ISSN 0976-2256 E-ISSN: 2249-6653 The journal is indexed with ‘Indian Science Abstract’ (ISA) (Published by National Science Library), www.ebscohost.com, www.indianjournals.com JADCH is available (full text) online: Website- www.adc.org.in/html/viewJournal.php This journal is an official publication of Ahmedabad Dental College and Hospital, published bi-annually in the month of March and September. The journal is printed on ACID FREE paper.

Editor - in - Chief Dr. Darshana Shah Co - Editor Dr. Rupal Vaidya Assistant Editor: Dr. Harsh Shah Editorial Board: TODAY... Dr. Mihir Shah Welcome to the new era of digital imaging! Today, the Dr. Vijay Bhaskar conventional imaging modalities like radiographic films and chemical processing are replaced by digital sensors with Dr. Monali Chalishazar digital processing. The conventional film based OPG machines Dr. A. R. Chaudhary have also been made obsolete by the high resolution digital OPG machines. Furthermore, medical CT and Dentascan have Dr. Neha Vyas been replaced by the latest CBCT (Cone Beam Computed Dr. Sonali Mahadevia Tomography) machines in private imaging centresrun by oral Dr. Shraddha Chokshi and maxillofacial radiologists across the country. The day is not far when the 3 dimensional CBCT imaging with a low Dr. Bhavin Dudhia patient radiation dose will be usedroutinely for cases of Dr. M Ganesh complicated / repeat RCT, maxillo-facial trauma, impacted third molars, oro-facial cysts and tumours, periodontal Dr. Mahadev Desai pathologies, orthodontic treatment planning and even Dr. Darshit Dalal scanning for CAD CAM fixed prosthodontics. The need has arisen for more and more professionals dedicated exclusively to the field of oral and maxillofacial radiology. The future is bright; the future is CBCT.

A Contents

EDITORIAL

FROM THE EDITOR'S DESK ...... 01 DARSHANA SHAH

REVIEW ARTICLES

1) LOCAL ANESTHETICS IN DENTISTRY - A REVIEW ...... 02 SUJAY B. SHAH*, JIGAR M. THAKKER**, SHRINAL MANKIWALA***, HIRAL SHAH****

2) PERI-IMPLANTITIS VERSUS PERIODONTITIS: AN IMPLIED METAPHOR ...... 06 HIRAL PARIKH*, ARCHITA KIKANI**, ANKINA JOSHI***, SUNITA DHAKA****, MIHIR SHAH*****

3) SJÖGREN'S SYNDROME – AN UPDATE FOR THE DENTAL PRACITITIONERS ...... 10 ROSELINE PATEL*, BHAVIN DUDHIA**, PARUL BHATIA***, STEFFY MACWAN****, YESHAJANI*****, PURV PATEL******

ORIGINAL ARTICLES

4) CHECK THE EXTRAS: A CLINICO – RADIOGRAPHIC STUDY OF SUPERNUMERARY TEETH...... 18 NARESH C. SONI*, ANJANI R. CHAUDHARY**, MADHURA S. DALAL***, PURV S. PATEL****, YESHA V. JANI*****, ROSELINE A. PATEL******

CASE REPORT

5) IN 87 YEAR OLD FEMALE PATIENT – A RARE CASE...... 27 ANJANIKUMAR R. CHAUDHARY*, PURV PATEL**, AMEYA PATWARDHAN***, ROSELINE PATEL****

6) SALVAGING FRACTURED MAXILLARY LATERAL INCISOR USING EXTRACORONAL AND INTRACORONAL SPLINTING ...... 32 DHARA PATEL*, SUHAG PATEL**, NISHIT PATEL***, SHRADDHA CHOKSHI****

7) BRONJ...... 36 RAHUL P. KHUBCHANDANI*, SACHIN DALAL**, DARSHAN PATEL***, NEHA VYAS****

8) PRECISION ATTACHMENT: A CONNECTING LINK BETWEEN FIXED & REMOVABLE PROSTHESIS: A CASE REPORT ...... 41 NAYAN SAPRA*, DARSHANA SHAH**, CHIRAG CHAUHAN***, ANKIT NAROLA****

Subscription: Rate per issue: ` 400/-, for one year: ` 750/-, for three years: ` 2,000/- Contact: Ahmedabad Dental College & Hospital Vivekanand Society, Bhadaj-Ranchhod Pura Road, Santej, Post: Rancharda, Ta: Kalol, Dist: Gandhinagar, Gujarat, India. B YOGA-THE HEALING REMEDY ____From Editor’s desk Dear friends,

Dentistry, as a profession, is very demanding, in terms of the focus and precision required while performing the procedure, more so, because we are working on a very small area, which requires sheer attention. In doing so, many a times, we forget or overlook the posture in which we are working continuously for long hours. When the dentist is working in a sitting position, over half of the body muscles provide support, so as to enable the body to be in a static position. If the same posture is continued for a longer period of time, muscle ischemia happens. As a result, what we get in return is the musculoskeletal disorders which exhibit in the form of pain. The intensity of this pain can vary from mild discomfort in the neck, shoulder and back region to excruciating one, so much so that it leaves us with no choice but for placing a halt on our professional work and then rushing to the concerned specialists for management and respite. As a matter of fact, as it is said “small things can make a big difference,” simple change in our lifestyle, can make a huge difference in the way we can escape this health hazard which is gulping the entire dental fraternity worldwide, like a monster. The “International Yoga Day” was celebrated worldwide on June 21, 2015, attracting everyone's attention on this indigenous tool in prevention of various health related issues. It is high time we, the dentists, also inculcate the practice of performing Yoga in our daily life regime, to strengthen our muscles of neck, shoulder and back, so as to save ourselves from musculoskeletal pains. The “Asnas” recommended in the Yoga, specifically for posture related problems can be of great help to the dental professionals in managing their day to day muscular discomfort and pain. The need of the hour is just to modify our life style so as to get maximum out of our professional and personal life. Donna Farhi rightly said “Yoga does not remove us from reality or responsibilities of everyday life but rather places our feet firmly and resolutely in the practical ground of experience. We don't transcend our lives; we return to life we left behind in the hopes of something better.” I hereby strongly recommend neck movements, stretching, intermittent eye closure, and deep breathing during exhaustive hours of working.

Dr. Darshana Shah Editor JADCH Editorial Office: Prof. & Head Dept. of Prosthodontics Ahmedabad Dental College & Hospital, Dist.: Gandhinagar, Gujarat. Email: [email protected]

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 01 Local Anesthetics In Dentistry - A Review Review Article

Sujay B. Shah*, Jigar M. Thakker**, Shrinal Mankiwala***, Hiral Shah**** ABSTRACT

More than 100 years Local anesthetics have been in use in dental practice. In new era of patient comfort while permitting more extensive and invasive dental procedures the local anesthetics developed of nerve blockade injection techniques. A brief history and summary of the current local anesthetics available is reviewed.

KEYWORDS: Local anesthesia, Topical Anesthetics, Injectable Anesthetics. Received: 17-01-2015; Review Completed: 14-04-2015; Accepted: 30-05-2015 INTRODUCTION: Unlike the majority of other anesthetic drugs, which act as central nervous system depressants, local “For there was never yet another philosopher who anesthetics prevent nociceptive impulses from could endure the toothache patiently” reaching the central nervous system by blocking the - William Shakespeare progress of an action potential. A local anesthetic binds to sodium channel receptors on the axonal Dental fear is very prevalent in all age groups, membrane, the permeability to sodium ions is lost across gender, and in all countries. In modern dental 4 and nerve conduction is interrupted. practice local anesthesia is the mainstay, with patients demanding better and more painless dental TOPICAL ANESTHETICS procedures. More than 120 years ago local anesthesia was introduced to the dental profession, A topical anesthetic is used to numb the surface of today's options for anesthetizing specific sites in the the gingiva in preparation for injecting a local mouth have become more varied, with dental anesthetic. Unlike injectable anesthesia, topicals professionals having many more options to ensure anesthetize only the top portion of the mucous the comfort and safety of their patients.1 membrane or tissue and do not provide anesthesia for the teeth or bony structures. They are used to Local anesthesia has been defined as a loss of anesthetize the surface of an injection site. Most sensation in an area of the body caused by a topical anesthetics require up to a minute to depression of excitation in nerve endings or an anesthetize the area. Whenever possible, use topical inhibition of the conduction process in peripheral anesthetics to minimize the patient's pain associated 2 nerves. with injections. For example, a topical anesthetic can be applied to a sterile cotton swab and placed The first local anesthetic agent to be widely used in just above a canine prior to an injection. It is dentistry was cocaine. Centuries before European important to use a topical anesthetic for maxillary exploration of the New World, Peruvian Indians had lingual injections just medial to the first molar found that chewing leaves of the coca plant because these can be among the most painful sites produced exhilaration and relief from fatigue and for injection. A variety of topical anesthesia agents hunger. Following the import of coca leaves to are available, including lidocaine and benzocaine. Europe, much research was conducted to elucidate In recent years, oral cavity patches have been the properties of the coca leaf extract. In 1859, developed that adhere to the gingiva and deliver Albert Niemann refined the coca extract to the pure targeted, consistent release of topical anesthesia. alkaloid form and named this new drug “cocaine.” 3

* Sr Lecturer, ** Consultant Oral Surgeon, *** Postgraduate Student. *DEPARTMENT OF PERIODONTOLOGY, KARNAVATI SCHOOL OF DENTISTRY. ***DEPARTMENT OF ORAL PATHOLOGY, KARNAVATI SCHOOL OF DENTISTRY.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. SUJAY B. SHAH, TEL: +91 9427955001

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 02 Sujay B. Shah et. al. : Local Anesthetics In Dentistry - A Review

These have been found to provide more effective A lidocaine and prilocaine periodontal gel is pain relief than topicals applied with a swab when packaged into single-use cartridges and applied using large needles that are inserted to the bone.1 directly into the pocket with a blunt-tip applicator and its specially designed dispenser; it is not for INJECTABLE ANESTHETICS injection. With a 30-second onset and 20-minute duration, it can be applied to one or more Local anesthetics are classified into two general periodontal pockets simultaneously. It can be categories according to linkages: amide (NHCO) reapplied as needed up to the maximum dosage of linkage and ester (COO) linkage. These specialized five full cartridges at one appointment.1 linkages join to a common carbon chain that is joined to a hydrophilic chain of amino (which Dentists currently have a variety of anesthetic confers the pKa of the anesthetic). One key solutions at their disposal, with the major difference exception is benzocaine, which lacks the amino being their expected duration of clinical anesthesia. terminus. While benzocaine is an ester and used Although these solutions are considered to be mainly in topical formulations, most injectable generally effective in providing a pain free oral anesthetics are amides.5 All anesthetics have a pKa environment for dental treatment, local anesthetic of 7.5 to 9.5, making them weak bases. Procaine is failure remains a common problem in certain the prototype for esters, although it is no longer instances. available in dental syringe cartridge form.6 Absorption of the pharmacologic agent is EFFICIANCY dependent on a number of factors, including whether the pH of the tissue has dropped due to The dentist is dependent on the local anesthesia 7 localized infection. Other factors include drug agents as well as his technique. The success of solubility, vascularity of the tissue at the injection mandibular block anesthesia has traditionally been site, and the impact of the agent on circulation. As determined by the presence of a feeling of “lip 4 such, duration is highly variable and specific for numbness”. Evaluating the efficacy of local each drug. Onset of anesthetic action and duration anesthetics is more uncertain in symptomatic teeth. are affected by a number of factors. The most Effectively anesthetizing a tooth that contains an significant among these appears to be the pH, which acutely inflamed pulp is often difficult. Many drops when infection is present. Other factors factors may affect the success of local anesthesia, include the pKa of the anesthetics, the concentration some within the practitioner's control and some of the drug, the amount of vasoconstrictor present, clearly not. While no single technique will be and the injection technique relative to nerve successful for every patient, guidelines exist that morphology. Since most anesthetics are can help reduce the incidence of failure. For this vasodilators, leading to rapid diffusion away from discussion, a failure will be defined as inadequate the site, use of vasoconstrictors, such as depth and/or duration of anesthesia to begin or to 8 epinephrine, increases the duration of anesthetics continue a dental procedure. Due to a number of alone.1 factors, such as thicker cortical plates; a denser trabecular pattern; larger, more myelin(lipid)-rich NON-INJECTABLE ANESTHETICS nerve bundles; and morevariable innervation pathways9,10 more problems of inadequate Non-injectable local anesthetics are a more recent anesthesia occur in the mandibular arch than in the development in dental anesthesiology. U.S. Food maxillary. Although failures are more common in and Drug Administration (FDA)-approved for use the mandibular arch, maxillary failures do occur in adults who need localized anesthesia in and can be equally frustrating.8 Most problems with periodontal pockets during scaling or root planing, maxillary anesthesia can be attributed to individual

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 03 Sujay B. Shah et. al. : Local Anesthetics In Dentistry - A Review variances of normal anatomical nerve pathways predictable success rate, is recommended.15,16 Less through the maxillary bone.11 predictable, but also potentially effective, is a periodontal ligament injection technique.17,18 A last Problems with mandibular anesthesia are most resort is to quickly access a pulp horn, creating a common in the molar region but are by no means hole just large enough to insert a needle, and 12,13,14 limited to these teeth. As in the maxilla, most injecting anesthetic directly into the pulp chamber anesthesia problems encountered in the mandible of the tooth. The major limitation of all three of are due to individual variations in the nerve these injection techniques is the inability to 14 pathways, in other words, accessory innervations. anesthetize multiple teeth with a single needle penetration and the relatively short duration of The first, and simplest, guideline relates to the anesthesia achieved.18 extent of anesthesia achieved if, for example, a patient reports profound anesthesia of his or her CONCLUSION lower lip and tongue after receiving an inferior alveolar and lingual nerve block injection, but the Local Anaesthesia remains the backbone of pain tooth in question is still sensitive, it is probable that control in dentistry. Research has continued both in those two nerves have been successfully medicine and dentistry to seek new and better anesthetized and that the tooth sensitivity is very means of managing pain associated with many likely due to accessory innervation.8 surgical treatments. Much of this research has focused on improvements in the area of local Anesthetizing the tooth with an irreversible anaesthetic needle and syringes, more successful pulpitis, can be one of the most frustrating problems teqniques of regional nerve block and newer drugs. for any dental practitioner. Whenever possible, prescribing antibiotic therapy to reduce With the current increased use of sedation inflammation and allowing the site to settle down techniques pain and anxiety control the need for may constitute the best course of action. When such local anaesthesia has not decreased. It must be a course is not an option, the first step in working remembered that the sedated patient is still through this situation is to deliver an appropriate conscious and will react to painful stimuli unless nerve block injection as far back as possible along these stimuli are properly blocked by a local the innervation pathway of the hypersensitive tooth. anaesthetic. That is why a good local anaesthetic If all of the surrounding soft tissues are numb, but technique is stressed as the cornerstone for effective the tooth itself is still sensitive, use of an pain and anxiety control. intraosseous technique, which has a highly

REFERENCES: local anesthesia, St. Louis: Mosby. 1. Scarlett MI. Local Anesthesia in Today's Dental 5. Meechan JG. Effective topical anesthetic Practice. Continuing Education Course. 2010 agents and techniques. Dent Clin North Am. Crest Oral-B at dentalcare.com 2002;46(4):759-66. 2. Brand GR. Efficacy of Local Anesthetics in 6. Haas DA. An update on local anesthetics in Clinical Dentistry A review and meta-anaylsis. dentistry. J Can Dent Assoc. 2002;68(9):546- University of Michigan, 2010. 51. 3. Robinson V, Victory Over Pain. Henry 7. Reader AL, Nusstein J, Drum M. Successful Schuman Publishing, New York, 1946. local anesthesia for restorative dentistry and endodontics, 2011 Quintessence Publishing 4. Malamed, S.F. & Imagineering Scientific and Co, Inc. Technical Artworks, I., 2004. Handbook of

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 04 Sujay B. Shah et. al. : Local Anesthetics In Dentistry - A Review

