JofIMAB-2016-vol22-issue3

e-ISSN: 1312-773X 

Journal of IMAB 

- Annual Proceeding 

(Scientific Papers) 

2016 

vol. 22, issue 3 

(July - September) 

ISSN: 1312 773X 

J of IMAB. 2016 Jul-Sep;22(3): 

DOI: 10.5272/jimab.2016223 

http://www.journal-imab-bg.org 

Publisher: 

“Peytchinski, Gospodin Iliev” ET 

Pleven, Bulgaria 

/ J of IMAB. 2016, vol. 22, issue 3/ http://www.journal-imab-bg.org 1187

Journal of IMAB - Annual Proceeding (Scientific Papers) 

Editorial Board 

Editor-in-chief: 

Prof. Dr. Krassimir Metodiev 

Deputy Editor-in-chief: 

Assoc. prof. Dr. George Kyuchukov 

Editors: 

Prof. Dr. Angelina Kisselova-Yaneva (Responsible for part Oral&Dental Medicine) 

Assoc. prof. Dr. Liana Gercheva (Responsible for part Medicine) 

Associate Editors: 

Prof. Dr. Bogdan Petrunov, 

Prof. Dr. Bojidar Popov, 

Dora Peychinska, 

Assoc. prof. Dr. Lyubomir Tzvetanov, 

Paula Lazarova, 

Prof. Dr. Pencho Kossev; 

International Members: 

Prof. Dr. Kurt G. Naber - Germany; 

Prof. Dr. Mario Di Gioacchino - Italy; 

Prof. Dr. Pio Conty - Italy; 

Prof. Dr. Dieter Falkenhagen - Austria; 

Prof. Dr. Ian Gould - UK; 

Prof. Dr. Bulent Berkarda - Turkey; 

Prof. Dr. Roman Kozlov - Russia; 

Prof. Dr. Dan Engelhard - Israel; 

Prof. Dr. Raphael Saginur - Canada; 

Part Medicine: 

Prof. Dr. Anelia Klissarova 

Prof. Dr. Ara Kaprelian 

Prof. Dr. Dimitar K. Gospodinov 

Prof. Dr. Ekaterina Titianova 

Assoc. prof. Dr. Galya Gancheva 

Prof. Dr. Iskren Kotzev 

Assoc. prof. Dr. Ivelina Yordanova 

Assoc. prof. Dr. Mariana Arnaudova 

Assoc. prof. Dr. Maya Danovska 

Prof. Dr. Snejina Vassileva 

Prof. Dr. Snezhanka T. Tisheva 

Prof. Dr. Valentin Stoyanov 

Prof. Dr. Zaharyi Krastev; 

Dr. Katarina Wassilew - Germany 

Prof. Dr. Goce Spasovski - Macedonia 

Prof. Dr. Sonja Genadieva-Stavric - 

Macedonia 

Part Oral&Dental Medicine: 

Assoc. prof. Dr. Ani Beltcheva, 

Assoc. prof. Dr. Assya Krasteva, 

Assoc. prof. Donka Kirova, 

Prof. Dr. Elka Popova, 

Prof. Dr. Hristina Lalabonova, 

Prof. Dr. Hristina Mihailova, 

Assoc. prof. Dr. Ilyana Stoeva, 

Assoc. prof. Dr. Maria Dencheva, 

Assoc. prof. Dr. Mariana Dimova, 

Assoc. prof. Dr. Metodi Abadjiev, 

Prof. Dr. Milena Peneva, 

Assoc. prof. Dr. Vladimir Panov, 

Prof. Dr. Alexandru Petre - Romania 

Dr. Bogdan Calenic - Romania 

Prof. Dr. Slave Naumovski - Macedonia, 

Executive Director: 

Gospodin Peytchinski 

Editor-in-chief: 

Prof. Dr. Krassimir Metodiev 

Headquarters of International Medical Association 

Bulgaria (IMAB); 55, M. Drinov str., 9002 Varna, 

Bulgaria, 

Tel./Fax: +359/52/634 107, 379 777; 

Mobile: +359/888 712 407 

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kr.metod@gmail.com; 

Deputy Editor-in-chief: 

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E-mail: kyuchger@abv.bg; 

Address for correspondence: 

Journal of IMAB - 2016 July-September;22(3) 

ISSN: 1312-773X; DOI: http://dx.doi.org/10.5272/jimab.2016223 

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the Journal of IMAB: 

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1188 http://www.journal-imab-bg.org / J of IMAB. 2016, vol. 22, issue 3/


ISSN: 1312-773X 


1. Magnetic Resonance Imaging units (MRI) 

The first Magnetic Resonance Imaging unit in Bulgaria 

was delivered back in 1966 – MRI spectrometer (JEOL 

– Japan 60 MHz) [4]. As seen from the graph, Japan is leading 

in terms of quantitative indicators with 45.94 MRI units 

per 1 million people, the difference with the other countries 

being significant. (Fig.1.) Japan also leads in early diagnohttp://dx.doi.org/10.5272/jimab.2016223.1189 

Journal of IMAB - Annual Proceeding (Scientific Papers) 2016, vol. 22, issue 3 

COMPARATIVE ANALYSIS OF MEDICAL 

EQUIPMENT USED IN DIAGNOSTIC IMAGING IN 

BULGARIA AND COUNTRIES WORLDWIDE AND 

OPTIMIZATION AIMED AT IMPROVING THE 

HEALTH CARE SYSTEM MANAGEMENT. 

Svetoslav Garov 1 , Tsvetelina Mihaylova 1 , Galina Makedonska 2 

1) Department of Health Policy and Management, Faculty of Public Health, MU 

- Sofia, Bulgaria 

2) NCRRP (National Center of Radiobiology and Radiation Protection), Ministry 

of Health, Bulgaria. 

ABSTRACT 

Purpose: to reveal the current condition of medical 

equipment in Bulgaria related to those major groups of socially 

significant diseases and to make an attempt to define 

guidelines for its optimization in view of improving the functioning 

and management of the healthcare system in this 

field. 

Material and methods: The following research methods 

have been applied: 

1. Document review method – research, processing 

and analysis of medical statistical information taken from 

data from WHO and annual reports of NRA. The study includes 

data from 2009 - 2015. 

2. Graphical method – summarizing data in relevant 

tables and diagram presentations. 

Results: The article analyzes the condition of medical 

equipment in the field of oncologic and cardiologic 

medical aid in Bulgaria based on data taken from WHO 

(World Health Organization) and annual reports of NRA (Nuclear 

Regulatory Agency). Six types of diagnostic imaging 

and radiation therapy devices have been studied: Magnetic 

Resonance Imaging units (MRI); Computed Tomography 

Scanners (CT), Positron Emission Tomography Scanners, 

Mammographs, Linear accelerators and Telecobalt units (Cobalt-60). 

The condition of medical equipment since 2009 

has been analyzed, results have been reported and trends – 

studied. 

Conclusion: The oncologic and cardiologic medical 

equipment in Bulgaria has been gradually improving in the 

last seven years, but quantitative indicators regarding the 

devices studied are still far away from the figures recommended 

by WHO with one single exception, i.e. Computed 

Tomography Scanners 

Key words: Oncologic medical aid, cardiologic medical 

aid, Magnetic Resonance Imaging units (MRI), Computed 

Tomography Scanners (CT), Positron Emission Tomography 

Scanners, Mammographs, Linear accelerators, 

Telecobalt units (Cobalt-60), 

INTRODUCTION 

The greatest challenge that medicine and healthcare 

face in XXI century is the increasing costs for socially significant 

diseases. The most specific feature of those diseases 

is their large scale distribution. They are the result of a 

number of reasons, endogenic andexogenic forces acting 

throughout one’s life. Those diseases mostly affect middleaged 

people, which threatens the social and economic welfare 

of individuals, their families and on a more general level 

– the welfare of the entire population of a country. A positive 

affect regarding those groups of diseases can be achieved 

through: limiting major risk factors and taking advantage 

of the advance in medical science and practice [1]. 

RESULTS AND DISCUSSION: 

The analysis includes data taken from 58 countries 

regarding 6 types of medical devices: Magnetic Resonance 

Imaging units (MRI); Computed Tomography Scanners 

(CT), Positron Emission Tomography Scanners, 

Mammographs, Linear accelerators and Telecobalt units (Cobalt-60). 

The source of information is WHO (World Health 

Organization) and part of the data for Bulgaria is provided 

by NCRRP (National Center of Radiobiology and Radiation 

Protection) and taken from annual reports of NRA [2, 3]. 

Countries from five continents take part in the research as 

follows: Europe – 25 countries; Asia - 13 countries; North 

and South America – 10 countries; Africa- 10 countries. The 

costs of medical equipment are related to 1 million inhabitants 

with the purpose of possible comparison and therefore 

most of them are not whole numbers. The research presents 

data from 2009 and in the graphs Bulgaria is marked in red 

so that it could be quickly and easily seen. Finally, average 

values are presented in tables and graphs for the six types 

of devices. 


sis and effective treatment of oncology diseases. Despite using 

cutting edge technologies, treatment in Japan is less expensive 

than, for example, Germany or Greece. Latest trends 

in Japanese medicine, serving as standard for other countries, 

are as follows: minimal invasiveness, efficiency and individual 

approach to patients. An evidence of the highly efficient 

Japanese healthcare system is their record-breaking 

life expectancy, directly related to the promotion of healthy 

lifestyle, use of cutting edge technical and scientific achievements 

and the availability of competent medical experts. In 

2015 Japan manufactured and commissioned the most powerful 

so far MRI unit with operating frequency of 1020 MHz. 

Before that the most powerful and ensuring the most precise 

diagnostics device was in Germany, with a frequency 

of 1000 MHz and functioning since 2009. Second among 

the countries studied is Belgium, having 24.89 MRI units 

per 1 million people, followed by Iceland with 21.69 MRI 

units per 1 million people, etc. Bulgaria in 2009 had 4.02 

devices per 1 million people. This means that Bulgaria, with 

its population of 7.25 million, had in 2009 30 MRI units 

registered and functioning according to data. The majority 

of them are not brand new, but second hand. The main reason 

is the high price of brand new equipment and that is 

why second hand devices are most often purchased in a relatively 

good condition at prices about 800 000 - 1 000 000 

BGN. Other reasons include high cost of maintenance, high 

operating costs and low return on investment. Profitability 

is ensured by a patient flow depending on the regulatory 

standards set by NHIF (National Health Insurance Fund) and 

on the patients’ solvency. NHIF covers 180 BGN, and the 

rest is paid by patients. Financial estimates show that at such 

prices it takes 140-145 patients per month so that such kind 

of apparatus can be profitable for the medical institution. 

The average price of an MRI in Bulgaria in 2015 was 550 

BGN with contrast agents and 350 BGN w/o contrast agents. 

Fig. 1. MRI units worldwide 

in 2009 


After 1998 the world of oncologic surgery welcomed a 

technical revolution thanks to robot-assisted surgery and proton 

therapy. Gamma knife was also introduced in 1998 to 

perform safe and minimal invasive operations through 

gamma ray radiation and with no cuts and bleeding. The device 

operates with the expensive radioactive cobalt and is 

mainly used in cases of malignant tumors in the head [5, 6, 7]. 

Cybeknife is a newer generation of equipment and is a 

robot-assisted radiosurgery set. It combines a radiation device 

attached to a mobile arm of a super precise robot and a 

special navigation system. The first European Cyberknife was 

made in Germany. Cyberknife operations are used in much 

more types and locations of malignant tumors and the apparatus 

also successfully treats some kinds of metastasis. The 

average duration of a Cyberknife surgery is approximately 1 

hour. Cyberknife is famous for its absolute precision and the 

therapy itself spares healthy tissues to the maximum possible 

extent [8, 9, 10]. 

Even newer generation of equipment used for nonoperative 

treatment of cancer is the so called Trilogy linear 

accelerator (Trilogy linac). The apparatus was introduced 

by a hi-tech American company and, in contrast to the two 

devices described above, operates directly through the electricity 

network so the cost of surgery is many times lower and 

the treatment become much less expensive [11, 12]. 

In Bulgaria, before 2016, Cyberknives were commissioned 

for radiosurgery and radiation treatment in Sv. Ivan 

Rilski Hospital in Sofia, Tokuda Hospital in Sofia and Sv. 

Georgi University Hospital in Plovdiv. 

2. Computed Tomography Scanners (CT) 

Bulgaria has a quite high number of CT devices – 

27.19 per 1 million people. (Fig. 2) Such figures are close 

to the ones reported for well-developed countries such as 

Austria, Portugal, etc. Japan is the world leader, having 

101.75 devices per 1 million people. The total number of 

CT sets functioning in Bulgaria in 2009 amounted to 198. 

According to their type they are single-slice and multi-slice. 

The latter can be subdivided further into 2-slice, 4-slice, 16- 

slice and 64-slice. In Bulgaria the majority of CT devices 

are manufactured by Siemens. Tests are usually made in four 

areas: head, chest, abdomen and pelvis [13, 14]. Their 

number has been gradually increasing: 235 in 2010; 237 in 

2011; 241 in 2012; 266 in 2013 and 287 in 2014. 

Fig. 2. Computed Tomography Scanners worldwide 

in 2009. 


3. Positron Emission Tomography Scanners (PET scanners) 

Positron Emission Tomography Scanners (or positron 

emission tomography) are diagnostic imaging devices that 

display biochemical and physiological changes and diagnose 

a disease at a very early stage before any morphological 

changes have occurred. This makes them different from 

MRI and CT devices that register structural anatomical 

changes that have already appeared in organs [15, 16]. In 

addition, they are used to monitor the effects of antitumor 

therapy. A disadvantage is their high price when compared 

to other diagnostic imaging tests: 2800 BGN, now entirely 

covered by NHIF, registration being subject to approval by 

a special medical committee. The first PET scanner was introduced 

in Bulgaria in 2009 at Sv. Marina University Hospital 

in Varna. Gradually their number increased and by 2016 

there were 3 hospitals operating PET scanners: Sv. Marina 

University Hospital in Varna, Sv. Georgi University Hospital 

in Plovdiv and Aleksandrovska University Hospital in 

Sofia. 

As seen from the graph the countries covered by the 

study that have the greatest number of PET scanners per 

capita are Belgium – 26.76 devices per 1 million people, 

Denmark – 6.03, Japan – 4.34, etc. (Fig.3.) 

To operate, PET scanners need a specific radioactive 

isotope consumable called radionuclide fluorine-18. In 2016 

Bulgaria had 2 cyclotron sets for their manufacturing: in Sv. 

Marina University Hospital in Varna and Aleksandrovska 

University Hospital in Sofia. A third set is to be constructed 

in INRNE (Institute for Nuclear Research and Nuclear Energy) 

at BAS (Bulgarian Academy of Sciences) – Sofia by the 

end of 2017. A cyclotron set consists of a mini cyclotron device 

producing individual doses of radioactive isotopes for 

about 180–200 patients a month. It guarantees constant availability 

of the PET scanner consumable. Until then isotopes 

for PET scanners will be delivered by air due to their short 

period of decay [17, 18]. 

The radiopharmaceutical most applied is 18F 

Fludeoxyglucose (F18 FDG). It is a substance analogous to 

glucose used in PET and suitable for testing metabolism of 

glucose in the heart, lungs and brain. It is also applied when 

monitoring treatment of Hodgkin’s disease, non-Hodgkin’s 

lymphoma, colorectal cancer, breast cancer, melanoma, lung 

cancer, etc. [19, 20]. 

Fig. 3. PET scanners worldwide in 

2009. 


4. Mammographs 

Each year more than 3500 women are diagnosed with 

breast cancer in Bulgaria. The most efficient method of prevention 

are the regular check-ups involving X-ray mammography 

(X-ray of the mammary glands). Mammography is a 

specific imaging method during which the structures forming 

the mammary gland are visualized using a relatively low 

amount of X-ray radiation [21, 22]. Routine preventive checkups 

are meant for women, and those who do not have a family 

history should have their first mammography after they become 

35-year old. Those who do have a family history should 

have their first mammography at about 30. Females up to 35- 

year old with no complaints and family history are recommended 

to have a echomammography (mammary gland ultrasound), 

where no X-rays are used [23, 24]. During mammography 

the mammary gland is placed between two planes 

and a slight controlled pressure is applied for several seconds. 

The X-ray mammography takes two views of the mammary 

gland. Bulgaria is well supplied with such equipment, 

the leading position being taken by Serbia with 210.18 devices 

per 1 million people, followed by Lebanon, Portugal, 

Finland, etc. (Fig.4.) The price of a mammography test (mammography 

and consultation) in Bulgaria is about 50 BGN 

and after the GP issues a medical referral, it is paid by NHIF. 

By 2009 the number of mammographs in Bulgaria was 199. 

In 2010 their number dropped down to 181. In 2011 they 

were 180, in 2012-213, in 2013 - 231 and in 2014 their number 

reached 255. 

Fig. 4. Mammographs worldwide in 2009. 

5. Linear accelerators 

Linear accelerators for medical purposes (LINAC) ensure 

the opportunity to apply one of the most modern methods 

of external radiation therapy. It destroys cancer cells with 

minimal effect on healthy tissues surrounding a tumor. It is 

followed by a chemotherapy treatment varying in duration 

from 5 to 6 months and sometimes such chemotherapy has 

to be repeated. LINAC can be used for all radiation sensitive 

tumors such as breast, cervix, oral cavity, larynx, nose 

and testicles carcinomas; lung, prostate, bladder, stomach 

and pancreas cancer, etc. [25, 26, 27]. 

According to the graph, the country best supplied 

with such equipment is Denmark, having 9.87 devices per 1 

million people, followed by Finland with 7.51, New Zea- 


land with 6.56, etc. (Fig.5.) 

By the end of 2009 Bulgaria had 3 linear accelerators 

used for radiation treatment of oncology diseases in Sv. 

Georgi University Hospital in Plovdiv, the Specialized Hospital 

for Active Treatment in Oncology in Sofia and the new 

one located in Tokuda Hospital in Sofia. 

In 2014 the total number of linear accelerators used 

for medical purposes was 10: 3 in Sofia, 2 in Plovdiv and 2 

in the town of Shumen, while 6 were being installed and 

tested: two new ones in Sofia, 2 in Varna, 1 in Plovdiv and 

1 in the town of Vratsa. 

Fig. 5. Linear accelerators worldwide in 2009. 

6. 6. Telecobalt units (Cobalt-60) 

Cobalt therapy is the use for medical purposes of 

gamma rays from cobalt-60 isotope in cases of malignant 

tumors. After World War II, cobalt radiation therapy equipment 

revolutionized oncology and such devices were widespread 

in the 1950s and 1960s. After the introduction of the 

medical linear accelerator in the 1970s their role was partially 

replaced by linear accelerators. Advantages: medically 

efficient, having simple design, less expensive in terms of 

purchase price and maintenance costs as compared to modern 

linear accelerators. Disadvantages: radioactive waste related 

problems; cobalt-60 radioisotope has a half-life of 5.3 

years and so it has to be periodically replaced [28, 29]. 

The modern cobalt therapy is also known as Gamma 

Knife therapy and can be applied in oncology for all body 

parts and organs. It is extremely precise and so it is used for 


patients having brain tumors [30, 31, 32]. 

As seen from the graph from the countries covered by 

the study Malta has 2.44 devices, Belarus has 2.33, Mauritania 

– 1.55, etc. It is obvious that in countries with welldeveloped 

economies linear accelerators prevail instead of 

Telecobalt units. ( Fig. 6) 

In 2009 the old devices were replaced by new gamma 

radiation therapy equipment in the Specialized Hospital for 

Active Treatment in Oncology in Sofia and the district oncology 

clinics in the towns of Stara Zagora and Ruse. NRA 

issued installation and testing permits for the new devices, 

approval committees were set up and operation licenses were 

granted. In 2010 the medical gamma radiation equipment 

in the Oncology Center in the town of Plovdiv was 

uninstalled and decommissioned. 

Fig. 6. Telecobalt units (Cobalt-60) 

worldwide in 2009. 

Comparative data of the 6 types of studied diagnostic 

imaging and radiation therapy devices used in Bulgaria 

is presented, comparing the average figures on the continents 

taken into account with the purpose of displaying the general 

condition of the infrastructure studied in different countries 

worldwide. For better data illustration North and South 

America are presented together under a single name, i.e. 

America. (Table 1 and Fig.7) 


2009. 

Table 1. Average number of the 6 types of medical equipment (per 1 million people) per continents and Bulgaria in 

MRI units CT PET scanners Mammographs Linear Telecobalt 

accelerators units 

EUROPE 8.78 15.84 2.09 81.49 3.13 0.61 

ASIA 5.99 13.71 0.58 50.38 0.89 0.3 

AMERICA 1.93 4.9 0.116 23.91 0.61 0.69 

AFRICA 2.29 4.17 0.08 34.6 0.92 0.397 

Bulgaria 4.02 27.19 0.13 26.64 0.4 0.4 

Fig. 7. Average number of the 6 types 

of medical equipment (per 1 million 

people) per continents and Bulgaria in 

2009. 

Key: 

I. MRI units; 

II. CT 

III. PET scanners 

IV. Mammographs 

V. Linear accelerators 

VI. Telecobalt units 

CONCLUSIONS: 

1. As seen from the study, the oncologic and cardiologic 

medical equipment in Bulgaria has been gradually improving 

in the last seven years, but quantitative indicators 

regarding the devices studied are still far away from the figures 

recommended by WHO with one single exception, i.e. 

CT. For example, WHO recommends a standard of 1 linear 

accelerator per 250 000-300 000 people, which means that 

our country by 2016 has approximately half of the numbers 

required for achieving this standard. 

2. There is a considerable difference in those indica- 

tors between Bulgaria and the countries with well-developed 

economies. However, it has to be emphasized that the results 

do show a significant modernization and fast reduction of 

those differences, especially during the last three years. 

3. The use of modern technologies by medical experts 

is directly related to improving the results in terms of diagnostics 

and treatment. Therefore, the recent year trend of increasing 

material resource has to be continued together with 

a steady improvement of medical specialists’ qualification 

with the purpose of their adequate adjustment to new technologies. 

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ISSN: 1312-773X 


http://dx.doi.org/10.5272/jimab.2016223.1198 


MANAGEMENT OF RISK SITUATIONS 

Desislava Todorova 1 , Tsvetelina Mihailova 2 , Rumiana Etova 3 , Svetoslav Garov 2 

1) Department of Preventive Medicine, Faculty of Public Health, Medical 

University - Sofia, Bulgaria 

2) Department of Health Policy and Management, Faculty of Public Health, 

Medical University - Sofia, Bulgaria 

3) Department of Epidemiology and Medicine of disastrous situations, Faculty 

of Public Health, Medical University - Plovdiv, Bulgaria 

ABSTRACT 

Risk is the probability of an event occurrence at a 

certain moment with a negative impact on the population, 

territory, environment, cultural values and material valuables. 

The management of risk situations is necessary for 

any organization in which unforeseen circumstances may 

arise. The management of risk situations includes quantitatively 

expressing risk and its manifestation; risk assessment 

and risk analysis. Effectiveness in dealing with risky 

situation coordination is needed to be established between 

the management vertical and horizontal structures 

in the State. Preventing, controlling and overcoming the 

consequences impose an integral process of management 

and planning events. The requirements for growing professionalism 

in the management of all levels are obvious. 

Keywords: management, disaster, risk, planning, 

management decisions, 

INTRODUCTION 

The management of risk situations is necessary for 

any organization in which unforeseen circumstances may 

arise. Risk is the probability of an event occurrence at a 

certain moment with a negative impact on the population, 

territory, environment, cultural values and material valuables. 

Any disaster, regardless of its nature and scope of 

manifestation is characterized by three main elements: surprise, 

time and threat. 

Surprise is expressed not so much time for the start 

of the crisis (the suddenness, according to some authors, 

[1] as with the nature of its manifestation and running by 

others [2]. The development usually differs from expectations 

and the crisis caused events that are not expected. 

Threat is any condition or trend in the external environment, 

which affects or will affect the activities of the 

organization and its results. They can be assessed and 

classified according to their seriousness of harming the 

organization and likelihood to happen with the help of 

“The Matrix of threats”. 

In the course of the daily activities of any organization 

some unforeseen circumstances can appear that 

may largely influence in making managerial decisions 

which include the following components: 

• Management of the risk situation with its main 

points: determining the structure and content of the risk 

situation - risk analysis; determining the magnitude of 

risk - the risk quantification; making regulatory decisions 

concerning the discrepancy between goals and results obtained 

as a manifestation of risk; 

• Assessing and overcoming risk. 


Risk Assessment is a process of collection, analysis 

and assessment of the available information to determine 

the acceptable levels of risks for the individual, 

group contingent, society and the environment. It includes 

the identification and characterization of the danger 

likely frequency, duration, volume and time of impact [2]. 

Risk analysis is a detailed study carried out in order 

to understand the nature of adverse consequences of 

an event, including human life, property and the environment. 

It can be defined as an analytical process that provides 

information about the likelihood of disaster and the 

consequences of an adverse event. [3] 

The damages that can occur in an emergency situation 

depend both on the parameters of the hazard and 

the vulnerability of exposed people, infrastructure, ecosystems 

and others. People, flora and fauna, buildings, 

material and cultural sites are exposed to risk.. In its simplest 

form, the vulnerability is comprised of exposure 

(Who / what will be affected?) And sensitivity (how the 

affected items will be damaged?). The combination of 

danger and vulnerability leads to risk, defined as the probability 

of occurrence of some damage within a certain period 

of time. [4] (Fig. 1) 


Fig. 1. Risk of emergency situation such as flood (Barredo, [5]) 

Risk = danger x exposure x vulnera bility 

Danger - scenario 

exposure-condition of the 

endangered areas 

Vulnerability-assessment 

of the possible damages 

In the recent decades, disasters in Europe have become 

a growing topic of concern for citizens, public authorities, 

insurance companies, businesses and politicians. 

The management of disasters is determined by a complex 

business of governing bodies of the appropriate management 

level [6]. Management is an integral process and 

consists of information process and organizational process. 

Information includes prevention process; forecasting and 

planning; development and utilization plans; publicity and 

information; assessment of the situation and decision / 

choice of options. Organizational process integrates maintaining 

operational readiness; study; storage and use of information; 

organization of insurance; monitoring the implementation 

of the activities. 

Leadership and management in case of emergencies 

are carried out according to the conventional country management 

system [7]. In Bulgaria the management in emergency 

situations is carried out in two directions: 

• Management system of state and local administration. 

Under the state (executive) power the control is vertical 

Council of Ministers - Ministry (whose portfolio is disaster) 

- Governor - Mayor of the Municipality - Economic 

site. 

• Management system of specialized bodies and agencies. 

In healthcare the medical insurance of the population 

in emergency situations is carried out by: top management 

(management at the political level) - represented by 

the Ministry of Health and participates in decision making 

of national importance; coordinating management (medium 

level of management) - Regional health inspections and operational 

management - carried out by the heads of medical 

institutions. For an effective management coordination is 

essential. [8] 

Management of events in risky situations: 

Management is a focused activity, a process of impact 

on the sites of government (structures, forces, units) for 

the preparation of actions targeting efforts to achieve certain 

goals and completing assigned tasks. 

Management is a combination of different types of 

principles, decisions and activities resulting in: 

• Monitoring of risk factors; 

• forecast and early warning of the occurrence; 

• determining management objectives in a particular 

situation; 

• action planning and use of forces and means; 

• making decisions in the situation, guide the actions 

and control over the results of management; 

• preparation and implementation of measures to overcome 

the consequences and achieve stability. 

Management of events in risky situations goes 

through several phases. (Table. 1) 

Tab. 1. Phases of management process 

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 

Indication Assessment of the crisis Development of options Planning Stability 

Warnings situation for response Execution restoration 

Preventing, controlling and overcoming the consequences 

of imposing a single process of management and 

planning events. 

In emergency situations, planning is a key step in the 

management of rescue operations. Success largely depends 

on well-developed, effective and comprehensive work plan. 

Planning is a complex set of events. Its drawing requires 

thorough analysis and preparation for an informed debate 

based on the huge amount of data. The planning includes 

resource planning, business planning and planning outcome 

[9]. There are different types of plans for risk situations: Plan 

ready for action; response plan; recovery plan; plan for mitigation. 

The plans identify priority projects and activities, 

outline responsibilities, provide time, include monitoring 

and risk assessment. [10] Planning is an indispensable stage 

in the work of the manager and is a key point, as it can save 

unnecessary delays and save lives, which is particularly important 

in emergency situations. [11] 

Besides planning the management of life-events also 

covers organizing, managing, leadership, coordination and 

control of the institution, organization, institution, etc. to 

achieve a goal. The process of managing management 

(scheme “PMM”) applies to all levels of healthcare organization 

and to all activities. Scheme “PMM” includes (Fig. 2): 


Planning: to determine what will be done, when and 

how. 

Organization: to provide the necessary resources. 

Operational management: to define in detail the 

time and cost; to take measures and be guided. 

Control: to compare achievements against the plan; 

to take appropriate action. 

Motivation: inciting subordinates for quality and efficient 

work to achieve the objectives. 

Fig. 2. Management process (scheme „PMM” in healthcare, 12) 

organizing 

planning 

motivation 

operational management 

control 

The management of the activities carried out in emergency 

situations includes both traditional and specific elements: 

• Action Plan before, during and after a disaster; 

• Assessment of the effectiveness and testing of the 

plan; 

• Change in the plan during a disaster; 

• Good management organization; 

• Effective communication; 

• Data management; 

• Response to the needs of the healthcare system. [13] 

For the effective implementation of the plan and readiness 

to act in any situation the human resources of the organization 

are very important [14]. The selection of staff is 

essential to the management of the organization. According 

to Lee Iacocca, a very important quality of a manager is to 

possess the feeling of the time factor, because the correct decision 

becomes wrong, if taken too late. This is absolutely 

true in disaster situations where events are moving too fast. 

According to Akio Morita among the pillars of a manager, 

which gives an idea of the conceptual model of the head, 

is his highly appreciated ability to organize people to maximum 

dedication, and without the knowledge it is not possible 

to generate “the sixth” sense of the manager. Effective 

leadership is a function of the correct diagnosis of the situation 

that precedes the selection of one or another style by 

the Head, managers can adapt to any situation. Managerial 

styles are deeply personal, human skills. Openness and willingness 

to adapt are perhaps the most important prerequisites 

for success in any new venture. 

Organizing workflow is important for the efficiency 

and quality of work. The manager and his subordinates 

should be a team, because only when there is this feeling 

subordinates will take effect by the Head. [15] The head 

must be confident that it has a sufficient number of people 

in his team. Each of them must be qualified enough to undertake 

the task, which is inserted and be able to find a solution 

to the problems that will almost certainly arise during 

the workflow. One problem for management is mutual 

influence between managers and subordinates (theories of 

“transformation” guide). Only after achieving activity on 

behalf of both nations and others organization protection 

can be achieved in emergency situations. This is a factor for 

dynamic leadership, which is important in disaster situations. 

Tanenbaum, Schmidt, Hersey-Blanchard, Vrum-Jensen account 

the influence of the environment (situation) on relations 

manager-subordinate and general ideas of leadership. 

Quality situational theories of leadership (Fiedler, Yedar) display 

situation (situation, environment) as the main factor determining 

the leadership style that is influenced and depends 

on many of the qualities of the head. [16, 17] 

CONCLUSIONS 

• The model of management indicates that any organization 

(health and each other) exists not in isolation but in 

particular for her external environment is changing in emergency 

situations. 

• Questions on the management of disasters appear 

an advantage of central, together with regional and local governments. 

• Preventing, tackling and overcoming the consequences 

of disasters impose a single management process. 

• The sooner problems are identified, the faster solution 

would be found for them. 

CONCLUSION: 

The effective response in a crisis situation requires 

taking the right decisions in terms of chaotic and emotionally 

charged environment. Management of disasters can be 

successfully implemented on the basis of prior information, 

events planning and preparation of the teams, as well as 

training and assistance to citizens. Health policy, planning 

and management are interrelated and interdependent. The 

requirements are obvious for growing professionalism in the 

management and use of non-standard approaches in the management 

of every area of social life at risk situations. 


REFERENCES: 

1. Chakurova R, Mihailova Il. General 

characteristics of disasters, Disaster 

medicine. Sofia: Arso. 2011, p 17. 

[in Bulgarian] 

2. Sapundzhiev P. Kostadinov R. 

Manual management of medical support 

in emergency situations, Plovdiv: 

Ik-VAP. 2010. p 20, 21. [in Bulgarian] 

3. Levees and National Research 

Council. The National Flood Insurance 

Program: Improving Policies and 

Practices. Washington, D.C.: The National 

Academies Press. 2013. p 230- 

250 [Internet] 

4. Merz B, Thieken A, Kreibich H. 

Quantification of Socio-Economic 

Flood Risks. In Flood Risk Assessment 

and Management: How to Specify Hydrological 

Loads, Their Consequences 

and Uncertainties. Editor Schumann 

AH. Springer Netherlands. 2011; 

Capter 11:229-247. [CrossRef] 

5. Barredo JI. Major flood disasters 

in Europe: 1950-2005. Nat Hazards. 

2007 Jul; 42(1):125-148 [CrossRef] 

6. Mihailova I. Management of medical 

insurance, Disaster medicine. Sofia: 

Arso. 2011. p 457. [in Bulgarian] 

7. Todorova D. National bodies and 

structures for civil protection of the 

Member States of the European Union, 

Socio-economic aspects of disasters 

and protection of the population. Sofia: 

CP Center. 2012. p 44-50. [in Bulgarian] 

8. Zlatanova T. Management Activities 

of General Practitioners in Bulgaria. 

Editors: Jeliazko Hristov, John 

Kyriopoulos, T.C. Constantinidis. In 

Public Health and Health care in 

Greece and Bulgaria: The challenge of 

the Cross-border collaboration. Athens: 

Papazissis Publishers. 2010. p 

657-663. 

9. Shipkovenska E, Popova S, 

Petrova G, Gladilov St, Benisheva T, 

Popova Cr, et al. Scientific research 

methodology. Sofia: EkoPrint. 2013. 

p 63-77. [in Bulgarian] 

10. Rasid H, Haider W. Floodplain 

Residents’ Preferences for Water Level 

Management Options in Flood Control 

Projects in Bangladesh. In Flood Problem 

and Management in South Asia. 

Editors: Qader Mirza MM, Dixit A, 

Nishat A. Springer Netherlands. 2003; 

Capter 5:101-129. [CrossRef] 

11. Vodenitcharov C, Popova S, 

Mutafova M, Shipkovenska E. Social 

Medicine. Sofia: Gorex Press; 2013. 

p. 482-487. [in Bulgarian] 

12. Yanachkov Iv, Pencheva M, 

Alvasov B. Management in Health. Sofia: 

Loren Publishing. 1999. p 39-40. 

[in Bulgarian] 

13. Wiedrich TW, Sickler 

JL, Vossler BL, Pickard SP. Critical 

Systems for Public Health Management 

of Floods, North Dakota. J Public 

Health Manag Pract. 2013 May- 

Jun;19(3):259-265. [PubMed] 

14. Prodanova J, Zlatanova T, 

Cheshmedzhieva A, Zlatanova R. 

«Health» workplace, wasted resources 

or investments. First National Conference 

of the Bulgarian Society for the 

Study and combat stress, with international 

participation, Plovdiv. 2003. p 

331-335. [in Bulgarian] 

15. Ivanov I. Key points of success 

in management, Fundamentals of Management. 

Plovdiv: Macros. 2003. p 

324. [in Bulgarian] 

16. Petkov A. Management and 

Health Management. Kazanluk, Irita. 

2009. p 8, 17. [in Bulgarian] 

17. Ivanov I. Situational approach, 

Fundamentals of Management. 

Plovdiv: Macros. 2003. p 68. [in Bulgarian] 

Please cite this article as: Todorova D, Mihailova T, Etova R, Garov S. Management of risk situations. J of IMAB. 2016 

Jul-Sep;22(3):1198-1201. DOI: http://dx.doi.org/10.5272/jimab.2016223.1198 

Received: 04/05/2016; Published online: 01/07/2016 


Assoc. Prof. DesislavaTodorova, MD 

Faculty of Public Health, Medical University - Sofia; 

1527, Sofia, 8, Bialo more Str., Bulgaria 

e-mail: d.todorova.dm@gmail.com 



ISSN: 1312-773X 




COMPLICATIONS AFTER EXTRACTION OF 

IMPACTED THIRD MOLARS- LITERATURE 

REVIEW 

Elitsa G. Deliverska, Milena Petkova. 

Department of Oral and Maxillofacial surgery, Faculty of Dental medicine, 

Medical University –Sofia, Bulgaria 

ABSTRACT 

Third molar surgery is the most common procedure 

performed by oral and maxillofacial surgeons worldwide. 

This article addresses the incidence of specific complications 

and, where possible, offers a preventive or management strategy. 

Complications, such as pain, dry socket, swelling, 

paresthesia of the lingual or inferior alveolar nerve, bleeding, 

and infection are most common. Factors thought to influence 

the incidence of complications after third molar removal 

include age, gender, medical history, oral contraceptives, 

presence of pericoronitis, poor oral hygiene, smoking, 

type of impaction, relationship of third molar to the inferior 

alveolar nerve, surgical time, surgical technique, surgeon 

experience, use of perioperative antibiotics, use of topical 

antiseptics, use of intra-socket medications, and anaesthetic 

technique. 

For the general dental practitioner, as well as the oral 

and maxillofacial surgeon, it is important to be familiar with 

all the possible complications after this procedure. This improves 

patient education and leads to prevention, early recognition 

and management. 

Key words: third molar surgery, complication, mandible, 

maxilla 

INTRODUCTION 

Surgical removal of impacted third molars is one of 

the most common procedures carried out in oral and maxillofacial 

surgery. Most third molar surgeries are performed 

without complications. However, such procedure can lead 

to serious complications to the patient, such as hemorrhage, 

persistent pain and swelling, infection, dry socket (alveolar 

osteitis), dentoalveolar fracture, paresthesia of the inferior 

alveolar nerve and of the lingual nerve, temporomandibular 

joint injury and even mandibular fracture. The accident or 

complication rates related to third molar extraction may vary 

between 2.6 and 30.9 %, being the results influenced by different 

factors, such as age and health condition of the patient, 

gender, tooth impact level, surgeon’s experience, smoking, 

intake of contraceptive medicine, quality of oral hygiene, 

and surgical technique among others [1]. The overall 

incidence of complication and the severity of these complications 

are associated most directly with the depth of impaction 

and with the age of the patient [2]. There appears to 

be a direct relation between the degree of impaction of the 

extracted tooth and the incidence of postoperative complications. 

Most of the complications are associated with a 

greater degree of impaction. Teeth classified as having IC, 

IIC and IIIC impaction have more complications than teeth 

classified as having B or A impaction [3]. There is also a 

relation between tooth position based on the Winter classification 

and the appearance of postoperative complications. 

