Balkan Journal of Stomatology

BALKAN JOURNAL OF STOMATOLOGY

Official publication of the BALKAN STOMATOLOGICAL SOCIETY

Volume 16 No 3 November 2012

ISSN 1107 - 1141

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L BALKAN JOURNAL OF STOMATOLOGY A ISSN 1107 - 1141 IC G LO TO STOMA

Editor-in-Chief Ljubomir TODOROVIĆ, DDS, MSc, PhD Faculty of Dentistry University of Belgrade Dr Subotića 8 11000 Belgrade Serbia

Editorial board ALBANIA ROMANIA Ruzhdie QAFMOLLA - Editor Address: Alexandru-Andrei ILIESCU - Editor Address: Emil KUVARATI Dental University Clinic Victor NAMIGEAN Faculty of Dentistry Besnik GAVAZI Tirana, Albania Cinel MALITA Calea Plevnei 19, sect. 1 70754 Bucuresti, Romania BOSNIA AND HERZEGOVINA Maida GANIBEGOVIĆ - Editor Address: Naida HADŽIABDIĆ Faculty of Dentistry SERBIA Mihael STANOJEVIĆ Bolnička 4a Dejan MARKOVIĆ - Editor Address: 71000 Sarajevo, BIH Slavoljub ŽIVKOVIĆ Faculty of Dentistry BULGARIA Zoran STAJČIĆ Dr Subotića 8 Nikolai POPOV - Editor Address: 11000 Beograd, Serbia Nikola ATANASSOV Faculty of Dentistry Nikolai SHARKOV G. Sofiiski str. 1 TURKEY 1431 Sofia, Bulgaria Ender KAZAZOGLU - Editor Address: FYROM Pinar KURSOGLU Yeditepe University Julijana GJORGOVA - Editor Address: Arzu CIVELEK Faculty of Dentistry Ana STAVREVSKA Faculty of Dentistry Bagdat Cad. No 238 Ljuben GUGUČEVSKI Vodnjanska 17, Skopje Göztepe 81006 Republika Makedonija Istanbul, Turkey GREECE CYPRUS Anastasios MARKOPOULOS - Editor Address: George PANTELAS - Editor Address: Haralambos PETRIDIS Aristotle University Huseyn BIÇAK Gen. Hospital Nicosia Lambros ZOULOUMIS Dental School Aikaterine KOSTEA No 10 Pallados St. Thessaloniki, Greece Nicosia, Cyprus

International Editorial (Advisory) Board Christoph HÄMMERLE - Switzerland George SANDOR - Canada Barrie Kenney - USA Ario SANTINI - Great Britain Predrag Charles LEKIC - Canada Riita SUURONEN - Finland

Kyösti OIKARINEN - Finland Michael WEINLAENDER - Austria

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BALKAN STOMATOLOGICAL SOCIETY L A IC G LO TO STOMA Council: Members: R. Qafmolla A. Adžić President: Prof. H. Bostanci P. Kongo M. Djuričković M. Ganibegović N. Forna Past President: Prof. P. Koidis S. Kostadinović A. Bucur President Elect: Prof. N. Sharkov A. Filchev M. Carević Vice President: Prof. D. Stamenković D. Stancheva Zaburkova M. Barjaktarević M. Carčev E. Kazazoglu Secretary General: Prof. A.L. Pissiotis A. Minovska M. Akkaya Treasurer: Prof. S. Dalampiras T. Lambrianidis G. Pantelas Editor-in-Chief: Prof. Lj.Todorović S. Dalambiras S. Solyali

The whole issue is available on-line at the web address of the BaSS (www.e-bass.org) BALKAN JOURNAL OF STOMATOLOGY

Official publication of the BALKAN STOMATOLOGICAL SOCIETY

Volume 16 No 3 November 2012

ISSN 1107 - 1141

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L BALKAN JOURNAL OF STOMATOLOGY A ISSN 1107 - 1141 IC G LO TO STOMA

VOLUME 16 NUMBER 3 NOVEMBER 2012 PAGES 129-184 Contents

LR I. Markou Natal and Neonatal Teeth: A Review of the Literature 132 A. Kana A. Arhakis

LR E. Lioliou The Maxillary Labial Fraenum - 141 A. Kostas A Controversy of Oral Surgeons vs. Orthodontists L. Zouloumis

OP L. Kanurkova Association between Condylar Position and Tilt of 147 J. Gjorgova Frontal Occlusal Plane in Patients with B. Dzipunova Transversal and Vertical Dentofacial Discrepancy N. Toseska A. Dorakovska M. Popovska M. Pandilova

OP E. Kongo Cephalometric Features of Class III Malocclusion among 154 Xh. Mulo Albanian Patients Seeking Orthodontic Treatment

OP E. Zabokova-Bilbilova Effect of Fluoride Varnish on Demineralization 157 A. Sotirovska-Ivkovska Adjacent to Orthodontic Brackets B. Evrosimovska L. Kanurkova

OP M. Carcev Sealing of Fissures and Pits of First Permanent 161 B. Getova Molar at Children with High Caries Risk O. Sarakinova H. Petanovski S. Carceva-Shalja

OP S. Georgieva Use of Topical Bio-stimulative Laser Therapy among Individuals 165 M. Pandilova with Glossopyrosis and Hypochromic Anaemia L. Zendeli-Bedzeti Balk J Stom, Vol 16, 2012 131

OP J. Nikolovska Oral Health-Related Quality of Life (OHRQoL) 169 D. Petrovski Before and After Prosthodontic Treatment with Full Removable Dentures

OP A. Uludamar Bond Strength of Resin Cements to Zirconia Ceramics 173 F. Aykent with Different Surface Treatments

CR U. Cılasun An Unusual Laryngeal Complication 179 E. Alper Sınanoglu Following Inferior Alveolar Nerve Block S. Yılmaz E. Guzeldemır G. Alnıacık

CR N. Güler Surgical Planning of Bilaterally Impacted 181 Maxillary Third Molars by Using Cone Beam Computed Tomography

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Natal and Neonatal Teeth: A Review of the Literature

SUMMARY I. Markou, A. Kana, A. Arhakis Normal eruption of primary teeth into the oral cavity begins at about 6 Aristotle University of Thessaloniki months of child’s age. Teeth that erupt prematurely have occasionally been School of Dentistry reported in the medical and dental literature and have been referred to as Thessaloniki, Greece congenital teeth, foetal teeth, pre-deciduous teeth and dentitio praecox. The most affected teeth are lower central incisors and only 1-10% of them are supernumerary teeth. The incidence of natal and neonatal teeth ranges from 1:2000 to 1:3500. The exact etiology has not been proved yet, but there is a correlation between natal teeth and hereditary, environmental factors and some syndromes. The management of the case depends on clinical characteristics of the natal or neonatal teeth, as well as on complications they might cause. The aim of this text is to present a literature review on important aspects of natal and neonatal teeth concerning prevalence, etiology, clinical and histological characteristics, differential diagnosis, complications and management. LITERATURE REVIEW (LR) Keywords: Natal Teeth; Neonatal Teeth Balk J Stom, 2012; 16:132-140

Introduction The rare occurrence of natal and neonatal teeth was associated in the past with superstition and folklore. Typical eruption of primary teeth begins at about 6 Today this phenomenon creates great interest and concern, months of age. Teeth observed at birth are considered not only to parents but to clinicians as well. This is due as natal teeth, while teeth observed within the first 30 to their clinical characteristics (small size, conical days as neonatal teeth, based on the classification given shape, and great mobility) which are the cause of certain by Massler and Savara in 1950 according to the time of complications (laceration of mother’s breasts, sublingual eruption78. In 1966, Spouge and Feasby categorized these ulceration, and danger of aspiration of the teeth). teeth based on clinical features as mature and immature110. Mature are those which are fully developed in shape and comparable in morphology to the deciduous teeth; immature are the teeth whose structure and development History are incomplete. Finally, Hebling in 1997 presented 4 clinical categories44: The rare occurrence of natal and neonatal teeth has -- Shell-shaped crown loosely attached to the alveolus by led to association with superstition and folklore. Some gingival tissue and absence of a root; cultures have believed that children born with teeth were -- Solid crown loosely attached to the alveolus by favoured, particularly in Western Europe and Malaysia, gingival tissue and little or no root; whereas other considered natal teeth as an ill omen. In -- Eruption of the incisal margin of the crown through England it was believed that natal teeth showed that the gingival tissue; children would grow into famous soldiers, in France and -- Mucosal swelling with the tooth non-erupted but Italy that they ‘would get on in the world’ and in Sweden palpable. that they could cure an injured finger if it were placed in Balk J Stom, Vol 16, 2012 Natal and Neonatal Teeth 133 their mouth. In many places like Poland India and Africa whose teeth grow early, will early sink into the grave’14. superstition still prevails considering these children to be Due to these superstitions it is suggested that a trans- monsters or evil children14. Among several native African cultural approach be adopted in managing cases in which tribes, such as in urban Bariba in Benin West Africa, one the parents feel particularly anxious and uncomfortable of the most dangerous signs suggesting a witch child is about prematurely erupted teeth in order to cater for the to be born with teeth and if that happened the child was social well-being of the child and family88. either abandoned or killed. Precautions in the form of a purification ritual are still taken today in such cases, and sometimes the teeth will be extracted101. In China a child born with teeth suggests misfortune for the family: if the Prevalence child is male then the father will die and if it is a female the mother. Many historic personalities, like Hannibal, Many authors have reviewed the incidence of natal Cardinal Richelieu, Broca, Zoroaster, Napoleon, English and neonatal teeth (Table 1). The estimated prevalence King Richard the III and King Louis XIV of France are ranges from 1:10 to 1:30.000. It is accepted by many said to be born with teeth. Also many proverbs and authors that the ratio of natal and neonatal teeth is apothegms are made up for natal teeth, such as ‘The one somewhere between 1:2000 and 1:350014,23,24,78,110,123.

Table 1. Prevalence of natal and neonatal teeth

Natal and Author(s) Location of study neonatal Total births Prevalence teeth Magicot (1883)71 Paris, France 3 17.578 1:6.000 Howkins (1932)48 Birmingham, England 1 10.000 1:10.000 Massler and Savara (1950)78 Chicago, USA 7 9.400 1:2.000 Allwright (1958)3 Hong Kong, China 2 6.817 1:3.400 Mayhall (1967)80 Juneau, Alaska (Tlinget Indians) 8 90 1:11.25 Oklahoma, USA (American Gordon and Langley (1970)41 4 407 1:100 Indian) Jarvis and Gorlin Alaska, USA 16 1.571 1:98 (1972)50 (Eskimo) Anderson (1982)5 Columbia, USA 1:800 Kates et al (1984) 52 Boston, USA 13 18.155 1:3.667 Leung (1989)67 Alberta, Canada 15 50.892 1:3.392

King and Lee (1989)57 Hong Kong, China 17 22.500 1:1.324

Gladen et al (1990)39 Taiwan 13 128 1:10 Rusmah (1991)100 Kuala Lumpur, Malaysia 4 9.600 1:2.325 To (1991)117 Hong Kong, China 48 53.678 1:1.118 Diaz-Romero et al (1991)30 Mexico 31 1.200 1:38,7 De Almeida and Gomide (1995)27 Brazil 47* 1019** 1:22 Alaluusua et al (2002)2 Finland 34 34.457 1:1.013 Liu and Huang (2004)70 Taipei, Taiwan 2 420 1:140 Freudenberger et al (2008)36 Mexico 50 2182 2.3:100

* 14 with complete unilateral cleft lip and palate and 33 with bilateral cleft lip and palate **692 with complete unilateral cleft lip and palate and 327 with bilateral cleft lip and palate 134 I. Markou et al. Balk J Stom, Vol 16, 2012

The prevalence of occurrence of natal and neonatal pyelitis during pregnancy15. Another theory refers to teeth in males and females is controversial, with some hormonal stimulation, meaning the excessive secretion authors giving a higher ratio for females 3,5,23, 36, 52, 65,78, of pituitary, thyroid or gonads78. It is also significant to Kates et al54 reporting a 66% proportion for females mention that congenital syphilis seems to have varying against a 31% proportion for males, and others suggesting effect; in some cases premature eruption was noticed, 14,25,106 that there isn’t any correlation with gender . while in others the eruption was retarded15. Moreover, Natal teeth are more common than neonatal febrile states can affect the normal eruption of teeth, for teeth14,23,33,57,78,110. example fever and exanthemata during pregnancy can cause premature eruption78. The hereditary factor is assumed a possible cause of 123 Etiology natal teeth. Zhu and King (1995) have reported natal teeth as a familiar trait in 8-62% of cases. Bondenhoff and 14 The exact etiology of natal and neonatal teeth has not Gorlin (1963) reported family association in 14.5% of been elucidated yet. Many theories have been expressed cases, while Kates et al (1984)52 found a positive family regarding the cause of the occurrence of these teeth. One history in 7 out of 38 cases of natal and neonatal teeth. A of them includes dietary deficiencies3 or hypovitaminosis hereditary transmission of an autosomal dominant gene due to poor maternal health, endocrine disturbances and has also been suggested24,49.

Table 2. Syndromes and developmental disturbances related to natal and neonatal teeth

Syndromes and developmental disturbances Author(s) Ellis-Van Creveld syndrome Himelhoch(1988)47; Kurian et al(2007)64 Hallerman-Streiff syndrome Fonseca and Mueller(1995)35; Oshihi et al (1986)87 Patent ductus arrteriosus and intestinal pseudo-obstruction Harris et al (1976)43 Opitz (G/BBB) syndrome Shaw et al (2006)103 Van der Woude syndrome Hersh and Verdi (1992)46 Pachyonychia congenital (Jadasshon- Lewandawsky syndrome) Feinstein et al (1988)34 Steatocystoma multiplex King and Lee (1987)56 Pivnick et al (2000), Arboleda (1997); Byung-Duk and Wiedermann-Rautenstrauch neonatal progeria Jung-Wook (2006); Castiñeyra et al (1992), Korniszewski et al (2001)91,7,18,22,62 Pfeiffer syndrome type 3 Alvarez et al (1993)4 Walker Warburg syndrome (Congenital hydrocephalus with congenital Mandal et al (2002)73 glaucoma) Hyper IgE syndrome Roshan et al (2009)98 Rubinstein-Taybi syndrome Hennekam and Van Doorne (1990)45 Bifid tongue and profound sensorineural hearing loss Darwish, Sastry and Ruprecht (1987)26 Cyclopia Boyd and Miles (1951)16 Transient Pseudohypoparathyroidism Koklu and Kurtoglu (2007)61 Pierre Robin syndrome Kharbanda et al (1985)54 Down syndrome Ndiokwelu et al (2004)[85] Short rib-polydactyly syndrome type II Strømme Koppang, Boman and Hoel (1983)113 (Saldino-Noonan syndrome ) Soto’s syndrome Callanan, Anand and Sheehy (2009)20 Adrenogenital syndrome Leung (1989)67 Epidermolysis bullosa simplex Liu, Chen and Miles (1998)69 Cleft lip-palate Cabate et al (2000)19 Odonto-Tricho-Ungual-Digital-Palmar Syndrome Mendoza and Valiente (1997)81 Bloch-Sulzberger syndrome (incontinentia pigmenti) Wolf (2007)122 Goltz syndrome Dias et al (2010)28 Teebi hypertelorism syndrome Koenig (2003)59 Clouston syndrome Reynolds, Gold and Scriver (1971)96 Finlay-Marks Syndrome Taniai et al (2004)114 Beare-Stevenson Syndrome Tao et al (2010)115 Balk J Stom, Vol 16, 2012 Natal and Neonatal Teeth 135

Another theory explaining the premature eruption is they occur in pairs65,123. The eruption of more than 2 teeth considered to be the abnormal position of the germ during is rare. Despite that, Masatomi et al77 in 1991 reported an its development in the alveolar bone8,97. Furthermore, 18-month-old Japanese boy with 14 natal teeth, Gonçalves Clergueau-Guerithault proposed that the eruption of natal et al40 in 1998 presented the case of a newborn with 12 and neonatal teeth could be dependent on osteoblastic natal teeth and Portela et al92 in 2004 reported a newborn activity within the area of the tooth germ102. with 11 natal teeth. As far as environmental factors are concerned, Natal teeth are described as conical or normal in some environmental toxins are considered to be size and shape, yellowish, with hypoplastic enamel and causative factors. Gladden et al (1990)39 reported that dentin, and poor or absent root development37,100,123. 13 of 128 newborns, whose mothers where exposed to The hypoplastic enamel might be related to gingival polychlorinated binephyls and dibenzofurans during the covering52 and has a tendency to discolour. The Yusheng environmental accident in Taiwan, had natal incomplete root formation is the reason for the great teeth. Also, 2 out of 12 live-borns from parents poisoned mobility of the natal and neonatal teeth. by PCBs in Kyushu, Japan were reported to have natal As far as histological characteristics are concerned, teeth82. Another report by Alaluusua et al (2002)2 despite the normal basic structure of the natal teeth, supports that there is no association between milk levels early eruption is associated with hypo-mineralization of 52 of polychlorinated binephyls, and dibenzofurans and the the enamel, which is usually described as dysplastic , occurrence of natal teeth. They suggest that the prevailing reduced in thickness and covering only the two thirds of 6,42 111 levels of polychlorinated binephyls and dibenzofurans are the crown , but has a normal ultrastructure . Complete 3,78 likely below the threshold to cause prenatal eruptions of absence of enamel is noted rarely . The enamel for teeth. the age of the child is normal but since the tooth erupts Moreover, the presence of natal and neonatal prematurely the matrix of the non-calcified enamel wears teeth has been associated with many syndromes and off in time and this is probably the reason why their developmental disturbances but there is no conclusive crowns look small in size and appear yellow brown in 52 42 evidence of a correlation with these systemic conditions25. colour . The dentino-enamel junction seems irregular . The conditions that are related with the appearance of Dentin and predentin appear normal coronally, natal teeth are shown in the table 2. but become irregular and with reduced number of dentinal tubules and large inter-globular spaces with Natal and neonatal teeth have also been reported in abnormal cell inclusions14,16,42 cervically and bonelike cutis gyratum and acanthosis nigricans10, Turnpenny apically resembling osteodentin, which is attributed to ectodermal dysplasia119, in association with primary stimulation by movement of the teeth. It has been further congenital glaucoma72, in a case of an anencephalic suggested that the mobility may cause degeneration of infant with cleft palate74, in association with giant Hertwig’s sheath, thus preventing root development and congenital nevocellular nevus53, in a case of restrictive stabilization109. Increased mobility causes histological dermopathy79, in a case of multiple joint dislocations with changes in the cervical dentin and cementum6,42,109. metaphyseal dysplasia90, in a case of multiple anomalies: Cementum is either absent14 or, if present, shows variation natal teeth, palatal cyst, bilateral lymphangiomas of the in thickness covers the cervical third of the crown and alveolar ridge and median alveolar notch21, in a case of is usually acellurar42. The pulp tissue has a normal complex craniofacial anomalies112, in Mohr syndrome9 appearance but the pulp cavity and the radicular canals are and in association with syringomas and oligodontia83. wider6,42,110. It is suggested that tooth abnormalities are dysmorphic In neonatal teeth the differences from normal markers of earlier developmental abnormalities, and could primary dentition are less pronounced due to their more 13 give warning signs in a syndrome diagnosis . mature state at the time of eruption6. Root formation in natal and neonatal teeth is grossly deficient14.

