MAGAZINE -48- total 10 chapter - issue 2 june to...

Official Publication of IDA Karnataka State BranchOfficial Publication of IDA Karnataka State BranchKSD

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ISSN : 09733442

Issue 2

Volume 36

June - August 2019

Dear colleagues,

EDITORIAL

Editorial Advisory Board

1

GreetingsfromtheeditorialboardofIDAKarnatakaStateDentalJournal.

The present scenario demands a paradigm shift towards a pioneeringapproachwheretheveryexistenceofdentistreliesonquotientofkeepingatparwithlatesttrendsandtechnologies.Thenewageresearchorientedstudiesundertaken by the newer generation dentists and the established seniorprofessionals are an integral part of the �ield.Withmodern dentistry, theprofession derives excitement and satisfaction from providing services,patientswantandnotjustneed.Thenewmaterialsandtechniquesrestsona�irmfoundationofsoundrestorativeanddiagnosticprinciples.Patientswhoseek modern dentistry today are informed consumers who have speci�icobjectives. The journal has been carefully kneaded to keep up with theupcomingtrendsindentalprofession.

IDAKarnatakaStateDentalJournalisindebtedtoallitsreaders,sponsorsandcontributorsDr. Supriya Manvi, 9448145452 / [email protected]

Professor & Head of Department, Department of Implantology KLESIDS(Assistant Editor, IDA Karnataka)

Dr.B.K.SrivastavaProfessorandHeadoftheDepartment,

K.L.ESociety'sInstituteofDentalSciences,Bengaluru.

(EditorIn-Chief,IDAKarnatakaStateBranch)

INSTITUTIONNAME DEPT EMAIL IDPH.NO.

[email protected] Oralmedicine CODS,Davangere

Dr.VivekHP CommunityDentistry CODS,Davangere 8095306448 [email protected]

Dr.MaheshChandra CommunityDentistry Maruthidentalcollege [email protected]

Dr.Prashanth ConservativeDentistry BIDAR 8861449056

Dr.PrashanthBR

Dr.PraveenB

Dr.Vinod

Dr.Sudarshan

Dr.Sathyadeep

Dr.Ramesh

Dr.Babitha

Dr.Jayprakash

Dr.Madhu

Dr.MallikarjunaK

ConservativeDentistry KLEIDS 9449638113 [email protected]

CODS,Davangere 9986393343

OralSurgery DayanandSagar 9845190783

KLEIDSOralSurgery

Orthodontics DayanandSagar 9980142380

Orthodontics Sharavathidentalcollege,Shimoga

9632522799

Periodontics 9448966166

Periodontics CoorgInstituteofDentalSciences

9972912662

Pedodontics KLEIDS 9535152325

Pedodontics CODS,Davangere 9448040502 [email protected]

Prosthodontics

9845571071

9449104316

[email protected]

[email protected]

[email protected]

[email protected]

[email protected]

[email protected]

[email protected],Davangere

[email protected]

[email protected]

PRESIDENT MESSAGE

SECRETARY MESSAGE

ItgivesmeenoughpleasureandhonourtobeapartofKarnataka.IDAbranchandservingasstatepresident.IheartedlycongratulateDr.Srivastavafordoingtremendousjobasheadofeditorialteam,inbringingupthesecondjournal.

IcongratulateBangaloreIDAbranchfororganizingtreasurehunt,manyCDES,CDHandawarenessprogrammes.

All the members are very active and enthusiastic to organize suchprogrammes.IwishalltheverybestforfutureinitiativesandrequestthemtobringupmoreinnovativeprogrammesfortheprogressofIDA.

Ithasbeenawonderfulyearsincewetookovertheof�ice. Wearetryingourbesttokeepuptheactivitiesforthebene�itofthemembers.

ThisyearwehaveconductedrecordnumberofCDEandCDHactivitiesthroughthestate,withconstantencouragementfromthepresidentandsupportoftheactive members of the state of�ice we were able to get to know workingconditionoftheof�ice. Iwouldliketosincerelythankallthemembersofthelocalbranchfortheirsincereeffortandhardworkforwonderfulactivities.

Thankyou

Dr. H.P. PrakashStatePresidentIDAKarnataka

Dr. Shivaprasad. SHon.StateSecretary,

IDAKarnatakaStateBranch

2

IDA KARNATAKA STATE BRANCHLIST OF OFFICE BEARERS FOR THE YEAR 2018-19

President:

Dental Surgeon,

# 118, Gauri, 13th Main, 7th Cross,Sector - 5, H.S.R. Layout, Bengaluru- 560 [email protected] 42043

Dr. H.P. PrakashProf. Oral Medicine & Radiology

Bapuji Dental College,Davanagere - 577 [email protected] 53148

Dr. Shivaprasad. S Dr. Sushanth V.HHon. State Secretary Hon. Treasurer

Veerabhadreshwara Krupa,#3501/1, 3rd Main, 6th Cross,M.C.C. ‘B’ Block, Davangere - [email protected] 14030

Dr. Sudhindra Kumar N.N Dr. Ashwath Raju

Dr. Nanda Kishore B.

Dr. Muralidhar Rai

Dr. Mohan Kumar K.P.

Dr. Praveen S. BasandiDr. Adarsh C.

Dr. M.G. Ravi

Dr. Raghavendra Kattri

Dr. Srinivasa B.K.

Dr. Jagadish KadammanavarDr. Ritesh K.B.Dr. Kishore HadelDr. Kirti ShettyDr. Shubhan AlvaDr. Manjunath RaiDr. Padmaraj HegdeDr. Shishir ShettyDr. Charan KajeDr. Roshan ShettyDr. Sanath ShettyDr. Prathap Kumar ShettyDr. Chaitanya BabuDr. Prabhuji M.L.V.Dr. Vijendra RaoDr. Pramod G.V.Dr. Deepak J.R.Dr. Raghunath ReddyDr. Arvind GopalDr. Shridhar SheelvantDr. Raghunath N.Dr. Pramod ShettyDr. Rajesh HegdeDr. Jithesh N.Dr. Mahesh K.PDr. Harish B.N.

Dr. Prakash H.P.Dr. Shivaprasad S.Dr. Tilakraj T.N.Dr. Mahesh ChandraDr. Narendra Kumar MDr. Ramamurthy T.K.Dr. Mahendra PimpaleDr. V. RanganathDr. Sanjay Kumar D.Dr. Girish SharmaDr. Uma S.R.Dr. Adarsh C.Dr. Annaji A.G.Dr. ShivasharanDr. Rama Chandra MallanDr. Raghavendra PidmaleDr. Srinidhi D.Dr. Charan Kumar Shetty

3

CONTENTS

1. Assessment Of Knowledge And Attitude Of Dental Students Towards Tobacco Cessation Methods: A Questionnaire Study. 05-10 - Dr. Fhelen Debbie da Costa, Dr. Prashant G.M, Dr. Sushanth V.H., Dr. Mohamed Imranulla, Dr. Vivek H.P, Dr. Sampada Suresh Kulkarni

2. Pyogenic Granuloma - A Case Report 11-13 - Dr. Sachin Shivanaikar, Dr Aruna .G

3. Avulsed Tooth? Know Transport Media-need Of The Hour : a Literature Review. 14-19 Dr. Sarah Paul, Dr. Prashant G.M, Dr. Sushanth V.H, Dr. Mohamed Imranulla, Dr. Allama Prabhu C.R, - Dr. Gayathri Rajeev

4. 3-D Printed Dentures in Rehabilitation of Completely Edentulous Patient- A Case Report 20-22 Dr. Deepti Kumar, Dr. M Shivshankar, Dr. Srivatsa G., Dr. Supriya Manvi,Dr. Rajeswari C.L, -

Dr. Rohit M Shetty , Dr. Ajay G. Doni

5. Validation of Kannada Version of Geriatric Oral Health Assessment Index Among Older People in Davangere City- a cross Sectional Survey 23-29 Dr. Sampada Suresh Kulkarni, Dr. Sushanth V.H, Dr. Prashant G.M, Dr. Mohammed Imranulla, - Dr. Allama Prabhu C.R, Dr. Fhelen Debbie da Costa

6. ZYGOMATIC FIXTURE:An alternative to maxillary rehabilitation. 30-34 - Dr. Supritha.A.R, Dr. Supriya Manvi, Dr. Veena G C

7. Versatility Of Chitosan In Dentistry 35-39 - Dr. Thanushree.H.M, Dr. Supriya. Manvi, Dr. Shruthi Eshwar

8. Trefoil Concept – Revolutionary Application For Edentulous Mandibular Patients 40-44 - Dr. Ms. Srishti Samanta, Dr. Moumita Chakraborty, Dr. Supriya Manvi

9. Digital impressions, not a science �iction anymore! 45-48 - Dr. M. Sunitha Roy, Dr. Soudhamini.V. Rao, Dr. Lakshmipathi Reddy.P

10. An Esthetic Orthodontic Solution for Congenitally Missing Bilateral Maxillary Lateral Incisors- a Case Report 49-53 - Dr. Shweta Nagesh, Dr Sujala Ganapathi Durgekar, Dr Sumitra Reddy, Dr Ann Sara George

4

Assessment Of Knowledge And Attitude Of Dental Students Towards

Tobacco Cessation Methods: A Questionnaire Study.

Authors : Dr. Fhelen Debbie da Costa¹, Dr. Prashant G.M², Dr. Sushanth V.H.³, Dr. Mohamed Imranulla⁴, Dr. Vivek H.P.⁵, Dr. Sampada Suresh Kulkarni⁶

Abstract

Introduction: Tobaccoconsumptionkillsaround6millionpeopleworldwide,ofwhichone-fourthdeathsoccurin

India.TobaccoprobleminIndiaiscomplex,withsmokedformsandanarrayofsmokelesstobaccoproducts.Tobacco

being addictive requires efforts on various levels besides rules and regulations. Thus, tobacco cessation services

providedbyvariousgroupsare important.The roleofhealthcareproviders in cessationof tobaccoconsumption

dependsontheknowledgeofthevariouscessationmethodspracticed.

Aim and objective: Toassesstheknowledgeandattitudeofdentalstudentstowardstobaccocessationmethods.

Methodology: ThequestionnairestudywasconductedinCollegeofDentalSciences,Davangere,Karnatakausingaself

administered, structured, close ended questionnaire. The study population comprised of undergraduate and

postgraduatedentalstudents,whowereprovidedwiththequestionnairesattheendofroutinelecturesorduring

clinicalpostings.The studentswereexplained thepurposeof the studyandgiven speci�ic instructions to �ill the

questionnaire.DatawasanalyzedusingSPSS(StatisticalPackagefortheSocialSciences)version22andstatisticaltests

usedwereFrequencydistributionandPearsonChisquaretest.

Results: Atotalof300studentsparticipatedinthesurveywithalmostequalnumberofstudentsfromeachyear.

Overall, postgraduate students showed a better knowledge of cessation methods when compared to the under

graduates. 22.0% and 23.7% of post graduates were aware of second hand smoking and available tobacco

replacements,respectively(p=0.000).

Conclusion: This study suggests an increasing need to bring about awareness among dental students regarding

tobaccocessationmethods.

Keywords: Tobaccocessation,KAPstudy,Dental

IntroductionIndia ranks third in global tobacco production and

1-3consumes almost 50% of its produce domestically. Tobacco use is generally described as the most

5

preventablecauseofmorbidityandmortalityallaroundthe world, with the World Bank fortelling over 450

4,5milliontobaccodeathsinthenextfiftyyears. Tobacco-relatedmortality in India is among the highest in the

1. Dr. Fhelen Debbie da Costa Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDental

Sciences,Davangere,Karnataka Phno:9620912728 Emailid:�[email protected]

2. Dr. Prashant G.M. ProfessorandHead, DepartmentofPublicHealthDentistry,CollegeofDental

Sciences,Davangere,Karnataka Phno:9886215111 Emailid:[email protected]

3. Dr. Sushanth V.H. Professor, DepartmentofPublicHealthDentistry,CollegeofDental


4. Dr. Mohamed Imranulla Reader,DepartmentofPublicHealthDentistry,Collegeof

DentalSciences,Davangere,Karnataka Phno:9886558148 Emailid:[email protected]

5. Dr. Vivek H.P. Reader, DepartmentofPublicHealthDentistry,CollegeofDental


6. Dr. Sampada Suresh Kulkarni Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDental


KSDJ/Vol36/Issue2/June-August2019

6

5world. InIndia,theproportionofalldeathsthatcanbeattributedtotobaccouseisexpectedtorisefrom1.4%

6,7in1990to13.3%in2020.

Tobaccouseincreasesandcomplicatestreatmentrisksby compromising the prognosis for periodontal andotheroraldiseasesandincreasingthelikelihoodofthe

8occurrenceandreoccurrenceoforalcancers. Dentaltreatment that often necessitates multiple visitsprovidesthemechanismsforinitiation,reinforcement,andsupportoftobaccocessationactivities.Cessationrateof8.6%afteroneyearofcounselingalonehasbeenreported, and when combined with prescription ofNicotine Replacement Therapies, the quit rate has

5,9increased.

Thescienti�icevidencerelatingto theburdenoforaldiseasesattributabletotobaccousehasbeenreviewedand the need for a well-structured dental teachingprogramconcentratingonoralcancereducationandtobacco ces sa t i on in te rven t ions has been

10-12emphasized. Introductiontodangersoftobaccouseand promoting tobacco cessation among youth are

3importantstrategiestocontroltheuseoftobacco. TheIndian government amendedmany laws such as theonein1978andtheCOTPA(TheCigarettesandOtherTobaccoProductsAct)in2003todecreasetobaccouse.InlinewiththeCOTPact,theMinistryofHealthinIndialaiddownguidelinesforhealthprofessionals,schoolsand several other key players in ways to prevent

13-15tobaccoexposureamongchildrenandteens.

Dental professionals play a signi�icant role inidentifyingtobaccousers,astheymaynoticeintraoralsigns such as odor, tooth stains, and oral hygieneproblemsearlierthanotherhealthcareprofessionals;theyare thus inabetterposition toofferpreventive

16,17care. Inaddition,theyhaveaccesstoprotocolsthatencourage smoking cessation and pharmaceutical

18,19support if needed. The present study was thusundertakentoassesstheknowledgeandattitudeofthedentalstudentstowardstobaccocessation.

MethodologyStudy Design and Ethical ClearanceAcross sectional surveywas carriedoutamong300dentalstudentsie.Thirdyears,�inalyears,internsandPost graduate students from the College of DentalSciences,Davangere.Thestudywascarriedoutinthe

month of November- December 2017. The ethicalclearancewasobtainedfromtheReviewBoardoftheCollegeofDentalSciencesinordertoconductthestudy.Permissiontocarryoutthesurveywasalsotakenfromtherespectiveheads.

ProcedureThe questionnaire consisted of 11 close endedquestions which attempted to assess the students'awareness, practice and attitude towards the varioust o b a c c o c e s s a t i o n me t h o d s . P r i o r t o t h ecommencementofthesurvey,apilotstudywascarriedout (Cronbach's alpha= 0.84). The students wereexplained the purpose and importance of the surveyandonlythosewillingtovoluntarilyparticipatewereincluded in the study. The questionnaires weredistributed to the participants immediately aftercompletion of theory lectures or during clinicalpostings.Suf�icienttimewasprovidedtothestudentstoanswerthequestionnaireandtheywerecollectedfromthestudentsonceitwascompleted.

Statistical AnalysisThedataobtainedwasrecordedandtabulatedontotheMicrosoft Excel sheet and subjected to statisticalanalysis. The tests done were the FrequencydistributionandPearsonChi-SquaretestusingtheSPSSversion22.(p≤0.05)

ResultsThe participants in the study consisted of 76 (25%)thirdyearundergraduatestudents,77(26%)�inalyearstudents, 71 (24%) interns and 76 (25%) postgraduates,makingupatotalof300participants.(Table1,Graph1)

Table2depictsthedescriptivestatisticsofthequestionsaccording to the year of study. To begin with, thestudentswereaskediftheywereawareofanytobaccocontrol programs or policies in India. 247 (82.3%)participantssaidtheywereawareofthesame.Amongthem, 66 (22%) were third year students and 58(19.3%)were�inalyearstudents.

When asked about their awareness about currenttobaccocontrolmeasures in India, a largenumberofparticipants(63%),answeredintheaf�irmativewith58(19.3%)postgraduateswhosaidtheywereawareofthesame(Graph2).Studentswerethenquestionedabout


7

theilleffectsoftobaccoonone'shealth;towhich152(50.7%) of the participants felt that the ill effects oftobacco include all, oral cancer, lung cancer, stomachcanceraswellasheartdiseaseandstroke.Thisresponsewascloselyfollowedby147(49%)oftheparticipantsoptingtochooseOralcancerandlungcancerastheilleffects. Surprisingly, none of the participants thoughttobaccocouldcausestomachcancerandheartdiseaseandstroke.(Graph3)

Theparticipantswereaskedregarding theconceptof'secondhandsmoking'andwhethertheywereawareofthe same. 184 (61.3%) of them answered in theaf�irmativewhile116(38.7%)saidtheywerenotawareof the term.Among thosewhowere aware66 (22%)werepostgraduatestudentswhile45(15%)thirdyearstudentswereamongthosewhowerenotawareoftheterm. Following this, participantswere asked about arelativelynewerconceptof'thirdhandsmoking'.Mostof the participants, 228 (76%) were unaware of theconceptwhileonly72(24%)wereawareof'thirdhandsmoking'.26(8.7%)ofthepostgraduatestudentswereaware of the conceptwhile thosewhowere unawarewere among the �inal year (21.7%) and third year(21.3%)students.(Graph4)

Whenquestionediftheparticipantsadvicepatientstoquit tobacco, 265 (88.3%) answered saying that theyalwaysadvicetheirpatientstoquitwhile29(9.7%)saidthey advice their patients only when required and 6(2%)saidtheydon'talwaysadvicetheirpatientstoquittobacco. Out of the studentswho always advice theirpatientstoquit,majoritywerepostgraduatestudents(23%), followedbythirdyears(22%), �inalyearsandinterns(21.7%each)(Graph5).Thestudentswerethenaskediftheywerecon�identwhengivingadvicetowhich244(81.3%)saidtheywerecon�identwhile56(18.7%)saidtheywerenot.Thepostgraduatesandthirdyearstudents(21.3%each)saidtheywerecon�ident.

Next, the participants were asked about tobaccocessationmethods.275(91.7%)feltthatcounselingandNicotinereplacementtherapy(NRT)werebothtobaccocessation methods. 12 (4%) felt NRT was the onlymethod and 11 (3.7%) felt that counseling alone is acessation method. The �inal year and post graduatestudents(23.7%)feltthatbothweretobaccocessationmethods.

Theparticipantswereaskediftheywereawareofany

nicotine replacements, to which 234 (78%) said theywere aware, out of which 71 (23.7%) were postgraduates.66(22%)saidtheywereunawareofnicotinereplacements amongwhommajoritywere from thirdyear BDS (10%) (Graph 6). The above question wasfurthernarroweddownbyaskingtheparticipantswhichoftheNRTswereeasilyavailableinIndia.163(54.3%)thoughttheanswertobepatchesandgums,followedby92(30.7%)whothoughtgumsandlozengeswereeasilyavailable,27(9%)thoughtnasalspraysandgumswereeasily availableand18 (6%)who felt theanswerwaslozengesandnasalsprays.(Graph7)

Lastly,participantswereaskediftheyfelttheneedformoreemphasisontobaccouseandmethodsofcessationinthedentalcurriculum.Avastmajority,295(98.3%)agreedthatitshouldbeemphasizeduponwhile5(1.7%)feltthattherewasnoneedfortheemphasis.A statistical signi�icance was seen when participantswerequestionedregardingtheilleffectsoftobacco(p=0.003),secondandthirdhandsmoking(p~0.001and0.018, respectively). When asked regarding advisingpatients to quit tobacco, a statistical signi�icance wasfound with p value of 0.030. A highly signi�icantdifferencewasseenwhenaskedabouttheawarenessofnicotinereplacementtherapy(p~0.001)andtheonesavailableinIndia(p~0.001).(Table3)

DiscussionResearch from the developed world has found thatdentists are in an ideal position to assist patients toreduceorstopsmokingaltogether. Thisisbecauseoftheregular contact many patients have with their

20,22dentists. Theneedforinvolvementofvarioushealthprofessionals to combat the tobaccomenacehasbeenhighlightedinastudyconductedbyMurthy P et al in

232010.

The present study was conducted with the aim tounderstand the level of knowledge possessed by theundergraduates regarding the tobacco cessationmethodsaswellastheirattitudetowardsit.Tobaccoisatopicofgreatinterestnotonlyinthemedical�ieldbutfordentists as well, due to its oral manifestations andassociatedrepercussions.Thus,itbecomesimportanttoknow the tobacco cessation techniques and theavailabilityoftheseoptionsatthelocallevel.

