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Official Publication of IDA Karnataka State BranchOfficial Publication of IDA Karnataka State Branch

ISSN : 09733442

Issue 1

Volume 36

April - June 2019

Dear colleagues,

EDITORIAL

Editorial Advisory Board

1

GreetingsfromtheeditorialboardofIDAKarnatakaStateDentalJournal.

Inthecurrentscenarioofwidespreadchallengesandinequitablecompetitionineveryprofession,dentistryisnodifferent.Theveryexistenceofdentistsdependsuponbeingthebestinalotratherthangood.Theneedtokeeponeselfupdatedwiththelatesttrendsandtechnologyisalsoanemergingdemand,especially while dealing with patients who seek treatment after doing anonlinestudyondentistry.

Thelatestresearchprotocolsandstudiesundertakenbytheyoung,emergingdentistsandtheestablishedseniorprofessionalsareanintegralpartofthe�ield.Thisjournalhasbeencarefullykneadedtokeepupwiththeupcomingtrendsindentalprofession.

IDAKarnatakaStateDentalJournalisindebtedtoallitsreaders,sponsorsandcontributors.Dr.SupriyaManvi,Ph.no.9448145452,email:[email protected],ProfessorandHeadoftheDepartment,DepartmentofImplantology,KLESIDS.(AssistantEditor,IDAKarnataka)

Dr.B.K.SrivastavaProfessorandHeadoftheDepartment,

K.L.ESociety'sInstituteofDentalSciences,Bengaluru.

(EditorIn-Chief,IDAKarnatakaStateBranch)

INSTITUTIONNAME DEPT EMAIL IDPH.NO.

[email protected] Oralmedicine CODS,Davangere

Dr.VivekHP CommunityDentistry CODS,Davangere 8095306448 [email protected]

Dr.MaheshChandra CommunityDentistry Maruthidentalcollege [email protected]

Dr.Prashanth ConservativeDentistry BIDAR 8861449056

Dr.PrashanthBR

Dr.PraveenB

Dr.Vinod

Dr.Sudarshan

Dr.Sathyadeep

Dr.Ramesh

Dr.Babitha

Dr.Jayprakash

Dr.Madhu

Dr.MallikarjunaK

ConservativeDentistry KLEIDS 9449638113 [email protected]

CODS,Davangere 9986393343

OralSurgery DayanandSagar 9845190783

KLEIDSOralSurgery

Orthodontics DayanandSagar 9980142380

Orthodontics Sharavathidentalcollege,Shimoga

9632522799

Periodontics 9448966166

Periodontics CoorgInstituteofDentalSciences

9972912662

Pedodontics KLEIDS 9535152325

Pedodontics CODS,Davangere 9448040502 [email protected]

Prosthodontics

9845571071

9449104316

[email protected]

[email protected]

[email protected]

[email protected]

[email protected]

[email protected]

[email protected],Davangere

[email protected]

[email protected]

PRESIDENT MESSAGE

SECRETARY MESSAGE

It gives me immense pleasure and honour to be part of Karnataka IDA and being State President, I heartly congratulate Dr. Shrivastava and his editorial team for bringing up the 1st Journal for the year 2019. Hatsoff for their dedica�on and hardwork they have put in. I request all my fellow Den�sts to keep up their research work on and publish in this IDA journal to make it eminent and colourful year by year. I am very Happy to announce that Our very own " Namma Mandya" is hos�ng the IDA conference in the month of December. As IDA mandya team is very spirited and working hard to get best keynote lectures on Advancements and inven�ons in digital den�stry, in a very beau�ful venue. I request all the prac��oners/ specialists, students and staff of all colleges to a�end this conference and make it a grand success and I am sure that you will go back with lots of good memories and messages with you.

I also appeal all of you to encourage your Dental friends and fellow colleagues to Become a member of this wonderful Associa�on and Strengthen the IDA to get More from us

From the Office of IDA Karnataka state branch,

Gree�ngs to all the members of IDA Karnataka state branch. The New office bearers took over in the month of December 2018 to manage the office for the nest 04 years. The good work done by previous office bearers have taken some significant decision that will benefit the members. Our task will be to effec�vely implement the programs. The new office bears along with the President wish the Editor in chief and the editorial team of KSDJ all the very best to bring out the journal for the next 04 years.

The local branches have done a wonderful job �ll date. We are thankful for all the hard work, Devo�on and �me spared by the members.

Dr. H.P. PrakashStatePresidentIDAKarnataka

Dr. Shivaprasad. SHon.StateSecretary,

IDAKarnatakaStateBranch

2

IDA KARNATAKA STATE BRANCHLIST OF OFFICE BEARERS FOR THE YEAR 2018-19

President:

Dental Surgeon,

# 118, Gauri, 13th Main, 7th Cross,Sector - 5, H.S.R. Layout, Bengaluru- 560 [email protected] 42043

Dr. H.P. PrakashProf. Oral Medicine & Radiology

Bapuji Dental College,Davanagere - 577 [email protected] 53148

Dr. Shivaprasad. S Dr. Sushanth V.HHon. State Secretary Hon. Treasurer

Veerabhadreshwara Krupa,#3501/1, 3rd Main, 6th Cross,M.C.C. ‘B’ Block, Davangere - [email protected] 14030

Dr. Sudhindra Kumar N.N Dr. Ashwath Raju

Dr. Nanda Kishore B.

Dr. Muralidhar Rai

Dr. Mohan Kumar K.P.

Dr. Praveen S. BasandiDr. Adarsh C.

Dr. M.G. Ravi

Dr. Raghavendra Kattri

Dr. Srinivasa B.K.

Dr. Jagadish KadammanavarDr. Ritesh K.B.Dr. Kishore HadelDr. Kirti ShettyDr. Shubhan AlvaDr. Manjunath RaiDr. Padmaraj HegdeDr. Shishir ShettyDr. Charan KajeDr. Roshan ShettyDr. Sanath ShettyDr. Prathap Kumar ShettyDr. Chaitanya BabuDr. Prabhuji M.L.V.Dr. Vijendra RaoDr. Pramod G.V.Dr. Deepak J.R.Dr. Raghunath ReddyDr. Arvind GopalDr. Shridhar SheelvantDr. Raghunath N.Dr. Pramod ShettyDr. Rajesh HegdeDr. Jithesh N.Dr. Mahesh K.PDr. Harish B.N.

Dr. Prakash H.P.Dr. Shivaprasad S.Dr. Tilakraj T.N.Dr. Mahesh ChandraDr. Narendra Kumar MDr. Ramamurthy T.K.Dr. Mahendra PimpaleDr. V. RanganathDr. Sanjay Kumar D.Dr. Girish SharmaDr. Uma S.R.Dr. Adarsh C.Dr. Annaji A.G.Dr. ShivasharanDr. Rama Chandra MallanDr. Raghavendra PidmaleDr. Srinidhi D.Dr. Charan Kumar Shetty

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CONTENTS

1. Dental records: Do we maintain it the right way? 8-12 - Dr.Amritha.N, Dr.Mahesh Chandra K, Dr. Vanishree Mk, Dr.Gurusuhas, Dr. PriyaBabu

2. A Comparative Evaluation Of Apical Root Resorption In Maxillary 13-17 Anterior Teeth In Patients Treated With Two-step And En Masse Space Closure Procedures-a Cbct Study - Kavitha Joy, Vinaya S Pai, Siri Krishna P, Gautham Kalladka, Shreyas Rajaram, Shivaprasad Gaonkar

3. Genetic Counselling -bridging The Gap Between 18-22 Genetic Field Complexity And Life - Dr. Priya Babu, Dr. Mahesh Chandra. K, Dr. Vanishree M. K, Dr. Guru Suhas, Dr. Amritha. N

4. Three-Dimensional Analysis Of Pharyngeal Airway 23-26 With Different Skeletal Patterns In Bangalore Population - Dr. Shabana Kouser, Vinaya S.Pai, Siri Krishna.P, Goutham Kalladka, Shreyas Rajaram, Dr. . Dr. Dr.

Dr. Shivprasad Gaonkar.

5. Three Dimensional Computed Tomographic Analysis Of 27-33 Immediate And Post Retention Skeletal, Dentoalveolar And Pharyngeal Airway Changes Following Rapid Maxillary Expansion Therapy - Dr. Zangpo HK, Dr. Pai VS, Dr. Kalladka G, Dr. Gaonkar SP, Dr. Rajaram S

6. An interdisciplinary concept of oral rehabilitation in a 34-37 nonsyndromic oligodontia with a novel mutation of PAX9. A clinical report - Dr. Umapathy. T, Dr. Karthikeyan BV, Dr. Prabhuji

7. Metoprolol induced gingival enlargement? - A case report 38-41 - Dr. Sachin Shivanaikar, Dr. Pradeep Somannavar, Dr. Sameer Pote, Dr. Arundhati Pote

8. Moriginal article:Assessment of Awareness, knowledge and 42-46 practices of Digital smile designing among practitioners in Davangere city: A cross sectional survey - Dr. Sunitha N.Shamanur, Dr. Nivedita Tiwari

9. Dermatoglyphics as a genetic marker for potentially 47-53 malignant disorders of the oral cavity - Dr.Dr. Y. Pavan Kumar, Dr. D. Ajit

10. A New Diagnostic Tenet For The Esthetic Midface Clinical 54- Assessment Of Anterior Malar Projection -Dr. Jerin Varghese George, Dr. Suma .T, Dr. Rajkumar. S. Alle, Dr. Lokesh . N.K, Dr. Shwetha G.S, Dr. Kiran.H, Dr. Dharmesh H.S

2

Dental records: Do we maintain it the right way?

Authors : Dr.Amritha.N¹, Dr.Mahesh Chandra K², Dr. Vanishree Mk³, Dr.Gurusuhas⁴, Dr. PriyaBabu⁵

1. Dr. Amritha.NDepartmentOfPublicHealthDentistry,AECSMaarutiCollegeofdentalsciencesandresearchcentreBangaloreKarnataka.

2. Dr.Mahesh Chandra K

3. Dr. Vanishree MK

Dr.Gurusuhas⁴, Dr. PriyaBabu⁵

4. Dr.Gurusuhas

5. Dr. PriyaBabu

Abstract

Withtheincreasingawarenessamongthepublicoflegalissuessurroundinghealthcare,andwiththeworryingrisein

malpracticecases,athoroughknowledgeofdentalrecordissuesisessentialforanypractitioner.Dentalrecordsare

essentialfordentistandpatientprotection,anditsmaintenanceisconsideredanethicalandlegalobligationofthe

dentist:Ethical,becauseitsatis�iesthedutyofcarethatthedentisthastowardhispatientandlegal,asitaidsinfuture

protectionagainstmedico-legalcomplications.It isthedentist'sprofessionalresponsibilitytoproduce,retainand

releaseofclearandaccuratepatientrecords.Thisnotonlyassiststhedentistinamedicolegalclaimbutalsohelpsthe

policeinidenti�icationofindividuals.Dentistscouldplayavitalroleinassistingforensicinvestigatorsinproviding

informationthatwouldhelpintheidenti�icationofperpetratorsorvictimsofcrimeandnaturalormanmadedisaster

situations.

Keywords: dentalrecords,dentists,medico-legal,professionalresponsibility.

Introduction“Verbavolant, scriptamanent” (spoken words �ly away, written words remain)- Caius TitusA dental record is the detailed documentation of thehistoryof the illness,physicalexamination,diagnosis,treatment, and management of a patient. Dentalprofessionals are compelled by law to produce andmaintainadequatepatientrecords.Withtheincreasingawareness among the general public of legal issuessurroundinghealthcare,andwiththeworryingriseinmalpractice cases, a thorough knowledge of dentalrecordissuesisessentialforanypractitioner.Theabilityof clinical practitioners to produce and maintainaccurate dental records is essential for good qualitypatientcareaswellas itbeinga legalobligation.Thedentalrecordprovidesforthecontinuityofcareforthepatient and is critical in the event of a malpractice

1insuranceclaim.

Dental records play an important role in the

identi�ication of a dead body, which has been grosslydecomposed and is dif�icult to identify visually.Whenthisoccurs,avarietyofmethodsofdentalidenti�icationisused.Thisisduetothecapabilityofdentaltissuestowithstandhightemperature,humidity,andpressure.TheAmerican Academy of Paediatric dentistry hasaddressedthemajorelementsofrecord-keepingwhichinclude,Generalchartingconsiderations,Initialpatientrecord,Componentsofapatientrecord,Patientmedicalanddentalhistories,Comprehensiveandlimitedclinicalexaminations, Treatment planning and informedconsent,Progressnotes;correspondence,consultationsandAncillarydocuments;andcon�identialnotes .Thedentalpractitionermustbeawareoftheimportanceofadental record due to legal circumstances andmaintenance of an accurate record ensures a high-qualitypatienthealthcareandservice.Theaccuracyofarecorddeterminesthevitalityofadentalpracticeanditsmaintenance determines good clinical practice and

2indicatesskillfulness.

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KSDJ/Vol36/Issue1/Apr-June2019

Despiteitsmanyuses,manypractitionersinIndiadonotmaintaindentalrecords,or, ifmaintained, theseareofpoor quality. A recent study byWadhwani et al. inMangalorereportedthat87%ofthedentistsmaintainedrecords, only 31% of them recorded all the detailsrequiredtobepresentinadentalrecord.Ofthese18%of

3themmaintained the records for>5years. In anotherstudy by Preethi et al. among dental practitioners inChennai, it was found that 21% did notmaintain anyform of dental record and that only 12%maintained

4completedentalrecords. Thistrendcouldbere�lectedinotherpartsofthecountryandisaveryalarmingsituationasmost dentists are unaware of the ethical and legalimplications of inadequate or improperly maintaineddentalrecords.

Importance of good clinical records1) Aid the sharing of relevant information and

multidisciplinaryteamcommunication2) Aidcoordinationofcare3) Aidcontinuityofcare4) Aid informed decision making for patient

management5) Improve the availability of data for risk

assessment6) Improvetheavailabilityofdataforrootcause

analysis in the investigation of seriousincidents

7) Improveauditcapabilities8) Provideinformativeevidenceinacourtoflaw9) Aid targeting of diagnostics and treatment

planswithoutunnecessaryrepetition10) Improvetimemanagement

Ideal requisites of a dental recordA dental record refers to all the information that isrelatedtotheprovisionofdentalcareservices,includingpatientrecords,businessrecordsincludebilling,claimsforms, laboratory charges, scheduling etc., and drugrecords.Asthedentalpractitionerissolelyaccountablefor complete and accurate patient records, there arecertainbasiccriteriathatneedtobefollowedinwritinga

5dentalrecord.

A.Patient record1. Allentriesshouldbeeitherrecordedininkandnot

in pencil legibly or recorded in an electronicformat.

2. Thedateofeverypatientvisitshouldbeenteredinachronologicalorder

3. Complete recording of all items in the patient'scasehistoryform,whichincludes

a. General patient information – age, gender,birth date, place of employment, contactinformationthatincludestelephonenumbersandaddressandanyreferringparty

b. Chief complaint, past dental,medical, family,drughistoriesandallergiesneedtobeupdatedregularly and, in the case of children, theimmunizationstatus.

c. Speci�icquestionsrelatedtowomenregardingpregnancyandlactation

d. Clinical and radiographic �indings, diagnosis,proposedtreatmentandprognosis

e. Copies of test results, instructions for homec a re , p a t i e n t f o l l ow- up a nd r e c a l lexaminations,feeschargedandreferrals

4. Duetothepaucityoftime,thedentistmaynotbeable to personally record all the details in thepatient'srecord.Someentriesmaybedelegatedtoof�ice staff. For example, the receptionist canrecordtelephonecalls,prescriptionchanges,andappointments. The dental assistant records thepatient's comments, concerns and disposition;vitalsigns;medicalhistory;radiographsandotherdiagnostictoolstakenandused;andinstructionsgiventothepatient,etc.Thedentistcanthenaddclinical impressions, treatments performed andany pertinent information. I t should beremembered that the dentist is ultimatelyresponsibleforthepatient'schart.

5. All diagnostic aids, which include radiographs,study models, photographs etc., should beproperlylabeledanddated

6. E s t ab l i shed t e rm ino logy, s ymbo l s , andabbreviations should only be used in order toavoid misunderstandings between differentmembersofthedentalteam

7. All entries should be signed or initialed by thetreatingclinician

8. Informedconsentformswithpatientsignatureforinvasiveprocedures,sedationetc.,shouldbetaken

9. Signature of the patient is also necessary if thepatient refuses to undergo a treatment eventhoughtheclinicianfeelsisessentialforthehealthofthepatient.Registeringinformedrefusalisasimportantasnotingdownthepatient'sinformedconsent

6


10. Record should be objective in nature. It shouldcontain only facts relating to the case andprofessional opinions in notations and notsubjectiveinterpretationsforwhichtheclinicianisnottrained.Itshouldnotcontainanyderogatoryremarksregardingthepatient

11. Anymistakes in therecordsshouldbecorrectedwith a single line drawn through the incorrectmaterial in an honest, open manner. Deliberateobliterationoralterationsoftherecordafterthefactshouldnotbemadeunderanycircumstances.

12. All communications with the patient, includingemergency telephonic consultations, should berecorded.

13. If a patient is dissatis�ied, all communicationsshould be recorded including the problem, theattempttodealwiththeproblemandthesolutiontotheproblem.

14. Ifapatientwishestodiscontinuetreatment,anoteofitshouldbemadeinthepatient'srecordalongwiththereason.

11. Classify all patient �iles into either active orinactive.Active �ileshold therecordsofpatientswho are at present having their dental careprovided by the practice. Inactive patients areconsideredtobethosewhohavenotreturnedtothedentalpracticefor24months.

Themostcommontypesoferrorscommittedinrecordkeepingare:(1)notrecordingthetreatmentplan,(2)notdocumentinghealthhistoryclearlyorfailuretoupdateitregularlyand(3)failuretodocumentinformedconsentorinformedrefusal.

B. Business record It should includedetailsofbillingwithdateand

amount,copiesofclaimsformssubmittedbythepatient, information related to name, address,nature of the laboratory services used andlaboratory charges, scheduling of appointments,etc.Thisinformationshouldnotbekeptalongwiththepatientclinicalrecord.

C. Drug record Dentistsprescribecertaindrugs foranumberof

conditionsrelatedtotheoralcavity.Althoughthenumberofthesedrugsislimited,theuseofthesedrugs has important implications and extremecareshouldbetakenuponprescribingtomakethebest use of these drugs and prevent their side-effects.

Adrugrecordofthepatientshouldinclude1. The da te and me thod o f p resc r ip t i on/

administration/dispensingofdrug2. Name,strength,quantity,andformofdrug3. Directionsforuseofthedrug4. The condition being treated and/or dental

treatmentprovided5. Prescriptionpadsshouldneverbepresignedand

kept out of reach of patients to avoid potentialmisuse.

Theuniversallyacceptedrecord-keepingformat–SOAP.Subjective data:Thissectioncontainsinformationaboutthereasonforavisittothedentist,whichincludesthepatient's chief complaint/s and symptoms. Objective �indings:This sectionrecordsall the �indingsobtainedfromtheclinicalexaminationanddiagnostictestsinanunbiased manner. Assessment : Diagnostic andtherapeutic judgment is reached based on subjectivedata and objective �indings. Plans: In this stage, theassessmentisconvertedintoaction.Herein,thevarioustreatment options along with their pros and cons,economic and time considerations, home careinstructions,appropriateuseofprescribedmedicationand consequences of unwillingness to undergotreatmentareexplainedtothepatientsothathe/shecanmake an informed decision regarding their course of

6treatment.

Storage of the records Theoutside coverof the chart shouldonlydisplay thepatient'snameand/oraccountnumber.Useofabstractisadvantageous in the in-of�ice system (color or symbolcoding) so that only your of�ice staff will be able todecipherit.Forallof�ices,asinglestickerontheoutsidecover can alert the team to look on the inside forimportantinformationregardingallergies,medications,antibioticpre-medications,andclinicalconditions thatcanaffectdentaltreatment.Allmedicalnotationsinside

7thechart,tobeseenonlybytheauthorizedpersonnel.Thereisnorequirementthatapatientrecordbekeptonpaper; indeed, no particular medium for recordingpatient information is prescribed by existing laws. Aslong as the record is an accurate re�lection of theevaluation and treatment of the patient and is readilyretrievable, itwill suf�ice legally.Having said this, it isimportanttonotethatwrittenpaperrecordsarestillthepreferredandcommonlyacceptedmethodforcreatingapatient record. They are regarded as being the mostavailable as well as the most accurate and credible,

7

1especially in court. However,manymoredentists aremakinguseofcomputerized�ilingsystemstomaintainpatient dental records. Electronic records have greatquality and patient-safety bene�its, and will likelyincrease asmore dental clinics and hospitals becomecomputerized.

Dental records and the ethical principle of con�identialityEthicsguidesthemoralconsciousnessofthehealthcareprofession, and con�identiality is one of its coreprinciples.Therelationshipofadentistandpatient isbasedon trust.Everydental record is thereforemadeunderthebasicpremisethatthehealthinformationofthepatientwouldbekeptcon�identialnotonlybythedentistbutalsobyeverymemberofthedentalteam.Thisinformationshouldbeprotectedfromanyunauthorizeduseordisclosureeventofamilymembersexceptwhenrequired by law orwhere the patient has given theirexpressconsent,ideallyinwriting.

A breach of con�identiality occurs when privateinformation that the clinician has learned within thepatientisdivulgedtoathirdpartywithoutthepatient's

5consentoracourtorder.

Duration of retention of recordsDifferentcountrieshavedifferentguidelinesregardingthedurationforthepreservationofrecords.

AccordingtoTheDepartmentofHealth(DH)forNationalHealth Service (NHS) organizations in England,communitydentalrecordsshouldbemaintained foraperiodof11years foradultsandchildrenoruntil thepatient is 25 years old, whichever is longer. Hospitalrecordsneedtobemaintainedfor8yearsinadultsanduntilthepatientis25yearsoldinchildren,orifsooner,8

8yearsaftertheirdeath. InIndia,therearenoclear-cutguidelines or law regarding retention of records.

9AccordingtotheMCIregulations 2002,everyphysicianshall maintain medical records pertaining to his/herindoorpatientsinastandardproformafor3yearsfromthe commencement of treatment (Section 1.3.1 andAppendix3).

AccordingtotheIndianCouncilofMedicalResearch,incaseofresearch-relatedrecords,itisrecommendedthatall records must be safely maintained after thecompletion/terminationof thestudy foraperiodof3yearsifitisnotpossibletomaintainthesameformorethan that due to lack of resources and necessary

1 0infrastructure . The Cl inical Establ ishments(RegistrationandRegulation)Act,2007,reintroducedin 2010, is an act aimed at streamlining public andprivate clinical establishments in India by theirregistrationandregulation.Thisactshallbeapplicabletoallunion territoriesand four states,which includeMizoram, Sikkim, Arunachal Pradesh,and HimachalPradesh,whileotherstatesmayadoptthesame.Asacondition for registration and continuation, everyclinical establishment shall ful�ill the provisions formaintenance of records and reports as may beprescribed (under clause [iii] of sub-section [1] of

11section12ofthe2010act. Nofurtherdetailsregardingthe manner of record maintenance or duration ofretentionofrecordsaremadeintheactasitisprobablylefttothediscretionofthestategovernments.

