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JOURNAL OF

CONTEMPORAR
Y DENTISTR
Y
CONTEMPORARY
DENTISTRY
Journal
of
Contemporary
Dentistry is the official publication
of the Mahatma Gandhi Mission
Dental College & Hospital and
issues are published in the last
week of June, October and
February.
All the rights are reserved. Apart
from any fair dealing for the
purposes of research or private
study, or criticism or review, no part
of the publication can be
reproduced, stored, or transmitted,
in any form or by any means,
without the prior permission of the
Editor
The journal and/or its publisher
cannot be held responsible for
errors or for any consequences
arising from the use of the
information contained in this
journal.
The appearance of advertising or
product information in the various
sections in the journal does not
constitute an endorsement or
approval by the journal and/or its
publisher of the quality or value of
the said product or of claims made
for it by its manufacturer.

Editorial Office
Dr
Dr.. Sabita M. Ram
Dean
MGM Dental College & Hospital
Sector 18, Kamothe
Navi Mumbai 410 209
E-mail: jcdent@mgmindia.co.in

Printed at
Anitha Art Printers
29/30 Oassis Industrial Estate,
Nehru Road,
Next to Vakola Market,
Santacruz (E), Mumbai 400 055.
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E-mail: printing@anitaprinters.com

Journal of Contemporary Dentistry

Patrons
Mr
Mr.. Kamal K. Kadam
Dr
Dr.. Sudhir N. Kadam
Dr
Dr.. Nitin N. Kadam
Associate Editors

Editor in Chief
Dr
Dr.. Jyotsna Galinde

Dr
Dr.. Sabita M. Ram
Dr
Dr.. Girish Karandikar

Assistant Editor
Dr
Dr.. Richard Pereira

ADVISORY BOARD
Lt. Gen. Murali Mohan
Brig. P.N. Awasthi
Dr. J. N. Khanna
Dr. Dinesh Daftary

Dr.
Dr.
Dr.
Dr.

Mahesh Verma
P.C. Gupta
Sureshchandra Shetty
R. P. Nayak

Dr.
Dr.
Dr.
Dr.

V.P. Jayade
L.S. Poonja
O.P. Kharbanda
A.K. Barua

EDITORIAL REVIEW BOARD


PROSTHODONTICS
Maj. Gen. Vimal Arora
Dr. Suhasini Nagda
Dr. Padmanabhan T. V.
Dr. Jyoti Undirwade
Dr. Usha Radke
Dr. Hetal Turakhia

ORAL PA
THOLOGY
PATHOLOGY
Dr. Vinay Hazare
Dr. Suresh Barpande
Dr. Jagdish Tupkari
Dr. Rajiv Desai
Dr. Sangeeta Patankar
Dr. Sachin Sarode

MAXILLOF
ACIAL SURGER
Y
MAXILLOFACIAL
SURGERY
Dr. R.R.Pradhan
Dr. Vinod Kapoor
Dr. Suhas Vaze
Dr. Rajiv Borle
Dr. Rajesh Dhirwani

CONSER
VATIVE DENTISTR
Y
CONSERV
DENTISTRY
Dr. Mansing Pawar
Dr. Naseem Shah
Dr. Manjunath N. K.
Dr. Sharad Kokate
Dr. Shishir Singh
Dr. Vibha Hegde

PERIODONTICS
Dr. Harshad Vijaykar
Dr. Mala Dixit
Dr. Abhay Kolte
Dr. Rajiv Chitguppi
Dr. Sudhindra Kulkarni

ORTHODONTICS
Dr Shalan Karbelkar
Dr Shweta Bhat
Dr Vaishali Vadgaonkar
Dr Jayesh Rahalkar
Dr Nikhilesh Vaid

PEDODONTICS
Dr. Rahul Hegde
Dr. Shobha Deshpande
Dr. Swati Karkare
Dr. Bhushan Pustake
Dr. Thejokrishna P.

ORAL MEDICINE
Dr. Hemant Umarji
Dr. Ajay Bhoosreddy
Dr. Freny Karjodkar
Dr. Anil Ghom
Dr. Deepa Das

PUBLIC HEAL
TH DENTISTR
Y
HEALTH
DENTISTRY
Dr. Navin Ingle
Dr. Suhas Kulkarni
Dr. Charu Mohan
Dr. Sabyasachi Saha
Dr. Ajay Bhambal
Dr. L. Nagesh

EDITORIAL COMMITTEE
Dr. Sachin Kanagotagi
Dr. Sunil Sidana
Dr. Rajesh Patil
Dr. Shwetha Kumar
Dr. Sonal Patil

October-December 2011 | Vol 1 | Issue 2

Dr. Ranganath Rao K. Jingade


Dr. Sumanthini M.V.
Dr. Varun Bhatia
Dr. Zohara Charania

Editor's Message
Dental research and scientific writing is of paramount importance to any institution.
And a scientific journal is one of the methods of this expression.
In India, clinical material is enormous and dental faculty large, but lack of
documentation and publication of scientific writing is a hindrance to academic growth.
A journal in place puts an added responsibility on a faculty member to keep pre and
post documentation of cases and instills him to think in a scientific manner.
Every journal article needs to be peer reviewed and that adds to the scientific credibility
of that article. We have striven hard to put in place senior academicians as advisors
and reviewers to offer their quality and positive inputs to boost the journal. It is this
team effort along with those of the journal committee that makes this exercise a
complete team work and a fulfilling academic experience.
In this issue we have introduced a guest article section; this will feature another
dimension of clinical expertise of those senior clinicians who will showcase their clinical
work and that combined with academic inputs from an institution will makes the journal
a holistic reading material.
We are also opening our doors to other institutes to contribute and make this journey
a complete scientific one for the betterment of our fraternity.

Dr
Dr.. Jyotsna Galinde
Assoc. Dean, Post Graduate Studies
Prof & Head, Dept. Oral & Maxillofacial Surgery, MGM

ANNOUNCEMENT
In keeping with our endeavour to disseminate scientific knowledge beyond the
boundaries of our institution, the Journal now invites Scientific articles from other
institutions. All contributing authors are requested to follow the author guidelines
outlined and send in your articles at the specified address.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

JOURNAL OF

CONTEMPORAR
Y DENTISTR
Y
CONTEMPORARY
DENTISTRY
OCTOBER - DECEMBER 2011 | VOL 1 | ISSUE 2

Contents
G UEST A RTICLE
Lifelike Anterior Composites
Ratnadeep Patil ...................................................................................................................................................... 7
O RIGINAL R ESEARCH
Evaluation of the stress distribution and displacement of the denture base in
edentulous mandible with varied implant positions
Meghna K. Dang, Sabita M. Ram ........................................................................................................................ 14
R EVIEW A RTICLES
Use of Functional Appliances in General Dental Practice
Anita G. Karandikar, Girish R. Karandikar, Madhur Vasudev Navlani ............................................................ 21
Pediatric Obturating Materials And T
echniques: A Review
Techniques:
Mihir Jha, Sonal D.Patil, Shrirang Sevekar, Vivek Jogani, Poonam Shingare .................................................. 27
Oral Lichen Planus : A Review
Rohini Salvi, Rohit Bhailal Gadda,Varun Gul Bhatia ......................................................................................... 33
Bioterrorism and Dentistry- A Review
Amit Chaudhari, Priya Chaudhari ...................................................................................................................... 37
CASE REPORT
Management of non vital maxillary central incisors with open apex using
Mineral T
rioxide Aggregate apical plugs A case report
Trioxide
Sumanthini M.V., Naisargi Shah, Mausami A Malgaonkar ................................................................................ 40
Factitious Injury of The Periodontal Tissues - Case Report
Vineet Kini, Richard Pereira, Ashvini M. Padhye, Sudarshan G. Kadam .......................................................... 44
Compound Composite Odontomes In Mandibular Symphysis
A Rare Case
Sushrut Vaidya, Usha Asnani, Smita Sonavane, Imran Khalid, Kartik Poonja, Alok Bhardwaj ...................... 46
Infiltrative T
ype of Bone Invasion in Oral Squamous Cell Carcinoma - A C ase R eport
Type
Jigna Pathak, Niharika Swain, Shwetha Kumar ............................................................................................... 49

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

JOURNAL OF

CONTEMPORAR
Y DENTISTR
Y
CONTEMPORARY
DENTISTRY

General Information
The Journal of Contemporary Dentistry publishes original
scientific papers, reviews, case reports, and method
presentation articles in the field of dentistry. Original articles
are published in all dentistry-related disciplines, all areas of
biomedical science, applied materials science, bioengineering,
epidemiology, and social science relevant to dental disease and
its management. Manuscripts submitted for publication must
be original articles and must not have appeared in any other
publication. The publisher reserves the right to edit
manuscripts for length and to ensure conciseness, clarity, and
stylistic consistency, subject to the author's final approval.
Authorship
Individuals identified as authors must meet the following
criteria established by the International Committee of Medical
Journal Editors: 1) substantial contributions to conception and
design, or acquisition of data, or analysis and interpretation of
data; 2) drafting the article or revising it critically for important
intellectual content; and 3) final approval of the version to be
published. The number of authors is limited to 6.
Ethical

Guidelines:

Experimentation involving human subjects will be published


only if such research has been conducted in full accordance
with ethical principles. Manuscripts must include a statement
that the experiments were undertaken with the understanding
and written consent of each subject and according to the
abovementioned principles, the statement should also state
that the protocol was approved by the author's institutional
review committee for human subjects or that the study was
conducted in accordance with the Helsinki Declaration of 1975,
as revised in 2000. Do not use any designation in tables, figures,
or photographs that would identify a patient, unless express
written consent from the patient is submitted. When animals
are involved, the methods section must clearly indicate that
adequate measures were taken to minimize pain or discomfort.
Experiments should be carried out in accordance with local
laws and regulations.
Clinical T
rials:
Trials:
Report clinical trials using the CONSORT guidelines at
www.consortstatement.org. A CONSORT checklist and a
flowchart should also be included in the submission material.
Conflict of Interest/Source of Funding:
It is necessary that information on potential conflicts of interest
be part of the manuscript. The journal requires all sources of
institutional, private, and corporate financial support for the
work within the manuscript to be fully acknowledged and any
Potential conflicts of interest noted. Please include the
information under Acknowledgments.

A rticle

Preparation

Original

Research

Should describe significant and original experimental


observations and provide sufficient detail so that the
observations can be critically evaluated and, if necessary,
repeated. Articles considered as original research include,
Randomized controlled trials, intervention studies, studies of
screening and diagnostic test, outcome studies, cost
effectiveness analyses, case-control series, and surveys with
high response rate. Up to 2500 words excluding references
and abstract.
Short Communication, Short Case Presentations, and
Method Presentation Articles
Short Case Presentation: Interesting cases authors would like
to share with the readers. Method Presentation Articles: Must
present significant improvements in clinical practice (a novel
technique, technological breakthrough, or practical approaches
to clinical challenges).Up to 1000 words excluding references
and abstract and up to 5 references.
Case reports
New / interesting / very rare cases can be reported. Should
have importance and significance. Repetition of well-known
and extensively published conditions will not be accepted.
Include a thorough literature review and emphasize the clinical
relevance. Up to 2000 words excluding references and abstract
and up to 10 references.
Review

articles

Must have broad general interest. Reviews should take a broad


view of the field rather than merely summarizing the authors
own previous work Systemic critical assessments of literature
and data sources. Up to 3500 words excluding references and
abstract.
Letter to the Editor
Should be short, decisive observation. They should not be
preliminary observations that need a later paper for validation.
Up to 400 words and 4 references.
Article submission to the Journal
Presentation: Clearly convey research findings or clinical
reports. Avoid technical jargon, but clearly explain where its
use is unavoidable. The background and hypotheses underlying
the study, as well as its main conclusions, should be clearly
explained. Titles and abstracts should be written in language
readily intelligible.
Abbreviations/acronyms: Abbreviations should be kept to a
minimum, particularly those that are not standard. Terms and

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

General Information
names referred to as abbreviations or acronyms should be written
out when first used with the abbreviation in parenthesis.
Standard units of measurement need not be spelled out.
Names of Teeth: The complete names of individual teeth must
be given in the text. In tables and figures, individual teeth can
be identified using the FDI 2-digit system if full tooth names
are too unwieldy.
Structure
1.

2.

First Page File: Prepare the title page, covering letter,


acknowledgement, etc. All information which can reveal
your identity should be here. Include the title of the article
and the full name, degrees, title, and professional affiliation
of every author. Provide the contact details and e-mail
address of the corresponding author.
Article file: The main text of the article, beginning from
Abstract till References (including tables) should be in this
file. Do not include any information such as
acknowledgement, your names in page headers, etc., in
this file. Illustrations and tables should be numbered and
cited in the text in order of appearance and grouped at the
end of the text. High-resolution images must be sent to
the Managing Editor upon article acceptance.

3.

Images: Submit good quality colour images. Submit TIFF/


JPEG (photographs) files only.

4.

Legends: Legends for the figures/images should be


included at the end of the article file. Figure legends should
begin with a brief title for the whole figure and continue
with a short description of each panel and the symbols
used; they should not contain any details of methods.

5.

References: Provided with direct references to original


research sources. Note that small numbers of references
to key original papers will often serve as well as more
exhaustive lists. List references at the end of the article in
numeric sequence.

The authors' form and copyright transfer form has to be


submitted to the editorial office, in original with the signatures
of all the authors.
Preparation of the Manuscript
Manuscripts must be submitted in Microsoft Word. Margins
should be at least 1'' on both sides and top and bottom. Materials
should appear in the following order:
Title Page
Abstract (or Introduction) and Key Words
Text
Footnotes
Acknowledgments
References
Figure Legends
Tables
Figures should not be embedded in the manuscript. Authors
should retain a copy of their manuscript for their own records.
The manuscripts should be typed in A4 size (212 297 mm) paper,
with margins of 25 mm (1 inch) from all the four sides. Use 1.5
spacing throughout. Number pages consecutively, beginning with
the title page. The language should be British English.
Title Page
The title page should carry:
1. Type of manuscript
2. The title of the article, which should be concise, but
informative;
3. Running title or short title not more than 50 characters;
4.

Name of the authors (the way it should appear in the

Journal of Contemporary Dentistry

journal), with his or her highest academic degree(s) and


institutional affiliation;
5.

The name of the department(s) and institution(s) to which


the work should be attributed;

6.

The name, address, phone numbers, facsimile numbers,


and e-mail address of the contributor responsible for
correspondence about the manuscript;

7.

The total number of pages, total number of photographs


and word counts separately for abstract and for the text
(excluding the references and abstract).

8.

Source(s) of support in the form of grants, equipment,


drugs, or all of these; and

Abstract (or Introduction) and Key W


ords
Words
The second page should carry the full title of the manuscript
and an abstract (of no more than 150 words for case reports,
brief reports and 250 words for original articles).The structured
abstract, should consist of no more than 250 words and the
following four paragraphs:
* Background: Describes the problem being addressed.
* Methods: Describes how the study was performed.
* Results: Describes the primary results.
* Conclusions: Reports what authors have concluded from these
results, and notes their clinical implications.
TEXT
Introduction
The Introduction contains a concise review of the subject area
and the rationale for the study. More detailed comparisons to
previous work and conclusions of the study should appear in
the Discussion section.
Materials and Methods
This section lists the methods used in the study in sufficient
detail so that other investigators would be able to reproduce
the research. When established methods are used, the author
need only refer to previously published reports; however, the
authors should provide brief descriptions of methods that are
not well known or that have been modified. Identify all drugs
and chemicals used, including both generic and, if necessary,
proprietary names and doses. The populations for research
involving humans should be clearly defined and enrolment
dates provided.
Results
Results should be presented in a logical sequence with reference
to tables, figures, and illustrations as appropriate.
Discussion
New and possible important findings of the study should be
emphasized, as well as any conclusions that can be drawn. The
Discussion should compare the present data to previous findings.
Limitations of the experimental methods should be indicated,
as should implications for future research. New hypotheses
and clinical recommendations are appropriate and should be
clearly identified. Recommendations, particularly clinical ones,
may be included when appropriate.
ACKNOWLEDGMENTS
INTEREST

AND

CONFLICTS

OF

Acknowledgments
At the end of the Discussion, acknowledgments may be made
to individuals who contributed to the research or the manuscript
preparation at a level that did not qualify for authorship. This
may include technical help or participation in a clinical study.
Authors are responsible for obtaining written permission from

October-December 2011 | Vol 1 | Issue 2

General Information
persons listed by name. Acknowledgments must also include a
statement that includes the source of any funding for the study,
and defines the commercial relationships of each author.
Conflicts of interest

abbreviations, should be listed as footnotes, not in the heading.


Every column should have a heading. Statistical measures of
variations such as standard deviation or standard error of the
mean should be included as appropriate in the footnotes. Do
not use internal horizontal or vertical rules.

In the interest of transparency and to allow readers to form


their own assessment of potential biases that may have
influenced the results of research studies, the Journal requires
that all authors declare potential competing interests relating
to papers accepted for publication. Conflicts of interest are
defined as those influences that may potentially undermine
the objectivity or integrity of the research, or create a perceived
conflict of interest.

FIGURE LEGENDS

Authors are required to submit:

FIGURES

1) A statement in the manuscript, following Acknowledgments,


that includes the source of any funding for the study, and defines
the commercial relationships of each author. If an author has
no commercial relationships to declare, a statement to that
effect should be included. This statement should include
financial relationships that may pose a conflict of interest or
potential conflict of interest. These may include financial
support for research (salaries, equipment, supplies, travel
reimbursement); employment or anticipated employment by
any organization that may gain or lose financially through
publication of the paper; and personal financial interests such
as shares in or ownership of companies affected by publication
of the research, patents or patent applications whose value
may be affected by this publication, and consulting fees or
royalties from organizations which may profit or loose as a
result of publication.

Digital files must be submitted for all figures. Submit one file
per figure. Human subjects must not be identifiable in
photographs, unless written permission is obtained and
accompanies the photograph. Lettering, arrows, or other
identifying symbols should be large enough to permit reduction
and must be embedded in the figure file. Figure file names
must include the figure number. Details of programs used to
prepare digital images must be given to facilitate use of the
electronic image. Use solid or shaded tones for graphs and
charts. Patterns other than diagonal lines may not reproduce
well.

2) A conflict of interest and financial disclosure form for each


author. Conflict of interest information will not be used as a
basis for suitability of the manuscript for publication.
REFERENCES
References should be numbered consecutively in the order in
which they appear in the text. A journal, magazine, or newspaper
article should be given only one number; a book should be
given a different number each time it is mentioned, if different
page numbers are cited. All references are identified, whether
they appear in the text, tables, or legends, by Arabic numbers
insuperscript. The use of abstracts as references is strongly
discouraged. Manuscripts accepted for publication may be cited.
Material submitted, but not yet accepted, should be cited in text
as ''unpublished observations.'' Written and oral personal
communications may be referred to in text, but not cited as
references. Please provide the date of the communication and
indicate whether it was in a written or oral form. In addition,
please identify the individual and his/her affiliation. Authors
should obtain written permission and confirmation of accuracy
from the source of a personal communication. Presented papers,
unless they are subsequently published in a proceedings or peerreviewed journal, may not be cited as references. In addition,
Wikipedia.org may not be cited as a reference. For most
manuscripts, authors should limit references to materials
published in peer-reviewed professional journals. In addition,
authors should verify all references against the original
documents. References should be typed double-spaced.
TA B L E S
Tables should be numbered consecutively in Arabic numbers in
the order of their appearance in the text. A brief descriptive
title should be supplied for each. Explanations, including

Legends should be typed double-spaced with Arabic numbers


corresponding to the figure. When arrows, symbols, numbers,
or letters are used, explain each clearly in the legend; also explain
internal scale, original magnification, and method of staining as
appropriate. Panel labels should be in capital letters. Legends
should not appear on the same page as the actual figures.

UNITS OF MEASUREMENT
Measurements of length, height, weight, and volume should
be reported in metric units or their decimal multiples. All
hematologic and clinical chemistry measurements should be
reported in the metric system in terms of the International
System of Units (SI).
ST
AT I S T I C S
TA
Statistical methods should be described such that a
knowledgeable reader with access to the original data could
verify the results. Wherever possible, results should be
quantified and appropriate indicators of measurement error
or uncertainty given. Sole reliance on statistical hypothesis
testing or normalization of data should be avoided. Data in as
close to the original form as reasonable should be presented.
Details about eligibility criteria for subjects, randomization, and
methods for blinding of observations, treatment complications,
and numbers of observations should be included. Losses to
observations, such as dropouts from a clinical trial, should be
indicated. General-use computer programs should be listed.
Statistical terms, abbreviations, and symbols should be defined.
Detailed statistical, analytical procedures can be included as an
appendix to the paper if appropriate.
FOOTNOTES
Footnotes should be used only to identify author affiliation; to
explain symbols in tables and illustrations; and to identify
manufacturers of equipment, medications, materials, and
devices. Use the following symbols in the sequence shown: *,
, , , k, , #,**, , etc.
IDENTIFICA
TION OF PRODUCTS
IDENTIFICATION
Use of brand names within the title or text is not acceptable,
unless essential when the paper is comparing two or more
products. When identification of a product is needed or helpful
to explain the procedure or trial being discussed, a generic
term should be used and the brand name, manufacturer, and
location (city/state/country) cited as a footnote.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

GUEST ARTICLE

Lifelike Anterior Composites


Ratnadeep Patil*

Introduction
Direct composite resin restorations can be a viable
treatment option when an esthetic restoration is desired
especially in case of uncomplicated tooth fractures.1,2
and standard veneer preparations for altering the shape
and size of the existing anterior teeth. In the past the
outcome of direct resin was compromised as they poorly
reproduced the optical properties of natural teeth.
Recent advances in adhesion technology, material
properties and better understanding of optical
properties of the natural tooth, has helped achieve
better vitality, character and depth of a restoration.
The direct resin buildup restoration based on
contemporary layering technique allows clinicians to
provide conservative treatment and a virtually
imperceptible blend with adjacent tooth structures.3

appearance of enamel and dentin. Every layer has


different shades and opacities when stratified, giving
a "polychromatic effect" with a more realistic depth of
color by creating an illusion of the way light is reflected,
refracted, transmitted and absorbed to simulate that
of dentin and enamel.
Though an exact recipe cannot be given since shade
layering would vary from case to case, the general rule
followed in anatomic stratification are
1.

