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Indian Journal of Comprehensive

Dental Care

JAN- JUNE 2016 • VOL 6 • ISSUE 1I J C D C

680Indian Journal of Comprehensive Dental Care

CONTENTS

ORIGINAL ARTICLES

EVALUATION OF INCIDENCE OF C-SHAPED ROOT CANALS AND STUDY OF CANAL MORPHOLOGY AND CLEANLINESS ETC. IN PERMANENT MOLARS USING SEM AND STEREOMICROSCOPE –AN IN-VIVO AND IN-VITRO STUDY 690*Shilpa Walia **C.S Bal ****Ripu Daman Singh ****Ramneek Khatter *****Rupam kaur

COMPARISON OF COMMERCIALLY MARKETED TOOTHBRUSHES IN AMRITSAR- IN ACCORDANCE TO ADA SPECIFICATION 696*Satinder Singh Walia **Amaninder K Randhawa ***Sumeen Malhotra ****Karen Multani *****Gurpreet Kaur ******Ms. Shifali

CASE REPORTS

DUPLICATION OF PALATAL RUGAE IN COMPLETE DENTURES : A CASE REPORT 699*Geetika Chawla **Kamleshwar Kaur ***Kavipal Singh ****Neelam Suman

HOLLOW MAXILLARY COMPLETE DENTURE- A TREATMENT OPTION FOR ATROPHIED RIDGES : A CASE REPORT 702* Harpreet Kaur **Aman Arora *** Preeti Arora ****Natish Kumar

USE OF PEDICLED BUCCAL FAT PAD FOR CLOSURE OF OROANTRAL FISTULA- A CASE REPORT 705* Navjot Kaur **Yashmeet Kaur ***Sarika Kapila

INTERDISCIPLINARY MANAGEMENT OF PEG LATERALS AND MESIODENS: A CASE REPORT 709* Parvinder Singh Dhingra **Tahira Kaur Bawa ***Shilpa Gupta ****Amrit Kaur

AMLODIPINE-INDUCED GINGIVAL OVERGROWTH : A CASE REPORT 712*Supreet Kaur **Vandana ***Harkiran Kaur ***Mandeep Kaur

“INTERDISCIPLINARY APPROACH IN ADULT ORTHODONTICS”- A CASE REPORT 716*Veneet Mehta ** Manmeet Kaur Bagga *** Kamaldeep Sharma ****Kiranjyot Kaur *****Prerna

SURGICAL MANAGEMENT OF A NON-HEALING LARGE RADICULAR CYST IN MAXILLARY ANTERIOR REGION: A CASE REPORT 719* Aashish Handa **Rajesh Khanna ***Ripu Daman Singh ****Rajni Sharma Handa *****Navneet Kaur

INTRAORAL SCWANNOMA- A CASE REPORT 723 *Adesh S Manchanda ** Ramandeep S Narang *** Meet Paras Kaur Randhawa

CENTRAL GIANT CELL GRANULOMA MANDIBLE - A CASE REPORT 727* Amreen Kaur ** Amit Dhawan *** Jasmine Kaur

PERIPHERAL OSSIFYING FIBROMA- A CASE REPORT WITH REVIEW OF LITERATURE 731*Arshdeep Kaur **Preeti Chawla Arora ***Chetan Dev Singh Boparai ****Gurpreet kaur

I J C D C


CONTENTS

CONSERVATIVE MANAGEMENT OF A LARGE RADICULAR CYST: A CASE REPORT 744*Anjali **Sunil Gupta ***Teena Gupta

THERMOPLASTIC GUTTA PERCHA OBTURATION WITH USE OF MTA AS APICAL PLUG IN TOOTH WITH OPEN APEX-A CASE REPORT 748*Prashant Monga **Nitika Bajaj ***Pardeep Mahajan ****Navkesh Singh *****Gurbant Singh ******Manjot Singh

REVIEW

DECORONATION: AN APPROACH TO TREAT ANKYLOSED TOOTH IN GROWING CHILDREN 753* Ankita Bhargava **Gunmeen Sadana ***Manjul Mehra ****Rashu Grover

PROTOTYPING: A PROSTHODONTIC REVIEW 756*Tarunpreet Kaur Gill **Kavipal Singh ***Kamleshwar Kaur ****Simrat Kaur

QUIZDENTAL DILEMMA-10 759


Dental Care

JAN- JUNE 2016 • VOL 6 • ISSUE 1

I J C D C


DR SUKHDEEP SINGH KAHLON


Dental Care


DR. RAJESH KHANNA

DR. SUMEET KAUR SANDHU (Principal S.G.R.D.)

DR. KAMALDEEP SHARMA

DR. ADESH MANCHANDA

Indian Journal of Comprehensive Dental Care

I J C D CI J C D C

683

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Greetings to all the readers of ijcdc for a splendid new year ahead. With a new start , the editorial board of

IJCDC encourages all the dental practitioners to undertake more and more clinical research and by means

of documentation make it available to the whole world .

Keeping the same in mind and on request of many readers , we have decided to include more case reports

in the first issue of this year. Latest clinical approaches and scientific handling rendered to atypical cases

and their successful management shall benefit all the readers in the day to day practice.

I urge all the readers also to indulge their time and acumen in conducting innovative and ethical research in

dentistry , which brings forth newer protocols to manage dilemmas in dentistry and also puts Indian

researchers on a higher global platform.

Regards

Dr. Sumeet Sandhu

Patron , IJCDC

From the Patron's Desk ………


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Wishing all the readers of IJCDC a very happy 2016 . While I pen the editorial for the very first issue of this

year, the following quote from Edith Lovejoy Pierce seems more than apt for all of us- “ We will open the

book. Its pages are blank. We are going to put words on them ourselves. The book is called Opportunity and

its first chapter is New Year's Day.”

The future is what we want it to be. Dentistry along with all other arenas is getting refined by the day .We at

the editorial board have been getting lots of suggestions to include more practice based literature timely

by various readers and colleagues. Keeping same in view we have structured this issue as case report

special issue, which has maximum pages dedicated to cases pertaining to everyday practice .

I hope the readers shall gain a lot from the innovative approaches rendered to practical dilemmas and

successful management of each case.

Regards

Dr. Shantun Malhotra

Editor IJCDC

Editorial

EVALUATION OF INCIDENCE OF C-SHAPED ROOT CANALS AND STUDY OF CANAL MORPHOLOGY AND CLEANLINESS ETC. IN PERMANENT MOLARS USING SEM AND STEREOMICROSCOPE –AN IN-VIVO AND IN-VITRO STUDY.

Abstract

The aim of the present study was to evaluate the incidence of C-shaped canals

in patients and to compare the stainless steel Kfiles with rotary Protaper Ni-Ti

files for canal center displacement, canal centring ability and cleaning at

various levels in extracted teeth in C-shaped canals. Four hundred mandibular

and one hundred maxillary extracted molars were taken and out of them, sixty

teeth having C-shaped canal system were used for in-vivo study. After access

cavity preparation, the teeth with C-shaped canal system were decoronated

and divided into two groups: Group I –Thirty teeth were instrumented using

hand stainless steel K files (Dentsply), Group II- Thirty teeth were instrumented

using Protaper (Dentsply) rotary files. Three parameters were evaluated : -

canal center displacement, canal centring ratio using stereomicroscope and

debris score using scanning electron microscope. The incidence was found to

be 7.7% in local Indian population for a period of one year. Protaper Ni-Ti rotary

files maintain better canal centring ability as compared to stainless steel Kfiles

in C-shaped canals. But stainless steel Kfiles results in more debris removal and

cleaning efficacy as compared to Protaper Ni-Ti rotary files.

Keywords: C-shaped cnalas. Kuttler's endodontic cube, stereomicroscope,

scanning electron microscope.

690

Corresponding author:Name: Dr. Shilpa WaliaAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.Phone no.: 9417065106Email: [email protected]

1. MDS, Senior Lecturer, Guru Nanak Dev Dental College Sunam.

2. Prof Head & Principal Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. MDS, Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.



INTRODUCTION on the lingual or buccal surface.

Root canal treatment helps to eliminate infected and C-shaped canals present the clinician with both diagnostic

necrotic pulp tissue remanants and shape the root canal and operational difficulties. Due to complex anatomy and

system to facilitate disinfection followed by three anastomoses, instrumentation of teeth with C-shaped

dimensional obturation. Recognition of unusual canal canals are difficult during biomechanical preparation and

configurations and variations are paramount but one of the also compromise adequate sealing of canals, thus reducing 1most important anatomic variations is the “C” configuration the prognosis of root canal treatment . Canal cleaning and

of canal system. The C- shaped canal is so named for cross- shaping may be further compromised when the flat fins of a

sectional morphology of root and root canal. Roots C-shaped canal are present. In addition, although manual

containing C-shaped canal often have a conical or square stainless steel K files may clean a higher percentage of the

configuration. The main etiology for formation of the C- walls of C-shaped canals than ProTaper instruments, they do 2shaped canals is failure of the Hertwig's root sheath to fuse so with more procedural errors.


I J C D C1. Shilpa Walia2. C.S Bal3. Ripu Daman Singh4. Ramneek Khatter5. Rupam kaur

Date of Submission : 17/9/15 Date of Acceptance : 9/10/15


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The aim of the present study was to evaluate the incidence of teeth with C-shaped canal system were decoronated up to

C-shaped canals in patients and to compare the stainless the level of cementoenamel junction using diamond disc

steel Kfiles with rotary Protaper Ni-Ti files for canal center (Dentoreum) at 300 rpm mounted on a straight handpiece.

displacement, canal centring ability and cleaning at various The teeth were embedded in to acrylic resin (cold cure resin,

levels in extracted teeth in C-shaped canals. Dental products of India) using Kuttler's Endodontic Cube

(Photograph-I). The tooth to be sectioned were correctly MATERIALS & METHODSoriented in the acrylic resin in the Endodontic Cube. After the

In-vitro analysis The present study was conducted on freshly acrylic had set, the endodontic cube was disassembled and extracted four hundred mandibular and one hundred embedded tooth was removed from the cube. Three sections maxillary molars collected from the Department of Oral and were made at equidistant level:- coronal, middle and apical Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental third of the root and examined under stereomicroscope for Sciences and Research. Out of five hundred teeth, sixty teeth the evaluation of pre-instrumentation tracings. having C-shaped canal system were used for in-vitro study.

The tooth sections were again reassembled in the Access cavity preparation was done initially with a No. 4 endodontic cube and divided into two groups: Group I- Thirty round carbide bur (Dentsply) in a high speed contra-angle teeth were instrumented using hand stainless steel K files handpiece at 400,000 rpm (NSK, Japan) with copious amount (Dentsply). Group II- Thirty teeth were instrumented using of water cooling to penetrate the enamel. In case of C shaped ProTaper (Dentsply) rotary files. After completion of teeth, pulpal floor usually exhibits a unique opening into the instrumentation, these sections were again examined under root endodontic area, in the shape of letter “C”.The selected stereomicroscope for evaluation of post-instrumentation

691

Table-IStatistical analysis of inter-group comparison of canal center displacement

on the basis of type of instrument used for preparation using t-test.

Level Mean±SD

P-value

Significance Group I Group II

Coronal 0.1957±0.2557 0.1347±0.1611 0.274 NS

Middle 0.1504±0.0112 0.0785±0.0036 0.000 HS

Apical 0.1683±0.0112 0.0519±0.0020 0.000

HS

Table-IIStatistical analysis of inter-group comparison of canal centring

ratio on the basis of type of instrument used for preparation using t-test.

Level Mean±SD

P-value


Coronal 1.3815±0.0992 1.0430±0.0200 0.000 HS

Middle 1.4737±0.2138 1.0432±0.0170 0.000 HS

Apical 1.4312±0.0920 1.0438±0.0152 0.000 HS

Indian Journal of Comprehensive Dental Care 692

Table-IIIStatistical analysis of inter-group comparison of debris score on the basis of type of instrument used for preparation using t-test.

Level Mean Rank

P-value


Coronal 16.80 44.20 0.000 0.000

HS

Middle 17.13 43.87 HS

Apical 16.63 44.37 0.000

HS

NS = non significant S = significant HS = highly significant

Photograph-IShowing Sectioned C-shaped Tooth

Mounted In Kuttler's Endodontic Cube

Photograph-IIshowing The Measurements For Evaluation

of Canal Center Displacement And Canal Centring Ability

Photograph-IIIMelton's Classification of C-shaped canals


tracings (Photograph-II) and two parameters were chamber of the C-shaped canal is a single ribbon-shaped

evaluated:-canal center displacement and canal centring orifice with a 180° arc starts at the mesiolingual line angle

ratio. and sweeps around the buccal to the end at the distal aspect

of the pulp chamber. Presence of accessory canals, lateral The sectioned samples were vertically split buccolingually canals, intercanal communications, apical deltas and with the help of diamond disc (Dentoreum) using straight chances of strip perforations makes the instrumentation hand piece (NSK, Japan) rotated at slow speed (5000 rpm). difficult in C-shaped canals. C-shaped canal instrumented by The specimen were examined under Scanning Electron Nickel-Titanium files showed the maintainence of original Microscope (Joel, Japan) for evaluation of cleanliness of root canal curvature and less transportation as compared to canal at a magnification X 2500 in both hand and rotary traditional hand instruments. groups.

Canal cleaning and shaping is also compromised due to flat In- vivo study:-fins of C-shaped canal. Also it was reported in the literature

The study of incidence of C-shaped canals was done on that manual stainless steel K-files clean a higher percentage patients visiting for root canal treatment for maxillary and of walls of C-shaped canal than ProTaper instruments but mandibular molars for a period of one year. After access they do so with more procedural errors. cavity preparation, the floor of the pulp chamber was

The results of the present study depicts that there was no assessed and the teeth having C-shaped canal system were statistical difference present between the canal center categorized using Melton's classification. (Photograph-III) displacement and canal centring ratio when the C-shaped The photographs of the sub pulpal wall were taken and canals were instrumented using hand and rotary files at the keeping the record for further investigation and data then coronal level. On the other hand a significant difference was collected were put to statistical analysis.present between the values of canal center displacement at

RESULTS: the middle and apical level.

The canal center displacement of Stainless steel K-files with The results are in concurrence with the study done by Miglani ProTaper Ni-Ti files, revealed no significant difference 4 S, et al. (2004) who found that there was no significant (p=0.275) at the coronal level of canal but at the middle level

difference between K-files and rotary files in the canal center and apical level, a highly significant difference (p=0.000) was

displacement as well as canal centring ratio at the coronal found. It was observed that when the canal centring ratio of

level. But at the middle level and at the apical level, a Stainless steel K-files was compared with ProTaper Ni-Ti files,

significant difference was found between the values of canal there was a significant difference (p=0.000) at the coronal ,

center displacement and canal centring ratios for both middle as well as apical level of canal. The debris score of

groups. Stainless steel K-files was compared with ProTaper Ni-Ti files,

5 A study done by Gambill JM, et al. (1996)who evaluated that a highly significant difference (p=0.000) was found at the the Ni-Ti instruments used with a reaming technique caused coronal level, middle level (p=0.000) and apical level significantly less canal transportation (P < 0.05), removed (p=0.000) of canal. Furthermore, the incidence was found to significantly less volume of dentin (P < 0.05), required less be 7.7% in local Indian population for a period of one yearinstrumentation time (P < 0.05), and produced more

DISCUSSIONcentered and rounded canal preparations than K-flex

The aim of endodontic treatment is the complete Stainless Steel used in quarter turn/pull technique. debridement of infected and necrotic pulp tissue remanants 6 Schafer E and Florek H. (2003) showed that the rotary K3 and obturation of the canal system.. It is also important to be

instruments achieved better canal geometry and showed familiar with variations in tooth anatomy and characteristic

significantly less canal transportation (P < 0.05) in curved features of canal in various racial groups because it can aid in

canals than stainless steel hand K-Flexofiles. Moreover, location and negotiation of canals as well as their subsequent 11 Tasdemir T, et al. (2005) observed that Ni-Ti Hero 642 rotary management.

instruments showed better canal centring ability especially Teeth with C-shaped canals were originally classified as at the middle and coronal levels than stainless steel hand K-taurodents. This term 'taurodontism' was given as these C- files.shaped canals were first found in cud-chewing animals. The

The results are also not in concurrence with the study by C-shaped canal was first documented in endodontic 7 Deplazes P, et al . (2001) who compared the canal shaping 3 literature by Cooke HG and Cox FL. (1979) and is so named for

ability of Ni-Ti hand and rotary files and found that there was the cross-sectional morphology of the canal. The pulp

no significant difference in the values of canal center

693


displacement and mean cross sectional areas of the canals centring ability as compared to stainless steel K-files in

after instrumentation. C-shaped canals.

Also the results are not in concurrence with Chan AW and 2. Both stainless steel K-files and ProTaper Ni-Ti rotary 8Cheung GS. (1996) who observed that there was no instruments did not differ much in the canal center

difference in the shaping ability of stainless steel hand files displacement and canal centring ratio at the coronal

and rotary Ni-Ti files i.e. perforations and fractures were not level but significant difference was found at the middle

present with both the instruments. It is due to the fact that and apical level.

the stainless steel files used in this study was flexofile, which 3. Stainless steel K-files results in more debris removal and is more flexible than the standard K-files used in our study. cleaning efficacy as compared to ProTaper rotary Ni-Ti

The results of the present study shows that the stainless steel files.

K-file group showed less debris score and more cleaning 4. In vivo study found that the incidence of C-shaped efficacy as compared to the rotary Ni-Ti group. The results of canals was 7.7% in maxillary and mandibular molars the present SEM study are in concurrence with the findings of over a period of one year. Furthermore, Melton's

9 Schafer E and Schlingemann R. (2003) who observed that classification Type II and Type III was found with highest Stainless steel K-flexofiles allowed significantly better frequency in C-shaped canals.removal of debris than Rotary Ni-Ti K3 files in severely curved

REFERENCEScanal canals of the extracted teeth. Ni-Ti instruments showed

1. Manning SA. Root canal anatomy of mandibular second a higher percentage of the uninstrumented canal surface molars. Part II C-shaped canals. Int Endod J. 1990; 23: when compared with the hand stainless steel K-files. The

10 40-45.results are also in concurrence with Ahlquist M, et al. (2001)

who compared canal debridement with manual and rotary 2. Yin X, Shun-pan Cheung G, Zhang C, Murakami Masuda techniques and found that manual technique produce more Y, Kimura Y, Matsumoto K. Micro-computed cleaner canal than the rotary instrumentation. tomographic comparison of nickel-titanium rotary

versus traditional instruments in C-shaped root canal The results of the present study are not in concurrence with 11 system. J Endod 2010; 36: 708–12.Melton DC, et al. (1991) who observed that large amount of

debris had been reported to remain at the fins or isthmus 3. Cooke HG and Cox FL. C-shaped canal configurations in area of a C-shaped canal after manual instrumentation. mandibular molars. J Am Dent Assoc. 1979; 99(5): 836-

839.The results of the present in vivo study depicts that the

incidence was found to be 7.7% in local Indian population for 4. Miglani S, Gopikrishna V, Parameswaran, Kandaswamy a period of one year. The results are in concurrent with the D, Kirithika. Canal centring ability of two Nickel-

3 findings of Cooke HG and Cox FL. (1979) who observed that Titanium rotary systems compared with SS hand 8% of the mandibular second molars treated endodontically instrumentation in curved canals using Kuttler's had the C-shaped canals. From the present study it can be endodontic cube – An in vitro study. J Endod. 2004; 16: concluded that the ProTaper Ni-Ti rotary files maintains the 42-49. canal centring ability as well as original curvature of the canal

5. Gambill JM, Alder M, del Rio CE. Comparison of Nickel-in comparison to stainless steel K-files. But the cleaning

Titanium and Stainless steel hand-file instrumentation efficacy of C-shaped canals is better achieved with stainless

using computed tomography. J Endod. 1996; 22(7): 369-steel K-files as compared to the ProTaper Ni-Ti files.

375.Therefore, i t can be recommended that after

6. Schafer E, Florek H. Efficiency of rotary nickel-titanium instrumentation of the C-shaped canals with Ni-Ti rotary K3 instruments compared with stainless steel hand K-instruments, hand stainless steel K-files should be passively Flexofile. Part 1. Shaping ability in simulated curved inserted into the canal and filing should be done specifically canals. Int Endod J. 2003; 36: 199-207.toward the isthmus area. Moreover a low incidence of C-

shaped canal was found among the Indian population 7. Deplazes P, Peters O, Barbakow F . Comparing Apical

preparation of root canals shaped by Nickel-Titanium CONCLUSION: rotary and Nickel-Titanium hand instruments. J Endod.

The following conclusions were drawn from the present 2001; 27(3): 196-202.

study:8. Chan AW, Cheung GS. A comparison of stainless steel

1. ProTaper Ni-Ti rotary files maintain the better canal and nickel-titanium K-files in curved root canals. Int

694


Endod J. 1996; 29: 370-375. 11. Melton DC, Krell KV, Fuller MW. Anatomical and

histological features of C-shaped canals in mandibular 9. Schafer E, Schlingemann R. Efficiency of rotary nickel-second molars. J Endod. 1991; 17(8): 384-388.titanium K3 instruments compared with stainless steel

hand K-Flexofile. Part 2- Cleaning effectiveness and

shaping ability in severely curved root canals of

extracted teeth. Int Endod J. 2003; 36: 208-217.

10. Ahlquist M, Henningsson O, Hultenby K, Ohlin J. The

effectiveness of manual and rotary techniques in the

cleaning of root canals: a scanning electron microscopy

study. Int Endod J. 2001; 34: 533-537.

