chapter 3: dental investigations: a collection of case reports422002, india *meenal nitin gulve:...

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Chapter 3: Dental Investigations: A Collection Of Case Reports

6 CE Hours

Edited by: Elite Staff

This is a collection of public domain case reports obtained from the National Library of Medicine (NLM). Each report lists original authors, copyright information, and references cited. Elite Professional Education, LLC does not endorse or recommend any commercial products, processes, or services. The views and opinions of the authors do not necessarily state or reflect those of Elite Professional Education, LLC, and they may not be used for advertising or product endorsement purposes. These case reports were chosen for this collection because of their informative and interesting content as it applies to general dentistry.

Learning objectives � Define barotrauma. � Describe Boyle’s law and how it affects the air bubbles mixed into

luting cement. � Identify and describe dyskeratosis congenita (DC). � Describe ways to overcome difficulties in making impressions

because of reduced access to the oral cavity. � Describe the presentation and treatment of radicular cysts. � Discuss the use of composite restorations as a tool in forensic

identification.

� Discuss overlay generation methods in bite mark analysis. � Discuss latent lip print development and its role in suspect

identification. � Discuss DNA quantification of acid-immersed teeth. � Describe the use of a pendulum appliance in the non-extraction

treatment of patients. � Discuss the use of electrosurgery as an alternate method to the

traditional scalpel.

Case Rep Dent. 2013; 2013: 749142. Published online 2013 July 28. doi: 10.1155/2013/749142PMCID: PMC3745870

PROvIsIOnAL CROwn DIsLODgEmEnt DuRIng sCubA DIvIng: A CAsE Of bAROtRAumA

Meenal Nitin Gulve and Nitin Dilip GulveCopyright © 2013 M. N. Gulve and N. D. Gulve.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1Department of Conservative Dentistry and Endodontics, M.G.V.’s K.B.H. Dental College and Hospital, Mumbai Agra Road, Panchavati,

Nashik 422002, India

2Department of Orthodontics, Dentofacial Orthopedics and Dental Materials, M.G.V.’s K.B.H. Dental College and Hospital, Nashik

422002, India

*Meenal Nitin Gulve: Email: [email protected]

Academic Editors: D. W. Boston and T. Lombardi

AbstractChanges in ambient pressure, for example, during flying, diving, or hyperbaric oxygen therapy, can lead to barotrauma. Although it may seem that this issue was neglected in dental education and research in recent decades, familiarity with and understanding of these facts may be of importance for dental practitioners. We report the case of a patient who experienced barotrauma involving dislodgement of a

provisional crown during scuba diving. Patients who are exposed to pressure changes as a part of their jobs or hobbies and their dentists should know the causes of barotrauma. In addition, the clinician must be aware of the possible influence of pressure changes on the retention of dental components.

Dental.EliteCME.com Page 50

1. IntroductionIn recent years it has become increasingly common to go to a tropical destination for a vacation [1]. There is often an opportunity to dive. Diving with self-contained underwater breathing apparatus (SCUBA) has witnessed explosive growth in the past decade, as 8.5 million people are certified in the United States alone. Around 3 million Europeans are thought to be recreational scuba divers, diving to depths up to around 40 meters sea water (msw). Additionally, there are approximately 800 professional civilians and 700 military divers registered in Germany as well as some 500 compressed air (caisson) workers, for example, for tunnel or bridge construction work [2]. With the increasing number of professional and leisure divers, the dentist may encounter related oral conditions that require immediate treatment. Although rare, dental emergencies while diving have been recognized as a potential cause of a diver suddenly becoming incapacitated, jeopardizing the safety of the affected person as well as others [3]. It is inevitable that the dental practitioner will have patients who participate in diving, and they should be aware of a number of problems that a diver can experience that are associated with the teeth and related structures.

An oral (dental or nondental) pain caused by change in barometric pressure in an otherwise asymptomatic organ is known as barodontalgia. The name of this dental pain was given the prefix “aero” (i.e., aerodontalgia) and was reported for the first time as an in-flight physiologic and pathologic phenomenon at the beginning of the 20th century. In the 1940s, with the appearance of SCUBA, many in-flight manifestations caused by barometric changes were found to be associated with diving as well. Consequently, the prefix was changed to “baro” [4, 5]. Barodontalgia has been experienced on one or more occasions by 9.2 percent to 21.6 percent of American and Australian civilian scuba divers. Among military divers, an incidence of 17.3 percent was reported [6]. Barotrauma is defined as pressure-induced damage that can occur both in high and low pressure [4]. Dental barotrauma can manifest itself as tooth fracture [7], restoration fracture, and dislodgement of the restoration [7, 8].

In this paper, we present a case in which a patient experienced barotrauma involving a provisional crown while diving.

2. Diagnosis and treatmentA 25-year-old man presented with a chief complaint of spontaneous pain on the left side of his face for the past three days. History revealed intermittent pain to hot and cold stimuli for the past one month. The medical history was noncontributory. Clinical examination revealed an amalgam restoration with secondary caries in the maxillary left first molar (Figure 1). The tooth was tender to vertical percussion. Tooth mobility was within physiologic limit, and the gingival attachment apparatus was normal. Vitality testing of the involved tooth with heated gutta-percha and dry ice caused an intense lingering pain, whereas electric pulp stimulation caused a premature response. The preoperative radiographic evaluation showed evidence of radiolucent area in relation to the maxillary left first molar approaching the pulp space with periodontal ligament space widening in relation to the mesial root (Figure 2). A diagnosis of symptomatic irreversible pulpitis with symptomatic apical periodontitis was made, and endodontic treatment was suggested to the patient.

Figure 1: Amalgam restoration with secondary caries in the maxillary left first molar.

Figure 2: Radiolucent area approaching the pulp space with periodontal ligament space widening.

Informed consent was taken. The tooth was anesthetized by using 1.8 mL 2 percent lignocaine containing 1 : 200,000 epinephrine. Endodontic treatment was completed, and the tooth was then restored with a posterior composite resin core (Figure 3).

Figure 3: The tooth was restored with a posterior composite resin.

The tooth was prepared one week after endodontic treatment to receive a metal-ceramic crown in a conventional manner with the aim of obtaining a 6-degree convergence between walls (Figure 4). Gingival displacement was done, and two impressions were made: an alginate impression to prepare a provisional crown and another with hydrophilic polyvinyl siloxane impression material to prepare a metal-

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ceramic crown, poured using type IV dental stone. The shade was determined with a shade guide. The patient was given a provisional crown, which was made from a bis-acryl material and was cemented with zinc phosphate cement (Figure 5). Excess cement was removed with a scalpel. The patient was recalled after seven days to receive the final crown.

Figure 4: The tooth was prepared to receive metal-ceramic crown.

Figure 5: Provisional crown cemented with zinc phosphate cement.

However, the patient presented with dislodged provisional crown (Figure 6). He gave a history of scuba diving at a destination where he went for a previously unplanned vacation. He reported that the provisional crown came out while he was diving at about 27 to 35 meters deep. After the crown dislodged, he had to keep it under

his tongue until he returned to the surface to avoid aspiration or swallowing.

Figure 6: Dislodged provisional crown.

The tooth was cleaned of the temporary cement with a slurry of fine flour of pumice. The metal-ceramic crown was tried in to assess the marginal fit and contacts. The patient previewed and approved the shape and the shade of the crowns. The crown was cemented with self-adhesive resin cement in accordance with the manufacturer’s instructions (Figure 7). Postoperative care instructions were given to the patient and recall appointments were scheduled.

Figure 7: The metal-ceramic crown was cemented with self-adhesive resin cement.

3. DiscussionIn recent years it has become increasingly common to go to a tropical destination for a vacation. There is often an opportunity to dive. Also scuba diving is one of the fastest growing sports in the world [1]. In the case we presented, a leisure diver experienced barotrauma in which a provisional crown was dislodged while he was diving at about 27 to 35 meters deep under the surface of the sea. A diver at 30 m is subjected to four times the pressure encountered on the surface [9]. Although the exact mechanisms of barodontalgia and barotrauma are not known, the air trapped beneath a restoration or an endodontically treated tooth may be a factor [10].

The possible reason for dislodging of a provisional crown cemented with zinc phosphate could be associated Boyle’s law, which states that at a constant temperature, the volume of a gas varies inversely with the surrounding pressure. As pressure increases, the volume of a confined gas decreases. Vice versa, volume increases as pressure decreases [9]. The problem arises when the enclosed spaces containing gases cannot expand or contract to adjust the internal pressure to correspond to the outer pressure. During the mixing process of luting cement, air may become incorporated into the mixture, forming voids [11]. The expansion or contraction of these microbubbles during pressure cycling, which eventually led to disruption and weakening of the cement layer, could affect the retention [12]. Davidson et al. [13] found that microcracks appear as a result of volumetric contraction in luting cements and, when subjected to the pressure cycling, may have

produced tensile stresses that exceeded the cohesive and adhesive strength of the material, resulting in the significant reduction in tensile bond strength.

Lyons et al. [12] studied the effect of cycling environmental pressure changes on the retention of crowns on the extracted teeth. The crowns that were cemented with either zinc phosphate or glass ionomer cement had significantly reduced retention (in approximately 90 percent and 50 percent, respectively), whereas crowns that were cemented with resin cement were not subjected to reduced retention after pressure cycling. Moreover, microleakage was detected in the zinc phosphate and glass ionomer cements after pressure cycling, whereas no microleakage was detected in the resin cement. Musajo et al. [9] also reported similar results with crowns cemented with zinc phosphate cement. Gulve et al [14] found that the pullout strength of orthodontic bands cemented with glass ionomer cement is reduced after pressure cycling.

It seems that currently, the incidence of in-flight dental barotrauma is relatively low compared to reported incidences from the first half of the 20th century, owing to the current inside compression of airplane chambers. The pressure inside the chamber fits pressure at altitudes of 5,000 to 10,000 feet, whereas cases of dental barotraumas were reported in pressure at altitudes of 18,000 feet and higher [15]. However, whereas in flight the theoretically possible pressure changes range from 1 atm (at ground level) to 0 atm (at outer space), in diving


the changes are more significant, since each descent of 10 meters (32.8 feet) elevates the pressure by 1 atm. Thus, the barometric changes during diving may be more significant and responsible for more frequent and/or severe related pathogenesis than in-flight barometric changes. However, while aviators are obligated to be examined periodically, it is a rarity among divers [16].

Divers and aircrew medical examiners should recommend their aviator and diver patients to be periodically examined by a dental practitioner

who is familiar with the subject. It is important for a dentist to be aware of the effect of pressure changes on dental components in terms of retentive strength, as danger resulting from dislodgement of component during a dive is obvious.

The dentist should advise patients not to dive while having a provisional crown or temporary cement in the mouth.

ConsentWritten informed consent was obtained from the patient for publication of this paper and accompanying images.

Conflict of interestsThe authors declare that they have no conflicts of interest.

Case Rep Dent. 2013; 2013: 845125. Published online 2013 August 6. doi: 10.1155/2013/845125PMCID: PMC3748431

DyskERAtOsIs COngEnItA: A REPORt Of twO CAsEsAnila Karunakaran, Rathy Ravindran, Mohammed Arshad, M. Kodanda Ram, and M. K. Shruthi LaxmiCopyright © 2013 Anila Karunakaran et al.


1Department of Oral Pathology and Microbiology, Kannur Dental College, Anjarakandy, P.O. Mamba, Kannur 670611, India

2Department of Oral Pathology and Microbiology, Azeezia College of Dental Science & Research, Diamond Hills, Meeyannoor, Kollam

691537, India

3Department of Preventive and Community Dentistry, Kannur Dental College, Anjarakandy, P.O. Mamba, Kannur 670611, India

*Anila Karunakaran: Email: [email protected]

Academic Editors: A. Kasaj, P. Lopez Jornet, and G. Spagnuolo

AbstractOral manifestations play an important role in the diagnosis of many systemic conditions. dyskeratosis congenita (DC) is a rare genodermatosis which exhibits oral leukoplakia, nail dystrophy, and reticular skin pigmentations as its primary features. DC has increased risk of developing constitutional anemias and malignancies, and early

diagnosis enables the patient to be monitored and proper interventional therapy to be instituted. Hence, dentists need to be aware of the various manifestations of this fatal syndrome. Only few cases have been reported on DC in the dental literature. Two cases of DC are reported here with a brief review of the literature.

1. IntroductionDyskeratosis congenita (DC) is a rare inherited bone marrow failure syndrome characterized by the triad of dystrophy of the nails (90 percent), reticular skin pigmentation (90 percent), and oral leukoplakia (80 percent). It is associated with a high risk of developing aplastic anemia, myelodysplastic syndrome, leukemia, and solid tumors. Atresia of the lacrimal ducts may occur causing continuous lacrimation. Patients have very short germline telomeres. Hence, many of the associated symptoms like premature graying are characteristic

of geriatrics and the tissues affected are those with a high cell turnover [17].

In this paper, two cases of DC, both showing oral mucosal changes, are reported.

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2. Case 1Figure 8: Case 1 – clinical picture showing oral leukoplakia, nail dystrophy, and hyperkeratotic pigmented patches on hands and feet.

A girl aged 11 reported with symptoms of burning sensation of the tongue since one year.

The patient showed pallor of the face but vital signs were within normal limits.

She was not exposed to tobacco in any form. There was no family history. Her milestones were normal up to 1 year, after which they slowed down.

Intraorally, the tongue showed an extensive leukoplakia of size 5×7 cm with black pigmentation and well-defined borders (Figure 8). The pigmentation had appeared subsequent to the leukoplakia and slowly increased to the present intensity. No induration was noted.

There was mild dystrophy with splitting of the fingernails since 5 years (Figure 8). Hyperkeratotic and pigmented patches were present on the back, feet, and hands (Figure 8). No soreness or watering of the eyes was noted.

Blood examination showed Hb 6 gm percent, prothrombin time 30 sec, and white blood cell count 6,000 per cu mm, indicating a pancytopenia.

3. Case 2

Figure 9: Case 2—clinical picture showing oral leukoplakia, nail dystrophy, and reticular pigmentation on neck and palm.

A female patient aged 20 presented with complaint of a white patch on the tongue with burning sensation since six months. This was previously diagnosed as lichen planus, and she was put under oral steroids. There was black pigmentation on the white patch which reportedly disappeared after the previous treatment.

Intraoral examination revealed a bald tongue with a leukoplakic patch of size 3×4 cm. The depapillated regions were erythematous (Figure 9).

Patient did not have a history of tobacco usage. No family history was reported.

There was dryness of skin with reticular pigmentation on the sun exposed areas, especially the back and the neck, as well as the palms and soles since three years (Figure 9). She also had brittle and cracked nails which were painful and present for the same period (Figure 9). Occasionally, there was pus discharge from the nails, which had been treated with antibiotics. There was associated sweating of palms and soles of feet. Patient had mild photophobia and epiphora. There was a significant alopecia of scalp over the past year.

