Narayana Journal of Research in Dental Specialties

Official Journal of
NARAYANA DENTAL COLLEGEEGE & HOSPITAL
Narayana Medical Campus, Chinthareddypalem, Nellore--524003, Andhra Pradesh, India.
Phone: +91-861-2313841
+91 Ext.2802; Fax: +91-861--2305092; +919490471078
email: dentkan1@gmail.com, ndc2001@gmail.com

Narayana Journal of
Research in Dental
Specialties

ISSN No. : 0976-6871

0976 EDITOR
EDITOR- IN CHIEF
Professor (Dr.) N. Kannan

Professor (Dr.) N.Kannan is presently working as the Professor and

Chief Editor
Dr. N. Kannan
Associate Editors
Dr. S. Gowrisankar
Dr. S.V.G.S. Nirmala
Dr. Rakesh Kumar Manne
Dr. Lavanya Suneel Kumar
Sub Editors
Dr. Swetha Taneeru
Dr. Sridhar Reddy
Head, Department of Oral Medicine and Maxillofacial Imageology in
Narayana Dental College and Hospital, Nellore
Nellore,, Andhra Pradesh, India
since February 2006. He presently has 20years of under undergraduate
graduate and
post graduate teaching experience in the specialty of Oral Medicine
and Maxillofacial Imageology.
He did his graduation from the Government Dental College,
Hyderabad in 1991 and his post graduation in the specialty of Oral
Medicine and Radiology gy from S.D.M. College of Dental Sciences,
Dharwad in 1995. He has done Diploma in Business Management
from ICFAI, Tripura, Diploma in Hospital Management from NIHFW,
New Delhi, M Sc. Biotechnology from Periyar University, Salem. He
is a registered TII specialist.
cialist. He is also a master in Reiki Therapy and
Pranic Healing. He has been office bearer of the Indian Academy of
Oral Medicine and radiology in various capacities as Joint Secretary,
E.C. Member, Vice-President
President and Hon. General Secretary. He is
recognized
zed as post graduate teacher and examiner in several
universities across the country. He is a life member of I.D.A.,
I.A.O.M.R., I.A.F.O., I.S.D.R., I.A.D.M.F.R., and I.S.R.P. He has
several publications in National and International Journals. He has
guidedd more than 50 post graduate students in the specialty of Oral
Medicine and Radiology.

Vol I Issue 1 JANUARY JUNE 2015

 Narayana Journal of Research in Dental Specialties
VOL. 1 ISSUE 1 JANUARY - JUNE 2015
Contents

Editorial
Editorial Advisory Boards
ICMJE Recommendations

Original articles

1. A Study on Prescription of Antibiotics by Dental Surgeons in 1-6

Nellore.
Lavanya Dalasari, Natarajan Kannan, Rakesh Kumar Manne, Prathi Venkata Sarath,
Swapna Sreedevi Beeraka, .Koliparthi Venkata Suneel

2. Knowledge, attitude, and practice of ENT Specialists 7-12

Oral (mucosal) potentially malignant disorders:

a cross sectional study
Sai Neelima, Rakesh Kumar Manne, Natarajan Kannan, Swapna Sreedevi Beeraka,
Prathi Venkata Sarath , Koliparthi Venkata Suneel

3. Relationship Between Lingual Frenulum And Craniofacial 13-19

Morphology in Adults
Sonika Priyadarshan, Ashutosh Shetty, Vivek Bhaskar, U.S. Krishna Nayak

4. Comparative Evaluation of Fracture Resistance of Marginal 20-23

Ridge In Tunnel Cavities Restored with Three Different Materials

Madhusudhana Koppolu, Deepthi Mandava, Dorasani Gogala, Shivaram Penigalapati,
Suneelkumar Chinni, Anumula Lavanya

Case Reports

5. Hollow denture a case report 24-30

Keerthi GK , Mahesh P, Divya Jyothi G

6. AOT arising from Dentigerous Cyst- A report of 3 rare cases 31-37

Ramya.D, Vandana Raghunath, Ajay Reginald, Firoz Kamal

Review Articles

7. Mandibular Distraction Osteogenesis 38-43

Venkata Naidu Bhavikati, Venkatesh Nettam, Mandava Prasad

8. Perinatal Oral Health Care 44-45

Naveen Kumar Kolli, . Nirmala SVSG

9. Advances in Periodontal Probes 46-50

Swetha Taneeru, .Vijay Kumar Chava
i Vol I Issue 1 JANUARY JUNE 2015
 INSTITUTIONAL EDITORIAL ADVISORY BOARD
Dr. Pulagam Mahesh Nellore Dr. Sivakumar Nuvvula Nellore
Dr. Vijay Kumar Chava Nellore Dr. Koppolu Madhusudana Nellore
Dr. Mandava Prasad Nellore Dr. Satyakumar Reddy Nellore
Dr. Vandana Raghunath Nellore Dr. Chandrasekhar Nellore

INTERNATIONAL EDITORIAL ADVISORY BOARD

Dr.Kamalamma G Pillai U.S.A. Dr.Preethi Chitgopekar U.S.A.

NON INSTITUTIONAL EDITORIAL REVIEW BOARD

Oral Medicine and Radiology
Dr.K.S.Ganapathy Bangalore Dr.Venkatesh Naik Masur Dharwad
Dr.Anjana Bagewadi Belgaum Dr.Keerthilatha Pai Manipal

Prosthodontics and Implantology

Dr.Mahesh Verma New Delhi Dr.K.Mahendranath Reddy Hyderabad Dr.Ramesh Nadiger Dharwad
---------------------------------------------------------------------------------------------------------------------------------------------------------
Pedodontics and Preventive Dentistry
Dr.Nikhil Srivastava Meerut Dr.Anand Shigli Pune Dr.M.S.Muthu Chennai

Public Health Dentistry

Dr.K.V.V.Prasad Dharwad Dr.Naveen Ingle Mathura Dr.Suhas Kulkarni Hyderabad
Periodontics
Dr.Srinath Thakur Dharwad Dr.Faizuddin Bangalore
Dr.Raja Murthy Visakhapatnam Dr.Narasimha Swamy Guntur
Orthodontics and Dentofacial Orthopedics

Dr.U.S.Krishna Nayak Mangalore Dr.Gangadhar Prasad Visakhapatnam

Dr.Satheesh Reddy Hyderabad Dr.Gurkeerat Singh New Delhi
Oral and Maxillofacial Surgery
Dr.Kumaravelu Chennai Dr.L.Krishna Prasad Guntur
Dr.Thangavelu Annamalai Dr.Muthusekhar Chennai
Dr.Chandrakantha Rao Hyderabad
Conservative Dentistry & Endodontics
Dr.Muralimohan Vijayawada Dr.Balaram Naik Dharwad
Dr.Karunakar Reddy Hyderabad Dr.N Sasidhar Vijayawada
Oral Pathology and Microbiology
Dr.Sivapathasundaram Chennai Dr.Alka Kale Belgaum Dr.Mandana Donoghues Davangere
Forensic Odontology
Dr.Ashith Acharya Dharwad Dr.B.V.Subrahmanyam Nellore

ii Vol I Issue 1 JANUARY JUNE 2015

 ICMJE RECOMMENDATIONS REVIEWER FORM

Originality : Are the problems discussed in the article new?

Poor Needs improvements Good Excellent
Significance : Does the article have a considerable contribution to a certain area of research?
Poor Needs improvements Good Excellent
Relevance: Does the article present relevant information for its area of research?
Poor Needs improvements Good Excellent
Presentation : Does the article have a logic structure?
Is the article correctly written (from the grammar point of view)?
Does the article present in an appropriate way the terminology for its area of interest?
Poor Needs improvements Good Excellent
Title : Does the title clearly express the content of the article?
Poor Needs improvements Good Excellent
Abstract : Does the abstract describe the research and the results?
Poor Needs improvements Good Excellent
Introduction :
Does the introduction correctly highlight the current concerns in the area?
Does the introduction specify the research objectives?
Poor Needs improvements Good Excellent
Methodology :
Are the methods used clearly explained?
Are the data and statistics used reliable?
Poor Needs improvements Good Excellent
Results
Are the results clearly presented?
The results sufficiently avoid misinterpretation?
Poor Needs improvements Good Excellent
Conclusions : Are the conclusions correctly / logically explained?
Poor Needs improvements Good Excellent
References
Do the references reflect the latest work/research in the considered area?
Are the references properly indexed and recorded in the bibliography?
Poor Needs improvements Good Excellent
Tables
Should correctly indicate the measuring units and the source?
Are the tables correctly named and numbered?
Are the data presented in tables correctly valued and interpreted in the article?
Poor Needs improvements Good Excellent
Graphs and figures
Graphs and figures should be properly illustrate the discussed subject
Are the graphs and figures correctly named and numbered?
Poor Needs improvements Good Excellent
PLAGIARISM
Accepted Rejected
Comments to the Author
...................................................................................................................................................................................
...................................................................................................................................................................................

Comments to the Editor

...................................................................................................................................................................................
iii Vol I Issue 1 JANUARY JUNE 2015
 Narayana Journal of Research in Dental Specialties

The Narayana Journal of Research in Dental Specialties (NAJORDS) aims to provide platform for publication of
original research papers in all dental specialties.

Topics intended to be covered include the management of oral mucosal diseases, periodontal diseases, pulpal
diseases, all types of restorative dental treatments, dental biomaterials science, clinical trials including
epidemiology and oral health, new scientific instrumentation or procedures, as well as clinically relevant oral
biology and translational research.

Narayana Journal of Research in Dental Specialties (NAJORDS) is a peer-reviewed, journal that publishes original
research articles, review articles, and clinical studies in all areas of dentistry, including Periodontal diseases, Dental
Implants, Oral Medicine, Maxillofacial Radiology, Orthodontics, Oral Pathology, Pedodontia, Prosthodontics, Public
Health Dentistry and Oral and Maxillofacial Surgery.

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iv Vol I Issue 1 JANUARY JUNE 2015

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v Vol I Issue 1 JANUARY JUNE 2015

 Narayana Journal of Research in Dental Specialties (NAJORDS)
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vi Vol I Issue 1 JANUARY JUNE 2015
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vii Vol I Issue 1 JANUARY JUNE 2015
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Original articles Narayana Journal of Research in Dental Specialties

A KAP STUDY ON PRESCRIPTION OF ANTIBIOTICS

BY DENTAL PRACTITIONERS IN NELLORE

1 1
Lavanya Dalasari Post graduate student
2 2
Natarajan Kannan Professor and Head
3 3
Rakesh Kumar Manne Reader
4 4
Prathi Venkata Sarath Reader
5 5
Swapna Sreedevi Beeraka Reader
6 6
Koliparthi Venkata Suneel Reader

1-6
Department of Oral Medicine and Radiology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh.

ABSTRACT:. Antibiotic are one of the most commonly prescribed medications by dentists all over the world. These are
usually prescribed for prophylactic or therapeutic purpose. Occasionally these are prescribed for therapeutic diagnosis.
Pharmacology is studied extensively by dentists in the second year of the B.D.S. and this knowledge is expected to be used
by them during their clinical postings in the later years of graduation and their clinical practice. The guidelines get modified
as a result of advancements in knowledge and advent of newer antibiotics. This study was intended to assess the levels of
awareness and updated knowledge regarding prescription of antibiotics among dental practitioners. The study revealed
considerable gaps between ideal and actual antibiotic prescription due to lack of appropriate knowledge updates.
Incorporation of guidelines for mandatory updating of knowledge for renewal of licence to practice would help in correcting
the anomaly and ensure proper antibiotic prescriptions.

KEYWORDS: Antibiotics, prescription, Dental practitioners, Updates , pharmacology, Odontogenic

INTRODUCTION

In India, the oral care infrastructure includes
1,80,000 dentists as of 2012, serving over one billion
12
population. These dentists are an important personnel,
other than the medical practitioners, who use the LIFE
SAVING DRUGS (The Antibiotics) in their day to day
practice for therapeutic and prophylactic purposes.
Scientific literature evidence suggests that dentists
prescribe around 7-11% of common antibiotics (beta
lactams, macrolides, tetracycline, clindamycin,
7
metronidazole). Studies revealed that 15% of the dentists
5
prescribe antibiotics on a daily basis.
The Irrational use of antibiotics will lead to an
increased burden on the patient and the society by
increasing treatment costs, adverse events and also the
10
risk of development of resistant bacterial species. In the
past 10 years, the incidence of penicillin resistance in
odontogenic infections in the UK has increased from 5% to
9
55%. Antibiotic abuse has already been considered as a
pandemic community issue by World Health Organization
18
(WHO). So WHO announced the theme for the year
2011 as Antibiotic resistance: No action today, No cure
7
tomorrow and has pressed for an international action.
Keeping all the problems of lack of knowledge on
the use of antibiotics based on previous studies showing
2-5
inappropriate use of antibiotics by dentists, over
1
prescription of prophylactic antibiotics. The aim of our
study is to determine the Antibiotic prescribing practices
for Dental diseases & to Evaluate the knowledge on
prescription of Prophylactic antibiotics among Dental
Practitioners in Nellore, Andhra Pradesh, India.
MATERIALS AND METHODS
A questionnaire was designed to assess dental
practitioners knowledge of prescribing antibiotics both
therapeutically, and prophylactically for their patients. The
proposed study was reviewed by the ethical committee of
the institution and clearance was obtained. A specially
prepared format exclusively designed for recording all the
required relevant general information and information
related to antibiotic prescribing patterns was used as a
tool for data collection.Voluntary, written informed consent
was obtained from each dentist who participated in this
study. The questionnaire was tested on a small group of
dentists by conducting a pilot study, to check the feasibility
and applicability. After the pilot study, necessary
corrections were made and the questionnaire was
finalized. The interviewer, in person carried the
questionnaire to the respective clinics and dental
practitioners marked the answers of their choice.
Criteria for inclusion in the study were dentists having a

Vol. I Issue 2 Jul - Dec 2015 1

Original articles Narayana Journal of Research in Dental Specialties
license for dental practice, and willing to participate in the
study. Exclusion criteria were unlicensed dental
practitioners and dentists unwilling to participate in the
study.
The first part of the questionnaire included details
regarding the type of practice, qualification of the dental
practitioners (BDS / MDS) , the most commonly prescribed
antibiotic, choice of antibiotic for pulpal, periodontal, space
infections and the duration of the prescription of the
antibiotic.
The second part of the questionnaire included
questions regarding the antibiotic to be prescribed when
the patient was allergic to penicillin for various infections
like pulpal, periodontal, periapical and space infections.
The third part of the questionnaire included
questions regarding the safe drugs to be prescribed in
pregnant and lactating patients. The last part of the
questionnaire included questions regarding cardiac
conditions that need antibiotics prophylactically, and the
dental procedures that needed the prescription of
prophylactic antibiotics.
All questions had space to mark a tick and
choose the answers. There were single options and 4
questions were given with multiple options as All the
Above / option 2 and 3 as required.
All returned forms were coded by a single
operator and the data were checked and entered twice in
a personal computer. Blank or multiple answers were all
treated as missing values. Only single unequivocal replies
were included in calculating percentages.
RESULTS
A total of 109 questionnaires were administered
to dental practitioners in Nellore. The questionnaires which
were incomplete were 8 in number and they were
excluded from the study. The age of the dental
practitioners ranged from 25yrs. to 40yrs.Amongst all the
participants, 73% had only private practice and 27% were
attached to an educational institution and also had a private
practice. 47% had a post graduate qualification while 53%
had a graduation. The demographic details of gender are
given in the table-I
DISCUSSION
The use of antibiotics can never be a substitute
1
for good surgical and septic operative techniques. The
unsystematic prescribing of antibiotics by health care
professionals is a major factor to be considered. Evidence
of the inappropriate use of antibiotics in dentistry has
increased and this could lead to the problem of
4
antimicrobial resistance.
Vol. I Issue 2 Jul - Dec 2015
The study was to investigate the knowledge of
antibiotics prescription amongst dental practitioners in
Nellore. The overall response rate was high. As the number of
dental practitioners in Nellore town were comparatively less
(108) it was reasonably easy for the interviewer to carry the
Questionnaire and wait for the response by the dental
practitioners. There was a request for all the questions to be
answered which lead to complete answers in almost all the
Questionnaires.
The results showed dental practitioners with post
graduation showing better scoring on use of Antibiotics as
there is significant increase in knowledge amongst dental
2
practitioners with post graduation as per Palmer et al. ,
7
karibasappa et al. .
The most commonly used antibiotic was
Amoxycillin in agreement with the study conducted by
1 3 4
Palmer et al. , Skucaite et al. , Vessal et al. , Antonio
5 7 9
et.al. , Karibasappa et.al. , kuriyama et al. , Palmer et
22
al. . Amoxycillin + Clavulanic Acid has a broader
spectrum of activity with lesser risk of development of
bacterial resistance but can be given for a shorter duration
3
of time. Some studies show they are being commonly
used as they are effective against most of the oral
1,7
microbes.
The duration of antibiotics in our study was
considered as 5 days by 48% and as 3 days by 46% of the
dental practitioners. It is a subject of ongoing debate as
shorter courses of antibiotics might aggravate the alarming
4
problem of antibiotic resistance. There are few countries
that prescribe for 5 days in order to eliminate the
5
infection. In recent years, more attention has been given
32
to short courses. Patients are reported to be partly
32-35
benefitted after 2 or 3 days of antibiotic therapy. There
are several advantages of short course therapy: increased
convenience, improved compliance, and improved
12,36
tolerability. Antibiotics should be used aggressively
and for as short period as is compatible with remission of
37
the disease. The ideal antibiotic duration is the shortest
time that will prevent both clinical and microbiological
relapse.
There were a total of 86% of dental practitioners
who prescribed Antibiotics if needed in pregnancy & 69%
of dental practitioners who prescribed in the lactating
mothers. Amoxycillin is one of the safest drug in them
26,27
belonging to category B in pregnancy and is safe in
28
lactating mothers. Pregnant women are usually given
medication doses and schedules identical to those of non
29
pregnant adults. This study 35% dental practitioners use
the regular dosage of antibiotics in pregnancy But some
suggest to keep the dosage at the lower end of the regular
28
range of drug .
The most common antibiotic used for pulpal
diseases observed in our study was amoxycillin +
clavulanic acid (47%) followed by amoxicillin(44%), while
2
Original articles Narayana Journal of Research in Dental Specialties

Table 1 Demographics of Study Population

Gender MALES FEMALES

63% 37%
Qualification MDS BDS
47% 53%
Type of Practice PRIVATE PRACTICE PRIVATE PRACTICE &
EDUCATIONAL INSTITUTION
73% 27%

Table 2 Factors Considered for Prescription of Antibiotic

Amoxicillin + Amoxicillin +
Most commonly Amoxicillin 38% Ofloxacin 11%
Clavulanic acid Metronidazole
prescribed Antibiotic
34% 17%

Varies as per the

Duration 5days 48% 3days 46% 7days 3%
disease 3%

Modification of Drug
Increase the The same dose
dose based on the
dose 43% 57%
Physical Build

