dental journal brochure 18-may-13 (final).cdr

VOL 1 NO.1 JUN 2013

JOURNAL OF DENTAL SCIENCES

DENTAL LAMINA

Orthodontics Prosthodontics & Implantology

Oral Medicine

Oral & Maxillofacial Surgery Periodontology

Public Health Dentistry

Conservative Dentistry Oral Pathology Pedodontics

Dr. N. GrewalDr. O.P Kharbanda Dr. Mahesh VermaDr. Samir DuttaDr. Anmol .S. Kalha Dr. Suhasini NagdaDr. Vasundhara Bhad Dr. Lt.Gen. T Ravindranath Dr. Babu MathewDr. Gurkeerat Singh Dr. Suchetan Pradhan Dr. H. UmarjiDr. Rekha Sharma

Dr. Sunali KhannaDr. J. N Khanna

Dr. C. Dwarkanath Dr. Ghosala ReddyDr. N.C. RaoDr. A. Kumarswamy Dr. Girish RaoDr. C.M. MaryaDr. Naresh Thukral Dr. T. K Shah

Dr. Sanjay JainDr. Naseem Shah Dr. B. Sivapathsundharam

Dr. Shobha Tandon Dr. Sanjay Tiwari Dr. D. DaftariDr. G. Indushekhar Dr. R.R PaulDr. D. Adhikari Dr. Vijay Mathur Dr. Vinay HazareyDr. Vivek Hegde

Publisher/ Printer

Mr Atul Kalra Published at : 5E/1A, NIT, Faridabad, Haryana

Printed at : Vinayak Colour Offset C-114, Naraina Industrial Area, Phase-I, New Delhi-110028. Jounal is to be Registered with Office of Registrar of Newspapers for India, Ministry of Information and Broadcasting.

JOURNAL REVIEW BOARD

( Biannual Journal of Manav Rachna Dental College)

“DENTAL LAMINA” JOURNAL OF DENTAL SCIENCES

Mr. Prashant Bhalla (Senior Vice President, MRIU)

Dr. Amit Bhalla (Vice President, MRIU)

Dr. N.C Wadhwa (Vice-Chancellor, MRIU)

Maj.Gen. (Retd) Dr. P.N Awasthi , M.D.S, VSM ( Advisor-MRDC)

Prof. Arundeep Singh, MDS (Principal, MRDC)

Prof. M.K Soni Exc. Dir., Dean, FET, MRIU Prof. Hind P Bhatia, MDS, HOD - PedoDr. G.L Khanna Phd, Dean, FAS, MRIU Prof. Shivani Aggarwal, MDS, HOD - Oral PathProf. Sarita Sachdeva HOD, Dept. of Biotech, MRIU

Prof. Pankaj Dhawan, MDS, HOD ProsthoProf. Pooja Palwankar, MDS, HOD - PerioProf. Ashim Aggarwal, FDSRCS, HOD - Oral SurgProf. Vishal Dang, MDS, HOD - OMR

Patron : Dr. O.P. Bhalla

(Chairman, MREI, Faridabad)

ADVISORS

Prof. Deepak Rai, MDS

EDITOR-IN-CHIEF

Prof. Vandana S. Chadha, MDS

Prof. Manish Bhargava, MDS

ASSOCIATE EDITORS

EDITORIAL BOARD

Prof. Ravindra Shah, University of British Columbia Vancouver, Canada

Dr. Bapanaiah Penugonda, Collage of Dentistry New York University, USA

INTERNATIONAL EDITORIAL CONSULTANTS

1

JOURNAL OF

DENTAL SCIENCES

“DENTAL LAMINA”

VOL 1 NO.1 JUNE 2013

2Dental Lamina - Journal of Dental Sciences Vol. 1 No.1, June 2013

I am glad to know that the Manav Rachna Dental College, Faridabad is

bring out maiden issue of a Dental Journal entitled as "The Dental Lamina-

Journal of Dental Sciences".

Such journals not Only highlight the activities and achievements of

institution, but also provide an opportunity to the budding writers to express

their views.

The Haryana Government is committed to provide quality medical

education to the youth. Therefore, the Government has focused on improving

infrastructure in health sector and is expanding the network of Medical

colleges in the state. While a University of Health Sciences and a Medical

College for Women have been set up and made functional, three other new

medical colleges are being opened in the State.

I hope the Manav Rachna Dental College will not only provide quality

health education to the students, but would also provide modern and

affordable oral health care services to the patients.

My best wished far the successful publication of the Dental Journal.

Message

(Bhupinder Singh Hooda)

BHUPINDER SINGH HOODA

HkwisUnz flag gqM~Mk

eq[; eU=kh] gfj;k.kk]p.Mhx<+

CHIEF MINISTER, HARYANA,CHANDIGARH

3

It gives me immense pleasure to write a message for inaugural issue of Manav

Rachna Dental College’s Journal -“The Dental Lamina”

Technical education achieves height when it is shared with its colleagues and for

that publishing the academic findings is a litmus test to judge the standard of

education at a particular institution.

There will be no progress without your enquiring minds putting your work and

thoughts for scrutiny of your peers. One is proud to be a teacher but to maintain

that height, the teacher has to burn the midnight oil to convert his scientific

experience into clinical practice so that the procedure becomes cost effective and

reach the poor patient, which has been my lifelong mission and the reason to start

Manav Rachna Dental College.

I congratulate the editor and the editorial board to have broken the ice with the

hope that this enthusiasm will hence forth be a regular feature in the years to come.

“Paths are made by walking”.

With best wishes

Dr. O.P Bhalla

Chairman, MREIChancellor, MRIU

Dental Lamina - Journal of Dental Sciences Vol. 1 No.1, June 2013

CHANCELLOR’S MESSAGE


MESSAGE

Last decade has witnessed a rapid growth in all scientific disciplines

including dentistry. Many new researchers and innovations have been

made in various sub specialities of Dentistry, the benefit of which is well

reaching to the patients. I am pleased to note that Manav Rachna

Dental College (MRDC) has taken initiative to publish a Research

Journal — "The Dental Lamina — Journal of Dental Sciences" to

highlight and disseminate it's research endeavors. This indeed is a

reflection of sincere and commendable efforts to inculcate an

environment conducive of research.

I congratulate the management, faculty and staff of Manav Rachna

Dental College for launching this journal. I wish that the Journal

embodies scientific literature of highest quality, integrity and ethical

standards to come to the expectations of professional dental

community. I extend my best wishes for the success of the Journal.

Message

(Dr. S.S. Sangwan)

DR. S.S. SANGWANM.S., D.N.B., F.I.C.S., F.I.A.M.S.Vice Chancellor

Pandit Bhagwat Dayal Sharma

University of Health SciencesRohtak-124001, (HARYANA)

INDIA

5

Foundation of Dental profession begins with the evidence of “The Dental

Lamina” in the embryo which begins at the sixth week in utero or three weeks after

the rupture of the buccopharyngeal membrane. Thus begins the formation of

teeth and stomatognathic system of the human body.

The most interesting thing is, like the 'Maya' of the Hindu Mythology to which

they say this whole world ultimately converts into, the Dental Lamina also

eventually disintegrates, looses its connection with teeth and is resorbed. The

function of this mysterious human tissue prompted the Dental Faculty of Manav

Rachna Dental College to name its scientific Journal commensurating with the

motto of 'Manav Racha Vidya Anatariksha'.

The second question is should Manav Rachna Dental College have its own

scientific publication? The answer is an emphatic “yes”. In the present world,

progress is possible only because people are prepared to share their discoveries

and knowledge with others and this is done through scientific publications,

commonly either, a journal or a thesis. Most medical publishing is done by people

who have clinical commitments and who give their time and experience freely and

without reward to bring their colleagues new ideas, the result of experiments and

trials and insights into current and future medical practice.

There is a well known aphorism that you should publish or perish, it is not only

applicable to individual but – if no one publishes medicine will perish. So here is

an opportunity, if you feel you have something to say, submit to the editor of

Journal of Dental Sciences, “The Dental Lamina” and publish, don't perish.

I request each and every reader, to kindly give us feed back in the form of “letters

to the editor” to help us in continuous improvement in the quality of this Journal.

With best wishes :Maj. Gen. (R) P.N. Awasthi, V.S.M.

MDS Oral Surgery


FOREWORDADVISOR, MRDC

6

EDITORIAL

In the beginning was Hrianyagarbha (Golden womb)

The seed of elemental existence.

The only lord of all that was born.

He upheld the heaven and earth together

To what God other than him, can we dedicate our life? (Atharva Veda 4.2.7)

Dear Readers,

The team of “Dental Lamina” JOURNAL OF DENTAL SCIENCES is proud to introduce the birth of our inaugural issue!

It is amazing to note that the Profession we practice has its origin with a determination of bunch of cells that get together with a Vision to lay down the tooth buds and we have “The Dental Lamina”-WHERE IT ALL BEGINS- the Hiranyagarbha of our Dental tissue's origin.. This Journal is an attempt to take us back to the origin that determines our present.

Nature designs things in such a way that DREAMS die in same proportion as a wild SALMON fish breeds .Out of thousands of eggs laid , majority die & out of few hundred hatched eggs only 1 or 2 get to become full adults , to return to their original breeding ground ,to fulfill the dream. Same ratio applies to Professionals who build a “Vision that is larger than life”. The great artist Michelangelo claimed that his sculptures were already present in the stone, and all he had to do was carve away everything else unnecessary. Such as been the journey of visionary Dr. O.P Bhalla sir who has created such acclaimed institutions.

The process of finding our true self is personal excavation and the tool used is none other than Choice. We measure our lives using markers like years , achievements , major events. We should ideally measure our lives by Choices we make, the sum total of which brings us wherever & whoever we are today. When we live our life through this lens, it gets clear that choice is an enormously powerfull force, an essential determinant of how we live. Our goal should be to become an original thinker- the only way to allow reason to win over reflex.

“Dental Lamina” is a compilation of work of original thinkers and we hope the contents will inspire and motivate True Professionals in service of rendering Dental care.

The team thanks the management of Manav Rachna Educational Institutions for this opportunity to create a medium of knowledge sharing , as an ode to our VIDYA ANTRIKSH philosophy.

Prof. Deepak Rai, MDSEDITOR IN CHIEF

email : [email protected]


INDEX

A) CLINICAL : CASE REPORTS, TECHNIQUES & INNOVATIONS

1. Indirect bonding in Orthodontics-an aid for precise Bracket placement. 8

Dr Karan Sharma, Dr Deepak Rai, Dr Rekha Mittal, Dr Saras Chadha, Dr AK Kapoor.

2. Unicystic Ameloblastoma-a case report. 13

Dr Shivani Aggarwal, Dr Ashim Aggarwal, Dr Deepak Chowdhary, Dr Sharanjeet Gill,

Dr Manish Bhargava ,Dr Nitin Ahuja.

3. Peripheral Giant cell granuloma-a case report. 16

Dr Sood Sveta, Dr Ahuja Vipin, Dr Sharma Naresh, Dr Choudhary Swati

4. Ankyloglossia(Tongue tie) and lingual frenotomy in 8 year old girl with speech

impairment-a case report. 20

Dr Hind Pal Bhatia, Dr Ahuja Vipin, Dr Sharma Naresh, Dr Choudhary Swati

5. Estabilishing speech intelligibility in complete denture wearers. 24

Dr Malathi Buddhi, Nikhil Jonwal

6. Unusual canal anatomy of mandibular first molar-a case report. 30

Dr Ravjot Ahuja, Dr Arundeep Singh, Dr Swati Sanghi, Dr Abhinav Kumar, Dr Neha Juneja.

B) REVIEW & ABSTRACTS

1. Chlorhexidine,a boon to dentistry-a review. 35

Dr Preeti Upadhyay, Dr Pooja Palwankar, Dr Vandana S. Chadha, Dr Kapil Arora,

Dr Ashish Verma, Dr Nipun Dhalla.

2. BOOK review 39

C) TECHNOBYTES

CEREC CAD-CAM a revolutionary technology; ONE DAY WONDER 40

Prof. Harshwardhan Arya

D) PRACTICE MANAGEMENT

Good to Great Dental Practice 41

Prof. Deepak Rai

E) POINT-COUNTERPOINT

Should wisdom molars be extracted prophylactically to prevent late mandibular crowding ? 43

Dr Gurkeerat Singh, Dr Reena R Kumar

F) GUIDELINES FOR CONTRIBUTORS 45

7. Surgical Management of Zygomatic Complex Fractures: 32

Dr Amit Gandhi, Dr Ashish Garg, Dr Dimple Grover, Dr Ashim Aggarwal


8

INDIRECT BONDING IN ORTHODONTICS-AN AID FOR PRECISION BRACKET PLACEMENT

Abstract:

Conclusion

Key Words

The Pre adjusted edgewise appliance requires precision in bracket positioning as the final treatment outcome is based upon it. Direct manual positioning of the brackets may not provide us with the precision required, thus the paper presents an indirect bonding technique which provides the clinician with an efficient way of precise bracket placement. Case Report: Patient reported to the Dept of Orthodontics and Dentofacial Orthopaedics with a chief complaint of forwardly placed upper front teeth. The patient was diagnosed with class II div 1 malocclusion. Upper first bicuspids were extracted and the maxillary anterior teeth were retracted to finish the case in class II molar. The indirect bonding protocol was followed.

Precision in bracket placement, reduced chair side time, decrease in the number of patient appointments and less patient discomfort are the advantages indirect bonding has over direct manual placement of brackets. Indirect bonding might prove to be a useful tool in the armamentarium of a busy practicing Orthodontist.

PEA, Indirect bonding, Sondhi Rapid Set

Dr Karan Sharma, MDS*; Dr Deepak Rai, MDS**; Dr Rekha Mittal, MDS*; Dr A.K Kapoor,MDS****

*Senior lecturers, Department of Orthodontics, MRDC

** Professor, Department of Orthodontics, MRDC

*** Reader, Department of Orthodontics, MRDC,

****Director-Principal, Head, Department of Orthodontics, MRDC

Introduction

REVIEW OF LITERATURE:

5. This technique is also less operator sensitive and allows

even relatively inexperienced orthodontists to obtain The Pre adjusted edgewise appliance is based on the 4–6

results that otherwise might be difficult to achieve.concept that ideal bracket placement will correct tooth position in all three planes of space during the treatment. Different techniques of indirect bonding have been Misplacement of a bracket in PEA can cause deviations in proposed, employing changes to the transfer tray type

(eg, single jigs or full arch), the material used (eg, acrylic rotation, tipping, in/out, extrusion/intrusion, and torque. resin, silicone, thermo-printed material, or a Accuracy in placement of brackets is very important in combination of two or more of these materials), and PEA and naturally would require a lot of chair side time so the type of preparation of the bracket base (eg, that each bracket is placed as precisely as possible. Indirect 7,8personalized or self- or light-cured resin).

bonding serves as an excellent technique for positioning of brackets

Advantages of Indirect Bonding Indirect bonding was first described in detail as a concept 9in 1972 by Silverman and Cohen.1. Reduces chair side time.

The basic method for Indirect bonding has not changed 2. Reduced composite excess around braces thus reducing much but the materials employed for it has been changing.decalcification.

10, 11,Various materials ranging from softened sugar candies 3. Accurate bracket positioning.12acrylic based adhesive (Newman) to composite resins

4. Compared to direct manual positioning, indirect 13(Thomas) have been used as a means to attach brackets to

bonding with transfer trays is a technique that when the working model.standardised, allows reduction in patient chair side

Chemical cured materials were used initially but later on time. The reduction in chair side time concerns not light cured adhesive were the material of choice for

only initial bracket positioning but also persists 14indirect bonding. Read and O'Brien used a visible light throughout the therapy because the positioning of the 15

cure adhesive in indirect bonding, Hamula discussed the braces is more accurate; thus fewer compensatory advantages of using light cure adhesive for indirect

16bends must be placed during finishing stages or less bonding. Cooper and co-workers described the use of pre 1-3 need of repositioning of poorly placed brackets. coated brackets.