Replace Palatal/lingual wall with an opaque composites.


Since they have higher color saturation, when light strikes
the optically dense layer, more light is reflected back to
the eyes and thus contributes to the hue and chroma by
optically replacing dentin.6,7

2.

Use thin increments and observe shade after every layer


is cured so that the shade of the next layer can be planned.
Another advantage of this technique is that it minimizes
the negative effects of shrinkage by creating small
incremental shrinkage.5

3.

Use translucent composites to encapsulate the inner


dentin core. This alters the quantity and quality of the
light reflected and thus decides the value of the restoration
by optically replacing enamel in the restoration.6,7

Shade judgment
Shade is analyzed before tooth preparation and
thereafter evaluated for every layer of composite. Shade
selection involves visual comparison between the
natural teeth and standard colored dental shade guides
by the dentist8. It does not imply that the same shade
composite will give us the desired outcome as the
inherent opacity and the layer thickness will determine
shade outcome. Shade matching, on the contrary, is
highly technical process with unpredictable outcome
since it depends on individual skill and knowledge8. It
has to be an integral part of the layering technique.
Dentin is an opaque and fluorescent tissue and is
responsible for the hue and chroma of the tooth by
reflecting the light through the enamel. Enamel is a
translucent and opalescent tissue and determines the
value of the tooth.3,6

Composite layering
Composite layering done with the anatomic
stratification technique helps reproduce natural
* The author is a graduate from Bombay University with a
Private practice in Mumbai, since 1988 with special interest
and expertise in Esthetic and Implant Dentistry. He is also a
Diplomate, International College of Oral Implantologists and
author of the clinical textbook on esthetic dentistry titled
'Esthetic Dentistry - An Artist's Science'. At present he is
pursuing his Phd from Utrecht University.

(The author wishes to aknowledge the contribution of


Dr. Anjali Dilbaghi)

Journal of Contemporary Dentistry

Case 1
A 19 year-old male patient reported with fractured upper
left central incisor and chipped surface of upper right
central incisor (Figure 1-C1) due to a sports injury.
Radiographic examination and cold test did not reveal
any pulpal damage.
Shade was determined to be A3 using the Tetric N
Ceram shade guide system. The patient being young,
the incisal edge displayed translucency and incisal
mamelons (Figure 1-C1)Occlusal view (Figure 2-C1) of
the fractured teeth reveals the difference in opacity
and translucency of dentin and enamel in #21.
In #11 a 1mm bevel was placed along the margin of
the chipped enamel surface (Figure 3-C1). An envelope
preparation design extending 2mm with a 1mm bevel
was prepared on the facial surface of #21(Figure 3-C1,4C1). On the palatal surface of #21 a rounded butt
margin was prepared. (Figure 4-C1)
The cavity preparation was disinfected using a 2%
chlorhexidine antibacterial solution. Etching was done
for 15 seconds using 37% phosphoric acid (Figure 5C1); the etchant was removed, and the tooth surface

October-December 2011 | Vol 1 | Issue 2

Patil and Dilabaghi : Lifelike Anterior Composites

Figure 1-C1
Figure 5-C1

Figure 6-C1
Figure 2-C1

Figure 3-C1

Figure 7-C1

Figure 4-C1

Figure 8-C1

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Patil and Dilabaghi : Lifelike Anterior Composites

rinsed with water spray for 30 seconds followed by air


drying taking care not to excessively dry the tooth
surface. (Figure 6-C1) A fifth-generation nano optimized
adhesive system (Tetric N-bond) was placed in the
preparation and agitated for 10seconds, then, gently
air thinned (Figure 7-C1,8-C1), and polymerized for 20
seconds (Figure 9-C1).
In this case a nano composite resin system (Tetric NCeram) was selected as the material of choice to restore
these teeth. Stratification was initiated with a thin
layer (Figure 10-C1) of flowable resin placed in the line
anglies of the preparation. ). A metal matrix strip was
placed interdentally and a triangular-shaped,

mesioincisal layer of the A3 body shade was placed and


sculpted to reconstruct the proximal surface of #11
(Figure 11-C1 ) Thereafter 1-mm of Bleach light shade
was placed and cured to replicate the opaque dentin
layer (Figure 12-C1, 13-C1, 14-C1)
Next increments of A3 enamel shades were layered
(Figure 15-C1, 16-C1) with a long bladed instrument
and texture lines created with a sable brush (Figure
17-C1) before curing. The mamelon effect was completed
using the highly translucent incisal shade (Artemis)
at the incisolingual matrix and two notches were placed
to duplicate the external contours of the mamelons.

Figure 9-C1

Figure 12-C1

Figure 10-C1
Figure 13-C1

Figure 14-C1

Figure 1
1-C1
11-C1

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Patil and Dilabaghi : Lifelike Anterior Composites

Figure 18-C1

Figure 15-C1

Figure 19-C1

Figure 16-C1

Figure 20-C1

Figure 17-C1

10

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Patil and Dilabaghi : Lifelike Anterior Composites

Figure 2-C2

Figure 21-C1

Case 2
A 20 year-old female patient wanted smile enhancement
as she unhappy with the shape of her teeth and the
fact that her teeth were hardly visible on smiling
(Figure 1-C2).
Direct Composite veneers were planned for 4 anterior
teeth using Tetric N-Ceram. Shade was determined to
be A2 using the standard vita shade guide. Since the
veneer preparation was in the enamel, value is of great
importance.
Minimal tooth preparation was done (Figure 2-C2) as
in this case more material had to be added, both to
allow us enhance the shape of the teeth, alter the incisal
edge placement and increase the height of the tooth.
Bulk on the labial surface would enhance the lip
support and make the smile more pleasing.

Figure 3-C2

Self etching adhesive (Adhese) (Figure 3-C2) was


scrubbed on to the tooth for 20 seconds, lightly air
thinned and then light cured.

Figure 4-C2

Figure 1-C2

Minimal amount of flowable composite was placed in


the line angles of the preparation. The first layer, also
called as the adaptive layer was a very thin layer which
helped in close contact of composite to the tooth surface.
The adaptive layer of Shade A1 (Figure 4-C2) was placed
on the entire prepared surface. Next, Shade A3 was
sculpted by a cervical contouring instrument to obtain

Journal of Contemporary Dentistry

Figure 5-C2

an accurate emergence profile (Figure 5-C2). This layer


extended to the middle of the middle third on the labial
surface. Body A2 shade was the next layer placed which
blended with the cervical shade and extended beyond

October-December 2011 | Vol 1 | Issue 2

11

Patil and Dilabaghi : Lifelike Anterior Composites

the incisal edge to form mamelons (Figure 6-C2). To


prevent overbuilding of the dentin layer, it was
imperative to monitor the thickness of the composite
material, in order to allow sufficient space for the
enamel layer. This translucent shade of Artemis
occupied spaced between the created mamelons and
extended up to the cervical area (Figure 7-C2).

Figure 8-C2

Figure 6-C2

Figure 9-C2

Figure 7-C2
Figure 10-C2

Finishing and polishing

Conclusion

Finishing focuses on contouring, adjusting, shaping,


texturing and smoothing the restoration (Figure 18C1, Figure 8-C2), while polishing concentrates on
producing a surface luster (Figure 19-C1) and highly
light-reflective surface 6. For creating texture in
finishing, certain areas on the facial surface of the tooth
can be highly polished to give a life-like effect to the
restoration1,2. Eminence of the proximal convexity, the
horizontal, vertical ridges, the lobe effect and facial
flattening can be effectively projected. The black and
white image of the finished restoration shows value of
tooth and restoration is similar (Figure 20-C1, 21-C1)
(Figure 9-C2,10-C2).

The success of the anatomic stratification lies largely


in the fact that it draws inspiration from the natural
layering of dentin and enamel. Continuous
technological advances have provided us with materials
that can successfully replicate and retain the
characteristics built into them while layering them on
tooth surfaces. With this concept and technique it is
possible for clinicians to provide a more conservative
yet functional and aesthetic care to their patients.

12

References
1.

Rufenacht C. Textbook of Fundamentals of Esthetics.


Chicago: Quintessence publishing, 1990, ISBN 0-86715230-3.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Patil and Dilabaghi : Lifelike Anterior Composites


2.
3.

4.

5.

Patil RC. Textbook of Esthetic Dentistry: An Artist's Science.


PR publications, 2002, ISBN 81-901319-07.
Belcheva A. Reconstruction of Fractured Permanent
Incisors In Schoolchildren Using Composite Resin BuildUp (Review). Journal of IMAB - Annual Proceeding
(Scientific Papers) 2008, book 2.
Lesage B. Aesthetic Anterior Composite Restorations: A
Guide to Direct Placement. Dent Clin N Am 51 (2007) 359378.
Deliperi S, Bardwell D N, Debora M, Kugel G. Layering
and Curing techniques for class III restorations: A Two-

Journal of Contemporary Dentistry

6.
7.

8.

year Case Report Pract Proced Aesthet Dent


2005;17(3):a-h.
Terry D. Restoring the incisal edge. NYSDJ Aug-Sept 2005;
30-35.
Kamisha N, Ikeda T, Sano H. Color and translucency of
resin composites for layering techniques. Dent Mater J
2005 Sep;24(3):428-32.
Esan T A, Bamise C T, Akeredolu P A. Evaluation Of Shade
Matching Practices Among Nigerian Dentists Rev Cln Pesq
Odontol. 2008 set/dez;4(3):161-168.

October-December 2011 | Vol 1 | Issue 2

13

ORIGINAL ARTICLE

Evaluation of the stress distribution and displacement of the


denture base in edentulous mandible with varied implant positions
Meghna K. Dang1, Sabita M. Ram2

Abstract
Aim: To evaluate the stress distribution and displacement of the denture base in a three dimensional finite element
edentulous mandibular model with varied implant positions. Objectives: 1)To evaluate the stresses induced by
implants placed in the anterior region of the edentulous mandible. 2)To evaluate the stresses induced by implants
placed in the anterior and posterior region of the edentulous mandible. 3)To compare the stresses induced by
implants placed in the anterior and posterior region of the edentulous mandible. 4)To evaluate the displacement of
the denture base with implants placed in the anterior and posterior region of the edentulous mandible.5)To compare
the displacement of the denture base with implants placed in the anterior and posterior region of the edentulous
mandible. Materials and Methods: The materials used were Nobel Biocare Mk III long implants 3.75x13mm and
short 5.0x7.0 implants, with O-ball head attachment. ANSYS: Version 8.0 software was used to create a threedimensional model of an edentulous mandible and the two implants. Three models were prepared having different
implant positions and locations. MODEL 1 Two long implants were placed interforaminally in lateral incisor region
one on either side, MODEL 2 Four long implants placed were interforaminally in the central incisor and canine
region two on either side and, MODEL 3 Two long implants were placed interforaminally in lateral incisor region one
on either side and two short implants were placed in premolar region 3mm posterior to the mental foramen, one on
either side. Two types of load were given ie. vertical load of 325N was applied in second premolar and first molar
region and 10N load at 150 angulation was applied in the anterior incisors area. The models were loaded separately
and stress pattern, amount of stresses and amount of displacement were analysed for each model. Results: The
observations obtained from the ANSYS software were analysed and evaluated. Model 3 showed the least amount
of stress and displacement as compared to the other models. Conclusion: When the implants were spread across
the arch both anteriorly and posteriorly, the stress induced in the bone and displacement of the denture base was
seen to be less.
Key Words: Implant, Load, Displacement, Stress.

Introduction
Edentulism leads to an acknowledged impairment of
oral function with both esthetic and psychological
changes. Severe atrophy of the inferior alveolar process
and underlying basal bone often results in other
problems with a lower denture such as, intolerance to
loading of the mucosa, pain, difficulty in eating and
speech, loss of soft tissue support, and altered facial
appearance.

that the incidence of surgical complications is very low.


The superior bone quality in the anterior mandible
along with the usual abundance of keratinized tissue
makes it a suitable location for implant placement.
Implants prevent alveolar bone resorption by about four
fold, when placed and selected properly. This makes
implant supported over dentures a very feasible
treatment option that will aid in the establishment of
stability and retention of the mandibular denture.

Professor & Head2


Dept. of Prosthodontics
MGM Dental College & Hospital, Kamothe, Navi Mumbai

An implant retained overdenture with attachment to


the implant can be supported and retained either fully
by the implant or by a combination of a prosthesis
retained both by implant and mucosa. In all incidences
of functional loading, the occlusal forces are transferred
to the bone implant interface and soft tissues by the
implant supported prosthesis. Studies have shown that
regardless of attachment type, patient satisfaction levels
are the same with a bar, ball, or magnet-retained
denture supported by implants.

Address for Correspondence:


Dr. Sabita M. Ram,
Dean
MGM Dental College & Hospital, Kamothe,
Navi Mumbai 410 209
E-mail: drsabita@rediffmail.com

Fabricating overdenture on implants placed in the


anterior region between the foramen results in the
cantilevering of the denture posteriorly leading to
posterior bone resorption along with increased load on
the implants. Since 1982, the evidence for mandibular

It has been established through longitudinal clinical


studies, that the survival of root form titanium
implants is very high in the anterior mandible and
Lecturer 1
DY Patil Dental College & Hospital

14

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Dang and Ram : Evaluation of the stress distribution and displacement of the denture

overdentures supported by two implants has


accumulated sequentially to see them now proposed as
the standard service, when opposing maxillary complete
dentures. Later, implant-supported dentures were
constructed using four implants interconnected by a
bar. It was a reliable option because it remained
functional even after failure of one of even two implants.
Also, placing four implants may reduce the amount of
stress over individual implants and may also reduce
the displacement of denture in the posterior region,
but, the resorption in the posterior region may
continue. It was suggested that a more "spread out"
arrangement of the implants across the arch gave a
"more favourable" distribution of bone stresses around
the implants. But the height of bone in the posterior
region many a times being inadequate, does not permit
the placement of long implants. Therefore short
implants could be an option. This would spread out
the implants in anterior and posterior regions.

Three Dimensional Model of Complete Alveolar


Portion of The Mandible

Therefore a finite element study was undertaken to


compare the stresses in the bone and displacement of
the denture base when implants were placed only in
the anterior region and when the implants were spread
out both anteriorly and posteriorly. These stresses were
analysed by the finite element method by creating a
three dimensional finite element model as it can more
accurately simulate the geometric and material
complexities that exist in real patients. These
situations can be simulated in patients, when implant
overdentures are planned.

Method
The study was divided into following steps:I

Model of Long Implant

Introduction T
o The Finite Element Analysis
To
Finite Element Analysis (FEA) is a computer-based
numerical technique for calculating the strength
and behaviour of engineering structures. The
behaviour of an individual element can be described
with a relatively simple set of equations. Just as
the set of elements would be joined together to build
the whole structure, the equations describing the
behaviours of the individual elements are joined
into an extremely large set of equations that
describe the behaviour of the whole structure. The
stresses will be compared to allowable or permissible
values of stress for the materials to be used, to see
if the structure is strong enough.

II

Construction Of The Fea Model : Preprocessor (Modelling)


A . Construction of the geometric model of
the edentulous mandible

1. Modeling the alveolar portion of the bone

Model of Short Implant

simulates bone with different material properties.


An edentulous mandible was taken and
measurements made at different points along the
bone in the antero-posterior and supero-inferior

Modeling is done as 3D solid modeling. This model


Journal of Contemporary Dentistry

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15

Dang and Ram : Evaluation of the stress distribution and displacement of the denture

plane with the help of vernier callipers. The


measurements were given co-ordinates in the x, y,
and z planes.
The mandible was made eight mm in width and
eighteen mm in height. The canal was modeled by
creating a cylindrical volume and the alveolar part
of the mandible was modeled till the ramal area.
The mental foramen was located at a distance of
30.41mm from midline and 19.38mm from base of
mandible.
2. Modeling the implant and attachments
Nobel Biocare Mk III implants were used in the
study which were made up of Titaniumaluminium-vanadium (Ti-6Al-4V).
The implant dimensions used were
Long implants- 3.75x13.0mm
Short implants- 5.0x7.0mm

Model 1- V
olume Modelling of Mandible
Volume

The threaded part of the implants was embedded


in the bone with the 'O-Ball' attachment outside
the bone on top of the implant. The 'O-Ball'
attachment was modeled as a 1.5mm sphere at
the platform of the implant. The external hex
design and cylindrical portion of the overdenture
attachment was not modeled so as to simplify the
nodal configuration and thereby the analysis. The
implants were constructed in a similar way to the
bone.
3. Placing the implants in bone
The implants were placed in specific positions of
the mandible. The mental foramen was taken as a
guide for the placement of the posterior implants.

Model 2- V
olume Modelling of Mandible
Volume

MODEL 1: Two long implants were placed


interforaminally in lateral incisor region one on
either side.
MODEL 2: Four long implants placed were
interforaminally in the central incisor and canine
region two on either side.
MODEL 3: Two long implants were placed
interforaminally in lateral incisor region one on
either side and two short implants were placed in
premolar region 3mm posterior to the mental
foramen, one on either side.
Complete bond (ankylosed) between implant and
bone was considered. The models were loaded
separately and stress pattern and amount of
stresses were analysed for each model.

5. Modeling of the denture base

4. Modeling the mucosa


Since 'Poissons ratio' for the mucosa was almost
negligible as compared to the bone and the implant,
it was considered not to create a significant impact
on the result and was not modeled.

16

Model 3- V
olume Modelling of Mandible
Volume
The overdenture was modeled as a SHELL element
(Shell 63 element). It had a modulus of elasticity
of 1.022x105 N/mm2 and poisons ratio of 0.3. It
was modeled as a two dimensional structure. The

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Dang and Ram : Evaluation of the stress distribution and displacement of the denture
Material

Properties

Materials
Poissons

Yo u n g ' s
Modulus
(Mpa)

Ratio

Implant

114

0.34

Cortical Bone

14

0.35

Type A

2.5

0.3

Type B

1.5

0.3

Type C

0.5

0.3

Cancellous Bone

D . Applying the boundary conditions


Simulated Load In Molar Area
plate was 3 mm in thickness and kept at a distance
of 2 mm from the bone to compensate for the
mucosal thickness. The plate touched the
overdenture attachments and covered the top part
of the alveolar bone and implants.
6. Splitting the mandible into two symmetric parts
Since the mandible is symmetric about its midline,
the mandible was sliced through the centre. This
simplifies the solving process as less computational
data would be generated.
B . Meshing the model

E . Loading of the model


Beam loading was used to put the load. Two loads
were applied.
LOAD 1 - A vertical load of 325 N was applied in
second premolar and first molar region.
LOAD 2 - A tipping force of 10 N at 150 angulation
was applied in the anterior incisor area.
II PROCESSOR (SOLVER)

A three dimensional Finite Element Mesh was


created using the Ansys pre-processor. Care was
taken to concentrate the mesh pattern in the region
where we wanted to study the distribution (i.e.
around the implant). For this reason the SOLID
45 element (brick element) type was selected. The
element had a 8 node element with quadratic
displacement behaviour and was well suited for
modeling irregular meshes. Each node had freedom
to move in the x, y and z planes. The elements
were constructed to be as accurate as possible
within the limitations of the software. The
completed model consisted of 28889 elements and
total of 6223 nodes (4956 for bone and 1267 for
implants) with 18669 degrees of freedom.
C . Assigning the material properties
All the structures depicted in the model (cortical
bone, cancellous bone, and the implant) were
assumed to be linearly elastic, homogenous and
isotropic. The Young's modulus and Poisson's ratio
for the different materials used in the study were
given by Pierrisnard L, Hure G, Barquins M,
Chappard D1. The models were given the properties
of Cancellous Type A bone.
Journal of Contemporary Dentistry

Symmetric boundary conditions were imposed at


the mid-symphyseal region since only half the
mandible was modeled. The rear end of the
mandible was fixed for displacement in all three
translations.

Once the geometry is converted to the finite element


form, it is to be solved by the solver which is a part
of the software. The results were generated after
all the equations were solved. The solver does the
following: it generates element matrices, computes
nodal displacement values and derivatives, and
solves governing matrix equations.
II POST PROCESSOR (RESULT)
The results for the stress and displacement are
interpreted from color coded images seen in the
3D finite element models.

Results
The observations were statistically analysed to
comparatively evaluate the values obtained. The Stress
analysis executed by the Ansys software provided
results that enabled visualization of Compressive
stress, Von-Mises stress fields in the form of Colour
coded bands along with the Displacement. Each colour
band represented a particular range of stress value
which is given in Newton-mm2. The displacement
values were observed in mm.

