issn : 09733442 volume 35 issue 4 jan - march...

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

ISSN : 09733442

Issue 4

Volume 35

Jan - March 2017

Dear colleagues,

Season's greetings, I thought at this point of time in the era of digital world, we as dental health care professionals should react by turning our dental clinics and dental colleges to paperless. Imagine the amount of paper wasted in the form of appointment upkeep, store maintenance etc and in dental schools large quantity of paper is wasted on photo copying on single side of paper, circulars, attendance,

stocks etc. Using E communication and converting the documents to soft copies and storing would amount to saving huge amount of paper. This would probably may save thousands of trees in our already balding country. Let's save the greenery for our future generation. Hence pledge to “reduce, reuse and recycle the paper”

With warm regards

EDITORIAL

Dr.Sudhakar M.CDr.Sadashiv ShettyDr.PruthvirajDr.Bharat ShettyDr.B. Sripathi RaoDr.Manjunath RaiDr.Veerendrakumar S.CDr.Sowmya B.Dr.Sumant GoelDr.Raghavendra KamatDr.B.S. BagiDr.C.JagadishDr.Sreenath ThankurDr.K.S GanapathyPradeepchandra ShettyDr.Ramesh ShenoyDr.Srinidhi D.Prabhuji M.L.V.Dr.Sateesh ReddyDr.Dayanand H.B.

Dr.Suraj HedgeDr.Moksha NayakDr.Padmaraj HedgeDr.B.Suresh ChandraDr.Tilak Raj T.N.Dr.Nandalal B.Dr.Jayakar ShettyDr.Ramchandra C.S.Dr.ShivaprakashDr.Veerendra B.Dr.Sreenivas VanakiDr.Sudeendra KumarDr.Beena Rani GoelDr.Ravi M.G.Dr.Krishna Nayak U.S.Dr.M.G. BhatDr.V.RanganathDr.ShivsharanDr.Pratap ShettyDr.Adarsh C.

Dr.Shashikhant RaiDr.Ramesh NadgirDr.K. UmeshDr.Asha M.LDr.Shivaprasad.S.Dr.Ramamurthy.T.KDr.Sanjay Mohan ChandraDr.Manjunath RaiDr.Uthkarsh Lokesh.Dr.Pradip RajuDr.Mohammed FaizuddinDr.Anirban ChatarjeeDr.Hemalatha SanjayDr.Anup Belludi.Dr.Santosh.RDr.Prithiv RajDr.Ravindra C. SavadiDr.Ramesh.T.RDr.Padma.K.BhatDr.Srivastava

Dr. RAJKUMAR.S.ALLEBDS, MDS, DNB, MFDS RCPS (Glasgow), FIMSA, FWFO

EDITOR-IN-CHIEF

EDITOR-IN-CHIEFDr. RAJKUMAR.S.ALLEBDS, MDS, DNB, MFDS RCPS (Glasgow), FIMSA, FWFO

Editorial Board

ASSOCIATE EDITORDr. KIRAN .H, MDS

Editorial Advisory Board

3

President:

My Dentist,Foundation of Preventive Dentistry118, Panchamantra RoadKuvempunagar, Mysore-570 [email protected]: 96866 77255

Dr. B. Nandalal

4

IDA KARNATAKA STATE BRANCHLIST OF OFFICE BEARERS FOR THE YEAR 2016-17

Mob: 98450 16003 Mob: 94481 75440

Dr. Sameer K PoteDr. Jagadish S KadamanarDr. Rithesh K BDr. Muralidhar Rai Dr. Srinivasulu P.Dr. Bharath S. V.Dr. Prashanth S Dr. Kirti Shetty Dr. M G Ravi Dr. Mahendra PimpaleDr. Kiran RaddarDr Manjunath RaiDr. Padmaraj HegdeDr. Shishir ShettyDr. Junaid AhmedDr. Roshan ShettyDr. Sanath ShettyDr. Prathap Kumar Shetty

Dr. Sudhindra Kumar NDr. Chaitanya BabuDr. SushanthDr. M L V Prabhuji Dr. Shridhar Sheelvant Dr. Sanjay KumarDr. Ashwath RajuDr. Deepak J R Dr. Satish Kumar Patil Dr. Raghunath ReddyDr. Utkarsha LokeshDr. Raghavendra N Dr. Sanjay Kumar D.Dr. Krishna PrabhuDr. Pramod ShettyDr. Smitha TDr. Jithesh NDr. Shivakumar Swamy

Dr. Tilakraj T.N.Dr. ShivasharanDr. Adarsh C.Dr. T K Ramamurthy Dr. Bhat M. G.Dr. H P Prakash Dr. Krishna NayakDr. Narendra Kumar M Dr. Bharath Shetty Y.Dr. Girish Sharma Dr. Mahesh ChandraDr. Raghavendra PidamaleDr. Veerendra Kumar S CDr. Ramachandra MallanDr. Sudhakar M. C.Dr. Jagadeesh C.Dr. Sanjay Mohan ChandraDr. Srinidhi D.Dr. Annaji A G

Dr. Ranganath V.Hon. Secretary, IDA Karnataka Branch

5

PRESIDENT’S MESSAGE

SECRETARY’S MESSAGE

I have been pleased and honored to serve you, the members and the Indian Dental Association Karnataka State Branch as President this year. The mission of IDA is to advance increase knowledge for the improvement of oral health across the region ; to support and represent the oral health community; and tofacilitate the communication and application by Awarenesss among the public.

In support of the mission, the Association continued to provide professional development and publication opportunities for members.Large number of attendees from all the branches allow delegatesopportunities to network with the community of clinicians and researchers while exploring the latest scientific discoveries in the field.

The IDA Karnataka StateJournal continued to serve this year, thanks to the high quality of research that scientists and clinicians submitted for publication in the Journal. The high caliber of science of the Journal has had high impact and helped it achieve appreciationproviding increased opportunities for publication encompassedthe complete spectrum of oral, dental and craniofacial investigation with a focus onclinical and translational research.

The increasing importance of translating findings into clinical practice provided impetus for Research. Under the editorship of DrRajkumar. This groundbreaking new softcopy version of the print journal will be dedicated to publishing more original dental, oral and craniofacial research at the interface between scientific discovery and clinical application with the translation of research into healthcare delivery at the individual patient, clinical practice and community levels.

As scientists, we know that research discovery does not occur in isolation. Science is a continuum of knowledge that builds on the previous work of others, and today's discoveries will provide the foundation for further efforts. We must support our research community and extend our reach if we wish to further our science.

Also IDA continues to encourage members to collaborate with their fellow member colleagues and be active in the Association by participating in at least at the CDE for clinical and research updaesboth at the State and local branch meetings.

I encourage all Ida members to remainengaged so that together we can support the Ida mission and improve oral healthNationwide.

Sincerely,

The sizzling hot summer is coming to an end with the hope of a good monsoon and it is time for me to share some wonderful news with all of you!!

The IDA Karnataka state branch is doing an excellent job in conducting innovative CDE programs, workshops and training programs. It is a great pleasure to visit different branches and interact with the members. I hope the trend continues.

It’s a great pleasure to share with all of you that the great pace at which the Dantha Bhavana expansion and renovation work is progressing. The columns of the second floor have been raised and now the roof work is going to commence. No words of appreciation are enough to thank Dr M C Sudhakar for all the efforts put in this regard.

I take this opportunity to request all the members of the state to register for the annual state conference in Hubli. The organizing team of the Hubli-Dharwad branch are working overtime to present a spectacular show and I am sure all the members will benefit from attending the conference.

Looking forward to meeting you all in Hubli soon.

Warm regards,

Dr. Ranganath

B NandlalPresident, IDA Karnataka Branch

Dr. Shubhan AlvaPast President, IDA Karnataka Branch

Greetings from the office of the Indian Dental Association – Karnataka State Branch

“Unity is Strength…….When there is teamwork and collaboration, wonderful things can be achieved” - Mattie J. T. Stepanch

As I come to the end of my term as the President of the Indian Dental Association, Karnataka State Branch, I can claim with conviction that our team has done it's best to take the association to greater heights. We have been working continuously for the welfare of the dental fraternity, an example being our efforts to curb the menace of unethical advertising by corporates and others in close co-ordination with Karnataka State Dental Council. Our leadership across the board including local branches is innovative and energetic, and it shows in every program they execute. The incredible work done by our grassroots members has allowed us to achieve a lot in the past one year.

For the first time IDA has taken steps to promote research at the undergraduate level by instituting research grants. I am happy to say that we have received a tremendous response and I am sure that this step of ours will bear fruit in the future by encouraging students to take up research based sciences as a career.

We have attempted to integrate oral health to primary health care by involving and educating Anganwadi workers. It was a huge endeavor undertaken in association with the Zilla Panchayaths and achieved reasonable success in its implementation.

Another innovative program was the training of primary school teachers in handling dental emergencies like tooth avulsion. Hank's solution was distributed in many primary schools of the state. We have also conducted school dental programs with special emphasis on tobacco control.

As a commitment towards the society an organ donation drive was launched among the dentists across the state wherein hundreds of dentists have pledged for this noble cause which in turn would motivate the general public.

On the going green initiative – Vanamahotsava was observed by distributing saplings to the Government schools. In addition to this, a lot of outreach programmes were conducted especially for the underprivileged.

th rdI am looking forward to the 44 Karnataka State and 3 Inter State Dental Conference at Hubli-Dharwad, the place which has rich culture, traditions, colorful folklore and warm hospitality. I am sure that this conference will be a memorable one as the entire organizing committee has put in a lot of hard work and has left no stone unturned.

It has been a privilege to be a part of IDA and I would like to express my sincere gratitude to each and every member for providing me an opportunity to serve this prestigious organization as the Karnataka State Branch President.

I would like to place on record my heartfelt appreciation to all the office bearers especially the secretary, Treasurer, EC and CC members, Branch Presidents, secretaries, editor and my friends for their unflinching support in the smooth functioning and conduct of all round activities at State and Local Branch Levels.

Wishing you all a Great Year ahead!

PAST PRESIDENT’S MESSAGE

6

CONTENTS

7

1.a Tertiary Care Hospital in India

2. A study to assess oral health related knowledge attitude and practices of 12anganwadi workers of Mangalore Taluk - A questionnaire study.

3. Strategic Approach to Restore Esthetics and Functional Balance: 18A Multi-Disciplinary Case Report

4. The quest for an attractive face & profile 24

5. Fusion or Germination : A Case Report 28-

6. ACP V/S Potassium nitrate -A Clinical evaluation-

31

7. Prosthodontic Management for Atrophied Foundation - A Review 35-

Awareness regarding HIV/AIDS among youth attending 8

3-Dr B. Divya Bhat, Dr Vijaya Hegde, Dr Shubhan Alva Dr Pooja J Shetty

- Dr. Vijaya Hegde, Dr. Ambili. Nanukuttan

- Dr. Anup Belludi, Dr. Navraj Mattu, Dr. Aravind. M Virupaksha

3-Dr. Faisal Arshad, Dr. Bharathi VS, Dr. Lokesh Nk , Dr. Suma T

Dr. Kaushal Jha, Dr. Swati Tripathi, Dr. SatyajithNaik, Dr. Pallavi Vashisth

Dr Souparna Madhavan, Dr Moksha Nayak, Dr Lavanya Varma, Dr Rajesh Shetty, Dr Manoj Varma

Gautam Shetty, Shweta Prakash, Shwetha Poovani, Krishna Kumar

8

Abstract:

Context: More than one third of reported cases of HIV/AIDS in India are among youth who are vulnerable. The challenge lies in developing a programme to induce behavioral changes among the youth. This can be done by knowing their baseline knowledge regarding the infection.

Aim: Aim of this study is to know the awareness among the youth visiting a tertiary care hospital towards HIV/AIDS.

Methodology: A cross sectional questionnaire based study was conducted to know the awareness about HIV/AIDS among the youth attending a tertiary care hospital. It was conducted for a period of three months among youth aged 15-18 years. The data was analyzed using SPSS Version 17 (Chicago: SPSS Inc).

Results: A total of 142 subjects completed the questionnaire. Among them 63.8% of the study subjects were aware that HIV could be diagnosed. Among the respondents 78.3% knew that HIV/AIDS is a sexually transmitted disease. It was alarming to know that 10.7%, of the study subjects felt that the infection spreads through mosquito/bedbug bite. Only 75.9% of the participants were aware regarding safe sex.

Conclusion: The study findings reflect that though a considerable number of study subjects had correct knowledge about HIV/AIDS they lacked the details about the disease.

Key-words: Cross sectional study; Acquired Immunodeficiency Syndrome; safe sex;

Key Messages: HIV prevention in India should be more focused on target groups such as Commercial Sex Workers, street Youth/Children who are vulnerable to sexual exploitation.

AIDS is a modern pandemic affecting industrialized and developing countries. More than one third of reported cases of HIV/AIDS in India are among

1youth. This group is vulnerable due to incomplete 2 social, emotional and psychological development.