695

COMPARISON OF COMMERCIALLY MARKETED TOOTHBRUSHES IN AMRITSAR- IN ACCORDANCE TO ADA SPECIFICATION

Abstract

Background: The toothbrush has under gone a degree of sophistication and is

by far the most widely accepted and adopted tooth-cleaning tool. People who

have not received any professional advice regarding the type of toothbrush to

be used for cleaning , usually choose brushes based on cost, availability and

advertising claims, family tradition or habits.

Aim & objectives: The aim and objective of the study was to evaluate the

claimed specification of toothbrushes available in the Amritsar market and

compare with the specification stated by American Dental Association (ADA).

Materials and Methods: In the present study 28 toothbrushes of various

brands available in the Amritsar market were used. The length and width of the

head (brushing surfaces) was found using a vernier callipers. The diameter of

the bristle thickness was determined using travelling microscope by optical

interference technique.

Results: Total number of rows varies from 3-6, only 17 toothbrushes were in

accordance to ADA specification. None of the 28 commercially toothbrushes

had average width head as per ADA specification.

Conclusion: The variation observed in the number, length and category of the

toothbrushes indicate that majority of the manufactures did not follow the

norms given by as per the ADA specification of the toothbrush.

Key words: ADA, specification, toothbrushes.

696

Corresponding author:Name: Dr. Satinder Singh WaliaAddress: Associate Professor, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M) 896858450Email: [email protected]

1. Associate Professor, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. Reader, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. Ex. Intern, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.



6. Intern, Department of Public Health Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

Introduction: often put the common man in dilemma about the best

design and they often seek professional advice on this Evidence are there that humans have been using toothbrush 1 matter. to clean their teeth for at least 5500 years back. The

5toothbrush has under gone degree of sophistication and is

by far the most widely accepted and adopted tooth-cleaning

tool. People who have not received any professional advice

regarding the type of toothbrush to be used for cleaning ,

usually choose brushes based on cost, availability and 2advertising claims, family tradition or habits. Manual

toothbrushes can be classified according to a number of 3features including the hardness, shape and type of bristles.

The various designs of toothbrushes available in the market

ADA specification for acceptable toothbrushes are as

follow:

Length: 1-1.25 inches.

Width: 5/16-3/8 inches.

Surface area: 2.54-3.2 cm

Number of rows: 2-4 rows of bristle.

Number of tufts: 5-12 tufts per row.

Number of bristle: 80-85 bristle per tuft


I J C D C1. Satinder Singh Walia

2. Amaninder K Randhawa

3. Sumeen Malhotra

4. Karen Multani

5. Gurpreet Kaur

6. Ms. Shifali



Dental Care



Diameter of bristles are: available in the Amritsar market were used. The length and

width of the head (brushing surfaces) was found using a Soft: 0.007 inch (0.2mm)vernier callipers. The diameter of the bristle thickness was

Medium: 0.012 inch (0.3 mm) determined using travelling microscope by optical

Hard: 0.014 inch (0.4mm) interference technique. All measurements were done for 3

trials and the mean + SD was calculated using the statistical Materials and method:package SPSS 11.5 version. The objectives of this study was

In the present study 28 toothbrushes of various brands to evaluate the claimed specification of toothbrushes

697

Table 1: Showing the toothbrushes with regard to length, width, no. of rows, no. of tufts and no. bristles/tufts.

Toothbrush**

No. of rows

No. of tufts / row

No. of bristles/

tuft

Length of

Head [Avg. 3 trials

(inch)]

Width of Head [Avg. 3 trials (inch)]

Colgate kids Toothbrush (Soft)

4

14

28

1.05*

0.98

Classic Toothbrush

(Hard)

4*

13

28

1.00*

0.73

Classic Toothbrush

(Medium)

4*

11*

84*

0.98

0.84

Colgate 3600(Soft)

5

10*

52

0.81

0.83

Colgate Extraclear(Medium)

4*

11*

30

0.99

0.76

Colgate Junior(Medium)

5

10*

57

0.80

0.77

Colgate Sensitive (Medium)

4*

9*

53

0.99

0.63

Colgate Supersoft(Soft)

5

10*

81*

1.04*

0.87

Colgate Toothbrush(Medium)

4*

11*

27

1.02*

0.85

Colgate Toothbrush (Soft)

4*

11*

46

1.06*

0.74

Colgate

Travel pack

Toothbrush(Hard)

4*

8*

42

0.97

0.66

Colgate Trigard(Medium)

3*

7*

31

0.81

0.76

Colgate Zigzag(Medium)

5

10*

34

1.11*

1.00

Colgate Zig zag (black)(Medium)

5

10*

58

1.03*

0.98

Colgate Zig zag(Soft) 5 10* 38 1.04* 0.92

Johnson & Johnson Baby

Toothbrush(Soft) 3* 6* 61 0.93 0.61

Lotus junior Toothbrush(Soft) 4* 6* 51 0.98 0.82

Lotus Toothbrush(Hard) 4* 11* 35 1.00* 0.82 Lotus Toothbrush(Medium)

5

12*

38

1.07*

0.86

Lotus Toothbrush(Soft)

6

14

26

0.98

0.85

Oral-B Toothbrush(Medium)

5

11*

48

0.98

1.01

Pepsodent Toothbrush(Soft)

4*

11*

38

1.02*

0.80

PYX-Perio(Hard)

4*

11*

58

1.06*

0.80

Quest Toothbrush(Hard)

5

10*

35

0.97

0.99

Sensodyne (Soft)

4*

12*

68

0.92

0.61

Colgate Ortho Toothbrush

(Medium

)

4*

11*

36

0.95

0.79

Thermoseal Toothbrush(Medium)

4*

10*

46

0.94

0.73

Travel Toothbrush(Hard)

3*

9*

23

00.79

0.75

Standard ADA specification

2-4

5-12

80-86

1-1.25

0.31-0.37

*In accordance with ADA

** Listed in alphabetical order


toothbrushes were as per ADA specification. In Medium, 5

out of 13 toothbrushes had diameter as per ADA

specification. (Table: 2)

Discussion:

There are no standardized methods for testing toothbrush

characteristics. This study was conducted to evaluate

whether the various marketed toothbrushes fulfil the

standards set by the ADA. The observation made in this study

was that few of the brand even failed to denote the category

of the toothbrush i.e soft, medium or hard. A large number of

surveyed toothbrushes showed irregularity in term of

number of bristles per tufts and did not fall in the range of

ADA specification. The greatest disparity was seen in

labelling of category of toothbrush, certain toothbrushes

showed dimensions of medium toothbrushes were as they

were labelled as soft. None of the analysed toothbrushes

fulfilled the standard ADA specification.

Conclusion:

Data from the present study showed a wide disparity in the

actual design, category and labelling of the toothbrushes to

the one stated by the manufactures. Majority of the

manufactures did not follow the norms given by as per the

ADA specification of the toothbrush probably due to lack of

strict quality control check by the government.

References:

1. Chong, M.P. & Beech, D. R.: Characteristics of

toothbrushes. Australian Dental Journal 28, 202-11.

2. Yankell SL, Saxer UP. Toothbrushes and toothbrushing

methods. In: Harris NO, Garcia- Godoy F. (eds.) Primary thPrevention Dentistry, 6 Ed. New Jersey: Pearson

Prentice Hall, 2004: 93-117. available in Amritsar market and compare with the

3. Francis A. Harvey EW: Fundamentals of optic, McGraw specification stated by ADA. thHill international 4 Ed. 293-94.1976.Analysis of the 28 commercially toothbrushes demonstrated

4. Melek D. Turgut,Tulin I. KeceLi, Bahar Tezel, Zafer C. that total number of rows varies from 3-6, only 17

Cehreli, Anil Dolgun, Meryem Tekcicek; Number, length toothbrushes were in accordance to ADA specification.

and end-rounding quality of bristles in manual child and When compared according to the bristles per tufts, only 2

adult toothbrushes. International Journal of Paediatric toothbrush had bristles per tufts as per ADA specification.

Dentistry 2011;21: 232-39. When evaluated according to the tufts per row 26 out of 28 thtoothbrushes showed as per ADA specification whereas only 5. Carranza F A : Clinical periodontology : Saunders , 9 Ed.

13 out of 28 toothbrushes had length of head as per ADA 651-4;2003.specification. None of the 28 commercially toothbrushes had

average width head as per ADA specification.(Table:-1)

When analyzed commercially toothbrushes according to the

diameter of the bristles 2 out of 5 hard toothbrushes were as

per ADA specification whereas only 2 out of 10 soft

698

Table 2: Showing the analysis of the toothbrushes according to diameter of the bristle and the type of toothbrushes

Type of Toothbrush

List of Toothbrushes Average diameter (d) of Bristles(mean)

Hard

* Control ADA specification = 0.4 mm

Classic Toothbrush 0.37

Colgate (travel pack) Toothbrush

0.39*

Lotus Toothbrush

0.32

Quest Toothbrush

0.53

Travel Toothbrush

0.41*

Medium


Classic Toothbrush

0.31*

Colgate Extraclear

0.36

Colgate Junior

0.34*

Colgate Sensitive

0.34*

Colgate Toothbrush

0.38

Colgate Trigard

0.49

Colgate Zigzag

0.28*

Colgate Zigzag (black)

0.31*

Lotus Toothbrush

0.43

Oral-B Toothbrush

0.27

PYX-perio

0.46

Colgate Ortho Toothbrush

0.36

Thermoseal Toothbrush

0.36

Soft


Colgate kids Toothbrush

0.12

Colgate 3600 0.27

Colgate Supersoft 0.21*

Colgate Toothbrush 0.35

Colgate Zigzag 0.24*

Johnson & JohnsonToothbrush

0.37

Lotus Junior Toothbrush 0.34

Lotus Toothbrush 0.29

Pepsodent Toothbrush 0.37

Sensodyne Toothbrush 0.36

DUPLICATION OF PALATAL RUGAE IN COMPLETE DENTURES : A CASE REPORT

Abstract

A satisfactory complete denture must fulfill the four basic requirements of

esthetics, phonetics, efficiency and comfort. Out of these, phonetics is the

factor which is most often neglected which may be due to the fact that most of

the complete denture patients tend to adjust and return to normal speech after

a post insertion practice period of several days to several weeks.

Various methods have been described in the literature to improve speech

intelligibility of patients wearing complete dentures. One of these methods is

duplication of the patient's palatal rugae pattern on the denture in order to

enhance the tactile location capability of tongue and air turbulence, make the

patient adaptation period after denture insertion easier and facilitate speech.

Palatal rugae play a vital role in the production of palatolingual sounds. This

case report will describe one such simple and cost effective method of

duplicating the palatal rugae pattern on maxillary denture.

Keywords : palatal rugae, speech intelligibility, phonetics.

699

Corresponding author:Name: Dr. Geetika ChawlaAddress: Sri Guru Ram Das Institute of Dental Sciencesand Research, Amritsar

(M) : 7508165900Email : [email protected]

1. Post Graduate, Deptt. of Prosthodontics, Sri

Guru Ram Dass Institute of Dental Sciences

And Research, Amritsar.

2. Prof., Deptt. of Prosthodontics, Sri Guru

Ram Dass Institute of Dental Sciences And

Research, Amritsar.

3. Prof. and HO.D., Deptt. of Prosthodontics,

Sri Guru Ram Dass Institute of Dental

Sciences And Research, Amritsar.

4. Reader, Deptt. of Prosthodontics, Sri Guru

Ram Dass Institute of Dental Sciences And

Research, Amritsar

Introduction : impede proper articulation and proprioceptive feedback,

one solution is to add palatal rugae to the maxillary denture.Optimal phonetics is one of the prime pre-requisites to the

successful functioning of complete dentures which can be This case report describes a simple and cost effective

best achieved by obtaining a correct occlusal vertical technique for duplication of palatal rugae in a patient's 2dimension and occlusal plane, correctly positioning the maxillary denture .

anterior and posterior teeth and adequately contouring the CASE REPORT1palatal surface .

A 70 year old male patient reported to the department of The tongue is the principal structure involved in articulation Prosthodontics and Crown & Bridge, Sri Guru Ram Das of consonant sounds. However, when natural teeth are lost Institute of Dental Sciences & Research, Amritsar, with chief and a maxillary denture is placed in the mouth, the tongue complaint of difficulty in chewing due to absence of his loses the tactile sensation and positional relationship with upper and lower teeth. He insisted on making the palatal palatal structures. In this new environment, the tongue contour of his upper denture as similar as possible to the usually has to function against a highly polished palatal natural palatal contour. Treatment followed was denture surface resulting in altered speech pattern replacement of all missing teeth with upper and lower immediately after denture insertion. Because the lack of complete denture with duplicated rugae pattern on the texture on the palatal portion of a complete denture can upper denture to facilitate speech intelligibility.


I J C D C1. Geetika Chawla

2. Kamleshwar Kaur

3. Kavipal Singh

4. Neelam Suman



Dental Care



The palatal rugae duplication was done in the following steps Patient was recalled one day, one week and fourteen days

after denture insertion. He was satisfied with the prosthesis 1.) After obtaining the final impressions of the maxillary and reported no problem regarding speech accomodation and mandibular edentulous ridges, the palatal rugae and mostication.were marked with a permanent marker on the

maxillary final cast ( Figure 1). DISCUSSION

2.) After applying separating medium on the cast, a record In the literature , many methods of improving speech have

base was made on the cast using clear self cure acrylic been suggested and evaluated. Snow suggested thickening

resin. The rugae markings were visible through the and contouring the area lingual to the collars of maxillary

transparent record base. incisors for speech facilitation. Pound advocated that the

entire lingual aspect of maxillary denture should be 3.) Using a straight fissure bur, the rugae pattern was contoured to simulate the normal palate, if proper phonetics inscribed on the record base to create depth and width is to be attained. simulating that of natural rugae of the patient (Figure

2). Many authors suggest palatal rugae fabrication to facilitate

speech. There are many methods of carving palatal rugae in 4.) Jaw relations and trial denture verification were done complete dentures. This can be done using plastic plate ( Figure 3).forms, corrugated metal palate, tinfoil adaptation and free

5.) After demounting the maxillary cast from the hand carving of anatomic palate. Use of palatogram has also articulator, condensation silicone putty material was 4been done to modify palatal portion of denture .mixed with the catalyst and kneaded in the form of

The procedure desribed in this case report involves use of self small threads which were adapted according to the cure acrylic resin and condensation silicone putty impression patient's rugae pattern on the record base ( Figure 4).material, which easily duplicates the width and thickness of

6.) Flasking was done followed by dewaxing, removal of rugae to an acceptable extent. The amount of putty used was

clear acrylic base plate along with the putty threads, very less so it is a cost-effective method. Putty can be molded

packing with heat cure denture base material and and shaped easily to customize individual rugae. Once set, it

curing in the conventional way.is hard enough to withstand the processing procedure

7.) The rugae pattern was duplicated in the finished without undergoing distortion in contrast to other materials 3denture ( Figure 5). such as waxes. As the rugae pattern was inscribed with the

700

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5


bur on the base plate, there was mechanical retention of REFERENCES

putty and negligible chances of displacement. The rugae 1. Phonetic considerations in denture prosthesis. J duplicated in finished denture did not interfere with speech. Prosthet Dent 1961; 11 : 214-223.In the event that the patient's speech is not improved, is

2. Functional contouring of the palatal vault for improving worsened, or the patient finds the texture annoying, it can speech with complete dentures. J Prosthet Dent 1982; easily be eliminated with an acrylic resin bur and routine

3 48(6) : 640- 646.polishing .

3. A simple method for patient's palatal rugae duplication Completely edentulous individuals using dental prosthesis

in complete denture. Int J Prosthodont Restor Dent tend to mispronounce certain sounds, phonation of which

2014; 4(2) : 46-47.depends upon the rugae pattern and the palatal contour.

4. Aesthetics and phonetics in full denture construction. Thus, prosthodontists need to create customized rugae and

Dent J Aust 1951; 23(3) : 126-134.palatal contours in complete dentures to achieve speech

which is much more normal and to reduce the waiting and 2training period after denture insertion .

701

HOLLOW MAXILLARY COMPLETE DENTURE- A TREATMENT OPTION FOR ATROPHIED RIDGES: A CASE REPORT.

Abstract

Extreme ridge resorption increases the interarch distance which decreases the

retention, support and stability and pose a clinical challenge to the success of

complete dentures. The restoration of the vertical dimension and esthetics

results in increased height of the prosthesis, which in turn leads to increase in

the weight of the prosthesis. Reducing the weight of the denture increases

retention and stability of the denture, decreases the ridge resorption, favoring

the prognosis of the denture.This case report describes the treatment of a

patient having resorbed edentulous ridges with excessive interarch space with

hollow maxillary complete denture.

Key words: Ridge resorption, inter arch space, hollow denture.

702

Corresponding author:Name: Dr Harpreet Kaur, Address: MMCDSR, Mullana, Ambala, Haryana.

(M): 09464141396E-mail: [email protected]

1. Senior Lecturer, Department of Prostho-

dontics And Crown & Bridge, Maharishi

Markandeshwar College of Dental Sciences

and Research.

2. Reader, Department of Prosthodontics And

Crown & Bridge, Sri Guru Ram Dass

Institute of Dental Sciences And Research.

3. Reader, Department of Prosthodontics And

Crown & Bridge, Sri Guru Ram Dass

Institute of Dental Sciences And Research.

4. Dental mechanic, Department of

Prosthodontics And Crown & Bridge, Sri

Guru Ram Dass Institute of Dental Sciences

And Research.

INTRODUCTION patient with resorbed maxillary and mandibular ridges and

increased inter ridge distance.Extreme resorption of the maxillary denture bearing area

may lead to problems with prosthetic rehabilitation. These CASE REPORT

may be due to narrower, more constricted residual ridges, A 60 years old female patient reported to the department decreased supporting tissues and a resultant large of Prosthodontics and Crown & Bridge with the chief restorative space between the maxillary and mandibular complaint of difficulty in chewing food and heaviness in ridges. This may result in a heavy maxillary denture that her upper denture. History of the patient revealed that the may further compound the poor denture bearing ability of patient was edentulous for the past two years and she had the tissues and lead to decreased retention and been wearing dentures for one and a half year. Medical

7resistance . history revealed that there was no underlying systemic

Various weight reduction approaches have been achieved disorder. The intra oral examination of the patient revealed

using a solid three dimensional space, including dental resorbed maxillary and mandibular ridges (figure 1 a,b).

stone (Ackermen 1955 ), cellophane wrapped asbestos The interarch distance was more than normal. The

(Worley and Kniejski 1983), silicon putty (Holt 1981), previous denture of the patient was heavy and over

modelling clay (Da Breo 1990) during laboratory extended. After analysing each available option, it was

processing to exclude denture base materials from the decided to fabricate hollow maxillary complete denture.

planned hollow cavity of the prosthesis. The patient also approved the treatment modality as it was

light in weight, inexpensive and non-surgical procedure. The present case report describes the technique for

fabrication of a hollow maxillary complete denture in a Preliminary and final impressions of maxillary and


I J C D C1. Harpreet Kaur

2. Aman Arora

3. Preeti Arora

4. Natish Kumar

Date of Submission : Date of Acceptance :


Dental Care



mandibular ridges were made. A processed record base dewaxing was done (figure 2). Acrylic stops were made on

was made on the maxillary definitive cast by following the processed record base which will help in the proper

conventional laboratory procedure. The conventional steps placement of two parts later (figure 3). A wax shim

of denture fabrication were followed till the denture consisting of two layers of base plate wax was then applied

processing. over the denture teeth area of the flask ensuring that the lid

of the flask containing invested definitive cast and the Two split dental flasks with interchangeable top halves processed record base is closed completely with the wax were used to construct the hollow denture. After trial, the shim in place. The wax shim was thinned out in the areas of waxed maxillary denture was invested in the first flask and interferences. On closure of the flask, the acrylic stops on

703

9)Photographs of patient before and after wearing prosthesis.(a,b)

1)Intra-oral photographs of ridges (a,b) 2)Laboratory procedure- after dewaxing.

3)Acrylic stops were made on thepermanent denture base.

4)A wax shim adapted over the teeth in the lowerhalf of the flask. The bottom half of the flask containing

wax shim in place was then topped and flasked usingthe lid of the second flask.

5)The wax shim was boiled out and processing was done.

6)Processed component of denture having teeth.

