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JOURNAL OF DENTAL PEERS July 2014 w Vol.2w Issue 2

Table of Contents

ORIGINAL RESEARCH

37 Evaluation of the Extent of Facial Asymmetry in Aesthetically Symmetric Faces of Bilaspur Population

Abhay Prem Prakash Agarwal1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4

43 Assessment of Dental Aesthetic Index Among School Children of Bilaspur (CG), India Hemlata Rajmani1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4

CASE REPORT

48 Resin Retained Prosthesis for anterior Tooth Replacement-Maryland Bridge- A Case Report Manoj Upadhayay1, Sudhanshu Srivastava2, Sakshi Chopra3, Mansi Rajput4, Pratim Talukdar5, Rashi Singh6

52 Bar & Clip Retained Overdenture- A Case Report Sahil Sekhri1, Shivali Goyal2, Sanjeev Mittal3

55 Management of Failed Implant using Platelet Rich Fibrin (PRF)- A Case Report Amarnath1, Pratim Talukdar2, Nitika Sachan3, Mukut Seal4, Meghali Langthasa5

59 Management of Partial Edentulism with Flexible Dentures- A Case Series Reeta Jain1, Gyan Chand2, Deepika3

LITERATURE REVIEW

62 Changing Perception and Attitude of Pediatric Dentistry Neetika Singh1, Rohit Thakur2, Nagender Chauhan3, Marisha Kaul4

ORIGINAL RESEARCH

Journal of Dental Peers, Vol. 2. Issue 2, July 2014 37

Evaluation of the Extent of Facial Asymmetry in Aesthetically Symmetric

Faces of Bilaspur Population *Abhay Prem Prakash Agarwal1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4

Abstract Background: Although minor asymmetries are rarely evident, but the asymmetries which affects function, aesthetics or social

acceptance of an individual need complete evaluation.

Aims: To evaluate the extent of facial asymmetry in aesthetically symmetric faces of the Bilaspur population.

Materials and methods: Simple random sampling was executed to select 500 Adult subjects (250 males and 250 females) aged 12-25

years from the daily out patients of the Department of orthodontics and Dentofacial Orthopedics, New Horizon Dental College,

Bilaspur, Chhattisgarh. A Poster anterior (PA) cephalogram was obtained with each subject in centric occlusion. Skeletal asymmetry

was determined using Grummon's analysis.

Results: The results indicate less asymmetry and more dimensional stability as the cranium is approached and mandibular region

shows the asymmetries of higher magnitude. A tendency toward right side dominance was statistically significant.

Conclusion: Asymmetries are common finding in the present group of population, with males showing higher rate of asymmetry then

the females.

Keywords: Facial asymmetry, Symmetry, aesthetics.

Introduction Asymmetry is defined as being present when one or

more of the facial or cranial bilateral components (bone or soft

tissues) are not equidistant from the midline or that the center

of each of the unpaired structures does not lie on that line[1].

Asymmetry of the face is one of the more difficult problems

with which orthodontists have to contend and which often

present serious diagnostic difficulties [2]. The recognition of

the actual site of asymmetry is essential for correct treatment

planning.

Gross asymmetries occur in developmentally

acquired as well as in congenital abnormalities, usually

involve both soft and hard tissues.

*1Post-Graduate Student, 2Professor & Head, 3Reader, 4Reader, Dept. Orthodontics & Dentofacial Orthopedics, New Horizon Dental College, Sakri, Bilaspur(CG), India. E-mail:[email protected] * Corresponding Author

Minor asymmetries of the face are a common finding

in normal individuals [1,3] although they are rarely evident

and generally pass unnoticed [2,4]. Asymmetry becomes

important when it affects function, aesthetics or social

acceptance of an individual. A more precise method to

measure asymmetry is to use radiographs of the subjects.

Asymmetry of the craniofacial bones can be quantified only

through X-ray techniques. In the lateral cephalometric film,

vertical asymmetries are often recognized by the failure of

bilaterally symmetric objects to superimpose, as they normally

will. An additional dimension can be added to the radiographic

examination by panoramic films, which are useful when the

sections of mandible are deformed. Sub-mental vertex view is

also useful when the mandibular ramus is severely deformed.

Computed tomography (CT) also allows the three

dimensional viewing but significantly more radiation is

required. Thus the most common view used is the Postero-

Anterior on which researchers have used different reference

points for construction of the midline of the face, which is

essential in the study of asymmetries [5]. So for, Postero-

ORIGINAL RESEARCH


Anterior (PA) view remains most widely used tool for the

research on asymmetries. The present article aims to assess the

nature of asymmetry in aesthetically pleasing faces in

Bilaspur, Chhattisgarh population using Postero-Anterior (PA)

films.

Materials And Methods A cross-sectional study was conducted on a sample of

500 adult subjects (250 male and 250 female). Simple random

sampling was executed for the sample selection. All the

subjects were taken from the daily out patients of the

Department of Oral Medicine and Radiology, and the

Department of Orthodontics and Dentofacial Orthopedics,

New Horizon Dental College and Hospital, Bilaspur,

Chhattisgarh, India. All the subjects selected had clinically

acceptable facial harmony and symmetry with full

complement of teeth. They had no history of orthodontic

treatment and mandibular displacement during opening and

closing.

To minimize the subjective error in selection, a panel

of three orthodontists examined each person and the subjects

were selected when all the three agreed. Ethical clearance was

obtained from the ethical committee of New Horizon Dental

College and Hospital, Bilaspur, Chhattisgarh. The purpose of

the study was explained to the subjects and the written consent

was obtained before exposing them to X-ray.

The single examiner on the acetate tracing paper

traced all the P-A Cephalometric X-rays. The intra examiner

variability was determined by randomly selecting a sample of

10 PA cephalograms for retracing within period of two

months. The error was found to be 0.5 mm, which was within

normal limits.

The analysis for assessment of transverse frontal

facial asymmetry was done by using parts of the frontal

asymmetry analysis suggested by Grummons [6]Fig.1. To

check the linear transverse asymmetry, the distance between

each landmark, left and right, and the MSR line was recorded

in millimeters. The difference between each pair of

measurements was also recorded in millimeters as left side

minus right side; in this way sidedness in facial asymmetry

could be evaluated. The total width between the bilateral

landmarks (sum of left and right side) was calculated.

The absolute value of the left and right difference was

used to compute the mean absolute asymmetry for each of the

dimensions studied. Separate computation was made to test for

left or right side dominance within the sample. Positive (+)

sign for the left side and negative (-) sign for the right side

were used to indicate sidedness. The data collected from the

tracing was fed into the computer and the SPSS 17 was used to

perform the statistical analysis. Mean absolute value, Standard

Deviation (SD) and absolute value of the left and right

difference (d) was calculated. To find the differences between

male and female for different measurements Independentt

test was applied.

Results All the subjects examined showed asymmetries in

one or more of the measured dimensions. Table 1 shows the

vertical asymmetry in between male, female and in the whole

group (including male and female) for the four planes

investigated. The comparison of the value depicted no

significant difference between the males and females. Mean

absolute value and sidedness (in degree and millimeter) for the

Mandibular morphology is depicted in Table 2A. In all the

linear measurements of mandibular morphology males showed

higher rate of asymmetry compare to females, and at Go-Me

length (5.10 mm) males have almost double the asymmetry in

comparison to females (2.65 mm), which is statistically

significant. In the sidedness, males showed left sidedness at

Co-Go, whereas at Go-Me and Co-Me they showed right

sidedness, which is statistically significant. In females all the

lengths showed right sidedness, but only Go-Me and Co-Me

are statistically significant (Table 2A). Table 3A gives the

description of skeleto-facial asymmetry in transverse direction.

ORIGINAL RESEARCH


Table 1: Mean absolute value for the vertical asymmetries (in degree).