Table 3 Prescribing antibiotics to pregnant and lactating patients

Prescription of
Routinely prescribed Avoid
Antibiotics in
86% antibiotics14%
Pregnancy

Safest Antibiotic in
Amoxycillin 50% Cephalosporins 5% Erythromycin 3%
pregnancy

Altered dose as per Unaltered dose

Decreased dose Increased
Alter the dose in severity 49% 35%
13% dose 3%
pregnancy

Prescription of
Antibiotics in Routinely prescribed Avoid antibiotics
Lactating mothers 69% 31%

Safest antibiotic in
Amoxycillin 50% Erythromycin 3% Cephalosporins 3%
Lactating mothers
All are safe 13%

Contraindicated
Cephalosporins
antibiotics in Ciprofloxacin 38% Both of them 29%
43%
lactating mothers

Vol. I Issue 2 Jul - Dec 2015 3

Original articles Narayana Journal of Research in Dental Specialties

Table 4. Commonly prescribed antibiotics for patients allergic to penicillin

Most commonly
prescribed Amoxycillin + Amoxycillin +
Amoxycillin 44%
Antibiotic in pulpal Clavulanic acid 47% Metronidazole 9%
diseases

Allergic to
Penicillin in pulpal Azithromycin 9% Cephalosporins11%
Erythromycin 76% Clindamycin 4%
diseases

Most commonly
prescribed Amoxycillin + Metronidazole 16%
Antibiotic in 32% Amoxycillin + Metronidazole 20% Clavulanic acid + Amoxycillin +
periodontal Clavulanic acid Metronidazole 19% Metronidazole13%
diseases

Allergic to
penicillin in
Erythromycin 56% Clindamycin 19% Cephalosporins 7%
periodontal Azithromycin 18%
diseases

Table. 5. Antibiotic Prescription for Space Infections

Antibiotic Amoxycillin + Metronidazole 29% Metronidazole + Amoxycillin 2%

prescribed Clavulanic acid 62% Clindamycin 5% Clindamycin 2%
commonly in
space infections

Allergy to Clindamycin 36% Azithromycin 21% Ofloxacin 4% Erythromycin 3%

Penicillin in space
infections

Table .6. Awareness of Prophylactic Antibiotics for Dental patients with Cardiac Diseases

Awareness on the cardiac Dental practitioners Unaware 94% Dental practitioners Aware 6%
conditions that need antibiotic
prophylaxis

Dental Procedures that require Dental practitioners Aware 84% Dental practitioners Unaware 16%
prophylaxis

there is gradually increasing use of clindamycin over

1 5,23
in most of the studies amoxycillin was most prescribed.
There is a lot of debate whether all pulpal infections need
an antibiotic coverage or it should be used as an adjunct
3,22
to conventional root canal therapy. Adjunctive
antibiotics should be prescribed to a very limited group of
patients, particularly those with specific clinical features or
4
evidence of gross local spread of infection.
In patients with allergy to penicillin, G. Vessal et
4 22
al. , Palmer et al. reported erythromycin as commonly
prescribed antibiotic similar to findings of our study. But
erythromycin as erythromycin, is not as effective
23
against anaerobes usually involved in dental infections.
Clindamycin is appropriate for penicillin allergic patients
even though, it is known that there is a higher risk of
23
pseudomembranous colitis than any other antibiotic.
Periodontitis, periodontal abscesses are treated
by local measures. A number of dental practitioners
4
prescribe Antibiotics for these conditions whereas in
some countries like England they would avoid antibiotics
22
for most of the periodontal diseases. Antibiotic

Vol. I Issue 2 Jul - Dec 2015 4

Original articles Narayana Journal of Research in Dental Specialties
prescribing should be exception rather than a rule and, in
majority of cases, considered only after the conventional
7
therapies have not been successful. In U.K. they are
primarily indicated for juvenile periodontitis, aggressive
periodontitis, large spreading infections, and systemic
.4,22
involvement
Antibiotics are commonly prescribed by the
4,7
dental practitioners for space infections. Amoxycillin was
4
the most commonly prescribed antibiotic. In case of
allergy to penicillin, Clindamycin was most commonly
prescribed but some dental practitioners tended to
4
prescribe erythromycin in case of allergy to penicillins.
There is inadequate knowledge on the cardiac
conditions that require antibiotic prophylaxis as per the
recent American Heart association 2015 with 94% being
unaware & 6% being aware in agreement with Palmer et
1 3
al. ,
The need for development on programs on
appropriate use of antibiotics against odontogenic
infections as there is poor understanding on use of
2
Antibiotics in dental practice as per Palmer et al. The
most important decision for the dental practitioner to make
is not which antibiotic to use but whether to use one at
23
all. When the decision is made to use an antibiotic, it is
important to adhere to basic principles of antibiotic dosing:
(a) use high doses for short durations; (b) use an oral
antibiotic loading dose; (c) achieve blood levels of the
antibiotic at 2 to 8 times the minimum inhibitory concentration;
(d) use frequent dosing intervals; and (e) determine duration
of therapy by remission of disease (8). The use of antibiotics
for minor infections, or in some cases in patients without
infections, could be a major contributor to the world problem
23
of antimicrobial resistance.
The limitations of our study are the presence of
20-25 questions in order to avoid a lengthy questionnaire
which tried to cover the common dental diseases but did
not specifically cover every possible infection.
It is recommended that knowledge of antibiotics
should be integrated with teaching about infections for
2
which they are used. As there is overuse of antibiotics
especially prophylactics antibiotics before surgical
1
procedures as per Palmer et al. , poor prescribing
30
knowledge amongst students in some dental colleges.
More use of antibiotics for all the dental procedure except
7
orthodontic treatment as per karibasappa et al. The
increasingly inappropriate prescription of antibiotics by
1,22,23,25
dental practitioners which is contributing to
.1,3,4
antibiotic resistance in the population The overuse
can be due to patients insistence on being prescribed
antibiotics for all conditions, even when uncertain about
22
diagnosis , high workload among busy practitioners and
3,5
lack of sufficient time allocation to a patient. There is a
clear need to re evaluate the teaching of antibiotic usage
to undergraduates to see that better guidelines are put into
2,4,22
practice. There is a need to conduct more number
CDE Programmes that will enhance the recent updates on
Vol. I Issue 2 Jul - Dec 2015
Antibiotic usage. Effective communication between
microbiologists and practitioners and the publication of
prescribing guidelines and protocols could help achieve
2,3
this. Prescription Audits conducted among the dental
practitioners leads to a reduction in number of faulty
2,4,8
prescription following introduction of guidelines.
23
Antibiotic therapy is an art and a science. There
are so many confounding variables, such as suspected
pathogen, ability to establish drainage, pharmacokinetic
properties of the drug, mechanism of action of the
antibiotic, virulence of the infection, the current health
status of the host, and host defense mechanisms, that it is
not possible to make antibiotic therapy into a mechanistic
24
technologic science. The most important decision for the
dental practitioner to make is not which antibiotic to use
5
but whether to use one at all. Trends of antibiotic
consumption should be monitored and recommendations
for antibiotic therapy should be updated periodically. .
Introducing guidelines and re-auditing after a few years
would be an important step in implementing rational
antibiotic use. Public needs to be educated at mass level
against self-medication with antibiotics and about
completing the entire course of antibiotics which will help
us in curbing antibiotic resistance to a greater extent.
REFERENCES
1. N. A. O. Palmer, R. Pealing ; A study of prophylactic
antibiotic prescribing in National Health Service
general dental practice in England ; British Dental
Journal, Vol 189, No. 1, July 8 2000
2. N. A. O. Palmer , M.V. Martin ; Antibiotic prescribing
knowledge of National Health Service General dental
practitioners in England and Scotland ; Journal of
Antimicrobial Chemotherapy , 47, 2001
3. Neringa Skuait , Vytaut Peiulien ; Antibiotic
prescription for treatment of endodontic pathology ;
Medicina (Kaunas) 2010;46(12):806-13
4. G. Vessal A. Khabiri ; Study of antibiotic prescribing
among dental practitioners in Shiraz, Islamic
Republic of Iran ; Eastern Mediterranean Health
Journal ; Vol. 17 No. 10 , 2011.
5. Antonio Rodriguez-Nunez , Rafael Cisneros-
Cabello ; Antibiotic Use by Members of the Spanish
Endodontic Society ; Journal of Endodontics ;
Volume 35, Number 9, September 2009
6. Dr. Karibasappa G.N, Dr.Sujatha A ; Antibiotic
Resistance A Concern for Dentists? ; Journal of
Dental and Medical Sciences; Vol 13, Issue 2 Ver.
IV. Feb. 2014
7. N. A. O. Palmer, Y. M. Dailey ; Can audit improve
antibiotic prescribing in general dental practice?
British Dental Journal; vol 191 no. 5 september 8
2001
8. T. Kuriyama,E. G. Absi ; An outcome audit of the
treatment of acute dentoalveolar infection: impact of
penicillin resistance ; British Dental Journal ; vol 198
no. 12 june 25 2005
5
Original articles Narayana Journal of Research in Dental Specialties
9. T. Kuriyama, E. G. Absi ; An outcome audit of the 25. An Investigation of antibiotic prescribing by general
treatment of acute dentoalveolar infection: impact of Dental practitioners : A pilot study : Prime Dental
penicillin resistance ; British Dental Journal ; vol 198 caries : 1997 J 11- 14 UKTIS ; Amoxicillin ; July
no. 12 june 25 2005 2012. Version: 2
10. Dr. Akilesh Ramasamy ; A review of use of 26. Krista et.al ; Antibacterial medication use during
antibiotics in dentistry and recommendations for pregnancy and risk of Birth defects ;Nov 2 , 2009 ,
rational antibiotic usage by dentists ; The vol 163 , No.11
International Arabic Journal of Antimicrobial agents ; 27. Benjamin Bar-Oz, Mordechai Bulkowstein ; Use of
Vol. 4 No. 2:1 2014. Antibiotic and Analgesic Drugs during Lactation ;
11. The Attitudes of Dentists Towards the Prescription Drug Safety ; Nov 2003, Vol 26, Issue 13, pp 925-
of Antibiotics During Endodontic Treatment in North 935 Nov 2012
of Saudi Arabia ; Journal of Clinical and Diagnostic 28. Joanne Cono, Janet D. Cragan ; Prophylaxis and
Research. 2015 May, Vol-9(5) Treatment of Pregnant Women for Emerging
12. Healthcare and Dental Industry in India Infections and Bioterrorism Emergencies ; Emerging
13. Ankita Jain, Dara John Bhaskar ; Drug prescription Infectious Diseases ; Vol. 12, No. 11, Nov 2006
awareness among the 3rd year and final year dental 29. Shivayogi Charantimath, Angel Dutta : Evaluating
students: A crosssectional survey ; Journal of knowledge, attitude among the interns from two
Indian Association Of Public Health Dentistry ; Vol. institution in belgaum district towards antibiotics ;
13, Issue 1, January-March 2015. international journal of pharmacology and
14. K. Pavan Kumar, Mamta Kaushik ; Antibiotic therapeutics ; Vol 3 Issue 3
Prescribing Habits of Dental Surgeons in
Hyderabad City, India, for Pulpal and Periapical
Pathologies: A Survey ; Advances in Corresponding Author
Pharmacological Sciences ; Vol : 2013
15. Characteristics and Cost Impact of Severe
Odontogenic Infections ; Dispatch May/June 2013
16. Shivayogi Charantimath, Angel Dutta ; Evaluating Dr. Lavanya Dalasari
Knowledge, Attitude among the interns from two Postgraduate student
institution in Belgaum district towards antibiotics ; Department of Oral Medicine and
International journal of Pharmacology and Radiology,
Therapeutic ; Vol 3 Issue 3 2013.
Narayana Dental College and
17. Rafael Poveda Roda 1, Jos Vicente Bagn ;
Antibiotic use in dental practice. A review ; Med Oral Hospital,
Path Oral Cir Bucal 2007; 12: Nellore, Andhra Pradesh
18. WHOs first global report on antibiotic resistance India-524003
reveals serious, worldwide threat to public health ;
30 April 2014 | Geneva
19. SR Goud, L Nagesh ; Are we eliminating cures with
antibiotic abuse? A study among dentists ; Nigerian
Journal of Clinical Practice Apr-Jun 2012 Vol 15
Issue 2
20. Steven Schwartz ; Commonly Prescribed
Medications in Pediatric Dentistry ; Continuing
Education Course, Dec 13, 2012
21. How are odontogenic infections best managed? ;
JCDA 2010 , Vol. 76, No. 2
22. N. A. O. Palmer,R. Pealing ; A study of therapeutic
antibiotic prescribing in National Health Service
general dental practice in England ; British Dental
Journal, Vol 188, NO. 10, May 2000
23. N. A. O. Palmer, R. Pealing : A study of therapeutic
antibiotic prescribing in National Health Service
general dental practice in England ; British Dental
Journal, Vol 188, No. 10, May 27 2000.
24. Nicole M. Yingling, B. Ellen Byrne ; Antibiotic Use
by Members of the American Association of
Endodontists in the Year 2000: Report of a National
Survey ; Journal of Endodontics ; Vol. 28, No. 5,
May 2002.

Vol. I Issue 2 Jul - Dec 2015 6

Original articles Narayana Journal of Research in Dental Specialties

KNOWLEDGE, ATTITUDE AND PRACTICE OF ENT SPECIALISTS TOWARDS ORAL

(MUCOSAL) POTENTIALLY MALIGNANT DISORDERS: A CROSS SECTIONAL STUDY
1 1
Sai Neelima Post graduate student
2 2
Rakesh Kumar Manne Reader
3 3
Natarajan Kannan Professor and Head
4 4
Swapna Sreedevi Beeraka Reader
5 5
Prathi Venkata Sarath Reader
6 6
Koliparthi Venkata Suneel Reader
1-6
Department of Oral Medicine and Radiology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh.

ABSTRACT:. Oral cancer is one of the most serious health problems faced by the mankind today. In India,
genetic, cultural, ethnic, geographic factors and the prevalence of a myriad of addictive habits, causes the
frequency of oral cancer to be high. The stage at which oral cancer is diagnosed is a major determinant of
mortality and morbidity following treatment. Early detection is the single most critical intervention influencing
survival.Dental and ENT professionals do commonly come across these PMDs in their practice. Literature on
KAP of PMDs among ENT professionals is sparse and no single survey has been reported in pub med
search till today. The present study intends to evaluate KAP of ENT professionals for early diagnosis and
appropriate treatment of PMDs. Knowledge and opinions related to PMDs were determined by means of a
cross sectional study of a probability sample of ENT surgeons in Nellore district. A 32-item questionnaire was
constructed from items previously tested for validity and new ones unique to this survey. The survey was self-
administered, voluntary and anonymous. The survey had questions in four major categories consisting of (4)
demographic questions, (22) on knowledge of PMDs & (6) on attitude & practice of ENT professionals
towards oral (mucosal) potentially malignant disorders. The entire data was tabulated & subjected to multi
variable statistical analysis.

KEYWORDS: Premalignant lesions, E.N.T.Surgeons, K.A.P.Study, Potentially Malignant Disorders

INTRODUCTION
Oral pharyngeal cancer constitutes the most life-
threatening of all dental and craniofacial conditions.
The U.S. five-year survival rate of 52 percent for
these cancers is one of the lowest and has not
changed in decades. An estimated 32,000 new cases
are diagnosed annually. In addition, more than 8,000
deaths are attributable to oral cancer each year.
When it is detected early, the likelihood of survival is
remarkably better than that for many other cancers.
Oral cancer presents with high mortality rates & the
likelihood of survival is remarkably better when
detected early. Ninety percent of cancers of the oral
cavity are squamous cell carcinomas (SCCs) arising
from the mucosal lining. The other 10 percent of oral
cancers are malignant melanomas, salivary gland
tumors, sarcomas of the soft tissues or jaw bones,
non Hodgkins lymphomas, or metastases from extra-
oral primary tumors. Most oral cancer is preceded by
visible premalignant lesions. Since not all
premalignant lesions progress to cancer, the World
Health Organization recommends classifying them as
potentially malignant disorders (PMDs), rather than
precancers, precursor lesions, or premalignant
lesions. Potentially malignant disorders (PMD) of oral
cavity were classified as lesions and conditions by
WHO in 1978.1 It was considered that in lesions, the
cancer would correspond with the site of PMD. On the
other hand, in conditions, cancer may arise in any
anatomical site of the oral cavity. It is now known that
even the clinically normal appearing mucosa in
patients harbouring a precancerous lesion may have
dysplasia on the contra lateral anatomic site or
molecular aberrations in other oral mucosal sites
suggestive of a pathway to malignant transformation,
and that cancer could subsequently arise in
apparently normal tissue. Hence, the current Working
Group (WHO) does not favour such subdivisions and
refers to all the clinical presentations that carry the
risk of oral squamous cell carcinoma (OSCC) as
potentially malignant disorders.PMDs are oral
lesions that include leukoplakia, erythroplakia, lesions
of the palate from reverse smoking (placing the
lighted end of a cigarette in the mouth), sub mucous
fibrosis, and actinic keratosis (with potential for lip
cancer). Whether lichen planus and discoid lupus

Vol. I Issue 1 Jan - June 2015 7

Original articles Narayana Journal of Research in Dental Specialties
erythematosus are potentially malignant is
controversial. There are also rare hereditary diseases
(e.g., dyskeratosis congenita and epidermolysis
bullosa) that involve PMDs. Most PMDs are oral
leukoplakia or erythroplakia. An estimated 2.6 percent
of the worlds population has oral leukoplakia. While
the reported malignant transformation rate varies
widely, a pooled estimate is 1.36 percent per year. An
estimated 0.2 to 0.8 percent worldwide has
erythroplakia, which has a malignant transformation
rate above 85 percent.
RISK FACTORS:
Several lifestyle factors, particularly tobacco use, affect
an individuals risk of acquiring oral cancer. Worldwide,
20 to 30 percent of oral cancer cases are attributable
to cigarette smoking. Other risk factors include betel
nut, alcohol, exposure to the sun (lip cancer), dietary
factors and exposure to carcinogens, low
socioeconomic status, specific blood group, familial
history, cosmic rays exposure, poor oral hygiene, ill
fitting dentures, chronic inflammatory conditions,
chronic bacterial, fungal & viral conditions etc. The
dental and ENT professionals share an important
responsibility towards early screening, prompt referral
& treatment of oral PMDs. Literature on KAP of PMDs
among ENT professionals is sparse and no single
survey has been reported in pub med search till today.
The present study intends to evaluate KAP of ENT
professionals for early diagnosis and appropriate
treatment of PMDs.
AIMS & OBJECTIVES:
Otolaryngologists. The information sheet included the
purpose of the study which was to know the current
levels of knowledge and awareness. The entire data
was tabulated & subjected to statistical analysis using
SPSS 20.0 software.
RESULTS:
The results are based on 34 respondents (Response
87.17%). More than half of the respondents were
from teaching institution, 25% were private
practitioners & about 10% were in government
service. 88.24% of respondents were males &
11.76% were females.
32.35% were in the age group of 25 30 years,
29.41% were in the age group of 30 45years,
38.24% were in the age group of 45 60 years.
Percentage wise tabulation of possible RISK
FACTORS for ORAL CANCER :
Tobacco, Areca nut & Poor oral hygiene-
94%,
Low economic status & Ill fitting Denture -
91%
Nutritional deficiency-88%
Old age- 85%
Immunosuppression - 79%
Alcohol intake- 76%
Family History- 73%
Lichen Planus & Spicy Food- 70%
Hot Foods & Actinic Radiation - 66%

The present study intends to evaluate KAP of

otolaryngologists for Oral PMDs.
To evaluate their concepts of risk factors related to KNOWLEDGE BASED QUESTION ANALYSIS:
oral cancer
To determine their opinions about their
professional preparedness to prevent & control
oral cancer.

