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Indian Journal of Dental Education

Volume 10 Number 3
Contents July - September 2017

Original Article

Confidence Level among Undergraduate Dental Cohorts Regarding

Restorative Dentistry: A Descriptive Study 157
Vergis Bettina, Shetty Neeta, Shenoy Ramya

Review Articles

The Use of Elastics in Orthodontics 161

Eltahir H.E., Mahmoud N.M., Mageet A.O.

Enamel and Dentin Adhesion Differences 170

Prashanth Kumar Katta

Supernumerary Teeth: A Literature Review 173

Mounabati Mohapatra, Priyanka Sarangi, Sukanta Satapathy

Case Reports

Beautiful Smiles with Functional Occlusal Harmony 178

Kamala Kakumanu

Middle Mesial Canal in Mandibular Second Molar 185

Seema Yadav

Guidelines for Authors 189

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

156

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Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

Original Article Indian Journal of Dental Education
157
Volume 10 Number 3, July ­ September 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10317.1

Confidence Level among Undergraduate Dental Cohorts Regarding

Restorative Dentistry: A Descriptive Study

Vergis Bettina*, Shetty Neeta**, Shenoy Ramya***

Abstract

Background: Monitoring the confidence of students in completing clinical tasks by dental institutions could
serve to assess their preparedness for future independent clinical practice. Aim: To obtain information regarding
the confidence level exhibited by clinical dental students in various aspects of restorative dentistry. Study
setting and design: The cross­sectional descriptive study was conducted among the final year undergraduate
dental students and interns of 2 dental colleges in Mangaluru, South Kanara. Materials and methods: Self
administered questionnaires were distributed among 293 final year undergraduate dental students and
interns.The cohorts were asked to score their level of confidence in 15 aspects of restorative dentistry using
Likert’s 5 point scale. Statistical analysis used: The descriptive statistics was calculated using the SPSS version
20.0 and Mann Whitney test was applied to assess the association. The level of statistical significance was
kept at p< 0.05. Results:The response rate for the survey was 100%. Interns showed higher confidence levels in
almost all aspects of restorative dentistry particularly in diagnosis (p =0.028), pre­operative procedures
(p=0.000), manipulation of glass ionomer cement (p=0.043) and dental composite (p=0.000). Final year students
and interns were comparably confident in restorative procedures (p=0.111) except for management of
inadvertent pulp exposure in which interns showed greater confidence (p=0.003). Both interns and final year
students exhibited low confidence in management of complex situations (p=0.217). Conclusion: Interns exhibited
high confidence in restorative dentistry when compared to final years. Further training in management of
complex situations could be of definite advantage.
Keywords: Confidence Level; Dental Education; Restorative Dentistry.

Introduction levels of proficiency to deliver restorative treatment.

Restorative dentistry deals with rehabilitation of
the dentition so as to fulfil the functional and aesthetic
requirements of the individual. The clinician needs
to undergo intense clinical and practical training and
acquire in­depth knowledge about the diseases of
teeth and the surrounding tissues to achieve high
Author’s Affiliation: *Final year Post Graduate Student
**Professor and Head, Department of Conservative Dentistry
and Endodontics ***Associate Professor & Deputy QMR,
Department of Public Health Dentistry, Manipal College of
Dental Sciences, Manipal University, Mangaluru, Karnataka,
India.
Reprints Requests: Neeta Shetty, Professor and Head,
Department of Conservative Dentistry and Endodontics,
Manipal College of Dental Sciences, Light House Hill Road,
Mangaluru, Karnataka 575001.
E­mail: neetaraj70@gmail.com
Received on 03.07.2017, Accepted on 22.07.2017
Indian
© Journal
Red Flower of Dental
Publication Pvt.Education,
Ltd Volume 10 Number 3, July ­ September 2017
The dental curriculum should be constantly updated
in information as well as teaching methodology to
create competent dental professionals who are
confident to face the prospect of independent practice
at the end of graduation [1]. But the present education
system is still primarily dependent on didactic
teaching and quota based systems rather than problem
–based teaching. The need of the hour is to assess
whether the students feel competent enough under
the current mode of dental education system.
It is a well­known fact that one cannot improve
what one cannot assess. Self­assessment becomes an
essential tool among dental professionals and dental
students in improving clinical proficiency and
competence. Regular and unbiased self­evaluation is
an essential feature of competency based education
[2]. Matheos et al had suggested that self­assessment
can enable the individual to define his or her learning
need in the pursuit of excellence [3]. By having an
accurate perception of one’s own knowledge and
158 Vergis Bettina et. al. / Confidence Level among Undergraduate Dental Cohorts Regarding
Restorative Dentistry: A Descriptive Study
skills, the dental undergraduate student can work
towards gaining increased competence in areas
where it is found to be lacking [4].
Different dental schools all across the world have
varying prerequisites for graduation in each
discipline of dentistry. In addition, the number of
training hours and number of treatment cases that a
student is supposed to complete in order to graduate,
vary among the dental schools [5]. In the discipline
of Restorative Dentistry, an undergraduate student
needs to develop adeptness in diagnosis of diseases
of the tooth and supporting structures , restoring the
tooth using various restorative materials like dental
amalgam, glass ionomer cement, dental composite
resins and diagnosis and treatment of pulpally
involved teeth [6]. Youngson et al stated that there
should be a robust method to see that these objectives
are met in the undergraduate dental program [7]. But
there is no known parameter against which an
undergraduate student can be assessed about their
confidence and preparedness for future independent
restorative clinical practice.
The questionnaire study aimed to enable the dental
undergraduate students or interns to self­assess their
knowledge and skills in terms of their confidence
levels in various aspects of restorative dentistry.
Materials and Methods
A descriptive cross sectional study was conducted
in October 2015 using a self administered
questionnaire after obtaining approval from the
Institutional Ethics Committee (IEC no. 15088).There
was no standardized validated questionnaire
available to assess confidence level in restorative
dentistry; hence a structured questionnaire was
formulated. The clarity of the given questionnaire
had been assessed prior to commencement of the
study, by two experts and corrections were
incorporated. The validity and reliability of the
questionnaire was achieved by pre­testing the
questionnaire on 10 respondents.
After obtaining written informed consent, the
questionnaires were distributed among 293 final
year dental students and interns of two Dental
colleges of Mangaluru. Confidentiality of the
participating dental students and interns was
preserved.
The questionnaire consisted of two parts, the first
section being a series of demographic questions such
as age, gender and whether the participant was a
final year undergraduate student or an intern. The
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
second section consisted of a list of 15 specific aspects
in the discipline of restorative dentistry, each of which
had been assigned a confidence rating by the student.
A Likert’s five point scale was used to assess
confidence with a range from 1 (very little confidence),
2 (little confidence), 3 (neutral), 4 (confident), 5 (very
confident). The 15 aspects could be further grouped
under five sub­headings for analytic purposes namely
diagnosis, pre­operative procedures, operative
procedures, material manipulation and management
of complex situations.The data was coded and
analysed using the SPSS version 20.0. The descriptive
statistics was calculated and Mann Whitney test was
applied to assess the association. The level of statistical
significance was kept at p < 0.05.
Results
The overall response rate was 100%. 51.8% of the
participants were final year students and 48.1% were
interns. The average age of the respondents was 21­
25 years. A score of 3 and below was indicative of
low confidence.
Interns showed generally a higher level of
confidence in almost all aspects of restorative dentistry
except in the domain of management of inadvertent
pulp exposure (2.93 ± 0.97), dealing with medically
compromised patients(2.82±0.95), handling of
medical/dental emergencies(2.57±1.01) (Table 1).
Interns showed significantly higher confidence
as compared to final year students with regard to
clinical diagnosis (p=0.028), especially in the area
of clinical diagnosis of pulpal pathology (p=0.010).
They also showed greater confidence in various
aspects of pre­operative procedures like asepsis,
infection control, isolation and administration of
local anaesthesia (p=0.000). The final year students
showed lower confidence in managing inadvertent
pulp exposure when compared to interns( p=0.003)
but were equally confident in performing other
restorative procedures. Interns showed significantly
greater confidence in handling of restorative
materials like glass ionomer cement (p=0.043) and
resin composite (p=0.000) when compared to students
(Table 1).
There was no significant difference between interns
and final years in the management of medically
compromised patients whereas the confidence levels
was low among both interns and final years in
handling medical/dental emergencies, Overall,
interns exhibited significantly higher confidence
levels (p=0.000) (Table 1).
 Vergis Bettina et. al. / Confidence Level among Undergraduate Dental Cohorts Regarding 159
Restorative Dentistry: A Descriptive Study

Table 1: Confidence levels of Interns, Final year dental students in Restorative Dentistry

Sl. No Procedure Mean ± Standard Deviation P value

Interns Final years

1 Clinical diagnosis of dental caries 3.96 ± 0.76 2.13 ± 0.83 0.300

2 Clinical diagnosis of pulpal pathology 3.27 ± 0.86 2.99 ± 0.94 0.010
3 Intra­oral radiographic interpretation 3.38 ± 0.87 3.19 ± 0.99 0.084
Diagnosis 10.60±2.06 10.04±2.29 0.028
4 Asepsis,infection control 4.07 ± 0.80 3.74 ± 0.87 0.001
5 Isolation 3.87 ± 0.92 3.61 ± 0.92 0.020
6 Administration of local anaesthesia 3.73 ± 0.94 2.35 ± 1.16 0.000
Pre-Operative Procedures 11.66 ± 2.14 9.75 ± 2.23 0.000
7 Tooth preparation 3.52 ± 1.11 3.55 ± 0.95 0.853
8 Caries removal 3.91 ± 0.82 3.81 ± 0.83 0.339
9 Management in case of inadvertent pulp exposure 2.93 ± 0.97 2.57 ± 1.05 0.003
Operative Procedures 10.36 ± 2.28 9.93 ± 2.28 0.111
10 Manipulation of dental cements 3.62 ± 0.89 3.59 ± 0.95 0.776
11 Placement of Amalgam restoration 4.01 ± 0.74 4.03 ± 0.81 0.836
12 Placement of Glass Ionomer Cement restoration 4.02 ± 0.78 3.81 ± 0.94 0.043
13 Placement of Composite restoration 3.77 ± 0.90 2.72 ± 1.29 0.000
Material Manipulation 15.42 ± 2.74 14.19 ± 3.25 0.001
14 Dealing with medically compromised patients 2.82 ± 0.95 2.77 ± 1.12 0.647
15 Handling medical/dental emergencies 2.57 ± 1.01 2.32 ± 1.09 0.047
Complex Situations 5.39 ± 1.80 5.10 ± 2.06 0.217
Cumulative Confidence Level 53.45 ± 8.88 49.05 ± 10.08 0.000

Discussion overcome any deficits in confidence before graduation.