Clinical and Histological Characteristics Differential Diagnosis

Regarding clinical characteristics, the most affected Most of the teeth that occur in the oral cavity at birth teeth are the lower primary central incisors (85%), or during the first days of life represent the early eruption followed by the maxillary incisors (11%), mandibular of the normal primary deciduous dentition44,65. The canines and molars (3%) and maxillary canines and prevalence of supernumerary teeth has been suggested molars (1%)123. Another characteristic of natal teeth is that to range from 1-10%17,37,123. At this point, it is important 136 I. Markou et al. Balk J Stom, Vol 16, 2012 to mention the need of radiographic examination, in breast106, inflammation of the surrounding tissues, pain order to differentiate the premature eruption of a primary associated with mobility, which all may lead to refusal deciduous tooth from a supernumerary tooth15,25,65. to nurse52. Although no case is reported, there is usually Moreover, radiographic verification reveals the root a concern about aspiration or swallowing of the teeth development of the tooth, adjacent structures and the due to excessive mobility or spontaneous exfoliation95. existence of a relative germ in the primary dentition. Furthermore there can be teething symptoms just as with There are also 3 types of inclusion cysts that might eruption of the primary teeth52 or even infantile diarrhea, be confused with natal teeth: Epstein’s pearls, Bohn’s drooling and malaise106,110. The development of an nodules and dental lamina cysts. Epstein’s pearls are abscess, probably due to the loss of attachment, has also located along the mid-palatine raphe in the line of fusion been reported32,51. of embryonic palatal processes. They are true cysts A complication that is common with natal teeth is derived from residual ectodermal cells covering these ulceration of the tip or the ventral surface of the tongue, processes. The cysts are lined by stratified squamous known as Riga-Fede disease. The ulceration occurs epithelium and the lumen contains keratin24. Bohn’s after repetitive tongue thrusting not only in newborns nodules are usually multiple and located along the buccal but also to elder infants with the eruption of the primary and lingual aspects of the mandibular and maxillary mandibular central incisors and in children with familiar ridges68. They represent remnants of minor mucous dysanatomia107. There has also been a report of prenatal salivary glands. They are true cysts comprised of stratified ulceration of the tongue due to natal teeth58. The lesion squamous epithelium lining a dense fibrous connective begins as an ulcerated area and with repeated trauma tissue wall that contains mucous acinar cells and well- it may progress to an enlarged fibrous mass with the formed ducts. The clinical appearance of Epstein’s pearls appearance of a granuloma. The pain occurring from and Bohn’s nodules is similar. They are both small the ulceration often results on dehydration, feeding white-gray, raised nodules, 0.5-3 mm in diameter and no difficulties and discomfort. It also may lead to bleeding treatment is necessary24. and in a child with other medical problems a potential of The third type of cyst is dental lamina cyst which infection is added to the concerns107. Periapical abscess is appears as single or multiple swellings on the maxillary possible because enamel breakdown may lead to carries52. or mandibular ridges. These cysts, also known as gingival Another complication in children with cleft lip-palate is cysts of the newborn, are lined by thin epithelium and the potential interference in naso-alveolar moulding124. show a lumen usually filled with desquamated keratin, There have also been reported a case of reactive occasionally containing inflammatory cells. It is believed fibrous hyperplasia by a natal tooth106, hypoplasia of that they are created by fragments of dental lamina that primary and permanent teeth following osteitis due to remain within the alveolar ridge mucosa after tooth infection by neonatal tooth55 and also microdontic teeth formation. Most of them degenerate and involute or succedaneous to natal teeth, suggesting that there might be rupture into the oral cavity within two weeks to five some unknown developmental influence common to the months of postnatal life63. occurrence of natal teeth and abnormally small (mesio- Furthermore, natal teeth should be discriminated distal dimension) permanent successors75 and in neonatal from epulis and odontogenic hamartomas. Epulis are orthopaedics31. tumour-like growths of the gum that might be either sessile or pedunculated, and are reactive rather than neoplastic lesions68. Odontogenic hamartomas are tumour-like lesions, without the growth characteristics of Management a neoplasm, and develop during the time dental structures remain capable of further development and maturation38. The treatment plan for natal and neonatal teeth has many factors to consider. If the tooth is not interfering with the nutrient intake of the child and is otherwise asymptomatic no intervention should be made78. Although Complications it is difficult to determine initially whether root formation will occur in natal or neonatal teeth104 those teeth that Problems that arise from the presence of natal and are stable beyond 4 months have a good prognosis52. neonatal teeth include interruption in breastfeeding93 The retention of a natal tooth, which is part of the normal either by pain on suckling or by ulceration of the primary dentition, is suggested because of possible space mother’s nipples, but the infant’s tongue usually loss, although the opinions differ23,32,38. If the tooth is overlies the lower incisors while nursing and any supernumerary or has an excessive mobility, if it is poorly trauma will be to the infants tongue rather than mother’s developed or is associated with soft tissue growth106 or if Balk J Stom, Vol 16, 2012 Natal and Neonatal Teeth 137 it interferes with naso-alveolar moulding124 or presents Paediatric dentists should educate parents an abscess, the treatment of choice is extraction32,51,52. and medical community about the preferred treatment Before extraction, a dental radiograph should be obtained and should conduct any necessary extraction in order in order to inform the parents of possible complications to prevent trauma. The child should be re-evaluated and to get their consent. It is suggested to leave the tooth periodically to ensure oral health. Management of natal in the mouth as long as possible in order to decrease the and neonatal teeth should consist of concern to avoid possibility of removing permanent tooth buds with the any complication, to make early diagnosis and provide natal tooth or risk defecting them76. The possibility of adequate treatment. hypoprothrombinaemia should be taken into consideration as the commensal flora of the intestine might not have been established until the child is 10 days old. Since vitamin K is essential for the production of prothrombin Conclusion in the liver it should be administered before extraction Natal and neonatal teeth are rare conditions (0.5-1.0 mg, intramuscularly) if the routine postnatal 32 in infancy. Most commonly involved teeth are the injection is not given . Also, haemophilia should be mandibular central incisors. Despite the fact that the 38 investigated . The extraction is usually done under local exact etiology is still unknown, superficial position of anaesthesia but can also be done without anaesthesia the tooth germ with association of hereditary factors is depending on the gingival attachment, with the use of the most accepted possibility. Many complications may gauze as a pharyngeal guard32. After the extraction, it is occur with the nursing problem most commonly reviewed. advised to curette the socket to prevent the cells of the Treatment and periodic follow-up should be conducted by dental papillae from continuing to develop and erupting as a paediatric dentist. odontogenic remnants11,25,108. If curettage is to become the routine treatment, then the injection of local anaesthetic to provide adequate anaesthesia would be required32. Residual natal teeth have been reported with a risk of References formatting without curettage about 9.1%32, 86, myxoid 1. Agostini M, León JE, Kellermann MG, Valiati R, Graner calcified hamartoma1, pulp polyp as erupted remnants121, E, de Almeida OP. Myxoid calcified hamartoma and natal 84 pyogenic granuloma due to trauma during extraction and teeth: A case report. Int J Pediatr Otorhinolaryngol, 2008; peripheral ossifying fibroma60. 72(12):1879-1883. Riga- Fede disease is another complication of 2. Alaluusua S, Kiviranta H, Leppäniemi A, Hölttä P, natal teeth and neonatal teeth but it’s not an indication Lukinmaa P-, Lope L, et al. Natal and neonatal teeth in for extraction78. The treatment options include relation to environmental toxicants. Pediatr Res, 2002; 52(5):652-655. smoothing off the incisal edges of lower incisors 3. Allwright WC. Natal and neonatal teeth: a study among 3 with an abrasive instrument , modifying feeding Chinese in Hong Kong. Br Dent J, 1958; 105:163-172. behaviour or feeding devise, treatment of symptoms 4. Alvarez MP, Crespi PV, Shanske AL. Natal molars in Pfeiffer with oral triamcinolone acetonide in orabase applied syndrome type 3: A case report. J Clin Pediatr Dent, 1993; on the lesion (Kenalog® in Orabase® Triamcinolone 18(1):21-24. 5. Anderson RA. Natal and neonatal teeth: Histologic Acetonide Dental Paste USP, APOTHECON® investigation of two black females. ASDC J Dent Child, A Bristol-Myers Squibb Company), or placement of 1982; 49(4):300-303. composite over the edges of the insicors89,107. As many 6. Anneroth G, Isacsson G, Lindwall AM, Linge G. Clinical, natal and neonatal teeth have hypo-mineralised enamel histologic and microradiographic study of natal, neonatal and are difficult to access and keep adequate moisture and pre-erupted teeth. Scand J Dent Res, 1978; 86(1):58-66. control, the bonding of the resin is questionable and 7. Arboleda H, Quintero L, Yunis E. Wiedemann- Rautenstrauch neonatal progeroid syndrome: report of three presents the risk of swallowing or inhaling it. In cases of new patients. J Med Genet, 1997; 34:433-437. mild-to-moderate irritation to the tongue, such treatment 8. Baghdadi ZD. Riga-fede disease: Report of a case and may suffice. If the ulcerated area is large, however, even review. J Clin Pediatr Dent, 2001; 25(3):209-213. the reduced incisal edge may still contact and traumatize 9. Balci S, Güler G, Kale G, Söylemezoĝlu F, Besim A. Mohr the tongue during suckling to such an extent that would syndrome in two sisters: Prenatal diagnosis in a 22-week- delay healing86,118. The fact that the lesion could reoccur old fetus with post-mortem findings in both. Prenat Diagn, 89,107 1999; 19(9):827-831. should also be taken into consideration . If none of 10. Beare JM, Dodge JA, Nevin NC. Cutis gyratum, acanthosis the more conservative measures is effective, the option is nigricans and other congenital anomalies. A new syndrome. extraction of the tooth or even excision of the lesion107. Br J Dermatol, 1969; 81(4):241-247. 138 I. Markou et al. 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11. Berendsen WJ, Wakkerman HL. Continued growth of the 32. Dyment H, Anderson R, Humphrey J, Chase I. Residual dentinal papillae after extraction of neonatal teeth: Report of neonatal teeth: A case report. J Can Dent Assoc, 2005; case. ASDC J Dent Child, 1988; 55(2):139-141. 71(6):394-397. 12. Berman DS, Silverstone LM. Natal and neonatal teeth. A 33. El Khatib K, Abouchadi A, Nassih M, Rzin A, Jidal B, clinical and histological study. Br Dent J, 1975; 139(9):361- Danino A, et al. Natal teeth: Apropos of five cases. Revue 364. de stomatologie et de chirurgie maxillo-faciale, 2005; 13. Bloch-Zupan A. When Neuropediatrics Meets Odontology. 106(6):325-327. Neuropediatrics, 2007; 38:57-58. 34. Feinstein A, Friedman J, Schewach-Millet M. Pachyonychia 14. Bodenhoff J, Gorlin RJ. Natal and neonatal teeth: Folklore congenita. J Am Acad Dermatol, 1988; 19(4):705-711. and fact. Pediatrics, 1963; 32:1087-1093. 35. Fonseca MA, Mueller WA. Hallermann-streiff syndrome: 15. Boras VV, Zaini ZM, Savage NW. Supernumerary tooth Case report and recommendations for dental care. J Dent with associated dentigerous cyst in an infant. A case report Child, 1995; 61:334-337. and review of differential diagnosis. Aust Dent J, 2007; 36. Freudenberger S, Santos Díaz MÁ, Bravo JM, Sedano HO. 52(2):150-153. Intraoral findings and other developmental conditions in 16. Boyd JD, Miles AE. An erupted tooth in a cyclops foetus. Br mexican neonates. J Dent Child, 2008; 75(3):280-286. Dent J, 1951; 91(7):173-181. 37. Galassi MS, Santos-Pinto L, Ramalho LT. Natal maxillary 17. Buchanan S, Jenkins CR. Riga-fedes syndrome: Natal or primary molars: case report. J Clin Pediatr Dent, 2004; neonatal teeth associated with tongue ulceration. Case 29(1):41-44. report. Aust Dent J, 1997; 42(4):225-227. 38. Gardiner JH. Erupted teeth in the newborn. Proc R Soc 18. Byung-Duk A, Jung-Wook K. Hallermann-Streiff syndrome: Med, 1961; 54:504-506. those are not supernumerary teeth. J Pediatr, 2006; 148:415. 39. Gladen BC, Taylor JS, Wu Y-, Ragan NB, Rogan WJ, 19. Cabate HF, Gomide MR, Costa B. Evaluation of primary Hsu C-. Dermatological findings in children exposed dentition in cleft lip and palate children with and without transplacentally to heat-degraded polychlorinated biphenyls natal/neonatal teeth. Cleft Palate Craniofac J, 2000; in Taiwan. Br J Dermatol, 1990; 122(6):799-808. 37:406-409. 40. Gonçalves FA, Birman EG, Sugaya NN, Melo AM. Natal 20. Callanan AP, Anand P, Sheehy EC. Sotos syndrome with teeth: review of the literature and report of an unusual case. hypodontia. Int J Paediatr Dent, 2006; 16(2):143-146. Braz Dent J, 1998; 9(1):53-56. 21. Camm JH, Mourino AP. Multiple anomalies of a newborn: 41. Gordon RC, Langley RN. Natal teeth in American Indian Report of case. J Am Dent Assoc, 1987; 114(3):335-336. children. J Pediatr, 1970; 76(4):613-614. 22. Castiñeyra G, Panal M, Lopez Presas H, Goldschmidt E, 42. Hals E. Natal and neonatal teeth. Histologic investigations Sánchez JM. Two sibs with Wiedemann-Rautenstrauch in two brothers. Oral Surg Oral Med Oral Pathol, 1957; syndrome: possibilities of prenatal diagnosis by ultrasound. 10(5):509-521. J Med Genet, 1992; 29(6):434-436. 43. Harris DJ, Ashcraft KW, Beatty EC. Natal teeth, patent 23. Chow MH. Natal and neonatal teeth. J Am Dent Assoc, ductus arteriosus and intestinal pseudo obstruction: A lethal 1980; 100(2):215-216. syndrome in the newborn. Clin Genet, 1976; 9(5):479-482. 24. Cohen RL. Clinical perspectives on premature tooth eruption 44. Hebling J, Zuanon ACC, Vianna DR. Dente Natal - A Case and cyst formation in neonates. Pediatr Dermatol, 1984; of natal teeth. Odontol Clin, 1997; 7:37-40. 1(4):301-306. 45. Hennekam RCM, Van Doorne JM. Oral aspects of 25. Cunha RF, Boer FAC, Torriani DD, Frossard WTG. Natal Rubinstein-Taybi syndrome. Am J Med Genet, 1990(Suppl. and neonatal teeth: Review of the literature. Pediatr Dent, 6):42-47. 2001; 23(2):158-162. 46. Hersh JH, Verdi GD. Natal teeth in monozygotic twins with 26. Darwish S, Sastry KA, Ruprecht A. Natal teeth, bifid tongue Van der Woude syndrome. Cleft Palate Craniofac J, 1992; and deaf mutism. J Oral Med, 1987; 42(1):49-56. 29(3):279-281. 27. De Almeida CM, Gomide MR. Prevalence of natal/ 47. Himelhoch DA, Mostofi R. Oral abnormalities in the Ellis- neonatal teeth in cleft lip and palate infants. Cleft Palate- van Creveld syndrome: Case report. Pediatr Dent, 1988; Craniofacial Journal, 1996; 33(4):297-299. 10(4):309-313. 28. Dias C, Basto J, Pinho O, Barbêdo C, Mártins M, Bornholdt 48. Howkins C. Congenital teeth. Br Dent Assoc, 1932; D, et al. A nonsense porcn mutation in severe focal dermal 53:402-405. hypoplasia with natal teeth. Fetal and Pediatric Pathology, 49. Hyatt Sr. HW. Natal Teeth. It’s occurrence in five siblings. 2010; 29(5):305-513. Clin Pediatr, 1965; 4:46-48. 29. Dias PF, Guimaraes LF, Sanchez AN, Primo LG. 50. Jarvis A, Gorlin RJ. Minor orofacial abnormalities in an Rehabilitation of a Child with History of Multiple Natal Eskimo population. Oral Surg Oral Med Oral Pathol, 1972; Teeth and Oligodontia in the Permanent Dentition. Rev Fac 33(3):417-427. Odontol Porto Alegre, 2009; 50(2):18-21. 51. Kamboj M, Chougule R. Neonatal tooth-how dangerous can 30. Díaz-Romero RM, Shor-Hass F, Benitez-Tirado C, it be? J Clin Pediatr Dent, 2009; 34(1):59-60. Fernández-Carrocera L. [Anomalies of the oral cavity 52. Kates GA, Needleman HL, Holmes LB. Natal and neonatal in Mexican neonates]. Bol Med Hosp Infant Mex, 1991; teeth: A clinical study. J Am Dent Assoc, 1984; 109(3):441- 48(11):832-835. 443. 31. Durning P, MacLeod RI. A neonatal tooth in a cleft palate 53. Karthikeyan G, Kumar P, Narang A. Giant congenital baby: A complicating feature in neonatal orthopaedics - a nevocellular nevus and natal teeth. Indian Pediatr, 1996; case report. J Paediatr Dent, 1988; 4(1):27-31. 33(5):417-419. 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54. Kharbanda OP, Kaushik A, Kumar R, Sadhna, Kumar P. 75. Marcushamer M, King DL, McCourt Jr. JW. Microdontic Pierre robin syndrome with neonatal teeth. A case report. J teeth succedaneous to natal teeth: A report of two cases. Indian Dent Assoc, 1985; 57(9):345-347. Pediatr Dent, 1992; 14(6):400-401. 55. Kimoto S, Suga H, Yamaguchi M, Uchimura N, Ikeda M, 76. Martinez CR. Management of natal teeth. J Fam Pract, Kakizawa T. Hypoplasia of primary and permanent teeth 1978; 6(3):654-655. following osteitis and the implications of delayed diagnosis 77. Masatomi Y, Abe K, Ooshima T. Unusual multiple natal of a neonatal maxillary primary molar. International Journal teeth: Case report. Pediatr Dent, 1991; 13(3):170-172. of Paediatric Dentistry, 2003; 13(1):35-40. 78. Massler M, Savara BS. Natal and neonatal teeth; a review 56. King NM, Lee AMP. Natal teeth and steatocystoma of 24 cases reported in the literature. J Pediatr, 1950; multiplex: A newly recognized syndrome. J Craniofac 36(3):349-359. Genet Dev Biol, 1987; 7(3):311-317. 79. Mau U, Kendziorra H, Kaiser P, Enders H. Restrictive 57. King NM, Lee AMP. Prematurely erupted teeth in newborn dermopathy: Report and review. Am J Med Genet, 1997; infants. J Pediatr, 1989; 114(5):807-809. 71(2):179-185. 80. Mayhall JT. Natal and neonatal teeth among the Tlinget 58. Kinirons MJ. Prenatal ulceration of the tongue seen indians. J Dent Res, 1967; 46(4):748-749. in association with a natal tooth. J Oral Med, 1985; 81. Mendoza HR, Valiente MD. A newly recognized autosomal 40(3):108-109. dominant ectodermal dysplasia syndrome: the odonto- 59. Koenig R. Teebi hypertelorism syndrome. Clin Dysmorphol, tricho-ungual-digital-palmar syndrome. Am J Med Genet, 2003; 12(3):187-189. 1997; 71(2):144-149. 60. Kohli K. Peripheral ossifying fibroma associated with 82. Miller RW. Congenital PCB poisoning: A reevaluation. a neonatal tooth: Case report. Pediatr Dent, 1998; Environ Health Perspect, 1985; 60:211-214. 20(7):428-429. 83. Morrison PJ, Young ID. Syringomas, natal teeth and 61. Koklu E, Kurtoglu S. Natal teeth and neonatal transient oligodontia: a new ectodermal dysplasia? Clin Dysmorphol, pseudohypoparathyroidism in a newborn. Journal of 1996; 5(4):363-366. Pediatric Endocrinology and Metabolism, 2007; 20(9):971. 84. Muench MG, Layton S, Wright JM. Pyogenic granuloma 62. Korniszewski L, Nowak R, Okninska-Hoffmann E, Skorka associated with a natal tooth: Case report. Pediatr Dent, A, Gieruszczak-Biatek D, Sawadro-Rochowska M. 1992; 14(4):265-267. Wiedemann-Rautenstrauch (neonatal progeroid) syndrome: 85. Ndiokwelu E, Adimora GN, Ibeziako N. Neonatal teeth New case with normal telomere length in skin fibroblasts. association with Down’s syndrome. A case report. Am J Med Genet, 2001; 103(2):144-148. Odontostomatol Trop, 2004; 27(107):4-6. 63. Kumar A, Grewal H, Verma M. Dental lamina cyst of 86. 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96. Reynold JM, Gold MB, Scriver CR. The characterization of 113. Strømme Koppang H, Boman H, Hoel PS. Oral hereditary abnormalities of keratin: Clouston’s ectodermal abnormalities in the Saldino-Noonan syndrome. Virchows dysplasia. Birth Defects Orig Artic Ser, 1971; 7(8):91-95. Arch Pathol Anat Histopathol, 1983; 398(3):247-262. 97. Roberts MW, Vann Jr WF, Jewson LG, Jacoway JR, Simon 114. Taniai H, Chen H, Ursin S. Finlay-marks syndrome: AR. Two natal maxillary molars: Report of a case. Oral Surg Oral Med Oral Pathol, 1992; 73(5):543-545. Another sporadic case and additional manifestations. 98. Roshan AS, Janaki C, Parveen B, GomathyIndian N. Rare Pediatrics International, 2004; 46(3):353-355. association of hyper IgE syndrome with cervical rib and 115. Tao Y-, Slavotinek AM, Vargervik K, Oberoi S. Hypodontia natal teeth. J Dermatol, 2009; 54(4):372-374. in Beare-Stevenson syndrome: An example of dental 99. Ruschel HC, Spiguel MH, Piccinini DD, Ferreira SH, anomalies in FGFR-related craniosynostosis syndromes. Feldens EG. Natal primary molar: clinical and histological aspects. J Oral Sci, 2010; 52(2):313-317. Cleft Palate-Craniofacial Journal, 2010; 47(3):253-258. 100. Rusmah M. Natal and neonatal teeth: A clinical 116. Tay WM. Natal canine and molar in an infant. Report of a and histological study. J Clin Pediatr Dent, 1991; case. Oral Surg Oral Med Oral Pathol, 1970; 29(4):598-602. 15(4):251-253. 117. To EW. A study of natal teeth in Hong Kong Chinese. Int J 101. Sargent FC. Born to Die: Witchcraft and Infanticide in Paediatr Dent, 1991; 1(2):73-76. Bariba Culture. Ethnology, 1988; 27(1):79-95. 118. Tsubone H, Onishi T, Hayashibara T, Sobue S, Ooshima T. 102. Seminario AL, Ivancaková R. Natal and neonatal teeth. Acta Medica (Hradec Kralove), 2004; 47(4):229-233. Clinico-pathological aspects of a residual natal tooth: A case 103. Shaw A, Longman C, Irving M, Splitt M. Neonatal teeth report. J Oral Pathol Med, 2002; 31(4):239-241. in X-linked Opitz (G/BBB) syndrome. Clin Dysmorphol, 119. Turnpenny PD, De Silva DC, Gregory DW, Gray ES, Dean 2006; 15(3):185-186. JC. A four generation hidrotic ectodermal dysplasia family: 104. Sibert JR, Porteous JR. Erupted teeth in the newborn. 6 an allelic variant of Clouston syndrome? Clin Dysmorphol, members in a family. Arch Dis Child, 1974; 49(6):492-493. 105. Sigal MJ, Mock D, Weinberg S. Bilateral mandibular 1995; 4(4):324-333. hamartomas and familial natal teeth. Oral Surg Oral Med 120. Uzamis M, Olmez S, Ozturk H, Celik H. Clinical and Oral Pathol, 1988; 65(6):731-735. ultrastructural study of natal and neonatal teeth. J Clin 106. Singh S, Subbareddy V, Dhananjaya G, Path R. Reactive Pediatr Dent, 1999; 23(3):173-177. fibrous hyperplasia associated with a natal tooth - A Case 121. Vergotine R, Hodgson B, Lambert L. Pulp polyp associated Report. J Indian Sot Pedo Prev Dent, 2004; 22(4):183-186. 107. Slayton RL. Treatment alternatives for sublingual traumatic with a natal tooth: Case report. J Clin Pediatr Dent, 2009; ulceration (Riga-Fede disease). Pediatr Dent, 2000; 34(2):161-163. 22(5):413-414. 122. Wolf N. Dental anomalies in neuropediatric disorders. 108. Southam JC. Retained dentine papillae in the newborn. Medizinische Genetik, 2007; 19(4):414-417. A clinical and histopathological study. Br Dent J, 1968; 123. Zhu J, King D. Natal and neonatal teeth. ASDC J Dent 125(12):534-538. Child, 1995; 62(2):123-128. 109. Southam JC. The structure of natal and neonatal teeth. Dent Pract Dent Rec, 1968; 18(12):423-427. 124. Ziai MN, Bock DJ, Da Silveira A, Daw JL. Natal teeth: A 110. Spouge JD, Feasby WH. Erupted teeth in the newborn. Oral potential impediment to nasoalveolar molding in infants with Surg Oral Med Oral Pathol, 1966; 22(2):198-208. cleft lip and palate. J Craniofac Surg, 2005; 16(2):262-266. 111. Štamfelj I, Jan J, Cvetko E, Gašperšič D. Size, ultrastructure, and microhardness of natal teeth with agenesis of permanent successors. Annals of Anatomy, 2010; 192(4):220-226. 112. Stanek J, De Courten-Myers G, Spaulding AG, Strub Correspondence and request for offprints to: W, Hopkin RJ. Case of complex craniofacial anomalies, bilateral nasal proboscides, palatal pituitary, upper limbs Arhakis Aristidis reduction, and amnion rupture sequence: Disorganization Ermou 73 phenotype? Pediatric and Developmental Pathology, 2001; 54623 Thessaloniki, Greece 4(2):192-202. E-mail: [email protected]

E I

L BALKAN JOURNAL OF STOMATOLOGY A ISSN 1107 - 1141 IC G LO TO STOMA

The Maxillary Labial Fraenum - A Controversy of Oral Surgeons vs. Orthodontists

SUMMARY Eva Lioliou, Apostolos Kostas, The maxillary labial fraenum is a normal anatomic structure in the Lampros Zouloumis oral cavity, formed by mucous membrane and connective tissue. Although it Department of Oral and Maxillofacial Surgery, is a normal structure, its presence has been associated with some unpleasant Aristotle University, School of Dentistry, and even pathological situations. Specifically, a thick, hypertrophic or broad Thessaloniki, Greece fibrous fraenum has been accused of causing a maxillary midline diastema, interfering with plaque removal, causing tension and gingival recession. A surgical removal of the fraenum is indicated in order to prevent these situations or facilitate orthodontic closure of the diastema. Frenectomy is the complete removal of the fraenum, including its attachment to the underlying bone. As shown in the literature there has been a controversy among researchers regarding the need of frenectomy and the time of the surgery. The purpose of this study was to demonstrate the controversy of researchers regarding the removal of the maxillary labial fraenum, as a result of the study of the literature. Additionally, there has been an attempt to suggest the appropriate therapeutic strategy and indications for frenectomy, counting the medical experience and the patient’s needs. At the beginning of the study, it was important to cite the characteristics of normal and abnormal fraenum and consequences that presence of a pathological fraenum causes. Finally, there is a brief description of the most important surgical techniques for removal of the maxillary labial fraenum. LITERATURE REVIEW (LR) Keywords: Maxillary Labial Fraenum; Frenectomy, controversy Balk J Stom, 2012; 16:141-146

