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The journal is indexed with ‘Indian Science Abstract’ (ISA)(Published by National Science Library), www.ebscohost.com, www.indianjournals.com

The journal is printed on ACID FREE paper.

JADCH is available (full text) online:Website- www.adc.org.in/html/viewJournal.php

This journal is an official publication of Ahmedabad Dental Collegeand Hospital, published bi-annually in the month of March andSeptember.

ISSN 0976-2256E-ISSN: 2249-6653

A

Depression, Let's talk

Depression is a common mental disorder that affects people of all ages, from all walks of life, in all countries.

The risk of becoming depressed is increased by poverty, unemployment, life events such as the death of a loved one or a relationship break-up, physical illness and problems caused by alcohol and drug use. Depression causes mental anguish and can impact on people's ability to carry out even the simplest everyday tasks, with sometimes devastating consequences for relationships with family and friends. Untreated depression can prevent people from working and participating in family and community life. At worst, depression can lead to suicide. Depression can be effectively prevented and treated. Treatment usually involves either a talking therapy or antidepressant medication or a combination of these. Overcoming the stigma often associated with depression will lead to more people getting help. Talking with people you trust can be a first step towards recovery from depression.

Editor - in - ChiefDr. Darshana Shah

Co - EditorDr. Harsh Shah

Editorial Board:Dr. Mihir Shah

Dr. Ganesh M

Dr. Monali Chalishazar

Dr. Neha Vyas

Dr. Sonali Mahadevia

Dr. Shraddha Chokshi

Dr. Bhavin Dudhia

Dr. Mahadev Desai

Dr. Darshit Dalal

Contents

Subscription:Rate per issue: ` 400/-, for one year: ` 750/-, for three years: ` 2,000/-Contact: Ahmedabad Dental College & Hospital Vivekanand Society, Bhadaj-Ranchhod Pura Road, Santej, Post: Rancharda, Ta: Kalol, Dist: Gandhinagar, Gujarat, India.

B

EDITORIAL

FROM THE EDITOR'S DESK .......................................................................................................................................................01

DR. DARSHANA SHAH

REVIEW ARTICLES

1) LIKE FATHER ; LIKE SON: IN SMOKING TOO.................................................................................................................02 HARSH G SHAH*, CHITRANG SHAH**, JINALI SHAH***, ASHAY SHAH****

2) CLINICAL APPLICATIONS OF MINI IMPLANTS IN ORTHODONTICS: A REVIEW.........................................................05 DWIJESH GOSWAMI*, SONALI MAHADEVIA**, NEHA ASSUDANI***, ARTH PATEL****

ORIGINAL ARTICLE

3) ASSESSMENT OF AWARENESS ABOUT PRE-REQUISITES AND INDICATIONS OF PERIODONTAL FLAP SURGERY IN UNDERGRADUATE DENTAL STUDENTS: A KAP STUDY. ............................................................13

PINAL PATEL *, KOMAL THAKKAR **, KHYATI MODI ***, ARCHITA KIKANI ****, HARSH SHAH*****, VACHA PATEL******

CASE REPORT

4) PERIPHERAL OSSIFYING FIBROMA: A CASE REPORT................................................................................................20

CHETAN DILIP ZAWAR*, NARENDRA B. SUPE**, TYAGI TELTUMDE***, KARAN JADHAVI****

5) MACLENNAN SPLINT: IN PEDIATRIC MANDIBULAR BODY FRACTURE- A CASE REPORT......................................23

HARSH SHAH *, DARSHAN PATEL **, NITU SHAH ***, NEHA VYAS ****

6) TREATMENT OF DEEP OVERBITE IN HIGH ANGLE PATEINT WITH SEGMENTED ARCH TECHNIQUE ...................28

KUNAL RAVAL*, SONALI MAHADEVIA**, AATMAN JOSHIPURA***, NEHA ASSUDANI****

7) CORRECTLY POSITIONING THE GEM IN THE NECKLACE - ORTHODONTICALLY…..!!! ...........................................32

MAULI SHAH*, SONALI MAHADEVIA**, AATMAN JOSHIPURA ***, NEHA ASSUDANI****

8) AMLODIPINE INDUCED GINGIVAL ENLARGEMENT: A CASE REPORT .......................................................................38

KRISHNA DAKA*, HARIT SHAH**, MITALI PATEL***, MEGHA PATEL****

9) SUBEPITHELIAL CONNECTIVE TISSUE GRAFT FOR ROOT COVERAGE: CASE-REPORT.......................................43

MEGHA PATEL*, KRISHNA DAKA**, ARCHITA KIKANI***, MIHIR SHAH****

01

Dr. Darshana ShahEditor JADCHEditorial Office:Prof. & Head Dept. of ProsthodonticsAhmedabad Dental College & Hospital,Dist.: Gandhinagar, Gujarat.Email: [email protected]

The Journal of Ahmedabad Dental College and Hospital; 8 (1), March 2017 - August 2017

____From Editor’s desk

Depression Threatens Oral Health

Depression is one of the most prevalent mental health issues and there is significant relationship between depression and oral health, oral health behavior and oral health related quality of life. Physiological consequences of depression may lead to poor oral health due to Xerostomia, Cariogenic diet and Impaired immune functioning contributing to oral infection. Antidepressant medication also causes Hyposalivation and Bruxism.

It is easy to see that the mouth is connected to the rest of the body and vice versa. As a oral health care taker, it is our duty to see the mental well being of each and every patient. So for that, we must take a thorough medical history and perform Intra and Extra Oral Examination which can assist us in delivering the best care to our patient.

Review Article

ABSTRACT

Children of parents who smoke are more likely to get addicted to it in future. The Kids who'd never smoked if exposed to tobacco use were more likely to hold positive beliefs about the killer habit. The longer the time a child is exposed to a parent addicted to smoking, the more likely the youth will not only take up cigarettes but also become a heavy smoker. The Parental smoking cessation early in their children's lives is critical to prevent habitual smoking in the next generation. Hence, other than secondary smoking, the greater risk is of developing an addicted child which is far more lethal and alarming. Thus, adult smoking is actually detrimental for the child's growth and life.KEYWORDS: Periodontal therapy, risk factors, failures.

Keywords: Parental Smoking, Addiction, Children.

Received: 24-01-2017; Review Completed: 17-04-2017; Accepted: 26-05-2017

Harsh G Shah*, Chitrang Shah**, Jinali Shah***, Ashay Shah****

02

LIKE FATHER ; LIKE SON: IN SMOKING TOO

* Reader, **Lecturer, ***Practicing Dentist, **** Practicing Dentist

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. HARSH G SHAH, TEL: +91 9429428940

DEPARTMENT OF PUBLIC HEALTH DENTISTRYAHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

INTRODUCTION:

Smoking among children / teenagers is a crucial concern all over the world. Even the countries like America have taken drastic measures in attempt to eliminate use of tobacco products among teenagers. 90% of smokers are estimated to have begun smoking before the age of 18 (the legal age), therefore it is necessary to reduce the number of youths who start smoking before this age in order to reduce the total number of smokers and harm done to society. There are a number of interpersonal relationships that greatly influence the likelihood that an adolescent will become a smoker. People who encounter smoking on a regular basis will be desensitized to cigarettes and will not likely see the health risks as readily. Parents are the greatest influence on their children's behavior. Children whose parents smoke are twice as likely to become

(1)smokers themselves . Perceived parental opinion is also a major contributing factor in youth smoking. If children believe their parents disapprove of smoking they will be less likely to become smokers. In addition to parental influence, siblings also serve as contributors to youth smoking. Overall, smoking families are much more likely to raise children who will become future smokers than families that instill a negative opinion of cigarettes in their children. Although there are other factors governing the alarming ratio, Parents influence do play an important role in the start and cessation of the habit in children.

Psychology and Perception :

Parental behavior about smoking, not attitudes, is the key factor in delaying the onset of daily smoking. What parents do have an influence on what their children do. Smoking and other habits have been said to be inherited by children, if not through their genes, through cultural conditioning. (2) (11) (12) The same report stated that Whites (43 percent) were more likely to have begun regular smoking by 21 than were blacks (35 percent) and Asian Americans (24 percent). However, Indians (54 percent) were the group most likely to have begun daily smoking by age 21. The lower rate of literacy and poverty were also among the factors which aided in the menace, however parental smoking is still considered to be a primary factor which affects the psyche of the children. Parents may feel that they don't matter to their teens, but this study indicates, they really do. It shows that such factors as not smoking, having good family management skills in setting rules and monitoring behavior, and having a strong emotional relationship with their children matter until the end of adolescence. Exposure to parental nicotine dependence is a critical factor influencing intergenerational transmission of smoking. Adolescents with nicotine-dependent parents are susceptible to more intense smoking patterns and this risk increases with longer duration of

3 exposure. As Parents smoke, children note that smoking cigarettes reduces anxiety and smoking often occurs after stressful events or in stressful situations. Studies find that depressed students are more likely to smoke and have a more difficult time quitting than non-depressed students. 31.9% of college smokers attribute their smoking behavior as a means to alleviate their depression. Depression is related to lower self-efficacy, and depressed individuals are considered less able to resist smoking during times of low self esteem, which leads to higher reports of smoking among depressed individuals. Smoking cigarettes actually increases the amount of depression in young adults. With this, we see a much higher number of depression and stress in college aged students because they are faced with problems they are not equipped to

4handle. Children eventually may model the behavior, particularly if a parent is nicotine dependent. It is difficult to dissuade children from smoking if one or both parents are heavily

dependent on cigarettes. Exposure to parental nicotine dependence is a critical factor influencing intergenerational transmission of smoking are striking and troubling - but they give us a direction

(5)to go in reducing that risk.

What should be done:

The solution is simple and the question rhetoric as the best way to avoid this is quitting the habit (the parents we are talking about here). Keeping children from smoking starts with parents and their behavior. Some parents say they disapprove of teenage smoking, but continue to smoke themselves. The evidence is clear from this study that if parents don't want their children to start smoking, it is important for them to stop or reduce their own smoking. Smoking prevention programs, he said, need components focused on parents, something they generally ignore, to help reduce adolescent smoking .The researchers suggest that

(2)

attitudes, beliefs, and behaviors toward cigarette use are learned through modeling. Therefore, children and adolescents who observe their parents smoking and absorb their experience of a favorable outcome, develop these expectations for themselves over time. Smoking appears to be pleasurable, relaxing, and social and this influences the adolescents' expectations for their own experiences. When parents are counseled about the impact of their smoking on their children, it can be a powerful tool for helping them change their behavior. Often "doing it for the children" is a stronger motivator than taking care of oneself.(6)

Conclusion:

Interventions to achieve cessation among parents, for the sake of the children, provide a worthwhile addition to the arsenal of cessation approaches, and can help protect vulnerable children from harm due to tobacco smoke exposure. However, most parents do not quit, and additional strategies to protect

(7) children are needed. For stressed-out parents, giving up smoking can seem particularly tough -- but it's also especially beneficial. Quitting is as important for your family's health as buckling your

(8)child into his car seat they say. Parents who quit smoking may be less likely to relapse when they discuss the dangers of cigarettes with their children,

(9) a U.S. study suggests. Although you may think that your kids only have ears for what they hear in movies and on TV, parents still have the greatest

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Harsh G. Shah et. al. : LIKE FATHER ; LIKE SON: IN SMOKING TOO

(10)influence on their adolescents' lives. Thus, children follow what their parents do; hence a good

(11)behavior from them instill good habits in them. In conclusion we can safely say that Smoking in Parents and Smoking in children are not different

issues per se and should be considered as two sides of the same coin.

REFERENCES:

1. UICC Factsheet: Effects of tobacco advertising Archived November 19, 2009, at the Wayback Machine.. Globalink.org. Retrieved on 2010-09-29.

2. Children-whose-parents-smoked-are-twice-as-likely-to-begin-smoking-between-ages-13-and-21 as - offspring-of-nonsmokers- washington.edu/news/2005/09/28.

3.ParentalSmokingexposureandadolescentsmokingtrajectories/pediatrics.aappublications.or g/content /133/6/983

4. Morrell, H.E.R., Cohen, L.M., McChargue, D.E. (2010) Depression vulnerability predicts cigarette smoking among college students: Gender and Nega t ive r e in fo rcement expectancies as contributing factors. Addictive Behaviors 35. 607-611.

5. Children of nicotine-addicted parents more l i k e l y t o b e c o m e h e a v y s m o k e r s / sciencedaily.com/releases/2014/05/140512101726

6. Smoke Signals: How Parents' Habits Influence Children's Behavior/the doctors will see you

now.com/content/kids/art2345/retrieved on 25.03.2009

7. Parental Smoking Cessation to Protect Young Children:A Systematic Review and Meta-a n a l y s i s / pediatrics.aappublications.org/content/129/1/141

8. S o L o n g , C i g a r e t t e s : H o w t o q u i t Smoking/parents.com/parenting/moms/healthy-mom/quit-smoking.

9. Talking to kids about smoking risks may help parents quit/www.reuters.com/article/us-health-smokingcessation-parents-kids/talking-to-kids-about-smoking-risks-may-help-parents-quit-idUSKCN0S927I20151015

10. H e l p Yo u r K i d s Q u i t S m o k i n g / stanfordchildrens.org/en/topic/default?id=help-your-kids-quit-smoking-1-2174

11. Textbook of Pedodontics/Shobha Tandon/5th Edition.

12. Essentials of Public Health Dentistry/Soben Peter/3rd Edition

Harsh G. Shah et. al. : LIKE FATHER ; LIKE SON: IN SMOKING TOO

04

Review Article

ABSTRACT

Among the various types of implants, orthodonticmicroscrews are widely used as they have a unique property of providing absolute anchorage and also increasing the range of biomechanical therapy by converting surgical case into a nonsurgical case, which is a boon to any orthodontist. And above all they provide skeletal anchorage without requiring patient cooperation or compromising esthetics. Mini implants are here to stay and will be an integrated part of the armamentarium as they make treatment outcome more predictable and satisfy both patient and orthodontist.

KEYWORDS: Periodontal therapy, risk factors, failures.


