vol 1 - mahatma gandhi mission`s dental college and …. rahul hegde dr. shobha deshpande dr. swati...

Journal of Contemporary Dentistry October-December 2011 | Vol 1 | Issue 2 1

Journal of ContemporaryDentistry is the official publicationof the Mahatma Gandhi MissionDental College & Hospital andissues are published in the lastweek of June, October andFebruary.

All the rights are reserved. Apartfrom any fair dealing for thepurposes of research or privatestudy, or criticism or review, no partof the publication can bereproduced, stored, or transmitted,in any form or by any means,without the prior permission of theEditor

The journal and/or its publishercannot be held responsible forerrors or for any consequencesarising from the use of theinformation contained in thisjournal.

The appearance of advertising orproduct information in the varioussections in the journal does notconstitute an endorsement orapproval by the journal and/or itspublisher of the quality or value ofthe said product or of claims madefor it by its manufacturer.

Editorial OfficeEditorial OfficeEditorial OfficeEditorial OfficeEditorial OfficeDrDrDrDrDr. Sabita M. Ram. Sabita M. Ram. Sabita M. Ram. Sabita M. Ram. Sabita M. RamDeanMGM Dental College & HospitalSector 18, KamotheNavi Mumbai 410 209E-mail: [email protected]

Printed atAnitha Anitha Anitha Anitha Anitha Art PrintersArt PrintersArt PrintersArt PrintersArt Printers29/30 Oassis Industrial Estate,Nehru Road,Next to Vakola Market,Santacruz (E), Mumbai 400 055.Tel.: 2665 2970, 2665 2978E-mail: [email protected]

Lt. Gen. Murali MohanBrig. P.N. AwasthiDr. J. N. KhannaDr. Dinesh Daftary

EDITORIAL REVIEW BOARDEDITORIAL REVIEW BOARDEDITORIAL REVIEW BOARDEDITORIAL REVIEW BOARDEDITORIAL REVIEW BOARD

PROSTHODONTICSPROSTHODONTICSPROSTHODONTICSPROSTHODONTICSPROSTHODONTICSMaj. Gen. Vimal Arora

Dr. Suhasini NagdaDr. Padmanabhan T. V.

Dr. Jyoti UndirwadeDr. Usha Radke

Dr. Hetal Turakhia

MAXILLOFMAXILLOFMAXILLOFMAXILLOFMAXILLOFACIALACIALACIALACIALACIAL SURGER SURGER SURGER SURGER SURGERYYYYYDr. R.R.Pradhan

Dr. Vinod KapoorDr. Suhas VazeDr. Rajiv Borle

Dr. Rajesh Dhirwani

PERIODONTICSPERIODONTICSPERIODONTICSPERIODONTICSPERIODONTICSDr. Harshad Vijaykar

Dr. Mala DixitDr. Abhay Kolte

Dr. Rajiv ChitguppiDr. Sudhindra Kulkarni

PEDODONTICSPEDODONTICSPEDODONTICSPEDODONTICSPEDODONTICSDr. Rahul Hegde

Dr. Shobha DeshpandeDr. Swati Karkare

Dr. Bhushan PustakeDr. Thejokrishna P.

Dr. Sachin KanagotagiDr. Sunil SidanaDr. Rajesh Patil

Dr. Shwetha KumarDr. Sonal Patil

EDITORIAL COMMITTEEEDITORIAL COMMITTEEEDITORIAL COMMITTEEEDITORIAL COMMITTEEEDITORIAL COMMITTEE

Dr. Ranganath Rao K. JingadeDr. Sumanthini M.V.

Dr. Varun BhatiaDr. Zohara Charania

JOURNALJOURNALJOURNALJOURNALJOURNAL OFOFOFOFOF

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Dr. Mahesh VermaDr. P.C. GuptaDr. Sureshchandra ShettyDr. R. P. Nayak

ORALORALORALORALORAL PA PA PA PA PATHOLOGYTHOLOGYTHOLOGYTHOLOGYTHOLOGYDr. Vinay Hazare

Dr. Suresh BarpandeDr. Jagdish Tupkari

Dr. Rajiv DesaiDr. Sangeeta Patankar

Dr. Sachin Sarode

CONSERCONSERCONSERCONSERCONSERVVVVVAAAAATIVE DENTISTRTIVE DENTISTRTIVE DENTISTRTIVE DENTISTRTIVE DENTISTRYYYYYDr. Mansing PawarDr. Naseem Shah

Dr. Manjunath N. K.Dr. Sharad KokateDr. Shishir SinghDr. Vibha Hegde

ORTHODONTICSORTHODONTICSORTHODONTICSORTHODONTICSORTHODONTICSDr Shalan Karbelkar

Dr Shweta BhatDr Vaishali Vadgaonkar

Dr Jayesh RahalkarDr Nikhilesh Vaid

ORAL MEDICINEORAL MEDICINEORAL MEDICINEORAL MEDICINEORAL MEDICINEDr. Hemant UmarjiDr. Ajay BhoosreddyDr. Freny Karjodkar

Dr. Anil GhomDr. Deepa Das

ADVISORY BOARDADVISORY BOARDADVISORY BOARDADVISORY BOARDADVISORY BOARD

PatronsMrMrMrMrMr. Kamal K. Kadam. Kamal K. Kadam. Kamal K. Kadam. Kamal K. Kadam. Kamal K. KadamDrDrDrDrDr. Sudhir N. Kadam. Sudhir N. Kadam. Sudhir N. Kadam. Sudhir N. Kadam. Sudhir N. KadamDrDrDrDrDr. Nitin N. Kadam. Nitin N. Kadam. Nitin N. Kadam. Nitin N. Kadam. Nitin N. Kadam

Editor in ChiefDrDrDrDrDr. Jyotsna Galinde. Jyotsna Galinde. Jyotsna Galinde. Jyotsna Galinde. Jyotsna Galinde

Associate EditorsDrDrDrDrDr. Sabita M. Ram. Sabita M. Ram. Sabita M. Ram. Sabita M. Ram. Sabita M. Ram

DrDrDrDrDr. Girish Karandikar. Girish Karandikar. Girish Karandikar. Girish Karandikar. Girish Karandikar

PUBLIC HEALPUBLIC HEALPUBLIC HEALPUBLIC HEALPUBLIC HEALTH DENTISTRTH DENTISTRTH DENTISTRTH DENTISTRTH DENTISTRYYYYYDr. Navin Ingle

Dr. Suhas KulkarniDr. Charu Mohan

Dr. Sabyasachi SahaDr. Ajay Bhambal

Dr. L. Nagesh

Assistant EditorDrDrDrDrDr. Richard Pereira. Richard Pereira. Richard Pereira. Richard Pereira. Richard Pereira

Dr. V.P. JayadeDr. L.S. PoonjaDr. O.P. KharbandaDr. A.K. Barua

2 Journal of Contemporary Dentistry October-December 2011 | Vol 1 | Issue 2

Editor's Message

ANNOUNCEMENTANNOUNCEMENTANNOUNCEMENTANNOUNCEMENTANNOUNCEMENT

In keeping with our endeavour to disseminate scientific knowledge beyond theboundaries of our institution, the Journal now invites Scientific articles from otherinstitutions. All contributing authors are requested to follow the author guidelines

outlined and send in your articles at the specified address.

DrDrDrDrDr. Jyotsna Galinde. Jyotsna Galinde. Jyotsna Galinde. Jyotsna Galinde. Jyotsna GalindeAssoc. Dean, Post Graduate Studies

Prof & Head, Dept. Oral & Maxillofacial Surgery, MGM

Dental research and scientific writing is of paramount importance to any institution.And a scientific journal is one of the methods of this expression.

In India, clinical material is enormous and dental faculty large, but lack ofdocumentation and publication of scientific writing is a hindrance to academic growth.

A journal in place puts an added responsibility on a faculty member to keep pre andpost documentation of cases and instills him to think in a scientific manner.

Every journal article needs to be peer reviewed and that adds to the scientific credibilityof that article. We have striven hard to put in place senior academicians as advisorsand reviewers to offer their quality and positive inputs to boost the journal. It is thisteam effort along with those of the journal committee that makes this exercise acomplete team work and a fulfilling academic experience.

In this issue we have introduced a guest article section; this will feature anotherdimension of clinical expertise of those senior clinicians who will showcase their clinicalwork and that combined with academic inputs from an institution will makes the journala holistic reading material.

We are also opening our doors to other institutes to contribute and make this journeya complete scientific one for the betterment of our fraternity.


Contents

GGGGGUESTUESTUESTUESTUEST AAAAARTICLERTICLERTICLERTICLERTICLE

Lifelike Lifelike Lifelike Lifelike Lifelike Anterior CompositesAnterior CompositesAnterior CompositesAnterior CompositesAnterior CompositesRatnadeep Patil ...................................................................................................................................................... 7

OOOOORIGINALRIGINALRIGINALRIGINALRIGINAL R R R R RESEARCHESEARCHESEARCHESEARCHESEARCH

Evaluation of the stress distribution and displacement of the denture base inEvaluation of the stress distribution and displacement of the denture base inEvaluation of the stress distribution and displacement of the denture base inEvaluation of the stress distribution and displacement of the denture base inEvaluation of the stress distribution and displacement of the denture base inedentulous mandible with varied implant positionsedentulous mandible with varied implant positionsedentulous mandible with varied implant positionsedentulous mandible with varied implant positionsedentulous mandible with varied implant positionsMeghna K. Dang, Sabita M. Ram ........................................................................................................................ 14

RRRRREVIEWEVIEWEVIEWEVIEWEVIEW AAAAARTICLESRTICLESRTICLESRTICLESRTICLES

Use of Functional Use of Functional Use of Functional Use of Functional Use of Functional Appliances in General Dental PracticeAppliances in General Dental PracticeAppliances in General Dental PracticeAppliances in General Dental PracticeAppliances in General Dental PracticeAnita G. Karandikar, Girish R. Karandikar, Madhur Vasudev Navlani ............................................................ 21

Pediatric Obturating Materials Pediatric Obturating Materials Pediatric Obturating Materials Pediatric Obturating Materials Pediatric Obturating Materials And TAnd TAnd TAnd TAnd Techniques: echniques: echniques: echniques: echniques: AAAAA Review Review Review Review ReviewMihir Jha, Sonal D.Patil, Shrirang Sevekar, Vivek Jogani, Poonam Shingare .................................................. 27

Oral Lichen Planus : Oral Lichen Planus : Oral Lichen Planus : Oral Lichen Planus : Oral Lichen Planus : AAAAA Review Review Review Review ReviewRohini Salvi, Rohit Bhailal Gadda,Varun Gul Bhatia ......................................................................................... 33

Bioterrorism and Dentistry- Bioterrorism and Dentistry- Bioterrorism and Dentistry- Bioterrorism and Dentistry- Bioterrorism and Dentistry- AAAAA Review Review Review Review ReviewAmit Chaudhari, Priya Chaudhari ...................................................................................................................... 37

CASE REPORT

Management of non vital maxillary central incisors with open apex usingManagement of non vital maxillary central incisors with open apex usingManagement of non vital maxillary central incisors with open apex usingManagement of non vital maxillary central incisors with open apex usingManagement of non vital maxillary central incisors with open apex usingMineral TMineral TMineral TMineral TMineral Trioxide rioxide rioxide rioxide rioxide Aggregate apical plugs – Aggregate apical plugs – Aggregate apical plugs – Aggregate apical plugs – Aggregate apical plugs – AAAAA case report case report case report case report case reportSumanthini M.V., Naisargi Shah, Mausami A Malgaonkar ................................................................................ 40

Factitious Injury of The Periodontal Tissues - Case ReportFactitious Injury of The Periodontal Tissues - Case ReportFactitious Injury of The Periodontal Tissues - Case ReportFactitious Injury of The Periodontal Tissues - Case ReportFactitious Injury of The Periodontal Tissues - Case ReportVineet Kini, Richard Pereira, Ashvini M. Padhye, Sudarshan G. Kadam .......................................................... 44

Compound Composite Odontomes In Mandibular SymphysisCompound Composite Odontomes In Mandibular SymphysisCompound Composite Odontomes In Mandibular SymphysisCompound Composite Odontomes In Mandibular SymphysisCompound Composite Odontomes In Mandibular Symphysis– – – – – AAAAA Rare Case Rare Case Rare Case Rare Case Rare CaseSushrut Vaidya, Usha Asnani, Smita Sonavane, Imran Khalid, Kartik Poonja, Alok Bhardwaj ...................... 46

Infiltrative TInfiltrative TInfiltrative TInfiltrative TInfiltrative Type of Bone Invasion in Oral Squamous Cell Carcinoma - ype of Bone Invasion in Oral Squamous Cell Carcinoma - ype of Bone Invasion in Oral Squamous Cell Carcinoma - ype of Bone Invasion in Oral Squamous Cell Carcinoma - ype of Bone Invasion in Oral Squamous Cell Carcinoma - AAAAA CCCCCase ase ase ase ase RRRRReporteporteporteporteportJigna Pathak, Niharika Swain, Shwetha Kumar ............................................................................................... 49


CONTEMPORARCONTEMPORARCONTEMPORARCONTEMPORARCONTEMPORARYYYYY DENTISTRDENTISTRDENTISTRDENTISTRDENTISTRYYYYYOCTOBER - DECEMBER 2011 | VOL 1 | ISSUE 2


The Journal of Contemporary Dentistry publishes originalscientific papers, reviews, case reports, and methodpresentation articles in the field of dentistry. Original articlesare published in all dentistry-related disciplines, all areas ofbiomedical science, applied materials science, bioengineering,epidemiology, and social science relevant to dental disease andits management. Manuscripts submitted for publication mustbe original articles and must not have appeared in any otherpublication. The publisher reserves the right to editmanuscripts for length and to ensure conciseness, clarity, andstylistic consistency, subject to the author's final approval.

Authorsh ipAuthorsh ipAuthorsh ipAuthorsh ipAuthorsh ip

Individuals identified as authors must meet the followingcriteria established by the International Committee of MedicalJournal Editors: 1) substantial contributions to conception anddesign, or acquisition of data, or analysis and interpretation ofdata; 2) drafting the article or revising it critically for importantintellectual content; and 3) final approval of the version to bepublished. The number of authors is limited to 6.

Ethical Guidelines:Ethical Guidelines:Ethical Guidelines:Ethical Guidelines:Ethical Guidelines:

Experimentation involving human subjects will be publishedonly if such research has been conducted in full accordancewith ethical principles. Manuscripts must include a statementthat the experiments were undertaken with the understandingand written consent of each subject and according to theabovementioned principles, the statement should also statethat the protocol was approved by the author's institutionalreview committee for human subjects or that the study wasconducted in accordance with the Helsinki Declaration of 1975,as revised in 2000. Do not use any designation in tables, figures,or photographs that would identify a patient, unless expresswritten consent from the patient is submitted. When animalsare involved, the methods section must clearly indicate thatadequate measures were taken to minimize pain or discomfort.Experiments should be carried out in accordance with locallaws and regulations.

Clinical TClinical TClinical TClinical TClinical Trials:rials:rials:rials:rials:

Report clinical trials using the CONSORT guidelines atwww.consortstatement.org. A CONSORT checklist and aflowchart should also be included in the submission material.

Conflict of Interest/Source of Funding:Conflict of Interest/Source of Funding:Conflict of Interest/Source of Funding:Conflict of Interest/Source of Funding:Conflict of Interest/Source of Funding:

It is necessary that information on potential conflicts of interestbe part of the manuscript. The journal requires all sources ofinstitutional, private, and corporate financial support for thework within the manuscript to be fully acknowledged and anyPotential conflicts of interest noted. Please include theinformation under Acknowledgments.

AAAAArticle Preparationrticle Preparationrticle Preparationrticle Preparationrticle Preparation

Original ResearchOriginal ResearchOriginal ResearchOriginal ResearchOriginal Research

Should describe significant and original experimentalobservations and provide sufficient detail so that theobservations can be critically evaluated and, if necessary,repeated. Articles considered as original research include,Randomized controlled trials, intervention studies, studies ofscreening and diagnostic test, outcome studies, costeffectiveness analyses, case-control series, and surveys withhigh response rate. Up to 2500 words excluding referencesand abstract.

Short Communication, Short Case Presentations, andShort Communication, Short Case Presentations, andShort Communication, Short Case Presentations, andShort Communication, Short Case Presentations, andShort Communication, Short Case Presentations, andMethod Presentation Method Presentation Method Presentation Method Presentation Method Presentation ArticlesArticlesArticlesArticlesArticles

Short Case Presentation: Interesting cases authors would liketo share with the readers. Method Presentation Articles: Mustpresent significant improvements in clinical practice (a noveltechnique, technological breakthrough, or practical approachesto clinical challenges).Up to 1000 words excluding referencesand abstract and up to 5 references.

Case reportsCase reportsCase reportsCase reportsCase reports

New / interesting / very rare cases can be reported. Shouldhave importance and significance. Repetition of well-knownand extensively published conditions will not be accepted.Include a thorough literature review and emphasize the clinicalrelevance. Up to 2000 words excluding references and abstractand up to 10 references.

Review articlesReview articlesReview articlesReview articlesReview articles

Must have broad general interest. Reviews should take a broadview of the field rather than merely summarizing the authors´own previous work Systemic critical assessments of literatureand data sources. Up to 3500 words excluding references andabstract.

Letter to the EditorLetter to the EditorLetter to the EditorLetter to the EditorLetter to the Editor

Should be short, decisive observation. They should not bepreliminary observations that need a later paper for validation.Up to 400 words and 4 references.

Article submission to the JournalArticle submission to the JournalArticle submission to the JournalArticle submission to the JournalArticle submission to the Journal

Presentation: Clearly convey research findings or clinicalreports. Avoid technical jargon, but clearly explain where itsuse is unavoidable. The background and hypotheses underlyingthe study, as well as its main conclusions, should be clearlyexplained. Titles and abstracts should be written in languagereadily intelligible.

Abbreviations/acronyms: Abbreviations should be kept to aminimum, particularly those that are not standard. Terms and


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General Information


names referred to as abbreviations or acronyms should be writtenout when first used with the abbreviation in parenthesis.Standard units of measurement need not be spelled out.

Names of Teeth: The complete names of individual teeth mustbe given in the text. In tables and figures, individual teeth canbe identified using the FDI 2-digit system if full tooth namesare too unwieldy.

S t r u c t u r eS t r u c t u r eS t r u c t u r eS t r u c t u r eS t r u c t u r e

1. First Page File: Prepare the title page, covering letter,acknowledgement, etc. All information which can revealyour identity should be here. Include the title of the articleand the full name, degrees, title, and professional affiliationof every author. Provide the contact details and e-mailaddress of the corresponding author.

2. Article file: The main text of the article, beginning fromAbstract till References (including tables) should be in thisfile. Do not include any information such asacknowledgement, your names in page headers, etc., inthis file. Illustrations and tables should be numbered andcited in the text in order of appearance and grouped at theend of the text. High-resolution images must be sent tothe Managing Editor upon article acceptance.

3. Images: Submit good quality colour images. Submit TIFF/JPEG (photographs) files only.

4. Legends: Legends for the figures/images should beincluded at the end of the article file. Figure legends shouldbegin with a brief title for the whole figure and continuewith a short description of each panel and the symbolsused; they should not contain any details of methods.

5. References: Provided with direct references to originalresearch sources. Note that small numbers of referencesto key original papers will often serve as well as moreexhaustive lists. List references at the end of the article innumeric sequence.

The authors' form and copyright transfer form has to besubmitted to the editorial office, in original with the signaturesof all the authors.

Preparation of the ManuscriptPreparation of the ManuscriptPreparation of the ManuscriptPreparation of the ManuscriptPreparation of the Manuscript

Manuscripts must be submitted in Microsoft Word. Marginsshould be at least 1'' on both sides and top and bottom. Materialsshould appear in the following order:

Title PageAbstract (or Introduction) and Key WordsTextFootnotesAcknowledgmentsReferencesFigure LegendsTables

Figures should not be embedded in the manuscript. Authorsshould retain a copy of their manuscript for their own records.

The manuscripts should be typed in A4 size (212 × 297 mm) paper,with margins of 25 mm (1 inch) from all the four sides. Use 1.5spacing throughout. Number pages consecutively, beginning withthe title page. The language should be British English.

Title PageTitle PageTitle PageTitle PageTitle Page

The title page should carry:1. Type of manuscript2. The title of the article, which should be concise, but

informative;3. Running title or short title not more than 50 characters;

4. Name of the authors (the way it should appear in the

journal), with his or her highest academic degree(s) andinstitutional affiliation;

5. The name of the department(s) and institution(s) to whichthe work should be attributed;

6. The name, address, phone numbers, facsimile numbers,and e-mail address of the contributor responsible forcorrespondence about the manuscript;

7. The total number of pages, total number of photographsand word counts separately for abstract and for the text(excluding the references and abstract).

8. Source(s) of support in the form of grants, equipment,drugs, or all of these; and

Abstract (or Introduction) and Key WAbstract (or Introduction) and Key WAbstract (or Introduction) and Key WAbstract (or Introduction) and Key WAbstract (or Introduction) and Key Wordsordsordsordsords

The second page should carry the full title of the manuscriptand an abstract (of no more than 150 words for case reports,brief reports and 250 words for original articles).The structuredabstract, should consist of no more than 250 words and thefollowing four paragraphs:

* Background: Describes the problem being addressed.

* Methods: Describes how the study was performed.

* Results: Describes the primary results.

* Conclusions: Reports what authors have concluded from theseresults, and notes their clinical implications.

T E X TT E X TT E X TT E X TT E X TIntroduct ionIntroduct ionIntroduct ionIntroduct ionIntroduct ionThe Introduction contains a concise review of the subject areaand the rationale for the study. More detailed comparisons toprevious work and conclusions of the study should appear inthe Discussion section.

Materials and MethodsMaterials and MethodsMaterials and MethodsMaterials and MethodsMaterials and Methods

This section lists the methods used in the study in sufficientdetail so that other investigators would be able to reproducethe research. When established methods are used, the authorneed only refer to previously published reports; however, theauthors should provide brief descriptions of methods that arenot well known or that have been modified. Identify all drugsand chemicals used, including both generic and, if necessary,proprietary names and doses. The populations for researchinvolving humans should be clearly defined and enrolmentdates provided.

R e s u l t sR e s u l t sR e s u l t sR e s u l t sR e s u l t s

Results should be presented in a logical sequence with referenceto tables, figures, and illustrations as appropriate.

Discuss ionDiscuss ionDiscuss ionDiscuss ionDiscuss ion

New and possible important findings of the study should beemphasized, as well as any conclusions that can be drawn. TheDiscussion should compare the present data to previous findings.Limitations of the experimental methods should be indicated,as should implications for future research. New hypothesesand clinical recommendations are appropriate and should beclearly identified. Recommendations, particularly clinical ones,may be included when appropriate.

ACKNOWLEDGMENTS ACKNOWLEDGMENTS ACKNOWLEDGMENTS ACKNOWLEDGMENTS ACKNOWLEDGMENTS AND CONFLICTS OFAND CONFLICTS OFAND CONFLICTS OFAND CONFLICTS OFAND CONFLICTS OFINTERESTINTERESTINTERESTINTERESTINTEREST

A c k n o w l e d g m e n t sA c k n o w l e d g m e n t sA c k n o w l e d g m e n t sA c k n o w l e d g m e n t sA c k n o w l e d g m e n t s

At the end of the Discussion, acknowledgments may be madeto individuals who contributed to the research or the manuscriptpreparation at a level that did not qualify for authorship. Thismay include technical help or participation in a clinical study.Authors are responsible for obtaining written permission from

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persons listed by name. Acknowledgments must also include astatement that includes the source of any funding for the study,and defines the commercial relationships of each author.

