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Editor in Chief :
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Dr. Chandramani More Dr. Vineet Vinayak
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REVIEW ARTICLES
1. Role of GCF As Potential Biomarker in the Diagnosis of Periodontal Disease...........................01-04
R.G.Shivamanjunath
2. Cone Beam Computed Tomography................................................................................................05-08
Ashish Aggarwal, Nitin Upadhyay, Nupur Agarwal, Sowmya G. V., Md.Asad Iqubal
3. Nanotechnology- Its Implications in Conservative Dentistry and Endodontics..........................09-14
Sumit Mohan, Anuraag Gurtu, Anurag Singhal, Ankita Mehrotra
4. Flapless Implant Surgery- An Overview.........................................................................................15-18
Rashi Jolly, Himanshu Thukral, Mansi Thukral Chandra
5. Fluorides and Their Role in Demineralization and Remineralization.........................................19-21
Sonal Soi, Vineet Vinayak, Anurag Singhal, Sonali Roy
ORIGINAL RESEARCH
6. Bacterial Quantification in teeth with Apical Periodontitis Related to Different Intracanal
Irrigant : A Clinical Study................................................................................................................22-24
K.K. Dixit, Krishna Dixit, Anurag Gurtu, Nivedita Dixit, Rahul Pandey
7. Evaluation of the Root Canal Morphology of Mandibular First Premolars in the Western
Uttar Pradesh Population Using Computed Axial Tomography: An in Vitro Study...........25-27
Nishtha Chauhan, Anurag Singhal, Vineet Vinayak
CASE REPORTS
8. Sialolithiasis : A Case Series with Review of Literature................................................................28-31
Sunil R Panat, Ashish Aggarwal, Nitin Upadhyay, Mallika Kishore, Abhijeet Alok
9. Maxillary Canine With Two Root Canals : A Case Report...........................................................32-34
Anuraag Gurtu, Anurag Singhal, Ridhi Bansal, Kunal Agnihotri
10. Denuded Root - is Free Gingival Graft an Answer : A Case Report............................................35-37
Rika Singh, Sunil Kumar Mall
11. Complication of a Dental Extraction: Osteomyelitis : A Case Report..........................................38-40
Sowmya G. V., Nupur Agarwal, Nitin Upadhyay, Abhijeet Alok, Mallika Kishore
12. Eagles Syndrome : A Case Report...................................................................................................41-43
Nupur Agarwal, Sunil R Panat, Ashish Aggarwal, Anuja Joshi, Kratika Ajai
13. A Modified Sectional Custom Tray for Making Master Impression in Microstomia Patient:
A Case Report................................................................................................................................... 44-46
Pratik Gupta, Dilip Kumar Nath, Nadira Saba
14. Telescopic Denture : A Case Report.................................................................................................47-50
Mayank Shah
15. Bilateral Maxillary Second Molar With Two Palatal Roots : A Case Report..............................51-53
C. Ram Mohan, C. Krishna Chaitanya, Hari Deva Raya Choudary, Sainath Reddy
Information For Authors..................................................................................................................54-56
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Abstract: Diagnosis of periodontal disease is very critical in the phases of its treatment. At present diagnostic
methods for periodontal disease are not precisely accurate and only allow retrospective diagnosis of attachment
loss. We are handicapped in making precisive diagnosis and prognosis by two important limitations ie no
reliable markers for disease activity and no reliable criteria for identifying the risk individuals. Therefore its
necessary to have a knowledge on the present available information regarding the advanced diagnostic
Biomarkers in Gingival crevicular fluid (GCF) for the better understanding of the onset of disease
pathogenisis,course of disease progression so that the treatment will be successful.
01
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
gingipain.(14,15). Polymorphonuclear collagena se, Gelatinase, Tissue
Main advantages of periodontal diagnostic test system using bacterial neutrophil inhibiting mettaloprotinase
markers19 leucocytes (PM Ns) (TIMP ), Plasminogen, Elastase,
Some appears to be predictive of disease activity in longitudinal study Cathepsin G, Cathepsin B,
Simple to use Cathepsin D
Ma crophages Cathepsin G, Cathepsin B,
Chair side test kits available eg:Evalusite, omnigene, perioccan. Cathepsin D, TIM P, 1
Chair side test kits produce visual results which can shown to patient antiprotinase inhibitor,
2m acroglobu lin, plasminogen
POTENTIAL INFLAMMATORY AND IMMUNE MARKERS activator, elastase, gelatinase
The primary cause for the periodontitis is no doubt dental Ma st cell Heparin enzyme complexes,
plaque and sub gingival flora. But the bacteria triggers the local tryptase, chymase,histamine
inflammatory response and general and local specific immune response Fibroblast Cathepsin B, Cathepsin L,
which, along with the direct effects of bacteria, causes most of the tissue DPP-II ,TIMP, 1
20
destruction . Most of the substances which are released from antiprotinase inhibitor,
inflammatory and immune cells in the tissue pass into the GCF. GCF is 2m acroglobu lin, collagenase
easy to sample and therefore these substances are easily available for
the analysis21, 22. Biomarkers of periodontal disease activity may be obtained
from potential proteolytic and hydrolytic enzymes of inflammatory
POTENTIAL IMMUNE AND INFLAMMATORY MEDIATORS cells.
The substances released by the inflammatory and immune
cells during the disease process include antibodies (immunoglobulin, COLLAGENASE AND RELATED METALLOPROTEINASE
Ig), complement proteins, inflammatory mediators such as Collagenases are members of a family of metalloproteinase
prostaglandins (PG) and the pro-inflammatory cytokines such as the which degrade collagen. They are synthesized by macrophages,
various interleukins (IL) and tumour necrosis factor(TNF)21,22. The neutrophills, fibroblasts and kerationocytes and are secreted by these
potential immune and inflammatory mediators relevant to periodontal cells as latent enzymes when stimulated by the appropriate cytokines
pathology are : and some bacterial products. These cells also produce inhibitors known
31
Immune response as tissue inhibitors of metalloproteinase. . In periodontitis, GCF
Antibody: total immunoglobulin and IgG sub groups collagenase activity has been shown to increase with increasing
Complement severity of gingival inflammation and increasing pocket depth and
Inflammatory response alveolar bone loss(32-36).
Arachidonic acid derivatives, eg prostaglandinE2(PGE 2) PROTEOLYTIC AND HYDROLYTIC ENZYMES IN
Cytokines, eg IL, IL-2, IL-4, IL-6, TNF-. INFLAMMATORY CELLS
Proteolytic enzymes
DIAGNOSTIC TEST Collagenase
GCF PGE2 has considerable potential as a screening test for
periodontal activity strangely no commercial efforts are currently Elastase
underway to develop one. Therefore it is now possible to assay GCF Cathepsin G
PGE2 with an ELISA assay using a monoclonal rabbit anti PGE2
23
Cathepsin B
antibody . Cathepsin D
POTENTIAL PROTEOLYTIC AND HYDROLYTIC ENZYMES Dipeptidylpeptidase
OF INFLAMMATORY CELL ORIGIN Tryptase
Inflammation leads to accumulation of polymorphonuclear Hydrolytic enzymes
neutrophil leucocytes (PMNs), macrophages, lymphocytes and mast Aryl sulphatase
cell which are very important in protecting the body against infection. glucoronidase
The inflammatory cell contains destructive enzymes within their
lysosomes which are normally used to degrade phagocytosed material. Alkaline phosphatise
These enzymes are, however , capable of degrading gingival tissue Acid phosphatise
components if released. Such enzymes may be released by the Myeloperoxidase
inflammatory cells during their function or when they degenerate or Lysozyme
die. Cells and tissues in the vicinity of these cells will be damaged and
this process is known as bystander damage. The main tissue damage in Lactoferrin
this process are the connective tissue components and the breakdown of
these tissues around the inflammatory cells helps the spread of these There are some test kits based on some of the GCF factors are
cells through the tissues24. currently available. For example, Periocheck to detect the presence of
neutral proteinases such as collagenase in GCF, Prognostik to detect
37
Inflammatory and connective tissue cells and the proteolytic the presence of the serine proteinase, elastase, in GCF samples .
enzymes and inhibitors which they contain within their Advantages of diagnostic test systems based on proteolytic and
cytoplasmic bodies.25-30 hydrolytic enzymes are;
Some are predictive of diseas activity in longitudinal studies eg;
cathepsin B, elastase, dipeptidylepeptidase II and 1V
Since it is a colour detective system, simple to use
Short chair side time
Can be shown to the patient related to the areas.
02
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
All enzymes released from inflammatory cells are likely to be Bone phosphoprotein (N-propeptide), Osteocalcin, Telopeptides of
associated with gingival inflammation. Since gingival inflammation is type I collagen have been considered for possible markers of bone
often present in the absence of disease activity this association with resorption and hence periodontal disease activity.
inflammation could produce a false association with disease activity. It
is therefore very important to show that a potential marker has a true OSTEONECTIN AND BONE PHOSPHOPROTEIN (N-
association with periodontal disease activity which is independent of PEPTIDE)
and stronger than any association it may have with gingival Osteonectin is a normal component of bone matrix which is
42
inflammation. thought to play an important role in the initial phase of mineralisation .
Bone phosphoprotein, which is an amino propeptide part of type I
POTENTIAL MARKERS OF CELL DEATH AND TISSUE collagen, appears to be involved in the attachment of connective tissue
DEGRADATION cells to the substratum. Both of these proteins have been detected in
Periodontal disease activity involves both damage to the GCF from patients with periodontitis. The total amount of both
epithelial cells of the pocket lining and to the connective tissue cells in component is increased in GCF at the site of increased probing depth.
the sites of connective tissue degradation. Active periodontal tissues are
densely infilterated with inflammatory cells most of these cells may be OSTEOCALCIN
damaged1. The damaged cells release their cytosolic enzymes (enzymes Osteocalcin is a calcium-binding proteins of bone and is the
within the cytoplasm of the cells) and the concentration of these may most abundant non-collagenous protein of the mineralised tissues43. It
well reflect the amount of cellular death within the lesion. Two of these chemotactically attracts osteoclast progenitor cells and blood
enzymes are Asperate amino transferase (AST) and lactate monocytes.44-46 In addition , it is stimulated by vitamin D3, producing
dehydrogenase (LDH), have been widely used in medicine for several concentration that inhibit collagen synthesis in osteoblasts, promote
decades as diagnostic aids to assess cell death and tissue destruction. bone resorption.47 Further elevated levels of osteocalcin are found in the
These enzymes would be expected to pass from the periodontal tissues blood during periods of rapid bone turnover such as osteoporosis and
in the inflammatory exudates into the gingival crevicular fluid (GCF). fracture repair.48,49 Therefore osteocalcin has been suggested as a
Therefore, GCF levels of these enzymes, should provide evidence of possible marker for bone resorption and hence periodontal disease
cell death within the periodontal tissues and hence, possibly disease progression, it is present in GCF.
activity. For these reasons they have been studied as potential marker of
disease activity.38 CONCLUSION
Periodontal practice ranges from the detection, diagnosis and
CONNECTIVE TISSUE DEGRADATION MARKERS treatment of attachment loss due to periodontitis. The new diagnostic
The degradation of connective tissue by inflammatory cells technologies may be capable of providing the clinician with effective
and possibly bacterial enzymes during active periodontitis can release tools that can assist in the early identification of periodontal disease that
components of these tissues. These components could be cleaved can result in expidated treatment. The newer diagnostic technique are
sections of the major molecules of the periodontal connective tissue and still at an adolescent stages of development and much work remains to
basement membrane such as collagens and proteoglycans39, 40. The performed to fully validate this utility such that they become important
components that could be degraded during periodontitis are listed in and cost effective for the successful periodontal management.
table -1
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23. Nakashima K, Roehirch N. Osteocalcin, Prostaglandin E2 and 42. Termine J D , Kleinmann H K. Osteonectin, a bone-specific
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periodontal status. J Clin Periodontol 1994: 21:327-333.
43. Lian J B, Gundberg C M. Osteoalcin: biochemical considerations
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Corresponding Address: Address:
31. Kowashi Y, Jaccard F. Increase of free collagenase and neutral
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Ram Mohan
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Email:dr_rammohanc@yahoo.co.in
drmanju75@rediffmail.com
32. Overall C M, Sodek J. Inetial charecterisation of a neutral
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Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Abstract: CBCT is a compact, faster and safer version of the regular CT, through the use of a cone shaped x-ray
beam. The size of the scanner, radiation dosage and time needed for scanning are all dramatically reduced and
can be easily fitted into the dental chair.It involves the use of rotating x-ray equipment, combined with a digital
computer, to obtain images of the body. Using CT imaging, cross sectional images of body organs and tissues
can be produced. CT imaging can provide views of soft tissue, bone, muscle, and blood vessels. Computed
tomography (CT) imaging, is also referred as computed axial tomography (CAT) scan clarity.