Introduction some of the cases a variation may lead to an “abnormal fraenum”; a fraenum which appears inordinately large The maxillary labial fraenum is a normal anatomic or is attached especially close to the gingival margin16. structure in the oral cavity, usually triangular in shape, Henry et al25, in their histological study, concluded that extending from the maxillary midline area of the gingiva there are also elastic fibres which extend sometimes to into the vestibule and mid-portion of the upper lip16. It the whole length of the fraenum, even perforating the consists of epithelium, collagen fibres, blood vessels, periosteum. Those authors considered that the harmful nerves and sometimes few elements of minor salivary effect of the fraenum is due to the presence of the elastic glands and isolated stratified muscle fibers19,42. and collagen fibres, while no evidence of substantial The fraenum is a dynamic and changeable structure, differences in composition of normal and abnormal fraena which tends to have variations in size, shape, and position were identified. Miller characterized as “pathological” of attachment during the different stages of growth a fraenum which is uncommonly wide, when there is and development12. It is found to be smaller in length, insufficient attached gingival zone in the midline, and thicker and more inferiorly attached in children12,34. The when the interdental papilla moves by stretch of the eruption of primary incisors, the development of the fraenum35. maxillary sinus and vertical growth of the alveolar process An abnormal labial fraenum has been implicated in make that insertion of the fraenum moves apically28. In functional and aesthetic problems, such as a maxillary 142 Eva Lioliou et al. Balk J Stom, Vol 16, 2012 midline diastema. Regarding the maxillary midline 6. When a maxillary labial fraenum prevents the diastema, two ways were suggested in which the fraenum installation of a removable denture; may cause it. In the first way, the bulk of the fraenum 7. In rare occasions, for aesthetic reasons. fibres, retaining their embryological connection with the incisive papilla, will physically prevent approximation of central incisors2,15,22. Alternatively, these fibres will interrupt the fibres of the periodontal ligament between The Fraenum by the central incisors and produce a weak link in the chain Orthodontic Approach of fibres that join the teeth from one end of the arch to the 1,5,13 other . The presence of the maxillary labial fraenum has a High fraenum insertion can lead to gingival recession great significance for the orthodontic community, since due to the tension which is applied on the tissues during it is considered to be the commonest causative factor for normal functions, such as speaking, chewing, and a maxillary midline diastema. An abnormal fraenum has laughing4,21,24,37,44. Moreover, a fraenum that encroaches also been accused of being a great danger for relapse after on the gingival margin and prevents the closure of space orthodontically treated diastema. Consequently, maxillary between the maxillary central incisors creates an area labial frenectomy was considered for many years as the for food impaction and difficulty in plaque removal24,37. indicated treatment for maxillary midline diastema9,14,34,37. The poor oral hygiene, due to difficulty in tooth brushing There has been a controversy even among results in inflammatory periodontal destruction33. orthodontists concerning the need at all, and the timing Aesthetics could be affected as well in cases of a high for a frenectomy. Some orthodontists support a viewpoint smile line4,44. Finally, a big and high attached fraenum that there is a need for an early removal of the fraenum, could eliminate lip movement4. so as to prevent any obstacles to complete diastema Over the years, the relationship between the closure. Other orthodontists propose to close the diastema maxillary midline diastema and the labial fraenum has first, and then carry out frenectomy in the hope that the been the subject of much controversy and confusion. In the 1939, Hirschfield advocated frenectomy as a resultant scar tissue will hold together the teeth in close mucogingival procedure to eliminate the aforementioned apposition. A third body of clinicians rarely, if ever, pathologic situations caused by an abnormal fraenum considers surgical removal of the fraenum. They prefer to attachment44. There is still a controversy among combat the undeniably increased relapse potential when a researchers concerning the need for it at all, as well as the diastema is closed, by using bonded retainers on the two 6,31,37 right time for frenectomy. central incisors . Many orthodontists support the idea that even in Literature offers a great variety of opinions during cases of an abnormal fraenum we should wait the eruption years and it is obvious that they differ a lot concerning of all 6 permanent anterior teeth first. If the eruption of the etiology of a persisting diastema, such as to the all 6 permanent teeth has failed to close the diastema, possibility of promoting closure of a diastema by means 9 frenectomy has a clinical validity only in conjunction of frenectomy . with orthodontic treatment16,27. They also state that the At the beginning it was thought that the labial relapse of orthodontically treated diastema caused by an fraenum interfered with the closure of the midline abnormal fraenum, which had not been excised, is a rare diastema. This belief resulted in misdiagnosis and 13,14 phenomenon3,5,16. On the other hand, surgeons accuse unnecessary surgical intervention of the fraenum . 1 a hyperplastic type of fraenum, usually with a fanlike Adams suggested that there is a specific type of fraenum attachment, of causing a diastema and enhancing the which interrupts the continuity of interdental fibre, forms possibilities of a relapse. A frenectomy could also prevent the factor that inducts the reaction for the development the other unpleasant situations cited previously, such as of the diastema. Although, he stated that there is a need gingival recession4,9,23,24,28,33,37. of presence of other causative factors. Campbell et al11 There are some clinical situations in which a stated the same. Shashua and Artun43 found that there is maxillary labial frenectomy is indicated4,24,37,49: a relationship between abnormal fraenum and the width 1. To avoid a relapse of an orthodontically treated of the maxillary midline diastema. Edwards16 supported maxillary diastema; the presence of a strong but not absolute correlation 2. In cases with a too short labial fraenum, which creates between the fraenum and the upper midline diastema. problems in upper lip movement, speech etc; Gardiner18 made a survey of 1000 children 5-15 years old. 3. To avoid gingival recession due to tension created 80% of the cases with midline diastema were associated during the normal oral function; with a prominent fraenum. He took this finding as an 4. To facilitate lip lengthening procedure; evidence to support the opinion that the fraenum is often a 5. To allow effective tooth brushing in the area of the contributory cause of midline diastema. Angle2 concluded fraenum; that the presence of an abnormal fraenum is a cause for Balk J Stom, Vol 16, 2012 The Maxillary Labial Fraenum 143 midline diastema. James29 used a sample of 10 girls 12-22 In case of a diastema, a hyperplastic type of fraenum, years old with medial diastema. A year after frenectomy, with a fanlike attachment, can inhibit the closure of the a reduction was noted in 8 cases. He assumed that diastema or even lead to a relapse of an orthodontically frenectomy leads to a reduction of the diastema. By the corrected diastema. Studies reveal that a midline diastema time researchers rejected this statement and proved that has closed earlier in operated cases. Thus, the result there is no evidence to establish a relationship between the implies that frenectomy is indicated, if early closure of the different types of fraenum and diastema. diastema is considered desirable, especially if patient finds Tait46 stated that the fraenum has no effect to the it very unsightly9. maxillary central incisors. Ceremelo12 concluded that The advantage of an early excision prior to the fraenum is not related to the presence or the width orthodontic treatment is the ease of surgical access33,37. of the diastema. Bergstorm et al9 stated that the long Access to the surgical procedure is more limited after term potential for spontaneous diastema closure, in orthodontic closure and it will not be possible to remove patients with abnormal fraenum, has no difference even all the residual fibrous tissue thoroughly from the if there has been a frenectomy, or not. Popovich et al40,41 interdental suture area37. suggested that the presence of the diastema leads to the In guides of paediatric, oral surgery treatment is abnormal fraenum, and not the adverse. suggested when attachment exerts a traumatic force on the Since there is no quite evidence concerning the fact gingiva, causing the papilla to blanch when the upper lip that the maxillary labial fraenum is the main causative is pulled, or if it causes a diastema to remain after eruption factor for a midline diastema, some orthodontists propose of permanent canines23. the following therapeutic methodology37,45: Initially, it Interference with oral hygiene measures, aesthetics is necessary for the dentist to make a diagnostic trial, in and psychological reasons are contributing factors that order to find out whether the fraenum is implicated in the relate the treatment of the maxillary fraenum23. pathogenecity of the diastema. Also, elimination of the maxillary labial fraenum is 1. Positive “blanch test” of the incisal papilla, when often indicated in edentulous or partial edentulous patients pulling the lips forward. By pulling the upper lip and to allow denture flange extension in this area49. exerting pressure on the fraenum, if there is a blanching, (ischemia in the papilla) it is safe to predict that the fraenum will unfavourably influence the development of the anterior occlusion; The Fraenum by 2. With the use of a periapical radiograph, in the Periodontal Approach area of central incisors we can discover: a presence of a mesiodens, an odontoma in the middle line; a presence The labial frenectomy must be examined by the of residual suture of alveolar bone. If we find out that the aspect of periodontists as well. In 1950, Friedman was diastema in our case is related to the fraenum, a maxillary the first to introduce the term “mucogingival surgery”, labial frenectomy is indicated. in order to describe techniques that aim to preserve the It is important to emphasize on the fact that attached gingiva, remove aberrant fraenum or muscle frenectomy has clinical validity only after the eruption attachment and increase the depth of the vestibule36. of all 6 permanent teeth if it failed to close the diastema, For years, clinicians targeted in removing the fraenum and then only in conjunction with orthodontic treatment. or deepening the vestibule17; today, it is approved that So after the eruption of all 6 permanent teeth, orthodontic the presence of an adequate zone of attached gingiva appliances are used to close the diastema. A frenectomy is the basic factor. When there is an adequate zone of is carried out, so as the scar tissue will hold the teeth attached gingiva, even a high fraenum attachment does 16,20,27,33,37,39,48 together . not constitute dangerous factor for the beginning and the During the primary dentition phase, surgical process of periodontal disease. On the other hand, in the 7 intervention of the labial fraenum is not recommended . case of inadequate zone of the attached gingiva, the draw of the fraenum and muscle attachment cannot be balanced, there is inability of good and atraumatic oral hygiene, and this is a fact that usually leads to gingival recession32,36. The Fraenum by Consequently, there exist anatomic (not adequate zone of Oral Surgery Approach attached gingiva), biologic (inflammation, inability for good oral hygiene) and functional (inability for protection Oral surgeons accused an abnormal fraenum of during chewing procedure) factors that lead to the causing unpleasant situations, such as maxillary midline decision of frenectomy32. The maxillary labial fraenum diastema and consequently suggested the operation of may present the aesthetic problem as well, compromise an maxillary labial frenectomy20,36. orthodontic result or create traumatic problems in tissues 144 Eva Lioliou et al. Balk J Stom, Vol 16, 2012 during oral hygiene actions. These situations also need and periosteum exposed3. After that, some modifications surgical intervention32. include the addition of horizontal relaxing incisions and The initial approach was to remove the fraenum the mucogingival junction, and the lateral underlying with simultaneous deepening of the vestibule. Later, this of the labial attached gingiva adjacent to the excision technique was replaced by plastic surgery, which aimed area. Disagreements have been expressed because of to cover the root of the tooth. Another technique was a the increased possibility for creating hematoma and frenectomy with a gingival augmentation procedure, using concerning the need for a dressing over the wound16. a pedicle graft36. Another procedure that was described called “the Edwards16 used a sample of 308 patients, who prior z-plasty technique”. In this technique, the fraenum is to orthodontic treatment demonstrated either diastema not removed but it is intended to relax the pull of the an abnormal fraenum or a combination of both. In his fraenum on the interdental soft tissue16,20. By the aspect of technique he noticed the aesthetic maintenance of the periodontists, there has been described a frenotomy with interdental papilla between the central incisors. Miller no excision of the marginal papilla, and “the curtain type” chose a surgical technique in which he avoided removal of of gingivotomy of the palatal tissue behind 4 incisors the entire fraenum, but emphasized in orthodontic stability (Frisch, Jones, Bhaskar)16. Other clinicians combined the without aesthetic sacrifice. His technique seemed to be classic frenectomy with a lateral pedicle graft, free papilla similar, but Edwards thought that the transeptal fibres of graft and free gingival graft taken from the papilla4,20. A the fraenum should be destroyed, whereas Miller made lateral pedicle graft does not offer a complete coverage no effort to destroy transeptal fibres35,36. Regarding the of the wound and has aesthetic problems creating an interdental papilla, it proved that it should be maintained, unsatisfactory colour match4. A technique known as even though clinically it may appear to be a part of the “Archer incision” is a simple frenectomy that is made labial fraenum36. with a V-shaped incision3. The disadvantage of this Periodontists do not tend to use the classical technique is that it leaves a longitudinal surgical incision frenectomy, in which interdental tissue and palatine and scarring, which may lead to periodontal problems and papilla are completely excised. Today, we use frenectomy an non-aesthetic appearance4. in which we have a partial removal of the fraenum and Recently a new frenectomy technique has been relocate it to a more apically position. This technique proposed by Bagga et al4, which provides a good aesthetic leads to an acceptable solution of the problem and to the result. In this technique, a V-shaped full-thickness incision movement of the fraenum more apically16,44. was placed at the gingival base of the fraenum attachment. In case of a diastema, the ideal time for this After the excision of a fraenum, a V-shaped defect on the technique is after the beginning of orthodontic treatment gingiva side has remained. An oblique partial thickness and about 6 weeks before the appliances are removed. incision is placed on adjacent attached gingiva extending That allows healing, tissue maturation and does not beyond the mucogingival junction. A partial-thickness prolong orthodontic treatment36. dissection of the attached gingiva is formed in an apico- coronal direction. Then we have a triangular pedicle of the attached gingiva with free apex and the base continuous with the alveolar mucosa. Finally, a bilateral triangular Surgical Techniques pedicle is sutured at the centre, covering the underlying defect4. Various surgical techniques have been described for the management of the abnormal upper labial fraenum8,20,30. It is important to refer that there is a distraction between the terms “frenectomy” and Discussion “frenotomy”. Frenectomy is the complete removal of the fraenum including its attachment to underlying bone; The study of the literature reveals that the presence frenotomy is the partial removal of the fraenum and is of the maxillary labial fraenum has been associated used extensively for periodontal purposes to relocate the with many pathological situations in the oral cavity; fraenum attachment, so as to create an increased zone of the most common of them is the maxillary midline the attached gingiva between the gingival margin and the diastema. Consequently, for decades there has been a fraenum16,24,37. tendency from every part of the dental community, to 2 main ways for the removal of the fraenum are remove the fraenum at an early age in order to achieve the conventional technique with scalpels or periodontal the diastema closure.13 Many researchers dealt with this knives and the technique with the use of soft tissue issue and many research papers have been published. laser24,47. Archer described the classic frenectomy The therapeutic approach gradually changed into a more technique in which the fraenum, interdental tissues and conservative management and a controversy among palatine papilla are completely excised, leaving bone researchers started, existing until nowadays. Balk J Stom, Vol 16, 2012 The Maxillary Labial Fraenum 145

In the orthodontic community there is unanimity 15. Bell WH. Surgical-orthodontic treatment of interincisal on this issue37. Orthodontists support that the fraenum diastemas. Am J Orthod, 1970; 57:158-163. should be maintained until the age of the eruption of all 16. Bergstrom K, Jensen R, Martensson B. The effect of 6 permanent anterior teeth. After that, and only if the superior labial frenectomy in cases with midline diastema. diastema remains the same, a frenectomy is indicated, Am J Orthod, 1973; 63:633-638. 17. Campbell A, Kindelan J. Maxillary midline diastema: a with subsequent orthodontic closure of the diastema9,16. case report involving a combined orthodontic/maxillofacial Periodontists concentrate on the issue of the adequate approach. J Orthod, 2006; 33; 22-27. zone of the attached gingiva. In case of inadequate zone of 18. Campbell PM, Moore JW, Matthews JL. Orthodontically the attached gingiva, the increased tension causes gingival corrected midline diastemas. A histologic study and surgical 24,32,36 recession and a frenectomy is recommended . procedure. Am J Orthod, 1975; 67:139-158. Oral surgeons suggest that in case of a maxillary 19. Ceremello PJ. The superior labial fraenum and the midline midline diastema, a small intervention of the fraenum diastema and their relation to growth and development of is useful. In this way, the closure of the diastema is the oral structures. Am J Orthod, 1953; 39:120-139. facilitated and the orthodontic treatment is not affected9,20. 20. Dewel BF. The labial fraenum, midline diastema, and In cases that the fraenum causes problems in periodontal palatine papilla: a clinical analysis. Dent Clin North Am, tissues, such as gingival recession, the removal of the 1966; pp 175-184. fraenum should be direct24,44. 21. Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema and fraenum morphology in the primary dentition. Journal Moreover, it is quite clear that when the presence of dentistry for children, 2006; 73:11-14. of the maxillary labial fraenum interrupts the installation 22. Dickson GC. Orthodontics in general dental practice. of a removable denture, the removal of the fraenum is London: Pitman, 1964. 49 imperative . 23. Edwards JG. The diastema, the fraenum, the frenectomy: A Today, the belief that the presence of a maxillary clinical study. Am J Orthod, 1977; 71:489-508. midline diastema does not prompt an early frenectomy 24. Friedman N. Mucogingival surgery. Texas Dent J, 1957; 75. predominates. We must wait for a short period, 25. Gardiner JH. Midline spaces. Dent Prac Dent Rec, 1967; specifically until the eruption of all 6 permanent anterior 17:287-298. teeth9,14,16,20,34,36,37. Yet, this is acceptable if the fraenum 26. Gartner LP, Schein D. The superior labial fraenum: a is not responsible for other pathological situations in the histologic observation. Quintessence Int, 1991; 22:443-445. oral cavity. 27. Gkantidis N, Topouzelis N, Zouloumis L. Differential diagnosis and combined treatment of maxillary midline On the other hand, it is important to remember that diastema caused by the fraenum and/or intermaxillary the final decision is taken by patients. The duration and suture. Balk J Stom, 2008; 12:81-88. the cost of the treatment are 2 basic factors. Patients rarely 28. Gottsegen R. Fraenum position and vestibule depth in compromise with expensive and long-term procedures, relation to gingival health. Oral Surg Oral Med Oral Pathol, especially if these include orthodontic treatment which 1954; 7:1069-1078. affects aesthetics8,9. 29. Graber TM. Orthodontics: Principles and Practice. Philadelphia: Saunders, 1972. 30. Guideline on Pediatric Oral Surgery, American Academy of Pediatric Surgery (AAPD). 2010; p 8. References 31. Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide 8. Adams CP. The relation of spacing of the upper central laser and scalpel techniques. J Periodontol, 2006; 77:1815- incisors to abnormal labial fraenum and other features of the 1819. dento-facial complex. Dent Prac Dent Rec, 1954; 74:72-86. 32. Henry SW, Levin MP, Tsaknis PJ. Histologic features of the 9. Angle EH. Malocclusion of the teeth. 7th ed. Philadelphia: superior labial fraenum. J Periodontol, 1976; 47:25-28. White dental manufacturing, 1907. 33. Herremans EL. Anterior diastema: frenectomy. Dent Surv, 10. Archer WH. Oral surgery for dental prosthesis. In: Archer 1971; 47:33-37. WH (Ed). Oral and maxillofacial surgery. Philadelphia: 34. Huang SW, Creath CJ. The midline diastema: a review of its Saunders, 1975; pp 135-210. etiology and treatment. Pediatr Dent, 1995; 17:171-179. 11. Bagga S, Bhat KM, Bhat GS, Thomas BS. Esthetic 35. Jacobs MH. The abnormal fraenum labii. Dent Cosmos, management of the upper labial fraenum: a novel 1932; 74:436-439. frenectomy technique. Quintessence, 2006; 37:819-823. 36. James GA. Clinical implication of a follow-up study after 12. Baum AT. The midline diastema. J Oral Med, 1966; 21:30- frenectomy. Dent Pract, 1967; 17:299-305. 39. 37. Kahnberg KE. Fraenum surgery. A comparison of three 13. Beasley WK, Maskeroni AJ, Moon MG, Keating GV, surgical methods. Int J Oral Surg, 1977; 6:328-333. Maxwell AW. The orthodontic and restorative treatment of a 38. Kinderknecht KE, Kupp LI. Aesthetic solution for large large diastema: a case report. Gen Dent, 2004; 52:37-41. maxillary anterior diastemas and fraenum attachment. Prac 14. Bedell WR. Nonsurgical reduction of the labial fraenum with Periodontics Aesthet Dent, 1996; 8:95-102. and without orthodontic treatment. J Am Dent Assoc, 1951; 39. Konstantinidis A. Periodontology. Vol 1.Thessaloniki: 42:510-515. Konstantinidis A, 2003; p 77. 146 Eva Lioliou et al. 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40. Koora K, Muthu MS, Rathna PV. Spontaneous closure of 50. Shashua D, Artun J. Relapse after orthodontic correction midline diastema following frenectomy. J Indian Soc Pedo of maxillary median diastema: a follow-up evaluation of Prev Dent, 2007; 25:23-26. consecutive cases. Angle Orthod, 1999; 69:257-263. 41. Lindsey D. The upper mid-line space and its relation to 51. Sorrentino JM, Tarnow DP. The semilunar coronally the labial fraenum in children and in adults. A statistical repositioned flap combined with a frenectomy to obtain root evaluation. Br Dent J, 1977; 143:327-332. coverage over the maxillary central incisors. J Periodontol, 42. Miller PD Jr. The frenectomy combined with a laterally 2009; 80:1013-1017. positioned pedicle graft. Functional and esthetic 52. Spiropoulou MN. Basic Principles of Orthodontic. Vol 2. considerations. J Periodontol, 1985; 56:102-106. 2006; pp 250-251. 43. Miller PD Jr. Regenerative and reconstructive periodontal 53. Tait CW. The median fraenum of the upper lip and its plastic surgery. Dent Clin North Am, 1988; 32:287-305. influence on the spacing of the upper central incisor teeth. 44. Mittal M. Maxillary labial fraenectomy: indications and Dent Cosmos, 1924; 76:991-992. technique. Dent Update, 2011; 38:159-162. 54. Takei HH, Azzi RA. Periodontal plastic and esthetic surgery. 45. Munshi A, Munshi AK. Midline space closure in the mixed In: Newman MG, Takei HH, Carranza FA (Eds). Carranza’s dentition: A case report. J Indian Soc Pedo Prev Dent, 2001; clinical periodontology. London: WB Saunders, 2002; pp 19:57-60. 870-871. 46. Oesterele LJ, Shellhart WC. Maxillary midline diastema: a 55. Taylor JE .Clinical observations relating to the normal and look at the causes. J Am Dent Assoc, 1999; 130:85-94. abnormal fraenum labii superiors. Am J Orthod, 1939; 47. Popovich F, Thompson GW, Main PA. The maxillary 25:646-660. interincisal diastema and its relationship to the superior 56. Terry BC, Hillenbrand DG. Minor preprosthetic surgical labial fraenum and intermaxillary suture. Angle Orthod, procedures. Dent Clin North Am, 1994; 38(2):193-216. 1977; 47:265-271. 48. Popovich F, Thompson GW, Main PA. Persisting maxillary Correspondence and request for offprints to: diastema: differential diagnosis and treatment. Dent J, 1977; Prof. Lampros Zouloumis 43:330-333. Ippodromiou Sq 17 49. Ross RO, Brown FH, Houston GD. Histologic survey of the 54621, Thessaloniki,Greece frena of the oral cavity. Quintessence Int, 1990; 21:233-237. E-mail: [email protected]

E I

L BALKAN JOURNAL OF STOMATOLOGY A ISSN 1107 - 1141 IC G LO TO STOMA

Association between Condylar Position and Tilt of Frontal Occlusal Plane in Patients with Transversal and Vertical Dentofacial Discrepancy

SUMMARY L. Kanurkova1, J. Gjorgova1, B. Dzipunova1, Asymmetric malocclusion is a common problem in children with N. Toseska1, A. Dorakovska2, M. Popovska3, 3 transverse and vertical dental anomalies. These asymmetries can be skeletal, M. Pandilova dental, functional or combination of these. The aim of this study was to 1Faculty of Dentistry, Department of determine condylar position and quantifying inclination of frontal occlusal Orthodontics, Dental Clinical Centre, Skopje, plane in patients with transversal and vertical dentofacial discrepancy. FYROM 2 Private Dental Practice, Skopje, FYROM The study group consisted of 80 patients, 40 had unilateral posterior 3Faculty of Dentistry, Department of cross-bite, and 40 had normal occlusion. The age of the patients ranged Periodontology and Oral Pathology, Dental between 13 and 18 years. In addition to transversal and vertical clinical Clinical Centre, Skopje, FYROM observation, Ricketts facial PA cephalometric analysis was made. Radiographic analysis showed the relationship between the cant of the occlusal plane and mandibular position. The obtained results showed that there was a very high statistical significance (p<0.001) for cephalometric measurements inclination of occlusal plane Zl-A6/Zr-A6 between the 18 patients with unilateral cross- bite and patients with normal occlusion. Mandibular displacement, facial asymmetry and strongest correlation with condyle path asymmetry were found in the experimental group. Unilateral cross-bites were very often associated with condylar deviations and, in some cases, signs and symptoms of temporomandibular joint disorders were present. Keywords: PA Cephalometric Analysis; Unilateral Cross-bite; Condylar Deviation; ORIGINAL PAPER (OP) Occlusal Plane, inclination Balk J Stom, 2012; 16:147-153

Introduction discrepancies usually have mandibular displacements and, if left untreated, they can lead to skeletal deformation4 The relationship between dentition and orofacial with vertical asymmetry of the mandible, such as skeletal structures is not always harmonious and it inclination of the frontal occlusal plane and inclination of depends on tooth number and position in dental arch. the frontal mandibular plane. Identification of dental or skeletal factors, negative Growth in the transverse dimension happens earlier influence of growth and development, and tooth than in the sagittal or vertical dimension and hence eruption is necessary to prevent orofacial malocclusion. early treatment is necessary. Early treatment can prevent Modelling of bone occurs as a result of different growth, associated mandibular dysfunction and facial asymmetry of interrelated anatomic skeletal parts in orofacial region, caused by posterior cross-bites13. However, mandible influence of the function in orofacial region and forces displacement may not be all or even part of the cause applied on bone. of a craniomandibular dysfunction because orthodontic Asymmetric malocclusion is a common problem in treatment may be responsible for the different degrees of children with transverse and vertical dental anomalies. symmetry. These asymmetries can be skeletal, dental, functional Patients with asymmetric malocclusion have lateral or combination of these. Patients who have transversal displacement of the mandible because the maxillary 148 Lidija Kanurkova et al. Balk J Stom, Vol 16, 2012 arch is too narrow, the mandibular arch is too wide, or need of detailed medical history for complete evaluation the maxillary arch is too wide and the mandibular arch of temporomandibular disorder, including patient’s is too narrow, and a combination of these situations. description of symptoms and physical examination of the Some asymmetries are genetic in nature30. Of prime face and jaw movement. Complete medical history may importance is the fact that uncorrected cross-bites can be useful for making a correct diagnosis. produce undesirable growth and dental compensations The aim of this study was to investigate the that may lead to asymmetric jaw growth. Mandible relationship between dental and skeletal morphologic lateral displacement is clinically characterized by changes in patients with transversal and vertical deviation of the chin, dental midline discrepancy and dentofacial discrepancy, and to determine condylar facial asymmetry; patients have cross-bites in the position and inclination of frontal occlusal plane. posterior region, and high prevalence of the internal 9 temporomandibular joint derangement . Mandibular displacements are present in most unilateral posterior cross-bites. Patients have a deflective Material and Method dental contact, resulting in a functional shift on closure. This functional shift can cause unbalanced muscular The study group consisted of 80 patients, 40 had activity, with hyperactivity on the cross-bite side. unilateral posterior cross-bite on the left side, and 40 This type of muscular hyperactivity has been shown patients had normal occlusion, and they were the control to influence the size and shape of the developing group. The age of the patients ranged between 13 and temporomandibular joint. Deviation of the midline 18 years, with equal sex distribution. Ricketts facial when the mouth is wide open suggests a mandible PA cephalometric analysis27,28 was used as a method for 8 laterognathia . transversal and vertical clinical observation. This analysis Diagnosis of temporomandibular joint disorders was made on the cephalometric films by standard methods is very difficult and confusing. In most cases, there is a (Fig. 1).

