. Banchs F Trope M. Revascularization of immature practice.Arch Oral Biol. 2013 Mar;58(3):227-38. permanent teeth with apical periodontitis: new
treatment protocol? J Endod. 2004 Apr;30(4):196-200. 3. Friedlander LT, Cullinan MP, Love RM. Dental stem cells
and their potential role in apexogenesis and 18. Thibodeau B Teixeira F, Yamauchi M, Caplan DJ, Trope apexification. Int Endod J. 2009 Nov;42(11):955-62. M. Pulp revascularization of immature dog teeth with
apical periodontitis. J Endod. 2007 Jun;33(6):680-9.4. Rafter M Apexification: A review. Dent Traumatol. 2005
Feb;21(1):1-8. Huang GT. 19. Shah N Logani A, Bhaskar U, Aggarwal V. Efficacy of
revascularization to induce apexification/apexogensis 5. A paradigm shift in endodontic management of in infected, nonvital, immature teeth: a pilot clinical immature teeth: conservation of stem cells for study. J Endod. 2008 Aug;34(8):919-25 regeneration. J Dent. 2008 Jun;36(6):379-86.
20. Gotlieb EL Murray PE, Namerow KN, Kuttler S, Garcia-6. L Sloan AJ Waddington RJ. Dental pulp stem cells: what, Godoy F. An ultrastructural investigation of tissue-where, how?. Int J Paediatr Dent. 2009 Jan;19(1):61-engineered pulp constructs implanted within 70. Robey PG Bianco P.endodontically treated teeth. J Am Dent Assoc. 2008
7. The use of adult stem cells in rebuilding the human Apr;139(4):457-65.face. J Am Dent Assoc. 2006 Jul;137(7):961-72.
21. Gebhardt M, Murray PE, Namerow KN, Kuttler S, Sonoyama WGarcia-Godoy F. Cell survival within pulp and
8. Liu Y, Fang D, Yamaza T, Seo BM, Zhang C. et al. periodontal constructs. J Endod. 2009 Jan;Mesenchymal stem cell-mediated functional tooth 35(1):63-6.regeneration in swine. PLoS One. 2006 Dec 20;1:e79.
9. Sonoyama W Liu Y, Yamaza T, Tuan RS, Wang S, Shi S. et
al. Characterization of the apical papilla and its residing
stem cells from human immature permanent teeth: a
pilot study. J Endod. 2008 Feb;34 (2):166-71.
10. Gronthos S Brahim J, Li W, Fisher LW. et al. Stem cell
properties of human dental pulp stem cells. J Dent
PROSTHETIC PLANES OF INTEREST FOR ESTABLISHIBG THE OCCLUSAL PLANE- A REVIEW
ABSTRACTS
Correct occlusal plane orientation is of great importance in prosthodontic
reconstructive and rehabilitative treatment to restore proper orofacial
complex functions. The occlusal plane in prosthetic reconstruction should be
oriented similar to the occlusal plane of lost natural teeth. Faulty orientation of
occlusal plane may jeopardize the function of masticatory system. Locating the
occlusal plane is a controversial matter but satisfactory solution about its
orientation in an individual patient isstill lacking.When the dentition or occlusal
plane is disturbed; for its rehabilitation, it is important to know the use of
orofacial landmarks to set up ideal occlusal plane.
KEY WORDS- occlusal plane, orofacial complex function, natural teeth,
masticatory system, orofacial landmarks.
669
Corresponding author:Name: Dr. Sagar R. Bhule,PG student, Dept. of Prosthodontics,MGV'S KBH Dental College and Hospital, Nashik.(M) 9561510367email- sagar200534@gmail.com
1. Reader, Dept. of Prosthodontics, MGV'S KBH Dental College and Hospital, Nashik.
2. PG student, Dept. of Prosthodontics, MGV'S KBH Dental College and Hospital, Nashik.
3. PG student, Dept. of Prosthodontics, MGV'S KBH Dental College and Hospital, Nashik.
4. Dept. of Prosthodontics, MGV'S KBH Dental College and Hospital, Nashik.
Indian Journal of Comprehensive Dental Care
I J C D C1. Seema B. Pattanaik
2. Sagar R. Bhule
3. Amanpreet Kaur Gill
4. Poonam V. Jaybhay
Date of Submission : 13/11/14 Date of Acceptance : 20/12/14
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
INTRODUCTION: the bolus and perform mastication between the buccinators 1, 3muscle and tongue .This inability to precisely locate the In edentulous patient it is necessary to restore the plane of
occlusal plane can hamper esthetics,phonetics,mastication occlusion which is compatible with the esthetics and and even stability of denture leading to residual ridge functional movements of mandible and to develop this is resorption. Although many planes have been referred in the solely the responsibility of the prosthodontist.Though the past to orient the occlusal plane but there are too many correct determination of occlusal plane forms basis of
3, 5controversies to come to a convincing conclusion. . A prosthodontic rehabilitation several studies and principles thorough review on the available literature on relation have evolved with time to restore the occlusal plane but
1,2,3. between occlusal plane and various craniofacial planes has neither of them are fool proof.been done in this articleto provide easy access to the related
Occlusal plane is the occlusal plane established by the incisal studies and to help decide the selection of reference plane and the occlusal surfaces of the teeth, it is not a plane but accordingly.represents the planar mean of the curvature of the surfaces
64 Roberts S. Ledley (1955) recommends that the occlusal (GPT-8) .Although the orientation of the occlusal plane is
plane be oriented as close as possible to the occlusal plane under the control of the clinician / operator, it should be that existed with the dentition. By doing so, they believe the established taking into considerations the esthetics, role of the tongue and cheeks would be most effective in the phonetics and biomechanical factors.functions of deglutition, mastication, and speech.