05
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
builds 2Dlateral and posterior-anterior cephalograms in Dolphin 3D implant treatment, appropriate site or size can be chosen before
(orthodontic imaging software) to allow me to digitize the cephalograms placement, and osseointegration can be studied over a period of time.
and provide me with further diagnostic and treatment planning This review discusses all the finer details of CBCT which has
information. This process is at this time a necessity for the orthodontist added a third dimension to the imaging in periodontics.
but 3D digitizing will soon be here and infact is being developed and
tested at this time. The quality of the cephalograms built from the CBCT USES OF CBCT IN HEAD & NECK REGION
is without a doubt a huge improvement over the conventional CBCT is being increasingly used for point of service head &
2Dradiographs. The CBCT and extra-oral photographs are taken with an neck and dento-maxillofacial imaging. This technique provides
operator assisted first tooth contact centric relation wax bite registration. relatively high isotrophic spatial resolution of osseous structures with a
We can make more appropriate treatment decisions as opposed to images reduced radiation dose compared with conventional CT scans. In this
taken in habitual jaw positions that may not reflect the true relationship second installement in a 2-part review, the clinical application in the
of the mandible to the maxilla and thus may inaccurately reflect condylar dentomaxillofacial and head & neck regions will be explored, with
position and the relative dental relationships The superior diagnostic particular emphasis on diagnostics imaging of the sinuses, temporal
information provided by CBCT over conventional radiographic bone and craniofacial structures.3
technology dictates that we make the transition from 2D diagnosis and Cone beam CT (CBCT) is an advancement in CT imaging that
treatment planning to 3D sooner rather than later. Most all of us have has begun to emerge as a potentially low-dose cross-sectional technique
inherent asymmetries and skeletal discrepancies but the greater the for visualizing bony structures in the head and neck. The physical
magnitude of these discrepancies the more important 3Dimaging, principles, image quality parameters, and technical limitations relevant
digitization and treatment planning becomes. For example, treatment to CBCT imaging were discussed in Part 1 of this 2-part series. The
planning of orthognathic surgical cases in 3D will provide us a more second part presented here will highlight the evidence related to CBCT
complete picture of treatment options and projected treatment outcomes, applications in head and neck as well as dentomaxillofacial imaging.
which in the end is a huge benefit for the patient.7 Controversial aspects of this technology will also be addressed,
including limitations in image quality and its often office-based
USES OF CBCT IN IMPLANTOLOGY operational model.3
In the field of periodontology and implantology, assessment of CBCT was first adapted for potential clinical use in 1982 at the
the condition of teeth and surrounding alveolar bone depends largely on Mayo Clinic Bio dynamics Research Laboratory. Initial interest focused
two-dimensional imaging modalities such as conventional and digital primarily on applications in angiography in which soft-tissue resolution
radiography though these modalities are very useful and have less could be sacrificed in favour of high temporal and spatial-resolving
radiation exposure, they still cannot determine a three dimensional capabilities. Since that time, several CBCT systems for use have been
architecture of osseous defects. Hence an imaging modality which developed both in the interventional suite and for general applications in
would gives an undistorted vision of a tooth and surrounding structures CT angiography. Exploration of CBCT technologies for use in radiation
is essential to improve the diagnostics potential. CBCT provides 3D therapy guidance began in 1992, followed by integration of the first
images that facilitate the transition of dental imaging from initial CBCT imaging system into the gantry of a linear accelerator in 1999.
diagnosis to image guidance throughout the treatment phase. This The first CBCT system became commercially available for
technology offers increased precision, lower doses and lower costs when dentomaxillofacial imaging in 2001 (New Tom QR DVT 9000;
2
compared with medial fan-beam CT. Quantitative Radiology, Verona, Italy). Comparatively low dosing
In the field of periodontology, assessment of the condition of requirements and a relatively compact design have also led to intense
teeth and surrounding alveolar bone depends largely on traditional two- interest in surgical planning and intra operative CBCT applications,
dimensional imaging modalities such as conventional radiography and particularly in the head and neck but also in spinal, thoracic, abdominal,
digital radiography. Though these modalities are very useful and have and orthopedic procedures. Diagnostic applications in CT
less radiation exposure, they still cannot determine a three-dimensional mammography and head and neck imaging are also under evaluation.
(3D) architecture of osseous defects. Hence, an imaging modality which The technical and clinical considerations pertaining to CBCT imaging in
would give an undistorted 3D vision of a tooth and surrounding many of these applications have been the subjects of several recent
structures is essential to improve the diagnostic potential. A well reviews.The recent review by Drfler et al of the neurointerventional
diagnosed periodontal lesion warrants an appropriate treatment. applications of CBCT is of particular interest to the field of
In the medical field, the 3D imaging using computed tomography (CT) neuroradiology.5
has been available now for many years, but in the dental specialty, its
application is restricted to the use in cases of maxillofacial trauma and
USES OF CBCT IN PROSTHODONTICS
diagnosis of head and neck diseases. Routine use of CT in dentistry is not
Today's computer aided design & manufacture (CAD/CAM)
accepted due to its cost, excessive radiation, and general practicality. In
technologies contribute greatly to restorative dentistry & provide
recent years, a new technology of cone-beam CT (CBCT) for acquiring
clinicals with advanced treatment options for various
3D images of oral structures is now available to the dental clinics and
indications,including inlays,onlays,fixed dentures & full dentures,thin
hospitals. It is cheaper than CT, less bulky and generates low dosages of
veneers and crowns.These systems also allow use of many restorative
X-radiations. The innovative CBCT machine (fig 1] designed for head
materials,including metal,metal-ceramic,compositive & all ceramic, to
and neck imaging are comparable in size with an orthopantomograph.
best meet the needs of the care & patients. Further CAD/CAM systems
CBCT provides rapid volumetric image acquisition taken at
are available for both chairable & laboratory applications,so dentists
different points in time that are similar in geometry and contrast, making
now have the ability to create highly aesthetic & strong restoration in
it possible to evaluate differences occurring in the fourth dimension 4
time. In its various dental applications, images of jaws and teeth can be office.
visualized accurately with excellent resolution can be restructured three
dimensionally, and can be viewed from any angle (Fig 2). Most ADVANTAGES OF CBCT
significantly, patient radiation dose is five times lower than normal CT. Being considerably smaller, CBCT equipment has a greatly
Today, CBCT scanning has become a valuable imaging reduced physical footprint and is approximately 20-25% of the cost of
modality in periodontology as well as implantology. For the detection of conventional CT. CBCT provides images of high contrasting structures
smallest osseous defects, CBCT can display the image in all its three and is therefore particularly well- suited towards the imaging of osseous
dimensions by removing the disturbing anatomical structures and structures of the craniofacial area. The use of CBCT technology in
making it possible to evaluate each root and surrounding bone. In clinical dental practice provides14 a number of advantages form
axillofacial imaging. These include
06
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
RAPID SCAN TIME patient. Surgical templates can then be laboratory fabricated on stone
Because CBCT acquires all projection images in a single casts, or directly CT-derived via stereo lithography, taking the scan data
rotation, scan time is comparable to panoramics of radiography. This is and turning it into solid resin models of the patient's mandible or maxilla.
desirable because artefact due to subject movement is reduced. However, as more companies invest in 3-D digital dentistry solutions,
Computer time for dataset reconstruction however is substantially linking the technologies together has become a reality. This presentation
longer and varies depending on FOV, the number of basis images will demonstrate how digital dentistry is evolving into a mainstream
acquired, resolution and reconstruction algorithm and may range from dentistry, allowing everyone to achieve successful "restoratively-
approximately 1 to 20 minutes. driven" implant dentistry.
BEAM REFERENCES
Collimation of the CBCT primary x-ray beam enables 1. Kau CH, Richmond S. Current products and practice three
limitation of the x-radiation to the area of interest. Therefore an optimum dimensional cone beam computerized tomography in orthodontics.
FOV can be selected for each patient based on suspected disease J Ortho 2005;32:282-93.
presentation and region of interest. While not available on all CBCT 2. Mohan R, Singh A, Gundappa M. Three-dimensional imaging in
systems, this functionality is highly desirable as it provides dose savings periodontal diagnosis Utilization of cone beam computed
by limiting the irradiated field to fit the FOV. tomgraphy. J Indian Soc Periodontol. 2011;15(1):7-11.
3. Miracle AC, Mukherji SK. Conebeam CT of the head and neck,
IMAGE ACCURACY part 2: clinical applications. AJNR Am J Neuroradio
CBCT imaging produces images with sub-millimeter 2009;30(7):1285-92.
isotropic voxel resolution ranging from0.4 mm to as low as 0.09 mm. 4. Alamri HM, Sadrameli M, Alshalhoob MA, Sadrameli M, Alshehri
Because of this characteristic, subsequent secondary(axial, coronal and MA. Applications of CBCT in dental practice: a review of the
sagittal) and MPR images achieve a level of spatial resolution that is literature. Gen Dent. 2012; 60(5):390-400.
accurate enough for measurement in maxillofacial applications where 5. Danforth RA, Peck J, Hall P. Cone beam volume tomography: an
precision in all dimensions is important such as implant site assessment imaging option for diagnosis of complex mandibular third
and orthodontic analysis molar anatomical relationships. J Calif Dent Assoc
2003;31(11):847-52.
REDUCED PATIENT RADIATION DOSE COMPARED TO 6. Halazonetis DJ. From 2-dimensional cephalograms to 3-
CONVENTIONAL CT. dimensional computed tomography scans. Am J Orthod
The effective dose (E) varies for various full field of view Dentofacial Orthop 2005;127(5):627-37.
CBCT devices from 29-477 Sv depending on the type and model of 7. Mah J, Hate er D. Current status and future needs in craniofacial
CBCT equipment and FOV selected (Table 2) (Schulze et al.,2004; Mah imaging. Orthod Craniofac Res. 2003; 6(1):79-82.
et al., 2003; Ludlow et al.,2003, 2006, 2007). Patient positioning 8. Noar JH, Pabari S. Cone beam computed tomography current
modifications (tilting the chin) and use of additional personal protection understanding and evidence for its orthodontic applications? J
(thyroid collar) can substantially reduce dose by upto 40% (Ludlow et Orthod 2013;40(1):5-13.
al., 2006). These doses can be compared more meaningfully to dose from 9. Chaushu S, Chaushu G, Becker A. The role of digital volume
a single digital panoramic exposure(Ludlow et al., 2003), equivalent CT tomography in the imaging of impacted teeth. World J Orthod
dose (Ngan et al., 2002), or the average natural background radiation 2004;5(2):120-32.
exposure for Australia (1,500 Sv) (ARPANSA, 2007)in terms of 10. Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption
background equivalent radiation time (BERT) (MacDonald, of maxillary canines: a CT study. Angle Orthod. 2000;70(6):415-
1997).CBCT provides an equivalent patient radiation dose of 5 to 80 23.
times that of a single film-based panoramic radiograph, 1.3% to 22.7% 11. Mah J, Enciso R, Jorgensen M. Management of impacted
of a comparable conventional CT exposure or 7 to 116 days of cuspids using 3-D volumetric imaging. J Calif Dent Assoc.
background radiation. 2003;31(11):835-41.
12. Aboudara CA, Hatcher D, Nielsen IL, Miller A. A three-
ORAL RADIOLOGY dimensional evaluation of the upper airway in adolescents.
Orthod Craniofac Res. 2003;6:173-5.
A number of novel medical diagnostic imaging modalities 13. Robb RA. The Dynamic Spatial Reconstructor: An X-Ray Video-
have emerged recently. Cone beam computed tomography (CBCT) is a Fluoroscopic CT Scanner for Dynamic Volume Imaging of Moving
radiographic imaging method that allows accurate, three-dimensional Organs. IEEE Trans Med Imaging. 1982;1(1):22-33.
imaging of hard tissues. CBCT has been used for dental and 14. Fahrig R, Nikolov H,Fox AJ, Holdsworth DW. A three-
maxillofacial imaging for more than ten years now and its availability dimensional cerebrovascular flow phantom. Med Phys.
and use are increasing continuously. However, at present, only best 1999;26(8):1589-99.
practice guidelines are available for its use, and the need for evidence- 15. Covalcanti MG. Cone beam computed tomegraplic imaging
based guidelines on the use of CBCT in dentistry is widely recognized. perspective, challenges and the impact of near trend future
CBCT is more reliable in evaluating the number of mandibular third applications. J Craniofac Surg 2012;23(1):279-82
molar roots than panoramic radiography. CBCT scanners provide 16. Suomalainen II., Kiljunen T, Kaser Y, Peltola J, Kortesniemi M.
adequate image quality for dentomaxillofacial examinations while Dosimetry and image quality of four dental cone beam computed
delivering considerably smaller effective doses.16 tomography scanners compared with rnultislice computed
tomography scanners, Dentomaxillofac Radiol. 2009;38(6):367-
CONCLUSION 78.
Even with CT imaging, clinicians have laboured to link the
information from the scan data to the surgical site, transferring angles
and positions manually. This is overcome with interactive software
applications that provide this information seamlessly. Corresponding
Corresponding Address:
Address:
As CBCT has become the state-of-the-art, the race is on to
identify opportunities which benefit from the digital information
Dr.Ashish
Dr. C. Ram Mohan
Aggarwal
embedded in each scan. Guided implant surgery has evolved as an Email: drashishagg@rediff mail.com
Email:dr_rammohanc@yahoo.co.in
important modality and aid in transferring the virtual 3-D plan to the
07
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
08
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
Fig. 2 Three different types of fillers components, non-agglomerated discrete silica nanoparticles,
prepolymerized fillers (PPF) and barium glass filler in nanocomposite.
14
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Abstract: As osseointegration is now considered highly predictable, the current trendis to develop techniques
that can provide function, esthetics, and comfort with aminimally invasive surgical approach. To achieve those
goals, flapless implantsurgery using a tissue punch technique has been suggested. This paper presents
anoutline of the indications and advantages of flapless implant surgery for delayed placementand loading
protocols.
