journal of international dental and medical research

Journal of International Dental and Medical Research 2009, Vol 2, No 1. Assoc. Prof. Dr. Izzet YAVUZ

Editor-in-Chief and General Director

Assist. Prof. Dr. Ozkan ADIGUZEL Associate Editor and Director

Prof. Dr. M. Zulkuf AKDAG, Prof. Dr. Sinerik N. AYRAPETYAN

Associate Editor for Biomedical research

Assoc. Prof. Dr. Refik ULKU Associate Editor for Medicine

Assist. Prof. Dr. Filiz ACUN KAYA

Associate Editor for Dentistry

Advisory Board

Betul KARGUL (TURKEY) Ferranti WONG (UNITED KINGDOM)

Filiz ACUN KAYA (TURKEY) Gauri LELE (INDIA)

Gulten UNLU (TURKEY) Jalen Devecioglu KAMA (TURKEY)

Moschos A. PAPADOPOULOS (GREECE) Nik Noriah Nik HUSSEIN (MALAYSIA)

Sabiha Zelal ULKU (TURKEY) Sadullah KAYA (TURKEY)

Editorial Board

Xiong-Li YANG (CHINA) Zurab KOMETIANI (GEORGIA) Gajanan Kiran KULKARNI (CANADA) Yuri LIMANSKI (UKRAINE) Gulten UNLU (TURKEY) Nik Noriah Nik HUSSEIN (MALAYSIA) Rafat Ali SIDDIQUI (PAKISTAN) Jalen Devecioglu KAMA (TURKEY) Ferranti WONG (UNITED KINGDOM) Betul KARGUL (TURKEY) Susumu TEREKAWA (JAPAN) Moschos A. PAPADOPOULOS (GREECE) Izzet YAVUZ (TURKEY) Halimah AWANG (MALAYSIA) Serdar ERDINE (TURKEY) Margaret TZAPHLIDOU (GREECE) Ozkan ADIGUZEL (TURKEY) Muhammad FAHIM (INDIA) Smaragda KAVADIA (GREECE) Sabiha Zelal ULKU (TURKEY) Abdel Fattah BADAWI (EGYPT) Sossani SIDIROPOULOU (GREECE) Mostaphazadeh AMROLLAH (IRAN) Sadullah KAYA (TURKEY) Medi GANIBEGOVIC (BOSNIA and HERZEGOVINA) Filiz Acun KAYA (TURKEY) Stephen D. SMITH (UNITED STATES OF AMERICA) Mehmet Zulkuf AKDAG (TURKEY)

Sinerik N. AYRAPETYAN (ARMENIA) Süleyman DASDAG (TURKEY) Gauri LELE (INDIA) Ali GUR (TURKEY) Refik ULKU (TURKEY) Shailesh LELE (INDIA) Murat AKKUS (TURKEY) Fadel M. ALI (EGYPT) Alpaslan TUZCU (TURKEY) Igor BELYAEV (SWEDEN) Sedat AKDENIZ (TURKEY) KING Nigel MARTYN (HONG KONG SAR, P R CHINA) Muzeyyen YILDIRIM (TURKEY) Christine Bettina STAUDT (SWITZERLAND) Senay ARIKAN (TURKEY) Karla PADILLA (MEXICO) Selahattin TEKES (TURKEY) Claudia DELLAVIA ( ITALY ) Feriha CAGLAYAN (TURKEY) Marco MONTANARI (ITALY) Aziz YASAN (TURKEY) Filippo BATTELLI (ITALY) Ugur KEKLIKCI (TURKEY) Ali Al-ZAAG (Iraq) Zeki AKKUS (TURKEY) Benik HARUTUNYAN (ARMENIA) Guliz Nigar GUNCU (TURKEY) Nurten ERDAL (TURKEY)

*Formerly the Name of “Journal of International Dental and Medical Research” was “International Dental and Medical Disorders”.

*Formerly the Name of “Journal of International Dental and Medical Research” was “International Dental and Medical Disorders”.

Journal of International Dental and Medical Research Table of Contents 2009 Volume 2 - Number 1

DENTISTRY Familial Hyperdontia In The Deciduous Dentition. Gercheon M. Wicomb, Peter H. Beighton. Pages 1-5 Early Treatment of Excessive Open Bite and Follow Up: Case Report Nihal Hamamci, Torun Ozer, Guvenc Basaran, Orhan Hamamci. Pages 6-10 Outcome and Long-Term Follow-Up of a Phenylketonuria Patient After Prosthetic Treatment: a Case Report. Aysegul G. Gurbulak, Mustafa Zortuk, Zekiye Eroglu, Filiz Yagcı, Bulent Kesim. Pages 11-15 The Oral Findings of The Gigantic Patient With Gingival Enlargement-(A Case). Filiz Acun Kaya, Ebru Saribas, Arzum Guler Dogru, Ahmet Dag, Ahmet Gunay. Pages 16-18 Direct Composite Resin Application, and Prosthetic Management in a Patient with Hypohidrotic Ectodermal Dysplasia: a Case Report. E.Caner Tumen, Nihal Hamamci, Yalcın Deger, Demet Suer Tumen, Engin Agackiran. Pages 19-24 MEDICINE Chylothorax with Down Syndrome: Unusual Case Report. Alper Avci, Refik Ulku, Serdar Onat. Pages 25-27 BIOMEDICAL RESEARCH The Effect of Extremely Low Frequency Pulsing Magnetic Fields on Pain Threshold of Human Frontal Teeth. Ruben Hovhannisyan, Sinerik Ayrapetyan. Pages 28-32 Alteration in Body Composition of Elite Professional Female Players in a Premier League Volleyball Bout. Suat Cerit, M. Zulkuf Akdag, Suleyman Dasdag, Yunus Karakoc, Mehmet Celik. Pages 33-36

Journal Of International Dental And Medical Research ISSN 1309-100X Familial Hyperdontia http://www.ektodermaldisplazi.com/journal.htm Gercheon M. Wicomb and Peter H. Beighton

Volume 2 ∙ Number ∙ 1 ∙ 2009

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Familial Hyperdontia in the Deciduous Dentition

Gercheon M. Wicomb1*, Peter H. Beighton2

1. BChD, BSc, PDD (Paediatric Dentistry), MBA. VersTand junior Dental Practice, Utrecht, The Netherlands. 2. MD, PhD, FRCP Department of Human Genetics, University of Cape Town, Cape Town, South Africa.

Abstract Two young brothers had identical supernumerary teeth in the deciduous dentition. The necessity of

obtaining radiographs when treating a patient with hyperdontia in the deciduous dentition is stressed, and the importance of utilizing a correct timed approach, when instituting treatment and management is emphasized. The etiology and dental implications of supernumerary teeth are reviewed. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 1-5 ) Keywords: Deciduous, Genetic, Supernumerary, Teeth. Received date: 22 February 2009 Accept date: 01 April 2009

Introduction

Supernumerary teeth or hyperdontia [OMIM 187100]a is defined as an excess number compared to the normal dental formula. These teeth mimic normal tooth morphology, and classification is dependent on their position and form. Hyperdontia may occur as a single tooth, multiple teeth, unilateral, bilateral and in one or both jaws 1-5. The morphological classification can be subcategorized into eumorphic (supplemental) and dysmorphic (rudimentary) elements. Eumorphic teeth have morphology similar to a tooth of the normal dentition, while dysmorphic teeth are small and conical, tuberculate or odontome. The morphology of supernumerary teeth in the primary dentition is usually normal or conical, and may vary in the permanent dentition 6. Supernumerary teeth in the primary dentition are often overlooked and undocumented. It is more frequently reported in the permanent dentition. The following reasons for this have been suggested:

1. Spacing often occurs in the primary dentition, which allows for extra teeth to be accommodated without producing irregularities.

2. Supernumerary teeth in the primary dentition

have less effect upon adjacent teeth than do supernumerary teeth in the permanent dentition.

3. They often erupt and exfoliate without being noticed by the parents.

4. They are often are mistaken as germination or fusion anomalies.

5. At the time of the first dental examination the primary incisors have exfoliated.4, 7, 8

Since children are presenting to the dentist earlier for the routine dental examination, the incidence of documented supernumerary primary teeth is increasing. In this article the dental manifestations in two Dutch brothers are depicted, documented and discussed. They presented with identical hyperdontia in their deciduous dentition. The familial occurrence of eumorphic (supplemental) supernumerary primary incisors in exactly the same position is very unusual.

Cases Report

A Dutch, Caucasian family consisting of healthy parents and their three children, all boys, presented for their routine dental examination at a private dental practice. The family’s medical history was non-contributory, but the dental history revealed that the parents were aware of an anomaly present in the deciduous dentition of two of the boys. Patient 1 A male child born in 2002 aged six years, the eldest of three brothers presented for a dental examination. Intra-orally, both dental arches were normal in form. The child had just started the exfoliation period, with subsequent eruption of the

*Corresponding author: Dr. G.M. Wicomb VersTand junior Dental Practice Blauwkapelseweg 141 3572 KE Utrecht The Netherlands Tel: +31-30 276 1581 E-mail: [email protected]

http://www.ektodermaldisplazi.com/dergi.htm�

http://www.ektodermaldisplazi.com/journal.htm�



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permanent mandibular central incisors. No evidence of crowding was observed in this mixed dentition, and primate spacing was evident between the primary maxillary lateral incisors and mandibular canines. The dental examination revealed the presence of a eumorphic supernumerary distal to the primary maxillary right lateral incisor. Mild dental attrition on these incisors and also on the molars (Fig 1) was indicative of bruxism, which was confirmed by the mother.

Fig. 1 Patient 1, primary maxillary dentition, with eumorphic supernumerary primary left lateral incisor distal to the lateral incisor. Radiographic examination with an orthopantomogram verified the presence of a supplemental primary maxillary lateral incisor (Fig 2).

Fig 2. Orthopantogram of patient 1, supernumerary primary left maxillary lateral incisors, and supernumerary permanent maxillary lateral incisor. Mild anterior crowding was expected in the pre-maxillary segment of the permanent dentition, since a permanent supplemental lateral incisor was present. From a peri-apical radiograph (Fig 3), the permanent maxillary right lateral incisor was normal in morphology and the supplemental lateral incisor was rotated so as to appear peg-shaped.

Fig 3. Occlusal radiograph of patient 1, a normal permanent left maxillary lateral incisor and rotated supplementary maxillary lateral incisor. The patient was referred for orthodontic evaluation and it was decided to postpone invasive dental treatment. At routine dental examination one and a half years later, the permanent maxillary central incisors had erupted with slight overlapping of these teeth. An orthopantomogram (Fig 4) showed that nearly 2/3 of the root formation of the permanent maxillary right lateral and supplemental incisors has occurred.

Fig 4. Orthopantogram of patient 1, one and a half years later, overlapping of the maxillary central incisors. Patient 2 The youngest brother, born in 2004 and aged three years when first examined, had dental crowding in the right pre-maxillary arch. The arch form and occlusion for both the maxilla and mandible was normal. Dental examination revealed a supplemental primary maxillary right lateral incisor, in exact the same position as in his brother. Due to slight mesial rotation of the primary maxillary lateral incisor minor gingival recession was evident. The supernumerary incisor was normal in form (Fig 5).





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Fig 5. Patient 2, the primary maxillary dentition, with an eumorphic supernumerary primary left lateral incisor. Compliancy during the examination was difficult but with effort an occlusal radiograph was obtained (Fig 6).

Fig 6. Occlusal radiograph of patient 2, root resorption of the primary left maxillary lateral incisor. The primary maxillary right central incisor showed evidence of resorption and the supernumerary still had an open apex. One and half years later an orthopantomogram (Fig 7) revealed that this patient processed no permanent supplemental lateral incisor.

Fig 7. Orthopantomogram of patient 2, one and a half years later, with no supplemental permanent left maxillary lateral incisor. Patient 3 The middle brother, born in 2003 and now aged five years, had a normal dental arch form and

his deciduous dentition was clinically and radiologically normal in form and number. An orthopantomogram taken one and half year later, revealed a rotated permanent maxillary right lateral incisor (Fig 8).

Fig 8. Orthopantomogram of patient 3, one and a half years later, revealed no supplemental teeth, a rotated or cone shaped permanent right maxillary lateral incisor. Dental management of the affected child (Patient 1) The appropriate approach in this patient is to minimize invasiveness of the dental treatment. Unerupted or supernumerary teeth are usually removed surgically. Since there has not been any reason for intervention, such as cyst formation or delayed eruption, treatment has been delayed. In addition, it is relevant that older children tolerate this form of treatment better. The eruption of maxillary incisors is often delayed due to the presence of supernumerary teeth; in these circumstances the supernumerary teeth are often extracted surgically 9. The orientation of the supernumerary teeth does not influence rotation or horizontal displacement of the permanent incisors, except for crowding as seen in Patient 1. Supernumerary teeth that are orientated vertically may cause eruption delay more frequently than those that are inverted 10. In Patient 1, in order to relieve anterior crowding of the permanent maxillary central incisors, it was decided to extract the primary right lateral and supplemental incisors and the permanent supplemental incisor. This will be undertaken during a single surgical procedure in order to minimize psychological trauma.

