Volume 2 - Issue 2 - IJMD

From the Editor’s deskFrom the Editor-in-chiefxxxxxxxxxLast issue’s editorial provoked lots of mycolleagues to pour their own ideas regardingthe insistence of governing councils of medical/dental education regarding publications. They felt thatthe present academic set up and curriculum, unlessrevised or revamped radically, is unlikely to makeresearch the main focus of the staff and the students.Hence this editorial continues my views on themedical/dental education systems. My perception thatmedical and dental education of a student dependedon so many years of studying under dedicated teachers,with probably a reasonable quantum of infrastructureand equipments underwent a radical revision when Iattended the research council meet of the University.One of the speakers asked the audience why his prodigychild should not complete her course in three yearsinstead of the five plus years when she can pass theexaminations in flying colours and meet the expectedcriteria within three years. He said she gathers moreknowledge through internet in a fraction of the timeit would take to accrue the same by slogging throughvoluminous books in musty libraries. Quite true. Whatwe want are results and not the process. When someonecan achieve the results much faster than others, is notthe present system of fixed duration courses standingin the way of the growth of the student, wasting theprecious productive time which could otherwise befruitfully engaged in acquiring more knowledge andskill? Are we not tailoring the student and his/herpotential to the insular boundaries of courses designeddecades ago when information technology was not inexistence and conventional therapeutic modalities ruledthe arena of patient’s treatments rather than evidencebased medicine? Are we not trying to train, ratherimpede a medical student to go by bullock carts in aten-lane highway where zipping cars are the byword?Further discussions in the research council on researchwork done by the staff really provoked some of theattendees who had poured their heart and soul intomedical/dental education for more than thirty years.One of them asked what exactly research is? Not outof ignorance, but out of his desire to point out theDr KMK MasthanProfessor and Head,Department of Oral Pathology and MicrobiologySree Balaji Dental College and HospitalChennaifallacy of assuming that research is something youdo surrounded by microscopes, impressive gadgetsand wearing a stained oversized coat. None of thetrue inventors seemed to have had such wherewithaland paraphernalia when they tackled their discoveriesand inventions. Sophisticated equipments are notmandatory for research.Now are the teachers of medicine and dentistry readyto take up research as part of their work? To be frank,willingness is there. But the exposure and trainingcircumscribe their effectiveness. How to overcome thisobstacle? For immediate purposes and near future,they can be sent to institutions which are focused onresearch like Tata Institute of Fundamental Research,Mumbai and AIIMS, Delhi etc. for familiarization andcrash courses in research methodology and protocols.But in the long run, catching them young alonewill work. What I try to convey is to introduce theconcept of research to the undergraduates as part oftheir syllabus and seed an aptitude and encouragetheir attitude towards research activities. Teachingand research should be interwoven in post graduationcourses as a mandate. In addition to this, employingteachers familiar to research can impact the thinkingtrends of students. To quote Confucius - “You hear andyou forget, You see and you remember, You do and youunderstand‘’.Another aspect of medical education that needs editingand improvement is adaptation of newer trends andtechnologies. Once you are trained in a certain patternIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012423

From the Desk of IJCP Group Editor-in-ChiefxxxxxxxxxHow long one can keep the money earned out ofCorrupt PracticesIs it eight years as defined by Chanakya in his sastra. Chanakya Neti Sastra (Political Ethics ) described thatthe cycle of corruption and any earning by unfair meanscannot last for more than eight years. Chanakya  said thatpeople who acquire money by unrighteous means will haveto pay back to the society within next eight years. Right orwrong, whether one believes in Chanakya Neti or not, thisrule provides youngsters a message to follow the right pathof truthfulness. Eight years mentioned by Chanakya is anarbitrary number and can vary plus-minus a few years.In Bhagwad Gita also Lord Krishna wrote that everybody hasto pay the price of oneâ€s good or bad deeds (Karma) sooneror later. As per Krishna, it is a sum total of bad and good deedswhich decides the ultimate fate of a person.Dr KK AggarwalPadma Shri and Dr BC Roy National AwardeeSr. Physician and Cardiologist, Moolchand MedcityPresident, Heart Care Foundation of IndiaGroup Editor-in-Chief, IJCP GroupEditor-in-Chief, eMedinewSChairman Ethical Committee, Delhi Medical CouncilDirector, IMA AKN Sinha Institute (08-09)Hony. Finance Secretary, IMA (07-08)Chairman, IMA AMS (06-07)President, Delhi Medical Association (05-06)emedinews@gmail.comhttp://twitter.com/DrKKAggarwalKrishan Kumar Aggarwal (Facebook)This law is also true for unfair practices. Public cannot bebefooled for more than eight years in succession. The classicalexamples can be seen in different health waves India has seen over the last three decades. In early 80s, SherryLewis Weight Management Programme came like a storm, stayed in the market for few years and then vanishedaltogether. At that time, everyone was crazy for getting their weight management done the Sherry Lewis way.Obesity is a disease and weight management is a medical program and advertising it is not allowed and thereforeis an unfair practice.Then came the era of Personal Point with a chain of weight management centres opened all over the country. Thischain also remained in limelight only for a few years. This wave was followed by the chain of Vandana Luthra.She is persisting in the market to some extent as she keeps on diversifying into other fields.Weight management era was followed by an era of Reiki. During this period, newspapers were full of Reikiadvertisements and every second person in the family wanted to become a Reiki master. This era also lasted onlyfor a few years.In the field of Yoga also, we saw similar waves. In Indira Gandhiâ€s time, Dhirender Brahmachari created a wavethrough the media. His wave also lasted only for a few years and now a similar wave seems to have been createdby Yoga Teacher Baba Ram Dev. How long will it last only the time will tell but in the current scenario where hecould not sustain fasting for more than six days has created doubt amongst the public about his way of teachingyoga. Ram Dev bought commercial time in television, advertised his products, charge fee from each fellow in thecamp. These principles of advertisement marketing used by him can only add a few years to his campaign butcannot last longer. His campaign of drinking ghiya juice is already on the decline.In the field of spirituality, we also saw a wave of transcendental meditation by Maharshi Mahesh Yogi but themovement did not last long. Probably, selling spirituality in India is not easy and the time for the same is still notripe. But, who knows tomorrow?In terms of public behavior also, we have seen eras of cycling, exercising, jogging, aerobics, western dancing andnow back to walking.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012425

ORIGINAL RESEARCHSpectrophotometric Analysis of Color reproduction of 3 Different Thicknesses of2 different commercial porcelains with a Standard Shade GuideNarayana Reddy *, Raghavendra Jayesh*, Cinil Mathew **AbstractSixty metal-ceramic specimen were made with 3 different thickness of 1, 1.5 and 2 mm using nickel chromium metal backingand with ceramic veneer of two popular companies of VITA and IVOCLAR. The metal was made of 0.4 mm , opaque of0.1mm and the ceramic dentin and enamel were the remaining 0.5,1 and1.5mm thickness respectively. The specimen werefabricated of A3 shade and compared with the A3 shade of VITAPAN shade guide using sprectrophotometer for the parametersof hue, value, chroma, a*value(red or green) and b*value (yellow or blue) Thicker specimen showed the hue closer to theshade tab compared to thinner specimen, with the IVOCLAR 2mm coming closest to the shade tab. The metal ceramicspecimen were brighter than the shade tab but thinner 1mm specimen showed the brightness closest to the shade tab. Themetal ceramic specimen showed higher chroma, redness and yellowness compared to the shade tab and the IVOCLAR 2mmspecimen showed these values closer to the shade tab.Key words: Spectrophotometer, shade tab, chroma, hue, value, a*value, b*valueColor is a psychophysical sensation that resultswhen the human visual system responds tothe light reflected from an object. 1 The coloreffect of the natural tooth is due to the light reflectedfrom the enamel, dentine and pulp along with theirinternal reflections and refractions. The color reflectedby the dentin is modified by the thickness and thetranslucency of the enamel. 2 The metal ceramicrestorations are the most popular restorations forthe past few decades. The color reproduction of themetal ceramic restorations like crown and pontic inrelation to the natural tooth is the major challenge inthe esthetic zone.Usually the dentists use the shade tab supplied bythe manufacturers to help in the shade selection ofthe natural teeth. Modern multi blended vaccumfired shade tab contain four basic colors namely red,blue, green and yellow. The shade tab contain a pinanchorage in the back with a darker dentin whichis overlaid by dentin and enamel on the labial side. 2*ProfessorDept. of ProsthodonticsSree Balaji Dental College and Hospital,Chennai**PG studentDept. of ProsthodonticsIndira Gandhi Institute of Dental Sciences,Kothamangalam, Ernakulam, Kerala.Address for correspondenceDr Narayana ReddyE-mail: narayanareddy_donapati@yahoo.co.inVita lumin vaccum shade guide (VITA Zahnfabric)was introduced into dental profession 50 yearsback to record the shade of the natural teeth andtransfer to the restoration. It is grouped into 4 seriesdepending on the hue and further numbered into 1to 4 in accordance with the increasing chroma anddecreasing value. Group A denotes reddish brown,B denotes reddish yellow, C denotes grey and Ddenotes reddish grey .Most of the clinicians are usingthe classical vitapan shade guide and high proportionof the natural teeth in the general population rangebetween A2 and A3.5. 3The instruments commonly used to measure thecolor of an object are Tristimulus calorimeters,spectroradiometers, sprectrophotometers and digitalcamaras. The spectrophotometric analysis of the colorof the ceramic restorations were consistently similar tothe visual examination. Different brands of the ceramicsproduced differences in their shades with the sameshade of the shade tab. 4 The thickness of the ceramiccrown depends on the amount of tooth reduction doneas the anterior and young teeth undergo less reductioncompared to the posterior ones. Uniform thickness ofthe ceramic on the pontic and crown are desirable foresthetics. Hence the present study was done to guidethe clinician for the optimum reduction of the toothstructure for two popular brands of ceramics to matchthe shade tab.426Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

original researchMethodologyImpression of the classical shade tab (vitazahnfabric,germany) was made with silicone impressionmaterial. In the silicone impression, inlay casting waxwas melted and poured to form the pattern of thesame shape of the shade tab. The pattern was attachedwith a sprue on the palatal side. The pattern wasinvested in a high-heat phosphate –bonded investmentand casted with ceramic nickel chromium alloy byinduction casting machine (bego, germany).The metalsubstructure trimmed to thickness of 0.4mm , airabraded with 100µ alumina and oxidized.The specimens were divided into 2 groups with groupI specimen overlaid with VITA porcelain and groupII specimen overlaid with IVOCLAR porcelain. Eachgroup again divided into 3 sub groups a, b and c with2mm, 1.5 mm and 1.0 mm thickness of metal ceramicrespectively. For each specimen metal composed of0.4mm thickness, opaquer of 0.1mm thickness andthe remaining composed of dentin and enamel. TheVITA A3 was selected for the test in the experimentin the shade tab. The opaque layer was overlaid withthe deep dentin, dentin and enamel of the thickness of1.5mm, 1mm and 0.5mm and fired in the respectivefurnaces according to the manufacturer’s instructions.The specimen was self glazed after the trimming bydiamond points. The final thickness of the specimenwith the metal and ceramic were 2mm,1.5mm,1mmrespectively for each sub group a, b and c of group 1( VITA) and group II (IVOCLAR) . The total of 60test specimen of 30 each group with 10 of each subgroup were fabricated to test their color similarity tothe shade tab.The color of the VITA A3 shade tab and the testspecimen were tested in the light source of D65illuminent representing the average day light. A metaldie was fabricated for the placement of the shadetaband the specimen during the spectrophotometricmeasurement of the color. The machine gave theparameters of the color like value or brightness(L),chroma or intensity(C),hue(h), redness or greenness (avalue),and yellowness or blueness(b value).ResultsThe present in-vitro study was conducted to find outthe effect of ceramic thickness on the color of the metalceramic restorations made using the ceramic powderof 2 different companies using a spectrophotometerand was compared with a standard shade guide tab ofVITAPAN CLASSICALThe Specimen Vitapan Classical Shade GuideIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012427

original researchThe final grouping of the specimens as followsGroup 1a-VITA specimens with 2mm thicknessGroup 1b- VITA specimens with 1.5mm thicknessGroup 1c-VITA specimens with 1mm thicknessGroup 11a-VITA specimens with 2mm thicknessGroup 11b-VITA specimens with 1.5mm thicknessGroup 11c-VITA specimens with 1mm thicknessThe statistical analysis was performed using the analysisof variance test (ANOVA) and t-testThe VITA CLASSICAL shade guide A3 shade tabshowed the spectrophotometer results ofHue (H) 87Value(L) 78Chroma(C) 26a*value (Red/Green) 1.4b*value(Yellow/Blue) 25.8The average values with each sub group are asfollows2mm 1.5mm 1.0mmHue VITA 80.2 79.9 77.7Hue IVOCLAR 84.5 82.7 78.3Value VITA 89.2 89.1 77.7Value IVOCLAR 86.9 85.9 76.1Chroma VITA 31.8 31.8 31.2Chroma IVOCLAR 28.9 31.4 31.7a*value VITA 5.5 5.6 6.7a*value IVOCLAR 2.8 4.0 6.6b*value VITA 31.3 31.3 30.4b*value IVOCLAR 28.9 31.4 31.7DiscussionIdeally the PFM restorations must duplicate the naturaltooth color and for this purpose the commerciallyavailable shade guides have been conventionally used.The clinician expects the restoration to match theshade tab reliably in color. The uniform thicknessof the ceramic on the pontic and retainer give morenatural appearance.TheA3 shade was selected in this study as it was foundout to be most frequently found in the natural teeth. Theaverage thickness of the ceramic restoration is usually1to 2mm, which includes the metal and ceramic. Theminimum thickness of the metal with the harder basemetal alloys is 0.35mm and the maximum thicknessof the ceramic is 2 mm, whereas more than 2mm ofthe ceramic is associated with the shear fracture of theceramic and less than 1mm of the metal ceramics givesunesthetic restoration. 5 The present study with 1 to 2mm thickness metal-ceramic restoration is relevant forclinical applications.The metal ceramic restorations can be made of goldbased, palladium based or base metal alloys like nickelchromium,cobolt - chromium or titanium alloys. Thenickel-chromium alloys are popular because of theirhigher hardness and elastic modulus, ease of casting,inexpensiveness and the reliable bonding with theceramic material. The base metal alloys are black andneed thicker opaque to mask the metal compared tothe gold and palladium based alloys. The commercialshade guides are 4mm thick bucco lingually and aremanufactured with high fusing denture tooth porcelainwhereas the metal-ceramic restorations are made withmetal backing with the overlaid opaquer, deep dentin,dentin and transparent enamel. The thinner ceramiclayer along with the matal backing of the metalceramicrestoration make the exact color reproductionof the shade tab given by the clinician challenging forthe dental technician. 6The specimen used in the study were approximatelysize of the maxillary central incisors ,since most shadeguides use this dimention. VITAPAN A3 was selectedfor the preparation of the test specimens as the studieshave shown that high proportion of the natural teethin the general population falls between A2 and A3.5. 1HUE- The thicker specimen in the range of 2 and 1.5showed hue values closer to the shade tab for VITAand IVOCLAR. The increased dentin thickness in thespecimen produced hue similar to the shade tab as theshade tab also has thick dentin. Similar results wereobtained in a previous study by S H Jacobs et al. 4 TheIVOCLAR produced the shade closer to the shade tab428Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

original researchcompared to the VITA for each thickness even thoughshade tab is also manufactured by VITA.Value (Brightness) - The value ranges from 0-100with black to perfect white. In this study there was aconsistant decrease in the brightness with the decreasein the thickness from 2 to 1mm,but no significantdifferences were present between 1.5 and 2mmspecimen. The brightness value of the 1mm specimenfalling well below that of the 1.5 and 2mm and closerto that of shade tab. But all metal-ceramic restorationsfound to have more brightness than the shade tab.These results are in accordance of the study done byJogrenson et al 7 , but does not correspond with thestudy of Jacobs et al. 4Chroma (Intensity or Saturation) - Chroma ranges from0-100 corresponding to the amount of saturation. TheVITA specimen showed increased chroma comparedto the shade tab with no differences between differentthickness. The IVOCLAR specimen showed similarlyincreased chroma for 1 and 1.5 mm specimen, butshowed lower chroma with the 2mm specimen closerto the shade tab chroma. These results are in agreementwith the study done by S.H.Jacobs et al. 4 and MichealW Jogrenson et al. 7 The higher chroma of the metalceramic restorations compared to the shade tab isexplained due to the metal backing with the opaqueand the lower thickness of the ceramic comparedthe shade tab. a* value (redness or greenness) - Thea*value represent the red or green chroma and rangesfrom -90 to70 and the positive values of a*representthe red and the negative values represent the green. Allthe specimen showed the a*value much higher thanthe shade tab and reduced a*value with the increasedthickness from1 to 2mm.Only the IVOCLAR 2mmshowed the a* value closer to the shade tab. But allthe metal-ceramic specimen showed the more rednesscompared to the shade tab very similar to the chromaresults and are explained due to the differences in thethickness of the dentin between the specimen andshade tab. These results are in agreement with the studydone by Tuncer Burak Ozcelic et al for nickel chromealloys. 8 b*value-the amount of yellowness or blueness -The b*color coordinate ranges from -80 to 100 and thepositive value of b*represents the yellowness and thenegative values represents the blueness. The b*value ofall the specimen were higher than the shade tab values.The IVOCLAR specimen with the 2mm thickness werehaving the lower b* values closer to that of the shadetab. The higher yellowishness of the metal ceramicspecimen compared to that of the shade tab are similarto that of the higher chroma and higher redness seenin this study. The results obtained in this study were inagreement with the study done by Stephen F.Rosensteiland William M.Johnston. 9ConclusionsThe metal ceramic restorations showed the hue valuesdifferent from the VITA CLASSICAL shade tab. TheIVOCLAR 2mm thickness specimen showed the hueclosest to the shade tab. The brightness of the metalceramic restorations is higher than the shade tab.The thinner 1mm metal ceramic restorations showedthe brightness closer to the shade tab compared tothe thicker 1.5 and 2mm ones. The metal ceramicrestorations showed more chroma, redness andyellowness compared to the shadetab. The IVOCLAR2mm specimen showed the hue, chroma, redness andyellowness closer to the shade tab compared to theother specimen.Bibliography1.2.3.4.5.6.7.8.9.Rade D.Paravina and John M.Powers. Esthetic colortraining in dentistry.John W. Mc Lean. The scince and art of dental ceramics.vol II.Martin Dunitz. Esthetic dentistry and ceramicrestorations.S.H.Jacobs,C.J.Goodacre,B.K.Moore. Effect of porcelainthickness and type of metal-ceramicalloy on color.R.Duane Douglas and Malgorata Pazybylska. Predictingporcelain thickness required for dental shade matches. JProsthet Dent 1999;82:143-149.John A .Sorenson and Tony J.Torres. Improved colormaching of metal-ceramic restorations J prosthet Dent1987;58:133-139.Micheal W.Jorgenson and Richard J.Goodkind.Spectrophotometric study of five porcelain shadesrelative to the dimentions of color,porcelain thickness,and repeated firings. J Prosthet Dent 1979;42:96-105.Tuncer Burak Ozeelik, Burak Yilmaz,Isil Ozean.Calorimetric analysis of opaque porcelain fired to differentbase metal alloys usedin metal ceramic restorations.JProsthet Dent 2008;99:193-202.Stephen F. Rosensteil and Willium M.Johnston.Theeffect of manipulative variables on the color of ceramicmetal restorations. J Prosthet Dent 1999;82;143-149.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012429