In the study conducted, 295 (98.3%) of the total 300

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participantswerewillingfortheintroductionoftobaccouseanditscessationinthepresentcurriculumindetailwith special training.Thiswas inunisonwitha studyconductedbyOmolara G. et al,amongNigeriandentistsand dental students regarding smoking cessationcounseling.InthestudyamongtheNigeriandentistsandstudents,majorityoftheparticipants,about80.9%werewillingtoundergoformaltrainingonsmokingcessation.Morethanaquarteroftherespondents(37.5%)wereverywillingormoderately (35.3%)willing toprovidesmoking cessation services while 27.2% were not

11interested. In contrast to these �indings, in a studyconducted by Salman et al, in Chennai only 44.7%respondentsfeltthattobaccocessationtrainingshould

5beapartoftheDentalcurriculum.

The awareness of the undergraduates regarding thetobacco control policies and the current measures inplacefortobaccocessationinIndiawerehighwith247(82.3%) and189 (63%)of the students af�irming thesame, respectively. Tobacco control programmes havebeeninplaceinIndiasince1975withtheintroductionoftheCigarettesAct(Regulationofproduction,supplyanddistribution)enactedbytheGovernment.FollowingtheinitialupriseinthecontroloftobaccoinIndia,severalother policies and programmes have been introducedover the years. These programmes have beenhighlightedbyKaur J et al, ina reviewarticleon theimplementation and challenges in the policies for

24controloftobacco.

Tobaccousehasvariousilleffectsonone'shealth.Theseeffects affect most of the parts of the body causingcancers,stroke,heartdiseaseandsoon.Inthepresentstudy,152(50.7%)agreedthattobaccousecouldleadtooral,lungandstomachcanceraswellasstrokeandheartdisease.Yet,aclosenumberofparticipants(49%)feltoral and lung cancerwas the only ill effects cause bytobaccoconsumption.ThiswasinaccordancewiththeresultsobtainedbyPolychonopoulou A et al inastudyconducted among Greek students. Almost all thestudents, irrespective of the year of study among theGreek dental studentswere aware of the ill effects of

25tobaccoonoverallhealth.

Passive smoking or second hand smoking orEnvironmental smoking is the complex mixture ofchemicals generated during the burning of tobaccoproducts. Similarly, third hand smoking means thechemicalresidualoftobaccosmokecontaminationthat

clings to inanimate objects after the cigarette is26,27

extinguished. Bothcouldexposeonetodiseasessuchassuddeninfantdeathsyndrome,middleearinfections,chronic respiratory diseases, low birth weight,per iodont i t i s and carc inomas ' such as lungoropharyngeal, prostate carcinoma etc

3,28,29. In the

present study, most of the participants (61.3%) wereawareof secondhandsmokingwhile228(76%)wereunawareofthirdhandsmoking.InastudyconductedbyAl Batanony MA et al, amongEgyptiannurses,toassesstheknowledgeregardingsecondhandsmoking,68.7%ofthestudiednursesreported that smoking is thesinglemost preventable cause of death, while manyunderestimated the risk of secondhand smoke whencompared to other risks. Most of the studied nurses(88.5%)wronglybelievedthathealthhazardofSHSare

30lessthananyotherairpollution.

265 (88.3%) of the participants in the present studyalwaysadvisedtheirpatientstoquitthehabitoftobaccowhile29(9.7%)and6(2%)saidtheyadviseonlywhenrequiredandnotalways,respectively.244(81.3%)oftheparticipants also agreed that they were con�ident toadvisepatients toquit tobacco.Thiswasopposite toastudy conducted by Salman et al, wherein only 184(43.3%)respondentswereconfident in theirability toeffectively offer the smoking cessation counseling to aconsiderableextent.

5 InastudyconductedbyShaheen S

et al,91(35%)oftheparticipantswereneutralintheir31

responsewhenassessedusingaLikertscale. InastudyconductedbyPolychonopoulou A et al, similarresultswereobtainedtothepresentstudywith88.5%studentsreferringtocounselingasthedutyofeverydentistand87.9% believed that dentists have a responsibility to

25encouragepatientstoquittobacco.

Majority of the participants (91.7%) believed thatcounselingandNicotinereplacementtherapybothwereused for tobacco cessation. 78% of the participantsagreedthattheywereawareofNicotinereplacements.This �indingwas incontrasttothestudyconductedbyOmolara G. et al.Smokingcessationwasdescribedascounseling and nicotine replacement therapy by only13.3%, while 66.7% said it was counseling and 6.7%

11describeditasgrouptherapy.

Nicotine Replacement Therapy (NRT) is an effectivetreatment to reduce cravings associatedwith smokingcessation. Various formulations available are chewinggums, transdermal patch, inhalator, nasal spray,


9

32,33sublingualtabletsandlozenges. Inthepresentstudy,163(54.3%)oftheparticipantsfeltthatthepatchesandchewinggumswere themost readilyavailableamongthe NRT's, while 92 (30.7%) felt it was gums andlozenges.

Overall, even though the participants showed a fairlygoodknowledgeregardingthetobaccocessation,afairlylarge number were unaware of certain options intobaccocessation.Thiscouldbeduetothedifferenceintheyearofstudy.Nonetheless,mostoftheparticipantswerewilling to learnand includean indetail tobaccocessationconceptinthepresentcurriculum.

ConclusionThestudyconcludedthatamajorityoftheparticipantswerewillingtoprovidetobaccocessationadvicetotheirpatients. However, knowledge among the studentsregardingthetobaccocessationtechniquesandpresentpoliciesinplaceforcessationoftobaccowasfoundtobeinadequate.Thisindicatesthattobaccocessationshouldbe brought into the limelight through the efforts ofacademicians in order to increase the awareness ofstudents.Theknowledgeacquiredbythestudentscanbecarriedforthtotheirprivatepracticewhichcanhelpmotivatepatients inquittingthehabitof tobacco.Thepoliciesputforwardbythegovernmentalsoneedtobehighlighted and regular updates regarding theimplementationofthesameshouldbeeasilyaccessibleto all to bring about a positive changewith regard totobacco.

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18. Wiener RC, Pla RM. Evaluation of educationalmaterial for tobacco prevention and cessationused in West Virginia University DentalPrograms. American Dental Hygienists'Association.2011Jun1;85(3):204-10.

19. Awan KH, Hammam MK, Warnakulasuriya S.Knowledge and attitude of tobacco use andcessationamongdentalprofessionals.TheSaudidentaljournal.2015Apr1;27(2):99-104.

20. Warnakulasuriya S, Dietrich T, Bornstein MM,Peidro EC, Preshaw PM, Walter C, et al. Oralhealth risks of tobacco use and effects ofcessation.IntDentJ2010;60(1):7–30.

21. Carr AB, Ebbert JO. Interventions for tobaccocessation in the dental setting. CochraneDatabaseSystRev2006;25(1):CD005084.

22. UtiOG,SofolaOO.Smokingcessationcounselingindentistry:attitudesofNigeriandentistsanddental students. Journal of dental education.2011Mar1;75(3):406-12.

23. Murthy P, Saddicchha S (2010). Tobaccoc e s s a t i o n s e r v i c e s i n I n d i a : Re c e n tdevelopments and the need for expansion.Indian J Cancer,47,69-74.

24. KaurJ,JainDC.TobaccocontrolpoliciesinIndia:implementationandchallenges. Indian journalofpublichealth.2011Jul1;55(3):220.

25. Polychonopoulou A, Gatou T, Athanassouli T.Greekdentalstudents'attitudestowardtobaccocontrol programmes. International dentaljournal.2004Jun;54(3):119-25.

26. http://www.smokefree.hk/en/content/web.do?page=SecondhandSmoking

27. http://www.smokefree.hk/en/content/web.do?page=ThirdhandSmoking

28. Potera C. Outdoor smoking areas: Does thesciencesupportaBan?EnvironHealthPerspect.2013;121:a229.

29. WHO. Toolkit for delivering the 5A's and 5R'sbrief tobacco interventions to TB patients inprimarycare.WHO;2014a.


10

30. Al-Batanony,Manal&EA,Salim&AA,Dawood&E,Kasem.(2008).Nurses'knowledge,attitudeandpractice regarding secondhand smoke, anintervention study. Egyptian Journal ofO c cupa t i ona l Med i c i n e . 32 . 117 -131 .10.21608/ejom.2008.662.

31. ShaheenS,ReddyS,DoshiD,ReddyP,KulkarniS.Knowledge, attitude and practice regardingtobacco cessation among Indian dentists. OralHealthPrevDent.2015Jan1;13(5):427-34.

32. YadavVK.Pharmacotherapyofsmokingcessationand the Indian scenario. Indian journal ofpharmacology.2006Sep1;38(5):320.

33. Sean C Sweetman, editor. Martin dale. Thec omp l e t e d r u g r e f e ren c e . 3 3 e d . UK :Pharmaceuticalpress;2002.

Correspondence Address : Dr. Fhelen Debbie da Costa Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDental

Sciences,Davangere,Karnataka Phno:9620912728 Emailid:�[email protected]

1 2Authors : Dr. Sachin Shivanaikar , Dr Aruna .G

1. Dr. Sachin Shivanaikar Reader, DepartmentofPeriodontics, MarathaMandal'sNGHInstituteofDentalSciencesand

ResearchCentre, Belgaum.

Abstract

Pyogenicgranulomaisacommon,usuallysolitary,benignsessileorpedunculatedvascularproliferationoftheskinand

mucousmembranes,presentingashemorrhagicgrowth.Thistermisamisnomerbecausethelesionisunrelatedto

infectionanditarisesinresponsetostimulisuchaslow-gradelocalirritation,traumaticinjuryorhormonalfactors.

Femalesarefarmoresusceptiblethanmalesbecauseofthehormonalchangesthatoccurinwomenduringpubertyand

pregnancy.Clinicallypyogenicgranuloma isa smooth rederythematouspapuleonapedunculatedor sometimes

sessilebase,whichisusuallyhemorrhagic.Thesurfacerangesfrompinktoredtopurple,dependingontheageofthe

lesion.Hereisacasereportofpyogenicgranulomain35yearsoldfemalepatientwherethelesionwasexcisedusing

electrocautery.

Keywords:

IntroductionPyogenic granuloma (PG) is a kind of in�lammatoryhyperplasia. The term “in�lammatory hyperplasia” isusedtodescribealargerangeofnodulargrowthoftheoral mucosa that histologically represent in�lamed

1,2�ibrousandgranulationtissues. Theterm“Pyogenicgranuloma” or “granuloma pyogenicum” was

3introduced by Hartzell in 1904. . It usually arises inresponse to various stimuli such as low-grade localirritation,traumaticinjury,hormonalfactors,orcertain

4kindsofdrugs .Pyogenicgranulomamayoccurinallagegroups, though it ispredominantlyseen inyoungfemales in the second decade of life because of the

4hormonal changes in this period. Clinically these

lesions usually present as a single nodule or sessile5

papulewithsmoothorlobulatedsurface. Thesemaybeseen in any size from a few millimeters to several

6centimeters. As lesions mature, the vascularity

decreases and the clinical appearance becomesmore5.

collagenousandpink. Thispaperpresentsacaseofapyogenicgranulomamanagedbyusingelectrocautery.

Case reportA femalepatient aged35years reportedwith a chiefcomplaintofenlargementoftheupperrightbacktooth

2. Dr Aruna .G AsstProfessor, DepartmentofPeriodontics, JSSDentalCollegeandHospital,Mysuru.

region since the last threemonths. The enlargementstarted as a small painless lesion which graduallyincreased in size. The patient also complained ofspacing being created between the teeth as theenlargementincreased. Norelevantdentalormedicalhistory and patient was not on any medication. Thepatientbrushedherteethoncedailyusingatoothpasteandbrushusingahorizontalstroke.

Clinical examinationOnexaminationof theenlargement, itwaspresent intheinterdentalareabetween13&14,measuringabout1x1cms, pale pink in colour, smooth shiny in surfacewith well de�ined margins. On palpation it was nontender,�ibrousinconsistencyandshowednosignsofbleeding and exudation with the same. Bloodinvestigationsshowednormallevelsandradiographicexaminationshowedahorizontalbonelossinthelesionarea.Basedonthe�indings,aprovisionaldiagnosisofPyogenicgranulomawasmade.Differentialdiagnosisincluded irritational �ibroma, giant cell granuloma,peripheralossifyinggranuloma.

TreatmentThe irritational factors (Plaque and Calculus) were

Pyogenic Granuloma - A Case Report

11

eliminatedbyscalingandrootplanning.Thepatientwaseducatedonoralhygieneand the treatmentplanwasexplainedtothepatient.After15days,theexaminationof the enlargement was done and the same wasscheduledforexcision.Underlocalanesthesia,completeexcis ion of the enlargement was done usingElectrocautery. There were no intraoperativecomplications.Periodontaldressingwasplacedandthepatient was prescribed analgesics for pain relief and0.2% Chlorhexidine mouth wash. The patient wasrecalledafter1weekforremovalofpackandcheckup.Theexcisedtissuemeasuredabout1x1cmandwassentforHistopathologicalExamination

The case was followed for 6months and no signs ofrecurrencesoranydiscomfortwasseen.

Histopathological ExaminationH&Estainedsectionrevealsulceratedparakeratinizedstrati�iedsquamousepitheliumwithpseudomembraneon the surface. The connective tissue stroma showsloose bundle of collagen �ibers, numerous dilated &engorgedbloodvessels,chronicin�lammatorycellsandareasofextravasatedRBCs.

DiscussionThepyogenicgranulomaisarelativelycommon,tumorlike,exuberanttissueresponsetolocalizedirritationortrauma.Thenamepyogenicgranulomaisamisnomersincetheconditionisnotassociatedwithpusanddoes

7notrepresentagranulomahistologically. Itoccursinallage groups, children to older adults, but are morefrequentlyencounteredinfemalesintheseconddecadedue to the increased levels of circulating hormones

8estrogen and progesterone Lesions are slightlymorecommononthemaxillarygingivathanthemandibulargingiva;anteriorareasaremorefrequentlyaffectedthanposterior areas. Also, Oral pyogenic granuloma is themostcommongingivaltumoraccountingfor75%ofallcases.Thelips,tongue,andbuccalmucosaarethenext

9most common site In the oral cavity, pyogenicgranulomasshowastrikingpredilectionforthegingiva,withinterdentalpapillaebeingthemostcommonsitein70%ofthecases.Gingivalirritationandin�lammationthat result frompoororal hygiene, dental plaque andcalculusoroverhangingmarginsrestorationsmaybe

10precipitating factors in many cases Pyogenicgranulomas of head and neck are uncommonly seenextragingivallyinareasoffrequenttraumasuchasthe

11lowerlip,tongueandpalate. MajorityofPGsarefound

onthemarginalgingivawithonly15%ofthetumorson12the alveolar part Clinically, PyogenicGranuloma is a

smooth or lobulated exophytic lesion manifesting assmall,rederythematouspapulesonapedunculatedorsometimessessilebase,whichisusuallyheamorrhagic

12andCompressible .Thesizevariesindiameterfromfewmillimetrestoseveralcentimeters,rarelyexceeding2.5

12cm . Clinically, development of the lesion is slow,asymptomaticandpainlessbutitmaygrowrapidly.Thesurfaceischaracteristicallyulceratedandfriablewhichmaybecoveredbyayellow,�ibrinousmembraneanditscolourrangesfrompinktoredtopurple,dependingonageofthelesion.Youngpyogenicgranulomasarehighlyvascularinappearance,becausetheyarecomposedofpredominantlyhyperplasticgranulationtissueinwhichcapillaries are prominent. Thus,minor trauma to thelesionmaycauseconsiderablebleeding,whereasolder

12lesions tend to becomemore collagenized andpink .

13Radiographic �indings are usually absent However,14

Angelopoulos concluded that, in some cases, longstandinggingivalpyogenicgranulomascausedlocalizedalveolar bone resorption. Differential diagnosisincluded peripheral giant cell granuloma, peripheralossifying �ibroma, metastatic cancer, hemangioma,pregnancy tumor, conventional granulation tissuehyperplasia, Kaposi's sarcoma, bacillary angiomatosisand non-Hodgkin lymphoma. Peripheral giant cellgranuloma can be histologically identi�ied due to thepresence ofmultinucleated giant cells and lack of aninfectious source. Ossifying �ibroma or peripheralodontogenic�ibromaoccursexclusivelyonthegingiva;however,ithasaminimalvascularcomponentunlikeapyogenic granuloma. Due to the proliferating bloodvessels,adifferentialdiagnosisofpyogenicgranulomafrom a hemangioma is made histologically in whichhemangioma shows endothelial cell proliferationwithout acute in�lammatory cell in�iltrate, which is acommon �inding in pyogenic granuloma. Metastictumorsoftheoralcavityarerareandattachedgingivaiscommonly affected, clinically resembling reactive orhyperplastic lesions such as pyogenic granuloma, butmicroscopically they usually resemble the tumor oforigin, which usually is distant from the metastatic

15lesionseenintheoralcavity. Managementofpyogenicgranulomadependsontheseverityofsymptoms.Ifthelesion is small, painless and free of bleeding, clinicalobservation and follow up are advised [23]. Othertreatment modalities include laser surgery andelectrodessication[24,25].Injectionofabsoluteethanol,sodium tetradecyl sulfate (sclerotherapy) and


12

corticosteroids have also been tried with successfulresults in cases with recurrent lesions [26,27].Recurrence occurs in upto 16% of the lesions,whichmightbeduetoincompleteexcision,failuretoremoveetiologicfactors,orduetoreinjurytothearea,making

16,17followupnecessary.

ConclusionA pyogenic granuloma is an exuberant growth ofgranulation tissue secondary to irritation. Individualswith poor oral hygiene and chronic are oral irritantsmostfrequentlyaffected.Intraorally,itcanpresentwitha wide array of clinical appearances, ranging from asessilelesiontoanelevatedmass.Theyareusuallymorecommoninfemales.Inthepresentcase,excisionofthegranulomawasdoneandthecasewasfollowedupforsixmonthsandgrowthdidnotrecur.

References.1. Eversole L R. Clinical outline of oral pathology:

rdDiagnosis and treatment (3 ed). Hamilton:BCDecker2002;113-14.

2. GreenbergMS, GlickM. Burkit's oralmedicine :rdDiagnosis and treatment (3 ed). Hamilton: BC

Decker2003;141-42.3. HartzellMB.Granulomapyogenicum.JCutanDis

Syph1904;22:520-525.4. Sumanth Shivaswamy, Nazia Siddiqui, A. Sanjay

Jain,AjitKoshy,SonalTambwekar,AkhilShankar.Arare case of generalized pyogenic granuloma: Acasereport.QuintessenceInt2011;42:493–499.

5. Ramirez. K, Bruce G: carpenter. Wpyogenicgranuloma:casereportina9-year-oldgirl.General Dentistry 2002,50(3):280-1.

6. NevileBW,DammDD,AllenCM,BouquotJE:oral and maxillofacial pathology Secondedition.W.B.saundersco;2004:444-449.

7. Regezi AJ , Sciubba J . Cl inical pathologiccorrelations. 2nd ed.Philadelphia: WB SaundersCo;1985.p.194–6.

8. Ojanotko-HarriAO,HarriMP,HurttiaHM,SewonLA.Alteredtissuemetabolismofprogesteroneinpregnancy gingivitis and granuloma. J ClinPeriodontol1991;18:262-66.

9. RageziJA,Sciubba,JamesJ,JordanRichorsCK.OralPathology,Clinicalpathologiccorrelation.Fourth.SandersCompany;2003.pp.115-176.

10. G re enbe r g MS , G l i c k M . B u rke t ' s o ra lmedicine:diagnosis and treatment. 10th ed, BCDecker,Hamilton,2003:141-2.

11. Patil K, Mahima VG, Lahari K. Extragingivalpyogenicgranuloma.IndianJDentRes2006;17:199-202.

12. Jafarzadeh H., Sanatkhani M. andMohtasham N.Oralpyogenicgranuloma:areview.JOralSci.2006;48:167-75.

13. Kamal R, Dahiya P, Puri A. Oral pyogenicgranuloma:Variousconceptsofetiopathogenesis.JOralMaxillofacPathol2012;16:79-82.

14. AngelopoulosAP.Pyogenicgranulomaoftheoralcavity:Statistical analysis of its clinical features. JOralSurg1971;29:840-7.

15. SheibaR.Gomes,QuaidJoharShakir,PrarthanaV.Thaker,JamshedK.Tavadia.Pyogenicgranulomaofthe gingiva: A misnomer? – A case report andreviewofliterature. JISP -Vol17,Issue4,Jul-Aug2013.