Discussion The presence of supernumerary teeth in the

primary dentition is rare, quoted by some authors as occurring in about 0.3-0.6 %1, 5, 7 and by others as 0.1-1% 11. In contrast, supernumerary permanent successors are present in 1.5-3% 1, 12. Although some authors suggest that there is an increase of supernumerary teeth on an evolutionary scale 4, 12,





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this phenomenon could be explained more parsimoniously by the observation that children are visiting the dentist at an earlier age, and thus only the detection of supernumeraries has increased.

Approximately 90-98% of all supernumeraries occur in the maxilla with a strong predication (90%) for the premaxilla 3, 8. Rajab and Handan have recently verified this point; their study revealed that 25% of these teeth are located in the midline, and that the most common supernumerary tooth is the lateral maxillary incisor 4. Hyperdontia in the primary dentition is often overlooked due to the morphology being eumorphic and often occurring non-impacted as a supplementary maxillary lateral incisor 3, 4. Males have shown a strong predilection to being affected with a sex ratio of 2.2:1 4. The occurrence of supernumerary teeth in both the primary and permanent dentitions of the same child has been reported and may occur in approximately one third of the cases 1. In view of the predominance in males, the hereditary component which has been proposed does not conform to a simple Mendelian pattern 8. Two separate cases of mirror imaging of supplemental primary incisors in the premaxillary area in identical twins have been documented 17, 18. Other familial cases have also been reported 3, 15, 16,

17. The case described in this article is unique as both brothers have eumorphic supplemental primary incisors in the same position in the pre-maxillary area. The inheritance pattern in this family could represent autosomal dominant transmission, with the lack of penetrance in some generations as explained in a theory by Sedano and Gorlin (1969) 18. Autosomal recessive and X-linked transmission are also feasible, but in the absence of additional genealogical evidence, it is impossible to accurately determine the mode of inheritance. Clinical problems which can occur due to supernumerary teeth are crowding, delayed eruption, diastema, rotations, cystic lesions, and resorption of adjacent teeth 1, 4, 5. Early clinical and radiographic assessment is an essential step in the diagnosis and treatment planning 19. Whenever a single supernumerary tooth is detected, an orthopantomogram is advisable in order to rule out the presence of multiple supernumerary teeth 1, 5, 20. Given sufficient space and time, the majority of teeth prevented from erupting by a supernumerary tooth will erupt spontaneously following the removal of the supernumerary alone 13,

21, 22. The optimal time for the removal of anterior

supernumerary teeth is controversial 1. Several factors influence eruption of the impacted tooth following the removal of the supernumerary. These include the type of supernumerary tooth, the distance the unerupted tooth was displaced at the time of surgical intervention, the space available within the dental arch for the unerupted tooth and the stage of root development 21, 23. Most authors agree that the time taken for an unerupted tooth to appear following the removal of supernumerary is between 6 months and 3 years 19. An interdisciplinary team management approach of pediatric dentist, orthodontist, and maxillofacial surgeon is advocated 19, 23. Not all supernumerary teeth require extraction; some can be left in situ and monitored if they remain asymptomatic.

Conclusions

Although there is no consensus on the etiology of supernumerary teeth in the primary dentition, it is evident from this case, as well as from others in the literature that there is a genetic influence. It would be of scientific importance to determine the precise hereditary factors which are involved. It is relevant that hyperdontia can be a component of a number of genetic syndromes, in which systemic ramifications may impact upon anaesthesia and other aspects of dental management. From a clinical perspective, radiographic detection of supernumerary successors is crucial. Affected persons would benefit from an interdisciplinary approach to the treatment, where each step is correctly timed, based on the patient’s dental age.

Acknowledgements:

It is with gratitude that we wish to thank Ruben Blijdorp for his diligence and enthusiastic assistance in the preparation and editing of this manuscript. The project was supported by grants from the Medical Research Council and the National Research Foundation of South Africa.

Electronic-Database Information Accession numbers and URLs for data in this article are as follows: a. Online Mendelian Inheritance in Man (OMIM),

http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=187100 Accessed June 22, 2009.





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References

1. Primosch RE. Anterior supernumerary teeth-assessment and surgical intervention in children, Pediatr Dent 1981;3:204-215.

2. Yusof WZ. Non-syndrome multiple supernumerary teeth: Literature review. J Can Dent Assoc 1990;56:147-49.

3. Orhan AL, Özer L, Orhan K. Familial occurrence of nonsyndromal multiple supernumerary teeth. Angle Orthod 2006;76:891-97.

4. Rajab LD, Hamdan MAM. Supernumerary teeth: review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-54.

5. Scheiner MA, Sampson WJ. Supernumerary teeth: A review of the literature and four case reports. Aust Dent J 1997;42:160-65.

6. Anlaw RJ, Rock WP. Abnormalities of tooth number. In: A manual of Paediatric Dentistry, 4th edn. New York: Churchill Livingstone;1996;155-57.

7. Taylor GS. Characteristics of supernumerary teeth in the primary and permanent dentition. Dent Pract 1972;22:203-08.

8. Luten JR. The prevalence of supernumerary teeth in primary and mixed dentitions. J Dent Child 1976;34:346-53.

9. McDonald RE, Avery DR, Dean JA. Management of the Developing Occlusion. In: Dentistry for the Child and Adolescent, 8th edn. Missouri: Mosby;2004:665-68.

10. Gregg TA, Kinirons MJ. The effect of the position and orientation of unerupted premaxillary supernumerary teeth on eruption and displacement of permanent incisors. Int J Paediatr Dent 1991;1:3-7.

11. Brook AH. Dental anomalies of number, form and size: their prevalence in British schoolchildren J Int Assoc Dent Child 1974;5:37-53.

12. Brabant H: Comparison characteristics and anomalies of the deciduous and permanent dentition. J Dent Res 1976;49:897-902.

13. Beere D, Hargreaves JA, Sperber GH, et al. Mirror image supplemental primary incisor teeth in twins: case report and review. Pediatr Dent 1990;2:390-92.

14. Carton A, Rees RT. Mirror image dental anomalies in identical twins. Br Dent J 1987;162:193-94.

15. Desai RS, Shah NP. Multiple supernumerary teeth in two brothers: a case report. J Oral Pathol Med 1998;27:411-13.

16. Manson C, Rule DC. Midline Supernumeraries: A family affair. Dental Update 1995;22:34-5.

17. Mercedes Gallas M, Garcia A. Retention of permanent incisors by mesodens: a family affair. Br Dent J 2000;2:63-4.

18. Sedano HO, Gorlin R. Familial occurrence of mesodens. Oral Surg Oral Med Oral Pathol 1969;27:360-2.

19. Ibricevic H, Al-Mesad S, Mustagrudic D. et al. Supernumerary teeth causing impaction of permanent maxillary incisors: consideration of treatment. J Clin Pediatr Dent 27: 2003;327-32.

20. Nayak UA, Mathian VM, V. Non-syndrome associated multiple supernumerary teeth: A report of two cases. J Indian Soc Pedod Prev Dent 2006;24:11-4.

21. Mitchell L, Bennett TG. Supernumerary teeth causing delayed eruption- a retrospective study. Br J Orthod 1992;19:41-6.

22. Di Base D. The effects of variations in tooth morphology and position on eruption. Dent Pract 1971;22: 95-108.

23. Bekker A, Bimstein E, Shteyer A. Interdisciplinary treatment of multiple unerupted supernumerary teeth. Report of a case. Am J Orthod 1982;81:417-22.



Journal Of International Dental And Medical Research ISSN 1309-100X Excessive Open Bite And Follow Up http://www.ektodermaldisplazi.com/journal.htm Nihal HAMAMCI et al.


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Early Treatment of Excessive Open Bite and Follow Up: Case Report

Nihal Hamamci1*, Torun Ozer2, Guvenc Basaran1, Orhan Hamamci3

1. Assistant Professor DDS PhD Department of Orthodontincs, Dicle University, DİYARBAKIR, TURKEY. 2. Associate Professor DDS PhD Department of Orthodontincs, Dicle University, DİYARBAKIR, TURKEY. 3. Professor DDS PhD Department of Orthodontincs, Dicle University, DİYARBAKIR, TURKEY.

Abstract Multiple factors play role in the etiology of openbite malocclusion. For a successful orthodontic

treatment the etiology of the malocclusion must be eliminated. A proper diagnosis of the malocclusion and elimination is an essential factor, especially in open bite cases.

In the present case, patient was a seven year one month old boy who had a severe open bite with class I molar relationship and tongue thrust. In the anemnesis of the patient, tonsillectomy and adenoidectomy surgery was reported at the age of four. Also, difficulty in the speach was another important finding of the patient.

The final outcome of the treatment was a great improvement in function andesthetics. The main reason this patient could be successfully treated nonsurgically was her initial compliance, and the proper therapy options used during this two-phase treatment. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 6-10 ) Keywords: Skeletal class III, Openbite, early treatment. Received date: 10 December 2008 Accept date: 05 February 2009

Introduction

Various effects may play role in the etiology

of open bite such as: intolerable growth pattern in vertical direction, genetics, sucking habits, habitual mouth breathing. These abnormal functions changes the morphology of the bony structures.1,2 Treatment alternatives include habit breaker, bite block, high pull headgear, vertical chin cap, vertical elastics, multilooped edge wise mechanics and surgery.3,4

Malocclusion characterized with open bite is one of the most difficult anomalies to treat. Multiple factors play role in the etiology of this malocclusion. Mostly, maxillary posterior dentoalveolar segments erupt downward in an unwanted manner. Posterior intrusion becomes very difficult with increased age and mechanic treatment alternatives are limited inadult patients.5-7 Tongue and the importance in the etiology of open bite malocclusions is considered as a stimulating factor in the epidemiology of the anomally.8 The etiological

consepts in the shape, physiology and the pressure that is exerted on the incisors while swallowing are common features in these patients.9,10

Orthodontists wondered had this habitual forward pressure on the incisors disappear after the orthodontic treatment or not. If not, this exerted pressure will cause debrimental effectson incisors. For a successful orthodontic treatment the etiology of the malocclusion must be eliminated. A proper diagnosis of the malocclusion and elimination is an essential factor in orthodontic treatment.11,12

Therefore, in open bite malocclusions, just closing the vertical opening by extruding or intruding the teeth is not always the true treatment alternative. Open bite generally is associated with other malocclusions like anterior-posterior, transversal and vertical anomalies.11,12

CASE REPORT History The patient was a seven year one month old

boy who had a severe open bite with class I molar relationship and tongue thrust.

In the anemnesis of the patient, tonsillectomy and adenoidectomy surgery was reported at the age of four.

Also, difficulty in the speach was another important finding of the patient (Figure 1-5).

*Corresponding author: Dr. Nihal HAMAMCI Dicle University,Faculty of Dentistry, Departments of Orthodontics, Diyarbakir / TURKEY Tel: 04122488101-3478, Fax: 04122488100 E-mail: [email protected]



mailto:[email protected]�



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Fig.1,2 Pretreatment extraoral photographs.

Fig. 3,4,5 Pretreatment intraoral photographs.

Radiographic evaluation

Cephalometric examination of the patient revealed skeletal Class III (ANB: -1°) and high angle (SN-GoGn: 45°) pattern. 9 milimeter open bite increased lower anterior face height (ANS-Me/N-Me: 59.1%) and decreased the ratio of posterior face height toanterior face height (S-Go/N-Me: 58.3%). Protrusion of the insisors (interincisal angle 125°) were also observed (Table1 and Figure 6,7).

Tab. 1 Pre-post treatment cephalometric analysis.

Fig. 6 Pretreatment cephalometric radiographs.

Fig. 7 Pretreatment panoramic radiographs.





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Treatment Objectives Elimination of the open bite, establishment of

an ideal overjet, overbite, canine, molar relationship, in combination witha good facial esthetics are the main goals of our treatment. Correction of axial inclinations of maxilary and mandibulary anterior teeth, establishment of a good functional occlusion, limitation of maxillary molar extrusion and stimulation of mandibular counter clockwise rotation, improvement of facial profile, lip closure, smile characteristics and dental esthetics were our targets.

Treatment Alternatives This case would traditionally have been

treated surgically because of the severityof the problem. Waiting for patient’s growth and development to finish and planning an orthodontic treatment with orthognatic surgery is an alternative to treat this patient. Because of the reason that the patient couldn’t afford the treatment, patient’s parents did not want any surgery. They preferred this long time treatment alternative.

Treatment Progress A two phase orthodontic treatment was

planned for the patient. In the first phase of the treatment vertical chincap and removable appliance to the upper arch was used. This removable appliance had a screw in the transversal direction to expand the maxilla slowly. Vertical chincap was for the limitation of mandibular vertical growth and stimulation of mandibular counter clockwise rotation. Patient left his tongue thrust habit in this treatment phase. As a result of controlled mandibular vertical growth open bite decreased to four milimeters. This treatment phase ended with mixed dentition.