Review articleObesity And Periodontal Disease - A ReviewV Gopinath,* V Shivakumar,** R Saravanakumar † , V Anitha ‡ , Karpagam $AbstractThe prevalence of obesity has increased substantially over the past decades in most industrialized countries. Obesity is asystemic disease that predisposes to a variety of co-morbidities and complications that affect overall health. Cross-sectionalstudies suggest that obesity is also associated with oral diseases, particularly periodontal disease, and prospective studies suggestthat periodontitis may be related to cardiovascular disease. The possible causal relationship between obesity and periodontitisand potential underlying biological mechanisms remain to be established; however, the adipose tissue actively secretes avariety of cytokines and hormones that are involved in inflammatory processes, pointing toward similar pathways involvedin the pathophysiology of obesity, periodontitis, and related inflammatory diseases. We provide an overview of the definitionand assessment of obesity and of related chronic diseases and complications that may be important in the periodontist’soffice. Studies that have examined the association between obesity and periodontitis are reviewed, and adipose-tissue-derivedhormones and cytokines that are involved in inflammatory processes and their relationship to periodontitis are discussed. Ouraim is to raise the periodontist’s awareness when treating obese individuals.Key words: obesity, adipose tissue, periodontits bmi.Obesity is a medical condition in which excessbody fat has accumulated to the extent thatit may have an adverse effect on health. 1 It isdefined by body mass index (BMI) and further evaluatedin terms of fat distribution via the waist–hip ratio andtotal cardiovascular risk factors. 2 BMI is closely relatedto both percentage body fat and total body fat. 3 BMI iscalculated by dividing the subject’s mass by the squareof his or her height, typically expressed either in metricor US “customary” units:Metric: BMI = kilograms / meters 2US customary and imperial:BMI = lb * 703 / in 2where lb is the subject’s weight in pounds and in is thesubject’s height in inches.*Reader**Prof and Head†Professor‡Reader$Dental SurgeonDept. of Periodontics,Chettinad Dental College and HospitalAddress for correspondenceDr.V Shivakumar,E-mail: siva932@yahoo.co.inThe most commonly used definitions, established bythe World Health Organization (WHO) in 1997 andpublished in 2000 , provide the values listed in thetable at right. 4ClassificationBMI Classification:• < 18.5 : Underweight• 18.5 – 24.9 : Normal Weight• 25.0 – 29.9 : Overweight• 30.0 – 34.9 : Class I Obesity• 35.0 – 39.9 : Class II Obesity• ≥ 40.0Obesity-Related DiseasesHypertension: Class III ObesityOverweight and obesity have long been recognizedas important determinants of elevated bloodpressure levels. It is well established that weightgain is consistently associated with increased bloodpressure, and that weight loss decreases blood pressureindependent of changes in sodium intake. Comparedwith normal-weight individuals, obese persons have anup to 5 times higher risk of hypertension, and up totwo thirds of cases of hypertension can be attributedto excess weight.430Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Peripheral Giant Cell Granuloma- A ReviewReview articleShaveta Sood *, Anubha Gulati**,Renu Yadav † , Shipra Gupta ‡AbstractBackground: The peripheral giant cell granuloma (PGCG) is a relatively common benign reactive lesion of the oral cavity,originating from the periosteum or the periodontal ligament. It occurs as a result of local trauma or chronic irritation. Thisarticle presents a case of peripheral giant cell granuloma with review of literature. Methods: A 40 year old woman reportedwith a nodular lesion in the maxillary right premolar region of four year duration. The lesion was excised and sent forhistopathologic examination which was carried out under light microscopy. Results: The biopsy specimen revealed featuresconsistent with PGCG. In addition, mineralized tissue resembling woven bone was also evident in the deeper connective tissue.Radiographically, there was superficial erosion of the alveolar crest. The clinical and radiographic 1 year follow-up revealeduneventful soft tissue healing. Conclusion: The usual line of treatment for PGCG is local excision down to the bony basealong with elimination of the local etiologic factors. Failing to do so, results in the recurrence of the growth.Key words: Peripheral giant cell granuloma, epulis, giant cellsThe peripheral giant cell granuloma (PGCG)is a relatively common tumor-like growth ofthe oral cavity. It is also known as giant cellepulis or peripheral giant cell reparative granuloma. 1It accounts for 7% of all benign tumors of the jaw. 2Although PGCG is the least commonly diagnosedamong the various hyperplastic gingival lesions(pyogenic granuloma, fibrous hyperplasia, peripheralossifying fibroma) 3,4 , it is a common giant cell lesionfound in the oral cavity. 3 It is probably a reactive lesioncaused by local irritation or trauma 1 which resultedin gingival or mucosal hemorrhage. 5 The aggressivefactors include trauma, tooth extraction, badly finishedrestorations, plaque, calculus, chronic infections andimpacted food. 5,6,7 The origin of the multinucleatedgiant cells is unknown; some believe them to showimmunohistochemical features of osteoclasts, whileothers suggest them to arise from mononuclearphagocyte system. 1 Other possible sources include*Senior Lecturer, Dept. of Periodontics**Associate Professor, Dept. of Oral and Maxillofacial Pathology†Senior Lecturer, Dept. of Oral and Maxillofacial Pathology‡Associate Professor, Dept. of PeriodonticsDr Harvansh Singh Judge Institute of Dental Sciences andHospital, PU, Chandigarh, IndiaAddress for correspondenceDr Shipra GuptaHouse Number 1472, Near Government Dispensary,Sector 21, Panchkula, Haryana, India.E- Mail: teena1472@yahoo.inosteoblasts, endothelial cells and spindle cells. 7 PGCGseems to be influenced by hormonal stimulus, especiallyestrogen. 6,8,9PGCG occurs exclusively on gingiva or edentulousalveolar ridge 1 as variable sized, sessile or pedunculatedlesion which is usually deep red to bluish red andbleed easily. 10 The final diagnosis however relies onthe histological diagnosis. 8,11 Histologically, fibroblastsare the basic elements. Scattered among the fibroblastsare abundant multinucleated giant cells. Islands ofmetaplastic bone occasionally may be seen. 12 Numerouscapillaries may be seen along with areas of hemorrhage,hemosiderin and inflammatory cells throughout thecellular connective tissue. 3,5,9,13,14 The treatment isusually local surgical excision down to underlying bonealong with scaling of adjacent teeth to remove anysource of irritation and to minimize risk of recurrence.A recurrence rate of 10% has been reported. 1A case of PGCG exhibiting woven bone formation ina 40 year female is presented along with 1 year clinicaland radiographic follow-up and a review of literature.Case Description and ResultsA 40 year old woman was referred by her physician toDr. Harvansh Singh Judge Institute of Dental Sciences& Hospital, Chandigarh, India to assess a nodulargrowth on the maxillary palatal mucosa in relation to theIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012435

Review ArticleFigure 1. Clinical picture of the lesion shows a bluish-pinknodular growth on the palatal gingiva in relation to the maxillarysecond premolar.Figure 2. Picture depicting the excised tissue specimen sentfor histopathologic examination.Figure 4. Photomicrograph showing giant cells in associationwith and within the blood vessels. Hemorrhagic areas arealso evident (H&E, x40).Figure 3. Photomicrograph revealing a focus of giant cellsalong with areas of extensive hemorrhage, separated fromthe overlying epithelium by a “clear zone” (H&E, x10).premolars present since 4 years. The patient reported thelesion to be asymptomatic but for bleeding tendency ifaccidentally bitten on during mastication. The medicalhistory was not contributory and the patient was noton any medications. Intraoral examination revealed anexophytic sessile nodular growth, bluish-pink in color,firm in consistency which measured 0.5cm in diameter(Fig.1). Other oral findings included a missing 16 anda very poor oral hygiene. Periapical radiograph revealedsuperficial erosion of the alveolar crest in relation tothe growth.Figure 5. Photomicrograph depicting woven bony trabeculaeperipheral to the foci of giant cells (H&E, x10).436Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Review ArticleBased on clinical and radiographic findings, thepreliminary diagnosis for the lesion was fibroma. Thedifferential diagnosis included pyogenic granulomaand peripheral giant cell granuloma. The lesion wasexcised under local anesthesia (Fig.2) and the areawas curetted. There were no complications in theimmediate post-operative period. A full mouth scalingand root planing was carried out for the patient andoral hygiene instructions were given. No relapse hasbeen observed during the 1 year follow-up.The specimen biopsied was processed for routine hematoxylinand eosin staining and 4-5 micron thick sections wereprepared and examined under light microscope. The sectionsrevealed well-circumscribed, unencapsulated cellular masscontaining oval to spindle-shaped fibroblasts, abundantmultinucleated giant cells, numerous capillaries and areas ofhemorrhage. The multinucleated giant cells were of variableshapes and sizes containing open-faced nuclei ranging from5 to 15 in number conforming to the type I giant cellsdescribed in literature. Many giant cells were found inassociation with and within blood vessels (Fig.3, Fig.4).The overlying epithelium was orthokeratinized stratifiedsquamous epithelium which was mildly hyperplastic. Inaddition the connective tissue revealed the presence of wovenbony trabeculae deep to the foci of giant cells (Fig.5). Thehistopathologic picture was diagnostic of peripheral giant cellgranuloma.DiscussionThe present report is regarding a case of PGCGsuccessfully treated with excision and curettage. Theclinical and radiographic 1 year follow-up indicatedno recurrence and suggested that the chosen surgicalmanagement along with the maintenance of ascrupulous oral hygiene are adequate to treat PGCGand prevent its recurrence.Jaffe first suggested the term “giant cell reparativegranuloma” for the similar central lesion of the jawbones 3 to help differentiate them from the giant celltumor 15 as he believed the former lesion to representa local reparative reaction rather than being a trueneoplasm. 16,17 Bernier and Cahn proposed the term“peripheral giant cell reparative granuloma” for thelesion. 3 The latter terminology is currently not beingused as the reparative nature of the lesion has notbeen proved. 18 Today, the term peripheral giant cellgranuloma is universally accepted. 3The histogenesis of PGCG and the nature of thelesion and the constituent cells remain controversialdespite intense studies. A reactive nature of originhas been found in several immunohistochemical andultrastructural studies. The mononuclear cells stainpositive with histiocyte markers (lysozyme and alpha1-antichemotrypsin) as well as show a positive reactionwith CD-68, a macrophage-associated antigen. 19,20 Thepresence of S-100 positive cells, which are evidence ofLangerhans cells or their precursors, and the presenceof fibroblasts, endothelial cells and myofibroblastspoint toward a reactive nature of the PGCG. 19,20,21An origin from periosteum rather than gingiva has beensuggested since the lesion can cause superficial erosionof bone and occurs in edentate as well as dentate areasof the jaws. 22 At present, it is generally agreed thatPGCG is a reactive, non-neoplastic lesion formed bygranuloma-like tissue dominated by multinucleatedgiant cells. 6PGCG may occur at any age, especially during the firstthrough sixth decades of life. 1 However, the highestincidence (40%) is in the fourth to the sixth decadesof life. 3,9,23 A survey by Maryam AHP showed a relativepredilection in the first four decades of life. 2 A slightfemale predilection has been reported in a large numberof studies 14 with the male: female ratio. 1:1.5. 24 Afemale predilection of 60% has been reported. 1,3 Thegender predilection was found to be more significantamong patients with larger PGCG in a study carriedout by Bodner et al. 25 However, PGCG was morecommon among men (M/F 1.4:1) in a study by Zareiet al. 26 Similar male predilections have been reportedby Bhaskar SN et al. 5 Salum FG et al. 27 , Chaparro-Avendano AV et al 28 and Peralles PG et al. 29 In thegiven case, the patient is a 40 year old female.The size of the lesion is usually smaller than 2cm in diameter, although larger ones may be seenoccasionally; 1 a diameter as large as 5 cm has beenreported. 25 Gradual growth in some cases, producesan important tumor mass that adversely affects normaloral function. 28 The maximum capability of peripheralgiant cell granuloma to expand is unknown. It is likelythat expansion of the peripheral giant cell granulomais a relatively slow process and that most lesions arediagnosed and surgically removed before they reachtheir full growth potential. 25 Peripheral giant cellgranulomas larger than 2 cm are seen more commonlyIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012437

Review Articlein females 11,25 with poor oral hygiene and xerostomia.This may indicate the important role of oral hygienein the development and growth of peripheral giant cellgranuloma. However, the association of large PGCGto oral or systemic factors is unclear. 25 Lesion growthin most cases is induced by repeated trauma. 7 Thesize of the lesion in the given case is within the abovementioned range.PGCG varies in appearance from smooth, welldemarcated25 regularly outlined mass to irregularlyshaped, multilobulated protruberance with surfaceindentation. Ulceration of the margin is occasionallyseen, 18 secondary to trauma which may give the lesiona focal yellow zone as a result of the formation of afibrin clot over the ulcer. 12 The lesion often clinicallyresembles a pyogenic granuloma. 30 The color can rangefrom dark red to purple or blue. 28 The lesion appearsblue-purple in color due to extensive hemorrhagic areasand hemosiderin deposition at the periphery. 1,3 PGCGis seen in the anterior or posterior region 1 of the gingivaor the soft tissue covering the edentulous alveolarridge (18%). 5,31 Usually found in the gingival marginbetween teeth anterior to the permanent molars, 31 withthe premolar molar region of the jaw being the mostcommon site of occurrence. 25 5% cases were reportedon the palate in a study by Maryam et al. 2 There are noreported cases occurring in extragingival sites. 3,7,14 Thismay be related to the anatomic nature of the gingivaand the irritational factors at this site. 7,14,32 The mandibleis affected slightly more often than the maxilla, 1,25 thereported proportion being 2.4:1.24 However, in ourcase the lesion was found in the maxillary arch. Uponpalpation, one may note a lesion that is either soft orhard, depending on the composition of collagen and/or inflammatory components. 24 In the given case, thelesion was an exophytic, sessile nodular growth whichwas bluish-pink in color, firm in consistency andwas found on the palatal gingiva in relation to rightmaxillary premolars involving the interdental papilla.Although the peripheral giant cell granuloma developswithin soft tissue, “cupping” resorption of the underlyingalveolar bone is sometimes seen radiographically. 1,12 Thisresorptive pattern is seen when the lesion occurs onedentulous ridge. 12 In some cases radiographic findingsmay point toward the possible irritational factor. 25 Thisis in contrast to the central giant cell granuloma, whereradiography is an important diagnostic tool. 33 X-raysare important for determining whether the lesion isof gingival (i.e. peripheral) origin or of bone (central)origin with spread toward the surface. 28 Radiographicevidence of superficial erosion of the crestal bone wasevident in the given case.There are no pathognomonic clinical features wherebythese lesions can be differentiated from other forms ofgingival enlargement 18 including pyogenic granuloma,fibrous epulis, peripheral ossifying fibroma, inflammatoryfibrous hyperplasia, peripheral odontogenic fibroma,hemangioma caverosum and papilloma. 28 Microscopicexamination is required for definitive diagnosis. 18Generally, this lesion is clinically indistinguishablefrom a pyogenic granuloma, although a peripheralgiant cell granuloma is more likely to cause boneresorption than pyogenic granuloma, the differencesare otherwise minimal. 12 Microscopically, the lesionarises from, or is at least attached to the periodontalligament or mucoperiosteum. 34 The most characteristichistologic features included a non-encapsulated highlycellular mass with abundant giant cells, inflammation,interstitial hemorrhage, hemosiderin deposits, maturebone or osteoid. 3 Fibroblasts are the basic element ofperipheral giant cell granulomas. Scattered among theplump, young fibroblasts are numerous multinucleatedgiant cells with abundant eosinophilic cytoplasm whichappear to be non-functional in the usual sense ofphagocytosis and bone resorption. 12 Two types of giantcells are mainly found, one representing metabolicallyactive cells and the other representing dying cells.The origin of these cells has not been defined yet.However, a striking similarity between these cellsand osteoclasts does exist. 3 The prevalent of the twoconsists of multiple large, ovoid, vesicular, somewhattranslucent nuclei with prominent nucleoli and thenuclear chromatin was located peripherally on distinctnuclear membrane. These cells are termed type I andvary in size, often exceeding 100µ in diameter. Thetype II giant cells are fewer in number, have smallerand more irregular nuclei than type I giant cells. Thenucleoli are not easily seen and the cytoplasm stainsdeeply eosinophilic and granular than the cells of typeI.5 Despite ultrastructural studies, the true nature of thegiant cells in PGCG remains debatable. 34 Inflammationis a constant finding but is varied not only in degreebut also in location. The inflammatory cells consistprimarily of lymphocytes, plasma cells, histiocytes and438Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Review Articleoccasional polymorphonuclear cells. Rarely, ulcerationwas an associated feature. 5 Vascular proliferation,especially capillary, was found in a study carried out byPeralles et al. 29 Calcified tissue which is found in someof the lesions varies from small amorphous foci to welldeveloped trabeculae. 5 The woven bone or lamellar boneis thought to be produced by mononuclear stromalcells, which resemble latent proliferative osteoblasts orosteoprogenitor cells. 13,14 Thus, it is not surprising thatwoven bone and lamellar bone are formed in PGCG. 14No correlation has been found between the presence oramount of bone with location or reported duration ofthe lesion. 6 The histologic appearance is similar to thatof a giant cell granuloma of the jaw, but for the factthat the epulis has a covering of stratified squamousepithelium. 12,31 In rare instances, both a soft tissue andintraosseous lesion can co-exist. 35 The overlying mucosalsurface is ulcerated in about 50% cases. A “clear zone”of dense fibrous connective tissue usually separates thegiant cell proliferation from the mucosal surface. 1,5 Thehistopathologic picture of our case conformed to theabove mentioned features with the periphery of thelesion exhibiting metaplastic woven bone formation.Very rarely, a giant cell epulis is a manifestationof hyperparathyroidism, in which case changes inblood chemistry confirm the diagnosis. 31 Theseapparently represent the so-called osteoclastic browntumors of hyperparathyroidism associated with thisendocrine disorder. However, the brown tumors ofhyperparathyroidism are much more likely to beintraosseous in location and mimic a central giant cellgranuloma. 1 The blood chemistry examination in thepresent case was negative for hyperparathyroidism.Treatment consists of local surgical excision down tothe underlying bone, 1 for extensive clearing of thebase. 10 Removal of local factors or irritants is alsorequired. 12 If resection is only superficial, the growthmay recur. 4 Exposure of all bony walls followingthorough surgical resection responds satisfactorily mostof the time. 15 Recurrence rate of 5.0-70.6% (average9.9%) has been reported in various epidemiologicstudies (Mighell et al). 24 A recurrence rate of 5%has been reported by Giansanti and Waldron 6 whilea study by Eversole & Rovin showed a recurrenceof 11%. 13 Recurrences are believed to be related tolack of inclusion of the periosteum or periodontalligament in the excised specimen. 12 A re-excision mustbe performed for these cases. 1 Aggressive tendencies 5or malignant transformation of these lesions has neverbeen reported. 3 PGCG lesions are self-limiting. 5 Thetreatment rendered in this case was surgical excision tothe bone and curettage followed by oral prophylaxis.The 1 year follow-up has shown no recurrence indicatingthat the given treatment along with maintenance of agood oral hygiene is sufficient to treat PGCG.ConclusionThe usual line of treatment for PGCG is local excisiondown to the bony base along with elimination of thelocal etiologic factors. Failing to do so, results in therecurrence of the growth.AcknowledgementWe thank Mr. Tarsem Raj (histopathology technician)for his skilful technical assistance.Disclosure: authors report no conflicts of interestReferences1.2.3.4.5.6.7.8.9.Neville BW, Damm DD, Allen CM, Bouquot JE. Soft TissueTumors. In Neville BW, Damm DD, Allen CM, BouquotJE, eds. Oral and Maxillofacial Pathology 3rd ed. St. Louis:Saunders; 2009: 507-563.Pour MAH, Rad M, Mojtahedi A. A Survey of Soft tissueTumor-Like Lesions of Oral Cavity: A ClinicopathologicalStudy. Iranian Journal of Pathology 2008; 3: 81-87.Katsikeris N, Kakarantza-Angelopoulou E, Angelopoulos AP.Peripheral giant cell granuloma. Clinicopathologic study of224 new cases and review of 956 reported cases. Int J OralMaxillofac Surg 1988; 17: 94-99.Flaitz CM. Peripheral Giant Cell Granuloma: A potentiallyaggressive lesion in children. Pediatr Dent 2000; 22: 232.Bhaskar SN, Cutright DE, Beasley JD, Perez B. Giant cellreparative granuloma (peripheral): report of 50 cases. J OralSurg 1971; 29: 110-15.Giansanti JS, Waldron CA. Peripheral giant cell granuloma:review of 720 cases. J Oral Surg 1969 Oct; 27: 787-91.Rajendran R. Benign and Malignant Tumors of the OralCavity. In Rajendran R, Sivapathsundaram B, eds. Shafer’sTextbook of Oral Pathology 5th ed. New Delhi: Elsevier;2006: 113-308.Gandara-Rey JM, Pacheo Martina Carneriro JL, Gandara-Vila P et al. Peripheral giant-cell granuloma: Review of 13cases. Med Oral 2002; 7: 254-59.Gunhan M, Gunhan O, Celasun B, Mutlu M, Bostanci H.Estrogen and progesterone receptors in the peripheral giantIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012439