9

A case report is presented, in which a step wise procedure 5. Using a bow divider a faint scratch was made 2mm for precision bracket placement was used to effect apically from the horizontal line.On the second molar,

17 this measurement was decreased by ½ mm. (fig3, fig4)idealized, customized, and optimal bracket placement.

Patient had reported to the Department of Orthodontics and Dentofacial Orthopaedics with a chief complaint of forwardly placed upper front teeth. Patient was diagnosed with class II div1 malocclusion. It was decided to treat the patient by upper first bicuspid extraction, retraction of maxillary anteriors and finishing in Class II molar relationship.

Following procedure was used for indirect bonding

1. The teeth were cleaned with a prophy cup and pumice, and then alginate impressions were made using mechanically mixed alginate. Fig 3: Measurement made for slot line 2mm apical

to the line for marginal ridges.2. The impressions were poured in vacuum- mixed stone. The casts were trimmed enough to allow for good visualization of the teeth, and then dried thoroughly.

3. A 0.03-mm black lead pencil was used to draw vertical lines on the upper and lower casts of the teeth from the second bicuspids forward, beginning on the crowns and continuing down the model onto the roots. These lines indicate the long axes of the teeth. (fig1)

Fig 4: Scratch made on the cast using the divider for the slot line.

6. Using this mark, a second line parallel to the marginal ridge line was made. This line is called the slot line. (fig5)

Fig 1: Model with vertical reference lines, indicating long axis of the teeth.

4. Horizontal lines were drawn on the molars and bicuspids connecting the mesial and distal marginal ridges.(fig2)

Fig 5: Model with the slot line.

7. The 2-mm slot line measurement is somewhat arbitrary and can be increased or decreased based on the size of the teeth.

8. The distance between the cusp tip of the first bicuspid and the slot line was measured; this measurement was transferred to the central incisor. Measurement for the

Fig 2: Model with horizontal lines (Red) made by maxillary lateral incisor was decreased by 0.5 mm and connecting mesial and distal marginal ridges. increased by 0.5 mm for the canine. (fig6, fig7,fig8)

Case Report


10

Fig 6: Distance between the buccal cusp tip and slot Fig 9: Bracket placed on the cast using light cure adhesive line measured. with reference lines acting as a guide.

12. After the position of the bracket was confirmed, curing was done.

13. The transfer trays were made from a High Viscosity Putty (addition silicone). Equal portions of the two putty components were mixed to form a thick rope.

14. The putty was then adapted to the model to cover the brackets and extended over occlusal and lingual surfaces.

15. Once the trays had hardened, the models were placed into a bowl of warm water and soaked for 30 minutes

16. The trays were then sectioned in such a manner that each section contained three brackets. Doing this ensures easy removal of the trays once the brackets have been placed on the patient's teeth.(fig10)

Fig 7: Measurement transferred to the central incisors.

Fig 8: Measurements made for lateral incisors and canines.

9. For the mandibular arch similar procedure is followed except that the measurement for the central and lateral incisor is kept the same and the measurement is Fig 10: Transfer trays made using high viscosity putty. increased by 0.5mm for the canine. 17. Teeth were isolated, etched and dried, Sondhi Rapid

®10. After fabrication of the working models with the Set Indirect Bonding Adhesive (3M Unitek),was customized prescription, the models were coated with placed with one component in a thin layer on the teeth two light coats of a separating medium, which was and the other component on the bracket bases in the diluted in a 1:3 ratio and allowed to dry thoroughly transfer trays.(fig11)

11. The bracket mesh was coated with a light cure 18. The tray was seated using light finger pressure and held adhesive. The brackets were seated against the models in place for 30 seconds. The tray was left in place for and were checked against the lines using a bracket- another 2 minutes so that curing could take place positioning instrument.(fig9) completely.(fig12)


11

Fig 14: Brackets placed with initial arch wires.

The method described makes use of vertical and Fig 11: Sondhi Rapid Set Indirect Bonding Adhesive ®

horizontal reference lines to position the brackets more (3M Unitek).

accurately. The markings ensure that the brackets are placed in such a manner that esthetic and functional needs of a case are fulfilled.

The method used here is a quick and a reliable mode of precise bonding, without the need for excessive chair side time. Patient discomfort is reduced and the overall time required to place the full appliance is also reduced with less number of appointments.

1. Joiner M. In-house precision bracket placement with the ind i r ec t bond ing t echn ique. Am J OrthodDentofacialOrthop. 2010;137:850–854.

2. Koo BC, Chung CH, Vanarsdall RL. Comparison of the accuracy of bracket placement between direct and

Fig 12: Transfer tray seated. i n d i r e c t b o n d i n g t e c h n i q u e s . A m J OrthodDentofacialOrthop. 1999; 116:346–351. 19. The trays were then removed easily using a curette or a

scaler. (fig13) 3. Shpack N, Geron S, Floris I, Davidovitch M, Brosh T, Vardimon AD. Bracket placement in lingual vs labial systems and direct vs indirect bonding. Angle Orthod. 2007;77:509–517.

4. Thomas RG. Indirect bonding: simplicity in action. J ClinOrthod. 1979;13:93–106.

5. Scholz RP. Indirect bonding revisited. J ClinOrthod. 1983; 17:529–536.

6. Hodge TM, Dhopatkar AA, Rock WP, Spary DJ. The Burton approach to indirect bonding. J Orthod. 2001;28:267–270.

7. Zachrisson B, Brobakkeen B. Clinical comparison of direct versus indirect bonding, with different bracket types adhesives. Am J Orthod. 1978;74:62.

Fig 13: Removal of transfer tray after the Bonding 8. Aguirre MJ, King GJ, Waldrom MJ. Assessment of

Adhesive has cured.bracket placement and bond strength when

20. Initial arch wires were then inserted and the patient comparing direct bonding technique. Am J Orthod. was given necessary care instructions.(fig14) 1982;82:269.

Discussion

References


12

9. Silvermann E, Cohen M: A universal direct bonding 14. Read MJF, O'Brien KD: A clinical trial of an indirect

system for both metal and plastic brackets. Am J bonding technique with a visible light cured adhesive.

Orthod 62:236-244, 1972. Am J Orthod Dentofacial Orthop 98: 259-62,1990

10. Simmons M: Improved laboratory procedures for 15. Hamula W: Technique clinic direct bonding with light

indirect bonding of attachments. J Clin Orthod 12: cured ashesive J Clin Orthod 7; 437-38.1991.

300-302,1978. 16. Cooper RB, Goss M, Hamula W: Direct bonding with

11. Gerkhardt K, Schopf P: Controlled etching system light cured adhesive precoated brackets. J Clin Orthod

for direct and indirect bonding. J Clin Orthod 21:842- 8: 477-79, 1992.

846,1987. 17. Kalange J.T. Prescription-Based Precision Full Arch

12. Newman GV: Direct and Indirect bonding of Indirect Bonding. SeminOrthod 2007;13:19-42.

brackets. J Clin Orthod 8: 264-272,1974.

13. Thomas RG: Simplicity in action. J Clin Orthod 13:

93-104, 1979.


Introduction Group 3 Mural UA (invasive islands of ameloblastomatous epithelium in the Unicystic ameloblastoma, a variant of ameloblastoma first connective tissue wall not involving the described by Robinson and Martinez in 1977, refers to entire epithelium).those cystic lesions that show clinical and radiologic

characteristics of an odontogenic cyst but in histologic examination show a typical ameloblastomatous epithelium

1lining with or without luminal and/or mural proliferation . This lesion occurs in a younger age group, with slightly more than 50% of cases occurring in patients in the second

2decade of life . In more than 90% of the cases, the unicystic ameloblastoma is located in the mandible, with 77% located in the molar ramus region. Between 50 and 80% of cases are associated with tooth impaction, the mandibular third molar being most often involved. Patients most commonly present with swelling and facial asymmetry, pain being an occasional presenting symptom. Mucosal ulceration is rare, but may be caused by continued growth of the tumor. Small lesions are sometimes discovered more on routine radiographic screening examinations or as a result of local effects (like tooth Another histologic subgrouping by Philipsen and

4mobility, occlusal alterations and failure of eruption of Reichart has also been described:3

teeth) produced by the tumor . Ackermann classified this Subgroups Interpretation

entity into the following three histologic groups:1 Luminal UA

Groups Interpretation1.2 Luminal and intraluminal

Group 1 Luminal UA (tumor confined to the 1.2.3 Luminal, intraluminal and intramuralluminal surface of the cyst)

1.3 Luminal and intramuralGroup 2 Intraluminal/plexiform UA (nodular proliferation into the lumen without The UAs diagnosed as subgroups 1 and 1.2 can be treated infiltration of tumor cells into the conservatively (careful enucleation), whereas subgroups connective tissue wall), 1.2.3 and 1.3 showing intramural growths require radical

Figure 1: Types of growth in Unicystic Ameloblastoma: 1.Luminal, 2. Intraluminal, 3. Intramural.

Abstract:Unicystic ameloblastoma (UA) refers to those cystic lesions that show clinical, radiographic, or gross features of a cyst, but on histological examination show a typical ameloblastomatous epithelium lining, with or without luminal and/or mural proliferation. It is a less encountered variant of ameloblastoma and shows considerable similarities with dentigerous cyst both clinically and radiographically but the biologic behavior varies. Recurrence of unicystic ameloblastoma may be long delayed so a long post term follow up is essential. In this case report we present a case of unicystic ameloblastoma in a 20 year old male patient.

****Dr. Shivani Aggarwal, MDS*; Dr Ashim Aggarwal¸ MDS**; Dr. Deepak Chaudhary, MDS ,Dr. Sharanjeet Gill, MDS****; Dr. Manish Bhargava, MDS*** ,Dr. Nitin Ahuja, MDS****

*Prof & Head, Department of Oral Pathology, MRDC

**Prof & Head, Department of Oral and Maxillofacial surgery, MRDC

***Prof, Department of Oral Pathology, MRDC

****Senior lecturer, Department of Oral Pathology, MRDC

Key Words Cystic lesion, Ameloblastoms, Recurrence

UNICYSTIC AMELOBLASTOMA :A CASE REPORT


14

5 Higher magnification showed lesional tissue composed of resection, as for a solid or multicystic ameloblastoma . cystic areas lined by ameloblastic epithelium with a basal cell layer composed of columnar cells displaying hyperchromatic pallisaded nuclei. Reverse polarity of the nuclei was present and a subnuclear vacuole was noted

A 20 year-old boy presented with a painless hard swelling between the basement membrane and nucleus. A thin in the right side of the lower jaw since 6 months. Clinical overlying layer of stellate reticulum like cells was also seen. examination revealed a bony hard swelling arising from the No luminal or mural proliferation was observed.( Figure 3) lower jaw. Intraorally a large, hard, nontender mass on the The histopathological impression was that of unicystic right side of the mandible, covered by red, intact, and ameloblastoma- subgroup1immobile mucosa was seen. No lymphadenopathy or fistulae were present. Past history and medical history were unremarkable He was taking no medication and had no history of known drug allergy. His physical examination revealed no abnormality other than those related to the chief complaint Radiography revealed a large unilocular radiolucency extending from right mandibular canine to first molar. (Figure 1)

Figure 3: Section showing hyperchromatic pallisaded nuclei in the basal layer and stellate reticulum like superficial cells. (H & E 40X)

The term unicystic is derived from the macro and A provisional diagnosis of odontogenic cyst or tumor was microscopic appearance, the lesion being essentially a well-made and fine needle aspiration cytology (FNAC) was

done. Aspirate of the fluid showed cholesterol crystals and defined, often large monocystic cavity with a lining, focally protein analysis revealed 4.3 gm/dl of protein, suggestive but rarely entirely composed of odontogenic

6of keratinizing cyst/tumor. An incisional biopsy was (ameloblastomatous) epithelium . The lesion is often performed and sent for histopathological examination. H asymptomatic, although a large swelling may cause painless

1& E stained section at Low magnification revealed a cystic swelling of the jaw . An age old debate for the lining with the basal cells displaying a palisading pathogenesis of this lesion still prevails. Three appearance. Hyalinization of the subjacent connective mechanisms have been proposed for the development of

7tissue capsule was noted at few places (Figure 2). the unicystic ameloblastoma :

1. The reduced enamel epithelium associated with a

developing tooth undergoes ameloblastic transformation

with subsequent cystic development

2. Ameloblastomas arise in dentigerous or other types of

odontogenic cysts in which the neoplastic ameloblastic

epithelium is preceded temporarily by a non-neoplastic

stratified squamous epithelial lining

3. A solid ameloblastoma undergoes cystic degeneration

of ameloblastic islands with subsequent fusion of multiple

microcysts and develops into a cystic lesion.

In the present case presence of non specific thin epithelial

lining of cystic tumor supports the second hypothesis. On

Figure 2: Thin cystic lining and fibrocellular capsule. removal of the cyst, it is important to examine both the

(H& E, 4X) interior and exterior of the cyst sac. Careful macroscopic

This paper illustrates a case of unicystic ameloblastoma of the mandible in a 20 year old male.

Figure 1: OPG. showing unilocular radiolucency extending from right mandibular canine to distal root of right mandinular first molar.

Case Report

Discussion


15

inspection of the specimen may reveal important Biological profile of 3677 cases. Oral Oncol Eur J Cancer 31B:86, 1995diagnostic clues. The cyst capsule may show one or several

protruding nodules when viewing the cyst wall from the 3. Ackermann GL, Altini M, Shear M: The unicystic outside. These have been named mural or intra-mural ameloblastoma: A clinicopathological study of 57

8nodules . In the present case no mural or intraluminal cases. J Oral Pathol 17:541, 1988nodule was seen on macroscopic examination confirming 4. Philipsen HP, Reichart PA: Unicystic ameloblastoma: A the histopathological diagnosis of type 1 unicystic review of 193 cases from the literature. Oral Oncology, ameloblastoma. 1998; 34(5):317- 325.The most important considerations regarding unicystic 5. Philipsen HP, Reichart PA: Unicystic ameloblastoma. ameloblastoma is that of biologic behavior. It has been Odontogenic tumors and allied lesions London: widely stated that these lesions are less aggressive than Quintessence Pub. Co. Ltd 2004, 77-86.their solid or multicystic counterparts. It has been

6. Eversole LR, Leider AS, Strub D: Radiographic suggested that recurrence following conservative surgery characteristics of cystogenic ameloblastoma. Oral is more likely to occur in the third group therefore these Surgery Oral Medicine & Oral Pathology, 1984; lesions should be treated in the same manner as solid 57(5):572-577.ameloblastomas. Whatever surgical approach the surgeon

decides to take, long term follow up is mandatory, as

recurrence of unicystic ameloblastoma may be long 9

delayed .

1. Robinson L, Martinez MG. Unicystic ameloblastoma: A prognostically distinct entity. Cancer 1977;40:2278-85

2. Reichart PA, Philipsen HP, Sonner S: Ameloblastoma:

References:

7. Leider AS, Eversole LR, Barkin ME. Cystic Ameloblastoma. Oral Surg Oral Med Oral Pathol 1985; 60:624-630.

8. Kessler HP. Intraosseous ameloblastoma. Oral Maxilofac Surg Clin North Am 2004 Aug; 16(3):309-22.

9. Li TJ, Kitano M,Arimura K, Sugihara K. Recurrence of unicystic ameloblastoma: A case report and review of the literature. Arch Pathol Lab Med 1998; 122:371-4.


16

Abstract

Keywords

Peripheral giant cell granuloma is the most frequent giant cell lesion of the jaws. It originates from the connective tissue of the periosteum or from the periodontal membrane; in response to local irritation or chronic trauma. The differential diagnosis includes lesions with very similar clinical and histological characteristics such as the central giant cell granuloma (CGCG), which are located within the jaw itself and exhibit a more aggressive behaviour. Only histological and radiological evaluation can establish a distinction. The early and precise diagnosis of the lesions allows conservative management without risk to the adjacent teeth or bone. In this article, We present a case report and discussion of the clinical, radiological, histological features and treatment modalities of peripheral giant cell granuloma (PGCG).