The economic growth of the country is also hampered as itaffects the most vulnerable group. It

has been a major Public health challenge with no state free from the virus. However in 1992, India's first National AIDS control Programme (1992-99) was launched and National AIDS control organization was constituted to implement this

3programme . year around 2.7 million people get infected with the virus and two million people die

4of AIDS. The challenge lies in developing a programme to induce behavioral changes among

Introduction:

Awareness regarding HIV/AIDS among youth attending a Tertiary Care Hospital in India

the youth. This can be done by knowing their baseline knowledge regarding the infection. Hence a study is conducted to know the awareness among the youth visiting a tertiary care hospital towards HIV/AIDS.

Methodology:A cross-sectional study was conducted among youths in the age group of 15 to 18 years attending a tertiary care hospital in India. The study was conducted for a period of 3 months. Ethical clearance was obtained from the Institutional Review Board. The study subjects were provided an overview of the purpose of the study. Voluntary nature of participation was emphasized and was informed that there was “right” or “wrong” answers to the survey items. The knowledge and attitude

1. Dr B. Divya BhatPostgraduate Student, Department of Conservative Dentistry and Endodontics, A.J. Institute of Dental Sciences, Mangalore, India

2. Dr Vijaya Hegde Professor and Head, Department of Public Health Dentistry, A.J. Institute of Dental Sciences, Mangalore, India

1 2 3 4AUTHORS : Dr B. Divya Bhat , Dr Vijaya Hegde , Dr Shubhan Alva , Dr Pooja J Shetty

3. Dr Shubhan Alva Reader, Department of Public Health Dentistry, A.J. Institute of Dental Sciences, Mangalore, India

4. Dr Pooja J ShettyAssistant Professor, Department of Public Health Dentistry, A.J. Institute of Dental Sciences, Mangalore, India

9

about HIV/AIDS was col lected using a Questionnaire obtained from a study conducted by

5Raut M et al. All items provided Yes (=1) or No (=0) responses.

Informed consent was obtained from the parents of the study subjects. Only the subjects who were willing to participate in the study were selected. To maintain the confidentiality of the subjects, their name was not obtained and the entire questionnaire was coded. The data from the questionnaire was entered into a computerized data base and analyzed using SPSS Version 17 (Chicago: SPSS Inc).

Results:A total of 142 subjects were interviewed visiting the tertiary care hospital, Mangalore City, India. The study subjects comprised of 35.2% boys and 64.8% girls. The mean age of the study subjects was 15.5 years.

Table-1 shows the awareness among study subjects to HIV/AIDS. Among them 63.8% of the study subjects were aware that it could be diagnosed. More than half of the study subjects knew that the disease could not be cured. Among the respondents 78.3% knew that HIV/AIDS is a sexually transmitted disease.

Table-2 shows the data regarding the source of the infection. The study found that 46% and 44.5% of them had acquired the information from newspaper, Television/Radio.

Table-3 shows the awareness regarding the disease transmission. It was alarming to know that 10.7%, 9.9% and 9.2% of the study subjects felt that the infection spreads through mosquito/bedbug bite, shaking hands, using contaminated water/ food respectively. It was encouraging to know that 93.2% and 81.1% of them knew that it spreads by sexual contact and from infected mother to her fetus respectively.

Table-4 shows that 86.4%, 67.9%, 44.3% were aware that the symptoms were loss of weight, long fever and diarrhea. Only 22.9% and 23.6% of them thought that cough and tuberculosis were the symptom of the infection.

Table-5 shows the attitude towards HIV/AIDS patients. It was revealed that 94.6% and 77.2% of

the participants think that HIV testing is necessary before marriage and that they should be allowed to do their job. Only 75.9% of the participants were aware regarding safe sex.

Discussion:Globally there is lack of knowledge among the youth related to HIV/AIDS infection. The world Health Organization (WHO) states that youths are at the epicenter of preventing the progression of

6this pandemic. Poverty, low socio economic status, illiteracy play a very important role in spread of this pandemic.

More than half of the study subjects knew that it is a sexually Transmitted Infection. 32.8% of the respondents responded that the disease can be cured. This finding is in contrast to a study done by

7 Singh A and Jain S. The main source of AIDS awareness among the Youth was from News Paper, Television and Radio. This is similar to study

8conducted by Gupta P, where the main source of information was Television. According to a study

9done by Bhalla S revealed that the students got the information from books, followed by TV, newspapers and the health personnel. Only a small per cent of the adolescents mentioned radio as a

10source of information for HIV/AIDS. Ahmad A reported similar results, where the study subjects obtained information from Television and Peers. This is because media plays a pivotal role both in a formal and informal way.

Majority of the study participants knew that the infection spreads through sexual route, from pregnant mother to her unborn fetus and infected blood transfusion. This may be due to various awareness campaigns and increased use of mass media among the youth. A small percentage of the study subjects thought that it spreads by eating together, kissing, sharing bathroom/toilet and use of contaminated food and water. Removal of such misconceptions among the youth is very important, as it might lead to phobia, stigma and discrimination against the infection among the mass. Similar observation was reported by Singh A

7 and Jain S. Sexual route was the main mode for transmission of infection was mentioned by 93.2% of the study subjects. Other similar studies have also reported maximum number of respondents

.2, 7being aware of sexual route of HIV transmissionScientific knowledge about HIV/AIDS is essential for the youth, which may lead them to take rational

KSDJ / Vol 35/Issue 4/Jan - March 2017

Table-3: Responses to questions regarding the Transmission of HIV/AIDS.

Route of Transmission

Knowledge regarding spread of infection

Spreads through mosquito bite Spreads through shaking hands Spreads through Blood

Transfusion Spreads through contaminated

water/food By Kissing

By Sexual Contact By Sharing Needles, Razor

blade Transmits from infected

mother to her foetus

Yes (%)

88.6

10.7 9.9

85.5

9.2

27.5 93.2 87.9

81.1

No (%)

11.4

89.3 90.1 14.5

90.8

72.5 6.8

12.1

18.9

10

decisions. In the current study 61.2% felt that sex education was good. Majority of the study subjects felt that HIV/AIDS patients should be allowed to do their job. Similar results have been reported by

5Raut Mohan. Only 24% of the study subjects had knowledge of safe sex. This finding was in contrast

4 to a study done by Shweta C et al. This may be because the emphasis laid on sex education in schools is less and in an orthodox Indian society it is usually not discussed. Majority of the study subjects responded that the main symptom of HIV/AIDS was weight loss followed by fever for a long time.Sexually transmitted infections in India rank third

among communicable diseases. HIV prevention in India should be focused on target groups such as Commercial Sex Workers, street Youth/Children

6who are vulnerable to sexual exploitation.

Conclusion:The study findings reflect that though a considerable number of study subjects had correct knowledge about HIV/AIDS they lacked the details about the disease which advocates the need of properly formulated awareness campaigns on HIV/AIDS.

Particulars Is there any relation between sexually transmitted infection and HIV/AIDS Is HIV a STI Can it be Diagnosed Can it be Treated Can it be Cured

Yes (%) 62.2

78.3 63.8 59.2 32.8

No (%) 37.8

21.7 36.2 40.8 67.2

Table 1: Respondents awareness regarding HIV/AIDS

Table 2: Responses to the questions about sources of Information

Particulars Friend Relatives News Papers TV/Radio Government Organisations

NGO

Yes (%) 38

20.4 46

44.5 27.7

10.9

No (%) 62

79.6 54

55.5 72.3

89.1


11

Table 4: Responses to the questions regarding Symptoms of HIV/AIDS

Particulars Longer Fever Weight Loss Chronic Diarrhoea Longer Cough Tuberculosis

Yes (%) 67.9 86.4 44.3 22.9 23.6

No (%) 32.1 13.6 55.7 77.1 76.4

Table 5: Respondents attitude towards HIV/AIDS patients

Particulars Respondents will remain Friendly to a person with HIV/AIDS Others will remain friendly with a HIV/AIDS person HIV testing is necessary before marriage Sex Education is Good Knowledge regarding safe sex Should they allowed to do their job

Yes (%) 78.5

32.4

94.6

61.2 24.1 77.2

No (%) 21.5

67.6

5.4

38.8 75.9 22.8

References:1) Yadav SB, Makwana NR, Vadera BN, Dhaduk KM,

Gandha KM. Awareness of HIV/AIDS among rural youth in India: a community based cross-sectional study. J Infect Dev Ctries. 2011; 5(10):711-6.

2) Rao S, Palani G, Iyer RH. A Cross-Sectional study of HIV/AIDS awareness among college students and influence of lifestyle. Sri Ramachandra Journal of Medicine 2011; 14(1): 5-10.

3) National AIDS Control Organisation: Department of Health and Family Welfare. About NACO. Accessed f r o m : http://www.naco.gov.in/NACO/About_NACO/ (02-05-2016)

4) Shweta C, Mundkur S, Chaitanya V. Knowledge and Beliefs about HIV/AIDS among Adolescents. Webmed Central PAEDIATRICS 2011;2(12): WMC002830

5) Raut M, Sampda R, Vilas M, Umesh J, Pravin S, Sanjay W. Knowledge, Attitude and Practice regarding HIV/ AIDS among auto drivers in one of the urban area of India. Journal of pharmaceutical and biomedical sciences 2013; 31(31): 1229-1232.

6) Banerjee P, Mattle C. Knowledge, Perceptions and Attitudes of youths in India Regarding HIV/Aids: A Review of Current Literature. The International Electronic Journal of Health Education 2005; 8:48-56.

7) Singh A, Jain S. Awareness of HIV/AIDS among School Adolescents in Banaskantha District of Gujarat. Health and Population Perspectives and Issues 2009; 32(2): 59-65.

8) Gupta P, Anjum F, Bhardwaj P, Srivastav J, Zaidi ZH. Knowledge About HIV/AIDS Among Secondary School Students. North American Journal of Medical Sciences. 2013; 5(2):119-123. doi:10.4103/1947-2714. 107531.

9) Bhalla S, Chandwani H, Singh D, Somasundaram C, Rasania SK, Singh S. Knowledge about HIV/AIDS among senior secondary school students in Jamnagar, Gujarat. Health Popul Perspect Issues. 2005; 28: 178–88.

10)Ahmed A. Knowledge regarding STDs, AIDs and reproductive health among male adolescents. Indian J Prev Soc Med 2007; 38 (3&4): 159-165.


INTRODUCTION

Oral healthplay an important part of general health.Poor oral health in early childhood is one of the most serious and costly health conditions in

1young children. Good oral health practices are necessary from a young age to ensure positive long-term oral health and hygiene and is an essential and leading component of children's overall health,

1,2functional capacity and social welfare. Globally the two most common oral diseases are dental caries and periodontal disease and they often begin in childhood and present a major public health

3problem in preschool children. India is a country which is predominantly rural, as over 72 % of people continue to live in rural areas with a critically low dentist to population ratio of only 1:1,00,000 compared to urban areas which is

41:35,000. The lack of availability and affordability of oral health services in India results in aggravation of the disease and also enhance the

5cost of treatment and care. In a developing country like India, it was observed that prevalence of early childhood caries and gum disease is higher (70%)

4compared to developed countries (1-12%). As the disease starts in early childhood with the eruption of the milk tooth, preventive strategies would be

A study to assess oral health related knowledge attitude and practices of

anganwadi workers of Mangalore Taluk - A questionnaire study.

AUTHORS: 1 2Dr. Vijaya Hegde Dr. Ambili. Nanukuttan

ABSTRACT:

INTRODUCTION: The anganwadi worker (AWW) is a community-based voluntary frontline worker of the ICDS program. They play a vital role in improving health of the community whom they serve especially in rural areas. They form a potential vehicle for disseminating oral health-related message and have successfully demonstrated their useful role in developing healthy habits in early childhood. Aim: To assess oral health related knowledge attitude and practices of anganwadi workers of mangaloretaluk. Materials and Methods: A specially designed, comprehensive, pretested, structured, close ended, self-administered questionnaire consisting of 16 questions were used for the study. The data was statistically analyzed using descriptive statistics. Results: A total of 160 anganwadi workers participated in the study.Almost 45% feels that there is no need to take care of milk teeth. 65.6% of them did not know that its important to start cleaning baby's mouth even before tooth erupts. Only 11.2% of them knew that fluoride helps in prevention of dental caries.92.5% of AWW strongly feels that they need more information/training to create more awareness regarding oral health. Conclusion: The results of the present study had shown that knowledge and awareness of AWWs is not adequate. Therefore, there is a need for further education on certain preventive and curative aspects of oral diseases and maintenance of oral health.

Key words: Anganwadi worker (AWW), awareness, knowledge, attitude, practices, oral health

1. Dr. VijayaHegde, MDS (Head of the Department of Public Health dentistry, A.J.Institute of Dental Sciences, Mangalore).

nd2. Dr. Ambili.Nanukuttan, BDS (2 year Post Graduate Student, Department of Public Health dentistry, A.J. Institute

most effective if it is started on or before the time of 4

eruption of milk tooth at about 6 months of age.

