The first issue of the Balkan Journal of Dental Medicine was published in 2014 The Journal continues the tradition of the Balkan Journal of Stomatology which was published between 1997 and 2013 Publisher: SCIENDO OPEN

Editor-in-Chief Prof. Dejan Marković, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Associate Editors Prof. Ruzhdie Qafmolla, DDS, PhD, Faculty of Dentistry, University of Medicine-Tirana, Albania [email protected] Prof. Maida Ganibegović, DDS, PhD, Faculty of Dentistry, University of Sarajevo, Bosnia and Herzegovina [email protected] Assoc. Prof. Nikolai Sharkov, DDS, PhD, Faculty of Dental Medicine, Medical University, Sofia, Bulgaria [email protected] Assoc. Prof. George Pantelas, DDS, PhD, The School of Medicine, European University Cyprus, Cyprus [email protected] Prof. Ana Minovska, DDS, PhD, Department of Dentistry, Goce Delcev University of Štip, FYR of Macedonia [email protected] Prof. Anastasios Markopoulos, DDS, PhD, School of Dentistry, Aristotle University, Greece [email protected] Assoc. Prof. Mirjana Đuričković, Faculty of Medicine, University of Montenegro, Montenegro [email protected] Prof. Forna Norina Consuela, DDS, PhD, Faculty of Dentistry, Grigore T. Popa U. M. Ph. Iasi, Romania [email protected] Prof. Slavoljub Živković, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Prof. Ender Kazazoglu, DDS, PhD, Dental School, University of Yeditepe, Turkey [email protected] Editorial Board Assoc. Prof. Dorjan Hysi, DDS, PhD, Faculty of Dentistry, University of Medicine-Tirana, Albania Prof. Virgjini Mulo, DDS, PhD, Faculty of Dentistry, University of Medicine-Tirana, Albania Assoc. Prof. Naida Hadžiabdić, DDS, PhD, Faculty of Dentistry, University of Sarajevo, Bosnia and Herzegovina Dr. Mihael Stanojević, DDS, MSc, Medical Faculty Foca, Bosnia and Herzegovina Prof. Andon Filtchev, DDS, PhD, Faculty of Dental Medicine, Medical University, Bulgaria Prof. Georgi Todorov, DDS, PhD, Faculty of Dental Medicine, Medical University, Bulgaria Dr. Huseyn Biçak, DDS, General Hospital Nicosia, Cyprus Dr. Aikaterine Kostea, DDS, General Hospital Nicosia, Cyprus Assoc. Prof. Ilijana Muratovska, DDS, PhD, Department of Dentistry, Goce Delcev UN of Štip, FYR of Macedonia Assoc. Prof. Vera R. Nikolovska, DDS, PhD, Department of Dentistry, Goce Delcev UN of Štip, FYR of Macedonia Prof. Lambros Zouloumis, DDS, PhD, School of Dentistry, Aristotle University, Greece Prof. Athanasios Poulopoulos, DDS, PhD, School of Dentistry, Aristotle University, Greece Assoc. Prof. Zoran Vlahović, DDS, PhD, Faculty of Medicine, University of Priština, Montenegro Prof. Andrei Iliescu, DDS, PhD, Faculty of Dentistry, Grigore T. Popa U. M. Ph. Iasi, Romania Assoc. Prof. Paula Perlea, DDS, PhD, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, Romania Assoc. Prof. Tamara Perić, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia Dr. Slobodan Anđelković, DDS, Private Dental Practice- Belgrade, Serbia Prof. Gül Işik Özkol, DDS, PhD, Istanbul University, Turkey Assoc. Prof. Zeynep Ozkurt Kayahan, DDS, PhD, Dental School, University of Yeditepe, Turkey Balk J Dent Med, Vol 22, 2018

International Editorial Board Prof. Nitzan Bichacho, DDS, PhD, The Hebrew University, Hadassah School of Dental Medicine, Israel Dr. Borko Čudović, DDS, Angle Society of Europe, Germany Prof. George Freedman, DDS, PhD, BPP University School of Health, Faculty of Dentistry, United Kingdom Assoc. Prof. Alex Grumezescu, PhD, Polytechnic University of Bucharest, Romania Prof. James Gutmann, DDS, PhD, Texas A&M University Baylor College of Dentistry, USA Prof. Christoph Hämmerle, DDS, PhD, Center of Dental Medicine, University of Zurich, Germany Dr. Chris Ivanoff, College of Dentistry, University of Tennessee Health Science Center, USA Dr. Barrie Kenney, DDS, Private practice- Los Angeles, USA Dr. Predrag Charles Lekic, DDS, PhD, University of Manitoba, Canada Prof. Joshua Moshonov, DDS, PhD, Hadassah School of Dental Medicine, Israel John Nicholson, PhD, DSc, Bluefield Centre for Biomaterials, United Kingdom Prof. Kyösti Oikarinen, DDS, PhD, University of Oulu, Finland Assoc. Prof. Sangwon Park, DDS, PhD, Chonnam National University, South Korea Prof. George Sandor, PhD, University of British Columbia, Canada Prof. Ario Santini, DDS, PhD, Faculty of General Dental Practice, United Kingdom Prof. Riitta Suuronen, DDS, PhD, Institute for Regenerative Medicine, University of Tampere, Finland Dr. Michael Weinlaender, DDS, Private Practice- Vienna, Austria Publications Committee Chair Prof. Ljubomir Todorović, DDS, PhD, Academy of Medical Sciences, Serbian Medical Society, Serbia [email protected] Editorial Medical Staff Assoc. Prof. Elizabeta Gjorgievska, DDS, PhD, Faculty of Dentistry, Ss. Cyril and Methodius UN, FYR of Macedonia Prof. Bojan Petrović, DDS, PhD, Faculty of Medicine, University of Novi Sad, Serbia Dr. Marijan Denkovski, DDS, FYR of Macedonia Dr. Georgios Tsiogas, DDS, Greece Dr. Ana Jotić, DDS, Private Dental Practice, Belgrade, Serbia Dr. Raša Mladenović, DDS, Faculty of Medicine, University of Priština, Serbia Translations supervisor Gordana Todorović Technical Editing Dr. Milica Cindrić, DDS Publishing Managers Jelena Jaćimović, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Res. Asst. Bojana Ćetenović, DDS, PhD, Institute for Nuclear Sciences „Vinca“ [email protected] Assis. Ana Vuković, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Statistical Advisor Prof. Biljana Miličić, MD, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Editorial Office: School of Dental Medicine, Clinic for Paediatric and Preventive Dentistry, Dr. Subotića 11, 11000 Belgrade, Serbia e-mail: [email protected], Tel: +381641149773, Fax: +381112685361 Papers published in the Balkan Journal of Dental Medicine are indexed in: Baidu Scholar, Case, Celdes, CNKI Scholar (China National Knowledge Infrastructure), CNPIEC, EBSCO Discovery Service, Google Scholar, J-Gate, JournalTOCs, KESLI-NDSL (Korean National Discovery for Science Leaders), Naviga (Softweco), Primo Central (ExLibris), ReadCube, Sherpa/RoMEO, Summon (Serials Solutions/ProQuest), TDOne (TDNet), WorldCat (OCLC).

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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA

VOLUME 22 NUMBER 3 NOVEMBER 2018 PAGES 115-174

Contents

RP S. Kamalakidis Success of Complete Denture Treatment, 115 V. Anastassiadou Detailed Investigation of Construction Protocols, A. Sofou Occlusal Schemes and Evaluation Questionnaires A. Pissiotis

RP T. Vouzara Separated Instrument in Endodontics: Frequency, Treatment and Prognosis 123 M. el Chares K. Lyroudia

OP B. Apaydın Evaluation of Mandibular Anatomical Formation for 133 D. Icoz Gender Determination in Turkish Population F. Yasar F. Akgunlu

OP H. Çankaya Awareness of Oral Complications and Oral Hygiene Habits of 138 P. Güneri Subjects with Diagnosed Diabetes Mellitus J.B. Epstein H. Boyacıoğlu

OP M.E. Kalaitzoglou Study of Internal Morphology of Root-Canal 146 C. Beltes Treated Single-Rooted Mandibular Second Molars in a Greek Population E. Kantilieraki P. Beltes

OP M. Özdede Morphometric Analysis of Greater Palatine Canal via 150 E.Y. Keriş Cone-Beam Computed Tomography B. Altunkaynak İ. Peker

OP E. Ximinis Electromyographic Activity Changes of Jaw-Closing Muscles in 157 D. Tortopidis Patients with Different Occlusion Schemes after Fixed Prosthetic Restoration

CR G. Altan Stafne Bone Defect in Anterior Mandible 163 S.C. İşler İ. Özcan

CR S.B. Badar Conservative Management of Displaced Horizontal Root Fracture 167 R. Ghafoor in Vital Maxillary Premolar: a Case Report M.H. Hameed N. Anwer

CR D. Torul Management of Large Residual Cyst in 171 M.C. Bereket Elderly Patient with Decompression Alone: Case Report E. Özkan

DOI: 10.2478/bjdm-2018-0021

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Success of Complete Denture Treatment, Detailed Investigation of Construction Protocols, Occlusal Schemes and Evaluation Questionnaires

SUMMARY Savvas Kamalakidis1,2, Vassiliki Background/Aim: The successful outcome of conventional complete Anastassiadou2, Afrodite Sofou2, Argirios 2 denture treatment can be defined with the use of both subjective and Pissiotis objective criteria. Denture satisfaction determinants may include denture 1 Department of Postgraduate Prosthodontics, quality, oral tissue condition, patient-dentist relationship, patient’s Tufts University School of Dental Medicine, attitude toward dentures, patient’s personality and socioeconomic factors. Boston, Mass-USA 2 Department of Prosthodontics, Aristotle Purpose: The aim of the current review was to identify and analyze the University Faculty of Health Sciences, School of different construction protocols and occlusal schemes that contribute to the Dentistry, Thessaloniki, Greece success of complete denture rehabilitation through the use of evaluation questionnaires. Material and Methods: A comprehensive literature search was performed through electronic databases (MEDLINE via PubMed) using the appropriate key words (complete denture construction, complete denture fabrication, complete denture occlusion and complete denture occlusal scheme). The related to the subject scientific papers were selected and evaluated for eligibility utilizing a predefined review process (English, full text articles, published from January 2000 up to April 2017). Results: None of the analyzed studies identified significant differences between dentures constructed with simplified, CAD/CAM and traditional protocols in terms of general satisfaction and Oral Health Related Quality of Life scales. The same condition applied to the studies which compared complete dentures with bilateral balanced, lingualized, monoplane and canine guided occlusion. Conclusions: Current scientific evidence suggested that patients could adapt comfortably to any type of bilateral balanced occlusal scheme and to complete dentures been fabricated with all types of complete denture construction protocol. Disease-specific questionnaires could be considered valuable tools and should be used to assess the outcome of any treatment modality. Key words: Complete Denture, Construction Protocol, CAD/CAM, Occlusal Scheme, REVIEW PAPER (RP) Lingualized Occlusion, Satisfaction, Questionnaires, Ohrqol Balk J Dent Med, 2018;115-122

Introduction for patients not selecting the implant-assisted removable prostheses as their treatment of choice. Conventional complete denture (CD) rehabilitation The laboratory fabrication procedures of a CD has been established as a valuable treatment modality have remained largely unchanged since the introduction despite major advancements in implant dentistry1. of poly-methyl-methacrylate (PMMA) by Hill in 19316. Biomechanical complications2, surgical procedures’ The standardized denture construction protocols could risk3 and overall cost of prosthetic components and be divided into two main categories: a) conventional procedures4,5 have been advocated as the main reasons construction, which included the traditional, the simplified 116 Savvas Kamalakidis et al. Balk J Dent Med, Vol 22, 2018 and the CAD/CAM protocols and b) duplication social activities. The Oral Health Impact Profile-20 construction protocols. (OHIP-20) was developed to measure the impact of Most undergraduate academic curricula in the United complete dentures to the OHRQoL of edentulous Kingdom and in the United States have adopted the patients44. Additionally, in order to record the patients’ traditional construction protocol as their teaching method self-perceived satisfaction, Awad and Feine45 proposed the for conventional CDs7,8. The simplified construction McGill denture satisfaction instrument. The validity and protocol, although it could be considered less labor- reliability of questionnaires related to complete denture intensive and time-consuming than the traditional assessments have been well established in several clinical protocol, has been granted limited application by the studies46-49. dental schools9. The main difference of a simplified The aim of the current review was to summarize the protocol compared to a traditional protocol has been results of all clinical studies addressing the subjects of established as the one step impression technique versus complete denture construction and their occlusal schemes. 10 the two-step one . Several randomized controlled The subject of the evaluation questionnaires was also 11–17 trials have been published which compared critically analyzed, but in an indirect approach, through the subjective and objective outcomes of these two the results of the reviewed papers. construction protocols and no definitive result could been drawn as to their effectiveness. Recently, the concept of computer-aided design and computer-aided manufacturing (CAD-CAM) has been Material and Methods introduced as an alternative CD construction protocol18. Computer-engineered complete dentures (CECD) could An electronic database (MEDLINE/Pubmed) search be either digitally designed or digitally fabricated, with was performed to retrieve relevant articles, dated from both additive methods (rapid prototyping-printing) and January 2000 until April 2017. It involved full-text papers, subtractive methods (CNC milling)19. Due to the fact that published in English with the following search terms: CAD-CAM construction protocols have not been widely “complete denture construction”, “complete denture used, only a few published clinical studies20,21 could be fabrication”, “complete denture occlusion” and “complete utilized for assessing this new technique. denture occlusal scheme”. Boolean operators (or, and) The second main group for the standardized CD were used to combine searches. Additionally, a manual construction protocol comprised the duplication of the search was performed to the following dental journals: existing dentures with various techniques7. The main Journal of Prosthodontics, Journal of Prosthetic Dentistry, advantage of replicated dentures could be considered the International Journal of Prosthodontics, and the the more comfortable adaptation of elderly patients Journal of Oral rehabilitation. to their new prostheses22. The inherent difficulties of randomization in a study design between traditional The inclusion criteria, apart from full text articles and duplication construction protocols led to only non- written in English, were human clinical studies with or randomized clinical studies23–25 been published to the without a randomization process. The exclusion criteria literature up to date. were studies with implant-assisted or teeth-supported It has been established that the crucial difference overdentures, in vitro studies, case reports and review between a CD and a natural dentition was that dentures papers. The reports were analyzed by two separate act as one unit and transfer the energy being applied to the reviewers to check the papers’ relevancy to the study whole denture base, while the natural teeth act as single subject. In cases of disagreement, a third reviewer was units26. That fact led the dental profession to adopt the consulted to achieve consensus. The reviewers were dogma of bilateral balanced occlusion for CDs in order not blinded as to the authors’ names or the journal of to minimize lateral forces been applied to the residual publication. ridge27. It has also been speculated that non-balanced monoplane occlusion exhibited lower masticatory efficiency and led to poorer patient satisfaction28. Various concepts of balanced occlusion (i.e. lingualized) and Results non-balanced occlusion (i.e. canine-guided) have been investigated through numerous randomized clinical Two separate searches were performed. The first trials29–42. identified 331 articles related to the subject of denture Psychometric questionnaires have been developed construction protocols, out of which only 12 studies to register patients’ feedback for the evaluation of their (Table 1) met the inclusion criteria. The second search denture treatment. The term Oral Health-Related Quality related to the subject of denture occlusion, identified a of Life (OHRQoL) was proposed by Gift and Redford43 total of 449 articles, with only 14 studies (Table 2) been to record the impact of patients’ oral disease to everyday selected for final analysis. Balk J Dent Med, Vol 22, 2018 Complete Denture Treatment 117

Table 1. Summary of studies assessing complete dentures’ construction protocols.

Study Sample size Construction Variables Follow-up Study design Patients’ preference (year) (n) protocols (instruments) (months) Simplified vs OHIP-EDENT, Baseline, Nunez et al17 (2015) RCT 50 No difference Traditional satisfaction 1 m, 6 m Vecchia et al16 Simplified vs Total cost, fabrication Baseline, Not applicable clinical RCT 39 (2014) Traditional time, # of adjustments 3 m, 6 m evaluation Regis et al14 Simplified vs OHIP-EDENT, Baseline, RCT 39 No difference (2013) Traditional satisfaction, FAD 3 m, 6 m Masticatory Cunha et al15 Simplified vs Baseline, RCT 39 performance and No difference (2013) Traditional 3 m, 6 m ability Kawai et al13 Simplified vs Total cost, fabrication Baseline, Not applicable clinical RCT 122 (2010) Traditional time, 3 m, 6 m evaluation Heydecke et al12 Simplified vs RCT-CO 20 Satisfaction 3 m, 6 m No difference (2008) Traditional Kawai et al11 Simplified vs Satisfaction, denture Baseline, RCT 122 No difference (2005) Traditional quality 3 m, 6 m Schwindling et al CAD/CAM vs Not applicable clinical PCS 5 Clinical evaluation Baseline (2016)21 Traditional evaluation Kattadiyil et al20 CAD/CAM vs Satisfaction, clinical Baseline, PCS 15 CAD/CAM (2015) Traditional evaluation 1 week Kamalakidis et al Duplication vs OHIP-20, satisf., sore Baseline, PCS 20 No difference (2016)25 Traditional spots, # adj. 3 m, 6 m Ellis et al24 Duplication vs PCS 40 OHIP-20, satisfaction Baseline, 1 m No difference (2007) Traditional Scott et al23 Duplication vs PCS 65 OHIP-14, satisfaction Baseline, 3 m No difference (2006) Traditional RCT: randomized clinical trial, CO: cross-over, PCS: prospective clinical study, FAD: functional assessment of dentures, #: number

Construction protocols fabrication methods, the simplified protocol was cheaper and demanded less time for denture completion. The search strategy yielded seven articles (Table 1) Kawai et al.15,16 conducted a randomized clinical which compared traditional and simplified construction trial, between simplified and traditional protocols, protocols. However, only four separate randomized comprising the largest sample size (n=122) of all reviewed clinical trials11–17 could be identified. The studies studies. No difference was detected in patients’ preference evaluated patients’ self-perceived satisfaction, oral health as assessed by overall satisfaction at 3 and 6 months related quality of life, masticatory performance and intervals. Denture quality was determined to be equal for ability, and finally fabrication time and total costs. All both fabrication protocols. The authors also concluded studies had a follow-up period of six months. that the simplified construction protocol cost significantly Nunez et al.11 conducted a randomized clinical trial less and the clinicians spent less chair-time than the which compared CDs with traditional and simplified traditional protocol. construction protocols. They utilized the OHIP-EDENT Finally, Heydecke et al.17 conducted the only instrument and a patient satisfaction questionnaire with randomized clinical trial with a crossover study design a Visual Analogue Scale (VAS) to record the patients’ between a simplified and a traditional construction responses. Follow-up time intervals were set at one and at protocol. The participants were instructed to use each six months with equal acceptance rates been registered by denture design for three months and then rated, using the patients for both construction protocols. a visual analogue scale, the following items: general One randomized controlled clinical trial, which satisfaction, ability to chew, ability to speak, esthetics, was divided into three separate articles12–14, compared stability, comfort and ease of cleaning. No significant the simplified protocol for complete denture fabrication differences were detected between the two protocols with the traditional protocol. The authors focused into regarding general satisfaction. masticatory performance and ability14; patients’ oral CAD/CAM dentures have only recently been health–related quality of life, satisfaction, and denture introduced. As a result, no randomized control trials could quality13, and finally, total cost, fabrication time and be identified in the literature. A prospective clinical study number of adjustment appointments12. They concluded by Schwindling et al.21 comprised five participants and that although patients’ preference was equal for both focused on the clinical evaluation of CDs fabricated with 118 Savvas Kamalakidis et al. Balk J Dent Med, Vol 22, 2018 a CAD/CAM and a traditional construction protocol. The CDs fabricated with a traditional and a duplication patients’ preference was not recorded in this study. construction protocol. They concluded, after a follow-up Kattadiyil et al.20 conducted a prospective clinical period of 6 months that the patients preferred their new study comparing a CAD/CAM denture construction prostheses irrespective of the construction protocol. protocol and a traditional one. They evaluated, after one In a prospective clinical study that also compared week, patients’ satisfaction and the clinical features of CDs fabricated with a traditional and a duplication the dentures. The fifteen patients in this study exhibited a protocol, Ellis et al.24 found no difference in patients’ higher preference for CDs fabricated with the CAD/CAM preference between the two construction protocols construction protocol. Three prospective clinical studies23–25 were identified, after a follow-up period of one month. Finally, Scott et 23 that compared CDs fabricated with a traditional and a al. utilized the OHIP-14 instrument and a satisfaction duplication construction protocol. Kamalakidis et al.25 questionnaire to determine the patients’ preference utilized both subjective evaluations (OHIP-20, satisfaction after three months. They concluded that CDs fabricated questionnaire) and objective evaluations (number of with the duplication construction and the traditional adjustment visits, total number of sore spots), to compare construction protocols were equally accepted. Table 2. Summary of studies assessing complete dentures’ occlusal schemes.

Study Study Sample Follow-up Patients’ (year) design size (n) Occlusal schemes Variables (instruments) (months) preference

42 Baseline, Kawai et al (2017) RCT 60 BBO vs LO OHIP-16, satisfaction 3 m, 6 m No difference Niwatcharoenchaikul et al40 Masticatory performance, Baseline, Not applicable (2014) PCS 10 BBO vs LO max. occl. force 2 m, clinical evaluation Shirani et al39 (2014) RCT-CO 15 BBO vs LO OHIP-EDENT 1,5 m LO Deniz et al38 Electromyography, Baseline, (2013) RCT 30 BBO vs LO satisfaction 3 m, 6 m LO Matsumaru37 Masticatory performance, Baseline, Not applicable (2010) RCT 22 BBO vs LO max. occl. force 3 m, 6 m clinical evaluation Sutton et al34,35 (2007) RCT-CO 45 BBO vs LO OHIP-20 2 m No difference

36 Satisfaction, masticatory Kimoto et al PCS 28 BBO vs LO performance, 2 m LO (2006) # of adjustments Sutton et al34,35 BBO and LO vs (2007) RCT-CO 45 MO OHIP-20 2 m BBO and LO Schierz et al33 (2016) RCT-CO 19 CG vs BBO OHIP-EDENT, OHIP-49 3 m No difference Paleari et al32 Satisfaction, (2012) RCT-CO 44 CG vs BBO kinesiography 1 m, 2 m No difference Neto et al31 Satisfaction, masticatory (2010) RCT-CO 24 CG vs BBO performance 3 m, 6 m No difference Rehmann et al30 2 weeks, (2008) PCS-CO 38 CG vs BBO Satisfaction 1 m BBO Baseline, Peroz et al29 Satisfaction, clinical 1 week, (2003) RCT-CO 22 CG vs BBO evaluation 1 m, CG 2 m, 3 m Heydecke et al41 (2007) RCT-CO 20 CG vs LO Satisfaction 3 m, 6 m No difference Schierz et al33 OHIP-EDENT, OHIP- (2016) RCT-CO 19 CG vs BBO 49 3 m No difference Paleari et al32 Satisfaction, (2012) RCT-CO 44 CG vs BBO kinesiography 1 m, 2 m No difference Neto et al31 Satisfaction, masticatory (2010) RCT-CO 24 CG vs BBO performance 3 m, 6 m No difference Rehmann et al30 2 weeks, (2008) PCS-CO 38 CG vs BBO Satisfaction 1 m BBO Baseline, Peroz et al29 Satisfaction, clinical 1 week, (2003) RCT-CO 22 CG vs BBO evaluation 1 m, CG 2 m, 3 m Heydecke et al41 (2007) RCT-CO 20 CG vs LO Satisfaction 3 m, 6 m No difference RCT: randomized clinical trial, CO: cross-over, PCS: prospective clinical study, BBO: bilateral balanced occlusion, LO: lingualized occlusion, MO: monoplane occlusion Balk J Dent Med, Vol 22, 2018 Complete Denture Treatment 119