Review Article10.11.12.13.14.15.16.17.18.19.20.21.22.cell granulomas of the oral cavity. J Oral Sci 1998; 40: 57-60.Kfir Y, Buchner A, Hansen LS. Reactive lesions of the gingiva.A clinicopathological study of 741 cases. J Periodontol 1980;51: 655-61.Hirshberg A, Kozlovsky A, Schwartz-Arad D, Mardinger O,Kaplan I. Peripheral giant cell granuloma associated withdental implants. J Periodontol 2003; 74: 1381-84.Regezi JA, Sciubba JJ, Jordan RCK. Red-Blue lesions. InRegezi JA, Sciubba JJ, Jordan RCK, eds. Oral Pathology.Clinical Pathologic Correlations 5th ed. St. Louis: Saunders;2009: 107-25.Eversole LR, Rovin S. Reactive lesions of gingiva. J OralPathol 1972; 1: 30-38.Dayan D, Buchner A, Spirer S. Bone formation in Peripheralgiant cell granuloma. J Periodontol 1990; 61: 444-46.Motamedi MHK, Eshghyar N, Jafari SM et al. Peripheraland central giant cell granulomas of the jaws: A demographicstudy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2007; 103: e39-e43.Kruse-Lӧsler B, Diallo R, Gaertner C, Mischke K-L, JoosU, Kleinheinz J. Central giant cell granuloma of the jaws: Aclinical, radiologic and histopathologic study of 26 cases. OralSurg Oral Med Oral Pathol Oral Radiol Endod 2006; 101:346-54.Jaffe HL. Giant cell reparative granuloma, traumatic bonecyst and fibrous (fibro-osseous) dysplasia of jaw bones. OralSurg 1953; 6:159-75.Carranza FA, Hogan EL. Gingival Enlargements. In NewmanMG, Takei HH, Klokkevold PR, eds. Carranza’s ClinicalPeriodontology 10th ed. St Louis: Saunders; 2009: 373-390.Carvalho YR, Lyola AM, Gomez RS, Ariyo VC. Peipheral giantcell granuloma. An immunohistochemical and ultrastructuralstudy. Oral Dis 1995; 1: 20-25.Regezi JA, Zarbo RJ, Lyoyd RV. Muramidase, alpha 1-antitrypsin, alpha 1-antichemotrypsin and S-100 proteinimmunoreactivity in giant cell lesions. Cancer 1987; 59: 64-68.Dayan D, Buchner A, David D. Myofibroblasts in peripheralgiant cell granuloma. Light and electron microscopic study.Int J Oral Maxillofac Surg 1989; 18: 258-61.Soames JV, Southam JC. Hyperplastic, neoplastic, and relateddisorders of oral mucosa. In Soames JV, Southam JC, eds.Oral Pathology 4th ed. New Delhi: Oxford University Press;2005: 101-115.23. Parbatani R, Tinsley GF, Danford MH. Primaryhyperparathyroidism presenting as a giant-cell epulis. OralSurg Oral Med Oral Pathol Oral Radiol Endod 1998; 85:282-84.24. Reichart PA, Philipsen HP. Gingiva. In Reichart PA, PhilipsenHP, eds. Color Atlas of Dental Medicine. Oral Pathology.New York: Thieme; 2000: 148-75.25. Bodner L, Peist M, Gatot A, Fliss DM. Growth potential ofperipheral giant granuloma. Oral Surg Oral Med Oral PatholOral Radiol Endod 1997; 83: 548-51.26. Zarei MR, Chamani G, Amanpoor S. Reactive hyperplasiaof the oral cavity in Kerman province, Iran: A review of 172cases British Journal of Oral and Maxillofacial Surgery 2007;45: 288-92.27. Salum FG, Yurgel LS, Cherubini K, De Figueiredo MA,Medeiros IC, Nicola FS. Pyogenic granuloma, peripheral giantcell granuloma and peripheral ossifying fibroma: retrospectiveanalysis of 138 cases. Minerva Stomatol. 2008; 57: 227-32.28. Chaparro-Avendano AV, Berini-Aytés L, Gay Escoda C.Peripheral giant cell granuloma. A report of five cases andreview of literature. Med Oral Patol Oral Cir Bucal 2005; 10:48-57.29. Peralles PG, Viana APB, Azevedo ALR, Pires FR. Gingivaland alveolar hyperplastic reactive lesions: clinicopathologicalstudy of 90 cases. Braz J Oral Sci 2006; 5: 1085-89.30. Esmeili T, Lozada-Nur F, Epstein J. Common benign oral softtissue masses. Dent Clin N Am 2005; 49: 223-40.31. Cawson RA, Odell EW. Common benign mucosal swellings.In Cawson RA, Odell EW, eds. Cawson’s Essentials ofOral Pathology & Oral Medicine 7th ed. Spain: ChurchillLivingstone; 2002: 275-80.32. Lucas RB. Giant cell lesions. In Lucas RB eds. Pathologyof Tumors of the Oral Tissues. 4th ed. London: ChurchillLivingston; 1984: 259-73.33. Whitaker SB, Waldron CA. Central giant cell lesions of thejaws: a clinical, radiologic and histopathologic study. OralSurg Oral Pathol Oral Med 1993; 75: 199-208.34. Bonetti F, Pelosi G, Martignoni G et al. Peripheral giant cellgranuloma: Evidence for osteoclastic differentiation. OralSurg Oral Med Oral Pathol 1990; 70: 471-75.35. Choi C, Terzian E, Schneider R, Trochesset DA. Peripheralgiant cell granuloma associated with hyperparathyroidismsecondary to end-stage renal disease: a case report. J OralMaxillofac Surg 2008; 66: 1063-66.440Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Fusion – Case Report And ReviewReview articleM R C Rajeswari*, R Ananthalakshmi**AbstractFusion refers to the union of two tooth germs resulting in a single large tooth. Fusion occurs due to union of two separate toothbuds at some stage in their development. Depending on the stage they are united, tooth may have only one pulp chamber asin gemination, or there may be two pulp chambers, with union only of the dentin. This is a rare case of fusion of permanentmandibular central and lateral incisors, with discussion of review ,diagnostic criteria and clinical implications.Key words: Fusion, mandibular incisors, double teethFusion is a developmental anomaly affecting theshape of teeth characterized by the union of twoadjacent teeth. In 1963 Tannenbaum and Alling 1, defined fusion as a union of two separate tooth budsat some stage in their development. Depending on thestage they are united, one tooth may have only onepulp chamber as a gemination, or there may be twopulp chambers, with union only of the dentin. Fusionand gemination are called as double teeth.Case ReportA nine year old girl reported to the clinic forcorrection of malocclusion. On intraoral examination,there was spacing in mandibular anterior regionand missing permanent mandibular incisor of theright side. On careful examination, Incisor presentin the right mandibular region was larger withincreased mesio distal width as compared with thatof the central or lateral incisor of the left quadrant(Fig 1). The single incisor also revealed a prominentmamelon. With detailed interrogation of the motherwe came to know that she had similar joined teethin her deciduous dentition in the same region. Theparent handed over the exfoliated joined tooth. TheIOPA and panoramic view X rays were taken and itrevealed a single mandibular permanent right incisorFig 1. Clinical photograph showing fused mandibularincisors*Professor and HOD, Dept. of Oral Pathology and Microbiology,Priyadharshi Dental College and Hospital, Chennai.**Senior Lecturer, Dept. of Oral Pathology and Microbiology, ThaiMoogambigai Dental College and Hospital, Chennai.Address for correspondenceDr. M R C Rajeswari,E-mail: mrcraj@yahoo.co.inFig 2. OPG showing fused mandibular incisorswith large pulp chamber and root canal (fig 2 ). Theclinico radiologic correlation confirmed the fusion ofpermanent mandibular right central and lateral incisors(41 and 42 ).Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012441

Review Articlein our case there was fusion between two mandibularincisors in the same quadrant. Also there was fusion ofprimary incisors in the same region.In fusion of teeth involving mandibular lateral incisorand canine, hypodontia of secondary dentition iscommon and no effects on the secondary dentitionwhen fusion is between primary mandibular incisors. 5But in our case though the fusion of primary teeth wasbetween mandibular incisors, secondary dentition alsopresented with the same complaint.Fig 3. Exfoliated fused deciduous incisors of the samequadrant.DiscussionFusion is more common in primary dentition than thepermanent dentition. But our case presented fusionin both the dentition of the same quadrant. Datasavailable in the literature points out that the prevalenceof fusion ranges from 0.5% - 2.5 % according to thepopulation surveyed. 2The etiology of fusion is unknown. But fusion resultswhen development of two tooth germs takes placeso closer and they come into contact and fuse beforecalcification. Some researchers believe that physicalpressure and force generated during growth causescontact between two tooth germs. 3 Viral infectionand usage of thalidomide during pregnancy is alsoconsidered as possible etiology. 4Fusion of primary teeth usually is seen in mandibularcanine and lateral incisor region. In contrast to this,The clinical problems associated with fused teethare esthetics-arch symmetry, spacing, malocclusion.These problems require cosmetic and orthodonticconsideration.Referrences1.2.3.4.5.Eliecer Eidelman, Dr Odont, MSD. Fusion of primaryteeth.pediatric dentistry. The American academy ofpedodontics vol.3.No.4.Grahnen et al. numerical variation in primary dentitionand their correlation with the permanent dentition,odont Rev 12:248-257,1961.White SC, et al oral radiology principles and interpretation5thed, St.louis:Mosby Inc,2004;337-338.Kjaer I,interrelation between fusions in the primarydentition and agenesis in the succedaneous permanentdentition seen from an embryological pointof view. Jcraniofac Genet Dev Biol2000;20:193-197.Ahmeterean sekerci et al, prevalence of double ( primary)teeth in Turkey- A study. Pakistan oral and dental journal,vol 31, No.1 june 2011.442Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Review article“Forensic Dentistry-what a dentist should know”Srinivasa Prasad*, G Sujatha**, G Sivakumar † , J Muruganandhan**AbstractTeeth with their physiologic variation and effects of therapy remain to record information throughout their life time. Theyalso act as a weapon under certain circumstances and leave the identity of the biter. Dentistry has much to offer the fieldof law in identifying and solving the civil and criminal cases. This paper gives the readers an understanding of the role of adentist as a forensic odontologist and also emphasizes the need for good quality and accurate dental records.Key words: Forensic, dentist, DNAForensic Odontology can be defined as a branchof dentistry, which deals with the properhandling and examination of dental evidenceand with the proper evaluation and presentation ofdental findings in the interest of the dentist. 1 A forensicodontologist assists the legal authorities by examiningdental evidence in different situations. There are threemajor areas of activity currently in forensic odontologynamely:1. The examination and evaluation of injuries toteeth, jaws, and oral tissues resulting from variouscauses (abuse, assault, mass disasters and crimerelated injuries).2. The examination of marks with a view to subsequentelimination or possible identification of a suspectas the perpetrator.3. The examination of dental remains (whetherfragmentary or complete, and including all typesof dental restorations) from unknown persons orbodies with a view to the possible identificationof the latter. 2This branch has been utilized for many years for theidentification of victims and suspects in mass disaster,abuse and organized crimes. 3 Forensic odontologyinvolves the management, examination, evaluation*Prof and Head, Dept. of Oral and Maxillofacial Surgery**Senior Lecturer†Prof and HeadDept. of Oral and Maxillofacial PathologySri Venkateswara Dental College and HospitalAddress for correspondenceDr. G SujathaE-mail: gsuja@rediffmail.comand presentation of dental evidence in civil orcriminal proceedings along with research. 4 A workingclassification is been proposed by Shamim T involvingall dental specialties( Table 1). 5Dental identification has played a very important rolein natural as well as manmade disasters. Identificationis based on comparison between known characteristicsof a missing individual (termed ante-mortem data)with recovered characteristics from an unknownbody (termed post-mortem data). When they haveno clue of the identity or no antemortem records arepresent, a detailed postmortem record is compiled forfurther use and a forensic anthropologist is used forcontributing information such as age, sex and ancestryof the deceased, which is known as postmortem dentalprofiling. 6An antemortem dental record will contain writtennotes, charts, diagrams, dental and medical histories,radiographs, clinical photographs, study models,results of specific tests, prescriptions, and referralletters and other information. Their accuracy andavailability have a huge impact on the speed andefficacy of identification. Problems are encounteredwhen the dental records are incomplete, irregular, lostor damaged and have poor quality radiographs. 7 Goodquality dental records are an essential part of patientcare, a medico-legal requirement, and are necessaryfor dental identification. 8 A forensic dentist recordsthe postmortem records completely by charting downthe dental findings and taking photographs andradiographs. On completion a comparison betweenthe two is carried out, similarities and discrepancies arenoted on the comparison and a result is established.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012443

Review ArticleTable 1. Working classification proposed for forensic odontology based on its relation with other dental specialities.Oral pathology and Microbiology1.Age estimation using ground sections(histological method)• Gustafson’s technique• Incremental lines of Retzius• Perkymata• Prenatal and postnatal lieformation• Racemization of collagen in dentin• Cemental incremental lines• Translucency of dentin2. Identification• Developmental disturbances ofteeth• Regressive alterations of teeth• Tumours and cysts of oral acvity• DNA profiling from teethCommunity dentistry1.Identification• Endemic fluorosis• Socioeconomic groupingi.ii.Dental caries, PeriodontaldiseaseOral cancer• Mass disasters2. Dental fraud and malpractice3. Elderly abusePeriodontics1.Age estimation• Periodontosis (gum recession)• Root transparency and root length2. Identification• Gingival morphology andpathology• Thickness and widening ofperiodontal ligamentOral medicine and Radiolgoy1.Age estimation using radiographic method• Secondary dentin formation• Changes in the orientation of mentalforeamenand interior alveolar canal• Eruption and formation of mandibularthird molar• Trabecular pattern in jaws• Pulp/tooth area ratio of teeth• Pattern of lamina dura2. Identification• Maintenance of dental records• Dental charting• Comparative dental identification• CheiloscopyOral and maxillofacial Surgery1.Identification• Maxillomandibular and dentoalveolarfractures• Surgical repairs and implants• LeFort I osteotomy procedure inautopsyConservative dentistry1.Identification and endodontics• Restorations• Endodontic treatmentPedodontics1.Age estimation• Eruption sequence• Schour and Massler chart• Demirjian’s methods using dentalmaturation chart• Nolla’s calcification stages• Child abuseOrthodontics1.Age estimationi.ii.iii.2. Identificationi.ii.iii.CephalometricsOrthopantomograph (OPG) X-ray andhandwrist3. Sexual dimorphismi.X-ray to determine pubertal stateTooth rotation and malpositionOrthodontic applicancesOrthodontic reconstructionMandibular canine index andmandibular first molar index4. Race identification2. Identification using radiographic method (Periapical radiograph)• Root canal treated restorations• Radiolucent and radio opaque restorative materials3. Effect of heat on restorative materialsi.Caphalic index5. Craniofacial superimpositionThe American Board of Forensic Odontologyrecommends that these be limited to the followingfour conclusions. 9• Positive identification: The antemortem andpostmortem data match in sufficient detail, withno unexplainable discrepancies, to establish thatthey are from the same individual.• Possible identification: the antemortem andpostmortem data have consistent features but,because of the quality of either the postmortemremains or the antemortem evidence, it is notpossible to establish identity positively.• Insufficient evidence: The available information isinsufficient to form the basis for a conclusion.• Exclusion: the antemortem and postmortem dataare clearly inconsistent.Dental ProfilingWhen dental records are unavailable and other methodsalso become impossible, a picture of the general featuresof the individual is produced and this is known as post444Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Review Articlemortem dental profiling which includes informationon the age, sex, socioeconomic status and ancestrybackground of the deceased. Additional informationssuch as habits, dietary pattern and occupation mayalso be provided. 10RaceDentists with the help of a forensic anthropologist candetermine the sex and ancestry from skull shape andform. A forensic dentist can determine race withinthe three major groups: Caucasoid, Mongoloid andNegroid based on the skull appearance. Additionalcharacteristics, such as cusps of Carabelli, shovelshapedincisors and multi-cusped premolars, can alsoassist in determination of ancestry. 11SexSex determination is usually based on cranialappearance, as no sex differences are apparent in themorphology of teeth. Discriminant function analysis,a statistical method used for determination of sexbased on tooth measurements showed a success rate of92.5%. 12 Minute quantities of DNA even from veryold tooth specimens are helpful in determining the sex.Ameloblasts of the enamel secrete amelogenin (AMELgene) which is present in the X and Y chromosomesof humans, females have two identical AMEL genes(XX) and males have two non identical AMEL genes(XY).Discrimination of male and female is based onthe length of the base pairs of the gene which is 106and 112 for X and Y gene respectively. A sample whichshows two discrete bands of 106 and 112 is identifiedas male and a female sample appears as a single bandof 106 for the AMEL gene. 13,14AgeTeeth act a reliable tool in estimation of age. Eruptionsequence, neonatal line formation, Incremental linesof Retzius, Schour and Massler chart and Gutafsson’smethod are parameters used for age estimation. 15 Theuse of radiographs is ideal to determine the stages ofmineralization, degree of formation of root and crownstructures, and stages of eruption which are reliableand helpful in predicting the age of an individual. 16HabitsHabits such as smoking or betel nut chewing are foundby the presence of stains and presence of erosion suggestalcohol or substance abuse. 17,18 Pipe stems, cigaretteholders, hairpins, carpet tacks or previous orthodontictreatment show unusual wear pattern. 19 Socioeconomicstatus is assessed by the quality, quantity and presenceor absence of dental treatment. 6DNATeeth present as an excellent source as DNA material20and its sources are pulp, dentine, cementum andperiodontal ligament fibers. DNA from teeth and boneare preserved for many years even after putrefactionof remains. 21 The other sources include saliva andmucosal swabs. Saliva may also be isolated fromvarious sources in the crime scene, for example, postagestamps and envelopes, glasses, cigarettes, straws, foodand chewing gum, toothbrushes and dental floss,and dental impressions. 22,23 Use of DNA for humanidentification is proved to be very effective and hasbeen documented. 24Polymerase chain reaction (PCR) technique allowsamplification of DNA from even negligible amountsof source material. 25 The amplified DNA is thencompared with antemortem samples such as storedblood, hairbrush, clothing, cervical smear, biopsyspecimens. Other methods include Restriction fragmentlength polymorphism (RFLP), single nucleotidepolymorphism-based (SNP) and micro-assays. 21 DNAcan also help in identification of a parent or sibling.Most of these techniques involve nuclear DNA butmitochondrial (mt) DNA is more abundant, and canbe identified in cases when nuclear DNA is insufficient.Dental tissues like dentin and cementum are rich inmtDNA. 26Bite MarksBite mark is vital evidence in case of crime and abuseand can go unnoticed by untrained individuals.Recording, comparing and determining whether themark is truly a result of biting is important for a forensicodontologist. Knowledge on the arch alignments andspecific tooth morphology of animals is also requiredfor a forensic odontologist to distinguish human bitesfrom non human.Bite marks are usually documented taking photographsor taking impressions. Measuring the size of the toothIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012445