Figure 1. PA cephalometric film Figure 2. Cephalometric transversal and vertical landmarks, reference lines, craniofacial angle, used in the PA analysis

The transversal and vertical landmarks, reference -- facial width (ZA-AZ), distance of the left and right lines and measurements, used in the PA analysis (Fig. 2), zygion point on the zygomatic arch; -- maxillary width (Jl-JR), distance between point jugale are useful for determination of: located on the maxillary corpus; and -- cranial width (Zr–Zl), distance between lateral left -- mandibular width (AGol-AGor), distance between and right zygomatico-frontal landmarks; bigonial point. Balk J Stom, Vol 16, 2012 Patients with Vertical Dentofacial Discrepancy 149

-- Other cephalometric measurements used in this condylar position (Fig. 4). Bilateral facial asymmetries analysis were done to measure: and development of the orofacial area can be better -- dental arch width, inter-canine maxillary assessed with a transverse analysis of PA cephalometric cephalometric width (A3-3A); radiographs16,17. This analysis shows changes in vertical -- inter-canine mandibular cephalometric width (B3-3B); and transversal dimensions of the face. -- inter-molar maxillary cephalometric width (A6-6A); -- inter-molar mandibular width (B6-6B); -- molar relation A6/B6, on the left side and molar relation on the right side 6A/6B. Craniofacial angle showing the cross-bite type, is the angle between points zygomatico-frontale-antegonion- jugale

Results

The results and comparison of the means of angular and linear skeletal dentofacial variables between patients with unilateral cross-bite and control group are presented in tables 1-3. Results of facial, maxillary and mandibular skeletal cephalometric measurements are shown in table 1. Patients with unilateral posterior cross-bite had constriction of the maxillary corpus on the left side in the region of the point Jugale. Moreover, maxillary dental Figure 3. Linear cephalometric measurements for inclination and evaluation of occlusal plane (Zl-A6/A6-Zr) arch was smaller and maxillary first molar had palatal inclination (Tab. 1). Results for angular cephalometric measurements Symmetry in maxillo-mandibular region and obtained by Ricketts P-A analysis are shown in table type of the facial asymmetry is measured with linear 2. Angle which shows cross-bite type

Table 1. Linear facial and dental cephalometric measurements (mm) used in Ricketts PA analysis in patients with cross-bite on the left side

Facial Cephalometric Patients with unilateral cross-bite Patients with normal occlusion Measurements n=40 n=40 Mean SD Mean SD “t“ P Zr - Zl 99.5 4.2 102.0 4.1 1.6 0.1 ZA - AZ 127.0 5.4 132.2 3.5 2.5 0.01** Jr - Jl 65.7 3.5 70.9 4.5 4.3 0.001*** Agor - Agol 86.3 3.3 88.9 3.1 1.8 0.72 Dental Cephalometric Measurements A3 - 3A 33.2 2.4 34.6 2.7 1.7 0.8 B3 - 3B 29.2 1.8 29.8 2.6 0.8 0.42 A6 - 6A 59.4 3.5 63.7 5.8 3.1 0.001*** B6 - 6B 61.2 3.5 62.3 5.7 0.8 0.416 A6 / B6 0.91 0.8 0.9 0.5 0.1 0.882 6A / 6B -1.97 1.1 1.0 0.5 3.4 0.001***

* p< 0.05; ** p< 0.01; *** p< 0.001

Table 2. Angular cephalometric measurements used in Ricketts PA analysis

Cephalometric Patients with Patients with angular measurements unilateral cross-bite normal occlusion n = 40 n= 40 Mean SD Mean SD “t“ p

Table 3. Cephalometric measurements (mm) for condylar position and

inclination of occlusal plane

Patients with Patients with Cephalometric unilateral cross-bite normal occlusion linear measurements n = 18 n= 40 Mean SD Mean SD “t“ p Zr -Agor 97.16 2.57 101.1 4.5 2.01 0.01* Zl - Agol 94.66 2.63 101.2 3.5 2.98 0.01** Zr - A6 73.55 3.36 76.6 2.3 1.96 0.5* Zl - 6A 73.47 3.35 76.6 3.5 1.96 0.05* * p< 0.05; ** p< 0.01; *** p< 0.001 Balk J Stom, Vol 16, 2012 Patients with Vertical Dentofacial Discrepancy 151

Results from PA cephalometric study provided useful of 19.8 degree, compared to that in the control group information for condylar position Zl-Agol and inclination (p<0.001). The value of this angle showed that patients of occlusal plane Zl-6A. Results from these measurements had skeletal lingual cross-bite. in patients with unilateral posterior cross-bite are PA cephalograms showed mandible asymmetry in presented in table 3. Out of 40 patients, 18 had inclination 18 patients; they had inclination of the frontal occlusal of the occlusal plane and mandibular displacements. plane for 3 mm (Zl-A6/ Zr-A6). The results suggest that the degree of asymmetry in the vertical dimension was statistically significant (p<0.01) and the inclination correlated with TMJ disorder symptoms. Irregular dental Discussion occlusion had also influence on the changes in cant of the occlusal plane3; differences in the heights of the right and Orthodontic diagnosis is mostly based on the left mandibular rami have been suggested as important 32 use of cephalometric radiographs as a diagnostic skeletal problem associated with TMJ pathology . Our tool. Transversal and vertical components are easily analysis was in agreement with the reports in similar viewed from lateral cephalograms, but cannot be fully studies2,27,32. Patients with facial asymmetry had shifted understood without the assistance of PA cephalometric position of the mandible, which showed the strongest 9,12 analysis. Roentgenograms, such as the postero-anterior correlation with condyle path asymmetry . Unilateral view, submental vertex21, 3-dimensional image of the cross-bites are very often associated with condylar patients’ face22, and computerized tomography images deviations and in some cases are signs of TMJ disorders25. are important methods for diagnosis and quantification Analysis of frontal PA radiographies in this study of dentofacial transversal and vertical discrepancies and showed that patients with cross-bite had: lingual facial asymmetries. inclination of maxillary buccal teeth, constriction of the Diagnosis of unilateral and bilateral vertical maxillary corpus on the level of the point jugale, skeletal, asymmetries and development of the orofacial area can lingual cross-bite, and facial asymmetry. Our results be better assessed with frontal transverse analysis of PA coincide with the findings presented in the studies of cephalometric radiographs8,10,17. PA cephalogram, in Hewitt10 and Kusayama14. fact, contains important diagnostic information, which Many studies have defined geometric and shows level and type of facial asymmetries23,27,28. Patients mathematical relationships between dental occlusion and with lateral occlusion and midline shift can be observed rotations of the occlusal plane in the frontal view6,8,10. in occlusal position. In patients with laterognathy, the As a general clinical guide, each degree of rotation of the midline shift can be observed in both situations, in occlusal plane will result in a half-millimetre change in occlusal position and when the mouth is wide open. If the dental occlusal relationship. This is important since cross-bite and lateral occlusion are not treated during changes in the cant of the occlusal plane are sometimes growth, they can lead to asymmetric jaw growth. Degree unintentional, as well as intentional, during occlusal of asymmetry in the vertical dimension significantly therapy. The distance in millimetres between the facial correlated with TMJ symptoms20. midline and the midline of the mandible incisors has PA cephalometric analysis is more conservative been described as the dental midline shift4. A dental than 3-dimensional image of the patients’ face22 or midline shift on the left and right side was considered as computerized tomography images. This analysis gives the absolute value for diagnostic criteria for transverse opportunity to show the severity of the skeletal problem. asymmetry. Analysis of PA cephalograms in this study showed Asymmetrical patients have also been found to have that patients with unilateral posterior cross-bite had a a higher incidence of morphological changes and internal constriction on the maxillary corpus in the point jugale TMJ derangement on the shifted side when compared to and smaller maxillary dental arch in inter-molar region. the non-shifted side20,21 and it has been suggested that Mandibular arch was within normal parameters. PA the incidence of disk displacement and TMJ disorder roentgenograms showed that maxillary width had lower symptoms on the deviated side is higher than on the non- values in patients with unilateral cross-bite (65.7 mm). deviated side. These values compared with the values of the patients An insufficient maxillary arch width in our with normal occlusion (70.9 mm) showed a very high study is a typical finding in the unilateral posterior statistical significance (p<0.001). Therefore, the patients crossbite14. Functional shift results in lateral mandibular with a cross-bite had a statistically significantly smaller displacement, and thus, there is a mandibular midline palatal volume with skeletal constriction on the maxillary discrepancy19. When the maxilla is severely constricted, a corpus. bilateral posterior cross-bite is present. Angle between point zigomatico-frontale and Causes of asymmetric malocclusion are antegonion malocclusions with a wide range of symptoms, resulting in normal function. leading to skeletal and dental arch deformities, tooth Early diagnosis and treatment will facilitate malposition, masticator disturbances, TMJ disorders, establishment of functional and aesthetic individual and facial asymmetry. Woodside and Linder-Aronson34 optimum to maintain the specific features of the listed a number of factors that were contributory to concerned person, and will correct growth and malocclusions and altered skeletal relationships. Several development of the orofacial region. studies confirmed the following contributory factors: genetic predisposition, enlarged adenoids, enlarged tonsils, allergic rhinitis, sleep apnea, deviated nasal septum, altered mandibular posture, altered tongue References posture, extended head posture, incorrect orthodontic treatment, weakness in the muscles of mastication, and 1. Bishara S, Burkey P, Khartouf J. Dental and facial thumb sucking34. Most TMJ problems are multifactorial asymmetries: a review. Angle Orthod, 1994; 64(2):89-98. in origin, including a number of possible causes, such as 2. Bonnie LP, Maureen OK, Leonard BK. Occlusal cant in the condylar deviations and TMJ diseases, or irregular dental frontal plane as a reflection of facial asymmetry. J Oral occlusion. Asymmetry of the mandible shows a high Maxillofacial Surg, 1997; 55:811-816. incidence of TMJ disorders14,32. 3. Braun S, Legan HL. Changes in Occlusion Related to the Cant of the Occlusal Plane. Am J Orthod Dentofacial Functional shift of the mandible in children with Orthop, 1997; 111(2):184-188. unilateral posterior cross-bite results in an asymmetric 4 Buranastidporn B, Hisano M, Soma K. Temporomandibular position of condyle and suggests that this functional joint internal derangement in mandibular asymmetry. What shift may transmit forces to the skeleton, resulting in is the relationship? Eur J Orthod, 2006; 28(1):83-88. asymmetry in the adult23,24. This asymmetrical function 5. Ciuffolo F, Manzoli L, D’Attilio M, Tecco S, Muratore F, reflects different development of the elevator muscles on Festa F. Prevalence and distribution by gender of occlusal each side of the jaws, leading to a thinner masseter muscle characteristics in a sample of Italian secondary school on the cross-bite side32. Hesse9 described that uncorrected students: a cross-sectional study. Eur J Orthod, 2005; cross-bites may lead to restriction of maxillary growth and 27:601-606. traumatic occlusion, producing undesirable growth and 6. Ferrario VF, Sforza C, Miani A, Tartaglia G. Craniofacial morphometry by photographic evaluations. Am J Orthod dental compensations that may lead to asymmetric jaw Dentofacial Orthop, 1993; 103:327-337. growth, and mandibular displacement resulting in facial 7. Gandini P, Mancini M, Grampi B. Functional treatment of mild asymmetry. Differences in the heights of the right and left skeletal asymmetry. J Clinic Orthod, 2004; 38(11):607-612. ramus mandible have also been suggested as important 8. Grayson BH, McCarthy JG, Bookstein F. Analysis of skeletal problems associated with TMJ pathology32. craniofacial asymmetry by multiplane cephalometry. Am J Occlusal instability, midline discrepancy, right and Orthod, 1983; 84(3):217-224. left differences in molar relationship, and inclination of 9. Hesse KL, Artun J, Joondeph DR, Kennedy DB. Changes in the frontal occlusal plane2,3 have also been considered condylar position and occlusion associated with maxillary to be important occlusal characteristics in patients with expansion for correction of functional unilateral posterior unilateral posterior cross-bite12,15. crossbite. Am J Orthod Dentofacial Orthop, 1997; 111:410-418. In patients with posterior cross-bite and midline 10. Hewitt AB. A radiographic study of facial asymmetry. Br J Orthod, 1975; 2(1):37-40. deviation orthodontic treatment is necessary to rehabilitate 11. Higley LB. Crossbite - Mandibular malposition. ASDC J the asymmetric muscular activity between the cross- Dent Child, 1968; 35(3):221-223. bite and the other side and the changed position of the 12. Keeling SD, McGorray S, Wheeler TT, King GJ. Risk condyle caused by mandibular deviation. The success of factors associated with temporomandibular joint sounds the treatment rests on the presence of skeletal or dental in children 6 to 12 years of age. Am J Orthod Dentofacial changes. Skeletal asymmetries are preferably treated with Orthop, 1994; 105:279-287. a combination of orthodontics and orthognathic surgery. 13. Kecik D, Kocadereli I, Saatci I. Evaluation of the treatment Dental and small skeletal asymmetries and functional changes of functional posterior crossbite in the mixed dentition. mandibular asymmetries are most often treated with Am J Orthod Dentofacial Orthop, 2007; 131:202-215. orthodontic therapy. A combination of orthodontic and 14. Kusayama M, Motohashi N, Kuroda T. Relationship between transverse dental anomalies and skeletal orthopaedic treatment has been shown to correct the asymmetry. Am J Orthod Dentofacial Orthop, 2003; maxillary transverse deficiency, allow better mandibular 123(3):329-337. growth and improve facial and dental aesthetics. 15. Lam PH, Sadowsky C, Omerza F. Mandibular asymmetry When patients have problems in transversal maxillary and condylar position in children with unilateral posterior development, maxillary expansion is the treatment of crossbite. Am J Orthod Dentofacial Orthop, 1999; choice for posterior cross-bite; correction of maxillary 115:569-575. Balk J Stom, Vol 16, 2012 Patients with Vertical Dentofacial Discrepancy 153

16. Major PW, Johnson DE, Hesse KL, Glover KE. Landmark 26. Primožič J, Richmond S, Kau CH, Zhurov A, Ovsenik M. identification error in posterior anterior cephalometrics. Three-dimensional evaluation of early crossbite correction: Angle Orthod, 1994; 64:447-454. a longitudinal study. Eur J Orthod, 2011; 10:198. 17. Melnik KA. A cephalometric study of mandibular asymmetry 27. Ricketts MR, Roth HR, Chaconas JS, Schulhof JR, Engel in a longitudinally followed sample of growing children. Am AG. Orthodontic diagnosis and planning. Volume 1. Denver: J Orthod Dentofac Orthop, 1992; 101(4):355-366. Rocky Mountain Data Systems. 1982; pp 42-143. 18. Mulick JF. An investigation of craniofacial asymmetry using 28. Ricketts RM. Clinical implications of the temporomandibular the serial twin-study method. Am J Orthod Dentofacial joint. Am J Orthod Dentofacial Orthop, 1966; 52 :416-439. Orthop, 1965; 94:163-168. 29. Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal 19. Nanda R, Margolis JM. Treatment strategies for midline derangements of the temporomandibular joint: effect on facial development. Am J Orthod Dentofacial Orthop, 1993; discrepancies. Sem Orthodontics, 1996; 2(2):84-89. 104:51-59. 20. Nerder PH, Bakke M, Solow B. The functional shift of the 30. Schmid W, Mongini F. A computer-based assessment of mandible in unilateral posterior crossbite and the adaptation structural and displacement asymmetries of the mandible. of the temporomandibular joints: a pilot study. Eur J Am J Orthod Dentofac Orthop, 1991; 100(1):19-34. Orthod, 1999; 21:155-166. 31. Solberg WK, Bibb CA, Nordstrom BB, Hansson TL. 21. O’Byrn LB, Sadowsky C, Schneider B, BeGole AE. Malocclusion associated with temporomandibular An evaluation of mandibular asymmetry in adults with joint changes in young adults at autopsy. Am J Orthod unilateral posterior crossbite. Am J Orthod Dentofac Dentofacial Orthop, 1986; 89:326-330. Orthop, 1995; 107(4):394-400. 32. Trpkova B, Major P, Nebbe B, Prasad N. Craniofacial 22. Peck S, Peck L, Kataja M. Skeletal asymmetry in asymmetry and temporomandibular joint internal esthetically pleasing faces. Angle Orthod, 1991; 61:43-48. derangement in female adolescents: a posteroanterior 23. Pirttiniemi P, Kantomaa T, Lahtela P. Relationship between cephalometric study. Angle Orthod, 2000; 70:81-88. craniofacial and condyle path asymmetry in unilateral cross- 33. Van Eslande DC, Russett SJ, Major PW, Flores-Mi C. bite patients. Eur J Orthod, 1990; 12:408-413. Mandibular asymmetry diagnosis with panoramic imaging. 24. Pirttiniemi PM. Associations of mandibular and facial Am J Orthod Dentofacial Orthop, 2008; 134:183-192. asymmetries - a review. Am J Orthod Dentofacial Orthop, 1994; 106:191-200. Correspondence and request for offprints to: 25. Pinto AS, Buschang PH, Throckmorton GS, Chen P. Lidija Kanurkova Morphological and positional asymmetries of young blvd, “Jane Sandanski“ No.118-3/11 children with functional unilateral posterior crossbite. Am J Skopje, FYR Macedonia Orthod Dentofacial Orthop, 2001; 120:513-520. [email protected]

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Cephalometric Features of Class III Malocclusion among Albanian Patients Seeking Orthodontic Treatment

SUMMARY E. Kongo1, Xh. Mulo2 Skeletal class III malocclusion can have many contributors, including 1Albanian University, Department of Dentistry mandibular protrusion, maxillary retrusion and deficiency or combination of Tirana, Albania both. The most reliable way to distinguish the nature of class malocclusion 2Faculty of Medicine, Department of Dentistry for every individual patient is cephalometric analysis. It is not only used to Tirana, Albania choose the appropriate treatment plan, but also to analyze the features of a group of patients. The aim of this paper was to describe features of Albanian patients with skeletal class III malocclusion by means of cephalometric analysis done in patients seeking orthodontic treatment. ORIGINAL PAPER (OP) Keywords: Skeletal Class III; Cephalometric Analysis Balk J Stom, 2012; 16:154-156

Introduction well established etiology, treatment difficulties and compromised outcomes being affected from growth, has Class III malocclusion seriously affects function and taken lot of researches toward this type of malocclusion. aesthetic. This malocclusion has long time been viewed This malocclusion has highest prevalence among Asian as one of the most severe facial deformities. In 1178 John populations, reaching 12% in China. In Europe, the Hunter stated: “It is not uncommon to find the lower jaw prevalence is 1.5-5.3%, in North American among projecting too far forwards, so that its fore teeth pass Caucasian 1-4%1. Relatively high was found to be the before those of the upper jaw, when the mouth is shut; prevalence among Mediterranean populations. Concerning which is attended with inconvenience, and disfigures the Balkan population, in Northern Greece this prevalence face”. is 1.21% 2. As we do not possess data regarding the According to Angle, class III malocclusion occurs prevalence of skeletal class III in our country we decided when the lower teeth occlude mesial to their normal to perform this study to evaluate class III malocclusion relationship for the width of 1 premolar or even more among Albanian patients by means of cephalometric in extreme cases. With the advent of cephalometric analysis. radiography in 1934 it was possible to discern the underlying skeletal pattern of the class III malocclusion. Using cephalometric analysis, orthodontists nowadays classify class III malocclusion as maxillary retrusion, mandibular protrusion or combination of both. Class Material and Method III patients may have combination of skeletal and dentoalveolar components. 50 cephalograms of patients aged 8-18 years were Thus identifying the causative factor, it is possible to extracted from the files of orthodontic patients at the choose the most appropriate treatment for every individual UFO Dental Clinic. Selected patients meet the following patient and also to perform differential diagnosis. criteria: Related to the other types of malocclusions, the Albanian ethnicity; III class has the smallest prevalence. Although its Not undergone orthodontic treatment; prevalence is not too high compared with class I and Molar and canine relationship of class III; class II, the complexity of facial deformation, the not Negative overjet. Balk J Stom, Vol 16, 2012 Class III Malocclusion in Albanian Population 155

Lateral cephalograms were traced by hand and Results measured from the same person using Ricketts and Jaraback methods. Among all measurements, 6 angular Mean values, range, mean ± SC, and CI (confidence (Fig. 1) and 4 linear (Fig. 2) were chosen as determinants interval) for respectively linear and angular parameters of class III. Angular parameters included: (1) Facial axis are shown in tables 1 and 2. The results for analysis and angle; (2) Mandibular plane; (3) Lower face height; (4) discussion were divided with regard to anteroposterior SNA angle; (5) SNB angle; and (6) ANB angle. Linear relationship and vertical dimension. parameters included: (1) Facial convexity A-N Pog (in Thus, regarding anteroposterior relationship, there mm); (2) Lower lip to E plane (in mm); (3) S-N; and (4) was a wide range of the SNA (720-870) and SNB (730-860) Go-Me. angles and the linear distance of point A-Npog line [(-9) - (-5)]. The vertical dimension showed normal values of both indicators - the mandibular plane and lower third.