October-December 2011 | Vol 1 | Issue 2

17

Dang and Ram : Evaluation of the stress distribution and displacement of the denture

Model

Compressive
N
325N
Stress 325
Ve r t i c a l
Load

Von Misses Von Misses


N Stress 10
N
325N
10N
Stress 325
Ve r t i c a l
Oblique
10N
Load
Oblique
Load

Resultant
Von Misses
Stress of
325N
Ve r t i c a l
Load
(Rounded)

Model 1 Max. Upto 132 0-352

0-1.2

351

Model 2 Max. Upto 60

0-261

0-0.9

260

Model 3 Max. Upto 33

0-160

0-1.1

159

Displacement Of Plate At 325n V


ertical And 10n
Vertical
Oblique Load

DISPLACEMENT
mm

Analysis of Stress Induced In Bone With Three


Different Implant Positions (N/Mm 2 )

Displacement of Denture Base (Mm)


Model

Displacement of Plate
W ith 325
N V
ertical
325N
Vertical
And 10
N Oblique Load
10N

Displacement of Plate
With 10
N Horizontal
10N
Load

Model 1

93

0.079

Model 2

46

0.026

Model 3

20

0.018

Displacement Of Plate At 10n Oblique Load

Graphs:

STRESS N/mm 2

Compressive Stress Induced In Bone

Discussion:

Resultant V
on Misses Stress Induced In Bone
Von

Edentulous patients require replacement of teeth for


performing function of mastication, speech and
esthetics. With advancing age, the rate of resorption
increases leaving the patient a dental cripple. The
placement of implants for such patients will overcome
the problems of retention, stability, comfort and
preservation of tissues. Fixed restoration with multiple
implants may be the first choice for these patients,
but with the deteriorating conditions of the alveolar
ridge, placing multiple implants may not be possible.
We need to take the maximum advantage of what
remains of the patient's oral condition. Complete over
dentures with few implants could be the treatment
option for these patients in order to fabricate prosthesis
that the patient appreciates without overloading the
poor denture foundation.
The placement of implant overdentures has become a
popular line of treatment. Factors such as location,
number, size and distribution of implants over the
edentulous arch have been a subject of much debate.

18

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Dang and Ram : Evaluation of the stress distribution and displacement of the denture

This study was 3-D finite element study planned with


the two lengths of Nobel Biocare Mk III implants having
two different diameters and lengths and three different
positions on the edentulous mandible.
The finite element model of the mandible was modeled
and the bone density was incorporated as suggested by
Perrishard, Hure, Barquins, Chappard1. For
simulation of the overdenture a SHELL element was
modeled and was two dimensional. The material
properties were assigned according to the literature
and the models were meshed. The selection of implants
was done to simulate different situations.
For Model 1 two implants of Nobel Biocare 3.75mm x
13mm were placed in the lateral incisor region which
according to Hong, Choi, Bak and Kwon2, was the best
position for placing them for overdentures.
For Model 2 four implants of Nobel Biocare 3.75mm x
13mm were placed in central and canine region as
suggested by Misch3.
For Model 3 the two anterior implants of Nobel Biocare
3.75mm x 13mm were placed as in Model 1 in lateral
incisor region and two posterior implants of Nobel
Biocare 5mm x 7mm were placed in posterior region
as suggested by Gherke, Spanel, Degidi, Piatelli, and
Dhom4.
Occlusal forces were applied to simulate the vertical
forces (y axis) and the oblique load was applied at 150
angle as suggested by Chun et al5 to simulate the
anterior component of the load that bought about the
tipping of the denture when tongue comes in contact
with the lingual surface of the anterior teeth6 (x-axis).
A combination of occlusal and oblique load simulated
the masticatory load in the model. The amount of load
applied was in accordance with Kampen, Bitt, Cune,
Bosman, and Bozkaya, Muftu7. the stresses were
observed and analyzed.
It was found that irrespective of the positions of
implant the concentration of stresses was near the
attachment of the O-ball head to the implant. Less
stresses were seen in model with four implants as
compared to model with two implants which is
contradictory to the studies carried out by different
researchers i.e Meijer, Starmans, Steen, Bosman8 and
Visser, Raghoebar, Meijer, Batenburg, Vissink 9.
Maximum stresses and displacement of denture base
were observed in model with two implants placed
anteriorly which may be attributed to less support.
Least stresses were seen in the model with two long
implants placed anteriorly and two short implants
placed posteriorly along with least displacement of
denture base. This may be attributed to the increased
number of implants and also their wide distribution
and spread across the arch.

Journal of Contemporary Dentistry

The Finite Element Method has proven to be an


extremely accurate and precise method for analyzing
structures. Although it is not a substitute for clinical
experimentation, the use of this method of analysis is
warranted as it simulates experimental results,
reduces experimentation costs and avoids destructive
experimentation.

Conclusion
The study was conducted to evaluate the stress
distribution in bone and displacement of the denture
base with varied implant positions. Within the
limitations of the 3D finite element study the following
conclusions were drawn:
1. The stresses were maximum with two implants
placed in the anterior region.
2. The stresses were minimum when the implants
were spread anteriorly and posteriorly i.e. two
implants in the anterior region and two short
implants in the posterior region.
3. The stresses with four implants in the anterior
region were less than the two implants placed in
the anterior region but more than the four implants
spread anteriorly and posteriorly.
4. Maximum displacement of the denture base was
observed with two implants placed in the anterior
region.
5. Minimum displacement of the denture base was
observed with implants spread anteriorly and
posteriorly.
6. The displacement with four implants placed in the
anterior region showed less displacement as
compared with two implants placed in the anterior
region but more as compared to the four implants
placed anteriorly and posteriorly.
7. When the implants were spread across the arch
both anteriorly and posteriorly, the stress induced
in the bone and displacement of the denture base
was seen to be less.

References:
1.

2.

3.

4.

5.

Pierrishard L, Hure G, Barquins M, Chappard D. Two dental


implants designed for immediate loading: a finit element
analysis. Int J Oral Maxillofac Implants. 2002;17:353-362.
Hong HR, Choi DG, Bak J, Kwon KR. 3D finite element
analysisof overdenture stability and stress distribution on
mandibular implant-retained overdenture. J Korean Acad
Prosthodont 2007;45(5):633-643.
Misch CE. Dental implant prosthetics. Treatment options
for mandibular implant overdentures. 2nd edition Elsevier
publishing; 2005.
Gehrke P, Spanel A, Degidi M, Piatelli A, Dhom G. FEM
analysis on deformation and stress distribution in fixed
metal-reinforcedprovisional restorations of immediately
loade XiVE implants in the edentulous mandible. Poster
presented at 12th International Friadent Symposium 2006
held on march 24-26 at Salzburg, Autria.
Chun HJ et al. Evaluation of design parameters of
osseointegrated dental implants using finite element
analysis. J Oral Rehab 2002;29:565-574.

October-December 2011 | Vol 1 | Issue 2

19

Dang and Ram : Evaluation of the stress distribution and displacement of the denture
6.

7.

20

Zmudzki J, Chladek W, Krukowska J. Attachments of


implant retained tissue supported denture under biting
forces. Archive Computational Mat Sc Surface Eng
2009;1(1):13-20.
Van Kampen FM, Van Der Bitt A, Cone MS, Bosman F.
The influence of various attachment types in mandibular
implant retained overdentures on maximum bite force
and EMG. J Dent Res 2002;81(3):170-173.

8.

9.

Meijer HJ, Starmans FJ, Steen WH, Bosman F. A threedimensional finite element study on two versus four
implants in an edentulous mandible. Int J Prosthodont
1994;7(3):271-279.
Visser A, Raghoebar GM, Meijer HjA, Batenburg RHK,
Vissink A. Mandibular implant overdentures supported by
two or four endosseous implants. A 5 year prospective
study. Clin Oral Impl Res. 2005:16;19-25.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

REVIEW ARTICLE

Use of Functional Appliances in General Dental Practice


Girish R. Karandikar1, Anita G. Karandikar2, Madhur Vasudev Navlani3

Abstract
Although most malocclusions pertaining to irregularities of teeth resolve through moving teeth, occasional
malocclusions confront us with a disharmonious inter-jaw-relationship owing to faulty size and/ or faulty anteroposterior location of the jaws or dentoalveolar regions. These malocclusions do not always respond favorably to
conventional tooth moving appliances and are ideal candidates for appliances that have the capability of molding
bones as well as relocating them. Through this article, the authors outline a way that General Dentists can get
enough 'food for thought' for treating such cases on their own by using simple removable appliances. Additional
reading/training may be needed to get to use the functional appliances with felicity.
Key Words: Skeletal pattern, Growth amount, Growth direction, Construction bite, Appliance manipulation

Introduction
Assuming that one subscribes to the theory that moving
teeth is easier than moving bones, it follows that the
degree of success in rearranging relationship of jaw
bones will be decided by attempting corrective steps
well before peak-growth-velocity is over. Thus, late
mixed dentition may be the best period for a clinician
to aim to start correction of the commonest problem:
large overjet (8-10 mm and beyond) often accompanied
by deep overbite, narrow maxillary dental arch,
recessive chin and a seemingly prognathic or, better
still, an almost normal maxillary element.
Such Class II type of cases may be ideal ones for a
General Dentist (GD) to familiarize himself with in
using Myofunctional Appliances (also referred to as
Functional Appliances). Class III cases are as such more

difficult ones to treat and hence should be avoided at


least initially.
Though functional appliances are also of a fixed variety,
the authors strongly recommend use of the removable
type for their minimalistic iatrogenic-damage-potential
(operator-induced-damage-potential).

Functional Appliances
These are muscle motivating appliances, often loose
fitting, which harness the natural forces of the orofacial
musculature that are transmitted to the teeth and
alveolar bone through the medium of the appliance.
Commonly used Functional Appliances include
Andresen's Activator12,13 (Fig.1), Balter's Bionator14

Professor and Head1


Department of Orthodontics
M.G.M. Dental College and Hospital, Navi Mumbai
Professor2
Department of Orthodontics
YMT Dental College, Kharghar, Navi Mumbai
Senior Lecturer3
Department of Orthodontics
Modern Dental College & Research Centre, Indore
Address

for

Correspondence:

Dr. Girish R. Karandikar


Department of Orthodontics
M.G.M. Dental College and Hospital, Kamothe
Navi Mumbai
E-mail: drgirishkarandikar@gmail.com

Journal of Contemporary Dentistry

Fig.1 : Activator

(Fig.2), Frankel Appliance16,17 (Fig.3, 4), Clark's Twin


Block10 (Fig.5), etc.

October-December 2011 | Vol 1 | Issue 2

21

Karandikar et.al. : Use of Functional Appliances in General Dental Practice

Fig.2 : Bionator
Fig.5 : Twin Block Appliance

Fig.3 : Frankel's Appliance for correction of Class IIs


Fig.6 : Cephalostat, the head holding devise
for taking Lateral Cephalograms

Fig.4 : Frankel's Appliance for correction of Class IIIs

22

Fig.7 : Patient's head


positioned in the Cephalostat,
Side View

Journal of Contemporary Dentistry

Fig.8 : Position of ear-rods


& Fronto-Nasal Rest,
Front View

October-December 2011 | Vol 1 | Issue 2

Karandikar et.al. : Use of Functional Appliances in General Dental Practice

Why Functional:
Irrespective of which functional appliance it is,
functional appliances are all based on same basic
principles (application, redirection and removal of force),
that of using Function Forces & of alternating their
direction, strength & duration. All of these appliances
are all muscle controlled even if screws & springs are
built in.
Development of Functional Appliances:
A major reason was recognition that function had an
effect on ultimate morphologic structure of dentofacial
complex 1 . Moss's Functional Matrix Theory 2 ,
contributions of Wolff on form & function, studies on
response of bone to functional forces by Kock,
Benninghof and ideas of Van Der Klauuw all
contributed in seeking to change and control the
direction of growth of the jaws in correcting imbalance
in the skeletal jaw bases.
These studies and several others paved a way in
proving that function plays a very important role in
controlling size & shape of bones in the membranous
bones of craniofacial area and especially more so in
regions of the alveolar base of jaws.
Effect of Functional Appliances:
Functional Appliances are unique not solely due to their
purported orthopedic effect influencing facial skeleton
of growing child in condylar & sutural areas as claimed
by several experts. They also exert an orthodontic effect
on dentoalveolar area. Unlike conventional appliances
which act on teeth using mechanical elements,
functional appliances act on dentoalveolar structures
by transmitting, eliminating or guiding natural forces
produced during various functions e.g. Swallowing,
Mastication, etc.
Functional Appliances help to reset the altered
equilibrium of the orofacial musculature and often help
in elimination of oral habits whilst being an effective
post-treatment retention appliance in certain types of
cases too.

Case Selection & Issues with Diagnosis &


Treatment Planning
Functional Analysis11 is a very important cog, in the
wheel of success while using Functional Appliances.
The reader is encouraged to be conversant with the
nuances involved herein before attempting to treat
cases.
Other important issues are:

The diagnostic criteria used to determine the


growth pattern (both antero-posterior and vertical)
in a case.

Status of lower anterior teeth (in terms of


proclination or crowding prevalent).

Journal of Contemporary Dentistry

Judging the efficacy of the expected clinical result


(clinical VTO).

Understanding the principles of, and taking a


proper Construction Bite12.

Despite being seemingly easy to use, functional


appliances need proper case election criteria to be
followed and, above all, a cooperative patient to
achieve the needed degree of success.

(1) Judging the Skeletal Pattern


The purpose of this step is to determine if a case belongs
to the correct type in being treated with a Removable
Functional Appliance.
This calls for routine lateral cephalometric skeletal
evaluation using suitable simple analysis for judging
the skeletal discrepancy between the upper and lower
jaws. Any standard textbook in Orthodontics 3,4 5,7,10, 12,13
will help the reader to reacquaint themselves of these
basic facts.
If a Cephalostat (Fig.6, 7, and 8) is not available, then,
a True Lateral X-ray of the Skull and Mandible taken
from the right side with a film-to-focus distance of 5
feet can be made use of.
(a) Antero-posterior Dimension: The normal ANB
relationship is about +2 with the plus sign
indicating that maxilla is ahead of the mandible.
Ideally, in treating Class II cases with removable
functional appliances, the antero-posterior position
of maxilla should be more or less normal and the
mandible should be retro-positioned in their
relationship to the anterior cranial base: thus
setting up a large ANB value in the angular
measurements.
Thus, all things being equal, cases with a SNA
value that is normal or near normal for a child at
that age with a concurrent ANB value of upwards
of about +5 are ideal (as this indicates that the
maxilla is normal and the mandible is retropositioned) for intervention with a functional
appliance.
(b) Vertical Dimension: For easy recall, in lateral
cephalometric analysis, this information is divulged
by angular measurements FMA, GoGn-SN and
Maxillo-Mandibular Plane Angle (Basal Angle). For
example, while using FMA values, the normal is
25. When the face is more oval or long: making
the nose-to-chin-distance increase substantially,
this value increases to well beyond about 30 for
the condition to be termed as a High Angle Case.
On the other hand, when the nose-to-chin-distance
shortens this angular value reduces well below 21
or so for the case to be described as a Low Angle
Case.

October-December 2011 | Vol 1 | Issue 2

23

Karandikar et.al. : Use of Functional Appliances in General Dental Practice

Genesis of a V
ertical Problem: Consider the
Vertical
fact that as a child starts to mature in the dentofacial area, the chin position is governed by growth
in the dento-alveolar areas of posterior teeth. This
is akin to creating premature contacts posteriorly,
or, as in a situation created by progressive vertical
eruption of teeth. Hence, the chin tends to swing
downward and backwards: making it assume a
retrognathic character. This is counterbalanced by
growth in the mandibular condylar area which
tends to make the chin go upwards and forwards:
making it assume a prognathic character. When
the mechanism works well in unison, the result is
a normal, balanced face. When growth in posterior
alveolar areas radically exceeds that in the condylar
region, the result may be a High Angle Case with
a longish face. If the roles are reversed, a Low Angle
Case may be the outcome.
All things being equal, best cases to start with
Functional Appliances are when the FMA value is
within the normal range: between 22 to 28 or so.
(2) Status of Lower Incisor T
eeth
Teeth
Since the construction bite is taken in a protrusive
mode for Class II cases, there is always a tendency
for the lower anterior teeth to be proclined. Hence,
in case selection, an important criterion is that
the lower anterior teeth should be either 'straight'
(sometimes also called as 'upright') or even
Retroclined rather than be in a state of proclination.
There should also be absence of any lower incisor
crowding.
(3) Positive Clinical VTO
VTO stands for Visual Treatment Objective. In
essence, this clinical test is an advance indication
of the projected/anticipated efficiency of the
attained result. Since it is a very accurate way to
determine if the treatment result will make a
positive effect on the personality change attempted,
it is an invaluable clinical advance planning tool
in clinical practice: especially since it does not need
any specialised equipment.
When a patient with large overjet is to be treated with
a functional appliance, the clinician needs to:
(a) Have the patient sit upright facing the clinician.
Patient must be at rest with the lips in their
normal unstrained position and the teeth in the
Centric Occlusion. If the patient can be relaxed
enough to give a physiological rest position, so much
the better. Patient is now observed and preferably
photographed from the:

The Frontal aspect


The Profile view

This gives us an accurate depiction of the patient's


facial features before treatment.

24

(b) Now, the patient is taught/trained to get his Lower


Central Incisor teeth in an edge-to-edge
relationship with the Upper Central Incisor teeth:
a position that he will be made to assume when
being treated with the functional appliance. He
then holds/maintains the teeth in the same
position. Patent is made to drape the lips on the
newly positioned teeth with minimum possible
strain reflected in them. Photographs are then
taken again from the:

The Frontal aspect


The Profile view

This position reflects the likely looks that the patient


will exhibit at the end of treatment with Functional
Appliance.
(c) The photographs taken in natural rest position (as
in "a") are then compared with those taken in the
protrusive (as in "b").
(d) If the patient's facial features show a marked
improvement between the two sets of photographs
("a" v/s "b"), the patient is said to have shown a +ve
Clinical VTO and therefore is a good candidate for
being treated with a suitable functional appliance.
(4) Construction Bite
The case-attributes that we are contemplating on
treating with Functional Appliance shall have a
significantly large over jet. This will be attempted to
be corrected by following the well laid out principles
of registering a Construction Bite12 using modelling
wax.
Although there are several ways and philosophies in
the precise way of registering a construction bite, in
its simplest form, the same can be broken down into:
(a) This involves training the patient to achieve the
maximal protrusive relationship of the lower
incisors, and then staying at least 3 mm less
protrusive (or, behind/distal) to this maximum
protrusive position while registering the Bite on
warm roll of horse-shoe-shaped wax.
With the construction bite passively in the mouth,
the patient's face should look decidedly better (as
in when Clinical VTO is taken).
If the patient has an overjet that is greater than 68 mm, often, it is necessary to advance the mandible
in two stages. However, this entirely depends upon
a patient's ability of giving a maximal-protrusiveposturing of lower jaw. Sometimes, it may be OK
to jump even 10 mm in a one-step-bite.
Care should be taken to ensure that:
i.

Upper and Lower dental midlines coincide/match

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Karandikar et.al. : Use of Functional Appliances in General Dental Practice

ii. While correcting the midline, there should be no


posterior cross-bite created artificially by abnormal
posturing of the mandible while taking the
construction bite.
iii. The vertical separation between molars on left and
right sides is equal.
iv. The vertical separation in molar region should be
at least 3-4 mm.

(b) This construction bite is then used for the lab to


mount the casts on a non-anatomical articulator
to fabricate the appliance using self curing acrylic
resin with a salt-and-pepper technique.

Mode of Action of Functional Appliances

(5) Appliance fabrication pre-requisites:

The authors wish to take a very simplistic model to explain


to a GD the mechanism of Class II correction with
Functional Appliances.

a) The impressions taken must be:


i. Deep and should register the Labial and
Buccal vestibules in totality.
ii. The lingual pouch area should also be very
well registered.
iii. Made in duplicates so that another set of
casts are available to check the accuracy
of fit of the fabricated appliance, etc.
b) The casts must be:
i. Made out of the impressions at the soonest
so that dimensional inaccuracies do not get
introduced through syneresis and
imbibitions.
ii. Made using good quality Dental Stone
iii. Without blemishes like air-bubbles or
voids.
c)

Undercut Areas, especially on the lingual side


should be blocked out with wax prior to
acrylisation.

(6) Choice of Myo-functional Appliance


Amongst the commonly used Functional Appliances
are Andresen's Activator12,13, Balter's Bionator14,
Frankel Appliance16,17, Clark's Twin Block10, etc.
Generally, choice of appliance is an operator driven
issue rather than it being a case-specific one. Other
factors like concurrent need for expansion of dental
arches; need to use extra-oral forces in tandem with
the functional appliance therapy, availability of lab
back-up, patient compliance etc., are some vital issues
which determine which appliance is preferred by a
clinician.
All in all, the attributes of a typical Class II Division I
Case to be treated well before peak growth velocity is
reached should be:
Mixed Dentition Phase: early, mid, or, late (in the
same preferential order of chronology). Second
permanent molars yet to erupt.
Normal Maxilla with retro-placed mandible (as
confirmed by Lateral Cephalometric Analysis).

Journal of Contemporary Dentistry

Normal Vertical Growth Pattern.


Lower Incisors: no proclination, no crowding/
rotations.
Large overjet of upper anteriors.
'V' shaped, narrow maxillary dental arch with
narrowing in cuspid region.
A positive Clinical V.T.O.

Several experts 3,4,5,6,7,8,9 have propagated proper theories


with a scientific base: all with significant variation in
views to pin down the exact mode of action.