Conflicts of interestConflicts of interestConflicts of interestConflicts of interestConflicts of interest

In the interest of transparency and to allow readers to formtheir own assessment of potential biases that may haveinfluenced the results of research studies, the Journal requiresthat all authors declare potential competing interests relatingto papers accepted for publication. Conflicts of interest aredefined as those influences that may potentially underminethe objectivity or integrity of the research, or create a perceivedconflict of interest.

Authors are required to submit:Authors are required to submit:Authors are required to submit:Authors are required to submit:Authors are required to submit:

1) A statement in the manuscript, following Acknowledgments,that includes the source of any funding for the study, and definesthe commercial relationships of each author. If an author hasno commercial relationships to declare, a statement to thateffect should be included. This statement should includefinancial relationships that may pose a conflict of interest orpotential conflict of interest. These may include financialsupport for research (salaries, equipment, supplies, travelreimbursement); employment or anticipated employment byany organization that may gain or lose financially throughpublication of the paper; and personal financial interests suchas shares in or ownership of companies affected by publicationof the research, patents or patent applications whose valuemay be affected by this publication, and consulting fees orroyalties from organizations which may profit or loose as aresult of publication.

2) A conflict of interest and financial disclosure form for eachauthor. Conflict of interest information will not be used as abasis for suitability of the manuscript for publication.

R E F E R E N C E SR E F E R E N C E SR E F E R E N C E SR E F E R E N C E SR E F E R E N C E S

References should be numbered consecutively in the order inwhich they appear in the text. A journal, magazine, or newspaperarticle should be given only one number; a book should begiven a different number each time it is mentioned, if differentpage numbers are cited. All references are identified, whetherthey appear in the text, tables, or legends, by Arabic numbersinsuperscript. The use of abstracts as references is stronglydiscouraged. Manuscripts accepted for publication may be cited.Material submitted, but not yet accepted, should be cited in textas ''unpublished observations.'' Written and oral personalcommunications may be referred to in text, but not cited asreferences. Please provide the date of the communication andindicate whether it was in a written or oral form. In addition,please identify the individual and his/her affiliation. Authorsshould obtain written permission and confirmation of accuracyfrom the source of a personal communication. Presented papers,unless they are subsequently published in a proceedings or peer-reviewed journal, may not be cited as references. In addition,Wikipedia.org may not be cited as a reference. For mostmanuscripts, authors should limit references to materialspublished in peer-reviewed professional journals. In addition,authors should verify all references against the originaldocuments. References should be typed double-spaced.

TTTTTA B L E SA B L E SA B L E SA B L E SA B L E S

Tables should be numbered consecutively in Arabic numbers inthe order of their appearance in the text. A brief descriptivetitle should be supplied for each. Explanations, including

abbreviations, should be listed as footnotes, not in the heading.Every column should have a heading. Statistical measures ofvariations such as standard deviation or standard error of themean should be included as appropriate in the footnotes. Donot use internal horizontal or vertical rules.

FIGURE LEGENDSFIGURE LEGENDSFIGURE LEGENDSFIGURE LEGENDSFIGURE LEGENDS

Legends should be typed double-spaced with Arabic numberscorresponding to the figure. When arrows, symbols, numbers,or letters are used, explain each clearly in the legend; also explaininternal scale, original magnification, and method of staining asappropriate. Panel labels should be in capital letters. Legendsshould not appear on the same page as the actual figures.

F I G U R E SF I G U R E SF I G U R E SF I G U R E SF I G U R E S

Digital files must be submitted for all figures. Submit one fileper figure. Human subjects must not be identifiable inphotographs, unless written permission is obtained andaccompanies the photograph. Lettering, arrows, or otheridentifying symbols should be large enough to permit reductionand must be embedded in the figure file. Figure file namesmust include the figure number. Details of programs used toprepare digital images must be given to facilitate use of theelectronic image. Use solid or shaded tones for graphs andcharts. Patterns other than diagonal lines may not reproducewell.

UNITS OF MEASUREMENTUNITS OF MEASUREMENTUNITS OF MEASUREMENTUNITS OF MEASUREMENTUNITS OF MEASUREMENT

Measurements of length, height, weight, and volume shouldbe reported in metric units or their decimal multiples. Allhematologic and clinical chemistry measurements should bereported in the metric system in terms of the InternationalSystem of Units (SI).

STSTSTSTSTAAAAATISTICSTISTICSTISTICSTISTICSTISTICS

Statistical methods should be described such that aknowledgeable reader with access to the original data couldverify the results. Wherever possible, results should bequantified and appropriate indicators of measurement erroror uncertainty given. Sole reliance on statistical hypothesistesting or normalization of data should be avoided. Data in asclose to the original form as reasonable should be presented.Details about eligibility criteria for subjects, randomization, andmethods for blinding of observations, treatment complications,and numbers of observations should be included. Losses toobservations, such as dropouts from a clinical trial, should beindicated. General-use computer programs should be listed.Statistical terms, abbreviations, and symbols should be defined.Detailed statistical, analytical procedures can be included as anappendix to the paper if appropriate.

FOOTNOTES

Footnotes should be used only to identify author affiliation; toexplain symbols in tables and illustrations; and to identifymanufacturers of equipment, medications, materials, anddevices. Use the following symbols in the sequence shown: *,†, ‡, §, k, , #,**, ††, etc.

IDENTIFICAIDENTIFICAIDENTIFICAIDENTIFICAIDENTIFICATION OF PRODUCTSTION OF PRODUCTSTION OF PRODUCTSTION OF PRODUCTSTION OF PRODUCTS

Use of brand names within the title or text is not acceptable,unless essential when the paper is comparing two or moreproducts. When identification of a product is needed or helpfulto explain the procedure or trial being discussed, a genericterm should be used and the brand name, manufacturer, andlocation (city/state/country) cited as a footnote.

General Information


GUEST ARTICLE

Lifelike Lifelike Lifelike Lifelike Lifelike Anterior CompositesAnterior CompositesAnterior CompositesAnterior CompositesAnterior Composites

Ratnadeep Patil*****

IntroductionDirect composite resin restorations can be a viabletreatment option when an esthetic restoration is desiredespecially in case of uncomplicated tooth fractures.1,2

and standard veneer preparations for altering the shapeand size of the existing anterior teeth. In the past theoutcome of direct resin was compromised as they poorlyreproduced the optical properties of natural teeth.Recent advances in adhesion technology, materialproperties and better understanding of opticalproperties of the natural tooth, has helped achievebetter vitality, character and depth of a restoration.The direct resin buildup restoration based oncontemporary layering technique allows clinicians toprovide conservative treatment and a virtuallyimperceptible blend with adjacent tooth structures.3

Shade judgmentShade is analyzed before tooth preparation andthereafter evaluated for every layer of composite. Shadeselection involves visual comparison between thenatural teeth and standard colored dental shade guidesby the dentist8. It does not imply that the same shadecomposite will give us the desired outcome as theinherent opacity and the layer thickness will determineshade outcome. Shade matching, on the contrary, ishighly technical process with unpredictable outcomesince it depends on individual skill and knowledge8. Ithas to be an integral part of the layering technique.

Dentin is an opaque and fluorescent tissue and isresponsible for the hue and chroma of the tooth byreflecting the light through the enamel. Enamel is atranslucent and opalescent tissue and determines thevalue of the tooth.3,6

Composite layeringComposite layering done with the anatomicstratification technique helps reproduce natural

* The author is a graduate from Bombay University with aPrivate practice in Mumbai, since 1988 with special interestand expertise in Esthetic and Implant Dentistry. He is also aDiplomate, International College of Oral Implantologists andauthor of the clinical textbook on esthetic dentistry titled'Esthetic Dentistry - An Artist's Science'. At present he ispursuing his Phd from Utrecht University.

(The author wishes to aknowledge the contribution ofDr. Anjali Dilbaghi)

appearance of enamel and dentin. Every layer hasdifferent shades and opacities when stratified, givinga "polychromatic effect" with a more realistic depth ofcolor by creating an illusion of the way light is reflected,refracted, transmitted and absorbed to simulate thatof dentin and enamel.

Though an exact recipe cannot be given since shadelayering would vary from case to case, the general rulefollowed in anatomic stratification are –

1. Replace Palatal/lingual wall with an opaque composites.Since they have higher color saturation, when light strikesthe optically dense layer, more light is reflected back tothe eyes and thus contributes to the hue and chroma byoptically replacing dentin.6,7

2. Use thin increments and observe shade after every layeris cured so that the shade of the next layer can be planned.Another advantage of this technique is that it minimizesthe negative effects of shrinkage by creating smallincremental shrinkage.5

3. Use translucent composites to encapsulate the innerdentin core. This alters the quantity and quality of thelight reflected and thus decides the value of the restorationby optically replacing enamel in the restoration.6,7

Case 1A 19 year-old male patient reported with fractured upperleft central incisor and chipped surface of upper rightcentral incisor (Figure 1-C1) due to a sports injury.Radiographic examination and cold test did not revealany pulpal damage.

Shade was determined to be A3 using the Tetric NCeram shade guide system. The patient being young,the incisal edge displayed translucency and incisalmamelons (Figure 1-C1)Occlusal view (Figure 2-C1) ofthe fractured teeth reveals the difference in opacityand translucency of dentin and enamel in #21.

In #11 a 1mm bevel was placed along the margin ofthe chipped enamel surface (Figure 3-C1). An envelopepreparation design extending 2mm with a 1mm bevelwas prepared on the facial surface of #21(Figure 3-C1,4-C1). On the palatal surface of #21 a rounded buttmargin was prepared. (Figure 4-C1)

The cavity preparation was disinfected using a 2%chlorhexidine antibacterial solution. Etching was donefor 15 seconds using 37% phosphoric acid (Figure 5-C1); the etchant was removed, and the tooth surface


Figure 1-C1Figure 1-C1Figure 1-C1Figure 1-C1Figure 1-C1








Patil and Dilabaghi : Lifelike Anterior Composites


rinsed with water spray for 30 seconds followed by airdrying taking care not to excessively dry the toothsurface. (Figure 6-C1) A fifth-generation nano optimizedadhesive system (Tetric N-bond) was placed in thepreparation and agitated for 10seconds, then, gentlyair thinned (Figure 7-C1,8-C1), and polymerized for 20seconds (Figure 9-C1).

In this case a nano composite resin system (Tetric N-Ceram) was selected as the material of choice to restorethese teeth. Stratification was initiated with a thinlayer (Figure 10-C1) of flowable resin placed in the lineanglies of the preparation. ). A metal matrix strip wasplaced interdentally and a triangular-shaped,

mesioincisal layer of the A3 body shade was placed andsculpted to reconstruct the proximal surface of #11(Figure 11-C1 ) Thereafter 1-mm of Bleach light shadewas placed and cured to replicate the opaque dentinlayer (Figure 12-C1, 13-C1, 14-C1)

Next increments of A3 enamel shades were layered(Figure 15-C1, 16-C1) with a long bladed instrumentand texture lines created with a sable brush (Figure17-C1) before curing. The mamelon effect was completedusing the highly translucent incisal shade (Artemis)at the incisolingual matrix and two notches were placedto duplicate the external contours of the mamelons.



Figure 1Figure 1Figure 1Figure 1Figure 11-C11-C11-C11-C11-C1








Figure 17-C1Figure 17-C1Figure 17-C1Figure 17-C1Figure 17-C1 Figure 20-C1Figure 20-C1Figure 20-C1Figure 20-C1Figure 20-C1





Case 2A 20 year-old female patient wanted smile enhancementas she unhappy with the shape of her teeth and thefact that her teeth were hardly visible on smiling(Figure 1-C2).

Direct Composite veneers were planned for 4 anteriorteeth using Tetric N-Ceram. Shade was determined tobe A2 using the standard vita shade guide. Since theveneer preparation was in the enamel, value is of greatimportance.

Minimal tooth preparation was done (Figure 2-C2) asin this case more material had to be added, both toallow us enhance the shape of the teeth, alter the incisaledge placement and increase the height of the tooth.Bulk on the labial surface would enhance the lipsupport and make the smile more pleasing.

Self etching adhesive (Adhese) (Figure 3-C2) wasscrubbed on to the tooth for 20 seconds, lightly airthinned and then light cured.



Minimal amount of flowable composite was placed inthe line angles of the preparation. The first layer, alsocalled as the adaptive layer was a very thin layer whichhelped in close contact of composite to the tooth surface.The adaptive layer of Shade A1 (Figure 4-C2) was placedon the entire prepared surface. Next, Shade A3 wassculpted by a cervical contouring instrument to obtain




an accurate emergence profile (Figure 5-C2). This layerextended to the middle of the middle third on the labialsurface. Body A2 shade was the next layer placed whichblended with the cervical shade and extended beyond




the incisal edge to form mamelons (Figure 6-C2). Toprevent overbuilding of the dentin layer, it wasimperative to monitor the thickness of the compositematerial, in order to allow sufficient space for theenamel layer. This translucent shade of Artemisoccupied spaced between the created mamelons andextended up to the cervical area (Figure 7-C2).



Finishing and polishingFinishing focuses on contouring, adjusting, shaping,texturing and smoothing the restoration (Figure 18-C1, Figure 8-C2), while polishing concentrates onproducing a surface luster (Figure 19-C1) and highlylight-reflective surface6. For creating texture infinishing, certain areas on the facial surface of the toothcan be highly polished to give a life-like effect to therestoration1,2. Eminence of the proximal convexity, thehorizontal, vertical ridges, the lobe effect and facialflattening can be effectively projected. The black andwhite image of the finished restoration shows value oftooth and restoration is similar (Figure 20-C1, 21-C1)(Figure 9-C2,10-C2).





ConclusionThe success of the anatomic stratification lies largelyin the fact that it draws inspiration from the naturallayering of dentin and enamel. Continuoustechnological advances have provided us with materialsthat can successfully replicate and retain thecharacteristics built into them while layering them ontooth surfaces. With this concept and technique it ispossible for clinicians to provide a more conservativeyet functional and aesthetic care to their patients.

References1. Rufenacht C. Textbook of Fundamentals of Esthetics.

Chicago: Quintessence publishing, 1990, ISBN 0-86715-230-3.


2. Patil RC. Textbook of Esthetic Dentistry: An Artist's Science.PR publications, 2002, ISBN 81-901319-07.

3. Belcheva A. Reconstruction of Fractured PermanentIncisors In Schoolchildren Using Composite Resin Build-Up (Review). Journal of IMAB - Annual Proceeding(Scientific Papers) 2008, book 2.

4. Lesage B. Aesthetic Anterior Composite Restorations: AGuide to Direct Placement. Dent Clin N Am 51 (2007) 359-378.

5. Deliperi S, Bardwell D N, Debora M, Kugel G. Layeringand Curing techniques for class III restorations: A Two-

year Case Report Pract Proced Aesthet Dent2005;17(3):a-h.

6. Terry D. Restoring the incisal edge. NYSDJ Aug-Sept 2005;30-35.

7. Kamisha N, Ikeda T, Sano H. Color and translucency ofresin composites for layering techniques. Dent Mater J2005 Sep;24(3):428-32.

8. Esan T A, Bamise C T, Akeredolu P A. Evaluation Of ShadeMatching Practices Among Nigerian Dentists Rev Clín PesqOdontol. 2008 set/dez;4(3):161-168.



IntroductionEdentulism leads to an acknowledged impairment oforal function with both esthetic and psychologicalchanges. Severe atrophy of the inferior alveolar processand underlying basal bone often results in otherproblems with a lower denture such as, intolerance toloading of the mucosa, pain, difficulty in eating andspeech, loss of soft tissue support, and altered facialappearance.

It has been established through longitudinal clinicalstudies, that the survival of root form titaniumimplants is very high in the anterior mandible and

that the incidence of surgical complications is very low.The superior bone quality in the anterior mandiblealong with the usual abundance of keratinized tissuemakes it a suitable location for implant placement.Implants prevent alveolar bone resorption by about fourfold, when placed and selected properly. This makesimplant supported over dentures a very feasibletreatment option that will aid in the establishment ofstability and retention of the mandibular denture.

An implant retained overdenture with attachment tothe implant can be supported and retained either fullyby the implant or by a combination of a prosthesisretained both by implant and mucosa. In all incidencesof functional loading, the occlusal forces are transferredto the bone implant interface and soft tissues by theimplant supported prosthesis. Studies have shown thatregardless of attachment type, patient satisfaction levelsare the same with a bar, ball, or magnet-retaineddenture supported by implants.

Fabricating overdenture on implants placed in theanterior region between the foramen results in thecantilevering of the denture posteriorly leading toposterior bone resorption along with increased load onthe implants. Since 1982, the evidence for mandibular

ORIGINAL ARTICLE

Evaluation of the stress distribution and displacement of theEvaluation of the stress distribution and displacement of theEvaluation of the stress distribution and displacement of theEvaluation of the stress distribution and displacement of theEvaluation of the stress distribution and displacement of thedenture base in edentulous mandible with varied implant positionsdenture base in edentulous mandible with varied implant positionsdenture base in edentulous mandible with varied implant positionsdenture base in edentulous mandible with varied implant positionsdenture base in edentulous mandible with varied implant positions

Meghna K. Dang1, Sabita M. Ram2

Abstract

Aim: To evaluate the stress distribution and displacement of the denture base in a three dimensional finite elementedentulous mandibular model with varied implant positions. Objectives: 1)To evaluate the stresses induced byimplants placed in the anterior region of the edentulous mandible. 2)To evaluate the stresses induced by implantsplaced in the anterior and posterior region of the edentulous mandible. 3)To compare the stresses induced byimplants placed in the anterior and posterior region of the edentulous mandible. 4)To evaluate the displacement ofthe denture base with implants placed in the anterior and posterior region of the edentulous mandible.5)To comparethe displacement of the denture base with implants placed in the anterior and posterior region of the edentulousmandible. Materials and Methods: The materials used were Nobel Biocare Mk III long implants 3.75x13mm andshort 5.0x7.0 implants, with O-ball head attachment. ANSYS: Version 8.0 software was used to create a three-dimensional model of an edentulous mandible and the two implants. Three models were prepared having differentimplant positions and locations. MODEL 1 Two long implants were placed interforaminally in lateral incisor regionone on either side, MODEL 2 Four long implants placed were interforaminally in the central incisor and canineregion two on either side and, MODEL 3 Two long implants were placed interforaminally in lateral incisor region oneon either side and two short implants were placed in premolar region 3mm posterior to the mental foramen, one oneither side. Two types of load were given ie. vertical load of 325N was applied in second premolar and first molarregion and 10N load at 150 angulation was applied in the anterior incisors area. The models were loaded separatelyand stress pattern, amount of stresses and amount of displacement were analysed for each model. Results: Theobservations obtained from the ANSYS software were analysed and evaluated. Model 3 showed the least amountof stress and displacement as compared to the other models. Conclusion: When the implants were spread acrossthe arch both anteriorly and posteriorly, the stress induced in the bone and displacement of the denture base wasseen to be less.

Key Words: Implant, Load, Displacement, Stress.

Lecturer1

DY Patil Dental College & Hospital

Professor & Head2

Dept. of ProsthodonticsMGM Dental College & Hospital, Kamothe, Navi Mumbai

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr. Sabita M. Ram,DeanMGM Dental College & Hospital, Kamothe,Navi Mumbai 410 209E-mail: [email protected]


overdentures supported by two implants hasaccumulated sequentially to see them now proposed asthe standard service, when opposing maxillary completedentures. Later, implant-supported dentures wereconstructed using four implants interconnected by abar. It was a reliable option because it remainedfunctional even after failure of one of even two implants.Also, placing four implants may reduce the amount ofstress over individual implants and may also reducethe displacement of denture in the posterior region,but, the resorption in the posterior region maycontinue. It was suggested that a more "spread out"arrangement of the implants across the arch gave a"more favourable" distribution of bone stresses aroundthe implants. But the height of bone in the posteriorregion many a times being inadequate, does not permitthe placement of long implants. Therefore shortimplants could be an option. This would spread outthe implants in anterior and posterior regions.

Therefore a finite element study was undertaken tocompare the stresses in the bone and displacement ofthe denture base when implants were placed only inthe anterior region and when the implants were spreadout both anteriorly and posteriorly. These stresses wereanalysed by the finite element method by creating athree dimensional finite element model as it can moreaccurately simulate the geometric and materialcomplexities that exist in real patients. Thesesituations can be simulated in patients, when implantoverdentures are planned.

Method

The study was divided into following steps:-

I Introduction TIntroduction TIntroduction TIntroduction TIntroduction To The Finite Element o The Finite Element o The Finite Element o The Finite Element o The Finite Element AnalysisAnalysisAnalysisAnalysisAnalysis

Finite Element Analysis (FEA) is a computer-basednumerical technique for calculating the strengthand behaviour of engineering structures. Thebehaviour of an individual element can be describedwith a relatively simple set of equations. Just asthe set of elements would be joined together to buildthe whole structure, the equations describing thebehaviours of the individual elements are joinedinto an extremely large set of equations thatdescribe the behaviour of the whole structure. Thestresses will be compared to allowable or permissiblevalues of stress for the materials to be used, to seeif the structure is strong enough.

II Construction Of The Fea Model : Pre-Construction Of The Fea Model : Pre-Construction Of The Fea Model : Pre-Construction Of The Fea Model : Pre-Construction Of The Fea Model : Pre-processor (Modelling)processor (Modelling)processor (Modelling)processor (Modelling)processor (Modelling)

A .A .A .A .A . Construction of the geometric model ofConstruction of the geometric model ofConstruction of the geometric model ofConstruction of the geometric model ofConstruction of the geometric model ofthethethethethe edentulous mandibleedentulous mandibleedentulous mandibleedentulous mandibleedentulous mandible

1. Modeling the alveolar portion of the bone

Modeling is done as 3D solid modeling. This model

simulates bone with different material properties.An edentulous mandible was taken andmeasurements made at different points along thebone in the antero-posterior and supero-inferior

Three Dimensional Model of Complete Three Dimensional Model of Complete Three Dimensional Model of Complete Three Dimensional Model of Complete Three Dimensional Model of Complete AlveolarAlveolarAlveolarAlveolarAlveolarPortion of The MandiblePortion of The MandiblePortion of The MandiblePortion of The MandiblePortion of The Mandible

Model of Long ImplantModel of Long ImplantModel of Long ImplantModel of Long ImplantModel of Long Implant

Model of Short ImplantModel of Short ImplantModel of Short ImplantModel of Short ImplantModel of Short Implant

Dang and Ram : Evaluation of the stress distribution and displacement of the denture


plane with the help of vernier callipers. Themeasurements were given co-ordinates in the x, y,and z planes.

The mandible was made eight mm in width andeighteen mm in height. The canal was modeled bycreating a cylindrical volume and the alveolar partof the mandible was modeled till the ramal area.The mental foramen was located at a distance of30.41mm from midline and 19.38mm from base ofmandible.

2. Modeling the implant and attachments

Nobel Biocare Mk III implants were used in thestudy which were made up of Titanium-aluminium-vanadium (Ti-6Al-4V).