7)Approximation and fusion of two parts with self cure acrylic resin.(a,b)

8)Denture floating in water to ensure a complete seal.


the permanent denture base made depressions in the wax advantages over the other techniques. It is a simple,

shim, the wax was thinned off from the areas in between economical, time saving procedure that eliminates the

the depressions. The flask containing the denture teeth need for a spacer for creating the hollow cavity. This

with the wax shim in place was then topped and flasked technique allows a control of the thickness of the acrylic 1using the lid of the second flask (figure 4). Dewaxing, resin occupying the hollow portion . Also, fusing the

packing and processing was done as usual (figure 5). This sections with autopolymersing resin minimizes processing

resulted in two halves, the processed denture base and the errors that would occur with heat cure acrylic resin.

half containing the denture teeth (figure 6). Any excess However, this technique has some limitations. The junction

acrylic resin in between the acrylic stops that would between the two halves of the denture is fused with

constrict the hollow cavity was reduced. The two halves of autopolymerising acrylic resin which poses a risk of 8the denture were then fused using auto polymerising microleakage and discolouration over a period of time .

acrylic resin (figure 7 a, b). The denture was checked for a SUMMARYcomplete seal by placing it in water. The floating denture

A technique of fabricating a hollow complete denture is ensured a complete seal (figure 8). The denture was described with the objective of emphasizing the need to inserted in the patient's mouth and the patient was very preserve the remaining alvelor bone by the use of hollow satisfied with the function and the comfort of the denture denture in the situations where there is excessive (figure 9 a,b).resorption of the residual alveolar ridge and implant

DISCUSSION treatment is not a realistic option. This technique is simple

Rehabilitation of patient with severly resorbed ridges is a to execute and allows a control of spacer thickness

challenge to the dentist. Even though, the choice of occupying the hollow portion, which results in a lighter

rehabilitation can be implant supported over denture and prosthesis.

ridge augmentation but many a times, the patient who REFERENCEScame with such a problem is a geriatric patient with

1) EL Mahdy AS. Processing a hollow obturator. Journal of systemic illness, economic enstrains, possesses reluctance Prosthetic Dentistry, 1969;22: 682-6.for a long duration treatment procedure and unwillingness

2) Brown KE. Fabrication of a hollow bulb obturator, for any kind of surgical procedure. Hence, the best way is to 9 Journal of Prosthetic Dentistry, 1969; 21: 97-103.rehabilitate the patient is in a conventional manner . The

dentist should use his specialised training and prosthetic 3) Holt RA. A hollow complete lower denture. Journal of abilities to overcome the above stated problems with Prosthetic Dentistry, 1981; 45: 452-4.simple techniques. To decrease the leverage, reduction in

4) Worley JL, Kneijski ME. A method for controlling the 2the weight of the prosthesis would be beneficial . Apart thickness of hollow obturator prosthesis. Journal of

from modifying the impression technique to get maximum Prosthetic Dentistry, 1983; 50: 227-9.

denture bearing area, modifying the type of denture may 9 5) Fattore LD, Fine L, Edmonds DC. The hollow denture: also be better accepted by the patient . Hollow maxillary

an alternative treatment for atrophic maxillae. Journal denture is the best method of rehabilitating the patient of Prosthetic dentistry, 1988; 59:514-6.with severly resorbed ridges and excessive interarch space.

Hollowing a denture not only reduces the weight of the 6) Da Breo EL. A light cured interim obturator prosthesis: denture but also the leverage action of the same. This a clinical report. Journal of Prosthetic Dentistry, 1990; ultimately results in increased retention and stability and 63: 371-3.upto some extent it is also possible to preserve the existing

7) O. Sullivan M, Hansen N, Cronin RJ, Canga DR. The 8residual alveolar ridges .hollow maxillary compete denture- a modified

Holt et al. processed a shim of indexed acrylic resin over the technique. Journal of Prosthetic Dentistry, 2004; 91(6) residual ridge and used a spacer which was then removed :591-594.and the two halves luted with autopolymerising acrylic

8) Bhat A. A hollow complete denture for severly 3. resin Fattore et al. used a variation of double flask

resorbed mandibular ridge. Journal of Indian 5technique for obturator fabrication . O' Sullivan described a

Prosthodontic Society, 2006: 6:157-61.modified method for fabricating a hollow maxillary denture

9) Kalavathy N, Shetty MM, Premnath, Pawashe K, Patel using silicon putty which was later on removed after the 7 RKV. Hollow mandibular complete denture- a case processing of denture .

report. SRM University Journal of Dental Sciences, The technique described in this article is a modification of 2010; 1(3): 243-246.the technique described by Holt. This technique has several

704

USE OF PEDICLED BUCCAL FAT PAD FOR CLOSURE OF OROANTRAL FISTULA- A CASE REPORT

Abstract

Oroantral communication and subsequent formation of an oroantral fistula is a

common complication of dental extractions. Many techniques have been

proposed for the closure of oroantral fistula, including buccal or palatal

alveolar flaps and their modifications. In recent years, the use of a pedicled

buccal fat pad (BFP) for closure of large oroantral communications has become

popular. This article demonstrates a case of a chronic oroantral fistula

successfully treated with the use of a pedicled buccal fat pad. Complete

epithelization of the pedicled BFP was observed after 4 weeks with no

postoperative complication. Pedicled buccal fat pad is a reliable flap for repair

of oroantral fistula. The easy mobilization of the BFP and its excellent blood

supply and minimal donor site morbidity makes it an ideal flap.

Key words: Closure, oroantral communication, oroantral fistula, buccal fat pad.

705

Corresponding author:Name: Dr. Yashmeet Kaur, Address: Sri Guru Ram Das Institute of Dental (M): 9876186764

1. Postgraduate student, Department of Oral

and Maxillofacial Surgery, Sri Guru Ram Das

Institute of Dental Sciences and Research,

Amritsar.

2. Reader, Department of Oral and

Maxillofacial Surgery, Sri Guru Ram Das


Amritsar

3. Reader, Department of Oral and

Maxillofacial Surgery, Sri Guru Ram Das


Amritsar

INTRODUCTION reconstruction of oral defects. It enables the closure of oral 2defects even upto an area of 60x50 mm and a thickness of 6

mm.

This article reports a case of chronic oroantral fistula in left

maxilla successfully treated with the use of a pedicled buccal

fat pad flap.

CASE REPORT

A 50 year old female reported to the Department of Oral and

Maxillofacial Surgery with the symptoms of nasal

regurgitation, postnasal discharge and halitosis. The patient

had a history of extraction of upper left second molar 3 Various methods for closure of oroantral fistula have been months ago and subsequently developed an oroantral described over the years, including buccal flaps, palatal fistula. On intra-oral examination, patient had partially flaps, tongue flaps, pedicled buccal fat pad (PBFP), cheek edentulous maxillary and mandibular arches. On inspection,

1flaps, and placement of bioabsorbable root analogs. a sinus opening (1cm x 0.8 cm) was present in relation to the the edentulous space of left maxillary second molar (Figure 1). A

buccal fat pad (BFP) has become more popular in oral and clinical diagnosis of chronic oroantral fistula was made. maxillofacial surgery and has often been used for the Diagnosis was further established radiographically using

Oroantral communications are a common complication in

dentoalveolar and maxillofacial surgery. These most

commonly occur following removal of maxillary molars as

there is a close relationship between the root apices of these

teeth and the antrum. Most small and acute oroantral

communications, between 1-2 mm in diameter, heal

spontaneously in the absence of sinus infection. However,

oroantral defects larger than 5 mm and presenting for more

than 3 weeks epithelialize into chronic oroantral fistula

requiring secondary surgical closure.

Since 2its first description of application in 1977 by Egyedi ,


I J C D C1. Navjot Kaur

2. Yashmeet Kaur

3. Sarika Kapila



Dental Care



intraoral periapical radiograph (IOPA), after the introduction submucosal space until the fat herniated. The buccal fat pad

of gutta-percha into the antrum through the sinus opening was teased from its bed and gently advanced, without

(Figure 2). Occipitomental radiographic view of the sinus tension, and sutured to the palatal mucosa using horizontal

(Water's view) was taken to exclude any other antral mattress 3-0 vicryl (Ethicon) sutures. The releasing incisions

pathology. The radiograph revealed haziness in left maxillary were closed and pedicled buccal fat pad was left exposed to

sinus. the oral cavity over the oroantral communication. The buccal

trapezoidal flap was sutured at its original position (Figure 3). Surgical TechniquePatient was advised soft diet and appropriate antibiotic

Under aseptic technique with local anaesthesia, an elliptical coverage (Tab. Augmentin 625 mg and Tab. Metrogyl 400 mg, incision was made around the opening and the fistulous tract three times a day for five days). Sinus regime was was excised. Two divergent incisions were then made from recommended to be followed for 7 days. Sinus pack was the anterior and posterior edges of the bony defect and removed after 48 hours. Full epithelization of the flap and carried superiorly to the depth of the mucobuccal fold. The uneventful healing of the oroantral communication had trapezoidal buccal mucoperiosteal flap was reflected. thtaken place at the end of 4 week (Figure 4).Caldwell-Luc procedure was performed to remove the

DISCUSSIONthickened sinus lining followed by nasal antrostomy. Sinus

was packed with iodoform roll gauze. A 1 cm vertical incision

was made in the periosteum posterior to the zygomatic

buttress. Curved hemostat was used to dissect the

The use of BFP has been documented for closure of oro-

antral fistula, reconstruction of the palatal region, buccal

mucosa, coverage of the surface of bone grafts and

706

Figure 1: Preoperative view showing

OAF in relation to 27 region

Figure 2: Preoperative IOPA showing sinus

tract following the introduction of

gutta percha into the antrum.

Figure 3:

A) Excision of the sinus tract

and buccal flap raised.

B) Periosteum under zygomatic

buttress incised

C) Advancement and closure of buccal fat

pad (BFP) over defect

D) Mucoperiosteum returned to original

vestibular depth.

Figure 4: Postoperative clinical appearance

after 4 weeks showing complete

epithelization of buccal fat pad

Figure 5: Illustration showing the

extensions of the buccal fat pad


reconstruction after post-traumatic defects in the maxillary 4-6region.

cled flap with an axial pattern and thus

act as an ideal and reliable tool for reconstructing defects in

the maxillary region. The body and buccal process can be

easily reached through the oral cavity and are therefore 11available for reconstructive procedures.

excessive granulation and sulcus obliteration.

Complete epithelization of the BFP was observed after 4

The buccal fat pad was first described by Heister in 1732 as a weeks of inset in our patient. This is in agreement with the 6 7glandular structure and recharacterized as fatty tissue by studies of Rapidis AD et al , Tideman H et al and Samman N et

7 8Bichat in 1802. The buccal fat pad is an encapsulated, al who reported that epithelization of the flap does take rounded, biconvex specialized fatty tissue which is located place without split skin graft coverafter 3-4 weeks. However,

2 between the buccinator muscle medially, the anterior Egyedi recommended coverage of the exposed BFP with a

margin of the masseter muscle and the mandibular ramus skin graft.6,8and zygomatic arch laterally. It consists of a central body The main advantages of the pedicled BFP flap for OAF closure

and four processes the buccal, pterygoid, superficial, and are that it is a simple procedure, widely applicable with low 6,8,11,12deep temporal process. The buccal and deep temporal incidence of failure with minimal donor site morbidity.

branches of the maxillary artery, transverse facial branches of Also, its success is independent of patient age and general the superficial temporal artery, and branches of the facial condition and can be used in conjunction with other flaps as a

9artery provide the blood supply. Each process has its own second layer. The main drawback is that it can only be used capsule and is anchored to the surrounding structures by once and limitations exist concerning the potential size of the ligaments. The functions of the BFP include the prevention of defects to be covered.negative pressure in newborns while sucking, enhancement

CONCLUSIONof intermuscular motion, and the protection of 9 Pedicled buccal fat pad is a reliable flap for the repair of neurovascular bundles. The BFP has its own mechanism of

6,10 oroantral fistula. It does not interfere with the buccal sulcus lipolysis, independent of the subcutaneous fat. Therefore, 11 depth. Also, the easy mobilization of the BFP and its excellent it can be applied even in thin or cachectic patients. It is

blood supply with minimal donor site morbidity makes it an considered as a pediideal flap for various oral reconstructive procedures.

REFERENCES

1) Lazow S K. Surgical management of the oroantral fistula:

f l ap procedures . Operat ive Techn iques in The use of the BFP for closure of oroantral fistula was first Otolaryngology- Head and Neck Surgery 1999; 10: 148-

2described by Egyedi in 1977. Successful closure of OAF with 15212 buccal fat pad is widely reported in the literature. Stajcic 2

2) Egyedi P. Utilization of the buccal fat pad for closure of reported the use of pedicled BFP in the closure of oro-nasal

oro-antral and/or oro-nasal communications. J max-fac. and oro-antral communications following extractions in 56

Surg 1977; 5: 241-244patients with excellent results. Despite postoperative

3) Fujimura N et al. Grafting of the buccal fat pad into infection in 1 patient and partial necrosis in 2 patients, all 4 palatal defects. J. Cranio-Max.-Fac. Surg. 1990; 18: 219-flaps were reported to be successful. Hanazawa Y et al also

222evaluated the use of pedicled BFP for closure of oroantral

fistulae in 14 patients. Successful results were found in 13 4) Hanazawa Y et al. Closure of oroantral communications patients. However, one patient had a small fistula remaining using a pedicled buccal fat pad graft. J Oral Maxillofac which was successfully treated with curettage and surgical Surg 1995; 53: 771-775

2dressings 2 weeks after the operation. Egeydi P and Poeschl 5) Yeh CY. Application of the buccal fat pad to the surgical

13PW et al also reported good results with the use of BFP in treatmenrt of oral submucous fibrosis. Int. J. Oral the closure of oro-antral/ oro-nasal communications. Maxillofac. Surg. 1996; 25: 130-133

Pedicled buccal fat pad has also been employed in the closure 6) Rapidis AD et al. The use of buccal fat pad for of surgical defects following tumor excision, excision of reconstruction of oral decfects: Review of the literature leukoplakia and submucous fibrosis, as well as closure of and report of 15 cases. J Oral Maxillofac Surg 2000; 58: primary and secondary palatal clefts, and coverage of 158-163maxillary and mandibular bone grafts. Although, no

7) Tideman H et al. Use of the buccal fat pad as a pedicled complication was observed in the present case, 8,11 graft. J Oral Maxillofac Surg 1986; 44: 435-440complications in large series range between 3.1- 6.9%.

These include partial necrosis, infection, excessive scarring, 8) Samman N et al. The buccal fat pad in oral

707


reconstruction. Int. J. Oral Maxillofac. Surg. 1993; 22: 2-6 12) Stajcic Z. The buccal fat pad in the closure of oro-antral

communications: a study of 56 cases. Journal of Cranio- 9) Zhang HM et al. Anatomical structure of the buccal fat Maxillo- Facial Surgery 1992; 20:193-197pad and its clinical adaptations. Plast Reconstr Surg

2002; 109: 2509- 2518 13) Poeschl PW et al. Closure of oroantral communications

with Bichat's buccal fat pad. J Oral Maxillofac Surg 2009; 10) Jackson IT. Anatomy of the buccal fat pad and its clinical 67: 1460-1466significance. Plast Reconstr Surg 1999; 103: 2059-2060

11) Baumann A and Ewers R. Application of the buccal fat

pad in oral reconstruction. J Oral Maxillofac Surg 2000;

58; 389-392

708

INTERDISCIPLINARY MANAGEMENT OF PEG LATERALS AND MESIODENS: A CASE REPORT

Abstract

Jackson has summarized the aims and objectives of orthodontic therapy as the

Jackson's triad comprising of three main objectives- Functional efficiency,

Structural balance and Esthetic harmony. With the ever- growing demand of

today's society for improved esthetics, adolescent patient can easily become

self conscious if their teeth are different to others. Mesiodens and peg laterals

are the most commonly seen developmental anomalies of the maxillary arch.

Any such alteration in the shape, size and number of teeth forming the ideal

smile can pose concern to the adolescents and adults. Thus, their early and

proper diagnosis and appropriate treatment plan is critical in eluding the

extent of treatment needed. The purpose of this article is to describe a case

report with successful orthodontic and esthetic management of a patient with

mesiodens and peg shaped laterals in the maxillary arch.

Keywords: aesthetics, composite, orthodontics

709

Corresponding author:Name: Parvinder Singh DhingraAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar(M) 91988850888Email: [email protected]

1. PG Student, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

2. PG Student, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

3. MDS, Reader, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

4. BDS, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

INTRODUCTION A peg-shaped maxillary lateral incisor is a developmental

anomaly characterized by an alteration in coronal Tooth development involves a complex interaction of morphology. Typically, these teeth have a reduced mesio-physiologic growth processes and morphologic stages to

distal diameter with the proximal surfaces converging achieve final form and structure. Interference in the 6markedly towards the incisal region. There are many new initiation stage may result in single or multiple

conservative options that are possible using direct and supernumerary teeth (alteration in number) and a indirect composite resin material. It is essential to discuss disturbance in the morphogenesis stage may lead to

1 these options with patients, their parents and the alteration in the shape and size. During dental 7interdisciplinary team that are involved in treatment.development, the presence of a supernumerary tooth in the

maxillary arch could be deleterious from the aesthetic and Rarely, we come across patients with multiple

functional point of view. Prevalence of supernumerary teeth developmental deformities where management of each

ranges from 0.1% to 3.6% of which mesiodens comprise deformity needs a multidisciplinary approach. The present 2 3 one-third. Incidence of mesiodens at 1.6% and case report shows a case with peg laterals and mesiodens

distribution of 87%, 12%, and 1% with one, two, and managed by giving due consideration to the patient's

multiple supernumerary teeth respectively has been esthetic concerns.4reported. Mesiodens may cause delayed or impaired CASE REPORT

eruption, displacement, rotation, dilacerations, root A 16-year-old male reported to the department of

resorption, crowding, diastema, cyst formation, infection or Orthodontics and dentofacial orthopaedics with a chief 5mesiodens pulpitis.


I J C D C1. Parvinder Singh Dhingra

2. Tahira Kaur Bawa

3. Shilpa Gupta

4. Amrit Kaur



Dental Care



complaint of unaesthetic appearance. There was no relevant interdisciplinary team regarding the different approaches,

medical or family history. On clinical examination patient had the decision was made to:

a mesoprosopic face, potentially competent lips and convex • Extract the mesiodens to relieve the patient of his profile. Dental hard tissue examination revealed permanent problems associated with speech and appearance.dentition with teeth up to second molar in both arches and

• Extract 63 and bring palatally placed 23 back into Angle' s class I molar relation bilaterally and class I canine alignment.relation on right side. Maxillary arch showed presence of a

• Retain 65 in its original position.mesiodens in the midline, peg shaped lateral incisors (12,

22), retained 63, 65 and a palatally placed 23 with a missing • Align upper and lower arches with fixed orthodontic 25 and mesiolingually rotated 33. (Figure 1) Lateral appliance.cephalogram and orthopantomograph were taken to

• Esthetic build up of the peg laterals.evaluate the status of the mesiodens along with complete

• Finishing and detailingdentition. Radiographs showed mesiodens with completely

formed roots and no associated root resorption or pathology • Attaining soft tissue harmonyand confirmed a missing 25. (Figure 2a, 2b) Model analysis

Orthodontic treatment was carried out with fixed showed 2.5 mm space excess in the maxillary arch and 3 mm

mechanotherapy using pre- adjusted edgewise appliance of space deficiency in the mandibular arch.

ROTH (0.018” x 0.028” slot). Bite blocks were cemented in TREATMENT PLAN the posterior mandibular region and upper arch was bonded.

0.012” Ni-Ti overlay wire was used over 0.016 x 0.022” After a comprehensive history, detailed examination and stainless steel base wire for alignment of palatally placed 23. discussion with the patient, his parents and the

710

Figure 1: Pre-treatment extraoral

and intraoral views

Figure 2a and 2b : Radiographs showing mesiodens

and missing left upper second premolar

Figure 3: Mid-treatment

extraoral and intraoral views


After the initial levelling and alignment of maxillary arch, CONCLUSION

posterior bite blocks were discontinued and mandibular arch The best treatment option is interplay of patient was bonded. Maxillary anterior spaces were closed using expectations and clinical efficacy which often requires a 0.017” x 0.025” stainless steel wire with elastomeric chains multidisciplinary approach and same was followed for the while maintaining spaces around the peg shaped laterals management of the patient in this case report.with Ni-Ti open coil springs on either side. Remaining spaces

REFERENCESin the mandibular arch was closed using continuous T- loops

1. Hattab FN, Yassin OM, Rawashdeh MA. Supernumerary on 0.017” x 0.025” stainless steel wire. Composite build up of

teeth: Report of three cases and review of the the peg laterals was done in the spaces maintained to

literature. ASDC J Dent Child 1994;61:382-93.enhance esthetics. Final settling is being carried out using

elastics. (Figure 3) 2. Primosch RE. Anterior supernumerary teeth:

Assessment and surgical intervention in children. DISCUSSION

Pediatr Dent 1981;3:204-15.Management of supernumerary teeth depends on the type

3. Shrivastava RP, Singh G, Kharbanda OP. Mesodens, and position of the tooth requiring analysis of all the clinical

incidence and distribution among 3000 patients of and radiographic findings. In the clinical management of

M.L.B. Medical College, Jhansi. J Indian Dent Assoc mesiodens, very often there is confusion whether and when

1981;53:325.they can be extracted. If teeth are causing no complications

and are not likely to interfere with orthodontic tooth 4. Sharma A, Gupta S, Madan M. Uncommon mesiodens: movement they can be monitored with yearly radiographic A report of two cases. J Indian Soc Pedod Prev Dent review, but if associated with complications, it is usual to 1999;17:69-71.

8extract such teeth. In this case report since mesiodens had 5. Prabhu NT, Rebecca J, Munshi AK. Mesiodens in the

displaced the central incisors causing major esthetic primary dentition: A case report. J Indian Soc Pedod

concerns to the patient. Thus, extraction of mesiodens and Prev Dent 1998;16:93-5.

closure of space was chosen as the appropriate treatment 6. plan.

