Vol 21 No. 1

Scientific Journal Published by the
College of Dentistry – University of Baghdad
Vol. 21 No.1 2009
ISSN
1680-0087

A quarterly peer reviewed published scientific journal of the College of Dentistry,
University of Baghdad.
Editor in chief: Prof. Dr. Ali Hussain AlKhafaji B.D.S., M.Sc. D (UK)
Vice editor in chief: Prof. Dr. Hussain Faisal Al-Huwaizi M.Sc., PhD
Editorial Board:
National Members
Prof. Dr. Khalid Mirza
Prof. Dr. Fakhri Al-Fatlawi MSc
Prof. Dr. Athraa Yahiai MSc, PhD
International Members
Prof. J. L. Gutmann D.D.S., Ph.D.(USA)
Prof. Dr. M. Goldberg PhD (France)
Prof. Dr. Adel Farhan Ibraheem M.Sc.
Prof. Dr. Khulood Al-Safi M.Sc. Ph.D.
Assist. Prof. Dr. Amer Maki MSc
Assist. Prof. Dr. Sabah Nema Ph.D.
Assist. Prof. Dr. Wesal Al-Obaidi MSc
Dr. Jamal Abid MSc
Dr. Aeda Zaki MSc
Board of editorial consultants:
1- Prof. Dr. Wael Al-Aloosi MSc 9- Prof. Dr. Waleed Al-Hashemi MSc
2- Prof. Sulafa Al-Samaria MSc, PhD 10- Prof. Abdullatif Al-Jubory PhD
3- Prof. Dr. Ausama Al-Mulla PhD 11- Prof. Dr. Widad Al-Naqash MSc
4- Prof. Dr. Raad Muhi AlDeen Helmi MSc 12- Prof. Dr. Ahlam Hameed MSc
5- Prof. Nidhal Hussein MSc 13- Assist. Prof. Akram Faisal Al-Huwaizi MSc, PhD
6- Prof. Nabeel Abdulfatah MSc 14- Assist. Prof. Jamal Aziz MSc
7- Prof. Dr. Zainab Al-Dahan 15- Assist. Prof. Dr. Bashar Hamed MSc, PhD
8- Prof. Riyad Al-Qaisi MSc, PhD 16- Assist. Prof. Kadim Al-Soudani MSc
Computer executives: Lecturer Dr. Abdalbasit Ahmed
Linguistic referee: Prof. Dr. Hussain Faisal Al-Huwaizi
Administrative secretary: Hadeel Abdul Wahab.
For consultation, please contact:
Website: www.baghdentistry.com
E-mail: baghdad_dentistry@yahoo.com
Telephone: (+9641)4169375 Fax: (+9641)4140738
i

Contents
i
ii
vi
Editor and Editorial Board
Contents
Instructions for the Authors
Restorative Dentistry
1
5
9
15
18
24
28
33
38
41
46
The influence of posterior composite type and application technique on the fracture resistance of maxillary
premolar teeth (an in vitro study). Shamma`a A. Sahib Al – Ansari, Ali H. Alkhafaji,
Depth of cure evaluation of four different light-activated composites using different curing modes. Ali A.
Razooki Al- Shekhli
The effect of using different impression techniques and materials on vertical tissue displacement in free end
extension ridges. (Dental survey and clinical study). Rawia. N. AL- Dafaii,, Amir. M. Khamas
The effectiveness of carbide fissure bur in cutting dentin with light, moderate and heavy work load. Angham G.
AL-Hashimi
Effect of ozonated water on adherent Mutans Streptococci (In vitro study). Hasanain M Habeeb, Abbas S Al-
Mizraqchi, Adel Farhan Ibraheem.
The effect of dowel length on the retention of two different endodontic posts. Lamis A. Al- Taie,
Assessment of consistency and compressive strength of manufactured dental base materials from enamel
powder and synthetic hydroxyapatite with or without CO 2 laser treatment. Mohammed R. Al-Jabouri, Haitham
J.Al- Aazawi, Hussein A.
The effect of amalgam condensation techniques on the tensile bond strength using different dentin adhesives (in
vitro study). Abdul Munaim S. AL-Khafaji
The visible portion of upper anterior teeth at rest. Reem A. Al Obaidy
Reliability of fovea palatinea in determining the posterior palatal seal. Yasmen Taha AL – Alousi
Study the Microleakage of class II Composite Using Different Etching Techniques. Zainab M. Abdul-Ameer
ii

Oral Diagnosis
49
Distribution and localization of ground substance of carbohydrate group in an inflammatory and phenytion
induced gingival enlargement using histochemical method. Athraa Al Hijazi, Saif S. Saliem, Ali A. Abdulkareem
53
57
60
66
70
Oral findings and health status among elderly Iraqi patients, (aged 65 and above). Fawaz Al-Aswad
Evaluation of Oral Hygiene, gingival health and dental knowledge among 4-12 years-old children attending
the dental hospital. Eman K. Chaloob
Serum and Salivary levels of proinflammatory cytokines as potential biomarkers in the diagnosis of oral
squamous cell carcinoma. Nazar G. Al Talabani, Shanaz Mohammad Gaphor, Abdul-Wahab R. Hamad
Assessment of Magnesium and Calcium Status in Oral Cancer Patients. Seta A.Sarkis, Suad AL-Ani,
Marwan Al-Nimr
The role of lipid peroxidation in the inducation and progression of chronic periodontitis. Taghreed F.
Zaidan
74
Clinical observation of recurrent aphthous stomatitis in Sulaimania. Shanaz M. Gaphor, Shokhan A. Hussien
Oral and Maxillofacial Surgery and Periodontology
80
Prevalence of dentine hypersensitivity in different age groups. Abdul-Karim Abd Ali Al- Muhammadawi
84
88
91
Prevalence and distribution of gingival recession and root caries in a group of dental patients in Ramadi city,
Iraq. Raad S. Al– Ani, Ahmed M. Abdul- Razzak
The effect of locally applied ciprofloxacin on the incidence rate of dry socket. Emad A. Salman, Jabbar J.
Sabur
Closed reduction for comminuted mandibular fractures. Thaer Abdul Lateef
Orthodontics, Pedodontic, and Preventive Dentistry
98
104
107
Hypodontia in Down’s syndrome patients. Nidhal H. Ghaib, Mustafa M. Al-Khatieeb, Dheaa H. Abd Awn
Malocclusion of Primary Dentition among kindergarten Children in Zayona Part of Baghdad City. Shahbaa
A. M. Al- Ajwadi
Mandibular antegonial notch depth distribution and its relationship with craniofacial morphology in
different skeletal patterns. Yassir A. Yassir Ausama A. Al-Mulla
iii

Instruction for the Authors
The Journal of the College of Dentistry accepts manuscripts that address all topics related to
dentistry. Manuscripts should be prepared in the following manner:
Typescript. Type the manuscript on A4 white paper, with page setup of 2.5 cm margins. Type the
manuscript with English language font Times New Roman and the sizes are as follows:
1) Font size 18 and Bold for the title of the manuscript.
2) Font size 14, Bold and capital letters for the headings as ABSTARCT, INTRODUCTION,
MATERIALS AND METHODS, RESULTS and REFERENCES.
3) Font size 12 Bold and italic for the names and addresses of the authors ex. Ahmed G. Husam
4) Font size 11 for the legends of the tables and figures.
5) Font size 10.5 for the text in the manuscript.
6) Font size 10 for the text inside the tables.
7) Font size 9 for the references at the end of the manuscript.
Use single spacing throughout the manuscript and numbering of the pages should be in the lower
right hand corner.
Title of the manuscript:
The title should be written with a capital letter for the first word as (Effect of the retention and
stability….etc).
Abstract and key words. The abstract should contain no more than 250 words. The abstract should be
divided to the following categories: Background: (It contains a brief explanation about the problem
for which the research was done as well as the aim of the study), Materials and methods:, Results:,
and Conclusion:. Below the abstract, write 3-5 key words that refer as close as possible to the article.
The abstract should be written by the font Century Gothic size 8.
Text. The body of the manuscript should be divided into sections preceded by the appropriate major
headings (INTRODUCTION, MATERIALS AND METHODS, RESULTS and REFERENCES)
which are written in bold and capital. Minor headings should be typed in bold and subheadings should
be not bold but underlined.
References. References are placed in the text using the Vancouver system (Numbering system).
Number references consecutively in the order in which they are first mentioned in the text. Identify
references in the text, tables, and figures by Arabic numerals, and place them in parentheses within the
sentence as superscription ex. (2) .
Use the style of the examples given below in listing the references at the end of the manuscript :
Book
1. Hickey JC, Zarb GA, Bolender CL. Boucher’s prosthodontic treatment for edentulous patients. 9 th
ed. St. Louis: CV Mosby; 1985. p.312-23.
Journal article
4. Jones ER, Smith IM, Doe JQ. Occlusion. J Prosthet Dent 1985; 53:120-9.
Tables. All tables must have a title placed above the table. Identify tables with Arabic numbers (e.g.
Table 1). The tables should be done with a width of no more than 8 cm.
Figures and illustrations. All figures must have a title placed below the figure. Identify figures with
Arabic numbers (e.g. Figure 1). The figures should be done with a width of no more than 8 cm.
The article should not exceed 7 pages. The author should submit three copies of the article (one
original and two copies) and a (CD) containing the article.
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J Bagh College Dentistry Vol. 21(1), 2009 The influence of posterior …..
The influence of posterior composite type and application
technique on the fracture resistance of maxillary premolar
teeth (an in vitro study)
Shamma`a A. Sahib Al - Ansari, BDS (1)
Ali H. Alkhafaji, BDS. MSc. D (UK) (2)
ABSTRACT
Background: A restorative material with the potential to increase resistance to cuspal fracture is available to dentists
and the packable composite is one of them. This in vitro study was conducted to evaluate and compare the cuspal
fracture resistance of weakened maxillary premolar teeth with MOD preparations restored with different composite
materials and techniques.
Materials and Methods: fifty maxillary premolar teeth were divided into five groups (n=10). Class II MOD cavities were
prepared in forty specimens. Group A, were sound. Group B were prepared but not restored. Group C and D were
restored with successive cusp build up using Z250 microhybrid for group C and P60 packable for group D. Finally,
Group E was restored with bulk using P60 packable. A 5 mm diameter steel sphere contacted the buccal and lingual
cusps of the tested teeth until fracture occurred. The values obtained in this study were subjected to Analysis of
Variance (ANOVA) and student t – test was carried out between the two types of posterior composite materials.
Results: There's a high significant improvement of the fracture resistance of restored teeth using posterior composite
as compared to the unrestored ones, but; there's no difference of the type of the posterior composite material used,
or the type of placement technique used, while the sound teeth remained the strongest teeth compared with all the
other groups.
Conclusions: The study concluded that Posterior composite resin restoration whatever type or technique used,
showed a great improvement in the resistance to cuspal fracture.
Keywords: composite resin, successive cusp build up, fracture resistance. J Bagh Coll Dentistry 2009; 21(1):1-4)
INTRODUCTION
Attention has focused on the strength of teeth
after preparation for restorative treatment as it
relates directly to their long – term longevity in
the oral environment. Actually the use of adhesive
materials to reinforce weakened teeth and support
undermined enamel has been widely supported
and many studies have shown that the weakening
effect of cavity preparation can be alleviated with
the use of such materials; the fracture resistance
of teeth restored with adhesive materials is
increased by 80 – 362% (!) . Packable composites
are promoted for stress – bearing posterior
restorations with improved handling properties
and possible bulk curing of the restorations are
some of the advantages (2) .
One way to reduce the effect of contraction
stress is the incremental layering of resin – based
composites during placement to minimize
bridging between cavity walls and to reduce
shrinkage stresses through the sequential use of
small volumes of material. But, the benefit of the
incremental technique for reducing
polymerization contraction stresses is somewhat
controversial (3)
(1) MSc Student, department of conservative dentistry, university
of Baghdad.
(2) Dean of the College of Dentistry. Baghdad University
The aim of this study was to evaluate and
compare the cuspal fracture resistance of
weakened maxillary premolar teeth with MOD
preparations restored with different posterior
composite materials and techniques.
MATERIALS AND METHODS
Fifty maxillary premolar teeth removed for
orthodontic purposes were collected immediately
after extraction and placed in distilled water at
room temperature before being evaluated for use
in this study. All of the teeth selected were intact,
noncarious, and unrestored. They were cleaned
with pumice and examined under a magnifying
lens to detect any pre-existing defects.
To simulate the periodontium, root surfaces
were dipped into melted sticky wax to a depth of
2 mm below the facial CEJ junction to produce a
0.2 to 0.3 mm layer approximately equal to the
average thickness of the periodontal ligament.
Teeth were then mounted in cold cure acrylic
resin confined in a casting metal ring. Each tooth
was removed from the resin when the
polymerization was observed. The wax spacer
was removed from the root surface and from the
alveolus of the acrylic resin. Polyether (Impregum,
ESPE, Germany) was delivered into the acrylic
resin alveolus. The tooth was then reinserted into
the test block, and the polyether material was
allowed to set. Excess polyether material was
removed to provide a flat surface 2 mm below the
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J Bagh College Dentistry Vol. 21(1), 2009 The influence of posterior …..
facial CEJ of each tooth. The thin layer of
polyether material simulated the periodontal
(4,
ligament
5) . Care was taken to prevent
dehydration of the specimens. They were then
stored in distilled water.
The distance from the buccal cusp tip to the
CEJ and the intercuspal distance on the occlusal
surface of each tooth were measured using a
vernier to standardize the cavity preparations.
Class II MOD cavities were prepared in all
specimens with parallel walls and no proximal
boxes, except group A. The resulting isthmus
width was 1/3 the intercuspal distance and 5mm
from tip of facial cusp depth of the cavity. After
preparation, the teeth were randomly divided into
five groups (n=10). The teeth in group A were
sound not prepared. Teeth in group B were
prepared not restored. With exception of the
composite type and placement technique,
specimens in group C, D, and E were restored
using the Adper Single Bond2 adhesive system
and Z250 composite resin for group C and P60
composite resin for group D and E (3M dental
product-ESPE, USA) following the
manufacturer’s recommendations. Ivory no.8
retainer and a metal matrix band were placed on
each specimen. Specimens in group C and D were
restored with successive cusp build up (Figure 1),
in this technique, the first composite increment is
applied to a single dentin surface without
contacting the opposing cavity walls and the
restoration is build up by placing a series of
wedge – shaped 1.5-mm, triangular apicoocclusal
layers of uncured composite that are condensed
and sculpted directly in the preparation using a
composite instrument. Specimens in group E were
restored in bulk technique (Figure 2) using P60
packable, and Z350 flowable as initial layer. The
specimens were stored for one week in distilled
water in 100%relative humidity at 37°C, and the
fracture test was conducted in an compressive
testing machine (Leybold Harris, England 36110),
A 5 mm diameter steel sphere contacted the
buccal and lingual cusps of the tested teeth until
fracture occurred. The fractured specimens in
group C, D, and E were stained with 1%
methylene – blue dye for 24 hours
(6) .the
specimens examined by stereo microscope ×40 so
that the type of failure could be evaluated.
RESULTS
Data obtained by the fracture test for each of
the studied treatments were submitted to ANOVA
for a totally random design. The estimated F value
was 17.83, showing a statistical significant
difference (P < 0.01) among five estimations of
means value (Table 1 and Figure 3). Student t –
test was used to show comparison between the
means of forces using one type of adhesive
bonding agent (Adper Single Bond2) with two
types of restorative composite materials, Z250
microhybrid and P60 packable (considering group
D and group E as one group). The results are
presented in Table (2) which showed that there
was a non significant difference (t = 0.30 P >
0.05). The ANOVA test revealed that between
group A (sound teeth) and group B (unrestored)
there was a highly significant difference (P <
0.01). Among group A and groups: C (Z250 /
incremental), D (P60 / incremental), E (P60 /
bulk), there was a significant differences (P <
0.05). Moreover; among group B and groups: C,
D, E, there was a highly significant differences (P
0.05). The mode of failure
observed after testing the specimens in
compressive testing machine, using the
stereomicroscope; are observed in the Table (3)
for the fractured restored groups C, D, and E.
DISCUSSION
The restorative material is not only restoring
the lost tooth structure, but also to strengthen the
tooth and provide an effective seal between the
restoration and the tooth. Comparing the results of
fracture resistance to cusps statistically of this
study revealed that the force required to fracture
the cusps of group B (unrestored) (force
mean=79.03Kgf) represents the lowest value
among the five groups, while the restorative
groups C (force mean=158.6Kgf), D (force
mean=158.1Kgf) and E (force mean=167.7Kgf);
their improvement in fracture resistance was
statistically high significant. This result concluded
that tooth reinforcement is another benefit of
posterior bonded composite resin restorations.
This high significant differences in fracture
resistance between the unrestored and restored
groups may be due to that the micro-mechanical
bonding between bonding system and tooth
structure tend to bind the walls of the cusps
together and strengthen the remaining tooth
structure and to distribute the forces more evenly
among the various interfaces in composite
restorative material that have been bonded to
enamel and dentin by adhesive bonding agent.
This reduction in localized forces offer greater
opportunity for reinforcing tooth structure and
increases the fracture resistance of the cusps. This
result was in an agreement with (5, 7). The present
study the statistical analysis of differences among
group D (P60 packable / incremental) and group E
Restorative Dentistry 2

J Bagh College Dentistry Vol. 21(1), 2009 The influence of posterior …..
(P60 packable / bulk) was statistically non
significant, despite that there's an improvement in
the fracture resistance force mean for group E(P60
/ Bulk) , in contrast to that of group D (P60 /
incremental) , even such improvement was not
significant. Which revealed that the mode of
application technique employed of the packable
composite has no difference on the cuspal
reinforcement of the weakened teeth to a cavity
depth of 5mm? The presence of white lines
between successive layers of resin composite or
inside layers is an indication for improper
adaptation of the layers with each other, which
also affects physical properties. In Bulk build up a
whole single increment was adapted properly to
the floor and cavity walls, which eliminates the
possible previous defects correlated to the
composite successive increments. This
explanation could be more accepted for the
packable composite (10, 11). In our study it’s seemed
that Z250 and P60 are sharing many of their
physical properties and have closure values for
each other including the modulus of elasticity (12) .
Also using of the same bonding system, these
factors for both posterior composite types are
approximate from each other which may explain
the comparable values of both materials of the
cuspal deflection and therefore on the cuspal
fracture resistance. The majority of cohesive
failure for group D supported the explanation; that
successive incremental technique with packable
composite resulted in weakening of the flexural
strength of the material itself and reduced the
surface hardness as a result of dry spots and voids
in between the resin layers coming from the
improper adaptation of the heavy filled material.
Table 1: Descriptive statistics of values of
five groups.
GA GB GC GD GE
Mean (Kg f) 204.5 79.03 158.6 158.1 167.7
S.D 39.01 35.51 42.48 27.82 22.86
S.E 12.34 11.23 13.44 8.799 7.229
C.V% 19.08 44.93 26.79 17.6 13.63
Table 2: Mode of failure observed in the
fractured restored specimens of groups C, D,
and E.
Groups Cohesive Adhesive Mixed
Group C 1 3 6
Group D 7 _ 3
Group E 1 6 3
A
Figure 2: Bulk technique using P60 packable
composite with flowable one
250
204,5
200
158,6 158,1
167,7
150
Mean
100
79,03
Figure 1: Successive cusp builds up
technique; A group C using microhybrid
Z250composite, B group D using packable
P60 composite with flowable composite
B
50
0
GA GB GC GD GE
Figure 3: Means of fracture forces values in
(Kg f) for the five groups
Restorative Dentistry 3

J Bagh College Dentistry Vol. 21(1), 2009 The influence of posterior …..
REFERENCES
1. Mackenzie DF. The reinforcing effect of MOD acid–
etch composite restoration on weakened posterior teeth.
Br Dent J 1984; 161: 410–4.
2. Fortin D, Vargas MA. The spectrum of composites: new
technique and new materials. J Am Dent Assoc 2000;
1(131): 26S – 30S.
3. Ghavamnasiri M, Moosavi H, Tahvildarnejad N. Effect
of centripetal and incremental methods in Class II
composite resin restorations on gingival microleakage. J
Contemp Dent Pract 2007; 2(8): 113–9.
4. Sirimai S, Riis DN, Morgano SM. An in vitro study of
the fracture resistance and the incidence of vertical root
fracture of pulpless teeth restored with post and core
systems. J Prosthet Dent 1999; 81(3): 262–9.
5. Franca FG, Worschech CC, Paulillo AM, Martins LR,
Lovadino JR. Fracture resistance of premolar teeth
restored with different filling techniques. J Contemp
Dent Pract 2005; 3(6): 85– 92.
6. Gorgul G, Alacam T, Kivanc B.H, Uzun O, Tinaz C.
Microleakage of packable composites used in post
spaces condensed using different methods. J Contemp
Dent Pract 2002; 2(3): 23–30.
7. Salih M.M. An evaluation of the cuspal fracture
resistance using different restorative materials and
techniques with reinforcing effect of adhesive bonding
system. A master thesis, Conservative Department,
University of Baghdad, 2000.
8. Giachetti L, Russo DS, Bambi C, Grandini R. A review
of polymerization shrinkage stress: Current techniques
for posterior direct resin restorations. J Contemp Dent
Pract 2006; 4(7): 79– 87.
9. Fano V, Ortalli I, Pozela K. Porosity in composite
resins. J Am Dent Assoc 1995; 16: 1291– 5.
10. Huysmans M, Varst P, Van de Lautenschlager EP,
Monaghan P. The influence of simulated clinical
handling on the flexural and compressive strength of
posterior composite restorative materials. J Dent Mater
1996; 12: 116–20.
11. 3M Dental products; Filtek P60 technical manual.
Minneapolis: 1999; 5–33.
Restorative Dentistry 4

J Bagh College Dentistry Vol. 21(1), 2009 Depth of cure evaluation…..
Depth of cure evaluation of four different light-activated
composites using different curing modes
Ali A. Razooki Al- Shekhli B.D.S., M.Sc., Ph.D. (1)
ABSTRACT
Background: As light passes through the bulk of the composite material, the light intensity is greatly reduced due to
light absorption and scattering by resin composites, thus, decreasing the effectiveness of cure through the depth of
the composite layer. This study investigated the influence of different new curing modes (conventional and
experimental) and composite formulations on depth of cure using the ISO scraping test.
Materials and methods: This study investigated the depth of cure (ISO scraping method) of four conventional
composites after exposure to different curing modes. A two-piece aluminum mold with a diameter of 4mm and a
height of 8mm was used as a mold for the composite specimens.VIP light curing unit was used to deliver all the
curing modes for photo-curing of all the composite specimens in this study. Parameters included six curing modes:
Control (C), Pulse Delay I (PDI), Pulse Delay II (PDII), Soft-start (SS), Pulse Cure I (PCI), and Pulse Cure II (PCII) plus three
experimental curing modes of higher energy density: Prolonged low-intensity pulse cure mode (PLPC), Prolonged
moderate-intensity pulse cure mode (PMPC) and Rapid high-intensity continues cure mode (RHCC) for each of the
four different light-activated composite materials (Tetric Ceram, Heliomolar, Herculite XRV and Degufill Mineral). The
height of the cylinder of cured material was measured with a micrometer to an accuracy of 0.01 mm. This value was
divided by two (in compliance with ISO CD4049: 2000), and recorded as the depth of cure in mm for that specific
specimen.
Results: Statistical analysis of the data by using the one-way analysis of variance revealed that, there is statistically
very highly significant difference for all the depth of cures between the curing modes and composite types.
Conclusion: This study indicated that, although, both curing mode and composite type significantly affect depth of
cure but the effect of composite composition on the depth of cure is more predominant than that of curing mode.
Key words: Resin composite, light curing modes, composite depth of cure. J Bagh Coll Dentistry 2009; 21(1):5-8)
INTRODUCTION
A common problem associated with
photocuring is that the amount of light available
to excite the photoinitiator, dramatically decreases
from the top surface inward as a result of light
absorption and scattering (1) . This decrease in light
intensity (attenuation) results in what is referred
to as the “depth of cure” problem. Knowing the
depth of cure of a particular shade of lightactivated
composite material would guide dentists
in regard to the thickness of a composite layer that
could be adequately cured clinically and provide
them with a valuable baseline information about
the specific depth of cure of different lightactivated
composite materials used by dentists.
The ISO depth of cure (scraping) test ensured
adequate polymerization of most resin-based
composites (2) . The International Standardization
Organization, or ISO (3) , standard for polymerbased
filling materials requires resin-based
composites to have a minimum depth of cure of
1.5 millimeters when irradiated for the
manufacturer’s recommended time. “Depth of
cure” is defined in the specification as 50% of the
length of the cured composite sample after the
soft, uncured portion has been scraped away
manually.
(1) Assistant Professor, Department of Conservative Dentistry,
Faculty of Dentistry, Ajman University of Science and
Technology Network, UAE.
The length of the cured portion is measured
with a micrometer to an accuracy of 0.1 mm, this
value is divided by two (in compliance with ISO
CD4049: 2000), and recorded as the depth of
cure, Morrow et al., (4) and Manhart et al., (5) used
the same procedure. The objective of this research
was to investigate the influence of different curing
modes plus three experimental curing modes of
high energy density on the depth of cure of four
different light-activated composites.
MATERIALS AND METHODS
A light-curing unit with programmable time
and intensity (variable intensity polymerizer)
(VIP Light, Bisco Inc., Schaumburg, Ill.;
Spectrum 800, Dentsply/Caulk, Milford, Del.)
was used as the light curing unit for all curing
procedures later on. A digital light meter
(Coltolux) (Coltène/Whaledent.com, France) was
used to measure the light intensity delivered from
the curing tip. Four different light-activated resin
composite materials of A2 Vita shade were
selected: Tetric Ceram (Ivoclar, Vivadent AG FL-
9494 Schaan/Liechtenstein.Lot: E58102),
Heliomolar (Ivoclar, Vivadent AG FL-9494
Schaan/Liechtenstein.Lot: C37535), Herculite
XRV (sds Kerr, 1717 West Collins Orange, CA
92867,
Restorative Dentistry 15

J Bagh College Dentistry Vol. 21(1), 2009 Depth of cure evaluation…..
U.S.A. Lot: 205466.Item No.: 22860) and
Degufill Mineral (Degussa-Hüls AG, Degussa
Dental GmbH & Co. KG, Postfach 1364. D-
63403 Hanau, Germany.Lot: 0885).
For the preparation of a cylindrical specimen,
a two-piece aluminum mold with a diameter of
4mm and a height of 8mm (Iraqi construction)
was used as a mold for the composite specimens.
A Transparent celluloid strip band (Hawe-Neos
Dental, CH-6925 Gentilino, Switzerland) was
placed on a flat glass slide (Blue star glass
industries, Delhi, India) (Blue star glass
industries, Delhi, India) on top of a white filter
paper (England) then, the mold was placed over
the transparent celluloid-strip and slightly
overfilled it in one increment with the composite
materials being tested then, a second transparent
celluloid-strip was placed on top of the mold and
overlaid it with a cover slide, then a finger
pressure was applied to the cover slide to extrude
excess material. The exit window of the curing
light was placed over the cover slide (the light tip
in contact with the cover slide) and each
composite material was irradiated, through the
transparent celluloid strip and the cover slide,
with the nine different curing modes (Table 1 &
2).
One hour after completing irradiation, the
composite specimen was removed from the mold
and the uncured material at the bottom of the
sample, was removed by scraping it away
manually with a plastic spatula. The height of the
cylinder of cured material was measured with a
micrometer (Hommel Werke, England) to an
accuracy of 0.01 mm (Figure 1). This value was
divided by two (in compliance with ISO CD4049:
2000), and recorded it as the depth of cure.
Mean and standard deviation were calculated
for each specific depth of cure. The results were
analyzed with one-way ANOVA and Least
significant difference (LSD)-test at significance
level 0.05.
RESULTS
Mean depth of cure in mm and standard
deviation of the four different light-activated
composites cured with the nine-different curing
modes are listed in Table 3. Figure 2 summarizes
mean depth of cure of the four different lightactivated
composites cured with the nine-different
curing modes. Statistical analysis of the data by
using the one-way analysis of variance revealed
that, there is statistically very highly significant
difference for all the depth of cures between the
curing modes and composite types. LSD-test of
the depth of cure according to the composite type
is summarized in Table 4.
Table 1: The conventional light- curing
Light-curing
mode
Control (CC)
Pulse Delay I
(PDI)
Pulse Delay II
(PDII)
Soft-start (SS)
Pulse Cure I
(PCI)
Pulse Cure II
(PCII)
modes (6) .
Regimen
400mW/cm2
(40 seconds)
100mW/cm2→Delay→
500mW/cm2 (3 seconds)
(3 minutes) (30 seconds)
200mW/cm2→Delay→
500mW/cm2 (20 seconds)
(3 minutes) (30 seconds)
200mW/cm2 → 600mW/cm2
(10 seconds) (30 seconds)
400 mW/cm2→Delay→ 400
mW/cm2→
Delay→ 400 mW/cm2 (10
seconds)
(10 seconds) (10 seconds)
(10 seconds) (20 seconds)
400 mW/cm2→Delay→ 400
mW/cm2
(20 seconds) (20 seconds) (20
seconds)
Table 2: The experimental light-curing
modes used in this study (7) .
Light-curing mode
Prolonged lowintensity
pulse cure mode
(PLPC)
Prolonged moderateintensity
pulse cure mode
(PMPC)
Rapid high-intensity
continues cure mode
(RHCC)
Regimen
100mW/cm2 → Delay →
300 mW/cm2
(20 seconds)(10
seconds)(120 seconds)
100mW/cm2 → Delay →
400 mW/cm2
(20 seconds)(10 seconds)
(90 seconds)
600mW/cm2
(60 seconds)
Figure 1: The micrometer devise for
measuring the depth of cure.
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J Bagh College Dentistry Vol. 21(1), 2009 Depth of cure evaluation…..
Table 3: Mean depth of cure in mm and standard
deviation of the four different light-activated
composites cured with the nine-different
curing modes.
Depth of cure in mm
Curing
Mode
Tetric
Ceram
Helio
molar
Herculite
XRV
Degufill
Mineral
Control
2.36 1.75 2.87
(0.01) (0.02) (0.05)
1.95 (0.03)
PDI
2.29 1.72 2.86 1.975
(0.04) (0.04) (0.02) (0.03)
PDII
2.46
2.85
1.9 (0.04)
(0.02)
(0.04)
2.01 (0.04)
SS
2.39 1.84 2.98
(0.05) (0.06) (0.04)
2.11 (0.05)
PCI
2.34 1.83 2.89
(0.03) (0.06) (0.05)
1.98 (0.06)
PCII
2.37 1.81 2.89
(0.04) (0.06) (0.05)
2.06 (0.03)
PLPC
2.47 1.87
(0.05) (0.04)
3.2 (0.05) 1.95 (0.04)
PMPC
2.52
3.25
1.9 (0.03)
(0.03)
(0.05)
2.08 (0.04)
RHCC
2.28 1.77 3.21
(0.03) (0.03) (0.07)
1.9 (0.06)
Standard deviation in parentheses.
DISCUSSION
In this study, although both curing mode and
composite type significantly affect depth of cure but
Figure 4 demonstrated that, the effect of composite
composition on the depth of cure is much more than
that of curing mode and this is due to the fact that, the
most important factors affecting the polymerization
depth are the composition and the physical
properties of the composite resins and not the
energy density and this finding is in agreement
with DeBacker & Dermaut (8) . Herculite XRV
light-activated composite exhibited the highest
depth of cure values for all the nine curing modes
(Figure 2) followed by Tetric Ceram, Degufill
Mineral, and Heliomolar, which exhibited the
lowest depth of cure values. Depth of cure of light
activated resin-based composites is a function of
the material’s filler composition and resin
chemistry, its shade and translucency, the intensity
of the light source, and the length of the radiation
exposure (9) . The data of this study indicated that,
microhybrid resin-based composite had the
greatest depth of cure because of their high filler
loading (79% by weight) and relatively large
Depth of cure in mm
3.5
3
2.5
2
1.5
Tetric Heliomolar Herculite Degufill
Composite type
Control
PDI
PDII
SS
PCI
PCII
PLPC
PMPC
RHCC
Figure 2: Mean depth of cure in mm of the
four different light-activated composites cured
with the nine-different curing modes
according to the composite type.
Table 4: LSD-test of the depth of cure
according to the composite type.
TetricTetric Tetric Helio Helio
molar molar
Herculite
Helio
HerculiteDegufillHerculite Degufill Degufill
molar
C *** *** *** *** *** ***
PDI *** *** *** *** *** ***
PDII *** *** *** *** *** ***
SS *** *** *** *** *** ***
PCI *** *** *** *** *** ***
PCII *** *** *** *** *** ***
PLPC*** *** *** *** ** ***
PMPC*** *** *** *** *** ***
RHCC*** *** *** *** *** ***
** : Highly significant difference
*** : Very highly significant difference
average particle size (0.6-0.7 micron) while for the
microfills (66.7% by weight) for the filler loading
and (0.04 micron) for the average particle size and
in this study, Herculite XRV and Tetric Ceram
composites are micro-hybrids and both of them
exhibited high depth of cure values in comparison
with Heliomolar composite which is a microfilled
composite and this finding is in agreement with the
findings of Jain & Pershing (10) . The findings of this
study, is not in agreement with the findings of Jain
& Pershing (10) in that, greater irradiance (energy
density) or longer exposure times are needed to cure
small particle resin-based composites in an attempt
to increase their depth of cure because in this study,
the experimental curing modes of high energy
density did not greatly increase the depth of cure
especially with Heliomolar microfilled lightactivated
composite (Figure 2).
Restorative Dentistry 7

J Bagh College Dentistry Vol. 21(1), 2009 Depth of cure evaluation…..
REFERENCES
1. Myers ML, Caughman WF, Rueggeberg FA.
Effect of restoration composition, shade, and thickness on
the cure of a photoactivated resin cement. J Prosthodont
1994; 3:149-57.
2. Cook WD, Standish PM. Cure of resin based
restorative materials, II: white light photopolymerized
resins. Aust Dent J 1983; 28: 307-11.
3. International Organization for Standardization:
ISO 4049:2000: Dentistry-polymer-based filling,
restorative and luting materials. 3 rd ed. Geneva,
Switzerland: International Organization for
Standardization; 2000.
4. Morrow L, Wilson NH, Setcos JC. Single-use,
disposable, presterilized light activation probe: the future?
Quintessence Int 1998; 29(12): 781-5.
5. Manhart J, Chen HY, Hickel R. The suitability of
packable resin-based composites for posterior
restorations. J Am Dent Assoc 2001: 132(5): 639-45.
6. Yap AUJ, Soh MS, Siow KS. Effectiveness of
composite cure with pulse activation and soft-start
polymerization. Oper Dent 2002; 27:44-9.
7. Al-Shekhli AA, Al- Azzawi HJ, Al-Aubi IA.
Effctiveness of four different light-activated composites
cure with different light energy densities. Mustansiria
Dental Journal 2006; 3(3):224-9.
8. DeBacker J, Dermaut L. Visible light sources and
posterior visible light cured resins: a particle mixture.
Quintessence Int 1986; 17: 635-41.
9. Rueggeberg FA, Caughman WF, Curtis JW &
Davis HC. A predictive model for the polymerization of
photo-activated resin composites. Int J Prosthodont 1994;
7: 159-66.
10. Jain P, Pershing A. Depth of cure and
microleakage with high-intensity and ramped resin-based
composite curing lights. J Am Dent Assoc 2003; 134 (9):
1215-23.
Restorative Dentistry 8

J Bagh College Dentistry Vol. 21(1), 2009 The effect of using different …..
The effect of using different impression techniques and
materials on vertical tissue displacement in free end
extension ridges. (Dental survey and clinical study)
Rawia. N. AL- Dafaii, B.D.S., MSc. (1)
Amir. M. Khamas, B.D.S., M.S.D. ( 2)
ABSTRACT
Background: Various impression techniques used in the construction of free- end extension partial denture are based
on theories relative to the compressibility and behaviour of the soft tissue during impression making and during
function, the aim of the study was to measure vertical tissue displacement during impression making for free- and
extension using different impression technique and materials.
Material and methods: the study consisted of two parts (question are and clinical) the questionnaire was circulated
among (90) dentists at different working places, to see which impression technique they use in free- and extension. In
the clinical part (24) mandibular distal extension impression were made using three impression techniques and
materials (special tray with alginate, special tray with polyether and double tray with zinc- oxide eugenol impression
paste). The amount of vertical tissue displacement was measured on stone cast using (dial indicator dimension).
Results: The results of the survey showed that (44%) of the dentist tend to use special tray with alginate, and (38.1%) of
prosthodontist use double tray impression, the clinical part showed that there was significant difference between the
impression techniques.
Conclusions: The most popular impression technique used is special tray with alginate, which showed more tissue
displacement in the clinical part of the study, while the double tray impression technique showed the least
displacement.
Keyword: Tissue displacement, free- end extension, impression technique. J Bagh Coll Dentistry 2009; 21(1):9-14)
INTRODUCITON
The major problem that may face the dentist
during making impression is the soft tissue
displacement, since the oral tissue is of varying
degree of displacability according to their health
and support. To provide physiologically and
mechanically acceptable function, it is
fundamental that the soft tissue must be copied
with out distortion to prevent impingement and
injury by the prosthesis (1) . In the impressionmaking
procedure for free-end extension
removable partial denture, the pressure produced
at eh interface of he soft mucosal tissue and the
impression is the most important factor for the
stability of the saddle under functional load (2) . To
achieve an impression with minimum tissue
displacement, soft tissue displacement,
impression concepts, impression techniques, and
impression materials are to be taken in
consideration, studies were carried out to
evaluate and measure tissue displacement of freeend
extension during impression making (3-5) . One
study showed that the space between the inner
surface of the tray and mucosal tissue, the flow
of the impression material, and the size of the
tray are interrelated with each other (6) .
(1) Private practice
(2) Assistant professor, Department of Prosthodontics, College
of Dentistry, University of Baghdad.
The tissue displacement can be under control
according to the impression theory used
(mucostatic mucofuncational, selective
pressure) (7-9) . The application of these theories is
though single impression, sectional impression
and special try impression technique (10,11) . In the
presence of all these factors (impression theories,
impression materials, and impression
techniques), this study was designed to find out
which impression techniques and material is
mostly used by dentist as first part, and the
second part of the study was to measure the
amount of vertical tissue displacement of distally
extended ridges made by three impression
techniques and materials and correlate it with the
survey results, to reach a conclusion and suggest
an impression technique, that cause least amount
of distortion.
MATERIAL AND METHODS
Survey part: A questionnaire was distributed
among 90 dentist (general, specialist and
prosthodontist) at different working place
(ministry of health, dental college, and private
clinic), to find out which impression technique
and material they use for free- extension lower
partial denture. The results were analyzed to be
correlated with the results of the clinical part.
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J Bagh College Dentistry Vol. 21(1), 2009 The effect of using different …..
Clinical part: The clinical part of the study was
carried out on 15 patients with total of 24
mandibular free-end extension ridges with age
range (24-45) years, attending the prosthodontic
clinic, college of dentistry, university of
Baghdad. All patients have healthy natural teeth,
free from periodontal involvement with last
abutment as first or second premolar; the saddle
area was healthy with well attached mucosa and
no previous prosthesis. Three impressions were
made for each patient; the impression technique
and material was special tray with alginate,
special tray with polyether and double tray
impression (zinc oxide-eugenol paste and
alginate). The special tray with alginate
impression was secured with a special perforated
tray constructed from autopolymersing acrylic
resin form preliminary cast with wax spacer and
stopper over the anterior teeth and residual ridge
for proper seating of the tray and to control the
pressure during the impression. The alginate
(cavex-Holland) was mixed according to
manufacture instruction, the impression obtained
was wax boxed a poured figure 1. As for the
double tray impression technique, an auto
polymerising custom tray with one layer of base
plate wax as spacer was constructed over the
edentulous area excluding the teeth, but with
occlusal stopper on last abutment to control the
pressure from a preliminary impression. Border
molding was made in the usual manner and
impression for the edentulous area was made
using zinc oxide- eugenol (S.S white group
England), after setting the impression was
removed and inspected, then it was reseated in
patient mouth with a suitable size stock tray
loaded with alginate an overall impression was
made for the teeth and removed picking with it
the zinc oxide- eugenol impression tray, so that
the final impression is made two sections, the
teeth with alginate and the edentulous area with
zinc oxide- eugenol paste as shown in figure 2.
Finally an impression with polyether impression
material (medium viscosity, impregum,
Germany), using perforated spaced special tray
as shown in figure 3.
Measurement and data collection: To measure
and compare the amount of vertical tissue
displacement of three casts for each patient, a
measuring machine with measuring accuracies
(0.001mm), (Mitutoyo corporation, Tokyo-
Japan), was used. To ensure the same relation
parallism of each cast to the measuring machine,
an autopolymerising acrylic plate was
constructed to the height of the occlusal surface
and incisal edge of the remaining teeth. The cast
and palate was placed on surveyor table with the
indicator of the measuring machine touching on
three selected points on the acrylic plate as
shown in figure 4. Measurements of vertical
tissue displacement were made on the cast at
three selected points (A, B, C) which represent
approximately the area of missing (first
premolar, first and second molar). The occlusal
surface of the last abutment was used as
reference point, as shown in figures 5, 6.
RESULTS
Survey results: The statistical analysis of the
survey results showed that a high percentage of
dentists (44.44%) used special tray with alginate
impression material, while 15.56% prefer the use
of double tray impression as shown in table 1.
According to working places, dentist in ministry
of health showed high percentage (50%) in favor
of special tray with alginate and 12.5% used
double tray impression, while in university
35.71% used special tray with alginate and
14.29% used double tray impression. Finally
private clinic dentist 46.67% used special tray
with alginate, and 20% double tray impression as
shown in table 2. According to specialty 50% of
the general dentists prefer to use special tray with
alginate, while 16.67% used double tray
impression, other specialists (51.28%) used
special tray with alginate, and 2.56% sued double
tray impression, as for prosthodontists 23.8%
used special tray with alginate and 38.1% used
double tray impression as shown in table 3.
Clinical results: The mean, standard deviation,
standard error, and coefficient of variation for
different impression techniques are shown in
table 3 for the points (A,B,C), it revealed that the
use of polyether impression material with special
tray gave the least amount of displacement
compared with double tray impression and
special tray with alginate. Table 5 show that the
special tray with alginate. The compression
between double tray impression and single tray
impression are shown in table 6, there were no
significant differences in the amount of tissue
displacement at points (A,B,C) between double
tray impression and special tray with alginate.
The compression of different impression
technique and materials at each selected points
are shown in table 7, which revealed that there
was no significant difference in the amount of
tissue displacement at points (A,B) a significant
difference existed at point ©, and special tray
with polyether and double tray causes less
displacement that special tray with alginate.
Restorative Dentistry 10