Occlusal designs Discussion

The studies which addressed occlusal designs were The main focus of the authors for the current divided into two main groups (Table 2). The first group review was to assess the CDs construction protocols and compared different designs of balanced occlusal schemes: occlusal designs from the patients’ perspective. It has bilateral balanced occlusion (BBO), lingualized occlusion been established that the patients’ subjective evaluation (LO) and monoplane occlusion (MO) and the second criteria were different than the objective criteria used by group compared balanced and non-balanced (canine- the dental professionals.45 In order to achieve the highest guided occlusion) occlusal designs. level of evidence, only randomized clinical trials and In relation to posterior tooth set-up, the search well designed clinical studies were included. Statistical identified eight articles34–40,42 which involved seven analysis and comparisons between the studies was not studies. All studies compared a bilateral balanced possible due to the limited number and heterogeneity of occlusal design with a lingualized occlusal scheme. Two the included studies. studies34,35 included a comparison between bilateral Regarding CDs construction protocols, it has been balanced occlusal schemes (BBO and LO) and a MO. A speculated that the simplification of the clinical and double blind randomized clinical trial42 used subjective laboratory stages would not have a significantly negative 7 evaluation instruments to assess patients’ preference effect on the overall denture quality . Based on the four 11–17 between a BBO and a LO design and concluded that there available studies , that assumption could be granted was no difference. The same conclusion was reached in a secure basis, since all of them revealed no difference RCT with a cross-over design, which resulted into two in the general patients’ preference between dentures published papers34,35. The authors used the OHIP-20 constructed either with a simplified or a traditional instrument to subjectively evaluate patients’ preference protocol. It must be noted that in the study by Heydecke 17 between CDs with a BBO, a LO and a MO scheme. It et al. , although the general satisfaction item scores must be noted that when a comparison was made between favored the simplified protocol (p=.044), five out of eight BBO and LO versus MO, the patients preferred the BBO items were in favor of the traditional protocol. When the and LO designs. simplified and the traditional construction protocols were assessed on the basis of total costs and fabrication time, On the contrary, three studies; an RCT with cross- two studies12,16 concluded that CDs fabricated with a over design39, a second RCT38 and a prospective clinical simplified protocol cost between 23% and 33.6% less and trial36 concluded that a LO design rated superior in that the required fabrication time was 4 visits compared to patients’ preference over a BBO design. Those studies 5-6 visits of the traditional construction protocols. utilized objective and subjective evaluation criteria The subject of CAD/CAM fabricated CDs has including masticatory performance, with follow-up compiled limited number of studies which focused on the periods ranging from six weeks to six months. Further on, clinical outcomes of the construction process. Two non- after an objective evaluation in an RCT by Matsumaru37, randomized clinical studies20,21 compared CAD/CAM it was concluded that a LO was more efficient in terms of dentures to CDs fabricated with a traditional protocol. masticatory performance when compared with a BBO. Only Kattadiyil et al.20 subjectively evaluated the patients’ Regarding canine-guided (CG) occlusal design, preferences with a five point Likert scale and reported 29–33 five studies were identified that compared CG with an 80% satisfaction preference for the CAD/CAM 41 BBO and one study which compared CG with LO. prostheses with a LO scheme. Additionally, one of the 31–33 Three RCTs with a cross-over design concluded main advantages of the CAD/CAM dentures that of the that there was no difference in patients’ preference reduced number of appointments, was still debated since between the two occlusal designs. They utilized both Kattadiyil et al.20 reported the need for two visits until the subjective and objective assessment criteria over a one denture delivery, while Schwindling et al.21 reported that 30 to six month follow-up period. Rehmann et al. in a they needed a mean number of 5.4 visits. prospective clinical trial concluded that patients preferred Duplication of existing complete dentures, as a BBO to a CG design over two week follow up period. part of a replacement denture construction protocol, On the contrary, in a cross-over RCT by Peroz et al.29, has been an alternative denture fabrication technique. it was concluded that dentures with a CG occlusal Three prospective clinical studies23–25 compared CDs design were more satisfying to the patients over a BBO. constructed with a duplication protocol to CDs with Finally, Heydecke et al.41 conducted the only study a traditional construction protocol. No significant that compared a CG occlusion to a LO. They utilized differences could be detected in all studies regarding subjective evaluation criteria in the form of a satisfaction patients’ preference, a fact that could be attributed to questionnaire, over a three to six evaluation period. The the strict adherence to each construction protocol since results indicated that there was no difference in patients’ all of the studies were set at an academic environment. preference between the two occlusal designs. Kamalakidis et al25 also recorded the total number of 120 Savvas Kamalakidis et al. Balk J Dent Med, Vol 22, 2018 sore spots, which were almost half for the duplication better stability and masticatory performance in patients construction protocol. This finding could suggest that a with severely resorbed residual ridges, (c) Disease- duplication construction protocol might provide a better specific questionnaires should be used to assess the solution for geriatric patients with poor neuromuscular outcome of any treatment modality. control and severe bone resorption, who require a more comfortable adaptation with fewer sore spots. Complete denture balanced occlusion could be provided by means of BBO and LO. The authors References identified five randomized clinical trials34,35,37–39,42 and two prospective clinical studies36,40 that compared those 1. Carlsson GE, Omar R. The future of complete dentures two occlusal designs. Those studies used subjective and in oral rehabilitation. A critical review. J Oral Rehabil, objecting criteria to determine patients’ preference and 2010;37:143-156. they concluded that there were no significant differences 2. Vahidi F, Pinto-Sinai G. Complications associated with between the two occlusal schemes. Additionally, in three implant-retained removable prostheses. Dent Clin North studies36,38,39 it was concluded that LO was preferred Am, 2015;59:215-226. by the patients over BBO in terms of masticatory ability 3. Leles CR, Ferreira NP, Vieira AH, Campos ACV, Silva ET. and performance. This finding was positively correlated Factors influencing edentulous patients’ preferences for with the height of the residual ridge, strengthening the prosthodontic treatment. J Oral Rehabil, 2011;38:333-339. belief that patients with severe residual ridge resorption might benefit from the occlusal design of LO. Further 4. Heydecke G, Penrod JR, Takanashi Y, Lund JP, Feine JS, on, when CDs with monoplane occlusion were compared Thomason JM. Cost-effectiveness of Mandibular Two- with bilateral balanced and lingualized occlusal schemes, implant Overdentures and Conventional Dentures in the the patients strongly preferred the latter on the basis of Edentulous Elderly. J Dent Res, 2005;84:794-799. esthetics and food comminution34,35. 5. Takanashi Y, Penrod JR, Lund JP, Feine JS. A cost One of the dogmas in removable prosthodontics comparison of mandibular two-implant overdenture has been the concept of bilateral balance occlusion. It and conventional denture treatment. Int J Prosthodont, has always been a subject of debate as to whether we 2004;17:181-186. need to provide our patients with simultaneous posterior 6. McCord JF. Contemporary techniques for denture contacts in centric and eccentric movements, while at fabrication. J Prosthodont, 2009;18:106-111. the same time they try to balance the food bolus during 7. Clark RKF, Radford DR, Fenlon MR. The future of teaching masticatory movements. Contemporary views on the topic of complete denture construction to undergraduates in the of complete denture occlusion have led to the introduction UK: is a replacement denture technique the answer? Br Dent of non-balanced occlusal schemes as an alternative to J, 2004;196:571-575. balanced occlusal designs. The current review identified 8. Arbree NS, Fleck S, Askinas SW. The results of a brief four RCTs29,31–33 with a cross-over design that compared survey of complete denture prosthodontic techniques in BBO versus CG. Only one of those studies, by Peroz et predoctoral programs in North American dental schools. J al.29, established that CG was preferred by the patients Prosthodont, 1996;5:219-225. with relation to esthetics, mandibular retention and 9. Duncan J, Taylor T. Teaching an abbreviated impression chewing ability. It must be pointed out that the topic of technique for complete dentures in an undergraduate dental CG for complete dentures needs further investigation and curriculum. J Prosthet Dent, 2001;85:121-125. has to be correlated with the anatomy of the mandibular 10. Carlsson GE, Örtorp A, Omar R. What is the evidence base residual ridge of individual patients in order to reach for the efficacies of different complete denture impression safe recommendation guidelines for future clinical procedures? A critical review. J Dent, 2013;41:17-23. applications. 11. Nuñez MCO, Silva DC, Barcelos BA, Leles CR. Patient satisfaction and oral health-related quality of life after treatment with traditional and simplified protocols for complete denture construction. Gerodontology, Conclusions 2015;32:247-253. 12. Vecchia MP Della, Regis RR, Cunha TR, de Andrade IM, da Within the limitations of this review the following Matta JCS, De Souza RF. A Randomized trial on simplified conclusions could be drawn: (a) Patients adapt to all and conventional methods for complete denture fabrication: construction methods when strict adherence to the Cost analysis. J Prosthodont, 2014;23:182-191. protocol is observed. The simplified construction 13. Regis RR, Cunha TR, Della Vecchia MP, Ribeiro AB, protocols may offer reduced costs and fabrication periods, Silva-Lovato CH, De Souza RF. A randomised trial of a (b) Patients adapt comfortably to any design of bilateral simplified method for complete denture fabrication: Patient balance occlusal scheme. Lingualized occlusion provides perception and quality. J Oral Rehabil, 2013;40:535-545. Balk J Dent Med, Vol 22, 2018 Complete Denture Treatment 121

14. Cunha TR, Della Vecchia MP, Regis RR, Ribeiro 30. Rehmann P, Balkenhol M, Ferger P, Wöstmann B. Influence AB, Muglia VA, Mestriner W Jr. et al. A randomised trial on of the occlusal concept of complete dentures on patient simplified and conventional methods for complete denture satisfaction in the initial phase after fitting: bilateral fabrication: Masticatory performance and ability. J Dent, balanced occlusion vs canine guidance. Int J Prosthodont, 2013;41:133-142. 2008;21:60-61. 15. Kawai Y, Murakami H, Shariati B, Klemetti E, Blomfield 31. Farias NA, Mestriner W Jr, Carreiro AA. Masticatory JV, Billette L. et al. Do traditional techniques produce better efficiency in denture wearers with bilateral balanced occlusion conventional complete dentures than simplified techniques? and canine guidance. Braz Dent J, 2010;21:165-169. J Dent, 2005;33:659-668. 32. Paleari AG, Marra J, Rodriguez LS, de Souza RF, Pero 16. Kawai Y, Murakami H, Takanashi Y, Lund JP, Feine JS. AC, Mollo Fde A Jr. et al. A cross-over randomised clinical Efficient resource use in simplified complete denture trial of eccentric occlusion in complete dentures. J Oral fabrication. J Prosthodont, 2010;19:512-516. Rehabil, 2012;39:615-622. 17. Heydecke G, Vogeler M, Wolkewitz M, Türp JC, Strub JR. 33. Schierz O, Reissmann D. Influence of guidance concept Simplified versus comprehensive fabrication of complete in complete dentures on oral health related quality of dentures: patient ratings of denture satisfaction from a life – Canine guidance vs. bilateral balanced occlusion. J randomized crossover trial. Quintessence Int, 2008;39:107-116. Prosthodont Res, 2016;60:315-320. 18. Bidra AS, Taylor TD, Agar JR. Computer-aided technology 34. Sutton AF, Worthington HV, McCord JF. RCT comparing for fabricating complete dentures: Systematic review posterior occlusal forms for complete dentures. J Dent Res, of historical background, current status, and future perspectives. 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Influence of mandibular residual ridge techniques for the fabrication of complete removable resorption on objective masticatory measures of lingualized dental prostheses: A pilot clinical study. J Prosthet Dent, and fully bilateral balanced denture articulation. J 2016;116:756-763. Prosthodont Res, 2010;54:112-118. 22. Müller F. Interventions for edentate elders--what is the 38. Deniz D, Kulak Ozkan Y. The influence of occlusion on evidence? Gerodontology, 2014;31:44-51. masticatory performance and satisfaction in complete 23. Scott BJ, Forgie A. H, Davis DM. A study to compare the denture wearers. J Oral Rehabil, 2013;40:91-98. oral health impact profile and satisfaction before and after 39. Shirani M, Mosharraf R, Shirany M. Comparisons of patient having replacement complete dentures constructed by either satisfaction levels with complete dentures of different the copy or the conventional technique. Gerodontology, occlusions: a randomized clinical trial. 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Carlsson GE. Critical review of some dogmas in 42. Kawai Y, Ikeguchi N, Suzuki A, Kuwashima A, Sakamoto prosthodontics. J Prosthodont Res, 2009;53:3-10. R, Matsumaru Y. et al. A double blind randomized clinical 28. Zhao K, Mai QQ, Wang XD, Yang W, Zhao L. Occlusal trial comparing lingualized and fully bilateral balanced designs on masticatory ability and patient satisfaction posterior occlusion for conventional complete dentures. J with complete denture: A systematic review. J Dent, Prosthodont Res, 2017;61:113-122. 2013;41:1036-1042. 43. Gift H, Redford M. Oral health and the quality of life. Clin 29. Peroz I, Leuenberg A, Haustein I, Lange KP. Comparison Geriatr Med, 1992;8:673-683. between balanced occlusion and canine guidance in 44. Allen F, Locker D. A modified short version of the oral health complete denture wearers- a clinical, randomized trial. impact profile for assessing health-related quality of life in Quintessence Int, 2003;34:607-612. edentulous adults. 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45. Awad MA, Feine JS. Measuring patient satisfaction with 49. Anastassiadou V, Heath MR. Food choices and eating mandibular prostheses. Community Dent Oral Epidemiol, difficulty among elderly edentate patients in Greece. 1998;26:400-405. Gerodontology, 2002;19:17-24. 46. Anastassiadou V, Heath MR. The effect of denture quality attributes on satisfaction and eating difficulties. Received on November 27, 2017. Gerodontology, 2006;23:23-32. Revised on January 22, 2018. 47. Anastassiadou V, Katsouli S, Heath MR, Pissiotis A, Kapari Accepted on May 25, 2018. D. Validation of communication between elderly denture wearers and dentists: a questionnaire on satisfaction with complete dentures using semi-structured interviews. Correspondence: Gerodontology, 2004;21:195-200. 48. Anastassiadou V, Naka O, Heath MR, Kapari D. Savvas N. Kamalakidis, Validation of indices for functional assessment of dentures. 72 Mitropoleos st., 54622, Thessaloniki, Greece Gerodontology, 2002;19:46-52. e-mail: [email protected]

DOI: 10.2478/bjdm-2018-0022

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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA

Separated Instrument in Endodontics: Frequency, Treatment and Prognosis

SUMMARY Triantafyllia Vouzara, Maryam el Chares, Instrument separation during endodontic therapy is a frequent Kleoniki Lyroudia accident with rotary instruments being more likely to separate than manual Department of Endodontology, ones. The treatment of cases with a separated instrument can be either School of Dentistry, Faculty of Health conservative or surgical. A conservative approach involves the following Sciences, Aristotle University of Thessaloniki, treatment choices: a) bypass of the fragment, b) removal of the fragment, c) Thessaloniki, Greece instrumentation and obturation coronally to the fragment. Concerning the removal of a separated instrument, a variety of techniques and systems have been developed. Ultrasonics, in combination with the operative microscope constitute the most effective and reliable tools for removing a separated endodontic instrument from a root canal. The likelihood of successful removal depends on: the level of separation (coronal, middle or apical third); location in relation to the root canal curvature; the type of separated instrument; its length; the degree of canal curvature and the tooth type. Several complications may occur during the management of a separated instrument: separation of the ultrasonic tip or file used for bypassing or removing the instrument; further separation of the fragment; perforation; ledge; extrusion of the file into periapical tissues; tooth weakening due to dentin removal, as well as excessive temperature rise in periodontal tissues. Prognosis for a tooth retaining a separated instrument depends on the presence of a periapical lesion, the microbial load of the root canal during the time of separation and the quality of the obturation. Key words: Broken Endodontic Instrument, Fractured Endodontic Instrument, Separated Endodontic Instrument, Treatment of Instrument Separation, Prognosis of Tooth with REVIEW PAPER (RP) Retained Instrument Balk J Dent Med, 2018;123-132

Introduction complications and the prognosis for teeth containing file fragments. Instrument separation may occur during the use of several endodontic instruments (hand or rotary files, Frequency of endodontic instrument separation Gates Glidden burs, lentulo, pluggers, spreaders) made According to clinical studies, the overall endodontic of different materials (NiTi, stainless steel). The mishap instrument separation frequency (either rotary or hand 1-3 of instrument separation, is a frustrating situation for the files) is between 1.83% and 8.2% . The frequency clinician as it may prevent access to the apex and most of rotary instrument separation ranges between 0,13% of the time, impedes full length instrumentation and and 10%2,4-15 and includes several kinds and types of obturation of the root canal. As a consequence, the level instruments. The manual instrument separation frequency of difficulty of the certain case augments, while the tooth is 0.25% to 6%2,10,16-18. healing is challenged. The aim of this review is to discuss The highest frequency of instrument separation approaches to, and techniques and methods of, treating is presented during the treatment of molars (77% - endodontic cases with separated instruments, the possible 89% of all cases)3,14,18-20. A greater risk of separation 124 Triantafyllia Vouzara et al. Balk J Dent Med, Vol 22, 2018 occurs during treatment of lower molars (50% - 55%), Bypass of the separated instrument compared to upper molars (25% - 33.3%)1,2. Regarding Bypassing the separated endodontic instrument is upper molars, the separation of endodontic instruments considered to be the safest treatment path, given that is three times more liable to occur in the mesio-buccal it does not involve removing an excessive quantity root canals than the disto-buccal ones, due to the distal of dentin from the root of the tooth25,26. It allows the curvature of the mesial root1-3. As far as the lower molars instrumentation and obturation of the root canal up to are concerned, the mesial root canals present a distal and a the apex and is believed to contribute to a successful buccolingual curvature21. In fact, the lingual curvature of treatment outcome6,17,27,28. It is also considered to the mesio-buccal root canal is more severe than the buccal be the first step towards the removal of the separated curvature of the mesio-lingual root canal. As a result, the instrument fragment from the root canal1, as it reduces frequency of instrument separation in the mesio-buccal the contact between the instrument and the root dentin, root canals is three times more common than in the mesio- and creates space for inserting other instruments, such 2 lingual ones . as ultrasonic tips, able to fully detach the fragment With respect to the root canal curvature, separation from the root dentin25. However, it is a very demanding frequency rises proportionally to increased curvature: technique where success depends on the clinician’s sense 7% in straight root canals, 35% in averagedly curved of touch and perseverance28. In addition, the success of 1,19 ones, and 58% in intensely curved ones . Regarding this procedure depends on the ISO size and taper of the the location of the separated fragment, a higher rate of separated instrument. separation is observed in the apical third (41% - 82.7%)1- Bypassing the separated instrument requires the 3,14,18,19, a lower one in the mesial third (14.8% - 32%)1- use of hand files25. The use of a rotary NiTi instrument 3,19, and an even lower one in the coronal third (2.5% - is not recommended as an increased risk of a new 20%)1-3,19. The most common separation site is 2mm separation exists21. A No 10 K file, precurved to the from the tip of the instrument. The most common sizes of edge, is used. The file is used with slight pressure and instruments undergoing separation are No 20-40 (ISO). As rotated a quarter of a turn to attempt to insert it between to taper, separation most commonly happens in files with the instrument and the root canal wall. Provided that this a taper between 4% and 9%14,19. can be achieved, the file is then carefully advanced until Madarati et al.22 conducted a study during which the separated instrument has been completely bypassed the frequency of separation of instruments was examined and the file reaches the apical foramen. During the in both general and endodontic dental practices. Overall, 88.8% of dentists and endodontists have reported instrument bypass attempt, radiographs are necessary to detect any separation. Instrument separation was more common among possible erroneous route of the file in time and risk of a 26 endodontists. This finding is explained by the fact that perforation avoided . endodontists carry out more root canal treatments, they treat Removal of the separated instrument more difficult cases, and they use rotary instruments to a The actual removal of a separated instrument is a greater extent than general dentists do22. rather challenging procedure. The difficulty is mainly Techniques and methods of endodontic treatment in related to the type of separated instrument and its position cases with a separated instrument in the root canal. As far as manual instruments are No officially approved instructions regarding concerned, Hedstroem files are more problematic than the treatment of instrument separation have been K files due to their morphology which causes a stronger 17,20 promulgated to date. An immediate periapical radiograph engagement with the dentin . With respect to NiTi is recommended so as to confirm the separation of the instruments, their removal is more difficult than removing instrument, locate the instrument in the root canal, evaluate instruments made of stainless steel. This is due to NiTi the anatomy of the root canal and measure the length of the instruments usually separating at a shorter fragment fragment23,24. When all the above factors have been taken length, more apically, in the curvature of narrow root into account, a decision has to be made about the type of canals, with the rotation movement locking them into the treatment to rectify the situation23,24. The management of a dentin29. NiTi instruments can further separate or shorten separated instrument can be conservative and/or surgical. due to damage from ultrasonics vibration during the There are three approaches to conservative treatment: attempt to remove the fragment. Additionally, the shape a) bypass of the separated instrument, b) removal of the memory of NiTi alloy increases the level of difficulty separated instrument, c) instrumentation and obturation because as they are released from the dentin, they tend to of the root canal coronally to the fragment25. It is also straighten and re-engage with the root canal wall21. So far, suggested that the patient should be informed about the a number of techniques and means of instrument removal instrument separation, the treatment to be followed, and the have been reported. However, none has been proved to be prognosis for the tooth23,24. fully effective30. Balk J Dent Med, Vol 22, 2018 Separated Instrument In Endodontics 125

Techniques and systems used for the removal of tips are made of stainless steel, some of which are coated separated instruments with diamond or zirconia. The coated tips burnish the A separated instrument can be removed with the dentin throughout their length, whereas the uncoated ones aid of an endodontic file: after bypassing the fragment only remove dentin at their cutting edge. There are also with K files No 10-20, instrumentation of the root canal tips made of titanium alloy which is considered to make 30,44 can take place in an effort to loosen the fragment from them more flexible . dentin, engage it with the cutting edges of the inserted Especially thin tips are used to remove dentin file and eventually remove it26. Tweezers, endodontic around the fragment to loosen it and make it more 30 forceps, mosquito and dental pliers can be used when easily removable from the root canal wall . During this the instrument projects from the root canal orifice. It process, the ultrasonic tips should move in the reverse is recommended to use them with a counterclockwise direction of rotation to that of the instrument. It has been rotation to assist in disengaging the fragment from the suggested that the use of citric acid or EDTA combined dentin31-33. Other techniques that can be applied when the with ultrasonics, can help the removal of debris and coronal part of the fragment is free and visible include a smear layer from the grooves of the instrument and thus 45,46 micro-tube or an injection needle that are applied over the facilitate the fragment removal from the root canal . free part of the instrument combined with a Hedstroem It is important to note the Ruddle technique, during file or an orthodontic wire which engage, pull and remove which Gates Glidden modified burs are used to create a the fragment34,35. flat platform in the dentin that surrounds the coronal edge of the separated instrument, before the use of Endo-Extractor system (Roydent Dental Products, ultrasonics47. Gates Glidden burs (No 2-4) are modified USA)/ Masserann kit (Micro Mega, France)/ by cutting them vertically along their linear axis at their 25 Instrument Removal System (San Diego Swiss, USA)/ maximum diameter . The platform has to be formed with Separated Instrument Removal System (Vista Dental great care in order for the Gates Glidden bur to remain centered above the instrument and remove equal quantity Products, USA)/ Cancelier instrument and Mounce of dentin from around it, so that any mishap is avoided25. extractor (SybronEndo, CA) After the formation of the platform, ultrasonics remove The above devices are tube-like systems which dentin circumferentially to the fragment. An important entrap and pull out the fragment. Removal of dentin aspect of this technique is the use of ultrasonics without around the separated instrument to reveal its coronal water to increase visibility40. section to a length of at least 2mm is required before their In order to reduce the possibility of secondary appliance. Dentin removal is carried out either with a instrument separation, a modified removal technique special trepan kit which is included in each system or with with ultrasonics has been suggested46: The ultrasonic tip the use of ultrasonics. Especially, the Cancelier instrument works in the inner surface of the curvature of the root removal system and Mounce extractor are systems canal, avoiding the outer surface of the curvature, so as properly designed for working under the Dental Operating to maintain the dentin wall that supports the fragment. Microscope, in a way which does not obstruct visibility The detachment of the fragment is assisted by the use of of the separated instrument. Most of these systems are EDTA. The removal of dentin from the inner surface of considered to be aggressive, since they entail the risk of the curvature ceases when there is a danger of perforation root weakening and perforation33,36-40. or excessive weakening of the tooth46. Although this technique is deemed interesting, it is relatively dangerous. Ultrasonics- Dental Operating Microscope When the dentin is removed from the inner surface of the The systems described above cannot be applied to curvature, where the thickness of the root canal wall can narrow and curved root canals, especially if the instrument be particularly limited, there is increased risk of a clinical 17 is located deep in the root canal . In contrast, ultrasonics mishap. can be inserted in depth into the root canal and can be used in several cases41,42. When using ultrasonics, both Laser immediate access and visual contact with the separated Laser ND:YAG can be used for the removal of a instrument are important. The use of an operative separated instrument in three ways: a) by melting the microscope allows working under bright illumination and dentin, bypassing the instrument and removing it with magnification30, so as to limit the risk of the excessive an H file, b) by melting the fragment, c) by welding removal of dentin and possible perforation2,10,43. The a connection between a tube and the coronal end of general opinion is that use of an operative microscope the fragment in order to retrieve it. The following increases the chances of success in removing a separated advantages of using the laser technique have been instrument20. reported: a) minimum dentin removal, b) quick removal Endodontic tips for ultrasonics of various sizes and of the instrument from the root canal. However, its lengths, are used in different parts of the root canal. Most safety regarding the adjacent periodontal tissues has 126 Triantafyllia Vouzara et al. Balk J Dent Med, Vol 22, 2018 not been established in relation to the possibility of an fragment in relation to the root canal curvature, the depth excessive increase in temperature in the outer root surface. of the fragment location in the root canal, the type of the Moreover, there is a possibility of carbonizing the dentin, instrument, its length, the radius of the curvature, as well due to high temperature, which may negatively affect as the location of the tooth17,20,29,56. A number of studies the adhesion of the obturation materials to the root canal have assessed the success rate of various techniques of wall48,49. removing instruments in relation to these factors. According to both in vitro and ex vivo studies, the Electrolysis success rate for treatment of a separated instrument ranges Dissolving the NiTi fragment through electrolysis between 70% and 91.8%56-62 Clinical studies (of in vivo has been suggested. The method involves filling of the treatment) indicate an even higher range, since they root canal with a solvent which acts as an electrolyte and start at 53% and reach 95%1,3,18,20,27-29,57. Both bypass dipping two electrodes (anode-cathode) in the electrolyte. and removal of the fragment are included in the above The electrode, functioning as the anode is placed in success rates. The lower success rates in some clinical contact with the fragment. The voltage between the two studies may be due to the increased difficulty of treatment electrodes causes a flow of electrons from the anode to under clinical conditions. Different ranges among clinical the cathode, release of metallic ions from the fragment to studies may be attributed to the fact that they were the solvent, and a progressive dissolution of the fragment. conducted under different and non-comparable conditions The efficiency of the method depends on the type of with respect to sample choice, technique used, as well solvent, its concentration, its pH, as well as the extent of as the capability of the clinician. The rate of successful 50-53 its contact with the fragment . fragment removal (44%-95%) is higher than that of 53 So far this method has only been tested in ex vivo successful instrument bypass (9%-47.7%)28,61; something or in vitro studies where the fragment was dissolved that could be ascribed to the challenging nature of bypass only sufficiently to allow it to be bypassed with a No procedure28. 52,54 10 K file after 60 minutes . What has been suggested Removing the instrument is easier with the use of is that the advantage of electrolysis is the avoidance of ultrasonics and an operating microscope compared to 50,51 dentin removal from the root canal wall . However, other techniques60. Visibility plays an important part in the disadvantage is that the solvent used as an electrolyte removing the fragment28,57. Removal is easier when the may cause cytotoxicity especially in combination with fragment is found in the coronal or mesial third, rather 55 insoluble components of the NiTi fragment . than when it is located in the apical third of the root 1,3,20 Instrumentation and obturation coronally to the canal . With respect to the location of the tooth, the possibility of a successful instrument removal is higher fragment for the anterior and upper teeth compared to the posterior When the conservative removal or bypass of the and lower ones20,27. When the fragment lies coronally to fragment is impossible, or there is a high risk of a mishap, the curvature, or at the level of the curvature, it is more instrumentation and obturation of the root canal coronally easily removed than when being beyond the curvature to the fragment with subsequent follow up of the tooth are 20,27,29,56,61. The more severe the curvature, the more the recommended. In cases of clinical symptoms, periapical difficulty of its removal20,27,59. Finally, longer fragments lesion, or enlargement of a pre-existing periapical lesion, a are more easily removed than shorter ones20. surgical endodontic treatment is suggested25,26. Complications Surgical endodontic treatment With respect to the surgical treatment of a separated Weakening of dentin mass – danger of perforation instrument, the following options are available: surgical or tooth fracture removal of the fragment from periapical tissues, apicectomy, root resection, bisection, and intentional Tooth fracture replantation. When intense clinical symptoms are observed and conservative removal or bypass of In vitro removal of separated instruments from the fragment is not possible, an immediate surgical extracted teeth using ultrasonics or the Masseran system, endodontic treatment is advised26. Instrumentation and increased the percentage of fracture in relation to the obturation of the root canal up to the fragment should take control group. The reduced resistance to fracture was place before surgery so that the microbial load of the root attributed to dentin removal during the formation of a 63 canal is significantly reduced25. staging platform . A platform made with a Gates Glidden bur coronally to the fragment significantly reduces Success rates of treatment techniques resistance to fracture, even if the fragment is not removed, The rates of successful removal of a fragment compared to teeth where no attempt at instrument removal vary, and depend on such factors as the location of the has been made64. Balk J Dent Med, Vol 22, 2018 Separated Instrument In Endodontics 127