The implant dimensions used wereLong implants- 3.75x13.0mmShort implants- 5.0x7.0mm

The threaded part of the implants was embeddedin the bone with the 'O-Ball' attachment outsidethe bone on top of the implant. The 'O-Ball'attachment was modeled as a 1.5mm sphere atthe platform of the implant. The external hexdesign and cylindrical portion of the overdentureattachment was not modeled so as to simplify thenodal configuration and thereby the analysis. Theimplants were constructed in a similar way to thebone.

3. Placing the implants in bone

The implants were placed in specific positions ofthe mandible. The mental foramen was taken as aguide for the placement of the posterior implants.

MODELMODELMODELMODELMODEL 1: 1: 1: 1: 1: Two long implants were placedinterforaminally in lateral incisor region one oneither side.

MODEL 2:MODEL 2:MODEL 2:MODEL 2:MODEL 2: Four long implants placed wereinterforaminally in the central incisor and canineregion two on either side.

MODELMODELMODELMODELMODEL 3: 3: 3: 3: 3: Two long implants were placedinterforaminally in lateral incisor region one oneither side and two short implants were placed inpremolar region 3mm posterior to the mentalforamen, one on either side.

Complete bond (ankylosed) between implant andbone was considered. The models were loadedseparately and stress pattern and amount ofstresses were analysed for each model.

4. Modeling the mucosa

Since 'Poissons ratio' for the mucosa was almostnegligible as compared to the bone and the implant,it was considered not to create a significant impacton the result and was not modeled.

Model 1- VModel 1- VModel 1- VModel 1- VModel 1- Volume Modelling of Mandibleolume Modelling of Mandibleolume Modelling of Mandibleolume Modelling of Mandibleolume Modelling of Mandible



5. Modeling of the denture base

The overdenture was modeled as a SHELL element(Shell 63 element). It had a modulus of elasticityof 1.022x105 N/mm2 and poisons ratio of 0.3. Itwas modeled as a two dimensional structure. The



plate was 3 mm in thickness and kept at a distanceof 2 mm from the bone to compensate for themucosal thickness. The plate touched theoverdenture attachments and covered the top partof the alveolar bone and implants.

6. Splitting the mandible into two symmetric parts

Since the mandible is symmetric about its midline,the mandible was sliced through the centre. Thissimplifies the solving process as less computationaldata would be generated.

B .B .B .B .B . Meshing the modelMeshing the modelMeshing the modelMeshing the modelMeshing the model

A three dimensional Finite Element Mesh wascreated using the Ansys pre-processor. Care wastaken to concentrate the mesh pattern in the regionwhere we wanted to study the distribution (i.e.around the implant). For this reason the SOLID45 element (brick element) type was selected. Theelement had a 8 node element with quadraticdisplacement behaviour and was well suited formodeling irregular meshes. Each node had freedomto move in the x, y and z planes. The elementswere constructed to be as accurate as possiblewithin the limitations of the software. Thecompleted model consisted of 28889 elements andtotal of 6223 nodes (4956 for bone and 1267 forimplants) with 18669 degrees of freedom.

C.C.C.C .C . Assigning the material propertiesAssigning the material propertiesAssigning the material propertiesAssigning the material propertiesAssigning the material properties

All the structures depicted in the model (corticalbone, cancellous bone, and the implant) wereassumed to be linearly elastic, homogenous andisotropic. The Young's modulus and Poisson's ratiofor the different materials used in the study weregiven by Pierrisnard L, Hure G, Barquins M,Chappard D1. The models were given the propertiesof Cancellous Type A bone.

Simulated Load In Molar Simulated Load In Molar Simulated Load In Molar Simulated Load In Molar Simulated Load In Molar AreaAreaAreaAreaArea

Material PropertiesMaterial PropertiesMaterial PropertiesMaterial PropertiesMaterial Properties

Mater ialsMater ialsMater ialsMater ialsMater ials YYYYYo u n g ' so u n g ' so u n g ' so u n g ' so u n g ' sPo i sson ’ sPo i sson ’ sPo i sson ’ sPo i sson ’ sPo i sson ’ s

M o d u l u sM o d u l u sM o d u l u sM o d u l u sM o d u l u s Rat ioRat ioRat ioRat ioRat io (Mpa) (Mpa) (Mpa) (Mpa) (Mpa)

Implant 114 0.34

Cortical Bone 14 0.35

Type A 2.5 0.3

Cancellous Bone Type B 1.5 0.3

Type C 0.5 0.3

D .D .D .D .D . Applying the boundary conditionsApplying the boundary conditionsApplying the boundary conditionsApplying the boundary conditionsApplying the boundary conditions

Symmetric boundary conditions were imposed atthe mid-symphyseal region since only half themandible was modeled. The rear end of themandible was fixed for displacement in all threetranslations.

E .E .E .E .E . Loading of the modelLoading of the modelLoading of the modelLoading of the modelLoading of the model

Beam loading was used to put the load. Two loadswere applied.

LOAD 1 -LOAD 1 -LOAD 1 -LOAD 1 -LOAD 1 - A vertical load of 325 N was applied insecond premolar and first molar region.

LOAD 2 -LOAD 2 -LOAD 2 -LOAD 2 -LOAD 2 - A tipping force of 10 N at 150 angulationwas applied in the anterior incisor area.

II PROCESSOR (SOLVER)

Once the geometry is converted to the finite elementform, it is to be solved by the solver which is a partof the software. The results were generated afterall the equations were solved. The solver does thefollowing: it generates element matrices, computesnodal displacement values and derivatives, andsolves governing matrix equations.

II POST PROCESSOR (RESULT)

The results for the stress and displacement areinterpreted from color coded images seen in the3D finite element models.

Results

The observations were statistically analysed tocomparatively evaluate the values obtained. The Stressanalysis executed by the Ansys software providedresults that enabled visualization of Compressivestress, Von-Mises stress fields in the form of Colourcoded bands along with the Displacement. Each colourband represented a particular range of stress valuewhich is given in Newton-mm2. The displacementvalues were observed in mm.



Discussion:Edentulous patients require replacement of teeth forperforming function of mastication, speech andesthetics. With advancing age, the rate of resorptionincreases leaving the patient a dental cripple. Theplacement of implants for such patients will overcomethe problems of retention, stability, comfort andpreservation of tissues. Fixed restoration with multipleimplants may be the first choice for these patients,but with the deteriorating conditions of the alveolarridge, placing multiple implants may not be possible.We need to take the maximum advantage of whatremains of the patient's oral condition. Complete overdentures with few implants could be the treatmentoption for these patients in order to fabricate prosthesisthat the patient appreciates without overloading thepoor denture foundation.

The placement of implant overdentures has become apopular line of treatment. Factors such as location,number, size and distribution of implants over theedentulous arch have been a subject of much debate.

Analysis of Stress Induced In Bone With ThreeAnalysis of Stress Induced In Bone With ThreeAnalysis of Stress Induced In Bone With ThreeAnalysis of Stress Induced In Bone With ThreeAnalysis of Stress Induced In Bone With ThreeDifferent Implant Positions (N/MmDifferent Implant Positions (N/MmDifferent Implant Positions (N/MmDifferent Implant Positions (N/MmDifferent Implant Positions (N/Mm22222)))))

M o d e lM o d e lM o d e lM o d e lM o d e l C o m p r e s s i v eC o m p r e s s i v eC o m p r e s s i v eC o m p r e s s i v eC o m p r e s s i v e VVVVVon Misseson Misseson Misseson Misseson Misses VVVVVon Misseson Misseson Misseson Misseson Misses R e s u l t a n tR e s u l t a n tR e s u l t a n tR e s u l t a n tR e s u l t a n tStress 325Stress 325Stress 325Stress 325Stress 325NNNNN Stress 325Stress 325Stress 325Stress 325Stress 325NNNNN Stress 10Stress 10Stress 10Stress 10Stress 10NNNNN VVVVVon Misseson Misseson Misseson Misseson MissesVVVVVe r t i c a le r t i c a le r t i c a le r t i c a le r t i c a l VVVVVe r t i c a le r t i c a le r t i c a le r t i c a le r t i c a l Oblique Oblique Oblique Oblique Oblique Stress ofStress ofStress ofStress ofStress ofL o a dL o a dL o a dL o a dL o a d 1 01 01 01 01 0 NNNNN Load Load Load Load Load 325325325325325NNNNN

O b l i q u eO b l i q u eO b l i q u eO b l i q u eO b l i q u e VVVVVe r t i c a le r t i c a le r t i c a le r t i c a le r t i c a lL o a dL o a dL o a dL o a dL o a d L o a dL o a dL o a dL o a dL o a d

( R o u n d e d )( R o u n d e d )( R o u n d e d )( R o u n d e d )( R o u n d e d )

Model 1 Max. Upto 132 0-352 0-1.2 351

Model 2 Max. Upto 60 0-261 0-0.9 260

Model 3 Max. Upto 33 0-160 0-1.1 159

Displacement of Denture Base (Mm)Displacement of Denture Base (Mm)Displacement of Denture Base (Mm)Displacement of Denture Base (Mm)Displacement of Denture Base (Mm)

M o d e lM o d e lM o d e lM o d e lM o d e l Displacement of PlateDisplacement of PlateDisplacement of PlateDisplacement of PlateDisplacement of Plate Displacement of PlateDisplacement of PlateDisplacement of PlateDisplacement of PlateDisplacement of PlateWWWWWith 325ith 325ith 325ith 325ith 325NNNNN V V V V Verticalerticalerticalerticalertical With 10With 10With 10With 10With 10NNNNN Horizontal Horizontal Horizontal Horizontal HorizontalAnd 10And 10And 10And 10And 10NNNNN Oblique Load Oblique Load Oblique Load Oblique Load Oblique Load L o a dL o a dL o a dL o a dL o a d

Model 1 93 0.079

Model 2 46 0.026

Model 3 20 0.018

G r a p h s :G r a p h s :G r a p h s :G r a p h s :G r a p h s :

Compressive Stress Induced In BoneCompressive Stress Induced In BoneCompressive Stress Induced In BoneCompressive Stress Induced In BoneCompressive Stress Induced In Bone

Resultant VResultant VResultant VResultant VResultant Von Misses Stress Induced In Boneon Misses Stress Induced In Boneon Misses Stress Induced In Boneon Misses Stress Induced In Boneon Misses Stress Induced In Bone

ST

RE

SS

N/m

mS

TR

ES

S N

/mm

ST

RE

SS

N/m

mS

TR

ES

S N

/mm

ST

RE

SS

N/m

m2222 2

Displacement Of Plate Displacement Of Plate Displacement Of Plate Displacement Of Plate Displacement Of Plate At 10n Oblique LoadAt 10n Oblique LoadAt 10n Oblique LoadAt 10n Oblique LoadAt 10n Oblique Load

Displacement Of Plate Displacement Of Plate Displacement Of Plate Displacement Of Plate Displacement Of Plate At 325n VAt 325n VAt 325n VAt 325n VAt 325n Vertical ertical ertical ertical ertical And 10nAnd 10nAnd 10nAnd 10nAnd 10nOblique LoadOblique LoadOblique LoadOblique LoadOblique Load

DI

SP

LA

CE

ME

NT

DI

SP

LA

CE

ME

NT

DI

SP

LA

CE

ME

NT

DI

SP

LA

CE

ME

NT

DI

SP

LA

CE

ME

NT

mm

mm

mm

mm

mm



This study was 3-D finite element study planned withthe two lengths of Nobel Biocare Mk III implants havingtwo different diameters and lengths and three differentpositions on the edentulous mandible.

The finite element model of the mandible was modeledand the bone density was incorporated as suggested byPerrishard, Hure, Barquins, Chappard1. Forsimulation of the overdenture a SHELL element wasmodeled and was two dimensional. The materialproperties were assigned according to the literatureand the models were meshed. The selection of implantswas done to simulate different situations.

For Model 1 two implants of Nobel Biocare 3.75mm x13mm were placed in the lateral incisor region whichaccording to Hong, Choi, Bak and Kwon2, was the bestposition for placing them for overdentures.

For Model 2 four implants of Nobel Biocare 3.75mm x13mm were placed in central and canine region assuggested by Misch3.

For Model 3 the two anterior implants of Nobel Biocare3.75mm x 13mm were placed as in Model 1 in lateralincisor region and two posterior implants of NobelBiocare 5mm x 7mm were placed in posterior regionas suggested by Gherke, Spanel, Degidi, Piatelli, andDhom4.

Occlusal forces were applied to simulate the verticalforces (y axis) and the oblique load was applied at 150angle as suggested by Chun et al5 to simulate theanterior component of the load that bought about thetipping of the denture when tongue comes in contactwith the lingual surface of the anterior teeth6 (x-axis).A combination of occlusal and oblique load simulatedthe masticatory load in the model. The amount of loadapplied was in accordance with Kampen, Bitt, Cune,Bosman, and Bozkaya, Muftu7. the stresses wereobserved and analyzed.

It was found that irrespective of the positions ofimplant the concentration of stresses was near theattachment of the O-ball head to the implant. Lessstresses were seen in model with four implants ascompared to model with two implants which iscontradictory to the studies carried out by differentresearchers i.e Meijer, Starmans, Steen, Bosman8 andVisser, Raghoebar, Meijer, Batenburg, Vissink9.Maximum stresses and displacement of denture basewere observed in model with two implants placedanteriorly which may be attributed to less support.Least stresses were seen in the model with two longimplants placed anteriorly and two short implantsplaced posteriorly along with least displacement ofdenture base. This may be attributed to the increasednumber of implants and also their wide distributionand spread across the arch.

The Finite Element Method has proven to be anextremely accurate and precise method for analyzingstructures. Although it is not a substitute for clinicalexperimentation, the use of this method of analysis iswarranted as it simulates experimental results,reduces experimentation costs and avoids destructiveexperimentation.

ConclusionThe study was conducted to evaluate the stressdistribution in bone and displacement of the denturebase with varied implant positions. Within thelimitations of the 3D finite element study the followingconclusions were drawn:

1. The stresses were maximum with two implantsplaced in the anterior region.

2. The stresses were minimum when the implantswere spread anteriorly and posteriorly i.e. twoimplants in the anterior region and two shortimplants in the posterior region.

3. The stresses with four implants in the anteriorregion were less than the two implants placed inthe anterior region but more than the four implantsspread anteriorly and posteriorly.

4. Maximum displacement of the denture base wasobserved with two implants placed in the anteriorregion.

5. Minimum displacement of the denture base wasobserved with implants spread anteriorly andposteriorly.

6. The displacement with four implants placed in theanterior region showed less displacement ascompared with two implants placed in the anteriorregion but more as compared to the four implantsplaced anteriorly and posteriorly.

7. When the implants were spread across the archboth anteriorly and posteriorly, the stress inducedin the bone and displacement of the denture basewas seen to be less.

References:1. Pierrishard L, Hure G, Barquins M, Chappard D. Two dental

implants designed for immediate loading: a finit elementanalysis. Int J Oral Maxillofac Implants. 2002;17:353-362.

2. Hong HR, Choi DG, Bak J, Kwon KR. 3D finite elementanalysisof overdenture stability and stress distribution onmandibular implant-retained overdenture. J Korean AcadProsthodont 2007;45(5):633-643.

3. Misch CE. Dental implant prosthetics. Treatment optionsfor mandibular implant overdentures. 2nd edition Elsevierpublishing; 2005.

4. Gehrke P, Spanel A, Degidi M, Piatelli A, Dhom G. FEManalysis on deformation and stress distribution in fixedmetal-reinforcedprovisional restorations of immediatelyloade XiVE implants in the edentulous mandible. Posterpresented at 12th International Friadent Symposium 2006held on march 24-26 at Salzburg, Autria.

5. Chun HJ et al. Evaluation of design parameters ofosseointegrated dental implants using finite elementanalysis. J Oral Rehab 2002;29:565-574.



6. Zmudzki J, Chladek W, Krukowska J. Attachments ofimplant retained tissue supported denture under bitingforces. Archive Computational Mat Sc Surface Eng2009;1(1):13-20.

7. Van Kampen FM, Van Der Bitt A, Cone MS, Bosman F.The influence of various attachment types in mandibularimplant retained overdentures on maximum bite forceand EMG. J Dent Res 2002;81(3):170-173.

8. Meijer HJ, Starmans FJ, Steen WH, Bosman F. A three-dimensional finite element study on two versus fourimplants in an edentulous mandible. Int J Prosthodont1994;7(3):271-279.

9. Visser A, Raghoebar GM, Meijer HjA, Batenburg RHK,Vissink A. Mandibular implant overdentures supported bytwo or four endosseous implants. A 5 year prospectivestudy. Clin Oral Impl Res. 2005:16;19-25.



IntroductionAssuming that one subscribes to the theory that movingteeth is easier than moving bones, it follows that thedegree of success in rearranging relationship of jawbones will be decided by attempting corrective stepswell before peak-growth-velocity is over. Thus, latemixed dentition may be the best period for a clinicianto aim to start correction of the commonest problem:large overjet (8-10 mm and beyond) often accompaniedby deep overbite, narrow maxillary dental arch,recessive chin and a seemingly prognathic or, betterstill, an almost normal maxillary element.Such Class II type of cases may be ideal ones for aGeneral Dentist (GD) to familiarize himself with inusing Myofunctional Appliances (also referred to asFunctional Appliances). Class III cases are as such more

difficult ones to treat and hence should be avoided atleast initially.Though functional appliances are also of a fixed variety,the authors strongly recommend use of the removabletype for their minimalistic iatrogenic-damage-potential(operator-induced-damage-potential).

Functional AppliancesThese are muscle motivating appliances, often loosefitting, which harness the natural forces of the orofacialmusculature that are transmitted to the teeth andalveolar bone through the medium of the appliance.Commonly used Functional Appliances includeAndresen's Activator12,13 (Fig.1), Balter's Bionator14

REVIEW ARTICLE

Use of Functional Use of Functional Use of Functional Use of Functional Use of Functional Appliances in General Dental PracticeAppliances in General Dental PracticeAppliances in General Dental PracticeAppliances in General Dental PracticeAppliances in General Dental Practice

Girish R. Karandikar1, Anita G. Karandikar2, Madhur Vasudev Navlani3

AbstractAlthough most malocclusions pertaining to irregularities of teeth resolve through moving teeth, occasionalmalocclusions confront us with a disharmonious inter-jaw-relationship owing to faulty size and/ or faulty antero-posterior location of the jaws or dentoalveolar regions. These malocclusions do not always respond favorably toconventional tooth moving appliances and are ideal candidates for appliances that have the capability of moldingbones as well as relocating them. Through this article, the authors outline a way that General Dentists can getenough 'food for thought' for treating such cases on their own by using simple removable appliances. Additionalreading/training may be needed to get to use the functional appliances with felicity.

Key Words: Skeletal pattern, Growth amount, Growth direction, Construction bite, Appliance manipulation

Professor and Head1

Department of OrthodonticsM.G.M. Dental College and Hospital, Navi Mumbai

Professor2

Department of OrthodonticsYMT Dental College, Kharghar, Navi Mumbai

Senior Lecturer3

Department of OrthodonticsModern Dental College & Research Centre, Indore

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr. Girish R. KarandikarDepartment of OrthodonticsM.G.M. Dental College and Hospital, KamotheNavi MumbaiE-mail: [email protected]

Fig.1 : Activator

(Fig.2), Frankel Appliance16,17 (Fig.3, 4), Clark's TwinBlock10 (Fig.5), etc.


Fig.2 : Bionator

Fig.3 : Frankel's Appliance for correction of Class IIs

Fig.4 : Frankel's Appliance for correction of Class IIIs

Fig.5 : Twin Block Appliance

Fig.6 : Cephalostat, the head holding devisefor taking Lateral Cephalograms

Fig.7 : Patient's headpositioned in the Cephalostat,

Side View

Fig.8 : Position of ear-rods& Fronto-Nasal Rest,

Front View

Karandikar et.al. : Use of Functional Appliances in General Dental Practice


Why Functional:Why Functional:Why Functional:Why Functional:Why Functional:Irrespective of which functional appliance it is,functional appliances are all based on same basicprinciples (application, redirection and removal of force),that of using Function Forces & of alternating theirdirection, strength & duration. All of these appliancesare all muscle controlled even if screws & springs arebuilt in.

Development of Functional Development of Functional Development of Functional Development of Functional Development of Functional Appliances:Appliances:Appliances:Appliances:Appliances:A major reason was recognition that function had aneffect on ultimate morphologic structure of dentofacialcomplex1. Moss's Functional Matrix Theory2,contributions of Wolff on form & function, studies onresponse of bone to functional forces by Kock,Benninghof and ideas of Van Der Klauuw allcontributed in seeking to change and control thedirection of growth of the jaws in correcting imbalancein the skeletal jaw bases.

These studies and several others paved a way inproving that function plays a very important role incontrolling size & shape of bones in the membranousbones of craniofacial area and especially more so inregions of the alveolar base of jaws.

Effect of Functional Effect of Functional Effect of Functional Effect of Functional Effect of Functional Appliances:Appliances:Appliances:Appliances:Appliances:Functional Appliances are unique not solely due to theirpurported orthopedic effect influencing facial skeletonof growing child in condylar & sutural areas as claimedby several experts. They also exert an orthodontic effecton dentoalveolar area. Unlike conventional applianceswhich act on teeth using mechanical elements,functional appliances act on dentoalveolar structuresby transmitting, eliminating or guiding natural forcesproduced during various functions e.g. Swallowing,Mastication, etc.

Functional Appliances help to reset the alteredequilibrium of the orofacial musculature and often helpin elimination of oral habits whilst being an effectivepost-treatment retention appliance in certain types ofcases too.

Case Selection & Issues with Diagnosis &Treatment PlanningFunctional Analysis11 is a very important cog, in thewheel of success while using Functional Appliances.The reader is encouraged to be conversant with thenuances involved herein before attempting to treatcases.

Other important issues are:

The diagnostic criteria used to determine thegrowth pattern (both antero-posterior and vertical)in a case.

Status of lower anterior teeth (in terms ofproclination or crowding prevalent).

Judging the efficacy of the expected clinical result(clinical VTO).

Understanding the principles of, and taking aproper Construction Bite12.

Despite being seemingly easy to use, functionalappliances need proper case election criteria to befollowed and, above all, a cooperative patient toachieve the needed degree of success.

(1)(1)(1)(1)(1) Judging the Skeletal PatternJudging the Skeletal PatternJudging the Skeletal PatternJudging the Skeletal PatternJudging the Skeletal Pattern

The purpose of this step is to determine if a case belongsto the correct type in being treated with a RemovableFunctional Appliance.

This calls for routine lateral cephalometric skeletalevaluation using suitable simple analysis for judgingthe skeletal discrepancy between the upper and lowerjaws. Any standard textbook in Orthodontics 3,4 5,7,10, 12,13

will help the reader to reacquaint themselves of thesebasic facts.

If a Cephalostat (Fig.6, 7, and 8) is not available, then,a True Lateral X-ray of the Skull and Mandible takenfrom the right side with a film-to-focus distance of 5feet can be made use of.

(a) Antero-posterior Dimension:Antero-posterior Dimension:Antero-posterior Dimension:Antero-posterior Dimension:Antero-posterior Dimension: The normal ANBrelationship is about +2° with the plus signindicating that maxilla is ahead of the mandible.

Ideally, in treating Class II cases with removablefunctional appliances, the antero-posterior positionof maxilla should be more or less normal and themandible should be retro-positioned in theirrelationship to the anterior cranial base: thussetting up a large ANB value in the angularmeasurements.