REFERENCES
1. Adell R, Lekholm U, Rockler B, Brnemark P-I. A 15-year
study of osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981;10:387416. Corresponding
Corresponding Address:
Address:
2. Brnemark P-I, Hansson BO, Adell R, et al. Osseointegrated
implants in the treatment of the edentulous jaw. Experience Dr. Neha
C.
Dr.Dr.
Dr. KKAggarwal
Ram
Rashi Mohan
Dixit
Jolly
from a 10-year period. Scand J Plast Reconstr Surg Suppl Email:
Email: dr_rammohanc@yahoo.co.in
Email:
Email: rashijolly5@yahoo.co.in
dixit.kk@gmail.com
dr.nehaaggarwal19@gmail.com
1977;16:1132.
17
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
18
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Abstract: Demineralization and remineralization begins with historical prespective on caries. Caries were
identified as a major public health problem in 1940s . Demineralization is a process of removal of minerals from
dental enamel. Remineralization on the other side is the process of restoring minerals to hydroxyapatite lattice.
The battle to keep teeth strong and healthy is dependent upon ratio between demineralizaton and
remineralization. In this scientific era new advances have changed our idea from "cure" to "prevention".
Remineralization can mainly be achieved by mineral or ionic technology .Ionic technology mainly includes
fluorides. Fluorides works primarily via topical mechanism which includes ,inhibition of demineralization at
crystal surface, enhancement of remineralzation at crystal surface, and at high concentration inhibition of
bacterial enzymes. This article deals with various aspects of fluorides in management of De/ Remineralization.
19
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
De Remineralization Cycle4-6 FACTORS INFLUENCING DE- REMINERALIZATION
It is apparent that the pH cycle depends on the strength of A high level of acid concentration and a high frequency
the acid that is present, the frequency and duration of its of contact will lead to demineralization of the tooth surface,
production and the remineralization potential in each particular however natural protective factors and repair mechanisms can be
situation, any one of the following sequelae can occur. enhanced and the problem controlled at least to a degree. There is
1. The enamel may continue to mature a delicate balance between health and disease, involving acid
2. Chronic caries may develop slow demineralization arising from bacteria laden plaque competing with protective
with active remineralization factors that are provided through normal salivary flow and good
3. Rapid (rampant) caries may arise rapid hygiene.9
demineralization with inadequate remineralization
4. Erosion may occur very rapid demineralization with ROLE OF FLUORIDES
no remineralization at all There have been many schools of thought over the years
The chemical basis of the demineralization as to the relative importance of different ways in which fluoride
remineralization process is similar for enamel, dentin and root acts to reduce dental caries. It is now well accepted that the
cementum. However the different structures and relative quantity primary mode of action is the inhibition of demineralization and
of mineral and organic tissue content of each of these materials enhancement of remineralization. Fluoride acts by inhibiting
causes significant differences in the nature and progress of the mineral loss at the crystal surfaces and by enhancing the
carious lesion.7 rebuilding or remineralization of calcium and phosphate in a form
more resistant to subsequent acid attack.
Enamel lesion
The initial enamel lesion results when the pH level at the Mechanism of action of fluoride
tooth surface exceeds that which can be counter-balanced by The most probable mechanism through which fluoride
remineralization but is not low enough to inhibit surface prevents dental caries is by stabilizing the enamel crystal i.e. by
remineralization. The acid ions penetrate deeply into the prism preventing enamel demineralization from the acid produced by
sheath porosities, leading to sub-surface demineralization. The the microflora or by favoring recrystallization of dissolved
tooth surface may remain intact through remineralization, which enamel surfaces or both. Preferably the fluoride should be bound
occurs preferentially at the surface due to increased levels of permanently to the enamel crystal in the form of fluorapatite.10
calcium, phosphate, fluoride ions and buffering by salivary Fluoride ion substitutes for the hydroxyl ion in the
products.7 apatite structure giving rise to a reduction of crystal volume and a
The clinical characteristics of such lesions are concomitant increase in the structural stability. Under the
1. Loss of normal translucency of enamel with a chalky influence of fluoride, large crystals with fewer imperfections are
white appearance on dehydration formed thus stabilizing the lattice and presenting a smaller
2. A fragile surface layer susceptible to damage from surface area/ unit volume for dissolution. Also enamel, which
probing particularly in pits and fissures. mineralizes under the fluoride influence, has lower carbonate
content, thus giving a reduced solubility.1,8,10
3. Increased porosity particularly of the sub-surface with
potential for uptake of stain. Fluoride can be firmly bound when it is incorporated in
the crystalline lattice of hydroxyapatite or loosely bound when it
4. Reduced density of the sub-surface detected is adsorbed to apatite forming calcum fluoride deposits. In the
radiographically or with Transillumination research on the cariostatic effect of fluoride, considerable
5. A potential for remineralization with an increased emphasis is placed on the role of free fluoride ions in the oral
resistance to further acid challenge fluid. Calcium fluoride is formed during treatments with high
concentration fluoride solutions. It can act as a fluid reservoir on
The advancing coronal lesion1,6 the tooth surface and release fluoride ions at low pH. This fluoride
If the demineralization - remineralization imbalance ion along with calcium and phosphate diffuses into the lesion and
continues the surface of the incipient lesion collapse through the precipititates as fluorhydroxyapatite. The acid cycle thus
dissolution of apatite or fracture of the weakened crystallite contributes to the conversion of loosely to firmly bound
resulting in cavitations. Plaque can now be retained within the fluoride.11,12
depths of the cavity and the remineralization phase is rendered The fluoride ion (F-) inhibits the bacterial enzyme
more difficult and less effective. The dentin-pulp complex will enolase, thereby interfering with production of
become involved at this point but there can still be fluctuations in phosphoenolpyruvate (PEP). PEP is a key intermediate of the
the degree of activity. glycolytic pathway and, in many bacteria, is the source of energy
and phosphate needed for sugar uptake. The presence of 10-100
Demineralization into dentin7,8 ppm of F-, inhibits acid production by most plaque bacteria (Fig.
The process of demineralization continues to be driven by 99-4). These levels are delivered easily by most prescription
dietary substrate after bacteria have invaded dentin. The acid fluoride preparations; of equal interest is the finding that at acidic
production by bacteria dissolves the hydroxyapatite of deeper pH values (5.5 or below), low levels of F- (1-5 ppm) inhibit the
dentin so there is a front of demineralization in advance of the oral streptococci. These levels are found in plaque, especially in
bacterial invasion. individuals who drink fluoridated water or who use fluoridated
The texture and color of dentin changes as dentifrices. If this plaque fluoride is derived from the tooth, an
demineralization advances. The color will darken because of antibacterial mode of action, which involves a depot effect, can be
bacterial products and stains from foods and beverages. If the postulated for systemic (water) and topical fluoride
lesion is left to extend through the dentin the enamel will become administration.
progressively undermined and weakened resulting in a wide-open The depot effect comes about in this manner. Water
cavity that is relatively self-cleansing. The caries process may fluoridation promotes the formation of fluorapatite, whereas
then slow down leading to the development of a hard leathery topical fluorides cause a net retention by the enamel of fluoride as
floor on the cavity that is more or less inactive. fluorapatite or as more labile calcium salts. Microbial
20
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
acid production in the plaque may solubilize this enamel-bound CONCLUSION
fluoride, which at the prevailing low pH in the plaque Florides have anticaries effect and it also prevents
microenvironment could become lethal for the acid-producing demineralisation, promotes remineralisation of early caries.
microbes. Such a sequence would discriminate against S mutans Fluoride is most commonly used remineralising agent. As the pH
and lactobacilli because they, as a result of their aciduric nature, rises, new and larger crystals that contain more floride forms are
are most likely the numerically dominant acid producers at the formed , therby reducing the enamel demineralisation by forming
plaque-enamel interface. The fluoridated tooth thus contains a fluorhydroxyapetite. crystals and enhancing remineralisation.
depot of a potent antimicrobial agent that is not only released at an
acid pH value but is most active at this pH value. This hypothesis, REFERENCES
then, attributes some of the success of water fluoridation and 1. Thylstrup A, Fejerskov O. Textbook of Clinical Cariology
topical fluorides to an antimicrobial effect. It further suggests that Second Edition Munksgaard .
judicious use of topical fluorides would be effective in patients
with highly active caries. The most effective dose schedule and 2. Bynum AM, Donly KJ. Enamel de/ remineralization on teeth
fluoride preparation have not been determined.13 adjacent to fluoride releasing materials without dentifrice
exposure: Journal of Dentistry for Children 1999;2: 89-91.
3. Anusavice KJ. Caries risk assessment: Op Dent 2001; 6: 19-
SOURCES OF FLUORIDES 26.
Fluoride containing dentifrices 4. Chow LC, Vogel GL.Enhancing remineralization: Op Dent
The use of fluoride containing toothpaste has been 2001; 6:27-38.
proven to reduce the incidence of caries in numerous clinical 5. Chow.L, Takagi, Carey CM. Remineralization effects of a
studies. During a typical one minute brushing period fluoride Two-solution Fluoride Mouth rinse: An in situ study: J Dent
rapidly permeates the tooth and is taken up by the enamel as Res 2000; 79(4): 991-995.
fluorapatite, calcium fluoride or even free fluoride. Rinsing the
mouth after brushing rapidly drops the salivary fluoride 6. Donly K J et al. Evaluating the effects of fluoride-releasing
concentration to 1 ppm or less within 15 minutes. However the dental materials on adjacent interproximal caries: J Am Dent
treated tooth enamel and perhaps the oral mucosa acts as a sink for Assoc. 1999 Jun; 130(6): 817-825.
fluoride and subsequently release it to the oral cavity.4 7. Donly K J. Enamel and dentin demineralization inhibition of
fluoride-releasing materials: Am J Dent. 1994 Oct; 7(5):
The FDA as safe and effective for use in dentifrices 275-8.
approves three sources of fluoride. They are Sodium Fluoride,
Sodium Monofluorophosphate and Stannous fluoride. Sodium 8. Duggal. M. S, K J Toumba, B T Amaechi, M B Kowash, S M
fluoride directly provides free fluoride. It is generally not found in Higham. Enamel demineralization in situ with various
toothpaste formulations containing calcium-based abrasives frequencies of carbohydrate consumption with and without
because of its potential to irreversibly bind to the abrasive and fluoride toothpaste: J Dent Res 2001; 80(8): 1721-1724.
form insoluble calcium fluoride on storage. Sodium 9. Featherstone. An in-situ model for simultaneous assessment
Monofluorophosphate is the fluoride of choice when calcium- of inhibition of demineralization and enhancement of
containing abrasives are used. The Monofluorophosphate ions remineralization : J Dent Res. 1992; 71: 804-810.
releases free fluoride when it hydrolyses on exposure to 10. Fazzi R, Vieria D Fad Zucas SM. Fluoride release and
phosphatase enzymes naturally present in the mouth. physical properties of a fluoride-containing amalgam: J
Stannous fluoride provides fluoride and stannous ions Prosthet Dent. 1977 Nov; 38(5): 526-31
which act as an antimicrobial agent. It can also produce stannous 11. FejerskovOT. Rationale use of fluorides in caries prevention:
phosphate fluoride precipitates which slows down the caries a concept based on the possible cariostatic mechanisms: Acta
process but has staining as a side effect.14 Odontalog Scada 1981; 39: 241-249
12. Francci C. Fluoride release from restorative materials and its
Fluoride mouth rinses effects on dentin demineralization: J Dent Res; 78, 1647-
They raise the concentration of fluoride in saliva for 1654.
several hours after use. Even though the residual concentrations 13. Kitasako, Nakajima, Foxton, Aoki, Pereira , Tagami.
of fluoride in plaque and saliva are small, the modest elevations in Physiological remineralization of artificially demineralised
fluoride concentration may be sufficient to boost the rate of dentin beneath glass ionomer cements with and without
remineralization and help inhibit caries development. Use of 0.05 bacterial contamination In Vivo: Op Dent 2003; 28(3): 274-
% sodium fluoride mouth rinses has been shown to be better than 280.
brushing with conventional fluoride toothpaste. 14. Rolla et al: Critical evaluation of the composition and use of
fluorides with emphasis on the role of calcium fluoride in
caries inhibition: J Dent Res 1990; 69: 780-785.
Fluoride releasing dental materials15,16
15. Ten Cate: Remineralization of caries lesions extending into
Resin modified GIC, conventional GIC and fluoride dentin: J Dent Res 2001; 80(5): 1407-1411.
releasing composites have been postulated to protect against
secondary caries in enamel and dentin. They have a synergistic 16. Ten Cate J M, Duinen V. Hypermineralization of dentinal
effect with fluoride rinses or dentrifrices in inhibiting lesions adjacent to glass ionomer cement restorations: J Dent
demineralization. Res 1995; 74(6): 1266-1271.
Abstract: The antibacterial efficacy of intracanal irrigants, metronidazole, normal saline, EDTA, 3%
Hydrogen peroxide, 3% sodium hypochlorite and 2% Chlorhexidine was assessed in teeth with asymptomatic
apical periodontitis. 25 canals were randomly divided into three groups, instrumented and irrigated with three
different combination of irrigants. Bacterological samples were collected from the root canals before and after
irrigation in the first visit of treatment. Later the bacterial growth was assessed. It was concluded that EDTA,
Sodium hypochlorite(3%),and Chlorhexidine(2%) reduced the bacteria significantly.
Key words : Apical Periodontitis, EDTA, Chlorhexidine, Hydrogen peroxide, Sodium Hypochlorite.