Table 1. Results of the measurements of linear parameters

Range Parameter Mean ± SD SE CI = mean ± 1.96 SE (min-max)

S: N 55 - 79 71.77 ± 4.44 0.79 69.01 - 74.53

Go-Me 54 - 90 74.70 ± 7.58 1.36 72.30 - 77.38

Point A (-9) - (-5) (-2.06) ± 3.56 0.64 3.57 - 1.06

E line (-11) - 5 (-2.87) ± 3.44 0.61 4.08 - 1.65

Table 2. Results of the measurements of angular parameters

Range Parameter Mean ± SD SE CI= min ± 1.96 SE min-max

SNA 72 - 87 78.54 ± 3.39 0.60 79.7 - 77.3

SNB 73 - 86 79.25 ± 3.31 0.59 78.09 - 80.42

Figure 1. Angular parameters done at the cephalograms ANB (-5) - 4 (-0.96) ± 2.49 0.44 1.84 - 0.088 Facial axis 84 - 97 90.61 ± 15.04 2.7 85.31 - 95.9 angle

Mandibular 14 - 35 26.19 ± 5.81 1.04 24.14 - 28.23 plane

Lower third 39 - 55 45.87 ± 3.73 0.67 44.55 - 47.18

Discussion

The statistically derived CI (confidence interval) indicates that skeletal class III among Albanian patients does not have significant difference with the values of referring authors: SNA angle is slightly reduced; maxilla is positioned posterior to the anterior cranial base; changes of the mandible to the sagittal plane are not registered. Class III malocclusion was more often caused by maxillary retrusion rather than mandibular protrusion in patients of Albanian ethnicity. Our sample could be classified as mesofacial type. Since the best choice for treatment of maxillary Figure 2. Linear parameters done at the cephalograms retrusion can be the forward movement of the maxilla 156 E. Kongo, Xh. Mulo Balk J Stom, Vol 16, 2012 by means of Delaire facial mask, it seemed to be the best 2. Kavadia-Tsatala S. Skeletal Class III Malocclusion. A choice for our skeletal class III patients. However, the Cephalometric Study in adult Greeks. Balk J Stom, 2004; success was greatly affected by age, nature of the patient 8(1):58-66. growth and patient’s collaboration. 3. Proffit WR. Contemporary Orthodontics. St Louis: Mosby, 2000.

References Correspondence and request for offprints to: Dr. Elona Kongo Albanian University, Department of Dentistry 1. Baccetti, Reyes, Mc Namara Jr. Gender differences in class Tirana, Albania III malocclusion. Angle Orthod, 2005; 75(4). E-mail: [email protected]

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Effect of Fluoride Varnish on Demineralization Adjacent to Orthodontic Brackets

SUMMARY E. Zabokova-Bilbilova1, Application of fluoride varnish is a preventive protocol that does A. Sotirovska-Ivkovska1, B. Evrosimovska 2, 3 not require patient compliance and permits the orthodontist to benefit L. Kanurkova from the bond strength of composite resins. The aim of this study was to School of Dentistry, Skopje, FYROM compare, in vitro, the effect of a fluoride varnish on inhibition of enamel 1Department of Pediatric and Preventive Dentistry demineralization adjacent to orthodontic brackets bonded with a resin- 2Department of Oral Surgery 3 modified glass ionomer cement (RMGIC) and a composite resin. A total of Department of Orthodontics 60 extracted human lower and upper premolars with no restorations, caries, and hypoplastic areas or pliers impressions were collected for this study. All teeth were cleaned and cut in half bucco-lingually with a diamond disc. The following adhesives for bonding brackets were used in this study: Con Tec LC (Dentaurum, Germany) and resin-modified glass ionomer cement Fuji Ortho LC (GC Corporation, Japan). Brackets in each group were bonded with a type of adhesive according to manufacturers’ bonding instructions. After brackets bonding, the premolars (test specimens) were kept dried carefully and the enamel received a single topical application of a fluoride varnish (Duraphat®; Germany) with the aid of a brush applicator. 3 minutes later, the teeth were wet with mild air/water spray and stored in artificial saliva until analysis, after 14 days and 1 month. Fluoride concentrations were measured by spectrophotometer. The results obtained indicated a significant increase in the levels of fluoride uptake in enamel after the use of resin-modified glass ionomer cement for bonding brackets and topical application of a fluoride varnish. Use of a fluoride varnish, when bonding brackets with GICs, is more effective in preventing enamel demineralization than the conventional composite resin. Based on these findings, it may be concluded that the examined fluoride varnishes had impact on the inhibition of enamel demineralization adjacent to orthodontic brackets. ORIGINAL PAPER (OP) Keywords: Enamel; Brackets; Decalcification; Fluoride Varnish Balk J Stom, 2012; 16:157-160

Introduction a few weeks after appliance placement1,2. These enamel scars can vary from microscopic alterations to visible It is well known that orthodontic treatment “white spot lesions” that may reach cavitations3. The with fixed appliances predisposes patients to a larger presence of these lesions is not usually observed until the accumulation of bacterial plaque and, hence, to enamel removal of orthodontic appliances and has been reported demineralization. This is due to the mechanical to be a frequent event4,5. Although previously published interference imposed by the orthodontic appliances, reports have indicated that molars are more susceptible maintaining adequate oral hygiene more difficult. to white-spot formation because of difficulties in Consequently, enamel demineralization lesions, resulting maintaining plaque control, the 6 maxillary anterior teeth from dissolution of the enamel, can appear within only are considered separately6. 158 Efka Zabokova-Bilbilova et al. Balk J Stom, Vol 16, 2012

Fluoride is important in the prevention of enamel cut in half bucco-lingually with a diamond disc. Thus, the demineralization. There are several methods of delivering control and test specimens were obtained from the same fluoride to teeth in patients during orthodontic treatment teeth. (in addition to fluoridated toothpaste). These include: -- topical fluorides (e.g. mouthrinse, gel, varnish, Table 1. Sample preparation toothpaste); -- fluoride-releasing materials (e.g. bonding materials, Group number Bonding agent Condition elastics). 1 Dentaurum no Duraphat Application of fluoride varnish is a preventive 2 Dentaurum with Duraphat protocol that does not require patient compliance 3 Fuji Ortho LC no Duraphat and permits the orthodontist to benefit from the bond 4 Fuji Ortho LC with Duraphat strength of composite resins. Prolonged contact time with fluoride varnish permits significantly more incorporation of fluoride than with other fluoride applications, e.g. After etching the enamel surface with a 37% acid phosphate fluoride gel, monofluoride phosphate phosphoric acid solution for 15 seconds and rinsing dentifrices, home fluoride rinses7,8. For instance, for 10 seconds, teeth were dried. Each bracket was Petersson et al9 observed that a 3-monthly application of positioned over the mid point of the clinical crown on fluoride varnish resulted in a dramatic reduction in caries buccal and lingual surfaces of the prepared premolar and incidence and the application of a fluoride varnish can be pressed firmly onto the surface. Any excess adhesive was easily adapted to current orthodontic bonding techniques. removed. The following adhesives for bonding brackets Fluoride varnishes have benefit of adhering to were used: Con Tec LC (Dentaurum, Germany) and RGIC the enamel surface longer than other topical fluoride Fuji Ortho LC (GC Corporation, Japan). Brackets in each products. Thus, fluoride varnishes have been reported to group were bonded with the same adhesive according be superior to sodium fluoride and monofluorophosphate to manufacturers’ bonding instructions. After brackets dentifrices in their ability to increase fluoride uptake in bonding, the premolars (test specimens) were kept enamel10. An increase was also found after 3 weeks when dried carefully and the enamel received a single topical comparing fluoride varnish with 2% sodium fluoride application of a fluoride varnish (Duraphat®; Germany) gel applied weekly, 2% acidulated phosphate fluoride with the aid of a brush applicator. 3 minutes later, the teeth gel applied weekly, or 0.25% sodium fluoride rinse were wet with mild air/water spray and stored in artificial used daily. Teeth with fluoride varnish applied around saliva (20 mmol/l NaHCO3, 3 mmol/l NaH2PO4 and 1 composite resin-bonded brackets showed a 35% reduction mmol/l CaCl2, neutral pH) until analysis, which is done 14 in demineralised lesion depth11. Teeth with RMGIC days and 1 month thereafter. Fluoride concentrations were (resin-modified glass-ionomer cement)-bonded brackets measured by spectrophotometer. demonstrated a 50% reduction in lesion depth with or For statistical evaluation, a 1-way analysis of without fluoride varnish application. The RMGI adhesives variance (ANOVA) followed by Tukey’s test was initially have been demonstrated to sustain fluoride release long used to see if there was a significant difference between after initial application, but they only protect a limited groups. area immediately adjacent to the orthodontic bracket. In addition, bond failures with RMGIC have been found to be similar or worse than composite resins12-14. The aim of this study was to compare, in vitro, Results the effect of a fluoride varnish on inhibition of enamel demineralization adjacent to orthodontic brackets bonded Table 2. The mean concentrations of total fluoride (ppm) in with a RMGIC and a composite resin. enamel in the group of teeth brackets bonded with composite resin 14 days after topical application of a fluoride varnish

Material and Methods Group N Mean SD t - value p test 15 1660.608 156.296 A total of 60 extracted human lower and upper 3.074 0.01326* premolars with no restorations, caries, and hypoplastic control 15 150.800 47.726 areas or pliers impressions were collected for this study. All extractions were indicated for orthodontic purposes in patients of 11-18 years of age. After being extracted, Table 2 shows the mean concentrations of total teeth were stored in artificial saliva and were divided in fluoride in enamel in the first group of tooth brackets 4 groups of 30 teeth (Tab. 1). All teeth were cleaned and bonded with Con Tec Duo 14 days after topical Balk J Stom, Vol 16, 2012 Effects of Fluorides on Demineralization 159 application of a fluoride varnish. The mean value of the bracket bonded with resin-modified glass ionomer fluoride in the examined group of teeth was 1660,608 cement Fuji Ortho LC and topical application of a fluoride ppm, and in the control group of teeth the value of F varnish is shown in table 5. After 1 month, a statistically was 150,800 ppm. There was a statistically significant significant difference occurred in the values of fluoride in difference between values of fluoride in the enamel in enamel between the experimental and control groups. both examined groups of teeth. Table 3 shows the mean concentrations of total fluoride in enamel in the group of teeth brackets bonded with RMGIC Fuji Ortho LC 14 days after topical Discussion application of a fluoride varnish. The mean value of fluoride in the examined group of teeth was 924,240 During orthodontic treatment, bonded brackets ppm, and in the control group of teeth the mean value promote more retention of dental plaque and make oral of fluoride was 664,052 ppm. There was a statistically hygiene difficult. A preventive method could be the use significant difference between values of fluoride in the of fluoride varnishes. Fluoride varnish applied around enamel in both examined groups of teeth. orthodontic appliances has been proven to diminish the incidence of white spot lesions. For instance, fluoride varnish, composed of a 5% sodium fluoride in a resin Table 3. The mean concentrations of total fluoride (ppm) in base, has shown a reduction in white spot incidence of enamel in the group of teeth brackets bonded with Fuji Ortho LC 18,19 14 days after topical application of a fluoride varnish about 50% . Therefore, periodic fluoride application may provide a clinically effective solution, although Group N Mean SD t - value p it was observed that such material cannot completely 20 test 15 924.240 428.865 prevent white spots . Moreover, application of fluoride 2.152 0.01862* varnish on existing lesions does prevent their progression and may help remineralisation. control 15 664.052 350.612 The aim of this study was to evaluate, in vitro, the effect of a fluoride varnish on the inhibition of enamel demineralisation adjacent to orthodontic brackets Table 4 shows the mean concentrations of total bonded with a RMGIC and a composite resin. Our fluoride in enamel in the group of examined teeth compared investigation was done on 2 different bonding materials to the control group of teeth 1 month after brackets bonded most commonly used in orthodontic practice. The with Con Tec Duo and topical application of a fluoride results obtained have indicated a significant increase in varnish. There was a statistically significant difference of the levels of fluoride uptake in enamel after the use of the values (389,300 ppm against 143,200 ppm). RMGIC Fuji Ortho LC for bonding brackets and topical application of a fluoride varnish. The analysis of the Table 4. The mean concentrations of total fluoride (ppm) in value of fluoride in enamel before and after bonding the enamel in the group of teeth brackets bonded with composite brackets with Fuji Ortho LC as well as the application of resin 1 month after topical application of a fluoride varnish a fluoride varnish clearly showed that after its application the fluoride level in enamel was significantly increased. Group N Mean SD t - value p Thus, the value of fluoride in enamel before bonding the test 15 389.300 326.209 brackets was 664,052 ppm. 14 days after bonding, the 2.321 0.04539* amount of fluoride in enamel was 924,240 ppm, which control 15 143.200 48.928 was significantly higher than the initially. After 1 month, the value of the quantity of fluoride in enamel in the examined (first) group was still high (534,788 ppm). The Table 5. The mean concentrations of total fluoride (ppm) in finding from this in vitro study indicates that application enamel in the group of teeth brackets bonded with Fuji Ortho LC of fluoride varnish may inhibit enamel decalcification 1 month after topical application of a fluoride varnish adjacent to orthodontic brackets. In our study enamel demineralization in vitro was Group N Mean SD t - value p inhibited to a certain degree. Similar decalcification test 15 534.788 178.327 prevention has been reported by many authors for other 2.076 0.04238* fluoride-releasing materials21-23. Besides the positive control 15 425.529 183.247 impact on local fluoride-release, cement used for bonding the brackets provides continuous presence of low concentrations of fluoride in the oral medium, which also The mean concentrations of total fluoride in enamel influences on inhibition of demineralised enamel around of the examined and control group of teeth 1 month after orthodontic brackets and bands. 160 Efka Zabokova-Bilbilova et al. Balk J Stom, Vol 16, 2012

The positive effects of fluoride varnish presented in caries-susceptible teenagers: A 3-year clinical study. Caries this study are in agreement with findings of other reports. Res, 2000; 34:140-144. 2 of these investigations used Duraflor varnish, which 10. Arends J, Lodding A, Petersson LG. Fluoride uptake in contains the same 5% concentration of sodium fluoride as enamel: in vitro comparison of topical agents. Caries Res, 1980; 14:403-413. Duraphat. Daily rinsing with a solution of 0.05% sodium 11. Todd MA, Staley RN, Kanellis MJ, Donly KJ, Wefel JS. fluoride also reduces the severity of white-spot lesions, Effect of a fluoride varnish on demineralization adjacent 15-17 although it cannot prevent them completely . The to orthodontic brackets. Am J Orthod Dentofacial Orthop, efficacy of this method depends on patient compliance, 1999; 116:159-167. which has generally been found to be lacking (13%). 12. Schmit J, Staley R, Wefel J, Kanellis M, Jakobsen J, Keenan Patients who do not practice proper oral hygiene are P. Effect of fluoride varnish on demineralization adjacent particularly unlikely to cooperate in using mouthrinses. to brackets bonded with RMGI cement. Am J Orthod Dentofacial Orthop, 2002; 122:125-134. 13. Voss A, Hickel F, Holkner S. In vivo bonding of orthodontic brackets with glass ionomer cements. Angle Orthod, 1993; 63:149-153. Conclusions 14. Gorton J, Featherstone JD. In vivo inhibition of demineralization around orthodontic brackets. Am J Orthod Use of a fluoride varnish, when bonding brackets Dentofacial Orthop, 2003; 123:10-14. with GICs, is more effective in preventing enamel 15. Bowman SJ. Use of a fluoride varnish to reduce demineralization than the conventional composite resin. decalcification. J Clin Orthod, 2000; 34:377-379. Fluoride varnishes examined in this study had impact 16. Derks A, Katsaros C, Frencken JE, Van’t Hof MA, Kuijpers- on the inhibition of enamel demineralisation adjacent Jagtman AM. Caries-inhibiting effect of preventive to orthodontic brackets. Orthodontists should consider measures during orthodontic treatment with fixed its routine use in clinical practice, especially in patients appliances. Caries Res, 2004; 38:413-420. 17. Geiger AM, Gorelick L, Gwinnett AJ, Griswold PG. The exhibiting poor oral hygiene. effect of a fluoride program on white spot formation during orthodontic treatment. Am J Orthod, 1998; 93:929-938. 18. Madlena M, Vitalyos G, Marton S, Nagy G. Effect of chlorhexidine varnish on bacterial levels in plaque and References saliva during orthodontic treatment. J Clin Dent, 2000; 11:42-46. 1. Ögaard B, Rolla G, Arends J. Orthodontic appliances and 19. Jenatschke F, Elsenberger E, Welte H, Schlagenhauf U. enamel demineralization: Part 1. Lesion development. Am J Influence of repeated chlorhexidine varnish applications on Orthod Dentofacial Orthop, 1988; 94:68-73. mutans streptococci counts and caries increment in patients 2. O’Reilly M, Featherstone J. Demineralization and treated with fixed orthodontic appliances. J Orofac Orthop, remineralization around orthodontic appliances: An in vivo 2001; 62:36-45. study. Am J Orthod Dentofacial Orthop, 1987; 92:33-40. 20. Gillgrass T, Creanor S, Foye R, Millett D. Varnish or 3. Gorelick L, Geiger A, Gwinnett A. Incidence of white spot polymeric coating for the prevention of demineralization? formation after bonding and banding. Am J Orthod, 1982; An ex vivo study. J Orthod, 2001; 28:291-295. 81:93-98. 21. Valk J, Davidson C. The relevance of controlled fluoride 4. Årtun J, Brobakken B. Prevalence of carious white spots release with bonded orthodontic appliances. J Dent, 1987; after orthodontic treatment with multibonded appliances. 15:257-260. Eur J Orthod, 1986; 8:229-234. 22. Ögaard B, Rezk-Lega F, Ruben J, Arends J. Cariostatic 5. Ögaard B, Larsson E, Henriksson T, Birkhed D, Bishara effect and fluoride release from a visible light-curing S. Effects of combined application of antimicrobial and adhesive for bonding of orthodontic brackets. Am J Orthod fluoride varnishes in orthodontic patients. Am J Orthod Dentofacial Orthop, 1992; 101:303-307. Dentofacial Orthop, 2001; 120:28-35. 23. Trimpeneers L, Dermaut L. A clinical evaluation of the 6. Mizrahi E. Enamel demineralization following orthodontic effectiveness of a fluoride-releasing visible light-activated treatment. Am J Ortod, 1982 July; 82(1):62-67. bonding system to reduce demineralization around 7. Demito CF, Vivaldi-Rodriguez G, Ramos AL, Bowman orthodontic brackets. Am J Orthod Dentofacial Orthop, SJ. The efficacy of a fluoride varnish in reducing enamel 1996; 110:218-222. demineralization adjacent to orthodontic brackets: An in vitro study. Orthod Craniofac Res, 2004; 7:205-210. 8. Vivaldi-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. Correspondence and requests for offprint to: The effectiveness of a fluoride varnish in preventing the Dr Efka Zabokova-Bilbilova, PhD development of white spot lesions. World J Orthod, 2006; Department of Pediatric and Preventive Dentistry 7:138-144. School of Dentistry 9. Petersson L, Magnusson K, Andersson H, Almquist Vodnjanska 17 B, Twetman S. Effect of quarterly treatments with a 1000 Skopje, FYR Macedonia chlorhexidine and a fluoride varnish on approximal caries in E-mail: [email protected]

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Sealing of Fissures and Pits of First Permanent Molar at Children with High Caries Risk

SUMMARY M. Carcev1, B. Getova2, O. Sarakinova1, The results of epidemiological study realized in 2007 by calibrated H. Petanovski1, S. Carceva-Shalja3 paedodontists for estimation of oral health condition of children in the 1University St. Cyril and Methodius, Faculty of Skopje region showed unfavourable values (DMFT-8.10 at 12 years old Dental Medicine, Department of Paediatric and children). Especially alarming is a condition of the first permanent molars Preventive Dentistry, Skopje, FYROM at 8 years old children (DMFT-3.18). In general aim to prevent caries, we 2Healthy Centre Valandovo, FYROM 3 sealed fissures of first permanent molars right after their eruption at 6386 University St. Cyril and Methodius, Faculty of Dental Medicine, Department of Orthodontics, children in the Skopje region (98.01% of total number of children born Skopje FYROM 2002) and 17.242 teeth (68.76%) were sealed. Non-erupted teeth were sealed later, right after their eruption. The teeth with registered presence of initial caries were not sealed. The sealing was conducted by GC Fuji Triage. The first evaluation of the effects of sealing was conducted after 2 years by the same calibrated paedodontists and the marked reduction of DMFT index 0.87 (reduction of caries of the first permanent molars from 72.65%) was noticed, and the second evaluation, 3 years after the beginning of the sealing, showed values of the DMFT index from 1.07 (reduction of 66.36%). These results show that sealing of fissures and pits is an effective primary preventive measure for caries control, especially in areas where there is a high caries risk in children population. ORIGINAL PAPER (OP) Keywords: Pits; Fissures; Caries Risk, prevention; Sealing; Glass-ionomer Balk J Stom, 2012; 16:161-164

Introduction eliminated when accumulated in the fissures and pits; that is why such places remain to be caries risk. According to the opinion of the most of the experts In the past years observation was made of the in preventive dentistry, the control of dental caries can be caries incident and conclusion was made that the caries successfully conducted by application of the following of occlusal surfaces is 56-70% of all caries lesions in primary preventive measures2,6,7,9: children from 5-17 years of age6. At the end of the sixties, ●● Mechanical and chemical control of dental plaque; putting plastic mass over occlusal surfaces of teeth, ●● Application of fluoride (systemic and topical); which penetrates into deep fissures and fulfils the parts ●● Discipline of sugar intake regime; that cannot be cleaned by toothbrush, was the suggested ●● Sealing of fissures and pits; procedure. Plastic mass had the role of sealant and ●● Education and motivation for keeping oral health. presented barrier between teeth and oral environment. The oral hygiene and sugar intake control have the Many studies show that fissure sealants are an primary role in the prevention of caries7,20. On the other effective primary preventive procedure for caries hand, the same are mostly related to the tradition and prevention in occlusal surfaces1,5. Many years ago, several mentality of people, so the measure of promoting oral materials were used as fissure sealant. More of dental health in these spheres give results in a longer time period. materials that were used for tooth filing were used also as But, even in the conditions with good oral hygiene, sealants, for example, some kinds of composites and glass with toothbrush, the dental plaque cannot be efficiently ionomer cements11,12,14,21. 162 M. Carcev et al. Balk J Stom, Vol 16, 2012

According to the fact that occlusal surfaces have the The sealing covered 6.386 children at age 6 in the highest participation in DMFT index between children, Skopje region and 17.242 first permanent molars were in this project we set the aim to seal occlusal fissures and sealed. The teeth which not erupted at the time of the pits of first permanent molars right after their eruption at activities were sealed later, right after their eruption. children in Skopje region. Before the beginning of the sealing activities, DMFT Fluorides have strong influence on the process of index was registered in children at age 8 and 12. demineralisation and remineralisation, which is the reason Coloured Fuji Triage was use as a sealant for that numbers of authors recommend sealing to be done better visualization if it eventually falls. The sealing with dental materials that will provide enough fluorides was conducted in professional conditions, in school after their application, which will help the process of dental offices. Before setting the sealant, professional remineralisation18. Having in mind the fact that glass- elimination of dental plaque was made and conditioning ionomer cements make chemical connection with enamel, with 20% polyacrylic acid in the period of 20 sec. The effects from sealing of DMFT index were humid environment does not compromise adherence, as followed-up twice; the first evaluation was done after well as that glass-ionomer cements from all dental materials 2 years and the second 3 years after sealing by the release most fluorides, sealing of fissures and pits was same calibrated paedodontist who were involved in the conducted with Fuji Triage, a glass-ionomer cement that preparation of the study in registration of the DMFT index releases even 5-6 times more fluorine from Fuji IX that was at the beginning. the riches material with fluorine until recently.

Results Material and Method The results for values of DMFT index in the Sealing the fissures and pits of the first permanent children at age 8 and 12 from the Skopje region, got from molar was conducted by 142 calibrated paedodontists epidemiologic study conducted in 2007, as the results of according to the standards of WHO, who, after the evaluation effects of sealing after 2 and 3 years, are shown privatization of the dental sector, continued to work on the following figures and tables - figure 1 depicts the in frame of public health. Except sealing, they have DMFT index of children at the beginning of the study, obligation to make other primary preventive measures tables 1 and 2 show the DMFT indices at the first and according to the National strategy of prevention of oral second evaluation, and figure 2 compares the results of the diseases in children at age 0-14 in FYROM. procedures after 2 years.