MATERIALS AND METHODS:

A cross sectional study was conducted regarding the
KAP of ENT surgeons towards oral PMDs in Nellore
from 2.10-2014 to 22-10-2014. ENT surgeons
knowledge attitude & practices related to PMDs were
determined by a questionnaire. A list of total 39
practicing ENT professionals was obtained from the
local medical association. Each professional was met
personally, a written consent was obtained & the
questionnaire was administered. 5 out of 39
professionals did not respond to the survey due to
unavailability on multiple visits and not being willing to
participate. A self administered questionnaire was
prepared with 32 questions, out of which (4) questions
covered the demographics of the professional, (22)
were based on knowledge of PMDs & 6 questions
were regarding attitude & practice of PMDs by the

Vol. I Issue 1 Jan - June 2015 8

Original articles Narayana Journal of Research in Dental Specialties
Questionnaire on knowledge, attitude, and practice of Otolaryngologists towards oral (mucosal) potentially
malignant disorders

1 Type of service/practice
A. Public. B. Private. C. Teaching institution

2 Place of service/practice
A. Urban. B. Rural C. Teaching institution

3 Age/Gender: __________

4 Average number of patients visit to you per day

A. Less than 10 B. 11 to 30. C. 31 to 50. D. More than 50

Do you practice examination of the oral cavity?

5 A. Yes, all the patients B. Yes, some patients C. No
If yes,
a. What is the criteria you follow to examine some patients?
A. patient complains of oral disorder
B. Disorders visualized while examining throat
C. To rule out common oral and ear-nose-and throat symptoms
D. any other ___________________________________________
E. Not applicable, if examining all the patients
b. What are the oral mucosal regions you commonly examine?
________________________________________________________________________
c. How many oral potentially malignant disorders do you come across in a month?
A. 0 5 B. 6-15 C. 16 -25 D. 26 and above
d. What are the oral mucosal regions you commonly come across with potentially malignant disorders?

e. What are the most common potentially malignant disorders you come across?

6 Which are the following disorders / factors do you think can carry some risk and/or predispose oral mucosa to
develop squamous cell carcinoma?
a. Old age (Above 70 years) A. Yes B. No C. Dont know
b. Low socioeconomic status A. Yes B. No C. Dont know
c. Specific blood group (ABO blood grouping) A. Yes B. No C. Dont know
If yes, a. Group A. b. Group B c. Group AB d. Group O

Vol. I Issue 1 Jan - Jun 2015 9

Original articles Narayana Journal of Research in Dental Specialties
d. Family history of cancer A. Yes B. No C. Dont know
e. Inherited oral disorders like white sponge
nevus, Fanconis anemia. A. Yes B. No C. Dont know
f. Unprotected sun exposure A. Yes B. No C. Dont know
g. Alcohol consumption and abuse A. Yes B. No C. Dont know
h. Hot foods and beverages A. Yes B. No C. Dont know
i. Spicy foods A. Yes B. No C. Dont know
j. Hyperglycemia A. Yes B. No C. Dont know
k. Hyperlipidemia A. Yes B. No C. Dont know
l. Poor oral hygiene A. Yes B. No C. Dont know
m. Ill fitting denture and sharp tooth A. Yes B. No C. Dont know
n. Tobacco associated oral disorders A. Yes B. No C. Dont know
o. Betel nut associated oral disorders A. Yes B. No C. Dont know
p. Oral nevus and tattoos A. Yes B. No C. Dont know
q. Prolonged untreated chronic inflammatory
Disorders like lichen planus etc. A. Yes B. No C. Dont know
r. Chronic bacterial infections A. Yes B. No C. Dont know
s. Chronic fungal infections A. Yes B. No C. Dont know
t. Chronic viral infections A. Yes B. No C. Dont know
u. Nutritional deficiency A. Yes B. No C. Dont know
v. Immunosupression therapy A. Yes B. No C. Dont know

Do you practice treatment of oral (mucosal) potentially malignant disorders?

A. Yes B. No
If No,
a. Do you refer patient to other specialist?
A. Yes B. No
If yes,
a. To whom do you refer?
A. Medical specialist B. Dental specialist
If to Dental specialist,
a. To which dental specialty do you refer _________________________________________

Thank you for your participation in the surveyX

Vol. I Issue 1 Jan - Jun 2015 10

Original articles Narayana Journal of Research in Dental Specialties
ATTITUDE & PRACTICE:
100% of the practitioners claimed to examine the oral cavity
to identify oral, and throat lesions. About 88.24% of them
reported examining the entire oral cavity, 23.53% examined
only the tongue & buccal mucosa.82.35% claimed to come
across 0-5 oral PMDs in a month & 14% claimed to come
across 6-15 PMDs in a month. 85.29% considered Tongue
common site for oral PMDs, buccal mucosa by 70.59%,
other sites by 50%. 58.82% of the practitioners identified
leukoplakia as the most common oral PMD, OSMF was
identified by 50%, carcinoma was identified by 49.2%.
85.29% of the respondents practiced treatment of oral
(mucosal) potentially malignant disorders by themselves,
64.71% referred oral PMDs to Oral Physicians, 32.35%
referred oral PMDs to Oral & Maxillofacial Surgeons and
35.29% referred oral PMDs to medical specialists.
ATTITUDE & PRACTICE:
DISCUSSION
Studies on KAP of PMDs among otolaryngologists have
not been reported in literature till date. Although the
reported response rate for this survey was less than
desirable, it was based on a conservative assessment of
responses. The Otolaryngologists responding to this
survey knew most of the real risk factors for oral cancer,
particularly use of tobacco and alcohol, although less
than half knew that most cases of oral cancer are
diagnosed in people 60 years of age or older. They were
much less certain about factors that do not pose a risk.
The smaller proportions of Otolaryngologists who
correctly reported factors such as poor oral hygiene and
a family history of cancer as not posing a risk indicate a
relatively high level of misinformation among these
Vol. I Issue 1 Jan - Jun 2015
practitioners Knowledge of major risk factors for oral
cancer - was proved to be high which was similar to
studies by Joanne .B. Clovis et al. on Oral and
Pharyngeal Cancer & Survey of U.S. dentists knowledge
and opinions about oral pharyngeal cancer by Janet A
et al. 50% of the respondents considered consumption
of spicy foods and obesity as not risk factors for oral
cancer which is in correlation with the results in the study
conducted by SE Syme et al. Conway DI et al.
considered low socioeconomic status as a risk factor. In
the present study 91% were in agreement.Individuals
with blood group A were considered at higher risk of
developing SCC compared to other blood groups by
Fathima Jaleel et al. in 2002. But in the present study
ABO blood grouping was not considered as a risk factor
by majority of the respondents. A new classification for
potentially malignant disorders of the oral cavity given by
Hooper SJ et. al. & Kuper H et. al. mentions chronic
bacterial, viral fungal infections as risk factors but in the
present study these were not considered by more than
50% of the respondents. Practitioners must have current
knowledge of risk factors for oral cancer, the factors that
do not pose any risk, and diagnostic procedures to
assess patient health, to enable them to provide oral
cancer examination and to assist patients in reducing
their risk through tobacco cessation counselling and
other patient education. As these results cannot be
extrapolated to other regions, it may be expedient to
determine levels of knowledge regarding oral cancer
risks and diagnostic procedures in other provinces and
territories.
CONCLUSION
Although this survey demonstrated gaps in ENT
professionals knowledge about oral PMDs, it also
demonstrated the need for upgrading their knowledge in
this area. In addition to their role in the prevention and
early detection of oral cancer, Otolaryngologists can be
instrumental in providing health education to patients and
the community. Knowledge on major risk factors for oral
cancer on some of the recently proven factors is
inadequate. Hence the findings in this study can be used
to develop, comprehensive oral cancer education &
awareness programmes (CME) among otolaryngologists.
In addition, investigations of other health care
professionals knowledge and practices in regard to
providing oral health assessments will assist in the
prevention and early detection of oral cancers.
REFERENCES:
1. Joanne B. Clovis, Alice M. Horowitz, Dale H. Poel.
Oral and Pharyngeal Cancer: Knowledge and
Opinions of Dentists in British Columbia and Nova
Scotia J Can Dent Assoc 2002; 68(7):415-20.
2. Shailee Fotedar, Kapil Rajeev Sharma, Girish M.
Sogi, Vikas Fotedar, Atul Chauhan. Knowledge and
Attitudes about HIV/AIDS of Students in H.P.
Government Dental College and Hospital, Shimla,
11
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India. Journal of Dental Education September 2013
.Vol7(9) 1218-1224.
3. Oluwatunmise Awojobi, Suzanne E Scott and Tim
Newton. Patients perceptions of oral cancer
screening in dental practice: a cross-sectional study.
BMC Oral Health 2012.Vol 12(55);2-9.
4. Katrin Hertrampf , Hans-Jrgen Wenz, Michael Koller
, Jrg Wiltfang. Comparing dentists and the publics
awareness about oral cancer in a community-based
study in Northern Germany. Journal of Cranio-Maxillo
- Facial Surgery 2010..28-32.
5. Naik Balachandra Ramachandra. The Hierarchy of
oral cancer in India. IJHNS Sep-Dec 2012.3(3).143-
146.
6. M. Terrades, W. A. Coulter, H. Clarke, B. H. Mullally
and M. Stevenson. Patients knowledge and views
about the effects of smoking on their mouths and the
involvement of their dentists in smoking cessation
activities. British dental journal.2009.
7. Syme SE, Drury TF, Horowitz AM. Maryland dental
hygienists knowledge and opinions of oral cancer risk
factors and diagnostic procedures. Oral Diseases
2001.Vol 7; 177184.
8. Che-Chun Su , Kuo-Yang Tsai , Yun-Ying Hsu , Yo-
Yu Lin , Ie-Bin Lian. Chronic exposure to heavy
metals and risk of oral cancer in Taiwanese males.
Oral Oncology 46 (2010) 586590.
9. Fathima Jaleel & Ramesh Nagarajappa. Relationship
between ABO blood group & oral cancer. Indian
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not with factor XII. Oncology reports 2007.18: 1537 -
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11. Amy Ming-Fang Yen , Sam Li-Sheng Chen , Sherry
Yueh-Hsia Chiu, Hsiu-Hsi Chen. Association
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Corresponding Author
Dr. Sai Neelima
Postgraduate student
Department of Oral Medicine and
Radiology,
Narayana Dental College and Hospital,
Nellore, Andhra Pradesh
India-524003
12
Original Articles Narayana Journal of Research in Dental Specialties

RELATIONSHIP BETWEEN LINGUAL FRENULUM AND CRANIOFACIAL

MORPHOLOGY IN ADULTS
1 1
Sonika Priyadarshan Post graduate student
2 2
Ashutosh Shetty Professor
3 3
Vivek Bhaskar Post graduate student
4 4
Krishna Nayak U.S. Professor and Dean

1-4
Department of Orthodontics, AB Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka

ABSTRACT:. Introduction: Craniofacial morphology is influenced by many factors, and understanding the
relationship between tongue posture and skeletal structures is vital to understand the growth and development of
the face. This study aims to assess the relationship between length of lingual frenum and the resultant
craniofacial morphology. Methods: One hundred and eight South Indian patients were included in the study and
divided into 3 groups: Group-1: thirty six patients with Class I skeletal relationship, Group-2: thirty six patients
with Class II skeletal relationship, Group-3: thirty six patients with Class III skeletal relationship on the basis of
their ANB angle. The lingual frenum was measured with a direct and indirect method and correlated with
cephalometric readings. Results:The median lingual frenulum length was significantly longer in the skeletal
Class III subjects when compared with the skeletal Class I and Class II subjects. The maximum opening of the
mouth was significantly reduced in the skeletalClass III subjects compared with Class I and Class II subjects.
Significant positive correlations were also found among the MLFL & MMOR, and the cephalometric variables
such as the SNB, Wits appraisal, mandibular length, and negative correlation with ANB and interincisal angle.
Conclusion: The present study supports the hypothesis that skeletal Class III malocclusion is related to long
median lingual frenulum oral tongue-tie tendency. Patients with tongue tie might have a tendency toward skeletal
Class III malocclusion.

KEYWORDS: Craniofacial, Morphology, Growth, Skeletal.

INTRODUCTION
The relationship between tongue posture
and skeletal structures of the face is an essential
element in understanding the growth and
development of craniofacial structures, the
etiology of malocclusions, and the prediction of
stability after orthodontic treatment. The teeth
and alveolus are packed in the middle of the
buccal mucosa, lips and the tongue and an
equilibrium among these is present, for
(1-2)
preservation of the position of the dentition. It
has been suggested that concurrence between
the genetic elements and the soft tissues
organization in the oral and facial region as a
(3, 4, 5)
cause of malocclusion.
The fibro-mucosal fold that connects the
under surface of the tongue and the mucosa of
(8)
oral pavement is called lingual frenum. Lingual
frenulum withdraws away from the tongue tip as
Vol. I Issue 1 Jan - Jun 2015
the cells undergo apoptosis during the
development of the tongue. Tongue tie or
Ankyloglossia could occur at this stage of
programmed cell death if there are any
disturbances. This is an inborn abnormality, in
which the lingual frenum attaches the ventral
surface of the tongue to the floor of the mouth.
This results in restriction of the frenulum length,
which causes malocclusion, speech defects and
(912)
breast feeding problems.
Previous literature focused more on the
improper tongue posture and effects of tongue
tie .However there wasnt any much literature on
the influence of the lingual frenulum in relation to
(4-6)
dentoalveolar anomalies.
Studies show that improper tongue posture
and variable frenulum length lead to various
malocclusions. So the purpose of this study was
13
Original Articles Narayana Journal of Research in Dental Specialties
to find out the relationship between the length of The measurements made by this
the lingual frenulum and craniofacial method were taken using a lingual
morphology and to test the hypothesis that frenulum ruler , having a resolution of
skeletal Class III malocclusion is related to
0.01 mm, a nominal capacity of 150 mm
tongue-tie, which presents with short lingual
frenulum is short and restricts the mobility of the (Hebich Technical Training Institute [
(16) HTTI ] , Mangalore ,Karnataka
tongue.
The isthmus of the ruler was fully
inserted into the patients oral cavity
MATERIALS AND METHODS and the other end of the lingual
frenulum ruler touching on the lower
SOURCE OF DATA
incisors in order to measure the median
One hundred and eight South Indian patients lingual frenulum length.
visiting the Dept. of Orthodontics and This measurement is representative of
Dentofacial Orthopaedics, A. B. Shetty the maximum lingual frenulum length in
Memorial Institute of Dental Sciences, the center of the tongue-tie.
Mangalore for Orthodontic treatment were
In order to reduce the error caused due
included in the study. The patients were divided
into 3 groups: to pressure of the hand while taking
measurement , lingual frenulum length
INCLUSIVE CRITERIA FOR SAMPLE was recorded with the ruler touching on
SELECTION the soft tissue as lightly as possible.

On the basis of ANB angle, patients were Maximum mouth opening reduction
categorised into three groups. The first group (INDIRECT METHOD):
o
was the skeletal Class I group in which ANB is
o o o o A digital caliper (Aero Space - Digital
greater than 0 and lesser than 4 (0 <ANB<4 ),
second group was the skeletal Class II group Caliper ) was used to measure the
o o
where in ANB is greater than 4 (ANB angle > maximum mouth opening.
o
4 ), and the third group was the skeletal Class The patient was asked to open his or
o is o
III group where in ANB less than 0 (ANB her mouth as widely as possible and
o
angle<0 ) and each group has 36 patients. the caliper was positioned so that its
extremities will be in contact with the
EXCLUSIVECRITERIA FOR SAMPLE
SELECTION incisal margins of the maxillary central
incisor and the mandibular homolateral
Previous lingual frenectomy, Previous central incisor. This measurement is
orthodontic treatment, Previous orthognathic considered as T1.
surgery, Disorders of the temporomandibular The patient were requested to put the
joint and jaw-muscle.
tip of the tongue on the incisive papilla
METHODOLOGY maintaining it on that point and to open
the mouth again to the maximum gap
The purpose and methodology of the study and the measurement thus taken is
were explained to the subjects. 108 patients considered as T2.
satisfying the above criteria were selected The reduced amount of maximum
irrespective of their sex.
mouth opening was then calculated by
In this study the length of the lingual frenum the difference of the 2 measurements
was measured using two methods; first method (T1- T2).
being the Direct Method and second method
being the indirect method.