The resistance of a tooth to fracture following periodontal tissues causes bone necrosis, bone resorption, the removal of a separated instrument is affected by tooth resorption, and ankyloses70,73,74. Various clinical the location of separation. Studies have shown that the cases of temperature increase in periodontal tissues caused process of removing an instrument from the coronal by ultrasonics have been reported75-79. third has no effect on resistance to fracture. Conversely, Temperature increase in the outer surface of roots instrument removal from the mesial third, and to a greater during the removal of separated instruments from extent, from the apical third requires significant dentin extracted teeth has been examined in the studies of removal and increases the possibility of a vertical root Hashem et al.79 and Madarati et al.80 where different fracture57,65,66. Similar findings relate to the position of ultrasonic tips, without air or water, were used at different the separated instrument and the canal curvature. The powers and durations. The use of ultrasonics at power removal of an instrument separated before the curvature 5 without water for ≥ 60sec and at power 1 for ≥ 90sec causes less dentin loss compared to an instrument increased the temperature in the outer surface of the that is separated inside the curvature or apically to the root ≥ 10˚C. Consequently, the use of power 5 is not curvature56. However, Shahabinejad et al.61 found that the recommended without water, whereas power 1 may be location of the fragment does not statistically affect the used without water for a time period of < 90 sec79,80. strength that is required to fracture the tooth. Madarati et al.81 examined the extent to which the use Fu et al.67 conducted a retrospective study, in the of ultrasonics without water, but with an air spray, can course of which they recalled 66 teeth over a period of restrict the increase of temperature in the outer surface of 1-5 years following attempts to remove fragments with the root. The use of air significantly reduced the rise of the Ruddle technique: no case of fracture was detected. temperature in the outer surface of the tooth; whereas, the This may be due to the conservative effort of removing use of ultrasound at volume 1.5 without water or air for the instrument, without excessive dentin removal, the ≥ 90 sec increased the temperature by > 10˚C. Adding an prosthetic restoration, and the occlusal adjustment. air spray at power 1.5 for 120sec prevented a temperature Moreover, the presence of periodontal ligament may augmentation. When considering the use of air cooling relieve the pressure of the occlusal forces and reduce for ultrasonics the risk of causing an air embolism must the possibility of tooth fracture67. This in vivo finding always be taken into consideration81. Generally speaking, contradicts in vitro research findings. the extent of temperature rise depends on the width of the Perforation root canal wall, the type of the tip used, the power, and the The rates for perforation from in vitro studies of duration of usage79,80. instrument removal range from 5.5% to 13.3%57-59,61. Whereas clinical research findings range from 0.5% to Secondary separation of the fragment 11.6%1,20,28,57. In the above studies, perforations occurred There is a risk of secondary separation of the in teeth where the instrument was in the apical third1,57, instrument during attempts at its removal, especially when beyond the root canal curvature68, and the removal using ultrasonics. In vitro studies have shown the rate of 58 attempt lasted more than 90min1. The latter was attributed secondary instrument separation to be low: 1.1% and 59 46 to the dentist’s fatigue, the increased difficulty of the case, 3.3% . Terauchi et al. found that fragments located in or the excessive access cavity preparation of the root dentin blocks separated in a shorter period of time when canal1. they were very curved and not supported by a dentin Special interest presents the retrieval of a separated wall. The researchers suggest that the most likely causes instrument from the middle third of the mesial root of of a secondary separation of a separated fragment are the maxillary molars. The shaping of a staging platform following: a) the instrument that broke inside a curvature in combination with ultrasonics, removes considerable is subject to internal pressure and the use of ultrasonics amounts of dentin. The remaining dentin thickness in the adds further fatigue leading to further separation, b) the distal wall of the mesial root, the so called “danger zone”, use of ultrasonics increases the temperature of the internal is notably reduced when a distal concavity is present. root canal surface considerably; much more than it does at Usually, the depth, or even existence, of the concavity the external root canal surface. As a result, the flexibility is impossible to measure or depict radiografically. As a of the instrument is reduced and its separation becomes 46 result, such cases run high risks of perforation69. more likely . On a clinical level, only one study exists where the Temperature increase in periodontal tissues secondary separation of a fragment during an attempt The use of ultrasonics without air or water may at its removal is mentioned. Suter et al.1 used various increase the temperature at the outer surface of the root. instrument removal techniques and recorded secondary An increase in temperature of more than 10˚C above separation only during the use of ultrasonics. The overall body temperature may inflict damage on the bone of the rate of secondary separation was 29%. Specifically, 28% alveolar process70-73. Experiments conducted on animals of NiTi instruments, 22% of stainless steel files, and have shown that an increase in the temperature of 57% of lentulo secondarily separated during the removal 128 Triantafyllia Vouzara et al. Balk J Dent Med, Vol 22, 2018 procedure. The further separation of the instruments The use of a thin ultrasonic tip requires great increased the difficulty in removing the fragment, but attention, because it entails the risk of the tip separating did not affect the chances of its removal. Researchers in the root canal. This indicates it should be used in low correlated the high rate of separation with the fact that power mode91. When the ultrasonic tip approaches a they used ultrasonics for a long period of time and at high NiTi instrument, it should be prevented from coming in power1. contact with the fragment, as the separated instrument could be broken or consumed. Regarding temperature Alteration of root canal morphology rise; ultrasonics should be set at low power when used During the process of removing a fragment, the without water92 and not exceed 60sec of constant use46. morphology of the root canal may suffer alterations. Up until now, no definitive instructions for the proper use Ward et al.56 implemented a modified Ruddle technique of ultrasonics in order to avoid a temperature increase in on acrylic blocks and teeth with separated instruments. A periapical tissues have been suggested. Overall, during large alteration in the morphology of the root canal was the removal of a separated instrument all the necessary observed following instrument removal. The frequency precautions should be taken so that the least possible and degree of alteration of the morphology varied with the damage is caused to the tooth and periapical tissues. location of the fragment in relation to the curvature (10% before the block curvature, 55% inside the curvature, and Prognosis 100% following the curvature)56. Shahabinejad et al.61 Several views have been voiced as to whether conducted research on extracted teeth using a modified instrument separation affects the prognosis of endodontic Ruddle technique and reported a transformation of the therapy. Generally, it has been reported that it reduces root canal by 5.7%. the prognosis for tooth maintenance93 because it inhibits access to the apex and full disinfection of the root Further complications canal83. In particular, when the instrument separates at the The removal of a separated instrument entails the risk beginning of instrumentation of an infected root canal, its of causing further complications such as: a) extrusion of presence affects therapy prognosis negatively, while if the the fragment in periapical tissues (1,1% - 7,5%)58,59,61,66 separation occurs during the last stages of instrumentation and b) separation of the ultrasonic tip or file used during of an infected root canal, or in an aseptic root canal, the removal or bypass process (1,4%)61. prognosis is better24,94,95. The healing rate of 66 clinical cases after an Prevention of complications attempt at separated instrument removal with the Ruddle The systems using trephine burs (e.g. Masseran) are technique was retrospectively examined67. Follow-up not fully effective and may cause complications42,82,83. periods of time ranged between 12 and 68 months and In contrast, the use of an operative microscope and the follow-up rate was 64.7%. Healing criteria included ultrasonics increases the possibility of a successful the absence of clinical symptoms, the periapical index removal and reduces that of complications29,47,56. In order PAI ≤ 2, and the maintenance of the tooth in function. to avoid a perforation, attention is necessary when using An overall healing rate of 81.8% was observed. During Gates Glidden No 3-4 to shape a platform, especially in the early stages of the statistical processing, three factors the mesial roots of upper or lower molars84-86, and lower were found to affect healing: Whether the instrument incisors87. During the shaping of a platform, radiographic was removed or not, the presence of perforation, and checks on the remaining dentin thickness may not the quality of the root canal obturation. In cases where prevent the possibility of perforation88. It has been found the instrument was removed, the healing rate was 86%, that, in the case of mesial roots of maxillary molars, whereas in those where it was retained, the healing rate radiographs taken with the parallel technique overestimate was 50%. In case of perforation, the healing rate was the remaining dentin thickness, while an angulated 57%, compared to teeth without perforation where it technique (21˚) provides the clinician with more accurate reached 88%. When the obturation of the root canal was information for assessing the risk of perforation89. When adequate, the healing rate was 93% compared to 64% in the fragment lies in the apical third, especially in curved cases where the obturation was inadequate. However, the root canals, excessive dentin removal is unavoidable to sole factor presenting a statistically significant difference achieve straight access to the fragment57. This is due was the quality of the obturation of the root canal67. to the difficulty of focusing a Gates Glidden bur on the In another study18, 30 clinical cases of separated coronal edge of the fragment90. If the fragment remains instruments that were either: removed, bypassed or invisible to in the microscope, after an attempt to create retained in the root canal were followed up. The follow-up immediate access, it is recommended that the removal period of time was at least 12 months, and the absence of attempt is abandoned36. In general, after 45-60 min of clinical symptoms and radiographic findings were set as attempting to remove the fragment, the risk of perforation an index of success. Overall, a success rate of 60% was increases1. observed, regardless of the removal or retention of the Balk J Dent Med, Vol 22, 2018 Separated Instrument In Endodontics 129 instrument, and irrespective of the initial diagnosis. In of teeth with a lesion healed, while teeth without a lesion cases of instrument removal, the success rate was 71.4%; showed 92.4% healing. When a lesion did not preexist, in those of instrument bypass it was 40%, and 64,7% in teeth with a separated instrument had the same healing those cases that were obturated coronally to the fragment. rate as those without an instrument (95%). When a lesion As to the initial diagnosis, the cases with vital pulp had did preexist, teeth with a separated instrument had the 72.7% success, those with primary pulp infection 58.3%, same healing rate (88%) as those without a fragment and those of retreatment 42.9%. These findings indicate (89%). The results of these studies may not be applicable that the instrument removal and the root canal infection to the conditions met in general dental offices, since they affect tooth prognosis. However, this correlation was not derive from specialist practices and university clinics supported by the statistical analysis18. where conditions are better controlled96. A systematic review and meta-analysis that included Therefore, the separation of an instrument per two case control studies has been performed96. The two se does not reduce tooth prognosis but makes the full studies comprised this systematic review, Spili et al.10, disinfection and hermetic sealing of the root canal Crump & Natkin16, included a total of 199 teeth with a problematic. The prognosis of a tooth with a separated separated instrument with their follow-up examination instrument depends on a number of factors like: the set at a time of at least 12 months. The following healing presence of a lesion, the microbial presence within the criteria were set: full healing, partial healing, and root canal at the time of instrument separation and the uncertain outcome. Regardless of lesions, teeth with a quality of the obturation. Particularly, in cases where the separated instrument healed in 91% of cases, compared instrument separation is combined with the presence of a with teeth without a separated instrument where 92% lesion, the tooth prognosis is compromised only when the healed. Irrespective of the presence of a fragment, 80.7% proper disinfection of the root canal is obstructed.

Figure 1. Suggested treatment protocol in cases with separated instruments 130 Triantafyllia Vouzara et al. Balk J Dent Med, Vol 22, 2018

Conclusions 3. Tzanetakis GN, Kontakiotis EG, Maurikou DV, Marzelou MP. Prevalence and management of instrument fracture in the postgraduate endodontic program at the Dental School In cases of instrument separation, the recommended of Athens: A five-year retrospective clinical study. J Endod, treatment option is first to endeavor to bypass the 2008;34:675-678. fragment because this is considered to be a conservative 4. Ramirez-Salomon M, Soler-Bientz R, de la Garza-González technique, with low risk of clinical mishap, with the R, Palacios-Garza CM. Incidence of Lightspeed separation additional advantage of possibly contributing to the and the potential for bypassing. J Endod, 1997;23:586-587. 5. Baumann MA, Roth A. Effect of experience on quality of final removal of the instrument. Where bypassing the canal preparation with rotary nickel-titanium files. Oral Surg instrument proves impossible, the next treatment option Oral Med Oral Pathol Oral Radiol Endod, 1999;88:714-718. is to try to remove the fragment. At this stage, a careful 6. Al-Fouzan KS. Incidence of rotary ProFile instrument assessment of the case is necessary so as to be fully aware fracture and the potential for bypassing in vivo. Int Endod J, of the risks involved of causing further complications in 2003;36:864-867. each particular case. If removing the instrument is deemed 7. Hülsmann M, Herbst U, Schäfers F. Comparative study of root-canal preparation using Lightspeed and Quantec SC a safe choice, the use of a microscope and ultrasonics is rotary NiTi instruments. Int Endod J, 2003;36:748-756. the suggested removal technique. 8. Ankrum MT, Hartwell GR, Truitt JE. K3 Endo, ProTaper, Removing the instrument is more likely to succeed and ProFile systems: breakage and distortion in severely when the fragment is found in the coronal third, before curved roots of molars. J Endod, 2004;30:234-237. the root canal curvature, when the root canal curvature is 9. Fishelberg G, Pawluk JW. Nickel-titanium rotary-file canal preparation and intracanal file separation. Compend Contin not severe, and when it concerns upper or anterior teeth. Educ Dent, 2004; 25:17-18, 20-22, 24, 47. However, in cases where the fragment is found either 10. Spili P, Parashos P, Messer HH. The impact of instrument in the apical third or beyond the root canal curvature, fracture on outcome of endodontic treatment. J Endod, or visibility and access are impossible, removing the 2005;31:845-850. instrument is not recommended, since there is a high 11. Knowles KI, Hammond NB, Biggs SG, Ibarrola JL. risk of perforation. Further complications that may occur Incidence of instrument separation using lightspeed rotary instruments. J Endod, 2006;32:14-16. are the weakening of the mass of the tooth, secondary 12. Wolcott S, Wolcott J, Ishley D, Kennedy W, Johnson S, separation of the instrument, extrusion of the fragment Minnich S, et al. Separation incidence of Protaper rotary into periapical tissues, transformation of the root canal, instruments: A large cohort clinical evaluation. J Endod, and raised surface temperature sufficient to cause tissue 2006;32:1139-1141. damage. 13. Wu J, Lei G, Yan M, Yu Y, Yu J, Zhang G. Instrument Where the removal of the instrument is impossible separation analysis of multi-used ProTaper universal rotary system during root canal therapy. J Endod, 2011;37:758-763. or dangerous, the possibility of retaining the fragment in 14. Wang NN, Ge JY, Xie SJ, Chen GZM. Analysis of Mtwo the root canal should be evaluated. If clinical symptoms rotary instrument separation during endodontic therapy: exist, immediate surgical treatment is recommended. If no a retrospective clinical study. Cell Biochem Biophys, symptoms are present, instrumentation and obturation of 2014;70:1091-1095. the root canal coronally to the fragment can be performed, 15. Cunha RS, Junaid A, Ensinas P, Nudera W, Bueno CE. Assessment of the separation incidence of reciprocating and the tooth entered into a follow-up schedule. The WaveOne files: a prospective clinical study. J Endod, possibility of a future surgical treatment, in case of failure, 2014;40:922-924. should be taken into account. Retaining the fragment in 16. Crump MC, Natkin E. Relationship of broken root canal the root canal does not seem to affect tooth prognosis, instruments to endodontic case prognosis: A clinical which depends mainly on the presence of a lesion, the investigation. J Am Dent Assoc, 1970;80:1341-1347. infection of the root canal at the time of separation, and 17. Hülsmann M, Schinkel I. Influence of several factors on the success or failure of removal of fractured instruments from the quality of the root canal obturation afterwards. the root canal. Endod Dent Traumatol, 1999;15:252-258. The conclusions of this review, regarding the 18. Ungerechts C, Bårdsen A FI. Instrument fracture in root indicated treatment of cases with separated instruments canals - where, why, when and what? A study from a student are briefly outlined in a flow chart (Figure 1). clinic. Int Endod J, 2014;47:183-190. 19. Di Fiore PM, Genov KA, Komaroff E, Li Y, Lin L. Nickel- titanium rotary instrument fracture: A clinical practice assessment. Int Endod J, 2006;39:700-708. 20. Cujé J, Bargholz C, Hülsmann M. The outcome of retained References instrument removal in a specialist practice. Int Endod J, 2010;43:545-554. 1. Suter B, Lussi A, Sequeira P. Probability of removing 21. Cohen SJ, Glassman GD, Mounce R. Rips, strips and fractured instruments from root canals. Int Endod J, broken tips: Handling the endodontic mishap. Oral Health, 2005;38:112-123. 2005:10-20. 2. Iqbal MK, Kohli MR, Kim JS. A retrospective clinical 22. Madarati AA, Watts DC, Qualtrough AJ. Opinions and study of incidence of root canal instrument separation in an attitudes of endodontists and general dental practitioners endodontics graduate program: A PennEndo database study. in the UK towards the intracanal fracture of endodontic J Endod, 2006;32:1048-1052. instruments: part 1. Int Endod J, 2008;41:693-701. Balk J Dent Med, Vol 22, 2018 Separated Instrument In Endodontics 131

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Hulsmann M. Methods for removing metal obstruction from Aristotle University of Thessaloniki, Thessaloniki, Greece the root canal. Endod Dent Traumatol, 1993;9:223-237. e-mail: [email protected]

10.2478/bjdm-2018-0023

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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA

Evaluation of Mandibular Anatomical Formation for Gender Determination in Turkish Population

SUMMARY Burak Apaydın1, Derya Icoz2, Fusun Yasar3, Background/Aim: Gender determination is one of the most Faruk Akgunlu3 challenging tasks in medico-legal research and forensic dentistry. Several 1 Pamukkale University, Faculty of Dentistry, skeletal components are investigated for this purpose and the mandible is Department of Maxillofacial Radiology, one of them. The mandible has several specific anatomical features. The Denizli, Turkey 2 purpose of this study was to analyze the effects of measurements related Beyhekim Oral and Dental Health Clinic, Konya,Turkey to the mental foramen, gonial angle and antegonial angle on gender 3 Selcuk University, Faculty of Dentistry, determination using digital panoramic radiographs. Material and Methods: Department of Maxillofacial Radiology, A retrospective study was planned with 150 digital panoramic radiographs Konya, Turkey (75 males and 75 females, aged between 20 to 49 years). The radiographs were analyzed by dividing them into two equal gender groups (male and female). Several parameters were compared to determine the gender. The distances from the superior and inferior border of the mental foramen to the basis of the mandible on the right side were measured. Gonial and antegonial angles were evaluated bilaterally. The difference between the males and females were analyzed with independent samples t-test (p<0.05). Results: There was statistically significant difference between the males and females in terms of all the evaluated parameters (p<0.05). The distances related to mental foramen is higher in the males however gonial and antegonial angles are larger in the females. Conclusions: The mental foramen position, gonial and antegonial angles can be used to predict the gender in Turkish population. Key words: Forensic Dentistry, Sex Determination Analysis, Mental Foramen, Gonial ORIGINAL PAPER (OP) Angle, Antegonial Angle, Panoramic Radiography Balk J Dent Med, 2018;133-137

Introduction As evident from the previous studies, the skull is the most reliable portion of the human skeleton after The determination of human skeletal components the pelvis to distinguish the gender, providing precision 1 is important in criminal cases for advanced analysis1,2. up to 92% . However, sometimes, intact skull cannot be found. In these cases, the mandible may play a vital Gender determination is the first step of the determination role in sex determination, because it is the strongest process3. If the whole adult bone structure is available, and the most dimorphic bone of the skull, and has a gender can be determined easily. However, when skeletal dense layer of compact bone7-9. The structure of the remnants do not present in good condition, morphological mandibular ramus may vary according to the gender, indicators of sexual dimorphism do not allow a because mandibular growth and development is different 4 correct diagnosis . Gender determination in forensic in both genders. Occlusal forces are also different in dentistry and human anthropology is mainly based on both genders. In addition, the anatomical changes of the anatomical variations and various skeletal morphological mandible are affected by the occlusal status10. Among characteristics that can be used to distinguish males from the craniofacial bones, the mandible is the most reliable females5,6. one for discriminating the sex, therefore, the anatomical 134 Burak Apaydın et al. Balk J Dent Med, Vol 22, 2018 structures of the mandible are commonly used in the positioned radiographs without distortion and artifacts. gender determination5,11. Any developmental problems, deformation, fractures or In the field of forensic dentistry and anthropology, edentulousness of the mandible were eliminated from the dentofacial radiographs are indispensable11. Panoramic study. No ethics committee report was required for this radiography is a very popular technique and commonly study. used in routine dental practices to evaluate mandibular The parameters used in this study were the distance and maxillary vital structures12,13. Panoramic radiographs between the inferior border of the mental foramen and are suitable as a means of radiologic approach to view the inferior border of the mandible (IBM), between the the integrity of whole dento-facial tissues12. Due to the superior border of the mental foramen and the inferior possibility of imaging the entire body of the mandible, border of the mandible (SBM) on the right side, and the position of the mental foramen is reasonably well gonial and antegonial angles on both sides. The distances depicted in panoramic radiographs both in horizontal between the IBM and SBM on the right side, bilateral and vertical dimensions. Panoramic radiographs are gonial and antegonial angles were measured on the images also the best choice for the determination of the gonial by a dento-maxillofacial radiologist (D.I.) with a Java 11,14 angle . Gonial angle is generally used to evaluate the Image Processing Software (ImageJ, a public domain 15 rotation of the mandible and diagnose growth patterns . program). This program can be downloaded from http:// In recent years, numerous studies have assessed the rsb.info.nih.gov/ij/. For measurements, a line was drawn reliability of panoramic radiographs for the determination tangent to the inferior border of the mandible and the 12,16,17 of morphological dimensions of the mandible . mental foramen was marked with a circular line. The The gonial angle was evaluated in some studies with perpendicular distances from the superior and inferior 14,18,19 controversial results . Skeletal characteristics borders of the mental foramen to the tangent line were differ in each population accentuating the need for measured (Figure 1). Gonial angle was obtained by population-specific bone metric standards for gender measuring the angle between the line tangent to the 1,20 determination . To our knowledge, there is no study lowest points of the anterior and posterior borders of the evaluating the mental foramen for gender determination in mandible and the line tangent to the two distal points the Turkish population. of the ramus. The antegonial angle was measured by Therefore, the aim of the present study was to drawing two lines parallel to the antegonial region which determine the effect of the average distances of the intersected at the deepest point of the antegonial notch superior and inferior borders of the mental foramen (Figure 2). For the study 10% of all the measurements to the inferior border of the mandible on right side, and were performed twice by the same observer (D. I.). The the average gonial and antegonial angles on both sides data were analyzed by independent samples t-tests using of the individuals on the gender determination. The null a statistical software (IBM SPSS 15.0 version IBM Corp). hypothesis was that there would be no effect of these parameters on gender determination.