8. Local Anesthetics in Dentistry: Then and Now 15. Replogle K, Reader A, et al, Anesthetic efficacy of the intraosseous injection of 2 percent 9. Carter RB, Keen EN, The intramandibular lidocaine (1:100,000 epinephrine) and 3 course of the inferior alveolar nerve. J Anat percent mepivacaine in mandiular first molars. 1971;108:433-40. Oral Surg Oral Med Oral PatholRadiolEndod 10. Rood JP, The nerve supply of the mandibular 1997;83:30-7. incisor region. Br Dent J 1977;143:227-30. 16. Coggins R, Reader A, et al, Anesthetic efficacy 11. Blanton PC, Roda RS, The anatomy of local of the intraosseous injection in maxillary and anesthesia. J Cal Dent Assoc 1995;23(4):55-69. mandibular teeth. Oral Surg Oral Med Oral PatholRadiolEndod 1996;81:634-41. 12. Wilson S, Johns P, Fuller PM, The inferior alveolar and mylohyoid nerves: an anatomic 17. D'Souza JE, Walton RE, Peterson LC, study and relationship to local anesthesia of the Periodontal ligament injection: an evaluation of anterior mandibular teeth. J Am Dent Assoc the extent of anesthesia and postinjection 1984;108:350-2. discomfort. J Am Dent Assoc 1987;114:341-4. 13. Chapnick L, Nerve supply to the mandibular 18. Walton RE, Abbott BJ, Periodontal ligament dentition: a review. J Can Dent Assoc injection: a clinical evaluation. J Am Dent 1980;146:446-8. Assoc1981;3:571-5. 14. Blanton PL, Jeske AH, Misconceptions involving dental local anesthesia part 1: anatomy. Texas Dent J 2002;4:296-306.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 05 PERI-IMPLANTITIS VERSUS PERIODONTITIS: Review Article AN IMPLIED METAPHOR

Hiral Parikh*, Archita Kikani**, Ankina Joshi***, Sunita Dhaka****, Mihir Shah***** ABSTRACT

Hard and soft tissues around an osseointegrated dental implant have some similarities with the periodontium of natural teeth. The major difference occurs in collagen fibers, which are parallel to the dental implant surface compared with insertion on the natural teeth, which is perpendicular and functional between bone and cementum. As untreated periodontitis can ultimately lead to loss of natural teeth, peri-implantitis can result in loss of dental implants. Recent studies show that the main causative factor of both tooth loss from Periodontitis and loss of dental implants due to Peri- implantitis is the microbial dental plaque. Another that resembles peri-implantitis is mucositis; affecting only the soft tissue component, the occurrence of inflammation at this level is due to plaque accumulation. Peri-implantitis can be considered analogous to periodontitis.

KEYWORDS: Periodontitis, Mucositis, Peri-implantitis Received: 17-01-2015; Review Completed: 14-40-2015; Accepted: 30-05-2015

INTRODUCTION: pathological conditions.3

Soft and hard tissues surrounding a dental implant PERIODONTITIS: have certain similarities with those of natural dentition. The major difference appears in collagen Chronic periodontitis is defined as infectious fibers, which are unattached and parallel to the disease resulting in inflammation within the dental implant surface, compared to the insertion of supporting tissues of the teeth, progressive the natural teeth, which is straight and functional, attachment loss and bone loss. between bone and cementum.1 The etiology of periodontitis has long been The epithelial junction sealing achieved in the unspecified, however etiological factors are gingival sulcus of natural teeth offers protection classified in: local, systemic, environmental and 2 against bacterial penetration in the mouth. If this genetic factors. seal is broken or gingival epithelial apical fibers are damaged or destroyed, the epithelium migrates The initial lesion in the development of rapidly in apical direction, and resulting in periodontitis is the inflammation of the gingiva in periodontal pockets.2 response to a bacterial challenge. Pocket formation starts as an inflammatory change in the connective Since there is no cementum or insertion of epithelial tissue wall of the gingival sulcus. The cellular and fibers in the case of a dental implant, mucosal fluid inflammatory exudate causes degeneration of sealing is extremely important. If the seal is lost, the the surrounding connective tissue, including the bacterial infiltration rapidly expands to bone gingival fibers. Just apical to the junctional structures.1 epithelium, collagen fibers are destroyed and the area is occupied by inflammatory cells and edema. The periodontal parameters' values (depth 4, 2 appreciation of the space around the implant, Clinical features in periodontitis : clinical gingival insertion levels, gingival bleeding on examination with the probing, mobility) are Characteristic clinical findings in patients with important indicators for detecting potential implant untreated chronic periodontitis may include

* Professor, ** Professor, *** Part III post graduate student, **** Part III post graduate student, ***** Professor and HOD DEPARTMENT OF PERIODONTICS AND ORAL IMPLANTOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Hiral Parikh TEL: +91 9825973584

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 06 Hiral Parikh et. al. : Peri-Implantitis Versus Periodontitis: An Implied Metaphor

• supragingival and subgingival plaque • Obtaining a superior aesthetic result accumulation (frequently associated with calculus • Optimal morphological and functional formation), integration of the implant • gingival inflammation, • pocket formation, Main reasons of peri-implantitis occurrence are6: • loss of clinical attachment, • The patient did not maintain a good oral • loss of alveolar bone, hygiene, hence failed osseointegration. • and occasional suppuration. • Abutment was not installed correctly; • Unadapted prosthesis in relationship to the In patients with poor oral hygiene, the gingiva gingiva in the neck of the implant. typically may be slightly to moderately swollen and exhibit alterations in color ranging from pale red to Implant failures due to infection are characterized magenta. Loss of gingival stippling and changes in by a peri-implant bacterial complex resembling that the surface topography may include blunted or of adult periodontitis. In edentulous subjects, rolled gingival margins and flattened or cratered Aggregatibacter actinomycetemcomitans and papillae. Porphyromonas gingivalis are not as frequently associated with peri-implant infection as in partially PERI IMPLANTITIS: edentulous cases.9

Peri-implantitis describes pathological changes that The bone around a dental implant has a higher occur in soft and hard tissues surrounding the thickness and density than that which surrounds implant. It implies bone damage, in addition to soft natural teeth. tissue damage7, and it is caused by bacterial factors, in combination with other predisposing factors.3 Histological studies have shown that fiber Peri implant mucositis is a disease affecting only the orientation around the implant has the appearance soft tissue component due to plaque accumulation.6 of slings.2 Although bone-implant interface can be seen, most tissue consists of collagen fibers.1 Peri Tissue integration of oral implants consists of two implant tissue has the same functions as the main components7: periodontal ligament, but structurally it is different. In the Peri-implant fibrous tissue, collagen fibers 6 A. Bone integration have a distinctive orientation and a specific interaction with the bone surrounding the implant in B. Peri-implant soft tissue integration8 direct interrelation with the implant design and 7 Clinical features of periimplantitis: loading. These fibers are oriented in the three • Bleeding and suppuration on probing dimensional space between implant and bone, 2 • Swelling of the peri implant tissues following the distribution of biomechanical forces. • Pain • Vertical bone destruction associated with the The bundles of collagen fibres in the periimplant formation a peri implant pocket. tissue are longer than those of the periodontal • Radiological evidence for vertical destruction ligament, passing from the bone trabeculae to the of the crestal bone. implant surface. The length of these collagen bundles is the key point for the stability and 3 Criteria for successful dental implant treatment : longevity of the implant.3 • Favorable underlying bone without any inflammatory processes Peri-implant tissue functions: • Primary stability of the implant after placement 1. Piezoelectric effect: It is assumed that occlusal • Osseointegration forces are transmitted to the peri-implant ligament,

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 07 Hiral Parikh et. al. : Peri-Implantitis Versus Periodontitis: An Implied Metaphor stimulating the bone where the fibers are inserted. • Restoration or temporization of carious lesions Studies have shown that deformation of the surface • Orthodontic tooth movement of the implant socket, immediately around the • Treatment of food impaction areas implant causes compression, generating a negative • Treatment of occlusal trauma charge, while the distal part of the trabeculae is in • Extraction of hopeless teeth • Possible use of antimicrobial agents including tension, causing a release that generates a positive necessary plaque sampling and sensitivity charge. The cells help post-traumatic scarring, testing. removes debris and form a protein network, which 1 will calcify later. 3. Phase II Surgical periodontal therapy • Periodontal therapy, including placement of 2. The hydraulic effect: Peri-implant ligament is implants bathed in fluids in the implant socket. Axial occlusal • Endodontic therapy forces are transmitted to collagen fibers, which in turn act on the fluid that is incompressible and are 4. Phase III Restorative phase pushed in the bone, to the bone marrow. Blood • Final restorations vessels create a hydraulic effect appearing also in • Fixed and removable prosthodontic appliances the natural tooth. When the action ceases, the fluid • Evaluation of response to restorative returns, then the process restarts.1 procedures • Periodontal examination 3. The buffer effect: Because collagen fibers can be deformed, a buffer effect appears between 4. Phase IV Maintenance phase implant and bone.1 • Periodic rechecking: Plaque and calculus

TREATMENT OF PERIODONTITIS Gingival condition (pockets, inflammation) Occlusion, tooth mobility. The goal of periodontal treatment is to maintain the health of the teeth and dental implants, to ensure TREATMENT OF PERI-IMPLANTITIS comfort, functionality and aesthetics. With the The treatment goals for Peri implantitis11: increasing number of patients receiving dental implants the prevalence of inflammatory problems 10 The treatments proposed for Peri-implant disease of the implant receiving tissues is also increasing. are based on the evidence gained from the treatment

2 of periodontitis. The surface of the implants The treatment stages of Periodontitis : facilitates adherence of the bacterial biofilm and 10 1. Preliminary phase: complicates its elimination. • Treatment of emergencies: Dental or periapical Periodontal • Regeneration of bone structures Other • Complete elimination of inflammatory processes in the peri-implant tissues Extraction of hopeless teeth and provisional • Reduction in the duration of the treatment replacement if needed (may be postponed to a more • Creation of aseptic conditions around the convenient time) implant • Securing the reliability of the implanted 2. Phase I periodontal therapy or Nonsurgical artificial supports

periodontal therapy: 2,6,7 • Complete removal of calculus. Treatment methods of Peri implantitis : • Correction or replacement of poorly fitting 1. Acute bacterial infection control to reduce restorations and prosthetic devices tissue inflammation:

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 08 Hiral Parikh et. al. : Peri-Implantitis Versus Periodontitis: An Implied Metaphor

• Mechanical debridement in local areas. CONCLUSION: • Irrigation in subgingival sulcus to reduce environmental pathogens Peri implant mucositis can be considered analogous • Administration of topical and systemic to and Peri-implantitis can be considered antibiotics.11 analogous to periodontitis. The borderline between gingivitis to periodontitis and mucositis to peri- 10 2. Regeneration of bone defects. implantitis is defined by the degradation of connective tissue and it is followed by epithelial 3. The treatment is surgical correction of the migration and bone resorption. pockets and regeneration of bone defects around the implant. Microbial colonization and inflammatory reactions in the peri-implant tissues might be analogous to Re-evaluation intervals post-therapy for Peri- key events in the pathogenesis of periodontitis. implantitis: Once a patient has developed Peri- Peri-implantitis can result in the loss of dental implantitis, there is an increased risk of recurrence implants just as untreated Periodontitis can lead to and is considered a high-risk patient especially if he 2 the loss of natural teeth. Periodontitis and Peri has a history of and should be implantitis both demand an aggressive treatment assessed at every 3-4 months. approach otherwise the exacerbation of the disease can lead to perpetual damage to the surrounding tissue.

REFERENCES: study of the ITI dental implant system. The implementation Oral Clin Res 2003, 14:129- 1. Sirbu I. 10. Practical Course of Oral 39. Implantology, second edition, CTEA Publishing House, Bucharest, 2006. 8. Berglundh, T., Lindh, J., Marinello, C., Ericsson, I., Liljenberg, B. Soft tissue reaction 2. Dumitriu H.T. Periodontology, Ed. Romanian to de novo plaque on implants and teeth. An Medical Life 2006. experimental study in the dog. Clinical Oral 3. Klinge B., Hultin M., Berglundh T. Peri- Implants Research 1992,3:1-8. implantitis, Dent Clin N I 49 (2005) 661-676. 9. Karoussis I.K., Muller S., Salvi G.E. 4. Dumitriu S., Dumitriu H.T. Microbial etiology Association between periodontal and peri- of marginal periodontitis chronic. implant Conditions: a 10 year prospective Antimicrobial prophylaxis and treatment.Ed study. The implementation Oral Clin Res 2004, Cermei, Bucharest 1996. 15:1-7. 5. Cawson R.A., Odell E.W. Cawson's essentials 10. Claffey N., Clarke E., Polyzois I., Renvert S. of oral pathology and oral medicine, Edition: 8, Surgical treatment of peri-implantitis. J Clin illustrated, ed. Elsevier Health Sciences, 2008 Periodontol2008; 35 (Suppl. 8): 316-332 6. Malmstrom H.S., Fritz M.E., Timmis D.P. 11. Renvert S., Roos-Jansaker A.M., Claffey Osseo-integrated implant. Treatment of the N.Non-surgical treatment of peri-implant patient with rapidly progressive periodontitis. mucositis and peri-implantitis: a literature A case report.J Periodontol1990; 61:300-4. review. J Clin Periodontol 2008; 35 (Suppl.8): 305-315. 7. Karoussis I.K., Salvi G.E., Heitz-Mayfield L.J.A. Long-term implant prognosis in Patients with and without a history of chronic periodontitis: a 10 year prospective cohort

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 09 SJÖGREN'S SYNDROME – AN UPDATE Review Article FOR THE DENTAL PRACITITIONERS

Roseline Patel*, Bhavin Dudhia**, Parul Bhatia***, Steffy Macwan****, YeshaJani*****, Purv Patel****** ABSTRACT

A normal flow of saliva is a luxury we enjoy unconsciously throughout our lives, little realizing the distressing effects that one experiences when this mechanism fails due to different reasons.There are different pathological conditions that cause xerostomia. E.g., , Sjogren's syndrome, chemotherapy, head and neck radiotherapy, Alzheimer's disease, etc. Sjogren's Syndrome (SS) is progressive, debilitating disorder in which the body's immune system destroys the mucinous secretions of exocrine tissues resulting in the hallmark features of dry mouth (xerostomia) and dry eyes (sicca syndrome).

Sjogren's syndrome is of particular interest to the dental profession, since the mouth is a major site of involvement? For optimal oral care of patients with SS, it is essential that the dentist recognize this condition and be involved intimately in the health care delivery team. This is a review on the Sjogren's Syndrome for the same

Received: 02-02-2015; Review Completed: 05-06-2015; Accepted: 01-07-2015 INTRODUCTION: like tooth decay and periodontal disease.2,3 For optimal care of patients with SS, it is essential that Salivary gland secretions are essential for the dentist recognize this condition and be involved maintaining the health and integrity of the oral intimately in the health care delivery team. This surfaces. The resting flow rate of whole saliva is 0.2 article reviews the Sjogren's Syndrome and its oral – 0.4ml/min and stimulated flow rate is 1.0 – 2.0 implications. ml/min.1 Reduced salivary secretion (stimulated and unstimulated) below 0.2ml/min is termed as HISTORY AND EPIDEMIOLOGY xerostomia.2 Sjogren's Syndrome (SS) is a The history of this disease is chronicled in a 1987 progressive, debilitating disorder in which the book entitled Sjogren's Syndrome: Clinical and body's immune system destroys the mucinous Immunological Aspects.4 The first description of SS secretions of exocrine tissues resulting in the is generally credited to Johann Mikulicz in 1892.5 hallmark features of dry mouth (xerostomia) and However, the disease is named after a Swedish dry eyes (sicca syndrome)1 (Figure 1) ophthalmologist Henrik Samuel Conrad Sjogren who studied the disease and published his findings in 1933 in his doctoral thesis. Over the next decades, many papers described the disease, and it appeared that rheumatoid arthritis was related to this syndrome.4,6

A recent review of surveys by the Centre for Disease Control (CDC) has estimated the prevalence of Sjögren's syndrome in the western countries to be 7 FIG 1: Sjogren’s Syndrome upto 1% ; however it was estimated to be 0.5% in 8 Reduced salivary flow is of importance to the dental North India. It has been reviewed that, Sjogren profession as there is subsequent loss of the syndrome is undiagnosed in nearly half of patients, 9 antibacterial properties of saliva, which accelerate due to its insidious nature. infection and aggravate different oral conditions

* Senior Lecturer, ** Professor & HOD, *** Professor, **** Tutor, ***** Senior Lecturer, ******Senior Lecturer DEPARTMENT OF ORAL MEDICINE & RADIOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Roseline Patel, TEL: +91 9638567167

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 10 Roseline Patel et. al. : Sjögren's Syndrome – An Update For The Dental Pracititioners

ETIOPATHOGENESIS AND CLINICAL autoantibodies - Ro⁄SSA and La⁄SSB, 1 4 FEATURES autoantibodies to muscuranic M3 receptors, X chromosome linked factors,15 and hormonal Sjogren's syndrome may occur in two forms: influences (estrogen and prolactin).16 Oral, ocular Primary Sjogren's syndrome (PSS) and Secondary and extraglandular manifestations occur as a result Sjogren's syndrome (SSS). Primary Sjogren's of lymphocytic infiltration into other tissues or syndrome manifests only as dry eyes and dry generation of pathogenetic autoantibodies.10 mouth. Secondary Sjogren's Syndrome (SSS) comprises of dry eyes, dry mouth together with a ORAL MANIFESTATIONS connective tissue or autoimmune disease.10 The salivary gland dysfunction in PSS is of Also, despite extensive study of the underlying significant clinical importance and may cause cause of Sjögren's syndrome, the pathogenesis salivary glande enlargement chronic oral remains obscure. In broad terms, the pathogenesis is discomfort as well as compromised oro-pharyngeal multifactorial; environmental factors are thought to functions.17 (Figure - 3) trigger inflammation in individuals with a genetic predisposition to the disorder. (Figture - 2).