Figure 1. DMFT index in children at age 8 and 12 in the Figure 2. DMFT at 8 year old children before sealing, after the first Skopje region in 2007 and the second evaluation

Table 1. DMFT index in children at age 8 in the Skopje region in 2010 - first evaluation

total number number of sealed first unsealed first decayed first extracted first filled first non-erupted number of and percent the examined permanent permanent permanent permanent permanent first permanent unexamined of children children molars molars molars molars molars molars children

6516 6386 17242 2265 3886 28 1654 469 130 100% 98,01% 68,76% 9,03% 15,49% 0,11% 6,59% 1,83% 1,98% Balk J Stom, Vol 16, 2012 Efficacy of Sealing of Fissures in High Caries Risk Children 163

Table 2. DMFT index in children at age 8 in Skopje region in 2011 - second evaluation

total number number of sealed first unsealed first decayed first extracted first filled first non-erupted number of of children examined permanent permanent permanent permanent permanent first permanent unexamined children molars molars molars molars molars molars children 6994 6374 16915 1638 4031 53 2763 96 620 100% 91,13% 66,34% 6,42% 15,81% 0,20% 10,83% 0,37% 0,88%

Discussion came 1 year or more later, and this would compromise the results after 2 and 3 years. The sealing of fissures and pits is a primary After the first evaluation (2 years after sealing), preventive measure providing maximum protection from we confirmed that on 3.886 (15.49%) teeth there was caries on occlusal surfaces, but apart from this, the experts caries, 1654 (6.59%) teeth were filled, and 28 (0.11) were opinion is that it is not enough used by dentist in everyday extracted, that means that reduction of caries is achieve practice. on the first permanent molar of 72.65%.The results of the Ripa et al16, made researches in children at age 8 researches in the second evaluation after 3 years of sealing and 9 during 2 years. The first group of children used 0.2 showed caries reduction of 66.36%. % fluoride solution for individual rinsing of mouth, and There is an insignificant increasing of the number of the second group used the same solution plus sealing of caries teeth registered after the second evaluation. After fissures and pits. From 51 participants in the first group, the first monitoring of the sealed teeth, we found certain 24 got occlusal caries lesion and from 84 participants inconsistency by same paedodontists who participated in the project (partial covering of fissures system with in the second group only 3 got caries lesion. Authors sealant); we considered that it could have some influence concluded that the implementation of these 2 preventive on the results of the achieved caries reduction. Such measures can almost fully eliminate caries. Sealing would inconsistency in fissures and pits sealing pointed to the be most economical if it is done on those teeth which are need for better education of next student generations of caries sensitive16. students. Glass-ionomer cements are materials that contain Increasing the caries reduction in the participants high level of fluorine release during the application. That in our study could also be due to participation in other is why glass-ionomers are frequently used, especially at primary preventive measures that are part of National caries-risk patients, and they provide fluorine protection strategy, but we consider that it is of minor influence from their application until fall out. because changing mentality (good oral hygiene, sugar The results of the presented epidemiological research intake control, fluorine intake, education and motivation by calibrated paedodontists, made in 2007, showed that for oral health) needs longer time. only 2 years after eruption, in 3 from 4 permanent molars Encouraged by the results in the first and second caries appeared on occlusal surfaces (DMFT at 8 years old evaluation concerning the reduction of caries of the first children was 3.18), which shows a high caries risk. permanent molar, Coordinative Body for implementation Having in mind the attitude of ADA (American and monitoring of National Strategy, recommended Dental Association) that the sealing of fissures and pits is sealing to be conducted on all permanent teeth with absolutely indicated, with no exception, on all individuals fissures system (first and second premolars and second with high caries risk, and it is best done with glass- molars) and the results of effect of the next clinical 15 ionomer cement . According to this, we decided to seal evaluation will be published soon. with Fuji Triage - glass-ionomer cement that releases the biggest quantity of fluorine compared to other glass- ionomer cements available at the market. The program activities planned sealing of all first permanent molars of Conclusion children in the Skopje region, right after their eruption. From total 6516 children at the age of 6, we examined The results of clinical evaluation of the sealing effect 6.386 (98.06%), and 17.242 (68.76%) erupted teeth of fissures and pits in the first permanent molars showed were sealed. The remaining teeth that were sealed later, that the fissure sealing is the primary preventive measure successively, after their eruption, were not included in for tooth caries control, especially in environments with the results presented in this study because their eruption high tooth caries risk in children. 164 M. Carcev et al. Balk J Stom, Vol 16, 2012

References 13. Poulsen S, Beiruti N, Sadat N. A comparison of retention and the effect caries of fissure sealing with a glass–ionomer 1. Ahovuo–Saloranta A, Hiiri A, Nordblad A, Worthington and a resin-based sealant. Community Dentistry and Oral H, Mäkelä M. Fissure sealants for preventing dental decay Epidemiology, 2001; 29(4):298-301. in the permanent teeth of adolescents. Cochrane Syst Rev, 14. Raadal M, Utkilen AB, Nilsen OL. Fissure sealing with 2004; n. 3 a light-cured resin reinforced glass–ionomer cement 2. Featherstone JDB. Prevention and reversal of dental (Vitrebond) compared with a resin sealant. International caries: role of fluoride. Community Dentistry and Oral Journal of Paediatric Dentistry, 1996; 6(4):235-239. Epidemiology, 1999; 27(1):31. 15. Report of the American Dental Association Council on 3. Forss H, Halme E. Retention of a glass ionomer cement and Scientific Affairs. J Am Dent Assoc, 2008; 139(3):257-268. a resin fissure sealant and effect on carious outcome after 7 16. Ripa LV, Leske GS, Forte F. The combined use of pit and years. Community Dentistry and Oral Epidemiology, 1998; 26(1):21-25. fissure sealants and fluoride mouth rinsing in second and 4. Gladys S, Van-Meerbeek B, Braem M, Lambrechts third grade children: Final clinical results after two years. P, Vanherle G. Comparative physico-mechanical Pediatr Dent, 2002; 9:118-120. characterization of new hybrid restorative materials with 17. Silva KG, Pedrini D, Delbem ACB, Cannon M. conventional glass-ionomer and resin composite restorative Microhardness and fluoride release of restorative materials materials. J Dent Res, 1997; 76(4):883-894. in different storage media. Brazilian Dental Journal, 2007; 5. Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, CDC 18(4):309-313. Dental Sealant Systematic Review Work Group, Bader J, 18. Silverstone LM, Wefel JS. The effect of remineralization Clarkson J, Fontana MR, Meyer DM, Rozier RG, Weintraub on artificial caries-like lesions and their crystal content. J JA, Zero DT. The Effectiveness of Sealants in Managing Crystal Growth, 1981; 53:148-159. Caries Lesions. J Dent Res, 2008, 87(2):169-174. 6. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn 19. Songpaisan Y, Bratthall D, Phantumvanit P, Somridhivej DM, Brown LJ. Coronal caries in the primary and permanent Y. Effects of glass ionomer cement, resin-based pit and dentition of children and adolescents 1-17 years of age: fissure sealant and HF applications on occlusal caries in a United States, 1988-1991. J Dent Res, 1996; 75(Spec developing country field trial. Community Dentistry and Issue):631-641. Epidemiology, 1995; 23:25-29. 7. Konig KG, Navia JM. Nutritional role of sugars in oral 20. Tooth brushing for oral health (Cochrane Review) In: The health. Am J Clin Nutr, 2005; 62(Suppl); 275 S-283S. Cochrane Library, Issue 1, 2003, Oxford: Update. 8. Luca-Fraga LR, Freire Pimenta LA. Clinical evaluation 21. Williams JA, Billington RW, Pearson GJ. A long term study of glass-ionomer/resin based hybrid materials used as pit of fluoride from metal-containing conventional and resin- and fissure sealants. Quintessence International, 2001; modified glass-ionomer. J Oral Rehabil, 2001; 28(1):41-47. 32(6):463-468. 22. Winkler MM, Deschepper EJ, Dean JA, Moore BK, Cochran 9. Mejäre I, Mjör IA. Glass-ionomer and resin-based fissure sealants: the clinical study. Scand J Dent Res, 1990; MA, Ewoldsen. Using a resin–modified glass ionomer as an 98(4):345. occlusal sealant: a one year study. J Am Dent Assoc, 1996; 10. Mertz-Fairhurst EJ, Schuster GS, Fairhurst CW. Arresting 127(10):1508-1514. caries by sealants: results of a clinical study. J Am Dent Assoc, 1986, 112:194-197. 11. Pardi V, Pereira AC, Mialhe FL, Meneghim MC, Ambrosano GM. Evaluation of two glass ionomer cements Correspondence and request for offprints to: used as fissure sealants. Community Dentistry and Oral Epidemiology, 2003; 31(5):386-391. M. Carcev 12. Pereira AC, Basting RT, Pinelli C, Castro-Meneghim M, University St. Cyril and Methodius Werner CW. Caries prevention of Vitremer and Ketac-Bond Faculty of Dental Medicine used as occlusal sealants after 6 and 12 months. Am J Dent, Department of Paediatric and Preventive Dentistry 1999; 12(2):62. Skopje, FYROM

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Use of Topical Bio-stimulative Laser Therapy among Individuals with Glossopyrosis and Hypochromic Anaemia

SUMMARY Silvana Georgieva, Maja Pandilova, Among numerous etiological factors that could be related to the Lindita Zendeli-Bedzeti onset of the complex symptom recognized as glossopyrosis and being most University Dental Clinical Centre frequent as well, is hypochromic anaemia. Through cytological analysis „St. Panteleimon”, Department of Oral Pathology of tongue epithelium, we tried to objectify the impact of laser light in the and Periodontology therapeutic treatment of patients with glossopyrosis and hypochromic Skopje, FYROM anemia. Clinical examinations revealed that among the representatives of the study group, beside subjective complain, alterations on the surface of the tongue could be seen (atrophic signs and metabolic furrowed tongue). Epithelial cytology investigation offered findings of tongue epithelial alterations. Beside disturbances in the keratinisation and presence of degenerated epithelial cells, reduced thickness of tongue epithelium and positive findings for acanthosis and mitotic activity was found as well. These findings denote to disturbances in oxygenation in the structure of oral mucosa as result of biochemical and metabolic changes caused by hypochromic anaemia. Topical use of bio-stimulative laser therapy has proved to produce positive effects in regulation of disturbed tongue epithelium keratinisation; by stimulation of mitotic activity and enhanced oxygenation, regenerative and reparatory mechanisms are being stimulated. ORIGINAL PAPER (OP) Keywords: Glossopyrosis; Tongue, epithelium; Laser Therapy Balk J Stom, 2012; 16:165-168

Introduction these individuals is complicated and very often without the expected treatment outcome. Experimental, professional and scientific investigations The light of the red spectrum is one of the most within the field of oral pathology by many authors all over investigated rays. Clinical and experimental investigations in the last 25 years stressed the influence of the laser beam bio- the world, as well as the continuing clinician’s experience, stimulation and the mentioned spectrum. The most important highlight the role of iron deficiency anaemia as a principal function when treating with laser beam and the red spectrum etiological factor in the clinical objectification of the oral is stimulation of the regenerative process in the cells. burning symptom. Gallagher et al3, Grushka et al4, Hadjadj Another important utility of the laser beam is 5 et al , among others, disclose that glossopyrosis in most its anti-inflammatory effect, which is one of its most cases generally reflects some systemic disorder of the important roles in clinical practice. The laser light in the human body, pointing out hypochromic anaemia as the most inflammatory process increases the lysosomes and the important cause. interferon protective proteins; increases microcirculation Knowing the grounds, the subjective symptoms and and furthermore normalizes penetration of the blood cells. objective status seem not enough in support of clarifying Factors of inflammation decrease under the influence the problem known as glossopyrosis. So the treatment of of the laser light and phagocytic activity increases. The 166 Silvana Georgieva et al. Balk J Stom, Vol 16, 2012 role of the laser beam on oral mucous membranes is Results confirmed by many histo-morphological, biochemical, and cytological, as well as immunological and microbiological From the presented results of the chart 1, it is evident investigations. The aim of our study was to objectify the that there are no obvious differences in the final results influence of the laser light in the treatment of individuals of hyperkeratosis, parakeratosis and altered epithelial with hypochromic anaemia through cyto-morphological cells between the both examined groups. Remarkable analysis of the tongue epithelium. results between control and study group were noted for acanthosis and mitotic activity.

Material and Method

Cytological examinations included cyto-morphological analysis of the tongue epithelium with determination of acanthosis, level of keratinisation, intensity of parakeratosis, intensity of mitotic activity, and the presence of altered epithelial cells. Cyto-morphological analysis was conducted among 10 patients with hypochromic anaemia and glossopyrosis before and after haematological therapy. Half of the individuals additionally received local bio-stimulative laser therapy with continuous mode of irradiation (Optica Laser- SCORPION 405.7A, λ= 630 nm), applied at the dorsum of the tongue, which was divided into 3 areas (the apical area and both lateral sides). Each area was exposed 1.5 minutes with non-contact mode of irradiation with a distance between the laser probe and the irradiated surfaces Chart 1. Cyto-morphological findings of the tongue epithelium among patients from study and control group of 1 mm and following specifications: power of 10 mW/ cm, exposition of 4-5 minutes, and interval of 10 days. In The chart 2 presents the results of cytological order to compare the obtained results, cyto-morphological analysis for all the examined parameters among analysis was conducted in a group of 10 individuals individuals from the study group after haematological comprising the control group with glossopyrosis, but therapy and those treated additionally with bio-stimulative without hypochromic anaemia. Cytological investigations were realized by taking laser treatment. Important differences between both study specimens with a plastic instrument from the parts with groups for the presence of hyperkeratosis, parakeratosis most emphasized burning symptom. The samples were and mitotic activity are evident. Figures 1-3 document the immediately fixed with 96% ethyl alcohol, and after 15 results of the cytological investigations. minutes they were stained by Papanicolaou technique. The staining of the slides was done with a suspension of 5 reagents; 3 of them differ from each other by the concentration of eosin, bismarck brown colour and light green colour. The prepared slides were cyto- morphologically analyzed with an optic microscope under immersion. The results from the conducted cyto-morphological analysis for each parameter were noted as follows: no changes +- weak positive ++ mild positive +++ strong positive Results of the cyto-morphologic analysis were compared as follows: -- the study group and control group -- the study group after the haematological therapy with and without local bio-stimulative laser treatment. Chart 2. Cyto-morphological findings from the tongue epithelium among The results of the conducted research are presented patients of the study group after the treatment with and without laser graphically and photographically. therapy Balk J Stom, Vol 16, 2012 Laser Therapy in Patients with Anaemia 167

It can be noted from the figure 1 that the cells contain 2 nucleuses in their cytoplasm. These results can be accepted as predictive, revealing the increased mitotic activity of the cells in the deeper layers of the epithelium. Cells like these are noted in patients of the study group treated with laser. The figure 2 illustrates the epithelial cell with cytoplasm filled with keratin and the nucleus being partly destroyed. Cells like these are being noted among individuals of the study group after laser bio- stimulative treatment. Epithelial cell in the form of keratin husk showed in figure 3. This result illustrates total keratinisation of the epithelial cells (orto-parakeratosis) with disappearing of the cell structures. This finding was Figure 1. Epithelial cells during mitotic activity present in a large percent of the patients from the study group treated with laser light.

Discussion

Cytological examination after the use of local bio- stimulative laser treatment verifies its positive effects. Clinical outcome resulted in improving the subjective symptoms8 due to stimulation of regenerative processes of cellular, nerve and epithelium tissues, thus activating vascularity and metabolic processes into the irradiated areas. Exfoliative cytological results revealed changes among individuals from the study group treated with laser light. It was markedly decreased presence of epithelial cells with hyperkeratosis and parakeratosis. The result demonstrates more epithelial cells in the form of Figure 2. Keratotic tongue epithelial cell with karyolitic nucleus Cell transforming into a keratin husk keratinized husk disclosing that laser treatment influences the regulation of keratinisation of the tongue epithelium (hyper-orto-parakeratosis). Results of many other investigators, like Biskin1, Frentzen and Koort2, Hansson6, and Kesic and Jovanovic7, provide evidence for the positive influence of the laser beam in the treatment of glossopyrosis, disclosing positive and good analgesic effect. Patients treated with laser beam revealed increased mitotic activity of epithelial cells evidenced through cytological investigations. Our results as many other experimental investigations, support the influence of the laser beam on mitotic activity of epithelial cells that stimulates regeneration. In this case regenerative factor is providing the balance between the oxygen and the tongue epithelium, which is realized through activation of enzymes that supply cells with oxygen. So, the use of laser therapy regulates the altered keratinisation and improves oxygenation in the treated area, resulting in positive treatment outcome of patients with glossopyrosis Figure 3. Epithelial cell transformed into a keratin husk and hypochromic anaemia. 168 Silvana Georgieva et al. Balk J Stom, Vol 16, 2012

Conclusion 3. Gallagher FJ, Baxter DL, Denobile J, Taybos GM. Gllosodynia, iron deficiency anaemia, and gastrointestinal malignancy. Oral Surg Oral Med Oral Pathol, 1998; Results of cytological analysis after the use of bio- 65:130-133. stimulative laser treatment verify its positive effect. This 4. Grushka M, SessiLe BJ. Burning mouth syndrome: Review. allows us to conclude that the laser beam influences Dent Clin North Am, 1991; 35(1):171-184. regulation of keratinisation and stimulates epithelial 5. Hadjadj ML, Martin F, Fichet D. Anemia caused by iron cells for increased mitotic activity; thus it stimulates and deficiency and pagophagia: A propos of a case. Rev Med expands the regenerative processes, providing oxygen Interne, 1990; 11(3):236-238. balance in the tongue epithelium. 6. Hansson TL. Infrared laser in the treatment of Positive effect of the laser beam resulted in craniomandibular disorders, arthrogenous pain. J Prosth Dent, 1989; 61(5):614-617. significant improvement of subjective symptoms among 7. Kesic Lj, Jovanovic G. Low power lasers in treatment of individuals with glossopyrosis. glossopyrosis. III Congress of Macedonian Dentists, Ohrid. Abstract Book, 2002; p 120. 8. Kato IT, Pellegrini VD, Prates AR, Ribeiro MS, Wetter NU, Sugaya NN. Low Level Laser Therapy in Burning Mouth References Syndrome Patients: A Pilot Study. Photomed Laser Surg, 2010; 28(6):835- 839. 1. Bishkin T. Biologic Influence of the Laser Beam. Apolonija, 2001; 3(6):45-56. Correspondence and request for offprints to: 2. Frentzen M, Koort HJ. Lasers in dentistry: new Silvana Georgieva possibilities with advancing laser technology? Int Dent J, University Dental Clinical Centre „St. Panteleimon” 1990; 40:323-332 Skopje, FYR Macedonia

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Oral Health-Related Quality of Life (OHRQoL) Before and After Prosthodontic Treatment with Full Removable Dentures

SUMMARY Julijana Nikolovska, Dragan Petrovski The aim was to present a possibility of the use of OHIP-MAC49 University “Ss. Cyril and Methodius” questionnaire, by determination of changes in relevant aspects of quality of Faculty of Dental Medicine, Skopje, FYROM life in patients with full removable dentures, before and after prosthodontic treatment. The OHIP-MAC49 questionnaire was administered to a total number of 35 participants (evaluated by sex, age, ethnics). Participants were edentulous patients attending the University Dental Clinic Centre “St. Pantelejmon” in Skopje. Authors selected a convenience sample of patients aged 45-83 years, who fulfilled the OHIP-MAC49 questionnaire twice, before the prosthodontic treatment and 1 month after the treatment with full removable dentures. The gathered values of total OHIP scores and all 7 subscales before and after treatment were compared using t-test. The statistical analysis showed significant difference of OHIP scores before and after treatment with full dentures in relation to functional limitations (p<0.01), physical pain (p<0.01), psychological discomfort (p<0.01), and psychological disability (p<0.01). In other subscales - physical disability, social disability and handicap, there were no statistically significant differences of the OHIP score before and after prosthodontic treatment. Statistically significant difference was registered for the total OHIP score before and after prosthodontic treatment with full dentures (p<0.01). The presented results indicate an impact of oral conditions associated with full denture wearing on the oral health-related quality of life. There is quality of life improvement in relation to oral health after prosthodontics treatment with full removable dentures, compared to the situation before treatment in certain wellbeing aspects defined by the OHIP model. ORIGINAL PAPER (OP) Keywords: Oral Health; Quality of Life; OHIP-MAC49 Balk J Stom, 2012; 16:169-172

Introduction of patients. Usually, patients’ assessment of their health- related quality of life is often markedly different to the Regarding the relationship of oral health and disease opinion of health care professionals. to quality of life, there appears to be an association The combination of clinical and subjective indicators between these domains, which is not clearly defined. provides a more comprehensive and multidimensional Locker suggested that health problems may affect quality assessment of a patient’s oral health condition, resulting of life, but such a consequence is not inevitable10,11. into benefits for clinical decision making and oral health Traditionally, dentists have been trained to recognise research19. The impact of oral disorders and interventions and treat disease, such as caries, periodontal disease and on patients’ perceived oral health state and oral health- tumours, but they give no indication on the impact of the related quality of life is an important component of disease process to function or psychosocial well-being health5. Oral healthcare researchers and policymakers 170 Julijana Nikolovska, Dragan Petrovski Balk J Stom, Vol 16, 2012 have recognised that assessment of oral health outcomes ethnics). Participants were edentulous patients attending is vital to planning oral healthcare programmes1; so, the University Dental Clinic Centre “St. Pantelejmon” in according to modern aspects, oral health evaluation of a Skopje. Authors selected a convenience sample of adult population must include social-dental indicators, beside patients aged between 45 to 83 years. The participants clinical indicators (KEP, CPITIN). This means realizing fulfilled the OHIP-MAC49 questionnaire twice, once the influence of an oral disease over physical, psychical before the prosthodontic treatment and the second time 1 and social wellbeing of humans, i.e. their subjective health. Being a physician, a dentist must estimate the month after the treatment with full removable dentures. influence of his therapy on the patient’s general health and According to the adequate epidemiological design, life quality, besides just resolving the oral disease. we used the questionnaire and interview method. This Oral health-related quality of life is a multi instrument consisted of 49 questions divided in 7 dimensional concept, meaning patients personal estimation subscales: functional limitation (9), physical pain (9), of his/her wellbeing in relation to: 1. Functional factors psychological discomfort (5), physical handicap (9), (mastication, swallowing, and speech); 2. Psychical factors psychological handicap (6), social handicap (5) and (personal appearance, self-respect); 3. Social factors (social handicap (6). The subjects answered questions in which interaction, communication, socializing); and 4. Factors they evaluated how frequent an oral health problem related to pain and discomfort (acute and chronic). occurred before and after prosthodontics treatment with In order to determine the relation between oral health and life quality, several instruments are developed. The removable dentures. Answers were evaluated by the Oral Health Impact Profile (OHIP-49) is accepted as one Lickert scale (0 = never, 1 = very rare, 2 = sometimes, 3 of the most widely used and sophisticated methods of = relatively often, 4 = very often). 0 presented absence of estimation7. It’s most important feature is the possibility problems. to measure oral health improvement or decline given Besides the OHIP-MAC 49 questionnaire, the by the patient. Original version of the OHIP-49 has subjects answered questions about their personal oral and been developed in Australia and was adopted in many general health perception, using an analogue scale from 5,9,12-14,17 countries worldwide . Now, it is available in 1 to 5 (1 = bad; 5 = excellent). These data were used to many languages, which makes the instrument as an compare 2 examined variables. excellent tool for conducting cross-cultural research in the realm of oral health-related quality of life2. In the Balkan The gathered values of consecutive measurements for region, the translation and adaptation of the instrument are the total OHIP score and all 7 subscales before and after already completed in several countries: there is a Turkish, treatment were compared using t-test. Romanian, Croatian, Greek and Serbian version3,15,16,18,20. In order to use this instrument in the FYROM, i.e. to measure quality of life of population in relation to oral health, a Macedonian version of the OHIP was needed Results (OHIP-MAC 49). The elaboration of the Macedonian version means adequate translation of the original, The statistical analysis showed significant difference cultural adaptation and review of the psychometrical of OHIP scores before and after treatment with full characteristics8. The Faculty of Dental Medicine in removable dentures in relation to functional limitations Skopje (University Ss. Cyril and Methodius) developed (p<0.01), physical pain (p<0.01), psychological the Macedonian version of OHIP (OHIP-MAC49) in collaboration with experts from the Faculty of Philosophy. discomfort (p<0.01), and psychological disability In this paper, we used OHIP-MAC49 instrument to (p<0.01). In other subscales - physical disability (p>0.05), evaluate the quality of life in patients after prosthodontics social disability (p>0.05) and handicap (p>0.05), there treatment with full removable dentures. The aim of this were no statistically significant differences of the paper was to present a possibility of the use of OHIP- OHIP score before and after prosthodontic treatment. MAC49, by determination of changes in relevant aspects Statistically significant difference was registered for the of quality of life in patients with full removable dentures, total OHIP score before and after prosthodontic treatment before and after prosthodontics treatment. with full removable dentures (Tab. 1). Arithmetic means along with the standard deviations of OHIP-MAC subscales before and after the Material and Methods prosthodontic treatment are presented in figure 1, and the arithmetic means of total OHIP score before and after the The OHIP-MAC49 questionnaire was administered treatment with full removable dentures is presented on to a total number of 35 participants (evaluated by sex, age, figure 2. Balk J Stom, Vol 16, 2012 Quality of Life with Full Removable Dentures 171