16. Taira JW,Hill TL, Everett MA. Lobular capillaryhemangiomawithsatellitosis.JAmAcadDermatol.1992;27:297-300.

17. Selvamuthukumar SC,Nalini Ashwath, Anand V.Unusual presentation of pyogenic granuloma ofbuccalmucosa.JIAOMR.2010;22(4):S45-47.

Correspondence Address :

Dr. Sachin .S. Shivanaikar“Vayshnoovi'Plno10,Vijaynagar,Hindalga,Belgaum.591108.Karnataka.Email:[email protected]


13

Abstract

Dentalavulsionisthemostseveretypeoftraumatictoothinjuriesbecauseitcausesdamagetoseveralstructuresand

resultsinthecompletedisplacementofthetoothfromitssocketinthealveolarbone.Theidealsituationistoreplantan

exarticulatedtoothimmediatelybecausetheextraoraltimeisadeterminantfactorfortreatmentsuccessandgood

prognosis.Thisdependsonanumberoffactorsthatmaycontributetooccurrenceofrootresorption,amongwhichis

thetypeandcharacteristicsofthemediumusedfortemporarystorageduringthetimeelapsedbetweenavulsionand

reimplantation.Recentresearchhasledtothedevelopmentofstoragemediathatproduceconditionsthatclosely

resembletheoriginalsocketenvironmentandthuscreatethebestpossibleconditionsforstorage.Althoughthese

storagemediacannowbepurchasedasretailproducts,themostcommonscenarioisthatsuchaproductisexpensive

andwillnotbereadilyavailableatthemomentofaccident.Thisreviewoutlinesthecommonstoragemediathatare

availableandhighlightstheirspeci�icfeaturesandlimitations.

Keywords:

IntroductionAvulsion,orexarticulation,isacompletedisplacementofatoothfromitsalveolarsocketasaresultoftrauma.Typically,theavulsedtoothisalsodisplacedcompletely

1outofthemouth. Thisformofdentaltraumacomprises1-11% of all traumatic injuries to the permanent

2 dentition. Avulsionisapotentialthreattothevitalityofperiodontalligament�ibers(PDL)cellsandthesecells

3areessentialforthe healingofreplantedavulsedteeth.

Theprognosisofareplantedtoothanditsmaintenanceonthedentalarchforthelongestpossibletimedepends

ontheviabilityoftheperiodontalligament(PDL)cells

Authors : Dr. Sarah Paul¹, Dr. Prashant G.M², Dr. Sushanth V.H³, Dr. Mohamed Imranulla⁴, Dr. Allama Prabhu C.R⁵, Dr. Gayathri Rajeev⁶

remainingonrootsurface,integrityofrootcementum45

andminimalbacterialcontamination. Replantationofatoothwithin5minutesusuallyensuresprompt

6returnofthePDLcellstonormalfunction. Immediatere-implantation of avulsed teeth impacts positivelyontheviabilityofPDLcellsandresultsinPDLhealing

7inupto85%ofmatureteeth. Wherere-implantationisnotfeasible,theextra-alveolarconditionsmaybemodi�ied by storing the tooth in a physiological

8storagemedium.

Astoragemediummaybede�inedasaphysiologicalsolutionthatcloselyreplicatestheoralenvironment

Avulsed Tooth? Know Transport Media-need Of The Hour :a Literature Review.

14

1. Dr. Sarah Paul Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDental

Sciences,Davangere,Karnataka Phno:9008347983 Emailid:re�[email protected]

2. Dr. Prashant G.M. ProfessorandHead, DepartmentofPublicHealthDentistry,CollegeofDental


3. Dr. Sushanth V.H. Professor, DepartmentofPublicHealthDentistry,CollegeofDental


4. Dr. Mohamed Imranulla Reader, DepartmentofPublicHealthDentistry,CollegeofDental


5. Dr. Allama Prabhu C.R Reader, DepartmentofPublicHealthDentistry,CollegeofDental


6. Dr. Gayathri Rajeev Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDental


to help preserve the viability of PDL cells following1

avulsion. Overtheyears,thecomposition,formulation,temperature, pH, and other aspects ofmany potential

9storagemediahavebeenthefocusofresearch. Therearesolutionswhicharecapableofpreservingthelifeofcellsfromtheperiodontalligamentduringthetimetheyareoutoftheiralveolarsocket.Thesesolutionsmustbeused

10when immediate reimplantation cannot be done. Thesearchforasingle,idealstoragemediumthatiscapableof maintaining PDL and pulp cell viability, whilepresentingclonogeniccapacity,antioxidantproperty,noor minimal microbial contamination, compatiblephysiologicalpHandosmolality,highavailability,readyaccessibilityandlowcost,isoneofthemaininterestsof

11,12dentaltraumaresearch.

Hank's Balanced Salt Solution (HBSS)HBSSisaspeciallydesignedstoragemediumcontaining

13essentialnutrients. Althoughitisnoteasilyavailableinmostpartsoftheworld,itismarketedinsomecountriesas “Save-a-tooth” (Save-A-Tooth,PA, USA). Hwang et alreported 94% cell viability after storage of culturedhumanPDLcellsfor24hours inthismedium,whichis

14considered an excellent result, and Souza et al hadsimilarresultstothoseofthepositivecontrol(MEM)by

.15theTripanblueexclusionmethodforupto6hours

However,itsuseisrestrictedtolaboratoryenvironmentsandisnotavailableatanaccidentsite,whichmakesit

12impracticableasastoragemedium .Inaddition,HBSSshouldbeusedat37ºCinacontrolledincubator,whichmay explain the inef�icacy of this solution in some

16studies,ifcomparedwithothermedia.

VIASPANIt is a widely used solution for the storage andtransportationoforganstobetransplanted.IndentistryitisusedasastoragemediumforavulsedteethbecauseitmaintainsPDLcellvitality,leadingthecasestoabetter

17prognosis. PDLcellmorphologyremainsunchangedinthemedium,providingoptimalpressureforcellgrowth18. Hiltz and Trope have compared the vitality of lip�ibroblasts,atroomtemperaturewhichwerestored inmilk,Hank'sbalancedsalt solutionandViaSpanr.TheViaSpanrwasthebeststoragemediumobservedatalltimes, and after 18 hours, therewas still 6%of living

19cells

Eagle's Minimal Essential MediumEagle'sMinimal EssentialMedium contains 4ml of L-

Glutamine;105 IU/L of Penicillin; 100μg/mL ofStreptomycin, 10μg/mL of Nystatin and calf serum

20(10%v/v) .Severalauthorshavereporteditsef�icacyinpreservingtheviabilityofPDLcellsandhaveindicatedit

21,22asastoragemediumbeforetoothreplantation.

MilkMilkasastoragemediumisthemostpracticaltransport

23medium for the short-termstorageof avulsed teeth. Milk issigni�icantlybetter thanothersolutions for itsphysiological properties, including pH and osmolalitycompatible to those of the cells from the periodontalligament;theeasywayofobtainingitandforbeingfree

2425ofbacteria. TropeandFriedmanrecommendmilkas

26anexcellentstoringsolutionfor6hours. Huangetalfoundthatmilkat40°Cprovidedshort-termviabilityto

14cells,buttheydidnotremainattachedafter48hrs. Thefavourable results of milk probably occur due to thepresenceofnutritionalsubstancessuchasaminoacids,

27carbohydratesandvitamins.

PropolisPropolisisamultifunctionalmaterialusedbybeesintheconstructionandmaintenanceoftheirhives.Ozanetalin his study concluded that propolis maintains thecellular viability of the periodontal ligament, besidesbeing anti-microbiotic, anti-in�lammatory and anti-

28 oxidant. Gopikrishnaetal.foundthatpropolishad50%ef�icacy inmaintainingcellviability,whileMartinandPileggi considered propolis as the most ef�icient

29medium.

Green tea extractHwangetalandJungetalinthesearchforamediumcapable of minimizing the infections after toothreplantation, maintaining PDL cell viability andreducing root resorption and ankylosis, reportedenthusiastic results with green tea, with the

1430maintenanceof90%ofcellviabilityforupto24h. Inview of this, the use of green tea extract and itscompoundsmaybeanalternativefortheconservationofavulsedteethanditsbene�icialeffectisenhancedbyhigherextractconcentrations.

Egg white and ovalbuminEggwhitehasapHof8.6–9.3anditsosmolalityis258

-1 mmolkg . SousaetalevaluationobservedthathumanPDL adhered to extracted tooth roots and wasmaintainedinthisstoragemediumsuggestingthattheegg white provided cell viability and histological


15

31characteristicssimilartothoseofmilk. Khademietalcomparedmilk and eggwhite as solutions for storingavulsedteeth,andfoundthatteethstoredineggwhitefor6to10hhadasuperioref�iciencycomparedtomilkto

32maintainviabilityofperiodontalligament�ibres.

Saliva Saliva may be used as an immediate interim storage

33medium. Salivacanbeusedasastoringmediumforashortperiodoftime,foritcandamagethecellsofthe

34periodontal ligament ifused for longer thananhour. Andreasen et al showed that saline and saliva weresuitable storage medium for protection against root

35resorptionforshortextra-alveolarperiods.

Coconut waterGopikrishnaetalfoundgreateref�icacyofcoconutwateroverHBSSandmilkfortheviabilityofPDL,alsoitisanatural,biologicallypure,sterileproductrichinamino

36acids, proteins, vitamins andminerals. Thomas et alfoundthat15to120minstorageincoconutwaterisasef�icientasstorageinHBBSbutstudiesbyPearsonetalobserved that in�lammatory resorption was morefrequent when the tooth was maintained in coconut

3738watercomparedwithmilk.

Normal salineIsotonicsalinehasbeenusedsuccessfullyasastoragemedium by researchers in both animal and humanstudies. Ithasa comparableosmolality to thatofPDLcells.Cveketalfoundthatatoothstoredinnormalsalinefor 30 minutes showed less resorption than a tooth

39storeddryforbetween15and40minutes. Krasneretalstatedthatsalinesolutionwasharmfultothecellsoftheperiodontal ligament in avulsed teeth, if it is used for

40longerthantwohours.

Tap waterSome studies have suggested that tap water may beaccepted as a storage medium for very brief periods

41whentherearenoalternatives Yet,tapwaterhasshowntobetheonewiththeleastdesirableresults,thoughitprotects the tooth from dehydration– for being ahypotonicmedium–itcausesrapidcellularlysisofthe

42periodontalligament.

GatoradeGatoradewasoriginallyformulatedasadrinkforsportspeople to replenish electrolytes during training andsportsevents.HarkaczetalandSigalasetalshowedthat

Gatoradeonicewasbetterthantapwateronice,andthatGatorade may be viable for the short-term storage of

4344avulsedteeth

Aloe veraAloevera is a cactus likeplant thatbelongs to familyLiliaceae.Saxenaetalinastudyfoundtheviabilityofthecellswerehighinanaloeveragel,butitisoftenlimitedbecausealoeverahasadryperiodanditisnotofteneasytoimplantrightaftertheavulsion,thus,reducingtheuse

44ofthismedium.

Red mulberryRedmulberry (Morus rubra) is a tree that is grown inalmostmostoftheclimaticconditionsaroundtheworld.Ozanetal.comparedfourdifferentconcentrationsofM.rubra (4%, 2.5%,1.5%, and 0.5%) with HBSS and tapwater at 1 hr, 3 hrs, 6 hrs, 12 hrs and 24 hours andconcluded the number of viable PDL cells wassigni�icantlyhighwhenanavulsedtoothwasstored in4.0%concentratedsolutionofMorus rubra, anditcould

45beusedasasuccessfultransportmedium.

Pomegranate juiceTavassoli-Hojjati S et al in a study found thatpomegranatecanpreservethespindlelikemorphologyofperiodontal�ibersfor24hrsafterstorage,thusmaking

46itagoodstoragemediaattherightconcentration.

Oral rehydration solutionsOralrehydrationsolutionsaremarketedinsealedsterilepouchesandeasilyavailableoverthecounter,inadditionto being economical. Its ability to maintain PDL cellviabilitywasdemonstratedtobeequaltoHBSSinastudy,

47bothretainingPDLvitalitybetterthanmilk.

Growth factorsLynchetal.demonstratedthatshort-termapplicationofa combination of platelet derived growth factor andinsulin-likegrowthfactorcanenhancetheformationoftheperiodontalattachmentapparatus5-10foldduring

48theearlyphaseofwoundhealing.

ConclusionAnappropriatestoragemediumcanhelpmaintain theviability of PDL cells and can lead to successfulreplantation of avulsed teeth. Considering the criticalrole of these media, an informed choice of a suitablemediumisessentialforasuccessfuloutcome.Compared


16

to synthetic products, natural productsmay bemoreeffectiveinmaintainingthePDLcellviability,especiallyintermsofaccessibilityandaffordability.Milkremainsthe most convenient, cheapest and readily availablesolutioninmostsituationswhilealsobeingcapableofkeepingPDLcellsalive,assyntheticmediumhaveagreatpotentialtomaintainthePDLcellsinaviablestateafteravulsion,thepracticalitiesofusingthesesolutionsandthelackofreadyavailabilitytothegeneralpublicmakethem less than ideal. Although research has beenundertakenonawidevarietyofmaterialstobeusedasstoragemediaforthetransportofavulsedteeth;lackofavailability,highcostlimitandlackofawarenesslimitthe usage of these media and a critical analysis andinformedchoiceofasuitablemediumisessentialforasuccessfuloutcome.

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11. Gopikrishna V, Baweja PS, Venkateshbabu N,ThomasT,KandaswamyD.Comparisonofcoconutwater, propolis, HBSS, and milk on PDL cellsurvival.JEndod2008;34:587-589.

12. Gopikrishna V, Thomas T, Kandaswamy D. Aquantitative analysis ofcoconut water, a newstoragemedia for avulsed teeth. Oral Surg OralMedOralPatholOralRadiolEndod2008;105:61-65.

13.ÇaglarE,SandalliN,KuscuOO,DurhanMA,PisiricilerR, CalıskanEA. Viability of �ibroblasts in a novelprobiotic storage media. Dent Traumatol2010;26:383-387.

14. HwangJY,ChoiSC,ParkJH,KangSW.Theuseofgreen tea extractas a storage medium for theavu lsed tooth . Bas i c research . B io logy2011;37:962-967.

15. Souza BDM, Luckemeyer DD, Reyes-Carmona JF,FelippeWT,SimoesCMO,FelippeMCS.Viabilityofhumanperiodontal ligament �ibroblasts inmilk,Hank'sbalancedsaltsolutionandcoconutwaterasstoragemedia.IntEndodJ2011;44:111-115.

16. SouzaBDM,BortoluzziEA,TeixeiraCS,FelippeWT,SimoesCMO,FelippeMCS.EffectofHBSSstoragetime on human periodontal ligament �ibroblastviability.DentTraumatol2010;26:481-483.

17. GoswamiM,ChaitraTR,ChaudharyS,ManujaN,SinhaA. Strategies for periodontal ligament cellv i ab i l i t y : an overv iew. J Conserv Dent2011;14:215-220.

18. Hupp JG, Mesaros SV, Aukhil I , Trope M.Periodontal ligament vitality and histologichealingofteethstoredforextendedperiodsbeforetransplantation.EndodDentTraumatol1998;14:79–83.

19. Hiltz J& Trope M. 1991. Vitality of human lip�ibroblastsinmilk,Hank'sbalancedsaltsolutionand ViaSpanr storage media. Endod DentTraumatol,7:69–72.

20. Bloml¨ofL,OtteskogP&Hammarstr¨omL.1981.Effect of storage in media with different ionstrenghtsandosmolalitiesonhumanperiodontalligamentcells.ScandJDentRes,89:180–7.

21. Malhotra N. Current developments in interimtransport(storage)mediaindentistry:anupdate.BrDentJ2011;211:29-33.


17

22. MarinoT,WestLA,LiewehrFR,MailhotJM,BuxtonTB, Runner RR, et al . . Determination ofperiodontalligamentcellviabilityinlongshelf-lifemilk.JEndod2000;26:699-702.

23. Hammarstrom L, Pierce A, Blomlof L, Feiglin B,Lindskog S. Tooth avulsion and replantation – areview.EndodDentTraumatol1986;2:1–8.

24. BlomlöfL,OtteskogP&HammarströmL.1981.Effect of storage in media with different ionstrenghtsandosmolalitiesonhumanperiodontalligamentcells.ScandJDentRes,89:180–7.

25. Blomlöf L. 1981. Milk and saliva as possiblestoragemediafortraumaticallyexarticuledteethpriortoreplantation.SwedDentJ,8:1–26.

26. TropeM&FriedmanS.1992.PeriodontalhealingofreplanteddogteethstoredinViaSpanr,milkandHank's balanced salt solution. Endod DentTraumatol,8:183–88.

27. CourtsFJ,MuellerWA&TabelingHJ.1983.Milkasan interim storagemedia for avulsed teeth.PediatricDentistry,5:183–6.

28. OzanF,PolatZA,ErK,ÖzanÜ&DegerO.2007.Effect of propolis on survival of periodontalligament cells: new storage media for avulsedteeth.JEndod,33:570–3

29. Gopikrishna V, Baweja PS, Venkateshbabu N,ThomasT,KandaswamyD.Comparisonofcoconutwater, propolis, HBSS, and milk on PDL cellsurvival.JEndod2008;34:587-589.

30. JungIH,YunJH,ChoAR,KimCS,ChungWG,ChoiSH. Effect of (-)-epigallocatechin-3-gallate onmaintainingtheperiodontalligamentcellviabilityofavulsedteeth:apreliminarystudy.JPeriodontalImplantSci2011;41:10-16.

31. Sousa HA, Alencar HG, Bruno KF, Batista AC,CarvalhoACP.Microscopicevaluationoftheeffectof different storage media on the periodontalligamentofsurgicallyextractedhumanteeth.DentTraumatol2008;24:628-632.

32. KhademiAA,AtbaeeA,RazaviSM,ShabanianM.Periodontalhealingofreplanteddogteethstoredin milk and egg albumen. Dent Traumatol2008;24:510-514.

33. Lekic PC, Kenny DJ, Barrett EJ. The in�luence ofstorageconditionsontheclonogeniccapacityofperiodontalligamentcells:implicationsfortoothreplantation.IntEndodJ1998;31:137–40.

34. Blomlöf L. 1981. Milk and saliva as possiblestoragemediafortraumaticallyexarticuledteethpriortoreplantation.SwedDentJ,8:1–26.

35. AndreasenJO.Effectofextra-alveolarperiodandstorage media upon periodontal and pulpalhealingafterreplantationofmaturepermanentincisors inmonkeys. Int J Oral Surg 1981; 10:43–53.

36. Gopikrishna V, Thomas T, Kandaswamy D. Aquantitative analysis of coconut water: a newstoragemediaforavulsedteeth.OralSurgOralMedOralPatholOralRadiolEndod2008;105:61-65.

37. Thomas T, Gopikrishna V, Kandaswamy D.Comparative evaluation ofmaintenance of cellv iabi l i ty of an experimental transportmedia“coconutwater”withHank'sbalancedsaltsolution and milk, for transportation of anavulsed tooth: an in vitro cell culture study.JConservDent2OO8;11:22-29.

38. PearsonRM, LiewehrFR,West LA, PattonWR,McPherson JC,RunnerRR.Humanperiodontalligament cell viability in milk and milksubstitutes.JEndod2003;29:184-186.

39. LauerHC,MullerJ,GrossJ,HorsterMF.Theeffectof storage media on the proliferation ofperiodontalligament�ibroblasts. JPeriodontol1987;58:481–5.

40. Krasner P. 1992. Tooth avulsion in the schoolsetting.JSchNurs,8:20–6.

41. BibbyKJ,McCullochCA.Regulationofcellvolumeand [Ca2+] in attached human �ibroblastsrespondingtoanisosmoticbuffers.AmJPhysiol1994;266:C1639–49.

42. AshkenaziM,MarouniM& SarnatH. 2000. Invitro viability, mitogenicity and clonogeniccapacity of periodontal ligament cells afterstorageinfourmediaatroomtemperature.DentTraumatol,6:63–70.

43. Hupp JG, Mesaros SV, Aukhil I, Trope M.Periodontal ligament vitality and histologichealing of teeth stored for extended periodsbefore transplantation. Endod DentTraumatol1998;14:79–83.

44. Harkacz OM Sr, Carnes DL Jr, Walker WA 3rd.Determinationof periodontal ligament cellviability in theoral rehydration �luidGatoradeandmilksofvarying fatcontent. JEndod1997;23:687–90.


18

44. Saxena P, Pant VA,Wadhwani KK, KashyapMP,Gupta SK, Pant AB.Potential of the propolis asstorage medium to preserve the viabilityofculturedhumanperiodontalligamentcells:Aninvitrostudy.DentTraumatol2011;27(2):102-8.

45. OzanF,TepeB,PolatZA,ErK.Evaluationof invitro effect of Morus rubra (redmulberry) onsurvivalofperiodontalligamentcells.OralSurgO r a l M e d O r a l P a t h o l O r a l R a d i o lEndod2008;105(2):e66-9.