FIG 3 : bilateral salivary gland enlargement The most common direct consequence of salivary gland dysfunction in Sjogren's syndrome is dry mouth.18 (Figure - 4)

FIG 2 : In contrast to many other organ-specific autoimmune disorders, affected tissue can be obtained easily in Sjögren's syndrome by minorsalivarygland biopsy.9 It has been reported that there are drastic changes in immune homeostasis in the salivary glands before SS patients present to a physician with symptoms of FIG 4: Dry Mouth 11 dry eyes and dry mouth. Several theories have been Since the extent of salivary dysfunction is variable suggested in the pathogenesis of SS, like and patients differ in their tolerance of dryness, abnormalities related to the upregulation of type I symptoms of dry mouth are also variable. SS interferon regulated genes, abnormal expression of patients with hyposalivation display a decrease in B-cell-activating factor (BAFF), environmental the concentration of mucin, MUC5B and amylase in 12 triggers like viral infections (HTLV-1, EBV, HIV), the saliva.19 The mucosa becomes dessicated and 13 activation of HLA independent immune system, friable causing dysphagia, adherence of food to the

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 11 Roseline Patel et. al. : Sjögren's Syndrome – An Update For The Dental Pracititioners buccal or palatal surfaces, trauma while chewing, present with a myriad complications like difficulty in speaking continuously, frequent need fibromylagia, leucopenia, dry skin, Raynaud's to sip water, discomfort with denture wearing, phenomenon, lymphoid interstitial pneumonitis, B burning sensation on eating spicy food.2,18 cell lymphoma of the mucosa-associated lymphoid tissue (MALT), gasterointestinal disturbances, Numerous signs of reduced salivation associated neurological complications, hypothyroidism, with Sjogren's syndrome include loss of papillae vaginal dryness, glomerulonephritis, etc.10 and a lack of normal salivary pooling beneath the tongue. The tongue may be furrowed, atrophic, DIFFERENTIAL DIAGNOSIS, DIAGNOSTIC coated and/or depapillated.20 In severe cases fissures CRITERIA AND INVESTIGATIONS may develop on the tongue and lips. The dryness extends to the nose, pharynx, larynx, and nasal When approaching a patient with possible SS, it is sinuses.21 important to rule out other causes of dry eyes (Xeropthalmia), dry mouth (Xerostomia), parotid Hyposalivation also means fewer buffering and gland enlargement and other autoimmune flushing opportunities for the oral hard tissues.22 disorders.3 The differential diagnosis of dry mouth Lack of saliva may predispose to atypical dental should include Sjögren's syndrome, drug-induced decay observed on the cervical, incisal and radicular hyposalivation, previous head and neck portions of the teeth.23 (Figure - 5) radiotherapy, pre-existing lymphoma, sarcoidosis, hepatitis C infection, AIDS and graft versus host disease.27 Early diagnosis and treatment are important for preventing disease complications. The sign of dryness like dry mouth, and caries are very useful signs to start investigating for Sjögren's syndrome.28 (Figure - 6)

FIG 5 : Cerival Caries With reduced saliva in the oral cavity, the ability to control opportunistic infections is also reduced.24 It has been suggested that most PSS patients exhibit with the clinical appearance ranging from psuedomembranous (white plaques that can be rubbed off) to erythematosus, hyperplastic and angular chelitis.17

OCULAR AND EXTRAGLANDULAR MANIFESTATIONS

SS patients present with reduced lacrimal secretions, diminished tear film quality, conjunctival inflammation and corneal ulcerations.25,26 Ocular complaints may include Until recently there were a various set of criteria photosensitivity, erythema, eye fatigue and 10 3 given for diagnoses of SS. But the discrepancies in discharge from the eyes. Secondary form of SS the diagnostic criteria led to substantial confusion in

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 12 Roseline Patel et. al. : Sjögren's Syndrome – An Update For The Dental Pracititioners research and clinical trials.10 Hence, the Sjögren's tolerated by patients.31 Stimulated saliva assessment International Collaborative Clinical Alliance can be complicated in patients who do not tolerate (SICCA) in 2012, proposed a new expert consensus the stimulus of salivation and, moreover, due to the approach consisting of classification criteria based wide variety of stimuli used like citric acid, gum, entirely on objective measures. According to this paraffin etc., there is a generalized lack of criteria case definition requires at least 2 out of the agreement for normal values.32 following 3:29 1. Positive serum anti-SSA &/or anti-SSB or SIALOCHEMISTRY [positive rheumatoid factor & ANA ≥ 1:320] Sialochemistry involves the analysis of salivary 2. Ocular staining score ≥ 3 composition, including both organic and inorganic 3. Presence of focal lymphocytic with constituents, by means of different biochemical, focus score ≥ 1 focus/4mm2 in labial salivary gland electrophoretic and immunological analytical biopsies methods. They aim to address the injuries submitted to salivary glands regarding secretion content.2 ORAL TESTS Differences regarding protein expression were SIALOMETRY found between SS patients and healthy subjects. Sialometry aims to measure the salivary flow, and However, individual analysis of SS patients can be conducted with whole saliva or saliva exhibited distinct patterns of protein expression and obtained from a specific gland, both with or without did not correlate with the clinical, serological or 2 stimulation. For a diagnosis of hyposalivation, the histological severity of disease. Also ionic changes unstimulated whole saliva flow rate (UWSFR) has were observed in SS-affected individuals, namely been proposed as the test of choice, as it may be regarding the levels of chloride, potassium, 17 reduced, even if the stimulated whole saliva is calcium, sodium and magnesium. Furthermore, unaffected30.Values lower than 0.1 ml/min are some SS patients produce little or no saliva which 33 considered abnormal.30 This test quantifies salivary limits sialochemistry applications. secretion from all the salivary glands and is believed MINOR SALIVARY GLAND BIOPSY to show alterations at the early stages of the disease, being highly reproducible. Minor salivary gland biopsy remains a highly used diagnostic procedure for the salivary component of According to the Revised International SS.26,29 (Figure - 7) Classification Criteria, the unstimulated whole saliva produced over a period of 15 minutes, without the subjects having eaten or smoked for at least 2 hours, should be measured. A result of lower than 1.5 ml values would transpose to a positive test 8 result for xerostomia. Collection of the stimulated FIG 7 : parotid saliva, and subsequent assessment of the flow rate, can be conducted with the help of special suction cups placed over the Stensen's duct. Stimulated saliva is usually collected for 3 minutes This is usually performed on the internalX100a surface of and values less than 0.5 ml/min are considered 2 the lower lip on normalappearing mucosa under abnormal. Despite the high sensitivity, the local anaesthesia.30 The biopsy contributes towards stimulated parotid saliva sialometry may fail to the diagnosis of SS if the histopathological reveal alterations at the initial stages of the disease, examination reveals a mononuclear infiltration with requires special equipment and may not be easily

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 13 Roseline Patel et. al. : Sjögren's Syndrome – An Update For The Dental Pracititioners periductal or perivascular distribution. The refers to contrast media collection of 2 mm in inflammatory infiltrate is quantified and a cluster of diameter; and stage 4 (destructive) refers to the 50 lymphocytes is termed a focus. The numbers of complete destruction of the gland parenchyma. foci in an area of 4 mm² of tissue surface render the focus score.2, 30A focus score of 1or more, as Sialography is a technically challenging, time according to SICCA is considered positive for SS consuming, painful and risky technique. In fact, it is diagnosis.26, 28 contraindicated in severe gland dysfunction due to the risk of indefinitely retaining the contrast A false negative biopsy result range from around 20 medium.34 Also, several reports showed that that the to 40% and false positive biopsy results have been diagnostic value of parotid sialography for found up to 10% of healthy individuals. Patients diagnosing SS greatly depends on the skills of the affected by myasthenia gravis, and observer.32 Nonetheless, given the potentially high other autoimmune disorders not associated with sensitivity and specificity in SS diagnosing, as well sicca symptoms may also reveal minor salivary as its useful staging potential, sialography still has gland infiltration.32 The extent of infiltrates in a lip its use in the evaluation of the oral component of SS. biopsy using the same methodological approach may vary greatly from gland to gland in a single SCINTIGRAPHY patient. The oral component of Sjogren's syndrome also SIALOGRAPHY may be evaluated by salivary gland scintigraphy. Scintigraphy is a non-invasive method to evaluate This technique requires the radiographic imaging of the function of salivary glands by observing the a salivary gland, following the retrograde injection uptake and secretion of a radioactive labelled of a contrast medium through the excretory duct. substance (sodium pertechnate of 99mTc).34 The (Figure - 8) radionuclide is infused intravenously, and the images of the salivary glands are captured after 1 hour. The uptake of the radionuclide by the glands is observed as well as the amount of saliva containing the radionuclide.2 InSjögren's syndrome, lower concentration and less secretion into the mouth are seen. The test reports a high sensitivity but a low

FIG 8 : specificity in SS diagnosis. Also, this technique needs special equipment and staff that can only be found in reference clinical centers. Further, it may The medium is distributed through the duct system, be unacceptable for the patient due to risk of allowing the analysis of the architecture and radiation damage and high cost.32 configuration of the glandular ducts' organization.2 In SS-affected patients it appears as a dilatation and TREATMENT & PROGNOSIS twisting of the ducts, with an uneven distribution of the contrast medium.34 Diagnosis is generally based As mentioned previously, Sjogren's syndrome (SS) on the classification of Rubin and Holt35 in which is not only a disease of the exocrine glands but a sys- stage 0 (normal) corresponds to no contrast media temic condition. Therefore, it is recommended that collection; stage 1 (punctate) refers to contrast all SS patients should be assessed at appropriate media collection = 1 mm in diameter; stage 2 specialist services, which should include oral medicine/dental and maxillofacial radiology, (globular) refers to contrast media collection 27 between 1 and 2 mm in diameter; stage 3 (cavitary) ophthalmology and rheumatology. At present,

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 14 Roseline Patel et. al. : Sjögren's Syndrome – An Update For The Dental Pracititioners only symptomatic treatment is available and no underlying inflammation treatment can modify the evolution of SS.11 • The treatment of choice for patients with • The primary therapeutic approach to sicca moderate or severe oral dryness and residual manifestations in Sjögren's syndrome (SS) should salivary gland function is an oral muscarinic agonist be symptomatic relief, using artificial tears and • The management of extraglandular features saliva substitutes must be tailored to the specific organ involved, • Patients with severe or refractory m a i n l y u s i n g c o r t i c o s t e r o i d s a n d keratoconjunctivitis sicca might require the immunosuppressive agents.37 (Table - 1) addition of topical cyclosporine A to suppress the

DISEASE MANIFESTATIONS & THERAPY (Table - 1) Manifestations Therapy Ocular Xeropthalmia Artificial tears: preserved/non-preserved Blepharitis Punctal occlusion Iritis/Uvitis Topical cyclosporin Topical androgen (in trial) Topical purinogenic receptor agonist (in trial) Topical (non-preserved) steroids Autologous serum tears Lid scrubs for blepharitis Bandage contact lens Oral Xerostomia Mechanical stimulation Periodontitis Regular oral hygiene Gingivitis Topical fluoride Oral candidiasis Artificial saliva and lubricants Secretagogues, including pilocarpine, cevimeline Anhydrous maltose lozenge Interferon alfa (in trial) Therapy for oral candidiasis Diet modification Gene therapies (preclinical) Joint/ Muscle Arthralgia/myalgia NSAIDs Arthritis/Myositis Antimalarial drugs Disease-modifying anti-arthritic drugs, including methotrexate, azathioprine, leflunomide TNF inhibitors Anti-CD20 (in trial) Cutaneous Raynaud's syndrome Corticosteroids (topical and systemic) Hyperglobulinaemiapurpura Tacrolimus (topical) Mixed cryoglobulinemia Antimalarials Erythema multiforme Disease-modifying anti-arthritic drugs for Erythema annulare vasculitis Necrotising vasculitis Cytotoxic agents Vitiligo, xerosis, alopecia Amyloid anetoderma Embolic and thrombotic lesions

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 15 Roseline Patel et. al. : Sjögren's Syndrome – An Update For The Dental Pracititioners

Sjogren's syndrome is a disease of exocrine glands reaching 9:1. It is characterized by lymphocytic which also manifests in other organs.27 It may infiltration of the exocrine glands, mainly the plateau or worsen, but very rarely undergoes into lacrimal and salivary glands, resulting in reduced remissions. Some people may experience only the secretory functions. mild symptoms of dry eyes and mouth, while others have more severe symptoms of disease.38 Patients The diagnosis and treatment of this disease are with severe cases are much more likely to develop frequently delayed, due to the unclear etiology, lymphomas than patients with mild or moderate pathogenesis and multiple system involvement. cases. The most common lymphomas are salivary Dental practitioners can play a crucial role in the extranodal marginal zone B-cell lymphomas early diagnosis and management of the oral (MALT lymphomas in the salivary glands) and manifestations of patients with SS. diffuse large B-cell lymphoma.39 Hence, educating the dental practitioners to CONCLUSION recognize the disease and refer to the proper Sjogren's syndrome (SS) is a slowly progressing specialist should be an ongoing effort. autoimmune disease, affecting predominantly middle-aged women, with a female to male ratio REFERENCES: 9. Rajesh Gutta, Landon McLain, Stanley H. 1. G.S. Kumar, editor. Orban's Oral histology and McGuff. Sjogren syndrome : a review for the embryology. 12th ed. New Delhi: Elsevier; maxillofacial surgeon. Oral Maxillofacial 2009. Clinics of North America.2008;20: p. 2. David T Wong. Salivary Diagnostics 567-575. Singapore: Wiley- Blackwell; 2008. 10. Robert Fox. Sjogren's syndrome. Lancet. 2005; 3. Kassan, S. S. & Moutsopoulos, H. M. Clinical 366: p. 321-31. manifestations and early diagnosis of Sjögren 11. M Ramos-Casals, A G Tzioufas, J Font. syndrome. Arch. Intern. Med.2004; 164: Primary Sjogren syndrome:current and 1275–84. emergent aetiopathognesis. Ann Rheum Dis 4. Talal N Moutsopoulos H, Kassan S. Historical 2005;64:347–354. perspective: the early years (1930-1960). 12. Delaleu N, Jonsson R, Koller M. Sjogren's S j o g r e n ' s s y n d r o m e C l i n i c a l a n d syndrome. European journal of oral science. immunological aspects. Berlin: Springer- 2005; 113: p. 103-113. Verlag; 1987. p. 3-6. 13. R Rajendran. Shafer's Textbook of Oral 5. Morgan W, Castleman B. A clinicopathological pathology. 7th edition New Delhi. Elsevier; study of Mikulicz disease. American journal of 2012. pathology. 1957; 29: p. 471-503. 14. Bayetto K, Logan RM. Sjogren's syndrome: a 6. C Scully, J Langdon, J Evans. Marathon of review of aetiology, pathogenesis, diagnosis eponyms: 19 Sjogren syndrome. Oral . and management. Australian Dental Journal. 2011; 17: p. 538-540. 2010; 55 Suppl 1: p. 39-47. 7. Helmick C et al. Estimates the prevalance of 15. Nakamura H et al. Expression and function of X arthritis and other rheumatic conditions in the chromosome-linked inhibitor of apoptosis United States. Arthritis Rheum. 2008; 58: p. 15- protein in Sjogren's syndrome. Laboratory 25. Investigations. 2008; 80 (9): p. 1421-7. 8. Misra R, Hissaria P, Tandon V, Aggarwal A, 16. Taiym S, Haghighat N, Al-Hashimi I. The Krishnani N, Dabadghao S. Primary Sjögrens comparision of the hormone levels in patientss syndrome: Rarity in India. Journal of with Sjogren syndrome and healthy controls. Association of Physicists in India 2003; 51: Oral surgery, oral medicine, oral pthology, oral 859-62. radiology and endodontics. 2004; 97: p. 579- 583.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 16 Roseline Patel et. al. : Sjögren's Syndrome – An Update For The Dental Pracititioners