Blood picture, however, was satisfactory.

4. Differential diagnosisDifferential diagnosis of the previous cases included Fanconi’s anemia, pachyonychia congenita, white spongy nevus, and graft versus host disease [18].

Biopsy was taken from the skin of the back in both cases and diagnosis of DC was confirmed (Figure 10).

Figure 10: H&E section of the pigmented area of upper back of case 2 showing atrophic epithelium overlying a moderately collagenous connective tissue. Melanocytes present in the dermis. Inflammatory cells are conspicuous by their absence (high power).


5. DiscussionDC was first described by Zinsser in 1910 and later by Engman and by Cole et al., leading to the designation of Zinsser-Engman-Cole syndrome [19]. Hyper- or hypopigmentation of tan-to-gray color, in a mottled or reticulated pattern, presenting as macules and patches is the primary diagnostic feature. Poikilodermatous changes with atrophy and telangiectasia are common. The sun-exposed areas, including the upper trunk, neck, and face, are the most affected areas. Ectodermal abnormalities, such as alopecia of the scalp, eyebrows, and eyelashes; premature graying of the hair; hyperhidrosis; hyperkeratosis of the palms and soles; and adermatoglyphia (loss of dermal ridges on fingers and toes) are noticed [20].

Approximately 90 percent of patients exhibit nail dystrophy. The fingernails are involved prior to toenails in most cases. Nail dystrophy begins with ridging and longitudinal splitting and progresses resulting in small, rudimentary, or absent nails [20].

Mucosal leukoplakia is a pathognomonic feature and occurs in approximately 80 percent of patients. It typically involves the buccal mucosa, tongue, and oropharynx [20]. Leukoplakic areas show an increased risk of malignant transformation and hence require frequent monitoring.

Approximately 90 percent have peripheral cytopenia of one or more lineages. In some cases, this is the initial presentation, with a median age of onset of 10 years. Adverse events include severe bone marrow

failure, myelodysplastic syndrome, acute myeloid leukemia, and solid tumors. Both Fanconi’s anemia and DC are major cancer susceptibility syndromes [21, 22]. Bone marrow failure is a major cause of death, with approximately 70 percent of deaths related to bleeding and opportunistic infections occurring as a result [23].

Pulmonary complications, including pulmonary fibrosis and abnormalities of pulmonary vasculature, are seen in about 80 percent of cases [23].

Patients have an increased prevalence of malignant mucosal neoplasms, particularly squamous cell carcinoma. These often occur within sites of leukoplakia. The prevalence of squamous cell carcinoma of the skin is also increased. Other malignancies reported include Hodgkin’s lymphoma, adenocarcinoma of the gastrointestinal tract, and bronchial and laryngeal carcinoma [18]. Malignancy tends to develop in the third decade of life [22].

The skeletal, gastrointestinal, and genitourinary systems also may be affected.

Female carriers of DC may have subtle clinical features.

To date, mutations in six genes of telomerase and telomere components have been identified in patients with DC [17]. Extreme telomere shortening causes the clinical features of DC. Alterations in posttranslational modification of ribosomal and spliceosomal RNAs may also play a role in the pathogenesis of DC [24].

6. Oral manifestationsThe most common oral changes in DC patients were oral leukoplakia (80 percent of the entire DC population), decreased root/crown ratio (75 percent with sufficient tooth development), and mild taurodontism (57 percent with sufficient tooth development). Multiple permanent teeth with decreased root/crown ratios further suggest DC. Patients

also may have an increased prevalence and severity of periodontal disease [19].

The primary findings of dermal pigmentation, nail dystrophy, and oral leukoplakia are observed in both cases reported here.

7. ConclusionDentists should take care not to overlook DC when they come across leukoplakia in a young individual with no history of tobacco usage. Proper history taking, clinical examination, relevant blood investigations, and biopsy will suffice to diagnose the condition [18].

Prompt referral to the clinician is essential as early treatment and constant monitoring can greatly increase the life expectancy of the patient [23].

Conflict of interestsThe authors declare that they have no conflict of interests.

Authors’ contributionAnila Karunakaran was responsible for concepts, design, the literature search, data acquisition, data analysis, paper preparation, paper editing, and paper review. Rathy Ravindran was responsible for concepts, design, the literature search, data analysis, paper editing, and paper review. Mohammed Arshad was responsible for design, the literature

search, and paper review. M. Kodanda Ram was responsible for the literature search, data acquisition, and paper editing. M. K. Shruthi Laxmi was responsible for the literature search, data acquisition, and paper editing.

Case Rep Dent. 2013; 2013: 275047. Published online 2013 July 24. doi: 10.1155/2013/275047PMCID: PMC3741938

fAbRICAtIOn Of CustOmIzED sECtIOnAL ImPREssIOn tRAys In mAnAgEmEnt Of PAtIEnts wItH LImItED mOutH OPEnIng: A sImPLE AnD unIquE APPROACH

Vamsi Krishna CH, K. Mahendranadh Reddy, Nidhi Gupta, Mahadev Shastry, N. Chandra Sekhar, Venkat Aditya, and G. V. K. Mohan ReddyCopyright © 2013 Vamsi Krishna CH et al.


Department of Prosthodontics, Sri Sai College of Dental Surgery, Kothrepally, Vikarabad 501101, India

*Vamsi Krishna CH:Email: [email protected]

Academic Editors: I. El-Hakim and C. Ledesma-Montes

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AbstractImpression making is not only important but is also the most significant step in the fabrication of any fixed or removable prosthesis. Proper impression making may be hindered by certain pathologic conditions. Reduced mouth opening is one of the common mechanical obstructions for proper orientation of the impression tray in the patient’s mouth. In patients with trismus induced by submucous fibrosis, the procedure may be even more difficult to carry out because

of reduced tissue resiliency and obliteration of vestibular spaces. Use of sectional trays offers one of the alternatives to overcome the problem of restricted mouth opening. Fabrication of customized impression trays according to the patient dentition improves the accuracy of impression making. The present case reports describe the fabrication of sectional custom trays designed for dentulous patients with chronic tobacco-induced submucous fibrosis.

1. IntroductionReduced mouth opening poses a challenge and is often a daunting task for the operator to perform any intraoral procedures. Reportedly, this problem has been associated commonly with orofacial cancer surgeries, scleroderma, traumatic injuries, temporomandibular joint disorders, oral submucous fibrosis, and so forth. One of the most commonly observed pathologies associated with limited mouth opening is oral submucous fibrosis. Rajendran, in 1994 [25], reported and named this condition as “atrophia idiopathica (tropica) mucosae oris” involving oral mucosa, palate, and pillars of the fauces. Later, it was termed as oral sub mucous fibrosis. It is called by various synonyms, like “diffuse oral sub mucous fibrosis,” “idiopathic scleroderma of the mouth,” “idiopathic palatal fibrosis,” “sclerosing

stomatitis,” and “juxta-epithelial fibrosis” [26]. The characteristic finding observed in these patients is pale mucosa with loss of elasticity and resiliency. Formation of fibrous bands in sub mucous connective tissue was reported to be the root cause behind gradual reduction in mouth opening. Prosthetic intervention for these patients entails an accurate impression of the patient’s mouth. Difficulties in impression making encountered due to reduced access to the oral cavity can be overcome by the use of sectional trays. Various types of sectional trays held together by different mechanisms have been designed and described in the literature. Present case reports describe simple and economic methods of fabrication of two-piece custom sectional trays for patients with oral sub mucous fibrosis.

2. Case reportsA 45-year-old male patient and a 31-year-old female patient who were suffering from chronic oral sub mucous fibrosis were reported to the department of prosthodontics (Sri Sai college of dental surgery, India) with a chief complaint of a missing teeth. On oral examination, maximum mouth opening was reported to be 2 cm and 2.4 cm, respectively, between incisal edges of maxillary and mandibular anteriors (Figure 11). Prognosis and probable prosthetic treatment options were explained to the patients, and informed consents were obtained.

Because of restricted size of the oral orifice and severe intraoral fibrous bands, preliminary impressions were made with polyvinyl siloxane putty material. Flexible impression tray technique described by Whitsitt and Battle [27] was used to make preliminary impressions. The material was manipulated, rolled, and adapted onto the hard and soft tissues. Catalyst proportion was altered to reduce setting time to 1 min. Once the material had been set, the impression was folded and removed from the patient’s mouth. The flexible impressions were stabilized using plaster and models obtained using pumice plaster method. Two-piece custom trays were designed and fabricated on the models.

Figure 11: Maximum mouth openings.

2.1. fabrication of Custom traysDesign 1. The custom tray was designed making sure that the sections of the tray could be joined firmly and oriented accurately both in patient’s mouth and after removal of the tray from the mouth. A 2 mm-thick wax spacer was adapted with four occlusal stops. Autopolymerizing resin was mixed and adapted using finger adaptation dough method on one side on the cast crossing midline. After the material polymerized, the tray section was removed, trimmed, and designed using an acrylic trimmer as shown in Figure 12. The orientation grooves helped in three-dimensional stabilization of

the tray. After designing the lock system for the first tray segment, a tin foil was adapted over that, and the second tray section was fabricated. After fabrication of the second segment, both the sections were approximated and secured using a screw. The screw helped in securing the tray segments together in a predetermined relationship (Figure 12).


Figure 12: Fabrication technique for the sectional tray – Design 1.

Design 2. Fabrication of maxillary sectional tray was demonstrated here. After proper relief and block-out, a wax spacer was adapted onto the model. The first section of the tray was fabricated by adapting self-activated resin and incorporating the female compartment of the press button on the center of the tray. The orientation lock was designed on the handle using acrylic trimmer as shown in Figure 13. After adapting a tin foil separating medium, the male part of the button was attached

to female part, and the second segment tray was fabricated. During fabrication of the second segment, acrylic material was extended onto the orientation lock on the first segment near the handle of the tray. The female part of the button was retrieved along with the second section of the tray (Figure 13).

Figure 13: Fabrication technique for the sectional tray—Design 2.

2.2. Impression makingAfter completion of the special tray fabrication, the first segment was used to make the first section of the impression. Wax spacer was removed and the tray was loaded with polyvinyl siloxane, and a sectional impression was made. The sectional impression was removed, and the excess material flown onto the lock region, and the screw hole was removed. The impression was placed back in the patient’s mouth. The second part of the tray was loaded with the same impression material and oriented onto the first segment.

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Figure 14: Impression making using the sectional tray Design 1.

In the first case report, after proper orientation of the tray, a screw was used to secure the segments together before the material set. The screw helped in securing the orientation of the sections of the tray properly within the patient’s mouth. After the material had been set, the screw

was removed, and the sections were removed separately. Both the sections were approximated and secured using the screw after removal from the mouth (Figure 14).

In the second case report, the sections of the tray were oriented making sure that the male part of the button was seated properly onto the female part. After the material had been set, both the sections were separated and removed from mouth. Both the sections of the tray were joined together with the help of the locking button (Figure 15).

Figure 15: Impression making using the sectional tray Design 2.

3. DiscussionImpression making in patients that planned for a fixed or removable partial denture with restricted mouth opening is a challenging task as it requires more accuracy and precision. The present case reports described simplified locking designs of the tray segments which could be used for both dentulous and edentulous patients for fabrication of custom trays.

In case report I, the patient was planned to receive a fixed partial denture replacing missing mandibular incisors. The patient in case report II was planned to receive a flexible removable partial denture to replace multiple missing teeth. Recording abutment finish line along with the remaining teeth is important for fabricating a fixed partial denture. Similarly, for fabrication of a removable partial denture, the teeth along with the functional depth of the sulcus have to be recorded.

Practical difficulties of reduced mouth opening were overcome by designing a sectional custom tray which provided an alternative for making an accurate impression.

Simple and economic sectional tray design was followed in the present case reports. Male and female segments of the tray were oriented by the locking mechanism which was designed using acrylic trimmer. Use of screws and press buttons helped in securing tray segments more accurately together with precision. Many techniques were described in the literature for impression making in dentulous and edentulous patients with limited mouth opening. Various mechanisms, like hinges [28], locking levers [29], plastic blocks [30, 31], orthodontic expansion screws [32], magnet systems [33], parallel pins [34], and so forth were used for fabricating sectional trays. In the present case


reports, incorporation of complicated locking devices was avoided by designing a locking mechanism within the tray handle to secure the tray segments three-dimensionally. Manual locks designed with trimmer on the surface of acrylic lack accuracy and precision.

Incorporation of screws and a press button into the design provides the precision in securing the trays together firmly. Accurate fit of fixed and removable prostheses was reported with the impressions obtained from both sectional tray designs.

4. ConclusionsSimple alterations in procedural techniques help to overcome clinical difficulties faced during prosthetic management of patients with oral sub mucous fibrosis. Present case reports facilitated the operator to

obtain accurate impressions for patients with limited mouth opening. These simple and logical sectional tray designs are easy to fabricate, consume less time, and require inexpensive locking mechanisms.

Conflict of interestsThe authors declare that they have no conflict of interests.

Case Rep Dent. 2013; 2013: 893791. Published online 2013 August 1. doi: 10.1155/2013/893791PMCID: PMC3747416

A nOvEL APPROACH fOR tREAtmEnt Of An unusuAL PREsEntAtIOn Of RADICuLAR Cysts usIng AutOLOgOus PERIOstEum AnD PLAtELEt-RICH fIbRIn In COmbInAtIOn wItH

DEmInERALIzED fREEzE-DRIED bOnE ALLOgRAftVeena A. Patil, Manthan Desai, Veerendra S. Patil, Hanisha Reddy Kaveti, Kiran Kumar Ganji, and Prasanna M. DanappanavarCopyright © 2013 Veena A. Patil et al.


1Department of Periodontology, HKES’s S.Nijalingappa Institute of Dental Sciences and Research, Sedam Road, Gulbarga, Karnataka

585105, India

2Department of Endodontics, HKES’s S.Nijalingappa Institute of Dental Sciences and Research, Sedam Road, Gulbarga, Karnataka

585105, India3Department of Periodontics, Sharad Pawar Dental College & Hospital, Sawangi Meghe Wardha, Maharashtra 442004, India

4Department of Oral and Maxillofacial Pathology, MNR Dental College & Hospital, Sangareddy, Medak, Andhra Pradesh 502294,

India

*Veena A. Patil: Email: [email protected]

Academic Editors: R. A. de Mesquita, J. J. Segura-Egea, and K. Seymour

AbstractRadicular cysts are the most common cystic lesions affecting the jaws. They are most commonly found at the apices of the involved teeth. This condition is usually asymptomatic but can result in a slow-growth

tumefaction in the affected region. The following case report presents the successful treatment of radicular cysts using autologous periosteum and platelet-rich fibrin with demineralized freeze-dried bone allograft.

