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CONTEMPORAR
Y DENTISTR
Y
CONTEMPORARY
DENTISTRY
Journal
of
Contemporary
Dentistry is the official publication
of the Mahatma Gandhi Mission
Dental College & Hospital and
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Dr.. Sabita M. Ram
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MGM Dental College & Hospital
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Dr.. Jyotsna Galinde
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Dr.. Sabita M. Ram
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Dr.. Girish Karandikar
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Dr.. Richard Pereira
ADVISORY BOARD
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THOLOGY
PATHOLOGY
Dr. Vinay Hazare
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MAXILLOF
ACIAL SURGER
Y
MAXILLOFACIAL
SURGERY
Dr. R.R.Pradhan
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CONSER
VATIVE DENTISTR
Y
CONSERV
DENTISTRY
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PERIODONTICS
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ORTHODONTICS
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PEDODONTICS
Dr. Rahul Hegde
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ORAL MEDICINE
Dr. Hemant Umarji
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PUBLIC HEAL
TH DENTISTR
Y
HEALTH
DENTISTRY
Dr. Navin Ingle
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Dr. L. Nagesh
EDITORIAL COMMITTEE
Dr. Sachin Kanagotagi
Dr. Sunil Sidana
Dr. Rajesh Patil
Dr. Shwetha Kumar
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Editor's Message
Dental research and scientific writing is of paramount importance to any institution.
And a scientific journal is one of the methods of this expression.
In India, clinical material is enormous and dental faculty large, but lack of
documentation and publication of scientific writing is a hindrance to academic growth.
A journal in place puts an added responsibility on a faculty member to keep pre and
post documentation of cases and instills him to think in a scientific manner.
Every journal article needs to be peer reviewed and that adds to the scientific credibility
of that article. We have striven hard to put in place senior academicians as advisors
and reviewers to offer their quality and positive inputs to boost the journal. It is this
team effort along with those of the journal committee that makes this exercise a
complete team work and a fulfilling academic experience.
In this issue we have introduced a guest article section; this will feature another
dimension of clinical expertise of those senior clinicians who will showcase their clinical
work and that combined with academic inputs from an institution will makes the journal
a holistic reading material.
We are also opening our doors to other institutes to contribute and make this journey
a complete scientific one for the betterment of our fraternity.
Dr
Dr.. Jyotsna Galinde
Assoc. Dean, Post Graduate Studies
Prof & Head, Dept. Oral & Maxillofacial Surgery, MGM
ANNOUNCEMENT
In keeping with our endeavour to disseminate scientific knowledge beyond the
boundaries of our institution, the Journal now invites Scientific articles from other
institutions. All contributing authors are requested to follow the author guidelines
outlined and send in your articles at the specified address.
JOURNAL OF
CONTEMPORAR
Y DENTISTR
Y
CONTEMPORARY
DENTISTRY
OCTOBER - DECEMBER 2011 | VOL 1 | ISSUE 2
Contents
G UEST A RTICLE
Lifelike Anterior Composites
Ratnadeep Patil ...................................................................................................................................................... 7
O RIGINAL R ESEARCH
Evaluation of the stress distribution and displacement of the denture base in
edentulous mandible with varied implant positions
Meghna K. Dang, Sabita M. Ram ........................................................................................................................ 14
R EVIEW A RTICLES
Use of Functional Appliances in General Dental Practice
Anita G. Karandikar, Girish R. Karandikar, Madhur Vasudev Navlani ............................................................ 21
Pediatric Obturating Materials And T
echniques: A Review
Techniques:
Mihir Jha, Sonal D.Patil, Shrirang Sevekar, Vivek Jogani, Poonam Shingare .................................................. 27
Oral Lichen Planus : A Review
Rohini Salvi, Rohit Bhailal Gadda,Varun Gul Bhatia ......................................................................................... 33
Bioterrorism and Dentistry- A Review
Amit Chaudhari, Priya Chaudhari ...................................................................................................................... 37
CASE REPORT
Management of non vital maxillary central incisors with open apex using
Mineral T
rioxide Aggregate apical plugs A case report
Trioxide
Sumanthini M.V., Naisargi Shah, Mausami A Malgaonkar ................................................................................ 40
Factitious Injury of The Periodontal Tissues - Case Report
Vineet Kini, Richard Pereira, Ashvini M. Padhye, Sudarshan G. Kadam .......................................................... 44
Compound Composite Odontomes In Mandibular Symphysis
A Rare Case
Sushrut Vaidya, Usha Asnani, Smita Sonavane, Imran Khalid, Kartik Poonja, Alok Bhardwaj ...................... 46
Infiltrative T
ype of Bone Invasion in Oral Squamous Cell Carcinoma - A C ase R eport
Type
Jigna Pathak, Niharika Swain, Shwetha Kumar ............................................................................................... 49
JOURNAL OF
CONTEMPORAR
Y DENTISTR
Y
CONTEMPORARY
DENTISTRY
General Information
The Journal of Contemporary Dentistry publishes original
scientific papers, reviews, case reports, and method
presentation articles in the field of dentistry. Original articles
are published in all dentistry-related disciplines, all areas of
biomedical science, applied materials science, bioengineering,
epidemiology, and social science relevant to dental disease and
its management. Manuscripts submitted for publication must
be original articles and must not have appeared in any other
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published. The number of authors is limited to 6.
Ethical
Guidelines:
A rticle
Preparation
Original
Research
articles
General Information
names referred to as abbreviations or acronyms should be written
out when first used with the abbreviation in parenthesis.
Standard units of measurement need not be spelled out.
Names of Teeth: The complete names of individual teeth must
be given in the text. In tables and figures, individual teeth can
be identified using the FDI 2-digit system if full tooth names
are too unwieldy.
Structure
1.
2.
3.
4.
5.
6.
7.
8.
AND
CONFLICTS
OF
Acknowledgments
At the end of the Discussion, acknowledgments may be made
to individuals who contributed to the research or the manuscript
preparation at a level that did not qualify for authorship. This
may include technical help or participation in a clinical study.
Authors are responsible for obtaining written permission from
General Information
persons listed by name. Acknowledgments must also include a
statement that includes the source of any funding for the study,
and defines the commercial relationships of each author.
Conflicts of interest
FIGURE LEGENDS
FIGURES
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well.
UNITS OF MEASUREMENT
Measurements of length, height, weight, and volume should
be reported in metric units or their decimal multiples. All
hematologic and clinical chemistry measurements should be
reported in the metric system in terms of the International
System of Units (SI).
ST
AT I S T I C S
TA
Statistical methods should be described such that a
knowledgeable reader with access to the original data could
verify the results. Wherever possible, results should be
quantified and appropriate indicators of measurement error
or uncertainty given. Sole reliance on statistical hypothesis
testing or normalization of data should be avoided. Data in as
close to the original form as reasonable should be presented.