As India's response to the challenge of meeting the holistic needs of the children, the Integrated Child Development Services (ICDS) program, one of the flagship programs of the Government of India, was launched on 2nd October 1975 in pursuance of the National Policy for Children, 1974. It is one of the world's largest and most unique outreach program for early childhood care and development. It symbolizes India's commitment to its children. And is Eligible beneficiaries covered under this program are children below 6 years of age, pregnant women, nursing mothers and adolescent girls. The package of services is provided to the beneficiaries through the anganwadi centers (AWC) managed by an anganawadi worker and

1helper at the village level and also in urban slums.

The anganwadi worker (AWW) is a community-based voluntary frontline worker of the ICDS

1 program. System of ICDS anganwadis has played useful role for developing healthy habits like brushing teeth and hand washing in the anganwadis through non-formal education

1 methods. They focus on pre-school children

1(under 6 years).

12

AWW are grass root workers (serves about 1000 5

population per AWW). They are formally trained for non-formal, pre-school education which caters to the developmental needs of children between 3 and 6 years of age, primary health care and first-aid to children under 6 years and pregnant and nursing mothers, supplementary feeding of children of ages 0-6 years, referral services for severely malnouri-shed children, and assisting health staff in

1 immunization. They have successfully demon-strated their useful role in developing healthy

5habits in early childhood.

Teachers are considered as role models to transmit values of life. Students follow what teachers do and

6say. Shaping ways of life and personality development should start from preschool level and

6is the key responsibility of teachers and parents. Since anganwadi workers play a role of teacher for preschool children, it is important for empowering anganwadi workers in oral health, and providing basic oral health awareness to the mothers through them is a feasible model for a country like India; where oral health is not a priority in the primary

1,5health care as yet. At the anganwadis, monthly meeting of mothers are held and these serve as

1,5platforms for health education.

Assessing the knowledge, attitude and practices (KAP) of AWW is the first step towards obtaining a baseline data for planning workshop on training courses and oral health education program for anganwadi workers which will help in strengthening their skills which will in turn enable them to identify high risk children and further

1,7empower the mothers for preventive action. 1

Studies on oral health of children is scarce till date.Hencethe present study aims to assess the level of the knowledge, attitude and practices of anganwadi workers regarding the oral health of preschool children in Mangalore taluk.

MATERIALS AND METHODS

The study was a descriptive, cross-sectional questionnaire survey. The study was conducted in Mangalore taluk, located in Dakshina Kannada district of Karnataka state, India. The permission to conduct the survey was obtained from Women and Child Development Department; Mangalore. The study population included 160 anganwadi workers of Mangalore taluk. Convenience sampling was done and those who were willing to participate

were included in the study.

A specially designed, comprehensive, pretested, structured, close ended, self-administered questionnaire consisting of 16 questions were used for the study. Questions were related to knowledge, attitude and practices regarding the oral health of children. The questionnaire was prepared in the local language of Kannada.

Inclusion criteria:

1.All anganwadi workers of Mangalore taluk, who were present on the day of study and who were willing to participate.

Exclusion criteria:

1. Those who were not available on the day of questionnaire distribution.

thThe study was conducted on 25 September 2016. The study participants were obtained during their monthly meeting at a primary health centre. The questionnaire was distributed to all anganwadi workers who were present on the day of the study.

Descriptive statistics were obtained andmeans, frequency distribution and percentages were calculated. The data was analysed using SPSS version 17.

RESULTS

The results of the study have been depicted in table 1 and 2. A total of 160 anganwadi workers responded to the questionnaire and all of them filled the questionnaire completely. Their age ranged from 29-47 years with a mean age of 37 years. It can be appreciated from table 2 that, 76.2% of them knew that the first milk tooth erupt in a child's oral cavity at 6 months of age. Almost 45% feels that there is no need to take care of milk teeth, because they will fall after some time.65.6% of them did not know the importance of cleaning baby's mouth even before tooth erupts. Only 11.2% of them knew that fluoride helps in prevention of dental caries. Though 80% of them knew that lack of nutrition in a pregnant mother affect her child's oral and dental health, only 21.2% of them knew that poor gum health in a pregnant woman may lead to preterm labour. 48.8% were aware of the effect of liquid sugar medications on teeth.When question was asked about attitude of angenwadi workers on putting a child to bed with sweetened milk in a bottle, only 3.8% of them strongly

13


disagreed and said it is not okay for child's teeth. Almost 92.5% of AWW strongly feels that they need more information/training to create more awareness regarding oral health among children and parents and 93.1% of them strongly agrees that they have an important role to play in the maintenance of the child's oral health and almost 94.4% of them strongly agrees that dental checkups must be integrated with the general health checkups for the anganwadi children. When question regarding the need to go to a dentist was asked, 40% of them were of the opinion that one need not go to a dentist unless he or she has a painful tooth. Almost 6.9% of them do not check whether the child gargles his/her mouth with water after meals/snacks. When questions regarding practices were asked, 95.6% of them use toothbrush and paste for brushing, 46.9% of them use sweet itemswith meals and only 21.2% knew that vigorous tooth brushing leads to abrasion.

Age in years Subjects

26-35

36-45

46-55

Total

68 (42.5%)

90 (56.3%)

2 (1.2%)

160 (100%)

Table1: Distribution of anganwadi workers according to age.

Table 2 : Questionnaire used to assess KAP of AWW regarding oral health.

Questions Responses Frequency (%)

Related to knowledge:

1.When does the first milk tooth erupt in a child’s oral cavity ?

a. 3 months 11 (6.9)

b. 6 months 122 (76.2)

c. 1 year

27 (16.9)

2.There is no need to take care of milk teeth, because they will fall after some time.

a. yes

72(45.0)

b. no

85(53.1)

3.: What time is appropriate to start cleaning baby’s mouth?

a.

before eruption of first milk tooth

55(34.4)

b.

after eruption of first mik tooth

68(42.5)

c.

after erution of all teeth

37(23.1)

4.What is the reason to add fluorides in drinking water supply?

a.

to prevent caries

18(11.2)

b.

to purify water

130(81.2)

c.

to prevent bad breath

12(7.5)

5.Will lack of nutrition in a pregnant mother affect her child’s oral and dental health?

a. yes

128(80.0)

b. no

20(12.5)

c. dont know

12(7.5

)

14


6.Poor gum health in a pregnant woman may lead to a. pre termlabour 35(21.9)b.no effect on child

56(35.0)

c. dont know

69(43.1)

7.Do you know effect of liquid sugar medications on teeth?

a. yes

78(48.8)

b. no

41(25.6)

c. dont know

41(25.6)

Related to attitude

8.Putting a child to bed with sweetened milk in a bottle is okay for child’s teeth

a. strongly agree

64(40.0)

b. agree

86(53.8)

c. disagree

4(2.5)

d.strongly disagree

6(3.8)

9.Do you feel you need more information/training to create more awareness regarding oral health among children and parents?

a.strongly agree

148(92.5)

b. agree

12(7.5)

10.AWW has an important role to play in the maintenance of the child’s oral health

a.strongly agree

149(93.1)

b. agree

11(6.9)

11.Dental checkups must be integrated with the general health checkups for the anganwadi children

a.strongly agree

151(94.4)

b. agree

9(5.6)

12.One need not go to a dentist unless he or she has a painful tooth

a. agree

64(40.0)

b. disagree

96(60.0)

13.Do you check whether the child gargles his/her mouth with water after meals/snacks

a. yes

149(93.1)

b. no

11(6.9)

Related to practice

14.q14: Type of material used for brushing

a.

toothbrush and paste

153(95.6)

b.

tooth 6(3.8)

DISCUSSION

This study presented a comprehensive view of the oral health knowledge, attitude and practices of anganwadi workers of Mangalore taluk.Anganwadi workers play a mojor role in developing behavior of preschool children of rural India. They teach cleanliness and basic knowledge of health to parents. Since children who suffer from poor oral health will inturn effect general health, hence they are more likely to have restricted activity than those who do not. Oral hygiene practices should be instilled at a very young age.Anganwadi workers can also contribute a major part for providing health education to parents so that they can also incorporate a healthy life for their children. To achieve this, knowledge attitude and practice level of anganwadi workers should be known for any further action to be taken.

In the present study, 76.2% of them knew that the first milk tooth erupt in a child's oral cavity at 6

1months of age. According to Shilpaet al , 68.9% of the AWW knew the appropriate eruption time. Almost 45% AWWfeels that there is no need to take care of milk teeth, because they will fall after some time which was on the contrary to a study

8conducted by Poornimaet al, where 64.7% of AWW agreed that there is no need to take care of the milk teeth because they will fall after sometime. In a

9study by Arora et al on AWW of Udaipur city, 21.6% of them feels thatit is appropriate to start cleaning baby's mouth after all the teeth erupts to oral cavity which is in accordance with the present study. In the present study, AWW had poor knowledge on fluorides and its effects on prevention of dental cariessimilar to a study conducted by Chanchal et

10al on AWW of Uttar Pradesh. Regarding effect nutrition in a pregnant mother on her child's oral and dental health, 80% of them knew that lack of nutrition in a pregnant mother affectson her child's oral and dental health this results were better than

15


11the one given by Schroth et al where only39.5% of the caregivers knew about influence of mothers diet on infants teeth.Regarding the relation of gum health in a pregnant woman on labor, 21.2% of them knew that poor gum health in a pregnant woman may lead to preterm labour which was in

[1]accordance with the study by Shilpa et al . Only 48.8% were aware of the effect of liquid sugar medications on teeth which was not in accordance

12with Almas et al , where almost all school teachers of Riyadh, Saudi Arabia knew the effect of sugary drinks in dental caries. When question was asked about attitude of anganwadi workers on putting a child to bed with sweetened milk in a bottle, 53.4% of them felt that it is not okay for child's teeth which was in accordance with the study conducted by

13Mani et al on caretakers of children attending day care center's, 56% thought that nighttime and frequent bottle feeding did not cause tooth decay. When question regarding the need for more information and training was asked, almost 92.5% of AWW strongly feels the need to create more awareness regarding oral health among children and parents which is similar to the study by

1Shilpaet al where 95.5% of AWW agreed that they need more training and information regarding oral health to create more awareness. Almost 93.1% of AWW strongly agrees that they have an important role to play in the maintenance of the child's oral health which is similar to the KAP study conducted

14on preschool teachers of Karachi, by Dwani et al. In the present study almost 94.4% of them strongly agrees that dental checkups must be integrated with the general health checkups for the anganwadi children. When question regarding the need to go to a dentist was asked, a40% of them were of the opinion that one need not go to a dentist unless he or she has a painful tooth which is on contrary to

[10]Chanchal et al where more than half (53.3%) go to dentist due to painful teeth. In the present study 93.1% of AWW check whether the child gargles his/her mouth with water after meals/snacks

5which is contradictory to Raj et al , where only 37.5% of AWW are aware of mouth rinsing habit of preschool children. Almost all anganwadi workers(95.6%)used toothbrush and paste for

15brushing,similar to the study by Pankajet al . In the present study 53.1% of them did not use sweet items with meals which is contradictory to

2Shakyaet al , where 57.2% of AWW of Mangalore city used sweet items with meals. According to

16Bhambalet al , 37.5% of anganwadi workers feels the important cause for gum bleeding is vigorous tooth brushingwheras in this study 21.2% knew that vigorous tooth brushing leads to abrasion.

Though the study showed that AWWs of Mangalore talukhave moderate knowledge about oral health,the study has certain limitations like the results presented here, are based on a small sample size and a much more detailed assessment on KAP needs to be assessed. Although there are few limitations,the study showed that heir KAP is less than desirable and very poor in some dimensions. It also highlighted that almost all workers were unaware of the preventive role of fluorides in prevention of dental caries. As health workers, it is imperative to reach the population at large with the requiredhealth message hence, anganwadi workers need to be trained for the same.The present data can be utilized for planning an education and training programmefor AWW which should include oral health related curriculum for up- gradation of their knowledge.

CONCLUSION

An anganwadi worker can be a vital link in the health care delivery system as she is in a position to provide a package of services to mothers and children.Several habits having influence on health and as well on oral health do get molded during early childhood period. Since the topic of oral health is given a low priority in anganwadi workers training curriculum, there is a need to educate them on oral health in order to reach children at an early and receptive age. On empowering them with adequate knowledge on oral health and related diseases, she can work as an oral health guide and educate the parents about oral health diet, reasons for different dental problems in children, oral habits, teething, dental caries process and the necessity to get the dental treatment at the earliest stage, educate pregnant women about the oral changes during pregnancy and finally, they can provide information proper oral hygiene practices for children up to 6 years of age. In order to do this effectively AWWs need to have themselves the required knowledge, attitudes and practices which

2,17are favorable towards oral health.