J Bagh College Dentistry Vol. 21(1), 2009 The effect of using different …..
DISCUSSION
The results of the survey showed that dentist
in working places used different impression
techniques. Most dentist in the ministry of health
and private practice used the special tray with
alginate impression material, this may be because
of its easy manipulation, relativity inexpensive,
time saving and comfortable to the patient, while
he result of the clinical part of the study showed
that the sue of special tray with alginate
impression material caused more soft tissue
displacement when compared with the polyether
with special tray and double tray techniques.
Dentist in the dental school used all types of
impression techniques; this may be due to that
the dental school as teaching institute is
responsible of teaching student all concepts and
impression techniques.
According to dentist specialty, half of the
general dentist used the special tray with alginate
and the vest uses the other techniques, while
dentist with other specialties other than
prosthodontist use special tray with alginate, in
addition to the use of polyether with special tray,
which indicate that specialist tend to use
techniques that causes less tissue displacement
prosthodontist prefer the use of double tray
impression which according to the clinical results
showed that least tissue displacement equally
with the polyether, this is because prosthodontist
are deeply involved in their filed in problems of
support, retention, resorption and tissue
displacement. There was as significant difference
in the amount of tissue displacement between
different impression techniques and materials at
point © which represent the area of the first
molar, may be extracted at different time during
life resulting in variable amount of bone loss at
that area. The results also showed that there was
significant difference between double tray
impression (less displacement at point ©) when
com pared with special tray with alginate, this
may be explained that the flow of impression
material influence tissue displacement and the
use of easy flowing zinc oxide- eugenol
impression paste recorded the soft tissue at time
of set gave better results when compared with
alginate which is effected by may factors such as
water/ powder ratio, humidity, temperature,
mixing time, in addition to the syneresis and
imbibitions that may cause poor dimensional
stability. These results agreed with Leupold (3) ,
James (12) , and Holmes (13) , who all demonstrated
that alginate impression with special tray causes
more tissue displacement, but disagree with
Wang (14) who believed that it is comparable to
double tray. As for the points (B and C) the
results showed that there was significant
difference between the special tray with alginate
and special tray with polyether and the later
showed least amount of tissue displacement. The
results of tissue displacement at points (A,B,C)
showed no significant difference between special
tray with polyether and double tray techniques,
this results agreed with EL- Shilich and adbdel
hakim (15) , AL- Judy, AL-Obaidi (17) , and Frant (18) .
.
Figure 1: Special tray with alginate impression
material
Figure 2: Double tray impression (zinc oxideeugenol
paste and alginate impression
material)
Restorative Dentistry 11

J Bagh College Dentistry Vol. 21(1), 2009 The effect of using different …..
Figure 3: Special tray with polyether
impression material
Figure 4: Ensure the parallism between the
cast and measuring apparatus
Figure 5: A vertical sliding pointed tool
descending on the occlusal surface of the last
tooth to be used as a reference point
Figure 6: Selection of three measurement
points (A, B and C)
Table 1: Questionnaire results according to the preference of the dentists.
Impression techniques No. of dentist %
Stock tray with alginate 16 17.78
Special tray with alginate 40 44.44
Double tray 14 15.56
Special tray with rubber base 20 22.22
Table 2: Number and percentage % of dentists in different working places with their choices of
impression techniques.
Impression techniques
Ministry of health (32) University (28) Private clinic(30)
No. of dentist % No. of dentist % No. of dentist %
Stock tray with alginate 6 18.75 5 17.86 5 16.67
Special tray with alginate 16 50 10 35.71 14 46.67
Double tray 4 12.5 4 14.29 6 20
Special tray with rubber base 6 18.75 9 32.14 5 16.67
Restorative Dentistry 12

J Bagh College Dentistry Vol. 21(1), 2009 The effect of using different …..
Table 3: Number and percentage % of dentists with different specialties and their choices of
impression techniques.
Impression techniques
General dentist (30) Specialist (39) Prosthodontist(21)
No. of dentist % No. of dentist % No. of dentist %
Stock tray with alginate 5 16.67 7 17.95 3 14.29
Special tray with alginate 15 50 20 51.28 5 23.81
Double tray 5 16.67 1 2.56 8 38.1
Special tray with rubber base 5 16.67 11 28.21 5 23.81
Table 4: Mean, standard deviation, standard errors and coefficient of variation of displacement
for the different impression techniques and materials at each measured points.
Impression techniques and materials
Statistic
Special tray with alginate
impression material
Double tray
impression
Special tray with polyether
impression material
Point A Point B Point C
Point Point Point
A B C
Point A Point B Point C
Mean 8.311 9.077 8.491 8.063 8.766 8.025 8.132 8.674 7.885
SD 1.786 1.706 1.627 1.814 1.653 1.581 2.010 2.042 2.124
SE 0.364 0.348 0.332 0.370 0.337 0.322 0.410 0.416 0.433
CV% 21.49 18.795 19.161 22.498 18.857 19.7 24.7 23.5 26.94
Table 5: t-test of displacement for two impression materials [special tray with alginate and
special tray with polyether]
Special tray with alginate and
Point Statistical t-test P-value Sig.
special tray with polyether
A
MD 0.179
SD 0.643
1.361 0.187 NS
B
MD 0.403
SD 0.142
2.832 0.009 S
C
MD 0.605
SD 0.189
3.336 0.003 S
*P>0.05 Non significant
**P0.05 Non significant
**P0.05 NS
B 2.604 0.084 P>0.05 NS
C 3.388 0.042 P0.05 Non significant
**P

J Bagh College Dentistry Vol. 21(1), 2009 The effect of using different …..
REFERENCES
1. Denen HE. Impression for dentures. J Prosthet Dent
1952; 2:737.
2. Geng Q. Influence of various impression procedures
for removable partial denture on displacement of soft
mucosal tissue. J Prosthet Dent 1993; 60(1): 35-53.
3. Leupold RJ. Comparison of vertical movement
occurring during loading of distal- extension
removable portical denture bases made by there
impression techniques. J Prosthet Dent 1992; 68(2):
290-9.
4. Vahidi F. Vertical displacement of distal extensions
ridges by different impression techniques. J Prosthet
Dent 1978; (4):374-7.
5. Sato M. Influence of various impression procedures
on displacement of residual ridges. Kokubyo Gakkai
Zasshi 1996; (4): 374-7.
6. Sato M. Influence of various impression procedures
for mandibular distal extension removable partial
denture on displacement of residual ridges. Kokubyo
Galkkai Zasshi 1996; 63(1): 88-107.
7. Khamas AH. Impression material as related to tissue
distortion. Thesis College of dentistry Alabama U.S.A
1979.
8. Jacobson TS, Krol AJ. A contemporary review of
the factor involved in complete denture. Part III
support. J Prosthet Dent 1983; 49(3): 306-13.
9. Duncan JP, Raghavendas, Tylor T. A selective
pressure impression technique for edentulous maxilla.
J Prosthet Dent 2004; 92(3): 224.
10. Rapuano JA. Single try dual- impression technique
for distal extension partial dentures. J Prosthet Dent
1970; 24(1): 41-5.
11. Frank RP, Brudvik JS, Noonan CJ. Clinical outcome
of the altered cast impression procedure compared with
the issue of a one piece cast. J Prosthet Dent 2004; 91:
468-76.
12. James JS. A simplified alternative to the alteredcast
impression technique for removable partial
denture. J Prosthet Dent 1985; 53(4): 598.
13. Holmes J.B: Influence of impression procedures and
occlusal loading on partial denture movement. J
Prosthet Dent 2001; 84(4): 335-41.
14. Wong H, Luy Shiauy, Tsou D. Vertical distortion in
distal extension ridges and palatal area of casts made
by different techniques. J Prosthet Dent 1996; 75(3):
302-8.
15. El-Sheikh, Abdel-Hakim AM. Sectional impression
for mandibular distal extension removable partial
dentures. J Prosthet Dent 1998; 80(2): 216-9.
16. AL- Judy HJ. Measurement of the extension ridges
tissue displacement on the cast obtained from various
impression techniques. M.Sc. Thesis, College of
Dentistry, University of Baghdad, 2001.
17. AL-Obaidi MS. Comparison of different impression
techniques in determining soft tissue displacement in
distally extended removable partial denture. M.Sc.
Thesis, College of Dentistry, University of Baghdad
2004.
18. Fran RP, Brudvik JS, Noonan CJ. Clinical outcome
of the altered- cast impression procedures compared
with the use of one- piece cast. J Prosthet Dent 2004;
91: 468-76.
Restorative Dentistry 14

J Bagh College Dentistry Vol. 21(1), 2009 The effectiveness of carbide ….
The effectiveness of carbide fissure bur in cutting dentin
with light, moderate and heavy work load.
Angham G. AL-Hashimi,B.D.S., M.Sc. (1)
ABSTRACT
Background: The dentist believes that pressing harder on the tooth enhances the cutting effectiveness of the bur
performance. The aim of the study: was to evaluate the effectiveness of carbide fissure bur in cutting dentin with
light, moderate and heavy work load.
Materials and Methods: The cutting of carbide bur under different work load was evaluated on dentin specimens
mounted in acrylic blocks. Group I: Cutting performed with light work load (=25g), Group II: Cutting performed with
moderate work load (=100g), Group III: Cutting performed with heavy work load (=175g). Ten cuts were performed
with each work load and atotal of 30 cutting rates or CRs (mm/sec.) were recorded and were statistically analyzed
using analysis of variance (ANOVA) test, student t-test.
Results: A significant difference (P< 0.5) appeared between CRs of group I and III, and between group II and III.
Conclusion: The effectiveness of carbide fissure bur in cutting dentin markedly reduced with heavy work load.
Keywords: Effectiveness, Carbide bur, Work load. J Bagh Coll Dentistry 2009; 21(1):15-17)
INTERODUCTION
Powered cutting equipment can be seen as a
search for improved sources of energy and means
of holding and controlling the cutting instrument.
This culminated in the use of replaceable bladed
or abrasive instrument held in a rotary hand
pieces usually powered by compressed air. (1-4)
Three speed ranges are generally recognized:
low or slow speed (bellow 12,000 rpm), medium
or intermediate speeds (12,000-200,000 rpm) and
high or ultra-high speeds (above 200,000 rpm).
Most useful instrument are rotated at either low
or high speed. (1)
Although most current air-turbine hand pieces
have free running speeds of approximately
300,000 rpm. The speed can drop to 200,000 rpm
or less with work load during cutting. (4)
Although intact tooth structure can be
removed by an instrument rotating at low speeds,
it is a traumatic experience for both the patient
and the dentist. Low-speed cutting is in effective,
time consuming, and requires a relatively heavy
force application. This results in heat production
at the operating site and produces vibration of
low frequency and high amplitude. Heat and
vibration are the main sources of patient
discomfort. Furthermore, at low speeds burs have
a tendency to roll out of the cavity preparation
and mar the proximal margin or tooth surface. (5-
10)
In addition, carbide burs do not last long
because their brittle blades as easily broken at
low speeds. (10) therefore , this study was done to
evaluate the effectiveness of carbide fissure bar
in cutting dentin with light, moderate and heavy
work load.
(1) Lecturer, Department of Conservative Dentistry, College of
Dentistry University of Baghdad.
MATERIAL AND METHODS
A controlled test regimen was performed
using KaVo high speed hand piece mounted on a
surveyor with a coolant flow rate of 25 milliliter
per minute. (7-9)
The specimens were prepared using extracted
teeth (molars) that had been stored in deionized
distilled water. The roots were removed and the
occlusal and axial surfaces of each tooth were
ground flat until all enamel was removed with a
high-speed diamond stones using air/water spray.
(11)
The occlusal surface of each tooth was placed
on glass slab and fixed by a sticky wax, then cold
cure acrylic resin loaded into a metal mold
(25x25x10 mm) on the tooth so that the crown
will be imbedded in acrylic resin totally except
it's occlusal surface that faces the glass.
Cutting was performed with carbide fissure
bur (Depha Carb FG 014), The bur was placed
into a high-speed hand piece under different
loading, and the cutting rates or CRs (mm/sec)
were recorded as the time in second it took the
carbide fissure bur to cut a straight channel (5mm
length and 2 mm depth) in dentin. The bur and
the tooth were painted with colored marks to the
desired length and width of the straight channel
(figure 1).
The specimens were divided into three groups
(each one of 10 specimens) according to the
working load of carbide fissure bur:
Group I cutting performed with carbide fissure
burs with light work load (=25 g).
Group II cutting performed with carbide fissure
bur with moderate work load (=100g).
Group III cutting performed with carbide fissure
bur with heavy work load (=175g).
Ten cuts were performed with carbide fissure
bur began with cut 1 up to cut 10 for each work
Restorative Dentistry 15

J Bagh College Dentistry Vol. 21(1), 2009 The effectiveness of carbide ….
load, a total of 30 CRs measurement were
recorded. The CRs data was statistically analyzed
using analysis of variance (ANOVA) test; the
mean CRs for all ten cuts were statistically
analyzed using student t-test.
RESULTS
The mean and standard deviation of burs CRs
(mm/sec) of dentin for the ten cuts are
summarized in table 1 and figure 2.
It is clearly obvious that CRs decreased with
increase work load, group I (light work load)
showed higher CRs, while group III (heavy work
load) showed the lowest CRs.
The statistical analysis of data using ANOVA
test showed a statistical significant difference
(P>0.5). Further analysis using student t-test
showed a significant difference between:
• group I vs. group III
• group II vs. group III
In addition to that, there was no significant
difference (P

J Bagh College Dentistry Vol. 21(1), 2009 The effectiveness of carbide ….
turbine resulted in slight reduction in the cutting
performance of carbide fissure bur since the
peripheral speed of the bur will reduced at the
lower speed thus reduce the cutting effectiveness
of the blades, however such a reduction was non
significant.
Group III: The heavy work load (=175) markedly
drop the rotational speed to a lower speed range
(from high moderate speed) as measured by
Siegel et al 2000 (13), Therefore the cutting
effectiveness of carbide fissure bur markedly
reduced and a significant difference began to
appear.
REFERENCES
1. Sturdevant CM, Roberson TM, Heymann HO.
Sturdevent JR, the art and science of operative
dentistry, 3 rd ed. St. Louis: Mosby 1995.
2. Morrant GA. Burs and rotary instruments:
introduction of a new standard numbering system,
Brit Dent J 1979; 147 (4):97-8.
3. Nelson RJ, Pelander CE, Kumpula JW. Hydraulic
turbine contra angle hand piece, J Dent Assoc 1953;
47:329.
4. Taylor DF, Perkius RR, Kumpula JW.
Characteristics of some air turbine hand pieces. J Am
Dent Assoc 1962; 64:794-805.
5. Peyton FA. Temperature rise in teeth developed by
rotating instrument. J Am Dent Assoc 1955; 50: 629-
30.
6. Eames WB, Nale JL. A comparison of cutting
efficiency of air -driven fissure burs. J Am Dent
Assoc 1973; 86:412-5.
7. Von- Frauhofer JA, Siegel SC. Enhanced dental
cutting through chemomechanical effects. J Am Dent
Assoc 2000; Oct; 131 (10) : 1465-9.
8. Von-Fraunhofer JA, Siegel SC. Hand piece coolant
flow rates and dental cutting. Oper Dent 2000; Nov-
Dec;25(5)544-8.
9. Peyton FA. Effectiveness of water coolant with rotary
cutting instrument. J Am Dent Assoc 1985; 56: 664-
75.
10. Sockwell CL. Dental hand pieces and rotary cutting
instrument, Dent Clin North Am 1971; 15(1): 219-44.
11. Lambert RL,Lambert RF. Variation in the design of
3 330 dental burs. Oper Dent 1989;14: 73-6.
12. Henry EE, Peyton FA. The relationship between
design and cutting efficiency of dental burs. J Dent
Res 1954; 33:281-2.
13. Siegel SC. Cutting efficiency of three diamond bur
grit sizes. J Am Dent Assoc 2000; 131:12.
14. Craig RG, Marcus L. Restorative Dental Materials,
10 th ed. St. Louis. Mosby 1997. Ch4: 56-103.
Restorative Dentistry 17

J Bagh College Dentistry Vol.21(1), 2009 Effect o ozonated…
Effect of ozonated water on adherent Mutans Streptococci
(In vitro study)
Hasanain M HabeeB, B.D.S., H.D.D., M.SC. (1)
Abbas S AL-Mizraqchi, B.B.S., M.SC., PhD. (2)
Adel Farhan Ibraheem, B.D.S., M.SC. (3)
ABSTRACT
Background: The aim was to evaluate the antibacterial efficiency of ozonated water against adherent bacteria (in
vitro).
Materials and Methods: Ten dentin samples per group were inoculated with bacterial suspension and treated as
follows: (I) untreated served as –ve control, (II) sterile distilled water for 10 seconds served as +ve control, (III) 5.25%
sodium hypochlorite (Sultan-USA) for 10 seconds, (IV) 0.2% chlorhexidine (Corsodyle ® , England) for 10 seconds, and
(V) 4mg/L ozonated water (Ozonesolution-Enaly, USA) for 10 seconds. Swab taken from all samples and an inoculum
was spread on the selective medium MSB (HiMedia, India). Count of bacteria was recorded expressed in colony
forming unit (CFU) taking in consideration the dilution factor.
Results: There was high significant reduction in viable count of adherent M.S treated with ozonatd water 4mg/L
compared with the other groups at P

J Bagh College Dentistry Vol.21(1), 2009 Effect o ozonated…
All teeth were embedded in a mold of
2×2×3cm dimensions filled with autopolymerizing
acrylic resin in such a way that the
teeth were parallel to the long axis of the mold
leaving 2 mm of the crown uncovered, then the
blocks were left to polymerize under 6 bar
pressure and 50°C for 10 minutes in the Ivomet
(Japan) (7) , then a loop of acrylic was added at
center base of the blocks, this will aid as an
attachment mean for the hangers.
The teeth samples were then sectioned
horizontally using diamond cutting disc and low
speed hand piece (MF-Tectorque, W&H,
Austeria) to expose dentin surface. Each disc was
used for 10 specimens, then the dentin surfaces
were grounded using fine stone bur under running
water to gain flat surface (12) .
All teeth samples were then abraded using
Rotofix machine with silicon carbide abrasive
paper of a grit size of P600A under water
irrigation, to create a standard surface i.e. a
uniform smear layer (12) , the teeth were then
inspected under dissecting microscope at 2X
magnification to exclude any tooth containing
perforations into the pulp (Figure 1). All abraded
teeth were then placed in distilled water at 37°C
in the incubator (11) .
Figure 1: Complete tooth preparation (2X
under dissecting microscope).
Ozonated water was prepared using ozone
generator based on corona discharge which
installed according to the manufacturer instruction
and the bubbling stone of the device was
immersed into the bottom of 500 ml measuring
cylinder filled with cooled distilled water. In this
current study we used 4mg/L.
Since the concentration of ozonated water
decreases with time (13,8) and to insure it is
correct, and keep it constant during the work, a
chemical diagnostic test by specialized kit
(CHEMets ® Kit) was used (Figure 2).
Figure 2: Ozone generating device
with tubing and stone and the ozone
CHEMets®Kit.
Saliva samples were collected from young-age
volunteer and dispersed with vortex for 2 minutes.
Ten folds dilutions were prepared (10 -1 -10 -4 )
using sterile normal saline solution then 0.1 ml
from 10 -1 -10 -4 was taken and spread in duplicate
on MSB. Plates were then incubated anaerobically
using a gas pack (bio Mériux, France) for 48
hours at 37 °C then aerobically for 24 hours at
room temperature (14,15) .
The colonies of Mutans Streptococci were then
identified first by colony morphology under
dissecting microscope 20×magnification
(Hamilton, ALTAY), second by gram's stain and
investigated under light microscope (Olympus-
XSZ-N107, Japan) with 1000×magnification (16)
and last by biochemical test using Cystine
Trypticase agar media (CTA) (17) .
A glass trough of 4.5×7.5×5.5 cm dimensions
was modified to be used as adhesion model for
samples (Figure 3) filled with 50 ml Sucrose-
Brain Heart Infusion Broth (SBHI-B) and
inoculated with 1 ml activated bacterial inoculum
then sterilized together at 15 Ibs pressure and
121ºC for 15 minutes.
Figure 3: Glass trough and teeth attached
to the suspenders (20 suspenders receiving
20 sample).
All dentin surfaces were rinsed by immersion
the samples in sterile distilled water (25ml) for 10
seconds to get rid of bacterial by-products,
followed by gentle drying with filter paper. An
adhesive tape with 4 mm hole was affixed on
dentin surface to achieve swab area
standardization, 10 samples for each group were
randomly selected (n=10) and treated as follows:
(I) untreated (negative control), (II) sterile
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J Bagh College Dentistry Vol.21(1), 2009 Effect o ozonated…
distilled water for 10 seconds served as positive
control, (III) 5.25% sodium hypochlorite (Sultan-
USA) for 10 seconds, (IV) 0.2 % chlorhexidine
(Corsodyle, England) for 10 seconds, and (V) 4
gm/L ozonated water for 10 seconds. Immediately
swab by scraping dentin surfaces using absorbent
paper point #140 (Roeko-Geramny) and
transferred to 10 ml sterile normal saline
(Fresenius Kabi, Germany). Serial dilutions in
saline were performed (10 -1 -10 -4 ). 0.1 ml
inoculum from each dilution was cultured onto
MSB agar plates using a sterile microbiological
spreader and incubated at 37°C for 48 hours
anaerobically followed by 24 hours aerobically.
The colony-forming units grown were then
counted in each plate and then recorded taking in
consideration the dilutions factor (no. of colonies
× reverse the dilution) and expressed as colony
forming unit (CFU/sample) of M.S. The final
result for the mean number of M.S binding to the
dentin was obtained by calculating the mean
scores of cultures from each dilution.
RESULTS
Two forms of colonies were revealed,
spherical or ovoid in shape with raised or convex
surface, light blue in color about 1-2 mm in
diameter (Smooth type), the other form of
colonies appeared as irregular with rough or
frosted glass surface (Rough type). Most of M.S.
colonies had a depression at the middle with a
drop of polysaccharide in it, or sometimes the
whole colony submerged in a pool of
polysaccharide. Both types of M.S. colonies were
adhered well to the agar surface (Figures 4,5).
Figure 4: Smooth form of M.S. colonies
(white arrow) submerged in polysaccharide
(black arrow) (20×).
The count of Mutans streptococci bacteria
adhered on the dentin surface was expressed as
colony forming unit (CFU x10 4 ). The number of
colonies recorded multiplied by reverse of the
dilution factor. The differences in M.S growth on
MSB agar that were cultured from dentin surfaces
of all groups are shown in figure (6).
Figure 5: Rough form of M.S (20×).
Figure 6: M.S grown on MSB from
dentin Surfaces of each group. a)
untreated, b) distilled water, c) Naocl, d)
CHX, e) ozonated water.
Table 1: Viable count of adherent M.S (values expressed in CFU x 10 4 ).
Group N Viable adherent MS
Mean ± SD*
I 10 11.91 ± 2.2
II 10 6.47 ± 0.68
III 10 4.25 ± 0.48
IV 10 3.02 ± 0.49
V 10 0.65 ± 0.19
* Highly significant difference at level P

J Bagh College Dentistry Vol.21(1), 2009 Effect o ozonated…
Dentin surfaces treated with 4mg/L ozonated
water exhibited the least viable count of adherent
M.S, followed by the dentin surfaces rinsed with
0.2% CHX, then the dentin surfaces rinsed with
5.25% NaOCl, next the dentin surfaces treated
with SDW (Table 1). This is clearly shown in
figure (7).
Figure 7: Mean of viable count of adherent
M.S (CFU x 10 4 )
Ozonated water exhibited high significant
correlation at P

J Bagh College Dentistry Vol.21(1), 2009 Effect o ozonated…
precipitation of cytoplasmic proteins, alters
cellular osmotic balance, interferes with
metabolism, growth, cell division, inhibits the
membrane ATPase and inhibits the anaerobic (29) .
To reach the maximum effect of the agents
mentioned before, one minute and up exposure
time needed based on several studies (27,30,31) . The
exposure time set in this study was 10 seconds, to
find if these agents able to eliminate adherent M.S
properly.
The results of study showed that the sensitivity
of M.S to ozonated water 4mg/L was the highest
among the other groups, chlorhexidine and
sodium hypochlorite in other hand exhibit a
sensitivity toward M.S too (4.25 ±0.48, 3.02
±0.49) respectively when compared with –ve
control and +ve control (11.91 ±2.27, 6.470
±0.68) respectively as seen in figure 7, but when
compared with ozonated water using ANOVA,
there was a high significance correlation (P

J Bagh College Dentistry Vol.21(1), 2009 Effect o ozonated…
engineering. Am Wat Works Assoc Res Found. Boca
Raton: Lewis Publ, 1991.
14. Ellen R, Banting D, Fillery E. Streptococcus mutans
and Lactobacilli detection in the assessment of dental
root surface caries risk. J Dent Res 1985; 64(10),
1254-9.
15. Holbrook W, Beighton D. Streptococcus mutans
levels in saliva and distribution of serotypes among
9-year-old Icelandic children. Scan J Dent Res 1986;
95, 37-42
16. Koneman EW, Schreckenberge PC, Allens SD,
Janada WM. Diagnostic microbiology, 4th edn.
Philadelphia: Lippincott, 1998.
17. Fingold S, Baron E. Methods for identification of
aetiologic agents of infectious disease: Diagnostic
microbiology, 7th edn. St. Louis: Mosby, 1986.
18. Van Houte J. Role of microorganisms in caries
etiology. J Dent Res 1994; 73, 672-81.
19. Love RM, Jenkinson HF. Invasion of dentinal tubules
by oral bacteria. Crit Rev Oral Biol Med 2002; 13(2),
171-83.
20. Thylstrup A, Fejerskov O. Textbook of clinical
cariology, 2nd edn. Copenhagen: Munksgaard, 1994.
21. Ikeda M, Matin K, Nikaido T, Foxton RM, Tagami J.
Effect of surface characteristics on adherence of
Streptococcus mutans biofilms to indirect resin
composites. Dent Mater J 2007; 26(6), 915-23.
22. Drobni M. Adhesion-related interactions of
Actinomyces and Streptococcus biofilm bacteria, M
Sc thesis, Umeå Univ, Umeå, 2006.
23. Ökte E, Sultan N, Dogan B, Asikainen S. Bacterial
adhesion of Actinobacillus actionmycetemcomitans
serotypes to titanium implants: Scanning electron
microscopic study evaluation: A preliminary report. J
Periodontol 1999; 70, 1376-81.
24. Tenuta LMA, Ricomini FAP, Del Bel Cury AA,
Cury JA. Effect of sucrose on the selection of mutans
streptococci and lactobacilli in dental biofilm formed
in situ. Caries Res 2006; 40, 546-9.
25. Bocangel JS, Kraul AOE, Vargas AG, Demar FF,
Matson E. Influence of disinfectant solutions on the
tensile bond strength of a fourth generation dentin
bonding agent. Pesq Odont Bras 2000; 14(2), 107-11.
26. Brannstrom M. The cause of postrestorative
sensitivity and its prevention. J Endod 1986; 10(4),
475-81.
27. Sim TPC, Knowles JC, Ng YL, Shelton J, Gulabivala
K. Effect of sodium hypochlorite on mechanical
properties of dentine and tooth surface strain. Int
Endod J 2001; 34, 120-32.
28. Gamage B. A guide to selection and use of
disinfectants. Brit Col Center Disease Control, 2003.
29. Estrela C, Ribeiro RG, Estrela CRA, Sousa-Netomd
MD. Antimicrobial effect of 2% sodium hypochlorite
and 2% chlorhexidine tested by different methods.
Braz Dent J 2003; 14(1), 58-62.
30. Radcliffe CE, Potouridou L, Qureshi R, Habahbeh N,
Qualtrough A, Worthington H, Drucker DB.
Antimicrobial activity of varying concentrations of
sodium hypochlorite on the endodontic
microorganisms Actinomyces israelii, A. naeslundii,
Candida albicans and Enterococcus faecalis. Int
Endod J 2004; 37, 438-46.
31. Yang SE, Cha JH, Kim ES, Kum KY, Lee CY, Jung
IY. Effect of smear layer and chlorhexidine treatment
on the adhesion of Enterococcus faecalis to bovine
dentin. J Endod 2006; 32(7), 663-7.
32. Nagayoshi M, Kitamura C, Fukuizumi T, Nishihara
T, Terashita M. Antimicrobial effect of ozonated
water on bacteria invading dentinal tubules. J Endod
2004; 30(11), 778-81.
33. Restaino L, Frampton EW, Hemphill JB, Palnikar P.
Efficacyof ozonated water against various foodrelated
microorganisms. Appl Environ Microbiol
1995; 61: 3471–5.
34. Goldstein BD, McDonagh EM. Effect of ozone on
cell membrane protein fluorescence I: in vitro studies
utilizing the red cell membrane. Environ Res 1975;
(9), 179-86.
Restorative Dentistry 23

J Bagh College Dentistry Vol.21(1), 2009 The effect of dowel …
The effect of dowel length on the retention of two different
endodontic posts
Lamis A. Al- Taie, B.D.S, M.Sc.
ABSTRACT
Background: Several factors govern the retentiveness of endodontic posts, the shape of the post and its length are
among the essential factors.
This invitro study formulated to compare the retentive values of stainless steel, parallel sided, serrated posts (Euro
post) to fiber reinforced, tapered ,smooth posts (Easy post) at two embedment depth (5and 10 mm).
Materials and methods: Thirty two intact human mandibular second premolars were selected for this study. These
samples were endodonticlly treated, and randomly divided in to four groups of eight teeth each:
Group Ι: teeth restored with Easy post at embedment depth 10mm. Group ΙΙ: teeth restored with Easy post at
embedment depth 5mm. Group ΙΙΙ: teeth restored with Euro post at embedment depth 10mm. Group ΙV: teeth
restored with Euro post at embedment depth 5mm. Tensile failure loads were measured in the absence of crowns
using an instron test machine at across head speed of 5 mm/min .Values were recorded in Newton Mean values and
standard deviations were analyzed with one way ANOVA test and the least significant differences test.
Results: retentive failure loads were recorded for all test specimens; the means and standard deviation for each
group were as follows: group Ι: 65.75±23.6 ; group ΙΙ: 64.25 ±22.2, group: 189.5±25.9,and group ΙV: 221.1±27.
Conclusion: Endodontically treated teeth restored with Euro post (stainless steel/parallel sided /serrated posts)
showed significantly greater retentive values than Easy post (fiber reinforced composite /tapered/smooth posts), also
there was no significant difference in retentive values are achieved with both systems at 5mm and 10mm post
length.
Key words: Euro post, fiber reinforced posts, post length, retention. J Bagh Coll Dentistry 2009; 21(1): 24-27)
INTRODUCTION
Endodontically treated teeth regularly receive
posts and cores to provide predictable
replacement for lost tooth structure and to
facilitate crown support and retention.
Prefabricated and cast metal posts are traditionally
used; they are as well as the novel all ceramic
posts rigid in nature. The rigidity may pose a risk
for root fracture. Recently, fiber reinforced
composite root canal posts have been introduced
as an alternative to more conventional materials
(1) . The bio- mechanical properties of fiber
reinforced composite posts have been reported to
be close to those of dentin. Fiber reinforced
composite posts exhibits high fatigue and tensile
strength, its chemical nature is compatible with
the BIS-GMA resins in the adhesive resin
cements which effectively transmit stresses
between the post and the root structure (2) . The
introduction of new resinous cement provides
dentistry with the opportunity to improve the
success rate of post endodontic restorations (3) .
Numerous studied of retentive properties have
been conducted relative to the shape, diameter,
length and surface configuration of the posts.
Most invitro post and core experiments have been
accomplished by evaluating the tensile force to
remove the posts from the root canals, this rarely
occurs clinically .
(1) Lecturer, department of conservative dentistry, college of dentistry,
university of Baghdad.
As a result of the test specimens' geometry in
the pullout test, a major portion of retention was
created not only by the adhesive bonding agent
but also through micro retention from the surface
roughness and macro retention from the frictional
fit between two surfaces (4) .
MATERIALS AND METHODS
Thirty two lower second premolars recently
extracted of comparable sizes and shapes were
selected for experimentation. All teeth were
cleaned from soft tissue debris and stored in
physiologic saline solution at room temperature
from the time of extraction to the time of testing.
Access opening for endodontic therapy was
established for all teeth with a fissure carbide bur
(No.21 R/12; Komet, Germany) rotating at high
speed under constant water spray the pulpal tissue
was removed with a barbed broach (Produits
Dentaire S.A Vevey , Switzerland), and a No.10
file was inserted until its tip just appeared at the
apex. The working length was recorded as 1 mm
shorter than that length. Instrumentation of the
canal was continued up to size 45 K-file
(Dentsply, Switzerland), with the use of step back
technique(filing action) under full sodium
hypochlorite irrigation (NaOCl 0.25%),then dried
with paper points. Zinc oxide based sealer cement
(Dorifill, Dorident, Austria) was mixed according
to manufacture's instructions, and a size 40 file
was used to carry the sealer inside the canal and
coat the walls of the canal. The canal was then
obturated with gutta percha in conjunction with
endodontic sealer using lateral cold condensation
Restorative Dentistry
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J Bagh College Dentistry Vol.21(1), 2009 The effect of dowel …
technique. The coronal portion of the teeth were
removed at the level of 1mm coronal to the
cementoenamel junction with a diamond disk
(Komet, Germany) and a full water spray coolant,
ending with root length of 14mm. Then the
samples were randomly divided in to four groups
of eight teeth each:
Group Ι: teeth restored with fiber reinforced,
tapered, smooth posts (Easy post) at embedment
depth 10mm.
Group ΙΙ: teeth restored with fiber reinforced,
tapered, smooth posts (Easy post) at embedment
depth 5mm.
Group ΙΙΙ: teeth restored with prefabricated
stainless steel, parallel sided, serrated posts (Euro
post) at embedment depth 10mm.
Group ΙV: teeth restored with prefabricated
stainless steel, parallel sided, serrated posts (Euro
post) at embedment depth 5mm.
The most similar sizes available among the post
systems used in the study were chosen. Each post
in group Ι (Easy post) was marketed at a distance
14mm from its apical end while posts in group ΙΙ
were marketed at a distance 9 mm. A line was
drawn around the post at this level, and all these
posts were sectioned horizontally with a water
cooled diamond fissure bur. This would
standardize the post lengths with established
similarity between post diameters of the different
designs, all post designs used in this study had
shown 1.8 mm diameter at the coronal and middle
level, considering that the apical part varies
according to post design which was left for
comparison. The gutta percha was removed from
the root canals of teeth with peeso drills
(Dentsply, Switzerland), to a depth 10 mm
measured from the coronal end of the root in
group Ι and ΙΙΙ , and to a depth 5mm in group ΙΙ
and ΙV then the post spaces were prepared with
the special preparation drills of each system. Easy
post (Fiber reinforced posts, tapered design, C
0602, Dentsply, Switzerland) were used in group Ι
and ΙΙ, posts No. 2 (C 0600, Dentsply,
Switzerland) were selected. The special
preparation drill of the system(C 0601 No.2) was
used to prepare the post spaces under full water
irrigation.
Euro post (stainless steel /parallel sided/serrated
posts), (Set ref 5320 Anthogyr, France) were used
in group ΙΙΙ and ΙV, posts No.3 (long) (3L 5312
Anthogyr, France) were selected for group ΙΙΙ,
while posts No.3 (short) (3S 5312 Anthogyr,
France)were selected for teeth in group ΙV. The
special drill of the system (No.5313 Anthogyr,
France) was used to prepare post spaces under full
water irrigation. All teeth were marked 3mm
below their coronal level and a line was drown
around the root at this level with right angle to the
long axis of the tooth, then teeth were embedded
in individual blocks of acrylic resin to the depth
identified by the circumferential line. All posts
were first tried inside the canals with out cement
to the full prepared length, then cementing using
VariolinkΙΙ (Dual cure adhesive resin cement,
Ivoclar Vivadent Ag Fl-94 Schan/Liechtenstein).
Following manufacturer's directions, one drop of
37% phosphoric acid gel (Alpha-Dent, Dental
Technologies, USA) was applied to post spaces
for 15 seconds then thoroughly rinsed with water
for 30 seconds, dried with paper point and air
blower. One drop of each base and catalyst of the
bonding resin (Alpha-Dent, Dental Technologies,
USA) was dispensed on a mixing dish and mixed
for 4 seconds then applied homogenously on
dentin on post spaces as well as on the surface of
the posts and allowed to set for 60 seconds, then
carefully dried with a faint air jet. The excess
bonding in the root canal was removed with paper
points. According to manufacture's instructions
equal parts of Variolink ΙΙ resin cement paste
were applied on a mixing pad and were gently
mixed for 20 seconds with a plastic spatula until
creamy consistency with a uniform color was
obtained (the working time is 3.5minutes), the
mixed cement was inserted in the prepared canal
with a lentulo spiral (Produits Dentaires, S.A.
Vevey Switzerland) and the post was uniformly
coated with the cement and fully seated in to the
canal to the prepared length(with finger pressure
for posts in groups Ι and ΙΙ, and screwing action
for posts in group ΙΙΙ and ΙV) . Excess cement was
removed immediately after the post was seated by
using a disposable brush. The light curing device
was applied at the margin to initiate curing
mechanism of the adhesive resin cement. Then the
samples were stored in normal saline until the
time of testing. The tensile forces required to
dislodge the posts from their cannels were
measured by a Zwick (Universal testing machine),
the mounted teeth were grasped by the lower jaw
of the testing machine. The posts were held by a
special holder specially made for this purpose that
assure loading along the long axis of the teeth,
this holder was mounted in to the upper jaw of
the testing machine. A constantly increasing
tensile force was applied at a cross head speed of
5mm/min until the post was displaced from the
root canal which determined by a sudden release
of load on the post as seen on recording graph.
Peak tensile force (in Newton) required to remove
posts were recorded on a strip chart.
Restorative Dentistry
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J Bagh College Dentistry Vol.21(1), 2009 The effect of dowel …
RESULTS
Retentive failure was recorded as point of
deflection on Instron recording sheet. Mean
failure loads (in Newton) and standard deviation
(±SD) were calculated for all tested groups (Table
1), and illustrated graphically in Figure 1.
Table 1: The data of tensile forces (in Newton)
for all test specimens with Mean and Standard
deviation of each group.
Mean
250
200
150
100
50
0
Mean ± SD
Group1 65.75 23.6
Group II 64.25 22.2
Group III 189.5 25.9
Group IIII 221.1 27.0
65.75 64.25
189.5
Group1 Group II Group III Group IIII
221.1
Figure 1: Bar chart graph to compare the
mean retentive values for the experimental
groups.
At an embedment depth of 5mm Euro post
(stainless steel, parallel sided, serrated posts)
(group ΙV) tended to be the most retentive post
among tested groups with mean retentive force of
221.1±27N.The next more retentive configuration
was Euro post (group ΙΙΙ) at embedment depth of
10mm,which was retained at 189.5 ±25.9N. Easy
post (fiber reinforced, tapered, smooth posts) at
embedment depth 10mm (group Ι) exhibited mean
retentive ability of 65.75±23.6 N while Easy post
at embedment depth of 5mm( group ΙΙ) was the
least retentive posts at 64.25 ±22.2 N.
Statistical analysis of data using analysis of
variance "ANOVA" revealed that there was a
statistically highly significant difference (p<
0.001) between the mean retentive values among
the four groups tested as shown in Table 2.
Further investigation using LSD (Least
Significant differences) test showed that there was
a statistically highly significant difference (P<
0.001) between group Ι and group ΙV, also
between group ΙI and group ΙV. There was
statistically significant difference (P< 0.05)
between group Ι and group ΙΙΙ, also between
group ΙΙ and group III, while there was no
significant difference (P>0.05) between group Ι
and group ΙΙ, also between group ΙΙΙ and group ΙV
(Table 3).
Table 2: Analysis of variance (ANOVA) test
for the four groups.
F-value P-value
Between
groups
29.40
0.000
HS
Table 3: Least significant difference LSD test
to compare the mean retentive values for the
experimental groups.
P-value Sig
Group I & Group II 0.90 NS
Group I & Group III 0.0014 S
Group I & group IV 0.000 HS
Group II & Group III 0.0012 S
Group II & Group IV 0.000 HS
Group III & Group IV 0.28 NS
DISCUSSION
The retention of a post in the root canal is
critical for the successful restoration of
endodontically treated teeth. The retention of
various types of posts has been the subject of
much experimentation; numerous studies of
retentive properties have been conducted relative
to the form, shape, diameter, length and surface
configuration of the posts. Although every effort
has been made to select specimens of comparable
characteristics and to standardize the experimental
procedure accurately, a range of retention values
with in each group couldn't be avoided. The
variability of the physical properties of human
teeth may be a reason for such data range, dentin
is a heterogeneous tissue, its structure, and degree
of calcification can vary from tooth to another.
Under the condition of the present study the
results showed that endodontically treated teeth
restored with Euro post (Stainless steel /parallel
sided /serrated posts) recorded significantly
higher retentive values than those restored with
Easy post (fiber reinforced /tapered /smooth
posts). Dowel design is very important variable
affecting both retention and protection potential
for the dowel. Dowels that are tapered and
cemented in their channels are least retentive and
act as wedges causing coronal stress
concentrations. Parallel sided, serrated dowels act
as intermediate retainers and distribute stress
evenly through remaining root structure. Surface
configuration of the dowel is another important
variable in retention; the marked increase of
Restorative Dentistry
26