1. IntroductionRadicular cysts are the most common (52 percent to 68 percent) cystic lesions affecting the jaw [35]. They are commonly found at the apices of involved teeth and sometimes lateral to accessory root canals. They are a direct sequel of chronic periapical infection [35]. Most of them are asymptomatic and are discovered when periapical radiographs are taken of teeth with nonvital pulps. Patient often complains of slowly enlarging swellings. Radiographically, most radicular cysts appear as

round or pear shaped unilocular radiolucent lesions in the periapical region. The cyst may displace adjacent teeth or cause mild root resorption [36].

The following case report presents the successful treatment of radicular cysts using autologous periosteum and platelet-rich fibrin (PRF) with demineralized freeze-dried bone allograft (DFDBA).

2. Case reportA 17-year-old female patient reported to the Department of Periodontics, HKES’s S.Nijalingappa Institute of Dental Sciences and Research, Gulbarga, India, with a chief complaint of pain, swelling ongoing and pus discharge in the lower anterior region since two months. Past history revealed trauma in the lower anterior region five years ago with recurrent swelling and pus discharge.

Figure 16: Preoperative view of the lesion.

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Figure 17: Preoperative radiograph.

On intraoral examination, inflamed and swollen gingiva was seen in relation to 41, 42, and 43 (FDI notation). A draining fistula was seen on the labial aspect in relation to 41 (Figure 16). 42 had grade I mobility, whereas no mobility was noticed with 31, 41, and 43. Pulp vitality test was negative with 41, 42, and 43, while adjacent teeth showed normal response. Periodontal probing depth was ≤3 mm for concerned teeth, and no clinical attachment loss was seen. They were also painless on vertical percussion. On radiographic examination, two radiolucent areas of size approximately 2 × 2 mm were seen in relation to 41, 42, and 43 (Figure 17). No root resorption was seen.

The treatment plan was comprised of endodontic treatment of nonvital teeth followed by surgical enucleation of cystic lesions if necessary. The treatment plan was explained to the patient, and a written informed consent was obtained. In the same visit, root canal treatment was started under rubber dam application followed by working length determination. After complete biomechanical preparation, 2 percent chlorhexidine gluconate was used as an irrigant and intracanal medicament. In the subsequent visits, root canal treatment was completed. Persistent pus discharge was observed at three months after endodontic treatment, and surgical enucleation was planned.

The procedure is as follows: local anesthesia was administered, crevicular incisions were given, and a full thickness mucoperiosteal flap from 41 to 43 and a split thickness flap in 31, 32 region were reflected. The area was degranulated revealing two small perforations of the buccal cortical plate in the regions of 41 to 43 of size 1 × 1 × 1 mm. The remaining buccal cortical covering was carefully removed with rotary and hand instruments to expose the rest of the lesions of size 3 × 3 × 2mm.

Fragmented pieces of the lesion were freed from the bone, and complete curettage of the cystic lesions was done (Figure 18). The cystic cavities were thoroughly irrigated, and root biomodification of involved teeth was done using tetracycline. DFDBA was mixed with sterile saline solution and grafted in an attempt to close the defect via osteoconduction (Figure 19). Autologous healthy periosteum was harvested from the 31-32 region (Figure 20), and PRF was prepared from the patient’s blood, as described by Choukroun et al. [37]. The lesion was covered with periosteum, over which PRF was placed as a second layer of barrier membrane covering the graft (Figures 21 and 22).

Figure 18: Debridement of the lesions.

Figure 19: DFDBA graft placement.

Figure 20: Harvested autologous periosteum.

Figure 21: Autologous periosteum placed as a barrier membrane.


Figure 22: PRF placed as a barrier membrane.

The flap was coronally advanced and closed with interrupted sutures using 3-0 black braided silk (Figure 23). A periodontal dressing was applied at the surgical site. The patient was prescribed amoxicillin 500 mg TID and diclofenac sodium 50 mg TID, both for five days, with 0.12 percent chlorhexidine gluconate rinse BD for seven days. The patient was asked to report after a week for suture removal, and the curetted tissue was submitted for histopathological examination. The patient returned for the postoperative visit, and the healing was uneventful.

Figure 23: Sutured flap with 3-0 silk suture.

Histopathology revealed the presence of a varying thickness of epithelium with fibrocellular connective stroma. The epithelium was disrupted with infiltration of chronic inflammatory cells along with vacuolations within the epithelium. Connective tissue showed dense infiltration of lymphocytes and plasma cells with few macrophages (Figure 24). A diagnosis of radicular cyst was given. Patient was followed up for nine months. Radiograph at six months shows a healing lesion (Figure 25). A subsequent radiograph nine months after operation (Figure 26) reveals increased radiopacity where the bone graft was placed, and no evidence of recurrence of the lesion was seen (Figure 27).

Figure 24: Histopathology of excised cyst.

Figure 25: Six months postoperative radiograph.

Figure 26: Nine months postoperative radiograph.

Figure 27: Healing at nine months after operation.

3. Discussion A radicular cyst is an odontogenic cyst of inflammatory origin preceded by a chronic periapical granuloma and stimulation of cell rests of Malassez found in the periodontal membrane. The pathogenesis of radicular cysts comprises three distinct phases: the phase of initiation, the phase of cyst formation, and the phase of enlargement [38]. The initial swellings of these radicular cysts are

usually bony hard, but as they increase in size, the covering bone may become very thin despite initial subperiosteal bone deposition. With progressive bone resorption, the swellings exhibit “egg shell crackling.” The associated teeth are always nonvital and may show discoloration. Although the associated teeth usually show no root resorption, there may be smooth resorption of root apices. When cysts

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are intact, cyst cavities may be filled with brown- or straw-colored fluid, giving them a shimmering gold appearance [38]. Radicular cysts are inflammatory lesions leading to bone resorption and can reach great dimensions and become symptomatic when infected or with great size due to nerve compression.

The main cause of failure of endodontic treatment is generally accepted to be the continuing presence of microorganisms in the root canal system that have either resisted treatment or have reinfected the root canal system. E. faecalis was the most frequently found microbe in such cases [39]. Chlorhexidine gluconate has been proposed for use both as an irrigant and as a medicament especially in endodontic retreatment. As a medicament, it is more effective than calcium hydroxide in eliminating E. faecalis infection inside dentinal tubules [40]. As an irrigant, it appears as effective or superior to sodium hypochlorite in the elimination of E. faecalis [41].

The adult human periosteum is highly vascular and is known to contain fibroblasts, osteoblasts, and stem cells. Skoog [42] subsequently introduced the use of periosteal flaps for closure of maxillary cleft defects in humans; he reported the presence of new

bone in cleft defects within three to six months following surgery. Furthermore, animal studies have reported heterotopic ossification in different organs after implantation of free periosteal grafts [43, 44]. In all age groups, the cells of the periosteum retain the ability to differentiate into various cells. [45]. On the basis of these observations, it can be hypothesized that the periosteal membrane can contribute to the stimulation of new bone formation and has an immense potential for regeneration.

PRF belongs to the new generation of platelet concentrates with simplified processing. PRF contains a variety of growth factors, which enhance healing by increasing angiogenesis and matrix biosynthesis [46]. The immense osteoinductive capability of DFDBA is well described in the periodontal literature [47].

The treatments of these cysts are still under discussion, and many professionals opt for a conservative treatment by means of endodontic technique [48]. However, in large or nonhealing lesions, the endodontic treatment alone is not efficient, and surgical treatments like marsupialization or enucleation should be considered [49]. In this case, surgical enucleation was preferred and was performed uneventfully.

4. Conclusion To conclude, a radicular cyst is a common condition found in the oral cavity. However, it usually goes unnoticed and rarely exceeds the palpable dimension. This case report illustrates the successful

management of a radicular cyst with enucleation and endodontic treatment. The use of autologous periosteum and PRF has a promising future in periodontal regeneration.

Conflict of interestsThe authors declare that they have no conflict of interest.

J Forensic Dent Sci. 2013 Jan-Jun; 5(1): 35–41. doi: 10.4103/0975-1475.114561

A stuDy Of COmPOsItE REstORAtIOns As A tOOL In fOREnsIC IDEntIfICAtIOnBahavathi Ananthan Hemasathya and Sundaresan BalagopalCopyright © 2013 Journal of Forensic Dental Sciences

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Department of Conservative Dentistry and Endodontics, Tagore Dental College and Hospital, The Tamilnadu Dr. M.G.R. Medical University,

Chennai, India

Address for correspondence: Dr. Hemasathya Bahavathi Ananthan, F-12, Block-2, Casagrande “The Riviera”, 193, Velachery-Tambaram

Main Road, Pallikaranai, Chennai - 600 100, India. E-mail: [email protected]

Copyright : © Journal of Forensic Dental Sciences


Abstract

IntroductionComparing antemortem and postmortem dental data is a principal method of identification in forensic odontology. Radiographic images

of amalgam have been used in dental forensics for identification due to their unique appearance.

AimThe aim of this study was to investigate whether radio-opaque composite restorations have a potential for identification in forensic odontology.

materials and methodsThirty typodont mandibular first molar teeth were prepared with Class-II (proximo-occlusal) cavities and restored with a radio-opaque composite. Two sets of standardized radiographs were taken from the 30 teeth, keeping the radiological parameters constant. One set of these 30 radiographs was named as SET 1. Ten randomly chosen

radiographs from the other set and two other radiographs of Class-II composite restorations in typodont teeth constituted SET 2. Thirty dentally trained examiners were asked to match the 12 radiographic images of SET 2 with those of SET 1.


ResultsThe results show that 15 examiners were able to correctly match all the 12 images. Statistical analysis was done using kappa statistical test.

ConclusionThis study shows that if the postmortem radiographs are accurate duplicates of antemortem radiographs of composite restorations, then

the shape of the composite restoration is unique and can be used for identification.

IntroductionForensic odontology plays a very important role in identification of persons, especially those who cannot be identified visually by members of the family, relatives, and friends of the deceased. Dental identification is a frequently applied method for identification of persons involved in mass disaster, accidents, and crime investigations [50,51], where the remains are disfigured, mutilated, or skeletonized. Dental identification predominantly involves comparison of antemortem and postmortem records. The records include charts or case sheets, photographs, radiographs, models, etc. Among these, dental radiography is a non-invasive method used to uncover data which are embedded within the soft tissues and in the teeth, which are not found by physical examination or are completely discernible during physical examination. A dental radiograph is a very common constituent of a patient record or case sheet. And comparison of these antemortem radiographs with postmortem dental radiographs produces reliable results in a simple manner [52]. Comparison involves examining the features of the same jaw sector, single tooth or even a tooth surface for concordance between the antemortem and postmortem data [53]. In different countries, the law requires a different number of concordant features to establish identification of a person [54]. Authors also differ in their opinion regarding the minimum number of concordant points required for positive identification [55,56,57,58,59]. Dental identification cannot be based on a predetermined number of comparative points because in dental identification certain coincident characteristics are accorded more weight than others. A single antemortem radiograph of a tooth compared with a postmortem radiograph could be the only basis for an identification, whereas antemortem and postmortem dental charts showing three or four matching restorations might be regarded as containing insufficient criteria for an identification [57].

Kieser-Nielson [59] in 1980 stated that no physical or dental feature is unique. But any physical feature does possess a certain discriminatory potential according to its frequency of occurrence. Further, Kieser-Nielson [51] stated that the restored tooth surface as seen in the radiograph should be regarded as the smallest unit to consider in the comparison of dental restorations for identification purposes. Comparing the antemortem and postmortem dental radiographs along with the written data helps in establishing identification of the individual. De Villiers and Phillips presented two cases in which

a single extraordinary dental feature was useful for identification of the individuals [60]. Similarly, Phillips [61] in 1983 studied the patterns of amalgam restoration and their uniqueness and found that amalgam fillings in first molar have a low degree of uniqueness. Contrary to Phillips, Borrmann and Gröndahl [62] in 1990 through their study concluded that when two sets of bitewing radiographs of restored teeth are compared, the observers could accurately identify all the cases when simple amalgam restorations were present. Later in 2009, Phillips and Stuhlinger [63] stated that if the antemortem and postmortem radiographs of a compound amalgam restoration are exactly the same, then this feature is unique and can be used for identification. Zondag and Phillips [64] in 2009 have done a study comparing composite restorations and have found encouraging results that can be used in the identification of victims.

According to the American Dental Association, Council on Dental Materials, Instruments and Equipment, radiopacity is one of the five basic requirements any restorative material must fulfill [65]. A radiopaque restoration allows for easy distinguishing of existing restorations and primary caries, evaluation of contours, overhangs and major voids in restoration, and also helps in the identification of recurrent caries [66,67,68,69,70,71,72]. Too high or too low radiopacity are both undesirable for a radiographic diagnosis. Several studies have suggested that the radiographic detection of caries is improved if radiopacity of the restorative material is similar or slightly greater than that of enamel [72,73]. The extreme radiopacity of amalgam is not ideal for radiographic detection of caries and defects adjacent to restorations, since the high radiopacity interferes directly in the contrast, impairs visual acuity and, consequently, diminishes the perception of details [67,74].

Resin-based composites have been rapidly replacing amalgam due to their physical characteristics, ease of handling, and especially due to their satisfactory esthetic features. The radiopacity of composite resins is due to the incorporation of filler particles into the matrix (glass and ceramic particles containing heavy metals such as aluminum, barium, strontium, zirconium, and ytterbium) [75].

The aim of this study was to investigate the standardized radiographic images of radiopaque composite restorations in molar teeth regarding their discriminatory potential for identification in forensic odontology.

materials and methodsThirty plastic typodont mandibular first molar teeth of natural size were used in this study. The typodont teeth that resemble the morphology of natural teeth are made of plastic materials such as ivorine, melamine, polycarbonate, etc., and are used for training students in restorative procedures. In this study, the teeth manufactured by Nissin Co., Nakagyoku, Kyoto, Japan, were used. In these 30 typodont mandibular teeth, Class-II (proximo-occlusal) cavities were prepared and restored with light cure composite (Tetric N-Ceram, Ivoclar-Vivadent, Schaan, Liechtenstein, Batch No.14523) by final year dental students [Figure 28]. Tetric N-Ceram is a light-curing, radiopaque nano-hybrid composite resin for direct dental restorative procedures [Figure 29]. Tetric N-Ceram has a high radiopacity of 400 percent aluminum compared to dental enamel which has a radiopacity of about 200 percent aluminum. The difference in radiopacity facilitates the radiographic detection of secondary caries, excess or

inadequate quantities of material, air bubbles, and other imperfections. In this study, we required sufficient contrast in radiograph between the typodont and the restoration, which was provided by this material. The teeth were marked from 1 to 30 and mounted individually in a special acrylic mold to standardize the radiographic technique [Figure 30]. Two exact radiographs were taken, one to simulate the antemortem and the other to simulate the postmortem radiographs by placing the cone perpendicular to the buccal aspect of each tooth and by maintaining the same source to object distance of 15 cm, same exposure time of 1 s, same mA of 10 units, and same kV of 70 units. The distance between the object (mounted tooth specimen) and the film was also standardized at 10 mm. One set of these 30 radiographs were labeled with a three-digit number and set aside as SET 1 (to simulate antemortem radiographs) [Figure 31]. Ten randomly chosen radiographic images from the other set of 30 radiographs and two other

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radiographs with Class-II composite fillings in similar typodont teeth were set aside as SET 2 (to simulate postmortem radiographs) [Figure 32]. The remaining 20 radiographs from this set were not utilized in this study. The radiographs from SET 2 were each labeled with a two-digit number. The accurate correlation between SET 1 and SET 2 was recorded separately and not revealed to the examiners [Table 1]. The examiners were also not told about the presence of the two radiographs in SET 2 which did not have a match.

