ISSN No: 2456-8872 Pacific Journal of Dentistry 2 Iss 4 Jan.pdfPacific Dental College & Hospital , Udaipur Pacific Journal of Dentistry Editor Editorial Board Dr. Saurabh Goel MDS,

Pacific Journal of Dentistry


UdaipurVolume 2 Issue 4 January-March 2019

ISSN No: 2456-8872

Pacific Dental College & Hospital , Udaipur


Editor

Editorial Board

Dr. Saurabh GoelMDS, Ph.DDept. of Oral Medicine & RadiologyPAHER [email protected]

Dr. Ajay PariharMDSDept. of Oral Medicine & RadiologyMP Medical University, [email protected]

Dr. Mohit Pal Singh on behalf of Pacific Academy of Higher Education and Research University, Udaipur, Rajasthan

Printed & Published byYuvraj Papers

11-A, Indra Bazar, Nada Khada,Near Bapu Bazar, Udaipur

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Printed atPublished atPacific Dental College & HospitalAirport Road, Debari, Udaipur

Rajasthan - 313024Email : [email protected]

Dr. Mohit Pal SinghMDS

Dept. of Oral Medicine & Radiology, PAHER [email protected]

Dr. Vivek Sharma, MDS, Dept.of Prosthodontics, RUHS, [email protected]

Dr. Bhagavandas Rai, MDS,

Dept. of Oral & Maxillofacial Surgery, PAHER University, [email protected]

Dr. Balaji Manohar, MDS,

Dept. of Periodontics & Implantology, PAHER University,

[email protected]

Dr. S Y Rajan, MDS, Dept.of Oral Medicine & Radiology, RUHS, [email protected]

Dr. Meenakshi T, MDS,

Dept. of Prosthodontics, RUHS,

[email protected]

Dr. Sapna Hegde, MDS,

Dept.of Pedodontics, PAHER University,

[email protected]

Dr. Junaid Ahmed, MDS, Dept.of Oral Medicine & Radiology,Manipal University, [email protected]

Dr. Sandeep Metgud,MDS,

Dept.of Conservative & Endodontics, PAHER University,

[email protected]

Dr. Rashmi Metgud, MDS,

Dept.of Oral Pathology, PAHER University,

[email protected]

Dr. Nagesh Bhatt, MDS,

Dept.of Community Dentistry, PAHER University, [email protected]

Dr. Hemant MathurMDS

Dept. of Oral Medicine & RadiologyPAHER University

[email protected]

Associate Editor in Chief Assistant Editor in Chief

By definition Journalism is the production and distribution of reports on the interaction of events, facts, ideas that

informs the society to at least some degree. Dentistry is a branch of Medicine that is involved in the study,

diagnosis, prevention and treatment of diseases of oral cavity, most commonly dentition (teeth), oral mucosa and

paraoral structures. The other terms form for study of dentistry is an ancient as the history of humanity. There are

evidences dating back to 7 – 9 thousand years back of teeth being drilled. Remains of Harappan periods and Indus

valley civilization show as such evidences. Since then mankind has evolved to present state of development,

where dentistry has evolved leaps and bounds. Now is the era of research and development and where evidence

based practice of dentistry is the need of hour.

Journal of an association is the media that brings the professional researcher and academicians on a common

platform to exchange their views and professional expertise. It is a peer reviewed dental journal with separate

seeding for original research, case report and review articles. We are launching website of the journal and

upgrading it to national level from this issue. We are trying our level best to restore back its status.

Pacific Journal of Dentistry (PJD) is an official journal of Pacific Academy of Higher Education & Research,

Udaipur. Journal has been designed keeping in mind need for all the dental specialties & journal places an

emphasis on publishing high quality and novel research. Any suggestions or comments regarding improvement

in journal are always welcome.

Dr. Mohit Pal Singh

Editor in chief

Editorial

(AN OFFICIAL JOURNAL OF PACIFIC ACADEMY OF HIGHER EDUCATION & RESEARCH)


Guidelines for Authors

General Information

Manuscripts are accepted for consideration with the understanding that they are only the work of the author(s) stated; that they have been submitted solely to Pacific Journal of Dentistry; that they have not been previously published or presented elsewhere, either in whole or in part; and that the findings have not been posted online. The editors reserve the right to make editorial changes in all matter published in the Journal and cannot enter into correspondence about manuscripts not accepted for publication. The editors, editorial board, sponsoring organizations, and publishers are not responsible for the statements expressed by authors in their contributions.

Pacific Journal of Dentistry decisions are independent, unbiased by scientific or national prejudices of particular individuals. The judgment about which papers are to be published is made by Pacific Journal of Dentistry editors, not its referees. The editors see all the papers and have a broader perspective to make a decision on a paper, while referees are experienced in one field and see a small part of submitted papers. Moreover, as we are over-subscribed and can only consider papers in certain subject areas, submissions might be declined without being sent for review. Policy on such matters is directed by the editorial board and the publisher, and is formulated to maximize the impact of the journal as well as control the number of papers sent out for review. In such cases, we deliberately reply within a matter of days, so that authors can quickly resubmit the paper elsewhere, and most authors appreciate this. If an author is unsatisfied with the decision on the manuscript, he or she can write to the Editor via the Contact us in their profile, citing the manuscript reference number, and wait for their response. Meanwhile, the manuscript must not be submitted for publication elsewhere.

If your question is not addressed on these pages then you may contact the Pacific Journal of Dentistry editorial office

The Editors invite contributions to the following sections of the Journal:

Editorials

Review articles

Original Research articles

Short Communications

Letter to editor

Clinical Case Reports

Review articles: These provide an in-depth review of a specific topic by systemic critical assessments of literature and data sources. Appropriate use of tables and figures is encouraged. Where relevant, key messages and salient features may be provided up to 4500 words excluding references and abstract. Maximum of six authors can be listed.

Original articles: These scientific reports give results of original research. These should have a structured abstract and should follow the IMRAD (Introduction, Methods, Results and Discussion) format (upto 3500 words). Randomised controlled trials, intervention studies, studies of screening and diagnostic test, outcome studies, case-control series, and surveys with high response rate. Maximum of eight authors can be listed

Short Communications/Letter to editor: These are brief reports on original research (approx. 1500 words). A short report may include up to 3 tables or figures and 15 to 20 references. Maximum of three authors can be listed.

Clinical case reports: Previously undocumented disease process, a unique unreported manifestation or treatment of a known disease condition. (approx. 2000 words) will be given priority. Maximum of six authors can be listed

Authorship Criteria

Authorship credit should be based only on substantial contributions to each of the three components mentioned below:

1. Concept and design of study or acquisition of data or analysis and interpretation of data;

2. Drafting the article or revising it critically for important intellectual content; and

3. Final approval of the version to be published.

Participation solely in the acquisition of funding or the collection of data does not justify authorship. General supervision of the research group is not sufficient for authorship. Each contributor should have participated sufficiently in the work to take public responsibility for appropriate portions of the content of the manuscript. The order of naming the contributors should be based on the relative contribution of the contributor towards the study and writing the manuscript. Once submitted the order cannot be changed without written consent of all the contributors. The journal prescribes a maximum number of authors for manuscripts depending upon the type of manuscript, its scope and number of institutions involved (vide infra). The authors should provide a justification, if the number of authors exceeds these limits.

Covering letter

Each manuscript should be accompanied by a covering letter which includes statements concerning authorship and informed consent (see above); confirms that the contents of the manuscript have not been published or are not being submitted for publication elsewhere, and by a disclosure of financial interests or other dual commitments that represent potential conflicts of interest for any of the authors. The name, full mailing address, telephone, fax number and e-mail address of the author responsible for correspondence on the paper, as well as the signatures of all authors should be included. Unless otherwise requested by the corresponding author, his or her fax number and e-mail address will be published.

Contribution Details

Contributors should provide a description of contributions made by each of them towards the manuscript. Description should be divided in following categories, as applicable: concept, design, definition of intellectual content, literature search, clinical studies, experimental studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing and manuscript review. Authors' contributions will be printed along with the article. One or more author should take responsibility for the integrity of the work as a whole from inception to published article and should be designated as 'guarantor'.

Conflicts of Interest

Authors must acknowledge and declare any sources of funding and potential conflicting interest, such as receiving funds or fees by, or holding stocks and shares in, an organization that may profit or lose through publication of your paper. Declaring a competing interest will not lead to automatic rejection of the paper, but we would like to be made aware of it.

Submission of Manuscripts

The submitted manuscripts that are not as per the “Instructions to Authors” would be returned to the authors for technical correction, before they undergo editorial/ peer-review. Generally, the manuscript should be submitted in the form of two separate files:

1) Title Page/ First Page

This file should provide

a) The type of manuscript (original article, case report, review article, Letter to editor) title of the manuscript, running title, names of all authors/ contributors (with their highest academic degrees, designation and affiliations) and name(s) of department(s) and/ or institution(s) to which the work should be credited, . All information which can reveal your identity should be here. Use text/rtf/doc files. Do not zip the files.

b) The total number of pages, total number of photographs and word counts separately for abstract and for the text (excluding the references, tables and abstract), word counts for introduction + discussion in case of an original article;

c) Acknowledgement, if any. One or more statements should specify 1) contributions that need acknowledging; 2) acknowledgments of technical help; and 3) acknowledgments of financial and material support. This should be included in the title page of the manuscript and not in the main article file.

d) Registration number in case of a clinical trial and where it is registered (name of the registry and its URL)

e) Conflicts of Interest of each author/ contributor. A statement of financial or other relationships that might lead to a conflict of interest, if that information is not included in the manuscript itself or in an authors' form

f) Criteria for inclusion in the authors'/ contributors' list

g) A statement that the manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work, if that information is not provided in another form (see below); and

h) The name, address, e-mail, and telephone number of the corresponding author, who is responsible for communicating with the other authors about revisions and final approval of the proofs, if that information is not included on the manuscript itself.

2) Blinded Article file

The main text of the article, beginning from Abstract till References (including tables) should be in this file. The file must not contain any mention of the authors' names or initials or the institution at which the study was done or acknowledgements. Page headers/running title can include the title but not the authors' names.Manuscripts not in compliance with the Journal's blinding policy will be returned to the corresponding author.

Full Title of the manuscript should be concise but informative; highlight rather than explain; be a label, and improve searchability of the article; use no symbols or abbreviations.

Abstract: Provide an abstract of not more than 250 words (150 words for case reports) for all types of articles except for letter to the editor. Structured format is required for original articles and brief reports. It should consist of four paragraphs, labeled Background, Materials and Methods, Results, and Conclusions. They should briefly describe, respectively, the problem being addressed in the study, how the study was performed, the salient results, and what the authors conclude from the results. No literature should be cited. Authors submitting review manuscripts should include a section describing the methods used for locating, selecting, extracting, and synthesizing data. These methods should also be summarized in the abstract.

Keywords: about 3 to 6 key words that will provide indexing references should be listed for all types of articles except letter to the editor.

Original Research

Text Pages: Organize the manuscript into following four main headings:

Introduction: This should summarize the purpose and the rationale for the study. It should neither review the subject extensively nor should it have data or conclusions of the study. It should be brief but complete enough for the reader to understand the reasons for the study without having to read previous publications on the subject.

Materials and Methods: This should include exact method or observation or experiment. If an apparatus is used, its manufacturer's name and address should be given in parenthesis. If the method is established, give reference but if the method is new, give enough information so that another author is able to perform it. If a drug is used, its generic name, dose and route of administration must be given. For patients, age, sex with mean age ± standard deviation must be given. Statistical method must be mentioned and specify any general computer program used. The Info system used should be clearly mentioned.

Results: These should be concise and include only the tables and figures necessary to enhance understanding of the text. Results should be presented in a logical, sequential order that parallels the organization of the methods section. Units of Measurement Restrict tables and figures to those needed to explain the argument of the paper and to assess its support. Use graphs as an alternative to tables with many entries; do not duplicate data in graphs and tables. The results should be written in the past tense when describing findings in the authors' experiments. This section may also include subheadings. Discussion, speculation and detailed interpretation of data should not be included in the Results but should be put into the Discussion section.

Discussion: The Discussion can include subheadings and should interpret the findings in view of the results obtained in this and in past studies on this topic. Emphasize what is novel about findings, discuss in context of published literature, and emphasize contribution to literature in medicine and public health.

Conclusion : in a few sentences at the end of the paper.

Do not repeat in detail data or other material given in the Introduction or the Results section. In particular, contributors should avoid making statements on economic benefits and costs unless their manuscript includes economic data and analyses. Avoid claiming priority and alluding to work that has not been completed. New hypotheses may be stated if needed, however they should be clearly labelled as such. About 30 references can be included. These articles generally should not have more than eight authors.

Review Articles

Accurately record the sequence of development of a particular phase of dentistry. It should be brief but complete and provide documentation by references. Review articles include a nonstructural abstract.

Case Report

Case report is a detailed report of the diagnosis, treatment, and follow-up of an individual patient and contains: 1) unique cases that may represent a previously undescribed condition; 2) unexpected and important association of two or more diseases; 3) adverse or unexpected treatment response; or 4) any other clinical observation based upon well-documented cases that provide important new information. Organize the manuscript into the following main headings: 1) a nonstructural abstract and keywords; 2) text [introduction, case report, discussion]; 3) References: up to 20 references; 4) Figures.

Letter to the Editor

Letters of opinion about articles, short reports of clinical interest and other current topics are accepted for consideration for publication. These should not exceed 800 words and one table and/or figure. These should list no more than ten references. Letters should be typewritten with double spacing throughout, including references. The editor reserves the right to edit such letters and to use his discretion in their selection for publication.

Ethical guidelines

Ethical considerations must be addressed in the Materials and Methods section. 1) In the case of clinical trials state that informed consent was obtained from all human adult participants and from the parents or legal guardians of minors. Include the name of the appropriate institutional review board that approved the project. 2) When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the last update of Helsinki Declaration

References

Responsibility for the accuracy and completeness of references rests entirely with the authors. References will not be checked in detail by the Editors but papers in which errors are detected are unlikely to be accepted. References should be numbered in the order in which they are first cited in the text, tables, figures and legend using Arabic numerals in superscript on the line. The list of references should be typed in double spacing and in numerical order on separate pages. The titles of journals should be abbreviated according to the style used in Index Medicus. Use complete name of the journal for non-indexed journals.

üJournal: Singh HP, Shetty DC.A quantitative and qualitative comparative analysis of collagen fibers to determine the role of connective tissue stroma on biological behavior of odontogenic cysts: A histochemical study. Nat J MaxillofacSurg 2012;3(1):15-20..

üBook: Torabinejad M, Walton RE. Principels and Practice of Endodontics. 3rd ed. Philadelphia: Saunders, 2002. p. 275-8.

üE-Journal: Vega KJ, Pina I, Krevsky B. Heart transplantation is associated with an increased risk for pancreatobiliary disease. Ann Intern Med. In press.

üWebpage: Medical Library Association. MLANET [Internet]. Chicago, IL: The Association; 1996 [rev. 1 Jan 2008; cited 24 Jan 2008]. Available from: http://www.mlanet.org

Tables: Tables should be presented on separate pages after the references, and numbered in the order in which they are cited in the text. Table headers should be fully descriptive of the contents. Tables should supplement, not duplicate, the text. Use only horizontal rules. Do not submit tables as photograph.These should be typed in double space, each table on a separate page with the table number (in Roman numerals) and title above the table, and explanatory notes below the table. Tables should be so arranged that comparisons of interest are horizontal (across columns) and from left-to-right.

Figures: Figures are free of charge. Acceptable formats for pictures, photos, and figures are PDF, DOC, PPT, JPG, GIF, TIF, BMP, EPS (jpeg is most suitable. Do not zip the files). You may either insert figures, photographs or images in the text file or upload your figures separately. However, inserting in the manuscript file may not work well for complicated graphics, or may increase the size of the manuscript file, which requires you to send the figures separately. Legends for all figures should be included in the file with the text at the end on separate page (not more than 40 words).

I N D E X

(AN OFFICIAL JOURNAL OF PACIFIC ACADEMY OF HIGHER EDUCATION & RESEARCH)


Original Research

Comparative Evaluation of Fiber Reinforced Composite Space Maintainer 01

Versus Conventional Band and Loop Space Maintainer: A Clinical Study

Kavikumar V, Shazia Nabi, Gagandeep Kaur, Neha, Aniyo Radhe, Sanjana Arora

Review Article

Orthodontitis- Orthodontically Induced Apical Root Resorption: A Review 09

Prerna, Kamlesh Garg, Bhavesh Kothari

Sports Dentistry – A review 14

Jinal R. Katira, Dinesh Rao, Dr. Sunil Panwar, Harleen Narula, R. Bhambhani

Wilckodontics- An Accelerated Orthodontic Technique- A Review 19

V R Balaji, D Manikandan, R Abinaya, A Ramsudar, T Nishanthini

White spot lesion of dental caries: A Review 21

Neel Chaudhary, Dinesh Rao, Sunil Panwar, Harleen Narula, D. Krishna Das

Case Reports

CBCT as a diagnostic tool in the diagnosis of Oroantral Fistula associated withright Maxillary Sinusitis: 30

a case report

Ch. Anupriya, Prashant Nahar, Mohit Pal Singh, Saurabh Goel, Hemant Mathur, Tulip Chakravarty

Calcifying Epithelial Odontogenic Tumor – Case Report 33

Deepika Tickoo, Mohit Pal Singh, Prashant Nahar, Bhagwan Das Rai, Bipin Bulgannawar, Abhijeet Masih

Eruption of A Labially Impacted Canine Using Closed Flap Technique - A Case Report 39

Jaydip Kalaria, Dr. Kamlesh Garg, Dr. Bhavesh Kothari, Dr. Ravindra Choudhary

Management of Highly Placed Ectopic Canine by Orthodontic Treatment Using Segmented T-Loop and 44

R-Loop – A Case Report

Ankur Kumar, Kamlesh Garg, Priya Sharma, Bhavesh Kothari, Manali Shah

Powerscope – “Fixed Functional Appliance” A Newer Approach to Correct Class ii Div 1 Malocclusion: 50

A Case Report

Shikha Singh, Kamlesh Garg, Bhavesh Kothari, Shruti Gupta

Previously, this Journal has been published as Journal of Pacific Academy of Higher Education & Research (JPAHER) and was publishing Articles related to Dentistry. On requesting for RNI No., the RNI allotted the title "Pacific Journal of Dentistry". So, forth the "JPAHER" would be known as "Pacific Journal of Dentistry". Therefore, we regret to our readers for their inconvenience.