J Bagh College Dentistry Vol.21(1), 2009 The effect of dowel …
retentive values was also attributed to the serrated
surface of the Euro post. The superior retentive
abilities of parallel sided design of the post over
tapered design in resisting tensile, shear, and
torque forces, and the serrations at the surface of
the post as well as the use of adhesive resin
cement for luting the post, all these factors will
greatly improved the retention of the post inside
the root canal. This finding is in agreements with
that obtained by Colley et al (5) , Johnson and
Sakamura (6) , Love and Purton (7) , Purton et al (8) ,
and Cohen et al (9) , but disagrees with the findings
of Stockton and Williams (10) who revealed that
the serrated C-post (parallel design) required
significantly more tensile force to dislodge them
than Para post (Plus post). The serrations at the
surface of the fiber post would significantly
increase the retention of the post inside the canal,
also with the findings of Drummond (11) who
found that there was no significance difference in
the retention of the fiber post versus stainless steel
Para post. All the tapered dowels could easily be
removed after the cement seal was broken, and
they came out cleanly with no cement attached.
The bond between the cement and the dowel was
the failure site, while in the parallel sided design
posts could not be removed from the tooth after
the fracture of the cement bond. Tensile forces
greater than the forces required to break the
cement bond were required to remove the parallelsided
dowels, once removed. The parallel sided
dowels were coated with cement as were the
dentinal walls of the prepared canals, thus failure
site with in the cement. The serrations on the
parallel sided dowels served as a mechanical
locking device for the cement and prevent failure
of the cement dowel bond.
Post length has a pronounced effect on post
retention .In this study although the retentive
values of group Ι (Easy post 10mm depth) were
higher than that of group ΙΙ (Easy post 5mm
depth) but still its statistically not significant, this
may be due to the fact that an increase in the
bonded post surface area 50% most likely
influenced the increased in the retentive strength.
There was no significant difference in the
retentive values of group ΙΙΙ (Euro post 10mm
depth) and group ΙV (Euro post 5mm depth) this
may due to that nearly the same number of
retentive spirals engaged the canal wall. The
results of this study are in agreement with that of
Rovatti et al (12) , Purton and Payne (13) and Borer
et al (14) , but disagree with that of Standlee et al
(15) , who claimed that the more deeply the dowel
were placed in their dentin canals the more
retentive they became. The result of Johnson and
Sakamura (6) who stated that an increase in length
of the dowel from 7 to 11mm lead to increase in
the retention by 30%.
Increasing the post depth must be well with in
the constraints of root length, canal morphology,
root diameter in the apical area, and the
maintenance of an endodontic apical seal.
However, the influence of post length on retention
should not be over emphasized and the temptation
to compromise the apical seal of a root filling by
increasing post length should be resisted. Each
tooth must be evaluated on an individual basis by
the dentist before its restored with a post.
REFERENCES
1. Reid LC, Kazemi RB, Meiers JC. Effect of fatigue
testing on core integrity and post microleakage of
teeth restored with different post systems. J Endod
2003; 29(2):125-31.
2. Duret B, Duret F, Reynaud M. Long life Physical
property preservation and post endodontic
rehabilitation with the composi post. Compend
Contin Educ Dent Supply 1996; 20:50-6.
3. Mendoza DB, Eakle WS. Retention of posts
cemented with various dentinal bonding cements. J
Prosthet Dent 1994; 72(6):591-4.
4. Christensen GJ. Posts and Cores: State of the art. J
Am Dent Assoc 1998; 128:96-7.
5. Colley IT, Hampson EL, Lehman ML. Retention of
post crowns. Br Dent J 1968; 124(2):63-9.
6. Johnson JK, Sakamura JS. Dowel form and tensile
force. J Prosthet Dent 1978; 40(6):645-9.
7. Purton DG, Love RM. Rigidity and retention of
carbon fiber versus stainless steel posts. Int Endod J
1996; 29: 262-5.
8. Purton DG, Love RM, Chandler NP. Rigidity and
retention of ceramic root canal posts. Oper Dent
2000; 25: 223-7.
9. Cohen BI, Pagnillo MK, Newman I, Musikant BL,
Deutsch AS. Retention of Four endodontic posts
cemented with composite resin cement. AGD (Gen
Dent) 2000; 48(3) 320-4.
10. Stockton LW, Williams PT. Retention and shear
bond strength of two post systems. Oper Dent 1999;
24: 210-6.
11. Drummond JL. In vitro evaluation of endodontic
posts. Am J Dent 2000; 13: 5B-8B.
12. 12-Rovatti LM, Mason PN, Dallari A. New research
on endodontic carbon Fiber post. Minerva Stomatol
1994; 43:557-63.
13. Purton D, Payne J. Comparison of carbon fiber and
stainless steel root canal posts. Quintessence Int
1996; 27: 93-7.
14. Borer RE, Britto LR, Haddix JE. Effect of dowel
length on the retention of two different prefabricated
posts. Quintessence Int (Abstract) 2007; 5(5):13-4.
15. Standlee JP, Caputo AA, Hanson EC. Retention of
endodontic dowels: Effect of cement, dowel length,
diameter and design. J Prosthet Dent 1978; 39 (4)
401-5.
Restorative Dentistry
27

J Bagh College Dentistry Vol.21(1), 2009 Assessment of consistency …
Assessment of consistency and compressive strength of
manufactured dental base materials from enamel powder
and synthetic hydroxyapatite with or without CO 2 laser
treatment
Mohammed R. Al-Jabouri,B.D.S.,M.Sc.,Ph.D. (1)
Haitham J.Al- Aazawi B.D.S.,M.Sc. (2)
Hussein A., B.L.P.M.Sc.Ph.D. (3)
ABSTRACT
Back ground: This study was done to assist consistency and, compressive strength of manufactured dental base
materials from enamel powder and synthetic hydroxyapatite with or without CO2 laser treatment.
Materials and methods: The ratio of the elements of the manufactured base materials and the parameters of CO2
laser (15.92W/cm 2 power density and 0.2 seconds exposure time) were detected from the pilot study. The standard
consistency test described in America dental association(ADA) specification No.8 was used so that all manufactured
base materials could be conveniently mixed and the results would be of comparable value and the compressive
strength test described by British standard specification for zinc polycarboxylate cement was used in this study,
Results: The results showed that a standard 0.5 ml of liquid (polycarboxylic acid) can be mixed with 350 mg of base
material that contains mixture of enamel powder ,hydroxyapatite and zinc oxide ,300 mg of base material that
contains Enamel powder and zinc oxide, and 400mg of base material that contains Synthetic Hydroxyapatite and
zinc oxide the manufactured base material that contains mixture of enamel powder and hydroxyapatite without
CO2 laser treatment has compressive strength of (48.36±2.07) MPa ,while the manufactured base material that
contains mixture of enamel powder and hydroxyapatite with CO2 laser treatment has compressive strength of
(62.47±2.52)MPa. However, the manufactured base material that contains enamel powder with CO2 laser treatment
has compressive strength of (66.08±2.33)MPa and the results also appeared that the compressive strength will
increases after one week storage.
Conclusion: The manufactured base materials that contains hydroxyapatite requires higher amount of powder to be
mixed with 0.5 ml polycarboxlic acid and the base material that contains mixture of enamel powder and synthetic
hydroxyapatite has higher compressive strength and the CO2 laser treatment will increase the compressive strength
of the manufactured base materials.
Key words: consistency, Compressive, manufactured base materials. J Bagh Coll Dentistry 2009; 21(1): 28-32)
INTRODUCTION
The dental base materials are important
therapeutic agents, they are used as a base under
metallic and tooth colored filling materials. (1)
The proportion of powder to liquid used in
mixing cements affects most physical properties
,The greater the amount of powder added to a
given quantity of liquid to produce a
workable consistency, the better the effect . The
properties of resin cements with exception of
shrinkage on polymerization are much less
affected by changing powder-liquid ratio than are
those of the other types of cements in comparing
cements of same type or other types.
It is essential to test them at same
consistency. (2)
(1) Lecturer, dept. of conservative dentistry, college of dentistry,
university of Baghdad.
(2) Professor, dept. of conservative dentistry, college of dentistry,
university of Baghdad.
(3) Assistant professor, Institute of laser for postgraduate studies,
University of Baghdad,
Compressive strength is important in many
restorative dental materials. This property is
particularly important in the process of
mastication because of the forces of mastication
are compressive. Compressive strength is most
useful for comparing materials that are brittle and
generally weak in tension. (3)
Hydroxyapatite is chemically similar to the
mineral component of bones and hard tissues in
mammals. It is one of few materials that are
classed as bioactive, meaning that it will support
bone ingrowths and osseointegration when used in
orthopedic, dental and maxillofacial applications.
It has the chemical formula of
3Ca 3 (PO 4 ) 2·Ca(OH) 2 and it is in crystal form. It
melts above 1100°C and cannot be dissolved in
water. The hydroxyapatite is strongly absorbing
light in certain regions of the infrared spectrum
because of the phosphate, carbonate and hydroxyl
groups in the crystal structure. The carbon dioxide
laser produces radiation in the infrared region that
coincides closely with same of the apatite
absorption band. (4)
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J Bagh College Dentistry Vol.21(1), 2009 Assessment of consistency …
MATERIALS AND METHODS
Pilot study to Select powders ratio
Three main mixtures were used:
1-mixture of zinc oxide, enamel and
hydroxyapatite powders.
2-mixture of zinc oxide and enamel powders
3-mixture of zinc oxide and hydroxyapatite
powders.
In the pilot study the powder of each
elements increased or decreased by 5% by weight
and the mixtures undergo three test; compression,
diametral and microhardness tests
The results showed that the first group with
35% of enamel ,35%hydroxyapatite and 30%zinc
oxide powders by weight mixed with
polycarboxylic acid to get base material gave
approximately higher measurements for those
three test. So these ratio of elements of the
powder was recorded as the ratio of powder
elements of this group, while the results of pilot
study for the second group showed that the 40%
enamel and 60% zinc oxide powder gave
approximately higher measurements for those
three test where the pilot study for the third group
showed that 40% of hydroxyapatite and 60% of
zinc oxide by weight mixed with polycarboxylic
acid showed approximately higher
measurements for these three tests so this ratio
was used for this group .
Pilot study to select CO 2 laser parameters
Laser device: In this study CO 2 laser was used,
emitting an infrared beam of 10.6-μm-wave
length and helium neon laser source, emitting a
visible red beam. The helium-neon beam is
coaxial with the infrared beam, and therefore it is
used as an aiming beam. The continuous wave
mode (CW) was used in this study. The CO 2 laser
device was used with hand piece with lens has
focal length of 12.5 cm and spot size of 0.2 mm
the hand piece was fitted on the hanger so that the
beam was hitting the base materials in the
perpendicular ,defocused manner, with laser beam
diameter of 4mm that can be gain when the target
site is about 3.3 cm from focal spot(3.3cm far
away from the tip of the spatula fitted to the hand
piece and 15.5cm from the lens) R1/L1=R2/L2
In this pilot study the compression, diametral
and microhardness tests were performed on the
three base materials with their selected ratios of
their elements and with CO 2 laser application with
different laser power densities and exposure time
that did not cause burn of base materials (black
color on the base material when saw by naked
eye), and with limitation of the laser device used
in this study In this study a holes of 4mm in
diameter (0.1256cm 2 surface area) and 1.5 mm in
depth on the cement slab were used to put the
base materials after mixing in these holes to be the
sites of laser application on the mixed material
The results of the pilot study for different power
densities and exposure times for all three base
materials used in this study and for three tests
(compression strength, diametral tensile strength
and microhardness tests), all showed
approximately higher measurements were located
when the power density was 15.92 w/cm 2 and
exposure time was 0.2 seconds.
Sample grouping: Eight groups were used in this
study (15 samples for each group in each test) as
shown in Table 1:
Table 1:The experimental and control groups of the base materials.
Group
I Zinc oxide+Enamel powder+Synthetic Hydroxyapatite mixed with polycarboxylic
(Experimental) acid(with out CO 2 treatment)
Group
II Zinc oxide+Enamel powder mixed with polycarboxylic acid(with out CO 2
(Experimental) treatment)
GroupIII
(Experimental)
Zinc oxide +Synthetic Hydroxyapatite mixed with polycarboxylic acid(with out
CO 2 treatment)
Group
IV Zinc oxide+Enamel powder+Synthetic Hydroxyapatite mixed with polycarboxylic
(Experimental) acid(with CO 2 treatment)
Group
V
Zinc oxide+Enamel powder mixed with polycarboxylic acid(with CO
(Experimental)
2 treatment)
Group
VI Zinc oxide +Synthetic Hydroxyapatite mixed with polycarboxylic acid(with CO 2
(Experimental) treatment)
Group VII (Control) Zinc polycarboxylate cement
GroupVIII (Control) Zinc phosphate cement
Consistency test
Especial apparatus was used in this test in
which a standard 0.5 ml of liquid (polycarboxylic
acid) was mixed with different weights of the
powders to detect a suitable weight of powder of
the experimental base material that can be mixed
to get a proper consistency for these manufactured
base materials base materials.
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J Bagh College Dentistry Vol.21(1), 2009 Assessment of consistency …
Compressive strength test: Specimens of the
base materials with or with out CO 2 laser
treatment were prepared as cylinders of 4mm in
diameter and 6mm in length which prepared by
using a stainless steel mold and kept in water bath
at 37±1 0 C and 90-100% relative humidity at two
intervals: 24 hours and 1 week (7days) after
mixing .The compressive strength were
determined by using compressive strength testing
machine at speed of 1 mm/minutes, the load was
applied on the long axis of the specimens .The
compressive strength were measured for each
specimen by detecting the force that caused early
sign of fracture of the specimen.
RESULTS
Consistency test: It was found that different
consistencies of base materials produce a discs of
varying sizes that amount of the powder in
milligram which can be mixed with 0.5 ml of
polycarboxylic acid to produce a consistency
giving a disc of 33cm ±1mm in diameter were 350
mg for the group I and 300 mg for the group II
and 400mg for the group III as shown in Table 2
and figures 1,2.
one day (Table 5)showed that there was statistical
significant difference between most compared
paired groups except when we compare the group
II and group III also we compare group VI with
group VII showed the was no statistical
significant difference.
mean disc diameter of the mixed base materials cm
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
0 100 200 300 400 500 600 700
powder weight of the base materials (gm)
group I
group II
group II
Figure 1: Relation between consistency (diameter of disc
of the mixed base materials) and weight of powder of the
base materials mixed with 0.5 ml polycarboxylic acid.
400
350
±0.087
±0.05
±0.0289
I
250
Table 2: Relations between the diameter of the mixed
Milligrams /0.5 ml 200
base materials and the weight of the powder that mixed
150
with 0.5 ml of polycarboxylic acid (liquid).
100
Weight
50
Disc mean Disc mean Disc mean
of
0
diameter (cm) diameter (cm) diameter (cm)
group I group II group III
Powder
of Group I of Group II of Group III
The manufactured base materials
No. (mg)
1 200 3.7 ±0.05 3.8 ±0.1 3.85 ±0.1 Figure 2: Weights of powders (mg ) of the
2 250 3.5 ±0.05 3.6 ±0.05 3.75 ±0.08 experimental(manufactured) base materials
3 300 3.2 ±0 3 ±0.05 3.65 ±0.09 mixed with 0.5 ml of polycarboxylic acid to
4 350 2.9 ±0.09 2.7 ±0.04 3.42 ±0.03 get disc diameter of 3 cm (standard
5 400 2.3 ±0.07 2.4 ±0.05 3.13 ±0.03
consistency).
6 450 2.1 ±0.25 2.35 ±0.05 2.86 ±0.06
7 500 1.9 ±0.13 1.8 ±0.09 2.65 ±0.1
±4.36
90
8 550 1.6 ±0.1 1.65 ±0.05 2.42 ±0.03
±4.03
80
±2.33
±2.52
9 600 1.3 ±0.13 1.4 ± 0.172.1 ±0.06
70
±2.41
±3.59
±2.34
± 2.09 ±3.8
60 ±1.75
±2.57
10 650 1.1 ±0.05 1.2 ±0.05 1.72 ±0.03
±2.07
Compressive strength test: The result showed that
the zinc phosphate cement in this study has the
highest values of the compressive strength at both
periods at the end of one day and the end of one
week while the group II has the lowest values at
both periods at the end of one day and the end of one
week as shown in figure 3. One-way ANOVA test
for the groups tested at the end of one day(Table
3) and One-Way ANOVA test for the groups
tested at the end of one week (Table 4)showed
that there was statistically significant difference
among the groups. LSD statistical test to compare
between each paired groups tested at the end of
Compressive
strength(MPa)
50
40
30
20
10
0
300
mgs of powder/0.5 ml liquid
±2.35
±2.78 ±1.84
±2.32
group I group II group III group IV group V group VI group VII group VIII
The groups of the base materials
Compressive strength at end of
24hours
Compressive strength at end of one
week
Figure 3: Compressive strength of all tested
groups at the end of first day and end of first
week.
LST statistical test to compare between each
paired groups tested at the end of one week
showed (Table 7) that there was statistical
significant difference between most compared
paired groups except when we compare the group
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J Bagh College Dentistry Vol.21(1), 2009 Assessment of consistency …
II and group III also we compare group IV with
group VI and group V with group VI and group V
with group VII showed the was no statistical
significant difference.
Table 3: ANOVA test of the compressive strengths of the tested groups at the end of first day.
Source Sum of square df Mean square F Sig.
Between groups 13921.445 7 1988.778 93.1 0.000
Within groups 2391.720 112 21.355
Total 16313.165 119
doff.=degree of freedom, P-value=probability
Table 4: ANOVA test of the ultimate compressive strengths of all groups at the end of first week.
Source Sum of square df Mean square F P(value).
Between groups 19.250.976 7 2750.139 150.997 P

J Bagh College Dentistry Vol.21(1), 2009 Assessment of consistency …
compared between each paired groups except as we
compare the group I tested at the end of one day
with the group I tested at the end of one week and
also as we compare the group VII tested at the end
of one day with the group VII tested at the end of
one week showed no statistical difference.
Table 8: Paired T-test to compare the groups
of the compressive strength test that tested at
the end of 24 hours and the same groups
tested at the end of one week.
Comparaison
1 : 2
Statistic
T
df
P.value
I X I 0.101 14 0.921
II X II -4.235* 14 0.001
III X III -4.257* 14 0.001
IV X IV -4.72* 14

J Bagh College Dentistry Vol. 21(1), 2009 The effect of amalgam…
The effect of amalgam condensation techniques on the
tensile bond strength using different dentin adhesives
(in vitro study)
Abdul Munaim S. AL-Khafaji , B.D.S., M.Sc., (1)
ABSTRACT
Background: The purpose of this in vitro study was to assess the effect of the condensation techniques of the
amalgam on the tensile bond strength of the amalgam to dentin.
Materials and Methods: The occlusal enamel surfaces of the teeth were ground flat to exposed the dentin surfaces,
and polished with 600-grit SiC papers. The dentin surfaces were treated with one of the combinations of dentin
bonding agents and condensation techniques. The tensile bond strengths were determined with a Zwick Universal
Testing Machine.
Results: Statistical analysis of the result revealed that for the Scotchbond Multi-Purpose adhesive and the control
groups, hand condensation was better and the difference was highly significant (p

J Bagh College Dentistry Vol. 21(1), 2009 The effect of amalgam…
The teeth were wet-polished with 600-grit
silicone carbide abrasive papers manually to
create a uniform smear layer. Specimens were
stored in distilled water at room temperature for
48 hours before bonding to prevent dentin
dehydration.
After that, the coronal diameter of each
specimen was measured by a measure in ribbon,
and the radius of each specimen was calculated
to find the interfaced surface area in square
millimeters (mm 2 ).
Sample Grouping. The dentin bonding systems
were used:
1. A dual-cure Scotchbond Multi-Purpose
system “4 th generation".
2. A light-cure Syntac “single-component,
multi-use” system “5 th generation”.
All specimens were randomly assigned to six
groups of ten each to receive one of the
following treatment combinations:
Group 1) Scotchbond Multi-Purpose and hand
condensation.
Group 2) Scotchbond Multi-Purpose and
mechanical condensation.
Group 3) Syntac and hand condensation.
Group 4) Syntac and mechanical condensation.
Group 5) without bonding agent and hand
condensation (control).
Group 6) without bonding agent and mechanical
condensation (control).
The Adhesives Application. Before dentin
conditioning, the dentin surface was repolished
with 600-grit SiC paper to produce a fresh smear
layer, rinsed and gently air dried. Dentin bonding
agents were used according to the manufacture’s
instructions.
For the Scotchbond Multi-Purpose, the
Scotchbond etchant (35% phosphoric acid) was
applied to enamel and dentin, waiting for 15
seconds, then rinsed for 15 seconds and dried for
2 seconds. Copper bands of different sizes
according to the different diameters of the
specimens were then attached to each specimen
and of 6.0 mm height and coated with vaseline
from the inner sides for easy removal after
amalgam hardening. The copper bands were
tightly fitted to the outer surfaces of the teeth
without any displacement. After that, Scotchbond
Multi-Purpose primer was applied to all etched
surfaces using brush and dried gently for 5
seconds. Scotchbond Multi-Purpose adhesive
was applied as one drop on each primed surface
and light-cured with a visible light-cure unit of
400 MW/Cm 2 for 10 seconds.
High-copper spherical amalgam capsules
were triturated for 5 seconds with a mechanical
amalgamator. The amalgam was carried with an
amalgam carrier and condensed into the mold.
Each specimen received one capsule.
For the Syntac, acid etchant (35% phosphoric
acid) was applied by brush to enamel and dentin,
waiting for 15 seconds, then rinsed for 15 seconds
and dried for seconds.
Syntac “single-component” (primer and
adhesive in one bottle) was applied to all etched
surfaces as first layer and air blown to a thin layer
for 2 seconds and light-cured for 10 seconds. The
copper bands then were attached to the specimens.
A second layer of Syntac then was applied with the
brush and again air blown to a thin layer for 2
seconds and light-cured for 10 seconds. The same
type of amalgam was used and condensed into the
mold.
Amalgam Condensation. The condensation
techniques used were:
1. Hand condensation using a modified single-end
amalgam condenser of 2.5 mm diameter serrated
condensation face. This condenser was sectioned
with diamond cutting disc using high-speed
handpiece with water cooling system and the shaft
was drilled to receive a spring that withstands 3.0
Kg. Pressure load and the other part of the
condenser “i.e. the shank and the condensing tip”
was slided in this hollow within soldered cylinder .
The spring was soldered to the shank so that when
the exact pressure that corresponded to 3.0 Kg. was
exerted, a contact occurred between two
projections; one attached to the shaft and the other
attached to the movable sliding shank and
condensing point. This modification was done to
have a standardized hand condensation pressure
during the condensation of the amalgam. The
condensation was started from the center of the
amalgam mass toward its peripheries. The
condensation frequency after each increment of
amalgam was 8 thrusts for 5 seconds, and the filling
of the amalgam cylinderical mold took 3 minutes.
After that, the amalgam was condensed for 15
seconds with 20 thrusts.
2. Mechanical condensation using mechanical
condenser point that was adapted to an ultra-sound
handpiece that was connected to an ultra-sound
generator of 25000-32000 H z straight-line
oscillations per second. The condensing tip was of
2.5 mm diameter and the condensing pressure was
of 3.0 Kg. Each increment of amalgam was
condensed from its center toward its periphery for 5
seconds, and took 3 minutes to fill the mold with
amalgam. After that, the amalgam was condensed
for 15 seconds. Then, the amalgam were carefully
carved and burnished with amalgam carver and
burnisher. The mechanically-condensed amalgams
were burnished with mechanical burnisher tip.
Restorative Dentistry 34

J Bagh College Dentistry Vol. 21(1), 2009 The effect of amalgam…
Fifteen minutes after condensation, the copper
bands were carefully dislodged and removed.
Samples Testing. After storage in distilled water
at room temperature for 48 hours, the specimens
were tested for tensile bond strengths between
amalgam cylinders and dentin using a Zwick
Universal Testing Machine with a loop attached
to amalgam at cross head speed of 5 mm/minute
until the amalgam separated from the tooth under
the vertical retraction that was exerted on the
bulk of the amalgam cylinders. The failure loads
were in kilogram and transferred into Newtons
by multiplying the value by 9.8 and divided it
into the corresponding interface surface area in
(mm 2 ) to get the tensile bond strengths in Mega
Pascal (Mpa).
RESULTS
Tensile Bond Strength Values. The mean
values and the standard deviations of the tensile
bond strength (TBS) of each group are presented
in table 1. By using the student-test for the
Scotchbond Multi-Purpose group; the SBS mean
value of hand condensation of amalgam was
higher than that of mechanical condensation and
the difference was highly significant (p

J Bagh College Dentistry Vol. 21(1), 2009 The effect of amalgam…
mechanism for such adhesive to amalgam is
micro-mechanical type that depends on the film
thickness of the adhesive. Hand condensation
effect may be more obvious than the mechanical
condensation under these circumstances.
Similarly, for the control groups, there was no
bonding mechanism between the amalgam and
dentin just the micro-mechanical adaptation
enhanced by heavy hand condensation. This
attribution is supported by the classic studies and
recent reports about the hand condensation
effects and the bonding mechanism of recent
dentin bonding agents to amalgam (14).
Sweeney (15) , Jorgensen (16) , and Mjor (17)
contributed to such researches. Some of them
found that the hand condensation performed
better in reducing porosities at amalgam / dentin
interface and it had better adaptability. Others
reported that there were some kinds of
mechanical interlocking between amalgam
particles and dentin irregularities even that the
self-sealing criteria of amalgam was not started
yet .
The Syntac adhesive / primer has 4-META
and HEMA co-monomers that may bond the
amalgam chemically and micro-mechanically.
This “real” bonding may show the obvious effect
of mechanical condensation to enhance the
bonding of amalgam to dentin. This explanation
is supported by the findings of Chapman &
Crim (12) , which had already mentioned.
The Use of Dentin Bonding Agents. For both
types of condensation techniques and under the
conditions of this study, there was highly
significant difference between the different types
of adhesives used on the one hand, and between
the groups with the bonding treatment and that
without bonding treatment (controls) on the
other. These results are in agreement with several
studies. Zardiackas & Stoner (2) , Shimizu et a1 (3) ,
and Varga et a1 (4) showed that the bonding of
amalgam to tooth structure was possible under
laboratory conditions with higher over the
unbonded one .
In addition, numerous clinical studies had
reported favorable results, which were obtained
when using amalgam bonding approach. Those
studies were done by Summitt et a1 (18) , Setcos et
a1 (19) , and Belcher & Stewart (35) . These results
support the finding obtained by this about the
bonding of amalgam to dentin by using dentin
adhesive systems and with higher TBS than that
of the controls.
The differences in the bond strengths different
generations of dentin binding agents have been
shown in various studies.
Under the circumstances of this study, the
Syntac adhesive showed higher TBS to dentin than
the Scotchbond Multi-Purpose. This finding is in
agreement with that of Retief et a1 (14) , although the
TBS values were higher than those of this study.
However, Chappell & Eick (22) and Holtan et a1 (23)
found that the Scotchbond Multi-Purpose had
significantly better bond strength between the
amalgam and dentin than the Syntac and
Scotchbond Multi-Purpose may be due to the
different chemistries of these bonding systems ,
although some similarities do exist. The similarity
found in the pretreatment procedure in using the
same chemical composition etchants 9355
phosphoric acid). The Scotchbond Multi-Purpose
primer contains HEMA and polyalkenoata copolymer
and the adhesive contains BIS-GMA and
HEMA (14) . The Syntac-one bottle-contains 4-
META and HEMA (24) . Examinations with an
electron microscope have shown that the
hydrophilic monomers connect with both organic
dental hard tissue by forming ion complexes with
calcium ions of enamel and dentin and hydrogen
bridges with collagen fibers of dentin (25) . This
complicated connection may be the reason for such
higher TBS values obtained in this study over the
Scotchbond Multi-Purpose.
REFERENCES
1. Fayyad MA, Ball PC. Cavity sealing ability of lathecut,
blend and spherical amalgam alloys: a laboratory
study. Oper Dent 1984; 9: 86-93.
2. Zardiackas LD, Stoner GE. Tensile and shear adhesion
of amalgam to tooth structure using selective
interfacial amalgamation. Biomaterials 1983; 4: 9-13.
3. Shimizu A, Ui T, Kawakami M. Bond strength
between amalgam and tooth hard tissues with
application of fluoride, glass ionomer and adhesive
resin cement in various combinations. Dent Mater
1986; 5: 225-32.
4. Varga J, Matsumura H, Masuhara E. Bonding of
amalgam filling to tooth cavity with adhesive resin.
Dent Mater 1986; 5: 158-64.
5. Staninec M, Holt M. Bonding of amalgam to tooth
structure: tensile adhesion and microleakage tests. J
Prosthet Dent 1988; 59: 397-402.
6. Edgren BN, Denehy GE. Microleakage of amalgam
restorations using Amalgambond and copalite. Am J
Dent 1992; 5: 296-8.
7. Clinical Research Associates: Adhesives: Silver
amalgam. Clinical Research Associates Newsletter.
1994; 18: 2-3 cited by Ratananakin T, Denehy GE,
Vargas MA. Effect of condensation techniques on
amalgam bond strengths to dentin. Oper Dent 1996;
21: 191-5.
8. Philips RW. Dental amalgam alloys: Amalgam
structures and properties and Chapter 18, Dental
amalgam: Technical condensations. In skinner’s
science of Dental Materials, 9 th ed. Philadelphia : W.
B. Saunders Company , P. 303-25 and 327-47, 1991.
9. Craig R G. Restorative Dental Materials. 8 th ed. St.
Louis: C. V. Mosby , P. 214-47, 1990.
Restorative Dentistry 36

J Bagh College Dentistry Vol. 21(1), 2009 The effect of amalgam…
10. Marzouk MA, Simonton AL, Gross RD. Operative
Dentistry, Modern Theory and practice. 1th ed . St.
Louis Ishiyaku Euro America , Inc., P. 105-34,
1985.
11. Ratananakin T, Denty GE, Vargas MA. Effect of
condensation techniques on amalgam bond strengths
to dentin. Oper Dent 1996; 21 (5): 191-5.
12. Chapman KW, Crim GA. Pneumatic versus hand
condensation of amalgam: Effect on microleakage.
Quint Int 1992; 23 (7): 495-8.
13. Sturdevant CM, Roberson TM, Heymann HO,
Sturdevant JR. The art and science of operative
dentistry. 3th ed. St. Louis; C.V. Mosby, p. 219-55,
1995.
14. Scotchbond Multi-Purpose Dental Adhesive System
technical product ptofile. St. Paul. MN. : 3M Dental
products Division. 1992.
15. Sweeney JT. Uncontrolled variables in amalgam,
with significant improvements in the making of
restorations. J Am Dent Assoc 1940; 27: 190.
16. Jorgensen KD. Adaptability of dental amalgams
Acta Odont Scand 1965; 23: 257-70.
17. Mjor IA. Clinical assessments of amalgam
restorations. Oper Dent 1986; 11: 55-62.
18. Summit JB, Burgess JO, Osborne JW, Berry TG,
Robbins JW. Two year evaluation of Amalgambond
plus and pin-retained amalgam restorations (Abstract
383). J Dent Res 1998; 77 (special issue A): 153.
19. Tcos JC, Staninec M, Wilson NHF. Clinical
evaluation of bonded amalgam restorations over two
years. (Abstract 2589). J Dent Res 1998; 77 (special
issue B): 955.
20. Belcher MA, Stewart GP. Two-year clinical evaluation
of an amalgam adhesive. J Am Dent Assoc 1997; 128:
309-14.
21. Retiev DH, Mandras RS, Russell CM. Shear bond
strength required to prevent microleakage at the dentin
/ restoration interface. Am J Dent 1994; 7(1): 43-6.
22. Chappell RP, Eick JD. Shear bond strength and
scanning electron microscopic observation of six
current dental adhesives. Quint Int 1994; 25 (50): 359-
68.
23. Holtan JR, Nystrom GP, Olin PS, Phelps RA, Phillips
JJ, Douglas WH. Bond strength of six dental
adhesives. J Dent 1994; 22(2): 92-6.
24. Syntac Single-Component Dental Adhesive System
technical product profile. Vivadent Ets., Liechtenstein.
1997.
25. Nakabayashi N, Takarada K. Effect of HEMA on
bonding to dentin. Dent Mater 1992; 8: 125-30.
Restorative Dentistry 37

J Bagh College Dentistry Vol. 21(1), 2009 The visible portion of…
The visible portion of upper anterior teeth at rest
Reem A. Al Obaidy, B.D.S., M.Sc. (1)
ABSTRACT
Back ground: Esthetics has become a respectable concept in dentistry. In the past, the importance of esthetics was
discounted in favor of concepts such as function, structure and biology. In today's, treatment planning must begin
with well defined esthetic objectives. The visibility of upper anterior tooth surface with lip at rest is an important factor
in determining prosthodontic outcome. A study was therefore, undertaken to investigate the degree of visibility of
maxillary anterior teeth surfaces when the lip at rest.
Materials and method: 140 patients were examined. The entire subject had maxillary anterior teeth present with no
caries, restorations; sever attrition, mobility, or obvious deformities. The portions of upper anterior teeth that were
visible were measured vertically using millimeter ruler.
Results: females showed more of the maxillary central and lateral incisors than males, while the difference in canine
was not significant. With increasing age, the amount of maxillary anterior teeth that was visible at rest decreased.
Most subjects with shorter upper lips displayed more maxillary anterior teeth than those with longer upper lips.
Conclusion: The degree of visibility of maxillary anterior teeth is determined by muscle position that varies from one
person to another. These results provide practical guidelines for vertical positioning of the maxillary teeth.
Key words: Anterior dental esthetics, tooth visibility, lip line. (J Bagh Coll Dentistry 2009; 21(1):38-40)
INTRODUCTION
The presence of the maxillary anterior teeth
plays an important role to the facial appeal. They
give each face a unique identity, just as eyes,
nose, and skeletal proportions make each face
distinctive (1,2) . The amount of visible upper
anterior teeth, with lip at rest or during function,
is an important esthetic factor in determining the
outcome of fixed and removable prosthodontic
care, implant dentistry, operative dentistry, and
orthognathic surgery (3) .
The mount of visible portions of upper anterior
teeth is influenced by muscle positions that vary
from person to another (4-6) . Lip coverage of the
maxillary anterior teeth at rest showed gender
difference; females displayed more maxillary
incisors than males (7,8) . It has also been reported
the display of upper anterior teeth tends to
decrease with age (9,10) .
In addition, individuals with shorter upper lips
expose more maxillary incisor surface than
people with longer upper lips (11,12) . Patients with
complete denture treatment, the maxillary
occlusion rims are adjusted to have proposed
position of maxillary anterior teeth. Several
guidelines were suggested to establish the lip
length-incisal edge relationship and, accordingly,
the visible portion of anterior teeth (13, 14) . One of
these guidelines was the vertical length of the
maxillary occlusion rim that extends in the
anterior region to approximately 2mm below the
relaxed lip (15,16) . The amount of visibility of
anterior teeth can be one of the helpful guidelines
for determining the appropriate vertical
dimension of occlusion (13) .
(1) Assistant lecturer, Department of Prosthetic, College of
Dentistry, Baghdad University
The number of studies on this desired visibility
of maxillary anterior teeth was non sufficient, so
the purpose of this investigation was to determine
the degree of visibility of maxillary anterior teeth
when the lips at rest.
MATERIALS AND METHODS
One hundred forty adult subjects [62(%44.28)
males and 78(%55.71) females] with ages ranging
from 16-70 years were selected randomly from the
prosthodontic department in Baghdad University
and others from many health centers in Baghdad.
The entire subjects had maxillary anterior teeth
present without caries, restorations, appreciable
attrition, mobility, extrusion, or obvious
deformities. Subjects with lip trauma, facial
surgery, or orthodontic treatment were excluded.
The measurements were taken by using a
millimeters ruler. The portions of anterior teeth
that were visible were measured vertically from the
lip to the incisal edge for the incisors, and to the
cusp tip for the canines, at the midpoint of the
tooth when the lips and lower jaw were at rest
position (Figure 1).
The measurement was considered to be zero if
the tooth could not be seen. Three measurements
for each tooth were taken and then the mean was
calculated. The length of the upper lip was
measured from the base of the columella to the tip
of the philtrum at the midline of the face (Figure
2). All the recorded data were statistically analyzed
by t – test and the results were obtained.
RESULTS
Tables 1 and 2 showed the mean and standard
deviation of these measurement in millimeters
which shown that there is a highly significant
Restorative Dentistry 38

J Bagh College Dentistry Vol. 21(1), 2009 The visible portion of…
differences between readings for both males and
females. The most significant differences in the
visible amounts of the maxillary anterior teeth
with lip at rest were between the genders. The
females displayed more of the maxillary central
and lateral incisors teeth than males (P0.05) (Table 3).
Table 4 showed the descriptive of total
readings and compartment between the amounts
of visible portion of teeth with age groups that
range from 16-70 years. The amount of maxillary
anterior teeth that was visible at rest decreased
(Table 5). For lip line, subjects with shorter
upper lips displayed more maxillary anterior
teeth than subjects with longer upper lips (Table
6).
DISCUSSION
The degree of visibility of maxillary anterior
teeth has been generally overlooked by
restorative dentists as an element of esthetic
assessment. It is a muscle–determined position
that varies from one person to another (2, 5) .
The mean visible amount of maxillary incisors
in males was 1.379 ± 1.405mm and in females
was 2.679 ± 1.802mm. These measurements
come in agreement with Al – Wazzan , Connor
and Moshiri , and Brundo and Vig, with some
extent of differences in measurements may due to
differencey in measuring techniques (2,9) . It was
found in the present study females exposed more
of the maxillary central incisors than males;
contrary to other study by AL – Obaid and
Fayyad who found that there is no statistical
significant difference between males and females
(17) . While for maxillary lateral incisors, the
mount of visible surface of teeth was also more
in females than in males (Table 4), and this
results dose not agree with the results of Al –
Wazzan (2) and Brundo and Vig (9) , who found
that the males significantly displayed more from
the maxillary lateral and canine than the females.
The variations may to some extent be explained
by ethnic differences between the populations
studied.
With the increasing age, the amount of
maxillary anterior teeth exposed when the lips
are at rest decreased from 7mm at age 16 to 0mm
at age 70 (Table 5). It is clear from this study that
the tissue surrounding the mouth sag and similar
finding was reported by Vig and Brundo (9) and
Al – Wazzan (2) . Facial muscle exercises might
help in preventing muscle sagging (5) .
Table 6 shows people with short upper lips
display the maximum maxillary anterior teeth
surfaces, while people with long upper lips
display less maxillary anterior teeth. This is in
agreement with Al–Wazzan (2) and Vig and Brundo
(9) .
In prostheses, the visible amount of anterior
teeth has been neglected in considering esthetics of
complete dentures, that the incisal edges of lower
incisors established by positioning the central
0.5mm vertically and 1-2mm horizontally overlap
to the maxillary centrals (16) . These guidelines do
not necessarily lead to the appropriate amount of
visible tooth structure that is compatible with
patient's age or upper lip length. The results
showed the maxillary central incisors never have
SD greater than the means, while for the lateral
incisors and canines SD may have larger value
than the means. This indicates the maxillary
central incisor is superior to the rest of upper
anterior teeth in regard to the amount of visible
tooth surface.
The results of this study showed the maxillary
central incisors is the most prominent tooth in the
mouth, accordingly, extra care should be taken
when selecting its size, form, and positioning.
REERENCES
1. Wilding RJC. Reconstructing a natural smile with
dentures. Br Dent J 1998; (184): 90-4.
2. Al Wazzan KA. The visible portion of anterior teeth at
rest. J Contemp Dent Pract 2004; Feb; (5)1: 53-62.
3. Jack P. Tooth position in full–mouth implant
restorations – A case report. J Gen Dent 2006; May–
June: 209–13.
4. Lamees AN, Reem AO, Mohammed KB.
Reproducibility of the vertical dimension by different
educational degrees. MDJ 2007; 4(2): 192-8.
5. Ruferacht CR. Fundamentals of esthetic. Chicago, IL:
Quintessence Publ. Co.Inc. 1990; 73.
6. Cho JE, Kim B, Kim K, Cho K, Lee H, Hwang. Lip
line at rest. Am J Orthod Dentofa Orthop 2003; 132:
3: 278. e7-278.e14.
7. William WH. Vertical dimension and its correlation
with lip length and interocclusal distance. J Am Dent
Assoc 1962; April: 64: 496-504.
8. Sarver DM. The importance of incisor positioning in
the esthetic smile: The smile arc. Am J Orthod Dent of
Orthop 2001; 120: 98-111.
9. Vig RG, Gerald C. Brundo. The kinetics of anterior
tooth display. J Prosth Dent 1978 May; 39(5): 502-4.
10. Bjorn U. Zachrisson. Esthetic factors involved in
anterior tooth display and the smile: vertical
dimension. J. Clinical Orthodontics1998; 32 (07): 432-
45.
11. Terry T. Tanaka. Fixed and Removable
prosthodontics, D.D.S. Clinical professor, University
of Sothern California, School of Dentistry, Chula
vista, CA. 2004.
12. Majid Bissasu. Copying maxillary anterior natural
tooth position in complete dentures. J Prosth Dent
1992; 67: 668-9.
13. Zarp GA, Bolender CL, Carlsson GE. Boucher's
prosthodontic treatment for edentulous patients. 11 th
ed. St. Louis, Missouri: Mosby 1997; 191-244.
Restorative Dentistry 39