Mesioangular and distoangular impaction are associated 

with nearly twice as many complications as the other tooth 

positions [3]. Other authors state that horizontal and 

distoangular impactions are inclined to develop more complications 

[4]. Deep impacted third molar surgery needs a 

bigger flap design. Tissues in the neighborhood and muscles 

can receive more damage because of this wide and large 

access flap [5]. 

There is a distinctive association between age and 

observed postoperative complications. These associations 

result from the fact that the intervention in older patients 

lasts longer because of increased bone density. Age depended 

maturing of tooth root formation and decreased healing capacity 

lead to intensive postoperative complications. Bruce 

and Chiapasco et al. state that older patients have more pain, 

edema and trismus as postoperative complications [5]. 

It seems that female patients show higher accident and 

complication rates [1]. Monaco et al. reported that the incidence 

of postoperative edema in female patients (12.7%) is 

significantly higher than in male patients (1.4%) [5]. 

The experience of surgeon also appears to be a determining 

factor in the development of postoperative complications 

and can result in a longer treatment process, social 

and financial difficulties and a corresponding decrease in 

patient’s life quality [5]. 

Prior to any surgical procedure, the patient must be 

informed about the possible accidents and/or complications 

that may occur during the entire treatment, being aware of 

the fact that any unexpected situation should be dealt with 

the best possible way [1]. 

It is thought that complications like pain, edema and 

trismus are caused by surgical trauma depending on the inflammatory 

process. In surgeries for impacted mandibular 

third molar, time of the intervention is thought to be associated 

with tooth position, angle and the experience of the 

surgeon and these parameters determine the difficulty of the 

surgery and are related to the intensity and time of pain, 

edema and trismus. Longer surgical interventions are 

thought to increase tissue damage and vascular permeability 

can cause postoperative edema and affect its intensity. 


In addition, it was reported that longer surgical interventions 

lead to increased surgical trauma [5]. 

While evaluating the postoperative complications 

regarding the width and depth of impaction, pain and 

swelling was common in IIIA (37.5%) followed by IIIB 

(20%); dry socket was common in IIIA, IA and IIA which 

was 12.5%, 5% and 4.8% respectively; trismus occurred 

more in Class IIIB (20%), Class IIIA (12.5%) and Class IB 

(6.8%) and paresthesia was least common and occurred in 

2 patients (0.7%) [4]. 

Bleeding 

Hemorrhage might happen during (accident) or after 

(complication) the surgery, being classified as late or recurrent 

hemorrhage. In situations of intense bleeding classified 

as late, the hemorrhage happens only once, after the end of 

the procedure. In recurrent hemorrhages, more than one intense 

bleeding situation takes place, even after initially extinguished. 

Anatomical variations, tooth proximity to the vascular 

nerve bundle of the mandibular canal, and coagulopathy 

are the main causes of hemorrhage [1]. Patients who have 

known acquired or congenital coagulopathies require extensive 

preparation and preoperative planning (eg, determination 

of International Normalized Ratio, factor replacement, 

hematology consultation) before third molar surgery [2]. 

Bleeding can be minimized by using a good surgical 

technique and by avoiding the tearing of flaps or excessive 

trauma to bone and the overlying soft tissue. When a vessel 

is cut, the bleeding should be stopped to prevent secondary 

hemorrhage following surgery [2]. 

The most effective way to achieve hemostasis following 

surgery is to apply a moist gauze pack directly over the 

site of the surgery with adequate pressure for some minutes 

or use of bone wax, absorbable hemostats or electrocoagulation. 

In some patients, immediate postoperative 

hemostasis is difficult. In such situations a variety of techniques 

can be employed to help secure local hemostasis, 

including over suturing and the application of topical 

thrombin on a small piece of absorbable gelatin sponge into 

the extraction socket [2]. 

Some authors affirm that the hemorrhage cases represent 

from 0.2 to 5.8% of the accidents/complications and 

that the compression technique is safe and reliable in the 

control of intense bleeding [1]. 

In comparing hemorrhage with gender, age, position 

of the tooth, classification of the tooth, retention, angle, systemic 

conditions, bad habits, use of oral contraceptives and 

menstruation, there weren’t any statistically significant differences 

[5]. 

Edema/ postoperative swelling 

Postsurgical edema is an expected complication after 

third molar surgery. It can be caused by the response of 

the tissues to manipulation and trauma caused during surgery. 

Its onset is gradual and maximum swelling is present 

during 48 h after surgery [6]. Regress of the swelling is expected 

by the 4th day and completely resolution occurs in 

7 days [7]. 

In comparing edema with gender, age, position of the 

tooth, classification of the tooth, retention, angle, systemic 

conditions, bad habits, use of oral contraceptives and menstruation, 

statistically significant differences were observed 

between edema and classification of the tooth. More edema 

was observed in class II than in classes I and III. There was a 

statistically significant difference between edema and partial 

bony and complete bony impaction [5]. 

The application of ice packs to the face may make 

the patient feel more comfortable but has no effect on the 

magnitude of edema [2]. 

Most of the surgeons prescribe corticosteroids to control 

surgical outcomes and yield a comfortable post-surgical 

healing period [6]. 

In the initial phase of the inflammatory process, 

corticosteroids acts by suppressing the production of vasoactive 

substances such as prostaglandins and leukotrienes. This 

reduces fluid transudation and edema. These drugs help to 

control mild pain hence they should be used in conjugation 

with potent analgesics. Prolonged use can delay healing 

and increase patient’s susceptibility to infections. But 

in dental extraction the doses are for shorter duration, hence 

chances of adverse effects are very rare. [6] 

The dose of the drug should be more than the cortisol 

released normally by the body. Due to this reason, some 

authors consider that 8 mg dexamethasone and 40 mg methylprednisolone 

were used which corresponded to 200 mg of 

cortisol. [6] 

Dexamethasone significantly reduced the incidence 

of swelling as compared to methylprednisolone. This is attributed 

to the half-life of the drug which is more than methylprednisolone. 

The efficacy of dexamethasone is also due 

to the reason that it reduces the formation of thromboxane 

A2 which in turn reduces the amount of prostaglandin E2 

that is formed [6]. Good results were also obtained with 32 

mg methylprednisolone and 400 mg ibuprofen administered 

12 h before and 12 h after surgery respectively. 

Postoperative edema can also be controlled with dexamethasone 

administered in the submucosa [8]. Submucosal 

administration of 4 mg dexamethasone 1 h before surgery 

has been compared with that of 8 mg dexamethasone plus 2 

g amoxicillin/clavulanic acid two times a day. Both dosages 

improved swelling versus untreated groups, but no differences 

were observed between the two dosage regimens. 

In striking contrast with this observation, some authors 

reported that in patients undergoing surgery for impacted 

third molars, administration of 8 mg dexamethasone 

1 h before surgery, followed by 750 mg paracetamol every 

6 h for 4 days produced a better control of swelling compared 

to treatment with 4 mg dexamethasone [9]. Dexamethasone 

has also been administered 1 h before surgery (4 

mg orally) and 12 h after surgery (4 mg IV), along with 

antalgic agents (30 mg ketorolac IV), when pain was present. 

[10] In this study, treatment with dexamethasone always produced 

a good control of swelling, as measured 24 and 48 h 

after surgery. 

Elhag et al. [11] reported that administration of 10 

mg dexamethasone IM, 1 hour before surgery and 10–18 h 


later together with antibiotic therapy (400 mg oral metronidazole, 

administered pre- and post-surgically), significantly 

reduces swelling when compared to only postoperative treatment, 

without corticosteroids. 

Although a significant reduction (50%) of swelling 

was observed 2 days after surgery in patients treated with 4 

mg dexamethasone IM, no effect was present after 7 days. 

However, when administered 5–10 min before surgery, 4 mg 

dexamethasone i.v. was not effective in controlling edema 

when no antibiotic therapy was associated with it. 

The investigated studies showed how the effectiveness 

of the corticosteroid administration before surgery could 

not be considered as a predictable therapy in order to control 

the postoperative swelling and edema of the surgical area. 

However, corticosteroids administration during the surgeries 

or in the postoperative period seems to give a great benefit 

for reducing the swelling and postoperative edema. 

Different surgical strategies have been reported in the 

literature to reduce the postoperative discomfort after the 

third molar surgeries. They can be used either separately or 

in association with pre- or postoperative strategies. Different 

kinds of flaps have been used during extraction of impacted 

third molars, specifically to assess whether a marginal 

flap could control postoperative swelling better than a 

paramarginal one [12]. No significant difference in the entity 

of swelling was observed after using the two kinds of 

flaps. However, there were no significant differences between 

the marginal and paramarginal flaps in terms of swelling. 

In contrast, Kirk et al. [13] reported significant differences, 

particularly for swelling and pain, during the 2nd 

day post-surgery between a group with a buccal flap and a 

group with a triangular flap modified by Szmyd [14]. In the 

latter case, an increased swelling was observed. Pasqualini 

et al. [15] have compared 100 patients treated with tight suture 

with 100 patients sutured after removal of 5–6 mm of 

mucosa distally to second molar to allow draining. Using 

this procedure, postoperative swelling was reduced especially 

on days 2 and 4, while in the group treated with tight suture, 

the peak of swelling was observed on day 3. 

According to several authors, [16, 17, 18] tight closure 

favors edema formation by creating a unidirectional 

valve that allows fragments of food to reach the cavity, but 

not to leave it easily. This can be the origin of local infection, 

inflammation, edema and potential alveolar osteitis and 

pain for difficult draining. [19] 

According to other authors different factors such as 

edema, pain and trismus that follow extraction of impacted 

third molars can be related to suture technique and to surgery 

length, and the use of a draining tube can be helpful in 

reducing or preventing postoperative swelling. [20]. This has 

been confirmed in a study specifically designed to compare 

postoperative responses in two groups, one treated with suture 

and the other with draining. In the latter, a clear reduction 

in edema formation was observed. Rakprasitkul and 

Pairuchvej [21] obtained similar results. They reported reduced 

swelling with suture in the presence of a draining tube 

when compared to the primary suture. 

In a different study, the effect of draining has been 

compared with methylprednisone treatment. [22] Although 

no significant differences were reported, pharmacological 

treatment reduced swelling and was better tolerated by patients. 

It is then reasonable to conclude that most authors 

prefer secondary healing and/or draining rather than primary 

closure. 

Different surgical procedures have also been related 

to postoperative swelling. Osteotomy through piezosurgery 

has given positive results on tumefaction compared to traditional 

techniques. However, often, the studies analyzed did 

not involve extraction of impacted third molars, but general 

osteotomy of the jaws. [23, 24, 25] 

Therapeutic effects of ice applied on a surgery wound 

are due to changes of hematic flow and consequent vasoconstriction 

and reduced metabolism. In surgery and orthopedics, 

in fact, the main function of ice on the treated area 

is to produce vasoconstriction and to control bleeding, resulting 

in reduced metabolism and control of bacterial 

growth. [26] The application of ice does not have to be too 

long as this may be responsible for tissue death due to prolonged 

vasoconstriction, ischemia and capillary thrombosis 

and lymph stasis. 

It is interesting to note that low laser dosage (4 J cm2), 

applied soon after surgery, produces a good control of swelling, 

especially in patients treated with 4 mg dexamethasone 

IM [27] 

The first physiological response of tissues to cryotherapy 

is reduction of local temperature that causes reduced 

cellular metabolism. In this way, cells consume less oxygen 

and resist longer to ischemia. [28] In the treatment of impacted 

third molars, the use of ice shows a good efficacy in 

reducing post-surgery swelling and pain. In the postoperative 

period, the use of ice pack is largely recognized to provide 

good results and it helps the patient to cooperate with 

pharmacological treatments and/or intraoperative strategies 

in the prevention of edema. All pharmacological therapies 

used post-surgery are valid although they differ in the compounds 

used and their ways of administration. [29] 

Trismus 

Trismus is a normal and expected outcome following 

third molar surgery. 

Trismus is evaluated by the distance between the upper 

and lower right central incisors at the maximum mouth 

opening; a modification of this method calculates the quotient 

between preoperative and postoperative distance. Other 

authors simply consider two possible alternatives: presence 

or absence of trismus, taking into account a difference of 

5mm. There is a reliable and valid patients’ self assessment 

of mouth opening using a cardboard scale [9] 

Like edema, jaw stiffness usually reaches its peak on 

the second day and resolves by the end of the first week. [2] 

There is a strong correlation between postoperative 

pain and trismus, indicating that pain may be one of the principal 

reasons for the limitation of opening after the removal 

of impacted third molars. [2] 

In comparing trismus with gender, age, position of the 

tooth, classification of the tooth, retention, angle, systemic 

conditions, bad habits, use of oral contraceptives and menstruation 

period, statistically significant differences were 


observed between trismus and partial bony impaction of 

tooth. The absence of trismus after the extraction of partial 

bony impacted tooth was 49.6%, presence of edema was 

62.5%, while these means were 0% and 37.2% for trismus 

after the extraction of mucosal impacted teeth and 13.3% 

and 37.5% for trismus after the extraction of complete bony 

impacted teeth. [5] 

Patients who are administered steroids for the control 

of edema also tend to have less trismus.[2] Dexamethasone 

caused less trismus compared to methylprednisolon. [6] 

Pain 

Another postsurgical morbidity expected after third 

molar surgery is pain. The post surgical pain begins when 

the effects of the local anesthesia subsides and reaches peak 

levels in 6 to 12 hours postoperatively. 37.7% patients reported 

mild pain on the third post-operative day and 43.4% 

patients had no pain on the seventh post operative day. [7] 

A large variety of analgesics are available for management 

of post surgical pain. The most common ones are 

combinations of analgetics (Metamizol), Paracetamol and 

nonsteroidal anti inflammatory analgesics. Analgesics should 

be given before the effect of the local anesthesia subsides. 

In this manner, the pain is usually easier to control, requires 

less drug, and may require a less potent analgesic. The administration 

of nonsteroidal analgesics before surgery may 

be beneficial in aiding in the control of postoperative pain. 

[2] 

Women may be more sensitive to postoperative pain 

than men; thus, they require more analgesics. [2] 

Swelling, pain and trismus are considered as transient 

complications and are expected with surgery. Although transitory, 

these conditions can be a source of anxiety for the 

patient.[7] 

Infection 

An uncommon post surgical complication related to 

the removal of impacted third molars is infection. 

The postoperative infection rate reported in the literature 

varies between 1.5% and 5.8%,or between 0.9% and 

4.3% depending on the articles consulted. [3] 

Infection after removal of mandibular third molars is 

not so common complication. About 50% of infections are 

localized subperiosteal abscess-type infections, which occur 

2 to 4 weeks after a previously uneventful postoperative 

course. These are usually attributed to debris that is left under 

the mucoperiosteal flap and are easily treated by surgical 

debridement and drainage. Of the remaining 50%, few 

postoperative infections are significant enough to warrant 

surgery, antibiotics, and hospitalization. [2] 

Antibiotic prophylaxis reduces the risk of experiencing 

infection, alveolar osteitis and pain after third-molar extractions 

in healthy adults, but it also results in an increased 

risk of mild, transient adverse effects. Given the low risk of 

infection after tooth extraction in healthy young adults, substantial 

increased risk of experiencing adverse effects, the 

potential development of resistant bacteria due to antibiotic 

use and the management of infection if it occurs, some authors 

did not support routine prescription of antibiotic 

prophylaxis for healthy people undergoing extraction of 

third molars. [30] 

The antibiotic prophylaxis is the most controversial 

factor among the others, and some studies highlight that its 

use is necessary only when there is exposure of the vascular 

nerve bundle of the mandibular canal, increasing the chances 

of infection in up to seven times. [1] 

Antibiotic therapy to treat established infection or as 

prophylactic strategy to prevent distance site infection or 

to control postoperative discomfort in third molar surgery 

is today a broadly accepted indication with documented efficacy. 

[8]. 

According to the literature review, the use of the antibiotics 

before surgery could be considered a predictable 

procedure to avoid and control the possible infection related 

to the surgery. If infection and inflammation are present in 

the surgical area, an antibiotic therapy seems to give a better 

clinical compliance of the tissues undergoing surgery. 

The antibiotic administration before, during and after surgery 

seems to be a better therapeutic choice for controlling 

the infection arising in the postoperative period [29] 

Factors such as the patient’s age, osteotomy techniques 

and/or tooth section, delay in repairing the socket, 

previous local inflammation, surgeons with little experience, 

and lack of antibiotic prophylaxis are considered to predispose 

the infection. [1] 

Alveolar Osteitis (AO) [dry socket] 

The sequence of normal healing after extraction does 

not always occur. In some instances, early clot formation in 

the socket is followed by premature clot necrosis or loss, accompanied 

by pain and a fetor oris. [31] 

The alveolar osteitis (dry socket, alveolitis sicca 

dolorosa, localized alveolar osteitis, fibrinolytic alveololitis 

is a disturbance in healing that occurs after the formation of 

a mature blood clot but before the blood clot is replaced 

with granulation tissue. [31] The primary etiology appears 

to be one of excess fibrinolysis, with bacteria playing an important 

but yet ill-defined role. This fibrinolysis occurs during 

the third and fourth days and results in symptoms of pain 

and malodor after the third day or so following extraction. 

The source of the fibrinolytic agents may be tissue, saliva, 

or bacteria. [2] 

The reported incidence of alveolitis varies widely, 

from as low as 0.5% to as high as 68.4%, but most studies 

indicate a rate between 5% and 10%. Diagnostic criteria, 

which vary from author to author, might partly explain this 

variation. [3] The alveolar osteitis or dry socket is characterized 

by an intense and throbbing pain that cannot be controlled 

by common pain killers, starting between the second 

and fifth days after the surgery, with unpleasant smell and 

without incorrupt tissue in the interior of the socket. [1] 

Some researchers classified alveolitis as being alveolar 

tissue necrosis with exposed bone, with a prolongation 

of pain between 5 and 7 days, of a neuralgic character, intense 

or severe. Other authors offer a more descriptive definition: 

the presence of a gray necrotic clot relative to a bare 

area of the socket, along with great stench and pain in the 

zone. A further diagnostic criteria was pain and discomfort, 


if medication does not alleviate the pain, and if exposed 

bone or necrotic debris is showing in the alveolus. [32] 

As possible risk factors, we can include untimely surgical 

maneuvers, surgery difficulty level, surgeon’s experience, 

tooth position in the arch, smoking, patient’s age, being 

a female, use of oral contraceptive and corticoids, use 

of local anesthetics with vasoconstrictor, and intrinsic factors 

such as coagulopathy among others.[1] 

The incidence of postoperative alveolitis in association 

with oral contraceptive (OC) use has been investigated 

by many authors, with conflicting results. Some studies have 

demonstrated an increased rate of alveolitis among women 

taking OC but others did not. This discrepancy can be explained 

by the lower estrogen concentration in the new generations 

of OC. [3] 

Cohen et al. suggest, on a literature review of the most 

relevant articles, that there are not enough data to consider 

oral contraceptive as an important risk factor to dry socket 

in elective surgeries to extract third molars. Not enough evidence 

was found to affirm that the menstrual cycle influences 

the development of dry socket. On the other hand some authors 

affirm that women who use oral contraceptive medicine 

have five times more chances of developing dry socket 

than men. [1] Other considerations that must be pointed out 

regarding dry socket is the patient’s age, which might hinder 

the repairing process and healing of older patients and 

worsen the bone tissue quality. [1] The incidence of dry 

socket seems to be higher in patients who smoke. [2] 

The occurrence of dry socket can be reduced by several 

techniques, most of which are aimed at reducing the bacterial 

contamination of the surgical site. Presurgical irrigation 

with antimicrobial agents such as chlorhexidine reduces 

the incidence of dry socket by up to 50%. Copious irrigation 

of the surgical site with large volumes of saline is also 

effective in reducing dry socket. Topical placement of small 

amounts of antibiotics such as tetracycline or lincomycin 

may also decrease the incidence of alveolar osteitis. [2] Maintenance 

of the coagulum inside the socket by using appropriate 

suture techniques may also help in the prevention of 

this complication. [1] To the subject of clot stabilization and 

healing, one should consider the use of resorbable substances 

such as gelatin sponge, polylactic acid, and methylcellulose 

as clotstabilizing socket implants. The record of such substances 

in preventing AO is mixed,but the combinations of 

these inexpensive materials with topical socket medicaments 

may yield a decreased tendency for clot lysis and greater 

mechanical strength to the bulk blood clot. [31] 

The goal of treatment of dry socket is to relieve the 

patient’s pain during the delayed healing process. This is 

usually accomplished by irrigation of the involved socket, 

gentle mechanical débridement, and placement of an obtundent 

dressing, which usually contains eugenol. The dressing 

may need to be changed on a daily basis for several days 

and then less frequently after that. The pain syndrome usually 

resolves within 3 to 5 days, although it may take as long 

as 10 to 14 days in some patients. There is some evidence 

that topical antibiotics such as metronidazole may hasten 

resolution of the dry socket.[2] 

Nerve Disturbances 

Neurological damage of the lingual or inferior alveolar 

nerve (IAN) is one of the least desired complications of 

third molar surgery. The incidence of IAN and lingual nerve 

injuries reported, ranges from 0.4% to 22% and most of these 

injuries undergo spontaneous recovery. [4, 7 ] 

Neurosensory deficit after lower third molar surgery 

occurs at prevalences of 0.1% to 22% for lingual nerve (LN) 

deficit and 0.26% to 8.4% for inferior alveolar nerve (IAN) 

deficit. Sensory deficits may present as anesthesia, 

hypoesthesia, hyperesthesia, or dysesthesia in the distributions 

of the LN or IAN, with or without taste disturbance, if 

the LN is also affected. Within 4 - 8 weeks after surgery, 96% 

of inferior alveolar nerve (IAN) injuries recover [33], and the 

recovery rates are not influenced by gender and only slightly 

by age [34]. Some injuries may be permanent, lasting longer 

than 6 months, and with varying outcomes ranging from mild 

hypoesthesia to complete anaesthesia and neuropathic responses 

resulting in chronic pain. The results showed that 

after 6 months, recovery seemed to be slight, and confirmed 

that permanent IAN dysfunction is more frequent after M3 

removal in patients older than 30 years. 

One third of neurosensory deficits after third molar 

surgery can be permanent. Although some patients can cope 

well with mild to moderate hypoesthesia of the affected area, 

those who are severely affected often request treatment for 

the condition. The quality of life of patients with anesthesia, 

severe hypoesthesia, hyperesthesia, dysesthesia, or taste disturbance 

of the affected area can be significantly impaired. 

Different treatments have been reported in the literature, yet 

their efficacies seemed to be variable. [35] 

The lingual nerve is most often injured during soft 

tissue flap reflection, whereas the inferior alveolar nerve is 

injured when the roots of the teeth are manipulated and elevated 

from the socket. [2] 

There are various neurosensory tests used to evaluate 

objectively the severity of nerve injury and monitor recovery 

of the sensation. [35] 

Risk factors as regards to damage to IAN are the depth 

of impaction and dental proximity to alveolar canal.[4] Accordingly, 

Blondeau and Daniel [3] recommended that prophylactic 

M3 extraction should be avoided in patients aged 

24 years or older because of a high possibility of complications 

such as permanent neurosensory deficits, infection, and 

alveolar osteitis. 

The risk factors associated with permanent neurosensory 

deficit are Pell and Gregory IC or IIC classification of 

impaction, age greater than 24 years, and in females. [3] 

When an injury to the lingual or inferior alveolar 

nerve is diagnosed in the postoperative period, the surgeon 

should begin long-term planning for its management including 

consideration of referral to a neurologist and/or 

microneurosurgeon. [2] 

The available treatment modalities for an LN and IAN 

injury after third molar surgery seem to have unpredictable 

clinical outcomes and rarely produce complete recovery. 

What is more, there is insufficient information to indicate 

the best timing for the treatment of nerve injury after third 

molar surgery. It has been shown that a significant portion 


of the neurosensory deficit of an LN or IAN after third molar 

surgery can recover spontaneously. Therefore, LN or IAN 

injuries tend to be treated in a delayed fashion, depending 

on the recovery pattern and the extent of disturbance on a 

patient’s social life. It was suggested Wallerian degeneration 

and a smaller Schwann cell population adjacent to the site 

of nerve injury can significantly affect the long-term outcome 

of delayed nerve repair. [35] 

Surgery (external neurolysis, direct suturing, autogenous 

vein graft bridging nerve defect, gore-tex 

tubing,bridging nerve defect) remained the mainstream of 

treatment of a neurosensory deficit after third molar surgery. 

Most subjects who underwent surgical treatment had LN injuries. 

This can be explained by the fact that the tongue is a 

very sensitive organ and any taste disturbance with an LN 

injury might contribute to a higher demand for nerve repair 

after an LN injury. Several reports suggested a higher chance 

of spontaneous reinnervation and recovery of the nerve 

within the inferior alveolar canal. Full recovery of sensation 

after surgical treatment of the IAN or LN injury is uncommon. 

Fewer than 30% of patients were reported to have 

achieved “complete recovery” after external neurolysis of 

the injured nerve. [35] 

Nonsurgical alternatives for treatment of neurosensory 

deficit are vit. B complex, laser therapy (LLLT), 

corticosteroids, electrophoresis with nivalin, acupuncture. It 

was believed LLLT could decrease scar formation and increase 

collagen formation and healing, which are favorable 

features in nerve regeneration. [35] Scarring at a site of nerve 

repair is thought to impede the regeneration of damaged 

nerve fibers. Our recent studies have shown that anti-scarring 

agents (such as antibodies to TGFâ1 and 2) can be used 

to reduce this problem, and hopefully will result in enhanced 

regeneration. [36] 

Temporomandibular disorders (TMDs) 

Temporomandibular disorders (TMDs) is the term 

used to refer to dysfunctions characterized by pain in the 

region of the temporomandibular joints and periauricular 

area, limitations and deviations in the mandibular movements, 

joint noises and an altered occlusal relation 

(Dworkin et al, 1990). [37] 

The etiology of TMD is multifactorial. When all risk 

factors for TMDs are considered individually, the two most 

prevalent factors identified on this population were tooth 

clenching (77% of the patients) and self-reported stress 

(59.3%) followed by antecedents of extraction of wisdom 

teeth (34.3%), endotracheal intubation (30.7%), biting habits 

(29.3%), gum chewing (28%), and previous orthodontic 

treatment (28%) [38] 

Third molar removal has been implicated as a precipitating 

event for temporomandibular joint disorders. [39, 37] 

That is the reason why Deangelis highlights the importance 

of including an assessment of the temporomandibular apparatus 

in the pre-operative evaluation of patients with impacted 

third molars. [39] 

The traumatic removal of the mandibular third molar 

may promote post surgical consequences such as orofacial 

pain and limited mandibular movements. [37] 

Another study demonstrated that when compared with 

untreated controls, subjects undergoing third molar surgery 

have a statistically insignificant increased incidence of TMDs 

6 months post-operatively. [40] 

Treatment of TMD may involve anterior splints occlusal 

splints, splints with posterior occlusal support, occlusal 

adjustment, removable therapeutic partial prostheses, although 

therapeutic support regimens in the areas of psychology, 

NAID(local and per oral), and physical 

therapy(exercises) and phisioterapy may be associated depending 

on the needs of each patient. [37] 

Rare complications include oro-antral fistulas (0.008– 

0.25%), maxillary tuberosity fractures (0.6%) and mandibular 

fractures (0.0049%) [41] 

Maxillary tuberosity fracture and oro-antral communication 

Upper third molar lies just in front and within the maxillary 

tuberosity. [42] 

Maxillary tuberosity fracture is one of the major complications 

of maxillary third molar extraction. [42] 

The incidence of tuberosity fracture during upper 

molar extraction is relatively low. [43] Bertram and al. reported 

this incidence to be around 0.6%. [44] 

Large fractures of the maxillary tuberosity should be 

viewed as a grave complication.[42] 

The fracture of a large portion of bone in the maxillary 

tuberosity area can result in torrential, life-threatening 

hemorrhage due to close proximity of significant vessels to 

the area. [42, 44] 

Fracture and loss of the maxillary tuberosity not only 

risks exposure and tearing of the maxillary sinus lining but 

also changes the shape of the alveolus such that subsequent 

prosthodontic management may be difficult. [45] 

There is a reported case of subconjunctival 

hemorrhage after tuberosity fracture. [42] 

Cattlin reported that, after maxillary tuberosity fracture, 

deafness occurred from the disruption of the pterygoid 

hamulus and the tensor veli palatine, in turn collapsing the 

opening of the eustachian tube. The patient also suffered permanent 

restricted mandibular movements because of the disruption 

of the pterygoid muscles and ligaments. [43] 

The etiological factors listed in the literature that are 

responsible for a fractured maxillary tuberosity during upper 

molar extraction include the following: large maxillary 

sinus with thin walls/sinus extension into the maxillary tuberosity 

and/or large projection lengths of root apices in 

the sinus cavity; unerupted maxillary third molar; fusion 

between the maxillary third and second molar; teeth with 

large divergent roots; teeth with an abnormal number of 

roots; teeth with prominent or curved roots; teeth with dental 

anomalies, such as tooth fusion and over-eruption;tooth 

ankylosis;hypercementosis of upper molar teeth; chronic 

periapical infection; excessive force during the tooth luxation 

accomplished by the dentist and others. [43] 

Upon discovering that a maxillary tuberosity has fractured, 

the dentist must first halt the procedure before inadvertent 

laceration of the adjoining soft tissue occurs and then 


determine the extent of the fracture by palpating the mobile 

fragment. After performing the dissection of the soft tissues, 

immediate removal of the small fractures, including the tooth 

with small bony fragments, may be the best option, because 

of the difficulty incurred when attempting to retain the 

bone.When a large bony fragment is present, it is recommended 

(i) that the extraction be abandoned and surgical 

removal of the tooth be performed using root sectioning, (ii) 

that the dentist tries to detach the fractured tuberosity from 

the roots, or (iii) that the dentist stabilizes the mobile part(s) 

of the bone by means of a rigid fixation technique for 4–6 

weeks and, at a future moment, attempts a surgical removal 

without the use of a forceps. [43] 

Oroantral communication is the consequence of a 

loss of continuity between the maxillary sinus and the oral 

cavity. Sinus floor perforation occurs due to the close anatomical 

relationship between this structure and the distal 

teeth. [46] 

Oroantral communications (OAC) are common surgical 

complications of dental procedures. An oroantral fistula 

is a pathological condition in which the oral and antral cavities 

have a permanent communication by means of a fibrous 

conjunctive tissue fistula coated by epithelium. [47] 

Intraoperative fracture of the root, higher degree of 

impaction and higher age of the patient are associated with 

a greater likelihood of oroantral perforation. [48] 

A study of 465 extractions and 592 osteotomies of 

the upper third molars revealed that 13% were related directly 

to the diagnosis of a perforated maxillary sinus. Acute 

oroantral communication occurred as a result of the removal 

of completely impacted teeth in 24%, by removal of partially 

impacted teeth in 10% and in fully erupted third molars 

in 5% of all cases. These differences are significant. In 

83%, the diameter of the oroantral perforation was less than 

3 mm. In 19% of all sinus openings, a buccal sliding flap 

was used to close the extraction wound.[48] 

OACs 2 mm in diameter or smaller are likely to close 

spontaneously, without the need for surgical intervention. 

[47] If the exposure of lining is at the apex of a deep socket 

with stable bone walls, and the coagulum is not displaced 

or breaks down, then it may not be necessary to make arrangements 

for complete soft tissue closure but to simply 

inform the patient, give advice on post-operative care and 

review as necessary. [45] 

It has been recognised for many years that some small 

oroantral communications will heal without the formation 

of a fistula or chronic sinusitis. However, this will depend 

upon many factors including the health of the patient and 

their oral soft tissues, the presence or absence of preexisting 

infection, the dimensions of the tooth socket and the postoperative 

care provided by the patient. [45] 

OACs 3 mm in diameter or larger, or OACs associated 

with maxillary or periodontal inflammation, may persist , and 

surgical closure is recommended. Several techniques have 

been used for OAC resolution, such as the use of mucoperiosteal 

flaps (vestibular, palatine, lingual or combined), bone 

grafts, or buccal fat pad grafts (Bichat ball). [47] Grafting of 

the pedicled buccal fat pad is thought to be an efficient, safe 

and easy alternative to a larger oroantral fistula closure. Pedicled 

buccal fat pad grafting could corrected the defect without 

generating any sequelae and/or great postoperative discomfort 

to the patient.[47] 

Mandibular fractures 

Mandibular fractures are a rare but severe complication 

of third molar removal. [49] 

Reports of mandibular fracture during and after third 

molar removal are uncommon. [50] 

The incidence is reported to range from 0.0046% to 

0.0075%. It may occure, either operatively, as an immediate 

complication during surgery or postoperatively as a late 

complication, usually within the first 4 weeks post surgery. 

[51] 

Its occurrence is likely to be multifactorial including: 

age, gender, angulation, laterality, extent and degree 

of impaction, relative volume of the tooth in the jaw, preexisting 

infection and associated pathologies (bone lesions) 

contributing to the risk of fracture. [49, 51] Other important 

factors are the anatomy of the teeth and the features 

of the teeth roots. [52] 

Weakening of the mandible as a result of decrease in 

its bone elasticity during aging may be the cause of the 

higher incidence of fractures reported among patients over 

40 years of age at the time of surgery. [51] De Silva reported 

that fractures predominantly occur in patients who are older 

than 25 years. [52] 

Men may be more likely to have late fractures [53]. 

The effect of gender may be related to biting force. Males 

usually show higher levels of biting force as compared to 

females. [51] 

Patients having full dentition are able to produce peak 

levels of biting forces, that are transmitted to the weak mandible 

during mastication and consequently the risk of fracture 

is high, regardless of gender. [51] 

The literature indicates that the risk of pathological 

(late) fracture of the mandibular angle after third molar surgery 

for total inclusions (class II-III, type C) is twice that of 

partial inclusions due to the necessity of ostectomies more 

generous than those for partial inclusions. [52] 

The true incidence of postoperative mandibular fractures 

as a result of the extraction is difficult to establish, 

as there are reports on postoperative traumatic mandibular 

fractures that could have happened with an intact mandible, 

and the occurrence of the two conditions may be just 

a coincidence. [51] 

Postoperative fractures were more common than 

intraoperative fractures (2.7:1) and occurred most frequently 

in the second and third weeks (57%). [49] Other studies show 

that 67.8% of fracture cases happened in the second and third 

week post surgery. [52] A ‘cracking’ noise was the most frequent 

presentation (77%). [49] Such cracking noise reported 

by the patient should alert to a possible fracture, even if initially 

the fracture is radiologically undetectable. [51] 

Intraoperative fractures were more frequent among females 

(M:F - 1:1.3) [49] 

Pathological mandibular fractures were typically located 

anterior to the mandibular angle. [54] Wagner et al. 

noticed a significant prevalence of fractures on the left side 


of the patient (70%) over the right side. This was explained 

by better visualization and control of the applied force by 

the surgeon on the right side of the patient as compared to 

the left side.[51] The danger of an immediate jaw fracture 

can be avoided by means of proper instrumentation and by 

refraining from excessive force on the bone. The tooth should 

be sectioned in such a way as to minimize the extent of bone 

removal and force caused by instrumentation. [50] It is more 

likely to occur with young or less experienced professionals. 

[51] The postoperative or late fractures usually occur 

during the second or third postoperative week, and are probably 

as a result of high level of biting forces during mastication, 

when the patient was feeling better. [51] 

This is why it is extremely important to always provide 

adequate instructions to the patient in order to avoid 

early masticatory loads and prevent this complication. [52] 

In selective cases, it is recommended that the patient follow 

a soft diet for up to 4 weeks after the operation. [54] 

CONCLUSION 

Although clinical conditions associated with retained 

third molars are well understood, little is known about the 

impact of those conditions on the quality of life among affected 

patients. There is growing recognition that the impact 

of oral conditions on quality of life is an important outcome 

that can be quite useful in making treatment decisions. 

All the information in this review could be useful for the 

clinicians in order to show all the surgical and pharmacologic 

parameters that may influence the postoperative discomfort 

in the third molar surgeries. 

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LK. Treatment Modalities of Neurosensory 

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Oral Maxillofac Surg. 2012 

Apr;70(4):768-78. [PubMed] 

36. Robinson PP, Loescher AR, 

Yates JM, Smith KG. Current management 

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37. Palinkas M, Nassar RMA, 

Nassar MSP, Bataglion SA, Bataglion 

C, Sverzut CE et al. Limited mandibular 

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38. Robin O, Chiomento A. Prevalence 

of risk factors for temporomandibular 

disorders: a retrospective survey 

from 300 consecutive patients 

seeking care for TMD in a French dental 

school. Int J Stomatol Occlusion 

Med. 2010 Dec;3(4):179-186. 

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39. DeAngelis AF, Chambers IG, 

Hall GM. Temporomandibular joint 

disorders in patients referred for third 

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Dec;54(4):323-325. [PubMed] 

40. Juhl GI, Jansen TS, Norholt SE, 

Svensson P. Incidence of symptoms 

and signs of TMD following third molar 

surgery: a controlled, prospective 

study. J Oral Rehabil. 2009 Mar; 

36(3):199-209. [PubMed] 

41. Kandasamy S, Rinchuse DJ. 

The wisdom behind third molar extractions. 

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RRB, Prasad GA, Sankar K. Maxillary 

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Please cite this article as: Deliverska EG, Petkova M. Complications after extraction of impacted third molars- literature 

review. J of IMAB. 2016 Jul-Sep;22(3):1202-1211. DOI: http://dx.doi.org/10.5272/jimab.2016223.1202 


Corresponding author: 

Elitsa Georgieva Deliverska – Assoc. prof., 

Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, 

Medical University- Sofia; 

1, St. Georgi Sofiiski str., 1431 Sofia, Bulgaria 

E-mail: elitsadeliverska@yahoo.com 



ISSN: 1312-773X 




TREATMENT OF ORAL MUCOSAL LESIONS BY 

SCALPEL EXCISION AND PLATELET-RICH 

FIBRINMEMBRANE GRAFTING: A case report 

Ivan Chenchev, Radka Cholakova 

Department of Oral Surgery, Faculty of Dental Medicine, Medical University – 

Plovdiv, Bulgaria 

ABSTRACT: 

Purpose: The treatment of oral mucosal lesions and 

mucosal hypertrophy in particular, is most often achieved 

by an excision with or without covering the surface of the 

wound. The platelet rich fibrin membrane (PRFm) is an autogenous 

product containing platelets and leukocytes and 

their secreted growth factors and cytokines. The purpose 

of the presented clinical case is to describe a new, recent 

technique used for the covering of mucosal wounds left after 

the removal of pathological lesions. 

Material and Methods: On a single patient mucosal 

hypertrophy was removed by an excision with scalpel and 

the resulting surgical wound was covered with an autogenous 

PRF membrane. Postoperatively the healing process 

was followed on the 7th, 14th and 30th day. 

Results: The healing period went smoothly with 

minimal postoperative discomfort and no complications. 

Conclusion: The results of the presented clinical 

case demonstrate that the PRF membrane can successfully 

be used to cover postoperative mucosal defects. 

