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Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
JOURNAL OF DENTAL SCIENCES & ORAL REHABILITATION

An Official Publication of Institute of Dental Sciences, Bareilly (U.P.) India
Chief Patrons :
Dr. Keshav Kumar Agarwal Chairman
Dr. Ashok Agarwal President
Dr. Lata Agarwal Vice Chairperson
Dr. Kiran Agarwal Vice President
Dr. S. R. Panat Principal
Editor in Chief :
Dr. Anuraag Gurtu
Assitant Editors :
Dr. Ashish Aggarwal Dr. Sumit Mohan
Reviewer :
Dr. Abhiney Puri Dr. G.M. Sogi
Dr. Anil Dhingra Dr. Nageshwar Iyer
Dr. Anirban Chatterjee Dr. Sanjay Labh
Dr. Anupama Sahay Dr. Tarun Kumar
Dr. Chandramani More Dr. Vineet Vinayak
Editorial Board Members :

Dr. S.S. Bharathi Dr. Anurag Singhal
Dr. Gokkulakrishnan Dr. Madhusudhan Astekar
Dr. R. G. Shivamanjunath Dr. Deepa Singhal
Dr. Hari Choudhary Dr. D. K. Agarwal
Advisors :
Dr. K. K. Dixit Dr. P. K. Singh
Published Quarterly By Institute of Dental Sciences, Bareilly

Editorial & Office :
The Editor in Chief, Editorial Office, Institute of Dental Sciences, Pilibhit Bypass Road, Bareilly - 243006,
E-mail editorjids@gmail.com
The statement and opinions expressed in this journal are the responsibility of the concerned authors and do not
necessarily reflect the opinions of the editorial board. The editorial board will not be responsible for any in
accuracy or misleading data, opinion or statement published in the journal Permission of the editorial board is
mandatory for reproduction of the contents of the journal in full or in part in any form.
Principals Message
I congratulate the editorial team for bringing out a good

collection of articles in the form of the current issue I hope the
readers find the contents valuable to provide new insights in current
trends in Dentistry.
I wish the journal all the success and hope that it continues to
enrich all its readers.
Dr. S.R. PANAT

Principal
Institute of Dental Sciences
Bareilly
Editorial
Greetings to all the readers from editorial team we present our

current issue July Sept 2013 with great enthusiasm and
anticipation. Taking inputs from the feedback provided to the
readers and current trends in dentistry we provide a collection of
articles which are thought provoking and informative.
Many Stalwarts of our specialty have joined hands with us as

members of review board in our journal. I welcome them and
expect a long and fruitful working relationship with them.
I take this opportunity to thank all our contributors, college

management, principal sir and members of the editorial team for the
joint effort which has taken the form of this edition.
Good wishes to one and all for the approaching festive season.
Dr. ANURAAG GURTU

Editor in Chief
Journal of Dental Sciences
and Oral Rehabilitation
Contents
REVIEW ARTICLES
1. Role of GCF As Potential Biomarker in the Diagnosis of Periodontal Disease...........................01-04
R.G.Shivamanjunath
2. Cone Beam Computed Tomography................................................................................................05-08
Ashish Aggarwal, Nitin Upadhyay, Nupur Agarwal, Sowmya G. V., Md.Asad Iqubal
3. Nanotechnology- Its Implications in Conservative Dentistry and Endodontics..........................09-14
Sumit Mohan, Anuraag Gurtu, Anurag Singhal, Ankita Mehrotra
4. Flapless Implant Surgery- An Overview.........................................................................................15-18
Rashi Jolly, Himanshu Thukral, Mansi Thukral Chandra
5. Fluorides and Their Role in Demineralization and Remineralization.........................................19-21
Sonal Soi, Vineet Vinayak, Anurag Singhal, Sonali Roy
ORIGINAL RESEARCH
6. Bacterial Quantification in teeth with Apical Periodontitis Related to Different Intracanal
Irrigant : A Clinical Study................................................................................................................22-24
K.K. Dixit, Krishna Dixit, Anurag Gurtu, Nivedita Dixit, Rahul Pandey
7. Evaluation of the Root Canal Morphology of Mandibular First Premolars in the Western
Uttar Pradesh Population Using Computed Axial Tomography: An in Vitro Study...........25-27
Nishtha Chauhan, Anurag Singhal, Vineet Vinayak
CASE REPORTS
8. Sialolithiasis : A Case Series with Review of Literature................................................................28-31
Sunil R Panat, Ashish Aggarwal, Nitin Upadhyay, Mallika Kishore, Abhijeet Alok
9. Maxillary Canine With Two Root Canals : A Case Report...........................................................32-34
Anuraag Gurtu, Anurag Singhal, Ridhi Bansal, Kunal Agnihotri
10. Denuded Root - is Free Gingival Graft an Answer : A Case Report............................................35-37
Rika Singh, Sunil Kumar Mall
11. Complication of a Dental Extraction: Osteomyelitis : A Case Report..........................................38-40
Sowmya G. V., Nupur Agarwal, Nitin Upadhyay, Abhijeet Alok, Mallika Kishore
12. Eagles Syndrome : A Case Report...................................................................................................41-43
Nupur Agarwal, Sunil R Panat, Ashish Aggarwal, Anuja Joshi, Kratika Ajai
13. A Modified Sectional Custom Tray for Making Master Impression in Microstomia Patient:
A Case Report................................................................................................................................... 44-46
Pratik Gupta, Dilip Kumar Nath, Nadira Saba
14. Telescopic Denture : A Case Report.................................................................................................47-50
Mayank Shah
15. Bilateral Maxillary Second Molar With Two Palatal Roots : A Case Report..............................51-53
C. Ram Mohan, C. Krishna Chaitanya, Hari Deva Raya Choudary, Sainath Reddy
Information For Authors..................................................................................................................54-56
Role of GCF As Potential Biomarker in the Diagnosis of Periodontal Disease

R.G.Shivamanjunath
Professor & Head, Department of Periodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 08/Jun/2013
Date of Acceptance : 15/Jul/2013
Abstract: Diagnosis of periodontal disease is very critical in the phases of its treatment. At present diagnostic
methods for periodontal disease are not precisely accurate and only allow retrospective diagnosis of attachment
loss. We are handicapped in making precisive diagnosis and prognosis by two important limitations ie no
reliable markers for disease activity and no reliable criteria for identifying the risk individuals. Therefore its
necessary to have a knowledge on the present available information regarding the advanced diagnostic
Biomarkers in Gingival crevicular fluid (GCF) for the better understanding of the onset of disease
pathogenisis,course of disease progression so that the treatment will be successful.
Key words : Periodontitis, Dental Plaque, GCF, Biomarker.

INTRODUCTION crevicular fluid is a complex mixture of substances derived from
Periodontitis is a group of inflammatory diseases that affect serum, leukocytes, structural cells of the periodontium and oral
the connective tissue attachment and supporting bone around the teeth. bacteria. These substances possess a great potential for serving as
The initiation and the progression of periodontitis are dependent on the indicators of periodontal disease8. In health GCF represents the
presence of virulent microorganisms capable of causing disease. transudate of gingival tissue interstitial fluid but inthe course of
Although the bacteria are initiating agents in periodontitis, the host gingivitis and periodontitis GCF is transformed into true inflammatory
response to the pathogenic infection is critical to disease progression.1-3
(9)
exudates. . The flow rate of GCF may increase about 30 fold in
After its initiation, the disease progresses with the loss of collagen periodontitis compared to the healthy sulcus. However, its resting
fibers and attachment to the cemental surface, apical migration of the volume also increases at the same time with the formation of gingival
junctional epithelium, formation of deepened periodontal pockets, and pocket10.
resorption of alveolar bone.4 If left untreated, the disease continues with
progressive bone destruction, leading to tooth mobility and subsequent POTENTIAL MICROBIAL FACTORS
tooth loss5. Bacterial plaque plays a primary role in the initiation and
A goal of periodontal diagnostic procedures is to provide progression of periodontal disease but the composition of the sub
useful information to the clinician regarding the present periodontal gingival flora is a complex and vary from patient to patient and site to
disease type, location, and severity. These findings serve as a basis for site. Despite these differences and the complex interactions that exist
treatment planning and provide essential data during periodontal between bacteria and the host a number of possible pathogens have
maintenance and disease-monitoring phases of treatment. Traditional been suggested on the basis of their association with disease
periodontal diagnostic parameters used clinically include probing progression and heir possession of virulence factors which could
depths, bleeding on probing, clinical attachment levels, plaque index, damage the tissue (11-13).
6
and radiographs assessing alveolar bone level. Under diagnosis of
periodontal disease results in significant amounts of untreated disease MAIN BACTERIA ASSOCIATED WITH PERIODONTAL
and low rates of appropriate therapeutic intervention. Researchers DISEASE
created biomarkers that indicated the presence or absence of Phorphyromonas gingivalis
periodontal pathogens, gingival and periodontal inflammation, the host Prevotella intermedia
inflammatory-immune response to certain pathogenic species, and host
tissue destruction. The biological media of choice included saliva, Bacteroides forsythus
serum, sub gingival plaque, tissue biopsies, and gingival crevicular Actinobacillus actinomycetemcomitans
fluid. As a result, and after many biomarkers and diagnostic tests were Capnocytophaga ochracea
developed. Eikenella corrodens
BIOMARKER Campylobacter recta
A biomarker is a substance used as an indicator of a biologic Fusobacterium nucleatum
state. It may be measured and evaluated as an indicator of normal or Treponema denticola
pathogenic biologic processes, or pharmacologic responses to a
therapeutic intervention7. Since periodontitis is a multifactorial disease BACTERIAL PROTEASES IN GCF
that includes initiation by bacteria and host interaction, it's unlikely that Bacterial proteases are released into the pocket by the
a single biomarker will be able to predict periodontal disease activity. A subgingival flora and can be detected in GCF. (14-18). Selective
combination of biomarkers may emerge eventually, and in the biochemical assays have been developed for two bacterial proteases ie
meantime, risk assessment is more meaningful than simple clinical dipeptidylpeptidase (DPP) and trypsin like proteases. The trypsin like
measures such as periodontal probing. Gingival crevicular fluid (GCF) protease detected by this assay is a cysteine proteinase and has the
is a fluid occurring in minute amounts in the gingival crevice. Gingival characteristics of the enzyme now called arg-gingivain or arg-
01
gingipain.(14,15). Polymorphonuclear collagena se, Gelatinase, Tissue
Main advantages of periodontal diagnostic test system using bacterial neutrophil inhibiting mettaloprotinase
markers19 leucocytes (PM Ns) (TIMP ), Plasminogen, Elastase,
Some appears to be predictive of disease activity in longitudinal study Cathepsin G, Cathepsin B,
Simple to use Cathepsin D
Ma crophages Cathepsin G, Cathepsin B,
Chair side test kits available eg:Evalusite, omnigene, perioccan. Cathepsin D, TIM P, 1
Chair side test kits produce visual results which can shown to patient antiprotinase inhibitor,
2m acroglobu lin, plasminogen
POTENTIAL INFLAMMATORY AND IMMUNE MARKERS activator, elastase, gelatinase
The primary cause for the periodontitis is no doubt dental Ma st cell Heparin enzyme complexes,
plaque and sub gingival flora. But the bacteria triggers the local tryptase, chymase,histamine
inflammatory response and general and local specific immune response Fibroblast Cathepsin B, Cathepsin L,
which, along with the direct effects of bacteria, causes most of the tissue DPP-II ,TIMP, 1
20
destruction . Most of the substances which are released from antiprotinase inhibitor,
inflammatory and immune cells in the tissue pass into the GCF. GCF is 2m acroglobu lin, collagenase
easy to sample and therefore these substances are easily available for
the analysis21, 22. Biomarkers of periodontal disease activity may be obtained
from potential proteolytic and hydrolytic enzymes of inflammatory
POTENTIAL IMMUNE AND INFLAMMATORY MEDIATORS cells.
The substances released by the inflammatory and immune
cells during the disease process include antibodies (immunoglobulin, COLLAGENASE AND RELATED METALLOPROTEINASE
Ig), complement proteins, inflammatory mediators such as Collagenases are members of a family of metalloproteinase
prostaglandins (PG) and the pro-inflammatory cytokines such as the which degrade collagen. They are synthesized by macrophages,
various interleukins (IL) and tumour necrosis factor(TNF)21,22. The neutrophills, fibroblasts and kerationocytes and are secreted by these
potential immune and inflammatory mediators relevant to periodontal cells as latent enzymes when stimulated by the appropriate cytokines
pathology are : and some bacterial products. These cells also produce inhibitors known
31
Immune response as tissue inhibitors of metalloproteinase. . In periodontitis, GCF
Antibody: total immunoglobulin and IgG sub groups collagenase activity has been shown to increase with increasing
Complement severity of gingival inflammation and increasing pocket depth and
Inflammatory response alveolar bone loss(32-36).
Arachidonic acid derivatives, eg prostaglandinE2(PGE 2) PROTEOLYTIC AND HYDROLYTIC ENZYMES IN
Cytokines, eg IL, IL-2, IL-4, IL-6, TNF-. INFLAMMATORY CELLS
Proteolytic enzymes
DIAGNOSTIC TEST Collagenase
GCF PGE2 has considerable potential as a screening test for
periodontal activity strangely no commercial efforts are currently Elastase
underway to develop one. Therefore it is now possible to assay GCF Cathepsin G
PGE2 with an ELISA assay using a monoclonal rabbit anti PGE2
23
Cathepsin B
antibody . Cathepsin D
POTENTIAL PROTEOLYTIC AND HYDROLYTIC ENZYMES Dipeptidylpeptidase
OF INFLAMMATORY CELL ORIGIN Tryptase
Inflammation leads to accumulation of polymorphonuclear Hydrolytic enzymes
neutrophil leucocytes (PMNs), macrophages, lymphocytes and mast Aryl sulphatase
cell which are very important in protecting the body against infection. glucoronidase
The inflammatory cell contains destructive enzymes within their
lysosomes which are normally used to degrade phagocytosed material. Alkaline phosphatise
These enzymes are, however , capable of degrading gingival tissue Acid phosphatise
components if released. Such enzymes may be released by the Myeloperoxidase
inflammatory cells during their function or when they degenerate or Lysozyme
die. Cells and tissues in the vicinity of these cells will be damaged and
this process is known as bystander damage. The main tissue damage in Lactoferrin
this process are the connective tissue components and the breakdown of
these tissues around the inflammatory cells helps the spread of these There are some test kits based on some of the GCF factors are
cells through the tissues24. currently available. For example, Periocheck to detect the presence of
neutral proteinases such as collagenase in GCF, Prognostik to detect
37
Inflammatory and connective tissue cells and the proteolytic the presence of the serine proteinase, elastase, in GCF samples .
enzymes and inhibitors which they contain within their Advantages of diagnostic test systems based on proteolytic and
cytoplasmic bodies.25-30 hydrolytic enzymes are;
Some are predictive of diseas activity in longitudinal studies eg;
cathepsin B, elastase, dipeptidylepeptidase II and 1V
Since it is a colour detective system, simple to use
Short chair side time
Can be shown to the patient related to the areas.
02
All enzymes released from inflammatory cells are likely to be Bone phosphoprotein (N-propeptide), Osteocalcin, Telopeptides of
associated with gingival inflammation. Since gingival inflammation is type I collagen have been considered for possible markers of bone
often present in the absence of disease activity this association with resorption and hence periodontal disease activity.
inflammation could produce a false association with disease activity. It
is therefore very important to show that a potential marker has a true OSTEONECTIN AND BONE PHOSPHOPROTEIN (N-
association with periodontal disease activity which is independent of PEPTIDE)
and stronger than any association it may have with gingival Osteonectin is a normal component of bone matrix which is
42
inflammation. thought to play an important role in the initial phase of mineralisation .
Bone phosphoprotein, which is an amino propeptide part of type I
POTENTIAL MARKERS OF CELL DEATH AND TISSUE collagen, appears to be involved in the attachment of connective tissue
DEGRADATION cells to the substratum. Both of these proteins have been detected in
Periodontal disease activity involves both damage to the GCF from patients with periodontitis. The total amount of both
epithelial cells of the pocket lining and to the connective tissue cells in component is increased in GCF at the site of increased probing depth.
the sites of connective tissue degradation. Active periodontal tissues are
densely infilterated with inflammatory cells most of these cells may be OSTEOCALCIN
damaged1. The damaged cells release their cytosolic enzymes (enzymes Osteocalcin is a calcium-binding proteins of bone and is the
within the cytoplasm of the cells) and the concentration of these may most abundant non-collagenous protein of the mineralised tissues43. It
well reflect the amount of cellular death within the lesion. Two of these chemotactically attracts osteoclast progenitor cells and blood
enzymes are Asperate amino transferase (AST) and lactate monocytes.44-46 In addition , it is stimulated by vitamin D3, producing
dehydrogenase (LDH), have been widely used in medicine for several concentration that inhibit collagen synthesis in osteoblasts, promote
decades as diagnostic aids to assess cell death and tissue destruction. bone resorption.47 Further elevated levels of osteocalcin are found in the
These enzymes would be expected to pass from the periodontal tissues blood during periods of rapid bone turnover such as osteoporosis and
in the inflammatory exudates into the gingival crevicular fluid (GCF). fracture repair.48,49 Therefore osteocalcin has been suggested as a
Therefore, GCF levels of these enzymes, should provide evidence of possible marker for bone resorption and hence periodontal disease
cell death within the periodontal tissues and hence, possibly disease progression, it is present in GCF.
activity. For these reasons they have been studied as potential marker of
disease activity.38 CONCLUSION
Periodontal practice ranges from the detection, diagnosis and
CONNECTIVE TISSUE DEGRADATION MARKERS treatment of attachment loss due to periodontitis. The new diagnostic
The degradation of connective tissue by inflammatory cells technologies may be capable of providing the clinician with effective
and possibly bacterial enzymes during active periodontitis can release tools that can assist in the early identification of periodontal disease that
components of these tissues. These components could be cleaved can result in expidated treatment. The newer diagnostic technique are
sections of the major molecules of the periodontal connective tissue and still at an adolescent stages of development and much work remains to
basement membrane such as collagens and proteoglycans39, 40. The performed to fully validate this utility such that they become important
components that could be degraded during periodontitis are listed in and cost effective for the successful periodontal management.
table -1
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drmanju75@rediffmail.com
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04
Cone Beam Computed Tomography

Ashish Aggarwal, Nitin Upadhyay , Nupur Agarwal, Sowmya G. V. , Md.Asad Iqubal
Senior Lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Stutent, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 21/Mar/2013
Date of Acceptance : 08/Apr/2013
Abstract: CBCT is a compact, faster and safer version of the regular CT, through the use of a cone shaped x-ray
beam. The size of the scanner, radiation dosage and time needed for scanning are all dramatically reduced and
can be easily fitted into the dental chair.It involves the use of rotating x-ray equipment, combined with a digital
computer, to obtain images of the body. Using CT imaging, cross sectional images of body organs and tissues
can be produced. CT imaging can provide views of soft tissue, bone, muscle, and blood vessels. Computed
tomography (CT) imaging, is also referred as computed axial tomography (CAT) scan clarity.
Key words : Cone Beam, Radiology, Medicine, Implantology, Orthodontic.