Consider a typical case: growing child well before


attaining peak-growth-velocity, having a large overjet,
narrow maxillary dental arch with distinct constriction
in the cuspid-premolar area, deep overbite with an
accentuated curve of Spee and a near-normal
mandibular dental arch with a non-contracted arch
form. The mandible, per say, is normal but is located
way behind/posterior to the maxillary unit
(distocclusion).
In such a situation, the narrowness of the maxillary
dental arch in the cuspid-premolar area does not permit
the lower anterior teeth to go forward by translation of
the mandible which should be occurring when growth
at the mandibular condyle occurs.
This is a bit like person who wears size 10 shoes trying
to get into a shoe that is size 4. The wide foot can go
only part of the way before the narrowness of the size
4 shoe prevents the foot from going any further. Thus,
a lot of the size 4 shoe will be unoccupied by a foot that
is normally clad in size 10 shoe. This empty space in
size 4 shoe is akin to the large overjet in the narrow
maxilla that the wide foot (mandible) is unable to get
to occupy due to the narrowness of the shoe's opening
(narrow inter-canine-width) in maxillary dental arch.
This results in a Class II occlusion and a retrognathic
profile. The lower anterior teeth often become more
upright and sometimes even Retroclined as a
compensatory effect.
Expansion of the maxillary dental arch is hence needed
either before or concurrent to use of functional
appliances for the mandible to relocate anteriorly.
Simply put, narrowness of the maxillary arch has to
be circumvented for the 'normal' growth potential of
the mandible can be given a chance to 'catch-up' with
the maxillary growth or, 'jump' ahead to correct the
bite (more like releasing the brake of a car on a slope
will allow it to move forward at a fast pace). This is
often called as 'jumping the bite'.

October-December 2011 | Vol 1 | Issue 2

25

Karandikar et.al. : Use of Functional Appliances in General Dental Practice

This circumventing is achieved through the


construction bite. The mandibular teeth are made to
assume a near edge-to-edge-relationship with the
maxillary incisors: thereby taking the posterior teeth
out of occlusion. Maxillary teeth are thus now ready to
be expanded by a suitable method depending on the
type of functional appliance used.
The construction bite when replicated into a fabricated
appliance locks the mandible into a more protrusive
position. The retractors muscles of the mandible (lateral
pterygoids) thus get activated to try to pull the mandible
backhowever, the appliance does not allow this to
happen. The pulling back impetus of the mandible is
transferred through the appliance on to the maxilla as
a reciprocal effect. At best, the forward and downward
growth of maxilla is prevented / retarded. But, the
mandibular condyle, owing to having been displaced
out of its normal position within the glenoid fossa for
the entire time that the appliance is worn then
undergoes reorganizational changes.
If the functional appliance is worn for a sufficiently
long period (long hours every day and night and doing
so continuously in excess of 6-8-10 months), the new
protrusive position of the mandible dictated by the
appliance then can become the normal position for the
patient. It brings about the needed correction in both
antero-posterior and vertical dimensions.
The concept is similar to a married lady, on staying at
her husband's home, over a period of time, gets to
identify and feel comfortable in her new home rather
than her parental home ('sasural' and maika' to lapse
into colloquial).
Selective grinding (called trimming) of the acrylic of
the functional appliance aids the condylar
reorganizational changes in allowing/guiding
movements in vertical and antero-posterior direction
for the teeth.

Care to be taken in using Functional


Appliances

retention appliance. This may be done by partial use


(about 9 hours daily).
It is impossible to make the reader aware of all
intricacies of using a treatment philosophy. The reader
should look for avenues to take Continuing Education
Programs to hone their skills before embarking on the
exciting journey to treat cases with Functional
Appliances.
Sometimes, despite the best diagnostic skills, a proper
choice of appliance exercised with adhering to all the
needed underlying principles, results are inadequate.
The reason for that is best described by a simple GAK
principle: God Alone Knows!!

Bibliography
1.
2.

3.

4.
5.
6.
7.

8.

9.

10.

11.
12.

When used early in a compliant patient, sometimes


the results seem to be attained very quickly: as seen
when the clinician asks the patient to take off the
appliance. However, when used for a shorter period of
time, this apparent correction may be just a transient
phase: more due to a dual-bite created rather than a
permanent correction.

13.

Therefore, the operator and the patient both need to be


patient in getting the appliance to be used for a much
longer period (10 months is a good ball-park-figure) for
the gains to be of a permanent nature.

16.

In presence of a familial trait/genetic pre-disposition


towards unfavorable growth, it is best to keep using
the appliance for an even longer period: more like a

18.

26

14.

15.

17.

FRANKEL R. A functional approach to orofacial


orthopedics. Br. J. Orthod. 1980;7:41-51.
MOSS M. L. The primary role of functional matrices in
facial growth. Am. J. Orthod. Dentofacial Orthop.
1969;55:566-77.
GRABER T.M., NEUMANN B:. In Concepts of functional
jaw emodelling . Removable orthodontic appliances. 2nd
ed. Philadelphia: Saunders; 1984.
PROFFIT W.R., FIELDS H.W. Contemporary orthodontics.
4th Ed. St Louis: Mosby; 2007.
MOYERS R.E. Handbook of Orthodontics. 4th Edn. Year
Book Medical Publishers ;1988.
h t t p : / / w w w. o r t h o d o n t i c s . a z / i n d e x . p h p ?
categoryid=9&p2_articleid=62
GRABER T.M., RAKOSI T., PETROVIC A.G In Dentofacial
emodelling with functional appliances.: Principles of
functional appliances. St Louis: Mosby; 1985.
CARELS, LINDEN V. Concepts on functional appliances'
mode of action. Am. J. Orthod. Dentofacial Orthop. 1987;
92: 162-168.
WOODSIDE, METAXAS, ALTUNA: The influence of
functional appliance therapy on glenoid fossa remodeling.
Am. J. Orthod. Dentofacial Orthop. 1987; 92:181-198.
WILLIAM CLARK. Twin Block Functional Therapy:
Applications In Dentofacial Orthopaedics. 2nd Edn. Mosby
Ltd.
RAKOSI T. Colour atlas of Dental Medicine - Orthodontic
Diagnosis. 1st Edn. Thieme Medical Publishers.1993.
SAMIR E. BISHARA. Textbook of Orthodontics.
Saunders.2001.
SALZMANN J.A: Practice of Orthodontics . J.B Lippincott
Co., Vol: I, II, 1966.
REEY R.W, EASTWOOD A. The passive activator: case
selection, treatment response, and corrective mechanics.
Am. J. Orthod. Dentofacial Orthop. Am. J. Orthod.
Dentofacial Orthop. 1978;73:378-409.
HIRZEL HG, GREWE JM. Activators: a practical approach.
Am. J. Orthod. Dentofacial Orthop. 1974; 66:557-570.
ALTUNA G., NIEGEL S. Bionators in Class II treatment.
J. Clin. Orthod. 1997; Mar: 185-191.
FRANKEL R: The treatment Of Class II, Division 1
maloccusion With functional correctors. Am. J. Orthod.
Dentofacial Orthop. 1969;55: 265-275.
MCNAMARA J., HUGE S. The Frankel Appliance (FR-2):
Model preparation and appliance construction. Am. J.
Orthod. Dentofacial Orthop. 1981; Nov.: 478-495.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

REVIEW ARTICLE

Pediatric Obturating Materials And T


echniques
Techniques
Mihir Jha1, Sonal D.Patil2, Shrirang Sevekar3, Vivek Jogani4, Poonam Shingare5

Abstract
Pulp therapy helps in preserving a pulpally involved primary tooth by eliminating bacteria and their products and
ensures hermetic seal of the root canals so that the primary tooth can complete its function without harming the
successor or affecting the health of the patient. A thorough understanding of the pulp morphology and root formation
and resorption in primary teeth as well as different materials and techniques used is imperative for a successful
pulp therapy. One of the major areas of continued research is in the area of finding obturating materials to suit the
specific properties of these teeth. This article seeks to present a review of the major obturating materials and
techniques with their modifications as well as their advantages and disadvantages.
Key words: Pulp therapy, Primary teeth, Obturation materials and techniques

Introduction
A dentist who provides emergency or restorative care
for children will inevitably encounter a situation where
a primary tooth has a pulp exposure.1 This could be
from a traumatic injury or as the result of a mechanical
or a carious pulp exposure. Pulp therapy for deciduous
teeth aims to preserve the child's health and to
maintain deciduous teeth in a functional state until
they are replaced by permanent teeth.2 The main
objective of endodontic treatment is total elimination
of micro-organisms from the root canal, and the
prevention of subsequent re-infection. This is achieved
by careful cleaning and shaping followed by the
complete obturation of the canal space.3 However, the
complex morphology of the root canal system in
deciduous teeth makes it difficult to achieve proper
cleansing by mechanical instrumentation and
irrigation of the canals.2 So, in order to increase the
chance of success of the endodontic treatment,
substances with antimicrobial properties are frequently
used as root canal filling materials in deciduous teeth.2
Senior Lecturer1
Senior Lecturer2
Reader 3
Senior Lecturer4
Senior Lecturer5
Department of Pediatric Dentistry
MGM Dental College and Hospital, Kamothe, Navi Mumbai.

Address for Correspondence:


Dr Mihir Jha
Dept of Pediatric Dentistry,
MGM Dental College and Hospital,
Kamothe, Navi Mumbai.
Mob.: 09561062790
E-mail: drmihirjha@gmail.com

Journal of Contemporary Dentistry

The ultimate goal of endodontic obturation has


remained the same for the past 50 years: to create a
fluid-tight seal along the length of the root canal
system, from the coronal opening to the apical
termination.3
Rifkin identified criteria for an ideal pulpectomy
obturant that include
(1) Resorbability
(2) Antiseptic property
(3) Non-inflammatory and nonirritating to the
underlying permanent tooth germ
(4) Radio-opacity for visualization on radiographs
(5) Ease of insertion and
(6) Ease of removal
However, none of the currently available obturating
materials meet all of these criteria. The present review
seeks to evaluate each of the presently available
obturating materials and present a few of the emerging
concepts related to obturation of primary teeth.
Presently, the commonly used materials for primary
root canal fillings are zinc oxide Eugenol, Iodoform
based pastes4 and calcium hydroxide.
Zinc oxide Eugenol is one of the most widely used
materials for root canal filling of primary teeth.
Bonastre (1837) discovered zinc oxide Eugenol and it
was subsequently used in dentistry by Chisholm (1876).
Zinc oxide Eugenol paste was the first root canal filling
material to be recommended for primary teeth, as
described by Sweet in 1930.3
Hashieh studied the beneficial effects of Eugenol. The
amount of Eugenol released in the periapical zone
immediately after placement was 10-4 and falls to 10-6
after 24 hrs, reaching 0 after 1 month. Within these

October-December 2011 | Vol 1 | Issue 2

27

Jha et.al. : Pediatric Oburating Materials And Techniques

concentrations Eugenol is said to have antiinflammatory and analgesic properties that are very
useful after a pulpectomy procedure. Since 1930's zinc
oxide Eugenol has been the material of choice. However,
it has certain disadvantages like slow resorption,
irritation to the periapical tissues, necrosis of bone and
cementum and alters the path of eruption of
succedaneous tooth.5 Colla J (1985) found that zinc oxide
may alter the path of eruption of succedaneous
permanent.6 Erasquin (1967) reported occurrence of
necrosis of cementum, bone and inflammation of
periapical tissue.7 Robin L W studied unresorbed zinc
oxide Eugenol was surrounded by several layers of
condensed cellular tissues. This was composed of inner
layer of tightly packed cells and outer layer of fibroblast
with chronic inflammatory cells. Segmentation of mass
occurs by ingrowth of collagen and fibroblast forming
septa. Within the septa sequestration of zinc oxide is
seen into smaller masses.8
Research is going on in this area to improve the
properties of zinc oxide Eugenol by adding antibacterial
substances or by altering it with other materials.
Success rates were reported after obturating with Zinc
Oxide Eugenol cement by various authors as follows 82.3%- Barr et al9 82.5% - Gould10 86.1% Coll et al.11
Formocresol, Formaldehyde and Paraformaldehyde
and cresol have been tried out 12 to improve the
properties and success of zinc oxide Eugenol, but the
addition of these compounds neither increased the
success rate nor made the material more resorbable
as compared to zinc oxide Eugenol alone.13
A study was conducted in which iodoformized zinc oxide
Eugenol was tested for its antibacterial effect against
the aerobic and anaerobic bacteria and was found to be
effective for both the aerobic and anaerobic bacteria of
the root canals of deciduous teeth with maximum
sustaining period of 10 days.14
A combination of zinc oxide powder and calcium
hydroxide paste for obturation of primary teeth has
shown promise in a short term study by Chawla15. They
found that the obturated material remained up to the
apex of root canals till the beginning of physiologic root
resorption. Also the material was found to resorb at
the same rate as teeth. Combination of calcium
hydroxide, zinc oxide, and 10% sodium fluoride solution
has been tested in a clinical study. It was observed
that the rate of resorption of this new root canal
obturating mixture was quite similar to the rate of
physiologic root resorption in primary teeth.16
Iodoform pastes have better resorbability and
disinfectant properties17,18,19 than ZOE, but they may

28

produce a yellowishbrown discoloration of the tooth


crowns which may compromise esthetics.17 Different
formulations of root canal filling materials containing
Iodoform are available: KRI paste (iodoform, camphor,
menthol, and parachlorophenol), Maisto paste
(iodoform, camphor, menthol, para-chlorophenol, zinc
oxide, lanolin, and thymol), Guedes-Pinto paste
(iodoform, camphorated parachlorophenol, and Rifocort
(Medley, Campinas/SP; prednisolone acetate and
sodium rifampicin), Endoflas (Sanlor Lab, Miami/FL;
iodoform, zinc oxide, calcium hydroxide, barium
sulfate, Eugenol, and paramonochlorophenol), and
Vitapex (Neo Dental International, Federal Way/WA;
calcium hydroxide and iodoform).16,20 Castagnola and
Orley (1952) stated that KRI paste loses only 20% of
its potency in 10 years.21 Garcia Godoy (1987) found
that KRI paste resorbs from the apical tissue in a week
or two; it does not set to a hard mass and can be inserted
and removed easily.22 Eliyahu Mass (1989) found Maisto
paste to be successful in infected posterior primary
teeth and had positive healing effect on periradicular
tissue.23
Since the introduction to dentistry of Calcium
Hydroxide by Hermann (1920, 1930), this medica-ment
has been identified to promote healing in many clinical
situations. Calcium hydroxide has been used either as
the sole root filling material for primary teeth or in
association with Iodoform. It is commercially available
as Vitapex and Metapex. These products resorb if
inadvertently pushed beyond the apex. However, the
rate of resorption of the material from within the canals
is faster than the rate of physiologic root resorption.24
Pitts studied the absorbable nature of Calcium
Hydroxide, he found that significant wash out of apical
plugs of Calcium Hydroxide occurred during the first
month after placement. By the ninth month, plugs were
virtually gone from the apical portion of the root canal.
Adjacent to remaining Calcium Hydroxide particles,
giant cells but no inflammatory cells were seen.25 Poor
success rates were reported due to high occurrence of
internal resorption by Via26 and Shroeder27.
The alkaline property of the material was said to
counteract the inflammatory process by acting as a
local buffer and by activating the alkaline phosphatase
activity, which was important for hard tissue formation.
The depletion of the material from the root canals was
found to be the main disadvantage of Calcium Hydroxide
as root canal filling material.28 Studies have reported
a success rate of 80 to 90%.23,28
Japanese researchers have introduced a calcium
hydroxide sealer named Vitapex that contains 40%
Iodoform along with silicone oil. The Iodoform is a

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Jha et.al. : Pediatric Oburating Materials And Techniques

known bactericide that is released from the sealer and


suppresses any residual bacteria in the canal or
periapical region. However, several clinical and
histopathological investigations of calcium hydroxide
and Iodofom mixture (Vitapex, Neo Dental Chemical
Products Co. Tokyo) have been published by Fuchino
and Nishino (1980). This material was found to be easy
to apply and resorbs at a slightly faster rate than that
of the root. It has no toxic effects on permanent
successor and is radio opaque. For these reasons, the
calcium hydroxide Iodoform mixture can be considered
to be a nearly ideal primary tooth filling material. Over
filling and resorption of the paste containing Iodoform
from the root canals had no effect on the success of the
treatment but regarded as having a positive healing
effect.3
Endoflas is a resorbable paste produced in South
America and contains components similar to that of
Vitapex, with the addition of zinc oxide Eugenol. This
paste is obtained by mixing a powder containing triiodomethane and iodine dibutilorthocresol (40.6%), zinc
oxide (56.5%), calcium hydroxide (1.07%), Barium
sulphate (1.63%) and with a liquid consisting of Eugenol
and Paramonochlorophenol.3
The material is hydrophilic and can be used in mildly
humid canals. It firmly adheres to the surface of the
root canals to provide a good seal. Due to its broad
spectrum of antibacterial activity, Endoflas has the
ability to disinfect dentinal tubules and difficult to
reach accessory ca-nals that cannot be disinfected or
cleansed mechanically. The components of Endoflas are
biocompatible and can be removed by phagocytosis,
hence making the material resorbable. Unlike other
pastes, Endoflas only resorbs when extruded extraradicularly, but does not wash out intraradicularly.
The disadvantage of this material is its Eugenol content
that can cause periapical irritation. It also has a
drawback of causing tooth discoloration. One study
showed a lower success rate of 58% when there was
overfilling but 83% success in cases with flush and
underfilled root canals.29 Thus, it can be concluded
that the Endofloss may be successfully used for root
canal treatments in primary teeth particularly if care
is taken not to overfill.
Comparative studies have indicated that Zinc oxide
Eugenol has better antimicrobial activity as well as
lower cytotoxicity than KRI paste30.
Pabla et al. evaluated the antimicrobial efficacy of zinc
oxide Eugenol, Iodoform paste, KRI paste, Maisto paste
and Vitapex against aerobic and anaerobic bacteria
obtained from infected non-vital primary anterior teeth.
Maisto paste had the best antibacterial activity.
Iodoform paste was the second best followed by zinc
oxide Eugenol paste. Vitapex showed the least antibacterial activity.31 Zinc oxide Eugenol (ZOE), Zinc

Journal of Contemporary Dentistry

oxide-Eugenol and Formocresol (ZOE+FC), Calcium


hydroxide and sterile water (CAOH+H2O), Zinc oxide
and Camphorated phenol (ZO+CP), Calcium hydroxide
and Iodoform (Metapex) and Vaseline (Control), were
checked for anti-microbial efficacy and ZOE+FC
produced strong inhibition against most bacteria when
compared to ZOE, ZO+CP and CAOH+H2O. Metapex
and Vaseline were found to be non inhibitory.32 A
mixture of calcium hydroxide, zinc oxide powder, and
sodium fluoride (10%) was used, combining the
advantages of both calcium hydroxide and zinc oxide.
Calcium fluoride as a reaction product added
radiopacity to the root canal filling material, without
the need for addition of any other radiopaque material.
The addition of fluoride was seen to give this material
a resorption rate that matched the resorption rate of
the roots of the primary pulpectomized teeth. The
overfilled material was not seen to completely resorb
even after 2 years of follow-up and so care should be
taken not to over push the material beyond the apex. A
study is already in progress to evaluate the resorption
of the root canal filling material intraradicularly,
interradicularly, and periapically, using mixtures of
zinc oxide and calcium hydroxide along with different
concentrations (2, 6, and 8%) of sodium fluoride as a
liquid. The mixture made by using 8% sodium fluoride
is showing good results in the mid-term evaluation.16
Retained primary teeth without permanent successor
present a unique challenge to the dentist. These teeth
are often prone to caries because of factors such as
longevity of the tooth in the oral cavity, discrepancies
in interproximal contact with permanent teeth and
variation in enamel thickness.33 A deciduous tooth
without permanent tooth bud shows no signs of root
resorption requiring different obturating material that
would not undergo resorption.34 This helps to prevent
arch length discrepancy and to maintain the space
without going for orthodontic or prosthetic
rehabilitation. 35 So, materials like Guttapercha,
Mineral Trioxide Aggregate (MTA), and Calcium
Enriched Mixture (CEM), that are biocompatible and
those would not be resorbed should be selected as a
root canal filling material for retained primary teeth.
Guttapercha is a desirable filling material because it
is nontoxic, least irritating to periapical tissues,
impervious to moisture. Mineral Trioxide Aggregate
(MTA) is recently introduced cement. Studies have
demonstrated cemental repair, formation of bone, and
regeneration of the periodontal ligament when MTA is
used.36 Table I shows comparison of properties of
different commonly used obturating materials.
Several techniques have been used for the filling of
material into primary teeth root canals. An ideal filling
technique should assure complete filling of the canal
without overfill and with minimal or no voids.

