Volume 2 - Issue 4 (Aug-Oct) Download Pdf - IJMD

From the Editor's DeskFROM THE EDITOR-IN-CHIEFDr. KMK MasthanProfessor and Head,Department of Oral Pathology and MicrobiologySree Balaji Dental College and Hospital, ChennaiMy editorial on the last issue drew scorchingcomments from several readers, especiallymy view that when the medical treatmentcan benefit very little, it is better to inform thepatient. One reader expressed the view that themedical personnel are essentially hope givers and ifthey were to adapt the attitude that there is no hope,what is the use of being medical personnel? “Noidea is ever dead unless those who believe in it sayit is dead” - was a part of his observation. Anotherreader, whose commitment to oncology is immense,strongly criticized my opinions. Few glimpses ofhis mail are “Doctors must be compassion incarnate.Never there shall be shortage of sympathy andcompassion”, “A physician must never express hisdespair and frustration to the patient when patientshows no improvement and is unlikely to showimprovement”. He has quoted the famous sayings'' Sabr Jamil” and ''The patience of Penelope'' tostress his views. I thank all of them for sharingtheir Solomonic wisdom and I stand corrected andhumbled. This editorial I continue the same topicwith oral cancer as the focus, since this mostlyavoidable disease witnesses the frustration anddespair of the dental and medical personnel veryclearly.A cancer patient undergoes three episodes of death.First, when his doctor hints at the feasibility that he/she might have developed the big C; Second, whenthe diagnosis is confirmed by biopsy or cytology orother diagnostic methods; Third, when untreated orafter prolonged treatment he/she dies. It is true thattoday's medicine has the capability and technologyto tackle this horrendous disease. But the realityis not that simple. The mental agony, the socialstigma, huge expenses associated with treatment,disfigurement following surgery, side-effects ofradiation and chemotherapy, uncertain results, nonavailabilityof treatment facilities at the place wherethe patient resides are some of the obstacles towardssuccessful results. My experience is restricted to oralcancer and my firm belief is that avoiding certainhabits, being aware of early signs and symptoms,early detection and attitude changes like avoidingprocrastination will help in about 90 percent ofcases.Habits like chewing tobacco, smoking, and alcoholare the main culprits and the person who doesnot want the disease must quit and no amount ofjustifying the habit will do. One driver, whenever Iadvised him to quit his pan- chewing and smokinghabit used to say that he can't do any night-drivingwithout his pan and cigarettes. Now he is undertherapy for his tongue cancer and is so incapacitatedhe cannot do any driving at all, leave alone nightdriving.Next is to be aware of the early signs and symptoms.In comparison with other cancers, oral cancer giveswarning signals early. An ulcer that does not heal formore than three weeks, a sharp tooth that frequentlyIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 543

FROM THE EDITOR-IN-CHIEFcauses sores on the tongue, a whitish or colored patchanywhere in the mouth that was not noticed earlierand is not going away, an unusual bulge that is sensedon the tongue or gums or insides of cheek whichgrows in size -any of this could be the beginningstage of oral cancer. Ignoring this or attempting selfmedication is a sure path to disaster. Hence beingaware of the symptoms, the person has more chancesof preventing this debilitating disease. Even a tinysuspicion, a physician or a dentist must be consulted.Spending time and money for a consultation can savethe person’s precious life and several lakhs of hardearned money.Early detection is another factor that plays a keyrole in successful treatment even if someone hasdeveloped the disease. When the doctor or dentistadvises a biopsy or cytology, the patient shouldnot cringe and escape from the premises. He / Shemay successfully escape the procedure but may notbe successful in escaping from the disease. OnceI advised biopsy for a prominent advocate for anulcer on the tongue and received a notice in returnfor unnecessarily advising an invasive diagnosticprocedure. Six months later he came and wasable to express his apologies only through writing,because he had lost his tongue to surgery when hewas abroad. Next is about attitude change. AgainI seek my repertory of anecdotes to elucidate thisaspect better. A government official, to whom I hadjust informed that his biopsy results show cancer,after deliberating for several minutes, informed thathe could find time for his treatment only after hisson's marriage. He said he was on the lookout fora suitable bride. Eight months later he came back,several pounds thinner, with a neck metastasis.When I was about to tell him that results might notbe good at that stage, he asked me whether I couldsuggest some interim treatment since his daughterin-law was expecting. I never saw him after that.No doubt his inculcated delay approach towards hisproblems cost him his life.Another common phenomenon I have observed amongpatients diagnosed with oral cancer is that they undergofour phases: Denial, anger, acceptance and resignation.Denial is that they refuse to accept the diagnosis andrun for second, third opinions and alternate medicines.Anger is sometimes at the doctor who informed thediagnosis, sometimes at the spouse who had not stoppedtheir smoking / chewing habits earlier and very rarelyat some of their friends and relatives who did not getthe disease, in spite of their chewing and smokinghabits. Acceptance phase is the most pathetic of all.The decision of whether to reveal the disease to theirrelatives especially the in-laws and friends really hauntsthem at this stage. Most patients perceive it as a socialembarrassment. Resignation is when they undergo thetreatment and its morbid side effects. It is definitelyunkind to ask them why they persisted in their avoidablehabits during these phases. But after seeing hundreds ofsuch patients, I am unable to restrain myself from askingthat question. Am I justified? Please share your viewsat ijmdent@gmail.com.Best Wishes544Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Reliability o f Lo w e r Lip Li n e as a Gu i d e in De t e r m i n i n g Oc c l u s a l Pl a n e inCo m p l e t e De n t u r e Fabrication-A Cephalometric St u d y o f Dentate Su b j e c tP.S.Manoharan*, B.N.Ganesh # , R.Venkateshwaran @ , R.Manikandan Ramasamy ~Original ResearchAbstractPurpose of the study: The purpose of the study was to emphasise on the reliability of using “lower lip line onsmile” as a guide to determine the cant of the occlusal plane by evaluating the relative parallelism of the occlusalplane to the lower lip line [LPL] and other traditionally used landmark such as ala tragus line in dentulouspatients.Material and methods: The study comprises of 50 dentulous individuals, the markings were done on the superiorborder of the lower lip[LPL], ala of the nose and three points on the tragus of the ear on superior, middleand inferior [ATS, ATM and ATI]. The cephalograms were traced and digital evaluation was made to calculatethe angle between the occlusal plane [OP] and the above mentioned planes - OP-LPL, OP-ATS, OP-ATM, andOP-ATI using a screen protractor. The obtained data were statistically analyzed.Results: The data was analysed with student ‘t’ test and ‘one way ANOVA’ analysis. The angle between OP-LPLwas minimal with a mean value of about 11.50 degrees and standard deviation of about 6.59 degrees.Conclusion: LPL on smile can be used as a reliable landmark to determine the cant of the anterior or posteriorocclusal plane during complete denture construction.Key words: Lower lip line, camper’s plane, smile line, occlusal planeIntroductionOrientation of the occlusal plane is one ofthe critical procedures in prosthodonticrehabilitation of completely edentulouspatients and because of it effects on, function, denturestability, and aesthetics, it should be reconstructedidentical to the position of the occlusal plane ofmissing natural teeth.Many authors have used anthropometric landmarksand techniques that have been reported over theyears to be used as a guide to determine the occlusalplane. They are parallelism to maxillary ridges 1 ,to the plane of condyle movement 2 , to line drawnfrom lower margin of the external auditory meatusto lower margin of alae of the nose 3 , line fromthe corner of the mouth to lower border of the ear* Professor, Department of Prosthodontics,Rajah Muthaiah Dental college, Annamalai university, Chidambaram#Lecturer, Department of Prosthodontics,Rajah Muthaiah Dental college, Annamalai university, Chidambaram@Senior Lecturer, Department of ProsthodonticsSree Balaji Dental College and Hospital, Chennai~Senior Lecturer, Department of ProsthodonticsKSR Dental College, ThiruchengodeCorresponding author:Dr.P.S.ManoharanEmail: manodent_2000@yahoo.comlobe 4 , camper’s line 5 , lateral border of the tongue atrest 6 , line from anterior teeth height to top of thedistal end of retromolar pad 7 , parotid papilla 8 , tosome cephalometric criteria such as line connectingporion, nasion, and anterior nasal spine to form anangle PONAANS 9 and the models mounted in thearticulator respectively.Studies have shown that the natural occlusal plane isat a lower level in the posterior region than the alatragusplane and these two planes showed deviationof about 2.88 degrees to 9.66 degrees 10 . From theliterature it is apparent that dental occlusion isinfluenced by changes in the cant of the occlusalplane.This study deals with the parallelism of occlusalplane to the lower lip line on smile and commonlyused landmarks such as ala-tragus line in dentatepatients, and this study is intended to compareparallelism of the occlusal plane with the justmentioned landmarks. It also tests the reliabilityof lower lip line on smile as a guide to determineocclusal plane.Materials and methodThe study used cephalometrics to compareparallelism of the occlusal plane in dentulousindividuals to the nearest parallel plane among theIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 545

Original Researchfollowing, the planes used were Lower lip line onsmile, Ala tragus line (superior border of the tragus,middle border of the tragus, and inferior border ofthe tragus)This objective study comprises of randomly selected50 dentulous patients, in which 37 samples weremales and 13 were females, for standardisation ofsamples, and to avoid errors with variable parametersthe following inclusion criteria was met with whileselecting the samples. All the subjects were selectedfrom age groups of 20 and 30 years and all subjecthad angle’s class I malocclusion and having at least28 teeth in functional form 11 .Reference points were marked with 1mm section oflead foil which was secured with zinc oxide paste onthe left side tragus and on the highest contour of thelower lip during smile zinc oxide paste (Figure.1).Figure 1 : Radioopaque markersmeared on the upper surface of the lower lipTable 1 – obtained data’s were tabulatedfor 50 samplesSamples Angle between Angle between Angle between Angle betweenOP-LPL OP-ATS OP-ATM OP-ATI1 13.27 19.19 15.03 12.272 12.97 21.60 16.70 13.203 13.69 21.38 17.31 13.834 17.68 25.40 21.30 17.705 15.23 22.87 20.24 17.516 5.28 15.68 12.34 8.887 18.35 13.01 9.51 6.098 11.47 18.55 14.24 10.829 19.75 24.36 19.27 15.2810 11.68 19.82 16.74 11.8411 12.73 12.87 11.07 9.0512 15.80 20.49 16.56 13.4313 16.60 20.42 16.62 14.7714 5.9 3.99 5.25 7.6515 9.13 15.68 13.93 9.616 21.15 20.54 18.83 16.617 8.94 17.99 16.96 15.3218 22.19 29.96 25.80 23.0519 1.57 19.37 16.21 13.5220 19.88 27.47 25.02 23.4121 16.92 17.66 14.64 13.9122 4.64 14.26 11.26 9.1623 26.37 21.8 19.84 17.1724 26.4 34.13 31.23 28.5425 16.55 21.68 17.76 13.9926 17.3 13.61 11.57 11.3727 8.34 14.85 14.03 8.4328 11.69 16.91 13.12 11.9229 14.45 23.53 18.51 14.7730 3.9 9.78 4.82 4.6731 25.86 31.28 29.59 29.4332 10.75 12.64 11.86 11.9233 4.8 26.26 24.15 18.3734 5.97 29.06 24.59 21.6235 4.76 24.25 19.68 17.3136 14.97 17.37 14.6 11.3537 5.57 23.78 20.42 16.6938 4.49 21.41 19.31 16.7939 5.76 17.22 14.08 11.2840 3.23 11.35 8.73 5.2641 3.88 8.98 5.97 4.4942 4.09 13.02 8.59 5.9143 4.42 7.78 5.01 4.6644 8.34 7.19 7.15 3.4245 6.68 17.19 14.22 11.2246 9.38 18.96 15.54 11.3647 11.31 15.27 11.74 7.3648 8.16 9.67 6.13 6.6149 7.84 23.61 18.89 14.5950 5.08 15.45 13.14 9.71Radiographs were made at 70kv at a fixed distance,in a radiograph machine [PLANMECA PROMAXPAN or PAN/CEPH USA.,]. All the subjects wererequested to smile during radiograph (figure.2).After obtaining the radiographs, tracing was carriedout. All the landmarks were identified and markedas dots on the sheet. By connecting the dots on thesheet, the reference lines and planes were drawn onthe tracing sheet such as, occlusal plane – OP, Lowerlip line plane - LP, Ala-tragus line (superior border –ATS, middle border – ATM, inferior border – ATI)546Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

DiscussionOriginal ResearchIn current practice, dentists establish the occlusalplane by constructing the maxillary occlusion rimto approximately 1 to 3 mm below the resting upperlip in the anterior region of the mouth and parallelto the ala-tragus line posteriorly. Then, whilearranging the teeth, the occlusal plane is slightlymodified according to individual needs as in theintroduction of compensating curve to achievebalanced occlusion.The smile line or incisal curve is composed of themaxillary anterior teeth and parallels the innercurvature of the lower lip 17,18 . This is a popularesthetic concept which was successfully used inanterior teeth rehabilitation but the use of abovementioned landmarks in edentulous patient hasnot yet been studied. So with this background, thepresent in vivo study was conducted,Figure 2 - Position of the patient in cephalostatTable – 2: comparison between all four groupsGroups N Mean SD F-value P-valueAnglebetweenOP-LPL in degrees 50 11.50 6.59Angle betweenOP-ATS in degrees 50 18.61 6.45Angle between 12.589 0.001OP-ATM in degrees 50 15.58 6.08 (Significant)Angle betweenOP-ATI in degrees 50 12.94 5.78Total 200 14.65 6.75All the tracings were scanned in the computer andsaved as an image for calculating angles betweenthe planes using a screen protractor V4.0 software[Iconico Co.,].Comparison were done for angles between theplanes such as,Angle between OP and LP : OP-LP, Angle betweenOP and ATS : OP-ATS, Angle between OP and ATM: OP-ATM, Angle between OP and ATI : OP-ATIThe obtained data was tabulated and allmeasurements were evaluated by “t test’ and ‘oneway ANOVA’analysis.All 50 subjects in this present study aged from 20 to32 years, which is younger to those who normallywear complete dentures. The occlusal plane and thelower lip line on smile are quite stable. One of themajor problems in complete dentures is the lack ofreproducible reference structures for determiningthe orientation and position of the occlusal plane,especially if increased resorption of the jawsoccurs.The obtained data revealed that lower lip line onsmile showed more parallelism and closest to theocclusal plane than the commonly used ala-tragusline. Among the three ala-tragus lines the inferiorborder was more parallel than superior and middleborders. The ala tragus line with superior borderof tragus showed more deviation from the occlusalplane.The exact points of reference do not agree amongstudies for ala tragal line. The study of Karkazis andPolyzois 19 , used the center of the external auditorymeatus as the posterior reference point of the alatragusline. On a similar study of Polyzois 20 showedthat if the lower border of the ear rod is used asthe posterior reference point of the ala-tragus line,then the occlusal plane was almost parallel withthe ala-tragus line. The study of Abrahams andCarey 21 showed that the natural occlusal plane isslightly lower in the posterior region than the alatragusplane. The point on the tragus border was notIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 547

Original Researchmentioned. The variation between those two planeswas found to be an average of 9.66 degrees with astandard deviation of 4.29 degrees.In this study all the three commonly mentionedreference points of tragus were taken intoconsideration [superior, middle and inferior point onthe border of the tragus of the ear], for comparison ofangles with occlusal plane in south Indian population.It was shown in this study that the mean differencebetween the inferior ala tragal plane angle and theocclusal plane angle was less and was almost equalto the mean difference between the occlusal planeangle and lower lip line on smile angle with the‘P’ value of 0.07 which was not significant (Table3), means both were relatively parallel to occlusalTable – 3: comparison between OP-LPL and OP-ATIGroups N Mean SD t-value P-valueAngle between OP-LPL in degrees 50 11.50 6.59 0.07Angle between OP 1.808 (Not-ATI in degrees 50 12.94 5.78 Significant)plane but angle between OP-ATI were recordedwith a maximum of 29.43 degrees and minimumof 3.42 degrees whereas, angle between OP-LPwere recorded with maximum of 26.4 degrees andminimum of 1.57 degrees. The conflicting ideasabout ala-tragus plane make it further a unreliablelandmark to be used for the construction of completedentures. However from the present study, we couldinfer that the ala to the lower tragus border line is alsonear parallel to the occlusal plane. The correlationcoefficients of the lower lip line to the occlusalplane were greater than that of the upper, middle orlower ala tragal plane to the occlusal plane. Also,when we predict the occlusal plane from the lowerlip line, the standard error of estimate is less. Thatmeant that the prediction of the occlusal plane fromthe lower lip line on smile is more reliable than fromthe ala-tragus plane.One study revealed that camper’s plane was notparallel but inclination was similar to naturalocclusal plane. In a similar study, Vojvodic et al 12recommended camper’s plane but the orientationwas questionable posteriorly. Masakata et al 13recommended that tongue margin should lie on lingualedge of the lower occlusal plane. Ismail 14 suggestedthat occlusal plane should lie on 2/3rd of retromolarpad but it was lower than natural plane. Ping Hsienet al 15 used the mandibular plane in determining theocclusal plane for complete denture patients since itwas a stable landmark and more reliable with classI malocclusion cases but the variation in the anglefor the other malocclusion makes it not possible.Weishy 16 studied on Frankfort’s horizontal plane butits variability makes it difficult to assess occlusalplane.An open rest concept 22 was mentioned in the literatureby James Douglas, in which, “open rest” position isan unstrained mouth-breathing position with minimallip separation. It is a position in which the dentistcan observe or obtain a mental picture of the mesialmarginal ridge of the upper and lower first bicuspidteeth in relation to the commissure of the lips and onstudy with this position showed the upper and lowerocclusal planes in relation to the commissure of thelips with the mandible in an “open rest” position in 50complete denture patients closely paralleled the studyof patients with natural teeth.In the present study, the farthest distance from theocclusal plane to the lower lip line on smile was0.7 mm showing that this landmark is closer tothe occlusal plane and is more reliable and easilymarked in the occlusal rims during the procedure.In addition, it is more convenient in a clinicalpractice to obtain a natural head position and lowerlip line by asking the patient to smile, in this studyout of 50 samples, 21 samples showed that the lowerlip line was parallel to only anterior plane and restof the 29 samples recorded that lower lip line wasparallel to both anterior and posterior occlusal plane.With these findings we reveal the probability thatlower lip line in most of the cases is parallel to bothanterior and posterior occlusal planes. However,further studies are encouraged to accept the validityof the statement mentioned above.ResultsOn gross evaluation, the angle between OP-LPL,has got minimum of 1.57 degrees and maximum of26.4 degrees (Table 1,2). Out of 50 samples, and in21 subjects the lower lip line was parallel to onlyanterior plane and rest of the 29 subjects recordedthat lower lip line was parallel to both anterior andposterior occlusal plane. Likewise for the anglebetween OP-ATS has got 3.99 degrees and maximumof 34.13 degrees, for the angle between OP-ATMhas got minimum of 4.82 degrees and maximum of548Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Original Research31.23 degrees, for the angle between OP-ATI hasgot minimum of 3.42 degrees and maximum of29.43 degrees (Graph 1)The scatter diagram (SC.1) shows maximum numberScatter chart : distribution of patients on rangefor the all four anglesof patients are between 0 – 5 degrees for OP-LPLwhich means lower lip line was nearly parallel thanala tragal line.On gross analysis it showed that lower lip line onsmile was more parallel to occlusal plane than alatragal plane and for the tragus the inferior bordershowed more parallelism than middle and superiorborders in this population.For correlation and for objective results, all themeasurements were subjected to statistical analysisusing student ‘t’ test and ‘ONEWAY ANOVA’.ConclusionWith the above findings and considering thelimitations of the study, the following conclusionscan be drawnLower lip line on smile is a definite reliable landmarkto determine the cant of the anterior or posteriorocclusal plane.It is most easy to record as the distance between theocclusal plane and the landmark which is used as aguide i.e., the lower lip line are close to each otherthan any other reference linesThe next closest parallel reference plane would be theala tragal line that is drawn to the inferior border.References1. Walker, W. E.: Prosthetic Dentistry : The Gl noid Fossa;The Movements of the Mandible; The Cusps of theTeeth, D. Cosmos 8:34-43: 18962. Walker, W. Ernest: The Facial Line and Anglesin Prosthetic Dentistry, D. Cosmos 39:789-800, 1897.3. Clapp, George Wood: Mechanical Side of AntomicalArticulation, New York, 1910, the Dental Digest Press,p. 18.4. Kurth, L. E: The Posterior Occlusal Plane in Full DentureConstruction, J. A. D. A. 27:85-93, 1940.5. Ruppe,, L. : The Occlusal. An Apparatus to Determinethe Position of the Occlusal Plane in Prosthetic andOrthodontia Cases, D. Rec. 40:637-639, 1920.6. Wright, C. R., Muyskens, J. H., Strong, L. H., Westerman,K. N., Kingery, R. H., and Williams, S. T.: A Study of theTongue and its Relation to Denture Stability, J. A. D. A.39:269-275, 1949.7. Boucher, Carl 0: Dental Prosthetic Laboratory Manual,ed. 2, St. Louis, 1950, the C. V. Mosby Company, p. 74-76.8. Foley and latta et al: “A study of the position of theparotid papilla relative to the occlusal plane” J ProsthetDent 1985, 53, 124 – 126.9. Brian D. Monteith, “Evaluation of a cephalometricmethod of occlusal plane orientation for completedentures”, J Prosthet Dent 1986; 55; 64-69.10. Katayoun Sadr: “A Study of Parallelism of the OcclusalPlane and Ala-Tragus Line” J Dent., 2009, Vol. 3, No. 4.11. Gaurav Singh, “Ala Tragus Line–A CephalometricEvaluation”, International Journal of ProstheticDentistry.2010:1(1):1-512. D. Vojvodic et al “A Study of the Occlusal PlaneOrientation by Extraoral Method (Camper's Line)” Coll.Antropol. 20 (Suppl.) (1996) 109-113.13. Masakata yasaki: “The height of the occlusion rim andthe interocclusal distance” J Prosthet Dent 11, 1961, 26-31.14. Ismail YH, Bowman JF “Position of the occlusal plane innatural and artificial teeth” J Prosthet Dent, 20: 405-411,1968.15. PING-HSIEN The use of the mandibular plane asa guide for the determination of the occlusal plane incomplete dentures Chin Dent J 12(1) : June 1993Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 549