INTRODUCTION appreciate the advantages that the third dimension gives to clinical
To understand the difference between CT imaging and other diagnosis, treatment planning and patient education with cbct
techniques, x-ray of the head should be considered. Using basic x-ray technology all possible radiographs can be taken in under 1 minute. The
techniques, the bone structures of the skull can be viewed. With orthodontics now has the diagnostics quality of periapicals,
magnetic resonance imaging (MRI), blood vessels and soft tissue can be panormic,cephalograms and occlusal radiographs and tmj series at their
viewed, but clear, detailed images of bony structures cannot be obtained. disposal along with views that cannot be produced by regular
On the other hand, x-ray angiography can provide a look at the blood radiographic machines like axial views and separate cephalograms for
vessels of the head, but not soft tissue. CT imaging of the head can the right and left sides.6
provide clear images not only of soft tissue, but also of bones and blood
vessels. UTILIZATION OF CBCT IN AN ORTHODONTIC PRACTICE
CT imaging is commonly used for diagnostic purposes. In Prior to seeing the patient, the tri-planner view of the CBCT is
fact, it is a chief imaging method used in diagnosing a variety of cancers, screened for any observable pathology. This is something we were only
including those affecting the lungs, pancreas, and liver. Using CT able to do in a limited manner with two dimensional .The second task is
imaging, not only can physicians confirm that tumors exist, but they can to review the tri-planner view examining the airways. This includes the
also pinpoint their locations, accurately measure the size of tumors, and retro-glossal airway, retropalatal airway, nasal passageways and all
determine whether or not they've spread to neighbouring tissues.In sinuses. Adequacy of airways can affect skeletal growth patterns in
addition to the diagnosis of certain cancers, CT imaging is used for growing individuals and can also affect dental stability in growing as
planning and administering radiation cancer treatments, as well as for well as non growing individuals. The airways are also a reflection of
planning certain types of surgeries. It is useful for guiding biopsies and a skeletal relationships and can give us a clue of those individuals that may
range of other procedures categorized as minimally invasive. Thanks to have or be at risk for sleep disorders including obstructive sleep apnea.
its ability to provide clear images of bone, muscle, and blood vessels, CT In addition, we will sometimes find sinus polyps, maxillary sinus
imaging is a valuable tool for the diagnosis and treatment of infections and even ethmoid sinus disease. Upon finding pathology, the
musculoskeletal disorders and injuries. It is often used to measure bone appropriate referrals are made accompanied by a video copy of the
mineral density and to detect injuries to internal organs. CT imaging is CBCT on a CD radiographs looking through a great depth of anatomy
even used for the diagnosis and treatment of certain vascular diseases with inherent distortion due to the manner in which the image was
that, undetected and untreated, have the potential to cause renal failure, obtained within the alveolar trough, relative horizontal bone levels and
stroke, or death.4 root proximity. Recognizing asymmetries and developing asymmetries
is an extremely important part of the orthodontic diagnostic process as
In layman's terms, CBCT is a compact, faster and safer version this has profound affects upon how we plan for the individual's
of the regular CT. Through the use of a cone shaped X-Ray beam, the size treatment. Following the tri-planner investigations, I will then build the
of the scanner, radiation dosage and time needed for scanning are all TMJ studies examining form, volume and position of the condyles
dramatically reduced. within the fossa as well as the anatomy of the fossa itself. Because our
A typical CBCT scanner can fit easily into any dental ( or patients have either completed their health history questionnaires on-
otherwise ) practice and is easily accessible by patients. The time needed line or in our office prior to my review of all of the above I am able to add
for a full scan is typically under one minute and the radiation dosage is up this information to the diagnostic information provided by the CBCT
to a hundred times less than that of a regular CT scanner.4 and the information obtained by my treatment coordinator all before I
have even met my patient. To have this information at my initial exam
CBCT IN ORTHODONTICS only enhances the diagnosis, treatment planning, an deducational
There has been an escalating interest in three dimensional process. Prior to my viewing the CBCT volume in the proprietary
imaging devices over the last decade. orthodontics are beginning to software another staff member takes a "step backwards in time" and
05
builds 2Dlateral and posterior-anterior cephalograms in Dolphin 3D implant treatment, appropriate site or size can be chosen before
(orthodontic imaging software) to allow me to digitize the cephalograms placement, and osseointegration can be studied over a period of time.
and provide me with further diagnostic and treatment planning This review discusses all the finer details of CBCT which has
information. This process is at this time a necessity for the orthodontist added a third dimension to the imaging in periodontics.
but 3D digitizing will soon be here and infact is being developed and
tested at this time. The quality of the cephalograms built from the CBCT USES OF CBCT IN HEAD & NECK REGION
is without a doubt a huge improvement over the conventional CBCT is being increasingly used for point of service head &
2Dradiographs. The CBCT and extra-oral photographs are taken with an neck and dento-maxillofacial imaging. This technique provides
operator assisted first tooth contact centric relation wax bite registration. relatively high isotrophic spatial resolution of osseous structures with a
We can make more appropriate treatment decisions as opposed to images reduced radiation dose compared with conventional CT scans. In this
taken in habitual jaw positions that may not reflect the true relationship second installement in a 2-part review, the clinical application in the
of the mandible to the maxilla and thus may inaccurately reflect condylar dentomaxillofacial and head & neck regions will be explored, with
position and the relative dental relationships The superior diagnostic particular emphasis on diagnostics imaging of the sinuses, temporal
information provided by CBCT over conventional radiographic bone and craniofacial structures.3
technology dictates that we make the transition from 2D diagnosis and Cone beam CT (CBCT) is an advancement in CT imaging that
treatment planning to 3D sooner rather than later. Most all of us have has begun to emerge as a potentially low-dose cross-sectional technique
inherent asymmetries and skeletal discrepancies but the greater the for visualizing bony structures in the head and neck. The physical
magnitude of these discrepancies the more important 3Dimaging, principles, image quality parameters, and technical limitations relevant
digitization and treatment planning becomes. For example, treatment to CBCT imaging were discussed in Part 1 of this 2-part series. The
planning of orthognathic surgical cases in 3D will provide us a more second part presented here will highlight the evidence related to CBCT
complete picture of treatment options and projected treatment outcomes, applications in head and neck as well as dentomaxillofacial imaging.
which in the end is a huge benefit for the patient.7 Controversial aspects of this technology will also be addressed,
including limitations in image quality and its often office-based
USES OF CBCT IN IMPLANTOLOGY operational model.3
In the field of periodontology and implantology, assessment of CBCT was first adapted for potential clinical use in 1982 at the
the condition of teeth and surrounding alveolar bone depends largely on Mayo Clinic Bio dynamics Research Laboratory. Initial interest focused
two-dimensional imaging modalities such as conventional and digital primarily on applications in angiography in which soft-tissue resolution
radiography though these modalities are very useful and have less could be sacrificed in favour of high temporal and spatial-resolving
radiation exposure, they still cannot determine a three dimensional capabilities. Since that time, several CBCT systems for use have been
architecture of osseous defects. Hence an imaging modality which developed both in the interventional suite and for general applications in
would gives an undistorted vision of a tooth and surrounding structures CT angiography. Exploration of CBCT technologies for use in radiation
is essential to improve the diagnostics potential. CBCT provides 3D therapy guidance began in 1992, followed by integration of the first
images that facilitate the transition of dental imaging from initial CBCT imaging system into the gantry of a linear accelerator in 1999.
diagnosis to image guidance throughout the treatment phase. This The first CBCT system became commercially available for
technology offers increased precision, lower doses and lower costs when dentomaxillofacial imaging in 2001 (New Tom QR DVT 9000;
2
compared with medial fan-beam CT. Quantitative Radiology, Verona, Italy). Comparatively low dosing
In the field of periodontology, assessment of the condition of requirements and a relatively compact design have also led to intense
teeth and surrounding alveolar bone depends largely on traditional two- interest in surgical planning and intra operative CBCT applications,
dimensional imaging modalities such as conventional radiography and particularly in the head and neck but also in spinal, thoracic, abdominal,
digital radiography. Though these modalities are very useful and have and orthopedic procedures. Diagnostic applications in CT
less radiation exposure, they still cannot determine a three-dimensional mammography and head and neck imaging are also under evaluation.
(3D) architecture of osseous defects. Hence, an imaging modality which The technical and clinical considerations pertaining to CBCT imaging in
would give an undistorted 3D vision of a tooth and surrounding many of these applications have been the subjects of several recent
structures is essential to improve the diagnostic potential. A well reviews.The recent review by Drfler et al of the neurointerventional
diagnosed periodontal lesion warrants an appropriate treatment. applications of CBCT is of particular interest to the field of
In the medical field, the 3D imaging using computed tomography (CT) neuroradiology.5
has been available now for many years, but in the dental specialty, its
application is restricted to the use in cases of maxillofacial trauma and
USES OF CBCT IN PROSTHODONTICS
diagnosis of head and neck diseases. Routine use of CT in dentistry is not
Today's computer aided design & manufacture (CAD/CAM)
accepted due to its cost, excessive radiation, and general practicality. In
technologies contribute greatly to restorative dentistry & provide
recent years, a new technology of cone-beam CT (CBCT) for acquiring
clinicals with advanced treatment options for various
3D images of oral structures is now available to the dental clinics and
indications,including inlays,onlays,fixed dentures & full dentures,thin
hospitals. It is cheaper than CT, less bulky and generates low dosages of
veneers and crowns.These systems also allow use of many restorative
X-radiations. The innovative CBCT machine (fig 1] designed for head
materials,including metal,metal-ceramic,compositive & all ceramic, to
and neck imaging are comparable in size with an orthopantomograph.
best meet the needs of the care & patients. Further CAD/CAM systems
CBCT provides rapid volumetric image acquisition taken at
are available for both chairable & laboratory applications,so dentists
different points in time that are similar in geometry and contrast, making
now have the ability to create highly aesthetic & strong restoration in
it possible to evaluate differences occurring in the fourth dimension 4
time. In its various dental applications, images of jaws and teeth can be office.
visualized accurately with excellent resolution can be restructured three
dimensionally, and can be viewed from any angle (Fig 2). Most ADVANTAGES OF CBCT
significantly, patient radiation dose is five times lower than normal CT. Being considerably smaller, CBCT equipment has a greatly
Today, CBCT scanning has become a valuable imaging reduced physical footprint and is approximately 20-25% of the cost of
modality in periodontology as well as implantology. For the detection of conventional CT. CBCT provides images of high contrasting structures
smallest osseous defects, CBCT can display the image in all its three and is therefore particularly well- suited towards the imaging of osseous
dimensions by removing the disturbing anatomical structures and structures of the craniofacial area. The use of CBCT technology in
making it possible to evaluate each root and surrounding bone. In clinical dental practice provides14 a number of advantages form
axillofacial imaging. These include
06
RAPID SCAN TIME patient. Surgical templates can then be laboratory fabricated on stone
Because CBCT acquires all projection images in a single casts, or directly CT-derived via stereo lithography, taking the scan data
rotation, scan time is comparable to panoramics of radiography. This is and turning it into solid resin models of the patient's mandible or maxilla.
desirable because artefact due to subject movement is reduced. However, as more companies invest in 3-D digital dentistry solutions,
Computer time for dataset reconstruction however is substantially linking the technologies together has become a reality. This presentation
longer and varies depending on FOV, the number of basis images will demonstrate how digital dentistry is evolving into a mainstream
acquired, resolution and reconstruction algorithm and may range from dentistry, allowing everyone to achieve successful "restoratively-
approximately 1 to 20 minutes. driven" implant dentistry.
BEAM REFERENCES
Collimation of the CBCT primary x-ray beam enables 1. Kau CH, Richmond S. Current products and practice three
limitation of the x-radiation to the area of interest. Therefore an optimum dimensional cone beam computerized tomography in orthodontics.
FOV can be selected for each patient based on suspected disease J Ortho 2005;32:282-93.
presentation and region of interest. While not available on all CBCT 2. Mohan R, Singh A, Gundappa M. Three-dimensional imaging in
systems, this functionality is highly desirable as it provides dose savings periodontal diagnosis Utilization of cone beam computed
by limiting the irradiated field to fit the FOV. tomgraphy. J Indian Soc Periodontol. 2011;15(1):7-11.
3. Miracle AC, Mukherji SK. Conebeam CT of the head and neck,
IMAGE ACCURACY part 2: clinical applications. AJNR Am J Neuroradio
CBCT imaging produces images with sub-millimeter 2009;30(7):1285-92.
isotropic voxel resolution ranging from0.4 mm to as low as 0.09 mm. 4. Alamri HM, Sadrameli M, Alshalhoob MA, Sadrameli M, Alshehri
Because of this characteristic, subsequent secondary(axial, coronal and MA. Applications of CBCT in dental practice: a review of the
sagittal) and MPR images achieve a level of spatial resolution that is literature. Gen Dent. 2012; 60(5):390-400.
accurate enough for measurement in maxillofacial applications where 5. Danforth RA, Peck J, Hall P. Cone beam volume tomography: an
precision in all dimensions is important such as implant site assessment imaging option for diagnosis of complex mandibular third
and orthodontic analysis molar anatomical relationships. J Calif Dent Assoc
2003;31(11):847-52.
REDUCED PATIENT RADIATION DOSE COMPARED TO 6. Halazonetis DJ. From 2-dimensional cephalograms to 3-
CONVENTIONAL CT. dimensional computed tomography scans. Am J Orthod
The effective dose (E) varies for various full field of view Dentofacial Orthop 2005;127(5):627-37.
CBCT devices from 29-477 Sv depending on the type and model of 7. Mah J, Hate er D. Current status and future needs in craniofacial
CBCT equipment and FOV selected (Table 2) (Schulze et al.,2004; Mah imaging. Orthod Craniofac Res. 2003; 6(1):79-82.
et al., 2003; Ludlow et al.,2003, 2006, 2007). Patient positioning 8. Noar JH, Pabari S. Cone beam computed tomography current
modifications (tilting the chin) and use of additional personal protection understanding and evidence for its orthodontic applications? J
(thyroid collar) can substantially reduce dose by upto 40% (Ludlow et Orthod 2013;40(1):5-13.
al., 2006). These doses can be compared more meaningfully to dose from 9. Chaushu S, Chaushu G, Becker A. The role of digital volume
a single digital panoramic exposure(Ludlow et al., 2003), equivalent CT tomography in the imaging of impacted teeth. World J Orthod
dose (Ngan et al., 2002), or the average natural background radiation 2004;5(2):120-32.
exposure for Australia (1,500 Sv) (ARPANSA, 2007)in terms of 10. Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption
background equivalent radiation time (BERT) (MacDonald, of maxillary canines: a CT study. Angle Orthod. 2000;70(6):415-
1997).CBCT provides an equivalent patient radiation dose of 5 to 80 23.
times that of a single film-based panoramic radiograph, 1.3% to 22.7% 11. Mah J, Enciso R, Jorgensen M. Management of impacted
of a comparable conventional CT exposure or 7 to 116 days of cuspids using 3-D volumetric imaging. J Calif Dent Assoc.
background radiation. 2003;31(11):835-41.
12. Aboudara CA, Hatcher D, Nielsen IL, Miller A. A three-
ORAL RADIOLOGY dimensional evaluation of the upper airway in adolescents.
Orthod Craniofac Res. 2003;6:173-5.
A number of novel medical diagnostic imaging modalities 13. Robb RA. The Dynamic Spatial Reconstructor: An X-Ray Video-
have emerged recently. Cone beam computed tomography (CBCT) is a Fluoroscopic CT Scanner for Dynamic Volume Imaging of Moving
radiographic imaging method that allows accurate, three-dimensional Organs. IEEE Trans Med Imaging. 1982;1(1):22-33.
imaging of hard tissues. CBCT has been used for dental and 14. Fahrig R, Nikolov H,Fox AJ, Holdsworth DW. A three-
maxillofacial imaging for more than ten years now and its availability dimensional cerebrovascular flow phantom. Med Phys.
and use are increasing continuously. However, at present, only best 1999;26(8):1589-99.
practice guidelines are available for its use, and the need for evidence- 15. Covalcanti MG. Cone beam computed tomegraplic imaging
based guidelines on the use of CBCT in dentistry is widely recognized. perspective, challenges and the impact of near trend future
CBCT is more reliable in evaluating the number of mandibular third applications. J Craniofac Surg 2012;23(1):279-82
molar roots than panoramic radiography. CBCT scanners provide 16. Suomalainen II., Kiljunen T, Kaser Y, Peltola J, Kortesniemi M.
adequate image quality for dentomaxillofacial examinations while Dosimetry and image quality of four dental cone beam computed
delivering considerably smaller effective doses.16 tomography scanners compared with rnultislice computed
tomography scanners, Dentomaxillofac Radiol. 2009;38(6):367-
CONCLUSION 78.
Even with CT imaging, clinicians have laboured to link the
information from the scan data to the surgical site, transferring angles
and positions manually. This is overcome with interactive software
applications that provide this information seamlessly. Corresponding
Corresponding Address:
Address:
As CBCT has become the state-of-the-art, the race is on to
identify opportunities which benefit from the digital information
Dr.Ashish
Dr. C. Ram Mohan
Aggarwal
embedded in each scan. Guided implant surgery has evolved as an Email: drashishagg@rediff mail.com
Email:dr_rammohanc@yahoo.co.in
important modality and aid in transferring the virtual 3-D plan to the
07
LIST OF PHOTOGRAPHS
Fig 1 CBCT Machine
Fig 2 CBCT Image
08
Nanotechnology : Its Implications in Conservative Dentistry and Endodontics

Sumit Mohan , Anuraag Gurtu , Anurag Singhal , Ankita Mehrotra
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Reader, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor & Head, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 27/Feb/2013
Abstract: Feynman postulated concept of nanotechnology as an unavoidable development in the progress of

science. Since then, nanotechnology has been part of mainstream scientific theory with potential medical and
dental applications. Numerous theoretical predictions have been made based on the potential applications of
nanotechnology in dentistry. The most substantial contribution of nanotechnology to dentistry is the more
enhanced restoration of tooth structure with nanocomposites. The field of nanotechnology has tremendous
potential, which if harnessed efficiently, can bring out significant benefits to the human society such as
improved health, better use of natural resources. The future holds in store an era of dentistry in which every
procedure will be performed using equipments and devices based on nanotechnology. This article reviews the
potential clinical applications of nanotechnology in conservative dentistry and endodontics.
Key words : Nanotechnology, Nanodentistry, Nanocomposites; Dentifrobots, Nanosolution.