Key words: oral mucosal hypertrophy, PRF, oral mucosal 

reconstruction 

INTRODUCTION: 

The treatment of oral mucosal lesions involves the 

elimination of the cause, medical and surgical treatment.[1] 

The surgical treatment of different mucosal lesions, and 

mucosal hypertrophy in particular, consists of an excision 

with or without placing a graft. [2, 3] Platelet rich fibrin 

(PRF) is defined as an autogenous, containing increased 

amount of leukocytes and platelets, solid biomaterial. [4, 

5] For the first time PRF is used in 2001 in France by 

Choukroun J, et al. [6] for purpose of the maxillo-facial surgery. 

The PRF polymerization is slow and occurs when the 

blood is being centrifugated and, due to the autogenous 

thrombin, a physiological autogenous fibrin begins its formation. 

This is an essential condition for the formation of 

the 3D fibrin network. [7] Such configuration suggests the 

prolonged survival of the growth factors (GF) and their prolonged 

release in the initial healing stages. GFs are available 

in situ longer among the surrounding cells and have 

more time to stimulate the healing process. [8,9] Release 

of the growth factors and matrix glycoproteins 

(glycosaminoglycans) may continue for up to 7 days, or 

according to other studies – up to 28 days. [10] PRF is 

made out of patient’s blood in clinical conditions and does 

not contain any chemical or biological supplements. PRF 

is used as a stimulating factor for the bone and soft tissue 

regeneration in dental implantology and periodontal surgery.[11] 

It is used for the healing of extraction wounds,[12] 

treatment of interosseous defects, [13] radicular cysts, [14] 

influencing the jaw bones in the case of biophosphonate 

osteonecrosis, [15] etc. Some authors [16, 17] use PRF membrane 

(PRFm) to cover excision defects of the mucosa while 

others [18, 19] cover palatinal defects left when taking free 

gingival graft (FGG). The aim of the presented clinical case 

is to clinically observe a new recently used technology to 

cover mucosal wounds left in the treatment of pathological 

lesions. 

METHODS AND MATERIALS: 

The patient was a woman aged 69 admitted in the 

department of oral surgery at the Medical University – 

Plovdiv for surgical treatment. The clinical examination 

uncovered mucosal hypertrophy on the right side due to 

chronic irritation by a denture. There were no other subjective 

complaints by the patient – Fig. 1. 

Fig. 1. 


The surgery was held under local anesthetics with 

4% Articaine and 1/200 000 Adrenaline. Excision of the 

altered tissue was done using a scalpel. The resulting mucosal 

wound was covered by PRFm prepared in advance. 

PRFm was stitched using resorbable thread 0000 to the 

margins of the mucosal defect – Fig. 2 a-c. 

Fig. 2c. 

Fig. 2a. 

Fig. 2b. 

The PRF membrane was prepared following the 

method of Choukroun J et al. [6] After the venipuncture 

of v. cubity with a 10ml vacuum test-tube (Advanced- 

PRF), 9ml of blood is taken from the patient. The blood 

is then immediately put into a PRF DUO (Processfor 

PRF®-France) centrifuge for 8 minutes at 1500 RPM. The 

resulting PRF clot is put back into a test-tube using a long, 

straight anatomical tweezers and using surgical scissors 

or scalpel it is separated from the red part (erythrocytes). 

The PRF membrane is formed out of two PRF clots by 

putting two of them on top of one another - Fig. 3a, b. 

The areas bordering with the red part are put on the opposite 

ends and it is then dried in a special for this case box 

A-PRF Box® - Fig. 3c. 

Fig. 3a. 


Fig. 3b. 

surgical intervention. The postoperative pain was measured 

using a standard VAS on 24 hours and the 7th day after the 

surgery. The value on the 24th hour was 3cm, while the 

final value on the 7th day was 2cm. Clinical measurement 

of the wound healing was done using the 5-score Clinical 

Healing Score. [17] The score on the 7th day after the treatment 

was 3 and on the 15th and 30th day it was 0 – Table 

1 end Fig. 4 a, b. 

Fig. 4a. 7th day after the treatment 

Fig. 3c. 

Fig. 4b. 30th day after the treatment 

Postoperatively the patient was assigned oral intake 

of NAIDs (Aulin 0.10g) for a period of 3 days. The patient 

was also given instructions for irrigation of the oral cavity 

with 0.2% solution of chlorehexidine for 7 days. Checkup 

examinations were assigned on the 1st, 7th, 14th and 

30th day after the surgery. 

RESULTS: 

The postoperative period was free of anxiety and 

complications. The threads were removed 7 days after the 

Table 1. Clinical Healing Score (Sum of 5 criteria) 

Criteria Score 7 day 14 day 30 day 

Redness absent 0 1 0 0 

Redness present 1 

Edema absent 0 1 0 0 

Edema present 1 

Healthy granulation tissue present 0 0 0 0 

Healthy granulation tissue absent 1 

Signs of epithelization present 0 1 0 0 

Signs of epithelization absent 1 

Note – The sum of 5 criteria is the clinical healing score; the score is to 0, the better the healing, and vice versa. 


DISCUSSION: 

Excision of oral lesions is preferred over drug treatment 

especially in cases with potential malignancy. [1] 

There is a variety of different care options for the resulting 

in the process wounds of the mucosa with different results. 

Initial covering of adjacent tissues is possible in cases of 

mucosal defects with small surface. In the case of bigger 

defects this is harder and can lead to complications. The 

healing afterwards is associated with a lot of discomfort for 

the patient with a possibility of early and late bleeding infections. 

[17, 19] The usage of the autogenous mucosal 

FGG or dermal graft for the covering of mucosal excision 

wounds results in an additional operative trauma. [3] The 

covering of postexcision wounds of the mucosa is done by 

a variety of auto-plastic material such as hyperdry amniotic 

membrane, artificial derma and collagen membrane. [2, 

17] PRFm was initially used to cover mucosal defects of 

the palate, after taking FGG, with very good results. [16, 

18, 19] Pathak H, et al. [17] use PRFm to cover mucosal 

defects after excision in different areas of the oral cavity 

and report some very good clinical results. The results of 

our study coincide with the results published by some 

other authors. [16 - 19] 

CONCLUSION: 

The results of our study allow us to assume that PRF 

membrane with its qualities can successfully be used to 

cover mucosal wounds for the purposes of the oral surgery. 

More and larger studies are necessary for better evaluation 

of the effects of the PRFm when covering mucosal wounds. 

REFERENCES: 

1. van der Waal I. Potentially malignant 

disorders of the oral and 

oropharyngeal mucosa; terminology, 

classification and present concepts of 

management. Oral Oncol. 2009 Apr- 

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Somanathan T, Mathew B, Pandey M, 

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surgical excision of leukoplakia in a 

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3. Yen DJ. Surgical treatment of 

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4. Dohan Ehrenfest DM, 

Rasmusson L, Albrektsson T. Classification 

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pure platelet-rich plasma (P-PRP) to 

leucocyte- and platelet-rich fibrin (L- 

PRF). Trends Biotechnol. 2009 Mar; 

27(3):158–67. [CrossRef] 

5. Dohan DM, Choukroun J, Diss A, 

Dohan SL, Dohan AJ, Mouhyi J, et al. 

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platelet concentrate. Part 

III: leucocyte activation: a new feature 

for platelet concentrates? Oral Surg 

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Endod. 2006 Mar;101(3):e51-5. 


6. Choukroun J, Adda F, Schoeffer 

C, Vervelle A. [PRF: an opportunity in 

perio-implantology] [in French]. 

Implantodontie. 2000; 42:55-62. 

7. Dohan Ehrenfest DM, Del Corso 

M, Diss A, Mouhyi J, Charrier JB. 

Three-dimensional architecture and 

cell composition of a Choukroun’s 

platelet-rich fibrin clot and membrane. 

J Periodontol. 2010 Apr;81(4):546- 

555. [PubMed] 

8. Dohan DM, Choukroun J, Diss 

A, Dohan SL, Dohan AJ, Mouhyi J, et 

al. Platelet-rich fibrin (PRF): a secondgeneration 

platelet concentrate. Part II: 

platelet-related biologic features. Oral 

Surg Oral Med Oral Pathol Oral 

Radiol Endod. 2006 Mar;101(3):e45- 

50. [PubMed] [CrossRef] 

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GM, Doglioli P, Sammartino G. Slow 

release of growth factors and 

thrombospondin-1 in Choukroun’s 

platelet-rich fibrin (PRF): A gold 

standard to achieve for all surgical 

platelet concentrates technologies. 

Growth Factors. 2009 Feb;27(1):63- 

69. [PubMed] 

10. Dohan Ehrenfest DM, Lemo N, 

Jimbo R, Sammartino G. Selecting a 

relevant animal model for testing the 

in vivo effects of Choukroun’s platelet-rich 

fibrin (PRF): rabbit tricks and 

traps. Oral Surg Oral Med Oral Pathol 

Oral RadiolEndod. 2010 Oct; 

110(4):413-6. [PubMed] [CrossRef] 

11. Dohan Ehrenfest DM. How to 

optimize the preparation of leukocyteand 

platelet-rich fibrin (L-PRF, 

Choukroun’s technique) clots and 

membranes: introducing the PRF Box. 

Oral Surg Oral Med Oral Pathol Oral 

Radiol Endod. 2010 Sep;110(3):275- 


12. Zhao JH, Tsai CH, Chang YC. 

Clinical and histologic evaluations of 

healing in an extraction socket filled 

with platelet-rich fibrin. J Dent Sci. 

2011 Jun;6(2):116-122. [CrossRef] 

13. Chang YC, Wu KC, Zhao JH. 

Clinical application of platelet-rich fibrin 

as the sole grafting material in 

periodontal intrabony defects. J Dent 

Sci. 2011 Sep;6(3):181-188. 

[CrossRef] 

14. Zhao JH, Tsai CH, Chang YC. 

Management of radicular cysts using 

platelet-rich fibrin and bioactive glass: 

a report of two cases. J Formos Med 

Assoc. 2014 Jul;113(7): 470-6. 


15. Saluja H, Dehane V, Mahindra 

U. Platelet-Rich fibrin: A second generation 

platelet concentrate and a new 

friend of oral and maxillofacial surgeons. 

Ann Maxillofac Surg. 2011 

Jan;1(1):53-7. [PubMed] [CrossRef] 

16. Mohanty S, Pathak H, Dabas J. 

Platelet rich fibrin: A new covering 

material for oral mucosal defects. J 

Oral Biol Craniofac Res. 2014 May- 

Aug;4(2):144-6. [PubMed] [CrossRef] 

17. Pathak H, Mohanty S, Urs AB, 

Dabas J. Treatment of Oral Mucosal 

Lesions by Scalpel Excision and Platelet-Rich 

Fibrin Membrane Grafting: 

A Review of 26 Sites. J Oral Maxillofac 

Surg. 2015 Sep; 73(9): 1865-74. 


18. Kulkarni MR, Thomas BS, 

Varghese JM, Bhat GS. Plateletrich 

fibrin as an adjunct to palata 

wound healingafter harvesting a free 

gingival graft: A case series. J Indian 

Soc Periodontol. 2014 May;18(3): 

399-402. [PubMed] [CrossRef] 


19. Shakir Q, Bhasale P, Pailwan N, 

Patil D. Comparison of Effects of PRF 

Dressing in Wound Healing of Palatal 

Donor Site During Free Gingival Grafting 

Procedures with No Dressing at the 

Donor Site. J Res Adv Dent 2015; 

4:(1):69-74. 

Please cite this article as: Chenchev I, Cholakova R. Treatment of Oral Mucosal Lesions by Scalpel Excision and Platelet-Rich 

FibrinMembrane Grafting: A case report. J of IMAB. 2016 Jul-Sep;22(3):1212-1216. DOI: http://dx.doi.org/ 

10.5272/jimab.2016223.1212 



Dr. Ivan Chenchev, 

Department of Oral Surgery, Faculty of Dental Medicine, Medical University – 

Plovdiv, Bulgaria 

E-mail: ivan_chenchev@yahoo.com, 



ISSN: 1312-773X 




A CASE OF COMPOUND MAXILLARY 

ODONTOMA AND MANDIBULAR HYPODONTIA 

Radka Cholakova 1 , Ivan Chenchev 1 , Svetla Jordanova 2 , Diana Oncheva 2 , 

Ljubomir Chenchev 3 

1) Department of Oral Surgery, Faculty of Dental Medicine, Medical University 

– Plovdiv, Bulgaria. 

2) Department of Orthodontics, Faculty of Dental Medicine, Medical University 

– Plovdiv, Bulgaria. 

3) Student in Faculty of Dental Medicine, Medical University – Plovdiv, Bulgaria. 

ABSTACT: 

Odontomas are formations which are still classified 

as benign tumors by the World Health Organization. They 

are lesions on any odontogenic tissue – enamel, cement and 

dentin, which are affected in different proportions and degree. 

We present a case of compound odontoma on upper 

jaw, on a 15 year-old girl, causing retention of a permanent 

canine tooth. After the extirpation 16 tooth-like structures 

were uncovered. The mandible was diagnosed with 

hypodontia of both 2nd premolars. Patient’s history showed 

that there was a trauma in the area of the upper jaw at 

younger age. 

In this article we will present the clinical and radiographic 

examination, the stages of the complex surgicalorthodontic 

treatment and a discussion of the etiology of 

the diagnosis, complications and the treatment itself. 

CASE REPORT: 

In the department of orthodontics of the Faculty of 

Dental Medicine - Plovdiv was admitted a 15 year-old girl 

with an open bite and a persistent right deciduous maxillary 

canine. Patient’s history showed that there was a trauma 

in the frontal area at younger age that lead to the devitalization 

of tooth 11. The history does not tell of any other 

family members with missing teeth and also tells of no other 

past diseases. Examination shows that the patient has an 

open bite, Angle class II, with a persistent 63 tooth and discoloration 

of tooth 11. It is also determined that both mandibular 

second premolars are missing. There were no indications 

of any other accompanying disease. 

Fig. 1. Bite, front 

Keywords: compound odontoma, supernumerary 

teeth, tooth retention, odontogenic tumors, hypodontia, 

complex treatment 

INTRODUCTION: 

Odontomas are formations which are still classified 

as benign tumors by the World Health Organization. They 

are lesions on any odontogenic tissue – enamel, cement and 

dentin, which are affected in different proportions and degree. 

[1, 2, 3, 4] Even though they are similar to hamartomas 

and malformations, the compound odontoma consists 

of multiple small tooth-like structures often firmly adapted 

to one another and covered by more or less continuous connective 

tissue capsule. [1, 5] Odontomas are usually small 

in size but when bigger they can contain up to a thousand 

denticles. The complex odontoma consists of homogenous 

amorphous mass of mature odontogenic tissues with some 

kind of structural organization. The degree of morphological 

differentiation varies for each lesion. A major part of 

some is calcified matrix, while in other cases there are sections 

of pulp tissue in association with cords and buds. 

Hypodontia is a condition of missing up to six tooth 

germs, while if there are more than six missing germs, excluding 

wisdom teeth, it is called oligodontia. Hypodontia 

is assumed to be a hereditary disease which most often affects 

wisdom teeth, 2nd premolars and lateral incisors. The 

absence of permanent teeth is called anodontia. 

Fig. 2. Bite, right profile 


Fig. 3. Bite, left profile 

Orthopantomography and 3D cone beam tomography revealed: 

Fig. 4. Panorama view and display of retained 23 tooth and 63 tooth 

Fig. 5. 3D cone beam tomography – showing palatinal location of the odontoma 

Radiographic assessment: 

· X-ray diagnose 

· Hypodontia 35, 45 

· Impacted canine 23 

· Diagnose of lateral cephalometry 

· Hyperdivergent type of growth 

· Skeletal Class I 

· Radiographic diagnose (3D cone beam tomography) 

- compound odontoma. 

Presence of a limited by a radiopaque unstructured 

matter with tooth-like formations on the upper jaw in the 

area of the right canine, located palatinally and occlusally 


from its germ. Missing germs of second mandibular 

premolars. 

The patient was directed to the Department of Oral 

Surgery for the extraction of the primary canine and extirpation 

of the formation. Under the effect of local anesthetics 

tooth 63 was extracted, while a vestibular and palatinal 

flaps were made. A capsulated formation was revealed containing 

multiple rudimental tooth-like formations which 

were removed in portions as the capsule was ruptured. There 

was a total of 16 such “teeth” with irregular form and size 

at different stage of differentiation. Histological study revealed 

a compound odontoma 

Fig. 8. Stitched operative wound 

Fig. 6. Vestibular and palatal mucoperiosteal flap 

Fig. 7. Tooth-like formation 

DISCUSSION. 

Odontomas are found at a frequency of 0.24% to 

1.12% according to some authors and 0.64% out of all biopsies 

in maxillo-facial surgery. They account for 30.4% 

of all diagnosed odontogenic tumors. [4] Complex odontomas 

are a little more common than the compound ones 

at a proportion of 1:0.96. Men and women are almost 

equally likely to be affected, but there is a characteristic 

gender distribution for some nations (for Egyptians it is 

0.37:1 for men/women, while for Japanese it is 1:0.65 for 

men/women). The complex odontoma is common for people 

about the age of 19.25±2.9 years, while the compound 

odontoma is diagnosed at an older age – 25.14±4.8 years 

old. Maxillary odontomas are most commonly located in 

the frontal area, while the mandibular ones are usually located 

in the molar area. [6] The etiology of the odontomas 

is vaguely known. [4, 7] They can be formed from the tooth 

germ or the teeth during their growth period induced by a 

local trauma, infection, odontoblast hyperactivity, genetic 

mutations. [2, 4, 7, 8, 9, 10] Odontomas are classified as 

tumors but usually stop growing in size when the tissues 

they are made of are fully mineralized. Their clinical 

behavior differs from that of other body tumors as it is characteristic 

for all non-tumor lesions which have dysplastic, 

hemartoma and malformation traits. 

Hypodontia in the deciduous dentition has a rate of 

about 0.4-0.9% for the European population. For the permanent 

dentition it differs for each continent: Europe - men 

4.6%, women 6.3%; Australia - men 5.5%, women 7.6%; 

North American white race - men 3.2%, women 4.6%. Overall 

tooth agenesis for women is 1.37 times more common 

than it is for men. [11, 12] Second mandibular premolar is 

the most often affected, followed by the lateral maxillary 

incisor and the second maxillary molar. [11, 13, 14, 15] It 

is often observed as unilateral than it is as bilateral with 

the exception of the lateral incisors which are usually affected 

bilaterally. Genetics and environmental factors can 

influence the development of the tooth germs. Mutations 

of the homeobox gene MSX 1 leads to hypo-/oligodontia 

of the premolars and molars. [11] External factors include 

inflammation, chemotherapeutics or dioxin. However, many 

cases are caused by genetic factors. Familial predisposition 


association between odontomas and the 

gubernaculum tracts. Oral Surg Oral 

Med Oral Pathol Oral Radiol. 2016 

Jan;121(1):91-5. [PubMed] 

9. Tarjan I, Gyulai SG, Soos A, 

Rozsa N. Tuberculate and odontoma 

type supernumerary teeth. J Craniofac 

Surg. 2005 Nov;16(6):1098-102. 

[PubMed] 

10. Yoda T, Ishii Y, Honma Y, Sakai 

E, Enomoto S. Multiple macrodonts 

with odontoma in a mother and son—a 

variant of Ekman-Westborg-Julin syndrome. 

Report of a case. Oral Surg Oral 

Med Oral Pathol Oral Radiol Endod. 

1998 Mar;85(3):301-3. [PubMed] 

11. Bailleul-Forestier Is, Molla M, 

Verloes Al, Berdal Ar. The genetic basis 

of inherited anomalies of the teeth: 

Part 1: Clinical and molecular aspects 

of non-syndromic dental disorders. Eur 

J Med Genet. 2008 Jul-Aug; 51(4):273- 

9151. [PubMed] 

12. Das G, Sarkar S, Bhattacharya B, 

Saha N. Coexistent partial anodontia 

and supernumerary tooth in the mandibular 

arch: A rare case. J Indian Soc 

Pedod Prev Dent. 2006 May; 24(Suppl 

1):S33-34. [PubMed] 

13. Gabris K, Fabian G, Kaan M, 

Rozsa N, Tarjan I. Prevalence of hypodontia 

and hyperdontia in paedodontic 

and orthodontic patients in Budacan 

be confirmed by the fact that hypodontia is a lot more 

common for monozygotic twins in comparison to dizygotic 

ones. [16, 17, 18] 

CONCLUSION: 

Overall the etiology of the odontomas is unknown. 

They can be formations of the tooth germ or the tooth itself. 

In this case there is the tendency of suppression of the 

development of the dental lamina and a development of 

hypodontia. The stimulated growth of the maxilla is probably 

caused by the local trauma during the development 

period of the tooth germs. The disturbance in the migration, 

proliferation and differentiation of the neural crest 

cells and the interaction between the epithelial and mesenchymal 

cells in the initial stages of the development of 

the dentition can be a possible cause for the simultaneous 

appearance of odontoma and hypodontia. 

REFERENCES: 

1. Atanasov D. (Editor) Oral surgery. 

Tafprint. Plovdiv. 2011: 755-760. 

2. Chrcanovic BR, Jaeger F, Freire- 

Maia B. Two-stage surgical removal of 

large complex odontoma. Oral Maxillofac 

Surg. 2010 Dec;14(4): 247-252. 


3. Kumazawa Y, Kawai T, Shirase 

T,Yagishita H. Multiple calcifying lesions 

in the maxilla and mandible of a 

4-year-old girl: report of a rare case and 

literature review. Oral Radiol. 2014 

Sep;30(3):259-264. [CrossRef] 

4. Pippi R. Odontomas and supernumerary 

teeth: is there a common 

origin?. Int J Med Sci. 2014 Nov; 

11(12):1282-1297. [PubMed] 

5. Meetkamal, Kaur P. Odontoma 

with non-syndrome multiple supplemental 

supernumerary teeth. JCDR. 

2011 Feb;5(1):142-145. 

6. Nelson BL, Thompson LD. Compound 

odontoma. Head and Neck 

Pathol. 2010 Dec;4(4):290-291. 

[PubMed] 

7. Kobayashi TY, Gurgel CV, Cota 

AL, Rios D, Machado MA, Oliveira 

TM. The usefulness of cone beam computed 

tomography for treatment of 

complex odontoma. Eur Arch Paediatr 

Dent. 2013 Jun;14(3):185-189. 

[PubMed] 

8. Oda M, Miyamoto I, Nishida I, 

Tanaka T, Kito S, Seta Y, et al. A spatial 

pest. Community Dent Health. 2006; 

23(2): 80-2. [PubMed] 

14.Yanagida I, Mori S. [Statistical 

studies on numerical anomalies of teeth 

in children using orthopantomograms. 

Hyperdontia]. [in Japanese] Osaka 

Daigaku Shigaku Zasshi. 1990 Dec; 

35(2):564-79. [PubMed] 

15. Yanagida I, Mori S. [Statistical 

studies on numerical anomalies of teeth 

in children using orthopantomograms. 

Congenital coexistence of hyperdontia 

and hypodontia]. [in Japanese] Osaka 

Daigaku Shigaku Zasshi. 1990 

Jun;35(1):6-12. [PubMed] 

16. Temilola DO, Folayan MO, 

Fatusi O, Chukwumah NM, Onyejaka 

N, Oziegbe E, et al. The prevalence, pattern 

and clinical presentation of developmental 

dental hard-tissue anomalies 

in children with primary and mix dentition 

from Ile-Ife, Nigeria. BMC Oral 

Health. 2014 Oct;14:125. [PubMed] 

17. Thesleff I. Epithelial-mesenchymal 

signalling regulating tooth morphogenesis, 

J Cell Sci. 2003 May; 

116(Pt 9):1647-1648. [PubMed] 

18. Townsend G, Bockmann M, 

Hughes T, Brook A. Genetic, environmental 

and epigenetic influences on 

variation in human tooth number, size 

and shape. Odontology. 2012 Jan; 

100(1):1-9. [PubMed] 

Please cite this article as: Cholakova R, Chenchev I, Jordanova S, Oncheva D, Chenchev L. A case of compound maxillary 

odontoma and mandibular hypodontia. J of IMAB. 2016 Jul-Sep;22(3):1217-1220. 

DOI: http://dx.doi.org/10.5272/jimab.2016223.1217 



Dr. Radka Cholakova, 

Department of Oral Surgery, Faculty of Dental Medicine, 

Medical University – Plovdiv, Bulgaria 

E-mail: r_cholakova1978@abv.bg, 



ISSN: 1312-773X 




CURRENT EPIDEMIOLOGY OF LICHEN SIMPLEX 

CHRONICUS 

Filka Georgieva 

Department of Dermatology and Venereology, Faculty of Medicine, Medical 

University- Varna, Bulgaria 

ABSTRACT 

Background Lichen Simplex Chronicus (LSC) is a 

common extremely pruritic dermatoses affecting seriously 

the wellbeing of patients. Although the diagnosis is easily 

confirmed the therapy is still a challenge for specialists. 

The aim of the study was to update the epidemiology 

of LSC. 

Objective and Methods To assess the tendencies in 

distribution of LSC were analyzed data collected from registers 

of Medical Centre “St. Anna” Varna from January 

2007 till July 2015. Data include reports of 39968 outpatients 

with different skin problems. The model of the study 

was retrospective and investigates the total morbidity, gender 

distribution, age distribution, peak condition and place 

of the disease in the structure of selected chronic recurrent 

dermatoses with negative impact on quality of life. Data 

were collected and processed after obtaining written permission 

from the leadership of MC “St. Anna” Varna. 

Results. The overall frequency of LSC was 4.04%. 

It increased from 2.59% (2007) to 4.62% (2015). Results 

show a tendency of rejuvenation of LSH with two peaks of 

morbidity: over 65 years of age 11.87% and second in the 

range 25-30 years -10.77%.The the ratio female / male is 

established to 1.2: 1.The distribution analysis shows the 

prevalence of LSC in winter season – January 5.14%, February 

– 4.57% and low morbidity in summer mouths - July 

1.92% and August 0.66%. (p = 0.001) The distribution of 

LSC was compared with that of several skin diseases with 

a chronic course and a negative influence on the quality 

of life of patients. Results show increasing of LSC from 

3.36% (2008) to 4.55% (2014) (p = 0.001). 

Conclusion This is the first study in our country, 

which aims to update the epidemiology of LSC. 

Key words Epidemiology, Lichen simplex 

chronicus, morbidity 

INTRODUCTION 

Lichen simplex chronicus (LSC) is a chronic skin 

condition occurring as a result of traumatic injury (scratching) 

of the skin. Constant irritation due to strong and uncontrollable 

itching formed infiltrated plaques [1]. The 

condition has been estimated to occur in 12% of the population 

[2]. The highest prevalence is middle to late adulthood, 

with a peak at 30-50 years. Pathogenesis of this dermatosis 

is not well distinguished. Disorders of skin barrier 

are described as a trigger or enhance pathological symptoms 

of LSC [3]. On the other hand, in the pathogenesis of 

LSC an important role have psychological factors. [4] The 

dominant symptom in LSC is pruritus. [1] Although LSC 

is quite common disease with strong impact on quality of 

patients’ life there are not recent studies on its distribution 

and morbidity. The purpose of this study was to update the 

epidemiology of LSC. 

OBJECTIVE AND METHODS 

To assess the tendencies in distribution of LSC were 

analyzed data collected from registers of Medical Centre 

“St. Anna” Varna from January 2007 till July 2015. Data 

include reports of 39968 outpatients with different skin 

problems. Taking into account the specifics of LSC all patients 

younger than 18 years of age were excluded and finally 

observed data include 31 981 dermatologic outpatients. 

Diagnosis LSC was placed in 1305 cases (4.08%). 

Data were collected and processed after obtaining 

written permission from the leadership of MC “St. Anna” 

Varna 

The model of the study was retrospective study. We 

analyzed the total morbidity, gender distribution, age distribution, 

peak condition and place of the disease in the 

structure of selected chronic recurrent dermatoses with 

negative impact on quality of life. 

The statistical analysis was performed with SPSS 

v.21.0 for Windows. Hypotheses were tested using ÷²-criteria 

(for the descriptive profile data). Results with p

Fig. 1. Morbidity of LSH 

The distribution according the gender show the ratio 

female / male to 1.2: 1 For a period of 102 months 571 

( 54.79% ) female and 471 (45.20%) male at first visit and 

141 (53.61%) female and 122 (46.38%) male at checkup 

were diagnosed with LSH (Table 1) 

Table 1. Gender distribution 

period 

LSH 

LSH 

female male 

female male female male 

First 

chec 

total 

n/% n/% 

n/% n/% 

n/% n/% 

visit 

kup 

2007 51 28(54,90) 23(45.09) 13 7(53.84) 6(46.15) 64 35(54.69) 29(45.31) 

2008 90 49(54,44) 41(45.55) 36 20(55.56) 16(44.44) 126 69(54.76) 57(45.23) 

2009 136 73(53,67) 63(46.32) 36 20(55.55) 16(44.44) 172 93(54.06) 79(45.93) 

2010 141 80(56,73) 61(43.26) 43 24(55.81) 19(44.19) 184 104(56.52) 80(43.34) 

2011 183 104(56,83) 79(43.17) 36 20(55.55) 16(44.44) 219 124(56.62) 95(43.37) 

2012 137 73 (53.47) 64 (46.55) 35 19(54.28) 16(45.71) 172 92(53.48) 80(46.51) 

2013 94 50 (53.19) 44 (46.80) 10 5(50) 5(50) 104 55(52.88) 49(47.11) 

2014 137 72 (52.55) 65 (47.77) 37 17(45.94) 20(54.05) 174 89(51.14) 85(48.85) 

july 

2015 

73 42 (57.53) 31 (42.46) 17 9(52,94) 8(47,05) 90 51(56.66) 39(43.44) 

total 1042 571(54.79) 471(45.20) 263 141(53,61) 122(46.38) 1305 712(54.55) 593(45,45) 

Results from distribution according the age show 

two peaks of LSH: over 65 years of age 11.87% and second 

in the range 25-30 years -10.75% .The exact distributions 

is shown on figure 2 

Fig. 2. Distribution according age 


The results of the comparison of age and gender of 

the patients show that in younger age groups most of patients 

are female and this ratio changes with increasing of 

age in favor of male. In group 25-30 years the ratio female / 

male is 1.7: 1, and at the age 65 up years, this ratio has been 

1: 2.3, which is dominated by male patients. (Figure 3) 

Fig. 3. Distribution according crossing age and gender 

In analyzing the possible seasonal distribution of the 

disease the following results were reported. We estimate a 

peak of morbidity during the autumn- winter season, and a 

strong reduction in July and August. The highest rate is 

found during the months January mean 5.14% ( range 2.7% 

-6.6% ) , February –mean 4.57% ( range 2.81% -5.17% ) 

and - December mean 4.44% (range 3.63% -6.14% ) The 

lowest morbidity was in July mean1.92% ( range0,92 % - 

2.28% ) and August mean0.66% . (range0 % -1.85%) (figure 

4) 

Fig. 4. Distribution by months 

The frequency of LSC was compared with that of several 

chronic skin diseases with influence on the quality of 

life of patients including – seborrheic dermatitis, atopic 

dermatitis 18up years, lichen planus, eczema. The morbidity 

of LSC was mean 3.98% with a range of 2.53% for 2007 

to 4.55% for 2014. (Figure 5) 

Fig. 5. The distribution of LSC in group of similar skin disorders 


DISCUSSION 

Although the disease is common in the literature 

there are no comprehensive studies on it epidemiology [5] 

The different authors indicate prevalence between 2% to 

12% [1,5] In the study of 1732 disabled people (aged 50 

up ), Williams W (2008) establishes that 33% of them suffer 

from skin disease , as 13 % are diagnosed with LSC[6]. 

Liao YH, et al (2014) reported the distribution of LSC in 

the range of 0.1 -0.5% [7]. Shukla S. et al (1984) found the 

distribution of LSC to 2% [8]. This study finds incidence 

of LSC- 4.04%. This correlates most to data pointed out in 

study of Khaitan et al (1999) [9]. Relatively large range in 

incidence of the disease could be explained by the different 

target groups, who were included in studies. For example 

Cybulski M. and co-authors (2015) reported that the 

disease commits 12% of patients, but they study the distribution 

of skin diseases among elderly patients [10] while 

we involved patients from different ages. 

In a conducted retrospective study we established, 

significant though slight trend of increasing morbidity over 

the years (p=0.002). As in 2007 frequency was 2.59%, and 

in 2014- 4.62%. The primary visits were respectively 2.54% 

for 2007 and 4.55% for 2014, and checkup - 4.08% for 

2007 and 5.01% for 2014.In literature we did not find such 

studies, which gives us reason to assume that this is the 

first study till now. 

Many data suggest that the peak of the disease is 

between 35 and 50 years of age with more prevalent in female 

than male and the ratio being 2:1[3]. Controversially 

there are data pointing out that LSC is more common in 

adults, with a peak above 65 years of age at the same distribution 

by gender. [10] The data obtained in our study 

showed a ratio of female / male, being 1.2: 1. The distribution 

by age showed two peaks of the disease: over 65 years 

of age 11.87% and second in the range 25-30 years - 

10.77%. The results of the peak of the disease in patients 

over 65 years correlate with the exported data that LSC is 

a dermatosis of adulthood. [1, 10, 11] In the literature we 

met no reports of “rejuvenation of the disease.” We assume 

that the peak in the age 25-30 years is due to the increased 

physical and mental stress, which is one of the major 

pathogenetic mechanisms of the disease [3]. It was further 

investigated the addiction between age groups and gender 

of the patients. In younger ages most of patients were female 

while with the increasing of the age number of male 

predominated. So in age group 25-30 years the ratio female 

/ male was 1.7: 1, and in age group 65up years this ratio 

was 1: 2.3. 

Results are discussed in the light of other dermatological 

pathologies which have similar characteristics with 

LSC. The distribution of LSC compared with that of several 

skin diseases with a chronic course and a negative influence 

on the quality of life of patients show increasing 

of LSC from 3.36% (2008) to 4.55% (2014) (p = 0.001). 

The seasonal modulation in LSC should be expected 

because etiopathogenetic mechanisms of the disease [12, 

13]. Link between skin hydration and cold seasons been 

known long ago [14] Boulter E.et al (2013) published data 

on the relationship between homeostasis of skin barrier 

(corneal layer) and the age and season. [15]. Slominski and 

colleagues (2013) found seasonal variations in hormonal 

activity [16] Several studies show an increased risk of depression 

and suicide attempts during the cold seasons and 

in countries with lower levels of sun [17] .All these data 

explain established in our study seasonal modulation in 

LSC. The results showed peak of the disease during the autumn- 

winter season, and a significant reduction in July and 

August. Most high percentage was recorded in January an 

average of 5.14 %, 4.57 % in February and 4.44% in December. 

Lowest was morbidity in July 1.92% and August 

0.66%. 

CONCLUSION 

Lichen Simplex Chronicus (LSC) is a skin disorder 

characterized by itching, which seems to have a marked 

psychological component. The disease is quite common. 

However, the epidemiological futures are few investigated 

so far. This is the first study in our country, which aims to 

update the epidemiology of LSC- including social, demographic, 

and disease related futures. 

REFERENCES: 

1. James WD, Berger TG, Elston DM. 

Andrew’s Diseases of the Skin. International 

edition. 12th Ed., Clinical Dermatology. 

Elsevier. May 2015. [Internet] 

2. Lotti T, Buggiani G, Prignano F. 

Prurigo nodularis and lichen simplex 

chronicus. Dermatol Ther. 2008 Jan-Feb; 


3. Martin-Brufau R, Corbalan- Berna 

J, Ramirez-Andreo A, Brufau-Redondro 

C, Liminana- Gras R. Personality differences 

between patiens with lichen simplex 

chronicus and normal population: 

A study of pruritus. Eur J Dermatol. 2010 

May-Jun;20(3):359-563. [PubMed] 

[CrossRef] 

4. McKoy K. Lichen Simplex 

Chronicus (Neurodermmatitis). Merck 

Manual, 2012 [Internet] 

5. Rajalakshmi R, Thappa DM, 

Jaisankar TJ, Nath AK. Lichen simplex 

chronicus of anogenital region: A 

clinico-etiological study. Indian J Dermatol 

Venereol Leprol. 2011 Jan-Feb; 


6. Williams W, Steward A, von 

Muitus E, Cookson W, Anderson HR. Is 

eczema really on the increase world- 

wide? J Allergy Clin Immunol. 2008 

Apr;121(4):947-54. [CrossRef] 

7. Liao YH, Lin CC, Tsai PP, Shen 

WC, Sung FS, Kao CH Increased risk of 

lichen simplex chronicus in people with 

anxiety disorders:a nationwide population-based 

retrospective cohort study Br 

J Dermatol. 2014 Apr;170(4):890-894. 

[PubMed] 

8. Shukla S, Mukherjee S. Lichen 

simplex chronicus during lithium treatment. 

Am J Psychiatry. 1984 Jul;141(7): 

909-10. [PubMed] 

9. Khaitan BK, Sood A, Singh MK. 


Lichen simplex chronicus with a cutaneous 

horn. Acta Derm Venereol. 1999 

May;79(3):243. [PubMed] 

10. Cybulski M, Krajewska-Kulak E. 

Skin diseases among elderly inhabitants 

of Bialystok, Poland. Clin Interv Aging. 

2015 Dec;10:1937–1943. [PubMed] 

11. Grundmann SA, Stonder S. 

Evaluation of chronic pruritus in older 

patients. Aging Health. 2010 Feb:6(1): 


12. Schaefer H, Redelmeier TE. Skin 

Barrier: Principles of Percutaneous 

Absorbtion. Basel:Karger, 2006: 310- 

336 

13. Rawlings AV, Harding CR. Moisturization 

and skin bappier function. 

Dermatol Ther. 2014 Feb; 17(Suppl 1): 


14. Rogers JS, Harding CR, Mayo A, 

Rawling AV. Stratum corneum lipids: the 

effect of aging and the seasons. Arch 

Derrmatol Res. 1996 Nov;288(12);765- 

770. [PubMed] 

15. Boulter E, Estrach S, Errante A, 

Pons C, Cailleteau L, Tissot F, et al. 

CD98hc(SLC3A2) regulation of skin 

homeostasis wanes with age. J Exp Med. 

2013 Jan;210(1):173-190. [PubMed] 

[CrossRef] 

16. Slominski A, Zbytec B, 

Nikolakis G, Manna PR, Skobowiat C, 

Zmijewski M, at al. Steroidogenesis in 

the skin:Implication for local immune 

functions. J Steroid Biochem Mol Biol. 