Anteriorly the plane of occlusion helps in achieving esthetics Furthermore, this would accurately restore the aesthetics. 7while posteriorly it helps to form a milling surface to position Victor H. Sears (1957) stated that the occlusal forces should
Indian Journal of Comprehensive Dental Care 670
be directed at right angles to the supporting structures .This tendency to place the posterior occlusal plane at a level
follows the first law of statics and should therefore enhance lower than the natural occlusal plane. He suggested that the
stability of the denture. Krishan K. Kapur and Sham Soman second molars be placed at the level of the upper third of the 8(1965) carried out one thousand four hundred and eighty retro molar pad to orient and position the occlusal plane in
masticatory performance tests in 12 denture wearers to the posterior region.
determine the effect of 9 positions of food platforms in 15Donald 0. Lundquist and Wallace W. Luther Major (1970) dentures on their chewing efficiency. They stated that the undertook an investigation to determine whether certain masticatory efficiency is influenced by the inclination of intraoral anatomic landmarks could accurately predict the occlusal plane. location of the occlusal plane. Patients with ideal occlusions
Several guidelines have been postulated for determining the were examined to determine the relationship between these
occlusal plane based on some landmarks that are extra-oral anatomic landmarks and the occlusal plane. Because of the
and intra-oral, few of them are: close correlation found among the occlusal plane, the
buccinator grooves, and the commissure of the lips, INTRAORAL LANDMARKS:vestibular impression technique for determining the location
Gysi advocated to set the mandibular teeth somewhat of the occlusal plane in completely edentulous patients was parallel to the curve of residual ridge so that masticatory suggested as previously given by Merkeley.
9force is directed perpendicular to the ridge .Howard J. 16
10 Martyn H. Spratley (1980) described a simplified technique Merkeley (1954) used vestibular impressions to locate the for determining occlusal plane in full denture construction occlusal plane. Vestibular impressions were made on the and the occlusal plane midway between the ridges.Celebic et lightly opposed trial bases in the mouth by making the
1al (1995) designed a study to check if the occlusal plane patient protrude the lip. A groove was thus formed in the terminating at the upper level of the retro molar pad is impression by the horizontal fibres of buccinators muscle reliable for clinical use. They concluded that the method of when the bottom of this groove was perforated with a series terminating the occlusal plane at the upper level of the retro of holes, the resulting line represented the occlusal plane.molar pad places the occlusal plane in complete denture
11DeVan M. M. (1956) recommend that the posterior teeth be wearers very close to the position of the natural one and can situated according to three specific positions : first, on, or therefore be used widely for clinical use.lingual to, the crest of the mandibular ridge ; second, parallel
EXTRAORAL LANDMARKS AND PLANES:to the flat portion of the posterior part of the mandibular
ridge; and third, closer to the mandibular ridge, which is CAMPERS PLANE
often the weaker member. They felt that this procedure Petrus Camper (1780) a Dutch anatomist postulated the would produce the maximum stability of dentures, thus camper's line which extends from the alae of the nose to the preserving the residual ridges. 9center of external auditor meatus .It is frequently used with a
12Walter A. Hall (1958) determined the anterior height of the third point on the opposing tragus,for the purpose of
occlusal plane by the length of the incisal edge of the upper establishing the ala tragus plane.Ideally the ala tragus plane 17occlusion rim above or below the upper lip while it is in is considered to be parallel to the occlusal plane .
repose and when the lip is properly supported. The two Anteriorly the occlusal plane should be parallel to posterior points of orientation of the occlusal plane fall interpupillary line and 1-3 mm below the resting upper lip within the height of the distal half of the retro molar pad. The 16,18,19while posteriorly it should be parallel to ala tragus line . entire plane was parallel to the ridge planes.
The Glossary of Prosthodontics Terms states that the ala-13MasakataYasaki (1961) adjusted the height of the lower tragus line runs from the inferior border of the ala of the nose
occlusal rim so that the lingual edge of the occlusion rim in to some defined point on the tragus of the ear, usually 4the bicuspid region is on the same plane as the margin of the considered to the tip of the tragus .Though alatragus line is
tongue while the mandible is in rest position. This helped to commonly used reference plane,it is still controversial as;its 14, control the food over the occlusal surfaces with the tongue exact point of reference on tragus is itself a controversy
20 21the posterior end of the rim terminates at the anterior .Zarb and Bolender advocate that the occlusal plane
margin of the retro molar pad. should be parallel to the ala-tragus line posteriorly without 22
14 defining or illustrating it. However, texts by Winkler , Yahia H. Ismail and John F. Bowman (1968) carried out an 23 24Rahnand Heartwell , and Boucher describe it as a line investigation to compare the occlusal plane established
running at the inferior border of the ala of the nose to the prosthetically with the one that existed before extraction of superior border of tragus of the ear.A study was conducted to the teeth in each subject. He concluded that there was a
Indian Journal of Comprehensive Dental Care 671
compare the artificial plane constructed prosthodontically middle of the tragus for the posterior border of Camper's
and natural plane by using lateral cephalograms of patients plane, two thirds the height of the retro molar pad for the
with natural teeth in centric occlusion .The study come to posterior border of the occlusal plane and 1 mm inferior to
conclusion that the artificial plane if oriented parallel to the upper lip for its anterior border.Katayoun Sadr and 28alatragus line will orient the plane at a lower level in posterior Makan Sadr (2009) conducted a study of 53 dental students
14region than the natural plane. to evaluate correlation between occlusal plane and posterior
19 reference point on ala tragus line. The results concluded that R. Hartono (1967) did a study to find a correlation between
there exist no parallelism between occlusal plane and the lateral aspects of the occlusal plane of natural teeth and
camper's plane and suggested the superior border of the facial types, which might be used in the construction of
tragus, as the posterior reference for the ala tragus line.complete dentures. It was encouraged by Dr. George A
FRANKFORT HORIZONTAL PLANE (FH PLANE)Hughes hypothesis that the face form in its lateral aspects is
of significant value to the problem of denture stability, and Downs in a study of 20 individuals age 12 years to 17 years, Ausburger's study, which indicated a strong correlation related the occlusal plane to the F-H plane and found the between the occlusal plane and the lateral aspects of facial 029 30average angle to be 9.30 . . Richard A. Riedel (1952) in a types. The results showed that line drawn from lowest point cephalometric study conducted in Washington on 52 adults of ala to inferior margin of tragus (camper's plane) are almost and 7 child patients having excellent occlusion showed that parallel to occlusal plane. the average inclination of the upper central incisors to
25 Frankfort horizontal plane (F-H plane) was approximately Bernard Levin and John L. Sauer (1969) conducted a 0 0
comprehensive survey of complete denture teaching 111 in adults and 110 in children.