Details about eligibility criteria for subjects, randomization, and
methods for blinding of observations, treatment complications,
and numbers of observations should be included. Losses to
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Statistical terms, abbreviations, and symbols should be defined.
Detailed statistical, analytical procedures can be included as an
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FOOTNOTES
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, , , k, , #,**, , etc.
IDENTIFICA
TION OF PRODUCTS
IDENTIFICATION
Use of brand names within the title or text is not acceptable,
unless essential when the paper is comparing two or more
products. When identification of a product is needed or helpful
to explain the procedure or trial being discussed, a generic
term should be used and the brand name, manufacturer, and
location (city/state/country) cited as a footnote.
GUEST ARTICLE
Introduction
Direct composite resin restorations can be a viable
treatment option when an esthetic restoration is desired
especially in case of uncomplicated tooth fractures.1,2
and standard veneer preparations for altering the shape
and size of the existing anterior teeth. In the past the
outcome of direct resin was compromised as they poorly
reproduced the optical properties of natural teeth.
Recent advances in adhesion technology, material
properties and better understanding of optical
properties of the natural tooth, has helped achieve
better vitality, character and depth of a restoration.
The direct resin buildup restoration based on
contemporary layering technique allows clinicians to
provide conservative treatment and a virtually
imperceptible blend with adjacent tooth structures.3
2.
3.
Shade judgment
Shade is analyzed before tooth preparation and
thereafter evaluated for every layer of composite. Shade
selection involves visual comparison between the
natural teeth and standard colored dental shade guides
by the dentist8. It does not imply that the same shade
composite will give us the desired outcome as the
inherent opacity and the layer thickness will determine
shade outcome. Shade matching, on the contrary, is
highly technical process with unpredictable outcome
since it depends on individual skill and knowledge8. It
has to be an integral part of the layering technique.
Dentin is an opaque and fluorescent tissue and is
responsible for the hue and chroma of the tooth by
reflecting the light through the enamel. Enamel is a
translucent and opalescent tissue and determines the
value of the tooth.3,6
Composite layering
Composite layering done with the anatomic
stratification technique helps reproduce natural
* The author is a graduate from Bombay University with a
Private practice in Mumbai, since 1988 with special interest
and expertise in Esthetic and Implant Dentistry. He is also a
Diplomate, International College of Oral Implantologists and
author of the clinical textbook on esthetic dentistry titled
'Esthetic Dentistry - An Artist's Science'. At present he is
pursuing his Phd from Utrecht University.
Case 1
A 19 year-old male patient reported with fractured upper
left central incisor and chipped surface of upper right
central incisor (Figure 1-C1) due to a sports injury.
Radiographic examination and cold test did not reveal
any pulpal damage.
Shade was determined to be A3 using the Tetric N
Ceram shade guide system. The patient being young,
the incisal edge displayed translucency and incisal
mamelons (Figure 1-C1)Occlusal view (Figure 2-C1) of
the fractured teeth reveals the difference in opacity
and translucency of dentin and enamel in #21.
In #11 a 1mm bevel was placed along the margin of
the chipped enamel surface (Figure 3-C1). An envelope
preparation design extending 2mm with a 1mm bevel
was prepared on the facial surface of #21(Figure 3-C1,4C1). On the palatal surface of #21 a rounded butt
margin was prepared. (Figure 4-C1)
The cavity preparation was disinfected using a 2%
chlorhexidine antibacterial solution. Etching was done
for 15 seconds using 37% phosphoric acid (Figure 5C1); the etchant was removed, and the tooth surface
Figure 1-C1
Figure 5-C1
Figure 6-C1
Figure 2-C1
Figure 3-C1
Figure 7-C1
Figure 4-C1
Figure 8-C1
Figure 9-C1
Figure 12-C1
Figure 10-C1
Figure 13-C1
Figure 14-C1
Figure 1
1-C1
11-C1
Figure 18-C1
Figure 15-C1
Figure 19-C1
Figure 16-C1
Figure 20-C1
Figure 17-C1
10
Figure 2-C2
Figure 21-C1
Case 2
A 20 year-old female patient wanted smile enhancement
as she unhappy with the shape of her teeth and the
fact that her teeth were hardly visible on smiling
(Figure 1-C2).
Direct Composite veneers were planned for 4 anterior
teeth using Tetric N-Ceram. Shade was determined to
be A2 using the standard vita shade guide. Since the
veneer preparation was in the enamel, value is of great
importance.
Minimal tooth preparation was done (Figure 2-C2) as
in this case more material had to be added, both to
allow us enhance the shape of the teeth, alter the incisal
edge placement and increase the height of the tooth.
Bulk on the labial surface would enhance the lip
support and make the smile more pleasing.
Figure 3-C2
Figure 4-C2
Figure 1-C2
Figure 5-C2
11
Figure 8-C2
Figure 6-C2
Figure 9-C2
Figure 7-C2
Figure 10-C2
Conclusion
12
References
1.
4.
5.
6.
7.
8.
13
ORIGINAL ARTICLE
Abstract
Aim: To evaluate the stress distribution and displacement of the denture base in a three dimensional finite element
edentulous mandibular model with varied implant positions. Objectives: 1)To evaluate the stresses induced by
implants placed in the anterior region of the edentulous mandible. 2)To evaluate the stresses induced by implants
placed in the anterior and posterior region of the edentulous mandible. 3)To compare the stresses induced by
implants placed in the anterior and posterior region of the edentulous mandible. 4)To evaluate the displacement of
the denture base with implants placed in the anterior and posterior region of the edentulous mandible.5)To compare
the displacement of the denture base with implants placed in the anterior and posterior region of the edentulous
mandible. Materials and Methods: The materials used were Nobel Biocare Mk III long implants 3.75x13mm and
short 5.0x7.0 implants, with O-ball head attachment. ANSYS: Version 8.0 software was used to create a threedimensional model of an edentulous mandible and the two implants. Three models were prepared having different
implant positions and locations. MODEL 1 Two long implants were placed interforaminally in lateral incisor region
one on either side, MODEL 2 Four long implants placed were interforaminally in the central incisor and canine
region two on either side and, MODEL 3 Two long implants were placed interforaminally in lateral incisor region one
on either side and two short implants were placed in premolar region 3mm posterior to the mental foramen, one on
either side. Two types of load were given ie. vertical load of 325N was applied in second premolar and first molar
region and 10N load at 150 angulation was applied in the anterior incisors area. The models were loaded separately
and stress pattern, amount of stresses and amount of displacement were analysed for each model. Results: The
observations obtained from the ANSYS software were analysed and evaluated. Model 3 showed the least amount
of stress and displacement as compared to the other models. Conclusion: When the implants were spread across
the arch both anteriorly and posteriorly, the stress induced in the bone and displacement of the denture base was
seen to be less.
Key Words: Implant, Load, Displacement, Stress.