Questionnaires evaluating the knowledge, attitude
and confidence of the students, aid in bridging the
chasm between students and the educationist so as
to overcome the obstacles faced by the students and
improve the standard of education being provided.
Unfortunately, this has not received adequate
attention in the course programme in most dental
institutions [8].
Self­confidence is a psychological character­istic
that reflects a person’s trust in his or her ability to
complete a task effectively and efficiently [9].
Although competence could be more applicable to
the practice of dentistry, the concept of confidence as
a manifestation of competence should not be
trivialized [10]. As Cowpe et al. noted, confidence is
one of the most important characteristics the newly
graduated dentists should develop as they stand at
the threshold of independent practice. Self­confidence
comes from acquiring knowledge and skills through
wide and varied experience. A high confidence level
generally indicates that the student or intern has
successfully worked with a certain number of clinical
cases and gained approval from instructors, which
is a reflection of competence to certain extent.
Moreover, it is highly essential for educators to assess
students’ confidence in every subject. Honey et al.
reported that regular monitoring of the confidence
levels of students in completing clinical tasks could
place the dental institutions in a better position to
Their study indicated that low confidence levels could
reveal inadequacy in qualitative and quantitative
dental training [9]. A questionnaire was used as a
tool in this study to poll students and help in their
self­assessment as well as evaluation of the training
[11].
The present study revealed an improvement in
confidence levels as the years of study progressed.This
was in agreement with the studies done by Murray
et. al and Davey et al. [10,12]. The low confidence
levels exhibited by the final year students in
diagnosis of dental caries and pulpal pathology,
administration of local anaesthesia, placement of
composite restorations was seen to show
improvement among the interns. This could be
attributed to the role of increased clinical experience
and exposure when it comes to putting theory into
practice.
The interns were found lacking in confidence in
the management of inadvertent pulp exposure
probably because of technique sensitivity involved
in pulp capping and the risk of requiring root canal
treatment eventually in case of failure. The interns
also exhibited low confidence levels in management
of medically compromised patients as well as
handling medical/dental emergencies. This could be
due to reduced exposure to such scenarios. This could
also prove to be a valuable pointer indicating the need
for continued education programs so as to better
equip the interns as they near the end of their

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

160 Vergis Bettina et. al. / Confidence Level among Undergraduate Dental Cohorts Regarding
Restorative Dentistry: A Descriptive Study
undergraduate course. Incorporation of the
competency based approach to dental education
where individual student learning curves are allowed
to vary based on practicality could positively boost
the competence as well as the confidence levels of the
graduating dental interns [14].
As earlier stated, this study only assessed the
confidence levels of the interns and final year students.
Similar studies were conducted by Honey et al [1]
and Tanalp et al [5], that evaluated the confidence
level of dental undergraduates rather than the
competence. Khanagar et al said that although self
administered questionnaires have been extensively
employed for data collection about self perceived
dental competencies and confidence levels, a certain
amount of bias could be incorporated due to over­
estimation of one’s own abilities. A more accurate
evaluation of the student competency could be
obtained from a teacher/instructor [13].
This study conducted to assess confidence levels
could be further extended to various streams of
Dentistry and could be coupled with objective tests to
assess the competence levels as well.
Conclusion
Within the limitations of the present study, the
interns showed a greater confidence level regarding
restorative dentistry when compared to the final year
undergraduate students due to increased and varied
clinical exposure.Problem­based approaches as well
specific training in management of complex clinical
situations could be employed to address the deficits
in confidence among graduating interns.
References
1. Honey J, Lynch CD, Burke FM, GilmourASM. Ready
for practice? A study of confidence levels of final year
dental students at Cardiff University and University
College Cork. Eur J Dent Educ. 2011 May;15(2):
98–103.
2. Dimiter Kirov, Stefka Kazakova JK. Students ’ self­
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
assessment in preclinical and clinical education of
prosthetic dentistry. J IMAB. 2014 Jul­Sep;20(3):
575–7.
3. Mattheos. N, Nattestad A, Falk­Nilsson E, Attström
R. The interactive examination: Assessing students’ self­
assessment ability. Med Educ. 2004 Apr;38(4):378–89.
4. Evans AW, Aghabeigil B, Leeson R, Sullivan CO,
Eliahoo J. Original article Are we really as good as we
think we are/ ? Ann R Coll Surg Engl. 2002;84:54–6.
5. Tanalp J, Güven EP, Oktay I. Evaluation of dental
students’ perception and self­confidence levels
regarding endodontic treatment. Eur J Dent. 2013
Apr;7(2):218–24.
6. Dental Council of India. Revised BDS Course
Regulations. 2007.
7. Youngson CC, Molyneux LE, Fox K, Boyle EL, Preston
AJ. Undergraduate requirements in restorative
dentistry in the UK and Ireland. Br Dent J. 2007
Sep;203(5 Suppl):9–14.
8. Awooda EM, Mudathir MS, Mahmoud SA. Confidence
level in performing endodontic treatment among
final year undergraduate dental students from the
University of Medical Science and Technology, Sudan
(2014). Saudi Endod J. 2016;6(1):26–30.
9. Wu J, Feng X, Chen A, Zhang Y, Liu Q, Shao L.
Comparing Integrated and Disciplinary Clinical
Training Patterns for Dental Interns: Advantages,
Disadvantages, and Effect on Students’ Self­
Confidence. J Dent Educ. 2016 Mar;80(3):318–27.
10. Murray CM, Chandler NP. Undergraduate endodontic
teaching in New Zealand/: Students’ experience ,
perceptions and self­confidence levels. Aust Endod J.
2014 Dec;40(3):116–22.
11. Alrahabi M. The confidence of undergraduate dental
students in Saudi Arabia in performing endodontic
treatment. Eur J Dent. 2017 Jan­Mar;11(1):17–21.
12. Davey J, Bryant ST, Dummer PMH. The confidence of
undergraduate dental students when performing root
canal treatment and their perception of the quality of
endodontic education. Eur J Dent Educ. 2015;19:
229–34.
13. Khanagar S, Naganandini S, Naik S, Rajanna V, Rao
R, Reddy S. Self­perceived competency among
postgraduate students of public health dentistry in
India: A cross­sectional survey. J Indian Assoc Public
Health Dent. 2014;12(2):106­12.
Review Article Indian Journal of Dental Education
161
Volume 10 Number 3, July ­ September 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10317.2

The Use of Elastics in Orthodontics

Eltahir H.E.*, Mahmoud N.M.*, Mageet A.O.**

Abstract

The use of elastics in orthodontic treatment is not new, for ages orthodontists used different techniques to
benefit from the unique physical properties of elastics. Keeping with the new industrial developments,
manufacturers developed synthetic elastics with different configurations and superior properties. This review
has been conducted to evaluate the available data regarding the different types of elastics used in orthodontics,
their forces, benefits and drawbacks.
Keywords: Intra­Oral Elastics; Extra­Oral Elastics; Vertical Elastics; Intramaxillary Elastics; Intermaxillary
Elastics.