INTRODUCTION particular tooth that requires treatment. After oral procedure
Nanotechnology also known as molecular is completed , dentist orders the nanorobots to restore all
nanotechnology or molecular engineering is production of sensations to relinquish control of nerve traffic and to egress
functional materials and structures in range of 0.1 to 100 from tooth by similar pathways used to ingress.5
nanometeres. Today the revolutionary development of 2. Hypersensivity cure:- Dentine hypersensitivity may be
nanotechnology has become the most highly energized caused by changes in pressure transmitted hydrodynamically
disciplined in science and technology.1The term Nanotechnology to pulp. Dental nanorobots could selectively and precisely
was coined by Prof. Kerie E Drexler.2 Nano is derived from vaos, occlude selected tubule in minutes, using native biological
the Greek word for dwarf and usually is combined with noun to materials, thus offering patients a quick and permanent cure.2
form words such as nanometer, nanotechnology or nanorobot.3 3. Nanorobotic dentifrices (dentirobots):- Subocclusal
First described in 1959 by physicist Richard P Feyman, dwelling nanorobotic dentifrices delivered by mouthwash or
who said it as an avoidable development in progress of science, toothpaste could patrol all supragingival and subgingival
nanotechnology has been a part of mainstream scientific theory surfaces at least once a day, metabolising trapped organic
with potential medical and dental application since early 1990's. matter into harmless and odourless vapours and performing
Nanoparticle, nanosphere, nanorodes, nanotubes, nanofibres, continuous calculus debridement. Toothpaste containing
dendrimers and other nanostructures has been studied for various synthesized hydroxyapatite, calcium peroxide, patented
applications to biologic tissue and systems. Growing interest in nano-technology aka Nanoxyd has proven useful to freshen
future medical application of nanotechnology is leading to the breathe as well as whiten teeth6.
emergence of new field called Nanomedicine. Emerging 4. Dental durability and cosmetics:- Tooth durability and
technologies and new nanoscale information have the potential to appearance may be improved by replacing upper enamel
transform dental practice by advancing all aspects of dental layers with pure sapphire and diamond which can be made
diagnostics, therapeutics and cosmetic dentistry into a new more fracture resistance as nanostructure composites,
paradigm of state-of-the-art patient care beyond traditional oral possibly including embedded carbon nanotubes.5
care methods and procedures.4 5. Orthodontic treatment:- Orthodontic nanorobots could
New potential treatment opportunities in dentistry may include directly manipulate the periodontal tissues allowing rapid
bottom up approach and bottom down approach. and painless tooth straightening, rotating and vertical
repositioning within minutes to hours.7 Sliding a tooth along
The bottom up approaches are: a archwire involves a frictional type of force that resist this
1. Local anaesthesia:- a colloidal suspension containing movement. Use of excessive orthodontic force might cause
millions of active analgesic micron size dental robot will be loss of anchorage and root resorption, but coating
instilled on patients gingivae. After contacting the surface of orthodontic wire with inorganic fullerene like tungsten
crown or mucosa, ambulating nanorobots reach the pulp. disulfide nanoparticles, reduction in friction has been
Once installed there, analgesic dental robots may be reported.
commanded by dentist to shut down all sensitivity in any 6. Photosensitizers and carriers:- Quantum dots can be used as
09
photosensitizers and carriers. They can bind to the antibody NanOSS .These can be used in maxillofacial injuries
present on surface of target cell and when stimulated by UV requiring bone graft, cleft patients and osseous defects in
light. They can give rise to reactive oxygen species and thus periodontal surgeries.7
will be lethal to target cell.5 8. Other products are:- Protective clothing and filtration masks,
7. Diagnosis and treatment of oral cancer:- Nano using antipathogenic nanoemulsions and nanoparticles.
electromechanical system (NEMS) which can convert Medical appendages for instantaneous healing. Bone
biochemical to electrical signal and cantilever array sensor targeting nanocarriers like calcium phosphate based
which is an ultrasensitive mass detection technology, can be biomaterials are developed.6,3
used for detection of 10-12 bacteria, viruses and DNA. These
are extremely useful for diagnosis of oral cancer and diabetes ROLE OF NANOTECHNOLOGY IN CONSERVATIVE
mellitus. Nanomaterials for brachytherapy like DENTISTRY & ENDODONTICS
'BrachySilTM' delivers P32, are in clinical trial. Drug delivery NANOCOMPOSITE
system that can cross the blood brain barrier is vision of the One of the most significant contributions to dentistry
future with this technology. Parkinson disease, Alzheimer has been the development of resin based composite technology.
disease, brain tumour will be managed more efficiently by Adhesively bonded composites have the advantage of conserving
the use of this technology. Nanovectors for gene therapy are sound tooth structure with the potential for tooth reinforcement,
in a developing stage to correct disease at molecular aspect.5 while at same time providing cosmetically acceptable
restorations. However, no composite material has been able to
Top-Down Approaches include: meet both functional needs of posterior class I or II restorations
1. Nanocomposites:- Nanocomposites has been successfully and superior esthetics required for anterior restorations. There
manufactured by non-agglomerated discrete nanoparticles was a need to develop a composite dental filling material that
that are homogenously distributed in resins or coatings to could be used in all areas of mouth with high initial polish and
produce them.4 The nanofiller used includes an alumino superior polish retention as well as excellent mechanical
silicate powder having a mean particle size of 80 nm2. properties suitable for high stress bearing restoration 1.
Commercially they are available as Filtek O Supreme Composition: Nanocomposite has the basic composition of
Universal Restorative Pure Nano O. conventional composite resin. Dental composites are composed
2. Nanosolutions:- It produces unique and dispersible of synthetic polymers, inorganic fillers, initiators, and activators
nanoparticles which can be used in bonding agents. This that promote light-activated polymerization of the organic matrix
insures homogeneity and adhesive is mixed every time.2 to form cross-linked polymer networks, and silane coupling
3. Impression materials:- Nanofillers are integrated in agents which bond the reinforcing fillers to the polymer matrix.
vinylpolysiloxanes, producing a unique additions of They have fillers that are 0.005 to 0.01m.6 Nanoproducts
siloxane impression materials, having better flow, improved Corporation has successfully manufactured nonagglomerated
hydrophilic properties and enhanced details.5 Commercially discrete nanoparticles that are homogeneously distributed in
available as Nanotech Elite H-D. resins or coatings to produce nanocomposites. The nanofiller
4. Nanoencapsulation:- Nanomaterials, including hollow used include an alumino silicate powder having a mean particle
spheres, core-shell structure, nanotubes and nanocomposite, size of 80 nm2.
have been widely explored for controlled drug release. Additionally, nanofillers are capable of increasing the
South-west research institute has developed targeted systems overall filler level due to their small particle sizes. More filler can
that encompass nanocapsules include novel vaccines, be accommodated if smaller particles are used for particle
antibiotics and drug delivery with reduced side effects.5 packing. Theoretically, with the use of nanofillers, filler levels
Pinon-Segundo et al studied Triclosan loaded nanoparticles, could be as high as 90-95% by weight. However, the increase in
500 nm in size, used in an attempt to obtain a novel drug nanofillers also increases the surface area of the filler particles,
delivery system adequate for the treatment of periodontal which limits the total amount of filler particles because of the
disease. These particles were found to significantly reduce wettability of the fillers. Since polymerization shrinkage is
inflammation at the experimental sites. An example of the mainly due to the resin matrix, the increase in filler level results in
development of this technology is arestin in which a lower amount of resin in nanocomposites and will also
minocycline is incorporated into microsphere for drug significantly reduce polymerization shrinkage and dramatically
delivery by local means to a periodontal pocket.8 improve the physical properties of nanocomposites. The
5. Nanoneedles:- Suture needles incorporating nano sized nanocomposite is composed of three different types of filler
stainless steel crystals have been developed. Nanoneedles components: nonagglomerated discrete silica nanoparticles,
like Sandvik Bioline, RK 91 needles are available.5 barium glass, and prepolymerized fillers.
6. Nanotweezers:- In 1999, Philip Kim and Charles Lieber at Caries prevention fillers: To increase mineral content to
Harward University created the first general purpose control dental caries, calcium and phosphate ion-releasing fillers
nanotweezer. Its working end is a pair of electrically have been developed, such as nanoparticles of dicalcium
controlled carbon nanotubes made from a bundle of phosphate anhydrous (DCPA) 11,12 and tetracalcium phosphate
multiwalled carbon nanotubes. To operate the tweezers, a [TTCP: Ca4(PO4) 4O]-whiskers.13
voltage is applied across the electrode, causing one nanotube
arm to develop a positive electrostatic charge and the other to LOCAL ANAESTHESIA
develop a negative charge.9 One of the most common procedures in dentistry is the
7. Bone replacement materials:- Hydroxyapatite nanoparticles injection of local anesthetic, which can involve long waits and
are used to treat bone defects are Ostium, Vitosso and varying degrees of efficacy, patient discomfort and
10
complications. Well-known alternatives, such as transcutaneous toothpaste, it could cause potential health effects. If the silver
electronic nervestimulation, cell demodulated electronic targeted particles build up in our water systems, they may start
anesthesia and other transmucosal, intraosseous or topical accumulating in other people and animals as well.
techniques are of limited clinical effectiveness.5,7 To induce oral 2. Risk of nanoparticles flowing through the body if the
anesthesia in the era of nanodentistry, dental professionals will toothpaste is actually swallowed.
instill a colloidal suspension containing millions of active 3. Some people feel that this is not friendly for the environment.
analgesic micrometer-sized dental nanorobot particles on the 4. They can even slip through the olfactory nerve into the
patient's gingival (fig.6). After contactingthe surface of the crown brain, evading the protective blood brain barrier. It's not clear
or mucosa, the ambulating nanorobots reach the dentin by whether they penetrate the skin. Once they're inside the body,
migrating into the gingival sulcus and passing painlessly through it's not clear how long they remain or what they do'' says
the lamina propria14 or the 1 to 3m thick layer of loose tissue at Caroline Bass of Environmental 360. 6
the cemento-dentinal junction.15 On reaching the dentin, the
nanorobots enter dentinal tubule holes that are 1 to 4 m in NANOFILLED RESIN MODIFIED GLASS IONOMER
diameter16,17and proceedtoward the pulp, guided by a combination A new nano-filled RMGI restorative material has been
of chemical gradients, temperature differentials and even introduced for restoration of primary teeth and small cavities in
positional navigation,7 all under the control of the onboard permanent teeth. It is based on a prior RMGI with a simplified
nanocomputer, as directedby the dentist. dispensing and mixing system (paste/paste) that requires the use
There are many pathways to choose from. Dentinal of a priming step, but no separate conditioning step. Its primary
tubule number density is typically 22,000 mm2 near the dentino- curing mechanism is by light activation, and no redox or self
enamel junction, 37,000 mm2 midway between the junction and curing occurs during setting. Apart from the user-friendliness, the
the pulpal wall, and 48,000 mm2 close to the pulp in coronal major innovation of this material involves the incorporation of
dentin, with the number density slightly lower in the root (for nano-technology, which allows a highly packed filler
example,13,000 mm2 near the cementum). Tubule diameter composition (69%), of which approximately two-thirds are nano-
increases nearer the pulp, which may facilitate nanorobot fillers. 20
movement, although circumpulpal tubule openings vary in Composition: Chemistry of nanoionomer is based on the
number and size.18 methacrylate modified polyalkenoic acid, which is capable of
both crosslinking via pendate methacrylate groups as well as the
MAINTAINANCE OF ORAL HYGIENE acid-base reaction between the fluoroaluminosilicate glass (FAS)
Nanorobotic dentifrice delivered by a mouthwash or and the acrylic and itaconic acid copolymer groups. It contains
toothpaste could patrol all supragingival and subgingival surface treated nanofillers (approx 5-25nm) and nanoclusters
surfaces, at least once a day, metabolizing trapped organic matter (approx 1 to 1.6 microns). Filler loading is approx. 69% by weight
into harmless and odorless vapors and performing continuous of which the relative proportion of two filler types (FAS and
combination of nanofillers ) are approx 2/5 and 3/5 respectively.
calculus debridement.19
All nanofillers are further surface modified with methacrylate
These almost invisible (1 to 10 micrometre)
silane coupling agents to provide covalent bond formation into
dentifrobots, perhaps numbering 1000 to 100000 per mouth and
crawling at 1 to 10 micrometre per second might have the free radically polymerized matrix.21
mobility of tooth amoebas but would be inexpensive purely
mechanical devices that safely deactivate themselves, if DENTAL HYPERSENSITIVITY
swallowed. Moreover, they would be programmed with strict Dentin hypersensitivity is defined as a sharp pain arising
protocol to avoid occlusal surfaces. Properly configured from exposed dentin as a result of various stimuli such as heat,
dentifrobots could identify and destroy pathogenic bacteria cold, chemical or osmotic, and that cannot be ascribed to any
residing in the plaque and elsewhere, while allowing the 500 or so other pathology. It a may be caused by changes in pressure
species of harmless oral micro flora to flourish in a healthy transmitted hydrodynamically to the pulp. This is based on the
ecosystem. Dentifrobots also would provide a continuous barrier fact that hypersensitive teeth have 8 times higher surface density
to halitosis since bacterial putrefaction is the central metabolic of dentinal tubules and tubules with diameters twice as large as
process involved in oral malodor. With this kind of daily dental nonsensitive teeth. Dental nanorobots could selectively and
care available from an early age, conventional tooth decay and precisely occlude selected tubules in minutes, using native
gingival disease will disappear. biological materials, offering patients a quick and permanent
cure.5 On reaching the dentin, the nanorobots enter dentinal
NANO TOOTHPASTE tubular holes that are 1 to 4 m in diameter and proceed toward
Nano-Whitening Toothpaste is toothpaste that contains the pulp, guided by a combination of chemical gradients,
synthesized hydroxyapatite, a key component of tooth enamel, as temperature differentials and even position of navigation, all
nanosized crystals. It has been proven to freshen breathe as well as under the control of the onboard nanocomputer as directed by the
whiten teeth. This toothpaste contains ingredents such as: dentist.
Patented nano technology aka Nanoxyd, Calcium peroxide, Novamin containing dentrifice has the ability to
Contains Enzymes such as (papain and bromelain), Fluoride significantly reduce dentin sensitivity within one week compared
combination, Co-enzyme Q10 and Vitamin E.7 to placebo dentrifices. 2 2 Novamin (calcium sodium
The risks of nanotechnology toothpaste: Nanotechnology phosphosilicate) is a bioactive glass in the class of highly
toothpaste has been shown to be harmful because some of the biocompatible material that were originally developed as bone
nanotechnology toothpastes are made with silver hydroxyapatite: regenerated material. The Chinese researchers have
1. If this accumulates in the tissues of people who use this demonstrated that dentinal tubules can be blocked with the aid of
11
gold nanoparticles. One of the method of closing sub micron sized microbiology started with the detection of cultivable as well as
dentinal tubules involved sintering of highly concentrated gold uncultivable bacteria by examining bacterial 16 sRNA and DNA.
nanoparticles that were brushed into exposed open ends of The spatial distribution of different oral bacteria within
tubules. Laser irradiation induced the photofusion of these the plaque has been revealed by fluorescent in situ hybridization.
particles via photothermal conversion. This method seems to be The metagenomic project for oral microbial flora will reveal the
very promising for the purpose of occlusion of dentinal tubules.23 metabolic genes and virulence factors of oral microbes.
Nanotechnology has been used to study the dynamics of
BONE REPLACEMENT MATERIAL demineralization/remineralization process in dental caries by
Although tooth enamel, cementum, and bone are using tools such as atomic force microscopy (AFM) which detect
composed of organized assemblies of carbonated apatite crystals, bacteria induced demineralization at an ultrasensitive level.
enamel is unusual in that it does not contain collagen and does not Using AFM the correlation between genetically modified
remodel. Self-assembly of amelogenin protein into nanospheres Streptococcus mutans sp. scale morphology has been assessed.
has been recognized as a key factor in controlling the oriented and The nanoscale cellular ultrastructure is a direct representation of
elongated growth of carbonated apatite crystals during dental genetic modifications as most initiate changes in surface protein
enamel biomineralization. and enzyme expression, where host- cell nutrient pathways and
immune response protection likely occur. The surface proteins
BIOCERAMICS and enzymes, common to S. mutans strains are a key contributor
Nanosized hydroxyapatite (HA) is the main component of to the cariogenicity of these microbes.
mineral bone in the form of nanometer sized needle-like crystals Another nanotechnology application used so far is
16 18
of approximately 5-20 nm width by 60 nm length. Synthetic HA O /O reverse proteolytic labelling to determine the effect of
possesses exceptional biocompatibility and bioactivity properties biofilm culture on the cell envelope proteome of oral pathogen,
with respect to bone cells and tissues, hence have been widely Porphyromonas gingivalis sp. which is linked to chronic
used clinically in the form of powders, granules, dense and porous periodontitis. A group of cell-surface located C-terminal domain
blocks and various composites. Nanophase HA properties such as family proteins including R gp A, Hag A, CPG 70 and PG99
surface grain size, pore size, wettability, etc, could control protein increased in abundance in the bio-film cells. The other proteins
interactions modulating subsequent enhanced osteoblast which increased were transport related proteins (Hmu Y and Iht
adhesion and long-term functionality. However, since nanophase B), metabolic enzymes (Frd AB) and immunogenic proteins.
materials can mimic the dimensions of constituent components of Nanotechnology can further enable us to detect both cultivable
natural tissues, implants developed from nanophase material can bacteria and non cultivable with the help of nanochip. Similarly
be a successful alternative. Several encouraging reports on plaque acidity which is a good index for monitoring tooth
nanophase materials encourage its use for tissue engineering demineralization can be monitored using a microscale planer pH
applications. This has been achieved by the combined effect of its sensor. Application of nanotechnology to this prototype will
ability to mimic the natural nano dimensions and also the cell further reduce the size of the sensors and make the device more
responses encouraging high reactivity and in turn helps in user friendly to both the patients and clinicians.
regenerating tissues. 5,7,24 New silver nanotechnology chemistry has proven to be
NanOssR bone void filler from Angstrom Medica is effective against biofilms. Silver works in a number of ways to
considered to be the first nanotechnology medical device to disrupt critical functions in a micro-organism. For example it has
receive clearance by the US Food and Drug Administration in a high affinity for negatively charged side groups on biological
2005. Utilizing nanotechnology, calcium and phosphate are molecules such as sulphydryl, carboxyl, phosphate and other
manipulated at the molecular level and assembled to produce charged groups distributed throughout microbial cells. Silver
materials with unique structural and functional properties. It is attacks multiple sites within the cell to inactivate critical
prepared by precipitating nanoparticles of calcium phosphate in physiological functions such as cell wall synthesis, membrane
aqueous phase and the resulting white powder is compressed and transport, nucleic acid (RNA and DNA) synthesis and translation,
heated to form a dense, transparent, and nano crystalline material. protein folding and function and electron transport. For certain
It is strong and also osteoconductive. 24 bacteria as little as one part per billion of silver may be effective in
OstimR is an injectable bone matrix in paste form which preventing cell growth. Recent studies show that ionic plasma
received CE marking in 2002. It is composed of synthetic disposition silver antimicrobial nanotechnology is effective
nanoparticulate hydroxyapatite which is indicated for against pathogens associated with biofilms including E.coli sp.,
metaphyseal fractures and cysts, acetabulum reconstruction and S.pneumoniae sp., S.pneumoniae, S.aureus and A.niger.
periprosthetic fractures during hip prosthesis exchange
operations, osteotomies, filling cages in spinal column surgery, CONCLUSION
combination with autogenous and allogenous spongiosa, filling Nanodentistry will give a new vision to comprehensive
in defects in children etc. 24 oral health care, as now trends of oral health have been changing
to more preventive intervention than a curative and restorative
NANOTECHNOLOGY AND BIOFILM23 procedure. This science might sound like a fiction now, but
Nanotechnology is a promising field of science which Nanodentistry has a strong potential to revolutionize dentistry as
offers better insight into the spatial relationship between different to diagnosing and treating dental diseases in future. It opens up
species and how their diversity increases over time. new avenues for vast, abundant research. Nanotechnology will
Nanotechnology can guide our understanding of the role of change dentistry, health care and human life more profoundly
interspecies interaction in the development of bio-film. The than other developments.
contribution of modern technology in the field of oral
12
REFERENCES 23. Bhardwaj SB, Mehta M, Gauba K. Nanotechnology: Role in
1. Mitra S, Holmes B. An application of nanotechnology in dental biofilms. Indian J Dent Res 2009;20(4 ):511-513.
advanced dental material. J Am Dent Assoc 2003; 134(10): 24. Paul W, Sharma CP. Nanoceramic Matrices: Biomedical
1382-1390. Applications. Am J Biochem Biotech 2006;2(2):41-48.
2. Schleyer TL. Nanodentistry Fact or Fiction. J Am Dent Assoc
2000; 131:1567-1568.
3. Saunders SA. Current practicality of nanotechnology in
dentistry. Part 1: Focus on nanocomposite restoratives and
biometics. Clin, Cos Investi Dent 2009:47-56.
4. Freitas RA. Personal choice in the coming era of
nanomedicine. Nanoethics: The Ethical and Social
Implications of Nanotechnology, John Wiley, NY, 2007, pp.
161-172.
5. Kumar S R, Vijayalakshmi R. Nanotechnology in dentistry.
Ind J Dent 2006;17 (2): 62-65.
6. Future of Nanotechnology Toothpaste: Nanodentistry
Archive for category Nanotechnology Toothpaste.
7. Freitas RA. Nanodentistry. J Am Dent Assoc 2000; 131(11):
1559-1565.
8. Verma SK et al. A critical review of the implication of
nanotechnology in modern dental practice. National J of oral
maxillofacial surgery. 2010 (1) : 1: 41-44.
9. Freitas RA. The future of nanofabrication and molecular
scale devices in nanomedicine. Studies in health technology
and molecular scale devices in nanomedicine. 2002;80:45-
59.
10. Chen MH. Update on Dental Nanocomposites. J Dent Res
2010;89(6): 549-560.
11. Xu HH. Nano DCPA-whisker composites with high strength
and Ca and PO4 release. J Dent Res 2006;85:722-727.
12. Xu HH. Effects of calcium phosphate nanoparticles on Ca-
PO4 composite. J Dent Res 2007;86:378-383.
13. Xu HH, Weir MD, Sun L. Calcium and phosphate ion
releasing composite: effect of pH on release and mechanical
properties. Dent Mater 2009;25:535-542.
14. Paulsen F, Thale A. Epithelial-Connective tissue boundary in
the oral part of human soft palate. J Anat 1998;93:457-67.
15. YamamotoT. The structure and function of the cemento-
dentinal junction in human teeth. J Perio Res 1999;34(5):
261-8.
16. Dourda AO. A morphometric analysis of the cross-sectional
area of dentine occupied by dentinal tubules in human third
molar teeth. Int End J 1994;27(4):184-89.
17. Arends J .The diameter of dentinal tubules in human coronal
dentine after demineralization and air drying: a combined
light microscopy and SEM study. Caries Res 1995;
29(2):118-21.
18. Marion D, Jean A, Hamel H. Scanning electron microscopic
study of odontoblasts and circumpulpal dentin in a human
tooth. J Endod 1991; 72(4) 473-8.
19. Ling Xue Kong. Nanotechnology and its role in the
management of periodontal diseases. Periodontol 2000;
40:184196.
20. Ketac Nano Light Curing Glass Ionomer Restorative. 3M
ESPE technical product profile.
21. Requicha AAG Nanorobots NEMS and Nanoassembly.
Proc. IEEE J Endod 2003;91(11):1922-1933. Corresponding Address:
22. Marini I, Checchi L, Greenspan D. Pilot clinical study
evaluating efficacy of NovaMin containing dentifrice for Dr.
Dr. C.Sumit
Neha
Dr.Dr. Ram Mohan
KKAggarwal
Mohan
Dixit
relief for relief of dentin hypersensivity. NovaMin Research Email:
Email: samsharma770@gmail.com
dr_rammohanc@yahoo.co.in
Email: dixit.kk@gmail.com
Email: dr.nehaaggarwal19@gmail.com
Report 2002.
13
LIST OF PHOTOGRAPHS
Fig 1: Comparison of nanoparicle with water molecule and tennis ball
Fig. 2 Three different types of fillers components, non-agglomerated discrete silica nanoparticles,
prepolymerized fillers (PPF) and barium glass filler in nanocomposite.
Fig.3 Nanorobots in local anaesthetic solution
14
Flapless Implant Surgery : An Overview

Rashi Jolly , Himanshu Thukral , Mansi Thukral Chandra
Senior Lecturer, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
Oral and Maxillofacial Surgeon, New Delhi.
Cosmetic Surgeon, New Delhi.
Date of Receiving : 28/Apr/2013
Date of Acceptance : 03/Jun/2013
Abstract: As osseointegration is now considered highly predictable, the current trendis to develop techniques
that can provide function, esthetics, and comfort with aminimally invasive surgical approach. To achieve those
goals, flapless implantsurgery using a tissue punch technique has been suggested. This paper presents
anoutline of the indications and advantages of flapless implant surgery for delayed placementand loading
protocols.
Key words : Flapless, Minimally Invasive, One-Stage, Tissue Punch.

INTRODUCTION useful.
Dental implant therapy has been used frequently for the Campelo and Camera (2002)6used flapless surgical
rehabilitation of missing dentition, It is replacing conventional procedures and placed 770 implants in 359 patients over a 10 year
treatment options like Fixed bridges and Removable partial period.They reported a success rate of only 74% in 1990 but a
dentures in many clinical situations of one or more missing teeth.1- 100% success in 359 patients over a 10 year period.They reported
2
a success rate of only 74% in 1990 but a 100% success rate in
The surgical procedure for placement of implants to 2000.Each patient was examined after 3 months,6 months,1 year
replace posterior teeth normally begins with an incision to and then once every year.Prosthesis was removed,if possible,and
uncover the osteotomy site. Conventionally, a two-stage surgical implant mobility was assessed,periapical radiographs were
approach using submerged implants was advocated with the obtained, and periodontal probing was performed.
concept that a healing period of at least 3 to 4 months should be Implants were considered failed if they had mobility or
allowed to provide a load-free environment and undisturbed pai,had to be removed,or if they showed more than 0.5mm of
healing for successful osseointegration.3The concept that bone loss per year and signs of active periimplantitis.They called
implants should be covered by tissue to ensure primary flapless surgery a blind surgical technique but said advantages
stabilization and reduce infection was standard of care in the include less time and minimal bleeding, with no suturing
original concept of surgical protocol.4 This is now being necessary.They also stated that patient selection and proper
challenged as unnecessary with flapless surgery for implant surgical technique were essential factors for success.
placement. In a 2 year study by Becker et al (2005)7, 79 implants
were placed in 57 patients from 24 to 86 years old using a
REVIEW OF LITERATURE minimally invasive one stage flapless technique.The parameters
Studies have recommended the use of a one-step punch evaluated were total surgical time, implant survival,bone quality
technique for many clinical situations requiring implants.30 These and quantity, implant position by tooth type, depth from mucosal
include a wide bony ridge, presence of a broad zone of keratinized margin to bone crest, implant length, probing depth,
tissue, the absence of vital structures, and surgery requiring inflammation, and crestal bone changes.Thirty two implants were
difficult and complex flap manipulation. This technique has also placed in the maxillae and 42 were placed in mandibles.The
been used when primary anchorage and stabilization were cumulative success rate was 98.7%. For remaining implants,
predictably obtained and to maintain the integrity and topography changes in crestal bone over time were clinically insignificant, as
of adjacent hard and soft tissues. For patients who cannot were mean changes for probing depth and inflammation.The
discontinue use of anticoagulants and patients with meticulous results of this study demonstrate that by following specific
plaque control, one-punch surgery is useful. diagnostic and treatment planning criteria, flapless surgery using
Landsburg and Bichacho (1998)5recommended use of a a minimally invasive technique is successful and predictable.The
one step punch technique for many clinical situations requiring benefits of this procedure are reduced surgical time, minimal
implants.These include a wide bony ridge,presence of a broad changes in crestal bone height, probing depth, and inflammation,
zone of keratinized tissue, the absence of vital structures, and minimal haemmorhage, and less postoperative discomfort.
surgery requiring difficult and complex flap manipulation. This Tae Ju Oh et al (2007) demonstrated successful use of
technique was also used when primary anchorage and flapless implant surgery for both immediate and delayed loading
stabilization were predictably obtained and to maintain the protocols in the esthetic region.Advantages of the flapless
integrity and topography of adjacent hard and soft tissues.For implant surgery shown in the cases included less traumatic
patients who cannot discontinue use of anticoagulants and surgeryand decreased operative time, which resulted in
patients with meticulous plaque control, one punch surgery is accelerated postsurgical healing, fewer postoperativ
15
complications, and increased patient comfort and TABLE 2
satisfaction.Especially with the immediate loading protocol, the Limitations of Flapless Implant Procedures.
advantages were more pronounced because of the absence of a
waiting period before prosthetic restoration. 1. Not suitable in ridges with concavities and parabolic
Another advantage of the flapless implant surgery was in shaped ridges
preservation of soft tissue profiles, including the gingival margins 2. Need for an experienced operator with sound clinical
of the adjacent teeth and the interdental papillae.This is attributed judgment
to the avoidance of flap reflection, which might cause 3. Absolute necessity for using axial tomography or CT
postsurgical bone resorption and soft tissue recession. for pre-operative evaluations.
Nadine Brodala (2009) reviewd the current literature
with regard to the efficacy and effectiveness of flapless surgery TABLE 3
for endosseous dental implants. Only clinical(human) studies Advantages of the Flapless Implant surgical procedure
with five or more subjects were included.The available data on
flapless technique indicate high implant survival overall.The 1. Reduced trauma
prospective cohort studies demonstrated approximately 98.6 % 2. reduced operative time
survival,suggesting clinical efficacy,while the retrospective 3. Faster soft tissue healing
studies or case series demonstrated 95.9% survival,suggesting 4. fewer complications
effective treatment. Six studies reported mean radiographic 5. Improved Patient comfort
alveolar bone loss ranging from 0.7 to 2.6mm after 1 year of 6. Patient resumes normal diet and Oral Hygiene habits
implant placement.Intraoperative complications were reported in following the procedure
four studies,and these included perforation of the buccal or
lingual bony plate.Overall,the incidence of intraoperative TABLE 4
complications was 3.8% of reported surgical procedures.It was Disadvantages of the Flapless Implant surgical procedure
concluded that flapless surgery appears to be a plausible treatment
modality for implant placement ,demonstrating both efficacy and 1. Inability to visualize anatomic landmarks.
clinical effectiveness. 2. Possibly thermal bone damage secondary to
Presently, one piece Implants with implant therapy inadequate irrigation during osteotomy preparation (
utilizing the one-stage surgical protocol (nonsubmerged In cases where Surgical templates are used)
implants) has also been available, and its successful use has been 3. Malposed angulations
proven comparable to the two-stage surgical approach.10-11 4. Inadequate depth of implant placement (if soft tissue
With the high predictability of osseointegration, the width is not taken into consideration)
current trend is geared toward developing methods to enhance 5. No access to contour the osseous ridge to facilitate
patient function, esthetics, and comfort. restorative procedures, if required.
Along with continuous improvements in implant materials, Some factors considered detrimental to this treatment
designs (macrostructures and microstructures), surface treatment modality include lack of direct visibility, difficulty in evaluation
and placement techniques, clinical usage of immediate implant of any existing facial osseous defects.
non functional loading has been adopted in implant therapeutics,
thus providing patients with enhanced function, esthetics, and FLAPLESS IMPLANT PLACEMENT
comfort. In case of immediate implant placement, the clinical
procedure for the flapless placement technique starts with an
Clinical Considerations atraumatic extraction of the unsalvageable teeth. Drilling is then
performed through a surgical template with the use of a buccally
TABLE 1 placed guiding finger, to avoid perforating the buccal bone.
Indications of the Flapless Implant surgical procedure Autogenous bone chips collected from the drill flutes may be
packed around the implant in case of any existing gaps. Finally
1. Wide Bony Ridge the round edges may be approximated and sutured. This not only
2. Presence of a wide Zone of Keratinized tissue provides better primary closure but also avoids post-operative
3. Absence of Vital Structures in the anatomical region soft tissue complications.
4. Surgical procedures requiring Complex Flap In the delayed implant placement protocol, gingival
manipulation tissue punching is done to remove a piece of soft tissue and
5. Patients on Anticoagulant therapy who cannot stop expose the bone for implant placement. This reduces post-
these medications operative soft tissue recession.
6. In cases where Predictably the surgeon can obtain a
Primary stability with the Implants. DISCUSSION
7. Not suitable in ridges with concavities and parabolic Advantages of the flapless implant surgery, include less
shaped ridges traumatic surgery and decreased operative time, which result in
8. Need for an experienced operator with sound clinical accelerated postsurgical healing, fewer postoperative
judgment complications, and increased patient comfort and satisfaction.
Another advantage of the flapless implant surgery is preservation
of soft tissue profiles, including the gingival margins of the
adjacent teeth and the interdental papillae. In our opinion, the
16
remaining buccal bone thickness after implant placement should 3. Albrektsson T, Brnemark P-I, Hansson HA, Lindstrom J.
be at least 2.0 mm to minimize postsurgical resorption. This is in Osseointegrated titanium implants. Requirements for
agreement with the critical facial bone thickness of 1.8 mm ensuring a long-lasting, direct bone-to-implant anchorage in
proposed by Spray et al. 12 The critical facial bone thickness must man. Acta Orthop Scand 1981;52:155170.
be carefully analyzed when surgical stents are constructed. 4. Brnemark PI, Hansson BO, Adell R, et al. Osseo-integrated
The feasibility of flapless implant surgery with implants in the treatment of the edentulous jaw. Experience
immediate loading 13or with delayed loading 14has been from a 10-year period. Scand J Plast Reconstr Surg Suppl.
demonstrated. However, prerequisites for the flapless implant 1977;16:1-132. .
surgery have also been reported; these include sufficient bone 5. Pract Periodontics Aesthet Dent 1998;10:1033-1039
width and height, adequate keratinized soft tissue, and an absence 6. Compelo LD, camara JR. Flaplesh implant surgery: a 10 year
of significant tissue undercuts.15 clinical reprospective analysis. Int J Oral Maxillofac
First, sufficient amounts of available bone and Implants 2002;17:271-276
keratinized tissue are necessary because direct visualization of 7. Becker W, Goldstein M, Becker BE, et al. Minimally
bone topography is limited and sacrifice of some keratinized invasive flapless implant surgery: a prospective multicenter
tissue, although minimal, is inevitable in this particular technique. study. Clin Implant Dent Relat Res. 2005;7(suppl 1):S21-
For example, required bone volume for the placement of a S27.
standard endosseous root-form implant. 16Computer software's 8. Oh TJ, Shotwell, Byun HY, Wanq HL. Flapless Implant
like SimPlant and NobelGuide definitely aid in increasing the Surgery in the esthetic region: advantag & Precautions. Int J
precision of surgical templates in guiding the direction of implant Perio Rest Dent 2007; 27: 27-33.
drilling.Although debatable, the presence of peri-implant 9. Brodala N. flapless surgery & its effect on dental implant
keratinized tissue is regarded beneficial, especially for the outcomes. Int J Oral Maxillofacial Implants 2009;24:118-
longevity of rough surfaced implants.17An adequate amount (i.e., 125.
more than 2 mm) of keratinized tissue must remain on the facial 10. Buser D, Mericske-Stern R, Bernard JP, et al. Long term
aspect of the implant site after tissue punch. If the soft tissue is evaluation of non-submerged ITI implants. Part I: 8-year life
insufficient or not expected to be esthetically pleasing after the table analysis of a prospective multi-center study with 2359
flapless surgery, soft tissue grafting procedures or papilla implants. Clin Oral Implants Res 1997;8:161172.
regeneration techniques should be considered. In addition to the 11. Weber HP, Buser D, Fiorellini JP, Williams RC.
factors described previously for case selection, precautions Radiographic evaluation of crestal bone levels adjacent to
should be taken during surgical and prosthodontic procedures. nonsubmerged titanium implants. Clin Oral Implants Res
Because of the lack of visibility of hard tissue contours 1992;3:181188.
in the flap, it is extremely crucial during implant site preparation 12. Spray JR, Black CG, Morris HF, Ochi S. The influence of
to place implant drills against surgical stents using the full length bone thickness on facial marginal bone response: Stage 1
of the apicocoronal drill orientation. Incorrect angulation of placement through stage 2 uncovering. Ann Periodontol
implant drills can cause perforation of the cortical plates, usually 2000;5:119128.
on the buccal aspect, resulting in dehiscence or fenestration. 13. Hahn J. Single-stage, immediate loading, and flapless
Although not presented here, perforation of the buccal plate is surgery. J Oral Implantol 2000;26:193198.
generally detected by palpation or by observation of implant 14. Campelo LD, Camara JR. Flapless implant surgery: A 10-
threads through the soft tissue. With regard to immediate loading, year clinical retrospective analysis. Int J Oral Maxillofac
primary stability should be confirmed with hand-torquing of the Implants 2002;17:271276.
provisional abutment. If any movement is noted during hand- 15. Hahn J. Single-stage, immediate loading, and flapless
torquing, a delayed loading protocol should be considered. surgery. J Oral Implantol 2000;26:193198.
16. Sclar AG. Guidelines and pitfalls of minimally invasive and
CONCLUSION flapless dental implant surgery. J Oral Maxillofac Surg.
Flapless implant surgery using a tissue punch technique 2007;65(suppl):9-10.
can be successfully employed when replacing posterior teeth. 17. Block MS, Kent JN. Factors associated with soft- and hard-
Careful diagnosis and treatment planning are essential. The tissue compromise of endosseous implants. Int J Oral
protocol for this procedure includes proper evaluation of bone Maxillofac Surg 1990;48:11521160.
type, height and width of the residual ridge, and amount of
available keratinized tissue. The surgical technique should
include use of a surgical stent, appropriate use of rotary punches
and implant burs, and an osteotomy that promotes a stable
implant.
REFERENCES
1. Adell R, Lekholm U, Rockler B, Brnemark P-I. A 15-year
study of osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981;10:387416. Corresponding
Address:
2. Brnemark P-I, Hansson BO, Adell R, et al. Osseointegrated
implants in the treatment of the edentulous jaw. Experience Dr. Neha
C.
Dr.Dr.
Dr. KKAggarwal
Ram
Rashi Mohan
Dixit
Jolly
from a 10-year period. Scand J Plast Reconstr Surg Suppl Email:
Email: dr_rammohanc@yahoo.co.in
Email:
Email: rashijolly5@yahoo.co.in
dixit.kk@gmail.com
dr.nehaaggarwal19@gmail.com
1977;16:1132.
17
LIST OF PHOTOGRAPHS
Figure 1- Drill used for Flapless Implant Surgery
Fig: 2 Pre- Treatment Photograph Fig: 3 Post- Treatment Photograph
18
Fluorides and Their Role in Demineralization and Remineralization