October-December 2011 | Vol 1 | Issue 2

29

Jha et.al. : Pediatric Oburating Materials And Techniques

Root Canal Filling With Hand Instruments


O'Riordan and Coll described a method of placing the
material in bulk and pushing it into the canals with
endodontic pluggers.37 Similar method for root canal
obturation was used by many authors11,12.
Another method has been described in the literature38,
which includes filling large primary canals with a thin
mix of the material coating the wall of the canals with
the help of a reamer in an anti-clock wise direction
while taking it out slowly followed by placement of the
thicker mix which is then pushed manually. An
endodontic plugger or a small amalgam condenser could
be used for compacting the paste at the level of the
canal orifice. For larger root canals lateral condensers
were used by Coll et al.39 Barr et al.9 recommended
Glick instrument for filling paste in root canals, where
as Hartman and Pruhs40 recommended the use of wet
cotton pellet to push the filling materials into the canals
of primary teeth. Paper points also been used to carry
the paste down into the root canals.41
Most of the time material of choice for filling the root
canal of a pulpectomized primary tooth is pure zinc
oxide eugenol and it can be carried into the canal using
Paper points, a Syringe, Jiffy tubes or a lentilspiral.1
Use of hand held Lentulospiral was recommended for
use in obturation of primary canals 42,43,15,28. Kopel
reported that the letulospiral hand held was most
effective in carrying zinc oxide Eugenol paste to
working length and also produced the highest quality
fill.1
Endodontic pressure syringe has been recommended
for use in obturation of primary canals. It was
developed by Greenberg44 in 1963 and consists of a
barrel and screw-in plunger and includes 13 to 30 gauge
needle which correspond to the largest endodontic file

used to instrument the root canal. It has been noted


that the needles are very flexible and can easily be
maneuvered in the tortuous canals of primary
molars45,46.
Vitapex, an iodoform calcium hydroxide based paste,
is delivered by a disposable plastic needle connecting
to a syringe. The syringe is introduced up to 1/5th the
distance from the apex of the canal and the material is
slowly injected as the syringe is withdrawn from the
canal. However, due to thickness and limited flexibility
of the plastic needle, it is questionable if the tip is able
to reach the apex of all canals.

Root Canal Filling With Rotary Instrument


Use of rotary paste filer was mentioned by Yacobi et
al.46 They suggested that spiral root canal filer should
be one size smaller than the last file used and cut with
sharp scissors to half its length. They claimed that
this made it easier to use in a child's mouth and also
prevented the filling material being pushed through
the apices of the primary tooth.
A lentulospiral mounted on the air motor hand piece
has been studied for use in obturation of primary root
canals. Sigurdsson et al.47 and Kahn et al.47 reported
that the letulospiral mounted on a slow speed handpiece
was most effective in carrying calcium hydroxide paste
to working length and also produced the highest
quality fill.
Aylard and Johnson48 and Dandashi et al.49 evaluated
root canal obturation methods in primary teeth in vitro
and reported that the lentulospiral mounted in a slowspeed handpiece was superior in filling straight and
curved root canals of primary teeth. Similar success
in obturating primary root canals with the use of rotary
lentulospiral over other techniques has been reported
by Allen50 and Torres et al.51

Table I: Properties of obturation materials

30

PROPERTIES

ZINC OXIDE

KRI PASTE

VITAPEX

Resorption

Slow as compared to
physiologic root
resorption3

Resorbs at the same rate as


the root 7,54

Faster resorption than


physiologic root resorption

Harmless

Harmful7

Harmless14

Harmless

Overfill resorption

Slow resorption and


inflammatory reaction3

Resorbs in1-2 weeks14

Resorbs in 1-2 weeks55

Antimicrobial

Weak antibacterial

Best antibacterial

Weak antibacterial

Easily removed

Difficult to remove

Easily removed

Easily removed3

Radiopaque

Radiopaque on
radiograph

Radiopaque on radiograph

Radiopaque on radiograph

Discolouration

No discolouration

Causes discolouration16

No discolouration

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Jha et.al. : Pediatric Oburating Materials And Techniques

Bawazir and Salama52 evaluated in vivo two different


obturation techniques, lentulospiral mounted in a slowspeed handpiece and hand-held in primary teeth. The
study was carried out on 24 children who had received
fifty single visit zinc oxide and eugenol pulpectomies
in primary molars. The authors reported 96% (21/22)
clinical success rate in the group obturated by the
lentulospiral mounted in a slow-speed handpiece and a
92% (23/25) clinical success rate in the group obturated
by a hand-held lentulospiral at 6 months following
treatment. Authors concluded that there was no
statistically significant difference between the two
techniques of obturation, according to the quality of
the root canal filling or success rate.
Recently, a thin and flexible metal tip was introduced
viz., NaviTip, in the market to deliver root canal sealer.
This NaviTip comes in different lengths and a rubber
stop may be adjusted to it. EndoSeal, a syringe delivered
zinc oxide eugenol based canal sealer can be expressed
by the NaviTip system.
Guelmann et al.53 assessed the quality of root canal fill
by using three filling systems: syringe with plastic
needle (Vitapex), syringe with metal needle, and lentulo
spiral. Filling quality was determined radiographically.
Authors concluded that NaviTip system offered a more
desirable filling quality than lentulo spiral and Vitapex
syringe techniques.
There is evidence that lentulospiral used as a hand
instrument and rotary lentulospiral mounted on a slow
speed handpiece may be better and practical obturating
techniques for primary molars.

References:
1.

2.

3.

4.

5.

6.

7.
8.

9.

10.
11.

12.
13.
14.

15.

16.

Conclusion
It has been found that the current obturating materials
for primary teeth while providing satisfactory clinical
results still need to be modified to suit the various
clinical situation that are encountered. Due to the
drawbacks of Zinc oxide eugenol material several other
materials have been investigated and various
combinations tried with some degree of success. The
current combinations of calcium hydroxide and
iodoform seem to provide better results than zinc oxide
eugenol cements. Similarly several obturation
techniques have been used with success, with rotary
slow speed lentilospiral being most satisfactory. Even
recently Navitip has been used for obturation with
good success. However, further controlled studies and
research is required to find the ideal obturating material
and techniques for primary teeth.
Journal of Contemporary Dentistry

17.

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20.

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Dummett CO and Kopel HM. Pediatric Endodontics. In Ingle


and Bakland. 5th ed. Endodontics: B.C. Decker Elsevier;
2002. P.861-902.
Fernanda BF, Michele MR, Maria AO, Branco HO. A
systemic review of root canal filling material for deciduous
teeth: is there an alternative for zinc oxide Eugenol. ISRN
dentistry; vol 2011.
Praveen P, Anantharaj A, Karthik V, Pratibha R. A review
of the obturating material for primary teeth. SRM
university journal of dental science 2011;1(3).
Rifkin A. A simple effective, safe technique for the root
canal treatment of abscessed primary teeth. J Dent Child
1980; 47:435-441.
Hashieh I A, Ponnmel L, Camps J. Concentration of
Eugenol apically released from ZnOE based sealers. JOE
1999; 22(11): 713-715.
Colla JA, Sadrian Roya. Predicting pulpectomy success
and its relationship to exfoliation and succedaneous
dentition. AAPD 1996; 18(1): 57-63.
Erasquin J, Muruzabal M. Root canal filling with zinc oxide
Eugenol in the rat molar. OOO 1967; 24: 547-558.
Woods RL, Kildea PM, Gabriel SA. A histologic comparison
of hydron and zinc oxide eugenol as endodntic filling
material in pimary teeth of dogs. Oral Surg 1984; 58: 82-93.
Barr ES, Flaitz CM, Hicks JM. A retrospective radiographic
evaluation of primary molar pulpectomies. Pediatr Dent.
1991; 13(1): 4-9.
Gould JM. Root canal therapy for infected primary molar
teeth: a preliminary report. J Dent Child 1987; 54: 30-34.
Colla JS, Josell S, Casper JS. Evaluation of a one
appointment formocresol pulpectomy technique for
primary molars. Pediatr Dent 1985; 7(2): 123-129.
Goerig AC, Camp JH. Root canal treatment in primary
teeth: a review. Pediatr Dent 1983; 5: 33-37.
Goodman JR . Endodontic treatment for children. Br Dent
J 1985; 158: 363-366.
Garcia- Godoy F. Evaluation of an Iodoform paste in root
canal therapy for infected primary teeth. J Dent Child
1987; 54: 30-34.
Chawla HS, Mathur VP, Gauba K, Goyal A. A mixture of
Calcium Hydroxide and Zinc Oxide as a root canal filling
material for primary teeth: a preliminary study. J Indian
Soc Pedo Prev Dent. 2001; 19 (3): 107-109.
Chawla HS, Setia S, Gupta N, Gauba K, Goyal A.
Evaluation of a mixture of zinc oxide, calcium hydroxide,
and sodium fluoride as a new root canal filling material for
primary teeth. J Indian Soc Pedo Prev Dent. 2008 Jun;
26(2):53-8.
F. Garcia-Godoy. Evaluation of an iodoform paste in root
canal therapy for infected primary teeth. ASDC Journal of
Dentistry for Children 1987; 54(1): 30-34.
R. E. Primosch. Primary tooth pulp therapy as taught in
predoctoral pediatric dental programs in the United States.
Pediatr Dent. 1997; 19(2): 118-122.
M. Mortazavi and M. Mesbahi. Comparison of zinc oxide
and eugenol, and Vitapex for root canal treatment of
necrotic primary teeth. International Journal of Paediatric
Dentistry 2004; 14(6):417-424.
C. Cunha, R. Barcelos, and L. Primo. Solues irrigadoras
e materiais obturadores utilizados na terapia endodntica
de dentes decduos. Pesquisa Brasileira de Odontopediatria
e Clnica Integrada 2005; 5(1): 75-83.
Castagnola L, Orlay HG. Treatment of gangrene of the
pulp by walkhoff method. Brit dent J 1952; 93: 93-102.
Garcia Godoy F. Evaluation of an iodoform paste in root
canal therapy for infected primary teeth. JDC 1987; 54:30-34.
Mass E, Zilberman LU. Endodontic treatment of infected
primary molar using Maisto paste. JDC 1989; 56:117-120.

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Jha et.al. : Pediatric Oburating Materials And Techniques: A Review


24. Nurko C, Ranly DM, Garcia Godoy et al. Resorption of a
Calcium Hydroxide/ Iodoform paste ( Vitapex) in root canal
therapy for primary teeth: a case report. Pediatr Dent.
2000; 22: 517-520.
25. Pitts. A histologic comparison of Calcium Hydroxide plugs
and dentin plugs used for the control of GP root canal
filling materials. JOE 1984; 10: 283-293.
26. Via WF. Evaluation of decidous molars treated by
pulpotomy and Calcium Hydroxide. J Am Dent Assoc 1955;
5: 34-43.
27. Schroder U. A 2-yr follow up of primary molar,
pulpotomized with a gentle technique and capped with
Calcium Hydroxide. Scand J Dent Res 1978; 86: 273-278.
28. Chawla HS, Mani .SA, Tewari. A Calcium Hydroxide as a
root canal filling material in primary teeth- a pilot study. J
Indian Soc Pedo Prev Dent 1998; 16(3): 90-92.
29. Fuks A, Eidelman E, Pauker N. Root canal with endofloss
in primary teeth. A retrospective study. JCPD 2002; 27(1):
41-46.
30. Wright KJ, Barbosa SV, Araki K. In vitro antimicrobial
and cytotoxic effects of KRI-paste and Zinc Oxide- Eugenol
used in primary tooth pulpectomies. Pediatric Dent. 1994;
16(2): 102-6
31. Pabla T, Gulati MS, Mohan U. Evaluation of antimicrobial
efficacy of various root canal filling materials for primary
teeth. J Indian Soc Pedod Prev Dent. 1997 Dec; 15(4):134-40.
32. Reddy S, Ramkrishnan Y. Evaluation of antimicrobial
efficacy of various root canal filling material used in primay
teeth. A microbiological study. JCPD 2008; 31(3):193-198.
33. Weine FS. Endodontic therapy. 5th ed. St. Louis: Mosby,
1996: 359-61.
34. Nagesh B, Naik B, Sarath R K, Lakshmi D V. Obtuation of
retained primary mandibular seond molar with missing
successor with Gutta-percha: A case report. JIDA, Vol. 5,
No. 2, February 2011
35. Kokich VG, Kokich VO. Congenitally missing mandibular
second premolars: Clinical options. Am J Orthod Dentofacial
Orthop 2006; 130: 437-44.
36. Howard W Roberts, Jeffrey M. Toth, David W. Berzins,
David G. Chartlon. Mineral trioxide aggregate material
use in endodontic treatment: A review of the literature
Dental Materials 2008; 24:149-164.
37. Coll JA, Josell S, Nassof S, Shelton P, Richards MA. An
evaluation of pulp therapy in primary incisors. Pediatr
Dent. 1988; 10(3):178-184.
38. Hartman CR and Pruhs RJ. A rationale for the evaluation
and treatment of pulp of carious primary molars. J Wis
Dent Assoc. 1980; 56(3):157-160.

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39. Greenberg M. Filling root canals of deciduous teeth by an


injection technique. Dent Dig. 1964; 67:574.
40. Krakow A. and Berk H. Efficient endodontic procedures
with the use of the pressure syringe. Dent Clin North
Am.1969; 17(1): 387-399.
41. Sigurdsson A, Stancill R, Madison S. Intracanal placement
of Ca(OH)2: a comparison of techniques. J Endod.1992;
18(8):367-70.
42. Kahn FH, Rosenberg PA, Schertzer L, Korthals G, Nguyen
PN An in-vitro evaluation of sealer placement methods.
Int J Endod. 1997; 30(3):181-6.
43. Aylard S. and Johnson. R. Assessment of filling techniques
for primary teeth. Pediatr Dent. 1987; 9:195-198.
44. Greenberg M. Filling root canals of deciduous teeth by an
injection technique. Dent Dig. 1964; 67:574.
45. Torres CP, Apicella MJ, Yancich PP, Parker MH. Intracanal
placement of calcium hydroxide: a comparison of
techniques, revisited. J Endod. 2004; 30(4):225-7.
46. Bawazir OA and Salama FS. Clinical evaluation of root
canal obturation methods in primary teeth. Pediatr Dent.
2006; 28(1):39-47.
47. Allen KR. Endodontic treatment of primary teeth. Aust
Dent J. 1979; 24(5):347-51.
48. Aylard S. and Johnson. R. Assessment of filling techniques
for primary teeth. Pediatr Dent. 1987; 9:195-198.
49. Dandashi BM, Mamoun MN, Thomas Z, Margaret AE,
Lawrence GS, Mario Czonstkowsky. An in vivo comparison
of three endodontic techniques for primary incisors. Ped
Dent. 1993; 15(4):254-256.
50. Allen KR. Endodontic treatment of primary teeth. Aust
Dent J. 1979; 24(5):347-51.
51. Torres CP, Apicella MJ, Yancich PP, Parker MH. Intracanal
placement of calcium hydroxide: a comparison of
techniques, revisited. J Endod. 2004; 30(4):225-7.
52. Bawazir OA and Salama FS. Clinical evaluation of root
canal obturation methods in primary teeth. Pediatr Dent.
2006; 28(1):39-47.
53. Guelmann M, McEachern M, Turner C. Pulpectomies in
primary incisors using three delivery systems: an in vitro
study. J Clin Pediatr Dent. 2004; 28(4):323-6.
54. Rifkin A. root canal treatment of abscessed primary teeth:
A three to four year follow-up. J Dent Child 1982;49: 428431
55. Carlos Nurko, Don M. Ranly, Franklin Garca-Godoy,
Kesavalu N. Lakshmyya. Resorption of calcium hydroxide/
Iodoform paste(Vitapex) in root canal therapy for primary
teeth. A case report. PD 2000; 22:6

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

REVIEW ARTICLE

Oral Lichen Planus : A Review


Rohini Salvi1, Rohit Bhailal Gadda2,Varun Gul Bhatia3

Abstract
Oral lichen planus (OLP) is a chronic mucosal condition commonly encountered in clinical dental practice. Lichen
planus is believed to represent an abnormal immune response in which epithelial cells are recognized as foreign,
secondary to changes in the antigenicity of the cell surface. It has various oral manifestations, the reticular form
being the most common. The erosive and atrophic forms of OLP are less common, yet are most likely to cause
symptoms. Topical corticosteroids constitute the mainstay of treatment for symptomatic lesions of OLP. Recalcitrant
lesions can be treated with systemic steroids or other systemic medications. However, there is only weak evidence
that these treatments are superior to placebo. Given reports of a slightly greater risk of squamous cell carcinoma
developing in areas of erosive OLP, it is important for clinicians to maintain a high index of suspicion for all intraoral
lichenoid lesions. Periodic follow-up of all patients with OLP is recommended.
Key words: Diagnosis of OLP, Review

Introduction
Lichen planus is a relatively common disorder,
estimated to affect 0.5% to 2.0% of the general
population.1 It is a chronic, inflammatory disease that
affects mucosal and cutaneous tissues. Approximately
half of the patients with cutaneous lichen planus have
oral involvement.2 However, mucosal involvement can
be the sole manifestation in up to 25% of affected
population.2 Oral lichen planus has a peak incidence
in middle age patients and has female predominance
of 2:1. 3 It is characteristically associated with
persistent clinical course and resistance to most
conventional treatments.

Table 1: Clinical Presentation of Oral Lichen


Planus
Symptom

A s y m p t o m a t i c Reticular

Professor and Head1


Senior Lecturer2
Senior Lecturer3
Department of Oral Medicine & Radiology,
M.G.M. Dental College and Hospital, Navi Mumbai
Address for Correspondence:
Dr. Rohit Bhailal Gadda
Senior Lecturer
Department of Oral Medicine & Radiology,
M.G.M. Dental College and Hospital, Navi Mumbai
E-mail: rohitgadda@gmail.com

Journal of Contemporary Dentistry

Description

Wickham's striae discrete


erythematous border

Plaque-like Resemble leukoplakia,


common in smokers

Symptomatic

Clinical Features
There are various clinical morphological
manifestations of the disease (Table 1). More than one
clinical subtype can co-exist in the same patient. The
reticular (92%), plaque (36%) and papule (11%) types
are usually asymptomatic and require no specific

Clinical
types

Papules

Small white pinpoint papules

Atrophic

Diffuse red patch, peripheral


radiating white striae, chronic
desquamative gingivitis

Erosive

Irregular erosion covered


with a pseudomembrane

Bullous

Small bullae or vesicles that


may rupture easily

treatment.4 On the other hand, the atrophic (44%),


erosive (9%) and bullous (1%) types usually cause
severe burning pain and are refractory to conventional
treatments.4
The lesions are usually symmetrical. It frequently
affects buccal mucosa, tongue, gingiva, lip and palate.
Extra-oral mucosal involvements include the anogenital
area (vulvovaginal-gingival syndrome), conjunctivae,
oesophagus or larynx.

Differential Diagnosis
The diagnosis of OLP can be rendered more confidently
when characteristic cutaneous lesions are present.
Except for the pathognomonic appearance of reticular

October-December 2011 | Vol 1 | Issue 2

33

Salvi et.al. : Oral Lichen Planus : A Review

OLP (white striae occurring bilaterally on the buccal


mucosa), in most cases histopathologic evaluation of
lesional tissue is required to obtain a definitive
diagnosis.
The differential diagnosis of erosive OLP includes
squamous cell carcinoma, discoid lupus erythematosus,
chronic candidiasis, benign mucous membrane
pemphigoid, pemphigus vulgaris, chronic cheek
chewing, lichenoid reaction to dental amalgam or
drugs, graft-versus-host disease (GVHD),
hypersensitivity mucositis and erythema multiforme.5
The plaque form of reticular OLP can resemble oral
leukoplakia.
The classic histopathologic features of OLP include
liquefaction of the basal cell layer accompanied by
apoptosis of the keratinocytes, a dense band-like
lymphocytic infiltrate at the interface between the
epithelium and the connective tissue, focal areas of
hyperkeratinized epithelium (which give rise to the
clinically apparent Wickham's striae) and occasional
areas of atrophic epithelium where the rete pegs may
be shortened and pointed (a characteristic known as
sawtooth rete pegs.5 Although the histopathologic
features of OLP are characteristic, other conditions,
such as lichenoid reaction to dental amalgam and
drugs, may exhibit a similar histologic pattern.
The histopathologic diagnosis of OLP can be
complicated by the presence of superimposed
candidiasis; diagnosis can also be more difficult if the
biopsy exhibits an ulcerated surface. In these situations,
the biopsy findings are sometimes interpreted as
representing a nonspecific chronic inflammatory
process.6 On occasion, the histo-pathologic features are
equivocal, and the oral pathologist examining the
submitted tissue may recommend that a second biopsy
be performed to obtain fresh tissue for
immunofluorescence.7 Immunofluorescent examination
of OLP lesional tissue usually demonstrates deposition
of fibrinogen along the basement membrane zone.