46. Tavassoli-HojjatiS,AliasgharE,BabakiFA,EmadiF, ParsaM,Tavajohi S, et al. Pomegranate juice(Punica granatum): A new storagemedium foravulsedteeth. JDent(Tehran)2014;11(2):225-32.

47. Rajendran P, Varghese NO, Varughese JM,MurugaianE.Evaluation,usingextractedhumanteeth, of Ricetral as a storage mediumforavulsions–Aninvitrostudy.DentTraumatol2011;27(3):217-20.

48. LynchSE,deCastillaGR,WilliamsRC,KiritsyCP,HowellTH,ReddyMS,etal.Theeffectsofshort-term application of a combinationof platelet-derived and insulin-like growth factors onperiodontal wound healing. J Periodontol1991;62(7):458-67

Correspondence Address Dr. Sarah Paul Postgraduatestudent, DepartmentofPublicHealthDentistry,Collegeof DentalSciences,Davangere,Karnataka Phno:9008347983 Emailid:re�[email protected]


19

1. Dr. Deepti Kumar PostGraduate DepartmentofProsthodonticsKLESocietys'Instituteof

DentalSciences,Bangalore

2. Dr. M Shivshankar M.D.S Prosthodontist DirectorCon�identDentallab,Bangalore

3. Dr. Srivatsa G M.D.S PrincipalandProfessor DepartmentofProsthodonticsKLESocietys'Instituteof

DentalSciences,Bangalore

4. Dr Supriya Manvi M.D.S Professor DepartmentofProsthodontics KLESocietys'InstituteofDentalSciences,Bangalore

Abstract

TheintroductionofCAD/CAMprinteddentureshasledanewerainremovableprosthodontics.CAD/CAMtechnology

hasmadefabricationofcompletedentureslesstediouswithimprovedwork�lowovercomingthedisadvantagesof

conventional complete denture. CAD/CAM dentures have better �it as well as aesthetics when compared with

conventionalcompletedentures.ThispurposeofthiscasereportistopresentonesuchcaseofCAD/CAMdenture

Keywords: CompleteDenture,CAD/CAM,3-Dprinteddentures

IntroductionAfternearly80yearsofminimallychangedmethodsandprotocols to fabricate complete denture, the �irstcommercially available CAD/CAM denture system

1heraldedanewerainremovableprosthodontics. Theclinical and laboratory steps in complete denturefabricationareverylongandtedious.The�irstclinicalstepofcompletedenturefabricationinvolvesprimaryimpression followed by border moulding and �inalimpression.Theclinicianthenrecordstheverticalandcentricjawrelationfollowedbyteetharrangementand�inal processing of the dentures. A patient comes forseverallongappointmentsfortheclinicalstepaswellasforfollow-up.

Theneweraoftechnologyhasmadethefabricationofremovable as well as �ixed prosthesis relatively easy.Few clinical steps are eliminated which indirectlyreduces the number of appointments and makesfabricationofprosthesislesstedious.Italsohashelpedtoreducethetreatmenttime.

Dr. 1 2 3 4 5 6 7Authors : Deepti Kumar , Dr. M Shivshankar , Dr. Srivatsa G. , Dr. Supriya Manvi ,Dr. Rajeswari C.L , Dr. Rohit M Shetty , Dr. Ajay G. Doni

5. Dr Rajeswari C.L M.D.S Professor DepartmentofProsthodontics KLESocietys'InstituteofDentalSciences,Bangalore

6. Dr. Rohit M Shetty, M.D.S ProfessorandHeadofDepartment DepartmentofProsthodontics KLESocietys'InstituteofDentalSciences,Bangalore

7. Dr Ajay G Doni PostGraduate DepartmentofProsthodontics KLESociety'sInstituteofDentalSciences,Bangalore

CAD/CAM has been used for fabrication of differentprosthesis such crown and bridges. In removableprosthodontics CAD/CAM is used to cast partialframework. The recent advancement is printing ofcompletedentures.Theuseof3-Dprintinghashelpedclinicianreduceclinicalandlabstepsmakingcompletedenturefabricationrelativelyeasy

Inthiscasereport,a3Dprinteddenturewasfabricatedfor the patient. A CAD/CAM printed denture was

thdeliveredtothepatientinthe4 appointment.

Case ReportPrimaryimpressionwasmadewithalginatefollowedbyfabricationofcustomtray.Bordermouldingwasdonewithgreenstickcompoundand�inalimpressionsweremadewithzincoxideeugenol.

3-D Printed Dentures in Rehabilitation of Completely

Edentulous Patient- A Case Report

20

Fig.1 Fig.2

Verticaljawrelationandcentricrelationwererecordedand sent to the lab for fabrication of dentures byCAD/CAM.Thepatientwantedaprosthesisasquicklyaspossible,henceatrialcouldnotbegiven.

In the dental laboratory, the de�initive maxillary andmandibularcastwerepreparedforscanningwithscanspray.TheCDswerevirtuallydesignedwithcomputersoftware[PaladenturebyKulzer].Thedigitaldentureswerefabricatedfromprepolymerizedresinacrylicpucksand were delivered with teeth bonded in the milled

1recesses. Thedenturebaseaswelltheacrylicteethwereboth3-Dprintedandbonded.

Fig.3a Fig.3b

Fig.4 Fig.6a

Fig.6b Fig.7

Afterthedentureswereplacedinthepatient'smouth,itwasevaluatedforstability,retention,borderextensions,aesthetics,phoneticsandocclusalrelationship.

Thefollow-upappointmentsscheduledafterplacementofdentureswere24hours,3daysandsevendays.

DiscussionBesidesareductioninthenumberofvisitsandreducedclinicalchair time, therepositoryofdigitaldata in themanufacturer database allows for the rapid future

1fabrication of spare or replacement dentures. Thepatienthadsatisfactory functionwith theseCAD/CAMdentures.Thedenturebaseaswelltheteethwereboth3-Dprintedandnotmilled.

CAD/CAM printed dentures indeed provide excellentretentionandoutstanding suctioneffect.Thematerialdoes not undergo polymerization shrinkage unlike

1conventionalcompletedentures.

Comparedtoconventionaldentures,CAD-CAMdenturesare found to have reduced resin volume and weight,

which can increasepatients' comfort and adaptability.However,CAD/CAMdenturebaseresinsgenerallydonothavehigherfracturetolerancethanmanuallyprocessed

2heat-polymerizingresins.

Although,digitaldenturesareef�icient, the inabilitytocustomize the dentures and accurately verify centric

2relationisoneofthedrawbacks.

The CAD/CAM dentures improves work�low andeliminatesthedisadvantageofthelabstepsrequiredforconventionaldentures.Thehazardofmaterialallergytolabpersonneliseliminated.

Furtherresearchisneededonthebiomechanical,clinicaland patient-centered outcomemeasures to determine

3thesuperiorityofCAD/CAMdentures.

Fig.8 Fig.9


21

References1. Janeva, Gordana, Janev, Complete Dentures

fabricated with CAD/CAM technology and atraditional clinical recordingmethod, JMed Sci,Oct2017;5(6):785-789

2. John,Abraham,Alias,TwovisitCAD/CAMmilleddentures in the rehabilitation of edentulousarches: A case series , Journal of IndianProsthodonticSociety,Jan-March2019;19(1):88-92

3. Kalberer N, Mehl A, Schimmel M, Muller F,Srinivasan M. CAD-CAM milled versus rapidlyprototyped(3D-printed)completedentures:Aninvitro evaluation of trueness. The Journal ofprostheticdentistry.2019Apr1;121(4):637-43.

4. Kattadiyil, Goodacre, Nadim Z Baba, CAD/CAMcompletedentures:A reviewof twocommercialfabr ica t ion sys tems , CDA Journa l , June2013;41(6):407-416

Correspondence Address Dr. Deepti Kumar PostGraduate DepartmentofProsthodonticsKLESocietys'Instituteof DentalSciences,Bangalore


22

Abstract

Introduction: Asageadvancestherearesomethingsthattendtoletfallbythewayside.Oralhealthproblemsinolder

peopleincludeexcessivetoothloss,periodontaldisease,dentalcariesandperceiveddrymouth.GeriatriclOralHealth

AssessmentIndex(GOHAI)isawell-establishedinstrumentusedtomeasureOHRQoL(oralhealthrelatedqualityof

life).HoweverthisquestionnaireisinEnglish.Itisimportantthatanadoptedinstrumentshouldbeculturallyrelevant

andvalidforthelocalpopulationwhiledemonstratingacceptablepsychometricproperties.

Aim: ToassessthevalidityofKannadaversionofGOHAIandtoassesstheperceptionofOralhealthrelatedqualityof

lifeanditsassociationwithsocio-economicstatusoftheolderpeopleofDavangerecityusingKannadaversionof

GOHAI.

Materials and methods: A cross-sectional questionnaire based survey was conducted at the College of Dental

Sciences.Thestudyincludedgeriatricsubjectsagedorabove65yearsTheGOHAIwastranslatedintoKannada.Socio-

economicstatusofthesubjectswascalculatedusingModi�iedKuppuswamySocioeconomicScaleforYear2018.Prior

todistributionofthequestionnairetheparticipantswereinformedabouttheimportanceofthestudy.Theresponse

fromtheparticipantswasevaluatedwithSPSS(Statisticalpackageforsocialsciences,softwareVersion22.0)

Results: Atotalof250participants(118menand132women)completedtheGOHAIquestionnaire.MeanGOHAIscore

wasfoundouttobe21.70±8.63.Whenparticipantswereaskedhowoftenweretheyabletoswallowcomfortably;

61(24.4%)saidnever;45(18%)saidseldom;20(8%)saidsometimes;58(23.2%)saidoftenwhereas66(26.4%)said

always.WhentheywereaskedHowoftendidtheyfeltnervousorself-consciousbecauseofproblemswiththeirteeth

and gums; 36(14.4%) said never, 42(16.8%) said seldom; 59(23.6%) said sometimes; 53(21.2%) said often and

60(24%)saidalways.

Conclusion:Amongthedifferentsocioeconomicclasses,themostaffectedsocioeconomicclasswasthelowermiddle

classfollowedbytheupperlowerclass.KannadatranslationoftheGOHAIshowedacceptablevalidityandreliability

whenusedonthepeopleinDavangerecity.ItcouldthereforebeavaluableinstrumentformeasuringOHQoLforpeople

inthisregion

Keywords: GOHAI,OHQoL,Crosssectionalsurvey

IntroductionAsageadvances,therearesomethingsthattendtoletfallbythewayside.Dentalhealthseemstobeoneofthe

Authors : Dr.SampadaSureshKulkarni¹,Dr.SushanthV.H²,Dr.PrashantG.M³,Dr.MohammedImranulla⁴,Dr.AllamaPrabhuC.R⁵,Dr.FhelenDebbiedaCosta⁶

Validation of Kannada Version of Geriatric Oral Health Assessment Index Among Older People in Davangere City- a cross Sectional Survey

personalhygienestepsthatcanbeforgotten.Sincedentalhealthaffectswhole-bodyhealth,it'simportanttokeeporalhealthapriority.

1. Dr. Sampada Suresh Kulkarni Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDentalSciences

Davangere MobNo.-9730326125/[email protected]

2. Dr. Sushanth V.H. Professor, DepartmentofPublicHealthDentistry,CollegeofDentalSciences


3. Dr. Prashant G.M. ProfessorandHead, Dep.ofPublicHealthDentistry,CollegeofDentalSciences

Davangere,MobNo.-9886215111/[email protected]

4.Dr. Mohammed Imranulla Reader, DepartmentofPublicHealthDentistry,CollegeofDentalSciences

Davangere,MobNo.-9886558148/[email protected]

5.Dr. Allama Prabhu C.R. Reader,DepartmentofPublicHealthDentistry,CollegeofDental

SciencesDavangere, MobNo.-9481359991/[email protected]

6.Dr. Fhelen Debbie da Costa Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDentalSciences

Davangere,MobNo.-9620912728/mail-�[email protected]

23

mailto:[email protected]

Oral health problems are widely prevalent healthconditions in older adults, and with the populationaging, the global burden of oral health problems has

1,2increasedoverthelast20years

Oralhealthproblemsinolderpeopleincludeexcessivetooth loss, periodontal disease, dental caries and

2perceiveddrymouth. Theseoralhealthproblemshavesigni�icanteffectsoneatingandswallowing,nutritionalintake, speaking, and smiling and thus affect several

3aspects of health and well-being. Tooth loss andperiodontaldiseasearealsofoundtobeassociatedwithgreaterrisksofmorbidity,physicalandcognitivedecline,

4,5andmortality.

Measuresoforalhealth–relatedqualityoflife(OHQoL)areessentialforepidemiologicalandclinicalstudiestoprovide accurate data for health promotion, diseaseprevention programmes and allocation of health

6resources

Geriatric Oral Health Assessment Index (GOHAI) is a7well-establishedinstrumentusedtomeasureOHRQoL.

HoweverthisquestionnaireisinEnglish.Itisimportantthatanadoptedinstrumentshouldbeculturallyrelevantandvalidforthelocalpopulationwhiledemonstrating

8-10acceptablepsychometricproperties.

Thusitisessentialtocarryoutarigoroustranslationofthe instrument inregional languagewhenused in thepopulationwithadifferentculture.

Consideringthis,theaimandobjectiveofthestudywastoassessthevalidityofKannadaversionofGOHAIandtoassess theperceptionofOralhealth relatedqualityoflife,anditsassociationwithsocio-economicstatusoftheolderpeopleofDavangerecityusingKannadaversionofGOHAI.

Materials And MethodsStudy design and population: A cross-sectionalquestionnaire based survey was conducted fromDecember 2017 to January 2018. The study includedgeriatric subjects aged or above 65 years from OutPatientDepartmentofCollegeOfDentalSciencesandanoldagehomeinDavangerecity• INCLUSION CRITERIA: Subjects aged or above

65years• Subjectswhogaveinformedconsent.

• EXCLUSIONCRITERIA:SubjectsunabletoreadorunderstandKannada.

Pre-testing of the questionnaire: The GOHAI wastranslated intoKannada.TheKannadadraftwas thenback-translated into English. The back-translatedversionwascomparedwiththeoriginalEnglishversiontoverifythatthequestionswereproperlytranslated.Inaddition,thequestionnaireincludedsocio-demographiccharacteristicssuch as age, sex, educational level,employmentandincome.Apilotstudywasconductedbeforeadministrationofthequestionnaire among 10 subjectswhose resultswerenotincludedinthestudy.(Cronbach'sα=0.90)

Administration of QuestionnairePrior to distribution of the questionnaire theparticipantswereinformedabouttheimportanceofthestudy. Participantswere includedonly on a voluntarybasis.Socio-economic status of the subjects wascalculatedusingModi�iedKuppuswamySocioeconomicScaleforYear2018

Statistical AnalysisTheresponsefromtheparticipantswerethencomputedinto a Microsoft excel worksheet and evaluated withSPSS (Statistical package for social sciences, softwareVersion22.0).FrequencydistributionandPearsonChi-square test was done to evaluate the statisticalsigni�icance.

ResultsAtotalof250participants(118menand132women)completedtheGOHAIquestionnaire.(�ig.1)

Outof250,majorityoftheparticipantswerefromtheupper lower class (86) followed by the lowermiddleclass(85),the upper middle class(45), the lower class(20) and least participants were from the upperclass.(14)(table1,graph1)

MeanGOHAIscorewasfoundouttobe21.70±8.63.

Whentheywereaskedhowoftendidtheylimitthekindsoramountsoffoodbecauseofproblemswiththeirteeth31(12.4%) participants said never, 38(15.2%) saidseldom; 59(23.6%) said sometimes 68(27.2%) oftenand54(21.6%)participantssaidalways.(table2)

On asking how often did they have trouble biting or


24

chewinganykindsoffoodsuchas�irmmeatorapples;40(16%)saidnever;32(12.8%)saidseldom;52(20.8%)participantssaidsometimes,76(30.4%)saidoftenand50(20%)participantssaidtheyalwayshadtroublebitingorchewingsuchfooditems.(table2)

Onbeingquestionedonhowoftenweretheyabletoeatanything without being in discomfort; 32(12.8%)answered never; 43(17.2%) answered seldom;54(21.6%)answeredsometimes;67(26.8%)answeredoftenand54(21.6%)answeredalways.(table2)

Whenparticipantswereaskedhowoftenweretheyabletoswallowcomfortably;61(24.4%)saidnever;45(18%)said seldom; 20(8%) said sometimes; 58(23.2%) saidoften whereas 66(26.4%) said always. Among theparticipants who were never able to swallowcomfortably; 11 participants belonged to the uppermiddleclass,19belongedtothelowermiddleclass;28belongedtotheupperlowerclassand23belongedtothelowerclass.Similarly,amongtheparticipantswhowereseldomabletoswallow;3belongedtotheupperclass;9participants were from the upper middle class; 14participants were from the lower middle class; 15participants belonged to the upper lower class and 4belongedtothelowerclass.Thisdifferenceamongtheparticipants was statistically signi�icant. (p=0.012)(graph2)(table2)

When participants were asked how often were theypleasedorhappywiththelooksoftheirteethandgums;21(8.4%) said never; 39 (15.6%) participants saidseldom;50(20%)participantssaidsometimestheywerehappywiththe lookof theirteeth;74(29.6%)of themsaid often and 66(26.4%) participants said they arealwayshappywiththelookoftheirteethandgums(table2)

On asking how often did they limit the contact withpeoplebecauseoftheconditionoftheirteeth64(25.6%)answered never; 37(14.8%) answered seldom;58(23.2%)answeredsometimes;56(22.4%)answeredoftenand35(14%)answeredthattheyalwayslimitthecontact with people because of their teeth condition.(table2)

Onaskinghowoftendidtheyusemedicationtorelievepain or discomfort from around their mouth; only38(15.2%)saidnever;46(18.4%)saidseldom;70(28%)said sometimes; 54(21.6%) said often and 42(16.8%)

saidtheyalwaystakemedicationforthesame.(table2)

WhentheywereaskedHowoftendidtheyfeelnervousorself-consciousbecauseofproblemswiththeirteethand gums;36(14.4%) said never, 42(16.8%) saidseldom; 59(23.6%) said sometimes; 53(21.2%) saidoftenand60(24%)saidtheyalwaysfeelnervousorselfconscious. Among these participants 3(never);5(seldom); 2(sometimes); 1(often) and 3(always)belonged to the upper class;Whereas 3(never);7(seldom); 11(sometimes); 14(often); 10(always)belonged to the upper middle class; similarly24(never);13 (seldom);23(sometimes); 19(often);6(always) belonged to the lower middle class;25(never); 10(seldom); 20(sometimes); 14(often);17(always)werefromtheupperlowerclassandlastly7(never);7(seldom);3(sometimes);3(often);0(always)belonged to the lower class. This difference in theperception of the participants was highly signi�icant(p=0.006).(graph3)(table2)

On being asked how often were they worried orconcernedabouttheproblemswiththeirteethandgums56(22.4%) said never 31(12.4%) said seldom;62(24.8%) said sometimes; 56(22.4%) said often and45(18%) said they are always concerned about theirteeth and gum problems. 7(50%) participants fromupper class said they are seldomworried; 13(28.9%)participantsfromuppermiddleclasssaidtheyareoftenworried; 25(29.4%) participants from lower middleclass said they are sometimes worried; 23(26.7%)peoplefromupperlowerclassand9(45%)participantsfrom lower class said that are never worried. Thisdifferencewasstatisticallysigni�icant.(p=0.002)(graph4)(table2)

Whentheywereaskedhowoftentheirteethdidpreventthem from speaking theway theywanted, 56(22.4%)said never; 41(16.4%) said seldom; 66(26.4%) saidsometimes 51(20.4%) said often and 36(14.4%) saidtheirteethalwayspreventthemfromspeakingthewaytheywanted.(table2)

Onaskinghowoftendidtheyfeeluncomfortableeatinginfrontofpeoplebecauseofproblemswiththeirteeth54(21.6%) said never; 36(14.4%) said seldom;66(26.4%) said sometimes; 59(23.6%) said often and35(14%) said they always feel uncomfortable. Amongthses 6(never); 0(seldom);2(sometimes); 4(often);2(always) beloneged to the upper class; 7(never);


25

7(seldom);10(sometimes); 15(often); 6(always)be longed to upper middle c lass ; 15(never) ;14(seldom);24(sometimes); 23(often); 9(always)be longed to lower middle c lass ; 16(never) ;13(seldom);28(sometimes); 15(often); 14(always)belonged to upper lower class, and lastly 10(never);2(seldom);2(sometimes);2(often);4(always)belongedtothelowerclass.Thisdifferenceintheperceptionoftheparticipants showed high statistical signi�icance.(p=0.05)(graph5)(table2)