In the second phase of the treatment fixed straight wire mechanics were applied to the patient. Treatment was begun with 0.016" round upper and lower nickel titanium leveling archwires. These were followed by 0.016"x 0.022" upper accentuated-curve and lower reverse-curve nickel titanium archwires; the intrusive force of the wires was counteracted with 3/16", 4oz elastics placed between each pair of opposing canines.

Results After 16 months of active treatment, upper

and lower Hawley retainers were placed. Incombination with Hawley retainers patient was asked to use vertical chin cap at night. Functional dental and skeletal class I occlusion in association with an improved facial appearance was obtained. A good smile line and esthetic facial appearance satisfied patient and patient’s family. Axial inclinations of the posterior teeth were corrected. The proclined upper andlower incisors were uprighted. Nine milimerters of open bite decreased

to three milimeters of over bite. Mandibular counter clock wise rotation was maintained (Ba-Ptm-Gn: 80°)( Figure 8-12).

Fig. 8,9 Posttreatment extraoral photographs.

Fig. 10 Posttreatment intraoral photographs.

Fig. 11 Posttreatment cephalometric radiographs.

Fig. 12 Posttreatment panoramic radiographs.





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In open bite cases, early orthodontic treatment increase posterior facial height, decrease anterior face height and corrects the direction of condylar and mandibular growth. By controlling maxillary and mandibulary teeth eruptions, ideal overjet and overbite relationship can be maintained. In the present case, all these precautions aided in correction of this malocclusion.

When the records were re-evaluated 4 years after the treatment, it was observed that the patient still had acceptable occlusion and facial esthetics (Figure 13-15).

Fig. 13,14 Extraoral photographs four years posttreatment.

Fig. 15 Intraoral photographs four years posttreatment. Discussion

Orthodontic correction of the functional and morphological problems that affect the patient’s psychology at an early stage could help eliminate a potential inferiority complex and also have a beneficial effect on general personality development.13 Faced with the limitations that orthodontic treatment alternatives present, most orthodontists would agree that this type of case is

ideally corrected with a combination of orthodontics and orthognathic surgery.14

The advantages of the orthognathic surgical treatment are that the overbite can be over corrected and relapse is less than with a nonsurgical option.15 Bell,16 realized that a skeletal open bite could be corrected with LeFort I osteotomy but some relapse of the open bite after surgery may occur.

In a nonsurgical plan, the orthodontist will camouflage the skeletal discrepancies to an extent that satisfies as many of the patient’s esthetic and functional concerns as possible. Nonsurgical options for open bite malocclusions include anterior vertical elastics, posterior bite blocks, high-pull headgear, vertical-pull chin cup and the use of microimplants. The patient must be told that nonsurgical correction usually requires a longer treatment time and is more difficult, especially for stability and retention.13 In this case, the nonsurgical correction of the anterior open bite included a high-pull headgear appliance, a vertical-pull chin cup and anterior vertical elastics.

The vertical-pull chin cup was successfully used to control excessive lower anterior face height and helped to prevent extrusion of posterior teeth.17-

19 Finally, anterior vertical elastics in combination with accentuated and reverse curve arches were used in order to intrude posterior segment and to extrude the maxillary and mandibular incisors and to close the remnant open bite.

The early treatment regimen under study led to increased condylar growth, altered direction of condylar growth, increased true forward mandibular rotation, increased posterior facial height, and decreased anterior facial height foropenbite patients; it also displaced the chin anteriorly, controlled maxillary and mandibular molar eruption, increased overbite, and decreased overjet.

The final outcome of the treatment was a great improvement in function and esthetics, although the stability of the open bite closure is questionable. The main reason this patient could be successfully treated nonsurgically was her initial compliance, and the proper therapy options used during approximately six years of this two-phase treatment.

Many previous studies have indicated that if open bite correction is not stable, it is because the tongue continues to be postured anteriorly which causes the bite to reopen.11,12,20 The successful repositioning of the tongue from the myofunctional therapy program and the mechanics used may have collectively provided the degree of stability seen in this patient. At the end of 4 year posttreatment period, relapse occured but this was not significant.





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Conclusions As a result of this early treatment, tongue thrust habit was left, ideal overjet and overbite relationship was established by controlling mandibular vertical growth. This early treatment resulted with a good smile and profile of the patient. Correction of this functional and morphological open bite problem at an early age could help eliminate a potential inferiority complex and also have a beneficial effect on general personality development of our patient.

References

1. Alexander CD. Open bite, dental alveolar protrusion, Class I malocclusion: A successful treatment result. Am J Orthod DentofacialOrthop. 1999;116:494-500. 2. Isaacson JR, Isaacson RJ, Speidel TM, Worms FW. Extreme variation invertical facial growth andassociated variation in skeletal and dental relations. Angle Orthod. 1971;44:219-29. 3. KimYH. Anterior openbite and its treatment with multiloop edgewise archwire. Angle orthod. 1987;57:290-321. 4.Hotokezaka H, Matsuo T, Nagakawa M, Mizuno A, Kobayashi K. Severe dental openbite malocclusion with tongue reduction after orthodontic treatment. Angle Orthod. 2001;71:228-36. 5. Subtenly JD. Openbite: diagnosis and treatment. Am J Orthod. 1964;50:337-58. 6. Dung DJ. Cephalometric and clinical diagnosis of openbite tendency. Am J Orthod Dentofacial Orthop. 1998;94:484-90. 7. Nielsen IL. Vertical malocclusions: etiology, development, diagnosis and some aspects of treatment. Angle Orthod 1991;61:247-60. 8. Lowe AA, Johnson WD. Tongue and jaw muscle activity in response to mandibular rotations in a sample of openbite subjects. Am J Orthod. 1978;76:565-76. 9. Harvold EP, Vargenik K, Chierici G. Primate experiment on oral sensation and dental malocclusion. Am J Orthod. 1973;63:494-508. 10. Hanson ML, Cohen MS. Effects of form and function on swallowing and anterior openbites. Am J Orthod. 1973;64:63-82. 11. Spyroulus NM, Askarieh M. Vertical control: A multifacial problem and its clinical implications. Am J Orthod.1976;70:70-80. 12. Kim YH. Overbite depth indicator with particular reference to anterior openbite. Am J Orthod.1974;65:586-611. 13. Kondo E, Aoba TJ. Nonsurgical and nonextraction treatment of skeletal Class III open bite: Its long term stability. Am J Orthod Dentofacial Orthop. 2000;117:267-87. 14. Hiller ME.Nonsurgical correction of Class II open bite malocclusion in an adult patient. Am J Orthod Dentofacial Orthop. 2002;122:210-6. 15. Denison TF, KokichVG, Shapiro PA. Stability of maxillary surgery in open bite versus non-openbite malocclusions. Angle Orthod.1989;59:5-10. 16. Bell WH. LeFort I osteotomy for correction of maxillary deformities. J Oral Surg 1975;33:412-26. 17. Lindsey CA, English JD. Orthodontic treatment and masticatory muscle exercises to correct a Class I open bite in an adult patient. Am J Orthod Dentofacial Orthop. 2003;124:91-8. 18. Pearson L. Vertical control in treatment of patients having backward-rotational growth tendencies. Angle Orthod. 1978;48:132-40. 19. Pearson L. Case report. Treatment of a severe openbite excessive vertical pattern with aneclectic non-surgical approach. AngleOrthod. 1991;61:71-6. 20. Subtenly JD. Openbite; diagnosis and treatment. Am J Orthod 1964;50:337-58.



Journal Of International Dental And Medical Research ISSN 1309-100X Phenylketonuria Patient After Prosthetic Treatment http://www.ektodermaldisplazi.com/journal.htm Aysegul G. Gurbulak et al.


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Outcome and Long-Term Follow-Up of a Phenylketonuria Patient After Prosthetic Treatment: a Case Report

Aysegul G. Gurbulak1, Mustafa Zortuk1*, Zekiye Eroglu1, Filiz Yagcı1, Bulent Kesim1

1. Department of Prosthodontics, Faculty of Dentistry, Erciyes University, Kayseri –Turkey

Abstract Phenylketonuria is the most common inborn error of amino acid resulting from hereditary factors. It occurs on average at a frequency of 1 in 3000 or 4000 in Turkey. If the treatment isn’t achieved, this aminoasit will be toxic to the developing brain, and mental retardation may progressively develop in the untreated individuals. Also Phenylketonuria effects the skeletal and dental development. A 10-year-old boy with phenylketonuria is presented in this case. This patient was referred to our clinic two years ago because of inefficient mastication resulting from absence of posterior teeth. At clinical examination, it was determined that maxillary and mandibular anterior teeth were present but posterior teeth were absent. The patient was treated with removable partial dentures that had been modified during eruption of permanent posterior teeth. The aim of the treatment was to reinforce the function of the chewing system and to accelerate eruption of the teeth. After the dentures were placed, they were controlled every month. The posterior parts of the dentures were renewed two times because of eruption of the premolar teeth. The patient has been controlled since 2005. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 11-15 ) Keywords: Phenylketonuria, teeth, denture. Received date: 23 January 2009 Accept date: 27 March 2009

Introduction Phenylketonuria (PKU) is an inborn error of phenylalanine metabolism resulting from deficient activity of L-phenylalanine-4-monooxygenase, the enzyme that catalyzes the synthesis of tyrosine from phenylalanine.1 Phenylalanine accumulation in plasma and tissues with decreased tyrosine biosynthesis seems to be involved in the PKU pathogenesis. Treatment of those with PKU consists of restriction of phenylalanine intake, which means a natural protein restricted diet supplemented with a phenylalanine free amino acid mixture enriched with some essential micronutrients, such as vitamins, minerals, and trace elements.2,3

Studies show that effective management of many children with inborn errors of PKU requires a highly cariogenic diet. Where protein intake must be restricted, for example, carbohydrate may be needed to supply up to 80% of energy intake per day. The role of sugars of all types is stresses in dietary management, including not only sucrose but also glucose polymers and cornstarch. Although they carry a risk to dental health, sugars have the advantage of being palatable and encouraging energy intake in children with poor appetite. Glucose polymers and cornstarch may also carry cariogenic potential. Recently studies have focused on caries, but other aspects of oral health may also be affected.4,5 There are few reports in the literature concerning with PKU after prosthetic treatment.This clinical study describes the long term follow-up and management of PKU in point of oral health.

CASE REPORT

A 10-year-old boy was referred to the prosthetics clinic at Dentistry Faculty of Erciyes University as his parents noted that his milestones were becoming delayed. He was diagnosed in Medicine Hospital, as having PKU and placed on a

*Corresponding author: Dr. Mustafa Zortuk Erciyes Üniversitesi Diş Hekimliği Fakültesi Protetik Diş Tedavisi Anabilim Dalı, Kampus. 38039 Melikgazi / Kayseri, Türkiye office: (+90352)4374937 -29078 Fax: (+90352) 4380657 E-mail: [email protected], [email protected]





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low-phenylalanine diet. However, the diet was hard to implement because of inefficient mastication resulting from absence of posterior teeth. His care was then transferred to our clinic where he was reviewed regularly during the following years. Firstly, the intraoral examination revealed bone atrophy of the alveolar ridges at posterior, on both the maxilla and the mandibula. Except central and lateral teeth, nearly no teeth were present. Orthopantomograph: displaying having less than half the normal number of the dentition (oligodontia), delayed eruption, and missed teeth. An acceptable solution to this complex case was sought, given the young age of the boy, and the emotional state of his parents, worried by the absence of numerous teeth in such esthetically compromised areas. Under these conditions, it was considered appropriate to make a lower and upper removable partial prosthesis that had been modified during eruption of permanent posterior teeth (Figure 1a,1b).

1a

Fig. 1a,1b Initial removable prostheses applied to the patient 1a and intraoral view of the prosthesis1b.

This design allows modifications to be made as and when necessary (Figure 2a,2b,2c,2d), as well as providing an acceptable masticatory function on complementing the lack of dentition, at the same time as attempting to maintain the alveolar ridges free of atrophy, and allowing an almost normal social life, which is so important at this stage in a child's personal and psychological development.

2a

2b

2c





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Fig. 2a, 2b, 2c, 2d Adjustment of prostheses during eruption of maxillary right first premolar and view of prostheses after trimming.

The importance of oral hygiene as a fundamental aspect of dental prognosis for PKU patients was stressed to the parents, in the sense that they monitor brushing, provide daily fluoride drops according to body weight, and control the eating of sweets and snacks between meals as far as possible. Periodic check ups were prescribed, approximately every months(Figure 3a,3b), at which topical applications of fluoride gel were to be applied as well as making small adjustments and modifications to the prosthesis, especially the upper one (Figure 4a,4b).

3a

Fig. 3a, 3b During eruption of maxillary right first

premolar and left first premolar, intraoral mucosa was marked for determining trimming areas.