Introduction malocclusions, they are amorphous polymers made

Elastomer is a general term that encompasses
materials that after substantial deformation, rapidly
return to their original dimensions [21, 36]. Elastics
in dentistry are not a new development. One of the
earliest applications of elastics was to extract teeth in
patients with bleeding disorders (e.g. hemophilia,
purpura), cardiac problems or mental deficiency. The
practitioner simply placed a rubber band around the
tooth to be extracted and waited for about 4­6 weeks
for the surrounding bone and soft tissues of the tooth
to be destroyed by the movement of the band. Currently
this procedure is advocated in patients treated with
bisphosphonates [29].
Elastics are mainly used in orthodontics as an
active component to correct the different types of
Author’s Affiliation: *Orthodontic Resident at Mageet
Orthodontic Training Center, affiliated to University of Gezira,
P.O.Box 13195, Khartoum 11111, Sudan. **Associate Professor
of Orthodontics, Mohammed Bin Rashid University, Hamdan
Bin Mohammed College of Dental Medicine, Orthodontic
Department, Dubai, UAE and Associate Prof Program Director
of Orthodontics, Mageet Orthodontic Training Center, affiliated
to University of Gezira, Khartoum, Sudan.
Reprints Requests: Mageet A.O., Mohammed Bin Rashid
University, Hamdan bin Mohammed College of Dental
Medicine, Dubai Healthcare City P.O.Box 505097 Dubai.
United Arab Emirates.
E­mail: adil.mageet@MBRU.ac.ae,
amageet2000@yahoo.co.uk
Received on 01.07.2017, Accepted on 17.07.2017
Indian
© JournalPublication
Red Flower of Dental Pvt.
Education,
Ltd Volume 10 Number 3, July ­ September 2017
of polyurethane material that has the characteristics
of rubber and plastic [2].
Elastics used in orthodontic treatment are either
natural or synthetic. Naturally produced latex elastics
are used in the Begg mechanics to provide
intermaxillary traction and forces [8]. Synthetic
elsastomeric materials in the form of chains find their
greatest application with edgewise mechanics where
they are used to move the teeth along the arch wire.
This differs from the latex elastics which are changed
by the patient daily [6].
History
A French man JMA Strange in 1841 claimed that
he used a rubber attached to some hooks on the
appliance surrounding the molars for retention. In
1843 – Dr. Edward Maynard was the first dentist to
use gum elastics as a technique used to correct
improper jaw alignment. An elastic material would
be connected to wiring in the mouth to slowly move
the jaw until it was in proper alignment. E.J. Tucker
in 1850 elaborated Dr. Maynard‘s idea of using gum
elastics to correct jaw alignment. Tucker took rubber
tubing, and cut it into small bands that could
comfortably fit into the mouth. In 1892 – Henry A.
Baker was the first to combine many of the concepts
used by previous dentists into one orthodontic
treatment. Baker devised the method known as the
“Baker anchorage.” Baker anchorage combines the
162 Eltahir H.E. et. al. / The Use of Elastics in Orthodontics
rubber tubing discovered by E.J. Tucker, with the wire
crib. This technique eliminated the need to completely
remove numerous teeth to help correct their
alignment [5].
The latex elastics have become an integral part of
orthodontics after Calvin S. Case discussed the use of
intermaxillary elastics in 1893 at the Columbian dental
congress but the credit goes to Henry A. Baker. Angle
described the technique before the New York institute
[24, 33]. In 1958 Fred Shudy recommended short class
II elastics in association with a high pull anterior extra
oral force in order to control vertical cases. Jarabak J in
1963 described the biomechanics of class II elastics for
the first time. In 1965 Raymond Begg used class II
elastics which were changed every 5 days.
Ricketts RM in 1970 originated the bioprogressive
segmental light square wire technique advising the
use of elastics in closing open bites. Roth R in 1972
recommended short class II elastics to help the curve
of Spee leveling. In 1996 Micheal Langlade developed
the clinical applications of elastic forces in different
situations such as occlusal elastics, crossbite elastics,
and proposing biomechanical comparisons in
clinical uses [22].
The elastic bands are either natural or synthetic.
Initially the elastic bands were made from natural
rubber which is known to absorb water and its
elasticity deteriorates quickly, later the early European
explorers came to Central and South America, they
saw the Incans playing with bouncing balls made of
rubber. The rubber tree was called “Cahuchu”,
weeping wood. The drops of latex oozing from the
bark of the tree made them think of big white tears
this is known as “Hevea brasiliensis”, this has been
used by the ancient Incan and Mayan civilization. It
is purified and mixed with gum, ammonia,
antioxidants, and antiozone agents and then further
processed for various uses [6,22,19].
Synthetic rubbers are chemical materials intended
as substitutes for natural rubber. These were
introduced in the 1960s ad have become an integral
part of the orthodontic materials [19]. Synthetic rubbers
are grouped into two classes: General­purpose and
special purpose. The general purpose include the
Styrene­butadiene rubber (SBR) which is made from
petroleum, and the special purpose include butyl
rubber, nitrile rubber, polysulphide rubbers,
polyurethane rubbers and many more. These are better
than natural and SB rubbers, as they have the ability to
resist harmful elements including heat and cold [39].
Properties of Elastics
The natural or tree rubber is a hydrocarbon
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
polymer of approximately 500 isoprene units. This
structure varies in molecular weight depending on
the plant, region and season. The most useful property
of natural latex rubber is its resiliency. High quality
latex more or less retains its resilience in water and
under optimal conditions. The most significant
limitation of natural latex is its enormous sensitivity
to ozone layers and UV light. These elements weaken
the latex polymer chain [39].
Most of the elastics currently used in orthodontics
are made of polyurethane. The synthetic elastics are
made of elastic polymer which has urethane linkage
and are synthesized by extending polyester or a
polyether glycol with a di­isocyanide. Polyurethane
rubbers resist heat and withstand remarkable stress
and pressure. However they tend to permanently
distort, following long periods of time in the mouth.
The major force decay occurs within the first 24 hours
of their use in the mouth [19,39].
Synthetic polymers are very sensitive to the effects
of free radical generating systems, notably, ozone and
UV light, the exposure to these elements results in
decrease in the flexibility and tensile strength of the
polymer. Thus, manufacturers have added
antioxidants and antiozone agents to overcome this
[39].
Elastics are active components of orthodontic
appliances. Due to their property of resiliency is used
to generate continuous force to be applied on teeth to
achieve tooth movement [39]. Their use combined with
good patient cooperation allows the clinician to
correct vertical, horizontal and transverse occlusal
discrepancies.
Orthodontic Elastics are
Elastic bands; elastic chains (power chains); elastic
ligatures (modules); elastic thread, tubes, sleeves and
separators.
1. Elastic Bands
Elastic bands are manufactured by slicing rubber
tubes of different lumen and wall thickness. The lumen
of the band and its wall thickness determine the force
value when stretched. Within each size of lumen
existing there is three types of bands light, medium
and heavy [19]. Classification is given in Table 1.
According to lumen size: The lumen of the elastic
band is usually expressed in parts of an inch. For
example; a 3/8 inches rubber band means that the
lumen of the band in three parts of the eight parts of
an inch [19].
 Eltahir H.E. et. al. / The Use of Elastics in Orthodontics
Table 1: Classification of elastic bands used in orthodontics
1. According to lumen size:
 1/8”; 3/8; 5/8”; 3/16”; 1/4”; 5/16”; 1/2”
2. According to force value
 Light 2 - 3½ oz; Medium 4½ - 5 oz; Heavy 6 - 8 oz
(These vary according to manufacturer. Force is measured when elastics are stretched three times their diameter).
3. According to color
4. According to use
a. Extra oral (used for face mask)
b. Intra oral
I. Intramaxillary elastics (Class I elastics)
II. Intermaxillary elastics (Class II, Class III, crossbite elastics and openbite elastics)
According to force value / tube thickness: Elastics are
made of rubber tubing of different thickness, mainly
three types: thin, medium and thick that determine
whether the elastic is light, medium or heavy in terms
of force value [19].
According to color: Different manufacturers use
different color­coding and names for different elastic
band size and force.
According to the use
Extra-Oral Elastics: These type of elastic are used
with the face mask for the correction of skeletal Class
III malocclusion to aid in maxillary protrusion in
cases where there is maxillary retrognathia (Class III
type I) skeletal relationship [25]. Types and force used:
¼ elastics 16 or 32 oz (Figure 1).
Intra Oral Elastics
Used intra orally and attached to bracket hooks,
buccal tube hooks, arch wire with anterior loop,
sliding hooks, Kobayashi ligature tie, sliding jig or
temporary anchorage devices, these are divided into
two:
• Intramaxillary Elastics
Class I Elastics or horizontal elastics placed
anteroposterior in the same side of the same arch.
Used for anterior segment retraction; space closure
within an arch; extrusion; intrusion; tipping
correction; rotation and midline shift correction. Could
also be used with removable appliance to retract
anterior segment here the elastic band is attached in
the hook of the left and right to the upper canine and
pass labial to the upper anterior teeth to push them
backward (Figure 2, A).
• Intermaxillary elastics: Intra­oral elastics placed
in both arches, classified into Class II and III:
Class II Elastics are intermaxillary elastics placed
anteriorly in the maxillary arch and posteriorly in
the mandibular arch. Uses: Skeletal and/or dental
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
163
Class II malocclusion; anchorage reinforcement;
backward movement of the upper incisors;
mandibular arch advancement and bite opening Class
II elastics can also be used to burn mandibular
anchorage for the activation of mandibular closing
loops [1]. In this case the force used is ¼ inch; 6 oz.
worn for a continuous 72 hours, followed by night
time only. The current literature suggests using light
forces obtained with a 3/16­inch diameter [17, 9]
Forces suggested were (1­2 [27, 26], 2.5 [30], 3.5 [34],
and 4 oz [9].) with a mean of 2.6 oz.
Clinical Problems with Class II Elastics: should not
be used with light wires that cannot control torque,
because they may cause: Flaring of the mandibular
anterior teeth; lingual tipping of the maxillary anterior
teeth; mandibular molar extrusion; alteration of the
occlusal plane and increase lower facial height. Class
II elastics are to be avoided in cases with anterior
open bite. There is a 20­25% decrease in the force
applied for the 24 hour period, whereas most of the
relaxation was shown to occur within the first 3­5
hours, after extension, regardless of size,
manufacturer or force level of the elastic [15]. To
minimize relaxation, patients may be instructed to
change elastics twice daily (Figure 2, B).
Class III Elastics: They are intermaxillary elastics
placed posteriorly on the maxillary arch and
anteriorly in the mandibular arch. Indicated to correct
Class II malocclusion; prevent advancement of the
mandibular anterior teeth in a crowded non­extraction
cases and deep bite cases with crowding. Indicated
forces are 3/16 inch 4 oz., 6 oz. and 8 oz. elastics [16].
Using excessive forces with Class III elastics may
cause periodontal problems, lingual tipping or
extrusion of lower incisors using light archwires and
extrusion of upper posterior teeth (Figure 2, C).
Open Bite Correction Elastics
Used for the correction of open bite up to 2 mm.
They can be in the shape of a box, triangle, ‘M’ or ‘W’,
‘V’ and reverse ‘V’ shape plus any vertical
164 Eltahir H.E. et. al. / The Use of Elastics in Orthodontics
configurations.
Box elastics: Have a box shape configuration and
can be used in a variety of situations to promote tooth
extrusion and improve intercuspation. Most
commonly include upper lateral incisors and lower
canines, upper canines and lower first premolars
(Class II) or lower canine to upper premolars, lower
lateral incisors to upper canines (Class III). Elastics
prescribed are ¼ (4.5 ­5 oz). Can also be applied to all
bicuspids for their extrusion in lateral open bites, with
3/16 (4.5­6 oz) elastics (Fig. 3, A and B).
Triangular Elastics or V Shape Elastics: These elastics
have a vertical component of extrusion. Indications:
Increase over bite of cuspids by 0.5­1.5 mm. Extended
from upper cuspid to lower cuspid and bicuspid.Can
be worn to bring a tooth on the occlusal plane in a ‘V’
or reverse ‘V’ shape according to the clinical need
(Figure 3, C and D). Triangular elastics are 1/8 (2.5 ­
4.5 oz).
The ‘M’ or ‘W’ Elastics: These are used for extruding
a group of teeth in order to establish a good
intercuspation [3,1]. The configuration for Class II
malocclusion is a ‘W’ shape with a tail. The
configuration for Class III malocclusion is an ‘M’
shape with a tail. In case of a Class I malocclusion,
the configuration is an M­1/2 shape (Figure 3, E and
F). The force recommended is ¾ (2.5­4.5 oz).
Vertical Elastics: Used when there is difficulty in
closing the open bite, whether anteriorly or posteriorly.
Contraindicated in malocclusions that were originally
characterized by deep bite. Have a tendency to narrow
the transversal dimension (Figure 4 A).
Midline Elastics (Alexander): Used to correct small
midline discrepancies. Forces used are 1/4"(6 oz).
Applied from maxillary canine over midline
diagonally to the contralateral canine. Can be used
with Class II and Class III elastics (may cause a cant
of occlusal plane). Worn full time except when eating
(Figure 4 B).
Crossbite Elastics: Indicated in unilateral or bilateral
cross bites, to expand and upright upper molars,
which have tipped palatally. Two types: Homolateral:
Applied to the buccal surface of one molar to the
lingual surface of the opposing molar. Bands applied
are 3/16" elastics 6 oz to be worn 24 hours per day. It
is to be avoided in open bite cases [1]. Contralateral:
Intermaxillary elastics placed on opposite sides of
the two dental arches, e.g. from the left upper molar
palatally to the right lower molar buccally (Figure 5
A and B). Useful in correcting posterior unilateral
crossbite [22].
Elastic bands storage and dispensing: Elastics should
be stored away from moist, heat and ozone or other
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
free radical generating systems such as sunlight or
ultra violet light that produce cracks, to avoid the
loss of their properties. One of the manifestations of
ozone on elastic bands is the reduced force value,
which may be seen after a short period of time after
manufacture. Therefore, manufacturers dispense
elastics bands in sealable opaque pouches to prolong
their shelf life. A new pouch of elastics should be
dispensed and the ones with reputed manufacturing
companies are more reliable in force delivery and
force degradation in the oral environment.
Manufacturers also follow a coding system to denote
different elastics; this helps the patient to be more
interested in the treatment and helps the staff in
differentiating between different types of elastic bands
and their uses [19,39]. For the ease of application by
the patient a special key is dispensed to the patient
(Fig. 6).
2. Elastic Chains (Power Chains)
After their introduction to the dental profession in
the 1960s, they have become an integral part of fixed
appliance orthodontic treatment [6]. Available in all
colors, and in three configurations according to the
length of the filament, these are closed, short and long
filaments (Figure 7B). The configuration of the chain
appears to affect the behavior of elastomeric chains
[6, 4,40,10,37]. Generally the longer filament chains
will deliver a lower initial force at the same extension
and exhibit a greater rate of force decay under load
than the closed loop chain.
Power chains are dispensed as long chains rolled
in an easy to handle spool. These should not be used
directly in mouth from spool, which results in its
contamination with saliva [11]. They are also
available in the form of small pieces of two or more
modules with variable filament lengths to
accommodate space closure in small segments [19].
Used to generate light continuous forces for [6,19]:
Canine retraction; Diastema closure; rotational
correction; extraction space closure; arch consolidation
and selective shift of the midline (Figure 7 A and B).
Force delivery and force degradation
During the first day of loading in the mouth most
chains lose 50­70% of their initial force, and at three
weeks they retain only 30­40% of the original force
[6,3,2]. It would also greatly depend on the
manufacturer, storage conditions and age of the
product. The prudent clinician should use a force
gauge to determine the desired initial force [6].
Pre-Stretching Effects
Wong AK recommended chain pre­stretching up
to one third of their original length to stress the
 Eltahir H.E. et. al. / The Use of Elastics in Orthodontics
molecular polymer chain [39]. Pre­stretching is
expected to give more stable force and prevent rapid
force decay. 100% pre­stretching of the chains original
length 10 seconds before loading resulted in clinically
insignificant improvement in force decay [38].
However the clinical value of pre­stretching is
questionable [6, 20].
Environmental Effects
The alkaline pH of saliva has a slightly deleterious
effect on the force decay of chains while the acidic pH
of plaque exhibited substantial less force decay [13].
The immersion of power chains in alkaline
glutaraldehyde solution for the purpose of
disinfection does not affect their properties [18].
Intraorally elastics are exposed to enzymatic
degradation, temperature relaxation and lipid
absorption, which induce plasticizing effects.
Therefore either clinicians should shorten the period
between appointments or use steel ligatures while
such mechanics are in place [6].
Elastic Chains vs. Coil Springs
Andrew L. Sonis in 1994 conducted a study on Ni­
Ti coil springs and elastics he found the following:
Ni­Ti coil springs showed the ability to produce
constant force over longer periods of time. Ni­Ti coil
springs produced nearly two times faster tooth
movement than elastics. No patient cooperation
needed and coil springs can stretch 500% more
without permanent deformation [31].
3. Elastic Ligatures (Modules / ‘O’ ring)
Modules are small ring elastics used to secure the
arch wires to the orthodontic bracket. They are
manufactured in two ways: injection molded and cut.
The injection molded ligature is made by injection of
liquefied elastomeric material into a mold and curing,
whereas the cut ligature is sliced from previously
processed elastomeric tubing [23]. They are available
in different colors to keep patients motivated (Figure
8, A and B).
They have highly replaced steel ligatures because:
They are easy to place and remove; save chair side
time; patient comfort; less traumatic force; smooth
borders that do not cause soft tissue irritation; long
lasting arch wire seating (six weeks) [19].
Disadvantages: Absorb water and odors [19];
discoloration and staining with certain foods [14];
microbial accumulation [33]; poor control during
torque and rotation correction; binding may occur
with sliding mechanics [23, 7, 11, 28].
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
165
Elastic Ligatures vs. Wire Ligatures
Rotation and torque control require high force
levels that elastic ligatures cannot provide [14]. Wire
ligatures provide complete wire engagement into the
bracket slot allowing complete prescription
expression. Wire ligatures strength provide close wire
placement in the slot, transferring elastic force from
the arch wire to tooth. Elastic ligatures exhibit a
greater number of micro­organisms in plaque than
wire ligatures [33].
4. Elastic Thread and Tube (Sleeves)
Available as a round thread, with a smooth non­
porous surface made of silk or nylon. It exerts light,
continuous, long lasting, predictable force. Used to
correct of rotations, traction of surgically exposed
impacted teeth, minor space closure and numerous
other intraoral applications with both fixed and
removable appliances [19].
Elastic tubing is similar to thread but with a
hollow core, which collapses when tied, resulting
in tighter knots, that will not slip (Figure 9 A and B).
Recently rectangular thread has been introduced
whose knot does not loosen unlike round thread.
Used initially to cover thin arch wires in an area
where there is unerupted or missing teeth or in 2 x 4
cases. It is changed to coil spring when advance to
stiff wires. Advantages: prevent irritation to the
cheeks and lips.
5. Elastic Separators)
These are ring shaped elastics (Figure 10 A), which
are placed around the contact points of teeth for a
short period of time, no longer than two weeks [35], to
slightly separate the teeth, to ease the placement of
the molar bands. They can be placed using separator
dental pliers or dental floss.
Elastic separators can slip into the gingival
crevicular sulcus causing significant bone loss and
tooth mobility [19,41] and because they are
radiolucent it is wise to use bright colors to make a
displaced elastic visible [28].
They can also be used to dislodge an impacted
maxillary first molar by wedging the separator
mesially to the first molar pushing it distally allowing
it to erupt. But they are not recommended because
they are difficult to place under the contact of the
impacted molar and they have the potential to
dislodge apically causing periodontal irritation [28].
For ease of placement separating pliers are used
(Fig. 10 B).
166 Eltahir H.E. et. al. / The Use of Elastics in Orthodontics

