SURGICAL MANAGEMENT OF ORAL SUBMUCOUS Review Article FIBROSIS: Case Report and Review Article

Dr. Nitu Shah*, Dr. Naman Pandya**, Dr. Devanshi Vaghela***, Dr. Neha Vyas**** ABSTRACT Objective: To assess the outcome of different surgical treatment modalities of Oral Submucous Fibrosis. Background: Oral Submucous Fibrosis (OSF) is a persistent, progressive, pre-cancerous condition of the oral mucosa, which is mainly related with betel quid chewing habit. OSF is strongly connected with the risk of oral cancer. Since decades, many treatment modalities are suggested and studied like medicinal treatment, intralesional injection and physiotherapy or surgical treatments with varying degrees of benefit. But complete eradication of disease is challenging. The present article shows the outcome of various surgical treatment modalities in the management of this condition. Method: In this article a total of 4 patients who were clinically and histologically diagnosed as Oral Submucous Fibrosis, grouped according to classification system for the surgical management of OSF proposed by Khanna JN and Andrade NN. Out of 4 patients 1 patient undergone fibrectomy with collagen membrane placement, 1 patient undergone fibrectomy with buccal fat pad placement ,in 1 case fibrectomy was done with Laser , in advanced cases coronoidectomy was done. Conclusion : In oral submucous fibrosis Fibrectomy followed by grafting is a one of the suggested treatment for prevention of the recurrence of the condition but advanced procedure like coronoidectomy gives better results related to the clinical mouth opening. Keywords: Oral Submucous Fibrosis, surgical treatment, collagen membrane, laser, buccal fat pad ,coronoidectomy

INTRODUCTION: due to recurrent fibrosis, poor patient compliance, discontinuing physiotherapy or restarting of the Oral submucous fibrosis is a condition with 7 chronic inflammatory reaction in the subepithelial habit tissue of the oral cavity which leads to increased Aetiology: OSF is multifactorial in origin, fibroelastic changes and epithelial atrophy by chewing of betel nut, consumption of spicy food, causing both increased collagen production and nutritional deficiency, hereditary, collagen and decreased collagen breakdown, results in stiffness autoimmune disorders, but it is accepted that betel of oral mucosa. Geographically, oral submucous nut chewing is the main cause of this condition8. fibrosis has a specific distribution and affects The chewing of betel quid (BQ) (containing predominantly Asians (and particularly areca nut, tobacco, slaked lime or other species) Indians)1,2with the frequency of malignant change 7,8 has been recognized as one of the most important from 3% to 6%. risk factors for OSF as supported by the It is characterized by stiffness, trismus, burning epidemiological evidence9,10 as well as from its sensation in the mouth, hypomobility of tongue histopathological effects on fibroblasts and and soft palate and inability to eat 3. The prevalence keratinocytes11,12. of OSF cases in India has been reported to be with a 4 Clinical presentation: Initially, most patients female to male ratio of 3: 1.2 . Treatment in stage I present with a burning sensation or intolerance to and stage II oral submucous fibrosis includes spicy food, and they may have vesicles, medicinal treatment (vitamins & iron particularly on the palate. Ulceration and dryness supplements),intra-lesional injections of of the mouth is later followed by fibrosis of the oral hyaluronidase5,6and steroid application.Surgery 7 mucosa, which leads to rigidity of the lips, tongue, has been proposed in stage III and stage IV for and palate, and pain on palpation and trismus is effective release of trismus. Though these caused mostly by fibrosis in the dense tissue surgeries gave good results, decrease in inter- around the pterygomandibular raphae.When the incisal opening in the long term follow up was seen

* Professor, **PG Student, ***PG Student, **** Head Of Department DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY, AHMEDABAD DENTAL COLLEGE & HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. NAMAN PANDYA, TEL: +91 99799 53795

2 Naman Pandya et. al. : SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS.

fibrosis involves oesophagus, patients may affected site. In all the 4 cases fibrectomy was done experience dysphagia usually these are features of by placing Y- shaped incision on the buccal more advanced disease.The most obvious clinical mucosa on the occlusal level approximately 7mm signs include blanched, opaque oral mucosa with below thestenson's duct. Out of four cases, in one palpable fibrous bands.All the four cases have case fibrectomy was done with Laser and no graft chief complaint of restricted mouth opening and material was placed( Fig.2) , and the other three most of the patients have history of betel nut cases were done with scalpel followed by collagen chewing since 5 to 10 years. All the patients were membrane placement (Fig.1-d) or buccal fat pad in the age group of 20 years to 40 years. Clinical g r a f t i n g ( F i g . 3 ) , a n d i n s e v e r e c a s e evaluation of this condition and grading was done coronoidectomy (Fig. 4) was performed to achieve and incisional biopsy was taken from the most better results

Fig. 1 Shows surgical treatment of Fibrectomy with Collagen Membrane grafting

Fig. 1 (a) Pre-operative Fig. 1 (b) Intraoperative Fig. 1 (d) Postoperative mouth opening: 7 mm mouth opening: 38mm mouth opening: 22mm

Fig. 1 (c) Collagen Membrane placed Fig. 1 Clinical Photographs of Surgical Treatment of Fibrectomy with Collagen Membrane grafting (a) preoperative (b) (c) (d)

3 Naman Pandya et. al. : SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS.

Patient-2 : shows Fibrectomy done with Laser

Fig. 2 (a) Pre operative Fig. 2 (c) Intraoperative mouth opening : 20mm mouth opening 32 mm

Fig. 2 (d) Postoperative Fig.2 (b) Fibrectomy with Laser mouth opening: 42mm

4 Naman Pandya et. al. : SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS.

Fig.3 Shows fibrectomy done with Buccal Fat Pad

Fig. 3(a) Preoperative Fig.3(b) Intraoperative mouth opening: 17mm mouth opening: 34mm

Fig.3(d) Postoperative Fig.3 (c) Buccal Fat Pad mouth opening 22mm placed on operated site

5 Naman Pandya et. al. : SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS.

Fig.4 Shows Fibrectomy with Coronoidectomy

Fig. 4 (a) Preoperative Fig.4 (c) Intraoperative mouth opening: 7mm mouth opening: 42mm

Fig.4 (d) Postoperative Fig. 4 (b) Intraoperative mouth opening: 25mm Coronoidtomy

6 Naman Pandya et. al. : SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS.

Discussion: Oral Submucous Fibrosis is a chronic, Khanna and Andrade16 gave a classification crippling condition of the mouth resulting in system for oral submucous fibrosis based on mean significant health and social problems, which may interincisal opening (IIO): stage I, early oral interfere with the regular inspection of the oral submucous fibrosis without trismus (IIO >35 mm); cavity for cancer, adequate nutritional intake, stage II, mild to moderate disease (IIO 26–35 mm); dental hygiene and speech.13 stage III, moderate to severe disease (IIO 15–25 The important histopathological characteristic mm); stage IVa, severe disease (IIO <15 mm); and of oral submucous fibrosis is the deposition of stage IVb, extremely severe–malignant collagen in the oral submucosa.14 The areca nut /premalignant lesions noted intraorally. (betel nut) component of betel quid, especially an In their study, considering the severity of the alkaloid called arecoline, plays a major role in the trismus and the histopathological findings of pathogenesis of oral submucous fibrosis by secondary muscle degeneration and fibrosis in causing an abnormal increase in the collagen stages III and IV, suggested surgical treatment was production.15 the only solution, and that bilateral temporalis areca nut, supporting an association between myotomy and coronoidectomy were highly the areca nut use and the disease. In the present effective surgical procedure. study, about all the 4 patients had gutkha chewing Following the same protocol, in the present habit and betel nut chewing with arca nut... study, all 4 patients with stage III oral submucous In the present study, duration of tobacco fibrosis and stage IVa oral submucous fibrosis were product abuse ranged from 5 -10 years.It was seen planned to be treated surgically to relieve trismus. that most patients present with a complain of an Various surgical approaches have been tried, irritable oral mucosa during the early stage of the with varying results, including: simple division of disease, especially when spicy foods are eaten. the fibrotic bands; use of Collagen membrane and Clinically, there are erosions and ulcerations. Buccal Fat Pad to cover the musculomucosal Subsequently, the oral mucosa becomes blanched defect. Simple excision of the fibrous bands with and loses its elasticity, and vertical bands occur in Laser and propping the mouth open to allow the buccal mucosa, the retromolar area, the soft secondary epithelialization causes rebound palate, and the pterygomandibular raphe. fibrosis and disability during healing. Relapse and failure to perform mouth-opening exercises were In the present study, out of 4 patients only 1 17 patient presented with burning sensation upon due to pain intolerance caused by the stretching eating spicy food, occasional ulcers and all action of degenerated strong mouth opening patients had white marbled appearance of the muscles. buccal mucosa, vertical fibrous bands in the buccal M a s t i c a t o r y m u s c l e m y o t o m y a n d mucosa and circular bands in the lips. However, coronoidectomy release the stretching action of clinical assessment of the hard & soft palate, strong degenerated muscles and aiding aggressive faucial pillars, uvula, tongue movements and floor postoperative mouth opening exercises, which are of mouth was not possible due to restricted mouth the most important factor in maintaining opening of 7mm in patient which was operated intraoperative IIO in the long term.18 with fibrectomy with collagen membrane, 20mm Over the years many authors have mentioned mouth opening in patient done with Laser, 17mm coronoidectomy as an adjuvant therapy in mouth opening in patient done with Fibrectomy increasing inter-incisal opening intra-operatively with buccal fat pad placement, and 7mm mouth and maintain it post-operatively. But, in the recent opening in patient done with coronoidectomy. In years bilateral coronoidectomy has been the present study, the minimum inter-incisal advocated as an intergral part of the surgical opening was 7 mm. Whereas, maximum inter- treatment of oral submucous fibrosis. incisal opening was 20 mm . The advantages of using coronoidectomy are: Oral submucous fibrosis treatment is based on 16 there are no adverse effects in removing the the severity of the disease. bilateral coronoids, no morbidities simple and easy

7 Naman Pandya et. al. : SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS. procedure to perform, achieving better intra- ice-cream sticks, hot water gargling, ballooning of operative inter-incisal opening, no problems mouth, acrylic screws, rubber mouth props, associated with post-operative healing and better Heister's jaw opener, localized heat such as with patient compliance to physiotherapy. microwave diathermyor ultra sound.The In the present study, 2 cases were surgically aggressive physiotherapy improves the local managed with fibrectomy and suitable graft circulation which minimizes the propensity of material was used to cover the buccal defect, 1 case fibrosis. was treated with Laser while in the other one case All the patients in the present study underwent along with the steps used for fibrectomy additional aggressive mouth-opening exercises with the help steps of bilateral temporal myotomy and of Heister's jaw opener from the third post- coronoidectomy were performed. The mean intra- operative day and were counselled to continue operative inter-incisal opening achieved in the 3 mouth-opening exercise at home with Heister's cases done with fibrectomywas around 40mm jaw opener 4-6 with frequent 15 minutes per while in case done with coronoidectomy was session. around 43 mm suggesting that coronoidectomy In the present study, it was observed that patient helped achieving greater intra-operative, inter- compliance was better in where bilateral incisal opening as compared to when only temporalis myotomy and coronoidectomy was fibrectomy was performed. This study also used in adjunct to bilateral fibrotomy and suitable showsed, that in post-operative follow-up period, graft material. the inter-incisal opening was maintained higher in the case with coronoidectomy over the period of This study showed, that coronoidectomy one year. helped achieve significant difference in intra- operative inter-incisial opening as well as Various inter-positional grafting material are maintenance in the follow up period. used to cover the raw area after excision of the fibrous bands for guided tissue healing and Conclusion:With the evaluation of the cases of prevention of wound contracture. The use of oral submucous fibrosis presented in this article, collagen are popular due to the ready availability we concluded that surgical treatment like and the decreased incidence of morbidity fibrectomy followed by graft material is a one of the treatment used to prevent the recurrence of the In the present study, all the patients were condition. But if the condition is severe and long explained about the importance of covering the term advanced procedure like coronoidectomy buccal defect after fibrotomy and the graft gives better results.Various mouth opening materials were used according to patient's consent. exercises, cessation of habits and improvement in The most commonly used graft material was nutritional status is a must for better results post- collagen membrane. Buccal fat pad was used in 1 operatively. of patients with good results. Various devices and techniques used for physical therapy in oral submucous fibrosis are:

REFERENCES: 3. Ahmad Alshadwi Excision of Oral Submucous 1. Angadi PV, Rao S. Management of oral Fibrosis and Reconstruction with Full Thickness submucous fibrosis: an overview. Oral and Skin Graft: A Case Study and Review of the maxillofacial surgery. 2010 Sep 1;14(3):133-42. Literature 2012 2. Pindborg JJ, Chawla TN, Srivastava AN, Gupta 4. Taneja L, Nagpal A, Vohra P, Arya V. Oral D, Mehrotra ML. Clinical aspects of oral submucous fibrosis: an oral physician approach. s u b m u c o u s f i b r o s i s . J Innov Dent. 2011 Sep;1(3). Actaodontologicascandinavica. 1964 Jan 5. Murti PR, Bhonsle RB, Pindborg JJ, Daftary 1;22(6):679-91. DK, Gupta PC, Mehta FS. Malignant

8 Naman Pandya et. al. : SURGICAL MANAGEMENT OF ORAL SUBMUCOUS FIBROSIS.

transformation rate in oral submucous fibrosis arecoline: a possible role in the pathogenesis of over a 17‐year period. Community dentistry and oral submucous fibrosis. Journal of oral oral epidemiology. 1985 Dec;13(6):340-1. pathology & medicine. 2003 Mar;32(3):146-53. 6. Canniff JP, Harvey W, Harris M. Oral 15. Aziz SR. Oral submucous fibrosis: case report submucous fibrosis: its pathogenesis and and review of diagnosis and treatment. Journal management. British dental journal. 1986 of Oral and Maxillofacial Surgery. 2008 Nov Jun;160(12):429. 1;66(11):2386-9. 7. Chiu CJ, Chang ML, Chiang CP, Hahn LJ, Hsieh 16. Yeh CJ. Application of the buccal fat pad to the LL, Chen CJ. Interaction of collagen-related surgical treatment of oral submucous fibrosis. genes and susceptibility to betel quid-induced International journal of oral and maxillofacial oral submucous fibrosis. Cancer Epidemiology surgery. 1996 Apr 1;25(2):130-3. and Prevention Biomarkers. 2002 Jul 17. Kshirsagar R, Chugh A, Rai A. Bilateral 1;11(7):646-53. inferiorly based nasolabial flaps for the 8. Sana Farista et al Diode Laser- Assisted management of advanced oral submucous Fibrotomy in the Management of Oral fibrosis. Journal of maxillofacial and oral Submucous fibrosis: A new technique in surgical surgery. 2010 Mar 1;9(1):22-6. management Journal of clinical and diagnostic 18. Wei FC, Chang YM, Kildal M, Tsang WS, Chen research July 2018. HC. Bilateral small radial forearm flaps for the 9. Chan RC, Wei FC, Tsao CK, Kao HK, Chang reconstruction of buccal mucosa after surgical Y M , Ts a i C Y, C h e n W H . F r e e f l a p release of submucosal fibrosis: a new, reliable reconstruction after surgical release of oral approach. Plastic and reconstructive surgery. submucous fibrosis: long-term maintenance and 2001 Jun;107(7):1679-83. its clinical implications. Journal of Plastic, 19. Huang IY, Wu CF, Shen YS, Yang CF, Shieh TY, Reconstructive & Aesthetic Surgery. 2014 Mar Hsu HJ, Chen CH, Chen CM. Importance of 1;67(3):344-9. patient's cooperation in surgical treatment for 10. Kamath VV. Surgical interventions in oral oral submucous fibrosis. Journal of Oral and submucous fibrosis: a systematic analysis of the Maxillofacial Surgery. 2008 Apr 1;66(4):699- literature. Journal of maxillofacial and oral 703. surgery. 2015 Sep 1;14(3):521-31. 20. Gupta DS, Gupta MK, Golhar BL. Oral 11. Bande C, Dawane P, Gupta MK, Gawande M, submucousfibrosis-Clinical study and Rode V. Immediate versus delayed aggressive management by physiofibrolysis (MWD). J physical therapy following buccal fat pad Indian Dent Assoc. 1980;52(1):375-8. interposition in oral submucous fibrosis—a prospective study in Central India. Oral and maxillofacial surgery. 2016 Dec 1;20(4):397- 403.

12. Chao CK, Chang LC, Liu SY, Wang JJ. Histologic examination of pedicled buccal fat pad graft in oral submucous fibrosis. Journal of oral and maxillofacial surgery. 2002 Oct 1;60(10):1131-4. 13. Sharma R, Thapliyal GK, Sinha R, Menon PS. Use of buccal fat pad for treatment of oral submucous fibrosis. Journal of Oral and Maxillofacial Surgery. 2012 Jan 1;70(1):228-32. 14. Tsai CH, Chou MY, Chang YC. The up‐regulation of cyclooxygenase‐2 expression in human buccal mucosal fibroblasts by

9 COMPARATIVE EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED Review Article VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS- A SYSTEMATIC REVIEW AND META-ANALYSIS.

Dr. Darshana Shah*, Dr. Chirag Chauhan**, Dr. Manushi Panchal***, Dr. Khushboo Jaiswal****, Dr. Shailin Thaker***** ABSTRACT Aim: The aim of this systematic review is to compare the marginal bone loss in screw versus cement retained implant prosthesis. Materials and Method: An electronic search was conducted for articles in English listed with PuBMeD, Science Direct, Ebsco host between 1966 to December 2018 and 14 studies were included based on the inclusion and exclusion criteria in which the marginal bone loss between screw and cement retained were evaluated and compared. Results: The mean marginal bone loss in cement retained restorations is 0.89 mm and the mean marginal bone loss in screw retained restorations is 0.98 mm. Conclusion: The conclusion of this review states that the mean marginal bone loss in cement retained and screw retained implant supported restorations is not statistically significant when compared and both can be used depending on the clinical situation. Keywords: Dental implant, Implant Supported Restorations, Dental Screws, Dental Implant Cementation, Screw- retained Restorations, Cement- retained Restorations, Marginal Bone Loss

INTRODUCTION: Advocates of cement retained restorations list At present the dental implants are widely used for improved esthetics and occlusion, simplicity of the oral rehabilitation of partially or fully fabrication, reduced cost of components, reduced edentulous patients in order to secure various chairside time, and easier access to posterior of the kinds of prosthesis. There are several factors that mouth as distinct advantages. Biomechanically, are responsible for long term success after placing the potential for passivity is more when a and loading implants. One of the many factors cemented restoration is placed on implants. Some involved is regarding the type of connection in vitro studies have demonstrated that cement- between the implant and restoration.1 retained prostheses exert less stress on other components and on bone tissue than screw- Marginal bone loss (MBL) around dental retained prostheses. As for disadvantages in implants is a serious problem, and extensive bone cemented restorations, retrievability remains loss has long been regarded as one key factor questionable. There is evidence that excess cement contributing to implant failure.This “standard from cement retained restorations may end up in MBL” stabilizes at approximately 12 months. The the soft tissues of the patient and then result in type of retention system for implant supported localized swelling and marginal bone loss. A prostheses must be decided before the surgical number of studies have shown that the bacterial stage to determine the most accurate location of loads associated with failing dental implants are implant. There are two methods of retaining a fixed the same organisms implicated in periodontal implant supported restoration: screw retention disease and that pro-inflammatory mediators and cement retention or occasionally a associated with soft-tissue inflammation are combination of both, eg, Cemented prosthesis differentially expressed in tissues surrounding with lingual or palatal fastening screws. failing implants versus healthy implants. Screw retained prosthesis remain the treatment The presence of a marginal gap located sub- of choice in completely edentulous patients gingivally has been demonstrated to influence because of its ease of retrievability, reduced soft-tissue health and implant survival, as the gap biological complications, ease of hygiene size can be associated with the accumulation of maintainence, repairs and provision for future plaque and debris, ultimately leading to surgical interventions if required. Restorations inflammation and loss of bone architecture. In that use screw retention have been an accepted light of all these factors, an essential question to treatment option in patients with limited inter arch ask is whether the differences in marginal gap space.4 * Head Of Department, **Professor, ***PG Student, **** PG Student, *****PG Student DEPARTMENT OF PROSTHODONTICS CROWN & BRIDGE, AHMEDABAD DENTAL COLLEGE & HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. MANUSHI PANCHAL, TEL: +91 96389 77429

10 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. between screw and cement retained implant EXCLUSION CRITERIA: prostheses will indeed manifest themselves in the 1. Duplicate and irrelevant studies health of peri-implant soft tissues.Presently, the dental literature is unequivocal on the association of 2. Studies that evaluated only one type of marginal bones loss (MBL) with the implant retention without a comparison group. retention mechanism.8 3. In vitro studies. Thus the purpose of present systematic review 4. In vivo animal studies. and meta-analysis is to compare and evaluate the 5. Studies reporting placement of implant in marginal bone loss in screw versus cement retained zygoma. fixed implant restorations. FLOW CHART FOR SEARCH TRATERGY: SEARCH STRATERGY:- An electronic search of dental literature in PuBMeD, Science Direct, Ebscowas performed for Broad Search articles published in english between 1966 to [PUBMED E-search Manual search] December 2018.The key words searched were Total Number Articles :Dental implant, implant supported restorations, N=1033 dental screws, dental implant cementation, screw- (Based On Key Words) retained restorations, cement- retained restorations and marginal bone loss.Manual searches of the references of all full-text articles and relevant articles also selected from the electronic search were also performed. Both abstracts and full text Excluded by Titles articles were included. N = 441 SELECTION OF STUDIES: For the review, first the titles and abstracts of the search were initially screened by two authors for Insufficient Data N = 219 relevance and the full text of relevant abstracts were obtained and accessed. From these relevant articles, by using inclusion and exclusion criteria, relevant and suitable articles were isolated for further Excluded by Abstracts processing and data extraction. N = 222 INCLUSION CRITERIA: 1. Study designs such as randomized controlled trial, prospective studies and retrospective studies were included. Full Text Articles 2. Studies reporting marginal bone loss of N = 72 dental implant in implant supported restoration with retention system by both of the following: a. Cement retained restoration Excluded articles considering b. Screw retained restoration inclusion and exclusion criteria 3. Age limit between 18-81 years were N = 65 selected. 4. Follow up period more than 6 months. 5. Minimum sample size : 20 Included Articles N = 14

11 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. Table 1:- Evidence level of included studies

No. Study and year Type of the study Evidence level

1 Hameed(2018)9 Retrospective 02

2 Francis(2018)10 Prospective 02

3 Shi(2018)11 Retrospective 02

4 Ferreiroa(2015)12 Prospective 02

5 Crespi et al.(2014)13 Retrospective 02

6 Cha et al.(2013)14 Prospective 02

7 Vigolo et al.(2012)15 Retrospective 02

8 Nissan et al.(2011)16 Retrospective 02

9 Sherif et al.(2010)17 Prospective 02

10 Jemt(2008)18 RCT 01

11 Drago and Prospective 02 Lazzara(2006)19

12 De Boever et al.(2006)20 Prospective 02

13 Vigolo et al.(2004)21 Prospective 02

14 Henriksson and Prospective 02 jemt(2003)22

12 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. Table 2:- Evaluation of marginal bone loss with cement retained restoration

No. Study and year No. of Total No. Mean Age Follow up in No. of cement Mean marginal patients Of implant (years) months retained bone loss (mm) restoration cement retained

restoration

1 Hameed(2018)9 41 104 59.8 12 58 0.86

2 Francis(2018)10 14 28 28.3 6 14 0.42

3 Shi(2018)11 176 176 46.8 30.2 82 1.97

4 Ferreiroa(2015)12 80 80 44.4 48 40 NR

5 Crespi et al.(2014)13 28 272 59.3 96 17 (full arch) 0.32

6 Cha et al.(2013)14 120 136 47 60 30 NR

7 Vigolo et al.(2012)15 16 32 33 120 16 1.11

8 Nissan et al.(2011)16 38 221 58 180 110 0.69

9 Sherif et al.(2010)17 99 193 47.3 60 90 NR

10 Jemt(2008)18 35 41 31.35 120 23 1.56

11 Drago and 27 151 62.4 18 15 (full arch) NR Lazzara(2006)19

12 De Boever et 105 283 59.1 40 127 (full arch) NR al.(2006)20

13 Vigolo et al.(2004)21 12 24 NR 48 12 0.8

14 Henriksson and 20 24 29 12 13 0.3 jemt(2003)22

Overall Mean Marginal Bone loss (mm ) 0.89

13 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. Table 3:- Evaluation of marginal bone loss with screw retained restoration

No. Study and year No. of Total No. Mean Age Followup in No. of Mean marginal patients of implant months screwretained bone loss (mm) restoration screw retained restoration