INTRODUCTION treatment were isolated by a rubber dam. The pulp cavity was opened
The main aim of root canal treatment is elimination of with sterile round bur of appropriate size under distilled water spray.
bacteria from root canal and prevention of recontamination after Briefly the first collection was made by means of size 15 or size 20
(1)
treatment . It has been reported that success rate of root canal sterile absorbent paper points to an approximate level of 1 mm short of
treatment was higher when teeth were free of bacteria after the tooth apex as determined by preoperative radiography and
chemomechanical instrumentation (2) . While instruments are maintained in place for 30 sec. Paper points were immediately
important in removal of infected dentin from the main root canal. transferred to transport to the autoclaved veil containing Nutrient
Irrigants play an important role in areas, where instruments cannot broth. After completing biomechanical preparation using step back
reach, viz lateral and accessory canals as well as fins and webs technique; Second sample was made by means of using appropriate
throughout the canal(3). size paper point and were immediately transferred to the autoclaved
A lot of root canal irrigants are available which are used singly or in veil containing Nutrient broth.
combinations. Despite advances in disinfection in root canal Isolation and identification of microorganisms
treatment, the irrigants are still not effective against all The average time between sample collection and laboratory
microorganisms found in the root canal system. The purpose of the processing was 6 hrs. It is important to emphasize that the samples
study was to evaluate the efficacy of different combination of were processed in the laboratory within 6 hrs to preserve the
irrigating solution during the first visit of treatment. reproductive capacity of bacterial cells and to prevent the growth of
0
microorganisms in the sample. Transport veil were placed at 37 C for
MATERIAL AND METHOD 30 min and then vigorously mixed for 20 30 sec using a vortex
Following materials tested and evaluated for antimicrobial efficacy : mixture and were incubated for 24 hours. Each sample was then
Group I : Metronidazole and normal saline. serially diluted in peptone water and aliquots (25l) were plated onto
Group II : EDTA, Hydrogen peroxide(3%) and sodium several media as follows: MacConkey and Blood Agar.
Hypochlorite(3%) Semi Quantization of Bacteria
Group III : EDTA, Sodium Hypochlorite(3%) and A platinum loop of 0.001 ml of diameter was taken for
Chlorhexidine(2%) streaking the specimen. And Semi Quotation of bacteria was done by
multiplying the colony count by 1000.
METHODOLOGY Heavy: If the colony count was uncountable and growth was present
Patient Selection in all three streaking it was taken as heavy.
Twenty five systemically healthy patient aged between 23 Moderate: If the colony count were more then 50 and was present in
49 years. The patients were selected at random and included both first and second streaking it was taken as moderate.
males and females. None of them had received systemic antibiotic Scanty: If the colony count was less then 50 and was present only in
therapy in the preceding 3 months. All selected teeth had single roots, first streaking it was taken as scanty.
Infected pulp chambers and showed an asymptomatic apical No growth: Was taken when there was no growth
periodontitis without communication to the mouth through fistula or
otherwise. RESULTS
Collection of clinical specimen In present study Enterococcus, Streptococcus,
Microbial samples and endodontic treatment were Staphylococcus, Neisseria and Pseudomonas were the frequent
performed for 60 sec with a 0.2 % chlorhexidine solution. Teeth under bacteria recovered from the first sample of canal. The second sample
of canal shows heavy, moderate, Scanty and no growth of bacteria.
22
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
DISCUSSION necrotic porcine muscle tissue. J Endod 1988;14: 125 7.
Several studies on root canal infections have focussed on 4. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB;
aerobic and anaerobic bacteria due to their predominance in Enterococcus faecalis. Its role in root canal treatment failure
samples taken from untreated teeth with necrotic pulps. and concepts in retreatment. J Endod 2002;32, 93 98.
Microorganisms were recovered from the first sample in 25 root 5. Kvist T, Molander A, Dahln G, Reit C, Micro biological
canals in agreement with previous studies that showed the evaluation of one and two visit endodontic treatment of teeth
relationship between the microorganisms and the development of with apical periodontitis ; a randomized clinical trial. J
apical periodontitis. (4) In majority of in vivo studies root canal Endod 2004; 30 : 572 6.
samples were acquired with paperpoint (5) as in the study. 6. Valli KS, Lata DA, Jagdish S An in vitro SEM comparitive
It is important to emphasize that the samples were Study of debridment ability of K files and canal Master. Ind J
processed in the laboratory within 6 hrs to preserve the Dent Res 1996;7:128 34.
reproductive capacity of bacterial cells. In the study K files were 7. Joao Vicente Baroni Barbizam, Luis Fernando Fariniuk,
used for the preparation of the root canal by step back technique. Melissa Andre ia Marchesan, Jesus Djalma Pecora, Manoel
As the result of various studies showed neither of instrument D. Sousa-Neto; Effectiveness of manual and rotary
techniques were more efficient in cleaning of root canals.(6) (7) instrumentation techniques for cleaning flattened root
In the present study Enterococcus, Streptococcus, canals. J Endod 2002;28(5):40-45.
Staphylococcus, Nesseria and Pseudomonas were the frequent 8. Shuping GB, Dorstavik D, Sigurdsson A, Trope M;
bacteria recovered from the canals before treatment. Despite Reduction of intracanal bacteria using nickel titanium
mechanical instrumentation and disinfection of the root canal instrumentation and various medication 2000; 26:751 5.
system in the first sitting, microorganisms were recovered in 22 9. By storm A, Sunvqvist G. Bacteriologic evaluation of the
canals (Sample 3), clearly showing that root canal preparation and efficacy of mechanical root canal instrumentation in
irrigation is unable to eliminate all bacteria from the root canal endodontic therapy Scand Journal of Dental Research 1981;
system. However preparation did reduce the bacterial population. 89: 321 - 8.
In accordance of the study carried out by Shuping AB et al(8), by 10. Siqueira JF Jr., Rocas IN, Santos SR, Lima KC, Magalhaes
Storm A et al(9) and Siqueira J.F et al(10) . FA, Deuzeda M, Efficacy of instrumentation technique and
Removal of smear layer from the surface of irrigation regimens in reducing the bacterial population
instrumented root canals should allow the penetration of irrigant within root canal. J Endod 2002; 28:181 4.
into root canal irregularities and the dentinal tubules. Various 11. SiqueiraJF Jr., Batista MM, Fraga RC, De Uzeda M;The
chemicals have been used to remove smear layer. They include Effects of endodontic irrigants on black pigmented gram
different formulation of EDTA, Acetic acid, Citric acid, negative anaerobes and facultative bacteria. J Endod 1998;
Polyacrylic acid, Tannic acid. In the study EDTA used in 24: 414 - 6.
combination of other irrigants. The result of study shows the 12. Yesiloy C, Whitaker E, Cleveland D, Phillips E, Trope M;
Group III irrigants shows significant reduction of bacterial Antimicrobial and toxic effects of established and potential
population may be attributed to EDTA and Chlorhexidine which root canal irrigants. J Endod 1995; 21: 513 15.
has a broader antibacterial spectrum(11)and even at a highest 13. Sjogren U, Sundquist G. Bacteriological evaluation of
concentration of chlorhexidine has a very low toxicity.(12) ultrasonic root canal instrumentation on oral surgery
It has been suggested that the bacterial population may be further 1987;63:366 - 70.
by adding ultrasonic.(13) The techniques such as ultrasonic, sonic
and pressure system might demonstrate different results and
further exploration is needed on this subject.
CONCLUSION
Among the three groups
Group 1: Normal saline and metronidazole reduced the micro-
organisms insignificantly.
Group 2: EDTA, Hydrogen peroxide and sodium hypochlorite
reduced micro-organisms more then group I.
Group 3: EDTA, sodium hypochlorite and chlorhexidine was the
one which reduced the root canal microflora significantly, and in
three cases there was no growth.
REFERENCES
1. Storm A. Sundquist G. Bacteriologic evaluation of the
efficacy of mechanical root canal instrumentation in
endodontic therapy. Scand J Dent Res 1981;89: 321 - 8
2. Sjogren U. Figdor, D. Persson S., Sundquist G. Influence of Corresponding
Corresponding Address:
Address:
infection at the time of root canal filling on the outcome of
endodontic treatment of teeth with apical periodontitis. Int Dr. Neha
C.
Dr.Dr.
Dr. KKAggarwal
Ram Mohan
Dixit
Dixit
End J 1997;30: 297 306 Email:
Email: dr_rammohanc@yahoo.co.in
Email:
Email: dixit.kk@gmail.com
dixit.kk@gmail.com
dr.nehaaggarwal19@gmail.com
3. Hasselgren G, Olsson B, Cvek M. Effect of calcium
hydroxide and sodium hypochlorite on the dissolution of
23
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF TABLES
Group I : Metronidazole and normal saline
No. Of Cases SAMPLE 1: Growth and Predominant SAMPLE 2: Growth and Predominant
bacteria bacteria
Case 1 Heavy Growth Moderate Growth
Staphylococcus, Bacillus, Enterococcus Staphylococcus, Enterococcus
Case 2 Moderate Growth Moderate Growth
E. Coli, Streptococcus Streptococcus
Case 3 Heavy Growth Moderate Growth
Streptococcus, Bacillus, Enterococcus Enterococcus, Bacillus
Case 4 Heavy Growth Heavy Growth
Pseudomonas, Streptococcus Streptococcus
Case 5 Heavy Growth Heavy Growth
Streptococcus Bacillus, Streptococcus
Case 6 Heavy Growth Heavy Growth
Staphylococcus, Bacillus, Enterococcus Enterococcus,
Case 7 Moderate Growth Moderate Growth
Neisseria, E.coli, Bacillus Bacillus
Case 8 Heavy Growth Heavy Growth
Enterococcus, Pseudomonas Enterococcus, Bacillus
Group II EDTA, Hydrogen peroxide(3%) and sodium Hypochlorite(3%)
No. Of Cases SAMPLE 1: Growth and Predominant SAMPLE 2: Growth and Predominant
bacteria bacteria
Case 1 Moderate Growth Moderate Growth
Streptococcus, Neisseria Dipthroids
Case 2 Heavy Growth Moderate Growth
Enterococcus Enterococcus, Bacillus
Case 3 Heavy Growth Heavy Growth
Enterococcus, Pseudomonas Enterococcus, Bacillus
Case 4 Heavy Growth Moderate Growth
Streptococcus, Enterococcus, Dipthroids, Enterococcus
Case 5 Heavy Growth Heavy Growth
Enterococcus, Neisseria Enterococcus
Case 6 Moderate Growth Moderate Growth
Neisseria, Bacillis Bacillus
Case 7 Heavy Growth Moderate Growth
Pseudomonas Pseudomonas
Case 8 Moderate Growth Moderate Growth
Staphylococcus, Enterococcus Enterococcus, Bacillus
Group III EDTA, Sodium Hypochlorite(3%) and Chlorhexidine(2%)
No. Of Cases SAMPLE 1: Growth and Predominant SAMPLE 2: Growth and Predominant
bacteria ba cteria
Case 1 Heavy Growth Scanty Growth
Pseudomonas Bacillus
Case 2 Moderate Growth No Growth
Staphylococcus, Enterococcus, Neisseria -------------
Case 3 Heavy Growth Scanty Growth
Enterococcus Bacillus
Case 4 Moderate Growth Scanty Growth
Streptococcus Streptococcus, Bacillus
Case 5 Heavy Growth Scanty Growth
Staphylococcus, Bacillus, Enterococcus Neisseria,Bacillus
Case6 Heavy Growth Scanty Growth
Neisseria, Bacillus Bacillus
Case 7 Moderate Growth No Growth
Streptococcus, Neisseria -------------
Case 8 Moderate Growth No Growth
Staphylococcus, Bacillus -------------
Case 9 Heavy Growth Scanty Growth
Pseudomonas, Bacillus Pseudomonas, Bacilli
24
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
MATERIAL AND METHODS The most prevalent canal pattern in this study was Type
One hundred extracted mandibular pre molars were I, occurring in 69 % of the mandibular first premolars scanned
collected from local dentists across Agra , Bareilly and Merrut . followed by Type III occurring in 29 % of the teeth and Type II
Exclusion criteria: and Type V which were each found in 1 % of all the teeth scanned.
I. Deep caries Although most mandibular first premolars have a single
II. Metallic restoration root, two-, three-, and even four-rooted forms have been reported
25
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Number of canals and apices in the mandibular first premolar (incidence by number of teeth)3
Reference No. of Teeth (n) Ty pe of study 1 canal >2 canals 1 canal at apex >2 canals at apex
Vertucci, 1984 400 (USA) In vitro; clearin g 70% (280) 30% (120) 74% (2 96) 26% (104)
In vitro; radiography
Lu et al. , 2006 82 (China) 54% (44) 46% (38) _ _
and sectioning
Sert and Bayirli, 2004 200 (Turkey; gender) In vitro; clearin g 60.5% (121) 39.5% (79) 89.5% (1 79) 10.5% (21)
Yoshiok a et al., 2004 139 (Japan) In vitro; clearin g 80.6% (112) 19.4% (27) 80.6% (1 12) 19.4% (27)
aliskan et al., 1995 100 (Turkey) In vitro; clearin g 64% (64) 36% (36) 75% (75 ) 25% (25)
In vivo; review o f
Sabala et al., 1994 1002 (USA) 81.8% (820) 18.2% (182) _ _
patient records
Milano et al., 1 (USA; 17-y.o. His panic Rad iographic All first and second mandibular premolars
2002 male) Study exhibited 2 roots
1 (USA; 49 -y.o. Caucasian Single main canal split into 3 separate canals
Nallapati, 2005 Clinical RCT
Jamaican male) and apical foramina
WESTERN
100 69 1 29 0 1 0 0 0 0
U.P
TURKISH8
200 60.5 18.5 10.5 7 2.5 0 0 1 Not reported
(Sert S,2004)
WESTERN9
CHINESE 178 86.8 0 1.7 0 9.8 0 0 0.6 1.1
(Xuan Yu,2012)
INDIAN10
(Sandhya R, Velmurugan 100 80 9 3 2 4 0 0 0 2
N, 2010)
as 2.1% incidence when grouped together. The majority 6. Robinson S, Czerny C, Gahleitner A, Bernhart T, Kainberger
of mandibular first premolar teeth have a single canal but there is a FM. Dental CT evaluation of mandibular first premolar root
relatively high incidence, or one-quarter of mandibular configurations and canal variations. Oral Surg Oral Med Oral Pathol
premolars, that have two or more canals (24.2%)3. Oral RadiolEndod. 2002;93(3):328-32.