Peripheral giant cell granuloma, reparatory giant cell granuloma, benign hyperplastic reactive lesion

Dr. Sood Shveta, MDS*; Dr. Ahuja Vipin, MDS**, Dr. Sharma Naresh, MDS**, Dr. Chowdhry Swati, MDS**

Professor* Senior Lecturer** Department of Pedodontics & Preventive Dentistry, Manav Rachna Dental College, Faridabad, Haryana

Introduction

Case Report

contributory. The patient's mother noticed the growth three months back. It was slightly smaller then, than the PGCG is not a true neoplasm but rather a benign size at the time of presentation. The patient could not hyperplastic reactive lesion caused by local irritation or recall the exact time of initiation of the growth. There had chronic trauma. It is the most frequent giant cell lesion of

1,2 been a gradual increase in size causing discomfort while the jaws. eating as the extent of the growth had reached the occlusal

The PGCG has been described for many years under a plane and used to bleed on being traumatized.

great variety of terms in dental and medical literature. This Intra-oral examination revealed a solitary swelling in the is indicative of the confusion which it has generally evoked edentulous region relating to the lateral incisor and canine and even today there is no universal agreement on the true region extending from the free gingiva to the mucogingival nature of the lesion. The condition has also been referred fold (Fig1)to as peripheral giant cell tumor, giant cell epulis,

osteoclastoma, reparatory giant cell granuloma and giant 3cell hyperplasia of the oral mucosa.

Clinically, it manifests as a firm, soft, bright nodule or as a sessile or pedunculated mass. The colour can range from dark red to purple or blue and the surface is occasionally ulcerated. The lesions range in size from small papules to enlarged masses, though they are generally under 2 cm in diameter and are located in the interdental papilla, edentulous alveolar margin or at the marginal gum level. The treatment comprises of surgical resection with extensive clearing of the base of the lesion to avoid relapses. The early and precise diagnosis of PGCG based

Fig 1: Pre-operative clinical photograph showing solitary on the clinical and radiological findings and histological swelling in the maxillary left lateral Incisor and canine study allows conservative management with a lesser risk regionfor the teeth and adjacent bone.

The swelling measured 2x1.4x1 cm (Fig 2)

The consistency of the lesion was soft and its colour was A nine year old cleft palate female patient presented with a dark red. The tooth #11 and 12 were fused. Patient complaint of swelling in the mouth involving the upper exhibited rotation of the fused tooth. The tooth # 22 and left anterior region which was dark red in colour. It 23 had not yet erupted. Patient had received stainless steel exhibited surface ulceration and interfered with crowns on tooth # 74 and 75.masticatory process. Her medical history was non

PERIPHERAL GIANT CELL GRANULOMA : A CASE REPORT


17

PGCG is a relatively frequent benign reactive lesion of the

oral cavity. Although the etiology is subject to controversy,

many authors consider the origin to comprise of an 3abnormal proliferative response to aggression Different

local causal factors have been associated to PGCG

including complicated dental extractions, dental

restorations in poor conditions, food impaction, plaque 2,5and calculus etc.

The lesions can appear at any age, though the highest 3,8,9incidence (40%) is in the 4th to 6th decades of life. In

20%-30% of the cases they manifest in the 1st and 2nd Fig 2 : Post Operative View after Excisional Biopsy Intra-2decades . Reichart and Philipsen consider the peak oral periapical radiograph showed slight bone resorption

incidence to be between 20 to 60 years of age. Andersen et in the form of a concave depression, with a normal al in a series of 97 cases of PGCG, reported a marked trabecular component. The hemogram of the patient was prevalence between 5 and 15 years of age. PGCG affects within normal limits. The lesion was removed under

1,2 females more often than males with a proportion of 1:1.5 infilteration local anesthesia using a cold scalpel (Fig or 1:2 according to Reichart and Philipsen or Giansanti and 3). The histological report confirmed the diagnosis of Waldron respectively. However, Bhaskar et al in a review of PGCG. There were no complications in the immediate 50 cases reported a slight predilection for the male sex. post operative period. At the successive controls, and after Before the 16th year of age, it is more common in males 10 months, there was no evidence of relapse.and after the 16th year of age, it is twice as common in

females. This granuloma reportedly is more common in

the lower jaw than in the upper jaw in a proportion of

2:4:1.

The clinical appearance may vary considerably. It always

occurs on the gingiva or alveolar process, most frequently

anterior to the molars and presents itself as a pedunculated

or sessile lesion that seems to be arising from deeper in the

tissue than many other superficial lesions of this area such

as the fibroma or pyogenic granuloma, either of which it Fig 3: Excised Specimenmay resemble clinically. Thus it seems to originate from the

Photomicrograph (Fig 4) shows a fibroblastic proliferation periodontal ligament or mucoperiosteum. The lesion also

with scattered multinucleated giant cells. The mass is varies widely in size, but usually is between 0.5 to 1.5 cm in

separated by a band of fibrous connective tissue from the diameter. It is most often dark red, vascular or

overlying epithelium. Occasional spicules of bone/ hemorrhagic in appearance and commonly exhibits

osteoid were noticed. The above histopathologic features surface ulceration. In the edentulous patient the lesion may

are suggestive of a PGCG.appear as a vascular, ovoid or fusiform swelling of the crest

of the ridge, seldom over 1 to 2 cm in diameter, or there

maybe a granular mass of tissue which seems to be

growing from the tissue covering the slope of the ridge.

The colour of these lesions vary but is usually similar to

that of the lesions in dentulous patients.

Histologically the PGCG are characterized by the presence

of numerous multinucleated giant cells and large numbers

of ovoid or spindle – shaped young connective tissue cells

lying in a delicate reticular and fibrillar connective tissue

stroma. Sapp reported that the giant cell in some instances

resemble osteoclasts, but in most of the cases are

considerably larger that the typical osteoclast. Capillaries Fig 4: Photo micrograph showing fibroblastic poliferation are numerous, particularly around the periphery of the with Scattered Multinucleated Giant Cells

Discussion


18

lesion and the giant cells sometimes may be found within A range of disorders should be considered in the

the lumina of these vessels. The origin of the giant cells differential diagnosis of peripheral granuloma, including remain uncertain. However, the strong resemblance pyogenic granuloma, fibrous epulis, peripheral ossifying between the nuclei of the giant cells and those of the fibroma, inflammatory fibrous hyperplasia, peripheral stromal fibroblasts suggests a common origin for both. odontogenic fibroma. The histological study of the Foci of hemorrhage, with liberation of hemosiderin resected tissues establishes the definitive diagnosis. pigment and its subsequent ingestion by mononuclear

From the histopathological perspective, the principal phagocytes, as well as inflammatory cell infilteration, are differential diagnosis is established with central giant cell also characteristic features. Spicules of newly formed granuloma, though the clinical and radiological findings osteoid or bone are often found scattered throughout the

1 offer a clear and conclusive distinction between central and vascular and cellular fibrosis lesion.

peripheral giant cell gramuloma. The x-ray features are The histologic study centers on 3 points – epithelium,

very important for determining whether the lesion is of connective tissue zone and medullary or core region:-

gingival origin or arises centrally with the spread towards � The lining epithelium corresponds to the squamous the surface.

structure of the gums, which may suffer ulcerative The treatment comprises surgical resection and

changessuppression of the underlying etiologic factors with

1,8� The subepithelial connective tissue zone is composed elimination of the entire base of the lesion. If resection is of connective tissue with abundant small caliber blood 1only superficial, the growth may recur. Most lesions vessels. An acute inflammatory infiltrate is often seen

respond satisfactorily to thorough surgical resection, with

� The medullary or core region is where the giant cells are exposure of all the bone walls. When the periodontal

located. These may be of 2 types:- membrane is affected, extraction of the adjacent teeth may

prove necessary to ensure full resection, though this is ©Type A cells: polynuclear eosinophillic cells with a

initially contraindicated.diffuse and abundant cytoplasm. The nucleus is

prominent and the chromatin is distributed along the Resection can be done by a cold scalpel or carbon dioxide internal membrane. laser. The literature reports no differences between the

two. The advantages of laser resection are that it causes ©Type B cells: cells with a regular and well defined, less intraoperative bleeding, sterilizes the wound, requires more chromatic and larger cytoplasm. The nuclei no suturing and affords improved post operative comfort. present show poorly defined limits and a central However, laser resection is not indicated in lesions with accumulation tendancy, with intense hyper

10 adjacent bone involvement where careful surgical chromatism.curettage is required.

The roentgenographic features are non-specific, with foci

of bone metaplasia in some cases. Some patients may

present evidence of bone involvement beneath the lesion, 1. Flaitz CM. Peripheral Giant Cell Granuloma: a in the form of superficial alveolar bone resorption- potentially aggressive lesion in children. Pediatr Dent observable on periapical x-rays. Widening of the 2000; 22:232-33.periodontal ligament space is often a finding associated to

2. Pandolfi PJ, Felefli CM, Johnson JV. An aggressive dental mobility, though in some situations it may represent

peripheral giant cell granuloma in a child. J Clin Pediatr lesion spread around the root. Detailed examination of the

Dent 1999; 23:353-55.zone can reveal small bone spicules extending vertically

towards the base of the lesion. In edentulous areas the 3. Kfir Y, Buchner A, Hansen L, Reactive lesions of

peripheral giant cell granuloma characteristically exhibits gingival: A clinicopathological study of 741 cases. J

superficial erosion of the bone with pathognomonic Periodontol 1980; 51:655-61.

peripheral “cuffing” of the bone. When the tumor is 4. Choung R, Kaban LB. Diagnosis and treatment of jaw

located in dentate areas, the x-ray may show superficial tumors in children. J Oral Maxillofac Surg 1985;

destruction of the alveolar crest or margin at interdental 43:323-32.

bone level. X-rays are important for determining whether

5. Katsikeris N, Kakarantza-Angelo poulou E. Peripheral the lesion is of gingival (i.e. peripheral) origin or of bone

giant cell granuloma: clinico – pathologic study of 224 (central) origin with spread towards the surface.

References


19

new cases and 956 reported cases. Int J Oral Maxillofac 8. Bodner L, Peist M, Gatol A, Filso DM. Growth

Surg 1988; 17:94-99. potential of peripheral giant cell granuloma. Oral Surg

Oral Med Oral Pahtol Oral Radiol Endod 1997; 83:548-6. Parbatani R, Tinsley GF, Danford MH. Primary

51.hyperparathyroidism presenting as a giant cell epulis.

Oral Surg Oral Med Oral Pahtol Oral Radiol Endod 9. Tanaka N, Murata A, Yamaguchi A. Clinical features and

1998, 85:282-84. management of oral maxilla facial tumors in children.

Oral Surg Oral Med Oral Pahtol 1999; 88:11-15.7. Chaparro – Avendano AV, Berini – Aytes L, Gay Es co

Peripheral giant cell granuloma. A report of five cases 10.Sato M, Tanaka N, Sato T. Oral and maxillofacial

and review of literature. Med Oral Patol Oral Cir Bucal tumors in children: a review. Br J Oral Maxillofac 1997;

2005; 10:48-57. 35:92-95.


20

ABSTRACT:

KEY WORDS

Tongue-tie or partial ankylogossia is manifested by an abnormally short and thick lingual frenum. Tongue tie is found in around 3–4% of children, with a male predominance with ratios varying from 1.5:1 to 2.6:1. Degree of tongue tie vary from the very mild, having only mucous membrane band to those in which both the frenum and underlying fibres of genioglossus muscle are markedly fibrosed, to the rare complete ankyloglossia where the tongue is actually fused to the floor of the mouth. This can impair the baby's ability to breastfeed and in some cases, causes speech problems as child grows.

Tongue tie, Ankyloglossia, Lingual frenotomy

Dr Hind Pal Bhatia, MDS*; Dr. Ahuja Vipin**, MDS, Dr. Sharma Naresh**, MDS,

Dr. Chowdhry Swati**, MDS

Professor & HOD* Senior Lecturer** Department of Pedodontics & Preventive Dentistry, Manav Rachna Dental College, Faridabad, Haryana

Introduction instrument at the insertion point and approximating the tip of the tongue determine this measurement. A Boley gauge Tongue-tie or ankyloglossia is the condition where lingual is then used to measure this distance. This ('Free Tongue' frenulum, the band of tissue that attaches the tongue to the

1 Length) forms the basis for the Kotlow Classification of floor of the mouth, restricts tongue movement . The 3

Ankyloglossia . (TABLE 1)simplest functional definition was outlined by Wallace as “a condition in which the tip of the tongue cannot be In an attempt to combine anatomical appearance and protruded beyond the lower incisor teeth because of a

tongue function, Hazelbaker developed an assessment 2short frenulum” . In tongue-tied infants, the frenulum is 4

tool for the lingual frenulum (TABLE 2) . In this usually attached close to the tongue tip, leaving little or no

assessment, five appearance items and seven function “free tongue,” but it can also be placed further back and be 1 items are scored. Significant ankyloglossia is diagnosed if unusually short or tight .

the total appearance score is 8 or less and/or the total The tongue is the major “player” in breastfeeding. It helps

function score total is 11 or less. Whilst this detailed pull the breast into proper position in the mouth, then scoring system enables objective definition, assessment, grooves along its length to make a channel to keep the and diagnosis of tongue-tie, its practicality for routine breast in place in the mouth and to catch milk to hold it at clinical assessment of infants is questionable. In clinical the back of the tongue in preparation for swallowing.

Normally, the free tongue measures at least 16 millimetres practice the most useful assessment of tongue-tie is based 1by the time a child is 18 months old . The term free-tongue on the position of frenular attachment to the tongue base,

is defined as the length of tongue from the insertion of the degree of maximal tongue tip protrusion, and impairment lingual frenum into the base of the tongue to the tip of the of activities requiring tongue function.tongue.

Table 2. Hazelbaker Assessment Tool for lingual frenulum

function.

TABLE 1 : KOTLOW CLASSIFICATION

Because the tongue is a muscle, which in young children is flexible and often difficult to stabilize, placing a dental

ANKYLOGLOSSIA (TONGUE TIE) AND LINGUAL FRENOTOMY IN 8 YEAR OLD GIRL WITH SPEECH IMPAIRMENT : A CASE REPORT

Clinically Normal: >16 mm

Class I: Mild Ankyloglossia 12-16 mm

Class II: Moderate Ankyloglossia 8-11 mm

Class III: Severe Ankyloglossia 3-7 mm

Class IV: Complete Ankyloglossia<3 mm

Appearance of tongue when lifted

Elasticity of frenulum

Length of lingual frenulum whentongue lifted

Attachment of lingual frenulum totongue

Attachment of lingual frenulum toinferior alveolar ridge

Function ItemsLateralisation

Lift of tongue

Extention of tongue

Spread of anterior tongue

Cupping

Peristalsis

2 : Round or square1 : Slight cleft in tip apparent0 : Heart or V-shaped

2 : Very elastic1 : Moderately elastic0 : Little or no elasticity

2 : >1 cm1 : 1 cm0 : <1 cm

2 : Posterior to tip1 : At tip0 : Notched tip

2 : Attached to floor of mouth or well below ridge

1 : Attached just below ridge0 : Attached at ridge

2 : Complete1 : Body or tongue but no

tongue tip0 : None

2 : Tip to mid-mouth1 : Only edges to mid-mouth0 : Tip stays at lower alveolar

ridge or rises to mid-mouth only with jaw closure

2 : Tip over lower lip1 : Tip over lower gum only0 : Neither of the above, or

anterior or mid-tongue humps

2 : Complete1 : Moderate of partial0 : Little or none

2 : Entire edge, firm cup1 : Side edges only, moderate

cup0 : Poor or no cup

2 : Complete, anterior or posterior

1 : Partial, originating posterior to tip

0 : None or reverse

Appearance Items


21

1,5-7Breast –feeding :

1,5,8Speech :

Problems associated with tongue-tie:

A plethora of literature is documented which proves that

the tongue is a major component of the suckling reflex.