2013 Sept;137:107-123. [PubMed] 

[CrossRef] 

17. Fang YX, He M, Lin JY, Ma KJ, 

Zhao H, Hong Z, et al. Suicidal drownings 

with psychiatric disorders in Shanghai: 

a retrospective study from 2010.1 

to 2014.6. PLoS One. 2015 Apr 27;10(4): 

e0121050. [PubMed] [CrossRef] 

Please cite this article as: Georgieva F. Current Epidemiology of Lichen Simplex Chronicus. J of IMAB. 2016 Jul- 

Sep;22(3):1221-1225. DOI: http://dx.doi.org/10.5272/jimab.2016223.1221 



Filka Georgieva 

74b, Tzar Assen str., 9002 Varna Bulgaria 

Tel.: +359 888 513565 

E-mail: filka@abv.bg, 



ISSN: 1312-773X 




HISTORICAL REVIEW OF GNATHODYNAMO- 

METRIC METHODS USED FOR THE ASSESS- 

MENT OF MASTICATORY FUNCTION 

Desislava Konstantinova 1 , Mariana Dimova 2 

1) Department of Prosthetic Dental Medicine and Orthodontics, Faculty of Dental 

Medicine, Medical University - Varna, Bulgaria 

2) Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical 


ABSTRACT 

Gnathodynamometric methods prove to be the oldest 

means available of obtaining an objective quantitative evaluation 

of masticatory efficiency. On the basis of data collected 

using these methods static methods were later introduced and 

in early 20th century functional dynamic methods were first 

applied. Referring to dental literature records, the authors’ 

objective was to provide a review of available historical facts 

about the origin, development and application of 

gnathodynamometers in the study of masticatory function. 

Fig. 1. Borelli’s gnathodynamometer [3] 

Keywords: gnathodynamometer, study of masticatory 

force, bite force, masticatory force 

Gnathodynamometric methods appear to be historically 

the oldest of all methods for the study of masticatory 

function [1]. They equip the dental clinician with information 

about the strength of the muscles of mastication, periodontal 

reactivity as well as the functional and physiological balance 

of teeth. The data can be obtained using a 

gnathodynamometer, a instrument for measuring the muscles 

which elevate or depress the mandible during mastication [2]. 

The aim of the present review is to explore the origin, 

development and application of gnathodynamometers in the 

study of masticatory function. 

MATERIALS AND METHODS 

For the purposes of retrieving literature data a thorough 

analysis was initially carried out on currently available 

relevant literature. Search Method: Over the period March - 

October 2015 the search was performed in stages based on 

the electronic data bases Pub-Med, Science-Direct, Scopus 

in English, German and Russian. Parallel to that search a 

manual literature search was implemented for paper sources 

in Bulgarian, English, German and Russian at the University 

Libraries in Varna and Sofia. The following key words were 

used for the purpose: gnathodynamometer, study of masticatory 

force, bite force, masticatory force. 

As far back as 1681 Borelli, a professor of anatomy in 

Rome first estimated the force of the muscles of mastication 

[1]. The scientist’s method of procedure was to transversely 

pass a loop of cord over the molar teeth of the open mandible 

and under the patient’s chin, onto which he then attached 

various weights (Figure 1). 

The best-known name in connection with 

gnathodynamometers is that of G. V. Black, who worked at 

the subject as far back as 1893. The chapter, „The Force in 

Mastication “ in his “Operative Dental Surgery” contains a 

concise, although by no means exhaustive, account of the 

subject. In 1900 Black constructed the first intraoral device 

for measuring the interplay of forces between the upper and 

lower dentition. He performed this study not only on natural 

but also on plastic teeth of plate dentures. It was established 

that the latter endured 1/4 to 1/3 of the pressure habitually 

exerted by natural teeth. Later Black created an instrument 

which he called a phagodynamometer, consisting of two rugged 

plates, between which he placed the test food, to estimate 

the force required for crushing. 

Much interest caused Haber’s book entitled “Die 

Aufgaben der Kaudruckmessung und der Zahndruck- 

Priifing” which comprised all known research on the subject 

until that time [4]. 

Gnathodynamometers may be divided into three 

classes according to the method of their construction:- 

1. Those which act directly on to the jaw or by means 


of a simple lever (Hebelkonstruktion), 

2. Those which contain a spring (Federkonstruktion), 

3. Those which combine lever and spring, or lever, 

spring and manometer (Kombinietekonstruktion). 

A fourth group is described in which splints are placed 

upon the teeth and a steel stud impinges upon lead 

(Kugelkonstruktion). 

GROUP I is represented by Borelli’s 

gnathodynamometer, which is a loop of cord passed over the 

open mandible with various weights from 60 kg to 200 kg attached 

to it. According to the weight which could be raised 

by closing the jaw, he estimated the force of the muscles of 

mastication. Haber gave a translation in German of the original 

Italian in which the weight was defined between 90-242 

kg, suggesting that the neck muscles came into play in addition 

to the muscles of mastication. 

A hundred years later, Sauer used the same method 

by placing a flat strip of iron across the molar teeth, of sufficient 

length to project beyond the corners of the mouth. A 

hole was bored, through which a cord was passed and secured. 

The end of the cords was attached to a weight standing 

on the floor and it was so arranged that with the mouth 

open the cord was quite tense. By elevation of the jaw, the 

weight, if not too heavy, was lifted and by means of suitable 

additions or subtractions the exact weight was found which 

could be raised and the force of the muscles accordingly estimated. 

In 1911 Eckermann assumed that a firmly closed jaw 

needed the same force to overcome the muscular effort as 

was exerted to achieve contact between the occlusal surfaces 

of the teeth. The apparatus he created, entirely made of steel, 

was quite simple and shaped like a pair of pliers. The jaws of 

the pliers, covered with a softer material on the outer side, 

were gripped between the teeth. Based on his research he 

prepared a formula to make the measurement easier. This 

method of estimation was untrustworthy since although it 

might be possible to build a model which would give results 

according to Eckermann’s formula, the individual characteristics 

of the patient, their speicific bite, root canals and so 

on change the values of the proposed formula, thus rendering 

the results unreliable. 

In 1920 Gysi introduced a new test food (spinach or 

cereals) and observed that in mastication there was “a working 

side” and “a balancing side” of the jaw. He created a 

wooden model representing the muscles of the body and this 

proved that in measuring the force exerted by the muscles of 

mastication, the muscles of both sides should be included. 

GROUP II was represented by gnathodynamometers 

which operate by means of a spring. 

Dr. Black used an instrument consisting of two bars, 

one of which is rigid, the other a strong flat spring. He made 

a trial of the force of the teeth among the students in his 

classes. In the tabulation of the results of 1,000 persons the 

average force was 64 kg. on the molar teeth, and considerably 

less on premolars and incisors. Black was the first to 

recognize the importance of the periodontium and the 

receptors located in it. 

Head criticized Black for testing only the forces transmitted 

vertically, arising from the vertical movement of the 

mandible, and not all the forces involved in a natural mastication 

process. He did not take into consideration the role of 

periodontium. Morelli compensated that by using Collin’s 

dynamometer to measure the forces between the pair of antagonists’ 

teeth and up to the moment the periodontium became 

tender. The time and force multiplied together gave a 

Pressure Constant figure. Observing the area of the root surfaces 

and the pressure constant, he found out that the tolerance 

of the periodontium is proportional to the area of the 

root surface. Morella and later Vesky explained the mechanism 

thanks to which the periodontium endured such pressure 

by comparing it to a hydraulic system. 

Kristiansen (1925, Copenhagen) utilized the principle 

of the parallel pliers. The jaws of the pliers were separated in 

the condition of rest. By compression of the biting plates the 

spiral spring was stretched and the amount of force used was 

registered. 

Haber devoted a considerable amount of time and energy 

to popularizing the use of the gnathodynamometer both 

for the specialist and for the general practitioner. He constructed 

three patterns of gnathodynamometers. Two of them 

belong to the group of gnathodynamometers which operate 

by means of a Spring (Figures 2 and 3). 

Fig. 2. Haber’s gnathodynamometer in box, together with „biting plate” for estimating the pressure of single teeth [4]. 


Fig. 3. Haber’s gnathodynamometer in use on the right-band side of the mouth [4] 

The two patterns are made, one to record up to 50 kg, 

the other up to 150 kg. 

GROUP III was represented by Gnathodynamometers 

which operate by means of more than one of the three factors 

- Spring, Lever and Manometer. 

In 1920 Giinther bored a hole through each of the 

shorter ends or jaws of the pliers in which the pin was received 

and attached to the interchangeable biting plates. The 

plates were of varying sizes according to the tooth which was 

to be tested. As a protection to the teeth each plate was covered 

by a felt pad which could be renewed. 

Each of the subsequently created gnathodynamometers 

was more advanced than the previous one. 

Fig. 5. Gomis’s gnathodynamometer [5]. 

Fig. 4. Johnson’s gnathodynamometer (1930) 

Fig. 6. Measurement of the central incisor’s masticatory 

force of a patient with progenism as per Suzuki [6]. 

Gnathodynamometers are also used in modern-day experimental 

studies (Figures 5 and 6) [5, 6, 7]. 


Fig. 7. Gnathodynamometer for animal testing [7]. 

CONCLUSIONS 

The historical review of gnathodynamometric methods 

enables us to draw the following conclusions: 

Gnathodynamometric studies are objective methods for 

quantitative evaluation of the state of the masticatory apparatus. 

However, they demand specialized equipment, time-consuming 

procedures and therefore are quite costly. More accurate 

results of the study of masticatory function can be 

obtained by complementing gnathodynamometric methods 

with another method of examination of the masticatory apparatus. 

REFERENCES: 

1. Rowlett AE. The gnathodynamometer 

and its use in dentistry. In: Proc 

R Soc Med. 26. ed 9. 1932–1933 :463. 

2. Ortuð G. A new device for measuring 

mastication force (Gnathodynamometer). 

Ann Anat. 2002 Jul;184(4): 

393-396. [PubMed] 

3. Uhlig H. Über die Kaukraft. 

Dtsch Zahnärztl Z. 1953; 8:30-45. 

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1926. 

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EI, Salsench J, Peraire M, Martinez- 

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Please cite this article as: Konstantinova D, Dimova M. HISTORICAL REVIEW OF GNATHODYNAMOMETRIC METH- 

ODS USED FOR THE ASSESSMENT OF MASTICATORY FUNCTION. J of IMAB. 2016 Jul-Sep;22(3):1226-1229. 




Desislava Konstantinova, 

84, Tzar Osvoboditel bul., 9000 Varna, Bulgaria. 

E-mail: konstantinovadesi@yahoo.com 



ISSN: 1312-773X 




IMPACT OF FOOD PREFERENCES ON THE 

DEVELOPMENT OF PATHOLOGICAL CHANGES 

IN THE MASTICATORY APPARATUS IN YOUNG 

PATIENTS 

Desislava Konstantinova 1 , Mariana Dimova 2 , Darina Naydenova 3 

1) Department of Prosthetic Dental Medicine and Orthodontics, Faculty of 

Dental Medicine, Medical University - Varna, Bulgaria 

2) Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, 


3) Department of Preclinical and Clinical Sciences, Faculty of Pharmacy, 

Medical University - Varna, Bulgaria 

ABSTRACT: 

Food can have a mighty biological, therapeutic and 

preventive effect, yet its breakdown can provide the perfect 

setting for tooth decay and its implications, diseases 

of the periodontium and the oral mucosa. Due to the high 

incidence of periodontal and hard dental tissues 

pathologies among adolescents they have been ranked as 

socially significant diseases. A damaged dental-jaw apparatus 

may lead to forming unhealthy eating habits, more 

sensitive food preferences and nutritional deficiency. 

The objective was to explore the prevalence of those 

diseases and the dental hygiene among final year high 

school students as well as to seek any correlation with their 

eating habits and preferences. 

Materials and Methods: The study involved 121 

students who underwent extraoral and intraoral examination 

in order to establish the state of the masticatory apparatus 

whereas the state of oral hygiene was measured as 

per Silness-Löe plaque index. A questionnaire filled out by 

the students provided data on the individual characteristics 

of the masticatory process, eating habits and frequency 

of consumption of certain cariogenic and anticariogenic 

foods and beverages. 

Results: The findings revealed unhealthy food preferences 

in the target group. The unsatisfactory oral hygiene 

habits and food preferences account for the high percentage 

of dental caries. 

Conclusion: Oral health of children and adolescents 

is problematic worldwide and can be resolved with the benefits 

of a balanced diet as well as personal and professional 

oral hygiene, etc. Teaching children the importance of 

proper oral care before reaching adolescence can build 

anticariogenic habits in them for a lifetime. 

Keywords: dental caries, eating habits, cariogenic 

foods and beverages, anticariogenic foods 

Diseases of the masticatory apparatus are among the 

most common chronic diseases and have become a significant 

public health issue owing to the increasing number 

of patients affected by them and the correlation with a 

number of other common diseases. [1] Due to the high incidence 

of periodontal and hard dental tissues pathologies 

among adolescents they have been ranked as socially significant 

diseases. [2] These issues play an important role 

in the etiology of many infectious, cardio-vascular, metabolic 

diseases, etc. [3] Evidence pointing to the fact that 

more and more teenagers enter adolescence with an already 

impaired dental-jaw apparatus is quite alarming. The relationship 

between dietary preferences and masticatory efficiency 

has been investigated by a number of authors. [3, 

4] The link between the beneficial effect of certain foods, 

among which fish, nuts, vegetables, etc., and the proper 

functioning of the human body have long been acknowledged. 

[5, 6, 7, 8, 9] Those studies urged us to shift our 

attention to the potential link between food preferences of 

young patients and their oral health. 

The objective was to explore the prevalence of dental 

caries and the level of dental hygiene among final year 

high school students as well as to seek any correlation with 

their eating habits and preferences. 


A pilot screening was performed targeted at final 

year high school students to establish the state of their masticatory 

apparatus and their food preferences. The study involved 

121 students in overall good health, whose participation 

was random and voluntary. The target group underwent 

a laboratory analysis of serum concentrations of vitamin 

D3, extraoral and intraoral examination to detect the 

presence of hard dental tissues pathologies whereas the 

level of oral hygiene was measured using Silness-Löe 

plaque index. A questionnaire filled out by the students 

provided data on the individual characteristics of the masticatory 

process, eating habits and frequency of consumption 

of certain cariogenic and anticariogenic foods and beverages. 

The data were analyzed using SPSS software for epidemiological 

and clinical research (Windows, V 17.0.0, 

Aug. 2008). The following statistical methods were applied: 

frequency and percentage distribution of data, correlation 

analysis, graphical representation of data. 


RESULTS 

The findings revealed an unhealthy trend of food 

preferences in the target group. Hard nuts and fish are 

among the foods having strong protective effect on dental 

health. Fish is a good dietary source of complete protein, 

essential fats and vitamin D. Each of these nutrients is related 

to dental health. We studied the amount of fish consumption 

among students in Varna, a city of traditions in 

the consumption of seafood. The findings showed that only 

16.7% of students consumed fish two or more times a week, 

as recommended [6, 7], while with more than half of the 

surveyed (55% of the students) fish consumption was so 

low that there was a potential risk of Hypovitaminosis D 

during the winter season (Figure 1). Fish consumption in 

that period is the most important in the protection of dental 

health. 

Fig. 1. Percentage distribution of respondents in the questionnaire on fish consumption 

Our findings strongly matched the results reported 

by other authors. The study of eating habits of students in 

10 th grade from Sofia revealed that only 7% of them consumed 

fish on a weekly basis [1]. The analysis of fish consumption 

data obtained from Varna students indicated those 

consuming least fish were young people aged under 20 

years, whereas the population over the age of 60 had fish 

most often most [5]. It is quite alarming that in a city of 

culinary traditions in fish consumption there is a tendency 

for low fish consumption by children and young people. 

This shift in food patterns increases the risk of Hypovitaminosis 

D among the young generation and thus exposes 

it to a number of socially significant diseases, such as dental 

caries [4]. A laboratory analysis of serum concentrations 

revealed that in 11% of respondents (13 adolescents) there 

was a serious deficiency of vitamin D3 (25-OH), for 46% 

of students the values were below 12.0 ng/ml, and in 30.7% 

the deficit was 12-30 ng/ml (n=4). Satisfactory levels of vitamin 

D3 (above 30 ng/ml) were measured in only 3 final 

year students (23.3%). 

Nuts are among the so called anticariogenic foods 

[10, 11, 12]. They are rich in protein and essential fats and 

contain a small amount of complex carbohydrates and fiber. 

Their nutritional value accounts for their most beneficial 

effect on dental health [8]. The results of the survey 

showed that 7.5% of students consumed nuts every day, 

32% - at least twice weekly, 31% - once a week, 23% - 1-2 

times a month, and 5.5% consumed less or no fish at all. 

The most preferred nuts appeared to be peanuts, almonds 

and hazelnuts (69%, 42%, 38%, respectively). Less frequently 

young people reached for nuts and sunflower seeds 

(33%, 27%, respectively). A small proportion of respondents 

chose raw and unsalted nuts (28%), most favoured 

salted (85%), roasted (79%) or fried (6%) nuts. 

The consumption of nuts within the target group was 

satisfactory. However, young people’s preference for salted 

and processed nuts to raw nuts was unsatisfactory as those 

processes diminish their health benefits. 

Students’ preference for soft drinks is also important 

to consider. About 34% of students (1/3) quenched their 

thirst with water, 31% of them mostly consumed unsweetened 

milk and yogurt drinks, 25% had sweetened drinks 

(tea, juice, sweetened/fruit-flavoured milk), and 11% preferred 

carbonated and energy drinks. 

Raw vegetables have protective effect against dental 

caries. They are part of the daily diet of 2/3 of students 

(74%). 23% of respondents shared that their vegetable intake 

was several times a week, while 13% had them less 

frequently. 48% of students consumed fresh fruit daily, 

whereas 40% had them several times a week. Only 12% of 

respondents did not have fruit regularly. Every third student 

drank processed fruit juices and nectars daily. 37% of 

children admitted to having juices regularly throughout the 

week, whereas about 1/3 of the respondents consumed them 

less frequently or thoroughly avoided them. (Figure 2) 


Fig. 2. Percentage distribution of respondents in the questionnaire on drink preferences when thirsty 

Nearly half of the students (47%) drank carbonated drinks daily, while 42% consumed them several times a week. 

Only 11% avoided them. (Figure 3) 

Fig. 3. Percentage distribution of respondents in the questionnaire on intake frequency of certain foods and drinks 

The hectic lifestyle nowadays has an inevitable impact on the eating stereotype of young people. Nearly 57% of 

them realized that they ate quickly without chewing the food enough times prior to swallowing. (Figure 4) 

Fig. 4. Percentage distribution of respondents in the questionnaire on their chewing patterns 


Nowadays the quite common fast chewing pattern is often implicated in the fast food preferences of young people. 

80% of polled adolescents preferred soft-textured foods; 7.60% chose normal textured foods, 12.40% consumed 

food with any texture and an alarming rate of 0.00% preferred solid food. 

The consumption of foods in their natural form (fruits, vegetables, nuts) is recommended to stimulate the natural 

self-cleansing action of the mouth. Personal oral hygiene is undoubtedly the main factor in oral health. The findings on 

the oral hygiene state of patients surveyed are quite worrying. (Figure 5) 

Fig. 5. The state of oral hygiene measured using Silness-Löe plaque index. 

The Silness-Löe plaque indices obtained in our study 

showed that nearly half of respondents (42.80%) were given 

Index 3, i.e. plenty of soft material was scraped off the 

probe. 30% displayed moderate buildup of plaque and were 

assigned Index 2. 25.20% had Index 1, i.e. there was no 

visible plaque, still a small amount was scraped. Only 2% 

of all patients surveyed were given Index 0. 

The data showed that 91.94% of patients had never 

been subjected to professional oral hygiene, 4.03% reported 

that once every 3-4 years they resorted to professional care, 

while 4.03% visited the dentist for regular checkups as well 

as professional oral hygiene every 6 months. 

The unsatisfactory oral hygiene habits and food preferences 

for cariogenic foods account for the high percentage 

of dental caries. The following disturbing trend was 

observed: 83.60% of boys surveyed and 78.90% of girls 

had at least one dental caries. A statistically significant 

correlation between young people’s oral hygiene state and 

the presence of active carious lesions was noted (P = 0.020). 

As findings showed, negligence of basic 

anticariogenic factors naturally led to a large percentage 

of subsequent complications (35%), including deep fractured 

teeth, radix reliqua (21%) and tooth loss (14%). 

DISCUSSION 

The results obtained from the study disclosed a high 

incidence of dental caries and poor oral hygiene habits. 

The trend towards unhealthy food preferences was 

implicated in the etiology of dental caries: 30% of students 

drank sweetened juices daily and 47% had sweetened carbonated 

beverages. The study also established insufficient 

consumption of fish and nuts, which are foods with proven 

anticariogenic effect. Fish was part of the daily diet in 

16.7% of students surveyed, whereas nuts were often consumed 

by nearly 32% of them. Most young people (85%) 

preferred salted and roasted nuts to natural raw nuts, thus 

diminishing their dental health benefits. A significant part 

of students daily consumed fresh fruit (48%) and vegetables 

(74%). 

CONCLUSION 

Oral health of children and young people has been 

a serious issue worldwide. It can be resolved with the benefits 

of a balanced diet as well as personal and professional 

oral hygiene, etc. This implies the collaboration of parents, 

teachers, dentists and nutritionists. Teaching children the 

importance of proper oral care before reaching adolescence 

can build anticariogenic habits in them for a lifetime. 


REFERENCES: 

1. Kiryakova S. [Dietary behavior 

of students as prevention of chronic 

non-infectious diseases]. [in Bulgarian] 

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Please cite this article as: Konstantinova D, Dimova M, Naydenova D. IMPACT OF FOOD PREFERENCES ON THE 

DEVELOPMENT OF PATHOLOGICAL CHANGES IN THE MASTICATORY APPARATUS IN YOUNG PATIENTS. J of 

IMAB. 2016 Jul-Sep;22(3):1230-1234. DOI: http://dx.doi.org/10.5272/jimab.2016223.1230 



Desislava Konstantinova, 

84, Tzar Osvoboditel bul., 9000 Varna, Bulgaria. 

E-mail: konstantinovadesi@yahoo.com 



ISSN: 1312-773X 




PERFORMING TRANSCATHETER AORTIC VALVE 

IMPLANTATION IN PATIENTS WITH CAROTID 

STENOSIS 

Veselin Valkov 1 , Dobrin Kalchev 1 , Atanas Kostadinov 1 , Branimir Kanazirev 2 

1) First Clinic of Cardiology, UMHAT “St. Marina”, Varna, 

2) Department of Internal Medicine, UMHAT “St. Marina”, Varna, 

Medical University, Varna, Bulgaria 

ABSTRACT: 

The management of carotid artery disease in patients 

with severe aortic stenosis referred for transcatheter aortic 

valve implantation is challenging. By reviewing the very 

limited amount of literature we will try to answer the question 

should we perform carotid revascularization before or 

after the TAVI procedure. 

Keywords: Transcatheter aortic-valve implantation 

(TAVI), aortic artery stenosis, carotid stenosis, carotid artery 

stenting (CAS), carotid endarterectomy (CEA) 

INTRODUCTION: 

Combination of aortic stenosis and carotid artery stenosis 

is not uncommon. 

Aortic stenosis is a disease with a long latency period, 

followed by fast progression of the symptoms with a 

high rate of death. 

The classic symptoms of aortic stenosis are: angina 

pectoris – usually during physical effort and relieved by rest; 

heart failure - typically presents with paroxysmal nocturnal 

dyspnea, orthopnea, dyspnea during exertion, and shortness 

of breath; syncope occurs upon physical stress. Syncope is 

caused by vasodilatation in the presence of a fixed stroke volume 

and inability of the left ventricle to compensate for a sudden 

drop of BP when standing up. Less common reason for 

syncope are AV-blocks and short lasting arrhythmias, due to 

ischemic arias in hypertrophied myocardium [1, 2, 3]. 

The atherosclerotic plaques consist of cholesterol crystals, 

necrotic sells and lipids. When present in carotid arteries 

they can lead to thrombosis and embolization. Atherosclerotic 

disease of the carotid artery is usually associated 

with focal neurological deficit (such as by ipsilateral visual 

loss, motor skills deficit) caused by transient ischemic attacks 

(TIAs), strokes and cerebral infarctions [4]. 

The main indication for carotid revascularization is 

stroke prevention. It is contraindicated in patients with a severe 

neurological deficit with cerebral infarction, patients 

with totally occluded carotid artery and concurrent diseases 

that reduce the patient’s life expectancy. 

Patients with severe and symptomatic stenoses have 

a higher risk of stroke. 

According to the North American Symptomatic Carotid 

Endarterectomy Trial (NASCET) symptomatic patents 

with >70% stenoses respond good to the treatment; In symptomatic 

patients with 50 – 69 % stenoses the profit is negli- 

gible and appears to be greater for males. Asymptomatic patients 

with greater than 60% narrowing profit significantly 

less than first group [5]. 

Depending on the periprocedural risk carotid endarterectomy 

(CEA) or carotid artery stenting (CAS) is chosen. 

Anatomical (bilateral stenosis, postoperative restenosis) and 

clinical (cardiopulmonary diseases, prior cranial injury) factors 

can increase the risk during an operation. For stenting 

they are as follows: anatomical (complex aortic arch and 

brachiocephalic arterial anatomy, presence of thrombus, and 

heavy calcification) and clinical (need for heart surgery 

within 30 days) [6]. 

“Carotid artery stenosis occurs in 8–13 % of patients 

with degenerative aortic stenosis. The risk of new postoperative 

stroke after cardiac surgery is thought to be two- to 

four-fold higher in patients with concomitant carotid stenosis” 

[7, 8]. 

AIM of the study: 

The aim of this study is to analyze retrospectively additional 

database containing patients who suffer from aortic 

and carotid stenosis simultaneously, undergoing TAVI. By 

reviewing the very limited amount of literature we will try 

to answer the question should we perform carotid revascularization 

before or after the TAVI procedure.We try to determine 

what is the proper way to treat those patient even when 

they are completely asymptomatic and the carotid stenosis 

was an accidental finding during the preparational studies 

for TAVI. 

Carotid artery stenting is performed in order to reduce 

the number of ischemic episodes. It has been proven that 

operative revascularization is highly beneficial for symptomatic 

patients. Interventional treatment has an advantage 

over operational when it comes to asymptomatic patients [9]. 

CAS has evolved rapidly over the last 15 years. Randomized 

trials comparing stenting with conservative treatment 

are not available. The role of stenting is not yet clear 

despite the existence of several studies comparing interventional 

with operational techniques. CAS should be considered 

in high surgical risk patients requiring revascularization 

according to the SAPPHIRE study results [7, 10]. 

It is recommended by the European Society of Cardiology 

(ESC) guidelines that symptomatic patients with high 

surgical risk undergo CAS (Class IIa). It is reasonable to perform 

CAS on asymptomatic patients with other indications 

for revascularizaion in high-volume centers with low rates 


of periprocedural stroke (50 000 [13]. 

The Placement of Aortic Transcatheter Valves (PART- 

NER) trial is the largest study comparing SAVR and TAVI. 

Stroke is considered one of the most important periprocedural 

complication of both procedures. “Stroke is defined 

as an acute episode of focal or global neurological dysfunction 

caused by the brain, spinal cord, or retinal vascular injury 

as a result of hemorrhage or infarction.” [16]. 

Sometimes the occurrence of stroke happens late after 

the TAVI procedure and can be attributed to other factors 

such as preexisting carotid stenosis and atrial fibrillation 

[16]. In those cases the direct cause of the stroke is hard to 

determine but reevaluation of the antithrombotic medication 

and stenting of a known carotid lesion is reasonable. 

When performing TAVI, strokes are related to debris, 

breaking off the aorta when crossing its arch and when passing 

the valve and deploying the valve. Improving the design 

and reducing the size of the implantable valves and the 

delivery systems leads to significant reduction in periprocedural 

stroke rates [17]. According to the STS database stroke 

occured in 1.5 % of the patients that underwent cardiac surgery 

[18]. The earlier TAVI trials showed higher incidence 

of stroke compared to SAVR but in PARTNER II trial where 

the new Sapien 3 valve was used only 0.9% had disabling 

stoke at 30 days after the procedure [17, 18]. 

The Cardiology department of Pomeranian Medical 

University in Poland conducted a study in which 246 patients 

underwent CAS. 14 of those had aortic stenosis and 2 

of those had procedure-related deaths which is higher mortality 

rate than the rest of the group. This study suggests that 

patients who undergo CAS and have aortic stenosis as a 

comorbidity are at higher risk of death [7]. 

Hospital of the University of Pennsylvania is described 

129 postoperative patients after SAVR. MRI study 

was performed on all of them and it was revealed that 60 

patients (46%) have embolic infarcts, watershed had 2 of 

them (2%), and both - 17 (13%). There was an association 

between watershed infarct and the presence of internal carotid 

artery stenosis ≥70% [19]. 

An American study described 294 TAVI patients, 51 

of which (19%) had at least 50% stenosis of a carotid or vertebral 

artery. Transfemoral access was less common in the 

carotid and vertebral artery disease group (55 % vs 77 %). 

Stroke had 6.8% of patients within 30 days after the procedure. 

None of the patients in the carotid and vertebral artery 

disease group had a stroke. Mortality and overall survival 

rate in the next 30 days in both groups was the same [20]. 

In Departments of Cardiology and Neurology, Tel- 

Aviv Medical Center in Israel a study included 171 patients 

with CAS in patients undergoing TAVI. Carotid plaques had 

164 (96 %) of the patients, severe stenoses (≥70 % stenosis) 

were present in 15 (9 %) patients. CAS was not associated 

with higher 30-day mortality or stroke rates [21]. 

Study of 52 patients by Kar et al. evaluated carotid 

interventions in patients with aortic valve stenosis. The procedure 

was successful in 51 cases. None of them had a stroke 

in 30 day follow up. Five patients (10%) died before AVR. 

DISCUSSION: 

Many of the patients with aortic and carotid stenosis 

are in the high risk group for both TAVI and SAVR. 

Stroke rate after cardiac surgery is 0.8 – 4 % . Combined 

procedures (SAVR and CABG) are more risky. The risk 

of stroke is much higher when a CS is present. Carotid 

revascularization before cardiac surgery is a common practice 

and a lot of data supports this approach. 

CAS and CEA both can lead to cardiovascular instability, 

whch can significantly worsen the condition of patients 

suffering from degenerative aortic stenosis (DAS). Particularly 

undesirable are any drops in systolic blood pressure 

which are more common and long lasting when performing 

CEA. 

CONCLUSION: 

The prevalence of CAS in patients undergoing TAVI 

is high. The presence or absence of carotid or vertebral artery 

stenosis was not significantly related to the occurrence 

of TAVI procedure related stroke. Routine screening for carotid 

and vertebral artery stenoses before TAVI does appear 

justified but always treating them first does not. 

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[CrossRef] 

21. Steinvil A, Leshem-Rubinow E, 

Abramowitz Y, Shacham Y, Arbel Y, Banai 

S, et al. Prevalence and predictors of 

carotid artery stenosis in patients with 

severe aortic stenosis undergoing transcatheter 

aortic valve implantation. Catheter 

Cardiovasc Interv. 2014 Nov 15; 


Please cite this article as: Valkov V, Kalchev D, Kostadinov A, Kanazirev B. Performing transcatheter aortic valve implantation 

in patients with carotid stenosis. J of IMAB. 2016 Jul-Sep;22(3):1235-1237. 




Veselin Valkov, 

First Clinic of Cardiology,Department of Internal Medicine, UMHAT St.Marina, 

Varna; 1, Hr. Smirnensky blvd., Varna, Bulgaria 

Mob: +359889232505 

E-mail: vd.valkoff@abv.bg 



ISSN: 1312-773X 


disease requires a genetic predisposition that interacts with 

the environment to result in illness. Imbalanced brain chemistry, 

specifically in the neurotransmitters dopamine and 

glutamate may also play a role in the development of AD. 

As the world’s population ages the number of people with 

AD is rising dramatically. Additional risks are female gender, 

history of head trauma, a low level of education [1]. 

People suffering from dementia exhibit two main 

types of symptoms: cognitive and neuropsychiatric. The decline 

in cognition involves one or more cognitive domains 

(learning and memory, language, executive function, complex 

attention, perceptual-motor, social cognition) [3]. 

Behavioural and Psychic Symptoms of dementia 

(BPSD) include hallucinations, delusions and different types 

of agitated behaviours [4, 5]. 

The treatment of AD addresses [6]: 

· Cognitive enhancers (cholinesterase inhibitor 

therapy; NMDA-receptor antagonists) to improve, temporally 

stabilize or slow the rate of cognitive decline 

· Disease-modifying factors to reduce progression (antioxidants, 

selegiline, ginkgo biloba, etc.) 

· Psychotropic agents to treat BPSD [7, 8] 

· Treatment of non-psychiatric comorbidity [9,10] 

· Working with caregivers –education, emotional and 

social support, etc. 

Neurotransmitter enhancement therapy with 

cholinesterase inhibitors (ChE-Is) improve cholinergic function 

in AD by inhibiting the destruction of intrasynaptic acetylcholine 

by acetyl-cholinesterase, thus increase cholinergic 

synaptic transmission by inhibiting acetylcholinesterase 

in the synaptic cleft. They still represent the mainstay of 

symptomatic treatment in AD. Three medications belonging 

to this class are currently widely available and are approved 

for the symptomatic treatment of AD for mild to moderate 

dementia: donepezil, rivastigmine, and galantamine. Several 

randomised, controlled trials (RCTs) of ChE-Is in AD have 

demonstrated variable rates of improvement, ranging between 

18 and 48 per cent [11]. The authors discuss that their 

beneficial effects, demonstrated through meta-analyses, are 

modest in terms of cognitive and global measures of response. 

A number of adverse effects associated with ChE-Is 

are not benign and may limit their use in individual patients. 

Another point of discussion concerns costs [12]. In a review 

Birks (2015) discussed the results of 10 randomized, douhttp://dx.doi.org/10.5272/jimab.2016223.1238 


FINANCIAL AVAILABILITY OF IN-HOME MEDICAL 

TREATMENT OF PATIENTS WITH ALZHEIMER’S 

DISEASE 

Mariana Arnaoudova 1 , Anna Todorova 2 , Antoaneta Tsvetkova 3 , 

1) Department of psychiatry and medical psychology, Medical University, Varna, 

2) Faculty of Pharmacy, Medical University, Varna, Bulgaria 

3) Medical College, Medical University, Varna, Bulgaria. 

SUMMARY 

Background: Alzheimer’s disease (AD) is a progressive 

neurodegenerative disorder and presents a great burden 

for the person, family and society as a whole. Since 2012, 

in Bulgaria, AD is accepted as a disorder of a great socioeconomic 

significance and the drugs for home treatment are 

included in the reimbursement list of the National Health 

Insurance Fund (NHIF). 

Objective: To trace the access to treatment of Alzheimer’s 

in-home patients, as a result of generic substitution 

on the base of share distribution of the original and generic 

products. 

Methods: We collected data for the sales of pharmaceutical 

products (PP’s), containing donepezil hydrochloride 

and memantine hydrochloride from a distributor for the 

Northeast region of Bulgaria (Varna) in the period 2014- 

2015. An analysis of the percentage share distribution of the 

original and generic products was conducted. 

Results: According to our results original product 

Aricept accounts for only 4%, while the market share for its 

generics is 96%. In this group the share to be paid from NHIF 

is 25%, the remaining 75% from the cost is paid by the patients. 

The original product Axura occupies 8% market share, 

the generics- 92%. In this group the share to be paid from 

NHIF is 50% for generics, while Axura was removed from 

the Positive reimbursement list. We comment the significant 

differences in the sale shares in several directions. 

Conclusion: The reduction of expenses, with the use 

of generics, would help more patients to receive an optimal 

treatment and the savings could be redirected for other costly 

treatments. 

Key words: Alzheimer’s disease, cholinesterase inhibitors, 

memantine, financial costs, generics 

Introduction: 

Alzheimer’s disease (AD) is the most common cause 

of dementia among people aged 65 and older and accounts 

for 60%-70% of all cases [1]. In Bulgaria they are about 60 

000 [2]. AD is a progressive neurodegenerative disorder and 

presents a great burden for the person, family and society as 

a whole. The underlying causes of Alzheimer’s dementia 

(AD) remain unclear, but it most likely results from a combination 

of genetic and environmental factors, meaning the 


le blind, placebo controlled trials. They demonstrate that 

treatment for 6 months, with donepezil, galantamine or 

rivastigmine at the recommended dose for people with mild, 

moderate or severe dementia due to Alzheimer’s disease, produced 

improvements in cognitive function. Benefits of treatment 

were also seen on measures of activities of daily living 

and behaviour. None of these treatment effects are large 

[13]. 

A dysfunction of glutamatergic neurotransmission, 

manifested as neuronal excitotoxicity, is hypothesized to be 

involved in the etiology of Alzheimer’s disease. Targeting 

the glutamatergic system, specifically NMDA receptors, offers 

a novel approach to treatment. Memantine is the first in 

a novel class of AD medications acting on the glutamatergic 

system by blocking NMDA receptors. Memory loss in Alzheimer’s 

disease is due to a disturbance of message signals in 

the brain. Memantine hydrochloride acts on these (NMDA)- 

receptors improving the transmission of nerve signals and 

the memory. Memantine hydrochloride is used for the treatment 

of patients with moderate to severe Alzheimer’s disease. 

Treatment with the cognitive enhancers should start 

as the diagnosis of AD is established and should be continued 

in advanced phases [5]. 

The long duration and pervasive social impact of the 

disease is reflected in the breakdown of the overall cost. ADassociated 

costs include direct medical costs such as medications, 

non-medication in-home or institutional care and 

indirect costs such as lost productivity of both patient and 

members of the family. 

Patients’ clinical characteristics include cognitive status, 

functional capacity, psychotic symptoms, behavioral 

problems, depressive symptoms, comorbidities, and duration 

of illness [14]. 

Since 2012, in Bulgaria, AD is accepted as a disorder 

of a great socio-economic significance and the drugs for 

home treatment are included in the reimbursement list of the 

National Health Insurance Fund (NHIF). 

Paying for care is a big concern during the course 

of AD. The type and level of care needed change over time. 

Some in-home care costs include: 

· Ongoing medical treatment for Alzheimer’s-related 

symptoms 

· Treatment for other medical conditions 

· Prescription drugs 

· Personal care supplies 

· In-home care services 

According to Rice et al. (2001) opportunities exist 

through patient management programs targeted toward 

early diagnosis, effective use of medications, control of 

comorbidities, and patient and family support to partially 

offset these costs while providing quality patient care [15]. 

The cost of dementia could be significantly reduced. 

Improvements in diagnosis, treatment and care and support 

for people with dementia and their carers would help planning, 

avoidance of future admissions and improved clinical 

management [16]. A great deal of cost savings come 

from generic substitution of drugs. 

The aim of our study is to trace the access to treatment 

of Alzheimer’s in-home patients, as a result of generic 

substitution on the base of share distribution of the original 

and generic products. 