4a

Figure 4a, 4b Adjustment of the maxillary prosthesis during maxillary right first, second and left second premolar erupted4a, readjustment prostheses4b. Now days, we are following the eruption of a still unerupted tooth, as well as insisting on good hygienic measures of daily brushing and mouth rinse, topical fluoride applications every six months, periodic checkups etc (Figure 5a,5b,5c,5d). Discussion

Dietary treatment is a primary choice avoids severe neurological damage in PKU. Good communication between the pediatrician, a specialist dietitian and, particularly, pediatric dentist is essential for effective management.6 According to Cleary at al.7 restorative treatment may be required for these cases. The main aim of restorative treatment should be to





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reduce the risk of further infection. Glass ionomer cements can be used temporarily and may provide useful fluoride release during the initial stages of caries stabilization. However, to date these materials have insufficient durability to be recommended for the long term.8 So, prosthetic treatments are fundamental in these patients, attempting to provide a functional and esthetic solution that will allow the child as normal a life-style as possible, without damaging psychological development.7,8

5a

Figure 5a, 5b After maxillary right first, second and left second premolar partially erupted, a second maxillary prostheses constructed. Conclusion In conclusion, the inborn errors of PKU are a group of individually rare but collectively relatively

common disorders in pediatric practice. The long term survival has improved as a result of early diagnosis. In addition, provision of dental treatment may be complicated by their metabolic disorders, and PKU requires careful multidisciplinary management of pediatric.

5c

Fig. 5c, 5d extraoral view of the second maxillary prostheses.

References

1. Scriver CR, Beaudet AL, Sly WS,Valle D. The Metabolic and Molecular Basis of Inherited Disease. New York: McGraw Hill.





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1667–1724. 2. Przyrembel H, Bremer HJ. Nutrition, physical growth, and bone

density in treated phenylketonuria. Eur J Pediatr 2000;159: 129–135.

3. Gassió R, Artuch R, Vilaseca MA, Fusté E, Boix C, Sans A, Campistol J. Cognitive functions in classic phenylketonuria and mild hyperphenylalaninaemia: experience in a paediatric population. Dev Med Child Neurol 2005;47:443-448.

4. Roberts JF, Sheriff M. the fate and survival of amalgam and preformed restorations placed in specialist paediatric practice. Br Dent J 1990; 169:237-244.

5. Cleary M, Walter JH. Assessment of adult phenylketonuria. Ann Clin Biochem 2001 ;38:450-458.

6. Arnold GL, Vladutiu CJ, Kirby RS, Blakely EM, Deluca JM. Protein insufficiency and linear growth restriction in phenylketonuria. J Pediatr 2002;1412:243-246.

7. Cleary MA, Francis DE, Kilpatrick NM. Oral health implications in children with inborn errors of intermediary metabolism. Int J Paediatr Dent 1997;3:133-141.

8. Kilpatrick NM. Durability of restorations in primary molars. J Dent 1993;21:67-73.



Journal Of International Dental And Medical Research ISSN 1309-100X Oral Findings of The Gigantic Patient http://www.ektodermaldisplazi.com/journal.htm Filiz Acun Kaya et al.


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The Oral Findings of the Gigantic Patient with Gingival Enlargement-(a Case)*

Filiz Acun Kaya1**, Ebru Saribas1, Arzum Guler Dogru1, Ahmet Dag1, Ahmet Gunay2

1 Assistant Professor, Dicle University Faculty Of Dentistry Department Of Periodontology, Diyarbakir, TURKEY. 2 Research Assistant, Dicle University Faculty Of Dentistry Department Of Periodontology, Diyarbakir, TURKEY.

Abstract This syndrome results from a chronic exposure to GH (Growth Hormone) leading to the classic

clinical features that the diagnosis seems to be easy. The early diagnosis and intervention may prevent irreversible changes associated with chronic overproduction of GH (as well IGF-1) and may also normalise life expectancy. These patients have an increased mortality rate from systemic sequela of hypersomatotrophism in 2-4 times that of the healthy population. The facial scene changes are generally coarsening of features prognathism and diastema (widely spaced teeth). In this case report it is aimed to represent the periodontal surgery findings of a 24 years old male gigantism patient suffering from gingival enlargement in the site of 11 and 12 teeth who applied to Dicle University Faculty of Dentistry Department of Periodontology. After oral hygiene instruction, initial periodontal treatment was performed and after these the patient was operated. The patients periodic follow ups are still lasting by three months intervals. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 16-18 ) Keywords: Gigantism, gingival enlargement. Received date: 02 November 2008 Accept date: 15 January 2009

Introduction

Gigantism is characterized by excessive height and body proportions; acromegaly is characterized by the disproportional enlargement of acral parts, hands, and feet and the coarsening of facial features, with enlargement of supraorbital ridges, nose, ears and chin, thick lips and exaggerated nasolabial folds. Although, there is no clear demarcation between a tall normal person and a pituitary giant, a height in excess of 225 cm (7 feet 4 inches) is considered to be in the gigantic range and almost invariably is due to excessive growth hormone (GH) secretion. In growing children, however, the possibility of gigantism should be considered when the height exceeds 3 or 4 standard deviation(1). Frequency of Gigantism is a rare disorder and probably no more than 100 patients have been reported (2). More

than 15 patients have been reported since 1989, when one counts patient reports (3-14) and patients included in group studies. Thus, it may be more frequent than previously thought. The most characteristic manifestations are increase in height and growth velocity and the enlargement of the acral parts of the body. The acral enlargement is due to an increase in soft tissue as well as to periosteal bone growth. Coarsening or thickening of the facial features, increased supraorbital ridges, and prognathism ocur sooner or later in all giants. The hands and feet attain extraordinary size. Enlargement of the viscera may be evident on physical examination. The patients may perspire profusely and have oily skin. Kyphosis, subluxations, joint deformities, and arthropathy are frequent problems. Arthralgia is a common complaint of patients with gigantism and acromegaly; it may involve the spine in addition to peripheral joints and may lead to irreversible cartilage degeneration. There is synovial and periarticular swelling.

CASE REPORT

In this case a 24 years old gigantic male patients applied to Periodontology Department of Dentistry Faculty of Dicle University with gingival swelling on maxillary anterior region which was causing speaking, eating and aesthetic problems. By the anamnesys it was recorded that the

* This case report submitted to the 12 th Congress of the Balkan Stomatological Society, İstanbul, April 12-14, 2007. **Corresponding author: Dr. Filiz ACUN KAYA, Assistant Professor, Dicle University, Faculty Of Dentistry, Department of Periodontology, 21280 Diyarbakir/TURKEY. Tel: +90 412 248 81 01-3430 Fax: +90 412 248 81 00 E-mail: [email protected]






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patient was 242 cm (7 feet, 11 inches) tall, 155 kg in weight and had been medicated in Dicle University Faculty of Medicine Department of Endocrinology. We interviewed his physician by the regard of the record of his treatment with injectable octreotide (sandostatin lar® ) and normal growth hormon levels which were controlled regularly. Intraoral examination was determined an epulis in the site of 11 and 12 teeth (Fig. 1, 2).

Fig. 1 Intra-oral scene.

Fig. 2 Radiographic scene.

Initial periodontal treatment was begun (scaling, root planing). Chlorhexidine rinse was recommended twice daily and the patient was instructed how to maintain proper oral hygiene. At the end of the treatment, gingival inflammation was decreased. In this way, enlargement decreased. Remaining of gingival enlargement was removed with gingivectomy (Fig. 3). The patient has a follow up two month later (Fig. 4).

Fig. 3 Post- Operative Intra-oral scene.

Discussion

Epulis is a generic term used clinically to designate all discrete tumors and tumorlike masses of the gingiva. It serves to locate the tumor but not to describe it. Most lesions referred to as epulis are inflammatory rather than neoplastic. İt is possibly originates as a response of tissues to minor trauma and/or chronic irritation, thus opening a pathway for invasion of non-specific microorganisms, although microorganisms are seldom demonstrated within these lesions.

They are more common in the maxillary anterior region. Gingival irritation and inflammations that result from poor oral hygiene, dental plaque, calculus and diastema or over-hanging restorations may be precipitating factors in many cases (15). Also may be caused by hormonal changes (16).

Conclusions We diagnosed that this case was caused by

food impaction associated with diastema and poor oral hygiene, not from excessive growth hormon release. It is marginal, interdental and caracterized by prominent bulbous interproximale papillae.

References

1. Sotos JF, Romshe CA. Giantism and Acromegaly. In: Gardner L, ed. Endocrine and Genetic Diseases of Childhood. Philadelphia: WB Saunders Co; 1975. 2. Blumberg DL, Sclar CA, David R, et al. Acromegaly in an infant. Pediatrics. 1989;83:998-1002. 3. Vogl TJ, Nerlich A, Dresel SH, Bergman C. CT of the "Tegernsee Giant": juvenile gigantism and polyostotic fibrous dysplasia. J

Fig. 4 The patient was 242 cm (7 feet, 11 inches) tall.





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Computer Asist Tomogr. 1994;18:319-322. 4. Gelber SJ, Heffez DS, Donohoue PA.Pituitary gigantism caused by growth hormone excess from infancy. J Pediatr. 1992;120:931-934. 5. Lu PW, Silink M,Johnston I, et al. Pituitary gigantism. Arch Dis Child. 1992; 67:1039-1041. 6. Iwatani N, Kodama M, Seto H. A childwith pituitary gigantism and precocious adrenarche: does GH and/or PRL advance the onset of adrenarche? EndocrinolJpn. 1992;39:251- 257. 7. Matsuura H, Kitazawa Y, Tanaka M, Morooka K. Pituitary adenoma and unexpected sudden infant death: a case report. Med Pediatr Oncol. 1994; 22:283-286. 8. Fazekas I, Pasztor E, Slowik F, et al. Pathological and experimental investigations in a case of gigantism. Acta NeuropathoL 1993;85:167-174. 9. Zimmerman D, Young WF Jr, Ebersold MJ, et al. Congenital gigantism due to growth hormone-releasing hormone excess and pituitary hyperplasia with adenomatous transformation. J Clin Endocrinol Metab. 1993;76: 216-222. 10. Moran A, Asa SL, Kovacs K, et al. Gigantism due to pituitary mammosomatotroph hyperplasia. New EnglJ Med. 1990;323:322-327. 11. Araki Y, Sakai N, Andoh T, et al. Central neurocytoma presenting with gigantism: case report. Surg Neurol. 1992;38:141-145. 12. Cuttler L, Jackson JA, Saeed us-Zafar M, Levitsky LL. Hypersecretion of growth hormone and prolactin in Mc- Cune-Albright syndrome. J Clin Endocrinol Metab. 1989;68:1148-1154. 13. von Werder K, Losa M, Stalla GK, et al. Long-term treatment of a metastasizing GRFoma with a somatostatin analogue (SMS 201-995) in a girl with gigantism. ScandJ Gastroenterol. 1986; 119 (Suppl 21):238. 14. Espiner EA, Carter TAH, Abbott GD, Wrightson P. Pituitary gigantism in a 31 month old girl: endocrine studies and successful response to hypophysectomy. J Endocrinol Invest. 1981;4: 445-450. 15. Neville BW, Damm DD, Allen CM, Bouquot JE (2002) Oral & maxillofacial pathology. 2nd ed, WB Saunders, Philadelphia, 437-495 16. Carranza FA ,Newman MG. Gingival enlargement .Clinical Periodontology. Ed: Carranza FA.9 th ed. W.B. Saunders Company, Philedelphia, London, New York, St. Louis,Sydney,Toronto.2002.



Journal Of International Dental And Medical Research ISSN 1309-100X Dental Menagement with HED http://www.ektodermaldisplazi.com/journal.htm E. Caner Tumen et al.


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Direct Composite Resin Application, and Prosthetic Management in a Patient with Hypohidrotic Ectodermal Dysplasia: a Case Report

E.Caner Tumen1, Nihal Hamamci2, Yalcin Deger3, Demet Suer Tumen4, Engin Agackiran5

1Assist. Prof. DDS PhD Dicle University, Faculty of Dentistry Department of Pedodontics Diyarbakir/TURKEY. 2Assist. Prof. DDS PhD Dicle University, Faculty of Dentistry Department of Orthodontics/Diyarbakir/TURKEY. 3Assist. Prof. DDS PhD Dicle University, Faculty of Dentistry Department of Prosthodontics/Diyarbakir/TURKEY. 4Research Assistant DDS Dicle University, Faculty of Dentistry Department of Orthodontics Diyarbakir/TURKEY. 5Research Assistant DDS Dicle University, Faculty of Dentistry Department of Pedodontics Diyarbakir/TURKEY.

Abstract Ectodermal dysplasia is a rare group of disorders affecting the nails, hair, teeth, and sweat glands

to a variable degree. The most common form of ectodermal dysplasia is X-linked hypohidrotic ectodermal dysplasia, which affects males more severely, while heterozygous females exhibit variable severity, ranging from mild to severe, because of inactivation of the X-chromosome.