Dwijesh Goswami*, Sonali Mahadevia**, Neha Assudani***, Arth Patel****

05

CLINICAL APPLICATIONS OF MINI IMPLANTS IN ORTHODONTICS: A REVIEW

* Post Graduate, **Professor & Head, ***Senior Lecturer, ****Senior Lecturer

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. DWIJESH GOSWAMI, TEL: +91 9662476389

DEPARTMENT OF ORTHODONTICS AND DENTOFACIALORTHOPAEDICSAHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

INTRODUCTION:

Orthodontics involves desired movement of teeth and this is brought about by a variety of appliances. In planning the biomechanical aspects of orthodontic treatment for a specific patient, it is imperative that the orthodontists consider not only the forces required for the necessary tooth movement to achieve the patient's objectives, but also the undesired tooth movement that may occur in response to these forces. One of the concerns of Orthodontists is to provide adequate anchorage for selective movement of individual tooth or a group of teeth in order to eliminate unwanted tooth movement. Maintaining maximum or absolute anchorage has always been an onerous goal for the practicing orthodontist.

Absolute anchorage is defined as no or minimal movement of the anchorage unit (zero anchorage loss) as a consequence to the reaction of forces

1applied to move teeth. Such an anchorage can only be obtained by using ankylosedteeth or dental implants as anchors, both relying on bone to inhibit

2movement. Anchorage provided by devices, such as implants or miniscrew implants fixed to bone, may be obtained by enhancing the support to the reactive unit (indirect anchorage) or by fixing the anchor units (direct anchorage), thus facilitating skeletal anchorage.

DEFINITION1Implants, as defined by Boucher are: 'Alloplastic

devices which are surgically inserted into or onto jaws. Terms such as mini-implants, miniscrews, microimplants, and microscrews have been used to

describe devices of temporary anchorage. The term "Mini-screw" is more appropriate than "micro-implant" from the perspective of scientific

6nomenclature since "micro" means < 10- . Also, the shape and design indicate that "screw" is more appropriate than 'implant'. However since 2004 it was agreed on that the word mini-implant should be applied both to palatal implants, to mini-implants,

3to miniscrews, and to microscrews. Intraoral 4

extradental anchorage systems and temporary 5anchorage devices are other terms that have also

been suggested to describe devices such as mini-implants.

HISTORICAL BACKGROUND6

In 1945, Gainesforth and Highley mentioned the use of implant supported anchorage; they used vitallium screws in six dogs. Creekmore8 1983 used vitallium implant for anchorage for intruding upper anterior teeth.

9In 1997, Kanomi described a mini-implant specifically made for orthodontic use, and in 1998,

10Costa et al. presented a screw with a bracketlike head. Several other miniscrew implants have been introduced since then, each presenting different designs and features. Further, during the last decade, other means of bone anchorage have also

11been proposed, including zygoma wires ,

12,13 14miniplates, and zygoma anchors.

CLASSIFICATION15

Labanauskaiteet al. suggested the following classification in 2005 which is widely accepted

● According to the shape and size

1) Conical (cylindrical)

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Dwijesh Goswami et. al. : CLINICAL APPLICATIONS OF MINI IMPLANTS IN ORTHODONTICS: A REVIEW

- miniscrew implants

- palatal implants

- prosthodontic implants

2) Miniplate implants

3) Disc implants (onplants);

● According to the implant bone contact

1) Osseointegrated

2) Nonosseointegrated;

● According to the application

1) used only for orthodontic purposes (orthodontic implants)

2) used for prosthodontic and orthodontic purposes (prosthodontic implants)

PARTS OF MINI IMPLANT

Implant head:It serves as the abutment and in the case of an orthodontic implant, it is the source of attachment ofelastics or coil springs.

Implant neck:It serves as an attachment of the body and the neck.

Implant body:It is the part embedded inside bone. This may be a screw type or a plate type.

Fig.1

Fig. 2 Various miniscrew implants. A, The Aarhus Anchorage System. B, The AbsoAnchor. C, The Spider Screw Anchorage System. D, The IMTEC Mini Ortho Implant

TYPES OF MINI IMPLANT

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SITES FOR MINI IMPLANT PLACEMENTIn Maxillary zone

Fig 3 Sites for mini implant placement in maxillary arch

In Mandibular zone

Fig 4 Sites for mini implant placement in Mandibular arch

C L I N I C A L A P P L I C AT I O N O F M I N I IMPLANTS IN ORTHODONTICS

1. Mini implant for Retraction2. Molar uprighting 3. Lingual Orthodontics4. Forced eruption of impacted canines5. Intrusion6. Non Extraction Treatment 7. Molar Distalization8. Molar Protraction

1. Mini implant for RetractionEn masse retraction of anterior may require

16heavy anchorage. Hyo-Sang Park used microscrew implants for retraction of six anterior teeth and concluded that treatment time can be reduced effectively and clinicians can move teeth without patient compliance for anchorage devices.

Fig 5

Fig 6 Clinical photograph of retraction using mini implants


08

By using an upward and backward force passing near the center of resistance, the maxillary anterior teeth showed bodily intrusion and retraction. For bodily retraction of the anterior teeth with a slight intrusion, the position of the maxillary microscrew implants should be 8-10 mm apical to the bracket slot with the anterior hooks 5-6 mm gingival to the bracket slot (Fig 5A). With this configuration, the force will pass just under the center of resistance and induce bodily retraction with only slight linguoversion and intrusion. The mandibular microscrew implants provide vertical intrusive force to the archwire distal to the first molars. The mesial movement of the mandibular posterior teeth could move a fulcrum forward and as a result close the mandibular plane in high angle cases. (Fig 5B)

2. Molar uprighting

N u m e r o u s a p p r o a c h e s a r e u s e d f o r uprightingmesially tipped mandibular molars after

stloss of 1 molars. They cause molar extrusion and movement of anchor unit. Hee Moon Kyung and

17Hyo Sang Park used mini implants to obtain absolute anchorage with no side effects on anterior teeth or extrusion of molars. In maxilla mini implants are placed in the tuberosity. In the mandible micro implant are placed in the retromolar area, distobuccal to the second molar. Hyo Sang

18 Park has reported the use of micro implants placed in the alveolar bone palatal to the upper 2nd molar and buccal to the lower 2nd molar which gives palatal and intrusive forces on the upper molar and buccal and intrusive forces on the lower molar. (Fig 7)

Fig 7 Molar Uprighting using mini implants

3. Lingual orthodonticsAnchorage requirements are even more critical in lingual orthodontics than in labial treatment because of the anatomical relationship between the tongue and cortical bone. The best position forplacement of the microscrew implants in the maxilla arch is the palatal interradicular alveolar bone between it and second molars. Jang Seop Lee19reported that mini screw (1.2mm-1.3mm diameter and 10mm-12mm length) can be placed in the palatal alveolar bone in maxillary 1stand 2nd molar at an angle of 300 – 400to the bone for controlling anchorage in lingual sliding mechanics.

4. Forced eruption of impacted caninesIn labial treatment the force required to move a palatally impacted canine into arch causes distortion of arch form and in lingual treatment small arch wires with short inter bracket span and smaller bracket slots may be unable to resist such distortion. To overcome these mini implants can

20play a key role. Hyo Sang Park et al reported that micro implant can be used for eruption of impacted canines.A small implant (1.2mm diameter and 8mm long) should be used due to lack of alveolar bone &should be placed in the labial cortical alveolar bone on this

0 0line of force at an angle of 10 – 20 to the bone surface andparallel to the long axis of tooth as possible. This keeps the apex of screw from contacting the root. The head of the implant should be located as incisally as possible to maximize the vertical component of force. (Fig 9)

Fig 8 Retraction using mini implants in lingual orthodontics

Fig 9 Forced eruption on impacted canine using mini implants


09

5. Intrusion21Yeon-Joo Chang has suggested use mini implants

for molar intrusion without side effects in which two mini implants are placed one on the buccal side and another on palatal side and force is applied on to the molar. In another method 2 mini implants are used buccally and one implant in palate to prevent the buccal faring.(Fig 10)

INCISORS INTRUSIONIt can be carried out by placing 2 mini implants between lateral incisor and canine and applying force on to the bracket or on to the wire (Fig11)

Fig 10 Molar intrusion

Fig 11. A) Pre Intrusion

Fig 11. B) Post Intrusion

6. Non Extraction Treatment22

Hyosang park reported that with the use of Microscrew implants one can retract whole dentitions and can eliminate the adverse reciprocal movement andmaximize the efficiency of the treatment.

In non-extraction treatment, the biomechanics of anterior teeth retraction invovles the contact of the teeth on the crown which act as a resistance to movement, whichcreates a counterclockwise moment on the anterior teeth. (Fig12.A) These movements are acceptable in the case of retracting lingually tipped upper anterior teeth.

Fig 12


When retracting the upper anterior teeth showing labial tipping or normal inclination in non extraction treatment, the counterclockwise moment on the upper anterior teeth should be eliminated. By applying distal force to the crown of the teeth, the distal force was transmitted through the crown. After creating space by moving the posterior teeth distally against the microscrew implants, the anterior crowding could be resolved without flaring of the maxillary incisors.(Fig 12.B. C)

The microscrew implants, placed deep to the vestibule sulcus, could not produce a sufficient horizontal component of force to retract the anterior teeth. This is because the higher the microscrew implants were placed the more vertical was the vector of the force. (Fig 12.D) The occlusogingival position of the microscrew implants therefore should be lower in non extraction treatment than in extraction, which will contribute to the increased horizontal-vector of the force.

When less than 3 mm of distal movement of the posterior teeth was needed, the microscrew implants could be placed between the maxillary second premolars and first molars. When more than 3 mm of posterior movement of the posterior teeth was required, the palatal alveolar bone between the maxillary first and second molars is a good position for microscrew implant placement because there was much more space on the lingual side.

7. Molar Distalization

Molar distalization can also be carried out by taking skeletal anchorage using mini implants. Various appliances can be fabricated which incorporates mini implants with them for anchorage. Using mini implants prevents undesirable movements of other teeth and gives control movement. Some of the implant supported molar distalizer includes Bone

23anchored Pendulum appliance , mini implant 24supported distal jet appliance , skeletal Pendulum

25K appliance (Fig 13), mini implant supported 26

sliding jig (Fig 14) etc.

Fig 13 Skeletal K Pendulum appliance

Fig 14 Mini implant supported Sliding jig


10

8. Molar ProtractionMini implants can also be used to protract the molar in cases where the extraction spaces need to be closed by bring the molar forward. With use of force modules or niti coil springs on mini implants molar protraction can be carried out. (Fig 15)

ADVANTAGES OF MINI IMPLANT• Insertion and removal is easy as it is a less invasive surgical procedure• Miniscrew implants can be easily inserted chair side in one appointment, even by the

Fig 15 Molar Protraction

orthodontist. • There is no need for complicated clinical and laboratory procedures (i.e., fabrication of acrylic splints by taking imprints with additional implant copying systems to accurately transfer the implant position to cast models) to facilitate safe and precise implant insertion.• Miniscrew implants can be immediate loaded (there is no need for a waiting period for osseointegration, in contrast to orthodontic implants), reducing the total treatment time.• Miniscrew implants can be inserted at safe location without damaging vital anatomic structures. • The p rov ided abso lu te anchorage eliminates undesirable effects on the teeth that otherwise would have been normally used as anchorage.• Pa t i en t coope ra t ion i s l imi t ed to maintaining immaculate oral hygiene. DISADVANTAGES OF MINI IMPLANT• Damage of the adjacent tissues or root injuries might occur as a result of improper insertion.• Irritation or inflammation of peri-implant tissues and consequent failure of the miniscrew implant is also possible, especially by patients with poor oral hygiene.

CONCLUSIONConsidering Newton's Third Law, it is virtually impossible to achieve absolute anchorage condition with intraoral anchorage thus making it extremely difficult to achieve excellent result without compromising treatment. With skeletal anchorage, orthodontic tooth movements beyond the realm of the conventional orthodontic practice can the accomplished successfully. It can be considered as an exceptional method to control anchorage, thus it is a boon to orthodontist.

Skeletal anchorage considerably extends the range of biomechanical therapy by decreasing the need for extra oral anchorage. The newer anchorage systems provide skeletal anchorage without requiring patient co-operation or compromising esthetics. With anchorage consideration no longer an issue, orthodontic mechanotherapy can be


11

greatly simplified. These skeletal fixtures make treatment outcome more predictable and satisfying for both the patient and the orthodontist.

REFERENCES:

1. Daskalogiannakis J. Glossary of orthodontic terms. Leipzig: Quintessence Publishing Co.; 2000.

2. Melsen B, Garbo D. Treating the “impossible case” with the use of the Aarhus Anchorage System. Orthod 2004;1S:13-20

3. Carano A, Melsen B. Implants in orthodontics. ProgOrthod 2005;6:62-9.

4. Melsen B, Verna C. A rational approach to orthodontic anchorage. ProgOrthod 1999;1:10-22.

5. Cope J. Temporary anchorage devices in orthodontics: a paradigm shift. SeminOrthod 2005;11:3-9

6. GainsforthBl Et Al. A Study Of Orthodontic Anchorage Possibilities In The Basal Bone . Am J Orthod Oral Surg 31:406-417,1945

7. Linkow LI. Implanto- Orthodontics. J ClinOrthod 1970; 4:685-90

8. Creekmore Td, Eklund Mk. Possibility Of Skeletal Anchorage. J ClinOrthod 1983; 17:266-9.

9. Kanomi R. Mini-implant for orthodontic anchorage. J ClinOrthod 1997;31:763-7.

10. Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic anchorage: a preliminary report. In t J Adul t OrthodonOrthognathSurg 1998;13:201-9.

11. Melsen B, Petersen JK, Costa A. Zygoma ligatures: an alternative form of maxillary anchorage. J ClinOrthod 1998;32:154-8.

12. Nagasaka H, Sugawara J, Kawamura H, Kasahara T, Umemori M, Mitani H. A clinical evaluation on the efficacy of titanium miniplates as orthodontic anchorage. Orthod Waves 1999; 58:136-47.

13. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H. Skeletal anchorage system for o p e n - b i t e c o r r e c t i o n . A m J OrthodDentofacialOrthop 1999;115:166-74.