methods and materials in 33 dental schools in America. It was 31Richard K.K OW et al (1989) undertook cephalometric study found that 50 % of the schools were taught to use camper's
to evaluate the orientation of natural occlusal line to various plane method for occlusal plane determination.Hideaki
craniofacial reference lines and their relation to maxillary 26Okane et al. (1979) in a study investigated the effect of occlusal line. Their study concluded that Frankfort horizontal
anteroposterior inclination of the occlusal plane on muscle line (F-H line) in particular cannot be considered activity during clenching and biting force to estimate advantageous as a clinical reference plane due to observed physiologically the applicability of the ala-tragus line. The variation in inclination between Chinese Singaporean and integrated electromyographic activity and biting forces of Swedish white people.patients were examined at three different anteroposterior
MAXILLARY PLANEinclinations of the occlusal plane at a constant vertical
dimension of occlusion. They concluded that the change in A study was carried out in dentulous and edentulous subjects anteroposterior inclination of the occlusal plane tends to to correlate between maxillomandibular space and occlusal affect the biting force and the biting force exerted was plane, the results showed a significant correlation between maximum when the occlusal plane was established parallel angulations of occlusal plane to maxillomandibular space to the ala tragus line. and found that in patients having long and low type of
20 maxiloomandibular space the occlusal plane was nearly H. C. Karkazis and G. L. Polyzois (1987) undertook a study to parallel to the maxillary plane while in short and high type of determine the relationship between the natural occlusal maxillomandibular space occlusal plane was more more plane and the Camper's plane and to determine at the steeply angulated to the maxillary plane. The occlusal plane delivery appointment the relationship between the deviates away from a mean angulation to the maxillary plane established artificial occlusal plane in complete dentures and when the height and length of maxillomandibular space tend the Camper's plane. The results showed that the natural
32to be towards the opposite extremes of normal range.occlusal plane diverges posteriorly from Camper's plane. The
angle formed by the two planes had an average of 2.88°.F. While in nearly a similar study on dentulous subjectsNeena L. 27Bassi et al (2001) in a cephalometric study found that the D'Souza and Kashyap Bhargava has found a correlation
complete denture constructed according to clinical between maxillary plane and occlusal plane, that is they form 0parameters showed a consistently lower VDO, an anterior a angle of 6.0500 in long and large maxillomandibular space,
rotation of the occlusal plane and a prevalence of the 3.3889 for subjects with long and large maxillomandibular 0maxillary dental arch in the subdivision of the denture space. space, 7.3462 for short and large maxillomandibular space 0A difference of around 11° was found between the occlusal and 5.4375 for subjects with short and small
33plane and the Camper plane. maxillomandibular space .18 34J. Nissan, E. Barnea, C. Zeltzer & H. S. Cardash (2003) used Davor Seifert et al (2000) in their investigation
Indian Journal of Comprehensive Dental Care 672
demonstrated that the occlusal plane is not parallel to the HAMULAR- INCISIVE PAPILLA PLANE
Frankfort plane. Such a position of the occlusal plane will 40Kojima et al (2003) used a three dimensional measuring decrease the anteroposterior inclination of the upper model
system to analyse the angle of the HIP plane to occlusal and can affect the position of the maxillary anterior teeth. 17plane.P.S. Fu et al (2007) carried out a study in Taiwanese The occlusal plane will be lowered in the posterior portion,
population using a three dimensional precise measuring which may harm not only the aesthetics of the denture but
devise. They stated that the occlusal plane tends to be more also the chewing effect.
parallel to the HIP in angle class I subjects and stated that
MANDIBULAR PLANE further study is needed.