Original Research16. Weishy, the variability of roentgenographic cephalometricline of line of reference. Angle orthod, 38; 74-78, 1968.17. Walter Donald Heinlein, “Anterior teeth: Esthetics andfunction”, J Prosthet Dent 1980; 44; 389-39318. Tjan AHL, miller GD: the JGP: some esthetic factors ina smile. J Prosthet Dent 1984;51:24-2819. Karkazis HC, Polyzois GL “A study of the occlusal planeorientation in complete denture construction” J OralRehabil, 14: 399-404, 1987.20. Polyzois GL. “Relationship between ala-tragus lineand natural occlusal plane. Implication in dentureprosthodontics”. Quentcssense Interna¬tional I, 17: 253255, 198621. Abrahams R, Carey PD “The use of the ala-tragus linefor occlusal plane determination in complete dentures” JDent, 7: 339-341, 1979.22. James r. Douglas, “open rest,” a new concept in theselection of the vertical dimension of occlusion, JProsthet dent; 1965; 15; 850-856550Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

COMPARISON OF FRICTIONAL RESISTANCE OF AESTHETIC ANDSEMI AESTHETIC SELF LIGATING BRACKETSM.S.Kannan*, R.V.Murali # , V.jayanth @ , P.R. Annamalai ~ ,Original ResearchAbstractAIM: The frictional resistance encountered during sliding mechanics has been well established in the orthodonticliterature, and it consists of complex interactions between the bracket, archwire, and method of ligation. The claimof reduced friction with self-ligating brackets is often cited as a primary advantage over conventional brackets.This study was done to compare and evaluate the frictional forces generated between fully aesthetic brackets andsemi-aesthetic self ligating brackets which are of passive form and SEM (scanning electron microscope) study ofthe Brackets after Frictional evaluation. Materials: Two types of Self-ligating aesthetic brackets, Damon Clear[Ormco] made of fully ceramic and Opal [Ultradent Products,USA] and, Two types of Self-ligating semi-aestheticbrackets, Clarity SL [3M Unitek] and Damon 3 [Ormco] both of which are made of ceramic with metal slot. Archwires with different dimensions and quality 17x25, 19x25 TMA and 17x25, 19x25 SS that came from plain strandsof wire were used for frictional comparison test. The brackets used in this study had 0.022x0.028 inch slot. Results:The Statistical tests showed significantly smaller amount of kinetic frictional forces is generated by Damon 3(semi-aesthetic self-ligating brackets). For each wire used, Damon 3 displayed significantly lower frictional forces(P≤.05) than any of the self-ligating system, followed by Opal (fully aesthetic self-ligating brackets) which generatedsmaller amount of frictional forces but relatively on the higher side when compared with Damon 3. Damonclear (fully aesthetic self-ligating brackets) generated the maximum amount of kinetic forces with all types ofwire dimensions and properties when compared to the other three types of self-ligating system. Clarity SL (semiaestheticself-ligating brackets) generated smaller amount of frictional forces when compared with Damon clearand relatively higher amount of frictional forces when compared to Opal and Damon 3.Key words: Frictional forces, Selfligating brackets, Aesthetic Selfligating, Semiaesthetic Selfligating.IntroductionT*Professor#Professor & Head@Postgraduate student~ReaderDepartment of OrthodonticsSree Balaji Dental College , Chennai, IndiaCorresponding author:Dr. M.S. KannanEmail: kannanace@gmail.comhe first self-ligating edgewise bracket Russellock was introduced by Stolzenberg toorthodontists 75 years ago, since then advancesin further bracket technology have resulted in anumber of new self ligating bracket ‘‘systems’’ andgreater interest in their use. Much of this interest isin response to information comparing the benefitsof self-ligating systems with conventional edgewisebrackets. The claim of reduced friction with selfligatingbrackets is often cited as a primary advantageover conventional brackets. Two different types ofself-ligating brackets were produced: those with aspring clip that pressed actively against the archwire,such as the Speed bracket, and self-ligating brackets,e.g. the Activa bracket whose self-ligating clip didnot press against the wire. Passive and active selfligatingappliances with many ligating mechanismswere introduced to presumably allow for efficientsliding mechanics.Self-ligating brackets are proposed to havethe potential advantages of producing morephysiologically harmonious tooth movement by notoverpowering the musculature and interrupting theperiodontal vascular supply.The frictional resistance encountered during slidingmechanics has been well established in the orthodonticliterature, and it consists of complex interactionsbetween the bracket, archwire, and method of ligation.Tooth movement associated with sliding mechanicshas been described as a series of short steps involvingoscillating tooth tipping and uprighting, rather than acontinuous, smooth, gliding process.Adherence to the tenets of evidence-basedorthodontic practice requires that, for any orthodonticintervention applied to a patient, 3 factors mustbe integrated: the relevant scientific evidence, theclinician’s expertise, and the patient’s needs andpreferences. On the topic of self-ligating bracketIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 551

Original Researchsystems, the current challenge for the clinician isto assess the merit of the assertions supporting thesuperiority of self-ligating brackets.Aims and objectivesThe aim of the study was to compare and evaluate thefrictional forces generated between fully aestheticbrackets and semi-aesthetic self ligating brackets ofpassive form.Materials and MethodsAn experimental model reproducing the right buccalsegment of the maxillary arch was used to assess thefrictional forces produced by two types of Self-ligatingaesthetic brackets, Opal [Ultradent Products, USA]Figure.1 made of a glass filled, polycrystalline resinand, Damon Clear [Ormco] Figure.2 made of fullyceramic. Two types of Self-ligating semi-aestheticbrackets, Damon 3 [Ormco] Figure.3 and ClaritySL [3M Unitek] Figure.4 both of which are made ofceramic with metal slot. Arch wires with differentdimensions and quality 17x25, 19x25 TMA and 17x25,19x25 SS that came from plain strands of wire wereused for frictional comparison test. The brackets usedin this study had 0.022x0.028 inch slot and are passiveform. All the five brackets of the upper right side ofEach wire was tested for five times with new set ofbrackets every time. The frictional force generatedby the testing unit consisting of wire and bracketswas measured under dry condition and at roomtemperature of 20°c. Friction was tested usingInstron UTM model no 3369 U.K with a load cellof 10 N, (Figure 5 0. The acrylic block was fixed toFigure1a OpalFigure 3a Damon3Figure 2a Damon clearFigure 4a Clarity SLFigure 5Figure 1 OpalFigure 2 Damon Clearthe clamp, the test wire was ligated with the bracketand one end of the wire was fixed.Figure 3 Damon 3Figure 4 Clarity SLthe quadrant were used [central-premolar].The brackets were fixed on to an acrylic block usingcyanoacrylate glue with interbracket distance of6mm (Figure.1a, 2a, 3a, 4a). A 16 cm long wireof each type was tested. The wire was securedinto the brackets by using the self ligation system.A total of 80 tests [20 tests for each of the fourtypes self ligation system] were carried out. Kineticfriction forces were recorded while 15 mm of wirewere drawn through the brackets at a speed of 15mmper minute. Software used in frictional evaluation isBluehill software, Instron, UK.Statistical analysisDescriptive statistics, including means, medians,and standard deviations values were calculated forthe kinetic frictional forces produced by the four552Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Original Researchcombination with the 0.019 × 0.025-inch TMA wirethan with the SS wire of the same dimension. Thisdifference was significant (P ≤ .05). These highfrictional forces are caused by the surface propertiesof the TMA wires. TMA has more porositiesand a noticeably rougher surface than SS. Thesefindings are in agreement with those of Angolkaret al. (1990) 2 and Drescher 7 et al. (1989), who alsoobserved higher frictional forces with TMA wires,compared with SS wires.Studies have proved that ageing of Opal selfligating brackets have showed significant increasein frictional qualities C.A.Reicheneder et al 6. Withall types of archwires, aged Opal Brackets exhibitedgreater frictional forces than new Opal brackets. Thisincrease was significant for Opal brackets aged for 9– 10 and 18 – 20 months with respect to SS wires. Thenegative influence of ageing on frictional behaviourmay be due to abrasion of bracket material causedby alternate warm and cold cycles in the chewingsimulator. This wear and tear resulted in increasedsurface roughness and probably in an accumulationof debris in the slot, which, in turn, increased friction.The results are in accordance with those of Riley 18 etal. (1979), who found that friction of polycarbonatebrackets gradually increased in distilled water dueto corrosion, and the results of the study by Keith etal. (1993) 14 on ceramic brackets.The current study results support previousinvestigation by C.A. Reicheneder6 (2007) bySims et al. (1994)15, Read-Ward 12 et al. (1997),and Kusy16 (2001), who also found self-ligatingbrackets to produce significantly less friction thanconventional brackets. Schumacher 17 et al. (1999)also reported reduced friction with Damon SL selfligatingbrackets in comparison with conventionallydesigned brackets, despite the fact that this decreasewas associated with negative side-effects in terms oflevelling losses after completion of retraction.Small differences in the torque prescriptionsbetween the active and passive brackets were notexpected to influence the outcome because thesewere outweighed by the large free play that was morethan two times higher than the torque differencesin a conventional bracket. RCT with the body ofevidence on this issue suggest that the bracket-archwire free play might not be the most critical factorin altering the tooth movement rate. This situation,however, changes drastically as treatment progressesand wires of higher stiffness are engaged in thebracket. Correction of rotations and achievementof proper buccolingual crown inclination (torque),which are frequently required in mandibular andmaxillary anterior teeth, respectively, necessitatea couple of forces. This assumes the formation ofcontacts of wire inside the bracket slot walls, andthus the major advantage of self-ligating bracketfree play is eliminated as the crowns gradually attaintheir proper spatial orientation.Especially for torque application, self-ligatingbrackets lose more torque compared withconventional brackets, whereas a clinical trialshowed that these brackets can achieve comparabletorque transmission only with reverse curve ofSpee archwires. Alternatively, torquing auxiliaries,higher torque prescription brackets, or pretorquedwires can be used to counteract the greater torqueloss from greater free play.These investigations demonstrated clearly thatminimal amounts of friction are generated withfour types of passive self ligating brackets thatare commercially available. The literature reportsvalues of frictional forces for active self ligatingbrackets that are five times greater than passive selfligating brackets.ConclusionThis (in vitro) study measures the frictional propertiesof different aesthetic brackets and semi aestheticself ligating brackets. The results demonstrate adifference in the friction produced by self-ligatingaesthetic and self ligating semi aesthetic brackets.Self ligating Semi aesthetic brackets had smalleramount of friction when compared to Aesthetic Selfligating brackets. Among the Four types of Selfligating brackets Damon 3 showed least amount offrictional forces. The difference was significant (P≤.05). TMA wires demonstrated more frictional forcesthan SS wires in all the four types of self ligatingbrackets. Opal self ligating brackets showed leastamount of friction with 19x25 TMA wire comparedto other four types.References1. Andreasen G F, Quevedo F R 1970. Evaluation offriction forces in the 0.022 ×0.028 edgewise bracket invitro. Journal of Biomechanics 3 : 151 – 160554Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Original Research2. Angolkar P V, Kapila S, Duncanson M G, Nanda R S1990. Evaluation of friction between ceramic bracketsand orthodontic wires of four alloys. American Journalof Orthodontics and Dentofacial Orthopedics 98:499 –5063. Baker K L, Nieberg L G, Weimer A D, Hanna M 1987.Frictional changes in force values caused by salivasubstitution . American Journal of Orthodontics andDentofacial Orthopedics 91 : 316 – 3204. Bednar J R, Gruendeman G W, Sandrik J L 1991.A comparative study of frictional forces betweenorthodontic brackets and arch wires. American Journalof Orthodontics and Dentofacial Orthopedics 100:513 –5225. Bourauel C, Drescher D, Thier M 1992. An experimentalapparatus for the simulation of three-dimensionalmovements in orthodontics. Journal of BiomedicalEngineering 14: 371- 3786. C.A. Reicheneder, U. Baumart 2007. Frictional propertiesof aesthetic self ligating brackets and conventionallyligated aesthetic brackets. European Journal ofOrthodontics 29: 359 - 3657. Drescher D, Bourauel C, Schumacher H A 1989. Frictionalforces between bracket and arch wire. American Journalof Orthodontics and Dentofacial Orthopedics 96: 397 –4048. Drescher D, Bourauel C, Thier M 1991. OrthodontischesMeß- und Simulationssystem (OMSS) für die statischeund dynamische Analyse der Zahnbewegung. Fortschritteder Kieferorthopädie 52: 133 – 1409. Henao SP, Kusy RP. Frictional evaluations of dentaltypodont models using four self-ligating designs and aconventional design. Angle Orthod 2005;75:75-8510. Ireland A J, Sherriff M, McDonald F 1991. Effect ofbracket and wire composition on frictional forces.European Journal of Orthodontics 13 : 322 – 32811. Kusy R P , Whitley J Q , Prewitt M J 1991 Comparisonof the frictional coefficients for selected archwire-bracketslot combinations in the dry and wet states . AngleOrthodontist 61:293-30212. Read-Ward G E , Jones S P , Davies E H 1997 Acomparison of self-ligating Andconventional orthodonticbracket systems . British Journal of Orthodontics 24 :309 – 31713. Stannard J G , Gau J M , Hanna M A 1986 Comparativefriction of orthodontic wires under dry and wet conditions. American Journal of Orthodontics and DentofacialOrthopedics 89 : 485 – 49114. Keith O , Jones S P , Davies E H 1993 The infl uenceof bracket material, ligation force and wear on frictionalresistance of orthodontic brackets .British Journal ofOrthodontics 20 : 109 – 11515. Sims A P , Waters N E, Birnie D J 1994 A comparisonof the forces required to produce tooth movement exvivo through three types of pre-adjusted brackets whensubjected to determined tip or torque values. BritishJournal of Orthodontics 21 : 367 – 37316. Thorstenson G A , Kusy R P 2001 Resistance to sliding ofself-ligating brackets versus conventional stainless steeltwin brackets with Secondorder angulation in the dry andwet (saliva) states American Journal of Orthodonticsand Dentofacial Orthopedics 120 : 361 – 37017. Schumacher H A , Bourauel C, DrescherD 1999 The influence of bracket design onfrictional losses in the bracket/arch wire system. Journal of Orofacial Orthopedics 60: 335 – 34718. Riley J L , Garrett S G , Moon P C 1979 Frictionalforces of ligated plastic and edgewise brackets. Journalof Dental Research 58 : 98 (Abstract)Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 555

eview articleTo p 5 In n o v a t i o n s t h a t w i l l c h a n g e t h e f a c e o f Dentistry in t h i s d e c a d eKrishna Prasanth B*, Bhuminathan S ** , Sivakumar M *** , Aruna U @ , Ganesh Ramesh @AbstractThere are many new innovations in dentistry that are set to cause waves in the future and these include- biomaterials,nano robotics in dentistry, salivary diagnostics, innovations in management of dental caries, photodynamictherapy in dentistry. Biomaterial science is undergoing the largest transition in its history in terms of refocusingand embracing new and exciting technologies. Nano robots are used to do preventive, restorative, curative procedures.Salivary diagnostics will allow healthcare providers to rapidly rule in or out diseases that need immediatetherapy. It is hoped that the eventual success of replacement therapy for the prevention of dental caries will stimulatethe use of this approach in the prevention of other bacterial diseases. The oral cavity is especially suitable forPhotodynamic Antimicrobial Chemotherapy, because it is relatively accessible to illumination.Key words:Innovations, Regenerative Biotechnology, Biomaterials, Nanorobotics, Salivary Diagnostics,Photodynamic TherapyIntroductionDentistry is often the one medical professionthat is overlooked as it is not exactly filledwith life-saving and life-changing events. Inactual fact, it is one with a history as rich as any othermedical profession and is one of the most innovativeand ever-changing fields. Understanding the needsand desires of each patient is the cornerstone ofDental Innovations. A complete oral evaluationand a well-planned course of treatment perpetuatea patient’s long term oral health. Changingdemographics and health care needs are alteringthe demands placed on dental practitioners, whilenew knowledge and technologies have enabled thedevelopment of treatments that, just a short timeago, were not possible. Although only in the earlystages of development and research, there are manynew innovations in dentistry that are set to causewaves in the future and these include-1.Biomaterials and RegenerativeBiotechnologyBiomaterial science is undergoing the largesttransition in its history in terms of refocusing and*Tutor,**Professor,***Research Officer@ReaderSree Balaji Dental College and Hospital,Bharath University, Pallikaranai, ChennaiCorresponding Author:Dr. Sivakumar M,E Mail id: sivakumarepid@gmail.comembracing new and exciting technologies. Theterm “Smart materials” refers to a class of materialsthat are highly responsive and have the inherentcapability to sense and react according to changesin the environment.Smart materials are materials that can change theirproperties in response to their environment and areoften called as ‘Responsive Materials’ such as:a. Shape memory alloysb. Smart composites containing amorphous calciumphosphate (ACP)c. Smart ceramicsd. Smart fibers for laser therapyThey can be active or passive materials. Biomedicalapplication of smart materials includea. Delivery of therapeuticsb. Tissue engineeringc. Cell cultured. Bio separationse. Thermo responsive surfacesRegenerative biotechnology:Stem cell-mediated root regeneration offersopportunities to regenerate a bio-root and itsassociated periodontal tissues, which are necessaryfor maintaining the physiological function of teeth.1Dental stem cell engineering may be applicable tohuman tooth regeneration. Furthermore, functionaltooth restoration in swine may shed light on humantooth regeneration in the future because of the closesimilarities between swine and human dental tissues. 1556Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Review ArticleFig: Timeline of the recent past, presentand future for the use of synthetic dentalbiomaterial vs. truly biological materials.2. Nano RoboticsThe growing interest in the future of dentalapplications of nanotechnology is leading to theemergence of a new field called Nanodentistry.Nanorobots induce oral analgesia, desensitize tooth,and manipulate the tissue to re-align and straightenirregular set of teeth and to improve durability ofteeth. 2 Further it is explained that how nanorobotsare used to do preventive, restorative, curativeprocedures. It is defined as "The art of manipulatingon an atomic or molecular scale especially to buildmicroscopic devices / robots".DentifrobotsDentifrobots can identify and destroy pathogenicbacteria residing in the plaque. A sub occlusaldwelling nano robotic dentifrice delivered by mouthwash or tooth paste, could control all supra gingivaland sub gingival plaque surface, metabolizing trappedorganic matter into harmless, odourless vapours &performing continuous calculus debridement.Dentin HypersensitivityDental nanorobots can selectively and preciselyocclude the specific tubules within a minute offeringpatients a quick and permanent cure.Orthodontic Nano robotsOrthodontic nanorobots can directly manipulate theperiodontal tissue, including gingival, periodontalligament, cemental and alveolar tissue allowingrapid and painless tooth straightening, rotating andvertical repositioning within minutes to hours.Tooth Durability and AppearanceNanocomposite materials are manufactured bynon agglomerated discrete nanoparticles that arehomogeneously distributed in resins or coatings,to produce nanocomposites which increases toothdurability and appearance.NanorImpressiontMaterialNanofiller are integrated in the polyvinylsiloxanes,producing a unique addition siloxane impressionmaterial. The main advantage of material being,better flow, and improved hydrophilic properties,hence fewer voids at margin, better modelpouringeandeenhancedddetaildprecision.Nano AnesthesiaTo induce oral anesthesia through Nanodentistry,professionals will install a colloidal suspensioncontaining millions of active analgesic micrometersized dental nanorobotic particle on the patient'sgingivae. The analgesic dental nano robots may becommanded by the dentist to shut down all sensitivityin selected tooth that requires treatment. When thedentist presses the icon for the desired tooth on thehand held controlled display monitor, the tooth isimmediately anesthetized. After the procedure iscompleted, the dentist orders the nanorobots viathe same acoustic data links to restore all sensation,to relinquish control the nerve traffic & to retrievefrom the tooth via similar path. 3 This analgesictechnique is patient-friendly as it reduces anxiety,needle phobia, and the most important one beingquick and reversible action.3. Salivary DiagnosticsIn near future, biomarker panels are likely to gainspecificity needed for the utility of saliva as a truediagnostic fluid. Saliva contains biomarkers derivedfrom serum, gingival crevicular fluid and mucosaltransudate. Detection of analyte in saliva showsgreat promise for enhancing the ability to diagnoseperiodontal disease and acute myocardial infarction.Several markers related to inflammation, connectivetissue destruction and bone remodeling are elevatedin chronic periodontitis. Inhibitors of proteinases arereduced in saliva in chronic periodontitis. 4 Specificmarkers such as macrophage inflammatory protein-Ia are associated with aggressive periodontitis.Markers of tissue necrosis (cardiac enzymes),inflammation and cell adhesion also appear in saliva.These enzymes are at altered levels in saliva duringthe first 48 h after an acute M.I.We expect that in a few years, salivary diagnosticswill be perfected such that a panel of six or fewerIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 557