METHODS: 

We collected data for the sales of pharmaceutical products 

(PP’s), containing donepezil hydrochloride and 

memantine hydrochloride from a distributor for the Northeast 

region of Bulgaria (Varna) in the period 2014-2015. An 

analysis of the percentage share distribution of the original 

and generic products was conducted. We chose to report sale 

rates shares because of the different distributors and the frequent 

updating in the prices of the PP’s in the reimbursement 

list, which limits the accuracy of the analysis. 


According to our results original product Aricept accounts 

for only 4%, while the market share for its generics 

is 96% (Fig. 1). In this group the share to be paid from NHIF 

is 25%, the remaining 75% from the cost is paid by the patients. 

Fig. 1. Market shares of Aricept and its generics 

The original product Axura occupies 8% market share, 

the generics- 92% (Fig. 2). In this group the share to be paid 

from NHIF is 50% for generics, while Axura was removed 

from the Positive reimbursement list. 

Fig. 2. Market shares of Axura and its generics 


We comment the significant differences of the sale 

shares in several directions. First, the considerable price 

differentials between original and generic PP’s. Cheaper 

does not mean lower quality. Secondly, the low reimbursement 

rate from the NHIF. Thirdly, the removal of the original 

PP from the Positive reimbursement list. 

Treatment tendencies of AD patients are aligned 

with the Rational Drug Policy, which is a part of the National 

Health Strategy and are prerequisites for successful 

access of the patients to medications, reimbursed by NHIF. 

The final goal is an expanded access to effective treatment 

and to meet the drug therapy needs of all health insured 

persons. The efforts are aimed at protecting the interests of 

patients through creating financial savings through generics 

and biosimilars and the generated resources to be redirected 

to expensive, modern and innovative therapies. 

It is not possible to develop adequate drug therapy 

without the base of generics. Generic drugs are required to 

have the same active ingredient, strength, dosage form, and 

route of administration as the brand name product. 

The stimulation of generics’ production and distribution 

after the expiry of patent protection of the original 

product is a part of the Drug policy and targets a facilitated 

access at a lower price for the patients and the society. 

Availability of generics’ drug treatment consists in their 

cost, which is between 20% and 90% lower in comparison 

with the original products [17]. 

Generic drug policy includes a number of measures 

to encourage physicians and pharmacists in prescribing and 

dispensing generic drugs as well as for patients receiving 

their free system for reimbursement. For countries like Bulgaria, 

where incomes are low, encouraging the use of generics 

is essential to improve patient access to treatment. 

Patients’ preference may depend on a number of factors, 

including knowledge about generics and branded drugs, 

drugs the patient is now using or has used in the past and 

financial incentives to use generic drugs [18]. 

Data from WHO show that the presence of generic 

competition for five years decreased drug prices by 3 times 

while in the absence of such policies drug prices remained 

almost unchanged [19]. 

We would like to give some recommendations: A 

consistent and coherent generic drug policy should be introduced. 

The automatic approval of a price, inclusion in 

the reimbursement list and a status of substitution for the 

generic drugs, as soon as they have received marketing authorization, 

in cases where the declared value is lower than 

the original product compared, to be enabled. Reimbursement 

should be performed according to more clear criteria 

among clinical adequacy and pharmacotherapeutic evaluation 

of one product to another and thus ensuring no replacement 

with pseudo-innovative products with the same 

characteristics and a high price on account of cheaper generic 

products. Physicians should be encouraged to prescribe 

generics and share information for successful prescription 

practices. Provision of information and promotion 

to patients to demand generic drugs. 

CONCLUSION: 

Neurotransmitter enhancement therapy with ChEIs 

and NMDA-receptor antagonists is a treatment approach for 

patients with mild to moderate and severe AD. Treatments 

slow cognitive decline, facilitate the care and delay placement 

of the patients in a nursing home, thus having economic 

benefits. The reduction of expenses, with the use of 

generics, would help more patients to receive an optimal 

treatment and the savings could be redirected for other 

costly treatments. The implementation of the above recommendations 

would lead to increased market competition 

between producers of original products and generics, in 

terms of production and distribution, and of price regulation. 

REFERENCES: 

1. American Psychiatric Association. 

Diagnostic and Statistical 

Manual of Mental Disorders, Fifth 

Edition (DSM-5), American Psychiatric 

Association, Arlington 2013 

[CrossRef] 

2. National Consensus on dementia 

diagnosis, treatment and care. Bulgarian 

Society of Dementia. 2015. 

[Internet] 

3. Larson EB. Evaluation of cognitive 

impairment and dementia. Editors 

DeKosky ST, Schmader KE, Eichel AF. 

Up to Date. 2016 Apr, last updated: 

2015 Oct 28. [Internet]. 

4. Finkel S, Burns A, Cohen G. 

Behavioral and Psychological symptoms 

of Dementia /BPSD/: A Clinical 

and Research Update. Overview. Int 

Psychogeriatr 2000; 12 /Suppl. 1/:13- 

18. 

5. Cummings J. The Neuropsychiatry 

of Alzheimer’s Disease and Related 

Dementias. London: Martin Dunitz 

Ltd. 2003. 309 p. 

6. Ballard C, Corbett A. Management 

of neuropsychiatric symptoms in 

people with dementia. CNS Drugs. 

2010 Sep; 24(9):729-739. [PubMed] 

7. Rosenberg PB, Mielke MM, Han 

D, Leoutsakos JS, Lyketsos CG, Rabins 

PV, et al. The association of psychotropic 

medication use with the cognitive, 

functional, and neuropsychiatric 

trajectory of Alzheimer’s disease. Int J 

Geriatr Psychiatry. 2012 Dec;27(12): 

1248-57. [PubMed] 

8. Maust DT, Kim HM, Seyfried LS, 

Chiang C, Kavanagh J, Schneider LS, 

et al. Antipsychotics, Other Psychotropics, 

and the Risk of Death in Patients 

With Dementia Number Needed 

to Harm. JAMA Psychiatry. 2015 May; 

72(5): 438-445. [PubMed] 

9. Poblador-Plou B, Calderón- 

Larrañaga A, Marta-Moreno J, Hancco- 

Saavedra Sicras-Mainar A, Soljak M, et 

al. Comorbidity of dementia: a crosssectional 

study of primary care older 

patients. BMC Psychiatry. 2014 Mar; 

14:84. [PubMed] 

10. Duthie A, Chew D, Soiza RL. 

Non-psychiatric comorbidity associated 

with Alzheimer’s disease. QJM. 

2011 Nov;104(11):913-20. [PubMed]. 

11. Lanctot KL, Herrmann N, Yau 

KK, Khan LR, Liu BA, LouLou MA, 


et al. Efficacy and safety of cholinesterase 

inhibitors in Alzheimer’s disease: 

A meta-analysis. CMAJ. 2003 Sep16; 

169(6):557-564. 

12. Loveman E, Green C, Kirby J, 

Takeda A, Picot J, Payne E, et al. The 

clinical and cost-effectiveness of donepezil, 

rivastigmine, galantamine and 

memantine for Alzheimer’s disease. 

Health Technol Assess. 2006 Jan; 

10(1):iii-iv. ix-xi: 1-160. [PubMed] 

13. Birks JS. Cholinesterase inhibitors 

for Alzheimer’s disease. Cochrane 

Database of Systematic Reviews, 2015. 

[CrossRef] 

14. Zhu W, Scarmeas N, Torgan R, 

Albert M, Brandt J, Blacker D, et al. 

Clinical features associated with costs 

in early AD. Neurology. 2006 Apr; 

66(7):1021-1028. [PubMed] 

15. Rice DP, Fillit HM, Max W, 

Knopman DS, Lloyd JR, Duttagupta S. 

Prevalence, costs, and treatment of 

Alzheimer’s disease and related dementia: 

a managed care perspective. 

Am J Manag Care. 2001 Aug;7(8):809- 

18. [PubMed] 

16. Living Well With Dementia: a 

national dementia strategy. Guidance. 

3 Feb 2009. [Internet] 

17. Ess SM, Schneeweiss S, Szucs 

TD. European healthcare policies for 

controlling drug expenditure. 

Pharmacoeconomics. 2003;21(2):89- 

103. [PubMed] 

18. ASPE ISSUE BRIEF. Expanding 

the Use of Generic Drugs. ASPE 

Staff. December 1, 2010 [Internet] 

19. Fischer MA, Avorn J. Economic 

consequences of underuse of 

generic drugs: evidence from Medicaid 

and implications for prescription 

drug benefit plans. Health Serv Res. 

2003 Aug;38(4):1051-63. [PubMed] 

Please cite this article as: Arnaoudova M, Todorova A, Tsvetkova A. Financial availability of in-home medical treatment 

of patients with Alzheimer’s disease. J of IMAB. 2016 Jul-Sep;22(3):1238-1241. 



Address for correspondence 

Assoc. prof. Arnaoudova Mariana, MD, PhD 

Department of psychiatry and medical psychology, Medical University, 

55, Marin Drinov str. 9002 Varna, Bulgaria 

Mobile: +359 888 512 627 

e-mail: marnaudova@hotmail.com 



ISSN: 1312-773X 




CORRELATIONS BETWEEN FINDINGS OF 

OCCLUSAL AND MANUAL ANALYSIS IN TMD- 

PATIENTS 

Mariana Dimova 1 , Hristina Arnautska 2 , Desislava Konstantinova 2 , Ivan 

Gerdzhikov 1 , Tihomir Georgiev 3 , Dimitar Yovchev 4 

1) Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical 


2) Department of Prosthetic dentistry and orthodontics, Faculty of Dental 

Medicine, Medical University - Varna, Bulgaria 

3) Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, 

Medical University - Varna, Bulgaria 

4) Department of Imaging and Oral Diagnostics, Faculty of Dental Medicine, 


SUMMARY 

The aim of this study was to investigate and analyze 

the possible correlations between findings by manual functional 

analysis and clinical occlusal analysis in TMD-patients. 

Material and methods: Material of this study are 

111 TMD-patients selected after visual diagnostics, functional 

brief review under Ahlers Jakstatt, intraoral examination 

and taking periodontal status. In the period September 

2014 - March 2016 all patients were subjected to 

manual functional analysis and clinical occlusal analysis. 

17 people (10 women and 7 men) underwent imaging with 

cone-beam computed tomography. 

Results: There were found many statistically significant 

correlations between tests of the structural analysis that 

indicate the relationships between findings. 

Conclusion: The presence of statistically significant 

correlations between occlusal relationships, freedom in the 

centric and condition of the muscle complex of masticatory 

system and TMJ confirm the relationship between the 

state of occlusal components and TMD. 

Key words: freedom in the centric, deep bite, TMD 

Specialized literature abounds with epidemiological 

studies [1, 2, 3, 4], according to which, 50% to 70% of the 

general population have one or more symptoms of functional 

disorders of the masticatory muscles, temporomandibular 

joints (TMJs), teeth or periodontal ligaments. Depending 

on the population studied, methods applied and 

criteria set, subjective symptoms and complaints (reported 

by the patients) with frequency of 60%, or objective findings 

(of clinical functional examinations) with possible frequency 

of up to 90% have been observed [5]. 

Okeson [6] summarizes that according to data of epidemiological 

studies, at least one objective symptom of 

functional disorders of the masticatory system, e.g. pain on 

palpation of the masticatory muscles, has been clinically 

confirmed in 40% to 75% of the adult population. According 

to the scientific researches of Rugh et al. [7] and 

Gremillion et al. [8], 50% to 70% of the general 

populations have at least one symptom of functional disorders. 

According to modern German scientific literature [9], 

the percentage of people suffering from craniomandibular 

disorders (CMDs) is even higher - 70% to 80% among the 

patients in Germany, with at least one clinical finding in 

58% of the studied patients on average. 

Last 10 years have marked a breakthrough in the scientific 

understanding of craniomandibular disorders and 

their relationships with the whole body. This gives grounds 

to Brocker [10] to conclude that 43% of the patients with 

orofacial pain have complaints and pain in five or more 

areas of the body. 

The signs and symptoms of CMDs frequently correlate; 

therefore, correct diagnosis of CMDs requires thorough 

knowledge of neurophysiology of pain [11, 12] and 

neuroanatomic convergencies [12, 13], and suggests an analytical 

diagnostic approach when interpreting the clinical 

findings of structural analysis tests. 

The aim of this study was to investigate and analyze 

possible correlations between the findings of manual functional 

analysis and clinical occlusal analysis in patients 

with CMDs. 

MATERIAL AND METHODS 

The study included 111 patients with CMDs (82 

women and 29 men) (Fig. 1 à, b), selected from five specialized 

dental practices (2 in Prosthetic dentistry, 1 in Orthodontics 

and 1 in Oral surgery), after taking the medical 

history and conducting visual diagnosis, brief functional 

examination according to Ahlers Jakstatt and intraoral examination. 


Fig. 1a b. 

In the period September 2014 - March 2016, all selected 

patients were subjected to manual functional analysis 

and clinical occlusal analysis, conducted by Dimova in 

conformity with the algorithm of AFDT at DGZMK [14]. The 

following findings were considered positive: presence of discomfort 

(+/-); mild pain (+), severe pain (++) or extremely 

severe pain (+++). In assessing the TMJ, positive findings 

included noises (crackling in the joint) during the tests for 

traction, translation and dynamic compression in the TMJ. 

For assessing freedom in centric, the patients were 

asked to close slowly to the first interdental contact, to hold 

a few seconds in this position, and then to clench the teeth. 

The patients performed in triplicate these movements, to exercise 

them; then, clinical correlations between the jaws in 

centric relation (CR) and central occlusion (CO) were registered 

by using: Shimstock foil; blue articulation paper 

PROGRESS 100 ì; red articulation foil Bausch®Arti-Fol® 8 ì 

(Bausch /Dr. Jean Bausch GmbH & Co. KG) and bilateral 

colored markings in the premolar regions. The following 

were considered normal findings: presence of bilateral contacts 

in CR when swallowing; coincidence between CO and 

CR; path of 0.5-1 mm between the two positions, directed 

anteriorly along the sagittal plane. 

17 patients (10 women and 7 men) were subjected to 

diagnostic imaging of the TMJ, by using cone-beam computed 

tomography. 

The resulting examination findings were systematized 

and subjected to statistical processing with the package of 

applied programs for data analysis of epidemiological and 

clinical studies SPSS for Windows, version 16.00 (15/11/ 

2007). Frequency analysis, cross-tabulation and graphical 

methods were used for data presentation; the method of c2- 

criteria (chi-square) or Fisher‘s exact (two-tail) test was used 

for identifying correlation between two qualitative variables. 

RESULTS 

The “Play in the joint” test, conducted as a part of 

the manual analysis, enabled the clinical diagnosis of the 

TMJ. Individual articular areas or the articular capsule were 

subjected to dosed pressure or traction, resulting in positive 

findings, observed in one or both TMJs (in 50.9% or 57 of 

the patients studied), which depended statistically significantly 

from the freedom in centric, documented in the occlusal 

analysis (P=0.013) (Table 1). 

Table 1. Distribution of patients by findings of the tests for traction and translation, and freedom in centric 

Freedom in centric 

CO and Sliding Sliding Sliding to Total 

CRcoincide to the left anteriorly the right number 

Number 20 50 8 9 87 

Positive findings of the tests Absent % by row 23.0% 57.5% 9.2% 10.3% 100.0% 

for traction and translation % by column 100.0% 75.8% 80.0% 60.0% 78.4% 

in the left TMJ Number 0 16 2 6 24 

Present % by row .0% 66.7% 8.3% 25.0% 100.0% 

% by column .0% 24.2% 20.0% 40.0% 21.6% 

Number 20 66 10 15 111 

Total number % by row 18.0% 59.5% 9.0% 13.5% 100.0% 

% by column 100.0% 100.0% 100.0% 100.0% 100.0% 


It is noteworthy that in 23.0% of the patients studied, 

in whom the positions of CO and CR coincided, the tests 

for traction and translation of the joint were asymptomatic. 

In the other patients, who had positive findings of the tests 

when passing from CR to CO, only 8.3% (2 patients) slipped 

anteriorly the mandible, and 91.7% deviated the mandible 

to the left or to the right. These movements away from the 

sagittal plane are coercive and occlusally conditioned by 

the presence of leading facettes or blockages in the occlusoarticulation 

relationships. The correlation between the presence 

of occluso-articulation disorders and the positive findings 

of the tests for traction and translation was also statistically 

significant (P=0.006). 

Statistical analysis of the data has shown a significant 

correlation between the freedom in centric and the results 

obtained from the tests for abduction (P=0.001), adduction 

(P=0.001) and isometric mediotrusion (P=0.005). These 

results confirm the interdependence between the presented 

or obstructed freedom in centric and the relevant state of the 

muscle complex of the masticatory system and the TMJ, and 

refute the opinions of some authors [15, 16, 17] for a lack of 

causality between the occlusal components and CMDs. The 

lateral deviation, recorded on the teeth, most frequently corresponded 

to the deviation of the ipsilateral articular head 

in the lateral and dorsal direction. The reaction in the joint 

was the resultant of the extent and direction of the deviation, 

the duration of the influence and compensatory capabilities 

of the body. For example, among the studied patients 

with CMDs and sliding to the left when passing from CR to 

CO, 75.8% had no symptoms during the tests for traction 

and translation. However, 24.2% of them reacted with pain 

of various intensities. The correlation between the occlusoarticulation 

disorders and the test results for traction and 

translation was statistically significant (P=0.006). 

Statistically significant correlations were also found 

between the presence or absence of freedom in centric and 

the test results for passive compression (P=0.041), dynamic 

compression and translation of the TMJ (P

A significant correlation (P=0.001) between the presence 

of deep bite and arthrosis of the TMJ was also found 

(Fig. 4, Table 2). 

Fig. 4. Patient À.S., aged 30 yrs. CBCT – osteo-arthrosis 

changes in the left TMJ 

Table 2. 

Distribution of patients by the presence of arthrosis in the TMJ and deep bite 

Deep bite 

Absent Present 

Total number 

Arthrosis in the TMJ 

Absent 

Number 24 15 39 

% by row 61.5% 38.5% 100.0% 

Present 

Number 2 15 17 

% by row 11.8% 88.2% 100.0% 

Total number 

Number 26 30 56 

% by row 46.4% 53.6% 100.0% 

It is interesting that the presence of deep bite is significantly 

dependent (P

Kobayashi and Hansson’s experiments on animals in 1988 

[18] to present researches of modern scholars [2, 9, 14]. 

The results confirm the need of modelling the occlusion 

in a way, protective against the TMJ. This means that 

in both central occlusion and articulation, the TMJ should 

not be influenced by retrusively acting forces that subject 

articular ligaments and the bilaminar zone to overload and 

subsequent damage, and produce hypertone in the masticatory 

muscles that resist these forces - m. pterygoideus lateralis, 

m. masseter pars superior and m. pterygoideus medialis. 

Examined with tests for isometric tension, these muscles 

react with pain, graded subjectively by the patients on the 

proposed scale. 

Knowing and understanding of the described correlations 

is essential for the medical practice of professionals 

in General dentistry, Prosthetics and Orthodontics, since the 

nature of their clinical work involves changes in the occlusal 

relationships that result in functional effects on the structures 

of craniomandibular and craniocervical systems (Fig. 

5 - 7). 

Fig. 6. Patient M.P., aged 31 yrs. Treatment with fixed 

appliances in the upper and lower jaw with intrusion of the 

upper front teeth 

Fig. 5. Patient M.P., aged 31 yrs. First clinical examination 

– traumatic deep bite, Angle’s class II 

Fig. 7. Patient M.P., aged 31 yrs. Intraoral view after 

completion of the orthodontic treatment 


CONCLUSION 

Manual functional analysis of the masticatory system 

is a set of tests for isometric muscle tensions, tractions, translations 

and dynamic compressions of the TMJs that upgrade 

the evidence obtained from palpation of the structures of 

masticatory system. 

The results, obtained from the manual analysis, should 

be considered in conjunction with the findings of clinical 

occlusal analysis. Such an analytical approach would allow 

a complete diagnosis of the masticatory system in the context 

of its functional unity and interdependence. 

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Illustrated medical dictionary. 27th ed. 

WB Saunders, 1988. 565 

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The Clinical Management of Orofacial 

Pain. 6th ed. Carol Stream, IL: Quintessence 

Publishing Co, Inc; 2005. 

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health status in the United States: tem- 

poromandibular disorders. J Dent Educ. 

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and etiology of temporomandibular 

disorders and orofacial pain. Tex Dent 

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G, Jakstat HA, Koeck B, Meyer G, et al. 

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konsiliarische Verfahren zur CMD- 

Diagnostik (Stellungnahme der 

DGZMK und der AFDT). Zahnärztl 

Mitt. 2003; 93:1744. 

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Craniomandibuläre Dysfunktionen - 

Wechselwirkungen mit dem Becken. 

[Diplomarbeit] Zürich. 2-2007; p.8-23. 

11. Gutowski A, Bauer A. Funktionsanalyse 

und Funktionstherapie im 

stomatognathen System. Berlin: 

Quintessenz; 1982. 

12. Köneke Ch. Craniomandibuläre 

Dysfunktion. Interdisziplinäre Diagnostik 

und Therapie. Quintessenz 

Verlag, Berlin. 2010 

13. Boisserée W, Schupp W. Kraniomandibuläres 

und musculoskelettales 

System. Quintessenz Verlag. 2012; 

Teile 2:83-126 

14. Dimova M. Contemporary tendencies 

and gnathological preconditions 

in diagnosis and rehabilitation of 

craniomandibular disorders. [Dissertation] 

Medical University Sofia, Bulgaria. 

2015; pp.136-142. [?in Bulgarian?] 

15. Cacchiotti DA, Plesh O, Bianchi 

P, McNeill C. Signs and symptoms in 

samples with and without temporomandibular 

disorders. J Craniomandib 

Disord. 1991 Summer;5(3):167-72. 

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16. Pullinger AG, Seligman DA. The 

degree to which attrition characterizes 

differentiated patient groups of temporomandibular 

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Please cite this article as: Dimova M, Arnautska H, Konstantinova D, Gerdzhikov I, Georgiev T, Yovchev D. CORRELA- 

TIONS BETWEEN FINDINGS OF OCCLUSAL AND MANUAL ANALYSIS IN TMD-PATIENTS. J of IMAB. 2016 Jul- 

Sep;22(3):1242-1247. DOI: http://dx.doi.org/10.5272/jimab.2016223.1242 



Assoc. Prof. Mariana Dimova, PhD, DSc 

Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical 

University - Sofia 

1, St. George Sofiyski blvd., 1431 Sofia, Bulgaria. 

E-mail: marianadimova@abv.bg 



ISSN: 1312-773X 




IMPROVING THE QUALITY OF LIFE THROUGH 

EFFECTS OF TREATMENT WITH LOW INTEN- 

SITY EXTREMELY LOW-FREQUENCY ELECTRO- 

STATIC FIELD WITH DEEP OSCILLATION® IN PA- 

TIENTS WITH BREAST CANCER WITH SECOND- 

ARY LYMPHEDEMA TO PATIENTS TREATED 

WITH STANDARD LYMPH EQUIPMENT. 

Atanas Petkov 1 , Yana Kashilska 2 , Angel Uchikov 1 , Dean Batzelov 3 

1) Department of Special Surgery, Faculty of Medicine, Medical University of 

Plovdiv, Bulgaria. 

2) Department of Health care management, Faculty of Public health, Medical 

University of Plovdiv, Bulgaria. 

3) Student in Faculty of Medicine, Medical University of Plovdiv, Bulgaria. 

ABSTRACT: 

Objective: To examine the damaged symptoms and 

functional disorders in women with secondary 

lymph>edema after breast cancer surgery in which to evaluate 

the therapeutic benefits of treatment with low intensity 

and extremely low frequency electrostatic fields reproduced 

by the - Deep Oscillation® with the program for a manual 

lymphatic drainage. 

Methods: Twenty-one patients, divided into two 

randomized groups. The first group of women consists of 

11 women treated with 10 session’s lymphatic drainage with 

Deep Oscillation. And second control group included 10 

women having undergone only standard lymphatic drainage. 

Subjective assessment includes pain and swelling; 

range of motion in the shoulder joint; movement of the 

neck and an analysis of the volume of the chest using a 

3D system measuring. 

Results: At the beginning of therapy, patients 

had high scores for sensation of pain; swelling of the 

extremities; restricted movement in the shoulder joint; 

restriction in the movement of the spine in the neck 

portion. In the course of treatment the pain reduces its 

intensity, the volume of movement in the shoulder joint 

is returns, but in the study group, which is subjected to 

lymph drainage with low-frequency electrostatic fields 

of apparatus - Deep Oscillation® indicators are much better. 

Moreover, significantly pain reduces. Subjective reduce 

swelling in both groups was confirmed objectively by 3D 

measuring only in the treatment group. 

Conclusion: Manual lymph drainage with deep oscillation 

leads to a significant reduction in pain relief and 

reduce swelling in patients with lymphoedema average 

breast compared with standard mechanical lymphatic drainage. 

Keywords: breast cancer, pain, swelling, lymphatic 

drainage, low intensity and low frequency electrostatic 

fields, 

INTRODUCTION: 

Specialized Hospital for Rehabilitation - Banya, 

Karlovo District is the only health institution on the territory 

of the country where the Physical and Rehabilitation 

Program for women operated on breast carcinoma is successfully 

developed. The program is 10 days and is held 

in groups of 8 women. It is performed by a multidisciplinary 

team of specialists that includes: Physicians in physical and 

rehabilitation medicine; physiotherapists 

(kinesiotherapists, rehabilitation therapists, occupational 

therapists); oncologists; dieticians; clinical psychologists, 

and art-therapists. 

Patients undergoing organ sparing surgery interventions 

respond by amplification of the breast fibrosis, i.e. 

fibrosis of the skin. Goffmann and others. [1] detect breast 

lymphoedema in 9.8% of their patients. They formulate a 

definition for breast lymphoedema: swelling of the breast 

and formation of “orange peel” skin, combined with the 

sensation of heaviness and pain. The largest study included 

160 patients conducted by Rönkä and others [2]. The authors 

found breast swelling in 34% of the patients, orange 

skin in 3.8%, and sensitivity to palpation of the breast in 

59% of the cases. They noticed that the risk of developing 

lymphedema increases with the severity of axillary trauma 

in lymph node dissection, namely by increasing the number 

of the removed lymph nodes under m. pectoralis major. 


Fig. 1. Quadrantectomy with lymph node dissection 

In lymphedema of the breast the patients experience 

a chronic pain of medium to high intensity, discomfort, 

which leads to deterioration in their quality of life. 

Velanovich & Szymanski [3] investigated the quality of life 

in patients with secondary lymphedema. In their study they 

reached to the conclusion that a better treatment of the 

lymphedema is needed to ensure adequate quality of life in 

the operated patients. The diagnosis is usually focused on 

the lymphedema of the arm while the breast lymphedema 

recedes into the background. The degree of lymphedema of 

the arm can be quantitatively reproduced by manually measuring 

the circumference of the arm. The only objective way 

to study the lymphedema of the breast is the altered thickness 

of the skin flap. This parameter, however, is poorly reproducible 

and unreliable. 

The objectives of this study are to examine the damaged 

symptoms and functional disorders in women with secondary 

lymphedema after surgical treatment in which to 

evaluate the benefits of the therapeutic treatment with low 

intensity and extremely low frequency electrostatic fields 

reproduced by the apparatus - Deep Oscillation® with a program 

for performing a manual lymph drainage versus the effect 

of treatment with a standard apparatus lymphatic drainage 

technique. 

To study the objectives set we established clear inclusion 

criteria for the test group as criteria in studies: 

Carlson LE, and others [4] and Moadel AB, et al. [5], 

namely: 

1. Patients who underwent organ sparing surgery due 

to breast carcinoma, completed active treatment; on adjuvant 

therapy, 3 months after the surgical treatment at the earliest. 

2. Women with classification of the tumor according 

to TNM as follows: pT1 pN0 M0; pT2 pN0 M0; pT4 

pN0 M0, with lymph node dissection L0, without distant 

metastases M0, i.e. in the 1st; 2nd A, and 3rd A stage. 

3. The ten-day treatment period is at least 20 days 

after radiotherapy, or 10 days after chemotherapy in succession. 

Exclusion criteria were: 

1. Conducted Deep Oscillation® treatment within 

3 months prior to study. 

2. Acute inflammation; acute thrombosis; cardiovascular 

diseases; electronic implant; pregnancy; subjective sensitivity 

to electrical fields. 

To objectify the targeted objectives we created special 

measurement forms they are in studies Egan MY and 

others [6] and Eifel P, et al. [7], that include: Scoring VAS for 

assessment of the pain; lymphatic drainage analysis of the 

upper limb; Kinesiological analysis of the upper limb for the 

range of motion in the shoulder joint, as well as for the range 

of motion in the neck (for reference limits of normal movement 

we accept the following indicators: lateral flexion at 

45°, rotation 60°, anteflexion 40°, retroflexion 30°); 3D measurement 

of the volume of the operated breast with calliper for 

craniometry in anthropological research; oncohematological 

analysis. The indicators are filled on admission and discharge 

of the patient. 

We grouped and evaluated these objective indicators 

so that we can measure the quality of life of patients in absolute 

values analogically to our earlier article about the quality 

of life in patients operated for breast cancer after rehabilitation 

in the Specialized Hospital for Rehabilitation - Banya, 

Karlovo District. 

MATERIALS AND METHODS: 

Deep Oscillation® is a therapeutic approach which 

consists in applying intermittent electrostatic field of low 

intensity (U = 100-400V; I = 150¼A) and extremely low frequency 

(30-200Hz, biphasic rectangular) to the target zone. 

The electrostatic field attracts and releases the patient’s tissue 

in the selected frequency, resulting in deep and permanently 

resonant vibrations. When the patient and the therapist 

are connected to the Deep Oscillation® device, serving 

as a voltage source of high internal resistance, a special glove 

serves as an insulator. The impulse of the voltage causes an 

electrostatic force of attraction of the tissues and leads to a 

higher frictional force while the swelling is massaged. Each 

session is for the duration of 30 minutes, starting with 15- 

minute procedures. 

At this point we should clarify the principle and the 

effect of the action of Deep Oscillation® which are expressed 

in two aspects. 

The first aspect - the ability to relax the edema is due 

to the deep and lasting vibrations caused by the electrostatic 

low intensity field, which is acting on the tissue level, and 

the accumulated toxins and sub-products in the extracellular 

space are released and drained by the lymphatic system. 

The second aspect - the reduction of the swelling is 


due to the created electrostatic field, which changes the polarity 

of the cell membrane, and instead if the chemical influences 

in a physical way the cell channels, and in its turn 

this makes them open and release the free radicals and metabolic 

sub-products accumulated in the cytoplasm of the cell 

into the extracellular space, from where the lymphatic system 

picks them up. 

The device has the following physical characteristics: 

low intensity U = 100-400V, low current I = 150¼A (about 

10 times less than in batteries of our mobile phones) and 

extremely low frequency 30-200Hz with a biphase rectangular 

sinusoid, so that the activation of the cells, either its 

own, or of eventual metastatic ones is not possible, thus making 

the therapy with this apparatus in these characteristics 

safe for patients who underwent surgery due to breast cancer, 

as well as for other cancer patients. 

Fig. 2. Manual technique with Deep Oscillation® 

To achieve the objective measurement in the control 

group and the test group we fill the obtained results in the 

table of Quality of Life and compare its absolute values. 

The assessment of each criterion allows for the objective 

inclusion of the patients in the created Total Life Quality 

Scale. According to it, each criterion can be assessed with 

three answers that give – 0; 1 or 2 points. With a score from 0 

to 3 points - there is no improvement in the quality of life. 

With a score from 4 to 7 points the assessment of the improvement 

in the quality of life is “Good”. “Very good” is the 

assessment of the improvement in the quality of life with a 

score from 8 to 10 points. 

Table 1. TLQ scale and table for determining the Quality of Life in women who underwent oncological surgery due 

to breast cancer. 

N CRITERION INDICATOR SCORE 

Mild pains 0-4 0 

1 Pain Severity (VAS) Moderate pains 5-7 1 

Severe pains 8-10 2 

No change 0 

2 Swelling of the limb Functional improvement 1 

Functional and cosmetic improvement 2 

No change – up to 90° 0 

3 Range of motion in the shoulder joint Increase – up to 120° 1 

Increase – over 120° 2 

No change 0 

4 Range of motion in the neck Increase – up to 45° 1 

Increase – over 45° 2 

3D anthropological measurement of No change 0 

5 the volume of the breast Reduction in one size 1 

Reduction in two sizes 2 

TOTAL: 


RESULTS: 

The performed study covered 21 women with breast 

cancer. Their ages ranged between 29 and 61 years. The 

average age was 45 years. Organ sparing surgery – 

quadrantectomy with lymph node dissection was performed 

in all patients who are with secondary lymph>edema in the 

area of the breast. Surgery on the left breast was performed 

in nine patients, and the on the right in 12 patients. The 

mean postoperative time is 2 years and one month. All patients 

had had adjuvant radiotherapy 4 to 5 months prior 

to study. 

Table 2. Stages of the patients included in the study according to the TNM classification. 

STAGES TEST GROUP CONTROL GROUP 

TNM-classification Number % TNM-classification Number % 

I pT1 pN0 M0 7 96% pT1 pN0 M0 9 90% 

I I A pT2 pN0 M0 3 3.1% pT2 pN0 M0 1 10% 

I II B pT4 pN0 M0 1 0.9% pT4 pN0 M0 - 0 % 

1. The evaluation of the moderate pain and the 

severity in all patients in both groups was 4.9 based on a 

visual analogue scale (VAS). The result of swelling is 5.9. 

There were no significant differences between the two 

groups. 

2. The lymph stasis of the upper extremity 

homolateral occurred in all the 11 operated women. The 

conducted low intensity and extremely low frequency 

electrostatic fields reproduced by the apparatus - Deep 

Oscillation® with program for performing a manual lymph 

drainage after instructions of the oncologist at the 11 patients 

with lymph stasis has led to 100% improvement in all of 

them. In 2, 18.5% of the cases a reduction in the 

circumference of the affected limb with 1 cm is observed – 

functional improvement, and in the rest 9 women, the 81.5% 

reduction in the swollen limb is by 1.5 to 3 cm, thus 

proportionality in the both limbs has been achieved – 

functionally and cosmetically. 

3. Increase in the range of motion in the affected 

shoulder joint of up to 50% was observed in 2 patients, 18.5 

%, and in 9 women, 81.5% and over 50% - which led to 

reference values of the motion in the joint. 

4. The mobility in the neck area is impaired in all 

patients. Only in the test group after the administration of 

the Deep Oscillation® this lead to a significant reduction in 

the pain. 

5. The subjective sensations of reduce in the swelling 

in both groups was confirmed objectively by the 3D 

measurement only in the group treated with Deep 

Oscillation® 

After analyzing the results achieved according to the 

TLQ-scale in the test group 1 female, 0.9% is with “Good” 

improvement in her quality of life, while the other 10 women, 

99.1% are with “Very Good” improvement in their quality 

of life. The results in the control group are 3 women, 30% 

with “Good” improvement in their quality of life, while the 

other 7 women, 70% are with “Very Good” improvement in 

their quality of life. We have not had patients with no 

improvement in their quality of life. 

We attribute the differences mainly to the fifth 

indicator, namely the change in the volume of the 

lymphedema breast in the test group, which was influenced 

by therapeutic low-intensity and extremely low frequency 

electrostatic fields, while on the control group a standard 

vacuum-machine lymph drainage was applied only in the 

area of the affected unilateral for operation upper limb. 

CONCLUSIONS: 

The Psychosocial Rehabilitation Program of the 

Specialized Hospital for Rehabilitation – Banya, Karlovo 

District with the participation of precise specialists, 

working in a team and in the underlying consistency of 

work and consultations with the women operated for breast 

cancer leads to: 

- Influenced the negative effects of the chemo- and 

radiotherapy. 

- Improving the physical activity of the affected upper 

limb, the general physical activity, and the overall condition 

of the body. 

- Improvement in muscle tone and the muscle strength. 

Improvement of the affected fine movements of the hand 

and the fingers. 

- Disappearance of the heaviness and pain in the hand, 

erysipelas of the affected limb. 

- In the therapeutic treatment of low intensity and 

extremely low frequency electrostatic fields reproduced by 

the apparatus - Deep Oscillation® with a program for 

performing a manual lymph drainage both the burden and 

the pain disappeared, as well as the erysipelas of the affected 

breast and its lymph stasis. 

The increase in the quality of life in the test group 

takes precedence over the increase in the quality of live in 

the control group. The difference is due to the administered 

therapy with low intensity and extremely low-frequency 

electrostatic fields versus a standard vacuum-machine lymph 

drainage in the control group. 

The apparatus used in the study is of innovative 

nature to our country, but our team will continue to work 

in this direction while we will gradually cover larger groups 

of patients while safe keeping their health and in the name 

of the better and modern treatment. The performed study 

and evidence material support the improvement of the 

quality of life of patients with breast carcinoma after 

treatment under the Physical and Rehabilitation Program 

of the Specialized Hospital for Rehabilitation – Banya, 


Karlovo District. We express our gratitude to Acad. Dr 

Damyan Damyanov, MD and Prof. Dr. Elena Ilieva, MD 

without the efforts of which hundreds of women operated 

for breast cancer could not receive an adequate 

postoperative rehabilitation treatment. 

REFERENCES: 

1. Goffman TE, Laronga C, Wilson 

L, Elkins D. Lymphedema of the arm 

and breast in irradiated breast cancer 

patients: risks in an ear of dramatically 

changing axillary surgery. Breast J. 2004 

Sep-Oct;10(5):405-411. [PubMed] 

2. Rönkä RH, Pamilo MS, von Smitten 

KA, Leidenius MH. Breast 

lymphedema after breast conserving 

treatment. Acta Oncol. 2004;43(6):551-7. 

[PubMed] 

3. Velanovich V, Szymansky W. Quality 

of life of breast cancer patients with 

lymphedema. Am J Surg. 1999 Mar; 

177(3):184-188. [PubMed] 

4. Carlson LE, Speca M, Patel KD, 

Goodey E. Mindfulness-based stress reduction 

in relation to quality of life, mood, 

symptoms of stress, and immune parameters 

in breast and prostate cancer outpatients. 

Psychosom Med. 2003 Jul- 

Aug;65(4):571-81. [PubMed] 

5. Moadel AB, Shah C, Wylie-Rosett 

J, Harris MS, Patel SR, Hall CB, et al. 

Randomized controlled trial of yoga 

among a multiethnic sample of breast 

cancer patients: effects on quality of life. 

J Clin Oncol. 2007 Oct 1;25(28):4387-95. 

[PubMed] 

6. Egan MY, McEwencd S, Sikorae L, 

Chasenfg M, Fitchh M, Eldredi S. Perspectives 

in Rehabilitation. Rehabilitation 

following cancer treatment. Disabil 

Rehabil. 2013; 35(26):2245-2258. 

[PubMed] 

7. Eifel P, Axelson JA, Costa J, 

Crowley J, Curran WJ Jr, Deshler A, et al. 