REFERENCES

1.Shilpa M, Jai J, Ananda SR, Hiregouda M, Abhishek KN, Sneha CK. Knowledge, Attitude, and Practices

16


of Anganwadi Workers Regarding Oral Health of Children in VirajpetTaluk. Journal of Advanced Oral Research. 2014;5:18-23.

2.Shakya A, Rao A, Shenoy R, Shrestha M. Oral Health Related Knowledge And Attitude Of Anganwadi of Mangalore City, India. Journal of Chitwan Medical College. 2014;3:6-8.

3.Priya M, Devdas K, Amarlal D, Venkatachalapathy A. Oral health attitudes, knowledge and practice among school children in Chennai, India. Journal of Education and Ethics in Dentistry. 2013;3:26-33.

4. Nair MK, Renjit M, Siju KE, Leena ML, George B, Kumar G. Effectiveness of a community oral health awareness program. IndianPediatr. 2009;46:86-90.

5.Raj S, Goel S, Sharma VL, Goel NK. Short-term impact of oral hygiene training package to Anganwadi workers on improving oral hygiene of preschool children in North Indian City. BMC oral health. 2013;13:1-7.

6.Sekhar V, Sivsankar P, Easwaran MA, Subitha L, Bharath N, Rajeswary K, Jeyalakshmi S. Knowledge, attitude and practice of school teachers towards oral health in pondicherry. Journal of clinical and diagnostic research. 2014;8:12-15.

7.Ahmad MS. Oral health knowledge and attitude among primary school teachers of Madinah, Saudi Arabia. The journal of contemporary dental practice. 2015;16:275-9.

8. Poornima K, Reddy CV, Shivakumar BN, Vidya M. A study to assess the knowledge, attitude and practices towards oral health among anganwadi workers of Mysore city. J Indian Assoc Public Health Dent. 2011;18:167-70.

9.Arora R, Malik S. To Evaluate The Awareness of Infant Oral Health Care in Anganwadi Workers of Udaipur City. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS). 2016;15:116-20.

10.Gangwar C, Kumar M, Nagesh L. KAP toward Oral Health. Oral Hygiene and Dental Caries Status among Anganwadi Workers in Bareilly City, Uttar Pradesh: A Cross-Sectional Survey. Journal of Dental Sciences and Oral Rehabilitation. 2014;5:53-7.

11. Schroth RJ, Brothwell DJ, Moffatt ME. Caregiver

knowledge and attitudes of preschool oral health and early childhood caries (ECC). Int J Circumpolar Health. 2007;66:153-67.

12.Almas K, Al-Malik TM, Al-Shehri MA, Skaug N. The knowledge and practices of oral hygiene methods and attendance pattern among school teachers in Riyadh, Saudi Arabia. Saudi medical journal. 2003;24:1087-91.

13. Mani SA, Aziz AA, John J, Ismail NM. Knowledge, attitude and practice of oral health promoting factors among caretakers of children attending day-care centers in KubangKerian, Malaysia: A preliminary study. J Indian SocPedodPrev Dent. 2010;28:78-83.

14. Dawani N, Nisar N, Khan N, Syed S, Tanweer N. Oral health knowledge, attitude and self-practices of pre-school teachers of Karachi, Pakistan. J Pak Dent Assoc. 2013;22:47-51.

15.Pankaj AA, Nagesh L, Pradnya H. Knowledge, attitude and practices towards oral health among anganwadi workers of Belgaum City, Karnataka. J Indian Assoc Public Health Dent 2005;5:14-6.

16. Bhambal A, Gupta M, Shanthi G, Saxena S, Bhambal A. Oral health knowledge, attitudes and practices of Anganwadi workers of Bhopal city, India. International Journal of Medical and Health Sciences. 2015;4:108-15.

17.Kakodkar P, Matsyapal CK, Ratnani N, Agrawal R. Anganwadi workers as Oral Health Guides: An interventional study.2015;2:33-7.

17


Strategic Approach to Restore Esthetics and Functional Balance: A Multi-Disciplinary Case Report

1 2 3 AUTHORS: Dr. Anup Belludi , Dr. Navraj Mattu , Dr. Aravind. M Virupaksha

1. Dr. Anup Belludi, BDS, MDSProfessor, Department of Orthodontics and Dentofacial Orthopedics, K.L.E. Society's Institute of Dental Sciences, No.

nd20, Yeshwanthpur Suburb, II Stage, Tumkur Road, Bangalore- 560022, Karnataka, INDIA. Email: [email protected]

2. Dr. Navraj Mattu, BDSRDMDS 3 year resident, Department of Orthodontics and

Dentofacial Orthopedics, K.L.E. Society's Institute of Dental ndSciences, No. 20, Yeshwanthpur Suburb, II Stage, Tumkur

Road, Bangalore- 560022, Karnataka, INDIA. Email: [email protected]

3. Dr. Aravind. M Virupaksha, BDS, MDSReader, Department of Orthodontics and Dentofacial Orthopedics, K.L.E. Society's Institute of Dental Sciences, No. 20, Yeshwanthpur

ndSuburb, II Stage, Tumkur Road, Bangalore- 560022, Karnataka, INDIA. Email: [email protected]

Abstract: The true Class III is not an all or none problem. There are varying degrees in the amount of abnormal growth which can occur in the lower jaw and the timing of such growth. Class III borderline cases pose a diagnostic as well as therapeutic challenge to the orthodontist. A wide range of skeletal sysplasias can be camouflaged with tooth movement without the need for surgery. This article describes an interdisciplinary case of Class III malocclusion which has been camouflaged by orthodontic treatment in conjunction with prosthetic replacement of teeth.

Introduction

Class III malocclusion is essentially described as supernormal class I molar relation accompanied by an edge to edge incisor relation in most of the borderline cases. Often, there is difference in the opinion about the choice of treatment for borderline cases. However, a wide range of saggital skeletal dysplasias can be successfully managed by

1camouflage with good retention. Achievement of good occlusion at the end of the treatment is a

2major factor that aids in the stability of the case.

In a true skeletal class III case, the growth of the mandible is often prolonged beyond adolescence, the amount and intensity of which cannot be predicted with accuracy. These factors contribute to the dilemma to the clinician for uncertainty in the outcome and unpredictable response to the

3 treatment. the relapse in orthodontic treatment of 4 class III malocclusion is as frequent as 50 %.

Achieving an ideal overjet and overbite would not only provide a stable occlusion but would also aid in maintaining the position of the mandible in its correct position. In a borderline class III case, when the soft tissue profile favors non extraction, the purpose of orthodontic treatment should be to relieve crowding, close the spaces and attain an ideal overject and overbite. An attempt to camouflage the skeletal class III by maxillary 2nd and mandibular 1st extractions in such cases would result in worsening of the class III profile. In such cases, extractions of mandibular incisors can be

taken up to take back the lower anteriors and give a 5 positive overjet. In this kind of camouflage

treatment planning, the underlying skeletal deformity is left untreated but teeth are moved to such positions to create an acceptable occlusion without violating the norms of aesthetics and stability. These patients must have passed their pubertal growth spurt and should be more of horizontal or average growers than vertical face types. Care must be taken to not to over-retract the lower incisors in the attempt to create positive overjet as this would cause labiogingival recession and root resorption in the lower incisors. Along with that, lingual tipping of these incisors would reduce the lower lip prominence and this would further cause the increased and undesired chin prominence.

Good cases for camouflage treatment are:

1. Mild to moderate severity

2. Subjects who have passed the active growth period

3. No skeletal facial asymmetery

4. Pleasing or acceptable soft tissue profile

5. Average or short face

6. Presence of good alveolar bone support in anterior teeth

CASE REPORT

18

A 26 year old male presented with a chief complaint of difficulty in biting and chewing food. The patient had a history of orthodontic treatment 5 years back and also gave history of some restorations done in the lower front teeth at about the same time. Clinical examination revealed that he had competent lips and straight pofile with no gross facial asymmetry. On smiling, he displayed 99% of his incisors. There was edge to edge bite in the incisors and the canines and molars were in Angles' class I relation (Fig. 1,2). There was no overject and overbite and no occlusion in the posterior teeth. Teeth no. 31 and 41 had ceramic crowns on them. Good oral hygiene was evident. OPG and lateral cephlogram evaluation revealed the presence of skeletal class III pattern and average growth relation (Fig. 3,4). The lower central incisors appeared to be deciduous as suggested by the length and width of the roots. There was sufficient amount of bone support and no signs of bone loss. Condyles appeared normal in shape and position. Model analysis showed the presence of 3 mm space in the lower arch and a Bolton's discrepancy of 3.6 mm mandibular excess. Based on these findings, the following problem list was developed:— Skeletal class III pattern— Egde to edge incisor relation— Spacing in the lower anteriors — Lack of buccal segment occlusion— Decreased overjet and overbiteDiagnosis:Class III skeletal relation with average growth pattern, meso-facial form and Angle's Class I malocclusion complicated by:· Egde to edge incisor relation· Spacing in the lower anteriors — Decreased overjet and overbite— Lack of occlusion in the posterior teethTreatment objectives:· Skeletal· To achieve skeletal class I relation (ideal)· Dental· To close spaces in lower arch· To achieve proper overbite and overjet · To achieve occlusion· Soft tissue· To achieve pleasing soft tissue profile

Treatment plan:

Keeping these objectives in mind, a non-extraction

line of treatment was decided as the profile of the patient was straight. Maxillary space requirement was minimal and slight proclination and arch development was sufficient in achieving good result. In the lower arch, space was planned to be gained by proximal slicing of lower teeth and re-shaping of the ceramic crowns. These crowns were eventually to be removed and the underlying deciduous teeth extracted and replaced by prosthesis. In case sufficient space could not be gained by slicing alone, extraction of the lower deciduous teeth was proposed and replacement with a single implant supported lower incisor was planned. This was analogous to a single lower incisor extraction plan.

Treatment progress:

MBT 0.022” fixed orthodontic appliance was chosen for the patient. Both the arches were bonded simultaneously. Initial alignment and leveling was done using a series of NiTi and stainless steel wires. Arch-wires used for the treatment were procured from 3M Unitek Orthodontic products, USA. The space in the lower arch was gained by slenderizing of the lower incisor crowns. Along with that minimal inter-proximal reduction was done in the fourth quadrant to obtain equal amount of space in both the arches. 0.021” X 0.025” stainless steel wire was placed in the upper arch for maximum torque expression. In the lower arch once space was consolidated distal to canines, class III elastics were given to achieve positive overjet and overbite (Fig. 5). Settling of occlusion was done with 0.016” A.J. Wilcock arch-wires and triangular elastics (Fig 6). Before de-bonding the appliance, brackets were removed from the lower central and lateral incisors and the deciduous incisors were extracted. Patient was referred to the dept. of Prosthodontics for crown preparation and replaced of missing teeth with a PFM bridge. Ideal overjet and overbite was maintained in the prosthesis. Retention was given with a custom-made removable Begg's retainer in the upper arch and an essix retainer in the lower arch.

Treatment results:

Facial photographs showed only little changes in the facial profile and a very good improvement in the smile of the patient (Fig 7). The post-treatment results showed a good occlusion between the upper and lower arches and a good inter-cuspation of the posterior teeth (Fig. 8). There was a pretty

19


good alignment of the upper and lower arches. An esthetically acceptable smile arc was achieved after the correction. Pre and post treatment cephalo-metric values are shown in table 1 (Fig. 9).

Discussion

The true genetic Class III growth pattern is the opposite of the most common orthodontic problem which is retrusion of the lower jaw. In the Class III the lower jaw is protrusive and it may be mistakenly referred to as an "under bite". Once the lower teeth move out in front of the upper incisors, the muscles influence their position and the size of the chin comes into play to determine how "bad" the condition looks. In reality, the lower jaw is too long relative to the rest of the face, and the chin appears to protrude too far in front of the rest of the face.The true Class III is a genetically directed problem which may express itself at an early age, but usually becomes more apparent as the child approaches the teenage growth spurt. Generally, we find a parent or grandparent with the exact same problem.

According to Angle, class III malocclusion is defined as class III molar relation with the mesio – buccal cusp of the maxillary first permanent molar occluding in the inter-dental space between the mandibular first and second molars. Or lower molar is ahead of the first molar by a distance of the width of a premolar or half the width of a molar.