The 7-year, 3-month-old boy presented the classical features of hypohidrotic ectodermal dysplasia, including diffusely sparse hair, eyelashes and eyebrows, severe hypohidrosis, and subsequent problems with thermoregulation, dry skin and fingernail defects. Considering the clinical situation, the age and potential growth of the young patient, a maxillary RPD and mandibular complete denture were determined to be the treatment of choice.

HED is usually a difficult condition to manage prosthodontically, because of the typical oral deficiencies and afflicted individuals are quite young to receive extensive prosthodontic treatment, which restores their appearance, for the development of a positive self-image. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 19-24 ) Keywords: Hypohidrotic ectodermal dysplasia, hypohidrosis, composite resin restoration, prosthetic management. Received date: 15 December 2008 Accept date: 25 February 2009

Introduction

Ectodermal dysplasia (ED) is a congenital

dysmorphogenesis of epithelial derivatives. This group of rare inherited disorders is characterized by the abnormal development in the embryonal stage.1,2 It comprises over 150 distinct conditions of pathogenesis.2 The commonly known signs of nail dystrophy (onchodysplasia), alopecia or hypotrichosis (scanty, fine light hair on the scalp and eyebrows), and palmoplantar hyperkeratosis3 is usually accompanied by a lack of sweat glands (hypohidrosis) and a partial or complete absence of the primary and/ or permanent dentition.

Orofacial characteristics of this syndrome include hypoplastic conical teeth, underdevelopment of the alveolar ridges, frontal bossing, a depressed nasal bridge and protuberant lips.4,5 The most frequently reported ED syndrome is X-linked recessive hypohidrotic ectodermal dysplasia4,6 (HED; OMIM#305100) where males are usually more severely affected, and female carriers show variable severity ranging from mild to severe because of X-chromosome inactivation.2,6

The X-linked form of HED is caused by mutations in the ED1 gene, located at Xq12-q13.1.2 HED also known as Christ-Siemens-Touraine syndrome affects 1 to 7 individuals per 10.000 live births.7 Most patients with HED have a normal life expectancy and normal intelligence. However, the lack of sweat glands may lead to hyperthermia, followed by brain damage or death in early infancy, if unrecognized. Thus an early diagnosis is important.8

Dentures typically are needed at an early age and can be problematic because of poorly developed alveolar ridges.9 Oral rehabilitation of the HED patient is recommended to improve both the sagittal and vertical skeletal relationship during craniofacial growth and development7, as well as to

*Corresponding author:

Dr. E. Caner TÜMEN Dicle University Faculty of Dentistry Department of Pedodontics Diyarbakir / TURKEY Phone: + 90. 412. 2488101/3406 Fax: + 90. 412. 2488100

E-mail: [email protected]






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provide improvements in aesthetics, speech and masticatory efficiency. Prosthetic solutions for HED patients have consisted of various combinations of RPDs, fixed partial dentures and endosseous implants.3,9-12. The aim of this paper is to present the early prosthetic oral rehabilitation of a young boy with HED associated with severe hypodontia; only the maxillary primary centrals were present and total lack of teeth in the mandible.

CASE REPORT

A 7-year, 3-month-old boy was referred to the Department of Pediatric Dentistry, Dicle University, Diyarbakır, Turkey for examination, evaluation and treatment. The chief complaints of the patient, who came to our clinic from an orphanage, accompanied by a nurse, were difficulty in eating because of a lack of teeth and mockery from his peer group. The child presented the classical features of HED, including diffusely sparse hair, eyelashes and eyebrows, severe hypohidrosis, and subsequent problems with thermoregulation, dry skin and fingernail defects. The facial profile showed a sunken nasal bridge, with prominent forehead and everted lips. An overclosed profile with decreased lower face height and creased oral commissures gave the impression of an older, more “aged” appearance12 (Figs.1,2).

Fig. 1 Frontal view of 7-year-old patient with hypohidrotic ectodermal dysplasia before treatment.

Fig. 2 Pretreatment lateral facial photograph shows extremely decreased vertical dimension.

Clinical oral examination revealed large tonque, a slightly dry and sticky oral mucosa, and severe hypodontia; only the maxillary primary centrals were present and total lack of teeth in the mandible (Fig. 3).

Fig. 3 Intraoral examination revealed severe hypodontia; maxillary conical shaped primary centrals are present.

He exhibited aplasia of alveolar bone in the edentulous area. Also, the two conical shaped maxillary permanent centrals, and the right maxillary canine, were evident on the panoramic radiograph (Fig. 4).

Fig. 4 Panoramic radiograph. Right maxillary permanent canine, 2 permanent centrals and 2





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primary centrals are present and total lack of teeth in the mandible. The nurse stated that it was difficult for the child to speak and eat properly because of the lack of teeth. Considering the clinical situation, dental and skeletal maturity and the early age of the patient, a maxillary RPD and mandibular complete denture were determined to be the treatment of choice. Cephalometric analysis findings revealed that the patient, with severe low angle pre-prosthetic rehabilitation was restored to a mesofacial status post-rehabilitation. The patient’s anterior facial height was determined to have increased from 91 mm to 107 mm, and as a result of analysis of the jaws’ relationship to the cranial base, the patient’s facial depth angle was determined to have decreased from 91 mm to 86 degrees (ideal normative value 86º±3). At the same time, SNB angle decreased from 76 to 69,5 degrees and the relationship between the mandible and cranial base was restored to normal. Mandibular plane angle was observed to have risen from 17 to 26 degrees (ideal normative value 17-28º) and nasolabial angle to have increased from 67 to 106 degrees (ideal normative value 102º±8), thus providing an aesthetically acceptable lip fullness (Figs. 5A, B).

Fig. 5A Cephalometric landmarks, linear and angular measurements used in this case report. (N), Nasion: Most anterior point on fronto-nasal suture; (S), Sella: Midpoint of sella turcica; (Pg), Pogonion: The most anterior point on the mandibular symphysis; (Me), Menton: The lowermost point on the shadow of the mandibular symphysis; (Go), Gonion: The most outward point on the angle formed by the junction of the ramus and body of the mandible on its posterior, inferior aspect; (Po), Porion: The superior aspect of the external auditory meatus; (Or), Orbitale: The lower border of the orbit of the eye; (B), Point B: The

deepest (most posterior) midline point on the bony curvature of the anterior mandible. (1) Anterior facial height: The measurement between nasion and menton points. Representing anterior face development of the patient. (2) Facial depth angle: The angle between facial plane (N-Pg) and frankfort horizontal plane (Po-Or). Representing the horizontal development of the chin. (3) SNB angle: The angle between S-N plane and B point. Determining mandibular position according to cranial base. (4) Mandibular plane angle: The angle between frankfort horizontal plane (Po-Or) and mandibular plane (Go-Me). Representing the vertical development of the patient. (5) Nasolabial angle: The angle formed by the intersection of the columella tangent and the upper lip. Determining the upper lip position according to the nose.

Fig. 5B Cephalometric superimposition. In addition to function, particular attention was paid to appearance of the anterior region of the patient, who had presented with aesthetic complaints. Therefore, the maxillary primary centrals were initially morphologically restored with composite resin. Preliminary impressions were made with irreversible hydrocolloid (Cavex, CA37, Cavex Holland B.V. of Haarlem, The Netherlands). Custom trays were fabricated with autopolymerized acrylic resin (Duracryl; Spofa Dental, Prague, Czech Republic), and definitive impressions (Elite, Zhermack, Rovigo, Italy) were made. Maxillomandibular records were made, and the casts were mounted in an articulator. The artificial teeth were arranged in wax for trial evaluation. The occlusion and position of the prosthetic teeth were evaluated intraorally, and the necessary corrections were made before processing the dentures. The completed dentures gave the patient a natural appearance (Figs. 6-8A,B).





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Fig. 6 Lateral facial photograph with dentures shows harmonious proportion of face.

Fig. 7 Frontal view of the patient after treatment.

Fig. 8A Pretreatment photograph.

Fig. 8B Posttreatment photograph. Instructions were given to the child and the nurse to maintain a soft diet for the first few days to facilitate accommodation; also, the necessity of regular cleaning and maintenance was explained. The patient was instructed to remove the dentures at night and to present the following day and once a week for a period of 2 months for inspection and possible corrections and adjustments.13 The child was monitored every 3 months, and the nurse reported only minor problems during the adaptation period, and the accommodation to both partial and complete dentures occurred relatively rapidly, with considerable improvements in speech, aesthetics and general well-being, including the social adaptation of the child. The denture must be periodically modified as alveolar growth, erupting teeth and rotational jaw growth change both the alveolar, occlusal and basal dimensions. As a result, the patient’s dentures had to be remade 7 months later due to the growth of his jawbones.





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Discussion

Children with ED present many and different clinical problems from early childhood through adolescence and also present a life-long need for maintenance care and revisions. The principal aims of dental treatment for HED patients are to restore missing teeth and bone, establish the normal vertical dimension and provide support for the facial soft tissues.

The treatment modalities generally used include operative and prosthodontic treatment. For the hypoplastic teeth common with ED, direct composites or crowns often are used to restore proper contours to the teeth.9,14 Treatment also can involve fixed, removable or implant prosthodontics, singly or in combination. Removable prosthodontics is the most frequent modality used for dental treatment of ED.15 Although complete dentures are an acceptable form of treatment, overdentures that are supported by natural teeth will preserve the alveolar bone. Implant-supported restorations can improve physiological and psychosocial function to a greater degree than can complete dentures.9

Oligodontia or total lack of teeth associated with ED is often characterized by underdeveloped alveolar bone structures with missing or reduced alveolar ridges. This results in less volume of bone for support of conventional prosthetic dentures, and it can also affect the bone volume available for the placement of dental implants.10 In developing the optimal surgical and prosthetic approach, the patient’s age, dental and skeletal maturity, and the bone volume that is available at the time of intervention must be considered.16

In the present case report, considering the clinical situation, the age and potential growth of the young patient, a maxillary RPD and mandibular complete denture were determined to be the treatment of choice. Required dental imlant application to provide an optimal treatment is postponed until the patient is fully grown. Early prosthetic rehabilitation of ED patients is crucial. Some authors recommend that the initial prosthesis be delivered before the child begins school so that the child has time to adapt to it.14 This results in significant improvement in aesthetics, masticatory and phonetic functions.12 In addition, the restoration of a natural and pleasing appearance is important for the normal psychological development of children with HED and their future social integration. Although dentures are poor alternatives to healthy teeth, they create conditions for the maintenance of a normal, satisfactory daily diet for the child. This is very important, considering that the establishment of lifelong dietary patterns occurs during

childhood.17 In HED patients, dryness of the oral mucosa

and the underdeveloped maxillary tuberosities and alveolar ridges are problematic factors for resistance and stability of dentures. Therefore, retention and stability of the prostheses are difficult to obtain. When planning dentures in these patients, care should be taken to obtain a wide distribution of occlusal load fully extending the denture base. The remaining anterior teeth, due to their atypical conical shape, may not be suitable to stabilize RPDs. However, they may be used as abutments for overdentures.11,13 Also, special attention must be paid to the impression technique; for complete dentures, support should not be limited to the denture base area but should also include the entire vestibular sulcus reflection for a retentive base construction with border seal.13 For RPDs, the occlusion should be compatible with the patient’s occlusion; generally, an occlusal scheme utilizing linear occlusal contact is recommended to preserve the existing teeth and to create freedom of movement.3 In this case report, the patient had only minor problems related to extremely reduced alveolar process, which generally result in having poor retention, stability and inability to use prosthesis; moreover, the accommodation to both partial and complete dentures occurred relatively rapidly.