Material and Methods

The study was performed at the Department of Maxillofacial Radiology, Selcuk University, Konya, Turkey. Panoramic radiographs of 150 patients (75 females and 75 males of Turkish population between the ages of 20 and 49 years) were selected from the archive of patients who were referred to the Maxillofacial Radiology Clinic for routine dental procedures. None of the images were obtained for the purpose of the present study. Suitable panoramic radiographs were selected randomly. All the radiographs were taken with the same panoramic machine (Kodak 8000 Panoramic system Carestream Health Inc, Rochester NY, USA) by the same technician (A.E.) and exposed under standard protocols (70 kV and 10 mA). Inclusion criteria comprised the lack of any pathologic bony lesion in the mandible, Figure 1. The measurements of IBM and SBM excellent visualization of the mental foramina and borders of the mandible, and high quality and correctly Balk J Dent Med, Vol 22, 2018 Gender Determination in Turkish Population 135

no study has evaluated the mental foramen for gender determination in the Turkish population. In this study gonial angle was significantly larger in females than males on both sides of the jaws. The current results are in agreement with the results reported by Abu Taleb et al7. The average gonial angle values reported in the study by Abu Taleb et al. (122.16 in males; 125.09 in females) 7 were higher than those of this study (110.74 in males; 113.03 in females). Average gonial angle varies according to different Figure 2. Measurement method of gonial and antegonial angles human population groups. The small differences between groups may be explained with homogeneity between these groups but relatively high differences should Results be considered for racial identification7. The results of the present study is also in agreement with the study 21 No statistically significant differences existed by Gungor et al. . However, according the studies by 5 14 between the first and second measurements (p>0.05). The Rupa et al. and Chole et al. , a statistically significant difference of measured parameters between the males and difference did not exist between genders in terms of females were analyzed with independent samples t-tests gonial angle measurements. This discrepancy may be explained by the difference in populations. The reason and the present study showed that, for all measurements, a for the larger gonial angle in females compared to males statistically significant difference was present between the can be that high masticatory force results in small gonial males and females (p<0.05) (Table 1). angles and males usually have a greater masticatory force than females16. Also it was found that females had Table 1. Dimensions of IBM, SBM, gonial and antegonial angles downward and backward rotation in mandible while of males and females males had forward rotation. So, the gonial angles in females are larger than males7. Some studies performed in Indian and Norwegian populations noted that gonial Gender N Mean Std. Dev. P angle was statistically non-significant between genders or larger in males than females and this was explained male 75 1.448 0.11 IBM 0.000* female 75 1.245 0.09 with the effect of insertion of the masticatory muscles into the gonion5,22,23. male 75 1.752 0.11 SBM 0.000* Sexual dimorphism is related to anatomical regions female 75 1.549 0.10 and their functions24. According to many researchers, male 75 109.96 5.19 gender determination can be performed using the skull Gonial angle (R) 0.014* female 75 112.22 5.88 and hipbone with more than 95% accuracy. Despite these findings, gender differences are not a dominant male 75 111.52 6.42 Gonial angle (L) 0.024* female 75 113.85 6.01 and static phenomenon and there are overlaps in each gender’s characteristics7. The literature revealed that male 75 160.99 8.46 Antegonial angle (R) 0.001* ultimate shape of a fully grown mandible can be female 75 165.65 7.69 used to differentiate the gender. The morphological male 75 159.56 9.09 features of the mandible are most commonly used Antegonial angle (L) 0.000* female 75 166.66 7.27 by anthropologists and forensic dentists in sex determination9. Radiographic X ray technology is a * refers to statistically significant difference (p<0.05). prominent tool for forensic dentistry and a simple and cheap method for human identification as well7. The reliability of measurements on radiographs depends on the quality of radiographs and panoramic radiographs Discussion can provide information about the localization and dimension of the anatomic structures13. In most of In this study, a statistically significant difference populations, the mandibles of the males are usually was found between the males and females in terms of larger, have prominent muscular attachment sites and measurements related to the mental foramen, gonial are slightly more robust than female mandibles. The and antegonial angles. Therefore the null hypothesis prominent male features of the mandible include broad ‘there would be no effect of these parameters on the ramus, high symphysis, small mental eminence and gender determination’ was rejected. To our knowledge, gonial flaring. Based on these features mandibular 136 Burak Apaydın et al. Balk J Dent Med, Vol 22, 2018 parameters can be considered as reliable markers for sex 5. Rupa KR, Chatra L, Shenai P, Veena KM, Rao PK, determination5. Prabhu RV et al. Gonial angle and ramus height as sex The mental foramen is a well observed anatomical determinants: A radiographic pilot study. J Cranio Max Dis, landmark in panoramic radiographs and it is possible to 2015;4:111-116. evaluate both horizontal and vertical dimensions related 6. Ghodousi A, Sheikhi M, Zamani E, Gale-Bakhtiari S, Jahangirmoghaddam M. The value of panoramic to the mental foramen25. In the present study, SLM and radiography in gender specification of edentulous Iranian ILM dimensions were significantly higher in the males population. J Dent Mater Tech, 2013;2:45-49. than females and the results were compatible with those 7. Abu-Taleb NS, El Beshlawy DM. Mandibular ramus and 11 25 reported by Thakur et al. and Naroor et al . In this study gonial angle measurements as predictors of sex and age SLM and ILM were evaluated only on the right side of the in an Egyptian population sample: a digital panoramic radiographs because some previous studies showed that radiographic study. J Forensic Res, 2015;6:1-7. the values on both sides were almost the same and there 8. Duric M, Rakocevic Z, Donic D. The reliability of sex was no statistically significant difference between the determination of skeletons from forensic context in the right and left sides25. Balkans. Forensic Sci Int, 2005;147:159-164. Bone deposition occurs on the inferior border 9. Hu KS, Koh KS, Han SH, Shin KJ, Kim HJ. Sex of the mandible with the exception of the antegonial determination using nonmetric characteristics of the mandible in Koreans. J Forensic Sci, 2006;51:1376-1382. region where bone resorption takes place and increases 10. Huumonen S, Sipilä K, Haikola B, Tapio M, Söderholm antegonial angle and antegonial depth. In the present AL, Remes-Lyly T et al. Influence of edentulousness on study, the males had a smaller antegonial angle than gonial angle, ramus and condylar height. J Oral Rehabil, the females and our results correlated with those 2010;37:34-38. of Bhardwaj et al. and they explained this with the 11. Thakur M, Reddy VK, Sivaranjani Y, Khaja S. Gender hormonal difference of testosterone in males and determination by mental foramen and height of the body of estrogen in females affecting the bone metabolism the mandible in dentulous patients a radiographic study. J and possibly resulting in visible differences between Indian Acad Forensic Med, 2014;36:13-18. genders16. This study has a limitation as the patients 12. Leversha J, McKeough G, Myrteza A, Skjellrup-Wakefiled were not classified according to their age. H, Welsh J, Sholapurkar A. Age and gender correlation of gonail angle, ramus height and bigonial width in dentate subjects in a dental school in Far North Queensland. J Clin Exp Dent, 2015;8:49-54. 13. Schulze R, Krummenauer F, Schalldach F, d’Hoedt Conclusions B. Precision and accuracy of measurements in digital panoramic radiography. Dentomaxillofac Radiol, Within the limitations of this study, following 2000;29:52-56. conclusions can be drawn: Panoramic radiography is an 14. Chole RH, Patil RN, Balsaraf Chole S, Gondivkar effective radiographic method to evaluate the mandible S, Gadbail AR, Yuwanati MB. Association of mandible and to determine the gender. The difference of gonial anatomy with age, gender, and dental status: a radiographic angle, antegonial angle and measurements related to the study. ISRN Radiology, 2013;18:453763. mental foramen between the males and females were 15. Kitai N, Mukai Y, Murabayashi M, Kawabata A, Washino K, Matsuoka M et al. Measurement accuracy with a statistically significant for the study population and these new dental panoramic radiographic technique based on parameters may be used in sex determination in Turkish tomosynthesis. Angle Orthod, 2013;83:117-126. population. 16. Bhardwaj D, Kumar JS, Mohan V. Radiographic evaluation of mandible to predict the gender and age. J Clin Diagn Res, 2014;8:66-69. 17. Ghosh S, Vengal M, Pai KM. Remodeling of the human References mandible in the gonial angle region: a panoramic, radiographic, cross-sectional study. Oral Radiol, 1. Saini V, Srivastava R, Rai RK, Shamal SN, Singh TB, 2009;25:2-5. Tripathi SK. Mandibular ramus: an indicator for sex in 18. Raustia AM, Salonen MA. Gonial angles and condylar fragmentary mandible. J Forensic Sci, 2011;56:13-16. and ramus height of the mandible in complete denture 2. Suragimath G, Ashwinirani SR, Christopher V, Bijjargi wearers- a panoramic radiograph study. J Oral Rehabil, S, Pawar R, Nayak A. Gender determination by radiographic 1997;24:512-516. analysis of mental foramen in the Maharashtra population of 19. Xie QF, Ainamo A. Correlation of gonial angle size with India. J Forensic Dent Sci, 2016;8:176-80. cortical thickness, height of the mandibular residual 3. Indira AP, Markande A, David MP. Mandibular ramus: An body, and duration of edentulism. J Prosthet Dent, indicator for sex determination - A digital radiographic 2004;91:477-482. study. J Forensic Dent Sci, 2012;4:58-62. 20. Kharoshah MA, Almadani O, Ghaleb SS, Zaki MK, Fattah 4. Scheuer L. Application of osteology to forensic medicine. YA. Sexual dimorphism of the mandible in a modern Clin Anat, 2002;15:297-312. Egyptian population. J Forensic Leg Med, 2010;17:213-215. Balk J Dent Med, Vol 22, 2018 Gender Determination in Turkish Population 137

21. Gungor K, Sagir M, Ozer I. Evaluation of the gonial angle 25. Naroor N, Shenai P, Chatra L, Veena KM, Rao PK, Shetty in the Anatolian populations: from past to present. Coll P. Gender determination using the mental foramen. J Cranio Antropol, 2007;31:375-378. Max Dis, 2015;4:144-147. 22. Upadhyay RB, Upadhyay J, Agrawal P, Rao NN. Analysis of gonial angle in relation to age, gender and dentition status Received on October 9, 2017. Revised on December 2, 2017. by radiological and anthropometric methods. J Forensic Accepted on April 10, 2018. Dent Sci, 2012;4:29-33. 23. Ohm E, Silness J. Size of the mandibular jaw angle related to age, tooth retention and gender. J Oral Rehabil, Correspondence: 1999;26:883-891. Burak Kerem Apaydın 24. Mahapatra GK, Nar OP, Joshi SN. Evaluation of Pamukkale University Faculty of Dentistry radiographic predictors to assess the rate of mandibular Department of Maxillofacial Radiology, Denizli, Turkey residual ridge resorption. Indian J Dent Res, 2004;15:24-27. e-mail: [email protected]

DOI: 10.2478/bjdm-2018-0024

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Awareness of Oral Complications and Oral Hygiene Habits of Subjects with Diagnosed Diabetes Mellitus

SUMMARY Hülya Çankaya1, Pelin Güneri1, Joel B. Background/Aim: The aim was to evaluate Diabetes Mellitus Epstein2, Hayal Boyacıoğlu3 (DM) patients’ awareness of their risk for oral and dental complications, 1 Ege University School of Dentistry, Department to evaluate their oral health behaviors, assess their sources of related of Oral and Maxillofacial Radiology, information, and to detect the influence of their awareness on oral health İzmir, Turkey 2 and dental management. Material and Methods: Total of 240 DM Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, CA, patients presenting to a university outpatient dental facility for routine USA; Division of Otolaryngology and Head and care completed a self-administered questionnaire about demographic- Neck Surgery, City of Hope National Medical socioeconomic characteristics, oral health care and awareness on oral Center, CA , USA complications of DM. Dental status of each patient was recorded. Data were 3 Ege University Faculty of Science, Department analyzed with Chi- square test; p was set as 0.05. Results: The patients’ of Statistics, İzmir, Turkey mean age was 52.85 years; the majority had Type 2 DM (72.1%) and 61.7% were females. Two thirds of the patients had tooth loss; 65% brushed daily and used toothpick for interproximal cleaning (35%). Only 12.9% had regular dental visits and 37.5% reported their oral health as “poor”. DM patients rarely received guidance from their health care professionals regarding their oral health (28.3%). Even though 62.5% were aware of oral complications of DM, only 46.3% knew that oral health may affect DM. The patients with Type 1 and Type 2 DM had similar perceptions about their oral health status (p=0.15>0.05). However, insulin users were more aware of the interaction between oral health and DM (p>0.05), and were more likely to consider their oral health as “poor” (p>0.05). Conclusions: DM patients’ awareness of the effect of DM on oral health was higher than that of the effect of oral health on DM management. Medical health care providers were failing to provide the necessary information regarding these issues when compared to dentists. Key words: Community Care, Dental Care, Developing Countries, Health Care, Health ORIGINAL PAPER (OP) Education Balk J Dent Med, 2018;138-145

Introduction have diabetes and it is anticipated that this number will increase to 592 million worldwide by 20354. Diabetes Mellitus (DM) is a chronic, progressive, The chronic complications of DM including metabolic disease that is characterized by high levels microvascular abnormalities and neuropathy result in a high of glucose in the blood. It results from the deficiency in risk of developing oral health problems, such as xerostomia insulin secretion from pancreatic beta cells or an increased (dry mouth) which results with increased susceptibility to cellular resistance to the actions of insulin1. Due to oral fungal infections (oral candidiasis) and dental caries, its high incidence and increasing prevalence, DM has poor wound healing, taste impairment, burning mouth been declared a pandemic disease by the World Health syndrome, and periodontal disease5-7. As a consequence of Organization 2,3. According to the 2013 International the impaired immunity and healing associated with DM, Diabetes Federation Diabetes Atlas, 387 million people periodontitis may be more severe and aggressive in these Balk J Dent Med, Vol 22, 2018 Oral Complications in Diabetes Mellitus 139 patients8,9. Additionally, periodontitis impairs glycaemic Institutional Review Board at Ege University (29.04.2016, control as it has been shown that DM management is #16-4/1) and were completed in accordance with the improved following treatment of periodontitis8,9.Therefore, Declaration of Helsinki. DM patients should be informed about this bidirectional A self-administered questionnaire which included 38 interaction between oral health and DM for both the questions was prepared after careful selection of relevant prevention and control of periodontal/oral disease and published reports in the literature26-29. DM patients management of DM3. completed this patient-reported questionnaire as they Among the health care professionals involved in DM waited for their appointment at the outpatient clinic. For management and patients care, the role of the nurses is of illiterate patients, a researcher (HÇ) read and explained increasing importance because of the increasing global prevalence of DM10. Consequently, nurses are essential the queries and recorded patients’ responses. The first in the multidisciplinary team to provide appropriate part of the questionnaire was related to the patients’ care to DM patients and to manage DM, both in primary demographic and socioeconomic characteristics such and secondary care settings11. Several papers have as age, gender, literacy and annual household income- assessed the knowledge of dental students and dental which was determined according to the minimum wage care providers12-16, internists and endocrinologists3,17,18, provided by the government (https://www.csgb.gov.tr). diabetes educators 19 and diabetic patients20-24 of the The type and duration of DM and DM management (diet, association between DM and oral health. Unfortunately, oral antidiabetic agents, and insulin) were recorded. The people with DM still lack important knowledge about second part of the questionnaire assessed participants’ oral the oral complications of the disease and may have poor health behaviors, such as frequency of dental visits, tooth levels of oral self-care 20-22,24-26. brushing, flossing and mouth rinse use. The third part of The increased incidence of DM and the high the questionnaire was related to participant’s awareness level of poor oral health among diabetics indicate the continuing need for education of DM patients by the about oral complications associated with diabetes. health care providers regarding the interaction between All participants underwent standard oral examination oral health and DM. However, establishing the actual related to their complaint by experienced clinicians under awareness of DM patients on this interaction is vital in standard clinical conditions and were referred to dental order to develop effective programs to enhance both the clinics for treatment of their routine dental complaints. general and oral health of DM patients. In this study; we Missing data were also presented in the tables, since aimed to assess the knowledge and awareness of DM these were considered important to show the actual patient patients about their heightened risk for oral diseases, to profile. Data were entered on an Excel spreadsheet and evaluate their oral health habits, to evaluate their sources statistical analyses were performed with SPSS version 12 of related information, and also to assess the influence (SPSS Inc., Chicago, IL, USA). Following assessment of of DM patients’ awareness about increased risk for oral descriptive features, Chi- square test was used to analyze diseases on their oral health and dental management. the categorical data. In all tests, P was set as 0.05.

Material and Methods Results This cross sectional study was performed on 240 DM The patients’ demographic and socioeconomic patients (both Type 1 and 2) among the patients who were characteristics and dental findings are presented in Table 1. referred to the Outpatient Dental Clinic for treatment of Two hundred and forty DM patients who were their dental needs in a routine, nonemergency basis. The consisted of 61.7% females and 38.3% males and whose inclusion criteria were DM diagnosis for at least 1 year, cognitive skills to understand the questions, and to accept ages were ranging between 13 to 82 years (mean=52.85 enrollment in the study. The patients with history of years) participated in this survey. Half of the patients cerebrovascular disease, uncontrolled systemic diseases, (51.53%) were either illiterate or had literacy level of major psychiatric conditions, using medications that elementary school, and their monthly income were low alter the cognitive function, diabetic medical personnel, (73.3%). The majority of patients (72.1%) had Type 2 DM and patients who had diabetes only during pregnancy and the duration of the disease ranged between 1-40 years. were excluded from the study. The patients entered the Most of the patients were using oral antidiabetic agents investigation voluntarily following an explanation of (62.5%) and insulin (20.8%), and 95% of patients were the study purpose and written informed consents were regularly controlling their blood glucose level at home obtained. All study protocols were approved by the (85%) (Table 1). 140 Hülya Çankaya et al. Balk J Dent Med, Vol 22, 2018

Table 1. Sociodemographic characteristics and diabetes related The patients were mostly aware of mouth dryness as information of DM patients an oral complication of DM (46.7%), and this was followed by tooth decay (25%), malodor (23.3%) and bleeding gums n during tooth brushing (22.9%) (Table 3). Patients were less aware of diabetes related mouth ulcers and taste impairment Male 92 Gender Female 148 (11.7%) and fungal infection (4.6%) (Table 2). <20 3 20-29 5 Table 2. Awareness of DM patients and the source of their 30-39 15 Age (years) information regarding the effect of diabetes on oral health 40-49 57 50-59 93 Yes n(%) 150 (62.5) Aware of the effect of No n(%) 74 (30.8) >60 66 diabetes on oral health Illiterate 21 Missing data 16 (6.7) Elementary school 102 Nurse/physician 13 (5.4) Education Secondary school 33 Internet 12 (5.0) High school 45 the source of this TV 36 (15.0) If yes: University 39 information Dentist 83 (34.6) Low 176 Combined 4 (1.85) Income High 64 Missing data 24 (10.0) Type I 67 Type of diabetes Type 2 173 Regarding information about the effect of oral health <5 years 92 on DM, 46.3% of the patients had some knowledge with 5-9 years 60 22.5% receiving this information from their dentists 10-14 years 47 (Table 3). 40.8% of the patients were not aware that oral Length of diagnosis 15-19 years 25 health may influence DM management. 20-24 years 9 >25 years 6 Table 3. Awareness of DM patients regarding oral problems Diet 11 linked to diabetes Oral antidiabetics 150 Treatment Does DM cause the following oral Insulin 50 Yes n(%) No n(%) Combined 25 complications? Mouth dryness 112 (46.7) 128 (53.3) Delayed healing 52 (21.7) 188 (78.3) Gingival bleeding during brushing 55 (22.9) 185 (77.1) Seventy-five percent of respondents were completely Mouth ulcers 28 (11.7) 212 (88.3) or partially edentulous. Of the participants, 7.1% did Malodor 56 (23.3) 184 (76.7) not brush their teeth on a daily basis, whereas 65% Tooth decay 60 (25.0) 180 (75.0) brushed once a day. Approximately 2/3 (63.3%) reported Tooth loss 51 (21.3) 189 (78.8) interproximal cleaning, mostly using a toothpick as an Oral fungal infections 11 (4.6) 229 (95.4) Swollen or tender gingiva 44 (18.3) 196 (81.7) adjunct tool (35%) to clean the problematic sites rather Taste impairment 28 (11.7) 212 (88.3) than dental floss (12.9%), and 56 patients (23.3%) used oral rinses regularly. As presented in Table 5, DM patients rarely received Only 12.9% reported that they had visits for regular guidance from their health care professionals regarding dental check-ups, and two-thirds of the patients visited their oral health (28.3%). Additionally, over 60% of the dentist when they perceived there was a need (74.2%). the patients reported that clinicians failed to provide More than half of the patients (55.4%) reported oral information about the importance of oral examination bleeding during tooth brushing; 21.7% of those kept on and oral care, tooth brushing, maintenance of optimal oral brushing whereas 14.6% did not have concerns about health and interdental cleaning (Table 4). Almost all DM patients informed their dentists bleeding. In our study, 37.5% of patients reported that about their diabetes. Most of the patients stated that their their oral health was poor and almost half of the patients dentist should inform them about the importance of good rated their oral health as “moderate”. oral health on the management of DM. Also, the patients Approximately two-thirds (62.5%) of the participants agreed on the necessity of regular dental appointments and had some knowledge of oral complications of DM, mostly stated that they would prefer to visit their dentist at the received from their dentists (34.6%) (Table 2). same time as medical follow-up (Table 5). Balk J Dent Med, Vol 22, 2018 Oral Complications in Diabetes Mellitus 141

Table 4. Awareness of DM patients and the source of their DM management had significant influence on information regarding the effect of oral health on diabetes some of patient responses. Most of the antidiabetic using DM patients (53.38%) considered their oral health Yes n(%) 111 (46.3) as “moderate”, but among insulin using DM patients, Aware of a negative effect of No n(%) 98 (40.8) oral health on diabetes 35.42% considered their oral health as “moderate”, Missing data 31 (12.9) and the difference between the groups was significant Nurse/physician 8 (3.3) (p=0.01). On the other hand, most of the insulin users (56.25%) described their oral health as “poor” whereas Internet 8 (3.3) this was observed in only 31.08% of oral antidiabetic the source of this TV 26 (10.8) agent users (p=0.01), which could reflect severity of If yes: information Dentist 54 (22.5) disease and diabetic control and impact upon oral health. Combined 6 (5.9) Similarly, there were significant differences between the oral antidiabetic and insulin users with respect to their Missing data 47 (19.6) awareness about the effect of DM on oral health. Most of the insulin users were aware of this influence (78%), but Table 5. The oral health care advices received by DM patients this incidence was lower among oral antidiabetic agent and the patients attitutes towards dentists involvement in users (57%), (p=0.03). Of insulin users, 64% were aware DM care of the potential impact of oral health on DM management, whereas this was observed in 41.33% of oral antidiabetic Are you informed by the Missing agent users (p=0.02). health care provider that in No n(%) Yes n(%) data The highest portion of the missing replies were diabetic patients: n(%) observed in the questions regarding the management Oral examination by a 165 (68.8) 68 (28.3) 7 (2.9) of gingival bleeding during brushing (35%) and the dental professional is vital information about the effect of oral health on DM (19.6%). Oral care and tooth 146 (60.8) 85 (35.4) 9 (3.8) brushing is important Regular visit to dentist is 163 (67.9) 68 (28.3) 9 (3.8) a requirement Gingival health status Discussion 162 (67.5) 68 (28.3) 10 (4.2) shall be controlled Use of dental floss is In the literature, previous studies have examined the 189 (78.7) 40 (16.7) 11 (4.6) essential interaction between DM and oral health3,30,31. However, in Did you tell your dentist order to develop appropriate health care recommendations, 14 (5.8) 222 (92.5) 4 (1.7) that you have diabetes patient education and health care delivery to diabetic Should your dentist inform patients, assessment of patient awareness level about the you about the importance 22 (9.2) 210 (87.5) 8 (3.3) oral manifestations of DM and related effects on oral health of oral health on diabetes are needed. Unfortunately, despite the development of management? numerous questionnaires to assess the patients’ knowledge Should you have a dental on DM and related medical problems32,33 to the authors’ appointment during your 28 (11.7) 205 (85.4) 7 (2.9) knowledge, there is no standard and validated questionnaire diabetes control? to establish the patients’ awareness about the interaction If yes, would you regulary attend to dental 19 (7.9) 203 (84.6) 18 (7.5) between DM patients’ oral health and their disease. Thus, as 26-29 appointments done in previous research a questionnaire was developed by the authors after thorough search of relevant published The patients’ knowledge regarding the interaction reports in the literature and the knowledge/ awareness of between DM and oral health was not associated with diabetic patients about their increased risk for oral diseases tooth brushing habits (p=0.81), gender (p=0.58), monthly were established in this study. Additionally, the sources of information and oral hygiene habits of DM patients were income (p=0.34) and education (p=0.22). Dental flossing examined so that the general physicians, DM specialists, and interproximal cleaning was more common among nurses, patient educators and others may be aware of the females than males (p=0.01, p=0.01, respectively). general practices of DM patients in their oral care. The patients with Type 1 and Type 2 DM provided Even though higher male predominance is reported similar results with respect to their perception of their in the literature, the disease appears to be increasing in oral health status (p=0.15). Additionally, the awareness females34, as observed in the present study. Our patients of the patients regarding the effect of DM on oral health were mostly middle-aged individuals, which parallels with (p=0.13) and the effect of oral health on DM management other reports1,35-37. Although several studies have reported (p=0.052) were not significantly different. the prevalence of Type 2 DM as high as 90% of diabetic 142 Hülya Çankaya et al. Balk J Dent Med, Vol 22, 2018 patients38,39 in the present study, 72% of the patients had brushing, only 5% preferred to go to a dentist for this Type 2 DM, and this was within the range provided for the problem and 15% did not care about bleeding at all. In a global prevalence20,23,24,37,40. This wide variation among similar study, more patients (33.2%) visited their dentists the incidence of Type 2 DM has been attributed to the for bleeding during brushing22. It’s suggested that the ethnicity, lifestyle, demographic differences, obesity and lack of awareness of the interaction between oral health genetics of the patients and the socioeconomic status of and DM may be a potential reason for patients not taking population studied3,37,38. action when this symptom is present. The same variability was observed within the oral Our patients’ knowledge regarding the interaction hygiene habits of DM patients in the literature. Oral between diabetes and oral health was not influenced by brushing frequency of our patients were comparable to the the parameters assessed including age, tooth brushing other studies: most of the patients in this study brushed habits, gender, monthly income and education. On the once a day (65%); this frequency was within the range other hand, others report a positive impact of education of the literature, reported between 24.2% and 95.3% on their knowledge and awareness21,40 . Considering 22,23,25,26,41-44 . Less DM patients brushed their teeth twice a that people may answer the questions to receive social day (22.5%), and this was similar to others with frequency approval42 , this could have led to higher positive 22,23,40,42,45 ranging between 17%-38% . responses from the undereducated patients in the present In some other reports, over 60% of diabetics brushed study. Diabetics were more aware of their increased risk 25,26,43 their teeth twice a day . Over one third of our for systemic complications associated with DM than they patients never performed interproximal cleaning as a were for oral and dental complications20,24,26,35,46 . As routine dental practice, comparable with other studies of reported in the literature1,20,21,24-26,35,41,49, our study also 23,26,40,43 DM populations . Our patients mostly preferred revealed a lack of information about oral complications a tooth pick as an adjunct tool to clean the problematic of DM in one-third of diabetic patients. The most sites rather than for regular interdental cleaning. reported oral complication was mouth dryness, as seen Although using a tooth pick is not advised by some dental in other studies25,26,29 . Our patients were less aware that practitioners, many diabetic patients continued on using it mouth ulcers, taste impairment and fungal infection as a cleaning tool22,42. Overall, reported dental floss and were additional oral complications of DM. Bowyer et interdental cleaning habits and oral rinse usage of our al. stated that fewer patients knew that delayed healing patients were comparable to the literature23-26,40,42. in the mouth, swollen or tender gums and loose teeth may The frequency of DM patients who have regular be associated with diabetes26.Limited awareness of the dental visits ranges widely20,22,23,25,29,40,45,46 . In our study, signs and impact of periodontal disease were recognized only 12.9% of DM patients attended to dental controls in other DM populations17,23,25,35,40,50. Our patients’ yearly, whereas 9.6% visited their dentists in every 6 awareness about DM related oral complications was months. The main reason for poor attendance to dental clinics was the socioeconomic status of the patients, higher than awareness of oral health on the management i.e., the level of education and financial sources1,26,46-48 of DM (63% and 46%, respectively). . The rates of our patients with regular dental visits were In the literature, DM patients have considered medical comparable to that reported by others, ranging between practitioners, nurses and other health care providers 12.6% and 14% 23,24,40 . On the other hand, higher rates inefficient to provide information regarding the oral 17,35, 51 of regular dental visits (up to 79.8%) are reported in other complications of DM . Even though the numbers countries1,20,26,41,42,45 . In the USA, the national health varied among the studies, oral complications of DM were objective aimed to increase the ratio of diabetic patients explained by less than half of the medical health care 17,23,35 who have annual dental check-ups up to 71% 40. Since providers and about half informed the patients about 1,35 regular dental appointments of DM patients are essential tooth brushing . Only up to 1/3 of DM patients were 40 not only to provide early detection of diabetes related guided to visit a dentist by a medical practitioner . In our oral complications, but also to eliminate any oro-dental study, nearly 90% of the patients thought that providing foci of pain and infection that may lead to difficulties in the information about the impact of poor oral health on metabolic control, the health authorities in developing DM management should be one of the tasks of a dental countries have included guidelines to comprise this issue professional, but only 34.6% of DM patients reported their in their future health programs1. dentists as the source of their knowledge and dental visits of Approximately 38% of our patients rated their oral our patients were infrequent, similar to other studies23,24,26. health as poor less than patient self-report (60%) in other Television programs were the second source of information reports1,22. Patients’ attitudes regarding frequency of in the present study. Other sources such as the Internet, brushing when they have observed bleeding after brushing magazines (10%-52%)22,23,40 and family/friends (55.3%)40 should also be investigated25. In our study, DM patients were also noted as sources of information. Even though our did not know how to manage bleeding gums and even results were in accordance with the literature, many patients though more than half reported bleeding during tooth did not respond to this query. Balk J Dent Med, Vol 22, 2018 Oral Complications in Diabetes Mellitus 143