Extraction of mandibular incisor for orthodontic treatment of class III malocclusion has long been

6,7discussed by many authors. Extraction of mandibular incisor is generally done in patients with Bolton's discrepancy of more than 2.0 mm. The case described here is a skeletal class III patient with good facial profile and no crowding of the arches. There was no frank anterior cross bite and the incisors were in edge to edge relation with each other. The mild spacing present in the lower arch eliminated the need for extraction in the lower arch to begin with although single incisor extraction was kept as an option if space requirement persisted in due course of treatment. Appropriate class III mechanics were performed to achieve the listed objectives by retraction of lower teeth and torquing of upper anteriors. The post treatment ortho-pantomogram showed good alignment of the roots and good amount of inter-dental bone present (Fig. 10). A very good amount of posterior occlusion and inter-cuspation was easily achievable. Vincent O

8Kokich demonstrated a case treated with carious

mandibular incisor extraction and presented a good maintenance of profi le and satisfactory

9outcomes at the end of treatment. Canut also found there is a better stability in patients treated with a single mandibular incisor extraction when compared with patients requiring premolar extraction. The present case was finished with a proper overjet of 2 mm, and the overbite was purposefully left at 3 mm in order to maintain the correction of anterior cross bite. In this case, the extraction of lower incisor was avoided and it did not lead to mismatch of maxillary and mandibular arch midlines and a loss of interdental papilla in the lower anterior region.

Conclusion

Camouflage of skeletal class III malocclusions when the patient has an acceptable profile need a meticulous effort in order to avoid unesthetic changes of the profile and to have a stable result. Proximal slicing and mandibular incisor extraction may be a good choice of treatment in such cases. A proper diagnosis and treatment planning is the key factor in determining the success of treatment outcomes in orthodontic patients. An esthetic replacement of teeth further added to the stability of correcton.

References

Orthodontic Camouflage in the Case of a Skeletal Class III Malocclusion. World J Orthod 2004;5:213-223.

Reidel RA. Retention and Relapse. J Clin Orthod 1976;10:454-72.

Baccetti T, Franchi L, McNemara JA. Growth in the untreatedclass III subject. Semin Orthod 2007; 13: 130-142.

Franchi L, Baccetti T, Tollaro I. Predictive variables for the outcome of early functional treatment of class III malocclusion. Am J Orthod Dentofacial Orthop 1997;112(1):80-6.

Canut JA. Mandibular incisor extraction: Indications and long-term evaluation. Eur J Orthod 1996;18:485-9.

Grob DJ. Extraction of a mandibular incisor in a class I malocclusion . Am J Orthod Dentofac Orthop 1995;108:533-41.

Prakash A, Tandur AP, Dungarwal N, Bhargava R. Mandibular incisor extraction – Case Report. Virtual J Orthod 2011;9:2.

Kokich VO Jr. Treatment of a class I malocclusion with a carious mandibular incisor and no Bolton discrepancy. Am J Orthod Dentofacial Orthop 2000;118:107-13

Canut JA. Mandibular incisor extraction: Indications and long-term evaluation. Eur J Orthod 1996;18:485-9.

1. Pinho T M C, Torrent J M, Pinto J G. R.

2.

3.

4.

5.

6.

7.

8.

9.

20


Corresponding AuthorName: Dr. Navraj MattuAffiliation address: K.L.E. Society's Institute of Dental

ndSciences, No. 20, Yeshwanthpur Suburb, II Stage, Tumkur Road, Bangalore- 560022, Karnataka, INDIA.Ph : +918971208860; E-mail: [email protected]

Table 1: Comparison of pre and post treatment cephalomeric values

Parameters Pre-treatment Post-treatment

SNA angle 820 820

SNB angle 840 810

ANB angle -2o 10 SN-GoGn 310 310

Lower ant. Facial height (mm) 83 83 U1 to Palatal plane 1150 1200

IMPA 920 900

FIG. 1: pre-treatment extra-oral photos of patient

FIG. 2: pre-treatment intra-oral photos of patient

Fig 3: pre-treatment lateral chephalogram

21


Fig. 4: pre-treatment opg

Fig. 5: mid-treatment photos

Fig.6: settling of occlusion

FIG. 7: post-treatment extra-oral photos of patient

22


Fig.10: post treatment OPG

FIG. 8: post-treatment intra-oral photos of patient

Fig.9: post treatment lateral cephalogram

23


The quest for an attractive face & profile

1 2 3 4AUTHORS: Dr. Faisal Arshad , Dr. Bharathi VS , Dr. Lokesh Nk , Dr. Suma T

ABSTRACT : The early studies of esthetics in orthodontic treatment focused on how clinicians viewed their patients.Changing demographics and cultural attitudes led researchers to look more seriously at consumer preferences and the public's attitudes. Their findings,that consumers preferred fuller lips,led to a swing back toward non-extraction treatment. Expansion appliances and molar distalization techniques became popular and surgical procedures to obtain more ideal esthetic results became more common. Since the 1990s, advances in computers and technology have allowed us to study, predict, and produce esthetic results previously thought unattainable. Today, at any other time in our specialty, we have the ability to provide esthetic results to our patients.

INTRODUCTION:

Facial esthetics have interested orthodontists for many years and although opinions as to what constitutes an attractive face have come from many sources, there is still considerable lack of information as to the longitudinal development of

1the nose,lips and soft tissue chin

The importance of facial esthetics in orthodontics has its origins at the beginning of orthodontic specialty. In 1900, Edward H. Angle believed that an esthetic or a “harmonious” face required a full complement of teeth, but many who came after him questioned this notion. In the 1930s, the development of cephalometrics laid the foundation for studying growth and development, treatment

2effects, facial forms, and esthetics. By the 1950s, the importance of diagnosing and planning treatment for an esthetic result was established, but the measurement of soft tissue variables was lacking, and this became an important area of research. In the 1970s, researchers were looking at the stability of hard tissue changes over time, and they were also interested in how the soft tissues change with age.

The current flash of magazines which might be presumed to represent a cultural ideal, one finds all sorts of profiles represented, from the full faced southern European or “Latin” type with its prominent dental area with prominent nose and chin.Themens faces in current advertising art show a more consistent pattern.They are in a general more concave with nose and chin well in advance of the denture in profile.

HISTORY

There are two concepts which are basic and essential to orthodontic planning and treatment , first is the integrity of an individual and second is the inevitability of change in the individual.In the

th5 century B.C, Hericlitus said “there is nothing permanent in life except change”.It is true ofcourse that individuals can be classified and measured and that the progression of changes certainly has a pattern which can be classified and measured and must be for scientific purposes.Theindividual ,is the patient himself.He is not a mean or average or group and is definite for a change, day by day, year

3by year.

Orthodontics cannot be practiced by numbers and that a pair of finely pointed dividers is no substitute for clinical judgement.It is the integrity of individual and his inevitable change which makes it foolish to apply these cook book concepts.

There are two terms, individuality and change, certain individual combinations of facial characteristics are accepted as representative of beauty.These may often vary as between cultures and with the times and fashions,also there is individuality and dignity in facial beauty. There are many examples of fine male faces throughout the history of representational art.Theearly Greek Apollos,eachwith an individual expression of male facial perfection Two major examples are: The Donatello saint and The Michelangelo David each a different type of male beauty. There has been considerably more attention given to the female face in art and examples of the many types of female

1. Dr. Faisal ArshadSenior Lecturer, Department of Orthodontics, Rajarajeswari Dental College & Hospital, Bangalore, Corresponding author e-mail -faisalking1335yahoo.in2. Dr. Bharathi VSSenior Lecturer, Department of Orthodontics, Rajarajeswari Dental College & Hospital, Bangalore

3. Dr. Lokesh NKReader, Department of Orthodontics, Rajarajeswari Dental College & Hospital, Bangalore4. Dr. Suma TReader, Department of Orthodontics, Rajarajeswari Dental College & Hospital, Bangalore

24

beauty are well known.From Neferititi through the Flapper, individuality has been a highly prized

3ingredient.

In search of an ideal profile, Angle had discussions with various Art teachersand in the end Dr.Wuerpel presented him with , “The Belvedere Apollo”, which Angle described as a “study of symmetry and beauty of proportion” and was considered only one of the many representations of the Apollo concept.In the sixth edition of Angles textbook, publishedin 1900, he devoted chapter II (8 pages) to “Facial art—line of harmony.” He referred to the profile of the statue of Apollo Belvedere as “a face so perfect in outline that it has been the model for students of facial art.” He discussed his “line of harmony,” a vertical line that touches glabella, subnasale, and pogonionin the profile “with perfect harmony.” In the seventh edition, published in

1907, the chapter on “Facial art” was increased to 28 pages, a reflection of the importance Dr Angle

2placed on the subject. He admitted that using the face of Apollo Belvedere was limited in gauging the harmony of other faces. It represents the ideal only of the Greek facial type, and not the admixture with races of different types.

A paper written by Goldesteinin 1953 called “The Dominance of the Morphological Pattern” where the author states that the morphogenetic pattern is unique, so we cannot transpose the pattern of one individual to another.In other words, instead of the orthodontist inflicting his pattern on the patient, it would be much better if he gave to that patient the

2,3patients own pattern.

PERSPECTIVE FACIAL PROFILE4In the early 20th century, Edward Angle believed

that if the teeth were in a balanced occlusion, the

The Flapper Nefertiti,

a queen of Egypt

The Belvedere Apollo David

by Michelangelo

face would adjust and also be in balance. Angle believed that his orthodontic appliance encouraged the growth of bone, which negated the need for extraction. He stated 100 years ago that there “should be a full complement of teeth and each tooth shall be made to occupy its normal

5position. ”. By contrast, Calvin Case believed that craniofacial growth and dental development were genetically determined. He counterargued that a patient's geneticblueprint determined whether they would have dental or skeletal discrepancies. The latter school of thought did not believe that it was possible to grow bone beyond its genetic potential. There is currently a renewed interest on the impact that extraction/nonextraction treatment has on the profile, face, and smile. Profile and cephalometric data have been examined extensively in orthodontics in the search for standards that define facial attractiveness.

6Downs was interested in facial balance and harmony, and investigated normal occlusions on which he based his cephalometric analysis. He discussed variations of facial growth, yet his analysis failed to reveal definitive numbers on which to base facial attractiveness.Riedel studied facial beautyfrom the perspective of the layperson. He attemptedto quantify beauty using photographs and cephalometrics from 30 beauty queens. Peck

7and Peck attempted to further address the public's attitude of esthetics by studying a large sample of television and motion picture personalities, beauty contests winners, and models. They concluded that the esthetic face presented in the mass media was more convex and more protrusive than our cephalometric standards of “normal.”Kerr and

8O'Donnell evaluated the facial complex using profile and full-face photographs. They asked a panel of orthodontists, dental students, art

25


students, and parents to evaluate “facial attractiveness.” The panel rated the full face as more attractive than the profile; the art students and parents were less critical than he orthodontists and dental students.

The face and profile have been analyzed, studied, and debated, yet investigators have not been able to offer a cephalometric analysis or trait to truly define individual facial attractiveness. Further more, Holdaway10 observe that treatment results that are based solely on any cephalometric analysis do not necessarily result in improved facial attractiveness.

In recent years various facial and dental measurement techniques have become more precise and statistics more sophisticated. Although many systems have been proposed by Reidel, Subtelny,Burstone,Ricketts and others. Angles illustration has a soft tissue plane scribed on it, although it does nt discuss its significance. The degree of accuracy that can be gathered from cephalometric analysis for treatment planning regarding facial attractiveness is changing, subjective, and controversial.

EXTRACTION PROFILE:

The effect of orthodontic treatment on facial attractiveness is of utmost importance to the orthodontist, general dentist, and layperson. Does the extraction of teeth have a detrimental effect on the profile or on the face? Can a person who has had premolars removed for orthodontic treatment be identified visually, that is, is there an “extraction face?”The extraction of premolars is criticized by some using extreme examples where the unfavorable profile is not the result of the orthodontictreatment. It has been stated that the “extraction of teeth makes the dental arches smaller, 'sinks in' lip support and makes the smile smaller, constricted and makes the extraction

9patient seem older.” The accuracy of this latter statement is questionable. In addition, the belief that nonextraction treatment produces a face that is more attractive than that of a patient who has undergone extraction treatment is also questionable. A possible reason for these perceptions could be misdiagnosis.

It is also possible for the previously held misconceptions that extraction treatment was inappropriate or that inaccurate biomechanics were used. It is also a possibility that a patient with

more “normative” cephalometric values would likely undergo nonextraction treatment, whereas, for example, a patient with a high mandibular plane (skeletal discrepancy) and dental crowding may be more likely to undergo extraction treatment. Comparatively, the patient with the more “normative” cephalometric values may likely have results that are more cosmeticallypleasing than the patient with skeletal and dental discrepancies.

Extractions may often be indicated where there is dentoalveolar discrepancy,

or in more severe cranio facial abnormalities, rather than in patients who have a well-balanced attractive face with minor dental discrepancies. Many factors, among others, including the size and shape of the nose, thickness and shape

of the lips, size and shape of the chin, facial proportions, facial type, skeletal relationships, facial contours, and significantly dental crowding, determine the decision to extract or not.

PROFILE PREDICTION :

It is essential to understand the predictions of soft and hard tissue changes that will occur as a result of treatment and how the various tissues of the face will change with growth and development in the young patient and with the agingprocess in the adult patient. The face is a complex and dynamic structure comprising various soft-tissue esthetic subunits supported by bone and teeth. It is the optimal relationships between the subunits that make for an esthetically attractive face. The interdependence of the individual facial components necessitates a comprehensive assessment of all subunits together when evaluating facial esthetics. However, it is important to examine the subunits individually to eliminate any undue influence that other units may have on the perception of the face as a whole.