Clinical Significance
OLP is one of the most common mucosal conditions
affecting the oral cavity.8 Therefore dentists in clinical
practice will regularly encounter patients with this
condition. Because patients with the atrophic and
erosive forms of OLP typically experience significant
discomfort, knowledge of the treatment protocols
available is important. The similarity of OLP to several

34

other vesiculoulcerative conditions, some of which can


lead to significant morbidity, makes accurate diagnosis
essential. For example OLP and GVHD can have
similar histologic and clinical presentations. GVHD is
a serious condition that occurs in bone marrow
transplant patients when transplanted marrow cells
react against host tissues. The extent of oral
involvement is highly predictive of the severity and
prognosis of GVHD.9
Erosive OLP and lichenoid drug reactions can be
indistinguishable both histologically and clinically.
Some of the drugs commonly associated with lichenoid
reactions are nonsteroidal anti-inflammatory drugs,
diuretics, angiotensin-converting enzyme inhibitors,
beta-blockers and antimicrobials.10
It is also necessary to distinguish isolated erosive or
reticular lesions from lichenoid reactions to dental
amalgam.11 Lichenoid reactions to amalgam do not
migrate, they occur on mucosal tissue in direct contact
with the restoration, and they resolve once amalgam
restoration is removed.11 Some studies indicate an
increased risk of squamous cell carcinoma in patients
with OLP lesions.12-15 This increased risk appears most
common with the erosive and atrophic forms and in
cases of lesions of the lateral border of the tongue. Other
studies suggest that in some cases of purported
malignant transformation, the malignancy may not
have developed from true lesions of OLP but may
instead have arisen from areas of dysplastic
leukoplakia with a secondary lichenoid inflammatory
infiltrate.16,17 A review of previously published studies
concluded that the risk of developing squamous cell
carcinoma in patients with OLP is approximately 10
times higher than that in the unaffected general
population.18 Other published reports have noted a
possible association between OLP and hepatitis C,19
sclerosing cholangitis, and primary biliary cirrhosis.20

Treatment
There is currently no cure for OLP. Excellent oral
hygiene is believed to reduce the severity of the
symptoms, but it can be difficult for patients to achieve
high levels of hygiene during periods of active disease.
Treatment is aimed primarily at reducing the length
and severity of symptomatic outbreaks. Asymptomatic
reticular and plaque forms of OLP do not require
pharmacologic intervention. Algorithm for the
management of oral lichen planus is shown in Fig. 1.21

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Salvi et.al. : Oral Lichen Planus : A Review


Fig. 1: Algorithm for the management of oral lichen planus

Corticosteroids
The most widely accepted treatment for lesions of
OLP involves topical or systemic corticosteroids to
modulate the patient's immune response. Topical
corticosteroids are the mainstay in treating mild to
moderately symptomatic lesions. Options (presented
in terms of decreasing potency) include 0.05%
clobetasol propionate gel, 0.1% or 0.05% betamethasone
valerate gel, 0.05% fluocinonide gel, 0.05% clobetasol
butyrate ointment or cream, and 0.1% triamcinolone
acetonide ointment.22 Patients are instructed to apply
a thin layer of the prescribed topical corticosteroid up
to 3 times a day, after meals and at bedtime. The gel
or ointment can be applied directly or can be mixed
with equal parts Orabase(a gelatin-pectin-sodium
carboxymethylcellulose-based oral adhesive paste,
ConvaTec, Division of Bristol-Myers Squibb, Montreal,
Que.) to facilitate adhesion to the gingival tissues. These
solutions can be prepared by a compounding pharmacy.
Patients should be instructed to gargle with 5 mL of
the solution for 2 minutes after meals and at night.
After rinsing, the solution should be expectorated, and
nothing should be taken by mouth for one hour.
Alternative delivery methods include the use of custom
trays to serve as reservoirs for the corticosteroid. The
advantage of topical steroid application is that side
effects are fewer than with systemic administration.
Adverse effects include candidiasis, thinning of the oral
mucosa and discomfort on application. Topical

Journal of Contemporary Dentistry

formulations of the more potent corticosteroids can


cause adrenal suppression if used in large amounts for
prolonged periods or with occlusive dressings. The
lowest-potency steroid that proves effective should be
used. Intralesional injection of corticosteroid for
recalcitrant or extensive lesions involves the
subcutaneous injection of 0.2-0.4 mL of a 10 mg/mL
solution of triamcinolone acetonide by means of a 1.0mL 23- or 25-gauge tuberculin syringe.
Systemic steroid therapy should be reserved for patients
in whom OLP lesions are recalcitrant to topical steroid
management. Dosages should be individualized
according to the severity of the lesions and the patient's
weight and should be modified on the basis of the
patient's response to treatment. The oral dose of
prednisone for a 70-kg adult ranges from 10-20 mg/
day for moderately severe cases to as high as 35 mg/
day (0.5 mg/kg daily) for severe cases.23 Prednisone
should be taken as a single morning dose to reduce the
potential for insomnia and should be taken with food
to avoid nausea and peptic ulceration. Significant
response should be observed within one to 2 weeks.

Other Treatment Modalities


Twice-daily topical application of compounded 0.1%
tacrolimus ointment was recently reported to be
effective in controlling symptoms as well as clearing
lesions of OLP. 24 Tacrolimus is a macrolide
immunosuppressant with a mechanism of action

October-December 2011 | Vol 1 | Issue 2

35

Salvi et.al. : Oral Lichen Planus : A Review

similar to that of cyclosporine, but is 10 to 100 times


more potent and is better able to penetrate the mucosal
surface.24
Other documented treatment modalities include
retinoids and vitamin A analogues, cyclosporine rinse,
the immunomodulating agent levamisole, PUVA
treatment (which consists of administration of 8methoxypsoralen and exposure to long-wave ultraviolet
A light), dapsone, griseofulvin, azathioprine and
cryotherapy.25 Even though evidence of the efficacy of
these treatment approaches is not overwhelming,
corticosteroid therapy remains the most common
approach for managing symptomatic lesions. Because
of the possibility of increased risk of malignant
transformation, periodic reassessment of all patients
with OLP is recommended.

Conclusion
Patients with OLP should be counselled as to the nature
of this chronic condition and the different approaches
to treatment. Patients should be informed that they
may experience alternating periods of symptomatic
remission and exacerbation. Clinicians should maintain
a high index of suspicion for all intraoral areas that
appear unusual, even in patients with a histologically
confirmed diagnosis of OLP. This vigilance is especially
important for isolated lesions occurring in locations at
higher risk for the development of squamous cell
carcinoma, such as the lateral and ventral surfaces of
the tongue and the floor of the mouth.

2.
3.

4.

5.
6.

36

8.

9.

10.

11.

12.

13.

14.

15.
16.

17.
18.

19.
20.

References
1.

7.

McCreary CE, McCartan BE. Clinical management of


lichen planus. Brit J Oral Maxillofacial Surg 1999;
37(5):338-43.
Mollaoglu N. Oral lichen planus: a review. Br J Oral
Maxillofac Surg 2000;38:370-7.
Setterfield JF, Black MM, Challacombe SJ. The
management of oral lichen planus. Clin Exp Dermatol
2000;25:176-82.
Thorn JJ, Holmstrup P, Rindum J, et al. Course of various
clinical forms of oral lichen planus. A prospective followup study of 611 patients. J Oral Pathol 1988;17:213-8.
Regezzi JA, Sciubba JJ. Oral pathology: clinical pathologic
correlations. 3rd ed. Philadelphia: WB Saunders; 1999.
Burgess KL, McComb RJ. The gingivae in dermatoses.
Ont Dent 1997; 74(5):25-9.

21.
22.
23.
24.

25.

Murrah VA, Perez LM. Oral lichen planus: parameters


affecting accurate diagnosis and effective management.
Pract Periodontics Aesthet Dent 1997; 9(6):613-20.
Pynn BR, Burgess KL, Wade PS, McComb RJ. A
retrospective survey of 2021 patients referred to the
Toronto Hospital Mouth Clinic. Ont Dent 1995; 72(1):21-4.
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and
maxillofacial pathology. 2nd ed. Philadelphia: WB Saunders;
2002.
Bernstein ML. The diagnosis and management of chronic
nonspecific mucosal lesions. J Calif Dent Assoc 1999;
27(4):290-9.
Ostman PO, Anneroth G, Skoglund A. Oral lichen planus
lesions in contact with amalgam fillings: a clinical,
histologic, and immunohistochemical study. Scand J Dent
Res 1994; 102(3):172-9.
17. Silverman S Jr, Bahl S. Oral lichen planus update:
clinical characteristics, treatment responses, and malignant
transformation. Am J Dent 1997; 10(6):259-63.
Barnard NA, Scully C, Eveson JW, Cunningham S, Porter
SR. Oral cancer development in patients with oral lichen
planus. J Oral Pathol Med 1993; 22 (9):421-4.
Holmstrup P. The controversy of a premalignant potential
of oral lichen planus is over. Oral Surg Oral Med Oral
Pathol 1992; 73(6):704-6.
Silverman S. Oral lichen planus: a potentially premalignant
lesion. J Oral Maxillofacial Surg 2000; 58(11):1286-8.
Eisenberg E, Krutchkoff DJ. Lichenoid lesions of oral
mucosa. Diagnostic criteria and their importance in the
alleged relationship to oral cancer. Oral Surg Oral Med
Oral Pathol 1992; 73(6):699-703.
Eisenberg E. Oral lichen planus: a benign lesion. J Oral
Maxillofacial Surg 2000; 58(11):1278-85.
Drangsholt M, Truelove EL, Morton TH Jr, Epstein JB. A
man with a thirty-year history of oral lesions. J Evid Base
Dent Pract 2001; 1(2):123-35.
Bellman B, Reddy RK, Falanga V. Lichen planus associated
with hepatitis C. Lancet 1995; 346(8984):1234.
Fantasia JE. Diagnosis and treatment of common oral
lesions found in the elderly. Dent Clin North Am 1997;
41(4):877-90.
Oliver GF, Winkelman RK. Treatment of lichen planus.
Drugs 1993; 45;56-6
Vincent SD. Diagnosing and managing oral lichen planus.
JADA 1991; 122(6):93-6.
Carrozzo M, Gandolfo S. The management of oral lichen
planus. Oral Dis 1999; 5(3):196-205.
Kaliakatsou F, Hodgson TA, Lewsey JD, Hegarty AM,
Murphy AG, Porter SR. Management of recalcitrant
ulcerative oral lichen planus with topical tacrolimus. J Am
Acad Dermatol 2002; 46(1):35-41.
Carrozzo M, Gandolfo S. The management of oral lichen
planus. Oral Dis 1999; 5(3):196-205.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

REVIEW ARTICLE

Bioterrorism and Dentistry


Amit Chaudhari1, Priya Chaudhari 2

Abstract
In modern world, to spread the confusion and panic among the people terrorist can use biological weapon. In such
Bioterrorism attack health professionals plays a key role. This paper reviews the historical aspect, definition,
classification of bioterrorism agents and the role of dentistry in such catastrophic event.
Key Words: Bioterrorism agents, Medical community

Introduction

would cause on the population4.

Terrorism is not new, and even though it has been


used since the beginning of recorded history it can be
relatively hard to define1. The term "terrorism" comes
from the French word terrorisme, which is based on
the Latin verb terrere (to cause to tremble). It dates
back to 1795 when it was used to describe the actions
of the Jacobin Club in their rule of post-Revolutionary
France, the so-called "Reign of Terror". Jacobins are
rumored to have coined the term "terrorists" to refer
to themselves2. Terrorism refers to a strategy of using
violence, social threats, or coordinated attacks, in order
to generate fear, cause disruption, and ultimately, bring
about compliance with specified political, religious, or
ideological demands. The European Union includes in
its 2002 definition of "terrorism" as the aim of
"destabilizing or destroying the fundamental political,
constitu-tional, economic or social structures of a
country." Terrorism is defined in the U.S. by the Code
of Federal Bureau of Investigation as: "The unlawful
use of force and violence against persons or property to
intimidate or coerce a government, the civilian
population, or any segment thereof, in furtherance of
political or social objectives."3

The medical community as well as the public should


become familiar with epidemiology and control
measures for a calm and reasoned response should there
be an outbreak5. In the event of a bioterrorist attack,
most important aspect is the need of trained health
professional and in such conditions dentists can render
help for increase surge capacities. Dentists may be
called upon to fulfill several functions: education, risk
communication, diagnosis, surveil-lance and
notification, treatment, distribution of medications,
decontamination, sample collection and forensic
dentistry6. Consequently aim of this paper to review1.
history regarding bioterrorism2. classifica-tion of
agents3. role of dentistry in preparedness.

Terrorists may choose to use biological weapons to


achieve their goals because biological agents are
relatively cheaper than conventional weapons.
Reportedly, many of these agents would be relatively
easy to prepare and easy to hide. Their use would also
allow bioterrorists to protect themselves and escape
before any illness is detected. The most attractive
feature of bioweapons, however, maybe the tremendous
psychological impact that their use, or threatened use,
Senior Lecturer1
Department of Public Health Desntistry, MGM Dental College
and Hospital, Kamothe, Navi Mumbai
Senior Lecturer2
Department of Prosthodontics, MGM Dental College and
Hospital, Kamothe, Navi Mumbai
Address for Correspondence:
Dr. Amit Chaudhari
Department of Public Health Dentistry, MGM Dental College
and Hospital, Kamothe, Navi Mumbai
Email ID- phdmgmdch@gmail.com

Journal of Contemporary Dentistry

Historical aspect
Biological terrorism dates as far back as Ancient Rome,
when faeces were thrown into faces of enemies7. This
early version of biological terrorism continued till the
14th century where the bubonic plague was used to
infiltrate enemy cities, both by instilling the fear of
infection in residences, so that they would evacuate,
and also to destroy defending forces that would not
yield to the attack. Over time, biological warfare
became more complex. Countries began to develop
weapons which were much more effective, and much
less likely to cause infection to the wrong party. One
significant enhancement in biological weapon
development was the first use of anthrax. Anthrax
effectiveness was initially limited to victims of large
dosages7. The development of biological weapons
became much more focused in the 20th century. During
World War I, Germany was thought to have employed
the agents of cholera and plague against humans and
anthrax and glanders against livestock8. In the period
between World Wars I and II, a number of countries,
including the USSR, Japan, and the United Kingdom,
stepped up their biological warfare research programs.
The Japanese effort was notable, with a number of
military units engaged in offensive biological weapons
research until the end of World War II. During the era
of Cold War, the Soviet Union as well as Iraq
independently developed their successful biological
weapon programs9. However, in 1972, Washington and
Moscow had agreed by treaty to give up biological

October-December 2011 | Vol 1 | Issue 2

37

Chaudhari and Chaudhari : Bioterrorism and Dentistry

weapons, but most countries were actively involved in


development of such bioweapon facilities9.

Bioterrorist events have occurred in recent history both


in the United States and abroad. In 1984, the salad
bars at two restaurants in the Dalles, Oregon, were
contaminated with Salmonella by followers of Bhagwan
Shree Rajneesh to prevent citizens from voting in an
upcoming election9.

One of the most frightening terrorist attacks involved


release of the nerve gas sarin in the Tokyo subway
system in 1995. Aum Shinrikyo, the cult responsible
for killing 12 people and injuring approximately 3,800
in the sarin attack, also attempted to develop
botulinum toxin, anthrax, cholera, and Q fever for
bioterrorist us10. In 2001, United States experienced
bioterrorism attack in the form anthrax spores which
were disseminated through postal system9.

They result in moderate illness rates and low death


rates
They require specific enhancements of CDC's
laboratory capacity and enhanced disease
monitoring.

Category C
These third highest priority agents include emerging
pathogens that could be engineered for mass spread in
the future because:
They are easily available
They are easily produced and spread
They have potential for high morbidity and
mortality rates and major health impact.
Bioterrorism agents name is given in Table 1.

Dentistry's role in a response


Bioterrorism attack is a silent attack. Bioterrorism

What is bioterrorism?
According to Center of Disease Control and Prevention
- A bioterrorism attack is the deliberate release of
viruses, bacteria, or other germs (agents) used to cause
illness or death in people, animals, or plants. These
agents are typically found in nature, but it is possible
that they could be changed to increase their ability to
cause disease, make them resistant to current
medicines, or to increase their ability to be spread into
the environment. Biological agents can be spread
through the air, through water, or in food. Terrorists
may use biological agents because they can be extremely
difficult to detect and do not cause illness for several
hours to several days. Some bioterrorism agents, like
the smallpox virus, can be spread from person to person
and some, like anthrax, cannot5.

Bioterrorism Agent Categories5


Bioterrorism agents can be separated into three
categories, depending on how easily they can be spread
and the severity of illness or death they cause. Category
A agents are considered the highest risk and Category
C agents are those that are considered emerging threats
for disease.
Category A
These high-priority agents include organisms or toxins
that pose the highest risk to the public and national
security because:
They can be easily spread or transmitted from
person to person

Table 1: Classification of Bioterrorism Agents


Category A

Category B

Category C

Anthrax
(Bacillus
anthracis)

Brucellosis
(Brucella
species)

Emerging
infectious
diseases
such as

Botulism
(Clostridium
botulinum toxin)

Epsilon toxin
of Clostridium
perfringens

Nipah virus

Plague
(Yersinia
pestis)

Food safety threats


(e.g., Salmonella
species, Escherichia coli
O157:H7, Shigella)

Hantavirus

Smallpox
(variola major)

Glanders
(Burkholderia mallei)

Tularemia
(Francisella
tularensis)

Melioidosis
(Burkholderia
pseudomallei)

Viral hemorrhagic
fevers (filoviruses
[e.g., Ebola,
Marburg]

Psittacosis
(Chlamydia
psittaci)

Arenaviruses
[e.g., Lassa,
Machupo])

Q fever
(Coxiella burnetii)
Ricin toxin from Ricinus
communis (castor beans)
Staphylococcal
enterotoxin B
Typhus fever (Rickettsia
prowazekii)

They result in high death rates and have the


potential for major public health impact
They might cause public panic and social disruption
They require special action for public health
preparedness.

Viral encephalitis
(alphaviruses
[e.g., Venezuelan
equine encephalitis,
eastern equine
encephalitis,
western equine
encephalitis])

Category B
These agents are the second highest priority because:

38

Water safety threats


(e.g., Vibrio cholerae,
Cryptosporidium parvum)

They are moderately easy to spread

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Chaudhari and Chaudhari : Bioterrorism and Dentistry

and emerging infectious diseases are a public health


issue first, then a criminal investigation. The
government and the local health care community must
be prepared to respond if they are to effectively limit
transmission of the disease and its associated morbidity
and mortality, as well as to prevent confusion and
panic.
Dentistry can contribute valuable assets, both in
personl and in facilities, to the preparation for and in
the immediate response to a bioterrorist attack and
its aftermath. These assets can make a significant
difference in the outcome. In a major bioterrorist
attack, the local needs could be massive and
immediate. The traditional medical resources-both
personnel and facilities- of a community under attack
will be overwhelmed, especially in the first few days
after the determination that the community has been
deliberately subjected to an infectious agent. It will
fall to nonphysicians to provide many services
ordinarily supplied by physicians (such as performing
triage, dispensing medications and providing general
medical support). As hospitals become filled, alternate
sites for the provision of health care may be required,
and dental offices could fill that need11.
Guey AH11 reviewed the areas in which dentists can
render the help to increase surge capacity in
bioterrorism attacks.
Surveillance and notification - Dental offices are
distributed across the community, dentists can serve
as an excellent surveillance resource. They can detect
characteristic intraoral or cutaneous lesions if they are
present and report them to public health authorities.
They also may be able to detect unusual patterns of
employee absences or patients' canceling or missing
appointments that are not explainable by recognizable
local circumstances. These occurrences may well be a
harbinger of serious events about to happen.
Diagnosis and monitoring - Besides assisting in the
early identification of the disease or diseases introduced
in a bioterrorist attack, dentists can provide individual
patient diagnosis by observing the physical and
behavioral signs people manifest when the nature of
the attack has been determined. Salivary and/or nasal
swabs may yield important diagnostic or treatment
information and can be collected by dentists for
laboratory testing to determine diagnoses when
necessary or to monitor treatment progress.
Referral - Dentists can refer suspicious cases to the
appropriate specialists for confirmation, treatment or
both.
Immunizations - In the event that rapid inoculation
or vaccination of the public is required to prevent the
spread of infection by a biological agent, dentists may
be recruited to assist in a mass inoculation program.
Medications - If the mass population requires
treatment, preventive medication or both, pharmacies'

Journal of Contemporary Dentistry

capabilities may become overpowered quickly. Dentists


could be called on to prescribe and dispense
chemotherapeutic or chemoprophylactic medications
for the public. When drugs are stockpiled in bulk,
dental personnel could help repackage them for
individual use before dispensing them.
Triage - Whenever there is a greater number of
casualties than the medical care system can
accommodate relatively quickly, or whenever medical
care resources are overwhelmed, some system for
establishing priorities for treatment must be
established. Appropriately trained dentists can fulfill
this function, thus freeing up medical professionals to
provide definitive care for the greatest number of
patients.
Medical care augmentation - Because of their training
and experience, many dentists may be able to augment
and assist medical and surgical personnel in providing
definitive treatment for victims of bioterrorist attacks.
Decontamination and infection control - Dentists and
dental auxiliaries are well-versed in infection control
procedures and can apply their knowledge in reducing
the spread of infections- between patients and between
patients and caregivers-in mass disasters.

Conclusion
Dentistry has an important role to play in the response
to a significant bioterrorism attack. With adequate
preparation, dentistry's valuable assets in terms of
personnel and facilities can help in determining that a
bioterrorist attack has occurred and in responding to
that attack. The profession should develop a disaster
response plan that can be integrated into each
community's disaster response plan.