Although the type of DM was not associated with the and DM, following appropriate education programs of the level of knowledge of our DM patients, the type of DM nurses on this issue. management influenced the results. Insulin users were Within the limitations of the study, the results more aware of the consequences of DM and oral health revealed that DM patients were aware of oral interactions than those on oral antidiabetic medications. complications associated with DM; however they were Additionally, the same group was more likely to consider unaware of the effect of oral health on DM management. their oral health as “poor” than the others. Previously, According to the patients, medical health care providers diabetic subjects have estimated their overall oral health were not efficiently providing the necessary information to be poorer than nondiabetic controls1 . We found that regarding these issues when compared to dentists. insulin users were more pessimistic about their oral health Following dentists, television programs were the second among DM patients, likely reflecting the severity of DM. source of information. Most of our DM patients agreed on the requirement A standard and validated questionnaire for patient of dental appointments and suggested regular dental reported outcomes is required to assess the oral hygiene evaluation at the time of medical visits. Unfortunately, habits and awareness of DM patients, regarding their only 13% had regular dental visits. This suggests a lack oral health and related consequences, especially on of appropriate oral health care knowledge and behavior the glycemic control. Training and advice about the among diabetic patients in our sample. interaction between oral health and DM should be planned Longitudinal studies have demonstrated a bidirectional by governmental organizations for medical and dental relationship between glycaemic levels and periodontitis, health care professionals, DM patients, but particularly indicating that chronic periodontal infection can complicate for nurses who are willing to take more responsibility in glycaemic control in DM patients, which, in turn, could DM management59. Subsequently, health care providers lead to more severe periodontal tissue destruction8,31,52-58 in primary and secondary settings may communicate with . Recently, Simpson et al. concluded in their meta-analysis DM patients about the oral manifestations of DM, and that there is no strong evidence to state that periodontal provide information related to oral care (brushing teeth at disease treatment by scaling and root planning improves least two times daily, flossing at least once a day, visiting DM management, suggesting periodontal status may more a dentist twice a year). Additionally, they may also remind closely reflect daily oral hygiene and systemic status31. the physicians about the annual dental control of DM However, they also stressed that larger, well conducted and patients and notify about the urgency of a dental referral clearly reported studies are required to assess the effect of when required. periodontal treatment on glycaemic control31. The main limitation of the study is that DM patients who participated in this study were admitted for routine dental control and were not referred by their DM doctor. Conclusions This study therefore represents a selected population and is not representative of all DM patients. Nevertheless, this DM patients’ awareness of the effect of DM on oral study does emphasize the need to develop the knowledge health was higher than that of the effect of oral health on and awareness in a high risk DM population. Additionally, DM management. Medical health care providers were since the aim was to determine only the awareness of the failing to provide the necessary information regarding patients in this study, the clinical and radiographic findings these issues when compared to dentists. of these patients were not assessed. For this reason, we were unable to comment on the effect of the oral health References status on the assessment of the treatment type of DM. 1. Moore PA, Orchard T, Guggenheimer J, Weyant RJ. 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DOI: 10.2478/bjdm-2018-0025

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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA

Study of Internal Morphology of Root-Canal Treated Single-Rooted Mandibular Second Molars in a Greek Population

SUMMARY Maria–Elpida Kalaitzoglou, Charalampos Background/Aim: To determine the prevalence of single-rooted Beltes, Eleni Kantilieraki, Panagiotis Beltes mandibular second molars in a Greek population and examine their internal Department of Endodontology, Dental School, morphology with the aid of intraoral periapical radiography. Material and Aristotle University of Thessaloniki, Greece Methods: Clinical records of 531 root-canal treated permanent single-rooted mandibular second molars were collected from the Postgraduate Clinic of the Department of Endodontology, Dental School, Aristotle University of Thessaloniki, Greece and from private dental clinics in the same city. The clinical records, along with the radiographic examination, were evaluated to determine the overall frequency of single-rooted mandibular second molars together with the number of root canals and their course. The root canals were categorized using Vertucci’s classification with the addition of 3 further types where appropriate. Results: Out of 531 mandibular second molars; 102 (19.2%) presented a single root; 427 (80.4%) presented two roots; 2 (0.4%) presented three roots. In a total of 102 single-rooted mandibular second molars 31 (30.3%) presented with Type I, 18 (17.6%) with Type II, 14 (13.7%) with Type IV, 7 (7%) with 3 additional root canal types and 32 (31.4%) with a C-shaped root canal system. Conclusions: One out five mandibular second molars was single-rooted in a Greek population. The internal morphology of these teeth can be very complex with regard to the numbers and courses of root canals. ORIGINAL PAPER (OP) Key Words: Greek Population, Internal Morphology, Single-Rooted Mandibular Second Molar Balk J Dent Med, 2018;146-149

Introduction rare according to the literature: ranging from 0.4%- 9.0%3,4 and 0.2% - 0.9%3,5 respectively. Single-rooted Knowing the morphology of the root canal system mandibular second molars show a remarkably wide range and its possible permutations are important determinants of incidence, varying from 1.3% to 41.2%2,5 (Table 1). for the success rate of endodontic treatment1. A wide Although a large number of studies have investigated variety of possibilities exists concerning the number the morphology of second mandibular molars, there is of roots and the forms of root canals in any given tooth little information in the literature concerning the internal group. morphology of single-rooted second mandibular molars. Second mandibular molars present with varying A very limited number of studies in the extant literature anatomic features regarding the number of roots and the have investigated the possible root canal configurations of prevalence of different root canal configurations in each single-rooted mandibular second molars2,4–8. root. The most frequent morphology of these teeth is the The aim of the present paper was to determine the two-rooted type, resembling the morphology of the first prevalence of single-rooted mandibular second molars in mandibular molar, with an incidence of 57.4%- 95.7%2,3 a Greek population and to examine the number and course with the three- and four-rooted variants being considered of their root canals. Balk J Dent Med, Vol 22, 2018 Internal Morphology of Root-Canal 147

Table 1. Number of Roots in Mandibular Second Molars in Different Populations.

Author (year) Population Sample Size 1 Root (%) 2 Roots (%) 3 Roots (%) 4 Roots (%) Gulabivala et al 20016 Burmese 134 26.9 73.1 - - Gulabivala et al 20027 Thai 60 10.0 90.0 - - Ahmed et al 20079 Sudanese 100 14.0 86.0 - - Peiris et al 200710 Sri Lankan 100 6.0 94.0 - - Rahimi et al 200811 Iran 139 9.3 86.3 4.3 - Al-Qudah & Awawdeh 20098 Jordanian 355 12.7 87.4 - - Neelakantan et al 20104 India 345 7.5 83.4 9.0 - Zhang et al 201112 Chinese 157 22.3 76.5 1.2 - Demirbuga et al 20135 Turkish 925 1.3 94.4 3.5 0.9 Silva et al 201313 Brazilian 226 9.5 87.0 3.5 - Nur et al 201414 Turkish 1165 10.0 90.0 - - Torres et al 201515 Chilean 112 8.9 86.6 3.6 0.9 Torres et al 201515 Belgian 112 14.3 83.9 0.9 0.9 Celikten et al 20163 Turkish Cypriot 421 3.5 95.7 0.4 0.2 Kim et al 20162 Korean 1920 41.2 57.4 0.7 - Akhlagi et al 201616 Iran 150 13.3 86.7 - -

Material and Methods

A total of 531 cases of root-canal treated mandibular second molars were collected. Of these cases, 182 originated from the Postgraduate Clinic of the Department of Endodontology, Dental School, Aristotle University of Thessaloniki, Greece over the period 2011-2016, and 349 from private dental clinics in the same city. The patients were adult men and women of Greek nationality. The patients’ case histories (clinical examination and intraoral periapical radiographs) were reviewed by the first three authors in order to record the prevalence of single-rooted mandibular second molars. The different root canal configurations of these teeth were categorized according to the Vertucci’s classification17 together with additional classes.

Figure 1. Representative radiographs of the different canal configurations of root-canal treated mandibular second molars. Results Types: I (a), II (b), IV (c), 2-3 (d), 3-1 (e) and 3-2 (f).

On a total of 531 mandibular second molars: Within a total of 102 single-rooted mandibular ●● 102 (19.2%) presented a single root; second molars, the following variations in the root canal ●● 427 (80.4%) presented two roots; number and course were recorded (Table 2): ●● 2 (0.4%) presented three roots; ●● 31 samples presented a single canal from the pulp chamber to the apex (Figure 1a); Table 2. Different Root Canal Configurations in Single-Rooted ●● 18 samples presented with two separate canals Mandibular Molars Recorded in the Present Study. leaving the pulp chamber but joining to form one Root Canal Type (%) canal by the apex (Figure 1b); Vertucci’s Classification Additional Types C-Shaped ●● 14 samples presented two separate canals from the Total I II IV pulp chamber to the apex (Figure 1c); (1-1) (2-1) (2-2) (2-3) (3-1) (3-2) ●● 3 samples with two separate canals from the pulp 102 31 18 14 3 1 3 32 chamber, one of which bifurcated, resulting in three (100%) (30.3%) (17.6%) (13.7%) (3.0%) (1.0%) (3.0%)(31.4%) canals at the apex (Figure 1d); 148 Maria–Elpida Kalaitzoglou et al. Balk J Dent Med, Vol 22, 2018

●● 1 tooth presented with three separate canals from the use the clearing technique to investigate the root and root pulp chamber, which, however, joined to form one to canal morphology4,6–8, whereas two are in-vivo cone- the apex (Figure 1e); beam computed tomography (CBCT) studies, which ●● 3 samples presented with three separate canals from analyzed a significantly larger sample2,5. the pulp chamber, two of which joined to form two In the present study, the Vertucci root canal canals at the apex (Figure 1f); classification was selected for the categorization of the teeth. ●● 32 samples presented a C-shaped canal system This stipulates eight basic types and is the most widely used (Figure 2a, b). categorization system for the description of possible canal configurations. In our study, Type I followed by types II and IV exhibited the greatest prevalence. In the aforementioned studies the most prevailing types were I and IV. Three additional types, not specified in the Vertucci system were also recorded in 7 teeth, which were also identified in four of the previous studies4,6–8. Moreover, Types III, V, VI, VII, VIII, 3-4, 4-2 and 5-4 are further variations which have also been recorded in the literature2,4,6–8, underlining the complexity of the possible root canal variants in single- rooted second mandibular molars. C-shaped roots and root canals are anatomical variations found mostly in mandibular second molars. This term is used to describe the presence of a fin or web between root canals which results in a C-shaped Figure 2. C-shaped mandibular second molar. Photo of the pulp chamber 18 floor (a), postoperative radiograph (b). canal cross-section . In the present study, the presence of a C-shaped root was also confirmed from the case history recordings and the clinical diagnosis, since the Discussion radiographic appearance of such teeth may be confusing. For this reason, C-shaped teeth were not categorized in The study of the information available in the terms of root canal types, as in the majority of the cases literature about single-rooted mandibular molars leads the type of C-shaped root canals changes from the cervical 19 to two basic observations. The first is that comparing the to the apical third . A limitation of this study is that the findings of different studies (Table 1), the range of the different cross-sectional root canal configurations cannot reported prevalence for these teeth is notably wide, with be visualized from radiographs, but could have been a minimum of 1.3% and a maximum of 41.2%. This could recorded with the CBCT technique. be attributed to the different methods of study, size of the C-shaped root canals are known to be common sample and nationalities. This varying prevalence between in Asians, but relatively rare amongst Europeans and different nationalities tends to increase in Chinese, Americans20. Specifically, a recent study evaluated Burmese and Korean populations2,6,12. Comparing studies the prevalence of a C-shaped anatomy in different in the literature to the findings of the present paper, the geographic regions of the world, finding the highest prevalence of single-rooted mandibular molars in a Greek prevalence in China (44%) and the lowest in Brazil population is slightly higher than the mean value of the (6.8%)21. The present paper reported 32 C-shaped teeth studies in the literature (13.2%). out of 102 single-rooted mandibular second molars, which The second observation concerns the internal corresponds to 6% of the whole sample of mandibular morphology of single-rooted mandibular second molars. second molars. This finding is compatible with another, Some studies focus on the internal anatomy of two- earlier study conducted under the auspices of the Aristotle rooted mandibular second molars, presenting possible University Dental School in a Greek population, which canal configurations of the mesial and distal roots without assessed 480 clinical records of root-canal treated providing sufficient information about the number and mandibular second molars and found a prevalence of 5% course of the root canals of the single-rooted variant9,10,15. regarding C-shaped canals in mandibular second molars22. Other studies record the number of root canals in the In summary, the findings of the present paper root system without supplying any information about underline the variations in root canal morphology of their relationship11–13. The findings of the present study single-rooted mandibular second molars. The reported are comparable to the few studies that have investigated data may help clinicians consider the possibility of the internal anatomy of single-rooted mandibular second encountering anatomical alterations in such teeth, in order molars in detail. Four of these studies are ex-vivo and to enhance the success rate of endodontic treatments. Balk J Dent Med, Vol 22, 2018 Internal Morphology of Root-Canal 149

Conclusions 13. Silva EJNL, Nejaim Y, Silva AV, Haiter-Neto F, Cohenca N. Evaluation of root canal configuration of mandibular molars One out five mandibular second molars was single- in a Brazilian population by using cone-beam computed rooted in a Greek population. The internal morphology tomography: An in vivo study. J Endod, 2013;39:849–852. 14. Nur BG, Ok E, Altunsoy M, Aglarci OS, Colak M, of these teeth can be very complex with regard to the Gungor E. Evaluation of the root and canal morphology of numbers and courses of root canals. mandibular permanent molars in a south-eastern Turkish population using cone-beam computed tomography. Eur J Dent, 2014;8:154–159. 15. Torres A, Jacobs R, Lambrechts P, Brizuela C, Cabrera References C, Concha G et al. Characterization of mandibular molar root and canal morphology using cone beam computed 1. Vertucci FJ. Root canal morphology and its relationship to tomography and its variability in Belgian and Chilean endodontic procedures. Endod Topics, 2005;10:3–29. population samples. Imaging Sci Dent, 2015;45:95–101. 2. Kim SY, Kim BS, Kim Y. Mandibular second molar root 16. Akhlaghi NM, Abbas FM, Mohammadi M, Shamlo canal morphology and variants in a Korean subpopulation. MRK, Radmehr O, Kaviani R et al. Radicular anatomy Int Endod J, 2016;49:136–144. of permanent mandibular second molars in an Iranian 3. Celikten B, Tufenkci P, Aksoy U, Kalender A, Kermeoglu F, population: A preliminary study. Dent Res J (Isfahan), Dabaj P, Orhan K. Cone beam CT evaluation of mandibular 2016;13:362–366. molar root canal morphology in a Turkish Cypriot population. Clin Oral Investig, 2016;20:2221–2226. 17. Vertucci FJ. Root canal anatomy of the human permanent 4. Neelakantan P, Subbarao C, Subbarao CV, Ravindranath M. teeth. Oral Surg Oral Med Oral Pathol, 1984;58:589–599. Root and canal morphology of mandibular second molars in 18. Fan W, Fan B, Gutmann JL, Fan M. Identification of a an Indian population. J Endod, 2010;36:1319–1322. C-shaped canal system in mandibular second molars- 5. Demirbuga S, Sekerci AE, Dinçer AN, Cayabatmaz M, Part III: Anatomic features revealed by digital subtraction Zorba YO. Use of cone-beam computed tomography to radiography. J Endod, 2008;34:1187–1190. evaluate root and canal morphology of mandibular first and 19. Fan B, Cheung GSP, Fan M, Gutmann JL, Fan W. second molars in Turkish individuals. Med Oral Patol Oral C-shaped canal system in mandibular second molars: Part Cir Bucal, 2013;18:737–744. II-Radiographic features. J Endod, 2004;30:904–908. 6. Gulabivala K, Aung TH, Alavi A, Ng YL. Root and canal 20. Kato A, Ziegler A, Higuchi N, Nakata K, Nakamura H, morphology of Burmese mandibular molars. Int Endod J, Ohno N. Aetiology, incidence and morphology of the 2001;34:359–370. C-shaped root canal system and its impact on clinical 7. Gulabivala K, Opasanon A, Ng YL, Alavi A. Root and endodontics. Int Endod J, 2014;47:1012–1033. canal morphology of Thai mandibular molars. Int Endod J, 21. Von Zuben M, Martins JNR, Berti L, Cassim I, Flynn D, 2002;35:478–485. Gonzalez JA et al. Worldwide prevalence of mandibular 8. Al-Qudah AA, Awawdeh LA. Root and canal morphology second molar C-shaped morphologies evaluated by cone- of mandibular first and second molar teeth in a jordanian beam computed tomography. J Endod, 2017;43:1442–1447. population. Int Endod J, 2009;42:775–784. 22. Lambrianidis T, Lyroudia K, Pandelidou O, Nicolaou A. 9. Ahmed HA, Abu-Bakr NH, Yahia NA, Ibrahim YE. Root Evaluation of periapical radiographs in the recongnition and canal morphology of permanent mandibular molars in a of C-shaped mandibular second molars. Int Endod J, Sudanese population. Int Endod J, 2007;40:766–771. 2001;34:458–462. 10. Peiris R, Takahashi M, Sasaki K, Kanazawa E. Root and canal morphology of permanent mandibular molars in a Sri Lankan population. Odontology, 2007;95:16–23. Received on November 8, 2017. Revised on January 2, 2018. 11. Rahimi S, Shahi S, Lotfi M, Zand V, Abdolrahimi M, Accepted on Jun 12, 2018. Es’haghi R. Root canal configuration and the prevalence of C-shaped canals in mandibular second molars in an Iranian population. J Oral Sci, 2008;50:9–13. Correspondence: 12. Zhang R, Wang H, Tian YY, Yu X, Hu T, Dummer PMH. Maria-Elpida Kalaitzoglou Use of cone-beam computed tomography to evaluate root Aristotle University of Thessaloniki and canal morphology of mandibular molars in Chinese Aggelon 4D Pefka 57010 Thessaloniki, Greece individuals. Int Endod J, 2011;44:990–999. e-mail: [email protected]

DOI: 10.2478/bjdm-2018-0026

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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA

Morphometric Analysis of Greater Palatine Canal via Cone-Beam Computed Tomography

SUMMARY Melih Özdede1, Elif Yıldızer Keriş2, Bülent Background/Aim: The morphology of the greater palatine canal (GPC) Altunkaynak3, İlkay Peker4 should be determined preoperatively to prevent possible complications in 1 Department of Dentomaxillofacial Radiology, surgical procedures required maxillary nerve block anesthesia and reduction Pamukkale University Faculty of Dentistry, of descending palatine artery bleeding. The purpose of this investigation was Denizli, Turkey to evaluate the GPC morphology. Material and Methods: In this retrospective 2 Canakkale Dental Hospital, Çanakkale, Turkey cross-sectional study, cone-beam computed tomography images obtained for 3 Department of Statistics, Gazi University various causes of 200 patients (females, 55%; males, 45%) age ranged between Faculty of Arts and Sciences, 18 and 86 (mean age±standard deviation=47±13.6) were examined. The mean Ankara, Turkey 4 Department of Dentomaxillofacial Radiology, length, mean angles of the GPC and anatomic routes of the GPC were evaluated. Gazi University Faculty of Dentistry, Results: The mean length of the GPC was found to be 31.07 mm and 32.01 mm Ankara, Turkey in sagittal and coronal sections, respectively. The mean angle of the GPC was measured as 156.16° and 169.23° in sagittal and coronal sections. The mean angle of the GPC with horizontal plane was measured as 113.76° in the sagittal sections and 92.94° in the coronal sections. The mean GPC length was longer in males than in females. Conclusions: The results of this study showed that the most common pathway of the GPC was “first inferior, and then anterior-inferior direction” in sagittal plane and “first medial-inferior, then inferior direction” in coronal plane. Key Words: Greater Palatine Canal, Anatomy, Anesthesia, Cone-Beam Computed ORIGINAL PAPER (OP) Tomography Balk J Dent Med, 2018;150-156

Introduction nerve block provides maxillary regional anesthesia due to the nerve located at the deep of the PPF2, 3, 6. Knowledge of the greater palatine canal (GPC) Maxillary nerve block anesthesia may cause many complications such as the penetration of the orbital and anatomy is very important for dentists, oral surgeons and nasal cavities, proptosis, blindness depending on the otolaryngologists. Some complications may occur during ophthalmic artery vasoconstriction, intracranial extension, several procedures such as local anesthesia in dental intravascular injection, nasopharynx penetration, neural implant placement, orthognathic and sinonasal surgery; tissue damage and lack of anesthesia3, 9. Knowledge of decreasing bleeding risk in osteotomy and fractures1-6. the anatomy, the mean length and angle of the GPC play The GPC connects the oral cavity and the pterygopalatine important roles during these procedures. The anatomical fossa (PPF), contains descending palatine artery, minor structure of the GPC can be determined by cone-beam 10 palatal nerve, major palatal nerve and its posterior inferior computed tomography (CBCT) . On the other hand, lateral nasal branches1,7. Major and minor palatal nerves clinicians’ knowledge of the GPC’s mean length and angle might be useful before the surgical procedures10. emerge on the hard palate by their foramina8. Depositing To our best knowledge, there are only three the anesthetic solution to the PPF via the major palatine published articles about the GPC morphology imaging foramen (MPF) is the most common technique for with CBCT, and no published article with previous work achievement of maxillary block. Injecting local anesthetic conducted in the Turkish population. solution into the GPC provides vasoconstriction for The aim of this retrospective study was to determine endoscopic sinus surgery2. The achievement of infraorbital the length, angle and the pathways of the GPC. Balk J Dent Med, Vol 22, 2018 Greater Palatine Canal 151

Material and Methods Anatomic pathways of the GPC were classified in sagittal sections (Figure 4) as described by Howard- The protocol of this study was approved by Ankara Swirzinski et al.10: University’s Faculty of Dentistry Clinical Research Ethics Committee (2014/36290600-109) and written informed consent was obtained from all patients. This study followed the Declaration of Helsinki on medical protocol. In total 200 CBCT images which were obtained between January 2012 and August 2012 at our Radiology Clinic, retrospectively. All evaluations were conducted by a dentomaxillofacial radiologist, approximately 50 cm away from the screen. Thirty percent of radiographic images Figure 1. Measurements of the length of the GPC in sagittal (A) and were reexamined one month later by the same observer coronal (B) sections. Elbow of the GPC was displayed by arrows. for intraobserver agreement. Inclusion criteria of the study was as follows: patients older than 18 years, no artifacts in the maxillary region which would affect the quality of the image and without any pathology in the maxillary region11. The adequacy of the sample size was statistically analyzed with power analysis and the sample size was found to be adequate (Power value = 0.958). CBCT images were obtained by ProMax 3D Mid (Planmeca Oy, Helsinki, Finland) using these exposure Figure 2. Measurements of the angle of the GPC in sagittal (A) and parameters: 90 kVp, 12 mA, scanning time of 13.85 coronal (B) sections. Elbow of the GPC was displayed by arrow. seconds and 0.4 mm voxel size. The field of views (FOVs) used were 20×10 and 20×17 cm. Scanning was performed by fixing the patient’s jaw and head support apparatus while the patient was standing. Images were examined in 24-inch Philips medical monitor with NVDIA Quadro FX 380 graphics card and 1920×1080- pixel resolution by using the original programme, Romexis® 2.7.0. (Planmeca Oy, Helsinki, Finland). Patients’ age and sex were recorded. Figure 3. Measurements of the angle of the GPC with horizontal plane in Measurements sagittal (A) and coronal (B) sections.