Computers and technology continue to allow us to study, predict, and produce esthetic results previously thought unattainable. Digital radiography and photography, and the associated software programs, have improved our ability to analyze hard and soft tissue data. Digitized tracings and photographs can be easily superimposed, and treatment simulation software allows the visualization of projected postoperative results. Three-dimensional visualization and analysis of craniofacial anatomy can also be produced from

26


cone-beam computer tomography, magnetic resonance imaging, medical computed tomo-graphy, and 3-dimensional facial camera systems. Proposed soft tissue changes can now be shown in real-time animations.

Currently, two software programs ,Dentofacial Planner Plus and Dolphin Imaging are used to predict the changes in pro? les. The predictive images can be compared with the actual ? nal photographs. The evaluated images could be used to plan treatment , or to educate, the patients. Theses predictive softwares have better prediction of nasal tip, chin, and submandibular area, nasolabial angle, and upper and lower lips.

THE PRESENT STANCE:

Of course, the debate as to what constitutes an esthetic face continues. Angle's reliance, first on Apollo's face and then on the face resulting from nonextractionorthodontic treatment, was no longer reliable. Tweed's initial attempts to flatten profiles with “marked bimaxillary protrusion” seemed reasonable, but extraction in patients with mild protrusion to achieve the cephalometric goal of an upright mandibular incisor began to be questioned. Who really was the best judge

of an esthetic face? To avoid the prejudices of orthodontists, artists were chosen to

10,11select esthetic profiles for study. However, artists also can have prejudices based on their training and

12study of art. Riedel thought it important to determine

what “modern” concepts of facial esthetics might be from the viewpoint of the general public.

Using profile photographs from leading fashion thmagazines in the 20 century, the answer to this

13question was attempted. The profiles of Caucasian female models were examined and found that indeed the profiles shown in the later part of the 20th century were fuller in the area of the lips. And this trend was not unique to women. The male face in fashion magazines also had fuller lips in the later

14decades of the 20th century. Previous studies had suggestedthat the esthetic African American profile was straighter and more like that of Caucasian people than the averageAfrican

15,16American profile.

A photographic study of Caucasian and African American profile photographs from fashion magazines in the 1990s revealed that the

Caucasian models had greater lip prominence and vermilion display than did the Caucasian controls. Although the African American models showed greater lip prominence than the Caucasian models,

thWhere the profiles in the mid 20 centurywere more like those of Caucasian people, the profiles shown in the 1990s were fuller in the area of the

17lips. Lip augmentation, which was an uncommon procedure just 30 years ago, has become a common cosmetic surgical procedure, especially for Caucasian women. A glance at Indian magazines also reveals that Indian actresses and models are trending for Lip augmentation that gives fuller, plumper lips and profile.

CONCLUSION:

Facial attractiveness is a matter of personal preference, and it is an unending debate as to which profile or smile is more desirable; there is a large range that is considered attractive. Facial balance, proportion, symmetry, and beauty are not

fixed perceptions. They vary from one person to another based on past experiences, race, culture, and socioeconomic group. After all these years, still debate on extraction/nonextraction treatment and its effect on facialattractiveness is poking the mind of clinicians,putting an end to a given disagreement can be done by following an individual “treatment plan” which needs to be customized based on “evidence based” treatment.

REFERENCES:

1. GS Jeffrey, DC Paul;Development of the nose and soft tissue profile.Angle Orthod. 1990; 60(3):191-8.

2. Margaret Collins The Eye of the Beholder: Face

Recognition and Perception. SeminOrthod 2012;18:229-234.

3. Baum AT. Orthodontic treatment and the maturing face. Angle Orthod. 1966 Apr; 36(2):121-35.

4. Angle EH: Treatment of Malocclusion of the Teeth (ed7). Philadelphia: SS White Dental Manufacturing Co., 1907

5. Case CS: The question of extraction in orthodontia. Am J Orthod 1964;50:660-691.

6. Downs WB: The role of cephalometrics in orthodontic case analysis and diagnosis. Am J Orthod 1952; 52:162-182.

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1 2 3 4AUTHORS: Dr. Kaushal Jha , Dr. Swati Tripathi , Dr. SatyajithNaik , Dr. Pallavi Vashisth

Fusion or Germination : A Case Report

Dr. Kaushal JhaIInd year Post Graduate studentDepartment of Pedodontics and Preventive DentistryInstitute of dental sciences, Bareilly,UP.Dr. Swati Tripathi, ReaderDepartment of Pedodontics and Preventive DentistryInstitute of dental sciences, Bareilly,UP.

Dr.SatyajithNaik, ProfessorDepartment of Pedodontics and Preventive DentistryInstitute of dental sciences, Bareilly,UP.Dr. Pallavi Vashisth, ReaderDepartment of Pedodontics and Preventive DentistryInstitute of dental sciences, Bareilly, UP.

Abstract:

Fusion of teeth is a developmental anomaly characterized by the union of two adjacent teeth. Few cases of this rare anomaly in primary dentition have been reported in Indian population. A rare case of fusion between primary mandibular central incisor and lateral incisor is presented in this report.

Key words: Developmental anomaly, double teeth, fusion, primary dentition.

Introduction The expressions Twinning, Joined tooth or Double tooth, is often used to depict both fusion and germination 1. The teeth fuses to each other due to the union of two separated tooth germs, it may be complete or incomplete in nature ,as it is dependent on the time of union and stages of tooth development. It may be between two normal teeth or sometimes between normal tooth and supernumerary tooth germ 2. The anomalous crown may represent fusion between two normal teeth; if when counting the bifid crown as one tooth, it appears that one tooth is missing3. It is a condition in which a tooth with a bifid crown has two distinct root canals as the result of a union of two adjacent tooth germs3. If when counting the bifid crown as one tooth, the normal numbers are present4 or, if when counting the bifid crown as two teeth, one more than the normal number is present5.

Various etiologies have been put forth for fused teeth like thalidomide, hypervitaminosis, pressure from physical contact of young tooth buds, and genetic factors6,7-9. A genetic etiology also has been suggested for the development of supernumerary teeth, as have etiologies such as c l e f t p a l a te , l o c a l i z e d d i s t u r b a n c e s i n odontogenesis, and extensions of, or epithelial remnants from, the dental lamina10-11.

Fusion is seen in primary as well as permanent dentition with a higher frequency in the anterior and maxillary regions. Prevalence for double teeth ranges from 0.1% to 1.5% in the primary

dentition12 .Due to its irregular morphology it causes an unpleasant asthetic. These teeth also tend to be greatly predisposed to caries and periodontal disease and, in some cases, endodontic treatment is very complicated. Hereby we are reporting a rare case of fused teeth in a mandibular arch .

CASE REPORT A 3 and half -year-old male patient reported to

Department of Pedodontics and Preventive dentistry with multiple carious teeth in the oral cavity. Medical history appeared noncontributory. There was no family history of dental anomalies and no consanguinity was reported in the parents. Intraoral examination revealed that <71-72> were

fused together with a deep groove on the labial and lingual aspect.[Figure 1] An incisal ditch was also seen in both <71-72> .We took IOPA w.r.t <71-72>

to rule out presence of fusion of between succadenous permanent teeth and to see the radiographic feature of fused <71-72> . The periapical radiograph exhibited that the crowns and the roots of <71-72> were fused with complete union of their pulp chambers and root canals. [Figure 2] The teeth number 51,52 ,54,61,62,64,74 and 84 were carious.

The treatment plan was designed to perform pulp therapy wrt 62 placement of omega loop followed by strip crown.[Figure 3] In the remaining teeth permanent restoration was planned. The treatment procedure was explained to the parents. After full mouth rehabilitation[ Figure 4], a preventive approach was also planned which consisted of topical fluoride application, dietary

28

changes, and periodic follow-ups. Parents were

informed about the fused deciduous teeth and were told to come for recall visit to prevent any decay to the fused teeth.

DiscussionFusion has been described as a developmental anomaly characterized by the union of two adjacent teeth. These teeth may be fused by enamel, dentin, or both. The fused crown is broader than non fused adjacent teeth and thus resembles gemination. However, tooth counting reveals decreased numbers. They are joined by the dentin; pulp chambers and canals may be linked or separated depending on the developmental stage when the union occurs. Thus, it involves epithelial and mesenchymal germ layers resulting in irregular tooth morphology13. The dentin ,however ,is always confluent in cases of true fashion. Fused teeth have separate or shared pulp chambers and canals. It may be between two normal teeth or s o m e t i m e s b e t we e n n o r m a l t o o t h a n d supernumerary tooth germ. Commonly fusion can occur between teeth of the same dentition, mixed dentitions, or between normal and supernumerary teeth like mesiodens or the distomolar.

'Two tooth' rule is introduced in 1979 to use the term fusion and germination. If the fused tooth is considered as one and the number of teeth in the dental arch is less, then the term fusion is considered14. Grahnen and Granath have reported that fusion of teeth is more common in the deciduous than in the permanent15. Very few cases of fusion in mandibular primary dentition have been reported from the Indian population. In Caucasians it is 0.02% and in Japanese population 0.32%14-16. Spacing, malocclusion, esthetic and periodontal problems are the common problems such cases.

Due to their abnormal morphology and excessive mesiodistal width, which cause problems with spacing, alignment and function most of the fused teeth are indicated for extractions. Management of fused primary teeth includes observation and allowance of normal exfoliation when a communication for bacterial access to the pulp chamber does not exist, endodontic therapy, restoration, separation with restoration, or extraction. Yuen et al. have revealed that the fusion

of primary teeth is also associated with hypodontia in succedaneous dentition17. Hence as fused teeth also results in delay in eruption of the permanent successors , cautious monitoring of the condition is advised.

Conclusion Among the anomalies of shape of teeth fusion is one of the uncommon findings. Tooth fusion in mandibular primary teeth has very little citations in Indian population. Clinical observation along with an orthopantomograph and periapical radiographs are necessary tools to prove if there is an aplasia or fusion in the permanent dentition. These conditions require a minimal intervention approach, preventive procedures, and a long-term follow-up.

Figure 1: Showing fusion between mandibular deciduous central and lateral incisors.

Figure 2: Intraoral periapical radiograph showing fused mandibular left primary central and lateral incisor with

single root and root canals.

Figure 4. Full mouth rehabilitation

29


Refrences:

1. Tomizawa M, Shimizu A, Hayashi S, Noda T. Bilateral maxillary fused primary incisors a c c o m p a n i e d b y s u c c e d a n e o u s supernumerary teeth: Report of a case. Int J Paediatr Dent 2002;12:223-7.

2. Peirera AJ, Fidel RA, Fidel SR (2000) Maxillary Lateral Incisor with Two Root Canals: Fusion or Gemination? Braz Dent J 11: 141-146.

3. Levitas TC: Gemination, fusion, twinning and concrescence. J Dent Child 32:93-100, 1965.

4. Tannenbaum KA, Alling FF: Anomalous tooth development. Case reports of gemination and twinning. Oral Surg 16:883-87,1963.

5. Mader CL: Fusion of teeth. J Am Dent Assoc 98:624, 1979.

6. Brook AH, Winter GB: Double teeth: a retrospective study of 'geminated' and 'fused' teeth in children. Br Dent J 129:123-30, 1970.

7. Croll TP, Rains NJ, Chen E: Fusion and gemination in one dental arch: report of case. ASDCJ Dent Child 48:297-99, 1981.

8. Lowell RJ, Solomon FF: Fused teeth. J Am Dent Assoc 68:762,1964.

9. Hagman FT: Fused primary teeth: a documented familial report of case. ASDCJ Dent Child 52:459-60, 1985.

10. Primosch RE: Anterior supernumerary teeth-- assessment and surgical intervention in children. Pediatr Dent 3:204-15, 1981.

11. Humerfelt D, Hurlen F, Humerfelt S: Hyperdontia in children below four years of age: a radiographic study. ASDC J Dent Child 52:121-24, 1985.

12. Ahmet ES, Yildiray S, Yasin Y, Halil S, Abdullah E. Prevalence of fusion and gemination in permanent teeth in Coppadocia region in Turkey. Pak Oral Dent J 2011;31:17-22.

13. Eidelman E. Fusion of maxillary primary central and lateral incisors bilaterally. Pediatr Dent 1981;3:346-7.

14. Bharghav M, Chaudhary D, Aggarwal S Fusion presenting as germination- A Rare Case Report.J Oral Maxillofac Pathol 2012 3: 211-214.

Corresponding author :

Dr. Swati Tripathi

Email address- [email protected]

F 20 ‘F’ Block Readers quarter RMCH

Bareilly, UP - 243 006

th15. Shafer Textbook of Oral Pathology 6 edition.