1 Hameed(2018) 9 41 104 59.8 12 46 0.96

2 Francis(2018) 10 14 28 28.3 6 14 0.39

3 Shi(2018) 11 176 176 49.6 31.4 94 1.67

4 Ferreiroa(2015) 12 80 80 44.4 48 40 NR

5 Crespietal.(2014)13 28 272 59.3 96 17 (full arch) 0.48

6 Chaetal.(2013)14 120 136 47 60 106 NR

7 Vigoloetal.(2012)15 16 32 33 120 16 1.12

8 Nissanetal.(2011)16 38 221 58 180 111 1.4

9 Sherifetal.(2010)17 99 193 47.3 60 103 NR

10 Jemt(2008) 18 35 41 31.35 120 18 1.67

11 Drago and Lazzara 27 151 62.4 18 12 (full arch) NR (2006)19

12 De Boeveretal. 105 283 59.1 40 45 (full arch) NR (2006)20

13 Vigoloetal. (2004)21 12 24 NR 48 12 0.8

14 Henriksson and 20 24 29 12 11 0.4 jemt(2003) 22

Overall Mean Marginal Bone loss (mm) 0.98

14 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. Table 4:- Evaluation of marginal bone loss with cement retained restoration and screw retained restoration

(IC - Internal Connection IPO - Implant Protected Ocllusion Ex - External Connection MIP - Maximam Intercuspul Position)

15 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. Table 5:- Overall Mean marginal bone loss with cement retained restoration and screw retained restoration

Retention system Mean marginal bone loss (m m)

Cement retained restorati on 0.89

Screw retained restoratio n 0.98

Fig. 1 Forest plot for the evaluation of Fig. 2 Forest plot for the evaluation of marginal bone loss with cement retained marginalbone loss with screw retained restoration restoration

Fig. 3 Overall Mean marginal bone loss with cement retained restoration and screw retained restoration

16 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. DISCUSSION: Plaque buildup may increase the risks of inflammation and, consequently, marginal The main purpose of this review was to 51 evaluate the marginal bone loss in cement- bone loss. and screw retained implant fixed Tonella BP 2 8 reported that the restorations. Along with the retention biomechanics of the different retention system, the included articles also assessed systems may also affect marginal bone loss, the follow up period, the type of implant with some studies reporting that cement- connection, the loading protocol used, the retained prostheses are better at stress type of opposing occlusion and the occlusal distribution. Access to the screw hole may scheme. also contribute to marginal bone loss Brandaoet et al23 compared marginal because different restorative materials can bone loss in a systematic review of different transfer occlusal loads laterally to the implant instead of axially. Furthermore, retention systems and he observed greater 29 loss in screw-retained prosthesis but this Guichet DL stated that cement may be difference was not statistically significant. better at filling discrepancies, absorbing the The present review, which investigated strain of the deformation caused by the only studies with direct comparisons, also mismatch between the abutment and found no significant differences favouring implant in the implant abutment- prosthesis cement-retained prostheses or screw structure, and helping to equalize retained prosthesis. distribution. Jemt18 observed higher levels of average The longevity of the dental implants bone loss for cemented control restorations depends on the amount of crestal bone loss before the final tightening, supporting the along the implant surface and the crestal observations made by Weber and bone remodels after loading of implants. 26 However, the meta- analysis included only colleagues. 13 27 2 studies by Crespiet et al and Draggo and Wannfors and Smedberg indicate that Lazzara19 which have immediately loaded single-implant restorations with wider the implants, and stated that in both delayed cement margins between the crowns and and immediate loading, there is initial bone abutments may experience more marginal loss which stabilizes after about a month of bone loss. Residue of cement can be loading. difficult to diagnose and remove, especially 16 when the crown margin is placed deep in Only one study by Nissan et al in the the gingival sulcus. In addition, bone may present review reported a high marginal be lost when wide cement margins are bone loss with screw retained restoration. present. This could be due to the greater preload 12 17 26 exerted by reduced passive fit of the screw- Ferreiroa , Sherif S , Weber reported retained framework which caused a greater that cement-retained prostheses had greater tendency of abutment screw loosening. tendency toward plaque buildup, sulcular This finding was in agreement with the bleeding, and gingival inflammation study conducted by Hameed9. A possible because of the inherent difficulty in explanation for observing greater MBL in removing excess subgingival cement.

17 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. screw-retained design could be the fact that CONCLUSION: the position of the access opening in the From the above systematic review and prosthetic restoration transfers occlusal meta-analysis, it is concluded that, the loads in a non- axial manner which results mean marginal bone loss in cement in increased marginal bone loss. Studies retained implant supported restorations is have shown that there is minimal stress 0.89 mm. exertion on implant and crestal bone with cement-retained prostheses than with The mean marginal bone loss in screw screw-retained prostheses. retained implant supported restorations is 0.98 mm. The present systematic review is a basic vision of the vast field of screw retained The conclusion of this review states that and cement retained restorations. The the mean marginal bone loss in cement results obtained from this review are retained and screw retained implant clinically insignificant and state that both supported restorations is not statistically screw retained and cement retained significant and both can be used depending implant supported fixed restorations can be on the clinical situation. used according to the clinical situation as there is negligible difference in the marginal bone loss between the two types of retention systems used.

1. RolaShadid, NasrinSadaqa. A comparison implant connection and restoration design between screw- and cement- retained (screwed vs. cemented) in reliability and implant prostheses. A literature review. failure modes of anterior crowns. Eur J Journal of Oral Implantology2012; Oral Sci 2011; 119:323–330. 38(3):298-307. 6. Christian Mehl, Sonke Harder, Mona 2. Paulo Vicente Barbosa da Rocha, Wolfart. Retrievability of implant retained MirellaAguiarFreitas, and Tiago de crowns following cementation. Clin. Oral MoraisAlves da Cunha. Influence of screw Impl. Res. 2008; 1304–1311. access on the retention of cement-retained 7. Ralf Smeets, Anders Henningsen, Ole implant prostheses. J Prosthet Dent 2013; J u n g , M a x H e i l a n d , C h r i s t i a n 109:264-268. Hammacher, and Jamal M Stein. 3. Michalakis, Hirayama, Garefis. Cement- Definition, etiology, prevention and retained versus screw-retained implant treatment of peri-implantitis - a review. restorations: a critical review. The Head Face Med. 2014; 10:34. International journal of Oral and 8. Modi R, Mittal R, Kohli S, Singh A, Sefa I. Maxillofacial implants 2003; 18(5):719- S c r e w v e r s u s C e m e n t R e t a i n e d 28. Prosthesis: A Review. Int J Adv Health Sci 4. SanathShetty, AditiGarg, K. Kamalakanth 2014; 1(6):26-32. Shenoy. Principles of screw-retained and 9. Muhammad-HasanHameed. Marginal cement-retained fixed implant prosthesis: bone loss around cement and screw- A c r i t i c a l r e v i e w. J o u r n a l o f retained fixed implant prosthesis. J Interdisciplinary Dentistry 2014; 4(3). ClinExp Dent. 2018; 10(10):949-54. 5. Amilcar C, Freitas J, Estevam A. Effect of 10. Litty Francis. Clinical and Radiological

18 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. Evaluation of Screw-retained and 18. TorstenJemt. Cemented CeraOne® and Cement-retained Single-implant Porcelain Fused to TiAdapt™ Abutment Restorations - A Comparative Study.Int J Single-Implant Crown Restorations: A 10- Oral Care Res 2018; 6(2):60-66. Year Comparative Follow-Up Study. 11. Shi. Peri-implant conditions and marginal Clinical Implant Dentistry and Related bone loss around cemented and screw- Research 2009; 11(4). retained single implant crowns in 19. Carl J. Drago. Immediate Occlusal posterior regions: A retrospective cohort Loading of Osseotite Implants in study with up to 4 years follow-up. PLOS Mandibular Edentulous Patients: A ONE 2018; 13(2). Prospective Observational Report with 12. Alberto Ferreiroa, Miguel Peñarrocha- 18-Month Data. J Prosthodont 2006; Diago, Guillermo Pradíes, María- 15:187-194. Fernanda Sola-Ruiz.Cemented and screw- 20. A. L. De Boever, K. Keersmaekers. retained implant-supported single-tooth Prosthetic complications in fixed restorations in the molar mandibular e n d o s s e o u s i m p l a n t - b o r n e region: A retrospective comparison study reconstructions after an observations after an observation period of 1 to 4 years. period of at least 40 months. Journal of J ClinExpDent. 2015; 7(1):89-94. Oral Rehabilitation 2006; 33:833-839. 13. Crespi R, Cappare P, Gastaldi G, Gherlone 21. Paolo Vigolo, Dr Odont. Cemented Versus EF. Immediate occlusal loading of full- Screw-Retained Implant-Supported arch rehabilitations: screw-retained S i n g l e - To o t h C r o w n s : A 4 - y e a r versus cement-retained prosthesis. An 8- Prospective Clinical Study. Int J Oral year clinical evalutation. Int J Oral Maxillofacial Implants 2004; 19:260-265. Maxillofac Implants. 2014; 29(6). 22. Kristina Henriksson, Torsten Jemt. 14. Cha, Kim. Cumulative survival rate and Evaluation of Custom-Made Procera complication rates of single-tooth Ceramic Abutments for Single-Implant implant; focused on the coronal fracture of Tooth Replacement: A Prospective 1-Year fixture in the internal connection implant. Follow-up Study. Int J Prosthodont 2003; Journal of Oral Rehabilitation 2013; 16:626-630. 40:595-602. 23. Brandao ML.Peri-implant bone loss in 15. Paolo Vigolo, Sabrina Mutinelli, Andrea cement- and screw-retained prostheses: Givani, Edoardo Stellini. Cemented Systematic review and meta-analysis. J versus screw-retained implant-supported Clin Periodontol 2013; 40:287-295. s i n g l e - t o o t h c r o w n s : a 1 0 - y e a r 24. C h a r l e s J . G o o d a c r e C l i n i c a l randomised controlled trial. Eur J Oral complications with implants and implant Implantol 2012; 5(4):355–364. prostheses. J Prosthet Dent 2003; 90:121- 16. Joseph Nissan, Demitri Narobai, Oded 32. Ghelfan. Long-Term Outcome of 25. Dale E. Smith. Criteria for success of Cemented Versus Screw-Retained osseointegrated endosseous implants. J Implant-Supported Partial Restorations. Prosthet Dent 1989; 62:567-72. Int J Oral Maxillofacial Implants 2011; 26:1102–1107. 26. Hans P. Weber, David M. Kim. Peri- implant soft-tissue health surrounding 17. Sami Sherif&Srinivas M.Clinician- and cement- and screw retained implant patient-reported long-term evaluation of restorations: a multicenter, 3-year screw- and cement-retained implant prospective study. Clin. Oral Impl. Res. restorations: a 5-year prospective study. 2006; 375-379. Clin Oral Invest 2011; 15:993-999.

19 Manushi Panchal et. al. : EVALUATION OF MARGINAL BONE LOSS IN SCREW- RETAINED VERSUS CEMENT- RETAINED IMPLANT SUPPORTED RESTORATIONS. 27. Wannfots K, Smedberg JI. A prospective 30. Amilcar C. Freitas, Effect of implant clinical evalution of different singletooth connection and restoration design restoration designs on osseointegrated (screwed vs. cemented) in reliability and implants. A 3-year follow-up of failure modes of anterior crowns. Eur J Branemark implants. Clin Oral Implants Oral Sci 2011; 119: 323–330. Res. 1999; 10(6):453-8. 31. Sagar. Implant protected occlusion: A 28. Photoelastic analysis of cemented or comprehensive review. European Journal screwed implant-supported prostheses of Prosthodontics 2013; 1(2). with different prosthetic connections. J Oral Implantol. 2011;37(4):401-10. 29. David L. Guichet, Passivity of Fit and Marginal Opening in Screw- or Cement- Retained Implant Fixed Partial Denture Designs. Int J Oral Maxillofacial Implants 2000; 15:239–246.

20 EVALUATION OF MARGINAL BONE LOSS IN IMPLANTS Review Article WITH VARIOUS COLLAR SURFACE DESIGNS – A SYSTEMATIC REVIEW AND META-ANALYSIS Dr. Chirag Chauhan*, Dr. Darshana Shah**, Dr. Rucha Gandhi***, Dr. Awa Parmar****, Dr. Paras Doshi***** ABSTRACT Aim: The purpose of the present systematic review and meta-analysis was to compare dental implants with different collar surfaces, evaluating marginal bone loss Materials and Methods:The literature was searched electronically and 1014 studies were identified and final 18 studies were included based on the inclusion and exclusion criterias in which the marginal bone loss was evaluated in different implant collar surface designs. Result: In the 18 studies it was concluded that marginal bone loss was seen less in laser collared and microtextured collared implant. Conclusion: The marginal bone loss around microthreaded collared and laser microtextured collared implants were significantly lower than for machined i.e polished and rough collared implants. Keywords: Dental implant, oral implant, collar, surface design, bone remodeling, and marginal bone loss.

INTRODUCTION: has led to the development of implants with new Osseointegration is an essential requirement for collar configuration and surface modification for allowing the survival of dental implants in the jaw improving the soft and hard tissue osseo- bone. Maintenance of osseointegration and a integration. steady state in marginal bone level are imperative. Different implant collar surface characterizations Factors such as unfavorable stress distribution, have been proposed in order to stabilize the surgical trauma, implant-abutment microgap, and marginal bone loss around an implant. bacterial infiltration can detrimentally affect Various implant collar surface characterizations osseointegration and accelerate bone loss. 1-3 include polished collars which are also known as Several factors such as implant surface quality, machined or turned collar; rough surfaced collar, implant neck macro and micro design and crestal in this type the collar surface has been roughened implant position play particularly crucial roles in by various treatments such as acid etching, osseointegration.4-6 sandblasting; in another type of collar surface modification there was an introduction of The long term result of implant-supported microgrooves in the rough surface of collars10; restoration both aesthetically and clinically laser microtextured surfaces11 of implant collars depends on preservation of soft and hard tissues are also used nowadays. around implant, thus the overall amount of marginal bone loss may influence the clinical MATERIALS AND METHOD: success of implants.4 Sources used: The initial breakdown of bone surrounding the An electronic search was conducted for articles in implant takes place in the most coronal portion of English, listed with PubMed, Medline, Embase, the bone-implant interface. 4 Cochrane. Bone resorption of 1.5 to 2 mm is observed during The search methodology applied was combination the first year of function and is generally of MeSH terms and keywords like dental implant, considered a normal physiologic process. oral implant, collar, surface design, bone Successive annual bone loss of 0.2 mm occurs in remodeling, and marginal bone loss. 7-9 subsequent years. Review articles as well as references from Implant collar surface characterization has been different studies were also used to identify the associated with reduced marginal bone loss which relevant articles.

*Professor, **Head Of Department, ***PG Student, ****PG Student, *****Professor

DEPARTMENT OF PROSTHODONTICS AND CROWN AND BRIDGE AHMEDABAD DENTAL COLLEGE AND HOSPITAL

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. CHIRAG CHAUHAN TEL: +91 98241 65096

21 Chirag Chauhan et. al. : MARGINAL BONE LOSS IN IMPLANTS WITH VARIOUS COLLAR SURFACE DESIGNS

Selection of studies: · Case reports. The review process consists of two phases. In first · Studies showing use of implants with phase, titles and abstract of the search were various collar surface characterizations. initially screened by two authors for relevance and the full text of relevant abstract were obtained and · Published in English. assessed. Any disagreements were solved by · Follow up period > 12 months. discussion or third author suggestion, if needed. The hand search of selected journals as well as · Age > 18 years. search of references of the selected studies were Exclusion Criteria: also done. The articles were obtained after first · In vitro studies. step of the review process using the following inclusion and exclusion criteria which were · Finite element analyses. screened in second phase andrelevant and suitable · Animal studies. articles were isolated for further processing and Results of the Search: data extraction. Duplicates and articles with insufficient necessary data were excluded by the The search from the electronic databases identified 1014 publications out of which 612 references were excluded two authors and any disagreements were resolved after reviewing the title and abstracts. From the remaining by the third author suggestions. 402 studies, after excluding the duplicate manuscripts, 39 Inclusion Criteria: studies were eligible for analysis. Upon reading the full texts, 21 studies were excluded based on the exclusion · Randomized Controlled Trials (RCTs). criteria. This resulted in a final number of 18 publications · Prospective studies. for the current systematic review.

First electronic search (n=1014) Articles excluded by reading the titles and abstracts (n=612)

Abstract searched for detailed evalution and full text analysis (n=402)

Articles excluded due to duplication (n=363) Articles without duplication (n=39)

Articles excluded based on exclusion criteria (n=21)

Articles included in the systematic review (n=18)

22 Chirag Chauhan et. al. : MARGINAL BONE LOSS IN IMPLANTS WITH VARIOUS COLLAR SURFACE DESIGNS

SUMMARY OF THE CHARACTERISTICS OF THE INCLUDED STUDIES.

23 Chirag Chauhan et. al. : MARGINAL BONE LOSS IN IMPLANTS WITH VARIOUS COLLAR SURFACE DESIGNS

Table showing comparative mean of marginal bone loss in implants with different collar surface designs

Graph showing comparative mean of marginal bone loss in implants with different collar surface designs

Forest plot

24 Chirag Chauhan et. al. : MARGINAL BONE LOSS IN IMPLANTS WITH VARIOUS COLLAR SURFACE DESIGNS

DISCUSSION: compared with normal acid etched roughened The present systematic review showed that surface. implants with machined, rough surface, Meanwhile the other study by Linkevicious11 only microthreaded and LMS collars had an influence included implant sites with soft tissue thickness on the rate of marginal bone loss as compared to less than 2mm. A minimum 2 mm of soft tissue the machined collar implants. Thus the null thickness is required for the establishment of hypotheses of the study that there would be no biologic width and in presence of thin tissue difference in the marginal bone loss for different higher values of marginal bone loss can occur. implant collar surfaces was rejected. The result of the selected studies revealed that Irrespective of the implant system, design, or marginal bone loss was decreased around surgical approach, it has been shown that a microthreaded and laser microtextured implants biologic width >3 mm or equal to 3mm will be as compared to rough collared and machined established once an implant becomes uncovered. collared implants. If this soft tissue thickness is not present, peri An important issue to consider is the presence of implant bone loss will occur to accommodate the several confounding factors in the included necessary soft tissue dimension.30 studies. Implant abutment connection being an In vivo experiments revealed that the rough important factor in marginal bone loss the most of surface dental implants enhanced the bone to the comparative studies included were having implant interface and lowered the rate of bone loss different implant abutment connections and with compared with smooth surfaces.30 Moreover the or without platform switching. presence of microthread might provide an The methods of radiographic evaluation of increased inter locking of the implant and the marginal bone loss were also different in the marginal bone thus reducing the marginal bone different included studies. loss.16 Hansson31 found that the implant surface In the studies rehabilitating the patients with fixed roughness at the implant collar area leads to an prostheses the effects of splinting were not increased interfacial shear strength and effective discussed. Splinting dissipates the loads between in counteracting marginal bone loss. The implants and reduces the stress and hence can investigations done by Hallman15 and Astrand² influence the result. found no clinically significant difference in CONCLUSION: marginal bone loss between a machined collar Hence, summarizing and highlighting the implant and a rough collared implant. findings of the included studies the marginal LMS collar is effective for prevention of peri bone loss in implants with various collar surface implant bone loss. The reason is a firm connective characterizations are: tissue attachment to LMS collar can diminish 1. For machined surface collars 1.36 mm apical migration of the epithelial tissue and 2. For rough surfaced collars 1.62 mm prevent the invasion of bacterial toxin, conferring 33 3. For implants with microthreads in their resistance to the alveolar bone against resorption. collars 0.805 mm Between LMS and roughened surface collars, no 4. For implants with laser microtextured surface significant difference in marginal bone loss was collars 0.89 mm detected in some studies. However in those studies 5. The comparative mean of marginal bone loss the roughened surface group in one study by 26 is 0.89mm Hegazy was nano surface treated. It has been Within the limitations of this study, the present reported that the nanoscale textured can augment systematic review indicates that the marginal bone surface energy and improve osseointegration. changes around microthreaded collared and laser This may indicate that both the LMS and the microtextured collared implants were nanosurface textured collar implants have an significantly lower than for machined i.e polished effect on marginal bone loss. It has been reported and rough collared implants. that nanoscale textured surface can augment surface energy and improve osseointegration

25 Chirag Chauhan et. al. : MARGINAL BONE LOSS IN IMPLANTS WITH VARIOUS COLLAR SURFACE DESIGNS

REFERENCES: Research, 1992 vol. 3, no. 4, pp. 181 188, 1. H. E. K. Bae,M.-K.Chung, I.-H. Cha, andD.- 10. A.M. Al-Thobity, A. Kutkut, K. Almas, H.Han, “Marginal tissue response to different Microthreaded implants and crestal bone loss: implant neck design,” The Journal of Korean a systematic review, J. Oral Implantology. Academy of Prosthodontics,2008 vol. 46, no. 2017 43 157–166 . 6, pp. 602–609. 11. Linkevicius T1, Puisys A, Svediene O, 2. Qian, Jie & Wennerberg, Ann & Albrektsson, Linkevicius R, Linkeviciene L Radiological Tomas. (2012). Reasons for Marginal Bone comparison of laser-microtextured and Loss around Oral Implants. Clinical implant platform-switched implants in thin mucosal dentistry and related research. 2012; 14(6) biotype. Clin Oral Implants Res. 2015 May; 3. N. Broggini, L. M. McManus, J. S. Hermann et 26(5): 599-605 al., “Persistent acute inflammation at the 12. Astrand P, Engquist B, Dahlgren S, Engquist implant-abutment interface,” Journal of E, Feldmann H, Grondahl K. Astra Tech and Dental Research, vol. 82, no. 3, pp. 232–237, Branemark System implants: A prospective 5- 2003 year comparative study. Results after one year. 4. T.-J. Oh, J. Yoon, C. E. Misch, and H.-L.Wang, Clin Implant Dent Relat Res 1999;1:17-26. “The causes of early implant bone loss myth 13. Puchades-Roman L, Palmer RM, Palmer PJ, or science?” Journal of Periodontology, 2002 Howe LC, Ide M, Wilson RF. A clinical, vol. 73, no. 3, pp. 322–333. radiographic, and microbiologic comparison 5. X. Rodrıguez-Ciurana, X. Vela-Nebot, M. of Astra Tech and Branemark single tooth Segala-Torres et al., “The effect of implants. Clin Implant Dent Relat Res 2000;2: interimplant distance on the height of the 78-84. interimplant bone crest when using platform- 14. Van Steenberghe D, De Mars G, Quirynen M, switched implants,” International Journal of Jacobs R, Naert I. A prospective split-mouth Periodontics and Restorative Dentistry, 2009 comparative study of two screw-shaped self- vol. 29, no. 2, pp. 141–151. tapping pure titanium implant systems. Clin 6. Ribes Lainez N, Monreal Bello A, Fuster Oral Implants Res 2000;11:202-209. Torres MA, Peñarrocha Oltra D, Peñarrocha 15. Hallman M, Mordenfeld A, Strandkvist T. A Diago M. Periimplant soft-tissue and bone retrospective 5-year follow-up study of two levels around dental implants with different different titanium implant surfaces used after neck designs and neck surface treatments: A interpositional bone graftingfor reconstruction retrospective cohort study with 3-year follow- of the atrophic edentulous maxilla. Clin up. J Oral Science Rehabilitation. 2017 Implant Dent Relat Res 2005;7:121-126. 3(4):16–23. 16. Lee DW, Choi YS, Park KH, Kim CS, Moon 7. D. E. Smith and G. A. Zarb, “Criteria for IS. Effect of microthread on the maintenance success of osseointegrated endosseous of marginal bone level: a 3-year prospective implants”, The Journal of Prosthetic study. Clin Oral Implants Res 2007;18:465-70. Dentistry, 1989 vol. 62, no. 5, pp. 567–572. 17. G. E. Pecora, R. Ceccarelli, M. Bonelli, H. 8. D. Buser, H. P. Weber, and N. P. Lang, “Tissue Alexander, and J. L. Ricci, “Clinical integration of non-submerged implants. 1-year evaluation of laser microtexturing for soft results of a prospective study with 100 ITI tissue and bone attachment to dental hollow-cylinderand hollow screw implants,” implants,” Implant Dentistry, 2009 vol. 18, no. Clinical Oral Implants Research, 1990 vol. 1, 1, pp. 57–66 no. 1, pp. 33–40. 18. E. A. Bratu, M. Tandlich, and L. Shapira, “A 9. H. P. Weber, D. Buser, J. P. Fiorellini, and R. C. rough surface implant neck with microthreads Williams, “Radiographic evaluation of crestal reduces the amount of marginal bone loss: a bone levels adjacent to nonsubmerged prospective clinical study,” Clinical Oral titanium implants, ” Clinical oral Implants Implants Research, 2009 vol. 20, no. 8, pp.