-Editor

Note

ABSTRACT

Premature loss of primary tooth is one of the most common etiologies for malocclusion. Space maintainers are employed to prevent this complication. The aim of this study is to evaluate the use of fiber-reinforced composite resin as a space maintainer and to compare it with conventional band and loop space maintainer. A total of 30 children aged 4-9 years were selected for the study. Each of them required maintenance of space due to premature loss of primary molar. Patients were recalled at regular intervals and evaluation of space maintainers was done. The band and loop space maintainer was found to be superior to that of fiber- reinforced composite space maintainer, but this difference was not statisticallysignificant

Keywords - Fiber reinforced composite space maintainer, conventional band, loop space maintainer

INTRODUCTION

The primary dentition plays a very important role in child growth and development not only in terms of speech, chewing, appearance, and the prevention of bad habits but also in the guidance and eruption of

1permanent teeth. However, if premature extraction or loss of tooth is unavoidable due to extensive caries or other reasons, the safest option to maintain arch space is by placing a space maintainer. The most effective way to prevent mesial drift after early loss of primary molars

2is to insert a durable space maintainer. The space maintainers are broadly classified as removable and fixed types which are further classified as banded and bonded, active and passive, functional and

3non-functional. Very few literatures reports on use of polyethylene FRCR (Everstick) as space maintainers. Hence, the present in vivo study was planned to clinically evaluate various space maintainers in terms of survival rate, gingival health and presence/absence ofcaries.

AIMS AND OBJECTIVES

The aims and objectives of the present study are:

1. To compare the efficacy of glass fiber-reinforced composite resin and conventional band-and-loop spacemaintainer.

2. To compare the overall success of glass fiber-reinforced composite resin and conventional band-and-loop space maintainer in terms of survival rate, gingival health and presence/absence ofcaries.

Comparative Evaluation of Fiber Reinforced Composite Space Maintainer

Versus Conventional Band and Loop Space Maintainer: A Clinical Study

01

Kavikumar VPost Graduate student, Department of Pediatric

Dentistry, Maharaja Ganga Singh Dental College

and Research Center, Sriganganagar

Shazia NabiPost Graduate student, Department of Pediatric



Gagandeep KaurProfessor and Head, Department of Pediatric



NehaReader, Department of Pediatric Dentistry

Maharaja Ganga Singh Dental College and

Research Center, Sriganganagar

Aniyo RadhePost Graduate student, Department of Pediatric



Sanjana AroraPost Graduate student, Department of Pediatric



Original Research

Address for Correspodence

Kavikumar VPost Graduate student,

Department of Pediatric Dentistry,

Maharaja Ganga Singh Dental College and

Research Center, Sriganganagar, 335002

Pacific Journal of DentistryVolume 2 Issue 4, January-March 2019

02

MATERIALS AND METHOD finishing burs. Instructions for oral hygiene and appliance maintenance were given to children and their parents.

The source of data was 30 patients in the age group of 4-9 Patients were recalled at 3, 6 months interval for evaluation

years visiting the out-patient Department of Pedodontics of space maintainers.

and Preventive Dentistry, Maharaja Ganga Singh Dental College and Research Center, Sri Ganganagar, Rajasthan. Clinical evaluation of the patient was carried out by both

visual and tactile examination to check for the survival rate, The patients were divided into two groups as follows:

presence of caries and gingival health at 3rd, 6th month Group - I: Patients who have been given glass fiber recall, according to the following criteria:reinforced composite loop space maintainers (FRCR).

Survival RateGroup – II: Patients who have been given conventional band

The survival rate was checked as per following comparable and loop space maintainers. 5criteria The study population was selected based on the following

a. Lost to follow-up(LF)inclusion and exclusion criteria's which include, patients requiring extraction of primary first/second molar or having b. Failed(F)pre- extracted primary first/second molars in any arches, age

c. Successful(S)group of 4-9 years, extraction sites with no space loss, erupting permanent tooth having adequate bone covering, d. Censored at the end of study(C).fully erupted carious free abutment teeth. Patients willing to

Cariesparticipate in the study were selected, and informed consent was sought. The presence of dental caries was checked visually and with

an explorer at 3, 6 months according to the following scale:Technique of Application of Glass Fiber Reinforced Composite Resin (Group I) • Presence of caries —'P'

The amount of Everstick to be placed was measured with • Absence of caries —'A'divider and ruler. The abutments were cleaned with pumice,

Gingival Healthisolated, acid etched with 37% orthophosphoric acid, washed with water and then dried. The bonding agent was Plaque deposition of the abutment tooth of the space applied and cured for 10 seconds according to maintainer was evaluated according to the index used by

6manufacturer's instructions. A thin layer of flowable Sillness and Loe H.composite was applied on distal surface of the mesial tooth,

The results obtained from the above-mentioned criteria and on the mesial surface of the distal tooth, and measured were tabulated accordingly and evaluated for statistical amount of Everstick was placed between these abutment significance.teeth as a saddle. After preliminary curing, at each end of

fiber network for 40 seconds additional restorative The data collected at 3, 6 months interval was then tabulated composite was further placed over the area where fiber and statistically analysed using the Chi-square test and contacted the tooth and light cured for 40 seconds to McNemar's test.completely bond the space maintainer with the abutment

RESULTS(Fig 1&2).Table – 1 compared the survival rate among the two groups Technique of Conventional Band and Loop Fabrication at 3 months and 6 months. At 3 months, 53.3% of glass fibre (Group II)reinforced composite loop space maintainer survived and

A conventional band and loop was fabricated according to 86.7% of conventional band & loop space maintainer 4the technique described by Finn and patient was instructed survived. But only 40% of glass fibre reinforced composite

not to eat or drink for 30 minutes and not to bite any hard loop space maintainer survived by the end of 6 months, food (Fig3&4). whereas 80% of conventional band and loop space

maintainersurvived.The space maintainer was checked for any occlusal and gingival interference. Finishing was done with composite


03

Volume 2 Issue 4, January-March 2019

Table –

1: Comparison of survival rate among two groups

Evaluation

period

Glass fibre

reinforced

composite loop (n=15)

Conventional

Band & loop

(n=15)

p-value

Inference

3 months 8 (53.3%) 13 (86.7%) 0.180 NS 6 months 6 (40%) 12 (80%) 0.078 NS

NS – Non-Significant, S - Significant

Table - 2 evaluated the gingival health among the two groups three months. By the end of 6 months, 33.3% of glass fibre which showed that 13.3% of glass fibre reinforced reinforced composite loop space maintainer and 25% of composite loop space maintainer resulted in poor gingival conventional band & loop space maintainer showed poor health whereas only 7.6% of conventional band & loop gingival health.space maintainer showed poor gingival health at the end of

Table –

2: Comparison of gingival health among two groups

Evaluation

period

Glass fibre

reinforced

composite loop

(n=15)

Conventional

Band & loop

(n=15)

p-value

Interference

No. of subjects

available for

gingival health at

3 months Three month poor

8

2 (13.3%)

13

1 (7.6%)

-

0.456

-

NS

No. of subjects

available for

gingival health at

6 months Six months poor

6

2 (33.3%)

12

3 (25%)

-

0.779

-

NS NS – Non- Significant, S – Significant

Table - 3 evaluated the presence of dental caries among the developed caries during the three months and six months two groups which showed that none of the patients follow-up.

04


Table – 3: Comparison of presence/absence of dental caries among two groups

Evaluation period

Glass fibre reinforced composite loop (n=15)

Conventional Band & loop (n=15)

No. of subjects available for caries examination at 3 months

Three months

8

A

13

A

No. of subjects available for caries examination at 6 months

Six months

6

A

12

A

Figure – 1.1: Preoperative Intraoral photograph Figure – 1.2: Preoperative Intraoral radiograph

Figure – 1.3: 6 month follow up intraoral photograph Figure – 2.1: Preoperative Intraoral photograph

05


Figure – 2.2: Preoperative Intraoral radiograph Figure – 2.3: 6 month follow up intraoral photograph

Figure – 3.1: Preoperative Intraoral photograph Figure – 3.2: Preoperative Intraoral radiograph

Figure – 3.3: 6 month follow up intraoral photograph Figure – 4.1: Preoperative Intraoral photograph

06


Figure – 4.2: Preoperative Intraoral radiographFigure – 4.3: 6 month follow up intraoral photograph

07


DISCUSSION formation or lodgement would hamper gingival health.

Conventional band and loop has long been used for In group I at 3 months recall, only 7.6% subject had poor 7 gingival health. Similarly at 6 months recall, 25% of patients maintaining space in cases of premature single tooth loss.

had poor gingival health. In group I, space maintainers were However, it has the following disadvantages viz tendency fabricated using custom made band along with a loop for disintegration of cement, inability to prevent rotation or respectively. Such metallic bands can easily cause plaque tipping of adjacent teeth, increased chairside and laboratory

8 traps to form. Though in the present study, we took all time. This indicates the need for newer designs and precautions toform smoothest solder margins with no materials of appliance. One such material is glass fiber-undercuts and patients were also instructed to maintain good reinforced composite resins (FRCRs) which are available to oral hygiene but, in spite of all these precautions, some the pediatric dental market and it can be used as an

9 plaque retentive traps might have formed leading to poor to alternative to the conventional space maintainer. Fiber-fair gingival health among different patients.reinforced composite resins have been used in removable

prosthodontics, fixed partial dentures, periodontal splints For group II at 3 months recall, 25% patients had poor and in orthodontic treatment as a retention splint. Nayak et gingival health; at 6 months recall, 33.33% patients had poor al., (2004) and Kulkarni et al., (2009) inferred that gingival health and around 66.67% were showing fair fabrication of conventional band and loop space maintainer gingival health.required more laboratory time and needed minimum of two

PRESENCE/ABSENCE OF CARIESappointments. They concluded that this procedure was time taking and labour intensive, therefore expensive. Also, The caries was examined visually and by tactile method. An impression making was difficult in young and explorer was used to check for the presence of caries on the

8,10uncooperative children. abutment tooth in the patients. None of the patients developed caries throughout our study over the time period SURVIVAL RATE

11of 6 months. Conventional band and loop and glass fibre reinforced

Space maintainer was cemented in groups I and II using composite resin loop space maintainer had success rate of luting GIC. After insertion of the appliance, the patients 86.7% & 72.7% at three months and 80% & 54.5% at six were thoroughly instructed about proper guidance for months. Though extreme care was exercised to follow the maintenance of oral hygiene and educated about proper ideal steps for band formation, fabrication of space

11brushing techniques. Inour study, good oral hygiene and maintainer appliance and its cementation, still there might fluoride releasing capacity of GIC might have attributed to have been some failure at the band cement interface, leading no caries development in groups I andII.to failure of space maintainer. Space maintainer might have

also failed because patient might not have followed the CONCLUSION11postoperative instructions.Survival times and success rates were better for

Glass fibre reinforced composite resin loop space conventional band and loop space maintainers than for glass maintainer is only bonded to natural tooth in form of a fiber reinforced composite loop space maintainers. Gingival bridge, with its saddle bonded to both teeth (mesial and health for conventional band and loop space maintainers distal to edentulous space) and this saddle is actually were better than for that of glass fiber reinforced composite maintaining the required space for permanent successor. loop space maintainers. In terms of caries, none of the Thus, the hanging fiber bridge is subjected to compressive patients developed caries among both conventional band and tangential forces that might lead to fracture of fiber and loop space maintainers and glass fiber reinforced frame. Secondly, the transmission of forces from fiber frame composite loop space maintainers. Patient acceptance of to bonding margins between tooth and Ribbond on either glass fiber reinforced composite loop space maintainers was side of framework might have weakened the bond and found to be better than that of conventional band and loop would have caused debonding of fiber composite interface space maintainers. The time taken to carry out the procedure

11or enamel cementinterface. for glass fiber reinforced composite loop space maintainer was significantly lower as compared to that taken by GINGIVAL HEALTHconventional band and loop spacemaintainers.

Regarding gingival health non-significant differences were obtained between the two groups of space maintainers at 3 and 6 months interval. (p<0.05)

Health of gingiva is inversely proportional to the presence of plaque. Any kind of appliance that would increase plaque

REFERENCES

1. Barberia E, Lucavechi T, Cardenas D, Maroto M. Free-end space maintainers: Design, utilization and advantages. J ClinPediatr Dent2006;31:5-8.

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2. Artun J, Marstrander PB. Clinical efficacy of two a n d m i x e d d e n t i t i o n s . D e n t C l i n N o r t h different types of direct bonded space maintainers. Am1978;22(4):579-601.ASDC J Dent Child1983;50:197-204.

8. Nayak UA, Louis J, Sajeev R, Peter J. Band and loop 3. Balaji SI. Orthodontics: The Art and Science. 3rded. space maintainer made easy. J IndSocPedoPrev Dent

New Delhi: Arya Publishing House: 2003. p.220. 2004;22(3):134-136.

4. Finn SB. Clinical pedodontics. 4th ed. Philadelphia: 9. Karman AI, Kir N. Four applications of reinforced fiber WB Saunders Company; 1998. p. 354. m a t e r i a l i n o r t h o d o n t i c p r a c t i c e . A m J

OrthodDentofacialOrthop2002;121(6):650-654.5. Tulonglu O, Ulusu T, Genc Y. An evaluation of survival

of space maintainers: a 6 years follow-up study. J 10. Kulkarni G, Lau D, Hafezi S. Development and testing Contemporary Dent Practice2005;6(1):1-11.6. P e t e r of fiber-reinforced composite space maintainers. J Dent S. Essentials of preventive and community dentistry. Child 2009;76(3):204-8.2nded. New Delhi: Arya Publishing House; 2004.

11. Setia V, Pandit IK, Srivastava N, Gugnani N, Gupta M. p.142.

Banded vs bonded space maintainers: finding better 7. Wright CZ, Kennedy DB. Space control in the primary way out. Int J ClinPediatr Dent2014;7(2):97-104.

Orthodontitis- Orthodontically Induced Apical Root Resorption: A Review

ABSTRACT

Apical root resorption is a common idiopathic problem associated with orthodontic treatment and has recently received considerable attention because of medico legal exposure. Loss of apical root material is unpredictable and when extending into the dentin, irreversible. Histologic studies report a high incidence, whereas clinical studies reveal a more varied incidence. Extensive post-orthodontic root resorption compromises the benefits of an otherwise successful orthodontic outcome. However, most root loss resulting from orthodontic treatment does not decrease the longevity or the functional capacity of the involved teeth. Although most root resorption studies attempt to investigate the etiologic factors and predictability of this phenomenon, its origins remains obscure. Individual susceptibility, hereditary predisposition, systemic, local, and anatomic factors associated with orthodontic mechanotherapy is commonly cited components.

Keywords: External apical root resorption, Orthodontic treatment, Tooth movement

INTRODUCTION

Root resorption is a condition characterized by a partial loss of root cementum and dentin. Root resorption of the deciduous dentition is a physiological process and it is a necessary predecessor to the eruption of permanent teeth. External root resorption or root resorption, is an undesirable as well as least predictable sequelae of orthodontic treatment. It can occur during the middle or post- orthodontic treatment phase, as applied orthodontic force can act as a stimulus to initiate the root resorption.

HISTOPATHOLOGY OF ROOT RESORPTION

Mechanism of root resorption is not completely explored. Inflammatory root resorption induced by orthodontic treatment is a part of process of elimination of hyaline zone. It is considered that occurrence of root resorption can be induced by the strong force through orthodontic treatment and hyalinisation of periodontal ligaments induced by increased activity of cementoclasts and osteoclasts. During tooth movement, areas of compression (where osteoclasts are in action inducing bone resorption) and areas of tension

1(where osteoblasts are active inducing bone deposition) are formed.