Tab1e. Differences before and after prosthodontic treatment with full removable dentures

Subscales OHIP М N SD t df p

Functional limitation 1 13.71 35 4.50 Pair 1 3.329 34 0.002** Functional limitation 2 10.6 35 4.30

Physical pain 1 11.69 35 4.87 Pair 2 7.140 34 0.000** Physical pain 2 6.46 35 3.76

Psychological discomfort 1 7.57 35 3.78 Pair 3 2.772 34 0.009** Psychological discomfort 2 5.71 35 3.64

Physical disability 1 10.34 35 4.71 Pair 4 2.004 34 0.053 Physical disability 2 8.49 35 4.91

Psychological disability 1 6.23 35 4.21 Pair 5 2.241 34 0.032* Psychological disability 2 4.83 35 4.82

Social disability 1 3.74 35 3.49 Pair 6 .548 34 -0.607 Social disability 2 4.17 35 4.02

Handicap 1 5.49 35 3.38 Pair 7 1.835 34 0.75 Handicap 2 4.03 35 4.11

OHIP total score 1 58.77 35 20.96 Pair 8 3.428 34 0.002* OHIP total score 2 44.28 35 25.19

Figure 1. Arithmetic means of OHIP-MAC49 subscales before and after Figure 2. Arithmetic means of total OHIP-MAC49 scores before and prosthodontic treatment after prosthodontic treatment 172 Julijana Nikolovska, Dragan Petrovski Balk J Stom, Vol 16, 2012

Discussion 5. John MT, et al. Oral health-related quality of life in Germany The German version of the Oral Health Impact Problems with chewing and eating dominated first Profile: translation and psychometric properties. Eur J Oral Sci, 2002; 110:425-433. month after prosthodontic treatment with full removable 6. John MT, et al. OHRQoL in patients treated with fixed, dentures. These problems were followed by the problems removable and complete dentures 1 month and 6 to 12 in pronunciation of some sounds. months after treatment. Int J Prosthodont, 2004; 17:503-511. The influence of oral diseases and interventions from 7. John MT, Hujoel P, Miglioretti DL, LeResche L,Koepsell the patient’s perspective, i.e. their personal estimation TD, Micheelis W. Dimensions of oral-health-related quality of oral health status and oral health-related quality of of life. J Dent Res, 2004; 83:956-960. life (OHRQoL) presents a very important social-dental 8. Kenig N, Nikolovska J. Assessing the Psychometric indicator. This aspect is especially relevant in elderly Characteristics of the Macedonian Version of the Oral population, in which edentulism is at raise and needs a Health Impact Profile Questionnaire (OHIP-MAC49). 6 OHDM, 2012; 11(1):29-38. broad oral health concept . 9. Larsson P, List T, Lundström I, Marcusson A, Ohrbach R. Location of tooth loss is very important for patients Reliability and validity of a Swedish version of the Oral and influences the quality of patient’s life. Based on the Health Impact Profile (OHIP-S). Acta Odontol Scand, 2004; systematic review and meta-analysis, Gerritsen et al4 62:147-152. concluded that there is a fairly strong evidence that tooth 10. Locker D. Issues in measuring change in self-perceived oral loss is associated with impairment of oral health-related health status. Community Dentistry and Oral Epidemiology, quality of life (OHRQoL), and location and distribution of 1998, 26:41-47. tooth loss affects the severity of the impairment. 11. Locker D. Measuring oral health: a conceptual framework. The fact that most of the problems disappear after Community Dental Health, 1988; 5:3-18. 12. Lopez R, Baelum V. Spanish version of the Oral Health prosthodontic treatment with full dentures, especially after 21 Impact Profile (OHIP-Sp). BMC Oral Health, 2006; 6:11. 6 to 12 months period of adaptation, is promising . 13. Meulen MJ, John MT, Naeije M, Lobbezoo F. The Dutch version of the Oral Health Impact Profile (OHIP-NL): Translation, reliability and construct validity. BMC Oral Health, 2008; 8: 11. 14. Montero-Martín J, Bravo-Pérez M, Albaladejo-Martínez A, Conclusion Hernández-Martín LA, Rosel-Gallardo EM. Validation the Oral Health Impact Profile (OHIP-14sp) for adults in Spain. The gathered data showed quality of life Medicina Oral Patologia y Cirugia Bucal, 2009; 14:E44-50. improvement in relation to oral health after prosthodontic 15. Murariu A, Hanganu C. Oral health and quality of life treatment with full removable dentures, compared to the among 45- to 64-year-old patients attending a clinic in Iasi, situation before treatment in certain wellbeing aspects Romania. Oral Health and Dental Management in the Black defined by the OHIP model. Beside our better results after Sea Countries, 2009; 8(2):7-11. the treatment with full removable dentures, the challenge 16. Petricevic N, Celebic A, Papic M, Rener-Sitar K. The for permanent improvement in the prosthodontic treatment Croatian version of the Oral Health Impact Profile questionnaire. Collegium Antropologicum, 2009; 3:315-321. still persists. The OHIP-MAC49 can be a valuable 17. Pires CPAB, Ferraz MB, DeAbreu M. Translation into instrument for evaluation of prosthodontics therapy. Brazilian portuguese, cultural adaptation and validation The present results indicate an impact of oral of the oral health impact profile (ohip-49). Braz Oral Res, conditions associated with full denture wearing on oral 2006; 20(3):263-268. health-related quality of life. 18. Roumani T, Oulis CJ, Papagiannopoulou V, Yfantopoulos OHIP-MAC49 can be use in future in cross-sectional J. Validation of a Greek version of the oral health impact studies on general population in order to determinate the profile (OHIP-14) in adolescents. European Archive of impact of oral health to quality of life of population Paediatric Dentistry, 2010; 11:247-252. 19. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dental Health, 1994; 11:3-11. 20. Stancic I, Tihacek Šojic Lj, Jelenkovic A. Adaptation of Oral References Health Impact Profile (OHIP-14) index for measuring impact of oral health on quality of life in elderly to Serbian language. 1. Allen FP. Assessment of oral health related quality of life. Vojnosanitetski Pregled, 2009; 66:511-515. (in Serb) Health Qual Life Outcomes, 2003, 1:40. 21. Szentpetery A, John MT, Slade G, Setz J. Problems Reported 2. Allison P, Locker D, Jokovic A, Slade G. A cross-cultural by Patients before and after Prosthodontic Treatment. Int J study of oral health values. J Dent Res, 1999; 78:643-649. Prosthodont, 2005; 18(2):124-131. 3. Caglayan F, Altun O, Miloglu O, Kaya MD, Yilmaz AB. Correlation between oral health-related quality of life (OHQoL) and oral disorders in a Turkish patient population. Correspondence and request for offprints to: Medicina Oral, Patologia y Cirugia Bucal, 2009; Julijana Nikolovska DDS, PhD 14(11):e573-578. University “Ss. Cyril and Methodius”

4. Gerritsen A, Allen PF, Witter D, Bronkhorst E, Creugers Faculty of Dental Medicine N. Tooth loss and oral health-related quality of life: a Vodnjanska 17 systematic review and meta-analysis. Health Qual Life 1000 Skopje, FYR Macedonia Outcomes, 2010; 8:126. doi: 10.1186/1477-7525-8-126 E-mail: [email protected]

E I

L BALKAN JOURNAL OF STOMATOLOGY A ISSN 1107 - 1141 IC G LO TO STOMA

Bond Strength of Resin Cements to Zirconia Ceramics with Different Surface Treatments

SUMMARY Altay Uludamar1, Filiz Aykent2 Purpose: To evaluate the influence of different surface preparation 1Private Practice, Ankara, Turkey methods on the bond strength of 2 composite resins to zirconium oxide 2University of Selçuk, Faculty of Dentistry ceramic restorations. Department of Prosthodontics, Konya, Turkey Material and Methods: 80 specimens 2 mm thickness of IPS e.max ZirCAD blocks were prepared and divided into 4 groups. The first group was left as a control (C). In the second group, specimens were treated with sand blasting (SB). In the third group, specimens were treated with roughening the surfaces with diamond burs (DB). Laser irradiation was applied for the last group (LI). Specimens were divided into 2 subgroups (n: 10) for each surface treatment protocol followed by the application of 2 resin cements: Multilink Automix (MA) and Multilink Sprint (MS). The shear bond strength was measured using the universal testing machine with a crosshead speed of 0.5 mm/min. The retentions force required to remove the specimens was recorded. After debonding of specimens, the fractured surfaces were evaluated with an optical microscope to classify the failure modes and selected specimens for each group were examined in a scanning electron microscope for determining interfacial morphologies of surface treatment. Data were submitted to 2-way ANOVA, Kruskal-Wallis and Mann-Whitney U tests (P<.05). Results: The bond strengths were significantly influenced by the resin cement and surface treatment (P<.05). Both cements showed the highest bond strength values when specimens were treated with sandblasting. The bond strength of the MA adhesive cement to the sandblasted zirconia resulted in the highest bond strength values (5.42 ± 1.28 MPa). Conclusions: Applying sandblasting surface treatment improves the bond strength of self- adhesive resin cement to zirconia. ORIGINAL PAPER (OP) Keywords: Zirconium Oxide; Resin Cements; Surface Treatment; Bond Strength Balk J Stom, 2012; 16:173-178

Introduction exceeding 1000 MPa, and a biologic harmony7. The use of zirconium oxide ceramic restorations is increasing All-ceramic restorations are metal free alternatives since they are stronger than aluminium oxide ceramics to widespread metal-ceramic composite structures1. and allow construction of multi unit restorations2,6. CAD/ The interest in using high-strength zirconium oxide CAM technologies have made working with this high ceramics for oral rehabilitation has been growing in recent crystalline material simpler, allowing the fabrication of years2-7. The evolution of tetragonal zirconia (Y-TZP) full coverage crowns or bridge frameworks7-9. materials has introduced a new class of dental ceramics The success of full ceramic restorations in serving to the market.5 Clinical use of zirconium oxide as the for a long time in the mouth depends on the success of core material brings about many advantages, such as bonding between the ceramic, adhesive agent and tooth satisfactory optical features, a high resistance to bending structures. Although improved mechanical properties are 174 Altay Uludamar, Filiz Aykent Balk J Stom, Vol 16, 2012 important for the long-term performance of a ceramic energy of 150 mJ at a 100 microseconds blasting time for material, the clinical success of fixed ceramic prostheses a duration of 60 seconds. The wavelength of the device seems to be strongly dependent on the cementation was 2940 nanometers and its focal spot size was 0.8 mm. procedure. There is a common thought that conventional During irradiation, the laser point was kept approximately methods of adhesive cementation, which include prior 8 to 10 mm away from the surface and the whole surface acid etching of the ceramic surface with hydrofluoric was treated for 60 seconds. acid and further silanation, are not efficient for Y-TZP ceramics, because of their lack of silica and glass Bonding Procedure phase10-12. Even though some Y-TZP manufacturers After appropriate surface treatment, each adhesive suggest the use of air abrasion or tribochemical coating resin cement was applied according to the manufacturers’ prior to adhesive cementation, the effect of those instructions at room temperature (23.0 ± 1.00C) and surface treatments on the mechanical properties of relative humidity (50% ± 5%)10. Application mode and Y-TZP materials is controversial, and both positive and chemical composition of the investigated materials are negative results have been described in the literature10. reported in table 1. To standardize the cementing of resin Therefore, the most appropriate surface treatment for cements on zirconium specimens, specially prepared ring- Y-TZP ceramics still has to be determined. Moreover, shaped plastic moulds with 5 mm inner diameter and 2 there are some possibilities for improving bonding to mm height were used. Resin cements were applied into Y-TZP ceramics that need to be tested, including modern the plastic ring from a syringe using an automatic mixing techniques for surface treatments and adhesive primer tip, which allows a homogeneous mixture. The ring was materials. covered with a cellulose tape and a standard weight of Therefore, the aim of this study was to compare 400 gm was applied on the specimen. Excess cement was the effect of various surface treatment methods on the removed with a dental explorer. It was left to rest for 10 zirconium oxide all ceramic restorations while using minutes in the room temperature for the cement to cure by common alternative products for adhesive cementation itself. Specimens were stored in distilled water at 370C for of such restorations. The null hypothesis was that there 24 hours before testing shear bond strength. is no difference in zirconia-composite cement bonding effectiveness among 4 different surface preparations. Shear Bond Strength Test Shear bond strength was determined according to ISO/TS 11 405:2 003 using a Universal Testing Machine (TSTM 02500, Elista Ltd Şti, Istanbul, Türkiye) at a Material and Method crosshead speed of 0.5 mm/min2. The force at separation (N) was divided by the cross-section area (100 mm2) to 80 specimens 15x12x1.6 mm in diameter were provide results in units of stress (MPa). After debonding, obtained of ZrO2 (87-95%) stabilized by 5% Y2O3 the fractured surfaces were evaluated with an optical ceramic (IPS e.max ZirCAD, Ivoclar Vivadent AG, microscope (100x magnification) to classify the failure Schaan, Liechtenstein). They were ground with 600 grit modes into 1 of the following categories (A) adhesive silicon carbide polishing paper (DCCS, Sankyo Fuji star, failure at the interface between the ceramics and resin- Japan) under water cooling and ultrasonically cleaned luting agent (C) cohesive failure within the ceramics, in acetone and distilled water for 15 minutes.2 A total of within the resin-luting agent only and (M) adhesive and 80 specimens available were randomly divided into 4 cohesive failure at the same site or a mixed failure2. groups (n: 20) according to the surface treatments. Group Representative interfacial morphologies of surface 1: No surface treatments (C); Group 2: Specimens were treatment and debonded specimens were examined in sandblasted (Easy Blast BEGO, Wilhelm-Herbest-Strabe, a Scanning electron microscopy (SEM) (JEOL JSM- Bremen, Germany) for 60 seconds with 110 μ particle size 6060LV Scanning Electron Microscope, Tokyo, Japan). Al2O3 sand (BEGO, Wilhelm-Herbest-Strabe, Bremen, Prior to analysis, specimens were dried and gold coating Germany) from a distance of 1 cm under 2.8 atmospheres was applied with a sputter coater (Polaron SC 502 Sputter of air pressure (SB). Group 3: Specimens were roughened Coater, SPI supplies/ Structure Probe, Inc. West Chester, from various directions by the same investigator with USA)10. a porcelain finishing diamond bur (Edenta AG, Dental Produkte St., St.Gallen, Switzerland), using a micro motor Statistical Analysis hand piece revolving at a speed of 15000 cycles (DB); The values obtained as a result of the shear test Group 4: Er: YAG laser irradiation (LI). The specimens were assessed using 2-way ANOVA, Kruskal-Wallis test, were roughened with a Fotona Fidelis Plus III Er: YAG which is a non-parametric statistical analysis, and Mann- laser device (Fotona Fidelis Plus 3 Lazer, Fotona dd, Whitney U statistical tests with Bonferroni correction. Ljubljana, Slovenia) The irradiation procedure was carried The statistical analyses were carried out in Windows XP out using a pulsation frequency of 10 Hz and pulsation environment using SPSS 13.0 package programme. Balk J Stom, Vol 16, 2012 Bond Strength of Resin Cements to Zirconia Ceramics 175

Table 1. List of materials used in this study

Product/Code//Manufacturer Main Compositions Application Resin cements Apply Zirconia primer on the surfaces of the specimens. Dimethacrylates and HEMA, Then apply into the plastic ring from a syringe using an Multilink® Automix resin cement adhesive monomer, barium automatic mixing tip which allows a homogeneous mixture. (MA) glass filler, SiO filler, The ring was covered with a cellulose tape and a standard Ivoclar Vivadent AG, Bendererstr2 2 Ytterbium triflorite, accelarator weight of 400 gm was applied on the specimen. It was left Schaan, Liechtenstein and stabilisator and pigments to rest for 10 minutes in room temperature for the cement to cure by itself. Apply into the plastic ring from a syringe using an automatic mixing tip which allows a homogeneous mixture without Multilink® Sprint resin cement Dimethacrylates, adhesive any prior treatment to the surfaces of the specimens as (MS) monomer, inorganic filler, recommended by the manufacturer. The ring was covered Ivoclar Vivadent AG, Bendererstr2 accelerator and stabilisator with a cellulose tape and a standard weight of 400 gm was Schaan, Liechtenstein applied on the specimen and again it was left to rest for 10 minutes in room temperature for the cement to cure by itself. Primer Metal/Zirconia Primer (P) Diluter, phosphonic acid Apply primer on the surfaces of the specimens and let to rest Ivoclar Vivadent AG, Bendererstr2 acrylate, ethoxile BIS-GMA, for 180 seconds Schaan, Liechtenstein accelerator and stabilisator

Results In all groups, the MA cement had higher bond strength than MS cement (P<.05). With the groups The results showed that bond strengths were cemented with MA, SB and DB resulted in significantly significantly influenced by the resin cement and surface higher bond strengths, while LI and C presented similar treatment (P<.05). The shear bond strength values and results. The same order was seen for the groups luted with the MS (Tab. 2). There were statistically significant the results of multiple comparisons are summarized in differences between all groups for both cements except C table 2 for all 2 resin cements and 4 surface treatments. and LI. The mean values were 1.84±0.27 to 2.47±0.31; Mean: Table 3 describes the distribution of failure modes in 2.15±0.42 MPa for C, 4.35±0.72 to 5.42±1.28; Mean: the groups. Adhesive failures were most prevalent in all 4.88±1.15 MPa for SB, 3.28±0.90 to 3.72±0.89; Mean: the experimental groups, with an average of 77% adhesive 3.50±0.90 MPa for DB and 1.74±0.30 to 2.37±0.39; failure between the ceramics and resin luting agent. No Mean: 2.05±0.46 MPa for C. The bond strength of the cohesive failure was observed. SEM images showed MA adhesive cement to sandblasted zirconia resulted in morphologic differences among the groups after surface the highest bond strength values (5.42±1.28 MPa). Both treatments (Fig. 1). SA (Fig. 1b) created rougher surface cements showed the highest bond strength values when compared to DB, LI and C (Figs. 1a and 1c). Er: YAG specimens were treated with sandblasting (SB). laser irradiation originated a smooth surface (Fig. 1d).

Table 2. Bond strength of self-adhesive resin cements to zirconia. Means, standard deviations (SD) MPa (n=10) and significancy (P<.05)

GROUPS C SB DB LI Mean±SD Mean±SD Mean±SD Mean±SD MA 2,47±0,31 (A) * 5,42±1,28 (C) 3.72±0,89 (EC) 2.37±0,39 (AB) MS 1,84±0,27 (B) 4.35±0.72 (DC) 3.28±0,90 (ADE) 1.74±0,30 (FB)

* The same letter denotes the results were not statistically significant. 176 Altay Uludamar, Filiz Aykent Balk J Stom, Vol 16, 2012

Table 3. Percentage of the failure modes in each experimental group

Surface Treatment Resin cement None SB DB LI Adhesive Mixed Adhesive Mixed Adhesive Mixed Adhesive Mixed MA 70 70 66 34 75 25 78 22 MS 80 20 78 12 85 15 86 13

a b in zirconia-composite cement bonding effectiveness among 4 different surface preparations. Moreover, SEM images demonstrated considerable qualitative differences in the surface topography of Y-TZP specimens after the surface treatments. Sandblasting appeared to be a more efficient method to modify zirconia surfaces compared to diamond burr and laser irradiation. This finding could be directly related to bond strength results, which showed that both resin cements yielded higher bond strengths after sandblasting10,17-22. Untreated zirconium oxide ceramic is a relatively inert substrate, with low surface energy and wettability17. De Oyague et al18 reported that atomic force microscopy c d analysis reveals a significant increase in surface roughness after sandblasting with 125 μm aluminum-oxide particles. Figure 1. SEM images (original magnifications 500X) of specimens’ surfaces: (a) Control (C); (b) Sandblasted (SB); (c) Diamond burr (DB); Sand blasted surfaces might present an increased surface (d) Er: YAG laser irradiated (LI) area, which favours wettability19-21. However, some authors have stated that the micro porosities created by surface treatments may act as crack initiators, weakening ceramic materials22,23. Thus, the effect of those alterations on the durability of Y-TZP restorations should be Discussion investigated in long-term clinical trials to determine whether the higher retention of sandblasted surfaces Previous studies investigated the bond strength of compensate for the changes in mechanical properties. adhesive restorative materials to Y-TZP ceramics13-16. Some studies have suggested the use of Er:YAG Adhesion tests were applied in laboratory conditions in (erbium-doped yttrium aluminum garnet) laser to order to assess the effectiveness of the restoration systems enhance the bond strength of adhesive materials to resin being used, or to make a prior estimation of the status of composites used for indirect restorations and lithia based a newly marketed adhesive system in the mouth. Clinical ceramics24,25. However, the capacity of the Er:YAG laser recommendations and selection of material related to resin to increase the roughness of Y-TZP ceramics for adhesive adhesion to ceramics are based on mechanical laboratory luting procedures has not been investigated. In this study, tests which demonstrate significant differences in the irradiation of Y-TZP surfaces with Er: YAG laser was choice of material and method. The widely preferred proposed as a surface treatment method. Our results bond strength tests are 3-point bending test, tensile and indicated that laser irradiation was not as effective in micro-tensile tests, and shear and micro-shear tests. Shear improving bond strength as treatment with sandblasting bond test was used for measuring bond strength in a large and diamond bur for both resin cements. Laser treated number of studies in the literature to investigate adhesion and untreated surfaces presented similar results10,24. The of resin cements to porcelain surface13-16. In this study Er: YAG laser has the ability to remove particles by micro shear bond test was used to measure the bond strength of explosions and by vaporization, a process called ablation. 2 different resins cements on the zirconium surfaces that During laser treatment, local temperature changes due to were roughened in a number of ways. heating and cooling phases create internal tensions that The surface treatments investigated in the current can damage the material10,24. The mechanical properties study resulted in significantly different bond-strengths. of Y-TZP ceramics can be negatively affected by changes So null hypothesis was rejected as there were differences in temperature, which can induce phase transformation10. Balk J Stom, Vol 16, 2012 Bond Strength of Resin Cements to Zirconia Ceramics 177