National Institutes of Health Consensus 

Development Conference Statement: 

adjuvant therapy for breast cancer, November 

1-3, 2000. J Natl Cancer Inst. 2001 

Jul;93(13):979-89. [PubMed] 

Please cite this article as: Petkov A, Kashilska Y, Uchikov A, Batzelov D. IMPROVING THE QUALITY OF LIFE THROUGH 

EFFECTS OF TREATMENT WITH LOW INTENSITY EXTREMELY LOW-FREQUENCY ELECTROSTATIC FIELD WITH 

DEEP OSCILLATION® IN PATIENTS WITH BREAST CANCER WITH SECONDARY LYMPHEDEMA TO PATIENTS 

TREATED WITH STANDARD LYMPH EQUIPMENT. J of IMAB. 2016 Jul-Sep;22(2):1248-1252. 




Dr Atanas Petkov PhD, 

One day surgery, 

bul. Peshtersko roud 66, 1-st floor, Plovdiv, Bulgaria, 

Mobile: +359898493554 

E-mail: tumbavw@abv.bg, 



ISSN: 1312-773X 




OUTBREAK INVESTIGATION AND CONTROL OF 

BRUCELLOSIS 

Biserka I. Vasileva 1 , Milena D. Karcheva 2 , Vanya A. Birdanova 3 , Metodi V. Valkov 4 , 

Georgi N. Nikolov 5 , Alexandar V. Valkov 5 

1) Department of Therapeutic Care, Faculty of Health Care, Medical University- 


2) Department of Epidemiology, Faculty of Public Health, Medical University- 


3) Department of Hygiene, Medical Ecology, Occupational Diseases and Disaster 

Medicine, Faculty of Public Health, Medical University-Pleven, Bulgaria 

4) Regional Health Inspectorate-Pleven, Bulgaria 

5) Department of Otolaryngology, Faculty of Medicine, Medical University- 


ABSTRACT 

Background: Brucellosis is an infectious and contagious 

disease caused by bacterial species of the genus 

Brucella. It is a major zoonosis with an important social 

and economic impact. 

Objective: The objective of this study was to investigate 

and analyze the measures application for control and 

eradication of brucellosis occurred in the region of Pleven. 

Methods: We conducted a retrospective epidemiological 

study. Respective documents were reviewed. We 

analyzed Case report form and Questionnaire for persons 

suspected of having brucellosis. Conclusions were made of 

the possible source of the disease and the risk factors leading 

to infection of humans. 

Results: A focus of Brucellosis among the animals 

to private goat farm in August was detected. The connection 

to other existing in the country focuses has been 

proved. Two of the persons, having had contacts with the 

animals developed clinical symptoms of the disease; referenced 

persons have consumed fresh goat cheese and milk. 

A joint epidemiological investigation with representatives 

of responsible authorities was carried out and measures undertook 

to restrict and liquidate the focus. 

Conclusion: Brucellosis in man can only be prevented 

effectively by elimination of the animal reservoir. 

This necessitates a close interaction between the medical 

authorities concerned with public health authorities on the 

one hand and the veterinary authorities on the other. 

Key words: brucellosis, epidemiological investigation, 

measures, 

INTRODUCTION 

Brucellosis is a zoonosis and the infection is transmitted 

by direct or indirect contact with infected animals 

or their products. It affects people of all age groups and of 

both sexes. The disease affects people in many parts of the 

world – Mediterranean countries of Europe, North and East 

Africa, the Middle East, South and Central Asia and Central 

and South America [1, 2]. The importance of brucellosis 

for public health is associated with expanded trade in 

animals and animal products [3, 4]. The reduced control of 

hygienic measures poses a risk of spreading the disease and 

return into Brucella-free regions. 

According to the data of Surveillance report (Annual 

epidemiological report 2014 – food- and waterborne diseases 

and zoonoses) in 2012, 376 confirmed cases of brucellosis 

were reported by 27 European Union (EU) and European 

Economic Area (EEA) countries (all except Denmark, 

Liechtenstein and Iceland). The overall rate was 0.08 

cases per 100 000. Greece, Spain, Italy and Portugal were 

the countries that reported a higher number of cases, accounting 

for 73% of all reported confirmed cases. Maleto-female 

ratio was 2:1 in 2012. The majority of the cases 

were adults over 25 years [5]. About 20% of the cases are 

related to traveling abroad. France, Germany and Sweden 

were among the countries with higher proportion of imported 

cases. Seasonality was with case peaks were reported 

from May to August. The morbidity rate among people in 

Bulgaria is sporadic. Sporadic cases have been recorded – 

8 (2008), 3 (2009), 2 (2010), 2 (2011), 1 (2012), 1 (2013), 

2 (2014). In 2015 an epidemic situation occurs in 

Kyustendil district, tenths of people falling ill (37) on the 

background of occurred epizooty among domestic animals. 

It was suspected that the contagious disease was spread out 

by illegally transported animals from neighboring countries.. 

Brucellosis is a disease of animals caused by bacteria 

of the genus Brucella. Main reservoirs of bacteria are 

sheep and goats (B. melitensis), cattle (B. abortus), swine 

(B. suis), dogs (B. canis). In endemic areas, reservoirs can 

be bison, buffalo, camels, dogs, horses, rodents and other 

animals. B. neotomae has been isolated on few occasions 

and has never been implicated in human disease. Brucellosis 

may produce abortion in goats or sheep at about the 

fourth month of pregnancy [3]. Brucella melitensis is a major 

problem in many countries [1, s2]. The possible means 

of acquisition of brucellosis include: infection from a con- 


taminated environment, occupational exposure usually resulting 

from direct contact with infected animals, and food 

borne transmission, bacteria breathing, person-to-person 

transmission (extremely rare). Food borne transmission is 

usually the main source of brucellosis for urban 

populations [5]. The objective of this study was to investigate 

and analyze the measures application for control and 

eradication of brucellosis occurred in the region of Pleven. 

MATERIAL AND METHODS 

We conducted a retrospective epidemiological study. 

Respective documents were reviewed. We analyzed Case 

report form (2 forms) and Questionnaire, suspected for brucellosis 

– 11 contact persons were interviewed. Data collection 

form containing questions about age, sex, residence 

place, occupation, education, contact with animals, food 

consumption, risk habits, geographical risk. Conclusions 

are made of the possible source of the disease and the risk 

factors leading to infection of humans. 

RESULTS 

In August 2015 on the territory of Pleven district 

there broke out a focus of brucellosis among animals in 

private farm, Rakita village, Cherven Bryag municipality. 

Competent authorities were notified – Regional Health Inspectorate-Pleven 

and Regional Food Safety Authority- 

Pleven. Representatives of those authorities conducted together 

epidemiological investigation and established the 

following: there are 60 goats in the farm; 25 bought from 

Rila town, where in spring a focus of brucellosis was recorded. 

Three of newly purchased animals died within the 

period May-August. The laboratory examinations of veterinary 

authorities discover brucellosis. The remaining 22 

goats were also positive to the disease. Meeting was summoned 

of district and municipal epizootic commissions. 

Following measures were undertaken: 

I Regarding the animals 

• Prohibition the movement of big, small ruminating 

and odd-toed animals to and from the affected area.. 

• Identification of animals and recording in Information 

System of Bulgarian Food safety agency (BFSA) 

was done. 

• Epizootic investigation to establish the source of 

infection was carried out. 

• Traceability of big and small ruminating animals’ 

movement to and from the village was performed in order 

to discover focus of the disease. 

• Serological examination of all animals in the settlement 

was done. The new samples from animals in Rakita 

village proved to be negative, so the disease brucellosis 

remained localized only to the initial site. Samples were 

taken from the neighboring village Radomirtsi. 

• Killing of all positive for brucellosis small ruminating 

animals and burning out in incinerating furnace in 

good practice was ordered. 

• Sending of fetuses to miscarried animals for examination 

in National reference laboratory in brucellosis, National 

Diagnostic Science-and-Research Veterinary Medical 

Institute – Sofia. 

• Sending blood samples for serological examination 

of animals within 15 days after proven miscarriage. 

• Forbidding the slaughtering of sheep and goats 

from inflicted area. 

II Regarding animal products and exterior environment 

• Available milk and milk products, own production 

with positive reaction to brucellosis animals to be demolished 

according requirements of Regulation (EO) 1069/ 

2004 dated 21 October 2009. 

• The milk, produced from big and small ruminating 

animals, intended for personal consumption, to be used 

for consumption or for production of milk products with 

ripening period at least 60 days or upon thermal processing 

- pasteurization at min. 72 degrees for 15 sec or at 63 

degrees for 30 minutes. 

• The milk, produced from big and small ruminating 

animals, intended for processing in milk processing enterprises, 

should be used in compliance to specific hygienic 

rules, regarding the foodstuffs from animal origin. 

• Disinfection of yards, premises, inventories and 

dunghills in agricultural areas with positive reaction to brucellosis 

animals. 

At the herein above described focus, 15 persons 

have been in contact with sick animals who consumed fresh 

goat cheese and milk. At the time of survey two persons 

with symptoms of the disease since a week (temperature, 

headache, fatigue, night sweating, muscle and joint pains). 

Blood for hemoculture was taken from those persons and 

directed for consultation and treatment. Three of contaminated 

persons left the settlement and for their new residencies 

the respective Regional health authority being notified. 

Blood was taken from remaining 11 persons for serological 

examination in NRL for Biohazard Level III Infections. 

Two of the samples were positive (of the persons with 

symptoms). Health-promotion activities were performed to 

the stock-breeders of the village. GP doctors in the municipality 

were notified for occurred epidemiological situation. 

As a result of described measures the seat of contamination 

was restricted and liquidated. 

DISCUSSION 

To the 40-ies of XX century the brucellosis among 

animals in Bulgaria had endemic nature and widely spread 

out. The first case with a person was diagnosed in 1903. 

Since then to the beginning of present century, single, sporadic 

cases among people have been registered. Distinguished 

merits in that regard is the contribution of strict 

veterinary control on brucellosis in animal farms as well 

border veterinary-medical control. The disease was liquidated 

among animals and only imported cases were registered 

with people. After 2007 when the country became a 

member of EU there came into force the principle for free 

movement of goods, capitals, services and people. So there 

were imported from Greece on the territory of South Bulgaria 

animals, contaminated with brucellosis [6]. They were 

sold in various areas of the country and renewed the en- 


demic nature of the diseases and respectively the risk for 

people, the evidence for that, registered cases in 2015. As 

in neighboring countries the disease is widely spread, the 

risk to import the contamination is always existing. Restriction 

shall be achieved by measures to liquidate the seats 

among animals as well prevent illegal import of such animals. 

Presented evidence about described focus of brucellosis 

place on the current agenda two basic issues: 

• probable source of infections are goats, bought 

from area where a focus of brucellosis has been identified 

[7]; 

• the persons, suffering from brucellosis have consumed 

fresh goat cheese and milk which is the main reason 

for the alimentary way become a means of contamination 

[8]. 

Common routes of infection include direct inoculation 

through cuts and abrasions in the skin, inoculation via 

the conjunctiva sac of the eyes, inhalation of infectious 

aerosols, and ingestion of infectious unpasteurized milk or 

other dairy products [9]. Blood transfusion, tissue transplantation 

and sexual transmission are possible but rare routes 

of infection. 

In countries with moderate or cold climates there is 

a marked seasonal variation in the incidence of acute brucellosis, 

with most cases occurring in spring and summer. 

This coincides with the peak period for abortions and 

parturitions among farm animals and hence for the highest 

level of exposure of those attending the animals and consuming 

their milk. 

So the prophylactic measures should envisage all 

possible manners of contamination. The recommendations 

in that regard are: 

• Public health education. Training of health workers 

and farm staff [10]. 

• Personal hygiene. All persons carrying out highrisk 

procedures should wear adequate protective clothing. 

This includes an overall or coat, rubber or plastic apron, 

rubber gloves and boots and eye protection (face shield, 

goggles or respirator). The hands should be rinsed in disinfectant, 

washed in soap and water and then treated with 

cream. Eye protection is particularly important as conjunctival 

contamination carries a high risk of infection. Should 

any infectious material enter the eye, it should be removed 

under clean or aseptic conditions away from the working 

area. The eye should be thoroughly rinsed with running 

water and chloramphenicol or tetracycline eye drops or 

ointment applied. Respiratory contamination is also a high 

risk in heavily infected environments. Inhalation of dust 

or aerosols derived from dried excreta or tissues released 

at abortion, parturition or slaughter should be prevented 

by the use of suitable respirators [10]. 

• Prevention of foodborne brucellosis. Boiling or 

high temperature pasteurization will kill Brucella in row 

milk [11, 12]. Ideally all milk produced in areas in which 

brucellosis is present should be pasteurized. If pasteurization 

facilities are not available, the milk should be heated 

to a minimum temperature of 80 - 85°C and the temperature 

held at that level for at least several minutes, or boiled. 

Cheese from non-pasteurized row milk should not be produced 

[13]. 

• Strengthening veterinary and epidemiological 

control in private farms [2, 9, 14]. 

• Ensure an accurate diagnosis - serological and 

microbiological and adequate therapy [15]. 

The lack of safe, effective, widely available vaccines 

approved for human use means that prophylaxis currently 

plays little part in the prevention of human disease. 

CONCLUSION 

Expansion of international travel, urbanization, the 

lack of hygienic measures in animal husbandry and in food 

handling partly account for brucellosis remaining a public 

health hazard. The disease in man can only be prevented 

effectively by elimination of the animal reservoir. This necessitates 

a close interaction between the medical authorities 

concerned with public health authorities on the one 

hand and the veterinary authorities on the other. Surveillance 

in animals and humans is an important step on the 

success of the eradication program. 

REFERENCES: 

1. Aloufi AD, Memish ZA, Assiri 

AM, McNabb SJ. Trends of reported 

human cases of brucellosis, Kingdom 

of Saudi Arabia, 2004–2012. J 

Epidemiol Glob Health. 2016 Mar; 

6(1):11-8. [PubMed]. 

2. Kassiri H, Amani H, Lotfi M. Epidemiological, 

laboratory, diagnostic 

and public health aspects of human brucellosis 

in western Iran. Asian Pac J 

Trop Biomed. 2013 Aug;3(8):589-594. 

[PubMed] 

3. Gul S, Khan A. Epidemiology and 

epizootology of brucellosis: a review. 

Pakistan Vet J. 2007;27(3):145-151. 

4. CDC Brucellosis [Internet] 

5. Asencio MA, Herraez O, Tenias 

JM, Garduão E, Huertas M, Carranza, 

R. et al. Seroprevalence survey of zoonoses 

in extremadura, southwestern 

Spain, 2002-2003. Jpn J Infect Dis. 

2015; 68 (2):106-112. [PubMed] 

6. Tzaneva V, Ivanova S, Georgieva 

M, Tasheva E. Investigation of the 

spread of brucellosis among human and 

animal populations in southeastern 

Bulgaria, 2007. Euro Surveill. 2009 

Apr;14(17):pii:19187. [PubMed] 

7. Rajala EL, Grahn C, Ljung I, 

Sattorov N, Boqvist S, Magnusson U. 

Prevalence and risk factors for Brucella 

seropositivity among sheep and goats 

in a peri-urban region of Tajikistan. Trop 

Anim Health Prod. 2016 Mar;48(3): 

553-558. [PubMed] 

8. Karagiannis I, Mellou K, 

Gkolfinopoulou K, Dougas G, 

Theocharopoulos G, Vourvidis D et al. 

Outbreak of brucellosis in Thassos, 

Greece, 2008. Euro Surveill. 2012 

Mar;17(11):pii:20116. [PubMed] 

9. Ganter M. Zoonotic risks from 

small ruminants. Vet Microbiol. 2015 

Dec;181(1-2):53-65. [PubMed] 

10. Corbel MJ. Brucellosis in hu- 


mans and animals. WHO/CDS/EPR/ 

2006.7:89. [Internet] 

11. Harvey RA, Cornelissen CN, 

Fisher BD. Microbiology. 3rd ed. 

Lippincott Williams & Wilkins. c2013. 

p.129-149. 

12. Enikova RK. Hygiene of nutrition. 

1st ed. Pleven:Medical University. 

EA-AD. 2014; p.151-157 [in Bulgarian] 

13. Enikova RK. [Microbiological 

processes and safety of Bulgarian white 

cheese]. [in Bulgarian] Bulgarian National 

Focal Point of EFSA. 2010; 36 

p. [Internet] 

14. European commission health 

and consumers directorate-general. 

Working Document on Eradication of 

Bovine, Sheep and Goats Brucellosis 

in the EU. SANCO/6095/2009. 

15. Denk A, Demirdag K, Kalkan A, 

Ozden M, Cetinkaya B, Kilic S. In vitro 

activity of Brucella melitensis isolates 

to various antimicrobials in Turkey. 

Infect Dis (Lond). 2015 Jun;47(6):364- 

369. [PubMed] 

Please cite this article as: Vasileva BI, Karcheva MD, Birdanova VA, Valkov MV, Nikolov GN, Valkov AV. Outbreak 

investigation and control of Brucellosis. J of IMAB. 2016 Jul-Sep;22(3):1253-1255. 



Correspondence to: 

Milena Karcheva, MD, PhD; 

Department of Epidemiology, Medical University-Pleven, Bulgaria; 

e-mail: milena_karcheva@abv.bg 



ISSN: 1312-773X 




EFFECTIVENESS OF NON-SURGICAL 

PERIODONTAL THERAPY BY GINGIVAL 

EXPRESSION OF IL-1β AND IL-6 

Antoaneta Mlachkova 1 , Velitchka Dosseva-Panova 1 , Christina Popova 1 , Maya 

Kicheva 2 

1) Department of Periodontology, Faculty of Dental Medicine, Medical University 

of Sofia, Bulgaria; 

2) PhD, biochemist, Progene Ltd., Sofia 

SUMMARY: 

Chronic periodontitis is a multifactorial disease that 

is characterized by attachment loss and loss of alveolar 

bone. Periodontal pathogens from the subgingival 

microbiota are suggested as a major etiological factor for 

the periodontitis. The host inflammatory response against 

bacteria and their virulence factors underlies the current 

understanding of the pathogenesis of chronic periodontitis. 

The destructive immune response was shown to be associated 

with an extremely increased production of inflammatory 

cytokines in periodontal tissues. The expression of 

several cytokines likeIL-1β and IL-6 is responsible for alveolar 

bone resorption, and loss of connective tissue attachment 

in chronic periodontitis. 

Authors reported a reduction in the levels of inflammatory 

cytokines after successful periodontal therapy. 

Measuring the levels of inflammatory factors may be diagnostic 

approach to assess the effectiveness of the therapy 

of periodontitis. 

Keywords: chronic periodontitis, cytokines, IL-1β, 

IL-6, periodontal therapy, periodontal diagnosis. 

INTRODUCTION: 

Inflammatory periodontal diseases are related with 

a response to complex dental biofilm that result in destruction 

of connective tissue attachment and alveolar bone [1, 

2, 3, 4]. Different periodontal diseases showed some variations 

in the histological and biochemical characteristics, 

but the molecular mediators and destructive mechanisms 

of pathological processes are similar. In the gingival tissue 

and the gingival crevicularfluid of patients with 

chronic periodontitis were detected high levels of pro-inflammatory 

factors: RANKL - (Receptor activator of NF- 

KB ligand), pro-inflammatory cytokines such as: IL-1β and 

IL-6 and TNF-α [1, 5, 6]. 

Studies on the expression levels of IL-1β and IL-6 

in relation to the periodontal treatment will lead to: completing 

the understanding of the pathogenesis of periodontal 

destruction, assessing the severity of periodontitis, assessing 

the effectiveness of therapy or refractory, prediction 

of a recurrence and determination of progression of 

periodontitis. 

There is evidence that non-surgical therapy of 

chronic periodontitis is effective leading to reduction of 

bacteria load and pathogenic species levels in periodontal 

pockets, elimination of inflammation and significant reduction 

of periodontal pockets depth. This also results in a shift 

of the local destructive response including expression levels 

of some pro - inflammatory factors IL- 1β and IL-6. Their 

evaluation may serve to evaluate the effectiveness of nonsurgical 

therapy [1, 2, 6, 7]. 

AIM: 

‣ Assessment of the effectiveness of non-surgical 

periodontal therapy in chronic periodontitis IL-1β and IL- 

6 gingival gene expression. 


In this study were used the following assessment 

methods: 

1. Clinical methods: Selection of patients - 20 patients 

with diagnosis chronic moderate to severe periodontitis. 

Including criteria: 

• presence of a minimum of 20 teeth, 

• presence of periodontal pockets with PPD ≤7 mm 

to ≥7 mm, 

• patients without periodontal therapy in the past 6 

months, 

• patients without systemic antimicrobial treatment 

in last 6 months. 

Survey excluded: pregnant women, patients with 

systemic diseases and systemic medication. 

Clinical parameters: 

Hygiene Index (HI); Bleeding on probing (BOP); 

Periodontal pocket depth (PPD); Clinical attachment loss 

(CAL); Gingival recession (R); Furcation degree - Hamp 

1975 classification (F). 

2. Molecular methods: 

‣ Gene expressionof IL-6 and IL-1β in the gingival 

tissue was determined by comparative quantitative analysis 

- TAQ MAN REAL-TIME PCR - (REVERSE TRAN- 

SCRIPT PCR) method. 


• Gingival biopsies were taken for assessment of 

gene expression of IL-6 and IL-1β (in relation to the pockets 

with depth ≥7 mm- before and after the non-surgical 

periodontal treatment). 

3. Statistical methods: 

• Descriptive analysis 

• Test c2 and exact Fisher test 

• nonparametric Shapiro-Wilk test 

RESULTS: 

In this study was assessed the effectiveness of mechanical 

treatment of chronic periodontitis. The average 

age of the participants in the study was 47.9 years with 

standard deviation 10.5 SD (12 women and 8 men); the severity 

of periodontitis was assessed including the prevalence 

of periodontal sites with different pocket depth (3-5 

mm, 5-7mm and over 7 mm). 

The results of the study are shown on histograms, 

presenting the periodontal measurements in the initial diagnosis 

and after periodontal treatment as well as biochemical 

measurements. The data from the histograms are displayed 

as rectangles. The horizontal axis (the axis X) 

presents the research categories of data (e.g. quantitative 

or biochemical parameter). The vertical axis (the axis Y) 

describes the distribution of the presented parameter (patient’s 

contribution in the study). The height of the rectangle 

represents the frequency or density of the cases. The 

highest point of the curve shows the average frequency of 

the distribution of the monitored parameter. 

Histograms in the Figure 1 and Figure 2 represent 

hygiene status and the associated with dental plaque 

gingival inflammation, expressed by bleeding on probing. 

It is seen that in the majority of patients with severe chronic 

periodontitis the percentage of free plaque surfaces is less 

than 10% (HI 7 mm). 

Fig. 3. Reduction of sites with PD

Fig. 5. Reduction of sites with PD>7mm from 2.50% 

to 1.50% 

Fig. 6. Reduction of the gene expression of IL-1β 

Presented on the charts data clearly show that the 

therapy (non-surgical) results in a reduction in the number 

(expressed as a percentage) of periodontal sites with pocket 

depth 5-7mm and sites with pocket depth more than 7 mm 

(Figure 4 and Figure 5). Figure 3 presents reduction of sites 

with periodontal probing depth 3-5 mm. 

In Figures 6 and 7 are shown the changes in gene 

expression of the two studied cytokines - IL-1β and IL-6 

after the non-surgical periodontal therapy compared to 

initial levels. The reduction of gingival expression of investigated 

markers is associated with improving the 

gingival status and confirms the effectiveness of the nonsurgical 

periodontal treatment in patients with chronic 

periodontitis. 

Fig. 7. Reduction of the gene expression of IL-6 

STATISTICAL CERTIFICATE OF CLINICAL 

PARAMETER’S REDUCTION 

Table 1 presents the statistically significant differences 

in examined parameters before and after non-surgical 

periodontal therapy in the current study. From our results 

it becomes clear that statistically significant differences 

in clinical parameters were found: HI (hygiene index), 

BOP (bleeding on probing), PD - 5mm, PD 5 - 7mm 

and PD> 7mm. 

Table 1. Statistically significant differences in studied 

clinical parameters before and after non-surgical periodontal 

treatment 

PARAMETER 

PAIRT-TEST 

/P COEFFICIENT / 

HI < 0,01 

BOP-distribution < 0,01 

PD-5 mm < 0,01 

PD5-7 mm < 0,01 

PD >7 mm 0,03 

CORRELATIONS BETWEEN THE GENE EX- 

PRESSION OF IL-1β AND IL-6 AND THE CLINICAL 

PARAMETERS 

Table 2 shows statistically significant correlations 

between investigated parameters in this study in patients 

with chronic periodontitis. There was established a significant 

correlation between gene expression of interleukin-6 

(expressed as Ct-value) and parameters: bleeding 

on probing (BOP) and periodontal pockets (PD) 5-7 

mm. Furthermore, the change in gene expression of 

interleukin-6 (expressed as dCt- IL6) was found to correlate 

with bleeding on probing, and also the change in gene 

expression of interleukin-6 (expressed as dCt -ILβ) correlates 

with the parameter - periodontal pockets with probing 

depth (PD) 5-7 mm (p

Table 2. Statistically significant correlations between evaluated in this study clinical and biochemical parameters 

BIOCHEMICAL CLINICAL CORRELATION 

PARAMETER PARAMETER COEFFICIENT (R) P


ISSN: 1312-773X 




CAPITAL STRUCTURE ANALYSIS OF THE 

MEDICAL DIAGNOSTIC-CONSULTATIVE 

CENTERS IN VARNA (absolute indicators) 

Lyubomira Koeva-Dimitrova, 

Department of Health Economics and Management, Medical University-Varna, 

Bulgaria 

SUMMARY: 

The capital structure analysis of medical institutions 

is related to the assessment of their financial sustainability. 

The degree of their financial sustainability indicates the extent 

to which the medical institution is exposed to financial 

risk. This financial risk is related to the use of foreign capital 

(debts, loans, etc.) and it is defined as the probability of insolvency 

and possible bankruptcy due to the existence of debts 

which could not be repaid at some point in the foreseeable 

future. 

Objective: To analyze the capital structure of the medical 

diagnostic-consultative centers in Varna city and on this 

basis to assess their long-term solvency and existence of financial 

risk. 

Materials and Methods: The materials for the study 

are the published annual financial statements (up to 05. 01. 

2016) in the Commercial Register for the period from year 

2008 to 2014 of all MDCCs (Medical Diagnostic Consultative 

centers), registered in Varna - 9 in total. 

In the study are applied logical-mathematical methods 

(comparison, grouping, detail, graphical method); financial 

and accounting analysis (balance sheet analysis; analysis 

of absolute ratios for financial sustainability). 

Results: Upon analysis of the capital structure of 

MDCC’s are studied the main absolute indicators characterizing 

the conditions for financial sustainability and the existence 

of financial risk regarding the solvency. A table represents 

the overall assessment of the degree of financial 

sustainability of the companies according to the type and 

structure of the fulfilled criteria. It was ascertained that for 

year 2014, DCC 3, 4, 5 and 8 have met all the conditions and 

according to them these hospitals have very high financial 

sustainability. DCC 7 has an average financial sustainability, 

DCC 1 and 2 are in a financial crisis and DCC 6 and 9 are 

facing bankruptcy. It must be emphasized that nearly half of 

the studied health care organizations (DCC 1, 2, 6 and 9) 

need urgent intervention by the owners regarding the preparation 

of remedial measures and programs, revaluation of assets, 

reduction of capital, reorganization, restructuring and 

others. Regarding the Municipal DCC’s that have the same 

owner - Varna Municipality, an individual approach for each 

consultative center should be applied, depending on the different 

nature and specifics of the activity. A strict monitoring 

of the financial performance and discipline is necessary. 

Conclusion: The capital structure analysis allows to 

all interested external users of information to evaluate the 

financial sustainability of the health care organizations, as 

well as their ability for debts repayment in the future. 

Keywords: analysis, capital structure, financial 

sustainability, financial risk, diagnostic- consultative centers, 

health care organizations, Varna 

INTRODUCTION: 

The capital structure analysis of medical institutions 

is related to the assessment of their financial sustainability. 

The degree of their financial sustainability indicates the extent 

to which the medical institution is exposed to financial 

risk. This financial risk is related to the use of foreign capital 

(debts, loans, etc.) and it is defined as the probability of insolvency 

and possible bankruptcy due to the existence of debts 

which could not be repaid at some point in the foreseeable 

future. 

OBJECTIVE AND TASKS: 

The aim of this article is to analyze the capital structure 

of the medical diagnostic-consultative centers in Varna 

city and on this basis to assess their financial sustainability, 

solvency and existence of financial risk. 

The relevant tasks to achieve the objective are: to 

present and analyze relevant indicators for analysis of capital 

stability; to make an overall analysis of the capital structure 

of DCCs based on the calculated indicators. To assess 

the capital stability and the existence of capital risk solvency. 


The materials for the study are the published annual 

financial statements (up to 05.01.2016) in the Commercial 

Register for the period from year 2008 to year 2014 of all 

MDCCs (Medical Diagnostic Consultative centers), registered 

in Varna - 9 in total [1]. There is no published data for 

DCC 2 for year 2009 and for DCC 9 for year 2014. For the 

purpose of this study, numbers from 1 to 9 have been assigned 

to the health care organizations. DCC from 1 to 7 

are Varna Municipality property, one of them is state property. 

DCC 8 and 9 are private property. 

In the study are applied logical-mathematical methods 

(comparison, grouping, detail, graphical method); financial 

and accounting analysis (balance sheet analysis; analysis 

of absolute ratios for financial sustainability). 


RESULTS AND DISCUSSION 

The analysis of the capital structure of DCCs is performed 

by calculating the absolute and/or relative indicators, 

based on which their financial stability (sustainability) 

is assessed. The group of absolute indicators relates to so 

called “Indicators - conditions for financial stability.” The 

study results of the second group (relative indicators) are not 

included in this article, but their values and their interpretation 

confirm the results and the conclusions made. They 

include all indicators that are obtained as a ratio of different 

elements or combination of elements (ratios and relative 

shares) of financial data. Indicators for financial independence 

and financial autonomy are calculated. 

Upon the analysis of the absolute indicators it is considered 

[2, 3, 4, 5, 6, 7] that in order to define the company 

as financially stable, the following conditions should be met: 

1. Total Assets – Total Liabilities > 0 i.e. 

Total Equity > 0, where Total E = Equity (E) + Funding 

+ Deferred Income 

2. Total Assets (TA) – Total Liabilities (TL) > Total 

Liabilities, i.e.(TA-TL)-TL>0 

3. Equity (E)+ Long term Debts (LD) > Fixed Assets 

(FA), i.e. (E+LD)-FA>0 

4. Current Assets – Current Liabilities > 0, i.e 

Working Capital (W) > 0, or Current Assets > Current 

Liabilities 

5. Working Capital + Short-term Loans > Inventories 

6.Current Assets – Current Liabilities > Inventories 

According to the first condition, total assets minus 

total liabilities should be greater than zero, i.e. the equity 

should have positive value. The balance sheet equality reveals 

that in this case, the total equity will include: Equity 

+ Funding + Deferred Income. There are cases where 

the equity of the company has negative value – DCC 6 (-9 

000 lv for 2014) and DCC 9 (-11 000 for 2011, -26 000 lv 

– 2012 and -45 000 for 2013.). The reason for that is their 

very high degree of deleveraging. Over several consecutive 

years, the companies’ reported losses and the accumulated 

negative financial result exceed the equity and the 

reserves. Usually, the financial situation of such companies 

is extremely severe and often they fall into bankruptcy. The 

fact that the equity is negative means that the financial obligations 

of these companies are greater than the book 

value of their assets. This explains situations where companies 

possessing assets for millions are sold at a symbolic 

price of BGN 1[2, p.2]. 

The second condition is related to the financial 

structure of the company. In general, the debt financing increases 

the financial risk. In order to control this risk within 

reasonable limits, it is recommended that the equity exceeds 

the financial obligations (Total Assets – Total Liabilities > 

Total Liabilities). DCCs 1, 2, 6, 7 8 9 do not meet this requirement 

(fig. 1). 

Fig. 1. Indicator’s values according to Condition 2 


The third condition is related to the sources of investment 

financing in the company. According to it, the 

sum of the equity and long-term liabilities must exceed the 

amount of fixed assets. This is a basic requirement in terms 

of return on capital and return on borrowings of the company 

(liabilities). If the above mentioned inequality is not 

satisfied, this means that the company has used short-term 

sources for creating a part of the fixed assets. Given that the 

fixed assets have slow liquidity this can lead to difficulties 

or even impossibility of the company to return the borrowed 

short-term liabilities, such as falling into arrears and insolvency, 

with all the negative consequences for the company. 

Figure 2 reveals that this condition is not met in DCCs 1, 2, 

6 and 9 during the last analyzed years. 

Fig. 2. Indicator’s values according to Condition 3 

The fourth condition is linked to third one. According 

to it, the working capital (W) must be positive or Current 

Assets - Current liabilities > 0. Let’s mention again that 

the W represents in absolute value the portion of the current 

assets that is funded by long-term sources of capital - 

own or borrowed. If the fourth condition is not met, this 

means that the entire working capital was financed by shortterm 

obligations. This could be a signal for financial problems 

like delay of payments to suppliers, staff, banks and 

others. If the fourth condition is not met, this automatically 

means that the third condition is also not met, and vice versa. 

This is due to the fact that the W equals the difference between 

the long-term sources of capital (E+LD) and fixed assets 

(FA), i.e. (E+LD) - FA=W. 

The graphic reveals that his condition has not been 

met for DCC 1, 2, 6 and 9 for the last analyzed years (fig. 2). 

The fifth condition is related to the funding sources 

of the usual operating activity of the company and in particular 

to the funding of the inventories. Usually, they are 

financed with long-term sources in the form of W and shortterm 

sources like bank and commercial loans. Failure to meet 

this condition means that one part of the inventory is financed 

by interest-free current liabilities, for example - to 

suppliers, customers, staff and others. This could be a signal 

for financial problems related to working capital shortage 

and is a cause for delay of payments to contractors, employees, 

etc. 

Because of the small amounts of inventories in the 

majority of the DCCs, the fifth and the sixth conditions are 

usually met (in the cases where W is positive) and are not 

crucial in the determination of their financial situation and 

sustainability. 

The sixth condition is similar to the fifth, but sets 

more strict requirements for the financial stability compared 

to the fifth one - W to exceed the amount of inventories. 

DCCs with negative value of W usually do not fulfill the 

sixth condition. This is why it is not surprising that DCCs 

1, 2, 6 and 9 again do not meet the last two conditions. 

Practically speaking, few companies satisfy this condition 

as the current activity is rarely funded solely by longterm 

sources of capital (E and LD). Great part of the companies 

overcomes the working capital shortage by using shortterm 

loans. 

In its publication, Todorov uses a table to determine 

the financial sustainability [2, p. 3-4]. Based on this, we have 

specified the financial stability degree of the DCCs (Table 1). 


Table 1. Determination of degrees for companies’ financial sustainability 

Degree of financial Fulfillment of financial sustainability conditions 2013 2014 

sustainability 

Very high All conditions are met DCC 3; 4; 5; 8 DCC 3; 4;5;8 

High 

6th condition is not met only 

Average 

First option: 5th and 6th conditions are not met 

Second option: 2ond condition is not met DCC 7 DCC7 

Low 

First option: 3rd, 4th, 5th and 6th conditions are not met 

Second option: 2ond, 5th and 6th conditions are not met 

Lack of sustainability 

(financial crisis) 

2nd, 3rd, 4th, 5th and 6th conditions are not met DCC 1;2;6 DCC 1;2 

Severe financial crisis 

(possible bankruptcy) 

None of the conditions is met DCC 9 DCC 6 

The analysis of the capital structure of the DCCs in 

Varna with the support of the table 1 for determination of 

the financial sustainability degree of the company reveals 

that for year 2013 and year 2014 DCC 3, 4, 5 and 8 have 

met all conditions, according to which these hospitals have 

very high financial stability. DCC 7 has an average financial 

stability, DCC 1 and 2 are in a financial crisis and DCC 

6 and 9 are facing bankruptcy. 

CONCLUSION: 

The capital structure analysis, carried out on the basis 

of an overall analysis of the absolute indicators for financial 

sustainability of the DCCs in Varna, concludes that 

almost half (DCC 1, 2, 6 and 9) of the studied hospitals need 

urgent intervention by the owners regarding the preparation 

of remedial measures and programs, revaluation of assets, 

reduction of capital, reorganization, restructuring and 

others. Regarding the Municipal DCC’s that have the same 

owner - Varna Municipality, an individual approach for each 

hospital should be applied, depending on the different nature 

and specifics of the activity. A strict monitoring of the 

financial performance and discipline is necessary. 

It is importantly that the health care managers continuously 

monitor, analyze and forecast the degree of financial 

stability of their hospitals. This enables timely implementation 

of various anti-crisis measures and procedures. 

In addition, the capital structure analysis allows to 

all interested external users of information to evaluate the 

financial sustainability of the diagnostic-consultative 

centers, as well as their ability for debts repayment in the 

future. It should be noted that the violations of economic 

sustainability of the organization leads to a crisis which 

extreme degree is the bankruptcy or termination of the organization. 

REFERENCES: 

1. Registry Agency, Ministry of Justice, 

Commercial register, last: 11. 05. 

2016. [in Bulgarian] [Internet] 

2. Todorov L. [Assessment of financial 

sustainability - part of anti-crisis 

business management]. [in Bulgarian] 

16. 05. 2012. [Internet] 

3. Timchev M. [Financial - economic 

analysis]. [in Bulgarian] Nova Zvezda. 

2011; p. 200- 270. 

4. Trifonov T, Trifonova S. [Financial 

analysis of the company]. [in Bulgarian] 

Siela, Sofia. 2001; p. 30- 50 

5. Kostova N. [Financial Accounting 

Analysis]. [in Bulgarian] Activ-K Ltd, 

Varna. 2010; p.190-200 

6. Todorov G. [Financial Accounting 

Analysis]. [in Bulgarian] Steno, Varna. 

2003; p. 60- 70 

7. Koeva-Dimitrova L. [Analysis of 

the Financial Condition of Diagnostic 

Consultative Centers – Theoretical and 

applied aspects]. [in Bulgarian] MU- 

Varna, Steno, Varna. 2016. 

Please cite this article as: Koeva-Dimitrova L. Capital structure analysis of the medical diagnostic-consultative centers in 

Varna (absolute indicators). J of IMAB. 2016 Jul-Sep;22(2):1261-1264. 




Lyubomira Koeva-Dimitrova, 

Department of Health Economics and Management, Medical University-Varna 

55, Marin Drinov Str., 9000 Varna, Bulgaria; 

E-mail: lubomira@yahoo.com; lubomiradimitrova@gmail.com 



ISSN: 1312-773X 




EFFICIENCY OF PROSTHETIC TREATMENT WITH 

POST RESECTION PROSTHESES WITH SOLID 

SUBSTITUTE PART 

Ivan Gerdzhikov 1 , Mariana Dimova 2 , Tihomir Georgiev 3 


University -Sofia, Bulgaria 


University-Sofia, Bulgaria 

3) Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, 

Medical University-Varna, Bulgaria 

ABSTRACT 

Aim: The aim of this study is to track the effectiveness 

of prosthetic treatment with post resection dentures 

with solid substitute part and their role in the restoration 

of damaged functions. 