Thus a tooth moves towards the side of bone resorption. An imbalance

PrernaPost graduate student – Dept of Orthodontics and

Dentofacial Orthopaedics, Pacific Dental College

Udaipur

Kamlesh GargReader, Dept of Orthodontics and Dentofacial

Orthopaedics, Pacific Dental College, Udaipur

Bhavesh KothariReader , Dept of Orthodontics and Dentofacial

Orthopaedics, Pacific Dental College, Udaipur


PrernaPost graduate student – Dept of Orthodontics and


Udaipur

Review Article


09

between bone resorption anddeposition, losing protective Factors related to orthodontic treatmentcharacteristics of cementum may contribute to the

While Jacobson stated that a 1-mm loss in the apex is not im-cementoclasts/ osteoclasts resorbing areas of the root. When

portant because the apical region has the smallest diameter hyaline zone forms, tooth movement will stop. Upon

in a tooth, Kalkwarf et al mentioned that there can be an regeneration of periodontal ligament, hyaline zone is

important relationship between the length of the root and removed by mononucleus cells similar to macrophages and

periodontal connection; thus, even the smallest loss in the by multinucleus gigantic cells and a tooth starts to move

root can be significant.again. During removal of hyaline zone an outer tooth root surface consisting of the layer of cementoblasts may be Magnitude of orthodontic forcedamaged, exposing the underlying highly dense mineralized

Harris et al, Barbagallo et al, Cheng et al and Paetyangkul et cementum. It is possible that a force occurring during

al stated that with an increasing force, root resorption also orthodontic treatment may directly damage outer root

increases. Paetyangkul et al concluded that even if a light surface. Tooth root surface underthe hyaline zone resorbes

force was applied, whenever there is an increase in the just after a few days, when a repair process is already

application time, root resorption also increases.happening in the periphery. On the grounds of the literature data it can be stated that the resorption process is completed Type of orthodontic forceafter removal of the hyaline zone, and/or when orthodontic

Although it is clinically difficult to apply intermittent forces 2force decreases. in fixed orthodontic treatment, it has been suggested that intermittent forces should be preferred instead of continuous ETIOLOGYforces to prevent serious root resorptions. Aras et al

The dental history, history of trauma and dental treatments, concluded that intermittent forces result in lesser root related systemic conditions, and medical details of patients resorption than continuous forces.could cause the pathogenesis of root resorption. While the

Direction of tooth movementmultifactorial etiology of root resorption is very complex, it is thought that a combination of the biological variability of According to the type of movement, high points of pressure, a person, genetic predisposition, and mechanical factors are where the force is intensified, are more prone to root the reason for resorption. In line with many studies on the resorption. In intrusive movements, almost all pressure is etiology of root resorption, the possible reasons for root gathered in the root apex; the risk of resorption markedly 3resorption can be classified as follows : increases because of root anatomy. When compared with

intrusive movements, extrusive movements occur easily, Factors related to orthodontic treatmentbut they also cause root resorption in interdental areas in the

These include the magnitude of orthodontic force, type of cervical third of the root. It has been stated that root force (continuous, interrupted or intermitted), direction of resorption occurs four times more during intrusion than tooth movement, amount of apical movement, sequence of during extrusion.the arch wire, type of orthodontic appliance, duration of

Li et al evaluated the amount of root resorption after mini-orthodontic treatment, and treatment technique.screw-supported molar intrusion and stated that the most

Factors related to the patient volumetric material loss occurs in the mesiobuccal root. During rotation, resorption lacunae are mostly prevalent in These include genetic factors, chronological age, dental age, the middle third of the root. gender, ethnic factors, syndromes, psychological stress,

increased occlusal force, tooth vitality, type of teeth, dental Amount of apical movementinvaginations, features of dentoalveolar and facial

While it has been stated that an increase in apical movement structures, existing root resorption before treatment, can lead to an increase in resorption, according to Philips, proximity of the root to the cortical bone, nutrition, systemic there was no direct relationship between root resorption and factors (illnesses that cause inflammation, asthma, allergy the sagittal or angular movements of the root apex. etc.), hormonal irregularities, systemic medicine use,

metabolic skeletal disorders, parafunctional habits, Sequence of the arch wire morphology of teeth/root, developmental abnormalities of

There is no information on the relationship between root re-roots, properties of cementum mineralization, hypofunction sorption and the arch wire sequence. The arch wire sequence of the periodontium, history of trauma, endodontic is mostly a clinician-dependent factor. A significant treatment, density of the alveolar bone and type and severity relationship between resorption and the arch wire sequence of malocclusion and alcoholism. has not been proven. This is important because the aim of the clinician is to reach the square stainless steel working arch


10


wires efficiently. However, a balance should exist between apexes than in roots with a normal shape. Generally, teeth the potential benefits of a more rapid progression to working with root dilacerations are prone to root resorption, wires and risks of root resorption. particularly in maxillary lateral incisors.

Type of orthodontic appliance Hypofunction of the periodontium

It has been found that the mean decrease in root length was The hypofunction of teeth during static or dynamic occlusal 8.2% in the straight wire group and 7.5% in the conventional relationships may result in atrophic changes in Sharpey's edgewise group. There was no a significant difference fibers, a decrease in the fibroblastic proliferation activity, between the mean prevalence of apical root resorptions and vascular constriction. Further, the periodontal space between the two groups. Scott et al stated that the amount of narrows, and the force becomes concentrated in pressure root resorption in Damon's self ligating brackets and areas. These histological changes accelerate the conventional brackets are similar. Barbagallo et al, in their resorption/destruction process. Motokawa et al. found that prospective randomized controlled clinical trial, found that the prevalence of root resorption in hypofunctional teeth the amount of resorption in thermoplastic removable (66.9%) is higher than that in normal teeth (33.5%).appliances is similar with light forces transmitted by fixed

Chronological ageorthodontic appliances. It has also been found that the use of Class II elastics might be a risk factor for root resorption. The risk of root resorption increases with age because of a de-

crease in periodontal membrane vascularity and an increase Heavy forces during rapid maxillary expansion might also

bone density. On the other hand, Cheng et al and Baumrind induce root resorption in attached premolars and molars.

et al stated that there is no significant relationship between Further, there are studies that have found that rapid

the chronological age and root resorption.expansion might induce root resorption in the unattached second premolar tooth. C L A S S I F I C AT I O N O F A P I C A L R O O T

RESORPTIONFactors related to the patient:

Root resorption index Genetic factors

Levander and Malmgren system described the following The resorption process, which may vary among patients and 5grading scale for apical root resorption. (Fig-1)cannot be explained either by orthodontic or environmental factors, has led researches to evaluate the presence of Index-0: - Normal apical contour, same length as genetic factors that may increase the tendency for pretreatmentresorption. Significant differences in root resorption

Index-1:- Irregular root contourbetween patients, even in situations where factors related to the treatment and clinician are standardized, reveal the Index-2:- Apical root resorption of less than 2mm (minor importance of personal tendency. There are studies inferring resorption)that personal tendency on root resorption may be more

Index-3:- Apical root resorption more than 2mm, less than effective than the amount and duration of orthodontic one third of original root length (severe resorption)force.Genetic factors account for at least 50% of the

variation in EARR. Variation inthe Interleukin 1 beta gene in Index-4:- Apical root resorption more than one third of orthodontically treated individuals accounts for 15% of the original root length (extreme resorption) variation in EARR. Historical and contemporaryevidence

DIAGNOSIS OF ROOT RESORPTION:implicates injury to the periodontal ligament and supporting structures at the site of root compression followingthe Even if the direction and amount of the orthodontic force are application of orthodontic force as the earliest event leading carefully determined, it is not possible to predict where and to EARR. Decreased IL-1_ production in the case of IL-1B how root resorption occurs. For this reason, while surface (+3953) allele 1 may result in relatively less catabolic bone resorptions are located in buccal, palatal/lingual, mesial or modeling (resorption) at the cortical bone interface with the distal areas in the apical region, a decrease in root length PDL,which may result in prolonged stress concentrated in may not be observed. In such situations, two-dimensional the root of the tooth, triggering a cascade of fatigue-related methods can be insufficient to diagnose and locate

4events leadingto root resorption. resorption. With an increase in the duration and amount of the orthodontic force, the depth of resorption lacunae may

Abnormal root morphologyproceed to the dentine, while there is no change in the root

6The geometrical forms of roots can affect the distribution of length.the force through the alveolar bone and root. The force is

Root resorption after orthodontic treatment was examined more concentrated on localized areas in trigonal sharp for many years with conventional radiographs (periapical

11


graphs, digital radiography, orthopantomogram and lateral cannot be noticed. cephalometric radiography), light microscopes and

Scanning Electron Microscopy scanning electron microscopes. Recently, computed tomography (CT) and micro-CT were prevalent and later on, It has been reported that Scanning Electron Microscopy cone-beam computed tomography(CBCT) has come to the (SEM) results in an enhanced visual and perspective forefront. assessment of root surfaces and that when recorded in stereo

pairs, they provide resolution and details that cannot be Conventional Radiological Evaluations

attained with histological models reconstructed from serial Although shortening of the root length might be detected sections. A study that examined root resorption with SEM with conventional methods, the location, depth, and width of calculated resorption craters with surface signs obtained resorption in different parts of the root cannot be detected or from micrographs. However, it is very difficult to obtain a measured. plain image without data loss as premolar teeth in particular

have curved root surfaces. Therefore, mistakes can occur The reliability of the results of several studies might

during the calculations. doubtful due to the magnification problems of two-dimensional radiographs.Surface root resorptions can only Micro-CTbe detected with two-dimensional methods in situations

Root resorption is essentially characterized by volumetric where the depth of resorption lacunae increases at a certain

material loss, and the localization of lacunae on the root is level. Normal anatomic formations can be seen as

changeable. The volumetric three-dimensional methods radiopaque or radiolucent shadows, and as a result of

used during diagnosis and the quantitative measures of root superimpositions, there can be a decrease in the diagnostic

resorption can provide more accurate results than those quality of images. To clearly evaluate the root of teeth that

obtained using either quantitative or semi-quantitative two-are lingually or buccally inclined, the clear and absolute

dimensional methods. Micro-CT, when compared with positioning of teeth along the focal spot is very difficult.

other methods, has a resolution as high as 3 ìm. For this According to evaluations made using OPG by Sameshima

reason, micro-CT in three-dimensional dental assessments and Asgarifar, there was a 20% or more material loss in the

is regarded as a reference method. With this method, root root compared to evaluations using periapical graphics

resorption can be measured or detected only in in vitro because the position of the focal spot in accordance with the

conditions, and to obtain high-resolution images in vivo, root was different between these two imaging methods.

high radiation levels are required. This restricts the use of The most important factor to be considered when evaluating micro-CT images in vivo. root resorption with periapical graphs is the repeatability of

Cone Beam Computed Tomographythe position between an X-ray and the tooth. If the position of the X-ray cannot be reproduced, it is not possible to Cone beam computed tomography was developed for perform a reliable and accurate quantitative analysis. The viewing the maxillofacial region, and it also caused a magnification factor is generally less than 5% in periapical paradigm shift from two-dimensional methods to three-graphs. Therefore, periapical films are superior to dimensional methods. When compared with conventional panoramic graphs as periapical graphs can provide detailed CT, the advantages in using CBCT are that it can take images information with less distortion. with lower doses, has a shorter scan time, and has an

improved image sharpness. Further, when compared with A magnification factor that may vary between 5% and 12%

micro-CT, one of the most significant advantages is that it should be considered while performing evaluations with

can be used in in vivo assessments. This situation is not a lateral cephalometric X-rays. Because the roots of central

routine procedure in each patient; however, in accordance incisors are superimposed, the reliability decreases, and it is

with “to obtain the best image with the minimal dose,” difficult to accurately visualize root resorption. 6CBCT comes to the forefront in terms of related indications.Serial Sectioning and Light Microscopy

REPAIR OF ROOT RESORPTION:Resorption craters can vary in size and depth. Therefore,

It is thought that active orthodontic forces have an important irregular C-form craters and/or small craters can be partially role in the continuity of root resorption; therefore, the repair or completely overlooked or miscalculated. Differences in process begins after the release of the orthodontic force or teeth morphologies in the first premolar tooth that are decrease in the magnitude of the force at a certain level. The constantly used at root resorption studies and changes in root repair is first observed around the resorption lacunae. This numbers can be challenging during cross-sectioning, and it process shows similarity to the early cementogenesis during is difficult to make an ideal longitudinal cross-sectioning the development of the teeth. Resorption lacunae are without any data loss along the long axis of the teeth. Apical recovered with the accumulation of new cementum and resorptions or resorptions in the middle third of the root

12


formation of a new periodontal ligamentum. Owmann-Moll Cheng et al found that resorption continued for 4 weeks after et al stated that the possible repair level in resorption cavities the stop of the orthodontic force. After four-week light force that can be histologically observed can be summarized as application which was followed by 4-week retention, there follows: was continuous and regular repair, while most of the repair

occurred where the heavy force was applied in 4 weeks, I- Partial Repair: Part of the surface of the resorption 6which was followed by the 4-week retention.cavity is covered with reparative cementum

(cellular or acellular cementum). CONCLUSION:

II- Functional Repair: The total surface of the resorption cavity is covered with reparative cementum without the re-establishment of the original root contour (cellular cementum).

III- Anatomic Repair: The total surface of the resorption cavity is covered with reparative cementum to an extent such that the original root contour is re-established.

The fundamental principle of medicine 'first do no harm' by Hippocrates also applies tothe field of orthodontics. Orthodontists should be wellaware of the risks and benefits of orthodontic treatment,specific to each case. Despite recent advances in molecularbiology, imaging modalities and clinical care of patients,our understanding of root resorption remains limited.Large clinical and genetic association studies are neededto further understand biology, detection, and treatment of this undesired complication.

Fig-1 Root resorption index for quantitative assessment of root resorption

REFERENCES 4. Harris EF. Root resorption during orthodontic therapy. Seminars in Orthodontics 2000 Sep; 6(3):183-194.

1. Brezniak N. Orthodontically inducted inflammatory root resorption.Part I: The basic science aspects. Angle 5. Topkara A. External apical root resorption caused by Orthod2002;72:175-9. orthodontic treatment: a review of the literature.

European Journal of Paediatric Dentistry. 2011 Sep 2. Vlaskalic V, Boyd R L. Root resorptions and tissue

1;12(3):163-6.changes during orthodontic treatment. In: Bishara S E (ed.) Textbook of orthodontics. W B Saunders Co.: 6. Lunardi D, Becavin T, Gambiez A, Deveaux E. Philadelphia 2001; 463-72. Orthodontically induced inflammatory root resorption:

apical and cervical complications. J Dentofacial Anom 3. Dindaroglu F, Dogan S. Root Resorption in

Orthod 2013;16(1):1-15.Orthodontics. Turkish journal of orthodontics. 2016 Dec;29(4):103.

13

Sports Dentistry – A Review

ABSTRACT

The role of dentistry in the sports is important, because it provides the athlete optimal oral health conditions which in turn can contribute to achievement of optimal performance during competitions. Sports Dentistry involves the prevention, maintenance and treatment of oral and facial injuries, as well as the collection and dissemination of information on dental trauma, in addition to stimulating research.Consequences of orofacial trauma for children and their families are substantial because of potential for pain, psychological effects and economic implications. Dentistry today must respond to these patient's specialized needs, providing them with the quality care which they deserve. In all, there is much to be carried out in the field of sports dentistry.

Keywords: Contact sports, dental trauma, mouthguards

INTRODUCTION

Dental injuries are the most common type of orofacial injury sustained during participation in sports with the increased popularity of contact sports and encouragement to participate at an early age. Sports Dentistry involves the prevention, maintenance and treatment of oral and facial injuries, as well as the collection and dissemination of information on dental trauma, in addition to stimulating research. It directs a duty of the dental professional to detect problems of the athlete, such as mouth breathing, poor positioning of the arches, and properly administer medications-free of substances, that may provide the positive doping present in many painkillers.

Among the different sports, there are those which the risk of injury due to the contact or impact can be considered high. For instance, some team sports and combat sports such as boxing,judo, karate, jiu-jitsu, wrestling, sumo, soccer, basketball, volleyball, handball, mountain biking, motocross, hockey and skating, etc.

The common orofacial sports related injuries include soft tissue injury and hard tissue injury such as tooth intrusions, luxations, crown and/or root f ractures , complete avuls ions and dental-facial fractures.Consequences of orofacial trauma for children and their families are substantial because of potential for pain, psychological effects and economic implications. Dentistry today must respond to these patient's specialized needs, providing them with the quality care which they deserve. In all, there is much to be carried out in the field of

Jinal R. KatiraPost graduate student, Department of Pediatric

Dentistry, Pacific Dental College and Hospital

Udaipur, Rajasthan state, India

Dinesh RaoProfessor and Head, Department of Pediatric



Dr. Sunil PanwarReader, Department of Pediatric Dentistry

Pacific Dental College and Hospital, Udaipur

Rajasthan state, India

Harleen NarulaSenior Lecturer, Department of Pediatric Dentistry



R. BhambhaniPost graduate student, Department of Pediatric




Dinesh RaoProfessor and Head

Department of Pediatric Dentistry

Pacific Dental College and Hospital

Udaipur- 313024, Rajasthan state, India

Review Article


14


sports dentistry. zygoma. Fractures of the zygoma account for approximately 10% of the maxillofacial fractures seen in sports injuries,

Athletes, coaches, athletic directors, athletic trainers, occurring as a result of direct blunt trauma from a fall, elbow,

parents, and members of the dental community should be or fist. In a study by Linn et al., of the 319 patients treated for

aware of how individuals who participate in sporting sports-related injuries, males proved to be more prone to

activities are at risk for dental trauma. The common zygomatic fractures than females, because of the powerful

orofacial sports related injuries include soft tissue injury and physical contacts during sports.Fractures in this region have

hard tissue injury includes those to the teeth and facial the potential for long-term facial deformity. Recent data

bones, such as tooth intrusions, luxations, crown and/or root suggest that condylar fractures in children can alter growth

fractures, complete avulsions and dentofacial fractures.of the lower face.