J Bagh College Dentistry Vol. 21(1), 2009 The visible portion of…
14. Michael S. Reddy. Achieving gingival esthetics J
Am Dent Assoc 2003; 134(3): 295-304.
15. Frank M. Spear, Vincent G. Kokich and David P.
Mathews. Interdisciplinary management of anterior
dental esthetics. J Am Dent Assoc. 2006; 137(2):
160-9.
16. Jeff Morley and Jimmy Eubank. Macro esthetic
elements of smile design. J Am Dent Assoc. 2001;
132(1): 39-45.
17. Mohammed AL. Obaid and Mohammed Fayyad.
Facial margin placement of veneer crowns. Saudi
Dental Journal 1994; 6(SI): 061: 66.
Figure 1: The measurement of the
amount of exposure of the
maxillary central incisors.
Table 1: Descriptive statistics and t- test for
males (mm)
Mean SD SE Min Max
Age 38.24 12.07 1.53 21.0 70.0
Lip line 16.87 2.58 0.337 12.0 32.0
Central length 1.379 1.4 0.18 0.00 6.0
Lateral length 0.653 1.22 0.15 0.00 5.0
Canine 0.145 0.56 0.07 0.00 2.50
Table 2: Descriptive statistics and t- test for
females (mm)
Mean SD SE Min Max
Age 37.40 12.37 1.40 16.0 70.0
Lip line 15.006 2.596 0.294 9.5 22.0
Central length 2.679 1.802 0.204 0.00 7.0
Lateral length 1.397 1.476 0.167 0.00 5.0
Canine 0.333 0.836 0.094 0.00 5.0
Table 3: Mean amounts of visible tooth for
both males and females
t-test P-value Sig
Age 0.41 0.68 NS
Lip line 4.26 0.000 HS
Central length 4.80 0.000 HS
Lateral length 3.27 0.014 S
Canine 1.59 0.11 NS
*P0.05 Non Significant
***P< 0.001 High significant
Figure2:The measurement of the
length of the upper lip.
Table 4: Descriptive statistics and t-test for
both males and females with age (mm).
Male Female
Mean SD Mean SD
Age 38.24 12.07 37.40 12.37
Lip line 16.875 2.578 15.006 2.596
Central length 1.379 1.405 2.679 1.802
Lateral length 0.653 1.22 1.397 1.476
Canine 0.145 0.560 0.333 0.836
Table 5: Age- group readings for each
maxillary tooth (mm)
Age (y) n
Max. cent. Max. lat. Max.
incisors incisors canines
16 – 26 32 0-7 0-5 0-3
27 – 37 38 0-6 0-5 0-2.5
38 – 48 43 0-2 0-3 0-1.5
49 – 59 21 0-4 0-2.5 0-0
60 – 70 6 0-3 0-1.5 0-0
Table 6: Mean amounts of visible tooth
surface by upper lip length (mm)
t-test P-value Sig
Lip line & central length 49.9 0.000 HS
Lip line & lateral length 56.84 0.000 HS
Lip line & canine 64.98 0.000 HS
*P

J Bagh College Dentistry Vol.21(1), 2009 Reliability of fovea …
Reliability of fovea palatinea in determining the posterior
palatal seal
Yasmen T. AL – Alousi, B.D.S, M.Sc. (1)
ABSTRACT
Background: The present study was carried out to study the position of fovea platinae in relation to posterior palatal
seal (post dam) in an Iraqi, population sample, whether in front, at or behind, and gender differentiations.
Material and methods: A clinical examination was carried out on 200 patients with edentulous maxillary arch,
attending prosthetic Department in the College of Dentistry, Baghdad University. Only 110 patients meet the study's
criteria. Each patient was examined for the location of vibrating line whether in front, at or behind the fovea
platinae.
Results: The results showed that 50.9% of patients had their vibrating line at their fovea platinae, 44.5% had it in front
and 6.4% behind. There were highly significant differences between; age groups of patients, gender distribution of
patients, significant differences between; age group and gender of patients, and non significant differences
between gender and position of posterior palatal seal in relation to fovea palatinae.
Conclusion: The study concluded that fovea palatinae is: A reliable anatomical land mark that helps in determining
the posterior palatal seal (post dam). The majority of patients had their vibrating line at their fovea palatinae
Key words: Posterior palatal seal, post dam, fovea platinae, vibrating line. J Bagh Coll Dentistry 2009; 21(1): 41-45)
INTRODUCTION
Determining the location of the posterior
border of the maxillary denture plays an
important role in its retention and patient
comfort.
Since the twenties of last century many
authors have evaluated techniques relating to the
location of the posterior border of the maxillary
denture. One of the easiest and most practical
methods is using the anatomical land marks
(fovea palatinae and hamuler notches). (1)
All authors agreed about the relation
between the vibrating line and the posterior
border of the maxillary denture. (2-4) The vibrating
line of the palate is the junction between the
movable and immovable portion of the soft
palate. (2,3)
To determine the location of the vibrating
line there are the fallowing techniques:
1. Phonation of the "ah" sound. (1,4)
2. The swallowing method. (5,6)
3. The nose blowing method. (4)
Some anatomical structures are significant
guides for locating the posterior border of the
maxillary denture. These guides include the
fovea palatinae which are close to the vibrating
line and are always in soft tissue, making them
useful guides for the location of the dentures
posterior border (3,7) .
The aim of this study is to investigate the
reliability of fovea palatinae for determining the
posterior border of the maxillary denture.
(1) Assistant lecturer, Department of Prosthodontics, College of
Dentistry, Baghdad University
MATERIALS AND METHODS
A clinical examination of the palate of 200
patients with edentulous maxillary arch, randomly
selected from patients at- tendering prosthetic
Department in the College of Dentistry Baghdad
University.
The palate of each patient was examined for
evidence of pathological changes, for the visibility,
number and location of the fovea palatinae, plus
the visibility of the vibrating line. From 200
patients only 110 met the study criteria, 76 male
and 34 female of age groups ranging from (40-85)
years. These patients were asked to open wide and
pronounce "ah" sound repetitively; both the fovea
palatinae and the vibrating line were marked with
an indelible pencil after drying the area with gauze.
Each patient was examined by three seniors
independently. If they agreed to the position of the
vibrating line whether in front, at or behind the
fovea palatinae. They will proceed to the next
patient if not they will repeat the examination until
their results coincide.
Suitable statistical methods were used in order
to analyze and assess the results using a computer
through the SPSS program and Excel application,
descriptive statistics and inferential statistics.
RESULTS
The following tables and figures involved
the results of many parameters investigated to
evaluate patients. These studied parameters
involved in this study will be reviewed and
discussed as follows:
Distribution of age groups (Year) of patients:
(Table and Figure 1)
A total of 110 patients were included in the
present study. Data from table and figure 1
indicated that the number and percentage of
Restorative Dentistry 41

J Bagh College Dentistry Vol.21(1), 2009 Reliability of fovea …
patients with age groups (51-60 and 61-70) years
were higher [44 (40 %) and 31 (28.2 %),
respectively], than other age group (40-50) years
was [19 (17.3 %)], with highly significant
difference (P0.05).
Relationship between test results: (Table and
Figure 7)
Generally, the behind position of post dam
was increased in negative result (103, 93.6%)
while decrease positive (7, 6.4%), with highly
significant difference (P0.05) for both test.
On other hand, the comparison between in front
& at position of post dam was non significant
difference (P>0.05) but highly significant
difference (P

J Bagh College Dentistry Vol.21(1), 2009 Reliability of fovea …
5. He concluded that the fovea platinae are
unreliable guides for locating the center portion
of the posterior border of the maxillary denture,
while in our study the results showed that fovea
palatinae may be considered as reliable
anatomical land mark. This was in agreement
with the results of Lye (9) , Fenn, et al. (8) , Jones
(12)
and Boucher, et al. (3) . The posterior border
can be located with great accuracy if it is possible
to see the two small pits (fovea palatinae) one on
either side of the mid line on the anterior part of
soft palate (8) . Anatomical landmarks that aid in
the determination of the vibrating line are the
fovea platinae. (15) . The fovea platinae are close to
the vibrating line and are always in soft tissue,
which makes them an ideal guide for the location
of the posterior border of the denture (3) .
Table 1: Distribution of age groups (Year)
of patients.
Age groups
Chi-Square ( χ 2 )
N %
(Year)
P-value Sig.
40-50 19 17.3
51-60 44 40
61-70 31 28.2
71-80 14 12.7 0.00 Highly Sig. (P

J Bagh College Dentistry Vol.21(1), 2009 Reliability of fovea …
Table 4: Relationship between gender & in
Positive Negative
front position of post dam.
60
Chi-Square (
in front
χ 2 )
50
Tota
Gender
Positiv Negativ l
P-
40
valu Sig.
e e
e
30
N 34 42 76
Male % 44.7 55.3 100 Non
20
Femal N 15 19 34 Sig.
10
e % 44.1 55.9 100 0.952
(P>0.05
0
N 49 61 110
Total
)
Male Female
N 36 40 76
20
Male % 47.4 52.6 100 Non
0
Femal N 18 16 34 Sig.
Male
e % 52.9 47.1 100 0.776 (P>0.05
N 54 56 110
Sex
)
Total % 49.1 50.9 100
Female
% 44.5 55.5 100
Sex
Figure 5: Relationship between Gender & at
position of post dam.
Positive Negative
60
Table 6: Relationship between Gender &
50
behind position of post dam.
40
Chi-Square (
Behind
30
χ 2 )
Tota
Gender
20
Positiv Negativ l
P-
valu Sig.
10
e e
e
0
N 6 70 76
Male Female
Male % 7.9 92.1 100 Non
Sex
Femal N 1 33 34 0.32 Sig.
e % 2.9 97.1 100 5 (P>0.05
N 7 103 110 )
Figure 4: Relationship between Gender & in Total % 6.4 93.6 100
front position of post dam.
Table 5: Relationship between Gender & at
Positive Negative
position of post dam.
100
Gender
Chi-Square (
At
χ 2 80
)
Tota
Positiv Negativ l
P-
60
valu Sig.
e e
40
e
Percentage % of in front
Percentage % of at
Percentage % of behind
Figure 6: Relationship between Gender &
behind position of post dam.
Restorative Dentistry 44

J Bagh College Dentistry Vol.21(1), 2009 Reliability of fovea …
Table 7: Relationship between test results.
Tests results Friedman test ( χ 2 )
Tests
P-
Positive Negative
value
Sig.
in N 49 61
Non Sig.
0.253
front % 44.5 55.5
(P>0.05)
At
N 56 54
Non Sig.
0.849
% 50.9 49.1
(P>0.05)
N 7 103 Highly Sig.
behind 0.00
% 6.4 93.6 (P0.05)
in front Vs behind 0.00
Highly Sig.
(P

J Bagh College Dentistry Vol.21(1), 2009 Microleakage of Class II….
Microleakage of Class II composite using different etching
techniques
Zainab M. Abdul-Ameer B.D.S., M.Sc. (1)
ABSTRACT
Background: Microleakage in the gingival floor of class II composite restorations can compromise the marginal
adaptation of the filling material to the cavity edges. The aim of this study was to evaluate the effect of different
etching techniques on Microleakage of class II Composite filling.
Materials and methods: Sixty extracted caries-free human premolars were randomly divided into six groups
according to etching technique. In group A and B the dentin of the cavities were etched with 35% phosphoric acid
gel, in group C and D the dentin of the cavities were irradiated using a 320 μm Nd: YAG laser beam, in group E and F
the dentin surfaces were initially treated with the laser and then etched as in group A and B with 35% phosphoric
acid. Proximal class II cavities were prepared in all samples with the gingival floor one millimeter below the CEJ.
Cavities were restored according to research protocol. The samples were subjected to 2500 thermal cycles (5-55oC),
immersed in 0.5% basic fuchsine solution, embedded in epoxy resin and cut centrally. Microleakage was scored and
collected data were statistically analyzed using one way analysis of variance.
Results: More microleakage was detected in group C (p0.05). Using the incremental technique significantly
decreased microleakage (P

J Bagh College Dentistry Vol.21(1), 2009 Microleakage of Class II….
(Gluma, Heraus Kulzer, Germany) on dentin and
light cured for 20 seconds. Tofflemire matrices
(no.1, Universal Matrix System, Tofflemire,
USA) were placed and then packable resin
composite (Solitaire, Heraus Kulzer, Germany)
was inserted. Composite resin was polymerized as
one complete unit in groups A,C, and E, but was
cured in 3 increments in groups B,D, and F. The
first layer was placed on the gingival floor with a
thickness of 0.5 mm. The second and third layers
were obliquely placed on the buccal and lingual
walls, respectively. Each layer was light cured for
80 seconds. The filling material was light-cured
for 80 seconds with a visible light curing unit (3H
light curing unit REGENSSIS 100-240Vac-
50\60HZ15max made by 3H) from an occlusal
direction. All restorations were finished by means
of a finishing carbide bur. The teeth in each group
were placed into separate mesh bags and
subjected to 2500 thermal cycles between 5 and
55oC with a dwell time of 30 seconds in each bath
and a 15-second transfer time between baths. The
external surface of each tooth was coated with
two layers of nail varnish, leaving a 1 mm wide
margin around the restoration free of varnish. All
teeth were immersed in a 0.5% basic fuchsine
solution for 24 hours at 37 o C. This was followed
by cutting the roots and embedding the specimens
in epoxy resin. All samples were sectioned in the
center of the restoration (Figure 1).
Dye penetration was examined with a
stereomicroscope (x6 magnification) and scored
as follows:
0 = no penetration
1= penetration less than half the gingival
floor;
2 = dye penetration extending to the axial
wall;
3 = dye penetration including the axial wall;
4= dye penetration towards the pulp.
One way analysis of variance was used to
compare the mean leakage for the experimental
groups.
Figure 1: Schematic illustration of section.
RESULTS
The mean and standard deviation of
microleakage in each study group is shown in
Table 1 and figure 2. According to the results of
the microleakage evaluation of this study, the
specimens in group C (laser +composite) showed
the most microleakage. While a statistically
significant difference was found between group A
and group C and between group B and group D
(p0.05).
Additionally, there was a statistically significant
difference between group A and group E and
between group B and F (p< 0.05). Sections
showed that using the incremental technique
significantly decreased microleakage (P

J Bagh College Dentistry Vol.21(1), 2009 Microleakage of Class II….
acid etching. However, these systems also have
some disadvantages. The Nd: YAG laser beam
(12)
causes an increase in heat. Cox et al. (13)
studied the effects of pulsed Nd: YAG laser
radiation on enamel and dentin. They observed
melted dentin, crazing on the surface, slight debris
formation, and modification of dentin tubule
structure where the tubule periphery had melted.
The laser irradiation group did not produce a dye
penetration-resistant interface, and the laser group
demonstrated the highest degree of microleakage.
This may be the result of the presence of a fused
layer in which interfibrillar spaces were lacking.
This probably restricted the diffusion of
composite resin into the subsurface of the
intertubular dentin resulting in more leakage.
Ceballo et al. (14) reported similar results using the
Er-YAG laser.
According to stereomicroscope observations,
dye absorption was different in each layer of
composite restorationsThis indicates different
degrees of polymerization and confirms Hellwig’s
theory stating that placing composites in multiple
layers can cause differences in the degree of
polymerization]. (15) Reduced shrinkage may be
due to the small bulk of material in each layer. (15)
In restoration of class II cavities, placing the
spectral output of the curing unit close to the
composite is impossible. Dental tissue or a matrix
band could cause light to become opaque or
shady. In addition illumination of light from
behind a 2mm layer of composite resin can
decrease the amount of transmission. According
to Ruyter and Oysaed (16) , placing the tip of a
curing unit at a 2mm distance from a detector
could cause a 7% decrease in output energy which
could be further reduced to 25% when the
distance is increased to 4mm. When restoring
class II cavities, the marginal ridges and cusps
usually demonstrate a distance of at least 4mm
from the gingival floor. Therefore the exposure
time should be increased in order to achieve
maximum hardness and durability of the filling
material. The recommended distance of a light
source from the composite surface is 1mm.
Various methods and instruments have been
proposed to transmit light to inaccessible areas of
the cavity such as transparent matrix strips, light
conducting wedges, mirror matrix bands and
transparent cones attached to the tip of the curing
unit (17) . However, controlling the exact distance
of the tip of a curing unit would be problematic in
clinical settings. It has been shown that addition
of inserts to composite resins can decrease their
microleakage, which is due to the lower thermal
expansion coefficient of the inserts. (18)
REFERENCES
1. Sazak H, Türkmen C, Günday M. Effects of Nd: YAG
Laser, air-abrasion and acid etching on human enamel
and dentin. Oper Dent 2001; 26: 476-81.
2. Corona SA, Borsatto M, Dibb RG. Microleakage of
Class V resin composite restorations after bur, airabrasion
or Er:YAG laser preparation. Oper Dent 2001;
26: 491-7.
3. Stern RH, Sognnaes RF. Laser effect on dental hard
tissues. A preliminary report. J South Calif Dent Assoc
1965; 33: 17-9.
4. Goldman L, Hornby P, Meyer R. Impact of the laser on
dental caries. Nature 1964; 203: 417.
5. Visuri SR, Gilbert JL, Wright DD. Shear strength of
composite bonded to Er:YAG laser prepared dentin. J
Dent Res 1996; 75: 599-605.
6- Bowen RL, Nemoto K, Rapson JE. Adhesive bonding
of various materials to hard tooth tissues: forces
developing in composite materials during hardening. J
Am Dent Assoc 1983; 106(4): 475-7.
7- Ilie N, Kunzelmann KH, Hickel R. Evaluation of microtensile
bond strengths of composite materials in
comparison to their polymerization shrinkage. Dent
Mater 2006; Jul: 22(7):593-601.
8- Hegdahl T, Gjerdet NR. Contraction stresses of
composite resin filling materials. Acta Odontol Scand
1977; 35(4):191-5.
9- Bausch JR, de Lange K, Davidson CL, Peters A, de Gee
AJ. Clinical significance of polymerization shrinkage of
composite resins. J Prosthet Dent 1982; Jul: 48(1):59-
67.
10. Kytridou V, Gutmann JL, Nunn MH. Adaptation and
sealability of two contemporary obturation techniques
in the absence of the dentinal smear layer. Int Endod J
1999; 32: 464-74.
١١. Moritz A, Schoop U, Goharkhay K. Procedures for
enamel and dentin conditioning: A comparison of
conventional and innovative methods. J Esthet Dent
1998; 10: 84-93.
12. Ariyaratnam MT, Wilson MA, Blinkhorn AS. An
analysis of surface roughness, surface morphology and
composite/dentin bond strength of human dentin
following the application of the Nd:YAG laser. Dent
Mater 1999; 15: 223-8.
13. Cox CJ, Pearson GJ, Palmer G. Preliminary in vitro
investigation of the effects of pulsed Nd:YAG laser
radiation on enamel and dentine. Biomaterials 1994; 15:
1145-51.
14. Ceballo L, Taledano M, Osorio R. Bonding to
Er:YAG-laser-treated dentin. J Dent Res 2002; 81: 119-
22.
15- Hellwig E, Klimek J, Achenbach K. Effects ofan
incremental application technique on the polymerization
of two light-activated composite filling materials. Dtsch
Zahnarztl Z 1991; Apr: 46(4):270-3
16- Ruyter IE, Oysaed H. Conversion in different depths
of ultraviolet and visible light activated composite
materials. Acta Odontol Scand 1982; 40(3):179-92.
17- Yazici AR, Frentzen M, Dayangac B. In vitro analysis
of the effects of acid or laser etching on microleakage
around composite resin restorations. J Dent 2001; Jul:
29(5):355-61.
18- Donly KJ, Wild TW, Bowen RL, Jensen ME. An in
vitro investigation of the effects of glass inserts on the
effective composite resin polymerization shrinkage. J
Dent Res 1989; 68(8): 1234-7.
Restorative Dentistry
48

J Bagh College Dentistry Vol. 21(1), 2009 Distribution and localization of…
Distribution and localization of ground substance of
carbohydrate group in an inflammatory and phenytion
induced gingival enlargement using histochemical method
Athraa Al Hijazi MSc,Ph.D (1)
Saif S. Saliem M.Sc. (2)
Ali A. Abdulkareem M.Sc. (2)
ABSTRACT
Background: Gingival enlargement detected as a result of pathological changes or by induction of drugs such as
Phenytoin. Changes in distribution of macromolecules of glycogen, proteoglycan and glycoprotein in gingival
enlargement were observed by histochemical method. The aim of the study was to illustrate the localization and
distribution of ground substance in an inflammatory and Phenytoin induced gingival enlargement, using
histochemical methods.
Materials and Methods: Twenty two individuals, ten with inflammatory gingival enlargement, other ten with Phenytoin
induced gingival enlargement and two healthy person extraction of impacted 3 rd molar as control .The specimens
were stained with periodic acid Schiff reagent (PAS).
Results: In the inflammatory gingival enlargement there is an increase in carbohydrate material production concern
to epithelial layer, basement membrane and underneath connective tissue showing reddish purple stain with PAS
reaction, while Phenytoin induced gingival enlargement showed increment in epithelial layer only.
Conclusion: Histochemical method by PAS stain used to show difference in distribution of carbohydrate group in
gingival specimens of inflammatory and Phenytoin induced gingival enlargement.
Key words: Gingival enlargement, Phenytoin, PAS stain. (J Bagh Coll Dentistry2009; 21(1): 49-52)
INTRODUCTION
Gingival enlargement is a common feature of
gingival disease and may be caused by fibrous
overgrowth or gingival inflammation or a
combination of two. (1) The types of gingival
enlargement can be classified according to
etiologic factors and pathologic changes as
follow: (2)
1. inflammation enlargement
2. Drug induced enlargement
3. Enlargement associated with systemic
disease
4. Neoplastic enlargement.
Inflammatory enlargement, showed inflamed
gingival, swollen and consequently hemorrhage
due to local factors (bacterial plaque, caries).
Histologically gingiva showed epithelial
hyperplasia with infiltration of inflammatory cells
in lamina propria. (3) Drug induced enlargement as
a consequence of administration of some
anticonvulsant immuno suppressants drugs,
calcium channel blocking agent have been shown
clinically and histologically to produce analogous
gingival enlargement. (4)
(1) Professor, Department of Oral Diagnosis, College of
Dentistry, University of Baghdad.
(2) Assist. Lecturer, Department of Periodontology,
College of Dentistry, University of Baghdad.
Phenytoin is an anticonvulsant drug induced
gingival hyperplasia in 50%-60% of patients with
various levels of inflammation. The degree of
inflammation, fibrosis and cellularity depend on
the duration, dose and identity of the drug, in
addition to individual susceptibility that explain
why the induction of the lesion is not of 100% in
the patients. (5) Phenytoin (sodium epanutin,
Dilantin) suggested to cause gingival over growth,
pronounced in the anterior teeth, histopathological
sections showed an increased in thickness of
epithelium and in sub epithelial region. (6)
All oral tissues, including gingival, are
primarily composed of connective tissue and
epithelial linings and associated glands. They
posses specific histological matrix includes
glycogen, proteoglycan, glycoprotein, mucin,
enzymes. These chemical compositions are
important in the considerations of the biologic
problem, related to oral health. (7)
It is suggested that such intercellular
macromolecular substances may play an
important role in the maintenance of gingival
tissue integrity. (8) Epithelial glycogen is known to
increase during inflammation and repair .While
glycoprotein showed to be decrease in connective
tissues and in basement membrane in cancer
disease. (9) Therefore the study was designed to
illustrate the localization and distribution of
ground substance in Phenytoin induced and
Oral Diagnosis 49

J Bagh College Dentistry Vol. 21(1), 2009 Distribution and localization of…
inflammatory gingival enlargement by
histochemical method.
MATERIALS AND METHODS
Twenty two patients participate in the present
study, included:
1. Ten patients with gingival enlargement of
Phenytoin induced. They were taking drug for
1.5-2 years duration.
2. Ten patients with inflammatory gingival
enlargement. Inflammation was assessed by
plaque score, bleeding score and gingival
depth. (10) Gingival enlargement was assessed
on plaster study models by method described
by Seymour et al 1985 (11)
3. two normal subjects with extraction of
impacted third molar
Histochemical methods
Gingival specimens were taken from all 22
subjects, fixed in 10% buffered formation for 48
hours. Then the periodic acid Schiff (PAS) stain
was used for detection of carbohydrate group. (12)
Procedure
1. Deparaffinize section in Xylene and
hydrate to water.
2. Oxidize in periodic acid for 5 minutes.
3. Rinse in distilled water.
4. Using Schiff’s reagent for 15 minutes.
5. Rinsing in three changes of sulfurous
acid 2 minutes each.
6. Washing in running tap water.
7. Counter stain with Harri's hematoxylin
for 30 seconds.
8. Dehydration of the section in graded
alcohol.
Positive reaction with PAS revealed as reddish
purple dye product.
RESULTS
Histochemical stain revealed that normal
gingival tissue showed faint pink (negative stain)
of PAS. All epithelial layers including basal,
spinosum, granulosum and keratinized layers.
Underneath connective tissue (papillary and
reticular) showed negative stain figure 1.
K
L
P
R
G
C
S
BC
C
Figure 1: normal gingival tissue showing:
epithelial layers, Basal cell (BC) Spinosum
cell (SC), granulosum cell (GC) and
keratinized layer (KL), Connective tissue 2
parts papillary (P), reticular (R), PAS stain
X 10
Figure 2: Gingivectomy specimen of phenytoin
induced gingival enlargement showing long and
thin retepegs, positive PAS reaction in epithelial
layer concerning spinosum layer (arrow) while
underneath connective tissue shows negative stain.
PAS stain X 10
BM
LP
Figure 3: High power view showing
spinosum cell positively react with PAS
stain. No histochemical reaction illustrates in
basement membrane (BM) and in lamina
propria (LP).PAS stain X 20
Figure 4: Spinosum cell stained with PAS (arrow)
PAS stain X 20
Oral Diagnosis 50

J Bagh College Dentistry Vol. 21(1), 2009 Distribution and localization of…
K
S
S
BC
BM
Figure 5: Inflammatory gingival
enlargement showing positive PAS reaction
in keratinized epithelia (K), in granular
layer (G) and in some layer of spinosum(S).
Basement membrane (BM) shows positive
stain too. PAS stain X 10
Figure 6: High magnifying view of inflammatory
gingival enlargement showing negative PAS
reaction in basal cell (BC) and Spinosum Cell (SC)
while basement membrane and Lamina propria
show positive reaction (arrow) PAS stain X 20
BM
LP
Figure 7: Inflammatory gingiva showing positive PAS stain in Basement membrane (BM) and in
Lamina propria (LP). PAS stain X 20
Specimens from gingival of Phenytoin
induced drug showed localization of positive
PAS reaction in spinosum layer while negative
stain showed in basement membrane and in
connective tissue. (Figures 2-4).
Histopathological slides for specimens of
inflammatory gingival stained with PAS showed
deep reddish purple stain in keratinized layer,
granulosum layer and includes some layers of
spinosum, basement membrane shows positive
stain (figures 5,6). Figure 7 showed band of
reddish purple stain in connective tissue
underneath the epithelium.
DISCUSSION
The gingival tissue consist of epithelial cells,
collagenous fibers, connective tissue cells,
intercellular substance (ground substance) which
includes glycogen, glycoprotein, proteoglycan
and mucin. Capillaries, arterioles and venules as
well as lymph vessels and nerves are also
present.
The macromolecular carbohydrate
components in epithelium and connective tissue
of gingival are secreted by epithelial cell and
(13)
fibroblast cells (respectively). The
carbohydrate group includes glycogen,
glycoprotein and proteoglycans detected by
periodic acid Schiff (PAS) method.
Changes in epithelial glycogen showed
during inflammation and repair and even
variation in keratinization may reflect the
glycogen content of tissue (4) . Thus the present
results showed an intense reaction of PAS stain
in area of keratin and granular layer of
inflammatory gingival which related to an
increase of production of glycogen by epithelial
cells basement membrane exhibit high PAS
reaction which may relate to increase in
fibronectin and lamanin (glycoprotein). As
basement membrane separates between the
epithelium and connective tissue, fibronectin
secretes by fibroblast in connective tissue while
lamanin secreted by epithelium cells.
Both proteoglycans and glycoprotein in
connective tissue undergo alteration in various
pathological state, therefore during inflammation
there is an increase in both glycoprotein and
proteoglycan level correlated with pathological
Oral Diagnosis 51

J Bagh College Dentistry Vol. 21(1), 2009 Distribution and localization of…
behavior, induce fibroblast cell to secrete
glycoprotein like fibronectin and proteoglycan,
so the result illustrated the PAS reaction in
basement membrane and in the connective
tissue. (14)
Results for induced Phenytoin gingival
enlargement showed reddish purple stain of
spinosum cell surface. This is contribute to the
ability of histochemical dye (PAS) stain to bind
to epithelium surface which constituents mainly
glycoprotein and glycosamine glycan.
In connective tissues PAS stain showed no
reaction indicated of absences of increment in the
ground substance in which fibroblast is
responsible for synthesis it.
Many studies use PAS method to investigate
clinical signs related to injury and disease.
Qualitative observations were corroborated by
quantitative histochemistry of sections stained
with PAS. In soft tissue injury showing high
glycogen investigated with increased PAS stain
when compared with healthy control. (15) Huang
et al 1993 (16) demonstrated glycogen in tumor
cell by PAS stain. Sexton and white in 1996 (17)
used PAS stain for identification of glycoprotein
in primary Ewings sarcoma. While Lee et al
(18)
2002 used PAS stain to investigate
progression of oral malignant tumor.
REFERENCES
1. Trackman P, Kantarci A. Connective tissue
metabolisum and gingival overgrowth. Crit Rev Oral
Bio Med 2004; 15(3): 165-75.
2. Wright HJ, Chapple LC, Ptair C. Cervicular fluid
level of TGFB1 in drug induced overgrowth. Arch
Oral Biol 2004; 49: 421-5.
3. Pitiphate W, Kerbs A. Gingivitis may increase
protein level in gingival. Periodontol 2006; 86:
1450-8.
4. Nurmennem PK, Pernu HE, Knuuttla LE. Mitotic
activity of keratinocytes in nifedipine and
immunosuppressive medication induced gingival
overgrowth. J Periodontol 2001; 72: 167-73.
5. Lzakovie J, buchner Sa, Lavioe MC. Phenytoin
induce proliferation n human gingival fibroblast. J
Periodontol 2003; 74(11): 1625-33.
6. Hasegawa A, gotah S, Miyatak S. Mechanisum of
human gingival overgrowth by phenytoin. J
Periodontol 2004; 14:10-1.
7. Weinberg jk, Torone WD. Oral tissue chemical
component. Arch Oral Biol 2007; 3(5): 12.
8. Laii RQ. Histopathological study of oral tissue.
Chung Hu Ping li-Hsueh-Tsa-Chih 1993; 22(2): 92-
4.
9. Das SJ, Newman H, Olsen L. Up regulation of
keratinocyte growth factor in gingival overgrowth. J
Periodontol 2003;74:506-11.
10. Carranza FA, Newman mg, Takei HH. Clinical
periodontology. 9 th edition WP Saunders Company
2002 281-95.
11. Seymour RA, Ellis JS, Thomasson JM. The effect of
phenytoin on periodontal health of adult patients. J
Clin Periodontol 1985; 12: 413-9.
12. Zugibe FT. Diagnostic histochemistry. 3 rd edition
C.V.Mosby Company.1979. 277-8.
13. Scroggos M, roggli V, Fraire A. Eosinophilic
intracytoplasmic globules in pulmonary
adenocarcinoma; a histochemical,
immunohistochemical study. Hum Pathol 1989;
20(9):845-9.
14. Morrison C, Prokoryn P, Piquero C. Oral tissue
changes associated with squamous intra epithelial
lesion.
15. Quiroz Rothe E, Novales M. Polysaccharide storage
with back pain. Equine Vet J 2002; 34(2): 171-6.
16. Huang SH, Ko WS, Jen Sc. Intrathoracic
extraskeletal Ewings sarcoma.Chung Hua Hsueh tsa
Chih 1993;51(6):474-8.
17. Sexton C, White W. Primary Ewings sarcoma. Am J
Dermatopathol 1996; 18(6): 601-5.
18. Lee Y, Nagai N, Siar C. Angioarchitecture of
primary oral malignant.J Histochem Cytochem
2002; 50(11): 1555-62.
Oral Diagnosis 52

J Bagh College Dentistry Vol. 21(1), 2009 Oral findings and health …
Oral findings and health status among elderly Iraqi
patients, (aged 65 and above)
Fawaz Al-Aswad Ph.D (1)
ABSTRACT
Background: The study hypothesis was that elderly patients with many concomitant diseases and drugs would have
different oral diseases, thus epidemiological information about their oral health is urgently needed in geriatric dental
care for diagnosis treatment and prevention. The aim was to obtain base line information on the prevalence of oral
problems and disease in elderly Iraqi patients.
Materials & Method: The study group consisted of 83 (43 males and 40 females) elderly patients, they were examined
to evaluate the oral health status.
Results: From 83 patients who verbalized their complaints 72% complained of dry mouth, 42% had burning mouth
syndrome and 48% had oral mucosal lesion. The commonest oral finding was denture stomatitis 30%.
Conclusion: This data suggests that there was considerable unmet dental need with significant oral disease in this
target group.
Key words: Geriatric dentistry,.saliva. BMS (J Bagh Coll Dentistry2009; 21(1):53-56)
INTRODUCTION
Geriatric dentistry is a branch of dentistry
concerned with dental care for aging populations,
the frail elderly need a special care because they
suffer from extensive oral disease, have medical
problems that complicate the oral health, and also
because their age and state of health complicate
their diagnosis and treatment (1) .
In addition older patients are less likely than
younger patients to report symptom complaints,
and often they are completely unware of
pathology that would create dramatic symptoms
in younger patients, in one study of older adults,
more than half of 20 potentially serious medical
systems were never reported to health
professional (2) .
Systemic disease may directly or indirectly
harm the oral cavity by altering saliva, which
play an essential protective role in the mouth (3) ,
or by the side effect of the medication (4) . On the
other hand, a number of significant age related
changes occurred, fortunately most of these
normal aging changes do not cause oral disease
(5,6) , instead it is the cumulative effects of both
oral and systemic disease that account for the
extensive pattern of oral disease among the
elderly (7,8) .
During the last decade several studies were
done to determine the oral conditions of the older
adults (9-13) . Berkey (14) , in a comprehensive
review of oral health studies of elderly published
between 1970 and 1989 described the
compromised oral health status of nursing home
residents.
(1) Lecturer, department of oral diagnosis, college of dentistry,
university of Baghdad.
Up to 70 percent of residents had unmet oral
(decay), poor oral hygiene, periodontal disease
and soft tissue lesion. Another survey conducted
in 1993 on 3479 elderly found that 93 percent of
edentulous had oral problem and 61 percent of
the dentate had oral problem also (15)
Gift (16) , reported that only 15 percent of the
residents of nursing home survey were described
as having excellent or very good oral health,
while other study reported that approximately
one third of community dwelling elderly have
untreated coronal or root caries and other oral
health problems including periodontal disease,
attrition, un replaced missing teeth, abrasion and
erosion. (17) Other reports give evidence that more
than 45.9% of elderly patients had one or more
oral mucosal lesion (18)
Therefore, the present study was conducted
since no extensive studies have been made in
Iraq to obtain information on the oral status
conditions among elderly patients and to
investigate the relationship between the finding
in relation to age and gender.
MATERIALS AND METHODS
The sample
The study sample consisted of 83 patients of
both genders with age range from (65 – 80)
referred to the college of dentistry, university of
Baghdad, from November 2005 to June 2006,
they were examined to detect the oral health
status including the complaining of dry mouth,
Burning mouth syndrome and oral mucosa
lesions.
The following questions have been shown to
help to identify people with, or at risk of
developing salivary gland hypofunction:
Oral diagnosis 53

J Bagh College Dentistry Vol. 21(1), 2009 Oral findings and health …
• Dose the amount of saliva in your mouth
seem to be little, too much or you do not notice
it?
• Do you have any difficulties
swallowing?
• Does your mouth feel dry when eating a
meal?
• Do you slip liquids to aid in swallowing
dry food? (Mahvash – 2003) (19) .
RESULTS
The sample consisted of 83 patients and
there were 43 (51.8%) males and 40 (48.1%)
females. The mean age of the total sample 71.1
years and the mean age for males was 71.1 and
for females 71.5 years. Table 1 shows the age
distribution by gender of the total sample.
Oral complain
Hyposalivation was the main oral symptom
observed in both genders 60(72%), with a
statistically significant different between males
and females, burning sensation observed in 35
(42%) again on application of chi–square. There
was a significant difference when males
compared to females (table 2).
Oral mucosal lesions (O.M.Ls)
Clinical examination revealed that 48% of
total elderly people have (O.M.Ls) the most
common lesions observed was denture stomatitis
also the prevalence of total (O.M.Ls) was higher
for women than men, with a highly significant
difference (table 3). Only 2 cases of candidosis
which was pseudo–membranous type was not
related to the use of a prosthesis.
Three case of herptic infection was detected
on the upper lip, without any recent history of
this infection by other patients of both groups.
Traumatic ulceration was observed in
relation to the poor conditions of denture in 5
cases and 2 cases of actinic chilities were
diagnosed. Proliferative lesions were observed in
2 cases represented by fibrous hyperplasia
(Confirmed by Biopsy) associated to the use of
prosthesis.
Table 1: Age and gender distribution of the
sample
Age
group
Male
N=43
Female
N=40
Total
N=83
n % n % n %
65 – 70 20 46.5 15 37.5 35 42.2
70 – 75 7 16.3 20 50.0 27 32.5
75 – 80 16 37.2 5 12.5 21 25.3
Total 43 100 40 100 83 100
Table 2: Distribution of the sample
according to the oral complain
Hyposalivation
N=60 (72%)
BMS
N=35 (42%)
S *
Male
N=43
Female
N=40
n % n %
37 61.7 23 38.3
11 31.4 24 68.6
* Chi – square=8.086 P= 0.04, P< 005 significant.
** Chi – square=6.556 P< 0.001. Highly significant
Table 3: distribution of the sample
according to the OML
Type of lesion
Male
N=43
Female
N=40
n % n %
Denture stomatitis 11 25.5 14 35.0
Herptic infection 1 2.3 2 5.00
Candidosis 0 0.0 2 5.00
Trumatic ulcer 3 6.9 2 5.00
Actnic cheilites 0 0.0 2 5.00
Leukoplakia 1 2.3 0 0.00
Denture hyperplasia 0 00 2 5.00
Total 16 37.2 24 60.0
H.S **
DISCUSSION
Information on the oral health of elderly
population in a number of countries is available
but, no data is available or published on the
elderly population of Iraq.
Hyposalivation a very common symptom
seems to be related to polyuria and the
involvement of the parenchyma of the major
salivary gland (19) , this study showed that the
hyposalivation is the major complain in elderly,
this may occur due to the fact that older subject
may have a chronic medical conditions or due to
medication, such a result is within the agreement
of the results obtained from other studies. (20-25)
The result showed that 42% of the elderly
patients complain of BMS, however this finding
is higher than that reported by Pajukoski and (26)
and Berydahl (27) they showed the prevalence rate
about 15% and 12.2% respectively. Our
explanation for that is, those elderly people may
ignore their oral health and loss their appetite
Oral diagnosis 54 1