When theywereaskedhowoften their teethorgumswere sensitive to hot, cold or sweets; 36(14.4%) saidnever;43(17.2%)saidseldom;50(20%)saidsometimes50(20%)saidoftenand70(28%)said their teethandgums were always sensitive to hot, cold or sweets.Among these7 participants from the upper class saidalways;13participantsfromtheuppermiddleclasssaidalways;23participantsfromthelowermiddleclasssaidalways;29participantsfromtheupperlowerclasssaidalways and 4 participants from lower class saidsometimes.Theyhavesensitivitytohotcoldandsweets.T h i s d i ff e r e n c e s h owed s t a t i s t i c a l l y h i g hsigni�icance(p=0.02)(graph6)(table2)

Fig.1

Table:1

Graph:1

Socio-economicclass NumberofParticipants

Upper class

Upper middle class

Lower middle class

Upper lower class

Lower class

14

45

86

20

85

Graph:2

Graph:3

Graph:4


26

Graph:5

Graph:6

Table 2Descriptivestatisticsofresponsesaccordingto

yearofstudy

·*Statisticallysigni�icant

DiscussionKannada is the native language in the region ofKarnataka,India.Thecurrentstudyaimedtoexaminethe validity and reliability of the GOHAI Kannadaversion and to assess the perception of Oral healthrelatedQualityofLife, and its associationwith socio-economicstatusinaselectedgroupofpeopleinIndia.TheGOHAI,whichwasoriginallydevelopedandtested

11inwell-educatedandelderlyAmericans hasalsobeendemonstratedassuitable inyounger,poorlyeducatedpopulations.FollowingstudiesontranslationsofGOHAI12-14,theauthorskeptcloselytotheoriginal6-category

7Likertscale .Itwasconsideredthatthe1990sentinelstudy under- pinnedall GOHAI studies and that thescorescouldbelaterrescoredasdescribedbyAtchison

11(1997) . On translation, though the question items11

remainedthesameasgivenbyAtchisonin1997 ,theorderoftheitemswasinterchanged.Whenusedamong


27

Indian people, the Kannada version of the GOHAIshowed acceptable validity and reliability. Since itsdevelopment 7, the GOHAI has been translated into

2 13 14Spanish1 ,Chinese andFrench .Theindexhasbeen

12,14foundvalidforuseonyoungeradults TheinternalconsistencyofGOHAIintheoriginalversioninEnglish

7wasreportedwithaCronbachalphacoef�icientof0.79 .15

IntheversionsadaptedandvalidatedinSwasof0.86 ,13 14 16China of 0.81 , France of 0.86 , Sweden of 0.86 ,

17 18 19Malaysiaof0.79 ,Japanof0.89 ,Germanyof0.92 ,

20 21 22.Turkeyof0.75 ,Jordanof0.88 .Mexicoof0.70 .TheCronbachcoef�icientofthecurrentstudywas0.90

Themost reportedproblem in thepresent studywasthatofphysicalfunctioning(especiallySwallowing)andpsychological functioning. Therefore, the items of'worriedaboutteeth,gums'45(always)56(often)and'l imit the kinds of food' were mostly repliedaf�irmativelyat35(always)and56(often).Thisisinline

7 23withthe�indingspresentedbyAtchinson ,Mathur and24

Rezaei. Majority of the population had dif�iculty inswallowing comfortably (66- always, 58-often) andsensitivity to hot, cold and sweets (70(28%)-always,50(20%)-often)whichiscontradictorytothe�indingsof

24Rezaei.

ThemeanGOHAIscoreinthecurrentstudywasfoundtobe 21.70±8.63, which was lesser than the scores

6 25obtainedbyOthmanetal andDeshmukhetal .

Intermsofthepsychosocialimpact,thepresentstudyshowed that amajoritywere not socially affected bytheir oral health, in terms of being self-conscious oruncomfortable in eating in front of people, which is

17 26similartothestudybyOthmanetal, andNiestenetal ,24

butincontrasttoRezaei.

It was found that majority of the current studypopulationwhofaceddif�icultiesinregardtotheiroralhealthandpoorOHRQOLbelongedtothelowermiddleandupperlowersocio-economicclass.

Toourcurrentknowledge,thereareaveryfewstudiesthat co relate GOHAI and the socio-economic classes,therefore,thecurrentstudyisuniqueinits�indings.Thestudy is also the �irst of its kind tobe translated in alanguagenativetoSouthernIndia.

ConclusionMajorityofthestudypopulationhadaproblemofsomesort. Among different socioeconomic classes mostaffectedsocioeconomicclasswasthelowermiddleclassfollowedbytheupperlowerclass.Itwasobservedthattheupperclasssufferedtheleastoralhealthproblemsamongall.Theparticipantsbelongingtothelowerclasshadoralhealthproblemsinspiteofwhichtherewasalackofawarenessandconcernforthesame.

InconclusionitcanbesaidthatKannadatranslationofthe GOHAI showed acceptable validity and reliabilitywhen used in people in Davangere city. It could,therefore, be a valuable instrument for measuringOHQoLforpeopleinthisregion

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2. Ramsay SE, Papachristou E,Watt RG, Tsakos G,LennonLT,PapacostaAO,MoynihanP,SayerAA,WhincupPH,WannametheeSG.In�luenceofpoororalhealthonphysicalfrailty:Apopulation-basedcohortstudyofolderbritishmen.JournaloftheAmericanGeriatricsSociety.2018Mar;66(3):473-9.

3. Petersen PE, Yamamoto T. Improving the oralhealthofolderpeople:TheapproachoftheWHOGlobalOralHealthProgramme.Community Dent Oral Epidemiol2005;33:81–92.

4. AidaJ, KondoK, YamamotoT et al. Oralhealthandcancer,cardiovascular,andrespiratorymortalityofJapanese. J Dent Res 2011;90:1129–1135.

5. Tsakos G, Watt RG, Rouxel PL et al. Tooth lossassociatedwithphysicalandcognitivedeclineinolderadults.J Am GeriatrSoc2015;63:91–99.

6. Fitzpatrick R, Fletcher A, Gore S, Jones D,SpiegelhalterD,CoxD.Qualityoflifemeasuresinhealth care. I: Applications and issues inassessment.Bmj.1992Oct31;305(6861):1074-7.

7. Atchison KA, Dolan TA. Development of thegeriatricoralhealthassessmentindex.Journalofdentaleducation.1990Nov1;54(11):680-7.

8. Guillemin F, Bombardier C, Beaton D. Cross-culturaladaptationofhealth-relatedqualityoflifemeasures: literature review and proposedguidelines.Journalofclinicalepidemiology.1993Dec1;46(12):1417-32.


28

9. AllisonP, LockerD, JokovicA, SladeG. A cross-cultural study of oral health values. Journal ofDentalresearch.1999Feb;78(2):643-9.

10. Corless IB, Nicholas PK, Nokes KM. Issues incross-culturalquality-of-liferesearch. JournalofNursingScholarship.2001Mar;33(1):15-20.

11. AtchisonKA.TheGeneralOralHealthAssessmentIndex (The Geriatric Oral Health AssessmentIndex).Chapter7.In:SladeGDed.Measuringoralhealthandqualityoflife.ChapelHill:Univer-sityofNorthCarolina,DentalEcology1997

12. Atchison KA, Der-Martirosian C, Gift HC.Components of self-reported oral health andgeneralhealthinracialandethnicgroups.JPublicHealthDent1998;58(4):301-8

13. WongMCM, Liu JKS, Lo ECM. Trans- lation andvalidation of the Chinese version of GOHAI. JPublicHealthDent2002;62(2):78-83

14. Tubert-JeanninS,RiordanPJ,Morel-PapernotA,PorcherayS, Saby-Collet S.Validationof anoralhealth quality of life index (GOHAI) in France.Com-munityDentOralEpidemiol2003;31:275-84

15. P i n z o n - P u l i d o S A , G i l - M o n t o y a J A .ValidaciondelındicedeValoraciondeSaludOralenGeriatrıaenunapoblaciongeriatricainstitucionalizada de Granada. Rev EspGeriatrGerontol. 1999;34:273-82.

16. Hagglin C, Berggren U, Lundgren JA. Swedishversion of the GOHAI index. Psychometricproperties and val idation. Swed Dent J . 2005;29:113-24.

17. OthmanWN,MuttalibKA,BakriR,DossJG,JaafarN,SallehNC,ChenS.Validationofthegeriatricoralhealth assessment index (GOHAI) in the Malaylanguage.Journalofpublichealthdentistry.2006Sep;66(3):199-204.

18. NaitoM,SuzukamoY,NakayamaT,HamajimaN,FukuharaS.Linguisticadaptationandvalidationof the General Oral Health Assessment Index(GOHAI) in an elderly Japanese population. J Public Health Dent. 2006;66:273-75.

19. HasselAJ,RolkoC,KokeU,LeisenJ,RammelsbergPA. German version of the GOHAI. Community Dent Oral Epidemiol. 2008;36:34-42.

20. Ergul S, Akar GC. Reliability and validity of theGeriatricOralHealthAssessmentIndexinTurkey.J GerontolNurs. 2008;34:33-9.

21. DaradkehS,KhaderYS.TranslationandvalidationoftheArabicversionoftheGeriatricOralHealthAssessment Index (GOHAI) . J O r a l S c i . 2008;50:453-59.

22. Sanchez-Garcıa, S., Heredia-Ponce, E., Juarez-Cedillo, T. , Gallegos-Carrillo, K. , Espinel-Bermudez, C., De La Fuente-Hernandez, J.,&Garcıa-Pena,C.(2010).Psychometric properties of the General Oral Health Assessment Index (GOHAI) and dental status of an elderly Mexican population. Journal of Public Health Dentistry, 70(4), 300–307.

23. MathurVP,JainV,PillaiRS,KalraS.TranslationandvalidationofHindiversionofGeriatricOralHealthAssessmentIndex.Gerodontol-ogy2013;

24. Rezaei, M., Rashedi, V., &KhedmatiMorasae, E.(2014).A Persian version of Geriatric Oral Health Assessment Index. Gerodontology, 33(3), 335–341

25. DeshmukhSP,RadkeUM.Retracted:TranslationandvalidationoftheHindiversionoftheGeriatricOral Health Assessment Index. Gerodontology.2012Jun;29(2):e1052-8.

26. Niesten D, Witter D, Bronkhorst E, Creugers N.ValidationofaDutchversionoftheGeriatricOralHealth Assessment Index (GOHAI-NL) in care-dependent and care-independent older people.BMCgeriatrics.2016Dec;16(1):53.

Corresponding Author: Dr. Sampada Suresh Kulkarni Postgraduatestudent, DepartmentofPublicHealthDentistry,CollegeofDentalSciences



29

Authors : Dr. Supritha.A.R¹, Dr. Supriya Manvi², Dr. Veena G C³

Abstract

Atrophied maxilla and hemimaxillectomy are a challenge to restore with a removable prosthesis. Under such

conditions,techniquessuchasbonegrafts,pterygomaxillaryimplantsandsinusliftproceduresareusedtoplacethe

endoesseousimplants.Sincetheseprocedureshavepost-operativecomplications,Zygomaimplantshaverisenasan

alternativetoatrophiedmaxilla.Thispaperreviewsdifferenttechniques,contra-indicationsandadvantagesofzygoma

implants.

Keywords: zygomaimplants,atrophiedmaxilla,boneaugmentation

IntroductionDental implants are designed to restore rudimentaryedentulous maxilla and mandible. The endosseousimplantsarepopularthesedaysforbothpartiallyandcompletely edentulous patients. Factors such aspneumatization of maxillary sinus,early tooth loss,periodontaldisease,trauma,pyorrhea,fractureleadstoa reduction in the volume of maxilla [1]. In implantprocedurestheminimumboneheightshouldbe10mm,elseitleadstobiomechanicalcomplications[2].Thesefactors avert endosseous implantation without bonegrafting/boneaugmentationprocedures.Itwasduringthisphase,newtechnologiessuchaspterygomaxillaryimplants, composite grafts, maxillary sinus grafts, LeFort I osteotomy, iliac crest grafts and distractionosteogenesis came into the picture to increase thevolume of the maxillary bone [Branemark et al] [1].However, these procedures caused severa linconveniences to the patients. It involved surgicalprocedures,extra-oralbonedonor,hospitalizationandrequiredmorehealingtime[3].

To overcome all these problems several studiesweredone.Theyfoundthatthecorticalpartofthezygomaticbonewasamoreviableoption[6].Consideringtheuseofzygomaticbone,zygomaimplantswereproposedforresorbed posterior maxilla, hemimaxillectomy and

1. Dr. Supritha.A.Rnd 2 yearUnderGraduatestudent

KLESInstituteofDentalSciences,Bengaluru. [email protected] Ph:9538724874

2. Dr. Supriya Manvi Professor&Head Dept.OfImplantologyKLESInstituteofDentalSciences Bengaluru. [email protected] Ph.9448145452

3. Dr. Veena G C Reader DeptofOMFS,KLEsInstituteofDentalSciences Bengaluru [email protected] Ph:9686684738

othersuchmaxillarydefects[2].Branemarkfoundanewtechnique as an alternative to dental implants andmaxillaryboneaugmentation,thatisZygoma�ixture[2]

Anatomy For Placement Of Zygoma Implants:The Zygoma is a horizontal bar on either side of theNormafrontalis,inpre-auricularregionslightlysuperiortotragus.Weischeretalfoundthatthezygomaisabettersupport for implants. Branemark researched on 12cadaversandfoundoutthattheapexofthezygomaticbone was 3.75mm whereas implantation required5.75mm,whichmay lead to infratemporal perforationdamaging the orbit. The risk of perforation can bereducedwhentheimplantisplacedatanangleof43.8ºintheverticaldirection[1].Hefoundthatcorticalpartofzygomaismorefavorablefortheimplant[Nkeneetal]

ZYGOMATIC FIXTURE:An alternative to maxillary rehabilitation.

30

Establishement Of Zygoma FixtureZygomaimplantsrequirestrans-sinusapproachinoralcavitytoreachthezygomaticbuttressarea[Bedrossianetal.andRossietal.]

For zygomatic �ixtures, commercially available self-tappingtitaniumscrewswithawell-equippedmachinesurfaces are used [2]. Internal hexagonal zygomaticimplants measuring 4X42.5mm titanium corticalscrews are used in the posterior region. Morse coneimplantswere used in the anterior regionmeasuring3.5x10mmmicrounit,withtheabutmentangledat30ºanda3mmcollar.TheMandrildiscisusedforrelatingthecomponentsontheimplants.3Dlaserscannerswereusedtocreateamodelofedentulousmaxillaincludingthe maxillary sinus [Nextengine HD, USA][4]. Themodelsweresavedinstereo-lithographyandimportedintothesoftwarewhichoneditingcreatedamodel.8such models were created to minimize possiblenumericalerrors.

Zygomatic Implant TechniquesThere are various techniques of zygoma implantplacements,outofwhichtheconventionaltechniqueismostaccepted.Theothertwotechniquesthathavebeen used are extra-sinus zygomatic placementtechniqueandthemodi�iedimplanttechnique.

Conventional Zygomatic Implant placement technique

Theprocedurecanbedonebylocalanesthesiaortocomfort thepatient total anesthesiaorneurolepticcan be given [Higuchi KW in Ann R Australas CollDentSurg.2000][2].Accordingtothisprocedure,a45º incision isdone fromthepremolararea in themaxillary crest between the base of zygoma andsinus. This incision is useful in cooling during thesurgicalprocedure[2].

Theentrypointplaysamajorrole.Iftheentrypointisthrough incisor or premolar path, the possibility forpenetration into the orbit increases. Whereas if theentry is through molars, the chances of damaginginfratemporal fossa increases, leading to hemorrhageandlackofOsseo-integration[2].

Modi�ied Zygomatic implant placement techniqueThe original concept promoted minimum of twoconventionimplantsintheanteriormaxilla.Accordingto [Vrielinick et al.][2], conventionalmethods requireboneaugmentation.Kahnbergetal.andKellesetal.intheir respective studies, presented a graft freeprocedurewithatrophicmaxillaanddefectedmaxilla.Inthistechniqueplacementofthreepositionisexplained.The two zygomatic implants should be symmetrical[Pareletal.][J.Prosthetdent.]

Themucosalmembraneofthesinusisclearedwheretheimplant should be placed. Implant placement takesplaceinthreeconvenientlocations.

I. Sharp twist drills are used to dry the posteriorpart �irst. In the secondmolars, the incision isdone by perforating the zygomatic bone. Sharptwistdrillsareused,elseitmayleadtobendingorfractureofzygomaticarch.

II. The middle aspect of the zygomatic bone isperforatedfromthepremolarregionthroughtheinfra-zygomaticcrest.

III. Throughthelateralnasalwall,thethirdimplantisplaced in the lateral incisor along the zygomaclosetothe�looroforbit.Crestalboneremovalissuggestedifthereisanyobstacle.

Sinus slot technique Acrestalmaxillaryincisionismadefromthetuberosityto contralateral tuberosity. Exposure is achieved bytraditionalLeFort I around the inferior regionof thepiriform rim, superior to the inferior aspect ofinfraorbitalnervesandonehalfofthezygomabody.


31

Extra-sinus zygomatic implant placement

The conventional procedures suggests intra-sinalapproachwhereintheoralmucosaofthesinushastobe maintained. Presence of buccal concavity inedentulous patients far from the alveolar crestresulted in heavy bridge connection. To avoid thisAparicioet al. in2010[2] stateshisexperienceandtechnique called extra-sinus protocol wherein theimplantwillbeatornearthetopofalveolarcrest.

Zygoma Implant, A Better ProcedureRatherthan�ixingtheimplantsintothealveolarbone,itis�ixedintothezygomaticbonethroughthepalatalaspect in the posterior maxilla without any bonegrafts.Zygomaimplantshavemanyusessuchaslesstreatment timeand lessmorbidityof thepatient. Itimprovesmastication, speech, aesthetic and overallimprovement of life[2]. The adaptation of thezygomaticboneduetosinusreactionismaintained.Iteliminates the need for donor site and treatmentfavors zygomal protocol. Zygoma implants reducepre-operatorriskcomparedtotraditionalmethodsofbone grafts. The potent and quick welfare of thisapproach is the ef�icacy to extend processesanchorageintothedistortedarea,thusreducingthecantileverforcesontheteeth.Zygomaimplantsoffereffective retention in anatomical areas, unlike boneaugmentation [2]. No acute sinusitis is observed.Importantly surgical time is also decreased ascomparedtoboneaugmentation[5].Zygomaimplantfailures are considerably less reported after a case

studyfor2years.

Patients' SatisfactionThe level of satisfaction after the rehabilitation wasobserved in contrast to that seen with boneaugmentation.Thestability,comfort,ability tospeak,self-cleaning,aesthetic,self-esteemandfunctionwerereportedtobebetter.

Zygomatic implant materialsThreedifferentImplantmaterialshavebeenusedI. MetallicimplantsII. CeramicandCeramiclike-implantsIII. Carbonandcarboncompoundimplants

I. Metallic Implants Metallicimplantsundergomanytreatments before�inalimplantationprocedure. Someofthetreatmentincludes:a) Passivation: It is to minimize ionization which

providesbiocompatibilityb) Anodization: the material is immersed in 40%

nitric acid.This is subjected to electric chargeswhich leads to deposition to oxide layerpreventingcorrosion.\

c) Texturing: the surface area is increased toenhancesuchcommunicationtotheunderlyingtissues, so that the stresses are equallydistributed.

Thetexturingprocedurealsoenhancescorrosion

resistance of the metal by the formation ofTitaniumNitride(TiN).

Popularly used metallic implants these days areTitanium, Titanium alloys and Calcium Phosphatecoatedmaterials.Titaniumhasmanydesirablephysicalpropertiessuchaslowdensity,highmodulusofrupture(�lexurestrength)comparedstainlesssteelalloysandcobalt, enhanced corrosion resistance. The mostregularly used Titanium product are grades 1-4 ofunalloyedTi,Titaniumalloy suchasTi-6-Al-7NbandTi6Al-4V.TheaddedfavorableusageofTitaniumisitsabilitytoformanoxidelayerofnanometerthicknesswithinmillisecondswhenitiserodedmechanically.

II. Ceramic And Ceramic-like Coated Implant System

Ceramic coatings are used along with metalimplants to enhance thermodynamic stability,


32

hydrophilic nature, insulation and to providehigh strength to bone and tissues. These arebrittle with low tensile strength, high elasticmodulus and low shear strength but canwithstandhighrangeofcompressivestrength.