Observing the need for expanding and disseminating Mandibular fractures

knowledge about this field of dentistry, due to scarce studies about sports dentistry, the objective is focused on the The most frequent site of mandibular fractures is the angle, prevention methods and frequent risk situations that involve followed by the condyle.Emshoff reported that, in skiing athletes. and cycling, the subcondylar region is the most commonly

affected. However, skiers and cyclists wear safety helmets Importance of sports injuries to dental professionals

that cover the chin and protect the condylar process. In their The very fact that certain patients will need treatment for analysis of 319 mandibular fractures, Hagan and Huelke tooth, bone, or oral and perioral soft tissue injuries as a result identified a clean-cut fracture pattern: of participation in sports makes an understanding of this

The condyle is the most common sitefield of dentistry practical. Beyond this obvious practicality, the overriding importance of dentistry's ability to meet the The angle is the second most commondiagnostic and therapeutic needs of those with oral injuries

However, if there is only one fracture, the angle is the most lies in the emotional and psychological importance to the

common site patient of having a normal appearance and function of the face. Multiple fractures are more common than single fractures

(ratio 2:1).Therefore, dentistry is needed for a practical side of health care as well as for the emotional consequences of facial or Midface facturesdental trauma. The patient suffering a sports injury of dental th In the late 19 century, René Le Fort described three lines of significance deserves both the practical approach to

midface fracture. Le Fort-type injuries are most commonly immediate and long-range health problems as well as the seen in mountain-bike accidents. Horse riding and, in one that accounts for the emotions associated with facial particular, horse-kick injuries can also lead to significant injury and its esthetic ramifications. Fortunately, modern maxillofacial trauma.dentistry has developed numerous techniques and

appliances to help protect the sports participant from a iii.TMJ injuriesvariety of orofacial injuries. In fact, preventive sports

Most blows to the mandible do not result in fractures, yet dentistry represents the most important contribution the s igni f icant force can be t ransmi t ted to the dental profession can make to assure a sports participant's temporomandibular disc and supporting structures that may welfare.result in permanent injury. In both mild and severe trauma,

Common athletic injuries the condyle can be forced posteriorly to the extent that the retrodiscal tissues are compressed. Inflammation and edema i.Soft Tissue Injuries can result forcing the mandibular condyle forward and down

The face is often the most exposed part of the body in athletic in acute malocclusion. Occasionally this trauma will cause competition and injuries to the soft tissues of the face are intracapsular bleeding, which could lead to ankylosis of the frequent. Abrasions, contusions, and lacerations are joint.common and should be evaluated to rule out fracture or other

iv.Tooth intrusionsignificant underlying injury. These usually occur over a bony prominence of the facial skeleton such as the brow, Tooth intrusion occurs when the tooth has been driven into cheek, and chin. Lip lacerations are also common. the alveolar process due to an axially directed impact. This is

the most severe form of displacement injury. Pulpal necrosis ii.Fracturesoccurs in 96% of intrusive displacements and is more likely

Fractures of the facial bones present an even more complex to occur in teeth with fully formed roots.problem. The most frequent site of bony injury is the

v.Crown and Root Fractures

15


Crown fractures are the most common injury to the Dentists of all specialties, including pediatric and permanent dentition and may present in several different general dentists, to provide education to parents and ways. The simplest form is crown infraction.The most patients regarding prevention of orofacial injuries as part severe crown fracture results in the pulp being fully exposed of the anticipatory guidance discussed during dental and contaminated in a closed apex tooth or a horizontal visits. impact may result in a root fracture. The chief clinical sign of

Dentists to prescribe, fabricate, or provide referral for root fracture is mobility.

mouthguard protection for patients at increased risk for vi.Avulsion orofacial trauma.

Certainly one of the most dramatic sports related dental Third-party payors to realize the benefits of injuries is the complete avulsion of a tooth. Two to sixteen mouthguards for the prevention and protection from percent of all injuries involving the mouth result in an orofacialsportsrelated injuries and, furthermore, avulsed tooth. encourages them to improve access to these services.

Prevention of sports- related traumatic orofacial Pediatric dentists to partner with other dentists and child injuries health professionals, school administrators, legislators,

and community sports organizations to promote the Many sports-related traumatic dental injuries are

broader use of mouthguards.preventable; the risk-to-benefit ratio can be improved by the use of appropriate, properly fitted, protective athletic Pediatric dental departments to teach dental students equipment. Furthermore, as the predictive risk factors fabrication of custom-fitting mouthguards.associated with such injuries are more clearly identified and

Although some sports-related traumatic injuries are defined, the design and development of new protective

unavoidable, most can be prevented. Helmets, facemasks, devices may contribute positively to future athletic injury

and mouthguards have been shown to reduce both the prevention.

frequency and severity of dental and orofacial trauma.At present, helmets, facemasks, and mouthguards are

Helmets and headgearrequired in some sports to reduce both the likelihood and the severity of sports-related traumatic injuries to the head, face, Protective headgear and helmets decrease the potential for and mouth of an athlete. severe traumatic brain injury after a collision by reducing

the acceleration of the head on impact, thereby decreasing The AAPD policy statement encourages:

the brain-skull collision and the sudden deceleration Dentists to play an active role in educating the public in induced axonal injury.The energy-absorbing material within the use of protective equipment for the prevention of a helmet accomplishes this by compressing to absorb force orofacial injuries during sporting and recreational during the collision and slowly restoring to its original activities. shape. This compression and restoration prolongs the

duration of the collision and reduces the total momentum Continuation of preventive practices instituted in youth,

transferred to the head.There is variation in helmet design high school and college football, lacrosse, field hockey,

based on the demands and constraints of each sport.ice hockey, and wrestling (for wrestlers wearing braces).

Face guardsAn ASTM-certified face protector be required for youth participating in baseball and softball activities. Face guards are designed to protect against facial injuries to

the mouth, nose, eyes, nasal pyramid and zygomatic arches, Mandating the use of properly-fitted mouthguards in

depending upon the style of facemask used. Facemasks are other organized sporting activities that carry risk of

manufactured from various numbers and diameters of orofacial injury.

plastic or rubber tubing or welded steel or aluminumand Coaches/administrators of organized sports to consult a covered with the coating of vinyl plastic. dentist with expertise in orofacial injuries prior to

The full cage facemasks afford the greatest degree of overall initiating practices for a sporting season, for

facial protection and are generally preferred by defensive recommendations for immediate management of sports-

players to avoid injuries. One major disadvantage of related injuries (e.g., avulsed teeth).

facemask is that it prevents a protruding object within the Continuation of research in development of a ready grasps of an opposing player. When the face mask is comfortable, efficacious, and cost-effective sports pulled or twisted by an opponent during the course of play, mouthguard to facilitate more widespread use of this serious physical consequences such as muscle, neck or proven protective device. spinal column damage can result.

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16


Mouthguards in equipment and regulations. There is need to popularize the use of orofacial protective devices in a variety of sports

Mouth guard is meant to act as a buffer by moving the soft events by interacting with coaches, sports administrators

tissues in the oral cavity away from the teeth preventing and sports persons as well as familiarizing the Indian

lacerations, bruising of lips, cheeks, and tongue during an dentists in a relatively new field.

impact. It is supposed to prevent tooth fractures or dislocations by cushioning the teeth from direct frontal blows while redistributing the force of the blow over all the teeth. Opposing teeth are protected from seismic contact with each other. Mandible is afforded elastic, recuperative support can prevent fracture or damage to the unsupported angle of the lower jaw. Their use can also provide substantial protection to patients receiving orthodontic treatment.

Professional responsibility as a dentist

Players' perceptions of mouthguard use and comfort largely determine their compliance and enthusiasm. Therefore, the dental profession needs to influence and educate all stakeholders about the risk of sports-related orofacial injuries and available preventive strategies. Routine dental visits can be an opportunity to initiate patient/parent education and make appropriate recommendations for use of a properly-fitted athletic mouthguard. Dental professionals need to develop effective ways of conducting research to determine the prevalence of sports-related injuries in their communities. Sports dentistry should encompass much more than mouth guard fabrication and the treatment of fractured teeth. As dental professionals, a responsibility exists to become and remain educated and pass that education on to the community regarding the issues related to sports dentistry and specifically to the prevention of sports-related oral and maxillofacial trauma. For optimal preventive techniques, it is recommended that sports dentistry should be included in dental curriculum at both undergraduate and postgraduate levels.

CONCLUSION

Orofacial injuries that occur during sports activities are largely preventable. Mouth protection for athletes is one of dentistry's contributions to sports medicine. It is the responsibility of the dental profession, therefore, to become more active in sports injury prevention programs.Many athletes are not aware of the health implications of a traumatic injury to the mouth or of the potential for incurring severe head and orofacial injuries while playing. The dentist can play an imperative task in informing athletes, coaches and patients about the magnitude of dental sciences in preventing orofacial injuries in sports. Education of all those involved is the key. Team physicians, dentists, athletic trainers, and coaches must take into consideration both the athlete's previous medical history and the sport. Our emphasis must be on improving the quality of mouth guards for player safety as one way of attempting to reduce the incidence of concussion in athletes.The epidemiology of orofacial injuries undergoes a paradigm shift with changes

REFERENCES

1. Scott J, Burke F, Watts D. A review of dental injuries and the use of mouthguards in contact team sports. Br Dent J. 1994;176(8):310-4.

2. Ranalli DN. Sports dentistry and dental traumatology. Dent Traumatol. 2002;18(5):231-6.

3. Soares PV, Tolentino AB, Machado AC et al. Sports dentistry: a perspective for the future. Rev. Bras. Educ. Fís. Esporte. 2014;28(2):351-8.

4. Kumamoto D, Maeda Y. A literature review of sports-related orofacial trauma. Gen. Dent. 2004;52(3):270-80.

5. Kerr G, Fowler B. The relationship between psychological factors and sports injuries. Sports Med. 1988;6(3):127-34.

6. Crow R. Diagnosis and management of sports-related injuries to the face. DCNA. 1991;35(4):719-32.

7. Guyette R. Facial injuries in basketball players. Clin. Sports Med. 1993;12(2):247-64.

8. Padilla R, Balikov S. Sports dentistry: coming of age in the'90s. CDA J. 1993;21(4):27-34, 6-7.

9. Linn EW, Vrijhoef MM, de Wijn JR et al. Facial injuries sustained during sports and games. J Maxillofac. surg. 1986;14:83-8.

10. Hammond D, Wain R, Reed A, Whitty J. A guide to sport-based injuries for the hospital-based dental trainee. Fac. Dent. J. 2016;7(1):40-5.

11. Luyk NH, Ferguson JW. The diagnosis and initial management of the fractured mandible. Am. J. Emerg. Med. 1991;9(4):352-9.

12. Le Fort R, Tessier DP. Experimental study of fractures of the upper jaw. Plast. Reconstr. Surg. 1972;50(5):497-506.

13. Karantanas AH. Sports injuries in children and adolescents: SSBM ; 2011.

14. Smith WS, Kracher CM. Sports-related dental injuries and sports dentistry. Dent Assist. 1998;67(3):12-6.

15. Camp J. Diagnosis and management of sports-related injuries to the teeth. DCNA. 1991;35(4):733-56.

16. Thierer T. Sports Dentistry and Public Health: Rules, Policy, and Politics. Modern Sports Dentistry:

17


Springer; 2018. p. 135-47. 20. Gupta s, gupta v. Prevention of sports related oro facial, injuries: a review.

17. Newman JA, Beusenberg MC, Shewchenko N. Verification of biomechanical methods employed in a 21. Heintz WD. The case for mandatory mouth protectors. comprehensive study of mild traumatic brain injury and Physician Sportsmed. 1975;3(4):60-3.the effectiveness of American football helmets. J.

22. Flanders RA, Bhat M. The incidence of orofacial Biomech. 2005;38(7):1469-81.

injuries in sports: a pilot study in Illinois. J. Am. Dent. 18. Pellman EJ, Viano DC, Withnall C et al. Concussion in Assoc. 1995;126(4):491-6.

professional football: helmet testing to assess impact 23. Winters Sr JE. Commentary: role of properly fitted

performance—part 11. Neurosurgery. 2006;58(1):78-mouthguards in prevention of sport-related concussion.

95.J. Athl Train. 2001;36(3):339-44.

19. Echlin PS, Upshur RE, Peck D, Skopelja E. 24. Lehl G. Perceptions of Chandigarh sports coaches

Craniomaxillofacial injury in sport: a review of regarding oro-facial injuries and their prevention. J

prevention research. Br. J. Sports Med. 2005;39(5):254-Indian Soc. Pedod. Prev. Dent.. 2005;23(2):67-73.

63.

18

Wilckodontics- An Accelerated Orthodontic Technique- A Review

ABSTRACT

Time taken for completion of treatment is one of the main disadvantage of conventional orthodontic therapy. Wilckodontics also known as periodontally Accelerated Osteogenic Orthodontics(PAOO) , is an effective orthodontic technique to achieve reduce the treatment time. This procedure involves a multidisciplinary approach, where Orthodontists and periodontists worked together to provide a predictable and rapid tooth movement.

Keywords: Periodontally accelerated osteogenicorthodontics, Corticotomy, Bone graft.

INTRODUCTION

Wilckodontics also called PeriodontallyAccelerated Osteogenic Orthodontics (PAOO) or alveolar osteogenicorthodontics, was

1.developed byDr.Wiliamswilckoand Dr.Thomaswilko in 2001 PAOO is an interdisciplinary approach that involves orthodontist and periodontist working together to provide rapid tooth movement.The clinical procedure involves selective alveolar corticotomy, particulate

2bone grafting and application of orthodontic forces . this procedure is based on bone healing pattern known as Regional Acceleratory

3Phenomenon(RAP) that was explained by Dr.Frost

SURGICAL PROCEDURE

Several surgical approaches have been tried to accelerate tooth movement. One of the surgical procedure which is most commonly employed is Corticotomy technique.

CORTICOTOMY5It was first tried in orthodontics by Kole in 1959 . This procedure

involves the following:-

1.Flap design

The purpose of the flap designing is mainly to access the alveolar bone during corticotomy procedure and also contribute the bone graft coverage procedure.It provides esthetic appearance by maintain the height, volume of interdentally surrounding tissues.

After placing sulcular releasing incision under local anesthesia on labial and lingual aspects of teeth,full thickness mucoperiosteal flaps is elevated in the coronal aspect and split thickness flap elevated at apices of the teeth and hence flap is made mobile and suturing will be done with minimal retention. To avoid the vertical incision, the flap should

V R BalajiProfessor and head, Department of Periodontics

and Implant Dentistry, CSI College of Dental

Sciences and Research, Madurai, India

D ManikandanReader, Department of Periodontics and Implant

Dentistry,CSI College of Dental Sciences and

Research, Madurai, India

R AbinayaPost ggraduate student, CSI College of Dental


A RamsudarPost graduate student, CSI College of Dental


T NishanthiniIntern, CSI College of Dental Sciences and

Research, Madurai, India.Tamil nadu


R AbinayaPost ggraduate student, CSI College of Dental


Review Article


19


be extended beyond mesial and distal corticotomy sites.In Coffeethe case of maxillary central incisor interdental papilla can CONCLUSION

5be preservedfor the esthetic purpose .If any granulation Corticotomy is considered as one of the most effective tissue is present in this site, it can be removed by usage of procedure for accelerating tooth movement.The successful curettes.treatment by wilckodontics can be achieved by proper

2.selectivecorticotomy coordination between the orthodontists and the periodontists with proper case selection. Orthodontist has a Selective alveolar cortication is done to initiate the Regional new treatment option to offer to the patient once they are Acceleratory Phenomenon by activating the labial and skilled in Periodontally accelerated orthodontic procedure lingual side of alveolar bone using piezo electric knife or there by speeding up the treatment.number 1,2 round bur. Vertical groove extending from just2-

3 mm below the crest of alveolar bone to 2mm beyond the 4apex of the root in interradicular space , which are connected

with circular shaped horizontal corticotomyto avoid damage underlying structure like maxillary sinus, mandibular canal. Corticotomy cuts and perforation are made through the entire thickness of cortical bone.

3.particulate bone graft

Bone graft material like deproteinized bovine bone, autogenous bone, decalcified freeze dried bone allograft or combination will be used to cover the decortication side. Placement of excessive graft should be avoided because of its interference with repositioning of flap.

4.Flap closure

The success of primary flap closure is determined by not causing any excessive tension in surgical side and also by proper suturing technique. Non resorbable interrupted loop suture will be placed. They are left for about 2-3 weeks and appropriate analgesic and antibiotics will be given for 5 days.

5.orthodontic adjustment

Week before the PAOO procedure orthodontic brackets are placed and the arch wires are activated. Brackets adjustment will be done for every two weeks by orthodontist and applied the immediate heavy orthodontic forces within 4 to 6 months.

OTHER PROCEDURES TO ACCELERATE THE TOOTH MOVEMENT:-

Piezocision technique

Intraseptal alveolar surgery

Low level laser therapy6Micro-osteoperforations(mops)

Photobiomodulation7Prostaglandin effect on tooth movement

10Vitamin –D

Local injection of biomodulators

Relaxin effect on tooth movement8Submucosal injection of PRP

9Gene therapy(GT)

�

REFERENCES

1. Wilcko WM, Wilcko MT, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: Two case reports of decrowding. Int J Periodontics Restorative

Dent 2001;21:9-19

2. Wilcko WM, Ferguson DJ, Bouquot JE, Wilcko MT. Rapid orthodontic decrowding with alveolar

augmentation: Case report. World J Orthod2003;4:197-505.

3. Dolas S, Shende A, Kulshrestha R, PatilH.Periodontally accelerated osteogenic orthodontics. Int J OrthodRehabil 2018;9:82-5.

4. Kumar s, parasharP, singla V, singlaN.wilckodontics :a m u l t i d i s p l i n a r y t r e a t m e n t a p p r o a c h i n dentistry.Int.j.res.dev. pharm.l.sci October to November ,2015,vol.4,no 6.

5. KoleH.surgical operation on the alveolar ridge to correct occlusalabnormalities.oralsurg oral med oral patho.1959;12:515-29.

6. Alikhani M, Raptis M, Zoldan B et al. Effect of micro-osteoperforations on the rate of tooth movement. Am J OrthodDentofacialOrthop2013;144:639-48.