16. Sekerci AE, Sisman Y, Yasa Y, Sahman H, Ekizer A (2011) Prevalance of fusion and gemination in permanent teeth in Copadocia region in Turkey. Pakistan Oral Dent Journal 31: 17-22.

17. Yuen SW, Chan JC, Wei SH. Double Primary Teeth and Their Relationship with the Permanent Successors: A Radiographic Study of Three Hundred Seventy-six Cases. Pediatr Dent 1987;9:42-8.

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ACP V/S Potassium nitrate -A Clinical evaluation

1. Dr Souparna Madhavan (Corresponding author) Reader, Department of Conservative dentistry & EndodonticsSrinivas Institute of Dental Sciences, Mukka , Surathkal.

2. (Prof.) Dr Moksha Nayak, Principal Department of Conservative dentistry & EndodonticsK.V.G. Institute of Dental sciences, Sullia

3. (Prof .)Dr Lavanya Varma Head of the department Department of Conservative dentistry & Endodontics Srinivas Institute of Dental Sciences, Mukka , Surathkal.

1 2 3 4 5AUTHORS: Dr Souparna Madhavan , Dr Moksha Nayak , Dr Lavanya Varma , Dr Rajesh Shetty ,Dr Manoj Varma

4. Dr Souparna Madhavan Head of the departmentDepartment of Conservative dentistry & EndodonticsK.V.G.Institute of Dental sciences , Sullia .

5. (Prof.) Dr Rajesh ShettyDepartment of Conservative dentistry & EndodonticsD Y Patel Dental College Pune, India

6. (Prof.) Dr Manoj Varma, Dean Department of Prosthodontics Srinivas Institute of Dental Sciences, Mukka , Surathkal.

Dentinal hypersensitivity : A compa(ACP) and potassium nitrate

ABSTRACT

Aim: This In Vivo investigation was conducted to determine the efficacy of two different desensitizing agents on exposed dentinal surface in reducing Dentin Hypersensitivity in subjects with Slight-To-Moderate Sensitivity.

Methods: A total of 90 patients, 20-40 years of age reporting with dentinal hypersensitivity due to abrasion, erosion, or gingival recession in relation to canine, premolars or molars were randomly divided into three groups of 30 patients each.

The two materials tested were Amorphous calcium phosphate (ACP) , potassium nitrate and Distilled water was used as control group. The response to airjet and tactile stimuli were measured using visual analogue

th th th thscale (VAS) before and after application of desensitizing agents on 1st , 7 , 15 , 28 and 60 day and final th

assessment was done on the 90 day without application of desensitizing agent.

Results: Statistical analysis was done using ANOVAs test and Tukey HSD multi comparison

test. The results showed all the teeth treated as part of study showed decrease in mean hypersensitivity values compared to control group over a period of three months .Intergroup comparison of mean scores revealed potassium nitrate to be more effective for all the tested days when compared with ACP.

Conclusion: Despite the differences in their apparent mechanism of action, both potassium nitrate and ACP gave useful reductions in symptoms of dentinal hypersensitivity proving to be efficient.

Keywords: Airjet stimulation, Dentinal hypersensitivity, Desensitizing agent, Tactile stimulation, Visual analogue Scale.

rative clinical evaluation of amorphous calcium phosphate

INTRODUCTION

Dentine hypersensitivity is an “enigma frequently 1encountered but poorly understood”. It is a

common clinical condition and age old complaint

presenting problems both to the patient and the .2

dentist It is characterized by short, sharp pain

arising from exposed dentin in response to stimuli,

typically thermal, evaporative, tactile, osmotic or

chemical that cannot be ascribed to any other 3dental defect or disease.

The relationship between dentinal hyper-

sensitivity and ageing is unclear. It has been suggested that with the lifespan of the general population increasing and more people keeping their teeth longer, dentinal hypersensitivity will

.4increase in prevalence These assumptions are confounded by reports in literature which indicates most sufferers of dentinal hypersensitivity range in the age group of 20-40 years with the peak incidence occurring at the end of third decade and decreasing during the fourth and fifth decade of life. This may be partly explained by the decrease in the permeability of dentin and neural sensitivity with

4ageing. Females appear to suffer more than males

31

13

presumably due to better oral hygiene awareness. Coleman et al found that 57% of molars and 37% of premolars exhibited dentinal hypersensitivity on the buccal aspects of the teeth and relatively few

5sites on the lingual surfaces.

The most widely accepted mechanism of dentin hypersensitivity is the hydrodynamic theory proposed by Branstorm, whereby outward fluid flow within the dentinal tubules is triggered by thermal, tactile or chemical stimuli near the exposed surface of the tubules. It has been demonstrated that patients with dentin sensitivity have large open tubules on the outer surface of the

6dentin. Although, a wide variety of factors contribute to the exposure of dentinal tubules, current desensitizing treatment tends to concentrate on two approaches; to occlude the

7tubules and to block the neurotransmission .

In office desensitizing agents applied topically deliver a wide range of complex and potent

3 desensitizing treatments. These include sodium fluoride, potassium nitrate, and oxalates, calcium phosphates (CPP-ACP, ACP, and CPP ACPF). Most of published information relates to prevalence of hypersensitivity, however currently there does not appear to be globally agreed Gold standard procedure for comparative purposes in clinical trial

5 setting for evaluation of new desensitizing agents.

The purpose of the present study was to clinically evaluate efficiency of ACP and Potassium nitrate in treating dentinal hypersensitivity.

METHODS AND MATERIALS

90 subjects between the age group of 20-40 years were recruited for the clinical study. The study subjects were selected after screening patients in whom a history of dentinal hypersensitivity was elicited as a persistent complaint of a recurrent hot short, sharp pain arising from the buccal cervical third of the teeth in response to touch or hot ,cold, or chemical stimuli.

Detailed medical and dental histories with complete clinical and radiographic investigations were performed on all patients to exclude the conditions of the teeth which might have caused pain similar to dentin hypersensitivity. All subjects exhibited good dental care and had their last oral prophylaxis within the last six months. Subjects presented with hypersensitive teeth with cavitated

lesion less than 2mm in depth at the cervical third of buccal and lingual or palatal surface of canines, premolars, and molars were included. Patients receiving any kind of medication and prior use of desensitizing agents and teeth with caries or periapical pathology were excluded from the study. Patients were randomly assigned to three groups Each subjects signed a consent form after a thorough explanation of the treatment procedure and the known risks and effects of medications used.

Sensitivity was confirmed by the subject's response to tactile and air blast stimulations. The sensitivity of the tooth to the tactile stimulation was determined using a periodontal probe which was passed perpendicular to the tooth surface with apical sweeps until subject responded. After an interval of ten minutes, evaporative stimuli of 1 second air blast was delivered using dental unit triple syringe and blowing a short blast of room temperature air, held perpendicular to and 2mm away from tooth surface, whilst shielding the adjacent teeth with fingers or cotton rolls. The desensitizing agents was applied over the tooth surface and left undisturbed for 60 seconds following which patient was asked not to rinse, eat or drink for 30 minutes after treatment. Post operative assessment of hypersensitivity was done using air jet stimulation and tactile stimulation with the aid of visual analogue scale thirty minutes after application .This procedure was repeated before and after the application of desensitizing

th th th thagents on the 7 day, 15 day, 28 day, 60 day. On

ththe 90 day measurements were recorded without any desensitizer application.

STATISTICAL ANALYSIS

ANOVAs test was used to determine the comparative mean and the standard deviations of all the groups and Tukey HSD multiple comparison test was used for air jet and tactile stimulation assessment over a period of three months with a significance level of P<0.05.

RESULTS

Group 1 (ACP ) and group 2 (Potassium nitrate), showed decreased mean hypersensitivity values compared to the Group 3, (placebo) over a period of three months from the baseline

Intergroup comparison of mean scores revealed

.

32


group 2(potassium nitrate ) to have the least mean value for air jet and tactile stimulation on the 1st, 7th, 15th,28th 60th and 90th day when compared to ACP and placebo groups

Very high significant differences were observed between group 1(ACP), group 2(potassium nitrate), vs group 3(placebo) on the 7th day ,15th day, 28th day, 60th and 90th day for both airjet and tactile stimulation

Very high significant differences were observed between group 1(ACP) vs group 2(potassium nitrate) on the 28th, 60th day for both airjet and tactile stimulation, and 90th day for tactile stimulation.

The change in sensitivity was much more apparent using the airjet stimulation than tactile stimulation.

DISCUSSION

Dentine hypersensitivity is a clinical situation characterized by a short , sharp pain initiated by many types of stimulation such as tactile, thermal, osmotic or chemical (Pashley in 1990). According to the hydrodynamic theory of Brannstorm, 1967 these stimulations applied at the exposed dentine surface, cause an inward pressure on the tubular fluid, exciting the nerve endings within the pulp

8causing pain .

Dentinal hypersensitivity though not life threatening, can be a particularly unpleasant sensation for patients dictating types of foods and

7 drinks ingested. There is a need to develop new treatment or products which permit the relief of symptoms.

T h e m o s t c o m m o n l y u s e d s e n s i t i v i t y measurements are tactile, airjet stimulation and

7subjective questionnaire. It is generally recommended that more than one stimulus should be used in c l in ica l s tudies of dent ine hypersensitivity to enhance the measurement of

9 sensitivity. In the present study subjective assessment was made from responses of subjects in terms of their tolerance to the air jet and tactile stimulation( Sowinski et al, Ide M, Walters P.A )in light of their hypersensitive teeth using visual analogue scale. The VAS is widely used in clinical research to assess intensity of acute pain. It would appear to have few disadvantages, although some workers doubt that patient's responses on visual

9analogue scale can be regarded as a linear scale.

The result of the present study for the two test groups showed decreased mean hypersensitivity values compared to the Group 3, (control group) over a period of three months from the baseline.(Table1)

Intergroup comparisons revealed group 2 (potassium nitrate) to be more effective in the treatment of dentinal hypersensitivity compared to ACP. The mean values of the tested groups showed group 2(potassium nitrate) to have a least sensitivity score on the first day (air jet stimulation), 7th, 15th, and 90th day (tactile stimulation).

Similar results have been concluded by Nagata T et al suggesting the usefulness of potassium nitrate dentifrice in treating dentinal hypersensitivity. The present study showed the effectiveness within half an hour, while Nagata T showed usefulness within four weeks. The differences in efficacy may be attributed to change in concentration of potassium nitrate (10 %gel instead of 5% dentifrice) Also the present study utilized air blast and tactile instead of

10cold and subjective assessment. Our study showed relief of symptoms of dentinal hypersensitivity on the 1st day with the use of group 2( potassium nitrate.).

Despite these encouraging findings it is interesting to note that a recent Cochrane Database Systematic Review failed to find strong evidence supporting the efficacy of potassium nitrate tooth paste for dentine hypersensitivity. Nonetheless, this review did report that the differences which were noted statistically significant in favour of treatment with potassium nitrate tooth paste. The mechanism of action of potassium nitrate is largely unknown, although an oxidizing effect or blocking of tubules by crystallization has been proposed but not proven. The effect of potassium nitrate on dentinal fluid flow has been reported to be minimal even at 30% concentration. A more likely explanation is that the potassium cation is the active component (Kim 1986), tends to concentrate in the interior of the dentinal tubule, causing a depolarization of the cellular membrane of the nerve terminal and a refractory period with decreased sensitivity(

4Pashley et al 1984, Markowitz and Kim 1992).

The results demonstrated relief of sensitivity for tactile and air stimulation for ACP, Tung et al have

33


postulated the material ACP, precipitate and obstruct the dentinal tubules and decrease dentinal

8permeability by 85% or more.

In our present study ACP verses potassium nitrate showed statistical significance for both airjet and

th thtactile stimulation from the 7 to 60 day and before application, significant differences were

th thobserved from 28 day to 90 day (Table 2). Our results are in contrast with study done by Yates R where he concluded that ACP produced no greater benefit than a placebo to the symptoms of dentinal hypersensitivity. The alleviation of dentinal hypersensitivity was noted after 7 days with further reduction in dentinal hypersensitivity after each repeated treatment which is in accordance with the study by Geiger S et al. The possible explanation for this phenomenon might be that a spontaneous reduction in sensitivity occurs probably due to calcium phosphate. Alleviating sensitivity to air stimulation was more striking than alleviating sensitivity to tactile stimulation. The mineral plugs of calcium phosphate that obstruct the tubular orifice at the dentine surface

8are not stable at the initial phase. Immediate contact of the explorer at the surface causes a pressure that is exerted on the tubular fluid, stimulating nerve endings at the pulp and causing pain sensation.

It is difficult to precisely stimulate the same area of the tooth from one examination to the other, leading to greater variation in result and the inability to discern differences in treatments.