Median lingual frenulum length (DIRECT

METHOD):
Vol. I Issue 1 Jan - Jun 2015 14
Original Articles Narayana Journal of Research in Dental Specialties
.
FIG 1- Armamentarium used in the study.
Median lingual frenulum ruler.
Fig 3.Measurement taken when mouth
opened to maximum with tongue touching
the incisive papilla.
Cephalometric analysis:
1. The lateral cephalograms was taken in
habitual occlusion by using a
standardized technique and fixed
anodemidsagittal plane distance.
2. The lateral cephalograms of each
subject were traced and cephalometric
analysis was carried out.
Cephalometric variables
SNA angle, SNB angle,ANB angle,Wits
appraisal (mm),Mandibular length (Co-
Pog) (mm),Interincisal angle
Vol. I Issue 1 Jan - Jun 2015
FIG 2. The lingual frenulum length
measured by using median lingual
frenulum ruler
Figure 4-measuring maximum mouth
opening using digital caliper
RESULTS
The students unpaired t test revealed no
genderdifference for the MLFL & MMOR
among the three skeletal groups. Hence, data
for both genders in each group were clubbed
together.Descriptive statistical analysis and
statistical comparisons of the MLFL & MMOR
measurements in 3 groups are shown in
(Graph
I). The mean MLFL were 3.8 +/- 0.7 mm in
skeletal Class I group, 3.7 +/- 2.6 mm in
skeletal Class II group, and 4.3 +/-1.4 mm in
skeletal Class III group.
15
Original Articles Narayana Journal of Research in Dental Specialties
The MLFL was significantly longer in the
skeletal Class III patients compared with skeletal
Class I (P<0.05) and II (P<0.01) patients. In
addition, the amount of maximum mouth
opening was significantly reduced in the skeletal
class III patients compared with the skeletal
class I and class II subjects (P<0.01)(graph II).
The MMOR was found to have a positive
correlation with SNB angle (r 0.173) ,
mandibular length (r0.100), and interincisal
angle (r.223), and a significant negative
correlation with the SNA angle (r -.240 ) , ANB
angle (r -.357 ) and Wits appraisal (r -.269 )
.(Graph III).
DISCUSSION
The arranging of the soft tissues and the
tongue posture has a major role in defining the
positioning of the teeth and it is also a
determiner of bone formation. Even though the
tongue seems to play a role in the orofacial
development, it often remains quiescent without
a frank skeleton per se. However, the neuro-
muscular complex of tongue is crucial in function
(22)
and development .
Ankyloglossia is a congenital condition in
which the tongue is attached to the floor of the
mouth at various degrees of severity. The
pharyngeal musculature tends to push the
tongue forward as its mobility is limited. Due to
this muscular influence, the mandible assumes a
forward position, resulting in a Class III
(23)
malocclusion . An association between
ankyloglossia and malocclusion has been
(16)
described in literature
Till puberty is attained, the tongue occupies
a lower position in the oral cavity, leading to a
(2)
prognathic mandible . This calls for an early
diagnosis of the prognathic mandible and the
tongue tie, which would enable the clinician to
correct the condition early, leading to a better
prognosis following treatment.
The literature reveals many studies on the
correlation between soft tissue posture and
malocclusion. However, there seems to be less
number of studies associating the frenulum with
skeletal malocclusion. Thus, this study was
carried out to assess the correlation between the
lingual frenum and malocclusion. The lengths of
the lingual frenum and the maximum mouth
opening reduction in all three classes of
Vol. I Issue 1 Jan - Jun 2015
malocclusion and the association between these
(16)
factors was assessed.
There is a scarcity of data supporting the
causal relationship between a short vertical
lingual frenum and skeletal malocclusion. The
reason for this could be that the tongue is wholly
composed of soft tissue and hence no fixed
landmark can be identified. This unfortunate fact
has led to most descriptions of the morphology
of the tongue to be prejudiced judgements and
(18)
not factual data.
To overcome the aforementioned issue, Lee
et al used a lingual frenulum ruler to assess the
abnormal lingual posture associated with
ankyloglossia and measured the median lingual
(22)
frenulum length with the same . The method
for the measurement of the lingual frenulum in
relation to the dimensions of the anterior and
inferior segments of the tongue was described
(26)
by Fletcher and Meldrum .
The lingual frenulum length and the
interincisal distance in maximum opening of the
mouth and with the tip of the tongue touching the
palatal papilla, was measured by Ruffoli et al,for
indirect measurement of the length of the lingual
(5)
frenulum.
In this study we used 2 different methods ie
direct and indirect method to measure the length
of the lingual frenulum. In the direct method we
measured thelength of the lingual frenulum
directly by recording the MLFL with a lingual
frenulumruler. This method has been shown to
produce accurate measurements . In the indirect
method the length of the lingual frenulum was
measured by the maximum mouthopening with
and without the tip of the tongue touchingthe
incisive papilla. The measurements of the
reducedamount of maximum mouth opening
were used to eliminate bias that could arise from
the difference in absolutevalue of maximum
mouth opening fromindividual variation of
(27-28)
mandibular function.
According to the results obtained from our
study, there was no gender differences among
the three skeletal groups.The scheffes test done
for inter group comparison showed that MLFL
was less in skeletal class II followed by skeletal
class I and MMOR was found to be less in
skeletal class II followed by skeletal class I
which was statistically insignificant .The present
study shows that in patients with class III
16
Original Articles Narayana Journal of Research in Dental Specialties

GRAPH I : Comparison of the mean values of

MLFL and MMOR in 3 skeletal groups
30
20
20.975
10 15.667 16.844
3.886 3.733 4.328
0
MLFL MMOR

CLASS I CLASS II CLASS III

Graph II :Scheffe's test

1
0
-1 MLFL MMOR
-2
-3
-4
-5
-6

CLASS I CLASS II CLASS III

Graph III : Pearson's correlation analysis among the

median lingual frenulum length, maximum mouth
opening reduction, and other variables
0.4

0.2

0
MLFL MMOR
-0.2

-0.4

SNA SNB ANB WITS MAND LENGTH INTERINCISAL ANGLE

Vol. I Issue 1 Jan - Jun 2015 17

Original Articles Narayana Journal of Research in Dental Specialties
malocclusion, there seems to be an increased
MLFL and a significant reduction in maximum mouth
opening. This suggested that patients with increased
MLFLs have a tendency to develop skeletal class III
malocclusion when compared with skeletal class I and
class II. A study was done by So-Jeong Jang et al and
their results were in accordance with other
clinicalreports that suggested a relationship between
(16)
ankyloglossiaand mandibular prognathism.
This was contradictory to other authors who
reported that ankyloglossia was more common in
class III skeletal malocclusion demonstrating no
relation between the short lingual frenum and any
(15)
dental or orthodontic anomalies.
Future research has to be done to further clarify
the role of the lingual frenulum, especially its
relationship with mandibular prognathism in skeletal
Class III malocclusion. Long term studies are
needed to assess if craniofacial morphology is
affected over time in patients with and without
frenectomy.If a conclusive evidence, taking into
considerations the above mentioned shortcomings
of this study, can be achieved about the correlation
between ankyloglossia and class III malocclusion,
then this would provide the clinician with a better
rationale for early class III treatment.
CONCLUSION:
According to the study the following conclusion can
be drawn
1. There was no gender difference found
between the median lingual frenulum length
and the reduced amount of maximum mouth
opening.
2. The longer median lingual frenulum length
was related with the reduction in the amount of
maximum mouth opening.
3. Skeletal Class III subjects were found to have
significantly longer median lingual frenulum
lengths and increased maximum mouth
opening reduction compared with skeletal
Class I , skeletal Class II subjects. Those with
tongue-tie tended to have skeletal Class III
malocclusion.
4. Correlations were also found between the
median lingual frenulum length, maximum
mouth opening reduction, and sagittal
Vol. I Issue 1 Jan - Jun 2015
components of craniofacial morphology such
as SNB and ANB angles, Wits appraisal, and
mandibular length.
REFERENCES
1. Proffit WR. Equilibrium theory revisited: factors
influencing position of the teeth. Angle Orthod.
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2. ProffitWR,MasonRM.Myofunctional therapy for
tongue-thrusting:background and recommendations.
J Am Dent Assoc 1975;90:403-11.
3. Mew JR. Factors influencing mandibular growth.
Angle Orthod. 1986;56:3148.
4. Defabianis P. Ankyloglossia and its influence on
maxillary and mandibular development. (A seven
year follow-up case report) Funct Orthod.
2000;17:2533
5. Ruffoli R, Giambelluca MA, Scavuzzo MC, Bonfigli
D, Cristofani R, Gabriele M, et al. Ankyloglossia: a
morphofunctional investigation in children. Oral Dis.
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6. Alhaddad Salwa Jeragh. Ankyloglossia in a Pseudo-
Class III malocclusion: A case report. Smile Dental
Journal. 2011;6(2):1216.
7. Pola Ma Jos Garca Garca, Gonzlez Manuel,
Martn, Manuel Jos, Garca Gallas, Mercedes,
Lestn Juan Seoane. A study of pathology
associated with short lingual frenum. Journal of
Dentistry for Children. 2002;69(1):5962.
8. LA Kotlow . Oral diagnosis of abnormal Frenum
Attachments in neonates and infants: Evaluation and
treatment of the maxillary and lingual frenum using
the erbium: YAG laser. The Journal of Pediatric
Dental Care. 2004;10(3):10612.
9. Chaubal Tanay V, Dixit Mala Baburaj. Ankyloglossia
and its management. Journal of Indian Society of
Periodontology. 2011;15(3):27072.
10. Dyad, Ballard Lauer CE, Khoury JC. Ankyloglossia:
assessment, incidence, effect of frenuloplasty on the
breast feeding. Pediatrics. 2002;110(5):63.
11. Coryllos Elizabeth, Salloum Alexander C, Genna
Catherine Watson. Congenital tongue tie and its
impact on breast feeding. American Academy of
Pediatrics. 2004
12. Notestine Gregory E. Importance of identification of
ankyloglossia as a cause of breast feeding problems.
Journal of Human Lactation. 1990;6(3):11315.
13. Kim YS, Kown SY, Park YG, Chung KR. Clinical
application of thetongue elevator. J Clin Orthod
2002;36:104-6.
14. Ruffoli R, Giambelluca MA, Scavuzzo MC, Bonfigli D,
Cristofani R,Gabriele M, et al. Ankyloglossia: a
morphofunctional investigationin children. Oral Dis
2005;11:170-4.
15. Skeletal and dental characteristics in subjects with
ankyloglossia Bhadrinath Srinivasan* and Arun B
Chitharanjan (progress in orthodontics, 2014).
16. Relationship between the lingual frenulum and
craniofacial morphology in adults
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17. So-Jeong Jang,a Bong-Kuen Cha,b Peter Ngan,c
Dong-Soon Choi,d Suk-Keun Lee, Am J Orthod
Dentofacial Orthop 2011;139:e361-e367
18. TuerkM, Lubit EC. Ankyloglossia. Plast Reconstr
Surg 1959;24:271-6Assessment of Lingual Frenulum
Lengths in Skeletal Malocclusion Meenakshi et al
19. Assessment of Lingual Frenulum Lengths in Skeletal
Malocclusion by Swarna Meenakshi and Nithya
Jagannathan.J Clin Diagn Res. 2014 Mar; 8(3): 202
204.
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Case Report ; Salwa Jeragh Alhaddad , smile dental
journal , 2010
21. Markovic MD. At the crossroads of oral facial
genetics. Eur J Orthod. 1992;14:46981.
22. Horowitz EP, Oxbourne RH, de George FC.
Cephalometric study of craniofacial variations in adult
twins. Angle Orthod. 1960;30:15.
23. Lee SK, Kim YS, Lim CY. A pathological
consideration of ankyloglossiaand lingual myoplasty.
Taehan Chikwa Uisa Hyophoe Chi1989;27:287-308.
24. Petit H, Davis W. The role of the tongue in facial
development. J Pedod. 1986;10:199210. Kotlow LA.
Ankyloglossia (tongue-tie): a diagnostic and
treatment quandary. Quintessence Int. 1999;30:259
62.
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and Maxillofacial Pathology. 2nd ed. Philadelphia:
WB Saunders Company; 1995. pp. 101.
26. Fletcher SG, Meldrum JR. Lingual function and
relative length ofthe lingual frenulum. J Speech Hear
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1999;30:259-62.

Corresponding Author

Dr. Sonika Priyadarshan

Department of Orthodontics,
AB Shetty Memorial Institute of
Dental Sciences, Mangalore,
Karnataka

Vol. I Issue 1 Jan - Jun 2015 19

Original Articles Narayana Journal of Research in Dental Specialties

COMPARATIVE EVALUATION OF FRACTURE RESISTANCE OF MARGINAL RIDGE

IN TUNNEL CAVITIES RESTORED WITH THREE DIFFERENT MATERIALS.
1 1
Madhusudhana Koppolu Professor and Head
2 2
Deepthi Mandava senior Lecturer
3 3
Dorasani Gogala In practice
4 4
Shivaram Penigalapati. senior Lecturer
5 5
Suneelkumar Chinni Reader
6 6
Anumula Lavanya Reader

1,5,6
Department of Conservative Dentistry & Endodontics, Narayana Dental College, Nellore, A.P
2
Faculty of Dentistry, AIMST Dental Institute, Malaysia.
3
In private practice, U.K.
4
Department of Conservative Dentistry & Endodontics, MNR Dental College and Hospital, Telangana

ABSTRACT:. Objective: Comparison of resistance of marginal ridge to fracture in tunnel cavities restored with
three different materials. Materials& Methodology: Forty premolar teeth were taken and tunnel cavities prepared
on the teeth maintaining the marginal ridge thickness of 2mm and height of 2.5 mm. All the teeth were mounted in
acrylic block and were divided into 4 groups of each having 10 teeth. Group 1 left unrestored (control group),
Group2 restored with Biodentine, Group 3 restored with Chemfil Superior, Group 4 filled with FUJI - IX Glass
ionomer cement (GIC). Then all samples were tested using universal testing machine for marginal ridge resistance
to fracture and values obtained were subjected to ANOVA. Results: Restorative material had a significant
(P<0.05) effect on mean score of tunnel prepared teeth. Results showed that Biodentine restored teeth were more
resistant to fracture than teeth restored with Chemfil Superior and FUJI IX GIC. ANOVA statistical analysis
showed statistifically significant difference between all groups and biodentine was superior among three materials
used. Significance: Premolars tunnel-restored with Biodentine were strong compared to Unrestored teeth, teeth
restored with Chemfil superior and FUJI - IX GIC.
.
KEYWORDS: Biodentine, Chemfil Superior, FUJI IX GIC, Tunnel preparation

INTRODUCTION
GV Black (1917) laid down principles for the
design of cavities for restoring carious lesion nearly
100 years ago. Conventionally for small proximal
carious lesions, the intact marginal ridge as well as
the contact point has to be sacrificed in order to
1
access the lesion area. It leads to food impaction
and decreased masticatory efficiency due to
difficulties in regaining the contact point and
2
contour .
3 4
Knight and Hunt (1980) introduced the
tunnel concept as a more conservative design than
Blacks Class II preparation.
due to difficulties in regaining the contact point, and
2
failure to contour the proximal surface properly.
The tunnel concept accesses proximal carious
lesions from the occlusal surface. It preserve the
marginal ridge and to minimize loss of healthy tooth
structure One of the most frequently reported
reasons for the clinical failure of total tunnel
restorations was marginal ridge fracture. It is
influenced by the strength of the marginal ridge after
tunnel preparation and the mechanical properties of
the restorative material used.

In Class II cavity the marginal ridge and
contact point should involve to access into proximal
lesion regardless of its size, so even for a small
carious lesion. This kind of treatment often leads to
food impaction and decreased masticatory efficiency
Glass ionomer cements were commonly used
for restoring tunnel cavities for many years. In this
study, three different restorative materials like
Biodentine, Chemfil superior and FUJI IX GIC
were used for restoring tunnel cavities.