Thus, all things being equal, cases with a SNAvalue that is normal or near normal for a child atthat age with a concurrent ANB value of upwardsof about +5° are ideal (as this indicates that themaxilla is normal and the mandible is retro-positioned) for intervention with a functionalappliance.

(b) VVVVVertical Dimension:ertical Dimension:ertical Dimension:ertical Dimension:ertical Dimension: For easy recall, in lateralcephalometric analysis, this information is divulgedby angular measurements FMA, GoGn-SN andMaxillo-Mandibular Plane Angle (Basal Angle). Forexample, while using FMA values, the normal is25°. When the face is more oval or long: makingthe nose-to-chin-distance increase substantially,this value increases to well beyond about 30° forthe condition to be termed as a High Angle Case.On the other hand, when the nose-to-chin-distanceshortens this angular value reduces well below 21°or so for the case to be described as a Low AngleCase.



Genesis of a VGenesis of a VGenesis of a VGenesis of a VGenesis of a Vertical Problem:ertical Problem:ertical Problem:ertical Problem:ertical Problem: Consider thefact that as a child starts to mature in the dento-facial area, the chin position is governed by growthin the dento-alveolar areas of posterior teeth. Thisis akin to creating premature contacts posteriorly,or, as in a situation created by progressive verticaleruption of teeth. Hence, the chin tends to swingdownward and backwards: making it assume aretrognathic character. This is counterbalanced bygrowth in the mandibular condylar area whichtends to make the chin go upwards and forwards:making it assume a prognathic character. Whenthe mechanism works well in unison, the result isa normal, balanced face. When growth in posterioralveolar areas radically exceeds that in the condylarregion, the result may be a High Angle Case witha longish face. If the roles are reversed, a Low AngleCase may be the outcome.All things being equal, best cases to start withFunctional Appliances are when the FMA value iswithin the normal range: between 22° to 28° or so.

(2)(2)(2)(2)(2) Status of Lower Incisor TStatus of Lower Incisor TStatus of Lower Incisor TStatus of Lower Incisor TStatus of Lower Incisor TeetheetheetheetheethSince the construction bite is taken in a protrusivemode for Class II cases, there is always a tendencyfor the lower anterior teeth to be proclined. Hence,in case selection, an important criterion is thatthe lower anterior teeth should be either 'straight'(sometimes also called as 'upright') or evenRetroclined rather than be in a state of proclination.There should also be absence of any lower incisorcrowding.

(3)(3)(3)(3)(3) Positive Clinical VTOPositive Clinical VTOPositive Clinical VTOPositive Clinical VTOPositive Clinical VTOVTO stands for Visual Treatment Objective. Inessence, this clinical test is an advance indicationof the projected/anticipated efficiency of theattained result. Since it is a very accurate way todetermine if the treatment result will make apositive effect on the personality change attempted,it is an invaluable clinical advance planning toolin clinical practice: especially since it does not needany specialised equipment.

When a patient with large overjet is to be treated witha functional appliance, the clinician needs to:

(a) Have the patient sit upright facing the clinician.Patient must be at rest with the lips in theirnormal unstrained position and the teeth in theCentric Occlusion. If the patient can be relaxedenough to give a physiological rest position, so muchthe better. Patient is now observed and preferablyphotographed from the:

The Frontal aspect The Profile view

This gives us an accurate depiction of the patient'sfacial features before treatment.

(b) Now, the patient is taught/trained to get his LowerCentral Incisor teeth in an edge-to-edgerelationship with the Upper Central Incisor teeth:a position that he will be made to assume whenbeing treated with the functional appliance. Hethen holds/maintains the teeth in the sameposition. Patent is made to drape the lips on thenewly positioned teeth with minimum possiblestrain reflected in them. Photographs are thentaken again from the:

The Frontal aspect The Profile view

This position reflects the likely looks that the patientwill exhibit at the end of treatment with FunctionalAppliance.

(c) The photographs taken in natural rest position (asin "a") are then compared with those taken in theprotrusive (as in "b").

(d) If the patient's facial features show a markedimprovement between the two sets of photographs("a" v/s "b"), the patient is said to have shown a +ve

Clinical VTO and therefore is a good candidate forbeing treated with a suitable functional appliance.

(4) Construction Bite(4) Construction Bite(4) Construction Bite(4) Construction Bite(4) Construction Bite

The case-attributes that we are contemplating ontreating with Functional Appliance shall have asignificantly large over jet. This will be attempted tobe corrected by following the well laid out principlesof registering a Construction Bite12 using modellingwax.

Although there are several ways and philosophies inthe precise way of registering a construction bite, inits simplest form, the same can be broken down into:

(a) This involves training the patient to achieve themaximal protrusive relationship of the lowerincisors, and then staying at least 3 mm lessprotrusive (or, behind/distal) to this maximumprotrusive position while registering the Bite onwarm roll of horse-shoe-shaped wax.With the construction bite passively in the mouth,the patient's face should look decidedly better (asin when Clinical VTO is taken).If the patient has an overjet that is greater than 6-8 mm, often, it is necessary to advance the mandiblein two stages. However, this entirely depends upona patient's ability of giving a maximal-protrusive-posturing of lower jaw. Sometimes, it may be OKto jump even 10 mm in a one-step-bite.

Care should be taken to ensure that:

i. Upper and Lower dental midlines coincide/match



ii. While correcting the midline, there should be noposterior cross-bite created artificially by abnormalposturing of the mandible while taking theconstruction bite.

iii. The vertical separation between molars on left andright sides is equal.

iv. The vertical separation in molar region should beat least 3-4 mm.

(b) This construction bite is then used for the lab tomount the casts on a non-anatomical articulatorto fabricate the appliance using self curing acrylicresin with a salt-and-pepper technique.

(5)(5)(5)(5)(5) Appliance fabrication pre-requisites:Appliance fabrication pre-requisites:Appliance fabrication pre-requisites:Appliance fabrication pre-requisites:Appliance fabrication pre-requisites:

a) The impressions taken must be:i. Deep and should register the Labial and

Buccal vestibules in totality.ii. The lingual pouch area should also be very

well registered.iii. Made in duplicates so that another set of

casts are available to check the accuracyof fit of the fabricated appliance, etc.

b) The casts must be:i. Made out of the impressions at the soonest

so that dimensional inaccuracies do not getintroduced through syneresis andimbibitions.

ii. Made using good quality Dental Stoneiii. Without blemishes like air-bubbles or

voids.

c) Undercut Areas, especially on the lingual sideshould be blocked out with wax prior toacrylisation.

(6)(6)(6)(6)(6) Choice of Myo-functional Choice of Myo-functional Choice of Myo-functional Choice of Myo-functional Choice of Myo-functional ApplianceApplianceApplianceApplianceAppliance

Amongst the commonly used Functional Appliancesare Andresen's Activator12,13, Balter's Bionator14,Frankel Appliance16,17, Clark's Twin Block10, etc.

Generally, choice of appliance is an operator drivenissue rather than it being a case-specific one. Otherfactors like concurrent need for expansion of dentalarches; need to use extra-oral forces in tandem withthe functional appliance therapy, availability of labback-up, patient compliance etc., are some vital issueswhich determine which appliance is preferred by aclinician.All in all, the attributes of a typical Class II Division ICase to be treated well before peak growth velocity isreached should be: Mixed Dentition Phase: early, mid, or, late (in the

same preferential order of chronology). Secondpermanent molars yet to erupt.

Normal Maxilla with retro-placed mandible (asconfirmed by Lateral Cephalometric Analysis).

Normal Vertical Growth Pattern. Lower Incisors: no proclination, no crowding/

rotations. Large overjet of upper anteriors. 'V' shaped, narrow maxillary dental arch with

narrowing in cuspid region. A positive Clinical V.T.O.

Mode of Action of Functional AppliancesSeveral experts 3,4,5,6,7,8,9 have propagated proper theorieswith a scientific base: all with significant variation inviews to pin down the exact mode of action.

The authors wish to take a very simplistic model to explainto a GD the mechanism of Class II correction withFunctional Appliances.

Consider a typical case: growing child well beforeattaining peak-growth-velocity, having a large overjet,narrow maxillary dental arch with distinct constrictionin the cuspid-premolar area, deep overbite with anaccentuated curve of Spee and a near-normalmandibular dental arch with a non-contracted archform. The mandible, per say, is normal but is locatedway behind/posterior to the maxillary unit(distocclusion).

In such a situation, the narrowness of the maxillarydental arch in the cuspid-premolar area does not permitthe lower anterior teeth to go forward by translation ofthe mandible which should be occurring when growthat the mandibular condyle occurs.

This is a bit like person who wears size 10 shoes tryingto get into a shoe that is size 4. The wide foot can goonly part of the way before the narrowness of the size4 shoe prevents the foot from going any further. Thus,a lot of the size 4 shoe will be unoccupied by a foot thatis normally clad in size 10 shoe. This empty space insize 4 shoe is akin to the large overjet in the narrowmaxilla that the wide foot (mandible) is unable to getto occupy due to the narrowness of the shoe's opening(narrow inter-canine-width) in maxillary dental arch.

This results in a Class II occlusion and a retrognathicprofile. The lower anterior teeth often become moreupright and sometimes even Retroclined as acompensatory effect.

Expansion of the maxillary dental arch is hence neededeither before or concurrent to use of functionalappliances for the mandible to relocate anteriorly.

Simply put, narrowness of the maxillary arch has tobe circumvented for the 'normal' growth potential ofthe mandible can be given a chance to 'catch-up' withthe maxillary growth or, 'jump' ahead to correct thebite (more like releasing the brake of a car on a slopewill allow it to move forward at a fast pace). This isoften called as 'jumping the bite'.



This circumventing is achieved through theconstruction bite. The mandibular teeth are made toassume a near edge-to-edge-relationship with themaxillary incisors: thereby taking the posterior teethout of occlusion. Maxillary teeth are thus now ready tobe expanded by a suitable method depending on thetype of functional appliance used.

The construction bite when replicated into a fabricatedappliance locks the mandible into a more protrusiveposition. The retractors muscles of the mandible (lateralpterygoids) thus get activated to try to pull the mandibleback…however, the appliance does not allow this tohappen. The pulling back impetus of the mandible istransferred through the appliance on to the maxilla asa reciprocal effect. At best, the forward and downwardgrowth of maxilla is prevented / retarded. But, themandibular condyle, owing to having been displacedout of its normal position within the glenoid fossa forthe entire time that the appliance is worn thenundergoes reorganizational changes.

If the functional appliance is worn for a sufficientlylong period (long hours every day and night and doingso continuously in excess of 6-8-10 months), the newprotrusive position of the mandible dictated by theappliance then can become the normal position for thepatient. It brings about the needed correction in bothantero-posterior and vertical dimensions.

The concept is similar to a married lady, on staying ather husband's home, over a period of time, gets toidentify and feel comfortable in her new home ratherthan her parental home ('sasural' and maika' to lapseinto colloquial).

Selective grinding (called trimming) of the acrylic ofthe functional appliance aids the condylarreorganizational changes in allowing/guidingmovements in vertical and antero-posterior directionfor the teeth.

Care to be taken in using FunctionalAppliancesWhen used early in a compliant patient, sometimesthe results seem to be attained very quickly: as seenwhen the clinician asks the patient to take off theappliance. However, when used for a shorter period oftime, this apparent correction may be just a transientphase: more due to a dual-bite created rather than apermanent correction.

Therefore, the operator and the patient both need to bepatient in getting the appliance to be used for a muchlonger period (10 months is a good ball-park-figure) forthe gains to be of a permanent nature.

In presence of a familial trait/genetic pre-dispositiontowards unfavorable growth, it is best to keep usingthe appliance for an even longer period: more like a

retention appliance. This may be done by partial use(about 9 hours daily).

It is impossible to make the reader aware of allintricacies of using a treatment philosophy. The readershould look for avenues to take Continuing EducationPrograms to hone their skills before embarking on theexciting journey to treat cases with FunctionalAppliances.

Sometimes, despite the best diagnostic skills, a properchoice of appliance exercised with adhering to all theneeded underlying principles, results are inadequate.The reason for that is best described by a simple GAKprinciple: God Alone Knows!!

Bibliography1. FRANKEL R. A functional approach to orofacial

orthopedics. Br. J. Orthod. 1980;7:41-51.2. MOSS M. L. The primary role of functional matrices in

facial growth. Am. J. Orthod. Dentofacial Orthop.1969;55:566-77.

3. GRABER T.M., NEUMANN B:. In Concepts of functionaljaw emodelling . Removable orthodontic appliances. 2nd

ed. Philadelphia: Saunders; 1984.4. PROFFIT W.R., FIELDS H.W. Contemporary orthodontics.

4th Ed. St Louis: Mosby; 2007.5. MOYERS R.E. Handbook of Orthodontics. 4th Edn. Year

Book Medical Publishers ;1988.6. h t t p : / / w w w . o r t h o d o n t i c s . a z / i n d e x . p h p ?

categoryid=9&p2_articleid=627. GRABER T.M., RAKOSI T., PETROVIC A.G In Dentofacial

emodelling with functional appliances.: Principles offunctional appliances. St Louis: Mosby; 1985.

8. CARELS, LINDEN V. Concepts on functional appliances'mode of action. Am. J. Orthod. Dentofacial Orthop. 1987;92: 162-168.

9. WOODSIDE, METAXAS, ALTUNA: The influence offunctional appliance therapy on glenoid fossa remodeling.Am. J. Orthod. Dentofacial Orthop. 1987; 92:181-198.

10. WILLIAM CLARK. Twin Block Functional Therapy:Applications In Dentofacial Orthopaedics. 2nd Edn. MosbyLtd.

11. RAKOSI T. Colour atlas of Dental Medicine - OrthodonticDiagnosis. 1st Edn. Thieme Medical Publishers.1993.

12. SAMIR E. BISHARA. Textbook of Orthodontics.Saunders.2001.

13. SALZMANN J.A: Practice of Orthodontics . J.B LippincottCo., Vol: I, II, 1966.

14. REEY R.W, EASTWOOD A. The passive activator: caseselection, treatment response, and corrective mechanics.Am. J. Orthod. Dentofacial Orthop. Am. J. Orthod.Dentofacial Orthop. 1978;73:378-409.

15. HIRZEL HG, GREWE JM. Activators: a practical approach.Am. J. Orthod. Dentofacial Orthop. 1974; 66:557-570.

16. ALTUNA G., NIEGEL S. Bionators in Class II treatment.J. Clin. Orthod. 1997; Mar: 185-191.

17. FRANKEL R: The treatment Of Class II, Division 1maloccusion With functional correctors. Am. J. Orthod.Dentofacial Orthop. 1969;55: 265-275.

18. MCNAMARA J., HUGE S. The Frankel Appliance (FR-2):Model preparation and appliance construction. Am. J.Orthod. Dentofacial Orthop. 1981; Nov.: 478-495.



REVIEW ARTICLE

Pediatric Obturating Materials Pediatric Obturating Materials Pediatric Obturating Materials Pediatric Obturating Materials Pediatric Obturating Materials And TAnd TAnd TAnd TAnd Techniquesechniquesechniquesechniquesechniques

Mihir Jha1, Sonal D.Patil2, Shrirang Sevekar3, Vivek Jogani4, Poonam Shingare5

Abstract

Pulp therapy helps in preserving a pulpally involved primary tooth by eliminating bacteria and their products andensures hermetic seal of the root canals so that the primary tooth can complete its function without harming thesuccessor or affecting the health of the patient. A thorough understanding of the pulp morphology and root formationand resorption in primary teeth as well as different materials and techniques used is imperative for a successfulpulp therapy. One of the major areas of continued research is in the area of finding obturating materials to suit thespecific properties of these teeth. This article seeks to present a review of the major obturating materials andtechniques with their modifications as well as their advantages and disadvantages.

Key words: Pulp therapy, Primary teeth, Obturation materials and techniques

IntroductionA dentist who provides emergency or restorative carefor children will inevitably encounter a situation wherea primary tooth has a pulp exposure.1 This could befrom a traumatic injury or as the result of a mechanicalor a carious pulp exposure. Pulp therapy for deciduousteeth aims to preserve the child's health and tomaintain deciduous teeth in a functional state untilthey are replaced by permanent teeth.2 The mainobjective of endodontic treatment is total eliminationof micro-organisms from the root canal, and theprevention of subsequent re-infection. This is achievedby careful cleaning and shaping followed by thecomplete obturation of the canal space.3 However, thecomplex morphology of the root canal system indeciduous teeth makes it difficult to achieve propercleansing by mechanical instrumentation andirrigation of the canals.2 So, in order to increase thechance of success of the endodontic treatment,substances with antimicrobial properties are frequentlyused as root canal filling materials in deciduous teeth.2

The ultimate goal of endodontic obturation hasremained the same for the past 50 years: to create afluid-tight seal along the length of the root canalsystem, from the coronal opening to the apicaltermination.3

Rifkin identified criteria for an ideal pulpectomyobturant that include

(1) Resorbability

(2) Antiseptic property

(3) Non-inflammatory and nonirritating to theunderlying permanent tooth germ

(4) Radio-opacity for visualization on radiographs

(5) Ease of insertion and

(6) Ease of removal

However, none of the currently available obturatingmaterials meet all of these criteria. The present reviewseeks to evaluate each of the presently availableobturating materials and present a few of the emergingconcepts related to obturation of primary teeth.Presently, the commonly used materials for primaryroot canal fillings are zinc oxide Eugenol, Iodoformbased pastes4 and calcium hydroxide.

Zinc oxide Eugenol is one of the most widely usedmaterials for root canal filling of primary teeth.Bonastre (1837) discovered zinc oxide Eugenol and itwas subsequently used in dentistry by Chisholm (1876).Zinc oxide Eugenol paste was the first root canal fillingmaterial to be recommended for primary teeth, asdescribed by Sweet in 1930.3

Hashieh studied the beneficial effects of Eugenol. Theamount of Eugenol released in the periapical zoneimmediately after placement was 10-4 and falls to 10-6after 24 hrs, reaching 0 after 1 month. Within these

Senior Lecturer1

Senior Lecturer2

Reader3

Senior Lecturer4

Senior Lecturer5

Department of Pediatric DentistryMGM Dental College and Hospital, Kamothe, Navi Mumbai.

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr Mihir JhaDept of Pediatric Dentistry,MGM Dental College and Hospital,Kamothe, Navi Mumbai.Mob.: 09561062790E-mail: [email protected]


concentrations Eugenol is said to have anti-inflammatory and analgesic properties that are veryuseful after a pulpectomy procedure. Since 1930's zincoxide Eugenol has been the material of choice. However,it has certain disadvantages like slow resorption,irritation to the periapical tissues, necrosis of bone andcementum and alters the path of eruption ofsuccedaneous tooth.5 Colla J (1985) found that zinc oxidemay alter the path of eruption of succedaneouspermanent.6 Erasquin (1967) reported occurrence ofnecrosis of cementum, bone and inflammation ofperiapical tissue.7 Robin L W studied unresorbed zincoxide Eugenol was surrounded by several layers ofcondensed cellular tissues. This was composed of innerlayer of tightly packed cells and outer layer of fibroblastwith chronic inflammatory cells. Segmentation of massoccurs by ingrowth of collagen and fibroblast formingsepta. Within the septa sequestration of zinc oxide isseen into smaller masses.8

Research is going on in this area to improve theproperties of zinc oxide Eugenol by adding antibacterialsubstances or by altering it with other materials.

Success rates were reported after obturating with ZincOxide Eugenol cement by various authors as follows -82.3%- Barr et al9 82.5% - Gould10 86.1% Coll et al.11

Formocresol, Formaldehyde and Paraformaldehydeand cresol have been tried out12 to improve theproperties and success of zinc oxide Eugenol, but theaddition of these compounds neither increased thesuccess rate nor made the material more resorbableas compared to zinc oxide Eugenol alone.13

A study was conducted in which iodoformized zinc oxideEugenol was tested for its antibacterial effect againstthe aerobic and anaerobic bacteria and was found to beeffective for both the aerobic and anaerobic bacteria ofthe root canals of deciduous teeth with maximumsustaining period of 10 days.14

A combination of zinc oxide powder and calciumhydroxide paste for obturation of primary teeth hasshown promise in a short term study by Chawla15. Theyfound that the obturated material remained up to theapex of root canals till the beginning of physiologic rootresorption. Also the material was found to resorb atthe same rate as teeth. Combination of calciumhydroxide, zinc oxide, and 10% sodium fluoride solutionhas been tested in a clinical study. It was observedthat the rate of resorption of this new root canalobturating mixture was quite similar to the rate ofphysiologic root resorption in primary teeth.16

Iodoform pastes have better resorbability anddisinfectant properties17,18,19 than ZOE, but they may

produce a yellowishbrown discoloration of the toothcrowns which may compromise esthetics.17 Differentformulations of root canal filling materials containingIodoform are available: KRI paste (iodoform, camphor,menthol, and parachlorophenol), Maisto paste(iodoform, camphor, menthol, para-chlorophenol, zincoxide, lanolin, and thymol), Guedes-Pinto paste(iodoform, camphorated parachlorophenol, and Rifocort(Medley, Campinas/SP; prednisolone acetate andsodium rifampicin), Endoflas (Sanlor Lab, Miami/FL;iodoform, zinc oxide, calcium hydroxide, bariumsulfate, Eugenol, and paramonochlorophenol), andVitapex (Neo Dental International, Federal Way/WA;calcium hydroxide and iodoform).16,20 Castagnola andOrley (1952) stated that KRI paste loses only 20% ofits potency in 10 years.21 Garcia Godoy (1987) foundthat KRI paste resorbs from the apical tissue in a weekor two; it does not set to a hard mass and can be insertedand removed easily.22 Eliyahu Mass (1989) found Maistopaste to be successful in infected posterior primaryteeth and had positive healing effect on periradiculartissue.23

Since the introduction to dentistry of CalciumHydroxide by Hermann (1920, 1930), this medica-menthas been identified to promote healing in many clinicalsituations. Calcium hydroxide has been used either asthe sole root filling material for primary teeth or inassociation with Iodoform. It is commercially availableas Vitapex and Metapex. These products resorb ifinadvertently pushed beyond the apex. However, therate of resorption of the material from within the canalsis faster than the rate of physiologic root resorption.24

Pitts studied the absorbable nature of CalciumHydroxide, he found that significant wash out of apicalplugs of Calcium Hydroxide occurred during the firstmonth after placement. By the ninth month, plugs werevirtually gone from the apical portion of the root canal.Adjacent to remaining Calcium Hydroxide particles,giant cells but no inflammatory cells were seen.25 Poorsuccess rates were reported due to high occurrence ofinternal resorption by Via26 and Shroeder27.