Review Articleof the suspect and comparing it with bite mark canbe done with metric analysis. 27 The amount of detailsrecorded on the surface may vary in each case. When agood impression of the bite is left behind the physicalcharacteristics like distance from cuspid to cuspid,shape of the arch, evidence of malalignment, spacing,teeth width and thickness, missing teeth and wearpatterns are taken into consideration for comparingbite mark wound and suspect’s teeth.Dentists should be in a position to explain the obstacleswhich interfere with accurate analysis and apply thebite mark evidence consistent with scientific principleswhile reporting bite mark evidence. 28Chelioscopy and RugoscopyChelioscopy is the study of lip prints. Although uniqueto an individual like fingerprints, it is not as reliablebecause of its deformable nature. Susuki and Tsuchihasihave classified lip prints into many types dependingon the pattern of grooves as type I (vertical), type II(branched), type III (intersected), type IV (reticular)and type V (other). 29 Studies have found genderdifferences with certain types predominant in females(I and II) and in males (III and IV). 30Rugoscopy is the study of palatal rugae patterns. Theyare ridges in the anterior hard palate and are uniqueamong individuals. They can be classified as primary(>5 mm), secondary (3-5 mm) and fragmentary (

Review ArticleConclusionKnowledge and importance of forensic dentistry isrequired for every dentist in injury and abuse casesfor proper recording of findings to help investigatingand legal officers. As forensic odontologists have amajor role to play in identification of victims in massdisasters, a good quality of dental records makes theidentification process easier. Teeth are unique andresistant to destruction and their records when wellmaintained have a major impact in identificationprocess. Dentists should also be aware of the legalaspects involved in forensic investigations and reportto the concerned authorities to help in obtaining legalremedies to the victims.References1. Dayal PK. Textbook of Forensic Odontology. First ed, Paras MedicalPublishers, 1998.2. Keiser-Neilsen S. Forensic Odontology. Int Dent J 1968. 18:668-681.3. Shamim T. Forensic odontology. J Coll Physicians Surg Pak 2010;20:1-2.4. Avon SL. Forensic Odontology: The Roles and Responsibilities of theDentist. J Can Dent Assoc 2004; 70:453-8.5. Shamim T. A New Working Classification Proposed For ForensicOdontology. Journal of the College of Physicians and SurgeonsPakistan 2011;21: 59-60.6. Pretty I A, Sweet D. A look at forensic dentistry – Part 1: The role ofteeth in the determination of human identity. British Dental Journal190, 359 - 366 (2001)7. Hinchliffe J. Forensic odontology part 1. Dental identification. BritishDental Journal 2011; 210: 219 - 224.8. Hinchliffe J. Forensic dentistry: an introduction to identification issues.Dental Tribune Asia Pacific Edition 2007; 11: 8-10.9. American Board of Forensic Odontology. Body identificationguidelines. J Am Dent Assoc 1994; 125: 1244-1254.10. Pretty IA. and Addy LD. Associated postmortem dental findings as anaid to personal identification. Sci Justice, 2002. 42: 65-74.11. Whittaker DK, Rawle LW. The effect of conditions of putrefactionon species determination in human and animal teeth. Forensic Sci Int1987; 35: 209-212.12. Shafer, Hine, Levy. Textbook of Oral Pathology. Eds Rajendran,Shivapathasundharam – 6th Ed: 871-899.13. Sweet D. Why a dentist for identification? Dent Clin Nor Am 2001;15:237-251.14. Slaykin HC. Sex, enamel and forensic dentistry: a search for identity. JAm Dent Assoc 1997; 128: 1021-1025.15. Shamim T, Ipe Varughese. V, Shameena PM, Sudha S. ForensicOdontology – A New Prespective. Medico Legal Update2006; 6, 1-3.16.17.18.19.20.21.22.23.24.25.26.27.28.29.30.31.32.33.34.35.Avon SL. Forensic Odontology: The roles and responsibilities of adentist. J Can Dent Assoc 2004; 70:453 - 58.Harley K. Tooth wear in the child and the youth. Br Dent J 1999;186: 492-496.Murray MO, Wilson NH. Ecstasy related tooth wear. Br Dent J 1998;185: 264.Gupta BN. Occupational diseases of teeth. J Soc Occup Med 1990;40: 149-152.Sweet D, Hildebrand D, Phillips D. Identification of a skeleton usingDNA from teeth and a PAP smear. J Forensic Sci 1999; 44: 630-633.Girish KL, Farzan S Rahman, Shoaib R Tippu. Dental DNAfingerprinting in identification of human remains. J Forensic Dent Sci2010; 2: 63-68.Kanto A, Hirata MH, Hirata RD, Nunes FD, Melani RFH, OliveiraRN. DNA extraction from human saliva deposited on skin and its usein forensic identification procedures. Braz Oral Res 2005;19: 216-22.Silva RHA, Musse JO, Francisco RH. Melani RF, Oliveira RN. Humanbite mark identification and DNA technology in forensic dentistry.Braz J Oral Sci 2006; 5: 1193-7.Lygo JE, Johnson PE, Holdaway DJ et al. The validation of shorttandem repeat (STR) loci for use in forensic casework. Int J Legal Med1994; 107: 77-89.Sweet D and Hildebrand D. Recovery of DNA from human teeth bycryogenic grinding. J Forensic Sci 1998; 43: 1199-202.Shiroma CY, Feilding CG, Lewis JA Jr, Gleisner MR, Dunn K. Aminimally destructive technique for sampling dentine powder formitochondrial DNA testing. J Forensic Sci 2004; 49:791-5.Pretty IA and Sweet D. A look at Forensic Dentistry Part 2: Teeth asweapons of violence – identification of bite mark perpetrators. BritDent J 2001; 190: 415-418.Rothwell BR. Bite marks in forensic dentistry. A review of legal,scientific issues. J Am Dent Assoc 1995; 126: 223-32.Tsuchihashi Y. Studies on personal identification by means of lip print.Foren Sci Int 1974; 3: 233-48.Sharma P, Saxena S, Rathod V. Cheiloscopy: The study of lip prints insex identification. J Forensic Dent Sci 2009;1 : 24-7.Thomas CJ, Kotze TJ. The palatal rugae pattern: A new classification. JDent Assoc S Afr 1983; 38:153-76.Caldas IM, Magalhaes T, Afonso A. Establishing identity usingcheiloscopy and palatoscopy. Forensic Sci Int 2007; 165: 1-9.McNeese Mc. When to suspect child abuse. Am Fam Physician 1982;25: 190 - 7.Neville B, Douglas D, Allen CM and Bouquot. Textbook of Oraland Maxillofacial Pathology. 3rd Ed: WB Saunders Co, 2009:887 - 916.Borrman HI, DiZinno JA , Wasen J, Rene N. On denture marking. JForensic Odontostomatol 1999; 17: 20-6.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012447

Review articleRole of Genetics in Patterning of Faceand JawsS Kishore Kumar*, Deepak Chandrasekaran*, Faisal Tajir**, A V Vidhya Lakshmi †AbstractGenetics is at present one of the most rapidly progressing fields in biology and biomedicine. The advances of gene technologyhave led to a rapid explosion in the understanding of the molecular mechanisms regulating embryonic development. New genesand their functions are continuously being discovered in experimental studies using animal embryos and molecular geneticstudies in humans are unraveling gene mutations causing congenital defects. It is now shown in the recent year studies thatthe homeobox gene plays an important role in the patterning of human face and jaws. Members of the homeobox – containinggenes are expressed in the cranial neural crest cell and function as transcriptional regulators that control cellular proliferationand differentiation during normal embryonic development.Key words: Neural crest cell, Hox group, Msx1 and Msx2 (muscle segment), Dlx (distalless), Otx (orthodontical), Gsc(goosecoid), and Endothelin -1, Sonic hedgehog.The development of human face is a well coordinated,complicated yet planned processthat requires integration of the surfaceectoderm, neural crest cell along with the mesodermaltissue.Patterning and morphogenesis of neural crest–derivedtissues rely on a complex balance between signalsacquired by neural crest cells in the neuroepitheliumduring their formation and signals from the tissuesthat the neural crest cells contact during theirmigration. Neural crest cells migrate ventrolaterallyto the frontonasal prominence and the branchialarches and give rise to the jaws, the anterior skull baseand the anterior skull vault. Neural crest cells carryinformation that directs the axial pattern and speciesspecificmorphology of the head and face. Signalinginteractions coordinate the outgrowth of the facialprimordia from buds of undifferentiated mesenchymeinto the intricate series of bones and cartilage structuresthat, together with muscle and other tissues, form theadult face.*Professor**Associate Professor†PG StudentDept. of Orthodontics and Dentofacial OrthopedicsSree Balaji Dental College and Hospital, Chennai.Address for correspondenceDr S Kishore KumarE-mail: spkkishorekumar@yahoo.comHowever, the way in which these molecules control theepithelial-mesenchymal interactions, which mediatefacial outgrowth and morphogenesis, is unclear. Thehomeobox genes Msx1 and Msx2 are highly conservedamong various species and function as transcriptionalregulators that control cellular proliferation anddifferentiation during normal embryonic development.It is now shown that Msx1 is strongly expressedin neural crest cells and plays a critical role inregulating epithelial-mesenchymal interactions duringorganogenesis 1Homeobox genes play a important role in patterningthe embryonic development. These can also be regardedas master genes of the head and face controllingpatterning, induction, programmed cell death, andepithelial mesenchymal interaction during developmentof the craniofacial complex.Those of particular interest in craniofacial developmentinclude the Hox group, Msx1 and Msx2 (musclesegment), Dlx (distalless), Otx (orthodontical), Gsc(goosecoid), and Shh (sonic hedgehog).This article outlines the role of these genes in patterningof the face and jaws.Neural crest cellThe development of the mesoderm of the vertebratehead involves different mechanisms from that of thetrunk. These differences may be related to the presence448Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Review Articleof a tissue, the neural crest, which is able to undertakeroles that in the rest of the body are played by theparaxial mesoderm. Neural crest cells originate fromthe boundary between the neural plate and the surfaceectoderm. The crest migrates ventrally and in thehindbrain region of all vertebrates populates a seriesof repeating structures, the branchial arches. 2 In thetrunk, there are subpopulations of crest that followdifferent temporal and spatial migration pathways,and it is possible that, in the head, there are differentpopulations as well. The early migrating cells in the headreach the branchial arches and adopt a mesenchymalfate, while later emerging cells remain closer to theneural tube and adopt a neural fate. 3Interactions with head epithelia such as the neuraltube and surface ectoderm seem to be important inneural crest differentiation and some aspects of headmorphogenesis in chick. 4 However, evidence suggeststhat while the neural crest is extensively dependenton surrounding tissue to allow differentiation, somepatterning information resides within the CTest itself.This has been shown in experiments where sectionsof chick midbrain neural plate, whose crest normallycolonises the first (maxillary and mandibular) arch,have been grafted to the second (hyoid) arch level. 5 Theneural crest migrated into the hyoid arch, but thereformed mandibles, which are first arch structures. Inaddition, these ectopic mandibles had a set of musclesattached to them that were derived from the secondarch paraxial mesoderm, but resembled first archmuscles. Duplicate beaks were also formed on thesurface, suggesting that the differentiation pattern ofsecond arch paraxial mesoderm and surface ectodermwas controlled by the neural crest.Homeobox geneMuch recent work has centred on the isolation offamilies of transcription factors potentially involved inearly developmental decisions such as establishing thebasic body plan.In humans a number of other homeobox-containinggenes are expressed in the maxillary and mandibulararches, and developing facial primoridia. Thesegenes, which all encode homeodomain–containingtranscription factors, include Msx-1, Msx-2, Dlx1-6and Barx-1. Again many of these homeobox-containinggenes are related to the families of gene found inDrosophila. Knockout studies have confirmed thatthese genes perform essential roles during the formationof the facial complex.Members of the Msx gene family (Msx-1 and Msx-2) arenormally expressed strongly in the neural crest derivedmesenchyme of the developing facial prominence, andthere is now strong evidence for a role of these genesin specification of the skull and face. 2Targeted disruption of Msx-1 in the mouse producesa number of defects in facial structures. There is cleftpalate associated with a loss of the palatine bones,maxillary and mandibular hypoplasia, and a highlypenetrant arrest of tooth formation at the bud stage oftooth development. 3In mice, defects in Msx-2 cause skull ossification withpersistence of calvarial foramen. This arises as a result ofdefective osteoprogenitor proliferation during calvarialmorphogenesis. 4Members of the multi-gene Dlx family are expressedin a complex pattern within the embryonic ectodermand mesenchyme of the maxillary and mandibularprocesses of the first arch. 5Targeted mutation in Dlx-1, Dlx-2 and Dlx 1/2provide evidence that these genes are required forthe development of neural crest derived skeletalelements of the first and second branchial arches. 6Analysis of these mutations reveals that Dlx-1 andDlx-2 regulate proximal first arch structures and that,in the mandibular primordium, there is considerablefunctional redundancy of Dlx-1 and Dlx-2 with othermembers of the Dlx family.Goosecoid GeneGoosecoid is another homeobox-containingtranscription factor, originally isolated in Xenopusfrom a dorsal blastopore lip cDNA library. The dorsalblastopore lip has long been known to be ultimatelyresponsible for organization of the complete body axisin the early embryo. However, when goosecoid wasknocked out in transgenic mice they formed a bodyaxis normally, but exhibited a number of craniofacialdefects. 7In wild type mice, goosecoid transcripts had beendetected at later stages of development in the osteogenicIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012449

Review Articlemesenchyme of the developing mandible, tongue andmiddle ear. In mutants, the mandible was hypoplastic,and lacked coronoid and angular process, whilst therewere defects in several bones, including the maxillary,palatine, and pterygoid. As a homeobox–containingtranscription factor it would appear that goosecoidis involved in essential inductive tissue interactionsduring the formation of the head.EndothelinAnother gene that has produced an even moreperplexing phenotype is Endothelin-1 which encodes avasoactive peptide expressed in vascular endothelial cellsand is thought to play a role in the regulation of bloodpressure. Mice with targeted disruption of Endothelin-1 have no abnormalities of their cardiovascular systembut do have a marked reduction in tongue size,micrognathia and cleft palate. 8One of the two G protein-coupled endothelinreceptors, ET-A is expressed in the neural crest derivedectomesechyme of the branchial arches, whilst itsprimary ligand, ET-1 is expressed in arch epithelium,pharyngeal pouch endothelium, and arch core paraxialmesoderm. The ET-A/ET-1 pathway appears to beimportant for proper patterning of the caudal regionsof the first arch. 9Target disruption of ET-A or ET-1 in mice producecraniofacial defects that resemble a human conditioncalled CATCH-22, which is characterized by abnormalfacies and cardiovascular defects. 10It has been recently been shown that the craniofacialdefects in ET-A mice are, in part, due to an absenceof the goosecoid transcription factor. 11 Sonic hedgehogShh Sonic hedgehog (Shh) is the vertebrate homologueof the Drosophila hedgehog segment polarity gene.In the vertebrate embryo, Shh encodes a signallingpeptide that is involved in mediating both long- andshort-range patterning in a number of well characterizeddevelopmental signalling centres. 16 Clues about theregulation of craniofacial morphogenesis have comefrom studies of the Shh gene. Mutations of Shh in thehuman leads to profound abnormalities in craniofacialmorphogenesis. 17Loss of Shh produces defective patterning of theneural plate resulting in holoprosencephaly, a failure ofcleavage in the midline forebrain, and cyclopia. Laterin development Shh is expressed in the ectoderm ofthe fronto-nasal and maxillary processes and has beenshown to be essential for their normal development.By manipulating developing chick embryos, it hasrecently been shown that a transient loss of Shhsignalling in these regions of the developing face canresult in defects analogous to hypotelorism and cleftlip/palate, which are characteristic features of themilder forms of holoprosencephaly. In contrast, excessShh leads to medio-lateral widening of the fronto-nasalprocess resulting in hypertelorism. In severe cases thiscan lead to facial duplications. 18References1.2.3.4.5.6.7.8.9.Hill R, Jones P, Rees A, Sime C, Justice M, CopelandN, Jenkins N, Graham E, Davidson D. A new family ofmouse homeo box-containing genes: molecular structure,chromosomal location, and developmental expression ofHox-7.1. Genes Dev 1989;3:26-37.Morjuss-kay, G. And Tan, S S (1987) Mapping CranialNeural crest migration pathways in mammalian embryos.TIG 3, 257-261.NICHOLS, D. (1986) Formation and distribution ofneural crest mesenchyme to the first pharangeal archregion of the mouse embryo Am. J Anat 176, 221-231.Thorocood, P , Bee, J And Von Der Mark, K(1986) Transient expression of collagen type II atepitheliomesenchymal interfaces during morphogenesisof the cartilaginous neurocranium Devi Bwl 116, 497-509NODEN, D M (1983) The role of the neural crest inpatterning of avian cranial skeletal, connective, andmuscle tissues Devi Bwl. 96, 144-165Ferguson M.w.j., (2000) , Ahole In The Head, NatureGenetics,24, 330-331Satokata, I. and Maas, R. (1994) Msx-1 deficient miceexhibit cleft palate and abnormalities of craniofacialdevelopment, Nature Genetics, 6, 348-355.Satokata, I., Ma, L., Ohshima, H., Bei, M., Woo, I.,Nishizawa, K., Maeda, T., Takano, Y., Uchiyama, M.,Heaney, S., Peters, H., Tang, Z., Maxson, R. and Maas,R. (2000) Msx2 deficiency in mice causes pleiotropicdefects in bone growth and ectodermal organ formation,Nature Genetics, 24, 391-395.Bulfone, E.,Kim, H-J. Puelles, L., porteus,M. H., Grippo,J.F.,and Rubenstein, J. L. R. (1993) The mouse Dlx-2(Tes-1) gene is expressed in spatially restricted domainsof the forebrain, face and limbs in mid-gestation mouseembryos, Mechanisms of Development, 40, 129-140.450Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Review Article10.11.12.13.Qiu, M., Bulfone, A., Ghattas, I., Meneses, J. J.,Christensen, L., Sharpe, P. T., Presley, R., Pederson, R. A.and Rubenstein, J. L. R. (1997) Role of the Dlx homeoboxgenes in proximodistal patterning of the branchial arches:mutations of Dlx-1 and –2 alter morphogenesis ofproximal skeletal and soft tissue structures derived fromthe first and second arches, Developmental Biology, 185,165-184.Rivera-Pérez, J. A., Mallo, M., Gendron-Maguire, M.,Gridley, T. and Behringer, R. R. (1995) Goosecoid is notan essential component of the mouse gastrula organizerbut is required for craniofacial and rib development,Development, 121, 3005-3012.Kurihara, Y., Kurihara, H., Suzuki, H., Kodama, T.,Maemura, K., Nagai, R., Oda, H., Kuwaki, T., Cao,W-H., Kamada, M., Jishage, K., Ouchi, Y., Azumi,S., Toyoda, Y., Ishikawa, T., Kumada, M. and Yazaki,Y. (1994) Elevated blood pressure and craniofacialabnormalities in mice deficient in endothelin-1, Nature,368, 703-710.Tucker, A. S., Yamada, G., Grigoriou, M., Pachnis, V.and Sharpe, P. T. (1999) Fgf-8 determines rostral-caudalpolarity in the first branchial arch, Development, 126,51-61.14.15.16.17.18.Wilson, D. I., Burn, J., Scambler, P. and Goodship, J.(1993) DiGeorge syndrome: part of CATCH 22, Journalof Medical Genetics, 30, 852-856.Clouthier, D. E., Hosoda, K., Richardson, J. A.,Williams, S. C., Yanagisawa, H., Kuwaki, T., Kumada,M., Hammer, R. E. and Yanagisawa, M. (1998) Cranialand cardiac neural crest defects in endothelin-A receptordeficient mice, Development, 125,813-824.Hammerschmidt, M., Brooke, A. and McMahon, A.P. (1997) The world according to hedgehog, Trends inGenetics, 13, 14-21.Belloni, E., Muenke, M., Roessler, E., Traverso, G.,Siegel-Bartelt, J., Frumkin, A., Mitchell, H. F., Donis-Keller, H., Helms, C., Hing, A. V., Heng, H. H., Koop,B., Martindale, D., Rommens, J. M., Tsui, L. C. andScherer, S. W. (1996) Identification of Sonic hedgehog asa candidate gene in holoprosencephaly, Nature Genetics,14, 353-356.Hu, D. and Helms, J. A. (1999) The role of sonic hedgehogin normal and abnormal craniofacial development,Development, 126, 4873-4884.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012451