14. De Clerck H, Geerinckx V, Siciliano S. The Zygoma Anchorage System. J ClinOrthod 2002;36:455-9

15. Labanauskaite B, Jankauskas G, Vasiliauskas A, Haffar N. Implants for orthodontic anchorage. Meta-analysis. Stomatologija 2005;7:128-32

16. Park Hs, BaeSm, Kyung Hm, Sung Jh. Micro-Implant Anchorage For Treatment Of Skeletal Class I Bialveolar Protrusion, J ClinOrthod. 2001;Jul; 35(7) :4127-22

17. Park Hs, Kyung Hm, Sung Jh. A Simple Method Of Molar Uprighting With Micro-Implant Anchorage. J Cl inOrthod. 2002 Oct ; 36(L0):592-6

18. Park Hs, Kwon Ow, Sung Jh, Uprighting Second Molars With Microimplant Anchorage. J. ClinOrthod 2004; 38: 100- 103

19. Lee Js, Park Hs, Kyung Hm, Microimplant Anchorage For Lingual Treatment Of A Skeletal Class- II Malocclusion. J. ClinOrthod 2001; 35(10) 643- 47.

20. Park Hs, Kwon Ow, Sung Jh, Microimplant Anchorage For Forced Eruption Of Impacted Canines J. ClinOrthod. 2004; 38; 297- 302.

21. Chang Yj, Lee Hs, Chun Ys, Microscrew Anchorage For Molar Intrusion J ClinOrthod 2004; 38; 326- 330.

22. Park Hs, Kwon Tg, Sung Jh, Non Extraction Treatment With Microscrew Implants. Angle Orthod 2004; 74: 539- 549.

23. Kircelli BH, Pektaş ZO, Kircelli C. Maxillary molar distalization with a bone¬anchored p e n d u l u m a p p l i a n c e . A n g l e O r t h o d 2006;76:650–9.

24. Kinzinger GS, Diedrich PR, Bowman SJ. Upper molar distalization with a miniscrew-supported Distal Jet. Journal of clinical orthodontics: JCO. 2006 Nov;40(11):672.

25. Ludwig B, Glasl B, Kinzinger GS, et al. The skeletal frog appliance for maxillary molar distalization. J ClinOrthod 2011;45:77.

26. Lim JK, Jeon HJ, Kim JH. Molar distalization with a miniscrew-anchored sliding jig. Journal o f c l in ica l o r thodont ics : JCO. 2011 Jul;45(7):368.


12

ABSTRACT

BACKGROUND: Periodontal flap surgery is indicated for surgical elimination of periodontal pockets, reattachment, and bone regeneration and to correct gingival and mucogingival defects. It becomes very important to know this otherwise it becomes precarious when there is a professional negligence or ignorance.

MATERAILS AND METHODS: The objective of our study was to access the knowledge, aptitude and practice about pre-requisites and indications of periodontal flap surgery among undergraduate dental students. A total of 200 undergraduate dental students who attended periodontology lectures and attended Periodontology clinics were selected for the study. Data on their knowledge and aptitude regarding pre-requisites and indications of flap surgery was collected by means of 15 self-administered close-ended questionnaires. Design: Institutional Based Cross- Sectional Study. Knowledge, Attitiue and Perception Study.

RESULTS: All students answered the questionnaire completely. It was shown that third year students were less accredited compared the final year dental students. These results were speckled for the final year students. This was all due their (fourth/final year students) more clinical experience in the field.

CONCLUSION: The present study indicates that awareness of pre-requisites and indications of flap surgery awareness among study participants was below average and needed to be improved.

KEYWORDS: periodontal flap surgery, gingival defects, mucogingival defects, periodontal pockets, knowledge, attitude, perception


Pinal Patel *, Komal Thakkar **, Khyati Modi ***, Archita Kikani ****, Harsh Shah*****, Vacha Patel******

13

ASSESSMENT OF AWARENESS ABOUT PRE-REQUISITES AND INDICATIONS OF PERIODONTAL FLAP SURGERY IN UNDERGRADUATE DENTAL STUDENTS: A KAP STUDY.

*Post Graduate, **Post Graduate, *** Post Graduate, ****Professor, *****Reader, ****** Post Graduate

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. PINAL PATEL, TEL: +91 7624066210

DEPARTMENT OF PERIODONTICS. DARSHAN DENTAL COLLEGE AND HOSPITAL, UDAIPUR, RAJASTHAN.DEPARTMENT OF PERIODONTICS AND ORAL IMPLANTOLOGY. AHMEDABAD DENTAL COLLEGE AND HOSPITALDEPARTMENT OF ENDODOTICS DHARAMSINH DESAI DENTAL COLLEGE AND HOSPITAL

Original Article

INTRODUCTION:

In our day-to-day dental practice, periodontal surgical therapy is generally administered for pocket elimination as the main objective. The main objective of periodontal surgery is to contribute to the long-term preservation of the periodontium by facilitating plaque removal & plaque control &

1,2periodontal surgery can serve this purpose.

Periodontal flap surgery describes the state of-the-art techniques and most commonly used approach to the surgical treatment and plastic surgical repair of periodontal pockets. “Pocketing” is the end result of inflammation and infection that causes the loss of tissue attachment to the teeth, one common

2consequence of periodontal (gum) disease.

Treatment is based on an understanding of the disease process, the interaction between the bacterial biofilm or plaque collections at the gum line and the immune (resistance) system in a person susceptible to (likely to get) this disease. The long-term goal of periodontal surgery is to help increase the life expectancy of the teeth.

It is not a cure, but rather creates an environment that makes it easier to maintain health. Treatment is

therefore aimed at controlling the basic cause — the bacterial biofilm — over a lifetime. Vigilance in home care and regular periodontal recall cleanings

3,4and monitoring are necessary to ensure success.

The purpose of periodontal surgery is to treat deformities and tissue loss created by the disease process, eliminating “pockets” of diseased tissue in order to create and maintain periodontal health. Techniques have been developed to deal with the gingival (gum) tissues and underlying bone. The objectives of periodontal flap surgery are to:

• Eliminate or reduce pockets.

• Regenerate periodontal tissues and their (re)-attachment to the teeth.

• Create more normal periodontal form, function, and aesthetics;

• Promote an environment more conducive to g o o d o r a l h y g i e n e p r a c t i c e s a n d

1,4professional maintenance care.

Current surgical flap techniques are based on a sound understanding of wound healing and are therefore designed to enhance and maximize the body's healing potential. Flap surgery is the most conservative and versatile way to treat periodontal

14

pocketing. An internal surgical opening is used to access the affected gum tissues to create and raise a “flap” of gum tissue, similar to opening the flap of an envelope, aimed at the conservation of all healthy tissue. This approach allows:

• Removal of inner diseased tissue lining the pockets. (This tissue is ulcerated, resulting in open sores within the gum tissues, which are chronically inflamed.)

• Access to treat and clean root surfaces completely.

• Regeneration of lost bone and periodontal ligament.

• Intimate closure of the healthy tissues leaving no open wounds for rapid and

2,3comfortable healing.

A periodontal specialist/periodontist trained in periodontal surgical techniques typically performs these procedures or general dentists who have taken advanced training in periodontal surgery. Most procedures are carried out with local anesthesia, which contains epinephrine (adrenalin) that ensures the anesthesia lasts for the procedure and that there is minimal bleeding. However, they are sometimes performed with the additional use of oral anti-anxiety/sedation medication or intravenous conscious sedation so that patients are awake, but in a more relaxed state. The innovations used in flap surgery are the result of years of periodontal research and the periodontal surgeon's knowledge, training and experience of what techniques to use —

4and when and how to use them.

It is very important for the undergraduate dental students who are soon going to be these good hands for treatment of periodontal conditions to know their indications.

This study was thus performed to assess their knowledge and awareness regarding the re-requisites and indications of flap surgery.

METHODS

A structured, self-administered questionnaire with 15 questions was used to access the knowledge and aptitude of 200 undergraduate dental students. Participants who attended Periodontology lectures r e g u l a r l y a n d w o r k e d e x c l u s i v e l y i n Periodontology Clinics were selected through convenient sampling in the study. There were 10

questions about knowledge and 5 questions about aptitude, which were accessed. The questionnaire study was conducted with participants with their consent and assurance of confidentiality was provided. Name and study year of the participants was noted. Experts f rom Department of Periodontology and Department of Preventive and Community Dentistry, Ahmedabad Dental College and Hospital, Ahmedabad checked for face and content validity of the surveying instrument (questionnaire). Based on the content validity ratio, the items in the questionnaire were modified or deleted. Pilot testing was done on 10 subjects selected from the undergraduate dental school selected through random sampling. Pilot study was conducted to check the adaptability of the questionnaire amongst the study group in respect to wording, clarity and comprehension. The pilot also helped to interpret the meaning of every question included in the questionnaire in an appropriate manner and the participant perception about it. The questions were objective questions or had multiple choices and participants had to select from the options. The study was undertaken after approval from ethical committee of Ahmedabad Dental College and Hospital. The answered questionnaire was converted to binary data and the data was analyzed using SPSS (SPSS 6.0 version 22). Number and percentage distribution of the participants' responses were calculated.

RESULTS

This study was conducted to assess the awareness about pre-requisites and indications of flap surgery in undergraduate dental students studying in a dental hospital in Ahmedabad.

A total of 200 study participants were selected for the study. All the students completed the questions and nobody refused. When questions were asked pertaining to their knowledge, 82% of the students knew at least two probes used in the field. 21% of students knew the brushing technique to be advised to periodontal-compromised patients. 96% of the students answered that medical history was important before treating the patient. 74% of the students did understand and state the correct signs of periodontal pathological condition. 49% of students did know the correct aids used to identify periodontal disease. When students' knowledge was tested regarding flap surgery, mere 11% of students knew the pathological probing depth when flap

Pinal Patel et. al. : ASSESSMENT OF AWARENESS ABOUT PRE-REQUISITES AND INDICATIONS OF PERIODONTAL FLAP SURGERY IN UNDERGRADUATE DENTAL STUDENTS: A KAP STUDY.

15

surgery could be indicated; 13% of students answered pertaining to tooth mobility and periodontal condition; 26% of students knew about the grafting materials used in dentistry; 46% of the students did know what outcomes could be achieved as a healing consequence of flap procedure; 9% of students knew about granulation tissue and calculus as a factor to be considered during debridement while doing flap procedure; 71% of students knew at least one suture material used during flap surgery. When considering perio-aesthetic surgeries, 8% of students considered periodontal approach for treating such conditions. 31% of students knew regarding the healing phase after flap surgery. 64% of students did tick maintenance phase to be important for the periodontal compromised patient.

DISCUSSION

This study assessed attitude, knowledge and practice of undergraduate dental students (third year and final year) attending periodontics clinics in a local dental institution regarding the pre-requisites of flap surgery. In this study, a private dental college and hospital was selected. These institutions apart from treating patients provide thorough dental schooling to students and prepare them for dental graduation. A number of hospitals provide such schooling. In the present study, all the study participants (third year and final year undergraduates) who attend Periodontics clinics at the hospital were selected. The data was collected by means of structured questionnaire. The questions were written at a language level that allowed comprehension even by the youngest subjects. Furthermore, the investigator was always available during the completion of the questionnaire, and the subjects were encouraged to approach him whenever they needed clarification of any point.

Flap procedures are the gold standard for correcting and treating any periodontal condition. But the main objective lies in diagnosing the condition and then meticulously treating the pathology. The above objective can be achieved when the operating personnel empowers thorough knowledge and apply it in clinical situations. Keeping this in mind, in the present study, undergraduate dental students (third year and final year) were selected to be the participants as they have periodontology syllabus in their curriculum. The questionnaire given was

close- ended and on most occasions in order to obtain accurate response in relevance to knowledge, whereas whenever the attitude and perception evaluation was required a leading question was given.

Evaluation of the results of the current study showed that all participants were aware that all participants were aware of the fact that, flap surgery is a means for treating a periodontal pathology, but detailed in-depth knowledge should be required pertaining to the subject. Among all the students evaluated, a subtle variation was noted in regard to knowledge and understating on basic periodontics in an ascending order from third year. A classic example is that, when questioned about the aids used in investigating periodontal disease, 91% of the third years preferred to follow, intra-oral radiographs and orthopentograms; whereas majority of the fourth years claimed it to be CBCTs and denta-scans also. This contrasting aspect can be attributed to less clinical experience of third year students.

From the current study it is arguable that the participants were aware of the basic knowledge regarding periodontal procedures, it was more so with final year students followed by third years. Although this study is first of its kind and no similar studies were available for comparison, the results fits well with our hypotheses that the KAP of undergraduates towards indications of periodontal flap procedure was limited and this can be attributed to the community as a whole. However further studies with a larger sample size are required to validate our hypotheses. Moreover, the current study is a single institution based, hence a cross-sectional study comprising of similar samples utilizing multiple institutional participants are required for authentication.

In the current study design, a week after completion of the study all the participants were recalled and a reassurance program was conducted regarding basic periodontics and indications and pre-requisites of flap surgery. The program included lectures on basic periodontics, definitions, anatomy of peridontium, instruments, pathology in periodontium and various surgical techniques with their indications, contr-indications, advantages and dis-advantages. Each participant was individually recalled, counseled and stressed to update


16

knowledge regarding periodontal flap procedure.

CONCLUSION

The present study indicates that awareness of pre-requisites and indications of flap surgery awareness among study participants was below average and needed to be improved. Although they gave importance to considering flap surgery as a modality for peridontally compromised patients, they could not replicate it in their practice due to lack of knowledge. The level of knowledge was speckled (more with final years) it is arguable that more they get exposure to clinical situations, more is the awareness. Similar studies with reassurance programs at regular intervals should be carried out at institutional and national level for assessment of their knowledge regarding basic periodontics, pathology and related surgical and non-surgical management.