Fig. 1: Heavy force elastic bands with face mask

Fig. 2: Class I (A), ClassII (B), Class III (C)

Fig. 3: Open bite correction elastics

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

 Eltahir H.E. et. al. / The Use of Elastics in Orthodontics 167

Fig. 4: Vertical Elastics (A) and midline elastics (B)

Fig. 5: Cross elastics (A) Homolateral, (B) Contraleteral Fig. 6: Elastic hooks

Fig. 7: Power chains in position (A), types of power chains (B)

Fig. 8: Modules (A), figure eight module (B)

Fig. 9: Elastic thread and tube (sleeve) Fig. 10: Separators (A), placement of separator (B)

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

168 Eltahir H.E. et. al. / The Use of Elastics in Orthodontics
Natural Latex Drawbacks
Latex allergy: Is a medical term encompassing a
range of allergic reactions to the proteins present in
natural rubber latex [39]. It develops after repeated
exposure to latex containing products. The amount
of latex exposure needed to produce sensitization is
unknown. Development of stomatitis with acute
swellings and erythematous buccal lesions to the use
of orthodontic elastics have been reported [19].
Orthodontic companies are marketing non­latex
orthodontic elastics as the incidence of latex allergy
continuous to rise and the use of non­latex orthodontic
elastics increases, however, the mechanical properties
of non­latex elastics cannot be assumed to be­and
indeed are not­the same as those of latex elastics [17].
Cytotoxicity: Preservatives present in rubber bands
may cause cytotoxicity to the gingival tissues [9].
Accelerating agents used in vulcanization and
nitrosunstable amines present in rubber exposed to
saliva are known to have the potential for nitrosamine
formation [27].
Missing rubber bands and bone loss: Orthodontic
rubber bands if not securely anchored to the
orthodontic appliance hooks may slip into the
gingival sulcus, causing pain, bone loss and tooth
mobility. Thorough instructions in their placement
and removal given to the patient can minimize such
accidents. Since elastic bands are radiolucent it is
wise to use bright colors to facilitate locating the
misplaced rubber band [26, 30, 34].
Latex staining: Yellowish color change in
orthodontic elastics compromise esthetics. Significant
changes in color were found following exposure to
different colored beverages and spices, color changes
were most significant in clear modules, and spice mix
had the most effect and cola beverage the least [15].
Lew K in 2009 found that coffee and tea beverages
produced rapid staining within only 6 hours,
chocolate beverages, red wine and tomato ketchup
caused gradual staining, while cola drinks did not
cause stains even after 72 hours [16].
Conclusion
• Detailed medical history including latex allergies
should be taken.
• Avoid Class II elastics in high angle cases.
• Select the type of elastics and place of attachment
carefully.
• If you are afraid to cause undesirable movement
of the anchor unit, consider using temporary
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
anchorage devices.
• If latex allergy developed during treatment,
discontinue and use non latex elastics.
• Inform the patients about the clear elastics staining
and you could use the colored ones.
• Advised to use light force in non­extraction cases
and medium to heavy for extraction cases.
Recommendations
More studies are needed, as the literature is
confusing regarding the force level of the elastic
needed to generate the desired tooth movement.
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Review
170 Article Indian Journal of Dental Education
Volume 10 Number 3, July ­ September 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10317.3

Enamel and Dentin Adhesion Differences

Prashanth Kumar Katta

Abstract

The bond strength of composite to enamel depends upon the depth the degree of demineralization, the
number and length of resin tags and their surface area. Although both dentin and enamel are different in many
aspects both equally contribute to the success of composite restoration. This article highlights the differences
in bonding mechanism to enamel and dentin and their significance.
Keywords: Enamel; Bonding; Dentin; Hybrid Layer; Resin Tags.

Introduction microstructure of both the hard tissues is totally

different. Only thing that is common to both is
hydroxyapetite crystals. Studies have sown that bond
Bonding of composite to tooth structure depends strength to enamel is more than dentin.
on both enamel and dentin but the composition and

Enamel and Dentin Properties [1]

Enamel Dentin

96% inorganics, the rest are water and organics
65%–70% minerals, the rest are organics
The maximum hardness (3.5 GPa) of enamel is located on the
surface, and the hardness decreases gradually with increasing
depth, whereas the enamel maintains a stable hardness of 2–2.5
GPa at a distance of 100–600 mm from the dentin enamel junction
(DEJ)
Inert, high­energy crystalline structure with high intermolecular
forces has been called a composite bioceramic 2.
Effective micromechanical bond of 20 MPa or more between resin
and tooth enamel3.
65%–70% minerals, the rest are organics
Dentina ltubule, peritubular dentin, intertubular
dentin
The factors influencing the dentinal mechanical
properties include the location, density and
direction of the dentinal tubules; the direction of
the collagen fibres; and the average density of the
mineral phase.
Highly mineralized peritubular dentin has a
Young’s modulus of 40–42 GPa, whereas weakly
mineralized intertubular dentin has a Young’s
modulus of 17 GPa

Resin Tags and its Surface Area as it Goes Deeper

Author’s Affiliation: Assistant Professor, Department of
Restorative Dental Sciences, Al Farabi Dental College, Jeddah,
Kingdom of Saudi Arabia.
Reprints Requests: Prashanth Kumar Katta, #33,
Mathrusai, Muneswara Nagar, 17th Cross, Ullal Main Road,
Bangalore 560056.
Email: drprashanthmds@gmail.com
Received on 17.04.2017, Accepted on 09.05.2017
Resin tags have been reported as penetrating up to
100 µm into etched enamel [4]. Resin penetration into
tubules can effectively seal the tubules and can
contribute to bond strength if the resin bonds to the
tubule wall. Resin infiltration into intertubular dentin
can only occur if the mineral phase of dentin is
removed by acidic conditioners or chelators [5]. Most
bonding systems use acidic conditioners designed to

© Red Flower Publication Pvt. Ltd Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
 Prashanth Kumar Katta / Enamel and Dentin Adhesion Differences
remove the smear layer and demineralize the dentin
surface. It would seem desirable to reduce the acid
concentration and/or application time to the
minimum required to obtain maximum bond
strengths and minimum microleakage [6].
Smear Layer
Smear layers are created on hard tissues whenever
they are cut with hand or rotary instruments. This
thin (1­2 microns) layer of denatured cutting debris is
very tenacious and, in fact, is often the surface to which
restorative materials are luted [5]. The exact
composition of smear layer has not been determined.
It is believed to contain thin particles of inorganic
material and organic elements. The thickness and
morphology of the smear layer probably varies with
the method used for producing the smear layer and
with the location within dentin in relation to the pulp.
Researchers have examined light­microscopically
smear layers generated by diamond burs with
different grain size and by silicon carbide (SiC) papers
with varying grit numbers. They concluded that the
smear layer’s thickness increases with increasing
roughness of the diamond bur or SiC paper. A regular
grit bur with a grain size of 100 µm (ISO number
806314141504014), often used in clinical cavity
preparations, creates a smear layer of 2.2 ± 0.5 µm [7].
Hybrid Layer
Application of the acid etchant leads to
demineralization of the enamel and dentin which gets
filled with hydrophilic monomers, and application
of the hydrophobic resin completely fills the
intercollagenous pores. This resultant layer is called
hybrid layer [9].
Acid etching removes approximately 10 µm of
enamel surface and creates a morphologically porous
layer (5 µm to 50 µm deep) [10].
Demineralized dentin matrix can shrink upto 65%
in volume because of collapse of collagen.
Micro­Raman spectroscopy revealed that dentine
demineralisation with phosphoric acid extends
beyond 10 µm whereas subsequently applied
adhesive resin is only able to penetrate the acid etched
dentine up to 8­10 µm. Furthermore, this technique
showed that the amount of adhesive resin gradually
decreases with depth within the hybrid layer [11].
Total Etching Strategy. The total­etching systems
require a conditioning, a rinsing and a priming step
in order to allow involvement of collagen fibers by
the resin monomers and the formation of the so­called
‘hybrid layer’ (Carvalho et al.). Demineralization of
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
171
intertubular dentin and maintenance of interfibrillar
porosities are required for adequate monomer
penetration into the conditioned dentin [12].
Wetting Agents
If the surface must be dried—eg, to check the enamel
etch—it should be remoistened. Various materials
have been tested as rewetting agents, including water,
which does not rewet the surface rapidly. Better
alternatives are aqueous solutions of HEMA such as
Aqua­Prep (Bisco, Inc.) or Gluma Desensitizer
(Heraeus Kulzer) [12,13]. The latter also contains
glutaraldehyde, which might stabilize the collagen
layer, thus facilitating resin penetration [13].
Factors that govern the adhesion
1. Composition of the bonding agent, whether its
ethanol based or acetone based
2. Status of the tooth. Prepared or unprepared
enamel, healthy dentin or sclerotic dentin, young
tooth or old tooth.
3. Surface area of enamel and dentin available for
bonding
4. Technique of etching (active or passive)
Conclusion
The bonding of composite to tooth structure is
micromechanical. The properties of enamel and
dentin are very important factor that governs the
success of bonding. The better we understand these
concepts the better we do the restorative procedure
by selecting the best restorative material available in
the market.
Conflict of Interest: None
Source of funding: Self
Acknowledgements
None
Ethical clearance: Not applicable
References
1. Ya­Rong Zhang*, Wen Du*, Xue­Dong Zhou and Hai­
Yang Yu, Review of research on the mechanical
properties of the human tooth, International Journal
of Oral Science 2014;6:61–69.
172 Prashanth Kumar Katta / Enamel and Dentin Adhesion Differences
2. White SN, Luo W, Paine ML, et al. Biological
organization of hydroxyapatite crystallites into a
fibrous continuum toughens and controls anisotropy
in human enamel. J Dent Res. 2001;80:321­326.
3. Anusavice KJ. Structure of matter and principles of
adhesion. In: Phillips’ Science of Dental Materials. 10th
ed. Philadelphia, PA: W.B. Saunders Company; 1996.
4. Pashley DH1. Smear layer: overview of structure and
function. Proc Finn Dent Soc. 1992;88 Suppl 1:215­24.
5. Pashley DH 1 , Ciucchi B, Sano H, Horner JA.
Permeability of dentin to adhesive agents.
Quintessence Int. 1993 Sep;24(9):618­31.
6. Pashley DH1, Horner JA, Brewer PD. Interactions of
conditioners on the dentin surface. Oper
Dent. 1992;Suppl 5:137­50.
7. Tani C, Finger W. Effect of smear layer thickness on
bond strength mediated by three all­in­one self­
etching priming adhesives. J Adhes Dent 2002;4:
283–289.
8. Van Meerbeek B1, Yoshihara K, Yoshida Y, Mine A, De
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
Munck J, Van Landuyt KL.State of the art of self­etch
adhesives. Dent Mater. 2011 Jan;27(1):17­28. 
9. Gwinnett AJ. Histologic changes in human enamel
following treatment with acidic adhesive
conditioning agents. Arch Oral Biol. 1971;16:731­738.
10. Santini A, Miletic V. Comparison of the hybrid layer
formed by Silorane adhesive, one­step self­etch and
etch and rinse systems using confocal micro­Raman
spectroscopy and SEM. Journal of Dentistry
2008;36:683­91.
11. De Freitas B.M.; Diesel, G. P.; Correa, G. F.; Bernardi,
E.; Fernandes M.A.; Skupien, J.A. & Susin, A. H.
Reflections about adhesive systems. Int. J.
Odontostomat., 2010;4(1):47­52.
12. Gwinnett AJ. Dentin bond strength after air drying
and re­wetting. Am J Dent. 1994;7:144­148.
13. Ritter AV, Heymann HO, Swift EJ, Perdigão J, Rosa
BT. Effects of different rewetting techniques on dentin
shear bond strengths. J Esthet Dent. 2000;12:85­96.
Review Article Indian Journal of Dental Education
173
Volume 10 Number 3, July ­ September 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10317.4

Supernumerary Teeth: A Literature Review

Mounabati Mohapatra*, Priyanka Sarangi**, Sukanta Satapathy***

Abstract

Most supernumerary teeth are located in the anterior maxillary region. They are classified according to their
form and location. Their presence may give rise to a variety of clinical problems. Detection of supernumerary
teeth is best achieved by thorough clinical and radiographic examination. Their management should form
part of a comprehensive treatment plan.
Keywords: Supernumerary Teeth; Supplemental Teeth.