The initial function of the tongue is to help draw the breast

into a correct position in the child mouth at the start of

breastfeeding. The tongue then forms a groove along its

length that provides a channel to maintain breast position,

as well as holding the milk at the back of the tongue before

swallowing is initiated. The tongue movement during

suckling involves elevation of the tongue tip which traps

milk in the front of the breast, before a wave of

compression passing from the tip to about halfway along

the tongue presses milk from the areola to the nipple. The

pressure within the mouth is then reduced by the back of

the tongue dropping to the floor of the mouth enabling

milk to be expelled from the nipple by a combination of

compression and suction. Efficient breastfeeding

therefore, relies on the child having an adequate length of

free tongue tip, having adequate overall tongue movement,

and also having sufficient flexibility of the floor of the

mouth. Infants with tongue-tie attempt to compensate for

restriction in these components in a number of ways. First,

they use their jaws to increase the compression on the

breast. This is often also accompanied by a shallow latch

onto the breast. The increase in pressure leads to the

mother sensing that the breast is being 'chewed' and in turn

leads to nipple soreness and cracking. As the nipples

become painful, the milk reflex slows and the baby has to

further increase jaw pressure, establishing a vicious circle

of increasingly painful suckling. Secondly, they use their

lips instead of their tongues to move milk from the breast.

This can be observed when the lips are turned outward

rather than inward during breastfeeding. This can lead to

frequent 'delatching' during feeding as well as feeds

becoming prolonged, even if latching is maintained.

One of the other principle reasons that parents request

revision of their child's tongue-tie is the widely held belief

that tongue-tie can impair normal speech development. In 4the study by Messner , 60% of otolaryngologists, 50% of

speech pathologists, but only 23% of paediatricians

believed that tongue-tie is at least sometimes associated

with speech difficulties. Many published cases of tongue-

tie and impaired speech are based on the observation that

established speech difficulties can be associated with

tongue-tie in some children, rather than definite evidence

that it actually causes speech impairment. Certainly

tongue-tie does not seem to be the cause of speech 1) Breast –feeding prevention or delay. However, many clinicians believe that

it can cause articulation difficulties in some patients. If the 2) Speech tongue tip is completely restricted, then perhaps

3) Oral hygieneunderstandably, the articulation of the sounds 't', 'd', 'l', 'th',

4) Social tongue movement and 's' may be affected.

Appearance of tongue when lifted

Elasticity of frenulum

Length of lingual frenulum whentongue lifted

Attachment of lingual frenulum totongue

Attachment of lingual frenulum toinferior alveolar ridge

Function ItemsLateralisation

Lift of tongue

Extention of tongue

Spread of anterior tongue

Cupping

Peristalsis

2 : Round or square1 : Slight cleft in tip apparent0 : Heart or V-shaped

2 : Very elastic1 : Moderately elastic0 : Little or no elasticity

2 : >1 cm1 : 1 cm0 : <1 cm

2 : Posterior to tip1 : At tip0 : Notched tip

2 : Attached to floor of mouth or well below ridge

1 : Attached just below ridge0 : Attached at ridge

2 : Complete1 : Body or tongue but no

tongue tip0 : None

2 : Tip to mid-mouth1 : Only edges to mid-mouth0 : Tip stays at lower alveolar

ridge or rises to mid-mouth only with jaw closure

2 : Tip over lower lip1 : Tip over lower gum only0 : Neither of the above, or

anterior or mid-tongue humps

2 : Complete1 : Moderate of partial0 : Little or none

2 : Entire edge, firm cup1 : Side edges only, moderate

cup0 : Poor or no cup

2 : Complete, anterior or posterior

1 : Partial, originating posterior to tip

0 : None or reverse


22

5,8Oral hygiene/dentition :

Case report

5Social tongue movement :

3,5-10Timing and technique of intervention :

child including simple linear division by scissors or bipolar diathermy (frenotomy or frenulotomy), excision of the Tongue ensures the movement of saliva around the mouth frenulum with simple closure of defect (frenectomy), and and helps to remove pieces of food between our teeth; excision with z-plasty repair (frenuloplasty). Indeed, hence preventing early childhood caries effecting lower elaborate variations of these themes have been incisors teeth. Several groups have advocated removal of recommended including the use of laser and an elaborate tongue-tie if oral hygiene is affected, but no prospective, four-flap z-frenuloplasty.controlled studies are available. Problems with dentition

have been reported with tongue-tie including lower incisor deformity, gingival recession, and malocclusion. A 8 year old girl reported came to the Department of

Pedodontics & Preventive Dentistry at Manav Rachna Dental College, Faridabad, India with history of inability The tongue is used for a wide variety of social activities to protrude the tongue fully and pronounce the words including licking ice creams, playing musical instruments properly. Clinical examination revealed presence of (particularly woodwind), and kissing. All these activities tongue tie. She had the tongue tie persisting since birth. rely on good tongue protrusion and elevation and there are The frenulum was smaller in length making condition a number of reports indicating that these can be impeded known as Ankyloglossia. Inferior surface and tip of the by tongue-tie and in turn improved with tongue-tie tongue showed a notch. No history of such abnormality division. An interesting study, albeit small, of adolescent was present in his family members. Physical and mental and adult patients aged between 14 and 68 years with health was normal. No other facial abnormality was previously untreated tongue-tie, indicated that 93% noted observed. Taste sensations were normal. Anomalous functional impairment and 57% mechanical limitations tongue movements (reduced) were observed when subject such as kissing and licking of lips, and that tongue function was asked to protrude her tongue. Right and left improved both subjectively and objectively in all patients

5 movement were normal. No digestive problem was found. undergoing division in this group . According to the Kotlow Classification of Ankyloglossia , it was Grade III (Severe ankyloglossia) ; According to

The timing of tongue-tie division is largely related to the Hazelbaker Assessment Tool for lingual frenulum indication for division. Clearly if difficulty with function the total appearance score was 07 and the total breastfeeding is the reason for division, it is important that function score total was 09, so significant ankyloglossia this is performed in the neonatal period to enable prompt was diagnosed and surgical intervention was the just re-establishment of breastfeeding and to prevent soreness necessary. Fig 1and cracking of the mother's nipples. When performed in a baby under three months of age, tongue-ties are usually divided without general anaesthesia, and can either be performed with blunt-ended scissors or bipolar diathermy. Topical anaesthesia is applied. The procedure is usually well tolerated with no more distress to the baby than having an injection. The key requirement is that the infant is held as still as possible during the division and that the procedure is abandoned if undue struggling is encountered so as not to risk damage to the underlying salivary ducts. After division with scissors, a small amount of bleeding is encountered, but this is usually self-resolving.

If feeding in the newborn with tongue-tie is normal and weight gain adequate, it is customary for most clinicians to wait until after the age of six months before division. One Bilateral lingual blocks and local infiltrations in the anterior reason for this is that a number of tongue-ties will resolve area were administered. The lingual frenum was clamped 'spontaneously', often by getting stretched or caught on a with a hemostat and incision was given in the transverse tooth. fashion at the base of the tongue to release the attachment

of fibrous connective tissue at the base followed by the In this older age group, division is usually performed under closure in linear direction to completely release the a short general anaesthetic. In addition to being much anterior portion of the tongue. The tongue was retracted kinder for the child, this also allows clear visibility of the superiorly with hands and margins were carefully salivary ducts. A wide number of different procedures undermined and sutured (with 4-0 gut suture) parallel to have been reported for division of tongue-tie in the older

Fig 1. Tongue Tie


23

the midline of the tongue (Fig 2). The movement of tongue after surgery was examined (Fig 3). The patient was 1) Genna C. Tongue-Tie and Breastfeeding. Leaven discharged with postoperative instructions to avoid juices 2002;38(2): 27-29.and to treat discomfort with non-narcotic analgesics.

2) Wallace A.F. Tongue Tie. Lancet 1963; 13: 377-88.Patient was recalled after 48 hours and examined.

3) Kotlow L A. Ankyloglossia (tongue-tie):A diagnostic and treatment quandary. Quint. Int. 1999;30:259-262.

4) Hazelbaker, A. K. The Assessment Tool for Lingual Frenulum Function. Columbus, Ohio: Self-published, 1993.

5) Johnson P R V. Tongue-tie – exploding the myths. Infant 2006;2(3): 96-99.

6) Morowati S, Yasini M , Ranjbar R, Peivandi A, Ghadami M. Familial Ankyloglossia (Tongue-tie): A Case Report. Acta Medica Iranica 2010; 48(2): 123-124.

7) Knox I.Tongue Tie and Frenotomy in theBreastfeeding Newborn. NeoReviews 2010; 11(9):e513-519.

8) Donkor P. a study of 112 cases of tongue tie at the Komfo Anokye teaching hospital. Ghana Med J 2004;38(1): 3-7.

9) Babu H.M. Surgical management of ankyloglossia- a case report. IJCD 2010;1(2):58-61.

10) Kotlow LA. Using the ERBIUM:YAG laser to correct an abnormal frenum attachment in newborns. J Acad Laser dent 2004;12;22-23.

Fig 2 . Division of Tongue Tie.

Fig 3. Immediate Post-Operative.

Fig 4. After 1 month follow-up.

REFERENCES:


24

Abstract

Key Words

Reestablishment of Phonetics, aesthetics, functional efficiency and comfort are the key elements of successful complete denture treatment. However, during complete denture fabrication the phonetic evaluation often takes a back seat. Patients are expected to adapt to new dentures and most of them do adapt within few weeks, but some patients take a longer time to compensate for changes in palatal contour of complete denture. Unfortunately, some patients never adapt to new dentures and continue to have trouble in speech, for such patients an accurate approximation of the palatal rugae has been suggested as one of the ways to improve speech patterns.This case article explains the use of a palatal rugae approximation in auto polymerizing resin to reproduce the functional palatal contours of a maxillary complete denture to improve speech intelligibility.

Phonetics, Palatogram , Palato print, Speech, Palatal contour, Complete denture, individualistic, rugoscopy, speech intelligibility, hindi test sentences.

Malathi Buddhi*, Nikhil Jonwal**

*Professor, Dept. of Prosthodontics, Manav Rachna Dental College, Faridabad

**Intern, Manav Rachna Dental College, Faridabad

Introduction Importance of palatal rugae in prosthodontics:

Palatal rugae: One of the primary objectives of replacement of teeth is restoration of speech. Restoration of speech intelligibility Rugae is the term used in anatomy that refers to a series of in the complete denture patient depends on various factors ridges produced by folding of the wall of an organ. Palatal viz:rugae formed on the hard palate immediately behind the

upper anterior teeth, have been extensively investigated in 1. Tooth positionorder to establish the uniqueness of the palatal rugae to 2. Occlusal planeeach individual, Subsequently the term “Palato print” has

3. Occlusal vertical dimensionemerged that refers to the study of the laterally extended curved ridges (rugae) and grooves on the anterior part of When all above factors are satisfactory or normal, the palate introduction of texture to the palate by an accurate

1 approximation of palate contours can improve speech It is also individualistic, like finger prints. Study of rugae is intelligibilityalso known as 'rugoscopy'.

By definition, articulation is the resonated sound Harrison Allen (1889) suggested the study of palatal prints formed into meaningful speech by the movements and as a method of identification.

interaction of the mandible, lips, tongue, soft palate, Study of the method is advantageous because:2,3

hard palate alveolar ridge and teeth.1. Prints (ridge pattern) do not change during growth.

Speech is formed by passing of air through valves 2. It is protected from trauma due to its situation. formed by approximation of the tongue, lips and soft

3. It is protected from heat by buccal pad of fat and palate to the teeth, hard palate and the alveolar

tongue.processes.

4. Even in twins, the pattern of rugosities may be similar Complete denture contours tend to alter the nature of but not identical.these valves. Complete denture wearers are expected to

Thomas &Kotze have classified palate prints basing adapt to the changed contours and most of them do

on the characteristic of the rugae as follows- adapt, however there are patients who are sensitive to

1. Primary rugae – 5 to 10 mm & 10 mm or more. the change in anatomy and do not achieve satisfactory 2. Secondary rugae – 3 to 5 mm. speech patterns. Such patients can be accommodated

by duplicating the palatal rugae in the denture. 3. Fragmented rugae – less than 3 mm.

ESTABLISHING SPEECH INTELLIGIBILITY IN COMPLETE DENTURE WEARERS


25

Methods: STEP 2 : Final impression made using zinc oxide eugenol after establishing the peripheral seal in low fusing The various methods that have been used to created palatal compound. (Fig:4)rugae in dentures are

1. Use of pre formed palatal pattern. (fig: 1,2)

Fig: 1. Pre formed wax pattern.

Fig: 4. Final impression.

STEP 3 : Master cast is made using dental stone. (Fig:5)

Fig: 2. Wax pattern adaptation over waxed up denture.

2. Exact palatal duplication using auto polymerizing on impressions ( primary or final ). (fig:3-23) Fig: 5. Master cast.

13. Use of adapted tin foil method. (fig: 24-28) STEP 4 : Separating media is applied over master cast.

(Fig:6)In this article, the second method has been described

in detail

Case #1 (fig 3-19)

STEP 1 : Primary impression made using impression compound. (Fig:3)

Fig:6. Seprating media application.

STEP 5 : A thin layer of Auto polymerizing resin is applied over master cast and final impression in the region of the

Fig:3. Primary impression. palatal rugae using sprinkle on method. (Fig:7)


26

STEP 9 : Teeth arrangement is done after recording jaw relations of the patient.(Fig:11)

Fig:7. Auto polymarizing resin application.

Fig:11. Palatal rugae in waxed up denture.STEP 6 : Final impression is placed over master cast and mild finger pressure is applied in dough of auto STEP 10 : Wax up and carving done after Try In. With polymerizing resin. (Fig:8) anterior palatal surface left uncovered with wax.(Fig:12)

Fig:8. Compression in dough stage by mild finger pressure.

STEP 7 : Acrylised anterior portion of palate is separated from master cast and final impression. (Fig:9) Fig:12. Waxed up denture.

STEP 11 : In flasking and pouring over palatal area is done with dental stone to get better surface details. (Fig:14)

Fig:9. Denture base tissue surface.

STEP 8 : Completed Denture base shows depression of rugae on the internal (tissue) surface and elevation of rugae on external surface. (Fig:10)

Fig: 14. Pouring with dental stone.

STEP 12 : Dewaxing packing and heat curing done.

( Fig:15)

STEP 13 : Trimming and polishing done, No polishing of

the palatal area should take place. The tongue finds it easier

to identify the somewhat irregular and rough region rather

than a slippery and smooth area. The patients generally do Fig :10. Denture base external surface (with palatal rugae). not complain of discomfort.4 (Fig:16,17)


27

Fig: 19. Denture palate (after dentue placement) .Fig: 15. Dewaxing

Case #2 (fig 20-23)STEP 14 : Denture insertion is done and patient is checked

All the steps done are same as written above in case # 1 for any error in articulation.Waxed up denture and polished denture are shown in Fig :

20-23

Fig :16. Polished maxillary denture.

Fig : 20. Palatal rugae in waxed up denture.

Fig:17. Polished maxillary denture.5 Fig: 21. Palatal rugae in polished denture.Table : 1 (Fig:19)

5Examples of error in articulation :

*An inappropriate human noise. Fig: 22. Polished denture with rugae.

Error type Examples Effects

Substitution "think" for “sink" /TH/replaces /S/; wrong word

Omission "ink" for "sink" /S/is omitted; wrong word

Distortion "ink"* for "sink" /S/ is distorted ; word is unintelligible


28

Fig : 26. Auto polymerizing acrylic resin is applied to

pattern to fabricate rugae.Fig : 23. Polished denture with rugae.