Therefore, in this study, a lower power setting for the Er: In this study, failure mode results indicated that, YAG laser was selected (150mJ) and the surfaces were regardless of the experimental group, most failures of the irradiated with constant water cooling. However, more resin cement-Y-TZP ceramic were adhesive, which left the studies need to be carried out in this area using different zirconia specimens free of remnants of adhesive materials. power and pulsation settings before and after the sintering Fractures being caused mostly by adhesive failure process. indicated that no real chemical bond could be established In this study of measuring bond strengths, the between the resin cement and the yttrium stabilized results of the shear test showed that the bond strength of zirconium oxide specimens2. MA (3.49±1.47) on zirconium surfaces was statistically significantly higher than that of MS (2.80±1.23). Multilink sprint (MS) is self etch, self adhesive resin based adhesive cement and designed for ease of use Conclusions with no bonding application. Multilink Automix (MA), on the other hand, is a resin cement used with bonding Within the limitations of the present in vitro study, applications on the teeth and metal/zirconia primer on the following conclusions can be drawn: the restoration in the aim of having higher bond strength. 1. Applying sandblasting surface treatment improves Metal/Zirconia Primer is only used with Multilink the bond strength of self-adhesive resin cement to Automix. Metal/Zirconia Primer was used on the zirconia; surfaces before applying MA as recommended by the 2. In the surface treatment of sand blasted and manufacturer, but no zirconium primer was used before diamond bur roughness, self-adhesive resin cement applying the new generation MS, which contains the Multilink Automix shows the highest bond strengths etch and adhesive systems in its own composition. It was to zirconia. The using of zirconium primer may have an reported in previous studies that the use of resin cements effect on the mechanical strength of the cement; containing phosphate-based monomer increased adhesion 3. Fractures were mostly adhesive failure, indicating to zirconium surface12,26. The phosphate-containing that no real chemical bond could be established between methacrylate in MA’s zirconium primer, which was the resin cement and the zirconium oxide specimens. used in this study, increased bond strength on zirconium surfaces in a similar way. Therefore, higher bonding values achieved by Multilink Automix may well be due to the application of Metal/zirconia primer. The reason References for such increase was because phosphate-containing methacrylate in the primer formed a salt-like bond with 1. Anusavice KJ. Recent developments in restorative dental zirconium. Due to low bond strength of Multilink Sprint, ceramics. J Am Dent Assoc, 1993; 124:72-74, 76-78, 80-84. 2. Lin J, Shinya A, Gomi H, Shinya A. Effect of self-adhesive it is not on the market anymore. However, the purpose resin cement and tribochemical treatment on bond strength of this in vitro study was to evaluate the influence of to zirconia. Int J Oral Sci, 2010; 2:28-34. different surface preparation methods on the bond strength 3. Guazzato M, Albakry M, Ringer SP, Swain MV. Strength, of 2 composite resins to yttrium stabilized zirconium fracture toughness and microstructure of a selection of all- oxide ceramics. ceramic materials. Part II. Zirconia-based dental ceramics. It is not the bonding strength of Multilink Sprint Dent Mater, 2004; 20:449-456. that is important, but the effect of surface treatment 4. Tsalouchou E, Cattell MJ, Knowles JC, Pittayachawan methods on the shear bond strength of resin cements P, McDonald A. Fatigue and fracture properties of yttria partially stabilized zirconia crown systems. Dent Mater, authors have focused on. The principal aim of this study 2008; 24:308-318. was to compare the effect of various surface treatment 5. Lüthy H, Loeffel O, Hammerle CHF. Effect of termocycling methods on the zirconium oxide all ceramic restorations on bond strength of luting cements to zirconia ceramics. while using common alternative products for adhesive Dent Mater, 2006; 22:195-200. cementation of such restorations. 6. Derand T, Molin M, Kvam K. Bond strength of composite It was interesting that the bond strength values of this luting cements to zirconium oxide ceramics. Dent Mater, study were quite lower than previous stated2,10,22,23. If 2005; 21:1158-1162. the bond strength values were achieved in the region of 7. Luthardt RG, Sandkuhl O, Reitz B. Zirconia-TZP and 20-30 MPa (avarage bonding values of adhesive cements alumina - advanced technologies for the manufacturing of single crowns. Eur J Prosthodont Restor Dent, 1999; 7:113- on tooth substances), there would be no problems as to 119. adhesive bonding of resin cements on zirconium oxide 8. El Zohairy AA, De Gee AJ, Mohsen MM, Feilzer AJ. restorations. Therefore, authors should question such high Microtensile bond strength testing of luting cements to bonding values rather than suspect more realistic numbers prefabricated CAD/CAM ceramic and composite blocks. found in this study. Dent Mater, 2003; 19:575-583. 178 Altay Uludamar, Filiz Aykent Balk J Stom, Vol 16, 2012

9. Luthardt RG, Holzhüter MS, Rudolph H, Herold V, Walter 19. Awliya W, Oden A, Yaman P, Dennison JB, Razzoog ME. MH. CAD/CAM machining effects on Y-TZP zirconia. Dent Shear bond strength of a resin cement to densely sintered Mater, 2004; 20:655-662 high-purity alumina with various surface conditions. Acta 10. Cavalcanti AN, Foxton RM, Watson TF, Oliveira MT, Odontol Scand, 1998; 56:9-13. Giannini M, Marchi GM. Bond Strength of Resin Cements 20. Derand P, Derand T. Bond strength of luting cements to a Zirconia Ceramic with Different Surface Treatments. to zirconium oxide ceramics. Int J Prosthodont, 2000; Oper Dent, 2009; 34:268-275 13:131-135. 11. Blatz MB, Sadan A, Martin J, Lang B. In vitro evaluation 21. Wolfart M, Lehmann F, Wolfart S, Kern M. Durability of the of shear bond strengths of resin to densely sintered high- resin bond strength to zirconia ceramic after using different purity zirconium-oxide ceramic after long-term storage and surface conditioning methods. Dental Mater, 2006; 23:45-50. thermal cycling. J Prosthet Dent, 2004; 91:356-362. 22. Zhang Y, Lawn BR, Rekow ED, Thompson VP. Effect 12. Kern M, Wegner SM. Bonding to zirconia ceramic: adhesion of sandblasting on the long-term performance of dental ceramics. J Biomed Mater Res Part B: Appl Biomater, 2004; methods and their durability. Dent Mater, 1998; 14:64-71. 71:381-386. 13. Kussano CM, Bonfante G, Batista JG, Pinto JHN. Evaluation 23. Kumbuloglu O, Lassila LV, User A, Vallittu PK. Bonding of of shear bond strength of composite to porcelain according to resin composite luting cements to zirconium oxide by two surface treatment. Braz Dent J, 2003; 14:132-135. air-particle abrasion methods. Oper Dent, 2006; 31:248-255. 14. Madani M, Chu FCS, McDonald AV, Smales RJ. Effects of 24. Gokce B, Ozpinar B, Dundar M, Comlekoglu E, Sen BH, surface treatments on shear bond strength between resins Gungor MA. Bond strengths of all-ceramics: Acid vs. laser cement an alumina core. J Prosthet Dent, 2000; 83:644-647. etching. Oper Dent, 2007; 32:173-178. 15. Nakamura S, Yoshida K, Kamada K, Atsuta M. Bonding 25. Burnett LH Jr, Shinkai RS, Eduardo CP. Tensile bond between resin luting cement and glass infiltrated alumina- strength of a one-bottle adhesive system to indirect reinforced ceramics with silane coupling agent. J Oral composites treated with Er: YAG laser, air abrasion, or Rehabil, 2004; 31:785-789. fluoridric acid. Photomed Laser Surg, 2004; 22:351-356. 16. Øilo M, Gjerdet NR, Tvinnereim HM. The firing procedure 26. Wegner SM, Gerdes W, Kern M. Effect of different artificial influences properties of a zirconia core ceramic. Dent aging conditions on ceramic composite bond strength. Int J Mater, 2008; 24:471-475. Prosthodont, 2002; 15:267-272. 17. Ozcan M. Evaluation of alternative intra-oral repair techniques for fractured ceramic fused to metal restorations. Correspondence and requests for offprints to: J Oral Rehabil, 2003; 30:194-203. Dr. Altay Uludamar 18. De Oyague RC, Monticelli F, Toledano M, Osorio E, Ferrari Filistin cad. Kader sok. No: 6 M, Osorio R. Influence of surface treatments and resin Kat: 1, D: 1, 06700 cement selection on bonding to densely-sintered zirconium- Gaziosmanpaşa, Ankara, Turkey oxide ceramic. Dent Mater, 2009; 25:172-179. E-mail: [email protected]

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An Unusual Laryngeal Complication Following Inferior Alveolar Nerve Block

SUMMARY Ulkem Cılasun1, E. Alper Sınanoglu2, Serdar Yılmaz1, Esra Guzeldemır3, Gamze Alnıacık4 Local anaesthetic administration is the most common procedure 1University of Kocaeli, Faculty of Dentistry, that accompanies almost all procedures in dentistry. Some of immediate Department of Oral and Maxillofacial Surgery, Kocaeli, Turkey post-injection local complications are fairly common, whereas some are 2University of Kocaeli, Faculty of Dentistry, Department of Oral Diagnosis and Radiology, less frequent and rarely reported. Some complications can be bizarre Kocaeli, Turkey 3University of Kocaeli, Faculty of Dentistry, and difficult to explain. In this cases report, 2 cases of unusual laryngeal Department of Periodontology, Kocaeli, Turkey 4Private Practice, Ankara, Turkey complications following inferior alveolar nerve block are presented. CASE REPORT (CR) Keywords: IAN Block; Complication; Acute Hoarseness Balk J Stom, 2012; 16:179-180

Introduction recent ones, some textbooks do not even mention this complication. In this cases report, 2 acute hoarseness Local anaesthetic (LA) administration is the most and mild dysphagia immediately after local anesthesia common procedure in dentistry. Although this procedure administration are presented. accompanies almost all dental procedures, it has many potential risks for the patient6. When LA is administered carefully and within recommended dosage limits, they have established an enviable record of safety7. Even Report of Cases though some life threatening systemic reactions may Case 1 occur, most adverse effects or complications are local and A 33-year-old man had received an inferior alveolar temporary. nerve (IAN) block for endodontic treatment of his LA complications can be classified as local right mandibular second molar. A few seconds after the or systemic7. Local and immediate post-injection, injection, hoarseness occurred and he complained of in-the-chair complications, such as needle breakage, dysphagia and claimed respiration difficulty. He was pain or burning sensation on injection, penetration of a immediately referred to the Oral and Maxillofacial blood vessel (venous or arterial), haematoma, oedema, Surgery Clinic where he was evaluated for laryngeal tissue blanching, nerve damage, facial nerve paralysis, oedema, bronchospasm and airway obstruction. None amaurosis, diplopia and adverse drug interactions was present and the symptoms were diagnosed as 7 (overdose, allergy or idiosyncrasy) to anaesthetic complications of the local anesthesia. 6 injections are fairly common , some are less frequent and The complication was explained to the patient and he rarely reported. Such complications can be bizarre and was followed-up until the symptoms completely resolved, difficult to explain. Especially neurological complications which lasted approximately 2 hours. following the administration of a local anaesthetic can be alarming. Case 2 There is only 1 case of vagus nerve inhibition A 42-year-old man had had LA injection for the IAN reported following dental anesthesia. Including the very block for endodontic treatment of his right mandibular 180 Ulkem Cılasun et al. Balk J Stom, Vol 16, 2012 first molar. Immediately after the injection, hoarseness be caused by accidentally medially located injection but occurred but he did not have any other complaints. He in the presented cases, as the doctors did not report an was immediately referred to the Oral and Maxillofacial unusual technique during injection, an anatomic variation Surgery clinic for further evaluation. The symptom was was taken into consideration as a possible cause. again diagnosed as LA complication. He completely Fortunately, permanent damage to nerves, facial recovered after approximately 3 hours. and oral tissues are extremely rare. Being aware of the Both patients were clear of any systemic diseases and anatomy and the properties of LA solutions, the clinician the injections were performed by using a LA solution of should be cognizant of even these rare complications that 4% articaine hydrochloride and 1:200.000 epinephrine can occur during regional nerve blocks, and should be hydrochloride (Ultracain D-S; Aventis, Istanbul, Turkey) prepared to manage them. with 50 mm, 27-gauge needles. This cases report highlights an event where individual anatomic variation of the sympathetic nerve may allow anaesthetic solution to be delivered to an ectopic site, which will cause unusual signs Discussion and symptoms, such as hoarseness and laryngeal complications. Fortunately, these complications were Complications of IAN blocks have been reported temporary and resolved totally by the time local in the literature and during the past decades, some anaesthesia resolved. studies have investigated the frequency of immediate complications during the administration of a LA3-5,6. Neurological complications have been reported as rare complications of local anaesthesia and can be divided References into: a) those that arise as a direct result of the procedure itself (IAN block and posterior superior alveolar nerve 1. Campbell RL, Mercuri LG, Van Sickels J. Cervical block); and b) those due to the toxicity of the agents sympathetic block following intraoral local anaesthesia. used2. Oral Surg Oral Med Oral Pathol, 1979; 47:223-226. Campbell et al1 reported the development of 2. Crean SJ, Powis A. Neurological complications of local Horner’s Syndrome, which arose due to penetration of the anaesthetics in dentistry. Dent Update, 1999; 26:344-339. 3. Daublander M, Muller R, Lipp MD. The incidence of LA through the lateral pharyngeal and prevertebral spaces, complications associated with local anesthesia in dentistry. causing blockade of the stellate ganglion. The features of Anesth Prog, 1997; 44:132-141. the syndrome include: 4. D’Eramo EM, Bookless SJ, Howard JB. Adverse events ●● flushing of the face on the same side; with outpatient anesthesia in Massachusetts. J Oral ●● ptosis of the eyelid; Maxillofac Surg, 2003; 61:793-800. ●● vasodilatation of the conjunctiva; 5. Keetley A, Moles DR. A clinical audit into the success rate ●● pupillary constriction; and (occasionally) of inferior alveolar nerve block analgesia in general dental practice. Prim Dent Care, 2001; 8:139-142. ●● a rash over the neck, face, shoulder and arm of the 6. Lustig JP, Zusman SP. Immediate complications of local ipsilateral side. anesthetic administered to 1,007 consecutive patients. J Am The case described by Campbell et al1 also had Dent Assoc, 1999; 130:496-499. a hoarse voice and difficulty in breathing due to the 7. Malamed SF. Handbook of Local Anesthesia. 5th Ed. involvement of the recurrent laryngeal nerve. All of these Philadelphia: Elsevier, Mosby, 2004. effects were transient1. In the presented cases, none of the above-mentioned symptoms of Horner’s Syndrome was observed but only the laryngeal complications occurred Correspondence and request for offprints to: right after the administration of articaine HCl. Hoarseness, Dr. U. Cilasun dysphagia, and claimed respiration difficulty resolved KocaeliUniversitesi, YuvacikYerleskesi within 2-3 hours. DisHekimligiFakultesi, 41190 Yuvacik, Basiskele, Kocaeli A possible cause of the hoarseness was reported as Turkey the involvement of the recurrent laryngeal nerve. It may E-mail: [email protected]

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L BALKAN JOURNAL OF STOMATOLOGY A ISSN 1107 - 1141 IC G LO TO STOMA

Surgical Planning of Bilaterally Impacted Maxillary Third Molars by Using Cone Beam Computed Tomography

SUMMARY Nurhan Güler Surgical planning of a case with bilaterally impacted maxillary teeth Yeditepe University, Faculty of Dentistry, by using cone beam computed tomography is presented. The 3D model Department of Oral and Maxillofacial Surgery, provide valuable information for improved diagnosis and treatment plan and Istanbul, Turkey ultimately results in more successful treatment, as in the present case. The surgeon, knowing the precise location of the tooth and shape of roots in all projections would reduce the invasiveness of surgery. Keywords: Impacted Third Molar; Maxillary Sinus; Headache; CASE REPORT (CR) Cone Beam Computed Tomography Balk J Stom, 2012; 16:181-184

Introduction cone-beam computed tomography (CBCT), which has a lower-dose, lower-cost alternative to conventional CT and Impaction of a tooth is a situation in which an is being used for localization of tooth impaction. These unerupted tooth is wedged against another tooth (or machines use cone-shaped radiation to gather information teeth) or otherwise located so that it cannot erupt in the maxillofacial region, with high spatial resolution normally. Many theories have been suggested on the and significantly decreased radiation doses3,8. aetiology of ectopic eruption such as trauma, infection, In this report, the surgical planning of a case with pathologic conditions, crowding and developmental bilaterally impacted maxillary teeth by using CBCT is anomalies10. The maxillary sinus, palate, mandibular presented. condyle, coronoid process, orbit, nasal cavity or through the skin are common maxillofacial areas for the ectopic eruption. Developmental disturbances such as cleft palate, displacement of teeth by trauma or cyst, infection, genetic Case Report factors, crowding and dense bone are the possible causes of the ectopic tooth into maxillary sinus2,5,6. Caldwell- A 37 years old woman was referred to our clinic with Luc procedure and the endoscopic surgical approach are a complaint of facial pain and headache for 8 months. common techniques for removing ectopic teeth from the The past medical history was unremarkable. There was sinus although latter has less morbidity4. no obvious sign of disorder on both extra- and intraoral Treatment decision on the impacted teeth has examinations. Her specialists (neurologist and ENT depended on several factors, including location of the physician) told her that no signs of any disorders but, impaction, prognosis of the intervention on the impacted based on panoramic radiograph, the possible cause of pain tooth and adjacent teeth, surgical accessibility, impact of might be the impacted maxillary teeth. There were no treatment on the final functional occlusion, and possible signs of temporomandibular joint disorders such as disc surgical morbidity. This decision has traditionally been displacement with or without reduction and osteoarthritis. based on planar 2-dimensional (2D) radiography. New On panoramic radiograph, both third molars were imaging techniques are now available in dentistry, like impacted with a connection to the root of second molar 182 Nurhan Güler Balk J Stom, Vol 16, 2012 and maxillary sinus (Fig. 1). CBCT scans were performed to evaluate the position and direction of the impacted teeth in the maxillary sinus and related tooth (NewTom Dental volumetric tomography). Both coronal and sagittal images showed the close proximity to the root of left second molar and right maxillary sinus. The root of left second molar without sign of resorption was placed in the middle of occlusal surface of the impacted tooth (Fig. 2). There was no dilacerations of roots of both impacted teeth. On the frontal view of 3D volumetric image, while the right tooth without bone coverage was in the maxillary sinus, the crown of the left impacted tooth was full covered with bone (Fig. 3). On sagittal views, there was no bony structure on the impacted teeth and close proximity to maxillary sinus (Fig. 4, a and b).

Figure 3. On the frontal view of 3D volumetric image, while the right tooth, without bony coverage, was in the maxillary sinus, the crown of the left impacted tooth was fully covered with bone

Figure 1. Panoramic view of bilaterally impacted maxillary third molar a b

Figure 4. The sagittal view of the right (a) and the left (b) impacted maxillary teeth

Figure 2. 3D CBCT image shows the close proximity to the root of the left second molar and proximity to the right maxillary sinus; the root of the left second molar is placed in the middle of occlusal surface of the Figure 5. The impacted tooth (white arrow) was seen under the sinus impacted tooth mucosa (black arrow) Balk J Stom, Vol 16, 2012 Surgical Planning with CBCT 183

Under sedation, Caldwell-Luc procedure was favourable, because one imaging session can provide performed for the removal of the right upper wisdom many views9. In the present case, both impacted third tooth, while a standard third molar surgery was made for molar with a connection to the root of second molar the other. The right wisdom tooth between sinus mucosa and maxillary sinus were not clearly demonstrated on and alveolar bone was carefully removed without mucosal panoramic radiography. The best images demonstrating perforation of the sinus (Fig. 5). Postoperative period was the bone and/or mucosa of maxillary sinus were taken on uneventful and no complaints at 2 years follow-up (Fig. 6). frontal view of 3D CBCT. A common application of CBCT is in evaluation and surgical planning of impacted teeth6,11. The additional third dimension provided by CBCT increases the information available for the surgeon while planning exposure or removal, and may notably alter the prevalence of root resorption1. To take full advantage of the information provided by CBCT, it is necessary to interpret volumetric images on a 3D scale. Such a technique would enable clinicians to describe and evaluate pathologies, deformities, and impactions with greater detail and accuracy7. In conclusion, the case presented here describes Figure 6. Final panoramic view of patient the spatial relationship of the impacted third molar to the surrounding anatomic structures using CBCT. 3D computed tomographic model provide valuable information for improved diagnosis and treatment plan Discussion and ultimately results in more successful treatment, as in present case. The surgeon, knowing the precise location of Although most of impacted teeth in the maxillary the tooth and shape of the roots in all projections would sinus are asymptomatic and usually found during routine reduce the invasiveness of surgery. clinical and radiographic examinations, facial pain associated with intermittent purulent nasal discharge and headache can be the main complaints2. It has been reported a case with facial asymmetry because of bilateral References ectopic third molars in the maxillary sinus causing osteomeatal complex obstruction5. Based on the present 1. Alqerban A, Jacobs R, Lambrechts P, Loozen G, Willems G. case complaints, the impacted maxillary teeth could be Root resorption of the maxillary lateral incisor caused by one of the factors of the facial pain and headache. impacted canine: a literature review. Clin Oral Invest, 2009; 13:247-255. CBCT images are inherently more accurate than 2. Baykul T, Doğru H, Yasan H, Cina Aksoy M. Clinical impact traditional x-rays, since beam projection is orthogonal; of ectopic teeth in the maxillary sinus. Auris Nasus Larynx, this means that the x-ray beams are approximately 2006; 33:277-281. parallel to one another, and the object is near the sensor. 3. Chaushu S, Chaushu G, Becker A. The role of digital This explains why there is little projection effect and volume tomography in the imaging of impacted teeth. World no magnification. In addition, the computer software J Orthod, 2004; 5:120-132. addresses the projection effect, resulting in undistorted 4. Hasbini AS, Hadi U, Ghafari J. Endoscopic removal of an 1:1 measurements. This contrasts with traditional imaging, ectopic third molar obstructing the osteomeatal complex Ear which always has some projection error because the Nose Throat J, 2001; 80:667-670. anatomic regions of interest are at varying distances 5. Jude R, Horowitz J, Loree T. A case report: Ectopic molars from the film. In this situation, the dentist must account that cause osteomeatal complex obstruction. J Am Dent for these imaging artefacts when reading the images. Assoc, 1995; 126:1655-1657. Another advantage of the CBCT scan is that the data 6. Kim SJ. Cone beam computed tomography findings of ectopic mandibular third molar in the mandibular acquired include information for the entire craniofacial condyle: report of a case. Imaging Sci Dent, 2011; region. Additional views, such as lateral cephalograms, 41:135-137. panoramic radiographs, airway evaluations and volumetric 7. Lou L, Lagravere MO, Compton S, Major PW, Flores-Mir images, are available from the original acquisition data. C. Accuracy of measurements and reliability of landmark These images can be manipulated with imaging software identification with computed tomography (CT) techniques in to aid the dentist in diagnosis and treatment planning. the maxillofacial area: a systematic review. Oral Surg Oral The costs, efficiency, and benefits of CBCT imaging are Med Oral Pathol Oral Radiol Endod, 2007; 104:402-411. 184 Nurhan Güler Balk J Stom, Vol 16, 2012

8. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB. 11. Scarfe WC, Farman AG, Sukovic P. Clinical applications of Dosimetry of 3 CBCT devices for oral and maxillofacial cone-beam computed tomography in dental practice. J Can radiology: CB MercuRay, NewTom 3G and i-CAT. Dent Assoc, 2006; 72:75-80. Dentomaxillofac Radiol, 2006; 35:219-226. 9. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two extraoral direct digital imaging devices: NewTom Correspondence and request for offprints to: cone beam CT and Orthophos Plus DS panoramic unit. Assoc. Prof. Nurhan Güler Dentomaxillofac Radiol, 2003; 32:229-234. Yeditepe Universitesi, Dis Hekimligi Fakultesi 10. Raghoebar GM, Boering G, Vissink A, Stegenga B. Eruption Bagdat cad. No: 238 disturbances of permanent molars: a review. J Oral Pathol Goztepe Istanbul, Turkey Med, 1991; 20:159-166 E-mail: [email protected]

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Instructions to authors

The BALKAN JOURNAL OF STOMATOLOGY provides tution address of each author, 3) name, address, telephone and contributors with an opportunity to publish review and original E-mail of the author responsible for correspondence and to papers, preliminary (short) communications and case reports. whom requests for offprints should be sent and 4) sources of sup- Review papers (RP) should present an analytic evaluation port in the form of grants if any. of certain problems in stomatology based on a critical approach Summary. This should consist of not more than 200 words to personal experience and to the published results of other summarizing the contents of the paper. It should include the title authors. of the paper, but without the names of authors and institutions. Original papers (OP) should be related to the results of Key word should be included, according to Index Medicus. scientific, clinical and experimental research. They should investi- Text. 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