Sonal Soi , Vineet Vinayak , Anurag Singhal , Sonali Roy
Senior Lecturer, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor & Head, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
PG Student, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 28/Mar/2013
Date of Acceptance : 01/May/2013
Abstract: Demineralization and remineralization begins with historical prespective on caries. Caries were
identified as a major public health problem in 1940s . Demineralization is a process of removal of minerals from
dental enamel. Remineralization on the other side is the process of restoring minerals to hydroxyapatite lattice.
The battle to keep teeth strong and healthy is dependent upon ratio between demineralizaton and
remineralization. In this scientific era new advances have changed our idea from "cure" to "prevention".
Remineralization can mainly be achieved by mineral or ionic technology .Ionic technology mainly includes
fluorides. Fluorides works primarily via topical mechanism which includes ,inhibition of demineralization at
crystal surface, enhancement of remineralzation at crystal surface, and at high concentration inhibition of
bacterial enzymes. This article deals with various aspects of fluorides in management of De/ Remineralization.
Key words : Demineralzsation, Remineralization, Fluorides.
INTRODUCTION Rationale for De / Remineralization

In early 1960 Massler, Fusayama and Branstorm dealt The solubility of the hydroxyapatite depends on both the
with the science of De / Remineralization. Earlier dental caries presence of impurities and the pH of the environment. pH is the
was thought to consist of a one-way progressive demineralization driving force for dissolution and precipitation of hydroxyapatite.4
of enamel crystallite followed by degradation of dentin leading to At low pH the saturation concentration of the calcium
cavity formation. Later with increased knowledge dental caries and phosphate ions with respect to apatite is higher than at high
was found to be a dynamic process with demineralization of the pH. At neutral pH saliva and plaque fluid are super-saturated with
hard dental tissue by the acidic products of bacterial metabolism respect to hydroxyapatite. Consequently mineral will precipitate
that alternates with periods of remineralization.1 When the two if a suitable precipitation nucleus is available. The consumption
processes are in balance no net mineral loss occurs at the tooth of fermentable sugars leads to acid production in the plaque and
surface, but when the magnitude of one exceeds the other it leads the resulting decrease in pH increases the calcium and phosphate
to net demineralization or alternatively to remineralization.2 The concentration needed for saturation. The decreasing pH also
notion that loss of tooth mineral can be compensated by mineral slows down the fermentation (rate of acid formation) by oral
deposition has considerable consequences in operative and bacteria.4
preventive dentistry. It implies that non-restorative clinical The calcium and phosphate content and in particular the
strategies have become a realistic option. pH of these liquids determine whether enamel and dentin will
dissolve or alternatively whether mineral will precipitate.The
DEMINERALIZATION acid ions react principally with the phosphates in saliva and
Demineralization is the process of removing minerals, in plaque, until the critical pH for the dissociation of hydroxypatite
the form of mineral ions, from dental enamel. In another words, is reached at approximately pH 5.5 - 5.2. Further decrease in pH
Demineralization is "dissolving the enamel." A substantial results in progressive interaction of acid ions with phosphate
number of mineral ions can be removed from hydroxyapatite groups of hydroxyapatite causing partial or full dissolution of the
latticework without destroying its structural integrity. When too surface crystallites.5
many minerals are dissolved from an area of the hydroxyapatite's The stored fluoride released in this process reacts with
latticework, results in a cavity that is the loss of the Ca2+ and HPO42- ion breakdown products, forming fluorapatite, or
hydroxyapatite's crystalline latticework structure. The fluoride enriched apatite. If the pH decreases further below 4.5
latticework can be strengthened and restored through the process that is the critical pH for fluorapatite dissolution, even
of remineralization.3 fluorapatite will then dissolve. If acid ions are neutralized, and the
Ca2+ and HPO4 2- ions are retained, then the reverse process of
REMINERALIZATION remineralization occurs. The composition of the apatite then
Remineralization is the process of restoring minerals in formed depends on the composition of the solution from which it
the form of mineral ions to the hydroxyapatite latticework is precipitated, in this case the plaque fluid. This periodic cycling
structure. Remineralization should be three-dimensional and of pH results in a step-by-step modification of the chemical
must be replaced with same shape, size and the same electrical composition of the outer layers of enamel that becomes
charge as those lost from the lattice. somewhat less soluble with time. This process is known as the
post-eruptive maturation of the enamel.4,5
19
De Remineralization Cycle4-6 FACTORS INFLUENCING DE- REMINERALIZATION
It is apparent that the pH cycle depends on the strength of A high level of acid concentration and a high frequency
the acid that is present, the frequency and duration of its of contact will lead to demineralization of the tooth surface,
production and the remineralization potential in each particular however natural protective factors and repair mechanisms can be
situation, any one of the following sequelae can occur. enhanced and the problem controlled at least to a degree. There is
1. The enamel may continue to mature a delicate balance between health and disease, involving acid
2. Chronic caries may develop slow demineralization arising from bacteria laden plaque competing with protective
with active remineralization factors that are provided through normal salivary flow and good
3. Rapid (rampant) caries may arise rapid hygiene.9
demineralization with inadequate remineralization
4. Erosion may occur very rapid demineralization with ROLE OF FLUORIDES
no remineralization at all There have been many schools of thought over the years
The chemical basis of the demineralization as to the relative importance of different ways in which fluoride
remineralization process is similar for enamel, dentin and root acts to reduce dental caries. It is now well accepted that the
cementum. However the different structures and relative quantity primary mode of action is the inhibition of demineralization and
of mineral and organic tissue content of each of these materials enhancement of remineralization. Fluoride acts by inhibiting
causes significant differences in the nature and progress of the mineral loss at the crystal surfaces and by enhancing the
carious lesion.7 rebuilding or remineralization of calcium and phosphate in a form
more resistant to subsequent acid attack.
Enamel lesion
The initial enamel lesion results when the pH level at the Mechanism of action of fluoride
tooth surface exceeds that which can be counter-balanced by The most probable mechanism through which fluoride
remineralization but is not low enough to inhibit surface prevents dental caries is by stabilizing the enamel crystal i.e. by
remineralization. The acid ions penetrate deeply into the prism preventing enamel demineralization from the acid produced by
sheath porosities, leading to sub-surface demineralization. The the microflora or by favoring recrystallization of dissolved
tooth surface may remain intact through remineralization, which enamel surfaces or both. Preferably the fluoride should be bound
occurs preferentially at the surface due to increased levels of permanently to the enamel crystal in the form of fluorapatite.10
calcium, phosphate, fluoride ions and buffering by salivary Fluoride ion substitutes for the hydroxyl ion in the
products.7 apatite structure giving rise to a reduction of crystal volume and a
The clinical characteristics of such lesions are concomitant increase in the structural stability. Under the
1. Loss of normal translucency of enamel with a chalky influence of fluoride, large crystals with fewer imperfections are
white appearance on dehydration formed thus stabilizing the lattice and presenting a smaller
2. A fragile surface layer susceptible to damage from surface area/ unit volume for dissolution. Also enamel, which
probing particularly in pits and fissures. mineralizes under the fluoride influence, has lower carbonate
content, thus giving a reduced solubility.1,8,10
3. Increased porosity particularly of the sub-surface with
potential for uptake of stain. Fluoride can be firmly bound when it is incorporated in
the crystalline lattice of hydroxyapatite or loosely bound when it
4. Reduced density of the sub-surface detected is adsorbed to apatite forming calcum fluoride deposits. In the
radiographically or with Transillumination research on the cariostatic effect of fluoride, considerable
5. A potential for remineralization with an increased emphasis is placed on the role of free fluoride ions in the oral
resistance to further acid challenge fluid. Calcium fluoride is formed during treatments with high
concentration fluoride solutions. It can act as a fluid reservoir on
The advancing coronal lesion1,6 the tooth surface and release fluoride ions at low pH. This fluoride
If the demineralization - remineralization imbalance ion along with calcium and phosphate diffuses into the lesion and
continues the surface of the incipient lesion collapse through the precipititates as fluorhydroxyapatite. The acid cycle thus
dissolution of apatite or fracture of the weakened crystallite contributes to the conversion of loosely to firmly bound
resulting in cavitations. Plaque can now be retained within the fluoride.11,12
depths of the cavity and the remineralization phase is rendered The fluoride ion (F-) inhibits the bacterial enzyme
more difficult and less effective. The dentin-pulp complex will enolase, thereby interfering with production of
become involved at this point but there can still be fluctuations in phosphoenolpyruvate (PEP). PEP is a key intermediate of the
the degree of activity. glycolytic pathway and, in many bacteria, is the source of energy
and phosphate needed for sugar uptake. The presence of 10-100
Demineralization into dentin7,8 ppm of F-, inhibits acid production by most plaque bacteria (Fig.
The process of demineralization continues to be driven by 99-4). These levels are delivered easily by most prescription
dietary substrate after bacteria have invaded dentin. The acid fluoride preparations; of equal interest is the finding that at acidic
production by bacteria dissolves the hydroxyapatite of deeper pH values (5.5 or below), low levels of F- (1-5 ppm) inhibit the
dentin so there is a front of demineralization in advance of the oral streptococci. These levels are found in plaque, especially in
bacterial invasion. individuals who drink fluoridated water or who use fluoridated
The texture and color of dentin changes as dentifrices. If this plaque fluoride is derived from the tooth, an
demineralization advances. The color will darken because of antibacterial mode of action, which involves a depot effect, can be
bacterial products and stains from foods and beverages. If the postulated for systemic (water) and topical fluoride
lesion is left to extend through the dentin the enamel will become administration.
progressively undermined and weakened resulting in a wide-open The depot effect comes about in this manner. Water
cavity that is relatively self-cleansing. The caries process may fluoridation promotes the formation of fluorapatite, whereas
then slow down leading to the development of a hard leathery topical fluorides cause a net retention by the enamel of fluoride as
floor on the cavity that is more or less inactive. fluorapatite or as more labile calcium salts. Microbial
20
acid production in the plaque may solubilize this enamel-bound CONCLUSION
fluoride, which at the prevailing low pH in the plaque Florides have anticaries effect and it also prevents
microenvironment could become lethal for the acid-producing demineralisation, promotes remineralisation of early caries.
microbes. Such a sequence would discriminate against S mutans Fluoride is most commonly used remineralising agent. As the pH
and lactobacilli because they, as a result of their aciduric nature, rises, new and larger crystals that contain more floride forms are
are most likely the numerically dominant acid producers at the formed , therby reducing the enamel demineralisation by forming
plaque-enamel interface. The fluoridated tooth thus contains a fluorhydroxyapetite. crystals and enhancing remineralisation.
depot of a potent antimicrobial agent that is not only released at an
acid pH value but is most active at this pH value. This hypothesis, REFERENCES
then, attributes some of the success of water fluoridation and 1. Thylstrup A, Fejerskov O. Textbook of Clinical Cariology
topical fluorides to an antimicrobial effect. It further suggests that Second Edition Munksgaard .
judicious use of topical fluorides would be effective in patients
with highly active caries. The most effective dose schedule and 2. Bynum AM, Donly KJ. Enamel de/ remineralization on teeth
fluoride preparation have not been determined.13 adjacent to fluoride releasing materials without dentifrice
exposure: Journal of Dentistry for Children 1999;2: 89-91.
3. Anusavice KJ. Caries risk assessment: Op Dent 2001; 6: 19-
SOURCES OF FLUORIDES 26.
Fluoride containing dentifrices 4. Chow LC, Vogel GL.Enhancing remineralization: Op Dent
The use of fluoride containing toothpaste has been 2001; 6:27-38.
proven to reduce the incidence of caries in numerous clinical 5. Chow.L, Takagi, Carey CM. Remineralization effects of a
studies. During a typical one minute brushing period fluoride Two-solution Fluoride Mouth rinse: An in situ study: J Dent
rapidly permeates the tooth and is taken up by the enamel as Res 2000; 79(4): 991-995.
fluorapatite, calcium fluoride or even free fluoride. Rinsing the
mouth after brushing rapidly drops the salivary fluoride 6. Donly K J et al. Evaluating the effects of fluoride-releasing
concentration to 1 ppm or less within 15 minutes. However the dental materials on adjacent interproximal caries: J Am Dent
treated tooth enamel and perhaps the oral mucosa acts as a sink for Assoc. 1999 Jun; 130(6): 817-825.
fluoride and subsequently release it to the oral cavity.4 7. Donly K J. Enamel and dentin demineralization inhibition of
fluoride-releasing materials: Am J Dent. 1994 Oct; 7(5):
The FDA as safe and effective for use in dentifrices 275-8.
approves three sources of fluoride. They are Sodium Fluoride,
Sodium Monofluorophosphate and Stannous fluoride. Sodium 8. Duggal. M. S, K J Toumba, B T Amaechi, M B Kowash, S M
fluoride directly provides free fluoride. It is generally not found in Higham. Enamel demineralization in situ with various
toothpaste formulations containing calcium-based abrasives frequencies of carbohydrate consumption with and without
because of its potential to irreversibly bind to the abrasive and fluoride toothpaste: J Dent Res 2001; 80(8): 1721-1724.
form insoluble calcium fluoride on storage. Sodium 9. Featherstone. An in-situ model for simultaneous assessment
Monofluorophosphate is the fluoride of choice when calcium- of inhibition of demineralization and enhancement of
containing abrasives are used. The Monofluorophosphate ions remineralization : J Dent Res. 1992; 71: 804-810.
releases free fluoride when it hydrolyses on exposure to 10. Fazzi R, Vieria D Fad Zucas SM. Fluoride release and
phosphatase enzymes naturally present in the mouth. physical properties of a fluoride-containing amalgam: J
Stannous fluoride provides fluoride and stannous ions Prosthet Dent. 1977 Nov; 38(5): 526-31
which act as an antimicrobial agent. It can also produce stannous 11. FejerskovOT. Rationale use of fluorides in caries prevention:
phosphate fluoride precipitates which slows down the caries a concept based on the possible cariostatic mechanisms: Acta
process but has staining as a side effect.14 Odontalog Scada 1981; 39: 241-249
12. Francci C. Fluoride release from restorative materials and its
Fluoride mouth rinses effects on dentin demineralization: J Dent Res; 78, 1647-
They raise the concentration of fluoride in saliva for 1654.
several hours after use. Even though the residual concentrations 13. Kitasako, Nakajima, Foxton, Aoki, Pereira , Tagami.
of fluoride in plaque and saliva are small, the modest elevations in Physiological remineralization of artificially demineralised
fluoride concentration may be sufficient to boost the rate of dentin beneath glass ionomer cements with and without
remineralization and help inhibit caries development. Use of 0.05 bacterial contamination In Vivo: Op Dent 2003; 28(3): 274-
% sodium fluoride mouth rinses has been shown to be better than 280.
brushing with conventional fluoride toothpaste. 14. Rolla et al: Critical evaluation of the composition and use of
fluorides with emphasis on the role of calcium fluoride in
caries inhibition: J Dent Res 1990; 69: 780-785.
Fluoride releasing dental materials15,16
15. Ten Cate: Remineralization of caries lesions extending into
Resin modified GIC, conventional GIC and fluoride dentin: J Dent Res 2001; 80(5): 1407-1411.
releasing composites have been postulated to protect against
secondary caries in enamel and dentin. They have a synergistic 16. Ten Cate J M, Duinen V. Hypermineralization of dentinal
effect with fluoride rinses or dentrifrices in inhibiting lesions adjacent to glass ionomer cement restorations: J Dent
demineralization. Res 1995; 74(6): 1266-1271.
Pit and fissure sealants

They are effective in preventing pit and fissure
caries.The currently available sealants are second and third
generation which are polymerized with chemical catalyst or Corresponding Address:
require visible light to initiate a auto-catalytic reaction. It has been Dr. Sonali Roy
suggested that fluoride released from sealants may have its great
effect at the base of the sealed groove helping remineralization of Email: sapney86@yahoo.com
incipient enamel lesion.3-5
21
Bacterial Quantification in teeth with Apical Periodontitis Related to