Review Articlediagnostic biomarkers can be assessed and resultsobtained in 15 minutes. This application will allowhealthcare providers to rapidly rule in or out diseasesthat need immediate therapy.4. Innovations in Managementof Dental Cariesa. Remineralization of incipient cariesusing peptides:The University of Leeds Dental Institute hasproduced a compound that temporarily fillsincipient caries and promotes remineralization.This new compound, called P 11-4, painlessly fillsthe microscopic cavities and encourages enamel tore-form and hence called ‘magic fluid’.It works by mimicking the protein scaffold aroundwhich tooth enamel naturally assembles itself as ourteeth grow. To create the cavity-repairing treatmentthe researchers have found a way of breaking upthe component parts of the protein scaffold into itscomponent parts – or peptides. The peptides are thenengineered such that they re-assemble themselveswhen they are applied to the tooth. Once appliedto the cavity, the compound forms a gel into whichnew enamel-forming calcium is naturally depositedfrom the saliva in the mouth and fluoride then helpsthe enamel to remineralize. The compound willonly fill the pores associated with incipient cariesand remains ineffective when dental caries has beenformed.b. Replacement therapy:There are many examples of positive and negativeinteractions between different species of bacteriainhabiting the same ecosystem. This observationprovides the basis for a novel approach forpreventing microbial diseases called replacementtherapy. 5 In this approach, a harmless effector strainis permanently implanted in the host's microflora.Once established, the presence of the effector strainprevents the colonization of a particular pathogen.In the case of dental caries, replacement therapyhas involved construction of an effector straincalled BCS3-L1, which was derived from a clinicalStreptococcus mutans isolate. Recombinant DNAtechnology was used to delete the gene encodinglactate dehydrogenase in BCS3-L1 making it entirelydeficient in lactic acid production. This effectorstrain was also designed to produce elevated amountsof a novel peptide antibiotic called mutacin 1140that gives it a strong selective advantage over mostother strains of S. mutans. In laboratory and rodentmodel studies, BCS3-L1 was found to be geneticallystable and to produce no apparent deleterious sideeffects during prolonged colonization. BCS3-L1was significantly less cariogenic than wild-type S.mutans in gnotobiotic rats, and it did not contributeat all to the cariogenic potential of the indigenousflora of conventional Sprague-Dawley rats. And,its strong colonization properties indicated that asingle application of the BCS3-L1 effector strainto human subjects should result in its permanentimplantation and displacement over time ofindigenous, disease-causing S. mutans strains. Thus,BCS3-L1 replacement therapy for the prevention ofdental caries is an example of biofilm engineeringthat offers the potential for a highly efficient, costeffective augmentation of conventional preventionstrategies. It is hoped that the eventual success ofreplacement therapy for the prevention of dentalcaries will stimulate the use of this approach in theprevention of other bacterial diseases.5. Photodynamic TherapyPhotodynamic therapy also known as photoradiationtherapy, phototherapy, or photochemotherapy,involves the use of a photoactive dye (photosensitizer)that is activated by exposure to light of a specificwavelength in the presence of oxygen. The transfer ofenergy from the activated photosensitizer to availableoxygen results in the formation of toxic oxygenspecies, such as singlet oxygen and free radicals.These reactive chemical species can damage proteins,lipids, nucleic acids, and other cellular components.Applications of PDT in dentistry are growingrapidly: the treatment of oral cancer, bacterial andfungal infection therapies, and the photodynamicdiagnosis (PDD) of the malignant transformationof oral lesions. 6 PDT has shown potential in thetreatment of oral leukoplakia, oral lichen planus andhead and neck cancer. Photodynamic antimicrobialchemotherapy (PACT) has been efficacious in thetreatment of bacterial, fungal, parasitic and viralinfections. The absence of genotoxic and mutageniceffects of PDT is an important factor for long-termsafety during treatment. PDT also represents anovel therapeutic approach in the management oforal biofilms. Distribution of plaque structure hasimportant consequences for homeostasis within the558Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Review Articlebiofilm. Studies are now leading toward selectivephotosensitizers, since killing the entire flora leavespatients open to opportunistic infections. Dentistsdeal with oral infections on a regular basis. The oralcavity is especially suitable for PACT, because it isrelatively accessible to illumination.ConclusionImplementation of scientific innovations is importantto advances in both dental science and the dental-caresystem. However, scientific information relevant todentistry is not always effectively and efficientlyutilized. Both academicians and practitioners inthe various dental fields should realize that it is ofstrategic importance that their professional expertiseand new discoveries be conveyed to both their fellowdental colleagues as well as to the layman in orderthat the innovation will be accepted and successfullyimplemented later.References:1. Sonoyama W, Liu Y, Fang D, Yamaza T, Seo B-M, ZhangC, et al. Mesenchymal Stem Cell-Mediated FunctionalTooth Regeneration in Swine. Csete M, editor. PLoSONE. 2006 Dec 20;1(1):e79.2. Md J, Raju K, Faizuddin, N N. Nanorobots. Annals andEssences of Dentistry. 2012;4(4):63–5.3. Malathi Suresh SV. Nanorobotics- A futuristic approach.Nano DIgest. 2011;3:34–7.4. Miller CS, Foley JD, Bailey AL, Campell CL, HumphriesRL, Christodoulides N, et al. Current developments insalivary diagnostics. Biomark Med. 2010 Feb;4(1):171–89.5. Hillman JD. Genetically modified Streptococcusmutans for the prevention of dental caries. Antonie VanLeeuwenhoek. 2002 Aug;82(1-4):361–6.6. Photodynamic therapy targets oral dysplasia, oralbacteria [Internet]. DrBicuspid.com. [cited 2013 Jan29]. Available from: http://www.drbicuspid.com/ index.aspx? sec = sup & sub = orc & pag = dis & itemid =311625Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 559

eview articleCo n c e p t o f Shortened De n t a l Ar c h: An OverviewMohit Bansal*, Sunint Singh # , Roohi Jindal @AbstractShortened dental arch (SDA) serves as a treatment option that ensures oral function by improving oral hygiene,comfort & possibly reduced cost. The shortened dental arch approach appears to fit well with problem solving approachin modern dentistry. This paper will highlight the various aspects of shortened dental arch.Key words: Dentition, shortened dental arch, treatment approachIntroductionFor the partially-dentate or edentulous patient,the dental surgeon has to consider numberof factors such as oral functionality, verticaldimension and occlusion, maintenance of hardtissue, temporomandibular joint health, as well aspatient comfort 1 . Dentists replace missing, damaged,and severely decayed teeth by fixed or removableprostheses to restore or improve masticatoryfunction 2 . The literature indicates that dental archescomprising the anterior and premolar regions can meetthe requirements of a functional dentition. ARNDKAYSER was the first to coin the term “shorteneddental arch” in 1981 to describe the concept ofacceptable oral function with partial dentition 3 .A shortened dental arch is defined as dentitionwhere most of the posterior teeth are missing. Theshortened dental arch concept was developed toavoid complex restorative treatment in posteriorregions of mouth as according to WHO dental archescomprising the anterior and premolar regions canmeet the requirement of a functional dentition 3 .Classification 4A classification for the shortened dental arch,suggested by “KAYSER”, according to the numberof teeth remaining in the arch and symmetry ofshortening is as followed:-*Senior Resident, Oral Health Sciences Centre,Post Graduate Institute of Medical Sciences, Chandigarh#Lecturer, Department of Prosthodontics,Swami Devi Dyal Hospital & Dental College, Barwala, Distt. Panchkula.@Demonstrator, Department of ProsthodonticsBhojia Dental College & Hospital Bhud, Baddi, Himachal Pradesh.Corresponding AuthorDr. Mohit Bansal,Email : mohit.bansal51@gmail.com• Symmetrically Shortened Dental Arch• Extremely Shortened Dental Arch with asymmetry.A system considering occlusal units as premolarequivalents was also developed in which a molar isequivalent to two premolar units and a premolar isequivalent to a single occlusal unit. Thus a singlearch of four molars and four premolars wouldaccount for 12 occlusal units.Effect of Shortened Dental Arch onOral Function & MasticationThe masticatory ability is closely related to thenumber of teeth, and there is impaired masticatoryability when the patient has less then 20 welldistributed teeth 5 . Masticatory efficiency andmasticatory ability are important components oforal functionality but due to patient’s adaptation tochanges in dental arch length it is not possible toquantify the minimum number of teeth needed tosatisfy functional demands because these demandsvary from individual to individual.Studies performed by Kayser et al suggested thatthere is sufficient adaptive capacity in patient’s withshortened dental arches when atleast four occlusalunits are left, preferably in a symmetrical position.However, the chewing ability deteriorates whenthe number of occlusal units is less then four insymmetrically shortened arches and less then six inasymmetrically shortened arches 6 .Over all, if the premolar regions are intact and thereis atleast one pair of occluding molars, the authorsconcluded that a shortened dental arch does not impairmasticatory efficiency. In contrast, there is severelyimpaired masticatory ability when the patient hasreduced number of occluding premolars and / or560Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Review Articleasymmetric arches, especially with the hard food.Impaired masticatory ability and associated changesor shifts in food selection are manifested only whenthere are less than 10 pairs of occluding teeth 7 .Comparision between ADA andComplete Demta; Arches 8, 9When subjects with shortened dental arches werecompared with complete dental arches with respectto occlusal stability it was concluded that –1. SDAs provided durable stability.2. Extension base removable partial dentures (RPD) did notcontribute to occlusal stability.3. SDAs with periodontally involved teeth demonstratedcontinuing periodontal break down.Occlusal stability was accessed by Witter et al 9 withthe following five parameters used as indicators:-1. Interdental spacing2. Occlusal contacts3. Vertical and Horizontal overlap4. Occlusal tooth wear.5. Periodontal support.They found that the occlusal changes were selflimiting and concluded that SDAs can provide longterm occlusal stability.When oral functionality for patients with shorteneddental arches was compared with that for patientswith dental arches lengthened by distal extensionremovable partial dentures, no significant differenceswere found in the oral functionality of subjects withSDAs and those who wore RPDs.Advantages of Shortened Dental ArchAlthough restoration of dental arches upto secondmolars is desirable both by patient and clinicians,it is not always possible for all the patients andcan be limited by financial reasons and surgicalcomplications. Furthermore, the current acceptedlevel of oral health is retention of a functional,esthetic, natural dentition of not less than 20 teethand not requiring the use of prosthesis.Financially, the shortened dental arch concept isacceptable to the patient as molars are more proneto be lost by both dental caries and periodontaldiseases and are considered being the most costlyteeth to preserve.Restoration of a shortened dental arch meets thecharacteristics of current theories of an acceptableocclusion by terminating occlusal platform at thesecond premolar region. It also provides a highstandard of care and minimal cost by avoidingrestorative treatment for the posterior regions ofmouth. This is beneficial for the potential implantpatient since no posterior implants are neededwhich eliminates both the surgical implant and finalrestorative procedures thus reducing cost 8 .When the oral comfort for shortened dental archespatients was compared with that for SDAs and distalextension RPD and for subjects with complete dentalarches, no significant were found between the threegroups with respect to pain or distress. While SDAscan compromise oral comfort to a small extent, itis still acceptable to the patient, and there were noindication that providing distal extension RPDsenhanced oral comfort for SDA patient 10 .According to Armellini and Vonfraunhofer SDA maybe beneficial for immunosuppressed patients andthose undergoing radiotherapy or chemotherapy ascomplete dental arch restoration may be inadvisablefor those patients. With restoration of shorteneddental arches the patient reported satisfaction interms of oral comfort, absence of pain or distress,masticatory ability, appearance of the teeth and easeof performing daily oral hygiene procedures 8 .Disadvantages of ShortenedDental ArchesAlthough restoration of shortened dental arches inpartially edentulous patients offers advantages, somedisadvantages have also been found associated withSDAs. It seems that most people can functionallyaccept a shortened dental arch, but this is not truefor everyone, many people with an SDAs found thattheir chewing ability is hindered or that they had tochange food preparation practices 1 .Some patients with shortened dental arches reportedthe prevalence of temporomandibular joint (TMJ)problems. A study performed by Witter et al showedthat there is greater prevalence of joint sounds withsubjects having only unilateral posterior supportand those with no posterior support. However, therewere no differences in pain, mandibular mobility,maximum mouth opening or clicking / crepitation ofthe joints for SDA and control groups. While therewas no evidence that SDAs provoke TMJ problems,it was noted that the risk for pain and joint soundsIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 561

Review Articleincreased when unilateral or bilateral support ismissing 11 .Shortened dental arch may be associated withgreater tooth migration and interdental spacing,although migration was deemed small and clinicallyinsignificant. An SDA may also be associated withgreater over eruption of teeth. People with SDAshave been found to have more mobile teeth and loweralveolar bone levels. The combinations of increasedocclusal loading and existing periodontal diseaserepresent a risk factor for further loss of teeth in thosepeople. Patient with SDA probably also represent ahigh risk group in term of periodontal disease 12 .Oocclusal and TMJ Loads inShortened Dental Arches 13To determine whether shortened dental arches(SDAs) cause functional over loading of theteeth and the temporomandibular joint, whichhas been implicated in periodontal diseases andtemporomandibular disorders, the influences ofSDA on occlusal and joint loads were investigated.The finding of the studies provide no evidence thatshortened dental arch causes overloading of the teethand the joints, which suggests that neuromuscularregulatory system are controlling maximumclenching strength under various occlusal conditions.A possible explanation for these findings which denya relation between temporomandibular disorderand shortened dental arch is that neuromuscularregulatory mechanisms protect the joints fromoverloading. Because the sensory innervationsof this joint is limited mainly to the joint capsule,retrodiscal area and the posterior band of disk, neitherthe mechanoreceptors nor the nocireceptors in thejoint are well suited for detecting excessive loadduring clenching. The neuromuscular regulatorysystem thus seems designed to control the clenchingstrength so as not to exceed the critical limit of theload bearing capacity of periodontal tissues.ConclusionThe Shortened dental arch concept does notcontradict current occlusion theories and appears tofit well with the problem solving approach. It offerssome important advantages one of which is decreaseemphasis on restorative treatments for the posteriorregions of mouth. However, functional demands, andthe number of teeth to satisfy such demands varyfrom individual to individual hence they should betreated according to each individual need and adaptivecapability. SDA may avoid risk of overtreatment ofthe patient while still providing a high standard of careand minimizing cost. It may therefore be concludedthat this concepts deserves serious consideration intreatment planning for partially edentulous patients.However, ongoing changes in dental health andeconomy, the concept require continuing research,evaluation and discussion.References1. Van der Bilt A, Olthoff LW, Bosman F, Oosterhaven SP. Theeffect of missing postcanine teeth on chewing performancein man. Archives of Oral Biology 1993; 38: 423-9.2. Rodriguez AM, Aquilino SA, Lund PS. Cantilever andimplant biomechanics: a review of the literature, Part 2.Journal of Prosthodontics 1994; 3: 114-8.3. Kayser AF. Shortened dental arches and oral function.Journal of Oral Rehabilitation 1981; 8: 457 – 62.4. Kayser AF. Limited treatment goals- shortened dentalarches. Periodontology 2000 1994; 4:7- 14.5. Sarita PT, Witter DJ, Kreulen CM, Van’t Hof MA,Creugers NH. Chewing ability of subjects with shorteneddental arches. Community Dentistry Oral Epidemiology2003; 31: 328-34.6. Kanno T, Carlsson GE. A review of the shortened dentalarch concept focusing on the work by the Kayser/Nijmegen group. Journal of Oral Rehabilitation 2006;33(11): 850–62.7. Rosenoer LM, Sheiham A. Dental impacts on daily lifeand satisfaction with teeth in relation to dental status inadults. Journal of Oral Rehabilitation 1995; 7: 4469-80.8. Debora Armellini, J Anthony Von Fraunhofer. Theshortened dental arch: A review of literature. Journal ofProsthetic Dentistry 2004; 531-5.9. Witter DJ, N.H.J. Creugers, C.M. Kreulen. A.F.J. deHaan. Occlusal Stability in Shortened Dental Arches.Journal of Dental Research 2001; 80: 432-6.10. Witter DJ, Van Elteren P, Kayser AF, Van Rossum GM.Oral comfort in shortened dental arches. Journal of OralRehabilitation 1990; 17: 137-43.11. Witter DJ, Van Elteren P, Kayser AF, Van Rossum GM.Oral comfort in shortened dental arches. Journal of OralRehabilitation 1990; 17: 137-43.12. Witter DJ, van Elteren P, Kayser AF. Migration of teethin shortened dental arches. Journal of Oral Rehabilitation1987; 14: 321-9.13. Kuboki T, Okamoto S, Suzuki H, Kanyama M, ArakawaH, Sonoyama W, et al. Quality of life assessment of boneanchoredfixed partial denture patients with unilateralmandibular distal-extension edentulism. Journal ofProsthetic Dentistry 1999; 82: 182-7.562Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Die Materials & Sy s t e m s f o r Fixed Partial DenturesS. Raghavendra Jayesh*, Sanjna Nayar # , Soumya. V.S. @review articlePart - 1AbstractPrecise fit of crowns and retainers in fixed partial dentures depends on the accuracy of the dies. Concepts and techniquesof different die systems are unique. This is the first part of a series of articles on die materials & systems.Key words:Die Materials, Die Systems – Techniques, Fixed Partial Dentures.for a single tooth, the rehabilitation of the entireocclusion or can be implant supported prosthesis.Cast with separable dies – maxillary archCast with separable dies – mandibular archFinal restoration in fixed prosthodontics canbe made with cast metal, metal ceramic or allceramic restorations. The restorations can be*Professor & Principal#Professor & Head@Post GraduateDepartment of Prosthodontics :Sree Balaji Dental College & Hospital, BharathUniversity, Chennai. India,Corresponding author:Dr. S. Raghavendra Jayesh,Email : srjayesh@yahoo.co.inDirect fabrication of wax patterns for castrestorations in the mouth is inconvenient, difficult,time consuming and virtually impossible. Practically,the wax patterns are made in the laboratory with anindirect technique. 1 This technique uses a workingcast which is a life size likeliness of the preparedtooth. This is followed with a preparation of waxpattern, casting and finishing of crown or fixed partialdenture with well established contacts, physiologiccontouring of embrasures, occlusion and marginalintegrity.To obtain an accurate reproduction of the preparedtooth, a precise positive replica should be fabricatedin the laboratory. This objective can be achievedthrough the preparation of a die. Die is a positivereproduction of the prepared tooth on which themargins of the wax pattern are finished. Theseindividual tooth replicas are advantageous in thatthey (a) allow easier handling during wax patternfabrication, (b) help to visualize the proximalcontacts and contours and (c) allow finishing ofpattern in inaccessible areas of the cast.The die must form an integral component of themaster cast and must be easily separated from thecast. This type of cast is called cast with separabledies. Various techniques have been advocated formaking removable die system. The separation ofindividual dies from solid cast requires that theybe replaced in precisely the same position that theyhad occupied prior to removal. Reduction of theinaccuracies in a working cast minimizes laboratoryerror and thereby saves chair - side time.Die materials used for fabrication of cast restorationsby an indirect technique should be durable,Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 563