Periodic recalls of young HED patients are also important because prosthesis modification or replacement will be needed as a result of continuing growth and development.18,19 In addition to adjustments related to fit, the occlusion of a prosthesis must be monitored for changes due to jaw growth.19 Other problems related to removable prostheses are speech difficulties, dietary limitation, and loss of the prosthesis.18

Conclusions

Young children with anadontia caused by hypohidrotic ectodermal dysplasia not only have difficulties in eating and speaking but can also sense that their appearance is different than others. Early rehabilitation of children with hypohidrotic ectodermal dysplasia will go a long way in helping them interact normally and integrate with their peers. But one must remember that any form of restoration or prosthesis should provide dentition confirming with the age of the patient. References

1. Johnson EL, Roberts MW, Guckes AD, Bailey LJ, Phillips CL, Wright JT. Analysis of craniofacial development in children with hypohidrotic





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ectodermal dysplasia. Am J Med Genet 2002;112:327-334. 2. Kere J, Srivastava AK, Montonen O, et al. X-linked anhidrotic (hipohidrotic) ectodermal dysplasia is caused by mutation in a novel transmembrane protein. Nat Genet 1996;13:409-416. 3. Bonilla ED, Guerra L, Luna O. Overdenture prosthesis for oral rehabilitation of hypohidrotic ectodermal dysplasia: a case report. Quint Int 1997;28:657-665. 4. Levin LS. Dental and oral abnormalities in selected ectodermal dysplasia syndromes. Birth Defects Orig Artic Ser 1988;24:205-227. 5. Champlin TL, Mallory SB. Hypohidrotic ectodermal dysplasia: a review. J Ark Med Soc 1989;86:115-117. 6. Freire-Maia N, Pinheiro M. Ectodermal dysplasia: a clinical and genetic study. New York: Alan R. Liss;1984: 25-31. 7. Buyse ML. Birth defects encyclopedia. St. Louis: Blackwell Publishing,1990:597-598. 8. Mortier K, Wackens G. Ectodermal dysplasia syndrome. Orphanet encyclopedia. September 2004. 9. Pigno MA, Blackman RB, Cronin RJ Jr, Cavazos E. Prosthodontic management of ectodermal dysplasia: a review of the literature. J Prosthet Dent 1996;76:541-545. 10. Guckes AD, Scurria MS, King TS, McCarthy GR, Brahim JS. Prospective clinical trial of dental implants in persons with ectodermal dysplasia. J Prosthet Dent 2002;88:21-25. 11. O’Dwyer MR, Renner RP, Fergusen FS. Overdenture treatment – one aspect of the team approach for the EEC syndrome patient. J Pedod 1984;8:192-205. 12. Ramos V, Giebink DL, Fisher JG, Christensen LC. Complete dentures for a child with hypohidrotic ectodermal dysplasia: a clinical report. J Prosthet Dent 1995;74:329-331. 13. Dyson JE. Prosthodontics for children. In: Wei SHY, editor. Pediatric dentistry and orthodontics: total patient care. Philadelphia: Lea & Febiger,1988: 259-274. 14. Till MJ, Marques AP. Ectodermal dysplasia: Treatment considerations and case report. Northwest Dent 1992;71:25-28. 15. Murdock S, Lee JY, Guckes A, Wright JT. A costs analysis of dental treatment for ectodermal dysplasia. J Am Dent Assoc 2005;136:1273-1276. 16. Imirzalioglu P, Uckan S, Haydar SG. Surgical and prosthodontic treatment alternatives for children and adolescents with ectodermal dysplasia: a clinical report. J Prosthet Dent 2002;88:569-72. 17. Kravitz E, Pollack RL, Mueller DH. Nutrition during pregnancy, infancy, childhood, and adolescence. J Pedod 1983;7:182-195. 18. Nowak AJ. Dental treatment for patients with ectodermal dysplasia. Birth Defects Orig Artic Ser 1988;24:243-252. 19. Nomura S, Hasegawa S, Noda T, Ishioka K. Longitudinal study of jaw growth and prosthetic management in a patient with ectodermal dysplasia and anodontia. Int J Paediatr Dent 1993;3:29-38.



Journal Of International Dental And Medical Research ISSN 1309-100X Chylothorax with Down Syndrome http://www.ektodermaldisplazi.com/journal.htm Alper Avci et al.


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Chylothorax with Down Syndrome: Unusual Case Report

Alper Avci1, Refik Ulku2*, Serdar Onat3

1 Dr. Alper Avci*MD, Resident in Thoracic Surgery Dicle University School of Medicine Thoracic Surgery Department Diyarbakir- TURKEY. 2 Dr. Refik Ulku* MD, Associate Professor, Dicle University School of Medicine Thoracic Surgery Department Diyarbakir- TURKEY. 3 Dr. Serdar Onat* MD, Assistant Professor, Dicle University School of Medicine Thoracic Surgery Department Diyarbakir- TURKEY.

Abstract Trisomy 21 or Down syndrome (DS) is the most common chromosome aberration in the newborn. Its

high incidence has led to better understanding of congeniatal anomalies and diseases in association with this syndrome. The presence of protein, triglycerides, and lymphocytes in the pleural effusion is diagnostic of chylothorax. Lymph vessel abnormalities or a leaky thoracic duct are thought to be origin of congenital chylothorax, which is repoted many times in the literature. But, there is no information in the english literature about 1-year-old baby with DS who is complicated with chylothorax. Aplasia of the twelfth rib is rare but found to be more common in DS than in normals. We report on a 1-year-old girl with DS refered to our clinic with signs and symptoms of respiratory distress. Diagnosis and treatment of chylothorax, pleural emphyema, and pericardial effusion were obtained in algorithm. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 25-27 ) Keywords: Chylothorax , Down Syndrome. Received date: 14 October 2008 Accept date: 10 January 2009

Introduction

Trisomy 21 may present with congenital

chylothorax giving rise to symptoms of respiratory distress. To the best of our knowledge, there is no information in english literature about 1-year old baby with DS who is complicated with chylothorax. We report on a case with trisomy21 and complicated cyhlothorax.

Case Report

One-year- old girl had admitted to a local hospital with fever and respiratory findings such as tachypnoea and dry cough for one week duration. She was refered to our emergency room after bilaterally chest tube insertion. She was first evaluated in the emergency room.

There was no history of trauma, surgery, and malignancy. On admission, her body temperature was 37.70C, pulse rate 128/min and respiratory rate 36/min.

Poor breath sounds were noted in auscultation.

She had atypical facies with low-ser ears, epicanthic folds, high-arched palate and short fingers. Initial laboratory findings were as follows: Hb 10.1 g/dl, haematocrit 28.5%, WBC 26300/mm3, platelets 261000mm3, total protein 4.4mg/dl, glucose 84mg/dl, LDH 1142 U/L, triglyceride 174 mg/dl, cholesterol 79 mg/dl.

She had bilaterally tube thoracostomy. Left chest tube drainage was 150cc and dirty-brown colored. Right sided chest tube drainage was 200cc and milky. Biochemical analysis of the left-sided pleural effusion was as follows: glucose 4mg/dl, protein 3.6mg/dl and LDH 5198 U/L. There was no bacteria on the gram stain.

Left-sided pleural effusion was diagnosed as pleural emphyema.

Biochemical analysis of the right-sided pleural effusion was as follows: glucose 40mg/dl, LDH 607 U/L, protein 2.3 mg/dl, triglyceride 266 mg/dl, cholesterol 32 mg/dl.

There was no bacteria on the gram stain. Right-sided pleural effusion was diagnosed as chylothorax. Antero-posterior plain chest graphy showed aeration defect (pleural effusion) in the left hemithorax, mediastinal shift into right side, aplasia of the twelfth rib and bilaterally chest tubes. (figure 1).


Dr. Refik ÜLKÜ Dicle University School of Medicine Thoracic Surgery Department 21280 Diyarbakır- TURKEY Fax: +90 412 2488440 (Dean Office)







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Fig. 1 Antero-posterior plain chest graphy at the admission. Abdominal ultrasound and throid hormones were all normal. Chest computed-tomography (CT) revealed significant pericardial effusion, pleural effusion in the left hemithorax, minimal pleural effusion in the right hemithorax, and bilaterally chest tubes (figure 2).

Fig. 2 Chest CT at the admission.

She was hospitalized into thoracic surgery clinic’s intensive care unit. Breast feding was stopped and intravenous total parenteral feding was started. Vancomycin and amicasin antibiotherapy was started. After 5 days, bilateral pleural effusion on the chest graphies resolved and disappeared. But, pericardial effusion continued.

Tube pericardiostomy was performed at the 6th day of hospital stay. Right chest tube was ended at the 8th day, and breast feeding was reinitiated at the 10th day. Pericardial tube and left chest tube were ended at the 13th and 14th days. Control chest CT revealed left-sided pleural thickness. Because of this left total decortication was performed at the 21st day via thoracotomy. The diagnosis of Down syndrome was established by

chromosomal analysis (figure 3).

Fig. 3 Genetic analysis for trisomy 21 diagnosis.

Postoperative course was uneventfull and patient was discharged 27 days after admission. At the 1st and 6th months controls, she was still on breast feding and in healthy state.

Discussion

Chylothorax is the leakage of chyle from the thoracic duct or its branches into the pleural space secondary to obstruction or disrubtion of the thoracic duct. Neonatal spontaneous chylothorax may be idiopathic, but often accompanies congenital heart diseases1. There was no congenital heart disease in our present case. Lymph vessel abnormalities or a leaky thoracic duct are thought to be origin of spontaneous chylothorax. The prevalence is approximately 1 in 2000 infants admitted to neonatal intensive careunits, and frequently associated with genetic anomalies such as trisomy 21, monosomy X, and Noonan syndrome, all with frequent lymph vessel abnormalities 2. This child was diagnosed as DS, and her spontaneous unilateral chylothorax might be related with genetic disease. Other causes of chylothorax include interruption of the thoracic duct by trauma or surgery and intrathoracic malignancies3.

The ideal management of the patients with chylothorax is unknown. Modalities used in treatment of chylothorax are as follows: Concervative ( nothing by mouth, medium-chain triglycerides, central hyperalimentation, drainage of pleural space ( thoracentesis, closed chest tube thoracotomy), complete expansion of lung), Operative ( direct ligation of thoracic duct, mass ligation of thoracic duct tissue, pleuroperitoneal shunting, pleurectomy, fibrin galue), and





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radiotherapy4. Closed chest tube drainage and central hyperalimentation provided succesfull management for present case. Willich E. Et al reported that abnormal ossification of the manubrium (33%), aplasia of the twelfth rib (18%), high lumbar vertebral bodies (50%), brachymesophalangia of the fifth ray ( 62%) are found to be more common in DS5. Our present case had also aplasia of rigt-sided twelfth rib, but it is not required any management. Conclusions

Spontaneous chylothorax may be associated with DS. Pleural effusion with DS must be promptly diagnosed and aspirated. Physicians should take into consideration DS patients with onset of shortness of breath, dry cough for pleural effusion. Physical, biochemical and radiological examinations have to be obtained for diagnosing.

References

1. Horn KD, Penchansky L. Chylous pleural effusions simulating leukemic infiltrate associated with thoracoabdominal disease and surgery in infants. Am J Clin Pathol. 1999; 111: 99-104.

2. Young S, Dalgleish S, Eccleston A, Akierman A, McMillan D. Severe congenital chylothorax treated with octeroide. J Perinatol. 2004; 24: 200-202.

3. Kallanagowdar C, Craver RD. Neonatal Pleural Effusion. Arch Pathol LabMed. 2006; 130: 22-23.

4. Shields TW, Locicero J, Ponn RB, Rusch VW. General Thoracic Surgery. Sixth ed. Philadelphia: Lippincott Williams&Wilkins, 2005: p885.

5. Willich E, Fuhr U, Kroll W. Skeletal changes in Down’s syndrome. A correlation between radiological and cytogenetic findings (author’s transl). Rofo. 1977; 127: 135-142.



Journal Of International Dental And Medical Research ISSN 1309-100X PMF effect on tooth pain threshold http://www.ektodermaldisplazi.com/journal.htm Ruben Hovhannisyan and Sinerik Ayrapetyan


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The Effect of Extremely Low Frequency Pulsing Magnetic Fields on Pain Threshold of Human Frontal Teeth

Ruben Hovhannisyan1, Sinerik Ayrapetyan1*

1. UNESCO Chair-Life Sciences International Postgraduate Educational Center, 31 Acharyan st. Yerevan, 375040 Armenia.

Abstract The purpose of this work was to study the effect of Extremely Low Frequency Pulsing Magnetic

Fields (ELF PMF) on pain threshold of human frontal teeth by means of algesimetric method. For the determination of pain threshold an electric current generated by electroodontometer

“Biophys-odontometr -1” (production of Armenian Radiophysics institute) was passed through the tooth. The application of PMF was performed with the help of ELF EMF source “Magniter--02” (frequency-50Hz, intensity-30mT) using in magnetotherapy (production of NPO “Polet” Nijni Novgorod, Russia). In total 720 measurements were performed: 360-control and 360-experiments.

The obtained data have shown that teeth had different pain thresholds and sensitivity to PMF. The differences were also observed in male and female teeth. The pain threshold in female was lower (about 31%), while the sensitivity to PMF was higher (about 20%) than in male. In female the PMF had significant elevating effect on pain threshold, while in male this effect was varied depending on their location in oral cavity.

It is suggested that the more detailed characterization of PMF-sensitivity of each tooth, i.e. pain threshold-dependency on PMF intensity and exposure time, would allow us to use the ELF PMF in dentistry as a pain releasing method. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 28-32 ) Keywords: Pain threshold; Tooth; Pulsing Magnetic Fields; Oral cavity. Received date: 12 January 2009 Accept date: 15 March 2009

Introduction The orofacial region very often serves as a pain

source for human beings and this pain could have physical and psychological natures. Physical pain could be generated by external or internal factors (acute pain) or could have a neuropathological nature (chronic pain). Tooth pain can be generated upon the effect of different factors on pain receptors (nociceptors).

They are concentrated in tooth tissues (15000-30000 nociceptors are located in 1 cm2 of dentin, while in the border of dentine-enamel this number is about 75000). It is considered that 25-40% of receptors in orofacial region are nociceptors, which could be stimulated by mechanical, thermal and chemical factors.