Different Intracanal Irrigant : A Clinical Study

K.K. Dixit , Krishna Dixit , Anurag Gurtu , Nivedita Dixit , Rahul Pandey
Professor, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor, Department of Pedodontics.
BDS Intern, Institute of Dental Sciences, Bareilly (U.P).
BDS Intern, Institute of Dental Sciences, Bareilly (U.P).
Abstract: The antibacterial efficacy of intracanal irrigants, metronidazole, normal saline, EDTA, 3%
Hydrogen peroxide, 3% sodium hypochlorite and 2% Chlorhexidine was assessed in teeth with asymptomatic
apical periodontitis. 25 canals were randomly divided into three groups, instrumented and irrigated with three
different combination of irrigants. Bacterological samples were collected from the root canals before and after
irrigation in the first visit of treatment. Later the bacterial growth was assessed. It was concluded that EDTA,
Sodium hypochlorite(3%),and Chlorhexidine(2%) reduced the bacteria significantly.
Key words : Apical Periodontitis, EDTA, Chlorhexidine, Hydrogen peroxide, Sodium Hypochlorite.
INTRODUCTION treatment were isolated by a rubber dam. The pulp cavity was opened
The main aim of root canal treatment is elimination of with sterile round bur of appropriate size under distilled water spray.
bacteria from root canal and prevention of recontamination after Briefly the first collection was made by means of size 15 or size 20
(1)
treatment . It has been reported that success rate of root canal sterile absorbent paper points to an approximate level of 1 mm short of
treatment was higher when teeth were free of bacteria after the tooth apex as determined by preoperative radiography and
chemomechanical instrumentation (2) . While instruments are maintained in place for 30 sec. Paper points were immediately
important in removal of infected dentin from the main root canal. transferred to transport to the autoclaved veil containing Nutrient
Irrigants play an important role in areas, where instruments cannot broth. After completing biomechanical preparation using step back
reach, viz lateral and accessory canals as well as fins and webs technique; Second sample was made by means of using appropriate
throughout the canal(3). size paper point and were immediately transferred to the autoclaved
A lot of root canal irrigants are available which are used singly or in veil containing Nutrient broth.
combinations. Despite advances in disinfection in root canal Isolation and identification of microorganisms
treatment, the irrigants are still not effective against all The average time between sample collection and laboratory
microorganisms found in the root canal system. The purpose of the processing was 6 hrs. It is important to emphasize that the samples
study was to evaluate the efficacy of different combination of were processed in the laboratory within 6 hrs to preserve the
irrigating solution during the first visit of treatment. reproductive capacity of bacterial cells and to prevent the growth of
0
microorganisms in the sample. Transport veil were placed at 37 C for
MATERIAL AND METHOD 30 min and then vigorously mixed for 20 30 sec using a vortex
Following materials tested and evaluated for antimicrobial efficacy : mixture and were incubated for 24 hours. Each sample was then
Group I : Metronidazole and normal saline. serially diluted in peptone water and aliquots (25l) were plated onto
Group II : EDTA, Hydrogen peroxide(3%) and sodium several media as follows: MacConkey and Blood Agar.
Hypochlorite(3%) Semi Quantization of Bacteria
Group III : EDTA, Sodium Hypochlorite(3%) and A platinum loop of 0.001 ml of diameter was taken for
Chlorhexidine(2%) streaking the specimen. And Semi Quotation of bacteria was done by
multiplying the colony count by 1000.
METHODOLOGY Heavy: If the colony count was uncountable and growth was present
Patient Selection in all three streaking it was taken as heavy.
Twenty five systemically healthy patient aged between 23 Moderate: If the colony count were more then 50 and was present in
49 years. The patients were selected at random and included both first and second streaking it was taken as moderate.
males and females. None of them had received systemic antibiotic Scanty: If the colony count was less then 50 and was present only in
therapy in the preceding 3 months. All selected teeth had single roots, first streaking it was taken as scanty.
Infected pulp chambers and showed an asymptomatic apical No growth: Was taken when there was no growth
periodontitis without communication to the mouth through fistula or
otherwise. RESULTS
Collection of clinical specimen In present study Enterococcus, Streptococcus,
Microbial samples and endodontic treatment were Staphylococcus, Neisseria and Pseudomonas were the frequent
performed for 60 sec with a 0.2 % chlorhexidine solution. Teeth under bacteria recovered from the first sample of canal. The second sample
of canal shows heavy, moderate, Scanty and no growth of bacteria.
22
DISCUSSION necrotic porcine muscle tissue. J Endod 1988;14: 125 7.
Several studies on root canal infections have focussed on 4. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB;
aerobic and anaerobic bacteria due to their predominance in Enterococcus faecalis. Its role in root canal treatment failure
samples taken from untreated teeth with necrotic pulps. and concepts in retreatment. J Endod 2002;32, 93 98.
Microorganisms were recovered from the first sample in 25 root 5. Kvist T, Molander A, Dahln G, Reit C, Micro biological
canals in agreement with previous studies that showed the evaluation of one and two visit endodontic treatment of teeth
relationship between the microorganisms and the development of with apical periodontitis ; a randomized clinical trial. J
apical periodontitis. (4) In majority of in vivo studies root canal Endod 2004; 30 : 572 6.
samples were acquired with paperpoint (5) as in the study. 6. Valli KS, Lata DA, Jagdish S An in vitro SEM comparitive
It is important to emphasize that the samples were Study of debridment ability of K files and canal Master. Ind J
processed in the laboratory within 6 hrs to preserve the Dent Res 1996;7:128 34.
reproductive capacity of bacterial cells. In the study K files were 7. Joao Vicente Baroni Barbizam, Luis Fernando Fariniuk,
used for the preparation of the root canal by step back technique. Melissa Andre ia Marchesan, Jesus Djalma Pecora, Manoel
As the result of various studies showed neither of instrument D. Sousa-Neto; Effectiveness of manual and rotary
techniques were more efficient in cleaning of root canals.(6) (7) instrumentation techniques for cleaning flattened root
In the present study Enterococcus, Streptococcus, canals. J Endod 2002;28(5):40-45.
Staphylococcus, Nesseria and Pseudomonas were the frequent 8. Shuping GB, Dorstavik D, Sigurdsson A, Trope M;
bacteria recovered from the canals before treatment. Despite Reduction of intracanal bacteria using nickel titanium
mechanical instrumentation and disinfection of the root canal instrumentation and various medication 2000; 26:751 5.
system in the first sitting, microorganisms were recovered in 22 9. By storm A, Sunvqvist G. Bacteriologic evaluation of the
canals (Sample 3), clearly showing that root canal preparation and efficacy of mechanical root canal instrumentation in
irrigation is unable to eliminate all bacteria from the root canal endodontic therapy Scand Journal of Dental Research 1981;
system. However preparation did reduce the bacterial population. 89: 321 - 8.
In accordance of the study carried out by Shuping AB et al(8), by 10. Siqueira JF Jr., Rocas IN, Santos SR, Lima KC, Magalhaes
Storm A et al(9) and Siqueira J.F et al(10) . FA, Deuzeda M, Efficacy of instrumentation technique and
Removal of smear layer from the surface of irrigation regimens in reducing the bacterial population
instrumented root canals should allow the penetration of irrigant within root canal. J Endod 2002; 28:181 4.
into root canal irregularities and the dentinal tubules. Various 11. SiqueiraJF Jr., Batista MM, Fraga RC, De Uzeda M;The
chemicals have been used to remove smear layer. They include Effects of endodontic irrigants on black pigmented gram
different formulation of EDTA, Acetic acid, Citric acid, negative anaerobes and facultative bacteria. J Endod 1998;
Polyacrylic acid, Tannic acid. In the study EDTA used in 24: 414 - 6.
combination of other irrigants. The result of study shows the 12. Yesiloy C, Whitaker E, Cleveland D, Phillips E, Trope M;
Group III irrigants shows significant reduction of bacterial Antimicrobial and toxic effects of established and potential
population may be attributed to EDTA and Chlorhexidine which root canal irrigants. J Endod 1995; 21: 513 15.
has a broader antibacterial spectrum(11)and even at a highest 13. Sjogren U, Sundquist G. Bacteriological evaluation of
concentration of chlorhexidine has a very low toxicity.(12) ultrasonic root canal instrumentation on oral surgery
It has been suggested that the bacterial population may be further 1987;63:366 - 70.
by adding ultrasonic.(13) The techniques such as ultrasonic, sonic
and pressure system might demonstrate different results and
further exploration is needed on this subject.
CONCLUSION
Among the three groups
Group 1: Normal saline and metronidazole reduced the micro-
organisms insignificantly.
Group 2: EDTA, Hydrogen peroxide and sodium hypochlorite
reduced micro-organisms more then group I.
Group 3: EDTA, sodium hypochlorite and chlorhexidine was the
one which reduced the root canal microflora significantly, and in
three cases there was no growth.
REFERENCES
1. Storm A. Sundquist G. Bacteriologic evaluation of the
efficacy of mechanical root canal instrumentation in
endodontic therapy. Scand J Dent Res 1981;89: 321 - 8
2. Sjogren U. Figdor, D. Persson S., Sundquist G. Influence of Corresponding
Address:
infection at the time of root canal filling on the outcome of
endodontic treatment of teeth with apical periodontitis. Int Dr. Neha
C.
Dr.Dr.
Dr. KKAggarwal
Ram Mohan
Dixit
Dixit
End J 1997;30: 297 306 Email:
Email:
dixit.kk@gmail.com
3. Hasselgren G, Olsson B, Cvek M. Effect of calcium
hydroxide and sodium hypochlorite on the dissolution of
23
LIST OF TABLES
Group I : Metronidazole and normal saline
No. Of Cases SAMPLE 1: Growth and Predominant SAMPLE 2: Growth and Predominant
bacteria bacteria
Case 1 Heavy Growth Moderate Growth
Staphylococcus, Bacillus, Enterococcus Staphylococcus, Enterococcus
Case 2 Moderate Growth Moderate Growth
E. Coli, Streptococcus Streptococcus
Streptococcus, Bacillus, Enterococcus Enterococcus, Bacillus
Case 4 Heavy Growth Heavy Growth
Pseudomonas, Streptococcus Streptococcus
Streptococcus Bacillus, Streptococcus
Staphylococcus, Bacillus, Enterococcus Enterococcus,
Neisseria, E.coli, Bacillus Bacillus
Enterococcus, Pseudomonas Enterococcus, Bacillus
Group II EDTA, Hydrogen peroxide(3%) and sodium Hypochlorite(3%)
bacteria bacteria
Streptococcus, Neisseria Dipthroids
Enterococcus Enterococcus, Bacillus
Enterococcus, Pseudomonas Enterococcus, Bacillus
Streptococcus, Enterococcus, Dipthroids, Enterococcus
Enterococcus, Neisseria Enterococcus
Neisseria, Bacillis Bacillus
Pseudomonas Pseudomonas
Staphylococcus, Enterococcus Enterococcus, Bacillus
Group III EDTA, Sodium Hypochlorite(3%) and Chlorhexidine(2%)
bacteria ba cteria
Case 1 Heavy Growth Scanty Growth
Pseudomonas Bacillus
Case 2 Moderate Growth No Growth
Staphylococcus, Enterococcus, Neisseria -------------
Enterococcus Bacillus
Case 4 Moderate Growth Scanty Growth
Streptococcus Streptococcus, Bacillus
Staphylococcus, Bacillus, Enterococcus Neisseria,Bacillus
Case6 Heavy Growth Scanty Growth
Neisseria, Bacillus Bacillus
Streptococcus, Neisseria -------------
Staphylococcus, Bacillus -------------
Pseudomonas, Bacillus Pseudomonas, Bacilli
24
Evaluation of the Root Canal Morphology of Mandibular First Premolars

in the Western Uttar Pradesh Population Using Computed Axial Tomography:
An in Vitro Study

Nishtha Chauhan , Anurag Singhal , Vineet Vinayak
PG Student, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor & Head, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 15/May/2013
AIM: To investigate the root and canal morphology of mandibular first premolar teeth in the Western UP
population.
METHODOLOGY: One hundred extracted mandibular pre molars were collected from local dentists in
western Uttar Pradesh and a CT scan was performed using Brightspeed Elite ,GE.
RESULTS: The most prevalent canal pattern in this study was Type I, occurring in 69 % of the mandibular first
premolars scanned followed by Type III occurring in 29 % of the teeth and Type II and Type V which were each
found in 1 % of all the teeth scanned.
Key words : Mandibular First Premolar, Root Canal , Morphology , CT Scan .

INTRODUCTION III. Fractures
A thorough knowledge of root canal anatomy and an IV. Incompletely formed roots
understanding of the potential for variations from the norm are V. Endodontically treated
essential for successful endodontic therapy. Failure to recognize
and treat an additional root canal can result in treatment RESULT
failure1.According to Cleghorn variations can be attributed to sex The most prevalent canal pattern in this study was Type
and ethinicity . I, occurring in 69 % of the mandibular first premolars scanned
Mandibular first pre molars are known for the complex nature of followed by Type III occurring in 29 % of the teeth and Type II
their canal configurations. and Type V which were each found in 1 % of all the teeth scanned.
The textbookdescription of the mandibular first
premolar is typically of a single-rooted tooth2 .Two-rooted, three- DISCUSSION
rooted and four-rooted varieties have also been reported, but are Many studies of root and canal morphology in
rare. Slowey has suggested that the mandibular premolars may mandibular premolars have been conducted because these teeth
present the greatest difficulty of all teeth to perform successful present complex morphology that often complicates treatment
endodontic treatment. (ENIGMA TO THE ENDODONTIST!)
A study at the University ofWashington in 1955 assessed the In the current study CT scan has been used to analyse the
failure rate of non surgical root canal treatment in all teeth. The canal morphology of the mandibular first pre molars among the
mandibular first premolar had the highest failure rate in the study western UP population.
at 11.45%3. Traditional radiography, hard tissue section, and root
Various population groups have been studied including: canal staining in vitro are commonly used tools in identifying the
I. Chinese configuration of canals. However, most of these studies have
II. Turkish been performed ex vivo and involved complete destruction of the
III. Mexican tooth during examination (hard tissue sections) or have acquired
IV. African american only two dimensional anatomic information (traditional
V. Iranian radiography)5
Robinson S, Czerny C, Gahleitner A, Bernhart T,
AIM Kainberger FMfirst used CT scan to evaluate the root canal
The aim of the study is to determine the root canal configuration and variations in mandibular first premolar6
morphology of the mandibular first premolar teeth in the Western Later on in 2006 Eder A et al reported that CT scan was a
UP population using computed axial tomography. viable tool for the evaluation of unclear root canal configurations
7
MATERIAL AND METHODS The most prevalent canal pattern in this study was Type
One hundred extracted mandibular pre molars were I, occurring in 69 % of the mandibular first premolars scanned
collected from local dentists across Agra , Bareilly and Merrut . followed by Type III occurring in 29 % of the teeth and Type II
Exclusion criteria: and Type V which were each found in 1 % of all the teeth scanned.
I. Deep caries Although most mandibular first premolars have a single
II. Metallic restoration root, two-, three-, and even four-rooted forms have been reported
25
Number of canals and apices in the mandibular first premolar (incidence by number of teeth)3
Reference No. of Teeth (n) Ty pe of study 1 canal >2 canals 1 canal at apex >2 canals at apex
Vertucci, 1984 400 (USA) In vitro; clearin g 70% (280) 30% (120) 74% (2 96) 26% (104)
In vitro; radiography
Lu et al. , 2006 82 (China) 54% (44) 46% (38) _ _
and sectioning
Sert and Bayirli, 2004 200 (Turkey; gender) In vitro; clearin g 60.5% (121) 39.5% (79) 89.5% (1 79) 10.5% (21)
Yoshiok a et al., 2004 139 (Japan) In vitro; clearin g 80.6% (112) 19.4% (27) 80.6% (1 12) 19.4% (27)
aliskan et al., 1995 100 (Turkey) In vitro; clearin g 64% (64) 36% (36) 75% (75 ) 25% (25)
In vivo; review o f
Sabala et al., 1994 1002 (USA) 81.8% (820) 18.2% (182) _ _
patient records
CASE REPORTS OF MANDIBULAR FIRST PREMOLAR ANOMALIES3

Reference MFP teeth in study (n) Type of study Anatomic variation
Milano et al., 1 (USA; 17-y.o. His panic Rad iographic All first and second mandibular premolars
2002 male) Study exhibited 2 roots
M oayedi and Lata 3 canals (DB, DLi, and M) and an MB root

1 (India; 35-y.o. female) Clinical RCT
2004 bifurcation
1 (USA; 49 -y.o. Caucasian Single main canal split into 3 separate canals
Nallapati, 2005 Clinical RCT
Jamaican male) and apical foramina
COMPARISON OF THE PRESENT POPULATION STUDY WITH THE STUDIES PERFORMED ON

OTHER POPULATIONS
SAMPLE
POPULATION TYPE TYPE TYPE TYPE TYPE TYPE TYPE TYPE C SHAPED
SIZE
STUDIED I II III IV V VI VII VIII CANAL
(n)
WESTERN
100 69 1 29 0 1 0 0 0 0
U.P
TURKISH8
200 60.5 18.5 10.5 7 2.5 0 0 1 Not reported
(Sert S,2004)
WESTERN9
CHINESE 178 86.8 0 1.7 0 9.8 0 0 0.6 1.1
(Xuan Yu,2012)
INDIAN10
(Sandhya R, Velmurugan 100 80 9 3 2 4 0 0 0 2
N, 2010)
as 2.1% incidence when grouped together. The majority 6. Robinson S, Czerny C, Gahleitner A, Bernhart T, Kainberger
of mandibular first premolar teeth have a single canal but there is a FM. Dental CT evaluation of mandibular first premolar root
relatively high incidence, or one-quarter of mandibular configurations and canal variations. Oral Surg Oral Med Oral Pathol
premolars, that have two or more canals (24.2%)3. Oral RadiolEndod. 2002;93(3):328-32.
CONCLUSION 7. Eder A, Kantor M, Nell A,Moser T , Gahleitner A , Schedle A, et
Among the Western U.P population , the Type I root canal al. Root canal system in the mesiobuccal root of the maxillary
morphology occurred most frequently ( 69%) in the mandibular first first molar: an in vitro comparison study of computed
premolar teeth. This result is consistent with the results of the tomography and histology. DentomaxillofacRadiol 2006;
previous studies done in India . 35:175-77
CT scan is a useful tool in assessing the root canal morphology . 8. Sert S, Aslanalp V, Tanalp J: Investigation of the root canal
configurations of mandibular permanent teeth in the Turkish
REFERENCES population. IntEndod J 2004, 37:494499.
1. Martin Trope, Leslie Elfenbein Mandibular Premolars with 9. XuanYu,BinGuo,Ke-Zeng Li et al.Cone-beam computed
More Than One Root Canal in Different Race Groups tomography study of root and canal morphology of mandibular
J.Endod1986 ;12:343-45 premolars in a western Chinese population. BMC Medical
2. Ash M, Nelson S. Wheeler's dental anatomy, physiology and Imaging 2012, 12:18
occlusion. 8th ed. Philadelphia: Saunders, 2003. 10. Sandhya R, Velmurugan N, Kandaswamy D. Assessment of root
3. Blaine M. Cleghorn William H. Christie et al The Root and Root canal morphology of mandibular first premolars in the Indian
Canal Morphology of the Human Mandibular First Premolar: A population using spiral computed tomography: an in vitro study.
Literature Review (J Endod 2007;33:509 516) Indian J Dent Res. 2010;21 2:169173.
4. Cohen S, Hargreaves KM: Pathways of the Pulp. 10th edition. St
Louis: Mosby-Elsevier 2011. p.144 Corresponding Address:
5. XuanYu,BinGuo,Ke-Zeng Li et al.Cone-beam computed
tomography study of root and canal morphology of mandibular Dr. Nishtha Chauhan
premolars in a western Chinese population. BMC Medical Email: chauhannishtha@gmail.com
Imaging 2012, 12:18
26
LIST OF PHOTOGRAPHS
Teeth were stuck on surgical plaster tape and 16 slice CT scan Vertucci's classification was used to 4determine
(BRIGHTSPEED ELITE 16, GE) was used to scan the 100 the pattern of the root canal .
premolars simultaneously.
RESULT
Type I (1-1)
CORONAL -------------------------------------------------- APICAL
Type II (2-1)
CORONAL -------------------------------------------------- APICAL
Type III (1-2-1)
CORONAL -------------------------------------------------- APICAL
Type V (1-2)
CORONAL -------------------------------------------------- APICAL
27
Sialolithiasis: A Case Series

Sunil R Panat, Ashish Aggarwal, Nitin Upadhyay, Mallika Kishore, Abhijeet Alok

Professor and Head, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Abstract: Sialoliths are the calcified organic matter that forms within the secretory system of the major salivary
glands. Sialolithiasis accounts for 30% of salivary diseases. Stones may be encountered in any of the salivary
glands but most frequently in the submandibular gland and its duct(83-94%), less frequently the parotid (4-
10%) and the sublingual glands (1-7%).Its occurrence in the adult population is approximately 12 per 1,000
patients, with a slight male predominance.While the majority of salivary stones are asymptomatic or cause
minimal discomfort, larger stones may interfere with the flow of saliva and cause pain and swelling. This case
report describes two patients presenting with submandibular gland sialolith and review of the literature
regarding the salivary sialothiasis.
Key words : Submandibular Salivary Gland, Sialolith, Warthon's Duct.
INTRODUCTION and pain on the right side of the jaw since 2 months. History of the
Heterotopic calcification which results from deposition present illness revealed that there was history of increase in the
of calcium in normal tissue despite normal serum calcium and size of swelling during meals and subsides during the rest of the
phosphate levels is known as idiopathic calcification. Sialoliths day. It was not associated with any discharge. Pain was dull,
belongs to the category of idiopathic calcification.1Salivary duct aggravated on eating food and relieved by itself. Extraoral
lithiasis refers to the formation of calcareous concretions or examination revealed a diffuse swelling won the right
sialoliths in the salivary duct causing obstruction of salivary flow, submandibular region roughly measuring about 2x3 cm in
resulting in salivary ectasia, sometimes even dilatation of the greatest dimension extending from base of mandible to 2 cm
salivary gland.2More than 80% of salivary gland calculi can be below the inferior border of mandible. The skin overlying the
found in the submandibular gland and located in the glandular swelling was normal(Figure 1). On palpation,it was firm in
parenchyma or the excretory duct.3 consistency and tender on palpation. In intraoral examination, a
Males are affected twice as much as females, especially firm mass was palpable on the floor of mouth extending from
in case of parotid gland lithiasis. Sialolithiasis usually occurs mesial aspect of 46 to 47(Figure 2).On the basis of history and
between the age of 30-60 years, though it can also occur during clinical examination,a provisional diagnosis of sialolith was
teen age. Children are rarely affected, but submandibular gland given. In the investigations a mandibular occlusal radiograph was
calculi have been reported in children aged from 3 weeks to 15 taken which revealed a well defined radiopaque structure
years.4Within the submandibular gland, the vast majority of measuring about 1x2 cm lingual to the body of mandible on the
sialoliths are found in the Wharton's duct. The ratio of sialoliths right side(Figure 3). In the treatment surgical excision was done
found within the gland to those found in Wharton's duct is 3:7.2.5 which revealed the final diagnosis of sialolith.
The classic symptom are that of obstruction manifested
by pain and swelling of the involved during eating. Sialoliths are CASE REPORT 2
usually unilateral and do not cause xerostomia. Submandibular A 45 year old female patient reported to the Department
stones consist of 82% inorganic and 18% organic material while of Oral Medicine and Radiology with a chief complaint of
the parotid stones are composed of 49% inorganic and 51% swelling and pain on the left side of the jaw since 2 months.
organic material.6 History of the present illness revealed that there was history of
Bimanual massage of the affected gland and the increase in the size of swelling during meals and subsides during
excretory duct should be carried out, observing the flow and the the rest of the day. It was not associated with any discharge. Pain
clearness of the saliva. Submandibular stones are typically was dull, aggravated on eating food and relieved by itself.In
removed surgically via either an intraoral or an external intraoral examination, a firm mass was palpable on the floor of
approach.7 mouth extending from mesial aspect of 36 to 37(Figure 4). On the
basis of history and clinical examination,a provisional diagnosis
CASE REPORT 1 of sialolith was given. In the investigations a mandibular occlusal
A 35 year old male patient reported to the Department of radiograph was taken which revealed a well defined radiopaque
Oral Medicine and Radiology with a chief complaint of swelling structure measuring about 1.5x1cm lingual to the body of
mandible on the left side(Figure 5). In the treatment surgical
28
excision was done which revealed the final diagnosis of sialolith. body, a phlebolith, or myositis ossificans.11Once a diagnosis of
DISCUSSION sialolithiasis is determined, effective treatment of the sialolith
Sialolithiasis accounts for more than 50% of diseases of depends on the location of the stone, and is accomplished by
the large salivary glands. Submandibular sialolith formation is extraoral or intraoral surgical removal of the sialolith. Removal of
more common because its saliva is more alkaline, has an the affected salivary gland and its associated duct may also be
increased concentration of calcium and phosphate, and has a necessary.12 However, initial management consists of antibiotic
higher mucous content than saliva from the parotid or sublingual therapy to reduce or eliminate the acute infection. The drug of
glands. Further, the submandibular duct is longer than that of the choice is penicillin (250 mg- 500 mg orally, every 6 hr). The
other major glands, and the saliva flows against gravity.8 The patient is also instructed to suck on sour lemon or orange candy to
etiological factors that account for sialolith formation are stimulate salivary flow.16Patients presenting with sialolithiasis
unknown, but saliva retention due to anatomical considerations, may benefit from a trial of conservative management, especially
and saliva composition, are believed to be important.9 Traditional if the stone is small. The patient must be well hydrated and the
theories suggest that the formation of sialoliths occur in two clinician must apply moist warm heat and gland massage, while
phases: 1. Formation of a central core and 2. A layered periphery. sialogogues are used to promote saliva production and flush the
The central core is formed by the precipitation of salts, which are stone out of the duct.17 In the management of large sialoliths which
bound by certain organic substances. The second phase consists are located in the close proximal duct, extracorporeal shock wave
of the layered deposition of organic and non-organic material. lithotripsy (ESWL) can be considered.18
Submandibular sialoliths are thought to be formed around a nidus Conclusion
of mucus, whereas parotid sialoliths are thought to be formed The dental practitioner has an important role to play in
around a nidus of inflammatory cells or a foreign body.4 the management and possible treatment of sialolithiasis.
It is likely that for stone formation to occur, intermittent Establishing a diagnosis of sialolithiasis requires a thorough
stasis of calcium-rich saliva occurs, producing a change in the history and physical examination along with routine radiographs.
mucoid element of saliva, and a gel forms. This gel produces the Patients should be educated regarding the mechanism of their
framework for deposition of salts and organic substances thus underlying pathology and methods of maintaining control over
creating a stone.8 Salivary calculi are usually small and measure them by emphasizing the value of hydration and excellent oral
from 1 mm to less than 1 cm. They rarely measure more than 1.5 hygiene, which lessens the severity of the attacks and prevents
cm .Mean size is reported as 6 to 9 mm .10 dental complications.The accepted treatment of sialolithiasis is
Sialoliths have been identified in the literature as surgical intervention, either removal of the sialolith or complete
causing repeated swelling during meals. However, symptomless excision of the gland.
sialoliths are common. If pain is present, the severity of the
symptoms depends on the degree of obstruction, which is related REFERENCES
to the size and location of the sialolith.11Sialolithiasis causes pain 1. White SC, Pharoah MJ. Oral radiology principles and
and swelling of the involved area by obstructing the food-related interpretation. Chapter 27. In: Soft Tissue Calcification and
surge of salivary secretion. In some cases, the sialolith may cause Ossification. Mosby, Missouri 2004:p597-614.
stasis of the saliva, leading to bacterial contamination of the 2. Torres-Lagares D, Barranco-Piedra S, Serrera-Figallo MA,
parenchyma of the gland, and clinical infection, with pain and Hita-Iglesias P, Mart inez-Sahuquillo-Mrquez A, Gutirrez-
swelling of the gland. Long-term obstruction in the absence of Prez JL. Parotid sialolithiasis in Stensen's duct , Med Oral
Patol Oral Cir Bucal 2006; 11: E80-84
infection can lead to atrophy of the gland with resultant lack of 3. Goncalves M, Hochuli-Vieira E, Lugao CE, et al. Sialolith of
secretory function and eventual fibrosis.12 unusual size and shape. Dentomaxillofac Radiol.
Correct diagnosis of a sialolith requires a proper history 2002;31:209-210.
and clinical examination. Sialoliths can occasionally be palpated 4. Ali Iqbal, Anup K Gupta, Subodh S Natu, Atul K Gupt a.
using a bidigital palpation approach at the floor of the mouth and Unusually large sialolith of Wharton's duct. Ann Maxillofa
parotid regions. Bi-manual palpation of the gland itself can Surg 2012; 2: 70-73.
identify a hypofunctional or nonfunctional gland associated with 5. Grases F, Santiago C, Simonet BM, et al. Sialolithiasis:
a uniformly firm and hard mass.13 In the anterior floor of the mechanism of calculi formation and etiologic factors. Clin
mouth, an occlusal radiograph may reveal the calculus. All Chim Acta. 2003;334:131-136.
salivary stones cannot be visualized through conventional 6. Giacomo Oteri, Rosa Maria Procopio and Marco Ciccci.
radiograph because a few of them are hypominelarized and are Giant Salivary Gland Calculi (GSGC) : Report of Two Cases,
superimposed by other radiodense tissues. In these cases other Open Dent J. 2011; 5: 90-95.
7. Zenk J, Constantinidis J, Al-Kadah B, Iro H. Transoral
advanced imaging modalities should be considered. 14 removal of submandibular stones. Arch Otolaryngol Head
Ultrasonography is widely reported as being very helpful in Neck Surg. 2001;127:432-6.
detecting salivary stones. As many as 90% of all stones larger than 8. Markiewicz MR, Margarone JE 3rd, Tapia JL, et
2mm can be detected as echodense spots on al.Sialolithiasis in a residual Wharton's duct after excision of
ultrasonography.However, detection of small calculi may be a submandibular salivary gland. J Laryngol Otol.
difficult with ultrasonography. Computed tomography (CT) is 2007;121:182-185.
also highly diagnostic.15Sialography is also useful to locate 9. Siddiqui SJ. Sialolithiasis: an unusually large submandibular
obstructions that cannot be detected by means of bidimensional salivary stone. Br Dent J. 2002;193:89-91.
radiography, especially whenever sialoliths are radiolucent or 10. Yu CQ, Yang C, Zheng LY, et al. Selective management of
whenever they are not present (as is the case with stenosis.2 obstructive submandibular sialadenitis. Br J Oral Maxillofac
Differential diagnosis of a sialolith could include a Surg. 2008;46:46-49.
calcified lymph node, an avulsed or impacted tooth or foreign 11. Mandel L, Hatzis G. The role of computerized tomography
29
in the diagnosis and therapy of parotid stones: a case report. J
Am Dent Assoc. 2000;131:479-482.
12. Soares LP, Gaiao de Melo L, Pozza DH, et al. Submandibular
gland sialolith in a renal transplant recipient: a case report. J
Contemp Dent Pract. 2005;6:127-133.
13. Van den Akker HP. Diagnostic imaging in salivary gland
disease. Oral Surg Oral Med Oral Pathol. 1988;66:625-37.
14. Weissman JL. Imaging of the salivary glands. Semin
Ultrasound CT MR. 1995;16:546-68.
15. Yousem DM, Kraut MA, Chalian AA. Major salivary gland
imaging. Radiology. 2000; 216:19-29.
16. Blatt IM: Studies in sialolithiasis. III. Pathogenesis,
diagnosis and treatment. South Med J 57:723-29, 1962.
17. Williams MF Sialolithisis Otolaryn Clin North Am 1999; 32:
819834.
18. Bodner L. Giant salivary gland calculi: diagnostic imaging
and surgical management. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2002 ; 94:320-3.
Dr. Mallika
Neha
C.
Dr.Dr. Ram Kishore
KKAggarwal
Mohan
Dixit
Email:
Email:
Email: dr.mallika.kishore01@gmail.com
30
LIST OF PHOTOGRAPHS
Fig: 1 Facial view of the patient
Fig: 2 Intraoral view Fig: 3 Mandibular occlusal