As part of good practice, it is recommended that thepatient�ilesbestoredforaperiodictermasfollows:1. Foroutpatientrecords–5years2. Forinpatientrecords–7-15years3. Formedicolegalcases–15yearsormore.

Records can also be stored inde�initely and madeavailableanytimebyscanninganddigitizingthem.

Release and Transfer of RecordsAll the original records of the patient are the solepropertyandresponsibilityofthetreatingdentistandshould be in his custody. If the patient moves to adifferentdentalpractice,acopyoftherecordsshouldbetransferredtothenewpractitioner.Aminimumfeecanbe charged by the dentist for copying of the recordsprovidedthepatientismadeawareofthecharges.

Disposition or Purging of RecordsAt the end of the retention period, records must bedisposed of in a manner that protects patientcon�identiality andmaintains physical security of theinformation.Methodsinclude:· Therecordscanbe returned to the individualor

deal t with in accordance with pat ient 'sinstructions

· Controlledphysicaldestructionofrecordssuchasshreddingorincineration

· Con�idential transfer to another agency thatwillprovide appropriate services to destroy theinformation

· The process used to destroy electronic recordsmust render themunreadable and eliminate thepossiblereconstructionoftherecordsinwholeor


8

inpart· For secure cast and model destruction, all

identifyinginformationoncastsandmodelsmust5

beremovedpriortodisposal.

ConclusionIntheviewofbetterclinicalpractice,itisthedentist'sprofessional responsibility to produce, retain andrelease of clear and accurate patient records.This notonlywillassistthedentistinamedicolegalclaimbutalsohelpsthepoliceinidenti�icationsofindividuals.

References1) LawneyM.Fortherecord:Understandingpatient

recordkeeping. New York State Dental Journal.1998May1;64(5):34.

2) WaleedP,BabaF,AlsulamiS,TarakjiB.Importanceofdentalrecordsinforensicdentalidenti�ication.ActaInformaticaMedica.2015Feb;23(1):49.

3) WadhwaniS,ShettyP,SreelathaSV.Maintenanceof antemortem dental records in private dentalclinics:Knowledge,attitude,andpracticeamongthepractitionersofMangaloreandsurroundingareas. Journal of forensic dental sciences. 2017May;9(2):78.

4) Preethi S, Einstein A, Sivapathasundharam B.Awarenessof forensicodontologyamongdentalpractitioners inChennai:Aknowledge,attitude,practicestudy.Journalofforensicdentalsciences.2011Jul;3(2):63.

5) DevadigaA.What'sthedealwithdentalrecordsforpracticingdentists?Importanceingeneralandforensic dentistry. Journal of forensic dentalsciences.2014Jan;6(1):9.

6) Leeuw W. Maintaining proper dental records.Crest® Oral-B® at dentalcare.com ContinuingEducationCourse,RevisedMarch25.2010.

7) Charangowda BK. Dental records: An overview.Journal of forensic dental sciences. 2010Jan;2(1):5.

8) Howlongshouldhealthrecordsmedicalrecordsbe kept for? National health service. [Lastaccessedon2018November12].Availablefrom:http://www.nhs.uk/chq/Pages/1889.aspx?CategoryID=68andSubCategoryID=160.]

9) Indian Medical Council Professional Conduct,EtiquetteandEthicsRegulations,2002PublishedinPartIII,Section4oftheGazetteofIndia,dated6thApril.2002.[Lastaccessedon2018Nov12].Available from: http://www.mciindia.org/rules-and-regulation/Code%20of%20.

10) Publishedby:Director-General,IndianCouncilofMedicalResearch;2006.[Lastaccessedon2018Nov 12]. Ethical Guidelines for BiomedicalResearch on Human Participants. Chapter 2:Ethicalreviewprocedures–Recordkeeping;p.19.Av a i l a b l e f r om : h t t p : / / i cm r. n i c . i n /ethical_guidelines.pdf.]

11) The Clinical Establishments (Registration andRegulation)ACT,2010No.23of2010August18th,2010.TheGazetteofIndia(Part2,Section1,No31). Ministry of Law and Justice, New DelhiAvailable from https://indiacode.nic . in/bitstream/123456789/2048/1/201023.pdf

Correspondence Address :


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1 2 3 4 5 6Authors : Kavitha Joy , Vinaya S Pai , Siri Krishna P , Gautham Kalladka , Shreyas Rajaram , Shivaprasad Gaonkar

1. Kavitha Joy Postgraduatestudent,

2. Vinaya S Pai ProfessorandHOD,

3. Siri Krishna P Professor,

4. Gautham Kalladka Reader

5. Shreyas Rajaram SeniorLecturer

66. Shivaprasad Gaonkar SeniorLecturer DepartmentofOrthodonticsandDentofacialOrthopaedics,

BangaloreInstituteofDentalSciencesandPostgraduateResearchcentre,Bangalore,Karnataka.

Abstract

Rootshorteningasaresultofapicalrootresorptionisanundesirableconsequenceoforthodontictreatment.Two-step

andEnmassetechniquewithfrictionless/frictionmechanicsarethecommonmethodsinpre-adjustededgewisefor

spaceclosure.TheaimofthestudywastoassesstheseverityofrootresorptioninmaxillaryanteriorsduringTwo-step

andEnmassespaceclosureproceduresusingthreedimensionalCBCTanalysis.20youngadultpatientswithAngle´s

ClassIandClassIIDivImalocclusionwereselectedforthestudyaccordingtotheinclusionandexclusioncriteria.All

patientswerebondedwiththesamepreadjustededgewiseapplianceMBT0.022inchslotwithtranspalatalarch.After

levelingandaligningpatientsweredivided into twoequalgroups.Group I (10patients ) -Two-stepretractionor

individualcanineretraction,followedbyincisorretraction,GroupII(10patients)-onesteporEnmasseretraction.Pre

treatmentandpostspaceclosureCBCTscansweretakenforall20patientsusingKodak93003.CBCTscanswere

analysedusingDolphinsoftwareinsagittal,coronal,andaxialplanesforassessingtheamountofrootresorptioninthe

two groups. Enmasse retraction showedmore resorption compared to Two-step retraction in all themaxillary

anteriors.

Keywords: Rootresorption,Two-step,Enmasse,CBCT,Dolphinsoftware.

IntroductionAcentraltenetoftheHippocraticoathisencapsulatedbythephrase,“First,donoharm”.Asclinicianswemustpreservethisgoalinallofourtreatments,buteveninthebest of hands, this isnot alwayspossible.Apical rootresorption is one of the most common iatrogenicproblems inOrthodontics. A study of apical root lossconcernedprimarilywithorthodonticprocedureswas

1reported�irst inthe literaturebyOttolengui in1914 .Rootresorptionthatoccursafterorthodontictreatmentisoftransientin�lammatorytypeandoccursinapical

2part of the root. The clinical diagnosis of apical rootresorption is based mainly on routine radiographic

3proceduresasperiapicalandpanoramicradiographs .Howeverthesehavetheirlimitations,asinpanoramicradiographs, root apices in anterior regions may beplacedoutsidethenarrowfocaltroughandproducebi-dimensional images of a tri-dimensional structure,leading to labiolingual superimposition of root

A Comparative Evaluation Of Apical Root Resorption In Maxillary Anterior Teeth In Patients Treated With Two-step And En Masse Space

Closure Procedures-a Cbct Study

3-4structure . The advent of cone beam computedtomography in 1990s, which provides images inslicesofdentalroots,broughtabouttheperspectiveof a precise quantitative evaluation of rootresorption.

During premolar extraction treatment , theorthodontisthas severaloptions for space closure.Two - s t ep and En mas se t e chn ique w i t hfrictionless/friction mechanics are the commonmethodsinpre-adjustededgewiseforspaceclosure.Althoughthetwo-stepprocedureispredictableandhasexcellentfail-safecharacteristics,ittakeslongertoclosespaceintwostepsthaninonestep.Becausetheriskofresorptionincreaseswiththedurationof�ixedappliancetreatment,ithasbeenpostulatedthatexternal apical root resorption would be morefrequentandseriousintwo-stepspaceclosurethan

5followinganEnmasseprocedure.

10

Aims and ObjectivesTocomparetheseverityofrootresorptioninmaxillaryanteriorsduringTwo-stepandEnMassespaceclosureproceduresusingthreedimensionalCBCTanalysis.

Materials and Methodology20youngadultpatientswithAngle'sClassIandClassIIDiv I malocclusion, treated with extraction of all �irstpremolarswereselectedforthestudy.CBCTScans(Fig1&Fig2)weretakenforall20patientsbeforetreatmentusing Kodak 93003 with the following parameters:1 0 M a , 9 0 K V , 3 0 0 µ m v o x e l r e s o l u t i o n[0.3mmx0.3mmx0.3mm]and scan timeof 16 secwith1024x1024pixelsand14bitsperpixel.

All patients were bondedwith the same pre adjustededge wise appliance MBT 0.022 inch slot withtranspalatal arch. After leveling and aligning patientsweredivided into twoequal groupsdependingon themechanicsoptedforspaceclosure.

Ø Group I - 10 patients- Two-step retraction orindividual canine retraction, followed by incisorretraction.(Fig3)

Ø Group II - 10patients – one steporEnmasseretraction.(Fig4)

IntheTwo-stepprocedure,canineswereretractedwith0.017x0.025inchTMATloopandincisorswereretractedwithslidingmechanics.IncisorretractionwasdonewithNiTicoilspringsandligatedwithawiretothearchwirehook,solderedmesialtocanine.InEnmassegroup,NiTicoil springswith a force level of 150gmswere placedacross extraction sites from buccal tube hook on �irstmolar to archwire hook, solderedmesially to canine.Patientswere recalledevery4weeks,excesswirewasclippeddistaltomolartubesandspringswerecheckedfor activation. Occlusal interferences were avoidedduring space closure. Pre treatment and post spaceclosure CBCT scans (Fig 5,6) were analysed usingDolphin software 11.8 version in multiplanarreconstruction visualization mode in sagittal, coronal,andaxialplanes(Fig7,8,9)forassessingtheamountofrootresorptioninthetwogroups.

Fig 1 : Pre- treatment CBCT Group I

Fig 2 : Pre- treatment CBCT Group II

Fig 3: Retraction with T loop


11

Fig 4: Retraction with NITI coil spring

Fig 5: Post space closure CBCT Group I

Fig 6: Post space closure CBCT Group II

I

CEJ

A

I

Li

A

CEJ

La

La-Themostapicalpointoflabialsurfaceofroot.Li-Themostapicalpointoflingualsurface.A-Mostapicalpointoftoothroot.CEJ-Cementoenameljunctionoftooth.I-Incisaledge

Fig 7: Land marks in Sagittal plane

Fig 8: Land marks in Coronal plane.

A-Mostapicalpointoftooth.CEJ-Cementoenameljunctionoftooth.I-Incisaledge.


12

b

c

a

d

a-Thepointofgreatestconvexityonthelabialside.b-Thepointofgreatestconvexityonthelingualside.c-Thepointofgreatestconvexityonthemesialside.d-Thepointofgreatestconvexityonthedistalside.

ResultsThe mean of the root resorption of each group and the standard deviation were found out (Table 1) using Independent Student t test. Signicant differences were found in the mean root resorption in all the three planes. Group II showed higher resorption compared to Group I for all the maxillary anteriors.

Fig 9: Land marks in Axial plane

Table 1 Comparison of mean root resorption between

groups in Sagittal, Coronal and Axial planes

Groups Tooth Sagittal Plane Coronal Plane Axial Plane

Group I

Mean SD Mean SD Mean SD

11 12 13 21 22 23

0.25 0.11 0.29 0.10 0.40 0.20

0.38 0.14 0.41 0.10 0.60 0.20

0.24 0.13 0.32 0.14 0.71 0.32

0.24 0.12 0.24 0.13 0.43 0.16

0.39 0.15 0.43 0.12 0.75 0.17

0.30 0.16 0.35 0.17 0.75 0.25

Group II

11 12 13 21 22 23

0.62 0.17 0.75 0.12 0.74 0.12

0.10 0.26 0.11 0.15 0.10 0.27

0.52 0.18 0.55 0.16 0.86 0.52

0.69 0.20 0.76 0.13 0.72 0.15

1.12 0.25 1.17 0.18 0.40 0.27

0.55 0.18 0.57 0.18 0.66 0.25

DiscussionMoststudiesonrootresorptionanditsrelationshipwithorthodontic treatment have found that it has got amultifactorialetiology(Baumrindetal,1996;Jiangetal,2001). Age, gender, nutrition, genetics, the type ofappliance,theamountofforceusedduringtreatment,extractionornonextraction,durationoftreatment,andthe distance the teeth are moved all have some

6in�luences on root resorption. The advent of CBCTprovides images in slices of the dental roots thateliminates superimposition of structures and showdifferent levelsof resorptionon the labialand lingualsurfaces, demonstrating it to be a precise tool in the

3diagnosisof root resorption lesions andpreclude theerror of radiographic interpretation. Leavander andMalmgren suggested a method to analyze rootresorption based on qualitative scores obtained fromtwo-dimensional images. Estrela et al used the i-CATsoftwareandthreedimensionalimagesandsuggestedaquantitative method to evaluate in�lammatory rootresorptionaccordingtorootthirdandsurfaceandthe

7extentofrootresorption.

Thepresentstudywasdonetocomparetheapicalrootresorption between En masse and and Two-stepretraction in maxillary anterior teeth. Signi�icantdifferenceswerefoundbetweenEnmasseandTwo-stepretraction for all the maxillary anteriors. Segmentalretractionshowedlesserrootresorptionhowever,rootshortening was greater in maxillary incisors andmaxillarylateralincisorwasmorepronetoresorption.Comparedwithotherstudies,whichstatesthattheriskof resorption increases with the duration of �ixedappliance treatment, root shortening was notdependent on the duration of space closure in thepresent study. Segmental retraction showed lessresorption as �irst canines were retracted with0.017x0.025 inch TMA T loop which exerts a lighterforcecomparedtoNiticoilspringswhichdelivershigherforce. The higher resorption in the En masse groupsuggests probable increased force levels and a lessbiologic environment for tooth movement. It wasinteresting tonote thatmaxillary lateral incisor rootsshowed higher levels of resorption that re�lects arelationshipoftheirrootstructurecombinedwiththe

8tipbuiltintothepreangulatedbracketsystem.

ConclusionEnmasseretractionshowedmoreresorptioncomparedto Two-step retraction in all the maxillary anteriors.


13

Maxillary lateral incisor showed more resorptioncomparedtocentralincisorandcanineinbothTwo-stepretractionandEnmasseretraction.

References1. Phillips JR. Apical Root Resorption under

Orthodontictherapy.AngleOrthod1955;25;1-22.

2. YuJH,ShuKW,TsaiMT,HsuJT,ChangHW,TungKL.A cone-beam computed tomography study oforthodonticapicalrootresorption.JDentSci2013;8;74-79.

3. CamposMJS,SilvaKS,GravinaMA,FragaMR,VitralRWF.Apicalrootresorption;Thedarksideoftheroot.AmJOrthodDentofacialOrthop2013;143;492-498.

4. LundH,GrondahlK,HansenK,GrondahlHG.Apicalroot resorption during orthodontic treatment -Aprospective study using cone beam CT. AngleOrthod2012;82;480-487.

5. HuangY,WangXX,ZhangJ,LiuC.RootShorteninginPatientsTreatedwithTwo-stepandEnmasseSpaceclosureProcedureswithSlidingMechanics.AngleOrthod2010;80;492-497.

6. JiangRP,McDonaldJP,FuM.Rootresorptionbeforeandafterorthodontictreatment;aclinicalstudyofcontributoryfactors.EurJOrthod2010;32;693-697.

7. CastroLO,AlencarAHG,NetoJV,EstrelaC.Apicalroot resorption due to orthodontic treatmentdetected by cone beam computed tomography.AngleOrthod2013;83;196-203.

8. AlexanderSA.Levelsofrootresorptionassociatedwith continuous arch and sectional archmechanics. Am J Orthod Dentofac Orthop 1996;110;321-324.



4

1. Dr. Priya Babu

2. Dr. Mahesh Chandra. K

3. Dr. Vanishree M. K

Abstract

Geneticcounsellingistheprocessofhelpingpeopleunderstandandadapttothemedical,psychologicalandfamilial

implicationsofgeneticcontributionstodisease.Theprocessintegrates:Interpretationoffamilyandmedicalhistories

toassessthechanceofdiseaseoccurrenceorreoccurrence,andeducationaboutinheritance,testing,management,

prevention, resources, research, and counselling to promote informed choices and adaptation to the risk or

condition.Geneticcounsellinghastobeprovidedorsupervisedbyahealthcareprofessionalappropriatelytrainedfor

geneticcounselling..

Keywords:

IntroductionAlthoughtheterm'geneticcounselling'wascoinedbySheldon Reed in 1947, the genetic counsellingprofession is relatively young in comparison withmedicine and nursing. Genetic counselling can beundertaken by trained professionals from a range ofdisciplines, those describing themselves as genetic

1counsellorsarespeci�icallytrainedforthework. Ithasbeen the topic of many studies and wide discussionbecauseofitsimportanceinprovidingandinterpretingg ene t i c i n fo rma t i on to pa t i en t s and t he i r

2relatives. Genetic counselling is the most complexaspectofpreventionanditisinseparablefromgeneticdiagnosis,aimingtoreplacemisunderstandingsaboutthecausesofgeneticdiseasewithcorrectinformation,andtoincreasepeople'scontroloftheirownandtheirfamily's health by informing them of the resourcesavailable for diagnosis, treatment and prevention.Although counselling has a role in many medicalconsultations, it is particularly important in medicalgenetics because of the often-predictive nature ofgenetic information, implications for other familymembers,thedif�icultchoicesthatsometimeshavetobemadeandtheimportantethicalproblemsthatcanbe

Genetic Counselling -bridging The Gap Between Genetic Field Complexity And Life

Dr. Priya Babu¹, Dr. Mahesh Chandra. K², Dr. Vanishree M. K,³ Dr. Guru Suhas⁴, Dr. Amritha. N⁵Authors :

4. Dr. Guru Suhas

5. Dr. Amritha. N

DepartmentofPublicHealthDentistry,AECSMaaruthiCollegeofDentalSciencesandResearchCentre,Bengaluru

3involved. Genetic counselling is the process throughwhich a professional, with specialized training ingenetics and counselling, evaluates an individual andassembles information about family medical history,genetic relationships, and pedigree to determineinheritancepatternsofgeneticconditions.TheHeredityClinicwas the �irst genetic counselling service centreestablishedin1940attheUniversityofMichigan,USA.Since then themany such centres have been opened

4aroundtheworld.

Geneticcounsellinghasbeendefinedas:

“Theprocessbywhichpatientsorrelativesatriskofadisorder that may be hereditary are advised of theconsequences of the disorder, and the probability ofdevelopingandtransmitting itandtheways inwhich

3thismaybepreventedorameliorated.”

Purpose Of Genetic CounsellingŸ Educatepatientsabouthowhereditycontributesto

geneticdisease in termsofspeci�icconditionsandpatternsofinheritanceandhis/herindividualriskofdevelopingthedisease.

3

Ÿ Helpstolookatthemedicalhistoryofthefamilyanddrawingupafamilytree.

Ÿ Discuss the various genetic tests, which can bearrangedifappropriate,includingtherisks,bene�itsandlimitationsofgenetictesting.

Ÿ Genetic counselling can aid couples in makinginformeddecisionsaboutpregnancies.

Ÿ Provideguidanceandpsychosocialsupport.Ÿ Aid patients in choosing a course of action that is

personallyappropriate.

Bene�iciaries For Genetic Counselling• Hereditarydiseaseinapatientorfamily• Birthdefects• Mentalretardation• Advancedmaternalage• Earlyonsetofcancerinthefamily• Miscarriages (women who had three or more

miscarriages)andinfertility• Malformations• Ifthecoupleisbloodrelativeandhaveenteredinto

consanguineousmarriage.• Ifapersonbelongstoaparticularethnicgroupthatis

athighrisktodevelopadisease.• Ifacouplealreadyhasachildwithageneticdisorder

andareplanningforthenextchild.

Guidelines For Genetic CounsellingŸ Geneticcounsellinghastobeprovidedorsupervised

by a healthcare professional appropriately trainedforgeneticcounselling.

Ÿ Non-genetics healthcare professionals have aresponsibility to recognize their abilities andlimitationswith regard to the provision of geneticservices.

Ÿ Healthcare professionals should not agree to testwithoutpre-testcounsellingincircumstances,wheredoing so would go against their professionaljudgment.

Ÿ Predictive tests for future severe illnesseswith nooptions for treatment or prevention should not beperformed without pre- and post-test geneticcounselling,psychosocialevaluationandfollow-up.

Ÿ Beforeactualtestingtakesplace,thereshouldbefreeandinformedconsent.

Ÿ Insituationswheretestingchildrenorotherpersonswho are not able to give informed consent isconsidered,thoseindividualsshouldbeinvolvedingenetic counselling and in the decision-makingprocess,accordingtotheircapacities.

§ Testing for adult-onset conditions in childrenshouldonly be consideredwhen treatment orsurveillancewouldbegininchildhood.

Types Of Genetic CounsellingTherearetwotypesofgeneticcounseling:1. Prospectivegeneticcounselling2. Retrospectivegeneticcounselling

Prospective genetic counsellingIn this, the genetic disorder has not yet expresseditself. ItisThisallowsforthetruepreventionofdisease.done in heterozygotic individuals to assess theprobabilityofhavingachildwithgeneticdisorders.Ifaperson is identi�ied as heterozygotic for a geneticcondition,he/sheshouldbeadvisedagainstmarryinganotherheterozygotic individualas there is increasedriskofthetraitexpressingitself inthephenotype.Theapplication in this �ield are sickle cell anemia and

5thalassemia.

Retrospective genetic counsellingIn this, the disease has already occurred in thefamily.This is more commonly done compared toprospectivecounselling.Thisisbecausepeopleusuallycome forgenetic counsellingonlyafterhavingachildwithcongenitalanomalies/mental retardation/inborn

5errors ofmetabolism. A survey byWHO showed thatgenetic advice was chie�ly sought in connection withcongenital abnormalities, mental retardation,psychiatricillnessandinbornerrorsofmetabolismand

6onlyafewsoughtpremaritaladvice.