Materials and methods: The study included 14 patients 

(9 men and 5 women) with different size and location 

of defects in the upper jaw treated in the period 2010- 

2016 with post resection prostheses with a solid substitute 

part. 

The impressions were taken with irreversible hydrocolloid 

impression material. The prostheses were completed 

by heat-curing acrylic with low quantity residual 

monomer. 

The effectiveness of prosthetics was evaluated by 

the method of Mihaylov for both oral-nasal examination 

of the pressure with the device “Oronasopneumotest.” 

For objectifying and assess the occlusal-articulation 

ratios was held computerized occlusal analysis with the system 

T-SCAN 8. 

Results: The results showed successful obturation 

and sealing of defects in all patients. 

It was found satisfactory recovery of the speaking 

function and normalization of occlusal-articulation ratios. 

Conclusion: The prosthetic treatment with post resection 

prostheses with a solid substitute part allows successful 

recovery of the lost speech and chewing functions, 

helping to restore self esteem and social rehabilitation of 

patients. 

Key words: palatal defects, maxillary resection, obturator, 

post resection prostheses. 

Damage in the maxillofacial area, occurring after 

maxillary resection, inflicts serious aesthetical changes, 

mental problems and functional disabilities in respect of 

impaired mastication, swallowing, speech and breathing [1, 

2]. A common opinion [3, 4, 5, 6] is that the degree of functional 

damage depends on the size and location of the defect. 

This is also confirmed by a research of Usui et al. [7, 8], 

who discovered lesser functional impairment in patients 

with smaller defects, a greater number of intact teeth and 

mouth opening greater than 20mm. Analogous is Devlin et 

Barker [9] position, who found that the localization of the 

defect, it’s size, and the condition of the remaining dentition 

are crucial for determining the degree of functional 

damage and for the prognosis the treatment. 

Prosthetic methods of treatment are of prime importance 

in complex treatment and rehabilitation in patients 

with maxillary resection (10, 11). According to the volume 

of the maxillofacial area engaged, treatment has its specifics, 

with respect to the degree of disability [12]. 

Scientific literature describes a multitude of methods 

and modifications for treatment of patients with maxillary 

resection [13, 14, 15]. Some of these advocate treatment 

with closed obturators and others prefer hollow bulb 

obturators [16, 17]. Whatever the clinical approach, the main 

point of the treatment is to restore the masticatory function 

[18, 19]. For its improvement and for heightening of the 

masticatory function Umino et al. [20] suggest restoring of 

the occlusal contacts of first and second molars. Through 

videofluoroscopic analysis Yonthcev et al. [5] visualize the 

leading role of these molars in the masticatory cycle along 

with the negligible contribution of incisors and the teeth on 

the side of the defect. In a similar research before and after 

prosthetic treatment of patients with single-sided defects 

Xing et al. [21] found a 59,98% raise in masticatory effectiveness 

one month after the end of treatment. Similar results 

were obtained by Vergo et Chapman [4], who improve 

nutrition by distributing the masticatory stress. 


With the method applied, a prosthetic rehabilitation 

of 14 patients (9 men and 5 women) with oncologic operations 

of the maxilla, treated between 2011 and 2016 with 

closed post resection prostheses was carried out. The passageway 

defects which occurred, were unilateral and engaged 

only the hard palate and the alveolar crest, with the 

natural teeth preserved (Fig. 1). 


Fig. 1. Intraoral view of a patient with unilateral maxillary 

defect. 

The prosthetic rehabilitation was carried out in 4 

clinical stages. In the first one we took impressions of both 

jaws with irreversible hydrocolloid impression material and 

to avoid it’s free entry we tamponed the defects with gauze. 

In the second clinical stage we determined the vertical dimension 

of occlusion and fixed the centric position with 

wax rims and light curing baseplates. After a successful clinical 

trial of the teeth in wax, the prostheses were finished in 

heat curing acrylic plastic with a low level of residual 

monomer. The cleaned and polished closed obturators with 

solid substitute part (Fig. 2a) were adjusted and articulated 

in the last clinical stage (Fig. 2b). 

Through Mihailov’s method of simultaneous oral and 

nasal cavity pressure measuring, we checked the effectiveness 

of the reached hermetization with the 

“Oronasopneumotest” gauge (Fig. 3) With one of the ducts 

the air pressure in the mouth was gauged by the oral light 

indicator and the other was fixed to the patient’s nostrils by 

a dough consistency silicone mass to affect the nasal light 

indicator. With each of the patients a triple examination was 

conducted, where a flashing of the respective indicator read 

presence or lack of hermetization between the oral and the 

nasal cavity. 

Fig. 3. “Oronasopneumotest” gauge 

Fig. 2. Closed obturator with solid substitute part (a), 

adjusted in the patient’s mouth (b). 

To objectify the obtained occlusal reflections, a computerized 

occlusal analysis with the T-SCAN 8 system was 

conducted. 

RESULTS 

The obtained results indicated an optimal degree of 

hermetization in all treated patients. The “Oronasopneumotest” 

examination found a successfully created barrier between 

the oral and nasal cavity. The achieved effectiveness 

was a result of the implemented treatment method in which 

forming of a closed substitute part provided good retention 

and sufficient stability of the prostheses. Vital for the good 

clinical results were the comparatively small diameter and 


the unilateral location of the defects, as well as the presence 

of natural teeth. 

Hermetization of postresection defects gave the opportunity 

to normalize the speech, mastication and swallowing 

in all of the patients. To the extent possible, occlusal 

relations were restored and documented by a computerized 

occlusion analysis with the T-SCAN 8 system (Fig. 4). 

The effect of the conducted prosthetic rehabilitation was 

restored self-confidence and social activity of the patients. 

Fig. 4. Computerized occlusal analysis with the T- 

SCAN 8 system 

support, but also to relieve pain and result in ease of use 

[11]. One of the most crucial parts in the application of obturator 

prostheses is retention. [4]. The volume and configuration 

of the defect, positioning of the remaining soft 

and hard tissues, and weight of the prosthesis are the major 

factors influencing the retention and stability of the 

prosthesis [8, 9]. 

In literature there is a multitude of methods for production 

of obturators, in which different materials and techniques 

are used [15]. Most authors recommend treatment 

with hollow bulb obturators, which reduces the volume and 

weight of the prostheses and aids their placement in the 

defect. Their main disadvantages have to do with worsened 

hygiene and risk of developing a bacterial infection. To 

overcome this, we applied prosthetic treatment with post 

resection prostheses with solid substitute part. The obtained 

results indicated good retention and stability of the prostheses, 

which ensured optimal hermetisation of the defects. 

The positive results were due to the comparatively small 

defects, taking up only the hard palate and the alveolar 

crest, with remaining natural teeth of the upper jaw. The 

applied prosthetic treatment confirmed the statement, that 

post resection prostheses ensure the successful restoration 

of speech and masticatory function. The computerized occlusal 

analysis with the T-SCAN 8 system indicated normal 

occluso-articulatory relations and confirmed the statement 

of Vergo et Chapman [4], that the even distribution 

of masticatory pressure significantly improves nutrition. 

DISCUSSION 

Prosthetic treatment with post resection prostheses 

is the most commonly used treatment method in patients 

with maxillary resection [1, 2, 3]. Well-designed post resection 

prostheses for maxillary defects were applied not 

only to maintain durable and good retention, stability, and 

CONCLUSIONS 

The most challenging part in rehabilitating the patient 

with maxillectomy is achieving adequate retention 

and stability of the prosthesis. The prosthetic treatment 

with post resection prostheses with a solid substitute part 

allows successful recovery of the lost speech and chewing 

functions, helping to restore self esteem and social rehabilitation 

of patients. 

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1. Depprich R, Naujoks C, Lind D, 

Ommerborn M, Meyer U, Kübler N, et 

al. Evaluation of the quality of life of 

patients with maxillofacial defects after 

prosthodontic therapy with obturator 

prostheses. Int J Oral Maxillofac 

Surg. 2011 Jan;40(1):71-79. [PubMed] 

2. Lethaus B, Lie N, Beer F, Kessler 

P, Baat C, Verdonck H. Surgical and 

prosthetic reconsiderations in patients 

with maxillectomy. J Oral Rehabil. 

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4. Vergo TJ Jr, Chapman R. Maximizing 

support for maxillary defects. 

J Prosthet Dent. 1981 Feb;45(2):179- 

182. [PubMed] 

5. Yontchev E, Karlsson S, Lith A, 

Almqvist S, Lindblad P, Engström B. 

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congenital and acquired maxillary defects: 

a fluoroscopic study. J Oral 

Rehabil. 1991 Nov;18(6):483-489. 

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6. Aramany MA. Basic principles of 

obturator design for partially edentulous 

patients. Part I: Classification. 

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7. Usui H. [Evaluation of maxillary 

prosthesis for better QOL]. [in Japanese] 

Nihon Jibiinkoka Gakkai Kaiho. 

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8. Usui H, Sakakura Y, Shimozato 

K. [Maxillary prosthesis for better QOL 

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Gakkai Kaiho. 1993 Apr;96(4):632-6. 

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9. Devlin H., Barker GR. Prosthetic 

rehabilitation of the edentulous patient 

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227. [PubMed] 

10. Chigurupati R, Aloor N, Salas 

R, Schmidt B. Quality of life after 

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Z, Zhang L, Li S, et al. Function of obturator 

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and prosthetic obturator rehabilitation. 

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Apr;82(2):177-183. [PubMed] 

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rehabilitation of maxillectomy defects. 

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Oct;15:75-79. [PubMed] 

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G. Management of Velopharyngeal 

Disorders. A Case Series. J Prosthodont. 

2010 Jul;19(5):397-402. 

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14. Patil PG. New technique to fabricate 

an immediate surgical obturator 

restoring the defect in original anatomical 

form. J Prosthodont. 2011 

Aug;20(6):494-498. [PubMed] 

15. Ariani N, Visser A, van Oort RP, 

Kusdhany L, Rahardjo TB, Krom BP, 

et al. Current state of craniofacial prosthetic 

rehabilitation. Int J Prosthodont. 

2013 Jan-Feb;26(1):57- 67. 

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A. Modified flasking technique for 

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with continuous pressure injection. 

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Pedemonte E, Escuin T. Pre-prosthetic 

surgical alterations in maxillectomy to 

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SD, et al. Oral function after maxillectomy 

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Please cite this article as: Gerdzhikov I, Dimova M, Georgiev T. Efficiency of prosthetic treatment with post resection 

prostheses with solid substitute part. J of IMAB. 2016 Jul-Sep;22(3):1265-1268. 




Dr. Ivan Gerdzhikov 

Department of Prosthetic dentistry, Faculty of Dental Medicine, Medical 

University - Sofia 

1, St. George Sofiyski blvd., 1431 Sofia, Bulgaria. 

E-mail: ivan_ger1971@abv.bg 



ISSN: 1312-773X 




ORAL MUCOSA DAMAGE BECAUSE OF 

HYPOCHLORITE ACCIDENT – A CASE REPORT 

AND LITERATURE REVIEW 

Elitsa Deliverska 



ABSTRACT 

Background Hypochlorite solution is widely used 

in dental practice during root canal treatment. Although it 

is generally regarded as being very safe, potentially severe 

complications can occur when it comes into contact with 

soft tissue especially due to its cytotoxic features. 

Objective The aim of our paper is to present a case of 

damage of oral mucosa because of leakage of 3% hypochlorite 

through rubber dam during endodontic treatment. 

Material and methods We present a 31 years old female 

with necrosis of buccal mucosa during the endodontic 

treatment of 46. 

Results Three days after the procedure the patient 

was referred to our department for consultation and treatment. 

Antiseptic lavage was performed and oral antibiotic 

was administrated. After 5 days intraoral examination 

showed signs of almost full recovery. 

Conclusion The need for proper tooth isolation during 

restorative procedures is obvious. Anything that obscures 

the operative field negatively impacts operator efficiency 

and effectiveness. Visibility, patient/operator safety, 

infection control and the physical properties of dental materials 

are all compromised when proper isolation is lacking. 

Key words: sodium hypochlorite, mucosa damage, 

rubber dam 

INTRODUCTION 

Sodium hypochlorite (NaOCl) is the most commonly 

used solution in root canal treatments, as it is a low-cost 

method that displays a very effective antimicrobial activity 

against microbiota of infected root canals [1]. Furthermore, 

the ability to oxidize and hydrolize cell proteins and its 

tissue solvent capacity, increases its value as an irrigant solution 

[2]. Root canal treatment aims at the complete removal 

of the connective tissue and the destruction of residual 

microorganisms found in infected root canals. In addition, 

it seeks an effective seal in order to prevent 

recolonization of the root canal system with bacteria. However, 

this solution can cause complications especially due 

to its cytotoxic features.[3, 4] The clinical efficacy of NaOCl 

relates to its nonspecific ability to oxidize, hydrolize, and 

osmotically draw fluids out of tissues. Thus, this chemical 

agent reaches and cleans new areas within infected root canals, 

dissolving necrotic-purulent tissues. However, the cytotoxic 

effects are directly proportional to the concentration 

of the NaOCl [3, 4]. When this solution is injected into 

the adjacent tissues, the patient usually experiences intense 

pain, and an urgent treatment should be implemented in 

order to prevent a long-term sequelae. [5, 6, 7] 

The purpose of this paper is to discuss the use of 

sodium hypochlorite in dental treatment, reviews the current 

literature regarding hypochlorite complications, and 

considers the appropriate management for a dental practitioner 

when faced with a potentially adverse incident with 

this agent. 

Complications causing severe tissue reactions associated 

with the accidental extrusion of NaOCl into periapical 

tissues have been described in the literature. Some authors 

have mentioned clinical situations where sodium hypochlorite 

was inadvertently injected into the maxillary sinus 

[6, 7], or was unintentionally injected into the oral mucosa 

[5] causing adverse tissue reactions and life-threatening 

allergic responses [8, 9]. 

With today’s heightened awareness of infection control, 

patient safety, and technique sensitive dental materials, 

meticulous operative field isolation is mandatory. Barrier 

isolation (rubber dam) is the most reliable method. If 

isolation is so important, why do so many clinicians resist 

using the rubber dam? Perhaps they never really learned 

to use it effectively. Today the rubber dam is the “Standard 

of Care” for isolation during restorative procedures and 

should be employed whenever possible. 

Rubber Dam Benefits 

· Dry, clean operating field 

· Improved access and visibility 

· Improved properties of dental materials 

· Patient protection 

· Improved infection control 

· Increased operating efficiency 

Sodium hypochlorite is a commonly used irrigant in 

endodontic practice. It has many potential complications 

ranging from permanent bleaching of clothes to severe soft 

tissue damage. NaOCl is highly irritant when extruded into 

vital tissues. [10 - 14] The well-perfused tissues of the oral 

cavity yet have considerable healing ability. The most 

common complication are described in Table 1. 


Table 1. 

Complication 

Extrusion Of 

Irrigant 

Damage to 

eye 

Damage to 

oral mucosa 

Allergic 

reactions 

Author 

Bosch-Aranda ML, Canalda-Sahli C, 

Figueiredo R, Gay-Escoda C. [15] 

Motta MV, Chaves-Mendonca MA, 

Stirton CG, Cardozo HF. [16] 

Gatot A, Arbelle J, Leiberman A, Yanai- 

Inbar I. [17] 

Ingram TA 3rd. [18] 

Becking AG. [19] 

Khodabukus R, Tallouzi M. [20] 

Markose G, Cotter CJ, Hislop WS. [21] 

De Sermeno RF, da Silva LA, Herrera 

H, Herrera H, Silva RA, Leonardo ML. 

[22] 

Linn JL, Messer HH. [23] 

Witton R, Brennan PA. [24] 

Tosti A, Piraccini BM, Pazzaglia M, 

Ghedini G, Papadia F. [25] 

Baumgartner JC, Ibay AC. [26] 

Study 

Response of the human eye to accidental exposure to 

sodium hypochlorite. 

Complications in the use of sodium hypochlorite during 

endodontic treatment. Report of three cases. 

Chemical eye injuries 1: presentation, clinical features, 

treatment and prognosis. 

Response of the human eye to accidental exposure to 

sodium hypochlorite. 

Complications in the use of sodium hypochlorite during 

endodontic treatment. Report of three cases. 

Chemical eye injuries 1: presentation, clinical features, 

treatment and prognosis 

Facial atrophy following accidental subcutaneous extrusion 

of sodium hypochlorite. 

Tissue damage after sodium hypochlorite extrusion during 

root canal treatment. 

Hypochlorite injury to the lip following injection via a 

labial perforation. Case report 

Severe tissue damage and neurological deficit following 

extravasation of sodium hypochlorite solution during routine 

endodontic treatment. 

Severe facial edema following root canal treatment. 

The chemical reactions of irrigants used for root canal 

debridement. 

We describe a case of buccal mucosa necrosis because 

of leakage of rubber dam during the root canal treatment 

procedure of 46 and irrigation with 3% sodium hypochlorite. 

During the rubber dam technique for operative 

field isolation of the tooth there occured a leakage of sodium 

hypochlorite and caused necrosis of the mucosa. 

Fig. 1. Necrosis of buccal mucosa because of sodium 

hypochlorite exposure 

severe pain started some hours after the procedure. Clinical 

examination showed extraorally swelling and intraoral 

exam revealed necrosis of mucosa 1/ 2 cm in vestibular fold 

of 46, 47 and inflammatory reaction of surrounding tissue. 

Treatment consisted of a combination of amoxicillin 

and clavulanic acid 875/125 mg (Augmentine® 875/125 

mg)1 tablet every 12 hours for 5 days; prednisolone- cortico 

(60-40-20) taper dose over a 3 day-period using a decreasing 

dosage; paracetamol (0,500g) 1 tablet every 8 hours; 

vit C 1,0g twice daily. 

Fig. 2. Healing process five days after treatment 

Three days after the procedure the patient was referred 

to our department for consultation and treatment. 

(fig.1) Thirty one years’ old female patient complained of 


Five days after treatment clinical examination revealed 

almost full recovery and epitelization of the lesion. 

(fig. 2) 

Based on the presented case reports, special attention 

must be drawn to the potential risks associated with 

the use of NaOCl as an irrigant for root canal therapy. Thus, 

it is important to carry out an effective technique (isolation 

of operative field with rubber dam)) in order to avoid 

complications. In the event of accidental extrusion of 

NaOCl, treatment guidelines should be applied according 

to the magnitude of each individual case. 

DISCUSSION 

Although a safe root canal irrigating solution, the 

use of NaOCL may also lead to life-threatening complications 

[27-33]. So, to ensure best safe, long lasting clinical 

practice, it is essential to recognize and manage these complications. 

Acute inflammation followed by necrosis results 

when NaOCl comes into contact with vital tissues. It causes 

severe inflammation and cellular destruction in all tissues. 

Sodium hypochlorite when comes in contact with tissue 

proteins, forms nitrogen, formaldehyde and acetaldehyde 

in short time and peptide links are broken resulting 

in dissolution of proteins. During the process, hydrogen in 

the amino groups is replaced by chlorine thereby forming 

chloramines which plays an important role in antimicrobial 

effectiveness. Necrotic tissues are thus dissolved and 

antimicrobial agent can reach and clean the infected areas 

better. Pashley et al. [3] demonstrated the cytotoxicity of 

Sodium hypochlorite using three independent biological 

models. They found that a concentration as low as 1:1000 

(v/v) of Sodium hypochlorite in saline caused complete 

haemolysis of red blood cells in vitro. As the solution used 

in this study was isotonic and thus excluded an osmotic 

pressure gradient, the observed haemolysis and loss of cellular 

protein was due to the oxidizing effects of Sodium 

hypochlorite on the cell membrane. Undiluted and 1:10 (v/ 

v) dilutions produced moderate to severe irritation of rabbit 

eyes whilst intradermal injections of undiluted, 1:2, 1:4 

and 1:10 (v/v) dilutions of Sodium hypochlorite caused 

skin ulcers. Kozol et al. [34] proved Dakin’s solution to be 

detrimental to neutrophil chemotaxis and toxic to fibroblasts 

and endothelial cells. 

Sodium hypochlorite reacts with the protiens and fats 

of oral mucosa which might lead to secondary infections. 

The patient must be monitored with immediate treatment 

if swallowed. 

NaOCl is the most widespread irrigant used on root 

canal debridement. Used solutions may vary from 0.5% to 

5.25% and its biocompatibility is inversely proportional 

to its concentration [1, 2, 4]. When it comes in contact with 

vital tissues, NaOCl may cause haemolysis, skin ulceration, 

marked cell injury in endothelial cells and fibroblasts, and 

inhibition of neutrophil migration [3]. Thus, several studies 

have been carried out in order to compare the cytotoxic 

effects with those of other irrigant solutions. Regarding this 

aspect, Navarro-Escobar et al. [35] compared the cytotoxicity 

of 15% citric acid, 5% phosphoric acid and 2.5% 

NaOCl. They concluded that the irrigating solution with 

the highest percentage of cell viability was 2.5% NaOCl 

at both 0.1% and 0.5% dilutions. Therefore chlorhexidine 

gluconate is recommended as an alternative irrigating solution 

to NaOCl, especially in cases of open apex, suspected 

allergies to NaOCl or in the event of accidental extrusion 

[1, 2, 4]. 

Author Year Findings 

Veeresh et al. [29] 2011 A patient with continuous , severe pain, oedema on left side of face, managed by antibiotics, 

analgesics, cold compress and on 10th day all symptoms suppressed. 

Loverty PD. [30] 2014 Patient with NaOCl extrusion followed endodontic treatment in maxillary first molar with 

excruciating pain, with blood stained fluid from left nostril; all managed by first ENT 

consultant for nasoscopy and then later root canal treatment completed. 

Jonathan et al. [31] 2015 A patient with NaOCl extrusion followed perforation during root canal treatmentin maxillary 

first premolar with swelling, bruising; pain was managed by i.v antibiotics, analgesics, 

steroids and then surgical intervention and finally full recovery was observed. 

Bernardo et al. [32] 2014 A patient with NaOCl apical extrusion followed root canal treatment returned in 24 hours 

with extreme pain, burning sensation in maxillary region with oedema and was managed 

by amoxicillin 500mg orally for 7 days then dexamethasone 4mg I.M. for 3days. Symptoms 

subsided after 8 months. 

If accident occurs treatment protocol should be followed 

[36]. 

Immediate irrigation of canal or damaged soft tissue 

with normal saline to dilute the sodium hypochlorite. 

- Let the bleeding response continue to flush the irritant 

out. 

- Advice ice pack compression for 24 hours (15 minutes 

interval) to minimize the swelling. 

- Recommend warm, moist compress after 24 hours 

(15 minutes interval). 

- Prescribe non steroid anti-inflammatory drugs and 

pain killers for 7 days. Analgesics and antibiotics must be 

prescribed to reduce secondary infection. Refer to emergency 

on inhalation or injection 

- Prophylactic antibiotic coverage for 10 days to prevent 

secondary infection. Amoxicillin 1,0 g (2x1) with/ 

without Metronidazole 500mg(3x1). In penicillin allergic 

patients prescribed Clindamycin (2x0,600). 

- Steroid therapy for 2-3 days to control inflammatory 

reaction. 


- Reassure the patient and provide with both verbal 

and written homecare instructions. 

- Monitor the patient periodically. 

CONCLUSION 

Sodium hypochlorite is an effective antibacterial 

agent but, when in contact with vital tissues it becomes a 

19. Becking AG. Complications in 

the use of sodium hypochlorite during 

endodontic treatment. Report of three 

cases. Oral Surg Oral Med Oral 

Pathol. 1991 Mar;71(3):346-348. 

20. Khodabukus R, Tallouzi M. 

Chemical eye injuries 1: presentation, 

clinical features, treatment and prognosis. 

Nurs Times. 2009 Jun;105(22): 

28-29. [PubMed] 

21. Markose G, Cotter CJ, Hislop 

WS. Facial atrophy following accidental 

subcutaneous extrusion of sodium 

hypochlorite. Br Dent J. 2009 Mar; 

206(5):263-264. [PubMed] 

22. De SermenÞo RF, da Silva LA, 

Herrera H, Herrera H, Silva RA, 

Leonardo ML. Tissue damage after sodium 

hypochlorite extrusion during 

root canal treatment. Oral Surg Oral 

Med Oral Pathol Oral Radiol Endod. 

2009 Jul;108(1):e46-49. [PubMed] 

23. Linn JL, Messer HH. Hypochlorite 

injury to the lip following 

injection via a labial perforation: Case 

report. Aust Dent J. 1993 Aug;38(4): 

280-282. [PubMed] 

24. Witton R, Brennan PA. Severe 

tissue damage and neurological deficit 

following extravasation of sodium 

hypochlorite solution during routine 

endodontic treatment. Br Dent J. 2005 

Jun;198(12):749-750. [PubMed] 

25. Tosti A, Piraccini BM, 

Pazzaglia M, Ghedini G, Papadia F. 

Severe facial edema following root canal 

treatment. Arch Dermatol. 1996 

Feb;132(2):231-233. [PubMed] 

26. Baumgartner JC, Ibay AC. The 

chemical reactions of irrigants used for 

root canal debridement. J Endod. 1987 

Feb;13(2):47-51. [PubMed] 

27. Marx JA, Hockberger RS, Walls 

RM. Rosen’s Emergency Medicine: 

Concepts and Clinical Practice. Mosby 

Elsevier. 6th edition. 2006; 931-933. 

28. Kavanagh CP, Taylor J. Inadvertent 

injection of sodium hypochlopotential 

irritant causing tissue destruction. So, to prevent 

this, injudicious use should be avoided by the use of a 

sealed rubber dam isolation during treatment, use of a Leur 

lock needle for irrigation, maintain a minimum of 2 mm 

reduction from the working length, avoid wedging of needle 

into the canal and most importantly avoid excessive 

pressure during irrigation. 

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layer removal by root canal irrigants. 

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CM, González-Rodríguez MP. The effectiveness 

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hand and rotatory instrumentation. J 

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McClanahan SB, Comparison of the 

Antimicrobial Activity of Six Irrigants 

on Primary Endodontic Pathogens. J 

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MA, Stirton CG, Cardozo HF. Accidental 

injection with sodium hypochlorite: 

Report of a case. Int Endod J. 

2009 Feb;42(2):175-82. [PubMed] 

6. Kavanagh CP, Taylor J. Inadvertent 

injection of sodium hypochlorite 

into the maxillary sinus.Br Dent J. 

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Please cite this article as: Deliverska E. Oral mucosa damage because of hypochlorite accident – a Case report and literature 

review. J of IMAB. 2016 Jul-Sep;22(3):1269-1273. DOI: http://dx.doi.org/10.5272/jimab.2016223.1269 



Associate prof. Elitsa Deliverska, PhD 


Medical University Sofia 

1, St. Georgi Sofiiski Str., 1431 Sofia, Bulgaria. 




ISSN: 1312-773X 




PERIPHERAL OSTEOMA OF MANDIBLE- A CASE 

REPORT AND ANALYSIS OF LITERATURE 

Elitsa Deliverska 


Medical University - Sofia, Bulgaria. 

ABSTRACT 

Background Osteoma is a benign osteogenic tumor 

arising from the proliferation of cancellous or compact bone. 

The osteoma can be central, peripheral or of an extraskeletal 

type. 

Objective: The purpose of our paper is to present a 

case of peripheral osteoma of the mandible and to evaluate 

the diagnosis and management of osteoma of the 

maxillofacial region with an analysis of the literature. 

Material and Methods: We present a 68 years old 

female patient with a hard, well defined swelling on the left 

side of the mandible in vestibular aspect near to the lower 

margin and medial to the angle. 

Results: Clinical evaluation (extraoral and intraoral) 

of patient and radiological findings directs for a diagnosisperipheral 

osteoma of left side of mandible and the patient 

was scheduled for surgical treatment. 

Conclusion: Peripheral osteoma of the jaw bones is 

uncommon. The post surgical follow-up should include 

periodic clinical and radiographic studies. Patients with 

osteoma associated with impacted or supernumerary teeth 

should be evaluated for possible Gardner’s syndrome. 

Key words: neoplasm, osteoma, mandible 

fibrofatty marrow enclosing osteoblasts with an architecture 

resembling mature bone [10, 11] “Recommended treatment 

is surgery, recurrence is rare and there are no reports of 

malignant transformation” [10, 12]. Most osteomas are small; 

however, in rare cases they may become large enough to 

cause displacement and damage to adjacent structures. 

Although osteomas may occur at any age, they are most 

frequently found in people over 40 years of age [1, 10]. 

Clinically, the PO is usually an asymptomatic slow 

growing lesion which can produce swelling and asymmetry. 

The pathogenesis of PO is unclear. Some investigators 

consider it a true neoplasm, while others classify it as a 

developmental anomaly [8]. The possibility of a reactive 

mechanism, triggered by trauma or infection has also been 

suggested [6]. The association between maxillofacial 

osteomas, cutaneous sebaceous cysts, multiple 

supernumerary teeth and colorectal polyposis is known as 

Gardner’s syndrome [8]. 

The purpose of this paper is to present the clinical 

and radiographic features of a case of huge osteoma of the 

mandible, its diagnosis and management. 

Fig. 1. Facial asymmetry because of osteoma of left 

side of mandible with no local sensitivity. 

INTRODUCTION 

Osteoma is a benign osteogenic tumour arising from 

the proliferation of cancellous or compact bone. Biological 

behavior includes slow expansive growth. It is a rare 

encapsulated bone neoplasm located in the bone tissue of 

the skull and the face [1, 2]. The osteoma can be central, 

peripheral or of an extraskeletal type. The central osteoma 

arises from the endosteum, the peripheral osteoma (PO) from 

the periosteum and the extraskeletal soft tissue osteoma 

usually develops within muscle [1, 2]. Peripheral osteomas 

in maxillofacial region are uncommon. 

It may occur as a solitary or multiple lesions on a 

single or numerous sections of the bone. The tumour may 

arise from cartilage or embryonal periosteum. “It may arise 

from the endosteal or periosteal surface” [3, 4, 5, 6]. One of 

the major differences of osteoma from other bony exostoses 

is the ability of this lesion to continue its growth during 

adulthood [3, 5, 7]. This is more common in men [1]. 

Histologically, osteoma may be of two types: 

1) Compact or “ivory” and 2) Cancellous, trabecular 

or spongy [1, 8, 9]. The compact osteoma comprises dense 

bone with few marrow spaces and only a few osteons. The 

cancellous osteoma is characterized by bony trabeculae and 


A 68-year-old woman came to the department of Oral 

and Maxillofacial Surgery of Faculty of Dental medicine, 

Medical University- Sofia for evaluation of a swelling in the 

left side of mandible which she found by chance a couple 

of months prior to examination and had grown slowly the 

last few months. A mild facial asymmetry was observed. 

(figure 1). Clinical examination revealed a non painful firm 

well-circumscribed palpable mass in the buccal vestibule 

aspect of the left side of the mandible near to the lower 

margin of the angle. The lesion was covered by normal skin. 

The patient had no paresthesia. The patient was in good 

health generally and with negative history of trauma in this 

region prior to the onset. 

Fig. 2. Peripheral osteoma affecting the body of the 

left mandible- panoramic radiograph showing a radiopaque 

mass attached to the body of the lower margin of the 

mandible. 

On panoramic radiography, a moderately well-defined 

radiopaque lesion was seen adjacent to the inferior border 

of the left side of the mandible extending from the lower 

border of mandible and with some degree of extension to 

the angle of the mandible. (figure 2). 

CT revealed a 4 × 4.3 cm well-defined, unilateral, 

pedunculated mushroom-like mass. The radiodense lesion 

is arising from the left buccal aspect of the inferior border 

of mandible, (figure 3). A working diagnosis of osteoma 

was established based on the clinical and radiographic 

findings. The lesion was scheduled for surgical removal 

under general anesthesia with extraoral approach. 

DISCUSSION 

Osteomas, which are benign, slow-growing and welldefined 

neoplasms, may originate from membranous 

maxillofacial bones. [1, 12, 19] The tumours are often 

asymptomatic and are usually detected as an incidental 

finding on radiographic examinations, “revealed in roughly 

1% of routine scans” [13, 14, 15, 16]. “Headache [15], 

epistaxis [18], visual changes, pain and proptosis” are the 

most common symptoms of unusual tumours inside the 

paranasal sinuses [14]. Osteomas are frequently 

accompanied by chronic inflammation of the adjacent 

mucous membranes lining the sinuses and by mucoceles 

[12, 14]. 

In the frontal sinus, an osteoma can cause erosion 

of the posterior wall, resulting in spontaneous 

pneumocephalus and cerebrospinal fluid (CSF) rhinorrhea 

[18, 20]. Obstruction of the draining ducts can facilitate 

the development of sinusitis or formation of a mucocele 

[20]. “Lesions larger than 3 cm in diameter are considered 

giant tumours” [20]. 

The mandible is more commonly involved than the 

maxilla. They usually occur in the posterior region of the 

mandible on the lingual side of the ramus or on the inferior 

mandibular border below the molars [1, 19, 13, 17, 21]. 

Other locations include the condylar and coronoid region. 

Structurally, osteomas are divided into three types: those 

composed of compact bone (ivory), those composed of 

Fig. 3. Bucco-lingual reconstruction of an axial CBCT scan of the 

mandible showing a radiopaque mass attached to the lower border of the 

mandible extending towards the buccal aspect. 


cancellous bone and those composed of a combination of 

compact and cancellous bone. Osteomas may have 

osteoblastoma-like areas and distinguishing it from true 

osteoblastoma may be challenging. Some believe osteomas 

with osteoblastoma-like features behave more aggressively. 

Cortical-type osteomas develop more often in men, while 

women have the highest incidence of the cancellous type 

[1]. 

As noted in previous reports in the literature, PO of 

the jaw bones is quite rare. These lesions usually appear 

as unilateral, pedunculated mushroom-like masses. In the 

mandible, the most common sites are the angle and lower 

border of the body, locations that are more susceptible to 

trauma. Also, the location of PO of the jaws is usually in 

close proximity to areas of muscle attachment, suggesting 

that muscle traction may play a role in its development [6, 

8, 16, 17]. Though the exact etiology and pathogenesis of 

PO is still unclear, traumatic, congenital, inflammatory and 

endocrine causes have been considered as possible 

etiologic factors [21]. There is evidence for some authors 

to suggest that the peripheral osteoma of the mandible is a 

traumatically induced reactive lesion and that muscle 

traction plays a role in its initiation. In view of this 

possibility, the term “perosteal osseous hyperplasia” may 

be more appropriate for those lesions in which a positive 

history of trauma preceded the onset. [6] 

Most cases of PO appear to have a very slow growth 

rate, without significant symptoms. In many cases, the 

discovery of the PO is an incidental finding. In some of 

the cases, however, depending on the location, the size of 

the tumour may cause facial deformity, deviation of the 

mandible on opening, headache or exophthalmos. 

Imaging of PO can be achieved by traditional 

radiography (i.e.: panoramic radiograph, Water’s view) or 

by CT scan. The use of CT scanning with 3-D 

reconstruction makes it possible to achieve a better 

resolution and more precise localization [6]. Bone scan was 

not performed routinely in all our patients, but when used, 

it was able to disclose the physiologic activity of the PO, 

enabling to determine whether it is a long standing, mature 

lesion with no further growth, or a relatively young lesion 

that is actively growing. 

CT, particularly three-dimensional CT scans, is so 

useful in defining the exact extension of the tumour and 

to determine the position of the lesion in relation with 

adjacent anatomical structures, when removal of the lesion 

is considered [14, 16, 17, 18]. CT scans, particularly CT 

scan in bone window and magnetic resonance imaging 

(MRI) give very good diagnostic possibilities, but plain 

radiography is also sufficient for the purpose of post 

operative follow-up. “Scan should be performed at least in 

six-month intervals during the first few years after surgery” 

[22]. Recurrence after surgical procedure is rare. 

The differential diagnosis includes exostoses–bony 

excrescences considered as hamartomas that stop growing 

after puberty, while osteomas may continue growth after 

puberty; peripheral ossifying fibroma – a reactive focal 

lesion; periosteal osteoblastoma; osteoid osteoma – those 

occur in young patients and are rare in the maxillofacial 

region and parosteal osteosarcoma–that present as painful 

destructive masses with rapid growth [1]. The appearance 

and homogeneity of osteoma is not difficult to characterize 

and diagnose. 

Osteomas involving the condylar head may be 

difficult to differentiate from osteochondromas, 

osteophytes or condylar hyperplasia and those involving 

the coronoid process may be similar to osteochondromas. 

A person who manifests with multiple intraoral or 

head and neck osteomas requires further radiographic work 

up to rule out Gardner’s syndrome. This syndrome, 

consisting of multiple epidermoid or sebaceous cysts, 

supernumerary teeth, retinal pigmentation and intestinal 

polyposis, necessitates a gastrointestinal radiographic 

evaluation because the polyps involved are premalignant 

[20]. The treatment for osteoma is surgical excision, 

particularly if there is a painful or active lesion growth [22, 

23]. 

Removal of PO is not generally necessary. Surgery 

is indicated only when the lesion is symptomatic or 

actively growing. The surgical approach should be case 

specific. For the mandible there are intraoral or extraoral 

approaches. The intraoral approach is preferable when 

possible, mainly for cosmetic reasons. For the maxillary 

antrum, the sub-labial gingivo-buccal (Caldwell-Luc) 

approach is convenient. Endoscopic techniques have been 

advocated in selected cases [24]. For the temporal, frontal 

and fronto-orbito-ethmoidal lesions the coronal or bicoronal 

approaches have been classically used. However, 

these require an extensive amount of dissection, and carry 

the potential for significant morbidity, especially 

considering that the lesion to be resected is benign. There 

have been recent reports of use of the endoscopic nasal 

approach for the resection of ethmoidal and frontal 

osteomas [12, 14, 18, 24, 25]. 

Recurrence of PO after surgical excision is extremely 

rare. There are no reports of malignant transformation of 

PO in the literature. There is very little understanding about 

the nature of PO, and three theories have been proposed: 

developmental, neoplastic and reactive [26]. It is unlikely 

that PO is a developmental anomaly, as most cases occur 

in adults and not during childhood or adolescence. It is 

also unlikely that PO is of a neoplastic nature, because of 

its very slow growth rate. The possibility that PO may be a 

reactive lesion, possibly to local trauma, is based on the 

history of trauma prior to the development of the lesion in 

some cases. However, this can be considered only in sites 

that are more susceptible to trauma, such as the angle or 

lower border of the mandible, but not in most of the cases. 