Fig : 24. Tinfoil trimmed and adapted to cast with Fig : 27. Acrylic resin rugae is secured to existing prominent rugae. prosthesis with auto polymerizing acrylic resin.

Fig : 25. Sealing of tinfoil pttern to palatal area of Fig : 28. Completed addition of rugae.completed wax-up.

Phoneme Contact Test sentence

p/b/m Bilabial contact Bobby popped my balloon.Pehelan bada mota tha.

k/g/ng Linguo-velar contact Go get the coat and bring it back.Kabutar gaya England .

t/d/n Linguo -alveolar contact Tom did not do it.Tanu dawa lene gaya?

f/v Labio - dental contact Father found some coffee.Phal aur phool vaha hain.

Th Linguo -dental contact They thought there were three.Thaanedar thane mein tha.

J, ch Linguo- palatal contact Jack jumped by the children.Jalebi ko chidiya nechabaya..

L Lateral lingual aperture The little lamp was lit in school.Laalu lajawab ladoo laya.

R Central lingual aperture Roy rogers horse was Trigger.Roti raat ko khana.

W Widening labial aperture Will you go with William?Waha kya hai?

Y Widening lingual aperture You and your young sister will go next year.Yaha subji hai.

S, z Linguo alveolar contact and narrow air blade Six sisters saw zebra in the zoo.Sub zoya ke saath gaye.

sh, zh Linguo- palatal contact and wide air blade She will wash the dish in the garage.Sharbat zyada lo.

Table : 2Test sentences for evaluation of articulatory factors involved in consonants sounds6along with suggested Hindi sentences:


29

Discussion:

References:

Conclusion

locational cues to patients who are unable to adapt to smooth and slippery contours of the polished palatal Speech evaluation must not be limited to testing isolated surface of the denture has been described.sounds or words, but the Prosthodontics must proactively

evaluate connected speech in order to get an accurate Additionally, Ten sentences in Hindi have been suggested along with English ones in order to facilitate testing of picture of the tongue-palate relationships as has been conversational speech in patients who are not well versed suggested by Chierici and Lawson. For speech purposes, in English.static positional concepts of incisor relationships and

denture contours should not be emphasised at the expense The technique for duplication of palatal rugae, described of dynamic consideration. Each patient's condition should in this article has been developed by Nikhil Jonwal.be evaluated to assure that the denture can provide an optimal environment for the rapid, coordinated muscle

1 Forensic medicine and toxicology. By R.N. movements requisite for acceptable speech. Table: 2 shows

Karmarkar.a list of test sentences that can be used to evaluate speech.

2 Christina A. Gitto, Salvatore J. Esposito and Julius M. Keeping in mind the fact, that the local population may not Draper.; A simple method of adding palatal rugaeto a be able to speak the English sentences comfortably, Hindi complete denture: J PROSTHET Dent 1999;81:237-alternatives have been created. 9.

3 Curtis TA, BeumerJ . ; Maxillofacial rehabilitation It is important to establish that the speech is indeed caused prosthesis and surgical consideration: St. Louis : by the denture and that there is no articulatory problem Ishiyaku Euro America 1996;285-9unrelated to dental status and a hearing loss must be ruled

4 John M. Palmer ; structural changes for speech out. Once other factors causing speech problems improvement in complete denture fabrication.: J unrelated to dental status are ruled out, the patient must be

given waiting period for accommodation to the fitting of PROSTHET DENT 1979;41(5) :507-510the dentures. It has been suggested that this period be at 5 John M. Palmer ; analysis of speech in prostho

7least 4 weeks by Lord and others and that the period practice : J PROSTHET DENT 1974;31:205-14should follow the initial placement of dentures. This 6 George Chierici and Lucie Lawson. ; Clinical period allows for the completion of basic accommodation

consideration in prosthodontics: Perspectives of the of the oral structures, especially the tongue, to the new

prosthodontist and speech pathologist : J environment.

PROSTHET Dent 1973;29: (1);29-39The denture should be adequate within the dynamic

7 Lord J: An evaluation of speech production in framework of speech, Silverman has suggested that the

immediate denture patients utilising continuous patient should be evaluated and observed in

dynamic palatography and tape recordings, M.S.D 8conversational speech at the try in appointment . In order thesis, University of Washington, 1970.to avoida prosthesiswhich accommodates only static

8 Silverman, S.I.: Oral Physiology, St.Louis, 1951, The positional speech elements. Use of an approximation of C.V. Mosby Company, pp.428-429Palatal rugae to provide texture to the palate and provide

Phoneme Contact Test sentence

p/b/m Bilabial contact Bobby popped my balloon.Pehelan bada mota tha.

k/g/ng Linguo-velar contact Go get the coat and bring it back.Kabutar gaya England .

t/d/n Linguo -alveolar contact Tom did not do it.Tanu dawa lene gaya?

f/v Labio - dental contact Father found some coffee.Phal aur phool vaha hain.

Th Linguo -dental contact They thought there were three.Thaanedar thane mein tha.

J, ch Linguo- palatal contact Jack jumped by the children.Jalebi ko chidiya nechabaya..

L Lateral lingual aperture The little lamp was lit in school.Laalu lajawab ladoo laya.

R Central lingual aperture Roy rogers horse was Trigger.Roti raat ko khana.

W Widening labial aperture Will you go with William?Waha kya hai?

Y Widening lingual aperture You and your young sister will go next year.Yaha subji hai.

S, z Linguo alveolar contact and narrow air blade Six sisters saw zebra in the zoo.Sub zoya ke saath gaye.

sh, zh Linguo- palatal contact and wide air blade She will wash the dish in the garage.Sharbat zyada lo.


30

Abstract

Key words

Endodontic literature reports the incidence of middle mesial canal of mandibular first molar of 2.07% to 13.3%.The middle mesial canal may be independent with its own apical foramen or may join with either of the 2 main canals. This article reports the case of root canal treatment in mandibular first molar containing 3 separate canals in its mesial root.

Middle mesial canal, mandibular first molar ,unusual

Dr Ravjot Ahuja* , Dr Arundeep Singh**, Dr Swati Sanghi***,

Dr Abhinav Kumar***, Dr Neha Juneja*

*senior lecturer

**Professor

***Reader

Department of conservative dentistry

Introduction

A thorough knowledge of both the external and internal

anatomy of teeth is an important aspect of root canal

treatment. However, in everyday endodontic practice,

clinicians have to treat teeth with atypical configurations.

Extra roots or root canals if not detected are a major 1,2

reason for failure. Unusual canal anatomy associated with

the mandibular first molar has been reported in several 3studies.

In 1974, Vertucci, Williams and Barker et al. described 4, 5presence of middle mesial canal. In a radiographic study

of extracted teeth Goel et al. reported mandibular first Fig. 1. Radiograph-Pretreatmentmolars had three mesial canals in 13.3% of specimens,

four mesial canals in 3.3% specimens, and three distal The tooth was isolated using a rubber dam and an 6

canals in 1.7% of specimens. In a clinical evaluation of endodontic access cavity was established and revealed 145 mandibular first molars Fabra Campos found four FIVE distinct orifices- 3 mesially (mesiobuccal, middle

molars (2.07%) with five canals, i.e., three in the mesial root and mesiolingual) and 2 distally. Fig. 27

and two in the distal.

In none of these four cases the middle mesial canal shows

an independent course and foramen. The occurrence of

three independent canals in the mesial root was reported

by Pomeranz et al and Beatty and Krell described a

mandibular first and second molar with three independent 8, 9 canals in the mesial root. The present report describes

root canal treatment in a mandibular first molar containing

three independent canals in the mesial root.

A 20 year old female patient reported to the dept. of Conservative dentistry with a complaint of pain in lower back tooth region. On intraoral examination, the tooth was found to be deeply carious.

Fig. 2. Rcanal OrificesAn intra-oral radiograph of the tooth reveals a deep

The canals were explored with a #15 K-file and revealed carious lesion in close proximity to the pulp and periapical four distinct orifices, three mesially and one distally. Fig. 3radiolucent area. Fig. 1

AN UNUSUAL CANAL ANATOMY OF THE MANDIBULAR FIRST MOLAR: CASE REPORT


31

Successful endodontic treatment depends on entering the pulp chamber, cleaning, shaping and obturating the canal system. Each of these procedures is very important, but any anatomical variation that is present in any of the teeth needs to be detected in order to avoid failure of the canal treatment. The present report confirms that the third canal in the mesial root of mandibular first molars and to locate it, it must be sought along the line between the two mesial canals after deroofing of the pulp chamber and of any cervical stenosis in this zone that might cover the opening of the canals, using dental burs.

Fig. 3. Instrumentation Instrumentation is one of the key factors in the success of endodontic therapy; therefore, the clinician should be Cleaning and shaping was performed and then canals were aware of the incidence of these extra canals in the obturated with gutta-percha and sealer AH plus using cold mandibular first molar. The clinician can only then lateral condensation technique. The tooth was restored perform a thorough examination of the pulp chamber to with composite and full coverage crown. Fig. 4, 5insure complete debridement of all canals. This increases the chance for long-term successful endodontic therapy

This case report describes mandibular first molar with an unusual number and arrangement of canals. It is characterized by the presence of three canals in the mesial root with all canals having separate orifices in the pulp chamber floor.

1. Slowey RR. Radiographic aids in the detection of extra Fig. 4. Intratreatment Fig. 5. Post Obturation root canals. Oral Surgery, Oral Medicine, Oral

Pathology1974;37(5):762-72.

2. Fava LRG. Root canal treatment in an unusual maxillary Many dental clinicians have the perception that a given first molar: a case report. International Endodontic

tooth will contain a predetermined number of roots Journal 2001;34 (8): 649-53.

and/or canals. Careful evaluation of research material has, 3. Baugh D, Wallace J. Middle mesial canal of the however, shown deviations from the norm in tooth

mandibular first molar: a case report and literature 7morphology are not uncommon . Therefore, when root review. Journal of Endodontics 2004; 30(3):185-6.

canal treatment is to be performed, the clinician should be 4. Vertucci FJ. Root canal anatomy of the human aware of abnormality in the root canal.

permanent teeth. Oral Surgery, Oral Medicine, Oral Middle mesial or multiple canals in the mesial root of Pathology1984;58(5):589-99. mandibular molars have been reported in the literature as 5. Walker RT. Root form and canal anatomy of

3,4having an incidence of 2.07% up to 13.3% . The canals mandibular first molars in a southern Chinese may be independent throughout their course in the root population. Dental Traumatology1988;4(1):19-22. with an apical opening of their own, or they may join either 6. Goel N, Gill K, Taneja J. Study of root canals of the two or more common main canals. Many authors configuration in mandibular first permanent molar. agree on the presence of three foramens in the mesial root Journal of the Indian Society of Pedodontics and but few report three independent canals, which presents Preventive Dentistry 1991; 8(1):12-4. itself as a rare anatomical variant. 7. Fabra-Campos H. Unusual root anatomy of Even though anatomical variations in mandibular first mandibular first molars. Journal of Endodontics molars are documented in the literature, variations in the 1985;11(12):568-72. anatomy of these teeth are not recognized by a great many 8. Pomeranz HH, Eidelman DL, Goldberg MG. dentists. Variations in the mesial root of mandibular first Treatment considerations of the middle mesial canal of molar can be identified through very careful observation mandibular first and second molars. Journal of of angle radiographs. Buccolingual views, 20º from mesial Endodontics1981;7(12):565-8. and 20º from distal, reveal the basic information on the 9. Beatty R, Krell K. Mandibular molars with five canals: tooth's anatomy and root canal system required for report of two cases. Journal of the American Dental endodontic treatment. Association 1987;114(6):802.

Conclusion

References

Discussion


32

Abstract:

Authors:

Displaced fracture of zygomatic bone can result in significant functional and aesthetic disability. Therefore the treatment must achieve adequate and stable reduction at fracture site so as to restore the complex multi-dimensional relationship of zygoma to surrounding craniofacial skeleton. Many experimental biophysical studies have compared stability of zygoma after one, two and three point fixation. We operated both patients with one miniplate following one point fixation principle and obtained good results.

Dr Amit Gandhi,* Dr Ashish Garg,** Dr Dimple Grover,** Dr Ashim Aggarwal***

***Professor and HOD-dept of oral and maxillofacial surgery, MRDC, Faridabad

**Reader-dept of oral and maxillofacial surgery

*Senior lecturer- dept of oral and maxillofacial surgery

Introduction

Case Reports:

wheeler one day before. The maximum impact of the fall

was on right side. Patient presented with the circumorbital Fracture of the Zygomatic-complex is among the most 1,2 ecchymosis & subconjunctival haemorrhage (Fig.1). On frequent maxillofacial trauma. The zygomatic complex is

examination worm eye view showed decreased responsible for the midface contour and for protection of 3 prominence on the right side (Fig.2) & tenderness was orbital contents. The etiology of ZMC fractures include

present on F-Z suture & zygomatic arch area. A CT was road traffic accidents, assault, falls, sports and missile done to confirm the diagnosis for management of ZMC injuries, their relative contribution varies from region to

4-9 fracture. Axial view of the CT showed displacement of region.fractured zygomatic arch(Fig.3), on viewing the coronal

The integrity of zygoma is critical in maintaining normal section considerable displacement was present at F-Z

facial width and prominence of the cheek. Sicher & suture. Reduction was achieved using keen`s approach.

Debrul were the first to depict facial anatomy & recognize Decision was taken to place a single plate at F-Z suture

the structural buttresses of the facial skeleton. These (Fig.4) as zygomatic arch invariably does not get displace

buttresses give zygoma an intrinsic strength such that after reduction. The patient was kept on follow up for one

blows to cheek usually result in fracture of the ZMC at the year and the reduced fracture was found to be completely

suture lines and less commonly the body of zygomatic stable during the follow up period. Patient had normal

10bone. facial symmetry and mouth opening in the follow up Most of the patients presented with ZMC fractures were period. males. The male to female ratio in developed countries is

3-5:1 whereas in developing countries, the ratio on an 11,12

average is 10-40:1.

Though 3 points fixation at F-Z suture; infra-orbital rim &

zygomatic-maxillary buttress conferred maximum

stability. Similar results were found by O' Hara et al,

different studies have been conducted to show that one

point fixation (Fujioka), two point fixation (Haiderz) also 13,14 show good results. In the cases discussed here we used

one point fixation and achieved good aesthetic &

functional stability.

Case Report I :

A 55 yr old male presented to our facility with fracture of Fig. 1.ZMC of the right side. Patient gave a history of fall from 2

SURGICAL MANAGEMENT OF ZYGOMATIC COMPLEX FRACTURES


33

Fig. 2.

Fig.5.

The zygoma is the 2nd most common site of facial bone fracture. The vast majority of zygomatic fractures occur in

15men in 3rd decade of life.

In 1994, Convington et al reviewed 259 patients with zygomatic fractures and found that ZMC fractures occurred in 78.8% of patients. Isolated orbital rim fracture occurred in 10.8% of patients & isolated arch fracture occur in 10.4% of patients. Among isolated arch fractures

16Fig. 3. 59.3% were displaced or comminuted.

The architectural pattern of zygomatic bone allows it to withstand blows of great forces without fracture, but usually gets separated from adjacent bones near its suture lines. The zygomatic bone may get separated from its four articulations, resulting in a zygomatico maxillary complex, zygomtaic complex or orbito zygomatic complex

15,17,18fracture.

Disruption of zygomatic position also carries psychological, aesthetic & functional significance, causing impairment of ocular & mandibular function.The fracture of zygomatic bone can result in restricted mouth opening Fig.4.due to impingement on the coronoid process & ocular

Case Report II :disturbances as a result of inferior displacement of orbital

A 32 yr old male with history of RTA one day before came contents. Therefore for both cosmetic and functional to our facility. The patient presented with bruising on the reasons it is manadatory that zygomatic bone injury should face along with circumorbital ecchymosis & 19

be properly diagnosed and adequately managed. subconjunctival haemorrhage (Fig 5). Examination

Radiographic examination in fracture of the zygomatic revealed limited mouth opening & tenderness in the complex appears somewhat unresolved. Pogrel et al buttress & infraorbital area. A CT was done to confirm the evaluated the efficacy of a single radiograph to screen for diagnosis for management of the fractured complex. The midface fracture & concluded that a single 30° coronal view showed displacement at the zygomatico-

maxillary buttress & axial view showed displacement at the occipitomental radiograph (augmented with CT scans) can 20arch as well as fracture of nasal bone on the right side. identify all midface fractures requiring treatment.