35 F.F. Schudy (1963) in accordance to the pronouncement of DISCUSSION
research workshop on cephalometrics in July 1959 stated Clayton Chan through his studies stated that the head
that all horizontal planes have significant relationship to posture and clinical significance of occlusal plane orientation
mandibular plane except the occlusal plane. The average OM must be considered if the clinician desires to bring stability
angle (occlusal mandibular angle) was 16±5 degree. 41and health to stomatognathic system .Madsen et al. 36Girard J. DiPietro and James R. Moergeli (1976) in their confirmed that a true horizontal plane registered in NHP
cephalometric study discussed about the vertical facial types represents a more valid craniofacial reference system.Even 42and the Frankfort-Mandibular plane angle pertinent to reproducibility of NHP is being proved by many authors .So
prosthodontics. The Frankfort-mandibular plane angle the occlusal plane determined parallel to the GHP in natural
(FMA) is formed by the intersection of the Frankfort head position will be more apt and in harmony with the
horizontal plane and the mandibular plane. An FMA of 25 + 5 stomathognathic system.
degrees is within normal range. A high-angle patient has an REFERENCES
FMA of 30 degrees or more, and a low-angle patient has an 1. Celebic A, Valentic-Peruzovic M, Kraljevic K, Brkic H. A FMA of 20 degrees or less. A high FMA is characterized by
study of the occlusal plane orientation by intra-oral open-bite skeletal patterns and a low FMA by closed-bite method (retromolar pad). J Oral Rehabil.1995; 22:233-skeletal patterns.236.
37D. Sinobad (1988) conducted a study to examine the level 2. Augsburger.R.H. Occlusal plane relation to facial type. J and inclination of the occlusal plane in dentulous subjects
Prosthet Dent 1953;3:755.with various skeletal jaw-relationships with the purpose of
finding more reliable guides for locating the occlusal plane in 3. L'Estrange, P.R. &Vig, P.S. A comparative study of the edentulous patients. According to the results no significant occlusal plane in dentulous and edentulous subjects. J correlation was obtained between the maxillary plane and Prosthet Dent.1975; 33: 495.occlusal plane in various skeletal jaw relationships, however
4. Glossary of prosthodontic terms. J Prosthet Dent2005; significant difference was obtained when the relationship of
94:10-92.occlusal plane to mandibular plane was concerned in various
5. Petricevic N, CelebicA,Celic R, Baucic-Bozic M. Natural skeletal relationships.head position and inclination of craniofacial planes. Int
GRAVITY HORIZONTAL PLANE (GHP)J Prosthodont. 2006; 19:279-280.
A study was conducted to assess the angles between the 6. Ledley RS. A New Method of Determining the
occlusal and craniofacial planes, as well as to assess the Functional Forces Applied to Prosthetic Appliances
angles between the occlusal and craniofacial planes and the and Their Supporting Tissues. J Prosthet Dent.1955;
real gravity horizontal plane (GHP) on 56 dental students with 5:546-62.
complete natural dentition and angles class I occlusion. The 7. Sears VH. The selection and management of posterior results showed that FoxP(represents the occlusal plane
teeth. J Prosthet Dent.1957; 7(6):723.extraorally) and BP (bipuppilary) line are parallel to GHP.In
lateral view FoxP was parallel to GHP but FH plane and 8. Kapur KK, Soman S. The effect of denture factors on camper's plane were not parallel to GHP, Stated that masticatory performance, Part III. The location of the CP(campers plane) is not a reliable landmark for establishing food platforms. J Prosthet Dent.1965; 15(3):451-63.the occlusal plane. In NHP(natural head position) and when
9. Carey PD. Occlusal plane orientation and masticatory the subject is in erect posture OC (occlusal plane) is almost
performance of complete dentures. J Prosthet 38parallel to GHP .While Ferrario et al found that the occlusal Dent.1978; 39(4):368-71. 039plane deviated from GHP by about 14 .
Indian Journal of Comprehensive Dental Care 673
10. Merkeley H J. The Labial and Buccal Accessory Muscles anteroposterior inclination of the occlusal plane on
of Mastication. J Prosthet Dent.1954; (4): 327-34. biting force. J Prosthet. Dent.1979; 42(5):497-501.
11. DeVan, MM. The Prosthetic Problem- Its Formulation 27. Bassi F, Deregibus A, Previgliano V, Bracco P, Preti G.
and Suggestions for Its Solution. J Prosthet Dent.1956; Evaluation of the utility of cephalometric parameters
6:291-301. in constructing complete denture. Part I: placement of
posterior teeth. J of Oral Rehabil.2001; 28:234-8.12. Hall WA. Important factors in adequate denture
occlusion. J Prosthet Dent.1958; 8(5):764-75. 28. Sadr K, Sadr M. A study of parallelism of the occlusal
plane and Ala-tragus line. J Dent Res Dent Clin Dent 13. Yasaki M. The Height of the occlusion rim and the Prospect.2009; 3(4):107-9.interocclusal distance. J Prosthet Dent.1961; 11(1):26-
31. 29. Downs,W.B.:Variation in facial relationships, Their
Significance in Treatement and prognosis, Am. J. 14. Ismail YH, Bowman JF. Position of the occlusal plane in Ortho. 1948; 34: 812-40. natural and artificial teeth. J Prosthet Dent.1968; 20:
407-11 30. Reidel RA. The relationship of maxillary structures to
cranium in malocclusion and in normal occlusion. 15. Lundquist DO, Wallace WH. Occlusal plane Angle Orthod.1952; 22(3):142-45. determination. J Prosthet Dent.1970; 23: 489-98.
31. Ow RK, Djeng SK, Ho CK. The relationship of upper 16. Spratley MH. A simplified technique for determining facial proportions and the plane of occlusion to the occlusal plane in full denture construction. J Oral anatomic reference planes. J Prosthet Dent.1989 Rehabil.1980; 7:31-3.Jun;61(6):727-33.
17. Fu .P.S, Hung C.C, Hong J.M, Wang J.C. Three 32. L'Estrange, P.R. &Vig, P.S. A comparative study of the dimensional analysis of the occlusal plane related to
occlusal plane in dentulous and edentulous subjects. J the hamular-incisive-papilla occlusal plane in young Prosthet Dent.1975; 33: 495.adults. J Oral Rehabil.2007; 34:136-140.