Review Articledimensionally accurate and show good reproductionof details. Ease of manipulation and cost are otherfactors important in guiding the selection of a diematerial.Although die materials are not directly used as dentalrestoratives, they are important adjunct materialsused in laboratory procedures. Most commonlyused materials are gypsum products. Alternative diematerials are silver & copper (in electroplated dies),epoxy resin and flexible material. Gypsum dies arewidely used, but gypsum has its disadvantages.Poor abrasion resistance, less strength and settingexpansion are some of the disadvantages ofgypsum.Epoxy resin dies are stronger and more abrasionresistant than gypsum dies, but they are slightlyundersized due to shrinkage during setting. So,a crown fabricated on epoxy resin die will becomparatively tighter for the same patient whilecrown fabricated on a gypsum die will be less tight.Each system of fabrication of dies is based ondefinite concepts. It is necessary to know about thedie materials and die systems with their respectiveadvantages & shortcomings. Selection of a particulartechnique may be dependent on doctor’s preference& feasibility of technical support. Clinicallysatisfactory accuracy can be given by all the availablesystems, provided they are used correctly.It is important to take maximum care to obtainan accurate die because “It is the only direct linkbetween the laboratory and the patient”.References:1) Contemporary fixed partial dentures – Rosenstiel etal –4th edition, 526 – 553.564Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

eview articlePe r i o d o n t a l Ma n a g e m e n t o f Po s t Menopausal Wo m e nNeeraj Deshpande*, Divya Sharma #ABSTRACTMenopause, resulting from the permanent cessation of menstrual cycle, acts as the potential risk factor forperiodontal diseases. Due to the long life-expectancy, today women live about half of their life after menopause.The systemic and oral changes occurring in menopause, due to estrogen deficiency, greatly affect the general comfortand quality of life of women. Menopause also puts women at an increased risk of alveolar bone loss due toosteoporosis. By using our knowledge of host modulation for treatment of periodontitis and the importance of supportiveperiodontal therapy, we can control the progression of periodontal disease in post-menopausal women. Theuse of subantimicrobial dose of doxycycline shows a promising and safe future in this regard. But at the same time,it is important to monitor the calcium and vitamin D intake after menopause, to prevent/delay osteopororsis.Keywords: Periodontal disease, Post-menopause, osteoporosis, sub-antimicrobial dose doxycyclineIntroductionMenopause is the transition from reproductiveto non-reproductive phase of women, due topermanent cessation of the primary functionsof the ovaries. It is characterized by irregular anddeclining production and secretion of estrogen andprogesterone. The permanent cessation of menstrualflow (amenorrhea) during menopause occurs inwomen at an average age of 47-55 years. 1SYSTEMIC CHANGES DUE TO MENOPAUSE:- 11]Vascular instability:- Leading toR Hot flashes, including night sweatsR Possible increased risk of atherosclerosisR MigraineR Rapid heartbeat2]Urogenital atrophy:- Thinning of membranes ofthe genitourinary tract.Prior to the onset of menopause, estradiol levelsmight hover around 100 pg/ml, but after menopausethe amount can plummet to 20 pg/ml or less. Theresponses to these decreasing levels can be:-3]Skeletal:-R Back pain, Joint pain, Muscle pain*Professor, Department of Periodontics,#Postgraduate Student, Department of PeriodonticsK.M.Shah Dental College & HospitalSumandeep Vidyapeeth University, Vadodara, IndiaAddress for Correspondence:Dr. Neeraj Deshpande,Email: drneeraj78@rediffmail.comR Osteopenia and the risk of osteoporosisgradually developing over time4]Skin, soft tissueR Breast atrophy& tendernessR Decreased elasticity of the skinR Formication, Skin thinning and dryness5] PsychologicalR Depression and/or anxietyR Fatigue,R Memory loss, and problems with concentrationR Mood disturbanceR Sleep disturbances, poor quality sleep, lightsleep, insomnia and sleepinessThe most important tissue getting affected by reducedestrogen levels is bone, leading to osteoporosis.Osteoporosis is defined as a skeletal disordercharacterised by low bone mass and microarchitecturaldeterioration of bone tissue leading to enhanced bonefragility, with a consequent increase in fracture risk.Periodontal Changes due to Menopause:The reduction in estrogen production leads to manychanges in the body and particularly in differentparts of the oral cavity too. Oestrogen deficiencyin post-menopausal women: (a) represents akey factor in the pathogenesis of osteoporosis; 2(b) involves accelerated bone resorption whichoverpowers the rate of bone formation; 3 and (c) has,been associated with increased alveolar bone loss 4leading to increased tooth loss. 5 Studies suggestthat low oestrogen production after menopause isIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 565

Review Articleassociated with increased production of interleukin-1(IL-1), IL-6, IL-8, IL-10, tumour necrosis factoralpha, granulocyte colony-stimulating factor, andgranulocyte-macrophage colony-stimulating factor,all of which stimulate mature osteoclasts, modulatebone cell proliferation, and induce resorption ofboth skeletal and alveolar bone. 6,7Systemic factors responsible for postmenopausalosteoporotic bone loss may combine with localfactors such as periodontal disease to enhancealveolar bone loss. Current evidence includingseveral prospective studies support the associationof osteoporosis with the onset and progression ofperiodontal disease in humans.8 The decreasedbone mineral density of osteoporosis in menopausalfemales can lead to an altered trabecular patternand more rapid alveolar bone resorption, thuspredisposing to periodontal disease. 5 Systemicloss of bone density in osteoporosis, including thatof jaw bones also provides a host system, withincreasing susceptibility to infectious destruction ofperiodontal tissue. 9These mechanisms of increased cytokinesproduction and altered bone turnover rate that leadto a host who is more susceptible to periodontaldisease, suggest that the treatment modalities thatcan be used to reduce rate of alveolar bone loss andperiodontal disease progression in post-menopausalwomen can be:-1] BISPHOSPHONATESThese bone sparing agents have been usedextensively since many years for the managementof osteoporosis. Bisphosphonates bind to bonehydroxyapatite crystals thus regulates mineralizationand prevent their dissolution. They have been shownto increase bone mass by stimulation of osteoblastdifferentiation and inhibition on osteoclast activity.In randomized, clinical trials in humans withperiodontal disease, bisphosphonate use resulted instatistically significant reductions in the proportionof teeth demonstrating alveolar bone loss after 9months10 and statistically significant improvementsin alveolar bone height. 11 However, more recently,a randomized clinical trial on patients withperiodontal disease who received either alendronateor placebo, reported that after 2 years of therapythere were no differences in alveolar bone level orbone density between the two treatment groups. 12But, in a subgroup of patients with low mandibularbone mineral density, alendronate significantlyreduced bone loss compared with placebo. Thissuggests that bisphosphonates can play a major rolein reducing alveolar bone loss especially in patientswith reduced bone density, e.g., post-menopausalosteoporotic women. However, a recent developmenthas been the publication of several case reportsof avascular necrosis of the jaws, particularly themandible, following bisphosphonate therapy, withan increased risk of bone necrosis following dentalextractions. 13 This has been termed bisphosphonateassociatedosteonecrosis and is a significant andclinically serious complication of bisphosphonatetherapy. 13 There are also other systemic side effectsbisphosphonates including oesophageal ulceration,gastric irritation, low serum calcium levels, all ofwhich prevent regular use of these agents for alveolarbone preservation in non-osteoporotic women.2] SUBANTIMICROBIAL DOSE OF DOXYCYCLINE &CHEMICALLY MODIFIED TETRACYCLINES:-Tetracyclines and their chemically modified nonantibacterialanalogues can inhibit certain hostderivedtissue destructive matrix metalloproteinasessuch as collagenases and gelatinases, including thosethat help mediate bone resorption. 14 Researchershave found that these drugs, can also enhanceosteoblast activity, collagen production and boneformation. 14Payne et al., conducted a clinical trial on postmenopausalosteopenic women with periodontitis,who received SDD or placebo (oral route) every12 hours over 2 years period. 15 Both groups werealso given daily calcium (1200 mg) and vitamin D(400 IU) supplements for 2 years, and periodontalmaintenance therapy every 3-4 months. This twoyearregimen of SDD produced no significantchanges, compared with placebo therapy, in theserum levels of bone-specific alkaline phosphataseand osteocalcin levels. However, in a subgroup ofpopulation of women who were post-menopausalfor more than 5 years, this regimen showed ahighly significant reduction in serum ICTP and amarginal reduction in CTX. These post-menopausalwomen also exhibited reductions in biomarkersof inflammation, collagen destruction, and boneresorption locally in the GCF. 16 These womenalso showed significant reductions in clinical andradiological measures of periodontal disease severity566Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Review Articleand progression. Among subjects who were beyond5 years of menopause, SDD was associated witha 29% reduction in the odds of more progressivedisease (bone height loss). This effect, seen onlyin women who are post-menopausal since >5 years,can be explained by the finding that most significantpostmenopausal bone loss occurs within 5–7 yearsof menopause. 17,18 The effect of SDD also had sitespecificity in this population. The sites with deeperperiodontal pockets and interproximal areas betweenmolar-molar and premolar-molar showed better gainin bone density than anterior regions or sited withshallow pockets. 19 These data suggest that SDDmay be a useful adjunct to periodontal maintenancetherapy in subjects with less rapid systemic boneturnover (subjects post-menopausal for more than 5years), who do not smoke and for sites with deeperprobing depths.3] DAILY DIETARY SUPPLEMENTATION OFCALCIUM & VITAMIN D:-Estrogen deficiency is an important risk factor in thepathogenesis of osteoporosis. 2 This may be becauseof reduced calcium absorption and reduced serumcalcium levels due to estrogen deficiency.The cohort in Payne et al., research was most likelystable over 2 years systemically because all subjectsreceived calcium and vitamin D supplements. 15These subjects received 1200 mg of calcium/400 IUvitamin D supplements daily throughout the clinicaltrial, which is a regimen that represents the standardof care for post-menopausal women. This finding issubstantiated by a recent publication which showscalcium and vitamin D may have beneficial effectson alveolar bone in post-menopausal women. 20Adequate calcium intake has been shown to reducebone loss and fractures in post-menopausal women(Position Statement, North American MenopauseSociety 2006). It is demonstrated that increasedcalcium/ vitamin D intake and conventionalperiodontal treatment improves the inflammatoryprocess and tooth mobility in osteoporotic patientssuffering from periodontitis. 21 The literaturesuggests that low level of vitamin D is associatedwith periodontal disease and that supplement ofVitamin D and calcium leads to better periodontalhealth though these supplementations are not therecognized way to treat periodontitis but can playpositive role along with other dental treatmentmodalities. 22,234] REGULAR FOLLOW UPS IN SUPPORTIVEPERIODONTAL THERAPY:-The Payne et al., study which the patients were kept ona 3-4 monthly follow up period of maintenance therapyhas shown that the periodontal status of postmenopausalwomen can be kept stable by maintaining good plaquecontrol. 15 In this study, the patients were counselledevery 3-4 months for oral hygiene maintenance also.This keeps the local etiologic factors of plaque andcalculus to the minimum, thus reducing the rate ofperiodontal disease progression.5] TREATMENT FOR OTHER ORALMANIFESTATIONS:-It should be noted that alveolar bone is not theonly oral tissue that is affected by menopause.With the overall reduction in estrogen output aftermenopause, a significantly different presentation ofthe gingiva also predominates. The effect of reducedestrogen levels on epithelial keratinization, alongwith decreased salivary gland flow independent ofmedication, 24 may have other significant effectson the periodontium. Friedlander described anatrophic gingivitis in some post-menopausal womenin which the gingival tissues develop an abnormalpaleness. 24 Post-menopausal women also complainof xerostomia and burning sensation in mouth.All these changes affect the patient’s oral comfortand thus their quality o life. Hence it is essentialto address these oral manifestations also. Severexerostomia can be managed by use of sialogogues.The epithelium with reduced keratinisation alsodemands extra care on part of the clinician duringtissue management in periodontal procedures.Co-ordination with gynaecologist can help in givingHormone Replacement Therapy (HRT) which hasbeen shown to greatly reduce post-menopausalsymptoms. If gingival and mucosal tissue thinningoccurs, soft tissue augmentation may be performed.Brushing with an extrasoft brush using the ‘toe’or ‘heel’ of the brush may prevent ‘scrubbing’ thethinning gingiva. Dentifrices with minimal abrasivesshould be used. Mouthrinses with low alcohol contentshould be prescribed, as high alcohol content willcause more burning sensation on thinning gingiva.ConclusionPeriodontal management of post-menopausalwomen can be successfully carried out with goodIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 567

Review Articleunderstanding of the clinician’s role in maintainingthe patient’s general health, nutritional state andgeneral well-being. It is extremely important to placethe patient on a customized supportive maintenancetherapy programme to keep the periodontal healthstable. In patients with severe periodontitis who arepost-menopausal for more than 5 years, SDD showsgood promise in improving their periodontal health,but only with regular maintenance therapy and dailydietary supplementation of calcium and vitamin D.References1. Xu J., Bartoces M., Neale A.V., Dailey R.K., Northrup J.,Schwartz K.L.. Natural History of Menopause Symptomsin Primary Care Patients: A MetroNet Study. J Am BoardFam Med 2005;18:374-382.2. Cranney, A., Guyatt, G., Griffith, L., Wells, G., Tugwell,P. & Rosen, C. Osteoporosis Methodology Group and TheOsteoporosis Research Advisory Group. Meta-analyses oftherapies for postmenopausal osteoporosis IX: summaryof meta-analyses of therapies for postmenopausalosteoporosis. Endocrine Reviews 2002;23:570–578.3. Riggs, B. L. & Melton, L. J. Involutional osteoporosis.New England Journal of Medicine 1986;314:1676–1686.4. Tezal, M., Wactawski-Wende, J., Grossi, S. G.,Dmochowski, J. & Genco, R. J. Periodontal disease andthe incidence of tooth loss in postmenopausal women. JPeriodontol 2005;76:1123–1128.5. Payne, J. B., Zachs, N. R., Reinhardt, R. A., Nummikoski,P. V. & Patil, K. D. The association between estrogen statusand alveolar bone density changes in postmenopausalwomen with a history of periodontitis. J Periodontol1997;68:24–31.6. Pacifici R. Estrogen, cytokines and pathogenesisof postmenopausal osteoporosis. J Bone Miner Res1996;11:1043-51.7. Pacifici R, Brown C, Pusheck E. Effect of surgicalmenopause and estrogen replacement on cytokine releasefrom human blood mononuclear cells. Proc Natl AcadSci USA 1991; 88:5134-8.8. Krijl. I.J, West See. Periodontal Abstr Osteoporosis andPeriodontal Disease;is there a relationship? 1996;44:37 – 42.9. Paganini Hill, A. The benefits of estrogen replacementtherapy on oral health. Archives of Int’l Medicine.1996;155: 325-29.10. Reddy MS, Geurs NC, Gunsolley JC. Periodontal hostmodulation with antiproteinase, anti-inflammatoryand bone-sparing agents. A systematic review. AnnPeriodontol 2003; 8:12–37.11. Rocha M, Nava LE, Vazquez de la Torre C, Sanchez-Marin F, Garay-Sevilla ME, Malacara JM. Clinicaland radiological improvement of periodontal diseasein patients with type 2 diabetes mellitus treated withalendronate: a randomized, placebo-controlled trial. JPeriodontol 2001;72:204–209.12. Jeffcoat MK, Cizza G, Shih WJ, Genco R, Lombardi A.Efficacy of bisphosphonates for the control of alveolarbone loss in periodontitis. J Int Acad Periodontol 2007:9:70–76.13. Lam DK, Sandor GK, Holmes HI, Evans AW, Clokie CM.A review of bisphosphonate associated osteonecrosis ofthe jaws and its management. J Can Dent Assoc 2007:73: 417–422.14. Golub LM, Lee HM, Ryan ME, Giannobile WV, PayneJ, Sorsa T. Tetracyclines inhibit connective tissuebreakdown by multiple non-antimicrobial actions. AdvDent Res 1998: 12: 12–26.15. Payne JB, Stoner JA, Nummikoski PV, ReinhardtRA, Goren AD, Wolff MS, et al. Subantimicrobialdose doxycycline effects on alveolar bone loss inpostmenopausal women. J Clin Periodontol 2007;34:776-787.16. Golub LM, Lee HM, Stoner JA, Sorsa T, Reinhardt RA,Wolff MS, et al. Subantimicrobial dose doxycyclinemodulates gingival crevicular fluid biomarkers ofperiodontitis in postmenopausal osteopenic women. JPeriodontol 2008;79:1409-1418.17. Lindsay, R., Hart, D. M., Forrest, C. & Baird, C.Prevention of spinal osteoporosis in oophorectomisedwomen. Lancet 1980;2: 1151–1154.18. Pacifici, R., Rifas, L., McCracken, R., Vered, I.,McMurtry, C., Avioli, L. V. & Peck, W. A. Ovariansteroid treatment blocks a postmenopausal increase inblood monocyte interleukin 1 release. Proceedings of theNational Academy of Sciences of the United States ofAmerica 1989;86: 2398–2402.19. Golub LM, Lee HM, Stoner JA, ReinhardtRA, Sorsa T, Goren AD et al. Doxycycline Effects onSerum Bone Biomarkers in Postmenopausa Women. JDent Res 2010;89:644-649.20. Hildebolt, C. F., Pilgram, T. K., Dotson, M., Armamento-Villareal, R., Hauser, J., Cohen, S. & Civitelli R. Estrogen and/or calcium plus vitamin D increase mandibular bone mass. JPeriodontol 2004;75:811–816.21. Ortega RM, Requejo AM, Encinas Sotillos A, Andrés P,López-Sobaler AM, Quintas E. Implication of calciumdeficiency in the progress of periodontal diseases andosteoporosis. Nutr Hosp. 1998;13:316-9.22. Amano Y, Komiyama K, Makishima M. VitaminD and periodontal disease. J Oral Sci. 2009;51: 11-20.23. Miley DD, Garcia MN, Hildebolt CF, et al.Cross Sectional study of vitamin D and Calciumsupolementation effects on chronic periodontitis.J Periodontol . 2009; 80:1433-39.24. Freidlander AH. The physiology, medica managementand oral implications of menopause. J Am Dent Assoc2002; 133;73-81.568Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Lasers In Th e Ma n a g e m e n t Of De n t i n a l Hypersensitivityreview articleA.Shafie Ahamed * , R. Meyyappan * , Guru Charan @ , Arun Kulandaivel #ABSTRACTTooth hypersensitivity is a relatively common problem that is encountered in routine clinical practices by the dentists.Hypersensitive dentin implies an abnormal sensitivity experienced by the patients when there is exposure of dentinaltubules to mechanical, chemical and thermal stimuli. Dentinal hypersensitivity has multi-factorial etiology and generallymore than one factor is found associated and active in this painful manifestation. Therefore, more than one treatmentmodality should be associated to desensitize the dentin to satisfactory levels. With the advent of laser technologyand its growing utilization in dentistry, an additional therapeutic option is available for the treatment of dentinalpain. Combination of laser energy with fluoride varnish is an effective treatment method. Hence treating dentinalhypersensitivity is no longer an enigma to dentists.Key words: Dentinal hypersensitivity, hydrodynamic theory, CO 2, Nd:YAG, fluoride varnishIntroduction:Dentinal hypersensitivity is defined as ashort, sharp pain from exposed dentin thatoccurs in response to stimuli typicallythermal,evaporative,tactile, osmotic or chemicaland which cannot be ascribed to any other form ofdental defect or pathology. 1 It is estimated that onein seven patients suffer from some degree of dentinalhypersensitivity. It occurs frequently inpatients 30-40years of age. Erosion, abrasion, attrition, gingivalrecession, periodontal treatmentand anatomic defectshave been suggested as possible risk factors fordentinal hypersensitivity. 2 Dentinal pain is elicitedby cold stimuli in up to 90%of patients, althoughmechanical and chemical stimuli also are effective. 3Mechanism of ActionBrannstrom et al 4 proposed that nerve endings in thedentin pulp border area are activated hydrodynamicfluid flow in response to dentinal stimulation.According to the hydrodynamic theory, rapiddentinal fluid flow serves as the final stimulus inactivating intradental nociceptors for many differenttypes of stimuli. Studies have confirmed that thepatency of the dentinal tubules is a prerequisite forthe sensitivity of exposed dentin. It was also shown*Professor,@Professor & Head,#Reader.Department of Conservative Dentistry & Endodontics,RMDCH, Annamalai UnivesityCorresponding author:Dr.A.Shafie AhamedEmail id: laserendo@hotmail.comusing scanning electron microscopy , that teeth withdentinal hypersensitivity have a significantly highernumber of patent dentinal tubules per millimeterand a significantly greater mean diameter per tubulethan control teeth 5 . The management of dentinalhypersensitivity involves the application of therapiesthat reduce the flow of dentinal fluid or lower theactivity of dentinal neuron.DiagnosisPrior to establishing the diagnosis of dentinhypersensitivity, one must first rule out other conditionswhich exhibit similar symptoms 6 Caries, Pulpitis,Marginal leakage, Restoration fracture, Crackedtooth, Polymerization shrinkage. It is important to usespecific clinical finding with the patient (like brief,sharp, localized) to differentiate dentin hypersensitivityfrom pulpal pain (which is prolonged, dull, aching,poorly localized and longer lasting). Risk factors fordentin hypersensitivity 7 include Peridontal disease,Gingival recession. Parafunction (abfractions), Acidicdiet, Xerostomia, Bleaching. These factors predisposethe patient to the essential components of dentinhypersensitivity: exposed, open and patent dentinaltubules leading to a vital pulp. There may also be apassage of fluids through the enamel. The enamelmay be thought of as a semipermeable membrane thatallows passage of fluids and small molecule throughthe organic defects between the enamel crystals. Withtime, the organic channels become plugged due to theformation of organic biofilm. When this occurs, thebidirectional flow of fluids stops and so does the pain.During bleaching the organic plugs may dissolved,reopening the enamel channel and casing sensitivity.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 569