17. Anne Marie Lynge, Allan Bardow, Birgitte Consensus approach in the Sjogren's Nauntofte. Salivary changes and dental caries International Collaborative Clinical Alliance as a potential oral marker of autoimmune Cohort. Arthritis care and Research. 2012; salivary gland dysfunction in primary Sjogren's 64(4): p. 475-487. syndrome. Biomedical Central Clinical 30. Claudio Vitali, Haralampos M Moutsopoulos, Pathology. 2005; 5(4): p. 1-13. Stefano Bombardieri, and The European 18. Daniels T, PC Fox. Salivary and Oral Community Study Group on Diagnostic Components of Sjogren's Syndrome. Criteria for Sjogren's Syndrome. Sensitivity Rheumatology clinics of North America. 1992; and specificity of tests for ocular and oral 18: p. 571-83. involvement in Sjogren's syndrome. Annals of 19. Almstahl A, Wikstrom M, Groenick J. the Rheumatic diseases. 1994; 53: p. 637-647. Lactoferrin, amylase and mucin MUC5B and 31. W W I Kalk, A Vissink, B Stegenga, H their relation to the oral microflora in Bootsma, A V Nieuw Amerongen,C G M hyposalivation of different origins. Oral Kallenberg. Sialometry and sialochemistry: a Microbiol. Immunol. 2001; 16(6): p. 345-352. non invasive approach for diagnosing Sjogren's 20. Philip C Fox et al. Sjogren's Syndrome: a model syndrome. Annals of Rheumatic disease. 2002; for dental care in 21st century. Journal Of 61: p. 137-144. American Dental Association. 1998; 129: p. 32. Pedro de Sousa Gomes, Gintaras Juodzbalys, 719-28. Maria Helena Fernandes, Zygimantas Guobis. 21. Gordon M. Bruce MD. Keratoconjunctivitis Diagnostic approached to Sjogren's syndrome : Sicca. New York. A literature review and own clinical experience. 22. Sreenby LM. Saliva in health and disease: an Journal of oral and maxillofacial research. appraisal and update. Int. Dent.J. 2002; 50: p. 2012; 3(1): p. 1-13. 140-161. 33. Pijpe J et al. Parotid gland biopsy compared 23. Papas AS et al. Caries prevalence in xerostomia with labial biopsy in the diagnosis of patients indivduals. J Can Dent Assoc. 1993; 59: p. 171- with primary Sjogren's syndrome. Journal of 174. Rheumatology. 2007; 46(2): p. 335-41. 24. Eugene N Myers Robert L.Ferris. Salivary 34. Burkett. Burketts Oral Medicine 11th ed: Gland Disorders New York: springer; 2007. Elsevier; 2011. 25. GRAY H. ANATOMY OF THE HUMAN 35. Hisao Tonami et al. MR Sialography in patients BODY; 1918. with sjogren's syndrome. American Journal fo 26. Vitali C, Bombardieri S, Jonsson R et al. Neuroradiology. 1998; 19: p. 1199-1203. Classification criteria for Sjögren's syndrome: a 36. Manuel Ramos-Casals, Pilar Brito-Zeron, revised version of the European criteria Anotni Siso-Almirall. Topical and systemic proposed by the American-European medications for the treatment of primary Consensus Group. Ann Rheum Dis 2002; 61: sjogren's syndrome. Nat. Rev. Rheumatol.. 1 554–558. may 2012,; 8: p. 399-411. 27. A. J. Carr,W.-F. Ng,F. Figueiredo,R. I. 37. Rani Somani, MK Sunil, Jaskirat Khaira, Dilip Macleod,M. Greenwoodand K. Staines. Kumar. Sjogrens syndrome review. Journal of Sjogren's syndrome - an update for dental Indian Academy of Oral Medicine and practitioners. British Dental JOurnal. 2012; Radiology, January-March 2011;23(1):61-64 213: p. 353-58. 38. Kassan S S, Thomas T L, Moutsopoulos H M et 28. Fujibayashi T, Sugai S, Miyasaka N, Toujou T, al. Increased risk of lymphoma in sicca Miyawaki M, Ichikawa Y. Revised Japanese syndrome. Ann Intern Med 1978; 89: 888–892. Criteria for Sjögren's syndrome. Tokyo 1999. p. 39. Jane C. Atkinson, Margaret Grisius, Ward 135-9. Massey. Salivary Hypofunction and 29. S. C. Shiboski et al. American College Of Xerostomia: Diagnosis and Treatment. Dent Rheumatology Classification Criteria for Clin N Am 49 (2005) 309–326 Sjogren's syndrome:A data driven Expert

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 17 CHECK THE EXTRAS: A CLINICO – Original Article RADIOGRAPHIC STUDY OF SUPERNUMERARY TEETH

Naresh C. Soni*, Anjani R. Chaudhary**, Madhura S. Dalal***, Purv S. Patel****, Yesha V. Jani*****, Roseline A. Patel****** ABSTRACT

The human dentition does not always consist of 32 teeth. At times, extra tooth/teeth may be present. A supernumerary tooth is any tooth or teeth substance in excess of the usual configuration of twenty and thirty two . Supernumerary teeth are one of the common dental anomalies which are prevalent in all populations, in both dentitions, in all age groups. They may present themselves in multiple locations within the oral cavity. Multiple supernumerary teeth are also associated with certain syndromes. Hence, a clinician must possess a sound knowledge about this developmental anomaly in order to correctly diagnose as well as plan the treatment. This study focuses on the clinical and radiographic findings of supernumerary teeth as well as their associated complaints and effects on surrounding structures.

KEYWORDS: supernumerary tooth, mesiodens, distomolar, Received: 01-03-2015; Review Completed: 05-06-2015; Accepted: 03-08-2015

INTRODUCTION & REVIEW : form arises from proliferation of the epithelial remnants of the dental lamina induced by dentition A supernumerary tooth (or hyperdontia) is defined pressure. The other proposed theory is dental germ as an increase in the number of teeth in a given dichotomy theory where the dental lamina is 1, 2, 3, 4, 5 individual. It is also defined as any tooth or divided into 2 parts of equal or different size, giving teeth substance in excess of the usual configuration rise to two teeth of equal length, or one normal tooth of twenty deciduous teeth and thirty two permanent and a dysmorphic one. 1, 2, 6, 8, 9, 19, 20, 21, 22 teeth. 6, 7, 8, 9, 10 The reported prevalence of single supernumerary The etiology of supernumerary teeth is not fully tooth in permanent dentition ranges between less understood. Both genetic and environmental factors than 1% and 4%, whereas the prevalence in the 5, 6, 8, 11 have been proposed. Sex-linked mode of primary dentition is said to be 0.3 to 0.8%. 4, 9, 10, 14, 18, 20 inheritance has been suggested as supernumerary teeth are twice as common in males as in females in The presence of only one supernumerary tooth the permanent dentition.8,12,13 Supernumerary teeth occurs in 76-86% of cases; two supernumerary occur due to disturbances during the dental teeth in 12-23% and only 1% of individuals have development stage of morphodifferentiation, three or more supernumerary teeth. Supernumerary possibly with alterations during the stage of teeth are found more commonly in males than in histodifferentiation. It was originally postulated females.3, 6, 9, 14, 16, 17, 21, 22, 23, 24 The male to female ratio has that supernumerary teeth (mesiodens) represented a been reported as 9:2.25 The most common site of phylogenetic relic of extinct ancestors who had 3 occurrence of supernumerary teeth is in the central incisors. This theory, known as phylogenetic maxillary midline, 21, 26, 27 where they are referred to reversion (atavism), 6, 8 has now been largely as mesiodens,10,17 representing 80% of all discarded by embryologists. The most widely supernumerary teeth. 9 This location is followed in accepted theory is local and independent decreasing order of frequency by upper fourth hyperactivity of dental lamina, 6, 11, 14, 15, 16, 17, 18 in which molars 27 (distal to third molars) also known as the lingual extension of an additional tooth bud distomolars, upper paramolars (supernumerary forms a eumorphic tooth, while the rudimentary teeth buccally placed to molars) 6 and

* Senior Lecturer, ** Professor, *** Reader, **** Senior Lecturer, ***** Senior Lecturer, ******Senior Lecturer DEPARTMENT OF ORAL MEDICINE & RADIOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL. *** COLLEGE OF DENTAL SCIENCES & RESEARCH CENTER, MANIPUR, BOPAL ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Purv S. Patel, TEL: +91 9427219470

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 18 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth proportionately far behind – by lower premolars, o r t h o p a n t o m o g r a p h ( O P G ) a n d l a t e r a l upper lateral incisors, lower fourth molars and cephalograph are taken to know position of lower central incisor region. Supernumerary teeth supernumerary teeth.6, 21 OPG is advised in cases of in upper premolars, upper and lower canines and multiple supernumerary teeth which serves as a lower lateral incisors are exceptional.1 The screening aid and provides additional information supernumerary teeth happen with smaller regarding supernumerary teeth. Tube shift frequency in deciduous teeth, being more common technique enables the practitioner to decide the in upper incisor area.18, 24 However, when multiple position of supernumerary teeth.6 Nevertheless, in supernumerary teeth are present in the absence of some cases, they do not provide all the information any associated systemic condition/ syndrome, the needed in order to locate the supernumerary teeth mandibular premolar region is the common site of three dimensionally in relation to the adjacent occurrence. 14, 37 structures and to make decisions about therapeutic options. In such cases, computed tomography (CT) According to their shape, supernumerary teeth can can be used as a basic technique to assess patients be classified into four types: (1) tuberculate (barrel- with supernumerary teeth, and recently, cone-beam shaped, with more than 1 cusp or tubercle); (2) computed tomography (CBCT) has been suggested supplemental (identical to the morphology of teeth as a substitute for CT due to its low radiation dose in the normal series); and (3) conoid (peg-shaped and lower cost. 9 conical tooth). (4) Odontoma. Conical shaped supernumerary teeth are the most common and are Extraction of these teeth is a general rule for usually found in the anterior maxillary area. avoiding complications. 6 Kruger considers that the Supplemental supernumerary teeth usually occur in extraction of supernumerary teeth should be the premolar region, while tuberculate are postponed until the apices of the adjacent teeth have associated with delayed eruption of adjacent sealed. According to Donado, treatment should be incisors. 6, 14, 16, 22 provided as soon as possible in order to avoid displacement and delayed eruption of permanent Multiple supernumerary teeth (hyperdontia) are teeth. 1 When dealing with unerupted commonly associated with various syndromes such supernumerary teeth, it should be understood that 2, 6, 9, 12, 13, 16, 21, 24, 25, 28, 29, 30 as Gardner’s syndrome, Fabry- each case must be fully studied with a 21 Anderson syndrome, Ehlers-Danlos syndrome, multidisciplinary approach (pedodontics, Nance-Horan syndrome, steroid dehydrogenase orthodontics and oral surgery) so as to decide the 15 deficiency, Rothmund-Thomson syndrome, facial prime moment for extraction. Likewise, an 2, 6, 9, 12, 13, 16, 21, 24, 28, 30, 31, 32, fistulas or cleidocranial dysplasia evaluative monitoring should also be done. 9 33, 34 or also in association with cleft lip and palate. 2, 6, 13, 16, 19, 21, 22, 24, 25, 26, 30, 35, 36 MATERIALS AND METHODS

Clinically, supernumerary teeth are able to cause • The study included total 50 patients coming to various local disturbances, including retention of the Out Patient Department (OPD) of the Oral the primary tooth, delayed eruption of the Medicine and Radiology Department of the permanent tooth, food lodgment, interproximal institute during the period July 2009 to June 2010. caries, ectopic eruptions, tooth displacements, • 50 patients were selected from the dental OPD diastema, follicular cysts and other alterations, with criteria of an extra tooth in any arch as clinical requiring surgical or orthodontic intervention. 1, 7, 9, 25 finding or incidental finding during routine clinical or radiographic examination. Conventional radiographs in the form of intraoral • All 50 patients were asked specific questions p e r i a p i c a l ( I O P A ) , o c c l u s a l , prepared for this study and the related details were

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 19 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth filled in the special proforma prepared for the study. TABLE I • General examination of all the patients was TABLE I Distribution of supernumerary teeth done to see any abnormality related to head, facial according to age and gender appearance, clavicle, abdominal pain, diarrhea, AGE (IN MALE FEMALE TOTAL YEARS) NUMBER OF constipation and rectal bleeding, etc. to rule out any PATIENTS related syndrome. 0-10 4 (66.67%) 2 (33.33%) 6(12%) • Intraoral examination was carried out to see the 11-20 10 (83.33%) 2(16.67%) 12(24%) dentition in which supernumerary teeth is present as 21-30 10 (76.92%) 3 (23.08%) 13 (26%) well as to determine its location, number, size and 31-40 9 (81.82%) 2 (18.18%) 11 (22%) shape, cuspal anatomy, eruption status and to see 41-50 5 (83.33%) 1 (16.67%) 6 (12%) 51-60 1 (100%) 0 (0%) 1 (2%) any harmful effect on the dentition. 61-70 0 (0%) 1 (100%) 1 (2%) • Clinical photographs of all patients were taken. TOTAL 39 (78%) 11 (22%) 50 • Radiographs in form of IOPA, radiovisuograph (RVG), occlusal or OPG were taken to evaluate the Table II shows distribution of patient based on their root morphology of supernumerary teeth & its chief complain. Out of 50 patients, most of the relation with surrounding structures. patient [34(68%)] came with a chief complain • In patients with erupted supernumerary teeth, which was not related to supernumerary teeth. Out diagnostic impressions were taken and study of these 34 patients, maximum patient models were prepared to evaluate the exact position [15(44.12%)] had other teeth (other than and relation of the supernumerary teeth with mesiodens, paramolar and distomolar) followed by adjacent teeth. mesiodens [9 (26.47%)], distomolar [6 (17.65%)] • On the basis of clinical and radiographic and paramolar [4 (11.76%)]. 11 (22%) patients findings, final diagnosis was made and treatment came with a chief complain which was related with plan was decided accordingly. effect of supernumerary teeth on surrounding dentition e.g. spacing, diastema, displacement, etc. RESULTS of which 7 (63.64%) patients were having A total of 50 patients were included in the study mesiodens and 4 (36.36%) patients were having selected from OPD (7649 patients) of the institute. paramolar. 5 (10%) patients came with a specific Based on the epidemiological results obtained, the complain of an extra tooth in oral cavity of which all prevalence rate of supernumerary teeth in the patients (100%)were having mesiodens. present study was 0.65%. TABLE II TABLE II Distribution of supernumerary teeth based on chief complain of patient Table I shows age and gender distribution of patient Chief Complain Mesiodens Paramolar Distomolar Other Total Related to 5 (100%) 0 0 0 5 with supernumerary teeth. Maximum patients [13 supernumerary (10%) teeth (26%)] were between age group of 21 to 30 years Related with 7 (63.64%) 4 0 0 11 effect caused by (36.36%) (22%) and least patients were recorded between 51 to 70 supernumerary teeth years [2(4%)]. It was found to be more common in Not related with 9 (26.47%) 4 6 15 34 males [39 (78%)] than in females [11 (22%)]. supernumerary (11.76%) (17.65%) (44.12%) (68%) teeth (Incidental Familial tendency for the occurrence of finding) Total 21(42.00%) 8 (16.00%) 6 (12.00%) 15 (30.00%) 50 supernumerary teeth was not seen in any patient. Table III shows distribution of supernumerary teeth in all the three types of dentition (deciduous/mixed/permanent). It was found that supernumerary teeth were commonly found in permanent dentition [38 (76%)] followed by mixed dentition [11 (22%)] and deciduous dentition [1