Figure 28: Typodont teeth numbered from 1 to 30 and restored with Class-II proximo-occlusal composite.

Figure 29: Tetric N-Ceram composite and Tetric N-Bond adhesive.

Figure 30: Typodont teeth were mounted individually in a special acrylic mold to standardize the radiographic technique.

Figure 31: Thirty radiographs in SET 1 to simulate antemortem radiographs.

Figure 32: Ten randomly chosen radiographic images from the other set of 30 radiographs and two other radiographs with Class-II composite fillings in similar typodont teeth to simulate postmortem radiographs in SET 2.

No. of random X-rays Set 1 Set 2

1 238 46

2 531 27

3 246 35

4 201 76

5 332 92

6 579 19

7 612 83

8 729 64

9 815 53

10 183 38

11 No match 71

12 No match 22

Table 1: Correlation between SET 1 and SET 2

Thirty dentally trained professionals were requested to match the radiographic images from SET 2 with those of SET 1. Each examiner viewed the radiographs on their own without consulting anyone else. The success rate of each examiner was recorded. The examiners were as follows: Eight faculty members from the Department of Conservative Dentistry, five faculty members from the Department of Prosthodontics, two faculty members from the Department of Pedodontics, four faculty members from the Department of Oral Medicine and Radiology, three faculty members from the


Department of Oral and Maxillofacial Surgery, and eight dentists with undergraduate degree.

The results were statistically analyzed using kappa statistical test.

ResultsThe result given by each and every examiner was documented by recording the number of exact matches between SET 1 and SET 2 [Table 2].

Examiner Score

Faculty-conservative dentistry 12/12

Faculty-prosthodontics 12/12


Faculty-pedodontics 11/12

Undergraduate dentist 10/12




Faculty-oral and maxillofacial surgery 11/12


Faculty-oral medicine and radiology 11/12



Faculty-pedodontics 12/12

















Table 2: Scores of 30 examiners

Specialty No. of members

Score of

12/12

Score of

11/12

Score of

10/12

Score of

09/12

Conservative dentistry

8 7 1 0 0

Prosthodontics 5 3 2 0 0

Pedodontics 2 1 1 0 0

Oral medicine and radiology

4 3 1 0 0

Oral and maxillofacial surgery

3 0 2 1 0

Undergraduate degree

8 1 1 4 2

Table 3: Scores of the examiners according to specialty

The scores of the examiners according to their specialty were separately tabulated [Table 3].

The results show that out of the 30 examiners, 15 examiners scored 12/12, eight examiners scored 11/12, five examiners scored 10/12, and two examiners scored 9/12.

The scores were statistically analyzed using kappa statistical test for interexaminer consistency and the result of the analysis was 0.83.

DiscussionSeveral studies are available in literature regarding the use of dental restorations for identification purposes [76,77,78,79]. In recent times, there has been an increase in demand for esthetic restorations among the patients, resulting in an increasing number of composite restorations over amalgam restorations. A variety of composite resins are available in the market, each having varying degree of radiopacity. The radiopacity of a composite restoration is an important property which helps in assessment of marginal overhangs, open gingival margins, interproximal caries, and recurrent caries. The radiopacity of composites also plays a significant role in forensic dentistry as it is very important for identification purposes [80,81,82]. In this study, the composite brand Tetric N-Ceram was used, which has a radiopacity of 400 percent aluminum [83,84].

The results show that out of the 30 dentally trained examiners, 15 were able to match all the 12 images correctly in spite of the presence of two random radiographs, i.e., success rate of 100 percent, eight were able to match 11 images correctly; i.e., success rate of 91.66 percent, five were able to match 10 images correctly; i.e., success rate of 83.33 percent.

The results were statistically analyzed using kappa statistical test for agreement between examiners, giving a value of 0.83, which denotes very good agreement.

The results show that the discriminatory characteristic of a radiographic image of a two-surface composite restoration is unique and could be used for identification purposes when antemortem and postmortem X-ray images are identical.

The 30 examiners in this study were selected at random from various specialties and also included undergraduate dentists. Examiners were not equally selected from each specialty since the objective of this study did not include the comparing ability of examiners from one specialty being better than the other. The objective also did not include comparison of undergraduate examiners with post-graduate examiners. Although it was not the aim of this study to evaluate the differences between the examiners from different departments, the results are shown in a separate table [Table 3]. Table 3 shows that there is a tendency for dentists who restore the tooth (restorative dentists) and who evaluate the status of the tooth (oral physicians) to match the radiographs better.

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Consultations among examiners were not allowed in this study, though in real life it is possible. None of the examiners were trained in forensic dentistry and so did not have the knowledge of the criticality of false-positive identification. Hence, many did not report about the two radiographs in SET 2 which did not have a match. If consultations were allowed, more examiners would have given a full score. If the examiners were given an option to report uncertainty (with “not sure”), then it would also have affected the results positively or negatively.

The examiners had to match the radiographs by analyzing the radiographic appearance of the composite restoration alone and not that of the teeth. Typodont teeth are easily available, and their use in this study

standardizes the morphology of the teeth and decreases the variability in their radiographic appearance. Natural teeth would have given a more challenging comparison, but would have contributed to variability in their radiographic appearance.

According to Kieser-Nielson, the restored tooth surface as seen in the radiograph should be regarded as the smallest unit to consider in the comparison of dental restorations for identification purposes. Even a single avulsed tooth collected from the scene of disaster may form the only evidence to the presence of a missing person in the scene. Hence, the validity of this study of a restoration in a single tooth is high.

ConclusionIf the postmortem radiographs are accurate duplicates of antemortem radiographs of composite restorations, then the shape of the composite restoration is unique and the radiographic image can be used for successful identification.

This preliminary investigation was carried out with the radiographs taken with absolute standardization. In real life, such exact antemortem and postmortem radiographs may not be possible due to factors like wear and fracture of the restoration, change in dentition and radiological errors. Further research can be done by conducting similar studies in patients with long-standing composite restorations which will mimic real-life situation.

J Forensic Dent Sci. 2013 Jan-Jun; 5(1): 16–21. doi: 10.4103/0975-1475.114550PMCID: PMC3746467

A COmPARAtIvE stuDy Of OvERLAy gEnERAtIOn mEtHODs In bItE mARk AnALysIsMihir Khatri, Mariappan Jonathan Daniel, and Subramanian Vasudevan SrinivasanCopyright © 2013 Journal of Forensic Dental Sciences


Department of Oral Medicine and Radiology, Mahatma Gandhi Post Graduate Institute of Dental Sciences, (Government of Puducherry

Institution), Indira Nagar, Gorimedu, Pondicherry, India

Address for correspondence:Dr. Mihir Khatri, Department of Oral Medicine and Radiology, Mahatma Gandhi Post Graduate Institute of Dental Sciences, (Government of Puducherry Institution), Indira

Nagar, Gorimedu, Pondicherry, India.E-mail: [email protected]

AbstRACt

AimTo evaluate the best method of overlay generation out of the three methods, i.e., manual, photocopying, and computer-assisted method.

materials and methodsImpressions of maxillary and mandibular arches of 25 individuals participating in the study were made and dental study models were prepared. Overlay production was done by manual, photocopying,

and computer-assisted methods. Finally, the overlays obtained by each method were compared.

ResultsThe Kruskal Wallis ANOVA test was used for the comparison of manual, photocopying, and computer-assisted overlay generation methods, with the value being highest in case of computer-assisted

overlays, thus making it the best method of overlay generation out of the three methods.

ConclusionWe conclude that the method of computer assisted overlay generation is the best among the three methods used in our study.

IntroductionBite marks may be found at the scene of a crime, and their analysis has been used for many years as an aid in forensic investigation. Bite marks can occur on the skin of a victim or on other objects, including foods such as cheese, chocolate, apples, or chewing gums. Solid food has an advantage in such cases [85, 86]. Bite marks tend to have a

double horseshoe pattern showing the six central teeth of the upper jaw and the corresponding six teeth in the lower jaw.

Bite marks made in food are usually well defined, but the bite marks made in flesh are usually less defined. Bite marks reveal features such as gaps between the teeth, ridges on the biting surfaces of the teeth, rough fillings, as well as missing, broken, chipped, or distorted teeth.


In fact, human teeth patterns are individual, and careful expert analysis of a bite is able to relate the mark to a suspect [87, 88, 89].

It must be again emphasized that the bite marks obtained on food items tend to be more accurate and reproducible than on skin of a person, and many studies have proved the fact. There are many different ways of analysis of bite marks on food substances, like impression making and hand tracing from dental study casts, photography method,

photocopying, and computer-assisted methods of overlay generation [90].

In this study, an attempt is made to compare the bite mark overlays generated by three methods, i.e., manual, photocopying, and computer-assisted methods of overlay generation to find the most reliable method out of the three methods used.

materials and methodsImpressions of maxillary and mandibular arches of 25 individuals participating in the study were made and dental study models prepared in dental stone. Overlay production was done by manual, photocopying, and computer assisted method of overlay generation.

In manual method, a sheet of transparency film and a fine-tipped pen were used to mark the perimeter of the biting surface. The transparent sheet was directly placed over the biting edges of the dental model [Figure 33]. Then with the help of a black fine-tipped marker, the biting edges were traced. Both the maxillary and mandibular models were traced individually in horseshoe shape pattern [Figure 34] to simulate a human bite [90].

Figure 33: Biting edges being traced.

Figure 34: Manual overlay.

In the photocopying method an accurate image of the dental model was made by placing the biting edges of the dental model over the

glass plate of the photocopying machine [Figure 35]. The dental models were again placed to simulate human bite. This image [Figure 36] was then placed upside down on a radiograph view box and the tooth edge outlines were traced [Figure 37]. These outlines were then photocopied on a transparent sheet [Figure 38] [91].

Figure 35: Dental model being photocopied.

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Figure 36: Photocopied dental model.

Figure 37: Traced biting edges.

Figure 38: Photocopied overlay.

In the computer assisted method, first the study models were scanned with the biting edges of the dental model over the glass plate of the scanner [Figure 39]. The images [Figure 40] were transferred to a laptop. The images were opened in Photoshop software version 7.0 already installed in the laptop. Then a gradual selection of biting edges of the teeth was done using magic wand selection tool [Figure 41] resident in the Photoshop software version 7.0. The outlines of the biting edges were reproduced [Figures 42 and 43]. The images obtained were printed on transparent sheet [Figure 44] [90, 92, 93]. Thus, three overlays were made for one set of dental model, and in total, 75 overlays were made. The three overlays corresponding to a set of dental model was placed directly over the biting edges one by one for matching and assigned one out of the four values (0-3) with “0” assigned to no matching and “3” assigned to excellent matching [Tables 4 and 5] [94, 95].

Figure 39: Dental model being scanned.

Figure 40: Scanned dental model.


Figure 41: Biting edges selected by magical wand selection tool.

Figure 42: Borders of biting edges being reproduced.

Figure 43: Reproduced borders.

Figure 44: Computer assisted overlay.

No matching 0Slight matching 1Moderate matching 2Excellent matching 3Table 4: Numeric values for matching

Patient serial no.

Matching

Manual method

Photo-copying method

Computer generated method

1 2 2 3

2 1 2 3

3 1 2 3

4 2 2 2

5 1 1 2

6 1 2 2

7 2 2 3

8 1 1 1

9 2 2 3

10 1 2 2

11 2 2 3

12 2 2 3

13 1 2 2

14 2 2 2

15 2 3 3

16 2 3 3

17 2 2 2

18 1 1 2

19 2 2 2

20 2 2 3

21 1 2 2

22 2 3 3

23 2 2 2

24 2 2 3

25 2 2 3

Table 5: Observations

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Manual Photocopying TotalNo Slight Moderate Excellent

No 0 0 0 0 0(0.0) (0.0) (0.0) (0.0) (0.0)

Slight 0 3 6 0 9(0.0) (33.3) (66.7) (0.0) (100.0)

Moderate 0 0 13 3 16(0.0) (0.0) (81.3) (18.8) (100.0)

Excellent 0 0 0 0 0(0.0) (0.0) (0.0) (0.0) (0.0)

Total 0 3 19 3 25(0.0) (12.0) (76.0) (12.0) (100.0)

Kruskal Wallis ANOVA H test, H value=5.74 (P<0.05-significant at 5% level)

Table 6: Manual vs. photocopying

Manual Computer-assisted TotalNo Slight Moderate Excellent

No 0 0 0 0 0(0.0) (0.0) (0.0) (0.0) (0.0)

Slight 0 1 6 2 9(0.0) (11.1) (66.7) (22.2) (100.0)

Moderate 0 0 5 11 16(0.0) (0.0) (31.3) (68.8) (100.0)

Excellent 0 0 0 0 0(0.0) (0.0) (0.0) (0.0) (0.0)

Total 0 1 11 13 25(0.0) (4.0) (44.0) (52.0) (100.0)


Table 7: Manual vs. computer-assisted

Manual Photocopying TotalNo Slight Moderate Excellent

No 0 0 0 0 0(0.0) (0.0) (0.0) (0.0) (0.0)

Slight 0 1 2 0 3(0.0) (33.3) (66.7) (0.0) (100.0)

Moderate 0 0 9 10 19(0.0) (0.0) (47.4) (52.6) (100.0)

Excellent 0 0 0 3 3(0.0) (0.0) (0.0) (100.0) (100.0)

Total 0 1 11 33 25(0.0) (4.0) (44.0) (52.0) (100.0)


Table 8: Photocopying vs. computer-assisted

ResultsThe Kruskal Wallis ANOVA test was used for the comparison of manual, photocopying, and computer-assisted overlay production methods. The value for manual vs. photocopying overlay generation method was 5.74 (P < 0.05 – Significant at 5 percent level) [Table 6];

for manual vs. computer overlay the generation method was 19.17 (P < 0.01 – Significant at 1 percent level) [Table 7] and for photocopying vs. computer overlay the generation method was 22.97 (P < 0.01 – Significant at 1 percent level) [Table 8].