Introduction
Edentulism leads to an acknowledged impairment of
oral function with both esthetic and psychological
changes. Severe atrophy of the inferior alveolar process
and underlying basal bone often results in other
problems with a lower denture such as, intolerance to
loading of the mucosa, pain, difficulty in eating and
speech, loss of soft tissue support, and altered facial
appearance.
14
Dang and Ram : Evaluation of the stress distribution and displacement of the denture
Method
The study was divided into following steps:I
Introduction T
o The Finite Element Analysis
To
Finite Element Analysis (FEA) is a computer-based
numerical technique for calculating the strength
and behaviour of engineering structures. The
behaviour of an individual element can be described
with a relatively simple set of equations. Just as
the set of elements would be joined together to build
the whole structure, the equations describing the
behaviours of the individual elements are joined
into an extremely large set of equations that
describe the behaviour of the whole structure. The
stresses will be compared to allowable or permissible
values of stress for the materials to be used, to see
if the structure is strong enough.
II
15
Dang and Ram : Evaluation of the stress distribution and displacement of the denture
Model 1- V
olume Modelling of Mandible
Volume
Model 2- V
olume Modelling of Mandible
Volume
16
Model 3- V
olume Modelling of Mandible
Volume
The overdenture was modeled as a SHELL element
(Shell 63 element). It had a modulus of elasticity
of 1.022x105 N/mm2 and poisons ratio of 0.3. It
was modeled as a two dimensional structure. The
Dang and Ram : Evaluation of the stress distribution and displacement of the denture
Material
Properties
Materials
Poissons
Yo u n g ' s
Modulus
(Mpa)
Ratio
Implant
114
0.34
Cortical Bone
14
0.35
Type A
2.5
0.3
Type B
1.5
0.3
Type C
0.5
0.3
Cancellous Bone
Results
The observations were statistically analysed to
comparatively evaluate the values obtained. The Stress
analysis executed by the Ansys software provided
results that enabled visualization of Compressive
stress, Von-Mises stress fields in the form of Colour
coded bands along with the Displacement. Each colour
band represented a particular range of stress value
which is given in Newton-mm2. The displacement
values were observed in mm.
17
Dang and Ram : Evaluation of the stress distribution and displacement of the denture
Model
Compressive
N
325N
Stress 325
Ve r t i c a l
Load
Resultant
Von Misses
Stress of
325N
Ve r t i c a l
Load
(Rounded)
0-1.2
351
0-261
0-0.9
260
0-160
0-1.1
159
DISPLACEMENT
mm
Displacement of Plate
W ith 325
N V
ertical
325N
Vertical
And 10
N Oblique Load
10N
Displacement of Plate
With 10
N Horizontal
10N
Load
Model 1
93
0.079
Model 2
46
0.026
Model 3
20
0.018
Graphs:
STRESS N/mm 2
Discussion:
Resultant V
on Misses Stress Induced In Bone
Von
18
Dang and Ram : Evaluation of the stress distribution and displacement of the denture
Conclusion
The study was conducted to evaluate the stress
distribution in bone and displacement of the denture
base with varied implant positions. Within the
limitations of the 3D finite element study the following
conclusions were drawn:
1. The stresses were maximum with two implants
placed in the anterior region.
2. The stresses were minimum when the implants
were spread anteriorly and posteriorly i.e. two
implants in the anterior region and two short
implants in the posterior region.
3. The stresses with four implants in the anterior
region were less than the two implants placed in
the anterior region but more than the four implants
spread anteriorly and posteriorly.
4. Maximum displacement of the denture base was
observed with two implants placed in the anterior
region.
5. Minimum displacement of the denture base was
observed with implants spread anteriorly and
posteriorly.
6. The displacement with four implants placed in the
anterior region showed less displacement as
compared with two implants placed in the anterior
region but more as compared to the four implants
placed anteriorly and posteriorly.
7. When the implants were spread across the arch
both anteriorly and posteriorly, the stress induced
in the bone and displacement of the denture base
was seen to be less.
References:
1.
2.
3.
4.
5.
19
Dang and Ram : Evaluation of the stress distribution and displacement of the denture
6.
7.
20
8.
9.
Meijer HJ, Starmans FJ, Steen WH, Bosman F. A threedimensional finite element study on two versus four
implants in an edentulous mandible. Int J Prosthodont
1994;7(3):271-279.
Visser A, Raghoebar GM, Meijer HjA, Batenburg RHK,
Vissink A. Mandibular implant overdentures supported by
two or four endosseous implants. A 5 year prospective
study. Clin Oral Impl Res. 2005:16;19-25.
REVIEW ARTICLE
Abstract
Although most malocclusions pertaining to irregularities of teeth resolve through moving teeth, occasional
malocclusions confront us with a disharmonious inter-jaw-relationship owing to faulty size and/ or faulty anteroposterior location of the jaws or dentoalveolar regions. These malocclusions do not always respond favorably to
conventional tooth moving appliances and are ideal candidates for appliances that have the capability of molding
bones as well as relocating them. Through this article, the authors outline a way that General Dentists can get
enough 'food for thought' for treating such cases on their own by using simple removable appliances. Additional
reading/training may be needed to get to use the functional appliances with felicity.
Key Words: Skeletal pattern, Growth amount, Growth direction, Construction bite, Appliance manipulation
Introduction
Assuming that one subscribes to the theory that moving
teeth is easier than moving bones, it follows that the
degree of success in rearranging relationship of jaw
bones will be decided by attempting corrective steps
well before peak-growth-velocity is over. Thus, late
mixed dentition may be the best period for a clinician
to aim to start correction of the commonest problem:
large overjet (8-10 mm and beyond) often accompanied
by deep overbite, narrow maxillary dental arch,
recessive chin and a seemingly prognathic or, better
still, an almost normal maxillary element.
Such Class II type of cases may be ideal ones for a
General Dentist (GD) to familiarize himself with in
using Myofunctional Appliances (also referred to as
Functional Appliances). Class III cases are as such more
Functional Appliances
These are muscle motivating appliances, often loose
fitting, which harness the natural forces of the orofacial
musculature that are transmitted to the teeth and
alveolar bone through the medium of the appliance.
Commonly used Functional Appliances include
Andresen's Activator12,13 (Fig.1), Balter's Bionator14
for
Correspondence:
Fig.1 : Activator
21
Fig.2 : Bionator
Fig.5 : Twin Block Appliance
22
Why Functional:
Irrespective of which functional appliance it is,
functional appliances are all based on same basic
principles (application, redirection and removal of force),
that of using Function Forces & of alternating their
direction, strength & duration. All of these appliances
are all muscle controlled even if screws & springs are
built in.
Development of Functional Appliances:
A major reason was recognition that function had an
effect on ultimate morphologic structure of dentofacial
complex 1 . Moss's Functional Matrix Theory 2 ,
contributions of Wolff on form & function, studies on
response of bone to functional forces by Kock,
Benninghof and ideas of Van Der Klauuw all
contributed in seeking to change and control the
direction of growth of the jaws in correcting imbalance
in the skeletal jaw bases.