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 20 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth

(2%)]. In permanent dentition, 16 (42.11%)patients according to their different shapes. Mesiodens was were having mesiodens, followed by paramolar and seen more in conical form [22(95.65%) patients] other in 8 (21.05%)patients each and 6 (Figure. 1) followed by molariform form (15.79%)patients with distomolar. In mixed [1(4.35%)patient] (Figure. 2) Tuberculate, dentition, 6 (54.55%)patients had other teeth and 5 supplemental and globular forms were not seen in (45.45%)patients were having mesiodens. In mesiodens. Paramolars (Figure. 3) were commonly deciduous dentition, only one patient (100%) with seen in conical form [6 (60.00%)patients] followed other teeth was seen. by supplemental [3 (30.00%)patients] and TABLE III tuberculate form [1 (10.00%)patients]. Distomolar Table – III Distribution of supernumerary teeth according to dentition were commonly seen in conical form [6 Dentition Mesiodens Paramolar Distomolar Other Total Deciduous 0 0 0 1 (100%) 1 (2%) (85.71%)patients] followed by tuberculate form Mixed 5 (45.45%) 0 0 6 (54.55%) 11 (22%) [1(14.29%)patient]. Other supernumerary teeth Permanent 16 (42.11%) 8(21.05%) 6 (15.79%) 8 (21.05%) 38 (76%) Total 21 (42%) 8 (16%) 6 (12%) 15 (30%) 50 w e r e s e e n i n s u p p l e m e n t a l f o r m [ 8 Table IV shows distribution of supernumerary teeth (53.33%)patients] followed by conical [6 in maxilla and mandible along with their presence in (40.00%)patients] and globular form [1 single and pair forms. It was found that mesiodens (5.88%)patient]. TABLE V were seen most common in maxilla [21 Table – V Distribution of supernumerary teeth according to their shape TOTAL (100%)patients]. Out of these 21 patients, it Teeth Mesiodens Paramolar Distomolar Others (Out of 50 occurred singly in 19 (90.48%) patientswhile in pair patients) Conical 22 (55.00%) 6 (15.00%) 6 (15.00%) 6 (15.00%) 40 (72.73%) in 2 (9.52%) patients. Paramolar were seen more in Tuberculate 0 1 (50.00%) 1 (50.00%) 0 2 (03.63%) Supplemental 0 3 (27.27%) 0 8 (72.73%) 11 (20.00%) maxilla [6 (75%)patients] than in mandible [2 Globular 0 0 0 1 (100%) 1 (01.82%) Molariform 1(100%) 0 0 0 1 (01.82%) (25%)patients]. In maxilla 4 (50%)patients had TOTAL 23 (41.82%) 10 (18.18%) 7 (12.73%) 15 (27.27%) 55 (Out of 50 single paramolars while 2 (25%)patients had paired patients) paramolars. In mandible, only 2 (25%)patients with single paramolar were seen. Distomolar were found more common in maxilla [4 (66.68%)patients] than in mandible [2 (33.32%)patients]. In maxilla they were all singly present whereas in mandible [1(50%)patients] was single and [1 (50%)patients] was paired. Supernumerary teeth in other locations w e r e m o r e c o m m o n i n m a x i l l a [ 1 2 (80.00%)patients] than in mandible [3 (20.00%)patients] and all were singly present. TABLE IV Table – IV Distribution of Supernumerary teeth in maxilla and mandible, according to their number Total out of TEETH Mesiodens Paramolar Distomolar Others 50 patients Single 19 (90.48%) 4(50%) 4 (66.68%) 12 (80%) 39 (78%) Maxilla Paired 2 (9.52%) 2 (25%) 0 0 4 (8%) Total 21(42%) 6 (12%) 4 (8%) 12 (24%) 43 (86%) Single 0 2 (25%) 1 (16.66%) 3 (20%) 6 (12%) Mandible Paired 0 0 1 (16.66%) 0 1 (2%) Total 0 2 (4%) 2 (4%) 3 (6%) 7 (14%) Table V shows distribution of various types s u p e r n u m e r a r y t e e t h (Mesiodens/Paramolar/Distomolar/other)

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 21 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth

Table VI shows distribution of supernumerary teeth based on their eruption status in oral cavity. Maximum supernumerary teeth were fully erupted [34 (61.82)patients] followed by unerupted [16(29.09)patients] and partially erupted [5 (9.09%)patients] supernumerary teeth. Fully erupted supernumerary teeth were 14 (41.18%) mesiodens followed by 9 (26.47%) other supernumerary teeth, 8 (23.53%) paramolars and 3 (08.82%) distomolars. Unerupted supernumerary teeth were 7 (43.75%) mesiodens followed by 5 (31.25%) other supernumerary teeth, 2 (12.50%) each paramolars and distomolars which were diagnosed incidentally on radiographs (Figures. 4 & 5). Partially erupted supernumerary teeth were 2 Table VII shows other lesions associated with each (40%) mesiodens and distomolars and 1 (20%) supernumerary teeth. Only 3 (6%)patients showed other supernumerary teeth. associated lesion with supernumerary teeth. The lesions seen were dentigerous cyst, partial TABLE VI (Figure. 6), and complex odontoma in 1 Table – VI Distribution of supernumerary teeth according to their eruption status patient (2%) each. Teeth Mesiodens Paramolar Distomolar Others TOTAL (out of 50 TABLE VII patients) Fully 14 (41.18%) 8 (23.53%) 3 (08.82%) 9 (26.47%) 34 (61.82%) Table – VII Lesion associated with supernumerary teeth Erupted Partially 2 (40.00%) 0 2 (40.00%) 1 (20.00%) 5 (09.09%) Lesions Total (out of 50 patients) Erupted Dentigerous Cyst 1 (2%) Unerupted 7 (43.75%) 2 (12.50%) 2 (12.50%) 5 (31.25%) 16 (29.09%) TOTAL 23 (41.82%) 10 (18.18%) 7(12.73%) 15 (27.27%) 55 Partial Anodontia 1 (2%) (out of 50 Complex Odontoma 1 (2%) patients) Total (out of 50 patients) 3 (6%)

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 22 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth

Table VIII shows the effects of supernumerary No effect was seen in 8 (28.57%) patients each with teeth on the dentition. The most common being paramolars and distomolars followed by 6 displacement [8 (16%)patients] (Figure. 7) spacing (21.43%) patients each with mesiodens and other [6 (12%)patients] and diastema [5 (10%)patients]. supernumerary teeth. Displacement was seen in 6 (75%)patients with mesiodens and 2 (25%)patients with other Treatment of supernumerary teeth depends on chief supernumerary teeth. Spacing was seen in 3 complain of patient and its effect on permanent (50%)patients each with mesiodens and other dentition. Extraction and orthodontic treatment is supernumerary teeth. Diastema was seen in 5 advised as required in patient with supernumerary (100%)patients with mesiodens. Impacted teeth, teeth. crowding and fusion were found in one (2%)patient each (Figure. 8). DISCUSSION TABLE VIII Supernumerary teeth are infrequent developmental Table – VII Distribution of supernumerary teeth according to its effects on dental alterations that may manifest in any zone of surrounding dentition Harmful Mesiodens Paramolar Distomolar Other Number of the dental arches and involve any tooth. They may Effects Patients Crowding 0 0 0 1 (100%) 1 (2%) be associated with syndromes or can be found in Displacement 6 (75.00%) 0 0 2 (25.00%) 8 (16%) non-syndromic population also.1 The prevalence Diastema 5 (100%) 0 0 0 5 (10%) Impacted 0 0 0 1 (100%) 1 (2%) rate of supernumerary teeth found in present study Teeth 1, 2, 6 Fusion 1 (100%) 0 0 0 1 (2%) was in accordance with the previous literatures. Spacing 3 (50.00%) 0 0 3 (50.00%) 6 (12%) None 6 (21.43%) 8 (28.57%) 6 (21.43%) 8 (28.57%) 28 (56%) Total 21 (42.00%) 8 (16.00%) 6 (12.00%) 15 (30.00%) 50 The present study reveals that supernumerary teeth are more common in 21-30 years of age, which is in coincidence with the findings of other authors. According to Salcido-Garcia et al, the appearance of supernumerary teeth is more frequent in the first three decades of life than in older age groups.1, 6 This observation may be due to the fact that a large percentage of such teeth tend to be a casual finding in the course of third molar extractions conducted in patients in this particular age range. As well as patient at this age are more conscious about their appearance and seek dental treatment for correction of spacing or displaced teeth caused by supernumerary teeth. 1, 8, 12, 30

Regarding the gender distribution, we coincide with most authors that males are more commonly affected than females.1, 7, 8, 9, 25, 28 No case with inheritance occurrence was noted in the present study. There are no satisfactory explanations for the mode of inheritance of supernumerary teeth in literature but occasionally a positive family history exists. 2

In present study, most patients having supernumerary teeth were diagnosed incidentally

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 23 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth either on clinical or radiographic examination. The and partial anodontia has been found in one patient most common complaints associated with each. Association of supernumerary teeth with supernumerary teeth are spacing, diastema, partial anodontia has been reported in literature displacement, etc. However, some patients also also. Disturbance in migration, proliferation and came with typical complain of an extra tooth 7, 8, 9, 25, 28 differentiation of the neural crest cells and which is in accordance with previous literatures. interaction between the epithelial and mesenchymal cells during initiation stage of tooth development Supernumerary teeth are also commonly found in has been suspected as possible cause. 3, 6, 17 No patient permanent dentition as compared to mixed and with cleidocranial dysplasia 31, 32, 33, 34 or Gardner's 6, 25 deciduous dentition which is in accordance with Syndrome29 or Cleft lip35 was found in our study present study. because of the rarity of these conditions and patients with such conditions rarely seek dental treatment as Supernumerary teeth are more common in maxilla first choice. So this study fell into the category of than in mandible. In maxilla, premaxillary region is non-syndromic supernumerary teeth.8, 9 the most common site. Mesiodens was the most common supernumerary teeth followed by Various effects like crowding, failure of eruption of paramolar and distomolar. Supernumerary teeth adjacent permanent teeth, ectopic eruption, occurring at other sites in the jaws (other than displacement, diastema, root resorption of adjacent mesiodens, paramolar, distomolar) are more teeth, spacing and eruption of teeth into the nasal frequently seen in maxilla and are singly present cavity and antrum are reviewed in the literature. In 6, 25 with supplemental shape. the present study, various harmful effects like crowding, displacement, diastema, impacted teeth The most common shape of supernumerary teeth is and spacing were recorded. 1, 2, 6, 20, 21, 24 conical shape 1, 8, 28, 37 followed by supplemental, 2, 8, 9, 28 tuberculate and rare is molariform shape. A In the present study, supernumerary teeth that dichotomy of the tooth bud and local hyperactivity caused harmful effects on the surrounding dentition in the dental lamina has also been suggested as a or was patient's chief complain were extracted 1, 2, 6, 13, 23, possible etiological factor for such findings. followed by orthodontic treatment as required. 25, 37 Patients with supernumerary teeth with other associated lesions were treated with the required Radiographs (in form of IOPA, occlusal and OPG) treatment. 2, 5, 6, 8, 13, 16, 20, 21, 25, 28, 37 were taken in all the patients as indicated. Most of the supernumerary teeth in present study were fully CONCLUSION erupted and diagnosed clinically only. However, unerupted supernumerary teeth were also present Based on this study, it can be concluded that which were diagnosed incidentally on radiographs. supernumerary teeth are one of the common dental Most common unerupted supernumerary tooth was anomalies; more commonly seen in maxilla than mesiodens which was often in inverted position.6, 8, 23 mandible, males than females, third decade than OPG was advised in patient with suspected multiple other decades of life and permanent dentition than impacted supernumerary teeth. This is supported by deciduous dentition. Most commonly the literature that thorough examination for supernumerary teeth are seen in conical shape. Most prevalence of supernumerary teeth is through common effects caused by supernumerary teeth on clinical and radiographic examination.1, 6, 9, 12, 20 surrounding dentition include displacement, diastema and spacing. They may occur as isolated In the present study association of supernumerary dental finding or as part of a syndrome. Detection of 7 teeth with dentigerous cyst, complex odontoma supernumerary teeth is best achieved by thorough clinical and radiographic examination. An alert

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 24 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth clinician should suspect and search for required and prevents development of associated supernumerary teeth when encountered by delayed, problems. ectopic or asymmetric eruption. Early diagnosis of supernumerary teeth minimizes the treatment

REFERENCES: 10. GKokten, HBalcioglu, MBuyukertan. Supernumerary Fourth and Fifth molars: A 1. MIBerrocal, JFMorales, JMGonzalez. An report of two cases. J Contemp Dent Pract. Observational study of the frequency of 2003; 4(4): 67-76. supernumerary teeth in a population of 2000 patients. Med Oral Patol Oral Cir Bucal. 2007; 11. SY Cho. Supernumerary premolars associated 12:E134-8. with : Report of 2 cases. J Can Dent Assoc. 2005; 71(6): 390-93. 2. SM Cochrane, JR Clark, RP Hunt. Late developing supernumerary teeth in the 12. HAOnn. The development of supernumerary mandible. BritJ Orthod. 1997; 24: 293-296. teeth in the mandible in cases with a history of supernumeraries in the pre-maxillary region. 3. JFZhu, RCrevoisier, RJ Henry. Congenitally JOrthod. 2006; 33: 250-255. missing permanent lateral incisors in conjunction with a supernumerary tooth: case 13. PJScanlan, SJ Hodges. Supernumerary report. PaediatrDent. 1996; 18(1): 64-66. premolar teeth in siblings. BritJ Orthod. 1997; 24: 297-300. 4. HSasaki, JFunao, HMorinaga, KNakano, TOoshima. Multiple supernumerary teeth in the 14. CLPatchett, PJCrawford, ACCameron, maxillary canine and mandibular premolar C D S t e p h e n s . T h e m a n a g e m e n t o f regions: a case in the postpermanent dentition. supernumerary teeth in childhood – a IntJPaediatrDent. 2007; 17: 304-308. retrospective study of practice in Bristol Dental Hospital, England and Westmead Dental 5. DG Shanmugha, P Arangannal, SM Muthu, L Hospital, Sydney, Australia. IntJPaediatr Dent. Nirmal.Supernumerary teeth associated with 2001; 11: 259-265. primary and permanent teeth: A case report. J Indian Soc Pedo Prev Dent. 2002; 20(3): 104- 15. RND'Souza, ODKlein. Unraveling the 106. Molecular mechanisms that lead to supernumerary teeth in mice and men: current 6. SJParikh, MJain. “A Clinical and radiographic concepts and novel approaches. Cell Tissues study of Supernumerary teeth”: Report of Org. 2007; 186: 60-69. Hundred cases with review of literature. JIndian Assoc Oral Med Radiol. 2006; 18(2): 16. R Arathi, R Ashwini. Supernumerary teeth: A 75-81. case report. J Indian Soc Pedod Prev Dent. 2005; 6:103-105. 7. JI Asaumi, Y Shibata, Y Yanagi, M Hisatomi, H Matsuzaki, H Konouchi, K Kishi. 17. G Bateman, PAMossey. Ectopia or concomitant Radiographic examination of mesiodens and hypohyperdontia? A Case report. JOrthod. t h e i r a s s o c i a t e d c o m p l i c a t i o n s . 2006; 33: 71-77. DentomaxillofacRadiol. 2004; 33: 125-127. 18. R Roberts, STBarlow, MMCollard, MLHunter. 8. LD Rajab, MAHamdan. Supernumerary teeth: An unusual distribution of supplemental teeth review of the literature and a survey of 152 in the primary dentition. IntJPaediatr Dent. cases. IntJPaediatrDent. 2002; 12: 244-254. 2005; 15: 464-467. 9. EFPadro, JPArmengol, EFAmat. A descriptive 19. KARussell, MA. Folwarczna. Mesiodens – study of 113 unerupted supernumerary teeth in Diagnosis and management of a common 79 pediatric patients in Barcelona. Med Oral supernumerary tooth. JCanDentAssoc. 2003; Patol Oral Cir Bucal. 2009; 14(3): 146-52. 69(6): 363-369.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 25 Naresh Soni et. al. : Check The Extras: A Clinico – Radiographicstudy of Supernumerary Teeth