“On the axial view, the long axis of the incisive canal and the internal occipital protuberance were made parallel to sagittal plane and this axial section was chosen as the reference view for reconstruction of the sagittal and the coronal slices. The coronal and sagittal images were Figure 4. The GPC pathway classifications in sagittal sections. Class reconstructed as 0.4 mm slice interval/thickness. The 1: “first inferior, then anterior-inferior direction”; Class 2: “direct measurements were established on the central sagittal anterior-inferior direction”; Class 3: “first posterior-inferior, then and coronal section of the incisive canal and the internal anterior-inferior direction”. occipital protuberance. In sagittal sections, the superior limit of the GPC was ●● Class 1: “first inferior, then anterior-inferior direction” determined as anterior-inferior point of foramen rotundum ●● Class 2: “direct anterior-inferior direction” (FR); inferior limit was identified as hard palate projection ●● Class 3: “first posterior-inferior, then anterior-inferior of the MPF10. In coronal sections, the superior limit of the direction” GPC was determined as the medial-inferior point of FR, inferior limit was identified as hard palate projection of Anatomic pathways of the GPC were classified in the MPF12. The GPC length (Figure 1) and angle (Figure coronal sections (Figure 5) as described by Howard- 10 2) were measured from the canal elbow in both sagittal and Swirzinski et al. : coronal sections10. The angle between the inferior part of ●● Class a: “direct inferior direction” the GPC and horizontal line (Figure 3) was measured from ●● Class b: “first medial-inferior, then inferior direction” the canal elbow in both sagittal and coronal sections13. ●● Class c: “first inferior, then medial-inferior direction” 152 Melih Özdede et al. Balk J Dent Med, Vol 22, 2018

the age distribution is symmetric, patients included in this study were divided into three groups: 18-40 years old (N=62, 31%), 41-50 years old (N=59, 29.5%) and 51-86 years old (N=79, 39.5%). All analyzes were performed at the 95% confidence interval. Figure 5. The GPC pathway classifications in coronal sections. Class a: “direct inferior direction”; Class b: “first medial-inferior, then inferior direction”; Class c: “first inferior, then medial-inferior direction”. Results All variables were examined in the right and left sides, respectively. In total 200 patients aged between 18-86 years old (mean age ± standard deviation: 47.2 ± 13.6) and consisted of 90 male (45%) and 110 female (55%) patients were included in the study. A total of 400 canal Statistical analysis morphologies were evaluated.

Data were statistically analyzed by using SPSS for Length and angle measurements of the GPC Windows software version 19.0 (SPSS Inc., Chicago, IL, The mean lengths of 400 GPC were found to be USA). The relationship between categorical variables 31.07 mm and 32.01 mm in sagittal and coronal planes, were statistically analysed with chi-square test and respectively. The mean angles of GPC were found to be t-test and ANOVA were used for comparison of the 156.15° and 169.23°, and also the mean angles of the mean measurements. According to ANOVA test, when GPC with horizontal plane were 113.76° and 92.94°in presence of the difference between the groups, a Scheffe sagittal and coronal planes, respectively. The statistically multiple comparison test was performed to determine significant difference (p<0.05) was found between right which groups are different from each other. The length and left sides in the angle of the GPC with horizontal and angle measurements; standard deviation, minimum plane. The mean right angles of this parameter were and maximum values ​​were calculated with descriptive higher than left angles. No statistically significant analysis. Right and left measurements were compared for difference was detected between the other measurements symmetry analysis. After determining the average around of right and left sides. Details are shown in Table 1.

Table 1. Statistical analyses and comparisons of the right and left GPC measurements

Measurements Side Mean SD Minimum Maximum t P value The GPC length (sagittal) Right 31.20 3.21 24.30 43.13 (mm) Left 30.94 3.15 23.59 41.40 1.96 0.06 The GPC length (coronal) Right 32.03 3.00 24.81 40.69 (mm) Left 31.99 2.92 24.63 40.00 0.36 0.72 Angle of the GPC Right 155.96 9.40 126.11 180.00 (sagittal) (°) Left 156.35 8.43 138.16 177.00 -0.61 0.54 Angle of the GPC with Right 113.95 5.50 95.00 132.74 horizontal plane 1.15 0.25 (sagittal) (°) Left 113.57 5.73 97.22 133.00 Angle of the GPC Right 169.68 8.24 146.72 180.00 (coronal) (°) Left 168.79 9.07 142.88 180.00 1.49 0.14 Angle of the GPC with Right 93.87 5.06 85.00 113.20 horizontal plane 4.96 0.00* (coronal) (°) Left 92.01 3.98 79.92 116.06 *Statistically significant at p<0.05 level. GPC: Greater palatine canal. SD: Standart deviation

There was a statistically significant difference females and males was detected for angle measurements (p<0.05) between females and males for the GPC length. (Table 2). Furthermore, no significant measurement The mean length of the GPC was longer in males than difference (p>0.05) was found between the age groups in females. No significant difference (p>0.05) between (Table 3). Balk J Dent Med, Vol 22, 2018 Greater Palatine Canal 153

Table 2. Comparison of the measurements by gender (SD: Standard deviation)

Measurements Side Gender N Mean SD t P value Female 110 29.66 2.36 Right Male 90 33.09 3.11 -8.62 0.00* The GPC length (sagittal) (mm) Female 110 29.40 2.60 Left Male 90 32.83 2.72 -9.08 0.00* Female 110 30.57 2.51 Right Male 90 33.82 2.56 -9.01 0.00* The GPC length (coronal) (mm) Female 110 30.55 2.60 Left Male 90 33.75 2.26 -9.20 0.00* Female 110 155.81 10.31 Right Male 90 156.15 8.20 -0.26 0.80 Angle of the GPC (sagittal) (°) Female 110 156.04 8.62 Left Male 90 156.73 8.23 -0.57 0.57 Female 110 113.52 5.57 Right -1.20 0.23 Angle of the GPC with horizontal Male 90 114.46 5.41 plane Female 110 113.58 5.75 (sagittal) (°) Left Male 90 113.55 5.73 0.03 0.97 Female 110 170.29 8.05 Right Male 90 168.93 8.45 1.16 0.25 Angle of the GPC (coronal) (°) Female 110 169.35 8.96 Left Male 90 168.11 9.20 0.96 0.34 Female 110 93.95 4.76 Right 0.26 0.80 Angle of the GPC with horizontal Male 90 93.78 5.43 plane Female 110 91.64 3.41 (coronal) (°) Left Male 90 92.47 4.56 -1.47 0.14 *Statistically significant at p<0.05 level. GPC: Greater palatine canal. SD: Standart deviation 154 Melih Özdede et al. Balk J Dent Med, Vol 22, 2018

Table 3. Comparison of the measurements by the age groups (SD: Standard deviation)

Measurements Side Age groups N Mean SD F P value 18-40 years old 62 31.04 3.41 Right 41-50 years old 59 30.90 3.13 0.82 0.44 The GPC length (sagittal) (mm) 51-86 years old 79 31.55 3.12 18-40 years old 62 30.92 3.68 Left 41-50 years old 59 30.49 3.03 1.08 0.34 51-86 years old 79 31.29 2.77 18-40 years old 62 31.88 2.93 Right 41-50 years old 59 31.61 3.14 1.53 0.22 The GPC length (coronal) (mm) 51-86 years old 79 32.47 2.93 18-40 years old 62 31.90 3.08 Left 41-50 years old 59 31.61 3.06 1.11 0.33 51-86 years old 79 32.34 2.69 18-40 years old 62 154.66 7.32 Right 41-50 years old 59 156.31 10.68 0.89 0.41 Angle of the GPC (sagittal) (°) 51-86 years old 79 156.72 9.83 18-40 years old 62 155.74 8.73 Left 41-50 years old 59 155.89 8.51 0.63 0.53 51-86 years old 79 157.18 8.18 18-40 years old 62 114.96 5.73 Angle of the GPC with Right 41-50 years old 59 112.60 5.65 2.95 0.06 horizontal plane (sagittal) (°) 51-86 years old 79 114.15 5.06 18-40 years old 62 114.26 5.77 Left 41-50 years old 59 112.65 5.53 1.23 0.29 51-86 years old 79 113.70 5.82 18-40 years old 62 169.61 8.56 Right 41-50 years old 59 169.25 8.54 0.16 0.85 Angle of the GPC (coronal) (°) 51-86 years old 79 170.05 7.83 18-40 years old 62 168.70 8.81 Left 41-50 years old 59 168.81 9.78 0.01 0.99 51-86 years old 79 168.85 8.82 18-40 years old 62 93.68 4.49 Angle of the GPC with hori- Right 41-50 years old 59 94.16 5.43 0.15 0.86 zontal plane (coronal) (°) 51-86 years old 79 93.80 5.25 18-40 years old 62 91.79 3.86 Left 41-50 years old 59 92.11 3.51 0.13 0.87 51-86 years old 79 92.10 4.41 GPC: Greater palatine canal. SD: Standart deviation Classification of the GPC Pathways of the GPC in the sagittal and coronal planes are shown in Table 4. The most common pathway of the GPC was Class 1 (72.25%, N=289) in the sagittal plane and Class b (57%, N=228) in the coronal plane.

Table 4. The distribution of the GPC pathways in sagittal and coronal plane

Right GPC Left GPC Total Class N % N % N % Sagittal 1 138 69.0 151 75.5 289 72.25 2 40 20.0 34 17.0 74 18.5 3 22 11.0 15 7.5 37 9.25 Coronal a 58 29.0 68 34.0 126 31.50 b 110 55.0 118 59.0 228 57.00 c 32 16.0 14 7.0 46 11.50 Total 200 100.0 200 100.0 400 100.0 GPC: Greater palatine canal. Balk J Dent Med, Vol 22, 2018 Greater Palatine Canal 155

Class 1 was the most common pathway of all the age from other CBCT studies. Different results may have groups in sagittal plane. Class b was the most common arisen from radiological methods, the choice’s superior pathway of the all age groups in coronal plane. limit of GPC, sample size, age groups and various ethnic No statistically significant difference was found characteristics2, 20. In accordance with previous studies, between the genders for the classification of the right and the length of the GPC was found to be shorter in females left GPC in sagittal plane (p>0.05). The most common than in males12, 17, 18. pathway of the right GPC was found to be Class 1 in both In this study, the mean angles of the GPC were found females (68.2%) and males (70%). The most common to be 156° and 169° for sagittal and coronal sections, pathway of the left GPC was Class 1 in both females respectively. These results were compatible with the (80%) and males (70%). previous studies10, 13. No statistically significant difference was found The anatomic pathways of the GPC have been between the genders for the classification of right and classified by different investigators and methods. In clinical left GPC in coronal plane (p>0.05). The most common practice, injection from the MPF to the PPF might be pathway of right GPC was found to be Class 1 in both difficult, because of the anatomical variations, especially females (54.5%) and males (55.6%). The most common in coronal plane10. Wang et al. studied 100 dried skulls and pathway of left GPC was found to be Class 1 in both reported that the long axis of the GPC opened to the oral females (57.3%) and males (61.1%). cavity 90.5% anteriorly and 9.5% vertically21. In this study, the anatomical pathways of the GPC were classified as similar with Howard-Swirzinski’s study10. The GPC travelled most frequently (72.3%) in Discussion first inferior, than anterior-inferior direction in sagittal plane, it travelled most commonly (57%) in first medial- The anatomical structure of craniofacial complex inferior, than inferior direction in coronal plane. Our depends on various factors such as age, gender and race; results for the sagittal plane were compatible with its symmetry may vary from individual to individual. Head Sheikhi’s study12, conversely Howard-Swirzinski’s10. and zygomatic arch sizes of females have been reported On the other hand, our results for coronal plane were as smaller than in males. Midsagittal curvature, top third not consistent with the previous studies10, 12. These of the face, nose, eyes and palate has been shown to be differences may be explained by the selection of different statistically different between females and males14-16. superior limits of the GPC. No statistically significant In the literature, the length and anatomic pathways of difference was detected between genders and age groups the GPC have been investigated with cadaver, computed for the GPC types. tomography (CT) and CBCT studies for different This study presents a number of limitations. We populations5, 10, 17. In the previous studies, the mean investigated and classified the GPC morphology in length of the GPC was found to be between 29-40 mm; sagittal and coronal planes, not in three-dimensional the mean angle of the GPC (sagittal plane) was found classification. Another limitation of the study is the lack to be between 148°-160°; the mean angle of the GPC of palatal soft tissue thickness measurements due to (sagittal plane) with horizontal plane was found to be CBCT’s deficiency in the soft tissue imaging. Therefore, between 112°-122° 2, 5, 10, 12, 14, 19, 20. the thickness of the palatal mucosa must be added to the The superior limit of the GPC was selected as distance of the injection depth5. different anatomical points -such as FR, orbital floor, In conclusion; the mean GPC lengths were foramen sphenopalatine, infraorbital fissure, pterygoid longer in males than in females and it was found to be canal- by different authors2, 5, 10, 12, 13, 18, 19. The anesthetic approximately 31-32 mm. The mean angles of GPC were solution must be deposited to the FR level of the measured as 156° and 169°, and also its mean angles with maxillary nerve for an efficacious anesthesia5. Thus, the horizontal plane were 114° and 93° in sagittal and coronal FR was selected as the superior limit of the GPC. planes, respectively. The most common pathway of the To our best knowledge, there are only two published GPC was “first inferior, then anterior-inferior direction” articles about the GPC length via CBCT10, 12. Howard- in sagittal plane and “first medial-inferior, then inferior Swirzinski et al. evaluated the length of the GPC in direction” in coronal plane. sagittal sections of 500 patients. Superior limit of the GPC was selected as pterygoid canal and the mean length of the GPC was found to be 29 mm±3 mm10. Sheikhi et al. examined the length of the GPC in sagittal sections of Conclusions 138 patients. The superior limit of the GPC was selected as pterygoid canal and the mean length was recorded The results of this study showed that the most as 31.8 mm, no statistically significant difference was common pathway of the GPC was “first inferior, and then found between three age groups (18-24 age, 25-40 age, anterior-inferior direction” in sagittal plane and “first 41 and over age). The results of our study were different medial-inferior, then inferior direction” in coronal plane. 156 Melih Özdede et al. Balk J Dent Med, Vol 22, 2018

References 13. Hwang SH, Seo JH, Joo YH, Kim BG, Cho JH, Kang JM. An anatomic study using three–dimensional reconstruction for pterygopalatine fossa infiltration via the greater palatine 1. Apinhasmit W, Chompoopong S, Methathrathip D, canal. Clin Anat, 2001;24:576-582. Sangvichien S, Karuwanarint S. Clinical anatomy of the 14. Bigoni L, Velemínská J, Brůzek J. Three-dimensional posterior maxilla pertaining to Le Fort I osteotomy in Thais. geometric morphometric analysis of cranio–facial sexual Clin Anat, 2005;18:323-329. dimorphism in a Central European sample of known sex. 2. Douglas R, Wormald PJ. Pterygopalatine fossa infiltration Homo, 2010;61:16-32. through the greater palatine foramen: where to bend the 15. Orish CN, Didia BC. Micrometric and micrometric study needle. Laryngoscope, 2006;116:1255-1257. of sexual dimorphism in foramina of middle crania fossa of 3. Lepere AJ. Maxillary nerve block via the greater palatine adult Nigerians. Int J Morphol, 2010;28:519-524. canal: new look at an old technique. Anesth Pain Control 16. Takegosh H, Kikuchi S. An anatomic study of the horizontal Dent, 1993;2:195-197. petrous internal carotid artery: Sex and age differences. 4. Malamed SF, Trieger N. Intraoral maxillary nerve block: an Auris Nasus Larynx, 2007;34:297-301. anatomical and clinical study. Anesth Prog, 1983;30:44-48. 17. Tomaszewska IM, Kmiotek EK, Pena IZ, Średniawa 5. Methathrathip D, Apinhasmit W, Chompoopong S, M, Czyżowska K, Chrzan R, et al. Computed tomography Lertsirithong A, Ariyawatkul T, Sangvichien S. Anatomy of morphometric analysis of the greater palatine canal: a greater palatine foramen and canal and pterygopalatine fossa study of 1,500 head CT scans and a systematic review of literature. Anat Sci Int, 2014;90:287-297. in Thais: considerations for maxillary nerve block. Surg 18. Das S, Kim D, Cannon TY, Ebert CS Jr, Senior BA. High– Radiol Anat, 2005;27:511-516. resolution computed tomography analysis of the greater 6. Wong JD, Sved AM. Maxillary nerve block anaesthesia via palatine canal. Am J Rhinol, 2006;20:603-608. the greater palatine canal: a modified technique and case 19. Soto RA, Cáceres F, Vera C. Morphometry of the reports. Aust Dent J, 1991;36:15-21. greater palatal canal in adult skulls. J Craniofac Surg, 7. Erdogan N, Unur E, Baykara M. CT anatomy of 2015;26:1697-1699. pterygopalatine fossa and its communications: a pictorial 20. McKinney KA, Stadler ME, Wong YT, Shah RN, Rose review. Comput Med Imaging Graph, 2003;27:481-487. AS, Zdanski CJ, et al. Transpalatal greater palatine canal 8. Norton NS. Netter’s head and neck anatomy for dentistry. injection: Radioanatomic analysis of where to bend 2nd ed. Philadelphia: Saunders; 2012:65-106 p. the needle for pediatric sinus surgery. Am J Rhinol, 9. Sved AM, Wong JD, Donkor P, Horan J, Rix L, Curtin J, 2010;24:385-388. et al. Complications associated with maxillary nerve block 21. Wang TM, Kuo KJ, Shih C, Ho LL, Liu JC. Assessment of anaesthesia via the greater palatine canal. Aust Dent J, the relative locations of the greater palatine foramen in adult 1992;37:340-345. Chinese skulls. Acta Anat, 1998;132:182-186. 10. Howard-Swirzinski K, Edwards PC, Saini TS, Norton NS. Length and geometric patterns of the greater palatine canal Received on November 16, 2017. Revised on March 8, 2018. observed in cone beam computed tomography. Int J Dent, Accepted on Jun 25, 2018. 2010 (2010) DOI:10.1155/2010/292753. 11. Rossi M, Ribeiro E, Smith R. Craniofacial asymmetry Correspondence: in development: an anatomical study. Angle Orthod, 2003;73:381-385. 12. Sheikhi M, Zamaninaser A, Jalalian F. Length and Melih Özdede Department of Dentomaxillofacial Radiology anatomic routes of the greater palatine canal as observed Pamukkale University Faculty of Dentistry by cone beam computed tomography. Dent Res J (Isfahan), Pamukkale/Denizli/Turkey 2003;10:155-161. e-mail: [email protected]

DOI: 10.2478/bjdm-2018-0027

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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA

Electromyographic Activity Changes of Jaw-Closing Muscles in Patients with Different Occlusion Schemes after Fixed Prosthetic Restoration

SUMMARY Evangelos Ximinis1, Dimitrios Tortopidis2 Background/Aim: To investigate the electromyographic (EMG) 1 Department of Prosthodontics, School of activity changes of jaw-closing muscles in patients with different occlusion Dentistry, Aristotle University of Thessaloniki, schemes and posterior edentulous span, after the placement of teeth- Thessaloniki, Greece supported fixed partial denture (FPD). Material and Methods: The study 2 Department of Prosthodontics, School of sample consisted of 20 patients (10 men and 10 women, the mean age Dentistry, Aristotle University of Thessaloniki, being 50 years) with a posterior edentulous area that includes two missing Thessaloniki, Greece premolars or one premolar and one molar. The participants were divided into two groups with different occlusion schemes: canine-guided occlusion (CGO) and group function occlusion (GFO). The metal-ceramic FPD were fabricated according to the clinic-standardized protocol. EMG activities of masseter and anterior temporalis patients’ muscles were recorded with bipolar surface electrodes during maximal voluntary clenching. EMG evaluation was repeated twice: (T1) before the fabrication of FPD (T2) after eight weeks of FPD cementation and intraoral functioning of restoration. The data were subjected to Analysis of Variance–ANOVA within the methodological framework of the General Linear Models with Repeated Measures. The Bonferroni test was used to compare multiple mean measures. Statistical analysis was conducted with SPSS ver. 11.5. The level of significance was predefined at a=0.05. Results: Group 1 with CGO presented significantly higher levels of masseter (mean maximum EMG average before 79.36μV and 139.68μV after) and temporalis (mean maximum EMG average before 79.07μV and 149.37μV after) EMG activity after FPD placement. Group 2 with GFO also showed significantly higher levels of masseter (mean maximum EMG average before 61.57μV and 165.30μV after) and temporalis (mean maximum EMG average before 56.94μV and 133.08μV after) EMG activity after the prosthetic restoration. Conclusions: It may be concluded that fixed prosthetic restoration, in both patients with canine-guided and group function occlusion, results in increased EMG jaw-muscle activity. Key words: Electromyography, Masseter, Temporalis Anterior, Occlusion Schemes, Fixed ORIGINAL PAPER (OP) Prosthetic Restoration. Balk J Dent Med, 2018;157-162

Introduction closing muscles’ recruitment and function1,2. The number of occluding teeth and the periodontal receptors provide It has been reported that masticatory function is positive feedback to the jaw-closing muscles during dependent on the state of the dentition, particularly on mastication and, therefore, loss of posterior teeth may lead the number of posterior occlusal contacts, the type of to a reduction in masticatory efficiency and in the overall dental prosthesis replacing missing teeth and the jaw- level of muscle activity3,4,5. 158 Evangelos Ximinis, Dimitrios Tortopidis Balk J Dent Med, Vol 22, 2018

Surface electromyography (EMG) has become 25 and 60 years; unilateral absence of two posterior an important research tool for analysis the function missing teeth with an edentulous span being defined and dysfunction of jaw-closing muscles during rest, by terminal teeth; absence of painful dental problems biting and mastication, because it captures information and periodontal disease; Class I Angle’s classification about the electrical potentials of these muscles6. In of occlusion relationship; and CGO or GFO occlusion addition, surface EMG has been used for investigating scheme. In contrast, the exclusion criteria were: no signs sleep or waking-state oral parafunctional activity (i.e. and symptoms of TND or recent occlusal splint therapy; bruxism)7, muscle function and dysfunction in patients no parafunctional habits and no skeletal malocclusions. with Temporomandibular disorders (TMD)8,9,10 and the The participants were divided into two groups: Group 1, maintenance of posture11. Moreover, surface EMG has consisting of ten patients, presented a canine guidance proven to be a valuable method for studying the influence occlusal pattern (CGO) and Group 2, made up of the of occlusal conditions on jaw-muscle activity2,12, the other ten patients, presented a group function occlusal influence of occlusion scheme on a patient’s masticatory (GFO) pattern. All participants provided written informed system physiology and the effectiveness of various consent for the study, which was approved by the Ethical prosthetic treatment interventions13,14,15. It has been Committee of Aristotle University of Thessaloniki’s postulated that an increase in working-side posterior tooth School of Dentistry and observed the guidelines in contact is associated with an increase in total jaw-closing accordance with the Declaration of Helsinki. muscle activity and the magnitude of EMG activity16. Previous studies have evaluated the effect of different Experimental protocol occlusion schemes such as canine-guided occlusion All patients underwent thorough clinical examination, (CGO) and group function occlusion (GFO) on muscle and the medical and dental history of their dental and activities by masticatory muscle EMG measurements, periodontal status was taken. The metal-ceramic 4 or 5-unit however the results were inconclusive14,17,18. CGO was FPDs were fabricated in accordance with the restorative defined as “a mutually protected articulation, in which procedures of the clinic-standardized protocol applied the horizontal and vertical overlap of the canine teeth by the Aristotle University of Thessaloniki, School of disclude the posterior teeth in the excursive movements of Dentistry, Fixed Prosthesis and Implant Prosthodontics 21,22,23 the mandible”19. On the other hand, GFO was described clinic . The fixed prosthetic restorations were as “the existence of multiple contact relations between provisionally cemented for a week for an intraoral the maxillary and mandibular teeth in lateral movement inspection before permanent cementation. The number on the working side”19. There is no sufficient scientific and position of patients’ anterior and posterior occlusal evidence to suggest that a CGO is better or worse than contact sites were recorded in the maximum intercuspation a GFO, either from a functional or from an EMG point position, before and after the placement of FPD, by using of view17,20. It seems that jaw-closing muscles were both 40μm-thick articulating paper (Bausch articulating influenced by the occlusion scheme in a different way, papers, Inc. Nashua, NH 03060, USA) and 8μ metal-foil with the anterior temporalis muscle being the most Shimstocks (Hanel, Roeko, D-89122 Langenau, Germany). affected20. Electromyographic (EMG) recordings were Thus, the aim of the present study was to investigate obtained from the left and right masseter and anterior the EMG activity changes of jaw-closing muscles in temporalis muscle bilaterally using surface bipolar, self- patients with different occlusion schemes and posterior adhesive and pre-gelled electrodes (FIAT Spa, Torino, edentulous span, after the placement of teeth-supported Italy) with an inter-electrode distance of 20mm. Bipolar fixed partial denture (FPD). electrode configuration was used in every case, with a ground electrode being placed below the earlobe. For the purpose of recording EMG activity of the superficial masseter muscle, the electrodes were placed parallel to the Material and Methods exocanthion-gonion line over the lower anterior part of the main belly of the muscle determined by palpation24,25,26. Study sample For the anterior temporalis, the electrodes were positioned vertically about 1cm above the zygomatic arch and 1.5cm Twenty volunteers (20 men and 20 women, the behind the orbital oris24,25,27. A detailed description of the mean age being 50±3.5years) having reported 2 missing method is given in a previous study26. EMG evaluation posterior teeth in one sextant (two premolars or one was repeated twice: (T1) before the fabrication of FPD premolar and one molar) as their main complaint to the and (T2) eight weeks after permanent cementation and Clinic of Fixed Prosthesis and Implant Prosthodontics, intraoral functioning of FPD . School of Dentistry, Aristotle University of Thessaloniki, The EMG recording instrument (Myotronics- were selected to participate in this study. The inclusion Noromed, Inc., Seattle, WA, USA) consisted of an criteria were: a history of good health and age between isolated preamplifier with an input impedance>100MΩ, Balk J Dent Med, Vol 22, 2018 Electromyographic Activity of Jaw-Closing Muscles 159 a differential main amplifier and computerized integrated Results system K6-I (K6-1/EMG hardware and software for eight channel surface EMG) connected to a compatible PC The results of the EMG recordings of the masseter computer for data storage and analysis. and anterior temporalis muscle, and specifically the mean The participants were seated upright in a dental chair value of peak and average for the side where the FPD with the Frankford plane parallel to the floor in a specially was placed (P), as well as for the opposing side (N), for modified clinic. Each subject was asked to clench as both groups (CGO and GFO) and for two time points of hard as possible on 9mm cotton rolls placed between recordings (T1 and T2), are presented below. The level of the maxillary and mandibular posterior teeth at least 3 significance was predefined at a=0.05. times for about 3s. EMG measurements during subject’s Mean maximum EMG Peak and Average (and maximum voluntary clenching were performed by a single Standard error-SE) of the masseter muscle (on the P-side operator who was blind to the patient’s group. with missing teeth, before and after FPD placement) for In each EMG recording the variables examined were both groups (CGO and GFO) are shown in Table 1. A the peak and the average EMG activity of the muscles statistically significant difference in mean EMG activity in each of the three clenches at maximum voluntary contraction. The data (EMG peak and average from the (peak and average) was found for the masseter muscle in four tested muscles) processed for statistical analysis two groups (CGO and GFO) between T1-T2. were the mean of the three values obtained from the three clenches for the masseter and temporalis muscles Table 1. Presents the mean maximum EMG Peak & corresponding to the side with FPD placement (Peak- Average (μV) and Standard error (SE) of the masseter muscle M-P, Average-M-P, Peak-T-P, Average-T-P), and the mean for the P-side with missing teeth before (T1) and after FPD value of the three clenches for the masseter and temporalis placement (T2) for both groups (CGO and GFO) muscles corresponding to the opposing side with natural EMG peak EMG average dentition (Peak-M-N, Average-M-N, Peak-T-N, Average- + + T-N). The side having received the fixed dental prosthesis Occlusion T1 T2 P T1 T2 P 154.57 239.82 79.36 139.68 appears as P, while the opposing side with natural dentition CGO 0.002 <0.001 ±25.32 ±32.74 ±13.20 ±21.44 appears as N. These constituted the comparable data on the 123.00 307.05 61.57 165.30 GFO <0.001 <0.001 EMG recordings resulting from the three EMG recordings ±25.32 ±32.74 ±13.20 ±21.44 of each patient, in two different sessions (T1, T2). P* 0.330 0.164 0.353 0.409 Statistical method * P-value for between groups’ comparisons The experimental design is considered to be mixed + P-value for within groups’ comparisons factorial with one factor between subjects and one factor within subjects, as far as the parameters of EMG activity Mean maximum EMG Peak and Average (and (peak and average) of the jaw-closing muscles are Standard error-SE) of the masseter muscle (on the N-side concerned (masseter and temporalis muscles for the side without missing teeth, before and after FPD placement) with fixed dental prosthesis (P) and for the opposing side for both groups (CGO and GFO) are shown in Table 2. with natural teeth (N)). A significantly higher mean EMG activity (peak and The two-level occlusion scheme (canine-guided average) of the N-side of the masseter muscle was found occlusion (CGO) and group function occlusion (GFO)) after the fixed prosthetic restoration in both groups (CGO constituted the “between” factor, while the two-level time and GFO). factor ((T1) before the fabrication of FPD and (T2) after eight weeks of FPD cementation and intraoral functioning of restoration) constituted the “within” factor. The Table 2. Presents the mean maximum EMG Peak & Average experimental data were subjected to Analysis of Variance (μV) and Standard error (SE) of the masseter muscle for the N- side without missing teeth before (T1) and after FPD placement (ANOVA) within the methodological framework of the (T2) for both groups (CGO and GFO) General Linear Model with Repeated Measures. The Bonferroni test was applied for multiple comparisons of EMG peak EMG average mean values and contrasts. Occlusion T1 T2 P+ T1 T2 P+ Testing the homogeneity of both groups of patients in 169.20 239.90 93.82 167.22 CGO 0.011 <0.001 terms of age and EMG activity of the masseter and anterior ±29.05 ±32.75 ±18.31 ±22.56 136.00 307.10 73.35 138.82 temporalis muscles at the first time point (T1), before the GFO <0.001 0.001 application of the FPD, was conducted using t-test. ±29.05 ±32.75 ±18.31 ±22.56 * Statistical analyses were conducted using SPSS P 0.430 0.164 0.440 0.385 software v.11.5. The level of significance was predefined * P-value for between groups’ comparisons at a=0.05. + P-value for within groups’ comparisons 160 Evangelos Ximinis, Dimitrios Tortopidis Balk J Dent Med, Vol 22, 2018