These studies and several others paved a way in
proving that function plays a very important role in
controlling size & shape of bones in the membranous
bones of craniofacial area and especially more so in
regions of the alveolar base of jaws.
Effect of Functional Appliances:
Functional Appliances are unique not solely due to their
purported orthopedic effect influencing facial skeleton
of growing child in condylar & sutural areas as claimed
by several experts. They also exert an orthodontic effect
on dentoalveolar area. Unlike conventional appliances
which act on teeth using mechanical elements,
functional appliances act on dentoalveolar structures
by transmitting, eliminating or guiding natural forces
produced during various functions e.g. Swallowing,
Mastication, etc.
Functional Appliances help to reset the altered
equilibrium of the orofacial musculature and often help
in elimination of oral habits whilst being an effective
post-treatment retention appliance in certain types of
cases too.
23
Genesis of a V
ertical Problem: Consider the
Vertical
fact that as a child starts to mature in the dentofacial area, the chin position is governed by growth
in the dento-alveolar areas of posterior teeth. This
is akin to creating premature contacts posteriorly,
or, as in a situation created by progressive vertical
eruption of teeth. Hence, the chin tends to swing
downward and backwards: making it assume a
retrognathic character. This is counterbalanced by
growth in the mandibular condylar area which
tends to make the chin go upwards and forwards:
making it assume a prognathic character. When
the mechanism works well in unison, the result is
a normal, balanced face. When growth in posterior
alveolar areas radically exceeds that in the condylar
region, the result may be a High Angle Case with
a longish face. If the roles are reversed, a Low Angle
Case may be the outcome.
All things being equal, best cases to start with
Functional Appliances are when the FMA value is
within the normal range: between 22 to 28 or so.
(2) Status of Lower Incisor T
eeth
Teeth
Since the construction bite is taken in a protrusive
mode for Class II cases, there is always a tendency
for the lower anterior teeth to be proclined. Hence,
in case selection, an important criterion is that
the lower anterior teeth should be either 'straight'
(sometimes also called as 'upright') or even
Retroclined rather than be in a state of proclination.
There should also be absence of any lower incisor
crowding.
(3) Positive Clinical VTO
VTO stands for Visual Treatment Objective. In
essence, this clinical test is an advance indication
of the projected/anticipated efficiency of the
attained result. Since it is a very accurate way to
determine if the treatment result will make a
positive effect on the personality change attempted,
it is an invaluable clinical advance planning tool
in clinical practice: especially since it does not need
any specialised equipment.
When a patient with large overjet is to be treated with
a functional appliance, the clinician needs to:
(a) Have the patient sit upright facing the clinician.
Patient must be at rest with the lips in their
normal unstrained position and the teeth in the
Centric Occlusion. If the patient can be relaxed
enough to give a physiological rest position, so much
the better. Patient is now observed and preferably
photographed from the:
24
25
Bibliography
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
16.
18.
26
14.
15.
17.
REVIEW ARTICLE
Abstract
Pulp therapy helps in preserving a pulpally involved primary tooth by eliminating bacteria and their products and
ensures hermetic seal of the root canals so that the primary tooth can complete its function without harming the
successor or affecting the health of the patient. A thorough understanding of the pulp morphology and root formation
and resorption in primary teeth as well as different materials and techniques used is imperative for a successful
pulp therapy. One of the major areas of continued research is in the area of finding obturating materials to suit the
specific properties of these teeth. This article seeks to present a review of the major obturating materials and
techniques with their modifications as well as their advantages and disadvantages.
Key words: Pulp therapy, Primary teeth, Obturation materials and techniques
Introduction
A dentist who provides emergency or restorative care
for children will inevitably encounter a situation where
a primary tooth has a pulp exposure.1 This could be
from a traumatic injury or as the result of a mechanical
or a carious pulp exposure. Pulp therapy for deciduous
teeth aims to preserve the child's health and to
maintain deciduous teeth in a functional state until
they are replaced by permanent teeth.2 The main
objective of endodontic treatment is total elimination
of micro-organisms from the root canal, and the
prevention of subsequent re-infection. This is achieved
by careful cleaning and shaping followed by the
complete obturation of the canal space.3 However, the
complex morphology of the root canal system in
deciduous teeth makes it difficult to achieve proper
cleansing by mechanical instrumentation and
irrigation of the canals.2 So, in order to increase the
chance of success of the endodontic treatment,
substances with antimicrobial properties are frequently
used as root canal filling materials in deciduous teeth.2
Senior Lecturer1
Senior Lecturer2
Reader 3
Senior Lecturer4
Senior Lecturer5
Department of Pediatric Dentistry
MGM Dental College and Hospital, Kamothe, Navi Mumbai.
27
concentrations Eugenol is said to have antiinflammatory and analgesic properties that are very
useful after a pulpectomy procedure. Since 1930's zinc
oxide Eugenol has been the material of choice. However,
it has certain disadvantages like slow resorption,
irritation to the periapical tissues, necrosis of bone and
cementum and alters the path of eruption of
succedaneous tooth.5 Colla J (1985) found that zinc oxide
may alter the path of eruption of succedaneous
permanent.6 Erasquin (1967) reported occurrence of
necrosis of cementum, bone and inflammation of
periapical tissue.7 Robin L W studied unresorbed zinc
oxide Eugenol was surrounded by several layers of
condensed cellular tissues. This was composed of inner
layer of tightly packed cells and outer layer of fibroblast
with chronic inflammatory cells. Segmentation of mass
occurs by ingrowth of collagen and fibroblast forming
septa. Within the septa sequestration of zinc oxide is
seen into smaller masses.8
Research is going on in this area to improve the
properties of zinc oxide Eugenol by adding antibacterial
substances or by altering it with other materials.