References
1.
2.

http://www.terrorism-research.com (accessed on 30.08.11)


Golder B, Williams G. What is 'terrorism'? Problems of
legal definition. UNSW Law Journal 2004; 27(2): 273-295
3. http://www.legalserviceindia.com/articles/anti_pota.htm
(accessed on 30.08.11)
4.
http://www.bacteriamuseum.org/cms/PathogenicBacteria/pathogenic-bacteria.html (accessed on 30.08.11)
5. http://www.bt.cdc.gov/agent/agentlist-category.asp
6. http://www.azdhs.gov/phs/edc/edrp/bioterrorism.htm
(accessed on 3.09.11)
7. Block, Steven M. The growing threat of biological weapons.
American Scientist 2001; 89(1): 28,
8. Christopher, G. W., T. J. Cieslak, J. A. Pavlin, and E. M.
Eitzen, Jr. Biological warfare: a historical perspective.
JAMA 1997; 278:412-417.
9. Klietmann WF. Ruoff KL. Bioterrorism: Implications for
the clinical microbiologist. Clinical Microbiology Reviews
2001; 14(2): 364-381
10. Olson KB. Shinrikyo A. Once and future threat? Emerg.
Infect. Dis. 5:513-516
11. Guay AH. Dentistry's response to bioterrorism: A report of
a consensus workshop. J Am Dent Assoc September 2002;
133: 1181-118

October-December 2011 | Vol 1 | Issue 2

39

CASE REPORT

Management of non vital maxillary central incisors


using Mineral T
rioxide Aggregate apical plugs
Trioxide

with open apex


Case report

Sumanthini M.V.1, Naisargi Shah2, Mausami A Malgaonkar3

Abstract
The case report describes the treatment of maxillary central incisors with open apex, due to apical root resorption,
as a consequence of trauma experienced three years earlier. Open apices pose a challenge during endodontic
treatment. Several materials and methods have been widely studied and tried in the past. Obtaining an adequate
apical seal is of paramount importance regardless of the material or technique used. In the present case the
involved teeth were treated nonsurgically using white Mineral Trioxide Aggregate (MTA) as an artificial apical barrier.
The treated teeth were asymptomatic and the follow up clinical and radiographic examination showed healing with
apparent regeneration of periradicular tissues. Extrusion of MTA beyond the root end was not an obstacle in the
healing process. MTA can be considered an effective material to treat infected open apex teeth with large periapical
lesions.
Key Words: Open apex, Periapical lesion, MTA, Non surgical method.

Introduction
Root canal treatment of teeth with open apices is
challenging. Conventional root canal filling techniques
rely considerably on the presence of apical constriction,
against which gutta-percha can be optimally
compacted. In the absence of apical constriction due to
incomplete root formation, apical resorption or over
instrumentation, inevitably there is extrusion of
obturating material which could compromise the long
term healing outcome of treatment. The treatment
options have been either to induce apex formation or
resort to surgical technique. Surgical method is more
radical involving incision, flap reflection, root resection
and root end filling placement, causing certain amount
of discomfiture to patient. Traditionally long term
calcium hydroxide (CH) apexification has been used
to induce apical closure and takes anywhere between
3-18 months1. Despite its high success rate it has

Professor 1
Professor 2
Lecturer 3
Department of Conservative dentistry and Endodontics
MGM Dental College & Hospital, Kamothe,
Navi Mumbai
Address for Correspondence:
Dr. Sumanthini M.V
Professor
Department of Conservative dentistry and Endodontics
MGM Dental College and Hospital, Kamothe, Navi Mumbai
Mob: 9869433642
Email: marg_suman@yahoo.com

40

many drawbacks, namely patient compliance,


multiple appointments, long drawn procedure,
microleakage around provisional restorations,
cervical fracture and reduction of fracture resistance
of root structure2,3.
Various materials have been considered as an
alternative to calcium hydroxide namely freeze dried
alogenic dentin powder, bone ceramic, tricalcium
phosphate, osteogenic protein, collgen, calcium gel and
in particular MTA and Portland cement have been
extensively evaluated in the recent past. White MTA
(Proroot, Dentsply) is composed of bismuth oxide,
tricalcium silicate, dicalcium silicate, calcium
dialuminate and calcium sulphate dehydrated, trace
elements like iron, nickel and copper, strontium4. The
popularity of MTA for apical barrier technique can be
attributed to its good sealing properties, excellent
marginal adaptation, ability to set in the presence of
moisture and the procedure can be completed in less
number of visits. The biocompatibility and hard tissue
inductive effect of MTA have been confirmed in animal
and human studies5. Evidence from previous published
reports support that MTA placement consistently
resulted in regenerating normal periradicular tissues
in teeth with immature apices and continued root
maturation when pulpal necrosis was present6,7.
The following case report describes the non surgical
management of non vital infected maxillary central
incisors with open apices associated with a large
periapical lesion in relation to 21, secondary to
trauma.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Sumanthini et.al : Management of non vital maxillary central incisors with open apex using Mineral Trioxide Aggregate

Case report
A young lady aged 21 years was referred to outpatient
clinic, Department of Conservative Dentistry and
Endodontics with a chief complaint of continuous
throbbing pain in relation to maxillary central incisors
(11 and 21) since two days, discoloration and pus
discharge from the palatal aspect, in relation to
maxillary central incisors since one year (Fig.1).
Patient gave a history of trauma 3 years ago. On
examination, 11 showed discoloration and Ellis class 3
fracture involving mesial angle. While 21 had brownish
discoloration. Both teeth were tender on percussion,
with a sinus tract in the palatal aspect and non vital.
The teeth 13,12,22 and 23 responded normally to
vitality tests. Following clinical and radiological (Fig.2)
examination a diagnosis of chronic periradicular
abscess, with an acute exacerbation was made.
Radiograph revealed apical root resorption with an open
apex in both the teeth in question. Medical history was
non contributory.
All treatment procedures were carried out under rubber
dam isolation. Root canal access cavities were
prepared in 11,21 and the canals were explored.
Copious pus exuded through the canal of 21. Both teeth

Fig. 1- Preoperative photograph showing mesial angle # in 11,


discoloration in 11, 21.

Fig. 2 - Preoperative
radiograph,
note
the
periapical lesion in 21,
indicated by the arrow.

Fig. 3 - Radiograph showing


Working
length
determination.

Journal of Contemporary Dentistry

had a single canal and no apical stop.An#80


file(Mani,inc) could easily pass through the apical
foramen without any resistance. Working length
(Fig.3) was established using radiographic technique
and canals irrigated with normal saline to encourage
drainage. Canals were circumferentially filed and a
thin paste of CH saline mix was placed in the canals
and temporized with zinc oxide eugenol cement
(Deepak Enterprise, Mumbai, India). Antibiotics and
analgesics were prescribed. Patient was recalled the
following day, her acute symptoms had subsided
.When the canals were re-entered, slight discharge
was noticed in 21. Canals were circumferentially filed,
thoroughly irrigated intermittently with 5% sodium
hypochlorite (Trifarma, Thane, India) (5% NaOCl) .A
thick
paste
of
extra
pure
calcium
hydroxide(Deepashree Products, India) mixed with
saline was placed in the canal and the access cavities
were temporized with zinc oxide eugenol cement. The
patient was recalled after a week and the same
treatment regimen was repeated. A week hence the
patient was asymptomatic and the sinus tract had
resolved. The CH dressing was removed from 11, 21
and the canals were irrigated thoroughly with 5%
NaOCl followed by saline. Canals were dried with
absorbent points. White MTA (Proroot, Dentsply) was
mixed with sterile water as per manufacturer's
instructions to thick putty like consistency. It was
carried in to the canals with sterile amalgam carrier
and condensed in to place with prefitted hand
pluggers.An apical plug of 4 mm was placed in both
11 and 21(Fig.4); a radiograph was taken to confirm
the dense packing of MTA. A moist cotton pledget
was placed in the canal to aid in setting and the
teeth were temporized with zinc oxide eugenol
cement. Patient was recalled the following day and
remaining canal portion was obturated with guttapercha (Dentsply Maillefer) and AH Plus (Dentsply)
root canal sealer (Fig.5). Finally the teeth were

Fig. 4 - Radiograph
showing MTA apical plug
placement in 11 and 21.

October-December 2011 | Vol 1 | Issue 2

Fig. 5 - Radiograph
showing obturation of 11
and
21
note
the
extrusion
of
MTA
indicated by the arrow.

41

Sumanthini et.al : Management of non vital maxillary central incisors with open apex using Mineral Trioxide Aggregate

restored with resin composite in both the access cavities


followed by metal ceramic crowns (Fig.6, 7). Patient
was recalled for regular checkups to follow the
treatment out come at regular time intervals, (Fig.8, 9)
and further long term follow-up.

Fig. 6 - Photograph showing tooth preparation done in 11, 21.

Fig. 7 - Photograph showing 11, 21 restored with metal ceramic


crowns.

Fig. 8 - Three month


follow up radiograph
showing hard tissue
deposition over MTA
surface indicated by the
arrow and extruded
MTA surrounded by
osseous tissue.

42

Fig. 9 - 9 Month follow up


radiograph
showing
satisfactory healing of
periapical lesion in relation
to 11 and 21.

Discussion
Traumatic injury to mature teeth results in pulp
necrosis due to periapical neurovascular supply damage
.When injury damages the protective layer of
precementum, inflammation of pulp or periodontium
will induce resorption in root and bone as the microbial
toxins can pass through the dentinal tubules and
stimulate an inflammatory response. In the present
case, the maxillary central incisors had open apices
caused due to apical root resorption and chronic apical
abscess in 11 and 21 respectively as a result of trauma
induced apical periodontitis and pulp necrosis. The
objective here is to control infection and induce apical
closure.CH as an intracanal dressing has been the most
widely used and clinically accepted for over 40 years.
Recent research evidence has demonstrated that the
long term calcium hydroxide apexification treatment,
significantly reduces the fracture resistance of the
tooth3.This is attributed to decreased organic support
of dentin matrix leading to disruption of the bond
between the collagen fibrils and hydroxyapatite
crystals that negatively influence the mechanical
properties of dentin. In the present case calcium
hydroxide was used for a short duration as an
intracanal medicament since it is known to
significantly reduce the endodontic micro flora without
compromising the fracture resistance of dentin.
Calcium hydroxide when placed for not more than 30
days does not cause any deleterious effect on dentin2.
Bidar etal found in their study that medication with
calcium hydroxide improved the marginal adaptation
of MTA8. Shabahang et al in their animal studies
demonstrated a more predictable healing outcome
when MTA is used to obturate open apex teeth when
compared with teeth treated with calcium
hydroxide9.MTA represents a contemporary version of
the primary monoblock in attempts to strengthen
immature tooth roots. Although MTA does not bond to
dentin interaction of the released calcium and hydroxyl
ions of MTA with a phosphate containing synthetic body
fluid results in formation of apatite like interfacial
deposits. These deposits improve the frictional
resistance of MTA to the root canal walls and accounts
for the seal of MTA in orthograde obturation and
perforation repair10.
Following the calcium hydroxide medication the
patient was asymptomatic and there was cessation of
pus discharge from the canal. A 4mm MTA apical plug
was placed in both the incisor teeth. Invitro studies
have suggested that a 4-5mm of MTA plug is sufficient
to provide an adequate seal. This is also supported by
retrospective studies under taken to evaluate the
treatment outcomes of artificial apical barrier with
MTA in teeth with immature apices 11,12. The
biocompatibility of MTA is well documented. It
promotes the formation of cementum coverage over

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Sumanthini et.al : Management of non vital maxillary central incisors with open apex using Mineral Trioxide Aggregate

the MTA surface with a high degree of structural


integrity and more complete periradicular architecture.
The production of bone morphogenetic protein-2
(BMP-2) AND transforming growth factor -beta-1
(TGF--1) could be instrumental for the favorable
biologic response stimulated in human periapical
tissues13. The stimulation of interleukin production
causes the cementum overgrowth. The above factors
collectively facilitates regeneration of periodontal
ligament and formation of bone.
In the present case no attempt was made to place an
internal matrix at the apex in order to retain the MTA
within the confines of the root canal space14. Absence
of apical constriction led to extrusion of MTA beyond
the root apex. The extruded MTA (Fig.8) was separated
from the root end and was surrounded by normal
bone.The follow up radiographs showed the gradual
resorption of the extruded material. Despite the
extrusion healing of the periapical lesion was
uneventful. There was regeneration of periradicular
tissue, normal periodontal space, decrease in size of
periapical lesion as compared with preoperative
radiograph and no evidence of inflammatory external
root resorption(Fig. 8,9) .This corroborates with the
retrospective study of Zafer et al and Johannes Mende
et al that the healing outcome of teeth was unaffected
by extrusion of MTA6,15.

Summary

3.

4.

5.

6.

7.

8.

9.

10.

11.

The present case report confirms that MTA acts as an


apical barrier and can be effectively used to support
regeneration of periapical tissue in traumatized infected
teeth with open apices, involving large periapical
lesions. Both clinical and radiographic follow ups
revealed optimal healing of the periapical lesion and
new hard tissue formation in the apical area of the
traumatized incisors in spite of extrusion of MTA.
Hence it can be concluded that MTA plugs predictably
induce apical closure in shorter treatment time and
without much dependence on patient compliance.

12.

13.

14.

References
1.
2.

John I. Ingle, Lief K Bakland, J. Craig Baumgartner, Ingle's


Endodontics 6th edition. page-1337.
Andreasen JO, Munksgaard EC, Bakland LK. Comparison
of fracture resistance in root canals of immature sheep

Journal of Contemporary Dentistry

15.

teeth after filling with calcium hydroxide or MTA. Dent


Traumatol 2006;22:154-6.
Glen .E. Doyon, Thom Dhumsha, J Anthony von
Fraunhofer. Fracture resistance of human root dentin
exposed to intracanal calcium hydroxide. J Endod
2005;31:895-897.
Araceli I, Bucio L, Cruz-chwez E. Phase composition of
Proroot MTA by x-ray powder diffraction. J Endod
2009;35:875-878.
N.K. Sarkar, R.Caicedo, P.Ritwik, R. Moiseyeva, I.
Kawashima. Physicochemical basis of biologic properties
of mineral trioxide aggregate Endod 2005; 31:97-100.
Zafer C. Cehreli, Sezgi Sara, Serdar Uysal, Melek D
Turgut. MTA apical plugs in the treatment of traumatized
immature teeth with large periapical lesions. Dent
Traumatol 2011; 27:59-62.
Holden DT Schwartz SA Kirkpatrick TC, Schindler WG.
Clinical outcomes of artificial root barriers with mineral
trioxide aggregate in teeth with immature apices ENDOD
2008;34:812-7.
Maryam Bidar, Reza Disfani, Salman Ghargozloo, Shirin
Khoynezhad and Armita Rouhani.J Endod 2010; 36:16791682.
Shabahang S, Torabenajed M, Boyne PP, Abedi H,McMillan
P. A comparative study of root end induction using
osteogenic protein-1, calcium hydroxide and mineral
trioxide aggregate in dogs Endod 1999;25:1-5.
Franklin R .Tay, David H Pashley. Monoblocks in root canals:
A hypothetical or a tangible goal. J Endod 2007;33:391398.
David E Witherspoon, Joel C Small, John D Regan, Martha
Nunn. Retrospective analysis of open apex teeth obturated
with MTA.J Endod 2008; 34:1171-1176.
Ahmed AL Kahtani, Sandra Shostad, Roebrt Schifferte,
Stish Bambhani. Invitro evaluation of microleakage of an
orthograde apical plug of MTA in permanent teeth with
simulated immature apices. J Endod 2005; 31:117-119.
Gunseli Gunsen, Zafer C Cehreli, Ali Ural, Muhittin A
Sedar, Feridun Basak. Effect of MTA cement on
Transforming Growth factor ?-1 and Bone Morphogenic
Protien production by human fibroblasts invitro.J Endod
2007;33:447-450.
C. Bargholz.Perforation repair with mineral trioxide
aggregate modified matrix concept.Int Endod J 2005;38:5969.
Johannes Mente, Nathalie Hage ,Thorsten Pfefferle,
Martin J ean Koch, Jens Dreyhaupt, Hans Joerg Staele,
Shimon Friedmann. Mineral trioxide aggregate apical plugs
in teeth with open apical foramina :A retrospective analysis
of treatment outcome.J Endod 2009;35:1354-1358.

October-December 2011 | Vol 1 | Issue 2

43

CASE REPORT

Factitious Injury of The Periodontal Tissues - C ASE R EPORT


Vineet Kini1, Richard Pereira2, Ashvini M. Padhye3, Sudarshan G. Kadam4

Abstract
Factitious or self-induced injuries are inflicted based on habit, frequently associated with psychogenic background;
related only in manner by which they are produced, bearing no particular anatomic, etiologic or microscopic
similarities. The following case report attributes a suspicious periodontal lesion to self-induced injury.
Key words: Factitious, Self-induced injury.

Introduction
A Factitious or self-induced injury of the periodontal
tissues occur with repeated voluntary trauma to
localized areas with toothbrushes, pacifiers, fingernails,
pens, toothpicks, eyeglass stems and other provocative
habits1. These mechanical injuries by secondary
infection and inflammatory disease manifest as a
localized recession to advanced bone loss if not
intercepted1. The etiology, frequency and force exerted
by the habit in addition to prevailing periodontal health
dictate the course of response to therapy1. The case
presented herewith showcases such elements testing
diagnostic acumen.

Case Report:
A thirteen year-old male patient reported with an ulcer
in the mouth since one month. The patient had a
decayed tooth in the right lower posterior jaw region
for which root canal treatment was initiated six months
ago but not completed. The patient became
symptomatic with pain in relation to the same tooth
since a month and a gum boil had appeared in the
gums adjacent to the same concerned tooth at the same
time. The patient ruptured the boil and continued to
Reader 1
Professor 2
Professor and Head3
Lecturer 4
Department of Periodontics,
M.G.M Dental College & Hospital,
Navi Mumbai 410 209.
Address for Correspondence:
Dr.Vineet Kini, M.D.S,
Department of Periodontics,
M.G.M Dental College & Hospital,
Navi Mumbai 410 209.
Mob.: 9769804390
E-mail: drvinkin@gmail.com

44

irritate it by massaging it. The site became tender and


was causing difficulty on mastication. The patient
developed a swelling in the right lower posterior jaw
region since one week The parent noticed the same
and reported for consultation. The parent reported that
the patient had been pricking the ulcer with objects
he found accessible : toothbrush, pens, pencils, and
sometimes his finger.
Examination revealed a pulpally involved 46 [FDI Tooth
numbering system]. The extra oral swelling was
present at the right mandibular jaw region measuring
2cm by 3cm extending from the base of the mandible
to the zygomatic arch having diffuse borders, was firm
in consistency and tender on palpation. The right
submandibular lymph nodes were palpable and tender.
The reported ulcer was solitary and present in the
region of the attached gingiva and lining mucosa in
between 45 and 46 [FDI tooth numbering system],
measuring 2cm by 3cm. The ulcer had sloping margins
and smooth borders with an erythematous halo
surrounding the border. The floor of the ulcer was
coarse and would bleed on palpation. The ulcer was
tender on palpation and its base was mobile. Within
the ulcer margin an intra oral fistulous tract opening
was found which could be traced to the apical region of
46 [FDI tooth numbering system].
Based on the history and examination findings a
diagnosis of factitious injury to the gingiva was made
caused by repetitive and deliberate irritation to the area
surrounding the intraoral sinus tract opening leading
to the present state of an ulcer in the concerned area.
The patient and the parents were made aware of the
problem and explained that the lesion was self induced
the patient need to refrain from the reported habit to
allow the ulcer to heal.
Root canal therapy was carried out in relation to 46
[FDI Tooth numbering system]. The patient was

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Kini et.al : Factitious Injury of The Periodontal Tissues

advised Quadrajel and Ubi-Q* ointments for topical


application on the ulcer to provide palliative relief,
antisepsis and promotion of healing respectively. The
patient was asked to abstain from rubbing the ulcer with
his tooth brush onto prevent further trauma. This was
personally supervised by the parent during oral hygiene
routine. The patient was reviewed every seven days.
After twenty one days the ulcer was found to have
healed. The patient's parent reported that the patient
had not reverted to the same habit since initial
consultation.

Conclusion
Baffling history and clinical picture could mask a selfinduced injury. In the present case the patient
developed a habit of traumatizing his periodontal soft
tissues with foreign objects; contributing towards a
self-induced etiology for present lesion. The causative
factor could not have been ascertained undisputedly if
it were not for the patient's confession. This highlights
the crucial role of interview and observation in
diagnosis.

Discussion
The presence of a large ulcer in the mouth conspicuous
by its isolated solitude, sharp contrast to normal
background was intriguing. This, supported by the
history given by the parent in regards to the patients
reported habit of traumatizing himself in the area
concerned with foreign objects was cause to suspect
factitious injury.
This features concurred with the suggestions of Stewart
and Kernohan2 as criteria for diagnosing self inflicted
gingival injury, considering that the area was easily
accessible to the patient. Contrary to the opinion that
such lesions occurred in unusually grouped multiple
numbers, solitary lesions were also found to meet such
criteria2.

Figure 1. The Ulcerative lesion as on first interview

Although the patient did report a habit, he related it


to relieve discomfort caused by the lesion. This did not
conform towards Stewart's Gingivitis artefacta major
by its' suggestion of a possible underlying emotional
disorder. This was more relevant to Stewart's Gingivitis
artefacta minor for which pre-existent lesions provoking
habit induced injury were mandatory3, as in this case.
The lack of any hereditary disorder [genetic,
biochemical or enzymatic deficiency] ruled out organic
etiology described by Ager and Levin4. Functional
etiology, according to Ager and Levin 4, required
performance of such behaviour with patient's
knowledge as was in this case. This lesion conformed
more towards Stewart and Kernohan4 described
injuries of complex and unknown etiology. This was
substantiated by the patient's procurement of
secondary gain of compassion and sympathy from the
parent. Neurotic excoriations and mutilation during
psychotic episodes, sans secondary gains were ruled
out4.As signs of pre-existent lesions were detected,
Stewart and Kernohan's4 functional etiology of
superimposed and secondary lesions were arrived upon.
A conclusion based on the subject's confession was made
that the lesion was indeed a self-induced factitious
injury with a functional etiology.
Lidocane HCl 2%, Metronidazole Benzode 1%, Chlorhexidine
Glnconate 1%
* Carotene 0.1%, Ubiguiane 0.1%

Journal of Contemporary Dentistry

Figure 2.
interlude

The

same

site

following

three

weeks

References
1.