Mean maximum EMG Peak and Average (and study have shown that there was a significant increase in Standard error-SE) of the anterior temporalis muscle the EMG activity of the masseter and anterior temporalis (on the P-side with missing teeth, between T1-T2) for muscles eight weeks after the completion of teeth- both groups (CGO and GFO) are presented in Table 3. supported FPD in both groups (Group 1 with CGO and A statistically significant difference was reported in Group 2 with GFO) (Tables 1, 2, 3, 4). the EMG activity (peak & average) of the P-side of the Surface EMG is a simple, non-invasive, sensitive temporalis muscle in the CGO and GFO groups, between method for the analysis of jaw-closing muscle function T1-T2. before and after various dental treatment interventions; for this reason prosthodontics, orthodontics and oral physiology have been the main fields of EMG Table 3. Presents the mean maximum EMG Peak & Average application6,15,28,29. The masseter and anterior temporalis (μV) and Standard error (SE) of the anterior temporalis muscle for the P-side with missing teeth before (T1) and after FPD muscles have been the most examined masticatory placement (T2) for both groups (CGO and GFO) muscles because of their ease of accessibility to surface- electrode recordings30,31. EMG measurement reliability EMG peak EMG average was found to be dependent on various factors such as Occlusion T1 T2 P+ T1 T2 P+ electrode type and location, impedance of the skin, 146.48 270.38 79.07 149.37 6,8,32 CGO 0.001 <0.001 subcutaneous fat and depth of the muscle under study . ±25.94 ±30.74 ±13.65 ±19.40 However, the use of standardized and repeatable 115.76 234.14 56.94 133.08 GFO <0.001 <0.001 protocols eliminates such factors and makes EMG signals ±25.94 ±30.74 ±13.65 ±19.40 measurement reliable as well as clinically useful33,34. P* 0.413 0.416 0.267 0.560 In regard to EMG muscle recording, a static analysis, * P-value for between groups’ comparisons such as maximum voluntary clench on cotton rolls, was + P-value for within groups’ comparisons proffered in the present study as it represents the simplest and best described oral task. It has been suggested that Mean maximum EMG Peak and Average (and with this mouth opening space, an ideal sarcomere length Standard error-SE) of the anterior temporalis muscle (on of 3μm is provided for the maximal force of muscle the N-side without missing teeth, before and after FPD contraction35,36, although other studies report the figure placement) for both groups (CGO and GFO) are presented to be 2.27 – 2.55μm37. Additionally, it has been reported in Table 4. A significantly higher mean EMG activity that a patient’s masseter and temporalis muscles contract (peak and average) of the N-side of the anterior temporalis similarly when clenching either with cotton rolls or in the muscle was found after the fixed prosthetic restoration in maximum intercuspation position38,39. both groups (CGO & GFO). The association of surface EMG activity and occlusion alterations has been reported in several studies, however Table 4. Presents the mean maximum EMG Peak & Average heterogeneous data emerge from the literature12,40,41. (μV) and Standard error (SE) of the anterior temporalis muscle A modification in the occlusion parameters and pattern for the N-side without missing teeth before (T1) and after FPD may indicate changes in surface EMG characteristics12. placement (T2) for both groups (CGO and GFO) The recruitment of the jaw-closing muscles changes EMG peak EMG average markedly depending on the number and position of 40 Occlusion T1 T2 P+ T1 T2 P+ occlusal contacts . The findings of the present study are 131.30 250.43 0.004 72.06 142.65 <0.001 in agreement with previous investigations on the jaw- CGO ±20.45 ±31.24 ±12.22 ±19.61 closing muscles, which have shown that subjects with 116.80 195.84 0.010 68.77 111.14 0.010 higher occlusal stability present larger EMG activity during GFO ±20.45 ±31.24 ±12.22 ±19.61 maximum clenching15,42,43. This might be because a higher P* 0.622 0.233 0.851 0.271 number of posterior contacts provides a stable occlusal * P-value for between groups’ comparisons support in the intercuspal position, which allows jaw-closing + P-value for within groups’ comparisons muscles to achieve higher levels of muscular activity during clenching and chewing42. This study demonstrated that the muscular activity of masseter and temporalis muscles in both groups (Group 1 with CGO and Group 2 with GFO) Discussion was improved by increasing the EMG activity of both sides after teeth-supported FPD placement (Tables 1,2,3,4). In the current investigation, masseter and anterior The results of this investigation are in line with previous temporalis EMG activity changes in patients with findings showing that the number of replaced missing different occlusion schemes were analyzed and compared, natural teeth and their position in the dental arch, the design after fixed prosthetic restoration of their posterior and type of conventional dental prosthesis or implant- unilateral edentulous span. The findings of the present supported prostheses could positively influence jaw- Balk J Dent Med, Vol 22, 2018 Electromyographic Activity of Jaw-Closing Muscles 161 closing muscle activity during clenching and, by extension, EMG activity resulting from the restoration of dental masticatory function15,44,45,46,47. It seems that the change occlusion is possibly related to a new neuromuscular in neuromuscular pattern and EMG activity is modified by pattern that was induced in both groups within the continuous sensory feedback from the state of the dentition, well-regulated, balanced occlusal contacts between the the balanced occlusal contacts between the opposite sides opposite sides. and other sensory inputs from the periodontal ligaments and The findings suggest that both occlusal schemes can bilateral temporomandibular joints. be used for the fixed prosthetic restoration of patients with Harmonious canine-guided occlusion and group a posterior edentulous area in one sextant. function occlusion have been described in the literature as being clinically acceptable elements of a functional occlusion20. 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Shupe RJ, Mohamed SE, Christensen LV, Finger IM, Weinberg R. Effects of occlusal guidance on jaw muscle activity. J Prosthet Dent, 1984;51:811-818. 14. Akören AC, Karaağaçlioğlu L. Comparison of the Conclusions electromyographic activity of individuals with canine guidance and group function occlusion. J Oral Rehabil, Within the limitations of this clinical study, it may 1995;22:73-77. 15. Tartaglia GM, Testori T, Pallavera A, Marelli B, Sforza be concluded that fixed prosthetic restoration and more C. Electromyographic analysis of masticatory and neck posterior occlusal contacts, in both patients with canine- muscles in subjects with natural dentition, teeth-supported guided and group function occlusion, results in increased and implant-supported prostheses. Clin Oral Implants Res, EMG jaw-muscle activity. It seems that the change in 2008;19:1081-1088. 162 Evangelos Ximinis, Dimitrios Tortopidis Balk J Dent Med, Vol 22, 2018

16. Okano N, Baba K, Akishige S, Ohyama T. The influence of 36. Manns A, Miralles R, Palazzi C. EMG, bite force, and altered occlusal guidance on condylar displacement. J Oral elongation of the masseter muscle under isometric voluntary Rehabil, 2002;29:1091-1098. contractions and variations of vertical dimension. J Prosthet 17. Belser US, Hannam AG. The influence of altered working- Dent, 1979;42:674-682. side occlusal guidance on masticatory muscles and related 37. Van Eijden TM, Raadsheer MC. Heterogeneity of fiber and jaw movement. J Prosthet Dent, 198;53:406-413. sarcomere length in the human masseter muscle. Anat Rec, 18. Okano N, Baba K, Igarashi Y. Influence of altered occlusal 1992;232:78-84. guidance on masticatory muscle activity during clenching. J 38. Botelho AL, Melchior Mde O, da Silva AM, da Silva Oral Rehabil, 2007;34:679-684. MA. Electromyographic evaluation of neuromuscular 19. Ferro KJ. The glossary of prosthodontic terms. J Prosthet coordination of subject after orthodontic intervention. Dent, 2005;94:10-92. Cranio, 2009;27:152-158. 20. Abduo J, Tennant M. Impact of lateral occlusion schemes: A 39. Forrester SE, Presswood RG, Toy AC, Pain MT. Occlusal systematic review. J Prosthet Dent, 2015;114:193-204. measurement method can affect SEMG activity during 21. Shillingburg HT et al. Fundamentals of fixed th occlusion. J Oral Rehabil, 2011;38:655-660. prosthodontics. 4 Edition Chichago: Quintessence 40. Mac Donald JW, Hannam AG. Relationship between Publishing, 2012; pp:5-150. occlusal contacts and jaw-closing muscle activity during 22. Goodacre CJ, Campagni WV, Aquilino SA. Tooth tooth clenching: Part I. J Prosthet Dent, 1984;52:718-728. preparations for complete crowns: an art form based on 41. Ferrario VF, Serrao G, Dellavia C, Caruso E, Sforza C. scientific principles. J Prosthet Dent, 2001;85:363-376. Relationship between the number of occlusal contacts and 23. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed masticatory muscle activity in healthy young adults. Cranio, Prosthodontics. 4th ed. St. Louis: Mosby; 2006; pp:209-285. 2002;20:91-98. 24. Yemm R. The orderly recruitment of motor units of the masseter and temporal muscles during voluntary isometric 42. Bakke M. Mandibular elevator muscles: physiology, contraction in man. J Physiol, 1977;265:163-174. action, and effect of dental occlusion. Scand J Dent Res, 25. Roy SH, De Luca CJ, Schneider J. Effects of electrode 1993;101:314-331. location on myoelectric conduction velocity and median 43. Kerstein RB. Combining technologies: a computerized frequency estimates. J Appl Physiol, 1986;61:1510-1517. occlusal analysis system synchronized with a computerized 26. Georgiakaki I, Tortopidis D, Garefis P, Kiliaridis S. electromyography system. Cranio, 2004;22:96-109. Ultrasonographic thickness and electromyographic activity 44. Haraldson T, Carlsson GE, Ingervall B. Functional state, of masseter muscle of human females. J Oral Rehabil, bite force and postural muscle activity in patients with 2007;34:121-128. osseointegrated oral implant bridges. Acta Odontol Scand, 27. Ferrario VF, Sforza C. Coordinated electromyographic activity 1979;37:195-206. of the human masseter and temporalis anterior muscles during 45. Jacobs R, van Steenberghe D. Masseter muscle fatigue mastication. Eur J Oral Sci, 1996;104:511-517. during sustained clenching in subjects with complete 28. Hugger A, Hugger S, Schindler HJ. Surface dentures, implant-supported prostheses, and natural teeth. J electromyography of the masticatory muscles for Prosthet Dent, 1993;69:305-313. application in dental practice. Current evidence and future 46. Bersani E, Regalo SC, Siessere S, Santos CM, Chimello DT, developments. Int J Comput Dent, 2008;11:81-106. De Oliveira RH, Semprini M. Implant-supported prosthesis 29. Wozniak K, Piatkowska D, Lipski M, Mehr K. Surface following Brånemark protocol on electromyography of electromyography in orthodontics - a literature review. Med masticatory muscles. J Oral Rehabil, 2011;38:668-673. Sci Monit, 2013;19:416-423. 47. von der Gracht I, Derks A, Haselhuhn K, Wolfart S. 30. Svensson P, Graven-Nielsen T. Craniofacial muscle pain: EMG correlations of edentulous patients with implant review of mechanisms and clinical manifestations. J Orofac overdentures and fixed dental prostheses compared to Pain, 2001;15:117-145. conventional complete dentures and dentates: a systematic 31. Suvinen TI, Kemppainen P. Review of clinical EMG studies review and meta-analysis. Clin Oral Implants Res, related to muscle and occlusal factors in healthy and TMD 2017;28:765-773. subjects. J Oral Rehabil, 2007;34:631-644. 48. Wood WW, Tobias DL. EMG response to alteration of tooth 32. Lund JP, Widmer CG. Evaluation of the use of surface contacts on occlusal splints during maximal clenching. J electromyography in the diagnosis, documentation, and Prosthet Dent, 1984;51:394-396. treatment of dental patients. J Craniomandib, 1989;3:125-137. 33. Suvinen TI, Malmberg J, Forster C, Kemppainen P. Postural Received on September 28, 2017. and dynamic masseter and anterior temporalis muscle Revised on November 2, 2017. EMG repeatability in serial assessments. J Oral Rehabil, Accepted on May 12, 2018. 2009;36:814-820. 34. Sforza C, Rosati R, De Menezes M, Musto F, Toma M. EMG analysis of trapezius and masticatory muscles: Correspondence: experimental protocol and data reproducibility. J Oral Evangelos Ximinis Rehabil, 2011;38:648-654. Department of Prosthodontics 35. Walker SM, Schrodt GR. I segment lengths and thin School of Dentistry, Aristotle University of Thessaloniki filament periods in skeletal muscle fibres of the Rhesus Thessaloniki, Greece monkey and human. Anatomical Record, 1973;178:63-82. e-mail: [email protected], [email protected]

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Stafne Bone Defect in Anterior Mandible

SUMMARY Gülay Altan, Sabri Cemil İşler, İlknur Özcan Backround/Aim: Stafne bone cavity which is also known as lingual Department of Oral and Maxillofacial Radiology, mandibular bone defect is generally seen in the posterior region of the Faculty of Dentistry, Beykent University, mandible. Stafne bone defects of the anterior mandible are very rare, with Istanbul, Turkey around 50 cases reported in the English literature. They are generally asymptomatic and incidental lesion findings may be diagnosed during a radiographic examination. Case Report: A 59 year-old female patient was examined for dental complaints. Panoramic radiography revealed a unilocular lesion at the left incisor- premolar area. Dental volumetric tomography scans showed a concavity at the lingual side of the related area. Magnetic resonance imaging was suggested for possible soft tissue pathology and, depending on MRI finding, the cavity was initially diagnosed as Stafne bone defect. Conclusion: The aim of this case report is to describe an unusually located Stafne bone cavity with special emphasis to the need of using special imaging modalities. Key words: Stafne Bone Cavity, Anterior Mandible, Cone Beam Computed Tomography, CASE REPORT (CR) Magnetic Resonance Balk J Dent Med, 2018;163-166

Introduction not advocated for the treatment of anterior or posterior SBD. Surgical intervention or biopsy should be performed Stafne bone defect (SBD) which is also called Stafne in atypical cases or in the presence of other suspected bone cyst or cavity, mandibular salivary gland inclusion, lesions6. lingual mandibular bone cavity or aberrant salivary The aim of this report is to present a case with gland; was first described by Edward Stafne at 1942 1. unusually located SBD with special emphasis to the These defects are generally asymptomatic unilocular radiographic features, differential diagnosis and the use of radiolucent areas with cortical borders, located at the imaging modalities. angle of the mandible below the mandibular canal1,2. It appears as a well-corticated radiolucency that retains a normal trabecular pattern internally3. SBD is mostly observed in males between 50-70 years old; the anterior Case Report variant, which is located in the premolar and canine region, is a rare occurrence1,2,4. Incidence of the anterior A 59-years-old female patient was referred to the bone defects are reported to be between 0.009-0.48% in Department Oral and Maxillofacial Radiology, Faculty of the literature1. Although aetiology of SBD is unknown, it Dentistry, Istanbul University, for an assessment of dental is also suggested that the main cause of SBDs might be complaints and the pain on the left side of the mandible. alterations in the trabecular bone pattern due to ischemia5. The patient’s medical history revealed mild hypertension, Such bone cavities in the anterior mandible are rare gastric ulcer, seronegative arthritis and postmenopausal therefore, it may be difficult to diagnose and to rule out osteoporosis. She also stated that she was using 70 mg other radiolucent lesions, such as traumatic and cystic once a week alendronic acid per oral (Fosavance, Merck lesions or tumours of the jaw6,7. Surgical intervention is Sharp&Dohme, Haarlem, Holland) for the last ten years. 164 Gülay Altan et al. Balk J Dent Med, Vol 22, 2018

Extra-oral head and neck examination was normal. A thorough physical examination revealed no facial asymmetry, swelling or lymphadenopathy. Therefore, infection was not considered. Intraoral examination revealed gingivitis, bacterial plaque accumulation, multiple metal fused porcelain bridge and partial denture at the lower jaw and complete denture at the upper jaw. During palpation at the lingual plate no concavity/ convexity was detected. The panoramic radiograph (Kodak 8000 Digital Figure 1. Patient’s panoramic radiography, revealing a radiolucent area between left incisor and premolar region Panoramic System, France) was taken (parameters of the device were Kv: 68, mA: 5 and s: 13.2); it showed In an attempt to rule out possible Stage 0 BRONJ unilocular periapical radiolucency between the apices and to examine the lesion, it was decided to perform a between left incisor and premolar teeth and in front of the CBCT dental volumetric tomography (Vatech Pax - Flex left mental foramen. Also the radiolucency was observed 3D, 2013, Korea) Parameters of the device were Kv:89 as it was related with the apices of left incisor-premolar mA: 5 s:12 FOV: 5*10. Cross-sectional and axial images teeth. During palpation at the lingual plate, patient had showed a concavity at lingual side of the mandible and no pain in the related area (Figure 1). radiolucent area at a cancellous region (Figure 2 & 3).

Figure 2. Cross-sectional images showing the lingual concavity at the related area

Figure 3. Axial tomographic slice showing the lingual concavity of the Figure 4. Axial T2-weighted magnetic resonance imaging (MRI) mandible revealing the isointense structure with salivary gland Balk J Dent Med, Vol 22, 2018 Stafne Bone Defect 165

is related to root apices on the panoramic radiography, it can mimic an odontogenic cyst. The presence of caries and changes or absence in the lamina dura of the teeth adjacent to the lesion may give the clinician clues for the accurate diagnosis. To avoid an unnecessary endodontic treatment, a pulp vitality test should be performed8,9. Lateral periodontal cysts are considered to originate from epithelial rests in periodontium lateral to the tooth, in a unilocular appearance. Lateral periodontal cysts are generally asymptomatic and present a round or oval uniform lucency with well-defined borders radiographically7,10. The traumatic bone cyst, belongs to the category of ‘pseudo-cyst’ due to its lack of a lining epithelial membrane11. Traumatic or simple bone cysts mostly appear to be scalloped between the roots of the teeth. Scalloped appearance can be distinguished from other lesions7. Ameloblastomas are benign odontogenic neoplasms of epithelial origin and represent about 12 Figure 5. Sagittal T1-weighted magnetic resonance imaging revealing 10% of odontogenic tumours . The unilocular type of isointense structure with salivary gland ameloblastoma can mimic SBDs in the anterior region of the jaws. In addition, root displacement, resorption and expansion of the jaws can be observed7,12,13. Displacement MRI (GE Signa HDe 1.5T, 2007 US.) was of teeth, painless swelling and expansion of bone can recommended for possible soft tissue pathology. potentially be caused by giant cell granulomas. Some of Depending on T1 and T2-weighted magnetic resonance the panoramic radiography signs can be bone destructions, imaging, soft tissue signal intensity was equivalent 7,12 to that of salivary glands (Figures 4 & 5). Analysis of divergence of roots and resorption of the lamina dura . this reference, revealed normal glandular tissue, thus Other lesions that can mimic SBDs are neurofibroma, confirming the diagnosis of SBD. arteriovenous fistulas, brown tumours, eosinophilic Patient was informed about the lesion which didn’t granulomas, central haemangiomas, multiple myeloma 7,13 need surgical intervention and was called for routine and bone metastasis . follow-up for 6 months. Panoramic radiography is a 2-dimensional method and may be insufficient to distinguish concavities from intraosseous lesions. Multi-planar imaging techniques like CBCT, CT and MRI can be used to identify SBDs but due Discussion to high dose and cost of CT examination, CBCT seems to be valuable option for detecting bony defects8. Especially SBDs are generally asymptomatic, unilateral, in atypical cases with anterior location, CBCT and MRI 8 oval shaped lesions that are diagnosed accidentally on imaging are recommended . In the present case, both pain panoramic radiographs. They are often located at the at the relevant area and anterior location of the lesion, posterior mandible below the mandibular canal1,2,7. Just a CBCT and MRI were performed to rule out possible few cases with pain at relevant area were reported before1. other pathologies. MRI proton density and T1-weighted SBDs located in the anterior area of the mandible are rare images may be used for examining the soft tissue lining and they were observed in premolar-canine region1,2,4. the cavity whether isointense of the lesion equivalent to SDBs may be either empty or may contain blood vessels, that of the salivary gland7,14,15. MRI has the advantages connective tissue fat, lymphoid tissue, muscle and salivary such as not using any ionizing radiation, and the ability gland1,8. The aetiology of the SDBs is still unknown of imaging the soft tissue detail that may line the cavity8. but some theories are present in literature. Pressure of It’s main disadvantages are the cost and field distortion the salivary gland tissue, remains of solitary bone cysts, artefacts from dental material7,16. Accurate visualization localized relative ischemia are some of the theories to of these tissues is obtained with a 1.0-mm slice thickness, explain SDB’s aetiology1. provided an sufficient quantity of saliva is present7,14,17. Differential diagnosis includes odontogenic cysts, MRI revealed the isointense structure with salivary gland lateral periodontal cysts, traumatic bone cyst, eosinophilic in the present case. Due to salivary gland presence in the granuloma, ameloblastoma, central giant cell granuloma, cavity, salivary glands pressure may be a reason for the benign tumours and bone metastasis7,8. If the bone cavity SBD in this case. 166 Gülay Altan et al. Balk J Dent Med, Vol 22, 2018