7. Ali Reza Sekhavat, KazemMousavizadeh, Hamid Reza Pakshir and Fatemeh Sari Aslani.Effect of misoprostol, a prostaglandin E1analog, on orthodontic tooth movement in rats. American Journal of Orthodontics and DentofacialOrthopedicsVolume 122, Number 5.

�8. Liou EJ. The development of submucosal injection of

�platelet rich plasma for accelerating orthodontic

� toothmovement and preserving pressure side alveolar bone. APOS Trends Orthod 2016;6:5-11.�

9. Andrade JR I, Sousa ABS, Silva GG. New therapeutic �modali t ies to modulate or thodontic tooth

�movement.Dental Press J Orthod. 2014 Nov-

� Dec;19(6):123-33.

� 10. Monte K. Collins and Peter M. Sinclair. The local use- of vitamin D to increase the rate of orthodontic tooth �movement. am j orthoddentofacorthop1988;94:278-84.

�

�

20

White spot lesion of dental caries: A Review

ABSTRACT

There has been a shift from Black's “extension for prevention” to a minimal intervention approach in the recent time. The diagnosis of earliest stages of demineralization of enamel, accurate and reliable detection of white spot lesions is very important. The recently developed diagnostic materials would help the dentist to detect and diagnose early to stimulate remineralization and conservation of the tooth substance. A high level of caries experience requires preventive strategies which are cost-effective in compare to surgical intervention and restorative procedures. The aim of modern dentistry is to manage white lesionsby remineralization to prevent progression of disease, function of teeth, esthetics, andto improve strength.

Keywords: Demineralization, Remineralization, White spot lesions

INTRODUCTION

The word 'caries' is derivative from the Latin word meaning 'rot' or 1'decay'. It is akin to the Greek word 'ker' meaning death. Dental caries

is defined as a pathological process of localized destruction of tooth tissues by microorganisms.Dental caries is a multifactorial disease, in which there is interplay of three principal factors, i.e., the host (saliva and teeth), the micro flora, and the substrate or diet. In addition, a forth factor, i.e., time must be considered in any discussion of etiology of dental caries. For occurrence of dental caries each of these factors must

2be favorable.

Dental carious lesions can be classified based on the anatomical site, progression, virginity of lesion, extends of caries, tissue involvement,

1pathway of caries spread, tooth surface involved. Early caries lesion in enamel is seen as a 'white opaque spot'. It is characterized by being softer than the adjacent sound enamel, at the same time is increasingly

3whiter when dried with air.

Russell has classified white discolorations of enamel as dental 4fluorosis, opacities, or white spot lesions. Types of enamel

demineralization include incipient lesions and “surface-softened 3defect”, which are the other names used to term white spot lesions.

Incipient lesions are active lesions which continue to progress under 5acid attack,but an arrested lesions does not progress.

There are many microorganisms which are capable of creating organic acids that reduce the pH of the dental plaque when they exposed to carbohydrates. The essence of the carious process is local

Neel ChaudharyPost graduate student, Department of Pediatric



Dinesh RaoProfessor and Head, Department of Pediatric



Sunil PanwarReader, Department of Pediatric Dentistry



Harleen NarulaSenior Lecturer, Department of Pediatric Dentistry



D. Krishna DasPost graduate student, Department of Pediatric




Neel ChaudharyPost Graduate Student

Department of Pediatric Dentistry

Pacific Dental College and Hospital

Udaipur- 313024, Rajasthan state, India

Review Article


21


3demineralization of enamel, causing degradation of remineralize and is, therefore, regarded as reversible.hydroxyapatites. This process is initiated within bacterial

CLINICAL SIGNSbiofilm. Caries lesions progress where oral biofilms are allowed to mature and remain on teeth for long Dental caries lesions are the outcome or symptoms of duration.Numerous streptococcus strains, including innumerable metabolic events in biofilms, which have streptococcus mutans, streptococcus sanguinisand to a covered a tooth surface. When this outcome results in a lesser extent, lactobacillus are considered as prime bacterias cumulative loss of mineral from the tooth, it gives rise to a involved in the development of dental caries. Dental enamel decrease in enamel translucency, which can be called as is composed of hydroxyapatite with slighter amounts of white opaque lesions. Early stages of enamel lesion water, protein, including fluoride. The enamel can be easily formation will manifest themselves as white-spot lesions. demineralized in presence of these acids causing cavitation. Because these are indicative of increased porosity of the But in the presence of remineralizing agents enamel is enamel and expected that food stain will sieve into the capable of maintaining its natural form without undergoing enamel and hence a white spot lesion may changes in color

6degradation. to brown and even almost black.Clinically the white-spot lesion has a characteristic chalky surface. This chalky white

The disease process is believed to be a beginning with the surface is evident as the internal enamel porosity increase

first atomic level of demineralization, and then the early due to demineralization, loss of translucency increase, thus

lesions of the enamel followed by the dentin involvement 7making the enamel appear opaque.and finally cavitation. However, the early lesion is known to

Deciduous dentition

Figure 1:A 3-year-old child with thick accumulations of dental plaque along the gingival margin of the buccal surfaces covering active caries lesions, some of which present with distinct cavities.

Figure 2:Upper deciduous canine from a 5-year-old with an active, cavitated lesion along the gingival margin. Provoke a pain reaction!

Figure 3:Inactive or arrested caries lesions on buccal surfaces of upper centralincisor teeth in a 5-year-old child. Note that the shape of the lesions indicates where the gingival margin was located at the time when these lesions developed.

Figure 4:Upper incisors in a 5-year-old child. Several narrow, white, opaqueinactive caries lesions are located 1–2 mm from the gingival margins. One of the lesions exhibits a large cavity which on probing is hard. This is an example of an inactive, cavitated lesion.

22


Figures 5, 6:A case of a 2-year-old child with extensive, active, partly cavitated caries lesions encircling the teeth. This is an example of bottle nursing caries,or bottle caries.

Figures 7, 8:Slightly discolored non-cavitated approximal lesions on exfoliated deciduous molar. Note that the shape of the lesions reflects where dentalplaque has been retained above the position of the gingival margin.

The approximal white-spot lesion border of the lesion is formed according to the shape of the gingival margin (fig 9-10). It is often possible in such

The shape of the white-spot lesion is determined by the surfaces to see thin extensions of the opaque area, in buccal

distribution of the microbial deposits between the contact and lingual directions, running in parallel with the gingival

facet and the gingival margin, which results in a kidney margin. Some of these lesions will be active and others

shaped appearance. On the proximal smooth surface, there inactive owing to different efforts to control the microbial

will typically be an interdental facet area surrounded by an 8accumulations, for example with dental floss.opaque area extending in the cervical direction. The cervical

23


Figures: 9-10:Active, non-cavitated early white-spot lesions on mesial surfaces of upper and lower first molars are easily observed following shedding of primary teeth. The shape of each lesion indicates the stagnant areas where the biofilm (dental plaque) remained undisturbed. In the most demineralized areas in the center of the lesions, the porous enamel has taken up stain. The lesion in Fig. 2.17 was treated non-operatively and has remained as an inactive, non-cavitated lesion for 25 years.

Figure 11:Scanning electron micrograph of initial surface dissolution cervical to contact facet (CF) in an active enamel lesion.

Surface features of the clinical white-spot lesion also comprise micro cavities. The surface enamel surrounding such cavities exhibits marked abrasion with

While examining the surface of an active white-spot lesion irregular scratches, but in between rows of pits of Tomes'

(fig 11), characteristic changes can be observed on processes, irregular deeper holes may be seen. The rod and

interproximal surfaces. The contact facet has a smooth interrod enamel in such areas is also smooth. In contrast, the

appearance without the perikymata pattern, but along the enamel surface in sheltered areas such as the bottom of the

periphery of the facet, irregular fissures and other small micro cavities appears densely granular, indicative of

defects can be observed. In the opaque surface enamel 8merging ends of the individual crystals.cervical to the facet, innumerable irregular holes are seen. These are deepened and more irregular pits of Tomes' Mechanism of lesionprocesses and also an increased number of eroded focal

The carious process takes place slowly which requires holes. In other areas the deepened pits of Tomes' processes repeated episodes of prolonged exposure to acidic appear to merge together, forming larger areas of irregular conditions consistently below the critical pH for enamel (pH cracks or fissures. The final enamel exhibits distinct patterns 5.5, demineralization) with intervening periods of the of dissolution with widened intercrystalline spaces, and 9-11resting pH of plaque. Failure to eliminate plaque from minor fractures of the perikymata edge are frequently found. retentive tooth areas, frequent carbohydrate ingestion and When examining inactive, arrested lesions, which still the equilibrium between remineralization and clinically appear as white-spot lesions, some of these may

24


demineralization.The early enamel lesion is characterized Radiography 12 ,13by fourhistopathologic zones. Two zones of Detection of occlusal carious lesions, especially in their

demineralization exist: early stages is difficult, so radiography should be used in conjunction with other detection methods, such as 1. The translucent zone (1% pore volume) and transillumination. The detection capabilities of digital

2. The body of the lesion (>5-25% pore volume), radiography are reported to be similar to that of film based demonstrating the majority of the lesion and situated methods and has the benefit of reduced radiation exposure approximately 15-30 ìm below the intact enamel surface. and also the ability to readily transfer the images. The

sensitivity of detecting cavitated and non-cavitated lesions Two zones of remineralization also exist: in posterior teeth increased from 0.34 to 0.63 after tactile

1. The dark zone (2-4% pore volume) situated near to the detection was included with radiography.translucent zone and

Light-induced fluorescence 2. The surface zone (1 to <5% pore volume) creating the

12,13 Quantitative light-induced fluorescence systems (including intact surface overlying the lesion.TM TMQLF , Inspektor BV, The Netherlands; Vistaproof , Durr

The initial dissolution results in the loss of a small amount of TMDental AG, Germany; and Sopralife , Acteon, Le Ciotat, mineral within the enamel and would have a similar

France) utilize differences in auto fluorescence between appearance to the translucent zone (negative birefringence

sound and demineralized enamel and also dentine. in quinoline). With ongoing removal of mineral from the

Demineralized enamel appears darker than the adjacent underlying enamel, a positively birefringent body of the

sound tooth structure, and the carious dentine fluorescence lesion (water imbibition) develops and separates the

red depending on the filters used. overlying surface zone from the translucent zone at the advancing front. If lesion development occurs over a The use of QLF enables the early detection of enamel relatively long period, a zone of remineralization (the dark demineralization and also there is the possibility that it may zone, positive birefringence in quinoline) with reciprocation be used to discriminate between affected and infected

TMof mineral phases from the translucent zone will occur. If dentine. Like the DIAGNOdent , QLF technology is reliant lesion formation is over a short period of time, the dark zone on standardized technique, especially control of ambient will not form and there will be rapid advancement of the light, and the results must be interpreted in conjunction with front with a large, heavily demineralized body of the other detection methods in the context of the caries risk of

14lesion. the individual.

DIAGNOSIS Photothermal radiometry

Visual detection A new system released recently uses laser-based photothermal radiometry/modulated luminescence (PTR-

For accurate visual assessment the tooth must be dry, clean LUM; Canary, Quantum Dental Technologies Inc., Toronto,

and there must be adequate lighting. The initial stages of Canada), detecting luminescence differences and also

caries presents as a white spot lesion, which is due to change in temperature to quantify mineralization changes.

presence of less mineral content resulting in the changed Images has been captured which are stored in the associated

visual characteristics of the enamel. In the early stages of 15software, a 'Canary' number.demineralization, white spot lesion may only be visible to the naked eye after drying. Radiography can improve the TREATMENTdetection of occlusal lesions when they have progressed into

Remineralizing Agents the dentine. The visualization of proximal caries in posterior teeth is difficult by the overlying tooth structure at the Compound of casein phosphopeptides-amorphous marginal ridge, mainlyin the earlycarious lesion. calcium phosphate

Tactile detection Compound of casein phosphopeptides-amorphous calcium phosphate (CPP-ACP) is an acronym for a CPPs and ACP. The use of tactile detection has been a mainstay of clinical Caseins are a heterogeneous family of proteins dentistry for more than 100 years, and using a sharp probe or preponderated by alpha 1 and 2 and b-caseins. CPPs are explorer as a caries detection method persists in both clinical phosphorylated casein which arederived peptides produced examination. It has been recommended for at least two by tryptic digestion of casein. decades that this technique be limited or replaced for

detection of fissural or smooth surface caries. The CPP containing the amino acid cluster sequence – Ser (P)-Ser (P)-Ser (P)-Glu-Glu has the capacity to bind and stabilize calcium and phosphate in solution, as well as to

25


bind dental plaque and tooth enamel. Through their multiple to keep the calcium and phosphorous components from phosphoryl residues, the CPPs bind to form clusters of ACP reacting with each other before treatment. The current in metastable solution, avoiding their growth to the critical sources of calcium and phosphorous are two salts, calcium size needed for nucleation and precipitation. The sulphate and dipotassium phosphate. When two salts are mechanism of anticariogenicity for the CPP-ACP is that it mixed, they quickly form ACP that will precipitate on the localizes ACP in dental plaque, which buffers the free tooth surface. These precipitated ACP then freely dissolve calcium and phosphate ion activities, thereby helping to into the saliva and can be available for tooth

26maintain a state of supersaturation with respect to tooth remineralization. It can be considered as a useful adjuvant e n a m e l r e d u c i n g d e m i n e r a l i z a t i o n a n d for the control of caries in orthodontic applications. increasingremineralization. The CPPs have been shown to Experimental ACP transfers throughout the body of the

27keep fluoride ions in solution, thereby enhancing the lesion and restore the mineral lost due to acid attack. The 16,17 28efficacy of the fluoride as a remineralizing agent. ACP technology was developed by Dr. Ming S. Tung in

1997, ACP was incorporated into toothpaste called Complex of casein phosphopeptides prevents adherence of Enamelon and later reintroduced in 2004 in Enamel Care oral bacteria to saliva-coated hydroxyapatite beads (S-HA). toothpaste by Church and Dwight.By selectively inhibiting the streptococcal adhesion to teeth,

it can modify the microbial composition of dental plaque Sodium calciumphosphosilicate (bioactive glass) and establishment of less cariogenic species like oral

18,19 When bioactive glass reacts with saliva, it rapidly releases actinomyces. It can be integrated into the pellicle in sodium, calcium, and phosphorous ions into the saliva that exchange for albumin and thus inhibits the adherence of are available for remineralization of the tooth surface. The Streptrococcusmutansand Streptococcus sobrinus, causing ions released form hydroxycarbonate apatite (HCA) 20enhancement of remineralization.directly. They also adhere to the tooth surface and continue

The Recaldent Technology was developed by Prof. Eric to release ions and remineralize the tooth surface after the Reynolds of the University of Melbourne. CPP-ACP has initial application. These particles release ions and been trademarked Recaldent and is propelled in sugarless transform into HCA for up to 2 weeks. Ultimately, these

29chewing gum and confectionery. Recently, a sugar-free, particles will completely transform into HCA.cream containing Recaldent™ (CPP-ACP) (GC Tooth

NovaMinattach to exposed dentin surface and forms a Mousse/Prospec MI Paste) has been available to dental mineralized layer that is mechanically strong and resistant to 21professionals.acid. There is a constant release of calcium, which maintains

3022 the protective effects on dentin. The NovaMin Technology Reynolds EC et al., completed a study in 2003 and stated was developed by Dr. Len Litkowskiand Dr. Gary Hack. that when CPP–ACP was present in a mouthwash, which NovaMin: SootheRx, DenShield, NuCare Root Conditioner helped in the increase of calcium and phosphate levels in with NovaMin, NuCare- Prophylaxis Paste with NovaMin, supragingival plaque. and Oravive are the products which are awailable in the 23Christos and George in 2007 carried out an in vitro study on 31,32market.

human teeth to demonstrate the effect of CPP–ACP Calcium carbonate carrier-SensiStatcommercial paste on demineralization and remineralization.

They used multiple internal reflection–Fourier transform The SensiStat technology is prepared of arginine infrared spectroscopies (MIR–FTIR) for analysis and found bicarbonate, an amino acid complex, and particles of that the presence of CPP–ACP agent on dentine caused calcium carbonate. The arginine complex is accountable for decreased demineralization and increased remineralization adhering calcium carbonate particles to the dentin/enamel when compared with the surfaces of dentine where surface and allows the calcium carbonate to dissolve and CPP–ACP agent was not used. release calcium which is then available to remineralize the

33Some researchers have added CPP–ACP into Glass ionomer tooth surface. The SensiStat Technology was developed by cements (GIC) and have found after their in vitro study that Dr. Israel Kleinbergof New York. The technology was first GIC containing CPP–ACP provided increased protection to incorporated into Ortek'sProclude desensitizing prophy

34dentine during acid attack. paste and later in Denclude.25 Xylitol carrier Azarpazhooh and Limeback exhibited that the long-term

effectiveness of CPP-ACP in preventing caries in vivo is The use of chewing gum carrying xylitol surges salivary

unknown due to lack of clinical trial evidence.flow rate and increases the protective properties of saliva. This is because the concentration of bicarbonate and Amorphous calcium phosphate phosphate is higher in stimulated saliva, and the resultant

Two-phase delivery system requires in the ACP technology

26


increase in plaque pH and salivary buffering capacity with 2.5% alpha-TCP by weight was chewed, when 44prevents the demineralization of tooth structure. In such compared to a control gum without added TCP.

saliva the higher concentration of calcium, phosphate, and Dicalcium phosphate dihydrate35hydroxyl ions also enhances remineralization.Dicalcium phosphate dihydratehas been used in some

Chewing xylitol gums showed a good report of reduction in fluoride dentifrices to enhance on the remineralizing effects

the caries incidence upto 5 years even after the therapy is of the fluoride component. Inclusion of DCPD in a

discontinued. The dental literature suggests that a minimum dentifrice rises the levels of free calcium ions in plaque fluid,

of 5-6 grams and three exposures per day is required for and these remain elevated for up to 12 hours after brushing,

clinical effect. An exposure of 3 times/day and 5-6 gms of 45when compared to conventional silica dentifrices.36xylitol gums or candies are proven to give clinical effects.Calcium from Dicalcium phosphate dihydrate was 37Zhan et al,. has done study for effects of Xylitol wipes on integrated into enamel and detected in plaque 18 hr post-

cariogenic bacteria and Caries in young children and stated treatment after brushing with a DCPD dentifrice which that daily xylitol wipe application significantly reduced the improvesremineralization of teeth in combination with

46caries incidence, and also suggested that the use of xylitol fluoride.

wipes may be a useful adjunct for caries control in infants.CONCLUSION38Ritter et al,. has done study to investigate whether xylitol The balance between demineralization and remineralization lozenges had a differential effect on cumulative caries determines the progression of white spot lesion. The increments on different tooth surfaces and stated that xylitol diagnostic armamentarium comprises of novel technologies appears to have a caries-preventive effect on root surfaces.