Success rates were reported after obturating with Zinc
Oxide Eugenol cement by various authors as follows 82.3%- Barr et al9 82.5% - Gould10 86.1% Coll et al.11
Formocresol, Formaldehyde and Paraformaldehyde
and cresol have been tried out 12 to improve the
properties and success of zinc oxide Eugenol, but the
addition of these compounds neither increased the
success rate nor made the material more resorbable
as compared to zinc oxide Eugenol alone.13
A study was conducted in which iodoformized zinc oxide
Eugenol was tested for its antibacterial effect against
the aerobic and anaerobic bacteria and was found to be
effective for both the aerobic and anaerobic bacteria of
the root canals of deciduous teeth with maximum
sustaining period of 10 days.14
A combination of zinc oxide powder and calcium
hydroxide paste for obturation of primary teeth has
shown promise in a short term study by Chawla15. They
found that the obturated material remained up to the
apex of root canals till the beginning of physiologic root
resorption. Also the material was found to resorb at
the same rate as teeth. Combination of calcium
hydroxide, zinc oxide, and 10% sodium fluoride solution
has been tested in a clinical study. It was observed
that the rate of resorption of this new root canal
obturating mixture was quite similar to the rate of
physiologic root resorption in primary teeth.16
Iodoform pastes have better resorbability and
disinfectant properties17,18,19 than ZOE, but they may
28
29
30
PROPERTIES
ZINC OXIDE
KRI PASTE
VITAPEX
Resorption
Slow as compared to
physiologic root
resorption3
Harmless
Harmful7
Harmless14
Harmless
Overfill resorption
Antimicrobial
Weak antibacterial
Best antibacterial
Weak antibacterial
Easily removed
Difficult to remove
Easily removed
Easily removed3
Radiopaque
Radiopaque on
radiograph
Radiopaque on radiograph
Radiopaque on radiograph
Discolouration
No discolouration
Causes discolouration16
No discolouration
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Conclusion
It has been found that the current obturating materials
for primary teeth while providing satisfactory clinical
results still need to be modified to suit the various
clinical situation that are encountered. Due to the
drawbacks of Zinc oxide eugenol material several other
materials have been investigated and various
combinations tried with some degree of success. The
current combinations of calcium hydroxide and
iodoform seem to provide better results than zinc oxide
eugenol cements. Similarly several obturation
techniques have been used with success, with rotary
slow speed lentilospiral being most satisfactory. Even
recently Navitip has been used for obturation with
good success. However, further controlled studies and
research is required to find the ideal obturating material
and techniques for primary teeth.
Journal of Contemporary Dentistry
17.
18.
19.
20.
21.
22.
23.
31
32
REVIEW ARTICLE
Abstract
Oral lichen planus (OLP) is a chronic mucosal condition commonly encountered in clinical dental practice. Lichen
planus is believed to represent an abnormal immune response in which epithelial cells are recognized as foreign,
secondary to changes in the antigenicity of the cell surface. It has various oral manifestations, the reticular form
being the most common. The erosive and atrophic forms of OLP are less common, yet are most likely to cause
symptoms. Topical corticosteroids constitute the mainstay of treatment for symptomatic lesions of OLP. Recalcitrant
lesions can be treated with systemic steroids or other systemic medications. However, there is only weak evidence
that these treatments are superior to placebo. Given reports of a slightly greater risk of squamous cell carcinoma
developing in areas of erosive OLP, it is important for clinicians to maintain a high index of suspicion for all intraoral
lichenoid lesions. Periodic follow-up of all patients with OLP is recommended.
Key words: Diagnosis of OLP, Review
Introduction
Lichen planus is a relatively common disorder,
estimated to affect 0.5% to 2.0% of the general
population.1 It is a chronic, inflammatory disease that
affects mucosal and cutaneous tissues. Approximately
half of the patients with cutaneous lichen planus have
oral involvement.2 However, mucosal involvement can
be the sole manifestation in up to 25% of affected
population.2 Oral lichen planus has a peak incidence
in middle age patients and has female predominance
of 2:1. 3 It is characteristically associated with
persistent clinical course and resistance to most
conventional treatments.
A s y m p t o m a t i c Reticular
Description
Symptomatic
Clinical Features
There are various clinical morphological
manifestations of the disease (Table 1). More than one
clinical subtype can co-exist in the same patient. The
reticular (92%), plaque (36%) and papule (11%) types
are usually asymptomatic and require no specific
Clinical
types
Papules
Atrophic
Erosive
Bullous
Differential Diagnosis
The diagnosis of OLP can be rendered more confidently
when characteristic cutaneous lesions are present.
Except for the pathognomonic appearance of reticular
33
Clinical Significance
OLP is one of the most common mucosal conditions
affecting the oral cavity.8 Therefore dentists in clinical
practice will regularly encounter patients with this
condition. Because patients with the atrophic and
erosive forms of OLP typically experience significant
discomfort, knowledge of the treatment protocols
available is important. The similarity of OLP to several
34
Treatment
There is currently no cure for OLP. Excellent oral
hygiene is believed to reduce the severity of the
symptoms, but it can be difficult for patients to achieve
high levels of hygiene during periods of active disease.
Treatment is aimed primarily at reducing the length
and severity of symptomatic outbreaks. Asymptomatic
reticular and plaque forms of OLP do not require
pharmacologic intervention. Algorithm for the
management of oral lichen planus is shown in Fig. 1.21
Corticosteroids
The most widely accepted treatment for lesions of
OLP involves topical or systemic corticosteroids to
modulate the patient's immune response. Topical
corticosteroids are the mainstay in treating mild to
moderately symptomatic lesions. Options (presented
in terms of decreasing potency) include 0.05%
clobetasol propionate gel, 0.1% or 0.05% betamethasone
valerate gel, 0.05% fluocinonide gel, 0.05% clobetasol
butyrate ointment or cream, and 0.1% triamcinolone
acetonide ointment.22 Patients are instructed to apply
a thin layer of the prescribed topical corticosteroid up
to 3 times a day, after meals and at bedtime. The gel
or ointment can be applied directly or can be mixed
with equal parts Orabase(a gelatin-pectin-sodium
carboxymethylcellulose-based oral adhesive paste,
ConvaTec, Division of Bristol-Myers Squibb, Montreal,
Que.) to facilitate adhesion to the gingival tissues. These
solutions can be prepared by a compounding pharmacy.
Patients should be instructed to gargle with 5 mL of
the solution for 2 minutes after meals and at night.
After rinsing, the solution should be expectorated, and
nothing should be taken by mouth for one hour.
Alternative delivery methods include the use of custom
trays to serve as reservoirs for the corticosteroid. The
advantage of topical steroid application is that side
effects are fewer than with systemic administration.
Adverse effects include candidiasis, thinning of the oral
mucosa and discomfort on application. Topical
35
Conclusion
Patients with OLP should be counselled as to the nature
of this chronic condition and the different approaches
to treatment. Patients should be informed that they
may experience alternating periods of symptomatic
remission and exacerbation. Clinicians should maintain
a high index of suspicion for all intraoral areas that
appear unusual, even in patients with a histologically
confirmed diagnosis of OLP. This vigilance is especially
important for isolated lesions occurring in locations at
higher risk for the development of squamous cell
carcinoma, such as the lateral and ventral surfaces of
the tongue and the floor of the mouth.
2.
3.
4.
5.
6.
36
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
References
1.
7.
21.
22.
23.
24.
25.
REVIEW ARTICLE
Abstract
In modern world, to spread the confusion and panic among the people terrorist can use biological weapon. In such
Bioterrorism attack health professionals plays a key role. This paper reviews the historical aspect, definition,
classification of bioterrorism agents and the role of dentistry in such catastrophic event.