Similarly, peg laterals was another concern to manage in the 7. Greenwall L. Treatment options for peg-shaped laterals patient but with wide range of treatment options available

using direct composite bonding. International Dentistry the treatment options were closely monitored and discussed SA.;12(1):26-33.with the patient. In the past, peg-lateral incisors were the

teeth of choice in extraction as part of the treatment plan for 8. Mitchell L, Bennett TG. Supernumerary teeth causing orthodontically correcting crowded dentitions. Nowadays, delayed eruption: A retrospective study. Br J Orthod modern restorative materials offer a numbers of more 1992;19:41-6.conservative options such as resin build-ups, porcelain

9. Fortin D, Guertin G, Papadakis A. Combining 9 veneers or crowns. Due to the space requirements in the Orthodontic and Restorative Treatment to Optimize

patient as analysed from the model analysis, it was decided Esthetics and Function In Space Management Cases.

to recontour the peg laterals for both esthetics and space Oral Health. 2004;94:24-31.

management.

Counihan D. The orthodontic restorative management

of the peg-lateral. Dent Update 2000;27:250-256.

711

AMLODIPINE-INDUCED GINGIVAL OVERGROWTH: A CASE REPORT

Abstract

Gingival enlargement is a known side effect of calcium channel blockers

especially the dihydropyridine group. Among the calcium channel blockers,

gingival enlargement has most frequently been described as a side effect

following administration of nifedipine. The incidence with amlodipine is much

lower; however, there have been few reports showing the association of this

drug with gingival enlargement. It causes aesthetic disfigurement, speech

disturbances, abnormal tooth movement and difficulty in mastication. In this

article, a case of amlodipine induced gingival overgrowth has been presented

which was managed with the conservative approach. The treatment aspect

included Phase-1 therapy, substitution of the drug, and the maintenance and

supportive therapy resulting in excellent clinical outcome.

KEY WORDS: Drug Induced Gingival Enlargement, Amlodipine, Gingival

Overgrowth, Calcium channe Blockers, Conservative approach

712

Corresponding author:Name: Dr. Supreet KaurDepartment of Periodontics, Sri Guru Ram Das Institute of Dental Sciencesand Research, AmritsarEmail address. - [email protected](M) +91-981-594-5330

1. Reader, Department of Periodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

2. Reader, Department of Periodontics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

3. Ex-student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar; Punjab

4. Ex-student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar; Punjab

INTRODUCTION described with phenytoin, the rate for cyclosporins and [2]calcium channel blockers is only about 5% to 30%. The Gingival enlargement” or “gingival overgrowth” are the

prevalence of gingival overgrowth in patients taking preferred terms for all medication-related gingival lesions amlodipine was reported to be 3.3% (Jorgensen, 1997) previously termed “gingival hyperplasia” or “gingival which is lower than the rate in patients taking nifedipine, hypertrophy. Patients medicated with certain drugs may be

[3]47.8% (Nery et al., 1995). This can have a significant effect implicated in this unwanted side effect that is drug induced on the quality of life as well as increasing the oral bacterial gingival overgrowth, which may interfere with aesthetics,

[1] load by generating plaque retention sites.mastication or speech. Various pharmacological agents

responsible for such a side effect include phenytoin, The pathogenesis of drug influenced gingival enlargement

cyclosporine, calcium-channel blockers (nifedipine, suggest that it is multifactorial including; age, genetic

verapamil, diltiazem, oxodipine, amlodipine) and antibiotics predisposition, pharmacokinetic variables, drug induced

(erythromycin).While a prevalence approximately of 50% is alterations in gingival connective tissue homeostasis,


I J C D C1. Supreet Kaur

2. Vandana

3. Harkiran Kaur

4. Mandeep Kaur



Dental Care



plaque induced inflammatory changes and drug induced (2) Substitution of the drug [4]action on growth factors. The effects of these drugs are not (3) Maintenance and supportive therapy

only directed at the primary target tissues but also on CASE REPORT

secondary target tissues, such as gingival connective tissue,

A 55-year-old male patient reported to the outpatient causing clinical and histopathological aberrations. Seymour [5] department of Periodontology and Oral Implantology of Sri et al were the first to report amlodipine-induced gingival

Guru Ram Das Institute of Dental sciences and Research overgrowth, and there have been only few reported Amritsar, with a chief complaint of pain and swelling in the associations of gingival overgrowth with this drug.gums and bleeding while eating and brushing of teeth, which

It starts as a painless, beadlike enlargement of the had been progressively increasing over the previous 6

interdental papilla and extends to facial and lingual gingival months (Image 1). None of his family members had this kind

margins. It may partially or completely cover the tooth of enlargement.

surfaces. If there is underlying periodontal disease then the A medical history of the patient revealed that the patient was tissues may appear inflamed. It tends to be more severe in hypertensive and taking antihypertensive drug, amlodipine areas where plaque accumulates. Otherwise the gingival (2.5 mg/day, single dose orally) since 72 months. The patient enlargement is distributed symmetrically and for the anterior noted a gradual enlargement of the gingiva of 24 months teeth to be more severely affected than the posterior

[5] duration. Dental history revealed that the patient had teeth. The diagnosis is mainly based on the medical history, [6] undergone scaling 18 months ago, after which there was only clinical features and histopathological features.

little reduction.It clinically presents as enlarged interdental papillae and

The patient's medical history revealed that he had been resulting in a lobulated or nodular morphology. The presence hypertensive for 6 years. Intraoral examination revealed of the enlargement makes plaque control difficult, often generalized pink gingiva with rolled out gingival margins, resulting in a secondary inflammatory process that lobulated papillae, and fibrous overgrowth throughout the complicates the gingival overgrowth caused by the drug.maxilla and mandible, particularly on the labial and buccal

In this article, a case of amlodipine induced gingival side (Image 2). Generalized deep pockets, exudation on

overgrowth has been presented wherein the AIGO was application of digital pressure, and bleeding on probing were

treated in the following phases:noted (Image 3). The oral hygiene status of the patient was

(1) Thorough Phase-1 therapy poor, accompanied by marked plaque and calculus

accumulation around all teeth. A provisional diagnosis of

713


drug-induced gingival enlargement was made for the Most drug-associated gingival enlargements appear to be

patient. clinically indistinguishable, with the possible exceptions of [9]CsA8 and phenobarbitone. In phenobarbitone-treated Investigations

patients, the gingiva may be enlarged uniformly without Complete Haemogram was normal. Intra-oral periapical

lobulations of the interdental papillae, and severity of the radiograph showed generalized mild bone loss.

clinical lesions has been reported to be greater in the

Provisional diagnosis posterior as compared to the anterior regions. In individuals

immunosuppressed with CsA, sometimes pebbly or papillary Based on clinical presentation and past history, a diagnosis of lesions appear on the surface of larger lobulations, which Amlodipine Influenced Gingival Enlargement was made.have been associated with the presence of candida hyphae

Management [10]invading the gingival epithelium. Referral to the physician: Amlodipine 2.5 mg/day was

The treatment options for drug-induced gingival replaced with Atenolol 50 mg/day.

enlargement should be based on the medication being used Phase I therapy: Scaling and root planing, along with and the clinical presentation of the individual case. First, meticulous oral hygiene maintenance (including 0.2% consideration should be given to the possibility of chlorhexidine use) by the patient (Image 4). discontinuing the drug or an alternate drug. The classical

surgical approach has been the external bevel gingivectomy. Maintenance phase: First after15 days for 1 month then at an However, a total or partial internal gingivectomy approach interval of 3 months for 6 months (Image 5).has been suggested as an alternative. In the present report,

DISCUSSIONas the gingival overgrowth was not associated with the true

Amlodipine is a dihydropyridine calcium antagonist that periodontal pockets and the osseous defects and it inhibits the transmembrane influx of calcium ions into responded well to the scaling and root planing, only phase 1 vascular smooth muscle and cardiac muscle. It is frequently therapy was carried out.used as an antihypertensive and for the treatment of angina.

Finally, it should be noted that one question still remains Mild hyperplasia was detected with amlodipine with a ambiguous, i.e., why is it that despite there being similar

[2]prevalence rate of 3.3%. . Tejnani et al (2014) suggested that conditions concerning plaque and amlodipine dosage, some bacterial inflammation, resulting from dental plaque, is of the drug receivers become affected with hyperplasia and essential for gingival hyperplasia induced by amlodipine. others do not? Probably, this can be attributed to the Therefore, higher the Plaque Index, more severe will be the biological differences among human beings, such as the

[7]hyperplasia. Considering the predominance of lymphocytes, existence of different subgroups of gingival fibroblasts . plasma cells, and mast cells in the connective tissue, the Therefore, investigating the interactions between factors significant role of inflammation in the incidence and severity such as the metabolism of gingival fibroblast subgroups,

[7]of gingival hyperplasia will be more obvious . hormonal effects and growth agents can be a guide to

discover such differences.The difference in the occurrence of enlargement between

nifedipine and amlodipine is of interest, since both drugs are Conclusiondihydropyridines and hence structurally similar. However,

The reported case is an example of a combined type of two drugs differ in a way that, amlodipine is more polar than

gingival enlargementbasically a drug-induced one, other dihydropyridines, with pKa value 8.7. Thus the drug

complicated by inflammatory changes due to plaque may not pass through cell membrane without an active

accumulation. Treatment should focus on drug substitution transport mechanism. By contrast, nifedipine is intensely

and effective control of local inflammatory factors such as lipophillic and will dissolve readily within the cell membrane

plaque and calculus. When these measures fail to cause and pass into the cytoplasm. The majority of amlodipine will

resolution of the enlargement, surgical intervention is be tissue bound (and hence inactive) rather than circulating

recommended.freely in the blood giving better patient compliance, and has

REFERENCESuntil now been associated with similar or reduced severity of [8]side effects compared to nifedipine. Amlodipine, like 1. Parwani RN, Parwani RS. Management of phenytoin-

nifedipine, can be detected in gingival crevicular fluid, and induced gingival enlargement: a case report. General

gingival sequestration of amlodipine associated with gingival Dentistry 2013: 61-67.

hyperplasia has also been reported.2. Dannewitz B. Proliferation of the gingiva: aetiology, risk

714


factors and treatment modalities for gingival 7. Tejnani A, Mani A, Sodhi NK, Mehta A, Gourkhede S,

enlargement. PERIO 2007; 4(2): 83-92. Thorat V. Incidence of amlodipine-induced gingival

overgrowth in the rural population of Loni. J Indian Soc 3. Taib H, Ali TBT, Kamin S. Amlodipine-induced gingival Periodontol 2014; 18: 226-8.overgrowth: a case report. Archives of Orofacial

Sciences 2007; 2: 61-64 8. Dhale PR, Phadnaik BM. Conservative management of

amlodipine influenced gingival enlargement. Journal of 4. Seymour RA, Ellis JS, Thompson JM. Risk factors for drug Indian Society of Periodontology 2009; 13(1): 41-43.induced gingival enlargement. J Clin Periodontol 2000;

27: 217:223 9. Gregoriou AP, Schneider PE, Shaw PR. Phenobarbital-

induced gingival overgrowth? Report of two cases and 5. Seymour RA, Ellis JS, Thompson JM. Amlodipine induced complications in management. ASDC J Dent Child. 1996; gingival overgrowth. J Clin Periodontol. 1994; 21(4):281-63(6):408-413.283.

10. Khocth A, Schneider LC. Periodontal management of 6. Triveni GM, Rudrakshi DC, Mehta DS. Amlodipine-gingival overgrowth in the heart transplant patient: a induced gingival overgrowth. J Indian Soc Periodontol case report. J Periodontol. 1997; 68(11):1140-1146.2009; 13 (3): 160-163.

715

“INTERDISCIPLINARY APPROACH IN ADULT ORTHODONTICS”- A CASE REPORT

Abstract

Interdisciplinary approach is indispensable for patients with mutilated

dentition. It is also of utmost importance in adult patients presenting with

severe jaw discrepancies, partially erupted or impacted teeth, abraded or worn

teeth, old failing restorations, transmigrated teeth, tipped teeth, gingival

recession and many other periodontal and restorative problems. A combined

interdisciplinary treatment approach will yield a result best suited for the

patient as well as the clinicians. The role of orthodontist in such an

interdisciplinary treatment approach can be primary or secondary.

Keywords: orthodontics, eruption, inter-disopunary

716

Corresponding author:Name: Dr. Veneet MehtaAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar(M) +919478508324Email: [email protected]

1. PG Student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

2. PG Student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

3. Reader, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

4. BDS Student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

5. BDS Student, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

INTRODUCTION treatment approach like Orthodontic Forced Eruption (OFE)

in the prosthetic treatment plan gives an alternative to the In the recent times, with the increasing expectations of the clinician which can be initiated prior to the extraction of the patients to an esthetically and functionally stable treatment compromised tooth to favourably alter the ridge result, the practice of dentistry is changing from a single topography. Forced orthodontic eruption (FOE) is a non-specialist or general dentist practice to that of a team surgical treatment option that allows modifying the osseous approach. This enables the best utilization of the skills and and gingival topography. The use of orthodontic extrusion, expertise of clinicians of different specialties for the best also referred to as forced eruption, has been suggested as an possible treatment outcome of the patient. Such joint care alternative to periodontal crown lengthening which involves of a patient's dental needs is defined as interdisciplinary

5 the removal of supporting alveolar bone and can treatment.compromise aesthetics.

The edentulous space may be due to an impaction, missing CASE REPORTor extracted tooth in the particular region. There are many

ways to treat impacted tooth. Sometimes Crown A 41 years old male patient was referred to department of

lengthening procedures (electrosurgery of the gingival orthodontics and dentofacial orthopaedics with a chief

margins) are attempted in some cases. Incorporation of a complaint of loosening of fixed partial denture in maxillary

right posterior region (Fig. 1a). Clinical intraoral examination


I J C D C1. Veneet Mehta

2. Manmeet Kaur Bagga

3. Kamaldeep Sharma

4. Kiranjyot Kaur

5. Prerna



Dental Care



showed partially erupted 15 which seemed to be the cause rectangular stainless steel wire, surgical crown exposure in

for the loosening of FPD (Fig. 1b & 1c). Medical history of the relation to 15 was done to have bonded attachment over the

patient was non-contributory. Dental history revealed root same. The surgical crown exposure in relation to 15 was done

canal treated 16. Patient had no sign of tooth eruption at the under local infiltration anesthesia. After 3 weeks of crown

time of fabrication and delivering of FPD which was given 3-4 exposure, involvement of 15 was done with 0.012”NiTi as a

years back from the current visit and patient himself has felt piggy back wire with mesially directing force applied with

some white hard structure in the region of 15 which implies elastomeric chain placed from 15 to 13 and 12. After 3 weeks,

that there was delayed eruption of 15. Intraoral peri-apical the patient was recalled and maxillary right second premolar

radiographic analysis revealed an altered path of eruption of was involved with the 0.014”NiTi as main arch wire. The

maxillary right second premolar accompanied by hindrance required extrusion was accomplished following this

from 16 (Fig 2). After evaluation of records different procedure (Fig.4a, 4b & 4c). The upper arch was stabilized

treatment options were given to the patient. Considering the with heavier rectangular stainless steel wire at the last for

age group of the patient, orthodontic forceful eruption was retention purpose. The total time duration for the whole

planned and started after taking the patient consent. procedure was 8-9 months. After the required extrusion the

Temporary crowns were given over 14 and 16 so that bonding patient was sent to department of prosthodontics to have

of respective teeth can be done. Fixed orthodontic treatment replaced the temporary crowns with the permanent crowns

with pre-adjusted edgewise technique (MBT 0.022”x0.028” w.r.t 14 and 16 (Fig 5a & 5b).

System) was carried out. After bonding the maxillary arch the DISCUSSIONinitial alignment and leveling was started with round 0.014”

The necessity for an interdisciplinary approach to treatments NiTi without involving 15 (Fig 3a & 3b). After alignment and of routine dental problems has been recognized for a long leveling of the maxillary arch till 0.019X0.025 inch time. In many cases, forced orthodontic eruption provides a

717

Fig. 1 (a): Patient with ill-fitting FPD in Maxillary right posterior region

Fig. 1 (b): Right buccal view of partially erupted 15

Fig. 1 (c): Occlusal view of partially erupted 15

Fig. 2: IOPA X-Ray I.R.T 15 & 16 (Pre-Treatment)

Fig. 3 (a): Initial Bonding(right buccal view)

Fig. 3 (b): Initial Bonding (Occlusal view) Fig. 4 (a): Alignment and Levelling Stage (Right buccal view)

Fig. 4 (b): Alignment and Levelling Stage (Occlusal view)

Fig. 4 (c): IOPA X-Ray i.r.t 15 & 16 (Post-Treatment)

Fig. 5 (a): Right buccal view (Post-Treatment)

Fig. 5 (b): Occlusal view (Post-Treatment)


useful alternative to extraction or extensive periodontal thorough examination of the patient's chief complaint and

surgery. The prevalence of impacted premolars has been treatment demands should be done. It is important that the

found to vary according to age. The overall prevalence in orthodontist together with the other specialists frame

adults has been reported to be 0.5% (the range is 0.1% to treatment objectives which are realistic and meet the needs

0.3% for maxillary premolars and 0.2% to 0.3% for of the patient. Constant interaction and communication

mandibular premolars). among the team members and the patient at all level of

treatment are the keys to the success of the interdisciplinary According to Ingle and Bakland the forced tooth eruption treatment.should be limited to maximum 5 mm in order to avoid relapse

and also to maintain the proper length of the root for the REFERENCES

future prosthetic restoration. Extrusion is the easiest 1. Biggerstaff RH, Sinks JH, Carazola JL. Orthodontic orthodontic movement to achieve because it closely extrusion and biologic width realignment procedures:

4resembles natural tooth eruption. Only 0.2-0.3 N of force is Methods for reclaiming non-restorable teeth. J Am Dent 1required for the forced eruption of a single rooted tooth. The Assoc 1986;112:345-8.

time required varies with the age of the patient, the distance 2. Bishara SE. Textbook of orthodontics. WB Saunders Co,

the tooth has to move, and the viability of PDL. It can be rapid 2001.

as 1mm/week so 3-6 weeks is sufficient for almost any 3. Clare McNamara and Timothy G. McNamara. patient. The speed of extrusion is also important. In slow

Mandibular Premolar Impaction:2 Case Reports. JCDA extrusion the alveolar bone surrounding the root moves with 6 2006;71(11):859-863.the tooth. Biologic width realignment is then required to

obtain proper contour of the gingiva and crestal bone. A 3-4 4. Ilken Kocadereli, Fugen Tasman and Sibel Bashan Guner. mm distance from the alveolar crest to the coronal extension Combined endodontic-orthodontic and prosthodontic of the remaining tooth structure has been recommended for treatment of fractured teeth. Case report . Australian optimal periodontal health. Forced eruption is usually Dental Journal 1998; 43(1):28-31limited to one, two or three maxillary anterior teeth or

5. Kharbanda O.P. Orthodontics: Diagnosis and premolars with as much as 5 mm of extrusion possible.

Management of Malocclusion and Dentofacial Various splint and modified Hawley appliances have been

Deformities 2nd edition, Elsevier; 2013.4proposed for orthodontic forced eruption.6. Proffit WR, Fields HWJr, Sarver MD. Contemporary

Heithersay and Ingber were the first to suggest the use of orthodontics. 4edn. St Louis: Mosby, 2007;644-47.

forced eruption to treat “non-restorable” or previously 7. Reitan K. Tissue reaction as related to the age factor. “hopeless” teeth. Since then, different clinicians have used

Dental Record 1954;74: 271-279.various techniques to extrude teeth using removable devices

or fixed brackets. The ultimate goal of all of these techniques 8. Savana Khumanthem, Ansari Akram, Hamsa Rani PR, has been to expose sound tooth structure, maintain an Kumar Mukesh, Jain Abhay Interdisciplinary Therapy in acceptable crown-to-root ratio, and to establish a biologic Orthodontics: An Overview International Journal of width before restoring the tooth, all the while maintaining Advanced Health Sciences 2014;1(5):23-31.

9good periodontal health.9. Uddin M., Mosheshvili N, Segelnick Stuart L. A New

Forced eruption should be considered in cases where Appliance for Forced Eruption. NYSDJ. 2006: 46-50.traditional crown lengthening via ostectomy cannot be

10. Vanarsdall RL, Musich DR. Adult orthodontics: Diagnosis accomplished. Ostectomy also removes bone from adjacent

and treatment. Graber TM, Vanarsdall RL, Vig KWL (eds). teeth, which can compromise the function of these teeth. thOrthodontics : Current principles and techniques. 4 The case described here presented with a situation where

edition, St Louis: Mosby, 2005.the tooth that required eruption was surrounded by fixed

crown and bridge. This situation can be challenging since

previously the only other way to use forced eruption was

with brackets, bonded bars and removable tissue-born

devices.

CONCLUSION

Many a times, in our dental practice, a fulminant patient's

care involves a multidisciplinary treatment approach. A

718

SURGICAL MANAGEMENT OF A NON-HEALING LARGE RADICULAR CYST IN MAXILLARY ANTERIOR REGION: A CASE REPORT

ABSTRACT

Radicular cyst is the most common type cyst of the jaw. A true cyst is self

sustaining so it does not depend on the presence or absence of root canal

infection. Only these true self sustaining cyst are less likely to be resolved by

conventional root canal treatment. So, the management involves the

periradicular surgery with retrograde root-canal obturation. The final diagnosis

can only be made after the histopathological examination. Presented here is a

case report in which periradicular surgery was performed for the removal of

radicular cyst and retrograde root end filling was done using MTA.