Areas Of Focus In Genetic Counselling

1. Pregnancy Couples who are planning a pregnancy and are

concernedabout geneticdisordersmay seek theassistance of a genetic counsellor. Members ofethnic communities in which recessive geneticconditions are particularly prevalent alsofrequently seek genetic counselling duringpregnancy planning. The genetic counsellorgathersrelevantinformationfromthecounseleesto assess their risk of passing on a particular

7conditiontotheiroffspring.

Indevelopedcountriesithasbecomeroutineforpregnantwomen,especiallythoseoverage35,tobe offered some form of genetic testing. Non-


4

invasive screening tests, such as ultrasound orserum screening, conducted between 10 and 20weeksofpregnancy,canprovideinformationaboutwhetherthefoetusisdevelopingnormallyorisatincreasedriskofbeingaffectedbyachromosomalcondition (e.g., Down syndrome) or neural tubedefect(e.g.,spinabifida).Usually,thosetestsallowcounsellors to provide risk estimates, notconclusive results. Diagnostic tests such asamniocentesisorchorionicvillussampling(CVS)maybeperformedafterapositivescreenresulttoobtain accurate results for chromosomalconditions. If a diagnostic test reveals a positiveresult(i.e.,thatthefoetusisaffectedbyageneticcondition), the woman must decide whether toterminatethepregnancyortocontinuewithitandgive birth to a disabled child. At that point it isessential that the woman receives unbiased andaccurateinformationabouttherelevantconditionandfeelssupportedinmakingtherightdecisionforher.Bothbeforeandaftertesting,awomanshouldhave access to the services of a trained geneticcounsellortoensurethatshecanmakegenuinelyinformeddecisionsandbeconfidentthatshehasmade the right ones, as terminating a wantedpregnancycanbeasdistressingasgivingbirthtoa

7disabledchild.

2. Infancy� Most babies in developed countries undergo

geneticscreeningwithinthefirst72hoursoflife,throughbloodistakenfromaneonatalheelprick(or Guthrie test). The blood is screened for anumber of genetic conditions for which earlydetection and intervention can offer increasedchancesofeffectivediseasemanagement.Althoughhospitalsseekparentalconsentpriortotakinganinfant's blood, no formal genetic counselling isprovidedunlessitisrequestedorapositiveresultis

7found.

� Familieswithchildrenwhoaredirectlyaffectedbygenetic conditionsmay seek genetic counselling.They may want to gain more information aboutparticular conditions and why those conditionsaffectthem,toexplorethespecificwaysinwhichgeneticconditionsaffectthem,toseekadviceaboutmanagingtheirchild'scondition,ortomeetotherswhoaresimilarlyaffected.Suchcounsellorstendtobefamiliarwiththeday-to-dayeffectsoflivingwith

particular genetic conditions and can help7individualstofindappropriatesupportgroups.

3. Adulthood� Genetic testing in adulthood has become

increasingly oriented toward predictive testing,whichisaimedatdeterminingwhetherapersonisatriskofdevelopingalate-onsetgeneticcondition(e.g.,Huntingtondiseaseandsomeformsofcancer)orhasageneticpredispositiontoacommondisease(e.g., heart disease). Before individuals begin thepredictive testing process, genetic counselling is

7advisable.

� Individuals in affected families may not wish toknowtheirstatusifthereisnothing,theycandotoavoid their fate. Even when preventive action ispossible—forexample,amastectomytominimizetheriskofbreastcancer—thatknowledgeitselfcanbetraumatic.Also,somerecommendedpreventiveactionsmaybehardforindividualstocomplywith(e.g., behavioral or dietary changes). There isevidencethatmanyindividualshaveadifficultyinunderstanding risk. Without the benefit ofcounselling, some may underestimate theirrisk.Alternatively, some individualswhoreceiveadiagnosisofgeneticdiseasesmaybelievethattheyare facing an unavoidable fate even though the

7preventiveactionmaybeeffective.

Pre-requisites For Genetic Counselling§ DetailedFamilyHistory§ AccurateDiagnosis§ Understandingthemedicalaspectsofthedisorder§ Understandingtheinheritancepattern§ Understanding the psycho-social impact of the

information§ Training/Experienceincounsellingtechniques§ Understanding the concepts of health/disease

/healthcareinappropriatecultures

Ideal Genetic CounsellingIdeal genetic counselling is comprised of three majorelements that form the process of communication:information giving, psychological support and ethical

2aspects.

1. InformationGiving Traditionally,information-givingandsupporthave

been considered to form the core of genetic


3

counseling. In the context of both informationprovisionandsupport,adaptationtothepatient'spersonalsituationwasencouraged.Thiswasseenasbeingespecially importantwhen thepatientshavedif�icultiesinunderstandingtheinformation,andincaseswheredif�icultdecisionsneedtobemade. Genetic counsellors were expected to betrainedprofessionals.Inadditiontoeducationingeneticknowledge,trainingwasseenasneededincommunication skills and developing empathicrelationships. The ideal counsellor was seen assomeone who has good knowledge of humangenetics and at the same time is an empathicperson,whose communication is clear andwhorealizes the special situations that patients are

2facing.

2. PsychologicalSupport� Psychological support and an empathic

relationship between the counsellor and thecounsellee were seen as important elements ofgenetic counselling.Providing support in geneticcounselling was seen as essential to enable thecounsellee to make informed choices and copewiththetestresult.Counsellorswereencouragedto suggest patients bring a support person,particularlywhenthetestresultisdisclosed,andtoreferthepatientstoappropriateprofessionalsfor further support whenever needed. Relativesand friends, as well as support groups, werementioned as important sources of emotional

2support.

Psychosocialaspectsofgeneticcounselingpassthroughfourdifferentphasesofthecopingprocess:• Initialshockanddenial• Subsequentangerandguilt• Followedbyanxietyanddepression• Thephaseofacceptanceandadjustments

3. Ethical issues to be considered in counsellingGenetic information was seen as ethicallychallenging, primarily because of its familialnature.Counsellorsshouldnotonlybeabletohavea con�idential relationship with the counselleesbutalsobeabletodealwiththeimpactthatthegenetic informationmayhaveonthe family.Thecounsellorswereadvisedtoaskthecounselleestodisseminate information to their at-risk family

members.Sometimesthisisnotpossible,andthecounse l l o r s need to ba l ance be tween

2con�identialityandthedutytowarn.

Majorethicalprincipleswhichgoverntheattitudesandactionsofcounsellorsinclude:

1. Respect for patient autonomy, or the patient'sright to information and his/her right to makehis/herowndecisions,non-male�icence.

2. Bene�icence, or taking action to help bene�itothers and prevent harm, both physical andmental.

3. Justice, which requires that services bedistributedfairlytothoseinneed.

4. Othermoral issues includeveracity, theduty todiscloseinformationortobetruthful,andrespectforpatient'scon�identiality.

Genetic CounsellorsGenetic counsellors are health professionals withspecialized graduate degrees and experience in theareasofbasicscience,medicalgenetics,epidemiology,andcounsellingtheory.Theyapplythespecializedskillin risk assessment, education, and interpersonalcommunicationandcounsellingtoprovideservicestoclientsandtheirfamiliesforadiversesetofgeneticandgenomicindications.Theyaremembersofahealthcareteamwhoprovideinformationandsupporttofamiliesofpatientswithbirthdefectsorgeneticdisordersandtofamilieswhomaybeat risk foravarietyof inherited

8conditions.

Manygeneticcounsellorsworkinlargemedicalcentersor hospitals . Others work in genetic testinglaboratories,privatepractices,HMOs,research,policy,advocacy, education, and more.Genetic counsellorsoftenworkwithmedicalgeneticistsandperformmanyof the same functions, including risk assessment,creatingadifferentialandevaluationplan,andorderingand interpreting genetic testing. However, medicalgeneticists provide medical evaluation whereascounsellors focusoncounsellingandrelatedsupport.Dependingontheirneeds,familiesmayseebothtypes

8ofprofessionals.

Role Of Dentist In Genetic CounsellingThedentististheonlyhealthprofessionalinvolvedinthe diagnosis and management of inherited defectsisolated to the oral cavity.Whether he is adequately


4

preparedorill-preparedtorecognize,treat,andcounselfortheseconditions,determinesthequalityofserviceherenders to the af�licted patient and the patient'sfamily.Heritableoraldisorderscanbeserious.Theycaninterferewithnormalphysiology,theycanbemalignantor premalignant, and they canbedis�iguring (Ehlers-Danlos syndrome, Osteogenesis Imperfecta etc).Treatmentisimportantfortheseconditions,butisnottheonlyconsideration.Counsellingabouttheriskfortheconditionrecurringinthefamilyisoftenasimportantaconsideration as treatment.Genetic counselling is ofparticularinterestasitappliestoorofacialclefting.Notonlyshouldthedentistrecognizetheseconditions,buthe should be prepared to counsel for them. Theexperienceddentistshouldbeascapabletocounselandshouldhavethesameobligationtocounselas foranyother specialist who sees a patient for a particularcompla int and recognizes mul t ip le systems

9involvement.

ConclusionManydiseaseshaveageneticroot.GeneticCounsellingaimistobridgethegapforpeoplebetweengenetic�ieldcomplexityandtheirlife.GeneticCounsellingisdoneinan objective manner, so that any treatment selectedremainsthepersonalchoiceoftheindividualinvolved.Itisapracticalmethodofcalculatingrisk�igures,intendedfor information regarding the unborn and uses it anef�icientmannerbutinadirection,whichourethicsandmortalitypointto.GeneticCounsellor�illsadistinctivepositioninthecomplicatedandvariedarenaofgenomicmedicineandhealth.

References1. Skirton H, Cordier C, Ingvoldstad C, Taris N,

Benjamin C.The role of the genetic counsellor:asystematicreviewofresearchevidence.EurJHumGenet2015Apr;23(4):452-58.

2. RantanenE,HietalaM,KristofferssonU,NippertI,SchmidtkeJ,SequeirosJetal.Whatisidealgeneticcounselling? A survey of current internationalguidelines.EurJHumGenet2008Apr;16(4):445-52.

3. Petrou M. Genetic Counselling. Available from:

h�ps://www.ncbi.nlm.nih.gov/books(accessedon2Nov2018)

4. WHO. Genetic counselling services. Availablefrom:h�p://www.who.int/genomics/professionals/counselling/en/(accessedon2Nov2018)

5. G e n e t i c C o u n s e l l i n g . Ava i l a b l e f r om :h�p://www.ihatepsm.com/blog/gene�c-counselling(accessedon2Nov2018)

6. WertzD.C,Fletcher J.C,Berg.K.ReviewofEthicalIssues in Medical Genetics- World HealthO r g a n i z a t i o n A v a i l a b l e f r o m :h�ps://www.who.int/genomics/publica�ons/en/ethical_issuesin_medgene�cs%20report.pdf(accessed2Nov2018)

7. Bowditch C. Genetic counseling. Available fromh�ps://www.britannica.com/science/gene�c-counselling(accessed2Nov2018)

8. What is a Genetic Counsellor? Available fromh�ps://www.cagc-accg.ca/?page=139 (accessed 2Nov2018)



3

https://www.ncbi.nlm.nih.gov/books

http://www.who.int/genomics/professionals/counselling/en/

http://www.who.int/genomics/professionals/counselling/en/

http://www.ihatepsm.com/blog/genetic-counselling

https://www.who.int/genomics/publications/en/ethical_issuesin_medgenetics%20report.pdf

https://www.who.int/genomics/publications/en/ethical_issuesin_medgenetics%20report.pdf

https://www.britannica.com/science/genetic-counselling

https://www.britannica.com/science/genetic-counselling

https://www.cagc-accg.ca/?page=139

1. Dr. Shabana Kouser Postgraduatestudent

2. Dr. Vinaya. S.Pai ProfessorandHOD

3. Dr. Siri Krishna.P Professor

Abstract

AIM: TheaimofthepresentstudywastocharacterizethroughCBCTandthedolphinimagingsoftwarethevolumesof

theupperpharyngeal portion andnasopharynx. The volume,minimumaxial area, andmorphologyof the lower

pharyngealportionanditssubdivisionsvelopharynx,oropharynxandhypopharynxrelatingtoalteredskeletalpattern

inBangalorepopulation.Materials andMethods:Thesamplecomprisedof60patients(averageage14-30years).The

patientsweredividedinto5groupsbasedonSNA,SNBandANBmeasurementsasGroup1;ClassIOrthognathicMaxilla

andMandible, Group 2; Class II Prognathic Maxilla, Group 3; Class II Retrognathic Mandible, Group 4; Class III

RetrognathicMaxilla,Group5;ClassIIIPrognathicMandible.Results:Resultsofthestudyofdifferentskeletalpatterns

amongBangalorepopulationshowsthat there isavariation in thevolumesof theupperpharyngealportionand

nasopharynx.Thevolume,minimumaxialarea,andmorphologyofthelowerpharyngealportionanditssubdivisions

velopharynx,oropharynxandhypopharynxamongGroup1,Group2,Group3,Group4andGroup5.Conclusion: In

conclusion,ourthree-dimensionalCBCTstudyshowedsigni�icantdifferencesinthepharyngealairwayspaceamong

differentskeletalpatterninBangalorepopulation.

Keywords: Cone-beamcomputedtomography,Dolphinsoftware,Upperpharyngeal,Nasopharynx.

IntroductionŸ Upper Airway Evaluation and Assessment of its

interactions with cranio-facial development andgrowth has been the subject of interest inorthodontics. Individual variations in airwaymorphologyarecommonlyfoundduetoinheritanceandfunctionaldisorders.

Ÿ Several methods have been proposed in order toassess the airway, including cephalometry,rhinoendoscopy, and tomography. The two-dimensional representation of three-dimensionalstructuresasaffordedbytheradiographicimageincephalometry provides l imited diagnosticinformation.

Ÿ The link between respiratory mode and thedevelopment of malocclusion could be soft-tissue

Dr. 1 2 3 4 5 6Authors : Shabana Kouser , Dr. Vinaya. S.Pai , Dr. Siri Krishna.P , Goutham Kalladka , Dr. Shreyas Rajaram , Dr. Shivprasad Gaonkar .

5. Dr. Shreyas Rajaram Reader

6. Dr. Shivprasad Gaonkar Seniorlecturer DepartmentofOrthodonticsanddentofacialOrthopaedics,

BangaloreInstituteofDentalSciencesandResearch12345Centre,Bangalore,Karnataka .

Three-Dimensional Analysis Of Pharyngeal Airway With Different Skeletal Patterns In Bangalore Population

pressures against the dentition that might affecttootheruption,dental arch form, andpossibly thedirectionofmandibularandmaxillarygrowth.

Ÿ Hence,thepurposeofthisstudywastoevaluatethecorrelations between different variables and theairway with a three dimensional analysis ofpharyngeal airway in Bangalore population, withnormalNaso-respiratoryfunctions,havingdifferentDentofacialskeletalpatterns.

Aims And ObjectivesŸ The aim of the present studywas to characterize

throughCBCTandthedolphinimagingsoftware:Ÿ Thevolumesof theupperpharyngealportionand

nasopharynx.Ÿ Thevolume,minimumaxialarea,andmorphologyof

the lowerpharyngealportionand its subdivisions

4

velopharynx,oropharynxandhypopharynxrelatingtoalteredskeletalpatterninBangalorepopulation.

Ÿ Materials & Methods

Ÿ Source Of Data

Ÿ Thesamplecomprisedof60patients(averageage14-30years).Thepatientsweredividedinto5groupsas:

Ÿ Group1:ClassIOrthognathicMaxillaandMandible(20Cases)(SNA=82°+2°;SNB=80°+2°;ANB=0+2°)

Ÿ Group2:ClassIIPrognathicMaxilla(10Cases)(SNA>84°;SNB=80°+2;ANB>2°)

Ÿ Group3:Class IIRetrognathicMandible(10Cases)(SNA=82°+2°;SNB<80°;ANB>2°)

Ÿ Group 4: Class III Retrognathic Maxilla (10 Cases)(SNA<82;SNB=80°+2°;ANB<2°)

Ÿ Group 5: Class III Prognathic Mandible (10 Cases)(SNA=82°+2°;SNB>80°;ANB<2°)

Landmarks For The Upper Phayngeal Airway:1. Theupper limit wasde�inedasaslicebeforethe nasal septum merges with the pharyngeal

posteriorwall.thelineunitingtheposteriornasalspineandSO(middlepointofthesella-basionline)points.

2. The lower limit wasde�inedbythepalatalplane,which is the line passing by the anterior nasalspineandposteriornasalspine,extendedto thepharyngealposteriorwall.

Landmarks For The Lower Pharyngeal Airway:• The3segmentsassessedinthelowerpharyngeal

portion:

Velopharynx:• upperlimit–palatalplane. Lowerlimit–planeparalleltothepalatalplane

thatintersectedtheuvula.

Oropharynx• upper limit –lowerlimitofvelopharynx.• Lower limit –planeparalleltothepalatalplane

intersectingtheupperpointoftheepiglottis.

Hypopharynx• upper limit –lowerlimitoforopharynx.• Lower limit -planeparallel to thepalatalplane

intersectingthelowerandmostanteriorpointofthefourthcervicalvertebra.


3

Ÿ Minimumaxialareainthelowerpharyngealportionwas determined using the ratio proposed by van holsbeke et al

Ÿ Positionratio:location=upperairwaylength/totalairwaylength.

Ÿ Mean area of each segment calculated as: mean area = volume / total airway length.

Ÿ Morphology of each segment calculated as: morphology = minimum area / mean area.

GROUPS UPPER

PHARYNGEAL

AIRWAY LOWER PHARYNGEAL AIRWAY

TOTAL

AIRWAY

LENGTH

UPPER

AIRWAY

LENGTH

MIN.

AXIAL

LENGTH

NASOPHARYNX

(VOLUME )

VELOPHARYNX

OROPHARYNX

HYPOPHARYNX

VOLUME MEAN

AREA VOLUME

MEAN

AREA VOLUME

MEAN

AREA

Group 1 2308.52

Lowest

62.37

Lowest

289.32

Lowest

35.630

Lowest

56.380

Highest

1.6954

Highest

13.9

Lowest

Group 2 4792.30

Lowest

81.20

Lowest

39.700

Lowest

Group 4 5123.20

Highest

5783.50

Highest

80.85

Highest

481.60

Lowest

6.040

Lowest

Group 5 4985.40

Highest

108.940

Highest

85.50

Highest

14.70

Highest

180.891

Highest

Results

Discussion

5Hakan et al conducted a study to evaluate theoropharyngeal (OP) and nasal passage (NP) volumesalong with various airway variables of patients withnormal nasorespiratory functions having differentdentofacial skeletal patterns and to evaluate thecorrelationsbetweendifferentvariablesandtheairway.The patients were divided into �ive group. Posteriorairwayspace,areaofthemostconstrictedregionatthebase of the tongue (minAx), and OP volume were

signi�icantlyhigherfortheCIIIMandPgroupwithameanvalueof9332.60±2468.67,whereasCIIMandRsubjectshadthelowestwithameanvalueof(5837.80±281230).The only signi�icant difference for the NP volumewasbetweenCIandCIIMandRgroupsasmallervolumeforthe CIIMandR groupwith amean value of (4962.80 ±2130.31)wasobserved.TheminAxwasthevariablethatpresented the best correlation with the OP airwayvolume.

Similartotheabovestudy,ourstudytook60samplesofBangalorepopulationanditwasdividedinto�ivegroups.TheresultswerecomparedwiththeKruskal-Wallisandthe Mann-Whitney U tests to identify intergroupdifferences.ClassIII(Retrognathicmaxilla)showedthehighestoropharyngealairwayvolumewithameanvalueof5796.97±829.44whereasClassIshowedthelowestoropharyngeal airway volume with a mean value of2726.74±289.40comparetotheothergroups.ClassIII(prognathicmandible) shows themaximumminimumaxialareawithameanvalueof142.01±27.57whereasClassII(Prognathicmaxilla)showstheminimumwithameanvalueof38.40±1.12compared toothergroups.Thisshowsthatthereissigni�icantcorrelationobservedbetweenthedifferentskeletalmalocclusionandvolumeoftheoropharyngealairwayandtheminimumaxialarea.Thustheabovestudysupportsourstudy.

3Claudino, et al conducted a study to characterize the

volumeandthemorphologyofthepharyngealairwayinadolescentsubjects,relatingthemtotheirfacialskeletalpattern. Fifty-four subjects who had cone-beamcompu ted tomography were d iv i ded i n to 3groups—skeletalClassI,ClassII,andClassIII—accordingtotheirANBangles.TheresultswerecomparedwiththeKruskal-WallisandtheDunnmultiplecomparisonteststoidentifyintergroupdifferences.Correlationsbetweenvariables assessed were tested by the Spearmancorrelation coef�icient. Correlations between thelogarithmsofairwayvolumesandtheANBanglevalueswere tested as continuous variables with linearregression, considering the sexes as subgroups. TheminimumareasintheClassIIgroup(112.9±42.9,126.9±

245.9,and142.1±83.5mm )weresigni�icantlysmallerthaninClassIIIgroup(186.62±83.2,234.5±104.9,and231.1±111.4mm2)forthelowerpharyngealportion,thevelopharynx, and the oropharynx, respectively, andsigni�icantly smaller than the Class I group for the

2velopharynx(201.8694.7mm ).TheClassIIsubjectshadsmaller minimum and mean areas (lower pharyngeal


4

portion,velopharynx,andoropharynx)thandidtheClassIII group and signi�icantly less uniform velopharynxmorphologythandidtheClassIandClassIIIgroups.

Similartotheabovestudy,ourstudytook60samplesofBangalorepopulationanditwasdividedinto�ivegroupsClassImalocclusion,ClassII(Prognathicmaxilla),ClassII(Retrognathic mandible), Class III (Retrognathicmaxilla),ClassIII(Prognathicmandible.Theresultswerecompared with the Kruskal-Wallis and the Mann-WhitneyUteststoidentifyintergroupdifferences.ClassIII(Retrognathicmaxilla)showedthemaximumvolumeof theupperpharyngeal airway – nasopharynxwith ameanvalueof4964.94±407.54whereasClassIshowedtheminimumwith amean value of 2270.08 ± 240.11compared to other groups. Class III (prognathicmandible) showed the highest velopharyngeal airwayvolumewithameanvalueof7899.93±490.84whereasClassII(Prognathicmaxilla)showedthe lowestwithameanvalueof4710.15±321.42.

ConclusionBasedontheresultsfollowingconclusionweredrawn:Ÿ Group 1showedlowestvolumeofnasopharynxand

oropharynx, lowest area of velopharynx andoropharynx ,maximum volume and mean area ofhypopharynxandminimumupperairwaylength.

Ÿ Group 2showedlowestvolumeofvelopharynx,totalairwaylengthminimummorphologyofvelopharynxandhypopharynxandlowestminimalaxialarea.

Ÿ Group 4showedmaximumvolumeofnasopharynxand oropharynx, mean area of oropharynx,morphology of velopharynx and hypopharynx. Itshowed lowest vo lume and mean area o fhypopharynx.