Angle Male (n=250) Female (n=250) Total(n=500) Mean

SD Mean

SD Mean

SD

Z - plane 89.920 1.550 89.90 1.090 89.910 1.330 ZA - plane 90.10 1.570 90.320 0.760 90.210 1.220 Occlusion -plane 90.220 1.740 90.160 1.490 90.190 1.600 Ag - plane 90.320 1.710 90.720 1.320 90.520 1.530

= Mean Table 2A: Gender wise mean absolute value and sidedness (in degree and millimeter) for the mandibular morphology

Absolute values ( |d|) Sidedness ( d ) Male

(N=250) Female (N=250)

P value

Male (N=250) Female (N=250) P value

|d| SD |d| SD |d| SD P value

|d| SD P value

Go - Angle

2.92 2.48 1.98 1.53 0.11 -1.08 3.71 0.15 0.22o 2.52o 0.66 0.34

Co-Go Length

2.76 2.42 1.70 1.25 0.05 1.80 3.23 0.01* -0.10 2.13 0.81 0.01*

Go-Me Length

5.10 3.25 2.82 2.65 0.009* -4.02 4.56 0.000*

-2.06 3.30 0.005* 0.08

Co-Me Length

2.94 2.61 2.18 1.74 0.23 -1.82 3.51 0.01* -1.58 2.32 0.002* 0.77

* = Significant, p

ORIGINAL RESEARCH


Table 4A : Gender wise Mandibular deviation: mean absolute value and sidedness (in millimeters)

DIMENSIONS Absolute values ( |d|) Sidedness ( d ) Male (N=250) Female

(N=250) P value

Male (N=250) Female (N=250) P value

|d| SD |d| SD |d| SD P value |d| SD P value

Mandibular offset at mention

2.56 1.59 1.82 1.51 0.099 1.20 2.80 0.043* 1.18 2.07 0.009* 0.97

* = Significant, p

ORIGINAL RESEARCH


statistically significant. All the transverse parameters used for

assessment of skeleto-facial asymmetry were measured from

MSR line and recorded individually for left and right side. The

asymmetry at Ag and Co distance is higher compare to Z, NC

and J distance. Peck et al., (1991)[9] found the asymmetry in

the upper facial region to be 0.87 mm.

In their study, Peck et al., (1991)[9] have used lateral

orbital (LO) point to check the asymmetry in upper facial

region, whereas in the present study as well as in the study of

Sumant Goel[8] zygomatico frontal suture (Z) point was used

for the same. The asymmetry observed for Z distance in our

study is 1.07 mm, which is higher in comparison to earlier

results[9].

When we considered the asymmetries from hairline

to chin, we found that the asymmetries decrease in magnitude

as we approach higher in craniofacial region and mandibular

region showed the asymmetries of higher magnitude. This

finding is in agreement with the results of earlier studies[8,9].

Zygomatic (ZA) point showed right sidedness and is

statistically significant, which is in accordance with the results

of the previous study [9]. Certain habits like sleeping only at

one side with pillow, during growing period may make

difference between left and right side at lateral zygomatic

(ZA) point.

Less asymmetry was seen in mandibular region (at

Ag) in comparison to the previous studies [8,9]. Mandibular

region shows left sidedness, which is opposite to the study

done by Peck et al., (1991)[9] but in agreement with the results

of Sumant Goel (2003)[8]. In both the studies, authors have

used gonial point (Go) to check the asymmetry in mandibular

region, whereas in the present study antigonial notch (Ag) was

used as suggested by Grummons[6] for the same.

The asymmetry for condylar distance indicates that

the mandibulo-facial region exhibit the highest asymmetries in

patients with malocclusion. Similar findings were reported by

Farkas and Cheung (1987)[10] and Sumant Goel (2003)[8].

Sleeping habits and other environmental influences may play a

role in the difference between left and right of Co, but

Lear[10] described a method for graphic and metric appraisal

of arch and palate form. He concluded that there was a marked

asymmetry in the arch form where the subject spent equal

positions at night with the right and the left cheeks pillowed.

Mandibular deviations showed asymmetry of 2.19 mm, which

is less compared to the study done by Sumant Goel (2003)[8].

This is in agreement with Severt and Proffit (1997)[11] who

found an incidence of 74% of chin deviations. This high

incidence of chin deviation may be due to the asymmetries of

mandibular length, which also showed high incidence.

Various parameters that showed right sidedness in the

present study are: Go angle, Go-Me and Co-Me in mandibular

morphology, ZA and Co in transverse skeletofacial

asymmetry, in which except Go angle all parameters are

statistically significant. Which is similar to the study done by

Shah and Joshi (1978)[3], Farkas and Cheuing (1981)[10],

Peck et al., (1991)[9], Ferrario et al. (1994)[13] and Sumant

Goel (2003)[8].

Conclusion Following conclusion can be drawn from the present study;

1. Asymmetries are common finding in the present

group of population.

2. The asymmetries decrease in magnitude as we

approach higher in craniofacial regions and

mandibular region shows the asymmetries of higher

magnitude.

3. Males show higher rates of asymmetries compare to

females.

4. There is a right side dominance of facial asymmetry.

Source of Interest/ Conflict: None Declared.

References 1. Sutton PRN. Lateral facial asymmetry. Angle Orthod

1968;38:82-93.

2. Mulick JF. An investigation of craniofacial asymmetry

using the serial twin study method. Am J Orthod

1965;5:112-29.

ORIGINAL RESEARCH


3. Shah SM, Joshi MR. An assessment of asymmetry in the

normal craniofacial complex. Angle Orthod 1978;48:141-

48.

4. Plint DA, Ellisdon PS. Facial asymmetries and

mandibular displacements. Br J Orthod 1971;1:227-35.

5. Marmary Y, Zilberman Y, Mirsky Y. Use of foramina

Spinosa to determine Skull Midlines. Angle Orthod 1979;

49:263-68.

6. Grummons DC, Kappeyne MA. A frontal asymmetry

analysis. J ClinOrthod 1987; 21:448- 65.

7. Scott JH. The analysis of facial growth in the anterior and

vertical dimension. Am J Orthod 1958;44:507-13.

8. Goel S, Ambedkar A, Darda M, Sonar S. An assessment

of facial asymmetry in Karnataka population. Journal of

Indian orthodontic society : 2003;36:30-38.

9. Peck S, Peck L, Kataja M. Skeletal asymmetry in

esthetically pleasing faces. Angle Orthod 1991;61:43-48.

10. Farkas LG, Cheung G. Facial asymmetry in Healthy

North American Caucasians. - Angle Orthod 1981;51:76-

78.

11. Lear CSC. Symmetry analysis of the palate and maxillary

dental arch. Angle Orthod 1968;38:56-62.

12. Severt, Proffit. The prevalence of facial asymmetry in the

dentofacial deformities population at the University of

North Carolina. Am J Orthod. Orthognath. Surg

1997;12:171-76.

13. Ferrario VF, Sforza C, Carlo EP, Tartaglia G. Distance

from symmetry: A three dimensional evaluation of facial

asymmetry. American association of oral and maxillo-

facial surgeons 1994; 52: 1126-32.

How to cite this Article; Abhay Prem Prakash Agarwal, Thilagrani P.R., Ashok Kumar Dhanyasi, Jaiprakash Mongia. Evaluation of the Extent of Facial Asymmetry in Aesthetically Symmetric Faces of Bilaspur Population. J. Dent. Peers 2014;2(2):37-42.

ORIGINAL RESEARCH


Assessment of Dental Aesthetic Index Among School Children of Bilaspur

(CG), India *Hemlata Rajmani1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4

Abstract Introduction-Malocclusion is one of the most widespread oral health problems that the society is facing. There is increased concern

for dental appearance during adolescents to early adulthood. Most of the malocclusion can be corrected if detected early by

correctional methods.

Objectives-This study is to know the prevalence of malocclusion and orthodontic treatment needs among 12-15yr old school children

of Bilaspur.

Materials and Methods-A total of 351 study subjects were selected based on convenience sampling and examination was carried out

under natural light and data was recorded using WHO Proforma 1997. The collected data was subjected to statistical analysis using

SPSS16.

Results-Out of the 351 children examined, 46.2% were boys & 53.8% were girls and their mean age was 13.89yrs. One and two

segment crowding was seen in 24.5% & 11.4% respectively. Normal molar relation was seen in 80.3% of children. Definite, severe

and very severe or handicapping malocclusion was seen in 9.7%, 4.3% & 3.4% of children respectively. There is no statistically

significant difference in malocclusion status between boys and girls.

Conclusion-Only 4.3% and 3.4% of children required highly desirable and mandatory orthodontic treatment needs.

Keywords- Malocclusion, Dental Aesthetic Index, Orthodontic Treatment needs.

Introduction Dento-facial appearance has a lot to do with the way

the people are perceived in the society.[1] People equate good

dental appearance with success in many aspects.[2] Social

interactions that have a negative effect on self-image, career

advancement and a peer group acceptance have been

associated with an unacceptable dental appearance.[3] The

prevalence of malocclusion varies from country to country and

among different races.[1] The reasons to develop malocclusion

could be genetic or environmental and/or combination of both

the factors along with various local factors such as adverse

oral habits, tooth anomalies, form and developmental posit ion

of teeth can cause malocclusion.