Keywords: radicular cyst, MTA, endodontic surgery

719

Corresponding author:Name: Dr. Aashish HandaReader, Department of Conservative Dentistry, SGRD Institute of Dental Sciences & Research, Amritsar-143006. (M) +919872866895Email id. [email protected],

1. Reader, Department of Conservative Dentistry, SGRD Institute of Dental Sciences & Research, Amritsar.

2. Professor & H.O.D. , Department o f Conservative Dentistry, SGRD Institute of Dental Sciences & Research, Amritsar

3. Reader, Department of Conservative Dentistry, SGRD Institute of Dental Sciences & Research, Amritsar.

4. Specialist Pedodontist (Private Practice)

5. M.D.S. Resident, Department of Conservative Dentistry, SGRD Institute of Dental Sciences & Research, Amritsar.

2INTRODUCTION: failures include periapical actinomycosis , a foreign body

reaction caused by extruded endodontic materials, an The major goals of root canal treatment are to clean and accumulation of endogenous cholesterol crystals in the shape the root canal system and seal it in three dimensions

3apical tissues, and an unresolved cystic lesion.so as to prevent re-infection of the tooth. Although initial

root canal therapy has been shown to be a predictable Endodontic pathosis not responding to non-surgical re-4procedure with a high degree of success, failures can occur treatment may be eliminated with surgical intervention.

after treatment. Recent publications reported failure rates Periradicular surgery, when indicated, should be considered 1of 14%16% for initial root canal treatment. an extension of nonsurgical treatment because of

underlying etiology of the disease of disease process and the Lack of healing is attributed to persistent intraradicular objective of treatment are the same: prevention or infection residing in previously uninstrumented canals, elimination of apical periodontitis.dentinal tubules, or in the complex irregularities of the root

canal system. The extraradicular causes of endodontic So here presenting a case in which periradicular surgery was


I J C D C1. Aashish Handa

2. Rajesh Khanna

3. Ripu Daman Singh

4. Rajni Sharma Handa

5. Navneet Kaur



Dental Care



Fig 1. Preoperative photograph and radiograph Fig 2. After 3 weeks

Fig 3. Post obturative radiographs Fig 4. Incision Fig 5. Flap reflected

Fig6. Osteotomy Fig. 7. Periapical pathology

removed in toto

Fig 8. After curettage

Fig 9. Apicoectomy irt 21,22 Fig 11. Flap repositioned and sutured Fig 12a. After 1 weekFig 10. MTA as root end filling material

Fig 12b. After 1 week Fig 13. After 6 months Fig 15. After 12 months Fig 14. After 12 months


preformed on a patient, who reported in the department inflammatory cells. There was no evidence of malignancy.

with a large periradicular lesion that failed to resolve with The final diagnosis made was Radicular cyst w.r.t. 21 and 22.

non-surgical endodontic treatment. FOLLOW UP:

CASE REPORT: 6 months follow up radiograph showed considerable healing

A 30-yr old male patient reported to the Department of of the periradicular area (Fig 13). 12 months follow up

Conservative Dentistry and Endodontics, Sri Guru Ram Das radiograph and photograph revealed complete healing of the

Institute of Dental Sciences and Research, Sri Amritsar with periradicular area w.r.t. 21, 22 (Fig 14) and (Fig. 15)

the chief complaint of discoloration and pus discharge from DISCUSSION:the upper front tooth. History dated back to a year when

The goal of periradicular surgery is to create optimum patient met with an accident and got his upper front tooth conditions for healing through the regeneration of tissues, discolored. Patient also complained of occasional pus including the formation of a new attachment apparatus. In discharge from the gums and sometimes swelling in relation periradicular surgery with retrograde root-canal obturation, to that tooth. On clinical examination, discoloration w.r.t. 21 several surgical steps are essential to achieve healing: was seen (Fig 1); tenderness on palpation and percussion surgical exposure of the root-end, debridement of present w.r.t. 21,22.pathological tissue, root-end resection, root-end cavity

The patient had no other contributory medical history. preparation, root-end filling, and wound closure.Intraoral periapical radiograph showed large circumscribed

The incidence of periapical cysts has been reported to be area of rarefaction w.r.t. 21,22 and sinus tracking done w.r.t 515% to 42% of all periapical lesions and determining 21,22 (Fig 2) and pulp vitality test revealed non vital 21,22.

whether periapical radiolucency is a cyst or more common Diagnosis and Treatment periapical granuloma cannot be done with radiographs. The

Chronic supporative apical periodontitis w.r.t. 21,22. The two types of periapical cyst are: periapical true cyst and

patient was informed about the endodontic treatment and periapical pocket cyst. A correct histo-pathologic diagnosis of

informed consent was taken. periapical cyst is possible only through serial sectioning or

step serial sectioning of the lesion removed in-toto. A true The teeth were anaesthetized and access cavity preparation cyst is self sustaining so it doesn't depend on the presence or was done. Working length was determined, followed by absence of root canal infection. Only these true self biomechanical preparation of the root canals. Calcium sustaining cyst are less likely to be resolved by conventional hydroxide which was used as an intracanal medicament was root canal treatment. then placed and access was sealed. After 2 weeks, canals

were obturated with gutta percha (Fig 3). However, even But, it has been reported that only around 10 % of the total

after 1 month of non-surgical endodontic treatment the periradicular lesions are true cyst. This means 90% of the

symptoms persisted, so surgical intervention was planned periradicular lesions, should heal with our conventional root

and same was informed to patient. canal treatment. In the presented case, we have first tried the

non-surgical treatment but that led to recurrence of the sinus Surgeryformation. So, surgical treatment was planned to remove the

After local anaesthesia (2% lignocaine hydrochloride with lesion. The microbiota responsible for the persistent or

1:200000 epinephrine), full thickness flap was elevated secondary endodontic infection includes Gram-positive

mesial to 12 extending distal to 23 (Fig 4 and 5). Osteotomy facultatives or anaerobes : streptococci, P. micra,

was performed (Fig 6) and the periapical pathology was Actinomyces species, Propionibacterium species, P.

removed in toto (fig 7). Curettage was performed using 6alactolyticus, lactobacilli, E. faecalis, and Olsenella uli. curettes (Fig 8). This was followed by apicoectomy of 21, 22

Endodontic surgery have reported less peri-radicular (fig 9) and then root end was filled and sealed with MTA (fig

inflammation and cementum deposition immediately 10). The flap was repositioned and sutured (fig 11). The 7adjacent to root end filling materials. The radiographs from periradicular pathology removed, was sent for

715 patient charts were analyzed to study the success and histopathological examination.

failure of apicectomies. Complete healing was found in 65% HISTOPATHOLOGICAL EXAMINATION: of the recall cases, while incomplete and unsatisfactory

healing occurred in 29.4% and 5.6% of the cases, H & E stained section showed a bit of stratified squamous 8respectively.epithelium underneath which was present connective tissue

stroma which was infiltered with acute and chronic In vitro sealing ability and biocompatibility studies

721


comparing root end filling materials have shown MTA to be 4. Friedman S and Stabholz A. Endodontic retreatment--9superior to other commonly used materials. MTA is an case selection and technique. Part 1: Criteria for c a s e

endodontic cement that is extremely biocompatible, capable selection. J Endod. 1986 Jan; 12(1): 28-33.

of stimulating healing and osteogenesis, and is hydrophilic. It 5. Nair PN. On the causes of persistent apical periodontitis: is a powder that consists of fine trioxides (tricalcium oxide, a review. Int Endod J. 2006 Apr; 39(4): 249-281.silicate oxide, bismuth oxide) and other hydrophilic particles

6. Hargreaves KM and Cohen S.Pathways of the Pulp, 10th (tricalcium silicate and tricalcium aluminate, responsible for

Ed. Editor:Berman LH; Mosby Elsevier, 2011.2the chemical and physical properties of this aggregate ), 7. Apaydin ES, Shabahang S, Torabinejad M. Hard-tissue which set in the presence of moisture. MTA is less cytotoxic

10 healing after application of fresh or set MTA as root-end-than amalgam, Super-EBA, or IRM root end filling materials.filling material. J Endod. 2004 Jan; 30(1): 21-24.

CONCLUSION: 8. Rapp EL, Brown CE Jr, Newton CW. An analysis of success

In the conclusion every case presented with a periradicular and failure of apicoectomies. J Endod. 1991 Oct; 17(10):

lesion should be tried with standardized non-surgical root 508-512.

canal treatment. If the lesions fail or symptoms develop to 9. Adamo HL, Buruiana R, Schertzer L, Boylan RJ. A resolve after standardized treatment only then the surgical

comparison of MTA, Super-EBA, composite and protocol should be undertaken.amalgam as root-end filling materials using a bacterial

REFERENCES:microleakage model. Int Endod J. 1999 May; 32(3): 197-

1. Salehrabi R and Rotstein I. Endodontic treatment 203.outcomes in a large patient population in the USA: an

10. Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP. epidemiological study. J Endod. 2004 Dec; 30(12): 846-

Tissue reaction to implanted super-EBA and mineral 850.

trioxide aggregate in the mandible of guinea pigs: a 2. Tronstad L, Kreshtool D, Barnett F. Microbiological preliminary report. J Endod. 1995 Nov; 21(11): 569-571.

monitoring and results of treatment of extraradicular

endodontic infection. Endod Dent Traumatol. 1990 Jun;

6(3): 129-136.

3. Simon JH. Incidence of periapical cysts in relation to the

root canal. J Endod. 1980 Nov; 6(11): 845-848.

722

INTRAORAL SCWANNOMA- A CASE REPORT

Abstract

Benign nerve cell tumors include schwannoma, which rarely has an intraoral

presentation. Schwannoma is a relatively uncommon, slow-growing benign

tumor that is derived apparently from the schwann cells. It's an asymptomatic

tumor which may sometimes present with pain. The tongue is the most

common site, followed by palate, floor of mouth, buccal mucosa, lips, and jaws.

Usually it is a solitary lesion but it can present as multiple lesions when

associated with neurofibromatosis. Schwannoma resembles with many other

benign tumours like salivary gland tumors, lipoma, fibroma, etc. Sofinal

diagnosis is established after complete histologic and immunohistochemical

analysis. Presence of Anti s-100 antibody is confirmative of schwannoma. Here,

we report a rare case of intraoral schwannoma in right submental region of

mandible, in a 16-year old male patient with emphasis on it's differentiation

from neurofibroma.

Keywords: Neurilemmoma, schwannoma, schwann cells

723

Corresponding author:Name: Dr. Ramandeep S Narang Professor, Department of Oral Pathology & Microbiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.E-mail: [email protected](M) : 09417551161

1. MDS, Reader, Department of Oral Pathology & Microbiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. MDS, Professor, Department of Oral Pathology & Microbiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. Intern, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

INTRODUCTION It usually occurs as an asymptomatic, solitary, smooth-

surfaced growth, emerging at any age, with as such, no Schwannoma also known as neurilemmoma is a rare, benign 4gender predilection.neural tumour, arising from neural sheath and schwanncells

of the peripheral, cranial, or autonomic nerves. The etiology Available clinical evidence indicates that schwannoma is a

is unknown,but it's postulated that the lesion arises by slowly growing lesion and is usually of long duration at the

proliferation of schwann cells at one point inside the time of presentation by the patient, however occasionally it

perineurium causing displacement and compression of may exhibit a relatively rapid course. Although these tumors

surrounding normal nerve tissue. This tumor has are neurogenic in origin, but still they are painless, exhibiting

predilection for the head and neck region where one-third pain only in case if they are causing pressure on adjacent 5of the cases are reported, however intraoral lesions being nerve rather than on nerve of origin.

rare. When it is found in oral structures, the tongue is Schwannomas can be divided into central/intraosseous and 1,2, 3reported to be the favoured site. peripheral lesions, also in addition to these a variant known


I J C D C1. Adesh S Manchanda

2. Ramandeep S Narang

3. Meet Paras Kaur Randhawa



Dental Care



as ancient schwannoma has been diagnosed which presents confirmed on clinical and histological examination.

with degenerative phenomena such as cystic cavities, CASE REPORThemorrhage, hyalinization or calcifications. A variant

A 16 year old male patient presented with a growth in the characterized by a nodular growth pattern (plexiform right side of mandible that had been present for 6 months. intraosseous schwannoma) is also present.Although the patient was well aware of the swelling but he

Radiological examinations such as a computed tomography reported after sometime as the swelling was painless and (CT) scan with contrast and magnetic resonance imaging asymptomatic. On intraoral examination a well defined firm

6(MRI) may be performed to show the extension of the tumor. and non tender soft tissue swelling measuring 1.5 cm x 1cm

This tumour typically shows closely packed spindle cells, was seen involving the inferior border of mandible in right

often with palisaded nuclei and verocay bodies (Antoni A submental region. The swelling was covered by normal

areas) and less cellular areas with a loose reticular pattern appearing mucosa.

and microcystic degeneration sometimes containing The swelling was ovoid in shape, reflecting a reddish white numerous xanthoma cells (Antoni B). The degree of colour, was firm on palpation and not fixed to the underlying cellularity of the neoplasm can be high or low. The spindle and surrounding tissues. From the above obtained data, a cells frequently are moderately pleomorphic, but mitotic provisional diagnosis of fibroma was established. figures are rare. The presence of pleomorphism does not Radiographic examination was non relevant. To establish a necessarily denote a malignant tendency, but in rare cases confirmative diagnosis excisional biopsy was done under undoubted malignant changes can appear associated with an local anaesthesia.increased growth rate. Thrombosis and necrosis may be

Microscopic examination revealed a connective tissue 7present focally.stroma covered by stratified squamous keratinized

The clinical differential diagnosis could be with any other epithelium. There were seen streaming fascicles of spindle benign tumoral lesions such as fibroma, lipoma, shaped cells which at places formed a palisaded neurofibroma, or salivary glands tumor. However, the arrangement around acellular, eosinophillic areas (verocay histological differential diagnosis is made with other neural bodies) indicative of Antoni type A pattern (Figure 1). The origin lesions, which could be neurofibroma and neuroma, or spindle cells in other areas were randomly arranged within a

1,8,9muscular or fibroblastic origin tumor. loose myxomatous stroma, indicative of Antoni type B

pattern (Figure 2). In other areas small hyaline structures Treatment of schwannomas includes complete surgical

were present. excision of the lesion with no reported cases of recurrence.

The prognosis is good and malignant transformation is very Based on the clinical and histological evidence obtained, a 10rare although a few isolated cases have been reported. confirmatory diagnosis of schwannoma was given. As of now,

the healing following biopsy has been uneventful with no The purpose of the following article is to discuss a case of evidence of recurrence.benign schwannoma present on the inferior border of

mandible in right submental region. The diagnosis was

724

Antoni A areas

Figure 1:Hypercellular areas showing palisaded

arrangement of fascicles suggestive of antoni

A areas (H&E, X 40)

Figure 2: Presence of antoniA areas (right side)

Alongwith hypocellular region which are randomly

arranged indicative of antoni B pattern( left side) (H&E,X10).


DISCUSSION immunohistochemical findings of both need to be

understood. Microscopically, both schwannoma and Tumors arising from peripheral nerves in theoral and neurofibroma contain elongated cells with irregular nuclei paraoral tissues are uncommon. Oralperipheral nerve sheath lying between bundles of collagen fibers; however tumors are rare and include neurofibroma, schwannoma, schwannoma is derived from schwann cells and palisaded encapsulated neuroma (PEN), nerve sheath neurofibroma on other hand is derived from fibroblasts of myxoma, mucosal neuromaassociated with multiple the perineurium. Schwannoma shows degenerative changes endocrine neoplasia type 2B, traumatic neuroma and

11 such as cystic alterations and haemorrhagic necrosis granular cell tumor. Schwannoma was first established as a whereas such changes are not seen in neurofibroma. In pathological entity by Verocay in 1908 who later called it schwannomas, complete perineural encapsulation is seen neurinoma in 1910. Later the term neurilemmoma was

12 with a total lack of axons unlike neurofibroma where there is coined by Stout in 1935.lack of encapsulation and presence of fewer axons with

About 2545% of all the extracranial schwannomas have been myelin sheath. Also, true schwannoma rarely occurs in 11 reported in the head and neck region. The most common site dermis. In the present case,histological features were of a

of the extracranial schwannomas in the head and neck region classical schwannoma revealing Antoni A & Antoni B pattern.1 2is the parapharyngeal space. The first case of

Immunohistochemical staining of tumoral cells in neurilemmoma within the parapharyngeal space was schwannoma shows greater positivity for s-100 protein when reported in 1933 by Figi. Other sites in the head and neck like compared with neurofibroma. Since positivity for s-100 submandibular space, para-nasal sinuses, cheek, oral cavity

13 protein is seen in both so to further delineate the two etc. are rare.

additional immunohistochemical stains are done.In a revision of 303 solitary neural tumors, 136 lesions (45%)

Cd34 is a useful stain for differentiating between the two, were located in the head and neck region and among these,

since neurofibromas typically demonstrate a significant 14only 30 patients presented lesions in oral cavity.Gallo et al. subpopulation of CD34-positive stromal cells, un like most

reported on 157 cases of schwannoma, where 45.2% of the schwannomas wherein only slight positivity for CD34 cells

cases involved the tongue and 13.3% involved the cheek.Kun can be found and that too in antoni B areas.Other markers 15et al. reported in their study that 18 out of 49 cases were in that may be of some utility include Factor XIIIa (reportedly

the neck and 11 in the tongue. In a review made by Leu and positive in neurofibroma but negative in schwannoma), and 16Chang. out of 52 cases of schwannomas which originated in CD56(reportedly negative in neurofibroma and positive in

the head and neck region, seven cases showed lesions which schwannoma. Schwannoma shows high positivity for

were located in the oral cavity, which included one in the hard Calretinin(a calcium-binding protein) when compared to

palate, one in the soft palate, two in submasseteric area, one neurofibroma. The pericapsular region of a schwannoma 4in the tongue, and one in lower lip.may contain EMA(epithelial membrane antigen) positivity. A

Schwannoma presents as an asymptomatic and slow growing very small minority of schwannomas may show rather lesion. Although schwannoma can be found to occur in any extensive immunoreactivity with cytokeratin antibodies, age; but it is more common between the second andthird which is thought to represent cross-reactivity with glial

17decades of life. William et al. revealed that in 83% of the fibrillary acidic protein (GFAP) rather than true expression of cases studied by them, predilection for male patients was cytokeratin proteins.

18 seen; while findings by Lucas presented with a greater The treatment is complete surgical excision of the benign

predilection for females. On the other hand, Hatziotis and tumour. Recurrence after successful enbloc removal of the 19Asprides ; Enzinger and Weiss agreed over an equal tumour is very rare.

prevalence of schwannoma in both sexes. Our case also CONCLUSIONpresented with similar demographic and clinical findings in

being asymptomatic, slow growing and occurring in a male Being a very rare neurogenic tumor, the diagnosis of patient who is 16 years of age. schwannoma is usually based on exclusion criteria from

other similar lesions. Definitive diagnosis of schwannoma is Macroscopic features reveal a well-delineated but non-established only after complete histopathologic examination encapsulated globular, firm to rubbery yellow-tan mass. The and mostly immunohisto chemical analysis. Only definitive cut surfaces show tan-grey, yellowish, solid to myxoid and treatment is complete surgical excision of schwannoma,and cystic tissue, commonly with haemorrhagic areas.while performing such procedure the potential risk of nerve

Since schwannoma and neurofibroma clinically resemble damage should always be kept in mind. Recurrence after

each other, so to overcome the dilemma, histologic as well as surgical removal is a rare phenomenon.

725


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1. Martins MD, Jesus LA, Fernandes KPS, Bussadori SK, 11. Manchanda AS, Narang RS, Puri G. Palisaded

Taghloubi SA, Martins MAT. Ind J Dent Res 2009; 20:121- encapsulated neuroma. J Orofac Sci 2015; 7:136-139.

5. 12. Putney FJ, Moran JJ, Thomas GK. Neurogenic tumours of

2. Takeda Y. Neurilemmoma in maxillary alveolar bone: the head and neck. Laryngoscope. 1964;74:10371059.

Report of a case. Br J Oral Maxillofac Surg 1991;29:208- 13. Hazarika P, Nayak DR, Pujary K, Rao L. Schwannoma of 10. the nose and paranasal sinuses. Indian J Otolaryngol

3. Pahwa R, Khurana N, Chaturvedi KU, Raj A. Head Neck Surg. 2003;55(1):3438.

Neurilemmoma of tongue. Indian J Otolatyngol Head 14. Gallo WJ, Moss M, Shapiro DN, Gaul JV. Neurilemoma: Neck Surg 2003;55:193-4. Review of the literature and report of five cases. J Oral

4. Parhar S, Singh HP, Nayyar A, Manchanda AS. Intraoral Surg 1977;35:235-6.

schwannoma- a case report. JClin Diag Res 2014;3:264- 15. Kun Z, Qi DY, Zhang KH. A comparison between the 265 clinical behavior of neurilemomas in the head and neck

5. Shafer, Hine, Levy. Shafer's textbook of oral pathology. and oral and maxillofacial region. J Oral Maxillofac Surg th6 ed: Saunders Elsevier 2009. 1993;51:769-71.

6. Sanchis JM, Navarro CM, Bagan JV, Onofre MA, Murillo J, 16. Leu Y-S, Chang KC. Extracranial head and neck

Andrade CRD, Diaz JM, Filho VAP. J Clin Exp Dent. 2013; schwannomas: A review of 8 years experience. Acta

5(4):e192-6 Otolaryngol 2002;122:435-7.

7. L. Barnes, J.W.Eveson, P. Reichart,D. Sidransky:World 17. William HK, Cannell H, Silvester K, Williams DM.

Health Organisation Classification of Tumours. Neurilemmoma of the head and neck. Br J Oral

Pathology and Genetics of Head and Neck Tumours. Maxillofac Surg 1993;31:32-5.