3 9 and non-invasive techniques l ike f iber-opt ic Miakeet al,. observed that xylitol can induce transillumination and electrical resistance methods which remineralization of deeper layers of demineralized enamel are helpful in detecting posterior approximal dentinal caries by facilitating Ca2+ movement and accessibility. Antonio et

40 and occlusal caries. Radiographs and direct digital imaging al,. suggests that xylitol could have tooth-surface-specific are still significant tools in estimation of caries. caries preventive effects but did not examine coronal vs. root Understanding of the mechanism of subsurface lesion surfaces.formation and progression, possibilities, and limitations of

Nano-hydroxyapatite newer methods and their clinical applications need to be recognized by the dentist to imply preventive strategies to A study was carried out to determine the effect of nano-HAP the high caries risk individuals. The emphasis currently is concentrations on initial enamel lesions under dynamic pH-given to new technologies for enamel remineralization cycling conditions. It was concluded that nano-HAP had the which suggest the changes in the understanding of dental ability to remineralize initial enamel lesions. A caries. Recent studies have mainly focused on different concentration of 10% nano-HAP may be optimal for

41 calcium phosphate-based technologies which are planned to remineralization of early enamel caries.supplement and enhance fluoride's ability to restore tooth

The trimetaphosphate ion mineral.

The mode of action of trimetaphosphate ion (TMP) is to involve in absorption of the agent to the enamel surface, which provide a barrier coating that is effective in retarding reactions of the crystal surface with its fluid, and hence

42reducing demineralization during acid challenge. Guet 43al,. highlighted the role of sodium TMP as a templating

analog of dentin matrix phosphoproteins for inducing intrafibrillarremineralization of apatite nanocrystals within the collagen matrix of incompletely resin infiltrated dentin.

Alpha-tricalcium phosphate

It is used in products likeCerasorb, Bio-Resorb, and Biovision. Tricalcium phosphate (TCP) has also been considered as responsible for enhancing the levels of calcium in plaque and saliva.

Little effects on calcium and phosphate levels in plaque fluid and in saliva have been found when an experimental gum

REFERENCES

1. Marwah N, Goenka P. Dental caries. In: Marwah N. Editor. Textbook of pediatric dentistry. New Delhi: Jaypee Brothers Medical Publishers. 2014:p.473-96.

2. Newbrun E, Caesar J. History and Early Theories of the Etiology of Caries. In: Newburn E. Editor. Cariology. Chicago: Quintessence publishing. 1989:p.13-28.

3. Roopa KB,Pathak S, Poornima P, Neena IE. White spot lesions: A literature review. J Pediatr Dent 2015;3(1):1-7.

4. Bishara SE, Ostby AW. White spot lesions: formation, p r even t ion , and t r ea tmen t . SeminOr thod 2008;14(1):174-82.

5. Arends J, Christoffersen J. Invited review article: the nature of early caries lesions in enamel. J Dent Res

27


1986;65(1):2-11. vitro study. Aus Dent J 2008;53(1):34-40.

6. John MK, Babu A, Gopinathan AS. Incipient caries: an 20. Rose R. Binding characteristics of Streptococcus early intervention approach. Int J Community Med mutans for calcium and casein phosphopeptide. Caries Public Health 2015;2(1):10-4. Res 2000;34(1):427-31.

7. Holmen L, Thylstrup A, Årtun J. Clinical and 21. Schüpbach P, Neeser J-R, Golliard M, Rouvet M, histological features observed during arrestment of G u g g e n h e i m B : I n c o r p o r a t i o n o f active enamel carious lesions in vivo. Caries Res caseinoglycomacropeptide and caseinophosphopeptide 1987;21(1):546-54. into the salivary pellicle inhibits adherence of mutans

streptococci. J Dent Res 1996;75(1):1779-88. 8. Fejerskov O, Kidd E, Nyvad. Clinical appearances of

caries lesions. In: Fejerskov O, Kidd E. Editor. Dental 22. Reynolds E, Cai F, Shen P, Walker G. Retention in caries: the disease and its clinical management. plaque and remineralization of enamel lesions by Australia: John Wiley & Sons: 2008:p.8-18. various forms of calcium in a mouthrinse or sugar-free

chewing gum. J Dent Res 2003;82(1):206-11. 9. Fejerskov O. Concepts of dental caries and their

consequences for understanding the disease. 23. Rahiotis C, Vougiouklakis G. Effect of a CPP-ACP Community Dent Oral Epidemiol 1997;25(1):5-12. agent on the demineralization and remineralization of

dentine in vitro. J Dent 2007;35(1):695-8. 10. Walsh LJ. Preventive dentistry for the general dental

practitioner. Aus Dent J 2000;45(1):76-82. 24. Mazzaoui S, Burrow M, Tyas M, Dashper S, Eakins D, Reynolds E. Incorporation of casein phosphopeptide-

11. Featherstone JD. The science and practice of caries amorphous calcium phosphate into a glass-ionomer

prevention. J Am Dent Assoc 2000;131(1):887-99. cement. J Dent Res 2003;82(1):914-8.

12. Silverstone LM, Hicks MJ, Featherstone MJ. Dynamic 25. Llena C, Forner L, Baca P. Anticariogenicity of casein

factors affecting lesion initiation and progression in phosphopeptide-amorphous calcium phosphate: a

human dental enamel. Surface morphology of sound review of the literature. J Contemp Dent Pract

enamel and carieslike lesions of enamel. Quintessence 2009;10(1):1-9.

Int 1988;19(2):773-81. 26. Tung M, Eichmiller F. Dental applications of

13. Silverstone L. Dynamic factors affecting lesion amorphous calcium phosphates. J Clin Dent

initiation and progression in human dental enamel. The 1999;10(1):1-6.

dynamic nature of enamel caries. Quintessence Int 1988;19(1):683-711. 27. Langhorst S, O'Donnell J, Skrtic D. In vitro

remineralization of enamel by polymeric amorphous 14. Hicks J, Garcia-Godoy F, Flaitz C. Biological factors in

calcium phosphate composite: quantitative dental caries: role of saliva and dental plaque in the

microradiographic study. Dent Mater J 2009;25(1):884-dynamic process of demineral izat ion and

91. remineralization. J ClinPediatr Dent 2004;28(1):47-52.

28. Sullivan R, Charig A, Blake-Haskins J, Zhang Y, Miller 15. Manton D. Diagnosis of the early carious lesion. Aus

S, Strannick M, Gaffar A, Margolis H. In vivo detection Dent J 2013;58(2):35-39.

of calcium from dicalcium phosphate dihydrate 16. Rose R. Effects of an anticariogenic casein dentifrices in demineralized human enamel and plaque.

phosphopeptide on calcium diffusion in streptococcal Adv Dent Res 1997;11(1):380-7. model dental plaques. Arch Oral Biol 2000;45(1):569-

29. Du M, Tai B, Jiang H, Zhong J, Greenspan D, Clark A. 75.

Efficacy of dentifrice containing bioactive glass (NovaMin) on dentine hypersensitivity. J Dent Res 17. R e y n o l d s E . C a l c i u m p h o s p h a t e - b a s e d 2004;83(1):1586-622. remineralization systems: scientific evidence. Aus

Dent J 2008;53(1):268-73. 30. Burwell A, Jennings D, Greenspan DC. NovaMin and dentin hypersensitivity-in vitro evidence of efficacy. J 18. Azarpazhooh A, Limeback H. Clinical efficacy of Clin Dent 2010;21(1):66-71. casein derivatives: a systematic review of the literature.

J Am Dent Assoc 2008;139(1):915-24. 31. Tai BJ, Bian Z, Jiang H, Greenspan DC, Zhong J, Clark AE, Du MQ: Anti- gingivitis effect of a dentifrice 19. Kumar V, Itthagarun A, King N. The effect of casein containing bioactive glass (NovaMin) particulate. J phosphopeptide- amorphous calcium phosphate on ClinPeriodontol 2006;33(1):86-91. remineralization of artificial carieslike lesions: an in

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32. Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds 40. Antonio AG, PierroVSdS, Maia LC. Caries preventive E. Acid resistance of enamel subsurface lesions effects of xylitol- based candies and lozenges: a remineralized by a sugar-free chewing gum containing systemat ic review. J Publ ic Heal th Dent casein phosphopeptide-amorphous calcium phosphate. 2011;71(1):117-24. Caries Res 2004;38(1):551-6.

41. Huang S, Gao S, Yu H. Effect of nano-hydroxyapatite 33. Nizel AE, Harris RS. The effects of phosphates on concentration on remineralization of initial enamel

experimental dental caries: a literature review. J Dental lesion in vitro. Biomed Mater 2009;4(1):34104-11. Res 1964;43(1):1123-36.

42. Gonzalez M. Effect of trimetaphosphate ions on the 34. McClure F. Further studies on the cariostatic effect of process of mineralization. J Dent Res 1971;50(1):1056-

organic and inorganic phosphates. J Dent Res 64. 1963;42(1):693-9.

43. Gu L, Kim J, Kim YK, Liu Y, Dickens SH, Pashley DH, 35. Mäkinen KK. Sugar alcohols, caries incidence, and Ling J-q, Tay FR. A chemical phosphorylation-inspired

remineralization of caries lesions: a literature review. design for Type I collagen biomimetic remineralization. Int J Dent 2009;981072(1):1-23. Dent Mater 2010;26(1):1077-89.

36. Milgrom P, Ly K, Rothen M. Xylitol and its vehicles for 44. Vogel G, Zhang Z, Carey C, Ly A, Chow L, Proskin H. public health needs. Adv Dental Res 2009;21(1):44-7. Composition of plaque and saliva following a sucrose

challenge and use of an a-tricalcium-phosphate-37. Zhan L, Cheng J, Chang P, Ngo M, Denbesten P, Hoover containing chewing gum. J Dent Res 1998;77(1):518-C, Featherstone J. Effects of xylitol wipes on cariogenic 24. bacteria and caries in young children. J Dent Res

2012;91(1):85-90. 45. Walsh LJ. Contemporary technologies for remineralization therapies: A review. Int Dent SA 38. Ritter A, Bader J, Leo M, Preisser J, Shugars D, Vollmer 2009;11(1):6-16. W, Amaechi B, Holland J. Tooth-surface-specific

effects of xylitol: randomized trial results. J Dental Res 46. Sullivan R, Masters J, Cantore R, Roberson A, Petrou I, 2013;92(1):512-7. Stranick M, Goldman H, Guggenheim B, Gaffar A.

Development of an enhanced anticaries efficacy dual 39. Miake Y, Saeki Y, Takahashi M, Yanagisawa T. component dentifrice containing sodium fluoride and Remineralization effects of xylitol on demineralized dicalcium phosphate dihydrate. Am J Dent enamel. J Electron Microsc 2003;52(1):471-6. 2001;14(1):3A-11A.

29

ABSTRACT

Oroantral communication (OAC) is an abnormal communication between the oral cavity and the maxillary sinus, the most common cause being as a result of extraction of upper premolars and molars. This may, subsequently, lead to the formation of oroantral fistula if left untreated at an early stage.

Keywords: Maxillary sinusitis,CBCT

CBCT as a diagnostic tool in the diagnosis of Oroantral Fistula associated

withright Maxillary Sinusitis: a case report

INTRODUCTION

CASE REPORT

A female patient,53 years old visited the department of Oral medicine and Radiology, Pacific Dental College and Hospital with the chief complain of pus discharge from her upper right back tooth region since 2 months.

The patient presented with a past history of extraction of 16 done 2 months back following which she experienced pus discharge from the socket and also heaviness on the right side of face along with nasal discharge .Patient did not have any relevant medical history.(Fig 1)

Oroantral fistula (OAF) is an epithelialized pathological communication between the oral cavity and maxillary antrum.It develops when the oro-antral communication fails to close spontaneously, remains patent and gets epithelialized. There is

1migration of oral epithelium into the defect. This epithelialization usually occurs when the perforation persists forat least 48-72 hours.The etiopathology for OAF is dental infection, radiation therapy, sequelae of removal of maxillary cysts and tumors, osteomyelitis, and

2trauma can cause OAC. The most common etiologic factor for OAC is 3upper molar extractions as it has anatomic close relationship between

the root apices of maxillary premolars and molars to the sinus floor. CBCT is essential in the diagnosis and treatment planning of OAFs

Ch. AnupriyaPost Graduate Student Dept. Of Oral Medicine And Radiology, Pacific Dental College & Hospital Debari, Udaipur

Prashant NaharProfessor, Dept. Of Oral Medicine And Radiology Pacific Dental College & Hospital, Debari Udaipur

Mohit Pal SinghProfessor and Head, Dept. Of Oral Medicine And Radiology, Pacific Dental College & HospitalDebari, Udaipur

Saurabh GoelDept. Of Oral Medicine And Radiology Pacific Dental College & Hospital, Debari, Udaipur

Hemant MathurReader, Dept. Of Oral Medicine And Radiology Pacific Dental College & Hospital, Debari, Udaipur

Tulip ChakravartyPost Graduate Student Dept of Public Health Dentistry,Pacific Dental College & Hospital Debari, Udaipur


Ch. AnupriyaPost Graduate Student Dept. Of Oral Medicine

And Radiology, Pacific Dental College & Hospital

Debari, Udaipur

Case Report


30


Figure 1: Extraoral view

Intraoral examination revealed a fistula approx 1 cm in diameter at the depth of extraction socket 16 with no pus discharge and was associated with tenderness on palpation.(Figure 2)

Figure 4:OPG SHOWING HAZINESS OF THE RIGHT ANTRUM

Figure 2:Intraoral view showing Fistula irt 16 region

A clinical diagnosis of Oroantral fistula /residual pathosis associated with 16 was given.

Radiographic investigations were advised. IOPAR irt16 ,OPG,PNS view were performed.

IOPARirt 16 revealed missing 16 with breach in the continuity of the maxillary sinus floor.(Figure 3)

Figure 5: PNS VIEW SHOWING GENERALISED HAZINESS INVOLVING THE RIGHT ANTRUM

To evaluatethe status of maxillary sinus, 3D CBCT Scan performed for Maxilla at 10x10 FOV with slice thickness of 0.9mm and spacing of 1mm was performed which revealed Missing 16 associated with a large breach in the continuity of floor of Rightantrum (measuring approx.. 13.2mm buccopalatally and 9.8mm mesiodistally) , with almost

Figure 3:IOPARirt 16 showing breach in continuity of complete obliteration of the sinus cavity , resorption of

maxillary sinus floorinternal septae and lateral wall of Right nasal cavity. There

OPG revealed missing 16 associated with breach in the was associated obliteration of anterior ethmoidal cells Right continuity of the floor of the right antrum with haziness side with mucosal hypertrophy of middle and inferior which was suggestive of oroantral communication/oroantral turbinate Right nasal cavity and obliteration of middle fistula associated with chronic right sinusitis right meatus which was suggestive of Oro-antral communication antrum(Figure 4).Generalized haziness of the rightantrum / OAF 16 region associated with Sinusitis Rightantrum and was evident inPNS view which was suggestive of ethmoid with involvement of Right nasal cavity.(Figure 6)sinusitis.(Figure 5)

31


Figure 6: CBCT SCANS SHOWING CORONAL,AXIAL AND SAGITTAL VIEW

MANAGEMENT: plays a key role in diagnosing OACs and the status of maxillary sinus and nasal cavities which was clearly

Under local anesthesia, the surgical procedure was carried traceable on 3D imaging, thus,CBCT is essential in the

out, the removal of fistula was done along with sinus diagnosis and treatment planning of OAFs.

irrigation with saline and the buccal fat pad was used to completely cover the defect and then sutured. The suture Acknowledgementwas removed after a 15-day postoperative period without

To the Department of Oral and Maxillofacial Surgery complications.

Pacific Dental College And Hospital,Debari, Udaipur for DISCUSSION providing the treatment and post treatment records.

OACs have various etiologies,out of which the removal of the maxillary posterior teeth is the major cause of the communication reported. These communications are diagnosed through clinical evidence, radiographic imaging which also aid in the diagnosis.The presented case shows how 2D imaging helps in the diagnosis , 3D imaging on the other hand also had helped in identifying OAF and also the status of maxillary sinus and nasal cavity,which was not traceable in 2D imaging.

For surgical treatment of OAFs gross or radiographic identification are requiredfor proper correction. This method eventually provides an additional modality to aid surgeons in treatment planning.Buccal Pad of Flat Flap is one of the satisfactory method to close the oro-

4antraldefects.