As many of the PO lesions are located in close proximity 

to muscle attachment (i.e.: masseter, medial pterygoid, 

temporalis), it is possible that muscle traction may play a 

role in the development of the PO. The combination of 

trauma and muscle traction was also suggested as a possible 

mechanism of the pathogenesis of PO. Patients with PO and 

supernumerary or impacted teeth should undergo a workup 

for Gardner’s syndrome [27, 28, 29, 30]. The triad of 

colorectal polyposis, skeletal abnormalities and multiple 

impacted or supernumerary teeth is consistent with this 

syndrome. The skeletal involvement includes peripheral 

and endosteal osteomas, which are found more frequently 


in the skull, ethmoid sinuses, mandible and maxilla.[26] 

Because the osteomas often develop before the colorectal 

polyposis, early recognition of the syndrome may be in 

some cases, a life saving event. Mandibular osteomas may 

be a genetic marker for the development of colorectal 

carcinoma [27, 28, 29, 30]. Therefore the patient with a 

diagnosis of mandibular osteoma, suspected to have 

Gardner’s syndrome, should be further examined to rule out 

colorectal carcinoma. 

CONCLUSION 

The peripheral type of osteoma is most common in 

the lower jaw, occurs at the surface of the cortical bone and 

is sessile or pedicled. The treatment for osteoma is surgical 

excision, particularly if there is painful or active lesion 

growth, or in order to correct asymmetry or other secondary 

problems, such as blockage of cavities, nerve foramina and 

vital organ compression. Recurrence after surgical 

procedure is rare. 

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Please cite this article as: Deliverska E. Peripheral Osteoma of Mandible - a case report and analysis of literature. J of 

IMAB. 2016 Jul-Sep;22(3):1274-1278. DOI: http://dx.doi.org/10.5272/jimab.2016223.1274 



Associate prof. Elitsa Deliverska, PhD 


Medical University Sofia 

1, St. Georgi Sofiiski Str., 1431 Sofia, Bulgaria. 




ISSN: 1312-773X 




USE OF PLASTIC MATERIAL AND TRIPLE SCAN 

IN THE PREPARATION OF SURGICAL GUIDES 

FOR THE DENTAL IMPLANT TREATMENT - CASE 

REPORT 

Rosen Borisov, 

Department of Oral and diagnostic imaging, Faculty of Dental Medicine, Medical 

University – Sofia, Bulgaria 

Summary: 

The use of surgical guides in implant treatment increases 

the accuracy of the dental implant positioning compared 

with manual methods. Regardless of how they are 

made, deviations of implants from their intended position 

are established in all kinds of surgical guides. This article 

considers the use of plastic material and new scanning technique 

for the production of CAD/CAM surgical guides that 

aim to overcome the deficiencies of the currently applied 

technologies in the production of surgical guides. 

Materials and methods: The study shows the techniques 

used to overcome degraded by metal artifacts CBCT 

images in implant treatment of patients with partial 

edentulism, and located medially to the defect metal-ceramic 

crowns. When planning implant treatment, a triple 

scan method has been implied. At the beginning, CBCT 

scan of the patient with a silicone impression material is 

made in the zone of interest. Secondly, CBCT scan only of 

the silicon impression is made, and thirdly - intraoral scanning 

of the patient with an intraoral scanner. Virtual analogues 

have been created of images from the three scans 

and have been repositioned one over another; as thereby 

an intraoral image have been accurately positioned over 

the CBCT image of the patient. Virtual planning of the implant 

positioning has been performed, and a model of surgical 

guide has been made for their placement. The guide 

has been printed with an SLA 3D printer technology of 

photopolymer with dualistic characteristics-rigid in the 

working part and plastic in the fixing part. Through it, implants 

have been placed to the treatment planning. Postoperative 

CBCT has been done on the patient to measure 

the implant deviation to their position in the treatment 

planning. 

Results: Axes angular deviation of the planned and 

placed implants has not been established. Average linear 

displacement of 240 µ (+/- 40 µ) has been found. 

Conclusions: Using the triple scan method is possible 

to overcome the poor image quality of the metal (metalceramic) 

structures artifacts in CBTC scan of patients for 

implant treatment. Using semi-plastic material for printing 

of the surgical guide allows its good fixation intraoperative 

and the accurate guidance of the implant drill that provides 

the implant placement with clinically negligible deviation 

from their intended position. 

Keywords: CAD/CAM surgical guides, CBCT, dental 

implant, intraoral scanner, 

INTRODUCTION 

With the increasingly widespread use of implant 

treatment, the expectations of its results increase. Its planning 

takes substantial part of it and largely determines the 

final result [1]. Modern digital technology allows this process 

to be performed entirely in the digital environment 

without the need for physical models. Future prosthetic 

constructions are generated with software, and the position 

of the future implants is planned according to them, and 

the available bone tissue. Their position is translated 

intraoperative with surgical guides, as with virtual 3D printing, 

their virtual model becomes a physical one. The use 

of surgical guides when inserting the dental implants leads 

to their more accurate positioning in comparison with 

manual methods [2, 3, 4]. 

The production of these CAD/CAM surgical guides 

include the use of so called double scan method [5], its 

virtual creation based on CBCT images of the patient, its 

plastic model and its printing. Although this approach is a 

qualitatively new level compared to laboratory methods of 

surgical guides’ production, it has several drawbacks: 

Detail of CBCT images is low - they are used to create 

a virtual anatomical model for planning the implant positioning 

and a contact surface of the surgical guide is carried 

out on them (Fig.1) 

Detail of the CBCT depends on the scan resolution 

and varies between 150 and 600 µ. The uneven absorption 

of X-rays from different hard tissue (bone, enamel, and dentin) 

is an additional complication. Therefore, virtual models, 

created directly from X-ray images of patients, have uneven 

surface and guides created on them could not be adjusted 

exactly on their real anatomical analogue. This is 

compensated by the double scan technique whereby a gypsum 

cast from the patient is scanned, and positioned on 

the X-ray images of the patient. Spatial variations that 

could occur from possible deformation of the patient’s impression 

and its cast can not be avoided. 

An alternative to casts could be the use of intraoral 

scanners whose images are superimposed on the CBCT 

study. Scientific data on the use of this approach are scarce. 

In fact, only 3 articles have been found describing individual 

cases [6, 7, 8]. Here again two scans are performed, 


Fig. 1 a, b. CBCT image and its virtual analogue; c, d. Virtual surgical guide created in the images of a and b. 

but the second one is not a CBCT of the plastic model, 

but an intraoral scanner. 

2. The classical approach is difficult or impossible 

for application where metal artifacts mask the X-ray 

anatomy in which to be repositioned the image of the impression 

model (Fig.2). The reason is that anatomical markers 

are lost, according to which are adjusted to fit the virtual 

images of the model, and the X-ray image of the patient. 

There is a very big risk both models not to be fully 

compliant and hence to obtain an implant variation. 

Fig. 2. Crown contours, which are the anatomic 

markers, are invisible due to so called “scattering” caused 

by the presence of metal-ceramic constructions. 

attempt to overcome these shortcomings in the planning 

and use of surgical guides for dental implant treatment. 


Implant treatment has been conducted on a 52-yearold 

male, nonsmoker, in good general health with distal 

unlimited partial edentulism in the field from 46 and 47. 

The patient had no contraindications to treatment (radioor 

chemotherapy, chronic systemic diseases or bruxism). 

After the initial view and discuss, we proceeded to treatment 

planning. 

Since from the clinical view, it has been found that 

medially located to the edentulous area teeth have metalceramic 

constructions, it has been decided to apply the 

method of triple scan to overcome artifacts that these 

crowns would cause scan of the patient in CBCT. 

The first scan is CBCT of the patient (ProMax 3D 

Mid, Planmeca). The special feature of this scan is that it is 

made with C-silicone impression material (Zetaplus, 

Zhermack®) in the patient’s mouth (Fig. 3). 

Fig. 3. CBCT of patient. Despite artifacts of metalceramic 

crowns, the outlines of silicone impression material 

are seen clearly. 

3. The printed surgical guide is hard (rigid). Because 

of the absence of any plasticity, its fixing part is arranged 

above the equatorial area (in tooth-supporting guides) and 

this leads to micro movement of the guide, and deviation 

respectively in its use. 

We believe that the above three issues are the main 

reason for registered by researchers many deviations in the 

use of surgical guides to the planned ones in the implant 

positioning [9, 10, 11, 12, 13, 14]. 

The study offers if not a decision, then at least an 

The second scan is on the impression itself, and it 

has been made with the same CBCT system. It is used to 

make a virtual model of the impression in a STL format 

(Fig. 4) 


Fig. 4. CBCT of the silicone impression and its virtual 

analogue in a STL format. 

As the silicon impression contours of the first scanner 

are clearly visible, its virtual replica of the second scanner 

is easily positioned on it (Fig. 6) 

Fig. 6. STL model contours of the silicon impression 

are visible with green color positioned on its shadow 

of the first CBCT. Crown contours are already well defined 

thanks to that reposition. 

The third scan has been made with a precise 

intraoral scanner (TRIOS® 3, 3SHAPE). It serves as a highquality 

digital impression from the zone of interest. It also 

creates a virtual model in a STL format (Fig. 5). 

Fig. 5 a. Image of intraoral scanner of the two jaws 

in the zone of interest; b. Image of the lower jaw; c. STL 

model of the same jaw. 

The intraoral scanner STL model is positioned on 

the crown contours of the repositioned already silicone impression 

(Fig.7). 

Fig. 7. Intraoral scanner STL model contour is 

marked with red. 

The intraoral scanner image has high resolution 

(about 20 µ in this case), this is the reason it recreates the 

actual anatomy very accurately in the zone of interest. It 

gives the opportunity to build up virtual wax-up, digitalup 

(dig-up) (Fig.8) 


Fig. 8. Dig-up 

sleeves for drill guidance are) it is rigid and allows stable 

movement of the osteotomy drill (Fig.10). 

Fig. 10 a. Digital design of the guide; b. Printed 

guide; c. Finished guide over the dental cast 

This dig–up allows us to define the best of prosthetic 

and osseointegration view to future implants. Their size, 

angle and depth of positioning (Fig.9) 

Fig. 9. Digital view of the future position of the implants. 

The guide has been used for the pilot drill. Osteotomy 

has been transgingival as the extension of the bone 

bed has been carried out manually. 

Postoperative period has passed without complications 

and a control CBCT has been made a week after the 

intervention. 

To compare the implant positioning with the 

planned one, a bone STL model has been made with 

preoperative scan. This model along with the guide have 

been superimposed on the bone outlines from the second 

scanner. For starting point for measurements of deviations 

has been used a central axis of the guide’s working part, as 

they have been made along the planned implants axes. The 

angular deviation and linear deviation of the central axis 

guide to the implant axis have been measured (Fig. 11). 

In the case we chose in the zone of 46, an implant 

with sizes 4,2 x10 mm to be placed, and in the zone of 47 

- implant with sizes 4,2 x 8 mm (Legacy 3, Implant Direct). 

In CAD software, based on this implant positioning, 

a guide, which has been created and printed with semi plastic 

material SLA technology (DentalXlab Guide, Dentalxlab). 

This guide of printing depth from 0,8 to 1 mm is 

semi plastic and its fixing part tightly cover the retention, 

under equatorial areas of crowns. Meanwhile in thickness 

more than 1 mm, such as its working areas are (areas where 


Fig. 11 a. STL model of the jaw in the implant zone 

with a guide’s model; b. Blue contour shows the positioning 

model of the jaw from the first CBCT on the bone outlines 

in the second CBCT. Guide’s outlines are marked with 

the red contour. 

Fig. 12 a, b. Distance between outlines of the 

planned implant (green) and placed implant (radiopacity) 

is measured . 

RESULTS 

In the implant in the area of 46, no angulation has 

been established, linear displacement in the vestibular direction 

of approximately 280 µ has been reported (Fig.12a). 

An implant in the area of 47 hasn’t been also angulated to 

the intended position. Linear displacement of 200 µ has 

been also measured in the vestibular direction. (Fig.12b) 

CONCLUSIONS: 

Using the triple scan technique, inaccuracies caused 

by metal artifacts are overcome in the creation of digital 

models when planning implant treatment. This technique 

allows the integration of high-quality images of intraoral 

scanners in the planning process. Since they are with high 

detail, the created on these surfaces surgical guides show 

very good agreement with the actual anatomical structures 

on which they are fixed intraoperative. 

Semi plastic materials used in the surgical guide 

printing are fixed many stably on teeth as they cover under 

equatorial areas. However, in the working areas of the 

guide (where the leading sleeves are located), they are rigid 

and do not allow deformation and deviation in drill guidance 

in osteotomy. 

Registered deviations can be explained by the fact 

that the surgical guide has been used for keeping only the 

pilot drill, and the expansion of the osteotomy bed has been 

completed manually. 

The method described shows that although registered 

deviations, they could be reported as clinically negligible 

as they are below 500 µ and in horizontal direction, 

as deviations of angulation and depth have not been 

registered. Described approach would be a decision of the 

‘extremely difficult’ in the words of Van Assche [15] task 

to reduce the accuracy of surgical guides below 500 µ. 

Of course, we need further research to confirm the 

clinical relevance of the described approach. 

REFERENCES: 

1. Misch CE. Contemporary Implant 

Dentistry. 3rd ed. St. Louis: 

Mosby. 2007. 

2. Scherer U, Stoetzer M, Ruecker 

M, Gellrich NC, von See C. Templateguided 

vs. non-guided drilling in site 

preparation of dental implants. Clin 

Oral Investig. 2015 Jul;19(6):1339-46. 


3.Noharet R, Pettersson A, Bourgeois 

D Accuracy of implant placement 

in the posterior maxilla as related to 2 

types of surgical guides: a pilot study 

in the human cadaver. J Prosthet 

Dent. 2014 Sep;112(3):526-32. 


4. Arisan V, Karabuda CZ, Mumcu E, 

Özdemir T. Implant positioning errors 

in freehand and computer-aided placement 

methods: a single-blind clinical 

comparative study. Int J Oral 


Maxillofac Implants. 2013 Jan-Feb; 


5. Vercruyssen M, Jacobs R, Van 

Assche N, van Steenberghe D. The use 

of CT scan based planning for oral rehabilitation 

by Means of implants and 

its transfer to the surgicalfield: acritical 

review on accuracy. J Oral Rehabil. 

2008 Jun;35(6):454-74. [PubMed] 

6. Lanis A, Alvarez Del Canto O. 

The combination of digital surface 

scanners and cone beam computed tomography 

technology for guided implant 

surgery using 3Shape implant studio 

software: a case history report. Int 

J Prosthodont. 2015 Mar-Apr;28(2): 


7. Flügge TV, Nelson K, Schmelzeisen 

R, Metzger MC. Three-dimensional 

plotting and printing of an implant 

drilling guide: simplifying 

guided implant surgery. J Oral 

Maxillofac Surg. 2013 Aug;71(8): 


8. Lee CY, Ganz SD, Wong N, 

Suzuki JB. Use of cone beam computed 

tomography and a laser intraoral scanner 

in virtual dental implant surgery: 

part 1. Implant Dent. 2012 Aug;21(4): 


9. Yatzkair G, Cheng A, Brodie S, 

Raviv E, Boyan BD, Schwartz Z . Accuracy 

of computer-guided implantation 

in a human cadaver model. Clin 

Oral Implants Res. 2015 Oct;26(10): 


10. Cassetta M, Giansanti M, Di 

Mambro A, Stefanelli LV.Accuracy of 

positioning of implants inserted using 

a mucosa-supported stereolithographic 

surgical guide in the edentulous maxilla 

and mandible. Int J Oral Maxillofac 

Implants. 2014 Sep-Oct;29(5):1071-8. 


11. Vieira DM, Sotto-Maior BS, 

Barros CA, Reis ES, Francischone 

CE.Clinical accuracy of flapless computer-guided 

surgery for implant placement 

in edentulous arches. Int J Oral 

Maxillofac Implants. 2013 Sep-Oct; 


12. Turbush SK, Turkyilmaz I. Accuracy 

of three different types of stereolithographic 

surgical guide in implant 

placement: an in vitro study. J Prosthet 

Dent. 2012 Sep;108(3):181-8. 

[PubMed] 

13. Soares MM, Harari ND, Cardoso 

ES, Manso MC, Conz MB, Vidigal GM 

Jr.An in vitro model to evaluate the accuracy 

of guided surgery systems. Int J 

Oral Maxillofac Implants. 2012 Jul- 

Aug;27(4):824-31. [PubMed] 

14. Giordano M, Ausiello P, 

Martorelli M.Accuracy evaluation of 

surgical guides in implant dentistry by 

non-contact reverse engineering techniques. 

Dent Mater. 2012 Sep;28(9): 

e178-85. [PubMed] 

15. Van Assche N, Vercruyssen M, 

Coucke W, Teughels W, Jacobs R, 

Quirynen M. Accuracy of computeraided 

implant placement. Clin Oral Implants 

Res. 2012 Oct;23 Suppl 6:112- 


Please cite this article as: Borisov R. Use of plastic material and triple scan in the preparation of surgical guides for the 

dental implant treatment - case report. J of IMAB. 2016 Jul-Sep;22(3):1279-1284. 



Address for correspondence 

Dr Rosen Borisov 

Department of Oral and diagnostic imaging, Faculty of Dental Medicine 

1, George Sofiiski str., 1431 Sofia, Bulgaria 

Mobile: +359889241512 

e-mail: rosenborisov@gmail.com 



ISSN: 1312-773X 




RADIOLOGICAL TEMPLATES AND CAD/CAM 

SURGICAL GUIDES. A literature review 

Rosen Borisov, 

Department of Oral and diagnostic imaging, Faculty of Dental Medicine, Medical 

University – Sofia, Bulgaria 

SUMMARY 

Modern digital technologies are changing significantly 

the classical approach when planning implant 

treatment. Cone-beam computed tomography (CBCT) 

and computer-aided design/computer-aided manufacturing 

(CAD/CAM) based radiological templates and surgical 

guides allow the clinical translation of the 

preoperative implant planning. In this review, literary 

sources concerning the use of radiological templates and 

surgical guides are reviewed in the dental implant treatment. 

On comparable bases, modern digital concepts 

have been explored in their preparation. The advantages 

and problems associated with their use have been 

analyzed. 

Keywords: CAD/CAM, CBCT, intraoral scanner, 

radiological template, surgical guide 

Branemark set scientific foundations of the dental 

implantology in middle of the last century, and it has 

been developed very seriously with the advent of digital 

technology. While in the past, as a successful was 

considered a treatment, in which the implants in different 

periods were fixed; nowadays, the implant treatment 

is laden with expectations to be permanently functional 

and aesthetic solution for patients with partial and complete 

edentulism. Since the oral cavity is relatively limited 

space, high precision in implant placement is very 

important for successful prosthetic treatment [1]. Misch 

added that this fidelity must be sought still in planning, 

to avoid iatrogenic damage during the implant treatment 

[2]. Poorly positioned or poorly oriented to others implant, 

often leads to problems during its placement or 

in the stages of prosthetic construction development. This 

could jeopardize the aesthetic result or have negative 

biological and mechanical effect for long term [3, 

4]. Translation of preoperative implant planning in the 

intraoperative clinical stage is the critical point that defines 

how the results will match expectations. To achieve 

this in the most controlled environment, visualization 

and navigation tools are used grouped under the conceptual 

name of surgical guides. 

The progress in imaging and particularly the development 

of CBCT technology allow the production of 

surgical guides and treatment planning, generally to be 

digitized. Thus making surgical guides is transferred 

from classical dental laboratory in cyberspace, where the 

use of impression materials, plaster casts and polymers – 

referred to as materials that undergo geometric changes, 

are avoided. The use of classical impression and casts 

materials is considered one of the main reasons for the 

registered differences in the planned and achieved implant 

positioning using guides [5, 6]. Therefore, so many 

hopes are pinned on digitization of this process. It is 

based on classical CAD/CAM technology, and based on 

imaging (Multislice computed tomography (MSCT), 

CBCT) implant positioning is defined. Subsequently a 

guide’s model is generated with software, which then is 

printed with stereo lithography (SLA- stereo lithographic 

apparatus) or with selective laser sintering (SLS). The traditional 

approach involves several stages: 

1. Developing a radiological template. 

2. Three-dimensional imaging (MSCT, CBCT). 

3. Implant planning with specialized software. 

4. Development of a surgical guide. 

Implant treatment is directed towards functional 

and esthetic restoration of patients with partial or complete 

edentulism. The final prosthetic structure is the 

starting point in planning this treatment or in other 

words, the concept of prosthetic guided implantology is 

followed [7], as this process begins with the production 

of wax-up laboratory (Fig.3). 

Our idea of where the future crowns will be placed 

is important as from mechanical - functional perspective 

the future implants respectively their abutments should 

be located ideally in the center of the future crowns. 

This is important not only for maximum resistance to bite 

force, but also for the aesthetic result. The substantial deviation 

from this ideal position requires compromises in 

size and vestibulo-lingual placement for future crowns 

(Fig.1). 


Fig. 1 a, b and c - On a digitally reconstructed situation of Figure 1 a and b, it can be seen (c) that the implants are 

situated prosthetic incorrectly. 

A radiological template is molded on the wax-up. The 

template’s purpose is to give a visual representation of the 

future implant ideal positioning in imaging. This 

is achieved, as in the central areas of the molded in wax-upa 

template an x-ray contrast material is placed directed to 

the central axis of the crowns. For this purpose, a guttapercha, 

metal cannulas, x-ray contrast plastics or varnish 

may be used. When using the last ones, crowns contours are 

presented with an x-ray as a guide for planning the implants 

positioning. Formation process, its variants and radiological 

image are represented from figures 2 to 7. 

Fig. 4. Thermoforming foil with metal sleeves 

Fig. 2. Diagnostic model 

Fig. 5. Thermoforming foil with gutta-percha 

Fig. 3. Wax-up on a diagnostic model 


Fig. 6. Vacuum-forming foil covered with X-ray contrast 

varnish 

Fig. 9. The prosthetic axis set by markers (gutta-percha 

in this case) matches with the osseointegration appropriate 

position of the implant. 

Fig. 7. X-ray image of the sleeve, gutta-percha and 

varnish cover 

1. X-ray image of a metal sleeve 2. X-ray image of 

the gutta-percha; 3. - image of X-ray varnished 

In this situation, we say that the prosthetic and Osseo 

integration implant positioning match. The next steps are 

straightforward and clear. We can easily transform the template 

in a guide (if we have used cannulas practically the 

template is a guide Fig .10) or we just use them for marking 

the pilot drill entry point and then, relying on our own 

manuality and sufficient bone volume, which allows slight 

spatial deviation to put implant. 

Fig. 10. Template guide with metal sleeves 

Imaging is held with the finished radiological template 

(Fig.8). 

Fig. 8. The gutta-percha is contrasting central axis of 

the X-ray invisible crown. 

The second case is when both osseointegration and 

prosthetic implant positioning do not match (Fig.11). 

Fig. 11. If you follow the axis of the contrast marker 

implant would be positioned almost entirely outside the 

bone. 

At this stage, it is important to ensure immobility of 

templates during scanning, so easily deformable materials 

(thin vacuum splints or easily breakable plastics) should be 

avoided because even minor shifts will compromise the planning. 

Since the study is three-dimensional, in combination 

with the x-ray template, it gives us a quantitative and qualitative 

picture of the bone base in the area of intervention. 

The results follow two directions- in one case, under 

the ideal implant positioning from prosthetic point 

(marked with template) there is sufficient bone substrate for 

the implant Osseo integration (Fig. 9). 

Unfortunately, in practice this is the most common 

variant, and this is easily explained as toothless areas, in 

which we implant, are such most often because of the accompanied 

with osteolysis pathological processes caused the 

tooth extraction. There is angulation (Fig. 11) or linear deviation 

in medio-distal or vestibulo-oral direction (Fig.12). 


Fig. 12. Transverse slices show that the position of the implant according to the contrast template allows its osseointegration, 

but media-distal inclination of the implant, if put through the template, would be unfavorable to the root of 

the medial tooth. 

Decisions are two: 

Radiological measurement of the deviation and correction 

- clinical or laboratory of this deviation. In practice, 

the clinical correction is more often and it is expressed in a 

very subjective judgment of the operator based solely on its 

manuality and its own idea of its magnitude. 

The laboratory correction is possible through exotic 

devices [8] or sophisticated equipment [9] but there is no scientific 

evidence for its practical applicability, unless the 

published by the authors of these methods. 

A frequent situation where prosthetic ideal implant 

positioning and its osseointegration do not match, actually 

makes the use of radiological template, non rationalize and 

implantologists have to solely rely on their own insight and 

knowledge about where, what angle and depth to place the 

implant. 

The radiological template, may not serve as a complete 

surgical guide, but it has intraoperative value by navigating 

benchmarks remain the clinical ones for the physician 

(crowns and axes of the adjacent teeth, geometry of the 

alveolar ridges etc.). The more important is it could be used 

as a visual reference to the crown contours intraoperative 

and thus the area, in which to strive to place the implants 

without it, is “marked” (Fig.13). 

Fig. 13. Surgical guide that outlines the contours of 

the crowns of Wax-up 

Not a rare situation in the absence of such benchmark 

are cases where in search of suitable for its osseointegration 

position, the implant is positioned so that the aesthetics of 

the prosthetic structure is compromised (Fig.1). 

The next stage is the analysis of survey of 3D images 

and implant treatment planning. 

In modern implantology, CBCT is perceived as 

the most appropriate three-dimensional method, and this role 

is defined by numerous studies [10, 11, 12, 13]. Bone zones 

are analyzed qualitatively and quantitatively in the areas of 

implantation. Number, size, dimension, type and positioning 

of the implants, and possibly augmentation procedures are 

planned. 

Crucial for making quality planning is the better 

knowing the nature of the images, possible artifacts, qualities 

and shortcomings of the software through which areas 

of interest are visualized gradually. This knowledge ensures 

that the implant treatment will be well planned. This means 

that we are able, based on analysis of images, to choose the 

right size and type of implants, to determine the clinical and 

postoperative behavior. Different phases will take place without 

complications and it will be unnecessary to adapt to unforeseen 

situations as in the course of implantation to choose 

the implant’s length, for example. 

The last stage of implant treatment planning is software 

design and manufacture of surgical guide. Through it, 

the planning’s translation is performed. It is the link between 

our planned implantology treatment and its immediate 

clinical implementation. With its help, the selected implants 

are placed exactly in the places that we have identified as 

the most suitable during the planning. They allow us to put 

them not only in the location but also in the position (inclination 

to three planes and depth) that we want. 

Surgical guides, as well as their very name suggest are 

the tools for surgical navigation. The common among them, 

regardless of their diversity, is that they are fixed in the oral 

cavity and guide the direction of movement, and some limit 

the depth of penetration of the pilot drill or any ones, necessary 

to form the bone bed prior to the implant placement. 


Depending on the fixation method, they are tooth-, mucosa 

- or bone supporting guides (Fig. 14-16). 

Fig. 16. Bone-supported surgical guide 

Fig. 14. Tooth -supported guide 

Fig. 15. Mucosa - supported guide 

They can be made to the already mentioned analogue 

manner, based on plaster models (transformation of radiological 

template in a surgical guide). Alternatively, they are 

manufactured with CAD/CAM technology, by simply using 

three-dimensional images of computed tomography study 

and 3D printing. For the first time, this method of manufacture 

for the purpose of dental implantology is mentioned in 

a scientific paper in 2003 [14, 15] and, in essence, is now 

used unchanged. 

The images from CT are the basis for the generation 

of three-dimensional virtual “replica” of the anatomical area 

subject to implantation (Fig. 17, 18). 

Fig. 17. Native-CBCT images 


Fig. 18. Virtual analogue of the CT images 

For mucosa supporting guides this mucosa is needed 

to contrast with X-ray scanning or apply the so called “double-scan 

method” [16]. The first scanning is tomographic 

(CBCT or MSCT) of the area of interest (the patient). The 

second one is also tomographic, but the diagnostic cast of 

the patient from the same area. The images of both tomographic 

studies superimpose (reposition) on one another, 

thereby to visualize all of the information within the area of 

interest, even invisible radiological soft tissue (Fig. 20-22). 

Fig. 20. CAD image of the scanned with CBCT cast. 

Fig. 19. The guide modeled by CAD software. The 

blue color marked its fixing part, the orange part is the working 

one, through which are guided the implant drills. 

Fig. 21. 3D reconstruction of X-ray image of the patient. 

This replica is used to design the surgical guide itself 

with CAD †software. The guides are composed of two parts 

– a fixing one, which is located on appropriate supporting 

part, and a working one where there are openings with a diameter 

corresponding to the implant drills (Fig.19). The 

tooth supporting and bone supporting guides are made in 

this way as in the tomography images mucosa is usually invisible. 

Fig. 22 a. On both models are marked identical points, by which software superimpose the images. b. The superimposed 

images. 


Fig. 23. Stereolithografic printed surgical guide. 

Once a surgical guide is modeled in the software, it 

is printed on a 3D printer (Fig. 24). It is printed in one of the 

two methods stereolithography (SLA) or with laser sintering 

(SLS). SLA is more suitable for implant purposes, because it 

allows to be made of transparent material (photopolymer), 

which further increases intraoperative control and generates 

smaller spatial deviation compared with the technique of selective 

laser sintering [17]. Thus, made guide is ready for use. 

• They allow an osteotomy depth control. 

• They allow preoperative preparation of prosthetic 

design and its immediate fixation. 

This way of working has disadvantages: 

• Prototype material is hard, rigid, no plasticity to 

overcome the equator of the teeth (in the case of tooth supporting) 

or undercuts areas (in bone and mucosa variants). To 

be stable they need additional laboratory processing and 

intraoperative fixation. (Fig. 25). 

Fig. 25 a - angulation between the axes of the implant 

planned position (the purple implant) and the placed 

one; b - linear displacement in the cervical region; c - linear 

displacement in the apical zone. 

Fig. 24. Surgical guide with fixing pins 

• Many often after the guides attachment, the limited 

intraoral (most often molar) space, makes impossible the introduction 

of the implant drills into osteotomy area. 

• When there are artifacts of prosthetic structures (e.g. 

metal-ceramic), determining the contours in the fixation areas 

and development of guides (teeth, bone, mucosa) are impossible. 

The advantages of these guides relative to the conventional 

and manual methods are several: 

• They are more precise by free manual procedures and 

from conventional guides with respect to the linear deviations 

from the intended position, angulation and depth of the 

osteotomy [18]. 

• They eliminate the need for development of radiological 

template - a laboratory stage is skipped, which reduces 

the time to clinical intervention and overall treatment 

time. 

• Trans gingival implants are possible through them, 

where we want to avoid the flap forming (e.g. preceding augmentation 

and possible flap would violate the integrity of 

the surface [19], or we want to avoid postoperative pain and 

hematoma associated with flap [20, 21]. The latter is especially 

true for older patients with compromised health [22]. 

• They provide accurate implant positioning relative 

to one another. 

• They allow proper angulation, which is often indispensable 

especially in the frontal aesthetic zone. 

Surgical guides’ precision 

Question with the precision of CAD/CAM guides has 

been the subject of many scientific researches [23 - 37]. In 

all these studies, different variations of the implant positioning 

compared to the planned ones are established. This position 

is assessed as linear and angular deviations of the implant 

axis to the axis of its virtual analogue (the digital replica 

of the actual implant used in treatment planning). Linear 

variations are measured in two zones - in the cervical portion 

of the implant and its apical area (Fig. 26). 

Van Asscheet et al. [38] properly noted that angulation 

is important, because the apical deviation in the same 

deviation of the axis would be different for implants with 

different length. We would add that exactly because of the 

same reason coronary deviation is important because no angulation 

can be found, but just parallel movement to the axis 

in one direction or another, different than the planned one, 

and again there will be a deviation. The announced results 

for the registered deviations vary widely. Most studies 

reported averages, but for the practice the maximum possible 

deviation is significant, but very few authors have focused 

their attention on this indicator [25, 28, 29, 32,]. There 

are cases in these studies in which the angle reaches 8.86 degrees 

[30]. Linear deviations in the cervical area reach 3.04 


mm, and in the apical one reach 5.03 [25]. According to 

Cassetta et al. [24] the deviation in the maxillary guides is 

smaller than those used for implantation in the mandible. 

Their study shows that it is important whether the patient is 

a smoker or not (it is associated with the more common 

hypertrophy of the mucosa in smokers and hence a poor stability 

of the guide). Ersoy et al. registered also smaller spatial 

variations in maxillary guides [31]. According to Turbush 

et al. [26] and Arisan et al. [21], mucosa as compared to the 

tooth and bone are of smaller deviation. Micro movements 

of the guide during implantation, use of more drills [34, 37], 

number and distribution of the remaining teeth, height and 

number of the cannula can influence it [35, 36]. Linear variations 

in the use of guides and the mentioned conventions 

lead to errors associated with adverse effects when they are 

used in dental implantology. Reasons for them can be sought 

in several directions. 

First are the images of CBCT, which serve as a basis 

on which the guides are made. In some cases, they are directly 

used to generate the guide contact interface. To be 

used for these purposes, the primary DICOM files are transformed 

with CAD software into usable STL files .The latter 

describe only the surface geometry of objects from the 

DICOM files. Therefore, if the scanning resolution is low, the 

surfaces detail of the generated from them STL objects is 

lower (Fig. 26, 27). 

Fig. 27. X-ray image when scanning with resolution 

of 400 µ and its corresponding STL analogue. 

Fig. 26. CBCT with a resolution of 150 µ; b-generated 

by X-ray data three-dimensional STL model. 

Differences among objects created from images of 

varying resolution are well illustrated in Fig. 28. A crosscut 

section of the three superimposed resolutions (Fig. 28 

c) shows that the less resolution is, the better the contour 

of the real object is followed. The picture with pink color 

shows the real geometry of the object (scanned with 

intraoral camera with high resolution); in the picture with 

yellow color is the object with the smallest resolution 

(400 µ), and the picture with gray color shows the object 

with the largest resolution (150 µ). It is clear that the yellow 

contour follows unevenly surface detail of the real 

object, as at times it crosses it. If the guide is made according 

to this contour, it will not be relevant to the real 

surface and it will be fixed in a position, which is not consistent. 

The gray contour displays accordance with the actual 

surface, but it naturally does not coincide with it. 


Fig. 28 a, b. - a software model of a real object taken with intraoral camera with high resolution (about 20 µ), c. The 

three image superimposed on the lines of coincidence, d. Crosscut of the three images with different resolution. 

Even with double-scan technique, the accuracy under 

150 µ can not be achieved (as the limiting resolution 

of the best so far CBCT sensors is). Solutions should be 

sought in the superimposition of images with bigger than 

the above mentioned resolution. 

However, which is the limit value, which will provide 

enough detailed image for making a precise guide? A 

surgical guide should be considered as a prosthetic construction. 

Its inner surface must be congruent, to follow the 

anatomy of the area, for which it is fixed with the accuracy 

of prosthetic construction. Therefore, we can determine, 

such as accuracy, the adopted for prosthetic designs accuracy 

- 50 µ by Gonzalo et al. [39]. In addition, the closer 

we are to the border in the final product geometry accuracy 

(the surgical guide), the less deviation from the 

planned position of the implants we can expect. 

The presence of artifacts in x-ray images, as it was 

mentioned, is an additional factor to generate errors. Especially 

strong is true that for artifacts of prosthetic appliances, 

filling material and the canal filling means. They are 

mainly in the crown areas, and in them - the contours, on 

which the guide should be generated is difficult or impossible 

to find. This explains the reported greater accuracy 

of mucosa supporting guides compared to tooth support- 

ing guides in some studies [21, 26]. The physical receipt 

of the guide is also a potential generator of error, because 

end models can be printed with different accuracy. They 

can be printed with a resolution of more than 25 µ and it 

can be a cause of spatial correspondence between both surfaces 

(one of the guide and one of its anatomical analog). 

Material from which it is printed is rigid, non-plastic 

structure, but must be positioned on non-linear, made 

up of different curves surface, such as anatomical areas of 

guides’ fixation. In addition, while medio-distal and vestibule-oral 

direction is no problem, its vertical adjustment 

is impossible because to overcome the equator of the teeth 

(or vertical vestibular and lingual/palatal ridges in cases 

of bone and mucosa support). These guides should be completed 

over the area of the teeth equator, because they lack 

plasticity to overcome this relief. This makes them movable 

in a vertical direction and creates an opportunity for 

different ‘stable’ positions of the guide, which displaces the 

position of the planned one of the cannula (Fig. 29 a, b, c, 

d). 

The additional fixing of the guides with locking pins 

does not solve the problem, because they can be wrongly 

positioned before fixation. This additional fixation prevents 

only its further shift in the use of implant drills. 

Fig. 29 a. With green color are visible equator areas for the development of fixing part of the guide; b. Sectional 

view of the crown of 15 with the generated of the outline of Fig. 29 a guide; d. If it can be superimposed the occlusal 

surface of the guide on the teeth - medial and vestibular, the contact between the two must be released, which creates 

conditions for micro-mobility and different “stable” positions of the guide relative to the axis of the tooth. 

DISCUSSION: 

The information we receive from three-dimensional 

imaging is essential when planning implant treatment, 

but it is not enough to get a full translation of this planning 

in the clinical setting. This is so, because it concerns the 

structures that are invisible clinically and intraoperative and 

we do not have landmarks, which spatially guide us on the 

anatomy of these structures. The purpose of radiological 

templates and guides is to help us in this direction. Modern 

digital methods of intra and extra oral scanning combined 

with CAD/CAM technologies output production and use of 

new qualitative level. Despite their proven advantage, compared 

to manual methods, their application, however, is associated 

with fluctuating results. The registered deviation in 

the use of surgical guides sometimes reaches values, which 

if security zones, as distance to critical structures are not provided; 

it could lead to unintended consequences. 

Analysis on the literature data refers theoretically to 

three main problems, related to spatial variations in the use 

of these guides: 


1. The low resolution of the scanned images should 

be overcome; 

2. The influence of metal artifacts, where there 

are such, should be neutralized on anatomical structures in 

areas of interest; 

3. Impression material should be used, which has a 

dualistic characteristics - to be flexible enough in areas, 

where the vertical relief have to be followed (its fixing part), 

and at the same time sufficiently rigid in the zones, in which 

implant drills will be used (the working part). 

Solution of the first problem is an answer of the issue 

with the quality on the base, from which the implant planning 

starts. An image with a resolution or surface detail of 

the order of 50 microns would be an ideal matrix for software 

modeling of the surgical guide, which subsequently 

will be fixed on its anatomical analogue with sufficient accuracy. 

The second task concerns the universality of surgical 

guides’ application. Artifacts in CBCT are very common 

problem and overcoming their influence would make surgical 

guides reliably applicable to all patients. 

The third issue is perhaps the most important, because 

in our opinion is the most largely responsible for registered 

variations in the use of surgical guides. Its decision will allow 

secure intraoperative fixation of the guide and in position, 

which will fully coincide with or have minimal deviation 

from the planned one. 

Aforesaid confirms the finding of a number of authors, 

who concluded in their researches, that CAD/CAM based 

guides need further improvement and that are necessary further 

researches to clarify and resolve problems associated 

with their use [8, 17, 21]. 

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