Ÿ Group 5showedmaximumvolumeandmeanareaofvelopharynx,morphologyoforopharynxandhighesttotalandupperairwaylengthandminimalaxialarea.

References1. VizzottoMB,LiedkeGS,DelamaraeEL,SilveiraHD,

DutraVandSilveiraHE.Acomparativestudyoflateral cephalograms and cone-beam computedtomographicimagesinupperairwayassessment.EurJorthod2012;34:390-393.

2. KimYj,SukHong-J,HwangYIand ParkYH.Threedimensional analysis of pharyngeal airway in

p re ado l e s c en t c h i l d ren w i t h d i ff e ren tanteroposterior skeletal pattern. Am J OrthodDentofacialOrthop2010;137:306.e1-306.e11.

3. ClaudinoLV,MattosCT,CarlosdeOliveiraRuellasA,and San t Anna EF . Pha ryngea l a i rwaycharacterization in adolescents related to facialskeletalpattern:Apreliminarystudy.AmJOrthodDentofacialOrthop2013;143:799-809.

4. GrauerD,CevidanesLSH,StynerMA,AckermanJL,Prof�itWR. Pharyngeal airway volumeand shapefrom cone –beam computed tomography:Relationship to facial morphology. Am J OrthodDentofacialOrthop2009;136:805-814.

5. ELHandPalomoJM.Anairwaystudyofdifferentmaxillaryandmandibularsagittalpositions.EurJorthod2013;35:262–270.

6. IwasakiT,HayasakiH,TakemotoY,KanomiR,andYamasakiY.OropharyngealairwayinchildrenwithClass III malocclusion evaluated by cone-beamcomputed tomography. Am J Orthod DentofacialOrthop2009;136:318.e1-318.e9.

7. Linder-AronsonS.RespiratoryFunctioninRelationtoFacialMorphologyandtheDentition.BrJOrthod1979;Vol6:59-71.

8. Solow B, Siersbaek-Nieisen S, Greve E. Airwayadequacy, head posture, and craniofacialmorphology. Am J Orthod Dentofacial Orthop1984;3:214-223.

9. Lowe AA, Gionhaku N, Takeuchi K, Fleetham JA.Three-dimensional CT reconstructions of tongueandairwayinadultsubjectswithobstructivesleepapnea.AmJOrthodDentofacOrthop90:364-374,1986.

10. Hellsing E. Changes in the pharyngeal airway inrelation to extension of the head. Eur J Orthod1989;11:359-345.

Correspondence Address


3

1. Dr.ZangpoHK

2. Dr.PaiVS

3. Dr.KalladkaG

Abstract

AIMS AND OBJECTIVES: To evaluate the three-dimensional cone-beam computed tomographic analysis of

pretreatment,immediatepostexpansionandpostretentionskeletalchanges,dentoalveolarchangesandpharyngeal

airway changes following rapid maxillary expansion therapy. MATERIALS AND METHODOLOGY: The sample

composedof15setsoftomographicimagesacquiredbythree-dimensionalvolumetricCBCT.Theconebeamcomputed

tomographic imageswere taken at pretreatment, immediate post expansion and post retention stages and then

compared.AllpatientsweretreatedwithastandardizedprotocolofrapidmaxillaryexpansionusingabondedHyrax

appliance.ActivationschedulewasaccordingtoZimringandIsaacson:twoquarterturnseachdayforthe�irst4-5days

andoneturneachdayforremainderofRMEtreatment.TheKodak–93003,(CarestreamIndiaPvt.Ltd)wasusedto

obtainCBCTimages.Patientswereevaluatedbefore(T0),postexpansion(T1)andafterretentionperiodof6months

(T2).TheCTscanswereperformedat90kVand10mAwithascantimeof16secsandvoxeldimensionsof0.3x0.3x0.3

mm.Eachpatient'sdataconsistedofaresolutionof1024x1024pixelsand14bitsperpixel.Theevaluationwasdonein

thesagittalplane,thecoronalplaneandtheaxialplaneusingDolphinImagingSoftware11.8version.RESULTS:The

resultswere tabulatedandanalyzedwithrepeatedmeasuresofANOVA.Therewasasigni�icantdifference in the

parametricmeasurementsinskeletal,dentoalveolarandpharyngealairwayspaceparametersinallthreeplanesat

threetimeintervalsi.e.,pretreatment,postexpansionandpostretentionfollowingRapidMaxillaryExpansiontherapy.

CONCLUSION: Thisstudyprovedthatthereisamarkedchangeintheskeletal,dentoalveolarandpharyngealairway

spaceinallthreeplanesi.e.,pretreatment,postexpansionandpostretentionfollowingRapidMaxillaryExpansion

therapy.

Keywords: HYRAX appliance, Rapid Maxillary Expansion, Cone-beam computed tomography.

IntroductionOrthodontic diagnosis is primarily based on amorphological and quantitative description ofstructuresinthreeplanes,namelysagittal,verticalandtransverse (Angle 1907). In the �irst two planes, thelateral cephalogram provides material that can bequantitated as linear or angular variables and, thus,formsthebasisofthecephalometricanalysisgenerally

1usedinorthodonticdiagnosis. Maxillaryde�iciencyinthe transverse plane is called maxillary constriction.Transverse de�iciency of the maxilla is related to

Dr. Authors : Zangpo HK¹, Dr. Pai VS², Dr. Kalladka G³, Dr. Gaonkar SP⁴, Dr. Rajaram S⁵

4. GaonkarSP

5. RajaramS

DepartmentofOrthodonticsandDentofacialOrthopaedics,BangaloreInstituteofDentalSciencesandResearchCentre,Karnataka.

Three Dimensional Computed Tomographic Analysis Of Immediate And Post Retention Skeletal, Dentoalveolar And Pharyngeal Airway Changes Following

Rapid Maxillary Expansion Therapy

insuf�icient development of the maxillary width,2usually showing a clinical posterior cross bite.

Anomaliesinmaxillarytransversedimensionsleadtoocclusal problems including scissors bite with orwithoutmandibularforcedbiteandmalocclusionsuchas moderate to severe posterior unilateral/bilateralcrossbite, Class II malocclusion with maxillaryconstriction, Class III malocclusion with maxillaryhypoplasia,severedentalcrowdingandimpairednasalbreathing. Corrections of these anomalies aregenerallyconsideredassomeofthemostimportantin

4

1orthodontics.

TheaimofRMEistoproduceagreaterdegreeofskeletalchange.Theincreaseinthepalatalwidthistheresultofthegrowthinthemidpalatalsuture.Asaresultofthematuration process, treatment of the transversediscrepancies depends both on the nature of themalocclusionandtheageofthepatient.Itisgenerallyacceptedthatsimplemethodsofpalatalexpansionusedin young children, are likely to be unsuitable for thetreatment of the more complicated suture seen inmaturepatients.

CBCT for themaxillofacial regionenablesmultiplanarimagingandprovides3-dimensional(3D)information,allowing formeasurement of axial inclinations of thedentitionandchangesinthetransversedimensionsfreefrom distortion, magni�ication, and superimposition.Recentadvances inconebeamcomputed tomography(CBCT)andrelatedsoftwarehavemade itpossible tovisualize and measure the upper airway as a solidstructure. Lower costs, lower radiation dose, shorterscanning time, and overall accuracy havemade CBCTtechnologyapreferredmethodtoassesstheairway.Themajority of dental transverse measurements changesigni�icantly as a result of RME. The maturity of themaxillo-facial structures determines the time andsuccess rate of the treatment with RME. The nullhypothesisstatesthatthereareconsiderableimmediateand post retention skeletal, dentoalveolar andpharyngeal airway changes following rapid maxillaryexpansion therapy.Thus, the aim of the study was toquantifytheeffectsofRapidMaxillaryExpansioninthetransverse, vertical and sagittal dimension of themaxillomandibular complex along with pharyngealairwayspace.

Materials And MethodologyThe inclusion criteria included patients in the agegroup of 6-15 years presenting with maxillaryconstriction, insuf�icientmaxillaryarchcircumferencewithunilateral/bilateralcrossbiteorwithoutcrossbiteandvariabledegreeofcrowding.

The exclusion criteriaincludedpatientsabovetheageof 15 years, with a history of previous orthodontictreatment, congenital malformations in dentofacialstructures, presence of airway pathology, history ofadenoidectomy or tonsil lectomy, presence of

s tperiodontal pathology, absence of maxillary 1permanentMolars.

Method Of StudyingThesampleconsistedof15setsoftomographicimagesacquired by three-dimensional volumetric CBCT.Extraoral (Fig. 1) and intraoral (Fig. 2) photographsweretakenforall15patients.Allpatientsweretreatedwith a standardized protocol of rapid maxillaryexpansionusingabondedHYRAXappliance(Fig.3).TheHYRAXappliancewascementedtothemaxillaryteethusing Glass Ionomer cement (Fig. 4). Intraoralphotographs were taken as records (Fig. 5). Postexpansionintraoralphotographs(Fig.6)wereobtainedalongwithCBCT.Eachset consistedof3 tomographicimages,whichweretakenat3intervals(pretreatment,immediatepostexpansionandfollowedby6monthsofretentionperiod.)AsproposedbyZimringandIsaacson,theactivationschedulewas:twoquarterturnseachdayforthe�irst4-5daysandonequarterturneachdayforremainderofRMEtreatment.TheKodak–93003,(CarestreamIndiaPvt.Ltd)wasusedtoobtainCBCTimages.Patients were evaluated before treatment (T0),immediate post expansion (T1) and after retentionperiodof6months(T2).TheCTscanswereperformedat90kVand10mAwithascantimeof16secsandvoxeldimensionsof0.3x0.3x0.3mm.Eachpatient'sdataconsistedofaresolutionof1024x1024pixelsand14bits per pixel. The evaluation was done in the threeplanes – the sagittal plane, the coronal plane and theaxialplaneusingDolphinImagingSoftware11.8version.A single examiner examined all the requiredmeasurements. In the evaluation of the skeletal anddentalchanges,boththerightandleftinferiorbordersoftheinfraorbitalforaminaandthemidpointbetweentherightandleftsuperiorbordersoftheexternalauditoryme a t u s we re u s e d a s r e f e r e n c e p o i n t s i nsuperimposition/orientation.

Materials & MethodsSagittal Plan

DataforlateralcephalogramobtainedfromCBCT.

There are 13 Angular and 3 linear measurements toobserve changes in anteroposterior and verticaldimensions,usingcompositeanalysis.

B) Linear Measurements1. Overjet2. Overbite3. LAFH(LowerAnteriorFacialHeight)


3

CORONAL slice for molars and canines: The mostanteriorcoronalsliceshowingtheentirepalatalrootofthe�irstuppermolarsandentirerootofthemaxillarycaninesforevaluatingchangesintransversedimension.

Measurements

1. Angular Measurements: Right and leftdentoalveolarangulationofmolars,rightandleftdentoalveolarangulationofcanines.

2. Linear Measurements: Maxillary basal width,Maxillaryalveolarwidth,Maxillarydentalwidth.

AXIAL sl ice for molars and canines : Afterstandardization, the coronal plane and the 3Dreconstructions of the images will be used fordetermining the axial slice and position of thelandmarksatthesamepositiondeterminedbycoronalslices.Theabove-mentionedlandmarksincoronalslicewi l l be reevaluated in ax ia l s l ice for l inearmeasurements (maxillary basal width, maxillaryalveolarwidthandmaxillarydentalwidthofmolarsandcanines.) In the evaluation of the pharyngeal airwayspace, the imageswill bepositioned the samewayatbothtimepoints.

Pharyngeal Airway Analysis1. Theupper limitwasde�inedasaslicebeforethe

nasalseptummergeswiththepharyngealposteiorwall.

2. Thelowerlimitwasde�inedbythepalatalplane,whichisthelinepassingthroughtheanteriornasalspine and posterior nasal spine, extended to thepharyngealposteriorwall.

3. Thelower limitofthenasopharynxsegmentwasthepalatalplane;itsupperlimitwasde�inedinthesagittalviewasthelineunitingtheposteriornasalspine and SO (middlepoint of the Sella - Basionline)points,anditsposteriorlimitwasde�inedinthe sagittal view as a line approximatelyperpendiculartothepalatalplanethat intersectstheSOpoint.

The 3 segments assessed in the lower pharyngealportion:

1. Velopharynx: a. Upper limit –palatal plane. b.Lower limit- plane parallel to the palatal plane

thatintersectedtheuvula.

2. Oropharynx: a. Upper limit – lower limit ofvelopharynx.b.Lowerlimit-planeparalleltothepalatalplane intersectingtheupperpointof theepiglottis.

3. Hypopharynx: a. Upper limit – lower limit oforopharynx.b.Lowerlimit-planeparalleltothepalatal plane intersecting the lower and mostanteriorpointofthefourthcervicalvertebra.

ResultsResults showed that there were changes seen in theparameters, which were considered in the sagittal,coronalandaxialplanes,whenthethreetimeintervalswerecompared,i.e.,atpretreatment,postexpansionandpost retention stages following Rapid MaxillaryExpansion.

The changes seen in the Sagittal Plane were as follows:

1. A decrease in the angulation of N- S- Ba frompretreatmenttopostexpansionbutanincreaseinangulationfrompostexpansiontopostretention.

2. A decrease in the angulation of SNA frompretreatmenttopostexpansionandalsofrompostexpansiontopostretention.

3. A decrease in the angulation of SNB frompretreatmenttopostexpansionandalsofrompostexpansiontopostretention.

4. A decrease in the angulation of ANB frompretreatmenttopostexpansionandalsofrompostexpansiontopostretention.

5. AnincreaseintheangulationofSN/ANS-PNSfrompretreatmenttopostexpansionbutadecreaseinangulationfrompostexpansiontopostretention.

6. An increase in the angulation of SN/MP frompretreatmenttopostexpansionbutadecreaseinangulationfrompostexpansiontopostretention.

7. AnincreaseintheangulationofANS-PNS/Pfrompretreatment to post expansion but a decreasefrompostexpansiontopostretention.


4

8. A decrease in the angulation of SN-OP frompretreatmenttopostexpansionbutanincreaseinangulationfrompostexpansiontopostretention.

9. A decrease in the angulation of N-A-POG frompretreatmenttopostexpansionbutanincreaseinangulationfrompostexpansiontopostretention.

10. An increase in the angulation of SN-11 frompretreatmenttopostexpansionbutadecreaseinangulationfrompostexpansiontopostretention.

11. A decrease in the angulation of SN-16 frompretreatmenttopostexpansionbutanincreaseinangulationfrompostexpansiontopostretention.

12. An increase in the angulation of MP-41 frompretreatmenttopostexpansionandalsofrompostexpansiontopostretention.

13. A decrease in the angulation of MP-46 frompretreatmenttopostexpansionandalsofrompostexpansiontopostretention.

14. AnincreaseinthelinearmeasurementsofOverjetfrom pretreatment to post expansion and alsofrompostexpansiontopostretention.

15. AdecreaseinthelinearmeasurementsofOverbitefrompretreatmenttopostretention.

16. AnincreaseinthelinearmeasurementsofLAFHfrom pretreatment to post expansion but adecreasefrompostexpansiontopostretention.

The changes seen in the Coronal Plane were as follows

1. A decrease in the angulation of DAA-16 from pretreatment to post expansion and also from post expansion to post retention.

2. A decrease in the angulation of DAA-26 from pretreatment to post expansion and also from post expansion to post retention.

3. A decrease in the angulation of DAA-13 from pretreatment to post expansion and also from post expansion to post retention was seen.

4. A decrease in the angulation of DAA-23 frompretreatmenttopostexpansionandalsofrompostexpansiontopostretentionwasseen.

5. An increase in the linear measurements ofMaxillaryBasalWidthfrompretreatmenttopostexpansionbutadecreasefrompostexpansiontopostretention.

6. An increase in the linear measurements ofMaxillary Alveolar Width from pretreatment topostexpansionandalso frompostexpansion topostretention.

7. An increase in the linear measurements ofMaxillaryDentalWidthfrompretreatmenttopostexpansionandalso frompostexpansion topostretention.

The changes seen in the Axial Plane were as follows

1. An increase in the linear measurements ofMaxillaryBasalWidthfrompretreatmenttopostexpansionbutadecreasefrompostexpansiontopostretention.

2. An increase in the linear measurements ofMaxillary Alveolar Width from pretreatment topostexpansionandalso frompostexpansion topostretention.

3. An increase in the linear measurements ofMaxillaryDentalWidthfrompretreatmenttopostexpansionandalso frompostexpansion topostretention.

Thechangesseeninthevolumetricmeasurements3(inmm )ofthePharyngealAirwaySpacewereas

follows:

1. AnincreaseintheairwayvolumeofVelopharynxfrom pretreatment to post expansion but adecreasefrompostexpansiontopostretention.

2. AnincreaseintheairwayvolumeofOropharynxfrom pretreatment to post expansion but adecreasefrompostexpansiontopostretention.

3. AnincreaseintheairwayvolumeofHypopharynxfrom pretreatment to post expansion but a


3

decreasefrompostexpansiontopostretention.

Thenull hypothesisstatingthatthereareconsiderableimmediate and post retention skeletal, dentoalveolarand pharyngeal airway changes following rapidmaxillaryexpansiontherapyisaccepted.

Discussion24

Garrett et al conducted a study using cone-beamcomputed tomography to quantitatively evaluateskeletalexpansionandalveolartippingofthemaxillaatthemaxillary canine (C1), �irstpremolar (P1), secondpremolar(P2),and�irstmolar(M1)afterrapidmaxillaryexpansion(RME).Thetransverseeffectstothemaxillarysuture, nasal width, and maxillary sinus were alsoassessed. 30 consecutive patients (17 boys, 13 girls;mean age, 13.8 ± 1.7 years) who required RMEwithHyrax appliances as part of their comprehensiveorthodontic treatment were studied. Measurementsbefore and after RME of palatal and buccalmaxillarywidths,palatal alveolarangle,nasalwidth,nasal �loorwidth,andmaxillarysinuswidthatC1,P1,P2,andM1werecomparedbyusingWilcoxonsignedrank,Kruskal-Wallis,andWilcoxonranksumtests.Pearsoncorrelationanalyseswerealsoperformed(α=.05).Resultshowedthatskeletalexpansionofthemaxillahadatriangularpattern with a wider base in the anterior region,accountingfor55%oftotalexpansionatP1,45%atP2,and38%atM1.Alveolarbendingortippingaccountedfor6%oftotalexpansionatP1,9%atP2,and13%atM1.Theremainingorthodontic(dentaltipping)portionsoftotalexpansionwere39%atP1,46%atP2,and49%atM1.RMEproducesastatisticallysigni�icantincreaseinnasal width and a decrease in maxillary sinus width(P<0.0001). Retention time showed a signi�icantnegativecorrelationtothechangeinpalatalmaxillarywidthatC1,P2,andM1(P<0.05),therateofapplianceexpansion had a signi�icant correlation with palatalmaxillaryexpansionatP1andP2(P<0.05),andagehadno statistically signi�icant association with anyparameter(P>0.05).

Similarly to the above study, our study took threedimensionalcomputedtomographicradiographsof15samplesatthreetimeintervalsi.e.,pretreatment,postexpansionandpostretentionfollowingRapidmaxillaryexpansion therapy and recorded the �indings. Resultsshowedastatisticallysigni�icant increase in themeanmaxillarybasalwidth(inmm)betweenpretreatment),postexpansionandpostretention.Themeanmaxillary

alveolarwidth(inmm)showedastatisticallysigni�icantincrease between pretreatment, post expansion andpost retention.Themeandentoalveolarangulationofmaxillaryrightcanine (indegrees)showedstatisticalsigni�icant decrease between pretreatment, postexpansionandpostretentionandalsoformaxillaryleftcanine (in degrees) between pretreatment, postexpansionandposttreatment.Astatisticalsigni�icant

stdecrease in maxillary right 1 molar (in degrees)between pretreatment, post expansion and post

stretention and also in the maxillary left 1 molar (indegrees) between pretreatment, post expansion andpost retentionwas seen, thereby showing transverseexpansionfollowingrapidmaxillaryexpansiontherapy.Thus,theabovestudysupportsourstudy.

30Baratieri et alconductedastudy toevaluatebyCone-Beam Computed Tomography (CBCT) transversalresponses,immediatelyandaftertheretentionperiod,to rapid maxillary expansion (RME), in Class IImalocclusionpatients.17children(meaninitialageof10.36 years), with Class IImalocclusion and skeletalconstrictedmaxilla,underwentHaas´protocolforRME.CBCTscanswere takenbefore treatment (T1), at theendof the active expansionphase (T2) and after theretention period of sixmonths (T3). The scansweremanagedinDolphinsoftware,wherelandmarksweremarked and measured, on a coronal slice passingthroughtheupper�irstmolar.ThepairedStudent´st-test was used to identify signi�icant differences(p<0.05)betweenT2andT1,T3andT2,andT3andT1.ImmediatelyafterRME,themeanincreaseinmaxillarybasal,alveolaranddentalwidthwas1.95mm,4.30mmand6.89mm, respectively. Thiswas accompaniedbybuccal inclinationof theright (7.31°)and left (6.46°)�irst molars. At the end of the retention period, theentiretransversedimensionincreasedwasmaintainedand the dentoalveolar inclination resumed. It wasconcluded that, the RME therapy was an effectiveproceduretoincreasetransversemaxillarydimensions,at both skeletal and dentoalveolar levels, withoutcausing inclination on anchorage molars in Class IImalocclusionpatientswithskeletalconstrictedmaxilla.

Similarly to the above study, our study took threedimensionalcomputedtomographicradiographsof15samplesatthreetimeintervalsi.e.,pretreatment,postexpansionandpostretentionfollowingRapidmaxillaryexpansion therapyandrecorded the �indings.Resultsshowedastatisticallysigni�icantincreaseinthemeanmaxillary basal width (in mm) in the coronal plane


4

between pretreatment, post expansion and postretention.Themeanmaxillaryalveolarwidth(inmm)showed a statistically signi�icant increase betweenpretreatment, post expansion and post retention. Astatistical signi�icant decrease in dentoalveolar

stangulation of maxillary right 1 molar (in degrees)between pretreatment, post expansion and post

stretention and also in themaxillary left 1 molar (indegrees) between pretreatment, post expansion andpostretentionwasseen.Itwasconcludedthat,theRMEtherapy was an effective procedure to increasetransversemaxillarydimensions, at both skeletal anddentoalveolarlevels.Thus,theabovestudysupportsourstudy.

ConclusionThepresentstudyprovedto�indsigni�icantdifferences,intheskeletalanddentoalveolaraspectsinthesagittalplane,coronalplaneandaxialplaneofallparametersfollowingRapidMaxillaryExpansiontherapy.

This study also proved signi�icant differences, in thevolumetricparametersofthepharyngealairwayspacefollowingRapidMaxillaryExpansiontherapy.