DRAWBACKS OF THE STUDY

Our current study is based on one single institution, which can lead to a bias due to non- normal data,

lower subjects and minimum variability. It could have been a multiple institutional cross-sectional study to cover more subjects (a bigger sample size) with their variable knowledge to control the skewness in the data. Moreover the data could become normal and all the biases could be controlled thereby. The study results cannot be hence considered to be authentic. A larger sample size should have been used including interns along with third year and final year students again to control the subject related errors. Furthur studies, which include national level institutions, should be done.

RECOMMEDATIONS

The drawbacks in our study should have to be corrected by increasing the sample size. Such programs along with reassurance program at regular intervals should be carried out. This will help students to be updated on their knowledge regarding periodontal procedures and thus improve their quality once they come out as dental graduates.

REFERENCES:

1. Wilson, Korman, Newman. Advances in periodontics.

2. Carranza. Clinical periodontology Newman, 9th edition

3. Pathology of periodontal disease. Williams, Hughes, Odell.

4. Outline of periodontics Manson, Eley, 4th edition.

5. SC Savant, S Hegde, RV Shirahatti, D Agarwal. Cultural Competency amongst dental practitioners in Mumbai- A KAP Study. JADCH. 2016: 7; 34-40

6. Harikiran A G, Pallavi S K, Hariprakash S, Ashutosh, Nagesh K S. Oral health-related KAP among 11- to 12-year-old school children in a government-aided missionary school of Bangalore city. Indian J Dent Res 2008;19:236-42

7. MPV Prabhat, S Sudhakar, B Praveen Kumar, Ramaraju. Knowledge, attitude and perception (KAP) of dental undergraduates and interns on radiographic protection- A questionnaire based cross- sectional study. J Adv Oral Res 2011: 2;3; 45-50

8. Khinda PK, Mahajan R, Gill AS, Uppal RS,

Kaur J, Shewale A, Saravanan S P, Bhatia N. Assessment of preventive dental care among dental students and dental professionals in India: A knowledge, attitude, and practice study. Saint Int Dent J 2015;1:105-11

9. Grewal N, Kaur M. Status of oral health awareness in Indian children as compared to Western children: A thought provoking situation (A pilot study). J Indian Soc Pedod Prev Dent 2007;25:15-9

10. Humagain M. Evaluation of Knowledge, Attitude and Practice (KAP) About Oral Health Among Secondary Level Students of Rural N e p a l - A Q u e s t i o n n a i r e S t u d y . W e b m e d C e n t r a l D E N T I S T R Y 2 0 1 1 ; 2 ( 3 ) : W M C 0 0 1 8 0 5 d o i : 10.9754/journal.wmc.2011.001805

11. KA Kolawole, EO Oziegbe, CT Bamise. Oral hygiene measures and periodontal status of school children. Int J Dent Hygiene 2011: 143-148

12. J alderhaug, JE Ellingsen, A Jokstad. Oral Hygiene, Periodontal conditions and carious lesions in patients treated with dental bridges: A 15- year clinical and radiographic follow-up study. J Clin Periodonl 1993: 482-489


ROLE OF BOTROCLOT AS A LOCAL HAEMOSTATIC AGENT DURING FLAP SURGERY

KRISHNA DAKA *, ARCHITA KIKANI **, MIHIR SHAH ***, MEGHA PATEL****, HARSH SHAH*****

17

Original Article

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. KRISHNA DAKA, TEL: +91 9825217274

DEPARTMENT OF PERIODONTICS AND ORAL IMPLATOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.DEPARTMENT OF PUBLIC HEALTH DENTISTRY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ABSTRACT

Botroclot is an enzyme complex. It has coagluative and antihemorrhagic properties. This prospective study compared two surgical sites in each subject. One site received topical botroclot while other site did not receive it. Both the sites were chosen in the same patient & flap surgery was done at separate intervals. Haemostasis during flap surgery was achieved by pressure pack technique on control side & on test side botroclot was applied & time measurement was done. It has been concluded from this study botroclot not only helps in achieving haemostasis but also helps in faster healing of the surgical site by rapid formation of healthy tissue & reducing the amount of infection which may alter the normal healing process.


*Post Graduate, **Professor, ***Professor and Head, ****Post Graduate, *****Reader

INTRODUCTION:

Bleeding during oral surgical procedures can cause distress agony & discomfort to the patient. It also distracts the surgeon from operating field leading to frustration and time consumption. Bleeding can be due to variety of local or surgical factors, control of which may require additional haemostatic agent as well as considerable armour of the surgeon.

Therefore, knowledge of fundamental of normal and deranged Hemostasis is a critical factor in successful and evenful conduction of a surgical procedure and obtaining of maximum patient compliance, along with achievement of clear dry surgical field.

Drugs that arrest bleeding promote epithelization and provide relief from pain have been widely used in oral surgical procedures, it is a well known fact that snake venom one of the most concentrated enzyme sources, is a valuable expedient of the healing process.

Botroclot (Juggat pharmaceuticals) a topical preparation that is prepared from snake venom contains extracted hemocoagulase. It is used for its procoagulant properties as well as healing properties. It has been introduced to arrest bleeding at the site of injury. Botroclot, a non toxic systemic hemocoaglunt fraction of venom is obtained from the Brazilian snake Bothrops-jararaca or atrox. Preparations are available all over the world by different names e.g. Batroxobin – a WHO approved product, Botrophase- a systemic procoagluant. The preparation of Botroclot topical solution in each ml contains (a) Bothrops atrox or Bothrops jararca 0.2

cu/ml (b) chlorhexidine 0.1% v/v (as a preservative) and (c) water for injection IP q.s.. Botroclot has multifaceted procoagulant actions. It accelerates the formation of fibrin monomers and hastens fibrin clot formation. It activates factor Xa helps in the formation of thrombin at the site of hemorrhage. It is also found to be stabilizing the fibrin by an action of the factor XIIIa. A few reports have suggested that this parental preparation acts like a prohealer, enhances epithelization, increases wound tensile strength and turnover of collagen in the healing wound. It reduces bleeding time, promotes wound healing by promoting the growth of capillaries in wound space. It is highly resistant to plasmin wherein no withdrawal bleeding is found. Considering all these therapeutic uses of Botroclot, a present study was carried out and analysis of 40

1cases was done.

Material & methods:

This study was conducted at period of 4 months duration. Patients were included during the study period if they satisfied the inclusion criteria. The study protocol was explained & informed consent was obtained from all patients who were involved in the study. Patients who could not adhere to the study protocol of follow up were excluded from the study. Inclusion criteria were; patients aged between 30 and 65 years having generalized chronic periodontitis undergoing flap surgical procedures. All the sites were chosen such that they were not located in close proximity and surgical procedures were done at different time intervals. The site where Botroclot/Botrophase was applied was taken as

18

“Test” site where as other site was chosen as the “Control” site in the same patient. Exclusion criteria included patients with known premorbid conditions like thromboembolic disorders, hypertension, hemophilia, diabetes mellitus, anticoagulant therapy, pregnant patients, hypersensivity to topical solution & other constituent of the formulation, HIV positive patients and patients with mental illness. Clinical information with respect to demographic details, reason for flap surgery was noted. Once, the patients were included in the study, complete blood count, coagulation profile, bleeding time & clotting time was evaluated.

Flap surgical procedure was done under local anesthesia (2% lignocaine with 1: 1,00,000 adrenaline) using standard technique. At the first site after debridement, site was filled with solution & measurement of time from application of solution into site up to complete stoppage of bleeding by

9stopwatch was done.

After 24 to 48 hours later, flap surgical procedure was carried out at another site which required, as identified on day one. Saline pressure pack was given to achieve hemostasis at this site. This site was chosen as the control site solution was not applied to this site. Postoperative care & follow up was done.

Results & Observations:

Table: patient distribution according to the time required to stop bleeding

Present study was conducted to study role of as a local haemostatic agent during flap surgery. 50

Time (Mins)

0.0-1.0

1.0-1.25

1.25-1.50

1.50-1.75

1.75-2.00

2.25-2.75

2.75-2.50

2.50-2.75

2.75-3.00

3.00-3.50

3.50-4.00

4.00-4.50

4.50-5.00

Test

-

15

10

18

-

2

5

-

-

-

-

-

-

Control side

-

-

-

-

-

-

-

5

12

18

8

7

-

patients were selected according to inclusion criteria and evaluated primarily for bleeding stoppage after debridement during flap surgery.Discussion:Hemostasis in oral cavity is dependent upon the dynamic balance between fibrin formation and resolution and is influenced by external environment, which contain both plasminogen and plasminogen activators. Therefore knowledge of normal and deranged Hemostasis is a critical factor to carry out a surgical procedure uneven fully and for obtaining good patient compliance. Resorbable haemostatic agents such as gel foam, absorbable collagen, microfibrillar collagen etc. have risk of adherence and infection specially if any portion remains unabsorbed by tissue, also owing to hydrophilic properties of microfibrillar collagen, it tends to adhere the gloves and instruments, and it is expensive and messy. Biological agents such as thrombin, fibrin glue are technically difficult to manipulate, especially in wet regions such as bleeding surgical sites, also they carry the risk of viral disease transmission and but not the least these

2agents are very expensive.The special features of centers on the fact that, its thrombin like action is present even in the absence of clotting factors. It also enhances the conversion of prothrobin into thrombin. The actions Botroclot/Botropase continue even in the presence of antithrombin and not absorbed in fibrin clot; hence the action of Botropase/Botroclot is prolonged. It helps to form a fibrin bridge that promotes growth of capillary and collagen fibers in wound space. This hastens the wound healing by reducing the wound infection and thus benefitting the patient.In this study bleeding was stopped in range of 1.00 to 2.50 minutes in all the patients, with mean value of 1.42 minutes on the test side. While on the control side bleeding was stopped in range of 2.50 to 4.50 minutes, with mean value of 2.18 minute, hence faster haemostasis was achieved on side (Table)Conclusion:It has been concluded from present study that application of Botroclot after debridement in flap procedure will achieve faster Hemostasis and helps in wound healing by rapid formation of healthy tissue and reducing amount of infection.

Krishna Daka et. al. : ROLE OF BOTROCLOT AS A LOCAL HAEMOSTATIC AGENT DURING FLAP SURGERY

19

REFERENCES:

1. Int j res med. 2015; 4(3); 14-17

2. Ann maxillofacial surg. 2014 Jan-Jun

3. Indian journal of pediatrics 2011; 78(7); 838- 844

4. Indian journal of surgery, may 1990; 52 (5); 218-221

5. Perspectives in clinical research; april-june 2014; (5)2

6. Introduction to blood coagulation. The medical b i o c h e m i s t r y p a g e . http://themedicalbiochemistrypage.org/blood-

coagulation.html. accessed november 14, 2012

7. Textbook of Medical Physiology Guyton 8th edition

8. Erwin P. Barrington. An Overview of Periodontal Surgical Procedures. Journal of Periodontology 1981 Sep (518 - 528)

9. Newman, Takei, Klokkevold Carranza. Carranza's Clinical Periodontology. 10thedn. Pg 926-936

10. Glickman. Clinical Periodontology: 8th edn.

11. Jan Lindhe. Clinical Periodontology and Implant Dentistry: 4thedn.

Krishna Daka et. al. : ROLE OF BOTROCLOT AS A LOCAL HAEMOSTATIC AGENT DURING FLAP SURGERY

PERIPHERAL OSSIFYING FIBROMA: A CASE REPORT

Chetan Dilip Zawar*, Narendra B. Supe**, Tyagi Teltumde***, Karan Jadhavi****

20

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. CHETAN DILIP ZAWAR, TEL: +91 9730183603

ABSTRACT

Peripheral ossifying fibroma (POF) is one of the inflammatory reactive hyperplasia of gingiva. It represents a separate clinical entity rather than a transitional form of pyogenic granuloma and shares unique clinical characteristics and diverse histopathological features. We present a case of POF in a 21-year-old male patient in the lower left premolar region gingiva, the clinical presentation of which differs from the usual presentation. Differential diagnosis and some interesting facts of POF are discussed.

Keywords: Calcifications, gingival hyperplasia, ossifying fibroma


*MDS Oral & Maxillofacial Surgery, **MDS Oral & Maxillofacial Surgery, ***MDS Oral & Maxillofacial Surgery, ****MDS Oral & Maxillofacial Surgery

A Case Report

INTRODUCTION:

Many types of localized reactive lesions may occur on the gingiva including focal fibrous hyperplasia, pyogenic granuloma and peripheral ossifying fibroma (POF).1-3 These lesions arise as result of local irritants, trauma, plaque, calculus, restoration and dental appliances.2-3 The purpose of this study is to present a case report of POF and to emphasize on the treatment modality.

CASE REPORT

A 21-year-old male reported to C.S.M.S.S. D E N TA L C O L L E G E A N D H O S P I TA L , Aurangabad, Maharashtra, India, with his slow growing, painless growth that had been present in lower left canine to premolar region. Lesion started as a small papule approximately 1 year earlier (fig. 1,2,3). According to the patient, there was no bleeding and pain except difficulty in mastication. Examination revealed approximately 3 × 1.5 cm pedunculated non-tender, firm, pinkish red growth present on the buccal gingival in relation to mandibular left canine to 1st premolar region, lesion extended up to the level of occlusal plane and revealed indentations made by the occluding mandibular premolar. The surface of the growth was pinkish red in color. No secondary changes were seen related to ulceration and fungation. The clinical differential diagnoses for the growth were pyogenic granuloma, traumatic fibroma, and peripheral giant

Cellgranuloma, and peripheral ossifying fibroma, and provisional diagnosis of pyogenic granuloma with respect to the 32-33 regions were made for the gingival growth.

Fig. 1

Fig. 2

Fig. 3

C.S.M.S.S. Dental College And Hospital, Aurangabad, Maharashtra, India

21

Fig. 4

Fig. 5

Radiographic examination

Radiographs were obtained. The radiographs did not reveal any abnormality and there was no finding pertaining to the multiple exophytic lesions. (fig.4, 5)

Histopathological examination

On histopathological examination, upon low power magnification (4x), the lesional tissue exhibited a keratinized stratified squamous epithelium (gingiva), overlying a fibrous connective tissue stroma exhibiting dense interlacing bundles of collagen and numerous ossifications. High power magnification (40 x) showed pink homogenous calcified tissue (ossification), with a presence of osteocytes entrapped in the lacunae. The histology for all the lesions was the same.