20. COGomes, BCJham, BQSouki, TJPereira, 29. LC Fonseca, NK Kodama, FC Nunes, PH RAMesquita. Sequential supernumerary teeth Maciel, M Roitberg, JX Oliveira, MG in nonsyndromic patients: report of 3 Cavalcanti. Radiographic assessment of cases.Pediatr Dent. 2008; 30(1): 66-69. Gardner's Syndrome. Dentomaxillofac Radiol. 2007; 36: 121-124. 21. ADiaz, JOrozco, MFonseca. Multiple hyperdontia: Report of a case with 17 30. RMFarahani, ATZonuz. Triad of Bilateral supernumerary teeth with non syndromic Duplicated permanent teeth, persistent open association. Med Oral Patol Oral Cir Bucal. apex, and tooth malformation: A case report. J 2009; 14(5): E 229-31. Contemp Dent Pract. 2007; 8(7): 94-100. 22. H Turkkahraman, HH Yilmaz, E Cetin. A non- 31. B Sivapathasundharam, A Einstein. Non- syndrome case with bilateral supernumerary syndromic multiple supernumerary teeth: c a n i n e s : r e p o r t o f a r a r e c a s e . Report of a case with 14 supplemental teeth. DentomaxillofacRadiol. 2005; 34: 319-321. Indian J Dent Res. 2007; 18(3): 144. 23. KWTai, MYChou. Multiple impacted 32. K Manjunath, B Kavitha, TR Saraswathi, B supernumerary teeth in premolar regions – case Sivapathasundharam,R Manikadhan. report. Chin Dent J. 2000; 19(1): 61-66. Cementum analysis in . Indian J Dent Res. 2008; 19(3): 253-256. 24. AIOrhan, LOzer, KOrhan. Familial Occurrence of Non Syndromal Multiple Supernumerary 33. GS Virender, S. Jayachandran. Cleidocranial teeth. Angle Orthod. 2006; 76(5): 891-897. dysplasia: Report of 4 cases and review. JIndian Acad Oral Med Radiol. 2008; 20(1): 23-27. 25. A Acikgoz, G Acikgoz, U Tunga, F Otan. Characteristics and prevalence of non- 34. ASharma, S Sharma. Cleidocranial Dysplasia – syndrome multiple supernumerary teeth: a Report of a case. J Oral Health Comm Dent. retrospective study.DentomaxillofacRadiol. 2009; 3(3): 62-65. 2006; 35: 185-190. 35. LDLopes, BSMattos, Marcia Andre. 26. AP Bernardes da Silva, BCosta, CFCarrara. Anomalies in number of teeth in patients with Dental Anomalies of number in the permanent lip and/or palate clefts. Braz Dent J. 1991; 2(1): dentition of patients with bilateral cleft lip: 9-17. Radiographic study. Cleft Pal CraniofacJ.2008; 36. MTGarvey, HJBarry, M Blake. Supernumerary 45(5):473-476. teeth - An overview of classification, diagnosis 27. A R o y c h o u d h a r y , Y G u p t a , H and management. J Can Dent Assoc. 1999; 65: Parkash.Mesiodens: A retrospective study of 612-6. fifty teeth. J Indian Soc Pedo Prev Dent. 2000; 37. N Kalra, S Chaudhary, S Sanghi. Non- 12: 144-146. s y n d r o m e m u l t i p l e s u p p l e m e n t a l 28. PFMontenegro, EVCastellon, LBAytes, supernumerary teeth. J Indian Soc Pedo Prev CGEscoda. Retrospective study of 145 Dent. 2005; 3: 46-48. supernumerary teeth. Med Oral Patol Oral Cir Bucal. 2006; 11: E339-44.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 26 PYOGENIC GRANULOMA IN 87 YEAR OLD A Case Report FEMALE PATIENT – A RARE CASE

Anjanikumar R. Chaudhary*, Purv Patel**, Ameya Patwardhan***, Roseline Patel**** ABSTRACT

The oral pyogenic granuloma is an exuberant tissue response to local irritation or trauma, commonly involving the gingiva of maxillary anterior region. It occurs predominately in the 2nd decade of life in young females. Clinically these lesions are usually present as single sessile or pedunculated mass with smooth or lobulated surface ranging from a few millimetres to several centimetres in size. Presented here is a rare case of an 87 year old female patient having pyogenic granuloma on the crest of lower residual alveolar ridge.

KEYWORDS: Pyogenic Granuloma Received: 02-02-2015; Review Completed: 05-06-2015; Accepted: 01-07-2015

INTRODUCTION: frequent trauma such as the lower lip (3,4,5), tongue (6) and palate (5,7,8). Similar lesion on palate is known as The pyogenic granuloma (PG) (also known as “lobular capillary hemangioma” (8,9). A case has also "Granuloma gravidarum") is a relatively common, been reported extraorally - in nasal cavity following tumour like, exuberant tissue response to localized nasal packing (10). irritation or trauma (1). Clinically, oral pyogenic granuloma is a smooth or Pyogenic granuloma was originally described in lobulated, exophytic growth; presenting as small 1897 by two French surgeons, Poncet and Dor, who erythematous papules on a pedunculated (or less named this lesion “Otyomycosis Hominis”. It was commonly sessile) base and usually haemorrhagic. initially considered to be a botryomycotic infection, The surface may be deep red or reddish purple an infection in horses thought to be transmissible to depending upon its vascularity. Young PGs are humans. The term “Pyogenic Granuloma” or highly vascular as they are predominantly “Granuloma Pyogenicum” was first coined by composed of hyperplastic granulation tissue with (1) Hartzell in 1904 . The name pyogenic granuloma prominent capillary network. Some lesions have a was applied based on an identical lesion found on brown cast if haemorrhage has occurred in the the skin, thought to be caused by pyogenic tissue. The surface may show ulceration which may (2) organisms . It is actually a misnomer since the be covered by yellow-white fibrinous condition is not associated with pus and does not pseudomembrane(1). If left untreated for a long (1) represent a granuloma histologically . The actual period of time, the lesion may undergo fibrosis due cause of pyogenic granuloma is unknown but many to decreased vascularity and becomes small, firm etiological agents have been proposed-like with little bleeding tendency. This lesion is called hormonal imbalance, chronic trauma etc. “Fibro-epithelial Polyp”(11). There are no radiographic findings in case of Pyogenic Pyogenic granuloma predominantly occurs in Granuloma. second decade of life and is more common in females than males due to vascular effects of female Two lesions which clinically appear similar to hormones. No racial predilection has been Pyogenic Granuloma are Peripheral Giant Cell observed. It shows a striking predilection for the Granuloma and Peripheral Ossifying Fibroma. gingiva. Extragingivally, it can be seen in areas of Only histological evaluation can reveal the true

* Professor, ** Senior Lecturer, *** PG Student, **** Senior Lecturer DEPARTMENT ORAL MEDICINE & RADIOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Purv Patel, TEL: +91 9427219470

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 27 Anjanikumar R. Chaudhary et. al. : Pyogenic Granuloma in 87 Year Old Female Patient lesion, especially when it is found on gingiva. growth was present on the lower left edentulous ridge measuring 4 cm X 1 cm in size, extending Histologically, Pyogenic Granuloma comprises of from 33 upto 37 region anteroposteriorly and from proliferating endothelial cells, much of which is the crest of the alveolar ridge to the depth of lingual canalized into a rich vascular network with minimal as well as buccal vestibules supero - inferiorly collagenous support. Polymorphs as well as chronic (figure - 1). inflammatory cells often infiltrate throughout the oedematous stroma, with microabscess formation(12).

An identical lesion with same histological features occurs in association with florid gingivitis and periodontitis. In such cases, it is referred to as “Pregnancy ” or “Pregnancy Tumour” (12). These lesions show increased prevalence towards the end of pregnancy, and characteristically, shrink following delivery. Lesion does not occur if proper oral hygiene is maintained, indicating that a local cause is also important in formation of the lesion.

Preferred treatment for most of the Pyogenic The surface was irregular, lobulated and showing Granulomas is removal of etiological agent and interspersed ulcerated and normal appearing areas. surgical excision. Other recent treatment modalities On palpation, it was soft in consistency, rough, non- tried in recent times includes use of LASERs or tender and easily bled on touch and manipulation. Cryosurgical excision and intralesional injection of IOPA of the region revealed no bony changes sclerosing agents (1). The lesion has a significant (figure - 2). potential to recur. Recurrence is most commonly due to incomplete excision, failure to remove irritant or re-injury (13) and thus long term follow up is necessary.

CASE REPORT:

A 87 year old female patient presented with a growth on the lower left posterior edentulous region since 15 days. The growth was of negligible size when she first noticed it, but then it rapidly grew to attain the current size. Patient did not recall any history of trauma to the region in the near past. No significant medical and family history was given by the patient. Patient had undergone extraction of From the above clinical findings, a provisional teeth under local anaesthesia with last tooth diagnosis of 'Pyogenic Granuloma' was made with extracted about 1 year ago without any 'Peripheral Giant cell Granuloma' kept as possible complication. differential diagnosis. Also, considering such an age of the patient, and the rapidity of the growth, On intraoral examination; 13, 14, 15, 22, 23, 24, 25 carcinoma was also considered as one of the were the teeth present. An exophytic, pedunculated

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 28 Anjanikumar R. Chaudhary et. al. : Pyogenic Granuloma in 87 Year Old Female Patient differential diagnosis and hence, excision with a wide margin was done and tissue was submitted for histopathology.

Histopathological evaluation showed connective tissue consisting of vast number of endothelium lined vascular spaces filled with RBCs, extravasated RBCs, collagen fibre bundles, fibroblasts and intense infiltration of lymphocytes and plasma cells. The histopathology confirmed the diagnosis of Pyogenic Granuloma (figure-3 and 4). On follow up after 7 days, absolutely uneventful healing was observed. DISCUSSION:

Pyogenic Granuloma (PG) in oral cavity is a reactive lesion of the mucosa in response to local irritant or infection of a low virulence which may act as irritant. It should be emphasized that, certain infective organisms have been identified in causation of other vascular lesions-like B. Henselaea (Peliosis Hepatis), B. Quintana (Bacillary Angiomatosis) and HHV8 (Kaposi's Sarcoma and Angiolymphoid Hyperplasia) (1) but no such association has been seen in case of Pyogenic Granuloma. In this case, oral hygiene of the patient appeared to be good. Thus, it appears to be a case of unknown origin.

The growth is typically seen in young adults, although it may occur at any age. This is due to hormonal changes occurring during puberty which causes exuberant response to a local irritant of small intensity. A case of Pyogenic Granuloma has been reported in as early as an 8 week old infant (6) but no case has been found in literature in such an old age as was in this case. For that same reason, wide excision was done keeping in mind differential diagnosis of squamous cell carcinoma.

PG has a positive female predilection (about 1:1.5) Since Pyogenic Granuloma has a reportedly high as in the present case. Females are far more recurrence rate, the patient is still under follow up. 3 susceptible than males because of the hormonal months follow-up photograph shows no signs of changes that occur in women during puberty, recurrence. (figure - 5) pregnancy and menopause.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 29 Anjanikumar R. Chaudhary et. al. : Pyogenic Granuloma in 87 Year Old Female Patient

The disease can occur at any site. Most common site appearing lesions of the gingiva are submitted for of occurrence though, is gingiva (around 75% of histologic examination, approximately 85% will be cases) (12) especially close to gingival margin, pyogenic granulomas, 10% will be peripheral suggesting that plaque and calculus, food debris and ossifying fibromas, and 5% will be peripheral giant overhanging margins of the restorations are cell granulomas (14). Peripheral Ossifying Fibroma is important irritants that may have a role in a reactive lesion that occurs exclusively on gingiva development of the lesion, other sites being lips (3), and clinically appears as pale pink to cherry red tongue (6), buccal mucosa (5,7,10). Lesions are more growth typically located in the interdental region common on facial than lingual surface and can and commonly encountered during pregnancy. occur involving both the sides including interdental Peripheral giant cell granuloma is also a reactive papilla (9). In this case, lesion appeared on the lesion predominantly affecting children and residual alveolar ridge and extended on both the showing giant cells histologically. Gingiva is the surfaces of the ridge. second most common site for occurrence of oral soft tissue metastasis of malignancy and may be the first Clinically, the lesion appears as small, sign of malignancy at a distant site. Clinically, pedunculated or sessile, painless, soft with smooth, metastatic lesions also appear similar to PGs (1,15) and lobulated or warty surface which is highly friable. thus microscopic examination is a must. In current Generally lesion grows slowly and reaches its peak case, microscopic examination ruled out any by few weeks to months and then remains the same malignancy and confirmed the diagnosis of (1) thereafter indefinitely . Some PGs may grow Pyogenic Granuloma. rapidly also. Lesions often ulcerate and bleed profusely even without provocation. PG in present CONCLUSION: case also had a characteristic appearance in accordance with the literature. Oral pyogenic granulomas are well documented in literature in young age but its occurrence in old age Lesion closely identical to pyogenic granuloma is is uncommon. So when it occurs in an old age, wide Peripheral Giant Cell Granuloma and Peripheral excision with the histopathological evaluation is Ossifying Fibroma when they occur on the gingiva must to rule out malignancy. (12). If 100 biopsies of pyogenic granuloma

REFERENCES: 5. Amirchaghmaghi M, Falaki F, Mohtasham N, Mozafari PM. http://www.casesjournal.com. 1. Jafarzadeh H, Sanatkhani M, Mohtasham N. [ O n l i n e ] . ; 2 0 0 8 . Av a i l a b l e f r o m : Oral Pyogenic Granuloma: A Review. Journal HYPERLINK"http://www.casesjournal.com/c of Oral Science. 2006; 48(4): p. 167-175. ontent/1/1/371"http://www.casesjournal.com/ 2. Hyne, Levy, Shafer. Shafer's Textbook of Oral content/1/1/371. P a t h o l o g y. 5 t h e d . R a j e n d r a n R , 6. Jurkiewicz BDZ. Rare case of pyogenic Sivapathasundharam B, editors.: Elsevier; granuloma of the tongue. Eur Arch 2006. Otorhinolaryngol. 2005;: p. 453–455. 3. Dave B, Sodani V, Shah HG, Bahuguna R. 7. Scully C. Handbook of Oral Disease- Diagnosis Extragingival Pyogenic Granuloma – A Case. and Management: Martin Dunitz; 1999. Journal of Advanced Dental Research. 2010 October; 1(1). 8. Giorgi Vd, Sestini S, Nardini P, Carli P. A 42- year-old man with a rapidly growing lesion of 4. Patil K, Mahima V, Lahari K. Extragingival the soft palate. CMAJ. 2005; 173(4): p. 367. pyogenic granuloma. Indian J Dent Res 2006. 2006; 17(4): p. 199-202. 9. Tolentino EdS, Tolentino LdS. Recurrent

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 30 Anjanikumar R. Chaudhary et. al. : Pyogenic Granuloma in 87 Year Old Female Patient

intraoral pyogenic granuloma: case report. 10th ed.: Elsevier India. Odontologia. Clín. -Científi c., Recife. 2009 13. JA R, JJ S, RCK J. Oral Pathology: Clinical jul/sep; 8(3): p. 263-267. Pathologic Considerations. 4th ed. 10. Lee HM, Lee SH, Hwang SJ. A giant pyogenic Philadelphia: W B Saunders; 2003. granuloma in the nasal cavity caused by nasal 14. Svirsky J. eMedicine. [Online].; 9. packing. Eur Arch Otorhinolaryngol. 2002;: p. 231–233. 15. Dudhia B, Patel P. Squamous Cell Carcinoma Clinically Presenting As Pyogenic Granuloma– 11. Kumar PS. Essentials of Oral Pathology. 2nd A Case Report. JADC. 2010; 1(1). ed.: Jaypee; 2003. 12. S. GM, Michael G. Burket's Oral Medicine.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 31 SALVAGING FRACTURED MAXILLARY LATERAL INCISOR A Case Report USING EXTRACORONAL AND INTRACORONAL SPLINTING

Dhara Patel*, Suhag Patel**, Nishit Patel***, Shraddha Chokshi**** ABSTRACT

Introduction: One of the main causes of permanent teeth loss is attributed to dental trauma; however root fractures are relatively uncommon in these situations. This case report presents the endodontic management of a horizontally fractured maxillary right lateral incisor using extracoronal splint for initial stabilization and then an intraradicular splinting technique for permanent stabilization. Case Report: Patient complained of pain and mobility of the upper right front teeth since 5 hours. After clinical and radiographic examination, a diagnosis of a horizontal fracture of maxillary right lateral incisor at the level of cervical line (Ellis class III) was made. The fracture segments were stabilized using extracoronal fiber splint and final intraradicular stabilization involved placing a fiber post in the canal and luting with resin cement. Discussion: This case demonstrates that both extracoronal and intraradicular splinting techniques together can be used to manage horizontally fractured teeth. The recent advances in the resin-based restorative materials with tooth colored fiber post are of choice because of several advantages such as esthetics, bonding to tooth structure, and low modulus elasticity similar to that of dentin.