IARC Press Lyon 2005. 18. Lucas RB. Pathology of tumors of the oral tissue. New

8. Das Gupta T, K, Brasfield RD, Strong EW, Hadju SI. Benign York: Churchill Livingstone; 1984.

solitaryschwannomas (neurilemmomas). Cancer 1969; 19. Hatziotis JC, Asprides H. Neurilemmoma (schwannoma) 24: 355-66. of the oral cavity. Oral Surg 1967;24:510-26.

9. Requena L, Sangueza OP. Benign neoplasms with neural

differentiation A review. Am J Dermatopathol

1995;17:75-96.

10. Lopez JI, Ballestin C. Intraoral schwannoma: A

clinicopathologic andimmunohistochemical study of

726

CENTRAL GIANT CELL GRANULOMA MANDIBLE- A CASE REPORT

Abstract

Central giant cell granuloma is a benign, intraosseous lesion of the jaws which

exhibits a spectrum of clinical behavior ranging from nonaggressive to

aggressive variants. It has been described variably as a reactive, inflammatory,

vascular, and endocrine process. It is a relatively uncommon pathological

condition accounting for less than 7% of all benign lesions of the jaws. It is

predominantly found in children and young adults with female predilection.

The aim of this article is to present a case of central giant cell granuloma

mandible in a 22 year old female.

Keywords: Central giant cell granuloma (CGCG), Multilocular, Intra-lesional

injections, corticosteroids

727

Corresponding author:Name: Dr. Amit DhawanAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.(M) 9779081667Email: [email protected]

1. Post graduate student, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. Assoc. Professor, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

3. Assoc. Professor, Department of Oral and Maxillofacial Surgery Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar

INTRODUCTION The site most frequently involved is the mandible, anterior

to the first molar region, especially in females under 30 years Central giant cell granuloma was first described by Jaffe in of age. Histologically CGCG shows an intraosseous lesion 1953. It is an uncommon, benign and proliferative non consisting of fibro-cellular tissue. It contains multiple foci of neoplastic process. The term central giant cell lesion has haemorrhage, aggregations of multinucleated giant cells, been proposed as a microscopic feature and not those of a

2 and occasional trabeculae of woven bone. The true granulomatous process. The clinical behavior of CGCG conventional and traditional treatment of CGCG is of the jaws is variable and difficult to predict. The etiology of

1 curettage.this lesion remains controversial. The origin of this lesion 2 can be assumed to be triggered by trauma or inflammation. However, application of non-surgical methods, including

It most often presents as a slow growing, painless lesion systemic administration of calcitonin, intra-lesional

with cortical expansion resulting in loosening and injection of corticosteroids and administration of alpha 1 2

displacement of teeth. interferon has been recommended.


I J C D C1. Amreen Kaur

2. Amit Dhawan

3. Jasmine Kaur



Dental Care



Fig. 1 Extraoral diffuse swelling on theright body region of mandible

Fig. 2 Intraoral bucco-lingual expansion on the right side of mandible

extending from right mandibular canine to right mandibular second molar region

Fig. 3 A) Pre-operative orthopantomogram B)Orthopantomogram 6 months afterintra-lesional corticosteroid therapy

C) Orthopantomogram after curettage

Fig. 4- A) Pre-operative CECT (Axial View) B) Post-operative CECT (Axial View) 6 months after intralesional corticosteroid injections.

Fig. 5- A)Pre-operative CECT (Coronal View) B) Post-operative CECT (Coronal View) 6 months after intralesional

corticosteroid injections.

Fig. 6- Intra-operative picture showing the lesion


This report presents a case of 22 year old female panoramic radiograph.

with central giant cell granuloma on right side of mandible. Following the intralesional injections, there was a decrease

Case Report in tumour size which was observed clinically. Radiographic

examination showed diminishing lesion growth, associated A twenty two year old female patient reported to with increased resistance to infiltration and revealed department of oral and maxillofacial surgery with chief increased peripheral radio-opacity of the lesions compared complaint of painless swelling on right lower side of face with the initial images. since 1 year.

Six months following the medical treatment the lesion was On extraoral inspection, there was a diffuse swelling on the removed. This involved intraoral exposure of the lesion. right body region of mandible, measuring approximately 4 X Curettage was done. The teeth 44, 45 and 47 were extracted.3 cms antero-posteriorly. Slight facial asymmetry was

observed (Fig. 1). On palpation, swelling was firm, hard and DISCUSSION

non-tender. There was no rise in local temperature and no Central giant cell lesion usually presents as a painless, slow 3 evidence of local lymphadenopathy. growing swelling of the jaw. In the jaws, lesion develops in

On intraoral inspection, there was bucco-lingual expansion the mandible more frequently than maxilla. Females are

on the right side of mandible extending from right affected more frequently than males suggests an

mandibular canine to right mandibular second molar region.

There was obliteration of the buccal vestibule. The overlying

mucosa was of normal colour and texture. Root stumps were

present in relation to 47 (Fig. 2). Intraorally, on palpation,

swelling was non-tender and firm in consistency extending

from right mandibular canine to right mandibular second

molar region. There was expansion of the buccal and lingual

cortical plates. Mobility was seen in relation to right

mandibular canine, first and second premolar. Teeth were

non- tender on percussion.

Haematological investigations showed normal levels of

serum calcium, phosphorus and alkaline phosphatase, hence

rul ing out the chances of Brown's tumour of

hyperparathyroidism. Pre-operative orthopantomogram

and contrast enhanced computerized tomography was done

to see the extent of the lesion. The

variability in the description of radiographic features is Aspiration was done which was negative. Incisional biopsy consistent with the nature of CGCG. was performed which revealed a fibrous tissue containing a

mixture of mononuclear cells and multinucleated giant cells

against a background of extravasated blood cells. Small

capillary vessels, chronic inflammatory cells and few foci of

new bony trabeculae in the form of osteoid and woven bone Despite the conventional surgical were seen. management, consisting of enucleation and curettage,

there is recurrence, and in these cases treatment may need On the basis of clinical findings, the differential diagnosis was to be more aggressive and requires en bloc resection. central giant cell tumour, ameloblastoma, odontogenic

myxoma and ossifying fibroma. On the basis of radiological

findings, the differential diagnosis was central giant cell

tumor, ameloblastoma, browns tumor and odontogenic

myxoma. Intralesional steroid injections were first described in 1988,

the protocol that has been suggested is a 50/50 mixture of Medicinal management consisted of administration of 2% lidocaine with 1:100,000 epinephrine with triamcinolone intralesional injections of a solution of triamcinilone (10 (Kenalog ) and to inject 2 ml/1 cm of lesion as seen on a mg/ml) for a period of 6 weeks at the dose of 1 ml of the Panorex X-ray and to repeat this six times at weekly intervals. solution for every 1 cm of radiolucency, as determined by the

association

between hormonal secretion and CGCG. In young children,

the craniofacial skeleton is actively developing to include

osteogenesis, exfoliation and eruption of teeth. These

processes cease in adulthood and may therefore predispose

to CGCG formation in younger individuals. The clinical

behavior of the lesion varies from an asymptomatic

osteolytic lesion that grows slowly without expansion, to an

aggressive, painful process accompanied by root resorption,

cortical bone destruction, displacement of anatomical

structures, teeth, mandibular canal and extension into the 6 soft tissues.

The radiological feature of CGCG described in the literature is

variable ranging from multilocular to unilocular radiolucent

lesions. CT is excellent for demonstration of bony thinning or 6 destruction. The lesion attenuation is similar to muscle.

Management of CGCG may be surgical or non-surgical. Non

surgical treatment of CGCG is by intralesional instillation of

corticosteroids, subcutaneous calcitonin injections and

alpha interferons.

The teeth are vital to electrical pulp testing and 8nerve dysesthesias are uncommon.

The

giant cell granuloma usually responds well to curettage and,

because of the possibility of recurrence, the bony margins 8need to be removed with a bur .

729


Experience with this technique is limited, but it does appear review of current treatments. Journal of Cranio-

to work more successfully in unilocular lesions than Maxillo-Facial Surgery 43(2015) e1127-e1132.

multilocular lesions, and this is probably because of the ease 2. Shirani G, Abbasi Mohebbi , Shirinbak I. of access in a unilocular lesion, whereas in a multilocular Management of a locally invasive Central Giant Cell

5lesion some areas may be missed. Granuloma (CGCG) of mandible: Report of an

Interferon (IFN) is a cytokine with antiviral and extraordinary large case. Journal of Cranio-Maxillo-

antiangiogenic properties. It is used in a variety of conditions, Facial Surgery 39(2011) 530-533

including life-threatening hemangiomas and several types of 3. Mohanty S, Jhamb A. Central giant cell lesion of malignancies. IFN is either produced by recombinant DNA mandible managed by intralesional triamcinolone technology or it is purified from cultured human cells. injections. A report of two cases and literature review. Amongst other effects, IFN suppresses the production of Med Oral Patol Oral Cir Bucal. 2009 Feb 1;14 (2):E98-fibroblast growth factors (FGF) which are involved in neo- 102.angiogenesis as is seen in tumors. The clinical observation

4. Kumar K R A, Gouder G. Central Giant Cell Granuloma- A that aggressive CGCGs may be highly vascularised and the

case report. Journal of Dental Sciences & Research 1:1: fact that IFN has been successful in the treatment of infantile

(1-5)hemangiomas, has led to the hypothesis that CGCGs are

5. Pogrel AM. The diagnosis and management of giant cell proliferative vascular lesions that would possibly respond to 9 lesions of the jaws. Ann Maxillofac Surg. 2012 anti-angiogenic therapy.

JulDec;2(2): 102106.The therapeutic concept for administration of calcitonin in

. Central Giant the treatment of CGCC' is based on an immunohistochemical Cel l Granuloma. study using osteoclast specific monoclonal antibodies,

demonstrating that giant cells in CGCG' are osteoclasts. This

was suspected on the in vitro reaction of giant cells to Stavropoulos F, Katz J. Central giant cell granulomas: A calcitonin and on the behaviour of giant cells in cortical bone, systematic review of the radiographic characteristics causing bone excavation similar to osteoclasts. The with the addition of 20 new cases. Dentomaxillofacial multinucleated giant cells further exhibit all cytochemical Radiology (2002) 31, 213 -217.and functional features of osteoclasts. Later on it was

, AM, Kopp WK. demonstrated that giant cells are directly inhibited in their

. 10function by calcitonin .

To conclude, the successful management of this patient has Lange J, Akker H P, Berg H, Richel D J, Gortzak R A.

illustrated the efficacy of intralesional steroid therapy for the Limited regression of central giant cell granuloma by

CGCG of the mandible. The clinical and radiographic features interferon alpha after failed calcitonin therapy: a report

of CGCG may resemble a benign-aggressive tumour rather of two cases. Int J Oral Maxillofacial Surg 2006.

than a granuloma and should be treated accordingly Lange J, Akker H P, Berg H, Zanten G O, Engelshove H A.

.BIBLIOGRAPHYCalcitonin therapy in central giant cell granuloma of the

1. Gupta B, Stanton N, Coleman H, White C, Singh. A jaw: a randomized double-blind placebo-controlled novel approach to the management of a central giant study. Int J Oral Maxillofacial Surg 2006.cell granuloma with denosumab: A case report and

A J, S Z

6. Venkateshwarlu M, Geetha P, Radhika B

Indian Journal of Dental

Advancements, 2(1), 2010

7.

8.

9.

10.

Cassady MG Greenberg Bilateral giant

cell granulomata of the mandible:report of case JADA,

Vol. 117, November 1988

730

1. Arshdeep Kaur

2. Preeti Chawla Arora

3. Chetan Dev Singh Boparai

4. Gurpreet kaur

PERIPHERAL OSSIFYING FIBROMA- A CASE REPORT WITH REVIEW OF LITERATURE

Abstract:

Localized gingival growths are seen often and are mostly reactive in nature

rather than neoplastic. Peripheral ossifying fibroma(POF) is a gingival reactive

lesion which comprises nearly 1% to 3% of oral lesions biopsied in various

histopathologic reports. It predominantly affects females mostly in the second

decade of life involving the anterior maxillary region as a well defined, smooth

surfaced gingival swelling. The purpose of this article is to present a case of POF

in a 62-year-old female and briefly review the current literature related to this

condition.

Keywords : peripheral ossifying fibroma, sessile, gingival growth

731

Corresponding author:Name: Dr. Arshdeep KaurAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar(M)Email:

1. Reader, Department of Oral Medicine and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

2. Reader, Department of Oral Medicine and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

3. Senior lecturer, Department of Orthodontics Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

4. Lecturer, Department of Oral Medicine and Radiology, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar.

Introduction growing painless swelling on the gingiva in upper front

region of 8 months duration (figure 1). It had progressed Intraoral ossifying fibromas have been described in gradually to increase in size and attained the present size. literature since the last 1940s. Ossifying fibroma occurs Growth was not associated with bleeding on brushing. The mostly in craniofacial bones and is generally categorized into patient did not give any history of trauma.two types: central and peripheral. The central ossifying

fibroma arises from the endosteum or the periodontal Intra oral examination revealed a solitary, sessile growth

ligament (PDL) adjacent to the root apex and expands from involving the attached gingiva in 11,12 region measuring

the medullary cavity of the bone whereas the peripheral approximately 2x1cm in size in its greatest dimensions.

type shows a contiguous relationship with the PDL, Mucosa over the growth was pale pink except in the superior

occurring solely on the soft tissues overlying the alveolar region where it was erythematous (figure 2). On palpation, 1process. Other terms used in reference to POF are the growth was firm in consistency, non-tender, and was

peripheral cementifying fibroma, peripheral fibroma with attached to the underlying structures. No bleeding was

cementogenesis, peripheral fibroma with osteogenesis, noticed on provocation. In clinical differential diagnosis,

peripheral fibroma with calcification, calcified or ossified pyogenic granuloma, inflammatory hyperplasia, fibroma, 2,3 peripheral ossifying fibroma, peripheral giant cell fibrous epulis, and calcified fibroblastic granuloma .

granuloma, peripheral odontogenic fibroma were Case reportconsidered.

A 62-year-old female reported with a chief complaint of slow Intraoral periapical radiograph of right maxillary anterior


I J C D C



Dental Care



3region showed mild horizontal interdental alveolar bone loss peripheral ossifying fibroma , epulis or peripheral fibroma

(figure 3). Maxillary soft tissue radiograph using occlusal film with calcification, peripheral cemento-ossifying fibroma,

(with reduced exposure time and technique variation) was calcifying fibroblastic granuloma, peripheral cementifying 4 taken which showed hazy radiopaque shadow suggestive of fibroma, peripheral fibroma with cementogenesis. The

soft tissue mass, with a small speck of calcification measuring sheer number of names used for fibroblastic gingival lesions

approximately 2mm in size (figure 4). indicates that there is much controversy regarding the 5classification of these lesions.The growth was surgically excised and submitted for

histopathological examination. Then, scaling of adjacent The etiology of POF is unknown. However, trauma or local

teeth was done to remove any local irritants. Histologically, irritants, such as dental plaque, calculus, ill-fitting dental

the specimen showed stratified squamous parakeratinized appliances, and poor quality dental restorations, play a

epithelium showing areas of epithelial hyperplasia and significant role in the etiology and pathogenesis.

atrophy. The connective tissue showed a dense fibrous tissue Inflammatory hyperplasia originating in the superficial

with few fibroblasts and dense collagen bundles. An area of periodontal ligament (PDL) is considered to be a factor in the 3ossification is seen within the fibrous tissue with a peripheral histogenesis of the POF. Miller et al. have enumerated

6rim of osteoid, confluent with the surrounding tissue. Focal findings supportive of a PDL origin. These findings include collections of chronic inflammatory cells are seen between the exclusive occurrence on the gingiva, the proximity of collagen fibre bundles close to blood vessels. The gingiva to PDL, and the inverse correlation of age distribution histopathological picture was compatible with peripheral of lesions with the number of lost teeth and their ossifying fibroma. The patient reported for a follow-up corresponding PDL.examination 20 days postoperatively. The surgical site

A POF may occur at any age but exhibits a peak incidence showed normal healing. There was no evidence of

between the second and third decades. However, our patient recurrence of the lesion, and the patient was asymptomatic.

was in the sixth decade of life. Almost 60% of the lesions Discussion occur in the maxilla and mostly occurs anterior to the molars

which was compatible with our present case. The lesion Menzel first described the lesion ossifying fibroma in 1872, 4 affects females more commonly than males (5:1 but its terminology was given by Montgomery in 1927. There

7respectively). Clinically, POF is sessile or pedunculated, are two types of ossifying fibromas, central and peripheral. usually ulcerated and erythematous or exhibits a colour The central type arises from the endosteum or periodontal similar to that of surrounding gingiva. It does not blanch on ligament adjacent to the root apex and expands from the

8palpation. The lesions of POF are usually less than 1.5-2 cm medullary cavity of the bone, whereas peripheral variant in diameter, but have been known to grow to larger sizes. POF occurs exclusively on the soft tissue covering the alveolar

1 can cause resorption of the alveolar crest and separation of process.adjacent teeth with pathologic migration but the latter

Many names have been given to similar lesions, such as

732

Figure 1: Extraoral picture

showing fullness of upper lip

due to the intraoral gingival growth.

Figure 2: Intraoral picture showing

a solitary, smooth surfaced, sessile

growth involving the attached

gingiva in 11,12 region.

Figure 3:

Intraoral periapical radiograph

of right maxillary anterior region

showing mild horizontal interdental

alveolar bone loss and widening of

PDL space in 11,12,13 region.

Figure 4: Maxillary soft tissue

radiograph (using occlusal film)

showing a hazy radiopaque

shadow suggestive of soft

tissue mass, with a small speck

of calcification measuring

approximately 2mm in size.


9 clinical feature was not seen in our case. Radiographic examination is required for confirmation of diagnosis.

features of POF vary. Radiopaque foci of calcifications have Thorough surgical removal should be done along with

been reported in literature, but not all lesions demonstrate removal of all the irritants and etiological factors so as to radiographic calcifications. In the present case, area of prevent the recurrence.

calcification was seen in the maxillary soft tissue radiograph References made by placing the occlusal film along the cheek and

1. Singh AP, Raju M S, Mittal M.Peripheral ossifying projection is made from the opposite side. In vast majority of

fibroma: A case report. Journal of Nepal dental cases, there is no apparent underlying bone involvement

association 2010; 11, Jan-june 70-72.visible on the roentgenogram. However, superficial erosion

(3, 6, 9) 2. Bhaskar SN, Jacoway JR. Peripheral fibroma and of bone is noted occasionally.peripheral fibroma with calcification: report of 376

Peripheral ossifying fibroma has to be differentiated from cases. J Am Dent Assoc 1966; 73(6):131220.

traumatic fibroma, peripheral giant cell granuloma (PGCG), 3. Eversole LR, Rovin S. Reactive lesions of the gingiva. J pyogenic granuloma and peripheral odontogenic fibroma.

Oral Pathol 1972; 1(1):30Traumatic fibroma occurs on buccal mucosa along the bite

line. Pyogenic granuloma presents as soft, friable nodule, 4. Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh small in size that has tendency to bleed and may or may not PP. Multicentric peripheral ossifying fibroma. J Oral Sci show calcifications but tooth displacement and resorption of 2006;48: 239-243. alveolar bone are not observed. Peripheral giant cell

5. Mathur S, Manjunath SM. Peripheral Ossifying Fibroma: granuloma has clinical features similar to POF however POF

A Review. Int J Dent Med Res 2014;1(4):116-118.lacks the purple or blue discoloration commonly associated

6. Miller CS, Henry RG, Damm DD. Proliferative mass found with peripheral giant cell granuloma and radiographically 10 in the gingiva. JADA 121:559-560, 1990. shows flecks of calcification.

7. Buchner A, Hansen LS. The histomorphologic spectrum It is possible to histologically differentiate PGCG and of peripheral ossifying fibroma. Oral Surg Oral Med Oral peripheral odontogenic fibroma from POF as PGCG contains Pathol 63:452-461, 1987. giant cells, whereas peripheral odontogenic fibroma

contains odontogenic epithelium and dysplastic dentin; all 8. Sujatha G, Sivakumar G, Muruganandhan J, Selvakumar 11the features may not be seen in POF . J, and Ramasamy M. Peripheral ossifying fibroma-report

of a case. Indian Journal of Multidisciplinary Dentistry Treatment includes local surgical excision and oral 2012; 2(1):415418. prophylaxis. Follow up is essential because of the recurrence

rates. Recurrence is due to incomplete excision and/or due to 9. Poon CK, Kwan PC, and Chao SY. Giant peripheral persistence of local factors. ossifying fibroma of the maxilla: report of a case. Journal

of Oral and Maxillofacial Surgery 1995;5(6): 695698.Conclusion

10. Farquhar T et al. Peripheral Ossifying fibroma: A Case POF is a well-defined pathologic entity among reactive Report. JCDA 2008; 74(9): 809-12. gingival lesions. POF is a slowly progressing lesion with high

recurrence rate. It is very important to differentiate it from 11. B.W. Neville, D. D. Damm, C. M. Allen, and J. E. Bouquot, various other gingival lesions, so that appropriate treatment Oral and Maxil lofacial Pathology, Saunders, can be carried out. Radiological and histopathological Philadelphia, Pa, USA,1995.

733

CONSERVATIVE MANAGEMENT OF A LARGE RADICULAR CYST: A CASE REPORT

Abstract

A radicular cyst arises from epithelial remnants stimulated to proliferate by an

inflammatory process originating from pulpal necrosis of a non-vital tooth.