*1Post-Graduate Student, 2Professor & Head, 3Reader, 4Reader, Dept. Orthodontics & Dentofacial Orthopedics, New Horizon Dental College, Sakri, Bilaspur(CG), India. E-mail: [email protected] * Corresponding Author

Orthodontics has traditionally focussed on children

and adolescents.[4] There is an increases concern for dental

appearance during adolescents to early childhood has been

observed.[2] Malocclusions are 3rd in the ranking of priorities

among the problems of dental public health worldwide,

surpassed only by dental cavity and periodontal diseases.[5]

The benefits of taking orthodontic treatment are to prevention

of tissue damage and correction of aesthetic component,

improve the physical function[2]. A variety of indices have

been developed to assist professionals in categorizing

malocclusion according to the treatment needs[6]. Dental

Aesthetic Index (DAI) introduced by Cons et al(1986), which

links clinical and aesthetic components. It was developed

originally based on North American Caucasian sample.[7] The

World Health Organization concerning to acknowledge the

real malocclusions conditions in different countries, adopted it

as a cross cultural index and advocated it in the 4th Edition of

ORIGINAL RESEARCH


the Manual of Basic Oral Health Survey, so there would be a

suitable instrument to gather epidemiological data collection

and assessment of orthodontic treatment needs [5,7-9]. DAI is

proven to be reliable, valid, versatile, simple and easily

applied index[7,9]. Most of the malocclusion can be corrected

if detected early by correctional methods.[1] This study was

intended to evaluate the prevalence of malocclusion, its

severity and the orthodontic treatment needs using DAI,

among 12-15yr old school children of Bilaspur, Chattishgarh.

Materials and Methods The present study was conducted among 12-15yr old

school children of Bilaspur, Chattishgarh. The schools were

selected based on convenience sampling. A total of 351 school

children of both sexes were selected for the study based on

convenience sampling. Approval was obtained from the

concerned authorities before the start of the study. All

examinations were performed at schools while children were

seated on chair under normal illumination. The examiners

were trained and intra-examiner calibration was done. Kappa

statistics showed a good agreement. Sufficient number of

autoclaved instruments was taken to the examination site. The

WHO Proforma (1997) was used to assess the malocclusion.

Data collected was coded, processed and subjected to

statistical analysis using SPSS version 16.

Results The study population consisted of about 351 school

children aged 12-15years in Bilaspur city, out of which 46.2%

were males and 53.8% were females (Table 1). Table 2 shows

the distribution of DAI components. Out of 351 school

children, 24.5% had one segment crowding and 11.4% had

two segments crowding. One and two segment spacing was

seen in 8.5% and 1.7% school children respectively. Diastema

of 1-3mm was seen among 5.7% of the study subjects. Largest

maxillary irregularity of 0, 1-3 and >3mm was seen among

80.9%, 17.1% and 2% of school children respectively. Largest

mandibular irregularity of 0, 1-3 and >3mm was seen among

72.1%, 27.6% and 0.3% of school children respectively.

Maxillary over-jet of 0-3mm is considered normal and was

seen among 76.4% of school children and >3mm was seen

among 23.6%of school children. Mandibular overjet of 0-3mm

was among 99.4% of school children and 0.6% of them had

>3mm of overjet. Open bite of >3mm was seen among 0.9%

of study subjects. Molar relation was normal among 80.3% of

school children whereas half cusp and full cusp molar relation

was seen among 14.8% and 4.8% of school children. There

was no statistically significant difference between the DAI

scores and the gender. Table 3 shows the distribution of

according to DAI score, severity of malocclusion, treatment

indicated and gender. 4.3% and 3.4% of the study subjects had

severe and very severe malocclusion respectively and required

highly desirable and mandatory orthodontic treatment needs.

Discussion Many epidemiological studies have been conducted

worldwide utilizing various indices for quantifying the extent

of malocclusion.[1] Crowding of incisal segment affects half

of all children in mixed dentitions and it worsens in adolescent

years as the permanent teeth erupt and continues to increases

as the age progresses.[2] In the current study, 35.9% of the

study population had incisal crowding. The results of the

current study are in correlation with the study conducted by

Shivakumar et al[2] and in contrast with a study conducted by

Bhardwaj et al[1].

Both the upper and lower incisal segments were

examined for spacing. In the present study, 10.2% had incisal

segment spacing either in one or both the arches which school

children and this result was in correlation to the study

conducted by Artenio Jose IsperGarbin et al[5].

Diastema>1mm was seen among 5.7% of school children and

this result was in correlation to the study conducted by Artenio

Jose IsperGarbin et al5. Irregularity may occur with or without

crowding. In the current study, 19.1% of the children had

maxillary anterior irregularity of >1mm, and the results are in

ORIGINAL RESEARCH


TABLE 1. Age Wise Distribution of Study Population

AGE FREQUENCY PERCENTAGE 12 13 3.7 13 95 27.1 14 133 37.9 15 110 31.3

TOTAL 351 100

TABLE 2. Distribution of Dai Component

DAI COMPONENTS PERCENTAGE (%) CROWDING 0

0NE SEGMENT TWO SEGMENT

64.1 24.5 11.4

SPACING 0 0NE SEGMENT TWO SEGMENT

89.7 8.5 1.7

DIASTEMA 0 1-3

94.3 5.7

LARGEST MAXILLARY IRREGULARITY(mm)

0 0-3 >3

80.9 17.1 2

LARGEST MANDIBULAR IRREGULARITY(mm)

0 0-3 >3

72.1 27.6 0.3

MAXILLARY OVERJET (mm) 0-3 >3

76.4 23.6

MANDIBULAR OVERJET(mm) 0 >3

99.4 0.6

OPEN BITE(mm) 0 >3

99.1 0.9

MOLAR RELATION NORMAL HALF CUSP FULL CUSP

80.3 14.8 4.8

TABLE 3. Distribution of the Subjects According to Dai Scores, Severity of Malocclusion, Treatment Needs and Gender (P=3.946).

DAI SCORE

Severity Of Malocclusion

Treatment Indicated

MALE (%)

FEMALE (%)

TOTAL (%)

35 Very severe or handicapping malocclusion

Mandatory 4.9 2.1 3.4

TOTAL 100 100 100

ORIGINAL RESEARCH


correlation with the study conducted by Shivakumar et al[2]

and Artenio Jose IsperGarbin et al[5]. 27.9% had mandibular

anterior irregularity >1mm and the result were in contrast with

the study conducted by Bhardwaj et al[1], DS Rwakatema et

al[8], B. Eduardo and F.M Carlos[9].

In the present study, maxillary overjet of >3mm was

seen in 23.6% and it was similar to the study conducted by B.

Eduardo and F.M Carlos9 and Bhardwaj et al1 and in contrast

to a study conducted by Matilda Mtaya et al10.

Mandibular overjet of >3mm was seen in 0.6% of

school children and it was in correlation with studies

conducted by Shivakumar et al2, DS Rwakatema et al8 ,

Bhardwaj et al1 and Artenio Jose IsperGarbin et al5.

An anterior openbite of >3mm was seen in 0.9% of

school children which was similar to studies conducted by

Bhardwaj et al1 and B. Eduardo and F.M Carlos9. Normal

molar relation was seen in 80.3% of the school children and

which was similar to the study conducted by Bhardwaj et al1

and was in contrast with the study conducted by Artenio Jose

IsperGarbin et al5. Definite malocclusion was seen in 9.7% of

the school children, severe malocclusion was seen in 4.3% of

school children and very severe or handicapping malocclusion

was seen in 3.4% of children. Similar results were found in the

study conducted by Vijaya Hedge and RekhaShenoy11,

Bhardwaj et al1 and Shivakumar et al2, whereas it was in

contrast with the study conducted by B. Eduardo and F.M

Carlos9 and D.S Rwakatema et al8.

Conclusion Thus the present study concluded that out of 351

study subjects, 4.3% and 3.4% of school children required

highly desirable and mandatory type of orthodontic treatment

needs respectively. The information from this study forms a

part of the basis not only for further research, but also for

planning orthodontic care.


References 1. VK Bhardwaj, KL Veeresha and KR Sharma.

Prevalence of malocclusion and orthodontic needs

among 16 and 17year old school going children in

Shimla city, Himachal Pradesh. Indian Journal of

Dental Research 2011;22(4): 556-560.

2. Shivakumar KM, Chandu GN, Subba Reddy VV, et

al. Prevalence of malocclusion and orthodontic

treatment needs among middle and high school

children of Davangere city, India by Dental Aesthetic

Index. J India SocPedodPrev Dent 2009; 27:211-218.

3. H. Nihal, B. Guvenc and U. Ersin.Dental Aesthetic

Index scores and perception of personal dental

appearance among Turkish university students.

European Journal of Orthodontics 2009; 31: 168-

173.

4. B.A Carlos, M.C Jose-Maria, M.P David, et al.

Orthodontic treatment need in Spanish young adult

population. Med Oral Patol Oral Cir Bucal 2012;

17(4):638-643.

5. I.G Artenio Jose , P.P Paulo Cesar, S.G CleaAdas, et

al. Malocclusion prevalence and comparison between

the Angle classification and the Dental Aesthetic

Index in scholars in the interior of Sao Paulo state-

Brazil. Dental Press J Orthod 2010; 15(4):94-102.