Review ArticleTreatmentSome of the treatment modalities that includeapplication to exposed dentinal tubules of resins,oxalate salts, isobutyl cyanoacrylate, fluoridereleasingresins or varnishes 8,9. Use of potassium containingdentifrices, fluoride containing medicaments and10% strontium chloride were partially effective inreducing dentinal hypersensitivity. 10,11 Recentlyremineralizing pastes like calcium sodiumphosphosilicate bioactive glass, amorphous calciumphosphate, and Pro-Argin Technology containingarginine, an amino acid that binds to the negativecharged dentin surface and attracts calcium richlayer from the saliva. 12,13NEWER TREATMENT A different treatmentmodality for reducing dentinal hypersensitivityinvolves the use of laser technologyThe rationale for laser induced reduction indentinal hypersensitivity is based on two possiblemechanisms that differ greatly from each other. Thefirst mechanism implies the direct effect of laserirradiation on the electric activity of nerve fiberswithin the dental pulp, whereas the second involvesmodification of the tubular structure of the dentinby melting and fusing of the hard tissue or smearlayer and subsequent sealing of the dentinal tubules.Among the different lasers used, desensitizingmechanism is distinct for each emitted wavelength;success rates reported differ according to laserdevice, irradiation parameters (adequate wavelength, power density, wave mode, frequency ofpulses, and number of irradiation repetitions) andinvestigation methods used to assess dentinal pain.The lasers used for the treatment of dentinalhypersensitivity may be divided into two groups:1. Low output power lasers (Heluium-neon andgallium/aluminum/arsenide (diode)2. middle output power lasers (Nd;YAG and carbondioide CO2)Matsumoto et al in 1985 introduced first diode laserfor the management of dentinal hypersensitivity. 17They applied an out applied an output power of30mW in a continuous wave irradiation mode for0.5to a3 minutes and reported treatment effectivenessranging from 85% to 100. The investigatorsconsidered that the analgesic effect was related todepressed nerve transmission caused by the diodelaser irradiation blocking the depolarization ofC-fiber afferents. Moritz et al 18 used a CO 2laserwith an output of 0.5 W for 5 seconds. Treatmenteffectiveness of 59%-100% was reported.Senda et al 19 were the first to apply the helium neonlaser in treating dentinal hypersensitivity. They usedan output power of only 6mW, which does not affectthe morphology of the enamel or dentin surface butallows a small fraction of the energy to reach thepulp tissue. It was reported that the effectiveness ofthis treatment ranges from 5.2% to 100%.Matsumoto et al 20 used a CO 2laser with an outputpower of 0.5 Win a continuous wave mode andan irradiation time of 5 seconds to treat dentinhypersensitivity. Treatment effectiveness rangedfrom 85% to 100%.Renton –Harper and midda 21 conducted a clinicaltrial on 30 patients to evaluate the efficacy of the Nd:YAG laser in reducing dentinal hypersensitivity.They reported it was 90% effective and themechanism is occluding or narrowing of the dentinaltubules. Direct nerve analgesia and suppressiveeffect achieved by blocking the depolarization of Adelta and C fibres.Stabhikz et al 22 investigated the effects of excimerlasers onexposed dentinal tubules of extractedhuman teeth and found melting of dentin and closureof exposed dentinal tubules. Main advantage ofexcimer lasers is safe and minimal thermal damageto the surrounding tissues.Wan-Hong Lan et al(2009) 14 conducted a study toevaluate the effectiveness of the Nd:YAG laser inthe treatment of dentin hypersensitivity. Thirtysubjects participated were followed for 3 months.The Nd:YAG laser treatment reduced dentinhypersensitivity to air by 65% and to mechanicalstimulus by 72% over 3 months. In conclusion,the Nd:YAG laser can be used to reduce dentinhypersensitivity without detrimental pulpal effectsIpci et al 15 conducted a study to evaluate and comparethe efficacy of CO 2and Er:YAG lasers alone andin combination with topical sodium fluoride inthe management of dentin hypersensitivity. Theyconcluded that both the CO 2and Er:YAG lasershave promising potential for the treatment ofdentine hypersensitivity. Zhang C et al 16 evaluatedthe combined occluding effect of sodium fluoridevarnish and Nd:YAG laser irradiation on human570Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Review Articledentinal tubules under SEM. Over 90% of thedentinal tubule orifices were occluded by sodiumfluoride varnish combined with Nd:YAG laser.A recent study conducted in our department ofconservative dentistry and endodontics, RMDCH, tocompare between CO 2and Nd:YAG laser irradiationfor their sealing ability on human dentinal tubuleswhen treated with and without fluoride varnish usingScanning Electron Microscopy. 23 It was concludedthat compared to conventional fluoridation or laserirradiation in the treatment of dentin hypersensitivity,CO 2lasers in combination with Fluoride varnishappear to show better efficacy than either treatmentmodality alone.FIG. 3Combined occluding effect of fluoridevarnish and Nd:YAG laser irradiation onhuman dentinal tubules ( X2500)FIG. 1Control specimen showed exposed dentinaltubule orifices. (X 2500)FIG. 4Combined occluding effect of fluoridevarnish and CO2 laser irradiation onhuman dentinal tubules (X2500)FIG. 2Fluoride varnished group showed smoothsurface, and almost all of the dentinal tubuleorifices were occluded. (X 2500)FIG. 5Nd:YAG lased specimen showed partialocclusion of dentinal tubules. (x 2500)Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 571

Review ArticleFIG. 6CO 2lased specimens showed melting of dentin andnarrowing of exposed dentinal orifices. (x 2500)It was concluded that compared to conventionalfluoridation or laser irradiation in the treatment ofdentin hypersensitivity, CO 2lasers in combinationwith Fluoride varnish appear to show better efficacythan either treatment modality alone [Fig.1-6].Conclusion: In the future, laser will be an importanttool in the armamentarium of a modern dental office. Itspotential for dental application in dentistry merits closerattention. Efforts should be focused on the search for a laserwavelength with optimal irradiation parameters that willenable the clinician to produce ideal modification of thedentin surface and other hard tissues of the tooth. Completefamiliarity with a safe and recommended protocol isessential at all times when treating vital teeth with lasers toalleviate the pain associated with hypersensitive dentin.References:1. Holland, G. R, Narhi, M. N. Addy, M.Gangarosa, L.&Orchardson, S. Guidelines for the design and conductof clinical trials on dentine hypersensitivity, Journal ofClinical Periodontology1997; 24:808–82. Adam Stabholz, SharonitSahar-Helft, Joshua Moshonov.Lasers in endodontics. Dent Clin N Am 2004; 48: 809–832.3. Rees J. The prevalence of dentine hypersensitivity ingeneral dental practice in the UK. Journal of ClinicalPeriodontology 2000; 27: 860–865.4. Branstrom M. The surface of sensitive dentin. OdontRev 1965;16:293-95. Kimura Y, Wilder-Smith P, Yonaga K, Matsumoto K.Treatment of dentine hypersensitivity by lasers: a review.J Clin Periodontal 2000;27: 715-216. Pashley D, Tay,FVaywood V, Collins, Drisco C. DentinHypersensitivity – Consensus based recommendations forthe diagnosis & management of dentin hypersensitivity,AEGIS Publications,20087. Strassler H, Serio ,F , Dentinal Hypersensitivity Etiology,Diagnosis and Management, ineedce.com8. Branstrom M, Johnson G, Nordenvall K. Transmissionand control of dentinal pain: resin impregnation for thedesensitization of dentin. J Am Dent Assoc 1979;99:612-89. Nordenvall KJ, Malmgren B, Brännström M.Desensitization of dentin by resin impregnation: aclinical and light-microscopic investigation. ASDC JDent Child1984 ; 51: 274-6.10. Plagmann HC, König J, Bernimoulin JP, Rudhart AC,Deschner J. A clinical study comparing two high-fluoridedentifrices for the treatment of dentinal hypersensitivityQuintessence Int 1997; 28: 403-811. Senda A, Gomi A, Tani T, Yoshino H, Hara G. A clinicalstudy on “soft laser 632”, a HeNelow energy medicallaser. Aichi-Gakuin J Dent sciences 1985;23:773-8012. Moritz A, Gutknecht N, Schoop U, Goharkhay K, EbrahimD, Wernisch J, Sperr. The advantage of CO2-treated dentalnecks, in comparison with a standard method: results of anin vivo study. J Clin Laser Med Surg 1996; 14: 27-3213. Renton-Harper P, Midda M.NdYAG laser treatment ofdentinal hypersensitivity. Br Dent J. 1992; 11:13-6..14. Wan-Hong Lan, Bor-Shiunn Lee, Hsin-Cheng Liu,Chun-Pin Lin. Morphologic study of Nd:YAG laserusage in treatment of dentinal hypersensitivity.Journal ofEndodontics 2004; 30: 131-13415. Ipci SD, Cakar G, Kuru B, Yilmaz S. Clinical evaluationof lasers and sodium fluoride gel in the treatment ofdentine hypersensitivity. Photomedicine and LaserSurgery 2009; 27:85-91.16. Zhang C, Lin Q, Zhao B. The combined occluding effectof fluor protector and Nd:YAG laser irradiation on humandentinal tubules Zhonghua Kou Qiang Yi XueZaZhi2001 Mar; 36:105-7.17. Matsumoto K, Funai H, Wakabayashi H, Oyama T. Studyon the treatment of hypersensitive dentine by GaAlAslaser diode. Japanese J Conserv Dent 1985;28:766-7118. Moritz A, Gutknecht N, Schoop U, Goharkhay K,Ebrahim D, Wernisch J, Sperr. The advantage of CO2-treated dental necks, in comparison with a standardmethod: results of an in vivo study. J Clin Laser MedSurg 1986; 14: 27-32.19. Senda A,GomiA,TaniT, A clinical studyon ~Soft Laser632~,a He Ne low energy medical laser Aichi-Gakuin JDent Sciences 1985;23:773-80.20. Matsumoto K,FunaiH, WakabayashiH, Oyama T. Studyon the treatment of hypersensitive dentine by GaAlAslaser diode. Japanese J Conserv Dent 1985;28:766-71.21. Renton-HarperP, MiddaM,.Nd YAGlaser treatment ofdentinal hypersensitivityBr.Dent J1992;172:13-6.22. StabholzA, NeevJ, LiawLL, StabholzAy, Torabinejad M.Sealing ability of dentinal tubulesbyXeCl308nm excimerlaser. Endod1993;19:267-71.23. Ahamed S, Gurucharan N, Meyappan R, Arun K, Deepa V,Babu S. A comparative analysis between Nd:YAG and CO2lasers for their sealing ability of dentinal tubules with andwithout fluoride varnish an in-vitro study. Journal of DentalLasers 2012;6:51-56.572Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Alloplastic Bo n e Gr a f t i n g Materialsreview articleAnurag Ashok Shendre*, Deepti Gattani @ , Arshad Sayed % , Narpat Singh Rajput ~ABSTRACTBone grafting has become a valuable mainstream clinical procedure in today’s dentistry in a variety of reconstructiveapplications. Various materials and formulations have been developed for this purpose. The synthetic bone graftsubstitutes as yet offer only a part solution to the management of localized bone loss. Ideally a synthetic bone graft substituteshould mimic the native bone in both mechanical and osteogenic properties. They possess some of the desiredmechanical qualities of bone as well as osteointegrative/conductive properties. It has given the clinicians the abilityto offer patients alternative treatment modalities that can serve to restore the missing bone anatomy. Present reviewdeals with the various alloplastic bone graft materials. Various advantages and disadvantages with these materials arediscussed.Key words: Reconstruction, Bone grafts, Osteointegration , Osteoconduction, OsteogenesisIntroductionBone grafting has become a valuable mainstreamclinical procedure in today’s dentistry in avariety of reconstructive applications. Ridgepreservation after tooth extraction is very importantfor making any kind of prosthesis, be it dentures, fixedbridge or implants. 1 Various materials and formulationshave been developed for this purpose. It has given theclinicians the ability to offer patients alternative treatmentmodalities that can serve to restore the missing boneanatomy for ridge maintenance or preservation, ridgeaugmentation and for enhanced bone foundation forendosseous implant placement and to fill in any bonydefects or voids such as caused by removal of a cyst ortumor. 2There are four characteristics that an ideal bone graftmaterial should exhibit which include: 61. Osteointegration, the ability to chemically bond to thesurface of bone without an intervening layer of fibroustissue.2. Osteoconduction, the ability to support the growth ofbone over its surface.3. Osteoinduction, the ability to induce differentiation ofpluripotential stem cells from surrounding tissue to anosteoblastic phenotype.*PG Student,@Professor,%Dean and Head , Dept of Periodontics, Swargiya DadasahebKalmegh Smruti Dental College and Hospital, Nagpur.~ Post Graduate, Dept of Periodontics. Sree Balaji Dental Collegeand Hospital, Bharath University, Pallikaranai, Chennai.Corresponding Author:Dr.Narpat Singh RajputE mail: narpat_singh_rajput@yahoo.co.in4. Osteogenesis, the formation of new bone by osteoblasticcells present within the graft material. Synthetic bonegraft substitutes currently possess only osteointegrativeand osteoconductive properties.The synthetic bone graft substitutes as yet offer onlya part solution to the management of localized boneloss. They possess some of the desired mechanicalqualities of bone as well as osteointegrative /conductive properties but are largely reliant onviable periosteum/bone for their success. Ideallya synthetic bone graft substitute should mimic thenative bone in both mechanical and osteogenicproperties.Classification of Bone Graft Materals 3(i) Autogenous bone grafts :They are osteogenic, osteoconductive and osteo inductive.There is no risk of host rejection or disease transmission.But its major disadvantages are procurement morbidity,limited availability and high cost. 4(ii) Allograft :It is nonvital , osseous tissue taken from one individualand transferred to another of the same species. Theyare osteoconductive and weakly osteoinductive. Itsadvantages include greater availability of bankedbone than autograft and no additional surgicalprocedure needed. Its disadvantages include riskof disease transfer, not osteogenic, immunogenic,variable clinical results and expensive. 5(iii) Xenogenic bone grafts :It is an osseous tissue that is harvested from onespecies, processed and then transferred to a recipientIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 573

Review Articlesite of a different species. If properly prepared itis well tolerated by the tissues. It involves the riskof autoimmune disease. For oral applications, itgenerally comes in a granular or powder form,making it somewhat difficult to handle. It mayalso require some form of retentive structure, suchas a membrane to hold the material in the desiredlocation, because of an increased potential formigration of the material.(iv) Synthetic/Alloplastic bone grafts :They are osteoconductive only. They eliminate therisk of disease transfer and procurement morbidityand it is abundantly available.(v) Composite grafts 7It offers the advantages of autografts and allograftto the synthetic materials, a composite graft may beconsidered. Such a graft can combine the syntheticscaffold with biologic elements to stimulate cellinfiltration and new bone formation.Synthetic Bone Graft Materals Cermics 8Its major advantages include:1. Potentially limitless availability,2. Do not require a second operative site,3. No risk of disease transmission or immunogenicresponse,4. The osteoconductive scaffold provides an appropriateenvironment in which bone cells and bone morphogenicproteins can adhere and proliferate. Although initially it lackscompressive and tensile strength, subsequently, it attains themechanical strength similar to cancellous bone. 9Its disadvantages include1. The main disadvantage of using pure ceramic as abone graft material is the minimal immediate structuralsupport,2. Absence of osteoinductive or osteogenic properties.Slowly resorbing ceramics (Calcitite):Hydroxyapatite exhibits brittleness and resorbsslowly; implants of this material can become asource of mechanical stress. It is often modifiedand combined with other materials for improvedfunctionality and faster resorption. According to astudy by Taylor et al, synthetic HA materials allowedosteoclast attachment but exhibited limited surfaceetching, which is consistent with limited osteoclastresorptive activity. 2Coralline Hydroxyapatite (e.g. Prosteon)It is a coral based bone graft substitute. It is derived fromthe hydrothermal chemical exchange of the calciumcarbonate exoskeleton of a South Pacific coral to acrystalline HA replica. It has a consistent pore size andimproved interconnectivity. Mechanically corallineHA is only slightly greater in compressive strengththan cancellous bone. Like other HA preparationsit is weak in tension, brittle and difficult to shape. Itsmain advantage is that its interporous structure. Allowscomplete ingrowth of fibro-osseous tissue 50-80% ofthe void is filled within 3 months. 6Rapidly absorbing ceramics (Tricalcium phosphate) 10It contains 39% calcium and 20% phosphorousby weight, which is similar to natural bone. Thematerials calcium phosphate rich surface layers seemto enhance bonding with adjacent host bone. Thisstimulates osteoclast resorption and osteoblasticnew bone formation within the resorbed implant.Injectable ceramic cementsInjectable calcium phosphates (e.g. Norian SRS)represent a class of ceramics that combines some ofthe qualities of cement with those of bone void filler.Norian cement contains alpha tricalcium phosphatemixed with calcium carbonate and monocalciumphosphate monohydrate. The initial compressivestrength of the hardened material is similar to thatof cancellous bone. The calcium phosphate implantundergoes long term remodeling, and is completelyreplaced by host tissue. A potential drawback of theliquid injectable cement is accidental extraosseousextrusion. Difficulties in controlling final placementmay result in soft-tissue or intra-articular deposits.4Ultraporous beta-tricalcium phosphate (e.g. Orthograft)A highly porous bone void filler that is composed of90% interconnected void space with a broad range ofpore sizes that is similar to the natural trabecular patternof cancellous bone. Small pores allows the wickingof phagocytic cells for resorption and bone formingcells, nutrients and growth factors for bone recoverythrough capillary refill. The larger size pores encouragevascularization and bone ingrowth. The material can bemanipulated during placement, sculpted as blocks, orpacked. After it is packed to conform to the shape ofthe bone defect, its high porosity remains intact. Theresorption rate of beta-tricalcium phosphate scaffold isintended to match the course of natural bone healingafter implantation. 5574Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Review ArticleCalcium SulphateIt is actually Plaster of Paris. It is a safe biocompatible,osteoconductive bone graft substitute that acts wellas space filler preventing the ingrowth of soft tissueallowing osseous ingrowth in bone defects. For this tooccur it is very essential that the calcium sulphate beplaced in close proximity to the viable periosteum orendosteum. Its rate of resorption corresponds to the rateof new bone formation in graft site. Calcium sulphatein its set form has a compressive strength greater thancancellous bone and a tensile strength slightly less thancancellous bone. Calcium sulphate however requires adry environment to set and if it is re-exposed to moistureit tends to soften and fragment. For this reason it has noreliable mechanical properties in vivo. The primary useof calcium sulphate is as a bone void filler. 6BioglassBioglass are particulate materials, slowly resorbingand when mixed with fluids form an adherent surfacelayer of silicon, calcium, fluoride and sodium,which binds the graft to the bone. They are notosteoinductive but conduct bone mineralization bypromoting absorption and concentration of proteinsused by osteoblasts to form the extracellular matrixof bone. In a study done by Oonish et al13 theycompared bioactive glass to hydroxyapatite andfound that bioactive glass was easy to manipulateand haemostatic and allowed full restoration of bonein 2 weeks compared to 12 weeks needed for HAto produce a comparable response. The Bioactivematerial is used up in the process and any problemsassociated with the production of a composite ofbone and biomaterials are avoided in the fullyrestored bone.Biocompatible oteoconductive polymers(e.g. HTR)It is a nonresorbable, particulate of calciumlayered with polymethylmethacrylate andhydroxyethylmethacrylate. 11 The HTR is reportedto act as its own barrier and prevent gingival softtissue migration ingrowth. Histologically it isosteoconductive and biocompatible and can beused both as bone substitute and as a barrier forguided tissue regeneration in implant therapy. 12 Nocomplications caused by infection, inflammationor rejection of the implanted graft material wereobserved in a study done by Harris AG in 224patients over a period of 5 years. 13Summary of the Alloplastic Bone GraftProducts 14Type Product Comment ApplicationHydroxyapatite Osteogen Nonresorbable, PeriodontalparticulateinfrabonymaterialdefectsProOsteon Coral derived Extraction sitesAlveolarreconstructionOther Ceramics Augmen Particulate TCP PeriodontalResorbable infrabony defectsExtraction sitesAlveolarreconstructionBone Source TCP and ReconstructionDicalciumof bone cavitiesphosphateCranial vaultdefectsHapset Degradable Extraction sitesPaste of TCP Coverage ofand calcium exposed implantssulphateImplant salvageproceduresReconstructionof bone cavitiesNorian SRS Paste of Cranial vaultmonocalcium defectsphosphate,TCP, calciumcarbonate, sodiumphosphateOsteoset Degradable Bone void fillerOrthograft Available as Used mainlypellets ofin orthpediccalcium sulphate surgeryParticulate TCPResorbablePeriodontalinfrabony defectsExtraction sitesSynthograft Particulate TCP AlveolarResorbable reconstructionReconstructionof bone cavitiesTrueBone Particulate Cranial vaultimplant containing defectsnumber ofcalcium phosphatesBioglasses Biogran Partially resorbable, Periodontalsynthetic particulate infrabonyChemically bonds defectsto boneExtraction sitesPerioglass Nonresorbable AlveolarreconstructionPolymers HTR-PMI Nonresorbable Periodontalinfrabone defectsCranial vaultdefects Alveolarreconstruction.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 575