There are also polimodal receptors, which are

sensitive to all these three factors. As the functions of all these receptors are realized through the activation of potential-dependent ionic channels (responsible for generation of action potentials) in the membrane of nerve endings, the minimal intensity of electric current passing through the tooth, able to generate the pain sense, could be considered as a pain threshold for each tooth.

There is a wide variability between pain thresholds of different teeth as well between the same teeth of different patients. The opiate receptors and endorphins, enkephalin release in nervous system form the antinociceptive system of organism. So, the determination of tooth pain threshold by odontometric method could be considered as an integrative response of nociceptive and antinociceptive networks of nervous system.

The early works have shown that abnormal hydration (cell swelling) of neurons led to its abnormal excitation (nociceptive signals) as a result of the increase of the number of functionally active protein molecules in membrane, having enzymatic, chemoreceptive and channel-forming properties, while cell dehydration had opposite (antinociceptive) effect on membrane excitation (Ayrapetyan et al., 1984; Ayrapetyan 1998). Thus, from the point of this

*Corresponding author: Prof. Sinerik Ayrapetyan, UNESCO Chair-Life Sciences International Postgraduate Educational Center 31 Acharyan str. Yerevan, 375040, Armenia E-mail: [email protected]






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hypothesis the nerve ending hydration is considered as a cell marker for determining the pain threshold. At the same time it was shown that static and pulsing magnetic fields (SMF, PMF) have dehydration effect on different tissues (Danielyan et al., 1999; Ayrapetyan 2006). On the basis of these data it is predicted that magnetic field (MF)-induced cell dehydration could have pain-releasing effect, which agree with well documented literature data on analgesic effect of SMF and PMF (Ayrapetyan 1996; Markov 2004; Hazlewood et al., 2006).

Although, at present the Electromagnetic Fields (EMF) are widely used for the treatment of various deceases and for pain releasing purposes (Bistolfi 1990; McLean et al., 2003), their application in dentistry is rather limited. Such limitation is due to our weak knowledge on the molecular and cellular mechanisms of generation of nociceptive signals as well as on metabolic nature of pain releasing effect of MF.

The recent our data on metabolic nature of MF-induced cell dehydration which is realized through the activation of cGMP-dependent Na+/Ca2+ exchanger leading to the reactivation of electrogenic Na-K pump (Ayrapetytan et al., 2005), allow us to predict that MF could serve as a universal pain releasing factor in dentistry, too. For testing this hypothesis the effect of 20 minutes 50 Hz PMF (intensity-30 mT) exposure on tooth pain threshold, determined by an electric current passing through it, was studied.

Methods

The studies described in the present work were

carried out according the Institutional Review Board (IRB) approval and comply with all state and local regulations.

The measurements of pain threshold of each frontal tooth of 6 male and 4 female patients were performed. The patients were chosen from 15-45-year-old 28 voluntaries having healthy medical conditions, nonsmoking, without any dental problems and they did not serve as volunteers for any other medical experiments. They were asked to ensure the eight-hour roosting time before the date of experiment and do not use any analgesics and tranquilizers.

For determination of pain threshold an electric current generated by electroodontometer “Biophys-odontometr -1” (production of Armenian Radiophysics institute) was passed through the tooth. The device has active and passive copper electrodes having cylindrical (1.5 cm length) and hooked (3 cm length) forms, accordingly. The diameter of both of electrodes is 1 mm2. The

passive electrode was fixed to the lower lip, while the active electrode was placed on the middle point of the cutting edges of the tooth. The testing current was in range of 1-100 mA. The threshold of pain sense was determined by the patient’s voice answer signal. Before each measurement the calibration of equipment was performed by passing 10 mA current through 500 kOhm electric demand.

The both, equipment and operator were beyond the vision of the patients and their voice answer signal was the reflection to the passing current through electrodes.

Because of wide variation of pain thresholds of each individual, the estimation of PMF-sensitivity of tooth pain threshold was performed by comparing the pain threshold before (control) and after PMF exposure (experiment) of the same patient. The electroalgesimetric data for each frontal tooth of upper and lower jaws of all volunteer participants were measured 3 times. The intervals between each measurement were 10 min. The mean value of the obtained data was considered as control. The intervals between control measurements and PMF exposure were 30 min. The application of PMF was performed with the help of ELF EMF source “Magniter--02” (frequency-50Hz, intensity-30mT) using in magnetotherapy (production of NPO “Polet” Nijni Novgorod, Russia). “Magniter--02” was applied on level of rima oris during 20 minutes. The measurements of pain threshold of each tooth after PMF exposure were carried out by the similar method as before the exposure. The PMF effect on pain thresholds was expressed in % to the initial value (control) of pain threshold.

In order to have a stable electrical contact between the active electrode and dental tissue, toothpaste was used. The tooth surface was dried by a cotton tampon in apical direction and the dried tooth was isolated with the tampons. In total 720 measurements were performed: 360-control and 360-experiments. The mean value, standard deviations, and the statistical probability, determined by Student T-Test were calculated with the help of computer program Sigma Plot (Version 8.02A).

Results Figure 1 presents the formula of frontal teeth

(according to WHO classification) on which the odontometric studies of pain thresholds of teeth in female and male patients were performed. As it was predicted, because of the different anatomical and morphological properties, each tooth had its own pain threshold to the testing current passing through it. The significant differences between pain





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thresholds of teeth in female and male patients were demonstrated: in female it was lower than in male (about 31%) (Figure 2 A, B).

Fig.1 The formula of frontal teeth (according to WHO classification).

The control population did not feel pain in case of absence of testing signal (current), i.e. when current between electrodes was absent. The studies of the effect of 20 minutes PMF exposure on level of rima oris have shown the changes of pain threshold of the teeth. The character of these changes (qualitative and quantitative) was specific for each tooth depending on their location in oral cavity (Figure 3 A, B). Significant differences between PMF-sensitivity of pain threshold in female (A) and male (B) were observed. In female patients 20-minute-PMF-exposure led to the elevation of pain threshold for all teeth (Figure 3A). In male patients the pain thresholds of the major part of the teeth (13,12,11,23,43,42,41,31) were less sensitive to PMF-exposure than in female: in teeth No 13,12,11,21,23,43,41,31,32 and 33 PMF had elevating, while in teeth No 22,23 and 42 -- depressing effect on pain threshold. Thus, in female, having comparatively lower tooth pain threshold, PMF mainly had significant pain releasing effect on it, while in male with comparatively higher tooth pain threshold, only in same teeth PMF-induced releasing effect was not pronounced.

Discussion Although the pain releasing effect of PMF is a

well documented fact (Markov 2004), its cellular and molecular mechanisms still remain unclear. On the basis of previous work of our laboratory the pain (nociceptive) signal was considered an abnormal membrane excitability of nerve endings as a result of overhydration (Ayrapetyan 1995).

This suggestion is based on the experimental data that cell membrane protein molecules, determining membrane function (enzymes,

receptors and ionic channels), in normal living state, are in functionally active and inactive states and the ratio of active and inactive molecules is changed depending on the size of active membrane surface (membrane packing) (Ayrapetyan 1980).

The cell swelling led to the increase of membrane excitability as a result of the increase of the number of functionally active potential-dependent ionic channels , while the shrinkage has the opposite effect on it (Ayrapetyan et al., 1988). It is known that the dysfunction of the Na/K pump which is the consequence of cell pathology, causes the elevation of intracellular Ca and cAMP contents having a promotional role in the generation of nociceptive signals (Kostyuk and Lukyanetz 2006, Julius & Basbaum 2001).

On the other hand it was shown that magnetic field has a dehydrating effect on nerve tissue, the decrease of the number of functionally active protein molecules in membrane, (Danielyan et al., 1999 a, b,), the decrease of intracellular cAMP and Ca ions and the increase of intracellular cGMP content (Ayrapetyan et al. 1994, 2005) causing the decrease of neuromembrane chemosensitivity and excitability (Ayrapetyan et al 2004 ). Thus, on the basis of presented data it was suggested that PMF could also serve as a novel therapeutic pain relief tool.

The preliminary data obtained in the present work on the modulation effect of PMF on teeth pain thresholds could be considered as convincing data on teeth pain relief effect of PMF. However, different sensitivity of each tooth depending on its location in oral cavity, as well as on sex differences of the patients serve as a main barrier for application of PMF as tooth pain relieving factor. Such variability of individual teeth to PMF from the point of view of our hypothesis can be explained by different initial levels of nerve ending hydration. (Ayrapetyan 1998).

Therefore, to use PMF as a novel tool for teeth pain relief therapy it is necessary to continue the study of the correlation between PMF-induced pain relief effect and impendence- metric parameters (marker for tissue hydration) of individual tooth, which is the subject of our current investigations.

Conclusions The obtained data have shown that the teeth

had different pain thresholds and sensitivity to PMF. The differences were also observed in male and female teeth. The pain threshold in female was lower (about 31%), while the sensitivity to PMF was higher in female (about 20%) as compared with male.

In female the PMF had significant elevating





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effect on pain threshold, while in male this effect varied depending on their location in oral cavity.

It is suggested that more detailed characterization of PMF-sensitivity of each tooth, i.e. pain threshold-dependency on PMF intensity and on

the exposure time, would allow us to use the PMF in dentistry as a pain releasing therapeutic tool.

Acknowledgements: Governmental Funding.

Fig.2 The mean value of pain thresholds of frontal teeth in female (A) and male (B) patients. The electroalgesimetric data for each frontal tooth of upper and lower jaws of female and male participants were measured 3 times. Each column represents the mean value of 12 measurements for 4 female (A), 18 measurements for 6 male (B) patients. The range of variations is not observed, because the values were so small as to be observed as symbol mark. On axis of Y is pain threshold measured by milliampere (mA). On axis of X is formula of tooth according to WHO classification.

Fig 3. The effect of 20 min. oral cavity exposure by 50 Hz, 30 mT Pulsing Magnetic Fields on pain





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thresholds of frontal teeth in female (A) and male (B) patients. PMF effect is expressed in % compared to the pain threshold of non-exposed (control) teeth (100%). On axis of X is formula of tooth according to WHO classification. On axis of Y is change of pain threshold calculated by percent according to the Control (100%). Symbols denote significance of the treatment effect evaluated across all experiments; P< 0.5(*), P< 0.05(**).

References

1. Ayrapetyan SN, Suleymanyan MA, Sagian AA, Dadalyan SS. Autoregulation of Electrogenic Sodium Pump. Cell. Mol. Neurobiol. 1984; 4: 367- 384.

2. Ayrapetyan SN. The application of the theory of metabolic regulation to pain. In Ayrapetyan SN, Apkarian A., eds. Pain Mechanisms and Management. Netherlands: IOS press, 1998: pp 3-14.

3. Ayrapetyan SN. Cell aqua medium as a preliminary target for the effect of electromagnetic fields. In: Ayrapetyan SN, Markov M, eds., Bioelectromagnetics: Current Concepts, NATO Science Series, Springer Press, The Netherlands 2006, pp: 31-64.

4. Ayrapetyan SN. Theoretical aspects of magnitotherapy of pain. Abstract of 7th International Symposium "The Pain Clinic", Istanbul, Turkey 1996, pp 171-172.

5. Ayrapetyan S.N., Hunanyan A.Sh, and Hakobyan S.N. 4Hz EMF Treated physiological Solution Depresses Ach-Induced Neuromembrane Current. Wiley-Liss 2004, 397-399.

6. Ayrapetyan G.S., Papanyan A., Hayrapetyan H. and Ayrapetyan S.N. Metabolic pathway of Magnetized Fluid-Induced relaxation Effects on Heart Muscule. Wiley-Liss 2005, 630-625.

7. Danielian A.A, Ayrapetyan SN. Changes of Hydration of Rats’ Tissues after in Vivo Exposure to 0.2 Tesla Steady Magnetic Field. Bioelectromagnetics 1999; 20(2): 123-128.

8. Danielyan A.A, Mirachyan M.M., Grigoryan G.E. Ayrapetyan S.N. The Static Magnetic Field Effects on 3H-Ouabain Binding by Cancer Tisssue. Pysiological chemistry and Physics and Medical NMR (USA), 1999, 31:139-144.

9. Julius D. & Basbaum A. I. Molecular mechanisms of nociception. Nature 2001, 413:203-210.

10. Kostyuk P.G. and Lukyanetz E.A. Intracellular Calcium Signalling-Basic Mechanisms and Possible Alteration. S.N. Ayrapetyan and M.S.Markov (eds.) Bioelectromagnetics, The Netherlands, 2006, 87-122.

11. Markov MS. Magnetic and electromagnetic field therapy: basic principles of application for pain relief. In: Rosch PJ, Markov MS, eds. Bioelectromagnetic Medicine, New York: Marcel Dekker, 2004, pp 251-264.

12. Hazlewood C, Markov M, Ericsson A. Electromagnetic field therapy: a role for water? In: Ayrapetyan SN, Markov MS, eds. Bioelectromagnetics: Current Concepts. The Netherlands: Springer Press, NATO Science Series, 2006: pp 227-240.