Radiograph
Fig: 4 Radiograph Showing Fig: 5 Intra Oral Photograph

Sialolithiasis
31
Maxillary Canine With Two Root Canals : A Case Report

Anuraag Gurtu , Anurag Singhal , Ridhi Bansal , Kunal Agnihotri
Profesor & Head, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Abstract: Endodontic therapy is essentially a micro neurologic surgical procedure involving complete
debridement and three dimensional obturation of the root canal system to obtain a fluid impervious seal. The
foundation of the procedure is based on the intimate knowledge and thorough understanding of the anatomy of
both the pulp chamber and the root-canal system. Teeth exhibit variations in their root canal anatomy and pose
a challenge in diagnosis and treatment. Maxillary canine are statistically more commonly single rooted, single
canalled but rarely may have single root with two root canals.
Key words : Endodontic Treatment, Maxillary Canine, Root Canal Anatomy, Two Root Canals
INTRODUCTION preparation was done, coronal preparation was done using
The pulp canal system in any tooth has the potential of #4,#3,#2 gates glidden drills(Tulsa dental, dentsply) middle and
being very complex with branching and divisions throughout the apical preparation by hand files (k-files) preparing the apical till
length of the root.1 Diagnosis and identification of variations in #30. The chemo-mechanical preparation was performed under
number of roots and root canals are the key factors in endodontic copious irrigation using 5.25% sodium hypochloride and 17%
treatment. The anatomy of root canal systems dictates the EDTA after use of each file. Final irrigant used was 2%
condition under which root canal therapy is carried out and can chlorohexidine. The root canals were obturated with gutta percha
directly affect its prognosis. Extra root canals if not detected are a and zinc oxide eugenol sealer using lateral condensation
major reason for failure of endodontic therapy.2 technique. Finally the tooth was restored with composite resin.
Maxillary canines are statistically more common to be
single-rooted, single-canaled teeth. It has been reported that 39% DISCUSSION
have straight canals, whereas 32% have root canals curved Knowledge to basic concepts is more important than the
distally. Lateral canal are present in 30% cases. Two root canals tools of measurement.8 Therefore it is of utmost importance to
in a permanent maxillary canine is a rare condition.3-6 Of those locate and treat all root canals in a tooth.
having two canals, majority join in apical third and exit at single During the past years, there have been many studies of
apical foramen.7 pulp morphology. The anatomical studies of Vertucci3, Pineda
and Kuttler4 Black9, and Green10 all state that maxillary incisors
CASE REPORT have a single root 100% of the time.. The percentage of
A 34 year old male patient reported to the department of permanent maxillary canines with type V canal configuration
conservative dentistry and endodontics with a chief complaint of (one canal leaves the pulp chamber and divides short of the apex
pain in upper front region past 4 months. Subjective symptoms into two type V canal configuration (one canal leaves the pulp
included dull, continuous, non radiating pain that aggravated on chamber and divides short of the apex into two separate and
mastication and relieved on medication. Past dental history and distinct canals with separate apical foramina 2 was 2.17 and type
Medical history were non contributory. III canal configuration (one canal leaves the pulp chamber,
Oral examination revealed deep dental caries extending divides into two
subgingivaly with no direct pulpal exposure. Tooth was within the root, and merges to exit as one canal 2 was 4.35. A
asymptomatic on palpation and tested negative using electric pulp review of the literature revealed that Alapati et al.6 reported a
tester. Periodontal status was within normal limits. Radiographic maxillary right canine with type II canal configuration and
examination spotted abnormal root canal anatomy, single root Weisman reported a bi-rooted maxillary left canine.
with two root canals. Periapical radiolucency was seen with size In the present case two distinct root canal orifices were
less than 1 cm in diameter. Provisional diagnosis made was located in a labial/palatal configuration. The palatal canal coursed
chronic periapical abscess. laterally and then curved back to join the buccal canal in the apical
Endodontic treatment was started under local third, forming a type II canal configuration. Although one of the
anaesthesia. Access cavity was made using #1014 round diamond two canals, the one most continuous with the large main passage,
bur and endo Z carbide bur, pulp extirpation was done using is usually amenable to adequate enlarging and filling procedures,
bared broach. Root canals were negotiated with #10 k- file and the preparation and filling of the other canal is often extremely
working length was established. Crown down root canal difficult.
32
CONCLUSION
Clinicians should be aware of anatomical variations in
the teeth they are managing, and should never assume that canal
systems are simple. Even though the most common anatomy of
maxillary canines comprises a single root and a single root canal,
clinicians should consider the possible variations and always
search for the second root canal in teeth with either one or two
roots.
REFERENCES
1. Nagesh bolla. Maxillary canine with two root canals. J
Conserv Dent 2011;14:80-2
2. Hulsmann M, Schafer E. Problems in gaining access to the
root canal system. In: Hulsmann Michael, Schafer Edgar,
editors. Problems in Endodontics: Etiology, Diagnosis and
Treatment. 1st ed. Germany:Quintessence Publishing Co
Ltd; 2009. p. 145-72
3. Vertucci FJ. Root canal anatomy of the human permanent
teeth. Oral Surg, Oral Med, Oral Pathol, Oral Radiol,
Endod1984;58: 589 -99.
4. Zeigler PE, Serene TP. Failures in therapy. In Cohen S, Burns
RC, eds. Pathways of the pulp. 4th ed. St. Louis: CV. 1994,
690-91.
5. Pineda F, Kuttler Y. Mesiodistal and buccolingual
roentgenographic investigation of 7,275 root canals. Oral
Surg, Oral Med, Oral Pathol, Oral Radiol, Endod
1972;33:101-10.
6. John. I. Ingle, James H. Simon, Pierre Machtou , and Patrick
Bogaerts.Outcome of endodontic treatment and re-
treatment. In.Ingle Ij, . Bakland Lk, Endodontics. 5th ed. BC
Decker Inc 2002;747-68.
7. Ravi SV.Maxillary canine with two root canals:a case report.
Ind J Dent Res 2012:69-71.
8. Krasner P, Rankow H J Anatomy of the Pulp-Chamber Floor.
J Endod 2004;30:5-16.
9. Alapati S, Zaatar EI, Shyama M, Al-Zuhair N. Maxillary
canine with two root canals. Med Principles Prac
2006;15:74-6.
10. Weisman MI. A rare occurrence: a bi-rooted upper
canine.Aus Endod J 2000;26:119-20.
Dr. C.
Dr. Ram Mohan
Anuraag gurtu
Email: anuraggurtu@yahoo.com
33
LIST OF PHOTOGRAPHS
Fig: 1 Pre - Operative IOPAR Fig:2 Working Length Estimation
Fig:3 Master Cone IOPAR Fig: 4 Post Obturation IOPAR
34
Denuded Root - is Free Gingival Graft an Answer : A Case Report

Rika Singh , Sunil Kumar Mall
Senior Lecturer, Department of Periodontology, Institute of Dental Sciences, Bareilly (U.P).
Oral and Maxillofacial Surgeon.
Abstract: Gingival recession is defined as the apical displacement ofthe gingival margin from the cemento-
enamel junction (CEJ). Gingival recessions require treatment for many reasons impaired aesthetic
appearance, root sensitivity, cervical caries or abrasion. Many surgical techniques have been advocated for
recession coverage. Since its introduction in 1963, the free gingival graft procedure has proven reliable in
increasing attached gingiva and stopping progressive gingival recession. In 1982, Miller proposed a
modification of the conventional technique for autogenous gingival graft surgery for root coverage. This paper
presents a case of denuded root coverage using free gingival graft technique.
Key words : Gingival Recession, Gingival Graft, Gingiva, Denuded Root, Cementoenamel Junction.
INTRODUCTION failure rates are also high for free gingival grafts when solely used
Gingival recession is defined as the location of gingival for root coverage procedure. Miller 19878 has proposed many
margin apical to cementoenamel junction.1When occurring in factors for incomplete or failure of root coverage. These include
anterior tooth regions of the oral cavity, gingival recession can be improper classification of marginal tissue recession, inadequate
aesthetically unpleasing for the patient and it can also further lead root planning, failure to treat the planed root with citric acid,
to root sensitivity, cervical abrasion and root caries. Besides improper preparation of recipient site, inadequate size of
periodontal disease, various other factors such as faulty tooth interdental papillae, improperly prepared donor tissue,
brushing, orthodontic tooth movements, faulty restorations, inadequate graft size, in adequate graft thickness, dehydration of
frenum pull, tooth malpositioning etc. are considered as a major graft, inadequate adaptation of graft to root and remaining
cause for gingival recession. periosteal bed, failure to stabilize the graft, excess or prolonged
Miller classified gingival recession into four pressure in captions of sutured graft, reduction of inflammation
categories.3The classification is used to assess the defect as well prior to grafting, trauma to graft during initial healing.
as predict root coverage which may be possible using various
surgical procedures. Root coverage is more predictable and more CASE REPORT
successful with Class I and II defects, whereas only partial A 22 years old female patient visited the department of
coverage can be expected with Class III defects. Root coverage in Periodontics, with a chief complaint of sensitivity of a tooth in
Class IV defects should not be expected. Various periodontal lower anterior region. The periodontal examination revealed
plastic surgical procedures are used alone or in combination for Miller's class II recession in relation to 31(Fig 1). There was
predictable root coverage such as connective tissue grafts, pedicle probing depth of 1.5mm and radiographic examination showed
flaps, free gingival grafts, guided tissue regeneration etc. no bone loss interdentally. The vestibular depth was also
Autogenous gingival grafting or epithelialized free gingival insufficient in relation to 31 (Fig 1).Patient's medical and dental
grafting was introduced in 1963,4 and the procedure has proven histories were non-contributory.
reliable in increasing attached gingiva and stopping progressive Four weeks before surgery full-mouth scaling and
gingival recession. Also, long-term stability (up to 4 years) of polishing were performed and oral hygiene instructions were
these treatment outcomes has been demonstrated.5 Although root given to eliminate habits related to the etiology of the recession.
coverage is not a primary goal of autogenous gingival grafting, Re-evaluation of the tooth (31) at 4 weeks showed apico-
however it may occur in cases of narrow recession (< 3 mm), as a coronary 5mm of recession, mesio-distally 3mm of recession.
result of bridging, whereby some of the grafted tissue remains Accordingly after the patient's consent, it was decided to treat the
vital over the avascular zone of the root.6 site by Miller's technique for free autogenous gingival grafting to
In 1982, Miller7 proposed a modification of the achieve root coverage and simultaneously increase the attached
conventional technique for autogenous gingival graft surgery for gingiva and the vestibular depth.
root coverage. This modification used a thicker graft (2 mm)
positioned over a carefully planed root surface that had been SURGICAL PROCEDURE
previously conditioned with citric acid. With detailed suturing Preparation of Recipient Bed: the patient was asked to rinse
marginally and apically, the graft could be adapted in intimate with 10ml of 0.12% chlorhexidine for 30 seconds, following
contact with the recipient site. He showed 95.5% of root coverage which local anesthesia was administered. After adequate local
when recession was less than 3mm, 80.6% when recession was 3 anesthesia had been achieved, the exposed root was planed
to 5mm and 76.6% when it exceeded 5mm. Despite these results, thoroughly to reduce the convexity. Root conditioning was
35
achieved by burnishing the root using a cotton pellet saturated coverage has drastically declined. However free gingival graft
with tetracycline solution for about 3 minutes. A horizontal appears to be the best treatment alternative to increase the amount
incision was made at the level of cementoenamel junction of keratinised tissue and for treatment of class I and class II
extending from the line angle of adjacent teeth on either side of the gingival recessions. With appropriate case selection, this
recession deep into the papilla, creating a well defined butt joint technique is predictable in achieving complete root coverage.
At the distal terminal of the horizontal incision, vertical incision
was given extending well into the alveolar mucosa, so that it is CONCLUSION
3mm beyond the apical extent of the recession. A partial thickness The free gingival graft for root coverage is still a feasible
flap was elevated and excised apically (Fig 2). and predictable procedure not only to increase the amount of
Preparation of Donor Tissue: A tin foil template was used to keratinised gingival tissue but also in achieving coverage of
accurately determine the amount of donor tissue. The template denuded roots. Adequate vestibular depth can be achieved by the
was made by adapting it to the recipient site. The right side of procedure which helps in better oral hygiene maintenance by the
palate was chosen as the recipient site. The area between first and patient. The results obtained in this case suggests that with proper
second premolar which had greater thickness was selected to case selection, the procedure of free gingival graft holds promise
harvest the donor tissue. The initial incision was outlined by the for successful management of denuded root coverage.
placement of tinfoil template with a no 15 scalpel blade. All
palatal incisions were made in such a fashion as to create the butt REFERENCES
joint margin in the donor tissue. Tissue pliers was used to retract 1. The American academy of periodontology. Glossary of
the graft distally as it is being separated apically and dissected, periodontic terms. 4th ed. 2001
until the graft was totally freed (Fig 3). The graft obtained was 2. Ashley F, Usiskin L, Wilson R, Wagaiyu E. The relationship
inspected for any glandular or fatty tissue remnants. The between irregularity of the incisor teeth, plaque, and
thickness of the graft was also checked to ensure the smooth and gingivitis: a study in a group of school children aged 11-14
uniform thickness (Fig 4). The graft was placed on the recipient years. Eur J Ortho1998;20(1):65.
bed and sutured by means of sling sutures (5-0 vicryl sutures) (Fig 3. Miller P D Jr. A classification of marginal tissue recession.
5). A vertical stretching suture was given for close adaption of the Int J Periodont Rest Dent 1985; 5: 813.
graft to the tooth surface. After suturing a periodontal dressing 4. Bjrn H. Free transplantation of gingiva propia. Sver
was placed to protect the surgical site (Fig 6). The palatal wound Tandlak Tidskr 1963; 22:684.
was protected by periodontal dressing stabilized by a passive 5. Dorfman HS, Kennedy JE, Bird WC. Longitudinal
Hawley's retainer. evaluation of free autogenous gingival grafts. A four year
Post Operative Instructions: The patient was asked to refrain report. J Periodontol 1982; 53(6):34952.
from tooth brushing at the surgical site for two weeks. 0.12% 6. Sullivan HC, Atkins JH. The role of free gingival grafts in
chlorhexidine mouth rinsing was advised twice daily for 3 weeks periodontal therapy. Dent Clin North Am 1969;
and for post operative pain control, combiflam was prescribed, 13(1):13348.
twice daily for 3 days. The periodontal dressing was removed 2 7. Miller PD Jr. Root coverage using a free soft tissue autograft
weeks post operatively (Fig 7 & 8). Healing was uneventful and following citric acid application. Part 1: Technique. Int J
was completed in about six weeks. There was significant Periodontics Restorative Dent 1982; 2(1):6570.
augmentation of attached gingiva and also reduction in the 8. Miller Jr P. Root coverage with the free gingival graft.
recession size (Fig 9). Factors associated with incomplete coverage. J
Periodontol1987;58(10):674.
DISCUSSION 9. Sullivan H, Atkins J. Free autogenous gingival grafts. 3.
This case report presented Miller's class-II recession of Utilization of grafts in the treatment of gingival recession.
31, which was successfully treated by free autogenous soft tissue Periodontics1968;6(4):152.
graft. Also there was increase in vestibular depth led to
improvements in mucogingival relationships and also better
opportunity for plaque control by the patient.
Miller's criteria8 for successful root coverage include:
the soft tissue margin must be at the cemento-enamel junction,
clinical attachment to the root, with sulcus depth of 2mm, and no
bleeding on probing. All these criteria were achieved in the
present case. According to Sullivan and Atkins9 when free
gingival graft is placed over recession, some amount of
bridging can be expected because a portion of grafted tissue
which is covering the root will survive by receiving circulation
from the vascular portion of the recipient site. In addition to
bridging, creeping attachment can result in a post operative
coronal migration of free gingival margin. Free gingival grafting
is a procedure of high degree of predictability when used alone or Corresponding
Address:
combined with other technique. However it is more technically Dr.
Dr.C.Rika
RamSingh
Mohan
demanding, time consuming, and the color match of the tissue is
often less than ideal. Due to the predictability and versatility of
Email: rikasingh22@gmail.com
connective tissue graft, the use of the free gingival graft for root
36
LIST OF PHOTOGRAPHS
Fig 1- Gingival Recession Fig 2- Preparation of Fig 3-The donor site

recipient bed
Fig 4- Free gingival graft Fig 5- Graft secure in position Fig 6- Periodontal
using 5-0 vicryl sutures dressing given
Fig 7- Donor site 2 Fig- 8 Recipient site 2 Fig 9-3 months after healing
weeks post operative weeks post operative
37
Complication of a Dental Extraction: Osteomyelitis : A Case Report

Sowmya G.V., Nupur Agarwal, Nitin Upadhyay, Abhijeet Alok, Mallika Kishore
Senior lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Senior lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P.G Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P.G Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 14/Feb/2013
Abstract: Osteomyelitis, an inflammation of bone & its marrow contents is a sequela of periapical infection
results in diffuse spread through medullary spaces with subsequent necrosis of bone. It may be acute, subacute
& chronic. The pain, the pus, the new bone formation and all the trouble, this case showed it all. Here we are
reporting a case with complication of dental extractions with clinical & histopathological examination,
diagnosed as chronic osteomyelitis.
Key words : Osteomyelitis, Extraction, Mandible.