Review ArticleReferences :1. Predictable synthetic bone grafting procedures forimplant reconstruction. GanzSD, Valen M. J OralImplantol 2002; 28(4):178-832. In vitro osteoclast resorption of bone substitutebiomaterials used for implant site augmentation: apilot study by Taylor JC, Cuff SE, Leger JP, Morra A,Anderson GI. Int J Oral Maxillofac Implants 2002 May-June 17(3):321-303. Vaccaro RA: The role of osteoconductive scaffold insynthetic bone graft, Orthopedics 2002 May; 25(5Suppl):571-804. Betz RR: Limitations of autograft and allograft: newsynthetic solutions, Orthopedics 2002 May;25(5Suppl):561-705. Bucholz RW: Non allograft osteoconductive bone graftsubstitute, Clin Orthop 2002 Feb(395):44-526. Moore WR, Grave SE, Bain GI: Synthetic bone graftsubstitutes, ANZ Surg 2001 Jun;17(6):354-617. Al Ruhaimi KA: Bone graft substitutes: a comparativequalitative histologic review of current osteoconductivegrafting materials, Int J Oral Maxillofac Implants 2001Jan-Feb;16(1):105-148. Rosen PS, Reynolds MA, Bowers GA: Treatment ofintrabony pockets with bone grafts, Periodontol 2000,2000 Feb;22:88-1039. Gazdag AR, Lane JM, Glasser D, Forester RA:Alternatives to autogenous bone graft efficacy andindication. J Am Acad Orthop Surg 1995;3:1-810. Bauer TW, Muschler GF: Bone graft materials: Anoverview of the basic science, Clin Orthop 2000Feb(371):10-2711. Passi P, Girardello G, PiatelliA, Scarano A: Syntheticbone graft in peri implant bone dehiscences: histologicalresults in humans, Gen Dent 1999 May-Jun;47(3):290-512. Haris AG, Szabo G, Ashman A, Divinyi T, SubaZ, Martonffy K: Five year 224 patient prospectivehistological study of clinical applications using asynthetic bone alloplast, Implant Dent 1998;7(4):287-9913. Oonish H, KushitaniS, Yasukawa E, Iwaki H, HenchLL, Wilson J, Tsuji E, Sugihara T: Particulate bioglasscompared with hydroxyapatite as a bone graft substitute,Clin Orthop 1997 Jan;(334):316-25.14. Dental Implants The Art and Science; Charles A Babbush,2nd Edition.2010; 79-80.576Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Treachear Collins Sy n d r o m ePratik Kumar Lahiri*, Gautam Kumar Kundu @ , Subrata Sarkar @A Case ReportAbstractTreacher Collins syndrome, also known as Treacher Collins–Franceschetti syndrome, or mandibulofacial dysostosis isa rare autosomal dominant congenital disorder characterized by craniofacial deformities. Treacher Collins syndrome isfound in about 1 in 50,000 births.. It is named after Edward Treacher Collins who described its essential traits in 1900.The cause of Treacher Collins Syndrome is a genetic mutation. TCOF1 is the only gene currently known to be associatedwith TCS, a mutation in this gene being found in 90-95% of the individuals with TCS. Mutation analysis has unveiledmore than 100 disease-causing mutations in TCOF1, which are mostly family specific mutations.Keywords: Mandibulofacial dysostosis, Treacher Collins syndrome, Franceschetti syndromeIntroductionTreacher Collins syndrome, alternatively calledmandibulofacial dysostosis (MFD), is anautosomal dominant disorder of craniofacialdevelopment. It has been mapped to the gene onchromosome 5q32-q33.1. 6 It occurs with an incidenceof 1 in 50,000 live births 4 . Early descriptions areattributed to Berry (1889) 1 , Treacher Collins (1900)(15)and Franceschetti and Klein (1949) 3 . While 40%of TCS cases have a previous family history, 60% ofcases possibly arise as a result of de novo mutations 7 .From the structures affected and from studies in miceexposed to teratogenic cis- or trans-retinoic acid, it hasbeen deduced that the disease results from interferencein the development of the first and second branchialarches 4 .Treacher Collin’s syndrome results from aretardation/failure of differentiation of the maxillarymesoderm at the 50 mm stage of intrauterinedevelopment (at about 2 months) 5 . A defect in thestapedial artery during embryogenesis may beresponsible for the anatomic defects seen. Stapedialartery dysfunction gives rise to defects of the stapesand incus and the first arch vessels supplying themaxilla. Failure of the inferior alveolar artery todevelop an ancillary vascular supply gives rise tomandibular abnormalities 11 .*Senior lecturer@ProfessorDepartment of Pedodontics & Preventive DentistryGurunanak Institute of DentalScience & Research, KolkataCorresponding author:Dr. Pratik Kumar Lahiri,Email: pratik.lahiri@gmail.comIndividuals have a convex profile with a prominentnose and retrusive chin. It is generally a bilateralanomaly with a characteristic facies, includingdownward sloping of the palpebral fissures,colobomas of the lower eyelids, mandibular andmidface hypoplasia and deformed pinnas. 10.12Improper orientation and hypoplasia of themandibular elevator muscles, resulting from anaplastic/hypoplasticzygomatic arch, may also be contributory. Mandibularretrognathia and midface vertical excess may beaccentuated by the pull of abnormally orientedmandibular elevator muscles causing a backwardrotation in the mandibular growth pattern.Great emphasis is placed on the genetic causesof Treacher Collin’s syndrome, the specific geneassociated has been identified as the ‘Treacle gene’and has been located on the long arm of (q) ofchromosome 5(5q32-33.1). 2, 8Recent animal experiments suggest a possibleteratogenic role of hypervitaminosis A in thecausation of facial defects in this syndrome.Case reportAn 8 year old boy reported to the Department ofPedodontics & Preventive Dentistry. The chiefcomplaint was difficulty in eating due to presenceof opening on the palate and malaligned teeth.The patient did not present history of any medicalproblems. He gave a history of surgical treatment ofbilateral cleft lip.Extra oral examination revealed underdevelopednose and zygomatic region, a retrognathic mandible.Decreased antero posterior lengths of neuroIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 577

A Case Reportcranium, diminished bitemporal width were noted.He had a convex profile due to a severely retrudedmandible. (Figure1A, 2A, 2B) Examination of theears revealed malformed pinnae with flabby tissueand less amount of cartilage. (Figure3A, 3B) Thepatient presented with typical anti mongoloid slantof palpebral fissures, coloboma of the eyelids.Notching of outer part of lower eyelids (colobomas)was seen and a deficiency of the lower eyelashes(medial to colobomas) was present.(Figure3)Therewere bilateral atypical tongue shaped processes ofthe hairline (hairlick) extending towards the cheek.Fig. 3 AMalformed Pinnae of EarFig. 1Frontal View of FaceFig. 2aLateral view of FaceFig. 3 BMalformed Pinnae of EarIntraoral examination revealed complete bilateralcleft of alveolus and hard palate.Inspection revealed solitary cleft of the premaxillarysegment extending in a “v” pattern, bilaterally, mesialto 53, 63. Central tissue anastomosis adjacent to thelabial vestibule and extending upto the vermillionborder of upper lip was noted. Coronal third of 11,21 were visible. Communication to the nasal cavitywas appreciated on inspection. (Figure4,5)Fig. 4 Cleft PalateFig 2bLateral view of FaceFig. 3 Coloboma of EyelidsOcclusal radiograph of maxilla showed hazyconverging radiolucencies mesial to 53, 63 regionextending posteriorly upto mid palatal regionadjacent to nasal septum. Conglomerate radiopaquemass resembling the permanent anteriors, showingectopic eruption pattern was present. (Figure 6A)Lateral cephalogram shows severe protrusion ofpremaxillary segment, steep mandibular incline andenlarged paranasal sinuses. (Figure 6B)Orthopantomogram of the patient showedradiographically absent 12, 22, displaced permanentcanines and multiple carious deciduous teeth.Suspected prominence of antigonial notch was alsonoted. (Figure 6C)578Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Fig. 5PolyductalyFIGURE 6 BLATERALCEPHALOGRAMFIGURE 6 AMAXILLARY OCCLUSALVIEW RADIOGRAPHA Case Reportthe age of 2 to 3 years or later. To promote normallanguage development, cleft palate repair as wellas evaluation by an otolaryngologist, audiologistand speech pathologist is recommended. Since thespectrum and degree of deformities related to TCSare extensive, a plan of management and timing oftreatment needs to be tailored to the patient’s specificproblems. As a rule, bone reconstruction shouldprecede soft tissue corrections. Autogenous tissues,such as calvarial (preferably vascularized) grafts,ribs and iliac bone should be used, while syntheticmaterials should be avoided. Although by 5 to 7 yearsof age the cranio-orbitozygomatic bone developmentis almost complete 16 , reconstructing before 10 yearsof age should be avoided. In order to minimize facialscarring, exposure for reconstruction of zygomaticand skeletal region is provided by a coronal (scalp)incision. Lateral canthopexies are completed duringthe same procedure. The lower face retrusion andincreased facial convexity on profile are consistentfeatures of TCS. Before facial growth is complete,chin augmentation and mandibular distraction arerecommended. Definitive orthognatic surgery isdelayed until the age of 16 to18 years. Most often themandible advancement with bilateral sagittal ramusosteotomy, maxillary segmental osteotomies or a LeFort I osteotomy to lower the posterior maxilla areperformed, while Tessier’s “integrale” procedure isreserved for severest cases 14 . The high-bridged nosecan be improved by a classical rhinoplastyFIGURE 6 CORTHOPANTOMOGRAMTreatmentFrom the time of birth, in severe cases the airway mustbe evaluated and secured. Either positioning alone ortracheostomy is required to manage the airway, anda gastrostomy for feeding. Operations of choanalatresia or mandibular lengthening are performed atColoboma of the lower eyelid is preferably correctedaccording to Tessier method (TESSIER 1976) 13 ,which consists in Z-plasty for cutaneous lengthening,overlapping sutures of the preseptal orbicularismuscle and canthopexy. The preferred method ofeyelid repair is the transposition of pedicled uppereyelid skin-muscle flaps to the lower eyelid deficientregion (Z-plasty). Simultaneously the lateral canthicorrection is performed to normalize the orbital area.Auricular reconstruction is one of the most difficultproblems. The low-set auricular remnants, hairy skinand depressed area produce the main difficulties.DiscussionAccording to a classification of craniofacial clefts,the complete form of the syndrome shows thepresence of clefts 6, 7 and 8 13 . The obligatory featuresare antimongoloid palpebral fissures, coloboma oflower eyelids, eyelash malformations, molar defects,Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 579

A Case Reportpreauricular hair displacement, micrognathia and“fishlike” facial appearance. The common featuresare macrostomia, auricular defects, high-archedpalate, nasal deformity, malocclusion, open biteand deafness. Other abnormalities, such as cleftpalate, colobomas of the upperlid, hypertelorismand mental retardation, are infrequent. In severelyaffected patients, the airway is compromised by thetemporomandibular joint mandibular deficiency,glossoptosis and choanal atresia. Sleep apnea andsudden infant death syndrome are of particularsignificance. A unilateral form of TCS does notexist. The only syndrome that TCS resembles in itsfacial aspects is Nager’s acrofacial dysostosis.The management of Treacher Collin’s syndromerequires co-ordinated efforts of a team of specialistsincluding pediatricians, surgeons, ENT specialists,speech therapists, oral surgeons and orthodontists toplan effective rehabilitation procedures. 9Due to the recent discovery of the defective gene thatcauses Treacher Collins, researchers are developingtests that will aid in more than accurate prenataldiagnosis of affected individuals. A prenatal diagnosismay be done by chorionic villus sampling at 10.5-12weeks of pregnancy/ amniocentesis between 14 and18 weeks, thus providing a chance to eliminate thegene from future generations’ altogether.References1. Berry G.A. (1889). Note On A Congenital DefectColobomata Of The Lower Lid. R. Lond. Ophthalmic.Hosp. Rep. 12: 255.2. Dixon Mj. Treacher Collins Syndrome. Hum MolecGenet 1996;1391-6.3. Francheschetti A., Klein D. (1949). The MandibulofacialDysostosis: A New Hereditary Syndrome. ActaOphthalmol. (Scand). 27: 143.4. Gorlin R.J., Cohen M.M., Levin L.S. (1990). SyndromesOf The Head And Neck. Oxford University Press. Oxford.5. Idem. The Pathogenesis Of The Treacher CollinsSyndrome (Mandibulofacial Dysostosis). Br J Oral Surg1975; 13:1.6. Jabs E.W., Li X., Coss C.A., Taylor E.W., Meyers D.A.,Weber J.L. (1991). Mapping The Treacher Collins SyndromeLocus To 5q31.3-Q33.3. Genomics. 11: 193-198.7. Jones K.L., Smith D.W., Harvey M.A., Hall B.D., QuanL. (1975). Older Paternal Age And Fresh Gene Mutation:Data On Additional Disorders. J. Pediatr. 86: 84-88.8. Neville, Damm, Allen, Bouquot. A Textbook Of OralAnd Maxillofacialpathology. 2nd Ed. Saunders; 2002. P.42-3.9. Posnick Jc. Treacher Collin’s Syndrome: PerspectivesIn Evaluation And Treatment. J Oral Maxillofac Surg1997;55:1120-33.10. Rajsekhar S, Govilla V, Mythili R. Treacher Collin’sSyndrome: A Case Report. Ida 1998; 69:224-5.11. Regezi Ja, Sciubba Jj. Oral Pathologic Correlations.W.B. Saunders Company; 1989.12. Shafer Wg, Hine Mk, Levy Bm. A Textbook Of OralPathology. 4th Ed. Philadelphia Pa: Saunders; 1997. P.681-2.13. Tessier P. (1976). Anatomical Classification Of Facial,Craniofacial And Latero-Facial Clefts. J. Maxillofac.Surg. 4: 69.14. Tessier P., Tulasne J-F. (1986). Cranial Surgery Update. In:Advances In Plastic And Reconstructive Surgery (HabalM.B., Ed.). Vol.2. Year Book Medical Publishers 30.15. Treacher Collins E.T. (1900). Cases With SymmmetricalCongenital Notches In The Outer Part Of Each LowerLid And Defective Development Of Malar Bones. TransOphthalmol. Soc. Uk. 20: 190.23216. Waitzman A.A., Posnick J.C., Armstrong D., Pron G.E.(1992). Craniofacial Skeletal Measurements Based OnComputed Tomography. Part 2: Normal Values AndGrowth Trends. Cleft Palate Craniofacial J. 29: 118-128.580Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

FIBROSARCOMA OF MAXILLA-A CASE REPORTA Case ReportPrakash Dhanavelu*, Krishna Prasanth @ , KMK Masthan # , Vijay Ebenezer ~AbstractThis paper presents a case of periosteal fibrosarcoma of maxilla in a 79 year old female patient which has typicalclinical and histopathological features. Various treatment modalities are discussed.Keywords: Sarcoma, soft tissues, local recurrenceINTRODUCTION:Soft tissue sarcomas occurring in the oral andmaxillofacial regions are rare and accountfor less than 1 percent of all head and neckmalignancies 12 . Fibro sarcoma is a malignantmesenchymal neoplasm of fibroblastic origin thatshows no other evidence of cellular differentiationand can cause local recurrence or metastasis 1 . Theetiology of Fibrosarcoma remains abstruse althoughit is thought to occur from previously irradiatedbony lesions or underlying conditions of the bonelike Paget’s disease, Fibrous dysplasia or chronicosteomyelitis.Fibrosarcoma involving the jaw bones may originatefrom medulla, periosteum or may invade from theadjacent soft tissues 9 . Fibrosarcoma involving themaxilla is very rare with an incidence of about0-6.1% of all primary fibrosarcomas of bone .Case ReportA 73-year-old female patient reported with a 9-Monthhistory of pain and swelling in the left side of theupper jaw. History from the patient reported that thepain was intermittent, dull and radiating to the leftside of the face. It got relieved on taking medication.The patient also reported that her left upper posteriorteeth were extracted due to advanced periodontaldisease. On extra-oral examination the patientwas normal. The submandibular, submental andcervical lymph nodes were not palpable. Intra orallythe patient exhibited an ulcerative, granulomatousgrowth of size 4 x 3 cm extending from the midlineof the palate to the buccal gingiva adjoining 24 to28 region (Fig.1). It exhibited erythematous mucosaand was soft, fixed and tender on palpation.Although Fibrosarcoma is reported in all age groups,it is most commonly seen between the 3rd and 6thdecades of life with no marked sex predilection 9 .It is clinically characterized by pain, swelling,parasthesia, loosening of teeth and ulceration ofthe overlying mucosa. Radiographically it remainsindistinctive of other destructive bone lesions. 2,3,6This article describes a case of Fibrosarcoma ofmaxilla and the adjacent soft tissues.Fig:2 OPGFig:1 Clinical picture*Senior Lecturer, Department of Oral & Maxillofacial surgery@Tutor, Department of Prosthodontics#Professor and Head, Department of Oral Pathology & Microbiology~Professor and Head, Department of Oral Surgery.Sree Balaji Dental College & Hospital, Pallikaranai, ChennaiCorrespondence Author :Dr Prakash DhanaveluEmail: prakash.oralsurgeon@gmail.comFig:3Histological pictureIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 581