DiscussionThe principle of bite mark analysis is based on the premise that no two people have similar teeth, and hence the bite marks made are also dissimilar. Historically, the manual method was the only method known for generating overlays and was used first in about 1966. Dailey (1991) presented a quick, inexpensive, and accurate technique for generating transparent overlays, using office photocopy machines, for use in bite mark case analysis. He discussed that the critical step in the fabrication process involves determination of the accuracy of the product produced by the photocopy machine [91]. Naru and Dykes (1996) introduced the computer-assisted overlay generation method to forensic odontology. They advocated a method of selection of tooth edges from the image by a technique known as “edge detection.” The selected edges were then printed onto transparent sheets as overlays [90]. The present study was undertaken to find the best method out of these three methods, i.e., manual, photocopying, and computer-assisted methods for overlay generation.

One of the limitations of the overlays is that they are two-dimensional representatives of three-dimensional bite marks. Sweet et al. (1998) in their study compared five different methods of overlay generation. The computer-based production method was determined to be the most accurate of those studied. It produced accurate representations of the biting edges of the teeth in an objective manner [96]. Kouble et al. (2004) in their study to compare direct and indirect methods available for human bite mark analysis found that the photocopier-generated overlays were significantly more accurate at matching the correct bite mark to the correct models [94]. Anne et al. (2005) conducted a study to compare the reliability of two methods used to produce computer-generated bite mark overlays with Adobe Photoshop®. One method was by using magical wand selection tool, while the other method is by inverting the glowing edges. It was concluded that both techniques were reliable methods to produce bite mark overlays in assessing

tooth position [97]. Wu et al. (2005) conducted an experimental study on human bite marks digital analysis and its accuracy. Their result showed that the human bite marks digital analysis was a more accurate approach to human bite marks identification [98]. Herb Blitzer et al. (2009) presented their experiments describing the development of a semi-automated method to compare 3D dental models taken from candidate humans and bite mark impression images left at the scene of the crime. Starvianos et al. (2011) conducted a study to evaluate the accuracy of two methods for the bite mark analysis in foodstuff. The results of their study showed that the computer-based method of bite mark analysis was as accurate as the docking procedure. Maloth et al. (2011) in their study to determine the most accurate bite mark overlay fabrication technique by studying two physical characteristics, i.e., area and rotation of biting edges of anterior teeth, concluded that forensic odontologists should discontinue the use of hand traced overlays in bite mark comparison as there is lot of scope for manipulation and observer bias [99].

A recently developed new software package, “Dental Print” (2004, University of Granada, Department of Forensic Medicine and Forensic Odontology, Granada, Spain) generates comparison overlays from 3D images of the suspect’s dental cast. This software allows users to accurately and objectively select the biting edges of interest from the suspect’s teeth when compared to 2D images. The procedure for generating comparison overlays is entirely automatic, and it is impossible for third parties to manipulate or alter the 3D images. This dental print software is an important step forward in Forensic Sciences for bite mark analysis [100, 101, 102].

In our study, the computer-assisted overlay generated matched excellently with study models in 13 cases. In comparison, only three overlays generated by photocopying method matched excellently with


the study models. None of the overlay generated in a manual method matched excellently with the study models. Thus, the results of our study show that photocopying method is better than manual method,

but computer-assisted method is more reliable than both manual method and photocopying method.

ConclusionAlthough many newer and sophisticated methods of bite mark comparison have evolved, comparison by overlay generation remains one of the best and easiest methods. Within various overlay generation methods, computer-assisted overlay generation method enjoys widest

acceptance because of its objectivity, ease of production, and being inexpensive along with being well researched. So it can be concluded that computer-assisted overlay generation method is the best method of overlay generation.

J Forensic Dent Sci. 2013 Jan-Jun; 5(1): 22–27. doi: 10.4103/0975-1475.114554PMCID: PMC3746469

LAtEnt LIP PRInt DEvELOPmEnt AnD Its ROLE In susPECt IDEntIfICAtIOnNidhi Dwivedi, Akhil Agarwal, Bina Kashyap, Vineet Raj, and Shaleen ChandraCopyright © 2013 Journal of Forensic Dental Sciences


Department of Oral Pathology and Microbiology, Saraswati Dental College and Hospital, Lucknow, U.P., India

1Department of Orthodontics and Dentofacial Orthopedics, Babu Banarsi Das College of Dental Sciences, Lucknow, U.P., India

Address for correspondence: Dr. Nidhi Dwivedi, 2/308 Vibhav Khand, Gomti Nagar, Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

AbstRACt

Aims and objectiveThe study aims to develop latent lip prints on glass surfaces using fingerprint black powder and its comparison with standard lipstick prints, and also determines the effectiveness of the technique.

materials and methodsThis study included a total of 100 subjects, comprised of 50 males and 50 females with age ranging from 17 to 38 years. Latent lip print was developed by pressing the lips against a glass slab with lips together, and the print formed was developed by sprinkling the black fingerprint

powder and transferred to a bond sheet. Subsequently, standard lipstick print was developed from the same subject. All the samples were coded and graded according to the patterns suggested in the literature.

ResultsOut of 100 latent prints, only 29 prints showed lip patterns in all four quadrants. The percentage matching with self lipstick print of good latent prints ranged from 25 percent to 100 percent, and those of

random prints ranged from 8 percent to 92 percent. Quadrant-wise matching ranged from 52.67 percent to 57.67 percent. Statistically significant difference was observed between males and females.

ConclusionThe study demonstrates the usefulness of latent lip print in personal identification.

IntroductionIdentification of humans is a prerequisite for personal, social, and legal reasons [103]. Traditional methods of personal identification include anthropometry, dactyloscopy, DNS finger-typing, sex determination, estimation of age, measurement of height, postmortem reports, and differentiation by blood groups. These methods have been proved to be successful in many cases [104, 105]. Criminal investigation involves identification of both murder victim and suspects [106].

Fingerprints and dental record comparison are the most commonly used scientific methods of forensic identification. The wrinkles and grooves on labial mucosa, known as sulci labiorum, form characteristic patterns known as lip prints, and the study of these lip prints is known as “cheiloscopy.”[107] Lip prints do not change during the life of a person. It is thought to be unique to a person, just like fingerprints [108, 109]. It has been verified that lip prints recover after undergoing alterations like minor trauma, inflammation, and diseases like herpes

[104]. However, major trauma to lips may lead to scarring, pathosis, and the surgical treatment rendered for lip correction may alter the size and shape of the lips, thereby altering the pattern and morphology of grooves [107]. The lip prints of parents and children and those of siblings have been shown to have some similarities [110, 111]. Various studies suggested that variations in patterns among males and females could help in sex determination [112].

Unlike fingerprints, unanimity still does not exist among investigators to accept cheiloscopy as a method of human identification. The present study was carried out to develop latent lip print on a glass surface, and its comparison was made with the standard lipstick prints of the same individual. Also, it was aimed to assess the reliability of technique in suspect identification at the crime site and investigate its potential role and usefulness in personal identification.

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materials and methodsThe study included 100 subjects (50 males and 50 females) with age ranging from 17 to 38 years, in the Department of Oral Pathology and Microbiology, Saraswati Dental College and Hospital, Lucknow, Uttar Pradesh, after ethical clearance. All the participants were briefed about

the purpose of the study and an informed consent was taken from them. Participants having any known allergy to cosmetic products or any lesion or scar on the lips were excluded from the study.

method for latent lip printThe lips of the subject were first cleaned thoroughly using wet cotton with cleanser and then with sterile cotton. The lips were gently pressed together against a glass slab for 3-4 seconds. The print formed on the glass slab was developed by sprinkling the black fingerprint powder composed of charcoal, lampblack, and graphite [Figure 45]. Gentle dusting using a special “marabou” feather brush loaded with fingerprint powder was carried out [Figure 46]. The excess powder was removed to visualize the hidden print and the print was transferred to a white bond sheet with the help of a 2-inch-wide lifting tape [Figures 47–51]. Later, standard colored lipstick was applied gently in the entire area of upper and lower lips of the same subject using disposable applicator in a single stroke and then the subject was asked to press the lips against a bond sheet with a firm base [Figure 52].

Figure 45: Materials used for development of latent and lipstick print: Black fingerprint powder, marabou brush, lifting tape, 2-inch-wide lifting tape, glass slab, standard company lipstick, lipstick brush, cellophane tape.

Figure 46: Photograph showing sprinkling of black fingerprint powder using marabou brush.

Figure 47: Photograph showing removal of excess fingerprint powder and development of the lip print.

Figure 51: Photograph showing developed latent lip print.

Figure 52: Photograph showing standard lipstick print.

Figure 48: Photograph showing application of lifting tape.

Figure 49: Photograph showing lifting of latent lip print.


Figure 50: Photograph showing transfer of lip print to the bond sheet.

Samples collected were coded and blindly graded on the basis of lip pattern suggested by Suzuki and Tsuchihashi, 1970[104].

● Type I: Clear cut vertical grooves that run across the entire lips. ● Type I’: Vertical grooves do not cover the entire lip. ● Type II: Branched grooves. ● Type III: Intersected grooves. ● Type IV: Reticular grooves. ● Type V: Undetermined (grooves do not fall into any type I-IV and

cannot be differentiated morphologically).

75.80%

48.30%

mean % matchingwith self

80.00%

60.00%

40.00%

20.00%

0.00%

good prints random prints

Graph 1: Comparison of percentage matching with self of good prints and random prints.

90

80

70

60

50

40

30

20

10

0First Second Third Fourth

Middle Mid-Lateral Lateral

Perc

enta

ge M

atch

ing

Graph 2: Percentage matching at different locations in different quadrants.

Analysis of lip printsUpper and lower lips were divided into four quadrants, and each quadrant was further divided into three parts, i.e., lateral (L), mid-lateral (ML), and middle (M) portions. The lip prints collected were coded by one observer, and the pattern of lip print present in each quadrant was recorded by two different observers by using a simple

magnifying glass. The lip prints that showed patterns in all four quadrants were classified as good prints, and the rest were considered as random prints.

All the data was analyzed statistically and P < 0.05 was considered to be statistically significant.

ResultsOut of 100 latent prints, 10 random cases were selected and the percentage matching with self was calculated, which ranged from 8 to 92 percent. Twenty-nine latent prints out of 100 were able to reveal lip patterns in all four quadrants and were regarded as good prints, and among them, 10 good latent print samples were taken and percentage matching with self was calculated, which ranged from 25 to 100 percent.

40.00%

35.00%

30.00%

25.00%

20.00%

15.00%

10.00%

5.00%

0.00%

Female

Male

Lip Print Patterns

I II II III IV V

Graph 3: Statistically significant difference was observed between two genders (P < 0.001). Type III pattern was more common among males, whereas types I’ and I were more common among females.

The comparison of good print and latent prints was also made. The good prints showed a mean percentage matching with self-print of 75.8 percent, while with that of random prints, the mean value of self-print matching was 48.3 percent [Graph 1]. Each quadrant-wise matching was assessed, where in the first quadrant, type II was the common pattern observed. The prominent pattern in middle location showed type IV pattern, mid-lateral showed type III, and lateral location showed type II. Overall percentage matching of latent lip print with self-lipstick print was 57.33 percent.

The second, third, and fourth quadrants showed type II pattern as the most common one. In the second quadrant, the midlateral portion showed type II. Overall matching of latent print with self-lipstick print was 57.67 percent. Type I pattern was observed in the middle locations of the third quadrant, and overall matching of latent print with self-lipstick print was 52.67 percent. The pattern in the fourth quadrant showed type I in the middle locations with types II and III in midlateral location. Overall matching of latent print with self-lipstick print was 53 percent. Overall, the quadrant-wise matching ranged from 52.67 to 57.67 percent [Graph 2].

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Between genders, type II was the most common pattern observed in both males and females. A statistically significant difference was observed between two genders (P < 0.001). Further, quadrant-wise matching of

the patterns was assessed; type III pattern was more commonly observed among males, whereas types I’ and I were more common among females [Graph 3].

DiscussionWith the ever-increasing demands placed upon law enforcement to provide sufficient physical evidence linking a perpetrator to a crime, it makes sense to utilize any type of physical characteristic to identify a suspect of an offense. Lip prints have unique markings that can be entered into a specific classification. Few studies on lip morphology and patterns they produce when they are impressed on to a variety of surfaces have shown that cheiloscopy has a potential to become an additional weapon for personal identification [113]. Most of the crime scene investigators ignore lip prints, but it is a very important suspect identification tool which is rarely used in forensic investigations. Previous studies analyzed the effectiveness of several fingerprint powders and reagents on lipstick prints, i.e., a black fingerprint powder is used for the development of fingerprint. The present study of the latent lip print follows the same technique used for developing fingerprints.

Literature suggests various ways of collection, analysis, and interpretation of lip prints, such as use in postmortem identification, use of magnifying glasses, use of a ruler in the software, use of fluorescent dyes, and use of fingerprint powder. Analysis of lip prints was done either by dividing the lips into quadrants or by dividing them into two parts or by division of each quadrant into further middle and lateral portions. All this is done to have a clear description of nearly all of the commonly encountered lip patterns and to make it easy for interpretation.

Sivapathasundaram et al. (2001) studied the lip print pattern in the middle part of lower lip up to 10 mm wide, and recommended this fragment as it is almost always visible in any trace [108]. They also stated that the uniqueness of patterns depended on the way the lip patterns are relaxed. Due to the diverse combination of patterns of the lip print, Augustine et al. divided lips into four quadrants and further each quadrant was divided into two equal parts as middle and lateral [111]. Lips frequently showed different patterns with combination of other types, but never occurred singly. Most of the areas showed superimposed patterns which were difficult to differentiate in his study. To get the precise and accurate lip print pattern, we divided the lips into quadrants and further each quadrant was divided into three parts as middle, midlateral, and lateral locations. These divisions made us record the complete quadrant with minimal superimposition and clear patterns in all the subdivided portions.

In a study of 100 samples, 29 latent print samples were able to reveal lip patterns in all four quadrants. Among the lip print patterns, types III, II, I, and I′ were evident, whereas type IV pattern was not clearly visible. Also, type IV pattern was the most commonly superimposed pattern, which was difficult to differentiate, and this finding is similar to that of Augustine et al. Another reason for the unclear and superimposed patterns could be attributed to the faint, smudged, non-identifiable grooves and incomplete patterns due to uneven pressure applied by the subjects [114].

Twenty-nine samples which showed the lip print patterns in all four quadrants were regarded as good prints, and their percentage matching with self-lipstick print ranged from 58.3 to 100 percent, while for random prints it ranged from 8 to 92 percent. When good latent prints and random latent prints were compared, the results showed mean percentage matching with self-print of random prints was 48.3 percent as compared to 75.8 percent of the good prints. Hence, we suggest that our method of recording, matching, and developing can be useful to help establish the validity of the technique and also that more research on the methods of development of latent prints is needed for making it a comparable tool to fingerprints in suspect identification.