Introduction deciduous dentition with a reported incidence of 0.3

Supernumerary teeth may be defined as any teeth
or tooth substance in excess of the usual configuration
of twenty deciduous, and thirty­two permanent teeth
[1]. Such a surplus can also be accompanied by a
deficit of other teeth. For example, thirty­two
permanent teeth may be present with five lower
incisors and only three lower premolars.
Supernumerary teeth may occur singly, multiply,
unilaterally or bilaterally, and in one or both jaws.
Cases involving one or two supernumerary teeth
most commonly involve the anterior maxilla, followed
by the mandibular premolar region [2]. When multiple
supernumerary teeth are present (>five), the most
common site affected is the mandibular premolar
region [3]. Single supernumeraries occur in 76 to 86
percent of cases, double supernumeraries in 12 to 23
percent of cases, and multiple supernumeraries in
less than 1 per cent of cases [4].
Supernumerary teeth are less common in the
Author’s Affiliation: *HOD, Dept of Dental Surgery, All
India Institute of Medical Sciences (AIIMS), Bhubanewar –
751019, Odisha. **Assistant Professor, Department of
Conservative Dentistry and Endodontics *** Senior Resident,
Department of Prosthodontics, SCB Dental college and
Hospital,  Cuttack, Odisha 753007.
Reprints Requests: Mounabati Mohapatra, HOD, Dept
of Dental Surgery, All India Institute of Medical Sciences
(AIIMS), Bhubanewar – 751019, Odisha.
E­mail: mounabatimohapatra@gmail.com
Received on 15.07.2017, Accepted on 16.08.2017
per cent to 1.7 per cent of the population [7]. Possible
explanations for the less frequent reporting of
deciduous supernumerary teeth include less
detection by parents, as the spacing frequently
encountered in the deciduous dentition may be
utilized to allow the supernumerary tooth or teeth to
erupt with reasonable alignment. Also, many children
have an initial dental examination following eruption
of the permanent anterior teeth so anterior deciduous
supernumerary teeth which have erupted and
exfoliated normally would not be detected [7].
Sexual dimorphism is reported by most authors
[2,5,8] with males being more commonly affected.
Mitchell [2] suggested no difference with the sex
distribution in cases with deciduous
supernumeraries, but a 2:1 ratio in favour of males in
cases exhibiting permanent super­numerary teeth.
Hogstrum and Andersson [9] also reported a 2:1 ratio
of sex distribution while Luten [5] found a sex
distribution of 1.3:1. A study of super­numerary teeth
in Asian school children found a greater male to
female distribution of 5.5:1 for Japanese, and 6.5:1 for
Hong Kong children [4].
Definition
A supernumerary tooth is one that is additional to
the normal series and can be found in almost any
region of the dental arch.
Etiology
The etiology of supernumerary teeth is not

Indian
© JournalPublication
Red Flower of Dental Pvt.
Education,
Ltd Volume 10 Number 3, July ­ September 2017
174 Mounabati Mohapatra et .al. / Supernumerary Teeth: A Literature Review
completely understood. Various theories exist for the
different types of supernumerary. One theory suggests
that the supernumerary tooth is created as a result of
a dichotomy of the tooth bud [1]. Another theory, well
supported in the literature, is the hyperactivity theory,
which suggests that supernumeraries are formed as
a result of local, independent, conditioned
hyperactivity of the dental lamina [1,2]. Heredity may
also play a role in the occurrence of this anomaly, as
supernumeraries are more common in the relatives of
affected children than in the general population.
However, the anomaly does not follow a simple
Mendelian pattern.
Prevalence
In a survey of 2,000 schoolchildren, Brook found
that supernumerary teeth were present in 0.8% of
primary dentitions and in 2.1% of permanent
dentitions [3]. Occurrence may be single or multiple,
unilateral or bilateral, erupted or impacted, and in
one or both jaws. Multiple supernumerary teeth are
rare in individuals with no other associated diseases
or syndromes [4]. The conditions commonly
associated with an increased prevalence of
supernumerary teeth include cleft lip and palate,
cleidocranial dysplasia (Figure 1), and Gardner
syndrome.
Supernumerary teeth associated with cleft lip and
palate result from fragmentation of the dental lamina
during cleft formation. The frequency of
supernumerary permanent teeth in the cleft area in
children with unilateral cleft lip or palate or both was
found to be 22.2% [5]. The frequency of supernumeraries
in patients with cleidocranial dysplasia ranged from
22% in the maxillary incisor region to 5% in the molar
region [6]. While there is no significant sex
distribution in primary supernumerary teeth, males
are affected approximately twice as frequently as
females in the permanent dentition [5].
Classification
Supernumerary teeth are classified according to
morphology and location (Table 1). In the primary
dentition, morphology is usually normal or conical.
There is a greater variety of forms presenting in the
permanent dentition. Four different morphological
types of supernumerary teeth have been described
[8,9]:
• Conical
• Tuberculate
• Supplemental and
• Odontome
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
Conical
This small peg­shaped conical tooth is the
supernumerary most commonly found in the
permanent dentition. It develops with root formation
ahead of or at an equivalent stage to that of permanent
incisors and usually presents as a mesiodens. It may
occasionally be found high and inverted into the
palate or in a horizontal position. In most cases,
however, the long axis of the tooth is normally
inclined. The conical supernumerary can result in
rotation or displacement of the permanent incisor,
but rarely delays eruption [10].
Tuberculate
The tuberculate type of supernumerary possesses
more than one cusp or tubercle. It is frequently
described as barrel­shaped and may be invaginated.
Root formation is delayed compared to that of the
permanent incisors. Tuberculate supernumeraries are
often paired and are commonly located on the palatal
aspect of the central incisors. They rarely erupt and
are frequently associated with delayed eruption of
the incisors.
Supplemental
The supplemental supernumerary refers to a
duplication of teeth in the normal series and is found
at the end of a tooth series (Figure 5). The most
common supplemental tooth is the permanent
maxillary lateral incisor, but supplemental
premolarsand molars also occur. The majority of
supernumeraries found in the primary dentition are
of the supplemental type and seldom remain
impacted.
Odontoma
Howardlists odontoma as the fourth category of
supernumerary tooth [1]. However, this category is
not universally accepted. The term “odontoma” refers
to any tumor of odontogenic origin. Most authorities,
however, accept the view that the odontoma
represents a hamartomatous malformation rather
than a neoplasm. The lesion is composed of more
than one type of tissue and consequently has been
called a composite odontoma [12]. Two separate types
have been described: the diffuse mass of dental tissue
which is totally disorganized is known as a complex
composite odontoma (Figure 6), whereas the
malformation which bears some superficial
anatomical similarity to a normal tooth is referred to
as a compound composite odontoma.
 Mounabati Mohapatra et .al. / Supernumerary Teeth: A Literature Review
Problems Associated with Supernumerary Teeth
Failure of Eruption
The presence of a supernumerary tooth is the most
common cause for the failure of eruption of a
maxillary central incisor. It may also cause retention
of the primary incisor. The problem is usually noticed
with the eruption of the maxillary lateral incisors
together with the failure of eruption of one or both
central incisors (Figures. 3 and 4). Supernumerary
teeth in other locations may also cause failure of
eruption of adjacent teeth.
Displacement
The presence of a supernumerary tooth may cause
displacement of a permanent tooth. The degree of
displacement may vary from a mild rotation to
complete displacement. Displacement of the crowns
of the incisor teeth is a common feature in the majority
of cases associated with delayed eruption [11].
Crowding
Erupted supplemental teeth most often cause
crowding. A supplemental lateral incisor may cause
crowding in the upper anterior region. The problem
may be resolved by extracting the most displaced or
deformed tooth.
Pathology
Dentigerous cyst formation is another problem
that may be associated with supernumerary teeth
(Figure 7) [13]. Primosch reported an enlarged
follicular sac in 30% of cases, but histological
evidence of cyst formation was found in only 4 to
9% cases [14]. Resorption of roots adjacent to a
supernumerary may occur but it is extremely rare
(Figure 8) [15].
Alveolar Bone Grafting
Supernumerary teeth may compromise secondary
alveolar bone grafting in patients with cleft lip and
palate. Erupted supernumeraries are usually removed
and the socket site allowed to heal prior to bone
grafting. Supernumeraries should not be extracted
without consultation with the cleft team. Cooperation
between the general dental practitioner and the cleft
team is essential. Unerupted supernumeraries in the
cleft site are generally removed at the time of bone
grafting.
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
175
Implant Site Preparation
The presence of an unerupted supernumerary in a
potential implant site may compromise implant
placement. The supernumerary may require removal
prior to implant placement. If removed at the time of
implant placement, bone grafting may be required.
Asymptomatic
Occasionally, supernumerary teeth are not
associated with any adverse effects and may be
detected as a chance finding during radiographic
examination.
Radiographic Examination
A radiographic examination is indicated if
abnormal clinical signs are found. An anterior
occlusal or periapical radiograph is useful to show
the incisor region in detail. The bucco­lingual
position of unerupted supernumeraries can be
determined using the parallax radiographic principle
[16]: the horizontal tube shift method utilizes two
periapical radiographs taken with different
horizontal tube positions, whereas an occlusal film
together with a panorex view are routinely used for
vertical parallax. If the supernumerary moves in the
same direction as the tube shift it lies in a palatal
position, but if it moves in the opposite direction then
it lies buccally. Intraoral views may give a misleading
impression of the depth of the tooth. A true lateral
radiograph of the incisor region assists in locating
the super­numeraries that are lying deeply in the
palate and enables the practitioner to decide buccal
rather than a palatal approach should be used to
remove them.
Management of Supernumeraries
Treatment depends on the type and position of the
supernumerary tooth and on its effect or potential
effect on adjacent teeth. The management of a
supernumerary tooth should form part of a
comprehensive treatment plan and should not be
considered in isolation.
Indications for Supernumerary Removal
Removal of the supernumerary tooth is
recommended where: central incisor eruption has
been delayed or inhibited; altered eruption or
displacement of central incisors is evident; there is
associated pathology; active orthodontic alignment
of an incisor in close proximity to the supernumerary
is envisaged; its presence would compromise
176 Mounabati Mohapatra et .al. / Supernumerary Teeth: A Literature Review
secondary alveolar bone, grafting in cleft lip and
palate patients; the tooth is present in bone designated
for implant placement; spontaneous eruption of the
supernumerary has occurred.
Indications for Monitoring Without
Supernumerary Removal
Extraction is not always the treatment of choice for
supernumerary teeth. They may be monitored without
removal where: satisfactory eruption of related teeth
has occurred; no active orthodontic treatment is
envisaged; there is no associated pathology; would
prejudice the vitality of the related teeth.
Recommendations Following Supernumerary
Removal
Three factors influence the time it takes for an
impacted tooth to erupt following removal of the
supernumerary [10,17]: the type of supernumerary
tooth; the distance the unerupted perma ­nent tooth
was displaced; the space available within the arch
for the unerupted tooth.
Removal of a supernumerary tooth preventing
permanent tooth eruption usually results in the
eruption of the tooth, provided adequate space is
available in the arch to accommodate it [18]. Di Biase
found 75% of incisors erupted spontaneously of the
supernumerary [17]. Eruption occurred on average
within 18 months, provided that the incisor was not
too far displaced and that sufficient space was
available.
Although the majority of authors recommend
exposure of the unerupted tooth when the
supernumerary is removed, Di Biase advocates
conservative management without exposure [17]. A
lower spontaneous eruption rate of 54% following
supernumerary removal was reported by Witsenburg
and Boering, who recommend the routine bonding of
an attachment and gold chain for orthodontic traction
at the time of surgery [19].
However, the time and expense involved in this
technique may not be justified if the rates of
spontaneous incisor eruption are found to be in the
region of 75 to 78%, as reported by both Di Biase and
Mitchell and Bennett [20,21]. If there is adequate space
in the arch for the unerupted incisor following
supernumerary removal, space maintenance can be
ensured by fitting a simple removable appliance. If
the space is inadequate, the adjacent teeth will need
to be moved distally to create space for incisor
eruption. In that case, the primary canines may need
to be extracted at the same time as the supernumerary
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
tooth. Where there is adequate space and the incisor
tooth fails to erupt, surgical exposure of the incisor
and orthodontic traction is usually required.
Conclusion
The presence of supernumerary teeth has the
potential to disrupt the development of normal
occlusion, and early diagnosis is crucial to minimise
complications such as the development of dentigerous
cysts, root resorption of adjacent teeth, and bone loss
[Primosch, 1981; Kessler and Kraut, 1989]. Therefore,
a timely intervention that aims to remove the
supernumerary teeth is recommended, followed by
an observation period until the eruption of the
impacted permanent incisor in the oral cavity. If the
impacted permanent incisor does not erupt
spontaneously, orthodontic intervention is required
to align the impacted tooth in the occlusal plane.
From the evidence available it would seem prudent
to treat by removal of the supernumerary only in cases
where adequate space is available for the adjacent
permanent tooth to erupt. The space should be
monitored to ensure that it does not close, and the
delayed tooth should be given approximately 18
months to spontaneously erupt. In cases where the
delayed tooth is displaced, or where further early
orthodontic treatment is indicated, concomitant
exposure and orthodontic traction may be considered.
In young patients who are unlikely to cope well with
a second operation, initial exposure and orthodontic
traction at the time of super­numerary removal may
be advisable, particularly when incisors are involved.
References
1. Schulze C. Developmental abnormalities of the teeth
and jaws. In: Gorlin RJ, Goldman HM, eds. Thoma’s
oral pathology. St Louis: CV Mosby, 1970:112­22.
2. Mitchell L. Supernumerary teeth. Dent Update
1989;16:65­9.
3. Yusof WZ. Non­syndromal multiple supernumerary
teeth: literature review. J Can Dent Assoc 1990;56:147­9.
4. So LLY. Unusual supernumerary teeth. Angle Orthod
1990;60:289­92.
5. Luten JR, Jnr. The prevalence of supernumerary teeth
in primary and mixed dentitions. J Dent Child
1967;34:48­9.
6. Shapira Y, Kuftinec MM. Multiple supernumerary
teeth: report of two cases. Am J Dent 1989;2:28­30.
7. Taylor GS. Characteristics of supernumerary teeth in
 Mounabati Mohapatra et .al. / Supernumerary Teeth: A Literature Review
the primary and permanent dentitions. Dent Pract
Dent Rec 1972;22:203­8.
8. Acton CHC. Multiple supernumerary teeth and
possible implications. Aust Dent J 1987;32:48­9.
9. Liu JF. Characteristics of premaxillary supernumerary
teeth: a survey of 112 cases. ASDC J Dent Child 1995;
62:262­5.
10. Levine N. The clinical management of supernumerary
teeth. J Can Dent Assoc 1961;28:297­303.
11. Brook AH. Dental anomalies of number, form and
size: their prevalence in British schoolchildren.J Int
Assoc Dent Child 1974;5:37­53.
12. Scheiner MA, Sampson WJ. Supernumerary teeth: a
review of the literature and four case reports. Aust
Dent J 1997;42:160­5.
13. Vichi M, Franchi L. Abnormalities of the maxillary
incisors in children with cleft lip and palate. ADSC J
Dent Child 1995;62:412­7.
14. Jensen BL, Kreiborg S. Development of the dentition
in cleidocranial dysplasia. J Oral Pathol Med 1990;
19:89­93.
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
177
15. Kinirons MJ. Unerupted premaxillary supernumerary
teeth. A study of their occurrence in males and
females. Br Dent J1982;153:110.
16. Mitchell L.An Introduction to Orthodontics.1st ed.
Oxford University Press; 1996.p.23­5.
17. Andlaw RJ, Rock WP. A Manual of Paediatric
Dentistry. 4th ed. New York: Churchill Livingstone;
1996.p.156.
18. Foster TD, Taylor GS. Characteristics of
supernumerary teeth in the upper central incisor
region. Dent Pract Dent Rec 1969;20:8­12.
19. Howard RD. The unerupted incisor. A study of the
postoperative eruptive history of incisors delayed in
their eruption by supernumerary teeth. Dent Pract
Dent Rec 1967;17:332­41.
20. Shafer WG, Hine MK, Levy BM. A Textbook of Oral
Pathology. 4th ed. Philadelphia: W.B. Saunders; 1983.
p. 308­11.
21. Awang MN, Siar CH. Dentigerous cyst due to
mesiodens: report of two cases.J Ir Dent Assoc 1989;
35:117­8.
Case
178 Report Indian Journal of Dental Education
Volume 10 Number 3, July ­ September 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10317.5