Reduction was achieved using keen`s approach. A single The most frequently, ZMC fracture`s at the zygomatico-point fixation was done that zygomatico-maxillary

maxillary and zygomatico-frontal sutures (38.8%). As the buttress for stabilization and closed reduction and

suture lines are the weak points of the bone. it is unusual stabilization was done for nasal fracture.The patient was 21for the body to be fracture.kept on follow up for one year and the reduced fracture

Skeletal healing of displaced zygomatic bone fragments was found to be completely stable during the follow up after insufficient fracture reduction results in facial period.

Discussion:



asymmetry. Accurate assessment of the positon of 7. Klenk G, Kovacs A. Etiology and pattern of facial zygomatic bone in relation to the cranial base posteriorly & fractures in the United Arab Emirates. J Craniofac Surg. midface anteriorly is key to accurate repair of midfacial 2003;14:78-84.

22 fractures. 8. Adebayo ET, Ajike OS, Adekeye EO. Analysis of the Three principle buttresses need to be considered are pattern of maxillofacial fractures in Kaduna, Nigera. nasomaxillary buttress, pterygomaxillary buttress & BrJ Oral Maxillofac Surg. 2003;41:396-400.zygomatico-maxillary buttress. Another important

9. Motamedi MH. An assessment of maxillofacial landmark with respect to zygomatic fracture is the

fractures: a five-year study of 237 patients. J Oral sphenozygomatic junction. The alignment of the zygoma

Maxillofac Surg. 2003;61:61-64.with the greater wing of sphenoid in the lateral orbit is

10.Sicher H, DeBrul E L. Oral Anatomy. 5th ed. St. Louis: critical for determining adequate reduction of zygomatic Mosby; 1970. p. 78.fractures. Reducing the three points that make up the

buttresses also helps to ensure proper alignment of the 11.Adekeye EO: Fracture of zygomatic complex in zygoma and proper reduction of other facial fractures Nigerian patient. J Oral Surg 1980, 38:596–599.

19present. 12.Foo GC: Fractures of the zygomatic-malar complex: a Any post reduction displacement of zygoma can result in retrospective analysis of 76 cases. Singapore Dent J malar asymmetry. The biomechanics of facial skeleton 1984, 9:29–33were investigated & discussed by Rudderman & Mullan.

13.Fujioka M, Yamanoto T, Miyazato O, Nishimura G: According to them fractured zygomatic segment has six

Stability of one-plate fixation for zygomatic bone possible direction of motion- translation across x,y and z

fracture. Plast Reconstr Surg 2002, 109:817–818.axis, & rotation about x,y, & z axis. A miniplate applied

14.Haider Z: Fractures of the zygomatic complex in South across the frontozygomatic suture will resist translatory East Region of Scotland. Br J Oral Surg 1977–78, movement & also rotation along an axis perpendicular to

23 15:265–267the plane of miniplate because of width of the plate.

15.Ho V: Isolated bilateral fractures of zygomatic arches: In the cases presented, we preferred to use one point report of a case. Br J Oral Maxillofac Surg. fixation at F-Z suture or Zygomatico-maxillary buttress. 1994;32:394–395.

16.Covington D S, Wainwright D J, Teichgraeber J F, Parks The fractures of ZMC are 2nd most common of facial D H. Changing patterns in the epidemiology and fractures. Adequate reduction & stabilization is necessary treatment of zygoma fractures: 10-year review. J for maintenance of facial symmetry. A single point fixation Trauma. 1994; 37:243–248. is done to achieve adequate stabilization. We did not prefer

2 or 3 point fixation in our cases as there are considerable 17.Medvedev IA, Sivolapov KA et al: The use of titanium evidence in the literature about the post operative stability devices in treating fractures of the zygomatico-orbital of fracture after one point fixation. Moreover increased complex. Stomatologia(Mosk) 1993; 72(1):19-23.surgical scars over the face & escalating cost of the

18.Crowe WW: Treatment of depressed fracture of hardware prevented us from using two or three point

zygomatic bone. J Oral Surg 1952;10: 3fixation. In our experience one point fixation was found to

19.Rohrich RJ, Watumull D: Comparison of rigid plate be adequate although further studies need to be versus wire fixation in the management of zygoma

fractures: a long-term follow-up clinical study. Plast 1. Fasola AO, Obiechina AE, Arotiba JT. An audit of mid-

Reconstr Surg 1995, 96(3):570–575.facial fractures in Ibadan, Nigeria. Afr J Med Med Sci.

20.Pogrel MA, Podlesh SW, Goldman KE. Efficacy of a 2001;30:183-186.single occipitomental radiograph to screen for mid-2. Hollier LH, Thornton J, Pazmino P, et al. The facial factures. J Oral Maxillofac Surg. 2000;58:24-26.management of orbitozygomatic fracture. Plast

Reconstr Surg. 2003;1 1 1:2386-2392. 21.Banks P, Brown A. Fractures of the facial skeleton. 1 st

ed. Oxford: Wright. 2001;40-155.3. Jansma J, Bos RR, Vissink A. Zygomatic fractures. Ned TijdschrTandheelkd. 1997;104:436-439. 22.Majeed Rana, Riaz Warraich, Salman Tahir et al.

Surgical treatment of zygomatic bone fracture using 4. Afzelius LE, Rosen C. Facial fractures. A review of 368 cases. Int J Oral Surg. 1980;9:25-32. two points fixation versus three point fixation-a

randomised prospective clinical trial. Trials 2012, 13:36 5. Oji C. Jaw fractures in Enugu, Nigeria. 1985- 1995. BrJ doi:10.1186/1745-6215-13-36Oral Maxillofac Surg. 1999;37:106-109.

23.Rudderman RH, Mullen RL: Biomechanics of facial 6. Banks P, Brown A. Fractures of the facial skeleton. 1 st ed. Oxford: Wright. 2001;40-155. skeleton. Clin Plast Surg 1992,19:11–29.

Conclusion:

References:


ABSTRACT

Key Words

Periodontal diseases are attributable to multiple infectious agents. The aim of periodontal treatment is to arrest the inflammatory disease. Chlorhexidine has been used as an effective adjunct in treatment for periodontal diseases. Chlorhexidine is the most effective chemical antiplaque agent and is considered as a gold standard anti plaque agent.

Periodontal Dieseases, Chloshexidine, Antiplaque agent

Dr. Preeti Upadhyay, MDS*; Dr. Pooja Palwankar, MDS**; Dr.Vandana S. Chadha, MDS***,

Dr. Kapil Arora****, Dr. Ashish Verma, MDS****, Dr. Nipun Dhalla, MDS*

* Senior lecturers,Department of Periodontology, MRDC

** Prof & Head, Department of Periodontology, MRDC

*** Prof, Department of Periodontology, MRDC

**** Reader, Department of Periodontology, MRDC

Introduction

Mechanism of Action:

Structure of Chlorhexidine

Properties of An Antiplaque agent:

Microbiological Activity

� Disruption of preformed bacterial masses

� Maintenance of a state of antimicrobial activityChlorhexidine was first developed in the 1940s by Imperial Chemical Industries, England and marketed in 1954 as an Chlorhexidine appears to meet all the above criteria, which

1,2antiseptic for skin wounds. Later, the antiseptic was more explains its superior antiplaque efficacy. In addition widely used in medicine and surgery including obstetrics, Chlorhexidine's exceptional antiplaque activity is gynaecology, urology and presurgical skin preparations for attributed to its ability to adsorb onto tooth surfaces and both patient and surgeon. Use in dentistry was initially for desorb from there gradually, providing a timed release of

4presurgical disinfection of the mouth and in endodontics. the antimicrobial agent (substantivity).

Plaque inhibition by chlorhexidine was first investigated in Up to 30% of chlorhexidine in an oral rinse may be 1962 by Schroeder but the definitive study was performed retained in the oral cavity following a single mouth rinsing,

3by Loe in 1976. This study showed that rinsing for 60 with a retention half-life of 63 minutes and residual 4seconds twice per day with 10ml of 0.2% chlorhexidine amounts detectable as long as a week later.

gluconate solution, in the absence of normal tooth cleaning inhibited plaque regrowth and the development

Chlorhexidine has two positive charges on either side, the of gingivitis.

molecule attaches to the pellicle by one cation (thereby readily adsorbing to the tooth surface), leaving the other cation free to interact with bacteria attempting to colonize the tooth surface. Once adsorbed, unlike some other antiseptics, chlorhexidine shows a persistent action lasting in excess of 12 hours. Chlorhexidine also binds to the negative groups on the bacterial cell surface, thereby preventing the bacteria from adhering to the tooth pellicle Chlorhexidine, a chlorophenyl biguanide with antibacterial surface. Additionally, chlorhexidine has the potential to action is a symmetrical molecule consisting of 4-displace calcium from sulfate groups in the plaque, chlorophenyl rings and two biguanide groups connected

5by a central hexamethylene bridge with the two positive disrupting the structure of established plaque.

charges on either side of the hexamethylene ring. The antiseptic binds strongly to bacterial cell membranes.

Chlorhexidine is available in three forms – as digluconate, At low concentration, this results in increased permeability

acetate and hydrochloride salts. The digluconate and with leakage of intracellular components including acetate salts are water soluble, while chlorhexidine potassium (bacteriostatic action) . At high hydrochloride is sparingly soluble in water. concentration, chlorhexidine causes precipitation of

5bacterial cytoplasm and cell death (bactericidal action) .

An ideal antiplaque agent should have certain specific properties to enable maximal drug efficacy Animal and human studies have demonstrated that

chlorhexidine administered at a concentration of 0.2% as � Prevention of bacterial adhesion

CHLORHEXIDINE A BOON TO DENTISTRY-A REVIEW

36

an oral rinse effectively inhibits the formation of dental d. Tooth pastes3

plaque, calculus and gingival disease. Chlorhexidine is difficult to formulate into tooth paste.

Chlorhexidine gluconate is effective against a wide range More recently, a 1% CH tooth paste with and without

of vegetative gram positive, gram negative bacteria, yeast, fluoride was found to be superior to the control 12fungi, facultative anaerobes and aerobes and certain product for the prevention of plaque and gingivitis.

viruses like HIV. It is not effective against spores. Its e. Varnishesactivity is not seriously affected by the presence of organic

Chlorhexidine varnishes have been used mainly for matter. It has been demonstrated that it can reduce the 13

6 prophylaxis against root caries.salivary bacterial flora by 85 – 95%.

f. Chewing gumsMicroorganisms with high susceptibility to chlorhexidine

include some Staphylococci mutans, Streptococcus Chewing gums containing chlorhexidine has been 14salivarius, Candida albicans, E. coli, Selenomonas and found to have anti plaque property.

anaerobic propionic bacteria. Streptococcus sanguis has Chewing gums may be suitable vehicles for the delivery

moderate susceptibility. Microorganisms with low of xylitol and chlorhexidine acetate, both of which can

susceptibility to chlorhexidine include proteus strains, aid oral health. Chewing xylitol and sorbitol sweetened

pseudomonas, klebsiella and gram negative cocci.gum after meals and snacks may reduce plaque

14� The minimum inhibitory concentrations for S. mutans, formation and gingival inflammation.salivarius and milleri are about 4 g/ml, for S. sanguis, 8 –

g. Chlorhexidine chip16 g/ml and for S. mitior strains 4 to over 64 g/ml of

Periochip is a small, orange – brown rectangular chip Chlorhexidine.7rounded at one end for insertion into periodontal

pockets. The chlorhexidine chip is a small Chlorhexidine has been formulated into a number of biodegradable film of hydrolyzed gelatin matrix into products which has been incorporated 2.5mg of chlorhexidine a. Mouth Rinses gluconate cross linked with glutaraldehyde and also

glycerin and water. Each periochip weighs Aqueous or alcoholic solutions of 0.2% chlorhexidine approximately 7.4mg. The chip resembles a baby's were first made available for mouth rinse products for finger nail measuring approximately 4 x 5mm and twice daily use in Europe.0.35mm thickness.

A 0.1% mouth rinse product also became available, Periochip releases chlorhexidine in vitro in a biphasic however, the efficacy of the product is less than would manner, initially releasing approximately 40% of the be expected from a 0.2% solution.chlorhexidine within the first 24 hours and then Later in US, a 0.12% mouth rinse was manufactured, releasing the remaining chlorhexidine in an almost but to maintain the optimum 20mg dose derived from

15,16linear fashion for 7 – 10 days .10ml of 0.2% rinses, the product was recommended as

9 This release profile may be explained as an initial burst a 15ml rinse.effect, dependent on diffusion of chlorhexidine from b. Gelsthe chip, followed by a further release of chlorhexidine

A 1% chlorhexidine gel product is available and can be as a result of enzymatic degradation.

delivered on a tooth brush or in trays. The distribution

of gel around the mouth appears to be poor and

preparation must be delivered to all tooth surfaces to be 1. As a chemical antiplaque agent along with scaling and effective. Now 0.2% and 0.12% chlorhexidine gel have root planing or during presurgical preparation of

10 17become available. periodontal patients.

c. Sprays 2. Post surgical therapy

0.1% and 0.12% chlorhexidine sprays are commercially The first few weeks following periodontal surgery available in some countries. Studies with 0.2% sprays present a challenge to patient relative to plaque control have revealed that small doses of approximately 1 – since the presence of sutures and dressings make it 2mg delivered to all tooth surfaces produces similar difficult to maintain good oral hygiene. Chlorhexidine plaque inhibition as a rinse with 0.2% chlorhexidine. offers significant benefits to the patient as measured by

better plaque control and improved wound healing Sprays appear particularly useful for the physically and 1811 when used following periodontal surgery.mentally handicapped groups.

8 Chlorhexidine Products (Flotra et al, 1973)

Clinical uses of chlorhexidine in dentistry



3. Aerosol reduction adjunctive preventive therapy to other antimicrobial drugs for patients with such conditions; however, it is Bacteria laden aerosols are generated in dental of little or limited value once the infections are operatories, especially during use of hand pieces and established.sonic and ultra sonic scalers. Preprocedural rinsing with

antimicrobial mouth rinses can significantly reduce 11. High caries risk patients19

both aerobic and anaerobic bacteria in these aerosols. Chlorhexidine rinses or gels can reduce considerably the Streptococcus mutans in individuals who are caries 4. Oral mucositis

13prone.Chlorhexidine significantly reduces both the incidence and severity of mucositis associated with 12. Prophylaxis for bacterial endocarditis patientsimmunosuppressive therapy. The American Heart Association in the 1990 revision Chlorhexidine mouth rinses and gel is also effective of its recommendations for prevention of reducing the incidence, duration and severity of endocarditis, stated that gingival crevicular irrigation

6 with effective antimicrobials may be used as an adjunct recurrent minor aphthous ulceration.to antibiotic prophylaxis in patients who are also at a 5. In the treatment of oral candidiasishigh risk and/or have poor oral hygiene. Since the

Chlorhexidine has been recommended in the treatment source of bacteremia is mainly bacteria around teeth, 6of candidal associated infections. both supragingivally and subgingivally, this is a logical

66. Implant maintenance recommendation.

Peri implantitis is becoming more common as increasing numbers of implants are placed. The

� Chlorhexidine's most clinically undesirable effect is its microbiology of early peri – implantitis is similar to that ability to cause brownish discoloration of the teeth and seen with gingivitis. Chlorhexidine is effective in 9the dorsum of the tongue on prolonged usage. reducing these microorganisms, so they should be used

Possible mechanisms for staining:adjunctively in patients with implants who are having 20 © Non enzymatic browning reaction between certain problems with plaque control.

carbohydrates and amino compounds – The 7. For oral hygiene and gingival health maintainence 10 Maillard reaction.in the mentally and physically handicapped.