CONCLUSION 7. Eder A, Kantor M, Nell A,Moser T , Gahleitner A , Schedle A, et
Among the Western U.P population , the Type I root canal al. Root canal system in the mesiobuccal root of the maxillary
morphology occurred most frequently ( 69%) in the mandibular first first molar: an in vitro comparison study of computed
premolar teeth. This result is consistent with the results of the tomography and histology. DentomaxillofacRadiol 2006;
previous studies done in India . 35:175-77
CT scan is a useful tool in assessing the root canal morphology . 8. Sert S, Aslanalp V, Tanalp J: Investigation of the root canal
configurations of mandibular permanent teeth in the Turkish
REFERENCES population. IntEndod J 2004, 37:494499.
1. Martin Trope, Leslie Elfenbein Mandibular Premolars with 9. XuanYu,BinGuo,Ke-Zeng Li et al.Cone-beam computed
More Than One Root Canal in Different Race Groups tomography study of root and canal morphology of mandibular
J.Endod1986 ;12:343-45 premolars in a western Chinese population. BMC Medical
2. Ash M, Nelson S. Wheeler's dental anatomy, physiology and Imaging 2012, 12:18
occlusion. 8th ed. Philadelphia: Saunders, 2003. 10. Sandhya R, Velmurugan N, Kandaswamy D. Assessment of root
3. Blaine M. Cleghorn William H. Christie et al The Root and Root canal morphology of mandibular first premolars in the Indian
Canal Morphology of the Human Mandibular First Premolar: A population using spiral computed tomography: an in vitro study.
Literature Review (J Endod 2007;33:509 516) Indian J Dent Res. 2010;21 2:169173.
4. Cohen S, Hargreaves KM: Pathways of the Pulp. 10th edition. St
Louis: Mosby-Elsevier 2011. p.144 Corresponding Address:
5. XuanYu,BinGuo,Ke-Zeng Li et al.Cone-beam computed
tomography study of root and canal morphology of mandibular Dr. Nishtha Chauhan
premolars in a western Chinese population. BMC Medical Email: chauhannishtha@gmail.com
Imaging 2012, 12:18
26
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
Teeth were stuck on surgical plaster tape and 16 slice CT scan Vertucci's classification was used to 4determine
(BRIGHTSPEED ELITE 16, GE) was used to scan the 100 the pattern of the root canal .
premolars simultaneously.
RESULT
Type I (1-1)
Type II (2-1)
Type V (1-2)
27
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Professor and Head, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Senior Lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Senior Lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 15/Apr/2013
Date of Acceptance : 03/Jun/2013
Abstract: Sialoliths are the calcified organic matter that forms within the secretory system of the major salivary
glands. Sialolithiasis accounts for 30% of salivary diseases. Stones may be encountered in any of the salivary
glands but most frequently in the submandibular gland and its duct(83-94%), less frequently the parotid (4-
10%) and the sublingual glands (1-7%).Its occurrence in the adult population is approximately 12 per 1,000
patients, with a slight male predominance.While the majority of salivary stones are asymptomatic or cause
minimal discomfort, larger stones may interfere with the flow of saliva and cause pain and swelling. This case
report describes two patients presenting with submandibular gland sialolith and review of the literature
regarding the salivary sialothiasis.
INTRODUCTION and pain on the right side of the jaw since 2 months. History of the
Heterotopic calcification which results from deposition present illness revealed that there was history of increase in the
of calcium in normal tissue despite normal serum calcium and size of swelling during meals and subsides during the rest of the
phosphate levels is known as idiopathic calcification. Sialoliths day. It was not associated with any discharge. Pain was dull,
belongs to the category of idiopathic calcification.1Salivary duct aggravated on eating food and relieved by itself. Extraoral
lithiasis refers to the formation of calcareous concretions or examination revealed a diffuse swelling won the right
sialoliths in the salivary duct causing obstruction of salivary flow, submandibular region roughly measuring about 2x3 cm in
resulting in salivary ectasia, sometimes even dilatation of the greatest dimension extending from base of mandible to 2 cm
salivary gland.2More than 80% of salivary gland calculi can be below the inferior border of mandible. The skin overlying the
found in the submandibular gland and located in the glandular swelling was normal(Figure 1). On palpation,it was firm in
parenchyma or the excretory duct.3 consistency and tender on palpation. In intraoral examination, a
Males are affected twice as much as females, especially firm mass was palpable on the floor of mouth extending from
in case of parotid gland lithiasis. Sialolithiasis usually occurs mesial aspect of 46 to 47(Figure 2).On the basis of history and
between the age of 30-60 years, though it can also occur during clinical examination,a provisional diagnosis of sialolith was
teen age. Children are rarely affected, but submandibular gland given. In the investigations a mandibular occlusal radiograph was
calculi have been reported in children aged from 3 weeks to 15 taken which revealed a well defined radiopaque structure
years.4Within the submandibular gland, the vast majority of measuring about 1x2 cm lingual to the body of mandible on the
sialoliths are found in the Wharton's duct. The ratio of sialoliths right side(Figure 3). In the treatment surgical excision was done
found within the gland to those found in Wharton's duct is 3:7.2.5 which revealed the final diagnosis of sialolith.
The classic symptom are that of obstruction manifested
by pain and swelling of the involved during eating. Sialoliths are CASE REPORT 2
usually unilateral and do not cause xerostomia. Submandibular A 45 year old female patient reported to the Department
stones consist of 82% inorganic and 18% organic material while of Oral Medicine and Radiology with a chief complaint of
the parotid stones are composed of 49% inorganic and 51% swelling and pain on the left side of the jaw since 2 months.
organic material.6 History of the present illness revealed that there was history of
Bimanual massage of the affected gland and the increase in the size of swelling during meals and subsides during
excretory duct should be carried out, observing the flow and the the rest of the day. It was not associated with any discharge. Pain
clearness of the saliva. Submandibular stones are typically was dull, aggravated on eating food and relieved by itself.In
removed surgically via either an intraoral or an external intraoral examination, a firm mass was palpable on the floor of
approach.7 mouth extending from mesial aspect of 36 to 37(Figure 4). On the
basis of history and clinical examination,a provisional diagnosis
CASE REPORT 1 of sialolith was given. In the investigations a mandibular occlusal
A 35 year old male patient reported to the Department of radiograph was taken which revealed a well defined radiopaque
Oral Medicine and Radiology with a chief complaint of swelling structure measuring about 1.5x1cm lingual to the body of
mandible on the left side(Figure 5). In the treatment surgical
28
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
excision was done which revealed the final diagnosis of sialolith. body, a phlebolith, or myositis ossificans.11Once a diagnosis of
DISCUSSION sialolithiasis is determined, effective treatment of the sialolith
Sialolithiasis accounts for more than 50% of diseases of depends on the location of the stone, and is accomplished by
the large salivary glands. Submandibular sialolith formation is extraoral or intraoral surgical removal of the sialolith. Removal of
more common because its saliva is more alkaline, has an the affected salivary gland and its associated duct may also be
increased concentration of calcium and phosphate, and has a necessary.12 However, initial management consists of antibiotic
higher mucous content than saliva from the parotid or sublingual therapy to reduce or eliminate the acute infection. The drug of
glands. Further, the submandibular duct is longer than that of the choice is penicillin (250 mg- 500 mg orally, every 6 hr). The
other major glands, and the saliva flows against gravity.8 The patient is also instructed to suck on sour lemon or orange candy to
etiological factors that account for sialolith formation are stimulate salivary flow.16Patients presenting with sialolithiasis
unknown, but saliva retention due to anatomical considerations, may benefit from a trial of conservative management, especially
and saliva composition, are believed to be important.9 Traditional if the stone is small. The patient must be well hydrated and the
theories suggest that the formation of sialoliths occur in two clinician must apply moist warm heat and gland massage, while
phases: 1. Formation of a central core and 2. A layered periphery. sialogogues are used to promote saliva production and flush the
The central core is formed by the precipitation of salts, which are stone out of the duct.17 In the management of large sialoliths which
bound by certain organic substances. The second phase consists are located in the close proximal duct, extracorporeal shock wave
of the layered deposition of organic and non-organic material. lithotripsy (ESWL) can be considered.18
Submandibular sialoliths are thought to be formed around a nidus Conclusion
of mucus, whereas parotid sialoliths are thought to be formed The dental practitioner has an important role to play in
around a nidus of inflammatory cells or a foreign body.4 the management and possible treatment of sialolithiasis.
It is likely that for stone formation to occur, intermittent Establishing a diagnosis of sialolithiasis requires a thorough
stasis of calcium-rich saliva occurs, producing a change in the history and physical examination along with routine radiographs.
mucoid element of saliva, and a gel forms. This gel produces the Patients should be educated regarding the mechanism of their
framework for deposition of salts and organic substances thus underlying pathology and methods of maintaining control over
creating a stone.8 Salivary calculi are usually small and measure them by emphasizing the value of hydration and excellent oral
from 1 mm to less than 1 cm. They rarely measure more than 1.5 hygiene, which lessens the severity of the attacks and prevents
cm .Mean size is reported as 6 to 9 mm .10 dental complications.The accepted treatment of sialolithiasis is
Sialoliths have been identified in the literature as surgical intervention, either removal of the sialolith or complete
causing repeated swelling during meals. However, symptomless excision of the gland.
sialoliths are common. If pain is present, the severity of the
symptoms depends on the degree of obstruction, which is related REFERENCES
to the size and location of the sialolith.11Sialolithiasis causes pain 1. White SC, Pharoah MJ. Oral radiology principles and
and swelling of the involved area by obstructing the food-related interpretation. Chapter 27. In: Soft Tissue Calcification and
surge of salivary secretion. In some cases, the sialolith may cause Ossification. Mosby, Missouri 2004:p597-614.
stasis of the saliva, leading to bacterial contamination of the 2. Torres-Lagares D, Barranco-Piedra S, Serrera-Figallo MA,
parenchyma of the gland, and clinical infection, with pain and Hita-Iglesias P, Mart inez-Sahuquillo-Mrquez A, Gutirrez-
swelling of the gland. Long-term obstruction in the absence of Prez JL. Parotid sialolithiasis in Stensen's duct , Med Oral
Patol Oral Cir Bucal 2006; 11: E80-84
infection can lead to atrophy of the gland with resultant lack of 3. Goncalves M, Hochuli-Vieira E, Lugao CE, et al. Sialolith of
secretory function and eventual fibrosis.12 unusual size and shape. Dentomaxillofac Radiol.
Correct diagnosis of a sialolith requires a proper history 2002;31:209-210.
and clinical examination. Sialoliths can occasionally be palpated 4. Ali Iqbal, Anup K Gupta, Subodh S Natu, Atul K Gupt a.
using a bidigital palpation approach at the floor of the mouth and Unusually large sialolith of Wharton's duct. Ann Maxillofa
parotid regions. Bi-manual palpation of the gland itself can Surg 2012; 2: 70-73.
identify a hypofunctional or nonfunctional gland associated with 5. Grases F, Santiago C, Simonet BM, et al. Sialolithiasis:
a uniformly firm and hard mass.13 In the anterior floor of the mechanism of calculi formation and etiologic factors. Clin
mouth, an occlusal radiograph may reveal the calculus. All Chim Acta. 2003;334:131-136.
salivary stones cannot be visualized through conventional 6. Giacomo Oteri, Rosa Maria Procopio and Marco Ciccci.
radiograph because a few of them are hypominelarized and are Giant Salivary Gland Calculi (GSGC) : Report of Two Cases,
superimposed by other radiodense tissues. In these cases other Open Dent J. 2011; 5: 90-95.
7. Zenk J, Constantinidis J, Al-Kadah B, Iro H. Transoral
advanced imaging modalities should be considered. 14 removal of submandibular stones. Arch Otolaryngol Head
Ultrasonography is widely reported as being very helpful in Neck Surg. 2001;127:432-6.
detecting salivary stones. As many as 90% of all stones larger than 8. Markiewicz MR, Margarone JE 3rd, Tapia JL, et
2mm can be detected as echodense spots on al.Sialolithiasis in a residual Wharton's duct after excision of
ultrasonography.However, detection of small calculi may be a submandibular salivary gland. J Laryngol Otol.
difficult with ultrasonography. Computed tomography (CT) is 2007;121:182-185.
also highly diagnostic.15Sialography is also useful to locate 9. Siddiqui SJ. Sialolithiasis: an unusually large submandibular
obstructions that cannot be detected by means of bidimensional salivary stone. Br Dent J. 2002;193:89-91.
radiography, especially whenever sialoliths are radiolucent or 10. Yu CQ, Yang C, Zheng LY, et al. Selective management of
whenever they are not present (as is the case with stenosis.2 obstructive submandibular sialadenitis. Br J Oral Maxillofac
Differential diagnosis of a sialolith could include a Surg. 2008;46:46-49.
calcified lymph node, an avulsed or impacted tooth or foreign 11. Mandel L, Hatzis G. The role of computerized tomography
29
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
in the diagnosis and therapy of parotid stones: a case report. J
Am Dent Assoc. 2000;131:479-482.