26 Chirag Chauhan et. al. : MARGINAL BONE LOSS IN IMPLANTS WITH VARIOUS COLLAR SURFACE DESIGNS

827–832 treatment of early loaded implant-retaining 19. M M. Goswami, “Comparison of crestal bone mandibular overdentures. Int J Oral loss along two implant crest module Maxillofac Implants 2016; 31:424-430. designs,” Medical Journal Armed Forces 27. Ana Messias, Ignacio Sanz‐Sánchez, Ana India,2009 vol. 65, no. 4, pp. 319–322 Carrillo de Albornoz, Pedro Nicolau, Tom 20. S. Botos, H. Yousef, B. Zweig, R. Flinton, Taylor, Florian Beuer, Alex Schär, Robert and S. Weiner, “The effects of laser Sader, Fernando Guerra and Mariano Sanz, microtexturing of the dental implant collar on Influence of implant neck and abutment crestal bone levels and peri-implant health,” characteristics on peri‐implant tissue health The International Journal of Oral & and stability. Oral reconstruction foundation Maxillofacial Implants,2011 vol. 26, no. 3, pp. consensus report, Clinical Oral Implants 492–498. Research, 2019; 30:6 (588-593). : 21. H.-J. Nickenig,M.Wichmann, A.Happe, J. E. 28. Klenise Silva Paranhos., et al. “The Effect of Z¨oller, and S. Eitner,“A 5-year prospective Implant Collar Design and Development over radiographic evaluation of marginal bone the Years on Soft Tissue and Bone Level– A levels adjacent to parallel-screw cylinder Systematic Review and Meta-Analysis”. Acta machined neck implants and rough-surfaced Scientific Dental Sciences 2019Volume 3 microthread implants using digitized issue 11: 97-109. panoramic radiographs,” Journal of Cranio- 29. Berglundh T, Lindhe J. Dimension of the peri- Maxillofacial Surgery, 2013 vol. 41, no. 7, pp. implant mucosa. Biologic width revisited J 564–568. Clin Periodontoln 1996; 23:971-973. 22. Bassetti R, Kaufmann R, Ebinger A, 30. N. Sato, T. Kuwana, M. Yamamoto et al., Mericske-Stern R, Enkling N. Is a grooved “Bone response to immediate loading through collar implant design superior to a machined titanium implants with different surface design regarding bone level alteration? An roughness,” Odontology, 2014 vol. 102,no. 2, observational pilot study. Quintessence pp. 249– 258. International 2014;45:221–9. 31. S. Hansson, “The implant neck: smooth or 23. D. Farronato, F. Mangano, F. Briguglio, V. provided with retention elements. A Iorio-Siciliano, F. Riccitiello, and R. biomechanical approach,” Clinical Oral Guarnieri, “Influence of Laser-Lok surface on Implants Research, 1999. vol. 10, no. 5, pp. immediate functional loading of implants in 394–405. single-tooth replacement: a 2-year prospective 32. Hansson S. Implant-abutment interface: clinical study,” The International Journal of Biomechanical study of flat top versus conical. Periodontics & Restorative Dentistry,2014 Clin Implant Dent Relat Res 2000; 2:33-41. vol. 34, no. 1, pp. 79–89. 33. Nevins M, Camelo M, Nevins ML, Schupbach 24. Calvo-Guirado JL, López-López PJ, Pérez- P, Kim DM. Connective tissue attachment to Albacete Martínez C, et al. Periimplant bone laser microgrooved abutments: A human loss clinical and radiographic evaluation histologic case report. Int J Periodontics around rough neck and microthread implants: Restorative Dent 2012;32:385-392 a 5-year study. Clin Oral Implants Res. 2016 . 25. B. A. Gultekin, A. Sirali, P. Gultekin, S. Yalcin, and E. Mijiritsky, “Does thelaser- microtextured short implant collar design reduce marginal bone loss in comparison with a machined collar?” BioMed Research International, 2016, 26. Hegazy S, Elmekawy N, Emera RM. Peri- implant outcomes with laser vs nanosurface

27 OPTIMUM NUMBER OF ORAL IMPLANTS REQUIRED FOR Review Article FULL ARCH FIXED PROSTHESIS TO REHABILITATE COMPLETELY EDENTULOUS PATIENTS – A SYSTEMATIC REVIEW AND META-ANALYSIS. Dr. Chirag Chauhan**, Dr. Darshana Shah*, Dr. Shikha Chaudhary***, Dr. Aiyushi Rajpal***, Dr. Aneri Chokshi*** ABSTRACT Statement of problem: Consensus is lacking regarding the optimal number of implants for supporting complete-arch prostheses with good survival rates and lower prosthetic complications and marginal bone loss. . Purpose: The purpose of this systematic review was to evaluate the influence of the number of implants used for complete-arch prostheses with at least 1 year of follow-up. Materials and method: An electronic search was conducted for articles in English, listed with PubMed, Medline, Embase, Cochrane, Google scholar till December 2019. Review articles as well as references from different studies were also used to identify the relevant articles. The search from the electronic databases identified 1025 publications out of which 611 articles were excluded by reading the titles. After evaluation of abstracts, 137 articles were eligible for analysis. After the full text of these articles had been read, 34 studies were excluded for the following reasons: they were retrospective studies, in-vitro studies and animal studies, studies that did not identify the number of implants per jaw per patient, same design and population and inappropriate follow up period and there were insufficient data to rehabilitate completely edentulous patients with optimum number of oral implants. This resulted in a final number of 10 publications for the current systematic review. Results: The implant survival rate in complete-arch prostheses with fewer than 5 implants was 98.7% for both jaws, 99% for the maxilla and 98.9% for the mandible. The implant survival rate in complete-arches prostheses with more than 4 implants was 96.6% for both jaws, 95.61% for the maxilla and 100% for the mandible. Conclusion: there is no significant difference in longevity when fewer than 5 implants or more than 4 implants are used for complete-arch implant-supported prosthesis. Thus, the number of implants used in complete-arch prostheses does not influence implant survival rate, prosthesis complications or marginal bone loss in studies with a follow-up period of 5 to 15 years. Keywords: Optimum number of implants, Implant survival rates, Full arch rehabilitation

INTRODUCTION: of more than 4 implants per jaw include Complete dentures are the most common insufficient bone height and anatomic features prostheses for the rehabilitation of edentulous such as the mandibular canal or maxillary sinus. Increasing the number of implants per jaw also patients and can restore both function and [3] esthetics. However, complete dentures have increases cost . limitations, including discomfort, decreased The “all-on-four” technique emerged to masticatory efficiency and instability of the maximize the use of the remaining atrophic ridge. prosthesis, more specifically in mandibular In this technique, 4 implants (2 axial anterior and 2 dentures. All of these can directly affect the quality tilted distal) are placed to support an immediately of life [1]. loaded complete-arch prosthesis [4]. Malo et al Implants have revolutionized the way described this technique, with data for up to 10 edentulous patients are rehabilitated and have years of follow-up, indicating long-term success. immensely improved their quality of life. Dental This arrangement with angled distal implants technology has been in overdrive over the past increases the support of the prosthesis and is decade to bring in a wide variety of prosthetic intended to reduce the length of the cantilever. solutions to restore completely edentulous patients Reducing the number of implants in complete- using implants. arch rehabilitation slightly increases stress in the Branemark et al [2] suggested the use of a abutment and bar-retaining screws. However, the minimum of 6 to 8 implants in the mandible and up biomechanics are similar in a prosthesis supported to 14 implants in the maxilla for each complete by fewer implants. Thus, a follow up is important arch rehabilitation. Difficulties with the placement for analyzing the longevity of implant-supported

*Head of the Department, **Professor, ***PG Student

DEPARTMENT OF PROSTHODONTICS AND CROWN AND BRIDGE AHMEDABAD DENTAL COLLEGE AND HOSPITAL

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. SHIKHA CHAUDHARY TEL: +91 9427498246 Email id: [email protected] 28 Shikha Chaudhary et. al. : ORAL IMPLANTS REQUIRED FOR FULL ARCH FIXED PROSTHESIS TO REHABILITATE COMPLETELY EDENTULOUS PATIENTS prostheses and the complications related to each i Minimum follow-up period of at least one year type of prosthesis. i Studies on completely edentulous patients for There are, however, several variables to be both arches considered when discussing the number of i The number of implants placed per jaw per implants utilized to support a complete-arch fixed patient restoration. These include the soft and hard tissue i conditions of the edentulous jaw, distribution of Study should include a minimum of 10 patients the implants, anatomic risks, aesthetics and facial rehabilitated with a full fixed prosthesis in one appearance, choice of material and design of or both jaws supported by implants prostheses, type of retention of the prostheses and i Studies report on Implant survival rate and type and timing of occlusal loading [5]. Complications Consensus regarding the ideal number of i Prospective studies implants for complete-arch prostheses is currently i Randomized controlled trials (RCTSs) lacking. The purpose of this systematic review is Exclusion Criteria: to evaluate the outcomes of complete-arch prostheses in studies with different numbers of i Non-clinical studies implants. i Retrospective studies i Animal subjects AIM: i Case reports and case series The aim of this systematic review is to evaluate the i In vitro studies influence of the number of implants utilized to i Studies that did not identify the number of support complete-arch prostheses in the implants per jaw per patient completely edentulous maxilla and mandible. OBJECTIVES: i To evaluate the optimum number of implants used for complete-arch implant-supported prostheses. i To evaluate an implant survival rate and the complication rate for full arch implantsupported prostheses.

MATERIALS AND METHOD: An electronic search was conducted for articles in English, listed with PubMed, Medline, Embase, Cochrane, Google scholar till December 2019. The search methodology applied was combination of MeSH terms and keywords like Dental implants, Number of Implants, Implant supported completely full arch fixed prostheses, Implant survival rates, Biological complication, Mechanical complication, Edentulous mandible, Edentulous maxilla. Review articles as well as references from different studies were also used to identify the relevant articles. Inclusion Criteria:

29 Shikha Chaudhary et. al. : ORAL IMPLANTS REQUIRED FOR FULL ARCH FIXED PROSTHESIS TO REHABILITATE COMPLETELY EDENTULOUS PATIENTS

Potentially relevent publication identified from databases (n=1025)

Articles excluded by reading the title (n=611)

Abstract selected reading the title (n=414)

Articles excluded by reading the abstracts (n=277)

Abstract searched for detailed evalution (n=137)

Articles excluded based on inclusion criteria (n=93)

Articles and cited articles included for full text analysis (n=44)

Articles excluded based on the exclusion criteria (n=34)

Articles included in this systematic review (n=10)

Flow-chart of the search strategy

30 Shikha Chaudhary et. al. : ORAL IMPLANTS REQUIRED FOR FULL ARCH FIXED PROSTHESIS TO REHABILITATE COMPLETELY EDENTULOUS PATIENTS Summary of the included studies for implant survival rates and complications in implant prosthesis

Sr. Author Total no. Region Total Number Follow Implant Loading Retent Mecha Biolog No. (year) of of number of of up(years) survival ion nical ical patients rehabilitat implants implants rate % compli compli ion per jaw cation cation

1 Agliradi et al, 173 Maxilla, 692 4 5 Years Maxilla Immediate Screw- 14 2 2010 Mandible 98.36 provisional retained Mandie 99.73

2 Ayna et al, 16 Mandible 64 4 7 Years 100 Immediate Screw- 2 3 2018 provisional retained

3 Francetti et al, 47 Maxilla, 196 4 5 Years 100 Immediate Screw- 8 2 2012 Mandible provisional retained

4 Malo et al, 245 Mandible 980 4 10 Years 93.8 Immediate Screw- 4 6 2011 provisional retained

5 Mertens et al, 17 Maxilla 99 6-8 8 Years 99 Conventional Screw- 8 3 2011 retained

6 Cannizzaro et 80 Mandible 160 2 5 Years 98.75 Immediate Screw- 9 3 al, 2016 provisional retained

7 Shigera et al, 27 Maxilla, 189 6 or 5 5 Years 100 Immediate Screw- 11 NR 2015 Mandible provisional retained

8 Tallarico et al, 40 Maxilla 200 4 or 6 5 Years G1 : 98.75 Immediate Screw- 6 2 2016 G2 : 95 provisional retained

9 Tealdo et al, 49 Maxilla 260 T :4-6 6 Years T :93.9 T:immediat Screw- 12 NR 2014 C :6-9 C :95.9 provisional retained C: delayed

10 Jokstad et al, 35 Mandible 140 4 5 Years 100 Delayed Screw- NR NR 2014 retained

RESULTS A total of 2980 implants were placed and a total of 728 patients (mean age of 60 years) were evaluated. The number of implants per jaw ranged between 2 and 9 in the maxilla, mandible, or both jaws. The antagonist arch had natural teeth, a removable partial denture, a tooth-supported fixed prosthesis, an implant-supported prosthesis or a complete denture.

Implant survival rate in complete-archprosthesis with Implant survival rate in complete-archprosthesis fewer than 5 implants per jaw with morethan 4 implants per jaw

101 102 100 100 99 98 98 96 97 96 94 95 92 94 90 93

yna et al A Malo et al allarico etJokstad al et al ealdo et al Agliardi et al T Francetti et al ellarico et al T Mertens et al T Cannizzaro et al Shigehara et al

31 Shikha Chaudhary et. al. : ORAL IMPLANTS REQUIRED FOR FULL ARCH FIXED PROSTHESIS TO REHABILITATE COMPLETELY EDENTULOUS PATIENTS Forest plot for implant survival rate in complete-arch prostheses with fewer than 5 implants per jaw

Forest plot for implant survival rate in complete-arch prostheses with more than 4 implants per jaw

Effect On The Implant Survival Rate In Some studies have reported that a reduction in Complete-Arch Prostheses the number of implants in complete-arch The implant survival rate in complete-arch prostheses contributes to increased stress on the prostheses with fewer than 5 implants was 98.7% structures. However, distribution in addition to the for both jaws, 99% for the maxilla and 98.9% for number of implants may affect rehabilitation. The the mandible. The pooled weighted event rate was all-on-four technique was developed to overcome 1.4%. anatomic limitations and reduce the cantilever. The high survival rates for this technique may be The implant survival rate in complete-arches attributable to appropriate patient selection prostheses with more than 4 implants was 96.6% because implant loss can be higher in patients with for both jaws, 95.61% for the maxilla and 100% local or systemic disease. Moreover, implant for the mandible. The pooled weighted event rate survival rates also depend on the amount of was 4.2%. residual ridge, independent of the arch. In DISCUSSION complete-arch prostheses, the failure of only 1 The number of implants utilized to support a implant represents a failure of the entire complete- complete-arch prosthesis is one of the popular arch prosthesis. Therefore, the use of at least 5 topics discussed since the beginning of implant implants in the mandible and 6 in the maxilla dentistry and still remains of interest, due to the could be indicated for immediate complete- arch several implications derived from the influence on prostheses. A study reported no impairment of the outcomes regarding the decision to place less rehabilitation in situations with at least 5 implants or more implants [16]. in the mandible and 6 implants in the maxilla.

32 Shikha Chaudhary et. al. : ORAL IMPLANTS REQUIRED FOR FULL ARCH FIXED PROSTHESIS TO REHABILITATE COMPLETELY EDENTULOUS PATIENTS Implant survival rates should not be evaluated compare different numbers of implants with the without assessing correlation with prosthesis same design (fewer than 5 implants versus more success rates [9]. than 4 implants); only 2 studies provided this The mean complication rate for complete-arch direct comparison. According to the results of prostheses was 15.75%. This indicates that these studies, the number of implants did not number of implants is independent of the influence the evaluated outcomes. Nevertheless, complication rate. The most common more RCTs are needed to evaluate the direct effect of the number of implants on treatment longevity complications observed in the selected studies [13] were screw loosening and acrylic resin fracture [17]. . These complications may occur because CONCLUSION individuals with a complete denture recover their Based on the findings of this systematic review, masticatory there is no significant difference in longevity when efficiency and change their diet from soft to fewer than 5 implants or more than 4 implants are harder foods, causing fracture of the acrylic resin. used for complete-arch implant-supported Furthermore, when the masticatory forces are prosthesis. Thus, the number of implants used in applied to the distal extension of the prostheses, complete-arch prostheses does not influence screw loosening/fracture or acrylic resin fracture implant survival rate, prosthesis complications or can occur, perhaps secondary to marginal bone marginal bone loss in studies with a follow-up loss. period of 5 to 15 years. However, additional key variables should ultimately be considered by The distribution of implants is as important as clinicians when planning treatment for edentulous the number of implants. Biomechanical studies arches such as prosthesis material, one-piece or have reported that the increase in stress is related segmented prostheses, aesthetic factors (lip to the increase in cantilever length, which could support, smile line), opposing dentition, available also contribute to increased bone resorption [18] prosthetic space, anatomy of the edentulous ridge around the implant . (maxilla, mandible, bone volume and quality, One limitation of the present systematic anatomic limitations), distribution of implants in review was that most of the selected studies did not the arch, cantilever length, hygiene space, patient directly describe the groups used to evaluate and preference and compliance.

BIBLIOGRAPHY Penarrocha-Diago M. The all-on-four treatment concept: Systematic review. J 1. Lemos CA, Verri FR, Batista VE, Junior JF, Clin Exp Dent 2017;9:e474-88. Mello CC, Pellizzer EP. Complete 5. Polido W, Aghaloo T, Emmett T, Taylor T, overdentures retained by mini implants: a Mortoon D. Number of implants placed for systematic review. J Dent 2017;57: 4-13. complete-arch fixed prostheses: A 2. Branemark PI, Svensson B, van systematic review and meta-analysis. Clin Steenberghe D. Ten-year survival rates of O r a l I m p l R e s . 2 0 1 8 ; 2 9 ( S u p p l . fixed prostheses on four or six implants ad 16):154–183. modumbranemark in full edentulism. Clin 6. Agliardi E, Panigatti S, Clerico M, Villa C, Oral Implants Res 1995;6:227-31. Malo P. Immediate rehabilitation of the 3. Kwon T, Bain PA, Levin L. Systematic edentulous jaws with full fixed prostheses review of short- (5-10 years) and longterm supported by four implants: interim results (10 years or more) survival and success of of a single cohort prospective study. Clin full-arch fixed dental hybrid prostheses Oral Implants Res 2010;21:459-65. and supporting implants. J Dent 7. Ayna M, Gulses A, Acil Y. A comparative 2014;42:1228-41. study on 7-year results of “All-on-Four” 4. Soto-Penaloza D, Zaragozi-Alonso R, i m m e d i a t e - f u n c t i o n c o n c e p t f o r

33 Shikha Chaudhary et. al. : ORAL IMPLANTS REQUIRED FOR FULL ARCH FIXED PROSTHESIS TO REHABILITATE COMPLETELY EDENTULOUS PATIENTS completely edentulous mandibles: metal- mandible: a randomized clinical trial over ceramic vs. bar-retained superstructures. 5 y e a r s . C l i n O r a l I m p l a n t s R e s Odontology 2018;106:73-82. 2014;25:1325-35. 8. Francetti L, Romeo D, Corbella S, 16. Tunkiwala A, Kher U, Bijlani P. Numerical Taschieri S, Del Fabbro M. Bone level guidelines for selection of implant changes around axial and tilted implants in supported prostheses for completely full-arch fixed immediate restorations. edentulous patients, Quitessence INDIA Interim results of a prospective study. Clin 2017;1(1):47-54. Implant Dent Relat Res 2012;14:646-54. 17. Goodacre C, Goodacre B. Fixed vs 9. Malo P, de Araujo Nobre M, Lopes A, removable complete arch implant Moss SM, Molina GJ. A longitudinal study prostheses: a literature review of of the survival of all-on-4 implants in the prosthodontic outcomes. Eur J Oral mandible with up to 10 years of follow-up. Implantol 2017;10:13-34. J Am Dent Assoc 2011;142:310-20. 18. Sertgöz A, Güvener S. Finite element 10. Mertens C, Steveling HG. Implant- analysis of the effect of cantilever and supported fixed prostheses in the implant length on stress distribution in an edentulous maxilla: 8-year prospective implant-supported fixed prosthesis. results. Clin Oral Implants Res J Prosthet Dent 1996;76:165-9. 2011;22:464-72. 11. Cannizzaro G, Felice P, Lazzarini M, Ferri V, Leone M, Trullenque-Eriksson A, et al. Immediate loading of two flapless placed mandibular implants supporting cross- arch fixed prostheses: a 5-year follow-up prospective single cohort study. Eur J Oral Implantol 2016;9:165-77. 12. Shigehara S, Ohba S, Nakashima K, Takanashi Y, Asahina I. Immediate loading of dental implants inserted in edentulous maxillas and mandibles: 5-year results of a clinical study. J Oral Implantol 2015;41:701-5. 13. Tallarico M, Meloni SM, Canullo L, Caneva M, Polizzi G. Five-year results of a randomized controlled trial comparing patients rehabilitated with immediately loaded maxillary cross-arch fixed dental prosthesis supported by four or six implants placed using guided surgery. Clin Implant Dent Relat Res 2016;18:965- 72. 14. Tealdo T, Menini M, Bevilacqua M, Pera F, Pesce P, Signori A, et al. Immediate versus delayed loading of dental implants in edentulous patients' maxillae: a 6-year prospective study. Int J Prosthodont 2014;27:207-14. 15. Jokstad A, Alkumru H. Immediate function on the day of surgery compared with a delayed implant loading process in the

34 FORENSIC DENTAL RADIOLOGY: A REVIEW Review Article

Dr. Rutu Jani*, Dr. Twinkal Patel**, Dr. Manisha Lalwani***, Dr. Surina Sinha**** ABSTRACT The word 'forensic' has been derived from the Latin word 'Forensis', which implies something pertaining to 'forum'. Forensic Medicine is the application of medical science to legal problems. It is typically involved in cases concerning blood relationship, mental illness, injury, or death resulting from violence. Autopsy is often used to determine the cause of death. Forensic Odontology refer to the study of teeth or dentistry. 'That branch of dentistry which, in the interest of justice, deals with the proper handling and examination of dental evidence, and with the proper evaluation and presentation of dental findings in order to assist law enforcement officers and in civil & criminal proceedings. In addition to a clinical examination and the annotations on a patient's clinical file, the forensic dentist can make use of dento-maxillo-facial radiography. Forensic dental radiology deals with comparison of ante-mortem and post-mortem radiographs. When bodies are to be identified, radiographs are made of the deceased person and compared with any radiographs of the presumed individual when alive. Radiographs are becoming more and more important in dental identification: as oral health is improving, oral diseases are regressing and consequently therapeutic features for comparison are decreasing. The positions of the post-mortem skull relative to the radiographic machine and the film, as well as the exposure time, are the greatest problems faced by the forensic dentist. In view of this fact, some recognize that radiographic techniques used in vivo must be adapted. Keywords: forensic radiology, forensic odontology, forensic dental radiology

INTRODUCTION: after the assassination attempt on him after the Forensic Dentistry / Forensic Odontology Second World War. In the hospital three refer to the study of teeth or dentistry. Forensic roentgenograms of his skull were obtained with Odontology, therefore, has been defined by the distinctive dental work. These earlier films were Federation Dentaire Internationale (FDI) as 'that compared with those taken of the burned remains branch of dentistry which, in the interest of justice, found in the ruins of the chancellery garden, and a deals with the proper handling and examination of positive identification was possible. It was used in the identification of Adolf Hitler and his wife dental evidence, and with the proper evaluation 5 and presentation of dental findings in order to Eva Braun at the end of World War II. assist law enforcement officers and in civil & With the above background, my review is on criminal proceedings.' The role of such an expert is forensic dental radiology and its various to identify bodies and skeletal remains from dental applications in the field of forensic emphasized in records, reconstruct faces from skulls as well as further sections. connect the crime scene with whatever little 1,2,3,4 E Q U I P M E N T S & T E C H N I C A L evidence is available from the scene. MODIFICATIONS Forensic dental Radiology usually comprises For accurate assessment of age and other the performance, interpretation, and reportage of identification details, quite apart from exact those radiological examinations and procedures 1 reproduction of ante mortem radiographs, that have to do with the courts and/or the law. necessitates the separation of the skull from the In 1944, on September 19th Adolph Hitler was spine so that the skull can be taken to a dental driven to an army field hospital at Rastenburg; surgery or x-ray department. (Chart-1)

* PG Student, **PG Student, ***Head of the Department, ****Reader DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

