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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


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


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JAN - JUNE. 2015 • VOL 5 • ISSUE 1

I J C D C


DR SUKHDEEP SINGH KAHLON


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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

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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 ………


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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: [email protected]

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


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


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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.


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


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.


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.


I J C D C1. Preeti Chawla Arora

2. Ruhi Duggal

3. Sargun Sarang

4. Arshdeep Kaur

5. Aman Arora



Dental Care


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


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


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


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


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


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: [email protected]

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.


I J C D C1. Satinder Singh Walia

2. Amaninder Kaur

3. Gurpreet Kaur

4. Gagan Deep



Dental Care


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.


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


(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: [email protected]

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


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



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


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


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


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: [email protected]

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


I J C D C1. Tejinder Kaur

2. Sumeet Sandhu

3. Pradeep Goyal



Dental Care


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


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.


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


A

2.5

A

A

A

A

A A

IV Left mandibular first molar

P

2

A

A

A

A

A A

Group

II


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


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


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,


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


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


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


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


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


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: [email protected]

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


I J C D C1. Harpreet Singh

2. Ramandeep Singh Bhullar

3. Amneet Kaur Sandhu



Dental Care


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


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


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. .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: [email protected]

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


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



Dental Care


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


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


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: [email protected]

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


I J C D C1. Navkiran

2. Aneet Kaur

3. Ashish Verma

4. Sahib Tej Singh



Dental Care


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.


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


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


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: [email protected]

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.


I J C D C1. Ramneek Khatter

2. C.S.Bal

3. Ripu Daman Singh

4. Shilpa Walia



Dental Care


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


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


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


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: [email protected]

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.


I J C D C1. Sunil Gupta2. Amit Dhawan3. Anjali



Dental Care


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 extraorally 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 intraoral 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.


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


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. – [email protected](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


I J C D C1. Vandana2. Supreet Kaur3. Navneet Kaur4. Vishakha Grover



Dental Care


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


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.herpetiformis. 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


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.


I J C D C1. Megha Majajan

2. Roma Goyal

3. Pardeep Mahajan

4. Prashant Monga

5. Nitika Bajaj



Dental Care


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


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.


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


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.


I J C D C1. Sumant Saoji

2. Surendra Agrawal

3. Anjali Bhoyar

4. Swapnil Parlani



Dental Care


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


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


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


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 [email protected]

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


I J C D C1. Navpreet Kaur

2. Gaurav Goyal

3. Sarfaraz Padda

4. Bhawandeep Kaur

5. Sunidhi



Dental Care


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


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


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,


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


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


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: [email protected]

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


I J C D C1. Kavipal Singh

2. Kamleshwar Kaur

3. Geetika Chawla



Dental Care


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


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


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 .


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: [email protected]

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


I J C D C1. Rashu Grover

2. Gunmeen Sadana

3. Manjul Mehra

4. Jasmeet Kaur



Dental Care


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


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.


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


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-

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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- [email protected]

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.


I J C D C1. Seema B. Pattanaik

2. Sagar R. Bhule

3. Amanpreet Kaur Gill

4. Poonam V. Jaybhay



Dental Care


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


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


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


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.

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A study was conducted to assess the angles between the 6. Ledley RS. A New Method of Determining the

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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

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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

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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.

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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

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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: [email protected]

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


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 :


Dental Care


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


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


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.


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


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.


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.

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