12. Soares LP, Gaiao de Melo L, Pozza DH, et al. Submandibular
gland sialolith in a renal transplant recipient: a case report. J
Contemp Dent Pract. 2005;6:127-133.
13. Van den Akker HP. Diagnostic imaging in salivary gland
disease. Oral Surg Oral Med Oral Pathol. 1988;66:625-37.
14. Weissman JL. Imaging of the salivary glands. Semin
Ultrasound CT MR. 1995;16:546-68.
15. Yousem DM, Kraut MA, Chalian AA. Major salivary gland
imaging. Radiology. 2000; 216:19-29.
16. Blatt IM: Studies in sialolithiasis. III. Pathogenesis,
diagnosis and treatment. South Med J 57:723-29, 1962.
17. Williams MF Sialolithisis Otolaryn Clin North Am 1999; 32:
819834.
18. Bodner L. Giant salivary gland calculi: diagnostic imaging
and surgical management. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2002 ; 94:320-3.
Corresponding Address:
Corresponding Address:
Dr. Mallika
Neha
C.
Dr.Dr. Ram Kishore
KKAggarwal
Mohan
Dixit
Email:
Email:
Email: dr.mallika.kishore01@gmail.com
dr_rammohanc@yahoo.co.in
Email: dixit.kk@gmail.com
dr.nehaaggarwal19@gmail.com
30
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
31
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Abstract: Endodontic therapy is essentially a micro neurologic surgical procedure involving complete
debridement and three dimensional obturation of the root canal system to obtain a fluid impervious seal. The
foundation of the procedure is based on the intimate knowledge and thorough understanding of the anatomy of
both the pulp chamber and the root-canal system. Teeth exhibit variations in their root canal anatomy and pose
a challenge in diagnosis and treatment. Maxillary canine are statistically more commonly single rooted, single
canalled but rarely may have single root with two root canals.
Key words : Endodontic Treatment, Maxillary Canine, Root Canal Anatomy, Two Root Canals
INTRODUCTION preparation was done, coronal preparation was done using
The pulp canal system in any tooth has the potential of #4,#3,#2 gates glidden drills(Tulsa dental, dentsply) middle and
being very complex with branching and divisions throughout the apical preparation by hand files (k-files) preparing the apical till
length of the root.1 Diagnosis and identification of variations in #30. The chemo-mechanical preparation was performed under
number of roots and root canals are the key factors in endodontic copious irrigation using 5.25% sodium hypochloride and 17%
treatment. The anatomy of root canal systems dictates the EDTA after use of each file. Final irrigant used was 2%
condition under which root canal therapy is carried out and can chlorohexidine. The root canals were obturated with gutta percha
directly affect its prognosis. Extra root canals if not detected are a and zinc oxide eugenol sealer using lateral condensation
major reason for failure of endodontic therapy.2 technique. Finally the tooth was restored with composite resin.
Maxillary canines are statistically more common to be
single-rooted, single-canaled teeth. It has been reported that 39% DISCUSSION
have straight canals, whereas 32% have root canals curved Knowledge to basic concepts is more important than the
distally. Lateral canal are present in 30% cases. Two root canals tools of measurement.8 Therefore it is of utmost importance to
in a permanent maxillary canine is a rare condition.3-6 Of those locate and treat all root canals in a tooth.
having two canals, majority join in apical third and exit at single During the past years, there have been many studies of
apical foramen.7 pulp morphology. The anatomical studies of Vertucci3, Pineda
and Kuttler4 Black9, and Green10 all state that maxillary incisors
CASE REPORT have a single root 100% of the time.. The percentage of
A 34 year old male patient reported to the department of permanent maxillary canines with type V canal configuration
conservative dentistry and endodontics with a chief complaint of (one canal leaves the pulp chamber and divides short of the apex
pain in upper front region past 4 months. Subjective symptoms into two type V canal configuration (one canal leaves the pulp
included dull, continuous, non radiating pain that aggravated on chamber and divides short of the apex into two separate and
mastication and relieved on medication. Past dental history and distinct canals with separate apical foramina 2 was 2.17 and type
Medical history were non contributory. III canal configuration (one canal leaves the pulp chamber,
Oral examination revealed deep dental caries extending divides into two
subgingivaly with no direct pulpal exposure. Tooth was within the root, and merges to exit as one canal 2 was 4.35. A
asymptomatic on palpation and tested negative using electric pulp review of the literature revealed that Alapati et al.6 reported a
tester. Periodontal status was within normal limits. Radiographic maxillary right canine with type II canal configuration and
examination spotted abnormal root canal anatomy, single root Weisman reported a bi-rooted maxillary left canine.
with two root canals. Periapical radiolucency was seen with size In the present case two distinct root canal orifices were
less than 1 cm in diameter. Provisional diagnosis made was located in a labial/palatal configuration. The palatal canal coursed
chronic periapical abscess. laterally and then curved back to join the buccal canal in the apical
Endodontic treatment was started under local third, forming a type II canal configuration. Although one of the
anaesthesia. Access cavity was made using #1014 round diamond two canals, the one most continuous with the large main passage,
bur and endo Z carbide bur, pulp extirpation was done using is usually amenable to adequate enlarging and filling procedures,
bared broach. Root canals were negotiated with #10 k- file and the preparation and filling of the other canal is often extremely
working length was established. Crown down root canal difficult.
32
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
CONCLUSION
Clinicians should be aware of anatomical variations in
the teeth they are managing, and should never assume that canal
systems are simple. Even though the most common anatomy of
maxillary canines comprises a single root and a single root canal,
clinicians should consider the possible variations and always
search for the second root canal in teeth with either one or two
roots.
REFERENCES
1. Nagesh bolla. Maxillary canine with two root canals. J
Conserv Dent 2011;14:80-2
2. Hulsmann M, Schafer E. Problems in gaining access to the
root canal system. In: Hulsmann Michael, Schafer Edgar,
editors. Problems in Endodontics: Etiology, Diagnosis and
Treatment. 1st ed. Germany:Quintessence Publishing Co
Ltd; 2009. p. 145-72
3. Vertucci FJ. Root canal anatomy of the human permanent
teeth. Oral Surg, Oral Med, Oral Pathol, Oral Radiol,
Endod1984;58: 589 -99.
4. Zeigler PE, Serene TP. Failures in therapy. In Cohen S, Burns
RC, eds. Pathways of the pulp. 4th ed. St. Louis: CV. 1994,
690-91.
5. Pineda F, Kuttler Y. Mesiodistal and buccolingual
roentgenographic investigation of 7,275 root canals. Oral
Surg, Oral Med, Oral Pathol, Oral Radiol, Endod
1972;33:101-10.
6. John. I. Ingle, James H. Simon, Pierre Machtou , and Patrick
Bogaerts.Outcome of endodontic treatment and re-
treatment. In.Ingle Ij, . Bakland Lk, Endodontics. 5th ed. BC
Decker Inc 2002;747-68.
7. Ravi SV.Maxillary canine with two root canals:a case report.
Ind J Dent Res 2012:69-71.
8. Krasner P, Rankow H J Anatomy of the Pulp-Chamber Floor.
J Endod 2004;30:5-16.
9. Alapati S, Zaatar EI, Shyama M, Al-Zuhair N. Maxillary
canine with two root canals. Med Principles Prac
2006;15:74-6.
10. Weisman MI. A rare occurrence: a bi-rooted upper
canine.Aus Endod J 2000;26:119-20.
Corresponding Address:
Corresponding Address:
Dr. C.
Dr. Ram Mohan
Anuraag gurtu
Email: dr_rammohanc@yahoo.co.in
Email: anuraggurtu@yahoo.com
33
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
34
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Abstract: Gingival recession is defined as the apical displacement ofthe gingival margin from the cemento-
enamel junction (CEJ). Gingival recessions require treatment for many reasons impaired aesthetic
appearance, root sensitivity, cervical caries or abrasion. Many surgical techniques have been advocated for
recession coverage. Since its introduction in 1963, the free gingival graft procedure has proven reliable in
increasing attached gingiva and stopping progressive gingival recession. In 1982, Miller proposed a
modification of the conventional technique for autogenous gingival graft surgery for root coverage. This paper
presents a case of denuded root coverage using free gingival graft technique.
Key words : Gingival Recession, Gingival Graft, Gingiva, Denuded Root, Cementoenamel Junction.
INTRODUCTION failure rates are also high for free gingival grafts when solely used
Gingival recession is defined as the location of gingival for root coverage procedure. Miller 19878 has proposed many
margin apical to cementoenamel junction.1When occurring in factors for incomplete or failure of root coverage. These include
anterior tooth regions of the oral cavity, gingival recession can be improper classification of marginal tissue recession, inadequate
aesthetically unpleasing for the patient and it can also further lead root planning, failure to treat the planed root with citric acid,
to root sensitivity, cervical abrasion and root caries. Besides improper preparation of recipient site, inadequate size of
periodontal disease, various other factors such as faulty tooth interdental papillae, improperly prepared donor tissue,
brushing, orthodontic tooth movements, faulty restorations, inadequate graft size, in adequate graft thickness, dehydration of
frenum pull, tooth malpositioning etc. are considered as a major graft, inadequate adaptation of graft to root and remaining
cause for gingival recession. periosteal bed, failure to stabilize the graft, excess or prolonged
Miller classified gingival recession into four pressure in captions of sutured graft, reduction of inflammation
categories.3The classification is used to assess the defect as well prior to grafting, trauma to graft during initial healing.
as predict root coverage which may be possible using various
surgical procedures. Root coverage is more predictable and more CASE REPORT
successful with Class I and II defects, whereas only partial A 22 years old female patient visited the department of
coverage can be expected with Class III defects. Root coverage in Periodontics, with a chief complaint of sensitivity of a tooth in
Class IV defects should not be expected. Various periodontal lower anterior region. The periodontal examination revealed
plastic surgical procedures are used alone or in combination for Miller's class II recession in relation to 31(Fig 1). There was
predictable root coverage such as connective tissue grafts, pedicle probing depth of 1.5mm and radiographic examination showed
flaps, free gingival grafts, guided tissue regeneration etc. no bone loss interdentally. The vestibular depth was also
Autogenous gingival grafting or epithelialized free gingival insufficient in relation to 31 (Fig 1).Patient's medical and dental
grafting was introduced in 1963,4 and the procedure has proven histories were non-contributory.
reliable in increasing attached gingiva and stopping progressive Four weeks before surgery full-mouth scaling and
gingival recession. Also, long-term stability (up to 4 years) of polishing were performed and oral hygiene instructions were
these treatment outcomes has been demonstrated.5 Although root given to eliminate habits related to the etiology of the recession.
coverage is not a primary goal of autogenous gingival grafting, Re-evaluation of the tooth (31) at 4 weeks showed apico-
however it may occur in cases of narrow recession (< 3 mm), as a coronary 5mm of recession, mesio-distally 3mm of recession.
result of bridging, whereby some of the grafted tissue remains Accordingly after the patient's consent, it was decided to treat the
vital over the avascular zone of the root.6 site by Miller's technique for free autogenous gingival grafting to
In 1982, Miller7 proposed a modification of the achieve root coverage and simultaneously increase the attached
conventional technique for autogenous gingival graft surgery for gingiva and the vestibular depth.
root coverage. This modification used a thicker graft (2 mm)
positioned over a carefully planed root surface that had been SURGICAL PROCEDURE
previously conditioned with citric acid. With detailed suturing Preparation of Recipient Bed: the patient was asked to rinse
marginally and apically, the graft could be adapted in intimate with 10ml of 0.12% chlorhexidine for 30 seconds, following
contact with the recipient site. He showed 95.5% of root coverage which local anesthesia was administered. After adequate local
when recession was less than 3mm, 80.6% when recession was 3 anesthesia had been achieved, the exposed root was planed
to 5mm and 76.6% when it exceeded 5mm. Despite these results, thoroughly to reduce the convexity. Root conditioning was
35
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
achieved by burnishing the root using a cotton pellet saturated coverage has drastically declined. However free gingival graft
with tetracycline solution for about 3 minutes. A horizontal appears to be the best treatment alternative to increase the amount
incision was made at the level of cementoenamel junction of keratinised tissue and for treatment of class I and class II
extending from the line angle of adjacent teeth on either side of the gingival recessions. With appropriate case selection, this
recession deep into the papilla, creating a well defined butt joint technique is predictable in achieving complete root coverage.