The alkaline property of the material was said tocounteract the inflammatory process by acting as alocal buffer and by activating the alkaline phosphataseactivity, which was important for hard tissue formation.The depletion of the material from the root canals wasfound to be the main disadvantage of Calcium Hydroxideas root canal filling material.28 Studies have reporteda success rate of 80 to 90%.23,28

Japanese researchers have introduced a calciumhydroxide sealer named Vitapex that contains 40%Iodoform along with silicone oil. The Iodoform is a

Jha et.al. : Pediatric Oburating Materials And Techniques


known bactericide that is released from the sealer andsuppresses any residual bacteria in the canal orperiapical region. However, several clinical andhistopathological investigations of calcium hydroxideand Iodofom mixture (Vitapex, Neo Dental ChemicalProducts Co. Tokyo) have been published by Fuchinoand Nishino (1980). This material was found to be easyto apply and resorbs at a slightly faster rate than thatof the root. It has no toxic effects on permanentsuccessor and is radio opaque. For these reasons, thecalcium hydroxide Iodoform mixture can be consideredto be a nearly ideal primary tooth filling material. Overfilling and resorption of the paste containing Iodoformfrom the root canals had no effect on the success of thetreatment but regarded as having a positive healingeffect.3

Endoflas is a resorbable paste produced in SouthAmerica and contains components similar to that ofVitapex, with the addition of zinc oxide Eugenol. Thispaste is obtained by mixing a powder containing tri-iodomethane and iodine dibutilorthocresol (40.6%), zincoxide (56.5%), calcium hydroxide (1.07%), Bariumsulphate (1.63%) and with a liquid consisting of Eugenoland Paramonochlorophenol.3

The material is hydrophilic and can be used in mildlyhumid canals. It firmly adheres to the surface of theroot canals to provide a good seal. Due to its broadspectrum of antibacterial activity, Endoflas has theability to disinfect dentinal tubules and difficult toreach accessory ca-nals that cannot be disinfected orcleansed mechanically. The components of Endoflas arebiocompatible and can be removed by phagocytosis,hence making the material resorbable. Unlike otherpastes, Endoflas only resorbs when extruded extra-radicularly, but does not wash out intraradicularly.The disadvantage of this material is its Eugenol contentthat can cause periapical irritation. It also has adrawback of causing tooth discoloration. One studyshowed a lower success rate of 58% when there wasoverfilling but 83% success in cases with flush andunderfilled root canals.29 Thus, it can be concludedthat the Endofloss may be successfully used for rootcanal treatments in primary teeth particularly if careis taken not to overfill.

Comparative studies have indicated that Zinc oxideEugenol has better antimicrobial activity as well aslower cytotoxicity than KRI paste30.

Pabla et al. evaluated the antimicrobial efficacy of zincoxide Eugenol, Iodoform paste, KRI paste, Maisto pasteand Vitapex® against aerobic and anaerobic bacteriaobtained from infected non-vital primary anterior teeth.Maisto paste had the best antibacterial activity.Iodoform paste was the second best followed by zincoxide Eugenol paste. Vitapex® showed the least anti-bacterial activity.31 Zinc oxide Eugenol (ZOE), Zinc

oxide-Eugenol and Formocresol (ZOE+FC), Calciumhydroxide and sterile water (CAOH+H2O), Zinc oxideand Camphorated phenol (ZO+CP), Calcium hydroxideand Iodoform (Metapex) and Vaseline (Control), werechecked for anti-microbial efficacy and ZOE+FCproduced strong inhibition against most bacteria whencompared to ZOE, ZO+CP and CAOH+H2O. Metapexand Vaseline were found to be non inhibitory.32 Amixture of calcium hydroxide, zinc oxide powder, andsodium fluoride (10%) was used, combining theadvantages of both calcium hydroxide and zinc oxide.Calcium fluoride as a reaction product addedradiopacity to the root canal filling material, withoutthe need for addition of any other radiopaque material.The addition of fluoride was seen to give this materiala resorption rate that matched the resorption rate ofthe roots of the primary pulpectomized teeth. Theoverfilled material was not seen to completely resorbeven after 2 years of follow-up and so care should betaken not to over push the material beyond the apex. Astudy is already in progress to evaluate the resorptionof the root canal filling material intraradicularly,interradicularly, and periapically, using mixtures ofzinc oxide and calcium hydroxide along with differentconcentrations (2, 6, and 8%) of sodium fluoride as aliquid. The mixture made by using 8% sodium fluorideis showing good results in the mid-term evaluation.16

Retained primary teeth without permanent successorpresent a unique challenge to the dentist. These teethare often prone to caries because of factors such aslongevity of the tooth in the oral cavity, discrepanciesin interproximal contact with permanent teeth andvariation in enamel thickness.33 A deciduous toothwithout permanent tooth bud shows no signs of rootresorption requiring different obturating material thatwould not undergo resorption.34 This helps to preventarch length discrepancy and to maintain the spacewithout going for orthodontic or prostheticrehabilitation.35 So, materials like Guttapercha,Mineral Trioxide Aggregate (MTA), and CalciumEnriched Mixture (CEM), that are biocompatible andthose would not be resorbed should be selected as aroot canal filling material for retained primary teeth.Guttapercha is a desirable filling material because itis nontoxic, least irritating to periapical tissues,impervious to moisture. Mineral Trioxide Aggregate(MTA) is recently introduced cement. Studies havedemonstrated cemental repair, formation of bone, andregeneration of the periodontal ligament when MTA isused.36 Table I shows comparison of properties ofdifferent commonly used obturating materials.

Several techniques have been used for the filling ofmaterial into primary teeth root canals. An ideal fillingtechnique should assure complete filling of the canalwithout overfill and with minimal or no voids.



Root Canal Filling With Hand InstrumentsO'Riordan and Coll described a method of placing thematerial in bulk and pushing it into the canals withendodontic pluggers.37 Similar method for root canalobturation was used by many authors11,12.

Another method has been described in the literature38,which includes filling large primary canals with a thinmix of the material coating the wall of the canals withthe help of a reamer in an anti-clock wise directionwhile taking it out slowly followed by placement of thethicker mix which is then pushed manually. Anendodontic plugger or a small amalgam condenser couldbe used for compacting the paste at the level of thecanal orifice. For larger root canals lateral condenserswere used by Coll et al.39 Barr et al.9 recommendedGlick instrument for filling paste in root canals, whereas Hartman and Pruhs40 recommended the use of wetcotton pellet to push the filling materials into the canalsof primary teeth. Paper points also been used to carrythe paste down into the root canals.41

Most of the time material of choice for filling the rootcanal of a pulpectomized primary tooth is pure zincoxide eugenol and it can be carried into the canal usingPaper points, a Syringe, Jiffy tubes or a lentilspiral.1

Use of hand held Lentulospiral was recommended foruse in obturation of primary canals 42,43,15,28. Kopelreported that the letulospiral hand held was mosteffective in carrying zinc oxide Eugenol paste toworking length and also produced the highest qualityfill.1

Endodontic pressure syringe has been recommendedfor use in obturation of primary canals. It wasdeveloped by Greenberg44 in 1963 and consists of abarrel and screw-in plunger and includes 13 to 30 gaugeneedle which correspond to the largest endodontic file

used to instrument the root canal. It has been notedthat the needles are very flexible and can easily bemaneuvered in the tortuous canals of primarymolars45,46.

Vitapex, an iodoform calcium hydroxide based paste,is delivered by a disposable plastic needle connectingto a syringe. The syringe is introduced up to 1/5th thedistance from the apex of the canal and the material isslowly injected as the syringe is withdrawn from thecanal. However, due to thickness and limited flexibilityof the plastic needle, it is questionable if the tip is ableto reach the apex of all canals.

Root Canal Filling With Rotary InstrumentUse of rotary paste filer was mentioned by Yacobi etal.46 They suggested that spiral root canal filer shouldbe one size smaller than the last file used and cut withsharp scissors to half its length. They claimed thatthis made it easier to use in a child's mouth and alsoprevented the filling material being pushed throughthe apices of the primary tooth.

A lentulospiral mounted on the air motor hand piecehas been studied for use in obturation of primary rootcanals. Sigurdsson et al.47 and Kahn et al.47 reportedthat the letulospiral mounted on a slow speed handpiecewas most effective in carrying calcium hydroxide pasteto working length and also produced the highestquality fill.

Aylard and Johnson48 and Dandashi et al.49 evaluatedroot canal obturation methods in primary teeth in vitroand reported that the lentulospiral mounted in a slow-speed handpiece was superior in filling straight andcurved root canals of primary teeth. Similar successin obturating primary root canals with the use of rotarylentulospiral over other techniques has been reportedby Allen50 and Torres et al.51


TTTTTable I: Properties of obturation materialsable I: Properties of obturation materialsable I: Properties of obturation materialsable I: Properties of obturation materialsable I: Properties of obturation materials

PROPERTIES

Resorption

Harmless

Overfill resorption

Antimicrobial

Easily removed

Radiopaque

Discolouration

ZINC OXIDE

Slow as compared tophysiologic rootresorption3

Harmful7

Slow resorption andinflammatory reaction3

Weak antibacterial

Difficult to remove

Radiopaque onradiograph

No discolouration

VITAPEX

Faster resorption thanphysiologic root resorption

Harmless

Resorbs in 1-2 weeks55

Weak antibacterial

Easily removed3

Radiopaque on radiograph

No discolouration

KRI PASTE

Resorbs at the same rate asthe root 7,54

Harmless14

Resorbs in1-2 weeks14

Best antibacterial

Easily removed

Radiopaque on radiograph

Causes discolouration16


Bawazir and Salama52 evaluated in vivo two differentobturation techniques, lentulospiral mounted in a slow-speed handpiece and hand-held in primary teeth. Thestudy was carried out on 24 children who had receivedfifty single visit zinc oxide and eugenol pulpectomiesin primary molars. The authors reported 96% (21/22)clinical success rate in the group obturated by thelentulospiral mounted in a slow-speed handpiece and a92% (23/25) clinical success rate in the group obturatedby a hand-held lentulospiral at 6 months followingtreatment. Authors concluded that there was nostatistically significant difference between the twotechniques of obturation, according to the quality ofthe root canal filling or success rate.

Recently, a thin and flexible metal tip was introducedviz., NaviTip, in the market to deliver root canal sealer.This NaviTip comes in different lengths and a rubberstop may be adjusted to it. EndoSeal, a syringe deliveredzinc oxide eugenol based canal sealer can be expressedby the NaviTip system.

Guelmann et al.53 assessed the quality of root canal fillby using three filling systems: syringe with plasticneedle (Vitapex), syringe with metal needle, and lentulospiral. Filling quality was determined radiographically.Authors concluded that NaviTip system offered a moredesirable filling quality than lentulo spiral and Vitapexsyringe techniques.

There is evidence that lentulospiral used as a handinstrument and rotary lentulospiral mounted on a slowspeed handpiece may be better and practical obturatingtechniques for primary molars.

Conclusion

It has been found that the current obturating materialsfor primary teeth while providing satisfactory clinicalresults still need to be modified to suit the variousclinical situation that are encountered. Due to thedrawbacks of Zinc oxide eugenol material several othermaterials have been investigated and variouscombinations tried with some degree of success. Thecurrent combinations of calcium hydroxide andiodoform seem to provide better results than zinc oxideeugenol cements. Similarly several obturationtechniques have been used with success, with rotaryslow speed lentilospiral being most satisfactory. Evenrecently Navitip has been used for obturation withgood success. However, further controlled studies andresearch is required to find the ideal obturating materialand techniques for primary teeth.

References:1. Dummett CO and Kopel HM. Pediatric Endodontics. In Ingle

and Bakland. 5th ed. Endodontics: B.C. Decker Elsevier;2002. P.861-902.

2. Fernanda BF, Michele MR, Maria AO, Branco HO. Asystemic review of root canal filling material for deciduousteeth: is there an alternative for zinc oxide Eugenol. ISRNdentistry; vol 2011.

3. Praveen P, Anantharaj A, Karthik V, Pratibha R. A reviewof the obturating material for primary teeth. SRMuniversity journal of dental science 2011;1(3).

4. Rifkin A. A simple effective, safe technique for the rootcanal treatment of abscessed primary teeth. J Dent Child1980; 47:435-441.

5. Hashieh I A, Ponnmel L, Camps J. Concentration ofEugenol apically released from ZnOE based sealers. JOE1999; 22(11): 713-715.

6. Colla JA, Sadrian Roya. Predicting pulpectomy successand its relationship to exfoliation and succedaneousdentition. AAPD 1996; 18(1): 57-63.

7. Erasquin J, Muruzabal M. Root canal filling with zinc oxideEugenol in the rat molar. OOO 1967; 24: 547-558.

8. Woods RL, Kildea PM, Gabriel SA. A histologic comparisonof hydron and zinc oxide eugenol as endodntic fillingmaterial in pimary teeth of dogs. Oral Surg 1984; 58: 82-93.

9. Barr ES, Flaitz CM, Hicks JM. A retrospective radiographicevaluation of primary molar pulpectomies. Pediatr Dent.1991; 13(1): 4-9.

10. Gould JM. Root canal therapy for infected primary molarteeth: a preliminary report. J Dent Child 1987; 54: 30-34.

11. Colla JS, Josell S, Casper JS. Evaluation of a oneappointment formocresol pulpectomy technique forprimary molars. Pediatr Dent 1985; 7(2): 123-129.

12. Goerig AC, Camp JH. Root canal treatment in primaryteeth: a review. Pediatr Dent 1983; 5: 33-37.

13. Goodman JR . Endodontic treatment for children. Br DentJ 1985; 158: 363-366.

14. Garcia- Godoy F. Evaluation of an Iodoform paste in rootcanal therapy for infected primary teeth. J Dent Child1987; 54: 30-34.

15. Chawla HS, Mathur VP, Gauba K, Goyal A. A mixture ofCalcium Hydroxide and Zinc Oxide as a root canal fillingmaterial for primary teeth: a preliminary study. J IndianSoc Pedo Prev Dent. 2001; 19 (3): 107-109.

16. Chawla HS, Setia S, Gupta N, Gauba K, Goyal A.Evaluation of a mixture of zinc oxide, calcium hydroxide,and sodium fluoride as a new root canal filling material forprimary teeth. J Indian Soc Pedo Prev Dent. 2008 Jun;26(2):53-8.

17. F. Garcia-Godoy. Evaluation of an iodoform paste in rootcanal therapy for infected primary teeth. ASDC Journal ofDentistry for Children 1987; 54(1): 30-34.

18. R. E. Primosch. Primary tooth pulp therapy as taught inpredoctoral pediatric dental programs in the United States.Pediatr Dent. 1997; 19(2): 118-122.

19. M. Mortazavi and M. Mesbahi. Comparison of zinc oxideand eugenol, and Vitapex for root canal treatment ofnecrotic primary teeth. International Journal of PaediatricDentistry 2004; 14(6):417-424.

20. C. Cunha, R. Barcelos, and L. Primo. Soluções irrigadorase materiais obturadores utilizados na terapia endodônticade dentes decíduos. Pesquisa Brasileira de Odontopediatriae Clínica Integrada 2005; 5(1): 75-83.

21. Castagnola L, Orlay HG. Treatment of gangrene of thepulp by walkhoff method. Brit dent J 1952; 93: 93-102.

22. Garcia Godoy F. Evaluation of an iodoform paste in rootcanal therapy for infected primary teeth. JDC 1987; 54:30-34.

23. Mass E, Zilberman LU. Endodontic treatment of infectedprimary molar using Maisto paste. JDC 1989; 56:117-120.



24. Nurko C, Ranly DM, Garcia Godoy et al. Resorption of aCalcium Hydroxide/ Iodoform paste ( Vitapex) in root canaltherapy for primary teeth: a case report. Pediatr Dent.2000; 22: 517-520.

25. Pitts. A histologic comparison of Calcium Hydroxide plugsand dentin plugs used for the control of GP root canalfilling materials. JOE 1984; 10: 283-293.

26. Via WF. Evaluation of decidous molars treated bypulpotomy and Calcium Hydroxide. J Am Dent Assoc 1955;5: 34-43.

27. Schroder U. A 2-yr follow up of primary molar,pulpotomized with a gentle technique and capped withCalcium Hydroxide. Scand J Dent Res 1978; 86: 273-278.

28. Chawla HS, Mani .SA, Tewari. A Calcium Hydroxide as aroot canal filling material in primary teeth- a pilot study. JIndian Soc Pedo Prev Dent 1998; 16(3): 90-92.

29. Fuks A, Eidelman E, Pauker N. Root canal with endoflossin primary teeth. A retrospective study. JCPD 2002; 27(1):41-46.

30. Wright KJ, Barbosa SV, Araki K. In vitro antimicrobialand cytotoxic effects of KRI-paste and Zinc Oxide- Eugenolused in primary tooth pulpectomies. Pediatric Dent. 1994;16(2): 102-6

31. Pabla T, Gulati MS, Mohan U. Evaluation of antimicrobialefficacy of various root canal filling materials for primaryteeth. J Indian Soc Pedod Prev Dent. 1997 Dec; 15(4):134-40.

32. Reddy S, Ramkrishnan Y. Evaluation of antimicrobialefficacy of various root canal filling material used in primayteeth. A microbiological study. JCPD 2008; 31(3):193-198.

33. Weine FS. Endodontic therapy. 5th ed. St. Louis: Mosby,1996: 359-61.

34. Nagesh B, Naik B, Sarath R K, Lakshmi D V. Obtuation ofretained primary mandibular seond molar with missingsuccessor with Gutta-percha: A case report. JIDA, Vol. 5,No. 2, February 2011

35. Kokich VG, Kokich VO. Congenitally missing mandibularsecond premolars: Clinical options. Am J Orthod DentofacialOrthop 2006; 130: 437-44.

36. Howard W Roberts, Jeffrey M. Toth, David W. Berzins,David G. Chartlon. Mineral trioxide aggregate materialuse in endodontic treatment: A review of the literatureDental Materials 2008; 24:149-164.

37. Coll JA, Josell S, Nassof S, Shelton P, Richards MA. Anevaluation of pulp therapy in primary incisors. PediatrDent. 1988; 10(3):178-184.

38. Hartman CR and Pruhs RJ. A rationale for the evaluationand treatment of pulp of carious primary molars. J WisDent Assoc. 1980; 56(3):157-160.

39. Greenberg M. Filling root canals of deciduous teeth by aninjection technique. Dent Dig. 1964; 67:574.

40. Krakow A. and Berk H. Efficient endodontic procedureswith the use of the pressure syringe. Dent Clin NorthAm.1969; 17(1): 387-399.

41. Sigurdsson A, Stancill R, Madison S. Intracanal placementof Ca(OH)2: a comparison of techniques. J Endod.1992;18(8):367-70.

42. Kahn FH, Rosenberg PA, Schertzer L, Korthals G, NguyenPN An in-vitro evaluation of sealer placement methods.Int J Endod. 1997; 30(3):181-6.

43. Aylard S. and Johnson. R. Assessment of filling techniquesfor primary teeth. Pediatr Dent. 1987; 9:195-198.

44. Greenberg M. Filling root canals of deciduous teeth by aninjection technique. Dent Dig. 1964; 67:574.

45. Torres CP, Apicella MJ, Yancich PP, Parker MH. Intracanalplacement of calcium hydroxide: a comparison oftechniques, revisited. J Endod. 2004; 30(4):225-7.

46. Bawazir OA and Salama FS. Clinical evaluation of rootcanal obturation methods in primary teeth. Pediatr Dent.2006; 28(1):39-47.

47. Allen KR. Endodontic treatment of primary teeth. AustDent J. 1979; 24(5):347-51.

48. Aylard S. and Johnson. R. Assessment of filling techniquesfor primary teeth. Pediatr Dent. 1987; 9:195-198.

49. Dandashi BM, Mamoun MN, Thomas Z, Margaret AE,Lawrence GS, Mario Czonstkowsky. An in vivo comparisonof three endodontic techniques for primary incisors. PedDent. 1993; 15(4):254-256.

50. Allen KR. Endodontic treatment of primary teeth. AustDent J. 1979; 24(5):347-51.

51. Torres CP, Apicella MJ, Yancich PP, Parker MH. Intracanalplacement of calcium hydroxide: a comparison oftechniques, revisited. J Endod. 2004; 30(4):225-7.

52. Bawazir OA and Salama FS. Clinical evaluation of rootcanal obturation methods in primary teeth. Pediatr Dent.2006; 28(1):39-47.

53. Guelmann M, McEachern M, Turner C. Pulpectomies inprimary incisors using three delivery systems: an in vitrostudy. J Clin Pediatr Dent. 2004; 28(4):323-6.

54. Rifkin A. root canal treatment of abscessed primary teeth:A three to four year follow-up. J Dent Child 1982;49: 428-431

55. Carlos Nurko, Don M. Ranly, Franklin García-Godoy,Kesavalu N. Lakshmyya. Resorption of calcium hydroxide/Iodoform paste(Vitapex) in root canal therapy for primaryteeth. A case report. PD 2000; 22:6

Jha et.al. : Pediatric Oburating Materials And Techniques: A Review


IntroductionLichen planus is a relatively common disorder,estimated to affect 0.5% to 2.0% of the generalpopulation.1 It is a chronic, inflammatory disease thataffects mucosal and cutaneous tissues. Approximatelyhalf of the patients with cutaneous lichen planus haveoral involvement.2 However, mucosal involvement canbe the sole manifestation in up to 25% of affectedpopulation.2 Oral lichen planus has a peak incidencein middle age patients and has female predominanceof 2:1.3 It is characteristically associated withpersistent clinical course and resistance to mostconventional treatments.

Clinical FeaturesThere are various clinical morphologicalmanifestations of the disease (Table 1). More than oneclinical subtype can co-exist in the same patient. Thereticular (92%), plaque (36%) and papule (11%) typesare usually asymptomatic and require no specific treatment.4 On the other hand, the atrophic (44%),

erosive (9%) and bullous (1%) types usually causesevere burning pain and are refractory to conventionaltreatments.4

The lesions are usually symmetrical. It frequentlyaffects buccal mucosa, tongue, gingiva, lip and palate.Extra-oral mucosal involvements include the anogenitalarea (vulvovaginal-gingival syndrome), conjunctivae,oesophagus or larynx.

Differential Diagnosis

The diagnosis of OLP can be rendered more confidentlywhen characteristic cutaneous lesions are present.Except for the pathognomonic appearance of reticular

REVIEW ARTICLE

Oral Lichen Planus : Oral Lichen Planus : Oral Lichen Planus : Oral Lichen Planus : Oral Lichen Planus : AAAAA Review Review Review Review Review

Rohini Salvi1, Rohit Bhailal Gadda2,Varun Gul Bhatia3

Abstract

Oral lichen planus (OLP) is a chronic mucosal condition commonly encountered in clinical dental practice. Lichenplanus is believed to represent an abnormal immune response in which epithelial cells are recognized as foreign,secondary to changes in the antigenicity of the cell surface. It has various oral manifestations, the reticular formbeing the most common. The erosive and atrophic forms of OLP are less common, yet are most likely to causesymptoms. Topical corticosteroids constitute the mainstay of treatment for symptomatic lesions of OLP. Recalcitrantlesions can be treated with systemic steroids or other systemic medications. However, there is only weak evidencethat these treatments are superior to placebo. Given reports of a slightly greater risk of squamous cell carcinomadeveloping in areas of erosive OLP, it is important for clinicians to maintain a high index of suspicion for all intraorallichenoid lesions. Periodic follow-up of all patients with OLP is recommended.