Vol. I Issue 1 Jan - Jun 2015 20

Original Articles Narayana Journal of Research in Dental Specialties
Hence the objective of this study was to
evaluate and compare resistance of marginal ridge
to fracture in tunnel cavities restored with three
different materials.
MATERIAL & METHODOLOGY:
Sample and study design
40 sound premolars which had been
extracted for orthodontic reasons were used for the
study. They are cleaned and stored in 4%
polyformaldehyde.
Preparation technique
A 1.0mm-deep cavity was prepared with a
round bur perpendicular to the long axis of the tooth
at occlusogingival distances of 2.5mm from the
marginal ridge to mimic carious lesion. Vernier
callipers was used to confirm the cavity size and
remaining marginal ridge height. The teeth were
mounted in a block of acrylic resin to a level of 1mm
below the cementoenamel junction. Standardized
tunnels were prepared with the same buccopalatinal
dimension (2.0mm) as well as the same distance
(2.0mm) between the proximal margin of occlusal
tunnel opening and the marginal ridge. The different
tunnel preparations were randomly divided into 4
groups of 10 each.
1. Group-1 left unrestored,
2. Group-2 restored with Biodentine
)
(SEPTODONT
3. Group-3 restored with Chemfil Superior
(DENTSPLY ) and
4. Group-4 restored with Fuji - IX GIC (FUJI )
Proximal cavity was supported with mylar strip
during restoration. Teeth in each group were
restored with respective materials according to
manufacturer instruction.
Biodentine was available in powder and liquid
form. Powder contains Tri-calcium Silicate (Main
core material), Di-calcium Silicate (Second core
material), Calcium Carbonate and Liquid contains
Calcium chloride Accelerator, Hydrosoluble polymer
(Water reducing agent). These were mixed and
carried to the tunnel preparation with the help of
amalgam carrier and condensed with small
condensers from occlusal aspect.
Chemfil Superior available as powder which
contains Aluminium-sodium-calcium-fluoro-
phosphoro-silicate and Polyacrylic acid. This powder
Vol. I Issue 1 Jan - Jun 2015
form was mixed with distilled water to initiate acid
base reaction carried to tunnel restoration with help
of probe and condensed with plastic filling
instrument.
FUJI IX GIC was available as powder
(Aluminium-sodium-calcium-fluoro-phosphoro-
silicate) and liquid (Polyacrylic acid) form mixed
according to manufacturer instructions and carried to
the tunnel cavity and condensed with plastic filling
instrument.
The adequacy of filling and absence of voids were
concluded by taking radiographs of tunnel filled
teeth.
Mechanical test
The strength of the marginal ridge was tested
in a universal testing machine (Instron, 8814, USA).
The restored teeth in the acrylic block were placed in
the test plateau and the load was transferred to the
marginal ridge by a steel rod of 1 mm diameter at
0.5 mm/min crosshead speed. The load level was
recorded at the time of fracture.
Data was statistically analysed using one way
ANOVA (Analysis of Variance) test using SPSS
(Statistical Package for Social Science) soft ware
version 16.
RESULTS:
Results were subjected to statistical analysis.
One way ANOVA test was applied to determine
differences between experimental and control
groups. The mean scores for groups Group-I, II, III
and IV was 310.4N, 504.7 N, 372.8N and 465.5 N
respectively. Group-II shows statistically highest
fracture resistance (p<0.05).
DISCUSSION:
Basic tenets for the design of cavities
prescribed for restoring carious lesion nearly 100
years ago by GV Black (1917). This classification
was designed using the available knowledge of the
caries process, diagnostic aids and restorative
materials, resulting in large cavities after
1
preparation . Amazingly, despite considerable
improvement in dental materials, increased
understanding of the caries process and the
availability of minimal intervention approaches,
21
 Original Articles Narayana Journal of Research in Dental Specialties
many dental schools and clinicians continue to use
Blacks cavity design. For example, according to
Blacks rationale of cavity design, a Class II cavity
should be prepared for treatment of a carious lesion
in the proximal surface, regardless of its size, so
even for a small carious lesion, the intact marginal
ridge as well as the contact point has to be
sacrificed in order to access the lesion area. This
kind of treatment often leads to food impaction and
decreased masticatory efficiency due to difficulties in
regaining the contact point, and failure to contour the
2 3 4
proximal surface properly . Knight and Hunt
introduced the tunnel concept that was more
conservative in its cavity design than Blacks Class II
preparation.
The tunnel concept accesses proximal
dentinal carious lesions from the occlusal surface. It
was designed to preserve the marginal ridge and to
minimize loss of healthy tooth structure, thus saving
clinical time while leaving relatively little of the
5,6
material externalized . The tunnel concept is
divided, according to the preparation technique, into
total tunnel when the proximal enamel is perforated
and removed, and into partial tunnel when the
6-10
proximal enamel is not perforated . However,
retrospective studies on tunnel restorations (both
partial and total) using glass-ionomer cements have
11
shown a higher annual failure rate (7.1%) than that
of conventional Class II amalgam (3.3%) or hybrid
12
posterior composite (2.3%) restorations .
In the present study, tunnel-prepared teeth
restored with Biodentine showed the highest
marginal ridge strength. Biodentine chemical
composition based on the Ca3SiO5 water
chemistry made with Active Bio silicate Technology
is a background applied to the high temperate
ceramic mineral chemistry. It produces pure
calcium silicate content of the formulation and the
absence of any aluminates and calcium sulphate in
the final product as MTA based cements. Thus
strength is achieved in biodentine. Unreacted tri
calcium silicate grains are surrounded by layers of
calcium silicate hydrated gels, which are relatively
13
impermeable to water .
One of the most frequently reported
reasons for the clinical failure of total tunnel
14
restorations were marginal ridge fracture . The
latter is influenced by the strength of the marginal
ridge after tunnel preparation and the mechanical
properties of the restorative material used. The
question arises as to whether the high failure rate of
tunnel restorations can simply be blamed on the
Vol. I Issue 1 Jan - Jun 2015
concept and what the factors are that play a
decisive role in the tunnel restoration failure process
Even though the elastic moduli of the
present materials differed by a factor of about two,
there was no correlation between the elastic moduli
and the strength of the ridge of the filled teeth. The
elastic moduli of the materials were lower than for
dentin or enamel
Concerning the reinforcement of the
marginal ridge by different restorative materials, in
vitro-studies found contradictory results. Several
authors showed that tunnel preparations restored
with conventional or metal-reinforced glass-ionomer
cements and composites had an increased fracture
15, 16
strength compared to unfilled preparations .
Moreover, it was demonstrated that glass-ionomer
21
cements, composites and amalgams increased
the strength of tunnel preparations to the fracture
resistance of sound teeth. In contrast, no significant
increase in fracture resistance could be observed by
restoring tunnel preparations with glass ionomers or
amalgam. Shetty and Munshi found that
conventional and metal-reinforced glass-ionomers
as well as amalgam and composite tunnel
restorations failed to reinforce the marginal ridge to
the level of an intact tooth.
17
According to G.F. Koubi et al biodentine
can be used as permanent dentine substitute
under composite restorations. According to Djou
18
et al sealing ability is comparable with
composites.
CONCLUSION
Tunnel preparations are minimal invasive
procedures for proximal carious lesions in posterior
teeth. The marginal ridge strength of tunnel restored
teeth was related to the restorative materials.
Biodentine achieved the highest marginal ridge
strength in tunnel prepared teeth when compared to
Chemfil Superior and FUJI IX GIC.
REFERENCES:
1. Mount GJ. Minimal intervention dentistry:
rationale of cavity design. Oper Dent 2003;
28:929.
2. Jinks GM. Fluoride-impregnated cements and
their effect on the activity of interproximal caries.
J Dent Child 1963; 30:8791.
22
Original Articles Narayana Journal of Research in Dental Specialties
3. Knight G. The tunnel restorations. Dent Outlook 18. Physical, Chemical and Mechanical Behaviour of a
1984; 10:5377. New Material for Direct Posterior Fillings. J. Djou,-
4. Hunt PR. A modified Class II cavity preparation for European Cells and Materials Vol. 10. Suppl. 4,
glass ionomer restorative materials. Quintessence 2005 (page 22)
Int 1984; 15:10118.
5. Holst A, Brannstrom M. Restoration of small Corresponding Author
proximal dentin lesions with the tunnel
technique. A 3-year clinical study performed in
Public Dental Service clinics. Swed Dent J 1998;
22:1438. Madhusudhana Koppolu
6. Hasselrot L. Tunnel restorations in permanent Professor and Head
teeth. A 7 year follow up study. Swed Dent J Department of Conservative Dentistry
1998; 22:17. Endodontics, Narayana Dental College,
7. Hasselrot L. Tunnel restorations. A 3 1/2-year Nellore, A.P
follow up study of Class I and II tunnel
restorations in permanent and primary teeth.
Swed Dent J 1993; 17:17382.
8. Jones SE. The theory and practice of internal
tunnel restorations: a review of the literature
and observations on clinical performance over
eight years in practice. Prim Dent Care 1999;
6:93100.
9. Nicolaisen S, der Fehr FR, Lunder N, Thomsen I.
Performance of tunnel restorations at 36 years. J
Dent 2000; 28:3837.
10. Pilebro CE, van Dijken JW, Stenberg R.
Durability of tunnel restorations in general
practice: a three-year multicenter study. Acta
Odontol Scand 1999; 57:359.
11. Strand GV, Nordbo H, Leirskar J, der Fehr FR,
Eide GE. Tunnel restorations placed in routine
practice and observed for 24 to 54 months.
Quintessence Int 2000; 31:45360.
12. Sundberg H, Mejare I, Espelid I, Tveit AB.
Swedish dentists decisions on preparation
techniques and restorative materials. Acta
Odontol Scand 2000; 58:13541.
13. Tveit AB, Espelid I, Skodje F. Restorative
treatment decisions on approximal caries in
Norway. Int Dent J 1999; 49:16572.
14. Svanberg M. Class II amalgam restorations,
glass-ionomer tunnel restorations, and caries
development on adjacent tooth surfaces: a 3-
year clinical study. Caries Res 1992; 26:3158.
15. Chalker SA, Lumley PJ. An in vitro assessment of
cavity margin finishing and marginal adaptation of
tunnel restorations. Eur J Prosthodont Restor Dent
1993;1: 1516.
16. Papa J, Cain C, Messer HH. Efficacy of tunnel
restorations in the removal of caries.
Quintessence Int 1993; 24:7159.
17. A Clinical Study of a New Ca3SiO5-based
Material Indicated as a Dentine Substitute G.F.
KOUBI1,(SEVILLE, SPAIN, MARCH 12th 14th
2009).

Vol. I Issue 1 Jan - Jun 2015 23

Case Reports Narayana Journal of Research in Dental Specialties

HOLLOW DENTURE A CASE REPORT

1 1
Keerthi GK Post graduate student
2 2
Mahesh P Professor and Head
3 3
Divya Jyothi G Post graduate student

1,2,3
Department of Prosthodontics, Narayana Dental College, Nellore, A.P

ABSTRACT:. The success of complete denture prosthesis relies on principles of retention, stability and
support and the prosthodontists skill in applying these principles efficiently in critical situations. Severely
resorbed edentulous ridges that are narrow and constricted with increased inter ridge space provide
decreased support, retention and stability. The consequent weight of the processed denture compromises
them further. This article describes a case report of an edentulous patient with resorbed ridges where a
simplified technique of fabricating a light weight maxillary complete denture was used for preservation of
denture bearing areas.
.
KEYWORDS: Neutral zone, Residual Ridge Resorption, Unconventional Complete
Dentures.

INTRODUCTION

Loss of teeth is a psychosocial disorder. laboratory processing to exclude denture base

Prosthodontists play an important role in treating this
disorder. With the advancements in the field, many
treatment options have evolved for treating
completely edentulous conditions. The treatment
modalities include conventional complete dentures
and unconventional complete dentures.
1 luted with auto polymerized acrylic resin. Fattore et
Unconventional dentures include hollow denture,
metal denture, liquid supported complete denture,
modified flange dentures etc. One common problem
with either conventional or unconventional dentures
is residual ridge resorption which is the term used for
the diminishing quantity and quality of the residual
ridge after teeth are removed. Severe resorption of
the edentulous ridges decrease the denture bearing
area for support, retention and stability of the
prosthesis. Also, it increases inter ridge distance
which complicates this problem further.
To decrease the leverage, reduction in the
weight of the prosthesis was recommended and was
also found to be beneficial.
2,3
Various weight
reduction approaches have been achieved using a
solid three-dimensional spacer, including dental
4-6
stone , cellophane wrapped asbestos, silicone
8 and the processing was done. The putty was later
putty
9,10
or modelling clay
11,12
during l
Vol. I Issue 1 Jan - Jun 2015
material from the planned hollow cavity of the
prosthesis.
9
Holt et al , processed a shim of indexed
acrylic resin over the residual ridge and used a
spacer which was then removed and the two halves
13
al , used a variation of the double flask technique for
obturator fabrication by adding heat polymerizing
acrylic resin over the definitive cast and processing a
minimal thickness of acrylic resin around the teeth
using a different drag. Both portions of resin were
attached using a heat polymerized resin.
14
Sullivan et al , described a modified method
for fabricating a hollow maxillary denture. A clear
matrix of the trial denture base was made. The trial
denture base was then invested in the conventional
manner till the wax elimination. A 2 mm heat
polymerized acrylic resin shim was made on the
master cast using a second flask. Silicone putty was
placed over the shim and its thickness was estimated
using the clear template. The original flask with the
teeth was then placed over the putty and the shim
removed from the distal end of the denture and the
24
Case Reports Narayana Journal of Research in Dental Specialties
openings were sealed with auto polymerizing resin.
The technique was useful in estimation of the spacer
thickness, but removal of putty was found to be
difficult especially from the anterior portion of the
denture.
Case-Report:
A 70-year old male patient visited the out-
patient department of Narayana Dental College and
Hospital with the chief complaint of worn out old
dentures and difficulty to chew food. The dentures
were 15 years old. Denture examination revealed that
the teeth were completely abraded, teeth and denture
base were discoloured giving an older look. Intraoral
examination revealed high well rounded maxillary
completely edentulous arch and highly resorbed
mandibular completely edentulous arch. It was
observed that inter-ridge distance was higher.
Technique:
1. Maxillary and mandibular primary
impressions were made with irreversible
hydrocolloid alginate (Zhermack). (Figure
1)
2. Using the special trays fabricated on the
primary casts, border molding (Figure
2) was done using low-fusing green stick
compound (DPI) and final impressions
were made with zinc-oxide eugenol paste
(DPI). (Figure 3)
3. Master casts were obtained on which
denture bases were fabricated using self
cure acrylic resin (DPI) and maxillary
occlusal rim was fabricated using
modelling wax (HDP).
4. The upper occlusal rim was customised to
the patient and it is observed that the
length of the rim was high.
5. Mandibular occlusal rim was built up
using a combination of green stick (DPI)
and impression compound (Y-DENT)
inorder to record the neutral zone in which
teeth are to be arranged to improve the
stability of the lower denture. The height
of the lower record was adjusted
according to the vertical dimension of the
patient and a interocclusal record was
made with zinc oxide eugenol impression
paste. (Figure 4)
6. Articulation of casts was done and it was
confirmed that inter-ridge distance was
Vol. I Issue 1 Jan - Jun 2015
higher, and a decision was made to
proceed with hollow denture in relation to
upper denture. (Figure 5)
7. By using a putty index to the neutral zone
record, teeth arrangement was done and
wax try in was done in the patient.
8. Flasking and dewaxing (Figure 6) of the
trial dentures were done. A thin layer of
acrylic resin was packed on the maxillary
teeth and a hollow fibre tube (Figure 7)
was filled with salt and the tube openings
were closed with wax and it was placed
on the packed resin (Figure 8) and rest of
the acrylic resin was packed in the
compartment and subjected to
conventional curing cycle.
9. A hole was made on the buccal side of
the denture and the salt was removed by
gently blowing air with a 3 -way syringe
(Figure 9) and the denture was weighed
before and after removal of salt and
considerable reduction in the weight was
observed.
10. The processed dentures were trimmed,
finished and polished. (Figure 10,11)
11. Insertion of the prosthesis was done and
patient was recalled after one week, 15
days and one month for follow up.
DISCUSSION:
Rehabilitation of edentulous mouth with
conventional complete denture always may not
yield satisfactory outcome in dentist as well as
patients biologic stand point. In cases with
severely resorbed ridges, problem arises in
attaining stability for the denture, especially with
15
mandibular one. There will be increased inter-
ridge distance in these cases, which eventually
causes shift in the occlusal plane away from the
residul ridge making unstable denture. For
these instances setting the teeth in neutral zone
is crucial, as occlusal plane is the one which
16
determines stability. Along with this, buccal
contours of the teeth influences the muscular
forces acting on the denture there by lifting the
17
denture. So fabrication of the prosthesis within
the confineness of oral musculature is
challenging task. Even though problems exist in
functional jaw positioning in highly resorbed
ridges, with the above technique we can easily
25
Case Reports Narayana Journal of Research in Dental Specialties

Figure 1: Maxillary and Mandibular primary impressions

Figure 2: Maxillary and Mandibular Border Molding

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Case Reports Narayana Journal of Research in Dental Specialties

Figure 3: Final impressions

Figure 4: Recording of Neutral Zone

Figure 5: Articulated Casts

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Case Reports Narayana Journal of Research in Dental Specialties
Figure 6: Dewaxed maxillary trial denture
Figure 8: Packing of Hollow Denture
attain the position with help of which teeth can
be set. Also, excessively resorbed ridges result
in increased inter ridge distance, which
increases the height, weight of the maxillary
denture which also effects the retention and
18,19,20
stability of the prosthesis. It is the dentists
responsibility to reduce the weight of the
prosthesis and make it stable and comfortable
to the patient.
Vol. I Issue 1 Jan - Jun 2015
Figure 7: Hollow tube with salt
Figure 9: Denture with access for salt removal
CONCLUSION:
Days and nights change, so do men,
so do tissues, so do our treatments. All the
diseases cannot be treated with a single drug;
similarly all the tissues cannot be treated with
single technique. It lies in the uniqueness of the
dentist to diagnose and treat according to the
clinical situation. Hollow denture is a simplified
technique for decreasing the weight of the
maxillary prosthesis and increasing the stability
of the mandibular prosthesis to improve the
comfort of the patient.
28
Case Reports Narayana Journal of Research in Dental Specialties

Figure 10: Final prosthesis

Figure 11: Pre and Post Operative Views

Vol. I Issue 1 Jan - Jun 2015 29

Case Reports Narayana Journal of Research in Dental Specialties
REFERENCES: 17. Vibha Shetty, Sivaranjani Gali, Smitha
Ravindran. Light weight maxillary complete
1. Norma Olvera, John D. Jones. Alternatives to denture: A case report using a simplified
Traditional Complete Dentures. DCNA technique with thermocol. J Interdisciplinary
2014;58:91-102. Dent 2011;1:45-49.
2. El Mahdy AS. Processing a hollow obturator. J 18. Laxman Singh Kaira. Light Weight Hollow
Prosthet Dent 1969;22:682-6. Denture A Case Series. NUJHS 2013;3:95-
3. Brown KE. Fabrication of a hollow bulb 100.
obturator. J Prosthet Dent 1969;21:97 103. 19. Usha Radke. Hollow Maxillary Complete
4. Ackerman AJ. Prosthetic management of oral Denture. J Indian Prosthodont Soc
and facial defects following cancer surgery. J 2011(4):246249.
Prosthet Dent 1955;5:413-32.
5. Nidiffer TJ, Shipman TH. Hollow bulb obturator
for acquired palatal openings. J Prosthet Dent Corresponding Author
1957;7:126-34.
6. Rahn AO, Boucher LJ. Maxillofacial
prosthetics: principals and concepts. St. Dr. Keerthi GK
Louis.Elsevier;1970, p.95 Post graduate student
7. Chalian VA, Barnett MO. A new technique for Department of Prosthodontics,
constructing a one-piece hollow obturator after Narayana Dental College,
partial maxillectomy. J Prosthet Dent 1972; Nellore, A.P
28:448-53.
8. Worley JL, Kniejski ME. A method for
controlling the thickness of hollow obturator
prostheses. J Prosthet Dent 1983;50:227-9.
9. Holt RA Jr. A hollow complete lower denture. J
Prosthet Dent 1981;45:452-4
10. Jhanji A, Stevens ST. Fabrication of one-piece
hollow obturators. J Prosthet Dent 1991;
66:136-8.
11. DaBreo EL. A light-cured interim obturator
prosthesis. A clinical report. J Prosthet
Dent 1990; 63:371-3.
12. Elliott DJ. The hollow bulb obturator: its
fabrication using one denture flask.
Quintessence Dent Technol 1983; 7:13-4.
13. Fattore LD, Fine L, Edmonds DC. The hollow
denture: an alternative treatment for atrophic
maxillae. J Prosthet Dent 1988; 59:514-6.
14. O'Sullivan M. The hollow maxillary complete
denture: A modified technique. J Prosthet Dent
2004;91:591-94.
15. Brill N, Tryde G, Cantor R. The dynamic nature
of the lower denture space. J Prosthetic
Dentistry 1965;15:401-417.
16. Beresin VE, Schisser FJ. The neutral zone in
complete denture. J Prosthet Dent
1976;36:357-67. Fish EW. Using the muscles to
stabilize the full lower denture. J Am Dent
Assoc 1933; 20: 2163-9.

Vol. I Issue 1 Jan - Jun 2015 30

Case Reports Narayana Journal of Research in Dental Specialties

AOT ARISING FROM DENTIGEROUS CYST: A REPORT OF 3 RARE CASES

1 1
Ramya D Post graduate student
2 2
Vandana Raghunath Professor and Head
3 3
Ajay Reginald Professor
4 4
Firoz Kamal Reader

1-4
Department of Oral Pathology and Microbiology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh.

ABSTRACT:. Adenomatoid odontogenic tumor (AOT) is an unusual benign tumor accounting for 3% of all odontogenic
tumors, unique to the maxillofacial area. Mainly affects females in their second decade & exhibiting predominance for
anterior maxillary region. It is categorized into three variants follicular, extrafollicular & peripheral. Follicular variants
involving all four canines & only maxillary canines accounts for 60% & 40% respectively. Three such rare cases are
presented which occurred in relation to maxillary right premolar, lateral & canine in 2nd, 3rd & 4th decades respectively

KEYWORDS: Adenomatoid, odontogenic, Tumor, AOT

INTRODUCTION
Adenomatoid odontogenic tumor (AOT) is an
uncommon benign epithelial lesion of odontogenic origin.
It was first described by Steensland in 1905 and Dreibaldt
in 1907 as pseudo adenoameloblastoma. Harbitz in 1915
described it as a cystic adamantinoma. In 1948 Staphne
considered it as a distinct pathological entity.
AOT contributes about 2-3 % of all odontogenic
tumors. In the WHO classification of 2005, AOT is
included under odontogenic epithelium with mature,
fibrous stroma without odontogenic ectomesenchyme.
Dental lamina remnants likely represents the progenitor
cells. Philpsen et al. subdivided this condition into three
groups referred to as follicular, extrafollicular, and
peripheral. The rare peripheral type occurs almost
exclusively in the anterior maxillary gingival. Intraosseous
AOT may be found in association with unerupted
permanent teeth (follicular type ), in particular the four
canines that accounts for 60 % with the maxillary canines
alone accounting for 40 %. Here we report a case of a
large follicular AOT or which could be a possible hybrid
variant apart from three types already established in the
literature. It is associated with a Dentigerous cyst in the
anterior maxilla in association with an impacted premolar,
canine and lateral respectively in 3 cases.
CASE REPORT 1:
A 16 year-old female reported to the hospital with a
chief complaint of a swelling of the right cheek associated
with pain since 3 months. The pain was dull in intensity
and intermittent in nature. The patient was moderately
built and moderately nourished. There were no signs of
pallor, icterus, cyanosis, clubbing, and koilonychias. All
her vital signs were within normal limits. On intraoral
examination, there was a firm well- defined swelling
extending from the distal side of upper right central incisor
to the mesial side of the second premolar of the same
side. The swelling was nontender. The overlying mucosa
was non tender & normal in color. The right first premolar
was missing. A lymph was palpated in the right
submandibular region. None of the teeth were tender on
percussion. The patient was subjected to radiological
examination for this lesion.OPG showed unilocular
radiolucency with well defined margins, in relation to apical
regions of upper right canine to second premolar of the
same with upper right first premolar tooth impacted .
The mass was enucleated completely along with the
impacted premolar. The specimen was subjected for
histopathological examination. The macroscopic
examination revealed a cystic lesion surrounding
completely crown of a single rooted teeth, 3 x3 cms, 2 mm
thickness. When it was cut open, outer surface is brownish
in color and inner surface is creamish with tiny nodular
growths.