At the distal terminal of the horizontal incision, vertical incision
was given extending well into the alveolar mucosa, so that it is CONCLUSION
3mm beyond the apical extent of the recession. A partial thickness The free gingival graft for root coverage is still a feasible
flap was elevated and excised apically (Fig 2). and predictable procedure not only to increase the amount of
Preparation of Donor Tissue: A tin foil template was used to keratinised gingival tissue but also in achieving coverage of
accurately determine the amount of donor tissue. The template denuded roots. Adequate vestibular depth can be achieved by the
was made by adapting it to the recipient site. The right side of procedure which helps in better oral hygiene maintenance by the
palate was chosen as the recipient site. The area between first and patient. The results obtained in this case suggests that with proper
second premolar which had greater thickness was selected to case selection, the procedure of free gingival graft holds promise
harvest the donor tissue. The initial incision was outlined by the for successful management of denuded root coverage.
placement of tinfoil template with a no 15 scalpel blade. All
palatal incisions were made in such a fashion as to create the butt REFERENCES
joint margin in the donor tissue. Tissue pliers was used to retract 1. The American academy of periodontology. Glossary of
the graft distally as it is being separated apically and dissected, periodontic terms. 4th ed. 2001
until the graft was totally freed (Fig 3). The graft obtained was 2. Ashley F, Usiskin L, Wilson R, Wagaiyu E. The relationship
inspected for any glandular or fatty tissue remnants. The between irregularity of the incisor teeth, plaque, and
thickness of the graft was also checked to ensure the smooth and gingivitis: a study in a group of school children aged 11-14
uniform thickness (Fig 4). The graft was placed on the recipient years. Eur J Ortho1998;20(1):65.
bed and sutured by means of sling sutures (5-0 vicryl sutures) (Fig 3. Miller P D Jr. A classification of marginal tissue recession.
5). A vertical stretching suture was given for close adaption of the Int J Periodont Rest Dent 1985; 5: 813.
graft to the tooth surface. After suturing a periodontal dressing 4. Bjrn H. Free transplantation of gingiva propia. Sver
was placed to protect the surgical site (Fig 6). The palatal wound Tandlak Tidskr 1963; 22:684.
was protected by periodontal dressing stabilized by a passive 5. Dorfman HS, Kennedy JE, Bird WC. Longitudinal
Hawley's retainer. evaluation of free autogenous gingival grafts. A four year
Post Operative Instructions: The patient was asked to refrain report. J Periodontol 1982; 53(6):34952.
from tooth brushing at the surgical site for two weeks. 0.12% 6. Sullivan HC, Atkins JH. The role of free gingival grafts in
chlorhexidine mouth rinsing was advised twice daily for 3 weeks periodontal therapy. Dent Clin North Am 1969;
and for post operative pain control, combiflam was prescribed, 13(1):13348.
twice daily for 3 days. The periodontal dressing was removed 2 7. Miller PD Jr. Root coverage using a free soft tissue autograft
weeks post operatively (Fig 7 & 8). Healing was uneventful and following citric acid application. Part 1: Technique. Int J
was completed in about six weeks. There was significant Periodontics Restorative Dent 1982; 2(1):6570.
augmentation of attached gingiva and also reduction in the 8. Miller Jr P. Root coverage with the free gingival graft.
recession size (Fig 9). Factors associated with incomplete coverage. J
Periodontol1987;58(10):674.
DISCUSSION 9. Sullivan H, Atkins J. Free autogenous gingival grafts. 3.
This case report presented Miller's class-II recession of Utilization of grafts in the treatment of gingival recession.
31, which was successfully treated by free autogenous soft tissue Periodontics1968;6(4):152.
graft. Also there was increase in vestibular depth led to
improvements in mucogingival relationships and also better
opportunity for plaque control by the patient.
Miller's criteria8 for successful root coverage include:
the soft tissue margin must be at the cemento-enamel junction,
clinical attachment to the root, with sulcus depth of 2mm, and no
bleeding on probing. All these criteria were achieved in the
present case. According to Sullivan and Atkins9 when free
gingival graft is placed over recession, some amount of
bridging can be expected because a portion of grafted tissue
which is covering the root will survive by receiving circulation
from the vascular portion of the recipient site. In addition to
bridging, creeping attachment can result in a post operative
coronal migration of free gingival margin. Free gingival grafting
is a procedure of high degree of predictability when used alone or Corresponding
Corresponding Address:
Address:
combined with other technique. However it is more technically Dr.
Dr.C.Rika
RamSingh
Mohan
demanding, time consuming, and the color match of the tissue is
often less than ideal. Due to the predictability and versatility of
Email: dr_rammohanc@yahoo.co.in
Email: rikasingh22@gmail.com
connective tissue graft, the use of the free gingival graft for root
36
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
Fig 4- Free gingival graft Fig 5- Graft secure in position Fig 6- Periodontal
using 5-0 vicryl sutures dressing given
Fig 7- Donor site 2 Fig- 8 Recipient site 2 Fig 9-3 months after healing
weeks post operative weeks post operative
37
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Abstract: Osteomyelitis, an inflammation of bone & its marrow contents is a sequela of periapical infection
results in diffuse spread through medullary spaces with subsequent necrosis of bone. It may be acute, subacute
& chronic. The pain, the pus, the new bone formation and all the trouble, this case showed it all. Here we are
reporting a case with complication of dental extractions with clinical & histopathological examination,
diagnosed as chronic osteomyelitis.
REFERENCES
1. Marc Baltensperger and Gerold Eyrich. Osteomyelitis of the Corresponding
Corresponding Address:
Address:
Jaws: Springer Berlin Heidelberg. November 07, 2008.
2. Aitasalo K, Niinikoski J, Grnman R, Virolainen E: A Dr. Neha
Dr.C.
Dr. RamAggarwal
Abhijeet Alok
Mohan
modified protocol for early treatment of osteomyelitis and Email:
Email:
Email: drabhijeet786@gmail.com
dr_rammohanc@yahoo.co.in
dr.nehaaggarwal19@gmail.com
osteoradionecrosis of the mandible. Head Neck 1998; 20(5):
4117.
39
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
Fig:2 Orthopantomogram
40
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
CONCLUSION
The elongated styloid process syndrome can be diagnosed
by a detailed history, physical examination, and radiological
investigations. It can be confused or mistaken for many other
conditions that must be excluded. An awareness of pain syndromes
related to the styloid process isimportant to all health practitioners
involved in the diagnosis and treatment of neck and head pain. In a
non specific orofacial pain there should be a high index of suspicision
of stylalgia Eagle's syndrome.
Corresponding Address:
Corresponding Address:
REFERENCES Dr.Dr.
Dr. Neha
C.
Dr. KKAggarwal
Anuja
Ram Joshi
Mohan
Dixit
1. Karam C, Koussa S. "Eagle syndrome: the role of CT scan with
3D reconstructions". J Neuroradiol. 2007; 34 (5): 3445. Email:
Email: dranujajoshi88@gmail.com
dr_rammohanc@yahoo.co.in
Email: dixit.kk@gmail.com
Email: dr.nehaaggarwal19@gmail.com
2. Veena k M, Ashwini S S, Jagdishchandra H. Carotid artery
42
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
43
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
DISCUSSION
It is always problematic to make an accurate impression
with a complete maxillary and mandibular arch for patients with a
constricted oral opening9. Various pins, bolt and lego pieces,
orthodontic devices have been used for locking mechanism of
sectional impression trays fabricated for patients with limited oral
openings7 and fixation of all these devices into trays requires
expert work. Here sectional trays were reoriented in and outside
the oral cavity accurately using autopolymerizing acrylic plate by
press buttons system and the technique was simple.
The main advantages for making sectional tray are
decreased patient trauma and no tear down of impression during
removal, moreover these trays has easy accessibility in patients
mouth and are less costly and easy to fabricate. The disadvantages
are additional time required for precise fabrication of sectional
tray. Extreme care should be taken during reorientation of
sections of sectional impressions in and outside the oral cavity.
CONCLUSION
It is often difficult to apply conventional clinical
procedures in fabricating complete denture prosthesis for
microstomia patients who demonstrate limited oral opening.
However with careful treatment planning, the use of sectional
impression procedure, many of the apparent clinical difficulties
can be overcome10.
REFERENCES
1. Baker PS, Brandt RL,Boyajian G.Impression procedure for
patients with severely limited mouth opening .J Prosthet
Dent 2000;84(2):241-244.
2. Kumar KA, Bhat V, K. Nair .Preliminary Impression in
Microstomia patient :An innovative technique . J Prosthet
Dent 2013; 13(1): 52-55.
3. The Academy of Prosthodontics. Glossary of Prosthodontic
terms- 8. J Prosthet Dent 2005; 94(1):52.
4. Geckili C, Altung C, Biling T . Impression procedures and
construction of sectional dentures for a patient with
microstomia : A clinical report. J Prosthet Dent
2006;91(3):387-90.
5. Wahle JJ, Gardner K, Fiebger . The mandibular swing lock
design for a patient with microstomia. J Prosthet Dent 1992;
68(3):523-7.
6. Benntti R, Zupi A, Toffanin A . Prosthetic Rehabilitation of a
patient with Microstomia: A clinical report. J Prosthet Dent
2004;92(4)322-7.
7. Cura C, Cotert HS, User A . Fabrication of sectional
impression tray and sectional complete dentures for a patient
with microstomia and trismus: A clinical report. J Prosthet
Dent2003; 89(6) : 540- 3 Corresponding Address:
Corresponding Address:
8. Geckili O,Cilinger A,Bilgin T. Impression procedure and Dr. Neha
Dr.Dilip
Dr. C.
Dr. Aggarwal
Kumar
Ram
KK Nath
Mohan
Dixit
construction of a sectional denture for a patient with
microstomia:A clinical report.J Prosthet Dent Email:
Email:
Email: dilip_nath2006@yahoo.co.in
dr_rammohanc@yahoo.co.in
Email: dixit.kk@gmail.com
dr.nehaaggarwal19@gmail.com
2006;91(3):387-90
45
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
Fig9,10,11-sectional special
tray with press buttons
Fig : 9 Fig : 10 Fig : 11
Fig : 14
Abstract: Preventive prosthodontics emphasizes the importance of any procedure that can delay or eliminate
future prosthodontic problems. In the past when patients presented themselves as candidates for a denture with
teeth that were badly broken down with periodontal involvement or without the ability to financially support an
extensive restorative treatment, those teeth were extracted that could have been retained under more favorable
conditions. A telescopic denture is a prosthesis which consists of a primary coping which is cemented to the
abutments in a patient's mouth and a secondary coping which is attached to the prosthesis and which fits on the
primary coping. It thereby increases the retention and stability of the prosthesis. Retention of the roots of one or
more teeth for overdenture offers the patient a lot of advantages like better stability, proprioception, and support
among a few. Telescopic crowns were initially introduced as retainers for the removable partial dentures at the
beginning of the 20th century. They were also known as a Double crown, a crown and sleeve coping or as
Konuskrone. The following case report is on telescopic over denture for mandibular arch.
Key words : Telescopic Denture, Double Crown System, Primary Coping, Secondary Coping, Preventive
Prosthodontics, Wedging Effect.
INTRODUCTION protection from the movements that dislodge the denture.
A telescopic denture is a prosthesis which consists of a The double crown systems are usually distinguished
primary coping which is cemented to the abutments in a patient's from each other by their differing retention mechanisms.6 There
mouth and a secondary coping which is attached to the prosthesis are three different types of double crown systems. These are
and which fits on the primary coping. It thereby increases the telescopic crowns which-achieve retention by using friction, and
conical crowns or tapered telescope crowns which exhibit friction
retention and stability of the prosthesis.1 According to GPT, a only when they are completely seated by using a wedging
telescopic denture is also called as an overdenture, which is effect. The magnitude of the wedging effect is mainly
defined as any removable dental prosthesis that covers and rests determined by the convergence angle of the inner crown: the
on one or more of the remaining natural teeth, on the roots of the smaller the convergence angle, the greater is the retentive force.
natural teeth, and/or on the dental implants. It is also called as The double crown with a clearance fit (also referred to as a hybrid
telescope or a hybrid double crown) exhibits no friction or
overlay denture, overlay prosthesis, and superimposed wedging during its insertion or removal. The retention is achieved
prosthesis.2 by using additional attachments or functional molded denture
Preventive prosthodontics emphasizes the importance borders.
of any procedure that can delay or eliminate future prosthodontics The telescopic denture which was supported by the
problems. The overdenture is a logical method for the dentist to natural teeth gained significant popularity as an alternative to the
use in preventive prosthodontics.3 Overdenture therapy is conventional dentures during the 1970s and the 1980s. The
essentially a preventive prosthodontic concept since it attempts to retained teeth that support the overdentures, preserve the bone
conserve the few remaining natural teeth. There are two and they minimize the downward and forward settling of a
physiologic tenets related to this therapy: the first concerns the denture, which otherwise occurs with alveolar bone resorption.