Key words: Diagnosis of OLP, Review

Professor and Head1

Senior Lecturer2

Senior Lecturer3

Department of Oral Medicine & Radiology,M.G.M. Dental College and Hospital, Navi Mumbai

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr. Rohit Bhailal GaddaSenior LecturerDepartment of Oral Medicine & Radiology,M.G.M. Dental College and Hospital, Navi MumbaiE-mail: [email protected]

TTTTTable 1: Clinical Presentation of Oral Lichenable 1: Clinical Presentation of Oral Lichenable 1: Clinical Presentation of Oral Lichenable 1: Clinical Presentation of Oral Lichenable 1: Clinical Presentation of Oral LichenP l a n u sP l a n u sP l a n u sP l a n u sP l a n u s

S y m p t o mS y m p t o mS y m p t o mS y m p t o mS y m p t o m ClinicalCl inicalCl inicalCl inicalCl inical Descr ipt ionDescr ipt ionDescr ipt ionDescr ipt ionDescr ipt iontypestypestypestypestypes

Asymptomat icAsymptomat icAsymptomat icAsymptomat icAsymptomat ic Reticular Wickham's striae ± discreteerythematous border

Plaque-like Resemble leukoplakia,common in smokers

Papules Small white pinpoint papules

Symptomat i cSymptomat i cSymptomat i cSymptomat i cSymptomat i c Atrophic Diffuse red patch, peripheralradiating white striae, chronicdesquamative gingivitis

Erosive Irregular erosion coveredwith a pseudomembrane

Bullous Small bullae or vesicles thatmay rupture easily


OLP (white striae occurring bilaterally on the buccalmucosa), in most cases histopathologic evaluation oflesional tissue is required to obtain a definitivediagnosis.

The differential diagnosis of erosive OLP includessquamous cell carcinoma, discoid lupus erythematosus,chronic candidiasis, benign mucous membranepemphigoid, pemphigus vulgaris, chronic cheekchewing, lichenoid reaction to dental amalgam ordrugs, graft-versus-host disease (GVHD),hypersensitivity mucositis and erythema multiforme.5

The plaque form of reticular OLP can resemble oralleukoplakia.

The classic histopathologic features of OLP includeliquefaction of the basal cell layer accompanied byapoptosis of the keratinocytes, a dense band-likelymphocytic infiltrate at the interface between theepithelium and the connective tissue, focal areas ofhyperkeratinized epithelium (which give rise to theclinically apparent Wickham's striae) and occasionalareas of atrophic epithelium where the rete pegs maybe shortened and pointed (a characteristic known assawtooth rete pegs.5 Although the histopathologicfeatures of OLP are characteristic, other conditions,such as lichenoid reaction to dental amalgam anddrugs, may exhibit a similar histologic pattern.

The histopathologic diagnosis of OLP can becomplicated by the presence of superimposedcandidiasis; diagnosis can also be more difficult if thebiopsy exhibits an ulcerated surface. In these situations,the biopsy findings are sometimes interpreted asrepresenting a nonspecific chronic inflammatoryprocess.6 On occasion, the histo-pathologic features areequivocal, and the oral pathologist examining thesubmitted tissue may recommend that a second biopsybe performed to obtain fresh tissue forimmunofluorescence.7 Immunofluorescent examinationof OLP lesional tissue usually demonstrates depositionof fibrinogen along the basement membrane zone.

Clinical Significance

OLP is one of the most common mucosal conditionsaffecting the oral cavity.8 Therefore dentists in clinicalpractice will regularly encounter patients with thiscondition. Because patients with the atrophic anderosive forms of OLP typically experience significantdiscomfort, knowledge of the treatment protocolsavailable is important. The similarity of OLP to several

other vesiculoulcerative conditions, some of which canlead to significant morbidity, makes accurate diagnosisessential. For example OLP and GVHD can havesimilar histologic and clinical presentations. GVHD isa serious condition that occurs in bone marrowtransplant patients when transplanted marrow cellsreact against host tissues. The extent of oralinvolvement is highly predictive of the severity andprognosis of GVHD.9

Erosive OLP and lichenoid drug reactions can beindistinguishable both histologically and clinically.Some of the drugs commonly associated with lichenoidreactions are nonsteroidal anti-inflammatory drugs,diuretics, angiotensin-converting enzyme inhibitors,beta-blockers and antimicrobials.10

It is also necessary to distinguish isolated erosive orreticular lesions from lichenoid reactions to dentalamalgam.11 Lichenoid reactions to amalgam do notmigrate, they occur on mucosal tissue in direct contactwith the restoration, and they resolve once amalgamrestoration is removed.11 Some studies indicate anincreased risk of squamous cell carcinoma in patientswith OLP lesions.12-15 This increased risk appears mostcommon with the erosive and atrophic forms and incases of lesions of the lateral border of the tongue. Otherstudies suggest that in some cases of purportedmalignant transformation, the malignancy may nothave developed from true lesions of OLP but mayinstead have arisen from areas of dysplasticleukoplakia with a secondary lichenoid inflammatoryinfiltrate.16,17 A review of previously published studiesconcluded that the risk of developing squamous cellcarcinoma in patients with OLP is approximately 10times higher than that in the unaffected generalpopulation.18 Other published reports have noted apossible association between OLP and hepatitis C,19

sclerosing cholangitis, and primary biliary cirrhosis.20

Treatment

There is currently no cure for OLP. Excellent oralhygiene is believed to reduce the severity of thesymptoms, but it can be difficult for patients to achievehigh levels of hygiene during periods of active disease.Treatment is aimed primarily at reducing the lengthand severity of symptomatic outbreaks. Asymptomaticreticular and plaque forms of OLP do not requirepharmacologic intervention. Algorithm for themanagement of oral lichen planus is shown in Fig. 1.21

Salvi et.al. : Oral Lichen Planus : A Review


formulations of the more potent corticosteroids cancause adrenal suppression if used in large amounts forprolonged periods or with occlusive dressings. Thelowest-potency steroid that proves effective should beused. Intralesional injection of corticosteroid forrecalcitrant or extensive lesions involves thesubcutaneous injection of 0.2-0.4 mL of a 10 mg/mLsolution of triamcinolone acetonide by means of a 1.0-mL 23- or 25-gauge tuberculin syringe.

Systemic steroid therapy should be reserved for patientsin whom OLP lesions are recalcitrant to topical steroidmanagement. Dosages should be individualizedaccording to the severity of the lesions and the patient'sweight and should be modified on the basis of thepatient's response to treatment. The oral dose ofprednisone for a 70-kg adult ranges from 10-20 mg/day for moderately severe cases to as high as 35 mg/day (0.5 mg/kg daily) for severe cases.23 Prednisoneshould be taken as a single morning dose to reduce thepotential for insomnia and should be taken with foodto avoid nausea and peptic ulceration. Significantresponse should be observed within one to 2 weeks.

Other Treatment Modalities

Twice-daily topical application of compounded 0.1%tacrolimus ointment was recently reported to beeffective in controlling symptoms as well as clearinglesions of OLP.24 Tacrolimus is a macrolideimmunosuppressant with a mechanism of action

Corticosteroids

The most widely accepted treatment for lesions ofOLP involves topical or systemic corticosteroids tomodulate the patient's immune response. Topicalcorticosteroids are the mainstay in treating mild tomoderately symptomatic lesions. Options (presentedin terms of decreasing potency) include 0.05%clobetasol propionate gel, 0.1% or 0.05% betamethasonevalerate gel, 0.05% fluocinonide gel, 0.05% clobetasolbutyrate ointment or cream, and 0.1% triamcinoloneacetonide ointment.22 Patients are instructed to applya thin layer of the prescribed topical corticosteroid upto 3 times a day, after meals and at bedtime. The gelor ointment can be applied directly or can be mixedwith equal parts Orabase(a gelatin-pectin-sodiumcarboxymethylcellulose-based oral adhesive paste,ConvaTec, Division of Bristol-Myers Squibb, Montreal,Que.) to facilitate adhesion to the gingival tissues. Thesesolutions can be prepared by a compounding pharmacy.Patients should be instructed to gargle with 5 mL ofthe solution for 2 minutes after meals and at night.After rinsing, the solution should be expectorated, andnothing should be taken by mouth for one hour.Alternative delivery methods include the use of customtrays to serve as reservoirs for the corticosteroid. Theadvantage of topical steroid application is that sideeffects are fewer than with systemic administration.Adverse effects include candidiasis, thinning of the oralmucosa and discomfort on application. Topical


Fig. 1: Fig. 1: Fig. 1: Fig. 1: Fig. 1: Algorithm for the management of oral lichen planusAlgorithm for the management of oral lichen planusAlgorithm for the management of oral lichen planusAlgorithm for the management of oral lichen planusAlgorithm for the management of oral lichen planus


similar to that of cyclosporine, but is 10 to 100 timesmore potent and is better able to penetrate the mucosalsurface.24

Other documented treatment modalities includeretinoids and vitamin A analogues, cyclosporine rinse,the immunomodulating agent levamisole, PUVAtreatment (which consists of administration of 8-methoxypsoralen and exposure to long-wave ultravioletA light), dapsone, griseofulvin, azathioprine andcryotherapy.25 Even though evidence of the efficacy ofthese treatment approaches is not overwhelming,corticosteroid therapy remains the most commonapproach for managing symptomatic lesions. Becauseof the possibility of increased risk of malignanttransformation, periodic reassessment of all patientswith OLP is recommended.

Conclusion

Patients with OLP should be counselled as to the natureof this chronic condition and the different approachesto treatment. Patients should be informed that theymay experience alternating periods of symptomaticremission and exacerbation. Clinicians should maintaina high index of suspicion for all intraoral areas thatappear unusual, even in patients with a histologicallyconfirmed diagnosis of OLP. This vigilance is especiallyimportant for isolated lesions occurring in locations athigher risk for the development of squamous cellcarcinoma, such as the lateral and ventral surfaces ofthe tongue and the floor of the mouth.

References1. McCreary CE, McCartan BE. Clinical management of

lichen planus. Brit J Oral Maxillofacial Surg 1999;37(5):338-43.

2. Mollaoglu N. Oral lichen planus: a review. Br J OralMaxillofac Surg 2000;38:370-7.

3. Setterfield JF, Black MM, Challacombe SJ. Themanagement of oral lichen planus. Clin Exp Dermatol2000;25:176-82.

4. Thorn JJ, Holmstrup P, Rindum J, et al. Course of variousclinical forms of oral lichen planus. A prospective follow-up study of 611 patients. J Oral Pathol 1988;17:213-8.

5. Regezzi JA, Sciubba JJ. Oral pathology: clinical pathologiccorrelations. 3rd ed. Philadelphia: WB Saunders; 1999.

6. Burgess KL, McComb RJ. The gingivae in dermatoses.Ont Dent 1997; 74(5):25-9.

7. Murrah VA, Perez LM. Oral lichen planus: parametersaffecting accurate diagnosis and effective management.Pract Periodontics Aesthet Dent 1997; 9(6):613-20.

8. Pynn BR, Burgess KL, Wade PS, McComb RJ. Aretrospective survey of 2021 patients referred to theToronto Hospital Mouth Clinic. Ont Dent 1995; 72(1):21-4.

9. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral andmaxillofacial pathology. 2nd ed. Philadelphia: WB Saunders;2002.

10. Bernstein ML. The diagnosis and management of chronicnonspecific mucosal lesions. J Calif Dent Assoc 1999;27(4):290-9.

11. Ostman PO, Anneroth G, Skoglund A. Oral lichen planuslesions in contact with amalgam fillings: a clinical,histologic, and immunohistochemical study. Scand J DentRes 1994; 102(3):172-9.

12. 17. Silverman S Jr, Bahl S. Oral lichen planus update:clinical characteristics, treatment responses, and malignanttransformation. Am J Dent 1997; 10(6):259-63.

13. Barnard NA, Scully C, Eveson JW, Cunningham S, PorterSR. Oral cancer development in patients with oral lichenplanus. J Oral Pathol Med 1993; 22 (9):421-4.

14. Holmstrup P. The controversy of a premalignant potentialof oral lichen planus is over. Oral Surg Oral Med OralPathol 1992; 73(6):704-6.

15. Silverman S. Oral lichen planus: a potentially premalignantlesion. J Oral Maxillofacial Surg 2000; 58(11):1286-8.

16. Eisenberg E, Krutchkoff DJ. Lichenoid lesions of oralmucosa. Diagnostic criteria and their importance in thealleged relationship to oral cancer. Oral Surg Oral MedOral Pathol 1992; 73(6):699-703.

17. Eisenberg E. Oral lichen planus: a benign lesion. J OralMaxillofacial Surg 2000; 58(11):1278-85.

18. Drangsholt M, Truelove EL, Morton TH Jr, Epstein JB. Aman with a thirty-year history of oral lesions. J Evid BaseDent Pract 2001; 1(2):123-35.

19. Bellman B, Reddy RK, Falanga V. Lichen planus associatedwith hepatitis C. Lancet 1995; 346(8984):1234.

20. Fantasia JE. Diagnosis and treatment of common orallesions found in the elderly. Dent Clin North Am 1997;41(4):877-90.

21. Oliver GF, Winkelman RK. Treatment of lichen planus.Drugs 1993; 45;56-6

22. Vincent SD. Diagnosing and managing oral lichen planus.JADA 1991; 122(6):93-6.

23. Carrozzo M, Gandolfo S. The management of oral lichenplanus. Oral Dis 1999; 5(3):196-205.

24. Kaliakatsou F, Hodgson TA, Lewsey JD, Hegarty AM,Murphy AG, Porter SR. Management of recalcitrantulcerative oral lichen planus with topical tacrolimus. J AmAcad Dermatol 2002; 46(1):35-41.

25. Carrozzo M, Gandolfo S. The management of oral lichenplanus. Oral Dis 1999; 5(3):196-205.



IntroductionTerrorism is not new, and even though it has beenused since the beginning of recorded history it can berelatively hard to define1. The term "terrorism" comesfrom the French word terrorisme, which is based onthe Latin verb terrere (to cause to tremble). It datesback to 1795 when it was used to describe the actionsof the Jacobin Club in their rule of post-RevolutionaryFrance, the so-called "Reign of Terror". Jacobins arerumored to have coined the term "terrorists" to referto themselves2. Terrorism refers to a strategy of usingviolence, social threats, or coordinated attacks, in orderto generate fear, cause disruption, and ultimately, bringabout compliance with specified political, religious, orideological demands. The European Union includes inits 2002 definition of "terrorism" as the aim of"destabilizing or destroying the fundamental political,constitu-tional, economic or social structures of acountry." Terrorism is defined in the U.S. by the Codeof Federal Bureau of Investigation as: "The unlawfuluse of force and violence against persons or property tointimidate or coerce a government, the civilianpopulation, or any segment thereof, in furtherance ofpolitical or social objectives."3

Terrorists may choose to use biological weapons toachieve their goals because biological agents arerelatively cheaper than conventional weapons.Reportedly, many of these agents would be relativelyeasy to prepare and easy to hide. Their use would alsoallow bioterrorists to protect themselves and escapebefore any illness is detected. The most attractivefeature of bioweapons, however, maybe the tremendouspsychological impact that their use, or threatened use,

would cause on the population4.

The medical community as well as the public shouldbecome familiar with epidemiology and controlmeasures for a calm and reasoned response should therebe an outbreak5. In the event of a bioterrorist attack,most important aspect is the need of trained healthprofessional and in such conditions dentists can renderhelp for increase surge capacities. Dentists may becalled upon to fulfill several functions: education, riskcommunication, diagnosis, surveil-lance andnotification, treatment, distribution of medications,decontamination, sample collection and forensicdentistry6. Consequently aim of this paper to review1.history regarding bioterrorism2. classifica-tion ofagents3. role of dentistry in preparedness.

Historical aspectBiological terrorism dates as far back as Ancient Rome,when faeces were thrown into faces of enemies7. Thisearly version of biological terrorism continued till the14th century where the bubonic plague was used toinfiltrate enemy cities, both by instilling the fear ofinfection in residences, so that they would evacuate,and also to destroy defending forces that would notyield to the attack. Over time, biological warfarebecame more complex. Countries began to developweapons which were much more effective, and muchless likely to cause infection to the wrong party. Onesignificant enhancement in biological weapondevelopment was the first use of anthrax. Anthraxeffectiveness was initially limited to victims of largedosages7. The development of biological weaponsbecame much more focused in the 20th century. DuringWorld War I, Germany was thought to have employedthe agents of cholera and plague against humans andanthrax and glanders against livestock8. In the periodbetween World Wars I and II, a number of countries,including the USSR, Japan, and the United Kingdom,stepped up their biological warfare research programs.The Japanese effort was notable, with a number ofmilitary units engaged in offensive biological weaponsresearch until the end of World War II. During the eraof Cold War, the Soviet Union as well as Iraqindependently developed their successful biologicalweapon programs9. However, in 1972, Washington andMoscow had agreed by treaty to give up biological

REVIEW ARTICLE

Bioterrorism and DentistryBioterrorism and DentistryBioterrorism and DentistryBioterrorism and DentistryBioterrorism and DentistryAmit Chaudhari1, Priya Chaudhari2

Abstract

In modern world, to spread the confusion and panic among the people terrorist can use biological weapon. In suchBioterrorism attack health professionals plays a key role. This paper reviews the historical aspect, definition,classification of bioterrorism agents and the role of dentistry in such catastrophic event.

Key Words: Bioterrorism agents, Medical community

Senior Lecturer1

Department of Public Health Desntistry, MGM Dental Collegeand Hospital, Kamothe, Navi Mumbai

Senior Lecturer2

Department of Prosthodontics, MGM Dental College andHospital, Kamothe, Navi Mumbai

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr. Amit ChaudhariDepartment of Public Health Dentistry, MGM Dental Collegeand Hospital, Kamothe, Navi MumbaiEmail ID- [email protected]


weapons, but most countries were actively involved indevelopment of such bioweapon facilities9.

Bioterrorist events have occurred in recent history bothin the United States and abroad. In 1984, the saladbars at two restaurants in the Dalles, Oregon, werecontaminated with Salmonella by followers of BhagwanShree Rajneesh to prevent citizens from voting in anupcoming election9.

One of the most frightening terrorist attacks involvedrelease of the nerve gas sarin in the Tokyo subwaysystem in 1995. Aum Shinrikyo, the cult responsiblefor killing 12 people and injuring approximately 3,800in the sarin attack, also attempted to developbotulinum toxin, anthrax, cholera, and Q fever forbioterrorist us10. In 2001, United States experiencedbioterrorism attack in the form anthrax spores whichwere disseminated through postal system9.

What is bioterrorism?According to Center of Disease Control and Prevention- A bioterrorism attack is the deliberate release ofviruses, bacteria, or other germs (agents) used to causeillness or death in people, animals, or plants. Theseagents are typically found in nature, but it is possiblethat they could be changed to increase their ability tocause disease, make them resistant to currentmedicines, or to increase their ability to be spread intothe environment. Biological agents can be spreadthrough the air, through water, or in food. Terroristsmay use biological agents because they can be extremelydifficult to detect and do not cause illness for severalhours to several days. Some bioterrorism agents, likethe smallpox virus, can be spread from person to personand some, like anthrax, cannot5.

Bioterrorism Agent Categories5

Bioterrorism agents can be separated into threecategories, depending on how easily they can be spreadand the severity of illness or death they cause. CategoryA agents are considered the highest risk and CategoryC agents are those that are considered emerging threatsfor disease.Category AThese high-priority agents include organisms or toxinsthat pose the highest risk to the public and nationalsecurity because: They can be easily spread or transmitted from

person to person

They result in high death rates and have thepotential for major public health impact

They might cause public panic and social disruption They require special action for public health

preparedness.

Category B

These agents are the second highest priority because:

They are moderately easy to spread

They result in moderate illness rates and low deathrates

They require specific enhancements of CDC'slaboratory capacity and enhanced diseasemonitoring.

Category CThese third highest priority agents include emergingpathogens that could be engineered for mass spread inthe future because: They are easily available They are easily produced and spread They have potential for high morbidity and

mortality rates and major health impact.Bioterrorism agents name is given in Table 1.

Dentistry's role in a responseBioterrorism attack is a silent attack. Bioterrorism

TTTTTable 1: Classification of Bioterrorism able 1: Classification of Bioterrorism able 1: Classification of Bioterrorism able 1: Classification of Bioterrorism able 1: Classification of Bioterrorism AgentsAgentsAgentsAgentsAgents

Category Category Category Category Category AAAAA Category BCategory BCategory BCategory BCategory B Category CCategory CCategory CCategory CCategory C

Anthrax Brucellosis Emerging(Bacillus (Brucella infectiousanthracis) species) diseases

such as

Botulism Epsilon toxin Nipah virus(Clostridium of Clostridiumbotulinum toxin) perfringens

Plague Food safety threats Hantavirus(Yersinia (e.g., Salmonellapestis) species, Escherichia coli

O157:H7, Shigella)

Smallpox Glanders(variola major) (Burkholderia mallei)

Tularemia Melioidosis(Francisella (Burkholderiatularensis) pseudomallei)

Viral hemorrhagic Psittacosisfevers (filoviruses (Chlamydia[e.g., Ebola, psittaci)Marburg]

Arenaviruses Q fever[e.g., Lassa, (Coxiella burnetii)Machupo])

Ricin toxin from Ricinuscommunis (castor beans)

Staphylococcalenterotoxin B

Typhus fever (Rickettsiaprowazekii)

Viral encephalitis(alphaviruses[e.g., Venezuelanequine encephalitis,eastern equineencephalitis,western equineencephalitis])

Water safety threats(e.g., Vibrio cholerae,Cryptosporidium parvum)

Chaudhari and Chaudhari : Bioterrorism and Dentistry


and emerging infectious diseases are a public healthissue first, then a criminal investigation. Thegovernment and the local health care community mustbe prepared to respond if they are to effectively limittransmission of the disease and its associated morbidityand mortality, as well as to prevent confusion andpanic.Dentistry can contribute valuable assets, both inpersonl and in facilities, to the preparation for and inthe immediate response to a bioterrorist attack andits aftermath. These assets can make a significantdifference in the outcome. In a major bioterroristattack, the local needs could be massive andimmediate. The traditional medical resources-bothpersonnel and facilities- of a community under attackwill be overwhelmed, especially in the first few daysafter the determination that the community has beendeliberately subjected to an infectious agent. It willfall to nonphysicians to provide many servicesordinarily supplied by physicians (such as performingtriage, dispensing medications and providing generalmedical support). As hospitals become filled, alternatesites for the provision of health care may be required,and dental offices could fill that need11.Guey AH11 reviewed the areas in which dentists canrender the help to increase surge capacity inbioterrorism attacks.Surveillance and notification - Dental offices aredistributed across the community, dentists can serveas an excellent surveillance resource. They can detectcharacteristic intraoral or cutaneous lesions if they arepresent and report them to public health authorities.They also may be able to detect unusual patterns ofemployee absences or patients' canceling or missingappointments that are not explainable by recognizablelocal circumstances. These occurrences may well be aharbinger of serious events about to happen.Diagnosis and monitoring - Besides assisting in theearly identification of the disease or diseases introducedin a bioterrorist attack, dentists can provide individualpatient diagnosis by observing the physical andbehavioral signs people manifest when the nature ofthe attack has been determined. Salivary and/or nasalswabs may yield important diagnostic or treatmentinformation and can be collected by dentists forlaboratory testing to determine diagnoses whennecessary or to monitor treatment progress.Referral - Dentists can refer suspicious cases to theappropriate specialists for confirmation, treatment orboth.Immunizations - In the event that rapid inoculationor vaccination of the public is required to prevent thespread of infection by a biological agent, dentists maybe recruited to assist in a mass inoculation program.Medications - If the mass population requirestreatment, preventive medication or both, pharmacies'

capabilities may become overpowered quickly. Dentistscould be called on to prescribe and dispensechemotherapeutic or chemoprophylactic medicationsfor the public. When drugs are stockpiled in bulk,dental personnel could help repackage them forindividual use before dispensing them.Triage - Whenever there is a greater number ofcasualties than the medical care system canaccommodate relatively quickly, or whenever medicalcare resources are overwhelmed, some system forestablishing priorities for treatment must beestablished. Appropriately trained dentists can fulfillthis function, thus freeing up medical professionals toprovide definitive care for the greatest number ofpatients.Medical care augmentation - Because of their trainingand experience, many dentists may be able to augmentand assist medical and surgical personnel in providingdefinitive treatment for victims of bioterrorist attacks.Decontamination and infection control - Dentists anddental auxiliaries are well-versed in infection controlprocedures and can apply their knowledge in reducingthe spread of infections- between patients and betweenpatients and caregivers-in mass disasters.ConclusionDentistry has an important role to play in the responseto a significant bioterrorism attack. With adequatepreparation, dentistry's valuable assets in terms ofpersonnel and facilities can help in determining that abioterrorist attack has occurred and in responding tothat attack. The profession should develop a disasterresponse plan that can be integrated into eachcommunity's disaster response plan.