CONCLUSION

Proper clinical examination,radiographic investigations

REFERENCES

1. Watzak G, Tepper G, Zechner W, Monov G, Busenlechner D, Watzek G. Bony Press-Fit Closure of Oro-Antral Fistulas: A Technique for Pre-Sinus Lift Repair and Secondary Closure. J Oral MaxillofacSurg 2005;63:1288-94.

2. Borgonovo AE, Berardinelli FV, Favale M, Maiorana C. Surgical options in oroantral fistula treatment. Open Dent J 2012;6:94-8.

3. Hernando J, Gallego L, Junquera L, Villarreal P. Oroantral communications. A retrospective analysis. Med Oral Patol Oral Cir Bucal 2010;15:e499-503.

4. Borgonovo AE, Berardinelli FV, Favale M, Maiorana C. Surgical Options in Oro-antral Fistula Treatment.Open Dent J 2012;6:94-8.

32

Calcifying Epithelial Odontogenic Tumor – Case Report

ABSTRACT

Pindborg in 1955,first described CEOT as a rare benign odontogenic neoplasm of epithelial origin. The tumor is associated with impacted teeth in approximately 52% of the cases. It ismore prevalent in the mandible than the maxilla. I hereby present a casereport of CEOT in a female patient of 30 years with a chief complaint of pain in lower left back tooth region, which on radiological examination revealed a well-circumscribed unilocular radiolucency with driven snow appearance associated with impacted mandibular third molar. Biopsy was performed on the patient and sent for histopathological examination which confirmed the diagnosis as CEOT.

Keywords: CEOT, Pindborgtumor

INTRODUCTION

CASE REPORT

A 30 year old female patient visited to the department of Oral Medicine and Radiology with a chief complaint of pain in the lower left back region since 6 months & a history of heaviness& swelling on the lower left side of the face since 6 months which gradually increased in size. History oftrauma due to fall from bike on the left side of face 1 year back.

On inspection, there was unilateral, diffuse swelling evident on the left lower third of the face extending below the inferior border of the mandible (Fig. 1 A& B). On palpation, swelling was soft in consistency with left submandibular lymph nodes tender on palpation.

Calcifying epithelial odontogenictumor (CEOT) first described by Jens JorgenPindborg in 1955as a rare benign odontogenic neoplasm of

1-epithelial origin that accounts for < 1% of all odontogenic tumors.5Shafer in 1963 introduced the eponym Pindborgtumor to the literature &described this remarkably unique odontogenictumor which typically

4contains calcifying masses. Its origin is controversial and it is believed to be derived from the oral epithelium, reduced enamel epithelium,

3stratum intermedium or dental lamina remnants.

This report illustrates a case of CEOT in the left posterior mandibular region associated with an impacted third molar tooth.

Deepika TickooPost Graduate Student, Dept. Of Oral Medicine


Debari, Udaipur

Mohit Pal SinghProfessor and HOD, Dept. Of Oral Medicine And

Radiology, Pacific Dental College & Hospital

Debari, Udaipur

Prashant NaharProfessor, Dept. Of Oral Medicine And Radiology

Pacific Dental College & Hospital, Debari, Udaipur

Bhagwan Das RaiPrincipal & HOD, Dept. Of Oral And Maxillofacial

Surgery, Pacific Dental College And Hospital

Debari, Udaipur

Bipin BulgannawarProfessor &HOD, Dept. Of Oral And Maxillofacial

Surgery, DarshanDental College And Hospital

Debari, Udaipur

Abhijeet MasihPractitioner


Deepika TickooPost Graduate Student, Dept. Of Oral Medicine


Debari, Udaipur

Case Report


33


Figure 1:Extraoral photographs: A. Frontal view B. Lateral view

On intraoral examination, 38 was missing with grade II mobility in relation to 37. There was obliteration of the left posterior buccal vestibule with expansion of the buccalcortex(Fig. 2)

Figure. 2 Intraoral photograph: Obliteration of posterior buccal vestibule

Provisional diagnosis of Developmental / Benign Intraoral periapical radiograph ( Figure 3 A)&Occlusal odontogenic cyst left posterior mandibular region & radiograph (Figure 3 B) revealed resorption of the distal Differential diagnosis of Dentigerous cyst 38 root of 37 with well- circumscribed radiolucency associated &Unicysticameloblastoma left side was given.Pulp vitality with flecks of calcification & expansion of the buccal& test was done using electric pulp tester which elicited lingual cortical plate respectively.negative response irt 37.

Figure. 3 A. Intraoral periapicalradiograph B. Occlusalradiograph

34


Panoramic radiograph (Figure 4) revealed a well-defined calcifications evident in between pushing the impacted 38 radiolucency of mixed density with corticated margins towards the lower border of the mandible. Mandibular nerve involving mandibular left posterior region & extending appears to be untraceble, buccolingual dimension cannot be anterioposteriorlyfrom the distal root of 36 till the ascending appreciated & also roots of 38 appears to be resorbed which border of ramus of the mandible &superioinferiorly from prompted us to take CBCT.alveolar ridge to the lower border of the mandible with

Figure 4:Panoramic radiograph

CBCT (Figure 5& 6) showed an expansile lytic lesion 36.9*28.6*37.6 mm with resorption of the distal root of involving left posterior mandible with both buccal and 37&displacement of the mandibular nerve inferiorly & lingual cortical plate perforation measuring approximately flecks of calcifications in between.

Figure 5 CBCT showing sagittal, axial & coronal view respectively.

Figure 6 3D reconstructive images showing erosion of the Radiographic Diagnosis of Calcifying odontogenictumor & superior cortex with mandibular nerve coursing lingually Ameloblasticfibroodontoma left posterior mandible was encircircling the crown of third molar & tip of the roots of framed.third molar towards the buccal side .

Incisional biopsy was done irt right retromolar region with

35


fea tures sugges t ive of Ca lc i fy ing ep i the l ia l which was followed by the placement of an obturator to fill odontogenictumor. the defect.

Based on clinical, radiographical&histopathological Patient was kept under follow-up & Post- operative findings & visualizing the complications related to vital panoramic radiograph&CBCT was taken after 3 & 5 structures, a conservative treatment approach months (Figure 7 & 8) showing considerable bone (marsupilization) was chosen along with extraction of 37 formation.

Figure 7 Panoramic radiograph: a. After 3 months b. After 5 months

Figure 8 CBCT images showing sagittal, axial & coronal view: A. After 3 months B. After 5 months.

36


On comparing the 3D reconstructive images (Figure 9) pre-operative & after 5 months, formation of the superior cortex was observed

Figure 9 : 3D reconstructive images : A. Pre-operative & B. After 5 months

Enucleation (Figure 10) was carried out after 6 months under G.A along with extraction of 38 & suture were placed.

Figure 10 A& B showing enucleation of the lesion

Post-operative panoramic radiograph of the patient was taken after 7 months in which considerable bone formation was appreciated.

Figure 11Panoramic radiograph : after 7 months

37


DISCUSSION immunohistochemical study. However, till now, the pathogenesis is uncertain and further research is needed.

CEOT occurs as a painless slow-growing mass in the mandible with a mean age of 40 years &equal incidence in

6men and women. CEOT can be classified as an intraosseous (central) or extraosseous(peripheral) tumor.Intraosseous CEOT is the more common type with the most common site in the mandible. The peripheral CEOT accounts for about

66% with most common site at the gingiva. Radiographically, intraosseoustype depicts radiolucent areas associated with calcifications occasionally, whereas the peripheral type

7depicts bone erosion near the tumor site.

The intraosseoustumor is thought to be derived from the stratum intermedium of enamel, while histogenesis of the extraosseous type is believed to be derived from dental

2 lamina epithelial rests of gingival epithelium. Intraosseous CEOT is more aggressive & has a reported recurrence rate of

714%. Histopathologically, CEOTit is characterized by the presence of epithelial cells, homogenous eosinophilic amyloid-like material, and calcifications.Anabsence of calcification indicates less tumor differentiation and

8therefore, favors more chance of recurrence. Thelack of calcification pose difficulties in diagnosing this tumor& also warrants an aggressive treatment approach.

CONCLUSION

CEOT is a rare& locally aggressive odontogenictumorwith no pathognomonic clinical or radiographic presentation & thus resulting in a diagnostic challenge. The histopathologic pattern will confirm the diagnosis. The exact nature of this tumor can be understood by a comprehensive

REFERENCES

1. C a l c i f y i n g e p i t h e l i a l o d o n t o g e n i c t u m o r (Pindborgtumor) without calcification: A rare entity. J Oral MaxillofacPathol 2012;16:110-2.

2. Recurrent calcifying epithelial odontogenictumor (Pindborgtumor): A case study. Oral Oncol Extra 2005;41:259-66.

3. Clinical, radiological and histological features of calcifying epithelial odontogenictumor: Case report. Braz Dent J 2006;17:171-4.

4. Giant Pindborgtumor (calcifying epithelial odontogenictumor): An unusual case report with radiologic-pathologic correlation. J Clin Imaging Sci 2013;3Suppl 1:11.

5. Pindborgtumor: Review of literature and case reports. J Indian Acad Oral Med Radiol 2011;23:660-3.

6. Cementum-like material in a case of Pindborgtumor. J Oral Pathol Med 1990;19:166-9.

7. Clear cell variant of calcifying epithelial odontogenictumor: Case report and review of the literature. Head Neck 1994;16:272-7.

8. Calcifying epithelial odontogenictumor. A survey of 23 cases and discussion of histomorphologic variations. Arch Pathol 1974;98:206-10.

38

Eruption of A Labially Impacted Canine Using Closed Flap Technique -

A Case Report

ABSTRACT

Impacted teeth are those that have not erupted during the time of their normal eruption and remain in the jaws where they are surrounded completely or partially by hard or soft tissues. Since impacted canines are encountered often, with an incidence rate of 1 to 2%in the general population.A 16 year old female patient presented with an irregularlyplaced upper and lower front teeth. The panoramic radiograph revealed maxillary left canine impacted. 42 extraction treatment plan followed by surgical exposure of 23. The comprehensive orthodontic treatment procedure with surgical exposure of maxillary left canine. However, this clinical report highlights the need for early diagnosis and management of maxillary left canine.

Keywords: Impacted Canine, Maxillary canine impaction, surgical exposure.

INTRODUCTION

Between 25% and 50% of the general population are affected by 1impacted teeth, with the incidence of upper-canine impaction

2-4reportedly ranging from 0.92-4.3%. Although some cases have iatrogenic or idiopathic origins, potential etiological factors include dentoalveolar discrepancies, transverse maxillary deficiencies, prolonged retention or early loss of deciduous canines, absence or anomalies of upper lateral incisors, abnormal positioning of dental buds, alveoloschisis, and physical obstacles such as supernumerary teeth, mesiodens, odontomas, neoplastic formations, cysts, and root

5-8dilacerations.

Dental impaction has also been correlated with a high incidence of certain syndromes, and palatal canine impaction has been found to run

4-9in families. Unsurprisingly, therefore, palatal impactions are far more common than labial ones, accounting for 85% of impacted

3,4canines. The procedures used for surgical exposure and traction are important in any impaction case, but a buccally impacted canine is especially problematic. If the tooth is positioned high in the alveolus, full-thickness flap surgery is generally required to expose the crown. After an appropriate attachment is placed for traction, the flap can be repositioned and sutured either in the same location or apical to the cementoenamel junction. Although the level of periodontal reattachment does not seem to significantly affect the clinical outcome, apical repositioning appears to be an inferior choice from an esthetic

Jaydip KalariaPost Graduate student, Dept of Orthodontics and

DentofacialOrthopaedics, Udaipur, Rajasthan

Dr. Kamlesh GargReader, Dept of Orthodontics and Dentofacial

Orthopaedics, Udaipur, Rajasthan

Dr. Bhavesh KothariReader, Dept of Orthodontics and Dentofacia

lOrthopaedics, Udaipur, Rajasthan

Dr. Ravindra ChoudharyPrivate practice, Surat, Gujarat


Dr. Jaydip KalariaPost Graduate student, Dept of Orthodontics and

DentofacialOrthopaedics, Udaipur, Rajasthan.

Case Report


39

1 2 , 1 3 surgically exposed with closed flap technique underlocal perspective. If the impacted canine is more anesthesia. The bracket was bonded on exposed canineand occlusallypositioned, it is usually preferable to close the flap ligature wire was tied and elastic distal traction given in its original position, with orthodontic traction obtained by (Figure:-2) from the ligature wire attached to the bracket of attaching a ligature wire or elastic chain to the archwire. exposed canine. In order to bring a maxillary left canine in Although this approach promotes tissue healing, it does the arch, an overlay (“Piggy Back”) wire of 0.014”NiTi, have several drawbacks, including the need for frequent over the 0.017 X 0.025”Stainless steel basearch wire was reactivation. The canine thus undergoes distal coronobuccal engaged on the bracket of the maxillary left canine.The traction in the direction of the adjacent crowns. The present alignment and leveling and extraction space closure was article shows a patient treated with this technique.completed with 0.019 X 0.025”NiTi and 0.019 X 0.025” stainless steel archwires.(Figure:-3) It took 14 month to bring the canine into the arch.A 16year adolescent female presented with a irregularly

placed upper and lower front teeth and Class I molar both Treatment resultside and End on canine occlusion on the right side and an

Intraorally, ideal overjet and overbite was achieved with unerupted upper left permanent canine and retained Class I molar and canine relationship with consonant smile. deciduous teeth present in upper arch and crowding present The radiograph showed good bone support and root in upper and lower anterior with overbite 1mm and reverse parallelism.(Figure:-4)overjetirt 11, 12, 22 and 32,41,42.She was in good general

health and has no history of major systemic diseases. The DISCUSSIONextra oral examination revealed a straight profile with

Impacted permanent maxillary canine are found regularly in competent lips.(Figure:-1)the clinical and radiographic examination of a young dental

Cephalometrically, the patient had a skeletal Class I patient. The most important step in the management of relationship (ANB angle: 1°) with normal maxilla and impacted teeth is the diagnosis and localization of impacted mandible. A horizontal growth pattern was seen (SN-GoGn: teeth. Failure of eruption of the maxillary canine is usual 24°). Maxillary incisor wereproclined with the upper event. Most number of studies revealing the occurrence of incisor-SN of 114°. The lower incisor wereuprighted with an the maxillary canine impactions.IMPA of 97°. The panoramic radiograph showed all

Delayed tooth eruption can cause necrosis of the pulp, permanent teeth was present expected mandibularthird ankylosis and external apical root resorption. It difficult to molars and upper left canine and missing maxillary third predict when root resorption will start. Thus, all impacted molars and retained deciduous teeth present in maxillary teeth having a high risk of external apical root resorption of arch.(Figure:-1) The commonly used radiograph for damage to the adjacent tooth. Periodontically, radiographic diagnosis of impacted canine includes OPG, Occlusal view examination should be used to monitor the impacted canine radiograph and intra oral periapical radiograph.for above risk.

Treatment objectivesThe surgical extraction of impacted maxillary canines are

The initial treatment objective were extraction of all the most unfavored treatment. In our case, Canine was in deciduous teeth, surgically exposure of the maxillary left favorable position and since canines are considered canine and bring into alignment, and extraction of 42 for important keystones in the dental arch, we decide to relieving lower crowding.(Figure:-2,3) Our treatment orthodontically bring it into most ideal position.objective also included correcting the Class I incisor

Therefore, a good knowledge of the clinician may improve relationship. The comprehensive treatment objective were situation in future treatment options, which can have a to established good functional and stable occlusion and to significant impact on the treatment outcome.improve the smile characteristics and dental esthetics.

CONCLUSIONTreatment planSatisfactory functional and esthetic results were achieved in 42 extraction treatment plan followed by surgical exposure this case with ideal skeletal and dental relationships. of 23 and alignment of the same in the arch.Thecombined effect of surgical maxillary canine and

Treatment progress orthodontically correcting itspositing and reestablishing the major components of a balanced smile.The case was started with MBT 0.022” slot pre adjusted

edgewise appliance. The initial alignment was achieved with 0.014” and 0.016” NiTi arch wire. The leveling was carried out with 0.018” AJ Wilcock arch wire and canine was

CASE REPORT


40


Figures

Figure 1:- Pretreatmentphotogroaph and radiograph

41


Figure 2:- Exposure of 23 and elastic distal traction

Figure:- 3 Mid treatment photograph and radiograph

42


Figure:- 4 post treatment photograph and radiograph

REFERENCES assessment of surgically exposed and orthodontically aligned impacted maxillary canines, Am. J. Orthod.,

1. Andreasen J.O, Pindborg, J J.,Hjörting- Hansen E, and 1998;113(9) :329-32.

Axell T. Oral health care: More than caries and periodontal disease. A survey of epidemiological 9. Zilberman Y, Cohen B, and BeckerA. Familial trends in studies on oral disease, Int. Dent. J. 1986;36(4):207-14,. palatal canines, anomalous lateral incisors, and related

phenomena, Eur. J. Orthod. 1990;12(2):135-9.2. Maverna R, Gracco A. Different diagnostic tools for the

localization of impacted maxillary canines: Clinical 10. Bishara S.E. Impacted maxillary canines: A review. Am. considerations, Prog. Orthod.2007;8(6):28-44. J. Orthod. 1992;101(4):159-71.

3. Hitchin, A.D.: The impacted maxillary canine, Dent. 11. Ngan P, Hornbrook R, and WeaverB.Early timely Pract. Dent. Rec. 1951;2:100-3. management of ectopically erupting maxillary

canines.Semin.Orthod. 2005;11(5):152-63.4. Sambataro S, Baccetti T, Franchi L and Antonini F.