J Bagh College Dentistry Vol. 21(1), 2009 Oral findings and health …
which led to poor diet and malnutrition, another
explanation was that post menopausal hormonal
changes may add to the existing problem. While,
studies carried by Moskona (28) , showed that the
most frequent complaint was pain associated
with wear of denture, other study showed that
dental caries is the most significant problem
facing older patients (29-31) .
The overall prevalence of (O.M.Ls) was
48%, this does not reflect the real prevalence of
(O.M.Ls) among Iraqi elderly due to
unrepresentativeness, however it could be used
as a preliminary indicator to present time, this
finding was slightly higher that reported by (17)
they reported that 45% of elderly have (O.M.Ls).
The main lesion observed was denture
stomititis, while other studies showed that the
varicosities of the tongue and Fordyce granules
were mostly found (32) . This variation in the
results between the present study and the studies
done by others could be explained on the basis of
several factors like: (Environmental factors
affecting the population examined, diet, habit of
using dental services, and lack of objective
diagnostic criteria.)
Our result explained that denture wearing
may contribute in initiation of the lesions or the
denture may alter the host response.
In a logistic regression, there was
considerable unmet dental need with significant
oral disease and poor levels of oral and denture
hygiene in this target group.
REFERENCES
1. Beak JD, Hunt RJ. Oral health status in the United
States: problems of special patients. J Dent Educ
1985; 49 (6):407–25.
2. Gaitz CM, Niederehe G, Wisons NL, eds. Aging
2000. our health care dentistry. Vol. ll. New York:
Springer. Verlag 1985: 37–380.
3. Mandel ID. The role of saliva in maintaining oral
dental statis. J Am Dent 1989; 119: 298–304.
4. Ship JA, Chaves FM. Management of systemic
disease and chronic impairments in older adults: oral
health consideration. Ger Dent 2000; 48(5) 557–8.
5. Baum BJ, Ship. Oral disorder. In beck J, editor.
Geriatrics review syllabus–A core curriculum in
geriatric medicine. New York; American Geriatrics
society 1991; P. 332–6.
6. Beck, JD. Epidemiology of dental diseases in
elderly. Gerodontology 1984; 3: 5–15.
7. Morse DR, Esposito Jv, Schoor Rs, Wolloams FL,
Furst ML. A review of aging of dental components
and retrospective radiographic study of aging of the
dental pulp and dentin normal health. Quintessence
Int 1991; 22: 711.
8. Kochari D, Gedalia I, Anois j. Effect of conditioning
with fluoride and phosphoric acid on enamel
surfaces as evaluated by scanning electron
microscopy and fluoride incorporation. J Dent Res
1975; 4: 304.
9. Holm Pedersen P, Vigild M, Nitschke I, Berley DD.
Dental care for aging populations in Denmark,
Sweden, Norway, United Kingdom and Germany. J
Dent Educ 2005; Sep: 69 (9): 987–97.
10. Doln TA, Tchison AK, Huynh TN. Access to dental
care among older adults in the United States. J Dent
Educ 2005; Sep; 69 (9): 961–74.
11. Bailey R, Gueldner S, Ledikwe J, Smiciklas wright
H. The oral health of older adult an interdisciplinary
mandate. J Gerontol Nurs 2005; Jul: 31 (7):11–7.
12. Locker D, Gibson B. Discrepancies between self–
ratings of and satisfaction with oral health in two
older adult populations. Community Dent Oral
Epidemiol 2005; Aug: 33 (4): 280–8.
13. Shah N. Need for gerodontology education.
Gerodontology 2005; Jun: 22 (2):104–5.
14. Berkey DB, Bery RG, Ethinger RL, Meskin LH.
Research review of oral health status and service use
among institutionalized older adults in the United
States and Canada. Spec care Dentist 1991; 11: 131–
6.
15. Beck JD, Hunt RJ. Oral health status in the United
States, problems of special patients. J Dent Educ
1985; 49 (6): 407–25.
16. Gift Hc, cherry Peppers G, Oldakowski RJ. Oral
health status and related behaviors of nursing home
residents 1995.Gerodentology 1997;14–98 99.
17. Centers for Disease control and prevention, National
center for Health statistics. Third national health and
nutrition examination survey (1988-1994). Available
at
http//www.cdc.gov/nchs/abuntmajor/nhanes/nh3data.htm.
Accessed March 26,
2001.
18. Avcu N, Ozbek M, kurtoglu E, Kansu O, Kansu H.
Oral finding and health status among hospitalized
patients with physical disabilities, aged 60 or above.
Arch Gerontol Geriatr 2005;Jul–Aug: 41 (1): 69–79.
19. Mahvash NAVAZesh. How can oral health care
providers determine if patients have dry mouth. J
Am Dent Assoc 134; 5:613–8.
20. Locker D, Matear D, Stephens M, Jokoris A. Oral
health related quality of life of a population of
medically compromised elderly people. Community
dent health 2002; Jun: 19 (2): 90–7.
21. Chiqppelli F, Bauer J, Speckman S, Prolo P,
Edgoton M, Armenian C, Dickmoyer J, Harper S.
Dental needs of the elderly in the 21st century.
22. Pajukoski H, Meurman JH, Snellman Grohn S,
Keiranen S, Sulkava R. Salivary flow and
composition in elderly patients referred to an acute
care. Oral Surg Oral Med Oral pathol oral Radiol
Endod 1997; Sep: 83 (3): 265–71.
23. Locker D. Xerostomia in older adults; a longitudinal
study. Gerodontology 1995; June: 12 (1) 18–25.
24. Narhi TO. Prevalence of subjective feelings of dry
mouth in the elderly. J Dent Res 1994; Jan: 73 (1):
20–5.
25. Rhodus NL, Brown J. The association of
Xerostomia and inadequate intake in older adults. J
Am Diet Assoc 1990; Dec: 90(12): 1688–92.
26. Pajukoski H, Meurman JH, Halunen p, sulkave R.
Prevalence of subjective dry mouth and burning
mouth in hospitalized elderly patients and out
patients in relation to saliva, medication, and
systemic disease. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2001; 92: 641 - 9
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J Bagh College Dentistry Vol. 21(1), 2009 Oral findings and health …
27. Berydahl M, Bergdahl J. Burning mouth syndrome:
Prevalence and associated factors. J Oral Pathol
Med 1999; Sep: 28(8) 350–4.
28. Moskona D, Kaplan I. Oral health and treatment
needs in non–institutionalized elderly population:
experience of a dental school associated geriatric
clinic. Gerodontology 1995; Dec: 12(12): 95–8.
29. Saunders RHJr, Meyerowitz C. Dental Caries in
older adults. Dent Clin North Am 2005; Apr: 49 (2):
293–308.
30. Anusavice KJ. Dental Caries: Risk assessment and
treatment solutions for an elderly population.
Compend Contin Educ Dent 2002; Oct: 23 (10
Suppl): 10–20.
31. Ra OA, Sequeira P, Peter SR, Jeev A. Oral health
status of the institutionalized elderly in Mangalora,
India. J Dent Res 1999; Ap–Jun; 10 (2) 55-61.
32. Taiyeb ATB, Razak IA, Raga, Latifah RJ, Zain RB.
An eqidemiological survey of oral mucosal lesions
among elderly. Gerodontology 1995; Jul: 12 (1): 37–
40.
Oral diagnosis 356

J Bagh College Dentistry Vol. 21(1), 2009 Evaluation of oral hygiene …
Evaluation of oral hygiene, gingival health and dental
knowledge among 4-12 years old children attending the
dental hospital
Eman K. Chaloob B.D.S., M.Sc (1)
ABSTRACT
Background: The main objective of all Dental Health Program is to prevent and control dental disease, Therefore this
study was conducted to evaluate the Oral Hygiene and Dental Health Knowledge of children that frequently
attended Pedodontic and Preventive Department in the College of Dentistry, University of Baghdad.
Materials and methods: A sample of 102 children participated in this study was examined using plaque, gingival and
calculus indices for three times interval. Information about age and gender were collected and five questions
fabricated by specialist dealing with brushing technique, frequency of brushing, type of tooth paste and which type
of food or snacks that cause dental caries.
Results: Major reduction in the PlI, GI, CalI has been found, the dental health knowledge and behaviors of children
could be changed positively.
Conclusion: Periodic dental visit, with motivation, instruction and continuous removal of plaque could successfully
improve gingival condition. (J Bagh Coll Dentistry 2009; 21(1): 57-59)
INTRODUCTION
Most important barrier that limits access to
oral health care is lack knowledge about the
prevention of oral disease and awareness of their
clinical need (1-3) . The Dental Health Programme
should be focusing on dental services by increase
motivation to seek dental care as we can say that
the prevention is always better than cure (1, 2, 4) .
This study was conducted to evaluate the oral
hygiene, gingival health and dental knowledge of
children that frequently attended the dental
hospital
MATERIALS AND METHODS
This study was consisted of 102 children
(48males, 54 females) with an age range 4-12 year
old participated to evaluate the affect of periodic
dental visit, instruction and motivation on the
dental health knowledge and gingival health of
children in Pedodontic and Preventive
Department, College of Dentistry, University of
Baghdad. The examination was done by the
researcher at three times interval every weak,
sterilized mouth mirrors (No.4) and blind probe
used to avoid any trauma to the gingival. oral
hygiene was assessed using the plaque index (5) ,
while gingival condition was assessed using the
criteria of gingival index (6) , calculus index system
assessed the calculus accumulation (7) , index teeth
of Ramfjord (8) were examined to represent the
whole dentition, the primary teeth examined are
upper right E, upper left A&D then lower left E
and right A&D.
(1) Assistant lecturer, Dept. of preventive and paedodontic
dentistry, college of dentistry, university of Baghdad.
Only fully erupted teeth were scored, if the
index tooth was partially erupted or missing, the
segment would be excluded. The five questions
was designed by specialist in Pedodontic and
Preventive Department to evaluate behavior, and
knowledge of children, these are dealing with
brushing technique, frequency of brushing, type
of toothpaste used, snacks between meals and
which type of food cause dental caries. We had
only one correct answer with degree two for each
correct answer, so the minimum was zero and
maximum was 10 as in the Table 1. All these
examinations were done for the same child every
week for three times interval, while questions
were applied in the first and third week. Scaling,
polishing and calculus removal were performed in
the Department. Data were statistically analyzed
using F – test to determine difference in the mean
PlI, GI and CalI scores among visits. For
questions parametric chi-square used to
identifying the number of children in relation to
degree of answer at level of significance< 0.001.
Pearson's correlation was carried out on individual
subject data, to determine interrelation ships
between the PlI and GI, at each visit.
RESULTS
The total sample consists of 102 children 48
males and 54 females. Table 3 revealed that there
is a reduction in the mean value of plaque,
gingival and calculus indices between visits with
highly significant differences for both males and
females (P

J Bagh College Dentistry Vol. 21(1), 2009 Evaluation of oral hygiene …
in third visit the number is decrease to 14
children. On the other hand 8 children answer
four questions correctly, while 11 children answer
all five questions correctly in the first visit, the
number of children increase to 28, 27 respectively
Table1: Questions designed
Questions
Answers Grade
Q1 Did you brush your teeth?
Yes 2
No
Q2 How many times do you twice
brush your teeth? Three times 2
Q3 Which type of tooth paste you
use?
Q4 Which type of snack you eat
between meals?
Q5 Which type of food cause
dental caries?
Non
fluoridated
fluoridated
sweat
vegetable
Milk sweat
2
2
2
in the third visit. The significance could be seen in
degree 4 and 8 only. Table 5 shows the Pearson's
correlation between the mean PlI score and mean
GI score according to first, second and third visit
for both males and females.
Table2: Distribution of children according to
age and Gender
Males Females Both
Age/ Years No. % No. % No. %
4-6 17 16.6 22 21.5 39 38.3
7-9 10 9.8 10 9.8 20 19.6
10-12 21 20.5 22 21.5 43 42.1
Total 48 47.1 54 52.9 102 100.0
Table3: Plaque index, gingival index, calculus index according to dental visits
Males Females Both
Oral Health Indices Visits Mean ±SD
F-test Mean ±SD
F-test Mean ±SD
F-test
PlI
GI
CalI
1 st 1.296 0.701 1.54 0.683 1.425 0.699
2 nd 8.86*
41.64*
42.77*
0.498 0.761 1.059 0.646 1.030 0.700
3 rd 0.688 0.657 0.444 0.537 0.558 0.606
1 st 0.963 0.537 0.94 0.732 0.951 0.645
2 nd 10.56*
26.39*
35.09*
0.773 0.618 0.65 0.620 0.707 0.619
3 rd 0.419 0.613 0.129 0.339 0.264 0.505
1 st 0.50 0.619 0.444 0.537 0.470 0.575
2 nd 10.48*
20.61*
25.8*
0.313 0.468 0.055 0.231 0.176 0.383
3 rd 0.063 0.245 0.055 0.231 0.058 0.236
*P

J Bagh College Dentistry Vol. 21(1), 2009 Evaluation of oral hygiene …
already predisposed to change (10,11) change in
dental Knowledge and behavior of the children
could be seen in other studies (14-16) . It is generally
agreed that bacterial dental plaque is the most
important predisposing factor of gingival
(5, 12, 13,
inflammation this could be established 17) .Data of the present study recorded strong
positive correlation between the presence of
plaque and gingivitis. Some other studies
recorded weak positive correlation between the
two (18-22) .
Males had a significantly higher GI than
females this could be related to the better oral
cleanliness in females than in males.
REFERENCES
1. Haden NK, Catalanotto FA, Alexander CJ, Bailit H,
Batterll A, Bachanan J, Doaglass CW, Fox ECIII,
Glassman P, Lugo R1, George M, Meyerowitz C,
Scott III EIR, Yaple N, Bresch J., Betts GZ, Luke
GG, Moss M, Sinkford Jc, Weaver RG, Valachovic
RW. Improving the oral health status of all
Americans: Roles and Responsibilities of academic
dental institutions, Association Report, Journal of
Dental Education 2003; 67; (5); 563-83.
2. Bently Jm, Cormier P, Oler J. The Rural dental health
program: The effect of a school–Based, Dental
Health Education Program on children's Utilization
of dental Services. American J Public health 1983;
73; (5): 500-5.
3. Evans CA, Kleinman DV, Maas WR, Slavkin HC,
Wilentz JS, Fogelman M. Oral Health in America: A
Report of the surgeon general, National Institutes of
Health. J Dental Education 2000; 67; 5.
4. Chandra S. Textbook of Preventive Dentistry. /1 st ed,
1999, P.1-3.
5. Silness J, Löe H. Periodontal disease in pregnancy II.
Correlation between oral hygiene and periodontal
condition. Acta Odont Scand 1964; 22: 121-35.
6. Löe H, Silness J. Periodontal disease in pregnancy.
Acta Odont Scand 1963; 21:533-51.
7. Greene JC, Vermillion JR. The simplified oral
hygiene index. J Am Dent Assoc 1964; 68:7-13.
8. Ramfjord SP. Indices for prevalence and incidence of
periodontal disease. J Periodontol 1959; 30: 51-9.
9. Williford JW, Johons C, Muhler JC, StookeyGK.
Report of a study demonstrating improved oral health
through education. J of Dentistry for children 1967.
P183-9.
10 Collier DR, Williams JE. The evaluation of an
education program in preventive periodotics. Dent
Assoc 1968; 48: 92-103.
11. Rayner JF, Cohen LK. School dental health education
In; Richards ND, Cohen LK(eds) social sciences and
dentistry aclinical bibliography. Sixth ed. The Hague,
1971 P. 286.
12. AL-Sayyab M. Oral health status among 15-years-old
school children in central region of Iraq. (Thesis);
1989.
13. AL- Obaidi W Gingival health status among 3-5years–
old children in AL- Edwania village, Baghdad, Iraq
Dent J 2005; 17(2): 84-6.
14. Addy M, Edmunds S. Effectiveness of Methods of
teaching dental health to 9 to 10 years old school
children in the United Kingdom. Community Dent
Oral Epidemiol 1977; 5:191-4.
15. Howat AP, Craft M, Croucher R, Rock WP, Foster
TD. Dental Health Education: a school visits program
for dental students. Community Dental Health
1984;2: 23-32.
16. Hodge H, Buchanan M, Jones J, O'Donnell P. The
evaluation of the infant dental health education
program developed in sefton. Community Dental
Health 1985; 2:175-85.
17. Lavsted S, Modeer T, Welander E. Plaque and
gingivitis in a group of Swedish school children with
special reference to toothbrushing habits. Acta
odontol Scand 1982; 40: 307-11.
18. EL-Samarri SKh. Relations between Dental plaque,
Gingivitis and Dental caries Among children
Attending clinic of prevention, Collage of Dentistry,
Baghdad, Iraq. Dent J 1992. Accepted for
publication.
19. Massler M, Schour I. Relation of malnutrition.
Endemic dental fluorsis and oral hygiene to the
prevalence and severity of gingivitis. J Periodontol
1951; 22:205.
20. Hoover DR, Robinson HB. Effect of automatic and
hand tooth brushing on gingivitis. JADA 1961;
65:361.
21. Curson I, Manson JD. A study of a group of dental
students including their diet and dental health. Br
Dent J 1965;119:197, 22.
22 .Alexander AG. The effect of lack of function of teeth
on gingival health, plaque and calculus accumulation
J. Periodontol.1970; 41:438.
Oral diagnosis 59

J Bagh College Dentistry Vol. 21(1), 2009 Serum and salivary levels…
Serum and salivary levels of proinflammatory cytokines as
potential biomarkers in the diagnosis of oral squamous cell
carcinoma
Nazar G. Al Talabani B.D.S,Ph.D (1) .
Shanaz M. Gaphor B.D.S., M.Sc, Ph.D (2) .
Abdul-Wahab R. Hamad B.Sc., M.Sc., Ph.D (3) .
ABSTRACT
Background: Oral squamous cell carcinoma is one of the prevalent cancers of the body . If not treated at its early
stages, the prognosis will be poor. Early diagnosis of oral cancer may not be easy clinically because of its
resemblance to a number of benign lesions in the mouth. The aim of the study was to evaluate the validity of
measurement of some proinflammatory cytokines levels in serum and saliva as biomarkers for early detection of oral
cancer.
Materials and methods: The levels of Interleukins IL-1α, IIL-6, IL-8 and Granulocyte Macrophage-Colony Stimulating
Factor (GM-CSF) in the serum and saliva of (30) patients with OSCC and (20) healthy (control) individuals were
measured by enzyme linked immunosorbent assay (ELISA).
Results: Higher concentrations of serum IL-6 and IL-8 levels were observed in patients with OSCC than the control
group (P

J Bagh College Dentistry Vol. 21(1), 2009 Serum and salivary levels…
serum and saliva of patients with oral squamous
cell carcinoma and healthy individuals to
investigate their validity as informative and useful
biomarkers in the early diagnosis of OSCC.
MATERIALS AND METHODS
Patients:
Thirty patients suffering from lesions that
were diagnosed clinically and histologically as
oral squamous cell carcinoma (OSCC) and twenty
healthy individuals (control group) were included
in the present investigation. Their age ranged
between 22-84 years (16 males and 14 females).
In twenty three patients, the lesions were newly
diagnosed untreated primary tumors, whereas 7
cases represented recurrent lesions after previous
surgical therapy. The malignant lesions in all
patients were in TNM stage I status. Twenty
clinically healthy persons were employed as
control (10 males and 10 females); their age
ranged between 13-63 years. Patients and control
individuals were evaluated by full medical history
to exclude any existing systemic conditions that
may affect the results.
Fluid Collection and Preparation:
Blood and saliva samples were collected from
both patients and control group in the following
methods:
Blood:
Ten milliliters of venous blood were
aspirated from antecubital vein from each
individual using plastic syringe and 21 gauge
stainless steel needles. The blood sample was
collected into plain polyethylene tube until blood
clot formation; the clot was separated from the
wall of the tube using a wooden applicator stick.
The serum was separated by centrifugation at
3000 rpm for 10 minutes and then transferred
immediately into another tube and divided into 5
equal parts and frozen at (-20°C) for subsequent
analysis.
Saliva:
Five to six milliliters of unstimulated
(resting) whole saliva were collected two minutes
after the patients had rinsed his mouth several
times with tap water. The accumulated saliva in
the floor of the mouth was drawn by a plastic
disposable pipette and collected into a plastic
polyethylene tube of 10 mls capacity. The
collection period was 20 minutes and sampling
time was always between 10 am -1 pm. The
collected saliva was centrifuged at 3000 rpm for
10 minutes; this was done within one hour after
collection to eliminate debris and cellular matter.
The centrifuged supernatants were divided into 5
equal parts and samples were stored frozen at (-20
˚C) in polyethylene tubes until assayed.
Immunological Assay:
Determination of Serum and Salivary Interleukin
levels:
Enzyme linked Immunosorbent Assay (ELISA)
kits for specific cytokines were used (Immuntech,
a beckman company, Marseille, France) according
to the manufacturer's protocol.
Statistical Analysis:
Data were calculated and included into a
computerized data base structure. Statistical
analyses were done by using SPSS (Statistical
Package for Social Sciences). Frequency
distribution for selected variables was done first.
The non-normally distributed variables were
described by median and interquartile range
instead of mean ±SD. The difference in median
range between the two groups was assessed by
Mann-Whitney tests. Receiver Operating
Characteristic (ROC) curve analysis was applied
to discriminate diseased cases from normal cases
and to compare the diagnostic performance of two
or more laboratory or diagnostic tests. ROC is a
graph that plots the true positive rate in function
of the false positive rate at different cut-off points.
RESULTS
Assessment of Interleukins Level:
Increased levels of serum IL-6 and IL-8 were
detected in patients with oral squamous cell
carcinoma. As shown in Table (1), highly
significant difference (p

J Bagh College Dentistry Vol. 21(1), 2009 Serum and salivary levels…
Cut-Off values for salivary and serum
Interleukins :
1. Interleukin-1α :
As shown in figure 1, the area under ROC
curve for serum IL-1α was not significantly
different (0.64) from 0.5 value of an equivocal
test, while the area under ROC curve for salivary
IL-1α was significantly higher(0.82) from 0.5
value of an equivocal test(

J Bagh College Dentistry Vol. 21(1), 2009 Serum and salivary levels…
in the diagnosis of OSCC. Moreover, significant
increase in the concentrations of serum and
salivary IL-6 and IL-8 among OSCC patients
when compared with that of control group may
also help in the same aspect.
Elevated serum IL-6 level in OSCC patients
was in accordance with other studies [4,9-12] . This
finding is also in agreement with the finding of
other investigators, who reported significant
increase in the level of serum IL-6 in patients with
other forms of cancers like ovarian cancer, renal
cell carcinoma, colorectal cancer, esophageal
squamous cell carcinoma, and cervical cancer [
2,6,14,19]
.
In this study, the area under ROC curve for
serum IL-6 (0.8) of patients with OSCC was
higher than the determined of an equivocal test of
0.5 with optimum cut-off value that can be used
for diagnosis purpose of highest accuracy
(positive test ≥ 7.5pg/ml) yields a specificity of
90% and a sensitivity of 63.3%, indicated that
serum IL-6 serve as useful biomarker in the
diagnosis of OSCC than salivary IL-6 since the
area under ROC for salivary IL-6 (0.73) was
higher than the determined of an equivocal test of
0.5 with optimum cut-off value of highest
accuracy (positive test ≥ 26.3 pg/ml) yields a
specificity of 100% and a sensitivity of 60%.
Elevated serum IL-8 in OSCC patients was
in accordance with the results of Chen and
coworkers 1999 [4] , who demonstrated a significant
increase of IL-8 level in serum of patients with
OSCC. This finding is in agreement with finding
of other investigators, who demonstrated a
significant increase in serum IL-8 in patients with
colorectal cancer [14] , hepatocellular carcinoma
[15] , metastatic melanoma [16] , cervical cancer [6]
and endometrial cancer [5] . IL-8 was also detected
in tumor specimens and primary cell cultures
from patients with HNSCC [3,7,8 20,22] .
IL-8 level was detected at higher
concentrations in saliva of patients with OSCC
than control group. This finding supported the
findings reported by John, et al., 2004 [12] .
In this study, detection of IL-8 in saliva and
serum holds great potential for OSCC diagnosis
as the area under ROC curve for both serum and
salivary IL-8 was (0.9) which is higher than the
determined of an equivocal test of 0.5 with
optimum cut-off value of highest accuracy(≥ 45
pg/ml) yields a specificity of 100% and a
sensitivity of 66.7% for serum IL-8 and optimum
cut-off value of highest accuracy (≥867.5pg/ml)
yields a specificity of 100% and a sensitivity of
70% for salivary IL-8. These findings were in
agreement with previous studies
[4,12] . These
variations in serum cytokine concentrations
observed among individual patients with OSCC,
indicates that serum levels of cytokines may also
depend in part upon individual host inflammatory
responses within the tumor, and biologically
active cytokines contribute to altered immune
status in OSCC patients [21] .
Salivary cytokines concentration increase in
patients with OSCC because these cytokines play
a role in the initiation of local inflammation and
activation of lymphocyte responses ; therefore it
can not be considered as specific markers since
the oral cavity may be a site for several
inflammatory conditions such as periodentitis
particularly in elderly.
The use of the fluid phase of saliva for
detection of tumor markers has unique advantages
over the use of exfoliated cells. Depending on the
location of the tumor, one may not be able to
easily access and swab the tumor bed. Although
salivary biomarkers could not identify the site
from which the tumor originated, they could at
least identify patients at risk. The ability to
analyze saliva would therefore be beneficial in the
diagnosis of OSCC although the use of saliva has
been criticized as a diagnostic medium since
informative analyses are generally present in
lower amounts than in serum [12,21] . However,
saliva based test could be a cost-effective
adjunctive tool in the diagnosis of patients with
OSCC may have contribution in early diagnosis
and management.
REFERENCES
1- Bhatti N, Downer MC, Bulman JS. Public Knowledge
and attitudes on oral cancer: a pilot investigation. J Inst
Health Educ 1995; 32:112-7.
2-Blay JY, Rossi JF, Wijdenes J,et al. Role of interleukin-
6 in the paraneoplastic inflammatory syndrome
associated with renal cell carcinoma. Int J Cancer 1997;
72: 424-30.
3-Chen Z, Colon I, Ortiz N, et al. Effects of interleukin-1
alpha, interleukin-1 receptor antagonist, and
neutralizing antibody on proinflammatory cytokine
expression by human squamous cell carcinoma lines.
Cancer Res 1998; 58: 3668-76.
4-Chen Z, Malhotra PS, Thomas GR, et al. Expression of
Proinflammatory and Proangiogenic Cytokines in
Patients with Head and Neck Cancer. Clinical Cancer
Research 1999; 5: 1369-79.
5-Chopra V, Dinh TV, Hannigan EV. Serum levels of
interleukins, growth factors and angiogenin in patients
with endometrial cancer. J Cancer Res Clin Oncol.
1997; 123: 167-72.
6-Chopra V, Dinh TV, Hannigan E.V. Circulating serum
levels of cytokines and angiogenic factors in patients
with cervical cancer. Cancer Invest 1998; 16: 152-9.
7-Cohen RF, Contrino J, Spiro JD, et al. Interleukin-8
exoression by head and neck squamous cell carcinoma.
Arch Otolarygol Head Neck Surg 1995; 121: 202-9.
8-Eisma RJ, Spiro JD, Kreutzer DL. Role of angiogenic
factors: Coexpression of interleukin-8 and vascular
Oral Diagnosis 63

J Bagh College Dentistry Vol. 21(1), 2009 Serum and salivary levels…
endothelial growth factor in patients with head and neck
squamous carcinoma. Laryngoscope 1999; 109: 687-93.
9-Gallo O, Gori AM, Attanasio M,et al. Interleukin-6 and
acute phase proteins in head and neck cancer. Eur Arch
Otorhinolaryngol 1995; 252: 159-62.
10-Gleich LL, Biddinger PW, Duperier FD, Gluckman JL.
Tumor angiogenesis as a prognostic indicator in T2-T4
oral cavity squamous cell carcinoma: a clinicalpathological
correlation. Head Neck 1997; 19: 276-80.
11-Jablonska E, Piotrowski L, Grabowska Z. Serum
Levels of IL-IB, IL-6, TNF-a, STNF-RI and CRP in
patients with oral cavity cancer. Patho and Onco Res
1997; 3: 126-9.
12-John MAR, Yang L, Zhou X, Denny P, Ho CM.
Interleukin 6 and Interleukin 8 as potential biomakers
for oral cavity and oropharyngeal squamous cell
carcinoma. Arch Otolaryngol Head Neck Surg 2004;
130: 929-35.
13-Mann EA, Spiro JD, Chen LL, Kreutzer DL. Cytokine
expression by head and neck squamous cell carcinoma.
Am J Surg 1992; 164: 567-73.
14-Oka M, Yamamoto K, Takahashi M, et al. Relationship
between serum levels of interleukin 6, various disease
parameters, and malnutrition in patients with
esophageal squamous cell carcinoma. Cancer Res 1996;
56: 2776-80.
15-Sakamoto K, Masuda T, Mita S, et al. Interleukin-8 is
constitutively and commonly produced by various
human carcinoma cell lines. Int J Clin Lab Res 1992;
22: 216-9.
16-Scheibenbogen C, Mohler T, Haefele J, et al. Serum
interleukin-8 (IL-8) is elevated in patients with
metastatic melanoma and correlates with tumor load.
Melanoma Res 1995; 5: 179-81.
17-Silverman S Jr. Demographics and occurrence of oral
and pharyngeal cancers. The outcomes, the trends, the
challenge. J Am Dent Ass 2001; 132: 75-115.
18-Swango PA. Cancer of the Oral Cavity and Pharynx in
the United States: An epidemiologic overview. J Public
Health Dent 1996; 56: 309-18.
19-Ueda T, Shimada E, Urakawa T. serum levels of
cytokines in patients with colorectal cancer: possible
involvement of interleukin-6 and interleukin-8 in
hematogenous metastasis. J Gastroenterol 1994; 29:
423-9.
20-Watanabe H, Iwase M, Ohashi M, Nagumo M. Role of
interleukin-8 secreted from human oral squamous cell
carcinoma cell lines. Oral Oncol 2002; 38: 670-9.
21-Woods KV, Naggar AEI, Clayman GL, Grimm EA.
Variable expression of cytokines in human head and
neck squamous cell carcinoma cell lines and consistent
expression on surgical specimens. Cancer Res 1998; 58:
3132-41.
22-Yamamura M, Modlin R, Ohmen J, Moy R. Local
expression of anti-inflammatory cytokines in cancer. J
Clin Investig 1993; 91: 1005-10.
Table 1: Level of interleukins ( in pg/ml) in serum
among OSCC patients and control group.
Interleukins
(Oral
Controls
Cancer)
(n=20)
(n=30)
P
Serum IL-1α
[NS]
concentration
Range (0 - 5) (0 - 137.5)
Median 1.3 3.8
Interquartile
range
(0 - 5) (0 - 12.5)
Serum IL- 6
concentration

J Bagh College Dentistry Vol. 21(1), 2009 Serum and salivary levels…
Table 2: Level of interleukins in saliva
among OSCC patients and control group.
(Oral
Controls
Interleukins
Cancer) P
(n=20)
(n=30)
Salivary IL-1α
concentration
Range
(187.5 - (175 -
675) 1000)
Median 225 968.8
Interquartile
range
(187.5 -
497.9)
(389.4 -
1000)
Salivary IL-6
concentration
Range (10 - 25)
(2.5 -
722.5)
Median 15 39.4
Interquartile
range
Salivary IL-8
concentration
(10.6 - 20)
(12.1 -
312.5)
Range (300 - 785)
(515 -
2000)
Median 550 1495
Interquartile
range
(300 -
676.3)
(701.7 -
2000)
Salivary GM-CSF
concentration
Range (0 - 0) (0 - 195)
Median 0 0
Interquartile
range
1.00
.90
.80
ROC Curve
(0 - 0) (0 - 43.1)

J Bagh College Dentistry Vol. 21(1), 2009 Assessment of Magnesium …
Assessment of Magnesium and Calcium status in oral
cancer patients
Seta A.Sarkis M.Sc. (1)
Suad AL-Ani M.Sc. (2)
Marwan Al-Nimr Ph.D (3)
ABSTRACT
Background: The aim was to determine whether Mg and Ca ions could serve as tumor markers.
Materials and methods: A total sample of 53 individuals was studied that includes 33 patients with oral cancer and 20
well-matching control. Estimation of Mg and Ca levels in the lymphocytes of healthy individuals and patients, in the
normal and diseased tissues of patients were performed using atomic absorption spectrophotometer.
Results: The values of both elements in the lymphocytes of patients were exchangeable according to the
histopathological diagnosis. They were generally elevated in comparison to the control. (Ca = (3.983±3.214mean
±SD), Mg = (2.598±2.364 mean ±SD). Decrease levels of either elements in the diseased tissues observed in
comparison to normal tissues in both sexes but it was more obvious in females than males (P

J Bagh College Dentistry Vol. 21(1), 2009 Assessment of Magnesium …
(sartorious 2432, maximum 200g), then digested
by 4ml conc. Nitric acid and heated without
boiling until the volume was reduced to about one
drop lastly 4ml HNO 3 (1%) was added.
Estimation of Mg and Ca was performed by direct
aspiration of the prepared samples using (Perkin –
Elmer 4000) atomic absorption
spectrophotometer.
Students (t) test and correlation test were used
for statistical analysis, results were considered
significant when P

J Bagh College Dentistry Vol. 21(1), 2009 Assessment of Magnesium …
immune disturbance could be the cause of these
results may be considered true but further
explorations are needed to confirm this
hypothesis.
Table 1: The histopathological presentation of the patients.
Histopathological diagnosis
Frequency
Male Female Total
Squamous all carcinoma (well, moderately
, poorly differentiated, invasive and verrucous)
11 13 24
Rhabdomyosarcoma 01 02 03
Adenocarcinoma 00 02 02
Malignant melanoma 02 00 02
Fibrosarcoma 00 01 01
Mucoepidermoid carcinoma 00 01 01
Total 14 19 33
Table 2: Ca and Mg status in lymphocytes (mg/mm 3 ) of patients
Male No. Female No. Total No. Normal No.
Ca 1.755±0.780 7 5.282±3.401 12 3.983±3.214 19 2.6±1.4 18
Mg 2.206±2.975 8 3.035±1.952 12 2.598±2.364 20 2.01±0.21 18
The results are expressed in (mg/mm 3 ) as mean – SD of number of cases
Table 3: Ca and Mg status in healthy and diseased tissues of both males and females.
The element Sex Healthy tissue Diseased tissue No.
Ca
Male 0.584±0.526 0.369±0.282 11
Female 1.796±2.969 0.628±1.228 15
Mg
Male 0.228±0.283 0.145±0.120 11
Female 0.854±1.577 0.247±0.599 15
The results are expressed in (mg/mg) as (Mean–SD) of number of cases
Table 4. The relationship between lymphocytes (µg/mm 3 ) and tissue (µg/mg) Mg in patients with
oral cancer.
Sex r t p df N
Male 0.1689 0.5141 o.620 9 11
Healthy vs diseased tissue
Female 0.721 3.759 0.002* 13 15
Male 0.806 2.361 0.099 3 5
Lymphocytes vs healthy tissue Female -0.0625 0.165 0.873 7 9
Male -0.601 1.304 0.283 3 5
Lymphocytes vs diseased tissue Female -0.114 0.305 0.769 7 9
Table 5: The relationship between lymphocytes (mg/mm3) and tissue (mg/mg) Ca in patients with
oral cancer
Sex R t p df N
Male 0.2334 0.720 o.490 9 11
Healthy vs diseased tissue
Female 0.749 4.685 0.001* 13 15
Male 0.3534 0.654 0.560 3 5
Lymphocytes vs healthy tissue Female 0.5441 1.715 0.130 7 9
Male -0.422 0.806 0.479 3 5
Lymphocytes vs diseased tissue Female 0.521 1.617 0.150 7 9
REFERENCES
1. Aikawa JK. Magnesium: Its biologic significance
CRC press, Boca Raton F, FL. 1981.
2. Shils ME. Experimental human magnesium depletion.
Medicine 1969; 48: 61.
3. Gullestad L, Nes M, Ronneberg R. Magnesium status
in healthy free living elderly.
J Am Coll Nutr 1994; 13: 45 -50.
4. Tietz A, Burtis AC, Ashwood ER. Trace elements.
Textbook of clinical chemistry. 4 th addition. A division
of hart court base and Company. Philadelphia London.
1994; 1137–62.
Oral diagnosis
68

J Bagh College Dentistry Vol. 21(1), 2009 Assessment of Magnesium …
5. Seeling MS. Magnesium in oncogensis and in anticancer
treatment, interaction with minerals and
vitamins. Cancer treatment research foundation 2001;
15: 238– 318.
6. Yoneda T, Nishikawa N, Nishimora P, Koto A,
Sakuda M. Three cases of oral sequamous cancer
associated with leukocytosis, hypercalcemia, or both.
Oral Surg Oral Med Oral Pathol 1989; 68:604–11.
7. Tsao SW, Burman JF, Caster RL. Hypercalcemia and
in vitro osteolysis associated with xenografts of
squamous carcinomas of the tongue. J Cancer 1983;
48: 103-7.
8. Vyas RK, Gupta AP, Aeron AK. Serum copper, zinc,
magnesim and calcium levels in various human
diseases. Indian J Med Res 1982; August: 301–4.
9. Capel ID, Pinnork MH, Williams DC, Haham IWF.
The serum levels of some trace and bulk elements in
cancer patients. Oncology 1982; 39: 38-41.
10. Promoo C, Promvait N, Keminds S, Lerdverasiri KP,
Srianjata SJ Serum trace element in chronic viral
hepatitits and hepatocellular carcinoma in Thailand.
Gastro Enterol 1994; 29: 610-5.
11. Leung PL, Lixl. Multielement analysis in serum of
thyroid cancer patient before and after a surgical
operation. Biol Trace Elem Res 1996; 51:259-66.
12. Fedoscew GB, Emelianov AV, Neskoromayi AF,
Sinitsina TM, Emanuel VL. Role of magnesium and
calcium ions in the pathogenesis of bronchial asthma.
Klin Med Mosk 1994; 72: 47-51.
13. Duester PA, Trostmana UH, Berrier LL, Dolev E.
Indirect versus direct measurement of magnesium and
zinc in erythrocytes. Clin 1987; 33: 529–32.
14. Fontino M, Merson EJ, Allen FH. Micromethod for
rapid separation of lymphocytes from peripheral
blood. Ann Clin Lab Sci 1971; 1: 131–3.
15. Scully C. The immunology of cancer of the read and
neck with particular reference to oral cancer. Oral
Surg 1982; 53: 157-68.
16. Wolf GT, Kerney SE, Chretien PB. Improvement of
impaired leukocyte migration inhibition by thymocin
in patients with head and neck squamous carcinoma.
Am J Surg 1980; 140: 531-7.
Oral diagnosis
69

J Bagh College Dentistry Vol. 21(1), 2009 The role of lipid peroxidation …
The role of lipid peroxidation in the inducation and
progression of chronic periodontitis.
Taghreed F. Zaidan B.D.S.,M.Sc., Ph.D. (1)
ABSTRACT
Backgrounds: Free-radical-induced lipid peroxidation has been implicated in the pathogenesis of several
pathological disorders. This study was aimed to assess the degree of oxidative stress in patients with chronic
periodontitis by estimation of plasma and saliva lipid peroxidation product malondialdehyde (MDA), and the
antioxidants erythrocyte glutathione (GSH), plasma and saliva thiol.
Patients and methods: Fifty patients with chronic periodontitis with mean age of 32.6 ± 10.3 years and fifty healthy
control subjects with normal gingival age study, 5 mls of blood and 3 mls of unstimulated saliva was collected from
each subjects for estimation of plasma and saliva MDA, thiol and erythrocyte glutathione spectrophotometricaly.
Results: The results showed that significantly increased p

J Bagh College Dentistry Vol. 21(1), 2009 The role of lipid peroxidation …
Saliva: Three mls of unstimulated (resting)
whole saliva from each subjects was collected
over ice and samples were centrifuged and frozen
at -20 o C until analysis.
Determination of plasma and saliva MDA:
Lipid peroxidation end products, particularly
malondialdehyde (MDA) react with thiobarbituric
acid under acidic conditions and heating to give a
pink color that measured spectrophotometricaly at
532 nm. The procedure is according to Shah and
Walker. (10)
Determination of plasma and saliva thiol:
5.5'- dithios (2-nitrobenzoic acid) (DTNB) is
a disulfide chromogen that is readily reduced by
sulfhydryl compounds to an intensely yellow
compound. The absorbance of the reduced
chromogen is measured spectrophotometricaly at
420 nm. and is directly proportional to the (SH)
concentration. The procedure is according to
Ellman.
Estimation of erythrocyte glutathione
erythrocyte (GSH):
The method for determining GSH is based on
the development of a yellow color when 5.5'
dithiobis (2 nitro benzoic acid) (DTNB) is added
to sulphydryl compound. The reaction is
measured spectrophotometrically at 412 nm
according to Beutler etal (9)
Statistical analysis:
Statistical package for the social sciences
(SPSS) was used; mean and standard deviation
(S.D.) of each parameters were calculated. The
independent sample T-test program was used to
get the significance level (p-value) for all the
parameters tested. A p-value less than 0.05 are
considered significant, less than 0.001 is highly
significant, and more than 0.05 is non-significant.
RESULTS
1. Age and gender.
Fifty patients with chronic periodontitis, their
age range was (20-60) years with mean age of
32.6 ± 10.3, they were 30 females and 20 males,
and fifty healthy control subjects of age range
(22-60) years with mean age 34 ± 10.5, they were
27 females and 23 males.
2. Plasma and saliva MDA.
Plasma and saliva MDA was found to be
significantly higher p

J Bagh College Dentistry Vol. 21(1), 2009 The role of lipid peroxidation …
DISCUSSION
Diseases of the periodontal tissues are among
the most wide spread inflammatory disorders
world wide and are a major cause of tooth loss in
the adult population. (12) In this study the level of
MDA in plasma and saliva were found to be
significantly higher in patients with periodontitis
than in healthy subjects. In periodontal disease,
polymorph nuclear leukocytes are the initial and
predominant defense cells produced during the
host response to bacterial pathogens. (13) Several
reports have demonstrated the ability of
periodontopathogens and their products to induce
the generation of reactive oxygen species (ROS)
by polymorphonuclear leucocytes.
Polymorphonuclear leukocytes are recognized as
a particulary rich source of ROS, which in the
absence of suitable antioxidants in the crevicular
space can lead to tissue damage. (14)
Free radical-induced tissue injury has been
demonstrated to be increased in individuals with
periodontitis. Enhanced lipid peroxidation was
repoted in the periodontal tissues of cats with
gingivitis. (15) Elevated lipid peroxidation and
disturbed antioxidant status has been reported in
experimental periodontitis. (16) Blawant (17) found
a significantly elevated levels of MDA in saliva of
periodontitis patients. As compared to controls
p

J Bagh College Dentistry Vol. 21(1), 2009 The role of lipid peroxidation …
chemilumines cent assay for measuring the total
antioxidant capacity of serum, saliva and crevicular
fluid. Anmn Clin Bioch 1997; 34: 412-21.
17. Blawant R. Salivary lipid peroxidation product
malondialdehyde in periodontal disease. The internal
Journal of Laboratory Medicine 2007; 2:2.
18. Kuppusamy P, Shanmugam M, Cinnamanoor RR.
Lipid peroxidation and antioxidant status in patients
with periodontitis. Cellular and Molecular Biology
letters 2005; 10: 255-64.
19. Tsai CC, Chey HS, Chem SL HO, Ya Wu YM, Hung
CC.Llipid peroxidation: a possible role in the
induction and progression of chronic periodontitis. J
Periodontal Res 2005; 40(5): 378-84.
20. Chapple ILC, Brock G, Estiniadi C, Mathews JB.
Flutathione in gingival crevicular fluid and it's
relation to local antioxidant capacity in periodontal
health and disease. Mol Pathol 2002; 55: 367-73.
21. Mashayekhi F, Agha-hosseini F, Rezaie A, Razmani
MJ. Alteration of Cyclic Nucleotides levels and
oxidative stress in saliva of human subjects with
periodontitis. J Contemp Dent Pract 2005; 6(4): 46-
53.
Oral diagnosis
73