Fig. 6

Fig. 7

Follow up

The patient presented for a follow-up examination 20 days postoperatively. The surgical site appeared to be healing well. There was no evidence of recurrence of the lesion and the child was asymptomatic (fig.8)

Fig. 8

Chetan Dilip Zawar et. al. : PERIPHERAL OSSIFYING FIBROMA: A CASE REPORT

22

Discussion

Menzel first described the lesion ossifying fibroma in 1872, but its terminology was given by Montgomery in 1927.4 Peripheral ossifying fibroma occurs mostly in craniofacial bones and categorized into two types central and peripheral. The central type of ossifying fibroma arises from the endosteum or the periodontal ligament (PDL) adjacent to the root apex and expands from the medullary cavity of the bone, and the peripheral type occurs on the soft tissues overlying the alveolar process. Peripheral ossifying fibroma is thought to be either reactive or neoplastic in nature. Considerable confusion has prevailed in the nomenclature of peripheral ossifying fibroma with various synonyms being used, such as peripheral cementifying fibroma, ossifying fibro epithelial polyp, peripheral fibroma with osteogenesis, peripheral fibroma with cementogenesis, peripheral fibroma with calcification, calcifying or ossifying fibroma epulis, and calcifying fibroblastic

5granuloma.

Approximately 60% of POFs occur in the maxilla and they are found more often in the anterior region, with 55- 60% presenting in the incisor-cuspid region. In our case the lesion was seen in the mandibular region involving the incisors, in a male patient aged 21 with a moderate amount of supra and sub-gingival calculus and interdental angular bone loss. It usually measures less than 1.5 cm and rarely reaches more than 3 cm in diameter, but

6lesions of 6 cm and 9 cm have also been reported. The surface may be either intact (34%) or ulcerated (66%). The reported case was of 2×1.5 cm in diameter with a smooth surface. The lesion represents varying stages of a fibroma with ossification, however, ossification or calcification may not be evident in all cases, particularly in earlier stages of growth. Foci of radiopaque material, bone formation or dystrophic calcification may be seen, particularly in large lesions or lesions with overt mineralization. POF can produce migration of teeth with interdental bone

7destruction.

Treatment of POF consists of elimination of etiological factors, scaling of adjacent teeth and total aggressive surgical excision along with involved periodontal ligament and periosteum to minimize the possibility of recurrence. Long term postoperative follow-up is extremely important because of the high growth potential of incompletely removed lesion and a relatively high recurrence rate.

Conclusions

POF being one of the commonest solitary swelling in the oral cavity is many times clinically diagnosed as pyogenic granuloma. Radiological and histopathological examination is required for confirmation of diagnosis. Close postoperative followup is required because of the growth potential of incompletely removed lesions and the 8%–20% recurrence rate.

REFERENCES:

1. Bhaskar SN, Jacoway JR. Peripheral fibroma and peripheral fibroma with calcification: report of 376 cases. J Am Dent Assoc 1966; 73(6):1312–20

2. Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol 1972; 1(1):30–8

3. Gardner DG. The peripheral odontogenic fibroma:an attempt atclarification. Oral Surg Oral Med Oral Pathol 1982; 54(1):40–8

4. G. Sujatha, G. Sivakumar, J. Muruganandhan, J. Selvakumar, and M. Ramasamy, “Peripheral ossifying fibroma-report of acase,” Indian Journal of Multidisciplinary Dentistry, vol. 2, no.1, pp. 415–418, 2012.

5. S. K. Kumar, S. Ram, M. G. Jorgensen, C. F. Shuler, and P.P. Sedghizadeh, “Multicentric

peripheral ossifying fibroma, ”Journal of oral science, vol. 48, no. 4, pp. 239–243, 2006.

6. Buduneli E, Buduneli N, Unal T. Long-term follow-up of peripheral ossifying fibroma: report of three cases. Periodontol Clin Investig 2001; 23:11-14.

7. Walters JD, Will JK, Cacchilo DA, Raabe DA. Excision and repair of the peripheral ossifying fibroma: a report of 3 cases. J Periodontol 2001; 72:939-944.

8. D. Gardener, “The peripheral ossifying fibroma: an attempt at clarification,” Oral Surgery, Oral Medicine, Oral Pathology, vol.54, no. 1, pp. 40–48, 1982.

9. T. Farquhar, J.MacLellan, H.Dyment, and R.D.Anderson, “Peripheral ossifying fibroma: a case report,” Journal of the Canadian Dental Association, vol. 74, no. 9, pp. 809–812, 2008.

Chetan Dilip Zawar et. al. : PERIPHERAL OSSIFYING FIBROMA: A CASE REPORT

MACLENNAN SPLINT: IN PEDIATRIC MANDIBULAR BODY FRACTURE- A CASE REPORT

Harsh Shah *, Darshan Patel **, Nitu shah ***, Neha Vyas ****

23

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. HARSH SHAH, TEL: +91 9825010184

ABSTRACT

Introduction: Children (below 13 yrs of age) are usually susceptible to cranio-facial trauma because of their greater cranial mass to body ratio. When compared to adults, the pattern of fractures and frequency of associated injuries are similar but the overall incidence is much lower. Treatment is usually performed without delay and can be limited to observation or closed reduction in non-displaced or minimally displaced fractures. Operative management should involve minimal manipulation and may be modified by the stage of skeletal and dental development. Open reduction and rigid internal fixation is indicated for severely displaced fractures. When tooth buds within the mandible do not allow internal fixation with plates and screws, this can be achieved with a mandibular compression splint (MacLennan splint) fixed to the teeth, to the mandible with circum-mandibular wire. Children require long-term follow-up to monitor potential growth abnormalities.

Case report: A case of a 7-year-old girl with fractured body of mandible managed by closed reduction using MacLennan splint and stabilization using circum mandibular wiring.

Conclusion: MacLennan splint for treatment of pediatric mandibular symphysis/parasymphysis/body fractures are reliable treatment modality with regard to occlusion-guided fracture reduction. We can also manage the pediatric dentoalveolar fracture with minimum invasion and minimum cost by this splint.

Keywords: pediatric maxillofacial trauma, mandibular dentoalveolar fracture, MacLennan splint


A Case Report

*Post Graduate Student, **Reader, ***Professor, **** Professor & Head

DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY, AHMEDABAD DENTAL COLLEGE & HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA

INTRODUCTION:

Dental trauma in children constitutes a major and serious dental public health problem. There is no single dental disturbance that has greater psychological impact on both parents and child than the child's facial esthetic. Trauma in primary teeth can result in pain and affect the development of the permanent dentition. The most common effects on the permanent successors are defects in mineralization or tooth morphology, changes in

[2]colouration and enamel defects.

Children are usually prone to craniofacial trauma because of their higher cranial mass to body ratio. The ratio of cranial volume to facial volume is approximately 8:1 at birth. By the completion of

growth, this ratio becomes 2.5:11. Facial bone fractures in children are relatively rare than in adults and if it occur, they are minimally displaced. The reason may be due to presence of thicker layer of adipose tissue covering the elastic bones and the suture lines are more flexible. In addition, presence of tooth buds within the jaws and the scarcity of

[3] sinus pneumatization increases stability.

The most common site of fracture in the child is the

nasal bone. The second most common fracture reported is the mandibular fracture. The angle, condyle and the subcondylar region contribute approximately 80% of the mandibular fractures in pediatric patients. Around 15-20% of cases have symphysis and parasymphysis fractures. Body

[3] fracture is rare.

The mandibular growth centre disturbance due to injuries can range from small temporary inconvenience to lifelong disfigurement. On-time suitable management of these injuries is important for the successful outcome for the patient. Treatment is usually performed without delay. The treatment can be observation or closed reduction in

[3] non-displaced or slightly displaced fractures.

MacLennan splint is a custom made appliance which can be constructed using acrylic material. It is made for the stabilization of mandibular arch, mainly in cases of fractures involving dentoalveolar segment in children, where there is mixed dentition and presence of developing tooth buds, where open reduction and direct fixation is contraindicated. It can also be used in cases where number of firm teeth for anchorage are inadequate, the wiring of the teeth

24

A

B

can not provide adequate fixation and in adult mandibular body fracture, where the stability cannot obtained by means of other type of

[4]horizontal wiring method.

CASE REPORT: A seven years old girl, reported to dept. of Oral and Maxillofacial Surgery having history of animal attack before one week. The patient was conscious and well oriented. Patient had History of oral bleeding without convulsion and vomiting. Primary

sttreatment of bridal wiring between lower left 1 and

nd2 primary molars was done and medicines were given at nearby civil hospital. Extra oral examination revealed that there was a diffuse facial edema (figure 1a) in the left cheek region, with palpable step deformity in the lower border of the mandible over the same area which was tender. There was normal TMJ movements. Intra oral examination revealed that there was restricted mouth opening with a laceration in the left labial

st ndvestibule in relation to 1 and 2 deciduous molar along with bleeding and mobility of the fractured fragments. Derangement of occlusion (figure 1b) with posterior open bite on left side was evident (figure 1c). Preoperative orthopantamogram (OPG)(figure 2), showed a fracture line running down on the left body region of mandible between 74 and 75. On the basis of OPG report and clinical examination, it was diagnose as unilateral displaced left body fracture of the mandible.

Figure 1aDiffuse Facial Edema

Figure 1bDearangement of occlusion

figure 1cposterior open bite

Figure 2Preoperative orthopantamogram

Harsh Shah et. al. : MACLENNAN SPLINT: IN PEDIATRIC MANDIBULAR BODY FRACTURE- A CASE REPORT

25

MANAGEMENT:Upper and lower alginate impressions were taken under local anesthesia and stone casts were prepared. These casts were occluded to check for occlusal derangement. [Fig: 3 (AandB)] Using OPG as a guide the fracture line was identified, and the model was sectioned with the help of die cutting saw. [Fig: 4] The lower model was assembled against maxillary arch in occlusion and seated with sticky wax. A MacLennan splint was fabricated [Figure 5a and b]. Then the splint was finished and polished and isolated in an antibacterial solution.

Figure 3(a)

Figure 3(b)

Pre-operative upper & lower cast

Figure 4Sectioned cast according to fracture line

The patient was administered General Anesthesia by nasal intubation. Digital pressure was used to reduce the mandibular arch. The prefabricated splint was placed in the mandibular arch. Occlusion was checked and the splint was stabilized with the help of circum-mandibular wiring using pre-streched 28-gauge SS wires. [figure 6]. Displaced tooth bud of permanent pre-molar did not caused difficulty during reduction, so removal was not done. Postoperative recovery was uneventful and occlusion achieved was satisfactory. On the third postoperative week, the splint was removed under local anesthesia. No mobility was present at the fracture site. Patient was reviewed monthly for 3 months.

Figure 5a


26

figure 5b

MacLennan splint

Figure 6Circum-mandibular wiring

Figure 7Post-operative radiograph Figure 8


27

Occlusion after 3 monthsDISCUSSION: Pediatric maxillofacial fractures are very uncommon. They demonstrate different clinical features when compared with that of adults. Treatment principles of mandibular fractures differ from that of adults due to concerns regarding mandibular growth and development of dentition. Most of the pediatric fractures are firmly united in 2 and 3 weeks, because of the increased osteogenic potential of periosteum and increased metabolic rate in children. In children, treatment of mandibular fractures is depicted by the fracture site and the stage of skeletal and dental development. Fracture of mandible limited to the alveolar process usually treated by open or closed reduction and immobilization by splints and arch bars for 2 to 3

[1]weeks. In pediatric patients, presence of tooth buds within the mandible limits internal fixation with plates and screws. Fixation of fractures can be achieved with a mandibular splint fixed to the teeth by interdental wiring, cementation or circummandibular wiring. After the age of six, in displaced symphysis fracture, open reduction and rigid fixation through an internal incision can be done as the permanent incisors have already erupted. In parasymphysis fractures open reduction internal fixation (ORIF) is possible after the age of nine, when the buds of canines have moved up from their inferior position at the mandibular border. Similarly, in body

fractures, the inferior mandibular border can be plated, when the buds of the permanent premolar and molar have migrated superiorly towards the

[1]alveolus.For the management of pediatric mandibular fractures suggested methods are as follows:0 to 2 years: Treated as edentulous problems with MacLennan type of splint.2 to 4 years: If deciduous teeth are well-formed eyelet wiring can be used. Cap splint.5 to 8 years: MacLennan cap splint9 to 11 years; Cap splints, arch bars, plating or

[3]tranosseous wiring at lower border. Alternative devices for closed reduction, in pediatric mandibular body fractures are pre-fabricated acrylic splints and Modified orthodontic brackets. MacLennan Cap splint is preferred because it covers both lingual and buccal cortical plates and

[2]hold the mandibular cortices securely. It also provides open occlusion, unimpaired function, smaller adjustment at the time of insertion and

[3]remodeling due to functional stresses. Conclusion: MacLennan splint for treatment of pediatric mandibular symphysis/parasymphysis/body fractures are reliable treatment modality with regard to occlusion-guided fracture reduction. We can also manage the pediatric dentoalveolar fracture with minimum invasion and minimum cost by this splint.

REFERENCES:1. Kaban LB. Facial trauma I: midface fractures. In:

Kaban LB, ed. Pediatric Oral and Maxillofacial Surgery. Philadelphia, PA: W.B. Saunders; 1990:209- 232.

2. Jain P, Yeluri R,Gupta S,Lumbini P; Management Of Pediatric Mandibular Parasymphyseal Fracture With Acrylic Closed Cap Splint: A Case Report; Annals of Dental Specialty Vol. 3; Issue 1. Jan – Mar 2015

3. Amod Pramod Patankar et al.; Lateral Compression Open Cap Splint (MacLennan) - A Treatment Modality for Pediatric Mandibular Parasymphysis Fracture: Case Report ; Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology, 2016; 2(2):102-104

4. Sheikh Md. Shahriar Quader et al; Lateral compression splint, a guide for stabilization of mandibular arch in case of dentoalveolar fracture of children; Update Dental College Journal Vol 3 Issue

2, October-20135. Thomas B. Dodson; Condyle and Ramus-Condyle

Unit Fractures in growing Patients: Management and Outcomes; Oral Maxillofacial Surg Clin N Am 17 (2005):447–453.