Key Words: Bioterrorism agents, Medical community
Introduction
Historical aspect
Biological terrorism dates as far back as Ancient Rome,
when faeces were thrown into faces of enemies7. This
early version of biological terrorism continued till the
14th century where the bubonic plague was used to
infiltrate enemy cities, both by instilling the fear of
infection in residences, so that they would evacuate,
and also to destroy defending forces that would not
yield to the attack. Over time, biological warfare
became more complex. Countries began to develop
weapons which were much more effective, and much
less likely to cause infection to the wrong party. One
significant enhancement in biological weapon
development was the first use of anthrax. Anthrax
effectiveness was initially limited to victims of large
dosages7. The development of biological weapons
became much more focused in the 20th century. During
World War I, Germany was thought to have employed
the agents of cholera and plague against humans and
anthrax and glanders against livestock8. In the period
between World Wars I and II, a number of countries,
including the USSR, Japan, and the United Kingdom,
stepped up their biological warfare research programs.
The Japanese effort was notable, with a number of
military units engaged in offensive biological weapons
research until the end of World War II. During the era
of Cold War, the Soviet Union as well as Iraq
independently developed their successful biological
weapon programs9. However, in 1972, Washington and
Moscow had agreed by treaty to give up biological
37
Category C
These third highest priority agents include emerging
pathogens that could be engineered for mass spread in
the future because:
They are easily available
They are easily produced and spread
They have potential for high morbidity and
mortality rates and major health impact.
Bioterrorism agents name is given in Table 1.
What is bioterrorism?
According to Center of Disease Control and Prevention
- A bioterrorism attack is the deliberate release of
viruses, bacteria, or other germs (agents) used to cause
illness or death in people, animals, or plants. These
agents are typically found in nature, but it is possible
that they could be changed to increase their ability to
cause disease, make them resistant to current
medicines, or to increase their ability to be spread into
the environment. Biological agents can be spread
through the air, through water, or in food. Terrorists
may use biological agents because they can be extremely
difficult to detect and do not cause illness for several
hours to several days. Some bioterrorism agents, like
the smallpox virus, can be spread from person to person
and some, like anthrax, cannot5.
Category B
Category C
Anthrax
(Bacillus
anthracis)
Brucellosis
(Brucella
species)
Emerging
infectious
diseases
such as
Botulism
(Clostridium
botulinum toxin)
Epsilon toxin
of Clostridium
perfringens
Nipah virus
Plague
(Yersinia
pestis)
Hantavirus
Smallpox
(variola major)
Glanders
(Burkholderia mallei)
Tularemia
(Francisella
tularensis)
Melioidosis
(Burkholderia
pseudomallei)
Viral hemorrhagic
fevers (filoviruses
[e.g., Ebola,
Marburg]
Psittacosis
(Chlamydia
psittaci)
Arenaviruses
[e.g., Lassa,
Machupo])
Q fever
(Coxiella burnetii)
Ricin toxin from Ricinus
communis (castor beans)
Staphylococcal
enterotoxin B
Typhus fever (Rickettsia
prowazekii)
Viral encephalitis
(alphaviruses
[e.g., Venezuelan
equine encephalitis,
eastern equine
encephalitis,
western equine
encephalitis])
Category B
These agents are the second highest priority because:
38
Conclusion
Dentistry has an important role to play in the response
to a significant bioterrorism attack. With adequate
preparation, dentistry's valuable assets in terms of
personnel and facilities can help in determining that a
bioterrorist attack has occurred and in responding to
that attack. The profession should develop a disaster
response plan that can be integrated into each
community's disaster response plan.
References
1.
2.
39
CASE REPORT
Abstract
The case report describes the treatment of maxillary central incisors with open apex, due to apical root resorption,
as a consequence of trauma experienced three years earlier. Open apices pose a challenge during endodontic
treatment. Several materials and methods have been widely studied and tried in the past. Obtaining an adequate
apical seal is of paramount importance regardless of the material or technique used. In the present case the
involved teeth were treated nonsurgically using white Mineral Trioxide Aggregate (MTA) as an artificial apical barrier.
The treated teeth were asymptomatic and the follow up clinical and radiographic examination showed healing with
apparent regeneration of periradicular tissues. Extrusion of MTA beyond the root end was not an obstacle in the
healing process. MTA can be considered an effective material to treat infected open apex teeth with large periapical
lesions.
Key Words: Open apex, Periapical lesion, MTA, Non surgical method.
Introduction
Root canal treatment of teeth with open apices is
challenging. Conventional root canal filling techniques
rely considerably on the presence of apical constriction,
against which gutta-percha can be optimally
compacted. In the absence of apical constriction due to
incomplete root formation, apical resorption or over
instrumentation, inevitably there is extrusion of
obturating material which could compromise the long
term healing outcome of treatment. The treatment
options have been either to induce apex formation or
resort to surgical technique. Surgical method is more
radical involving incision, flap reflection, root resection
and root end filling placement, causing certain amount
of discomfiture to patient. Traditionally long term
calcium hydroxide (CH) apexification has been used
to induce apical closure and takes anywhere between
3-18 months1. Despite its high success rate it has
Professor 1
Professor 2
Lecturer 3
Department of Conservative dentistry and Endodontics
MGM Dental College & Hospital, Kamothe,
Navi Mumbai
Address for Correspondence:
Dr. Sumanthini M.V
Professor
Department of Conservative dentistry and Endodontics
MGM Dental College and Hospital, Kamothe, Navi Mumbai
Mob: 9869433642
Email: marg_suman@yahoo.com
40
Sumanthini et.al : Management of non vital maxillary central incisors with open apex using Mineral Trioxide Aggregate
Case report
A young lady aged 21 years was referred to outpatient
clinic, Department of Conservative Dentistry and
Endodontics with a chief complaint of continuous
throbbing pain in relation to maxillary central incisors
(11 and 21) since two days, discoloration and pus
discharge from the palatal aspect, in relation to
maxillary central incisors since one year (Fig.1).
Patient gave a history of trauma 3 years ago. On
examination, 11 showed discoloration and Ellis class 3
fracture involving mesial angle. While 21 had brownish
discoloration. Both teeth were tender on percussion,
with a sinus tract in the palatal aspect and non vital.
The teeth 13,12,22 and 23 responded normally to
vitality tests. Following clinical and radiological (Fig.2)
examination a diagnosis of chronic periradicular
abscess, with an acute exacerbation was made.
Radiograph revealed apical root resorption with an open
apex in both the teeth in question. Medical history was
non contributory.
All treatment procedures were carried out under rubber
dam isolation. Root canal access cavities were
prepared in 11,21 and the canals were explored.
Copious pus exuded through the canal of 21. Both teeth
Fig. 2 - Preoperative
radiograph,
note
the
periapical lesion in 21,
indicated by the arrow.
Fig. 4 - Radiograph
showing MTA apical plug
placement in 11 and 21.
Fig. 5 - Radiograph
showing obturation of 11
and
21
note
the
extrusion
of
MTA
indicated by the arrow.