III. Carbon And Carbon Compounds (C and SiC) Theyhavetheleastresponsetohosttissuesand

are one of the best biocompatible materials.Carbonismoreinertandhasmodulusstrengthsame as that of bone and dentine. But it issusceptibletofractureundertensilestress,sinceit isbrittle.Carbon-based biomaterials isusedforceramic-basedimplants.Sincetherearemanybiomaterials available, proper material isselectedbasedupontheindicationofthepatient,design, availabil ity, economy, � inishing,biomechanics,bonetypeandabutmentchoice.

Titanium is widely accepted since some of the

researchesbelievethatAluminiumandVandiumreleasestoxins.[7]

Prosthetic ProcedureThezygomaticimplantsareeitherunsupportedorofmore length. These two factors lead to horizontalbendingintheanteriorofthemaxilla.Whentherearetwo zygomatic implants it should be guided by tworidingconventionalimplantsontheanterioraspectofmaxilla.

Theprovisionalprosthesisisimportant.Theaimistoprovide satis�ied aesthetics, healing, speech,mastication.Theprostheticoptionshouldhavescrewretained structure so that implant can be removedduringanycomplication.Thesurgeonshouldprovideproper implant angulat ion as per opposi tedentition[13]

ContraindicationThe contraindications are mainly acute sinusitis,maxillary or zygoma pathology, malignant systemicdisease,sinus�loorcomplexity,narrowsinus,removalofdamagedmucosa fromantrumofhighmorecalledCaldwellLucoperation.

ComplicationsPost-operative complications: formationof oroantral�istula, peri-orbital hematoma edema, lip laceration,

pain and temporary paresthesia, epistaxis, gingivalin�lammation or orbital penetration or injury, peri-implantsofttissuesin�lammation.Dif�icultyinspeechwasalsonoted.[6]

Maxillary Sinus ComplicationsAcutesinusitisisobservedwithnasalobstructionperi-orbital edema with or without hyperemia, halitosiscausedduetopurulentsecretionfromnasalfossaeandfacialpain[14].

ConclusionThediseasedconditioncausedbythebonegraftinganddelay in bone incorporation lead to the evolution ofosseointegration.TheZygomaimplantconcept[14][3]favored stress distribution on bone tissues[4].Theinternal stress is reduced from the support of thealveolar bone to the zygomatic bone. The zygomaimplantshavebecomeanalternativetobonegrafts.Themost notable and instant use of the zygoma implantprocedure is the capacity to extend the prosthesisanchoragepointtotheabnormalareas,whichreducesthecantileverforces.Itprovidessuf�icientretentioninanatomicalareas[11].

Randamized control clinical trials are required to beconducteddespiteofhighsurvivalrates.Acomparativestudyalsoneedstobedonewithothertechniquestotreattheatrophicmaxilla.Zygomaimplantsdealwithsensitiveanatomicalstructuressuchas thebrainandorbit,thereforeitrequiredexperienceddoctors.

Reference 1. Shihab A.Romeed, Raheel Malik,Stephen M.

Dunne. Zygomatic Implants; The implant ofzygomabonesupportonbiomechanics.J.ofOralImplant.10.1563/AAID-JOI-D-11-00245.

2. A s h u s h a r m a , G . R . R a h u l . Z y g o m a t i cImplants/Fixture:A Systemic Review.J of OralImplant.10.1563/AAID-JOI-D-11-00055.

3. Dr.Prithviraj ,RIcha Vashist ,Harleen KaurBhalla.From maxilla to Zygoma:A view onzygomatic implant.J of Dental implant.Jan-Jun2014

4. PauloH.T.Almeida, SerigoH.Cacciacane,FabianaM.G.Franca.Stressesgeneratedbytwozygomaticimplant placement techniques associated withconventionalinclinedanteriorimplants.AnnalsofMedicineandSurgery.30(2018)22-27.


33

5. Eric .D.Ferrara, J ihn Stel la .Restoration ofedentulous maxilla:The case for the zygomaticimplants.J Oral Maxillofac Surg.62:1418-1422,2004.

6. A hmad M , G l e nn J .Wo l � i n g e r, S t e ph enF.Balshi.Zygomatic Implants as a rehabilitationAprroach for a severely De�icient Maxilla. TheInternational Journal of Oral & MaxillofacialImplants2014;29.10.11607/jomi.3662.

7. Anusavice,Shen,Rawls.Philips'sScienceofDentalMaterials.DentalImplants.Pg.543.

8. Gunaseelan Ranjan,Gowri Natarajarathinam,SaravanaKumar,HarinathParthsarthy.Fullmouthrehabilitation with zygomatic implants inp a t i en t s w i t h g ene ra l i z ed a g g re s s iveper iodont i t i s ; 2 year fo l low-up o f twocases.JournalofIndianSocietyofPeriodontology.September25,2019.

9. JoanPiUrgell,VeronicaRevillaGutierrez,CosmeGayEscoda.RehabilitationofArophiedmaxilla:Areviewof101zygomaticimplants.MedOralPatolOralCirBucal,2009jun1;(6):E36370.

10. Bruno Ramos Chrcanovic,Mauro HenriqueNogueira Guimaraes Abreu. .Survival andcomplication of zygomatic implants:A systemicreview.OralMaxillofacSurg(2013)17:81-93.

11. StephenM.Parel,Per-IngvarBranemark,Lars-OlofOhrnell ,Barbo Svensson.Remote.Implantanchorage for the rehanilitation of maxillarydefects.J.ofProsthetDent2001;86:377-81.

12. Milglioranca RM,Irschlinger AL,Penarrocha-Diago M,Fabris RR,Javier Aizcorbe-Vicente andZotrelli Filho IJ.Histroyof zygomatic implants:Asystematic review and meta-analysis.Dent OralCraniofacRes,2019,doi:10.1576/DOCR.1000289.

13. Carlos Aparicio and 7 authors,Zygomaticimplants:Indication, techniques and outcome ,and the Zygomatic Success Code.Article inPeriodontology2000.October2014.

14. P. P. T. A r a u j o , S . A . S o u s a , V. B . S . D i n i z z ,P . P . G o m e s , J . S . P . d a S i l v a a n dA.R.Germano.International Journal of ImplantDentistry.(2016)2:2.

Corresponding Author: Dr. Supritha.A.R

nd 2 yearUnderGraduatestudent KLESInstituteofDentalSciences,Bengaluru. [email protected] Ph:9538724874


34

Authors : Dr. Thanushree.H.M¹, Dr. Supriya. Manvi², Dr. Shruthi Eshwar³

Abstract : Chitosanisabiopolymerobtainedfromchitinthroughdeacetylationprocess.Itisthemajorcomponentsof

exoskeleton of crustaceans and insects. The versatility of chitosan application in various biomedical and

pharmaceutical�ieldsforapromisinghealthcarehasbeenseeninmanyclinicalstudiesconducted.Itsbiological

properties have been helpful in avoiding and treatment of chronic diseases. Its antimicrobial, non-toxic, bone

regenerative,haemostaticandwoundhealingactivity,anti-tumourpropertieshavebeenaboontobiomedical�ields.

Gingival

Keywords: chitosan, biopolymer, antimicrobial, non-toxic, bone regenerative, haemostatic, wound healing, anti-

tumour.

IntroductionChi t in i s one o f the most commonly foundpolysaccharideinecosystemafterCellulose.Thischitinisaconstituentofthehardouterskeletonofshell�ish,crab,lobster,shrimpandothercrustaceans.Itisalsoasigni�icantcomponentoffungicellwall.Chitinisalinerchainof2-acetoamido-2-deoxy-(beta)D-glucopyranosemonomers(�igure1)[1].

1.Dr. Thanushree.H.Mnd 2 yearstudent

KLESInstituteofDentalSciences,Bengaluru.

2. Dr. Supriya. Manvi ProfandHeadDept.OfImplantology,KLESInstituteofDental

Sciences,Bengaluru.

Versatility Of Chitosan In Dentistry

3. Dr. Shruthi Eshwar Reader,Dept.OfPublicHealthDentistry KLESInstituteofDentalSciences,Bengaluru.

Figure-1 Structure of chitin

Chitosanisapolysaccharidemadebydeacetylationof

theextractedchitin.Itconsistsof(1-4)linked2-amino-

2-deoxy-b-D-glucopyranose monomers. It has low

molecularweight.Oneofthestrongmethodsusedto

obtainchitosanisdeacetylationofchitinusingstrong

alkalinemedium.Thewasteproductsofcrab,shrimp

canningindustriesarethenaturalresourcesforchitin

andchitosan.Thecrustaceanshellsinvolvetheremoval

of proteins and dissolution of CaCo3,the resulting

chitin isdeacetylated in40%NaoHat120°C for1-3

hours. Thus treatment produces 70% deacetylated

Chitosan(�igure2).

Figure - 2 Structure of Chitosan

35

Figure - 3 Structural comparison of Chitin, Chitosan, Cellulose.

Synthesis Of ChitosanTheelementalcompositionofthechitosanpolymeriscarbon(44.11%),hydrogen(6.84%)andnitrogen(7.97%).Due to their high percentage of nitrogencompared to synthetically substituted cellulose(1.25%), they are of commercialinterest.Itis auniquelinearpolycationwithahighchargedensity,reactive hydroxyl and amino groups as well asexcessive hydrogen bonding.It can be isolatednatural ly from the cel l wal l of fungi , butcommercially it is prepared from chitin. Chitin iswhite, hard, inelastic, high molecular weightcrystalline polysaccharide extracted from shrimpand crab shells. At least 10 giga tons (1013kg) ofchitinaresynthesizedanddegradedeachyearinthebiosphere. Chitin is deacetylated by using sodiumhydroxide in excess as a reagent and water as asolventtoformchitosan.ThecommerciallyavailableCSis66%to95%deacetylatedandithasanaveragemolecular weight ranging between 3800-20,000Daltons[27].

The degree of deacetylation is determined by thecontentoffreeaminogroupsinthepolysaccharidesand used to differentiate between chitin andChitosan. Chitosan can be characterized physico-chemicallybydeterminingdegreeofdeacetylation,molecularweight, solubility, viscosity, crystallinity,andphysicalforms.

BiologicalApplicationsOfChitosan1. Biocompatiblenaturalpolymer:safeandnon-

toxic,easilybiodegradable.2. Itisanti-bacterial,anti-fungal,anti-viral,anti-

in�lammatory.3. Helpsinhaemostasis.4. Abilitytoregeneratetissues.5. By increasing osteoblasis, it helps in bone

formation6. Itisanti-tumor.7. Actsasaspermicidal.8. Immunoadjuvant.9. Anticholesteremic.10. Livefunctionregulations.11. BloodpressureRegulation.

General Applications Of Chitosan

Applications In Dentistry


36

Uses In DentistryToothPaste,ChewingGumsAndMouthWashes

Chitosan has ant cariogenic effect when used intoothpastes , chewing gums andmouthwashes, andincreasesthesalivarysecretionand�low.Thisinhibitsthe formation of plaque upto 80%(18,19).Severaltoothpastes are currently being used as potentialmeans of oral hygiene products. In a study (20) theextractsofPterocarpusmarsupium,SteviarebaudianaandGlycyrrhizaglabrapossessantimicrobialactivity,with chitosan acting as a therapeutic agent,gellingagent in toothpastereducesplaque indexby70.47%andbacterialcountby87.29%,helpinginmaintaininggoodoralhygiene.

Streptococcusmutanscolonizationisinhibitedbythechitosan containing chewing gums.One of the studysuggests that with increase salivary secretion thenumberofbacterialcolonizationwasless(21).

When chitosan is used in mouthwashes it showsantibacterialandeffectivenessinreductionofplaqueaccumulation.

Butduetoitsinsolubilityinwateritsuseasachemicalagentintoothpastesandmouthwashesis�inite.

Operative DentistryAstudysaysthatafterrootcanalinstrumentationusingchitosan to remove smear layer has positive results(23)byscanningelectronmicroscopy.15%EDTAand0.2%chitosanshowedmarginaldifferenceinthestudyasachelatingagentcomparedto10%citricacidand1%aceticacid.

AnotherapplicationofChitosanisinatraditionalglassionomer cement (TGIC) which can be used fortreatmentofpulp.NanoparticlesofchitosanareaddedtoTGICwhichmakeithighlyresistanttobendingandwearingthannormalTGIC.Themechanicalpropertiesareimprovedwithantcariogeniceffectbythereleaseof �luoridemuch signi�icantly greater than TGIC(24)thus chitosan in regenerative endodontics helps inbuildingafriendlyrestorativematerial.

Adhesion And Dentine BondingImproved effects are observed when chitosanantioxidant gel is used on dentin by increasing the

bonding of composite resins. In a study ,shear bondvalues of Chitosan-H, Chitosan- propolis, Chitosan-nystatintreateddentinishigherthanphosphoricacidtreatedornottreateddentin(25).

Chitosan with high viscosity acts as a good dentureadhesiveincompletedenturesbyimprovingpropertieslikeretensionandmasticatorypropertyofthedenture.

Haemostasis And PulpotomyMassive bleeding can be arrested by using Chitosan.CeloxisahemostaticagentconsistingChitosan(6).Inconditions of Normothermia, Hypothermia, it can beusedforhemorrhagecontroleffectively.Itcanalsobeused as a replacement for warfarin as a oralanticoagulant (12). It works by entering into directinteraction with RBCs and thrombocytes forming acrosslinked polymer clot barrier. It is also used ashemostaticagentforpulpotomyofdeciduousteeth.

Sterile saline and diluted chitosan is applied to pulpchamberwhichhelpsinremovalofcoronalpulpandisleft for 15-20 seconds for hemostasis to occur.Formationofreparativedentineandhardtissuecanbeobservedwithchitosanapplication[4,14].

Bone Regenaration

Forbonerepairandregenerationhasbeenancenterofinterest for bone tissue engineering. Compositematerialslikechitinandchitosanareusedinthe�ieldofbone tissue engineering. Bone extracellular matrixconsistsofglycosaminoglycanwhich is similar to thestructure of chitosan. The positive surface charge ofchitosanhasdirecteffectondifferentiationsynthesisandadhesionofthecelltothesurface[7,8].Intheapicalandmiddlethirdofthetoothsocketafterextractionofpre molar showed increased bone density whenchitosanwasused[9].

Medication s like freeze-dried methylpyrrolidinonechitosan. Desirable mechanical and physiologicalcharacteristics of chitosan were observed afterextractionspacebeing�illedbynewbonetissueduetoosteogenesis.[10]Recentlyanotherstudy[11]saysthata new treatment protocol for Medication RelatedOsteonecrosisoftheJaw[MRONJ]byadministrationofhuman parathyroid hormone (Htph) loaded withchitosan microspheres synthesized by ionotropic


37

gelationhaspositiveoutcomeofthetreatmentstrategy.

Implant DentistryPeriimplantitisisde�inedasin�lammatoryactionofthetissue around the dental implant due to loss ofsupporting bone is still a challenge for implantdentistry.Theinterfacebetweenimplantandahealthysofttissueissimilartotheoneinvolvingnaturalnaturalteeth[15].Titaniumhasremarkablepropertiesandisideal as an implantbut it doesn'thaveantimicrobialproperties.

Surfacemodi�icationoftitaniumwithchitosancoatingcan help in bone-cell attachment in�lammatoryimmunological defenses, growth factor and cytokineproduction, wound healing, stabilizing the implant[16].InastudyTi6A14Bplatescoatedwithchitosanwasfabricated[17].Thisreducedstressconcentrationarea, compactablitic between implant surface andalveolarbone.

ConclusionChitosanbeingaboon todentistry isuseful forbothtooth and overall oral hygiene. It has emerged as arenewable, biocompatible non toxic polymer. Theabovestudyhenceconcludestheversatilityofchitosaninvariousbranchesofdentistry.

Bibliography 1. DuttaPK,DuttaJ,TripathiVS.ChitinandChitosan.

chemistry and applications. J science Ind Res.2904;63:20-31

2. LiQ,DunnET,GrandmaisonEWandGoosenMFA.Applications ans Properties of Chitosan.TechnomicPublishingcompany,Lancaster.1997,PP3-29.

3. Muzzarelli RAA. Some modi�ied Chitosan andtheir niche applications, chitin handbook.EuropeanchitinsocietyItaly.1997,PP47-52.

4. Rihaudo M chitin and Chitosan. Properties andapplications.Programpolym2006;31:603-32.

5. HiranoS.N-acetyl,N-arylideneandN-alkylideneChitosan and their hydrogels chitin handbook.EditedbyRAAMuzzarelliandMGPeter.1997,PP71-76.

6. Pizza M and Millner R W Celox (Chitosan) forhaemostasis in massive traumatic bleeding:experience in Afghanistan. Eur J Emerg Med2011;18;31-3.

7. Hurt AP, Getti G, Coleman NJ. Bioactivity andBiocompatibility of a Chitosan tobermoritecomposite membrane for guided t issueregeneration.IntJbiolmacromol.2014;64;11-6.

8. CheungRL,NgTB,Wong JH, et al. Chitosan:Anu p d a t e o n p o t e n t i a l b i omed i c a l a n dpharmaceutical applications Mar drugs.2015;13:S156-86.

9. FatemehEzoddini,Ardakini,AlirezaNavabAzam,Soghra Yassaiv, Farhand Fatehi. Health 3(04),200,2011.

10. MuzzarelliRA1,BiaginiG,BellardiniM,SimonelliL , Cas ta ld in i C , Fra t to G .B iomater ia l s .Osteoconductionexertedbymethylpyrrolidinonechitosan used in dental surgery.1993;14(1):39-43.

11. The ef�icacy of sustained-release chitosanmicrospheres containing recombinant humanparathyroid hormone on MRONJ.Braz. oral res.vol.33SaoPaulo2019EpubAug29,2019.

12. Koksal O1, Ozdemir F, Cam Etoz B, IşbilBuyukcoşkunN, SıgırlıD.Hemostatic effectof achitosan linear polymer (Celox®) in a severefemoral artery bleeding rat model underhypothermia or warfarin therapy.Ulus TravmaAcilCerrahiDerg.2011May;17(3):199-204.

13. Begum Erpacal Ozkan Adiguzel, Susan Cangul,Musa Acarturk. A general overview of Chitosanandit'suseindentistry.Winter2019,Vol,no1.

14. Delikan E. Hemostatic agents for pulpotomytreatment. Yedi yepe klinik. 2018;14:109-106.[ArticleinTurkish].

15. HLMyshin, I. P, Wins. Journal of ProsthodonticDentistry. 94(2005),440-444,doi: 10.1016/jprosdent-2005.08.021.

16. P.Schupbach,R.Glauser,JournalofProsthodonticDentistry, 97(2007), 15-25, doi: 1016/S0022-3913(07)60004-3.

17. Ulku Tugba Kalyoncuoglu, Bengi Yilmaz, SerapGungor,ZaferEvis,PembegulUyar,GulcinAkea,Gulay Kansu:Evaluation of the chitosan coatingeffectivenessonadentaltitaniumalloyintermsofmicrobial and �ibroblastic attachment and theeffectofageing:doi:10.17222/mit2014.238.

18. YildirimZ,OnculN, YildirimM. Chitosan and itsantimicrobial properties. Omer HalisdemirU n i v e r s i t y J o u r n a l o f E n g i n e e r i n gSciences.2016;5:19.36[ArticleinTurkish].


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19. STMandSAEvaluationoftheeffectsofvariousgums on o ra l and den ta l hea l th . Ac taOdontologica Turcica.2015;32:42-6.20.Nittin CMohire, Adhikroa V Yadav: Chitosan-basedpolyherbal toothpaste as novel oral hygieneproduct;IndianJournalofDentalResearch;vol21,Issue3,2010,pp380-384.

21. Y.Hayashi,NOhara,TGanno,H Ishizaki, chitosancontaininggumchewingacceleratesantibacteriale ff e c t w i t h a n i n c r e a s e i n s a l i v a r ysecretion:Vol35;Issue11,2007,pp871-874.

22. FujiwaraM,HayashiY,OharaNInhibitoryeffectofwa t e r s o l ub l e c h i t o s an on g row th o fS t r e p t o c o c c u s m u t a n s .NewMicrobiol.2004;27:83-6.

23. PVSilva,DFCGuedes,FVNakadi;JDPecora,AMCruzFilho.Chitosan:anewsolutionforremovalofsmearlayerafterrootcanal instrumentation.doi.10.1111.j.1363-2591.2012.02119.x.

24. Kumar S R,Ravikumar N, Kavitha S,et .al .Nanochitosan modi�ied glass ionomer cementwith enhanced mechanical properties and� l uo r ide re l e a se . I n t J B i o l Mac romo l2017;104:1860-5.

25. PerchyonokVT,ZhangS,GroblerSR,etal.Insightsintoandrelativeeffectofchitosan-H,chitosan-H-propolis,chitosan-H-propolis-nystatin andch i to s an -H -nys t a t i n on den t i ne bondstrength.EurJDent2013;7:412-8.

26. J I A Hong-Cheng,Ll Xiang-bin,ZHEN Lei,WANGXing-qiang:Astudyontheabilityofchitosanwithhighviscositytoserveasdentureadhesive;2004-03.