6. Poonacha KS, Deshpande SD, Shigli AL. Dental

Aesthetic Index, applicability in Indian population: a

retrospective study. J Indian Pedod Prev Debt 2010;

28: 13-17.

7. B. Venkatesh, Gopu H. Assessment of Orthodontic

treatment needs according to Dental Aesthetic Index.

Journal of Dental Sciences and Research 2011;

2(2):9-13.

8. D.S Rwakatema, P.M. Ng'ang'a and A.M. Kemoli.

Orthodontic treatment needs among 12-15 year olds

in Moshi, Tanzania. East African Medical Journal

2007; 84(5): 226-232.

ORIGINAL RESEARCH


9. B. Eduardo and F.M Carlos. Orthdontic treatment

need in Peruvian young adults evaluated through

Dental Aesthetic Index. Angle Orthodontist 2006;

76(3): 417- 421.

10. M Matilda, B. Pongsri and A. Anne Nordrehaug.

Prevalence of malocclusion and its relationship with

socio-demographic factors, dental caries and oral

hygiene in 12 to 14 year old Tanzanian school

children. European Journal of Orthodontics 2009;

31: 467-476.

11. H. Vijaya and S. Rekha.Dentition status, treatment

needs and malocclusion status among 15-year-old

school children of Mangalore- a pilot study. JIDA

2010; 4 (12): 568-569.

How to cite this Article; Hemlata Rajmani, Thilagrani P.R., Ashok Kumar

Dhanyasi, Jaiprakash Mongia. Assessment of Dental

Aesthetic Index Among School Children of Bilaspur (CG),

India. J. Dent. Peers 2014;2(2):43-47.

CASE REPORT


Resin Retained Prosthesis for anterior Tooth Replacement-Maryland Bridge- A

Case Report. Manoj Upadhayay1, Sudhanshu Srivastava2, Sakshi Chopra3, Mansi Rajput4, *Pratim Talukdar5, Rashi Singh6 Abstract Restoring a missing single central incisor is one of the most difficult esthetic procedures in dentistry. A space in the anterior region of

the dental arch either due to trauma, congenital missing tooth, tooth lost to decay, trauma, root fracture, failed root canal treatment, or

pathology can produce a huge amount of psychological impact on the patient. The various treatment option like implant, removable

partial denture and fixed partial denture are available. However these treatment options are not applicable in every case due to various

reasons like growth of the jaws, cost, amount of tooth reduction, and chair side time for the procedure. In some of such situation, a

resin- bonded fixed partial denture (RBFPD) such as Maryland Bridge fulfills all the requirements of an ideal interim solution.

Keywords- Missing single central incisor, Resin- bonded fixed partial denture, Maryland Bridge.

Introduction Over the last several decades, dentistry has focused

on more conservative treatment modalities and preventive

techniques. This has been possible not only because of

improved techniques and materials, but also because of the

understanding that tooth preparation, regardless of how

conservative it may be, is an irreversible procedure.

It is said that restoring a missing single central incisor

is one of the most difficult esthetic procedures in dentistry. A

number of dental concerns need to be considered when

treating an anterior tooth such as shade, morphology, gingival

contours, bone levels, and occlusion. Additionally, a choice

between a fixed prosthesis, removable prosthesis, and an

implant needs to be determined. Finally, in present era patient

is more demanding in terms of esthetics, they opt for more

conservative and less invasive procedures [1].

A missing tooth in the anterior region is not only a

physical loss, but also has a physcological impact on the

patient.

1Reader, 2,3,4PG Student, Department of Prosthodontics,

Babu Banarsi Das University, Lucknow, Uttar Pradesh, India. *5,6Private Dental Practitioner.

E-mail:[email protected]

* Corresponding Author

To remove healthy tooth structure of adjacent teeth to

replace a congenitally missing tooth or a tooth lost to decay,

trauma, root fracture, failed root canal treatment, or pathology

is a very aggressive treatment option for both patients and

dentists. Infection in any of these situations creates an

environment in the hard and soft tissues that makes

regeneration procedures more difficult, thereby complicating

the ability to create a natural appearance in the definitive

restoration

Today techniques and materials are available that

provide the typical clinician a number of options which are

both professionally satisfying to the dentist and aesthetically

and functionally appropriate to the patient.

1. FlipperThe only advantage for the flipper was the

cost factor. A few of the disadvantages were the lack

of mastication ability, and the possibility of problems

during speaking.

2. ImplantThe implant option had the advantage of

long-term stability. The disadvantages were the cost

and the time factor before a final restoration could be

completed.

3. Three-unit bridgeThe advantages for this option

included excellent stability and function. The major

CASE REPORT


disadvantage was the necessity of reducing viable

tooth structure.

4. Maryland BridgeThe advantage for this type of

bridge was in the minimal reduction on the lingual of

the abutment teeth. The given disadvantage for this

option was the possible debonding of the bridge.

While a conventional three-unit fixed partial denture

is a predictable technique to replace a missing tooth, the

invasive nature of the treatment can lead to other

complications throughout the life of the restoration.

Complications may include mechanical overload of the

abutment teeth with weakening or fracture, risk of endodontic

treatment, periodontal problems, decay, and cement failure. If

any of these complications occurs on one of the abutment

teeth, the entire prosthesis will fail.

This case report describes the use of resin bonded

fixed partial denture as a valuable treatment plan in restoring

smile and oral functions with minimal biological cost.

Case Report

A male patient, aged 31 years presented with a

missing upper left maxillary central incisor (21). Patient gave

a history of tooth lost due to trauma 2 years back. On

examination it was revealed that the entire tooth was missing

with an edentulous area with no space loss (Fig.1). An intra

oral periapical radiograph was taken and the radiography

revealed complete root formation of the adjacent teeth (12 &

21).

After considering the patients wish and the clinical

situation, other treatment options like removable partial

denture, fixed partial denture and implant were eliminated and

it was decided to replace it with a Maryland bridge as an

interim solution. Tooth preparation for both 12 and 21 was

done following the standard technique. Lingual preparation

ended 1mm from the incisal edge and a light chamfer finish

line was prepared 1 mm supra-gingivally (Fig.2, 3) an

impression was made in polyether impression material and

sent to the laboratory.

After the metal try-in was successful (Fig.4) shade

selection was done using a shade guide. The trial fitting of the

prosthesis was done. Esthetics, mastication and speech were

evaluated. The laboratory technician was instructed to keep the

metal wings of the prosthesis off the incisal third to prevent

darkening of the tooth because of the inhibition of light

transmission. In addition, care was taken to make sure metal

would not be visible interproximally or at the embrasure areas.

After isolation, the Maryland Bridge was cemented (Fig. 5,6,

7) using conventional composite resin cement. A 12-month

follow-up was advised until the patient is ready to replace the

bridge with a more permanent solution.

Discussion For more than 50 years, dentistry has sought amore

conservative approach to replacing a single missing tooth with

a conventional fixed prosthesis, which involves the cutting of

sound tooth structure. Treatment possibilities have evolved

from bonding a natural extracted tooth or composite resin

restoration to the adjacent teeth, [2-4] to the Rochette bridge,

[5,6] to the maryland bridge,[79] and currently to the single-

implantsupported crown. It is debatable which technique is

the most conservative, and in many instances the patients

preference tells the restoration of choice. The clinician must

also evaluate the advantages and disadvantages of such

techniques in order to provide the patient with the best clinical

result since not all patients should be treated with the same

restoration type or design.

With improvements in the field of adhesive dentistry,

resin-bonded bridgework has become a viable option for the

long-term replacement of missing teeth. One study reported a

median survival time of 7 years 10 months [10]. Possible

designs include: cantilever, fixed-fixed and hybrid where one

of the retainers is conventional. A major advantage of resin-

bonded prostheses is that minimal tooth preparation is required

and so they can usually be considered a reversible procedure.

As dentine preparation is not involved, the integrity of a young

pulp is maintained. Other advantages include the fact that

anaesthesia is not normally required, soft tissues are not

CASE REPORT


disturbed which simplifies impression procedures, and

margins are supragingival, facilitating plaque removal.

Fig. 1. Intra oral view of missing tooth.

Fig.2 & 3. Palatal view of prepared tooth surfaces.

Fig.4. Metal Try In.

Fig.5 & 6. Cemented Restoratin Frontal and Palatal View.

Fig.7. Extra oral view of Cemented restoration.

The Rochette bridge replaces the missing tooth

without any tooth preparation, it was, at best, considered a

temporary solution, and its framework was designed with a

gold substructure and hence resulted in a thick metal

framework. Such restorations were designed with macro-

mechanical retentions to lock the composite into the gold and

through the bonded lingual surface. This technique met the

patients conservative requirements of replacing the missing

tooth, even though it required the patients compliance not to

overload the prosthesis during masticatory function and

necessitated a modified flossing technique because of the

splinted prosthesis. Resin-bonded prosthesis continued to

improve, and their evolution led to the development of the

Maryland Bridge.