Pharyngeal Airway Analysis:(Fig.1) De�initionoftheplanesandareasforpharynealmeasurements: a) 3d CBCT reconstruction of thepharyngealairway (1. the superiorboundarywas thenasal �loor plane, parallel to the frankfort horizontalplanethroughtheposteriornasalspine(pns);2.and3,themiddleandinferiorboundarieswerethesoftpalateplaneandtheepiglottalplane,whichwereparalleltothefrankfort horisontal plane through the top of the softpalateandthebaseoftheepiglottis,respectively;4,thef ronta l p lane was the anter ior nasa l p lane ,perpendicular to the frankfort horizontal and sagittalplanesandpassingthroughtheposteriornasalspine;thesuperiororopharyngealairwayarea[a]wasformedbythenasal�loorandsoftpalateplanes,andtheinferiororopharyngealairwayarea[b]wasformedbythesoftpalateandtheepiglottalplanes).b) sagittalsliceimageofthepharyngealairway.


3

Landmarks For The Upper Phayngeal Airway

(Fig.2) Superior And Inferior Limits Of Op And NpVolume,Pas,AndMinax(areaOfTheMostConstrictedRegionAtTheBaseOfTheTongue).TheCircleOnTheLeft Illustrates The Last Axial Slice Before The NasalSeptumFusesWithThePosteriorWallOfThePharynx.InTheCenterImage,TheTopLineRepresentsAxalSliceOnTheSagittalView(superiorBorderOfNp).InTheLowerRightImage,TheAreaInEvidenceRepresentsThePasOnTheAxial View; Pp (linePassing FromThePalatalPlane),2cv(linePassingFromTheMostAnteroinferiorAspectOfTheSecondCervicalVertebraeAndParallelToPp).

Landmarks For The Lower Pharyngeal Airway

(Fig.3) Two Dimensional Axial Slice Images Of ThePharyngealAirwayInThe3De�inedPlanes:A)TheNasalFloorPlane;B)TheSoftPalatePlane;C)TheEpiglottalPlane. 1.anteroposteriorWidth; 2. Lateral Width, TheAreas Outlined In Green Indicate The Cross SectionalAreaOfThePharyngealAirway.


4

(Fig.4) LocationsOfLandmarksAndMeasurementsOnThe 3d Cbct Images Of The Craniofacial Skeleton.a)Sagittal View; B) Rear View Of The Mandible; C)De�initionOfLinearDistancesBetweenTheNPlaneAndPointsAAndB.WhenPointsAAndBWereAnteriorToTheNPlane,TheValuesArePositive.

Bibliography:1. Podesser B, Williams S, Bantleon HP, Imhof H.

Quantitationoftransversemaxillarydimensionsusing computed tomography: a methodologicaland reproducibi l i ty study. Eur J Orthod2004;26(2):209-215.

2. Ribeiro ANC, Batista de Paiva J, Rino- Neto J,Illipronti–FilhoE,TrivinoT,FantiniSM.Upperairwayexpansionafterrapidmaxillaryexpansionevaluatedwithconebeamcomputedtomography.AngleOrthod.2012;82:458-463.

3. AngelieriF,FranchiL,CevidanesLHS,Bueno-SilvaB,McNamaraJrJA.Predictionofrapidmaxillaryexpansion by assessing the maturation of themidpalatalsutureonconebeamCT.DentalPressJOrthod2016;21(6):115-25.

4. PodesserB,WilliamsS,CrismaniAG,BantleonH-P.Evaluation of the effects of rapid maxillaryexpansion in growing children using computertomographyscanning:apilotstudy.EurJOrthod2007;29:37-44.

5. Hakan El , Palomo JM. Three-dimensionalevaluation of upper airway following rapidmaxillaryexpansion:ACBCTstudy.AngleOrthod.2014;84:265-273.

6. AngelieriF,CevidanesLHS,FranchiL,GoncalvesJR,Benavides E,McNamara Jr JA.Midpalatal suturematuration: Classi�icationmethod for individualassessmentbeforerapidmaxillaryexpansion.AmJOrthodDentofacOrthop2013;144:759-69.

7. Barber AF, Sims MR. Rapid maxillary expansionandexternalrootresorption inman:Ascanningelectron microscope study. Am J Orthod1981;79(6).

8. Langford SR, Sims MR. Root surface resorption,repair, and periodontal attachment followingrapidmaxillary expansion inman. Am J Orthod1982;81(2).

9. MewJ.Relapsefollowingmaxillaryexpansion.AmJOrthod1983;83(1).

10. Hartgerink DV, Vig PS, Abbott DW. The effect ofrapid maxillary expansion on nasal airwayresistance. Am J Orthod Dentofac Orthop1987;92:381-9.

11. Sandstrom RA, Klapper L, Papaconstantinou S.Expansionofthelowerarchconcurrentwithrapidmaxillaryexpansion.AmJOrthodDentofacOrthop1988;94:296-302.

12. OdenrickL,KarlanderEL,PierceA,KretschmarU.Surface resorption following two forms of rapidmaxillary expansion. Eur JOrthod1991;13:264-270.

13. SilvaFilhoOG,PradoMontesLA.RapidMaxillaryexpansion in thedeciduousandmixeddentitionevaluatedthroughposteroanteriorcephalometricana lys is . Am J Orthod Dentofac Orthop1995;107:268-75.

14. Chang JY, McNamara JA, Herberger TA. Alongitudinalstudyofskeletalsideeffectsinducedby rapid maxillary expansion. Am J OrthodDentofacOrthop1997;112:330-7.

15. SilvaFilhoOG,MagroAC,FilhoLC.EarlytreatmentoftheClassIIImalocclusionwithrapidmaxillaryexpansionandmaxillaryprotraction.AmJOrthodDentofacOrthop1998;113:196-203.

16. BaccettiT,FranchiL,McNamaraJA.Treatmentandpost treatment craniofacial changes after rapidmaxillaryexpansionand facemasktherapy.AmJOrthodDentofacOrthop2000;118:404-13.

17. BaccettiT,FranchiL,CameronCG,McNamaraJrJA.TreatmentTimingforRapidMaxillaryExpansion.AngleOrthod2001;71:343-350.

18. Basciftci FA, Mutlu N, Karaman AI, Malkoc S,KucukkolbasiH.DoestheTimingandMethodofRapidMaxillaryExpansionHaveanEffectontheChanges in Nasal Dimensions? Angle Orthod2002;72:118-123.

19. McNamaraJr JA,BaccettiT,FranchiL,HerbergerTA.RapidMaxillaryExpansionFollowedbyFixedAppliances:ALongtermEvaluationofChangesinArchDimensions.AngleOrthod2003;73:344-353.

20. DorukC,BicakciAA,BasciftciFA,AgarU,BabacanH.AComparisonoftheEffectsofRapidMaxillaryExpansion and Fan-Type Rapid MaxillaryExpansion on Dentofacial Structures. AngleOrthod2004;74:184-194.

21. LagravereMO,MajorPW,Flores-MirC.LongTermDental Arch Changes After Rapid MaxillaryExpansionTreatment:ASystematicReview.AngleOrthod2005;75:155-161.

22. Garib DG, Henriques JFC, Janson G, Freitas MR,Fernandes AY. Periodontal effects of rapidmaxillary expansion with tooth – tissue –borneand tooth- borne expanders: A computedtomographyevaluation.AmJOrthodDentofacialOrthop2006;129:749-58.

23. YuHS,BaikHS,SungSJ,KimKD,ChoYS.Three-dimensional �inite-element analysis ofmaxillaryprotraction with and without rapid palatalexpansion.EurJOrthod2007;29:118-125.

Correspondence Address


3

Authors : Dr. Umapathy. T¹, Dr. Karthikeyan Bv², Dr. Prabhuji³

Abstract

Oligodontiaisthecongenitalabsenceofoneormoreteethwhichhasfamilialabnormalityandattributabletovarious

mutationsorpolymorphismsofgenesoftenassociatedwithmalformativesyndromesThepresentstudydescribesthe

interdisciplinaryapproachtothemanagementofacaseofoligodontiain8yearoldgirlwithmissing16permanent

teeth in mixed dentition. In conclusion the theoretical possibilities for orthodontic treatment and alternative

prosthetic, surgical solutions indiagnoses,management inwhich there isa reduction in thenumberof teethare

discussed.Earlydentalinterventionimprovedthepatient'sappearanceandminimizedtheonsetofemotionaland

psychosocialproblems.

Keywords: oligodontia,diagnosis,treatment,interdisciplinaryapproach.

Key Messages :ThisclinicalreporthighlightstheimportanceofgeneticdiagnosisbymappingofPAX9genefollowed

bymultidisciplinaryapproachinthemanagementofnonsyndromicoligodontia.

IntroductionAgenesis of one or more teeth is one of the mostcommonofhumandevelopmentalanomalies Theterm.,Hypodontiameansabsenceofonlyfewteethwhereasoligodontia(multipleaplasia)isde�inedasacongenitalabsence of six or more teeth which excludes thirdmolars.3 Oligodontiaisaveryrareconditionhavingapopulationprevalenceof0.03%to0.07%4andoccursmost frequently in girls at a ratio of 3:2. The mostfrequently missing teeth were the maxillary lateralincisors,followedbythemandibularsecondpremolarsandthemandibularcentralincisors⁴.

The etiology of tooth agenesis is still largely fromphysicalobstructionordisruptionofthedentallamina,space limitation and functional abnormalities of thedental epithelium or failure of initiation of theunderlyingmesenchyme Itmayalsooccuraspartofa.4systemic genetic syndrome5or can alsobedue to anisolatedcondition(nonsyndromicoligodontia)thathasmutation in LTBP3, the gene encoding latent TGF-bbinding protein 3, an extracellular matrix protein

An interdisciplinary concept of oral rehabilitation in a nonsyndromic oligodontia with a novel mutation of PAX9. A clinical report

1. Dr. Umapathy. T Seniorlecturer DepartmentofPedodontics&Preventivedentistry KrishnadevarayaCollegeofdentalscienceandHospital Bangalore,Karnataka. Email:[email protected]

2. Dr. Karthikeyan BV Reader DepartmentofPeriodontics KrishnadevarayaCollegeofdentalscienceandHospital Bangalore,Karnataka. Email:[email protected]

3. Dr. Prabhuji Professor&HOD DepartmentofPeriodontics KrishnadevarayaCollegeofdentalscienceandHospital Bangalore,Karnataka. Email:[email protected]

believed to be required for osteoclast function6 ormutations in the homeobox gene MSX1 or paireddomaintranscriptionfactorPAX9.

The absence of permanent teeth may cause severalclinical problems and the inconvenience topatientswill vary depending on the speci�ic teeth and thenumber of teeth that aremissing.Moreover, inmostcasesanomalies in thenumberof teeth (hypodontia,oligodontia)areconnectedwithanomaliesintheshapeand size of the teeth. Microdontia often occurs inpersons with oligodontia. Oligodontia is oftena c compan i ed by t au rodon t i sm , d i s t u rbedmineralization and late development of teeth,particularly of the permanent second premolars .8Theseclinicalsituationalsohastobeaddressedinthemanagementofoligodontia.

This clinical report describes a rare case of non-syndromicoligodontiainaeightyearsoldgirlinmixeddentition stage who had problems with esthetics,

3

mastication, and phonation. Since, the therapeuticconcept of oral rehabilitation by multi-displinaryapproaches are decisive for a successful treatmentoutcome an early diagnosis, and comprehensivetreatmentplanningwithgoodcoordinationandtimingoftheindividualtreatmentphasesarepresented.

Case- ReportA8year-oldfemalepatientreportedtothedepartmentof pediatric dentistrywith a chief complaint ofmanydecayedteethlower left back tooth.Thepatientspastmedical history and the family history were notcontributory. It was patient's �irst visit to a dentist.Extra-oralexaminationrevealednoabnormalitiesoftheskin, hair or nails. Intraoral examination, revealedgrossly decayed teeth in relation to (54,65,84) andhypoplastic teeth in relation to (64,74,55), A fewretainedcariousdeciduousteeth(#53,55,65,81,85)were also present with huge midline diastema.. TheOrthopantomographic (OPG) examination revealedagenesisof------permanentteethincludingthirdmolars.The missing teeth were# 12,13,15,17,18,22,23,25,27,28,33,35,37,38,43, 45,46,46,47,48 (�ig 4). The panoramic radiography also revealed a few developing permanent teeth # 13, 17 and 27.Groslydecayed 14 and root resorption14. The teeth presentwerenormalinsize,shapeandcolor.

Therewaslackofdevelopmentofmandibularalveolarbone height. No presence of periodontal disease wasnoted.Studycastsmadeofbothjawsdisclosedocclusionwasdisturbed.Queriesrevealedmissingteethwerenotextractedandwereabsencentsincechildhood.Familyhistorywastaken, shehas brotherandsister,aged4yearsand18Monthsandhadsimilarproblem.fatherdidnot had any missing teeth, her mother had retainedteethinrelationto63,12,22,18,28,38,48.Brotherofage17yearswasexaminedclinicallyandradiographically,OPG revealed retained primary teeth in relation to52,53,62,71,72,73,75,81,82, and missing permanentteeth 12,13,22,31,32,33,35,41,42,45,18,28,38 exceptpermanentmandibularrightmolar.

Onceitwascon�irmedthatthepatientandelderbrotherwereaffectedwitholigodontia,eldersisterandmotherwith hypodontia, genetical evaluation was done byobtainingbloodsampleofallthefamilymembersandfound out that PAX9 was associated with thenonsyndromicformoftoothagenesis.PAX9isapaireddomaintranscriptionfactorthatplaysacriticalrolein

odontogenesis.Basedontheclinicalandradiographicexamination the diagnosis was con�irmed as nonsyndromicformofoligodontia.

Treatmentwasplannedbasedonthediagnosis.Initiallyoral prophylaxiswas done, the decayed teeth did notshow the signs of pulpal involvement, so endodontictreatmentwasnotrequired.Thedecayedprimaryteethwith deep dentinal caries (55,85) was restored withglass ionomer cement. Hypoplastic teeth (64,84)wasrestoredwithstainlessssteelcrowns.Grosslydecayedteeth(54,65,84)wereextractedunderlocalanesthesia.Bandandloopspacemaintainerwasgiveninrelationtoprimary maxillary right �irst molar (54), primarymandibular right �irstmolar (84) and,Mayen's spacemaintainerwasgiven inrelationtoprimarymaxillaryleft second molar (65), and the patient is underobservationandfurtherfollowupismaintaineduntilallthe permanent teeth which are present completelyerupts and then fol lowed by orthodontic orprosthodonticcorrection.Fluorideapplicationisdoneregularly.

The clinical �indings were clearly explained to theparentsandoptionsfortheprostheticrehabilitationforthemissingprimaryteethwithacrylicpartialdenture,dental health education and periodic recall checkupweregiven.Parentswerenotwillingforanytreatment.

DiscussionAtoothisde�inedtobecongenitallymissingifithasnoterupted in the oral cavity and is not visible in aradiograph.Oligodontiaisusedtodescribeagenesisofsixormoreteethexcludingthethirdmolars.⁴Oligdontiacan be associated with syndromes or can benonsyndromic.Howevermostofthecasesarecausedbygeneticfactors.Thegeneticfactorsmaybedominantorrecessiveanditisobviousthatinmanycasesmultiplegeneticandenvironmentalfactorsareactingtogether.Itis also reported that several genes which, whendefective,causecongenitallymissingteeth.MutationsofMSX-1 and PAX-9 genes have been associated withagenesisofteeth.

StudieshaveshownthatMSX1andPAXgenesplayarole

inearlytoothdevelopment.79 PAX isapaireddomain

transcription factor that plays a critical role inodontogenesis and is a major determinant of toothdevelopment. 10 A frameshift mutation recentlyidenti�iedwithinthepaireddomainofthetranscription


4

factor, PAX9, has been linked to a unique form ofoligodontia inasinglemultigenerational family.Severecasenonsyndromicoligontiawasassociatedwithalargeheterozygous deletion on chromosome14, whichincluded the whole PAX9 gene. MSX1 mutation isassociatedwithorofacialcleftingandtoothagenesisinhumans.11 MSX1-associated oligodontia typicallyincludes missing maxillary and mandibular secondpremolarsandmaxillary�irstpremolar.AdistinguishingfeatureofMSX8associatedoligodontia is the frequentabsence o f max i l l ary � i r s t premolars , whi lePAXassociatedoligodontiaisassociatedwithanabsenceof themaxillary andmandibular secondmolarsMSX1mutationisassociatedwithorofacialcleftingandtoothagenesis in humans.11 MSX1-associated oligodontiatypically includes missing maxillary and mandibularsecond premolars and maxillary �irst premolar. AdistinguishingfeatureofMSX8associatedoligodontiaisthefrequentabsenceofmaxillary�irstpremolars,whilePAX . associated oligodontia is associated with anabsence of the maxillary and mandibular secondmolars.12LTBP3isthethirdgenewhichisidenti�iedascausing oligodontia or selective tooth agenesis.TheliteraturereportseightfamiliesinwhomPAX9mutationssegregate with nonsyndromic autosomal-dominantinheritedoligodontia.7

Thepresentcasereportshowsdevelopmentalagenesisof8permanentteethexcludingthethirdmolarswithnoidenti�iable etiology. In this case genetic analysis wasdone and itwas found that PAX9was the etiology. Allmutations of PAX9 identi�ied to date have beenassociatedwithnonsyndromicformoftoothagenesis.13ThehomeboxgeneMSX1hasbeenpreviouslyassociatedwithagenesisofthesecondpremolarsandthirdmolarsin a single family, but in this case it is PAX9. TheinvolvementofMSX1hashoweverbeenexcludedinotherforms of hypodontia involving both second premolarsandlateralincisorsandcanines.,,,

Inthecaseofpatientswitholigodontia,prompt,accuratediagnosisisnecessaryandcarefulplanningoftreatment,with a preconception of the �inal solution in order topreventaestheticandfunctionalproblemsindentition.The use of panaromic radiography is recommended,togetherwithclinicalexamination for thedetectionorcon�irmationofdentaldevelopmentandperformingthediagnosisofhypodontia.,Patientageplaysasigni�icantrole inselectingandplanning treatment.Other factorsthatmustbeevaluatedincludenumberandconditionof

present teeth, number of missing teeth, presence ofcariousteeth,conditionofsupportingtissues,occlusion,andinter-occlusalrestspace.–15Patientssufferingfromoligodontiamayhaveseverepsychological,estheticandfunctional problems. Thus, early diagnosis andtreatmentofthesepatientsisveryimportant.Thereareanumberofoptionsavailabletorestorespacegeneratedbymissingteeth.Treatmentoptionsincludeorthodontictherapy, implants, adhesive techniques, removablepartialprostheses,�ixedprosthesesandoverdentures.Treatmentnot only improves speech andmasticatoryfunctionbutalsohaspsychologicalimplications.16Theorthodontic treatment of patients with congenitallymissinglateralsiscontroversialastowhethertoclosethe spaces left by the missing lateral incisorsorthodontically or to open or maintain spaces forp r o s t h o d o n t i c ( F P D ) r e p l a c e m e n t o rimplants.17Advocates of opening or maintaining thespace for prosthodontic replacement or implantssuggestthatabetterocclusionandless�latteningofthefacialpro�ileisobtained.¹⁸

It is a general rule that the �inal prosthetic solutionshould be avoided until the end of growth anddevelopment.Symptomatictreatmenttilltheageof18yrs, no crowns and bridges, give only stainless steelcrowns.Allowcompleteeruptiontotakeplace,surgicalopeningandorthodonticguidance intoposition.Aftercompleteeruption,repositioningandminorcorrectiontobestofestheticsandfunction.Verticaldimensiontobeevaluated.Occlusalplanetobecorrected.Anycentricandeccentricinterferencesremoved.

Inourcaseconsideringtheageofthechildandthestatusof the dentition i,e primary and permanent teeth,necessarytreatmentslikeoralprophylaxis,restorations,stainless steel crowns and space-maintainers waspreferred in this case . As the chi ld grows amultidisciplinaryapproachisessentialtoachievebetteraestheticsandfunctioninsuchcases.

ConclusionIn conclusion early diagnosis, and comprehensivetreatmentplanningwithgoodcoordinationandtimingof the individual treatment phases are decisive for asuccessful treatment outcome. Theparents should beeducatedaboutprobable futuretreatmentoptions fortheir growing child to prevent future functional andaestheticproblems.Theinconveniencetopatientswillvarydependingonthespeci�icteethandthenumberof


3

teeththataremissing.Itisnecessaryforustomonitorthiscasetoachievebetterresultsinthefuture.

References1. MostowskaA,KobielakA,TrzeciakWH.Molecular

basisofnon-syndromic toothagenesis:mutationsofMSX1 andPAX9 re�lect their role in patterninghumandentition.EurJOralSci.Oct2003;111:365-370.

2. Hunstadbraten K. Hypodontia in the permanentdentition.ASDCJDentChild.Mar-Apr1973;40:115-117.

3. Stewart REWJC, Bixler D.In . . The dentition andanomalies of tooth size, form, structure, anderuption..In:StewartREBT,TroutmanKC,WeiSHY,ed. Pediatric Dentistry: Scienti�ic Foundations ofClinicalProcedures.1steded.StLouis:CVMosbyCo1982.

4. CelikogluM,KazanciF,MilogluO,OztekO,KamakH,Ceylan I. Frequency and characteristics of toothagenesisamonganorthodonticpatientpopulation.MedOralPatolOralCirBucal. Sep2010;15:e797-801.

5. PolderBJ,Van'tHofMA,VanderLindenFP,Kuijpers-JagtmanAM.Ameta-analysisof theprevalenceofdental agenesis of permanent teeth. CommunityDentOralEpidemiol.Jun2004;32:217-226.

6. NoorA,WindpassingerC,VitcuI,etal.OligodontiaiscausedbymutationinLTBP3,thegeneencodinglatentTGF-betabindingprotein3.AmJHumGenet.Apr2009;84:519-523.

7. Mostowska A, Biedziak B, Trzeciak WH. A novelmutation in PAX9 causes familial form of molaroligodontia.EurJHumGenet.Feb2006;14:173-179.

8. Dhanrajani PJ. Hypodontia: etiology, clinicalfeatures, and management. Quintessence Int.2002;33:294-302.

9. Lammi L, HalonenK, Pirinen S, Thesleff I, Arte S,NieminenP.AmissensemutationinPAX9inafamilywithdistinctphenotypeofoligodontia.Eur JHumGenet.Nov2003;11:866-871.

10. PereiraTV,SalzanoFM,MostowskaA,etal.NaturalselectionandmolecularevolutioninprimatePAX9gene, amajor determinant of tooth development.ProcNatlAcadSciU SA.Apr112006;103:5676-5681.

11. VandenBoogaardMJ,DorlandM,BeemerFA,vanAmstel HK. MSX1 mutation is associated withorofacialcleftingandtoothagenesisinhumans.NatGenet.Apr2000;24:342-343.