PRETORIA UNIVERSITY, SOUTH AFRICA ADDRESS FOR AUTHOR CORROSPONDENCE : DR. TWINKAL PATEL, TEL: +91 97148 02656 35 Twinkal Patel et. al. : FORENSIC DENTAL RADIOLOGY

above the object (anode object distance usually about 80-120 cm).The decomposed object too fragile to be moved requires radiography. This is usually combined with soil and gravel, in which case it is very radiolucent and the exposure factors must be reduced, preferably with a low kilovoltage. Alternately the specimen could be set in concrete like a fossil, here a high kilovoltage giving greater differentials is recommended.8 · In the dental surgery or x-ray room: – The specimen, whether it is a complete skull or a small portion of the mandible, maxilla or facial bones, down even to individual teeth, the main problem is to immobilize and control the position of the object.6,9 Radiographs may need to be taken at the scene of the accident or crime, at the mortuary, or in the – This combined with the ultra-mobility of the hospital x-ray department or dental surgery.3 In dental x-ray apparatus, makes careful 6,9 practicality, for accurate assessment of age and monitoring essential. other identification details, quite apart from exact · Procedure: reproduction of ante mortem radiographs, – Leave the specimen on a plastic or other necessitates the separation of the skull from the radiolucent rigid surface. Immobilize the spine so that the skull can be taken to a dental 7 specimen in the required position with plastic surgery or x-ray department. Modifications are foam pads or other radiolucent material or required in the normal procedures followed, cotton rolls. requiring the operator to adopt techniques to suit individual patients.6It is also important to note that – Place the film or cassette under the rigid surface. the beam may travel through structures with – Position the x-ray tube as required.6,10 different thickness when comparing the ante SCOPE mortem to the post-mortem exposure, i.e. an inflammatory process or increased cheek thickness The scope of forensic applications of may cause a change in the density of the image diagnostic dental radiology as currently understood obtained in the ante mortem radiograph as and practiced can be summarized in the following 11,12 compared with the post mortem radiograph. Teeth manner: and bones that have been incinerated or immersed I. IDENTIFICATION in water for a long period of time, or that have been i. Comparative Identification subjected to other effects of nature, may show variation in structural density, or in the material Individual Identification – Identifying unknown used to restore the teeth.7 human remains through comparison of post-mortem dental evidence with dental records of the presumed A dry skull has a lower density than a live skull; deceased. 11 therefore, the kVp to be used should be lower. Skulls with vestiges of soft tissue should be Identification in Mass disaster – Assisting at the scene of a mass disaster and in the victim's exposed with half to two-thirds of the normal 13,14 exposure time.6,7 identification. A portable x-ray apparatus is used. The only ii. Reconstructive / profiling radiographic projection possible is an Race – Eliciting the ethnicity/population affinity anteroposterior view of the skull. The x-ray cassette and assisting in building up a picture of lifestyle and protected by a plastic bag is placed under the skull diet with the help of skeletal remains at forensic and and the x-ray tube positioned as far as possible archaeological sites. 6

36 Twinkal Patel et. al. : FORENSIC DENTAL RADIOLOGY

Sex - Estimation of sex is of immense help in The radiographic images must be such that they identification of human remains investigation and include developing teeth of interest and that all the solving crimes. Determination of sex by anatomical stages of dental development can be rated according method which includes skull, angle of mandible to chosen development standards.7 6,7,11,15 and tooth morphology. In humans, age determination is done for various Age - The age assessment methods are reasons. Age determination of cadavers is carried relatively simple and involve the identification of out for reasons such as criminal cases and very the stage of mineralization on radiographic images mutilated victims of mass disasters, such as fires, followed by their comparison with the standard crashes, accidents, homicides, feticides and stage to estimate the approximate age range.6,7 infanticides, etc. In living persons, the age II. CHILD ABUSE AND NEGLECT: estimation is done to assess whether the child has attained the age of criminal responsibility in cases Child abuse may be defined as any act of such as rape, kidnapping, employment, marriage, commission or omission that endangers or impairs premature births, adoption, illegal immigration, a child's physical or emotional health and pediatric endocrinopathy, orthodontic malocclusion development. Such acts include physical, sexual, or and when the birth certificate is not available and emotional abuse, as well as physical neglect, records are suspect. 6,7 inadequate supervision, and emotional deprivation. Child abuse is second only to SIDS (Sudden Infant In forensic radiology, there is a need to assess the Death Syndrome) as the leading cause of death in chronological age, which is the actual age of the children under one year of age. In older children it is patient. The stages of tooth formation can be used to estimate the chronological age in young persons by second only to accidents. It is now widely agreed 19 that an absolutely crucial factor in the fight against applying the appropriate dental survey. child abuse is early recognition of the problem so The triad for odontological age estimation can be that effective intervention can be undertaken.16,17 listed as: 19 III. MALPRACTICE AND NEGLIGENCE: 1) The subject for age estimation A forensic dentist is often called upon to review 2) Appropriately chosen dental development survey cases by both defence and plaintiff attorneys 3) Legal consideration. because of the courtroom experience of the forensic The radiological age determination is based on dentist. Nothing is more difficult and challenging 19 than a dental malpractice case. Evidence review assessment of various features as follows: including the defendant dentist records and charts, 1. Jaw bones prenatally (Figure:1) x-rays, models, hospital reports, etc. are crucial, subsequently treating doctors and their statements will play a vital role in the overall opinions formed. As with all forensic analysis the more data that is provided and the interrelationship between this data provides for the most accurate and truthful opinion in the cases.16,17,18 IV. PRESENTING EVIDENCE IN COURT AS EXPERT WITNESSES.11,12 ESTIMATION OF AGE FROM TEETH Various radiographic images that can be used in age identification are intraoral periapical radiographs, lateral oblique radiographs, cephalometric radiographs, panoramic radiographs, digital imaging and advanced imaging technologies.7

37 Twinkal Patel et. al. : FORENSIC DENTAL RADIOLOGY

2. Appearance of tooth germs (Figure:2,3,4,5) 3. Earliest detectable trace of mineralization or beginning of mineralization (Figure:4) 4. Early mineralization in various deciduous teeth during intrauterine life (Figure:4) 5. Degree of crown completion (Figure:4) 6. Eruption of the crown into the oral cavity (Figure:4) 7. Degree of root completion of erupted or unerupted teeth (Figure:4) 8. Degree of resorption of deciduous teeth (Figure:4)

Age estimation is grouped into three phases: 19 A. Pre-natal, neonatal and post-natal7 1) Kraus and Jordan method (Figure:1) B. Children and adolescents 1) Schour and Masseler method (Figure:2)19,20,21 2) Moorees, Fanning and Hunt method (Figure:3)22,23 3) Demirjian, Goldstein and Tanner method (Figure:4)24

9. Measurement of open apices in teeth (Figure:6) 10. Volume of pulp chamber and root canals /formation of physiological secondary dentine (Figure:7) 11. Tooth-to-pulp ratio (Figure:7) 12. Third molar development and topography (Figure:8) 13. Digitization of the available radiographs for analysis of images to obtain the dental information. 14. Analysis of these various radiographic features in the dentition of an individual corresponding to the phase of human development aids age determination.

38 Twinkal Patel et. al. : FORENSIC DENTAL RADIOLOGY

4) Nolla's method (Figure:5)19,25 5) Age estimation using open apices (Figure:6)19,25

RECENT ADVANCES – VIRTOPSY Virtopsy is one step towards the end of the old age techniques for autopsy being used. (Figure:9) · Virtopsy basically consists of: (a) body volume documentation and analysis using CT, MR imaging, and microradiology (b) 3D body surface documentation using forensic photogrammetry and 3D optical scanning. 27,28

C. Adults 19,20 1) Volume assessment of teeth (Figure:7) 12,19,20 2) Development of third molar (Figure:8)26

ADVANTAGES OF VIRTOPSY PROCEDURE: 29,30 i. Most effective in study of the wounds including the matching of the probable weapon. The wound can be studied without disturbing the body architecture. ii. No scalpel method, so no hazard of infections from the blood or other tissue fluids. iii. No mutilation of the body. so, can be examined again without any autopsy artifacts. iv. Less time consuming and body can be released immediately after the scanning.

39 Twinkal Patel et. al. : FORENSIC DENTAL RADIOLOGY v. Better acceptance for the relatives of the and blood groups etc. Imaging techniques are a diseased and also by the religious customs as powerful tool in forensic science. Medical incisions not are used. examiners and forensic anthropologists are SUMMARY AND CONCLUSION required to interpret findings from imaging studies to further medico legal investigations. Often, the Forensic odontology includes: dental forensic investigators call on the radiologist, identification, age and sex estimation of an whose expertise proves valuable in forensic individual from teeth, identification in mass investigations and findings. disasters, identification from bite marks, lip prints

REFERENCES edition. Jaypee brothers 2013. 1. Brogdon BG. Forensic Radiology. CRC Press 12. Bell GL. Dentistry's role in the resolution of 1998: 1 – 314. missing and unidentified person's cases. 2. Chanrdashekhar T, Vennila P. Role of Dental Clinics of North America 2001; 45: radiology in forensic dentistry. J Indian Oral 293 – 308. Med Radiol 2011; 23(3): 229 – 31. 13. Gaurav S, Mukesh Y, Harnam S, Aggarwal D, 3. Kahana T, Hiss J. Forensic radiology. Brit J of Raminder S. Forensic Odontology: Role in Radiol 1999; 72: 129 – 33. Mass Disasters. J Indian Academy Forensic Med 2006; 28(2): 105 – 8. 4. Rehani S, Chanrashekhar C, Radhakrishnan R. The Role of Radiography in Forensic 14. Voelker M. forensic dentistry. Crest oral-B at Dental Practice. Indian J Dent Res 2011; dentalcare.com continuing education course, 3(1): 413 – 7. 2012: 1 – 19. 5. H a p p o n e n R P e t a l . U s e o f 15. Aghayev E et al. Virtopsy post-mortem multi- o r t h o p a n t o m o g r a p h s i n f o r e n s i c slice computed tomography (MSCT) and identification. Am J Med Pathol 1991; 12(1): magnetic resonance imaging (MRI) 41 – 9. demonstrating descending tonsillar herniation: comparison to clinical studies. 6. Karjodkar FR. Role of dental radiology in Neuroradiology 2004; 46: 559 – 64. forensic odontology. Text book of dental and maxillofacial radiology. 2nd ed. Jaypee 16. Brown T. Radiography's role in detecting Brothers Medical Publishers (P) Ltd 2009: child abuse. Radiol Technol 1995; 66: 389 – 929 – 63. 90. 7. Achary AB, Sivapathasundharan B. Forensic 17. Cramer EC. Orthopedic aspects of child odontology. Shafer's textbook of oral abuse. Orthop Clin North Am 1996; 43: 1035 pathology. 6th edition. Elsevier 2009: 871 – – 51. 92. 18. Averill D. manual of forensic odontology. 8. Langland O, Langlais R: Principles of Dental ASFO manual 1991, 1 – 353. Imaging, 1st edition, Williams & Wilkins 19. Panchbhai AS. Dental radiographic 2006. indicators, a key to age estimation, 9. K. Nicopoulou-Karayianni, A. G. Mitsea, K. Dentomaxillofacial Radiol 2011; 40: 199 – Horner. Dental diagnostic radiology in the 212. forensic sciences: two case presentations. J 20. Willems G. Dental Age Estimation in Belgian Forensic Odontostomatol 2007; 25(1): 12 – Children: Demirjian's Technique Revisited. J 6. Forensic Sci 2001; 46(4): 893 – 5. 10. Suzana P. Use of images for human 21. Phillips VM, van Wyk Kotze TJ. Testing identification in forensic dentistry. Radiol standard methods of dental age estimation by Bras 2009; 42(2): 125 – 30. moorees, fanning and hunt and demirjian, 11. Nitul J. Textbook of forensic odontology. 1st goldstein and tanner on three south African

40 Twinkal Patel et. al. : FORENSIC DENTAL RADIOLOGY

children samples. J Forensic Sci 2003; 47(5): 27. Patowary AJ. Virtopsy: one step forward in 20 – 8. the field of forensic medicine - a review. J 22. Moorees CFA et al. Age variation of Indian Acad Forensic Med 2005; 30(1): 32 – formation stages for ten permanent teeth. J 6. Dent Res 1963; 42: 1490 – 1502. 28. Dirnhofer R et al. Virtopsy: minimally 23. Nolla CM. Development of the permanent invasive, imaging-guided virtual autopsy. teeth. J Dent child 1960; 27: 254 – 66. Radiographics 2006; 26: 1305 – 59. 24. Demirjian A et al. A new system of dental age 29. Zimmermann D. Virtopsy & forensic assessment. Hum Biol 1973; 45: 211 – 27. imaging: legal parameters and impact. 2011: 1 – 22. 25. To w n s e n d a n d R i c h a r d s A . S e x determination of Autralian Aboriginal skulls 30. Tejaswi A. Virtopsy (virtual autopsy): A new by discriminant function analysis. Aust Dent phase in forensic investigation. J Forensic J 1982; 27: 320 – 26. Dent Sci 2013; 5(2): 146 – 8. 26. Heglund WD. How can the forensic anthropologist help? Handout presented at the American Academy of Forensic Science, Seattle 1995: 105 – 30.

41 INTRALESIONAL INJECTIONS IN Original Article OSMF- A CLINICAL RESEARCH

Dr. Nupur Shah*, Dr. Siddharth Chhabaria**, Dr. Bhavin Dadhia***, Dr. Naresh Soni****, Dr. Rutu Jani***** Background: Oral submucous fibrosis (OSMF) is a chronic insidious collagen-related disorder associated with betel quid chewing and characterized by progressive hyalinization of the submucosa. It is a well-recognized potentially malignant condition of the oral and oropharyngeal mucosa with initial inflammation followed by progressive fibrosis of the underlying connective tissues. Its treatment is not yet fully standardized, although one of the medical treatment is intralesional injections of steroids or placental extract (Placentrax). Aims and Objectives: The objective of the study was to evaluate the efficacy of intralesional injections of Placentrax in various stages of OSMF. Study Design: The study sample consisted of 8 OSMF patients with various clinical stages of Jani YY and Dudhia BB's staging system. Materials & Methods: Patients received 2 ml of intralesional Placentrax injection, weekly intervals of 5 weeks. Treatment outcome was evaluated on the basis of improvement in trismus and reduction in burning sensation. Results: Improvements were found in trismus and burning sensation. Conclusion: Intralesional placental extract acts as a biogenic stimulant, it is cost-effective and improves the condition with minimal side-effects.

INTRODUCTION: carbohydrates and trace amount of lipids mostly bound to proteins steroids and vitamins. It acts by OSMF is insidious chronic debilitating disease 5,27 affecting any part of the oral cavity and sometimes “biogenic stimulation”. the pharynx. Although occasionally preceded by The aqueous extract of placenta acts as follows: and/or associated with vesicle formation., it is 1. Hasten cellular metabolism always associated with juxta epithelial inflammatory reaction followed by a fibro-elastic 2. Aids in the assimilation of exudates changes of the lamina propria with epithelial 3. Stimulates regenerative development atrophy leading to stiffness of the oral mucosa and 4. Increases physiological purpose of organs causing trismus and inability to eat.4,9,15,21 The most 5. Produces noteworthy enhancement of wound common etiology considered for causation of healing OSMF is “arecoline” which is a constituent of 7 areca nut.1,4,6,12,19,25 In the early cases of OSMF, oral 6. Has an anti-inflammatory consequence. mucosa becomes blanched and slightly opaque. Review Of Literature: Fibrosis of mucosa occurs in the late cases of The use of Placetal extract is mainly due to the OSMF; leading to stiffness & progression of 6,29 method of “tissue therapy” introduced by Filatov fibrosis leads to difficulty in opening the mouth. in 1933 and later in 1953.7 The main goal of the treatment of OSMF is to Sur and Bis was showed that it is a necessary reduce trismus, blanching/fibrosis and burning 1,2,3 biogenic stimulator. It stimulates pituitary adrenal sensation. Several therapeutic and surgical cortex and regulates metabolism of tissue. It also methods have been tried in the treatment of increases vascularity of tissue.7 OSMF.14,16,17,23,28 One of the important therapeutic modalities is intralesional injection therapy of Materials and Methods: placental extract.4,5,9,18,24,30 The injection placentrex The study sample consisted of 08 randomly is an aqueous extort of human placenta containing selected patients coming to the Oral Medicine and nucleotides, enzymes, peptides/proteins, small Radiology department of the institute. organic components like amino acids, nucleotides, The patients who were habitual of eating spicy p o l y d e o x y r i b o n u c l e o t i d e s ( P D R N s ) , food and/or chewing areca nut/tobacco in addition * PG Student, **PG Student, ***Head Of the Department, ****Reader, *****Reader DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. NUPUR SHAH, TEL: +91 89802 02255

42 Nupur Shah et. al. : INTRALESIONAL INJECTIONS IN OSMF to having examined for two or more of the following signs and symptoms suggestive of OSMF were included in the study: i· Burning sensation and difficulty in eating hot and spicy food i· Reduced mouth opening i· Presence of blanching and fibrosis. The clinical staging was done by evaluating the clinical findings as per the criteria of Jani YY and Dudhia BB's staging system, which depends upon the severity of clinical features. After clinical examination and staging, a punch biopsy was taken from the buccal mucosa, and the tissue was sent to the department of Oral Pathology Figure 2: Method of Punch biopsy from of the institute for detailed histopathological left buccal mucosa examination. Histological grading was done by the Oral 2ml of intralesional placentrax were given on Pathology department as per the criteria of Khanna both buccal mucosa at different sites. and Andrade grading system, which depends upon According to the presence of blanching/fibrosis, the involvement of epithelium (keratinization and injections were given first at the occlusal level of thickness) as well as connective tissue upper teeth and then followed by at middle occlusal (hyalinization, fibrous tissue, fibroblasts, blood level and occlusal level of lower teeth in all patients vessels, and inflammatory cells). Epithelial atypia at different sittings. in form of mild to severe dysplasia was summarized according to the criteria by Krammer.

Figure 3: Instruments used for intralesional Figure 1: Instruments used for punch biopsy placentrax injections

43 Nupur Shah et. al. : INTRALESIONAL INJECTIONS IN OSMF

Figure 4: Application of intralesion placentrax in left buccal mucosa RESULTS The selected patients included 06 males, 02 females (n=08). Among all the youngest patient was male 27 years and eldest patient was female 50 years .In the present study, 2 cases were of stage II, 3 cases were of stage III and 3 cases were of stage IV. Among 8 cases, 4 were showing mild dysplasia and 4 were showing moderate dysplasia histopathologically.

Figure 6: Mild Dysplasia Figure 6: Moderate Dysplasia

44 Nupur Shah et. al. : INTRALESIONAL INJECTIONS IN OSMF

All the 8 patients were having different mouth opening at the time of diagnosis. It was recorded using vernier caliper to measure IID (inter-incisal distance). The significant improvement was seen in mouth opening after the treatment in all patients. (Table 1, Graph 1)

Graph 1: Improvement of mouth opening Figure 8: Post-op mouth opening

Graph 2: Improvement in burning sensation

Severity of burning sensation was measured by VAS(visual analog scale) and it was significantly improved after treatment. (Table 2, Graph 2)

Figure 7: Pre-op mouth opening

45 Nupur Shah et. al. : INTRALESIONAL INJECTIONS IN OSMF

DISCUSSION stimulators. Such tissues or their extract when OSMF is a chronic debilitating condition with a implanted or injected into the body after resistance 5,6,9,12,20,26 of pathogenic factors stimulates metabolic or high risk of malignant transformation. It is 3 a chronic disease and differs in symptoms and regenerative process thereby favoring recovery. severity at every stage. Many surgical and CONCLUSION therapeutic treatments have been tried for the cure 9,14,16,17,23,28 OSMF is a chronic insidious disease associated of OSMF. Intra-lesional injections of with areca nut chewing.1,4,6,19,20,25 placental extract is one of the modalities and have shown relief from the symptoms and improvement It is a premalignant condition with a very high in the mouth opening in patients with OSMF. 1,3,5 rate of malignant transformation, and hence its early diagnosis and treatment is mandatory.5,6,9,12,20 In the present study, increase in mouth opening Intralesional placental extract is effective in and reduction in burning sensation were 1,5 considered as two basic parameters to evaluate the treating OSMF and present study is showing efficacy of Placental extract in the treatment of significant improvement in OSMF in all OSMF. parameters of burning sensation and mouth opening. In all cases, statistically significant improvement was observed in mouth opening and Intralesional placental extract acts as a biogenic stimulant, it is cost-effective and improves the burning sensation with the use of placental extract 7 indicating the efficacy of this regimen in the condition with minimal side-effects. treatment of OSMF. Singh et al. and Shah et al., conducted a similar study to evaluate effectiveness of placental extract injections in the treatment of OSMF and favorable treatment outcomes were noted.1,5 Placental extract contains growth factors and anti-inflammatory agents and also antiplatelet activity. The action of placental extract is essentially biogenic stimulation and use is based 1,3,5,7 on the tissue therapy method. According to theory when animal and vegetable tissues are severed from the parent body and exposed to unfavorable conditions, but not mortal to their existence, undergo biogenic readjustment leading to development of substance in the state of their survival to ensure their vitality biogenic

46 Nupur Shah et. al. : INTRALESIONAL INJECTIONS IN OSMF

REFERENCES [8] Anila Koneru1, Santosh Hunasgi1, Kaveri [1] Singh DT, Padshetty S, Shreen S, Begam N, Hallikeri2, R. Surekha1, Ganesh Shreekanth Vishwakarma SK, Khan AA. Injection Nellithady3, M. Vanishree1. Journal of [14]of placentrx in the management of oral Advanced Clinical & Research Insights submucous fibrosis. International Journal (2014), 2, 64–72 of Modern Sciences and Engineering [9] Usha Dayanarayana1, Nagabhushana Technology. 2015;2(1): 23-30. Doggalli2,Karthikeya Patil3, Jai Shankar 4, [2] Katharia SK, Singh SP, Kulshreshtha VK. Mahesh K.P5, Sanjay.6 Non surgical The effects of placenta extract in approaches in treatment of OSF. IOSR management of oral submucous fibrosis. Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p- Indian J Pharmacol 1992;24:181-83. ISSN: 2279-0861.Volume 13, Issue 11 Ver. [3] Sudhir M Naik, Mohan K Appaji, S III (Nov. 2014), PP 63-69 R a v i s h a n k a r a , M K G o u t h a m , [10] Danish Uz Zama Khan1., Karabi Das*2., Nonthombam Pinky Devi, Annapurna S Shivakumar G C3., Mehak Dogra4., Kushal Mushannavar, Sarika S Naik. Comparative Singh5., Sunil Kumar K6 and Smriti study of Intralesional Triamcinolone Singh7. International Journal of Recent Acetonide and Hyaluronidase vs Placental Scientific Research Research Vol. 8, Issue, Extract in 60 cases of Oral Submucous 10, pp. 20505-20510, October, 2017 Fibrosis. International journal of Head & [11] Leena James1, Akshay Shetty2, Diljith Neck Surgery, May-August 2012;3(2):59- Rishi3, Marin Abraham4. Management of 65. Oral Submucous Fibrosis with Injection of [4] Tejavathi Nagaraj, Durga Okade, Arundhati Hyaluronidase and Dexamethasone in Biswas, Poonam Sahu, Swati Saxena. Intralesional injections in oral submucous Grade III Oral Submucous Fibrosis: A fibrosis - A series of case reports. Journal of Retrospective Study Medicine, Radiology, Pathology & Surgery (2018), 5, 23–26. [5] Palak Hasmukhbhai Shah1, Rashmi Venkatesh2, Chandramani Bhagawan More3, Vaishnavee Vassandacoumara4. Comparison of Therapeutic Efficacy of Placental Extract with Dexamethasone and Hyaluronic Acid with Dexamethasone for Oral Submucous Fibrosis - A Retrospective Analysis.Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): ZC63- ZC66. [6] J a n i Y V , D u d h i a B B . T h e clinicohistopathologic study of oral submucous fibrosis: A new staging system with treatment strategies. J Indian Acad Oral Med Radiol 2016;28:111-8. [7] Koneru, et al. A systematic review of various treatment modalities for oral submucous fibrosis. Journal of Advanced Clinical & Research Insights (2014), 2, 64–72

47 The Effect of Access Cavity Design on Fracture Resistance Original Article of Endodontically Treated First Molars: An Vitro Study.