In this technique, the tooth required a conservative

preparation in the enamel only with a gingival rest to create a

definite seat. The preparation design included an interproximal

wraparound to help prevent lingual displacement and to

increase stability on a bondable surface area (enamel) with a

solid, non-perforated, metal substructure that could be as thin

as 0.2 mm. Use of a non-noble metal alloy significantly

increases the mechanical retention of the etched framework

and more easily prevents degradation of the luting resin in the

oral cavity. Care must be exercised so the framework does not

involve the incisal third of the abutment teeth, since this could

block translucency and result in a graying effect. While use of

a resin-bonded retainer involves a very conservative technique

and preparation of the enamel is minimal care must be

exercised to prevent occlusal overload during function

Conclusion

Resin bonded bridges can be highly effective in

replacing missing teeth, restoring oral function and aesthetics

and result in high levels of patient satisfaction. They represent

a minimally invasive, cost effective and long lasting treatment

modality. Reference

1. Parker RM. An Ultraconservative Technique for

Restoring a Missing Central Incisor. Contemporary

Esthetics 2007: 30-34.

2. Ibsen RL. One-appointment technic using an

adhesive composite. Dent Surv 1973;49:3032.

3. Ibsen RL. Fixed prosthetics with a natural crown

pontic using an adhesive composite: Case history. J

South Cal Dent Assoc1973;41:100102.

CASE REPORT


4. Jordan RE, Suzuki M, Sills PS, Gratton DR,

Gwinnett JA. Temporary fixed partial dentures

fabricated by means of the acid-etch resin technique:

A report of 86 cases followed for up to three years. J

Am Dent Assoc1978;96:9941001.

5. Rochette AL. Attachment of a splint to enamel of

lower anterior teeth. J Prosthet Dent 1973;30:418

423.

6. Howe DF, Denehy GE. Anterior fixed partial

dentures utilizing the acid-etch technique and a cast

metal framework. J Prosthet Dent 1977;37:2831.

7. Livaditis GJ, Thompson VP. Etched castings: An

improved retentive mechanism for resin-bonded

retainers. J Prosthet Dent 1982;47:5258.

8. Simonsen R, Thompson V, Barrack G. Etched Cast

Restorations: Clinical and Laboratory Techniques.

Chicago: Quintessence, 1983.

9. Rubinstein S, Jekkals V. Preparation for anterior

resin-bonded retainers. Compend Cont Educ Dent

1986;7:631632.

10. Djemal S, Setchell D, King P, Wickens J. Long-term

survival characteristics of 832 resin-retained bridges

and splints provided in a post-graduate teaching

hospital between 1978 and 1993. J Oral Rehab

1999;26: 302320.

How to cite this Article; Manoj Upadhayay, Sudhanshu Srivastava, Sakshi Chopra,

Mansi Rajput, Pratim Talukdar, Rashi Singh. Resin

Retained Prosthesis for anterior Tooth Replacement-Maryland

Bridge- A Case Report. J. Dent. Peers 2014;2(2):48-51.

CASE REPORT

Journal of Dental Peers, Vol. 2 Issue 2, July 2014 52

Bar & Clip Retained Overdenture- A Case Report

*Sahil Sekhri1, Shivali Goyal2, Sanjeev Mittal3 Abstract It is more important to preserve what already exists than to replace what is missing as stated by MM De Van has never been questioned or disagreed. Considering this the preservation of one or more teeth/roots to facilitate an overdenture has many advantages, including preservation of alveolar bone overtime. Overdentures provide better function than conventional complete dentures through a variety of factors, such as improved biting force chewing efficiency, and increased speed of controlled mandibular movement. In addition, they minimize the downward and forward setting of a denture, which otherwise occurs with alveolar bone resorption. This article presents a case report in which bar and clip retained overdenture was constructed for the patient. Keywords overdenture, bar, clip, ridge preservation.

Introduction It is more important to preserve what already exists than to replace what is missing as stated by MM De Van has never been questioned or disagreed. Considering this the preservation of one or more teeth/roots to facilitate an overdenture has many advantages, including preservation of alveolar bone overtime[1]. Retaining teeth for an overdenture is an old concept and a viable treatment modality[2-5]. Through a reduction of crown to root ratio, it is distinctly possible that retained roots could support retentive elements that would be used to secure a dental prosthesis. Overdenture can be defined as a complete or partial removable denture supported by retained roots or teeth to provide improved support, stability, and tactile and proprioceptive sensation and to reduce bone resorption. The clinician must face a number of decisions when planning for over denture. Overdentures provide better function than conventional complete dentures through a variety of factors, such as improved biting force chewing efficiency, and increased speed of controlled mandibular movement[5]. In addition, they minimize the downward and forward setting of a denture, which otherwise occurs with alveolar bone resorption[6].

With increasing stress on preventive prosthodontics, the use of over dentures has reached a point where it is now a feasible alternative to most treatment plan outlines in the construction of prosthesis for patients with remaining teeth.

*1P.G. Student, 2P.G. Student, 3Professor, Department of Prosthodontics, M.M. College of Dental Sciences & Research, Mullana, Ambala, India. E-mail: [email protected]

*House No.427, Sec-46-A,Chandigarh-160047

The overdenture, a complete or partial denture prosthesis constructed over existing teeth or root structure, is not a new concept in a technical approach to a prosthodontic problem. Indeed its use dates back to 100 years. Overdenture is also known as Overlay dentures, Onlay dentures, Hybrid dentures, Superimposed dentures, Telescoped dentures, Biologic dentures, Coping prosthesis [5-7].

Advantages

Preservation of alveolar bone. Preservation of proprioceptive response. A simple approach to a problem patient. Simplicity of construction ease of obtaining accurate

records and superior denture stability Support Periodontal maintenance Retention Open palate possible Cost effective Ideal occlusion Superior patient acceptance Less trauma to supporting tissues Conversion to complete denture

Indications Patients with poor prognosis for complete dentures In maxilla in cases with excessive vertical overlap

of anterior teeth Unilateral overdenture with bone loss is excessive on

one side of the arch Contraindications

Lack of patient acceptance Lack of proper oral hygiene and periodontal tissue

maintenance When other treatment modalities promise superior

results. Cost considerations

CASE REPORT


Denture stability is believed widely to be related to resistance against other forces like oblique and anterior-posterior forces. The patient's satisfaction is directly influenced by the amount of denture retention as it has been shown through several studies. The need for correcting the patients problems with faulty denture is an inevitable consequence of retention failure and residual ridge resorption. Various methods to connect overdentures have been described. Industrial balls and cast round or oval (e.g. Dolder bar) bar attachments are frequently used. Following clinical case report describes the procedure of fabricating bar retained mandibular overdenture with a superior retention and stability as compared to conventional complete denture. Case report An 80 year old male patient reported to Department of Prosthodontics, M. M. college of Dental Sciences & Research, Mullana, Ambala for replacement of missing teeth. The patient with lower partial edentulism with intact canines, thorough intraoral examination presented periodontally sound mandibular canines and patient wanted to preserve his teeth. So keeping in consideration patients needs and oral findings it was planned to fabricate a mandibular overdenture for the patient. An OPG (Orthopantomogram) along with IOPAR (intra oral periapical radiograph) i.e. 33 and 43 were taken to rule out any underlying pathology. Thorough oral prophylaxis was performed on both upper and lower arches before impression procedures. Diagnostic impressions were made and tentative jaw relation record was made to carefully evaluate the interarch space and for occlusal considerations to aid in further treatment planning. Considering the close proximity of abutments and clinical condition of abutments it was decided to provide a bar splinted mandibular overdenture. Intentional RCTs were performed on both the canines. Clinical Steps

1. Tooth preparation was done on abutments (33,43). Crowns were reduced to approx. 4mm length with uniform axial taper.

Fig. 1 Final Impression of lower ridge

Fig.2 Wax pattern prepared on to the cast

Fig.3 Casting tried on to the patients mouth

Fig.4 Denture with metallic clip

Fig.5 Nylon rider in place

Fig.6 Post-operative

2. For additional retention of copings radicular means of retention was opted and post space was prepared upto depth of 5mm.

3. Border moulding of the lower ridge was done. Impression of both the space created and the lower ridge was taken with light body impression material (indirect technique)(Fig 1).

CASE REPORT


4. The cast was poured in die stone. 5. Inlay wax copings were fabricated on cast which

were connected by pre-fabricated bar; as it is known that the splinting of two or more teeth with a bar produces stability similar to that obtained with rigid stud-type attachment when the overdenture is in place.The design was similar to that of a dolder bar. The Dolder bar is the one most often mentioned in discussions of the bar system. (Fig 2).

6. The sprues were attached over copings as well over the bar and casting was done in Ni-Cr using conventional technique, it was finished and polished.