12. Kim JW, Simmer JP, Lin BP, Hu JC. Novel MSX1frameshiftcausesautosomal-dominantoligodontia.JDentRes.2006;85:267-271.

13. LammiL,ArteS,SomerM,etal.MutationsinAXIN2cause familial tooth agenesis and predispose toco lorec ta l cancer. Am J Hum Genet . May2004;74:1043-1050.

14. Prof�it WR. FH. contemporary orthodontics.2000;3rdedition:658-666.

15. Imirzalioglu P US, Haydar SG[ Surgical andprosthodontic treatment alternatives for childrenand adolescents with ectodermal dysplasia: aclinicalreport..JProsthetDent.2002;88:569572.

16. Zelimer M, M, Zarcovic, D. An interdisciplinsryapproach to the treatment of oligodontia. ActaStomatolcroat.2001;35:117-120.

17. Robertsson S, Mohlin B. The congenitally missingupper lateral incisor. A retrospective study oforthodontic space closure versus restorativetreatment.EurJOrthod.Dec2000;22:697-710.

18. Kokich VO, Jr. Congenitally missing teeth:orthodonticmanagementintheadolescentpatient.AmJOrthodDentofacialOrthop.Jun2002;121:594-595.

Corresponding Author:Dr.Umapathy.TFormerMentorDeptofPedodontics&PreventivedentistryKrishnadevarayaCollegeofdentalscienceandHospitalBangalore,Karnataka.Email:[email protected]


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Authors : Dr. Sachin Shivanaikar¹, Dr. Pradeep Somannavar², Dr. Sameer Pote³, Dr. Arundhati Pote⁴,

Metoprolol induced gingival enlargement? - A case report

Abstract

Gingival overgrowth is frequently observed in patients taking certain drugs such as calcium channel blockers,

anticonvulsantsandimmunosuppressant.Thiscanhaveasigni�icanteffectonthequalityoflifeaswellasincreasing

the oral bacterial load by generating plaque retention sites. Metoprolol, a selective used inβ1 receptor blocker

treatment of several diseases of the cardiovascular system, especially has been shown to promotehypertension

gingivalovergrowthalthoughinverylimitedcasesreported.Themanagementofgingivalovergrowthseemstobe

directedatcontrollinggingivalin�lammationthroughagoodoralhygieneregimen.Howeverinseverecases,surgical

excision is the most preferred method of treatment, followed by rigorous oral hygiene procedures. This article

describesararecaseofgingivalovergrowthinducedbymetoprololina50yearoldfemalepatientdiagnosedwith

hypertension.Surgicalgingivectomywasdonetoexcisethegingivalovergrowthandfollowupforayearshowedno

recurrence.Thiscasereporthasalsoshownthatperiodontaltreatmentalongwithchangeinassociateddrugcanyield

satisfactoryclinicalresponse.

Keywords: DrugInduced,GingivalEnlargement,Metoprolol.

IntroductionAn increasing number of medications are associatedwith gingival enlargement. Currently, more than 20prescriptionmedications are associatedwith gingival

1 enlargement . Drugs associated with gingivalenlargement can be broadly divided into threecategories:Anticonvulsants,calciumchannelblockers,

2and immunosuppressants. Histologically it ischaracterized by an accumulation of extracellularmatrix within the gingival connective tissue,particularly the collagenous component,with various

3degreesofchronicin�lammation. The prevalencerateofthisdisorderhasbeenreportedtovary:10%to50%foranticonvulsants, 8% to 70% to immunosuppressants

4and 0.5% to 83% to calcium channel blockers. Theaccuratedeterminationof theprevalencerate ineachdrug category is dif�icult. These differences in thereportedprevalencemaybeduetothedifferingindicesof gingival overgrowth. It is the responsibility of thedental practitioner to recognize the potential of

1. Dr.SachinShivanaikarMDSReader, DepartmentofPeriodontics,MarathaMandal'sNGHInstituteof

DentalSciencesandResearchCentre,Belgaum,Karnataka,INDIA.

2. DrPradeepSomannavarMDS Reader, DepartmentofOralPathology,MarathaMandal'sNGHInstitute

ofDentalSciencesandResearchCentre,Belgaum,Karnataka,INDIA.

3. DrSameerPoteBDS Privatepractitioner,Belgaum,Karnataka,INDIA.

4)DrArundhatiPoteBDS Privatepractitioner,Belgaum,Karnataka,INDIA.

medicationsthatcontributetogingivalenlargementandtoprovidetheproperprophylacticcareorappropriatelyrefer the patient for periodontal therapy. A teamapproach involving a consultationwith a periodontistandthepatient'sphysicianisacriticalstepinsuccessful

5treatment. We report a rare caseof localizedgingivalovergrowthinpatientwithmetoprololmedication.

Case report 56yearoldfemalepatient,socialworkerbyprofessionvisited the dental clinic with the chief complaint ofdislodgedlowerfront�ixedprosthesis.Shehadahistoryofextractionwiththelowerincisorsduetomobilitytwoyears back,whichwas replacedwith the �ixed partialdenture.Pastmedicalhistoryofpatientrevealedtobehypertensive since 10 years and had cardiac pain forwhich she is been put on aspirin 75mgdaily andTabmetoprolol for hypertension. General physicalexaminationrevealedpatientwascooperativeandwellorientedwith the time, place and all vital parameters

3

http://en.wikipedia.org/wiki/Beta_blocker

http://en.wikipedia.org/wiki/Hypertension

werenormal.Onintraoralexaminationpatienthad�ixedpartial denture in relation tomissing 31, 32, 41& 42where 33& 43 were used as an abutments. Theprosthesiswasmadeupofmetalwithacrylicfacing.Theprosthesiswasdiscoloredandshowedaccumulationofplaqueandcalculus.Onexamination itwasfoundthattherewasabilateralgingivalenlargementonthelabialaspectof33and43whichwasreddishpinkincolor,withsmooth shiny surface, measuring about 1x1cms withwell de�ined borders. Patient was not aware of thegingival enlargement as there was no signs andsymptomsassociatedwithit,sotheonsetanddurationcouldnotbefoundout.Onpalpation,enlargementwasnon tender, semi �ibrotic, and non �luctuantwithwellde�ined borders. Based on the history and clinical�indings the provisional diagnosis of reactive gingivalenlargementwasmade.Thedifferentialdiagnosiswasgiven as in�lammatory enlargement, drug inducedenlargement and irritational �ibroma. Before anytreatment the patient was advised to take a medicalconsentandundergototalbloodexaminationincludingINRtestforprothrombinsincepatientwasonaspirin.Onthesecondvisitthepatientgotthemedicalconsentandalsoherantihypertensivedrugwaschanged.Herbloodexaminationwasinnormalrange.Thesupragingivalandsubgingivalscalingwasdoneandpatientwasadvisedtouse10mlof0.2%chlorhexidinemouthwashtwicedailyfor two weeks. Folic acid supplements were alsoprescribed.Subsequenttoscalingontherecallvisitthesizeoftheenlargementdecreasedto7mmx7mmanditwaspinkishincolorandtheconsistencywaschangedto�ibrotic. The enlargement was excised under localanesthesia with aseptic precautions. Only oneenlargementwas excised at a time and the otherwasexcisedwiththeintervalofoneweek.Theexcisedlesionwas �ixed in 10% buffered formalin and sent to thelaboratory for the histopathological examination. Thepatientwasprescribedwithanalgesicsandadvised tomaintainthegoodoralhygiene.Healingwasuneventfulwith no post operative complications. Patient wasadvised with ceramic �ixed partial denture. Norecurrenceoftheenlargementwasnotedaftertwoyearsofexcision.

Histopathologicalexaminationrevealedparakeratinizedstrati�iedsquamousepitheliumwiththinandlongreteridgesandshowingpseudohyperplasia.Theconnectivetissue stroma shows irregularly arranged densecollagenic�iberbundleswithmildchronicin�lammatorycell in�iltrate predominantly plasma cells and few

engorged blood vessels. Based on histopathologyshowinglessin�lammation,wewereoftheopinionitasDruginducedgingivalenlargement.

DiscussionThe pathogenesis of gingival overgrowth is uncertainand the treatment is still largely limited to themaintenanceof an improved leveloforalhygieneandsurgicalremovaloftheovergrowntissue.Severalfactorsmay in�luence therelationshipbetween thedrugsand

6gingivaltissuesasdiscussedbySeymouret al Thoseareage,geneticpredisposition,pharmacokineticvariables,alteration in gingival connective tissue homeostasis,histopathology, ultrastructural factors, in�lammatorychangesanddrugactionongrowthfactors.Moststudiesshowanassociationbetweentheoralhygienestatusandtheseverityofdrug inducedgingivalovergrowth.Thissuggeststhatplaque-inducedgingivalin�lammationmaybe important risk factor in the development and

7 expressionofthegingivalchanges. Inthispresentcasethe local environmental factors such as poor plaquecontrol and multiple prosthesis at the initialpresentationmayactasriskfactorsthathadcontributedto worsen the existing gingival enlargement and

8thereforecomplicatetheoralhygieneprocedures.

Therewassomereductionoftheovergrowthobservedparticularly at the abutment teeth after the initialtherapy was advocated including scaling and rootplaning.Ageisalsoanimportantriskfactorforgingivalovergrowthwithparticularreferencetophenytoinand

9cyclosporin Themanagementofgingivalovergrowthseems to be focusing at goodoral hygiene regimen to

10control the gingival in�lammation The interactionbetween the drug and the gingival tissues could beenhancedbygingivalin�lammationcausedbypoororal

11hygiene Ithasbeenshownthattherewassigni�icantreductionofnifedipine-inducedgingivalovergrowthbythoroughscalingandrootplaningandscrupulousplaque

12control. Surgicalreductionsoftheovergrowntissuesisfrequently necessary to accomplish an aesthetic and

12functional outcome. The treatment may consist ofsurgical gingivectomy and/ or laser gingivectomy.Discontinuationoftherelateddrughasbeenshowntoreducethegingivalovergrowth;howeverthegrowthwill

13recurs when the drug was readministered. In caseswherealternatemedicationcanbeused,substitutionintherelateddrughasbeenshowntoresultinregressionoft h e o ve r g row t h . I s r a d i p i n e , a c ompan i o ndihydropyridine calcium channel blocker has shown


4

regression about 60% of the gingival overgrowth14previously induced by nifedipine. Another treatment

modalitythathasbeensuggestedwastheuseoftopicalapplicationoffolatesolutiononthegingivalovergrowth.

15Drewet al havedemonstratedsigni�icantdecreasedofthe gingival overgrowth when acid folic was topicallyappliedonthephenytoin-inducedgingivalhyperplasia.

16 Inoue and Harrison also found that folic acidsupplementationdecreases theseverityof thegingivalovergrowth. Phenytoin interferes with folic acidmetabolism and lead to folic acid de�iciency which isknown to be associated with gingival in�lammation.Howevertherewasnostudyreportedtheuseoffolicacidinthemetoprololinducedgingivalovergrowth.

In this present case, gingival overgrowth wassatisfactorily treated via initial periodontal therapyincluding oral hygiene instruction and motivation,followed with surgical gingivectomy. This case reportdemonstratedthatwithachangeinassociateddrugandperiodontal treatment can yield satisfactory clinicalresponse.Our study is in contrastwith case reportby

8Ikawa et al. As the periodontal condition was undercontrolled,prosthesiswasconstructedinordertoful�illthefunctionandaestheticofthepatient.Theprosthesiswas designed to minimize the plaque retention sites.Howeverthereispossibilityforthegingivalovergrowthtorecuraslongastheassociatedmedicationiscontinued

17and persistence with other risk factors. Thereforepatient must be informed of this tendency and theimportanceofmaintenanceoftheeffectiveoralhygieneas key factors in preventing and managing gingivalovergrowth associated with these drugs. Supportivefollow up is necessary in an effort to monitor hergingival/periodontalstatus,toassessandreinforceoralhygiene and to periodically provide professional care,

12thuspreventtherecurrenceofgingivalovergrowth.

ConclusionDrug-inducedgingivalenlargementisacommonsequelato treatment with anticonvulsants, calcium channelblockersandimmunosuppressants. Evidencesuggeststhatgingivalin�lammationiscriticalinitspathogenesis.While it may be prevented through meticulousperiodontalmaintenanceandhomecare,it isessentialfor the dentist to work together with the patient'sphysicianandperiodontistinordertosuccessfullytreatthisconditiononceitoccurs.

Image1:PreOperativeShowingBilateralEnlargement

Image2:AfterRemovalOfTheProsthesis

Image3:ProsthesisWithCalculusAttachedToIt

Image4:Prosthesis


3

Image5:PostOperative(oneMonthAfterExcision)

Image6:H&eStaining

References1. ReesTD,LevineRA.Systemicdrugsasariskfactor

forperiodontaldiseaseinitiationandprogression.CompendContinEducDent1995;16:20-42.

2. Nishikawa S, Tada J, Hamasaki A. Nifedipineinducedgingivalhyperplasia:Aclinicalandinvitrostudy.JPeriodontol1991;62:30-35

3. Yamasaki A, Rose GG, Pinero GJ, Mahan CJ.Ultrastructure of �ibroblasts in cyclosporin A-induced gingival hyperplasia. Journal of OralPathology & Medicine 1987; pages16,Issue 3,129–134.

4. BarclayS,ThomasonJM,IdleJR, SeymourRA.Theincidence and severity of nifedipine-inducedgingival overgrowth. J Clinicalperiodontal1992;19(5),311–314.

5. CraigK,FoisieDC,GetkaP.Drug-inducedgingivalenlargement.ClinicalUpdate2008;30(6);1-2.

6. Seymour RA. Effects of medications on theperiodontal tissues in health and disease. Perio2000;4:120-129.

7. BarclayS,ThomasonJM,IdleJRandSeymourRA.the incidence and severity of nifedipine inducedgingivalovergrowth. JClinPeriodontol,1992;19:311-314.

8. Ikawa K, IkawaM, Shimauchi H, IwakuraM andSakamoto S. Treatment of gingival overgrowthinduced by manidipine administration: A casereport.JPeriodontol2002;72:115-122.

9. Seymour RA, Ellis JS and Thomason JM. Riskfactorsfordrug-inducedgingivalovergrowth.JClinPeriodontol2000;27(4):217-223.

10. NeryEB,EdsonRG,LeeKK,PruthiVKandWatsonJ.Prevalence of nifedipine-induced gingivalhyperplasia.JPeriodontol1995;66:572-578.

11. Seymour RA. Calcium channel blockers andgingivalovergrowth.BrDentJ1991;170:376-379.

12. HallmonWMandRossmannJA.Theroleofdrugsinthe pathogenesis of gingival overgrowth. Acollective review of current concept. Perio2000;21:176-196.

13. Lederman D, Lumerman H, Reuben S andFreedmanPD.Gingivalhyperplasiaassociatedwithnifedipinetherapy.Reportofacase.OralSurgOralMedOralPathol1984:57620-622.

14. KheraP,ZirwasMJandEnglishJC.Diffusegingivalenlargement. J Am Acad Dermatol 2005;52:491-499.

15. DrewHJ,VogelRI,MolofskyW,BakerHandFrankO.Effectoffolateonphenytoinhyperplasia.JClinPeriodonto1987,14:350-356.

16. InoueFandHarrisonJ .Folicacidandphenytoinhyperplasia.Lancet1981,2:86.

17. Mavrogiannis M, Ellis JS, Thomason JM andSeymour RA. The management of drug-inducedg ing iva l overgrowth . J C l in Per iodonto l2006;33:434–439.

Corresponding Author:Dr.Sachin .S. Shivanaikar“Vayshnoovi' Pl no 10, Vijaynagar,Hindalga, Belgaum. 591108.Karnataka, INDIA.Email: [email protected]:+919538547127


4

http://onlinelibrary.wiley.com/doi/10.1111/jop.1987.16.issue-3/issuetoc

http://onlinelibrary.wiley.com/doi/10.1111/cpe.1992.19.issue-5/issuetoc

Authors : Dr. Sunitha N.Shamanur¹, Dr. Nivedita Tiwari²

Moriginal article:Assessment of Awareness, knowledge and practices of Digital smile designing among practitioners in Davangere city: A cross sectional survey

Abstract

Background: Digitizationhasbecomepartandparcelofthecontemporaryprosthodonticswiththeprobabilityof

mostoftheproceduresbeingbasedonthedigitaltechniquesinnearfuture.Digitalsmiledesigningisoneofmany

digitalinventionsin�ieldofdentistry,whichgivesscopeforanumberofproceduresandinterdisciplinaryapproach.

Aim: To assess awareness, knowledge, and practices of digital smile designing among dental practitioners in

Davangerecity.

Materials and method: Aself-designedvalidatedquestionnairewas administered toDentists inDavangere city,

practicingwithinthegeographicalareaofDavangerecity.Surveyparticipantswereaskedabouttheirknowledge,

practicesandawarenessregardingdigitalsmiledesigning.

Results: Thedatarevealedthatmaximumnumberofpractitionerswereawareofdigitalsmiledesigningbutatthe

sametime80.2%oftheparticipantswerenotusingdigitalsmiledesigningintheirdailypractices.

Conclusion: The�indingsofthissurveyarethatthemajorityofpractitionerswereawareofdigitalsmiledesigningbut

duenumberoffactorsliketheirno.ofyearsofpractice,costeffectiveness,andlimitedevidencebasedpracticesthey

werenotusingdigitalsmiledesigningintheirdailypractices.

Keywords: Digitalsmiledesigning,awareness,knowledge,practices,digitaldentistry,survey

IntroductionThe widely known popular saying "The smile is ourbusiness card" must always be respected andconsidered, since there is scienti�ic evidenceevincingthesmileasthemostimportantelementinthecontextofdentfacialaesthetics.Inthelastcentury,thescientistAlfred Yarbus17 designedequipmentthatregisteredthemovement of human eyes in different situations. Hisstudies revealed that whi le analysing facia lphotographs,peopletendtofocusattentionmostlyonthemouthandtheeyes.This�indingiscorroboratedbyrecent publications con�irming that during personalinteractionsgreaterattentionisgiventothemouthandtheeyes.Additionally,becausethemouthisoneofthecentresofattentionoftheface,thesmileplaysessential

1role in facial aesthetics . This demand for a pleasantsmiledrivesustoa�ieldofdentalaestheticsandthustherole of a prosthodontics become signi�icant. It isdetermining not only in the perception of facialattractiveness, but also with the perception of one's

1psychologicalcharacteristics .Understandingtheuses

1. Dr.SunithaN.Shamanur

Departmentofprosthodonticsandcrown&bridge,BapujidentalcollegeandhospitalDavangere,Karnataka

2. Dr.NiveditaTiwari Departmentofprosthodonticsandcrown&bridge,Bapuji

dentalcollegeandhospitalDavangere,Karnataka

of smile design is very important so understands therecenttrendsindentistry,whichhasmadetheworkofdentistmoreeffortless.Dentistryhasevolvedfurthertomeet highly aesthetic demands and expectations ofpatients – the treatments are becomingmore precise,

2delicate,minimallyinvasive,andcomfortableandfaster .Inachievingthis,wemustgobeyondtheboundariesoft r ad i t i ona l d en t i s t r y a nd a cqu i re a s e t o fartistic/communication skills and vision, and this is

3wheretechnologycanplayapivotalrole .Inviewoftheabovementioned, someofpotential benefitsofdigitaldentistry include‟‟DIGITAL SMILE DESIGNING'' ,whichhelpsinimprovementoftreatmentplanningand“smiledesign” process, transforming the patient into a co-author of his/her own new smile and helps in

3developmentofeffectivetreatmentplanning.

Recently,therequestofpatientsischangedintermsofnot only aesthetic but also revisualization therapyplanning

Patientsexpectcomplexfunctionalrehabilitationsthat

3

are aesthetically appealing. Using the digital smiletechnologyitispossible,toobtainavirtualwax-upofthe�inalrestorationbymakingacut-outoftheoriginalteeth.Thevirtualwax-upoffers importantadvantages to theclinician and to the laboratory and allows an ef�icient

3planningoftheworkatthesametime .

Thedigitalsmiledesignisapracticaldiagnosismethodthat can assist the clinician to visualize and measuredentogingivaldiscrepancies,seeingtheseadvantagesastudy to evaluate the awareness of digital smiledesigningamongpractitionersofDavangereisneeded.

Needofthestudy:a) To assess awareness of Digital smile designing

amongpractitionersofDavangerecity.

b) Literaturesearchrevealednosuchstudycarriedout in Davangere city to assess knowledge andpractices of digital smile designing amongpractitionersinDavangerecity.

Materials And Method: Datawillbecollectedbyusingself-designedquestionnairehavingtwosections;

Section1:Provisiontocollectdemographicdatalikeage,gender,andtheiryearsofexperienceaspractitioners

Section 2: Questionnaire to assess the awareness,knowledge and practice related to digital smiledesigning.[One question to assess the awareness,11questionstoassesstheknowledge,9questionstoassessthepracticeofdigitalsmiledesigning].

Self-designedquestionnairewere subjected to validitytestbygivingittopanelofexpertstoexplorethefacevalidityandtheoreticalconstructofthequestionnaire.Thereliabilityofthequestionnairewasdonebyapilotteston10dentalpractitionersnotincludedinthemainsurveywithatimeperiodof4weeks.Datasoobtainedwassubjectedtostatisticalanalysis.

Internalconsistencyshowedcronbach‟salphaof0.81,whichisconsideredtobeacceptablereliability.

Administration Of The Questionnaire:After explaining the studydetails to practitioners andgetting their consent to participate, pretestedquestionnairewasadministeredtodentalpractitionersin their respective workplaces by prior permission

seeingtheirfreetime.

Data from the consultants was collected by knowingtheirvisitingdatespriorlyfromthedentalclinicswheretheyvisit.Completedresponsewillbecollectedonthesamedaycheckingitscompleteness.DatawascompiledinMicrosoftexcelsheetandanalysed.

Contentvalidityofquestionnairewasassessedby�ive5experts. Three prosthodontics and two public healthdentistandoneEnododontistContentvalidityindexforrelevance was 0.88, clarity 0.75, simplicity 0.93,ambiguity0.97.Henceasatisfactorylevelofagreementwasfound.Responses:20questionswereprovided,witheachquestionhaving threeoptions–YES,NO,MAYBE.Exceptquestion threewhichhadmultipleoptions forselecting,variousprogramsofdigitalsmiledesign.