Beautiful Smiles with Functional Occlusal Harmony

Kamala Kakumanu

Abstract

The purpose of this article is to highlight the importance of relationship of teeth with masticatory system.
Masticatory system includes TMJ, muscles of mastication and teeth. Treatment plan is designed after evaluation
of masticatory system; collecting detailed data of records and facebow mounted casts in centric relation.
Success of occlusal treatment depends on anterior and canine guidances as they protect the posterior teeth. It
is important to have absolute harmony between all the three components of masticatory system while doing
any dental treatment.
Keywords: Masticatory System; Facebow; Centric Relation; Anterior and Canine Guidances.

Introduction Case Report

90% of cases that fail, fail not during the restorative
phase but in the treatment planning phase. “Failing
to Plan is Planning to Fail” .
You cannot be effective in making the best treatment
decisions without facebow mounted casts in centric
relation.
To evaluate TMJ, determining centric relation is
very important. Bilateral manipulation to find
“verified centric relation” or “adapted centric
position” is crucial in diagnosis and treatment
planning of the whole case. Centric relation is the
only condylar position that permits an interference
free occlusion.
Treatment planning in detail helps the dentist and
the patient to work out every detail in provisional
stage and “Ensures Error Free Finals”.
Author’s Affiliation: *BDS, JSS Dental College, Mysore,
Dawson Scholar, Completed Core Curriculum Program and
Graduated from Florida, Dawson Academy, Diploma in
Lasers­AACHEN University, Germany, Esthetic Dentistry
Program­Dr Galip Gurel (Istanbul, Turkey). PG Certificate in
Cosmetic Dentistry­Sunny Buffalo, New York.
Reprints Requests: Kamala Kakumanu, Dental Care, A­
24, first floor, Abve HDFC Bank , Hauz Khas, New Delhi ­
110016, India.
E­mail: kamalabds@gmail.com
Received on 17.07.2017, Accepted on 13.08.2017
© Red Flower Publication Pvt. Ltd Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
This case which is presented is a speciality patient.
She is concerned about front teeth becoming shorter
and also sensitivity on her back teeth. Patient had
composite laminates done on all upper front teeth, 47
was missing, old crowns seen wrt 33,35,36, 37,38,
45,48. Severe wear, dentin exposed on all upper
posterior teeth and on all lower teeth.
A facebow relates the upper arch to the condylar
axis. Transfer to the articulator maintains that
relationship of the upper cast to the axis on the
articulator. The lower cast is then mounted with the
Centric Relation bite record.
So it is also related to the correct axis. Even The
Most Perfect Centric Relation bite record is inaccurate
if used without relating it to the condylar axis. A
Facebow is A Necessity For Accuracy.
(Centric relation record and facebow pictures are
of other patient as we could not take the pictures for
the presented case.)
Anterior Guidance
• Principle role of anterior guidance is protecting
posterior teeth
• Success of occlusal treatment depends on anterior
guidance
• Incisal edge position is important as it reflects
 Kamala Kakumanu / Beautiful Smiles with Functional Occlusal Harmony 179

Picture 1: The Centric relation record Picture 2: Facebow

Diagnostic Pictures

Picture 3:

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

180 Kamala Kakumanu / Beautiful Smiles with Functional Occlusal Harmony

Picture 4: Articulated Models Using Kinematic Facebow

Picture 5: Anterior Teeth Wax up’s on Articulated Models

provisionals into patient with indices made on

difference in envelope of function. So, customize
wax up’s.
incisal edge position.

Provisionals
Canine Guidance
Waxed up models are used to fabricate indices
• The principle role of canine guidance is to protect
using polyvinyl material. Provisionals are fabricated
posterior teeth from lateral stresses.
by direct transfer in the patient’s mouth.

Posterior Teeth Wax Up’s on Articulated Models

Provisional Check List
Decided to keep vertical dimension of occlusion at
1. Refine and verify incisal edge position.
the first point of contact (which is upper right 2nd
molar in this case) and use that space to do additive 2. Establish centric holding stops.
equilibration. 3. Lip closure path.
Check equal intensity centric stops on all teeth. 4. Lip support in the line with alveolar bone.
Check balancing side and working side 5. Determine incisal edge length (using the smile
interferences on both sides and clear all interferences. line)
Finally, harmonize the anterior guidance. a. Rest position, ‘E’ position
• Check for complete posterior teeth disclusion on b. ‘F’, ‘V’ sounds
protrusion
6. Establish lingual contours in harmony with the
• Check for canine guidances on both sides envelope of function.
• Once wax up’s are ready, transfer them as 7. Evaluate ‘S’ sounds.

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

 Kamala Kakumanu / Beautiful Smiles with Functional Occlusal Harmony 181

Picture 6:
Picture 8

Picture 6,7 and 8: Posterior Teeth Wax Up’s on Articulated

Models

Picture 7

Treatment Sequencing
Stage 1 Stage 2 Stage 3

Scaling Reshape lower anteriors Mandibular anteriors (Ceramic Laminates)

Caries control Extraction of 38,48 Maxillary anteriors (Ceramic Laminates)
Occlusal equilibration Lower Posteriors (Crown and Bridge work wrt
35,36,37,45,46­onlay)
Composite restorations on all upper bicuspids
& molars wrt 14,15,16,17,24,25,26,27.

Final Tooth Preparation

1) Burs Chamfer
Check list of required items: 3­grid preparation burs
Matrices made on final provisionals.
Incisal Matrix Upper
Lower
Labial Matrix Upper Specific set of matrices are fabricated from the
Lower waxed up’s to be utilized while doing tooth
Occlusal matrix Upper
preparations which will aid us to do conservative
Lower
Upper & Lower full matrix - for transfer of temporaries.
preparations.