INTRODUCTION present suggestive of pathological fracture (fig 2).
The word Osteomyelitis originates from the ancient Patients's lesion was surgically excised and sent for
Greek words osteon (bone) and muelinos (marrow) and means histopathological investigations which revealed that soft tissue
infection of medullary portion of the bone.1 Osteomyelitis is an component that consists of chronically or subacutely in flamed
inflammatory condition of bone that involves the medullary fibrous connective tissue filling the lntertrabecular areas of the
cavity and has a tendency to progress along this space.2 It can be bone which was suggestive of chronic suppurative osteomyelitis.
classified as acute, subacute or chronic, depending on the clinical So final diagnosis of chronic suppurative osteomyelitis was
presentation.The decline in prevalence can be attributed to the given.
increased availability of antibiotics and the progressively higher
standards of oral and dental health.3 The incidence of DISCUSSION
osteomyelitis has dramatically decreased since the introduction Chronic Suppurative Osteomyelitis (CSO) is an often
of antibiotics.4 preferred term in Anglo-American texts and can mostly be used
Moreover, osteomyelitis of the head and neck skeleton is rare, interchangeably with the term secondary chronic
particularly in the jaws.5,6 Osteomyelitis which is predominantly used in literature from
continental Europe. Suppurative Osteomyelitis can involve all
CASE REPORT three components of bone: periosteum, cortex, and marrow.7
A 60 year old male patient reported to the Department of Marx (1991) and Mercuri (1991) were the first and only authors to
Oral Medicine and Radiology with a chief complaint of swelling define the duration for an acute osteomyelitis until it should be
and pain in left lower back tooth region since 6 months (fig 1). considered as chronic. They set an arbitrary time limit of 4 weeks
History of present illness revealed that pain was present. Pain was after onset of disease.1 It is by far the most common osteomyelitis
sudden, intermittent and localised. Patient got his tooth extracted type. The primary cause of chronic osteomyelitis of the jaws is
in left lower back tooth region 6 months back after which there is infection caused by odontogenic microorganisms. It may also
continuous pus discharge. History of paresthesia was there. On arise as a complication of dental extractions and surgery,
extra oral examination, a diffused swelling, roughly oval in shape, maxillofacial trauma and the subsequent inadequate treatment of
roughly 1x 2 cm in diameter extending from infra orbital margin a fracture, and/or irradiation to the mandible.3,8,9 The four primary
till base of mandible, antero-posteriorly it extends from .5 cm factors which are responsible for deep bacterial invasion into the
from ala of nose to .5 cm from tragus of ear. Overlying mucosa medullar cavity and cortical bone and hence establishment of the
appears normal. No secondary changes was seen. On palpation it infection are: 1. Number of pathogens, 2. Virulence of pathogens,
was hard in consistency, non tender. On intra oral examination, 3. Local and systemic host immunity, 4. Local tissue perfusion.
missing 37 and 38 was there. Pus discharge from that region was Additionally, exposure of the head and neck region to
present. On palpation Grade I mobility was present w.r.t. 36,35. radiotherapy, uncontrolled diabetes,and immunosuppressive
Based on the clinical appearance and history, a provisional therapies as well as heavy smoking and drinking increase risk for
diagnosis of chronic suppurative osteomyelitis was given w.r.t 36 mandible osteomyelitis development.10,11 Other predisposing
region. factors are those that are characterized by the formation of
In investigations, orthopantomogram was done which avascular bone for example, therapeutically irradiated bone,
revealed an ill defined radiolucency on the left mandibular region, osteopetrosis, Paget's disease, and florid osseous dysplasia. A
roughly oval in shape, roughly 1x2 cm in diameter extending study by Taher, of 88 cases of osteomyelitis of the mandible,
from distal of 35 to the coronoid area. Ill defined borders are found trauma to be the most common predisposing cause for
38
osteomyelitis, attributing it to the geo-political 3. Yeoh SC, MacMahon S, Schifter M. Chronic suppurative
difficulties.12 osteomyelitis of the mandible: A Case report. Aust Dent J
In the healthy individual with sufficient host immunity 2005; 50(3): 200-03.
mechanisms these factors form a carefully balanced equilibrium. 4. Kushner G M, Alpert B. Osteomyelitis and
If this equilibrium is disturbed by altering one or more of these osteoradionecrosis.In: Miloro M, Ghali GE, Larsen PE,
factors, deep bone infection establishes.1 Osteomyelitis is more Waite PD, eds. Peterson's Principles of Oral and
commonly observed in the mandible because of its poor blood Maxillofacial Surgery, 2nd ed. London:BC Decker ; 2003:
supply as compared to the maxilla, and also because the dense 313-21.
mandibular cortical bone is more prone to damage and, therefore, 5. Fonseca RJ, Turvey TA, Betts NJ. Oral and Maxillofacial
to infection at the time of tooth extraction.1 Although Surgery, 1st ed. Philadelphia: WB Saunders; 2000: 485-90.
osteomyelitis of the maxilla is rare, it is more frequently seen in 6. Barry CP, Ryan CD, Stassen LF. Osteomyelitis of the maxilla
infants and children, as more bone is available in the maxilla a secondary to osteopetrosis: a report of 2 cases in sisters.
during infancy. Osteomyelitis of the maxilla is much less frequent Oral Maxillofac Surg 2007;65:144-7.
than that of the mandible because the maxillary blood supply is 7. Mallikarjun K, Kohli A, Arvind K, Vatsala V, Bhayya DP
more extensive.13 The typical age of presentation is in the fifties to ,Shyagali TR. Chronic suppurative osteomyelitis. of the
the sixties, with males more likely to be affected.14 Clinical mandible- A Case Report. J. Int Oral Health 201;3:57-62.
features documented are deep intense pain, high intermittent 8. Eyrich Gk, Baltensperger Mm, Bruder E, Graetz Kw:
fever, parasthesia or anesthesia of the lip due to involvement of Primary chronic osteomyelitis in childhood and
the mental nerve, pus and sequestra exudates through fistulae, adolescence: a retrospective analysis of 11 cases and review
trismus, regional lymphadenopathy, induration of soft tissue, and of the literature. J OralMaxillofac Surg 2003; 61 (5): 56173.
wooden character of bone with pain and tenderness on palpation. 9. treatment of chronic osteomyelitis of the mandible: case
The associated teeth may be mobile and sensitive to percussion.15 report. Br J Oral Maxillofac Surg 2008; 46 (5): 4002.
Teher12found that 37% of his patients had fistulas and 10. Jorge LS, Chueire AG, Rossit AR. Osteomyelitis: a current
sequestrations and 3% had pathological fractures, fistulas, and challenge. Braz J Infect Dis 2010;14 (3):3105.
sequestrations. In the present series, discharging sinus with 11. Slough Cm, Woo Bm, Ueeck Ba, Wax Mk: Fibular free flaps
sequestra was seen in 88% of patients and pathological fractures in the management of osteomyelitis of the mandible. Head
in 6%. Neck 2008; 30 (11):153134.
Culture and sensitivity of the discharge usually reveals 12. Taher AAY. Osteomyelitis of mandible in Tehran, Iran. Oral
staphylococci, streptococci, pneumococci, and anaerobes such as Surg Oral Med Oral Pathol 1993;/76:/28-31.
bacteroides, as was the case in the present series. Before 13. Topazian RG. Osteomyelitis of jaws. In: Topazian RG,
application of any cross sectional imaging modality, the Goldberg MH, editors. Oral and maxillofacial infections, 3rd
orthopanoramic view is indispensable in recognizing direct edn. Philadelphia, PA: Saunders; 1994. 251-86.
radiographic signs of osteomyelitis. The orthopanoramic view is 14. Jagdhari SB, Patni VM, Motwani M, Gangotri S. chronic
the procedure of choice in follow-up examinations in patients suppurative osteomyelitis of jaw - report of two cases. Int J
who have osteomyelitis.16 This showed scattered areas of bone Dent Case Reports 2013; 3(1): 93-97.
destruction, sequestra/ involucrum, alteration in the contour of 15. Lee L. Inflammatory lesions of the jaws. In: White SC,
the mandible, and occasionally pathological fractures. If surgical Pharoah MJ, editors. Oral radiology: principles and
treatment is planned, high-resolution CT is required to specify the interpretation, vol 3, 4th edn. Missouri: Mosby; 2000. p. 338-
degree of cortical destruction, the presence of sequestra in 54.
particular, and to define the extent of osseous removal required.16 16. Schuknecht B, Valavanis A. Osteomyelitis of the mandible.
To detect early osteomyelitis, a two-phase technetium bone scan Neuroimaging Clin North Am 2003;/13:/605-18.
followed by a gallium citrate scan may help to confirm 17. Gutierrez K.Bone and joint infections in children. Pediatr
diagnosis.15 Clin North Am 2005; 52(3): 779-794.
Histopathological examination of the surgical specimen 18. Mandracchia VJ, Sandres SM, Jaeger AJ, Nickles WA.
or granulation tissues was carried out in most of our cases, which Management of osteomyelitis. Clin Pediatr Med Surg 2004,
helped in accurate diagnosis of the predisposing factors such as 21: 335-351.
malignancy, tuberculosis or other granulomatous conditions. The
treatment protocol consisted of a combination of surgery and
antimicrobial treatment amoxicillin, co-amoxiclav, cephalexin,
and metronidazole.17,18 Other options include Clindamycin due to
its excellent absorption and bioavailability in bone infections,
HBO therapy is also one treatment modality which can be used in
osteomyelitis.
REFERENCES
1. Marc Baltensperger and Gerold Eyrich. Osteomyelitis of the Corresponding
Address:
Jaws: Springer Berlin Heidelberg. November 07, 2008.
2. Aitasalo K, Niinikoski J, Grnman R, Virolainen E: A Dr. Neha
Dr.C.
Dr. RamAggarwal
Abhijeet Alok
Mohan
modified protocol for early treatment of osteomyelitis and Email:
Email:
Email: drabhijeet786@gmail.com
osteoradionecrosis of the mandible. Head Neck 1998; 20(5):
4117.
39
LIST OF PHOTOGRAPHS
Fig:1 Intra Oral Photograph
Fig:2 Orthopantomogram
40
Eagles Syndrome : A Case Report

Nupur Agarwal , Sunil R Panat , Ashish Aggarwal , Anuja Joshi , Kratika Ajai
Principal, Professor and Head, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly.(U.P)
P.G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P)
P.G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P)
Abstract: Elongation of the styloid process or stylohyoid ligament calcification is a well recognized finding of
dental practice, and an incidence of 4 to 30 percent has been reported on radiographs. Eagle syndrome is an
aggregate of symptoms caused by an elongated ossified styloid process, the cause of which remains unclear.
Ossification of the stylohyoid and stylomandibular ligament causes prolongation of the styloid process and
clinical symptoms. Eagle's syndrome is defined as the symptomatic elongation of the styloid process or
mineralization of the stylohyoid ligament complex. The symptoms related to this condition can be confused with
those attributed to a wide variety of facial neuralgias. Here we report a case of eagle syndrome in which patient
exhibiting unilateral symptoms with bilateral elongation of styloid process is reported and the literature is
reviewed.
Key words : Styloid process, Stylohyoid Ligament, Facial Neuralgia, Ossification.

INTRODUCTION present on left and right post auricular region and neck region. On
Eagle's syndrome was first described by an American intraoral examination no significant findings are observed. On the
Otorhino laryngologist Watt weems Eagle in1937.1 Styloid process is basis of history and clinical findings provisional diagnosis of Eagles
normally a slender; cylindrical bone that arises from the temporal syndrome was given with a differential diagnosis of
bone in front of the stylomastoid foramen which is normally varies temporomandibular arthritis was made. On radiographic
from 2.0 to 2.5 cm in adults.2 examination, OPG of the oral cavity (Figure 1) revealed an elongated
Eagle further described it as atypical facial neuralgia and styloid process on both sides measuring about 32.1 on left side. On
reported that it has various symptoms like feeling of a foreign body the basis of history, clinical features and radiographic features, final
lodged in the throat, difficulty and pain during swallowing, throat diagnosis of Eagles syndrome were made.
pain, pain on turning the head, pain in infraorbital, infratemporal, ear
and occipital areas, pain on wide opening of mouth, headache, DISCUSSION
tinnitus and vertigo.3 Eagle's syndrome is characterised by the Carotid artery syndrome or stylohyoid syndrome is caused
following symptoms: pharyngeal pain localised in the tonsillar fossa, by the elongated styloid process.2 Specific orofacial pain secondary
radiating to the oesophagus, to the hyoid bone, painful head rotation to calcification of stylohyoid ligament or elongated styloid process
and lingual movements.4 Male : female ratio is 1:3. Bilateral is quite has been known as Eagle's syndrome.1Stylalgia (elongated styloid
common, but symptoms are mostly unilateral.1 There is high process, long styloid process syndrome, Eagle's syndrome) is related
variability in prevalence studies about elongated styloid process with to abnormal length of the styloid process, to mineralisation of the
a slight gender prediction for females (KEUR, CAMPBELL, styloid ligament complex , or to calcification of digastric
McCARTHY et al., 1986; O'CARROLL, 1984).2 The length of the muscles.4(3)7Embryologically, it has been derived from the Reichert's
styloid process is variable. Kaufman et al. reported that 30 mm is the cartilage of the second branchial arch. It is a slender, pointed
upper limit for normal styloid processes.5 The styloid process structure which projects anteroinferiorly from the inferior aspect of
normally measures 2.2-3 cm in length; when length exceeds 3 cm it is temporal bone.3
said to be elongated.6 Here we present a case of 25 yr old female The actual cause of the elongation is a poorly understood
patient suffering from eagles syndrome. process. Several theories have been proposed:
1) Congenital elongation of the styloid process due to persistence of a
CASE REPORT cartilaginous analog of the stylohyal (one of the embryologic
A 25 year old female patient reported to Department of Oral precursors of the styloid),
Medicine and Radiology,Institute of Dental Sciences, Bareilly (U.P) 2) Calcification of the stylohyoid ligament by an unknown process,
with a chief complaint of pain in left neck region since 4 mnths. and
History of present illness reveals that there was pain in throat which 3) Growth of osseous tissue at the insertion of the stylohyoid
was radiating to the head and neck, the pain was continuous and ligament.8
moderate and it is more on the left side especially on turning the head From Eagle's early descriptions, patients were categorized
towards left.General physical examination revealed that, bilaterally, into two groups: those who had classical symptoms of a foreign
there is no clicking and popping sound was present on TMJ and there body lodged in the throat with a palpable mass in the tonsillar region
is no deviation of mandible.In extraoral examination tenderness were following tonsillectomy; and those with pain in the neck following
41
the carotid artery distribution (carotid artery syndrome).9 Although syndrome: a case report. J. Morphol. Sci., 2012;29(1):58-59.
these two types have a common etiology, their symptomatology 3. More CB, Asrani MK. Eagle's syndrome: report of three cases.
differ. Indian J Otolaryngol Head Neck Surg. 2011;63(4):396-9.
The pain aggravates typically on rotation of the head.10The 4. Nemeth O, Csaki G, Csado K,Kivovics C.Case report of a 27
cause of onset of pain in patients previously free of symptoms is year old patient suffering from Eagle's
unknown, but several mechanisms have been proposed that include syndrome.OHDMBSC.2010;9(3)
rheumatic styloiditis caused by pharyngeal infections, trauma, 5. Savranlar A, Uzun L,Ugur M B,Ozer T. Three-dimensional CT
tonsillectomy, and involutional changes associated with aging (e.g., of Eagle's syndrome. Diagn Interv Radiol 2005; 11:206-209.
degenerative cervical discopathy,which may shorten the cervical 6. Raina D, Gothi R, Rajan S.Eagle's syndrome.Indian J
spine and alter the direction of the styloid process)11 Radiol.2009;19(2) 107-108.
Elongation of the styloid process or stylohyoid ligament 7. Mortellaro C, Biancuccci P, Picciolo G, Vercellino V. Eagle's
calcification is a well recognized finding of dental practice. Most syndrome. Importance of a.corrected diagnosis and adequate
cases are asymptomatic; however, a small number of such patient's surgical treatment. J Craniofac Surg. 2002 Nov; 13(6):755-8.
experience symptoms of Eagle's syndrome, related to the 8. Murtagh R D, Caracciola J T, Fernandez G. CT findings
compression of adjacent nerves and blood vessels.12 In about 4% of associated with Eagle syndrome. Am J Neuroradiol.2001; 22;
general population an elongated styloid process occurs, while only 1401-1402.
about 4% of these patients are symptomatic; thus the true incidence is 9. Feldman V B.Eagle's syndrome: a case of symptomatic
0.16% with a female predominance of 3:1.13 calcification of the stylohyoid ligament. J Can Chiropr Assoc
14
Langlais et al. (1986) classified elongated styloid process 2003; 47(1) 21-27.
and mineralised styloid complexes based on the radiographic 10. Ryan MD. CT findings associated with Eagle's syndrome.
appearance and structures as follows: AJNR AMJ Neuroradiol 2001; 22:1401-2.
Type I: the elongated type pattern represents an uninterrupted 11. Khandelwal S, Hada Y S, Harsh A. Eagle's syndrome- a case
process. report and review of the literature. Saudi Dent J.2011;
Type II: characterised by a single pseudoarticulation that seems an 23:211215.
articulated elongated styloid process. 12. Shahoon H,Kianbaht C. Symptomatic Elongated Styloid
Type III: represents an interrupted process that gives the appearance Process or Eagle's syndrome: A case report. JODDD, 2008; 2(3)
of multiple pseudo- articulations within the ligament. 102-105.
The diagnosis of ES must be based on a good medical 13. Casale M, Rinaldi V, Quattrocchi C, Bressi F, Vincenzi B,
history and physical examination. It should be possible to feel an Santini D, Tonini G, Salvinelli F. atypical chronic head and neck
elongated styloid process by careful intraoral palpation, placing the pain: don't forget Eagle's syndrome.Eur Rev Med Pharmacol
index finger in the tonsillar fossa and applying gentle Pressure.15 The Sci.2008 12:131-133.
diagnosis of ES can be ascertained with imaging which includes 14. Langlais RP, Miles DA, Van Dis ML. Elongated and
lateral head and neck radiograph, Towne radiograph, panoramic mineralized stylohyoid ligament complex: A proposed
radiograph, lateral-oblique mandible plain film etc.16 classification and report of a case of Eagle's syndrome. Oral
In differential diagnosis, laryngopharyngeal dysesthesia Surg Oral Med Oral Pathol. 1986 May; 61(5):527-32.
has to be considered as well as dental malocclusion, neuralgia of 15. Montalbetti, L., Ferrandi, D., Pergami, P., Savoldi, F., 1995.
sphenopalatine ganglia, temporomandibular arthritis, Elongated styloid process and Eagle's syndrome. Cephalalgia
glossopharyngeal and trigeminal neuralgia, chronic tonsillo- 15, 8093.
pharyngitis, hyoid bursitis, Sluder's syndrome, histamine cephalgia, 16. Dayal, V., Morrison, M.D., Dickson, T.J.M., 1971. Elongated
cluster type headache, esophageal diverticula, temporal arteritis, styloid process. Arch. Otolaryngol. 94, 174175.
cervical vertebral arthritis, benign or malign neoplasms, and 17. Harma, R., 1966. Stylalgia clinical experiences of 52 cases.
migraine type headache (Harma, 1966).17 Eagles syndrome can be Acta Otolaryngol. 224, 149.
6
treated by surgical and non surgical means. Non surgical treatment
involve reassurance to the patient, analgesics, and steroid injections.
Surgical treatment can be performed using one of two approaches:
transpharyngeal or extraoral. The latter is thought to be superior
because it is likely to cause deep space infections.6Also, barium
swallow studies can show the indentation of the elongated styloid
process as a filling defect.16
CONCLUSION
The elongated styloid process syndrome can be diagnosed
by a detailed history, physical examination, and radiological
investigations. It can be confused or mistaken for many other
conditions that must be excluded. An awareness of pain syndromes
related to the styloid process isimportant to all health practitioners
involved in the diagnosis and treatment of neck and head pain. In a
non specific orofacial pain there should be a high index of suspicision
of stylalgia Eagle's syndrome.
REFERENCES Dr.Dr.
Dr. Neha
C.
Dr. KKAggarwal
Anuja
Ram Joshi
Mohan
Dixit
1. Karam C, Koussa S. "Eagle syndrome: the role of CT scan with
3D reconstructions". J Neuroradiol. 2007; 34 (5): 3445. Email:
Email: dranujajoshi88@gmail.com
2. Veena k M, Ashwini S S, Jagdishchandra H. Carotid artery
42
LIST OF PHOTOGRAPHS
Fig : 1 Elongation of styloid process
43
A Modified Sectional Custom Tray for Making Master Impression in

Microstomia Patient : Case Report

Pratik Gupta , Dilip Kumar Nath , Nadira Saba
P. G. Student, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
1.
Abstract: Patients with limited mouth opening are often found during prosthodontic practice Micrstomia has
been defined as an abnormally small oral orifice associated with various etiopathologic factors. Management
of these patients poses extreme difficulties in every procedures during fabrication of prosthesis2. Restricted
mouth opening of the patient makes the insertion and removal of the tray extremely difficult. So sectioning of the
tray is necessary, so that the trays can be inserted and removed in sections. The main problem encountered
during this procedures reorientation of the tray back in position. This article present a simple technique for easy
handling of the sectioned tray.
Key words : Sectional , Microstomia , Press Buttons , Constricted, Reorientation.

INTRODUCTION euginol paste.
Micrstomia has been defined as an abnormally small Sectional impression tray was designed with right and
oral orifice 3. It can occur either due to trauma or burns of left sections that could be detached and rejoined together in
electrical, thermal or chemical origin. The condition can be result correct original position in and outside the oral cavity for final
from genetic disorders, plummer-vinson syndrome, scleroderma, impression and cast making procedure. For each tray a total of
surgical treatments of orofacial tumors and reconstruction of lip five press buttons were used two on the each side of the section
defects4,5,6. and one on the handle. Press buttons were fitted symmetrically
Prosthetic Rehabilitation micrstomia patients presents and parallel to each other.
difficulties from primary impression to insertion of dentures. This
is mainly due to the decreased oral opening and tongue rigidity. A PROCEDURE
maximal possible mouth opening does not accommodate the 1) Conventional custom trays for maxilla and mandible was
smallest impression trays7. first fabricated using autopolymerizing acrylic resin and then
Insertion and removal of impression tray is extremely with diamond disc each custom tray was divided into two
difficult and various modification of the trays have been tried in equal halves at the midline along with the handle. (fig
the past. Mirfazalian for example used orthodontic expansion 2,4,9,10)
screws to fabricate sectional trays . Cura et al used metal pins and 2) Two male component of press buttons were attached with
an acrylic resin block to attach the sections of the impression autopolymerizing acrylic resin on both sides of sectional
trays7. Bennetti et al used a flexible plastic tray intended for trays.
fluride application to make the preliminary impression 6. On one 3) Then two acrylic plates were fabricated with female
of sections, Benetti et al prepared a stepped butt joint to make a component of press buttons on each side(fig 3,10).
definitive impression8. 4) Female component on acrylic plate engages the male
The purpose of this article is to describe a sectional component on the sectional trays when pressure is applied
custom tray system that is much helpful for making final with fingers.(fig 4,11)
impression with a constricted oral opening without giving any 5) On the handle of maxillary tray one male-female component
oral injury and tearing down of impression.. of press buttons attached for extra rigidity as it is large in size.
6) With each section of sectional tray, first border molding was
CASE REPORT done.(fig 6,12)
A 54 year old edentulous male patient with limited oral 7) After that sectional impression tray were inserted into the
opening appeared in the department of prosthodontics, IDS, patients mouth in two separate pieces left and right loaded
Bareilly, (U.P), India. for complete dentures prosthesis giving the with zinc oxide eugenol impression material.
history of surgery followed radiotherapy on the right side of the 8) After placement the sections of sectional tray were stabilized
cheek three years back due to carcinoma. Oral opening was found by means of preformed acrylic resin plate in patients mouth.
22mm (Fig1). Because of reduced oral opening, it was impossible 9) After impression material was set, the acrylic resin plates
in making accurate impressions with usual custom tray. So in this were removed first and the right and left sections of
patient, sectional custom tray using press buttons was planned for impression were removed separately from the oral cavity by
making final impression of maxilla and mandible with Zinc oxide carefully fracturing the impression material.(fig 7)
44
10) Then extraorally female component on acrylic resin plate 9. Ohkub C, Ohkubo C, Hosoi T, Kurtz KS .A sectional stock
reattached with the male components on sections of sectional tray system for making impressions.J Prosthet Dent
tray with help of press buttons and thus we get the final 2003;90(3):201-4.
impression.(fig 8,13) 10. Dhanasomboon S,Kiatsiriroj K.Impression procedure for a
11) Carefully determine that the fracture line was joined progressive sclerosis patient;A clinical report. J Prosthet
smoothly and then dental stone was poured to get master Dent 2000;83(3):279-282.
cast.
DISCUSSION
It is always problematic to make an accurate impression
with a complete maxillary and mandibular arch for patients with a
constricted oral opening9. Various pins, bolt and lego pieces,
orthodontic devices have been used for locking mechanism of
sectional impression trays fabricated for patients with limited oral
openings7 and fixation of all these devices into trays requires
expert work. Here sectional trays were reoriented in and outside
the oral cavity accurately using autopolymerizing acrylic plate by
press buttons system and the technique was simple.
The main advantages for making sectional tray are
decreased patient trauma and no tear down of impression during
removal, moreover these trays has easy accessibility in patients
mouth and are less costly and easy to fabricate. The disadvantages
are additional time required for precise fabrication of sectional
tray. Extreme care should be taken during reorientation of
sections of sectional impressions in and outside the oral cavity.
CONCLUSION
It is often difficult to apply conventional clinical
procedures in fabricating complete denture prosthesis for
microstomia patients who demonstrate limited oral opening.
However with careful treatment planning, the use of sectional
impression procedure, many of the apparent clinical difficulties
can be overcome10.
REFERENCES
1. Baker PS, Brandt RL,Boyajian G.Impression procedure for
patients with severely limited mouth opening .J Prosthet
Dent 2000;84(2):241-244.
2. Kumar KA, Bhat V, K. Nair .Preliminary Impression in
Microstomia patient :An innovative technique . J Prosthet
Dent 2013; 13(1): 52-55.
3. The Academy of Prosthodontics. Glossary of Prosthodontic
terms- 8. J Prosthet Dent 2005; 94(1):52.
4. Geckili C, Altung C, Biling T . Impression procedures and
construction of sectional dentures for a patient with
microstomia : A clinical report. J Prosthet Dent
2006;91(3):387-90.
5. Wahle JJ, Gardner K, Fiebger . The mandibular swing lock
design for a patient with microstomia. J Prosthet Dent 1992;
68(3):523-7.
6. Benntti R, Zupi A, Toffanin A . Prosthetic Rehabilitation of a
patient with Microstomia: A clinical report. J Prosthet Dent
2004;92(4)322-7.
7. Cura C, Cotert HS, User A . Fabrication of sectional
impression tray and sectional complete dentures for a patient
with microstomia and trismus: A clinical report. J Prosthet
Dent2003; 89(6) : 540- 3 Corresponding Address:
8. Geckili O,Cilinger A,Bilgin T. Impression procedure and Dr. Neha
Dr.Dilip
Dr. C.
Dr. Aggarwal
Kumar
Ram
KK Nath
Mohan
Dixit
construction of a sectional denture for a patient with
microstomia:A clinical report.J Prosthet Dent Email:
Email:
Email: dilip_nath2006@yahoo.co.in
2006;91(3):387-90
45
LIST OF PHOTOGRAPHS
Fig : 1- Mouth Opening = 22mm
Fig- 2,3,4- Sectional Special

Tray With Press Buttons
Fig : 2 Fig : 3 Fig : 4
Fig 5,6 - Border Fig 7,8 - Final ZOE

Molding Impression
Fig : 5 Fig : 6 Fig : 7 Fig : 8
MANDIBULAR SECTIONAL TRAY AND IMPRESSION
Fig9,10,11-sectional special
tray with press buttons
Fig : 9 Fig : 10 Fig : 11
Fig 12,13 final ZOE impression