13. Bistolfi F. Biostructures and Radiation Order Disorder, Torino: Edizioni Minerva Medica S.p.A 1990.

14. McLean MJ, Engstrom S, Holcomb RR. Magnetotherapy: Potential Therapeutic Benefits and Adverse Effects, New York: TFG Press 2003.

15. Ayrapetyan GS, Papanyan AV, Hayrapetyan HV, Ayrapetyan SN. Metabolic pathway of magnetized fluid-induced relaxation effects on heart muscle. Bioelectromagnetics 2005; 26(8): 624-630.

16. Ayrapetyan SN. Cellular Mechanism of pain. In: Kepplinger B, eds. Pain- Clinical Aspects and Therapeutical Issues. Edition Selva Verlag Linz 1995; pp 311-327.

17. Ayrapetyan SN. On the Physiological Significant of Pump Induced Cell Volume Changes. Adv. Physiol.Sci 1980; 23: 67-82.

18. Ayrapetyan SN, Rychkov GY, Suleymanyan MA. Effects of Water Flow on Transmembrane Ionic Currents in Neurons of Helix Pomatia and in Squid Giant Axon. Comp. Biochem. Physiol 1988; 89(2):179-186.



Journal Of International Dental And Medical Research ISSN 1309-100X Volleyball And Body Composition http://www.ektodermaldisplazi.com/journal.htm Suat Cerit at al.


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Alteration in Body Composition of Elite Professional Female Players in a Premier League Volleyball Bout

Suat Cerit1, M.Zulkuf Akdag2, Suleyman Dasdag2*, Yunus Karakoc3, Mehmet Celik4

1Department of Physical Training and Sport, Dicle University, 21280 Diyarbakir, Turkey 2Department of Biophysics, Dicle University Faculty of Medicine, 21280 Diyarbakir, Turkey 3Department of Physiology, Inonu University Faculty of Medicine, 44280 Malatya, Turkey 4Teacher of Physical Training, D.U. Lojmanlari No:50 , Diyarbakir, Turkey

Abstract In this study, we aimed to investigate the effects of single bout of volleyball on body composition in elite professional female players. Sixteen elite professional female players that play volleyball in a club in Turkish Premier League were enrolled in the study. Prior to one league match (pre-exercise) bioelectric impedance analyzes were performed using a bioelectric impedance analyzer. After the final period (3rd set) of match was ended, bioelectric impedance analyzes were repeated (post-exercise). There were no significantly changes in body mass index, body cell mass, body capacitance, lean body mass, and basal metabolic rate at post-exercise time. Body resistance, reactance and fat mass were all significantly lower than pre-exercise time (p<0.01). On the other hand, extracellular mass increased at post-exercise time, and that significances were found to be p<0.05. As an intense aerobic exercise, single bout of volleyball (three sets) decreases body fat mass at post-exercise time. This change is associated with decreases in body resistance and reactance. Excess lost of body fat may be related to frequently using anaerobic process for energy requirement in volleyball players and prolonged exercise for competition. (Journal of International Dental and Medical Research 2009; 2: (1), pp. 33-36) Keywords: Volleyball, sports, exercise, body composition, bioelectric impedance. Received date: 10 October 2008 Accept date: 03 February 2009

Introduction

Contemporary sports imply huge training

volumes, with thus an increasing danger of overloading. The timely detection of the state of overloading in the organism as a whole or in skeletal muscles presents a difficult and complicated problem.1 In the last decades, the sport of volleyball has become popular all over the world. The increasing number of high-quality professional teams has made official matches more and more spectacular but also more intense and longer-lasting. Today, competitions such as the World Championship, the Word League and the Olympic Games entail several exhaustive matches played very close to one another.2

During the normal conditions or exercise, body water and electrolyte balance are essential to optimal physiological function and health.3 Bioelectric impedance analyze (BIA) is commonly used in clinical settings and field studies for estimating body composition parameters such as total extracellular, intracellular water compartments, fat mass, body mass, resistance, reactance, body capacitance and basal metabolic rate.4-9 Recently, great advances were made in the art of accurately measuring the electrical properties of matter.7However, giving the definition of some BIA parameters such as resistance, reactance, phase angle, body capacitance and basal metabolic rate would help to understand physics of BIA. Resistance and reactance are terms from physics which are part of the complex field of materials and their effects on electricity. Resistance is the ratio of electrical potential (voltage) to the current in a material. A material with low resistance conducts well, while a material with high resistance conducts poorly. In the human body, low resistance is associated with large amounts of fat-free mass.

High resistance is associated with smaller amounts of fat-free mass. Reactance is the effect on an electrical current caused by a material’s ability to


Suleyman Dasdag, PhD Department of Biophysics Dicle University Faculty of Medicine (21280) Diyarbakir Turkey






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store energy. Reactance is seen as a time delay between an applied electrical potential and current. A material that stores energy readily has high reactance, and causes a large delay in the current. A material that stores energy poorly has low reactance and causes a small delay in the current. In the human body, high reactance is associated with large amounts of body cell mass (intracellular mass).

Low reactance is associated with smaller amounts of body cell mass. Phase angle is proportional to the ratio of reactance and resistance. Phase angle is an indicator of cellular health and integrity. Research in humans has shown that the relationship between phase angle and cellular health is increasing and nearly linear. A low phase angle is consistent with an inability of cells to store energy and an indication of breakdown in the selective permeability of cellular membranes. A high phase angle is consistent with large quantities of intact cell membranes and body cell mass.10

Body capacitance is the total energy storage capacity of the body cell mass compartment. A high capacitance is an indicator of large quantities of intact cellular membranes. A low capacitance indicates lower quantities of intact cellular membranes. Capacitance is determined by the number and quality of cell membranes contained within the body cell mass compartment. Basal metabolic rate (BMR) is the number of calories metabolized at rest during 24 hours.10 Bioelectric impedance analyze has also potential use in the area of sports and exercise.11 Fornetti et al showed that the method of BIA was extremely reliable and valid for estimating body composition values in female collegiate athletes.12 As an aerobic exercise, long-time training of volleyball can lead to some alterations in the body shape and functions.13-15 Single bout of volleyball can also force the body functions for some skilled manner and maintaining of match performance. In this study, we aimed to investigate the effects of single bout of volleyball on body composition in elite professional female players.

Material and Methods

Sixteen elite professional female players that

play volleyball in a club in Turkish Premier League were enrolled in the study. Informed consent was taken from each subject and, Helsinki Recommendations was regarded. These subjects were questioned about the performance and the health problems.

Physical parameters such as age and height were noted. Prior to one league match (pre-

exercise) bioelectric impedance analyzes were performed using a portable bioelectric impedance analyzer (Bioimpedance Analyzer, BIA 450, BIODYNAMICS, USA). After the final period (3rd set) of match was ended (post-exercise), bioelectric impedance analyzes were repeated for all subject that they participated in a period of match by substitution with each other. Just before impedance analyzes, subjects were weighed and then they lied face up on a bench in a supine position. Two pairs of sensor electrodes (ecg pads) were placed on the subject's right hand and wrist, and right foot and ankle. A cable was connected between the analyzer and the sensor electrodes. Using the analyzer's keypad, the patient's gender, age, height, and weight (determined at this time) are entered. 50 kHz alternating electric current was applied to current electrodes and, bioelectric impedance parameters were recorded by means of voltage electrodes in accordance with the manufacturer’s instructions.10,16

When a test was performed, a printout was generated. From the recorded parameters, body mass index (kg/m2), body capacitance (pF), resistance (Ohm), reactance (Ohm), body cell mass (kg), etracellular mass (kg), lean body mass (kg), fat mass (kg), and basal metabolic rate (cal) were evaluated. All players had free access to water intake at the break times of match.

SPPS for Windows 13.0 version was used to analyze of data. Normality of data was analyzed by Shapiro Wilks normality test. Because of the not normal distribution of all variables (p<0.05), Wilcoxon test was used to compare variables between pre- and post-exercise periods. p < 0.05 was regarded to be statistically significant.

Results

Average age of these volleyball players was 22.6±5.2 years and their body mass indexes (BMIs) were 21.6±1.05 and 21.4±1.06 at pre-exercise and post exercise periods, respectively. All subjects were in good health and had no noteworthy health or traumatic problems within the last one month. Pre-exercise and post-exercise parameters determined by bioelectric impedance analyze were shown on Table 1.

Tab. 1 Pre-and post-exercise parameters determined by bioelectric impedance analyze (Mean±SD).





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There were no significantly changes in body mass index, body capacitance, body cell mass, lean body mass and basal metabolic rate (Table 1). Body resistance, reactance and fat mass were all significantly lower than pre-exercise time (p<0.01). On the other hand, extracellular mass increased at post-exercise time, and that significances were found to be p<0.05.

Discussion

In human body, several functions and

parameters such as cardiac function and metabolic rate change at any time of exercise, and these changes are depending on type and duration of exercise.17, 18

It is generally accepted that exercise is beneficial for young women, since it increases cardiovascular fitness and reduces adiposity. Too much exercise can have negative effects on the reproductive and skeletal systems.19, 20 During exercise, work, or high temperatures, a significant level of dehydration can develop, and the ratio of extracellular to intracellular fluid can change, despite an ample supply of water. Physical and cognitive performances are impaired at 1-2% dehydration, and the body can collapse when water loss approaches 7%. 3

In our study, we revealed that single bout of volleyball altered the body composition of these trained female players. Increase in extracellular mass at post-exercise time seems to be related to increase in extracellular water volume. Excess amount of sweating can cause water loss and then fluid shift from intracellular area to extracellular area, and the later causes redistribution of body water in the body compartments.21

The ability of the body to redistribute water within its fluid compartments provides a reservoir to minimize the effects of water deficit. Each body water compartment contains electrolytes, the concentration and composition of which are critical for moving fluid between intracellular and extracellular compartments and for maintaining membrane electrochemical potentials.22

At the post-exercise time, increase in extracellular mass (probably water) and decrease in fat mass may help to decrease in body resistance and reactance. The resistance of tissues to electrical current is directly related to their fluid content: the highly hydrated fat-free mass is a good electrical conducting medium, whereas the poorly hydrated adipose tissue is a good electrical insulator. In normal and ill subjects, Bioelectric impedance analyze is correlated with total body water, and the variations of both are also correlated.

23 In the present study, resistance and reactans decreased after the bout. As it is known, low resistance is associated with small amounts of fat mass and low reactance is associated with smaller amounts of body cell mass. Therefore, decreasing of resistance and reactance has an agreement with decreasing of fat mass and body cell mass measured in this study.

In our study, body fat mass markedly decreases after three sets of volleyball match. This result may be a consequence of the hardness of this sport. In a previous study, it was reported that beach volleyball players had lost their body weight at about 750 g ranging from 200 to 1800 g during one tournament.24 Volleyball players, like high jumpers, exhibit the highest values for mechanical power of the leg extensor muscles on the force-platforms when compared to athletes in other sports. During ball-in-play time, the energy needs are almost exclusively provided by the anaerobic alactic energy sources, namely by the breakdown of muscle ATP and phosphocreatine.2 This process may cause to deplete too much substance for ATP synthesis and leads to body fat lost.

In conclusion, as an intense aerobic exercise, single bout of volleyball (three sets) decreases body fat mass at post-exercise time. This change is associated with decreases in body resistance and reactance. Excess lost of body fat may be related to frequently using anaerobic process for energy requirement in volleyball players and, intensity and long-lasting periods of volleyball competition. Finally, it can be said that a premier league volleyball match (three set) can alter the body composition parameters of female players.

Conclusions

In conclusion, as an intense aerobic exercise,

single bout of volleyball (three sets) decreases body fat mass at post-exercise time. This change is associated with decreases in body resistance and reactance. Excess lost of body fat may be related to frequently using anaerobic process for energy requirement in volleyball players and, intensity and long-lasting periods of volleyball competition. Finally, it can be said that a premier league volleyball match (three set) can alter the body composition parameters of female players.

References

1. Ferretti A, Zeppill P. Volleyball: description, injuries, physiology, training. Available at: http://www.sportsci.org/encyc/drafts/Volleyball.doc; 2003 [Accessed March 03, 2009].





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7. Lafargue A.L, Cabrales L.B, Larramendi R.M. Bioelectrical parameters of the whole human body obtained through bioelectrical impedance analysis. Bioelectromagnetics. 2002; 23:450-454.

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16. Singhal A, Farooqi I.S, O'Rahilly S, Cole T.J, Fewtrell, M, and Lucas A. Early nutrition and leptin concentrations in later life. Am. J. Clin. Nutr. 2002; 75: 993-999.

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20. Warren, M.P, and Goodman L.R. Exercise-induced endocrine pathologies. J. Endocrinol. Invest. 2003; 26: 873-878.

21. Sato K, Kang W.H, Saga K, and Sato K.T. Biology of sweat glands and their disorders. I. Normal sweat gland function. J. Am. Acad. Dermatol. 1989; 20:537-563.

22. Sawka M.N, and Montain S.J. Fluid and electrolyte supplementation for exercise heat stress. Am. J. Clin. Nutr. 2000;72:564-572.

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