Dr. Charmi Shah*, Dr. Pruthvi Patel**, Dr. Sharddha Chokshi***, Dr. Purav Mehta****, Dr. Zarna Sagar*****, Dr. Aanjan Parikh****** ABSTRACT TITLE: The Effect of Access Cavity Design on Fracture Resistance of Endodontically Treated First Molars: An Vitro Study. INTRODUCTION: Fracture was found to be the main cause of extraction of endodontically treated teeth. Susceptibility of endodontically treated tooth to fracture is mainly associated with loss of tooth structure because of dental caries or due to endodontic procedures such as access cavity preparation and root canal preparation. Recently concept of conservative access cavity is inspired by concepts of minimally invasive dentistry. METHODOLOGY: The null hypothesis tested was that there is no difference in fracture strength of sound molars, molars with conservative and those with traditional access cavities design. Forty two extracted human intact maxillary and mandibular molars were assigned to Traditional Access Cavity (TAC), Conservative Access Cavity (CAC) and Sound Control groups (SC) [n=7 maxillary and 7 mandibular teeth in each of three groups]. TAC groups were prepared with pulp chamber de-roofing and straight line access. For CAC a soffit and pericervical-dentine were maintained. Working length was determined and canals were left un-obturated and mounted in self-cured acrylic resin molds of PVC for testing. Specimens were then tested with a compression testing machine and data for force required to fracture was recorded in Newton for analysis. Data was normally distributed; Oneway ANOVA and post-hoc Tukey tests was used for analysis. The software R & R Studio was used for statistical analysis. RESULTS: Fracture strength of conservative access cavity was higher than traditional access cavity. CONCLUSION: A balance is required between cleaning and preserving tooth structure and if tooth condition permits, preservation of pericervical dentine, avoidance of aggressive flaring and retaining even some soffit as practically as possible needs to be taken into consideration. KEYWORDS: CONSERVATIVE ACCESS CAVITY,TRADITIONAL ACCESS CAVITY, FRACTURE STRENGTH

INTRODUCTION: magnification have inspired the emergence of the One of the most important steps in successful recent conservative endodontic access cavity endodontic treatment is access cavity preparation. design. The trend is preserving sound dentine by avoiding deroofing of the pulp chamber and Traditional endodontic access cavity involves avoiding over-flaring of canal orifices as well as removal of much amount of dentine, coronally to avoiding aggressive dentine removal for shaping. gain straight-line access to canals, and radiculary by overflaring the canals orifices, which may weaken Hence the aim of this study was to check the the tooth and increases its susceptibility to fracture. fracture strength of conservative access vs traditional access cavity. Extended preparation of endodontic access cavity is necessary for proper debridement of root AIM: canal but it critically reduces the amount of sound The aim is to evaluate the fracture strength of dentin and increases the deformability of tooth. conservative versus traditional access cavity design Moreover, in root canal and post space in molar teeth in vitro. preparation it was found that loss of coronal tooth Materials and method structure to gain straight-line access has a In this study 21 maxillary and 21 mandibular significant loss of fracture resistance. molars extracted for periodontal reasons were Extraction was found to be the most frequent collected and after debridement and removal of consequence of fracture of endodontically treated staining, calculus, and attached soft tissue with tooth. hand scalers, the teeth were stored in 10% formalin The emergence of Minimally Invasive Dentistry until used. and the modern imaging devices, illumination and To standarize preparation and to minimize *PG Student, **Professor, *** Professor, ****Professor, *****Reader, ******Reader CONSERVATIVE DENTISTRY AND ENDODONTICS. AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. CHARMI SHAH, TEL: +91 84013 00749

48 Charmi Shah et. al. : EFFECT OF ACCESS CAVITY DESIGN ON FRACTURE RESISTANCE confounding factors and variables; all preparations CONSERVATIVE ACCESS CAVITY: were carried out by one operator,42 teeth were In conservative access cavity(CAC) ,Coronal divided into three group each cointaining 14 access preparation objective used was to remove as Maxillary and 14 Mandibular in standard control little tooth structure as necessary to locate canals group(SC) , traditional access cavity group(TAC) orifices and to maintain a soffit which has been group and conservative access cavity (CAC) group. defined as a small piece or tiny lip of dentinal roof The endodontic cavities were made with tapered of 0.5-3.0 mm around the entire pulp chamber. diamond points at high speed and a pathway to the Access was accomplished by cutting near pulp space and the canal orifices achieved, the functional cusps, while staying 1-2 mm away from pathway was unimpeded and unobstructed for nonfunctional cusps, and the distal half of the traditional access cavity(TAC) group to create occlusal surface was avoided,Radicular apical straight-line access. preparation was just wide enough to clean canals TRADITIONAL ACCESS CAVITY: and remove the biofilm, without aggressive dentine In traditional access cavity(TAC) External removal for shaping.(Fig-2) outline form was established by projecting the In this study design canals were left prepared internal anatomy of the pulp onto the external without obturation, contrary to normal clinical surface, by complete deroofing of the pulp chamber setting. This was to eliminate and exclude to gain straight line access to canals orifices. confounding variables such as types, methods and The convenience form used was to allow for efficiency of obturation and restorations. unobstructed access to the canals orifices, direct Conventional coronal flaring for traditional access to the apical foramen, cavity expansion to access cavity(TAC) and minimal flaring for accommodate filling techniques, and cavity conservative access cavity(CAC) was used to open enlargement to have control on instrumentation and canals orifices and enlarge the coronal aspect of the obturation. root canal. For maxillary molars, access was made in the mesial fossa without involving the distolingual cusp and was kept mesial to the oblique ridge. Access cavities had a rhomboid shape to allow for locating MB-2, and were not extended into the mesial marginal ridge and they were widest Fig-2- Prepared conservative access cavity buccolingually. (CAC) (n=14) For mandibular molars, the entry point used was Irrigation with sodium hypochlorite 2.5% was just mesial to the central pit with access cavity used thoroughly between each instrument change located in the mesial half of the tooth to create and throughout canal preparation, using a 30 gauge straight line access for the mesial canals. The distal needle. Working length was determined visually extension was allowed to gain straight line access to using ISO size 10 K-file to negotiate canals to full the distal canals.(Fig-1) working length The apical part of canals were negotiated with a series of progressively increasing size hand K files #15 and #20, #25 and #30.(Manikin, Tochigi, Japan). Apical Canal preparation continued in step back in sequence until #25 k file apical size achieved for mesial canals of mandibular molars and maxillary molars. Distal canals of mandibular molars and Fig-1- Prepared traditional access cavity(TAC) palatal canals of maxillary molars were prepared to (n=14) working length upto #30 k file sizes.

49 Charmi Shah et. al. : EFFECT OF ACCESS CAVITY DESIGN ON FRACTURE RESISTANCE

SPECIMEN MOUNTING AND LOADING The PVC molds were adjusted to place the FOR TEST: loading arm of the universal testing machine(fig-4) All teeth including the sound control groups, over the center of the cavity preparation, with the after instrumentation were mounted on polyvinyl load applied to the occlusal inclines of the buccal chloride (PVC) cylinders (25 mm diameter x 25 mm and lingual cusps vertically down the long axis of height), with the roots embedded in self-curing the tooth. resin 3 mm apical to the cementoenamel Junction to All teeth were then subjected to gradual simulate the alveolar bone level. continuous nondestructive occlusal loading until failure, in a compression testing machine . Failure was defined as a 25% or more drops in the applied load and this was noticed to be frequently preceded by a crack sound. RESULTS: Fracture strength of conservative access cavity(CAC) was statistically significantly higher in mandibular molars (P Value = 0.0431) compared to traditional access cavity(TAC) groups, without differing significantly from the sound control groups. Fracture strength of Maxillary Molars conservative access cavity (CAC) group did not Fig-3 –Mounted specimen(n=42) differ significantly from that of the standard control The resin was mixed according to the (SC) control group with a P Value of (0.2706), manufacturer's instructions and was inserted in the whereas that of the traditional access cavity(TAC) PVC cylinders (fig 3) immediately after mixing,and group was statistically significantly lower than the allowed to set for 24 hours ,stored in normal distal control group with a P value ( 0.003601). water to prevent cracking till loading , and then the All Root-canal treated teeth were more teeth were centrally-positioned with the long axis of susceptible to fracture than sound teeth essentially the tooth parallel to the PVC cylinder walls teeth. due to dentinal tooth structure removal during endodontic therapy.

MANDIBULAR MOLARS:

Fig-4- Loading of specimen for testing

50 Charmi Shah et. al. : EFFECT OF ACCESS CAVITY DESIGN ON FRACTURE RESISTANCE

MAXILLARY MOLARS This new philosophy of conservation discourages the use of Gates-Glidden burs and large round burs so as to avoid walls gouging and loss of precious dentine, especially around the Pericervical dentine where it acts as a buttress against structural flexure and ultimate fracture. In our study, the results for mandibular molars were consistent with previous work of Krishan R. et al. 2014 for mandibular molars and also in agreement with Plotino G. et al. 2017 who found fracture load was significantly higher for conservative access cavity(CAC) group in all posterior teeth including maxillary molars. The current study results for maxillary molars were STATISTICAL ANALYSIS:- consistent with the findings of Moore B et al. 2016 and Rover G. et al. 2017 studies, both have shown Mandibular Molars: no differences in fracture strength of maxillary molars accessed with traditional access cavity(TAC) compared to conservative access cavity(CAC). Our results for maxillary molars were also in agreement with a recent study which found ON conservative access cavity(CAC), compared with traditional access cavity(TAC) had no significant

NEWT effect on fracture resistance. These findings could be supported with the observation that endodontically treated maxillary molars have a lower incidence of fracture than LOAD mandibular molars. Maxillary Molars: The shape and size of the access opening is governed by the extent of caries or previous restorations, and the conservative access cavity(CAC) model may appear inappropriate, but conservative access cavity(CAC) model even if

ON applied partially may increase the fracture strength of endodontically treated molars.

NEWT However the main drawback of conservative access cavity preparation(CAC) is the limitation in the examination of the pulp chamber and the difficulties in the debridement of the area under the pulp roof that does not get exposed according to LOAD Taba Ozyurek et al 2018. DISCUSSION: CONCLUSION: The emergence of minimally invasive dentistry has A balance is required between cleaning and led to the recent concept of conservative endodontic preserving tooth structure and if tooth condition access cavity; the aim is to preserve sound dentine permits, preservation of pericervical dentine, by avoiding un-roofing of the pulp chamber and avoidance of aggressive flaring and retaining even avoiding over-flaring of canal orifices as well as some soffit as practically as possible needs to be avoiding aggressive dentine removal for shaping. taken into consideration.

51 Charmi Shah et. al. : EFFECT OF ACCESS CAVITY DESIGN ON FRACTURE RESISTANCE

REFFERENCES: 1. The Effect of Access Cavity Design on Fracture Resistance of Endodontically Treated First Molars: In Vitro I.A. Osman & H.A Ahmed., Sch. J. Dent. Sci., Vol-5, Iss-9 (Sept, 2018): 443-451. 2. European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. International Endodontic Journal. 2006 Dec; 39(12):921-30. 3. Gluskin, AH & Peters, Christine & Peters, Ove. Minimally invasive endodontics: Challenging prevailing paradigms. British dental journal. 2014; 216. 347-53.3 4. Caplan D, Cai J, Yin G, Alex B. Root Canal Filled Versus Non‐Root Canal Filled Teeth: A Retrospective Comparison of Survival Times. Journal of public health dentistry. 2005; 65: 90-6. 5. Vire E. Failure of endodontically treated teeth: Classification and evaluation. Journal of endodontics. 1991;17:338-42.5 6. Helfer R, Melnick S, Schilder H. Determination of moisture content of vital and pulpless teeth. Oral surgery, oral medicine, and oral pathology.1971; 34: 661-70.6 Papa J, Cain C, Messer H. Moisture content of vital vs endodontically treated teeth. Endodontics & dental traumatology. 1994; 10: 91-3.

52 COMPARATIVE EVALUATION OF COMMONLY CONSUMED CATECHU Original Article AND CATECHU WITH LIME ON COLOR STABILITY OF THE NANO-HYBRID COMPOSITE - AN IN VITRO STUDY Dr. Vedanshi Patel*, Dr. Zarna Saghai**, Dr. Shraddha Choksi***, Dr. Pooja Trivedi****, Dr. Nishit Patel*****, Dr. Purvav Mehta****** ABSTRACT AIM: Comparative evaluation of commonly consumed catechu and catechu with lime on color stability of the nano- hybrid composite. METHOD: A total of 25 uniform cylindrical disks of 10-mm diameter and 1-mm thickness prepared from the nano-hybrid composite were used in the study. Each sample was randomly divided into three subgroups. Group 1 (n = 10) Catechu, Group 2 (n = 10) Catechu with lime, Group 3 (n = 05) Artificial saliva (Control group) The samples were immersed in each agent for 15 days. Color changes measurements were noted at the baseline and 15th day by two-dimensional profilometer and spectrophotometer, respectively. RESULTS: It was found that nano-hybrid composite resin showed more color change when immersed in catechu and catechu with lime as compared to the control group. Intergroup comparison showed statistically significant increase in color change in the catechu group followed by the catechu with the lime group and artificial saliva. CONCLUSION: Within the limits of the present study, it can be concluded that all experimental specimens showed discoloration. At the end of 15th day, among the groups, catechu showed more color change followed by the catechu and lime and the control group. KEYWORDS: Catechu; lime; nano-hybrid composite; spectrophotometer

INTRODUCTION: have a drastic statistical value in the South Asian countries. However, the rate is extremely higher in Esthetics plays a major role in the field of dentistry [5] and its development and research. The trend toward India and the Indian subcontinent. a natural look has paved the way for the Consumption of these products may affect the development of tooth-colored restorations that esthetic and physical properties of the resin simulates the tooth as closely as possible.[1] composites thereby undermining the quality of Esthetic failure is one of the most common restorations. The chemicals in them can lead to wear reasons for the replacement of the restorations. and surface degradation of composite restorations resulting in unesthetic external pigmentation such Color changes in resin composites occur from [6] intrinsic and extrinsic factors. Intrinsic factor as stains. depends on the composition of the resin matrix, the Hence, nano-hybrid composites are considered type of bonding between the filler and matrix, etc., to be the gold standard materials as posterior Extrinsic factors such as adsorption or absorption of restorative material. Still one of the properties of the extrinsic stains pose a major problem for esthetic composite resins that have to pass the test of time is restorations. Erikson et al. suggested that retention its color stability. In modern day dentistry, a large of the colored substances from dietary constituents emphasis is laid over esthetics. Surface staining significantly contribute to the formation of extrinsic occurs in nano-hybrid composite due to the stains.[2],[3],[4] oxidation of tertiary amines accelerator which Certain unique topographic patterns are causes a change in hue from whitish-to-yellowish observed with respect to the consumption of appearance. Color stability is directly proportional addictive substances in India, with paan (betel nut to the surface roughness of the composite leaf) being a highly consumed thing in India, in restoration. Increased surface roughness can lead to various forms and compositions. Furthermore, greater plaque retention and stain absorption than there is a higher consumption of katha (catechu) and relatively smoother surface. Catechu itself bearing lime in the betel nut leaf preparation. This a strong color and being in a close association of the consumption rate of betel nut leaf has been shown to restoration can lead to staining. There have been

*PG Student, **Professor, *** Professor, ****Reader, *****Reader, ******Reader CONSERVATIVE DENTISTRY AND ENDODONTICS. AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. VEDANSHI PATEL, TEL: +91 99098 92142

53 Vedanshi Patel et. al. : EVALUATION OF COMMONLY CONSUMED CATECHU AND CATECHU WITH LIME ON COLOR STABILITY OF THE NANO-HYBRID COMPOSITE studies demonstrating the effect of beverages and To prepare the agent for Group 2, lime was other foodstuffs as well as cigarette smoking on added to the primary solution in the ratio of 0.25:1 composite resin; however, there is no literature till with continuous stirring until a creamy date on the effect of catechu and lime on the homogenous formulation is obtained. [7],[8] composites. 25 composite discs were then randomly divided Hence, the present study AIMS to evaluate the into three groups. effect of commonly consumed catechu and Group 1 (n = 10) Catechu catechu with lime on color stability of the conventional nano-hybrid composite resins. Group 2 (n = 10) Catechu with lime The NULL HYPOTHESIS is there will be no Group 3 (n = 05) Artificial saliva (Control change in the color stability of the nano-hybrid group) composite at the end of 15 days after they are The discs of Group 1 and Group 2 were then immersed in catechu and catechu with lime. immersed in the agents for 10 min twice daily for MATRIALS & METHOD 15 days. The discs were removed and stored in distilled water at 37°C. Discs of group 3 were 25 composite discs of 10 mm in diameter and 1 mm continuously kept in artificial saliva for 15 days. in thickness were prepared using nanohybrid composite (Tetric N-Ceram) with the help of Color change for all the samples were assessed Teflon molds placed on a clean glass slab covered using spectrophotometer after 15 days. on both sides by cellophane strip to provide RESULTS uniform thickness and texture. Comparing within the test solutions, catechu has Color for all the samples were assessed using shown more color change than catechu with lime spectrophotometer for baseline data. at the end of 15 days. The test agents were prepared using the dilution One-way ANOVA test revealed, color changes method. It contains an aqueous solution of the showed a statistically significant difference (P catechu powder. The primary solution was made <0.001) between the baseline and at the end of 15 by using the ratio of 4:1. day (Table 1). To prepare solution for group 1, the measuring There was a greater color change observed in quantity was 2.5 g of catechu powder in 10 mL of Group 1 as compared to that of the Group 2 and water. This solution was boiled and then allowed to minimal changes observed in the Group 3 (control cool at the room temperature, to make the primary group) solution (catechu solution).

Table 1 : Mean value of baseline data and at the end of 15th day

54 Vedanshi Patel et. al. : EVALUATION OF COMMONLY CONSUMED CATECHU AND CATECHU WITH LIME ON COLOR STABILITY OF THE NANO-HYBRID COMPOSITE Tukey's post hoc test revealed a statistically significant difference in color change between Groups 1 and 2 (P < 0.001), Group 1 and control group (P < 0.001), and Group 2 and Group 3 (control group) (P < 0.001) (Table 2).

Table 2 : Mean difference between values of different groups

DISCUSSION: present are pyrocatechin. Nano-hybrid composite combines the The acids bear a relative pH of around 3–4 that properties of earlier hybrid and microhybrid might be the reason for the dissolution of the resin composite. Nano-hybrid composite has improved matrix leading to water sorption and further mechanical properties. leading to color changes. Hence, nano-hybrid composite is considered Lime is calcium oxide or calcium hydroxide to be the gold standard material as posterior and pH of the lime is around 11.8–12.4. Hence, on restorative material. However, the problem with interaction with acid present in catechu, lime nano-hybrid composite is surface staining and increase the pH, hence reducing acidity and color stability. increasing alkalinity. The staining agents catechu and catechu with Increase in pH does not lead to the dissolution lime that are selected for the study are common of the resin matrix and color change. Hence, this ingredients of paan preparation, that is, consumed might be reason for the less color change in very commonly in India and the Indian catechu with lime group compared to catechu subcontinent and also has the potential for group. discoloration of the restorative material. As it is in vitro study, it is difficult to The samples were immersed for 10 min twice a extrapolate the result of this study to in vivo day because an average consumption of an conditions. Furthermore, the agents used in this individual in India is about 2–3 in a day that study were used alone where as they are consumed accounts to roughly about 10 min in one time. in combination with areca nut, betel leaves, and The reason for the increased color change and various other constituents which might affect the surface roughness in catechu group may be results. attributed to the composition of the material that However, there are no studies and a very less showed the presence of the acid and other phenolic literature available about the effect of catechu or compounds. lime on composite resins. Catechu is composed of 13%–33% of crude The literature has widely revealed the potential catechin, also called catechuic acid, and from 22% effects of certain food items and beverages on to 50% of a peculiar tannic acid, called catechu- composite resins' surface characteristics affecting tannic acid. Besides, these other compounds the clinician's choice of material and the patient's

55 Vedanshi Patel et. al. : EVALUATION OF COMMONLY CONSUMED CATECHU AND CATECHU WITH LIME ON COLOR STABILITY OF THE NANO-HYBRID COMPOSITE control of dietary habits, but there is no report on Hence, it should be noted that the patients whether or how the catechu or lime affects should be made aware about the staining composite resins. characteristics of the catechu in the betel leaf CONCLUSION: preparation on tooth-colored restorations. Furthermore, clinicians should take every possible Within the limitations of the present study, it measure to aware patients about health hazards can be concluded that all specimens showed related to consumption of these substances and discoloration after the completion of the test adverse effect on such tooth colored restorations period which was visually perceptible and as well. clinically unacceptable. FINANCIAL SUPPORT & SPONSORSHIP: Comparing within the test solutions, catechu Nil has shown more color change than catechu with lime at the end of 15 days.

REFERENCES Manton DJ. Influence of beverages and 1. Omata Y, Uno S, Nakaoki Y, Tanaka T, surface roughness on the color change of Sano H, Yoshida S, et al. Staining of hybrid resin composites. J Investig Clin Dent composites with coffee, oolong tea, or red 2018;9:e12333.10. Negi BS, Dave wine. Dent Mater J 2006;25:125-31. BP.In vitro antimicrobial activity of acacia catechu and its phytochemical analysis. 2. Fontes ST, Fernández MR, de Moura CM, Indian J Microbiol 2010;50:369-74. Meireles SS. Color stability of a nanofill composite: Effect of different immersion 11. Thomas SJ, MacLennan R. Slaked lime and media. J Appl Oral Sci 2009;17:388-91. betel nut cancer in Papua New Guinea. Lancet 1992;340:577-8. 3. Bagheri R, Burrow MF, Tyas M. Influence of food-simulating solutions and surface 12. Shadap AM, Pala V. Nutritional Intake and finish on susceptibility to staining of consumption pattern in the states of aesthetic restorative materials. J Dent Himachal Pradesh and Meghalaya. NEHU J 2005;33:389-98. 2017;15:15-28. 4. Guha P. Betel leaf: The neglected green 13. Jefferies SR. Abrasive finishing and gold of India. J Hum Ecol 2006;19:87-93. polishing in restorative dentistry: A state- of-the-art review. Dent Clin North Am 5. Dietschi D, Campanile G, Holz J, Meyer 2007;51:379-97. JM. Comparison of the color stability of ten new-generation composites: An in vitro 14. Miyazaki CL, Medeiros IS, Santana IL, study. Dent Mater 1994;10:353-62. Matos Jdo R, Rodrigues Filho LE. Heat treatment of a direct composite resin: 6. Senawongse P, Pongprueksa P. Surface Influence on flexural strength. Braz Oral roughness of nanofill and nanohybrid resin Res 2009;23:241-7. composites after polishing and brushing. J Esthet Restor Dent 2007;19:265-73. 15. Tuncer D, Karaman E, Firat E. Does the temperature of beverages affect the surface 7. Mitra SB, Wu D, Holmes BN. An roughness, hardness, and color stability of a application of nanotechnology in advanced composite resin? Eur J Dent 2013;7:165-71. dental materials. J Am Dent Assoc 2003;134:1382-90. [Full text] 8. Lu H, Roeder LB, Lei L, Powers JM. Effect 16. Parle M, Kadian R, Sharma K. of surface roughness on stain resistance of Phytopharmacology of acacia catechu wild: dental resin composites. J Esthet Restor A review. World J Pharm Pharm Sci Dent 2005;17:102-8. 2014;3:1380-9 9. Tavangar M, Bagheri R, Kwon TY, Mese A,

56 OSSEODENSIFICATION- INNOVATION IN IMPLANT DENTISTRY A Case Report A CASE REPORT

Dr. Babita Chandwani*, Dr. Dipali Sampat**, Dr. Dhwanit Thakore***, Dr. Tejal Sheth**** ABSTRACT Primary stability plays a pivotal role in osseointegration. The quality of bone and surgical procedure are the crucial factors which affect primary stability. Adequate density and bone to implant contact area are essential for achieving biomechanically stable implants. Osseodensification (OD), a novel technique using specially designed burs was developed by Huwais in 2013 for increasing the density of bone during simulateous osteotomy preparation. This technique allows bone preservation and condensation through compaction autografting thus increasing the bone density and implant stability for long term success. Keywords: Osseodensification, primary stability, bone density

INTRODUCTION: On intra-oral examination, the patient had a Dental implants have transformed the field of missing left mandibular first molar. The patient's oral rehabilitation with a success rate of over 90% general periodontal condition was assessed and the over 10 years, they can now be used for predicatable patient was presented with various treatment replacement of missing teeth in oral cavity[1]. options and implant placement was considered after Osseintegration is defined as the “direct structural discussing the advantages and disadvantages of and functional connection between living bone and each option. the surface of a load bearing implant”[2]. Primary A thorough oral hygiene prophylaxis was done stability is one of the most important factor for and a CBCT was advised to evaluate the density and achieving osseointegration [3].Many techniques dimensions of bone at the site for implant have been developed to increase the primary placement. On, Radiographic examination the stability of implants in conditions with reduced width of the bone was 5mm which was insufficient bone density. Salah Huwais in 2013 introduced a to place a standardized implant of diameter 3.75 bone preserving technique to increase the density of mm. Osseodensification procedure was planned to bone at the osteotomy site by exapansion of bone increase the dimension of the osteotomy site with during implant site preparation. It is a bone simultaneous implant placement. nonextraction technique that helps densify the bone After proper treatment planning, endosseous as the osteotomy is prepared rather than excavation implant (Genesis) measuring 3.75x11.5 mm in of bone as in during osteotomy by standardized dimension was selected. Following administration drills, thereby increasing bone density and of local anaesthesia (2% lidocaine with 1: 80,000 improving the biomechanical stability of implants. anaesthetic agent) in the area of the missing first The present case report depicts the advantages of molar, a full thickness flap was elevated. Bone osseodensification procedure in a patient with low width was measured and was found to be 4.5 mm. bone density and reduced bone width. The osteotomy was performed following the CASE REPORT: densah protocol where a pilot drill was done A 40 year old male patient with a chief complaint followed by sequential drilling with densifying burs of missing tooth in the left posterior tooth region of diameter 2.3mm, 2.5mm and 3mm. A parallel, visited the Department of Periodontics and Oral threaded rough surface implant was then placed Implantology at Ahmedabad Dental College and with a cover screw. The primary stability was found Hospital. *PG Student, **PG Student, *** Sr. Leacturer, ****Professor DEPARTMENT OF PERIODONTICS AND IMPLANTOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. BABITA CHANDWANI, TEL: +91 90996 47483

57 Babita Chandwani et. al. : OSSEODENSIFICATION- INNOVATION IN IMPLANT DENTISTRY to be about 35N and the flap was closed with the the healing abutment was replaced and the shade help of 4.0 polyamide sutures. Appropriate was selected. The impression was sent to the antibiotic (amoxycillin 500mg, 3 times daily for 5 laboratory for preparation of crown. days) and analgesic (ibuprofen 800 mg, twice Patient was recalled after 10 days and the healing daily). The patient was recalled after one week for cap was removed and the abutment was placed suture removal and no untoward sign or symptom followed by a radiograph to evaluate its seating on was noted. the implant. The abutment was torqued to 35N with Three months after implant placement the implant a torque wrench and the crown was then tried- in. was exposed and healing abutment was placed. A The occlusion and proximal contacts was verified radiograph was taken to confirm the seating of the and the crown was cemented using a resin modified healing abutment. Patient was recalled after 15 days glass-ionomer cement. Oral hygiene instructions for impression making. The healing abutment was were given and the patient was recalled for regular removed and an impression coping was placed follow-up. followed by open tray impression for determining the implant position. After the impression was taken Pre-operative examination