case reportManagement of Multiple Complicated CrownFractures of 21-yet Another ApproachV Prakash*, A Subbiya*, P Vivekanandhan*, VG Sukumaran **AbstractThe clinical presentation and radiographic signs of multiple complicated crown fractures are extremely variable and canpresent difficulties in diagnosis and management. This case report discusses yet another alternative management of maxillaryanterior tooth with multiple fractures.Key words: Endodontics, diagnosis, multiple complicated fractures.Complicated crown fractures involve enamel,dentin and pulp 1 or a class 3 fracture (Ellis& Davey 1970). The incidence of complicatedcrown fractures ranges from 0.9% to 13% of all dentalinjuries 2-4 and the most commonly involved tooth isthe maxillary central incisor (Andreasen and Andreasen1993). When a tooth is diagnosed to have multiplefractures, practitioner is prejudiced for extractionbecause of poor prognosis but for the patient it is ashocking experience especially when it is an anteriortooth because of aesthetic trauma. Multiple fracturedtooth exhibit specific clinical and radiographic signswhich should alert the practitioner to the possibilityof salvaging the tooth. This case report discusses yetanother alternative management of upper anteriortooth with multiple fractures.and extending straight along the entire clinical crown.The fracture was extending 0.5mm below the gingivalmargin both on the labial and palatal aspect. Intacttooth substance was seen apical to the fracture. Thiswas confirmed by passing a sharp probe gently over thetooth surface above the fracture line. A step deformitywas felt as the probe was passed over the fracture linealong the gingival margin.Case ReportA 12-year-old male patient came with the complaintof multiple fractures in the upper anterior tooth.Patient had pain during eating and during movementof the mouth. Patient gave history of trauma theprevious day. On Clinical examination, tooth number21 had multiple fractures. Fracture on the labial side,commences from the incisal third and extends upto themiddle third, there it bifurcates into a Y shaped fracture(figures 1 and 2) on the labial side. On the palatal sideof tooth no.21, fracture starting from the incisal thirdFigure 1. Multiple fractures present in 21*Professor**Professor and HeadDept. of Conservative DentistrySree Balaji Dental College and Hospital, Chennai - 600 100Address for correspondenceDr. V. PrakashE-mail: drprakashmds@gmail.comFigure 2. Fractured fragments separated in 21452Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case ReportFigure 3. Multiple fractures in 21 seen in the radiographThe tooth no.21 was anaesthetized with 2% lignocaine.Pulp tissue was extirpated using a barbed broach.Fractured fragments were reduced with digital pressure,checked for good approximation and splinted with adual cure composite resin (figures 4 and 5). Crownpreparation was done judiciously in 21 the followingday allowing adequate time for stabilization and propercure of the luting cement. Crown margin was placedsubgingivally apical to the fracture line and elastomericimpression was taken. Temporary acrylic jacket crowncemented immediately. In the following appointment,access was opened through the temporary jacket crownfollowed by cleaning and shaping. As the radiographrevealed the tooth had open apex, obturation was doneby rolled cone technique customized to suit the apicalthird (figure8).Main advantages of roll cone techniqueis, it is a passive form of obturation without extendingthe fracture apically by avoiding the use of spreader.This customization of gutta percha has demonstratedgood apical adaptation (figure 8) to open apex as seenFigure 4. Fractured fragments splinted in 21 with dual curecomposite resinFigure 5. Fractured fragments splinted in 21 with dual curecomposite resin-pulatal viewFigure 6. Temporary jacket crown cemented in 21Figure 7. Permanent jacket crown cemented in 21after rootcanal treatmentIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012453

Case ReportAdvantages of dual cure resin is that the viscosity andworking time permits better and closer adaptation offractured fragments. Temporary acrylic jacket crownhelped in stabilizing the fractured fragments togetherduring the root canal treatment. Temporary jacketcrown helped in restoring patient confidence regardingaesthetics and function. Placing the crown marginapical to the fracture helps in better stabilization andprevent the fracture extending apically.ConclusionFigure 8. Radiograph taken after obturationin the post obturation radiograph. After the root canaltreatment, the patient was asymptomatic. Two weekslater temporary jacket crown was removed, elastomericimpression taken. Permanent acrylic heat cured jacketcrown cemented. The patient was recalled 3 months,6 months, 1 year and 2 years later. Patient wasasymptomatic, clinically there was no development ofperiodontal pocket or gingival recession.DiscussionOnce the presence of multiple fractures are confirmed,the decision needs to be made regarding the treatmentof the tooth with a view on its long term prognosis.This prognosis depends on the extent, duration andlocation of the fracture. While it is possible to seefracture images clearly on a radiograph, care shouldbe taken to isolate and identify fracture lines fromother anatomical features, palatal grooves and artefacts.Important features in the evaluation and prognosisof multiple fractures are the direction and depth offracture plane, separation or movement along thefracture line, evidence of pulpal involvement and thelength of the fracture which should be judiciouslytaken into account for better long term prognosis. 5In this case, the fractured fragments were bonded withdual cure resin, which is ideal for cementing veneers.There is no given generalized treatment methodologyfor multiple complicated crown fractures. Each toothwith multiple fractures has its own unique clinicaland radiographic presentation and findings. It requiresproper planning and management best suited to thepresented clinical findings. The desirability for savingthe tooth should be carefully weighed up against othermethods of treatment. The treatment done in this casecould be yet another viable and practical alternativeas compared to many other innovative treatmentprocedures.“I affirm that I have no financial affiliation (e.g.,employment, direct payment, stock holdings, retainers,consultantships, patent licensing arrangements orhonoraria), or involvement with any commercialorganization with direct financial interest in the subjector materials discussed in this manuscript, nor haveany such arrangements existed in the past. Any otherpotential conflict of interest is disclosed”.References1.2.3.4.5.Andreasen JO, Andreasen FM. Textbook and color atlasof traumatic injuries to the teeth 3rd edition Copenhagenand St.Louis: Munksgaard and CVMosby; 1994.Canakci V, Akgul HM, Akgul N, Canakci CF. Prevalenceand handedness correlates of traumatic injuries to thepermanent incisors in 13-17 year old adolescents inErzurum Turkey. Dent Traumatology 2003; 19: 248.Saroglu I, Sonmez H. The prevalence of traumatic injuriestreated in the pedodontic clinic of Ankara University,Turkey, during 18 months. Dent Traumatology 2002;18: 299.Tapias MA, Jimenez – Garcia R, Lamas F. Prevalenceof traumatic crown fractures to permanent incisorsin a childhood population: Mostoles, Spain. Dent.Traumatology 2003; 19: 119.Franklin S. Weine Endodontic therapy 6th edition. Pg62-67.454Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case Report6.7.8.9.10.11.12.13.Gher ME, Dunlap RM, Anderson MH, etal. Clinicalsurvey of fractured teeth. J Am Dent Assoc. 1987; 174-177.Ingle, Bakland Endodontics 5th edition. Pg 788.Stephen Cohen, Kenneth M. Hargreaves, Pathways ofthe pulp. 9thedition. 614-625.Abou – Rass M. Cracklines: The precursors of toothfractures - their diagnosis & treatment. QuintessenceInt. 1983; 14: 437-447.Esin Pusman, Zafer C. Cehreli, Nil Altay etal Fractureresistance of tooth fragment reattachment: effects ofdifferent preparation techniques and adhesive materials.Dental Traumatology 2010; 26: 9-15.Anna- Louise Bate, Fabrizio Lerda. Multidisciplinaryapproach to the treatment of an oblique crown-rootfracture. Dental Traumatology 2010; 26: 98-104.Antoniella Busuttil Nandi, DianeE.Fung. Tooth fragmentreattachment in multiple complicated permanent incisiorcrown-root fractures - a report of two cases. DentalTraumatology 2008; 24: 248-252.Celia Tomiko Matida Hamata Saito. Managementof a complicated crown – root fracture using adhesive14.15.16.17.18.19.fragment reattachment and orthodontic extrusion.Dental Traumatology 2009; 25: 541-544.Andreasen FM, Steinhardt U, Billa M, Munksgaard EC.Bonding of enamel–dentin crown fragments after crownfracture. An experimental study using bonding agents.Endod. Dent Traumatology 1993; 111-114.Nagarajan S, Sockalingam MP, Alida Mahyuddin.Complicated crown root fracture treatment option. ACase report. Archives of Orofacial Sciences 2009; 4: 25-28.Aggarwal V, Logani A & Shah N. Complicated crownfractures - management and treatment options.International Endodontic Journal 2009; 42: 740-753.Jaime Andres Diaz. Crown fractures in Maxillary Centralincisors; 24 months follow up and clinical outcome inchildren. Int. J. Odontostomat. 2008; 2: 83-94.Dunn NA, Eichenbaum IW. Diagnosis and treatmentof fractured anterior teeth. J Am Dent Assoc. 1952; 44:166-172.DiAngelis AJ, Jungbluth M. Reattaching fractured toothsegments: an esthetic alternative J Am Dent Assoc. 1992;123: 58-62.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012455

case reportConservative Treatment of A Large PeriapicalLesion Using Aspiration and IrrigationA R Pradeep Kumar*, T Ilango**, A Subbiya †AbstractTreatment of a mandibular central incisor with an associated cystic lesion by conventional endodontic therapy combinedwith aspiration and irrigation is reported. Small cystic lesions may frequently heal with endodontic treatment only. However,larger lesions may need additional treatment. If surgical enucleation is done, other teeth or structures may be damagedunnecessarily. Therefore, it may be better to attempt non surgical conservative treatment of aspiration and irrigation and aworking protocol is presented for this.Key words: Periapical lesion, healing, aspiration, irrigationThe treatment of choice for the management ofnon-vital teeth with large periapical lesions isconventional root canal therapy. 1 When thistreatment is not successful in resolving the periapicalpathology, other options such as non surgical retreatmentor periapical surgery are considered. Surgical curettageand apical resection is most often the treatment donefor persistent periapical lesions. By these proceduresan environment conducive to healing is established.According to Natkin et al 2 there is no doubt that largerlesions are more likely to be cysts and will be less likelyto heal with endodontic therapy alone.The undesirable consequences of surgical curettagein very extensive lesions have led to the use ofmarsupialization or tube decompression devices. 3Marsupialization is actually described as “… unroofingthe outer wall of the cyst by making a surgicalincision, evacuating its contents, and establishing alarge permanent opening by suturing the remainingpart of the cystic membrane to the mucosal surfacearound the periphery of the opening”. 4 Decompressionis favoured due to lower morbidity and as bonyingrowth occurs as the lesion shrinks resulting in morenormal contours. 5 A variety of devices have been usedin establishing drainage and decompression of large*Professor and Head, Dept. of Conservative Dentistry and Endodontics,**Professor, Dept. of Prosthodontics,Thai Moogambigai Dental College, Chennai, India.†Professor, Dept. of Conservative Dentistry and EndodonticsSree Balaji Dental College and Hospital, Chennai, India.Address for correspondenceAR Pradeep KumarE-mail: arpradeep@vsnl.comperiapical lesions. Polyvinyl or polyethylene drainagetubes can be placed through the alveolar mucosa overthe lesion. 6 Walker and Davis described the placementof a stainless steel canula into the lesion through theinvolved tooth. 7 But, the use of these techniques wasassociated with a variety of problems. Patients wereresponsible for maintaining the patency of the canula,the tubes in the oral mucosa could get displaced andoral hygiene was compromised. 8Efficient neutralization of microorganisms and theremoval of byproducts of cells and microorganismsas well as preventing reinfection are prerequisites intreating apical pathosis. 9 The greatest impact may beachieved by effective biomechanical preparation andcalcium hydroxide medication, which promotes antisepsisof the root canal system and mineralized tissueformation in the apical region. 10,11 Aspiration of acystic lesion may cause decompression of the lesionas well as provide information as to the presenceof purulence, cystic fluid, or haemorrhage. Theaspirant may be utilized for microbial identificationand immunohistochemical analysis. Saline irrigationin wound debridement is a mainstay of surgicaltreatment. Regardless of the histological diagnosisof the periapical pathology, a local change in theosteoblastic: osteoclastic ratio must allow for anincrease in bone deposition. It has been suggested byHoen et al that this local change may be caused byaspiration and a thorough saline rinse. 12A combination of conventional root canal therapy withinter-appointment calcium hydroxide medication and456Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case Reportthe use of aspiration and irrigation to cause resolutionof a large periapical lesion is described.Case ReportA 11-year-old male patient attended a SpecialtyDental Centre, Chennai, India requesting an oralhealth examination. He presented with mobility oflower anterior teeth. He was otherwise healthy witha noncontributory medical history. There was nopast dental history as this was his first dental visit.Intraoral clinical examination revealed painless swellingof the labial mucosa adjacent to teeth No# 33 - 43.The labial muccobuccal fold was obliterated and theswelling had a firm consistency. There was no lingualswelling. Tooth decay and periodontal pockets wereabsent. Tooth No# 41 presented with Ellis Type IIfracture and brownish discoloration. The patient wasnot aware of a history of dental trauma. Electronic(Parkell EPT) and thermal (Heat test with Gutta-Percha stick, Harvard) testing was negative only intooth no # 41. All mandibular anterior teeth werepainless on percussion. Mobility grade II was present inteeth No# 32-42. A diagnostic orthopantomograph(Fig1) showed an extensive radiolucent area extendingfrom the mesial aspect of tooth no#33 including theperiapical region of teeth no# 32,31,41 and 42 up tothe mesial aspect of tooth no#43. The periapical area ofteeth no#33 and #43 were not involved. The extent ofperiapical radiolucency was 19mm x 40 mm (H x L) asestablished by orthopantamograph. Taking into accountthe medical and dental history a presumptive diagnosisof pulp necrosis of traumatic origin with extensiveinflammatory apical periodontitis was established . Itwas decided to splint the lower anterior teeth and toperform root canal treatment on tooth no#41.Fig 1. Diagnostic orthopantomograph showing an extensiveradiolucent area in lower anterior region.Fig 2. Aspiration and Irrigation.Root canal treatmentSplinting with composite resin was done from canine tocanine in the mandible. Following infiltration anesthesiaand rubber dam isolation, root canal treatment wasinitiated in tooth no #41. The tooth was found tohave a small amount of necrotic pulp tissue and mucopurulentfluid. Working length was established using theROOTS ZX apex locator and confirmed with a periapicalradiograph. The canal was prepared with size 15-40 kfiles using a step back technique while maintaining apicalpatency. The root canal was copiously irrigated with 5%sodium hypochlorite and 17% EDTA. Calcium HydroxideFig 3. A Radiograph taken six months later demonstratessignificant bony healing.paste(Non setting) was placed into the canal with a lentulospiralpaste carrier and the access cavity was closed withCavit G(3M ESPE). The intracanal dressing was changedweekly for four weeks at which time the canal couldbe dried. At this visit following irrigation with EDTAand NaOCl, the canal was obturated with gutta-percha( Maillefer-Dentsply) and AH Plus (Maillefer-Dentsply)by lateral compaction. Access cavity was sealed withIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012457