Fig : 12 Fig : 13
Fig : 14
Fig 14,15- complete denture in patient mouth

Fig : 15
46
Telescopic Denture : A Case Report

Mayank Shah
Senior Lecturer, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
Abstract: Preventive prosthodontics emphasizes the importance of any procedure that can delay or eliminate
future prosthodontic problems. In the past when patients presented themselves as candidates for a denture with
teeth that were badly broken down with periodontal involvement or without the ability to financially support an
extensive restorative treatment, those teeth were extracted that could have been retained under more favorable
conditions. A telescopic denture is a prosthesis which consists of a primary coping which is cemented to the
abutments in a patient's mouth and a secondary coping which is attached to the prosthesis and which fits on the
primary coping. It thereby increases the retention and stability of the prosthesis. Retention of the roots of one or
more teeth for overdenture offers the patient a lot of advantages like better stability, proprioception, and support
among a few. Telescopic crowns were initially introduced as retainers for the removable partial dentures at the
beginning of the 20th century. They were also known as a Double crown, a crown and sleeve coping or as
Konuskrone. The following case report is on telescopic over denture for mandibular arch.
Key words : Telescopic Denture, Double Crown System, Primary Coping, Secondary Coping, Preventive
Prosthodontics, Wedging Effect.
INTRODUCTION protection from the movements that dislodge the denture.
A telescopic denture is a prosthesis which consists of a The double crown systems are usually distinguished
primary coping which is cemented to the abutments in a patient's from each other by their differing retention mechanisms.6 There
mouth and a secondary coping which is attached to the prosthesis are three different types of double crown systems. These are
and which fits on the primary coping. It thereby increases the telescopic crowns which-achieve retention by using friction, and
conical crowns or tapered telescope crowns which exhibit friction
retention and stability of the prosthesis.1 According to GPT, a only when they are completely seated by using a wedging
telescopic denture is also called as an overdenture, which is effect. The magnitude of the wedging effect is mainly
defined as any removable dental prosthesis that covers and rests determined by the convergence angle of the inner crown: the
on one or more of the remaining natural teeth, on the roots of the smaller the convergence angle, the greater is the retentive force.
natural teeth, and/or on the dental implants. It is also called as The double crown with a clearance fit (also referred to as a hybrid
telescope or a hybrid double crown) exhibits no friction or
overlay denture, overlay prosthesis, and superimposed wedging during its insertion or removal. The retention is achieved
prosthesis.2 by using additional attachments or functional molded denture
Preventive prosthodontics emphasizes the importance borders.
of any procedure that can delay or eliminate future prosthodontics The telescopic denture which was supported by the
problems. The overdenture is a logical method for the dentist to natural teeth gained significant popularity as an alternative to the
use in preventive prosthodontics.3 Overdenture therapy is conventional dentures during the 1970s and the 1980s. The
essentially a preventive prosthodontic concept since it attempts to retained teeth that support the overdentures, preserve the bone
conserve the few remaining natural teeth. There are two and they minimize the downward and forward settling of a
physiologic tenets related to this therapy: the first concerns the denture, which otherwise occurs with alveolar bone resorption.
continued preservation of alveolar bone around the retained teeth4 The overdenture occlusion is maintained rather than shifting
while the second relates to the continuing presence of periodontal forward to simulate the appearance of a prognathic mandible.4
sensory mechanisms5 that guide and monitor gnathodynamic The telescopic denture philosophy postulated a transfer
functions. of occlusal forces to the alveolar bone through the periodontal
Telescopic crowns were initially introduced as retainers ligament of the retained roots. A proprioceptive feedback from
for the removable partial dentures at the beginning of the 20th the periodontal ligament prevents the occlusal overload and it
consequently avoids the residual ridge resorption which is
century. They were also known as a Double crown, a crown and adjacent to the roots and the rest of the ridge, due to excessive
sleeve coping or as Konuskrone,1 a German term that described a forces. They also provide improved functions as compared to the
cone shaped design. These crowns are an effective means for conventional dentures, such as an improved biting force, chewing
retaining the RPDs and dentures. They transfer forces along the efficiency and even phonetics. The impairment of these
ling axis of the abutment teeth and provide guidance, support and functional parameters which are created by edentulism reflects
47
the significant role of the periodontal receptors for a sensory DISCUSSION
feedback and a discriminatory ability from the retained roots. Telescopic crowns have been used mainly in RPDs to
Tooth loss results in loss of the proprioception mechanism that connect dentures to the remaining dentition7, but these can be
has been a part of the sensory programme throughout life.2 used effectively to retain complete dentures which receive their
support partly from the abutments and partly from the underlying
CASE REPORT residual tissues. Telescopic crowns have also been used
A 56-years old male reported to the department of successfully in RPDs and FPDs, supported by endosseous
Prosthodontics with the chief complaint of difficulty in chewing implants, in combination with the natural teeth, which includes
due to the missing lower teeth. On intraoral examination all teeth the overdentures.8,9
were present in upper arch except 16, 21, 22 and the teeth present Telescopic crows can also be used as effective direct
in lower arch were 38, 48. The teeth present were firm with retainers for RPD. Their degree of retention can be planned to suit
generalized abrasion in relation to maxillary teeth. The different situations by modifying their designs. The amount of
mandibular edentulous span had favorable ridge with firmly intersurface friction depends on the configuration of the taper
attached keratinized mucosa. Further determination of the angle and the area of the surface contact. One of the main
vertical dimension of occlusion (VDO) was achieved using advantages of the telescopic retainers is that, being pericoronal
Phonetics, Swallowing, patient preferences and facial devices, they transmit the occlusal forces in the direction of the
appearance. It was determined that there was loss of VDO and the long axes of the abutment teeth. This has proven to be the least
TMJ was normal (Fig1). damaging application force. The lateral forces exert traumatic
The treatment plan decided was to fabricate a pressure on the abutments.10
mandibular telescopic denture and a maxillary interim prosthesis. Careful assessment of the interarch space is very
important for the successful fabrication of the telescopic
After the intentional root canal treatment of the abutments 38 and
dentures. Sufficient space must be present to accommodate the
48, they were prepared with a tapered round end diamond rotary primary and secondary copings, to have a sufficient denture base
bur with a chamfer finish line for the primary coping. The thickness to avoid fracture, space for the arrangement of the teeth
abutments had to be prepared almost parallel with the minimum to fulfill the aesthetic requirements and to have an interocclusal
taper for a better retention. After the preparation of the abutments, gap. The space consideration usually requires the devitalization
of the abutments. The selected abutments should be periodontally
the impression was made by using a polyvinyl siloxane
sound with adequate bone support and no/ minimal mobility.
elastomeric impression material (putty and light body) by a There should be at least one healthy abutment in each quadrant.
double step putty wash technique. The impression was poured An even distribution of the abutment in each quadrant of the arch
into a die material to obtain the cast, on which the primary copings is preferable for better stress distribution and for increased
were fabricated. The fit of the primary coping was evaluated in the retention and stability of the prosthesis. The interocclusal gap/
interarch distance should be 10 mm, in order to have sufficient
patient's mouth, after which they were cemented on the abutments
space for the copings, denture base, teeth placement and adequate
with glass ionomer cement. Another impression was made by a closest speaking space.11
double step putty wash technique after the cementation of the The telescopic dentures which are supported by the
primary copings, by using a custom acrylic resin tray to obtain a roots of natural teeth have more predictable prosthodontic
cast on which the secondary copings attached with the metal outcomes because of increased support, stability and retention
and decrease in rate of the residual ridge resorption. Patients with
framework were fabricated (Fig2,3) The fit of the metal
natural teeth can masticate more effectively than when they are
framework with secondary copings over the primary copings was edentulous. This is due in part to their degree of accuracy in the
evaluated in the patient's mouth. The frictional contact between functional jaw movements, which are possible with a better
the primary and secondary copings helped in the retention of the neuromuscular feedback mechanism from the periodontal
prosthesis. ligaments. The proprioceptive nerve endings in the periodontal
The metal framework had to be placed on the cast, it had ligaments feed information into the neuromuscular mechanism.
to be covered with wax and the special tray for border moulding In the absence of teeth, this information is missing. By retaining
and final impression, had to be fabricated with chemically cured the roots of some teeth, it may be possible to use this
acrylic resins after applying separating media over the cast. After proprioceptive apparatus with complete dentures.9 If this is so, a
the final impression was made, the master cast was obtained and higher degree of accuracy in the jaw movements and the
occlusion rims were fabricated over the trial denture base. masticatory performance could result. By this means, teeth that
Horizontal and vertical maxillomandibular records were obtained normally might have a very short life span can be retained for long
with the record bases and the occlusion rims and these were periods of time. This can thus benefit the patients in their denture
transferred to a semiadjustable articulator by using a face bow. function.
The artificial teeth were selected and arranged on the record bases It has been found that telescopic dentures have better
for a trial denture arrangement and they were evaluated retention, stability, support and chewing efficiency as compared
intraorally for phonetics, aesthetics, occlusal vertical dimension to the conventional complete dentures and also, there is a
and centric relation. After the wax up, the dentures were decrease in the rate of the residual ridge resorption because of
processed, finished, polished and delivered to the patient proprioception, better stress distribution and the transfer of
(Fig4,5). The patient was scheduled for follow-up visits every 3 compressive forces into the tensile forces by the periodontal
months and he reported no complaints during the 2 years of ligament, which effects rate of bone remodeling. A clinical study
follow-up (Fig6,7). which was conducted by Bo Bergman et al on conical crown
48
retained dentures, concluded that most of the patients were very
satisfied with the restorations, both functionally and aesthetically
and it found their chewing comfort to be better after the treatment
with the conical crown-retained dentures.12
Complete denture fabrication for maladaptive elderly
patients becomes difficult. Therefore, they are the group of
patients who will benefit most with telescopic dentures.
Overdentures which are supported and/or retained with a few
remaining teeth or implants can be a predictable treatment that
will fulfill most of the demands of the elderly denture patients.
CONCLUSION
Tooth-supported, removable over dentures with
telescopic crowns may be considered as a good alternative to the
conventional removable dentures, because they provide better
retention, stability, support, stable occlusion, decrease in the
forward sliding of the prosthesis and better control of the
mandibular movements because of the proprioception feedback
which increases the chewing efficiency and even phonetics, as
compared to the conventional complete dentures. Also, the rate of
the residual ridge resorption was decreased because of the transfer
of compressive forces into the tensile forces by the periodontal
ligament and better stress distribution.
REFERENCES
1. Langer Y, Langer A. Tooth supported telescopic prostheses in
compromised dentitions: A clinical report. J. Prosthet Dent.
2000; 84: 129-32.
2. Glossary of Prosthodontic terms. J Prosthet Dent 2005; 94:
10-92
3. John J Sharry. Complete Denture Prosthodontics. Third
edition, New York, McGraw-Hill Book Co., 1974.
4. Prince IB. Conservation of the supporting mechanism. J
Prosthet Dent 1965; 15: 327.
5. Yalisove IL. Crown and sleeve coping retainers for
removable partial prosthesis. J Prosthet Dent 1966; 16: 1069-
85.
6. Wenz HJ, Lehmann KM. A telescopic crown concept for the
restoration of the partially endentulous arch: the Marburg
double crown system. Int J Prosthodont 1998;11:54150.
7. Langer A. Telescope retainers for removable partial dentures.
J Prosthet Dent 1981;45:37-43.
8. Laufer BZ, Gross M. Splinting osseointegrated implants and
natural teeth in the rehabilitation of partially edentulous
patients. Part II: principles and applications. J Oral Rehabil
1998;25:69-80.
9. Besimo C, Graber G. A new concept of overdentures with
telescope crowns on osseointegrated implants. Int J
Periodontics Restorative Dent 1994;14:486-95.
10. Langer A. Telescope retainers and their clinical applications.
J Prosthet Dent 1980;44:516-22.
11. Preiskel H W. Overdenture made easy a guide to implant
and root supported prostheses 61: Quintessence Publishing
Co. Ltd. London.
12. Bergman B, Ericson , Molin M Long-term clinical results
after treatment with conical crown-retained dentures. Int J
Prosthodont 1996;9:53339. Corresponding Address:
Dr.Dr.
Dr.
Dr. Mayank
Neha
C. Ram Shah
KKAggarwal
Mohan
Dixit
Email:
Email: mashdreams33@gmail.com
49
LIST OF PHOTOGRAPHS
Fig 1: Pre Operative Intra Oral View Fig 2: Wax Pattern
Fig 3: Tooth Supported Metal Framework Fig 4: Mandibular Telescopic Denture
Fig 5: Intra Oral View of Prosthesis Fig 6: Post Operative Intra Oral View
Fig 7: Post Operative Extra Oral View
50
Bilateral Maxillary Second Molar With Two Palatal Roots : A Case Report

C. Ram Mohan , C. Krishna Chaitanya , Hari Deva Raya Choudary , Sainath Reddy
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad.
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad.
Senior Lecturer, Department of Conservative Dentistry and Endodontics, S.V.S. Institute of Dental sciences, Mahboobnagar.
Abstract: Variations in root number and canal morphology are challenges for successful endodontic therapy.
Unusual root and root canal morphologies associated with both buccal roots of upper molars have been
recorded in several studies in the literature. However, scientific information focusing on variations of the
palatal root is rare. This case report describes presence of two palatal roots in maxillary second molar of the
same patient bilaterally, a rare entity, diagnosed and confirmed with the help of spiral computed tomography.
Key words : Maxillary Second Molar, Number of Canals, Number of Roots, Computed Tomography, Buccal, Palatal.
INTRODUCTION Analytic Technology, Glendora, CA) was indicative of

The majority of endodontic literature is replete with root irreversible pulp damage. After extensive clinical and
canal anatomy of maxillary first molar and there are relatively few radiographic examination, the maxillary right second molar was
studies reporting the root canal anatomy of maxillary second prepared for nonsurgical endodontic therapy. A preoperative
molar. Wong et al1 reinforced the importance of knowing the radiograph was obtained which revealed the presence of two
anatomical variations of maxillary molars when he reported a independant palatal roots (fig 1), which were relatively broad,
case of a maxillary first molar with the palatal canal trifurcating at presenting two distinct foramina at the apical level. This
the apical level, with three independent foramina. indicated a type I tooth, according to the classification of Christie
The commonest occurrence of two palatal canals in et al2. Spiral CT was used to determine morphology of root
double palatal roots (21/24 teeth) was found in maxillary second canals. CT scan was done with a multi-detector CT scanner (16
molar(Christie et al2). Anamoly seemed to occur as: slices/second). slices were obtained at different levels to
1. Two palatal roots being long and divergent determine the canal morphology. CT confirmed the presence of
2. Two palatal roots being shorter, nearly parallel and four totally separated roots, each with a distinct root canal. The
comparable to 2 buccal roots striking feature noted in CT was that maxillary left second molar
3. Variation of root fusion that included a two canal system on also had four roots (fig. 2).
the palatal aspect. The patient received local anesthesia of 2% lidocaine
Benenati3, Barbizam et al4 reported a maxillary second with 1:100,000 epinephrine. A rubber dam was placed, and a
molar with two palatal roots. Fava et al5 reported the presence of conventional endodontic access opening was made. The
just one canal and one root in the second maxillary molars of the conventional triangular access was modified to a trapezoidal
same patient. while Alani6 encountered four roots in the second shape to improve access to additional canal. After removing the
maxillary molars of the same patient bilaterally. Baratto - Filho et coronal pulp and probing with a DG16 endodontic explorer, four
al7 carried out an in vitro study of two maxillary second molars principal root canal orifices mesiobuccal, distobuccal,
with four canals and two different palatal roots. mesiopalatal and distopalatal. The working length of each canal
Libfield and Rostein8 1989 examined 1200 molar and was estimated by means of an apex locator (Root ZX : Morita,
found 0.4% incidence of maxillary molar with four roots, while Tokyo, Japan), and confirmed with intra oral periapical
Peikoff et al9 1996 observed that 1.4% of maxillary molars may radiograph (fig 3). The canals were initially instrumented with
have second palatal roots. #15 nickel titanium files (Dentsply Maillefer) under irrigation
The present case report confirms the presence of 2 with 3% sodium hypochlorite. Biomechanical preparation was
separate palatal roots in maxillary second molar with the help of a performed using the crown down technique with nickel
spiral Computed Tomography. titanium rotary instruments (Protaper rotary files, Dentsply
Maillefer). Palatal canals were enlarged upto F5 and
CASE REPORT mesiobuccal and distobuccal canals were enlarged upto F3 file.
A 45 year old female presented with pain, both Master cone radiograph was taken (fig 4). Final irrigation with
spontaneous and temperature related, on the right side of the face 17% EDTA followed by 3% sodium hypochlorite and sealing of
for several days. The patients medical history was root canal space with gutta percha and AH plus resin sealer using
noncontributory. Clinically the right maxillary second molar had lateral condensation technique and tooth was restored with a
a deep carious lesion. Electric pulp testing (Vitality Scanner; posterior composite filling (fig 5). The patient was followed up
51
for 6 months postoperatively and was found to be asymptomatic. second molar; Literature review and radiographic survey of
DISCUSSION 1200 teeth. J Endod 1989;15;129-31.
Unusual canal anatomy of maxillary molars has been 9. Peikoff MD, Christie WH, Fogel HM. The maxillary second
investigated in several studies. Most of the studies were based on molar: Variations in the number of roots and canals. Int
radiographic examination of the teeth which is 2-dimensional Endod J. 1996;29:3659.
view of a 3 dimensional object. Tachibana and Matsumoto10 10. Tachibana H, Matsumoto K. Applicability of x-ray
studied the applicability of CT to endodontics. They concluded computerized tomography in endodontics. Endod Dent
that this method allowed the observation of the morphology of the Traumatol 1990;6;16-20.
root canals, the roots, and the appearance of the tooth in every 11. Christoph GD, Wilfried GH, Engel, Britta R, Hermann KP,
direction. Moreover, the image could be analyzed, altered, and Oestmann JW< Must radiation dose for ct of the maxilla and
reconstructed by the computer. mandible be higher than that for conventional panoramic
A major concern with use of CT scan is its high radiation dosage. radiography? Am Soc Neuroradiol 1996;96;1758-60.
In the present study, CT was done with a multi detector CT 12. Curzon ME. Miscegenation and the prevalence of three
scanner (16 slices/second), as per Christoph et al11 guidelines to rooted amndibular first molars in the Baffin Eskimo.
reduce the radiation dosage. Community Dent Oral Epidemol 1974;2;130-1.
Curzon12 suggests that additional rooted molar trait has high
degree of genetic penetrance. Supernumerary root formation
could be related to external factors during odontogenesis or
penetrance of atavistic gene.
Additional root may be suspected when indistinct images of
palatal roots are presented in preoperative X-ray images, the
clinician must consider the possibility of two palatal roots.
Dissociation of images must be performed and, if this anamoly is
confirmed, a broad coronal access will allow the correct
localization of root canals. Also clinically, cervical prominence
or an extra cusp associated with cervical prominence on a tooth
point towards presence of extra root.
CONCLUSION
The four rooted anatomy in maxillary molars is very rare and is
more likely to occur in the second or third maxillary molar.
Careful examination of radiographs and internal anatomy is
essential. Although such cases occur infrequently, clinician
should be careful while considering endodontic treatment of a
maxillary molar, as these undetected extra roots or root canals are
a major reason for the failure. Hence the ability to locate all the
canals in the root canal system is an important factor in
determining the eventual success of a case.
REFRENCES
1. Wong M. Maxillary first molar with three palatal canals. J
Endod 1991;17;298-9.
2. Christie WH, Peikoff MD, Fugel HM. Maxillary molar with
two palatal root a retrospective clinical study. J Endod
1991;17;80-4.
3. Benenati Maxillary second molar with two palatal canals and
a palatogingival groove. J Endod 1994;11;308-10.
4. Fava LR, Weinfeld I, Fabri FP, Pais CR. Four secondmolars
with single roots and single canals in the samepatient. Int
Endod J. 2000;33:13842.
5. Barbizam JV, Ribeiro RG, Tanomaru Filho M.
Unusualanatomy of permanent maxillary molars. J Endod.
2004;30:668702.
6. Alani AH. Endodontic treatment of bilaterally occurring 4-
rooted maxillary second molars: Case report. J Can Dent
Assoc. 2003;69:7335.
7. Baratto-Filho F, Fariniuk LF, Ferreira EI, Pecora JD, Cruz- Corresponding Address:
Filho AM, Sousa-Neto MD. Clinical and macroscopic study Dr. C. Ram Mohan
of maxillary molars with two palatal roots. Int Endod J. Email: dr_rammohanc@yahoo.co.in
2002;35:796801.
8. Libfield H, Rostein I. Incidence of four rooted maxillary
52
LIST OF PHOTOGRAPHS
Fig: 1 Pre- Operative Radiograph Fig: 2 CBCT Image
Fig: 3 Working Length Radiograph Fig: 4 Master Cone Radiograph
Fig: 5 Post Obturation Radiograph
53
Journal of Dental
Sciences & Oral Rehabilitation
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Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

JOURNAL OF DENTAL SCIENCES & ORAL REHABILITATION

Editorial Board Members :

Published Quarterly By Institute of Dental Sciences, Bareilly

I congratulate the editorial team for bringing out a good

Dr. S.R. PANAT

Greetings to all the readers from editorial team we present our

Many Stalwarts of our specialty have joined hands with us as

I take this opportunity to thank all our contributors, college

Dr. ANURAAG GURTU

Role of GCF As Potential Biomarker in the Diagnosis of Periodontal Disease

Key words : Periodontitis, Dental Plaque, GCF, Biomarker.

Cone Beam Computed Tomography

Key words : Cone Beam, Radiology, Medicine, Implantology, Orthodontic.

Fig 1 CBCT Machine

Fig 2 CBCT Image

Nanotechnology : Its Implications in Conservative Dentistry and Endodontics

Abstract: Feynman postulated concept of nanotechnology as an unavoidable development in the progress of

Key words : Nanotechnology, Nanodentistry, Nanocomposites; Dentifrobots, Nanosolution.

Fig 1: Comparison of nanoparicle with water molecule and tennis ball

Fig.3 Nanorobots in local anaesthetic solution

Flapless Implant Surgery : An Overview

Key words : Flapless, Minimally Invasive, One-Stage, Tissue Punch.

Figure 1- Drill used for Flapless Implant Surgery

Fig: 2 Pre- Treatment Photograph Fig: 3 Post- Treatment Photograph

Fluorides and Their Role in Demineralization and Remineralization

Key words : Demineralzsation, Remineralization, Fluorides.

INTRODUCTION Rationale for De / Remineralization

Pit and fissure sealants

Bacterial Quantification in teeth with Apical Periodontitis Related to

Evaluation of the Root Canal Morphology of Mandibular First Premolars

Key words : Mandibular First Premolar, Root Canal , Morphology , CT Scan .

CASE REPORTS OF MANDIBULAR FIRST PREMOLAR ANOMALIES3

M oayedi and Lata 3 canals (DB, DLi, and M) and an MB root

COMPARISON OF THE PRESENT POPULATION STUDY WITH THE STUDIES PERFORMED ON

CORONAL -------------------------------------------------- APICAL

CORONAL -------------------------------------------------- APICAL

Type III (1-2-1)

CORONAL -------------------------------------------------- APICAL

CORONAL -------------------------------------------------- APICAL

Sialolithiasis: A Case Series

Key words : Submandibular Salivary Gland, Sialolith, Warthon's Duct.

Fig: 1 Facial view of the patient

Fig: 2 Intraoral view Fig: 3 Mandibular occlusal

Fig: 4 Radiograph Showing Fig: 5 Intra Oral Photograph

Maxillary Canine With Two Root Canals : A Case Report

Fig: 1 Pre - Operative IOPAR Fig:2 Working Length Estimation

Fig:3 Master Cone IOPAR Fig: 4 Post Obturation IOPAR

Denuded Root - is Free Gingival Graft an Answer : A Case Report

Fig 1- Gingival Recession Fig 2- Preparation of Fig 3-The donor site

Complication of a Dental Extraction: Osteomyelitis : A Case Report

Key words : Osteomyelitis, Extraction, Mandible.

Fig:1 Intra Oral Photograph

Eagles Syndrome : A Case Report

Key words : Styloid process, Stylohyoid Ligament, Facial Neuralgia, Ossification.

Fig : 1 Elongation of styloid process

A Modified Sectional Custom Tray for Making Master Impression in

Key words : Sectional , Microstomia , Press Buttons , Constricted, Reorientation.

Fig : 1- Mouth Opening = 22mm

Fig- 2,3,4- Sectional Special

Fig 5,6 - Border Fig 7,8 - Final ZOE

MANDIBULAR SECTIONAL TRAY AND IMPRESSION

Fig 12,13 final ZOE impression