41
Sumanthini et.al : Management of non vital maxillary central incisors with open apex using Mineral Trioxide Aggregate
42
Discussion
Traumatic injury to mature teeth results in pulp
necrosis due to periapical neurovascular supply damage
.When injury damages the protective layer of
precementum, inflammation of pulp or periodontium
will induce resorption in root and bone as the microbial
toxins can pass through the dentinal tubules and
stimulate an inflammatory response. In the present
case, the maxillary central incisors had open apices
caused due to apical root resorption and chronic apical
abscess in 11 and 21 respectively as a result of trauma
induced apical periodontitis and pulp necrosis. The
objective here is to control infection and induce apical
closure.CH as an intracanal dressing has been the most
widely used and clinically accepted for over 40 years.
Recent research evidence has demonstrated that the
long term calcium hydroxide apexification treatment,
significantly reduces the fracture resistance of the
tooth3.This is attributed to decreased organic support
of dentin matrix leading to disruption of the bond
between the collagen fibrils and hydroxyapatite
crystals that negatively influence the mechanical
properties of dentin. In the present case calcium
hydroxide was used for a short duration as an
intracanal medicament since it is known to
significantly reduce the endodontic micro flora without
compromising the fracture resistance of dentin.
Calcium hydroxide when placed for not more than 30
days does not cause any deleterious effect on dentin2.
Bidar etal found in their study that medication with
calcium hydroxide improved the marginal adaptation
of MTA8. Shabahang et al in their animal studies
demonstrated a more predictable healing outcome
when MTA is used to obturate open apex teeth when
compared with teeth treated with calcium
hydroxide9.MTA represents a contemporary version of
the primary monoblock in attempts to strengthen
immature tooth roots. Although MTA does not bond to
dentin interaction of the released calcium and hydroxyl
ions of MTA with a phosphate containing synthetic body
fluid results in formation of apatite like interfacial
deposits. These deposits improve the frictional
resistance of MTA to the root canal walls and accounts
for the seal of MTA in orthograde obturation and
perforation repair10.
Following the calcium hydroxide medication the
patient was asymptomatic and there was cessation of
pus discharge from the canal. A 4mm MTA apical plug
was placed in both the incisor teeth. Invitro studies
have suggested that a 4-5mm of MTA plug is sufficient
to provide an adequate seal. This is also supported by
retrospective studies under taken to evaluate the
treatment outcomes of artificial apical barrier with
MTA in teeth with immature apices 11,12. The
biocompatibility of MTA is well documented. It
promotes the formation of cementum coverage over
Sumanthini et.al : Management of non vital maxillary central incisors with open apex using Mineral Trioxide Aggregate
Summary
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
References
1.
2.
15.
43
CASE REPORT
Abstract
Factitious or self-induced injuries are inflicted based on habit, frequently associated with psychogenic background;
related only in manner by which they are produced, bearing no particular anatomic, etiologic or microscopic
similarities. The following case report attributes a suspicious periodontal lesion to self-induced injury.
Key words: Factitious, Self-induced injury.
Introduction
A Factitious or self-induced injury of the periodontal
tissues occur with repeated voluntary trauma to
localized areas with toothbrushes, pacifiers, fingernails,
pens, toothpicks, eyeglass stems and other provocative
habits1. These mechanical injuries by secondary
infection and inflammatory disease manifest as a
localized recession to advanced bone loss if not
intercepted1. The etiology, frequency and force exerted
by the habit in addition to prevailing periodontal health
dictate the course of response to therapy1. The case
presented herewith showcases such elements testing
diagnostic acumen.
Case Report:
A thirteen year-old male patient reported with an ulcer
in the mouth since one month. The patient had a
decayed tooth in the right lower posterior jaw region
for which root canal treatment was initiated six months
ago but not completed. The patient became
symptomatic with pain in relation to the same tooth
since a month and a gum boil had appeared in the
gums adjacent to the same concerned tooth at the same
time. The patient ruptured the boil and continued to
Reader 1
Professor 2
Professor and Head3
Lecturer 4
Department of Periodontics,
M.G.M Dental College & Hospital,
Navi Mumbai 410 209.
Address for Correspondence:
Dr.Vineet Kini, M.D.S,
Department of Periodontics,
M.G.M Dental College & Hospital,
Navi Mumbai 410 209.
Mob.: 9769804390
E-mail: drvinkin@gmail.com
44
Conclusion
Baffling history and clinical picture could mask a selfinduced injury. In the present case the patient
developed a habit of traumatizing his periodontal soft
tissues with foreign objects; contributing towards a
self-induced etiology for present lesion. The causative
factor could not have been ascertained undisputedly if
it were not for the patient's confession. This highlights
the crucial role of interview and observation in
diagnosis.
Discussion
The presence of a large ulcer in the mouth conspicuous
by its isolated solitude, sharp contrast to normal
background was intriguing. This, supported by the
history given by the parent in regards to the patients
reported habit of traumatizing himself in the area
concerned with foreign objects was cause to suspect
factitious injury.
This features concurred with the suggestions of Stewart
and Kernohan2 as criteria for diagnosing self inflicted
gingival injury, considering that the area was easily
accessible to the patient. Contrary to the opinion that
such lesions occurred in unusually grouped multiple
numbers, solitary lesions were also found to meet such
criteria2.
Figure 2.
interlude
The
same
site
following
three
weeks
References
1.
2.
3.
4.
45
CASE REPORT
Abstract
Compound odontomas are considered as hamartomatous malformation rather than true neoplasms & are
generally asymptomatic . The exact etiology is unknown and is often associated with the overretained deciduous
teeth, most commonly in maxillary anterior region. In this case, multiple denticles or rudimentary teeth numbering
42 were enucleated from the mandibular symphysis region of 17 yr old female which makes this case rare and
unusual. Evidence of concrescence, fusion, dilaceration were observed in the denticles enucleated, the size of
which ranged from 2mm to 10mm.
Key Words: Odontoma, Compound Odontoma, Denticles, Hybrid Odontoma, Impacted Teeth
Introduction
Odontomas are considered as developmental anomalies
arising from completely differentiated epithelial and
mesenchymal cells that give rise to ameloblast &
odontoblast. They are hamartomatous lesions rather
than true neoplasms.1 The term 'odontoma' was coined
by Paul Broca in 1867 which by definition alone refers
to any tumour of odontogenic origin. Most of the
odontomas are asymptomatic, although some signs &
symptoms relating to their presence may occur. The
compound composite odontomas are a malformation
in which all the dental tissues are in a more orderly
pattern than in the complex odontoma so that the lesion
may consist of many tooth like structures.2 Compound
odontomas are generally most commonly seen in
maxillary anterior region with denticles varying from
4-28. 3 The sheer number of denticles extracted
Reader 1
Professor2
Reader 3
Case History
A 17 yr old female presented with chief complaint of
malaligned mandibular anterior teeth (Fig.1). Patient
was asymptomatic without any specific complaint. On
examination she had over retained lower deciduous left
central incisor, partially erupted and medially tipped
lower left permanent lateral incisor with missing
canine. The mandibular right central incisor was
tipped labially. Patient was advised orthopantamogram
for further treatment. OPG showed multiple tooth like
structures of different size and shape in relation to root
of mandibular anterior teeth in the symphysis region
which was surrounded by circumscribed radiolucent
zone. There was displacement of permanent right
mandibular central incisor(Fig.2). The left mandibular
lateral incisor was displaced and the canine was
impacted apical to the premolars. Upon the clinical
and radiographic findings a provisional diagnosis of
compound composite odontoma was made. It was
Lecturer4
Post graduate5
Post graduate6
Dept Oral and Maxillofacial Surgery,
MGM Dental College and Hospital, Navi Mumbai.