Lucas Smacki (2010) in his study compared lip trace with a collection of lip prints stored in a database and observed that automatic identification of lip print traces was a very difficult task as the results obtained by the proposed system were average [115]. Similar findings were obtained in our study; the overall matching among different quadrants did not show much difference as it ranged from 52.67 to 57.67 percent and quadrant-wise matching was observed to be average in all four quadrants. These findings are encouraging enough to allow further research in this direction.

The quadrant-wise matching showed that different areas of the lip prints showed different matching, with maximum matching of 82 percent in the lateral location of the first quadrant and minimum matching of 44 percent in the middle and midlateral locations of the third quadrant. Even though the lines and furrows are present in both upper and lower lips from one corner of the mouth to the other, only the middle lip portion was taken into account in most of the studies as this portion is always visible in any trace. But in the present study, patterns present in all four quadrants in both upper and lower lips were matched. Lateral locations revealed better matching than middle and midlateral locations. Type II was the most common pattern seen in lateral locations in all quadrants, as compared to the middle portion which showed type IV to be the most common pattern in first and second quadrants (upper lip) while type I was the most common pattern in third and fourth quadrants (lower lip). The midlateral location showed type III in the first quadrant and type II in the remaining quadrants. Thus, different locations of the lips revealed different patterns and this variation in patterns between upper and lower lips may be attributed to the following factors: a) lip muscles relaxed to produce a particular pattern; b) furrows and grooves on the lips provide privileged routes for saliva; c) upper lip is more hydrated than lower lip; and d) continuity of lips with adjacent skin lines. All these variations might have a functional significance.

In our study, type II was the most common pattern seen in both upper and lower lips in the entire study population, followed by type III, while according to Augustine et al., type III was the most common pattern observed followed by type II [115]. The variations in pattern could be due to the factors mentioned earlier in the literature.

Comparisons of the lip print patterns between males and females have been recorded in various studies and by various authors. Tsuchihashi reported type III to be the commonest in both males and females [104]. Sharma et al., suggested undetermined lip pattern (27.5 percent) in males and vertical and partial vertical lip pattern in females (25 percent) [116]. Saraswati et al., reported that intersecting pattern was the most common among males (39.5 percent) and females (36.5 percent) and similar findings were reported by Sivapathasundaram et al [117]. In the study of Gondivkar et al., crisscross pattern was reported to be the most common in males (51.05 percent) and branched lip pattern (37.06 percent) in females [118]. Augustine et al., found type III pattern to be the most predominant pattern in both males and females, accounting for 49.15 percent and 47.78 percent of all patterns, respectively [114].

In the present study, type II (branched pattern) was the most common pattern observed in both males (36.3 percent) and females (35.5 percent), and a similar finding was reported by Nagasupriya et al [119]. A significant difference (P < 0.001) was observed between males and females. Types I and I′ were more commonly seen in females and type III pattern was most commonly seen in males. This was in accordance with Vahawala et al., who reported similar findings [120].


The permanent nature of lip prints still requires more long-term studies to be substantially documented. Advanced methods of developing lip prints at a scene of crime are still confined to research laboratories. Full utilization of lip depends to a high degree on the skill of members

of law enforcement agencies. Progress in research will contribute not merely to its direct use in personal identification in forensic medicine and odontology, but will also open up a new field that can contribute extensively to criminal investigation and identification.

ConclusionThe limitation of the study could be the sample size and the technique used, and suggests further refining to develop easy and efficient techniques for development of latent lip prints and their use in suspect

identification in order to make it comparable with fingerprint in the crime scene area.

AcknowledgementState Forensic Science Lab, Mahanagar, Lucknow, Uttar Pradesh for helping in development of latent lip print through finger print powder.

Forensic Dent Sci. 2013 Jan-Jun; 5(1): 42–46. doi: 10.4103/0975-1475.114560

AssEssmEnt Of mORPHOLOgICAL CHAngEs AnD DnA quAntIfICAtIOn: An In vItRO stuDy On ACID-ImmERsED tEEtH

K Sowmya, US Sudheendra, Samar Khan, Neelu Nagpal, and SJ PrathameshCopyright © 2013 Journal of Forensic Dental Sciences


Department of Oral and Maxillofacial Pathology, People’s College of Dental Sciences and Research Centre, Bhopal (MP), India

1Department of Oral and Maxillofacial Pathology, Coorg Institute of Dental Sciences, Virajpet, Karnataka, India

Address for correspondence: Dr. Sowmya Kasetty, Department of Oral and Maxillofacial Pathology, Peoples College of Dental Sciences and

Research Centre, Bhopal, Madhya Pradesh, India.E-mail: [email protected]

AbstRACt

ContextAcid immersion of a victim’s body is one of the methods employed to subvert identification of the victim, and hence of the perpetrator. Being hardest and chemically the most stable tissue in the body, teeth can be an important forensic investigative medium in both living and nonliving populations. Teeth are also good reservoirs of both cellular

and mitochondrial DNA; however, the quality and quantity of DNA obtained varies according to the environment the tooth has been subjected to. DNA extraction from acid-treated teeth has seldom been reported.

AimsThe objectives of the present study were to assess the morphological changes along with DNA recovery from acid-immersed teeth.

materials and methodsConcentrated hydrochloric acid, nitric acid, and sulfuric acid were employed for tooth decalcification. DNA was extracted on an hourly

basis using phenol-chloroform method. Quantification of extracted DNA was done using a spectrophotometer.

ResultsResults showed that hydrochloric acid had more destructive capacity compared to other acids.

ConclusionSufficient quantity of DNA was obtainable till the first two hours of acid immersion, and there was an inverse proportional relation

between mean absorbance ratio and quantity of obtained DNA on an hourly basis.

keywordsAcid-immersed teeth, DNA, forensic odontology, forensic sciences, gel electrophoresis, inorganic acids, nanodrop spectrophotometer

IntroductionDNA analysis is an important method employed for forensic identification with a higher degree of certainty as compared to the other traditional methods. Teeth are a good source of DNA as they are lodged in the jaws, well protected by the soft tissues of the oral cavity,

and their composition ensures a better resistance against extreme conditions of temperature, pH, water, and aging, and in many cases serve as the only tool available for victim identification [121].

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The practice of destroying the human body by immersing in acid or some other caustic substance in order to avoid any personal identification is drawing a great deal of importance in forensic sciences. The idea of such crime is to destroy any physical evidence of cause of death, time interval of death to body identification, and victim identification. In such cases, the whole body will be scorched, and very few identification marks are left. DNA extraction from soft tissues from bodies immersed in acid has proven to be difficult, if not

impossible[122]. In such cases, teeth by virtue of their physical and chemical properties can prove the criminal’s proverbial “Achilles heel.” Few studies exist on the extraction of DNA from hard tissues of the body after immersion in acids. This study was performed to assess the morphological changes of teeth at regular intervals of time upon immersion in inorganic acids till their complete dissolution and extraction of DNA followed by quantification from these teeth.

materials and methodsStudy group consisted of 85 freshly extracted human teeth. The teeth were extracted either for orthodontic or surgical reasons. Only non-carious teeth with visibly sound morphology were selected. The teeth were cleaned of any blood clot, bone, and soft tissue debris, followed by surface decontamination procedure by immersion in 5 percent sodium hypochlorite for 15 min, washed with 96 percent

ethanol, and rinsed in distilled water. The teeth were then taken for decalcification. Sixty teeth were immersed in three different inorganic acids [concentrated hydrochloric acid (HCl), sulfuric acid (H2SO4), and nitric acid (HNO3)] to assess morphological changes, and 25 teeth were used for DNA extraction after acid immersion.

Assessment of morphological changes and dissolution time in acidThe 60 extracted teeth were divided into three groups of 20 each, which were immersed in three different concentrated acids, HCl, HNO3, and H2SO4, placed in different containers. Morphological changes and softness of teeth were then observed and tabulated at time

intervals starting at 0.5 hour followed by 1 hour and subsequently on an hourly basis until there was complete dissolution or precipitation of the tooth.

DnA extractionBased on the results obtained, 25 teeth were then immersed in concentrated hydrochloric acid and DNA extraction procedure was performed at a regular time interval of 1 hour each. Conventional DNA extraction using phenol chloroform method was employed. Samples were collected by conventional endodontic approach in 1.5 ml microcentrifuge tube (Eppendorf) in phosphate-buffered saline (PBS) buffer. For digestion, 500 μl of DNA extraction TE buffer is used, which contains: 1 M NaCl, 1 M Tris-HCl, pH 8.0, 0.5 ethylenediaminetetraacetic acid (EDTA), 10 percent sodium dodecyl sulfate (SDS) was added and washed by centrifuging the microcentrifuge tube in 10,000 rpm at room temperature for 10 min. The supernatant was discarded and the pellet was re-suspended in 100 μl of DNA extraction TE buffer containing 40 μl of proteinase K (Merck, microtubes were briefly vortexed and were incubated at

60-65 degrees C for 2 hrs. Proteinase K was inactivated by heating at 85 degrees C for 15 min and centrifuging it in 10,000 rpm at room temperature for 10 min. Supernatant was collected carefully and phenol:chloroform:isoamyl alcohol (Merck) was added in a ratio of 25:24:1 followed by centrifugation in 10,000 rpm at room temperature for 10 min. The upper phase was carefully transferred into a new microcentrifuge tube. The obtained DNA was precipitated by adding 2.5 volume parts of 100 percent chilled ethanol (Merck) and centrifuging in 10,000 rpm at room temperature for 10 min. The supernatant was discarded and DNA pellet formation was seen at the end of microcentrifuge tube. This pellet was washed with 75 percent ethanol and air dried at room temperature, re-suspended in 100 μl TE buffer, and quantification was done.

DNA quantificationDNA was electrophoretically separated on an agarose 2 percent gel, and visualized on a UV screen after staining with ethidium bromide. DNA quantification was done by using Nanodrop Spectrophotometer (ND-

1000, Thermo Fischer Scientific, Wilmington DE, USA), along with determining absorbance ratio at 260/280 nm for evaluating the quality of obtained viable DNA.

REsuLts

morphological changes and dissolution time in acidMorphological changes of teeth upon immersion in three organic acids were assessed at 0.5 hour followed by 1 hour and subsequently on an hourly basis until there was complete dissolution or precipitation of the tooth [Table 9].

Morphological changes

Conc. hydrocloric

acid (h)

Conc. nitric acid (h)

Conc. sulfuric acid

(h)Effervescence Within 0.5 Within 0.5 No changeChange in enamel transparency

1-2 1-4 No change

Loss of enamel 1-4 2-6 4-12Disintegration of root

4-12 12-15 24-56

Complete dissolution

13-14 16-20 72-97

Table 9: Morphological changes observed in tooth samples on hourly basis in three different acids.


Figure 51: Sequential morphological changes after immersion in concentrated hydrochloric acid.

Figure 52: Sequential morphological changes after immersion in concentrated nitric acid.

Figure 53: Sequential morphological changes after immersion in concentrated sulfuric acid.

Hydrochloric acid samples Effervescence in solution was noticed in 0.5 hour, followed by mild softness with loss of enamel observed after two hours. Disintegration of apical third, middle third, and cervical third took place in the next

4-10 hours. Loss of structural details was noticed in eight hours and complete dissolution was seen in 13 hours [Figure 51].

nitric acid samples The changes observed in 1 hour were presence of effervescence in solution followed by yellow-colored deposits on tooth surface. Loss of enamel was observed in 2 hours and softness of tooth increased gradually from four to 10 hours. Disintegration of apical third,

middle third, and cervical third was seen around 12, 14, and 15 hours, respectively, and complete dissolution was seen in 18 hours [Figure 52].

sulfuric acid samples No change was seen in the first 1 hour, but increased color alteration was seen in 4 hours. Mild structural alteration in root portion was observed in the next 10 hours. White precipitate was observed around 18 hours. Disintegration of apical third, middle third, and cervical third was seen around 24, 40, and 56 hours, respectively, and complete dissolution was seen in 97 hours [Figure 53].

The average time taken for complete dissolution of tooth in hydrochloric acid was 13 hours, in nitric acid was 18 hours, and in

sulfuric acid was 97 hours. The P value between HCl and HNO3 (<0.0001), HCl and H2SO4 (<0.0001), and HNO3 and H2SO4 (<0.0001) was considered to be statistically significant.

Thus, based on the above observation of shorter time required for tooth dissolution, hydrochloric acid was considered for the second part of the study involving decalcification followed by DNA extraction.

DNA extraction and quantificationBased on the above findings, further experiment of DNA analysis for both quantity and quality was carried out on 25 tooth samples immersed in hydrochloric acid with five samples each in 1-5 hours.

Results [Table 10] showed that the quantity of DNA extracted from one-hour samples varied from 167.9 to 210.3 ng/μl, with an average of 194.7 ng/μl and a mean absorbance ratio of 1.62. The quantity of DNA extracted showed a steady decline over the next four hours. The five-hour samples showing a steep decrease in extracted DNA with a mean of 29.4 ng/μl. The difference between four- and five-hour samples was extremely statistically significant (P < 0.0001).

The mean absorbance ratio also showed similar change. The mean absorbance ratio also showed a decline from the one-hour sample onward and the ratio of the five-hour sample was 1.35.

Hours Mean absorbance ratio (160/180nm)

Mean quality (ng/µl)

Standard deviation (SD)

1. 1.62 194.7 16.862. 1.58 167.1 46.03. 1.54 128.2 21.414. 1.44 105.4 9.125. 1.35 29.4 9.51

Between 4 and 5 hour sample. Significance t = 12.89, P<0.0001. The value is significant if P<0.05.

Table 10: Mean absorbance ration and quality of DNA in hourly samples.

DiscussionPractice of forensic sciences often involves person/victim identification. As methods in personnel identification have increased or improved, so have the attempts of perpetrators of crime in circumventing those methods. Destruction of evidence including dead bodies by the use of concentrated inorganic acids is one such attempt. This is not entirely a novel method and came out to the fore of public realm probably half a century ago. George John Haigh, “famously”

nicknamed the acid bath murderer, had murdered five people in UK between 1944 and 1948 using concentrated sulfuric acid, which took two days to destroy the body. The only remains left were gallstones and false teeth [123].

In such cases of destruction of body by acids, soft tissues are destroyed faster than bone and tooth. Identification by morphological assessment

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of teeth can be hampered by dissolution of teeth or at least the surface traits of teeth. Use of advanced techniques like DNA analysis in such scenarios has seldom been studied. Samples containing degraded DNA are an obstacle to the resolution of practical forensic cases that involve trace amounts of evidence and offer limited or no opportunities for meaningful analysis or conclusion [124]. Hence, this study was undertaken to assess the effect of acid dissolution on DNA extraction.