33. D'Souza N.L, Bhargava K. A cephalometric study 18. Nissan J, Barnea E, Zeltzer C, Cardash HS. Relationship comparing the occlusal plane in dentulous and between occlusal plane determinants and craniofacial edentulous subjects in relation to the maxillo-structures. J Oral Rehabil.2003; 30:587-91. mandibular space. J Prosthet Dent. 1996; 75:177-82.
19. Hartono R. The occlusal plane in relation to facial 34. Seifert D, Jerolimov V, Carek V, Ibrahimagic L. Relations types. J Prosthet Dent.1967; 17:549-58.
of reference planes for orientation of the prosthetic 20. Karkazis HC, Polyzois GL. A study of the occlusal plane planes. ActaStomatol Croat.2000 34(4):413-6.
orientation in complete denture construction. J of Oral 35. Schudy FF. Cant of the occlusal plane and axial Rehabil.1987; 14:399-404.
inclinations of teeth. Angle Orthod.1963; 33(2):69-82.21. Zarb GA, Bolender CL. Prosthodontic Treatment for
36. DiPietro GJ, Moergeli JR. Significance of the Frankfort-Edentulous Patients: Complete Dentures and Implant-mandibular plane angle to prosthodontics. J Prosthet. Supported Prostheses, 12th ed. St. Louis: Mosby; Dent.1976; 36(6):624-35.2004:262.
37. Sinobad D. The position of the occlusal plane in 22. Winkler S. Essentials of Complete Denture dentulous subjects with various skeletal jaw-Prosthodontics, 2nd ed. St. Louis: Mosby year-book; relationships. J of Oral Rehabil.1988; 15:489-98.1998:140.
38. Petricevic N, CelebicA,Celic R, Baucic-Bozic M. Natural 23. Rahn AO, Heartwell CM. Textbook of Complete head position and inclination of craniofacial planes. Int Denture, 5th ed. Philadelphia: Lea &Febiger; J Prosthodont. 2006; 19:279-280.2002:270.
39. Ferrario VF, Sforza C, Serrero G, Ciusa V. A direct in vivo 24. Boucher CO. Current clinical dental terminology. 3rd measurement of the three-dimensional orientation of ed. St.Louis: Mosby; 1982:175. the occlusal plane and of the sagital discrepancy of the
25. Levin B, Sauer JL. Results of a survey of complete jaws. ClinOrtod Res.2000; 3:15-22. denture procedures taught in American and Canadian
40. Kojima T, Sohmura T, Nagao M, Wakabayashi K, dental schools. J Prosthet Dent.1969;22: 171-77.Nakamura T, Takahashi J. A preliminary report on a
26. Okane H, Nagaswa T, Tsuru H. The effect of
Indian Journal of Comprehensive Dental Care 674
computer-assisted dental cast analysis system used for 42. Madsen PD, Sampson J, Townsend GC. Craniofacial
prosthodontics treatement. J of Oral Rehabil.2003; reference plane variation and natural head position.
30:526-31. Eur J Orthod.2008; 30:532-540.
41. Chan C. A review of the clinical significance of the
occlusal plane: its variation and effect on head
posture. International college of Craniomandibular
Orthopedics (ICCMO) Anthology VIII, 2007.
AN OVERVIEW OF MUSCULOSKELETAL DISORDERS AMONG ORAL HEALTH PROFESSIONALS:
Abstract
Oral health professionals are constantly exposed to a number of specific
occupational hazards which cause the appearance of various ailments, specific
to the profession and intensified with over period of time resulting in diseases
and disease complexes, some of which are regarded as occupational illnesses.
Relying on relevant literature, the present paper discusses occupational
hazards leading to the musculoskeletal system diseases. Awareness regarding
these occupational hazards and implementation of preventive strategies can
provide a safe working environment for all the dental personnel. There is also a
need for continuing dental education programs in dentistry so that dentists can
update themselves with the latest and newer techniques.
Keywords: Oral health professional; Musculoskeletal disorder; Prevention
675
Corresponding author:Name: Dr. Pankaj MishraSenior Lecturer; Department of Conservative & Endodontics, Rishiraj College of Dental Sciences & Research Centre, Bhopal, (M.P)M : 07748052176 Email id: drpankajmsr007@gmail.com
1 Senior Lecturer; Department of Conservative & Endodontics, Rishiraj College of Dental Sciences & Research Centre, Bhopal, (M.P)
2 Senior Lecturer; Department of Oral Medicine & Radiology, Rishiraj College of Dental Sciences & Research Centre, Bhopal (M.P) India
3. Senior Lecturer; Department of Oral Medicine & Radiology, Rishiraj College of Dental Sciences & Research Centre, Bhopal (M.P) India
4 Senior Lecturer; Department of Oral Medicine & Radiology, Rishiraj College of Dental Sciences & Research Centre, Bhopal (M.P) India
5 Lecturer, Department of Oral Medicine & Radiology, Rishiraj College of Dental Sciences & Research Centre, Bhopal (M.P) India
Indian Journal of Comprehensive Dental Care
I J C D C1. Pankaj Mishra
2. Manas Gupta
3. Neha Singh
4. Kriti Shrivastava
5. Pushpraj Singh
Date of Submission : Date of Acceptance :
Indian Journal of Comprehensive
Dental Care
JULY-DEC. 2015 • VOL 5 • ISSUE 2
Introduction: instantaneous event (e.g., slips or falls). These disorders are
considered to be work-related when the work environment India has been battling traditional public health problems and the performance of work contribute significantly, but like communicable diseases, malnutrition, growing are only one of a number of factors contributing to the population, and inadequate medical care, apart from the
3 1 causation of a multifactorial disease”.occupational health problems. Dental professionals are
commonly exposed to a variety of occupational hazards MSD is one of the major occupational health problems in
such as chemical, biological and legal as well as ergonomic, India and estimates have shown that MSD contributes to 2which create musculoskeletal disorders (MSD). In Greek, about 40% of all costs towards the treatment of work related
1 “Ergo,” means work and, “Nomos,” means natural laws or injuries. A wide variety of deleterious work environmental
systems. Ergonomics, therefore, is an applied science factors are proved to affect the physical health of dentists or
concerned with designing products and procedures for even aggravate their preexisting disorders. Studies have
maximum efficiency and safety. Ergonomic conditions are shown that dentists report more frequent and worse health
simply the safest, most efficient, and easiest way to work. problems particularly musculoskeletal pain. There is
Improving the ergonomic delivery of dental services and increasing evidence that unique working conditions in
accounting for working conditions in dental offices enhance dentistry can significantly affect the health of dentists.