Address for Correspondence:
Dr. Sushrut Vaidya,
Reader
Dept Oral and Maxillofacial Surgery,
MGM Dental College and Hospital, Navi Mumbai.
Mob.: 9869160530
E-mail: ezeesush79@gmail.com
46
Discussion
The term odontoma by definition refers to a benign,
mixed, calcified tumour of odontogenic origin. The
absolute incidence of odontogenic tumours varies from
0.002% to 0.1%4 out of which odontomas constitute
about 22%,5 of which 10% are compound odontomas.
There are essentially 2 types of odontomas:
1) Complex composite odontoma
2) Compound composite odontoma
47
48
References
1.
CASE REPORT
Infiltrative T
ype of Bone Invasion in Oral Squamous Cell Carcinoma
Type
C ase R eport
Jigna Pathak1, Niharika Swain2, Shwetha Kumar3
Abstract
Oral squamous cell carcinoma (OSCC) is a well known malignancy which accounts for more than 90% of all oral
cancers. OSCC are malignant tumors that frequently invade bone and bone invasion is a common clinical problem.
Bone invasion by oral squamous cell carcinoma may progress by either an infiltrative or an erosive histological
pattern. The pattern of bone invasion co-relates with the clinical behavior of OSCC thus having a potential prognostic
value. The present case report is of a 35-year- old female patient presenting with a lesion in the lower right buccal
vestibule which was histopathologically confirmed as OSCC.The type of bony invasion was also assessed
microscopically. The objective of this paper was to define the characteristics associated with each histological
pattern of invasion and its significance when reviewing oral squamous cell carcinoma with mandibular invasion.
Key Words: Oral cancers, Osteoclastogenesis, Osteoprotegerin
Introduction
OSCC is the sixth most common cancer and more than
3, 00,000 new cases are diagnosed each year world wide.1
Oral carcinoma of the mandibular region has been
defined as carcinoma of the mandibular alveolar ridge,
lower buccal sulcus, sublingual sulcus and mandibular
retro molar trigone.2 Carcinoma at this site may
eventually progress to directly invade the mandible, a
feature associated with a worse prognosis. Mandibular
invasion is one criterion of the American Joint
Committee on Cancer classification for the most
advanced primary stage (T4) and overall stage (IV) for
these tumors. The 5-year determinate survival of
patients with stage IV oral lesions has been
demonstrated to be 39%, as compared with 53%, 68%,
and 70% for stages III, II, and I disease, respectively.3
OSCC invades the mandibular bone through an
erosive, infiltrative or mixed pattern that correlates
with clinical behavior. The erosive pattern is
characterized by a broad, expansive tumor front with
a sharp interface between tumor and bone. In contrast,
the infiltrative pattern is composed of nests of tumor
cells with fingerlike projections along an irregular
tumor front. The recent distinction between these two
histological patterns challenges the previously held
Professor 1
Senior Lecturer2
Senior Lecturer3
Department of Oral Pathology,
MGM Dental College and Hospital, Navi Mumbai
Address for Correspondence:
Dr. Jigna Pathak
501, Pleasant View Society, Plot 56/57
Sector-14, Vashi, Navi Mumbai-400703
Mobile: +919819175805
E-mail: drjignapathak@gmail.com,
Case report
A 35-year-old female patient reported in MGM dental
college and hospital with a chief complaint of a non
healing cut in lower right cheek since the past 3-4
months. Past medical history was non contributory.
The patient had habit of chewing tobacco since the past
20 years. She also had history of Misheri application
on teeth and gums since the past 20-25 years. There
was no history of trauma, sinus or pus discharge.
Extraoral examination revealed a very mild facial
deformity with a diffuse swelling in the right side of
the face. Ipsilateral cervical lymphadenopathy (level
IB) was also noticed. Intraorally there was presence of
a linear endophytic lesion extending from lower right
first premolar to lower right third molar region in the
gingivo- buccal sulcus region.(Fig. 1) Additional feature
i.e. Grade II mobility of teeth from mandibular right
third molar to mandibular left canine was seen. On
radiological examination, Orthopantamogram (OPG)
revealed an ill-defined radiolucency extending from
mandibular right third molar (48) to mandibular right
canine (43). Computed tomography (C.T scan) showed
an osteolytic lesion involving the right side of the
mandible crossing the midline. (Fig.2) A provisional
diagnosis of Squamous Cell Carcinoma involving the
bone was given. Incisional biopsy was taken. The
histopathological report of well differentiated SCC was
49
Pathak et.al. : Bone Invasion in Oral Squamous Cell Carcinoma - A Case Report
50
Pathak et.al. : Bone Invasion in Oral Squamous Cell Carcinoma - A Case Report
By
RANKL
(Receptor activator of nuclear
Factor kB ligand)
RANK
(receptor)
Hemopoetic Osteoclast
progenitor, mature
Osteoclasts, chondrocytes &
Mammary gland epithelial cells
OSTEOPROTEGERIN
Regulated
Osteoblasts and
stromal cells
Thus a balance between expression levels of RANKL and OSTEOPROTEGERIN is crucial because both are produced by the same
cells.
PTHrP
Il-6
STROMAL CELLS
CANCER CELLS
IL-6
OSTEOCLASTS
BONE RESOPTION
Discussion
OSCC is a well known malignancy which accounts for
more than 90% of all oral cancers. The annual
estimated incidence is around 275000 for oral and
130300 for pharyngeal cancers excluding nasopharynx.
In high risk countries like Sri Lanka, India, Pakistan
and Bangladesh, OSCC is the most common cancer in
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Pathak et.al. : Bone Invasion in Oral Squamous Cell Carcinoma - A Case Report
Conclusion
The infiltrative pattern intuitively appears to be an
aggressive tumor that is difficult to resect surgically.
The intraoperative and preoperative determination of
invasion pattern remains problematic. If the
preoperative imaging studies do show radiographic
characteristics suggesting an infiltrative pattern such
as an irregular front or bone spicules, a wide surgical
margin should be taken around the grossly apparent
tumor. Pattern of invasion provides important
prognostic information and therefore should be
routinely commented on by pathologists reviewing cases
with mandibular bone invasion.
In addition, new approaches have been developed to
examine cellular and molecular mechanisms of bone
invasion by OSCC. Inhibition of osteoclast
differentiation and function by blocking RANKL and
RANK by inhibitor antibody constitutes a novel
approach to development of target therapy.
References
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