6. Abhishek Khairwa et al; Management of Symphysis and Parasymphysis Mandibular fractures in children treated with MacLennan splint: stability and early results; International journal of c l i n i ca l ped ia t r i c den t i s t ry, mayaugus t 2015;8(2);127-132.

7. Yarington CT J. Maxillofacial trauma in children.;Otolaryngolclin north Am 1977;10(1):25-32.

8. Shobha Tandon; Textbook of Pedodontics; 2nd edition

9. Fonseca, Oral and maxillofacial surgery; Trauma volume 3

10. Rowe & Williams, oral & maxillofacial surgery; volume 1


28

A Case ReportTREATMENT OF DEEP OVERBITE IN HIGH ANGLE PATEINT WITH SEGMENTED ARCH TECHNIQUE

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. KRUNAL RAVAL, TEL: +91 9909032069

Kunal Raval*, Sonali Mahadevia**, Aatman Joshipura***, Neha Assudani****

* Post Graduate Student, ** Professor and Head, *** Reader, **** Sr Lecturer

DEPARTMENT OF ORTHODONTICS & DENTOFACIAL ORTHOPAEDICSAHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

ABSTRACT

This case report describes the orthodontic and orthopedic treatment of a 18-year-old female patient who presented with the prognathic maxilla, deep overbite, high mandibular plane angle, and increased incisal display at rest and smile. Burstone three piece intrusion arch was used for the true intrusion of maxillary incisor. The final treatment outcomes were satisfactory and true intrusion was achieved with proper selection of biomechanics.


INTRODUCTION:

Strang defined overbite as the overlapping of the upper anterior teeth over the lowers in the vertical plane. The ideal overbite in a normal occlusion may range from 2 to 4 mm or 5% to 25%. The overbite >40% should be considered as deep overbite and a f f e c t s t h e p e r i o d o n t a l s t r u c t u r e s a n d

1temporomandibular joints . A deep overbite can be corrected by extrusion of upper/lower posterior teeth, intrusion of upper/lower incisors and combination. Extrusion of posterior teeth is indicated in patients with a short lower facial height, excessive curve of spee in growing patient and moderate to minimal incisor display, whereas intrusion of incisor is indicated in patients with long lower facial heights, excessive incisor display,

1,2increased interlabial gap, and gingival smile . The orthodontic appliances used to carry out intrusionare J hooks pull headgear, tip back bends, burstone .

three piece intrusion arch, Ricketts utility arch, Nanda Connecticut intrusion arch, and mini-

1,3,4implants assisted intrusion

Intrusive tooth movements are most eff ectively 5done with low force magnitudes . The advantage of

lower force magnitudes are reduced molar tip back 1,6moment and root resorption . Burstone three piece

intrusion arch is based on statically determinant force system, which implies magnitude of all the forces produced by activation is measurable. 1-6 This paper report a treatment of deep overbite in high angle patient who needs true intrusion of upper anterior teeth which is done by segmented arch technique.

CASE REPORT

A 18 year old female Patient came to our department

Complaints of proclined upper front teeth and unable to approximate lips. Her medical history was unremarkable, and no history of deleterious habits in childhood was reported by her parents. Extra oral examination showed mesocephalic head, mesoprosopic facial form, convex facial profile, incompetent lips, everted lower lip, acute nasolabial angle, increased incisal display at rest and smile, increased interlabial gap, (Figure 1). Intraoral examination showed Class I molar and canine on both sides, increased overjet of 4 mm, increased overbite of 4 mm. (Figure 2).Treatment objectives

1. Decrease lower facial height

2. Establish ideal overjet and overbite

3. Level curve of spee

4. Decrease incisal display at rest and smile

5. Improve soft tissue lip relation.

FIGURE-1

29

FIGURE-2

TREATMENT OBJECTIVES AND PLAN

The objectives of orthodontic treatment for the patient were non- extraction and in two phase. In phase one three piece intrusion utility arch given for true intrusion and in phase two leveling and aligning all other remaing teeth.

It was decided to use three piece intrusion utility arch for intrusion of upper anterior teeth. After achive intrusion bond other all lower teeth and continuous Niti wire were given including all teeth.

TREATMENT PROGRESS

0.022 slot MBT brackets were bonded in maxillary arch. transpalatal arch was cemented to maxillary fi rst molar. Burstone three piece intrusion arch consist of two cantilever coil spring made of 0.017 ×

0.025 β-titanium alloy wire, 0.019 × 0.025 stainless wire extends from lateral to lateral incisor with vertical steps and elastomeric chains. The vertical step anterior wire was ligated with stainless steel wire from lateral incisor into lateral after that cantilever spring was inserted into the auxiliary maxillary first molar buccal tube. The spring was pulled downward and engaged into the anterior segment before that force was calculated with Corex gauge. The elastomeric chain was engaged

from maxillary hook to anterior segment for retraction purpose. [FIGURE-3]

TREATMENT RESULTS

Within 6 months of active orthodontic treatment using three piece intrusion utility arch True intrusion of upper incisors was very well achived [figure -4].

FIGURE-3

FIGURE-4

FIGURE-5

Kunal Raval et. al. : TREATMENT OF DEEP OVERBITE IN HIGH ANGLE PATEINT WITH SEGMENTED ARCH TECHNIQUE

30

FIGURE-6

Upper 1 to

NF(linear)

Upper 1 to

NF(angle)

Lower 1 to

MP(linear)

Lower 1 to

MP(angle)

Upper 6 to

NF

Lower 6 to

MP

Parameters Mean value

pretreatment posttreatment

30 +_ 2.1mm

0111 +_ 4.7

45 +_ 2.1 mm

095.9 +_ 5.2

26.2 +_ 2 mm

35.8

2.6mm +

32 mm

0120

41 mm

0100

24mm

30mm

28mm

111

41mm

104

24mm

30mm

DISCUSSION

Absolute intrusion, relative intrusion, and extrusion of posterior teeth are the three methods used for deep overbite correction. Relative intrusion is achieved by preventing the eruption of the lower incisor while ramal growth provides vertical space into which the posterior teeth erupt, whereas in extrusion of the posterior of teeth mandible rotates down and back in the absence of growth. As a general rule, extrusion is undesirable, while relative intrusion is acceptable during growing stage and

5.absolute intrusion in non-growing stage

In low angle cases with deep bite, bite opening with molar eruption is usually desired, whereas in high angle cases with a deep overbite, bite opening should be carried out with upper and lower anterior teeth intrusion. Clinically intrusion is a difficult movement to achieve, and it requires three

dimensional controls. Intrusion mechanics basically depend on the initial inclination of the incisor. Clinically pure bodily intrusion is difficulty owing to the complexity of the movement. A slight change in the relationship of the line of action of the force with the center of resistance can change the type of movement If the forces passes anterior to the center of resistance the incisor protrude, which can

2be prevented with a light chain elastic . Leveling by intrusion can be accomplished with continuous archwires that bypass the premolar and segmented

5. archwires with auxiliary depressing arch Anchor bends in Begg's technique and Rickett's utility arch

7,8are example for the continuous method . Burrstone three piece intrusion and mini-implant assisted intrusion are an example for the segmented method.

Difficulty in controlling posterior anchorage and application of intrusive force through center of resistance are the two limiting factors in continuous

5archwire method . This limitation can be easily controlled in segmented method and skeletal anchor. In the segmented arch technique, amount of forces and moments are predictable or statically determinate. Meta-analysis in non-growing patients showed that the segmented arch technique can produce 1.5 mm of true incisor intrusion in the

9maxillary arch and 1.9 mm in the mandibular arch . Micro-implant provides good anchorage support and for absolute incisor intrusion in both the maxilla

1,5and mandible .

CONCLUSION

Optimal correction of deep overbite requires proper diagnosis, treatment planning, and efficient execution of treatment mechanics. A careful combina t ion of t rea tment p lanning and biomechanics to correct deep overbite can help to achieve a desirable esthetic result and to minimize relapse during the post-retention phase.


REFERENCES:1. Nanda R, Kapila S. Current Therapy in

Orthodontics, St. Louis: Mosby Elsevier; 2010.2. Nanda RS, Tosun YS. Biomechanics in

Orthodontics Principles and Practice, Hanover Park, IL: QuintessencePublishing Co., In.; 2010.

3. Shroff B, Lindauer SJ, Burstone CJ, Leiss JB. Segmented approach to simultaneous intrusion and space closure:Biomechanics of the three- piece base arch appliance. AmJ Orthod Dentofacial Orthop 1995;107(2):136-43.

4. Shroff B, Yoon WM, Lindauer SJ, Burstone CJ.Simultaneous intrusion and retraction using a three-piece base arch. Angle Orthod 1997;67(6):455-61.

5. Proff i t WR, Fie lds HW, Sarver DM. Contemporary Orthodontics, 4th ed. St. Louis: Mosby; 2007.6. Nanda R. Biomechanics and

Esthetic Strategies in Clinical Orthodontics. Philadelphia: Elsevier Saunders; 2005.

7. Ricketts RM. Bioprogressive therapy as an answer to orthodontic needs. Part I. Am J Orthod 1976;70(3):241-68.

8. Ricketts RM. Bioprogressive therapy as an answer to orthodontic needs. Part II. Am J Orthod 1976;70(4):359-97.

9. Ng J, Major PW, Heo G, Flores-Mir C. True incisor intrusion attained during orthodontic treatment: A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2005;128(2):212-9.

10. van Steenbergen E, Burstone CJ, Prahl-Andersen B, Aartman IH. The infl uence of force magnitude on intrusion of the maxillary segment. Angle Orthod 2005;75(5):723-9.


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32

A Case ReportCORRECTLY POSITIONING THE GEM IN THE NECKLACE - ORTHODONTICALLY…..!!!

* Post Graduate, ** Professor & Head, ***Reader, ****Sr. Lecturer

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. MAULI SHAH TEL: +91 9067300344

Mauli Shah*, Sonali Mahadevia**, Aatman Joshipura ***, Neha Assudani****

ABSTRACT

Simplified approach in correction of highly placed canines are necessary to place the teeth in correct ideal position without disturbing the other teeth or occlusion. Prudent treatment planning is necessary to achieve the various treatment goals. This article describes two case reports for the orthodontic management of patients with labially and highly placed permanent maxillary canines.


INTRODUCTION:

Eruptive disturbances are alterations of normal tooth eruption, including accelerated, delayed,

1failed, or deviated in the direction of tooth eruption. Because of overretained deciduous teeth, permanent teeth haven't gotenough space In the arch so that ultimately disturb the eruptive path of that teeth.

Impaction is the total or partial lack of eruption of a 2tooth well after the normal age of eruption.

Between 25% and 50% of the general population are affected by impacted teeth, with the incidence of upper canine impaction reportedly ranging from

3,40.92% to 4.3%, respectively. Maxillary canine impactions are twice more common in females

5(1.17%) than in males (0.51%). Eight percent of patients with impacted maxillary canines have

5bilateral impactions. Impaction of a maxillary canine is a common problem because it has the longest period of development, the deepest area of development, and the long eruption path of all the

3teeth. They are also the teeth that frequently require surgical and orthodontic intervention for their eruption.

According to Kokich and Mathews the cause of labial impaction of the canines probably is related to either a retained deciduous tooth, diversion of the canine tooth bud, or idiopathic failure of eruption of

6unknown origin.

CASE REPORT - I

A 19-year-old female presented for orthodontic treatment with the chief complaint of impaired facial esthetics during smile due to irregular upper front teeth. She had a grossly symmetric, mesocephalic head & mesoprosopic face with

interlabialgap of 1 mm [Figure - 1]. Intraoral examination [Figure - 2] showed unilaterally labially highly placed permanent canine and crowding in lower arch. In the occlusion, she had 1 mm of openbite and a 2 mm overjet. The molar relationship was Class I. The upper dental midline was concordant with the face, and lower dental midline wasshifted to left side by 3 mm. There was no relevant history of any medical problem.

FIGURE-1

DEPARTMENT OF ORTHODONTICS & DENTOFACIAL ORTHOPAEDICSAHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

33

FIGURE-2

TREATMENT OBJECTIVESANDPLAN

The objectives of orthodontic treatment for the patient were to extract the first premolarsand then get the labially& highly placed maxillary canine in proper position, then level and align the arches, obtain normal overjet, and overbite, and achieve a well-intercuspated bilateral Class I canine and molar occlusion.

It was decided to use cantilever springs on the left side to pull the highly placed canines downwards in nearly maximum occlusal plane and then bond the other remaining teeth and continuous Niti wire was given including all teeth.

TREATMENT PROGRESS

Both the side first molar banding and maxillary canine bonding were done. Cantilever spring was fabricated from 17*25 beta-titanium alloywire and attached actively to canine bracket on left side.[ figure – 3

Mauli Shah et. al. :CORRECTLY POSITIONING THE GEM IN THE NECKLACE - ORTHODONTICALLY…..!!!

34

FIGURE-3

TREATMENT RESULTS

Within 2 months of active orthodontic treatment using cantilever springs, the left side canine camenearly straight to the occlusal plane[figure -4]. After that, bonded the remaining teeth and leveling and alignment was done with continuous Ni-ti wire including all teeth followed by retraction of anteriors in the extraction space.[figure -5].

FIGURE-4


35

FIGURE-5

CASE REPORT - II

A 16-year-old female presented for orthodontic treatment with the chief complaint of impaired facial esthetics during smile due to irregular upper& lower front teeth and over-retained deciduous teeth. She had a grossly symmetric, mesocephalic head &mesoprosopic face. [Figure - 1]. Intraoral examination [Figure - 2] showed unilaterally labially highly placed permanent canine and overretained deciduous canine on right side and crowding in lower arch with gingival recession in the lower left central incisor. In the occlusion, she had anterior crossbite and a 2 mm overjet. The molar relationship was end-on on right side and Class I on left side. The upper dental midline was concordant with the face, and lower dental midline wasshifted to left side by 2 mm. There was no relevant history of any medical problem.