Sample questionnaire:Assessment of awareness, knowledge, and practicesabout Dig i ta l smi le designing among dentalpractitionersinDavangerecity–acrosssectionalsurvey(Nameofprincipalinvestigator:Dr.NiveditaTiwari)

1. Areyouawareofdigitalsmiledesigning?a) Yesb) No

2. Do you use digital smile designing for aestheticsmiledesigning?

a) Yesb) No

3. Which of the following programs do youuse/recommendfordigitalsmiledesigning?

a) PhotoshopCs6b) PowerPointc) Keynoteb) Aestheticdigitalsmiledesign(ADSD)e) CerecSW4.2f) 3dGPSg) Digitalsmiledesignapp(DSDapp)h) Smiledesignerpro(SDP)I) Visagismilej) Planmecaromexissmiledesign(PRSD)

4. Isdigitalsmiledesigninguserfriendly?a) Yesb) Noc) Don‟tknow


4

5. HaveyouundergoneanyspecialtrainingforusingDigitalsmiledesigning?

a) Yesb) No

6. Can digital smile designing improve patienteducation and motivation when compared toconventionaltechniques?

a) Yesb) Noc) Don‟tknow

7. Can digital smile designing improve thecommunicationbetweendentistandtechnician?

a) Yesb) Noc) Maybe

8. Candigital smile designing act as a „‟marketingtool‟‟fordentist?

a) Yesb) Noc) Maybe

9. Can digital smile designing help in preliminaryfacialanalysis?

a) Yesb) Noc) Maybe

10. Can DSD help in measuring and visualizingdentogingivaldiscrepanciesmoreaccurately?

a) Yesb) Noc) Maybe

11. Can digital smile designing enable moreconservative tooth preparation in Prosthetic orcosmeticcases?


12. Can prognosis be determined for aestheticdesigningusingDSD?


13. Can you store and transfer data easily throughDSD?


14. Can the patient act as a ‟‟ co- designer‟‟ of thetreatment?

a) Yesb) Noc) Maybe

15. Can digital smile designing help to evaluatelimitationsandriskfactorsofaestheticprinciples?


16. Can DSD superimpose pre and post treatmentimages?


17. Can digital smile designing simulate �inalrestoration?


18. Can you do additive/reductive changes intreatment outcomes through digital smiledesigning?

a) Yesb) Noc) Maybe

19. Candigitalsmiledesigningreducechairtimeandprovidebetterpatientcompliance?

a) Yesb) Noc) Maybe

20. Canyoudo„‟smiledonation‟‟throughDSD?a) Yesb) Noc) Don‟tknow


3

Results:

Atotalof90surveyformsweresuccessfullydeliveredbytheinvestigatoraccountingforatotalof50surveyforms were responded. There were 50 participants,withanoverallpositiveresponserateof55.55%.Asthepurposeof this survey,was toassess theknowledge,practice and awareness of digital smile designingamong practitioners of Davangere city, the surveyparticipants comprised of all the dentists in the twodentalcollegesofDavangerecity,practicingwithinthegeographicalareaofDavangerecity.Therespondentsofoursurvey,comprisedof47.4%wereteachingfacultywithlessthan5yearsofexperience,24.8%werefaculty

with5-10yearsofexperience,22.3%werefacultywith11-20yearsofexperience,3.8%werefacultywith21-30 years of experience and 1.6% respondents werefacultywithaclinicalexperienceofmorethan30years.Among all experience groups, the data indicate that94%ofrespondentswereawareofdigitalsmiledesign,but a remarkable 80%of the practitioners were notusing digital smile designing in their daily practices.Reasonsfornotusingdigitalsmiledesigningwerenotevaluated by the survey. 79% of the practitionersrevealed that theyhadundergone special training inorder to use digital smile designing in their dailypractices. Hence ONLY 48% found digital smiledesigningtobeuserfriendly.

Discussion:The main objective of the survey was to assessknowledge, practices and awareness of digital smiledesigningamongpractitionersinDavangerecity.While assessing knowledge regarding digital smiledesigning,itwasconcludedthatmaximumparticipantswereawareofdigitalsmiledesigning.Onlyexceptionwas observed for question regarding smile donatorconceptwhere64%participantswerenotawareofthisconcept.

On assessing practices related to digital smiledesigning, it was concluded that 56% of theparticipants recommended using digital smiledesigningintheirdailypractices.MostrecommendedSoftware used for digital smile designing is 25% forPhotoshopCS6,18%forDSDappbycoachmanand10%for keynote. (This �inding was supported by theapplication of parameters for comprehensive smileaestheticsbydigitalsmiledesignprograms:Areviewofliterature ,,TheSaudiDentalJournalVolume30,Issue1January2018,Pages7-12).

Whereasinspiteofknowledge,22%practitionersdidnot recommend any of the digital smile designingprograms.Possiblereasonswerenotassessedbutwereestimatedasolderdentisthadlowercomputerliteracy(this �inding was supported by the Smith etal(17)).Alternate reason being that 78%of theparticipants never underwent any training or doneworkshop on digital smile designing, hence did notincorporate digital smile designing in their dailypractices. Also many dentists were concerned withinvestmentsneeded to godigital in their practices. (similar studywas foundbyDIGITTIZEDDENTISTRY:SAUDIJOURNALOFORALSCIENCESBYFaroukM.Sakr,


4

https://www.sciencedirect.com/science/journal/10139052

https://www.sciencedirect.com/science/journal/10139052/30/1

KaisG.AlObaidy.)

AlsolimitedevidencebasedpracticesbypractitionersofDavangerecitywasfoundtobeevident,whichcouldnot accept patient preferences, characteristics orsituations for better treatment planning.( �indingsupportedbyastudydonebyBhatePMetalDentists‟knowledge,attitude,andpracticeregardingevidence-based practice in Davangere, India. J Indian AssocPublicHealthDent2017;15:359-67).

Limitationsofthestudywere�irstlylowrespondrateinvitesbiasestothestudyandsecondlyreasonsfornotusingdigitalsmiledesigningbythepractitionerswasnotassessedbythestudy.

Conclusion:It was concluded, that in spite of knowledge aboutdigital smile designing, maximum number ofpractitionersofDavangereCitywerenotusingdigitalsmile designing in their daily practices. Hence,structured education programmes and courses toimproveknowledgeandpracticeofdentistsespeciallythosewithlessquali�icationandworkexperiencesisthe need of the hour also Training of dentalpractitionerspertainingtodigitalsmiledesigningandup gradation of their practices with moderntechnologiesin�ieldofdentistryisrecommended.

References:1. Machado AW .10 commandments of smile

esthetics. Dental Press J Orthod. 2014 Jul-Aug;19(4):136-57.

2. BhambhaniritikaBhattacharyajayantaSensaibalkr. Digitization and Its Futuristic Approach inProsthodontics. J Indian Prosthodont Soc (July-Sept2013)13(3):165–174

3. Coachman C Paravina RD Digitally EnhancedEstheticDentistry -FromTreatmentPlanning toQualityControl.JEsthetRestorDent.2016Mar;28Suppl1:S3-4.

4. NDkravitzSmileAnalysisandDesignintheDigitalEra.JClinOrthod.2017Sep;51(9):602-605.

5. Coachman C Digital design process. Int JP e r i o don t i c s Re s t o ra t i ve D en t . 2 017Mar/Apr;37(2):183-193.

6. ZimmermannM,MehlA.Virtual smiledesign: ac u r r e n t r e v i e w . I n t J C o m p u t D e n t .2015;18(4):303-17

7. AckermanMBSmileanalysisanddesignindigitalera:JClin.Orhtod.Apr;36(4):221-36.

8. Ercus s,Chung E Esthetics with minimal toothpreparat ion achieved through a d ig i ta la p p r o a c h . C omp e n d c o n t i n E d u D e n t2013jun(6)428-31

9. GurelGApplyingfundamentalprinciplestodigitaltechnologies .dentistry Today 2014 may33(5)144-148

10. Levrini L , Tieghi GBini V, ClinCheck and theAesthetic Digital Smile Design Protocol. J ClinOrthodinvisalign2015Aug;49(8):518-24.

11. BhambhaniR,BhattacharyaJ,SenSK,Digitizationand its futuristic approach in prosthodontics. JIndianProsthodontSoc.2013Sep;13(3):165-74.

12. JonathanB.LevineEssentialsofEstheticdentistryvoltwo.Pgnumber256to300

13. Coachman et al smile design from treatmentplanningtoclinicalreality

14. G.Finelle:DigitalSmileDesignininterdisciplinaryand orthodontic dental treatment planning JDentofacialAnomOrthod2017;20-303

15. Josiele et al Digital smile design as a principleoptimizerof dental aesthetics two case reports.International Journal of Development ResearchVol. 07, Issue, 09, pp.14882-14884, September,2017

Corresponding Author:


3

Authors : Dr.Dr. Y. Pavan Kumar¹, Dr. D. Ajit²

Dermatoglyphics as a genetic marker for potentially malignant disorders of the oral cavity

Abstract

Aim : ThepresentstudyaimstocomparetheoccurrenceofdermatoglyphicDigitalandPalmpatternsofindividuals

withtobaccochewing/smokinghabitswithpotentiallymalignantdisorders[PMD's],individualswithoutpotentially

malignantdisordersandthosewithouttobaccochewing/smokinghabitinVisakhapatnampopulation.Thisstudymay

helpforearlydetectionofindividualswhoareatriskofdevelopingPMDsandoralcancer.

Materials and Methods:Acomparativepreliminarystudywasconductedon45subjectswhovisitedDepartmentof

OralMedicineandRadiology,GITAMDentalCollegeandHospital,Visakhapatnam,AndhraPradesh,India.Thesubjects

weredividedintothreegroups;15subjectswithtobaccochewing/smokinghabitswithclinicallydiagnosedpotentially

malignantdisoorderslikeLeukoplakia,LichenplanusandOralSubmucous�ibrosis(GroupA).15subjectswithtobacco

chewing/smokinghabitsandwithoutassociatedpotentiallymalignantdisorders(GroupB),and15healthycontrols

without tobacco chewing/smokinghabits (GroupC).Dermatoglyphicdigital andpalmerprintswereobtainedby

standardIndiainkmethod.Printswereanalyzedbytwoobserversanddataobtained.Theobtaineddatawassubjected

tostatisticaltestusingSPSSsoftware20version.

Results:Group1patientshadmorepercentage(76%)ofloopdigitaldermatoglyphicpatterncomparedtothepatients

withhabitswithoutPMDs[Group2](32.6%),controlgroup(38.8%)(Group3).Nosigni�icantdifferencespresentin

hypothenarpattern,thenar,I1,I3areapattern,whencomparedamongallthreegroupsonrightandleftsidepalmand

signi�icantdifferencespresentinI2,I4areapattern,whencomparedamongallthreegroupsonrightandleftsideofthe

palm.

Conclusion:AsPMDsandOSCChaveageneticbasis,withtheknowledgeofdermatoglyphicpatterns,individualswho

arepronetodeveloptheselesionscanavoidthetriggeringfactors.

Keywords: Potentiallymalignantdisorders[PMDs],Dermatoglyphics.

IntroductionDermatoglyphicswasestablishedbyGaltonintheyear1892andthistermwascoinedbyCumminsandMidloin

11926. Dermatoglyphicsreferstothebranchofgeneticsdealingwithepidermalridgepatternsandgrooveson�ingertips,palms,solesandtoesoffeet.Itisanemergingtool,usedasageneticmarkerinpredictingthediseases

2ordisorderscurrently.

thDermatoglyphicpatternsaredevelopedinthe6 weekof embryonic life starts with fetal pads and reach a

th thmaximum size between the 12 and13 weekswhileth

becomingmatureinthe24 weekofgestation.Fromthisstageonwards,theyareunchangedbytheextraneous

1. Dr.Y.PavanKumar. Professor&HOD

DepartmentofOralMedicineandRadiology,GITAMDentalCollegeandHospital,Visakhapatnam,AndhraPradesh.

2. Dr.D.Ajit. Professor

DepartmentofOralMedicineandRadiology,GITAMDentalCollegeandHospital,Visakhapatnam,AndhraPradesh.

factors, and thisexplains theirunique roleasan ideal3markerforindividualidenti�ication.

Dermatoglyphics is a non-invasive diagnostic tool todetect and predict different medical conditions thatoccurinearlylife.Thedermatoglyphicsofdiseasessuchas thalassemia, sickle cell anaemia, acute lymphocyticleukaemia, ischemic heart disease, hypertension,schizophrenia, diabetes, epilepsy, rheumatic heartdisease, dilated cardiomyopathy are evaluated in theliterature.Italsoplaysanimportantroleinthediagnosisof chromosomal disorders like Down's syndrome,

4Turner'ssyndromeandintheTrisomy18syndrome.

Dermatoglyphicsiswidelyusedinthedentistrytodetect

4

thegeneticbasisofvariousconditionslikecleftlipandpalate,earlychildhoodcaries,developingmalocclusioninpediatricpopulation,periodontaldiseases,bruxism,and also potentially malignant and malignant

5conditions.

Potentiallymalignantandmalignantconditionsareduetotobacco,alcoholabuseandunhealthy lifestyles. It isalsoaknownfactthatmillionsofpeopleusetobaccoorgutkha,butonlyafractionofsuchpeopledeveloporalpremalignant lesions and conditions, such asLeukoplakia, Lichenoid reactions andOral Submucous�ibrosis.Geneticallydetermineddifferencesamongtheseindividuals would probably explain this susceptibility.Several researches have proven that genetic andenvironmental factors are important determinants incausationoforalpotentiallymalignantdiseases(PMDs)

6andoralcancer. Inthiscontext,dermatoglyphicscanbeavaluable adjunct tool to other diagnostic methods inidentifyingvariousdiseasesofgeneticorigin.

Material and MethodsAcomparativepreliminarystudywasconducted in45subjectswhovisitedDepartmentofOralMedicineandRadiology, GITAM Dental College and Hospital,Visakhapatnam,AndhraPradesh, India.Theprocedurewasexplainedtothepatientsandinformedconsentwasobtained from them prior to obtaining the �inger andpalmprints.Itwasexplainedtothepatient,thatthesolepurposeofprocuringthe�ingerprintswasforacademicpurpose, would not be misused and that thecon�identialitywouldbemaintained.

Inthisstudy45subjectsweredividedintothreegroups;15subjectswithtobaccochewing/smokinghabitswithclinicallydiagnosedpotentiallymalignantdisorderslikeleukoplakia,LichenplanusandOralSubmucous�ibrosis(GroupA).15subjectswithtobaccochewing/smokinghabits and without associated potentially malignantdisorders(GroupB),and15healthycontrolswithoutanyhabit of tobacco chewing or smoking (Group C).Thedigitalandpalmerprintsofindividualswithhistoryoftobacco-relatedhabits(smoking/smokeless),pan,betelnut chewing and a l coho l consumpt ion wi thpremalignant disorders (Group A), individuals withhistoryoftobacco-relatedhabits(smoking/smokeless),pan,betelnutchewingandalcoholconsumptionwithoutpotentiallymalignantdisorders(GroupB)andhealthynormal individuals who were age and sex matchedwithout any tobacco-related habits (Group C), weretaken for the study. Subjectswithother causesoforal

lesions like cavities, sharp tooth irritation, dentures,aphthousulcers,etc.,anddermatologicaldiseaseswereexcludedfromthisstudy.

Theindividualstakenforinstudywerebetween20and65years.13werefemalesand32weremales.Amongthese5femalesand10maleswereincludedinGroupA;3femalesand12maleswereincludedinGroupBand10malesand5femaleswereincludedinGroupC.ThestudyGroupAincludedindividualswithclinicallydiagnosedcasesofLeukoplakia(5Cases),LichenPlanus(5Cases),Oral Submucous �ibrosis (5 Cases). A detailed casehistorywasrecordedandclinicaldiagnosiswasmadeinpatients who showed characteristic clinical featuresconsistentwiththediagnosisoforalleucoplakia,lichenPlanusandOralSubmucousFibrosis,andthe �indingswererecordedinthecasehistoryproforma.

The digital and palmer prints were obtained by thestandard India ink method. The armamentariumcomprisedstandardink,whitepaper,magnifying lens,protractor, scale and pencil. Hands were thoroughlywashed with soap and water before taking prints toremovesoil,oilanddirt,sweatfromtheskintoenhancethe quality of dermatoglyphic prints followed by air-drying.Thenrequisiteamountofinkwasplacedonthepalms. The ink was evenly spread on the palms and�ingers.To take thepalmprint, thepalmwaskeptonwhitepaperand�irmpressurewasgivenonthecenterofthe dorsum of hand and interdigital areas. For �ingerprintstheywereplacedonawhitepaperwithonelateraledge and then rolled over in the opposite direction.Thesedermatoglyphicpatternswerethenanalysedwithamagnifyinglens.Thepatternsofthethreegroupswereanalysed by examiner trained for analysing thedermatoglyphic patterns and these prints were re-analysedbytheotherexaminerafter2days.

According to Galton's Classi�ication Fingertip print5patterns wereclassi�iedintoarches(A),Loops(L)and

Whorls(W)[Fig-1].Patternsonallthe10�ingersonboththehandswereanalyzed.Ineverysubject,thefrequencyof each pattern was recorded and the percentage ofpatternfrequencywascalculatedfortheentiregroup.Palmerpatternswereobservedinthehypothenar(Hy),thenar,interdigitalareas1,2,3and4(I1,I2,I3,I4)[Fig-2]. Various patterns encountered in both handswerenoted.Thefrequencyofpalmarpatternswascalculatedinbothhandsseparatelyandacomparisonwasmadebetweenthestudygroups.


3

Figure 1: Digital Dermatoglyphic patterns

Figure 2: Palmer dermatoglyphic patterns

Figure3:LichenPlanusaffectingbuccalmucosaandtongue

Figure4:OralSubmucous�ibrosisaffectingbuccalmucosaanduvula,palate

Figure5:Leukoplakiaaffectingbuccalmucosa

Figure 6: Digital Dermatoglyphic Print

Figure 7: Palmer Dermatoglyphic Print

Statistical analysisStatistical analysis was done using SPSS version 20software. Forqualitative analysis, Chi-square testwasusedto�indtheP values.Forquantitativeanalysis,meanandstandarddeviationswereestimatedinthesamplefor each study group. P < 0.05 was consideredstatisticallysigni�icant.


4

Group I Group II Group III

Hypothenar

loop

right

13.3 20.0 31.3

left

13.3 26.7 31.3

Whorl

right

0 0 0

left

0 0 0

arch

right

86.7 80.0 68.8

left

86.7 73.3 68.8

Thenar

loop

right

6.7 0 6.3

left

6.7 20.0 25.0

Whorl

right

0 20.0 43.8

left

0 0 0

arch

right

93.3 80.0 50.0

left

93.3 0 56.3

I1

loop

right 13.3 13.3 12.5

left 20.0 0 31.3

Whorl

right 0 0 0

left 0 0 0

arch

right 86.7 86.7 87.5

left 80.0 100 68.8

I2

loop

right 20.0 13.3 100

left 20.0 46.7 100

Whorl

right 0 0 0

left 0 0 0

arch

right 80.0 86.7 0

left 80.0 53.3 0

Table 1: Percentage of Digital Dermatoglyphic patterns in group wise

Group I Group II Group III

Little finger

loop

right

93.3 33.3 50.0

left

80.0 0 43.8

Whorl

right

0 66.7 50.0

left

20.0 100 37.5

arch

right

6.7 0 0

left

0 0 18.8

Ring finger

loop

right

60.0 73.3 68.8

left

66.7 73.3 68.8

Whorl

right

40.0 26.7 31.3

left

33.3 13.3 18.8

arch

right

0 0 0

left

0 13.3 12.5

Middle finger

loop

right

100 26.7 50.0

left 80.0 46.7 50.0

Whorl

right 0 60.0 43.8

left 6.7 40.0 50.0

arch

right 0 13.3 6.3

left 13.3 13.3 0

Index finer

loop

right 60.0 13.3 12.5

left 60.0 60.0 18.8

Whorl

right 20.0 60.0 50.0

left 20.0 26.7 12.5

arch

right 20.0 26.7 37.5

left 20.0 13.3 68.8

Thumb loop

right 86.7 0 18.8

left

73.3 0 0

Whorl

right

13.3 0 0

left

20.0 0 0

arch

right 0 100 81.3

left 6.7 100 0

Table 2: Percentage of Palmer Dermatoglyphic patterns group wise

I3

loop

right

60.0 66.7 43.8

left

60.0 33.3 62.5

Whorl

right

6.7 0 0

left

0 0 0

arch

right

33.3 33.3 56.3

left

40.0 66.7 37.5

I4

loop

right 60.0 53.3 50.0

left 60.0 53.3 0

Whorl

right 0 46.7 50.0

left 0 6.7 12.5

arch

right 40.0 0 0

left 40.0 40.0 87.5

Group 1 Group 2 Group 3

Loops

76

32.6

38.1

Whorls

17.3

36

29.3

Arches 6.6 28 22.5

Group 1 Group 2 Group 3

Loop

29.4

28.8

41.1

Whorl

0.5

6.1

8.8

Arch 70 58.3 48.4

Table 3: Average percentage of Digital Dermatoglyphic patterns group wise

Table 4 : Average percentage of Palmer Dermatoglyphic patterns group wise

Graph 1:

Comparative distribution of Digital Dermatoglyphic patterns


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Graph 2:

Comparative distribution of Palmer Dermatoglyphic patterns

RESULTSTable 1: Shows percentage of various digital printpatterns in individuals with habits with potentiallymalignantdisorders(Group1),individualswithhabitsandwithoutassociatedpotentiallymalignantdisorders(Group2)andhealthycontrolswithouthabits(Group3).

WhenthepercentageofvariousDigitaldermatoglyphicpatternsinGroup1wasstudied, itwasobservedthat76%hadloopspattern,17.3%hadwhorlspatternand6.6%hadarchespattern.InGroup2wasobservedthat32.6% persons had loops pattern, 36% persons hadwhor l s pa t te rn and 28% persons had a rchdermatoglyphicpatterns.InGroup3wasobservedthat38.1%personshadloopspattern,29.3%personshadwhorlspatternand22.5%personshadarchpattern.

Whenthepercentageofvariouspalmerdermatoglyphicpatterns in group 1was studied, itwas observed that29.4% had loops pattern, 0.5 % had whorl patternand70%hadarchespattern. InGroup2wasobservedthat28.8%personshad loopspattern,6.1%personshad whorls pattern and 58.3% persons had archesdermatoglyphicpatterns.InGroup3wasobservedthat41.1%personshadloopspattern,8.8%personshadwhorlspatternand48.4%personshadarchespattern.

Insubjectswithtobaccochewing/smokinghabitsandLeukoplakia,LichenPlanusorOralSubmucous�ibrosistherewas an increased frequencyof loops andwhorldigital dermatoglyphic pattern whereas in tobaccochewing/smokinghabitswithoutassociatedpotentiallymalignantdiseases persons had whorl and loop

dermatoglyphicpatternandincontrolgrouptherewasan increased frequency of loop and arch digitaldermatoglyphic pattern. Intergroup comparisonshowed signi�icant difference of the dermatoglyphicpattern.Pvaluewaslessthan0.05,whichisstatisticallysigni�icant.