Radiographically, the classical description of the lesion is a round or oval, well-

circumscribed radiolucent image involving the apex of the tooth. A radicular

cyst is usually sterile unless it is secondarily infected. This paper presents a case

report of conservative non-surgical management of a radicular cyst associated

with permanent maxillary left central incisor, lateral incisor and canine in a 15

year old male patient.

Key words: radicular cyst, conservative management

744

Corresponding author:Name: Dr. AnjaliPG Student, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, AmritsarEmail: [email protected]

1. Post Graduate Student, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar.

2. Professor, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar

3. Reader, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar

Introduction: feature if secondarily infected and inflamed. In some

instances these cysts can grow large in size and cause A cyst is a pathologic cavity filled with fluid, lined by expansion of the cortical plate. It is difficult to differentiate a epithelium and surrounded by a definite connective tissue radicular cyst from a periapical granuloma based on wall. The cyst fluid is either secreted by the cells lining cavity radiological analysis as both present as a well-defined round or derived from the surrounding tissue fluid. or oval radiolucency associated with the root apex of a non-

Radicular cysts are the most common jaw cyst comprising vital tooth and continuous with the lamina dura. Over the more than 60% of all odontogenic cysts. They most years cyst may regress, remain static or grow in size. commonly present in the fourth and fifth decades but affect

The treatment of the cysts can be either nonsurgical a wide age range with little gender difference. Most management or surgical management being either radicular cyst are found in the maxilla, especially around

1 marsupialization or enucleation. Nevertheless, no matter incisors and canines. The majority of radicular cysts go what choice it might be, the treatment option should be unnoticed and are asymptomatic, with pain usually only a


I J C D C1. Anjali

2. Sunil Gupta

3. Teena Gupta



Dental Care



kept as conservative as possible.This case report evaluates stimulated by inflammation to form a true epithelium lined

the successful conservative non-surgical management of a cyst or periapical cyst. The inflammatory response appears to

large radicular cyst. increase the production of keratinocyte growth factor by

periodontal stroma cells leading to increased proliferation of Case reportnormally quiescent epithelium in the area. The source of the

A 15 year old male patient reported to department of epithelium is usually a rest of Malassez but also may be pediatric and preventive dentistry along with his parents.His traced to crevicular epithelium, sinus lining, or epithelial chief complaint was continuous severe pain in left upper lining of fistulous tracts. Cyst development is common; the front region of the jaw since 5-6 months.He gave a prior reported frequency varies from 7% to 54% of periapical history of incomplete root canal treatment w.r.t 21, 22, 23.On 3radiolucencies.intra oral examination left maxillary central incisor, lateral

Occasionally, the lining epithelium may demonstrate linear incisor and canine had open root canal orifices and were or arch-shaped calcifications known as Rushton bodies. tender on percussion. Periapical radiograph revealed round Dystrophic calcif ication, cholesterol clefts with radiolucent area around the root apices of 21, 22, and 23. The multinucleated giant cells, may also be present in the lumen cystic lesion measured around 2.5 cm in diameter and had wall. The wall of the cyst consists of dense fibrous connective well defined corticated borders (fig. 1).

3tissue often with an inflammatory infiltrate.Based on the history, clinical examination and radiographic

The uninfected cystic fluid is straw coloured or brownish and examination, a clinical diagnosis of infected radicular cyst in has cholesterol clefts; a small quantity of keratin flakes may relation to 21, 22, and 23 was made and a treatment plan was also be identified. In case of a long-standing infection, a dirty-formulated to manage the case through conservative non-

2white caseous material or frank pus may be present.surgical approach.

st Differential diagnosisOn the 1 dental visit itself, biomechanical preparation(BMP)

of root canals of all the three involved teeth was carried out If an untreated asymptomatic tooth with non-vital or

using K- files (Sybronendo) according to the step back diseased pulp has a well-defined radiolucency at its apex, it is

technique. Normal saline (0.9%), sodium hypochlorite dental granuloma or radicular cyst in 90% of the cases.

(2.5%), hydrogen peroxide (3%)were used as root canal Although these entities cannot be distinguished by

irrigants to augment the effectiveness of BMP. Additionally radiographic features alone, but if the radiolucency is 1.6cm 2 4metronidazole (5%) was used as the final irrigant because of or more in diameter or 200mm , it is more likely to be a cyst.

its bactericidal action. The canal orifices were then closed Other diseases to be included in differential diagnosis are:with temporary filling material (cavit) and patient was

• Periapical scarsprescribed antibiotics and analgesics and recalled after 3

days. All procedures were carried out under absolute • Early lytic and fibroblastic stage of periapical

isolation. cement osseous dysplasia (PCOD)Traumatic bone cyst

ndOn 2 visit,provisional restoration was removed and • Malignancies

intracanal medicament (Metapex, Meta biomed)was placed • Nasopalatine cystw.r.t 21, 22, 23 (fig. 2).

• Globulomaxillary cystrdAfter one month(on 3 visit), calcium hydroxide dressing was

• Dentigerous cystchanged w.r.t. 21, 22, 23 (fig. 3).Obturation was done with

• Odontogenic keratocystguttapercha using zinc oxide eugenol as sealer after 2 months t hon 4 denta l v i s i tas pat ient was complete ly The treatment of these cysts are still under discussion and

asymptomatic(fig. 4). many professionals opt for a conservative treatment by

means of endodontic technique.Parendodontic surgeries One month later the teeth were restored with composite may have direct procedural consequences that make restoration and intra oral periapical radiograph showed nonsurgical endodontic treatment preferable over them in healing of the cystic lesion (fig. 5). 5 months and 1yr recall cases of periapical cyst. Periapical surgical interventions visit IOPA showed further increase in the bony trabaculation might be associated with loss of bone support, there is a around the apex of 21, 22, and 23. (Fig. 6 and7)possibility of damaging blood vessels and nerves present

Discussionadjacent to the lesion, possibility of damaging nearby

Radicular cysts are the most common type of cyst in the jaws. anatomic structures like mental foramen, inferior alveolar Epithelium at the apex of a nonvital tooth can be presumably

745


nerve and the maxillary sinus, production of anatomic scars the alkaline phosphatase, antibacterial effect and the

and refusal to undergo surgical procedures, especially in destruction of the cystic epithelium, allowing conjunctive

pediatric patients. tissue invagination to the lesion.

During conservative management of radicular cyst, There are few studies which have reported that periapical

endodontic infection control is a crucial point to be cysts are refractory to non-surgical endodontic therapy but

addressed while planning the intervention. For elimination the fact that these findings are associated to other etiological

or maximum reduction of microorganisms in the root canal factors, such as extraradicular infection, presence of foreign

system, the dentist should associate with debridement bodies and cholesterol crystals, has also been discussed in 5 6methods using endodontic files with efficient irrigating the literature. DeepakrajDandotikar et al 2013 , non-

solution and intracanal medication. Patency and surgically managed a large radicular cyst associated with

enlargement of the canals in case of necrotic teeth with upper incisors with palatal swelling extending upto 1st 7periapical lesions helps in eliminating microorganisms from premolars. Penumatsa NV et al 2013 ,presented a case

the apical foramen, thus preventing the inflammatory report of a patient with radicular cyst associated with a

process to perpetuate. Calcium hydroxide dressing was primary molar. Conservative treatment of the cyst that is

selected because it is reported to provide excellent clinical marsupialization rather than enucleation was considered to

and laboratorial results. Calcium hydroxide allows rapid save the premolar tooth bud.

release of Ca++ and OH. The benefits of this procedure Correct planning of the intervention in cases of periapical include anti-inflammatory action through hygroscopic cyst is of paramount importance for a successful therapy.properties forming calcium proteinate bridges and inhibiting

Conclusionphospholipase, neutralization of acidic products such as

hidrolases, which can affect the clastic activity, activation of Non-surgical management of radicular cyst should be

746

Fig. 1 Fig. 2 Fig. 3 Fig.4

Fig. 5 Fig. 6 Fig. 7


considered as seen in this clinical case report with emphasis nonsurgical endodontic therapy--case report. Braz Dent

being laid on thorough debridement, disinfection and J. 2005; 16(3): 254-8.

obturation of the root canal system.However, in specific 6. Dandotikar D, Peddi R, Lakhani B, Lata K, Mathur A, situations where the size and extent of the lesion is of critical Chowdary UK. Nonsurgical Management of a Periapical importance, surgical management is a viable option. Cyst: A Case Report. Journal of International Oral Health.

References JIOH. 2013;5(3):79-84.

1. Oral Radiology: Principles and Interpretation, 7e by 7. Penumatsa NV, Nallanchakrava S, Muppa R,

Stuart C., Michael J. Pharoah. Dandempally A, Panthula P. Conservative approach in

the management of radicular cyst in a child: case 2. Textbook of Oral and Maxillofacial Surgery 3e by report.Case Rep Dent. 2013; 2013: 123148.Neelima Anil Malik.

3. Oral and Maxillofacial Pathology, 3e by Brad W. Neville,

Douglas D. Damm, Carl M. Allen.

4. Differential Diagnosis of Oral and Maxillofacial Lesions,

5e by Norman K. Wood, Paul W. Goaz.

5. Valois CR, Costa-Júnior ED. Periapical cyst repair after

747

THERMOPLASTIC GUTTA PERCHA OBTURATION

WITH USE OF MTA AS APICAL PLUG IN TOOTH

WITH OPEN APEX-A CASE REPORT

Abstract: The case presentation highlights the use of MTA and thermoplastic

gutta percha obturation to manage a case of open apex. Where conentional

obturation techniques fail to achieve a hermetic ceal of apex, the use of such

techniques waterant a more successful approach for management of such

cases. Thus prolonging the taste of such teeth.

Keywords: open apex, MTA, Thermoplastic gutta percha.

748

Corresponding author:Name: Dr. Prashant MongaReader, Department of Conservative Dentistry and Endodontics, Genesis institute of Dental Sciences and Research,Ferozepur,Punjab.Mob: +91-9780623558Email: [email protected]

1. Department of Conservative Dentistry and Endodontics, Genesis institute of Dental Sciences and Research, Ferozepur, Punjab.

2. Department of Pedodontics and Preventive Dentistry, Dasmesh Institute of Research and Dental Sciences, Punjab.

Introduction have been proposed as alternatives to the traditional

apexification treatment method with calcium hydroxide. The primary objective of endodontic therapy is the Mineral trioxide aggregate (MTA) is one of the most popular complete obturation of the root canal space to prevent re-materials used for this purpose. It has been advocated for infection. Incomplete root development may be caused by use as an apical barrier because of its better sealing trauma; caries or any other pulpal pathosis. The absence of capabilities, ability to set in the presence of blood, and the natural constriction at the end of the root canal presents

7 biocompatibility. So it can be material of choice to create an a challenge and makes control of root canal obturating apical plug at the root-end that prevents the extrusion of the material difficult. So, the main aim in this type of case is to

2 root canal obturating material. In this article a case having seal a sizeable communication between the root canal tooth with open apex has been presented. Apical plug was system and the periradicular tissue, thus providing a barrier

1 prepared using Mineral Trioxide Agent (MTA) and then against which obturation material can be compacted.obturation was completed using thermoplastic gutta percha

Recently, synthetic apical barriers with a variety of materials obturating technique.


I J C D C1. Prashant Monga

2. Nitika Bajaj

3. Pardeep Mahajan

4. Navkesh Singh

5. Gurbant Singh

6. Manjot Singh



Dental Care



CASE REPORT 1 At follow up visit tooth was isolated using rubber dam and

metapex was removed using H files (Dentsply Maillefer, A 23 old male patient reported to Out Patient Department of Ballaigues, Switzerland) and copious irrigation with 5% Genesis Institute of Dental Sciences and Research, Ferozepur NaOCl followed by final rinse of 5ml 17% EDTA repeated with chief complaint of fractured and discolored upper right rinsing with 5% NaOCl followed by rinsing with sterile water ( front tooth. Patient gave history of fracture at the age of 7 Figure 4) . The canal was dried with paper points and the MTA years and gave no history of swelling. Clinical examination (Dentsply/Tulsa; Tulsa, Okla), was mixed according to revealed fractured and discolored 11. Tooth showed mild manufacturer's instructions and placed in the apical portion tenderness on percussion but no response to vitality tests. of the canal with help of small amalgam carrier (Dovganin Medical history was non contributory.MTA Carrier 1.6mm. Bendable) (Figure 5). After the

Radiographic examination revealed fractured tooth with positioning of the MTA apical plug, the mixture was adapted open apex and radiolucent lesion in proximity to apex of to the canal walls using Schilder's posterior plugger with a tooth 11 (Figure 1). So the final diagnosis of pulpal necrosis size proportional to the apical gauge to form a tight apical and apical periodontitis with open apex with respect to 11 plug of approximately 5mm. To check the correct position of was made. The periapical status as observed on radiographs the MTA mixture, an X-ray control was done. A wet cotton was assessed using Periapical Index (PAI) score. The pellet with sterile water was then placed in the pulp chamber preoperative PAI score was 4. and the access cavity was closed with temporary filling

After the application of the rubber dam access cavity was material Cavit.

prepared and then working length was determined (Figure After a week, the Cavit and the cotton pellet were removed 2). The canal was then lightly cleaned by using intracanal and the set of the MTA was gently tested and MTA barrier felt instruments. Irrigation was done with 5% sodium hard to an explorer. The rest of the canal was obturated with hypochlorite (Niclor OGNA) using max I probe (Dentsply thermoplastic gutta-percha using calamus (Dentsply/Tulsa; International Inc) to prevent extrusion of irrigant. Then, the Tulsa, Okla), (Figure 6) in association with a canal sealer (Pulp canal was dried with sterile papers (C Tips, Ultradent) and Canal Sealer EWT Kerr). Temporary restoration was done metapex (Meta, Biomed Co.,Ltd, Korea) was then placed in again (Figure 7) and patient was recalled after 1 week for non the canal for disinfection and temporary restoration was vital bleaching of 11.done using Cavit(3M ESPE, St Paul, MN). (Figure3). Patient

On recall visit the temporary restoration was removed and was recalled after 2 weeks.

749

Figure 1Preoperative

Figure 2Working Length

Figure 3Metapex Placed

Figure 4Metapex Removed

Figure 5MTA PLUG

Figure 6use of Calamus for

Obturation

Figure 7Obturation Done

Figure 86 Months Follow up

Figure 912 Months Follow up


17coronal GP was removed using a Gates-Glidden bur to below that calcium hydroxide must contact vital tissue.

the level of the cemento-enamel junction by about 2–3 mm The larger the apical opening, the longer is time necessary to measured using a periodontal probe. A glass ionomer base induce apical closure. Induction of apical healing takes at was then used to seal the coronal end of the root canal least 3–4 months and requires multiple appointments. completely. The bleaching paste was the prepared mixing Patient compliance with this regimen may be poor and many sodium perborate with saline to a semi-thick consistency. fail to return for scheduled visits. The temporary seal may fail The pulp chamber was packed with the paste and excess resulting in reinfection and prolongation or failure of liquid was removed by tamping with a cotton wool pellet. 10treatment. Temporary restoration was done and patient was recalled

For these reasons one-visit apexification has been after 2 weeks.suggested. A number of materials have been proposed for

On fourth visit temporary restoration and cotton were this purpose including tricalcium phosphate, calcium removed and tooth was irrigated with saline followed by 15hydroxide, freeze dried bone, and freeze dried dentine. placement of composite resin as permanent restoration

Placement of MTA has been considered in these cases as it is (Valux plus, 3M, ESPE).

effective as an apical barrier and its application results in

Patient was recalled after 6 months and 12 months for follow predictable apical closing, reduced treatment time and a 10up. The radiographic follow up at 6 months revealed a reduced number of exposures to radiographs. It is a

decrease of the periapical rarefaction, regeneration of the biomaterial that has been investigated for endodontic periradicular tissue and hard tissue deposition. The PAI score applications since the early 1990s. It was first described in the decreased to 2 indicating healing of lesion (Figure 8) and at 1 dental scientific literature in 1993 and was given approval for year follow up significant healing and decrease in PAI index to endodontic use by the U.S. Food and Drug Administration in

5. 1 was observed clearly (Figure 9). 1998 It is a powder that consists of fine hydrophilic particles

that set in the presence of moisture.The setting time in DISCUSSION4 moisture is less than 4 hours.

During tooth development, the inner and outer dental Basically MTA is a mixture of a refined Portland cement and epithelia fuse and form the cervical loop, which results in

bismuth oxide, and contains trace amounts of SiO2, CaO, Hertwig's epithelial root sheath, a structure responsible for 5

12 MgO, K2SO4, and Na2SO4. Two commercial forms of MTA root formation. The presence of healthy pulp is essential for are available : ProRoot MTA as the grey (GMTA) and white root development and apical closure. When the pulp is vital f o r m s ( W M TA ) a n d M TA - A n g e l u s ( A n g e l u s , and the apex is not fully formed, it is imperative to maintain

6 Londrina,PR,Brazil) is without calcium sulphate. Hydrated the pulp vitality for dentine formation. Dental caries and MTA products have an initial pH of 10.2, which rises to 12.5 trauma are the most common challenges to the integrity of a three hours after mixing. The setting process is described as a tooth as it matures. Both insults can render the pulp non-hydration reaction of tricalcium silicate (3CaO·SiO2) and vital. If this occurs prior to complete root formation and

13 dicalcium silicate (2CaO·SiO2), which the latter is said to be apical closure, normal root development is halted.6responsible for the development of material strength.

Clinically, there are several difficulties associated with It not only fulfills the ideal requirement of being treating non-vital teeth that have a widened or open apical bacteriostatic, but it might have potential bactericidal foramen. Firstly, the apical diameter of the canal is often properties. The release of hydroxyl ions, a sustained high pH larger than the coronal diameter, so debridement is difficult. for extended periods, and the formation of a mineralized In addition, the lack of an apical stop makes the obturation in interstitial layer might provide a challenging environment for all dimensions virtually impossible. Finally, the thin walls of

18bacterial survival. These antibacterial properties can be a the root canal are prone to fracture, so that surgical 14 potent inhibitor of bacterial growth against species such as treatment is generally not a viable option. To avoid these

19Entercoccocus faecalis, a microorganism prevalent in root complications, apexification prior to root canal filling should canal failures. Moreover, Candida albicans, commonly be attempted.present in refractory endodontic disease, is susceptible to

20 the antifungal activity of freshly mixed MTA. These factors The use of calcium hydroxide for apical closure was first are important when considering nonsurgical treatments for introduced in 1964 by Kaiser, when he proposed that using it patients with large periapical lesions associated with initial mixed with camphorated parachlorophenol (CMCP) would 3root canal treatment.induce the formation of a calcified barrier across the apex.

MTA has also presented promising outcomes when used for For the procedure to be effective, it has been suggested that

750


the repair of lateral and furcation perforations. Formation of — Volume 35, Number 6, June 2009. Pp. 777- 790.

cementum surrounding MTA was observed, even after 4. GiulianiV, BaccettiT, Pace R, Pagavino G.The use ofMTA in 8extrusion of MTA into a furcation. On the basis of these teeth with necrotic pulps and open apices. Dent

findings, MTA may be an appropriate material for apical Traumatol 2002;18:217-221sealing of mature root canals with open apices, which may

5. Mineral trioxide aggregate material use in endodontic impose technical challenges in obtaining adequate

treatment: A review of the literature Howard obturation because of apical perforation, over-

instrumentation, resorption, or former surgical treatment.

Successful prognosis from conservative treatment with MTA W.Robertsa,*, Jeffrey M. Tothb, David W. Berzinsc, David

for such difficult cases without surgical treatment is a great 9benefit for patients.

Furthermore, MTA provides scaffolding for the formation of G. Charlton. dental materials 2 4 ( 2 0 0 8 ) 149–16416 hard tissue and the potential of a better biological seal. It

6. Mineral Tri Oxide Aggregate Used As Apical Plug In Open also facilitates formation of normal periradicular

Apex Cases - A Review And Case Report. C.Meena architecture by inducing hard tissue barriers. The rationale is

Kumari, Harsh Takkar, Neeraj Nigam, Sandhya Kapoor to establish an apical stop that would enable the root canal to

Punia. Indian Journal of Dental Sciences.October 2011 be filled immediately. There is no attempt at root end

17 Supplementary Issue Issue:4, Vol.:3, pp 15-17closure. Rather an artificial apical stop is created.

7. Comparative Study of White and Gray Mineral Trioxide

Aggregate (MTA) Simulating a One- or Two-Step Apical Obturat ion in th i s case was completed wi th

Barrier Technique Gary D. Matt, DDS, MS, Jeffery R. thermoplasticized gutta-percha, since it can be placed

Thorpe, DDS, James M. Strother, DDS, MS, and Scott B. without applying any compaction forces on thin dentinal

McClanahan. Journal of Endodontics, Vol. 30, No. 12, walls in contrast to lateral condensation method. The

December 2004, pp 876-80application of MTA mixture was preceded by a temporary

8. Pitt Ford TR, Torabinejad M, McKendry JD, Hong CU, calcium hydroxide dressing in order to limit bacterial 11infection in the tooth. Kariyawasam SP. Use of mineral trioxide aggregate for

repair of furcal perforations. Oral Surg Oral Med Oral PAI scoring is a fairly error-free, reproducible, and objective Pathol Oral Radiol Endod 1995;79:756–62system based on the correlation of reference radiographs

21 with histological diagnosis. So PAI score was used to access 9. MTA for Obturation of Mandibular Central Incisors with

treatment outcome in these cases. Open Apices: Case Report Mikako Hayashi, Ayako

Shimizu and Shigeyuki Ebisu, Journal of endodontics, CONCLUSIONVOL. 30, NO. 2, Feb 2004, pp 120-122.