References1. http://www.terrorism-research.com (accessed on 30.08.11)2. Golder B, Williams G. What is 'terrorism'? Problems of

legal definition. UNSW Law Journal 2004; 27(2): 273-2953. http://www.legalserviceindia.com/articles/anti_pota.htm

(accessed on 30.08.11)4. http://www.bacteriamuseum.org/cms/Pathogenic-

Bacteria/pathogenic-bacteria.html (accessed on 30.08.11)5. http://www.bt.cdc.gov/agent/agentlist-category.asp6. http://www.azdhs.gov/phs/edc/edrp/bioterrorism.htm

(accessed on 3.09.11)7. Block, Steven M. The growing threat of biological weapons.

American Scientist 2001; 89(1): 28,8. Christopher, G. W., T. J. Cieslak, J. A. Pavlin, and E. M.

Eitzen, Jr. Biological warfare: a historical perspective.JAMA 1997; 278:412-417.

9. Klietmann WF. Ruoff KL. Bioterrorism: Implications forthe clinical microbiologist. Clinical Microbiology Reviews2001; 14(2): 364-381

10. Olson KB. Shinrikyo A. Once and future threat? Emerg.Infect. Dis. 5:513-516

11. Guay AH. Dentistry's response to bioterrorism: A report ofa consensus workshop. J Am Dent Assoc September 2002;133: 1181-118

Chaudhari and Chaudhari : Bioterrorism and Dentistry


CASE REPORT

Management of non vital maxillary central incisors with open apexManagement of non vital maxillary central incisors with open apexManagement of non vital maxillary central incisors with open apexManagement of non vital maxillary central incisors with open apexManagement of non vital maxillary central incisors with open apexusing Mineral Tusing Mineral Tusing Mineral Tusing Mineral Tusing Mineral Trioxide rioxide rioxide rioxide rioxide Aggregate apical plugs – Case reportAggregate apical plugs – Case reportAggregate apical plugs – Case reportAggregate apical plugs – Case reportAggregate apical plugs – Case report

Sumanthini M.V.1, Naisargi Shah2, Mausami A Malgaonkar3

Introduction

Root canal treatment of teeth with open apices ischallenging. Conventional root canal filling techniquesrely considerably on the presence of apical constriction,against which gutta-percha can be optimallycompacted. In the absence of apical constriction due toincomplete root formation, apical resorption or overinstrumentation, inevitably there is extrusion ofobturating material which could compromise the longterm healing outcome of treatment. The treatmentoptions have been either to induce apex formation orresort to surgical technique. Surgical method is moreradical involving incision, flap reflection, root resectionand root end filling placement, causing certain amountof discomfiture to patient. Traditionally long termcalcium hydroxide (CH) apexification has been usedto induce apical closure and takes anywhere between3-18 months1. Despite its high success rate it has

Professor1

Professor2

Lecturer3

Department of Conservative dentistry and EndodonticsMGM Dental College & Hospital, Kamothe,Navi Mumbai

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr. Sumanthini M.VProfessorDepartment of Conservative dentistry and EndodonticsMGM Dental College and Hospital, Kamothe, Navi MumbaiMob: 9869433642Email: [email protected]

Abstract

The case report describes the treatment of maxillary central incisors with open apex, due to apical root resorption,as a consequence of trauma experienced three years earlier. Open apices pose a challenge during endodontictreatment. Several materials and methods have been widely studied and tried in the past. Obtaining an adequateapical seal is of paramount importance regardless of the material or technique used. In the present case theinvolved teeth were treated nonsurgically using white Mineral Trioxide Aggregate (MTA) as an artificial apical barrier.The treated teeth were asymptomatic and the follow up clinical and radiographic examination showed healing withapparent regeneration of periradicular tissues. Extrusion of MTA beyond the root end was not an obstacle in thehealing process. MTA can be considered an effective material to treat infected open apex teeth with large periapicallesions.

Key Words: Open apex, Periapical lesion, MTA, Non surgical method.

many drawbacks, namely patient compliance,multiple appointments, long drawn procedure,microleakage around provisional restorations,cervical fracture and reduction of fracture resistanceof root structure2,3.

Various materials have been considered as analternative to calcium hydroxide namely freeze driedalogenic dentin powder, bone ceramic, tricalciumphosphate, osteogenic protein, collgen, calcium gel andin particular MTA and Portland cement have beenextensively evaluated in the recent past. White MTA(Proroot, Dentsply) is composed of bismuth oxide,tricalcium silicate, dicalcium silicate, calciumdialuminate and calcium sulphate dehydrated, traceelements like iron, nickel and copper, strontium4. Thepopularity of MTA for apical barrier technique can beattributed to its good sealing properties, excellentmarginal adaptation, ability to set in the presence ofmoisture and the procedure can be completed in lessnumber of visits. The biocompatibility and hard tissueinductive effect of MTA have been confirmed in animaland human studies5. Evidence from previous publishedreports support that MTA placement consistentlyresulted in regenerating normal periradicular tissuesin teeth with immature apices and continued rootmaturation when pulpal necrosis was present6,7.

The following case report describes the non surgicalmanagement of non vital infected maxillary centralincisors with open apices associated with a largeperiapical lesion in relation to 21, secondary totrauma.


Case reportA young lady aged 21 years was referred to outpatientclinic, Department of Conservative Dentistry andEndodontics with a chief complaint of continuousthrobbing pain in relation to maxillary central incisors(11 and 21) since two days, discoloration and pusdischarge from the palatal aspect, in relation tomaxillary central incisors since one year (Fig.1).Patient gave a history of trauma 3 years ago. Onexamination, 11 showed discoloration and Ellis class 3fracture involving mesial angle. While 21 had brownishdiscoloration. Both teeth were tender on percussion,with a sinus tract in the palatal aspect and non vital.The teeth 13,12,22 and 23 responded normally tovitality tests. Following clinical and radiological (Fig.2)examination a diagnosis of chronic periradicularabscess, with an acute exacerbation was made.Radiograph revealed apical root resorption with an openapex in both the teeth in question. Medical history wasnon contributory.

All treatment procedures were carried out under rubberdam isolation. Root canal access cavities wereprepared in 11,21 and the canals were explored.Copious pus exuded through the canal of 21. Both teeth

had a single canal and no apical stop.An#80file(Mani,inc) could easily pass through the apicalforamen without any resistance. Working length(Fig.3) was established using radiographic techniqueand canals irrigated with normal saline to encouragedrainage. Canals were circumferentially filed and athin paste of CH saline mix was placed in the canalsand temporized with zinc oxide eugenol cement(Deepak Enterprise, Mumbai, India). Antibiotics andanalgesics were prescribed. Patient was recalled thefollowing day, her acute symptoms had subsided.When the canals were re-entered, slight dischargewas noticed in 21. Canals were circumferentially filed,thoroughly irrigated intermittently with 5% sodiumhypochlorite (Trifarma, Thane, India) (5% NaOCl) .Athick paste of extra pure calciumhydroxide(Deepashree Products, India) mixed withsaline was placed in the canal and the access cavitieswere temporized with zinc oxide eugenol cement. Thepatient was recalled after a week and the sametreatment regimen was repeated. A week hence thepatient was asymptomatic and the sinus tract hadresolved. The CH dressing was removed from 11, 21and the canals were irrigated thoroughly with 5%NaOCl followed by saline. Canals were dried withabsorbent points. White MTA (Proroot, Dentsply) wasmixed with sterile water as per manufacturer'sinstructions to thick putty like consistency. It wascarried in to the canals with sterile amalgam carrierand condensed in to place with prefitted handpluggers.An apical plug of 4 mm was placed in both11 and 21(Fig.4); a radiograph was taken to confirmthe dense packing of MTA. A moist cotton pledgetwas placed in the canal to aid in setting and theteeth were temporized with zinc oxide eugenolcement. Patient was recalled the following day andremaining canal portion was obturated with gutta-percha (Dentsply Maillefer) and AH Plus (Dentsply)root canal sealer (Fig.5). Finally the teeth wereFig. 1- Preoperative photograph showing mesial angle # in 11,

discoloration in 11, 21.

Fig. 2 - Preoperativeradiograph, note theperiapical lesion in 21,indicated by the arrow.

Fig. 3 - Radiograph showingWorking lengthdetermination.

Fig. 4 - Radiographshowing MTA apical plugplacement in 11 and 21.

Fig. 5 - Radiographshowing obturation of 11and 21 note theextrusion of MTAindicated by the arrow.

Sumanthini et.al : Management of non vital maxillary central incisors with open apex using Mineral Trioxide Aggregate


restored with resin composite in both the access cavitiesfollowed by metal ceramic crowns (Fig.6, 7). Patientwas recalled for regular checkups to follow thetreatment out come at regular time intervals, (Fig.8, 9)and further long term follow-up.

DiscussionTraumatic injury to mature teeth results in pulpnecrosis due to periapical neurovascular supply damage.When injury damages the protective layer ofprecementum, inflammation of pulp or periodontiumwill induce resorption in root and bone as the microbialtoxins can pass through the dentinal tubules andstimulate an inflammatory response. In the presentcase, the maxillary central incisors had open apicescaused due to apical root resorption and chronic apicalabscess in 11 and 21 respectively as a result of traumainduced apical periodontitis and pulp necrosis. Theobjective here is to control infection and induce apicalclosure.CH as an intracanal dressing has been the mostwidely used and clinically accepted for over 40 years.Recent research evidence has demonstrated that thelong term calcium hydroxide apexification treatment,significantly reduces the fracture resistance of thetooth3.This is attributed to decreased organic supportof dentin matrix leading to disruption of the bondbetween the collagen fibrils and hydroxyapatitecrystals that negatively influence the mechanicalproperties of dentin. In the present case calciumhydroxide was used for a short duration as anintracanal medicament since it is known tosignificantly reduce the endodontic micro flora withoutcompromising the fracture resistance of dentin.Calcium hydroxide when placed for not more than 30days does not cause any deleterious effect on dentin2.Bidar etal found in their study that medication withcalcium hydroxide improved the marginal adaptationof MTA8. Shabahang et al in their animal studiesdemonstrated a more predictable healing outcomewhen MTA is used to obturate open apex teeth whencompared with teeth treated with calciumhydroxide9.MTA represents a contemporary version ofthe primary monoblock in attempts to strengthenimmature tooth roots. Although MTA does not bond todentin interaction of the released calcium and hydroxylions of MTA with a phosphate containing synthetic bodyfluid results in formation of apatite like interfacialdeposits. These deposits improve the frictionalresistance of MTA to the root canal walls and accountsfor the seal of MTA in orthograde obturation andperforation repair10.

Following the calcium hydroxide medication thepatient was asymptomatic and there was cessation ofpus discharge from the canal. A 4mm MTA apical plugwas placed in both the incisor teeth. Invitro studieshave suggested that a 4-5mm of MTA plug is sufficientto provide an adequate seal. This is also supported byretrospective studies under taken to evaluate thetreatment outcomes of artificial apical barrier withMTA in teeth with immature apices 11,12. Thebiocompatibility of MTA is well documented. Itpromotes the formation of cementum coverage over

Fig. 6 - Photograph showing tooth preparation done in 11, 21.

Fig. 7 - Photograph showing 11, 21 restored with metal ceramiccrowns.

Fig. 8 - Three monthfollow up radiographshowing hard tissuedeposition over MTAsurface indicated by thearrow and extrudedMTA surrounded byosseous tissue.

Fig. 9 - 9 Month follow upradiograph showingsatisfactory healing ofperiapical lesion in relationto 11 and 21.



the MTA surface with a high degree of structuralintegrity and more complete periradicular architecture.The production of bone morphogenetic protein-2(BMP-2) AND transforming growth factor -beta-1(TGF-β-1) could be instrumental for the favorablebiologic response stimulated in human periapicaltissues13. The stimulation of interleukin productioncauses the cementum overgrowth. The above factorscollectively facilitates regeneration of periodontalligament and formation of bone.

In the present case no attempt was made to place aninternal matrix at the apex in order to retain the MTAwithin the confines of the root canal space14. Absenceof apical constriction led to extrusion of MTA beyondthe root apex. The extruded MTA (Fig.8) was separatedfrom the root end and was surrounded by normalbone.The follow up radiographs showed the gradualresorption of the extruded material. Despite theextrusion healing of the periapical lesion wasuneventful. There was regeneration of periradiculartissue, normal periodontal space, decrease in size ofperiapical lesion as compared with preoperativeradiograph and no evidence of inflammatory externalroot resorption(Fig. 8,9) .This corroborates with theretrospective study of Zafer et al and Johannes Mendeet al that the healing outcome of teeth was unaffectedby extrusion of MTA6,15.

SummaryThe present case report confirms that MTA acts as anapical barrier and can be effectively used to supportregeneration of periapical tissue in traumatized infectedteeth with open apices, involving large periapicallesions. Both clinical and radiographic follow upsrevealed optimal healing of the periapical lesion andnew hard tissue formation in the apical area of thetraumatized incisors in spite of extrusion of MTA.Hence it can be concluded that MTA plugs predictablyinduce apical closure in shorter treatment time andwithout much dependence on patient compliance.

References1. John I. Ingle, Lief K Bakland, J. Craig Baumgartner, Ingle's

Endodontics 6th edition. page-1337.2. Andreasen JO, Munksgaard EC, Bakland LK. Comparison

of fracture resistance in root canals of immature sheep

teeth after filling with calcium hydroxide or MTA. DentTraumatol 2006;22:154-6.

3. Glen .E. Doyon, Thom Dhumsha, J Anthony vonFraunhofer. Fracture resistance of human root dentinexposed to intracanal calcium hydroxide. J Endod2005;31:895-897.

4. Araceli I, Bucio L, Cruz-chwez E. Phase composition ofProroot MTA by x-ray powder diffraction. J Endod2009;35:875-878.

5. N.K. Sarkar, R.Caicedo, P.Ritwik, R. Moiseyeva, I.Kawashima. Physicochemical basis of biologic propertiesof mineral trioxide aggregate Endod 2005; 31:97-100.

6. Zafer C. Cehreli, Sezgi Sara, Serdar Uysal, Melek DTurgut. MTA apical plugs in the treatment of traumatizedimmature teeth with large periapical lesions. DentTraumatol 2011; 27:59-62.

7. Holden DT Schwartz SA Kirkpatrick TC, Schindler WG.Clinical outcomes of artificial root barriers with mineraltrioxide aggregate in teeth with immature apices ENDOD2008;34:812-7.

8. Maryam Bidar, Reza Disfani, Salman Ghargozloo, ShirinKhoynezhad and Armita Rouhani.J Endod 2010; 36:1679-1682.

9. Shabahang S, Torabenajed M, Boyne PP, Abedi H,McMillanP. A comparative study of root end induction usingosteogenic protein-1, calcium hydroxide and mineraltrioxide aggregate in dogs Endod 1999;25:1-5.

10. Franklin R .Tay, David H Pashley. Monoblocks in root canals:A hypothetical or a tangible goal. J Endod 2007;33:391-398.

11. David E Witherspoon, Joel C Small, John D Regan, MarthaNunn. Retrospective analysis of open apex teeth obturatedwith MTA.J Endod 2008; 34:1171-1176.

12. Ahmed AL Kahtani, Sandra Shostad, Roebrt Schifferte,Stish Bambhani. Invitro evaluation of microleakage of anorthograde apical plug of MTA in permanent teeth withsimulated immature apices. J Endod 2005; 31:117-119.

13. Gunseli Gunsen, Zafer C Cehreli, Ali Ural, Muhittin ASedar, Feridun Basak. Effect of MTA cement onTransforming Growth factor ?-1 and Bone MorphogenicProtien production by human fibroblasts invitro.J Endod2007;33:447-450.

14. C. Bargholz.Perforation repair with mineral trioxideaggregate modified matrix concept.Int Endod J 2005;38:59-69.

15. Johannes Mente, Nathalie Hage ,Thorsten Pfefferle,Martin J ean Koch, Jens Dreyhaupt, Hans Joerg Staele,Shimon Friedmann. Mineral trioxide aggregate apical plugsin teeth with open apical foramina :A retrospective analysisof treatment outcome.J Endod 2009;35:1354-1358.



IntroductionA Factitious or self-induced injury of the periodontaltissues occur with repeated voluntary trauma tolocalized areas with toothbrushes, pacifiers, fingernails,pens, toothpicks, eyeglass stems and other provocativehabits1. These mechanical injuries by secondaryinfection and inflammatory disease manifest as alocalized recession to advanced bone loss if notintercepted1. The etiology, frequency and force exertedby the habit in addition to prevailing periodontal healthdictate the course of response to therapy1. The casepresented herewith showcases such elements testingdiagnostic acumen.

Case Report:A thirteen year-old male patient reported with an ulcerin the mouth since one month. The patient had adecayed tooth in the right lower posterior jaw regionfor which root canal treatment was initiated six monthsago but not completed. The patient becamesymptomatic with pain in relation to the same toothsince a month and a gum boil had appeared in thegums adjacent to the same concerned tooth at the sametime. The patient ruptured the boil and continued to

CASE REPORT

Factitious Injury of The Periodontal Tissues - Factitious Injury of The Periodontal Tissues - Factitious Injury of The Periodontal Tissues - Factitious Injury of The Periodontal Tissues - Factitious Injury of The Periodontal Tissues - CCCCCASEASEASEASEASE R R R R REPORTEPORTEPORTEPORTEPORT

Vineet Kini1, Richard Pereira2, Ashvini M. Padhye3, Sudarshan G. Kadam4

Abstract

Factitious or self-induced injuries are inflicted based on habit, frequently associated with psychogenic background;related only in manner by which they are produced, bearing no particular anatomic, etiologic or microscopicsimilarities. The following case report attributes a suspicious periodontal lesion to self-induced injury.

Key words: Factitious, Self-induced injury.

Reader1

Professor2

Professor and Head3

Lecturer4

Department of Periodontics,M.G.M Dental College & Hospital,Navi Mumbai 410 209.

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr.Vineet Kini, M.D.S,Department of Periodontics,M.G.M Dental College & Hospital,Navi Mumbai 410 209.Mob.: 9769804390E-mail: [email protected]

irritate it by massaging it. The site became tender andwas causing difficulty on mastication. The patientdeveloped a swelling in the right lower posterior jawregion since one week The parent noticed the sameand reported for consultation. The parent reported thatthe patient had been pricking the ulcer with objectshe found accessible : toothbrush, pens, pencils, andsometimes his finger.

Examination revealed a pulpally involved 46 [FDI Toothnumbering system]. The extra oral swelling waspresent at the right mandibular jaw region measuring2cm by 3cm extending from the base of the mandibleto the zygomatic arch having diffuse borders, was firmin consistency and tender on palpation. The rightsubmandibular lymph nodes were palpable and tender.

The reported ulcer was solitary and present in theregion of the attached gingiva and lining mucosa inbetween 45 and 46 [FDI tooth numbering system],measuring 2cm by 3cm. The ulcer had sloping marginsand smooth borders with an erythematous halosurrounding the border. The floor of the ulcer wascoarse and would bleed on palpation. The ulcer wastender on palpation and its base was mobile. Withinthe ulcer margin an intra oral fistulous tract openingwas found which could be traced to the apical region of46 [FDI tooth numbering system].

Based on the history and examination findings adiagnosis of factitious injury to the gingiva was madecaused by repetitive and deliberate irritation to the areasurrounding the intraoral sinus tract opening leadingto the present state of an ulcer in the concerned area.The patient and the parents were made aware of theproblem and explained that the lesion was self inducedthe patient need to refrain from the reported habit toallow the ulcer to heal.

Root canal therapy was carried out in relation to 46[FDI Tooth numbering system]. The patient was


References1. McMullen JA. Inflammatory Periodontal Disease, Etiology

and Additional Local Influences. In Goldman HM, CohenDW. Editors, Periodontal Therapy .6th Edition. St. Louis:The C.V. Mosby Company ;1980.p.105-151.

2. Altom RL, DiAngelis AJ. Multiple Autoextractions: OralSelf-mutilation Reviewed. Oral Surg Oral Med Oral Pathol1989; 67:271-274.

3. Groves BJ. Self-inflicted Periodontal Injury. Br Dent J1979; 147:244-246.

4. Owen D., Michael AM , O'Riordan W and Kline R. OralHabits. In Forrester DJ, Wagner ML, Feming J. Editors.Pediatric Dental Medicine. 1st Edition. Philadelphia: Lea& Febiger; 1981.p535-557.

Kini et.al : Factitious Injury of The Periodontal Tissues

advised Quadrajel† and Ubi-Q* ointments for topicalapplication on the ulcer to provide palliative relief,antisepsis and promotion of healing respectively. Thepatient was asked to abstain from rubbing the ulcer withhis tooth brush onto prevent further trauma. This waspersonally supervised by the parent during oral hygieneroutine. The patient was reviewed every seven days.

After twenty one days the ulcer was found to havehealed. The patient's parent reported that the patienthad not reverted to the same habit since initialconsultation.

DiscussionThe presence of a large ulcer in the mouth conspicuousby its isolated solitude, sharp contrast to normalbackground was intriguing. This, supported by thehistory given by the parent in regards to the patientsreported habit of traumatizing himself in the areaconcerned with foreign objects was cause to suspectfactitious injury.

This features concurred with the suggestions of Stewartand Kernohan2 as criteria for diagnosing self inflictedgingival injury, considering that the area was easilyaccessible to the patient. Contrary to the opinion thatsuch lesions occurred in unusually grouped multiplenumbers, solitary lesions were also found to meet suchcriteria2.

Although the patient did report a habit, he related itto relieve discomfort caused by the lesion. This did notconform towards Stewart's Gingivitis artefacta majorby its' suggestion of a possible underlying emotionaldisorder. This was more relevant to Stewart's Gingivitisartefacta minor for which pre-existent lesions provokinghabit induced injury were mandatory3, as in this case.

The lack of any hereditary disorder [genetic,biochemical or enzymatic deficiency] ruled out organicetiology described by Ager and Levin4. Functionaletiology, according to Ager and Levin4, requiredperformance of such behaviour with patient'sknowledge as was in this case. This lesion conformedmore towards Stewart and Kernohan4 describedinjuries of complex and unknown etiology. This wassubstantiated by the patient's procurement ofsecondary gain of compassion and sympathy from theparent. Neurotic excoriations and mutilation duringpsychotic episodes, sans secondary gains were ruledout4.As signs of pre-existent lesions were detected,Stewart and Kernohan's4 functional etiology ofsuperimposed and secondary lesions were arrived upon.