KEYWORDS: Fiber splint, extracoronal splinting, Fiber post, intraradicular splinting, mid-root fracture, resin cement. Received: 01-03-2015; Review Completed: 05-06-2015; Accepted: 03-08-2015

INTRODUCTION: CASE REPORT

One of the main causes of anterior permanent tooth A 25 year old male patient reported to the loss is dental trauma. Upper central incisors are Department of Conservative Dentistry and vulnerable to this type of injury, being affected in Endodontics with chief complaint of pain and 80% of dental trauma, followed by upper lateral mobility of the upper right front teeth since 5 hours. incisors and lower incisors1. Incidence of horizontal History revealed trauma because of the blow of a root fractures ranges from 0.5% to 7% in permanent mechanical tool. Pain aggravated on consuming teeth and from 2% to 4% in primary teeth for all food and also on consumption of hot or cold traumatic dental injuries2. A single tooth fracture beverages. Patient gave non contributory medical occurs in most cases and multiple teeth fracture is a history. rare finding3,4. On intraoral examination, soft tissue examination The success of the treatment of a root fracture revealed bleeding gingiva with respect to maxillary depends on many factors like pulpal status and level right lateral incisor (Fig 1). Upper lip was found to of fracture. Complication in the healing of the root be inflamed and lacerated due to trauma on right fracture is because of damage to the dental tissues side. Hard tissue examination revealed grade I including pulp, dentin, periodontal ligament, mobility in relation to maxillary right lateral cementum and sometimes the alveolar bone. incisor.The tooth was tender on horizontal and vertical percussion. This case report presents the endodontic management of a horizontally fractured right lateral Intraoral periapical radiograph of maxillary right incisor at the cervical third of the root, using lateral incisor revealed a radiolucent horizontal line extracoronal splint for initial stabilization and then near the cervical third of the root of the right lateral an intraradicular splinting technique for permanent incisor (Fig 2). Based on the clinical and stabilization of the fracture fragments of the tooth. radiographic findings, a diagnosis of horizontal

* PG Student, ** Reader, *** Senior Lecturer, ****Professor DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Dhara Patel, TEL: +91 8460857234

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 32 Dhara Patel et. al. : Salvaging Fractured Maxillary Lateral Incisor Using Extracoronal And Intracoronal Splinting fracture of the root at the level of cervical line (Ellis PROCEDURE class III) was made. As the fracture line was subgingival, though the fractured fragment was As the trauma was recent, single sitting root canal mobile; it was held in position by the soft tissues. treatment was planned for the patient. Local anaesthesia (Lignocaine) was administered and access opening was made. Holding the tooth in position by light digital pressure radiographic working length determination was done using number 15 K file (Mani) (Fig 3).

Fig 3. Working length determination radiograph.

File was kept in position to approximate the fracture segments (Fig 4), right central incisor, right lateral Fig 1: Preoperative clinical photographs incisor and right canine were splinted using (labial and palatal aspect) of maxillary extracoronal fiber splint (Angelus), bonded on the right lateral incisor. middle third of the labial surface of the three teeth using flowable light cure composite (3M ESPE) (Fig 5). After splinting, cleaning and shaping was done using Hand Protaper file system to a master apical size of F2. Obturation was done using F2 cone and AH Plus sealer (Dentsply) (Fig 6). The access cavity was sealed with temporary restorative material (Orafil, Prevest).

Fig 2: Preoperative radiograph of maxillary right lateral incisor.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 33 Dhara Patel et. al. : Salvaging Fractured Maxillary Lateral Incisor Using Extracoronal And Intracoronal Splinting

Patient was then recalled after 3 days for endodontic post placement. Gutta percha filling was removed with peeso reamer by retaining 9 mm of gutta- percha apically. Minimum postspace preparation was done to minimize trauma to the periodontium during the procedure and a radiograph was taken for confirmation (Fig 7). Then a fiber post (Parapost system,Coltene) was tried in the tooth and another radiograph was taken, thus confirming the post in prepared canal (Fig 8).

Fig 4. Fracture segments stabilized using #15 K file for extracoronal splinting.

Fig 7. Post space Fig 8. Fiber Post try-in preparation radiograph. radiograph. The post was cemented into the canal using self adhesive resin cement (Rely X U 200, 3M ESPE). Excess cement was removed from the access cavity Fig 5. Extracoronal splinting using fiber splint. and the cement was cured for 40s. A radiograph was taken to confirm the post placement (Fig 9). The access cavity was restored with composite resin.

Fig 6. Post Fig 9. Post operative obturation radiograph. radiograph.

Discussion Preservation of the natural dentition and rehabilitation of oral cavity to a normal functional

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 34 Dhara Patel et. al. : Salvaging Fractured Maxillary Lateral Incisor Using Extracoronal And Intracoronal Splinting state is the primary goal in dentistry. Direct trauma was advocated. caused by automobile accident, sporting activity, violence, or on the jaw or on A progressive improvement in the field of adhesive individual tooth may result in tooth fractures. Initial dentistry allows clinician to reattach a broken tooth treatment of horizontal root fracture5. involves structure mechanically, chemically and esthetically. repositioning the fractured tooth segments and then In the present case, a fiber post was used along with stabilizing the tooth to allow healing of the the resin cement as an intraradicular splint to periodontal ligament.6 reattach the coronal fragment. Several advantages of fiber post for reattachment are conservation of The treatment of transverse root fracture may be tooth structure, esthetics, bonding to the tooth accomplished by means of extracoronal splinting, structure, cost effective, functional rehabilitation7. endodontic treatment of the coronal root fragment, Luting agents such as zinc phosphate, zinc intraradicular splinting of the two fragments using polycarboxylate, glass ionomer, and filled and fiber post or extraction of the apical fragment unfilled resin cements have been investigate depending upon the site of fracture. extensively. However the use of various types of fiber-reinforced post and resin cements is becoming Various extracoronal splinting techniques available popular8. for splinting of fracture fragments are orthodontic band-arch wire splint, cap splint, proximal bonding CONCLUSION with composite, bonded orthodontic wire, bonding with fiber splint4. According to a study conducted by Reattachment of tooth fragment is a variable Andreason et al, extracoronal fiber splint was found technique that restores function and esthetics with a to be optimal splint as compared with other very conservative approach. Adhesive techniques, splinting techniques. This splint was found to be sometimes in conjunction with intra-canal slightly flexible (semirigid immobilization) and retention, like a post, can be used to reattach application implies minimal damage to the injured fractured segments and an esthetic result can be tooth4. Hence in the present case, for initial obtained, preserving the natural tooth with stabilization of the fracture fragments, fiber splint minimum procedure and cost to the patient.

REFERENCES: 11. 1. Andrade ES, Campos Sobrinho AL, Andrade 5. Versiani MA, de Sousa CJ, Cruz-Filho AM, MG, Matos JL. Root healing after horizontal Perez DE, Sousa-Neto MD. Clinical fracture: a case report with a 13-year follow up. management and subsequent healing of teeth Dent Traumatol. 2008;24(4):e1-3. with horizontal root fractures. Dent Traumatol 2008;24:136-9. 2. Sübay RK, Sübay MO, Yilmaz B, Kayataş M. Intraradicular splinting of an horizontally 6. Taşdemir T, Yeşilyurt C. Repair of untreated fractured central incisor: A case report. Dent horizontal root fracture: A case report. Traumatol 2008;24:680-4. Hacettepe Dis Hek Fak Derg 2006;30:47-9. 3. Zorba YO, Ozcan E. Reattachment of coronal 7 Adanir N, Ok E, Erdek Y. Re-attachment of fragment using fibre reinforced post: A case subgingivally oblique fractured central incisor report. Eur J Dent 2007;1:174-8. using fiber post. Eur J Dent 2008;2: 138-41. 4. Andreasen JO, Andreasen FM, Mejàre I, Cvek 8 Cheung W. A review of the management of M. Healing of 400 intra alveolar root fracture.2. endodontically treated teeth. Post core and the Effect of treatment factors such as treatment final restoration. J Am Dent Assoc delay, repositioning, splinting type and period 2005;136:611-9. and antibiotics. Dent Traumatol 2004;20:203-

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 35 BRONJ A Case Report

Rahul P. Khubchandani *, Sachin Dalal**, Darshan Patel ***, Neha Vyas **** ABSTRACT

Bisphosphonates (BPs) have been widely used in medical practice as anti-resorptive agents owing to their anti- osteoclastic action. These compounds are also used for their analgesic action and their potential anti-tumor effect. Patients treated with BPs develop ostenecrosis of jaw or maxillary bone after minor local trauma labeled as bisphosphonate related osteonecrosis of jaw (BRONJ). The etiopathogenic mechanism of this pathological condition is poorly understood. In the present case report, a case with follow up of left maxillary osteomyelitis due to BPs is presented.

Received: 01-03-2015; Review Completed: 05-06-2015; Accepted: 03-08-2015 INTRODUCTION: associated with bone metastases secondary to solid cancer, and in the management of the lesions of Bisphosphonates (BPs) are a class of drugs derived multiple myeloma, Pagets disease, primary and from pyrophosphates, endogenous inorganic secondary hyperparathyroidism and osteoporosis.[1] regulators of mineralization, by substituting the IV bisphosphonates are primarily used and effective oxygen atom in the basic pyrophosphate chain with in treatment and management of cancer-related [1] a carbon, this leads to osteoclast inhibition. conditions. These include hypercalcemia of Historically, bisphosphonates date back to the malignancy, skeletal related events associated with middle of the 19th century, where their use was bone metastases in the context of solid tumors such mainly industrial. Their biological characteristics as breast cancer, prostate cancer, lung cancer, and in were first reported in 1968. In the early 1990s the management of lytic lesions in the setting of bisphosphantes were employed as a diagnostic multiple myeloma. IV bisphosphonates are agent in various disorders of bone and calcium effective in preventing and reducing metabolism. Currently oral bisphosphantes are used hypercalcemia, stabilizing bone pathology and widely in the treatment of osteoporosis. Intravenous preventing fractures in the context of skeletal regimes are designed to treat the complications of involvement. While they have not been shown to metastatic disease and primary osteolytic pathology improve cancer specific survival, they have had [2] of bone. significant impact on the quality of life for patients with advanced cancer that involves skeletal Bisphosphonates appear to express their effects at system.[3] three levels: tissue, cell and molecular. Two broad theories have been articulated to explain the Bisphosphantes are thought to concentrate in the pathogenesis in BRONJ. One is bisphosphonate jaws due to the associated physiology of this part of induced osteoclast induced inhibition and other is the skeleton. The greater degree of vascularization [2] its antiangiogenic mechanism. The effects of BPs and the daily remodeling that occurs around the include the reduction of bone loss and the risk of periodontal ligament of the teeth. In addition the pathological fracture; these drugs are thus chronic nature of invasive dental disease, and the administered to patients suffering from destructive treatment it requires occurs in a location where bone lesions resulting from osteoclast-induced adjacent bone is minimally protected by a thin resorption; they are mainly used to treat and prevent mucosal covering. This serves to explain why malignant hypercalcemia, skeletal related events bisphosphonates related osteonecrosis (ON)

* PG Student, ** Professor, *** Senior Lecturer, **** Professor And Hod DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Rahul Khubchandani, TEL: +91 9428315023

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 36 Rahul P. Khubchandani et. al. : BRONJ manifest itself mostly in the jaws and not other sites of skeleton.[2] Bisphosphonate related (BRONJ) adversely affects the quality of life and produces significant morbidity in afflicted patients.[3] In this case report, we describe a case of BRONJ in left maxillary region.

CASE REPORT:

A 76 year old male reported to department of oral and maxillofacial surgery with complain of pain and pus discharge in upper left front and back region of upper jaw since two and half months. Patient gives history of pain and pus discharge in upper left front Fig 2: exposure of necrotic bone after reflection and back region (22-27) since three months following which he underwent extraction of teeth, but pus discharge and pain continued following extraction. Patient had past history of prostate cancer surgery twice (2004 & 2007) and angioplasty in 2004. Patient has been taking anti- hypertensives, oral bisphosphonates (alendronate), calcium tablets since 2007. Intraoral examination showed exposed necrotic bone of 4.5 * 3 cm in 25, 26, 27 region with inflamed surrounding mucosa. (Fig 1)

Fig 3: after sequestrectomy saucerisation & extraction of 21, 22, 23, 28

done along with extraction of 21, 22, 23, 28 followed by primary closure (Fig 4).

Fig 1: intra oral view of exposed necrotic bone

CT scan of maxilla showed generalized cortical thinning, irregular and patchy osteolysis, osteolytic pattern involving left maxillary arch and floor of left maxillary sinus. Left maxillary sinus was completely opacified with soft tissue. Sequetrectomy and saucerisation (Fig 2 & 3) was Fig 4: primary closure

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 37 Rahul P. Khubchandani et. al. : BRONJ

Histopathology report showed granulation tissue, strength in diseases like osteoporosis, large number of extravasated red blood cells, hypercalcemia, Paget's disease, bone metastasis, chronic inflammatory cells and dead bone with multiple myeloma, primary hyperparathyroidism, empty lacunae in H & E stained section (Fig 5). osteogenesis imperfecta, and numerous other Postoperatively patient was rehabilitated by conditions that feature bone fragility. obturator (Fig 6). Bisphosphonates can be given by oral or IV administration. IV bisphosphonates are used extensively to treat osteolytic bone lesions related to multiple myeloma, and bone metastasis of solid cancers, breast cancer or prostate cancer.[4] An increased risk of osteonecrosis in the jaw bones is noted since 2003, causing large and therapy resistant bone exposures of the maxilla and mandible in patients with a history of bisphosphnate administered orally or by IV route. Marked inhibition of bone resorption is seen, particularly when administered by IV infusion.[4]

The exact origin of BRONJ is not known but many hypothesis seem to explain the pathogenesis under as:

• On bone remodeling: it is noted that Fig 5: histopathology of specimen bisphosphonate causes bone remodeling suppression. The jaw bones have high rate of remodeling than other bones hence rapid remodeling of jaw and suppression of remodeling DISCUSSION: leads to osteonecrosis. • On osteocytes: in normal bone osteocytes at the end of their life cycle are removed and replaced with new ones. This process will be absent when bone remodeling is suppressed by bisphosphonates. Healthy osteoytes have canaliculi by which they communicate with adjacent osteocytes as well as exchange nutrients through blood supply. So, once Fig 6: obturator in place the osteocytes, die the nutrition is also cut off leading to necrosis of bone. It is also noted Bisphosphonates are stable analogs of bisphosphonates attached to the bone act as pyrophosphates, which are naturally occurring cytotoxic agents to the ostocytes thereby leading to modulators of bone metabolism. They are potent their death and later their necrosis. inhibitors of osteoclast – mediated bone resorption and have cytotoxic effects on mature osteoclasts • On antiangiogenesis: bisphosphonate have and inhibit the formation of osteoclasts from antiangiogenic property as they suppress capillary [4] precursors. Hence they are used as antiresorptive regeneration, epithelial growth factor and medicines to maintain or increase bone density and angiogenesis. The normal healing mechanism in

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 38 Rahul P. Khubchandani et. al. : BRONJ jaw bone following extraction or invasive dental treatments is disturbed as the blood clot will not form due to angiosuppression by bisphosphonate. Bone remodeling is also inhibited as osteoclasts are suppressed by bisphosphonates leading to delay in wound healing process and BRONJ ultimately.[5]

In order to standardize the criteria for BRONJ the Amercian Association of Oral and Maxillofacial Surgeons (AAOMS) in 2007 has come up with three following criteria:[6]

• Current or previous treatment with bisphosphonate

• Exposed, necrotic bone in the maxillofacial Fig7: follow up after 6 months region that has persisted for more than eight weeks CONCLUSION:

• No history of radiation therapy to the jaws.[5,7] Bisphosphonate related osteonecrosis of the jaws is a clinical and pathological entity that is not yet fully The present case report is of 76 year old male who understood; the true incidence of this adverse effect was taking oral bisphosphanates followed by is almost certainly underestimated.[1] Although the prostate cancer surgery and patient had undergone definitive role of bisphosphonates remains to be extraction of teeth in upper left quadrant due to pain elucidated, the alteration in bone metabolism and pus discharge. But pain and pus discharge did together with surgical insult or trauma appear to be not subside following extraction. Clinically there key factors in the development of osteonecrosis.[4] was bare necrosed bone in upper left maxillary region. Criteria given by AAOMS in 2007 for BRONJ were present in this case suggesting osteonecrosis post bisphosphonate therapy. Post operatively patient had satisfactory healing with no exposed bone. Patient was kept on follow up for six months. Healing after six months was satisfactory (Fig 7). Opening present in buccal vestibule was closed by means of an obturator.