Picture 9:

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

182 Kamala Kakumanu / Beautiful Smiles with Functional Occlusal Harmony

Restoration & Material Selection

Type of Restoration Material Used Tooth no’s

Veneer E­MAX­CAD­Lithium 11,12,13,14,

Disilicate 21,22,23,24,
(Strength­360 MPa) 31,32,
41,42,43
Full coverage crown E­MAX­PRESS­ 33,45
Monolithic
(Strength­400MPa)
Bridge Monolithic Zirconia with 35,36,37
ceramic layering
( Strength­1200 MPa)
Onlay E­MAX­PRESS­ 46
Monolithic
(Strength­400MPa)
Composites Nano Hybrid 15,16,17,25,26,27,
Composites 34,44
(Strength­270MPa)

Picture 10:

Picture 11:
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
 Kamala Kakumanu / Beautiful Smiles with Functional Occlusal Harmony
Lab Communications
Finals / Definitive Restorations
Now we can provide the lab with all the
information required:
1. Upper and lower rubber base impressions.
2. Articulated models of final provisionals.
3. Incisal edge matrix (using putty on the mounted
provisional restoration, make an incisal edge
matrix)
This will help the lab to reproduce the horizontal
and vertical incisal edges of anterior teeth.
Picture 13:
Final Cementation
When dentist receives final restorations from the
lab, dentist should receive back the two key indices ­
Incisal edge matrix, anterior guide table.
If all protocol is followed, there is absolutely no
stress about patient’s acceptance and expectations
not being met. Restorations can be presented with
confidence and very little adjustments.
Try in of Final Restorations
1. Removal of provisionals and isolation of teeth.
2. Try in the restorations individually.
3. Try in the restorations all together.
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
183
Picture 12:
4. Custom anterior guide table: A small ball of resin
or composite is placed on incisal table with
lubricated surface. The provisional models are
then moved in all excrusive movements, which
will capture the guidances and lingual guidance
surfaces of finally worked up provisionals.
4. Try in the restorations with a cement simulator
(try in paste of same shade as final adhesive resin
cement)
5. Evaluation :­
Have the goals of esthetics and function been met?
Check with the photographs whether the desired
goals are met?
Delivery of Final Restoration
1. Removal of provisionals and isolation of teeth.
2. Try in restorations individually.
3. Try in the restorations all together.
4. Evaluation­ Have the goals of esthetics and
184 Kamala Kakumanu / Beautiful Smiles with Functional Occlusal Harmony

function been met? Conditioning of tooth using bonding agents (Primer)

5. Preparation and Conditioning of the teeth and 6. Bonding, cementation and clean up.
restorations Applying bonding agents on tooth (adhesive and
Preparation of the restoration using 5% Hydrofluoric helio bond).
acid etchant. Cementation of ­ Veneers using light cured base
IPS EMPRESS­ for 60 sec (transparent shade­ Variolink N).
IPS E­MAX ­ for 20 sec • Onlay using multilink N.
No etching required for zirconia • Crown using multilink N
Conditioning of the restoration using primer (silane)­ • Zirconia bridge using multilink N.
all restorations for 60 sec. 7. Occlusal verification
Preparation of tooth using 37% phosphoric acid 8. Review after 48 hour’s post cementation
(etchant).

Conclusion

By following a disciplined protocol and going

through the whole process in a systematic step wise
manner, we can reach our destination without errors.
Being able to complete patient’s work with good
esthetic result which is predictable and durable makes
it worthwhile for the patient and the dentist.

Acknowledgement

I would like to express my sincere thanks to Dr.

Peter E. Dawson who inspired me.
Dr. Peter E. Dawson, D.D.S. is considered to be one
of the most influential clinicians and teachers in the
history of dentistry. He authored the best selling dental
text, Evaluation, Diagnosis and Treatment of Occlusal
Problems, which is published in 13 languages. Dr.
Protrusive Dawson is the past president and life member of the
American Equilibration Society, a past president of
the American Academy of Restorative Dentistry and
the American Academy of Esthetic Dentistry.
I would like to thank Dr. Ritika Aggarwal and Dr.
Preeti Suhag for all the help and support in the entire
case.

Lateral Excursive
References

1. Galip Gurel; The science and art of porcelain laminate

veneers; 2003, Quintessence publishing co. ltd.
2. Peter. E. Dawson DDS; Functional occlusion from TMJ
to smile design; 2007, Mosby Inc an affiate of Elsevier
Inc.
Picture 14:

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

Case Report Indian Journal of Dental Education
185
Volume 10 Number 3, July ­ September 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10317.6

Middle Mesial Canal in Mandibular Second Molar

Seema Yadav

Abstract

The success of endodontic therapy relies on thorough debridement, shaping and completely filling the
entire root canal system.Failure to recognize additional canal results in poor prognosis of the treatment. The
advances in the technology and knowledge and experience of the clinician has led to meticulous attention in
locating as well as treating these extra canal successfully. Middle mesial canal is an additional canal found in
the mesial root of mandibular molars. These canals may either merge with the main canal or may leave as an
independent canal.The present case report describes the successful treatment of three independent mesial
canals in mandibular second molar
Keywords: Middle Mesial Canal; Mesial Root; Mandibular Second Molar.

Introduction second molar (Table 1). The case report presented

Vertucci and Williams [1] in 1974 were the first to
report the middle mesial canal in the mandibular first
molar.Thereafter many clinical studies and case
report with unusual middle mesial canal associated
with mandibular molars has been reported. Pomeranz
et al [2] studied 100 mandibular molars and found
12% middle mesial canals in the mesial roots. They
categorized them into three morphologic types
namely fins, confluent and independent.
Mandibular second molar usually have two roots
and three root canals.However various studies have
been reported with diverse anatomy.The middle
mesial canal is one of the variation found in
mandibular molars.The incidence of these ranges from
1 to 15% [5].The middle mesial canal are more
common finding in mandibular first molar [2] and
are less frequently seen in mandibular second molar
[3].Very few case report were reported with
independent middle mesial canal in mandibular
Author’s Affiliation: Professor, Deptt. of Conservative
Dentistry and Endodontics, Maulana Azad Institute of Dental
Sciences, New Delhi, Delhi 110002.
Reprints Requests: Seema Yadav, Professor, Deptt. of
Conservative Dentistry and Endodontics, Maulana Azad
Institute of Dental Sciences, New Delhi, Delhi 110002.
E­mail: seemayadav2008@gmail.com
Received on 29.07.2017, Accepted on 16.08.2017
here shows endodontic management of three
independent canals in mesial root and one canal in
distal root of mandibular second molar.
Case Report
A 28 year old female patient visited the department
with chief complaint of sharp shooting pain in the
lower right region. Medical history was
noncontributory. On clinical examination,there was
carious exposure evident in the lower right second
molar. There was no response to electrical pulp test.
There was severe sensitivity to percussion. Palpation
of the buccal and lingual mucosa of the tooth did not
reveal any tenderness.There was no intraoral or
extraoral swelling present. The tooth was firm with
normal periodontium. Radiograph revealed carious
exposure with periapical radiolucency in the distal
root (Figure 1a). Based on the clinical and
radiographic findings, diagnosis of pulpal necrosis
with symptomatic apical periodontitis was made for
tooth 47 and root canal treatment was initiated.
Rubber dam was placed and access preparation
was made on 47. The distal, mesiobuccal and
mesiolingual orifices were located. However with
further probing with the help of DG16 along the
groove between mesiobuccal and mesiolingual
orifices, an additional canal orifice was identified

Indian
© JournalPublication
Red Flower of Dental Pvt.
Education,
Ltd Volume 10 Number 3, July ­ September 2017
186 Seema Yadav / Middle Mesial Canal in Mandibular Second Molar

closer to the mesiobuccal. On manual exploration

with 10no Kfile, the additional canal was found to be
independent. The working length of the three mesial
canals was determined with apex locator and later
confirmed with radiograph (Figure 1b). For mesial
canals, coronal orifice enlargement was done with
GG drills no1 & 2. Subsequently prepared with
stainless steel hand K file till ISO 25/02(Mani Inc,
Japan) followed by Hero Shaper file no 30/04
(Micromega) was used. The distal canal was prepared
with Protaper till F2. Irrigation was performed with
2.5% sodium hypochlorite and normal saline solution.
Final irrigation was performed with 17% EDTA
solution. Calcium hydroxide paste was placed .

Fig. 1c:

Fig. 1a:

Fig. 1d:

After one week, the patient was asymptomatic and

obturation was performed using cold lateral
condensation of gutta percha and AH plus sealer
(Figure 1c). The tooth was then restored with
composite resin (Figure 1d).
Fig. 1b:

Table 1:

Case Reports
Author Year Tooth Identification method

JV karunakaran14 2012 37 Probing with explorer

Reddy13 2013 37 Surgical operating microscope(8X)
Ragavendran15 2014 37 Manual Probing, radiograph with instrument
Paul 11 2015 47 Manual Probing, radiograph with instrument
Present case report 2016 47 Manual Probing, radiograph with instrument

Discussion middle mesial canal. The middle mesial canal is an

additional canal located in the mesial root of
mandibular molars. Additional canal identification
Various studies has been published related to the and management can be challenging but if not
anatomic diversity of mandibular molars along with
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
 Seema Yadav / Middle Mesial Canal in Mandibular Second Molar
detected will results in failure of endodontic treatment.
The middle mesial canal may be confluent and merge
with either mesiobuccal or mesiolingual canal in the
apical third [5] or it may exit as an independent canal
[12]. The confluent anatomy [6,7] in middle mesial
canals were the most commonly found configuration
followed by fin anatomy and least were with
independent anatomy [8]. The three independent
mesial canal with different apical foramen is the most
uncommonly seen morphological types [9].
There are various methods for locating the extra
canal. Careful exploration with sharp explorer,
bleeding spots, scrutiny of the dentinal map, removing
calcification from the chamber floor and angled
radiographs with instrument within the canals helps
in identification of the additional canal [10]. For
middle mesial canal, the dentinal map between
mesiobuccal and mesiolingual orifices should be
carefully explored with the sharp explorer and small
files. The middle mesial canal in this case was
identified with the DG16 explorer and confirmed by
angled radiograph with 10 no Kfile placed in the
canal. Various authors have used different methods
for identification of the middle mesial canal such as
DG16 explorer [11], CBCT imaging [12], dental
operating microscope [6], Troughing technique along
with dental operating microscope [7], angled
radiograph with instrument, gutta percha [5] placed
in the canal.
Sherwani et al [8] studied the location of the orifice
of middle mesial canal in relation to the orifice of the
main mesial canals from 73 located cases of middle
mesial canal from 258 mandibular molars and found
that the middle mesial orifices were located in the
middle in 67% of the cases followed by 20% closer to
the orifice of the mesiolingual canal and 12% closer
to the orifice of the mesiobuccal canal. However in
this case report the middle mesial canal orifice was
located closer to the mesiobuccal orifice.
The incidence of middle mesial canal is also related
to the age of the patient . The younger age group has
higher incidence of presence of middle mesial canal.
Nosrat et al [6] found that the incidence of middle
mesial canals was 32.1% in patients 20 years old,
23.8% in patients 21–40 years old, and 3.8% in
patients >40 years.  As the age advances,the
calcification in the chamber and the canal may reduce
the chances of locating these canals [4,8].
Conclusion
Clinician should bear in mind the possibility of
middle mesial canal in the mesial root of mandibular
Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
187
molar and its management. Failure to identify these
canal can lead to unfavourable prognosis of the
endodontic therapy.
References
1. Vertucci FJ, Williams RG. Root canal anatomy of the
mandibular first molar. JNJ Dent Assoc. 1974;48:27–8.
2. Pomeranz HH, Eidelman DL, Goldberg MG.
Treatment considerations of the middle mesial canal
of mandibular first and second molars. J Endod.
1981;7:565–8.
3. Sert S, Bayirli GS. Evaluation of the root canal
configurations of the mandibular and maxillary
permanent teeth by gender in the Turkish
population. J Endod. 2004;30:391–8.
4. Goel NK, Gill KS, Taneja JR. Study of root canals
configuration in mandibular first permanent molar.
J Indian Soc Pedod Prev Dent. 1991;8:12­14.
5. Baugh D, Wallace J. Middle mesial canal of the
mandibular first molar: A case report and literature
review.J Endod. 2004;30(3):185­186
6. Nosrat A,Deschenes RJ,Tordik PA,Hicks ML,Fouad
AF.Middle mesial canals in mandibular molars:
incidence and related factors. J Endod. 2015;41(1):28­
32
7. Azim AA,DeutschAS,SolomonCS,Prevalence of
Middle Mesial Canals in Mandibular Molars after
Guided Troughing under High Magnification:
An In Vivo Investigation. J Endod. 2015;41(2):164­68
8. Sherwani OA,Kumar A,Tewari RK,Mishra SK,Andrabi
SM,Alam S.Frequency of middle mesial canals in
mandibular first molars in North Indian population­
An invivo study. Saudi Endod J. 2016;6:66­70.
9. Fabra­Campos H. Three canals in the mesial root of
mandibular first permanent molars: a clinical study.
Int Endod J. 1989;22:39–43.
10. Bhargavi N,Velmurugan N,Kundaswamy D.The hunt
for the elusive canals.Endodontology. 2005;
17(1):18­21.
11. Paul B and Dube K. “Identification and endodontic
management of middle mesial canal in mandibular
second molar using cone beam computed
tomography,”. Case reports in Dentistry. vol. 2015,
Article ID 867976, 4 pages, 2015. doi:10.1155/2015/
867976.
12. La SH, Jung DH, Kim EC,and Min KS.Identification of
independent middle mesial canal in mandibular first
molar using cone­beam tomography imaging. J
Endod. 2010;36(3):542­5.
13. S Reddy SM, Kaushik M, Bai Y , Padmini C.A report of
three independent mesial canals in the mesial root of
a mandibular second molar.MRIMS J Health Sciences.
2013;1(2):69­72.
188 Seema Yadav / Middle Mesial Canal in Mandibular Second Molar