Case Reportcomposite resin ( Z 100 3M ESPE).The patient wasrecalled after 2 months when radiographic examinationrevealed no change in the size of the periapical lesion.Due to the large size of the lesion it was then decidedto perform the aspiration and irrigation technique asdescribed by Hoen et al. 12Aspiration and IrrigationFollowing labial infiltration anesthesia and povidoneiodineswabbing of the mandibular anterior region, an18-guage needle attached to a 20-ml syringe was used topenetrate the buccal mucosa mesial to tooth no# 33 andaspirate about 4 ml of blood-tinged fluid from the lesion.A second syringe filled with saline was used to rinse thebony lesion. A sterile, disposable 18-guage needle was usedto penetrate the bony lesion mesial to tooth no#43(Fig 2).Saline injected via the first needle exited via the secondneedle. This rinsing procedure was repeated until the fluidexiting the second needle was found to be clear. About 50ml of saline was used. The patient was given a prescriptionof analgesic and was asked to report after 48hrs. The patientwas reviewed 2 days later and a minor hematoma was seenat both the entry and exit wound sites. The procedurewas repeated after two weeks. A Radiograph taken sixmonths later demonstrates significant bony healing(Fig3).DiscussionThe treatment options for large periapical lesions mayrange from conventional nonsurgical root canal therapywith calcium hydroxide intracanal medication to varioussurgical interventions. 13 The technique reported in thispaper could be used as an alternative to apical surgeryfor large cystic periapical lesions. Case selection isimportant. If upon attempting aspiration the clinicianis unable to remove fluid from the bony cavity, it wouldindicate the presence of granulation tissue or someother type of soft tissue mass. Such a case would requireconventional surgical exploration and management. 12The success of this conservative technique was based onappropriate shaping, cleaning, antisepsis and filling ofthe root canal. Calcium hydroxide intracanal medicationwas used as it neutralizes remaining microorganisms inthe root canal. 11 An important aspect of the irrigationprocedure is to ensure that there is an escape wound forthe saline to drain. Gentle irrigation would cleanse thecavity and saline will not be forced into the surroundingtissues. The irrigation seemed to initiate bleeding intothe defect. This bleeding and subsequent clot formationmay be the start of a healing mechanism as describedby Seltzer. 14Periapical lesions of endodontic origin are expected toheal after non surgical root canal therapy. Previously, itwas thought that 40 to 50% of periapical lesions werecystic. 15,16 However, it has been revealed that only 15%of lesions are cystic of which somewhat more than halfare true apical cysts. 17,18,19 According to Nair 20 , there aretwo types of cysts, a periapical pocket cyst which is incommunication with the root canal and a true apicalcyst which is a separate entity. The apical true cyst is lesslikely to resolve with root canal therapy alone and willrequire additional intervention.Very recent research suggests that IL-1 alpha expressionmay be partly regulated by intracystic pressure. 21IL-1 alpha has many functions including induction ofosteoclast formation and stimulation of prostaglandinand collagenase production. 22 Therefore reduction ofintracystic pressure is a key factor. It is also plausiblethat reduction of the concentration of inflammatorymediators by irrigation of the cystic lumen could reduceepithelial proliferation and reverse bone resorption,leading to shrinkage of the cyst cavity. 5 However theexact mechanisms of cyst expansion and shrinkageremain unknown at this time.ConclusionSuccessful resolution of large periapical lesions is possiblewith non surgical root canal therapy in combinationwith aspiration and irrigation. However case selection iscritical and surgical management can be done if the lesionpesists.AcknowledgementThe authors wish to thank Dr. Prasad ReddyE.(Late),(In-Charge Apollo Dental Centres) for hisvaluable support.References1.2.3.Walton RE, Torabinejad M, Principles and practice ofendodontics. 3rd ed, WB Saunders Co.; 2002.Natkin E, Oswald RJ, Carnes LI. The incidence of lesionsize to diagnosis, incidence and treatment of periapicalcysts and granulomas. Oral Surg 1984; 57: 82-94.Oztan MD. Endodontic treatment of teeth associatedwith a large periapical lesion. Int Endod J 2002; 35(1): 73-8.458Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case Report4.5.6.7.8.9.10.11.12.13.Neaverth EJ, Burg HA, Decompression of large periapicalcystic lesions. J Endod, 1982; 8: 175- 82.Martin SA. Conventional endodontic treatment of uppercentral incisor combined with cyst decompression: A casereport. J Endod ,33(6) june 2007 753-757.Freedland JB, Consrevative reduction of large periapicallesions. Oral Surg Oral Med Oral Pathol 1970; 29(3):455-63.Walker TL, Davis MS. Treatment of large periapicallesions using cannulization through the involved tooth. JEndod 1984; 10(5): 215-20.Active nonsurgical decompression of large periapicallesions-3 case reports. J Can Dent Assoc 2004; 70(10):691-4.Soares J, Santos S, Silveira F, Nunes E. Nonsurgicaltreatment of extensive cyst-like periapical lesion ofendodontic origin. Int Endod J, 39, 566-575, 2006.Sjogren U, Figdor D, Persson S, Sundqvist G. Influenceof infection at the time of root filling on the outcome ofendodontic treatment of teeth with apical periodontitis.Int Endod J, 30, 297-306, 1997.Soares JA, Leonardo MR, Tanomaru Filho M, Silva LAB,Ito IY. Effect of biomechanical preparation and calciumhydroxide pastes on the anti-sepsis of root canal systemsin dogs. Journal of Applied Oral Science 13, 93-100,2005.Hoen MM, LaBounty GL, Strittmatter EJ. Conservativetreatment of persistent periradicular lesions usingaspiration and irrigation. JOE , 16(4), 182-186, 1990.Meija JL, Donado JE, Basrani B. Active nonsurgical14.15.16.17.18.19.20.21.22.decompression of large periapical lesions-3 case reports. JCan Dent Assoc 2004; 70 (10): 691-4.Seltzer S. Endodontology 2nd ed. Philadelphia: Lea &Febiger, 1988: 2391-428.Bhaskar SN. Oral surgery-oral pathology conference#17. Walter Reed Army Medical Center. Periapicallesions-types, incidence and clinical features. Oral Surg1966;21:657-72.Lalonde ER. A new rationale for the managementof periapical granulomas and cysts: An evaluation ofhistopathological and radiographic findings. J Am DentAssoc; 1970; 80: 1056-9.Nair PNR, Pajarola G, Schroeder HE, et al. Types andincidence of human periapical lesions obtained withextracted teeth. Oral Surg Oral Med Oral Pathol OralRadiol Endod 1996;81: 93-102.Simon JHS. Incidence of periapical cysts in relation tothe root canal. J Endod 1980;6: 845-8.Nair PNR. Apical Periodontitis: a dynamic encounterbetween root canal infection and host response.Periodontology 2000 1997; 13: 121-48.Nair PNR. New perspectives on radicular cysts: do theyheal? Int Endod J. 1998;31: 155-60.Kubota Y, Ninomiya T, Oka S, Takenoshita Y, ShirasunaK. Interleukin-1 alpha dependent regulation of matrixmetalloproteinase-9 (MMP-9) secretion and activationin the epithelial cells of odontogenic jaw cysts. J DentRes 2000;79:1423-30.Motamedi MHK, Talesh KT. Management of extensivedentigerous cysts. Br Dent J 2005;198:203-6.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012459

case reportA Variant of Monostotic Craniofacial Type ofFibrous Dysplasia – A Rare Case ReportVennila P*, Chandrasekar T**, Sheetal S Menon †AbstractFibrous dysplasia is an uncommon, sporadic skeletal disorder characterized by proliferation with secondary bony metaplasia,producing immature, newly formed and weakly calcified bone, without maturation of osteoblasts, typically presenting infirst or second decade of life and then slowly progressing until the patient reaches the age of thirty years. The aim of thispresentation is to represent a rare case of monostotic craniofacial fibrous dysplasia, in a 55 year old male, which is a goodexample of somatic mosaicism in which a wide spectrum of disease is possible.Key words: Fibrous dysplasia, sporadic, metaplasia, osteoblasts, monostotic, somatic mosaicismFibrous dysplasia is a bone development anomalycharacterised by hamartoma proliferation offibrous tissue within the medullary bone, withsecondary bony metaplasia, producing immature,newly formed and weakly calcified bone, withoutmaturation of osteoblast which appears radiolucenton radiographs, with classically described groundglass appearance. 1 Fibrous dysplasia is described interms of three major types, monostotic involving asingle bone, polyostotic involving multiple bonesand Mc Cune-Albright syndrome, a polyostoticform of fibrous dysplasia that also involves endocrineabnormalities. 2 Fibrous dysplasia was first reported byVon Recklinghausen in 1891 and he coined the termOsteitis Fibrosa Generalisata. In 1938, Lichtensteinand Jaffe first introduced the term Fibrous dysplasia.In this paper, we describe a variant of monostoticcraniofacial fibrous dysplasia. This case is interestingfor its unusual features and to our knowledge is thefirst of its kind to be reported.Case ReportA 55- year- old male, presented to the Department ofOral Medicine and Radiology, Sri Ramakrishna DentalCollege and Hospital, Coimbatore, Tamil Nadu, with*Senior lecturer, Dept. of Oral Medicine and Radiology**Professor and Head of the Dept.†BDSDept. of Oral Medicine and RadiologySri Ramakrishna Dental College and Hospital, Coimbatore - 641006Address for correspondenceDr Vennila P, MDSE-mail: velsdentcare@yahoo.comthe chief complaint of pain on the left side of the facefor the past 8 days. The patient had associated swellingon the same side for the past 5 years. The swelling wasinitially asymptomatic and it gradually increased in size.It was also associated with discharge of pus which wasevident on the left side of the mandible. Past medical anddental history were not contributory. There was no familyhistory with similar findings.General examination showed no abnormalities. On extraoral examination, gross facial asymmetry was noted dueto the presence of a diffused swelling on the left side ofthe face, extending anteriorly from the midline crossing33, posteriorly to the tragus of the ear, superiorly fromcondyle and inferiorly to angle of the mandible. Therewas draining sinus in the body of the mandible on theleft side. On intraoral examination, a unilateral diffuseexpansile mass was seen on the alveolar ridge on the leftside. It was tender and hard in consitency. On hard tissueexamination, there was generalized severe attrition. Basedon the clinical examination, the initial diagnosis was a fibroosseous lesion of the mandible with periapical pathologyleading to a sinus opening.On further investigation, the occlusal radiograph revealed aunilateral expansile mass of mixed radiolucency. Bicorticalexpansion was seen on the left side of the mandible. OPGrevealed a well defined mixed radiolucent and radiopacitieson the left side of the mandible, extending from left lowercanine 33 to the condyle on the same side. There was alsodisplacement of teeth and associated resorption of roots.CT Scan showed gross expansion with areas of sclerosisand lucencies seen in the left ramus and adjacent body of460Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case ReportFig 1. Extra oral photograph showing gross asymmetry offaceFig 2. Intraoral photograph showing expansile mass on theleft side of the mandibleFig 4. OPG showing well defined mixed radiolucent andradiopacities on the mandibleFig 3. Occlusal radiograph showing bicortical expansion onthe left side of mandibleFig 5. CT showing gross expansion with areas of sclerosisand lucenciesFig 6. Photograph showing 3D reconstruction image oflesionIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012461

Case ReportFig 7. Photograph showing the biopsy specimenFig 8. Histological section of the lesion revealing trabeculaeof irregular woven bone, in a fibrous connective tissue.mandible. Expansile lesions were also seen in sphenoidalbone, right ethmoidal sinus, orbit, frontal sinus, hardpalate and the zygomatic process of left maxilla. Laboratoryinvestigations like the parathyroid hormone assayrevealed that the level was 58pg/ml (7-53pg/ml), alkalinephosphatase level was 300U/L at 37’c up to 306U/L at37’c, serum calcium level was 8.2mg/dl (8.1 to 10.4mg/dl)and Serum phosphorus level was 2.8mg/dl (2.5 to 4.8mg/dl. Biopsy was done under local anesthesia. Histologicalexamination revealed trabeculae of irregular woven bone,in a fibrous connective tissue. There was no osteoblasticrimming seen around the bony trabeculae.Based on this, the final diagnosis was made as a rarecase of craniofacial monostotic fibrous dysplasia withbilateral involvement. Due to wide variety of involvementof the craniofacial regions, the treatment of this case isa multidisciplinary approach and the case was eventuallyreferred to a higher centre and later the patient had lostfollow up.DiscussionReed’s definition states that fibrous dysplasia is an arrest ofbone maturation, woven bone with ossification resultingfrom metaplasia of a nonspecific fibro osseous type. 2 FD iscaused due to the activating mutations in the GNAS genewhich encodes for the alpha subunit of the signalling Gprotein, Gs alpha. 3 FD has four different disease patterns.They are monostotic, polyostotic, craniofacial form andcherubism. Polyostotic form is again sub - classified intoJaffe’s type and Albright’s syndrome. Both types consist ofvarious bony involvements with cafe-au-lait spots. Albrightsyndrome has additional feature of endocrine disturbancesof various type. Polyostotic fibrous dysplasia with softtissue myxomas is called Mazabraud syndrome. 4Approximately 70 – 80% of fibrous dysplasias aremonostotic. It most frequently occurs in the ribs (28%),femur (23%), tibia, craniofacial bones and humerus, indecreasing order of frequency. FD is usually distributedin the unilateral side, although few cases of bilateralinvolvement have been reported. Maxilla is more commonlyaffected than mandible. 4 It involves one or two contiguousbones. 5 In this case, bilateral craniofacial bones of varioustypes are affected.Initial manifestations of fibrous dysplasia are most commonlyfound in patients aged 3 – 15 years. In monostotic diseasepatient as old as 20 or 30 years are asymptomatic. 4 Theaverage age of patients with craniofacial fibrous dysplasiais 20 to 30 years. 6 The incidence is equal in males andfemale. 2 But in this case, age of the patient is 55 years.The patients with monostotic FD is often asymptomaticand discovered incidentally on the radiological imaging forother reasons. The main clinical symptoms are caused bythe expanding mass, which may result in bony deformity,and nasal or sinus obstruction. 5 Cystic degeneration mayoccur spontaneously in the FD lesions years after the initialdiagnosis. 7 All the features correlate with the present case,except for the cystic degeneration which was absent.Radiograph usually reveals a lytic, ground glass lesionconsistent with FD. 8 Evaluation with CT scanning isparticularly valuable for the diagnosis of FD because itprovides information about the characteristic and extent ofthe lesion. This entity may be classified into 3 types basedon its CT appearance as follows: pagetoid, sclerotic andcystic. Pagetoid describes a mixture of dense and radiolucentareas of fibrosis; sclerotic lesions are homogenously dense,462Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case Reportwhereas cystic describes one or more spherical or ovoidlucencies that are surrounded by a dense periphery. 9 MRIis useful in identifying fluid filled non FD-filled cysticlesions. 8 This case makes the second category of sclerotictype.FD is histologically characterized by a benign– appearing spindle cell fibrous stroma containingscattered, irregularly shaped trabeculae of immature( woven ) bone, lacking osteoblast, that evolve directlyfrom the stroma. 10 FD may occasionally contain cartilage,the amount of which is quite variable. This correlates withthe present case.Treatment for FD is always multidisciplinary, due to varyingsomatic mosaicism of craniofacial involvement of fibrousdysplasia, indicating need for a neuro- ophthalmologicaland an audiological testing. An early non surgical attempt oftreatment of FD includes glucocorticosteroids, calcitonin,and external beam radiation. 11 The only medications thathave shown any efficiency in the treatment of FD arebisphophonates. The most rigorously conducted study todate using high dose, intravenous pamidronate (1 – 1.5mg/kg per day on three consecutive days, given every 4months) was by Plotkin et al. 8 Generally, a conservativesurgical approach including facial osseous debulking andcontouring has been recommended for stable disease withminor symptoms. In progressive and more symptomaticcases with functional impairment and cosmeticdeformity, radical resection of diseased tissue, optic nervedecompression, and reconstruction of the facial areaswith autogenous bone grafts may be needed. 12 Althoughthe case of total resection of the craniofacial bones havebeen reported, the complete excision may result in thedeformity and loss of function of the surgically involvedpart and consequently lower the patient’s quality of lifecaused by the significant complications of the surgery suchas serious infection, leakage of cerebrospinal fluid, orbitaldamage, and intracranial injury. 13 Therefore endoscopicsinus surgery (ESS) is done to resect most of the diseasedbone. Stem cell treatment for FD is attractive. As such, asa stem cell disease, it may be a candidate for mesenchymalcell tissue engineering also. 14ConclusionFibrous dysplasia can be a good example of somaticmosaicism as a wide variety of disease is possible. Thegeneral dental practitioner can be the first to detect suchconditions especially when the only affected areas are in themaxilla-mandibular region, so sufficient knowledge on thiscondition is important for the proper diagnosis, treatmentand prevention of further complications. For obtaining thedefinite diagnosis, treatment and further management offibrous dysplasia, imaging studies, histological examinationand laboratory tests are considered mandatory. Effortsshould be made to define the optimal approach to thediagnosis and treatment of this challenging disease.ACKNOWLEDGEMENTDr. Dinakaran. J, MDS, Professor and Head of theDepartment, Department of Oral Pathology, SriRamakrishna Dental College and Hospital, Coimbatore.Dr. Jeyaraj J M, Principal, Head of the Department ofOrthodontics, Sri Ramakrishna Dental College andHospital, Coimbatore.ABBREVATIONSFD – fibrous dysplasiaBMSCs – bone marrow stromal cellsGNAS – guanine nucleotide binding protein, alphastimulatingcAMP – cyclic adenosine monophosphateOPG – orthopantamogramCT – computed tomographyMRI – magnetic resonance imagingReferences1. Ben hadj Hamida F, Jlaiel R, Ben Rayana N, MahjoubH, Mellouli T, Ghorbel M, Krifa F. Craniofacial fibrousdysplasia: A case report. J Fr. Ophthalmol, (2005);Oct;28(8):e6.2. Cholakova. R,Kanasirska. P, Kanasirska. N, Chenchev. Iv,Dinkova. A. Fibrous dysplasia in the maxillomandibularregion – A case report, Journal of IMAB – AnnualProceeding (Scientific Paper) (2010); vol. 16, book 4.3. Bianco P, Riminucci M, Gronthos S, Robey PG Bonemarrow stromal stem cells: nature, biology, and potentialapplications. Stem cells (2001); 19:180-192.4. Suneedh Gupta, Umesh. K, Warad N. M and ShakeelAhmed. Fibrous dysplasia of maxillary bone: A casereport. Al Ameen J Med Sci (2011); 4(1):92-97.5. Zhaowei Gu, Zhiwei Cao, Yunxiu Wang. EndoscopicManagement in Fibrous Dysplasia of Ethmoid Sinus:One case report and literature review.. Clin OncolCancer Res (2009); 6:152-154.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012463

Case Report6.7.8.9.Eich G. F, Babyn. P, Amstrong. D, Burrows. P, Posnick J.C and Becker. L. An unusual case of craniofacial fibrousdysplasia presenting in early infancy. Pediatric radiology(1990) 20: 495-498.Enrina Diah, M. D., David E. Morris, M. D., Lun-JouLo, M. D., and Yu-Ray Chen, M. D., Cyst degenerationin craniofacial fibrous dysplasia : clinical presentationand management J. Neurosurg (2007) 107:504-508.Arabella I. Leet, Michael T. Collins. Current approachto fibrous dysplasia of bone and McCune-Albrightsyndrome. J Child Orthop (2007); 1:3-17.Fries JW: The roentgen features of fibrous dysplasia ofthe skull and facial bones. A critical analysis of thirtyninepathologically proved cases. AJR Radium Ther NuclMed (1957) 77:71-88.10.11.12.13.14.Michael Kyriakos, Douglas J. Mc. Donald, MuraliSundaram. Fibrous dysplasia with cartilaginousdifferentiation (“fibrocartilaginous dysplasia”): A review,with illustrative case followed for 18 years. SkeletalRadiol (2004); 33:51-62.Di. Figlia SE. Cortisone in polyostotic fibrous dysplasia.NY State J Med (1951) 51:2665Antii A. Makitie, Jyrki Torawall, Outi Makitie.Bisphosphonate treatment in craniofacial fibrousdysplasia- a case report and review of the literature. ClinRheumatol (2008); 27: 809-812.Ikeda K, Suzuki H, Oshima T et al. Endonasal endoscopicmanagement in fibrous dysplasia of the paranasal sinuses.Am J Otolaryngol (1997); 18: 415-418.Bianco P, Robey P Disease of the bone and the stromalcell lineage. J Bone Miner Res (1999); 14:336-41.464Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Ectodermal Dysplasia- A Case Reportcase reportJ Jananee*, M Satishkumar**, Sumathi Balaji***AbstractEctodermal dysplasia syndrome(EDS) is a large hetrogenous group of inherited disorders, the manifestations of which could beseen in more than one ectodermal derivatives. The tissues primarily involved are skin, hair, nail, eccrine glands and teeth. Herewe present a case of Hyphohidrotic (anhidrotic)Ectodermal dysplasia (HAED) in a 7yr old girl along with dental defects .Key words: Ectodermal dysplasia, Hyphohidrotic ectodermal dysplasia.The ectodermal dysplasias (EDs) comprisea large, heterogeneous group of inheriteddisorders that are defined by primary defectsin the development of 2 or more tissues derived fromembryonic ectoderm. The tissues primarily involved arethe skin, hair, nails, eccrine glands, and teeth. AlthoughThurnam published the first report of a patient withectodermal dysplasia in 1848, 1 the term ectodermaldysplasia was not coined until 1929 by Weech. 2The ectodermal dysplasia(ED) are congenital, diffuse,and nonprogressive disorder. To date, more than 192distinct disorders have been described. The mostcommon ectodermal dysplasias are X-linked recessivehypohidrotic ectodermal dysplasia (HAED).The most common classification of ectodermal dysplasiainclude Hypohidrotic (anhidrotic) (HAED)and HidroticED(HED). 3 In HAED Clinically there is anhidrosis,hypodontia, and hypotrichosis. Other features includefrontal bossing, thick lips, broad depressed nasal bridgeof nose and deformed ears. 2 Inheritance is usually Xlinked recessive triad. 4 Ectodermal dysplasia resultsin aberrant development of ectodermal derivativesin early embryonic life. Hidrotic include the samewithout dental anomalies. 3 Here we report a caseof Hypohodrotic (anhidrotic) ectodermal dysplasia(HAED) in a 7yr old child.Case ReportA six year old female, reported with a complaint ofmissing tooth in upper and lower anterior region.Patient gives no history of exfoliation of teeth butgives a history of delayed eruption of teeth (at the ageof 2yrs only). Patient also complains of dry skin (Fig1)and absence of sweat in her skin. She is intolerable towithstand hot water and hot environment. Patient giveshistory of dry mouth and difficulty in swallowing.On examination extra orally patient had less hairin eyebrows and eyelashes(Fig 1). There was frontalbossing and depressed ala of nose (Fig 4).She did not give a positive family history. Her skinappeared soft, dry in face, upper and lower limbs.*Reader, Dept. of Oral PathologyAsan Memorial Dental College and Hospital,Chengalpet, Tamilnadu**Professor, Dept. of Oral Pathology,Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram***Reader, Dept. of Oral PathologyIndragandhi Dental college., PondicherryAddress for correspondenceDr J JananeeE-mail: jananeej@yahoo.comFig 1.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012465