7. The casting was tried on cast and then intraorally to check for passive fit. (Fig 3).

8. Jaw relation recording was done in conventional way and a tooth set up was done which was tried in patients mouth.

9. The metal rider and the spacer were placed and the cast was blocked with type IV die stone.

10. Rest of the acrylization procedure is similar to conventional complete denture, after dewaxing stage, the metal rider clip was snapped onto the bar and packing is done.

11. After curing was complete, the denture was retrieved with metal clip picked up in denture, the denture was finished and polished. (Fig 4).

12. Seating tool was used to place the nylon rider in the metal clip which will be attached to the bar. (Fig 5).

13. The copings with bar attachment are cemented in patients mouth, and the denture was delivered to patient after checking the fit in patient. The patient was given placement and home care instructions. Patient was recalled for examination after 24 hrs and was advised to get check up done every 6 months. (Fig 6).

Discussion It is well known fact that the residual ridge resorption is an inevitable pathophysiological phenomenon. The mandibular residual ridge resorbs almost 4 times faster than the maxillary ridge according to the literature. It is also proven that the bone/supporting structures around the retained teeth or implants are maintained for a longer duration of time. It is thus essential and well required that a clinician endeavors to preserve the last tooth/root. For this type of patient, mandibular overdenture are less expensive than implant prosthodontics, have a better

prognosis than would a replacement fixed partial denture, and are more retentive stable, and functional than complete dentures, the mandibular bar retained overdenture provides a sense of proprioception. It also reduces torquing of the remaining root structures because crown-root ratio is decreased. The bar affords adequate retention without unduly torquing the bar and canine abutments. Further, the patient can more easily perform plaque-control procedures because access is unimpeded. Last, the abutments are less susceptible to caries because the cast coping covers the exposed tooth structure[6].

Conclusion The use of teeth as over denture abutments is beneficial to the patients. The patients strict compliance with oral hygiene procedures and maintenance instructions will greatly increase the long-range prognosis of the denture tooth complex.

Source of Interest/ Conflict: None Declared References

1. Crum AJ, Rooney GE, Jr. Alveolar bone loss in overdentures: a 5 year study. J Prosthet Dent 1978; 40:610-3.

2. Tallgren A. Changes in adult face height due to aging, wear, loss of teeth and prosthetic treatment. Acta Odontol Scand. 1957;15:24.

3. Brill N. Adaptation and the hybrid prosthesis. J Prosthet Dent. 1955;5:811823.

4. Miller PA. Complete dentures supported by natural teeth. J Prosthet Dent.1958;8:924928.

5. Prince JB. Conservation of the supportive mechanism. J Prosthet Dent.1965;19:327338.

6. Williamson RT. Retentive bar overdenture fabrication with preformed castable components: A case report. Quintessence Int 1994;25:389-94.

7. Dole VR, Marathe SS, Singh GS, Dable RA. Cost effective pre-fabricated semi-precision attached overdenture- a case report. J Evo Med Dent Sci 2012;1(6):1263-6.

How to cite this Article; Sahil Sekhri, Shivali Goyal and Sanjeev Mittal. Bar & Clip Retained Overdenture- A Case Report. J. Dent. Peers 2014;2(2):51-53.

CASE REPORT


Management of failed implant using platelet rich fibrin (PRF)- A case report

Amarnath1, *Pratim Talukdar2, Nitika Sachan3, Mukut Seal4, Meghali Langthasa5

Abstract Implant-supported restoration offers a predictable treatment for tooth replacement. Reported success rates for dental

implants are high. Nevertheless, failures that mandate immediate implant removal do occur. The consequences of implant removal

jeopardize the clinicians efforts to accomplish satisfactory function and esthetics. Appropriate use of the contemporary techniques

like PRF will enable the successful treatment of almost any complicated case with bone deficient regions of the jaw. This case

reports the step-by-step procedures in a case of failed maxillary right central incisor implant which was removed and restored by

placement of implant simultaneous with the use of bone grafting and PRF for the re-establishing predictable bone volume to

support the new implant.

Key words: Implant failure, PRF, centrifuge, predictable bone volume.

Introduction Dental surgeons are constantly looking for

maximizing the healing response of the patient during

reconstructive procedures. The search for predictable

outcomes in terms of volume of bone and implant

osseointegration had lead to development of many bioactive

surgical additives [1]. In 1974, platelets regenerative

potentiality was introduced, and Ross et al., [2] were first to

describe a growth factor from platelets. After activation of

the platelets which are trapped within fibrin matrix, growth

factors are released and stimulate the mitogenic response in

the bone periosteum during normal wound healing for repair

of the bone.[3] Better understanding of physiologic

properties of platelets in wound healing since last two

decades led to increase its therapeutic applications in the

various forms showing varying results.

Platelet-rich plasma (PRP) was proposed as a

method of introducing concentrated growth factors PDGF,

TGF-, and IGF-1 to the surgical site, enriching the natural

blood clot in order to expedite wound healing and stimulate

bone regeneration.[4]

1M.D.S. Orthodontics, *2M.D.S. Prosthodontics, 3M.D.S. Prosthodontics, 4M.D.S. Endodontics, 5M.D.S. Pedodontics. Email: [email protected]

*Dr. Pratim Talukdar, House No. 13, Bye Lane-2, Swahid Dilip Huzuri Path, Sarumotoria, Dispur, Guwahati-781016, Assam, India.

Platelet-rich fibrin (PRF), developed in France by

Choukroun et al (2001), is a second-generation platelet

concentrate widely used to accelerate soft and hard tissue

healing. PRF is a strictly autologous fibrin matrix containing

a large quantity of platelet and leukocyte cytokines. Platelet-

rich fibrin (PRF) represents a new step in the platelet gel

therapeutic concept with simplified processing minus

artificial biochemical modification[5]. Unlike other platelet

concentrates, this technique requires neither anticoagulants

nor bovine thrombin (nor any other gellation agent), making

it no more than centrifuged natural blood without

additives.[6,7]

Case report

A 21 year old male reported to the dental clinic

with chief complaint of loosening of implant and unesthetic

appearance. On clinical examination, implant placed in

region of 11 was found to be mobile and showed signs of

peri-implantitis (Fig 1). Due to implant failure, the length of

the offending prosthesis was visibly longer compared to the

contra-lateral tooth. Radiograph showed considerable bone

loss around the implant (Fig 2). History revealed that

implant had been placed 3 years back which progressively

became loose over the period of last six months. After

examination and history, decision was taken to remove the

existing implant and restore the surgical site with bone graft

mixed with platelet rich fibrin and place a new implant at the

same visit.

CASE REPORT


Procedure Before starting the surgical procedure, patient was

prepared to draw 3 vials of blood to prepare PRF. It required

a 24 gauge butterfly needle and 9 ml blood collection tubes.

For PRF preparation, whole blood was drawn into the tubes

without anticoagulant and immediately centrifuged using

laboratory centrifuge(R-8C, SRL Diagnostics) (Fig 3).

Within a few minutes, the absence of anticoagulant

allows activation of the majority of platelets contained in the

sample to trigger a coagulation cascade. Fibrinogen is at first

concentrated in the upper part of the tube, until the effect of

the circulating thrombin transforms it into a fibrin network.

The result is a fibrin clot containing the platelets located in

the middle of the tube, just between the red blood cell layer

at the bottom and acellular plasma at the top (Fig 4).

The platelet rich fibrin also called as the snot clot

was removed from the tubes and the RBC portion was

carefully seperated. (Fig 5) PRF from one tube was kept to

be mixed with bone graft (Nova bone, bioactive synthetic

bone graft) , while the other two were placed into a PRF box

which flattens the PRF into a membrane with 1mm

thickness. (Fig 6)

Patient was then prepared for surgery. The failed

implant that had a diameter of 3mm was removed (Fig 7);

use of trephine drill was not necessary due to extreme

mobility of implant. Incisions were made to expose the

surgical site (Fig 8). The socket left by the extracted implant

was curetted and all granulation tissue and socket debris

were removed. A new implant was placed in the surgical site

(Nobel Active , 3.0*11.5mm). The defect around the implant

was filled with bone graft mixed with PRF. After

condensing the graft around implant the PRF membrane was

delicately placed over the implant (Fig 9) and the surgical

site, followed by flap replacement and sutures (Fig 10).

Patient was recalled after 24hrs and 1 week to

assess healing and then after 3months for radiographic and

clinical examination. Adequate bone was found surrounding

the implant and signs of osseointegration could be

appreciated on the radiograph. (Fig 11) A healing period of

3 months was found to be sufficient to resist a torque of 25

N.cm applied during abutment tightening.

Discussion Dentists are often faced with implant failure that

may occur due to multiple reasons. It is important to manage

such cases with techniques that will give predictable

outcomes and which are considerably less technique

sensitive and economical. Removal of failed implants often

leads to large bone defects due to use of trephines. This

necessitates placement of larger dimension implant which

might not be feasible due to limited available bone. Such

cases require use of bone graft to restore the defect. To

maximise the benefits of grafting and to ensure good bone

volume, PRF membranes are used.