Unlike other lesions, SBDs have been observed 9. Griffa A, Zavattero E, Passalacqua F, Berrone S. Anterior anatomically. Radiologic diagnosis by use of different stafne bone defect mimicking an odontogenic cyst. J techniques such as CBCT and MRI with routine clinical Craniofac Surg, 2014;25:1126-1128. follow-up, would be more conservative than surgical 10. Meseli SE, Agrali OB, Peker O, Kuru L. Treatment of intervention or biopsy7,18. In our case, both MRI and lateral periodontal cyst with guided tissue regeneration. Eur CBCT images revealed no pathology at the related area; J Dent, 2014;8:419-423. therefore, surgery was not considered. 11. Surej Kumar LK, Kurien N, Thaha KA. Traumatic bone cyst of mandible. J Maxillofac Oral Surg, 2015;14:466-469. 12. Scholl RJ, Kellett HM, Neumann DP, Lurie AG. Cysts and cystic lesions of the mandible: Clinical and radiologic- Conclusions histopathologic review. Radiographics, 1999;19:1107-1124. 13. Wakoh M, Harada T, Inoue T. Follicular/desmoplastic Stafne bone defects in the anterior mandible are very hybrid ameloblastoma with radiographic features of concomitant fibro-osseous and solitary cystic lesions. rare; therefore, a radiolucency at the anterior mandible Oral Surg Oral Med Oral Pathol Oral Radiol Endod, could be difficult to diagnosed and rule out other 2002;94:774-780. pathologies. For that reason, a diagnosis of SBD should 14. Smith MH, Brooks SL, Eldevik OP, Helman JI. Anterior also be taken into consideration when a radiolucency at mandibular lingual salivary gland defect: A report of a the anterior mandible was observed. case diagnosed with cone-beam computed tomography and magnetic resonance imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007;103:e71-78. 15. Yousem DM, Kraut MA, Chalian AA. Major salivary gland References imaging. Radiology, 2000;216:19-29. 16. Taysi M, Ozden C, Cankaya B, Olgac V, Yildirim S. Stafne 1. Sekerci AE SY, Etoz M, Aksu Y. Aberrant location of bone defect in the anterior mandible. Dentomaxillofac salivary gland inclusion: Report of a case with review of the Radiol, 2014;43:20140075. literature. Eur J Rad Extra, 2011;79:27-31. 17. Morimoto Y, Tanaka T, Tominaga K, Yoshioka I, Kito 2. Shimizu M, Osa N, Okamura K, Yoshiura K. Ct analysis of the stafne’s bone defects of the mandible. Dentomaxillofac S, Ohba T. Clinical application of magnetic resonance Radiol, 2006;35:95-102. sialographic 3-dimensional reconstruction imaging and 3. Solomon LW, Pantera EA Jr, Monaco E, White SC, Suresh magnetic resonance virtual endoscopy for salivary gland L. A diagnostic challenge: Anterior variant of mandibular duct analysis. J Oral Maxillofac Surg, 2004;62:1237-1245. lingual bone depression. Gen Dent, 2006;54:336-340. 18. Philipsen HP, Takata T, Reichart PA, Sato S, Suei Y. 4. de Courten A, Kuffer R, Samson J, Lombardi T. Anterior Lingual and buccal mandibular bone depressions: A review lingual mandibular salivary gland defect (stafne defect) based on 583 cases from a world-wide literature survey, presenting as a residual cyst. Oral Surg Oral Med Oral including 69 new cases from Japan. Dentomaxillofac Pathol Oral Radiol Endod, 2002;94:460-464. Radiol, 2002;31:281-290. 5. Lello GE, Makek M. Stafne’s mandibular lingual cortical defect. Discussion of aetiology. J Maxillofac Surg, Received on September 5, 2017. 1985;13:172-176. Revised on November2, 2017. 6. Dereci O, Duran S. Intraorally exposed anterior stafne bone Accepted on October 12, 2017. defect: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol, 2012;113:e1-3. 7. Turkoglu K, Orhan K. Stafne bone cavity in the anterior Correspondence: mandible. J Craniofac Surg, 2010;21:1769-1775. Gülay Altan 8. Schneider T, Filo K, Locher MC, Gander T, Metzler P, Department of Oral and Maxillofacial Radiology Gratz KW et al. Stafne bone cavities: Systematic algorithm Faculty of Dentistry, Beykent University for diagnosis derived from retrospective data over a 5-year Istanbul, Turkey period. Br J Oral Maxillofac Surg, 2014;52:369-374. e- mail: [email protected]

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Conservative Management of Displaced Horizontal Root Fracture in Vital Maxillary Premolar: a Case Report

SUMMARY Sheikh Bilal Badar1, Robia Ghafoor1, 1 2 Background/Aim: The management of horizontal root fracture is not Muhammad Hasan Hameed , Natasha Anwer straight forward. It depends upon the location of the fracture, mobility and 1 Dental section, Department of Surgery, Aga vitality of fractured tooth segment. The goal of treatment is to restore the Khan University Hospital, Karachi, Pakistan shape and function of affected tooth. Case report: This following case report 2 Dental section, Jinnah Medical and Dental described the conservative management of horizontal root fracture which College, Karachi, Pakistan was also displaced but somehow maintained its vitality. The affected tooth was initially stabilized and followed up in the subsequent appointments for evaluation of vitality that turned out to be vital, thus, preventing any unnecessary intervention. Conclusions: Horizontal root fractures in the vital teeth should be initially managed conservatively and every effort should be made to preserve the vitality of tooth. Key words: Horizontal Root Fracture, Vital Tooth, Conservative Management, Displaced CASE REPORT (CR) Fracture, Splint Balk J Dent Med, 2018;167-170

Introduction fragment is displaced the initial management comprise of repositioning the fractured fragments, followed Root fractures constitute 0.5–7% among all dental by stabilization to allow healing of the surrounding traumatic injuries and horizontal root fractures comprise periodontal tissues2. The decision to perform endodontic only 3% of all dental injuries1, 2. Horizontal root fracture procedure should be deferred till the assessment of tooth (HRF) can occur at coronal, middle or apical third but vitality on the subsequent visits till the signs of necrotic 7, 8 mostly occurred in the middle third of the root3. HRF tooth appears . presents a diagnostic and treatment challenge for the The purpose of the case report is to present a case in endodontist3. Clinically, root fracture can present which conservative management of displaced horizontal as a mobile, extruded or displaced segment, but the root fracture at the middle third of root was performed and definitive diagnosis requires appropriate radiographic followed up to 2.5 years. examination4. The management of HRF is based on the location of the fracture, mobility and the vitality of the tooth. Case Report Fractures in the apical third usually have good prognosis and do not require any treatment while cervical third A 58 years old male attended Aga Khan University fractures have worse prognosis and usually require Hospital dental clinics with the complaint of pain on extraction of the tooth especially when the coronal biting from upper right tooth since last four days. Patient fragment displays severe mobility5, 6. Fractures at the had incident of biting hard object from that side. Clinical middle third of root have favorable prognosis and depends examination revealed uncomplicated fractured palatal on whether it is displaced or un-displaced. If the coronal cusp of tooth # 14 (Federation Dentaire Internationale). 168 Sheikh Bilal Badar et al. Balk J Dent Med, Vol 22, 2018

Tooth exhibited tenderness to percussion and grade Periapical radiograph was taken that showed with intact II mobility. Pulp sensibility testing was carried out and uniform periodontal ligament space and lamina dura using electric pulp tester (Gentle pulse, Parkell) that around the root of tooth # 14 (Figure 1C). Sensibility demonstrated a positive response on the affected testing of the tooth showed positive response on electric tooth. Periapical radiographs revealed fracture at the pulp tester (Gentle pulse, Parkell). Splint was removed, middle third of root of tooth # 14 (Federation Dentaire patient was counseled and advised to report back after 6 months for follow up visit. Internationale) with mild displacement of coronal Patient was recalled after six months for fractured segment. (Figure 1A) tooth assessment. The clinical and radiographical The treatment plan comprised of reduction and examinations were carried out that showed normal flexible splinting of the coronal fragment of tooth periodontal ligament space and lamina dura. The followed by evaluation for tooth sensitivity on subsequent periapical radiograph showed a less radiopaque line appointments. Patient was informed about the treatment and between fractured segments with slight rounding of informed consent was taken. Flexible splinting was carried edges, which means that healing had occurred with out from tooth # 13 to 15 with co-axial wire and light cure interproximal connective tissue (Figure 1D). Patient composite resin (Figure 1B). Analgesic was prescribed and was called for follow up after one year to evaluate the patient was called for follow up after two week. fractured tooth and he was perfectly doing well clinically On the follow up appointment after two weeks, and radiographically and tooth remained vital. sensibility testing was repeated using electric pulp tester that revealed a positive response; however, tooth was A 2.5 years follow up was performed with clinical mildly tender on percussion. Patient was reassured and examination and a 3D cone beam computed tomogram called after two weeks to evaluate and remove the splint was obtained to evaluate the healing of the fractured if symptoms improved. On the next appointment after root segment. No signs of pathology were observed and four weeks, sign and symptoms were improved with healing had occurred with interproximal connective tissue no tenderness to horizontal and vertical percussion. (FIGURE 2).

Figure 1. A: radiographs showing horizontal root fracture at the middle third of the root. B: radiographs showing composite and wire splint. C: radiographs showing healing at four weeks of follow up with normal periodontal ligament space and intact lamina dura. D: healing at six months follow up with radio opaque line between the fractured segments Balk J Dent Med, Vol 22, 2018 Management of Horizontal Root Fracture 169

Figure 2. Cone beam computed tomography showing healing of the fractured segment without any signs of pathology

Discussion in terms of tooth vitality because of increased chances of revascularization as compared to the middle and apical The prognosis and healing of root fractures is third of root15. Even then the attempt should be made to governed by the extent of the fracture line, status of the stabilize the tooth having fracture at the middle or apical pulpal and periodontal tissues, occlusion, dislocation/ and keep the patient on follow up for the evaluation of displacement of fractured segments and the overall health signs of pulpal necrosis before embarking any endodontic of the patient9. procedure. In the present case report, clinical and radiographic Thus it can be concluded that maintenance of vitality examination reveals favorable healing pattern of a tooth is the primary outcome that must be considered when with horizontal root fracture i.e. healing of calcified treating a tooth with horizontal root fracture because tissue with interposition of connective tissue. This type of fractured roots tend to heal spontaneously if the vitality of union is achieved by the presence of vital pulp tissue and the pulp is preserved. Fixation of fragments using flexible healthy periodontium. Available literature and multiple splints without any other treatment leads to favorable case reports suggest that healing outcome in horizontal treatment outcome in the presence of non –dislocated root fractures is considered ideal if pulp remains vital and fragments and vitality. However, these patients require fragments heal with absence of any pathological changes long‑term follow‑up because pathological changes can after several years of trauma9-11. Endodontic therapy of appear after several years following injury. coronal portion should be performed only in cases where pulp testing reveals non-vital pulp tissue, or if signs and Conclusions symptoms of pain or discomfort arise in affected tooth9, 10. Horizontal root fractures in the vital teeth should be Endodontic therapy should not be provided as a managed conservatively and every effort should be made prophylactic intervention in cases with horizontal root to preserve the vitality of tooth. However, periodic follow fracture12, 13. The pulp remains vital in many of the cases up is mandatory for long term success of the treatment. once the affected tooth is repositioned and adequately splinted as performed in the above case. However, the consensus on duration and type of splinting has not yet been established14. References The prognosis of treatment also depends upon the location of the fracture line. The fracture in the 1. Davidovich E, Heling I, Fuks AB. The fate of a mid-root cervical third of the root results in the better prognosis fracture: a case report. Dent Traumatol, 2005;21:170-173. 170 Sheikh Bilal Badar et al. Balk J Dent Med, Vol 22, 2018

2. Karhade I, Gulve MN. Management of Horizontal Root 11. Tziafas D, Margelos I. Repair of untreated root fracture: a Fracture in the Middle Third via Intraradicular Splinting case report. Endod Dent Traumatol, 1993;9:40-43. Using a Fiber Post. Case Rep Dent, 2016;2016:9684035. 12. Pan CS, Walker RT. Root fractures: a case of dental non- 3. Welbury R, Kinirons MJ, Day P, Humphreys K, Gregg intervention. Endod Dent Traumatol, 1988;4:186-188. TA. Outcomes for root-fractured permanent incisors: a 13. Flores MT, Andersson L, Andreasen JO, Bakland retrospective study. Pediatr Dent, 2002;24:98-102. LK, Malmgren B, Barnett F, et al. Guidelines for the 4. Tsai YL, Liao WC, Wang CY, Chang MC, Chang SH, management of traumatic dental injuries. I. Fractures Chang SF, et al. Horizontal root fractures in posterior teeth and luxations of permanent teeth. Dent Traumatol, without dental trauma: tooth/root distribution and clinical 2007;23:66-71. characteristics. Int Endod J, 2017;50:830-835. 14. Cvek M, Mejare I, Andreasen JO. Healing and prognosis of 5. Gorduysus M, Avcu N, Gorduysus O. Spontaneously teeth with intra-alveolar fractures involving the cervical part healed root fractures: two case reports. Dent Traumatol, of the root. Dent Traumatol, 2002;18:57-65. 2008;24:115-116. 15. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing 6. Ranka M, Shah J, Youngson C. Root fracture and its of 400 intra-alveolar root fractures. 1. Effect of pre- management. Dent Update, 2012;39:530-532, 535-538. injury and injury factors such as sex, age, stage of root 7. White I, Spiers G. Taking the trauma out of trauma: an development, fracture type, location of fracture and severity easy to follow guide for the management of trauma to the of dislocation. Dent Traumatol, 2004;20:192-202. permanent dentition. Dent Update. 2013;40:643-644, 647- 648, 650-652 passim. Received on November 12, 2017. 8. Clarkson RM, John K, Moule AJ. Horizontal palatal Revised on January 8, 2018. root fracture in a vital upper first premolar. J Endod, Accepted on April 2, 2018. 2015;41:759-761. Correspondence: 9. Oztan MD, Sonat B. Repair of untreated horizontal root fractures: two case reports. Dent Traumatol, Sheikh Bilal Badar 2001;17:240-243. Resident Operative Dentistry, Dental Clinics, Aga Khan University Hospital 10. Kucukyilmaz E, Botsali MS, Keser G. Treatments of Stadium Road, Karachi 74800, Pakistan horizontal root fractures: Four case reports. J Pediatr Dent, e-mail: [email protected] 2013;1:19-23. [email protected]

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Management of Large Residual Cyst in Elderly Patient with Decompression Alone: Case Report

SUMMARY Damla Torul1, Mehmet Cihan Bereket1, Enes Background/Aim:Residual cysts comprise approximately 10% of Özkan2 th th all odontogenic cysts. They are more commonly seen in 4 -6 decades of 1 Department of Oral and Maxillofacial Surgery, life, and occur due to incomplete previous surgical removal of a radicular Faculty of Dentistry, Ondokuz Mayis University, cyst; or due to left epithelial remnants stimulated by tooth extraction. These Samsun, Turkey lesions are often treated with enucleation. However, this procedure is not 2 Bafra Oral and Dental Health Hospital, always the ideal treatment solution for elderly people due to the presence of Samsun, Turkey physical and mental disorders, and risk of jaw fracture. Case Report: In this case report, the successful treatment of a large residual cyst in the symphysis of a 93 year-old female patient by performing decompression alone is presented. A plastic drain was placed on the wall of the cyst to allow irrigation. Regeneration was observed in the cyst cavity 3 months after surgery. The 1-year follow up showed that the majority of the cyst cavity was filled with new bone. Conclusions: In elderly patients, large inflammatory cysts can be successfully treated with decompression considering the limited regeneration capacity and difficulties in follow-up. CASE REPORT (CR) Key words: Odontogenic Cyst, Decompression, Geriatrics, Mandible Balk J Dent Med, 2018;171-174

Introduction and are often detected as an incidental finding during routine radiographic examination. However, because of Jaw cysts are closed sacs that may contain air, their tendency of expanding, they may cause expansion fluid, or semi-solid material and be either odontogenic of the jaw cortical plates or displacement of the related or non-odontogenic in accordance with the origin of the anatomical structures7. They can be accurately diagnosed epithelium that covers the cystic cavity1,2. Residual cyst combining clinical, radiographic and histologic findings7. (RC) or recurrent radicular cyst is an inflammatory type of RCs can be treated by enucleation, marsupialization, odontogenic cyst that originates as a result of proliferation or decompression to reduce the intraluminal pressure of of the odontogenic epithelial remnants3. The cyst may the cystic lesion2. Enucleation aids in complete surgical occur in the edentulous area at the site of a previously excision of the cyst and is an ideal treatment choice for extracted tooth months or even years later3,4. Stimulation benign cystic lesions. However, in certain cases, the size, of the odontogenic epithelial remnants entrapped in location of the cystic lesion, its proximity to adjacent vital hard and soft tissues of the jaws using inflammatory and structures, and patient’s age contraindicate enucleation8. immunological processes is considered as the primary Thus, particularly in younger, elderly, or high-risk mechanism responsible for RC development1,5. patients, minimally invasive treatment is a treatment of RCs comprise approximately 10% of all odontogenic choice9. Marsupialization is a well-accepted treatment cysts4,6. Radiographically, a RC is a well-defined, round- option that involves cystic wall fenestration and suturing to-oval unilocular radiolucency of varying size, located of the inner cystic lumen with the oral mucosa for in the jaw bones in edentulous areas and is commonly reducing the intra-cystic pressure and allowing new bone detected in the maxilla4,6. The cyst is usually encountered growth around the defect10. Decompression is another in individuals in the age range of 50-60 years with female treatment option that reduces the pressure caused by the predominance6. The majority of RCs are asymptomatic cystic mass. This technique requires a smaller window, 172 Damla Torul et al. Balk J Dent Med, Vol 22, 2018 which is kept open by suturing a device to it2. Even Because the cyst was of a large size, we planned though both decompression and marsupialization are to take a conservative approach and performed based on the rationale that releasing intramural pressure decompression under local anesthesia. We initiated to diminish the cyst size allows gradual bone growth decompression by performing a fenestration in the cystic around the lesion, decompression seems the more suitable wall lining with a scalpel, and placed a pacifier at the treatment option in cases that require a more conservative opening for daily cystic cavity irrigation (Figure 3). We approach9. RC has a low recurrence rate. However, follow sent an excised specimen for histologic examination; up is required to rule out malignancies and recurrences6. histopathological examination results confirmed the Since with aging, various compromising medical diagnosis of a residual cyst (Figure 4). We performed conditions may appear, dental management of geriatric follow-up after decompression, which included clinical patients requires special attention, particularly in cases of and radiographic examinations every 15 days. After 3 oral surgery. This paper presents the conservative treatment months, we observed new bone formation within the cyst of a large-sized residual cyst in a 93-year-old female. cavity. Recurrence and malignant transformation were not noted at the 1-year follow-up (Figure 5).

Case Report

A 93-year-old female was referred to our clinic with a complaint of slowly progressing and painless swelling located in the anterior mandible. The medical history of the patient did not indicate any previous conditions other than severe osteoporosis. Findings of intraoral examination revealed a swelling in the anterior region of the mandible. The mucosa surrounding the lesion appeared to be normal, and the swelling was non- tender and displayed cystic consistency. On panoramic Figure 3. The pacifier adapted to the cystic window for irrigation radiography (Figure 1) and cone beam computed tomography (CB-CT scan), large, well-defined, radiolucent expansive lesion was detected (Figure 2), extending from the area of the mandibular right premolar to the mesial aspect of left canine area, inferiorly to the mandibular basis and superiorly to the level of the alveolar crest. On the basis of these findings, residual cyst was provisionally diagnosed.

Figure 4. Histopathological view shows features of residual cyst

Figure 1. Initial panoramic radiograph of the patient

Figure 2. (A) Axial view of the lesion on the CBCT; (B) View of the lesion on 3D reconstruction Figure 5. Panoramic radiograph at the follow-up control after 1 year Balk J Dent Med, Vol 22, 2018 Management of Large Residual Cyst 173

Discussion Conclusions

Cystic lesions of the jaws are frequently encountered Decompression may be preferred over invasive among elderly patients, and the management of these surgical approaches in the treatment of huge residual lesions presents a challenge for the surgeon because of cysts; especially in elderly patients with systemic potential comorbidities associated with aging11. Reports diseases. Since chronic inflammation has been considered indicate that the occurrence of coexisting diseases as a predisposing factor for malignancy, long-standing 12 increases from 20% to 90% from 20-30 to 70-80 years . inflammatory cysts require particular attention, especially Elderly population generally suffers from bone and joint in elderly patients as in the case described herein. diseases, hypertension, diabetes mellitus, cancer, stroke, 12 along with other degenerative diseases . They show Acknowledgment We thank Ondokuz Mayıs University poorer tolerance toward stress and impaired visual and Faculty of Medicine Department of Pathology staff for functional capacity of the body systems. Also, impaired making pathological evaluation. oral health and oral pathologies have negative effects on nutrition, esthetics, psychological status, and other social activities of daily life13. Medical, psychological, socioeconomic status of the References patient in addition to the dental status, must be considered while treating cystic lesions in elderly patients14. 1. Demirkol M, Ege B, Yanik S, Aras MH, Ay S. Different treatment procedures have been preferred; in Clinicopathological study of jaw cysts in southeast region of 2003, Nishide et al.12 treated a huge dentigerous cyst in a Turkey. Eur J Dent, 2014;8:107-111. 72-year-old patient with irrigational therapy that involves 2. Allon DM, Allon I, Anavi Y, Kaplan I, Chaushu G. periodic irrigation of the cyst with antibiotics. They Decompression as a treatment of odontogenic cystic lesions claimed that the cystic cavity size rapidly diminished in children. J Oral Maxillofac Surg, 2015;73:649-654. 3. Sisman Y, Etoz OA, Mavili E, Sahman H, Tarim Ertas E. when compared with marsupialization and suggested this Anterior Stafne bone defect mimicking a residual cyst: a technique for geriatric patients because it does not require case report. Dentomaxillofac Radiol, 2010;39:124-126. additional surgery. 4. Jamdade A, Nair GR, Kapoor M, Sharma N, Kundendu A. 9 According to Enislidis et al. , all large mandibular Localization of a Peripheral Residual Cyst: Diagnostic Role cysts of any histologic type can be successfully treated, of CT Scan. Case Rep Dent, 2012;2012:760571. with no recurrence, by decompression and second-stage 5. Ruiz PA, Toledo OA, Nonaka CF, Pinto LP, Souza LB. enucleation. Because our patient had severe osteoporosis Immunohistochemical expression of vascular endothelial that prevented her from staying in the dental unit for an growth factor and matrix metalloproteinase-9 in extended period of time and showed poor tolerance to radicular and residual radicular cysts. J Appl Oral Sci, stress as a result of aging, we preferred decompression 2010;18:613-620. 6. Sridevi K, Nandan SR, Ratnakar P, Srikrishna K, Vamsi as the treatment option. Also, the cystic lesion, in Pavani B. Residual cyst associated with calcifications in an our patient, reached a large size that could lead to elderly patient. J Clin Diagn Res, 2014;8:246-249. pathologic fracture of the mandible. Thus, we considered 7. Boffano P, Gallesio C. Exposed inferior alveolar decompression as more conservative, which can be neurovascular bundle during surgical removal of a residual easily and rapidly performed. Using this technique, we cyst. J Craniofac Surg, 2010;21:270-273. also attempted to limit intraoperative and postoperative 8. Bodner L, Bar-Ziv J. Characteristics of bone formation discomfort of the patient. The chief explanation for the following marsupialization of jaw cysts. Dentomaxillofac rapid regeneration of large cyst cavity in this patient Radiol, 1998;27:166-171. without recurrence is that the residual cyst responded 9. Enislidis G, Fock N, Sulzbacher I, Ewers R. Conservative well to decompression. treatment of large cystic lesions of the mandible: a Although this is a rare condition, a case of malignant prospective study of the effect of decompression. Br J Oral Maxillofac Surg, 2004;42:546-550. transformation of cystic epithelium has been reported. 10. Anavi Y, Gal G, Miron H, Calderon S, Allon DM. Reports indicate that more than 50% of reported cases of Decompression of odontogenic cystic lesions: clinical long- malignant transformation originated from inflammatory term study of 73 cases. Oral Surg Oral Med Oral Pathol Oral 15 periapical or residual cysts . For this reason, the Radiol Endod, 2011;112:164-169. follow-up should continue for a long period of time; at 11. Lei F, Chen JY, Wang WC, Lin LM, Huang HC, Ho KY, et least 1-year follow-up is needed to evaluate possible al. Retrospective study of oral and maxillofacial lesions in transformation. older Taiwanese patients. Gerodontology, 2015;32:281-287. 174 Damla Torul et al. Balk J Dent Med, Vol 22, 2018

12. Nishide N, Hitomi G, Miyoshi N. Irrigational therapy of a 15. Bereket C, Bekcioglu B, Koyuncu M, Sener I, Kandemir B, Turer A. Intraosseous carcinoma arising from an dentigerous cyst in a geriatric patient: a case report. Spec odontogenic cyst: a case report. Oral Surg Oral Med Oral Care Dentist, 2003;23:70-72. Pathol Oral Radiol, 2013;116:e445-e449.

13. Bonwell PB, Parsons PL, Best AM, Hise S. An Received on December 14, 2017. interprofessional educational approach to oral health Revised on February 29, 2018. Accepted on Jun 2, 2018. care in the geriatric population. Gerontol Geriatr Educ, 2014;35:182-199. Correspondence: Enes Özkan 14. Patil MS, Patil SB. Geriatric patient - psychological Bafra Oral and Dental Health Hospital and emotional considerations during dental treatment. Department of Oral and Maxillofacial Surgery, Bafra/Samsun, Turkey Gerodontology, 2009;26:72-77. e-mail: [email protected]

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ERRATUM

Erratum: A Case of Dental Fusion in Primary Dentition from Late Bronze Age Greece

In the article that appeared on pages 102–105 of the July 2018 issue of the Balkan Journal of dental Medicine the incorrect affiliation was places; and it should be The Malcolm H. Wiener Laboratory for Archaeological Science, ASCSA, Athens, Greece. We regret this error.

In the same article, an incorrect year appeared on page 103, and it sholud be: 1400-1200. We regrets this error. CIP - Каталогизација у публикацији Народна библиотека Србије, Београд

616.31

BALKAN Journal of Dental Medicine : official publication of the Balkan Stomatological Society / editor-in-chief Dejan Marković. - Vol. 18, no. 1, (March 2014)- . - Belgrade : Balkan Stomatological Society, 2014- . - 30 cm

Tri puta godišnje. - Je nastavak: Balkan Journal of Stomatology = ISSN 1107-1141 ISSN 2335-0245 = Balkan Journal of Dental Medicine COBISS.SR-ID 206352140