27. Agarwal,Megha&Agarwal,Mukesh&Shrivastav,Nalini&Pandey,Sarika&Gaur,Priyanka.(2018).ASimpleandEffectiveMethodforPreparationofChitosan from Chitin. International Journal ofLife-Sciences Scienti�ic Research. 4. 1721-1728.10.21276/ijlssr.2018.4.2.18.

Corresponding Author: Dr. Thanushree.H.M

nd 2 yearstudent KLESInstituteofDentalSciences,Bengaluru.


39

Authors : Dr. Srishti Samanta¹, Dr. Moumita Chakraborty², Dr. Supriya Manvi³

Abstract

TrefoilsystemisbasedupontheBranemarkNovumtechnique,developedbyprofessorBranemark,thefatherof

modernimplantdentistry.Thetrefoilsystemisabreakthroughinef�iciencyfortreatingthemandible.Ithascome

intoexistenceduetoproblemsfacedbysomeoftheremovablepartialdenture.Becauseofsomedrawbacksinallin

the4/6/8concept,thistrefoilconceptcameintoexistence.Theonesbasedontheformerareexpensive,invasiveness

andrequirealongerchairsidetime.Itsframeworkincludesanextendedarch,clinicalscrew,screwdisc,framework

discsandroundabutment.Thereforetoconcludethetrefoilsystemshowsimprovedqualityoflifeevenwithlow

marginalbonelevel.Sothistrefoilsystemisnotmeanttoreplacethepreviousimplanttechnologiesbuttoprovidea

betterlifewithcomparativelylessproblemsandimprovedqualityoflife.

Keywords: Trefoil,Implant,framework.

IntroductionFormanypatients,beingedentulousmustberegardedas a handicap with respect to oral function andpsychosocialimpactonqualityoflife.

Patientwearingremovablepartialdenturemayhavelotof problems especially inmandibular ridge problemslikelossofretention,ulceration,lossofarti�icialteeth,looseningofdentureandstomatitisetc.

Therefore, �ixed prosthesis like implant can achievegoodclinicalresults.

Implant offers many practical advantages overconventional complete denture and removal partialdentures: These includes decreased bone resorption,reduced prosthesis movement, better esthetics,improved tooth position, better occlusion, increasedocclusal function and maintenance of the occlusalverticaldimension.

1. Ms. Srishti Samanta nd 2 yearUnderGraduatestudent

KLESInstituteofDentalSciencesBengaluru. Email:[email protected] Phoneno.–7073690936

2. Dr. Moumita Chakraborty PostGraduatestudent Dept.OfProsthodontics,KLESInstituteofDentalSciences

Bengaluru. Email:[email protected] Phoneno.-9591677675

3. Dr. Supriya Manvi Prof&Head Dept.OfImplantology KLESInstituteofDentalSciences,Bengaluru. Email:[email protected] Phoneno.-9448145452

Assomepatientswillhaveresorbedridgeswheresome�ixed prosthesis like implant [all-on-4/6/8] will haveproblemsinpassive�it.Somedrawbackswhichpatientmayfaceare:Ÿ ItwillbeexpensiveŸ EffectonanatomicallandmarksŸ InvasivenessŸ Morechairsidetimeandrestorativework

Therefore, to avoid this short coming, trefoil systemprovidesaprobablesolution.

The trefoil system is a breakthrough in ef�iciency fortreating the mandible. Three ways the trefoil system

Fig:1

Trefoil Concept – Revolutionary Application For Edentulous Mandibular Patients

40




reducesthechairtime–Ÿ Pre manufactured de�initive bar with an acrylic

prosthesis.Ÿ Astraightforwardprostheticwork�low.Ÿ Reduced re s tora t ive component s due to

compensationmechanism.

History:PALO MALO was the �irst person to suggest �ixedprosthesisforedentulousmandiblepatient.HewastheinventorofAll-on-4concept.

Later,PIBRANEMARKcreatorofmoderndentalimplantin1990's,inventedthe3-implantsystemwhichhasitssurvivalrateof95%ormore.

Moreutilizationofthisproductwasseenbetween1998-2007, though it has 20% complication rate withtitaniumbar.

Diameterof the3-implant system is5.0mmdiameterwhereas4.3mmisthediameterofAll-on-4.

AccordingtoPaloMalo,thenumberofimplantsdoesnotmake an impact, instead the size of implants isimportant.Hesaid“[Hypothetically]youcouldsupportan entire mandibular arch of teeth with a one 1cmimplant”.[2]

Initially,whilethinkingaboutthethousandsofpatientsaroundtheworldBranemarkmighthavereckonedthat“ifthistrefoilismadeaffordableandreducedchairsidetime,itwouldbene�itthem.”Hence,BranemarkreferredNovumas“ChinaBridge”.[3]

Latest ConceptsTrefoil system is based upon the Branemark Novumtechnique, developed by professor Branemark, thefatherofmodernimplantdentistry.

ItincorporatesmanyofthesamesurgicalstepsastheoriginalNovumprotocol,buttheprostheticaspectisanhighlyevolvedimprovementoftheoriginalapproach.

Here the trefoil surgical guide has been used for'positioningtemplate'forthecentralimplant.

The pre-manufactured titanium bar simpli�ies thecreationof thede�initive acrylic prosthesis and savessubstantial time for the restorative clinician and the

dental lab. The pre-manufactured framework,anatomically designed for the natural arch of themandible, contains adaptive joints that adjust tocompensate for horizontal, vertical and angulardeviations from the ideal implantpositionandenablethepassive�itofthede�initiveprosthesis.

ThetrefoilVtemplateisusedforthedistalimplant.

ASpeciallydesignedconicalconnectionimplantsisusedforthetrefoilsystem.

SDAconceptcanbeusedintrefoil.Thecurrentcriteriaare-Ÿ AbsenceofpathologicalmanifestationŸ SatisfactoryfunctionŸ VariabilityinformandfunctionŸ Adaptivecapacitytochanging[4]

Pre-requisiteTherearesomerequirementswhicharerequiredforaproper and successful �ixed prosthesis specially thistrefoilsystem.Theyareasfollows:Ÿ Suf�icientamountorheightofboneshouldbepresent

i.e.approx.minimumheightof13mmandminimumwidthof6-7mm.[5]

Ÿ Themouth should open up to a certain height i.e.minimumof40mmforeasyaccessworking.[5]

Forreducedverticalbone:Trefoilheightrequirement[6]Ÿ Theminimumdistancerequiredfrombone level to

maxillaryocclusionplane–22mm

Ÿ Tissueheight–3mmŸ Acrylicintaglio–2mmŸ Lingualtoothheight–3mm

Framework And Dimentions:

1.ImplantDesignFeatures[5]


41

TECHNOLOGICAL CHARACTERISTICS TREFOIL SYSTEM

Implant body design Parallel walled

Implant tip design 3.8mm apex w/9.5 degree angle Tapered self-cutting

Implant length 16.0 mm overall (11.5mm body w/4.5mm collar) 17.5mm overall (11.5mm body w/6.0mm collar)

Implant diameter 4.93 mm

Platform diameter 4.5 mm

Thread angle/pitch 60 degree/ 0.8 mm

Connection type Internal hex with snap feature

Device material CP titanium

Surface modification TiUnite (anodic oxidation)

TREFOIL implant (internal conical

TECHNOLOGICAL CHARACTERISTICS TREFOIL SYSTEM

Bar design Preshaped single piece design screw retained to implant.

Intended platform connection with snap fit)

Materials Titanium vanadium alloy

Surface modifications Machined titanium

Compensation mechanism framework and screw disks. Round abutment and corresponding

Prosthetic media Acrylic

Fixed cantilever length 18.8 mm

2.BarDesignFeatures[5]

3.SurgicalToolingType[5]

A)Drill

TECHNOLOGICAL CHARACTERISTICS

TREFOIL SYSTEM

Diameter 2.0, 3.0, 3.8, 4.0, 4.2, 4.4 mm

Flute length 16.0 mm (including tip)

Material Stainless steel

Markings All drills marked at 11.5mm and 13.5mm

Flute design Two flutes

Tip design 90 degree2mm) 130 degree (3.0, 3.8, 4.0, 4.2, 4.4 mm)

Intended use The drills are used together with corresponding templates for drill in the preparation of implant sites.


TREFOIL SYSTEM

Flute length 17.0mm

Diameter 5.0mm

Materials Stainless steel

Intended use The screw tap is used when dense bone is present to prepare for the threaded implant


TREFOIL SYSTEM

Core diameter 1.8

Length 14.0mm (to stop) 19.3 mm (overall)

Materials Stainless steel

Intended use The stabilizing screw is used to temporarily connect the V-template to the alveolar ridge.

b)SCREWTAP

c)STABILISINGSCREW

More About Trefoil:Theintentionofthistrefoilsystemisnottoreplacetheexistingimplantprocedures,rathertogivethepatientamoreaffordable,comfortablealternative.

Primarily, a 3D CT scan is done, with preciseradiographic planning, and thenBranemark's originalguidedsurgeryisperformed.It includesseveralsteps,likeincrementallypreparingthesitesandthenplacingthe three specially designed implants in preplannedpositioninanteriormandible[7].

Thetrefoilstructure isprefabricated intitaniumalloy.With advanced technology, this structure has themechanism to allow passive �it in an individual. ThisredesignedbarisstrongerthanthatofCAD/CAMusedincurrentAll-on-4.

Arecentstudyshowsthattherangeofpassive�itandthemechanicalperformanceisdeterminedbyitsadaptivejoints.


42

Advantages:The trefoil system has come into existence due toproblems faced by some of the removable partialdenture patients, so keeping in mind the above-mentioned problems, the advantages of this newconceptare:-1. Easily affordable: Due to less involvement of

prosthodonticsand labstages,andsinceonly3implants are used, in comparisonwith all-on-4conceptitislessexpensive.

2. Reducedchair time:Thewholeproceduretakesaround4-6hrsi.e.Prosthodontist–1hr.,surgery–2hr.,laboratorywork–2hr.

3. De�initive teeth in one day: This trefoil systemprovidesade�initivetoothinonedaythatallowsimmediatefunction.[1]

4. Massiveboneloss:Thistrefoilsystemprovidesasolution for all thosewhohaveamassiveboneresorption.

5. Fastrecoverytime:Manyatimesafterthesetypeofsurgeriestheonlyworrythatapatienthasisabouttherecoverytime.Butsincebiocompatiblematerialsareused,therecoverytimeisless.

6. Ithasbetterretentionascomparedtoremovabledentures.

7. Ithasagreaterstabilitythantheremovaldentureswhichtendtofallincertainconditions.

8. Ithasahigherbiteforce9. It has the capacity to restore a life of a fully

edentulousmandible.

Disadvantages:Followingarethedisadvantagesofthetrefoilsystem:1. Itmaycausemucosalproblems.2. Wearofcomponentsofthetrefoilsystem.3. Duetoinvolvementofsurgery,manypeopleresist

thistreatmentoutoffear.4. Itincludesonlylowerjaw.

Precautions:Somepointsarekepttobeinmindbeforeplacingthistrefoiltoavoidfailuredentition:Ÿ Implants to be inserted in mandible, should be

minimum of 5mm diameter and 11.5- 13 mmlength.[6]

Ÿ Skeletal jaw relationship should be recordedappropriately.[6]

Ÿ Topreventinterferencewithmentalnerveanatomy,thereshouldbesuf�icientspacebetweentwomentalforamens.[6]

Ÿ Maxillary arch should have proper plane ofocclusion.[6]

Ÿ Dentalimplantcontraindicationsarenotavailableinstandardizedform.[6]

Eventheskeletalcriteriaarealsokeptinmind:[6]

SkeletalclassI:idealforthistypeofsurgery.SkeletalclassII:canbedonewithlittlecorrections.Skeletal class III: complicated, hence should be doneverycautiously.

Procedure:1. Centralimplantsiteisprepared.2. The central implant is inserted using the

positioningtemplate.3. Thecentralimplantisinposition.4. AllthreetrefoilimplantsCCRPwith4.5mmcollar

areinplace.5. The transfer abutments are placed to construct

theveri�icationindex.Thetransferabutmentsarelutedwithlight-curedresinto�ixtheveri�icationindex.

Conclusion:Accordingtoreports,thetrefoilsystemshowsimprovedqualityoflifeevenwithlowmarginalbonelevelchange.So,wecanconcludebysayingthatthistrefoilsystemisnotmeanttoreplacethepreviousimplanttechnologies,but an alternative that can provide a better life withcomparatively less problems and improved quality oflife.[9]


43

References:1. Higuchi K, Davo R, Liddelow G, Albanese M,

Riveros N, Baden S, Rosenberg R. An adaptiveprefabricated full-arch framework on threeimplants in the mandible: preliminary results.ClinOralImplantsRes.2017Oct5;28:169.

2. BranemarkPI,HanssonBO,AdellR,etal.Osseointegrated implants in the treatment of theedentulous jaw: experience from a 10-yearperiod. .1977;Scand J Plast Reconstr Surg Suppl16:1–132.

3. HiguchiK. et al. An adaptive prefabricated full-arch framework on three implants in themandible- preliminary results. Oral posterpresentationacceptedtobepresentedatthe26thAnnual Scienti�ic Meeting of the EuropeanAssociation for Osseointegration. Saturday 7thOctober,2017.IFEMAFeriadeMadrid,Spain.

4. KariM,CarrettaR,HiguchiKW.Passivityof�itofanovel Prefabricated Implant-SupportedMandibular ful l -arch Reconstruction: AComparative In Vitro Study. The Internationaljournalofprosthodontics.2018;31(5):440-2

5. Chung S, McCullagh A, Irinakis T. Immediateloading in the maxillary arch: evidence-basedguidelines to improve success rates: a review.Journal of Oral Implantology. 2011 Oct;37(5):610-21.

6. K, Liddelow G. An Innovative Implant-HiguchiSupported Treatment for the EdentulousMandible: CaseReport. International Journal ofOral&Maxillofacialimplants.2019Mar1;34(2)

7. HiguchiK. et al. An adaptive prefabricated full-arch framework on three implants in themandible- preliminary results. Oral posterpresentationacceptedtobepresentedatthe26thAnnual Scienti�ic Meeting of the EuropeanAssociation for Osseointegration. Saturday 7thOctober,2017.IFEMAFeriadeMadrid,Spain.

8. TribstJP,deMoraisDC,AlonsoAA,DalPivaAM,BorgesAL. Comparative tree-dimensional �initeelement analysis of implant -supported �ixedcomplete arch mandibular prostheses in twoma t e r i a l s . T h e J o u rna l o f t h e I nd i anProsthodonticssociety.2017July;17(3):255

9. HiguchiK,DavoR,LiddelowG,etal.Anadaptiveprefabricated full-arch framework on threeimplants in themandible: preliminary results.ClinOralImplantsRes2017;28(Suppl)

Clinicaltrials.gov. the TREFOIL Concept 5 YearCl inical Invest igat ion (NCT02940353).https://clinicaltrials.gov/show/NCT02940353.

Correspondence Address : Ms. Srishti Samanta

nd 2 yearUnderGraduatestudent KLESInstituteofDentalSciencesBengaluru. Email:[email protected] Phoneno.–7073690936


44

https://www.implantsource.us/trefoil

https://clinicaltrials.gov/show/NCT02940353


Authors : Dr. M. Sunitha Roy¹, Dr. Soudhamini.V. Rao², Dr. Lakshmipathi Reddy.P³

Abstract

Making of impression for traditional crown and-bridge restorations utilizingmaterials like polyvinylsiloxane or

polyetherhasbeenthestandard.Buttheseimpressionsarenotdevoidofinaccuracies,thuswerequireamoreaccurate

methodofreplicatingthetoothpreparationsforcrownsandbridges.Thecontinuoussearchforbettermentofthe

impressionmakingprocedurehasledtotheevolutionofthestateoftheartdigitalimpressiontechniquewhichhas

causedaparadigmshiftintheconceptofmakingdentalimpressions. Thevariousresearcheshavebeenproviding

positiveresultsandannouncingthedigitalimpressiontechnologytobeverypromising.Thus,thedigitalimpressions

canbecomeoneofthemostpowerfulandimportantstandardsinprovidingsuperior�ixedrestorationsindentistry.

Keywords:Digitalimpressiondevices,Parallelconfocalimaging,Activewavefrontsampling,scanningprobe.

IntroductionMakinga�ixedpartialimpressionisprobablythemostcritical step for dentists in the process of creating asuperior prosthetic restoration. A perfect impressionneedstodeliveranexactreplicaoftheclinicalsituationincludingacompletevoidfree,andaccuratere�lectionof

1themargins,ideallyonthe�irsttake .

Though we have the access to a wide range ofimpression materials, which meets virtually all therequirements and preferences, even the mostexperienced dentists can encounter dif�iculties inobtainingapreciseimpression.

Impressions for �ixed prostheses have always been achallenge for both the clinician and the dental labtechnician because of the wide range of variablesinvolved.

Clinicalproblems thatnegatively impactconventional1,2,3impressionsinclude.

1. Incomplete reproduction of the preparedmargins.

1. Dr. M. Sunitha Roy. MDS Assistantprofessor,DepartmentofProsthodontics,K.L.E.

InstituteofDentalSciences,Bangalore,Karnatakastate,India

2. Dr. Soudhamini.V. Rao, MDS Assistantprofessor,DepartmentofProsthodontics, K.L.E.InstituteofDentalSciences,Bangalore,Karnataka

state,India.

Digital impressions, not a science �iction anymore!

2. Inadequate tissue management, which fails toproperlyisolatethemargins.

3. Voidsinthemarginsoftheimpression.4. Tearingofthemargins.5. Lightbodyimpressionmaterialbeingdisplaced

by putty material resulting in loss of sharpsurfacedetail.

6. Distortionofimpressionfrompatientmovement&/orremovalofimpressionpriortothoroughset.

7. Poorbondbetweentrayandimpressionorputtyandlightbodymaterial.

8. Dentalstonecastsdiscrepancies.

We are in the age where patients are extremelyconcerned about the time and money spent on theaestheticdentaltreatmentsandtheyaskforthebestofthe material and technology. Even though we canprovide fairly acceptable restorations to theaesthetically demanding patients using conventionalimpressionprocedures,timefactoralsoplayacrucialfactorforpatientswithhecticschedule.

Fortunatelyourworldofdentistryhasbeenintroduced

3. Dr. Lakshmipathi Reddy.PMDS Assistantprofessor,DepartmentofProsthodontics, K.L.E.InstituteofDentalSciences,Bangalore,Karnataka

state,India.

45

toanewdigital impressioningtechnology,whichwasvirtualhasnowbecomeareality.

The technologies that have made the use of three-dimensional (3D) digital scanners an integral part ofmanyindustriesfordecadeshavebeenimprovedandre�ined for application in dentistry. Since theintroduction of the �irst dental impressioning digitalscanner in the 1980s, development engineers at anumberofcompanieshaveenhancedthetechnologiesand created in-of�ice scanners that are increasinglyuser-friendly and able to produce precisely �itting

4dentalrestorations.

Thedigitalimpressionconceptisemergingrapidlyonthe high-tech horizon. Some optimistic proponentsinferthatdigitalimpressionswillsolvethechallengesnowfacedwithconventionalelastomericimpressions.

Commerciallyavailabledigitalimpressiondevicesare:The iTero (Cadent, Carlstadt, N.J.) and the LavaChairsideOralScannerC.O.S.(3MESPE,St.Paul,Minn.).

Additionally, themanufacturers of computer-directed

in-of�icemillingsystemsCEREC(SironaDentalSystems,

Charlotte, N.C.) and the new E4D system (D4DTechnologies, Richardson, Texas) are working to

providedigital impressionsthatcanbesent todental5,6

laboratories.

This article reviews the revolutionary digitalimpressiontechnology,thetechniqueofmakingdigitalimpressionanditsprosandconsincomparisontotheconventionalimpressiontechnique.

Digital impression technology:Thistechnologyisbasedonalaserscanningprotocolwhichallowsthedentisttotakeelectronicimpressionsintraorally.

The laser scanning technology presently used in7

dentistryforintraoralscanningare :1. Parallelconfocalimaging.2. Activewavefrontsampling.

1. Parallel confocal imaging (E.g. iTero (Cadent, 7Carlstadt, N.J) : (Fig 1)

Parallel confocal imaginguses laserandopticalscanning to digitally capture the surface andcontoursofthetoothandthegingivalstructure.Thistypeofscannercaptures100,000pointsof

red laser light and has perfect focus images ofmorethan300focaldepthsofthetoothstructure.All of these focal depth images are spacedapproximately 50 μm apart. Parallel confocalscanning system captures all structures andmaterials found in the oral cavity without theneedforscanningpowdersthatcoattheteeth.