© Degradation of the chlorhexidine molecule to Chlorhexidine has been found to be particularly useful release parachloraniline.in institutionalized mentally and physically

© The formation of pigmented metal sulfides.handicapped groups, improving both oral hygiene and gingival health. © Reactions between food and beverage component

and chemical antiplaque agent.8. Removable and fixed orthodontic appliance 13wearers � Chlorhexidine may also interfere with taste function.

Salt taste appears to be preferentially affected to leave Plaque control in the early stages of orthodontic 8

food and drinks with a rather bland taste.appliance therapy may be compromised and chlorhexidine can be prescribed for the first 4 – 8 � Chlorhexidine also enhances supragingival calculus weeks. formation. This is due to precipitation of salivary

proteins onto the tooth surface, thereby increasing the 9. In patients with jaw fixationthickness of the pellicle or by precipitation of inorganic Oral hygiene is particularly difficult when jaws are

8salts on to the pellicle layer.immobilized by such methods as intermaxillary

� In a very few subjects, painful desquamation of the oral fixation. Chlorhexidine has been shown to reduce mucosa have been reported. It appears to be an markedly the bacteria load which tends to increase idiosyncratic reaction and concentration dependent.during jaw immobilization and improves plaque

18control. � Unilateral or bilateral parotid gland swelling after long

term use has been reported but this reversed when 10.Medically compromised individuals and geriatric rinsing was discontinued. patients

A number of medical conditions requiring bone marrow transplantation and/or radiotherapy, blood Good oral hygiene is a key to prevent dental diseases. dyscrasias such as leukemia, HIV & AIDS, predispose Mechanical plaque control plays an important role but is individuals to oral infection including acute and chronic not fully successful thus use of chemical antiplaque agents

6candidal infections. Chlorhexidine appears useful as an as an adjunct, plays an important role. Chlorhexidine is the

SIDE EFFECTS

Conclusion

38

most effective and commonly used chemical aid. It is 11.Needleman I.G. Controlled drug release in available readily in market for professional and patient use, periodontics: A review of new therapies. Br Dent J

1991; 170:405-407. but its irrational use should be prevented.

12.S. Jenkins, M. Addy, R. Newcombe. T he effects of a chlorhexidine toothpaste on the development of

1. Löe H, Anerud A, BoysenH, Smith M. The Natural plaque, gingivitis and tooth staining. J Clin Periodontol

History of Periodontal Disease in Man the Rate of 1993;1:59-62.

Periodontal Destruction Before 40 Years of Age. J 13.Nurit Beyth, Meir Redlich, Doron Harari, Michael Periodontol1978; Dec: 607 – 620.

Friedman, Doron Steinberg. Effect of sustained-2. Greenstein G, Berman C and Jaffin R. Chlorhexidine release Chlorhexidine varnish on Streptococcus

An Adjunct to Periodontal Therapy. J Periodontol mutans and Actinomyces viscosus in orthodontic 1986; 57: 370-377. patients. Am J Orthod Dentofacial Orthop

3. Loe H, Schiott C, Karring G, Karring T. Two years oral 2003;123:345-8. use of chlorhexidine in man. I. General design and 14.Cosyn J, Verelst K. An efficacy and safety analysis of a clinical effects. J Periodont Res1976; 11:135-144. chlorhexidine chewing gum in young orthodontic

patients.J Clin Periodontol. 2006 Dec;33(12):894-9. 4. Schiott RC, Briner WW and Loe H. Two year oral use of chlorhexidine in man(ii).The effect on the salivary 15.Jeffcoat MK et al. Adjunctive use of a subgingival bacterial flora : J Periodont Res 1976;11(a);145-52. controlled-release chlorhexidine chip reduces probing

depth and improves attachment level compared with 5. G. Rolla & B. Melson.On the mechanism of plaque scaling and root planing alone. J Periodontol inhibition by Chlorhexidine. J Dent Res Spl Iss 1998;69:989-97.1975;54:57-62.

16.Heasman PA, Heasman L, StaceyF, McCracken GI 6. Zucchelli G, Polini F, Clauser C, De Sanctis. The effect

Local delivery of chlorhexidine gluconate of chlorhexidine mouthrinses on early bacterial

(PerioChipTM) in periodontal maintenance patients. J colonization of guided tissue regeneration membranes.

Clin Periodontol 2001;28:90-95 An in vivo study. J Periodontol, 2000;71 (2) 263-71.

17.Eley. B.M Antibacterial agents in the control of 7. Stanley A. Wilson M& Newman H. The invitro effects supragingival plaque- a review. Br Dent J 1999;186:286-

of chlorhexidine on subgingival plaque bacteria. J Clin 296. Periodontol 1989;16:259-64.

18.Vaughan ME, Garnick JJ. The effect of a 0.125% 8. Flotra L. Different modes of chlorhexidine application chlorhexidine rinse on inflammation after periodontal

and related side effects. J Periodont Res 1973;12(suppl): surgery. J Periodontol. 1989 Dec;60(12):704-8.41-44. 19.Quirynen M, Mongardini C, De Soete M,Pouwels M,

9. Jan A.M. Keijser, Verkade H, Mark F, Timmerman et al. Coucke W, Van Eldere J, Van Steenberghe D. The role Comparison of 2 commercially available chlorhexidine of chlorhexicine in one stage full mouth disinfection mouthrinses. J Periodontol 2003;74:214-18. treatment of patients with advanced adult

periodontitis. Long term clinical and microbiological 10. Pannuti CM, Saraiva MC, Ferraro A, Falsi D, Cai S, observations. J Clin Periodontol 2000; 27: 578-589.Lotufo RFM. Efficacy of a 0.5% chlorhexidine gel on

20.Andrea Mombelli. Microbiology and antimicrobial the control of gingivitis in Brazilian mentally therapy of peri-implantitis. Periodontology 2000 handicapped patients. J Clin Periodontol 2003;30:573-2002;28:9–312.76.

References:



ORTHODONTICS-DIAGNOSIS & MANAGEMENT OF MALOCCLUSION AND

DENTOFACIAL DEFORMITIES BY OM PRAKASH KHARBANDA

The new edition of textbook by highly acclaimed faculty from prestigious AIIMS, Prof. OP

Kharbanda is expanded and rejuvenated with greater focus on PG students, orthodontic

educators,UG students & practitioners.The information provided is in-depth, literature

supported,complimented with real life scenarios and case reports.The book has updated

information on interdisciplinary treatment,cleft lip and palate and emerging fields as surgically

facilitated rapid tooth movement. The book has a companion website where procedural videos

can be seen .Its a must read for all UG's, orthodontia postgraduates and faculty.For more details

log on to http://www.manthan.info/.

SECOND EDITION,ELSEVIER

BOOK REVIEW

40

Prof (Dr) Harshwardhan Arya* Other advantages include;

1. Conservative restoration of teeth with minimal A typical scenario at the dental clinic; the RCT on a molar done, now the patients comes over for the mandatory preparation of the tooth surface. crown, and asks “It will be fitted today, right?” and we 2. No need for temporaries.politely explain that its long drawn process requiring

3. Excellent fit.multiple steps, involving a laboratory, at least 5 to 7 working days, and only then would the crown be fixed! 4. Excellent color match.

What if we could actually do what the patients demanded? 5. Reduced treatment and chairside times.What if we could deliver high quality permanent

6. Restorations made with All ceramics.restorations in a single visit?7. Choice of various materials (Feldspathic Ceramic,

That dream is very much a reality now with CEREC! emax, Zirconia, Nano ceramic composites).

The best part is that it is not just now, CEREC has been 8. Lab errors eliminated and lab cost overhead reduced.

around for almost 28 years. It is just that now more Various restorations possible are Inlays, Onlays, half dentists around the world have access to and are using this crowns, Veneers, Full crowns and bridges. fantastic technology.

So now you can create conservative accurately fitting The advantages…. PLENTY! restorations made up in materials closer to natural teeth

For starters, you do not take a physical impression! So and all this in matter of minutes.Go ahead and enter the no alginate, no elastomers, no dirty ill sized impression world of digital dentistry.Following are our first cases trays and no mess using all of them. No gagging from the treated with cerec restorations.patient.More importantly, no loss of detail in inaccurate

impressions taken by an inaccurate technique. CEREC uses an intra-oral scanner which is simply glided over the teeth to create a virtual 3D model in real time. It hardly takes over 10 min to complete multiple scans. Then the dentist aligns the bite, marks the margins and designs the restorations in few easy steps. The software is quite intuitive and user friendly. Then the appropriate ceramic block is selected and the CAD-CAM milling machine begins to craft the block, and the restoration is created in just a few minutes.

*Dr Harshwardhan Arya has done BDS from Nair The restoration is tried in the patient's mouth and most of Hospital Dental College, Mumbai and MDS in the times, it simply slips on the tooth into its position, Prosthodontics from GDC Nagpur. He is a Co-guide to requiring minimal adjustments. The restoration may be PhD research projects on FEM and Rapid prototyping at subjected to a short glazing cycle, although restorations the Regional Engineering college ( VNIT), Nagpur with made from Feldspathic and Nano ceramic composites can two international publications. Has his own dental be simply hand polished and delivered. Lithium-di-silicate laboratory with focus on All Ceramics, CAD-CAM (Emax) requres a short crystallization cycle and Zirconia restorations and Implant super-structures.requires a fast sintering cycle.

TECHNOBYTES: CEREC CAD CAM- ONE DAY WONDER!



Prof. (Dr) Deepak Rai * 3. Hedgehog Concept

(To be able to see what is essential , ignore the rest.)

Very few DENTISTS attain great practices ,largely An essay about “fox & hedgehog” divides the world into

because its so easy to settle for good , which almost every foxes and hedgehogs. A fox knows many things ,but

dentist worth his mettle attains predictably after 5 years of Hedgehog knows one big thing. Fox is cunning and able to

practice. Good to GREAT dentists do not focus devise complex strategies to attack upon Hedgehog. Fox is

principally on what to do to become great practitioners; fast ,crafty and looks like a sure winner, Hedgehog on the they focus equally on what NOT to do and what to STOP other hand is a genetic mix-up between porcupine and doing. Technology driven change has only minimal effect small armadillo, a dowdier creature. to ignite transformation from good to great, it accelerates Day in and day out hedgehog walks into the trap laid by fox transformation but does not cause transformation in itself. and sensing danger rolls into a perfect ball with sharp

spikes. Fox seeing hedgehog defense calls off attack Transformation from good to great is a process of repeatedly. Despite greater cunningness of fox, hedgehog buildup followed by breakthrough.always wins.It can be broken in three broad stages:Fox’s pursue many ends at same time and see the world in Disciplined People,all its complexity, never integrating their thinking into

Disciplined Thought & one overall concept or unifying vision.Disciplined Action Hedgehogs simplify complex world into single

organizing idea. It doesn't matter how complex the world is, hedgehog reduce all challenges and dilemmas to simple ideas.1. High Quality leadership:Great practitioners have hedgehog like piercing insight � Practice leader must exhibit extreme personal that allows them to see through complexity and discern humility with intense professional will. underlying patterns ,they see what is essential and ignore

� Great practitioners are fanatically driven, infected with the rest.

incurable need to produce results. So what is your hedgehog concept:

� They not only possess inspiring personality but they To be the best most convenient practice with high profit have inspired standards.per patient visit?

� They look out of the window to give credit to factors Or

outside themselves when things go well and look in the Be scattered and diffuse with multiple multicity mirror when things go poorly.

practices ?� They display workmanlike diligence:more of a plow

Or horse than a show horse.Be in academics as well as practice?2. Build a Right Team:

Or � Just people are not your Be totally devoted to be a most important assets but

great academician.“Right people “are the

most important asset. Hedgehog concept is simple crystalline concept that flows � Get the right people on the from deep understanding of bus , wrong people off the intersection of 3 circles. bus and then right people

in the right seats- and then It is important to know what they will figure well how to you can be best at and where drive your practice to you cannot be. It may be

greatness. possible you are engaged in activities where you can't excel.� When in doubt ,don't hire-One must have piercing insight keep looking.

Good is the enemy of GREAT !!!

Six step guide to good to Great DENTAL

PRACTICE:

GOOD TO GREAT DENTAL PRACTICE

What you aredeeply passionate

about ?

What drives youreconomicengine ?

What youcan be best atin the world ?

42

To create great enduring practices and lives, immutable into how to most effectively generate robust cash flow and laws of organized human performance will always endure. profitability (profit per patient visit).Adhere to basic principles with rigor and disciplineAlso most important is to remain focused on activities that

ignite one's passion.

To have fully developed hedgehog concept you need all the circles .If you make a lot of money doing things where you cant be best, you will only build a successful practice , not a great one. Also if you become best at something , you will never remain at top if you don't have intrinsic passion for what you are doing.

Finally you can be passionate about all you want, but if you cant be the best at it or it doesn't make economic sense ,then you might have lot of fun but you wont be able to produce long term great results.

4. Create Culture of discipline

Disciplined thought ,action and disciplined people around are magical alchemy of great performance.

Good is the enemy of great , is not just a business 5. Technological accelerators. problem, it's a human problem.

Great practices never use their technological assets If we have cracked the code of good to great, good (rvg, opg, intraoral camera, apexlocator, etc list is Colleges would become great Colleges, good Hospitals endless)as primary means of transformation but they would become great Hospitals and good Practices are always pioneers in application of carefully managed by good Dentist will become great Practices selected technologies as accelerators of growth. passionately led by great Dentists.

6. Fly wheel concept Our patients deserve great job by great dentists.Many feel dramatic interior cosmetic changes in clinic *Prof. (Dr) Deepak Rai, MDS, and massive restructuring with hi-tec equipment will Dept. of Orthodontics, MRDCensure leap from good to great . Good to great transformation never happens in single defining action

Author would like to acknowldege the concepts ,one killer innovation or lucky break.mentioned in the article are from a great management text

Good to great process resembles relentlessly pushing a “Good to Great” by JIM COLLINSgiant flywheel in one direction, turn upon turn,

building momentum until a point of breakthrough and beyond.

Acknowledgements:


“Prophylactic extraction of third molars to prevent late mandibular crowding”

1. Prof ( Dr) Reena R. Kumar, MDS

2. Prof (Dr) Gurkeerat Singh, MDS , MOrth.RCS, DiBO

Dr Reena: Dr Gurkeerat-

Despite literature reports as those cited the influence of the third molars on the alignment of the anterior dentition still remains controversial, though there is no conclusive Experts-evidence to indicate that the third molars as the major etiologic factor in the post treatment changes in incisor

Editor, Journal of Orofacial & Health Sciences alignment. Extraction of any tooth needs a valid justification and so does the extraction of third molars Prof & Head, Dept Of Orthodontics, DJ Dental “prophylactically” .However third molar extractions may College, Modinagar, U.P.be considered in cases to combat space requirements and micro implant supported distalizations of the buccal segments may be a viable option to manage space

Editor, Journal of Indian Orthodontic Society; discrepancies in the anterior segment in current day Vice Principal SRDC, orthodontic practice where patients are averse to

extractions in the premolar segment due to a variety of Prof & Head, Dept Of Orthodontics, SRDC, reasons ranging from apprehension of loss of an erupted Faridabad.tooth to unaesthetic extraction space visible in the mouth.

Laskin in 1971 reported that the removal versus the Prophylactic Extraction of Wisdom Teeth is JUSTIFIEDpreservation of third molars was a subject of contention in

dental circles. The different views range between the Majority of orthodontic treatment is undertaken either to extremes expressed in two different statements –“There is align crowded arches or decrease the prominence of no scientific evidence of a cause-and-effect relationship protruding teeth- both procedures which require space.