J Bagh College Dentistry Vol. 21(1), 2009 Clinical observation of …
Clinical observation of recurrent aphthous stomatitis in
Sulaimania
Shanaz M. Gaphor B.D.S, M.Sc., PhD (1)
Shokhan A. Hussien B.D.S (1)
ABSTRACT
Background: Recurrent aphthous stomatitis is the most common recurring oral ulcerative condition in many parts of
the world, characterized by painful oral ulcerations recurring with varying frequency the aim of this Study: To: record
the distribution of aphthous ulcers in Sulaimani, find the clinical features and effect of local factors and medical
disorder on occurance of aphthous ulceration.
Patients and Methods: This prospective study was performed on 80 patients and seen in period from January 2008 to
August 2008. Complete medical history and full history of present illness was obtained, physical examination and
laboratory investigations were carried out to asses patients condition.
Results: In this study 80 patients were examined, 53 of them 66.25 % were females, 27 patients 33.75 % were males. 56
patients (70 %) had minor aphthous ulceration, 22 patients (27.5 %) had major aphthous ulceration, and 2 patients
(2.5 %) had herpetiform ulceration. In our sample the most common etiological factor of RAU was stress and anxiety
which constitute (45 %) followed by hematological deficiency and hormonal causes in which each of them
constitute (16.25 %), Behcet's disease (12.5 %), gastrointestinal diseases (10 %).
Conclusions: From this study the researcher concludes that: Recurrent aphthous ulcer is more common in females
than males. Minor aphthous ulceration is more common than major aphthous ulceration and herpetiform ulcer is a
very rare form of aphthous ulceration and is also seen in older age group. Minor aphthous ulcers occurs only in nonkeratinized
mucosa the most common site is lower lip, but major and herpetiform ulcers occur anywhere in oral
cavity including keratinized and non-keratinized mucosa.
Key words: RAU, clinical presentation. (J Bagh Coll Dentistry 2009; 21(1): 74-79)
INTRODUCTION
Recurrent aphthous stomatitis is an ulcerative
condition that affects the oral mucosa without
evidence of an underlying medical disorder, or
may be associated with other systemic diseases .
(1,2) . Recurrent aphthous ulceration is
characterized by the appearance of round, shallow
ulceration surrounded by inflammation. (3,4).
Emotional and physical stress have been
implicated in the pathogenesis, certain foods,
including coffee, potatoes, cheese, nuts, and
gluten-containing foods have also been
implicated. (5) . Deficiencies in iron, folate, and
vitamin B12 have been noted in relation to these
ulcers. (1,6) .
Recurrent aphthous stomatitis has been noted
in patients with systemic diseases such as
inflammatory bowel disease, Crohn's disease,
HIV. (1,7) . Behcet's disease is another systemic
disease in which recurrent aphthous ulcers are the
most frequent manifestation ulcers are found in
95-100 % of the patients. (8,9) .
The condition ranges in severity from minor
recurrent aphthous stomatitis; it is characterized
by self-limited ulcerations, to a very debilitating
form, and is called major recurrent aphthous
stomatitis.
(1) College of dentistry, University of Sulaimania.
A third and much less common form of the
condition is herpetiform aphthous ulceration. (1).
The present study was designed to: 1-Record
the distribution of recurrent aphthous ulceration in
Sulaimani.2-Find out the clinical presentation and
etiology of aphthous ulceration.
PATIENTS AND METHODS
This prospective study was performed on 80
patients and lasted for eight months period from
January to August 2008. The patients were
collected from Oral medicine Department
(College of Dentistry/University of Sulaimani),
Dermatology Department of Consultant Clinic,
Maxillofacial Department of Teaching Hospital,
Dermatology Department of Ali kamal Health
Center, and Piramerd Dental Community.
Patients' age ranged between (10-60) years,
(53 females and 27 males).A complete medical
history including serious injuries or illness,
history of previous hospitalization, pregnancies,
allergy to food or drugs, present medication, also
patients were asked about alcohol, smoking,
history of systemic diseases was obtained from
each patient to ensure that if the ulcers were a
manifestation of other systemic disorder, or it is
the only complaint of the patient.
Full history of present illness including time
of onset of ulceration, recurrence, factors related
to recurrence, presence or absence of similar ulcer
Oral Diagnosis 74

J Bagh College Dentistry Vol. 21(1), 2009 Clinical observation of …
in the body, relieving and precipitating factors
was also obtained.
The diagnosis was supported by the clinical
findings, duration of lesions, symptoms and
presence or absence of systemic diseases and also
presence or absence of similar lesions in other
parts of the body. Laboratory investigations were
carried out included Hematological examinations:
CBC, Hb g/dl, PCV %, W.B.C (differential
count), Serum iron level and total iron binding
capacity (T.I.B.C). Pathergy Test was done for
those patients that had ulcers with frequent
recurrence and increased severity, to confirm or
exclude Behcet's disease, or possibility of
developing this syndrome. This test was included
subcutaneous pricking in the forearm, and waiting
until 24 hours, after 24 hours patients with
behcet's syndrome mostly develop pustules.
RESULTS
Table 1 shows that the majority of patients
(26.25 %) were in 31-40 years, only 9 patients
(11.25 %) were below 20 years. Tables 2 and 3
show that majority of patients had minor aphthous
ulceration which constituted 70 % and minority of
patients had herpetiform ulceration which
constituted 2.5 %., minor aphthous ulceration
were found in all age groups, while major
aphthous ulcer and herpetiform ulceration were
not seen in 10-20 years age group.
Table 1: Distribution of all 80 patients with
RAU according to age and gender.
Gender
(10-
20)
(21-
30)
(31-
40)
(41-
50)
(51-
60) Total
years years Years years years
Female 7 7 13 13 13
53
(66.25
%)
Male 2 9 8 4 4
27
(33.75
%)
Total 9 16 21 17 17
80
(100
%)
The majority of the minor aphthous ulcers
24.8 % were seen in the lower lip (figure 1),
followed by the tip of tongue and lateral side of
tongue (23.52 %, 21.13 %) respectively as shown
in figure (2), followed by buccal mucosa and
upper lip 11.8 %, 10.5 % respectively figure (3).
Minority of them (3.5%) were located in
mucobuccal fold areas. In the 80 patients
examined in this study, 22 patients 27.5 % had
major aphthous ulceration. In all of them the total
number of major ulcers was 34 ulcers. Every site
of the oral cavity might be involved, including
non-keratinized and keratinized mucosa of
dorsum of tongue and palate (Figure 4), but the
lower lip 26.5 % seemed to represent the most
common site of involvement (figure 5), followed
by lateral side and dorsal surface of tongue (23.5
%, 20.6 %) respectively (figure 6).
Minority of major aphthous ulcers were seen
in the tip of tongue, upper lip, and floor of mouth
in which each of them constitute 2.9%. Figure 7
shows major aphthous ulcer on the upper lip.
Table 2: Distribution of aphthous ulcers in
all 80 patients according to type and gender.
Gender Minor Major
ulcer ulcer Herpetiform Total
Female 41 12
53
(66.25 %)
Male 15 10 2
27
(33.75 %)
Total 56 22 2
80
(100 %)
Table 3: Distribution of aphthous ulcers in
all 80 patients according to type and age
Age Minor Major
Herpetiform
groups ulcer ulcer
Total
(10-20) 9
9
(11.25
%)
(21-30) 7 8 1
16
(20 %)
(31-40) 16 5
21
(26.25
%)
(41-50) 14 3
17
(21.25
%)
(51-60) 10 6 1
17
(21.25
%)
Total
56
(70
%)
22
(27.5
%)
2
(2.5 %)
80
(100 %)
Oral Diagnosis 75

J Bagh College Dentistry Vol. 21(1), 2009 Clinical observation of …
Figure 1: 32 years old male, with 4 minor
aphthous ulcers in the lower lip
Figure 2: 27 years old female, had minor
aphthous ulcer on lateral side of tongue
Figure 3: 17-years old male with minor
aphthous ulcer on the upper lip
Figure 4: 42-years old female with major
aphthous ulcer on the palate
Figure 5: 25-years old female with major
aphthous ulcer on the lower lip
Figure 6: 32 years old female, had major
aphthous ulcer on lateral side of tongue
Figure 7: 25 years old female with major
aphthous ulcer on the upper lip
In all 80 patients that were examined, only 2
patients had herpetiform ulceration, the total
number of herpetiform ulcers were 4 ulcers. The
herpetiform ulcers were only found in males, and
distribution of herpetiform ulcers were seen in
involved sites equally. Herpetiform ulcers might
be found anywhere in the oral cavity including
keratinized and non-keratinized mucosa figure
(8).
Figure 8: 56-years old male had herpetiform
ulcer on the dorsal surface of tongue.
Possible etiological factors of RAUs according to
age and gender:
According to etiology, 36 patients 45 % had
RAU due to stress and otherwise healthy
systemically, 13 patients 16.25 % had RAU due to
hematological deficiency (iron deficiency
anemia), 13 cases of female patients 16.25 % had
RAU due to hormonal changes during menstrual
cycle, 10 cases 12.5 % had RAU as a
Oral Diagnosis 76

J Bagh College Dentistry Vol. 21(1), 2009 Clinical observation of …
manifestation of Behcet's disease, 8 cases 10 %
had RAU as a manifestation of gastrointestinal
problem (gastric ulcer & chron's disease) as seen
in tables (4 and 5).
Patients with positive pathergy test:
Among the 70 patients with recurrent
aphthous ulceration. Pathergy test for early
diagnosis of future development of Behcet's
disease was done for 10 patients 14.3 % that
were have RAU for long time and (3-4) episodes
of ulceration within 12 months period. Only 4 of
them 40 % had positive pathergy test, 3 females
and 1 male as seen in table 6.
Table 4: Distribution of recurrent aphthous ulcers in all 80 patients according to etiology and
gender
Gender Behcet's Disease Stress Hematological G.I.T Hormonal Total
Female 3 20 11 6 13 53 (66.25%)
Male 7 16 2 2
27
(33.75%)
Total 10 (12.5%)
36 13 8 13 80
(45%) (16.25 %) (10%) (16.25 %) (100%)
Table 5: Distribution of recurrent aphthous ulcers in all 80 patients according to etiology and
age
Age (years) Stress Hematological G.I.T Behcet's disease Hormonal Total
(10-20) 4 1 4 9 (11.25%)
(21-30) 8 2 1 3 2
16
(20%)
(31-40) 9 3 1 1 7
21
(26.25%)
(41-50) 5 4 5 3
17
(21.25%)
(51-60) 10 3 1 3
17
(21.25%)
Total
36 13 8 10 13 80
(45 %) (16.25 %) (10 %) (12.5 %) (16.25 %) (100 %)
Table 6: Distribution of patients with positive pathergy test
Gender (10-20) (21-30) (31-40) (41-50) (51-60)
years years years years years Total
Female 1 1 1 3 (75 %)
Male 1 1 (25 %)
Total 1 1 1 1
4
(100 %)
DISCUSSION
In this study eighty patients were examined,
53 patients 66.25 % were females and 27 patients
33.75 % were males. The most affected age group
26.25 % was between age 31-40 years, and only 9
patients were below 20 years 12.8 %, this is
compatible with other studies that were done in
London, and USA in which recurrent aphthous
ulcers were more common among females (1,3,10).
This study is also compatible with other studies
which were done in London and Middle East
Countries in which recurrent aphthous ulcers
started in childhood and seen in all ages especially
adults. (1,10,11).
Among 80 patients that were examined, 56
patients 70 % had minor aphthous ulceration, 22
patients 27.5 % had major aphthous ulceration,
and 2 patient 2.5 % had herpetiform ulceration.
This is compatible with studies which were done
in America, Turkey, and Middle East Countries
which stated that minor aphthous ulceration is the
most common type of RAS, major aphthous
ulceration is less common than minor aphthous
ulcer, herpetiform ulceration is a rare form of
RAS and mostly occurs in men.
(1,3,12) , but
incompatible with other studies that were done in
other countries which stated that herpetiform
ulcers mainly found in females. (3,13) .
The present study showed that age group
10-20 years contains 9 patients all of them 100 %
had minor aphthous ulceration, and no major and
herpetiform ulcers were found in this age group,
this study is compatible with other studies that
Oral Diagnosis 77

J Bagh College Dentistry Vol. 21(1), 2009 Clinical observation of …
were made in Israel, Turkey and Iran in which
minor aphthous ulcers mostly occur in childhood,
adolescence and young adults, major aphthous
ulcers may begin soon puberty, and herpetiform
ulcer is appear in late stage of age. (1,3.11.13).
In eighty patients with RAU examined,
fifty six patients 70 % had minor ulceration, the
total number of all minor ulcers were 85 ulcers.
The majority of the minor aphthous ulcers
were seen in the lower lip which contained 21
ulcers which constituted 24.8 % followed by tip of
tongue which contained 20 ulcers which
constituted 23.52 %, followed by 18 ulcers 21.18
% were seen in the lateral border of tongue, 10
ulcers 11.8% were seen in the buccal mucosa, 9
ulcers 10.5 % were seen in the upper lip, 4 ulcers
4.7 % were seen in the ventral surface of tongue,
3 ulcers 3.5 % were located in the mucobuccal
fold area. This is in agreement with other studies
which were done previously in Middle East
Countries, and USA which stated that minor
aphthous ulcers were found in non-keratinized
mobile mucosa of the oral cavity. (1,3,12,14).
In the present study, eighty patients with
recurrent aphthous ulceration were examined, in
the eighty patients 22 patients (27.5 %) had major
aphthous ulceration, and the total number of
major aphthous ulcers was 34 ulcers. The most
common site of major aphthous ulcer was lower
lip which contained 9 ulcers which constituted
26.5 %, followed by 8 ulcers which constituted
23.5 % were seen in the lateral border of tongue, 7
ulcers which constituted 20.6 % were seen in the
dorsal surface of tongue, ulcers in the buccal
mucosa were 5 ulcers which constituted 14.8 %, 2
ulcers which constituted 5.9 % were seen in
palate, 1 ulcer which constituted 2.9 % was found
in the upper lip, 1 ulcer 2.9 % was located in the
floor of mouth, 1 ulcer was seen in the tip of
tongue which constituted 2.9 %. This is in
agreement with other studies that were done in
Middle East Countries, and USA in which the
major aphthous ulcers are found in any area of the
oral cavity including the non-keratinized and
keratinized area of the dorsal surface of tongue
and palate in males and females without
difference. (1,3,13) .
From eighty patients with recurrent
aphthous ulceration, two patient had herpetiform
ulceration, he had four ulcers: one ulcer which
constituted 25 % in the mucobuccal fold area, one
ulcer which constituted 25 % was seen on the
lower lip, one ulcer which constituted 25 % was
seen on the lateral surface of tongue, and one
ulcer which constituted 25 % were seen in the
dorsal surface of tongue. This is compatible with
other studies that were done previously in Iran,
Kuwait, and USA in which herpetiform ulceration
was the rare one and found in keratinized and
non-keratinized mucosa in the oral cavity. (1,3,13) .
According to etiology they were classified
in to five groups. First group contains 36 patients
constituted 45 % their oral ulceration was
associated with stress, those patients mentioned
that during stress and anxiety their oral ulceration
became worse. This is compatible with other
studies that were done in USA, Turkey and Iran in
which stress and anxiety were the most common
etiology of RAS. (1,11,15)
Second group contains 13 patients 16.24 %,
after laboratory investigation the researcher found
that they had hematological deficiencies (iron
deficiency, low PCV count and low hemoglobin
count), because one of the manifestation of iron
deficiency anemia include recurrent oral
ulceration. This is in agreement with studies that
were done in Middle East Countries in which
nearly 20% of patients with RAS had hematinic
deficiency. (16,17).
Third group contains 13 female patients
16.24 % in whom the aphthous ulceration is
associated with different stages of menstrual cycle
due to hormonal changes during stages of
menstrual cycle, and cessation of ulceration occur
during pregnancy. (1,10,11,13).
Forth group contains 10 patients 1.25 %
with Behcet's disease, because one of the
manifestations of Behcet's disease is recurrent oral
aphthous ulceration, and all of the three types
(minor, major, and herpetiform) ulceration are
found. This is compatible with other studies that
were done in North America and Turkey in which
Behcet's disease is one of the systemic diseases
that will cause recurrent aphthous ulceration.
(8,9,18,19).
Fifth group contains 8 patients constituted
10 % with gastrointestinal diseases (celiac
disease, Crohn's disease, and peptic ulcers). Five
patients of them had celiac disease, two patients
of them had peptic ulcer, and one patient of them
had Crohn's disease. Patients with peptic ulcers
have aphthous ulceration, because of histological
similarities between peptic ulcers and RAS and
the identified role of helicobacter pylori in peptic
ulcer, the possibility of bacterial involvement in
the progression of aphthae has been suggested.
This is compatible with other studies that were
done in London, USA, and Turkey in which one
cause of RAS is gastrointestinal disorders. (12,20,21).
In this study ten patients from seventy
patients with recurrent aphthous ulceration who
had 3-4 or more episodes of RAS in 12 months
duration and ulcers were very sever and painful
with suspected Behcet's disease, pathergy test
Oral Diagnosis 78

J Bagh College Dentistry Vol. 21(1), 2009 Clinical observation of …
were done for them, 4 patients 40 % of them had
positive pathergy test. This is compatible with
other studies in that were done in Turkey, Iran,
Jordanian, Iraq which stated that patients that had
three or more episodes of oral ulceration in a year
duration may have positive pathergy test, at same
time patients with no Behcet's disease may have
negative result of pathergy test, or normal
individuals may have false positive pathergy test,
so for diagnosis of Behcet's disease (8,9)
20.Aydemir S, Tekin NS, Aktun E, et al. Celiac disease in
patients having recurrent aphthous stomatitis. Turk J
Gastroenterol 2004; Sep: 15(3):192-5.
21.Robinson NA, Porter SR. Ann Acad Med Singapore
2004; July: 33(4 suppl): 43-7.
REFERENCES
1. Rogers RS 3 rd . Recurrent aphthous stomatitis: clinical
characteristics and associated systemic disorders. Semin
Cutan Med Surg 1997 Dec; 16(4):278-283.
2.Bornstein MM, Suter VG, Stauffer E, Buser D. The
CO2 Laser in Stomatology: part 2. Schweiz Monatsschr
Zahnmed. 2003; 113(7):766-85.
3. Scully C. Clinical practice. Aphthous ulceration. N Engl
J Med 2006; Jul: 13: 355(2): 165-72.
4. Greenberg MS, Pinto A. Recurrent apthous ulcerative
disease: presentation and management. Australian
Dental J 2007; 52(1).
5. Petersen MJ, Baughman RA. Recurrent aphthous
stomatitis: primary care management. Nurse Pract 1996;
May: 21(5):36-40, 42, and 47.
6.Schneider LC, Schneider AE. Diagnosis of oral ulcers.
Mt Sinai J Med 1998; Oct-Nov; 65 (5-6):383-7.
7.MacPhail L. Topical and systemic therapy for recurrent
aphthous stomatitis. Semin Cutan Med Surg 1997; Dec;
16(4):301-7.
8.Kontogiannis V, Powell RJ. Behcrt’s disease. Postgrand
Med J 2000; 76:629-37.
9.Lee LA. Behcrt’s disease. Semin Cutan Med Surg 2001;
20:53-7.
10.Porter S, Scully C. Aphthous ulcers (recurrent). Clin
Evid 2004; 12: 360-1.
11.Ship JA, Chavez EM, Doerr PA, et al. Recurrent
aphthous stomatitis. Quintessence Int 2000; Feb:
31(2):95-112.
12.Porter SR, Hegarty A, Kaliakatsou F, Hodgson TA,
Scully C. Recurrent Aphthous Stomatitis. Clin Dermatol
2000; Sept-Oct:18(5):569.
13.Scully C, Gorsky M, Lozada-Nur F. The diagnosis and
management of recurrent aphthous stomatitis: a
consensus approach. J Am Dent Assoc 2003; 134:200-
7.
14.Porter SR, Scully C, Pedersen A. Recurrent aphthous
stomatitis. Crit Rev Oral Biol Med 1998; 9(3):306-21.
15.Soto Araya M, Rojas Alcayaga G, Esguep A.
Association between psychological disorders and
presence of Recurrent Aphthous Stomatitis. Med Oral
2004; Jan-Feb: 9(1):1-7.
16.Piskin S, Sayan C, Durukan N, Senol M. Serum iron,
ferritin, folic acid, & Vitamin B12 levels in recurrent
aphthous stomatitis. J Eur Acad Dermatol Venereol
2002; 16:66-7.
17.Akintoye SO, Greenberg MS. Recurrent Aphthous
Stomatitis. Dent Clin North Am 2005; Jan: 49(1):31-47.
18.Serdarorlu P. Behcet’s disease and the nervous system.
J Neurol 1998; 245:197-205.
19.Eguia A, Villarroel M, Echebarria MA, Aguirre JM.
Med Oral Pathol Oral Cir Bucal 2006; Jan: 11(1):E6-11.
Oral Diagnosis 79

J Bagh College Dentistry Vol. 21(1), 2009 Prevalence of dentine….
Prevalence of dentine hypersensitivity in different age
groups
Abdul-Karim A. A. Al- Muhammadawi , B.D.S, M. Sc. (1)
ABSTRACT
Background: Hypersensitivity of teeth is a common condition. It indicates that enamel or cementum is not present on
teeth cervical area and that dentine is exposed, therefore; it will be sensitive to stimuli like tactile, thermal, .etc.
Materials & Methods: Hypersensitivity was recorded as present or absent on probing the surfaces of teeth in 500 subjects
attending Oral diagnosis clinic, College of Dentistry, University of Baghdad. The subjects were examined for Tooth / root
exposure, Oral hygiene status, and cervical abrasions.
Results: Seventy five patients of 500 (15%) showed hypersensitive teeth and a total of 330 teeth were found to be
sensitive. Hypersensitivity was observed in 16 years of age and more, with highest incidence between 26-35 years. The
intraoral distribution showed that half hypersensitive teeth are the upper and lower premolars. The lower molars were the
less affected teeth.
Conclusion: The most affected intraoral areas on the vestibular surfaces of teeth, most frequently affected teeth are 1 st
premolars. Correlation with other factors like root exposure and cervical abrasion suggests the occurrence of
hypersensitive teeth and to be enhanced by improper oral hygiene habits.
Key words: Dentine hypersensitivity, hypersensitive teeth, abrasion (J Bagh Coll Dentistry 2009; 21(1): 80-83)
INTRODUCTION
Hypersensitivity of teeth is a common condition
with an estimated prevalence of 15-30 % ( 1-3) . It
indicates that enamel or cementum is not present on
teeth cervical area and that dentine is exposed,
therefore; it will be sensitive to stimuli like tactile,
thermal, .etc. (4, 5) . Hirsefeld carried out a clinical
study on tooth brush trauma which discussed the
connection of tooth brush to lesions of gingival
margin, recession, cervical abrasion and
hypersensitivity (6) .
Graf and Galasse stated that 51 patients of 351
(14.5%) showed hypersensitive teeth and he
suggests that incorrect tooth brushing factors
enhance the occurrence of hypersensitive teeth (7) .
Another study done by Addy had shown that
gingival recession which is due to faulty tooth
brushing and presence of plaque are factors in the
etiology of hypersensitive teeth, however his results
showed that brushing is relevant with distribution of
hypersensitive teeth but plaque is not a factor in
pain initiation. He showed also that sensitivity
scores were greater in upper canines and premolars
with an increase in mean findings for left compared
with right contra- lateral teeth (8) .
Moreover, Wichgers and Emert showed nearly
20% of adults have dentine hypersensitive and
problem become even more common as people
retain their teeth longer and more dental surfaces
exposed (9, 10) .
(1) Assistant lecturer, Department of Periodontics, College of
Dentistry, University of Baghdad
A positive relationship between root exposure
and cervical abrasion was founded and the exposed
roots in middle age group showed more abrasion
areas and were more frequently in patients with
better oral hygiene (11-13) .
No epidemiological data could be found in the
literatures about the prevalence and intraoral
distribution of hypersensitive teeth in Iraqi people.
The purpose of the study was to fill this gap of
knowledge and find correlation with factors that
may be associated with hypersensitivity.
MATERIALS AND METHODS
Hypersensitivity was recorded as present or
absent on probing the surfaces of teeth in 500
subjects attending Oral diagnosis clinic, College of
Dentistry, University of Baghdad. The subjects
were examined for:
1- Tooth and/ or root exposure as to be more
than 1mm according to Kitchen (14) .
2- Oral hygiene status assessed according to
Sangners and Gjermo (15) .
3- Cervical abrasions were recorded according
to Bergestrom and Laustedt (1) .
The distribution of subjects and number of teeth
present are shown in Table 1 according to age and
gender.
RESULTS
Prevalence and distribution of hypersensitive
teeth in subjects according to age and gender is
shown in table 2. A total of 75 persons (15%)
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J Bagh College Dentistry Vol. 21(1), 2009 Prevalence of dentine….
exhibit hypersensitive teeth from 16 years of age
and more, with highest incidence (38.61%) in the
(26-35) years of age group. There is a decrease in
frequency of hypersensitivity with increasing age in
60s group of both genders (Figure 1).
Table 3 shows the distribution of hypersensitive
teeth according to tooth type and intraoral region,
330 teeth were shown to be hypersensitive. Both
genders were affected almost equally.
Hypersensitivity were absent on lingual surface of
the teeth and they were felt on the vestibular
surfaces only in both maxilla and mandible most
often in the region of 1 st premolars reaching to 147.
On the other hand, they were also frequently seen in
the mandibular front teeth.
The distribution of cervical abrasion defects,
tooth/ root exposure and hypersensitivity within the
dentition are shown in Figures 2-4. It is obvious that
these three parameters are more in maxillary teeth
than in mandibular and they are more on the left
side of the dentition with the 1 st premolars were the
mostly affected teeth.
Table 4 shows the distribution of the three
parameters in the dentition of the four age groups.
The highest incidences of affected teeth with the
parameters were in the 3 rd age group, whereas more
hypersensitive teeth recorded in the 2 nd age group.
Table 1: The distribution of subjects and number
of teeth present according to age and gender
Age Men Woman Total No. of teeth
16-25 50 38 88 1176
26-35 78 54 132 3168
36-45 76 70 146 3212
> 46 68 66 134 2680
Total 272 228 500 10236
Table 2: Distribution of hypersensitive teeth in
subjects according to age and gender
Age Men Woman Total Prevalence
16-25 10 11 21 28%
26-35 17 12 29 38.6%
36-45 8 7 15 20%
> 46 5 5 10 13.3%
Total 40 35 75 100%
Table 3: Distribution of hypersensitive teeth
according to tooth type and intraoral region
Tooth type Maxillary Mandibular Total
Incisors 37 25 62
Canines 32 35 67
Premolars 88 59 147
Molars 31 22 54
Total 188 141 330
All being on the vestibular surfaces of teeth
Table 4: Distribution of affected teeth with
hypersensitivity, cervical abrasion and root
exposure in different age groups
Agegroup
Hypersensitive
teeth
Cervical
Tooth/root
Exposure Total
abrasion
16-25 98 95 224 1176
26-35 125 152 386 3168
36-45 63 206 636 3212
> 46 40 240 1013 2680
Total 330 693 2259 10236
DISCUSSION
Hypersensitive teeth constitute the main
problem in this investigation. The reported
prevalence in this study was 15% and this
approximately the same as that reported by Graf and
Galasse (7) which are 14.5%. But this percentage
was lower than that found by Sangners and Gjermo
(15)
which is about 23% because the latter had
estimated it from the abraded teeth only. However,
all agreed in those premolars were the mostly
affected in addition, the condition appears most
frequently in the age between 25- 35 years. The
majority of subjects exhibiting hypersensitivity in
this study were not aware of it and only a few
persons suffered from the symptoms.
The reported distribution of abrasion defects
(Figure 3) and root exposure (Figure 4) within
(10, 12, 14,
dentition found support in previous studies 15) since the mean number of teeth was high in all
samples. The slight tendency towards more frequent
observations of lesions (Figure 3 and 4) and
hypersensitivity (Figure 2) in the left side of the
mouth is probably due to the fact that most people
were right handed which inverts the tooth brushing
habits.
The study agreed with Gillette and Van house
(16) , Melosevic and Rylomma et al. (17, 18) , in that
concomitant root exposure and dental problems in
the same area were observed in more than one half
of the cases indicating a common etiology.
However, some cases with abrasion but no root
exposure was also observed, and this maybe due to
individual factors. Meanwhile our own observations
appear to justify the frictional factors causing these
dental problems and that cervical hypersensitivity
may accompany these lesions. These factors also
had been implicated in the etiology of
hypersensitive teeth by Graf and Galasse Addy,
Zero and Taan and Awartani (7, 19, 20) . Finally, the
following points summarize the outcome of this
study:
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J Bagh College Dentistry Vol. 21(1), 2009 Prevalence of dentine….
1- Prevalence of hypersensitive teeth in this
Iraqi sample is 15%
2- Hypersensitivity occur most frequently in
the age range of 25-36 years
3- The most affected intraoral areas on the
vestibular surfaces of teeth
4- Most frequently affected teeth are 1 st
premolars
5- There is a definitely a site correlation
factors which are the cervical abrasion and
root exposure that is enhanced by improper
oral hygiene procedures
No. of Hypersen. teeth
18
16
14
12
10
8
6
4
2
0
16-25 26-35 36-45 > 46
Age group
Men
Woman
Figure 1: Bar chart showing distribution of hypersensitive teeth according to age and gender
No. of Hypersen. teeth
90
80
70
60
50
40
30
20
10
0
Incisors Canines Premolars Molars
Tooth type
Maxillary
Mandibular
Figure 2: Bar chart showing distribution of hypersensitive teeth within the dentition
Figure 3: Bar chart showing distribution of cervical abrasion defects within the dentition
Oral and Maxillofacial Surgery and Periodontology 82

J Bagh College Dentistry Vol. 21(1), 2009 Prevalence of dentine….
Figure 4: Bar chart showing distribution of tooth/ root exposure within the dentition
REFERENCES
1. Bergestrom J, Laustedt S. An epidemiological
approach to tooth brushing and dental abrasion.
Community Dent Oral Epidemiol 1979; 7: 57-64.
2. Irwin C, McCusker P. Prevalence of dentine
hypersensitivity in general dental population. J
Irish Dental Assoc 1997; 43: 7-9.
3. Schuurs AHB, Wesselink PR, Eijkman MAJ.
Dental hypersensitivity. Endodont Dent Traumatol
1995; 11: 240-4.
4. Pashely DH. Theory of dentine sensitivity. J Clin
Dent 1994; 5: 65-7.
5. Meloservic A, Lo M. Tooth wear in three ethnic
groups in sabah (north Borneo). International
Dental Journal 1996; 46: 572-8.
6. Hirsefeld I. Toothbrush trauma recession–A
clinical study. J Dent Res 1931; 11: 61-3.
7. Graf H, Galasse R. Morbidity, prevalence and
intraoral distribution of hypersensitive teeth. IRAD
Abstracts 1977; 479: A 162.
8. Addy M. Hypersensitivity, cause and treatment.
Dent Update 1986; 13(5): 207-8.
9. Wichgers TG, Emert RL. Dentine hypersensitivity.
Gen Dent 1996; 44: 225- 30.
10. Rees J. The prevalence of dentine hypersensitivity
in general dental practice in the UK. J Clin
Periodontol 2000; 27: 860-5.
11. Al- Safi. The prevalence of tooth/ root exposure
related to mechanical tooth cleaning procedure in
different age group. J College of Dentistry 1999; 6:
62- 6.
12. Al-Shaikani, Al-Talabani. Tooth root exposure and
cervical abrasion in different age groups. Iraqi
Dent J 2002; 3b: 289- 99
13. Al- Shaikani. The prevalence of cervical abrasion
related to mechanical tooth brushing in different
age groups. Iraqi Dent J 2002; 29: 131.
14. Kitchen P. The prevalence of tooth root exposure
and the relation of the extent of such exposure to
degree of abrasion in different age classes. J Dent
Res 1941; 20: 565- 81.
15. Sangners G, Gjermo P. Traumalization of teeth
and gingiva relate to habitual tooth brushing
procedures. J Clin Periodontol 1976; 3: 94-103.
16. Gillette WB, Van House RL. III effect of improper
oral hygiene procedure. J Am Dent Assoc 1980;
101: 476-80.
17. Melosevic A. Tooth wear: Etiology and
presentation. Dental Update 1998; 25: 6-11.
18. Rylomma H, Jarvien V, Kanerva R, Heinonen O.
Bulimia and tooth erosion. Acta Odontol Scand
1998; 56: 36-40.
19. Zero D. Etiology od dental erosion- extrinsic
factors-. European J Oral Sciences 1996; 104: 162-
77.
20. Taan D, Awartani F. Prevalence and distribution of
dentine hypersensitivity and plaque in a dental
hospital population. Quintes Intern 2001; 32: 372-
6.
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J Bagh College Dentistry Vol. 21(1), 2009 Prevalence and distribution …..
Prevalence and distribution of gingival recession and root
caries in a group of dental patients in Ramadi city, Iraq
Raad S. Al– Ani B.D.S., H.D.D., M.Sc., PhD
(1)
Ahmed M. Abdul- Razzak B.D.S., M.Sc.
(2)
ABSTRACT
Background: With respect to increase in the rate of gingival recession in the adults and elderly people which is
considered as a risk factor for root caries ,the prevalence and attack rate of root caries may differ This study
determine the prevalence of both alterations among a group under study .
Subjects and methods: Three hundred and thirty six subjects ranging in age from 20 – 49 years divided into three age
groups of both genders (176 males and 160 females). Four surfaces were examined in each tooth. Gingival recession
was regarded as present when ever more than 1mm of root surface was exposed and its vertical width was measured
in millimeters from the cemento-enamal junction to the gingival margin in addition to the presence of caries on the
exposed surface.
Results: Gingival recession was observed in 52.4 % of the total sample (52.8 % in males and 51.9 % in females) and at
least in one dental surface in the affected teeth. The prevalence was found to increase with increasing age. First
molar teeth exhibit more surfaces with gingival recession. The average value was (21.6 %). 18 .5 % of the sample have
root caries .It increases as age and recession increase, it affects males (19.3 %) more than females (17. 5 %) and first
molar teeth (32.3) was mostly affected.
Conclusion: The high prevalence of gingival recession and root caries demonstrate attention must be provided by
dentist and people themselves, preventive measures must be conducted among population to control their increase.
Key word: Gingival recession, root caries, epidemiology(J Bagh Coll Dentistry 2009; 21(1): 84-87)
INTRODUCTION
Gingival recession is an undesirable
condition resulting in exposure of root surfaces
of teeth on which the gingival margin is located
apical to cemento – enamel junction (1) . It affects
aesthetic and leads to cervical dentin
hypersensitivity and considered as a risk factor of
root caries because of the exposure of the root
surface to the oral environment
(2) . The
occurrence of gingival recession associated with
effects of several factors (3) , include dental plaque
(4) , calculus (5) , Mechanical trauma by hard
bristled toothbrush (6) , and its technique (7) ,
frequency of tooth brushing Orthodontic
treatment and trauma from removable partial
denture (9) , and chemical trauma related smoking
(10) , also associated with periodontal attachment
loss (11) , with abnormal tooth position and with
inflammation of gingival margin (12) .
Regarding root caries, studies showed that it
is located adjacent to the crest of gingiva where
dental plaque accumulated on the proximal and
buccal surfaces, its location was positively
associated with age and gingival recession
affected by dietary habits and decreased salivary
flow (13) .
Regarding prevalence, in Brazil (2) reported
that gingival recession in USA in middle age
individuals affected 22–53 % of the teeth, in
(1)Lecturer, Preventive, Orthodontic and Pedodontic department,
Al–Anbar dental college
(2) Assistant lecturer, periodontal department, Al–Anbar dental
college,
(8)
Norway, it affects 51% of 18 years adult, and in
New Guinia, 11–40% of the adults present this
alteration, as in Finland reported 68%. Studies
indicate that maxillary canine, premolars, first
molars and mandibular central incisors are the
most affected teeth (5) . Regarding root caries, (2)
reported that 98.9% had root caries and gingival
recession and 78.1% had at least one root caries
lesion and maxillary canine, first premolars and
mandibular molars presented the greatest root
caries index and was greater in buccal and
proximal surfaces. Hellyer etal (14) reported 88.4%
in 55 years MacEtee etal (15) reported 36–67%.
while Imazto etal (13) concluded that 39% had one
or more decayed roots and 53.3% had one decayed
root lesion and canine teeth were more frequently
affected followed by first premolars, they found
that 56.9% of males had one or more root caries
and 53.3% in females and concluded that canine
most commonly affected by root caries was canine
in maxilla and premolar in mandible. In addition
they found that 17.5% of the exposed surface in
males affected by root caries and 11.5% in
females.
SUBJECTS AND METHODS
Three hundred and thirty six subjects ranging
in age from 20–49 years dividing into three age
groups (20-29, 30-39 and 40-49 years) of both
genders (176 males and 160 females) were
examined. Four surfaces were examined in each
tooth: mesial, distal, buccal and lingual or palatal.
Measurement of the gingival recession was
obtained from the cemento– enamel junction up to
the gingival margin in the affected teeth, three
categories were established according to the
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J Bagh College Dentistry Vol. 21(1), 2009 Prevalence and distribution …..
apicocoronal dimension of the root surface
exposed, this was done according to criteria
suggested by Miller (16) :
1- Small recession: less than 3mm of root surface
exposed.
2- Moderate recession: 3 to 4 mm of root surface
exposed.
3- Advanced recession: more than 4mm of root
surface exposed to the dental environment.
Measurement of root caries was done using root
caries index (RCI)
(R – D) + (R – F) x 100
RCI = ---------------------------------------------
(R – D) + (R + F) + (R – N)
R – N= Recession present (root surface normal or
sound)
R – D= Recession present (with a decayed root
surface)
R – F=Recession present (with a filled root
surface)
Measurement was done according to age
group and gender. The association between root
caries and gingival recession was evaluated using
logistic regression (LR).
RESULTS
Table 1 presented the number and percentage
of subjects with gingival recession and root
caries with the value of root caries index (RCI)
measured according to age groups and gender. It
shows that 52.8% of males affected by gingival
recession in comparison with that of female 51.9,
the age group 40–49 years old constitute the
mostly affected group (76.5% of males and
71.7% of females). The difference was statically
not significance. Regarding root caries, 19.3% of
males who have gingival recession was affected,
where it is 17.5% in females in the total sample,
the difference was statically not significance; in
addition, RCT in males (29.1) was more than that
of females (27.7). This table demonstrated that
both gingival recession and root caries are
increased with increasing age but not significant.
Table 2 shows the distribution of subjects
with gingival recession according to depth (in
millimeter), age group and gender. It shows that
37.5% of the 20–29 years old have gingival
recession of 3–4mm in depth which constitute
the highest percentage among this age group and
it was the same among all other age group.
According to gender, males have the highest
percentage of gingival recession of the 3–4 mm
depth which constitutes 39.8 in comparison with
that of female (39.1). The difference was highly
significant ( F = 53.21 , P = 0.000 ).
Table 1: Number and percentage of subjects
with gingival recession (GR) and root caries
(RC) according to age group and gender with
the value of root caries index (RCI)
Age group and gender *
Age 20 - 29 30 - 39 40 – 49 Total All
Gende
F M F M F M F M
r
Sampl
60 68 54 57 46 51 160 176 336
e
With
GR
% GR
With
RC
% RC
RCI
22
36.
7
6
26
38.
2
8
28
51.
9
10
30
52.
6
12
33
71.
7
12
37
76.
5
14
83
51.
9
28
93
52.
8
34
176
52.
4
62
10.
1
11.
8
18.
5
21.
1
26.
1
27.
5
17.
5
19.
3
18.
5
13. 10. 27. 30. 48. 50. 27. 29. 27.
6 0 8 8 0 0 7 1 9
* Not significant according to age group
** Association between GR and RC was highly
significant ( F = 62. 59 , P = 0.001 )
*** According to gender not significant
Table 3 demonstrated the number and
percentage of surfaces affected by gingival
recession and root caries according to age group It
shows that buccal surface was the highest surface
affected by gingival recession which constitute
33.8 % followed by proximal surfaces ( 23.0 % in
mesial and 22.2 % in distal surfaces ) .
Table 2: Number and percentage of subject
with gingival recession according to age
groups, gender and depth in mm
Age
group
Number
Gender
3 – 4
Less than
mm
3mm
No. %
No. %
4mm
&
more*
No. %
M 26 11 42.3 10 38.5 5 19.2
20- 29
F 22 10 45.5 8 36.4 4 18.2
T 48 21 43.8 18 37.5 9 8.8
M 30 7 23.3 13 43.3 8 26.7
30- 39 F 28 8 28.6 10 35.7 7 25.0
T 58 15 25.9 23 39.7 15 25.9
M 39 3 8.1 14 37.9 12 32.4
40- 49
F 33 3 9.1 12 36.4 10 30.3
T 70 6 8.6 26 37.1 22 31.4
M 93 21 22.6 37 39.8 25 26.9
F 83 21 25.3 30 36.1 21 25.3
All
T 176 42 23.9 67 38.1 46 26.1
F = 53.21, P = 0.000, highly significant according to
depth.
Regarding root caries, mesial and distal
surface found to be more affected (34.8% for
mesial and 30.4% for distal surfaces) followed by
buccal surfaces which constitute 28.3%. Lingual
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J Bagh College Dentistry Vol. 21(1), 2009 Prevalence and distribution …..
surfaces are least affected. The difference was
statically significance (F = 4.79, P 0.05).
Table 4 demonstrated the number and
percentage of teeth affected by gingival recession
and root caries according to age group. It shows
that first and second molar teeth was the mostly
affected by gingival recession among all teeth
21.6 % for first molar , 19.3% for second molar
followed by 17.6% for canine and 15.3% for
central incisors. Regarding root caries, first and
second permanent molar constitute the highest
percentages which affected by root caries (32.3
and 24 .2 respectively) followed by first premolar
(16.1%) and canine (14.5%) whereas the lateral
incisor was the least tooth to be affected by root
caries (3.2 %).Regression analysis showed highly
significant association between gingival
recession and root caries (F = 62. 59, P = 0 .001).
Table 3: Number and percentage of surfaces
affected by gingival recession (GR) and root
caries (RC) according to age group and
surfaces
Age
group
20-
29
GR
RC
30 -
39
GR
RC
40 -
49
GR
RC
Total
GR
RC
Buccal
No. %
65 32.5
7 29.2
73 32.9 14
28.0
103 5.5 18
8.1
241 3.8 39
28.3
Gingival
No. %
20 20
1 4.2
49 22.1
3 6.0
60 22.1
5 7.8
149 21
9 6.5
Mesial
No.
%
49 24
9 37.5
51 23
17 34
64 22
22 34
164 23
48 35
Distal
No.
%
46 23
7 29
49 22
16 32
63 21
19
29.7
158 22
42 30
* According to surfaces not significant
** According to age group not significant
X2 = 10.01, F = 6, P = 0.12 Not significant
Total
No.
%
200 28
24 17
222 31
50 36
290 41
64 46
712 100
138 100
DISCUSSION
The current study demonstrates levels of
gingival recession among a group of people lived
in Ramady city to the west of Iraq , dental health
services is available there throw several of health
centers with good equipment and dental materials
in addition to good number of dentist but people
still suffer from oral and dental diseases . This
study was conducted to determine the prevalence
of gingival recession and root caries among a
group of 20–49 years old dentally attendance
people which considered part of parameters used
to evaluate gingival health condition. The main
findings of the currents study were that 52.4% of
the total samples have gingival recession, this was
in agreement with that found by Albander and
Kingman (5) and this problem was affected young
adult of 20–29 years old.
Table 4: Number and percentage of teeth
affected by gingival recession (GR) and Root
caries (RC) according to age group
Age group
20 - 29
GR
RC
30-39
GR
RC
9 15.5
3 13.6
4 6.9
1 4.5
10 17
2 9.1
40-49
GR RC
Total
GR RC
7 14.6 11 15.7 27 15.3
Central incisor
2 14.3 3 11.5 8 12.9
Lateral incisor
2 4.2 6 8.6 12 6.8
0 0.0 1 3.8 2 3.2
Canine
9 18.8 12 17.1 31 17.6
0 0.0 2 7.7 4 14.5
First premolar
6 12.5 7 12.1 9 12.9 22 6.8
2 14.3 3 13.6 5 19.2 10 16.1
Second 3 6.3 4 6.9 5 7.1 12 6.8
premolar 1 7.1 1 4.5 1 3.8 3 4.8
First molar
11 23 13 22 14 20 38 21.6
5 33 7 31.8 8 31 20 32.3
Second molar
10 21 11 19 13 18.9 34 19.3
4 28.6 5 22.7 6 23.1 15 24.2
Total
48 27 58 33 70 39.7 176 100.0
14 2.6 22 35 26 41.9 62 100.0
This percentage indicated that this alteration
could occur in people with good oral hygiene and
in those with bad oral hygiene. Those of good oral
hygiene have brushed away gingival tissue to have
0.5 mm or more exposed cementum on the buccal
surfaces of one or more teeth. Many studies
concluded that traumatic mechanical tooth
brushing was considered a factor in the etiology of
gingival recession (6,9) ., while those with poor oral
hygiene, periodontitis play a role in its occurrence
and the loss of attachment which was the result of
localized Inflammatory process
(17) . When
compared the result of this study with other, it was
found to be in agreement with that found by
Kallestal etal (18) . According to age, results of this
study indicated that prevalence of gingival
recession was increased with increasing age; this
was in agreement with that found by Kallestal etal
(18) and Pimenta etal (19) . This was due to the longer
period of exposure to the factor which cause
gingival recession (6) , also due to cumulative affect
of the lesion itself (3) , as concluded by many
studies that the prevalence of gingival recession
was depend on the type of agent or the cause (2) .
Data of this study showed that molar teeth display
the highest frequency of gingival recession due to
aggressive periodontal disease and pocket
formation when provide the accumulation of food
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J Bagh College Dentistry Vol. 21(1), 2009 Prevalence and distribution …..
debris and dental plaque and cause bone
destruction, lead to root surface exposure in
addition to incorrect traumatic tooth brushing.
These surfaces with gingival recession are less
favorable to self cleansing, lead to formation of
root caries. This indicated that interproximal and
buccal surfaces are the most frequent site
affected by gingival recession and this was in
agreement with that found by Albander and
Kingman (5) , Marlivia and Watanabe (2) , Pimenta
et al (19) .
Regarding root caries, this study found that
18.5 % of the subjects affected by root caries.
The Root Cries Index proposed by Katz (20)
compete a true attack rate for root caries. Results
of this study found that root caries prevalence
and root caries index was lower than that found
by MacEntee etal (15) and Imazato etal (13) . This
was due to variation in the sample, the country
where the study was conducted, their habits and
environments. The prevalence of root caries was
found to be increased with increasing age of the
people and results of this study was in agreement
with that found by Katz etal
(20) , regarding
prevalence of root caries, while in case of Root
caries index, results of this study was in
agreement with that found by MacEntee etal (15) ,
and Imazato etal (13) . Root caries was seen most
frequently on roots of molar teeth and this was in
agreement with that found by Imazato etal (13) .
Exposed root caries will develop root caries and
the increase in prevalence of root caries in the
manifestation of gingival recession. The
increasing prevalence of root caries with
increasing age is an indicator of increased root
exposure to the oral environment. This study
concluded that these alterations could increase
among population so it is important to conduct
oral dental health care. Programs including
dental health education and periodontal health
care in addition to fluoride preventive measures
to control this increase.
and older in the United States 1988–1994. National
Institute of dental and craniofacial research, National
Institute of health. J.
6. Khocht A, Simon G, Person P, Denepitiya J. Gingival
recession in relation to history of hard tooth brush use. J
Periodontal 1993; 74 (9): 900–5.
7. Joshipura KJ, Kent RL, Depaola PF. Gingival recession:
intra–oral distribution and associated factors. J
Periodontal 1994; 65 ( 9 ): 864–71
8. Vehkalahti M. Occurrence of gingival recession in
adults. J Periodontol 1989; 60: 599.
9. Checchi, L, Daprile, G, Gatto, MRA, Pelliccioni A.
Gingival recession and tooth brushing in an Italian
school of Dentistry: a pilot study. J Clin Periodontol
1999; 26 (5): 276–80.
10. Martinez–Canut P, Lorca A, Magan R. Smoking and
periodontal disease severity. J Clin Periodontol 1995; 22
(10):734–49.
11. Beck JD, Kock GG. Characteristics of older adults
experiencing periodontal attachment loss as gingival
recession or probing depth. J Periodontal Res 1994; 29
(4): 290–8.
12. Ainamo J, Paloheimo L, Nordblad A, Murtomaa H.
Gingival recession in school children at 7 , 12 and 17
years of age in Espoo , Finland. Community Dentoral
Epidemiol 1986; 14: 283–6
13. Imazato S, ikebe K, Nokubi T, Ebisu S, Walls AWG.
Prevalence of root caries in a selected population of
older adult in Japan. J Oral Rehab 2006; 33 (2): 137–43.
14. Hellyer, Beighton et al. Root caries in older people
attending a general dental practice in East Sussex. Brit
Dent J 1990; 169 (7): 201–6.
15. MacEntee Clark DC, Glick N. Predictors of caries in
old age. Gerodontology 1993; 10: 90–7.
16. Miller JRPD. A classification of marginal tissue
recession. Int J Periodontics Restorative Dent 1985; 5
(2): 8–13
17. Marini MG, Greghi SLA, Passane E, Passane AC, Ana
S. Gingival recession: prevalence, extension and severity
in adult. J Appl Oral Sci 2004; 12 (3).
18. Kallestal C, Matsson L, Holm AK. Periodontal
conditions in a group of Swedish adolescents (1): a
descriptive epidemiologic study. J Periodontol 1990; 17:
601–8.
19. Pimenta LA, Ritter A, Beck J. Predictors of root caries
in older adults in US, 2008. (Medline abst.).
20. Katz RV, Newitter DA, Clive JM. Root caries
prevalence in adult dental patients. J Dent Res 1985; 64:
293.
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1. Gupta B, Marya CM, Juneja V, Dahiya V. Root caries:
An aging problem. Int J Dent Science 2007; 5 (1).
2. Marlivia, Watanabe. Root caries prevalence in a group
of Brazilian adult dental patients. Braz Dent J 2003; 14
(3).
3. Serino G, Wennstrom JL, Eneroth L. The prevalence
and distribution of gingival recession in subjects with a
high standard of oral hygiene. J Clin periodontol 1994;
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4. Ericsson I, Lindhe J. Recession in sites with inadequate
width of the keratinized gingiva. An experimental
study in the dog. J Clin Periodontol 1984; 11 (2): 95–
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5. Albandar JM, Kingman A. Gingival recession, gingival
bleeding and dental calculus in adults 30 years of age
Oral and Maxillofacial Surgery and Periodontology 87