Figure 1 Mesio-Distal width (11mm) Figure 2: Bucco-lingual width (6mm)

Figure 3: Pre-operative CBCT

58 Babita Chandwani et. al. : OSSEODENSIFICATION- INNOVATION IN IMPLANT DENTISTRY

Surgical procedure

Figure 4: Incision Figure 5: Flap Reflection

Figure 6: Intra – operative assessment Figure 7: Pilot drill of ridge width

Figure 8: Intraoperative RVG Figure 9: Osteotomy Prepared

59 Babita Chandwani et. al. : OSSEODENSIFICATION- INNOVATION IN IMPLANT DENTISTRY

Figure 10_1 and 10_2: Implant 3.75x11.5mm

Figure 11: Implant in place Figure 12: Sutures in place

Figure 13: Post Operative RVG Figure 14: Follow up after 1 week

60 Babita Chandwani et. al. : OSSEODENSIFICATION- INNOVATION IN IMPLANT DENTISTRY

Follow up after 3 months

Figure 15: Healing abutment in place Figure 16: IOPA after healing abutment placement DISCUSSION: drilling [8]. High insertion torque is directly related Osseointegration leads to bone formation on the to implant density and also improves the clinical implant surface and contributes to the secondary o u t c o m e f o r i m m e d i a t e o r e a r l y stability. In conditions of low bone density, there is loading [9]. decrease in the bone to implant contact area Berardini et al [10] and Li et al.[11] reported no affecting the primary and secondary stability [4]. significant difference in resorption of the crestal The rationale of osseodensification is that the bone and failure rate of implants inserted at either densifying burs at the point of contact creates a high or low insertion torques. They demonstrated densified layers along the base and walls of that the OD drills increased the amount of BV and osteotomy, through autografting and compaction of the amount of BIC in poor density bone which helps the adjacent bone while plastically expanding the in increasing osseointegration. ridge at the same time [5]. CONCLUSION: The osteotomy prepared by osseodensification is The osseodensification technique is a unique, smaller than that of the conventional osteotomies efficient process which reduces the amount of bone and the BIC was also found to be increased three excavation which is unavoidable using times compared with standardized drilling conventional drills. It facilitates ridge expansion protocols by increasing the bone density around the while maintaing the ridge integrity, thereby osteotomy site. So by osseodensification wider allowing for total implant placement in autogenous diameter of implants can be placed in narrow ridges bone with adequate primary stability and a shorter without leading to bone fenestration and dehiscence waiting period for restoration. This concept has [7]. changed the paradigm of implant dentistry to a more Trisi et al found an increase in insertion torque with preservative option over conventional protocols. reduction in micromotion by densification Implant Dent 2016;25:532-40. techniques in comparision with that of standard

References: 3. T. Albrektsson, P.I. Branemark, H.A. Hansson, J. 1. T. Albrektsson, T. Jansson, U. Lekhholm. Lindstrom. Osseointegrated tanium implants: Osseointegrated dental implants. Dent Clin N requirements for ensuring a long- lasng, direct Am, 30 (1986), pp. 151-174. bone- to – implant anchorage in man. Acta 2. P.I Branemark Osseointegraon and its Orthop Scand, 52(2) (1981), pp. 155-170. experimental background. J Prosthet Dent, 50 4. Pai, Umesh y. and Rodrigues, Shobha J and (1983), pp. 399-410. Talreja, Karishma S and Mundathaje, Mahesh

61 Babita Chandwani et. al. : OSSEODENSIFICATION- INNOVATION IN IMPLANT DENTISTRY

(2018) Osseodensificaon – A Novel approach Implantology”. Clinical Oral Implants Research in Implant Denstry. The Journal of 11(2000);12-25. Prosthodonc Society, 18(3). ISSN 0972-4052. 10. Berardini M, Trisi P, Sinjari B, Rutjes AW, Capu 5. Gayathri S. “Osseodensificaon Technique – A S. The effects of high inseron torque versus Novel Bone Preservaon Method to Enhance low inseron torques on marginal bone Implant Stability”. Acta Scienfic Dental resorpon and implant failure rates: A Sciences 2.12(2018): 17-22 systemac Review with meta-analyses. 6. Huwais S.., et al. “A Novel Osseous 11. Li. H. Liang Y, Zheng Q. Meta-analysis of Densificaon Approach in Implant Osteotomy Correlaons between marginal bone resorpon Preparaon to increase biomechanical primary and high inseron torque of dental implants. stability, bone mineral density, abd bone to Int J Oral Maxxillofac Implants 2015;30:767-72. implant contact”. The Internaonal of Oral and Maxillofacial Implants. (2016): 1-10 7. Trisi P., et al. “New Osseodensificaon Implant site preparaon Method to increase bone density in low density bone bone: In- vivo evaluaon in sheep”. Implant Denstry 25.1 (2016): 24-31. 8. Trisi P., et al. “Implant micromoon is related to peak inseron torque and bone density”. Clinical Oral Implants Research 20 (2009);467- 471. 9. Szmukler-Moncler S., et al “Consideraons Preliminary to the applicaon of early and immediate loading protocols in Dental

62 NON-FAMILIAL CHERUBISM IN AN ADULT FEMALE: A Case Report A CASE REPORT

Dr. Dishant Pandit*, Dr. Neha Vyas*, Dr. Nitu Shah**, Dr. Darshan Patel*** ABSTRACT Cherubism is a congenital childhood disease of autosomal dominant inheritance. This disease is characterized by painless bilateral enlargement of the jaws, in which bone is replaced with fibrous tissue. The condition has sui generis clinical, radiographic and histological features, of which the clinician should be aware for a better differential diagnosis in the presence of a fibro-osseous lesion affecting the bones of the maxillomandibular complex.

INTRODUCTION: CASE REPORT: Cherubism is a rare disease of autosomal dominant A 27-year-old female patient suffering from inheritance and is characterized by painless, cherubism reported to the department of OMFS frequently symmetrical, enlargement of the jaws as with the chief complain of swelling in lower left jaw a result of the replacement of bone with fibrous back region since one and a half months. History tissue 1-6. The disease is also known as familial revealed that the patient had symmetrical and fibrous dysplasia of the jaws, but it has been has bilateral swelling of the face since the age of 2 years. shownto be a separate entity at the molecular This enlargement had continued in gradually levelby recent genetic investigations7. progressive fashion throughout the subsequent Furthermore, Lannon et al.8 mentioned necessity to years. No familial history of similar swelling was distinguish cherubism from central giant cell seen. At the age of 7, she had visited the granuloma and giant cell tumour of the jaws, with Government hospital where she was diagnosed with which it holds a false synonymity. cherubism and had undergone corrective surgical A molecular pathogenesis of cherubism has been p r o c e d u r e s f o r t h e s a m e . S h e w a s proposed, with the detection of a mutation in the relativelyasymptomatic for the next few years. gene encoding SH3 - binding protein 2 However, at the age of 11, she noticed a recurrence (SH3BP2)6,9,10 and possible degradation of the of the swelling of the jaws which again gradually Msx-1 gene which is involved in the regulation of increased over a period of time but she did not seek mesenchymal interaction during craniofacial any medical intervention for the same. Since the last morphogenesis11. It is believed that the different one and a half months, she noticed loosening of clinical manifestations of cherubismare due to the teeth in the offending region which gradually changes secondary to mutations or incomplete exfoliated. 10 days later she noticed bleeding and penetrance 9 swelling in that region. She went to a local dental clinic forthat from where she was referred to ADCH Clinically, cherubismis characterized by bilateral for further treatment. enlargement of the mandible and/or maxilla, causing a rounded face and swollen cheeks accompanied by upward-looking eyes. This condition gives the patient the appearance of cherubs depicted in baroque artwork1-4 hence, the name of the disease introduced by Jones 12, who published the first four cases affecting the same family.

PG Student*, Professor & Head**, Reader***

ORAL AND MAXILLOFACIAL SURGERY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, BHADAJ, GANDHINAGAR ADDRESS FOR AUTHOR CORROSPONDENCE : DR. Dishant Pandit, TEL: +91 96249 22609

63 Dishant Pandit et. al. : NON-FAMILIAL CHERUBISM IN AN ADULT FEMALE

Upon intra oral examination and palpation, it was observed that the mouth opening was reduced to 20 mm. Blanching was present on both buccal mucosae, retromolar area, soft palate. Tongue & soft palate movements were found to be restricted. De-pappilation of tongue was also present. No signs of bleeding and ulceration were present. A single, ovoid shaped growth was present on lower left alveolar region extending antero-posteriorly from,1cm away from the midline to 2 cm posteriorly and supero-inferiorly from the upper occlusal line to depth of vestibule. On the superior surface of the growth there was pinching of the maxillary left canine tooth. Size of the growth was 2.5 cm in diameter approx. which was extending Fig 1: Front profile of the patient bucco-lingually from buccal aspect to lingually floor of the mouth. The lesion was found to be well- defined, sessile, hyperplastic, exophytic growth and was normal in colour with bluish red tinge on the entire surface of the lesion. Upon palpation, it was non-tender and soft in consistency.Excisional

Fig 2: Orthopantomogram

Upon extra-oral examination and palpation, a single, round swelling was present on the right and left side of the face extending antero- posteriorly from corner of the mouth to 3cm posteriorly and supero-inferiorly from 2 cmbelow Figure 3: Intra-oral site the Ala-tragus line to lower border of mandible with size of 3 cm in diameter with involving sub mandibular region on both sides with ill-defined borders. It was non-tender, firm, bony hard consistency and non-mobile upon palpation. Margins of the swelling were well-defined and the swelling was attached to the underlying tissue. Bilateral submandibular lymph nodes were palpable, firm and mobile. There was no sign of bleeding and pus discharge. Mouth opening was reduced to 20 mm. The face appeared square shaped with non-prominent chin. Figure 4: Excised tissue

64 Dishant Pandit et. al. : NON-FAMILIAL CHERUBISM IN AN ADULT FEMALE biopsy for the lesion was planned to rule out the differential diagnosis. The tissue was excised to full length from the involved region with help of BP blade No.15.Heamostasis was obtained using a pressure pack. The area was examined properly for the presence of local irritating factors and extraction of second pre molar and first molar was done. Primary closure was done with 3-0 silk sutures. The patient was prescribed analgesics and antibiotics for five days and chlorhexidine mouthwash for two weeks. The specimen was sent for histopathological examination. Sutures were removed after 1 week. The patient was followed up after 6 months and the surgical area showed uneventful healing. The biopsy report obtained showed the presence of vascular fibrous stoma, extravasated RBCs, aggregates of multinucleated giant cells and trabeculae of bone.Dilated blood vessels with perivascular eosinophilic cuffing were also seen at some places. A diagnosis of peripheral giant cell granuloma was reported.

1. Discussion: tissue in the lesions expands, the protuberant masses can infiltrate the orbital floor and cause the Cherubism is a rare hereditary autosomal 13. characteristic upward tilting of the eyes exposing dominant benign lesion of childhood the sclera below the iris. Cherubism lesions are According to the World Health Organization, limited to the jaws, and in most cases, the cherubism belongs to a group of nonneoplastic dysplastic expansile masses begin to regress with bone lesions that affect only the jaws. It is also the onset of puberty14. considered a member of the family of On average, the disease manifests in fibrous-osseous diseases and some authors refer to 13 childhood, is stabilized by the age of 12 years, this disorder as familial fibrous dysplasia. and begins to regress during puberty. Bone Cherubism or multilocular cystic disease of recontouring continues through the third decade jaws was first recognized as a separate entity in of life, and the face alteration gradually 1933 by William A. Jones in a family with several disappears. However, it was observed in this affected members. He designated the descriptive case that the lesion showed no signs of name “cherubism” because “the full round cheeks regression even though the patient was well past and the upward cast of the eyes give the children a puberty, showcasing a deviation to the usually peculiarly cherubic appearance.” As this name so seen sequelae in the development and accurately captured the clinical features of the progression of this condition disease, it became the standard nomenclature. The prevalence in male is 100% when Cherubism is defined by the appearance of compared with female 50%–70%, i.e., 2:1 symmetrical, multilocular expansile, radiolucent ratio15.Two forms exist: hereditary (familial) and lesions of the mandible and/or maxilla that nonhereditary (nonfamilial)16. typically appears at the age of 2–7 years. Swelling In 1978, Arnott suggested a grading system for of the submandibular lymph nodes in the early the lesions of cherubism. Cherubism is divided stages contribute to the fullness of the face as is into Grades 1, 2, 3 and 4 depending on location and seen in our case also. As the soft fibrous dysplastic

65 Dishant Pandit et. al. : NON-FAMILIAL CHERUBISM IN AN ADULT FEMALE the severity of involvement of jaws. These resulted in remission of the lesion. The classifications are based on the extent of lesion at administration of calcitonin was done with nasal the time of evaluation. The grade often increases spray instead of by subcutaneous injections. The on follow-up examination17. rationale of calcitonin administration is that it On the basis of extent of involvement, Ramon inhibits the osteoclastic activity of the giant cells. and Engelberg proposed a grading system for R a d i a t i o n t h e r a p y i s i n e ff e c t i v e a n d cherubism: contraindicated in view of the risk of osteoradionecrosis, interference with dentofacial Grade 1 - Involvement of both mandibular growth and development and the effect on future ascending rami surgical procedure21. Grade 2 -Same as Grade 1 plus involvement of Curettage is the surgery of choice. Simple both maxillary tuberosities-, countering of lesions produces good cosmetic Grade 3 - Massive involvement of whole maxilla appearance. Liposuction has also been used to and mandible, except the condylar processes achieve good contour. Surgery showed that – good Grade 4 - Same as Grade 3 with the involvement of immediate results arrested the active growth of the floor of the orbits causing orbital remnant. Cherubic lesions and even stimulated compression18. b o n e r e g e n e r a t i o n . R a d i o t h e r a p y i s contraindicated because of fear of retardation of Microscopically, the lesions showed numerous jaw growth radio osteonecrosis and chances of multinucleated giant cells and vascular spaces malignant degeneration. Medical therapy such as which are randomly distributed against a calcitonin is theoretically appropriate but without background of highly cellular connective tissue. proven result. The recent advancement in the Histochemical and immunohistochemical 22 treatment of cherubism is the genetic therapy . characterization of the multinucleated giant cells reveals that these are osteoclasts since they are Calcitonin was tried as it inhibits the osteoclastic positive for tartrate-resistant acid phosphatase and activity of the giant cells, but with varying results. express vitronectin receptor19.The giant cells are Based on the genetic mutations related to the foreign body type with 5–20 nuclei20.The cellular disease, gene therapy is expected to play a role in stroma contains focal deposits of hemosiderin future treatment23. Gene testing for known pigments. Eosinophilic collagen perivascular mutations in SH3BP2 gene is offered by several cuffing can be seen in some cases, and this commercial reference laboratories and testing on a perivascular hyalinosis is considered research basis is available. pathognomonic for cherubism19. 2. CONCLUSION: The diagnosis of cherubism is based on patient age, family history, clinical examination, Despite the exceptions, cherubism is a radiographic findings, biochemical analyses and clinically well-characterized disease which molecular analysis14. confers to the patient the appearance of a baroque cherub; therefore, this derived the name of the Treatment of cherubism has not been disease. In cases of a suspicion of cherubism, standardized. Surgical treatment appears to be radiographic examination is essential since the unnecessary for Grades 1 and 2 cases, in the clinical presentation and the location and absence of secondary disturbances. Curettage distribution of the lesions may define the appears to be necessary in more aggressive cases diagnosis. Histopathological examination is (Grade 3), to reduce maxillofacial deformity that complementary. Nowadays, genetic tests should occurs after puberty. Dukart et al. found that be used for final diagnosis of cherubism. surgical curettage and recontouring performed during a period of rapid growth of cherubism Knowledge of the clinical and radiographic lesions not only offer a favorable immediate result alterations observed in patients with cherubism is but also arrests the active growth of remnant important since the dentist might be the first lesions while stimulating bone regeneration. professional sought for a diagnosis of this disease. Calcitonin therapy seemed to be effective and

66 Dishant Pandit et. al. : NON-FAMILIAL CHERUBISM IN AN ADULT FEMALE

5. REFERENCES: 13. Goyal V, Jasuja P. Cherubism: A case report. Int J ClinPediatr Dent 2009;2:49-52. 1. Ayoub AF, el-Mofty SS. Cherubism: report of an aggressive case and review of the 14. Papadaki ME, Lietman SA, Levine MA, literature. J Oral Maxillofac Surg. 1993 Olsen BR, Kaban LB, Reichenberger EJ. Jun;51(6):702-5. Cherubism: Best clinical practice. Orphanet J Rare Dis 2012;7Suppl 1:S6. 2. Cabral LA, dos Santos GM. [Cherubism]. ArsCurandiOdontol. 1977 Jul;4(4):44-51. 15. Kaur M, Shah S, Babaji P, Singh J, Nair D, Portuguese. Kamble SS. Cherubism: A rare case report. J Nat SciBiol Med 2014;5:488-91. 3. Kaugars GE, Niamtu J 3rd, Svirsky JA. Cherubism: diagnosis, treatment, and 16. Yamaguchi T, Dorfman HD, Eisig S. comparison with central giant cell Cherubism: Clinicopathologic features. granulomas and giant cell tumors. Oral Surg Skeletal Radiol 1999;28:350-3. Oral Med Oral Pathol. 1992 Mar;73(3):369- 17. Arnott DG. Cherubism – An initial unilateral 74. presentation. Br J Oral Surg 1978;16:38-46. 4. KalantarMotamedi MH. Treatment of 18. Ramon Y, Engelberg IS. An unusually cherubism with locally aggressive behavior extensive case of cherubism. J Oral presenting in adulthood: report of four cases MaxillofacSurg 1986;44:325-8 and a proposed new grading system. J Oral 19. Tamgadge A, Modak N, Bhalerao S, Maxillofac Surg. 1998 Nov;56(11):1336-42. Tamgadge S. Cherubism: A rare case report 5. Kozakiewicz M, Perczynska-Partyka W, a n d l i t e r a t u r e r e v i e w. I n t J O r a l Kobos J. Cherubism--clinical picture and MaxillofacPathol 2012;3:56-60. treatment. Oral Dis. 2001 Mar;7(2):123-30. 20. Elshafey R. Imaging of cherubism: Case 6. Li CY, Yu SF. A novel mutation in the report and review of the literature. Tanta Med SH3BP2 gene causes cherubism: case report. J 2014;42:42-5. BMC Med Genet. 2006 Dec 5;7:84. 21. Reddy G, Reddy GS, Reddy NS, Badam RK. 7. Jain V, Gamanagatti SR, Gadodia A, Kataria Aggressive form of cherubism. J Clin P, Bhatti SS. Non-familial cherubism. Imaging Sci 2012;2:8. Singapore Med J. 2007 Sep;48(9):e253-7. 22. Pal P, Singh S, Singh J. Cherubism: A case 8. Lannon DA, Earley MJ. Cherubism and its report and review of literature. Int J Dent Case charlatans. Br J Plast Surg. 2001 Rep 2011;1:61-72. Dec;54(8):708-11. 23. Bilahari N, Kumar R, Kuruvilla VE, Mani 9. Sarda D, Kothari P, Kulkarni B, Pawar P. V. Cherubism: Report of a case. Cherubism in siblings: A case report. J Indian ContempClin Dent 2013;4:356-9 SocPedodPrev Dent. 2007 Mar;25(1):27-9. 10. Hatani T, Sada K. Adaptor protein 3BP2 and c h e r u b i s m . C u r r M e d C h e m . 2008;15(6):549-54. 11. Carvalho Silva E, Carvalho Silva GC, Vieira TC. Cherubism: clinicoradiographic features, treatment, and long-term follow-up of 8 cases. J Oral Maxillofac Surg. 2007 Mar;65(3):517-22. 12. Jones WA, Gerrie J, Pritchard J. Cherubism-- familial fibrous dysplasia of the jaws. J Bone Joint Surg Br. 1950 Aug;32-B(3):334-47.

67 AN UNUSUAL CASE OF CHRONIC SUPPURATIVE A Case Report OSTEOMYLITIS WITH ALL FOUR CANINES IMPACTED

Dr. Twinkal Patel*, Dr. Naresh Soni**, Dr. Siddharth Chhabaria***, Dr. Nupur Shah**** ABSTRACT The term osteomyelitis encompasses a wide group of infectious diseases involving the disease of the bone and/or bone marrow further extending to periosteum. It is a disturbing disease and involves a series of causative host and pathogen factors. The primary cause of this disease is usually taught to be microbiological especially Staphylococcus aureus and Staphylococcus epidermis. The diagnosis of osteomyelitis is strenuous, mainly in the early stages, and this disease is at all times complex to treat. Eradicating microorganisms and recuperating circulation in the regions involved, in the early stages have been the mainly employed treatment modalities. The case presented here is of chronic osteomyelitis with an extraoral draining sinus. Surgical debridement and oral antibiotics were considered as the treatment of choice. Key words: Chronic suppurative osteomyelitis, coronoidectomy, debridement, sequestrectomy, localized osteomyelitis, osteomyelitis of mandible, furunculosis, boils, abscess, staphylococcosis

INTRODUCTION: submental region from midline of chin upto Osteomyelitis is the inflammation of bone and parasymphysis region on left side mediolaterally bone marrow that develops in the jaws after a and from submental region upto 1 cm below anterio chronic odontogenic infection or a variety of other 1,2 posteriorly.There was yellow fluid (pus) like reasons . Advances in the field of anesthesia, discharge seen on submental region with surface is antibiotic therapy, preventive and restorative appearing crusted. There was localised rise in dentistry, as well as the availability of component temprature near the submental region on palpation. medical and dental care have reduced the incidence Intraorally there was no abnormality seen ,however of the disease. Chronic osteomyelitis may show a all 4 canines were missing. Submeantal and suppurative course with abscess or fistula formation submandibular lymph nodes were palpable, tender, and sequestration at some stage. Several reports mobile, and soft to firm. Cervical chain of have concluded that chronic suppurative lymphnodes were non palpable. Chronic osteomyelitis (CSO) can be treated successfully by suppurative osteomylitis was our provisional a combination of antimicrobial therapy with diagnosis based on clinical examination .On surgery, either sequestrectomy or decortication of radiological investigation the panoramic view the affected bone. The aim of surgery is to eliminate [Figure2] showed a large irregular shaped all of the infected and necrotic bony tissue and, if radiolucent area of around 2-3 cm seen at the center incomplete, surgical debridement may lead to 1 of mandible from mesial of 35 upto mesial of 44 persistence of the osteomyelitis . which is extending upto the lower border of CASE REPORT: mandible. There were also 2 tooth like structure A 55 year old male patient came to our seen in relation to apex of root of 45 and another department of oral medicine and radiology of horizontally impacted in relation to lower border of Ahmedabad Dental College And Hospital with mandible on left side. There were also 2 tooth like chief complaint of draining sinus in relation to structure seen overlaping the root of 12 and 22 submental region since 3 years. Dental history of all respectively. In the mandibular region near the missing canine since childhood. Patient had impacted canines surrounding bone is showing undergone extraction in relation to 31,32 and 41 3 more radiopecity suggestive of surrounding bone years back and exfoliation of 42 6 months reaction. On further radiological investigation that ago[figure1]. Patient had habit of snuff rubbing is CBCT [Figure3] it was found that there was a since 40 years 5 times a day. During clinical horizontally impacted mesiodistally placed 33, examination it was found that a single round of there was also a huge bony defect seen in relation around 1 cm in diameter draining sinus was seen on

*Sr. Lecturer, **Sr. Lecturer, ***PG Student, ****PG Student DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY, AHMEDABAD DENTAL COLLEGE AND HOSPITAL, TA. KALOL, DIST: GANDHINAGAR, GUJARAT, INDIA.

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. TWINKAL PATEL, TEL: +91 97148 02656

68 Twinkal Patel et. al. : CHRONIC SUPPURATIVE OSTEOMYLITIS WITH ALL FOUR CANINES IMPACTED buccal and lingual border of mandible leading to pathological fracture. There was also a bony defect seen in the inferior border of mandible. Panoramic reconstruted image was showing a discontinuation in relation to lower cortex of mandible near symphysis. region.33 was mesio-distally angulated and 43 vertically impacted.