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Case Reports Narayana Journal of Research in Dental Specialties

CASE REPORT-1

Case Report 1: preoperative photograph Case Report 1:Orthopantomogram

showing the lesion. showing unilocular radiolucency with
well defined margins, i.r.t. apical regions
of 13-15 with 14 impacted

Case Report 1: Gross examination shows Case Report 1:Cut section shows outer
cystic lesion surrounding completely crown brownish, inner creamish with tiny nodular
of a single rooted tooth growths

Case Report 1: Cystic lining of 2-4 layers

thickness .A large area of luminal proliferation Case Report 1:Cut section shows outer
which is detached shows, many spindle, ovoid brownish, inner creamish with tiny
nodular growths
and cuboidal odontogenic epithelial cells
arranged in the form of whorls/ sheets/ strands
with scattered eosinophilic hyaline droplets and
hyaline stroma

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Case Reports Narayana Journal of Research in Dental Specialties
CASE REPORT-1( cont..)
Case Report 1: Ducts lined by columnar cells and
containing eosinophilic material
CASE REPORT 2:
A 41 year-old female reported to the hospital
with a chief complaint of a swelling of the right cheek
associated with pain since 3 months. The pain was dull in
intensity and intermittent in nature. The patient was
moderately built and moderately nourished. There were no
signs of pallor, icterus, cyanosis, clubbing, and
koilonychias. All her vital signs were within normal limits.
On intraoral examination, there was a firm well- defined
swelling extending from the distal side of upper right
central incisor to the mesial side of the first molar antero-
laterally of the same side obliterating the right buccal
vestibule. The swelling was non tender. The overlying
mucosa was non tender & normal in color. A lymph was
palpated in the right submandibular region. None of the
teeth were tender on percussion.The patient was
subjected to radiological examination for this lesion.OPG
showed a large radiolucency with well defined margins, in
relation to apical regions of upper right central to mesial
side of the molar of the same with displacement of the
incisors. Lesion seems to pushing the inferior wall of the
sinus.
Under macroscopic examination a single soft
tissue specimen, which is greyish brown in colour with
attached 13, oval in shape, approximately 4 x5 cm in size,
smooth surface soft in consistency which appeared cystic
was received. It was cut into two bits and one half was
taken for processing.
CASE REPORT 3
A 39 year-old male reported to the hospital with
a chief complaint of a swelling of the right cheek
associated with pain since 3 months. The pain was dull in
Vol. I Issue 1 Jan - Jun 2015
Case Report 1 : Capsule is fibrocellular, spindle-
shaped cells forming rosette-like
intensity and intermittent in nature. The patient was
moderately built and moderately nourished. There were no
signs of pallor, icterus, cyanosis, clubbing, and
koilonychias. All his vital signs were within normal limits.
On intraoral examination, there was a firm well defined
swelling extending from the distal side of upper right
central incisor to the mesial side of the canine of the same
side. The swelling was non tender. The overlying mucosa
was non tender & normal in color. A lymph node was
palpated in the right submandibular region. None of the
teeth were tender on percussion. The patient was
subjected to radiological examination for this lesion.OPG
showed a unilocular radiolucency with well defined
margins, from apical regions of upper right central to
mesial side of the canine of the same with impacted
upper right lateral incisor.
Under macroscopic examination a single soft
tissue specimen measuring approximately 3x 3.2 cm in
size resembling a cyst, attached to the crown of upper
right lateral incisor with a bifurcated root was noted. The
cyst was ruptured and revealed empty lumen. It was
further cut open, the cyst lining measured around 2 mm
and crown of lateral incisor was revealed. Cyst was
attached to neck of lateral incisor .Portion of cyst lining
was cut and two bits were taken for processing.
Upon the basis of the clinical and radiographic findings of
all three cases a provisional diagnosis of dentigerous cyst
was given. The differential diagnosis include AOT .
Histopathological examination of all the three
cases shows the following features. The cystic specimen
shows a discontinuous odontogenic epithelial cyst lining of
variable thickness ( from 3-8 cell layers ) which is
proliferating in areas. A large area of luminal proliferation
which is detached shows, many spindle, ovoid or cuboidal
33
Case Reports Narayana Journal of Research in Dental Specialties

CASE REPORT-2

Case Report 2: Orthopantomogram shows a

Case Report 2 : Shows swelling extends from upper large radiolucency extends from apical
right central to molar, obliterating he vestibular regions from central to first mola r.
sulcus. displacement of anteriors

Case Report 2: Gross examination shows grayish brown in color with attached 13, oval in shape. Cut section
shows smooth surface soft consistency which appeared cystic.

Case Report 2: A cystic lining of 2-4 layers along with luminal proliferations. Ducts lined with columnar
cells and containing eosinophilic material are seen scattered. Spindle cells forming rosette like structures.

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Case Reports Narayana Journal of Research in Dental Specialties

CASE REPORT-3

Case Report 3 : Swelling extends from distal side of Case Report 3: Unilocular radiolucency with well
central incisor to mesial of canine defined margins from apical of 11-13, with 12
impacted

Case Report 3: On gross examination shows 3 x3.5 cm along with 12, thickness of 2 mm, bifurcated root of the
upper right lateral incisor. Cut surface shows cyst was attached to neck of 12.

Case Report 3: Shows a discontinuous odontogenic epithelial cyst lining of variable thickness from 3-8 cell layers
which is proliferating in areas. A large area of luminal proliferation which is detached shows many spindle, ovoid
and cuboidal odontogenic epithelial cells arranged in the form of whorls/ sheets/ strands with scattered eosinophilic
hyaline droplets and a hyaline stroma.

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Case Reports Narayana Journal of Research in Dental Specialties

CASE REPORT-3(cont..,.)

Case Report 3: Ducts lined with columnar cells and containing eosinophilic material are also seen scattered.The capsule is
fibrocellular with many spindle / plump fibroblasts and parallel aligned collagen bundles. Few calcifications are seen close
to lining. Immature bony trabeculae are seen at the periphery of the capsule forming a discontinuous rim.

odontogenic epithelial cells arranged in the form of whorls/
sheets/ strands with scattered eosinophilic hyaline
droplets and a hyaline stroma. Ducts lined with columnar
cells and containing eosinophilic material are also seen
scattered. The capsule is fibrocellular with many spindle/
plump fibroblasts and parallel aligned collagen bundles.
Few strands and small islands of odontogenic epithelial
cells and small/ large basophilic calcifications are noted
close to the lining. Immature bony trabeculae are seen at
the periphery of the capsule forming a discontinuous rim.
Based on these histological findings a diagnosis of
Adenomatoid odontogenic tumor arising from Dentigerous
Cyst (hybrid variant) was given to above all three cases.
DISCUSSION
AOT was first recognized as a distinct
pathological entity by Stafne in 1948. It has been reported
that some odontogenic cysts occur in association with
odontogenic tumors or epithelial lining from cyst transform
into odontogenic neoplasm like ameloblastoma or AOT.
Because neoplastic and hamartomatous lesions can occur
at any stage of odontogenesis, odontogenic tumors with
combined features of epithelial and mesenchymal
components may arise within the odontogenic cyst.
Garica-pola et al. described the proliferation of an
adenomatoid odontogenic cyst in the epithelial border of a
dentigerous cyst.
The structure of the cyst in this case and its
insertion around the crown of an unerupted tooth were
typical of dentigerous cyst. Some believe that they
originate from the odontogenic epithelium of a dentigerous
cyst. Therefore, the hypothesis that follicular AOT arise
from the reduced enamel epithelium that lines the follicles
of unerupted teeth is fairly conclusive. This is further
supported by both morphological and immune
histochemical evidence. According to this hypothesis, the
lesions grow next to or into a nearby dental follicle lading
to the envelopmental theory.
If the tumour grows after cystic expansion, then
this makes certain its orgin from a dentigerous cyst. If it
occurs before cystic expansion, then tumor tissue will fill
the follicular space and the AOT will present as a solid
tumor.
Some features of AOT arising from Dentigerous cyst
are these are entirely cystic with AOT like proliferation,
attached at CEJ, more amount of straw colour fluid.
Histologically the cystic lining is reduced enamel
epithelium ie 2-4 layers / non keratinized stratified
squamous epithelium or solid masses of AOT in walls of
connective tissue wall or dentigerous cyst lining may
proliferate in the wall or AOT proliferation can be seen in
the lumen also.
Radiologically, it should be differentiated from
dentigerous cyst, which most frequently occurs as a
pericoronal radioucency in the jaws. Dentigerous cyst
encloses only the coronal portion of the impacted tooth,
whereas the AOT shows radiolucency usually surrounding
both the coronal and radicular aspects of the involved
tooth. However, the irregularity in the wall of the cyst may
indicate the development of AOT. These lesions may often
appear completely radiolucent; however, they contain fine
specks of dystrophic calcifications or tooth material like
enamel, dentin, enamel and dentin, cementum, dentin and
cementum, a feature differentiating AOT from dentigerous
cyst.

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Case Reports Narayana Journal of Research in Dental Specialties
This tumor manifests as an intraosseous lesion 9. L.S.Valderrama, dentigerous cyst with intracystic
(central type) in the majority of cases (96 %). adenomatoid odontogenic tumor and complex
Extraosseous or peripheral lesions account for less than 4 odontoma,the journal of the Philippine dental
%. Intraosseous AOT may be radiographically divided into association,vol.41, no.3,pp.35-41,1988
2 types: follicular ( pericoronal ) and extrafollicular (
extracoronal ).The former is characterized by a well-
defined unilocular radiolucency surrounding the crown and
partly the root of an unerupted tooth. The latter is not Corresponding Author
associated with an unerupted tooth and the well-defined
unilocular radiolucency is found between, above or
superimposed upon the roots of unerupted, permanent
teeth. Dr. Ramya D
Postgraduate student
AOT and dentigerous cyst are both benign, Department of Oral Pathology and
encapsulated lesions and conservative surgical
Microbiology,
enucleation or curettage is the treatment of choice.
Narayana Dental College and
CONCLUSION Hospital,
Nellore, Andhra Pradesh
To conclude, while histopathological features are India-524003
usually considered the gold standard for diagnosis of most
lesions. Further, it would be an important point to note that
investigations into the possibility of fourth type of a hybrid
kind of AOT, apart from the already established three
types of AOT are required. Till now a total of 39 cases are
reported in the systemic search including our above three
cases.

REFERENCES

1. Vikramjeet singh et al,Adenomatoid Odontogenic

tumor with dentigerous cyst : report of a rare case
with review of literature, sep 2012, vol. 3, supplement
2
2. Anshita agarwal et al,The interrelation of
adenomatoid odontogenic tumour and dentigerous
cyst : A report of a rare case and review of literature,
november 2012.
3. Visalakshi devarakonda et al, Extrafollicular
adenomatoid odontogenic tumor, jan-apr 2012, vol
2,iisue 1.
4. Yogesh mittal et al, adenomatoid odontogenic tumor
mimicking a dentigerous cyst, 2012; 1 (3) :js003 E.
5. Balasundari Shreedhar et al, Case report-A huge
adenomatoid odontogenic tumor of maxilla,
december 2012.
6. Philipsen HP, Reichart PA, et al Adenomatoid
odontogenic tumor : Biologic profile based on 499
cases. j. oral pathol Med 1991 ; 20 :149-58.
7. Philipsen HP, Reichart PA, Adenomatoid
odontogenic tumor : Facts and figures , oral oncol
1998 ; 35 : 125-31.
8. Y. Tajima, E. Sakamoto et al, odontogenic cyst
giving rise to an adenomatoid odontogenic tumor :
report of a case with peculiar features, journal of oral
and maxillofacial surgery, vol. 50, no.2, pp.190-193,
1992.
Vol. I Issue 1 Jan - Jun 2015 37
Review Articles Narayana Journal of Research in Dental Specialties

MANDIBULAR DISTRACTION OSTEOGENESIS

1 1
Venkata Naidu Bhavikati Post graduate student
2 2
Venkatesh Nettam Post graduate student
3 3
Mandava Prasad Professor and Head

1,2,3
Department of Orthodontics, Narayana Dental College and Hospital, Nellore, Andhra Pradesh.

ABSTRACT:. Distraction osteogenesis is one of the latest techniques for the correction of bone deformities.
Distraction osteogenesis is gaining popularity as it not only grows bone but also it grows the surrounding soft tissue
and neurovascular bundle. Its application in dentistry is increasing day by day. It can be used to correct various
deformities which may congenital, pathological resection, craniofacial anomalies and alveolar ridge for prosthetic
purposes. Mandible is the jaw bone most commonly used for doing distraction osteogenesis.

KEYWORDS: Distraction osteogenesis, Distraction Techniques, Retrognathia, Mandibular deficiency,

Orthognathic surgery

INTRODUCTION

One of the most common dentofacial deformities includes
mandibular deficiency in any one or all dimensions. It may
be present as individual entity or in combination with other
deformities or associated with syndromes. Traditionally
these problems are corrected using orthodontics alone or
with combination with orthognathic surgery. But recently
new technique distraction ontogenesis, which has become
1 7mm).
a boon for these type of deformities.
3. Mandibular corpus distraction osteogensis:
4
According to Diner et al, mandibular corpus
lengthening can be done in all cases except
OSAS patient below 4 years. This includes young
patients with unsuccessful functional treatment
and severe mandibular deficiencies (greater than

INDICATIONS OF DISTRACTION OSTEOGENESIS 4. Mandibular symphyseal distraction

5
osteogenesis:
2
1. Sagittal mandibular distraction osteogenesis: Distraction osteogenesis in the mandibular
Major mandibular advancement (>7mm). symphyseal area is indicated when it is
Presurgical Temporo mandibular joint necessary to significantly alter the mandibular
disease. arch form (e.g. V shaped mandible) and the
Sleep Apnea. treatment requirements exceed the
Inadequate mandibular anatomy. possibilities of the conventional orthodontic or
Secondary mandibular advancement. surgical treatment (> 4 mm).

To increase the mandibular width to
2. Transverse mandibular osteodistraction:
3 compensate for arch length inadequacy,
Narrow V-shaped mandibular arch, crowded anterior teeth, or absolute bone
deficiency.
Scissor bite (Brodie syndrome),
Osteodistraction is most applicable when the
Impacted anterior teeth,
chin appears narrow clinically.
Severe mandibular anterior crowding with
Mandibular symphyseal osteodistraction may
perfectly aligned maxillary teeth and a
be indicated in Hanharts syndrome, Brodie
normal nasolabial angle,
syndrome (unilateral or bilateral), Freeman-
Orthodontic retreatment with mandibular
sheldon syndrome, Hypoglossia-
crowding and previous extractions, and
hypodactyly syndrome, hemifacial
Severe maxillomandibular crowding with narrow
microsomia, craniosynostosis.
arches
Vol. I Issue 1 Jan - Jun 2015 38
Review Articles Narayana Journal of Research in Dental Specialties
Maxillomandibular transverse deficiency
(Crocodile bite, Tunnel smile).
Impacted anterior mandibular teeth with no
available space.
PREDISTRACTION ORTHODONTICS
It is primarily done to reverse the dental decompensation,
align and level the arches, improving the arch widths and
coordination between the arches and correction of other
6
abnormalities like cant of occlusal plane etc .
Before initiating orthodontic treatment one should plan the
final outcome of the treatment with distraction and
accordingly the appliance is selected and designed in a
way allow the movement of the distraction segment
6
starting the pre distraction orthodontincs
Pre surgical records are collected once the above
objectives are reached, surgical prediction should be done
both on the cast and using software for prediction
outcome.
Once mock surgery is performed, a surgical guide is
fabricated to help the surgeon during surgical
2
procedure. .Presurgical orthodontic treatment usually lasts
2
from 6 to 10 months.
MANDIBULAR DISTRACTION DEVICES
Can be classified as
1. Extra Oral And Intra Oral appliances
2. Uni Directional, Bi Directional And Multi Directional
3. Rigid And Semi Rigid appliances
EXTRA ORAL APPLIANCES
UNIDIRECTIONAL
o Hoffmann uniplanar device
o Unidirectional mandibular distractor
o Synthesis mini lengthening apparatus
o Orthofix mini fixator
BIRECTIONAL
o Bidirectional mandibular distractor
MUTIDIRECTIONAL
o Ace normed multidirectional distractor
o Multi guide mandibular distractor device
o Multi vector mandibular distractor
o Frankfort mandibular distraction system
EXTRA ORAL APPLIANCES
Hoffman Uniplanar Device
7
McCarthy , in 1989, was the first to clinically
apply an external fixation device for mandibular
lengthening. It is a four- pin device that allows calibrated
8
lengthening for the total distance of 25mm. It consists of
two double-pin fixation clamps secured to a telescopic rod
that activated by a screw mechanism.
Uni-directional Mandibular Distractor
7
Bitter and Klien introduced their own external
fixation device for mandibular lengthening the Uni
directional mandibular.
Synthesis Mini Lengthening Apparatus
The Synthesis Mini Lengthening Apparatus is
another mini version of an apparatus the Wagner Leg
Lengthener. It has a similar structure, consisting of two
double-pin clamps connected by a linear telescopic
distractor.
Orthofix Mini Fixator
The Orthofix Module System was originally
designed for long bone fracture reduction and fixation. The
Orthofix Mini Fixator consists of a sliding clamp directly
attached to the distraction mechanism and a rotating
clamp connected to the body of the apparatus by a special
ball-and-socket joint.
BI-DIRECTIONAL DISTRACTORS:
Bi-directional devices( Fig- 1) can distract both vertically
and horizontally following either a single or double level
osteotomy. In addition, an adjustment in the angular
relationship between the two distraction vectors can be
accomplished during lengthening.