J Bagh College Dentistry Vol. 21(1), 2009 The effect of locally …..
The effect of locally applied ciprofloxacin on the incidence
rate of dry socket
Emad A. Salman, B.D.S., M.Sc (1)
Jabbar J. Sabur, B.D.S., M.Sc. (1)
ABSTRACT
Background: Dry socket is a common and unpleasant local complication following the extraction and surgical
removal of teeth. This study was constructed to prevent or minimize this post operative complication.
Material and Methods: 81 patients were involved in this study, divided into two groups, an experimental group: the
extraction socket was irrigated intra and immediate postoperatively with 0.5ml/ socket Ciprofloxacin, and a control
group: the extraction site was irrigated in the same manner with normal saline.
Results: A total of 5 dry sockets were developed in this study, one case in the experimental group, and four cases in
the control group. The incidence rate of dry socket in the experimental group was 2.4% while in the control group
was 10%.
Conclusion: Although the incidence rate of dry socket was reduced from 10% in the control group to 2.4% in the
experimental group, but the statistical analysis showed no significant effect for the Ciprofloxacin in the reduction of
dry socket.
Keywords: Dry socket, Ciprofloxacin, incidence, prevention. (J Bagh Coll Dentistry 2009; 21(1): 88-90)
INTRODUCTION
Dry socket is a rather common and very
unpleasant local complication of the extraction or
the surgical removal of teeth. The clinical picture
of the disease is well known and was first
described in 1890.
Two or three days after the removal of the
tooth, disintegration of the normal blood clot
occur, the alveolus is empty, with completely or
partially denuded, very sensitive bone surfaces,
covered by grayish-yellow layer of detritus and
necrotic tissue. The surrounding gingiva often
shows inflammatory reaction. The patient
complains of intense, continuous and often
irradiating pain of neuralgic character. Halitosis is
pronounced and the patient complains of bad
(1, 15, 17)
taste.
Dry socket developed in 2% - 4.4% of all
extractions of permanent teeth (1) . It developed in
2% of cases following simple extraction, in 7.3%
of cases after surgical extractions, and 23% of
cases following surgical extractions of mandibular
third molars (15, 10) .
Dry socket occurs most frequently in the age
group of 20–40 years (1) . The etiology and
pathogenesis of dry socket are only inadequately
known, and the wide array of suggested risk
factors indicates this fact (1, 5, 7) . Inflammation
triggered high fibrinolytic activity in and around
the alveolus is believed to be the underlying
pathology that causes blood clot dissolution and
the release of kinins responsible for the
characteristic neuralgic pain in dry socket. (1-3) .
(1) Assistant lecturer, Dept. of oral and maxillofacial surgery,
college of dentistry, university of Baghdad.
A possible role for bacterial infection in the
etiology of dry socket has been suggested by
Birn (1) , Kay's (12) and Rud's (16) findings of high
incidence rates of dry socket following the
removal of mandibular third molars with
pericoronitis also suggest a possible role for
bacterial infection in the etiology of dry socket.
The higher bacterial counts, which continued
to rise during the first postoperative hours,
isolated from the wound, and saliva of the patients
who developed dry socket following mandibular
third molars surgical removal, and the lower
counts isolated in patients who did not developed
the condition also point to a possible role for
bacterial infection in the etiology of dry socket (4) .
Because of the proposed microbial origin,
prevention of dry socket has focused on systemic
and topical antimicrobial therapy, Lincomycine,
Tetracycline, Crystalline Penicillin, Chlorhexidine
in different regimens has been used with varying
degree of success. (7-9,11,13) .
Ciprofloxacin is a flourquinolone that was
first approved for systemic infections in 1988.
Like other quinolones, Ciprofloxacin is an
inhibitor of bacterial gyrases (topoisomerases I
and II). It is rapidly bactericidal and is effective
against a wide range of bacteria (14) .
The mean concentration of Ciprofloxacin in
bones of patients with osteomyelitis reached (1
mcg/g) and (1.4 +-1 mcg/g) following single oral
doses of 500mg and 750mg. respectively (6) . As a
new agent the therapeutic uses of Ciprofloxacin
remain unsettled.
Currently none of the quinolones are
indicated for dental use, however Ciprofloxacin
has a spectrum of activity that includes selected
pathogens of the oral cavity (14) . Tozum and others
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J Bagh College Dentistry Vol. 21(1), 2009 The effect of locally …..
advised to use the drug as adjunctive therapy for
infected periodontal sites (18) .
To our knowledge no previous study has been
made to investigate the possible effect of small
topical doses of Ciprofloxacin, applied to
extraction site both intra and immediate
postoperatively, on the incidence rate of dry
socket.
MATERIAL AND METHODS
This randomized, controlled, clinical trial was
conducted at the oral and maxillofacial
Department of the College of Dentistry– Baghdad
University and a private clinic owned by the
second investigator.
The basic inclusion criterion in our study was
having a complicated extraction of lower posterior
teeth. The extraction procedure was lengthy,
required the use of chisels, elevators, rotary
cutting instruments, it involved roots sectioning,
bone cutting, often mucoperiosteal flaps raising
and resulted in inflicting surgical trauma judged
by the two operators to be of moderate degree of
severity i.e. much higher than that severity of a
simple forceps extraction but did not mount to
reach that caused by the surgical extraction of
deeply buried mandibular third molars, the
amount of bone cut and crushed during surgery in
addition to the soft tissue damage amount were
the factors that governed the investigators
decision on trauma degree of severity ranking.
All patients presenting for the extraction of
lower posterior teeth were considered for
inclusion. Patients who have had acute periapical
or marginal infections, patients who were taking
antibiotics, and females taking oral contraceptives
at the time of the extraction or shortly before were
all excluded from the study.
A total of 81 healthy adults of both sexes, 41
female and 40 males aged between 19 – 62 years
(age mean 30.9 years) met the criteria above and
were included in the study. They were assigned
into two almost equal groups, an experimental and
a control group.
The extraction sites in patients of the
experimental group were irrigated both intra and
immediate post operatively with 0.5ml/ root
socket of the standard 0.2% Ciprofloxacin
intravenous infusion solution (CIPREF– OUBARI
PHARMA-Syria). Irrigation was made at two
stages, half of the dose was used to irrigate the
exposed bony walls of the socket and the
surrounding gingiva during the extraction
procedure, the remainder was used to fill the
empty socket and irrigate the surrounding gingiva
immediately following the delivery of the tooth.
Extraction sockets of the patients with control
group were irrigated in the same way with a
similar volume of a normal saline. All extractions
were done under local anesthesia using Xylocaine
2% with 1/80000 adrenaline solution. Interrupted
3/0 black silk sutures were placed to properly hold
the interdental papillae in all extraction sites and
to force patients to come back for suture removal
and re-examination after 7 days, all patients have
had cotton wool pressure packs applied post
operatively to their extraction sockets and for the
same period of time which was one hour, and
were prescribed ten 500mg acetaminophen tablets
(Panadol–Smithkline Becham– Ireland) to control
pain following surgery. No antibiotics were used
in our study. The patients were given the usual
post extraction instructions and they were clearly
informed to come back to surgery immediately or
as soon as possible if they develop one or more of
the following:
Severe continuous or throbbing pain that
develops at the extraction site during the second
post extraction day or later, not relieved by the
usual dose of Panadol.
a. Massive facial swelling.
b. Bleeding that does not stop after 24 hours.
If non of the above occur, patients were
instructed to return back to surgery for
examination and suture removal after 7 days.
A positive diagnosis of dry socket was made
on the basis of both clinical and subjective
findings. The clinical findings include completely
or partially empty socket with exposed sensitive
bony wall, or socket filled with foamy
disintegrating blood clot. The subjective findings,
were severe or increasing persistent post operative
pain that could be throbbing in character develops
during the second post extraction day or later, and
is not usually relieved by the usual dose of
Panadol.
The number of Panadol tablets taken by the
patient and whether or not he had to refill the
prescription were all considered before reaching a
diagnosis of dry socket.
RESULTS
Quantitative Data
A total of five cases of dry socket have
developed in the present study (table 1). Dry
socket developed in one of the fourty-one
extraction sites of the experimental group and in
four of the forty extraction site of the control
group.
The incidence rate of dry socket in the
experimental group was 2.4% versus 10% in the
control group. This represents a 76% reduction in
the incidence rate of dry socket following the
Oral and Maxillofacial Surgery and Periodontology 89