Case ReportFig 2. Fig 3.Fig 5.Fig 4.Nails appear normal. Scanty eyebrows were seen. Areasof hyperpigmentation were seen around ala of nose(Fig 2). Intra orally patient was partially edentulous.Tooth number 51,61,53,63,83 appears conical (Fig 3).Tooth number 52,62,72,72,81,82 are missing. Upperand lower alveolar ridges appear normal. Her OPGwas relevant to the above findings (Fig 5). So withthe above clinical findings we came to an diagnosis ofHypohidrotic(Anhidrotic) ectodermal dysplasia.DiscussionCurrent classification of ectodermal dysplasias is basedon clinical features. Pure ectodermal dysplasias aremanifested by defects in ectodermal structures alone,while ectodermal dysplasia syndromes are defined bythe combination of ectodermal defects in associationwith other anomalies.Freire-Maia and Pinheiro proposed the first classificationsystem of the ectodermal dysplasias in 1982, 5 withadditional updates in 1994 and 2001. 6,7 Their originalclassification system stratified the ectodermal dysplasiasinto different subgroups according to the presence orabsence of 1 hair anomalies or trichodysplasias, 2 dentalabnormalities, 3 nail abnormalities or onychodysplasias,and 4 eccrine gland dysfunction or dyshidrosis. 6,7Overall, the ectodermal dysplasias were classified intoeither group A disorders, which were manifested bydefects in at least 2 of the 4 classic ectodermal structuresas defined above, with or without other defects, andgroup B disorders, which were manifested by a defectin one classic ectodermal structure (1-4 from above)in combination with 5 a defect in one other ectodermalstructure (ie, ears, lips, dermatoglyphics). Eleven466Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case Reportgroup A subgroups were defined, each with a distinctcombination of 2 or more ectodermal defects (eg, 2-4, 1-2-3, 1-2-3-4 from above). The group B disorderswere indicated as 1-5, 2-5, 3-5, or 4-5 (from above).We didn’t want to cayegorise according to the abovementioned classification so remained with basic subtypes of Hypohidrotic and Hidrotic. Our case fittedwell with Hyphohidrotic (anhidrotic) ectodermaldysplasia (HAED) with positive clinical findings.Thandani et al 8 (1921) many cases in Hindhu familiesaround Sindhu, India. De Silva et al 9 reported four casesin Ceylon. Many other families have been reported fromIndia. So this case adds up to the previous reportedcases. This case presents with many features suggestiveof diagnosis of Hypohidrotic ectodermal dysplasiaOral findings are of particular interest, since patientswith hyphohidrotic ectodermal dysplasia manifestanodontia, or oligodontia, complete or partial absenceof teeth, seen both in permanent and deciduousdentition. Even the tooth erupted are conical in shape,interestingly growth of jaws are not affected. Howeverin the absence of teeth the alveolar process does notdevelop much resulting in reduction of normal verticaldimension resulting in protuberant lips. In additionhigh arch palate can be more frequent resulting inmore incidence of cleft palate. 3 In our case we hadprotrubernet lips but absence of high arch palate. Ourcase supported all the above findings except for higharch palate.Although mental retardation has been documentedin various subtypes of ectodermal dysplasiab, its realincidence per sub group is not yet firmly establishedso far. 10,11 In this case patient was well co operative anddid not have any mental retardation. In favour of thisdiagnosis the key features are sparse fine hair, conditionsof teeth and decreased sweating. The defective sweatingin this syndrome prevents adequate thermal regulationand predisposes to hyperpyrexia. Febrile seizures,brain damage and death in early life may result fromexposure to hot enviorments. 12 Our patient also wasunable to withstand hot bath or handle any vessels. Soall this is above clinical findings (hair, teeth, skin andits appendages) confirmed our case as Hypohidroticectodermal dysplasia.Reference1.2.3.4.5.6.7.8.9.10.11.12.Thurnam J. Two cases in which the skin, hair and teethwere very imperfectly developed. Proc RM Chir Soc.1848;31:71-82.Weech AA. Hereditary ectodermal dysplasia (congenitalectodermal defect). Am J Dis Child. 1929;37:766-9.Shafer WG, Hine MK, Levy BM. A text book of OralPathology 4th edition. Philadelphia: WB Saunders;1993.pp814-16.Upshaw B.Y, Montgomery.H (1949). Heriditaryectodermal dysplasia- A clinical pathological study.Archeives of dermatology and Syphilology, 60,1170.Pinheiro M, Freire-Maia N. The ectodermal dysplasias.Arch. Dermatol. Apr 1982;118(4):215-6.Pinheiro M, Freire-Maia N. Ectodermal dysplasias:a clinical classification and a causal review. Am J MedGenet. Nov 1 1994;53(2):153-62.Freire-Maia N, Lisboa-Costa T, Pagnan NA. Ectodermaldysplasias: how many?. Am J Med Genet. Nov 152001;104(1):84Thandani k(1921), A tooth less type of man : theBhudaa of India: a case linked inheritance. Journal ofheridty,12,87.De Silva, P.C(1939). Heriditary ectodermal dysplasia ofanhydirotic type. Quarterly journal of medicine,8,97.Tanner BA.Intelectual functioning and ecto.dermaldysplasia. Pediatrics 1985;75:126.Hoyme HE. Reply to Tanners letter. Paediatrics1985;75:126-7.Drago R.P and Ehrenreich T (1961). Ectodermaldysplasia anhydirotic type and prolonged fever in aninfant. New York State Journal Of Medicine, 61, 2473.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012467

case reportFinal Impression and Centric Jaw Relation in Complete DenturesUsing Single Appointment Technique –A Clinical FeasibilityS K Jagdish*, Shyam Singh**, R Shakila † , Dhruv Arora*, V R Arun Kumar*, Santosh Anand*, Balaji J*AbstractFabrication of complete denture consists of numerous clinical and laboratory procedures. Any effort made by the dentistto reduce the number of appointments will be appreciated by the patient. Combining one or more clinical appointmentsreduces the total duration of treatment. This is more helpful in cases of complete denture patients who are physically andpsychologically compromised. This case report is a clinical evaluation of a previously described technique which combinesfinal impression and centric relation recording to one appointment. The feasibility of the technique, its reliability, advantagesand its limitations are described based on clinical findings.Key words: Single appointment technique, final impressions, centric jaw relation.Any effort made to improve the treatmentoutcome while reducing the time requiredwill be welcomed by the patients. This is morerelevant in cases of complete denture patients whoare physically and psychologically compromised. 1,2,3Fabrication of dentures requires numerous laboratoryand clinical procedures. A complete denture patientis usually required to make five to six appointmentsfor completion of his treatment. Combination of twoor more clinical steps into a single appointment thushelps to reduce the number of appointments.A critical search for methods to reduce the numberof appointments for complete dentures revealedsome techniques previously described in literature. 4,5,7Helft M. et al. described a technique of combiningmaxillomandibular relations (using intra-oral tracers)and final impressions into one appointment. 5 Thedisadvantage of this technique was that the impressionswere made after the Gothic arch tracings were recorded.Thus the record bases remained unstable during thetracing procedure. The final impressions and the finaljaw relations were made using this gothic tracing as*Junior Resident**Director, Professor and Head.†Associate ProfessorDept. of Prosthodontics and ImplantologyMahatma Gandhi Postgraduate Institute of Dental Sciences,Govt. of Puducherry Institution, Gorimedu, Puducherry, Pondicherry(U.T), India,Pin- 605006Address for correspondenceDr. S K JagdishE-mail: jagdishsk@gmail.coma guide, which could be a potential source of error. 6Ansari IH described a technique of using detachableocclusal rims and detachable handles on the samerecord base. 7 This facilitated recording centric relationon the same record base after the final impressionswere made. This article is a clinical evaluation of thetechnique described by Ansari IH to check for thefeasibility and reliability of this technique.MethodsCase ReportA 77-year-old completely edentulous male patientreported to the Department of Prosthodontics andImplantology for replacement of missing teeth.Considering his age and the long distance travelled bythe patient to receive treatment, decision was made tolimit the number of visits to as low as possible. Thisalso allowed us to evaluate the effectiveness of thistechnique.The TechniqueThe technique is described in brief here. The techniquecan be divided into three basic steps for convenience:1.2.3.Fabrication of detachable handles and occlusalrims on record bases.Impression procedure and jaw relations.Pouring the master casts and articulation.a) Fabrication of detachable handles and occlusalrims on record bases:468Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case Report1.2.3.4.5.6.7.Primary maxillary and mandibular impressionsand casts were made.Wax spacers were adapted on the primary casts andfour die pins with the sleeves were fixed verticallyparallel to each other on to the spacers as shownon each cast (Fig 1).Acrylic resin record bases were fabricated with thepins and sleeves in position. The final length of thepins and sleeves were trimmed to just 2mm abovethe bases (Fig 2).Aluminum foil was adapted over the record basesas shown (Fig 3).An occlusal rim base was made over the recordbase using acrylic resin, with the pins and sleevesin position (Fig 4).Wax occlusal rims were made over the occlusal rimbases (Fig 5). It should be noted that now theseocclusal rims could be removed from the recordbases (Fig 6).The occlusal rims were removed and two pinsand sleeves were fixed on the anterior part of therecord bases and removable handles were made ina similar method (Fig 7).b) Impression procedure and jaw relations:1.The detachable handles were fixed to the recordbases and thus the border molding and finalimpressions were made in a conventional manner(Fig 8). Impressions were verified for accuracy and2.3.4.fit in patient’s mouth.The handles were removed and replaced with theocclusal rims.The rims were adjusted and the centric record wasobtained.Entire assembly was removed from the patient’smouth. This centric record could now be detachedfrom the bases and the impressions (Fig 9).C) Pouring the master casts and articulation:1. The centric record was detached from theimpressions. Beading and boxing was done andthe casts poured.2. After the casts were set the record bases with theimpressions were not removed from the casts.3. The centric record was repositioned over recordbases (Fig 10). The casts were articulated.4. After articulation only the maxillary rim wasremoved and the maxillary impressions separatedfrom casts (Fig 11).5. Keeping the mandibular rim as reference, newrecord bases and rims were fabricated over themaxillary casts (Fig 12).6. Similar procedure was used for mandibular rims.7. Teeth were set on the rims and denture completedin conventional manner.Clinical results of the procedure:The total number of appointments for the patient wasFig 1 Fig 2Fig 3 Fig 4Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012469

Case ReportFig 5 Fig 6Fig 7 Fig 8Fig 9 Fig 10Fig 11 Fig 12470Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case Reportas follows:Appointment 1: Primary impressionsAppointment 2: Final impressions and jaw relationsAppointment 3: Try-inAppointment 4: Denture insertion.Discussiona) Perceived advantages of the procedure:1.2.3.4.Patient received his trial denture on his thirdvisit rather than on the fourth or fifth visit as inconventional method.Record bases were stable while making the jawrelations.Error in the jaw relation was minimal.Patient showed a positive response to treatmentand was satisfied with the treatment.b) Perceived limitations of the procedure:1.2.3.4.This technique cannot be used in patients withlimited inter-arch space. Fabrication of removableocclusal rims requires adequate inter-arch space.Laboratory procedures in between appointmentsare cumbersome.The technique requires adequate operator skill tocomplete border molding and final impression inshort time.If this is not achieved the duration of theappointment will be frustrating for the patient– which in turn leads to errors in jaw relations.ConclusionThe above described procedure has its own advantageswith limitations as it cannot be applied to all patients.The laboratory procedures involved may not be providedby all dental technicians due to lack of familiarity withthis technique and may result in higher treatmentcost.References1.2.3.4.5.6.7.Sheldon Winkler: Essentials of complete dentureProsthodontics, 2nd edition, AITBS Publishers, India ,2000.George A. Zarb: Boucher’s Prosthodontic treatment foredentulous patients, 12th edition, Mosby Company,2003.Detroit Dental Clinic Club, Complete Denture Section.Nutrition for the denture patient. J Prosthet Dent 1960;10(1):53-60.Krantz WA et al. Combining final impressions and thecentric jaw relation records into one appointment byusing an irreversible hydrocolloid blockout technique. JProsthet Dent 1991; 66(6):821-822.Helft M et al.Combining final impressions withmaxillomandibular relation records in stabilized recordbases. J Prosthet Dent 1978; 39(2):135-138.Tucker KM. Accurate record bases for jaw relationprocedures. J Prosthet Dent 1966; 16(2):224-226.Ansari IH. A one-appointment impression and centricrelation record technique for compromised completedenture patients. J Prosthet Dent 1997; 78(3):320-323.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012471

case reportManagement of Ankyloglossia with Scalpel andElectrosurgery MethodV Ramya*, N Mani Sundar*, Anitha Balaji**AbstractThe tongue is the important oral structure that is responsible for speech, swallowing and positioning of the teeth. Ankyloglossiaor tongue tie is the result of short tight frenulum that causes limitation in tongue movement, therefore when the tongue isretruded it causes blanching of the soft tissue and also place excessive force on the mandibular anteriors. The lingual frenummay cause midline diastema in lower central incisors. This case report describes two cases where the patient diagnosed withankyloglossia underwent lingual frenectomy procedure by two different techniques electrosurgery and scalpel method underlocal anesthesia without any complications. After a follow up of 6 months the healing was uneventful without scar formationin both the cases. The tongue showed good healing with protrusion several millimeters beyond the lower lip.Key words: ankyloglossia, lingual frenum, electro surgery,Etymologically ankyloglossia comes from aGreek word agkylos-“crooked”, glossa-“tongue”.The term free-tongue is defined as the lengthof tongue from the insertion of the lingual frenuminto the base of the tongue to the tip of the tongue. 2Partial ankyloglossia (also called tongue-tie ) is causedby a frenum of the tongue that is abnormally shortor is attached too close to the tip of the tongue.This condition may be surgically corrected by simpleexcision. Complete ankyloglossia requires extensivesurgical reconstruction of the tongue and the floor ofthe mouth.CASE REPORTCASE 1A 22 year old patient reported to OP, Departmentof Periodontics and implantology of Rajah MuthiahDental College And Hospital, Annamalai University,With complaint of difficulty in complete protrusionof the tongue. His ENT and physical examinationwas normal. On intraoral examination the individualwas diagnosed with class II ankyloglossia by utilizing*Senior Lecturer** ReaderDept. of PeriodonticsSree Balaji Dental College and Hospital, Chennai.Address for correspondenceV RamyaSenior LecturerDept. of PeriodonticsSree Balaji Dental College and Hospital, Chennai.E-mail: dr.ramya@yahoo.co.inkotlow assessment. 2 [fig I]. There was no recessionin relation to mandibular incisors lingualy. Whenthe patient was asked to retrude the tongue, slightblanching was seen lingual to the anterior teeth withmidline diastema in lower anteriors. The patient wasinformed about the treatment procedure and lingualfrenectomy was undertaken under local anaesthesiawith 2% lignocaine and l: 80000 adrenaline, No 15blade was used to make incisions on the either sideof the frenum [fig II]. A diamond shaped wound wasmade and the frenum was removed [fig III]. The bluntend of the instrument was used to relieve the pull bymuscle fibres so that tension free closure of the woundedges can be obtained. The wound was approximatedwith (4-0) black braided silk sutures [fig IV]. Thepatient was given medication for 3 days to reduce postoperative pain and infection. After a week sutures wereremoved and after a follow up of 6 months the healingwas uneventful without scar formation [fig v]. Thetongue showed good healing with protrusion severalmillimeters beyond lower lip.CASE 2A 24-years-old male reported to OP with difficulty inspeech and was diagnosed with class II ankyloglossia.(Able to protrude upto lower lip) (fig VI and VII). Thepatient was under taken for frenectomy procedure byelectrosurgery under local anaesthesia. It is a surgicaltechnique performed on soft tissues using controlled,high frequency electrical (radio) current in range of 1.5472Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case ReportFig. I Class II ankyloglossiaFig. II Excision with scalpel methodFig. III Excision of frenumFig. IV Sutures placedFig. V Six months post operativeFig. VI class II ankyloglossiaFig. VIIFig. VIII electrosection doneIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012473