INTRA ORAL APPLIANCES

o Intra oral device (how medica)
o Spiral distractor
o Semi buried fixed trajectory curvilinear distractor
o Hybrid appliance
o Mandibular advancement with md-dos appliance
o Multiaxis intra oral distraction of mandible
o Rod intra oral custom distractor

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Review Articles Narayana Journal of Research in Dental Specialties
Bi-directional Mandibular Distractor
9
Molina and Ortiz-Monasteri were the first to use bi-
directional osteodistraction in the mandible (Fig.11.12).
They generated two distraction sites via a double-level
corticotomy (horizontal in the ramus and vertical in the
corpus). Three pins were used for fixation: a central pin
introduced between the two corticotomies at the
mandibular angle, one in the corpus, and one in the
ramus.
Multi-directional Distractor (Fig -2)
It is composed of two geared distraction rods with
one freely movable rider. Both rods are connected in the
middle by a special joint piece with attachments for two
fixation pins, permitting double-level lengthening. In
addition, the central piece has two universal joint
mechanisms allowing each arm to have independent
three-dimensional rotation.
The Multi-Guide Mandibular Distraction Device
also consists of two distraction rods with gradually sliding
clamps connected in the middle by a universal hinge.
The Multi Vector Mandible Distractor from
SYNTHESIS Maxillofacial consists of two threaded
interchangeable arms connected in the middle by a three-
dimensional hinge. As a general rule, the multidirectional
distractor is used in older children and the bidirectional
8
distractor in younger children.
Extraoral Mandibular Distraction Osteogenesis Using
The Frankfurt Modular Distraction System:
The "Frankfurt Craniofacial Distraction System"
for mandibular lengthening was developed by Klein with
cooperation of Normed, Tuttlingen, Germany. The Bi-
Directional Distractor consists of two limbs connected to
an angulation joint. The half pins are mounted to a mobile
slide on each limb. A third pin holder is mounted to the
angulation piece. The slides are driven on a geared rod,
which is calibrated in millimeters. The angulation piece
Vol. I Issue 1 Jan - Jun 2015
allows controlled rotation of the two limbs from 180 to 90
positions. Radial grooves on the inner surface of the
angulation joint apply slight friction, thereby avoiding
uncontrolled angular changes between the two limbs.
INTRA ORAL APPLIANCES
INTRAORAL DEVICE ( HOWMEDICA)
10
Vazquez, Diner, Kollar et al. developed a intraoral
device but it was too large to be placed on hypoplastic
mandible.
MANDIBULAR ADVANCEMENT WITH MD-DOS DEVICE
Mandibular Distraction with a Dynamic
Osteosynthesis System (MD-DOS) device is used for
mandibular lengthening in mandibular retrognathism. It
11
was introduced in 1997. The MD-DOS device consists of
four major components: a posterior fixation unit (PFU), a
spacer, a distraction unit (DU), and an anterior fixation unit
(AFU).
ROD INTRAORAL CUSTOM DISTRACTION DEVICES:
12
ROD technique was developed by Razdolsky et al. It
relies primarily on tooth borne distractors. This method
provides a predictable, convenient, less costly method for
correction of Class II mandibular skeletal deficiency
compared with traditional surgical advancement. In
addition, it is now possible to distract first and then
decompensate the teeth by moving them into the new
regenerate bone, thus eliminating the need for presurgical
extractions of lower premolar in Class II cases with lower
incisor crowding or protrusion.
The ROD Devices are intraoral, custom made distraction
devices preprogrammed along a desired vector of
12
distraction.
CATEGORIES OF ROD:
1. ROD-1 (tooth- borne): used for interdental
mandibular distraction to generate bone in which
teeth can be moved for simultaneous resolution of
dental crowding and skeletal deficiency.( Fig -3)
40
Review Articles Narayana Journal of Research in Dental Specialties
2. ROD-2 (Hybrid): used for distraction posterior to the
mandibular dentition for the correction of skeletal
deficiency.
3. ROD- 3 (tooth borne): used to widen the mandibular
symphysis for resolution of lower anterior crowding in
cases with significant mandibular anterior arch
constriction
4. ROD-4 (Hybrid): used to widen and advance the
maxilla for correction of transverse and antero-
posterior deficiencies.
5. ROD-5 (Hybrid): used for alveolar ridge distraction to
generate bone for dentoalveolar implant placement.
BURIED BIDIRECTIONAL TELESCOPIC MANDIBULAR
DISTRACTION:
13
Study done by Walker, showed that the unidirectional
distraction done with buried intraoral telescopic bone plate
led to the development of asymmetric occlusion due to
lack of distraction vector control in medio lateral direction.
This led to development of the Bidirectional Telescopic
Mandibular Distractor (BTMD). Bidirectional Telescopic
Mandibular Distractor (BTMD) has a medio lateral offset
with an adjustable screw allowing intraoperative
adjustment of the distraction vector and postoperative
correction of midline occlusal discrepancies.
MULTIAXIS INTRAORAL DISTRACTION OF
MANDIBLE:
Multiaxis Intraoral Distraction was introduced by Tracia et
14
al.(2001) to overcome the unidirectional nature of the
intraoral distractors.
SPIRAL DISTRACTOR FOR MANDIBULAR
OSTEODISTRACTION:
15, 16
According to studies done by Ricketts (1972,1982),
17
Moss et al.(1970), mandible grows along a logarithmic
spiral i.e. it grows in archial manner. During growth,
eruption of the posterior teeth occurs, thereby maintaining
the occlusion while advancing the chin anteriorly through
space. This led to the development of a semi buried
distractor with a curvilinear distraction vector. By placing
the osteotomy and device at the mandibular ramus, the
archial path of distraction would mimic the logarithmic
spiral of mandibular growth.
IMPLANTS IN MANDIBULAR DISTRACTION:
Osteointegrated implants are used as abutments and then
connectors are used to distract the mandible. This
removes the requirement to place pins which can loosen,
become infected, or cause nerve damage. The
disadvantage of this technique is that there is bone loss
when the implants are removed. Subperiosteal Implants
are useful since these can be removed with minimal bone
18
loss.
Vol. I Issue 1 Jan - Jun 2015
DEVICE SELECTION:
The intraoral devices are usually unidirectional. Clinical
cases of mandibular hypoplasia may demand bidirectional
distraction, including severe hypoplasia of the ramus in
combination with a significant occlusal cant, or when the
mandibular hypoplasia involves both the ramus and the
corpus, particularly when an obtuse gonial angle is
present (Treacher Collins). This led to the introduction of
Bi-directional devices. This device is useful for increasing
ramus and corpus length, as well as the angle between
the ramus and corpus. In addition, angulation of the device
is used to allow the ramus and chin to reposition
4
posteriorly and to create a posterior openbite.
DISTRACTION PROTOCOL:
After a latency of 3 to 4 days, distraction is initiated at a
rate of 1mm per day performed in one increment at each
osteotomy site. In small children under 3 years of age, the
rate is 2 mm per day performed in two equal increments
.
ORTHODONTIC TREATMENT DURING DISTRACTION
2
AND CONSOLIDATION:
Active orthodontics can be continued during the
distraction/ consolidation phase to improve the quality of
results by directing the tooth bearing segment toward its
87
post distraction position . By this orthodontic/ orthopedic
treatment metabolic response can be increased and
6
healing of the surgical site can be enhanced.
Class II elastics (4 to 6 oz per side) must be worn 24
hours per day during distraction and consolidation. This is
done to counteract the soft tissue forces at the time of
bone healing. If this is not done, reciprocal forces will act
against the TMJ, causing detrimental arthritic changes in
19
the condyle, disk, and the glenoid fossa . The patient will
experience pain and discomfort. Unloading the joints with
elastics during consolidation avoids Class II relapse and
minimizes patient discomfort. Inter maxillary elastics can
be used to modify the direction of skeletal change and fine
20
tune the occlusal outcome of distraction.
Inter arch elastic traction applied during distraction has
been shown to influence the vectors of distraction in the
6
vertical, antero posterior and transverse directions. Class
II malocclusion, as a result of distraction, may be
corrected with Class II interarch elastics. A Class III
malocclusion may be corrected with Class III elastics.
Class III elastic traction may be further supported by the
use of protraction headgear.
The most important use of elastic traction during the
active distraction phase is to control
21
laterognathism. Laterognathism is frequently experienced
phenomenon in the unilateral distraction of asymmetric
41
Review Articles Narayana Journal of Research in Dental Specialties
mandible (e.g. Hemifacial microsomia, craniofacial
microsomia, asymmetry secondary to trauma).
ORTHODONTIC TREATMENT AFTER DISTRACTION
AND CONSOLIDATION:
The post distraction orthodontic treatment depends on
the age of the patient. When the patient is in the
deciduous or mixed dentition, functional treatment is
performed so as to continue the correction of the occlusal
cant and stimulation of growth on the affected side. The
patient in the permanent dentition, orthodontic treatment
must continue so as to coordinate both arches in three
dimensions. It is important to treat the patient during peak
growth possibly using a functional appliance to maintain
4
symmetric growth.
After consolidation, the distraction device is removed
and the tooth bearing segment of the mandible derives its
support from the new bone that was generated across the
distraction gap. Post distraction orthodontics/orthopedics
is instituted at this time to accomplish the original
6
treatment goals.
The post distraction needs vary depending on whether
the mandibular distraction is unilateral or bilateral.
a. Bilateral Distraction patient:
In the growing bilateral distraction patient, an anterior
crossbite may have temporary treatment objective in
anticipation of future deficient mandibular growth.
Additional treatment objectives would include eruption
guidance and alignment of the dentition over the alveolar
bone. Orthodontic treatment for growing children may
need to take into consideration future distraction or
orthognathic surgery.
In the non growing bilateral distraction patient,
orthodontic finishing is done at this time. Some patients
may require orthognathic surgery after mandibular
distraction. These patients undergo orthodontic
87
preparation for the surgery at this time.
b. Unilateral Distraction Patients:
In unilateral distraction patients, the post distraction
orthodontic therapy will most likely involve occlusal plane
management, correction of dental midlines, and correction
of maxilla mandibular transverse disharmony. Unilateral
distraction usually requires extensive post distraction
orthodontic support. This may include eruption guidance,
alignment of dentition over alveolar bone, correction of
latero gnathism, and controlled vertical closure of the
6
unilateral posterior open bite.
Posterior open bite management: The posterior open
bite is closed by selective eruption of maxillary posterior
Vol. I Issue 1 Jan - Jun 2015
dentition and alveolar process. This is accomplished by
22
using bite plate worn on the mandibular dentition.
C. Occlusal plane management:
An occlusal acrylic wafer that is reduced one tooth at
a time to allow serial eruption of maxillary posterior
dentition
A functional appliance with a lingual shields to provide
lateral control of mandibular position. Included in this
appliance is a bite plane which is adjusted one at a time
for passive eruption of the maxillary teeth, and Occlusal
build ups that are reduced one tooth at a time to allow
serial eruption of the maxillary teeth. Elastic traction
decreases the treatment time for correction of maxillary
87
occlusal plane and improves the appliance retention.
Leveling of the maxillary occlusal plane may be
accomplished with the use of interarch elastics utilized in
combination with rapid palatal expansion, which has been
shown to induce bony changes at all of maxillary
23
sutures. After consolidation is complete the arches are
coordinated and orthodontic finishing proceeds for an
additional 6 months. Once treatment is completed, the
patient is debanded. Retention in these cases depends on
the individual patient, but if positioner is worn for 4 months
prior to conventional retainer fabrication.
COMPLICATIONS OF MANDIBULAR DISTRACTION
24
OSTEOGENESIS:
Complications include relapse (64.8% incidence),
tooth injury (22.5%), hypertrophic scarring (15.6%), nerve
injury (11.4%), infection (9.5%), inappropriate distraction
vector (8.8%), device failure (7.9%), fusion error (2.4%),
and temporomandibular joint injury (0.7%).
REFERENCES
1. Pamela R. Hanson,Michael B.
Melugin, Surgical/Orthodontic Treatment of
Mandibular AsymmetriesSeminars in Orthodontics
SeminOrthod 2009;268278.
2. Guerrero CA, Bell WH, Contasti GI, Rodriguez AM.
Mandibular widening by intraoral distraction
osteogenesis. Br J Oral MaxillofacSurg 1997;35:383
392.
3. Converse JM, Horowitz SL. The surgical-orthodontic
approach to treatment of dentofacial deformity, Am J
OrthodDentofacOrthop 1969;55:21743
4. Diner PA, Tomat C, Soupre V, Martinez H, Vazquez
MP.Intraoral mandibular distraction: indications,
techniqueand long term results. Ann Acad Med
Singaport 1999;28:634-641.
5. Tomat C, Diner PA, Coquille F, Sergent B, Vasquez
MP. Mandibular symphyseal widening by distraction.
42
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In Samchukov ML, Cope JB, Cherkashin AM. Editors. 23. Haas AJ. Rapid palatal expansion of the maxillary
Craniofacial distraction osteogenesis, 2001, Mosby. dental arch and the nasal cavity by opening the mid
6. Hanson PR, Melugin MB. Orthodontic management of palatal suture, Angle Orthod. 1961; 31:3.
the patient undergoing the mandibular distraction 24. Master, Daniel L., Hanson, Pamela R., Gosain, Arun
osteogenesis, SeminOrthod. 1999; 5:25. K. Complications of Mandibular Distraction
7. McCarthy JG, Schreiber JS, Karp NS, et al. Osteogenesis. Journal of Craniofacial Surgery
Lengthening the human mandible by gradual 2010;1565-1570.
distraction, PlastReconstr Surg. 1992; 89:1.
8. Nakagawa K, Ueki K, Takatsuka S, Marukawa
K, Yamamoto E.A device for determining the position
of intraoral distractors for protracting the maxilla. J Corresponding Author
CraniomaxillofacSurg 2003;31(4):234-7.
9. Molina F, Ortiz- Monasterio F. Mandibular elongation
and remodeling by distraction: A farewell to major
osteotomies, PlastReconstr Surg. 1995; 96:825. Dr. Venkata Naidu Bhavikati
10. Diner PA, Kollar EM, Martinez H, Vazquez. Intraoral Postgraduate student
distraction for mandibular lengthening: a technical Department of Orthodontics
innovation. J Cranio- Maxillo Facial Surg. 1996; 24:92.
Narayana Dental College and Hospital,
11. Mommaerts, M. Office based mandibular
advancement with the MD-DOS device. in: Nellore, Andhra Pradesh
Craniofacial distraction osteogenesis.. : Mosby, St India-524003
Louis; 2001:266.
12. Razdolsky Y., Dessner S., El-Bialy T., Clinical
Application of ROD Intraoral Custom Distraction
Devices. In: Craniofacial Distraction Osteogenesis,
Mosby, 2001, 269-27
13. Walker DA.Management of severe mandibular
retrognathia in the adult patient using distraction
osteogenesis. J Oral
MaxillofacSurg 2002;60(11):1341-6.
14. Triaca A, Minoretti R, Dimai W, Merz BR. Multiaxis
intraoral distraction of the mandible. In Samchukov
ML, Cope JB, Cherkashin AM. Editors: Craniofacial
distraction, 2001, Mosby.
15. RickettsRM. A principle of arachial growth of the
mandible, Angle Orthod. 42:368, 1972.
16. RickettsRM. The biologic significance of divine
proportions and Fibronacci series, Am J Orthod. 1982;
81:351.
17. Moss M, Salentjin L. the logarithmic growth of human
mandible, ActaAnatom. 1970; 77:341.
18. Davies J, Turner S, Sandy JR. Distraction
Osteogenesis: A review. British Dent J. 1998;
185(9):462-467.
19. Hanson PR1, Melugin MB Orthodontic management
of the patient undergoing mandibular distraction
osteogenesis. SeminOrthod. 1999 Mar;5(1):25-34
20. Grayson BH, Santigao PE. Treatment planning and
biomechanics of distraction Osteogenesis from
orthodontic perspective, SeminOrthod. 1999; 5:9-24.
21. Diner PA, Kollar EM, Martinez H, Vazquez. Intraoral
distraction for mandibular lengthening: a technical
innovation. J Cranio- Maxillo Facial Surg. 1996; 24:92.
22. McCarthy, Joseph G., et al. "Distraction of the
mandible." Distraction of the craniofacial skeleton.
Springer New York. 1999. 80-203.

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Review Articles Narayana Journal of Research in Dental Specialties

PERINATAL ORAL HEALTH CARE

1 1
Naveen Kumar Kolli Post graduate student
2 2
Nirmala S.V.S.G Professor
1,2
Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh.
,

ABSTRACT:. Improved health outcomes for the mother and unborn child are the ultimate goal yet, The
achievement of optimal oral health in pregnant women hampered by myths surrounding the safety of dental care
during pregnancy. Prenatal care providers integrate oral health into the care of their pregnant patients so that
mother and baby can lead healthy lives. Fortunately, opportunities exist to educate health professionals who
work with women about the importance of oral health care during the perinatal period and to engage these
health professionals in promoting womens oral health during that period that could result in improved oral as
well as general health of expectant mothers and to their children.

KEYWORDS: Perinatal, Oral health care, Foetal health, Cariogenic, Microbial Transmission

INTRODUCTION

The perinatal period is defined as the period RECOMMENDATIONS:

around the time of birth, beginning with the completion of
the 20th through 28th week of gestation and ending one to
four weeks after birth. Perinatal oral health plays a crucial
role in the overall health, well-being of pregnant women as
well as health and well-being of their new-born children.
By employing principles of perinatal oral health care we
can achieve decreased incidence of early childhood
caries, opportunity to provide anticipatory guidance and
establishment of dental HOME no later than 6 months of
age or by first birthday of child, opportunity to a child to
have a lifetime free from preventable oral diseases and to
lower the numbers of cariogenic bacteria in an expectant
mothers mouth so that Mutans Streptococci (MS)
colonization of the infant can be delayed as long as
1
possible.
There is an association between poor oral health
of expectant mothers and an increased risk of adverse
pregnancy outcomes, such as preterm deliveries, low birth
weight babies, preeclampsia and high risk for vertical
2
transmission of cariogenic bacteria.
Clinical specialities involved in perinatal oral
health care, provided by advanced practice nurses, allied
health personnel, dentists and physicians, are Dentistry,
Obstetrics and Gynaecology, Paediatrics and Preventive
Medicine.
An opportunity to educate women regarding oral
health by providing a teachable moment in self-care and
future child-care is offered during pregnancy. Early
intervention and counselling during the perinatal period
from all health care providers are essential to ensure good
3
oral health for the mother and infant.
Pregnant woman experiencing frequent vomiting and
nausea makes them to avoid tooth brushing that results in
increased caries rate, so they are advised to rinse with a
cup of water containing a teaspoon of baking soda and
wait an hour before brushing that helps in minimizing
4
dental erosion and to facilitate tooth brushing.
Tooth brushing with fluoridated toothpaste, flossing
and rinsing with an alcohol-free, over-the-counter mouth
rinse containing 0.05% sodium fluoride once a day or
0.02% sodium fluoride rinse twice a day have been
suggested to reduce plaque levels as well as to promote
enamel remineralisation.
A healthy diet is necessary to provide adequate
amounts of nutrients for the mother-to-be and unborn
child. Dietary recommendations include eating small
amounts of nutritious food throughout the day that helps to
minimize their caries risk. Prenatal diet supplementation
with proteins, folic acid, calcium, phosphate and vitamin A,
C, D are recommended. The cariogenic potential of the
mothers diet (i.e., cariogenicity of certain foods,
beverages, medicines) as well as its effect on her child

Vol. I Issue 1 Jan - Jun 2015 44

Review Articles Narayana Journal of Research in Dental Specialties
should be addressed. The frequency of consumption of 3. American Academy of Pediatrics. Policy on oral health risk
cariogenic substances and resulting assessment timing and establishment of the dental home.
demineralization/remineralisation process also are Pediatrics 2003;111:1113-6.
important. Chewing sugarless or xylitol-containing chewing 4. New York State Department of Health. Oral health care
gum (2-3 times a day)by the mother is important to reduce during pregnancy and early childhood: Practice Guide-
bacterial plaque levels. lines. August, 2006.
5. Gajendra S, Kumar JV. Oral health and pregnancy: A
Comprehensive dental examination and review. NY State Dent J 2004;70:40-4.
treatment should perform to the expectant mother during 6. Berkowitz RJ. Acquisition and transmission of Mutans
5
second trimester, or the 14th through 20th weeks. streptococci. J Calif Dent Assoc 2003;31:135-8.