The presented case showed placement of an apical barrier 10. Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA using MTA is an alternative to conventional long-term

in teeth with necrotic pulps and open apices. Dent calcium hydroxide therapy. In conclusion, MTA appeared to

Traumatol 2002;18:217–21.be a valid option for apexification with the added advantage

of speed of completion of therapy. 11. Mineral trioxide aggregate for obturation of maxillary

REFERENCES central incisors with necrotic pulp and open apices. Arzu

Pinar Erdem, Elif Sepet. Dental Traumatology 2008; 24: 1. Abhishek Agrawal.Single visit apexification with MTA: A e38–e41report of two cases. C l i n i c a l D e n t i s t r y , M u m b a i S

e p t e m b e r 2 0 1 2, pp 20-25. 12. Hargreaves KM, Goodis HE. Seltzer and Bender's Dental

Pulp. St Louis: Quintessence Publishing Co, Inc; 2002. p. 2. Betül Günes, Hale Ari Aydinbelge, Mineral trioxide 13–40.aggregate apical plug method for the treatment of

nonvital immature permanent maxillary incisors: Three 13. Farhad A, Mohammadi Z. Calcium hydroxide: a review. case reports. Journal of Conservative Dentistry , Jan-Mar Int Dent J 2005 55: 293–3012012 , Vol 15 , Issue 1, Pp 73-76.

14. Cohen S, Hargreaves KM. Pathways of the Pulp. St Louis: 3. Mineral Trioxide Aggregate Obturation: A Review and Mosby Inc.; 2006. p. 610–649.

Case Series, George Bogen, DDS* and Sergio Kuttler, JOE 15. Morse DR, O'Larnic J, Yesilsoy C. Apexification: review of

751


theliterature. Quintessence Int 1990 21: 589–598. 19. Molander A, Reit C, Dahle´n G, Kvist T. Microbiological

status of root-filled teeth with apical periodontitis. Int 16. Steinig TH, Regan JD, Gutmann JL. The use and Endod J 1998; 31:1–7.predictable placement of Mineral Trioxide Aggregate in

one-visit apexification cases. Aust Endod J 2003 29: 20. Al-Nazhan S, Al-Judai A. Evaluation of antifungal activity

34–42. of mineral trioxide aggregate.J Endod 2003;29:826–7.

17. Strategies to manage permanent non-vital teeth with

open apices: a clinical update. Zahed Mohammadi

International Dental Journal 2011; 61: 25–30.

18. Santos AD, Moraes JCS, Arau´ jo EB, Yukimitu K, Vale´rio

Filho WV. Physico-chemical properties of MTA and a

novel experimental cement. Int Endod J 2005;38:443–7.

752

DECORONATION: AN APPROACH TO TREAT ANKYLOSED TOOTH IN GROWING CHILDREN

Abstract

There is no greater treatment challenge for a dental clinician than the scenario

resulting when tooth in young growing children becomes ankylosed following a

traumatic episode. In such cases only few good treatment options are left with

the clinician .This review article will present most commonly recommended

treatment options for this clinical challenge. Of the possible options,

decoronation procedure is one of the best with most predictable clinical

outcomes. Performing this procedure at appropriate time allows facio-palatal

width of alveolus to be maintained for years, while allowing additional vertical

growth of alveolus. The long term goal of this procedure is to facilitate future

rehabilitation with minimal, if any, ridge augmentation procedures.

Keywords: decoronation, ankylosis, pediatric

753

Corresponding author:Name: Dr. Ankita BhargavaMDS, Student, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, AmritsarEmail: [email protected]

1. MDS Student, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar

2. Professor and Head, Department of Paediatric and Preventive Dentistry, Sri Guru Ram Das Institute of Dental Sciences and Research, Sri Amritsar



INTRODUCTION extra alveolar time of avulsed tooth, treatment of root

surface prior to replantation, severity of trauma and extent Injury to an immature tooth can be a catastrophic event for 3of periodontal ligament necrosis .both the tooth and the child. The majority of dental injuries

usually affect the children between 8-10 years of age with a As a consequence of ankylosis, due to local arrest of alveolar 1prevalence rate of 22% . Of these, intrusions and avulsions bone, progressive infraocclusion gradually develops

account for 0.5 -3% of traumatic dental injuries and are following these injuries. This leads to aesthetic compromise,

considered to be the most severe ones damaging pulp and lack of mesial drift and arch length irregularities in these 2the periodontal ligament . patients. According to Malmgren et al, the severity of

infraocclusion depends on the stage of development of Progressive replacement resorption and dentoalveolar occlusion and facial growth. Infraocclusion is found to be ankylosis are the frequently encountered complications more intense in 6.5-10 years of age group and less in 12-16 following these injuries. The rate of replacement resorption

4years of group .is variable and depends on various factors including: age,


I J C D C1. Ankita Bhargava

2. Gunmeen Sadana

3. Manjul Mehra

4. Rashu Grover



Dental Care



Dentoalveolar ankylosis can be diagnosed within first 2 In early 1970's, experimentally it was demonstrated that new

months after injury and most often within a year after a marginal bone may form over coronal surface of submerged 5severe trauma . The condition is progressive and till date roots which were covered by mucoperisosteal flap. When

there is no treatment modality which can arrest or reverse vital roots have been submerged very few inflammatory

the process. Only few treatment options are therefore left changes were seen, whereas it was a consistent finding in

with the clinician in cases where a tooth is ankylosed and is submerged endodontically filled roots.

infra-positioned in a growing child. It has been Based on this concept, in 1984, Malmgren et al suggested the recommended to remove the ankylosed tooth before the removal of crown rather than extracting the ankylosed tooth child experiences the growth spurt. in young and root is submerged to preserve the alveolus until

Frequently the first professional to diagnose the ankylosis of it has attained the full growth. The volume of alveolar ridge

young permanent teeth is paediatric dentist and it is crucial thus could be maintained and allows more optional

for him to be aware of different treatment options which can conditions for prosthetic measures in future.

be considered in these situations. DECORONATION TECHNIQUE

VARIOUS TREATMENT OPTIONS: The main indication for this option is presence of an infra-

Build up may be an option for this condition if the positioned tooth and the procedure could be done in

infraposition of tooth is minimal and patient has passed the children who have not yet experienced a major growth spurt.

pubertal growth spurt. If patient is still in a growing age, there According to Malmgren, decoronation is recommended

will be increase in infraposition and build up need to be when severity of infra-positioning is moderate or

repeated. Hence this technique is not recommended for corresponds to an index score of two (> 1/8 but <1/4) of 8, 9growing children. crown height of neighbouring tooth .

Surgical repositioning can be considered as a treatment The decoronation procedure involves raising a full

option if ankylosed area is minimal. Tooth is likely to get mucoperisosteal flap. Crown is removed with a diamond bur

reankylosed under this option in its new position and at level of crestal border. The root surface's coronal part is

remains an aesthetic challenge for the clinician. (Straumann further reduced to 2 mm below the marginal bone with a

USA, Andover, Mass )have reported few cases using round bur. The root filling material should be removed with a

“Emdogain® “ to coat roots of ankylosed teeth prior to file or bur. The blood is then allowed to fill the lumen of root

replantation to prevent further root resorption. But the long canal. Primary soft tissue closure over retained root should

term prognosis is poor as Emdogain® can delay the onset of be attempted. The mucoperisosteal flap is drawn over the

root resorption rather than preventing it. alveolus and submerged with a single suture.

Extraction followed by autotransplantation of a tooth can be The tooth's crown can be used as a temporary replacement 6considered a good option for a child with foreseeable tooth by attaching it to adjacent tooth . Care must be taken

crowding that includes a possible tooth donor like premolar that this attachment should not hamper the development of

which can be used for autotransplantation. To achieve teeth involved and alveolus.

revascularization of pulp and periodontal healing, the ideal HOW DOES DECORONATION WORK?root development should be three-quarters of the full root

According to Malmgren et al, the marginal collagen fiber 6length . One of the critical elements required for this option is system and periodontal fibers that are formed during

presence of good alveolar bone.eruption of teeth play an important role in development of

2An ankylosed tooth left in situ in children and young alveolar ridge . During the eruption of two adjacent teeth adolescents will arrest the vertical growth of alveolar ridge there is deposition of bone on top of interdental septum via and tilting of adjacent teeth may worsen the condition forces from both periodontal and gingival fibers. Forces further. To prevent these complications, the ankylosed tooth imposed by these marginal fibers form an active alveolar should be removed. Moreover, it has been shown that periosteum.extraction of ankylosed tooth often leads to considerable

When a tooth is ankylosed, periodontal fibers are replaced by bone loss in oro-facial region, reducing the volume of bone

bone and tooth eruption is arrested. After decoronation, a that later necessitates for the complex augmentation

blood clot is organised from surrounding tissues and new 7procedures for future rehabilitation of the affected area .bone is created on top of alveolar crest, and the ongoing

Root submersion and transplant or osseous implant at later eruption of adjacent teeth induces apposition of bone time: Decoronation through traction in periosteum from the reorganized fibers.

754


TIMING OF DECORONATION 1. Malmgren B, Tsilingaridis G, Malmgren O .Long-term

follow up of 103 ankylosed permanent incisors In two separate studies, Malmgren et al suggested that surgically treated with decoronation--a retrospective decoronation in patients diagnosed with ankylosis in early cohort study. . Dent Traumatol. 2015 Jun; 31(3):184-9mixed dentition (7-10 years) should be performed within 2

2,6years of diagnosis or prior to growth spurt . However in late 2. Malmgren B. Ridge preservation/decoronation. Pediatr

mixed dentition (10-12 years), one should use discretion Dent. 2013 Mar-Apr; 35(2):164-9.

based on each case and decoronation is intervene sooner. If 3. Sapir S, Kalter A, Sapir MR. Decoronation of an ankylosis is diagnosed during the growth spurt with ankylosed permanent incisor: alveolar ridge progressing infraocclusion, decoronation is done as soon as preservation and rehabilitation by an implant problem is diagnosed. supported porcelain crown. Dent Traumatol. 2009 Jun;

ADVANTAGES OF DECORONATION 25(3):346-9.

1. Preserves the width and height of alveolar process. 4. Sapir S, Shapira J. Decoronation for the management of

an ankylosed young permanent tooth. Dent Traumatol. 2. Negates the need of an extensive and invasive 2008 Feb; 24(1):131-5.augmentation procedure.

5. Díaz JA, Sandoval HP, Pineda PI, Junod PA. Conservative 3. Vertical bone apposition is possible after the crown treatment of an ankylosed tooth after delayed removal.replantation: a case report. Dent Traumatol. 2007 Oct;

DISADVANTAGES ASSOCIATED WITH DECORONATION 23(5):313-7.

1. This intervention is surgical in nature, which may be 6. Sigurdsson A. Decoronation as an approach to treat

challenging in young children.ankylosis in growing children. Pediatr Dent. 2009 Mar-

2. “Temporary” replacement of missing tooth will be Apr; 31(2):123-8.needed for long term.

7. Filippi A, Pohl Y, von Arx T. Decoronation of an ankylosed 3. If a tooth underwent ankylosis at a very early age, it will tooth for preservation of alveolar bone prior to implant

most likely be resorbed years prior to time when it is placement. Dent Traumatol. 2001 Apr; 17(2):93-5.possible to implant into the area.

8. Cohenca N, Stabholz A. Decoronation - a conservative Despite these disadvantages, long term results of early method to treat ankylosed teeth for preservation of ankylosed, decoronated teeth have shown increased bone alveolar ridge prior to permanent prosthetic level in patients treated before or during pubertal growth reconstruction: literature review and case presentation. periods. Placement of implants in the alveolus once the Dent Traumatol. 2007 Apr; 23(2):87-94.individual is fully grown has been reported to be relatively

9. Malmgren B, Malmgren O. Rate of infraposition of easy and without complications.

reimplanted ankylosed incisors related to age and Summary: growth in children and adolescents. Dent Traumatol.

2002 Feb; 18(1):28-36.1. Clinical consequences of ankylosis are complicated in

growing patients and require multidisciplinary 10. Khalilak Z, Shikholislami M, Mohajeri L. Delayed tooth treatment planning. replantation after traumatic avulsion: a case report. Iran

Endod J. 2008;3(3):86-9.2. Early diagnosis of ankylosis is important and progression

of infraposition must be followed up. 11. Spinas E, Aresu M, Canargiu F, Giannetti L. Preventive

treatment of post-traumatic dental infraocclusion: 3. Timing of decoronation procedure is an important factor

study on the knowledge of dental decoronation in a and planned according to age, growth intensity and

sample of Italian dental students and dentists. Eur J growth pattern of an individual.

Paediatr Dent. 2015 Dec; 16(4):279-83. 4.Reported success rates of decoronation, indicates for

replantation of avulsed tooth in children, even when

extra alveolar conditions indicates that healing might be

compromised.

BIBLIOGRAPHY:

755

PROTOTYPING: A PROSTHODONTIC REVIEW

ABSTRACT

The use of computers in dental education and practice goes back to the mid

1960's when they were used for specific and limited tasks in the administration

of dental schools and large dental practices. The fast pace of technological

advancement has finally merged with the world of dentistry. Computers and

digital imaging, digital x-rays, lasers and computer assisted design and

computer assisted milling (CAD / CAM) all play a major role in dentistry today.

Rapid prototyping, one among the widely used integrated systems these days,

is the process of producing physical prototypes of an object in a layer by layer

manner from their CAD models without any human intervention or any tools,

dies or fixtures specific to the geometry of the object being produced. This

review shall describe its applications, techniques and advantages over

conventional methods.

Keywords: prototyping, CAD-CAM, Prosthodontics

756

Corresponding author:Name: Dr. Tarunpreet Kaur GillAddress: Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar(M) 9417983839Email : [email protected]

1. Department of Prosthodontics and Crown & Bridge, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar




INTRODUCTION extraoral facial prostheses. Integrated manufacturing

systems for producing extraoral facial prostheses include Human face constitutes a center of attention in human laser surface scanning/digitizing, computer-aided design relationships, the emotional pressures caused by facial (CAD; i.e three dimensional modeling) and computer-aided disfigurement due to congenital or acquired defects, can manufacturing. produce high degrees of handicap. As such, rehabilitation is

of primary importance in restoring self-confidence and a DEFINITION

normal way of life. Although corrective surgery is capable of Rapid prototyping is a method by which physical models are restoring some lost tissue and the physical appearance of a automatically constructed from computerized 3-patient to satisfactory levels, surgery may not be the ideal dimensional data. Rapid prototyping operates on the choice of treatment because of patient age, medical principle of depositing material in layers or slices to build a condition, or preference. Under such circumstances, an model (additive technique), rather than milling a model alternative treatment is prosthetic restoration through from a solid block (subtractive technique). Rapid


I J C D C1. Tarunpreet Kaur Gill

2. Kavipal Singh

3. Kamleshwar Kaur

4. Simrat Kaur



Dental Care



prototyping refers to a group of techniques that are used to in hours or at most days.

produce stereolithographical models based on digital PRINCIPLE OF RAPID PROTOTYPINGimages, including reverse engineering (RE), computer-aided

Basic concept of rapid prototyping is discretization and design (CAD), rapid prototyping (RP), etc. Reverse sequential stacking. By discretization, a complex 3D building engineering is a viable approach to create a 3-dimensional problem can be changed into a simpler 2D layer building virtual model of an existing physical part by measuring an problem. By sequential stacking, building material is object using 3-dimensional scanning technologies such as precisely deposited in a pre-determined order to form the laser scanners, structured light digitizers, computed desired 3D dental model. Usually, a support material is tomography (CT) or magnetic resonance (MR). needed in case model has overhangs or undercuts. For

HISTORY certain RP systems, no separate support material is needed

An engineer Charles W Hull had been working for a small because the building material can also be the support

company that used ultraviolet lamps to harden material.

photosensitive plastic coatings on glass and other objects. He RAPID PROTOTYPING SYSTEMShad always been bothered by the long time it took to make

Stereolithography (Figure 1) : Stereolithography builds prototype models of plastic by hand. So he attempted to plastic parts or objects at a time by tracing a laser beam on substitute a laser for an ultraviolet lamp and to develop a the surface of a vat of liquid photopolymer. When the UV prototyping machine. The result was that 3-D Systems light strikes the surface of liquid polymer, it solidifies one company introduced the first prototyping machine. It could layer of polymer. Once the first layer, which adheres to the fabricate small, transparent plastic parts from CAD drawing platform, has been completely traced, the elevator is

757

Figure 1: Stereolithography Procedure

Figure 3: 3d Printing

Figure 2: Fused Deposition Modelling


lowered to the depth of the next layer. This process continues assisted densification (MMLD) : RFP process is used to

layer by layer until the part fabrication is completed. This fabricate ice patterns instead of conventional wax patterns

technique has advantages of its high part-building accuracy, for investment casting of dental restorations. RFP is a novel,

smooth surface, fine building details, high strength and its environmentally conscious solid freeform fabrication

drawbacks are that it includes expensive equipment and process. MMLD was developed at the University of

material. Connecticut to deliver dental restorations built with powders

(dental alloy and porcelain) by slurry extrusion, followed by Selective laser sintering : The selective laser sintering process laser densification of these extruded slurries. This process creates a solid, 3D object by fusing powdered materials with can fabricate artificial dental units layer-by-layer directly a CO laser. These powders offer advantages over resin-based 2

from a computer model without part-specific tooling and technologies as well, including higher yields and faster post-human intervention. finishing.

USES OF RAPID PROTOTYPING : It can be used to manufacture Fused deposition modeling (Figure 2): This is a widely used dental devices, visualization, diagnostication and education, rapid prototyping technology. It utilizes a temperature-surgical planning, customized implant design, orthotics, controlled head to extrude thermoplastic material layer by prosthetics, anthropology, forensics, biologically active layer. A plastic filament is unwound from a coil and supplies implants. material to an extrusion nozzle. Nozzle is heated to melt the

DISADVANTAGES : plastic to a semiliquid state and has a mechanism which

allows the flow of melted plastic to be turned on and off. This This technology requires expensive equipment, complicated process allows a variety of modeling materials and colors and machinery and reliance on special expertise to run it is appropriate for creation of bone models due to machinery during production. production of hard, robust models in a single step

SUMMARY AND CONCLUSIONmanufacturing process.

Rapid prototyping technology is becoming more pervasive 3D printing (Figure 3): It is an additive printing process. The

and portable. Several educational and medical institutions technology is based on inkjet principle producing the object

currently have close ties to Rapid Prototyping companies layer by layer with support from a water soluble material.

that have access to the technical equipment, resources, and This process brings large cost savings in material and has

expertise required and offer site visit services to personally unlimited design and manufacturing capability.

facilitate the scan and build of the prototype. Laminated object manufacturing : This process stacks layers

REFERENCESof thin sheets of paper or other material to make the

1. Rapid Prototyping and its Application in Dentistry. V. N. prototype. Each layer is cut using a laser to match a cross-V. Madhav , Rajendra Daule. Journal of Dental & Allied section of the model. Mechanical part of the system contains Sciences 2013;2(2)57-61.an unwinding and a rewinding roll connected by a ribbon of

sheet material routed through several idler rollers. These 2. A review of dental CAD/CAM: current status and future rolls store and supply the material. Located above the perspectives from 20 years of experience. Dental platform is a heated roller capable of heating and Materials Journal 2009; 28(1): 44- 56.compressing the ribbon between itself and the stack of

3. CAD-CAM generated ear cast by means of a laser laminations on the platform. Areas of cross-sections to be

scanner and rapid prototyping machine. Leonardo removed in the final object are heavily cross-hatched with

Ciocca, Roberto Scotti. JPD 2004.08.021the laser to facilitate the removal.

Rapid freeze prototyping (RFP) and multimaterial laser-

758


DENTAL DILEMMA-10

Dr. Balwinder Singh, Senior Lecturer, Department of Oral Medicine & Radiology, SGRD Institute of Dental Sciences and Research,

Sri Amritsar.

Dr. Adesh S Manchanda, Reader, Department of Oral Pathology & Microbiology, SGRD Institute of Dental Sciences and Research,

Sri Amritsar

Dr Ramandeep S Narang, Professor & Head, Department of Oral Pathology & Microbiology, SGRD Institute of Dental Sciences and

Research, Sri Amritsar

QUESTION:

A 14 year old female patient complained of swelling in left upper anterior region since two months. The swelling gradually

increased in size to attain size of 2 cm ×3 cm. Swelling was associated with pain but there was no evidence of any blood, pus and

serous discharge. On intra oral examination showed a solitary gingival swelling pinkish red in colour, firm in consistency and non-

tender. Orthopantomograph & IOPA showed a well-defined radiolucency in the left maxillary region extending from 22 to 23 with

displacement of teeth and divergence of roots in relation to 22 and 23 (Figure 1).

Histopathological examination showed numerous multi - sized nodules of cuboidal or columnar epithelial cells forming ducts,

rosettes and nest like structures with scanty connective tissue stroma. Few ducts and rosettes contained eosinophilic material.

Polygonal to spindle shaped epithelial cells with hyperchromatic nuclei and dark eosinophilic cytoplasm were seen in spaces

between the nodules. Periphery of section showed fibrous capsule around the tumor mass. (Figure 2)

Identify the condition?

Figure 1. Figure 2

Answer to DENTAL DILEMMA 9 -: Schwannoma

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