2.

3.
4.

McMullen JA. Inflammatory Periodontal Disease, Etiology


and Additional Local Influences. In Goldman HM, Cohen
DW. Editors, Periodontal Therapy .6th Edition. St. Louis
:The C.V. Mosby Company ;1980.p.105-151.
Altom RL, DiAngelis AJ. Multiple Autoextractions: Oral
Self-mutilation Reviewed. Oral Surg Oral Med Oral Pathol
1989; 67:271-274.
Groves BJ. Self-inflicted Periodontal Injury. Br Dent J
1979; 147:244-246.
Owen D., Michael AM , O'Riordan W and Kline R. Oral
Habits. In Forrester DJ, Wagner ML, Feming J. Editors.
Pediatric Dental Medicine. 1st Edition. Philadelphia: Lea
& Febiger; 1981.p535-557.

October-December 2011 | Vol 1 | Issue 2

45

CASE REPORT

Compound Composite Odontoma in Mandibular Symphysis


A Rare Case
Sushrut Vaidya1, Usha Asnani2, Smita Sonavane3, Imran Khalid4, Kartik Poonja5, Alok Bhardwaj6

Abstract
Compound odontomas are considered as hamartomatous malformation rather than true neoplasms & are
generally asymptomatic . The exact etiology is unknown and is often associated with the overretained deciduous
teeth, most commonly in maxillary anterior region. In this case, multiple denticles or rudimentary teeth numbering
42 were enucleated from the mandibular symphysis region of 17 yr old female which makes this case rare and
unusual. Evidence of concrescence, fusion, dilaceration were observed in the denticles enucleated, the size of
which ranged from 2mm to 10mm.
Key Words: Odontoma, Compound Odontoma, Denticles, Hybrid Odontoma, Impacted Teeth

Introduction
Odontomas are considered as developmental anomalies
arising from completely differentiated epithelial and
mesenchymal cells that give rise to ameloblast &
odontoblast. They are hamartomatous lesions rather
than true neoplasms.1 The term 'odontoma' was coined
by Paul Broca in 1867 which by definition alone refers
to any tumour of odontogenic origin. Most of the
odontomas are asymptomatic, although some signs &
symptoms relating to their presence may occur. The
compound composite odontomas are a malformation
in which all the dental tissues are in a more orderly
pattern than in the complex odontoma so that the lesion
may consist of many tooth like structures.2 Compound
odontomas are generally most commonly seen in
maxillary anterior region with denticles varying from
4-28. 3 The sheer number of denticles extracted

Reader 1
Professor2
Reader 3

numbering 42 from the mandibular symphysis region


makes the case a rare and unique one.

Case History
A 17 yr old female presented with chief complaint of
malaligned mandibular anterior teeth (Fig.1). Patient
was asymptomatic without any specific complaint. On
examination she had over retained lower deciduous left
central incisor, partially erupted and medially tipped
lower left permanent lateral incisor with missing
canine. The mandibular right central incisor was
tipped labially. Patient was advised orthopantamogram
for further treatment. OPG showed multiple tooth like
structures of different size and shape in relation to root
of mandibular anterior teeth in the symphysis region
which was surrounded by circumscribed radiolucent
zone. There was displacement of permanent right
mandibular central incisor(Fig.2). The left mandibular
lateral incisor was displaced and the canine was
impacted apical to the premolars. Upon the clinical
and radiographic findings a provisional diagnosis of
compound composite odontoma was made. It was

Lecturer4
Post graduate5
Post graduate6
Dept Oral and Maxillofacial Surgery,
MGM Dental College and Hospital, Navi Mumbai.
Address for Correspondence:
Dr. Sushrut Vaidya,
Reader
Dept Oral and Maxillofacial Surgery,
MGM Dental College and Hospital, Navi Mumbai.
Mob.: 9869160530
E-mail: ezeesush79@gmail.com

46

Fig.1 : Preoperative intraoral photograph

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Vaidya et.al. : Compound Composite Odontomas In Mandibular Symphysis

Fig.2 : Preoperative radiograph showing the denticles

Fig.5 : Postoperative bony defect seen

decided to extract the deciduous central incisor and


surgically enucleate the tumour. Under local
anaesthesia deciduous central incisor was extracted. A
labial mucoperiosteal flap was raised. The bone
covering the odontoma was removed and (Fig.3)
numerous denticles around 42 were enucleated along
with the capsule. Evidence of concrescence were seen

in 4 groups of denticles. Fusion and dilaceration were


also noticed (Fig.4). Size of denticles varied from 4mm
to 10mm. The partially erupted and displaced lateral
incisor and impacted canine were left in place. Closure
was done with 3-0 vicryl. Post operative period was
uneventful.

Discussion
The term odontoma by definition refers to a benign,
mixed, calcified tumour of odontogenic origin. The
absolute incidence of odontogenic tumours varies from
0.002% to 0.1%4 out of which odontomas constitute
about 22%,5 of which 10% are compound odontomas.
There are essentially 2 types of odontomas:
1) Complex composite odontoma
2) Compound composite odontoma

Fig.3 : Mucoperiosteal flap raised showing the lesion

As per the WHO classification complex composite


odontoma is defined as a malformation in which all
dental tissues are well formed but are arranged in
disorderly pattern.
Compound composite odontoma is a malformation in
which all dental tissues are represented in a more
orderly pattern than in the complex odontomas, so that
the lesion contains tooth like rudimentary structures
in which each enamel, dentin, cementum and pulp are
arranged as in normal teeth.

Fig.4 : Specimen after excision

Journal of Contemporary Dentistry

The exact etiology of odontoma is not known6 yet cases


have related odontoma to local trauma, infection and
genetics. It arises from an exubrant proliferation of
dental lamina or its remnants and is termed as laminar
odontome ,or forms as a result of multiple schizontia
i.e a locally conditioned hyperactivity of dental lamina.7
It may be associated with Gardners syndrome of
intestinal polyposis.8 Compound odontomas are twice
as commonly observed as complex and commonly in
the maxillary anterior region. Clinically odontomas
usually remain small rarely exceeding the diameter
of the teeth. It may become large and causes expansion
of cortical bone most commonly when associated with

October-December 2011 | Vol 1 | Issue 2

47

Vaidya et.al. : Compound Composite Odontomas In Mandibular Symphysis

dentigerous cyst. They usually present with unerupted


or impacted teeth or retained deciduous teeth.9 Despite
interference with eruption there is no resorption of
adjacent tooth root. There is often displacement of the
adjacent tooth with loss of vitality.
Radiographically odontomas appear as an irregular
radioopacity or denticles surrounded by a radiolucency
with or without bony expansion.
Odontomas are successfully treated by surgical
enucleation with least rate of recurrence. Kaban stated
that odontomas are easily enucleated and adjacent teeth
that may have been displaced by lesion are seldom
harmed by surgical excision because they are usually
separated by the septum of bone.10
Although odontomas are considered as hamar-tomatous
lesions having a limited growth potential, there are
chances of undergoing secondary changes like
dentigerous cyst formation, ameloblastic
transformation, causing weaking of the surrounding
bone. Hence on detection, surgical enucleation of
odontomas, followed by curettage is recommended to
prevent further complication.

48

References
1.

Budnick, S., 1976. Compound and complex odontomas.


Oral Surg. Oral Med. Oral Pathol. 42, 501-506.
2. Philipsen, H.P., Reichart, P.A., Praetorious, F., 1997. Mixed
odontogenic tumours and odontomas. Considerations on
interrelationship.Review of literature and presentation of
134 new cases of odontomas. Oral Oncol. 33, 86-99.
3. Amado-Cuesta, S., Gargallo-Albiol, J., Berini-Aytes, L.,
Gay-Escoda, C., 2003. Review of 61 cases of odontoma.
Presentation of an erupted complex odontoma. Med. Oral.
8, 366-373.
4. Yeung, K.H., Cheung, R.C.T., Tsang, M.M.H., 2003.
Compound odontoma associated with an unerupted and
dilacerated maxillary primary central incisor in a young
patient. Int. J. Ped. Dent. 13, 208-212.
5. Saadettin, Dagistan, Mustafa, Goregen, Ozkan, Miloglu,
2007.Compound odontoma associated with maxillary
impacted permanent central incisor tooth: a case report:
the internet. J. Dent. Sci. 5,1-6.
6. Shafer, Hine, Levy, 1993. A Textbook of Oral Pathology,
fourth ed. W.B. Saunders & Co., pp. 308-312.
7. Philipsen HP, Reichart PA, Praetorious F. Mixed
Odontogenic Tumours and Odontomas. Considerations on
Interrelationship. Review of Literature and Presentation
of 134 New Cases of Odontomas. Oral Oncol1997;33:8689.
8. Cawson, R.A., Binnie, W.H., Barrett, A.W., Wright, J.M.,
2001. Oral Disease, third ed. Mosby, p. 6.24.
9. Singh, S., Singh, M., Singh, I., Khandelwal, D., 2005.
Compound composite odontome associated with an
unerupted deciduous incisor - a rarity. J. Ind. Soc. Ped.
Prev. Dent. 23, 146-150.
10. Kaban LB.Pediatric Oral and Maxillofacial surgery
Philadelphia: Saunders; 1990.p.111-2.

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

CASE REPORT

Infiltrative T
ype of Bone Invasion in Oral Squamous Cell Carcinoma
Type
C ase R eport
Jigna Pathak1, Niharika Swain2, Shwetha Kumar3

Abstract
Oral squamous cell carcinoma (OSCC) is a well known malignancy which accounts for more than 90% of all oral
cancers. OSCC are malignant tumors that frequently invade bone and bone invasion is a common clinical problem.
Bone invasion by oral squamous cell carcinoma may progress by either an infiltrative or an erosive histological
pattern. The pattern of bone invasion co-relates with the clinical behavior of OSCC thus having a potential prognostic
value. The present case report is of a 35-year- old female patient presenting with a lesion in the lower right buccal
vestibule which was histopathologically confirmed as OSCC.The type of bony invasion was also assessed
microscopically. The objective of this paper was to define the characteristics associated with each histological
pattern of invasion and its significance when reviewing oral squamous cell carcinoma with mandibular invasion.
Key Words: Oral cancers, Osteoclastogenesis, Osteoprotegerin

Introduction
OSCC is the sixth most common cancer and more than
3, 00,000 new cases are diagnosed each year world wide.1
Oral carcinoma of the mandibular region has been
defined as carcinoma of the mandibular alveolar ridge,
lower buccal sulcus, sublingual sulcus and mandibular
retro molar trigone.2 Carcinoma at this site may
eventually progress to directly invade the mandible, a
feature associated with a worse prognosis. Mandibular
invasion is one criterion of the American Joint
Committee on Cancer classification for the most
advanced primary stage (T4) and overall stage (IV) for
these tumors. The 5-year determinate survival of
patients with stage IV oral lesions has been
demonstrated to be 39%, as compared with 53%, 68%,
and 70% for stages III, II, and I disease, respectively.3
OSCC invades the mandibular bone through an
erosive, infiltrative or mixed pattern that correlates
with clinical behavior. The erosive pattern is
characterized by a broad, expansive tumor front with
a sharp interface between tumor and bone. In contrast,
the infiltrative pattern is composed of nests of tumor
cells with fingerlike projections along an irregular
tumor front. The recent distinction between these two
histological patterns challenges the previously held
Professor 1
Senior Lecturer2
Senior Lecturer3
Department of Oral Pathology,
MGM Dental College and Hospital, Navi Mumbai
Address for Correspondence:
Dr. Jigna Pathak
501, Pleasant View Society, Plot 56/57
Sector-14, Vashi, Navi Mumbai-400703
Mobile: +919819175805
E-mail: drjignapathak@gmail.com,

Journal of Contemporary Dentistry

assumption that mandible invasion universally


presents a poor prognosis. The erosive pattern of bone
invasion has been hypothesized to extend in a more
predictable fashion than the infiltrative pattern.
Infiltrative pattern of bone invasion is associated with
a higher recurrence rate of about 53% compared with
the erosive pattern which is about 17%.4 The present
case report describes about the infiltrative pattern of
bony invasion by squamous cell carcinoma originating
from the buccal vestibule in a middle aged woman.

Case report
A 35-year-old female patient reported in MGM dental
college and hospital with a chief complaint of a non
healing cut in lower right cheek since the past 3-4
months. Past medical history was non contributory.
The patient had habit of chewing tobacco since the past
20 years. She also had history of Misheri application
on teeth and gums since the past 20-25 years. There
was no history of trauma, sinus or pus discharge.
Extraoral examination revealed a very mild facial
deformity with a diffuse swelling in the right side of
the face. Ipsilateral cervical lymphadenopathy (level
IB) was also noticed. Intraorally there was presence of
a linear endophytic lesion extending from lower right
first premolar to lower right third molar region in the
gingivo- buccal sulcus region.(Fig. 1) Additional feature
i.e. Grade II mobility of teeth from mandibular right
third molar to mandibular left canine was seen. On
radiological examination, Orthopantamogram (OPG)
revealed an ill-defined radiolucency extending from
mandibular right third molar (48) to mandibular right
canine (43). Computed tomography (C.T scan) showed
an osteolytic lesion involving the right side of the
mandible crossing the midline. (Fig.2) A provisional
diagnosis of Squamous Cell Carcinoma involving the
bone was given. Incisional biopsy was taken. The
histopathological report of well differentiated SCC was

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49

Pathak et.al. : Bone Invasion in Oral Squamous Cell Carcinoma - A Case Report

invasion. Level IB lymph nodes were positive for tumour


with extra capsular spread. Serial sectioning of the
mandible was done. The anterior bony margin
representing socket of mandibular left first premolar
(34) and lower border of the mandible microscopically

Fig. 1- An endophytic lesion extending from 44 to 48 in the


gingivo- buccal sulcus region.

Fig. 4 - H & E Section showing intramedullary invasion of


tumour islands (10X)
Fig. 2 - C.T scan showing an osteolytic lesion involving the
right side of the mandible crossing the midline.

Fig. 5 - H & E Section showing tumour islands resorbing the


cortical bone (10X)
Fig. 3 - H & E Section showing islands of malignant epithelial
cells with moderate amount of keratin pearl formation(40X)

confirmed. Excisional biopsy was done which included


hemimandibulectomy extending from 48 to 34 with
supra-omohyoid neck dissection (SOND).
Histopathological examination revealed dysplastic
stratified squamous epithelium. The underlying
connective tissue showed infiltration by nests & small
islands of malignant epithelial cells. Some of the larger
islands showed keratin pearl formation.
(Fig. 3). Also seen was moderate degree of chronic
inflammatory cell infiltration and prominent stromal
activity at the tumour invasion front. In some areas
perivascular and muscular invasion of tumour islands
was also noticed. There was no evidence of perineural

50

Fig. 6 - H & E Section showing tumor island resorbing the


cortical bone. (40X)

Journal of Contemporary Dentistry

October-December 2011 | Vol 1 | Issue 2

Pathak et.al. : Bone Invasion in Oral Squamous Cell Carcinoma - A Case Report

By

RANKL
(Receptor activator of nuclear
Factor kB ligand)

RANK
(receptor)

Osteoblasts and bone marrow


Stromal cells

Hemopoetic Osteoclast
progenitor, mature
Osteoclasts, chondrocytes &
Mammary gland epithelial cells

OSTEOPROTEGERIN

Regulated

men and may contribute up to 25% of all new cases of


showed intramedullary invasion of tumour cells.
cancer. At least 95% of OSCC cases occur in individuals
Extensive and deep invasion by small groups and
aged 40 years or older and is twice as often in men as
islands of tumor cells was seen in the mandible (Fig.
in women. In the present case report the female patient
4) with irregular resorption of cortical bone (Fig. 5 and
is 35 years old which is a relatively younger age group.
6). H & E section of the tissue excavated from the bony
Most important risk factors are tobacco use, increased
margin also proved positive for tumour showing sheets
consumption of alcohol and betel quid usage all of
of keratin with few islands of malignant cells. The
which act separately and synergistically together. Oral
overall impression was consistent with Moderately
cancer risk due to consumption of tobacco and alcohol
Differentiated Squamous Cell Carcinoma. Anneroth's
combined is estimated to be more than 80%.In our case
histological classification also showed Grade II SCC.
the patient had history of chewing tobacco and applying
(Table 1) with level IB lymph nodes being positive for
Misheri on the teeth and gums since the past 20-25
tumor and apparently safe anterior bony margin also
years. This well correlates the association of tobacco
and OSCC.5
involved (not free) showing infiltrative pattern of bony
invasion.
OSTEOCLASTOGENESIS

Osteoblasts and
stromal cells

Thus a balance between expression levels of RANKL and OSTEOPROTEGERIN is crucial because both are produced by the same
cells.

PTHrP

Il-6

STROMAL CELLS

CANCER CELLS

IL-6

RANKL (stromal cells/ present on osteoblasts lining the bony front)


+

RANK (Osteoclast Precursors in Hemopoetic marrow)

OSTEOCLASTS

BONE RESOPTION

GROWTH FACTORS (TGF beta, IGF-1, FGF)

Increased proliferation of cancer cells + reduced Apoptosis.

Discussion
OSCC is a well known malignancy which accounts for
more than 90% of all oral cancers. The annual
estimated incidence is around 275000 for oral and
130300 for pharyngeal cancers excluding nasopharynx.
In high risk countries like Sri Lanka, India, Pakistan
and Bangladesh, OSCC is the most common cancer in

Journal of Contemporary Dentistry

Clinical examination requires an imaging correlation.


Various imaging techniques(i.e.: Orthopantamogram,
Bone Scintigraphy, Computed Tomography, Magnetic
Resonance Imaging and Positron emission tomography)
are used to make a diagnosis of mandibular invasion
by tumour of the oral cavity6. In the present report,
OPG and C.T scan were used to detect the extent of
mandibular invasion. On the CT scan the lesion seemed

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Pathak et.al. : Bone Invasion in Oral Squamous Cell Carcinoma - A Case Report

to be crossing the midline. This was initially suspected


clinically as the teeth showed mobility from 48 to 33.
As tumor cells grow and mitosis increases, they invade
the basement membrane, destroy the surrounding
tissue regionally, resist the immune system, and secrete
certain proteins and angiogenic factors that will
facilitate lymphovascular invasion and metastasize
regionally or distantly. OSCC tends to invade the
adjacent bone due to its close anatomical proximity, so
higher bone invasion will occur in the OSCC that lies
in direct contact with the bone. The size and proximity
of the primary tumor to the jaw bone will determine
the degree of bone invasion. Prognosis is affected by
the pattern of bone invasion, which could be either an
erosive, infiltrative or mixed7. The erosive pattern of
bone invasion is marked by a broad pushing front, a
sharp interface between tumour and bone, osteoclastic
bone resorption and fibrosis along the tumour front
and an absence of bone islands within the tumour mass.
In contrast, the infiltrative pattern is characterized
by nests and projections of tumour cells along an
irregular front, residual bone islands within the tumour
and Haversian system penetration. The histological
pattern of mandibular invasion seems to correlate with
the clinical behavior. Infact the infiltrative lesions are
more likely to have primary, regional and distant
recurrence8.The 3 year disease free survival in the
infiltrative pattern is reported as 30% as against that
in erosive pattern is 73%4.The present case showed an
infiltrative pattern of bone invasion suggesting that it
was an aggressive lesion. It is seen that cellular and
molecular mechanisms regulate osteoclast
differentiation.
Thus, it can be deduced that stromal cells regulate
osteoclast formation induced by OSCC. Also IL-6 and
PTHrP released from oral cancer cells induce
Osteoclastogenesis through RANKL expression in
stromal cells.8
Patients with mandibular invasion should be treated
surgically but the extent of mandibular resection
required remains controversial8.Histological pattern of
mandibular invasion has prognostic significance. Poor
clinical outcome is highly correlated with the
infiltrative histological pattern of invasion. Infiltrative
pattern has a 4-fold increased risk of death as compared
to erosive pattern. In the present case
hemimandibulectomy was performed and considering
a 1 cm safe margin, the mandible was resected up to
Lower left first premolar.(34) However, on
histopathology of the resected mandible, the margin
considered to be safe showed infiltrative pattern of bone
invasion, thus being positive for tumor. Therefore the
patient was informed about the prognosis, advised
radiotherapy and explained about the need of another
surgical intervention.
A recent study has demonstrated that tumour invasion
of the mandible is not significantly correlated with the
52

survival of the patient with OSCC and if bone invasion


is identified histologically, the prognosis is not worsened
and additional surgery need not be undertaken.9
However, more studies are required with more
number of cases to prove the prognostic value of the
pattern of bony invasion in OSCC.

Conclusion
The infiltrative pattern intuitively appears to be an
aggressive tumor that is difficult to resect surgically.
The intraoperative and preoperative determination of
invasion pattern remains problematic. If the
preoperative imaging studies do show radiographic
characteristics suggesting an infiltrative pattern such
as an irregular front or bone spicules, a wide surgical
margin should be taken around the grossly apparent
tumor. Pattern of invasion provides important
prognostic information and therefore should be
routinely commented on by pathologists reviewing cases
with mandibular bone invasion.
In addition, new approaches have been developed to
examine cellular and molecular mechanisms of bone
invasion by OSCC. Inhibition of osteoclast
differentiation and function by blocking RANKL and
RANK by inhibitor antibody constitutes a novel
approach to development of target therapy.

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