Avoidance or delay of MS transmission can be

accomplished by educating the mother or caregiver on
behaviours that directly pass saliva to the child such as
sharing utensils or cups or straws, cleaning a dropped Corresponding Author
pacifier by mouth, kissing the baby on mouth, sharing a
6
spoon when tasting baby food.

Routine preventive efforts should include wiping an Dr. Naveen Kumar Kolli
infant mouth with a soft cloth or gauge cloth after every Postgraduate student
breast or bottle feed, tooth brushing, optimizing the childs Department of Pedodontics
fluoride exposure and limiting the childs frequency of
Narayana Dental College and Hospital,
carbohydrate intake.
Nellore, Andhra Pradesh
All primary health care professionals who serve India-524003
pregnant women should provide education on the etiology
and prevention of Early Childhood Caries(ECC). Oral
health counselling and referral for a comprehensive oral
examination and treatment during pregnancy is especially
important for the mother.

CONCLUSION:

Many expectant mothers are unaware of the

implications of poor oral health for themselves, their
pregnancy, and/or their unborn child. Timely delivery of
educational information and preventive therapies by
physicians, nurses, and other health care professionals
are far more likely to see expectant or new mothers and
their infants than are dentists will improve the quality of life
of a child. Legislators, policy makers and third party
payers should also be educated about the benefits of
perinatal intervention in order to support efforts that
improve access to oral health care for pregnant women.

REFERENCES:

1. Sacco G, Carmagnola D, Abati S, et al. Periodontal disease

and preterm birth relationship: A review of the literature.
Minerva Stomatol 2008;57:233-50.
2. Meyer K, Geurtsen W, Gunay H. An early oral health care
program starting during pregnancy: Results of a prospec-
tive clinical long-term study. Clin Oral Investig 2010;
14(3):257-64.

Vol. I Issue 1 Jan - Jun 2015 45

Review Articles Narayana Journal of Research in Dental Specialties

ADVANCES IN PERIODONTAL PROBES

1 1
Swetha Taneeru Senior Lecturer
2 2
Vijay Kumar Chava Professor and Head

1,2,3
Department of Periodontics, Narayana Dental College and Hospital, Nellore, Andhra Pradesh.

ABSTRACT: The Periodontal pocket, one of the definitive signs of periodontal disease, is the most common
parameter to be assessed by dental clinicians. Periodontal probes have been the instruments most commonly used
to locate and measure these pockets. Regular use of periodontal probes in routine dental practice facilitates and
increases the accuracy of the process of diagnosing the condition, formulating the treatment, and predicting the
outcome of therapy. Advances in the field of periodontal probing have led to the development of probes that may
help reduce errors in determining this parameter used to define the state of active periodontal disease. One such
advance is the emergence of probes that purportedly assess periodontal disease activity noninvasively. The
selection of periodontal probe depends on the type of dental practice: A general dental practitioner would require first
or second generation probes, while third through fifth-generation probes generally are used in academic and
research institutions as well as specialty practices.

KEYWORDS: Periodontal probes, Clinical diagnosis, pressure sensitive probes

INTRODUCTION

A clinical diagnosis of periodontitis is made by
measuring the loss of connective tissue attachment to the
root surface (clinical attachment loss) and loss of alveolar
bone (bone sounding and radiographic assessment). The
word probe is derived from the Latin word Probe, which
means "to test." Periodontal probes are used primarily to
detect and measure periodontal pockets and clinical
attachment loss. In addition, they are used to locate
calculus; measure Gingival Recession, width of attached
Gingiva, and size of Intraoral Lesions; identify tooth and
soft-tissue anomalies; locate and measure furcation
involvements; and determine Muco Gingival relationships
1 3
and bleeding tendencies.
The third edition of G.V.Blacks Special Dental
Pathology published in 1924 after his death mentions The
use of very thin flat explorers to determine the depth of
Periodontal Pockets. These instruments were not
1
calibrated and they were not used for decades.
Periodontal probes are used to locate, measure, and
mark pockets, as well as determine their course on
individual tooth surfaces. Periodontal probe and its use
were first described by F.V. Simoton of the University of
California, San Francisco in 1925. Typical probe is a
tapered, rod like instrument calibrated in millimeters, with a
1
blunt rounded tip.
Vol. I Issue 1 Jan - Jun 2015
However, periodontal probing has its limitations. Reading
errors may result from naturally occurring states, such as
interference from the calculus on the tooth or root surface,
the presence of an overhanging restoration, or the crown's
contour. Another factor is operator error, such as incorrect
angulation of the probe, the amount of pressure applied to
the probe, misreading the probe, recording the data
2
imprecisely, and miscalculating the attachment loss.
Various factors, such as probe-tip size, angle of insertion of
the probe, probing pressure, precision of probe calibration,
and degree of inflammation in the underlying periodontal
tissues, affect the sensitivity and reproducibility of
measurements. Because the probe passes through the
junctional epithelium into the underlying connective tissue
in an inflamed gingival sulcus, readings of clinical pocket
depth obtained with the periodontal probes do not normally
coincide with the measurements up to the base of the
3
pocket.
The National Institute for Dental and Craniofacial
Research (NIDCR) has defined eight criteria for overcoming
4
the limitations of conventional periodontal probing. Table 1
shows how conventional probing criteria has been altered
by the NIDCR for this objective.
Generations of Periodontal Probes
For consistency of use and academic purposes, in 1992,
5
Pihlstrom et al. classified probes into three generations.
46
Review Articles Narayana Journal of Research in Dental Specialties
Table 1: National institute for dental and craniofacial research criteria

Limitation Conventional NIDR Criteria

Precision 1.0mm 0.1mm
Range 12.0mm 10.0mm
Probing force Non standardized Constant
Applicability Non invasive Non invasive
Reach Easy to access Easy to access
Angulation Subjective Guidance system
Read out Voice dictation and recording Direct electronic reading
Security Easily sterilized Complete sterilization

Table 2 - Advantages and disadvantages of Different generation of probes

.

First generation

Advantages
Easily available and inexpensive
Tactile sensitivity is preserved
Even in presence of sub gingival
calculus, probe can be inserted with
little navigation by operator
Tip is rounded to avoid tissue trauma
Many are colour coded for easier and
faster
Second generation probes
standardization of probing forces
Comfortable to the patient
Disadvantages
Heavy
Probing force is not controlled so the tip
of the probe may pass beyond the base
of the pocket
Errors during visualizing the readings are
possible
An assistant is needed to transfer the
readings to chart
Probe tip may pass beyond the junctional
epithelium in inflamed sites
Readings have to be taken manually and
an assistant is needed to record them
on the patient chart. No computer
storage of data

Third Generation
Advantages
Standardization of probing forces
Errors in reading the data are eliminated
Printout of data from the computer can be
used for the patent education
Disadvantages
Tactile sensitivity is decreased
Probe may pass beyond the transferring
junctional epithelium in inflamed sites,
overestimating pocket depth
After inflammation has resolved, probe
may not penetrate beyond the long
junctional epithelium, leading to
underestimation of the pocket depth

Vol. I Issue 1 Jan - Jun 2015 47

Review Articles Narayana Journal of Research in Dental Specialties
Fourth generation
Advantages
Three dimensional probe
Sequential probe positions are
measured
Fifth generation
Advantages
A non invasive probe.
Probe do not pass beyond the
junctional epithelium as ultrasound
waves detect, image and map the
boundary of the image.
Computer storage of data and
printout or visuals can be used for
patient education
Guidance path is predetermined
6
In 2000, Watts extended this classification by adding
fourth- and fifth-generation probes. These various
generations, along with their advantages and
disadvantages, are in table 2.
DISCUSSION
Diagnosis in periodontics has responded to changes in
technology as well as to new ways of understanding the
pathophysiology of periodontitis, a family of related
diseases with differing host responses to local bacterial
insult. As more sensitive and quantitative diagnostic
methods are developed, it is useful to reflect on the
historical context that surrounded the evolution of this
7
procedures.
The use of traditional clinical parameters for identifying
patients and sites at risk for current or future clinical
attachment loss has been the subject of controversy.
Studies have shown that the penetration of the probe is
positively correlated with probing force. This has been
solved with the development of pressure-sensitive probes,
which have a standardized controlled insertion pressures.
These studies show that with forces of up to 30g, the tip of
the probe seems to remain within the junctional epithelium.
Forces of up to 50 g are necessary to diagnose periodontal
8 9
osseous defects. Osborn J B. et al (1992) compared
measurements obtained from Florida Probe, Florida Disk
Probe, and conventional periodontal probe in persons
having moderate to severe periodontitis and concluded that
use of the Florida Probe and Florida Disk Probe may offer
significant advantages in reducing measurement error for
some clinical examiners.
Vol. I Issue 1 Jan - Jun 2015
Disadvantages
Currently under development
Invasive
Disadvantages
Expensive
Operator needs to understand the
images provided by the computer
Requires a learning curve for use
The depth of clinical probe penetration has been shown
to be influenced by the force to be applied. Previously force
of 25 g, 50 g and 75 g has been used
during evaluation of clinical studies. Pilot trials indicated
that 25 g probing force was not sufficient to provide
reproducible measurement in the deeper regions. Forces
up to 30g, the tip of the probe seems to remain within
10
junctional epithelium (Armitage GC 1977) and forces up
to 50g are necessary to diagnose periodontal osseous
11
defects (Kalkwarf KL 1986). A recent investigation by
10
Chamberlain et al.(1985) hypothesized that a light
probing force (0.25 N) was not capable of consistently
measuring deep pockets.
10
Freed and co-workers (1983) documented that intra
examiner variations occur during the clinical probing of
individuals with healthy periodontium. Specifically, they
found that clinicians tended to probe around teeth in
anterior regions with less force than around teeth in
posterior regions. They also showed that distal surfaces
were probed with greater force than other surfaces and that
facial surface were probed with the least amount of force.
The results of this investigation tend to confirm that a
similar phenomenon takes place when clinicians probe
individuals with evidence of past exposure to periodontitis.
Greater probing depths indicating greater probing force
were consistently obtained on the facial and lingual
surfaces with the pressure-controlled technique. Probing
depths obtained on the posterior disto-lingual surfaces tend
to indicate that greater probing force was used with manual
10
probing in that region.
In addition, current techniques for data readout and
storage are inaccurate and time consuming. This has
48
Review Articles Narayana Journal of Research in Dental Specialties
resulted in the development of new periodontal probing
systems like automated probes. The automated probe is
capable of measuring probing attachment levels relative to
the cemento-enamel junction with better than 0.2 mm of
12
accuracy according to. Jeffcoat M K (1991)
In a comparison of periodontal pocket penetration
by conventional and micro ultrasonic inserts done by
13
Clifford LR et al.(l999) stated that the slim line insert might
more easily penetrate to and debride the apical plaque
border in deep pockets, whereas the P10 insert might be
more effective in disrupting the apical plaque border in
shallow pockets.
14
Clark WB et al.(1992) stated that Pressure-
Controlled Periodontal Probes produce higher significance
when by comparing them with manual probing system.
15
Osborn J (1990) compared measurement variability using
a standard and constant force periodontal probe and
concluded that the Florida Disk Probe offers significant
advantages for measuring relative attachment level in
longitudinal studies of early periodontitis.
16
Quirynen M (1993) demonstrated that the
automatic computerized constant force electronic probe
correlates well with the conventional manual probe. The
manual probe seems to be slightly more reproducible,
whereas the automatic probe has the advantage of an
automatic registration thereby probably reducing the
examination time, writing errors and parameters. Electronic
probing systems, such as the Interprobe System provide
constant probing force, computer storage of data, and
precise electronic management of the resulting
inflammation. However, clinical evaluations of these
systems have reported only slightly improved reproducibility
when compared with conventional probing, although not
clinically significant. Studies by Biddle AJ, Palmer RM et
17
al.(2001) suggested that the use of automated probing
system does not offer any advantage over conventional
probing, rendering a similar level of reproducibility. They
clearly showed that with the use of trained operators and
performing double-pass method, the measurements taken
with the Florida probe system are significantly less variable
than those obtained with conventional probe.
The Florida probe system obtained mean standard
deviations for clinical attachment level measurements of
about 0.3mm, which is superior to an average of 0.82 mm,
10
reported by Haffajee et al. using manual probe in 1983.
Other commercially available electronic probing systems,
such as Interprobe and Periprobe , have also been
evaluated. They provided constant probing force, computer
storage of data, and precise electronic management of the
resulting inflammation. However clinical evaluations have
reported only slightly improved reproducibility compared
with conventional probing, although not clinically
10
significant
Vol. I Issue 1 Jan - Jun 2015
12
According to Jeffecoat MK (1986, 1991) other
electronic probing systems like Foster-Miller probe capable
of coupling pocket depth measurement with detection of
cement-enamel junction, from which the clinical attachment
level is automatically detected have never been released
for general use except for the literature. Researchers at the
University of Toronto have described Toronto Automated
probe at uses the occlusal and the incisal surface to
measure clinical attachment levels like Florida probe. The
sulcus is probed with a 0.5mm Ni-Ti wire that is extended
under air pressure. It controls angular discrepancies by
means of a mercury tilt sensor that limits angulation with in
30, but requires reproducible positioning of the patients
19
head and cannot easily measure second or third molars.
The Florida PASHA Probe can reproducibly and reliably
18
identify the CEJ in human skulls (Preshaw PM et al.1999)
19
and according to Karpinia K et al.(2004) it shows promise
in measuring CAL in humans. But longitudinal clinical
studies and long term evaluation is lacking with this
instrument.
10
Kung et al. claim that the thermal probes are
sensitive diagnostic devices for measuring early
inflammatory changes in the gingival tissues. Haffajee et
10
al. used this probe to assess its predictability in identifying
loss of attachment, concluding that sites with a red (higher)
temperature indication had more than twice the risk for
future attachment loss than did those with a green
indication. However, the influence of pocket depth on
temperature is still not clear, and further studies are needed
to demonstrate the accuracy of this device and its utility in
10
clinical diagnosis.
CONCLUSION
Newer developments in the field of periodontal
probes provide the potential for error-free determination of
pocket depth and clinical attachment level at a very early
stage. Screening periodontal diseases earlier is gaining
importance as these diseases are being associated with
systemic conditions. With more research and innovation,
the advent of newer error-free probes may resolve the
remaining problems and those yet to be realized
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Clinical Practice of the Dental Hygienist. 9th ed.
Philadelphia, PA: Lippincott Williams and Wilkins;
2005:222-245.
2. Badersten A, Nilvus R, Egelberg J. Reproducibility of
probing attachment level measurements. J Clin
Periodontol. 1984; 11(7):475-485.
49
Review Articles Narayana Journal of Research in Dental Specialties
3. Badersten A, Nilvus R, Egelberg J. Reproducibility of
probing attachment level measurements. J Clin
Periodontol. 1984; 11(7):475-485.
4. Parakkal PF. Proceedings of the workshop on
quantitative evaluation of periodontal diseases by
physical measurement techniques. J Dent Res. 1979;
58(2):547-553.
5. Pihlstrom BL. Measurement of attachment level in
clinical trials: Probing methods. J Periodontol.1992;
63(12 Suppl):1072-1077.
6. 7. Watts TLP. Assessing periodontal health and
disease. In: Periodontics in Practice: Science with
Humanity. New York, NY: Informa Healthcare;
2000:33-40.
7. Steven I, Gold. Diagnostic techniques in
periodontology; a Historical review.
Periodontology 2000, vol;34, 2004
8. Meissner G, Oehme B, Strackeljan J, Kocher T.
Clinical subgingival calculus detection with a smart
ultrasonic device: a pilot study. J Clin Periodontol
2008; 35:126132.
9. Joy B. Osborn, Jill L. Stoltenberg, Beverly A. Huso,
Dorothee M. Aeppli and Bruce L, Pihlstrom;
Comparison of Measurement Variability Using a
Standard and Constant Force Periodental Probe. J
Periodontol 63:283-289:1992.
th
10. Carranzas Clinical periodontology 10 Edition: By
Michael G. Newman, DDS, Henry Takei, DDS, Perry
R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr.
Odont 2006.
11. Kenneth L. Kalkwarf, Wayne B. Kaldahl and Kashinath
D. Patil. Comparison of Manual and Pressure-
Controlled Periodontal Probing. J Periodontol 57:467-
471:1986.
12. Marjorie K. Jeff coat and Michael S. Reddy.
Progression of Probing Attachment Loss in Adult
Periodontitis. J Periodontol 62:185-189:1991.
13. Clifford LR, Needleman IG, Chan YK: Comparison of
periodontal pocket penetration by conventional and
ultrasonic inserts. J Clin Periodontol 1999:26:124-130.
Vol. I Issue 1 Jan - Jun 2015
14. Clark WB, Yang MC, Magnusson I: measuring clinical
attachment: reproducibility and relative measurements
with an electronic probe. J Periodontol 63;831:1992
15. Osborn J, Stoltenberg J, Beverly H, Dorothee A, and
Pihlstrom B. Comparison of Measurement Variability
Using a Standard and Constant Force Periodontal
Probe.
J Periodontol 61:497-503:1990.
16. Quirynen M, Callens A, Daniel van Steenberghe, and
Marleen Nys. Clinical Evaluation of a Constant Force
Electronic Probe. J Periodontol 64:35-39:1993.
17. Biddle AJ, Palmer RM, Wilson RF, Watts TLP:
Comparison of the validity of periodontal probing
measurements in smokers and non-smokers. J Clin
Periodontol 2001; 28: 806812.
18. Preshow P M, Kupp L, Hefti A F, Mariotti A:
Measurement of clinical attachment levels using a
constant force periodontal probe modified to detect the
cement-enamel junction. J Clin Periodontal
1999:26:434-444.
19. Karpinia K, Magnusson I, Gibbs C et al; accuracy of
probing measurement levels using a CEJ probe versus
traditional probes, J Clin Periodontal 31:173: 2004.
Corresponding Author
Dr. Swetha Taneeru
Senior Lecturer
Department of Periodontics
Narayana Dental College and Hospital,
Nellore, Andhra Pradesh
India-524003
50