Commonly used acids in such crimes are hydrochloric acid, nitric acid, and sulfuric acid because of their ease of availability, cost effectiveness, and faster destruction. In the present study, these acids were employed and their ability to destruct teeth was compared.

Among the three acids, complete dissolution of teeth was faster in concentrated hydrochloric acid and was the slowest in sulfuric acid. This is in agreement with the previous studies done by Mazza et al [122], and Kiran et al [125]. The time taken for dissolution varied in these studies as the acids were of varying concentrations. Morphological changes in the teeth can help the forensic investigator to deduce the acid used and the time elapsed since immersion of the body in the acid until it can be further corroborated with biochemical investigations. Recognizable morphological appearance of teeth persisted for eight hours in HCl, for 12 hours in HNO3, and for 25 hours in H2SO4. However, enamel changes were noticed very early, leading to complete loss of enamel within the first four hours. Any identification by morphological assessment of teeth is thus lost within the first four hours. The time taken for dissolution of tooth with hydrochloric acid in vitro was 13 hours. In actual crime settings, this may be prolonged as teeth are well protected within the jaws and the soft tissues (cheeks and tongue).

Pulp and the hard tissues (dentin and cementum) are the sources of DNA from teeth. The corrosive action of inorganic acids affects the macromolecules of the teeth, including DNA. The low quantity or impure DNA in forensic samples often results in partial or unsuccessful short tandem repeat (STRs) profiles. Studies have been done on fresh water and salt water drowning cases, where genetic material recovery was possible in only 37.5 percent of teeth, demonstrating that the water interfered directly in DNA preservation [126]. Mechanism by which water affects DNA recovery is not known; however, some components such as microbial growth and humidity are able to degrade genetic material [127] or inhibit the Taq DNA polymerase enzyme (humic acid). Effect of short- and long-term

storage of teeth was studied wherein higher concentration of DNA was found in freshly extracted teeth than in long-term stored teeth (two, five, and 10 years), which was found to be statistically significant [124].

Our study showed marked reduction in the quantity of DNA obtained in correlation to the increase in duration of acid immersion. The first 4 hours after immersion of teeth in acids provide sufficient quantity of DNA. In the fifth-hour samples, the quantity of DNA extracted reduced dramatically. This was also true for the quality of DNA extracted. Absorbance ratio of the obtained DNA can be used as an indicator of the quality of DNA, with the range of 1.6-1.8 nm for pure DNA. Pure quality of DNA was obtained in 1-hour samples and there was progressive decrease in terms of quality of the obtained DNA in later hours, which signifies the presence of impurities in the form of RNA or protein content into it. Mechanisms such as depurination have been suggested for DNA degradation by acids. Absorbance ratio, though not entirely precise in assessing the molecular changes involved in DNA degradation, is widely used as an indicator of purity of DNA. DNA typing post quantization is more precise in assessing the extent of DNA damage.

The quality and quantity of DNA obtained from teeth depend on several external factors, such as storage temperature, degree of humidity, time between death and examination, and on individual factors such as type of teeth, pathological conditions, dental treatments, and pulp weight [128]. An important factor that may lead to DNA non-amplification is the quality of the forensic biological sample. The insignificant amount of biological material to DNA extraction may result in absence of the target sequence in the fraction used for the reaction or the same can be degraded, not allowing DNA amplification by polymerase chain reaction (PCR) [129]. Our study indicates that teeth could possibly show inconsistent results for DNA analysis after acid treatment for more than five hours. The results, however, should be seen in perspective of different tooth types used in the study, age of teeth, and absence of jaw and soft tissue protection for the teeth.

Further investigations on the effects of inorganic acids on DNA, analysis of the total residue solution and not only pulpal tissue, study of different DNA extraction protocols, and DNA typing of acid-treated teeth need to be carried out to improve the efficacy of DNA analysis in such scenarios.

AcknowledgmentsThe authors thank Mr. Pramod Sarikar, Laboratory Technician, Biotechnology, Madhya Pradesh Council of Science and Technology, Bhopal, for his guidance and assistance in DNA analysis.

footnotesSource of Support: Nil Conflict of Interest: None declared

J Pharm Bioallied Sci. 2013 July; 5(Suppl 2): S185–S189. doi: 10.4103/0975-7406.114323PMCID: PMC3740674

nOn-ExtRACtIOn tREAtmEnt Of sEvERE CROwDIng wItH PEnDuLum APPLIAnCEChandrasekhar Gandikota, Yudhister Palla Venkata, Padmalatha Challa, and Shubhaker Rao JuvvadiCopyright © 2013 Journal of Pharmacy and Bioallied Sciences


Department of Orthodontics and Dentofacial Orthopedics, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre,

Hyderabad, India

1Department of Orthodontics and Dentofacial Orthopedics, Mamtha Dental College and Hospital, Khammam, Andhra Pradesh, India

Address for correspondence: Dr. Shubhaker Rao Juvvadi, E-mail: [email protected]


AbstractAn extraction case was planned for non-extraction treatment using a pendulum appliance and the effect of the appliance was evaluated in a 14-year-old girl with a severe maxillary and mandibular crowding followed by non-extraction fixed appliance pre-adjusted edgewise appliance mechanotherapy. Total treatment time was for 22 months. The obtuse nasolabial angle was maintained intact. Correction of crowding, coordinated arch forms was achieved with molar distalization. The impetus on soft-tissue paradigm is stressed in this case report and a pendulum appliance can indeed boost our clinical acumen and swing our priorities toward non-extraction treatment.

KEY WORDS: Molar distalization, non-extraction, PEA mechanotherapy, pendulum appliance, soft tissue paradigm

Maxillary molar distalization for non-extraction treatment of class II patients has become increasingly popular in recent years [130,131]. The pendulum appliance is a hybrid that uses a large Nance acrylic button in the palate for anchorage, along with 0.032-inch titanium

molybdenum alloy (TMA) springs that deliver a light, continuous force to the upper first molars without affecting the palatal button [131]. Thus, the appliance produces a broad, swinging arc or pendulum of force from the midline of the palate to the upper molars.

Bussick and McNamara [132], studied the largest sample of subjects treated with pendulum appliance to date, suggested moving the first molars distally before the eruption of second molars to avoid significant increases in mandibular plane angle and lower anterior facial height. Most studies on treatment effects induced by either the distal jet or pendulum appliance have been limited to the analysis of post-distalization changes. There is a little information about outcomes after comprehensive orthodontic treatment including a second phase of therapy with fixed appliances [133,134]. The aim of this case report is to evaluate the effect of pendulum appliance in a case of severe crowding and treatment effects were analyzed both at the end of distalization and at the end of comprehensive orthodontic treatment comprising fixed appliance therapy.

Clinical historyAn adolescent girl, aged 14 years [Figure54a-’], had a chief complaint of irregular upper and lower front teeth with no abnormal oral function and no dental or skeletal discrepancies. She had a symmetrical face, competent lips, no gingival exposure on smiling, relatively straight profile and an obtuse nasolabial angle. There was a bilateral end-on molar relationship and class I canine relationship on the right side. Maxillary left canine was not positioned in the arch and was buccally blocked out. Bilaterally the maxillary second molars were in buccal crossbite. The lower right lateral incisor was displaced lingually. The panoramic radiograph showed all third molars were present and unerupted.

Figure 54: (a-’) Pre-treatment photographs.

Figure 55: (a and b) Pre-treatment radiographs.

The maxillary and mandibular dental arch length discrepancy was − 10 mm and − 7 mm respectively. There was a Bolton’s discrepancy of 2.5 mm maxillary anterior excess, especially due to the increased mesio distal width of maxillary lateral incisors. The maxillary midline was deviated 2 mm to the right side. The over jet was 2 mm and overbite was 5 mm. There was 2 mm gingival recession in relation to 41, but without any attachment loss. Composite analysis revealed no skeletal discrepancy. Facial height and growth pattern were normal [Figure 55a and b].

treatment objectivesThe main treatment objectives were to relieve the maxillary and mandibular dental crowding, preserve good facial profile and give the patient an esthetic smile. In spite of the severe crowding, her nasolabial angle was obtuse and lips were competent. Although space requirement is indicating more toward extractions, molar distalization was opted followed by non-extraction fixed appliance mechanotherapy.

If the only consideration for this patient had been alignment, the treatment plan could have included extraction of maxillary and mandibular second premolars at the least. Extractions would have allowed alignment of the dentition easily, but may not have enhanced facial esthetics.

treatment progressSummary of treatment progress: 1. Bonding of maxillary arch, 0.014-inch Heat Activated NiTi

(HANT) on 0.022-inch Preadjusted Edgewise Appliance (PEA) with Mclaughlin Bennet Trevisi (MBT) prescription.

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Figure 56: Pendulum appliance cemented in maxillary arch.

Figure 57: Post-molar distalization photographs.

2. Two weeks later: Pendulum appliance was delivered as described by Hilgers[131], with a modification of crossover wires onto occlusal surface of both the premolars. The appliance was stabilized with glass ionomer cement onto the premolar occlusal surfaces. With the appliance in place, the 0.032-inch TMA springs with 60 degree activation were placed in the lingual sheaths on maxillary first molar bands [Figure 56].

3. Eight months: Active molar distalization phase. Further activation of pendulum appliance was stopped and maintained passively for the purpose of retention as soon as bilateral super class I molar relation was achieved [Figure 57]. At the end of this phase, cephalogram and orthopantamogram (OPG) were taken with initiation of lower bonding.

4. 12 months: U/L 19 × 25” HANT given after proximal slicing of upper laterals medially, distally resulting in 2 mm of space gain. Maxillary left canine was not engaged, maxillary second molars which were in buccal cross bite were bonded.

5. 15 months: Left upper canine was brought into occlusion with piggy back 0.014-inch HANT on 17 × 25” SS base arch wire. Distalization of premolars was carried out by open coil springs placed distal to left upper lateral incisor. Pendulum appliance was removed and 12-O-tetradecanoylphorbol-13-acetate was placed for anchorage requirements.

6. 18 months: Co-ordination of dental arches [Figure 58a -e].7. 20 months: Finishing, detailing with lateral cephalogram and OPG.8. 22 months: Debond [Figure 59].9. Retention by essix clear retainers, vacuum formed with 0.75 mm

bio-acryl sheet.

Figure 58: (a-e) Pre-finishing photographs.

Figure 59: (a-’) Post-treatment photographs.

Long-term resultsThe fixed appliance was removed after a period of 22 months. Good intercuspation was achieved. No further gingival recession was noted in relation to lower right lateral incisor. Clear retainers made of bioacry l 0.75 mm sheet were vacuum-formed and the patient was

instructed to wear them full time. Overall, the treatment result was pleasing in delivering a vibrant and consonant smile to the patient preserving the pleasing facial profile of the patient.

DiscussionMany intraoral molar distalization appliances have been designed to minimize or eliminate the need for patient cooperation. Pendulum appliances, though succeeded by many non-compliant molar distalization appliances, stands its test in delivering a range of forces for distalization and a broad, swinging arc or pendulum of force from the midline of the palate to the upper molars. Severe crowding of the upper and lower anterior teeth, buccally blocked out canine, buccal crossbite of second molars, predispose the case for extraction protocol. The decision to go ahead with molar distalization was taken up as there was no gross skeletal discrepancy and the patient still has some residual growth left. There was severe crowding, but an obtuse nasolabial angle is present along with retroclined incisors. Though studies showed that molar distalization is best achieved when the second molars are not erupted [135], a recent understanding on molar distalization by Kinzinger [136],

who stated that molar distalization is even possible in fully erupted second molars and it is the angulation of second molar and third molar tooth bud which is a detrimental factor and not the eruption status that is necessary, led to taking a decision whether to opt for molar distalization or not. The advantage with the Pendulum appliance is its design and the customized fabrication, which can be performed with ease as compared to other non-compliance molar distalization appliances, which may require stocking of inventory. Thus, a pendulum appliance can be a part of cost-effective treatment plan.

The treatment results achieved in this case report can be summarized [Table 11] as skeletal changes: During the distalization phase of treatment, there was an increased mandibular growth that was associated with a more protruded chin, in spite of slight downward and backward rotation of the mandible and resultant increase in


lower anterior facial height. These findings were expected with molar distalization [137]. The bite opening might have been caused by extrusion of posterior teeth or maxillary molars being distalized into the arc of closure. The amount of changes in vertical skeletal relationships during molar distalization is comparable with those reported in previous studies [132].

Very little change occurred in the inclination of the mandibular plane at the end of the two-phase treatment. This partly can also be attributed to the differential mandibular growth which could have occurred during the 22-month treatment period. Overall, the entire treatment shows a favorable response on the mandibular growth in improving the mild class II skeletal relationship.

Parameter Pre Rx Mid Rx Post Rx

SkeletalSNASNBGoGn S NLAFHY axis

80°75°32°

58mm64°

80°78°32°

62mm67°

80°78°33°

62mm67°

DentalU1-NAL1-NBIMPA

15°,-1mm25°, 4mm

93°

31°,-7mm25°, 4mm

93°

29°,-6mm25°, 4mm

94°

Soft TissueS Line-U LipS Line-L Lip

+2mm+2mm

0mm+2mm

+1mm+2mm

Table 11: Comparison of cephalometrics

Dentoalvelolar changesA super class I molar relationship was achieved during the active eight-month therapy with a pendulum appliance for molar distalization. The effect of cementing the appliance with glass ionomer cement applied onto premolars was detrimental in creating the posterior open bite for the unimpeded molar distalization. The molars moved posteriorly by 3 mm overall after the uprighting, during the consolidation phase, which was sufficient to achieve bilateral class I, molar and canine relationship. The amount of tipping initially was greater immediately post-distalization and later was normalized. The overall degree of tipping was acceptable. However, the anchorage loss in the anterior region was of concern in terms of mild proclination of

upper anteriors by 2 mm and 5 degrees. The overall increase in the upper anterior proclination can be partly attributed to the expression of torque with the PEA appliance and the incisors that were retroclined pre-treatment. The difference between planned incisor position and the incisor angulation achieved was 2 mm and 2 degrees, which is in the normal range keeping in view the pleasing esthetics and an obtuse nasolabial angle post-treatment. The final root paralleling, which was achieved, is a good aspect as far as retention is concerned. This stresses the proper study of assessing the treatment results only after a comprehensive fixed appliance therapy post-molar distalization.

ConclusionA pendulum appliance is a non-compliant intraoral molar distalization appliance commonly used in the treatment of class II malocclusions. This case report provides a valuable insight in opting for a non-extraction therapy. The swing to non-extraction therapy has to be more

enhanced when there is an obtuse nasolabial angle and pleasant profile to start with in spite of severe crowding. Molar distalization can be a valuable option in delivering the treatment for the above conditions.