A conclusion based on the subject's confession was madethat the lesion was indeed a self-induced factitiousinjury with a functional etiology.

ConclusionBaffling history and clinical picture could mask a self-induced injury. In the present case the patientdeveloped a habit of traumatizing his periodontal softtissues with foreign objects; contributing towards aself-induced etiology for present lesion. The causativefactor could not have been ascertained undisputedly ifit were not for the patient's confession. This highlightsthe crucial role of interview and observation indiagnosis.

Figure 1. The Ulcerative lesion as on first interviewFigure 1. The Ulcerative lesion as on first interviewFigure 1. The Ulcerative lesion as on first interviewFigure 1. The Ulcerative lesion as on first interviewFigure 1. The Ulcerative lesion as on first interview

Figure 2. The same site following three weeksFigure 2. The same site following three weeksFigure 2. The same site following three weeksFigure 2. The same site following three weeksFigure 2. The same site following three weeksin ter ludeinter ludeinter ludeinter ludeinter lude

† Lidocane HCl 2%, Metronidazole Benzode 1%, ChlorhexidineGlnconate 1%

* β Carotene 0.1%, Ubiguiane 0.1%


IntroductionOdontomas are considered as developmental anomaliesarising from completely differentiated epithelial andmesenchymal cells that give rise to ameloblast &odontoblast. They are hamartomatous lesions ratherthan true neoplasms.1 The term 'odontoma' was coinedby Paul Broca in 1867 which by definition alone refersto any tumour of odontogenic origin. Most of theodontomas are asymptomatic, although some signs &symptoms relating to their presence may occur. Thecompound composite odontomas are a malformationin which all the dental tissues are in a more orderlypattern than in the complex odontoma so that the lesionmay consist of many tooth like structures.2 Compoundodontomas are generally most commonly seen inmaxillary anterior region with denticles varying from4-28.3 The sheer number of denticles extracted

numbering 42 from the mandibular symphysis regionmakes the case a rare and unique one.

Case HistoryA 17 yr old female presented with chief complaint ofmalaligned mandibular anterior teeth (Fig.1). Patientwas asymptomatic without any specific complaint. Onexamination she had over retained lower deciduous leftcentral incisor, partially erupted and medially tippedlower left permanent lateral incisor with missingcanine. The mandibular right central incisor wastipped labially. Patient was advised orthopantamogramfor further treatment. OPG showed multiple tooth likestructures of different size and shape in relation to rootof mandibular anterior teeth in the symphysis regionwhich was surrounded by circumscribed radiolucentzone. There was displacement of permanent rightmandibular central incisor(Fig.2). The left mandibularlateral incisor was displaced and the canine wasimpacted apical to the premolars. Upon the clinicaland radiographic findings a provisional diagnosis ofcompound composite odontoma was made. It was

CASE REPORT

Compound Composite Odontoma in Mandibular SymphysisCompound Composite Odontoma in Mandibular SymphysisCompound Composite Odontoma in Mandibular SymphysisCompound Composite Odontoma in Mandibular SymphysisCompound Composite Odontoma in Mandibular Symphysis– – – – – AAAAA Rare Case Rare Case Rare Case Rare Case Rare Case

Sushrut Vaidya1, Usha Asnani2, Smita Sonavane3, Imran Khalid4, Kartik Poonja5, Alok Bhardwaj6

Abstract

Compound odontomas are considered as hamartomatous malformation rather than true neoplasms & aregenerally asymptomatic . The exact etiology is unknown and is often associated with the overretained deciduousteeth, most commonly in maxillary anterior region. In this case, multiple denticles or rudimentary teeth numbering42 were enucleated from the mandibular symphysis region of 17 yr old female which makes this case rare andunusual. Evidence of concrescence, fusion, dilaceration were observed in the denticles enucleated, the size ofwhich ranged from 2mm to 10mm.

Key Words: Odontoma, Compound Odontoma, Denticles, Hybrid Odontoma, Impacted Teeth

Reader1

Professor2

Reader3

Lecturer4

Post graduate5

Post graduate6

Dept Oral and Maxillofacial Surgery,MGM Dental College and Hospital, Navi Mumbai.

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr. Sushrut Vaidya,ReaderDept Oral and Maxillofacial Surgery,MGM Dental College and Hospital, Navi Mumbai.Mob.: 9869160530E-mail: [email protected] Fig.1 : Preoperative intraoral photograph


decided to extract the deciduous central incisor andsurgically enucleate the tumour. Under localanaesthesia deciduous central incisor was extracted. Alabial mucoperiosteal flap was raised. The bonecovering the odontoma was removed and (Fig.3)numerous denticles around 42 were enucleated alongwith the capsule. Evidence of concrescence were seen

in 4 groups of denticles. Fusion and dilaceration werealso noticed (Fig.4). Size of denticles varied from 4mmto 10mm. The partially erupted and displaced lateralincisor and impacted canine were left in place. Closurewas done with 3-0 vicryl. Post operative period wasuneventful.

Discussion

The term odontoma by definition refers to a benign,mixed, calcified tumour of odontogenic origin. Theabsolute incidence of odontogenic tumours varies from0.002% to 0.1%4 out of which odontomas constituteabout 22%,5 of which 10% are compound odontomas.

There are essentially 2 types of odontomas:

1) Complex composite odontoma2) Compound composite odontoma

As per the WHO classification complex compositeodontoma is defined as a malformation in which alldental tissues are well formed but are arranged indisorderly pattern.

Compound composite odontoma is a malformation inwhich all dental tissues are represented in a moreorderly pattern than in the complex odontomas, so thatthe lesion contains tooth like rudimentary structuresin which each enamel, dentin, cementum and pulp arearranged as in normal teeth.

The exact etiology of odontoma is not known6 yet caseshave related odontoma to local trauma, infection andgenetics. It arises from an exubrant proliferation ofdental lamina or its remnants and is termed as laminarodontome ,or forms as a result of multiple schizontiai.e a locally conditioned hyperactivity of dental lamina.7

It may be associated with Gardners syndrome ofintestinal polyposis.8 Compound odontomas are twiceas commonly observed as complex and commonly inthe maxillary anterior region. Clinically odontomasusually remain small rarely exceeding the diameterof the teeth. It may become large and causes expansionof cortical bone most commonly when associated with

Fig.2 : Preoperative radiograph showing the denticles

Fig.3 : Mucoperiosteal flap raised showing the lesion

Fig.4 : Specimen after excision

Fig.5 : Postoperative bony defect seen

Vaidya et.al. : Compound Composite Odontomas In Mandibular Symphysis


dentigerous cyst. They usually present with uneruptedor impacted teeth or retained deciduous teeth.9 Despiteinterference with eruption there is no resorption ofadjacent tooth root. There is often displacement of theadjacent tooth with loss of vitality.

Radiographically odontomas appear as an irregularradioopacity or denticles surrounded by a radiolucencywith or without bony expansion.

Odontomas are successfully treated by surgicalenucleation with least rate of recurrence. Kaban statedthat odontomas are easily enucleated and adjacent teeththat may have been displaced by lesion are seldomharmed by surgical excision because they are usuallyseparated by the septum of bone.10

Although odontomas are considered as hamar-tomatouslesions having a limited growth potential, there arechances of undergoing secondary changes likedentigerous cyst formation, ameloblastictransformation, causing weaking of the surroundingbone. Hence on detection, surgical enucleation ofodontomas, followed by curettage is recommended toprevent further complication.

References1. Budnick, S., 1976. Compound and complex odontomas.

Oral Surg. Oral Med. Oral Pathol. 42, 501-506.2. Philipsen, H.P., Reichart, P.A., Praetorious, F., 1997. Mixed

odontogenic tumours and odontomas. Considerations oninterrelationship.Review of literature and presentation of134 new cases of odontomas. Oral Oncol. 33, 86-99.

3. Amado-Cuesta, S., Gargallo-Albiol, J., Berini-Aytes, L.,Gay-Escoda, C., 2003. Review of 61 cases of odontoma.Presentation of an erupted complex odontoma. Med. Oral.8, 366-373.

4. Yeung, K.H., Cheung, R.C.T., Tsang, M.M.H., 2003.Compound odontoma associated with an unerupted anddilacerated maxillary primary central incisor in a youngpatient. Int. J. Ped. Dent. 13, 208-212.

5. Saadettin, Dagistan, Mustafa, Goregen, Ozkan, Miloglu,2007.Compound odontoma associated with maxillaryimpacted permanent central incisor tooth: a case report:the internet. J. Dent. Sci. 5,1-6.

6. Shafer, Hine, Levy, 1993. A Textbook of Oral Pathology,fourth ed. W.B. Saunders & Co., pp. 308-312.

7. Philipsen HP, Reichart PA, Praetorious F. MixedOdontogenic Tumours and Odontomas. Considerations onInterrelationship. Review of Literature and Presentationof 134 New Cases of Odontomas. Oral Oncol1997;33:86-89.

8. Cawson, R.A., Binnie, W.H., Barrett, A.W., Wright, J.M.,2001. Oral Disease, third ed. Mosby, p. 6.24.

9. Singh, S., Singh, M., Singh, I., Khandelwal, D., 2005.Compound composite odontome associated with anunerupted deciduous incisor - a rarity. J. Ind. Soc. Ped.Prev. Dent. 23, 146-150.

10. Kaban LB.Pediatric Oral and Maxillofacial surgeryPhiladelphia: Saunders; 1990.p.111-2.

Vaidya et.al. : Compound Composite Odontomas In Mandibular Symphysis


IntroductionOSCC is the sixth most common cancer and more than3, 00,000 new cases are diagnosed each year world wide.1

Oral carcinoma of the mandibular region has beendefined as carcinoma of the mandibular alveolar ridge,lower buccal sulcus, sublingual sulcus and mandibularretro molar trigone.2 Carcinoma at this site mayeventually progress to directly invade the mandible, afeature associated with a worse prognosis. Mandibularinvasion is one criterion of the American JointCommittee on Cancer classification for the mostadvanced primary stage (T4) and overall stage (IV) forthese tumors. The 5-year determinate survival ofpatients with stage IV oral lesions has beendemonstrated to be 39%, as compared with 53%, 68%,and 70% for stages III, II, and I disease, respectively.3

OSCC invades the mandibular bone through anerosive, infiltrative or mixed pattern that correlateswith clinical behavior. The erosive pattern ischaracterized by a broad, expansive tumor front witha sharp interface between tumor and bone. In contrast,the infiltrative pattern is composed of nests of tumorcells with fingerlike projections along an irregulartumor front. The recent distinction between these twohistological patterns challenges the previously held

assumption that mandible invasion universallypresents a poor prognosis. The erosive pattern of boneinvasion has been hypothesized to extend in a morepredictable fashion than the infiltrative pattern.Infiltrative pattern of bone invasion is associated witha higher recurrence rate of about 53% compared withthe erosive pattern which is about 17%.4 The presentcase report describes about the infiltrative pattern ofbony invasion by squamous cell carcinoma originatingfrom the buccal vestibule in a middle aged woman.

Case reportA 35-year-old female patient reported in MGM dentalcollege and hospital with a chief complaint of a nonhealing cut in lower right cheek since the past 3-4months. Past medical history was non contributory.The patient had habit of chewing tobacco since the past20 years. She also had history of Misheri applicationon teeth and gums since the past 20-25 years. Therewas no history of trauma, sinus or pus discharge.Extraoral examination revealed a very mild facialdeformity with a diffuse swelling in the right side ofthe face. Ipsilateral cervical lymphadenopathy (levelIB) was also noticed. Intraorally there was presence ofa linear endophytic lesion extending from lower rightfirst premolar to lower right third molar region in thegingivo- buccal sulcus region.(Fig. 1) Additional featurei.e. Grade II mobility of teeth from mandibular rightthird molar to mandibular left canine was seen. Onradiological examination, Orthopantamogram (OPG)revealed an ill-defined radiolucency extending frommandibular right third molar (48) to mandibular rightcanine (43). Computed tomography (C.T scan) showedan osteolytic lesion involving the right side of themandible crossing the midline. (Fig.2) A provisionaldiagnosis of Squamous Cell Carcinoma involving thebone was given. Incisional biopsy was taken. Thehistopathological report of well differentiated SCC was

CASE REPORT

Infiltrative TInfiltrative TInfiltrative TInfiltrative TInfiltrative Type of Bone Invasion in Oral Squamous Cell Carcinomaype of Bone Invasion in Oral Squamous Cell Carcinomaype of Bone Invasion in Oral Squamous Cell Carcinomaype of Bone Invasion in Oral Squamous Cell Carcinomaype of Bone Invasion in Oral Squamous Cell Carcinoma– – – – – CCCCCase ase ase ase ase RRRRReporteporteporteporteport

Jigna Pathak1, Niharika Swain2, Shwetha Kumar3

Abstract

Oral squamous cell carcinoma (OSCC) is a well known malignancy which accounts for more than 90% of all oralcancers. OSCC are malignant tumors that frequently invade bone and bone invasion is a common clinical problem.Bone invasion by oral squamous cell carcinoma may progress by either an infiltrative or an erosive histologicalpattern. The pattern of bone invasion co-relates with the clinical behavior of OSCC thus having a potential prognosticvalue. The present case report is of a 35-year- old female patient presenting with a lesion in the lower right buccalvestibule which was histopathologically confirmed as OSCC.The type of bony invasion was also assessedmicroscopically. The objective of this paper was to define the characteristics associated with each histologicalpattern of invasion and its significance when reviewing oral squamous cell carcinoma with mandibular invasion.

Key Words: Oral cancers, Osteoclastogenesis, Osteoprotegerin

Professor1

Senior Lecturer2

Senior Lecturer3

Department of Oral Pathology,MGM Dental College and Hospital, Navi Mumbai

Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Address for Correspondence:Dr. Jigna Pathak501, Pleasant View Society, Plot 56/57Sector-14, Vashi, Navi Mumbai-400703Mobile: +919819175805E-mail: [email protected],


Pathak et.al. : Bone Invasion in Oral Squamous Cell Carcinoma - A Case Report

confirmed. Excisional biopsy was done which includedhemimandibulectomy extending from 48 to 34 withsupra-omohyoid neck dissection (SOND).Histopathological examination revealed dysplasticstratified squamous epithelium. The underlyingconnective tissue showed infiltration by nests & smallislands of malignant epithelial cells. Some of the largerislands showed keratin pearl formation.(Fig. 3). Also seen was moderate degree of chronicinflammatory cell infiltration and prominent stromalactivity at the tumour invasion front. In some areasperivascular and muscular invasion of tumour islandswas also noticed. There was no evidence of perineural

Fig. 1- An endophytic lesion extending from 44 to 48 in thegingivo- buccal sulcus region.

Fig. 2 - C.T scan showing an osteolytic lesion involving theright side of the mandible crossing the midline.

Fig. 3 - H & E Section showing islands of malignant epithelialcells with moderate amount of keratin pearl formation(40X)

Fig. 4 - H & E Section showing intramedullary invasion oftumour islands (10X)

Fig. 5 - H & E Section showing tumour islands resorbing thecortical bone (10X)

Fig. 6 - H & E Section showing tumor island resorbing thecortical bone. (40X)

invasion. Level IB lymph nodes were positive for tumourwith extra capsular spread. Serial sectioning of themandible was done. The anterior bony marginrepresenting socket of mandibular left first premolar(34) and lower border of the mandible microscopically


showed intramedullary invasion of tumour cells.Extensive and deep invasion by small groups andislands of tumor cells was seen in the mandible (Fig.4) with irregular resorption of cortical bone (Fig. 5 and6). H & E section of the tissue excavated from the bonymargin also proved positive for tumour showing sheetsof keratin with few islands of malignant cells. Theoverall impression was consistent with ModeratelyDifferentiated Squamous Cell Carcinoma. Anneroth'shistological classification also showed Grade II SCC.(Table 1) with level IB lymph nodes being positive fortumor and apparently safe anterior bony margin alsoinvolved (not free) showing infiltrative pattern of bonyinvasion.

men and may contribute up to 25% of all new cases ofcancer. At least 95% of OSCC cases occur in individualsaged 40 years or older and is twice as often in men asin women. In the present case report the female patientis 35 years old which is a relatively younger age group.Most important risk factors are tobacco use, increasedconsumption of alcohol and betel quid usage all ofwhich act separately and synergistically together. Oralcancer risk due to consumption of tobacco and alcoholcombined is estimated to be more than 80%.In our casethe patient had history of chewing tobacco and applyingMisheri on the teeth and gums since the past 20-25years. This well correlates the association of tobaccoand OSCC.5


OSTEOCLASTOGENESIS

Regulated By

RANKL RANK OSTEOPROTEGERIN(Receptor activator of nuclear (receptor)

Factor kB ligand)

Osteoblasts and bone marrow Hemopoetic Osteoclast Osteoblasts andStromal cells progenitor, mature stromal cells

Osteoclasts, chondrocytes &Mammary gland epithelial cells

Thus a balance between expression levels of RANKL and OSTEOPROTEGERIN is crucial because both are produced by the samecells.

CANCER CELLS STROMAL CELLS

Il-6 PTHrP IL-6

RANKL (stromal cells/ present on osteoblasts lining the bony front)

+

RANK (Osteoclast Precursors in Hemopoetic marrow)

OSTEOCLASTS

BONE RESOPTION

GROWTH FACTORS (TGF beta, IGF-1, FGF)

Increased proliferation of cancer cells + reduced Apoptosis.

DiscussionOSCC is a well known malignancy which accounts formore than 90% of all oral cancers. The annualestimated incidence is around 275000 for oral and130300 for pharyngeal cancers excluding nasopharynx.In high risk countries like Sri Lanka, India, Pakistanand Bangladesh, OSCC is the most common cancer in

Clinical examination requires an imaging correlation.Various imaging techniques(i.e.: Orthopantamogram,Bone Scintigraphy, Computed Tomography, MagneticResonance Imaging and Positron emission tomography)are used to make a diagnosis of mandibular invasionby tumour of the oral cavity6. In the present report,OPG and C.T scan were used to detect the extent ofmandibular invasion. On the CT scan the lesion seemed



to be crossing the midline. This was initially suspectedclinically as the teeth showed mobility from 48 to 33.

As tumor cells grow and mitosis increases, they invadethe basement membrane, destroy the surroundingtissue regionally, resist the immune system, and secretecertain proteins and angiogenic factors that willfacilitate lymphovascular invasion and metastasizeregionally or distantly. OSCC tends to invade theadjacent bone due to its close anatomical proximity, sohigher bone invasion will occur in the OSCC that liesin direct contact with the bone. The size and proximityof the primary tumor to the jaw bone will determinethe degree of bone invasion. Prognosis is affected bythe pattern of bone invasion, which could be either anerosive, infiltrative or mixed7. The erosive pattern ofbone invasion is marked by a broad pushing front, asharp interface between tumour and bone, osteoclasticbone resorption and fibrosis along the tumour frontand an absence of bone islands within the tumour mass.In contrast, the infiltrative pattern is characterizedby nests and projections of tumour cells along anirregular front, residual bone islands within the tumourand Haversian system penetration. The histologicalpattern of mandibular invasion seems to correlate withthe clinical behavior. Infact the infiltrative lesions aremore likely to have primary, regional and distantrecurrence8.The 3 year disease free survival in theinfiltrative pattern is reported as 30% as against thatin erosive pattern is 73%4.The present case showed aninfiltrative pattern of bone invasion suggesting that itwas an aggressive lesion. It is seen that cellular andmolecular mechanisms regulate osteoclastdifferentiation.

Thus, it can be deduced that stromal cells regulateosteoclast formation induced by OSCC. Also IL-6 andPTHrP released from oral cancer cells induceOsteoclastogenesis through RANKL expression instromal cells.8

Patients with mandibular invasion should be treatedsurgically but the extent of mandibular resectionrequired remains controversial8.Histological pattern ofmandibular invasion has prognostic significance. Poorclinical outcome is highly correlated with theinfiltrative histological pattern of invasion. Infiltrativepattern has a 4-fold increased risk of death as comparedto erosive pattern. In the present casehemimandibulectomy was performed and consideringa 1 cm safe margin, the mandible was resected up toLower left first premolar.(34) However, onhistopathology of the resected mandible, the marginconsidered to be safe showed infiltrative pattern of boneinvasion, thus being positive for tumor. Therefore thepatient was informed about the prognosis, advisedradiotherapy and explained about the need of anothersurgical intervention.

A recent study has demonstrated that tumour invasionof the mandible is not significantly correlated with the

survival of the patient with OSCC and if bone invasionis identified histologically, the prognosis is not worsenedand additional surgery need not be undertaken.9

However, more studies are required with morenumber of cases to prove the prognostic value of thepattern of bony invasion in OSCC.

ConclusionThe infiltrative pattern intuitively appears to be anaggressive tumor that is difficult to resect surgically.The intraoperative and preoperative determination ofinvasion pattern remains problematic. If thepreoperative imaging studies do show radiographiccharacteristics suggesting an infiltrative pattern suchas an irregular front or bone spicules, a wide surgicalmargin should be taken around the grossly apparenttumor. Pattern of invasion provides importantprognostic information and therefore should beroutinely commented on by pathologists reviewing caseswith mandibular bone invasion.

In addition, new approaches have been developed toexamine cellular and molecular mechanisms of boneinvasion by OSCC. Inhibition of osteoclastdifferentiation and function by blocking RANKL andRANK by inhibitor antibody constitutes a novelapproach to development of target therapy.

References1. Choi S, Myers J N .Molecular pathogenesis of oral

squamous cell carcinoma: Implications for therapy. J DentRes 2008:87;14-32.

2. Pandey M, Rao LP, Das S R , Mathews A, Chacko EM,Naik BR . Patterns of mandibular invasion in oralsquamous cell carcinoma of the mandibular region. WorldJ Surg Oncol. 2007; 5: 12.

3. Shah J, Lydiatt WM. Buccal mucosa, alveolus, retromolartrigone, floor of mouth, hard palate, and tongue tumors.In: Thawley SE, ed. Comprehensive Management of Headand Neck Tumors.II Ed. Philadelphia: WB Saunders;1999: 686-693.

4. Wong R J,. Keel SB, Glynn RJ ,. Varvares MA. HistologicalPattern of Mandibular Invasion by Oral Squamous CellCarcinoma .The Laryngoscope. January 2000;110(1):65-72.

5. Warnakulasurya S, Living with oral cancer: epidemiologywith particular reference to prevalence and life stylechanges that influences survival.Oral Oncology2010;45:407-10

6. Vidiri et al. MDCT and MRI in the evaluation of mandibularinvasion by OSCC. Correlation with pathological data.Journal of Experimental & Clinical Cancer Research 2010,29:73

7. Alkindi Mohammed.Effects of soluble factors released byOSCC on osteoclasts. M.Sc thesis February 2011,McGillUniversity,Montreal,Canada.

8. Jimi, H.Furuta, K.Matsuo, K.Tominaga, T.Takahashi,O.Nakanishi. The cellular and molecular mechanisms ofbone invasion by Oral Squamous Cell Carcinoma. Reviewarticle. Oral Diseases 2011;17:462-468.

9. Mu¨cke T , Ho¨lzle F , Wagenpfeil S , Wolff K , Kesting M.The role of tumor invasion into the mandible of oralsquamous cell carcinoma.J Cancer Res Clin Oncol2011;137:165-171.

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