Early predictive variables for upper canine impaction as 12. Vermette M.E, Kokich V.G and Kennedy D.B. derived from posteroanteriorcephalograms, Angle Uncovering labially impacted teeth: Apically Orthod.2005;75(6):28-34. positioned flap enclosed-eruption techniques.Angle

Orthod. 1995;65(5):23-32.5. Becker A, Smith P, and Behar R.The incidence of

anomalous maxillary lateral incisors in relation to 13. Kohavi D, Zilberman Y, and BeckerA. Periodontal pa la t a l lyd i sp lacedcusp ids , Ang le Or thod . status following the alignment of buccally ectopic 1981;51(8):24-9. maxillary canine teeth. Am. J. Orthod.1984;85(7):78-

82.6. Baccetti T.A controlled study of associated dental

anomalies, Angle Orthod. 1998;68(5):267-74. 14. Fournier A, Turcotte J.Y and Bernard C. Orthodontic considerations in the treatment of maxillary impacted

7. Conley R.S, Boyd S.B, Legan H.L,Jernigan C.C, canines. Am. J. Orthod.1982;81(2):236-9.

Starling C, and PottsC. Treatment of a patient with mu l t i p l e imp ac t ed t e e th , A n g le O r th o d . 15. Burden D.J, Mullally B.H and Robinson S.N.Palatally 2007;77(3):735-41. ectopic canines: closed eruption versus open eruption,

Am. J. Orthod.1999;115(7):640-4.8. Blair G.S, Hobson R.S, and LeggatT.G.Posttreatment

43

Management of Highly Placed Ectopic Canine by Orthodontic Treatment

Using Segmented T-Loop and R-Loop – A Case Report

ABSTRACT

The displacement of canine from their normal position leads to the development of ectopic canine which may be due to environmental and genetic in origin. Ectopic canine can migrate and may cause damage to the adjacent tooth root and bone. A 16 years old female presented with ectopic eruption of canine on both right and left side in the upper arch, with crowding in the lower arch. Upper first premolar extraction was planned to gain space in the upper arch and to correct the position of highly placed canine and also extraction of the lower incisor to relieve crowding in the lower arch.

Keywords: Ectopic canine, upper premolar and lower incisor extraction.

INTRODUCTION

Ectopic eruption of maxillary canines are one of the common condition. They are believed to occur because of wide variety of systemic and local factors. The environmental factors may contribute to this anomaly because of the long, tortuous eruption path of canine. The arch-length discrepancy is another factor for ectopic eruption of the tooth. It is approximately 1-2% in general population and palatally displaced canine occurs two times more than bucally displaced canine. The following case report illustrates a case of Angle's Class II division 1 malocclusion with highly placed upper canines and crowding in the lower arch, which was treated with upper first premolar and lower incisor extraction, and T-loop and R-loop was used for the retraction

1-3and proper positioning of canines in the arch .

CASE HISTORY

A 16 years adolescent female patient reported to the Department of Orthodontics, PDCH, with the chief complaint of irregularly placed upper and lower front teeth. On extra-oral examination patient had convex profile and competent lips. On intraoral examination she had Angle'sClass II division 1 malocclusion with end-on molar and canine relation on the both sides. Crowding in upper and lower anteriors, highly placed 13and 23 on buccal side, rotation irt 14, 16, 26.Overjet and overbite of 2mm. The lateralcephalogram showed a skeletal Class I with hypo-divergent jaw bases, protrusive maxilla and mandible and proclined upper anteriors.(Figure 1, 2).

Ankur KumarPost Graduate student, Dept of Orthodontics and


and Hospital, Udaipur

Kamlesh GargReader, Dept of Orthodontics and Dentofacial

Orthopaedics, Pacific Dental College and Hospital

Udaipur

Priya SharmaPrivate practitioner

Bhavesh KothariReader, Dept of Orthodontics and Dentofacial

Orthopaedics, Pacific Dental College and Hospital

Udaipur

Manali ShahPost Graduate Student, Dept of Orthodontics and




Ankur KumarPost Graduate student, Dept of Orthodontics and



Case Report


44

Treatment objectives and overjet were achieved with improved smile(Figure 5). Pre and post treatment cephalogram(Figure 2 and 6)were

Treatment objective included the followingcompared which showed that proclinedupper and normal

�Alignment and levelling lower incisor angulation after treatment whereas there was increase in the vertical growth as shown in Table I.

�Relieve crowding in both archesDISCUSSION

�De-rotation 14, 16, 26Maxillary canines that are potentially impacted or

�Retraction of anteriorsectopically erupting may be inadvertently overlooked in

�Achieving normal overjet and overbite mixed dentition patient, and may be due to individual variations in eruption pattern and timing. Ectopic highly

�Achieving good profile 1-3placed canine is a commonly seen clinical problem .The Treatment plan space required for the proper positioning of canine into the

arch can be gained by expansion of arch, proclination of Extraction of maxillary first premolars and lower incisor anteriors or by extraction of first premolars. was planned to overcome the arch length discrepancy.

Retraction of maxillary canines with T-loop and R-loop was The segmented R-loop and T-loop made up of served as a planned. retraction spring, which offered not only a distal traction on

the canine but also a moment for anti-distal tipping as well as Treatment progresstorque control of the canine. They also provides a relatively

�The treatment progressed with banding on molars. continuous force which is well controlled and can be easily 4-6modified .�0.022” slot MBT prescription brackets were

bonded on the upper canines, and extraction of The present case is of an adolescent female patient with upper first premolars were done. crowded upper and lower arches and proclined upper

incisors, protrusive maxilla and ectopic highly placed �A segmented R- loop placed on 13 and T-loop on 23 canines. Hence in this patient, R-loop placed on the rotated bracketmesiallyand distally in accessory molar canine and T-loop on the other side in upper arch. Later both tube made up of 0.017 x 0.025 TMA the loops were activated for positioning of canines in upper archwire(Figure 3).arch. During alignment and levelling of upper and lower

�T-loop and R-loop were activated by 3-4 mm at arch lower incisor (42) and upper first premolars were subsequent appointment. extracted to camouflage skeletal Class II malocclusion with

7protrusive maxilla . At the end of orthodontic treatment �The activation was done by pulling the distal arm good smile aesthetics were obtained.and cinching it distal to the first molar tube.(Figure

4) CONCLUSION

�After space closure in the upper arch, upper and The successful orthodontic treatment of a patient with lower bonding was done with 0.022” slot MBT highly placed upper uppercanine and crowding in both the prescription brackets, and extraction of lower arches can be a challenging task for the orthodontic incisor (42) was done. treatment. A proper diagnosis and treatment planning is

required for a successful treatment. So, the decision to �F o r a l i g n m e n t a n d l e v e l l i n g , i n i t i a l extract the upper first premolars and lower incisor is to be archwire(0.014” NiTi)wasplaced in upper and good aesthetically, functionally and for most stable results in lower arch followed by 0.016'', 0.018'', 0.017 x the patient. In the present case, the molar relation was Class 0.025'' NiTi and 0.019 x 0.025” S.S wire.II with Class I canine relation and good smile esthetics was

�Finishing and detailing was carried out for 2 achieved at the end of treatment.months and fixed spiral retainers were bonded upper and lower arches from canine to canine and circumferential retainers were given.

Treatment results

At the end of the treatment, Angle's Class II molar relation was maintained on right side and left side. Ectopic highly placed canines were brought into the arch. The crowding was resolvedin the upper and lower arch. Normal overbite


45


Table I: Pre and post treatment cephalometric measurements

Cephalometric measurements

Pre-treatment

Post-treatment

SNA 85o

84o

SNB 83o

82o

ANB 2o

2o

N-A-Pog 0o

1o

SN-GoGn

21o

25o

Facial Axis

95o

96o

U1-SN 109o

111o

L1- MP 89o

95o

U1-NA 24o, 3

mm

29o, 3 mmL1-NB 17o, 2mm 24o, 2 mmNasolabial angle 86 91

Lip strain 1.5 0.5

Figure 1: Pre-treatment extra and intra oral photographs

46


Figure 2: Pre-treatment lateral cephalogram and OPG

Figure 3: Placement of R-loop on 13 and T-loop on 23

Figure 4: After space closure with R-loop and T-loop

47


Figure 5: Post-treatment extra and intra oral photographs

Figure 6: Post-treatment lateral cephalogram and OPG

48


Figure 7: Overall superimposition Figure 8: Maxillary and mandibular superimpositions

REFERENCES ExtractionSpace Closure. Biomechanics in Clinical Orthodontics, 1997, 1st ed, WB Saunders Company,

1. Jacoby H. The etiology of maxillary canine impactions. Philadelphia.

Am J Orthod 1983, 84: 125-132.5. Burstone CJ. Rationale of the segmented arch. Am J

2. Von der Heydt, K.: The surgical uncovering and Orthod 1962;48(11):805-822.

orthodonticpositioning of unerupted maxillary canines, Am J Orthod.1975;68:256-276. 6. Burstone CJ. The mechanics of segmented arch

techniques. Angle Orthod 1966:36:99-120.3. Bishara, S. E., Kommer, D. D., MC Neil, M. H.,

Montagana, L. N., Oesteler, L. J..andYoungquist, H. 7. Scott Conley R, Jernigan C. Soft tissue changes after W.: Management of impacted canines, Am J upper premolar extraction in Class II camouflage Orthod.1976, 69: 371-387. therapy. The Angle Orthodontist. 2006 Jan;76(1):59-

65.4. Nanda R., Kuhlberg A. Biomechanical Basis of

49

Powerscope – “Fixed Functional Appliance” A Newer Approach to Correct

Class ii Div 1 Malocclusion: A Case Report

ABSTRACT

Angle's Class II div 1 malocclusion still remains the mainstay problem in patientsrequiring orthodontic treatment. Numerous orthodontic approaches and appliances have been introduced to treat Class II malocclusions. In post pubertal patients with almost no growth remaining fixed functional appliances are choice for growth modulation. For correcting Class II malocclusion various fixed and removable functional appliance have been introduced and powerscope is the latest appliance that has been introduced to treat mandibular deficiency cases. This case report demonstrates the treatment effects of powerscope appliance in a patient with Class II div 1 malocclusion.

Keywords: powerscope, fixed functional appliance, class ii malocclusion

INTRODUCTION

Class II malocclusion can manifest in various skeletal and dental configurations. Skeletal Class II jaw relation may be due to retrognathic mandible, prognathic maxilla or it can be combination of both. Class II Div 1 malocclusion with retrusion of the mandible is one of the most common trait.In such cases, various removable and fixed functional appliances are commonly used to stimulate the mandibular

1growth by forward positioning.

Power Scope is a recently developed noncompliant hybrid fixed functional appliance that holds the mandible anteriorly and corrects the Class II anteroposterior discrepancy. Power scope is manufactured by American Orthodontics.Powerscope address the critical need of orthodontist,including patient comfort and acceptance. It has simple installation. The appliance is attached from mesial to maxillary first molar in upper arch to distal of mandibular canine in the lower arch. It is delivered as one size with powerscopearmamentarium. The activation is done by crimpable hook that are available in different sizes that is 1mm, 2mm and 3mm.

This case report demonstrate the correction of Class II malocclusion using fixed functional appliance powerscope.

CASE REPORT

A 16 year old female patient reportedto the department of orthodontics in Pacific Dental College and Hospital with a chief complaint of forwardly placed upper front teeth. On intraoral examination end on molar relation was observed both side with mandibular midline shifted

Shikha SinghPost graduate student – Dept of Orthodontics and


Udaipur

Kamlesh GargReader – Dept of Orthodontics and Dentofacial

Orthopaedics, Pacific Dental College Udaipur

Bhavesh KothariReader - Dept of Orthodontics and Dentofacial

Orthopaedics, Pacific Dental College Udaipur

Shruti GuptaPrivate practice, Gurugram


Shikha SinghPost graduate student – Dept of Orthodontics and


Udaipur

Case Report


50


to left side by 2 mm, spacing in upper and lower anteriors TREATMENT RESULTSwith overjet 12mm and overbite 3 mm.Cephalometric

Satisfactory improvement were seen in profile of the patient. analysis indicated normal maxilla(SNA-80°) and

Class I canine and molar relation and ideal overjet and °retognathic (SNB-74 ) and skeletal class II jaw relationship overbite was achieved.(ANB- 6°).Upper central were proclined (U1-S /N

DISCUSSION121°)(fig:1) (table:1).

The Powerscope represents a new evolution in the use of TREATMENT OBJECTIVESintermaxillary Class II appliances.The use of fixed

Correction of skeletal class II functional orthopaedic appliances in patients at postpeak 5Space closure of upper and lower anterior stage of growth has been reported in the literature . As the

Class II correction is done closer to completion of active Derotation of 25 35 43 44

craniofacial growth, relapse tendency due to re-Achieving Class I molar and canine relation both side establishment of Class II growth characteristics is expected

5to occur less often . A fixed functional appliance produces Achieving normal overjet and overbite.orthopaedic force directed at the mandibular condyle. When

TREATMENT PLAN orthopaedic forces are applied by fixed functional appliance, remodelling changes occur at ate condyle and Phase I: Non-extraction treatment plan glenoid fossa and autorotation of the mandible can be

2Phase II: Fixed functional. seen. This paper exemplifies the skeletal, dental, and soft tissue changes when treated with Powerscope- fixed TREATMENT PROGRESS functional appliance. The reduction in overjet and

Treatment began using Preadjusted edgewise appliance with correction of molar relation post-functionally was due to O.22 bracket slot and 0.14 niti wire was placed in upper and proclination of mandibular incisors, mesial movement of lower arch. Wires were changed every month (0.016”niti, mandibular molars and retroclination of upper incisors 0.018”niti, .018”ss, 0.017”*0.025”niti, 0.017”*0.025”ss, which showed statistically highly significant values 0.019”*0.25”niti, 0.019”*0.025”ss) sequentially. Space compared to increase in mandibular length. Hence, it was closure was carried out at 0.019” *0.025”ss wire using concluded that although there were significant skeletal active tie back.After the space closure 0.019”*0.025”ss was changes dentoalveolar change contributed mostly to continued and figure eight ligation was done upper and correction of Class II relation.Thus, the results show that this lower arches. Lingual crown torque of 10 degrees was appliance can successfully correct Class II malocclusion in incorporated in the lower 0.019” *0.025”ss arch wire for the post-pubertal subjects.anterior segment to counteract the labial inclination of

CONCLUSIONmandibular incisors due to Class II corrective forces.Powerscope was inserted bilaterally for 6 months Powerscope can provide excellent results by reducing the (fig:3).After achieving Class I canine and molar need of patient compliance. It could be one of the best relationpowerscope was discontinued (fig:4). Class II treatment optionsfor Class II correctionin patients who are at elastics were given at the same wire for one month. their postpeak growth stage and require soft tissue Finishing and detailing was carried out using round niti improvement in soft tissue profile and in aesthetic wires and settling elastic were given at 0.14”ss wire. appearance.Class II correction was achieved through a

combination of skeletal and dental changes.

�

�

�

�

�

51


PARAMETERS PRE-TREATMENT POST-TREATMENT

ANTERO-POSTERIOR

ANB 6°

3°

A PER-B PER

9°

6°

WITS APPRAISAL

3°

2°

NA-APOG

5°

5°

VERTICAL

SN-GO-GN

31°

3°2

FMA 30°

31°

BASAL PLANE ANGLE

27°

31°

MAXILLARY

SNA 80°

78°

A PER- N PER 7 mm 3 mm

S PER- PTM PER 18 mm 21 mm

MANDIBULAR

SNB 74°

77°

B PER-N PER

-16 mm

-8 mm

GO-POG

64

mm

67

mm

SADDLE ANGLE

134°

128°

POSTERIOR CRANIAL

BASE

32 mm

33 mm

DENTAL

U1-SN

121°

106°

U1-NA

36°,11mm

29°, 5 mm

U1-A POG 41°, 13 mm 26°, 6 mm

L1-MP 94° 108°

Table 1: Pre-treatment and post-treatment cephalometric values

52


Figure 1: Pre-treatment photographs

Figure 2: Pre-functional intraoral

53


Figure 3 :Powerscope insertion

Figure 4: Post-functional photographs and radiographs

54


Figure 5: Post -treatment

REFERENCES AN. Early prevention and intervention of class II division 1 in growing patients. J IntSocPrev

1. Malhotra A, Negi KS, Kaundal JR, Negi N, Mahajan M, Community Dent 2016;6:S79-83.Chainta D. Cephalometric evaluation of dentoskeletal

and soft-tissue changes with powerscope Class II 6. Manni A, Pasini M, Mauro C. Comparison between corrector. Journal of Indian Orthodontic Society. 2018 herbst appliances with or without miniscrew anchorage. Jul 1;52(3):167

Dent Res J (Isfahan) 2012;9:S216-21. 25. Elkordy SA, 2. Prakash k, Meena SC, Kothari B, Dhaduk M, PATEL Abouelezz AM

spower scope appliance for correction of class II 7. RAlvares JC, Cançado RH, Valarelli FP, de Freitas KM, malocclusion-A Case Report 2017 JPAHER; 1(3);25-

Angheben CZ. Class II malocclusion treatment with the 32herbst appliance in patients after the growth peak.

3. Paulose J, Antony PJ, Sureshkumar B, George SM, Dental Press J Orthod 2013;18:38-45.Mathew MM, Sebastian J. PowerScope a Class II

8. Rittio Ak, Ferreira AP.Fixed functional appliance – A corrector–A case report. Contemporary clinical classification. Funct Orthod. 2000;17:12-30.dentistry. 2016 Apr;7(2):221.

9. Alexander M,Simplified correction of class II using 4. http://www.americanortho.com/powerscope.html.powerscope.Clinical orthod.2016;20-7

5. Keerthi VN, Kanya SD, Babu KP, Mathew A, Kumar

55

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