A Case ReportThe OPG (Fig.2), PNS and Intra oral radiographsdisplayed an undefined radiolucent lesion extendingfrom the region of left maxillary lateral incisor to leftmaxillary III molar involving the inferior labial partof the left maxillary antrum ,sparing the posteriorlateralwall of antrum. Chest X-rays, Hematological& bio-chemical tests were within normal limits.An incisional biopsy was performed and histopathology(Fig.3) revealed fascicular arrangement of dysplasticspindle shaped fibroblasts and herring boneappearance 5 . There was a mild degree of nuclearpleomorphism and rare mitosis with a collagenousstoma, suggestive of a low-grade fibrosarcoma.Following the above diagnosis the patient wasadvised resection of the lesion with wide freemargins 4 , but the patient did not follow up.DISCUSSIONFibrosarcoma occurring as primary malignantbone tumor has an incidence of less than 5%. 10Fibrosarcoma may arise from the medullaryconnective tissue of the skeleton or can originate inthe soft tissues adjacent the bone, the later lesioncalled as Periosteal fibrosarcoma has a betterprognosis 9 . Fibrosarcoma arising from the normalbone is called as Primary fibrosarcoma, whereasthose originating from the pre-existing bony lesionsare called as Secondary fibrosarcoma.Histologically these tumors consist of largelyinterlacing fascicles of fibroblasts. The “Herrringbone” patterns of interlacing bundles are arrangedperpendicular to each other and is very pronouncedin certain cases. The tumor can be divided in to welland poorly differentiated types. In the present case,the tumor cells were large & spindle shaped withelongated & hyperchromatic nuclei. The cytoplasmwas scanty and it exhibited mitotic figures in largenumbers exhibiting the characteristics of Mild gradeFibrosarcoma.Differentiating fibrosarcoma of the bone from theone that occurs in soft tissues signifies a betterprognosis. The five year survival rate for soft tissuefibrosarcoma was approximately 60% 8 as againstthe fibrosarcoma occurring in bone which has afive year survival rate of 31.7%. 6 The treatmentof choice was resection with wide free margins¹’.Radiotheraphy is beneficial in inoperable cases andchemotherapy is indicated for palliative treatment.Local recurrence is very common but metastasisis rare and occurs mostly in lungs 9 or to distantbones ¹3 . Lymph node metastasis is extremely rare 9 .The prognosis however is not good but is favorablethan most other malignant neoplasm occurring inthis region. 6,7References1. Mark RJ, Sercarz JA, Tran L, Selch M, CalcaterraTC. Fibrosarcoma of the Head and Neck. The UCLAexperience. Arch Otolaryngol Head Neck Surg 1991;117:396-401.2. Lo Muzio L, Mignogna MD, Pannone G, Staibano S,Testa NF. A rare case of fibrosarcoma of the jaws in a4-year-old male. Oral Oncol 1998;34:383-63. Sadoff RS, Rubin MM. Fibrosarcoma of the mandible: acase report. J Am Dent Assoc 1990;121:247-8.4. McKenna WG, Barnes MM, Kinsella TJ, Rosenberg SA,Lack EE, Glatstein E. Combined modality treatment ofadult soft tissue sarcomas of the head and neck. Int JRadiat Oncol Biol Phys 1987;13:1127- 33.5. Antonescu CR, Erlandson RA, Huvos AG. Primaryfibrosarcoma and malignant fibrous histiocytoma ofbone – a comparitive ultrastructural study: evidence ofa spectrum of fibroblastic differentiation. UltrastructPathol 2000;24:83-91.6. Pereira CM, Jorge J Jr, Di Hipσlito O Jr, Kowalski LP,Lopes MA. Primary intraosseous fibrosarcoma of jaw.Int J Oral Maxillofac Surg 2005;34:579-81.7. Handlers JP, Abrams AM, Melrose RJ, Milder J.Fibrosarcoma of the mandible presenting as a periodontalproblem. J Oral Pathol 1985;14:351-6.8. Pritchard DJ, Sire FH, Ivins JC, Soule EH, DahlinDC(1977) Fibrosarcoma of bone and soft tissues of thetrunkand extremities. Orthop Clin North Am 8:8699. Huvos AG, Higinbotham NL (1975) Primaryfibrosarcoma of bone. A clinicopathologic study of 130patients. Cancer35:83710. Huvos AG (1979) Bone tumours. Diagnosis, treatmentandprognosis. WB Saunders, Philadelphia LondonToronto, p25011. Hoggins GS, Brady CL (1962) Fibrosarcoma of maxilla.Report of a case. Oral Surg 15 : 3412. Gorsky M, Epstein.J.B. Head and neck and intra-oralsoft tissue sarcomas. Oral Oncology 1998:34: 292-296.13. Grace M. Jeffree and C. H. G. Price, Metastatic spread offibrosarcoma of bone, a report of 49 cases and comparisonwith osteosarcoma. J of bone and joint surgery 1976:418-425.14. Jeffery.E.krygier Fibrosarcoma of the mandible:Review of a rare primary of malignancy of bone.http://sarcomahelp.org learning_center/fibrosarcoma.html582Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

Unilateral Fu s i o n o f Lateral In c i s o r w i t h Supernumerary Teeth- A c a s e reportBaishali Saha*, S.C.Chandrasekharan @ , Md.Nazish Alam # , Subbiya ~A Case ReportAbstractFusion is a developmental anomaly characterized by the union of two adjacent teeth. This paper reports a rare caseof unilateral fusion of maxillary left lateral incisor with supernumerary element which was misdiagnosed as palatogingivalgroove and surgically accessed for treatment of the same after root canal treatment, and then the fusion cameto forefront..Keywords: Fusion, Supernumerary Tooth, Palatogingival Groove, Anomaly, Germination.IntroductionWhen nature diverts from normal it givesrise to abnormal or anomalies. Dentalanomalies can affect either primaryor secondary dentition and can cause aesthetic,spacing, or periodontal problem. Among themfusion is a commonly identified anomaly. In 1963Tannenbaum and Alling defined fusion as a unionof two separate tooth buds at some stage in theirdevelopment. They have joined dentin but the pulpchambers can be joined or separated depending onthe stage when union occurs. This process involvesepithelial and mesenchymal germ layer resulting inirregular morphology 1 . Review of literature revealsgreat difficulty in correctly differentiating betweengermination and fusion. The etiology can be:(a) Excessive pressure and physical force betweento developing tooth. 2(b) Genetic predisposition and racial difference.Mostly seen in deciduous teeth and most prevalentin anterior region 3 bilateral fusion are even lessfrequent. 6 Few cases of fusion involving molarand premolar teeth have been reported. 3-5 Turelland Zmener described a case of fusion involving 2 ndand 3 rd molar 3 . Unfortunately they require surgicalremoval because of excessive width and alignmentand function problem. 6,8 Anterior region, unpleasant*Post Graduate, Department of Periodontology & Implantology@Professor & Head, Department Of Periodontology & Implantology#Senior Lecturer, Department of Periodontology &Implantology~Professor, Department Of Conservative Dentistry & EndodonticsSree Balaji Dental College & Hospital, Pallikaranai, ChennaiCorresponding Author :Dr. Baishali Saha,email: dr.baishalisaha@gmail.comaesthetic tooth shape predisposing them to caries,periodontal disease and complicated endodontictreatment. 7,10Fusion can occur between teeth of same dentitionor mixed dentition and between normal andsupernumerary teeth. 3,7-9,11,12 In these cases numberof teeth in dental arch is also normal making thedifferentiation of germination from fusion difficultor almost impossible.Case ReportA 22 year old female reported to Departmentof Endodontics, Sree Balaji Dental College andHospital with the complaint of pain in upper left fronttooth region for the last 6 months which aggravateson intake of hot and cold. Clinical examinationrevealed the presence of an irregular morphology oflateral incisor with an increased mesiodistal widthand mild caries in the palatal aspect of same teethwith pain on percussion. The remaining maxillaryand mandibular permanent teeth were normal in size,shape and no tooth was absent. The examinationrevealed the presence of deep palatogingival groovebelow the gingival margin but no pocket depth wasnoticed in association and no attachment loss.Radiographic examination showed a wider diameterof tooth throughout the length with two pulp canaland a periapical abscess in relation to tooth no. 22.Two root canals were located (mesial and distal)in tooth number 22 and treated with RCT sent toDepartment of Periodontology for the managementof palatogingival groove.Under local anaesthesia, with the help ofcrevicular and interdental incison, a full thicknessmucoperiosteal flap is elevated palatally, where itwas found out that it was actually a fusion of 22Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 583

A Case ReportCLINICAL PHOTOGRAPHS:Figure 1 : Mucoperiosteal Flap ElevationFigure 2: Incomplete Fusion of Lateral Incisor withSupernumerary TeethFigure 3:CompletedEndodonticProcedureand a supernumerary tooth and not a palatogingivalgroove. No bone loss or attachment loss is observed.The flap as sutured back with the help of interruptedsuture with 3-0 silk. Post operative instruction andmedication was given. Suture removal and postoperative revaluation was done 1 week after surgeryand satisfactory healing was noticed. (Figure 1-3)DiscussionThe differential diagnosis between germination and fusionhas always been difficult. The clinical and radiographicexamination of the lateral incisor showed a clear caseof palatogingival groove and was sent to departmentof periodontology for conventional management of thesame. So, when the site was surgically accessed, to oursurpise the tooth revealed two separate roots provingthe presence two different teeth and not a palatogingivalgroove. Since all the teeth in the arch were present, wecan confirm the presence of supernumerary tooth whichcaused the union with the lateral incisor. Definitely, teethwith this type of anomalies are un-aesthetic due to theirincreased mesiodistal width and also tend to land up inperiodontal complication due to grooves in the unionarea and at the same time plaque accumulation tendsto be very high. Furthermore, fusion in the primarydentition may have an adverse effect on occlusioncausing deviation and delayed eruption of secondarydentition. Again trauma from this type of occlusion maybe the reason for pulp necrosis, subsequent resorptionand periradicular lesion. Proper understandings of theanatomy are very important for better managementof such case and at the same time the technical skills.Locating the canals and maintenance of oral hygienewas a difficult job in such case. Nerwich et al 13 reportedthe use of calcium hydroxide as root canal dressingwhich helped in subsiding the lesion. These problemsneed cosmetic and orthodontic consideration.References1. Tannenbaum AK, Alling EE. Anomalous toothdevelopment: case reports of gemination and twinning.Oral Surg Oral Med Oral Pathol 1963;16:883-888.2. Shafer WG, Hine MK, Levy BM. A textbook of pathology.4 th ed. Philadelphia: WB Saunders Company, 1983.3. Turell IL, Zmener O. Endodontic therapy in a fusedmandibular molar. J Endo 1999;25: 208-209.4. Beltes P, Huang G. Endodontic treatment of an unusualmandibular second molar. Endod Dent Traumatol1997;13:96-98.g5. Caceda JH, Creath CJ, Thomas JP, Thornton JB.584Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

A Case ReportUnilateral fusion of primary molars with the presence ofa succedaneous supernumerary tooth: case report.PaediatDent 1994;16:53-55.6. Delany GM, Goldblatt LI. Fused teeth: a multidisciplinaryapproach to treatment. J Amer Dent Assoc 1981;103:732-734.7. Peyrano A, Zmener O. Endodontic management ofmandibular lateral incisor fused with supernumerarytooth. Endod Dent Traumatol 1995;11:196-198.8. Hülsmann M, Bahr R, Grohmann U. Hemisection andvital treatment of a fused tooth – literature review andcase report. Endod Dent Traumatol 1997;13:253-258.9. Velasco LF de, Araujo FB, Ferreira ES, Velasco LE.Esthetic and functional treatment of a fused permanenttooth: a case report. Quintessence Int 1997;28:677-680.10. Pereira AJA, Fidel RAS, Fidel SR. Maxillary lateralincisor with two root canals: fusion, gemination or densinvaginatus? Braz Dent J 2000;11:141-146.11. Camm HJ, Wood JA. Gemination, fusion andsupernumerary tooth in the primary dentition: report ofcase. J Dent Child 1989;56:60-61.12. Spatafore CM. Endodontic treatment of fused teeth. JEndod 1992;18:628-631.13. Nerwich A, Figdor D, Endo D, Messer HH. pH changes inroot dentin over a 4-week period following root canal dressingwith calcium hydroxide. J Endod 1993;19: 302-306.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 585

A Case ReportAn e u r y s m a l Bo n e Cyst o f Mandibular Co n d y l e: Re p o r t o f a A Rare CaseSaeed Nezafati*, Shirin Fattahi @ , Faranak Moradi Abbasabadi #AbstractAneurysmal bone cyst (ABC) is a rare benign lesion of bone, which is infrequent in the craniofacial skeleton. Thisrare jaw lesion usually affects the mandible but origin from the mandibular condyle is even rare. We describe acase of ABC in a 15-year-old male patient, affecting the left ramus and condyle of the mandible with expansion andthinning of the buccal and lingual cortical plates. The lesion had led to facial asymmetry. Patient had a history ofmandibular trauma which had occurred 8 month earlier. Treatment consisted of surgical curettage of the lesion.Keywords: Aneurysmal bone cyst, condyle, mandibleIntroductionAAneurysmal bone cyst is a benign neoformationwhich can affect all the skeletal bones. Morethan half of the cases occur in the metaphysisof long bones (especially femur and tibia). ABCoccurs very rarely in the jaws. The reported caseshave been located in the mandible and maxilla intwo-thirds and one-third of the cases, respectively.They represent about 1.5% of all non-odontogenicand non-epithelial cysts of the jaws. An aneurysmalbone cyst of the condyle is even more unusual. 1Aneurysmal bone cyst of the jaw is a pseudocysticlesion. It is a rapidly growing and destructive bonelesion characterized by replacement of the normalbone with fibro-osseous tissue containing bloodfilledsinusoidal or cavernous spaces. However,an unusual solid, focally hemorrhagic variant hasrecently been reported. 2Radiological features of ABC in the jaws are quiteconflicting; the bone is expanded, appears cysticresembling a honeycomb or soap bubble and iseccentrically ballooned. There may be destructionand perforation of cortex and a periostal reactionmay be evident. 4 The lesion can easily be mistakenfor an odontogenic cyst or tumor, central giant cellgranuloma, myxoma, central hemangioma of bone,giant cell lesion of hyper- parathyroidism, cherubismand even low-grade metastatic carcinoma. 5Histologically, ABC is considered a pseudocystdue to the absence of an epithelial wall. ABC is anexpanding osteolytic lesion containing blood-filledspaces of variable sizes, separated by connectivetissue, by bone trabeculae or osteoid tissue andmany osteoclastic giant cells. 3 The treatment of thislesion consists of complete surgical excision. Thelesion demonstrates a low recurrence rate. Radiationtherapy has been suggested; however, the risk ofsubsequent malignant degeneration is present. 6Case reportA 15-year-old male patient presented to private office,Tabriz, Iran, on August 21, 2011, with a compliantof sudden swelling on the left ramus, condyle and*Assistant Professor, Department of Oral and Maxillofacial Surgery@Post-graduate Student#Assistant ProfessorDepartment of Oral and Maxillofacial Pathology,Faculty of Dentistry, TabrizUniversity of Medical Sciences, Tabriz, IranCorresponding author:Dr. Faranak Moradi Abbasabadi,Email:faranakmoradi@yahoo.com.Figure 1: Preoperative image showing the swelling onthe left ramus, condyle and zygomatic arch586Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

A Case Reportzygomatic arch. On extraoral examination ,theswelling was firm and tender and facial asymmetrywas apparent. The patient had restriction ofmouth opening, but there was no malocclusion ordysesthesia [Figure 1]. He had a history of childabuse 8 month ago, leading to left condylar fracture,which had been treated by physiotherapy.Due to his history, computed tomography [CT]was ordered. The CT showed the presence of amultilocular radiolucent lesion in the left condyleand the anterior-posterior of the ramus region. Thelesion was well-circumscribed and had replacedthe bone marrow of these anatomical structures;the cortical bone was substantially expanded andperforated [Figure 2].A modified risdom incision applied in mandibularlower border and ramus. After exposing cyst wall,a complete excision of the lesion was performedfollowed by an extensive curettage and peripheralostectomy. Then bleeding controlled and cystcavity irrigated by sodium chloride and gentamycin.Finally Hemobag inserted and suture performed inthree layers [Figure 3].Histopathological examination showed numerousvariably sized blood filled spaces separated by fibrousseptae containing spindle shaped cells and scatteredmultinucleated giant cells. The final histologicaldiagnosis was aneurysmal bone cyst [Figure 4].A panoramic radiograph was taken after 1 year offallow-up, which revealed complete healing of thelesion with no evidence of recurrence.Figure2: CT scans show a well-circumscribed lesionwith expansion and perforation of cortical bone.He was scheduled for surgical excision. Theoperation was performed under general anaesthesia.Figure4: Histopathological examination showsvascular spaces separated by septa containing giantcells and fibroblasts. (H&E stain, x100).DiscussionAlthough the aneurysmal bone cyst is a lesionrelatively common in the skeletal structure, is notusual to find it in the facial region of the skeleton.Considering all types of jaw cysts the ABC isextremely rare with 0.5%. The average age ofoccurrence is 13 years and 80% of patients are lessthan 20 years old with no gender predilection. 1,7Figure3: Intraoperative view of theenucleation of the cystThe main symptoms include dull pain and/or edema.It usually exhibits rapid growth that lead to suddenswelling and facial asymetry. Depending on location,other signs/symptoms can be found, includingheadache, diplopia, loss of vision, proptosis, etc . 8Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 587

A Case ReportThe cause and pathogenesis of aneurysmal bone cystare poorly understood. Several investigators haveproposed that aneurysmal bone cyst arises from atraumatic event, vascular malformation or neoplasm,disrupting the normal osseous hemodynamics andleading to an enlarging hemorrhagic extravasation.6In the present case,there was a history of trauma 8month ago.It is important to differentiate the ABC fromother pathologies that occur in the maxillofacialregion. These include peripheral and central giantcell reparative granuloma, traumatic bone cyst,brown tumor of hyperparathyroidism, myxoma,fibrous dysplasia, desmoplastic fibroma, fibroushistiocytoma, hemangioma, osteogenic sarcoma,globulomaxillary cyst, hamangioendothelioma, andhemangiopericytoma. 2,9Surgery is the treatment of choice. Conservativetreatment with enucleation and curettage may bepreferred to mandibular resection in view of thebenign nature of the lesion. Radiation therapyshould not be used owing to the increased risk ofdeveloping radiation-induced sarcomas. 10The gold standard treatment of ABC is surgicalexcision and curettage of the cavity.The useof Radiotherapy is not recommended becauseprobability of radio-induced tumors .Recurrence is seen in 10-44% of cases, with 90%recurring within 2 years. 8In conclusion, this case presents a rare aneurysmalbone cyst of the mandibular condyle. The lesion hasbeen found in association with a history of trauma.Enucleation and curettage was the surgical choice.References[1] Motamedi MH, Navi F, Eshkeveri PS, Jafari SM, ShamsMG, Taheri M, Abbas FM, Motahhari P. Variablepresentations of aneurysmal bone cyst of the jaws: 51cases treated during a 30-year period. J Oral MaxillafaceSurg 2008;66:2098 103.[2] Perrotti V, Runini C, Fioroni M, Piattelli A. Solidaneurysmal bone cyst of the mandible. Int J PediaterOtorhinolaryngol 2004;68:133944.[3] Segall L, Cohen-Kerem R, Ngan BY, Forte V. Aneurysmalbone cyst of the head and neck in pediatric patients: a caseseries. Int J Pediater Otorhinolaryngol 2008;72:97783.[4] Rosenberg AE,Nielsen GP,Fletcher JA.In:World HealthOrganization Classification of Tumours. Pathologyand Genetics of Tumours of Soft Tissue and Bone. IARCPress: Lyon 2002.p338.[5] Mohamed EL. Deeb, Heddie O. Sedano, Daniel E. Waite.Aneurysmal bone cyst of the jaws: report of a caseassociated with fibrous dysplasia and review of theliterature. Int J Oral Surg 1980;9:301311.[6] Neville BW, Damm DD, Allen CM, Bouquot JE. Oral andMaxillofacial Pathology, 3r ed. St. Louis: Saunders;2008:547.[7] Wiatrak BJ, Myer CM 3rd, Andrews TM: Alternatives in themanagement of aneurysmal bone cysts of the mandible.Int J Pediatr Otorhinolaryngol 1995, 31:247-57.[8] Pelo S, Gasparini G, Boniello R, Moro A. Aneurysmalbone cyst located in the mandibular condyle. Head FaceMed 2009;5:8.[9] Motamedi MH: Destructive aneurysmal bone cyst of themandibular condyle: report of a case and review of theliterature.J Oral Maxillofac Surg 2002, 60:1357-61.[10] Rapidis AD, Nalliantou D, Apostolidis C, LagogiannisG. Large lytic lesion of th ascending ramus, the condyle,and the infratemporal region.J Oral Maxillofac Surg2004; 62 : 996-1001.588Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

A Case ReportFOREWARNED IS FOREARMEDR. Riaz Baig*, Mahumud Khan @AbstractWe as dental surgeons are being forced to keep in pace with recent advances in the field of dentistry in our day to daypractice. Methodological approach, starting from screening the patient until post operative follow up is mandatory.This article discuses about the importance of collecting the data and it’s retrieval at that time of need. The patient'sdata that has been recorded and treatment rendered forms the backbone of evidence based dentistry.Keywords: Recording , Data, Evidence based dentistry.IntroductionDental practice relies heavily on clinicalexperience…situations cannot be simplyanalyzed only using textbooks or researchwork 1 .Methodological approach are being discussed underthe following headsCASE SHEETPRE-OPERATIVE INVESTIGATIONS(COMPLETE BLOOD ROUTINE,RADIOLOGICINVESTIGATION)PHOTOGRAPHS,MODELSPROVISIONAL DIAGNOSISTREATMENT PLANTREATMENT DONERECORDINGSPOST OPERATIVE FOLLOW-UPIMPORTANCE OF CASE HISTORY:The first step that is taken once the patient walksinto the dental office is a question that is put forwardto the patient by the dentist, to find out the intentionof the patient's visit to the dentist. A broad groupof parameters are involved such as word selection,modulation, facial expression etc.A scheme is required to perform any kind of complextask too considering how crucial each and everytreatment is performed, properly documented withdetailed description of the health status.The data that is collected has to be as accurate andas relevant as possible.*Reader@Professor & HeadDept. of Oral and Maxillofacial SurgeryMadha Dental College and Hospital, Kundrathur, Chennai- 600069.Corresponding Author :Dr. R. Riaz BaigE-mail : riazcmfs@yahoo.comThis collected data is known as Case history, it is avery important step as it is the primary lead to thesequence, planning the treatment and predicting theprognosis.After collection of the data, it should serve itspurpose of guiding the doctor throughout every step,proceeding further until recall appointments, andnot to be ignored as a piece of paper or an archivefile that might never be dusted again.Another key component of the case history is a consentform which should serve its purpose of keenly jottingthe acceptance of the treatment and its outcomeby the patient in full consciousness. 3 It should alsopossess the advantage of serving as a legal document.Hence it should be on paper and be also supportedwith the patient's signature and one other signature ofthe accompanying person (the witness). 4SUPPLEMENTARY DATA:(Photographs and Models)"A picture is equivalent to million words" is not justan old saying but a practical fact that can help toeliminate all of subjective opinions and comments,For Example: A patient who was recently treated formalocclusion can turn up within a few days sayingthat he/she is not very happy with the new profileand it’s unpleasant after the treatment. 5At times like these Photographs and models not onlyhelp you to educate the patient to understand betterand also helps to protect yourself from avoidableallegations.Apart from the above mentioned advantages, themaintenance of a fully descriptive file containingphotographs and models also help in situations offorensic identifications.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 589