Case ReportFig. IX Frenum excisionFig. X 6 months post operativeto 7.5 million cycles per second or megahertz. There arethree classes of active electrodes, single wire electrodefor incisions and excisions, loop electrode for planningprocedure and heavy bulkier electrode for coagulationprocedure of which single wire electrode was used forfrenectomy procedure. Electrosection also referred aselectrotomy was the basic technique performed forexcision (fig VIII). The tip was kept moving withinterrupted application at adequate interval for tissuecooling (5-10 sec) to reduce or to eliminate heat buildup. Approximation of the wound was not required andbleeding was less (fig IX). Medications were prescribedto reduce post operative pain and infection. After 6months of post operative review, healing was uneventfulby primary intention (fig X).DISCUSSIONAnkyloglossia is a rare congenital oral anomalythat causes difficulty in breast feeding and speecharticulation. The prevalence of ankyloglossia is alsohigher in studies investigating neonates (1.72% to10.7%) than in studies investigating children and adults(0.1% to 2.08%). 5 In many individuals ankyloglossiais asymptomatic and may resolve spontaneously. 3 Theankyloglossia can be classified into four classes basedon KOTLOW’S assessment; 1Clinically acceptable - normal range of free tonguegreater than 16mm,Class I Mild ankyloglossia: 12 to 16 mmClass II Moderate ankyloglossia: 8 to 11 mmClass III Severe ankyloglossia: 3 to 7 mmClass IV Complete ankyloglossia: less than 3 mmTherefore the surgery for ankyloglossia should beconsidered at any age depending on patient’s historyof speech, mechanical and social difficulty. In boththe cases there was no significant difference in healingafter soft tissue resection by both the methods. This issimilar to the study done by Fisher SE and FlockenJE. 4 However the electrosurgery permitted adequatecontouring of the tissue and adequate control ofhemorrhage in accordance to study done by OringerM et al 3 The major disadvantage of this electrosurgerywas that it caused unpleasant odour and furthermoreextreme care had to be excised to avoid contactingtooth surface, as the heat generated by injudicious usecan cause tissue damage.CONCLUSIONTo conclude, if severe/complete ankyloglossia is presentin adult there is usually an obvious limitation of thetongue protusion, elevation and speech problems,which can be improved by surgical intervention.REFERENCES1.2.3.4.5.Lawrence A. Kotlow Ankyloglossia (tongue-tie): Adiagnostic and treatment quandary. QuintessenceInternational 1999; 30:259-262Tanaj, chaubal, maladixit Ankyloglossia and itsmanagement. J Indian Soc Periodontal 2011: vol 15;270-272Oringer MJ Electrosurgery for definitive conservativemodern periodontal surgery .Dent clin North Am vol13; 53: 1969Fisher SE, Frame JW Electrosurgical management of softtissues and restorative dentistry. Dent clin North Am vol24:247; 1980Suter VG, Bornstein MM Ankyloglossia: facts and mythsin diagnosis and treatment J Periodontol. 2009 Aug;80(8):1204-19474Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Maxillary Custom Bar Retained Over Denture – ACase ReportBijoy Thomas*, C Ramu**, Jayanth Christian † , T V Padmanabhan ‡ , Bhakti S Jain $case reportAbstractThe use of overdentures can aid in preservation of alveolar ridge height. The retention and stability of such prosthesesis enhanced greatly in bar supported overdentures. Patient reported to the Department of Prosthodontics with the chiefcomplaint of missing teeth in maxillary arch. Patient had given a history of multiple temporary partial dentures that she wasnot satisfied with. The chief reason for dissatisfaction was poor retention. The treatment plan that was decided upon wasa custom fabricated bar supported overdenture. The bar was cemented intraorally and a female component on the intagliosurface of the denture ensured retention. The mode of retention was primarily through frictional resistance. The availabilityof different types of attachments has enabled a wide variety of treatment options.Key words: Attachment, bar supported, overdenturePreservation of tooth and surrounding tissuesis one of the primary goals in prosthetictreatment. Any treatment plan must factor inthis important principle. The use of overdentures canimprove overall stability and retention of a removableprosthesis. The overdentures help overcome many ofthe problems faced by conventional complete denturessuch as progressive bone loss, low masticatory efficiencyand loss of periodontal proprioception. 1 This casereport explores the treatment of a patient with a toothsupported – bar retained overdenture.Case ReportPatient reported to the Department of Prosthodonticswith the chief complaint of missing teeth in maxillaryarch. On examination maxillary arch showed onlythe presence of three teeth. Both canines (13 and23) and tooth number 17(maxillary second molar)were present. All teeth were periodontally sound.The situation can be classified as a Kennedy’s class II*Registered Dental Practitioner**Senior Lecturer†Reader‡Professor and Head of Department$Post Graduate StudentDept. of prosthodonticsFaculty of Dental Sciences, Sri Ramachandra University, Porur, ChennaiAddress for correspondenceDr Jayanth ChristianDept. of prosthodontics,Faculty of dental sciences, Sri Ramachandra University, No.1,Ramachandra Nagar, Porur, Chennai-600116E mail: drjayanthchristian@gmail.commodification 2. Patient had given a history of multipletemporary partial dentures that she was not satisfiedwith. The chief reason for dissatisfaction was poorretention. Sufficient inter arch space was present. Amaxillary and mandibular impression was made withalginate. The patient was informed about the varioustreatment options ranging from fixed implant therapyto conventional complete dentures after extraction ofremaining teeth. After careful consideration of thevarious treatment plans, the patient opted for a toothsupported overdenture. Usually canines, premolars, andincisors are retained for overdenture support 2,3,4 and inthis case the canines were favourable abutments. Aninformed consent was then obtained from the patient.ProcedureTooth preparation was done on both maxillary canines.A heavy chamfer finish line was prepared. Impressionswere made using two step putty wash technique(addition silicone). Casts were fabricated using diestone and wax pattern copings were fabricated for thetwo prepared canines. The two copings were connectedwith a bar of 2 mm thickness and 3 mm height. Asit is known that the splinting of two or more teethwith a bar produces stability similar to that obtainedwith rigid stud-type attachment when the overdentureis in place. 5 The design was similar to that of a dolderbar. The Dolder bar is the one most often mentionedin discussions of the bar system. 6 Preiskel 7,8 discussedthe Dolder bar joints and units in the second editionIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012475

Case Reportof his book. An in-depth review of Dolder’s writingindicates that it is possible to bend the Dolder barsystem and shape it to approach the configuration ofany ridge. 9,10,11 Both the inventor, Dolder, 12 and themanufacturers recommend this broad application ofthe system. The male portion of the bar joint was madeof a rigid bar of metal, made to lie on the edentuloustissue and attached to the abutment teeth by meansof copings and metal posts, extending into the rootcanals. (Figure 1).The bar is egg shaped with the narrower part closest tothe tissue. 13 Casting was finished and highly polished toavoid any plaque accumulation along the bar to makethem easily cleansable and the metal bar with retainerson the canines was tried in intra orally. (Figure 2)This bar was fabricated in such a way as to allowfrictional resistance that will provide for retention. Theremainder of the procedures were carried out the sameas for a conventional complete denture. A tentative jawrelation record was used. Minimal modification of theocclusal plane was necessary.After metal try, in a female component was fabricatedas a sleeve to snugly fit over the bar. This sleeve wasperforated to allow for retention of the same in theintaglio surface of the denture. This sleeve now servedas the female component of the assembly and wasembedded in the tissue surface of the denture. Theacrylic denture base was designed to exclude a part ofthe palate in a U shaped design (Figure 3).An opening was made in the denture to correspond tothe maxillary second molar. Since the denture lackedborder seal due to the design, retention was provided forby the interlocking of the male and female componentof the bar system. The denture also provided supportand proprioception due to the presence of underlyingabutment teeth (Figure 4).Figure 1. Male portion of the bar joint.Figure 2. Metal bar with retainers on the canines intraorally.Figure 3. U shaped design of acrylic denture base andopening to accomadate second molar.Figure 4. The denture providing support andproprioception.476Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Case ReportDiscussionThe earliest reference to the use of roots for providingsupport was by Prothero 14 in 1916, he stated,“Oftentimes two or three widely separated roots orteeth can be utilized for supporting a denture”. 15 Theoverdenture offers many advantages not obtainedwith the conventional mandibular complete denture.The most important benefits are the preservation ofthe remaining alveolar supporting bone and increasedstability and retention of the denture. 16 The patientalso enjoys a degree of proprioceptive guidance withresultant psychological advantages. 17 This case involvesthe preservation of two canines and one molar. Ametal bar is used in this case with a female componentembedded in the tissue surface of the denture. Thedesign for the denture includes a U-shaped majorconnector design. An opening was made in thedenture to accommodate the maxillary second molarin the first quadrant. This tooth was retained as thepatient was unwilling for extraction. After tooth loss,any sharp edges are rounded off by external resorption.This resorption continues from the labial and lingualaspects thereby leading to a thin narrow ridge 18 ,which can be prevented by preservation of teeth bythe use of overdentures.The use of two canines as abutments splinted togetherwith a bar is more advantageous than using theindividual abutments separately. This is due to thesplinting effect of the bar. Both teeth become firm andare safer abutments. 19 The use of a bar also increasesthe stability of the prosthesis. Over dentures alsoprovide positive retention by preventing any furtherbone loss. 20ConclusionThe judicious use of overdentures can aid in retention,stability and support of prosthesis. The availabilityof different types of attachments has enabled a widevariety of treatment options. The modern clinicianmust consider use of overdentures whenever possible.References1.2.Journal: R.C.Dhir. Clinical assessment of overdenturetherapy. Journal of Indian Prosthodontic Society 2005;Vol 5; 187-192.Journal: Glenn E. Richard, D.D.S., M.Sc., Robert J.Sarka, D.D.S., M.S.,Ralph M. Arnold, D.D.S., MS., and3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.Kenneth I.Knowles, D.D.S., M.S. Hemisected molars foradditional overdenture support. J. Prosthet. Dent. July1977, Volume 38 Number 1, pg 16-21.Journal: Lord, J. L., and Teel, S.: The Overdenture, Dent.Clin. North Am. 13: 871-881, 1969.Book: Boucher, C. O., Hickey, J. C., and Zarb, G. A.:Prosthodontic Treatment for Edentulous Patients, Ed. 7. St. Louis, 1975. The C. V. Mosby Company. Pg. 517-527.Journal: Merrill C. Mensor, Jr., D.D.S. Attachmentfixation of the overdenture: Part II. J. Prosthet. Dent.January 1978, Volume 39, Number 1, Page 19.Journal: J. Prosthet. Dent, January 1978, Volume39 Number 1, Page 18. Attachment fixation of theoverdenture: Part II Merrill C. Mensor, Jr., D.D.S.Preiskel, H. W.: Precision Attachments in Dentistry.London, 1968, Henry Kimpton, pp 117, 143, 150, 156.Preiskel, H. W.: Precision Attachments in Dentistry, ed 2.London, 1973, Henry Kimpton, p 113.Journal: Dolder, E. J.: Die Steg-Gelenk-Prothese inUnterkiefer. Dtsch Zahnaerztl Z 14:11, 1959.Journal: Dolder, E. J.: The bar joint mandibular denture. JPROSTHET DENT11:694, 1961.Dolder, E. J.: Steg-Prothetik. Heidelberg, 1966, AlfredHuthig.Dolder, E. J.: Personal communication. Zurich,Switzerland, 1963.Journal: George L. Marquardt .Dolder bar joint mandibularoverdenture: A technique for nonparallel abutment teeth.Journal of Prosthet Dent 1976; Vol 36; 101-111.Prothero, J. H.: Prosthetic Dentistry, ed. 2, Chicago, 1916,Medico-Dental Publishing Company, p. 519.Journal: Phillip V. Reitz, D.D.S., M.Ed., Marshall C.Weiner, D.D.S., and Bernard Levin, D.D.S., M.Ed. Anoverdenture survey: Preliminary report. J. Prosthet. Dent.March 1977, Volume 37, Number 3, Pg- 246-258.Journal: H.H Thayer, A.A Caputo. Occlusal forcetransmission by overdenture attachments. Journal ofProsthet Dent 1979; 41; 266-271.Journal: H.H Thayer, A.A Caputo. Effects of overdenturesupon remaining oral structures. Journal of Prosthet Dent1977; Vol 37; 374-381.Journal: Douglas Allen Atwood. Reduction of residualridges: A major oral disease entity. Journal of ProsthetDent 1971; Vol 26; 266-278.Journal: Eugen J. Dolder. Bar joint mandibular denture.Journal of Prosthet Dent 1961; Vol 11; 689-707.Journal: Charles A. Dodge. Prevention of complete dentureproblems by use of overdentures. Journal of Prosthet Dent;1973; Vol 30; 403.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012477

short communicationBrighter Smiles for Shining IndiaSmitha Kakde*The media has recently highlighted episodesof medical negligence, misconduct andissues surrounding medical ethics or thelack thereof. Although the media focused onmedical professionals, they did not explore thesocial responsibility we as dentists have towardsour community, many will agree that currently thedental fraternity leaves a lot to be desired. Havingsaid that, it would be iniquitous to overlookthe individuals/organisations that work hard toimprove the oral health conditions of the IndianDiaspora.One such organisation is the Global Child Dental Fund(GCDFund)1, which is a UK based dental charitythat reaches out to the most disadvantaged childrenglobally. The charity invests in dentists by equippingthem with essential leadership skills through their Seniorand Young Dental Leadership Programmes. Theseprogrammes are aimed at improving child oral health,promoting public oral health agendas and developingsocial responsibility. The GCDFund also runs Smiles&Hopes projects in various parts of the world primarilyamongst disadvantaged children who suffer from war andpoverty. For instance, in Timor Leste, a place affectedby the civil war and severe poverty, the GCDFundhas partnered with local charitable trusts as well as theMinistry of Health to raise much needed resources interms of finance, manpower and dental equipment inorder to address important issues including the lack ofvital dental equipment and oral health professionals.Professor Raman Bedi is currently the Chairman of theGCDFund and oversees all the programs undertaken bythe charity. In addition he is the Head of the Centre forInternational Child Oral Health at the King’s College,*BDS, MSc. Public Health Research (Edin)Indian Strategy Project ConsultantAddress for correspondenceDr Smitha KakdeGlobal Child Dental FundKing’s College London,26-29 Drury Lane,London,UK WC2B 5RLE-mail: kakde.smitha@googlemail.comLondon and is also the former Chief Dental Officer inEngland. His recently published book “Indian HealthProfessionals Around the World: a common agenda”,2demonstrate the pressing need for a common platformby which to mobilise the Indian health professionalsto work together to improve the health status in India.Bearing this in mind, the GCDFund is contemplatingventuring and investing in India. This project willprimarily revolve around social responsibility as wellas oral health treatment camps, particularly in relationto the underprivileged communities in India. As partof their project in India, the GCDFund has takenthe first successful step towards developing this socialmovement through the creation of a Facebook group,which currently counts over 2500 users. Additionally,the GCDFund is also conducting a national survey toassess the oral health needs of the Indian Diaspora basedon the perceptions of dentists practising in India with aparticular emphasis on how these issues can be resolvedboth internally as well as with the help of the widerglobal Indian Diaspora. Your contribution is essential tomake this project a success. Therefore, the GCDFundcalls all dental health professionals to be a part of thechange and the social movement which aspires toimprove the oral health conditions of our community.You can take the first step by joining our Facebookgroup (Indian Health Professionals Around the World: acommon agenda) and/or taking part in the short survey.The results generated from this survey will be utilised toplan further activities and projects of the GCDFund.Please note – You can purchase a copy of the book“Indian Health Professionals Around the World: acommon agenda” by logging on to the GCDFundwebsite. All profits generated by the book will go to theSmiles & Hopes India.Reference1. Global Child Dental Fund | [Internet]. [cited 2012 Jul22]. Available from: http://www.gcdfund.org/2. Bedi R, Davidson E, Liu JJ. Indian Health ProfessionalsAround the World: a common agenda. London: GlobalChild Dental Fund; 2012.478Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012

Indian Journal ofMultidisciplinary DentistryInformation for AuthorsCase ReportManuscripts should be prepared in accordance with the ‘Uniformrequirements for manuscripts submitted to biomedical journals’ compiledby the International Committee of Medical Journal Editors (Ann. Intern.Med. 1992;96:766-767). The Journal strongly disapproves of the submissionof the same articles simultaneously to different journals for consideration aswell as duplicate publication and will decline to accept fresh manuscriptssubmitted by authors who have done so.The boxed checklist will help authors in preparing their manuscriptaccording to our requirements. Improperly prepared manuscripts may bereturned to the author without review. The checklists should accompanyeach manuscript.Covering Letter: The covering letter should explain if there is anydeviation from the standard IMRAD format (Introduction, Methods,Results and Discussion) and should outline the importance of thepaper. Principal/Senior author must sign the covering letter indicatingfull responsibility for the paper submitted, preferably with signatures ofall the authors. Articles must be accompanied by a declaration by allauthors stating that the article has not been published in any Journal/Book. Authors should mention complete designation and departments,etc., on the manuscript.Manuscript: Three complete sets of the manuscript should be submittedand preferably with a CD; typed double spaced throughout (includingreferences, table and legends to figures). The manuscript should bearranged as follow: Covering letter, Checklist, Title page, Abstract,Keywords (for indexing, if required), introduction, Methods, Results,Discussion, References, Tables, Legends to Figures and Figures. All pagesshould be numbered consecutively beginning with the title page.Types of Submission: Original Research articles, Review articles, Casereports and Clinical studyTitle Page: Should contain the title, short title, names of all the authors(without degrees of diplomas), names and full location of the departmentsand institutions where the work was performed, name of the correspondingauthors, acknowledgement of financial support and abbreviations used. Thetitle should be of no more than 80 characters and should represent themajor theme of the manuscript. A subtitle can be added if necessary.A short title of not more than 50 characters (including inter-word spaces)for use as a running head should be included. The name, telephoneand fax numbers, e-mail and postal addresses of the author to whomcommunications are to be sent should be typed in the lower right cornerof the title page.Abstract: The abstract of not more than 200 words. It must convey theessential features of the paper. It should not contain abbreviations, footnotesor references.Introduction: The introduction should state why the study was carried outand what were its specific aims/objectives were.References: These should conform to the Vancouver style. Referencesshould be numbered in the order in which they appear in the texts andthese numbers should be inserted above the lines on each occasion theauthor is cited.Tables: These should be typed double spaces on a separate sheet andfigure number (in Roman Arabic numerals) and title above the table andexplanatory notes below the table.Legends: These should be typed double spaces on a separate sheet andfigure numbers (in Arabic numerals) corresponding with the order in whichthe figures are presented in the text. The legend must include enoughinformation to permit interpretation of the figure without reference to thetext.Figures: Two complete sets of glossy prints of high quality should besubmitted. The labeling must be clear and neat. All photomicrographsshould indicate the magnification of the print. Special features should beindicated by arrows or letters which contrast with the background. Theback of each illustration should bear the first author’s last name, figurenumber and an arrow indicating the top. This should be written lightlyin pencil only. Please do not use a hard pencil, ball point or felt pen.Color illustrations will be accepted if they make a contribution to theunderstanding of the article. Do not use clips/staples on photographs andartwork. Illustrations must be drawn neatly by an artist and photographsmust be sent on glossy paper. No captions should be written directly onthe photographs or illustration. Legends to all photographs and illustrationsshould be typed on a separate sheet of paper. All illustrations and figuresmust be referred to in text and abbreviated as ‘Fig’.Please complete the following checklist and attach to the manuscript:1. Classification (e.g. original article, review, etc.)_________________2. Total number of pages____________________________________3. Number of tables________________________________________4. Number of figures_______________________________________5. Special requests_________________________________________6. Suggestions for reviewers (name and postal address)Indian 1.______________ Foreign 1. _______________2._____________________ 2._______________7. All author’s signatures____________________________________8. Corresponding author’s name, current postal and e-mail address andtelephone and fax numbers__________________________________________________________Material and Methods: Theses should be described in sufficient details topermit evaluation and duplication of the work by others. Ethical guidelinesfollowed by the investigations should be described.Results: These should be concise and include only the tables and figuresnecessary to enhance the understanding of the text.Discussion: This should consist of a review of the literature and relatethe major findings of the article to other publications on the subject. Theparticular relevance of the results to healthcare in India should be stressed,e.g., practically and cost.For Editorial CorrespondenceIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012Dr KMK Masthan,479Professor and Head Department of Oral Pathology and Microbiology, Sree Balaji Dental College and HospitalVelachery Main Road, Narayanapuram, Pallikaranai Chennai - 600 100, Website: www.ijmdent.com, E-mail: ijmdent@gmail.com

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 2, February-April 2012