the well-being and safety of patients, staff, and Musculoskeletal pain, particularly back pain, has been found 4practitioners. The World Health Organization defines MSD to be a major health problem for dental practitioners.
as “a disorder of the muscles, tendons, peripheral nerves or 5Musculoskeletal Disorders Classification: vascular system not directly resulting from an acute or
Indian Journal of Comprehensive Dental Care 676
1. Nerve Entrapment Disorders: Carpal tunnel syndrome, 9. Present dental chairs allow adaptation of the patient´s
Ulnar neuropathy. position in height, inclination of the torso, flexion or
hyper extension of the head of the patient.2. Occupational Disorders of the Neck and Brachial
Plexus: Tension neck syndrome, Cervical spondylosis, Various Factors leading to MSDs due to incorrect dental 8, 9Cervical disc disease, Brachial plexus compression. setup are highlighted below:
3. Shoulder disorders: Trapezius myalgia, Rotator cuff 1. Dentist's or patient's chair is too high/low.
tendonitis, Rotator cuff tears, Adhesive capsulitis. 2. Dentist's chair has no lumbar, thoracic, or arm support.
4. Tendonitis of the Elbow, Forearm and Wrist: 3. Instrument table is not positioned properly.
deQuervain´s disease, Tendonitis, Tenosynovitis, 4. Lighting is inadequate for the task.Epicondylitis
5. Edges of tab les/work sur faces are sharp/ 5. Hand-Arm Vibration Syndrome: Raynaud's disease. uncomfortable.
6. Low Back Disorders: Chronic low back pain6. Ventilation makes work space cold.
Mechanisms leading to musculoskeletal disorders (MSDs) 7. Work environment is damp and cold.in dentistry:
Aggravating factors leading to MSDs due to improper Various researchers highlighted that work duration, operator posture of dental professionals while performing positioning and the physiological effects of various static
9 procedures are as follows: sitting postures have direct or indirect relationships between
prolonged muscle contraction and muscle imbalances which 1. Working with the neck in flexion and tilted to one side.6in turn causes musculoskeletal disorder. Lake et al in 1995
2. Shoulders elevated.implicates several mechanisms in the generation of pains and
3. Side bending to left or right.soreness among the dental professionals which are 7mentioned below: 4. Excessive twisting.
1. Elevated work area with permanent static positions of 5. Forward bending/overreaching at waist.more than 30 degrees, which would produce a reduction
6. Shoulders flexed and abducted.of blood flow in the supra spine tendon and would also
7. Elbows flexed greater than 90°.originate high muscle tension on the trapezoids.
8. Wrists flexed/deviated in grasping.2. Lack of support of the forearms during repetitive
holding of instruments which would compromise 9. Thumb hyperextension.different body segments such as spine, shoulder, and
10. Position maintained for 40+ minutes per patientwrists.
Various signs & symptoms of MSDs among the dental health 3. The handling of vibrating instruments is associated with 10, 11professionals are summarized below:specific lesions such as nerve trapping, early arthrosis
and even, with Raynaud syndrome. Signs:
4. Forced cervical static postures. 1. Decreased range of motion
5. Poor posture when seating. The flexion of the lumbar 2. Loss of normal sensation
spine, when seating forward, produces marked pressure 3. Decreased grip strength
increments between the interdiscal spaces. 4. Loss of normal movement
6. Lighting at the work place: the lack or excess of light can 5. Loss of coordinationgenerate myopia and irreversible retinal lesions, among
others7. Temperature, ventilation and humidity at Symptoms:the work place. If the temperature is high and the air is
1. Excessive fatigue in the shoulders and necksaturated with humidity, there is exhaustion, increased
2. Tingling, burning, or other pain in armsbody temperature and, respiratory and circulatory
disorders. 3. Weak grip, cramping of hands
8. Intermittent and continuous noise produced by high and 4. Numbness in fingers and handslow speed instruments
5. Clumsiness and dropping of objects
Indian Journal of Comprehensive Dental Care 677
6. Hypersensitivity in hands and fingers hands at the level of the heart, being able to easily reach
necessary equipment and materials; the patient lying Discussion:18horizontally. Shaik AB et al revealed a significant association
Patel H et al has found that 63.6% of dentist is suffering from between musculoskeletal symptoms experienced by the pain at back due to prolong sitting as one of the main dentists and socio demographic variables like; age, field of
4aggravating factor in their study. Muralidharan D et al also dental practice, number of years in profession and average 19found the high prevalence of musculoskeletal disorders patients treated per day. Khan SA et al conducted the study
among dental practitioners which is affecting the daily to assess the prevalence and awareness of Work-related practice of more than one third by involving the neck (52%), Musculoskeletal Disorder (WMSD) amongst the Malaysian
1 low back (41%), shoulders (29%) and wrist (26%). Desai V et dental students and results showed that WMSD is common in al have found that dentist have started wearing spectacles in females in comparison to males involving neck and lower their study due to stress felt in the eyes by adopting wrong back region. Moreover students of clinical year are more
postures in order to gain appropriate vision of the working prone than non clinical year students. They concluded that 12field. Leggat PA et al have conducted a study by a self- theory and practice of ergonomics should be incorporated
20reporting questionnaire among the 400 dentists of into the dental undergraduate curriculum.Queensland Branch of the Australian Dental Association.