TREATMENT OBJECTIVES AND PLAN

FIGURE-1


FIGURE-2

The objectives of orthodontic treatment for the patient were to extract the over-retained deciduous canine and then get the labially & highly placed maxillary right canine in proper position, then level and align the arches, obtain normal overjet, correct the anterior crossbite, and achieve a well-intercuspated bilateral Class I canine and molar occlusion.

It was decided to use cantilever springs on the right side to pull the highly placed canines downwards in nearly maximum occlusal plane and then bond the other remaining teeth and to give a continuous Nitiwire including all teeth.

TREATMENT PROGRESS

The first molar banding and maxillary canine bonding was done. Cantilever spring was fabricated from 17*25 beta-titanium alloy wire and attached actively to canine bracket on rightside.[ figure – 3 ]

FIGURE-3

TREATMENT RESULTS

Within 3 months of active orthodontic treatment using cantilever springs, the right side canine came nearly straight to the occlusal plane[figure -4]. After that, included the remaining teeth and leveling and alignment was done with continuous Ni-ti wire.

FIGURE-4


36

DISCUSSION

Maxillary permanent canines play an important role for an attractive smile and are also essential for a functional occlusion.

The cantilever spring is easy to fabricate and biomechanically efficient for occlusal movement of buccaly & highly placed canine. When tied with the braided ligature strands, the stored energy in the spring generates optimum eruptive force in the occlusal direction.

The segmental beta-titanium alloy cantilever spring is used to provide a point force application to the canine, a low load-deflection rate, and a large range

of activation. In this statically determinate force system, the buccal segments were more efficiently managed, and intrusive side-effects were distributed over a wider area to minimize the

7clinical side effects.

CONCLUSION

Understanding the biologic principles and proper application of the biomechanics enable us to carry out challenging tooth movements. Best treatment goals can be achieved in limited time using the magical effect of cantilever spring without interfering the other teeth or occlusion and provide good orthodontic treatment outcome.

REFERENCES:1. Brin I, Zilberman Y, Azaz B. The unerupted

maxillary central incisor: Review of its etiology a n d t r e a t m e n t . A S D C J D e n t C h i l d 1982;49:352-6.

2. Orthodontic Glossary. St. Louis: American Association of Orthodontics; 1993

3. Jacoby H. The etiology of maxillary canine impactions. Am J Orthod1983;84:125-32.

4. Ngan P, Hornbrook R, Weaver B. Early timely management of ectopically erupting maxillary

canines. SeminOrthod2005;11:152-63.5. Bishara SE. Impacted maxillary canines: A

r e v i e w . A m J OrthodDentofacialOrthop1992;101:159-71.

6. Kokich VG, Mathews DP. Surgical and orthodontic management of impacted teeth. Dent Clin North Am 1993;37:181-204.

7. Lindauer SJ, Isaacson RJ. One-couple o r t h o d o n t i c a p p l i a n c e s y s t e m s . SeminOrthod1995;1:12-24.


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38

A Case Report

*Post Graduate, ** Post Graduate, *** Post Graduate, **** Post Graduate

AMLODIPINE INDUCED GINGIVAL ENLARGEMENT: A CASE REPORT

ABSTRACT

Gingival enlargement is a side effect associated with certain drugs. Amlodipine, a calcium channel blocker, used as an antihypertensive drug has been found to be associated with gingival hyperplasia. This case report presents diagnosis and management of amlodipine-induced gingival hyperplasia. Amlodipine-induced gingival enlargement was diagnosed and managed through scaling and root planning. Drug substitution and surgical intervention was performed in first two cases. The pathogenesis of gingival enlargement is uncertain and treatment is still largely limited to the maintenance of an improved level of oral hygiene and surgical removal of the overgrown tissue. Several factors may influence the relationship between the drugs and gingival tissues. Meticulous oral hygiene maintenance, switchover to an alternative drug, professional scaling and root planning and surgical excision of enlarged gingival tissue may help overcome the effect of these drugs.

Key words: Calcium channel blocker, drug-induced gingival overgrowth, gingivectomy


Krishna Daka*, Harit Shah**, Mitali Patel***, Megha Patel****

INTRODUCTION:

Gingival enlargement or Gingival overgrowth (GO) is one of the most important clinical features of gingival pathology. Its etiology is multifactorial and is associated with inflammatory changes in the

1 gingiva. Other factors related to this condition are hereditary malignancies and those resulting from adverse effects associated with systemic administration of certain drugs. Currently, more than 20 drugs are associated with gingival enlargement. These drugs are broadly divided into three categories: Anticonvulsants, Calcium Channel Blockers and Immunosuppressants. Many Calcium Channel Blockers which are used as antihypertentive drugs have been implicated in

2causing gingival enlargement.

Amlodipine is dihydropyridine derivative used as antihypertensive drug having longer action and comparatively lesser side effect than Nifedipine (Calcium Channel Blocker). Amlodipine, a dihydropyridine derivative is a third generation Calcium Channel Blocker, was first reported for

causing gingival overgrowth by Seymour et al in 3,41994. Lafzi et al had reported rapid development

of gingival hyperplasia in patients who received 10 mg per day of

5 amlodipine within two months of onset. It has shown to have longer action and a weaker side effect compared to first generation such as

6nifedipine. The prevalence of GO in patients taking

amlodipine was reported to be 3.3%, which is lower than the rate in patients taking nifedipine 47.8%. The clinical features of GO usually present as enlarged interdental papillae resulting in a lobulated

7or nodular morphology. The effects are normally limited to the attached and marginal gingivae and is

8more frequently observed anteriorly.

In this case report, we treated severe GO in patient taking amlodipine for treatment of hypertension. The management consisted of oral hygiene procedures and alteration in medication.

CASE REPORT:

A 47-year-old female was referred to the Department of Periodontics of Ahmedabad Dental College and Hospital, Ahmedabad with complaints of gingival enlargement and foul odor, bleeding, fetid discharge from gums since 1 year. General examination revealed normal built of the patient. Patient was hypertensive with a history of taking amlodipine 5 mg once daily last 7 years. Intraoral examination revealed poor oral hygiene, generalized nodular enlargement of gingiva mainly on the facial aspect of teeth. Gingiva was inflammed and soft in consistency [Figure 1].

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. KRISHNA DAKA, TEL: +91 9825217274

DEPARTMENT OF PERIODONTICS AND ORAL IMPLATOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

39

Fig. 1: Preoperative view

Fig 2: Post operative view after phase-1

InvestigationRoutine blood and orthopantomographical examination were within normal limit. [Figure. 3]

Fig. 3: Orthopantomograph

Treatment

Amlodipine was omitted after a consult with the physician, switching over to monotherapy of losartan 50 mg once in a day. Patient was educated and motivated for maintenance of proper oral hygiene. Professional scaling and root planning was performed. After 3 months of phase-1 therapy, remaining excess gingival tissue was planned to

correct by surgical intervention through an internal bevel gingivectomy and periodontal flap procedure.[Figure 4 ] After 3 months of follow-up inflammation was markedly reduced with some reduction in gingival enlargement [Figure 5].

Fig. 4a: Incision 12-16

Fig 4b: Incision 22-27

Fig 4c: Incision 32-38

Krishna Daka Et. Al. : AMLODIPINE INDUCED GINGIVAL ENLARGEMENT: A CASE REPORT

40

Fig 4d: Incision 43-48

Fig 4e: After debridment 12-16

Fig 4f: After debridemnt 22-27

Fig 4g: After debridment 32-38

Fig 4h: After debridment 43-48

Figure 4: periodontal flap procedure

Histopathological examination

Excised tissue was sent for histopathological examination. Section stained with H and E revealed the presence of hyperplastic squamous epithelium without any dysplastic features. There was mild chronic inflammatory cells infiltrate in the connective tissue.

Follow up visit

On seventh day of follow-up visit, healing procedure was uneventful. Clinical outcome on 3 months of follow-up visit is shown in [Figure 5]

Figure 5: Follow up after 3 months


DISCUSSION:

Gingival hyperplasia, with its potential cosmetic implication and tendency to provide niche for further growth of microorganism, possess a serious concern to patients and clinicians. Calcium channel blockers are considered as potential etiological agent for inducing gingival enlargement. Lafzi et al. (2006) had reported rapidly developing gingival hyperplasia in patient receiving 10 mg/day of

9amlodipine within 2 month of onset.

The prevalence of amlodipine-induced gingival overgrowth was reported to be 3.3% (Jogersen, 1997). The underlying mechanism of gingival enlargement still remains to be fully understood. However, two main inflammatory and non-inflammatory pathways have already been suggested.

The proposed non-inflammatory mechanisms include defective collagenase activity due to

10decreased uptake of folic acid, blockage of aldosterone synthesis in adrenal cortex and

11consequent feedback increase in ACTH level and 12

upregulation of keratinocyte growth factor. Alternatively, inflammation may develop as a result of direct toxic effects of concentrated drug in

13crevicular gingival fluid and/or bacterial plaques. This inflammation could lead to the upregulation of

14several cytokine factors such as TGF-β1. Marked reduction in inflammation and gingival overgrowth was observed in all three cases after phase-1 therapy and substitution of amlodipine to other drug. Meticulous oral hygiene maintenance by patient may also be responsible for reduction in gingival overgrowth.

Marvogiannis et al., 2006 suggested that there may be recurrence of gingival hyperplasia if medication is continued and also persistence of other risk

15factors.

In this case we reported clinical results achieved by the periodontal flap in the treatment of amilodipine induced gingival enlargement. It has been the traditional technique utilized to treat such cases. Due to its healing by primary intention, the periodontal flap appeared to be an attractive treatment alternative for drug-induced gingival enlargement.

The role of bacterial plaque in drug induced gingival enlargement is not clear. Although many

believe that plaque plays a significant role in the development of drug induced gingival enlargement cases, others argue that plaque accumulation is a consequence of oral hygiene impairment posed by the enlarged gingival tissues.

CONCLUSION

Adverse aesthetics and impaired function are associated with the presence of drug-induced gingival enlargement. Comprehensive treatment of these cases is multidisciplinary in nature, and dentists and physicians should first consider the nonsurgical approach, including the removal of local factors and discontinuation of the offending drug. If the nonsurgical approach is not effective, periodontal surgery in form of the gingivectomy or periodontal flap procedures can effectively reduce the enlarged gingival tissues.

Gingivectomy is a simpler and faster technique, and its best indications are gingival enlargement areas where there is no need to access the alveolar bone during surgery. Also, an abundant area of kerat inized t issue should be present for gingivectomy to be the technique of choice. The periodontal flap should be used in areas in which the alveolar bone needs to be accessed for osseous recontouring purposes and in areas with limited keratinized tissue.

Despite being technically more demanding, healing following the periodontal flap less uncomfortable for the patient and there is less chance of postoperative hemorrhage. It is also possible for the patient to resume mechanical oral hygiene earlier with the periodontal flap due to primary closure of the surgical wound. The maintenance of treated cases should included meticulous home care and professional recalls. Surgical re-treatment of recurrence areas needs to be periodically reconsidered.

Stringent maintenance of oral hygiene, switchover to alternative drugs and surgical therapy if required, remains the main stay of available treatment modalities. Better results were obtained where drug substitution along with oral prophylaxis were followed.

41


REFERENCES:1. Triveni MG, Rudrakshi C, Mehta DS.

Amlodipine-induced gingival overgrowth. J Imdian Soc Periodontol. SepeDec 2009;13(3).

2. Bhatia V, Mittal A, Parida AK, et al. Amlodipine-induced gingival hyperplasia: a rare entity. Int J Cardiol. 2007;122:23e24.

3. Jose J, Santhosh YL, Naveen MR, Kumar V. Case report of amlodipine induced gingival hyperplasia – late onset at a low dose. Asian J Pharm Clin Res 2011; 4: 65–6.

4. Seymour RA, Ellis JS, Thomason JM, Monkman S, Idle JR. Amlodipine induced gingival overgrowth. J Clin Periodontal 1994; 21: 281–3.

5. Lafzi A, Farahani RM, Shoja MA. Amlodipine induced gingival hyperplasia. Med Oral Patol Oral Cir Bucal 2006; 11: 480–2.

6. Nery EB, Edson RG, Lee KK, Pruthi VK, Watson J. Prevalence of nifedipine-induced gingival hyperplas ia . J Per iodontol . 1995;66:572e578.

7. Hallmon WM, Rossmann JA. The role of drugs in the pathogenesis of gingival overgrowth. A collective review of current concept. Periodontol 2000. 1999;21:176e196.

8. Taib H, Ali TBT, Kamin S. Amlodipine-induced gingival overgrowth: a case report.

Arch Orofacial Sci. 2007;2:61e64.

9. Amit B, Shalu BV. Gingival enlargement induced by anticonvulsants, calcium channel blockers and immunosuppressants: a review. IRJP 2012; 3: 116–9..

10. Brown RS, Sein P, Corio R, Bottomley WK. Nitrendipine-induced gingival hyperplasia. First case report. Oral Surg Oral Med Oral Pathol 1990;70:593-6.

11. Nyska A, Shemesh M, Tal H, Dayan D. Gingival hyperplasia induced by calcium-channel blockers: Mode of action. Med Hypotheses 1994;43:115-8.

12. Das SJ, Olsen I. Keratinocyte growth factor is upregulated by hyperplasia-inducing drug nifedipine. Cytokine 2000; 12:1566-9.

13. Van der Vleuten CJ, Trijbels-Smeulders MA, van de Kerkhof PC. Telangiectasia and gingival hyperplasia as side-effects of amlodipine (Norvasc) in a 3-year-old girl. Acta Derm Venereol 1999;79:323-4.

14. Border WA, Noble NA. Transforming growth factor beta in tissue fibrosis. N Engl J Med 1994;331:1286-92.

15. Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA. The management of drug-induced gingival overgrowth. J Clin Periodontol 2006;33:434-9.