14. Karunakaran JV, Shobana R, Kumar M, Kumar S, 15. Ragavendran N, Bhat G, Hedge MN. Mandibular
Mankar S. Management of middle mesial canal in second molar with three mesial canals and a radix
mandibular second molar. J Pharma Bioallied sci. paramolaris. J Pharma Bioallied sci. 2014;6(1):182­184.
2012;4(Suppl 2):S161.

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192 Guidelines for Authors
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Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017
Language and grammar
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 193
Revised Rates for 2018 (Institutional)
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Community and Public Health Nursing 3 5500 5000 430 391
Dermatology International 2 5500 5000 430 391
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Indian Journal of Agriculture Business 2 5500 5000 413 375
Indian Journal of Anatomy 4 8500 8000 664 625
Indian Journal of Ancient Medicine and Yoga 4 8000 7500 625 586
Indian Journal of Anesthesia and Analgesia 4 7500 7000 586 547
Indian Journal of Biology 2 5500 5000 430 391
Indian Journal of Cancer Education and Research 2 9000 8500 703 664
Indian Journal of Communicable Diseases 2 8500 8000 664 625
Indian Journal of Dental Education 4 5500 5000 430 391
Indian Journal of Emergency Medicine 2 12500 12000 977 938
Indian Journal of Forensic Odontology 2 5500 5000 430 391
Indian Journal of Hospital Administration 2 7000 6500 547 508
Indian Journal of Hospital Infection 2 12500 12000 938 901
Indian Journal of Law and Human Behavior 2 6000 5500 469 430
Indian Journal of Library and Information Science 3 9500 9000 742 703
Indian Journal of Maternal­Fetal & Neonatal Medicine 2 9500 9000 742 703
Indian Journal of Medical & Health Sciences 2 7000 6500 547 508
Indian Journal of Obstetrics and Gynecology 4 9500 9000 742 703
Indian Journal of Pathology: Research and Practice 4 12000 11500 938 898
Indian Journal of Plant and Soil 2 65500 65000 5117 5078
Indian Journal of Preventive Medicine 2 7000 6500 547 508
Indian Journal of Research in Anthropology 2 12500 12000 977 938
Indian Journal of Surgical Nursing 3 5500 5000 430 391
Indian Journal of Trauma & Emergency Pediatrics 4 9500 9000 742 703
Indian Journal of Waste Management 2 9500 8500 742 664
International Journal of Food, Nutrition & Dietetics 3 5500 5000 430 391
International Journal of Neurology and Neurosurgery 2 10500 10000 820 781
International Journal of Pediatric Nursing 3 5500 5000 430 391
International Journal of Political Science 2 6000 5500 450 413
International Journal of Practical Nursing 3 5500 5000 430 391
International Physiology 2 7500 7000 586 547
Journal of Animal Feed Science and Technology 2 78500 78000 6133 6094
Journal of Cardiovascular Medicine and Surgery 2 10000 9500 781 742
Journal of Forensic Chemistry and Toxicology 2 9500 9000 742 703
Journal of Geriatric Nursing 2 5500 5000 430 391
Journal of Microbiology and Related Research 2 8500 8000 664 625
Journal of Nurse Midwifery and Maternal Health 3 5500 5000 430 391
Journal of Organ Transplantation 2 26400 25900 2063 2023
Journal of Orthopaedic Education 2 5500 5000 430 391
Journal of Pharmaceutical and Medicinal Chemistry 2 16500 16000 1289 1250
Journal of Practical Biochemistry and Biophysics 2 7000 6500 547 508
Journal of Psychiatric Nursing 3 5500 5000 430 391
Journal of Social Welfare and Management 3 7500 7000 586 547
New Indian Journal of Surgery 4 8000 7500 625 586
Ophthalmology and Allied Sciences 2 6000 5500 469 430
Otolaryngology International 2 5500 5000 430 391
Pediatric Education and Research 3 7500 7000 586 547
Physiotherapy and Occupational Therapy Journal 4 9000 8500 703 664
Psychiatry and Mental Health 2 8000 7500 625 586
Urology, Nephrology and Andrology International 2 7500 7000 586 547

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2. All back volumes of all journals are available at current rates.
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4. All legal disputes subject to Delhi jurisdiction.
5. Cancellations are not accepted orders once processed.
6. Demand draft / cheque should be issued in favour of “Red Flower Publication Pvt. Ltd.” payable at Delhi
7. Full pre­payment is required. It can be done through online (http://rfppl.co.in/subscribe.php?mid=7 ).
8. No claims will be entertained if not reported within 6 months of the publishing date.
9. Orders and payments are to be sent to our office address as given above.
10. Postage & Handling is included in the subscription rates.
11. Subscription period is accepted on calendar year basis (i.e. Jan to Dec). However orders may be placed any time throughout the year.

Order from
Red Flower Publication Pvt. Ltd., 48/41­42, DSIDC, Pocket­II, Mayur Vihar Phase­I, Delhi ­ 110 091 (India), Tel: 91­11­22754205, 45796900, Fax: 91­
11­22754205. E­mail: sales@rfppl.co.in, Website: www.rfppl.co.in

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

194
Revised Rates for 2017 (Institutional)
Title Frequency Rate (Rs): India Rate ($):ROW
Community and Public Health Nursing 3 5000 4500 357 300
Dermatology International 2 5000 4500 357 300
Gastroenterology International 2 5500 5000 393 340
Indian Journal of Agriculture Business 2 5000 4500 500 450
Indian Journal of Anatomy 4 8000 7500 571 500
Indian Journal of Ancient Medicine and Yoga 4 7500 7000 536 500
Indian Journal of Anesthesia and Analgesia 4 7000 6500 500 450
Indian Journal of Biology 2 5000 4500 357 300
Indian Journal of Cancer Education and Research 2 8500 8000 607 550
Indian Journal of Communicable Diseases 2 8000 7500 571 500
Indian Journal of Dental Education 4 5000 4500 357 300
Indian Journal of Emergency Medicine 2 12000 11500 857 800
Indian Journal of Forensic Medicine and Pathology 4 15500 15000 1107 1050
Indian Journal of Forensic Odontology 2 5000 4500 357 300
Indian Journal of Genetics and Molecular Research 2 6500 6000 464 400
Indian Journal of Hospital Administration 2 6500 6000 464 429
Indian Journal of Hospital Infection 2 12000 9000 857 800
Indian Journal of Law and Human Behavior 2 5500 5000 393 350
Indian Journal of Library and Information Science 3 9000 8500 643 600
Indian Journal of Maternal­Fetal & Neonatal Medicine 2 9000 8500 643 600
Indian Journal of Medical & Health Sciences 2 6500 6000 464 410
Indian Journal of Obstetrics and Gynecology 4 9000 8500 643 600
Indian Journal of Pathology: Research and Practice 4 11500 11000 821 780
Indian Journal of Plant and Soil 2 65000 60000 4623 4100
Indian Journal of Preventive Medicine 2 6500 6000 464 410
Indian Journal of Research in Anthropology 2 12000 11500 857 800
Indian Journal of Surgical Nursing 3 5000 4500 357 300
Indian Journal of Trauma & Emergency Pediatrics 4 9000 8500 643 600
Indian Journal of Waste Management 2 9000 8000 643 579
International Journal of Food, Nutrition & Dietetics 3 5000 4500 357 300
International Journal of Neurology and Neurosurgery 2 10000 9500 714 660
International Journal of Pediatric Nursing 3 5000 4500 357 300
International Journal of Political Science 2 5500 5000 550 500
International Journal of Practical Nursing 3 5000 4500 357 300
International Physiology 2 7000 6500 500 450
Journal of Animal Feed Science and Technology 2 78000 70000 5571 5000
Journal of Cardiovascular Medicine and Surgery 2 9500 9000 679 630
Journal of Forensic Chemistry and Toxicology 2 9000 8500 643 600
Journal of Geriatric Nursing 2 5000 4500 357 300
Journal of Medical Images and Case Reports 2 5000 4500 357 300
Journal of Microbiology and Related Research 2 8000 7500 571 520
Journal of Nurse Midwifery and Maternal Health 3 5000 4500 357 300
Journal of Organ Transplantation 2 25900 25000 1850 1700
Journal of Orthopaedic Education 2 5000 4500 357 300
Journal of Pharmaceutical and Medicinal Chemistry 2 16000 15500 1143 1100
Journal of Practical Biochemistry and Biophysics 2 5500 5000 393 340
Journal of Social Welfare and Management 3 5000 4500 357 300
New Indian Journal of Surgery 4 7500 7000 536 480
New Journal of Psychiatric Nursing 3 5000 4500 357 300
Ophthalmology and Allied Sciences 2 5500 5000 393 340
Otolaryngology International 2 5000 4500 357 300
Pediatric Education and Research 3 7000 6500 500 450
Physiotherapy and Occupational Therapy Journal 4 8500 8000 607 550
Psychiatry and Mental Health 2 7500 7000 536 490
Urology, Nephrology and Andrology International 2 7000 6500 500 450
Terms of Supply:
1. Agency discount 10%. Issues will be sent directly to the end user, otherwise foreign rates will be charged.
2. All back volumes of all journals are available at current rates.
3. All Journals are available free online with print order within the subscription period.
4. All legal disputes subject to Delhi jurisdiction.
5. Cancellations are not accepted orders once processed.
6. Demand draft / cheque should be issued in favour of “Red Flower Publication Pvt. Ltd.” payable at Delhi
7. Full pre­payment is required. It can be done through online (http://rfppl.co.in/subscribe.php?mid=7 ).
8. No claims will be entertained if not reported within 6 months of the publishing date.
9. Orders and payments are to be sent to our office address as given above.
10. Postage & Handling is included in the subscription rates.
11. Subscription period is accepted on calendar year basis (i.e. Jan to Dec). However orders may be placed any time throughout the year.

Order from
Red Flower Publication Pvt. Ltd., 48/41­42, DSIDC, Pocket­II, Mayur Vihar Phase­I, Delhi ­ 110 091 (India), Tel: 91­11­22754205, 45796900, Fax: 91­
11­22754205. E­mail: sales@rfppl.co.in, Website: www.rfppl.co.in

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

 195

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Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

 196

Indian Journal of Dental Education

Library Recommendation Form

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Dear Librarian,
I would like to recommend that your library subscribe to the Indian Journal of Dental
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Phone: Phone: 91­11­45796900, 22754205, 22756995, Fax: 91­11­22754205
E­mail: sales@rfppl.co.in

Indian Journal of Dental Education, Volume 10 Number 3, July ­ September 2017

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