PRF is easy to obtain, less costly, and a possibly

very beneficial ingredient to add to the regenerative mix.

The easily applied PRF membrane acts much like a fibrin

bandage,[8] serving as a matrix to accelerate the healing of

wound edges. [9] It also provides a significant postoperative

protection of the surgical site and seems to accelerate the

integration and remodeling of the grafted biomaterial. [10-

12]

Release of growth factors from PRF through in

vitro studies and good results from in vivo studies has led to

increased clinical application of PRF. It was shown that

there are better results of PRF over PRP. Dohanet al.,[13]

proved a slower release of growth factors from PRF than

PRP and observed better healing properties with PRF. It was

observed and shown that the cells are able to migrate from

fibrin scaffold; while some authors demonstrated the PRF as

a supportive matrix for bone morphogenetic protein as well.

There are several advantages of PRF over PRP like

no biochemical handling of blood, simple and cost-effective

process, use of bovine thrombin and anticoagulants not

required, favorable healing due to slow polymerization,

more efficient cell migration and proliferation. PRF has

supportive effect on immune system and also helps in

hemostasis.[14,15]

Conclusion Although PRF belongs to a new generation of

platelet concentrates, the biologic activity of fibrin molecule

is enough in itself to account for significant cicatricial

capacity of the PRF. The slow polymerization mode confers

CASE REPORT


to PRF membrane as a particularly favorable physiologic

architecture to support the healing process. This case report

demonstrates the clinically predictable outcomes obtained in

management of failed implant using PRF.

Fig. 1 & 2: Pre-operative intra-oral photograph showing failed implant which is considerably longer than its counterpart and Radiographic view showing severe bone loss around the failed implant in the region of 11.

Fig. 3 & 4: Vials of blood collected from the patient are centrifuged and Fibrinogen concentrated in the upper part of the tube resulting in a fibrin clot.

Fig. 5 & 6: Plasma rich fibrin removed from the tubes with RBC portion removed and PRF box, which flattens the PRF into a membrane with 1mm thickness.

Fig. 7 & 8: Failed implant was removed and Incisions made to expose the surgical site. A new implant was placed in the surgical site.

Fig. 9 & 10: After condensing the graft around implant the PRF membrane was delicately place over the implant and closed surgical site with sutures.

Fig. 11: 3-months post-operative radiograph showing osseointegrated implant with adequate surrounding bone.


References 1. Dohan DM, Choukroun J, Diss A, Dohan SL,

Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin

(PRF): A second-generation platelet concentrate.

Part I: Technological concepts and evolution. Oral

Surg Oral Med Oral Pathol Oral Radiol

Endod. 2006;101:e3744.

2. Ross R, Glomset J, Kariya B, Harker L. A platelet-

dependent serum factor that stimulates the

proliferation of arterial smooth muscle cells in

vitro. Proc Natl Acad Sci U S A. 1974;71:120710.

3. Gassling V, Douglas T, Warnke PH, Ail Y,

Wiltfang J, Becker ST. Platelet-rich fibrin

membranes as scaffolds for periosteal tissue

engineering. Clin Oral Implants Res. 2010;21:543

9.

4. Soffer E, Ouhayoun JP, Anagnostou F. Fibrin

sealants and platelet preparations in bone and

periodontal healing. Oral Surg Oral Med Oral

Pathol Oral Radiol Endod 2003; 95:521-528.

5. Dohan DM, Choukroun J, Diss A, Dohan SL,

Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin

(PRF): a second-generation platelet concentrate.

Part I: technological concepts and evolution. Oral

CASE REPORT


Surg Oral Med Oral Pathol Oral Radiol Endod

2006; 101:e37-44.

6. Marx RE, Carlson ER, Eichstaedt RM, Schimmele

SR, Strauss JE, Georgeff KR. Platelet-rich plasma:

Growth factor enhancement for bone grafts. Oral

Surg Oral Med Oral Pathol Oral Radiol Endod

1998; 85(6):638-646.

7. Weibrich G, Kleis WK, Buch R, Hitzler WE,

Hafner G. The Harvest Smart PReP system versus

the Friadent-Schutze platelet-rich plasma kit. Clin

Oral Implants Res 2003; 14:233-239.

8. Vence BS, Mandelaris GA, Forbes DP.

Management of dentoalveolar ridge defects for

implant site development: An interdisciplinary

approach. Compend Cont Ed Dent 2009; 30(5):250-

262.

9. Gabling VLW, Ail,Y, Springer IN, Hubert N,

Wiltfang J. Platelet-rich Plasma and Platelet-rich

fibrin in human cell culture. Oral Surg Oral Med

Oral Pathol Oral Radiol Endod 2009; 108:48-55.

10. Choukroun J, Adda F, Schoeffler C, Vervelle A.

Une opportunit en paro-implantologie: le PRF.

Implantodontie 2001; 42:55-62.


Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin

(PRF): a second-generation platelet concentrate.

Part II: platelet-related biologic features. Oral Surg

Oral Med Oral Pathol Oral Radiol Endod 2006;

10145-50.


Dohan AJJ, Mouhyi J, Gogly B. Platelet-rich fibrin

(PRF): A second generation platelet concentrate.

III. Leukocyte activation: A new feature for platelet

concentrates? Oral Surg Oral Med Oral Pathol

Oral Radiol Endod 2006; 101:51- 55.


Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin

(PRF): A second-generation platelet concentrate.

Part II: Platelet-related biologic features. Oral Surg

Oral Med Oral Pathol Oral Radiol

Endod. 2006;101:e4550.

14. He L, Lin Y, Hu X, Zhang Y, Wu H. A

comparative study of platelet-rich fibrin (PRF) and

platelet-rich plasma (PRP) on the effect of

proliferation and differentiation of rat osteoblasts in

vitro. Oral Surg Oral Med Oral Pathol Oral Radiol

Endod. 2009;108:70713.

15. Vinazzer H. Fibrin sealing: Physiologic and

biochemical background. Fac Plast

Surg. 1985;2:2915.

How to cite this Article; Amarnath, Pratim Talukdar, Nitika Sachan, Mukut Seal, Meghali Langthasa. Management of failed implant using platelet rich fibrin (PRF)- A case report. J. Dent. Peers 2014;2(2):54-58.

CASE REPORT


Management of Partial Edentulism with Flexible Dentures- A Case Series *Reeta Jain1, Gyan Chand2, Deepika3 Abstract The fabrication of prosthesis for partially edentulous arches creates a challenge when soft tissue and bony undercuts, interferences,

multiple paths of placement, tilted teeth and deranged occlusion are present to complicate the treatment plan. Flexible dentures are the

best treatment options to treat partial edentulous conditions. These case reports describe the management of partially edentulous

conditions with flexible partial dentures rather than with cast partial dentures.

Key words: Thermoplastic Resin FRS Lucitone, Injection System, Flexible Denture, Acrylic clasps.

Introduction Restoration of esthetics is an important factor to

consider in the fabrication of a removable partial denture

(RPD). Several types of polymers and metal alloys have been

used in RPD construction. Frequently, RPD clasps made from

the same alloy as the metal framework. The most common

alloys used for clasps are cobalt-chromium (Co-Cr) alloy and

gold and titanium alloys; although these may be unaesthetic

[1]. Thermoplastic materials for dental prostheses were first

introduced to dentistry in the 1950s. These materials were

similar grades of Polyamides (nylon plastics). It is reported

that these materials have a sufficiently high resilience and

modulus of elasticity to allow its use in the manufacture of

retentive clasps, connectors, and support elements for

removable partial dentures [2, 3].

FRS Lucitone is a pressure injected, flexible denture

base resin that is ideal for partial dentures and unilateral

restorations.

*1Professor and Head, Department of Prosthodontics,

Crown and Bridge Including Implantology, 2Sr. lecturer,

Department of Oral and Maxillofacial surgery, 3Sr. lecturer,

Department of Prosthodontics, Crown and Bridge Including

Implantology, Genesis Institute of Dental Sciences and

Research, Ferozepur, (Punjab).

E-Mail:- [email protected]

*55/6, Gandhi Nagar, Jind (Haryana)

This material generally replaces the metal, and the

pink acrylic denture material used to build the framework for

standard removable partial dentures. Flexible partials blend in

well with the natural appearance of your gums, making the

partial virtually invisible. The plastic has almost a chameleon

effect; it is so strong that the partial dentures can be made very

thin and also picks up the characteristics of the underlying

tissue. This article presents cases of partially edentulous

patients who are successfully treated with pressure injected

FRS Lucitone flexible removable partial dentures.