3, 4, 8, 11, 15Recommendation: Overall results of the study showed that MSD is a major
occupational health issue which interfere the daily activities Ergonomics problems in dentistry can be reduced by
of the dentists and also need medical attention for their implementing various strategies.13symptoms. Harutunian K et al have evaluated the intensity 1. Dentist should avoid working in bent position. Straight
and location of musculoskeletal pain suffered by students posture while working helps to prevent development of and professors from different postgraduate programs of the pain as it maintains the normal “s” shape of the spinal School of Dentistry of the University of Barcelona (Spain) and cord and reduces stress on inter vertebral discs.found the high incidence of pain among females and younger
14 2. Education of correct posture should be part of under dentists particularly in the cervical region.graduate dental education and always bring their
Yousef MK et al have recommended that students should attention to the postural mistakes observed during their continuously evaluate and correct their whole body posture clinical sessions.during a clinical work because correct dentist posture and
3. Regular breaks in between continuous long dental position during clinical work are of great importance to 15 procedureprevent neck, back pain and muscle fatigue. Alexopoulos EC
et al have found that the physical load mainly due to high 4. Assess & Reposition the correct patient and chair
exertion and moreover associated with sickness absence positions before any dental procedure
among dentist is the major risk factor for the occurrence of 5. Always use indirect vision when working in the maxillary
musculoskeletal disorders and stressed on evaluating arch, except when working on directly accessible areas.
psychosocial factors and other personal characteristics 6. Magnifiers should be encouraged during clinical work.consideration while investigating the influence of work
16related risk factors. 7. Avoiding static postures with preferred alternating
between standing and sitting position
8. Releasing trigger points
Valachi & Valachi (2003) have suggested some body
strengthening exercises in order to prevent musculoskeletal 21disorders:
1. Stretching and strengthening the muscles that support With the advancements in the latest technologies to reduce the back and neck and those used in the forearm, wrist, musculoskeletal problem among dentist, Chaikumarn M et al and hand will help them remain strong and healthy.stressed on following proprioceptive derivation (Pd) concept
and four handed dentistry which gives more comfort and 2. Periodic stretching throughout the workday.reduces the risk of musculoskeletal discomfort. The Pd
3. Resting hands should be followed during procedure.concept was first developed by Dr. Daryl R. Beach, also known
4. To relieve eyestrain caused by focusing intensely at one as performance logic The Pd concept has an Ideal Posture,
depth of vision for long periods, look up from the task which is simply described as the dentist sitting upright, both
Kumar SP et al also emphasized on the
biopsychosocial risk factors evaluation which are highly
predictive for developing musculoskeletal disorders among
dentist and suggested that further research should be carried
out for the prevalence of MSD among Indian dental
population before implementation of preventive 17educational programmes among dentists.
Indian Journal of Comprehensive Dental Care 678
and focus eyes at a distance for approximately 20 acquired by the dentists during their clinical practices.
seconds. REFRENCES:
5. Move the head down slowly and allow the arms and 1- Muralidharan D, Fareed N and Shanthi M. head to fall between the knees; hold for a few seconds; Musculoskeletal Disorders among Dental Practitioners: raise slowly by contracting the stomach muscles and Does It Affect Practice? Epidemiology Research rolling up, bringing the head up last. International. 2013, Article ID 716897: 6.
6. Try head rotation for neck stiffness. Head rotation 2- Rabiei M, Shakiba M, Shahreza HD, Talebzadeh M. involves tilting the head from right to left, as well as Musculoskeletal Disorders in Dentists. International forward and backwards without forcing the motion Journal of Occupational Hygiene. January 2012; 4 (1): beyond a range of comfort. 36-40.
7. Shoulder shrugging can be used to stretch the shoulder 3- Sudarshan R, Ganesan SV. Ergonomics in dentistry- a muscles that may be stressed from holding oral review J Environ Occup Sci 2012; 1(2):125-128.evacuator, instruments and telephone handset. Pull the
4- Harshid P, Mehul M, Mihir R, Piyanka P. Prevalence and shoulders up toward the ears, roll them backward and associated factors of back pain among dentists in South then forward in a circular motion.Gujarat. National Journal of Medical Research. Apr –
June 2012; 2 (2): 229-231.
Yamalik (2007) has given some tips for working with good 5- Anghel M, Veronica Argesanu V, Niculescu CT, Lungeanu 22 posture: D. Musculoskeletal disorders (MSDs)- consequences of
(1) Maintain an erect posture prolonged static postures. Journal of Experimental
Medical & Surgical Research 2007; 4:167-172.(2) Use an adjustable chair with lumbar, thoracic and arm
support 6- Valachi B, Valachi K: Mechanisms leading to
musculoskeletal disorders in dentistry. Journal of (3) Work close to your body
American Dental Association. 2003; 134 (10):1344- (4) Minimize excessive wrist movements 1350.