A Case ReportTeeth are one of the very few components thatwithstand high temperature and environmentalvariations that can be used for forensic odontologicpurposes, apart from identification it can also aidin various other purposes such as DNA isolationhence to match them it is required by the dentist tomaintain a through file of the data that support thematch of the present models and photographs withthe other remains. 6INVESTIGATIONS:A through investigatory report has to be providedbefore initiating any treatment procedure tounderstand the better outcome of the treatment andto decide or modify the treatment modality, all thevalues have to be webbed to form a clearer picture,and the investigations that are done should bepertaining to the course of the case history.Minimum required tests are to be prescribed. Oneshould not be hesitant, in obtaining consultationwith other specialties of medicine and dentistry. 7PROVISIONAL DIAGNOSIS:A perfect & accurate diagnosis is more importantthan an aesthetic treatment, after collection of all thenecessary information regarding the case, it is veryimportant for us to keep a through track. 8TREATMENT PLAN :The procedure to be carried, even if less than a 30minute time period, should be given the similar kindof attention and fine details that a major neurosurgeryor craniofacial surgery, in terms of documentations,all the details should be as accurately recorded,and it should bear the badge of being brief anddescriptive.The treatment plan, outcome should be discussedin detail with the patient this helps to build up thepatient doctor rapport and also educates the patientto understand the treatment outcome.Treatment DoneAfter and during the treatment procedure it is best torecord every precise detail of the procedure as thishelps in the followings aspects1. Helps the operator to self assess2. Can be used as a legal documentation3. Can be used for making a detailed report fordocumentation processes such as publicationsin journals and so on.This process can not only gift us the gift of immunityagainst medico legal controversies but also be helpfulin the process of educating the next generation.ADVANTAGES OF RECORDING :1. Provides a platform where an intra communitycomparisons and discussions can be held2. Can be helpful in discovering newer optionsthat can be applied for the same situationand modifying the existing ones. 9POSTOPERATIVE FOLLOW UP:After every treatment there has to be a routine periodicfollow up, this should not become mechanical in duecourse of time. But should be given immense prioritybecause any complication that is diagnosed at theearliest, is easier to be looked upon and corrected.CONCLUSION:In the current era the whole globe is in the verge ofevolving into newer and better alternatives every otherday, science is never constant; "change is only theunchangeable" is the only constant rule of science."DENTISTRY" is no exception, treatments thatwere the best option a decade ago are obsolete now,so we have to update ourselves with newer emergingand yet not be pretentious on believing that today'stechnology is the best because "newer does notalways translate into better".The only solution is practicing "EVIDENCEBASED DENTISTRY", as this serves as a shieldagainst Medico Legal complications and alsomakes us a more knowledgably confident medicalprofessional. 10At the end of the day it's all about satisfaction ,whichis guaranteed if this practice is followed in everyday practice, in spite of economic and manpowerconstraints.References1. Miller RA: Why the standard view is standard - people,not machines,understand patients problems. Journal ofMedicine and Philosophy 1990,15(6):581-591.2. Dawes M, Summerskill W, Glasziou P, Cartabellotta A,Martin J, Hopayian K,Porzsolt F, Burls A, Osborne J:Sicily statement on evidence-based practice. BMC MedEduc 2005, 5(1):1.590Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

A Case Report3. Flores-Mateo G, Argimon JM: Evidence based practicein postgraduate healthcare education: A systematicreview. BMC Health Serv Res 2007, 7:119.4. Shaneyfelt T, Baum KD, Bell D, Feldstein D, HoustonTK, Kaatz S, Whelan C,Green M: Instruments forevaluating education in evidence-based practice - Asystematic review. JAMA 2006, 296(9):1116-1127.5. Ilic D: Teaching Evidence-based Practice: Perspectivesfrom the Undergraduate and Post-graduate Viewpoint.Annals Academy of Medicine Singapore 2009, 38(6):559-563.6. Greenhalgh T: How to read a paper: the basics ofevidence-based medicine. 3edition. Malden, Mass.: BMJBooks/Blackwell Pub; 2006.7. Freeth D, Hammick M, Koppel I, Reeves S, Barr H:A critical review of evaluations of interprofessionaleducation. London: LTSN HS & P; 2002.8. Kirkpatrick D: Evaluation of Training. In Training andDevelopment Handbook. Edited by: Craig RL, BittelLR. Development. ASfTa. New York,: McGraw-Hill;1967:, xii, 650 p..9. Straus SE, Green ML, Bell DS, Badgett R, DavisD, Gerrity M, Ortiz E, Shaneyfelt TM, Whelan C,Mangrulkar R: Evaluatin the teaching of evidencebased medicine: conceptual framework. BMJ 2004,329(7473):1029-1032.10. Drescher U, Warren F, Norton K: Towards evidencebasedpractice in medical training: making evaluationsmore meaningful. Med Educ 2004, 545Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 591

A Case ReportTo o t h Sp l i n t i n g u s i n g Fiber Reinforced Co m p o s i t e & Metal -A c o m p a r i s o nP. Preethe Paddmanabhan*, S.C. Chandrasekaran @ , V. Ramya # , Manisundar #AbstractMobility of the teeth is one of the most common compliant in patients with periodontitis. Splinting is the methodof stabilization of these mobile teeth in mild to moderate condition. Tooth splinting has been accomplished sinceancient civilization to decrease tooth mobility. Both fiber reinforced splinting and metal wire splinting has its ownadvantages and disadvantages. The various procedures in splinting technique indicate that this problem has receivedmuch attention.Keywords: Tooth stabilization, Fiber reinforced splinting, metal ligature wire splintingIntroductionSplinting is the most common techniquepracticed in dentistry. Patients with severeand chronic periodontitis development oftooth mobility will affect the prognosis of thepatient. Mobility may be caused by inflammationof periodontium, loss of periodontal attachmentor functional or parafunctional forces on teeth 2 .Splinting therapy may be applied with bondedexternal appliances, intra coronal appliances, orindirect cast restorations to connect multiple teeth,with a goal of improving tooth stability. Accordingto Glossary of Periodontic terms 1986 defined as“An appliance designed to stabilize mobile teeth”.“Any apparatus, appliance or device employedto prevent motion or displacement of fractured ormovable parts in order to distribute occlusal forcesevenly”-AAP(1996).Aims of Splinting1. Rest is created on the supporting tissues, permittingrepair of trauma.2. Mobility is reduced immediately & it is hopedpermanently Hirschfled L;1950.3. Force received by any one tooth is distributed to numberof teeth.4. Proximal contacts are stabilized, & food impaction isprevented.5. Migration of teeth is prevented.*Senior lecturer@Professor and Head#Senior lecturerDepartment of Periodontics,Sree Balaji Dental College & HospitalAddress for correspondence :Dr.Preethe Paddmanabhan,drpreethimds@gmail.com6. Masticatory function is improved.7. Discomfort & pain is eliminatedIndications1. Mobility of teeth that is increasing.2. Mobility of teeth that impairs patient comfort.3. Migration of teeth.4. Prosthetics where multiple abutments are necessary.According to Tarnow & Fletcher described theindication and contraindications for splintingperiodontally involved teeth. 3 According to themthe rationale of splinting teeth include the severityof periodontal disease as determined by the amountof radiographic bone loss and /or measured toothmobility. Literature indicates that the reasonsfor tooth mobility with periodontal splinting are1. Primary occlusal trauma, 2. Secondary occlusaltrauma and 3. Progressive tooth mobility migration,pain on function. 3 Earlier it was assumed thatsplinting was done to control tooth mobility, Gingivalinflammation, periodontal pocket formation,because increase in the tooth mobility was a directconsequences of traumatic occlusion, bruxisimand clenching. It was suggested that even normalfunctions like mastication and swallowing wouldcontribute tooth mobility. 4 It was suggested thatwhen teeth were subjected to occlusal overloadingand other variables that contribute periodontaldisease were well controlled, gingival inflammation,periodontal pocket formation did not occur. 5Wally Kegel et al performed a study in which patientswith chronic destructive periodontitis patients were takenwho had mobility in their teeth. Initial therapy, consistingof oral hygiene instruction, root curettage and occlusaladjustment, was performed over a 2-week period. At592Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

A Case Reportflexural strength and no requirement for mechanicalretention on supporting teeth when compared to theconventional metallic-structured fixed prosthesis. 14This feature led to investigations concerning preimpregnatedand non pre-impregnated fibers usedin conjunction with adhesive materials. Freilichet al. (2000) concluded that pre-impregnatedsystems are well indicated for direct applications,i.e., splinting or direct adhesive bridges. In theseclinical applications, mechanical and physicalproperties of composite materials are stronglyinfluenced by the structure and properties of thefiber-matrix interface, and differences between theelastic properties of the matrix and the fibers maymodify the force transmission through the interface.The pre-impregnated reinforcement fibers createa substructure that has been shown to support 2-3times more load and to have a flexural modulus thatis 10 times higher than that of the hand-impregnateddesigns. 15,16,17,18 Investigations done by K AEbeleseder et al in 1996 done a study in 103 posttraumatic splints, and tooth mobility was measuredusing periotest immediately before and after splintremoval. The splints were made of composite resinand an 0.017 X 0.025" orthodontic steel wire. 481teeth were measured. A statistic evaluation revealedthat the immobilization effect did not exceed normaltooth firmness. Fixation to one neighboring toothhad less effect than fixation to two. Adjacent toothgaps reduced the effect. The result was splintextensions had no influence. With the use of thePeriotest device, more than 50% of all teeth witha true mobility of 20 Periotest-units or more weredetectable as mobile in spite of the fixed splint. 19The following case reports describes the comparisonof both fiber reinforced composite resin splintingand Stainless steel wire splinting placed to stabilize aseverely periodontally compromised dentition. Thiscase reports demonstrate that using the treatmenttechniques described when treatment planningsimilar clinical situations can lead to improvedprognosis.Case report 1: Fiber reinforced composite splintingFemale patient aged 23 years has reported to theDepartment of Periodontics, complaining of grade Imobility in 32, 33 42, 43, grade II gingival recessionin relation to 43. On examination of medical history,no relevant history was noticed. On evaluation ofdental history shows that she had a prior visit todentist and got her 31, 41 extracted 2 months beforedue to mobility. Radiographic examination wastaken reveals horizontal bone loss in middle thirdof the root in relation to lower anteriors (Fig 1).Consent of the patient was taken before schedulingthe treatment plan. Complete history was taken,since the main focus was based on splinting themobile teeth, initial therapy was based scaling androot planning and was done in relation to 42 and 43due to presence of sub gingival calculus and gingivalinflammation (Fig 2). Patient is asked to report after4 weeks after scaling and root planning.PROCEDUREBased on prognosis of the teeth, a fiber reinforcedcomposite splinting was planned for the patient.The area to be splinted is etched for 60 seconds(Fig 3). Then remove the acid by spraying it for30 seconds and carefully blow the operated sitedry. Then the bonding agent is applied over theteeth and cured. The length of the fiber splintmaterial is assessed and the fiber splint is cutto the required size (Fig 4). The fiber splint ispositioned in the tooth surface. Place the stripon the tooth surface and composite placed overit and curing is done in separately in individualtooth. The strip is placed on the next adjacentteeth and the procedure is repeated until the teethto be splinted is completed (Fig 5). Patient isgiven oral hygiene instruction and asked to reportafter every 4 weeks and splint was removed after4 months. The mobility was reduced and theocclusion was functional.Case report 2: Stainless steel metal wire splintingMale patient aged 25 years male had reported to theDepartment of Periodontics complaining of mobilityin the lower anterior teeth region (Fig 6). Onexamination of medical history reveals no relevanthistory was noticed .On examination of dentalhistory reveals that this is the first visit to dentist.Radiographic evidence showed that there was auniform horizontal bone loss (Fig 10). Completehistory was taken. Grade III gingival recession wasobserved in 31 and Grade II gingival recession wasobserved in 32. Grade I mobility was noticed in 31and 41 region. Through scaling and root planningwas done (Fig 7). Patient was asked to report after 4weeks for review. Stainless steel wire splinting wasplanned for the patient to control mobility.594Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

A Case ReportPROCEDURESplinting was planned in relation to 31-33 & 41-43. The acid etching is done using phosphoric acid(etchant) on the tooth surface. Ligature wire is usedto splint the anterior teeth. Bonding agent is appliedon the teeth to be splinted, composite resins areplaced on the adjoining teeth and they are reinforcedwith the metal wire (Fig 8,9).DISCUSSIONSplinting if well placed and maintained underpatients compliance, and on removal helps toreduce mobility and gives stability. The advantageof stainless steel metal wire bonded with compositesplinting is it quick and easy to adapt and removal ofthe splint is easy, good vertical flexibility & controlstooth mobility. The advantage of fiber reinforcedcomposite splinting is that aesthetically pleasing,low level of fracture frequency. More superior thanany other type of splintingCASE REPORT 1 : FIBER REINFORCEDCOMPOSITE SPLINTINGFigure 3 : Facial preparation of 42 43 44 regionFigure 4 : Fiber is cut to the desired sizeFigure 1 : RadiographFigure 5 : Fiber reinforced composite splint is placedFigure 2 : Pre operative photographbefore Sub gingival scaling and rootplanningwas done (The arrow indicating calculus &gingival inflammation present subgingival areas)Figure 6 : Pre –Operative PhotographIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 595

A Case ReportFigure 10 : RadiographFigure 7 : Scaling & Root Planning doneFigure 8 : Composite splinting reinforced with Metal wireFigure 9 : Post operative PhotographReferences1. RenggliHH, SchweizerH Splinting of teeth withremovable bridges. Biological effects.JClin Periodontol1974;1:43–462. Serio FG. Clinical rationale for tooth stabilization andsplinting. Dent Clin North Am.1999;43:1-6.3. Tarnow DP, Fletcher P. Splinting of periodontallyinvolved teeth: indications and contraindications. NYState Dent J. 1986;52:24-25.4. Waerhaug J. Justification for splinting in periodontaltherapy. J Prosthet Dent. 1969;22:201-208.5. Bhaskar SN, Orban B. Experimental occlusal trauma. JPeriodontol. 1955;26:270–2846. Kegel W, Selipsky H, Phillips C. The effect of splintingon tooth mobility. I. During initial therapy. J ClinPeriodontol. 1979;6:45-58.7. McGuire MK, Nunn ME. Prognosis versus actual outcome.II.The Effectiveness of clinical parameters in developingaccurate prognosis. J Periodontol.1996;67:658-665 .8. Bernal G,Carvajal JC, Munoz-Viveros CA.A review inclinical management of mobile teeth. J Contemp DentPract 2002;3:10-12.9. Liatukas EL. An amalgam and composite resin splint forposterior teeth. J Prosthet Dent. 1973;30:173-175.10. Fusayama T. Permanent Splint of highly mobile teeth. JProsthet Dent.1973;30:53-55.11. Pollack LP.Non crown and bridge stabilization ofseverely mobile,periodontally involved teeth. A 25 –YearPerspective Dent Clin North Am.1999;43:77-103.12. Miller TE.A new material for Periodontal splinting andorthodontic retension. Compendium.1993;14:800-812.13. Vallittu PK, Narva K. Impact strength of a modifiedcontinuous glass fiber polymethyl methacrylate. Int JProsthodont. 1997;10(2):142-814. Feinman RA, Smidt A. A combination porcelain/fiber-reinforced composite bridge: a case report. PractPeriodontics Aesthet Dent. 1997;9(8):925-9.596Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012

A Case Report15. Freilich MA, Karmaker AC, Burstone CJ, GoldbergAJ. Development and clinical applications of a lightpolymerizedfiber-reinforced composite. J Prosthet Dent.1998 Sep;80(3):311-816. Goldberg AJ, Burstone CJ. Flexural properties and fiberarchitecture of commercial fiber reinforced composites.J Dent Res. 1998;77:226.17. Freilich MA, Ducan JP, Meirs JC, Goldberg AJ.Preimpregnated, fiber-reinforced prosthesis. Part I.Basic rationale and complete-coverage and intracoronalfixed partial denture designs. Quintessence Int.1998;29(11):689-96.18. Meiers JC, Freilich MA. Conservative anterior toothreplacement using fiber-reinforced composite. OperDent. 2000;25(3):239-43.19. K A Ebeleseder, K Glockner, C Pertl, P Städtler:Splints made of wire and composite: an investigationof lateral tooth mobility in vivo. Endodontics & dentaltraumatology 01/1996; 11(6):288-93.Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 597

Short CommunicationAN UPDATE ON GENE THERAPY – A SHORT OVERVIEWGayathiri.K * , Sudha Manikkam * , Priyadharsini.C * , Masthan.K.M.K @Gene therapy is the use of DNA as apharmaceutical agent to treat diseases. Thediseased cell genome can be repaired orreplaced by gene therapy retaining the normal cellstructure and function. Knowledge on geneticmalfunction, therapeutic agent, duration of actionand side effects of the therapeutic agent determinesthe success of gene therapy. Germ cells or somaticcells are targeted. Approaches like suicidal genetherapy, immuno gene therapy also are emerging.Gene transfer can be done in ex vivo or in vivo. 1 Adrug delivery vehicles is a prime need for it.Vectors are the vehicles used by scientists to get theirsequences expressed in the proper host. There are amyriad of viral vectors and non-viral vectors. Adenovirus and retro virus are commonly used viral vectors.Non-viral vectors, also called physical mechanismsof gene transfer, can be traced back to 1944. It wasnot until the advent of cationic liposomes in 1988that non-viral vectors become efficient means totransfer genes into cells. Exosomes is one suchnon-viral vector developing in recent years. Theyare biological membrane vesicles measuring 30-100nm. These are secreted by most biological cells andare involved in plethora of physiological functionslike transport of genetic materials, modulationof immune system, communication betweenneighboring and distant recipient cells. Exosomeshave virus like transfection efficiency and inherentbiological function. 2 They have shown promisingresults in treating melanoma.Modified Vectors with desired gene can beadministered through intravenous route, intratumoural route, intra peritonial route, and more.Enhancing the immunogenic potential of cancer cellis an important criterion in gene therapy. Researchconducted using Murine Interleukin -12 haveshown striking anti-tumour effects. Adenoviralp53 were tried as adjuvant in intra-tumoural routefor treating squamous cell carcinoma. This targetsp53 gene which plays a key role in regulating cellcycle and have shown favorable results. 3 SucidialGene Therapy involves introduction of gene into acell which stimulates cytotoxicity and cell death. InOSCC HSV-TK were targeted. Anti-Sense RNAgene are remedial genes that prevent defectivegene expression. In OSCC the target area are ras,myc and thus tumour growth can be controlled.Gene Therapy thus is an upcoming field that mayrevolutionize cancer treatment.References:1. Biju mammen, Ramakrishnan.T .Principles of genetherapy. Indian Journal of dental research 18(4), 2007;pg 196-200.2. Aaron Tan, Jayakumar Rajadas.Exosomes as nanotheranosticdelivery platforms for gene therapy. AdvancedDrug Delivery reviews, vol 65, issue 3,March 2013 .pg357-367.3. Saraswathi.T.R..Kavitha.B, Gene therapy for oralSquamous cell carcinoma- An overview. Indian Journalof dental research 18(3), 2007; pg 120-3.*Post Graduate Student@Professor & HeadDepartment of Oral Pathology & Microbiology,Sree Balaji Dental College & Hospital,Bharath University, Pallikaranai, Chennai.Corresponding author:Dr. Gayathiri.KEmail id: gayathri.krishnasamy@gmail.comIndian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 4, August-October 2012 598