continued preservation of alveolar bone around the retained teeth4 The overdenture occlusion is maintained rather than shifting
while the second relates to the continuing presence of periodontal forward to simulate the appearance of a prognathic mandible.4
sensory mechanisms5 that guide and monitor gnathodynamic The telescopic denture philosophy postulated a transfer
functions. of occlusal forces to the alveolar bone through the periodontal
Telescopic crowns were initially introduced as retainers ligament of the retained roots. A proprioceptive feedback from
for the removable partial dentures at the beginning of the 20th the periodontal ligament prevents the occlusal overload and it
consequently avoids the residual ridge resorption which is
century. They were also known as a Double crown, a crown and adjacent to the roots and the rest of the ridge, due to excessive
sleeve coping or as Konuskrone,1 a German term that described a forces. They also provide improved functions as compared to the
cone shaped design. These crowns are an effective means for conventional dentures, such as an improved biting force, chewing
retaining the RPDs and dentures. They transfer forces along the efficiency and even phonetics. The impairment of these
ling axis of the abutment teeth and provide guidance, support and functional parameters which are created by edentulism reflects
47
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
the significant role of the periodontal receptors for a sensory DISCUSSION
feedback and a discriminatory ability from the retained roots. Telescopic crowns have been used mainly in RPDs to
Tooth loss results in loss of the proprioception mechanism that connect dentures to the remaining dentition7, but these can be
has been a part of the sensory programme throughout life.2 used effectively to retain complete dentures which receive their
support partly from the abutments and partly from the underlying
CASE REPORT residual tissues. Telescopic crowns have also been used
A 56-years old male reported to the department of successfully in RPDs and FPDs, supported by endosseous
Prosthodontics with the chief complaint of difficulty in chewing implants, in combination with the natural teeth, which includes
due to the missing lower teeth. On intraoral examination all teeth the overdentures.8,9
were present in upper arch except 16, 21, 22 and the teeth present Telescopic crows can also be used as effective direct
in lower arch were 38, 48. The teeth present were firm with retainers for RPD. Their degree of retention can be planned to suit
generalized abrasion in relation to maxillary teeth. The different situations by modifying their designs. The amount of
mandibular edentulous span had favorable ridge with firmly intersurface friction depends on the configuration of the taper
attached keratinized mucosa. Further determination of the angle and the area of the surface contact. One of the main
vertical dimension of occlusion (VDO) was achieved using advantages of the telescopic retainers is that, being pericoronal
Phonetics, Swallowing, patient preferences and facial devices, they transmit the occlusal forces in the direction of the
appearance. It was determined that there was loss of VDO and the long axes of the abutment teeth. This has proven to be the least
TMJ was normal (Fig1). damaging application force. The lateral forces exert traumatic
The treatment plan decided was to fabricate a pressure on the abutments.10
mandibular telescopic denture and a maxillary interim prosthesis. Careful assessment of the interarch space is very
important for the successful fabrication of the telescopic
After the intentional root canal treatment of the abutments 38 and
dentures. Sufficient space must be present to accommodate the
48, they were prepared with a tapered round end diamond rotary primary and secondary copings, to have a sufficient denture base
bur with a chamfer finish line for the primary coping. The thickness to avoid fracture, space for the arrangement of the teeth
abutments had to be prepared almost parallel with the minimum to fulfill the aesthetic requirements and to have an interocclusal
taper for a better retention. After the preparation of the abutments, gap. The space consideration usually requires the devitalization
of the abutments. The selected abutments should be periodontally
the impression was made by using a polyvinyl siloxane
sound with adequate bone support and no/ minimal mobility.
elastomeric impression material (putty and light body) by a There should be at least one healthy abutment in each quadrant.
double step putty wash technique. The impression was poured An even distribution of the abutment in each quadrant of the arch
into a die material to obtain the cast, on which the primary copings is preferable for better stress distribution and for increased
were fabricated. The fit of the primary coping was evaluated in the retention and stability of the prosthesis. The interocclusal gap/
interarch distance should be 10 mm, in order to have sufficient
patient's mouth, after which they were cemented on the abutments
space for the copings, denture base, teeth placement and adequate
with glass ionomer cement. Another impression was made by a closest speaking space.11
double step putty wash technique after the cementation of the The telescopic dentures which are supported by the
primary copings, by using a custom acrylic resin tray to obtain a roots of natural teeth have more predictable prosthodontic
cast on which the secondary copings attached with the metal outcomes because of increased support, stability and retention
and decrease in rate of the residual ridge resorption. Patients with
framework were fabricated (Fig2,3) The fit of the metal
natural teeth can masticate more effectively than when they are
framework with secondary copings over the primary copings was edentulous. This is due in part to their degree of accuracy in the
evaluated in the patient's mouth. The frictional contact between functional jaw movements, which are possible with a better
the primary and secondary copings helped in the retention of the neuromuscular feedback mechanism from the periodontal
prosthesis. ligaments. The proprioceptive nerve endings in the periodontal
The metal framework had to be placed on the cast, it had ligaments feed information into the neuromuscular mechanism.
to be covered with wax and the special tray for border moulding In the absence of teeth, this information is missing. By retaining
and final impression, had to be fabricated with chemically cured the roots of some teeth, it may be possible to use this
acrylic resins after applying separating media over the cast. After proprioceptive apparatus with complete dentures.9 If this is so, a
the final impression was made, the master cast was obtained and higher degree of accuracy in the jaw movements and the
occlusion rims were fabricated over the trial denture base. masticatory performance could result. By this means, teeth that
Horizontal and vertical maxillomandibular records were obtained normally might have a very short life span can be retained for long
with the record bases and the occlusion rims and these were periods of time. This can thus benefit the patients in their denture
transferred to a semiadjustable articulator by using a face bow. function.
The artificial teeth were selected and arranged on the record bases It has been found that telescopic dentures have better
for a trial denture arrangement and they were evaluated retention, stability, support and chewing efficiency as compared
intraorally for phonetics, aesthetics, occlusal vertical dimension to the conventional complete dentures and also, there is a
and centric relation. After the wax up, the dentures were decrease in the rate of the residual ridge resorption because of
processed, finished, polished and delivered to the patient proprioception, better stress distribution and the transfer of
(Fig4,5). The patient was scheduled for follow-up visits every 3 compressive forces into the tensile forces by the periodontal
months and he reported no complaints during the 2 years of ligament, which effects rate of bone remodeling. A clinical study
follow-up (Fig6,7). which was conducted by Bo Bergman et al on conical crown
48
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
retained dentures, concluded that most of the patients were very
satisfied with the restorations, both functionally and aesthetically
and it found their chewing comfort to be better after the treatment
with the conical crown-retained dentures.12
Complete denture fabrication for maladaptive elderly
patients becomes difficult. Therefore, they are the group of
patients who will benefit most with telescopic dentures.
Overdentures which are supported and/or retained with a few
remaining teeth or implants can be a predictable treatment that
will fulfill most of the demands of the elderly denture patients.
CONCLUSION
Tooth-supported, removable over dentures with
telescopic crowns may be considered as a good alternative to the
conventional removable dentures, because they provide better
retention, stability, support, stable occlusion, decrease in the
forward sliding of the prosthesis and better control of the
mandibular movements because of the proprioception feedback
which increases the chewing efficiency and even phonetics, as
compared to the conventional complete dentures. Also, the rate of
the residual ridge resorption was decreased because of the transfer
of compressive forces into the tensile forces by the periodontal
ligament and better stress distribution.
REFERENCES
1. Langer Y, Langer A. Tooth supported telescopic prostheses in
compromised dentitions: A clinical report. J. Prosthet Dent.
2000; 84: 129-32.
2. Glossary of Prosthodontic terms. J Prosthet Dent 2005; 94:
10-92
3. John J Sharry. Complete Denture Prosthodontics. Third
edition, New York, McGraw-Hill Book Co., 1974.
4. Prince IB. Conservation of the supporting mechanism. J
Prosthet Dent 1965; 15: 327.
5. Yalisove IL. Crown and sleeve coping retainers for
removable partial prosthesis. J Prosthet Dent 1966; 16: 1069-
85.
6. Wenz HJ, Lehmann KM. A telescopic crown concept for the
restoration of the partially endentulous arch: the Marburg
double crown system. Int J Prosthodont 1998;11:54150.
7. Langer A. Telescope retainers for removable partial dentures.
J Prosthet Dent 1981;45:37-43.
8. Laufer BZ, Gross M. Splinting osseointegrated implants and
natural teeth in the rehabilitation of partially edentulous
patients. Part II: principles and applications. J Oral Rehabil
1998;25:69-80.
9. Besimo C, Graber G. A new concept of overdentures with
telescope crowns on osseointegrated implants. Int J
Periodontics Restorative Dent 1994;14:486-95.
10. Langer A. Telescope retainers and their clinical applications.
J Prosthet Dent 1980;44:516-22.
11. Preiskel H W. Overdenture made easy a guide to implant
and root supported prostheses 61: Quintessence Publishing
Co. Ltd. London.
12. Bergman B, Ericson , Molin M Long-term clinical results
after treatment with conical crown-retained dentures. Int J
Prosthodont 1996;9:53339. Corresponding Address:
Corresponding Address:
Dr.Dr.
Dr.
Dr. Mayank
Neha
C. Ram Shah
KKAggarwal
Mohan
Dixit
Email:
Email: mashdreams33@gmail.com
dr_rammohanc@yahoo.co.in
Email: dixit.kk@gmail.com
Email: dr.nehaaggarwal19@gmail.com
49
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
LIST OF PHOTOGRAPHS
Fig 5: Intra Oral View of Prosthesis Fig 6: Post Operative Intra Oral View
50
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
Bilateral Maxillary Second Molar With Two Palatal Roots : A Case Report
C. Ram Mohan , C. Krishna Chaitanya , Hari Deva Raya Choudary , Sainath Reddy
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad.
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad.
Professor, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Senior Lecturer, Department of Conservative Dentistry and Endodontics, S.V.S. Institute of Dental sciences, Mahboobnagar.
Date of Receiving : 12/Apr/2013
Date of Acceptance : 01/Jun/2013
Abstract: Variations in root number and canal morphology are challenges for successful endodontic therapy.
Unusual root and root canal morphologies associated with both buccal roots of upper molars have been
recorded in several studies in the literature. However, scientific information focusing on variations of the
palatal root is rare. This case report describes presence of two palatal roots in maxillary second molar of the
same patient bilaterally, a rare entity, diagnosed and confirmed with the help of spiral computed tomography.
Key words : Maxillary Second Molar, Number of Canals, Number of Roots, Computed Tomography, Buccal, Palatal.
51
Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
for 6 months postoperatively and was found to be asymptomatic. second molar; Literature review and radiographic survey of
DISCUSSION 1200 teeth. J Endod 1989;15;129-31.
Unusual canal anatomy of maxillary molars has been 9. Peikoff MD, Christie WH, Fogel HM. The maxillary second
investigated in several studies. Most of the studies were based on molar: Variations in the number of roots and canals. Int
radiographic examination of the teeth which is 2-dimensional Endod J. 1996;29:3659.
view of a 3 dimensional object. Tachibana and Matsumoto10 10. Tachibana H, Matsumoto K. Applicability of x-ray
studied the applicability of CT to endodontics. They concluded computerized tomography in endodontics. Endod Dent
that this method allowed the observation of the morphology of the Traumatol 1990;6;16-20.
root canals, the roots, and the appearance of the tooth in every 11. Christoph GD, Wilfried GH, Engel, Britta R, Hermann KP,
direction. Moreover, the image could be analyzed, altered, and Oestmann JW< Must radiation dose for ct of the maxilla and
reconstructed by the computer. mandible be higher than that for conventional panoramic
A major concern with use of CT scan is its high radiation dosage. radiography? Am Soc Neuroradiol 1996;96;1758-60.
In the present study, CT was done with a multi detector CT 12. Curzon ME. Miscegenation and the prevalence of three
scanner (16 slices/second), as per Christoph et al11 guidelines to rooted amndibular first molars in the Baffin Eskimo.
reduce the radiation dosage. Community Dent Oral Epidemol 1974;2;130-1.
Curzon12 suggests that additional rooted molar trait has high
degree of genetic penetrance. Supernumerary root formation
could be related to external factors during odontogenesis or
penetrance of atavistic gene.
Additional root may be suspected when indistinct images of
palatal roots are presented in preoperative X-ray images, the
clinician must consider the possibility of two palatal roots.
Dissociation of images must be performed and, if this anamoly is
confirmed, a broad coronal access will allow the correct
localization of root canals. Also clinically, cervical prominence
or an extra cusp associated with cervical prominence on a tooth
point towards presence of extra root.
CONCLUSION
The four rooted anatomy in maxillary molars is very rare and is
more likely to occur in the second or third maxillary molar.
Careful examination of radiographs and internal anatomy is
essential. Although such cases occur infrequently, clinician
should be careful while considering endodontic treatment of a
maxillary molar, as these undetected extra roots or root canals are
a major reason for the failure. Hence the ability to locate all the
canals in the root canal system is an important factor in
determining the eventual success of a case.
REFRENCES
1. Wong M. Maxillary first molar with three palatal canals. J
Endod 1991;17;298-9.
2. Christie WH, Peikoff MD, Fugel HM. Maxillary molar with
two palatal root a retrospective clinical study. J Endod
1991;17;80-4.
3. Benenati Maxillary second molar with two palatal canals and
a palatogingival groove. J Endod 1994;11;308-10.
4. Fava LR, Weinfeld I, Fabri FP, Pais CR. Four secondmolars
with single roots and single canals in the samepatient. Int
Endod J. 2000;33:13842.
5. Barbizam JV, Ribeiro RG, Tanomaru Filho M.
Unusualanatomy of permanent maxillary molars. J Endod.
2004;30:668702.
6. Alani AH. Endodontic treatment of bilaterally occurring 4-
rooted maxillary second molars: Case report. J Can Dent
Assoc. 2003;69:7335.
7. Baratto-Filho F, Fariniuk LF, Ferreira EI, Pecora JD, Cruz- Corresponding Address:
Filho AM, Sousa-Neto MD. Clinical and macroscopic study Dr. C. Ram Mohan
of maxillary molars with two palatal roots. Int Endod J. Email: dr_rammohanc@yahoo.co.in
2002;35:796801.
8. Libfield H, Rostein I. Incidence of four rooted maxillary
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Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
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