Figure4: Histopathological section Histopathological examination revealed that the section showed granulation tissue exhibiting chronic inflamatory cells in large number bundles of collagen fibers and blood vessels [figure 4].3 DISCUSSION Osteomyelitis is an inflammatory condition of Figure1: Extraoral photograph showing the bone that involves the medullary cavity and has draining sinus in relation to sub mental region. a tendency to progress along this space and involve the adjacent cortex, periosteum and soft tissue.4 It is more common in the mandible than in the maxilla because of the dense, poorly vascularized cortical plates and the single blood supply from the inferior alveolar neurovascular bundle5. The primary cause of the chronic osteomyelitis is usually microbiologic and results from an odontogenic infection, post-extraction complications, inadequate removal of necrotic bone, early termination of antibiotic therapy, inappropriate Figure2: OPG showing a huge bony defect at the selection of antibiotics, diagnostic failure, trauma, center of mandible with all 4 impacted canines. inadequate treatment for fracture or irradiation to the mandible. The most common bacteriologic results reported to the treating clinicians were mixed oral flora or mixed anaerobic flora.The distribution of osteomyelitis in the jaws dominated by cases that occurred in the mandible, with the highest frequency found in the angle and the body regions. In chronic secondary osteomyelitis, the clinical findings usually are limited to fistulas, induration of soft tissue and thickened or wooden character to the affected area, with pain and tenderness on palpation. In cases of recurrence, Figure3 CBCT image showing pathological symptoms often occurred immediately adjacent to fracture in symphysis region and impacted 33 the decorticate area. Culture, bone biopsy, and 43.

69 Twinkal Patel et. al. : CHRONIC SUPPURATIVE OSTEOMYLITIS WITH ALL FOUR CANINES IMPACTED conventional radiography, radioisotope bone feruncleitis because there was not only scanning, laser Doppler flowmetry, computerized involvement skin but also bone when seen in tomography and magnetic resonance imaging are OPG.6 With this we also found that there was a used to diagnose chronic osteomyelitis. huge bony involvent with all 4 impacted canines Management entailed a course of antibiotics in and radiolucency with surrounding bone reaction. combination with surgical debridement. In Actinomycosis was also kept as differential chronic suppurative osteomyelitis of the diagnosis and not provisional because when mandible, several authors recognize resistance to viewed macroscopically there were no sulphur therapy as an infrequent but possible problem. granules visible.7 Intraosseous carcinoma was also Topazian recommends to continue post-surgical ruled out as there was surrounding bone reaction treatment for 2–4 months after the resolution of seen near the impacted canines irt 33,43 which is the symptoms where as Bartkowski et al . use suggestive of inflamatory condition however it intravenous therapy for 10–24 days. This is was important to completely rule out consistent with the published protocols of Van carcinomatous involvement which was done with Merkesteyn et al . It has been suggested that the help of histopathological examination.8,9 antibiotic therapy combined with surgical CONCLUSION intervention is effective in the treatment of chronic Proper diagnosis and treatment planning is of suppurative osteomyelitis. Some reports have also utmost importance to cure any disease. 6 advocated the use of hyperbaric oxygen in the Considering clinical presentation and course of treatment of this condition, especially in the the disease with successive previous treatment irradiated mandible. For osteomylitis older age is failure in this case it was very important to more common but as far the history of snuff diagnose the condition clinically ,radiographically rubbing was there intraosseous carcinoma was and histopathologically. With proper diagnosis also amongst one of the diffrential diagnosis and it successful treatement was delivered and further was important to be ruled out. In this case we have relapse of the condition was avoided.10,1 kept chronic suppurative osteomylitis and not

REFERENCES: T. Miki, K. Aota, T. Sumi, K. Matsumoto, and Y. 1. Rajkumar GC, Hemalatha M, Shashikala R, Yura, “Garré's osteomyelitis of the mandible Veerendra Kumar D. Recurrent chronic caused by an infected wisdom tooth,” Oral Science suppurative osteomyelitis of the mandible. Indian International, vol. 5, no. 2, pp. 150–154, 2008. J Dent Res 2010;21:606-8. 7. Florent valour1–3 Agathe Sénéchal1,2 Céline 2. S. Swetha Kamakshi, Vatsala Naik, Kavita Vittal, Dupieux2–4 Judith Karsenty1,2 Sébastien R. Shriyanka Chronic suppurative osteomyelitis: Lustig2,5 Pierre Breton2,6 Arnaud Gleizal2,7 A case report Journal of Advanced Clinical & Loïc Boussel2,8,9 Frédéric Laurent2–4 evelyne Research Insights (2016), 3, 220–223 Braun1 Christian Chidiac1–3 Florence Ader1–3 Tristan Ferry1–3 Infection and Drug Resistance 3. Tiemann, G.O. Hofmann V. Krenn, S. Langwald, 2014:7 GMS Interdisciplinary Plastic and Reconstructive Surgery DGPW 2014,Vol.3 8. Saeed Nezafati 1, Mohammad Ali Ghavimi, Amir Saeed Yavari J Dent Res Dent Clin Dent 4. David J. Pincus, M.D.,1 Milton B. Armstrong, Prospect 2009; 3(2):67-69 M.D.,1 and Seth R. Thaller, M.D., D.M.D., F.A.C.S., F.A.A.P.1 SEMINARS IN PLASTIC 9. Geetha P, Avinash Tejasvi ML, Babu BB, Bhayya SURGERY/VOLUME 23, NUMBER 2 2009 H, Pavani D. Primary intraosseous carcinoma of the mandible: A clinicoradiographic view. J Can 5 . AyaazHabib,,NagarajSivaji, and TauseefAshraf Res Ther 2015;11:651. Hindawi Publishing Corporation Volume 2016, Article ID 9723806, 3 pages 10. Elena García del Pozo1 Julio Collazos2 José Antonio Cartón3,4 Daniel Camporro1 Víctor 6. Kristina Sophie Ibler Charles B Kromann Asensi3 8. F. R. Karjodkar, Textbook of Dental and Department of Dermatology, Roskilde Hospital, Maxillofacial Radiology, Jaypee, Panama City, Copenhagen University, Denmark 10. H. Nakano, Panama, 2nd edition, 2009.

70 EXOPHYTIC AND REACTIVE LESIONS: A Case Report REPORT OF THREE CASES

Dr. Amena Ranginwala*, Dr. Nidhi Hirani**, Dr. Himani Dave***, Dr. Anjali Sadhawani**** ABSTRACT The reactive lesions are relatively common in the oral cavity because of the frequency with which the tissues are injured. Oral exophytic lesions often have proven to be diagnostically challenging due to the varied clinical presentation. The proliferative activity of the reactive lesions is considered to be initiated by local irritants. The elimination of local irritants and proper dental replacement may contribute to the reduction of these lesions. Careful clinical interpretation with a better histological understanding of exophytic lesions may ease the diagnosis from the differential diagnosis panel. Keywords: reactive lesion, exophytic lesion, traumatic fibroma, pyogenic granuloma, epulis fissuratum.

INTRODUCTION: Patient had undergone complete denture before Lesions in the oral cavity generally present as 4 years and that cracked before a year, then he had ulcerations, red and white lesions, pigmentations, undergone a new denture before a year but that and exophytic lesions. Clinical classification of oral denture was not accommodated, so he wore lesions is of great importance in the diagnostic cracked denture for a year but now as it was process. There are several underlying mechanisms completely broken so patient consulted our OPD. responsible for oral exophytic lesions such as On examination of denture, the upper denture had hypertrophy, hyperplasia, neoplasia, and pooling of been broken in two halves from middle. the fluid, which makes it difficult to approach such lesions clinically.[1] The term oral exophytic lesions represent any pathological growth that projects above the normal contours of the oral surface epithelium.[2] Exophytic lesions can be classified according to their surface texture (smooth and rough), base (pedunculated & sessile), shape (nodular, and dome shaped), and consistency (soft, cheesy, rubbery, firm and bony hard)[1] Reactive lesions are tumor-like hyperplasias which show a response to a low-grade irritation or injury, such as chewing, food impaction, calculus, iatrogenic injuries such as broken teeth, overhanging dental restorations and extended flanges of denture.[3] The clinical appearance of reactive lesions is very similar to that of neoplastic proliferations.[4] CASE REPORT: CASE REPORT 1 A 60 years old male, Hindu patient residing at Nandasan belonging to lower socio-economic class, came to oral medicine and radiology department with the chief complain of broken, ill fitting denture and the growth around the flanges.

* Professor, **PG Student, ***PG Student DEPARTMENT OF ORAL PATHOLOGY, DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. NIDHI HIRANI, TEL: +91 90993 76158

71 Nidhi Hirani et. al. : EXOPHYTIC AND REACTIVE LESIONS

On intraoral inspection, small multinodular growth On intraoral examination, patient had reduced was present on the upper labial vestibule, left side of mouth opening up to 25 mm. Maxillary left third the labial frenum. The color of the growth was same molar (28) was buccally erupted. The right and left as the surrounding. Irregular in shape, sessile and buccal mucosa were blanched, the tongue total size approximately 10-12 mm. There is no sign movement was restricted and uvula was shrunken. of bleeding or pus discharge. Vertical fibrous bands were palpable on left buccal On intraoral palpation, the growth was irregular mucosa. in shape, sessile, firm and non-tender. There was A single exophytic growth present on the left noble eding and pus discharge on manipulation. buccal mucosa opposite 28, extending Provisional diagnosis of epulis fissuratum on the inferosuperior from the level of occlusal plane of 28 upper left labial vestibule was considered as the to the depth of buccal vestibule. The growth was lesion was approximating the flanges of broken irregular in shape, reddish pink in color, size denture. approximately 6-7 mm and no sign of bleeding and The treatment plan was outlined by complete pus discharge was seen. removal of the lesion by means of laser surgery, with a minimally invasive approach. The excised tissue sent for the histopathological report.

On palpation all inspectoryfindings were confirmed, the growth was soft to firm in consistency, non- tender and sessile. There was no sign of bleeding and pus discharge on manipulation. Provisional diagnosis of oral submucous fibrosis (OSMF) and traumatic fibroma on left buccal The histopathology showed parakeratinized mucosa were considered. stratified squamous epithelium. Underlying OPG was advised to the patient which revealed connective tissue showed collagen fibers, normal condylar process, TMJ, maxilla and fibroblast, RBCs filled dilated blood vessels and maxillary sinus. All teeth were present except 38. extravasated RBCs. The 18 was distoangular impacted, 28 was Followup after 15 days showed complete vertical and 48 was mesioangular impacted. healing of the lesion so patient was advised for construction of new set of dentures.

CASE REPORT 2 A 29 years old male, Hindu patient residing at Sattadhar belonging to lower socio-economic class, came to oral medicine and radiology department with the chief complain of pain on the left buccal mucosa due to cheek biting for 2-3 months. Patient had habit of Gutkha with tobacco chewing 2-3 packets per day and smoking bidi i.e. 1-2 per day for The lesion was excised surgically (excisional last 15 years. biopsy) and punch biopsy was taken from left buccal mucosa for the investigation of OSMF.

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On intraoral inspection, a single round of around 1 cm of diameter growth was present on the marginal gingiva between 41 & 42. It was pink in color with small bleeding spot on the surface. There was no sign of pus discharge. On palpation all inspectory findings were confirmed,the growth was pedunculated, non- tender, firm in consistency with no sign of bleeding or pus discharge on manipulation. Provisional diagnosis of pyogenic granuloma was considered.

The histopathological examination of growth showed parakeratinizedstratified squamous epithelium with long anastomosing rete ridges. Underlying connective tissue showed collagen fibers, fibroblast, RBCs filled dilated blood vessels and extravasated RBCs. The histopathological e x a m i n a t i o n o f O S M F s h o w e d parakeratinizedatrophic stratified squamous epithelium exhibiting dysplastic changes like basilar hyperplasia, hyperchromatism, increased N:C ratio and abnormal mitotic figures. Underlying connective tissue showed large numbers of collagen Intraoral periapical (IOPA) radiograph of lower fibers, chronic inflammatory cells and dilated blood anterior region was taken for examining any bone vessels. involvement. The lamina dura of all radiographed Final diagnosis was confirmed as fibroma on left teeth were intact with mild interdental horizontal buccal mucosa and OSMF with mild dysplasia. bone loss. Patient was advised to quit habit but he was not Oral prophylaxis (scaling) was completed and willing for extraction of 28 and for treatment of the lesion was excised up to and including the OSMF. mucoperiosteum under local anesthesia. CASE REPORT 3 A 33 years old female, Hindu patient residing at Bhadaj belonging to lower socio-economic class, came to oral medicine and radiology department with the chief complain of growth at the lower front tooth region for last two months, gradually increasing in size.

73 Nidhi Hirani et. al. : EXOPHYTIC AND REACTIVE LESIONS

[10] H i s t o p a t h o l o g i c a l r e p o r t r e v e a l e d excision, electrical surgery, and laser surgery. parakeratinized stratified squamous epithelium Pyogenic granuloma, also known as lobular capillary with long rete ridges. Underlying connective tissue hemangioma, is a benign vascular neoplasm. It results [7] shows large numbers of dilated blood vessels filled from inflammatory hyperplasia of mucosa or the skin. with RBCs, large number of chronic inflammatory They usually present as a red mass composed cells and extravasated RBCs were also seen. predominantly of hyperplastic granulation tissue in which capillaries are very prominent commonly seen The diagnosis pyogenic granuloma was arising from interdental gingiva.[8] It is commonly seen in histologically confirmed. middle age population and usually in females then Post-operative instructions were given and patient males. advised to maintain proper oral hygiene. Other reactive gingival lesions are fibrous epulis, DISCUSSION: peripheral giant cell granuloma, fibroepithelial polyp, peripheral ossifying fibroma, and giant cell fibroma. The information on clinical character and histological That we can considered as differential diagnosis. origin of the exophytic growth are two important Here in this case, treatment of pyogenic granulomas parameters in decision making. The clinical characters conservative surgical excision is performed, and it is such as consistency of the lesion (soft/ hard), colour and pigmentation of the lesion, shape of the swelling, base of also achieved by cryosurgery, or laser. the exophytic growth, location of the lesion (anterior/ CONCLUSION: posterior jaw; labial/buccal mucosa). Whereas, the Exophytic mass in the oral cavity a clinician should histological origin of the growth such as bony, dental, consider some features such as surface texture, shape of gingival or epithelium. The obtained information should base, color, and consistency in order to categorize the be analyzed step by step for successful diagnosis of the [2] lesion. lesion. Proper diagnosis, prevention, management, and Epulis fissuratum is a tumor-like hyperplasia of fibrous treatment of these lesions are of chief importance. connective tissue, which develops in association with an Treatment involves removal of the local irritants along ill-fitting\fractured denture. The anterior portion of the with surgical excision of the lesion. jaw is affected much more commonly than posterior areas.[10] In this case we kept it as Epulis fissuratum and not papilloma, peripheral giant cell granuloma, mucocele because the site of lesion denotes the lesion is due to constant irritation of fractured denture. Epulis fissuratum is commonly seen in old age population and usually on the oral mucosa of the vestibular sulcus or the palatal region. When the hyperplastic tissue is composed of significant fibrosis, surgical excision is the treatment of choice.[5] In a recent case report, the use of laser surgery has been suggested to manage epulis fissuratum. Fibroma, a benign neoplasm of fibroblastic origin, is reactive in nature and represents a reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma rather than being a true neoplasm.[6] It develops frequently between second and fourth decades of life.[10] In this case we kept it as traumatic fibroma and not papilloma, and carcinoma of buccal mucosa because clinically and radiographically shows distoangular 28 which is causing constant trauma to the left buccal mucosa. The lesion typically appears as pink growth which is smooth surfaced and similar in color to the surrounding mucosa. Kinds of treatment for soft-tissue lesions include scalpel

74 Nidhi Hirani et. al. : EXOPHYTIC AND REACTIVE LESIONS

REFERENCES: 1. HamedMortazavi, Yaser Safi, Maryam Baharvand, Somayeh Rahmani and Soudeh Jafari. Peripheral Exophyc Oral Lesions: A Clinical Decision Tree, Int. J. Dent.2017;7(5):144-52 2. Arvind Babu Rajendra Santosh, Doryck BoyD2, Kumar Aswamy, KikeriLaxminarayana. Proposed Clinico-Pathological Classificaon for Oral Exophyc Lesions, J. clin. diagn. res. 2015;9: 1-8 3. Sangle VA, Pooja VK, Holani A, Shah N, Chaudhary M, Khanapure S. Reacve hyperplasc lesions of the oral cavity: A retrospecve survey study and literature review. Indian J Dent Res 2018; 29:61-6. 4. HamidehKadeh, ShirinSaravani, Mohammad Tajik. Reacve Hyperplasc Lesions of the Oral Cavity, Irn. J. orl2015; 27:137-144 5. Jain G, Arora R, Sharma A, Singh R, Agarwal M. Irritaon fibroma: Report of a case. J Curr Res Sci Med 2017; 3:118-21. 6. Ramesh Parajuli & SushnaMaharjan, Unusual presentaon of oral pyogenic granulomas: a review of two cases. Clinical Case Reports 2018; 6(4): 690–693 7. Khaitan T, Sinha R, Sarkar S, Kabiraj A, Ramani D, Sharma M. Conservave approach in the management of oral pyogenic granuloma by sclerotherapy.Jain PR, Jain S, Awadhiya S, Sethi P. Excision of traumac fibroma by diode laser. J Dent Lasers 2018; 12:67-9. 8. Ashish Lanjekar, Sunita Kulkarni, SonaliAkhade, SonalSonule. 9. Carla Gadea Rosa, Andrea Cartagena Lay, AndreéCáceres La Torre, Oral pyogenic granuloma diagnosis and treatment: a series of cases, Revista Odontológica Mexicana 2017; 21 (4): 244-52. 10. Sharma S, Chandra S, Gupta S, Srivastava S. Heterogeneous conceptualizaon of eopathogenesis: Oral pyogenic granuloma. Natl J Maxillofac Surg 2019; 10:3-7.

75 Frenectomy with Paralleling Technique: A Case Report A Case Report

Dr. Pinkal Patel*, Dr. Mihir Shah**, Dr. Archita Kikani***, Dr. Dhar Thakar**** ABSTRACT A frenum is a fold of tissue or muscle connecting the lips, cheek or tongue to the jaw bone. Clinically, papillary and papilla penetrating frenum are considered as pathological and have been found to be associated with loss of papilla, recession, diastema, difficulty in brushing, alignment of teeth and psychological disturbances to individual. Frenectomy is the complete removal of the frenum, including its attachment of the underlying bone. There are two techniques for frenectomy. One of these is the conventional technique with scalpels and periodontal knives, and the other is using the soft tissue laser. both the techniques has certain disadvantages, conventional scalpel technique causes large rhomboidal wound area where primary closure is not possible in the lower part and healing takes place by secondary intension. It also causes more pain and discomfort to the patient when compared with the laser technique. On the other hand laser is a costly instrument, and the use require more precision and control, if the beam touches the bone surface it will cause necrosis of the bone. The aim of this article is to report a case of paralleling technique frenectomy, along with literature review & its advantages over conventional technique frenectomy. Keywords: Paralleling technique frenectomy, Frenum, Conventional technique Frenectomy

INTRODUCTION: 3. Papillary: When fibers are extending into A frenum is a fold of mucous membrane, usually interdental papilla with enclosed muscle fibers, that attaches the lips 4. Papilla penetrating: When the frenal fibers and cheeks to the alveolar mucosa and/or gingiva cross the alveolar process and extends up to the and underlying periosteum. Frenum problem most palatine papilla. often occurs on the labial surface between the Clinically, papillary and papilla penetrating frenum maxillary and mandibular central incisors and in are considered as pathological and have been found canine and premolar areas. They occur less often on 1 to be associated with loss of papilla, recession, the lingual surface of the mandible. diastema, difficulty in brushing, alignment of teeth Aetiology: and psychological disturbances to individual.5,6 The maxillary labial frenum develops as a post- The aberrant frena can be treated by frenectomy or eruptive remnant of the ectolabial bands which by frenotomy procedures. Frenectomy is the connect the tubercle of the upper lip to the palatine complete removal of the frenum, including its papilla. When the two central incisors erupt widely attachment to the underlying bone, while frenotomy separated, no bone is deposited inferior to the is the incision and the relocation of the frenal frenum. A V-shaped bony cleft between the two attachment.7 central incisors and an abnormal frenum attachment Frenectomy can be accomplished either by the results. The mandibular frenum is considered as routine scalpel technique, electrosurgery or by aberrant when it is associated with a decreased using lasers. The conventional technique involves vestibular depth and an inadequate width of the 2,3 excision of the frenum by using a scalpel. However, attached gingiva. it carries the routine risks of surgery like bleeding Depending upon the extension of attachment of and patient compliance. 4 fibres, frena have been classified by Placek et al: The use of electro surgery and lasers has also been 1. Mucosal: When the frenal fibers are attached proposed for frenectomy.8-13 Researchers have up to mucogingival junction advocated the use of an electrocautery probe due to 2. Gingival: When fibers are inserted within its efficacy and due to the safety of the procedure, attached gingiva the mild bleeding and the absence of postoperative complications. However, it is associated with *PG Student, **Head Of the Department, ***Professor, ****PG Student

DEPARTMENT OF PERIODONTICS & ORAL IMPLANTOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. PINKAL PATEL, TEL: +91 99044 12582

76 Pinkal Patel et. al. : Frenectomy with Paralleling Technique certain complications which include burns, the risk positive. There was presence of local factors & of an explosion if combustible gases are used, absence of gingival recession, trauma from interference with pacemakers and the production of occlusion. surgical smoke. These complications have not been Diagnosis: -Looking at the clinical picture and reported with the new improvement in the electro detected visually by applying tension over the surgical techniques, like the Argon Beam 8,9 frenum to see the movement of the papillary tip or Coagulation (ABC). the blanch which is produced due to ischaemia in Recently, the use of a CO2 laser in lingual the region. The frenumis characterized as frenectomy has been reported as a safe and effective pathogenic of papilla penetrating type that made the procedure with the advantages of a shorter duration distema& psychological problems to the patient. of the surgery, simplicity of the procedure, the absence of postoperative infections, lesser pain, swelling and the presence of a small or no scar.8 A delayed healing as compared to that in the conventional scalpel techniques, a reduced surgical precision which results in an inadvertent laser- induced thermal necrosis and/or a photo acoustic injury, are some of the complications which are associated with lasers. The application of diode and Er:YAG lasers10 in labial frenectomies in infants and Er,Cr:YSGG lasers11 in labial frenectomies in the adolescent and the pre-pubescent populations have also been reported. Since the conventional procedure of frenectomy was first proposed, a number of modifications14-16 of the various surgical techniques like the Miller's Figure 1: Papilla penetrating labial frenum technique, V-Y plasty and Z-plasty have been with midline diastema developed to solve the problems which are caused by an abnormal labial frenum, but conventional Treatment: - She was treated with Phase I therapy scalpel technique causes large rhomboidal wound scaling followed by decided to perform: area where primary closure is not possible in the Paralleling technique frenectomy for papilla lower part and healing takes place by secondary penetrating frenal attachment. (Figure 1) The intension. It also cause more pain and discomfort to details of the Paralleling technique frenectomy the patient. To overcome this, modern technology procedurewere explained verbally to patient. now offers an alternative mode of treatment, the Patient signed an agreement informed consent for present article, apart from reporting a case is a surgery. Patient was evaluated by clinical succinct review of Paralleling technique examinations and documented by digital photos frenectomy, which highlights the advantages of this and patient was prepared for surgery. technique over conventional technique frenectomy. Local anesthesia (lignocaine HCl with 2% CASE REPORT: epinephrine at 1:80,000) was administered in the maxillary vestibular mucosa surrounding labial A 19 years aged Female patient reported to the frenum. The upper lip was pulled upward by the Outpatient Department of Periodontics and Oral assistant hands, then frenum was tightened.Two Implantology at Ahmedabad Dental College & paralleling incisions were placed on the side of Hospital, Gandhinagar with the chief complaint of ridge of the frenum with a number 11 blade (Figure spacing in the upper front tooth region of jaw. A 2). detailed history was taken & revealed no positive features. On clinical examination, the patient had midline diastema in upper arch. This diastema associated with frenal attachment & tension test

77 Pinkal Patel et. al. : Frenectomy with Paralleling Technique

After frenumexcision the wound was closed with suture to attain primary closure (Figure 5).

Figure:2 Two parallel incisions on either side of frenum After initial incision, deep dissection of the muscle fiberswas done to eliminate all the attachments Figure 5:Sutures taken (Figure 3). After surgery, Post-operative instructions the patient was given verbal instructions that including; avoid taking hot, spicy, citrus and hard foods for a few days, soft diet instructions, meticulous oral hygiene and they were told to use an analgesic if needed. The patients were asked to rate the degree of postoperative pain and speech complication on a 10 cm horizontal visual analogue scale (VAS) by placing a vertical mark to assess position between the two endpoints. The left endpoint of the pain scale was designated as “no pain,” and the right end point was designated as “worst pain imaginable.” The patients were asked to mark the position Figure 3: Deep dissection of the muscle fibers between the two endpoints that best describe their Incised frenum was removed by giving releasing personal perception of the degree of pain and incision on the top and bottom of the frenum(Figure 4) . discomfort during speech on postoperative days 1, 7 and 30.