REFERENCES: 3. American Association of Oral and Maxillofacial Surgeons Position Paper on 1. M. Migliario, A. Melle, V. Fusco, L. Rimondini. Bisphosphonate Related Osteonecrosis of Bisphosphonate related osteonecrosis of jaws: Jaws; Journal of Oral and Maxillofacial A report on 30 cases; Journal of Stomatology, Surgery, 2007, 65, 369-376. 2013, 3, 247-254. 4. J. Kurien, E A Sunil, A. Mukunda, S R Philip. 2. C. Hewitt, C S Farah. Bisphosphonate related An update on bisphosphonate related osteonecrosis of the jaws: A comprehensive osteonecrosis of the jaw; Indian Journal Of review; Journal of Oral Pathology Med, 2007, Clinical Practice, Vol 24, No. 3, 267-270. 36, 319-328.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 39 Rahul P. Khubchandani et. al. : BRONJ

5. Kim YG, Lee YD, Kwon YD, Suh JH, Jeen SM. 7. Ruggiero SL, Dodson TB, Assael LA, S t u d y o n b i s p h o s p h o n a t e s r e l a t e d Landesberg R, Marx RE, Mehrotra B; osteonecrosis of the jaw (BRONJ): Case report American Association of Oral and and literature review. J Korean Assoc Oral Maxillofacial Surgeons. American Association Maxillofacial Surg 2010, 36: 291-302. of Oral and Maxillofacial Surgeons position paper on bisphosphonate related osteonecrosis 6. Ikebe T. Pathophysiology of BRONJ: Drug of the jaws – 2009 update. J Oral Maxillofacial related osteoclastic disease of the jaw. Oral Surg 2009; 67: 2-12.- Science International. 2013; 10 (1): 1-8.

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 40 PRECISION ATTACHMENT: A CONNECTING LINK BETWEEN A Case Report FIXED & REMOVABLE PROSTHESIS: A CASE REPORT

Nayan Sapra*, Darshana Shah**, Chirag Chauhan***, Ankit Narola**** ABSTRACT

Satisfactory restoration in a patient with a partially edentulous situation can be challenging especially when unilateral or bilateral posterior segment of teeth is missing. Successful restoration can be done with various conventional and contemporary treatment options. One such treatment modality is precision attached partial dentures. It provides better retention and esthetics in distal extension cases. This paper describes a case report of a patient with Maxillary and Mandibular Kennedy's class I mod. II extension edentulous span restored with an attachment retained partial denture having an extra coronal precision attachment (Ceka attachment: Preci-vertix and preci-sagix).

KEYWORDS: Kennedy's classification, Precision attachment, Matrix and Patrix, preci vertix and sagix. Received: 01-03-2015; Review Completed: 05-06-2015; Accepted: 03-08-2015

INTRODUCTION: development of precision attachments are two basic objectives7. These are: From their first introduction to the dental profession, precision attachments have been 1. To relate the desired platform to the surrounded by an aura of mystery, implying that available tooth support. great skill is required in their successful use. This has served as a contributing factor in discouraging 2. To distribute as far as possible the load to their general use. From the patient's viewpoint, a be thrust on the teeth by the appliance. precision attachment appliance offers more comfort and security than a corresponding appliance with In order to achieve these two objectives precision clasps, with an obvious advantage in esthetic attachments have been constructed into two halves, appearance1, 2, 3. a matrix and a patrix, the two halves being so arranged that they articulate with one another to By definition, the term precision denotes “the form a precise but separable joint. The two halves quality or state of being precise”. Precision are also referred to as the male and female parts. The attachments are sometimes said to be a connecting abutment retainers houses a slot (female portion) link between the fixed and removable type of partial which fits, (embraces or envelops) the male 8, 9, 10 dentures because it incorporates features common portion . to both types of construction4. PROSTHETIC REHABILITATION Precision attachments retain and attach a removable bridge or partial denture on natural teeth, vital or • DIAGNOSTIC PHASE A 43 year old female patient, reported to the nonvital. Some serve as retainers for full dentures department of Prosthodontics, Ahmadabad Dental (overdenture) where few abutments remain. The College & Hospital; complaining of missing teeth. main purpose of each precision attachment besides Intraoral examination revealed missing 14, 15, 24, retention is its concealment within or under a 25, 26 teeth in Maxillary arch and missing 31, 34, restoration as an esthetically better alternative to a 5, 6 35, 36, 41, 44, 45, 46, 47 teeth in Mandibular arch visible clasp retainer . (Fig 1). Inherent in the conceptions which have led to the

*PG Student, **Professor, ***Professor, ****Post Graduate Student DEPARTMENT OF PROSTHODONTIA AND CROWN AND BRIDGE AND ORAL IMPLANTOLOGY AHMEDABAD DENTAL COLLEGE AND HOSPITAL.

ADDRESS FOR AUTHOR CORROSPONDENCE : Dr. Nayan Sapra, TEL: +91 9099476963

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 41 Nayan Sapra et. al. : PRECISION ATTACHMENT: A CONNECTING LINK BETWEEN FIXED & REMOVABLE PROSTHESIS: A CASE REPORT 22, 23, 32, 33, 42, and 43 & cast partial denture with precision attachment in 14, 15, 24, 25, 26, 34, 35, 36, 44, 45, 46, 47.

• TREATMENT PHASE

Tooth preparation was done following the basic principles in 13, 22, 23, 32, 33, 42 & 43. Gingival retraction was done and final impression was made using two-step technique using Elastomeric impression material. Impressions were poured in dental stone. Wax up of prepared teeth was Pre-treatment intra oral view maxillary arch. performed and the articulation spaces and bulkiness were evaluated in order to proceed with optimal positioning of attachments using parallelometer mandrel (Fig 2).

Pre-treatment intra oral view after removal of faulty prosthesis in mandibular anterior arch (Fig 1)

Patient had faulty restoration in lower anterior teeth. Patient was not willing for removable prosthesis. Wax up and positioning of attachment using Implant supported prosthesis was ruled out due to parallelometer (Fig 2) financial reasons as well as long duration of treatment for the same. Hence, extra coronal Joint crowns were fabricated with the attachments bilateral precision attachments, Preci-sagix in and the trial of the same was done to check the exact Maxillary arch and Preci-vertex in Mandibular arch fit of the crowns (Fig 3). Framework was fabricated were planned, and patients consent was taken after and jaw relation & final try in was done (Fig 4). explaining the details of the treatment. Partial denture was acrylised and tried in patient mouth. Diagnostic impressions were taken & diagnostic mounting was done to evaluate current occlusal plane, inter arch space in edentulous areas, occlusal interferences and occlusion. Radiographic evaluation of selected abutment teeth was also done through IOPA.

Planned treatment was PFM (Porcelain fused to metal) joint crowns with precision attachment in 13,

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 42 Nayan Sapra et. al. : PRECISION ATTACHMENT: A CONNECTING LINK BETWEEN FIXED & REMOVABLE PROSTHESIS: A CASE REPORT

Try in of joint PFM crowns with attachment (Fig 3)

Final prosthesis (Fig 5)

• MAINTAINANCE PHASE

The patient was explained about the usage and maintenance of the prosthesis. Proper follow up schedule was planned at 1st week, 1st month and 2nd month and then every six month to evaluate fit of prosthesis, hygiene, plaque control etc.

DISCUSSION Jaw relation and try in (Fig 4) Precision attachment is a connector consisting of After that, the matrix part was picked up in denture two or more parts. One part is connected to a root, using self cure acrylic. After setting of acrylic, tooth, or implant and the other part to the prosthesis excess material was removed and finishing and providing a mechanical connection between two. polishing was done. This pink cap (matrix) would These attachments allowed prosthesis to combine 9, fit into the round surface of the beveled bars (part of the advantage of fixed and removable restorations 11 fixed prosthesis) providing snap kind of retention . (Fig 5). It was Dr. Herman Chayes who first reported the invention of attachment in the early 20th century. Precision attachment gives a removable prosthesis

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 43 Nayan Sapra et. al. : PRECISION ATTACHMENT: A CONNECTING LINK BETWEEN FIXED & REMOVABLE PROSTHESIS: A CASE REPORT the exceptional feature of improved esthetics, less the attachments are very small and come with many postoperative adjustments, and improved comfort. parts to assemble. Construction of such attachment It is mostly indicated for long-span edentulous requires skill from dental technicians which cannot arches, distal extension bases, and nonparallel be acquired easily and needs training. The parts of abutments. There is a wide range of attachments the attachment are usually exposed to wear and tear available for use in all manners of restorative and needed to be replaced over time. procedures, from partial dentures to implant- supported prosthesis. CONCLUSION By analyzing study models and x-rays, the clinician can make several important points of Removable partial dentures still have a good place determination, each of which will influence final as a treatment option for partially edentulous attachment selection12, 13. Apart from improving Kennedy's class I and class II conditions. With esthetics and retention of removable partial proper case selection and treatment plan, precision dentures, the availability of precision attachment attachment such as CEKA attachments system can has made designing of removable partial dentures be used to improve retention, esthetics, and function more flexible. Various cases with esthetic and of removable partial denture. With the mentioned retention challenges can be solved with correct procedure, allows fabrication of very functional and selection of attachment. comfortable prosthetic solution for the long span edentulous extension patient cases. Attachments Thus, unnecessary surgery and cutting of sound retention can be monitored and upgraded during tooth for abutment preparation can be avoided in time just replacing retentive caps into the restoring missing teeth. However, precision framework of dentures for patients comfort and attachments are not without disadvantages. Most of satisfaction. REFERENCES: Precision Removable Partial Denture Utilizing 1) Schuyler CH. An analysis of the use and relative Bredent VKS-SG Attachment System. New value of the precision attachment and the clasp York State Dent J 2009;36-8. in partial denture planning. J Prosthet Dent 8) Baker JL, Goodkind RJ. Precision attachment 1953; 3:711-4. 2 removable partial dentures. San Mateo, CA: 2) H. W. Preiskel, Precision Attachment in Mosby, 1981 Prosthodontics, vol. 1-2, Quintessence 9) Lorencki FS. Planning Precision attachment Publishing, London, UK, 1995. restorations. J Prosthet Dent 1969;21(5):506- 3) Mc Craken's Removable partial denture 508. prosthodontics 12th edition. Pg 12. 10) Preiskel H. Precision attachments for free-end 4) The Academy of Denture Prosthetics .Glossary saddle prostheses. Br Dent J 1969;127:462- of prosthodontics term J Prosthet Dent 468. 2005;94(1):37. 11) Preiskel HW. Precision Attachments in 5) Burns DR, Ward JE. A review of attachments Prosthodontics: Overdentures and Telescopic for removable partial denture design: part 1. Prostheses. Volume 2. Chicago, II: Classification and selection. Int J Prosthodont. Quintessence Publishing Co,Ltd; 1985. 1990;3:98-102. 12) Feinberg E. Diagnosis and prescribing 6) Burns DR, Ward JE. A review of attachments therapeutic attachment retained partial for removable partial denture design: part 2. dentures. Treatment planning and attachment selection. NYS Dent J. 1982;48 (1): 27-29 Int J Prosthodont 1990;3:169-74. 13) Sumit Makkar. Attachment retained removable 7) Barry Rubel, Edward E. Hill, Unilateral Semi- denture: A case report. IJCDS. 2011;(2) 39-43

The Journal of Ahmedabad Dental College and Hospital; 6 (1), March 2015 - August 2015 44 DEPARTMENT OF PERIODONTICS: Dr. Balaji Manohar Dr. Pravin Kudva Dr. Bela Dave DEPARTMENT OF CONSERVATIVE DENTISTRY: Dr. Sunita Garg Dr. Medha Jain DEPARTMENT OF PROSTHODONTICS: Dr. Sunilkumar M. V. Dr. Rajesh Seturaman Dr. Saumil Mathur Dr. Keval Shah DEPARTMENT OF ORAL MEDICINE & RADIOLOGY: Dr. F. R. Karjodkar Dr. Jigna Shah DEPARTMENT OF ORAL PATHOLOGY: Dr. Raksha Shah Dr. B. Sivapathasundra DEPARTMENT OF ORTHODONTIA: Dr. A. F. Bhatia Dr. N. Daruwala DEPARTMENT OF ORAL SURGERY: Dr. Bhagvandas Rai Dr. Anisha Maria Dr. Kiran Desai Dr. Babu Parmar DEPARTMENT OF PEDODONTICS: Dr. Rashmin Naik Dr. Vaishali Nandiniprashad DEPARTMENT OF PUBLIC HEALTH DENTISTRY: Dr. Ajith Krishnan Dr. Janki Shah Dr. Sujal Parkar

Mr. P. K. Kulkarni Ex. Deputy Director, Senior Grade Stastatician, National Institute of Occupational Health, Gujarat

45 ETHICS COMMITTEE

CHAIRPERSON Dr. Monali Shah Dr. Mahendra K. Joshi Professor Advocate & Medico Legal Advisor Department of Oral Pathology DEPUTY CHAIRPERSON Dr. G. C. Patel Dr. Mahadev Desai Statistician Professor & Head, Dept of General Medicine, ADCH. Dr. Harsh Shah Sr. Lecturer MEMBER SECRETARY Department of Public Health Dentistry, ADCH. Dr. Rupal Vaidya Professor & H.O.D Dr. Archita Kikani Conservative Dentistry & Endodontics, ADCH. Professor Department of Periodontology ADCH. COMMITTEE MEMBERS Dr. Darshana Shah Dr. Bhavin Dudhia Professor & H.O.D Professor Dept of Prosthodontics & Crown & Bridge, Department of Oral Medicine & Radiology, ADCH ADCH

Dr. Vijay Bhaskar Dr. Dilip Zaveri Professor & H.O.D Director Paedodontics & Preventive Dentistry, ADCH. Biocare Research (India) Pvt. Ltd. Paldi, Ahmedabad. Dr. Neha Vyas Professor & H.O.D COMMUNITY REPRESENTATIVE/SOCIAL Oral & Maxillofacial Surgery, ADCH. WORKER Mr. Ashish Shah Dr. Dolly Patel Professor & H.O.D Orthodontics & Dentofacial Orthopedics, GDCH.

Dr. Chetana Desai Professor Dept of Pharmacology BJMC, Ahmedabad.

46