(5) Avoid excessive finger movements 7- Caballero DAJ, Palencia GIP, Cárdenas DS. Ergonomic
factors that cause the presence of pain muscle in (6) Alternate work positions between sitting, standing and students of dentistry. Med Oral Patol Oral Cir Bucal. side of patientNovember 2010; 15 (6):e906-11.
(7) Adjust the height of your chair and the patient's chair to 8- Sarkar PA, Anand L Shigli AL. Ergonomics in General a comfortable level
Dental Practice. People's Journal of Scientific Research. (8) Consider horizontal patient positioning
Jan. 2012; 5 (1): 56-60.(9) Check the placement of the adjustable light
9- Sadig W. Ergonomics in dental practice. Pakistan Oral & (10) Check the temperature in the room Dental Journal. 2000; 20(2):205-213.
Conclusion: 10- Biswas R, Sachdev V, Jindal V, Ralhan S, Musculoskeletal
Disorders and Ergonomic Risk Factors in Dental Practice. Ergonomics related health hazards are a common affliction in Indian Journal of Dental Sciences. March 2012; 1(4): 70-oral health professionals which begins at the time they start 74.their professional studies and it stays with them during their
professional practice affecting various parts of the body. A 11- Hamann C, Robert A. Werner RA, RhodeN, Rodgers PA thorough understanding of the ergonomics is essential to and Sullivan K. Upper Extremity Musculoskeletal know about the musculoskeletal problems that could arise Disorders in Dental Hygiene: Diagnosis and Options for because of improper ergonomics in dentistry. Adopting Management. Contemporary Oral Hygiene June 2004: adequate postures in clinical practice and having a favorable 2-8.work environment could reduce the frequency of lesions to
12- Desai V, Pratik P, Sharma R. Ergonomics: a must for the muscular skeletal system avoiding an early retirement
dentistry: a cross-sectional study in various parts of from the profession. Therefore, it is of vital importance to
Northern India www.journalofdentofacialsciences.com promote occupational health training and prevention
2012; 1(2): 1-5.programs regarding ergonomic postures which must be
Indian Journal of Comprehensive Dental Care 679
13- Leggat PA, Smith DR. Musculoskeletal disorders self- 19- Shaik AR, Sripathi Rao BH, Husain A, D'Sa JL. Association
reported by dentists in Queensland, Australia. Between Musculoskeletal Symptoms Experienced By
Australian Dental Journal 2006; 51(4):324-327. Dentists and Selected Socio Demgraphic Variables in a
Southern Karnataka District. Kathmandu Univ Med J 14- Harutunian K, Albiol JG, Figueiredo R, Escoda CG. 2012; 38(2):9-13.Ergonomics and musculoskeletal pain among
postgraduate students and faculty members of the 20- Khan SA and Chew KY. Effect of working characteristics
School of Dentistry of the University of Barcelona and taught ergonomics on the prevalence of
(Spain). A cross-sectional study. Med Oral Patol Oral Cir musculoskeletal disorders amongst dental students.
Bucal. May 2011; 16 (3):e425-9. BMC Musculoskeletal Disorders 2013; 14:118
15- Yousef MK and Zain AO. Posture Evaluation of Dental 21- Valachi B, Valachi K. Preventing musculoskeletal
Students. JKAU: Med. Sci. 16 (2): 51-68. disorders in clinical dentistry: strategies to address the
mechanisms leading to musculoskeletal disorders. J Am 16- Alexopoulos EC, Stathi IC and Charizani F. Prevalence of Dent Assoc. 2003; 134:1604-12.musculoskeletal disorders in dentists BMC
Musculoskeletal Disorders 2004, 5:16. 22- Yamalik NA. Musculoskeletal Disorders (MSDS) and
Dental Practice part 2. Risk Factors for dentistry
Magnitage of the problem, prevention, and dental
ergonomics. International Dental Journal, 2007; 57
(1):45-54..
18- Chaikumarn M . Differences in Dentists' Working
Postures When Adopting Proprioceptive Derivation vs.
Conventional Concept. International Journal of
Occupational Safety and Ergonomics (JOSE) 2005; 11
(4): 441–449.
17- Kumar SP, Kumar V, Baliga M. Work-related
musculoskeletal disorders among dental professionals:
An evidence-based update. Indian Journal of Dental
Education January - March 2012; 5(1): 5-12.
Indian Journal of Comprehensive Dental Care 680
DENTAL DILEMMA-9
Dr Ramandeep S Narang, Professor & Head, Department of Oral Pathology & Microbiology, SGRD Institute
of Dental Sciences and Research, Sri Amritsar
Dr. Balwinder Singh, Senior Lecturer, Department of Oral Medicine & Radiology, SGRD Institute of Dental
Sciences and Research, Sri Amritsar.
Dr. Adesh S Manchanda, Reader, Department of Oral Pathology & Microbiology, SGRD Institute of Dental
Sciences and Research, Sri Amritsar
QUESTION:
A 45 year old male complained of swelling in anterior mid- palatal region since 2 years. The swelling was
3cm x 2cm in dimension with diffused borders, soft to firm in consistency, mildly tender on palpation. The
swelling has gradually enlarged in size over the time. (Figure 1)Radiologically no significant findings were
observed. Microscopic examination showed streaming fasciles of spindle shaped which at places formed a
palisaded arrangement around central acellular, eosinophilic areas (Verocay bodies). The spindle cells at
other places were randomly arranged within a loose, myxomatous stroma. (Figure 2).
Identify the condition?
Figure 1 Figure 2
Answer to DENTAL DILEMMA 8 -: Dentigerous Cyst.