Figure 4: Excision of the frenum showing exposed tissue Figure 6: 15 days Follow Up

78 Pinkal Patel et. al. : Frenectomy with Paralleling Technique

long journey from Archer's 17 and Kruger's 18 “classical techniques” of total frenectomy to Edward's19 more conservative approach. Recent techniques added frenal relocation by Z-plasty, 20frenectomy with soft-tissue graft 14and laser 10- 13 applications to avoid typical diamond-shaped scar and facilitate healing. Each method has its own advantages and disadvantages. In our case report patient treated by paralleling technique had significantly less postoperative pain and functional complication .Conventionally, a frenectomy procedure involve holding of frenum with the hemostat, incising above and below the hemostat, creating a large diamond shape wound, Figure 7: 1 Month follow up often with copious bleeding. Patient often experience postsurgical bleeding and pain mainly On follow up patient showed good oral hygiene & because of the open area at the base of the less postoperative pain and discomfort during frenectomy site, where primary closure is not speech on postoperative days. (Figure 6, 7). possible because large part of mucosa has been removed. To overcome these problems a new paralleling technical is used in this study for frenectomy. In case of paralleling technique two paralleling incisions are made on the side of ridge of the frenum this will reduce the removal of excess mucosal tissue. After that deep dissection for the muscle fibersare done to remove the attachment. This will decrease the chances of recurrence. Then the thin incised tissue is removed by making sharp cut above and below frenum. Primary closure is possible in this case throughout the length of frenum because of close approximation of margin produced by thin paralleling incision (Figure 2). Primary closure and less removal of gingival and mucosal tissues could Figure 8: composite buid up to treat midline be the reason for less postoperative pain and speech diastema discomfort (Figure 4). Then patient was referred to conservative department for composite build up between maxillary central incisors to close diastema. (Figure CONCLUSION: 8) Paralleling technique provides better patient DISCUSSION: perception in terms of postoperative pain and speech. High frenum causes hindrance in oral This case report showed postoperative subjective hygiene maintenance and psychological problems effects of paralleling techniques after frenectomy. and this measures improves after frenectomy. In the era of periodontal plastic surgery, more Neverthless, more investigation & comparison conservative and precise techniques are being studies are needed to establish the exact efficacy of adopted to create more functional and aesthetic paralleling technique frenectomy used. results. The management of aberrant frenum has travelled a

79 Pinkal Patel et. al. : Frenectomy with Paralleling Technique

REFERENCES: retrospective evaluation of 156 consecutive 1. Takei HH, Azzi RA. Periodontal plastic and cases. Gen Dent. 2010;58:126-33. esthetic surgery. In: Newman MG, Takei HH, 12. Shetty K, Trajtenberg C, Patel C, Streckfus Carranza FA, editors. Carranza's Clinical C. Maxillary frenectomywhich was done by Periodontology. 9th ed. London: W.B. using a carbon dioxide laser in a pediatric Saunders Co.; 2002. p. 870-1. patient: a case report. Gen Dent. 2008;56:60- 2. Huang WJ, Creath CJ. The midline diastema: 3. a review on its etiology and treatment. 13. Kafas P, Stavrianos C, Jerjes W, Upile T, Pediatric Dentistry 1995;17:171-9. Vourvachis M, Theodoridis M, et al. Upper- 3. Jhaveri H. The Aberrant Frenum. In: Dr. lip laser frenectomy without infiltrated HiralJhaveri (ed), Dr. PD Miller the father of anaesthesia in a paediatric patient: a case periodontal plastic surgery, 2006;29-34. report. Cases Journal 2009;2:7138. 4. Taylor JE. Clinical observation relating to the 14. Coleton SH. The mucogingival surgical normal and abnormal frenumlabiisuperioris. procedures which were employed in re- Am J Orthod Oral Surg 1939;25:646-50. establishing the integrity of the gingival unit (III). The frenectomy and the free mucosal 5. Dewel BF. The labial frenum, midline graft. Quintessence Int 1977;8(7): 53-61. diastema, and palatine papilla: A clinical a n a l y s i s . D e n t C l i n N o r t h A m 15. Kahnberg KE. Frenum surgery. I.A 1966;10:175-84. comparison of three surgical methods. Int J Oral Surg 1977;6:328-33. 6. Diaz-Pizan ME, Lagravère MO, Villena R. Midline diastema and frenum morphology in 16. Ito T, Johnson JD. Frenectomy and the primary dentition. J Dent Child (Chic) frenotomy. In: Ito T, Johnson JD (eds). Color 2006;73:11-4. A t l a s o f P e r i o d o n t a l S u r g e r y . London:Mosby Wolfe, 1994;225-39 7. Dibart S, Karima M. Labial frenectomy alone or in combination with a free gingival 17. Archer WH, editor. Oral Surgery – A Step by a u t o g r a f t . I n : S e r g e D i b a r t , Step Atlas of Operative Techniques. 3rd ed. M a m d o u t h K a r i m a ( e d s ) P r a c t i c a l Philadelphia: WB Saunders Co.; 1961. p. Periodontal Plastic Surgery. Germany: 192. Blackwell Munksgaard: p53. 18. Kruger GO, editor. Oral Surgery. 2nd ed. St. 8. Cunha RF, Silva JZ, Faria MD. A clinical Louis: The C.V. Mosby Co.; 1964. p. 146. approach of ankyloglossia in babies: a report 19. Edwards JG. The diastema, the frenum, the o f t w o c a s e s . J C l i n P e d i a t r D e n t frenectomy: A clinical study. Am J 2008;32:277-82. Orthod1977;71:489-508. 9. Verco PJW. “A case report and a clinical 20. Tait CH. Median frenum of upper lip and its technique: argon beam electrosurgery for the influence on spacing of upper central incisor tongue ties and maxillary frenectomies in teeth. N Z Dent J 1929;25:116. infants and children”. European Archives of Paediatric Dentistry. www.findarticles.com, accessed on January 2010. 10. Gontijo I, Navarro RS, Naypek P, Ciamponi AL, Haddad AE. The application of diode and Er:YAG lasers in labial frenectomies in infants. J Dent Child 2005;72(1):10-5. 11. Olivi G, Chaumanet G, Genovese MD, Beneduce C, Andreana S. The Er,Cr:YSGG laser labial frenectomy: a clinical

80 IMPACTED MAXILLARY CENTRAL INCISOR: A Case Report A CASE REPORT

Dr. Sonali Mahadevia*, Dr. Bhavya Trivedi**, Dr. Richa Vakil*** ABSTRACT This case report describes the treatment of a patient with a vertically impacted maxillary central incisor having Class I molar relationship on either side. a 2-stage treatment plan was planned. In the first stage, enough space for the eruption of the maxillary left permanent incisor was created. The second stage included surgical exposure and traction of the impacted central incisor with a fixed orthodontic appliance. An excisional uncovering technique was needed to expose the impacted incisor. Traction was given in this exposed crown surface to achieve eruption and bring it into alignment. Keyword: impaction, orthodontics, cbct

INTRODUCTION: part of it, at the end of the surgical exposure. This Impaction of a permanent central incisor is not as has been termed “open-eruption” exposure. common as that of a maxillary canine. The Removal of soft tissue overlying an unerupted impaction of the maxillary central incisor manifests tooth, although more direct, has disadvantage that at itself at an early age.1 This tooth usually erupts the end of treatment the erupted tooth will have a several years before the canine, when the child is nonkeratinized labial gingival margin, on the other between 8 and 10 years of age, and its impaction is hand, apical repositioning can be expected to more conspicuous to the parents.2 provide adequate width of the attached gingiva. With a bonded attachment, an extrusive force can be The principal factors involved in impaction of applied to augment the diminished natural eruptive central incisor are supernumerary teeth, odontomas force.13-15 and trauma. There are other alternatives for treatment of impacted central incisor which include DIAGNOSIS AND ETIOLOGY extraction, restoration with a bridge, implant, An 18-year-old boy with chief complaint of missing extraction followed by space closure and surgical upper left central incisor having all other permanent exposure, orthodontic space opening, and traction teeth (except third molars)in the arch (Figs 1 and 2). of the impacted central incisor into its proper 10,11 On evaluation he had a balanced facial pattern. The position. however surgical exposure and maxillary left central incisor was impacted, and the positioning impacted tooth in line of occlusion provides the best method for naturally restoring the adjacent teeth had drifted into the unoccupied missing tooth. There are some factors which might space. There was Class I molar relationship. Overjet enhance the outcome of the orthodontic-surgical was 3 mm and overbite 4 mm. The patient had a plan for the ultimate outcome of impacted central history of trauma at age 10. Radiographs showed incisors but, particularly, the manner in which the that the maxillary left central incisor was impacted impacted tooth is exposed. Impacted teeth can be in a vertical position in the region of the nasal floor. exposed by reposition or else removal of soft tissue envelope and afterward leaves tooth in full view or a (Fig 3)

Fig 1. Pretreatment extraoral photographs

*Head Of the Department, **Professor, ***PG Student DEPARTMENT OF ORTHODONTICS & DENTOFACIAL ORTHOPAEDICS AHMEDABAD DENTAL COLLEGE AND HOSPITAL

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. RICHA VAKIL, E-mail : [email protected]

81 Richa Vakil et. al. : IMPACTED MAXILLARY CENTRAL INCISOR

Fig 2. Pretreatment intraoral photographs

Fig 3. Pretreatment panoramic x-ray

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TREATMENT OBJECTIVES The following treatment objectives were established: (1) recover space in the maxilla for the eruption of the left incisor, (2) provide orthodontic traction for the impacted tooth, (3) create a stable functional occlusion, and (4) establish adequate attached gingiva and symmetric gingival margins for both maxillary central incisors. TREATMENT PLAN After discussing the possible treatment alternatives, the parents and the clinicians chose to try to save the tooth and bring it into its proper position. The treatment plan consisted of 2 stages. In the first stage, enough space for the eruption of the maxillary left permanent incisor. The second stage included surgical exposure of impacted central incisor followed by traction. TREATMENT PROGRESS After the bands or brackets were placed on all teeth. Once the maxillary arch was in a relatively rigid stabilizing wire (0.019-in × 0.025-in stainless steel in a 0.022-in slot), a coil spring was used to create adequate space for aligning the impacted incisor. A surgery was performed to expose the maxillary left central incisor (Fig 4). A flap was elevated to expose the tooth, and it was necessary to bond an attachment on the buccal surface of the incisor to tie it to a 0.010-in ligature wire and bond it to an elastic module for applying force in the apical direction. Once the impacted tooth had erupted, a bracket was bonded to the crown and tied to archwire (0.014-in nickel-titanium). In the mandibular arch, alignment and leveling were achieved with a sequence of 0.014-in and 0.016-in nickel-titanium archwires, later replaced by rectangular nickel-titanium archwires (0.017-in×0.025-in).

Fig 4. Surgical Exposure

Active treatment is being done since 12 months. CBCT, Photographs, dental casts and panoramic and cephalometric radiographs were taken at the beginning of the treatment. (Fig 5. CBCT).

83 Richa Vakil et. al. : IMPACTED MAXILLARY CENTRAL INCISOR

Fig 5. CBCT TREATMENT RESULTS The impacted maxillary left central incisor crown is completely visible in oral cavity. Tooth is now bonded with bracket and engaged in continuous niti wire. Bilateral Class I canine relationships and ideal overjet and overbite are being achieved. (Fig 6. Present stage)

Fig 6. Present stage DISCUSSION diagnosed exact location and depth of impaction An impacted maxillary central incisor in a with help of CBCT radiograph. teenager poses a disturbing esthetic dilemma We first determined whether the impacted tooth because of its prominent location. Neither could be successfully aligned in its proper position orthodontists nor parents want to wait for starting on the basis of its position and orientation, the orthodontic treatment. However, it is important to amount of root formation, and the degree of root 11 properly inform the patient and the parents of the dilaceration. It is important to plan when and how possibility of failure. Although the panoramic the impacted tooth will be moved to its proper radiograph cannot be used as the sole radiograph to position, as well as the positions of adjacent teeth locate impacted maxillary tooth, in this patient, we and the intermaxillary relationships. In this

84 Richa Vakil et. al. : IMPACTED MAXILLARY CENTRAL INCISOR patient, there was insufficient space for the treatment might be required in some cases treated maxillary left central incisor; the lateral incisors with this method to achieve an esthetic gingival had drifted into the unoccupied space. There is margin contour over the central incisor and relatively high prevalence of gingival defects, so provide the teeth with an adequate zone of that adjunctive post orthodontic periodontal attached gingiva.1,16

REFERENCES 9) Millar BJ, Taylor NG. Lateral thinking: the 1) Becker A, Brin I, Ben-Bassat Y, Zilberman management of missing upper lateral incisors. Y, Chaushu S. Closed-eruption surgical British Dental Journal. 1995 Aug;179(3):99. technique for impacted maxillary incisors: a 10) Lin YT. Treatment of an impacted dilacerated postorthodontic periodontal evaluation. maxillary central incisor. American journal of American journal of orthodontics and orthodontics and dentofacial orthopedics. dentofacial orthopedics. 2002 Jul 1999 Apr 1;115(4):406-9. 1;122(1):9-14. 11) Tanaka E, Hasegawa T, Hanaoka K, Yoneno 2) Crawford LB. Impacted maxillary central K, Matsumoto E, Dalla-Bona D, Yamano E, incisor in mixed dentition treatment. Suekawa Y, Watanabe M, Tanne K. Severe American journal of orthodontics and crowding and a dilacerated maxillary central dentofacial orthopedics. 1997 Jul 1;112(1):1- incisor in an adolescent. The Angle 7. Orthodontist. 2006 May;76(3):510-8. 3) Brin I, Becker A, Shalhav M. Position of the 12) Frank CA. Treatment options for impacted maxillary permanent canine in relation to teeth. The Journal of the American Dental anomalous or missing lateral incisors: a Association. 2000 May 1;131(5):623-32. population study. The European Journal of 13) Becker A. Orthodontic treatment of impacted Orthodontics. 1986 Feb 1;8(1):12-6. teeth. John Wiley & Sons; 2012 Apr 23. 4) Pinho T, Neves M, Alves C. Impacted 14) Kokich VG, Mathews DP. Surgical and maxillary central incisor: surgical exposure orthodontic management of impacted teeth. and orthodontic treatment. American Journal Dental Clinics of North America. 1993 of Orthodontics and Dentofacial Orthopedics. Apr;37(2):181-204. 2011 Aug 1;140(2):256-65. 15) Vanarsdall RL, Corn H. Soft-tissue 5) Jacobs SG. The impacted maxillary canine. management of labially positioned unerupted Further observations on aetiology, teeth. American journal of orthodontics. 1977 r a d i o g r a p h i c l o c a l i z a t i o n , Jul 1;72(1):53-64. prevention/interception of impaction, and when to suspect impaction. Australian dental 16) Chaushu S, Brin I, Ben‐Bassat Y, Zilberman journal. 1996 Oct;41(5):310-6. Y, Becker A. Periodontal status following surgical–orthodontic alignment of impacted 6) Jacoby H. The etiology of maxillary canine central incisors with an open‐eruption i m p a c t i o n s . A m e r i c a n j o u r n a l o f technique. The European Journal of orthodontics. 1983 Aug 1;84(2):125-32. Orthodontics. 2003 Dec 1;25(6):579-84. 7) Bass TB. Observations on the misplaced upper canine tooth. The Dental practitioner and dental record. 1967 Sep;18(1):25. 8) Oliver RG, Mannion JE, Robinson JM. Morphology of the maxillary lateral incisor in cases of unilateral impaction of the maxillary canine. British journal of orthodontics. 1989 Feb;16(1):9-16.

85 CLASS II CORRECTION USING THE TWIN STAR APPLIANCE: A Case Report A Case Report

Sonali Mahadevia*, Bhavya Trivedi**, Vaishali Gayakwad*** ABSTRACT The aim of this study was to see the effect of twin star appliance in growing patient. Functional appliances can be used successfully in growing patient with certain Class II malocclusion. It is dependent on patient's compliance. Even the Twin-Block, which is claimed to be one of the most patient friendly appliances, is not so easily accepted by the growing child. An innovative modification of the Twin-Block called Twin-Star. Compared with the traditionally constructed Twin- Block, The Twin-Star proves to be esthetically superior, with a higher level of comfort and is less bulky and hence easily accepted by the patient. A 14-year 4month old girl was treated with twin star appliance. The design of appliance and treatment results were demonstrated in following case report. Keyword: Chairside, innovative, invisible, myofunctional appliance, Twin-Block

INTRODUCTION: either social or psychological reasons. The main objective of functional appliance therapy An innovative method has been devised in which is to encourage or to redirect the growth in a a Twin-Block can be fabricated chair side in a single favourable direction. Many functional appliances sitting with the help of a Biostar unit (Biostar® VI have been fabricated for the correction of Class II with Scan Technology, Great Lakes Tonawanda, division 1 malocclusion. The major differences in NY) or any other pressure molding unit. This the effects between various orthopaedic appliances unique Twin-Block, which we have called “Twin- are mainly related to the technique of fabrication, Star,” is made using a Biocryl sheet (Clear Splint construction bites, and hours of wear. The Twin- Biocryl 1 mm round, Great Lakes Tonawanda, NY). block appliance was originally developed by It is patient friendly, as it has a perfect fit, is less Clark1 and is widely used as a functional appliance bulky, has no wire components and above all it can for the management of Class II malocclusion. Its be easily fabricated by the orthodontist himself.7 popularity is attributable to its ability to produce 2. CASE REPORT rapid treatment changes and perhaps it is the only myofunctional appliance which has been A 14-year 4 month old girl came to the extensively studied. However, it has certain Orthodontic department having a chief complaint of undesirable effects, such as mandibular incisor forwardly place upper front teeth. On extra-oral proclination2,3 an increase in the vertical facial examination, the patient had a convex profile, dimension, which is not acceptable in high-angle incompetent lips with an interlabial gap of 5 mm, patients4, clockwise rotation of the maxillary acute nasolabial angle, receded chin position and plane4, limited increase in mandibular growth, deep mentolabial sulcus, and average growth which might not be present in the long term5 and pattern (Fig.1). On intra-oral examination, it moderate but not excellent patient compliance6. showed class II molar relation and canine relation bilaterally, overjet of 7 mm, and upper and lower Over the years a need to overcome the adverse midlines coincide with the facial midline (Fig.2). effects of the twin block led to the development of a modified version of the appliance, termed the twin The case was diagnosed as Class II skeletal star appliance. It has been developed as an attempt malocclusion with mandibular deficiency and to overcome some of these limitations especially maxillary dental proclination. The cephalometric dealing with the patients compliance. It has been analysis confirmed the diagnosis of division I on widely seen that aesthetics and comfort play a major skeletal Class II base (Fig.3). Patient has average role in increasing the patient compliance, which is growth pattern and mandibular retrusion. of ultimate concern to the orthodontist to achieve Evaluation of patient's cervical radiograph and hand optimum results. We orthodontists find young wrist radiograph indicated that she was at the peak patients reluctant to wear a Twin-Block because of of a pubertal growth spurt with a considerable

*Head Of the Department, **Professor, ***PG Student DEPARTMENT OF ORTHODONTICS & DENTOFACIAL ORTHOPAEDICS AHMEDABAD DENTAL COLLEGE AND HOSPITAL

ADDRESS FOR AUTHOR CORROSPONDENCE : DR. VAISHALI GAYAKWAD, E-mail : [email protected]

86 Vaishali Gayakwad et. al. : CLASS II CORRECTION USING THE TWIN STAR APPLIANCE amount of growth remaining. The patient has positive visual treatment objective in figure 1.

Figure 1: Pre-Treatment Extra Oral Photos

Figure 1. Positive visual treatment objective

87 Vaishali Gayakwad et. al. : CLASS II CORRECTION USING THE TWIN STAR APPLIANCE

Figure 2: Pre-Treatment Intra Oral Photos

Figure 3: Pre-Treatment Lateral Orthopantograph and Lateral Cephalograph

Figure 3: Pre-Treatment Hand wrist Radiograph

88 Vaishali Gayakwad et. al. : CLASS II CORRECTION USING THE TWIN STAR APPLIANCE

2.1 Treatment Objectives iReduction of profile convexity and lip incompetence. iCorrecon of molar and canine relaon. iAchievement of normal overjet and overbite. 2.2 Treatment Plan As the patient had skeletal and dental Class II relationship in growing phase (cervical vertebrae maturation indicators 5, Hand wrist maturation indicators 8) growth modification was planned using twin star functional appliance and after that the fixed orthodontic appliance plane for final detailing of occlusion. 2.3 Treatment Progress Twin star was fabricated for the patient (Figure 4). After 12 months period of wear, significant improvement was noted in lip competence and facial profile. (Figure 5). A significant correction in molar and canine relation was obtained along with significant reduction in over jet and overbite (Figure 6). Figures 7 and 8 show comparison of extra-oral and intra-oral changes brought about by twin star.

Figure 4: Twin star Appliance in the patient mouth

89 Vaishali Gayakwad et. al. : CLASS II CORRECTION USING THE TWIN STAR APPLIANCE

Figure 5: Post functional Extra Oral Photos

Figure 6: Post functional Intra Oral Photos

90 Vaishali Gayakwad et. al. : CLASS II CORRECTION USING THE TWIN STAR APPLIANCE

Figure 7: Pre and Post functional Extra Oral Changes

Figure 8: Pre and Post functional Intra Oral Changes

91 Vaishali Gayakwad et. al. : CLASS II CORRECTION USING THE TWIN STAR APPLIANCE

3. DISCUSSION Class II malocclusion either have a skeletal or dental componet. Hence, identifying and understanding the etiology and expression of Class II malocclusion and identifying differential diagnosis is helpful for its correction and to select treatment planning whether functional, orthodontic or surgical. In this case twin star appliance is use for growth modification in class II malocclusion. The patient can wear the twin star appliance full time with little discomfort. Other advantages include esthetic. It is suitable for mixed dentition as well as deciduous dentition 7. Here, comparison of pre-treatment and post-functional lateral cephalogram (Figure 9) showed SNA remained unchanged, and SNB increased by 3°. ANB angle reduced up to 3°. The inclination of maxillary remains same and Mandibular incisors was proclaimed by 2°. (Table 1).

Figure 9: Comparison of Pre-Treatment (a) and Post-Treatment (b) Lateral Cephalogram.

Table 1: Comparison of Pre- and Post Functional Parameters

92 Vaishali Gayakwad et. al. : CLASS II CORRECTION USING THE TWIN STAR APPLIANCE

CONCLUSION An attempt has been made to modify a myofunctional appliance in a way that is beneficial to the patient, as it proves to be more comfortable, esthetic and well-fitting and can be fabricated in a single sitting at the chairside. Use of this appliance during growing phase with good patient co-operation produce significant skeletal or soft tissue changes

REFERENCES 10 Clark WJ. The Twin Block technique. In: Graber TM, Rakosi T, Petrovic AG, editors. Dentofacial Orthopedics with Functional 1 Clarke WJ. The Twin block traction Appliances. 2nd ed. St. Louis: Mosby; 1997. technique. Eur J Orthod1982;4:129-38. p. 268-98. 2 Lund DI, Sandler PJ. The effects of Twin 11 Chadwick SM, Banks P, Wright JL. The use of Blocks: a prospective controlled study. Am J myofunctional appliances in the UK: A survey Orthod Dentofacial Orthop 1998;113:104-10. of British orthodontists. Dent Update 3 Mills CM, McCulloch KJ. Treatment effects 1998;25:302-8. of the twin block appliance: A cephalometric 12 Sidlauskas A. The eff ects of the Twin-block study. Am J Orthod Dentofacial Orthop appliance treatment on the skeletal and 1998;114:15-24. dentolaveolar changes in Class II Division 1 4 Illing HM, Morris DO, Lee RT. A prospective m a l o c c l u s i o n . M e d i c i n a ( K a u n a s ) evaluation of Bass, Bionator and Twin Block 2005;41:392-400. appliances. Part 1—The Hard Tissues. Eur J 13 Trenouth MJ. Cephalometric evaluation of the Orthod 1998;20:501-16. Twin-block appliance in the treatment of 5 Mills CM, McCulloch KJ. Post treatment Class II Division 1 malocclusion with changes after successful correction of Class II matched normative growth data. Am J Orthod malocclusions with the Twin Block appliance. Dentofacial Orthop 2000;117:54-9. Am J Orthod DentofacialOrthop2000;118:24- 14 Sidlauskas A. Clinical eff ectiveness of the 33. Twin block appliance in the treatment of Class 6 McDonagh S. A prospective cephalometric II Division 1 malocclusion. Stomatologij a and optical scanning assessment of the effects 2005;7:7-10. of functional appliances on the hard and soft tissues [thesis]. London: University of London; 1996. 7 Mahadevia SM, Assudani NP, Gowda K, Joshipura AJ. Twin-Star: Adding a new dimension for treatment of Class II noncompliant patients. APOS Trends Orthod. 2014 Jan 1;4:21-5. 8 Singh A. comparison between conventional twin block and a modified essix twin block in adolescents with class. Dentistry: Advanced Research. 2016 Dec 21. 9 Clark WJ. Treatment of Class II division 1 malocclusion deep overbite.In: Clark WJ, editor. Twin Block Functional Therapy Applications inDentofacial Orthopaedics. 2nd ed. London: Mosby Wolfe; 2002. p. 89- 100.

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