Placebo effects are commonly referred to in the dentinal hypersensitivity clinical trial literature but not studied. The placebo effect is a response to medical intervention that results from the intervention itself and not from any particular

11mechanism of action. This study was peculiar in being one of the few where a true placebo, water was applied to the test teeth. In the present study, the control group did not show any relief of symptoms from hypersensitivity. Since the control treatment was distilled water, it was not be expected to have any therapeutic potential

Dentin hypersensitivity studies are subject based and have certain limitations. Widely used stimulation methods have deficiencies that affect their reproducibility and complicate longitudinal monitoring of hypersensitivity. It is difficult to

precisely stimulate the same area of the tooth from one examination to the other. Also attempts to translate subjective feedback to objective data for research purposes can influence the measurement of pain. To date, none of the methods used to assess the measurements have been seen to be completely successful. However, it may be suggested that the aim in dentin hypersensitivity studies is to relieve patient's discomfort. Hence, long-term studies and repeated applications of desensitizing agents are necessary. Since no standard procedures have been developed to test products designed for treatment of the condition, comparison of products between trials is difficult.

The ultimate test of any treatment is a clinical trial. A randomized and controlled trial is the gold standard for determining efficacy. Well-designed control groups and working with more subjects may be of great help in obtaining more reliable results.

Conclusion

Within the parameters of this study on comparison of the clinical efficiency of ACP and Potassium nitrate in treating dentinal hypersensitivity, the following conclusion were drawn.

1. Both the test groups were effective in reducing dentinal hypersensitivity although they differed in rapidity of action over a period of three months.

2. Potassium nitrate showed rapid decrease in hypersensitivity values from the baseline compared to ACP.

3. The change in sensitivity was much more apparent using the airjet stimulation than tactile

Corresponding author: Dr. Souparna Madhavan, Reader, Department of Conservative dentistry &EndodonticsSrinivas Institute of Dental Sciences, Mukka , Surathkal.Pin code-574146Email : [email protected]

[email protected]

Contact number- 09535649469

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Prosthodontic Management for Atrophied Foundation - A Review

1 2 3 4AUTHORS: Gautam Shetty , Shweta Prakash , Shwetha Poovani , Krishna Kumar

1. Dr. Gautam ShettyProfessor and Head, Department of Prosthodontics, Rajarajeswari dental college and Hospital, Bangalore -560040.

2. Dr. Shweta PrakashPost Graduate student, Department of Prosthodontics, Rajarajeswari dental college and Hospital, Bangalore -560040

3. Dr. Shwetha PoovaniReader, Department of Prosthodontics, Rajarajeswari dental college and Hospital, Bangalore -560040

4. Dr. Krishna KumarReader, Department of Prosthodontics, Rajarajeswari Dental College and Hospital, Bangalore -560040

ABSTRACT

Prosthodontic rehabilitation of patients with atrophied ridges is a quite a challenging tasks. Extreme resorption of maxilla and mandible denture bearing area may lead to shrunken and wrinkled appearance of cheeks, unstable non-retentive and unstable denture with resultant pain and discomfort. The loose and unstable lower complete denture is most common problems by denture. The aim of the study is review various impression procedure for atrophic mandibular ridge. The ultimate goal, regardless of the treatment modality chosen , is to restore the patient to a level of satisfactory masticatory function .

Keywords- Atrophic ridges, flabby ridges , functional impression

INTRODUCTION

The basic need of Prosthodontic rehabilitation of completely edentulous patients are the establishment of function, speech, esthetic and the maintenance of patient's health. With the advancement of age , there is greater or lesser degree of resorbtion of bony tissue, with the potential for constant excessive atrophy due to less efficient osteoblasts, declined estrogen production, and overall reduction of calcium absorption from the intestine. Also, when the new denture is placed and adjusted into the patient's mouth, the patient complains of pain caused by compression of soft tissues between the denture and the bone. Therefore, the tissue surface of the dentures or the pressure transmitting surface should have maximum possible area to reduce pressure on the oral mucosa.

The key to successful denture therapy lies in precise execution of the treatment plan formulated by evaluation of a complete comprehensive history and through examination. Such a treatment plan must be based on Devan's principles concerned with rehabilitation that is, preservation of what already exists than the mere replacement of what is missing. Ridge atrophy poses a clinical challenge

1towards the fabrication of a successful prosthesis.

MATERIALS AND METHODS

A literature review article using data bases such as:

Medline, PubMed (1996-2015) was utilized with a strategy to identify the maximum of studies in each base. The search terms used were: atrophic ridges, consequences of atrophic ridges, management of resorbed ridges. The objective of this article is to produce an updated literature review for the oral rehabilitation in patients with atrophic ridges.

DISCUSSION

Atrophic Ridges

Treatment of atrophied ridges is a clinical challenge faced by dental professionals worldwide as severely resorbed ridges present difficulty in

1-4fabrication of an adequate prosthesis. Severely atrophied ridges are a more common finding with

5,6the mandibular residual ridges than the maxilla This is because the mandible resorbs at a faster rate than the maxilla.

A good impression holds the key to a successful treatment in cases of resorbed mandibular ridges where we have minimum tissue to fulfil the fundamental requirement of compromised ridges, abused tissues, impression techniques retention,

15stability and support .No matter how good the prosthesis is constructed, it will not function as intended if it was not made on an accurate

18impression.

Gross mandibular atrophy:

Multifactorial biomechanical disease resulting

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from a combination of anatomic, metabolic, and mechanical determinant varying with time from patient to patient in an infinite number of combinations . There are various causes of atrophy such as disuse atrophy .localized excessive pressure during incising and unilateral function under a denture , Periodontal bone loss before extraction of the teeth , Hyperparathyroidism , Hypogondism , Nutritional deficiencies and tissue resistance to stress.

Problems as a result of extensive changes in the facial and intraoral tissues following the loss of permanent

Morphological changes: caused by either reduction in facial tissue support due to resorption and remodeling of the alveolar tissues.

Neuromuscular changes: Resulting in indefinite occlusal positions

Facial morphological changes

Various changes can be seen such as Changes in facial contour, Facial support, Rest facial height, Changes in facial muscles, Loss of support for the facial musculature, Muscle attachment and Changes in temporomandibular joints

Intraoral morphological changes:

Such as Apparent loss of sulcus width and depth

-Muscle attachment

-Bony prominence

1.Sharp, spiny ridges

2. Uneven alveolar bone

3. Prominent mylohyoid and internal oblique ridge.

4. Sharp mentalis eminence.

5. Enlarged genial tubercle.

The problem of the Mandibular reduced residual ridge:

As we know the average maxillary denture bearing area is 23cm², while the average mandibular denture bearing area is only 12cm² and the mandible is susceptible to resorption four times than the maxilla.

The surface contour of the resorbed ridge may prejudice denture support and the superficial aspect of the mylohyoid ridge may also be sharp, irregular, and prominent which makes it unfavorable for support due to painful loading of the covering mobile mucosa. In cases of nerve

dehiscence and ridge irregularity the master cast should be relieved before construction of the conventional denture base, where surgery is

7-8thought to be inappropriate.

Lack of retention and stability of the conventional mandibular complete denture is commonly a complaint of patient's with reduced residual ridges because of the unfavorable flat ridge from which does not provide any resistance to anteroposterior or lateral movements. Chronic mucosal irritation, discomfort, and the inability to properly masticate

11are usually attendant history findings as well.

As a result of the reduction of the residual ridge, the floor of the mouth becomes relatively superficial and severe mandibular atrophy will result in the genial tubercle and attached muscle becoming sufficiently superficial to interfere with the lingual

14flange.

On the labial surface of the anterior region several muscles show proximity to the crest of the ridge, especially in badly resorbed ridges. These muscles should not be impinged on because their action is nearly at right angles to the flange.

The influence of the lip on lower denture stability becomes more critical as resorption of the ridge increases or as the patient becomes older. The lip instead of being everted as in young individual becomes thinner and inclines backward into the

17mouth.

The large intermaxillary space that results from excessive bone loss creates prosthesis problems of esthetics related to loss of facial support, occlusion, and the patient ability to control the prosthesis.

These cases with grossly resorbed lower ridges often have the crest of the ridge at the level of the mental foramina, in which the nerves and blood vessels are impinged on easily. This causes paresthesia of the lower lip occurring during mastication.

TREATMENT :

What are the options??.......

1. PREVENTIVE PROSTHODONTICS:

a. Prevention of loss of natural teeth

b. The greatest way to preserve the mandibular anterior ridge comes from the maintenance of one or more endodontically treated roots and the placement of an overdenture.

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The advantages of the overdenture over the conventional denture are:

1.The denture bearing mucosa of the residual ridges are spared abuse.

2.Maintenance of the alveolar bone.

3.Sensory feedback.

4.Minimal load thresholds.

5.Tactile sensitivity discrimination.

6.Masticatory performance.

7.Reduction of Psychological trauma.

PRE-PROSTHETIC SURGERY

Excessive RRR leads to loss of sulcus width and depth with displacement of muscle attachment more to the crest of residual ridge, osseous reconstruction surgeries, removal of high frenal at tachments , augmentat ion procedures , vestibuloplasties etc may be required to correct

22-23these conditions.

Immediate dentures:

Some authors claim that extraction followed by immediate dentures reduces the ridge resorption but this has still to be proved.

2. PROSTHODONTIC TREATMENT:

Many techniques have been developed to deal with the problem of the compromised ridge.

Change in design of denture

Impression procedures

-Minimal pressure impression technique.

-Selective pressure impression technique: places stress on those areas that best resist functional forces

- Adequate relief of non stress bearing areas eg. Crest of mandibular ridge.

- Broad area of coverage helps in reducing the force /unit area (Snow Shoe Effect)

- Avoidance of inclined planes to minimize dislodgment of dentures and shear forces.

- Centralization of occlusal contacts to increase stability and maximize compressive forces.

- Provision of adequate tongue room to improve stability of denture in speech and mastication.

- Adequate interocclusal distance during jaw rest to

decrease the frequency and duration of tooth contact.

-Occlusal table should be narrow

- Diet counseling for prosthodontic patients is necessary to correct imbalances in nutrient intake.

- Denture patients with excessive RRR report lower calcium intake and poorer calcium

10,11,12phosphorus ratio, along with less vitamin D.

1. Principle of mucostatics.

2. Using metal bases for snugness of fit of the mandibular denture.

3. Implanting platinum cobalt magnets to increase mandibular denture stability.

4. The flange technique which provided greater denture-bearing surface for stabilization.

Proper coverage of all available denture-bearing surface is fundamental to good denture construction.

FLANGE TECHNIQUE BY LOTT AND LEVIN

Frank lott and Bernard Levin gave an physiologic and anatamic approach to increased retention appearenc function and comfort denture, in which main attention was given to impression for the formation of efficient dentures.and occlusion was taken also taken in consideration.

Roberto von krammede et al in their study used modeling compound to record surface extention which didn't interfere with masticatory function and deglutition.

MODIFIED FOURNET TULLER TECHNIQUE

Here they used softer impression compound to make secondary impression so that maximum pheripheral seal is obtained with minimal pressure on the crest of ridge.

WRINKLE TECHNIQUE

Here tissue conditioner are used and secondary impression is made with light body elastomeric impression materials.

SHANAHAN TECHNIQUES

Training the patient to achieve an ideal tongue position helps to attain an effective lingual border seal, so alginate was used for premilary impression then resin special tray static impression was made, then the trail denture was given to the patients to

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21wear and return in two days.

3.SURGICAL MANAGEMENT:

1. Enlagement of denture-bearing areas

a) Vestibuloplasty.

b) Ridge augmentation- use of allogeneic bone block grafts represent a reliable alternative to autogenous block grafts for augmenting the

24-30atrophic maxilla.

2. Implants

There are several surgical techniques available to 31--33

enhance bone volume for implant placement . These procedures include bone grafting (4), Guided bone regeneration(5), and Distraction osteogenesis. These methods have several drawbacks including invasive surgical procedures, resorption of grafting materials, memberane collapse, exposure to infection and delaying of implant installation for gafting maturation.(6) Expansion of the existing residual ridge is another method to prepare the atrophied maxilla and/or mandible for implant insertion and aug-

34-36mentation. This approach has been referred to as ridge splitting, bone spreading, ridge expansion,

38or the osteotome technique.

CONCLUSION

Faulty prostheses can alter the character, condition and form of the underlying oral tissues. The pathological changes must be carefully examined and resolved, prior to the beginning of the new prosthetic rehabilitation. A thorough history, a keen eye in clinical examinations and sound knowledge about the possible treatment alternatives will help the prosthodontist to provide his patients with satisfactory complete denture prosthesis. The basic objective of taking impression to obtained all potential denture bearing space available. A complete denture fabricated using modified impression procedures to ensure broad and intimate coverage of denture foundation can be given to a patient with severe ridge atrophy and increased inter-arch space.

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CORRESPONDING AUTHOR

Dr.Gautam shetty

Professor and head,

Department of Prosthodontics,

Raja Rajeswari Dental College & Hospital,

Bangalore, Karnataka 560060, India

E-mail:[email protected]

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