Case Report- 1

A healthy 58-year-old man was reported in

department of prosthodontics, with chief complaints of

difficulty of eating food and poor appearance. Clinical

Examination of the patient revealed 5 missing maxillary teeth

11, 16, 17, 26, 27 and 4 missing mandibular teeth 34, 37, 46,

47 (Fig.1, 2). As the maxillary and mandibular teeth were

periodontally sound and caries free, they were retained. The

planned treatment was placement of a maxillary and a

mandibular flexible removable partial denture (RPD).

With the aim of maximizing the border seal to ensure

retention, the decision was made to incorporate flexible

flanges in the undercut region using resilient FRS lucitone

material to allow optimal height (extension) and thickness

(width) of the denture flange. The denture flange was designed

to fill the entire available vestibular space. Preliminary

impressions were made in alginate, the model poured.

CASE REPORT


Secondary impressions were made with dual impression

technique. Bite registration and try-in was done. FRS Lucitone

uses the Retento Grip tissue bearing technique for retention.

No tooth or tissue preparation is needed. After designing the

case on the master model, placing all necessary relief and

blocking in wax, sprue was attached as straight as possible.

After investing and washing out, the teeth were prepared for

mechanical retention. The FRS lucitone resin was injected into

a closed flask using success injection system (Dentsply).

After the case is deflasked, it is finished and fit on the

master model, polished, and placed in water. The partials were

left in the hot water for about one minute. The hot water

treatment permits a very smooth initial insertion and a good

adaptation with the natural tissues in the mouth. If the patient

senses any discomfort because of tightness of a clasp, the clasp

may be loosened slightly by immersing that area of the partial

in hot water and bending the clasp outward. Like any

removable prosthesis, the patient was instructed to utilize good

hygienic practices to maintain the appearance and cleanliness

of the FRS Lucitone restoration (Fig. 3, 4, 5).

Fig. 1 & 2. Front and Intraoral pre-operative view

Fig. 3. Flexible maxillary and mandibular prosthesis

Fig. 4 & 5. Front and Intraoral post-operative view

Case Report- 2

A healthy 53-year-old man was referred to

department of prosthodontics from oral medicine department.

Intraoral examination of the patient revealed 7 remaining

maxillary and 7 mandibular teeth (Fig. 6, 7). Missing teeth

were 11, 14, 16, 17, 21, 22, 25, 26, 34, 35, 36, 37, 45, 46, 47.

As the maxillary and mandibular teeth were periodontally

sound and caries free, they were retained. The planned

treatment was placement of a maxillary and a mandibular

flexible removable partial denture (RPD). Similar procedure

was followed as in Case 1 (Fig. 8, 9, 10).

Fig. 6 & 7. Front and Intraoral pre-operative

Fig. 8: Flexible maxillary and mandibular prosthesis

Fig. 9 & 10. Front and Intraoral post-operative view

Discussion Thermoplastic resins have been used in dentistry for

over 50 years. During that time the applications have

continued to grow, and the interest in these materials of both

the profession and the public has increased. The materials

CASE REPORT


have superior properties and characteristics and provide

excellent esthetic and biocompatible treatment options. With

the development of new properties, elastomers and copolymer

alloys, there are certain to be additional new applications for

thermoplastic resins in the future, to help patients with

damaged or missing teeth [4].

Retentive clasp arms must be capable of flexing and

returning to their original form and should retain an RPD

satisfactorily. The tooth should not be unduly stressed or

permanently distorted during service and should provide

esthetic results [5]. The clinical experience of loss of retention

of the RPD after the prosthesis is worn for some time raises

the question of whether constant deflection of the clasp during

insertion and removal of the denture fatigues the clasp. The

rationale for using flexible flanges and clasp was to aid

retention by ensuring seal around the entire border of the

denture.

Flexible dentures absorb small amounts of water to

make the denture softer and tissue compatible. They do not

warp or become brittle. These dentures stand aesthetically

superior removable dentures with full functionality and

comfort [6]. Complete biocompatibility is also achieved

because the material is free of monomer and metal, these being

the principle causes of allergic reactions in conventional

denture materials [7].

Conclusion Due to their ability of excellent mould ability,

lightweight to density ratio and high thermal strength,

thermoplastic materials have occupied an envious place for

making complete and partial dentures. However careful case

selection and clinical judgment is required to use flexible

dentures in appropriate situations in order to obtain a

successful treatment outcome.


References 1. Vallittu PK, Kekkonen M. Deflection fatigue of

cobalt chromium, titanium, and gold alloy cast

denture clasp. J Prosthet Dent 1995;74:412-21.

2. Turner JW, Radford DR, Sherriff M. Flexural

properties and surface finishing of acetal resin

denture clasps. J Prosthodont 1999;8:188-95.

3. Fitton JS, Davies EH, Howlett JA, Pearson GJ. The

physical properties of a polyacetal denture resin. Clin

Mater 1994;17:125-9.

4. Chittaranjan B, Aswini Kumar Kar. Management of a

case of partial edentulism with esthetic flexible

dentures. Indian Journal Of Dental Advancements

2009;1(1):60-2.

5. Kotake M, Wakabayashi N, Ai M, Yoneyama T,

Hamanaka H. Fatigue resistance of titanium-nickel

alloy cast clasps. Int J Prosthodont 1997;10:547-52.

6. Prashanti E, Jain N, Shenoy VK. Flexible denture - A

flexible option to treat edentulous patient. J of Nepal

Dental Association 2010;11(1): 85-7.

7. Shamnur SN, Jagdish KN, Kalavathi K. Flexible

Dentures - An alternate for rigid dentures? Journal of

Dental Sciences and Research 2010;1(1):74-9.

How to cite this Article; Reeta Jain, Gyan Chand and Deepika. Management of Partial Edentulism with Flexible Dentures- A Case Series. J. Dent. Peers 2014;2(2):59-61.

REVIEW


Lasers - Changing Perception and Attitude of Pediatric Dentistry *Neetika Singh1, Rohit Thakur2, Nagender Chauhan3, Marisha Kaul4

Abstract Past several years have witnessed emergence of lasers entering the field of dentistry. Some of the first reports of their use

invitro date to late 1960s. With laser technology, clinical experience has become beneficial for treatment of children than with

conventional methods, as it eliminates need of high-speed drill along with its noise and vibration, prevents hemorrhage by sealing

blood vessels, providing excellent visibility and reducing operating time. Children and adolescents are best candidates as they are

bothered by pain, bleeding, incapacitation and need for office visits for extensive post-operative activities. Although presently the use

of lasers in dentistry is not as widespread, its use will continue to gain support as more knowledge is gained about its advantages over

the drill. It will only be a matter of time before it becomes the new standard of care in dentistry. There is no doubt that fear of the

infection and pain keeps most patients dreading the dentist. Therefore this is a valuable instrument to provide patients with a satisfying

experience, thus changing the perception and attitude many have of dentistry.

Key words: Lasers, Micro dentistry, Children, Pediatric Dentistry

Introduction Over the years, the use of medical lasers have

become so wide spread that it has grown to be the standard of

care for a vast variety of medical procedures that were once

performed with scalpels. Similarly with the advent of new

technological advances in dentistry the drill can also now be

replaced by the laser, introducing a new philosophy in

dentistry called microdentistry[1]. This development in

laser dentistry has led to an increasing acceptance of this

technology by both practitioners and general public[2].

Review of Literature Taylor R (1965)[3] stated that with 55 joules beam,

pulp tissue of incisors were destroyed, cavitation was

produced in enamel and dentine, and enamel adjacent to

cavitation appeared to be fused so that rod structure was no

longer apparent as compared to 35 joules beam. Adrian JC

*1Senior Lecturer, Institute of Dental Studies and Technology, Meerut, Uttar Pradesh, India., 2Dental Officer, Military Dental Centre (MDC), Meerut., 3M.D.S., Prosthodontics and Crown & Bridge., 4M.D.S., Orthodontics and Dentofacial Orthopedics. E-mail: [email protected]

*H.No 634, Sector 37, Noida, Uttar Pradesh, India.

(1977)[4] suggested that pulp was more resistant to injury by

Nd laser than by the ruby laser. Wigdor H et al (1993)[5]

concluded that Er:YAG laser has lesser thermal effect as

compared to CO2 and Er:YAG lasers. Moshonov J et al

(1995)[6] stated mean cleanliness in non-lased specimens was

approximately 9% and in laser treated it reduced to 2%.Visuri

SR et al (1996)[7] concluded that laser preparation leaves a

suitable surface for strong bond than the standard dental bur.

Baggett FJ et al (1999)[8] stated that Nd:YAG laser removes

soft tissue by photoablative reaction with resultant coagulation

and haemostasis. Medeiros F et al (2005)[9] evaluated

performance of DIAGNOdent for detection and quantification

of smooth surface caries in primary teeth. Radatti D et

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Lasers in Pediatric Dentistry

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