Insubjectswithtobaccochewing/smokinghabitsandLeukoplakia,LichenPlanusorOralSubmucous�ibrosistherewasan increasedfrequencyofarchesandloopspalmer dermatoglyphic pattern whereas in tobaccochewing/smoking habits and without associatedpotentiallymalignantdiseasespersonshadarchesandloops palmer dermatoglyphic pattern and in controlgrouptherewasanincreasedfrequencyofarchesandloops palmer dermatoglyphic pattern. The palmerdermatoglyphic pattern between the 3 groups wasstatisticallysigni�icant(P≤0.05).

DiscussionDermatoglyphics are formed due to multifactorialreasons. A large number of genes interplay withenvironmental in�luences in forming these distinctdermatoglyphic patterns. The pattern remainsunchangedthroughoutlifeexceptforanincreaseinsizewithgeneralgrowth.Theuniquenessofdermatoglyphicpatternshasbeenutilizedasapersonalidenti�icationbylaw enforcement of�icials during the past century.Widespread medical interest in epidermal ridgesdevelopedaftertheobservationofcorrelationbetweenthe chromosomal aberrations and unusual ridge

7patterns.

Leukoplakia is the most commonly diagnosedpotentiallymalignantorallesionintheoralcavityandthese lesions are associatedwith the development oforalsquamouscellcarcinoma.Oralcarcinomasareoneofthecommonmalignanciesoccurringintheworld.IntheSouth-EastAsianregion,cancersofthemouthandoropharynx are the second leading cause of cancerdeaths according to reports from the World Health

6Organization(WHO). Consideringthehighprevalenceof oral premalignant disorders in our geographicalregion and also relatively low availability of non-invasivetechniquesforprimaryscreeningofthesame,dermatoglyphic patterns assessment in patients withthesedisordersmaygiveanunderstandingwhetherifanycorrelationexistsbetweenthemandpositivedigitalandpalmerdermatoglyphicpatterns.Hence,thisstudyon dermatoglyphic patterns provides a simple,inexpensivemeansofinformationabouttheprevalence


4

and type in various PMDs and may prove to be apredictivefactorfororalcancer.

Inexaminingdermatoglyphicsinpotentiallymalignantdisorder patients, in general, one of the studies hadnoted that patients with OSMF and OSCC had anincreasedfrequencyofloopswhencomparedwiththatof controls who had whorls as the most frequent

6pattern; but in thisstudy Group 1 patients hadmorepercentage (76%) of loop digital dermatoglyphicpattern compared to the patients with habits andwithout PMDs (32.6%) and control group (38.8%)(Group3).Anotherstudyfoundanincreasedproportionofulnarloopsincancerpatients.Substantialevidencealsosuggeststhatthecarcinogenicprocessisdrivenbythe interaction between exposure to exogenouscarcinogens and an inherent genetic susceptibility. Inresponse toenvironmentalexposures,geneticdamageaccumulatesmore quickly in individualswith geneticsusceptibilitytoDNAdamagethaninthosewithoutsuchinstability butwith a similar exposure. Consequently,individualswithgeneticinstabilitymightbeatagreater

8riskfordevelopingtheselesions.

Nosigni�icantdifferenceswerepresent inhypothenarpattern, thenar, I1, I3 area pattern, when comparedamongall three groupson right and left palmsandasigni�icantdifferencewaspresentinI2,I4areapattern,when compared among all three groups. However,accordingtoGuptaet al.andGanvirandGajbhiyestudiesthere were no signi�icant difference in hypothenar,

6t henar a rea pa t te rn among s tudy g roups .Epidemiologicalstudiesindicatearelationshipbetweentobacco and the development of various potentiallymalignantdisordersandmalignantdisorders,however,only a fraction of people exposed to tobacco developsuchlesions.Geneticallydetermineddifferencesamong

8,9individualsexplainthissusceptibility.

ConclusionThecurrentstudyopensneweravenuesinthe�ieldofdentistry as it holds de�inite potential to diagnosepotentiallymalignantdiseasesandatanearlystageinacost-effective manner. The results of this study havefurther added to the exist ing importance ofdermatoglyphics. As PMDs and OSCC have a geneticbasis,withtheknowledgeofdermatoglyphicpatterns,individualswhoarepronetodeveloptheselesionscanavoid the triggering factors. The relevance ofdermatoglyphicsisnotfordiagnosis,butforprevention,

bypredictingadisease,andnotforde�ininganexistingdisease,butforidenti�icationofpeoplewiththegeneticpredispositiontodevelopcertaindiseases.

References1. DeepaJatti,YashodaDeviBhoomareddyKantraj,

Rakesh Nagaraju. Role of dermatoglyphics inmalignantandpotentiallymalignantdisordersoftheoralCavity:Across-sectionalstudy.JournalofIndian Academy of Oral Medicine & Radiology2014:26(4);379-384.

2. L a k shmana , e t a l . D i g i t a l a nd p a lma rdermatoglyphics in early detection of oralpremalignantandmalignantlesions,AdvancesinHumanBiology2016:6(3);136-142.

3. NeeravDutta,RakshithShetty,VijayendraPandey,SunilKumarNayak,NehalRathore.ComparisonofFingerPrintPatternsinPatientswithandwithoutOral Submucous Fibrosis - A DermatoglyphicsStudy. International Journal of ContemporaryMedicalResearch2016:3(4);1172-73.

4. ShettyP,ShamalaA,MuraliR,YalamalliM,KumarAV.Dermatoglyphicsasageneticmarkerfororalsubmucous �ibrosis: A cross-sectional study. JIndianAssocPublicHealthDent2016:14;41-5.

5. AmitaAditya,SwarupaGaikwad,DayaKJangam,Vineet Vinay, Shruti Joshi, Swanandi Gaikwad.AnalysisofFingerPrintsPatterninPatientswithPotentially Malignant Disorders: A Cross-SectionalStudy.2016:IOSRJournalofDentalandMedicalSciences (IOSR-JDM)2016;15(11):121-124.

6. G Vinothini, Ramasamy Sarvathikari, SakthivelSambasivam, JVenkatesh, JohnHeartyDeepak, JNandhini. Evaluating the Relation betweenPalmar Detmatoglyphics with SubmucousFibrosisandSquamousCellCarcinomaoftheOralCavity, International JournalofAdvancedHealthSciences2017:4(1);1-7.

7. LakshmanaN,AbhishekSinghNayyar,RavikiranA,Samatha Y, Vamsi Pavani B, Kartheeki B.Dermatoglyphics:Revivalinoralpre-cancersandcancers,areview,CHRISMEDJournalofHealthandResearch2017:4(1);1-4.

8. Patil PB, Reddy JJ, Joshi V, KumarKR, ShilpaRT,SatyanarayanaP.Dermatoglyphicsinpatientswithoral potentially malignant diseases and oralcancer. J IndianAcadOralMedRadiol2017:29;191-4.


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9. Geetanjali Darna et al. “Unraveling the myth-dermatoglyphics in oral potentially malignantdisorders”. International Journal of currentResearch,2018:10(2),65741-65746.

Corresponding Author:Dr.P.SureshKumar.ReaderDepartment of Oral Medicine and Radiology, GITAMDental College andHospital, Visakhapatnam,AndhraPradesh.


4

1 2 3 4 5 6 7Authors : Dr. Jerin Varghese George , Dr. Suma .T , Dr. Rajkumar. S. Alle , Dr. Lokesh . N.K , Dr. Shwetha G.S , Dr. Kiran.H , Dr. Dharmesh H.S

A New Diagnostic Tenet For The Esthetic Midface Clinical Assessment OfAnterior Malar Projection

Abstract

AIM AND OBJECTIVES:Arnett'sfacialanalysisiscurrentlyusedforsofttissueanalysisbutitisdesignedforsurgical

treatmentplanningbutlacksclinicalconvenience.Thereisashortageofdiagnosticcriteriainorthodonticliterature

pertainingtomidfaceanalysisdespitetheroleofmidfaceinfacialesthetics.Thereforethisstudyhopestocreateanew

diagnostic tenet for the estheticmidface by seeking to determinewhether visual classi�ication of anteriormalar

projectionusingvectorrelationshipsissupportedbycephalometricanalysis.

METHODOLOGY: 60subjectsbetweentheagegroupof15-21yearswereselectedbasedonthevisualassessmentof

malargloberelationship.Theywerefurtherdividedinto3groups,GroupA,GroupBandGroupChaving10malesand

10femaleseachandshowingneutral,negativeandpositivevectorrelationshiprespectively.LateralCephalogram's

weretakenoftheselectedsubjectsandtraceddigitallyusingDolphincephalometricsoftware.TheSNO(Sella-Nasion-

Orbitale)anglewastracedandcomparedwiththevectorrelationshipphotographs.Thestatisticalanalysiswasdone

usingANOVAandStudentsunpairedttest.

RESULTS: Thetestshowedthattherewasastatisticalsigni�icancebetweenthethreegroups(P<0.001%)withmean

valuesof54.1°fortheneutralgroup,60.7°forthepositiveand48.9°forthenegativegroup.Theresultsshowedthat

there was a statistically signi�icant difference between the three groups and that the neutral value of SNOwas

statisticallydifferentformalesandfemales.

CONCLUSION: Visual vector relationship is an effective clinical assessmentof anteriormalarprojection and it is

supportedbycephalometricanalysis.

Keywords: Softtissuediagnosis;Midfaceesthetics;Malarprojection.

IntroductionInOrthodontics,thereisashortageofdiagnosticcriteriadespite the role of the midface in facial esthetics.Arnett's facial analysis currently offers the mostcomprehensivesoft tissueanalysis inboththe frontal

Dr.JerinVargheseGeorgePostgraduatestudentDepartmentoforthodonticsanddentofacialorthopaedicsRajarajeshwariDentalcollegeandhospital

Dr.Suma.TProfessorDepartmentoforthodonticsanddentofacialorthopaedicsRajarajeshwariDentalcollegeandhospital

Dr.Rajkumar.S.AlleProfessorandHODDepartmentoforthodonticsanddentofacialorthopaedicsRajarajeshwariDentalcollegeandhospital

Dr.Lokesh.N.KReaderDepartmentoforthodonticsanddentofacialorthopaedicsRajarajeshwariDentalcollegeandhospital

Dr.ShwethaG.SProfessorDepartmentoforthodonticsanddentofacialorthopaedicsRajarajeshwariDentalcollegeandhospital

Dr.Kiran.HReaderDepartmentoforthodonticsanddentofacialorthopaedicsRajarajeshwariDentalcollegeandhospital

Dr.DharmeshH.SReaderDepartmentoforthodonticsanddentofacialorthopaedicsRajarajeshwariDentalcollegeandhospital

and sagittal planes, and he was the �irst author to1systemizesuchanapproach.

Arnett and Bergman presented the Facial Keys toOrthodontic Diagnosis and Treatment Planning as a

3

three-dimensional clinical blueprint for soft tissue2

analysisandtreatmentplanning. However,thisanalysisis designed for surgical treatment planning but lacks

3,4clinicalconvenience.

Extensiverecordsmustbetakentoevaluatemaxillarysofttissuepointsrelativetotruevertical,andthereareno readily available instruments formaking accurate,reproduc ib l e measurements o f o rb i t a l r im

5relationships. Additionally, skeletal structures of themid-face have been notoriously dif�icult to assess inlateralcephalograms,andthishasledorthodontiststofocus entirely on the pre-maxilla for classi�ication of

6maxillary skeletal development. As a result, regionaldisharmoniesintheanatomyofthemaxillahavebeenneglectedandclinicalunderstandingofthemidfacehas

7developedintotheuseofsubjectivedescriptors.

Concavefacesoftenareconsideredlessattractivethanconvex faces. The lesser mid-face skeletal projectionintrinsic to concave faces poorly supports the softtissues, resulting in premature lower lid and cheek

8descentaswellasvisiblebags.

Less severe mid-face hypoplasia is a common facialskeletal variant. In patients with this morphologyocclusion is normal or has been compensated byorthodontics.Theyhaveneitherrespiratorynorocularcompromise. It is in this population that mid-faceskeletal augmentation with multiple implants cansimulate the visual effects of skeletal osteotomy and

9advancement. Theimplantsusedtoeffectthesechangesinclude those that augment the infra-orbital rim, the

10,11piriform aperture, and the malar area. In a youngadult, the ideal projection of the cheek prominenceshould be approximately 2mm beyond the anteriorsurface of the cornea in the sagittal plane along theFrankfurthorizontal.Maxillaryhypoplasiainthisregionproduceswhat iscalledanegativevectorrelationshipwith the globe positioned anterior to the malar

12eminence.

Hinckley reported that the Class I male had a largermalarprominencethantheClassIIImale.TheClassIandClass III femaleshadsimilarprominenceof themalarcomplex, but the anterior component of the Class IIIfemale's malar complex was more posteriorlypositioned. The Class I male and Class I female hadsimilarsizeandpositionofthemalarcomplex.TheClass

IIImale'smalarcomplexwaslarger,positionedfurtherlaterallyandelongatedmoreanteriorlycomparedtothefemaleClassIII.Nodifferencewasfoundintheshapeof

13,14themalarprominences.

Additionally,recentscienti�icevaluationsoftheeffectsofbone-anchoredmaxillaryprotraction(BAMP)onthemalareminencesuggest thatanegativevectorcanbeviewedasanindicatorinskeletaldysplasias,whichmay

15,16,bene�itfromBAMPtherapyintheadolescentpatient.17

Hence, this study seeks to determine whether visualclassi�icationofanteriormalarprojectionusingvectorrelationshipsissupportedbycephalometricanalysis.Inotherwords,thisstudytriestoevaluatethevalidityofvector relationships as a means of diagnosing anddescribinganteriormalarprojectionandesthetics.

Materials And MethodsPretreatmentpro�ilephotographswere takenand therelationshipoftheanteriorcheekmasstotheanteriorcorneal plane were used as a guideline for vectorrelationship. Determination of each subject‟s vectorrelationship were made by one operator using onlypretreatment pro�ile photographs from the patient‟sinitialrecords.

Pre-treatment lateral cephalogram's were taken andtheywereusedtoevaluatetheanteroposteriorpositionofthemalareminenceinrelationtothecranialbase.Thefollowinglandmarkswereused.

TheSella,thenasionandtheorbitale.1. Sella:Thisisthepointrepresentingthemidpointof

thepituitoryfossa(SellaTursica).(�ig1)2. Nasion:Thepointofdeepestconcavityofthesoft

tissuecontouroftherootofthenose.(�ig1)3. Orbitale:Thelowestpointintheinferiormarginof

the orbit, midpoint between right and leftimages.(�ig1)

Fig1:SNO


4

The cephalometric pointswhich are sella, nasion ando r b i t a l e w e r e t r a c e d o n d i g i t a l t r a c i n g susingdolphinimagingsoftware.Theangleformedbythethreepoints(SNO)weremeasured.

Cephalometric AnalysisIn order toquantify skeletal support for each subject,sella-nasion-orbitale (SNO) angulations were used toevaluate the antero-posterior position of the malareminencerelativetothecranialbase.AllcephalogramsweredigitallytracedbyoneexaminerusingDolphin‟sImaging Software. Cephalograms were traced by theexaminerthreetimeswithaminimumof2daysbetweentracings.

Prior to thecephalometricanalysis,15randomlateralcephalogramsfromsubjectsinthestudywereselected,andSNOanglesweretracedandmeasuredattwotimeswithin a week by the same operator. The intraclasscorrelation coef�icients indicated excellent intra-observer agreement for SNOmeasurements using thespeci�iccriteriaforlandmarkidenti�ication.

Recording Of The DataEach Pre-treatment pro�ile photographsweremarkedusingMicrosoftPower-pointsoftware.

EachlateralcephalogramweredigitallytracedbyusingDolphincephalometricsoftware.

ResultsThefollowingtestswereusedforStatisticalanalysis.1. Student‟sunpaired t testwereused to compare

t h e g e n d e r d i ff e r e n c e s b e twe en SNOmeasurementsforgroupA,groupBandgroupC.

2. ANOVA testwasused to compare thedifferencebetween the three groups. The following SNOanglevalueswerefoundfromthecephalometricanalysis and visual assessment of the neutralgroup.(TableIandII)

Genderw i se compar i son o f mean obse rvedcephalometric values in the neutral group werecompared and in this group, themean observed SNOvalueis53.89°(52.8°-57.2°)forfemalesand55.6°(53°-56°) formalesrespectively.Thisshowedastatisticallysigni�icantdifference(P<0.0005*)betweenthevalues.Thedifferencefoundwasabout2°.Thisshowedthattheaverage SNO value would change according to thegender.


3

ThefollowingSNOanglevalueswereobservedfromthepositivevectorgroup.

AcomparisonofmeanobservedvaluesindifferentstudyvectorgroupsusingANOVAtestwasconducted.Thetestshowedthattherewasastatisticalsigni�icancebetweenthethreegroups(P<0.001%)withmeanvaluesof54.1fortheneutralgroup,60.7forthepositiveand48.9forthenegativegroup.

Discussion:Oneoftheprimarygoalsoforthodontictreatmentistoattain and preserve optimal facial attractiveness. Toaccomplish this, it is important that the orthodontistconduct a thorough facial examination so that theorthodontic correction will not adversely affect thenormal facial traits.Treatment planning of facialattractivenessisdif�icult,especiallywhenthe2goalsofattractiveness and bite correction are combined.Unfortunately, bite correctiondoesnot always lead tocorrection, or even maintenance, of facial traits.Sometimes the orthodontist‟s zeal to correct the bitemay even result in a decrease of facial attractiveness.This result, when it occurs, may be due to a lack ofattention to facial esthetics or simply a lack of

2,3,4understandingofwhatisdesirableasanestheticgoal.

Whatreallydeterminesaperson‟sattractivenessistheskeletalmassoftheface.Threepromontoriesdeterminefacialfeatures:thenose,thetwomalareminences,andthechin.Thestrengthofthemassandthevolumethatare characteristic of each promontory affects theirrelative balance with each other. Balance in bonestructureiswhatgivestheformofthefaceitsmaximum

18,31attractivenesscalled“beauty”.

Thecheekbonecontourischaracterizedbyacurvedlinethatstartsatapointjustanteriortotheearandextendsanterior-inferiorly, endingadjacent to thealarbaseofthe nose. For descriptive purposes, it is divided intothreeareas:1)thezygomaticarch,2)themiddlecontourarea, and 3) the subpupillary area. In normoskeletalpatients, the cheek bone - nasal base - lip contourcomplex formsasmoothcontinuous,anteriorly facingcurved line.31 Augmentation has been proposed toimprove the appearance of patientswith a �latmalareminence, to create a more youthful-looking face, to


4

makethefacemoreoval,andtodeemphasizeprominent18nasalormentalpro�iles.

Cephalometricshasconcerneditselfwiththestudyoftherelationshipofthemaxillatothecranialbase(SNAangle)aswellastherelationshipofthemandibletothecranialbase(SNBangle),andtherelationofthemandibletothe

21maxilla (ANB angle). The malar eminence not onlyaffordsprotectiontotheorbitlaterallybutcosmeticallyis the"highpoint"of the face,high"cheekbones"beingregarded as esthetically pleasing. The lateralcephalometric radiograph does not show the malareminencebutitis,infact,alwayslateralandinferiorto

29theorbitale. Thus,ifthepositionoforbitalewasknowninrelationtonasionandApoint,thiswould,ineffect,tellustherelationshipofthemalareminencetotheselatter

.14positions

Relying on cephalometric dentoskeletal analysis fortreatment planning can sometimes lead to estheticproblems, especially when the orthodontist tries topredictsofttissueoutcomeusingonlyhardtissuenormalvalues.Toaccuratelypredictsofttissueresponsetohard-tissue changes, theorthodontistmustunderstand softtissuebehaviorinrelationtoorthopedicandorthodonticchangesandmustalso take intoconsiderationgrowth

2anddevelopmentofsofttissuetraits.

This study sought to evaluate the validity of vectorrelationshipsasameansofdiagnosinganddescribinganterior malar projection and esthetics. The visualclassi�icationco-relateswiththecephalometric�indings.These�indingssuggestthatvectorrelationshipsareaneffective means of classifying anterior malar supportduringmacro-esthetic evaluation of the patient.Widevariationinlandmarkidenti�icationoforbitalehasbeenobserved in the past; however, using the protocolsoutlinedinthisstudy,excellentintraobserveragreement

5wasattainedforSNOmeasurements.

A positive vector relationship has been identi�ied inanthropometricstudiesasanimportantelementoftheyouthful face and malar complex, and should be

8consideredtheestheticideal. However,estheticnormsare not a substitute for good artistic judgment, andnaturally,careshouldbeexercisedinapplyingguidelinestoorigidlyacrossdifferentracialbackgrounds.Youthful,estheticfacialcontoursrequiresuf�icientmaturationandgrowthofbothhardandsofttissues,andalthoughorbitaland malar retrusion are often associated with

33craniofacialsyndromes , lessseverehypoplasiaof the8

mid-faceisacommonfacialskeletalvariant.

Consequently,greaterattentionmustbepaidtoregionalhypoplasias within the maxilla, including thosepresenting in the absence of malocclusion. De�icientmalarandmid-facialprojection leaves thesoft tissuespoorlysupported,resultinginprematurelowerlidandcheekdescentaswellasvisiblebags,scleralshow,andamoreagedappearance.8

Inthisstudy,itwasfoundthattherewasastatisticallysigni�icantgenderdifferenceintheneutralgroup.ThisprovesthatthenormalmeanvalueofSNOanglewhichis54°wouldchangeaccordingtothegender.

Additionally,recentscienti�icevaluationsoftheeffectsofbone-anchored maxillary protraction (BAMP) on themalareminence suggest that anegativevector canbeviewedasanindicatorofskeletaldysplasias,whichmaybene�itfromBAMPtherapyintheadolescentpatient.

16,17Furtherinvestigationisindicated.

Intheyoungagegroup,wecanidentifymalarretrusionregardingthevectorselectionsS,NandO.Comparisonofangular measurements for SNO from positive vectorgroup and negative vector group showed retrusion ofmalareminenceby12°insubjectswithnegativevectorgroup.

Innegativevectorgroup,onclinicalexaminationalongwith the other classical features such as scleral show,dished-inappearanceandagedappearance,thisvectorrelationship canbeusedas an indicationofmaxillary

8hypoplasia.

Using vector relationships as part of a dento-facialanalysis provides the orthodontist with a convenientmeansofclassifyingmalarsupporttothemid-faceandwillhelptobetterinformtreatmentdecisions.

Conclusion:Thefollowingconclusionsweredrawnfromthestudy:· Visual vector relationship is an effective clinical

assessmentofanteriormalarprojectionand it issupportedbycephalometricanalysis.

· There was a statistically signi�icant genderdifference in the neutral group and hence thenormalmeanvalueofSNOwouldchangeaccordingtogender.


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· There was no statistically signi�icant sexualdimorphism between the positive or negativevectorgroups.

But furtherradiographicexaminationsarerequired toevaluate the extent of malar de�iciency mainly whensurgicalcorrectionofthedefectisplanned.Visualvectorrelationshipcanonlybeusedasaclinicaldiagnostictoolforgrossassessmentofmalarde�iciency.

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