1between the presence of third molars and orthodontic and Mesial migration is an excepted phenomenon . And 2periodontic problems” and the others opining that “Third shorter arches are more stable . And the human dentition

molars should be removed, even on a prophylactic basis, was basically “designed” on the premise that extensive because they frequently are associated with future wear will occur, a conclusion that seems reasonable when orthodontic and periodontic complications as well as one realizes that humans evolved in heavy-wear other”.Bergstrom and Jensen in 1961 indicated that environments until relatively recently. Some dental presence of a third molar did not seem to effect the problems in contemporary societies appear to reflect the midline and concluded that the presence of a third molar disparity between the original design of our dentition and appeared to exert some influence on the development of our present environment, in which extensive wear no

3the dental arch, but not to the extent that would justify longer occurs . either the removal of the tooth germ or the extraction of

Also according to Dr. Louis K. Rafetto of Wilmington, the third molars other than in exceptional instances. Del., who headed the American Association of Oral and Kaplan in 1974 concluded that, the theory that third Maxillofacial Surgeons' task force on wisdom teeth- “It's molars exert pressure on the teeth mesial to them could hard to get a percentage, but probably 75 to 80 percent of not be substantiated and the presence of third molars does people do not meet the criteria of being able to not produce a greater degree of lower anterior crowding or successfully maintain their wisdom teeth”. Adding to this- rotational relapse after cessation of retention. Ades

4 Stanley et al after examination of panoramic radiographs ,Joondeph , Little and Chapko in 1990 concluded that of 11,598 patients found 1,756 patients with 3,702 there is no basis for recommending third molar extractions impacted teeth. Of these, dentigerous cystic changes to alleviate or prevent mandibular incisor crowding . occurred in about 30 ITMs (0.81%), internal resorption in Bishara in 1999 suggested that the only relationship 16 (0.43%), periodontal ligament damage and bone loss between anterior crowding and third molars is that they distal to the 2nd molar 166 times (4.48%), and pressure occur at approximately the same stage of development, ie, resorption of the 2nd molar 113 times (3.05%). And they in adolescence and early adulthood, but there is no cause concluded that: some type of pathological change can be and effect relationship. Šidlauskas Antanas, Trakinienė expected eventually in approximately 12.0% of an Giedrė in 2006 concluded that there was not enough impacted 3rd molar population and 1.82% of the general evidence to incriminate third molars as being the only or

5population. A study by Stathopoulos et al confirmed the even major etiologic factor in the late lower dental arch incidence of pathologic conditions related to Impacted crowding.

POINT - COUNTERPOINT


44

Third Molars to approximately 2.77%. Considering that 2) Witter, D. J., Creugers, N. H. J., Kreulen, C. M., & De these case were not categorised as orthodontic Vs non- Haan, A. F. J. (2001). Occlusal stability in shortened orthodontically treated cases, it can be said that retained dental arches. Journal of dental research, 80(2), 432-3rd molars could pose health complications in a 436.percentage of the patients. 3) Kaifu, Y., Kasai, K., Townsend, G. C. and Richards, L. We are not sure if they will help us chew….ever, we can't C. (2003), Tooth wear and the “design” of the human maintain them, they might cause trouble, they are surely dentition: A perspective from evolutionary medicine. more painful to get extracted with increasing age and they Am. J. Phys. Anthropol., 122: 47–61. doi:

might cause relapse of orthodontic treatment!! When we 10.1002/ajpa.10329

have the option of a relative less traumatic option of a 4) Stanley HR, Alattar M, Collett WK, Stringfellow HR Jr, prophylactic extraction or enucleation of wisdom teeth, Spiegel EH, Pathological sequelae of "neglected" where is the justification of keeping them till they cause impacted third molars. J Oral Pathol. 1988 trouble? Mar;17(3):113-7.

1) A Björk, V Skieller: Normal and abnormal growth of 5) Stathopoulos P, Mezitis M, Kappatos C, Titsinides S, the mandible. A synthesis of longitudinal Stylogianni E;Cysts and tumors associated with cephalometric implant studies over a period of 25 impacted third molars: is prophylactic removal years, Eur J Orthod (1983) 5 (1): 1-46.doi: justified? J Oral Maxillofac Surg. 2011 Feb;69(2):405-8. 10.1093/ejo/5.1.1 doi: 10.1016/j.joms.2010.05.025. Epub 2010 Nov 2.



The journal publishes original scientific papers, reviews, support for the work within the manuscript to be fully case reports, and method presentation articles in the field acknowledged and any potential conflicts of interest of dentistry. Original articles are published in dentistry noted. Please include the information under –related disciplines, areas of biomedical science, applied acknowledgements. material science, bioengineering, epidemiology, and social sciences relevant to dental disease and its management.

Original researchManuscripts submitted for publication must be original Should describe significant and original experimental articles and must not have appeared in any other observations and provide sufficient detail so that publication. The publisher reserves the right to edit observations can be critically evaluated and, if necessary, manuscripts for length and to ensure conciseness, clarity repeated. Articles considered as original research include , and stylistic consistency, subject to author's final approval.randomized controlled trials ,intervention studies, studies of screening and diagnostic test, outcome studies, case

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Report clinical trials using the CONSORT guidelines at email : [email protected]. A CONSORT checklist and

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It is necessary that information on potential conflicts of underlying the study, as well as its main conclusions should interest be part of the manuscript. The journal requires all be clearly explained. Titles and abstracts should be written sources of institutional, private and corporate financial in language readily intelligible.

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Conflict of interest/source of funding

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Abbreviations/acronyms: abbreviations should be kept 2. Abstract(or introduction) and key wordsto a minimum particularly those that are not standard. 3. Text Terms and names referred to as abbreviations or acronyms 4. Footnotes should be written out when first used with the abbreviation 5. Acknowledgements in parenthesis. Standard units of measurement need not be 6. References spelled out.

7. legends Names of teeth; the complete names of individual teeth 8. Tables must be given in text. In tables and figures, individual teeth

Figures should not be embedded in the manuscript. can be identified using the FDI 2- digit system.Authors should retain a copy of their manuscript for their

Structure own records.1. First page file: prepare the title page, covering letter, The manuscripts should be typed in A 4 size (212x297mm)

acknowledgement etc. all information which can reveal paper ,with margins of 25mm(1 inch)from all four sides. your identity should be here. Include the title of the Use 1.5spacing throughout. Number pages consecutively, article and full name, degrees, title, and professional beginning with the title page. The language should be affiliation of every author. Provide the contact details British English.and e-mail address of corresponding author

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The title page should carry:Abstract till references (including tables) should be in 1. Type of manuscriptthis file. Do not include any information such as

acknowledgment, your names in page readers, etc. in 2. The title of the article, which should be concise , but this file. Illustrations and tables should be numbered informative;and cited in the text in order of appearance and 3. Running title or short title not more than 50 characters;grouped at the end of the text. High –resolution images

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journal),with his/her highest academic degree (s) 3. Images: Submit good quality color images. Submit institutional affiliation;

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included at the end of the article file. Figure legends 6. The name, address, phone numbers, facsimile numbers, should begin with a brief title for the whole image and and e mail address of the contributor responsible for continue with a short description of each panel and correspondence about the manuscript;symbols used; they should not contain any details of

7. The total number of pages, the total number of the methods.

photographs and word count separately for the 5. References: provided with direct references to original abstract and text.

research sources. Note that small number of references 8. Source of support in form of grant, equipment, drugs

to key original papers will often serve as well as more etc.

exhaustive lists. List references at the end of the article The second page should carry the full title of the in numeric sequence following International manuscript and an abstract(of no more than 150 words Committee of Medical Journal Editors (ICMJE) for case reports and 250 for original articles).the structured Uniform Requirements for Manuscripts Submitted to abstract ,should consist of no more than 250 words and Biomedical Journals: Sample Referencesthe following paragraphs:

For help see: � Background: describes the problem being addressed.http://www.nlm.nih.gov/bsd/uniform_requirements

.html � Methods: describes how the study was performed.

http://www.icmje.org/urm_main.html � Results: describes the primary results.

The author's form and copyright transfer has to be � Conclusions: reports what authors have concluded submitted to the editorial office, in original with the from the results. signatures of all the authors.

IntroductionManuscripts must be submitted in Microsoft word. The introduction contains a concise review of the subject Margins should be at least 1” on both sides and top and area and the rationale for the study. More detailed bottom. Materials should appear in the following order: comparisons to previous work and conclusions should 1. Title page appear in the Discussion section.

TEXT Preparation of Manuscript



Materials and methods research (salaries, equipment, supplies, travel reimbursement); employment or anticipated This section lists the methods used in the study in employment by any organization that may gain or lose sufficient detail so that other investigators would be able to financially through publication of paper; and personal reproduce the research. When established methods are financial interests such as shares in or ownership of used, the author need only refer to previously published companies affected by publication of research ,patents reports; however, the authors should provide brief or patent applications whose value may be affected by description of methods that are not well known or that this publication, and consulting fees or royalties from have been modified. Identify all drugs and chemicals used, organizations which may profit or loose as a result of including both generic and if necessary, proprietary names publication.and doses. The populations for research involving humans

should be clearly defined and enrolment dates provided. 2) A conflict of interest and financial disclosure form for each author. Conflict of interest information will not Resultsbe used as a basis for suitability of the manuscript for

Results should be presented in logical sequence with publication.

reference to tables, figures, and illustrations as appropriate.

Discussion References should be numbered consecutively in the order

New and possible important findings of the study should in which they appear in the text. A journal, magazine, or

be emphasized as well as conclusions that can be drawn. newspaper article should be given only one number; a

The discussion should compare the present data with book should be given a different number each time it is

previous findings. Limitations of the experimental mentioned, if different page numbers are cited. All

methods should be indicated as should implications for references are identified, whether they appear in the text,

future research. New hypotheses and clinical tables or legends, by Arabic numbers in superscript. The

recommendations are appropriate and should be clearly use of abstracts as references is strongly discouraged.

identified.Manuscripts accepted for publication may be cited. Material submitted, but not yet accepted, should be cited in text as “unpublished observations”. Written and oral Acknowledgements personal communications may be referred to in text, but At the end of the discussion, acknowledgements may be not cited as references. Please provide the date of the made to individuals who contributed to the research or communication and indicate whether it was in a written or manuscript at the preparation level that did not qualify for oral form. In addition, please identify the individual and authorship. This may include technical help or his/her affiliation. Authors should obtain written participation in a clinical study. Authors are responsible for permission and confirmation of accuracy from the source obtaining written permission from persons listed by name. of a personal communication. Presented papers, unless Acknowledgements must also include a statement that they are subsequently published in a proceedings or peer includes the source for any funding for the study, and reviewed journal, may not be cited as references. For most defines the commercial relationships of each author.manuscripts, authors should limit references to materials

Conflicts of interest published in peer-reviewed journals. In addition, authors In the interest of transparency and to allow readers to should verify all references against the original documents. form their own assessment of potential biases that may References should be typed double-spaced.have influenced the results of research studies, the journal List references at the end of the article in numeric requires that all authors declare potential competing sequence following International Committee of Medical interests relating to papers accepted for publication. Journal Editors (ICMJE) Uniform Requirements for Conflicts of interest are defined as those influences that Manuscripts Submitted to Biomedical Journals: Sample may potentially undermine the objectivity or integrity of Referencesthe research, or create a perceived conflict of interest.

For help see: Authors are required to submit: http://www.nlm.nih.gov/bsd/uniform_requirements.ht1) A statement in the manuscript, following ml

acknowledgments, that includes the source of any http://www.icmje.org/urm_main.htmlfunding for the study, and defines the commercial relationships of each author. If an author has no

Tables should be numbered consecutively in Arabic commercial interest to declare, a statement to that numbers in the order of their appearance in the text. A effect should be included. This statement should brief descriptive title should be supplied for each. include financial relationships that may pose a conflict Explanations, including abbreviations, should be listed as of interest. These may include financial support for

REFERENCES

Acknowledgents and Conflicts Of Interest

TABLES

48

footnotes, not in the heading. Every column should have a heading. Statistical variations such as standard deviation or Statistical methods should be described such that a standard error of the mean should be included as knowledgable reader with excess to the original data could appropriate in the footnotes. Don't use internal, horizontal verify the results. Whenever possible, results should be or vertical rules. quantified and appropriate indications of the

measurement error or uncertainity given Sole reliance on statistical hypothesis testing or normalization of data Legends should be typed, double spaced with Arabic should be avoided. Data in as close to the original form as numbers corresponding to the figure. When arrows, reasonable should be presented. Details about eligibility symbols, numbers or letters are used, explain each clearly critera for subjects, randomization, and methds for in the legend; also explain internal scale, original blinding of observations, treatment complication, and

magnification and method of staining as appropriate. number of observations should be included. Losses to

Panel labels should be in capital letters. Legend should not observations, such as drop out from a clinical trial, should

appear on the same page as actual figures.be indicated. General use computer programmes should be listed. Statistical terms, abbriviations, amd symbols should be defined. Detailed statistical, analytical Digital files must be submitted for all figures. Submit one procedures can be included as a appendix to the paper if file per figure. Human subject must not be identifiable in appropriate.photographs, unless written permission is obtained and

accompanies the photographs. lettering, arrows or other

identifying symbols should be large enough to permit Footnotes should be used only to identify author reduction and must be embedded in figure file. Figure file affiliation; to explain symbols in tables and illustrations; names must include the figure number. Details of and to identify manufactrurers of equipments, medication, programs used to prepare digital images must be given to materials and devises. Use the following symbols in the facilitate use of electronic image. Use solid or shaded tones sequence shown *, †, ‡, §, k, #, **, ††.for graphs and charts. Patterns other than diagonal lines

may not reproduce well.Use of brand names within the article or text is not acceptable, unless essential when the paper is comparing

Measurements of length, height, weight and volume two or more products. When identification of the product should be reported in metric units or their decimal is needed or helpful to explain the procedure or trial being multiples.All haematological and clinical chemistry discussed, a generic term should be used and the brand measurements should be reported in the matrix system in name, manufacturer and location (city/ state/ country) terms of the International System of Units (SI) . cited as a footnote.

STATISTICS

FIGURES LEGENDS

FIGURES

FOOTNOTES

IDENTIFICATION OF PRODUCTS

UNITS OF MEASUREMENTS

CORRESPONDENCE ADDRESS :

EDITOR IN CHIEFProf. (Dr.) Deepak Rai, M.D.S.Dental Lamina - Journal of Dental SciencesManav Rachna Dental Collage, Dept. of OrthodonticsDelhi - Surajkund Road, Aravalli Hills, Faridabad, Haryana, INDIAPhone : +91-9811604974email : [email protected]


1. Place of publication 5E/1-A, NIT, Faridabad

2. Periodicity of its publication Bi-Annual

3. Printer/Publisher’s name Mr. Atul Kalra

Nationality Indian

Address 5E/1-A, NIT, Faridabad

4. Particulars of printing press M/s. Vinayak Colour Offset

C-114, Naraina Industrial Area,

Phase-I, New Delhi-110028

5. Editors name Prof (Dr) Deepak Rai

Nationality Indian

Address G-163 sector 41 Noida

6. Name & address of individuals M.R. Education Society

who own the newspaper [A Society Registered Under The Societies

Registration Act 1960 - Regd. No. 2242/1987-88]

I, Dr. Deepak Rai, hereby declare that the particulars given above are true to the best of my

knowledge and belief.

Sd/-

(Dr. Deepak Rai)

STATEMENT ABOUT THE

“DENTAL LAMINA” JOURNAL OF DENTAL SCIENCES

(Published twice a year in the months of January and July)

CAMPUS: Sector - 43, Aravali Hills, Delhi - Surajkund Road, FaridabadPh: +91-129-4268800 (30 Lines)

ADMINISTRATIVE HEADQUARTERS: 5E/1-A, G.F., Bungalow Plot, N.I.T. FaridabadPh: +91-129-4198600 (30 Lines)

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