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A Case ReportSUBEPITHELIAL CONNECTIVE TISSUE GRAFT FOR ROOT COVERAGE: CASE-REPORT

ABSTRACT

The goal of the treatment for gingival recession coverage is to restore the tissue margin to the cementoenamel junction (CEJ) and to create a normal gingival sulcus with a functional attachment. Over the years, numerous surgical techniques has been practiced to correct gingival recession since its introduction by Norberg in 1926. The advent of subepithelial connective tissue graft for root coverage has demonstrated high degree of success. The advantages of this technique are dual blood supply to the graft, better aesthetics, increased keratinised tissue width, and better postoperative healing in the donor site. Periodontal microsurgery for periodontal plastic surgery was introduced by Dr. Shanelac and has proven to be an effective means of improving predictability in periodontal aesthetic procedures. The surgical microscope enhances complete visualisation of the operative field and provides superior magnification and

1better optical performance compared with dental loupes.

Key words : Subepithelial connective tissue graft; marginal tissue recession; root coverage.

Case report and conclusion: This case report a clinical case in which a Miller's Class 1 & class 2 recession was treated by the surgical technique of subepithelial connective tissue graft, obtaining total coverage, eliminating the aesthetic deficiency and the dentin hypersensitivity complained by patient.2


Megha Patel*, Krishna Daka**, Archita Kikani***, Mihir Shah****

INTRODUCTION:

Marginal tissue recession is a common condition in Periodontology and is characterized by the displacement of the gingival margin towards to the mucogingival junction with root surface exposure; it may occur at isolated or multiple areas of oral

4cavity with different extension degrees. Today, “marginal tissue recession” has been the most accepted term, because the tissue showing the problem can be the alveolar mucosa instead of the

5gingiva.

Several etiological factors may account for the recessions' appearance, such as traumatic toothbrushing, tooth malpositioning, periodontal disease, frenum and bridle insertions, occlusal trauma, restoration with subgingival overhanging margins, maladapted crowns, extractions of adjacent teeth, orthodontic movement, iatrogenic

5factors and bone dehiscences. A more detailed analysis of such agents shows that most of them present a common feature: gingival inflammation.

When present, marginal tissue recessions may implicate in compromising the patient's periodontal health, aesthetic, and comfort. Concerning to periodontal health, the recessions are capable of acting as a local modifying factor for the installation and progression of periodontal disease, because an

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*Post Graduate, ** Post Graduate, *** Professor, **** Professor and Head

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. MEGHA PATEL, TEL: +91 9909544866

alteration in the normal gingival contour (regular concave arch) occurs, which collaborates for greater bacterial plaque accumulation. This alteration also contributes for an unfavorable aesthetics. Finally, the recessions may compromise the patient's comfort due to the possibility of cervical dentinal hypersensibility occurrence after the root surface exposure to oral cavity.

The surgical treatment is an alternative to obtain patient's aesthetic, diminish or eliminate dentinal hypersensibility and allow better conditions of dental hygiene performance in the affected area. Subepithelial connective tissue graft is the surgical technique mostly studied and presents the most predictability of root coverage; however, the evaluation of factors such as defect's width and height and condition of interproximal gingival and bone tissue are determinant to reach a good prognosis.

In 1985, Mil ler es tabl ished the c l inical classification of marginal tissue recessions: class I – the recession does not reach the mucogingival junction without loss of interproximal tissue; class II – the recession reaches or surpasses the mucog ing iva l j unc t ion w i thou t l o s s o f interproximal t issue; class III – loss of interproximal tissue is seen and the proximal

DEPARTMENT OF PERIODONTICS AND ORAL IMPLATOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

gingival tissue is apically to the enamel-cementum junction and coronally to the recession; class IV – proximal gingival tissue is at the recession base level. The higher the periodontal tissue loss (Miller's class III and IV), the worse the prognosis related to root coverage amount obtained after

3surgery.

CASE REPORT

Patient kiranbhai patel, 40 years-old, male, systemically health, non-smoking, presented as chief complaints the esthetic deficiency at tooth #31,41 (figure 1) and dentinal hypersensibility in this same teeth.

After phase 1 therapy, Antisepsis was carried out through aqueous solution of 0.12% chlorhexidine digluconate. After local anesthesia with 2% lignocaine hydrochloride with adrenaline Bitrate (xicaine 2% with adrenaline 1:80,000), scaling and root planing were executed on tooth #31,41. Scaling procedure is necessary to remove the contaminated and exposed cementum.

Baseline data was recorded preoperatively with vertical component of gingival recession as 4 mm on 31 & 3 mm on 41, horizontal component 5 mm, probing depth 1 mm, Clinical attachment level (CAL) 8 mm, and keratinised gingiva 1 mm

(Figure 1).

FIGURE 1 (a) Gingival recession

FIGURE 2(b)

FIGURE 2(a)

FIGURE 2(b)

RECEPIENT SITE :

Then, preparation of the recipient site was performed through horizontal incisions, towards enamel-cementum junction direction, at each

Megha Patel Et. Al. : SUBEPITHELIAL CONNECTIVE TISSUE GRAFT FOR ROOT COVERAGE: CASE-REPORT

44

a. surgical template

papilla (figure 2.a). Following, two vertical relaxing incisions and one intrasulcular incision were executed. Next, full-thickness flap was raised, up to the mucogingival junction and continued as a partial-thickness flap based on this junction. Later, the papilla's epithelium was coronally removed up to their apexes. (figure 2.b) Thorough root planning was done. The concavity in the root was reduced with air-rotor hand piece.

DONOR SITE :

A second surgical site was created on the palate. After administration of local anaesthesia, Connective tissue graft was procured using trape door technique. In this technique ct graft was harvested from palatal area between maxillary first molar and maxillary canine. The graft then placed on sterile gauze pad. Excess fatty glandular tissue was removed and graft is irrigated with saline. Following the reflection of the flap, connective tissue graft was positioned on recipient site to cover the expose facial surface of the roots of the treated teeth with coronal extension of graft corresponding to the level of the cemento-enamel junction. The periosteal side of the connective tissue graft was positioned facing the root surface and was not sutured. The flap then coronally advanced to completely cover the connective tissue graft. Tensionless flap elevation was facilitated by split-thickness flap apical to the bone margin through the periosteum in the vestibule to allow movement of the flap in coronal direction so that the graft was completely covered. Finally, the flap was stabilized with simple interrupted 4-0 vicryl suture. The surgical site was dressed with coe-pack periodontal dressing to prevent apical displacement of flap

7during the healing period.

b. Donor site

c. connective tissue


45

e placement at recipient site

f 4-0 vicryl suture

g 4-0 vicryl suture

h. periodontal dressing(coe-pack)

FIGURE 3 (a,b,c,d,e,f,g,h)

At postoperative period, patient was oriented to use aqueous 0.12% chlorhexidine digluconate mouthrinse for 10 days, and analgesics for pain. Sutures were removed 7 days post-surgery. At 15, 30, and 60 days, as well as 3 months patient’s follow-up was performed by radiographs, in which were seen a good root coverage and significant aesthetic improvement.

1 Week follow up


46

1month follow up

3 month follow up

DISCUSSION :

Several mucogingival techniques have been introduced in literature aiming to correct marginal

8tissue recessions. During the decades of 1960s and 70s, the most used techniques were coronally

9positioned flap, laterally displaced flap , and the combination of coronally positioned flap with free gingival graft. At the beginning of the decade of 1980s, the use of subepithelial connective tissue graft was disseminated, assuring the obtainment of excellent results in areas with localized root

10exposure.

The choice of the adequate technique and the long-term success of the procedure depend on the careful evaluation of the defect type, recession's etiology, operator's ability, presence of keratinized tissue, tissue width, predictability, single or multiple gingival recessions, healing, aesthetic result, and risk factors.

Subepithelial connective tissue graft can be indicated for the treatment of single or multiple gingival recessions, correction of the papilla's volume or deformities of the edentulous gingival border, creation and increasing of the amount of the keratinized mucosa and perspective improvement of the root coverage associated with restorative

11procedures, abrasion or dental caries.

7In 1985, Langer and Langer described a technique of subepithelial conjunctive tissue graft for root coverage in the treatment of recessions at single or multiple areas, attributing the procedure success to the double blood supply for the graft's nutrition, originating from the In 1985, Langer and Langer described a technique of subepithelial connective tissue graft for root coverage in the treatment of recessions at single or multiple areas, attributing the procedure success to the double blood supply for the graft's nutrition, originating from the connective tissue of both the periosteum and flap. Additionally, this aforementioned technique is less invasive at the palatal area, causing a minimum postoperative discomfort to patient and offering a great predictability of coverage. Consequently, this technique is the first choice in cases needing good aesthetical outcomes, as the case reported here. Notwithstanding, this methodology also exhibit disadvantages: need of a greater amount of tissue than the required for covering the area due to the contraction suffered by the tissue, from the surgery to its functional incorporation within the receptor site ; and difficulty of standardization of the graft thickness, which may result in aesthetical alterations. Accordingly, these aspects must be observed during the surgical procedure.

In this case report, full-thickness flap up to the mucogingival junction in the receptor site was performed. A partial-thickness flap may implicate in perforation, capable of resulting in flap necrosis,

12and consequently in bone tissue loss. Furthermore, in partial-thickness flaps, the presence of the highly vascularized tissues adjacent to the root surface may be a necessary condition for root resorption.

13According to Harris, the desired results after the surgical procedure are: root coverage up to the enamel-cementum junction, tissue firmly attached to the tooth with sulcular probing depth smaller than 2 mm, absence of bleeding on probing, presence of an adequate keratinized tissue, color similar to the


47

adjacent tissues, tissue's aesthetical contour, and decreasing of the sensibility reported by the patient.

Special attention should be given concerning to subepithelial connective tissue graft indication in cases of Miller's class III and IV marginal tissue recession. The aforementioned technique presents less predictability of root coverage in such recessions, because of the difficulty of graft's adaptation and nutrition which may result in

14necrosis.

CONCLUSION

The success of this clinical case may be attributed to the precise indication of the technique of subepithelial connective tissue graft due to the high predictability of root coverage in Miller's class I and II and the double blood supply for the graft's nutrition.

REFERENCES:1. Dhir.V et al Microsurgical treatment of

gingival recession by subepithelial connective tissue graft : A case report (periodontology and oral implantology) ADC MJAFI 2011,67:293-295.

2. Alcaras.J et al subepithelial connective tissue graft : a case report RSBO jul-september,2011 8(3)357-62

3. Miller Jr. PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8-13.

4. Steffens JP, Santos FA, Pilatti GL. Cirurgias mucogengivais para recobrimento radicular: o enxerto de conjuntivo subepitelial como técnica de sucesso para defeitos isolados. Dental Science. 2008;2(7):207-14

5. Cardoso RJA, Gonçalves EA. In: Proceedings of the 20th Congresso Internacional de Odontologia; 2002. São Paulo: Artes Médicas; 2002. p. 201-48.

6. Fontanari LA, Rodrigues MR, Scremin EI, Kitano MSI, Sampaio JEC, Trevisan Júnior W. Enxerto de tecido conjuntivo subepitelial: uma alternativa em cirurgia plástica periodontal. Perionews. 2009;3(2):131-5.

7. Langer.B,Langer.L Subepithelial connective tissue graft technique for root coverage, J periodontal 1985;56:715-720

8. Wennstrom JL. Mucogingival therapy. Ann Periodontol. 1996;1(1):671-701.

9. Guinard EA, Caffesse RG. Treatment of localized gingival recessions. Part I. Lateral sliding flap. J Periodontol. 1978;49(7):351-6.

10. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol. 1985;56(12):715-20.

11. Nevins M, Melloning JT. Periodontal therapy: clinical approaches and evidence of success. Tokyo: Quintessence; 1998. p. 355-64.

12. Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva. J Clin Periodontol. 1974;1(4):185-96.

13. Harris RJ. The connective tissue and partial thickness double pedicle graft: a predictable method of obtaining root coverage. J Periodontol. 1992;63(5):477-86.

14. Polson AM. Periodontal regeneration: current s t a t u s a n d d i r e c t i o n . H o n g K o n g : Quintessence Books; 1994. p. 53-70


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DEPARTMENT OF PERIODONTICS:Dr. Sarat ChandranDr. Neeraj DeshpandaDr. Vasumati Patel

DEPARTMENT OF CONSERVATIVE DENTISTRY:Dr. Sonali Kapoor

DEPARTMENT OF PROSTHODONTICS:Dr. Rajesh SeturamanDr. Saumil MathurDr. Keval Shah

DEPARTMENT OF ORAL MEDICINE & RADIOLOGY:Dr. F. R. KarjodkarDr. Jigna ShahDr. Chandrmani Mori

DEPARTMENT OF ORAL PATHOLOGY:Dr. Vandana ShahDr. Madhusudan AstekarDr. Dharmesh Vasavada

DEPARTMENT OF ORTHODONTIA:Dr. A. F. BhatiaDr. N. Daruwala

DEPARTMENT OF ORAL SURGERY:Dr. Bhagvandas RaiDr. Anisha MehtaDr. Kiran Desai

DEPARTMENT OF PEDODONTICS:Dr. Bhavna DaveDr. Anshula DeshpandeDr. Dinesh Rao

DEPARTMENT OF PUBLIC HEALTH DENTISTRY:Dr. Nisarg ChaudharyDr. Rahul PatelDr. Suyog Savant

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ETHICS COMMITTEE

CHAIRPERSONDr. Chetana DesaiProfessorDept of PharmacologyBJMC, Ahmedabad.

DEPUTY CHAIRPERSONDr. Mahadev DesaiProfessor & Head,Dept of General Medicine, ADCH.

MEMBER SECRETARYDr. Harsh ShahReaderDepartment of Public Health Dentistry, ADCH.

COMMITTEE MEMBERSDr. Darshana ShahProfessor & H.O.DDept of Prosthodontics & Crown & Bridge, ADCH

Dr. Dolly PatelProfessor & H.O.DOrthodontics & Dentofacial Orthopedics, GDCH.

Dr. Mahendra K. JoshiAdvocate & Medico Legal AdvisorDEPUTY CHAIRPERSON

Dr. G. C. PatelStatistician

Dr. Dilip ZaveriDirectorBiocare Research (India) Pvt. Ltd.Paldi, Ahmedabad.

COMMUNITY REPRESENTATIVE / SOCIAL WORKERMr. Darshak Shah

Dr. Janki VasantNGO. Samvedna

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