Our findings can be summarized as follows1. Molar distalization achieved was 3 mm overall, and there was a

significant correction in the crowding.2. There was a mild increase in the resultant upper incisor angulation

than the planned incisor position, but obtuse nasolabial angle remained unchanged, resulting in a pleasing profile and esthetics.

3. A pleasant and consonant smile arc was achieved.

J Pharm Bioallied Sci. 2013 July; 5(Suppl 2): S154–S159. doi: 10.4103/0975-7406.114317PMCID: PMC3740665

sCALPEL vERsus ELECtROsuRgERy: COmPARIsOn Of gIngIvAL PERfusIOn stAtus usIng uLtRAsOunD DOPPLER fLOwmEtRy

N. Manivannan, R. S. Ahathya, and P. C. RajaramCopyright © 2013 Journal of Pharmacy and Bioallied Sciences


Department of Oral and Maxillofacial Surgery, Vivekananda Dental College for Woman, Tiruchengodu, Namakkal, Tamil Nadu, India

1Department of Periodontics, Vivekananda Dental College for Woman, Tiruchengodu, Namakkal, Tamil Nadu, India

2Department of Radiology and Imaging, Meenakshi General Hospital, Chennai, Tamil Nadu, India

Address for correspondence: Dr. Manivannan, E-mail: [email protected]

AbstractThe main prerequisites of any surgical procedure are achievement of good visibility and access to the site with minimal bleeding and rapid and painless healing. With the advancement of technology the armamentarium for oral surgical procedures has also widened.

The use of alternate methods to the traditional scalpel, such as electrosurgery, laser, and chemicals, has been widely experimented with. This article aims to report the gingival perfusion pre-operatively and post-operatively, comparing the use of scalpel and electrosurgery

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in different anatomic sites in a patient. Since wound healing is influenced by its revascularization rate, which follows the pattern of new connective tissue formation, the perfusion status of the gingiva has been studied using ultrasound spectral Doppler. The results of our study show that there was 30 percent more blood flow by the seventh day, 19 percent more blood flow by the 15th day and 11 percent more blood flow by the 30th day in sites where the scalpel was used compared with sites where electrosurgery technique was used.

KEY WORDS: Electrosurgery, gingival vascularity, scalpel technique, ultrasound Doppler, wound healing

The main objectives of any minor oral surgical procedures are an improvement of prognosis of teeth and improvement of esthetics. While surgical entry relies mainly on the scalpel, it can be approached by other means also that include electrodes, lasers or chemicals. In all cases, however, certain technical goals are essential, including control of hemorrhage, visibility, absence of harmful effects to the surgical site and adjacent tissues, post-operative comfort and rapid healing.

Successful wound healing following oral surgery is strongly influenced by the revascularization rate as well as by the preservation and reconstruction of the microvasculature of the tissues. Repair of connective tissue also depends on the development of a new vascular system, which can supply blood and nutrients to the wound area. The nutritional demands of the wound are greater than those of the non-wounded connective tissue, and they are the greatest at the time when the local circulation is least capable of complying with the demand. Furthermore, an improved healing process would also imply fewer

post-operative complications and improved post-operative comfort for the patients [138].

Several methods have been documented for measuring the gingival blood flow (GBF), including vital microscopy of the gingival margin [139], implantation of microspheres into the internal carotid artery [140], infused radioisotopes and radio labeled microspheres [141] and high speed cinematography [142], most of which are invasive and not suitable for clinical application on patients. The laser Doppler flowmetry [143], is a non-invasive and real-time method for perfusion measurements, but it has several significant shortcomings. Only a localized small area of gingival tissue beneath the area of placement of the laser probe can be studied at a time. Furthermore, comparison of blood flow changes between different sites in the same patient and between different patients is not possible [138].

To overcome the above mentioned shortcomings, we have measured the perfusion status of the gingiva by using ultrasound Doppler based on the use of soft-tissue ultrasonography (USG) and spectral Doppler studies in patients with soft-tissue [144,145], vascular [146], and osseous lesions [147] in oral and maxillofacial regions.

A case of delayed apical migration of the gingiva (excessive gingival display due to delayed migration of the gingival margin apical to the cementoenamel junction during tooth eruption) [148], with hyperpigmentation is reported. Gingivoplasty and depigmentation was carried out using both scalpel and electrosurgery at different anatomic sites. Their perfusion status was compared with soft-tissue USG and spectral Doppler study.

Case report

Figure 60: Pre-operative view.

A 22-year-old female patient reported, with a chief complaint of small teeth and black gums. On examination, gingiva appeared hyperpigmented (blackish purple in color) and the marginal gingiva was enlarged thick and fibrotic [Figure 60]. Complete medical history and blood investigation was carried out to rule out any systemic condition. A diagnosis of delayed apical migration of the gingiva with hyperpigmentation was made. Treatment plan included gingivoplasty and depigmentation under local anesthesia. The surgical procedure was explained to the patient and informed consent was obtained.

The procedure was planned to be performed using a scalpel in lower anterior and electrosurgery (surgical techniques performed using controlled, high frequency electrical currents, i.e., 1.5-7.5 million cycles/s) in the upper anterior to determine the healing pattern with these two different techniques. Gingival vascularity was determined using soft-tissue USG with spectral Doppler study.

ultrasound Doppler methodologyUSG studies were performed using a high definition USG unit with 2D, 3D and color Doppler facilities [Figure 61]. For gingival study, intracavitary convex transducer with 9-5 MHz capacity was used since this probe facilitated adequate and satisfactory intra-oral accessibility. For the study of anterior segment gingiva, a cheek retractor was used and a water-filled glove finger was placed over the gingiva. The transducer was applied over the water-filled glove finger in a coronal plane with interspersed ultrasonic gel for proper contact. The water-filled glove finger served as a water path for the sound waves and provided better clarity and detail. USG settings were adjusted for 4.5 cm depth, which would be adequate for covering the depth of the water path and the gingiva.

In Doppler settings, sound waves pass through blood vessels and get scattered (reflected) by moving red blood cells. Color Doppler settings delineate the color coded blood vessels as rounded or oval dots or linear or cylindrical structures. The number of color coded structures will indicate the number of blood vessels in the region under

study. Thus, color Doppler gives information about the amount of vascularity in the region of interest. For spectral Doppler studies, pulse wave Doppler cursor is focused over the blood vessels, which are depicted as color coded blood vessels and the update key is pressed. This enables delineation of flow pattern in the gingival graphically. Recording the flow pattern in the form of a graph (spectral Doppler) allows measurement of velocity of flow both in peak systolic velocity (PSV) and end diastolic velocity phases. These values are displayed on the monitor once the tracing over the graph is marked by auto or manual mode. This helps to measure the velocity of flow.

By the placement of the transducer in a sagittal plane over both upper (13-23 region) and lower (33-43 region) segments, study of the gingiva in both arches is possible in the same field.


Figure 61: High definition ultrasonography unit with 2D, 3D and color Doppler facilities.

Pre-operativePre-operatively the spectral Doppler study was performed in both upper [Figure 62] and lower anterior gingival segment [Figure 63]. The PSV was determined.

Figure 62: Pre-operative spectral Doppler of upper anterior segment.

Figure 63: Pre-operative spectral Doppler of lower anterior segment.

Figure 64: Scalpel being used in lower anterior segment.

surgical procedureAfter administration of local anesthesia, gingivoplasty and depigmentation (the entire pigmented epithelium along with a thin layer of connective tissue was removed) was performed using No. 15 blade (scalpel) in the lower anterior segment [Figures 64 and 65]. Hemostasis was obtained using sterile gauze and applying direct pressure on the surgical wound.

In relation to the upper anterior segment, the procedure was performed using the electrosurgery. Using a loop electrode, the entire pigmented epithelium along with a thin layer of connective tissue was removed by a planning motion from the mucogingival junction to the marginal gingiva [Figures 66 and 67]. The region was irrigated with saline frequently to dissipate the heat generated by the electrode. Care was taken that the electrode did not touch the bone. Compared with the surgical technique carried out by using a scalpel, the electrosurgery procedure produced less bleeding, which offered better visibility. The patient was placed on analgesics and 0.2 percent chlorhexidine digluconate mouth rinse twice daily for two weeks.

Figure 65: Immediate post-operative view of lower anterior segment.

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Figure 66: Loop electrode being used in upper anterior segment.

Figure 67: Immediate post-operative view of lower anterior segment (below).

Post-operative follow-upPatient was recalled on the seventh, 15th and 30th day following surgery. Both clinical examination [Figure 68a-d] and spectral Doppler studies [Figure 69a- f] were performed in the upper and lower anterior region to compare the perfusion state.

Figure 68a: Seventh day post-operative view of lower anterior segment.

Figure 68d: 30th day post-operative view of upper anterior segment.

Figure 69a: Seventh day post-operative spectral Doppler of lower anterior segment.

Figure 69f: 30th day post-operative spectral Doppler of upper anterior segment.

Figure 68b: 30th day post-operative view of lower anterior segment.

Figure 68c: Seventh day post-operative view of upper anterior segment.


Figure 69b: 15th day post-operative spectral Doppler of lower anterior segment.

Figure 69c: 30th day post-operative spectral Doppler of lower anterior segment.

Figure 69d: Seventh day post-operative spectral Doppler of upper anterior segment.

Figure 69e: 15th day post-operative spectral Doppler of upper anterior segment.

ResultsFrom the table, it is shown that there was about 30 percent more blood flow by the seventh day, 19 percent more blood flow by the 15th day and 11 percent more blood flow by the 30th day with scalpel technique when compared to that with the electrosurgery technique.

Time Scalpel (cms/s) Electrocautery (cms/s)

Pre-operative day 2.67 2.817th day 4.35 3.7715th day 3.93 3.6230th day 3.28 3.13

Table 12: Data analysis of peak systolic velocity values.

DiscussionWound healing is influenced by revascularization rate, preservation and reconstruction of microvasculature. Revascularization of the wound area generally tends to follow the pattern of new connective tissue formation. The initial response after gingivoplasty and depigmentation is the formation of protective surface clot; the underlying tissues become acutely inflamed, with some necrosis. The clot is then replaced by granulation tissue. Capillaries derived from blood vessels of the periodontal ligament migrate into the granulation tissue, and within two weeks, they connect with gingival vessels [149]. Vascularity increases initially, then begins to decrease gradually as healing takes place and returns to normal in about two to three weeks [150]. After 5-14 days, surface epithelialization is generally complete, but complete epithelial repair takes about one month [151].

In the present case report, soft-tissue USG with spectral Doppler facility was used to record the changes in GBF following gingivoplasty and depigmentation carried out by two different techniques i.e., scalpel and electrosurgery.

We have performed USG with 9-5 MHz capacity convex intracavitory transducer with color Doppler facility to determine the gingival vascularity. Color Doppler studies depict vascular areas by color coding. The flow pattern by spectral Doppler clearly indicates the velocity of venous blood flow to the region.

Doppler results in this case show comparatively decreased blood flow with electrosurgery especially by the seventh day, which could be a reason for delayed wound healing. Our results are in agreement with Almas and Sadig [152], who reported that healing was faster with a

scalpel than other techniques. The only disadvantage of the scalpel technique was unpleasant bleeding during and after the operation. Furthermore, in a comparative study of electrosurgical and scalpel wounds carried out by Nixon et al., it was observed that healing of electrosurgical wounds were delayed [153]. If only the preceding reports are taken into account, then electrosurgery has no place in dentistry. There are as many reports [154, 155, 156] that have shown that there is no difference in the clinical healing of electrosurgery and scalpel wounds. The inconsistency of reports on healing of electrosurgical wounds may be attributed to the lack of standardization of factors such as power setting, cutting stroke, surface condition of the tissue, thickness and shape of the active electrodes and depth of incision [157].

The advantages of scalpel technique include less amount of damage to adjacent tissue and comparatively faster wound healing. However, it is time consuming and allows more bleeding at the operative site. On the other end of the balance, the advantages of using electrosurgical procedures include [157]:

● Clean tissue separation, with little or no bleeding. ● Clear view of the surgical site. ● Planing of soft-tissue is possible. ● Access to difficult-to-reach areas is increased. ● Chair time and operator fatigue are reduced. ● The technique is pressureless and precise.

However, this technique has certain disadvantages [157], such as: ● The initial cost of the equipment is far greater than the scalpel.

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● Odor of burning tissue is present if high volume suction is not used.

● Although electrosurgical units are compatible with most modern pacemakers, it cannot be used on patients with older pacemakers that are not shielded against external interference.

● It cannot be used near inflammable gases.

ConclusionBefore planning a surgery, the merits and demerits of both the techniques should be evaluated and a decision on which technique to follow should be taken, keeping both the surgeon’s convenience and patient’s comfort in view. Our results in this case have shown the use of a scalpel to be more advantageous over the use of electrosurgery as far as wound healing is concerned. The use of ultrasound Doppler

flowmetry as a simple, non-invasive technique enabling direct and continuous observation of ongoing changes and alterations in the blood flow has also been depicted.

Further longitudinal studies on larger samples are required to confirm the merits of scalpel over the use of electrocautery in minor oral surgical procedures.

footnotesSource of Support: Nil Conflict of Interest: None declared.

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Dental InvestIgatIons: a ColleCtIon of Case RepoRts

final examination QuestionsSelect the best answer for each question and mark your answers on the Final Examination Answer Sheet found on page 136,

or for faster service complete your test online at Dental.EliteCME.com.

1. Barotrauma is defined as pressure-induced damage. ¨ True ¨ False

2. Boyle’s law states that as pressure increases, the volume of a confined gas doubles.

¨ True ¨ False

3. The expansion or contraction of microbubbles during pressure cycling, which eventually leads to disruption and weakening of the cement layer, could affect the retention of luting cement mixtures.

¨ True ¨ False

4. Dyskeratosis congenita (DC) is a rare inherited cardiopulmonary failure syndrome characterized by the triad of dystrophy of the nails (90 percent), reticular skin pigmentation (90 percent), and oral leukoplakia (80 percent).

¨ True ¨ False

5. Difficulties in impression making encountered due to reduced access to the oral cavity can be overcome by the use of cheek retractors.

¨ True ¨ False

6. When radicular cysts are intact, cyst cavities may be filled with brown- or straw-colored fluid, giving them a shimmering bronze appearance.

¨ True ¨ False

7. When examining bite marks for a identification purposes, apples would provide a very good advantage in positive identification.

¨ True ¨ False

8. The most reliable and best method of overlay generation in bite mark analysis is the computer-assisted method.

¨ True ¨ False

9. Being hardest and chemically the most stable tissue in the body, bones are an important forensic investigative medium in both living and nonliving populations.

¨ True ¨ False

10. Pulp and dentin are the sources of DNA from teeth. ¨ True ¨ False

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