J Bagh College Dentistry Vol. 21(1), 2009 The effect of locally …..
application of Ciprofloxacin to the extraction sites
in the experimental group.
The data were analyzed using Fisher's exact
test to compare the number of occurrences of dry
socket for the two groups for statistical
significance. Fisher's exact test showed no
significant difference between the two groups in
regard to number of occurrences of dry socket
(p=0.16).
Investigator's Impressions
From gross clinical observations the two
investigators noticed that the soft tissue covering
the extraction sites in the experimental group
showed milder edema and congestion on the
seventh postoperative day than that of patients in
the control group.
Table 1: The occurrence of dry socket in the
experimental and the control groups.
Group
No. of % of
No. of No. of
Dry Dry
patients Extractions
Sockets Socket
Experimental 41 41 1 2.4%
Control 40 40 4 10%
Total 81 81 5
DISCUSSION
Dry socket develops because of high
fibrinolytic activity in and around the alveolus
triggered by the release of stable tissue activators
of plasminogen from the osteoblasts of the
endosteum and probably to a lesser extent from
the surrounding gingiva and epithelium caused by
inflammation in these tissues. The inflammation
may have two different causes; infection of the
alveolus or trauma, which may often work
together to create the degree of inflammation
necessary for the development of dry socket.
The conflicting opinions as to the importance
of the later two causes in the development of dry
socket, often encountered in the literature, are
probably due to the fact that one has been more
pronounced than the other in individual studies (1) .
The 2.4% dry socket incidence rate in patients
of the experimental group, when compared with
the (10%) rate of the control group though may
indicate an apparent preventive role for
Ciprofloxacin, definitive conclusions in this
regard can not be drawn owing to the small
sample size and the small size of the biologic data
in the present study.
The incidence rate of dry socket among
patients of the control group was considerably
higher than the 7.3% reported by Hansen (10)
occurring following the surgical extraction of
mandibular posterior teeth in his study. This could
be due to differences in the diagnostic criteria and
uncontrolled variations within the populations
evaluated.
The single dry socket occurrence among
patients of the experimental group indicates that
the preventive role of Ciprofloxacin was
incomplete, a fact which may suggest that
bacterial infection is an important but not the sole
etiologic factor in dry socket.
REFERENCES
1. Birn H. Etiology and pathogenesis of fibrinolytic
alveolitis. Thesis: Int J Oral Surg 1973; 2: 211–63.
2. Birn H. Fibrinolytic activity in ((dry socket)). Acta
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3. Birn H. Fibrinlytic activity of normal alveolar bone.
Acta Odont Scand 1971; 29:141-53.
4. Braun LR, Merril SS and Allen RE. Microbiologic
study of intra oral wounds. J Oral Surg 1970; 28: 89-
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5. Cattelanic JE. Review of factors contributing to dry
socket through enhanced fibrinolysis. J Oral Surg
1977: 37: 42 – 6.
6. Fong IW, Ledletter WH, Vandenbrucke AC, Simbul
M, Rahm V. Ciprofloxacin concentration in bone and
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7. Fridrick KL, Olsen RA. Alveolar osteitis following
surgical removal of mandibular third molars Anesth
Prog 1990; 37(1): 32-41.
8. Goldman DR, Panzer JD, Athkinson MA. Prevention
of dry socket by locally applied Lincomycin in gel
foam. Oral Surg 1973; 35: 472-4.
9. Hall HO, Bildman BS, Hand CD. Prevention of dry
socket with local application of Tetracycline. J Oral
Surg 1971; 29:35-7.
10. Hansen E. ALveolitis Sicca dolorosa (dry socket):
Frequency of occurrence and treatment with trypsin. J
Oral Surg 1960; 18:409-16.
11. Holland MR, Tan JC. The use of pure crystalline
penicillin G tablets in extraction wounds. Oral Surg
1954; 7: 145.
12. Kay LW. Investigations into the nature of
pericoronitis. Br J Oral Surg 1966; 4: 52-78.
13. Metin M, Tek M, Sener I. Comparison of two
chlorhexidine rinse protocols on the incidence of
alveolar osteitis following the surgical removal of
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14. Neidle EA, Yagiela JA. Pharmacology and
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1989; 543-4.
15. Ritzan M. The prophylactic use of tranexamic acid
(CYCLOCAPRON) on alveolitis sicca dolorosa. Int J
Oral Surg 1973; 2: 196-9.
16. Rud J. Removal of impacted lower third molars with
acute pericornitis and necrotizing gingivitis. Br J Oral
Surg 1970; 7:153-9.
17. Seward GR, Harris M, McEowan DA. Killey and
Kay's Outline of Oral Surgery, part one. 2 nd ed.
Bristol Wright: 1987: 174-8.
18. Tozum HF, Yildrim A, Caglaya NF, Dinsel A,
Bozkurt A. Serum and gingival crevicular fluid levels
of Ciprofloxacin in patients with periodontitis. J Am
Dent Assoc 2004; 135: 1728-32.
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J Bagh College Dentistry Vol. 21(1), 2009 Closed reduction for...
Closed reduction for comminuted mandibular fractures
Thaer Abdul Lateef, B.D.S., H.D.D., F.I.C.M.S. (1)
ABSTRACT
Background: Closed reduction and indirect skeletal fixation is a well known modality for treatment of mandibular
fractures. The aim of this study was to evaluate this modality as the treatment of choice for comminuted mandibular
fractures due to missile injuries.
Materials and methods: This study included 32 patients presented with comminuted mandibular fractures due to
missile injury. The patient ages ranged from 21-58 years, 26 of them were males and 6 females. Closed reduction with
the use of maxillomandbular fixation for 6 weeks was the modality of choice.
Results: The most common site was the body region 50%, complication rate (transient and permanent) was 53.1%
with significant bone loss in 13 patients 35.1%.
Conclusion: Initial conservative treatment found to be effective and the complex hard and soft tissue reconstructions
reserved later for definitive approach.
Keywords: Missile injury, comminuted fracture, closed reduction. (J Bagh Coll Dentistry 2009; 21(1): 91-97)
INTRODUCTION
Surgeons, because of differences in training
and experience prefer some types of treatment
over others and it propably matters little what
method is used as long as the desired result in
treatment of mandibular fractures are obtained,
this include the restoration of function of the jaw
occlusion of the teeth and normal appearance of
the face. Regardless the method or methods
employed, certain basic principles must be
understood and followed closely in order to
ensure the successful completion of treatment,
and these include Reduction, Fixation and
Immobilization.
Wounding characteristics of missile injuries
The principal mechanism of injury from the
low velocity bullet is laceration and crushing of
tissue, while the high velocity missile has two
additional very important means of causing
extensive tissue damage cavitation & production
of pressure and shock wave
(1) . Cavitation
develops during the passage of high velocity
bullets through tissue. When penetration occurs,
there is rapid energy release, a large cavity is
formed that reaches its maximal size in only a
few milliseconds and may be 30-40 times the
diameter of the bullet (2) .
Gunshot injuries usually involve multiple
types of tissue that vary in their susceptibility to
injury. An important variable is the tensile
strength of the involved tissue. Bone is the least
elastic organ in the body and the most resistant to
cavitation, it is also the most severely damaged
organ struck by a high-velocity missile (1,3) .
(1) Lecturer, Department of oral and maxillo-facial surgery,
College of dentistry, University of Baghdad.
A temporary cavity produced in close
proximity to bone can cause to shatter and propel
many secondary missiles, thereby increasing
tissue damage that account for the extensive
destructive nature of high velocity missiles
(4) .The more importance in maxillofacial region
is the stress wave caused by the missile, it
preceds the cavitation phenomenon, since it
moves faster than the speed of sound before
cavitation occurs. Fracture of bone away from
the wound track is a definite feature of highly
energy transfer wounds (5) . In dentulous patients
the shock wave causes fracture of teeth just
below the gingival margin in other parts of the
jaw (6) .
Comminuted fractures. Mandibular fractures
are classified into: simple, compound,
comminuted (fractures that characterized by the
shattering of bone into multiple fragments at any
one fracture site), complicated, impacted,
greenstick and pathological (7) .
Injuries produced by firearm vary depending
on several variables including the size, shape and
nature of projectile, the muzzle velocity, distance
of the firearm from the body at the time of
discharge, the angle of firing and the part of the
body involved (8) .
Treatment of Mandibular fractures:
Definitive treatment is considered under two
main headings:
a) Closed reduction & indirect skeletal fixation
(direct interdental wiring, interdental eyelet
wiring, continuous or multiple loop wiring,
arch bars, cap splints, gunning-type splints and
pin fixation).
b) Open reduction & direct skeletal fixation
(tansosseous wiring, intramedullary pinning,
nylon circumferential strap, bone clamps, bone
staples, metallic mesh implants and mandibular
plating (7) ).
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Barber et al, 1997 advocated the use of simplest
means possible to reduce and fixate a mandibular
fracture by closed technique whenever possible
as the open reduction carries an increased
morbidity risk (9) .
Immobilization
Maxillomandibular fixation (MMF) is
usually used for mandibular fracture (10) . Proper
immobilization at the fracture site is aprerequisite
for undisturbed healing and ossification of
callus (11) . The period of stable fixation required
to ensure full restoration of function varies
according to the: site of fracture, the presence or
otherwise retained tooth in the fracture line, the
age of the patient and presence or absence of
infection. In fractures of the body of the
mandible the blood supply to the fracture site is
significant. Where endosteal vascularity is
relatively poor as in the ageing jaw and
particularly in the symphysis region healig to be
prolonged. In contrast, the rich blood supply and
exuberant osteoblastic activity of the child
growing mandible ensures extremely rapid
union (6) . Traditionally the length of time for
MMF used for immobilization of adult fractures
has been 6 weeks (12) .
Imaging Studies
The treatment plan for fractures of the
mandible is very dependent on the precise
radiological diagnosis (13) . Plain radiography and
CT scanning help to ascertain the location of the
fracture, the degree and direction of displacement
and the presence or absence of associated
injuries. All of this information is integral in
developing an appropriate treatment plan for the
patient (14) . CT scanning and plain radiography
including panoramic, lateral oblique,
posteroanterior, mandibular occlusal, reverse
Towens and periapical views may be helpful in
diagnosis of mandibular fractures (9) .
CT scanning is generally the best imaging
modality in the evaluation of penetrating injury
when a retained foreign body is suspected. It is
useful in defining the relationships of foreign
bodies to surrounding muscles, bones and soft
tissues (15) .
Three-dimensional reconstructions of CT
scans can be useful to evaluate complex
mandibular fractures. The ultimate imaging tool
is the stereolithographic model which some
centers are able to make from CT scan images.
These life-size models of the facial bones can be
useful in planning treatment and may be used as
templates for contouring rigid hardware or
constructing splints and other adjunctive
appliances (16) .
Complications
Complications are classified under two headings:
1. Complications arising during primary
treatment (infection, nerve damage, displaced
teeth and foreign bodies, pulpitis, gingival and
periodontal complications, drug reaction).
2. Late complications (malunion, delayed and
non-union, derrangement of the TMJ, late
probems with transosseous wires and plates,
sequestration of bone, traumatic myossitis
ossificans and scars) (13) . Chang et al, 2005 (17)
classified mandibular fracture complications into:
1. Acute complications are the result of trauma
itself.
2. Intermediate complications are caused
during MMF.
3. Late complications occur after MMF.
Sensory disturbances in the distribution of
the trigeminal nerve are common after facial
injuries and are due to contusion, stretching,
compression or division of nerves concerned.
The inferior alveolar nerve is frequently
contused, stretched or severed at the time of
mandibular injury. Temporary or permanent
alteration of sensation around the lips may result
(18) .
Anesthesia of the lower lip as a result of
neuropraxia or neurotmesis of the inferior
alveolar nerve is the most common complication
of fracture of the body and angle of the mandible
producing anesthesia or paresthesia within the
distribution of the mental nerve on the side of
injury (13) .
Any facial injury demands a complete
functional evaluation of the main trunk and its
branches before any treatment. Injuries to the
mandibular area margins affect the marginal
mandibular nerve causing wry mouth. Buccal
branch inguries cause inability to smile and loss
of nasolabial crease as well as sagging upper lip
(19) .
Injury to the lower part of the face by a high
velocity missile commonly result in avulsion of
part of the mandible, and in such cases, there is
almost always associated loss of soft tissue. The
loss of bone in the ramus and proximal part of
the body of the mandible is much less a problem
than at the symphysis. Every possible effort
should be made to bridge the symphysis and to
avoid any gaps between the bone ends during the
initial surgery and if bone has been irritrievably
lost from this area, the two sides of the mandible
should be maintained in normal anatomical
relationship (6) .
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MATERIALS & METHODS
Patients' age & gender
The study discuss and prospectively review
the results of 32 dentulous patients derived from
population of patients with missile injuries
admitted at the oral & maxillofacial surgery
department at Al-Yarmouk Teaching Hospital in
the period between october 2006 – october
2007.The extremes of patient age ranged from
21-58 years.
Diagnosis
Diagnosis of mandibular fractures based on
clinical and radiographic examination. Clinical
examination of the face included extra and
intraoral examination. The local examination was
done to diagnose or exclude the presence of
mandibular fractures. Extraoral examination
achieved by inspection for the presence of
swelling, ecchymosis, bleeding, soft tissue
laceration, changes in facial contour, limitation
or any abnormal mandibular movements.
Bimanual palpation of the mandible with both
hands to detect any step deformity, tenderness or
crepitation on pressure. Compression test was
used by the application of gentle compression of
the mandible using both hands in two opposite
directions under the lower border to elicit pain
which indicate mandibular fracture.
Intraoral examination was started by
inspection for the presence of sublingual
hematoma, mucosal lacerations and changes in
occlusion. Teeth were examined for quantity,
quality and occlusal relationship, gentle
manipulation for mobility of fractured segments
and displacement.
Radiographic examination include the
essential radiographs and according to their
availability (plain radiographs as
posteroanterior view of the mandible, oblique
lateral view, intraoral occlusal view), Panoramic
view OPG as shown in (Figure 3 and 4),
computed tomography CT scans (axial and
coronal).
Maxillomandibular fixation MMF
Closed reduction and indirect skeletal
fixation the sole method of treatment, with jaws
fixed using arch bars (Erich pattern) as a mean
of intramaxillary fixation for the maxilla and
mandible (Figure 2), MMF was carried out with
soft stainless steel wires (0. 35 mm gauge or 0.4
mm) for all patients. Circumferential wiring
used in two cases only for support and elevation
of badly displaced mandibular fractures.
Immobilization for 6 weeks being the general
guideline. Reduction and fixation of
comminuted mandibular fractures achieved in
25 cases under local anesthesia and in 7 cases
under general anesthesia. All patients were
placed on antibiotic treatment (prophylactic or
therapeutic for already present infection) with
possible use of culture and sensitivity test if
possible from the time of admission until five
days postoperatively. Osseous union of the
fracture was tested clinically after 6 weeks of
MMF, tie wires replaced if union is not
satisfactory. To follow patients and monitoring
for late complications, patients seen every 2
weeks after immobilization for the first 2
months then every month for at least 6 months.
RESULTS
In this study 26 of the injured patients were
males 81.8% (table 1). Patients with age group
20-29 years are mainly sujected to missile
injuries as shown in table 2. Mandibular body
was the commonest site for comminuted
fractures 50% (table 3). Transient and permanent
complications showed high rate 53.1% and less
than half of patients 40.6% required further
reconstructive surgery as shown in tables 5 and
6. There was statistically significance at
probability level < 0.05.
Table 1: Gender distribution.
Gender Number %
Male 26 81.8
Female 6 18.8
Table 2: Age distribution.
Age group Number %
10-19 year 2 6.2
20-29 18 56.2
30-39 8 25
40-49 4 12.5
Table 3: Number of patients and fracture
site.
Number of
Site of fracture %
patients
body region
angle
symphysisparasymphysis
Ramus
16
7
6
3
50
21.8
18.7
9.3
Table 4: imaging studies.
Imaging study number %
Posteroanterior
True lateral
OPG
Oblique lateral
Occipitomental
Occlusal
CT scan
32
32
20
5
4
2
3
100
100
62.5
15.6
12.5
6.2
9.3
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Table 5: 37 complications in 17 patients
with 53.1% complication rate .
complication number
Wound infection
Significant bone loss
Neurological complication
Occlusal abnormalities
6
3
12
6
1
6.2
5.1
2.4
6.2
Table 6: Patients that required further
surgery .
Number of % of total
Site of fracture %
patients number
Body
Angle
Symphysisparasymphysis
7
2
4
53.8
15.3
30.7
21.8
6.2
12.5
Total 13 100 40.6
DISCUSSION
The majority of missile injuries to the lower
face region in this study occurred in the age
groups 20-29 years 56.2% this finding concur
with most reported series of facial missile
injuries of Hollier
(20) (21)
, Motamedi and
Kummoona (22) which show that these injuries
were most common in young adult males.The
frequency of missile injuries among males 81.2%
more far greatly than that for females 18.8%, the
reason may be due to the higher activity and
males were mostly involved in the outdoor
activities in this Arab Society, they were the
most target victims for attacks as a result of
deterioration in the circumstances at the present
time in our country due to occupation.
Mandibular body was the most common
fracture site 50%, Newlands et al (23) reported the
distribution of a total 67 mandibular fractures
due to gunshot injuries, in that the body fractures
were the most common 38.8 followed by the
angle and then the anterior region, while
Akhlaghi & Aframian- Farnad (24) found during
the Iraq-Iran war that the most common injury
site to the mandible was a defect in the anterior
region. The mandibular body region comprises a
large surface area while condyles and coronoid
regions were subjected to fewer fractures due to
its smaller surface area. In addition, most of
cases were injured from the lateral side which
tend to involve the body region rather than other
sites, this differ from the battlefield face to face
front line conflict in the anterior region of the
mandible was the most commonly involved.
Missile injuries ranges from gross
comminution of the mandible to simple fracture,
M.Shaker (25) reported 76.9% in 60 patients of
mandibular fractures were comminuted, the high
incidence of fracture comminution due to missile
injury related to the high energy dissipated from
the missile on impact the compact mandibular
bone leading to its fragmentation .
In this study, the panoramic radiograph was
the best informative view in diagnosing
mandibular fractures in only single radiograph,
however it was used in only 20 patients 62.5%
according to the availability in our center, 2 plain
radiographs at right angle to each other
(poseroanterior and true lateral views) were used
for all patients for localization of retained bullets
or sharpnells and for diagnosis of fractures.
A stereolithographic model as illustrated in
(Figure 1) in which a three-dimentional
reconstruction of mandibular bone were made
from CT scan images in 2 patients to determine
the amount of bone loss, these were handheld
life-size model of the facial bones made of a
plastic resin which were useful in planning
treatment and allow our surgeons to estimate the
extent of damage to the maxillofacial skeleton
and determine the size of mandibular bony defect
for subsequent reconstructive procedure with
bone graft. CT scan was recommended for only 3
patients due to its cost, time consuming and
hospital facilities that limits its use.
Numerous series like Chen et al (26) , Deveci
et al (27) and Hollier et al (20) advocated early
aggressive intervention for one stage
reconstruction and open treatment of all involved
structures. However several series favor a more
coservative approach likes Demetriades et al (28) ,
(29)
Perry & Phillips who advocating nonoperative
management of these injuries due to
high incidence of infection. Haug & Assael (30)
said that a simpler method should be choosen
whenever it is as effective as a more invasive
one. We preferred the conservative approach in
treatment and reserve the complicated
reconstructon for later, the traditional and most
proven approach was to use the simplest,
inexpensive and most direct feasible method for
fracture reduction, fixation and immobilization
usually with the use of maxillomandibular arch
bar fixation. In severely comminuted and
contaminated war injuries the blood supply may
be compromised, the additional trauma by open
procedures may lead to devitalization of bone
fragments (sequestration) and loss of bony
substance (due to necessary stripping of
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J Bagh College Dentistry Vol. 21(1), 2009 Closed reduction for...
mucoperiosteal attachment and its blood supply
to the osseous fragments in open procedures).
Closed reduction and indirect skeletal
fixation was used as the modality of choice in
this study for all cases. Arch bars (Erich pattern)
applied due to their avaliability, ease of
application and shorter operation time. Displaced
fractures were treated initially with interarch
elastics applied to the arch bars (Figure 2), and it
was noted that fracture displacement will be
reduced wihin short time (5 minutes) provided
that it was applied in the right way (no crossing).
Complications were common in these series
with 17 out of 32 patients experiencing one or
more complications 53.1%, this high
complication rate was acceptable since many of
complications were transient. There is a
relatively high rate of wound infection in this
study 16.2% compared with Zaytoun et al (31)
(24)
12% and Akhlaghi & Aframian-Farnad
11.4%, this high rate may be explained that many
of missile injuries could not be treated in a strict
aseptic techniques which were not always
possible in the event of mass casualities due to
hospital facilities.
The incidence of significant bone loss was
35.13% in 13 patients who subsequently require
the use of autogenous bone graft. Chambers &
Scully (32) reported a less incidence of bone loss
from the mandible 27.5% in 16 out of 58 patients
with missile injuries. The loss is related to the
high energy imparted at impact and to the effect
of shock wave and temporary cavitation
produced by high velocity missile resulting in
extensive tissue damage.
Fracture of the mandible within the course of
inferior alveolar nerve frequently results in nerve
injury and altered neurosensory function; this
may be due to direct injury or secondary injury
due to the line of fracture or missile path or a
secondary insult due to manipulation and
temporary reduction of the fracture. The
predominant sign was paraesthesia in the lower
lip and chin regions in addition to the gingiva
and teeth which was found in 32.4%. The degree
of nerve injury determine whether the
impairement of sensory function being transient
or permanent.
Occlusal abnormalities reported in 6 patients
16.2% in which minor or gross abnormalities
were seen, this may be due to severe bone
destruction under the influence of muscle pull or
simultaneous severe bone destrucion to upper
jaw and teeth. Minor discrepancies may be
acceptable or can be corrected by selective
grinding of teeth, while gross abnormalities
require further treatment (Figure 5).
Figure 1: 3-d reconstruction life-size model
of facial bones made from CT scan image,
amount of bone loss can be accurately
estimated.
Figure 2: (A) Postoperative view showing
comminuted fracture of left mandibular
angle.
(B) Closed reduction utilizing arch bars &
elastic traction.
(C) Frontal view 3 months after injury.
(D-E) Postoperative occlusal relationship,
note the nice occlusion result.
95
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J Bagh College Dentistry Vol. 21(1), 2009 Closed reduction for...
Figure 3:
(A) Transverse perforating missile injury.
(B) Postoperative OPG showing bilateral
fractures (comminuted right body) treated
by closed reduction using arch bars.
(C) Axial CT scan demonstrating bilateral
fractures (arrowed).
(D) Frontal view showing reasonable
occlusal relationship.
(E) Acceptable mouth opening without
limitation at the longest follow up.
(F) Outlet side healed by secondary
intention, note the bony prominence at the
lower border.
Figure 4:
(A) Bullet injury causing bilateral multiple
comminuted fractures with massive tongue
injury decussating urgent tracheostomy &
nasogastric tube feeding.
(B) Lateral radiograph demonstrating
severe downward & posterior displacement
of the anterior mandible.
(C) Postoperative panoramic view
demonstrating the acceptable lower border.
96
Figure 5:
(A) Avulsive injury caused by high velocity
missile with extensive disruption of bone &
soft tissues.
(B) Postoperative view showing comminuted
fracture of the left angle region of the
mandible.
(C) Three months after treatment with fair
results and adequate mouth opening, note
the residual defects (loss of premaxilla, loss
of part of the upper lip and deformity of
fractured nose) need further reconstructive
surgery.
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Oral and Maxillofacial Surgery and Periodontology
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J Bagh College Dentistry Vol. 21(1), 2009 Hypodontia in Down’s …..
Hypodontia in Down’s syndrome patients
Nidhal H. Ghaib B.D.S., M.Sc. (1)
Mustafa M. Al-Khatieeb B.D.S., M.Sc. (2)
Dheaa H. Abd Awn B.D.S., M.Sc (3)
ABSTRACT
Background: The intention of this study was to quantify the occurrence of hypodontia in a group of individuals with
Down syndrome.
Materials and method: The sample consisted of 164 subjects with Down syndrome with an age ranged 14-18 years,
the subjects were examined clinically, when radiographs were in need, orthopantomograph, occlusal, or periapical
were often taken to confirm the diagnosis.
Results: The results show a notably high prevalence of hypodontia in individuals with Down syndrome (45.2%) being
higher in females (47.4%) than males (42.3%), the hypodontia in the maxilla was higher than in the mandible and on
the right side of females was higher than the left side, while males show on the left side was higher than the right side
though this difference was not significant. The number of congenitally missing teeth also in females was higher than in
males; the most congenitally missing teeth were the lower second premolars, upper lateral incisors, lower second
premolars and lower lateral incisors respectively. The distribution of peg–shaped lateral incisors was 15% and more
unilaterally than bilaterally.
Conclusions: This study reveals a high prevalence of hypodontia (missing teeth and peg-shaped lateral incisors) in
patients with Down syndrome. No explanation other than genetics is immediately available to explain why
hypodontia should represent another phenotypic expression of this trisomy
Keyword:Down's syndrome, Hypodontia, Peg-shaped lateral incisors. (J Bagh Coll Dentistry 2009; 21(1): 98-103)
INTRODUCTION
Many international statistical studies have
been done in different countries on hypodontia, as
it is the most important among the other dental
anomalies.
Missing teeth (tooth agenesis) is one of the
most common developmental problems in
children. The congenital absence of teeth results
from disturbances during the initial stages of tooth
formation: initiation and proliferation, it has a
much higher prevalence in certain groups. (1,2)
Missing teeth may occur in isolation, or as
part of a syndrome. Isolated cases of missing teeth
can be familiar or sporadic in nature. Familiar
tooth agenesis is transmitted as an autosomal
dominant, autosomal recessive, or X-linked
genetic condition (3-6) .
In addition, tooth agenesis has been
associated with more than 49 syndromes. Various
dental abnormalities, particularly hypodontia,
have frequently been reported in children who
also have a cleft lip, cleft palate or both (7) ,
ectodermal dysplasia (8-10) and Down, Rieger and
Book syndrome (11) . Specific terms are used to
describe the nature of tooth agenesis.
(1)Professor, Department of Orthodontics, College of Dentistry,
University of Baghdad.
(2)Assistant lecturer, Department of Orthodontics, College of
Dentistry, University of Baghdad
(3)Assis.Prof, Department of Orthodontics, College of Dentistry,
University of Baghdad
The term hypodontia is used when one to six
teeth, excluding third molars, are missing, and
oligodontia when more than six teeth are absent
(excluding the third molars). Anodontia is an
extreme case, denoting complete absence of teeth.
There is no clear definition in the literature
concerning the limits of these classes. Anodontia
or oligodontia is usually associated with an
unusual but mild systemic abnormality,
ectodermal dysplasia, or congenital syndrome. As
a general rule, if only one or a few teeth are
missing, the absent tooth will be the most distal
tooth of any given type (12,13) .
Hypodontia in the primary dentition is more
common in the maxilla and is frequently
associated with the lateral incisors. Hypodontia
of permanent teeth occurs with equal frequency in
the upper and lower arches and usually affects the
third molar. The type of permanent missing teeth
and the population prevalence for the anomaly
vary with racial group, although females are more
frequently affected excluding the third molar,
population prevalences across the world vary
between 1.6 and 9.6 percent (6,14-17) .
In many populations it has been reported that,
except for third molars, the most commonly
missing teeth are the upper lateral incisor and
lower second premolar. For Europeans, the
mandibular second premolar is the tooth most
frequently absent after the third molar, followed
by the maxillary lateral incisor and upper second
premolar (12) .
Down syndrome, the most common
chromosomal abnormality in man, is caused by
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J Bagh College Dentistry Vol. 21(1), 2009 Hypodontia in Down’s …..
trisomy of all or a critical portion of chromosome
21 (21q22.3). The birth prevalence of trisomy 21
syndrome is 1/650 live births, with the risk of
having a child with Down syndrome increasing
with maternal age (18) .
Down syndrome is characterized by a
combination of phenotypic features that includes
typical dysmorphic features and mental
retardation. Congenital malformations of the heart
(30-40% of the patients) and gastrointestinal tract
are common. Congenital absence of teeth has
been reported in 23 to 47%, One or both primary
upper lateral incisors are missing in more than
10% of the patients, and peg-shaped maxillary
lateral incisors are seen in 10% (18) .
The present study endeavors to achieve the
following:
• To find out the prevalence of hypodontia in
Down’s syndrome patients.
• To find out the distribution of hypodontia
according to sex, type, number, and position of
missing teeth in Down’s syndrome patients.
• To compare the hypodontia according to
gender and site.
MATERIALS AND METHODS
The Sample
This work was carried out in Iraq. The
sample was selected from center of health care for
Down's syndrome (Hibbat-Allah) and patients
attended private dental clinic in Baghdad city.
The sample consisted of 164 Down's syndrome
patients who fulfill the criteria of the sample
selection which are:
1. They are known cases of Down's
syndrome Iraqi nationality with an age ranged 14-
18 years.
2. All subjects with marked facial abnormality or
asymmetry like cleft lip and palate were excluded.
3. Subjects with extracted teeth for the
reason of caries or accident were excluded.
4. Third molars were excluded.
5. Differential diagnosis was done to exclude:
• Impacted teeth.
• Delayed eruption.
• Ectopic eruption.
• Retained deciduous teeth.
• Delayed mineralization.
• Gemination.
Methods
The congenital absence of teeth was
determined by clinical and radiographic
examination.
Clinical examination: All subjects (164) were
subjected to clinical examination under daylight
using dental mirrors and probes. Each one was
seated on a chair with his head and back in
straight position, supported by the wall of the
examination room and they were looking forward
horizontally. For all the cases that were not clearly
diagnosed as hypodontia during clinical
examination, radiographic examination was
undertaken. A tooth was considered congenitally
missing when it could not be seen in the dental
arch or in the radiograph of the region and there
was no history or evidence that it was lost by
accident or extraction.
Radiographical examination: All subjects with
impaction, retained deciduous teeth, gemination,
and delayed development or with space in the
arch were subjected to radiography (periapical,
occlusal and O.P.G.).Radiographs were retaken if
it was not clear. The radiographs were viewed on
a light-box without magnification.
RESULTS AND DISCUSSION
The distribution of hypodontia: Out of 164
subjects with Down’s syndrome resembling the
total sample, 74 cases had hypodontia giving a
percentage of 45.12 % (Males 42.3% and females
47.4%) as shown in table and figure 1. It was
deduced that hypodontia increased 20 folds in
Down syndrome individuals if compared with
other studies (19,20) on normal individuals. While
other study (21) found that the percentage was
59%, this may be due to smaller number of the
sample if compared with the high number of the
present study and difference in ethnic group. The
hypodontia (dental reduction in number or size)
could be the expression of a known decrease in
number (rather than size) of cells in many body
organs due to the slower intermitotic period in
trisomic cells (22,23) . This phenomenon has been
held responsible for the general growth
retardation in Down syndrome (24) .
According to the site, table 2 shows that the
prevalence of hypodontia in the maxilla was
greater than the mandible this is in agreement
with other study (19) . In the maxilla males show
high prevalence of hypodontia on the left side,
while females show high prevalence on the right
side. In the mandible both males and females
show high prevalence on the right side than the
left side. Some investigators have speculated that
blood circulation is impaired in Down syndrome
individuals (25) and an inadequate blood supply to
the upper jaw could hamper its growth and cause
degeneration of the odontoblasts leading to
smaller missing teeth (26) , perhaps it is no
coincidence that there are several phenomena that
occur frequently together and appear to be
concentrated in the anterior maxilla, namely
missing teeth and peg-shaped lateral incisors. On
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J Bagh College Dentistry Vol. 21(1), 2009 Hypodontia in Down’s …..
other hand, other investigators have made an
association between missing teeth and prenatal
peripheral nerve tissue development (27) , where the
more severe neurological disturbance disturbance
in Down syndrome individuals the more missing
teeth will occur (28) .
According to its presence unilaterally or
bilaterally, table 3 shows that the maxillary dental
arch has more unilateral hypodontia than bilateral,
and more in males than females, while the
mandibular dental arch has more bilateral
hypodontia than unilateral and more in females
than males, this is probably due to the females
mandible is smaller than of males, therefore it is
more liable to bilateral hypodontia than unilateral.
According to number of missing teeth in both
genders, table 4 shows that the number of
congenitally missing teeth in females was higher
than in males (Male/female ratio is 0.6:1),this
probably that females had smaller jaw size than
males. Table 5 shows that almost half the sample
(54.05%) had only one congenitally missing
tooth, males had higher percentage of hypodontia
of one tooth, while females had higher percentage
of hypodontia when it involved more than one
tooth missing, this could be due to that all the
skeletal dimensions which harbored the teeth are
smaller in females than males Down syndrome
individuals (29) , therefore females were more liable
to hypodontia of more than one tooth..
According to tooth type for both genders,
table 6 shows that maxillary second premolar is
the tooth the most affected with hypodontia
followed by maxillary lateral incisor,mandibular
second premolar and then mandibular lateral
incisor respectively. But the present study does
not pursue the same agenesis pattern of missing
teeth as in the normal individuals, presumably
indicating a more severe teeth genesis (tooth
formation, timing of calcification, order of tooth
eruption and delay in tooth development) in Down
syndrome individuals.
Regarding the reduced in size and/or pegshaped
maxillary lateral incisors, table 7 shows
the percentage was 15%. It was deduced that this
percentage increased 37 times in Downs
syndrome if compared with other studies (30,31) on
normal individuals. The same table revealed that
males had higher percentage of peg-shaped
maxillary lateral incisors than females with more
occurrence unilaterally than bilaterally; the
distribution on the left side was higher than the
right side (table8), the left side preference of
dental anomalies in Down's syndrome patients is a
finding supported elsewhere in literatures and is
reminiscent of other anomalies such as cleft lip
and palate (32,33) .
Table 9 revealed that 25 cases (15%) of
maxillary lateral incisors were reduced in size
and/or peg-shaped, 4 cases (2%) associated with
hypodontia of the opposite lateral incisor, and in
21 cases (13%) the other lateral incisor was
present. The great prevalence of peg-shaped
maxillary lateral incisors in Down's syndrome
patients in present study could agree with other
study (34) .This provides a strong argument for a
genetic basis to this conditions.
Comparison of hypodontia frequency
according to gender and site for the teeth:
Significant difference was detected between
females and males with regared to maxillary and
mandibular lateral incisors at p0.05. Such findings have been
used as a persuasive argument for a significant
genetic basis for this condition in both arches, and
the genetic modes of transmission may play a
further role for gender distribution of this
condition.
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Table 1: Distribution of hypodontia in the
examined sample.
Gender Subjects Subjects
% Of
with
examined
hypodontia
hypodontia
Males 71 30 42.3 %
Females 93 44 47.4 %
Total 164 74 45.12 %
Figure 1: Prevalence of hypodontia in the
examined sample.
54.88%
Table 2: Frequency and prevalence of hypodontia according to site
Total
Right
Left
N=164
Arch
Males Females Males Females Males Females
N=71 N=93 N=71 N=93 N=71 N=93
Maxilla 9(31.03%) 35(59.32%) 20(68.97%) 24(40.68%) 29(53.70%) 59(65.56%)
Mandible 14(56.00%) 18(58.06%) 11(44.00%) 13(41.94%) 25(46.30%) 31(34.40%)
Total 23(42.60%) 53(59.00%) 31(57.40%) 37(41.00%) 54(100%) 90(100%)
Numbers refer to missing teeth
Table 3: Distribution of hypodontia according to its presence unilaterally or bilaterally.
Arch Tooth Males Females Total
Unilat. Bilat. Unilat. Bilat. Unilat. Bilat.
Lateral Incisor 4 1 2 17 6 18
Maxillary Second premolar 17 3 13 5 30 8
Lateral Incisor 6 6 4 1 10 7
Mandibular Second premolar 3 2 1 12 4 14
Numbers refer to missing teeth
Subjects without
hypodontia
Subjects with
hypodontia
45.12%
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J Bagh College Dentistry Vol. 21(1), 2009 Hypodontia in Down’s …..
Table 4 : Distribution of hypodontia according to number of missing teeth in both genders.
Number of
affected subjects
Number of
missing teeth
Average number of
missing t eeth per subject
Males 30 54 1.80
Females 44 90 2.05
Male/Female Ratio 0.69:1 0.60:1
Total 74 144 1.95
Table 5: Distribution of the subjects with hypodontia by gender and number of missing teeth.
Number of congenitally missing teeth
More than
Four
One tooth Two teeth Three
four teeth Total
teeth
[n(%)] [n(%)] teeth
[n(%)]
[n(%)]
[n(%)]
Males 24(80%) 3(10%) 3(10%) 30(100%)
Females 16(36.36%) 18(40.91%) 4(9.09%) 5(11.36% 1(2.28%) 44(100%)
)
Total 40(54.05%) 21(28.38%) 7(9.46%) 5(6.76%) 1(1.35%) 74(100%)
Numbers refer to cases with hypodontia
Table 6: Frequency and prevalence of hypodontia according to tooth type for both genders.
Arch Tooth Males
N=71
Lateral 5
|Maxillary
Incisor (7.04%)
Second
4
premolar (5.63%)
Lateral 12
Mandibular
Incisor (16.90%)
Second
2
premolar (2.81%)
Right
Females Total
N=93 N=164
18
23
19.35%) (14.02%)
17
21
(18.27%) (12.80%)
5
17
(5.37%) (10.37%)
13
15
(13.98%) (9.15%)
N= Number of the sample
Males
N=71
1
(1.40%)
19
(26.76%)
6
(8.45%)
5
(7.04%)
Left
Females
N=93
18
(19.35%)
6
(6.45%)
1
(1.08%)
12
(12.90%)
Total
N=164
19
(11.59%)
25
(15.24%)
7
(4.27)
17
(10.37%)
Total
42
(25.61%)
46
(28.04%)
24
(14.64%)
32
(19.52%)
Table 7: Distribution of reduced in size and /or peg shaped maxillary lateral incisors by gender
occurrence and presence unilaterally or bilaterally.
N(%) Unilaterally Bilaterally
Males 17 (10%) 16 1
Females 8 (5%) 7 1
Total 164 (15%) 23 2
N: refers to number of subjects
Table 8: Distribution of reduced in size and /or peg shaped maxillary lateral incisors according to
gender in each side.
Gender 17 Males 8 Females Total
Side Right Left Right Left Right Left
N(%) 4 (15%) 14 (52%) 2 (7%) 7 (26%) 6 (22%) 21 (78%)
Total 18 (67%) 9 (33%) 27 (100%)
N= Number of the peg lateral .
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J Bagh College Dentistry Vol. 21(1), 2009 Hypodontia in Down’s …..
Table 9: Prevalence and frequency of reduced in size and /or peg shaped maxillary lateral
incisors.
Males Females Total
3 On right side 1 On left side
Other side absence 4 (2%)
(4%) (1%)
14 On left side 7 On right side
Other side present 21 (13%)
(20%) (8%)
25 (15%)
Total 17 (24%) 8 (9%)
Table 10: Comparison of frequency of hypodontia according to gender for the teeth.
Arch Tooth Males Females Total χ 2 Significance
Lateral
42
6 (11.11%) 36 (40%)
9.656 *
Incisor
(29.16%)
Maxillary
Second
premolar 23 (42.59%) 23 (25.55%) 46
3.066 NS
(31.94%)
Lateral
18 (33.33%) 6 (6.66%) 24 (16.66%) 14.400 *
Incisor
Mandibular
Second
7 (12.96%) 25 ( 27.77%) 32 (22.22%) 3.333 NS
premolar
Total missing teeth 54 (100%) 90(100%) 144(100%) …….. ……..
* =Significant “p0.05”, d.f. =1
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J Bagh College Dentistry Vol. 21(1), 2009 Malocclusion of Primary …..
Malocclusion of primary dentition among kindergarten
children in Zayona part of Baghdad City.
Shahbaa A. M. Al- Ajwadi, B.D.S., M.Sc.
ABSTRACT
Background: The aim was to evaluate the type of malocclusion in primary dentition to give the parents information
about their child future teeth in order to try to minimize the malocclusion in permanent dentition.
Materials and methods: An oral health survey was conducted among 200 kindergarten children aged 4-5 years from
randomly selected kindergarten in the Zayona part of Baghdad city. The numbers of females were 100 and the
numbers of males were 100.
Results: Highest percentage of children showed mesial terminal end( 60.5%) followed by flat terminal end( 29%) and
the smallest percentage for distal terminal end( 10.5%),high percentages of children showed Cl I Canine relation and
Cl I over jet relation followed by ClI and small percentage showed ClII canine and over jet relation.
Conclusion: Most children had mesial terminal end so will guide the permanent first molars to Cl I molar relation, and
most children had Cl I canine and over jet relation so we will expect the future permanent teeth will be within normal
over jet and canine relation.
Key words: Malocclusion, primary dentition, over jet. (J Bagh Coll Dentistry 2009; 21(1): 104-106)
INTRODUCTION
Malocclusion refers to any degree of irregular
contact of the teeth of the upper jaw to the teeth of
the lower jaw. There is no single cause of
malocclusion. Many different factors are involved
including genetic factors and/or environmental
factors (1) . Baume (2) in his classic articles in the
1950 showed that the relationship of the primary
teeth could be divided into three categories:
1. Straight terminal plane.
2. Mesial step terminal plane.
3. Distal step terminal plane.
The mesial step is on ideal relationship that
guides the permanent first molars in to a
favourable class I intercuspation. The straight
terminal plane, which is by far the most
frequently occurring relationship is the one that
must be observed the critically, it can quid the
permanent molars into a normal class I or
abnormal class II, the distal step, as rule guides
the permanent first molars into an abnormal class
II malocclusion (3) .The over jet is measured as the
greatest distance between the incisal edges of the
maxillary and mandibular incisors in the occlusal
plane (2-4mm) normally (4) ,according to Foster
and Hamilton (5) , over jet is defined as horizontal
over lap of the incisors. If the lower incisors are in
front of the upper incisors, the condition is called
lower over jet, reverse over jet, or anterior cross
bite (6) . Developing class III malocclusion is
clinically expressed as anterior cross bite in the
primary dentition (7) .
(1) Assistant lecturer, department of orthodontics, college of
dentistry, university of Baghdad.
The malocclusion could be classified
awarding to the upper and lower canines relation
the upper canine should occlude into the
Embrasure between the lower canine and first
molar. In class II cases, the embrasure between
the lower canine and first molar will be distal to
the cusp of the upper canine, whereas in class III
cases, it will be far for forwards (8) .
Classification of occlusion in the permanent
dentition describes relationship of the buccal
surfaces of the maxillary and mandibular first
molars ) . In the primary dentition, classification is
routinely based on the anteropostesterior distanceterminal
plane difference between the distal
surfaces of the opposing primary maxillary and
mandibular second molars. Investigations have
focused on the types of terminal plane
relationships in the primary dentition in an effort
to forecast occlusal relationships in the permanent
dentition (10,11) .
This study aimed to evaluate occlusal
deviations in the deciduous dentition that can
adversely affect the permanent dentition.
MATERIALS AND METHODS
The sample consists of 200 kindergarten
children age of 4-5 years. All kindergartens in
Zayona part of Baghdad city were chosen
according to a random statistical table, permission
was obtained from Ministry of Education in Iraq.
The number of kindergartens was about 6 schools;
each child was seated upright in a normal chair
and was observed in centric occlusion under
natural day light using a mirror and a vernia
caliper. The criteria used in this study depend on
Baume classification of primary teeth (1) , because
the chosen age was 4-5 years and no one child had
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J Bagh College Dentistry Vol. 21(1), 2009 Malocclusion of Primary …..
permanent first molar yet. Especial case sheet was
prepared for each child which contain in addition
to name, gender, age, the malocclusion involved
mesial terminal end (M.T.E), distal terminal end
(D.T.E) and flat terminal end (F.T.E) the analysis
was done by simple method of collection of the
frequency of each malocclusion and its
percentage. In this study in order to create a stable
centric occlusion, the children were examined in a
seated position and natural light, mouth mirror
used with a vernia for evaluation.
RESULTS
Table 1 showed that 60.5% of children had
M.T.E, 10.5% had D.T.M and 29% had E.T.E.
The percentage of M.T.E children was 68.6%
males and 43.8% females, the percentage of
D.T.E children were 47.6% for males and 52.4%
for females, and the percentage of F.T.E were
37.9 for males and 62.1 for female. The high
percentage was noticed for children with M.T.E
which will end according to Baume classification
to class I malocclusion and the next percentage
was for F.T.E and lastly D.T.E. the F.T.E may end
with Cl I or Cl II malocclusion, and the D.T.E
will end with an abnormal Cl II malocclusion.
Table 1: Frequency and percentage of
malocclusion (M.T.E, D.T.E, F.T.E).
Teeth relation
Male Female Total
Freq. % Freq. % Freq. %
M.T.E 68 68.6 53 43.80 121 60.5
D.T.E 10 47.6 11 52.4 21 10.5
F.T.E 22 37.9 36 62.1 58 29
Total 100 50% 100 50% 200 100%
Table 2: Frequency and percentage of each
type of malocclusion according to canine
relation.
Type of
malocclusi
on
M.T.E
M.T.E
M.T.E
D.T.E
D.T.E
D.T.E
F.T.E
F.T.E
F.T.E
Canine
classificati
on
C I
C II
C III
C I
C II
C III
C I
C II
C III
Males Females Total
Fre Fre Fre
% %
q. q. q.
%
53
54. 45.
45
1 9
98 80.9
8 80 2 20 10 8.3
7
53. 46.
6
8 1
13 10.7
4
zer
100 zero
o
4 19.1
6
35. 64.
11
3 7
17 80.9
zer zer
zero zero
o o
Zero Zero
16
43. 56.
21
2 8
37 63.8
4
26. 73.
11
7 3
15 25.9
2
33. 66. 10.3
4 6
3 7 5
Table 2 showed that the frequency and
percentage of each class of malocclusion (M.T.E,
F.T.E and D.T.E) each classified according to
deciduous canine relation on to Cl I, Cl II and Cl
III. Mesial terminal end molar relation child
showed the highest percentage for Cl I canine
relation (80.99%) followed by flat terminal end
(63.8%) and lastly by distal terminal end
(19.05%). The highest percentage of Cl II canine
relation was observed in D.T.E children (80.9%),
followed by flat terminal end (25.9%) and lastly
M.T.E (8.3%).The higher percentage of Cl III
canine relation was observed in M.T.E (10.7%)
followed by F.T.E (10.35%) and no D.T.E was
recorded.
Table 3 showed the frequency and percentage
of malocclusion according to O.J classification.
The highest percentage of Cl I O.J relation was
observed in M.T.E children (78.5%) followed by
F.T.E children (50%) and lastly D.T.E (33.3%).
The highest percentage of CII O.J. relation was
observed in D.T.E children (66.6%) followed by
F.T.E (41.4%) and lastly M.T.E (10.7%).The
highest percentage of CIII O.J relation was
observed in F.T.E children (8.6%) followed by
M.T.E (6.6%) and lastly D.T.E zero (%).
Table 3: Frequency and percentage of each
type of malocclusion according to over jet
relation.
Type of
malocclusi
on
M.T.E
M.T.E
M.T.E
D.T.E
D.T.E
D.T.E
F.T.E
F.T.E
F.T.E
O.J
classificati
on
C I
C II
C III
C I
C II
C III
C I
C II
C III
Males Females Total
Fre Fre Fre
% %
q. q. q.
%
51
53. 46. 78.
44 95
7 3 5
9
69. 30. 10.
4 13
2 8 7
8
zer
100 zero
o
8 6.6
6
85. 14. 33.
1 7
8 3 3
4
28. 71. 66.
10 14
6 4 6
zer zer zer
zero zero zero
o o o
12
41. 58.
17
4 6
29 50
10
41. 58. 41.
14 24
7 3 4
zer
zero
o
5 100 5 8.6
DISCUSSION
In order to foresee the possibility of
malocclusion treatment in the permanent
dentition, one should know the occlusion and/ or
the malocclusion in the primary dentition (12) .
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J Bagh College Dentistry Vol. 21(1), 2009 Malocclusion of Primary …..
In the present study the primary second molar
occlusal relationship was observed to be on the
mesial terminal plane about (60.5%). Bishara et
al (13) evaluated the changes that occur during the
passage from primary second molar relationship
to permenant first molar relationship. They stated
in the cases showing flat terminal end in the
primary dentition 56% Cl I and 44% Cl II
relationship developed in the permanent dentition.
Zigmond (14) and later Chapman (15) observed
that in the occluded primary dentition the distal
surface of the maxillary and mandibular second
molars were approximately flat terminal end, and
Friel (16) suggests that the coincidental nature of
the opposing primary maxillary and mandibular
second molars is due to the differential
mesiodistal crown width of the teeth the
mandibular being wider than the maxillary second
molar causing flat terminal plane.
In this study, the most common relationship
in primary canine was found to be Cl I followed
by Cl II and small percentage showed Cl III
canine relation. The differences in the results of
both primary canine and primary molar
relationship spring from the methods used in the
researches and the number of sample.
A review of other researches showed that
most common form of primary canine relationship
is class I in ethnic group (17-19) which are agree
with this research.
Although the results of this present study
about the frequency of Cl II and Cl III primary
canine relationship are consistent with the result
reported by Banker et al (19) they conflict with the
results of other research (20,21) which showed the
highest percentage of canine relation were Cl II.
REFERENCES
1. Ngan P, Fields H. Orthodontic diagnosis and treatment
planning in the primary dentition. J Dent Child
1995;62:25-33.
2. Baume L. Developmental and diagnostic aspects of the
primary dentition. Int Dent J 1959; 349-66.
3. Proffit RW, Field HW. Contemporary orthodontics; 2 nd
ed, Mosby year book 1993.
4. Foster TD. A text book of orthodontic .2 nd ed,
Blackwell scientific publication, 1985.
5. Foster TD, Hamilton M. Occlusion in the primary
dentition .study of children of 2.5 to 3 years of age.
Br Dent J 1969; 126:76-9.
6. Bishara SE. Text book of orthodontic. WB. Saunders
company;1 st ed ,2001.
7. Jones ML, Oliver RG. Wather and Houston
orthodontic notice.5 th ed, Professional publishing
L.T.D 2000.
8. Graber TM .Vandersdall RL. Orthdontics current
principles and techniques.2 nd ed, Mosby. 1984.
9. Tschill P, Bacn W, Soko A. Malocclusion in the
deciduous dentition of Caucasian children. Eur J
Ortho 1997; 19:361-7.
10. Nanda RS, Khan I, Anand R. Age changes in the
occlusal pattern of deciduous dentition. J Dent Res
1973; 52: 221-4.
11. World Health Organazation. Oral health surveys
basic methods. 4 th ed .1997.
12. Farrira RI, Aves AC, Barrier AK, Soares CD.
Prevalence of normal occlusal characteristics on
deciduous. J Dent Res 2000; 79:1159 (abstract B-
345).
13. Bishara SE, Hoppen SBG, Jakopsen JR, Kobout F.
Changes the molar relationship between the
deciduous and permanent dentition; longitudinal
study. Amj Orthod Dentofa Orthop 1988; 93: 19-28.
14. Zsigmondy O. Ueber die Varanderungen des
Zahnbogens bei der zweiten Dentition. Archiv Fur
Entwick Geschichte 1890; 14; 367-90.
15. Chapaman H. The development of deciduous
occlusion. Tr Brit Soc for the study of orthodontics
Bristol, England: Published for the Society by
Wright; 1988: 10-18.
16. Friel S. The development of ideal occlusion of the
teeth. Am J Orthodont 1954; 40: 196-227.
17. Thomas C, Townced G, Richards L. Occlusal
variability in the primary dentition of Australian
Children J Dent Res 2000; 79: 1056 (abstract C.33).
18. Otuyemi OD, Sote EO, Isiekwe MC, Jones SP.
Occlusal relationships and spacing or crowding of
teeth in the dentition of 3-4 years (Old Nigrian
Children). Int J Paediatr Dent 1997; 7: 155-60.
19. Banker AC, Berlocher CW, Muller HB. Primary
dental arch characteristics of development. Mexican.
American Children. J Dent Child 1984; 51: 200-2.
20. Farsi NMA, Salama FS. Characteristics of primary
dentition occlusion in a group of Saudi children. Int J
Pediat Dent 1996; 6: 253-9.
21. Stahl F, Grabowski R. Orthodontic findings in the
deciduous and early mixed dentition: inferences for a
preventive stategy. J Orofac Orthop 2003; 64; 401-6.
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J Bagh College Dentistry Vol. 21(1), 2009 Mandibular antegonial …..
Mandibular antegonial notch depth distribution and its
relationship with craniofacial morphology in different
skeletal patterns
Yassir A. Yassir B.D.S., M.Sc. (1)
Ausama A. Al-Mulla B.D.S., Dr.D.Sc. (2)
ABSTRACT
Background: Antegonial notch is a small concavity at the inferior surface of the mandible. The purpose of this study is
to identify the distribution of mandibular antegonial notch depth and its relationship with craniofacial morphology in
different skeletal patterns.
Materials and method: The sample included 191 pretreatment digital lateral cephalometric radiographs (93 males,
98 females) collected from the Orthodontic Department in the College of Dentistry, University of Baghdad. The
sample was divided into three groups according to the skeletal classes, and then each group divided according to
depth of mandibular antegonial notch into: shallow, medium, and deep groups. Sixteen angular and thirteen linear
measurements were used.
Results: Cl I had the highest percentage of medium antegonial notch. Cl II had the highest percentage of deep
notch, while Cl III had the highest percentage of shallow notch. Males had significantly deeper notch than females in
Cl I and Cl II. Significant difference found between males skeletal Cl II and Cl III. The craniofacial measurements
showed significant changes with the increase in antegonial notch depth variably in different classes.
Conclusions: Angular measurements of cranial base more concerned with mandibular morphology than linear
measurements. The increase in vertical growth pattern and backward rotation of the mandible in association with
the increase in notch depth appeared particularly in skeletal Cl II.
Keywords: antegonial notch, craniofacial morphology, skeletal patterns. (J Bagh Coll Dentistry 2009; 21(1): 107-111)
INTRODUCTION
A successful treatment of malocclusions often
depends on appropriate orthopedic intervention
to correct underlying skeletal discrepancies. The
ability to predict the magnitude and direction of a
patient's facial growth early in life would enable
the clinician to identify those who required
interceptive growth identification and to ensure
that the appropriate treatment can be rendered
while growth is possible, and to forego
unnecessary treatment on patients with skeletal
discrepancies whose growth pattern would
probably lead to correction without orthopedic
intervention. (1) Directional growth prediction has
assumed greater relevance with the increased
realization that considerable individual variation
occurs in craniofacial growth and morphology. (2)
Since Broadbent (3) in his pioneering work on
facial growth, suggested that the face of the
average person develops downward and forward
in more or less a straight line, many studies have
shown that individual variation does occur. (4-6)
Of special importance is the fact that the
mandible, as a result of rotation during growth,
can develop either protrusively or retrusively in
relation to the maxilla and cranial base in
different subjects. (7)
(1) Assistant lecturer, Department of Orthodontics, College of
Dentistry, University of Baghdad.
(2) Professor, Department of Orthodontics, College of Dentistry,
University of Baghdad.
Mandible which demonstrates backward and
downward rotation during growth experience
pronounced apposition beneath the angle with
excessive resorption under the symphysis. (4-6)
The resulting upward curving of the inferior
border of the mandible anterior to the angular
process (gonion) is known as antegonial
notching. (8) Subjects with deep antegonial
notching have been reported to have disturbed
condylar growth. (9-12) Other studies have shown
that the mandibular growth potential is
diminished in subjects with pronounced
antegonial notching. (13) Several studies done to
find relation between antegonial notch depth and
direction of mandibular growth, most of them
found subjects with deep antegonial notch
associates with vertical growth pattern (8,13) , and
the above previous studies found that deep
antegonial notch become deeper during growth
and shallow antegonial notch become shallower
during growth.
MATERIALS AND METHOD
The sample
The sample of the present study included 191
pretreatment digital lateral cephalometric
radiographs which had been collected from the
files of the patients who attended the Orthodontic
Department, in the College of Dentistry,
University of Baghdad. All the patients are Iraqi
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J Bagh College Dentistry Vol. 21(1), 2009 Mandibular antegonial …..
in origin with complete permanent dentition and
age range between 18-25 years. No history of
previous orthodontic, orthopedic or surgical
treatment was present. Sample classification
depended on the sagittal skeletal classification
according to Houston (14) , Foster (15) , Rani (16) ,
Mitchell and Carter (17) :
Skeletal Cl I: 2° ≤ ANB ≤ 4°.
Skeletal Cl II: ANB > 4°.
Skeletal Cl III: ANB < 2°.
Every lateral cephalometric radiograph was
digitized by AutoCAD (2007) software computer
program to calculate angular and linear
measurements. First of all every radiograph was
copied twice; one for angular and one for linear
measurements, then cephalometric points were
located for each one and lines joined between
these points to form angles and planes.
Figure 1: Cephalometric angular
measurements. 1: SNA. 2: SNB. 3: ANB. 4: N-S-
Gn. 5: SN- Mandibular plane. 6: SN-Maxillary plane.
7: N-S-Ba. 8: S-N-Pog. 9: N-S-Ar. 10: S-Ar-Go. 11:
Ar-Go-Me (Gonial). UGo: upper gonial angle. LGo:
lower gonial angle. 12: lower incisor/mandibular
plane angle. 13: upper incisor/maxillary plane angle.
sheet for the whole sample (each class
separately); angular measurements were taken
directly, while linear measurements were divided
by scale for each picture to overcome
magnification factor (the ruler of the nasal
positioner used to calculate the magnification
factor).
The sample of each skeletal class classified
into three groups according to the depth of
mandibular antegonial notch: shallow (< 1mm.),
medium (≥ 1─ < 3), and deep (≥ 3), and analyzed
statistically. Figure 1and 2 show the angular and
linear measurements used in this study.
Table 1: Genders' differences of AGN depth
(in mm) by student t-test in the classes of
skeletal pattern and differences between
classes of skeletal pattern for AGN depth by
ANOVA test according to gender.
Gender differences
Skeletal Males Females
(t-test)
Pattern
Mean Mean t d.f. P
Class I 2.258 1.660 2.998 73 0.004**
Class II 2.546 1.724 3.964 76 0.000***
Class III 1.826 1.552 0.962 36 0.343
F 3.409 0.318
d.f. 92 97
p 0.037* 0.729
Table 2: Least significant difference (LSD)
test of males in different skeletal patterns
for the mean values of AGN depth.
Skeletal Pattern p
Class I Class II 0.222
Class I Class III 0.127
Class II Class III 0.011*
Figure 2: Cephalometric linear
measurements. 1: anteroposterior extent of anterior
cranial base. 2: lateral extent of cranial base. 3: ramus
length. 4: mandibular body length. 5: total mandibular
length. 6: maxillary base length. 7: ramus notch depth. 8:
antegonial notch depth. AFH: total anterior facial height.
UFH: upper facial height. LFH: lower facial height. PFH:
posterior facial height.
After classifying the sample according to the
skeletal patterns, sixteen angular and thirteen
linear measurements were recorded for each
radiograph. All measurements were put in excel
All the data of the sample were subjected to
computerized statistical analysis using SPSS
software computer program version 11.00. The
statistical analyses included:
• Paired t-test: For intra and inter-examiner
calibrations.
• Student t-test: To detect the genders'
differences of antegonial notch total depth in
the three skeletal classes.
• Chi square test: To find the distribution of
the patients according to AGN depths.
• ANOVA and LSD post hoc tests: used to
detect the statistically significant differences
between skeletal classes for antegonial notch
depth and to detect the statistically significant
differences in the mean values of different
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J Bagh College Dentistry Vol. 21(1), 2009 Mandibular antegonial …..
craniofacial measurements with shallow, medium
and deep antegonial notch depth groups.
P values less than 0.05 were considered as
statistically significant.
Table 4: Least significant difference test for
the craniofacial measurements of skeletal Cl
I according to the depth of AGN.
Cl I
Antegonial Notch
Variables
Shallow - Shallow - Medium -
Medium Deep Deep
p p p
Ramus Notch 0.453 0.071 0.005**
N-S-Gn 0.948 0.046* 0.016*
U1/Max.P 0.032* 0.774 0.021*
Figure 3: Graphical presentation of the
distribution of the patients according to
AGN depths. X 2 =7.207, d.f. =4, NS.
Table 3: ANOVA test for the craniofacial
measurements of skeletal Cl I, Cl II and Cl
III according to the depth of AGN.
Variables p p P
Ramus Notch Depth 0.020* 0.010** 0.168
Cranial
Measurements
Facial Angles
and Facial
Convexity
S-N 0.370 0.331 0.687
S-Ar 0.351 0.107 0.931
N-S-Ar 0.078 0.003** 0.931
N-S-Ba 0.058 0.001*** 0.972
SNA 0.457 0.859 0.541
SNB 0.343 0.986 0.710
ANB 0.798 0.578 0.700
Measurements S-N-Pog 0.098 0.729 0.920
AFH 0.369 0.000*** 0.312
Facial Heights
Measurements
Mandibular
and Maxillary
Rotation
Measurements
UFH 0.905 0.050* 0.787
LFH 0.130 0.000*** 0.242
PFH 0.239 0.004** 0.441
JR 0.401 0.627 0.125
SN-MP 0.299 0.054 0.130
N-S-Gn 0.047* 0.024* 0.384
S-Ar-Go 0.294 0.001*** 0.879
Ar-Go-
Me
0.374 0.073 0.221
UGo 0.671 0.001*** 0.914
LGo 0.255 0.000*** 0.253
SN-
Max.P
0.111 0.150 0.762
ANS-PNS 0.443 0.872 0.724
TML 0.829 0.079 0.441
Ar-Go 0.423 0.061 0.299
Mandibular
and Maxillary
Length
Measurements Go-Me 0.257 0.762 0.374
Incisors L1/MP 0.785 0.052 0.254
Inclination U1/Max.P 0.019* 0.683 0.861
Measurements U1/L1 0.147 0.879 0.805
Angular measurements in degree
Linear measurements in mm.
Table 5: Least significant difference test for
the craniofacial measurements of skeletal Cl
II according to the depth of AGN.
Variables
Cl II
Antegonial Notch
Shallow
-
Medium
Shallow
- Deep
Medium
- Deep
p p p
Ramus Notch 0.023* 0.003** 0.190
N-S-Ar 0.340 0.003** 0.004**
N-S-Ba 0.352 0.001*** 0.001***
AFH 0.670 0.000*** 0.000***
UFH 0.186 0.563 0.018*
LFH 0.780 0.000*** 0.000***
PFH 0.615 0.006** 0.002**
N-S-Gn 0.866 0.064 0.008**
S-Ar-Go 0.154 0.001*** 0.003**
UGo 0.143 0.000*** 0.002**
LGo 0.670 0.005** 0.000***
RESULTS AND DISCUSSION
Genders' differences and classes' differences
Both in skeletal Cl I and Cl II males had
significantly deeper notch than females, so it
may be regarded (the notch) as one of the linear
measurements of craniofacial morphology which
are usually higher in males than females. This
finding agrees with Dutra et al (18) who stated that
the antegonial notch depth was significantly
greater for males than females (table 1).
According to the classes' differences the
significant difference between the mean values of
the AGN of males found to be present mainly
between skeletal Cl II and skeletal Cl III (table
2); this may be attributed to extreme difference
in the direction of mandibular growth in these
skeletal classes.
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J Bagh College Dentistry Vol. 21(1), 2009 Mandibular antegonial …..
Distribution of antegonial notch depth
The highest percentage of the patients fell in
the medium group of the notch depth, so it may
be regarded as the normal range for the AGN
depth with normal condylar and ramus growth.
The highest percentage of the deep notch (DN)
found in skeletal Cl II, while the highest
percentage of shallow notch (SN) found in
skeletal Cl III. These findings may be related to
the direction of the growth of the mandible,
which agree with Lambrechts et al (8) , and
Mitchell et al (17) who mentioned that there is an
association between pronounced notching of the
lower mandibular border and the vertical growth
pattern (backward rotation of the mandible), and
shallow notching with the horizontal growth
pattern (forward rotation of the mandible) (figure
3).
Relationships of the craniofacial morphology
with the antegonial notch depth
Ramus notch depth
Skeletal Cl I: There was a significant difference
in the mean values of the ramus notch depth, but
it was only significantly higher in the deep than
the medium AGN group (table 3, 4); Al-Attar (19)
found that the ramus notch is significantly higher
in the DN than that of SN group. This may
indicate that these morphological variations of
the mandible tend to be associated together in
their depths.
Skeletal Cl II: The ramus notch was significantly
smaller in SN subjects compared to that of
medium notch (MN) and DN subjects (table 3,
5). This may come in accordance with
Lambrechts et al (8) , and also with Ali et al (20) who
found a close relation of the increased
mandibular antegonial notch depth and ramus
notch depth particularly when associated with
condylar bone changes, and this suggests that
condylar remodeling might therefore be closely
related to changes in craniofacial morphology,
especially mandibular morphology.
Cranial measurements
Skeletal Cl II: The saddle angle (N-S-Ar) and the
cranial base angle (N-S-Ba) were significantly
smaller in the DN subjects than that of MN and
SN subjects (table 3, 5), this mean that when
these angles open the notch becomes shallower.
Enlow (21) has suggested that an acute cranial
base angle has a mandibular protrusive effect
which would tend to offset the retrusive effect of
the short mandible reported in DN subjects. The
finding of decrease in notch depth when the
cranial base angle increase agrees with
Houghton (22) who believed that a more obtuse
cranial base angle is the most important cranial
factor involved in the formation of ''rocker
mandibles'' (rocker mandibles are mandibles with
no distinct AGN).
Facial heights measurements
Skeletal Cl II: The increase in the AFH, LFH and
PFH (table 3, 5) may give an indication that the
increase in the mandibular antegonial notch
depth in skeletal Cl II associated with a tendency
toward a long face syndrome without open bite.
Schendel et al (23) found that the principal
differences between long face syndrome with and
without openbite were the increase in the PFH
and ramus height in the long face syndrome
without openbite group, while AFH and LFH
were increased in both groups.
Mandibular and maxillary rotation measurements
Skeletal Cl I: The higher mean value of the N-S-
Gn angle in the DN group than that of MN and
SN groups (table 3, 4), indicates that as the
mandible rotates backward and posteriorly
positioned the notch becomes deeper.
Skeletal Cl II: With the exception of the UGo
angle there were general increase in mandibular
rotation angles in deep notch group (table 3, 5),
which suggest that the notch becomes deeper
when there is a tendency toward a backward
rotation of the mandible.
Isaacson and associates (24) suggested that the
amount of condylar growth indirectly affects the
direction of mandibular rotation, if the sum of
vertical growth at the midfacial sutures and the
alveolar processes exceeds the component of
vertical condylar growth, then the mandible
should exhibit a backward rotational growth
pattern. DN group had reduced condylar growth,
so they will be subjected to a backward rotation
of the mandible.
These findings mean that the depth of AGN
positively correlated with backward rotation of
the mandible and demonstrate a pattern of bone
remodeling as described by BjÖrk and Skeiler (6) ,
''whereby the anterior part of the corpus is
pressed down into the matrix resulting in
resorption at the lower surface of the symphysis,''
while, ''the posterior part of the corpus is lifted
up from the soft tissue matrix, stretching the
periosteum, and apposition takes place below the
angle.''
S-Ar-Go angle was higher in deep compared
to the medium and shallow notch subjects, (table
3, 5), this may be attributed to the compensation
of the saddle and articular angles to each others,
so when the saddle angle decreases the articular
angle increases resulting in increase in AGN
depth.
N-S-Gn angle was significantly higher in the
DN than MN groups (table 3, 5), this indicates
that as the mandible becomes steeper and
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J Bagh College Dentistry Vol. 21(1), 2009 Mandibular antegonial …..
backward positioned the notch deepens, which
come in agreement with Singer et al (13) ,
Lambrechts et al (8) , Wu and Zhang (25) , and Zhang
et al (26) . This vertical growth pattern also
explains the increase in the AFH.
The mean value of SN-Max.P angle showed no
significant difference between the groups (table
3), which may contribute to the increase in the
lower facial height as that reported by Proffit et
al (27) , ''In long face individuals, who have
excessive lower anterior face height, the palatal
plane rotates down posteriorly''.
REFERENCES
1. Kolodziej RP, Southard TE, Southard KA, Casko
JS, Jakobsen JR. Evaluation of antegonial notch
depth for growth prediction. Am J Orthod Dentofac
Orthop 2002; 121(4): 357-63.
2. Hirschfeldt WJ, Moyers RE. Prediction of
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