Whiletheabilityofthecameratoscanwithouttheneed for powdering may be advantageous, itnecessitatestheinclusionofacolourwheelintotheacquisitionunit itself, resulting inacamerawith a larger scanner head than the othersystems.

2. Active wave front sampling (E.g . Lava 7

C.O.S) :(Fig 2) Themethodused for capturing3D impressions

involves Active Wave front Sampling. Thistechnology is based on the concept of “3D inMotion”whichincorporatesrevolutionaryopticaldesign, image processing algorithms, and real-timemodelreconstructiontocapture3Ddatainavideosequenceandmodelthedatainrealtime.The scanningwand contains a complex opticalsystem comprised of multiple lenses and blueLED cells. Thus, it is capable of capturingapproximately 20 3D data sets per second, orcloseto2,400datasetsperarch,foranaccurateand high-speed scan. This technology basedsystemrequiresenoughpowderingtoallowthescannertolocatethereferencepoints.Duringthescan, a pulsating blue light emanates from thewandheadandanon-screenimageoftheteethappearsinstantaneously.

8, 9, 10, 11Making of the digital impression :Thedigitalimpressionsystemcomeswithanintraoralscannerthatisattachedtoamonitorwhichdisplaystheimagesrecordedby thescanner.Thesystemwillalsohavesoftwarewhichhelpsinreadingandanalyzingtherecorded images.Thepatients information is enteredintothedigitalprescriptionformwhichcanbeusedforfuture communicationwith the lab. Once the type ofrestorativetreatmentisdecidedthecliniciandoesthepreparationoftoothaccordingtothetypeofrestoration(fullmetalcrown,goldcrowns,porcelainfusedtometal,allceramicrestoration)tobefabricated.

Thepreparedtoothrequiresgingivalretractionlikeany


46

otherconventionalimpressionprocedure.Themarginshavetobede�initelyexposed,suchthatitcanbescannedand recorded. The double cord gingival retractiontechniqueisbetterandstypticagentshouldbeusedtopreventanygingivalbleeding.Beforestartingwiththescanningtheuppercordisremovedandthepreparedtooth should be cleaned of the saliva or any debris.Digitalimpressionsystemlikelavarequirestheuseofspecial powder that has to be sprinkled over theprepared tooth before scanning whereas the i-Terosystemdoesnotrequirepowdering.

Thescanningprobeispassedoverthepreparedtoothwhich will take a series of images. Once the systemidenti�ies the tooth to be scanned, it will guide thecliniciantoscanbyvoiceandvisualprompts.Theentirescanning process will take about 2 - 3 minutes. Theopposing arch is scanned and also themaxillary andmandibularbuccalsurfaceofteethincentricrelationisscanned and the images are transferred onto themonitor.With the click of a button the entire digitalimage of the arch of the prepared tooth and also theopposingarchwillbeconstructedinaminuteandwillbedisplayedonthecomputermonitor.

Oncetheimageisconstructedthecliniciancanvisualizethe scanned digital image in any desired position byrotatingtheimage.Onecanvisualizetheocclusalviewtoevaluatethemarginswhichwillhelptoanalyzethepreparationforanyfurthermodi�ication.Thecliniciancan visualize the maxillary and mandibular arch incentric relation and check for the amount of toothreduction(occlusalclearance).Onecanalsocheckthelingualocclusion.Neededadjustments,ifany,aremadeatthistimeandafewadditionalscanswillregisterthechanges that were made on the prepared tooth. Thepatient can also visualize the digital image on themonitorandtheentireongoingprocess.

Oncetheclinicianissatis�iedwiththedigitalimageofthepreparedtoothhe/shecansendthedatadirectlytothelaboratory.

Oncethelaboratorygetsthecopyofthedigital�ile,thedataisfedtothemillingmachine,whichmillstheresinmodelofthedigitalimpression.Thisresinmodelisusedfor fabricating the restoration. Steriolithiograghytechnique can also be used for the fabrication of thedigitalimagemodel.

5, 8, 9, 12, 13Advantages of digital impression :Time factor:Theaveragetimetakenforentireprocessofscanninganaveragecasetakesabout2minutesfromstart to �inish which is much lesser compared toconventionalimpressiontechnique.

Gives clear digitalized image: Thistechnologyhastheabilitytocapturecontinuousthree-dimensionalvideostreamsinthemouthanddisplaythedataonthetouchscreeninrealtime.Thisenablesinstantfeedbackforboththedentistandpatienttoseetheanatomyofthemouthandspeci�icareasofinterest.

Dimensional accuracy: There is no scope fordistortion of impression as it is a digitalizedimpression.

Use of impression tray is avoided:Impressiontraysare not required for digital impressions. Therefore,digital impressionscaneliminatethe frequentlyseenproblemofseparationofimpressionfromthetray.

Clean procedure which is comfortable for the patient too. Gaggingcanbeconsiderablyreducedforthepatient.

Prepared tooth can be analyzed better: Digitalimpressiongivesbetterviewofthevarioussurfacesofthe prepared tooth and the clinician can do anyrequiredcorrectionswithoutmakinganycheckcast.

Helps in patient's education:Patientcanviewtheliveimagesofentireimpressioningprocedurewhichcanbeasourceofeducationtothepatient.

Easy storage of digital data for future use:It'seasytostorethedigitalimagesforfuturelegalreasonsorifitrequirestorepeattherestoration.

Avoids cross contamination:Crosscontaminationisavoidedwhich is of great concernwith conventionalimpression.

5, 8, 9, 12, 13Disadvantages of digital impression :Requires proper training:It'saverynewtechnologyanditrequiresonetogetfamiliarizedwiththedigitalimpressiontechnology.

Requires computer operational knowledge: Itrequiresthecliniciantobecomputerliterate.


47

Used for making only �ixed restorations: Cannotbeused to make impressions for complete denture andremovablepartialdenture.

Further research in necessary: Since it's a newtechnology it still requires long term researches tofurther validate its accuracy in comparison toconventionalimpressiontechnique.Highly expensive:Notcosteffective.

Requires good tissue management and clean dry

�ield:Thecameraswillrecorddebris,salivaorgingivalhangingovermarginswhichcancauseinaccuraciesintheresultantdigitalimages.

Conclusion:DigitalimpressionsmadebyusingthesystemslikeiTeroandLavaChairsideOralScannerC.O.Sareslowlybeing

5, 9accepted worldwide . It is being considered as thefuture of dentistry which can help raise the overallqualityoftheserviceweprovidetoourpatients.Variousstudiesdonebydifferentresearchershavebackedthis

12,13,14,15stateofthearttechnology .

Digital impressions eliminate some of the negativecharacter is t ics o f convent ional e lastomericimpressions, but proper soft-tissuemanagement andisolation of tooth preparation margins are stillnecessary.Thesedigitalimpressionsystemsalsodonotcomewithoutaprice.

Nevertheless,thedigitalimpressiontechnologyisverypromising and looks like it's here to stay, however, itrequireslongtermresearchestovalidateitsaccuracy.

References:1. Gordon j. Christensen. The state of �ixed

Prosthodontic impressions. J Am Dent Assoc2005;136:343-6.

2. , .AccuracyofintraoralLuthardtRGLoosR QuaasSdata acqu is i t ion in compar ison to theconventionalimpression. 2005;IntJComputDent8:283-94.

3. Gordon J . Christensen. The Challenge toConventionalImpressions.AmDentAssoc2008;139:347-49.

4. Henkel GL. A comparison of �ixed prosthesesgeneratedfromconventionalvsdigitallyscannedDental impressions. Compend Curr EducDentistry2007;28:422-31.

5. BirnbaumNS,AaronsonHB,Dental impressionsusing3Ddigitalscanners:virtualbecomesreality.CompendContinEducDent2008;29(8):494-505.

6. Gordon J. Christensen. Will Digital ImpressionsE l im ina te t h e Cu r ren t P rob l ems W i thConventionalImpressions?JAmDentAssoc2008;139:761-763.

7. Nathan S. Birnbaum, Heidi B. Aaronson, ChrisStevens, et al. 3D Digital Scanners: A High-TechApproach toMoreAccurateDental Impressions.2009. http://www.insidedentistry.net/print.php?id=2682..

8. ScottHenkel.ACloserlookatdigitalimpression.Aestheticdentistry,2003,6(3).

9. CRA foundation. Digital impressions challengeconventionalimpressions.CRANewsletter2007;31:3-4.

10. Steven Glassman, Digital Impressions for theFabricationofAestheticCeramicRestorations:ACaseReportPPAD2007;21:60-4.

11. ProductNews.BritishDental Journal2009;206,598.

12. Robert A. Lowe, Digital Master Impressions: AC l in i ca l Rea l i t y Den ta l compare .2009 .http://www.dentalcompare.com/featuredarticle.asp?articleID=572.

13. , , .AcomparisonKeatingAPKnoxJ BibbR ZhurovAIofplaster,digitalandreconstructedstudymodelaccuracy.JOrthod2008;35:191-201.

14. FasbenderDJ .Clinicalperformanceof chair sideCAD/ CAM restorations, .J Amdent assoc 2006;137:225–315.

15. , , ,Ireland AJ McNamara C Clover MJ House KWenger N BarbourME Alemzadeh K Zhang L, , , ,SandyJR.3Dsurfaceimagingindentistry-whatwearelookingat. 2008;11:205:387-92.BrDentJ.

Correspondence Address Dr. M. Sunitha Roy, MDS Assistantprofessor, DepartmentofProsthodontics,K.L.E.Instituteof

DentalSciences, NO.20,YeshwanthpurSuburb,Bangalore-560022Karnatakastate,India.

PHONENUMBER–091-9886120415 E-MAIL–[email protected]


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Authors : Dr. Shweta Nagesh¹, Dr Sujala Ganapathi Durgekar², Dr Sumitra Reddy³, Dr Ann Sara George⁴

Abstract

Thepurposeofthisarticleistoreportthetreatmentofa13yearoldpatientwithAngle'sClassImalocclusionwith

congenitallymissingupper lateral incisorsand lowerarchcrowding.The treatment involvedextractionof lower

premolarstorelievecrowdingandcaninesubstitutioninplaceoflateralincisorstoachieveoptimalesthetics.Good

esthetics andocclusionwasachievedat theendof treatment and the treatment remained stable6monthspost

retention.Theresultsshowavalidandcosteffectivetreatmentalternativetoprostheticrehabilitationinpatientswith

maxillarylateralincisoragenesis.

Key Words:Ageneis,Caninesubstitution,ClassIImalocclusion,Crowding,Lateralincisor.

An Esthetic Orthodontic Solution for Congenitally Missing Bilateral Maxillary Lateral Incisors- a Case Report

IntroductionThemaxillarylateralincisorsareoneoftheteethwiththehighestprevalenceof agenesis andmalformation.Owingtothelocationintheestheticzone,thepatientswith maxillary lateral incisor agenesis usually seek

1orthodontic correction. Treatment planning forpatientswithbilateralmaxillarylateralincisoragenesisneeds a multidisciplinary team. There are varioustreatmentoptionsforthereplacementofcongenitallymissing lateral incisors that includes caninesubstitution, single-tooth implants, and tooth-

supportedrestorations. Ideally,eachalternativeshouldful�il individual esthetic concerns, functionalrequirements,andperiodontaltissuehealth,notonlyat

2the end of treatment but also in the long term.Commonly the choice is related to ageof thepatient,typeofmalocclusion,overjet,overbite,caninerelation,pro�ile, arch length,and toothsizediscrepancies.Themorphologyofthecanine, intermsofsizeandshape,gingivallevelanditscolouralsomayaddressdifferenttreatment strategies. Finally, patient expectation and

1. Dr Shweta Nagesh, MDS Lecturer DepartmentofOrthodonticsandDentofacialorthopaedics KLESociety'sInstituteofDentalSciences, Bengaluru560022 EmailId:[email protected] Ph:91-8870120723

2. Dr Sujala Ganapathi Durgekar, MDS Reader DepartmentofOrthodonticsandDentofacialorthopaedics KLESociety'sInstituteofDentalSciences, Bengaluru560022 EmailId:[email protected] Ph:91-9916623547

3. Dr Sumitra Reddy, MDS, IBO Diplomate ProfessorandHOD DepartmentofOrthodonticsandDentofacialorthopaedics KLESociety'sInstituteofDentalSciences, Bengaluru560022 EmailId:[email protected] Ph:91-9448388716

4. Dr Ann Sara George Postgraduatestudent DepartmentofOrthodonticsandDentofacialorthopaedics KLESociety'sInstituteofDentalSciences, Bengaluru560022 EmailId:[email protected] Ph:9497602890

3compliancecanin�luencethetreatmentplanning.

In patients, who also have indications for premolarextraction due to crowding or proclination of teeth,carefulplanningisessentialduringthemanagementofmaxillarylateralincisoragenesis.Insteadofextractingpremolars,thecaninescanbesubstitutedinplaceofthelateral incisors. This option gives the patient a noninvasive, cost effective treatment option, whileachievingidealestheticsandfunction.

This case reports describes the management ofmaxillarylateralincisoragenesisinapatientrequiringpremolarextractionusingcaninesubstitution.Variousorthodontic considerations starting from bracketplacementrequiredtoachieveoptimalestheticshasalsobeendiscussed.

Case HistoryA 13 year old female patient reported with a chiefcomplaint of forwardly placed upper front teeth. On

49



clinicalextraoralexamination,thepatienthadaconvexfacialpro�ile, incompetentlips,shortupperlipsandanon consonant smile arc. Intra oral examinationrevealedAngle'sClass IMolar relationshipbilaterallywithproclinedmaxillaryanterior teeth,pacing in themaxillaryarchmandibulararchcrowding,missing12and 22 (Maxillary right and left lateral incisors),reducedoverjetandreducedoverbite(Figure1).

Radiographic examination revealed congenitallymissingupperlateralincisors.Thepatienthad10-25%growth remaining on examining theMP3 radiographandcervicalvertebrae.

LateralCephalometricanalysisshowedthatthepatienthas a Class II skeletal base, vertical growth pattern;maxillary and mandibular dental proclination and aretrognathicchin(Table1).

Treatment objectives Ÿ CorrectionofmaxillaryanteriorproclinationŸ ManagementofretrognathicchinŸ MaxillaryspaceclosureŸ MandibulardecrowdingŸ Management of missing upper lateral incisors for

optimalaestheticsŸ Toachieveoptimalsofttissueesthetics

Based on the treatment objectives, the followingtreatmentalternativeswereconsidered1. NonExtractionlineoftreatmentwithcreation

ofspaceforlateralincisorreplacement2. Extractionofupperand lower �irstpremolars

forcorrectionofproclinedteethandcrowdingfollowedbyprostheticreplacementoftheupperlateralincisors.

3. Extractionlineoftreatmentwithextractionoflower �irst premolars and upper caninesubstitutioninplaceoflateralincisors,followedby advancement genioplasty and upper liplengthening procedures a f ter growthcompletion.

The upper and lower arches can be treated by nonex t rac t ion t rea tment us ing expans ion andinterproximal reduction. But the space required forreplacementofupperlateralincisorswouldhaveledtoinadequate correction of the incisal proclinationthereby not addressing to the reduction in the lip

incompetence. Also, extraction treatment planinvolvingextractionofbothpremolarsisnotnecessaryasthelateralincisorsarealreadymissing.

Hence,basedonthespacerequirement,thirdtreatmentplan involving lower �irst premolar extraction andcanine substitutionwas the least invasive anda costeffective option and was chosen after the patient'sconsent.

Treatment ProgressBracketswithMBTprescriptionand0.022”slotwerebonded following lower �irst premolar extractions.Maxillary lateral incisor bracket was bonded on themaxillary canines following surface recontouring toachieve bracket base adaptation and upper caninebracketswerebondedontheupper�irstpremolars.Thepalatal cusps of the upper �irst premolars weretrimmed at regular intervals to prevent cuspaloverhang.

Alignment and levelling was initiated with 0.014”,0.016”and0.017x0.025”NiTiarchwires.Lower0.018”AJWilcockwasusedduringdecrowdingandUpperandlower 0.019x0.025” SS archwireswere used duringretractionandspaceclosure.Activetiebackswereusedtoachieveupperandloweranteriorretraction.

Following space closure, the upper canines andpremolars were reshaped to laterals and caninesrespectively, prior to initiation of �inishing phase(Figure 2). The patient was debonded after �inal�inishing and detailing stage and the total treatmenttimewas21months.Upperremovableandlower�ixedretainerswereplaced(Figure3).

Post treatment photographs revealed good dentalestheticsandocclusion.ThepatienthasaClassImolarandcanineocclusion,andoverjetandoverbitearestillwithin normal limits. There were no occlusalinterferences.Incisalandcanineguidancewaspresent.Thelipcompetenceimprovedposttreatmentbutsomeamountofincompetencewasstillpresentduetoashortupperlip.Posttreatmentlateralcephalogramrevealedoptimalincisalinclination.Theresultsremainedstable6monthspostretention.Advancementgenioplastyandliplengtheningprocedureshavebeenplannedafterthepatient'sgrowthcompletiontoachieveoptimalfacialestheticsandlipcompetence.


50

Fig. 1: Pretreatmentphotographsandradiographs

Parameters Pre Treatment Post Treatment Normal

SNA

SNB

ANB

FMA

Basal Plane Angle

TVL-Chin

U1-PP

IMPA

Nasolabial Angle

080

077

03

027

032

-10mm

0121

098

094

080

o77

03

027

031

-10mm

0112

090

0114

082±2

080±2

02

025

025 -

5.3-1.7mm

0110-115

095

0102±8

Fig. 2: Midtreatmentintraoralphotographs

Fig. 3: Post treatmentphotographsandradiographs

Table 1: PreandPostTreatmentLateralCephalometricValues

DiscussionCaninesubstitutionisaneffectivetreatmentalternativeinthemanagementofmaxillarylateralincisoragenesis.Butpropercaseselectioniscrucialinachievingoptimalestheticandfunctionalgoals.Therearespeci�icdentaland facial criteria that must be evaluated beforechoosingcaninesubstitutionasthetreatmentofchoice

4forreplacingamissingmaxillarylateralincisor.

Firstcriterionisthepatient'sage.Adolescentpatientsbene�it from canine substitution as the treatmentoutcomeisstableandef�icient.Thealveolarboneheightin theactual region ismaintainedby theearlymesialmovementofthecanine,andtheneedforremovableorresin-bonded retainers until implants placement is

5 avoided. Considering these factors, the caninesubstitutiontreatmentplanforthepatientisjusti�ied.

Evaluation of the anterior tooth-size relationship isimportantwhensubstitutingcaninesforlateralincisors.The anterior tooth size excess that is created in the


51

maxillary arch must often be reduced to establish anormaloverbiteandoverjetrelationship.Therefore,acritical step in the patient selection process iscompletion of a diagnostic wax-up. This enables theorthodontist to evaluate the �inal occlusion,measure,and determine whether an esthetic �inal result is

6possible. However, the patient had a mandibularanterior tooth material excess. Hence, mesiodistalreductionofthecaninewasnotdone.

Thecolorofthenaturalcanineshouldbeaddressedandshouldapproximatethatofthecentralincisor.Generallythecaninetendstobedarkerthantheincisors.Themostconservativeway to correct the color difference is toindividually bleach the canine. If this fails toapproximate the desired color, a veneer may beindicated.Also,thegingivalmarginofthenaturalcanineshould be positioned slightly incisal to the centralincisor gingival margin. This helps camou�lage thesubstituted canine. Occasionally, a gingivectomy mayneedtobeperformedtoproperlypositionthemarginalgingival.

Thechoiceofbracketforasubstitutedmaxillarycanineshouldbebasedprimarilyon two factors: thepalataltorqueandtheshapeofthebracketbase.Aninvertedcaninebracketiscommonlyrecommended,butitmaynot provide suf�icient torque. A lateral incisor and acentralincisorbracketprovideslightlygreatertorque,but enameloplasty is generally required prior tobonding to ensure adequate bracket base adaptationowing to the labial convexity of the canines. Ifenameloplastyisdelayeduntiltheendoftreatmentandsigni�icant torque is needed, an invertedmandibularsecondpremolarbracketoftheoppositesidecanalsobe

8considered. The patient was bonded with a lateralincisor bracket following enameloplasty for properbracketbaseadaptationandgoodtorqueexpression.

Generally,wheneverteethofthemandibulararchneedtobeextractedfororthodonticreasons,suchasseverecrowdingorprotrusion,closureofspaceintheupper

9arch with canine substitution is the suitable option.Premolar extractions relieved the mandibular archcrowding. Maxillary �irst premolars assumed thepositionofthecanine.Enameloplastyinthepalatalcuspofthe�irstpremolarspreventedcuspaloverhangthatmightcauseocclusalinterferences.

Adjunctive restorative treatment was required to

ideally recreate the shape and contours of a lateralincisor. It was done using composite resin. Porcelinveneerscanalsobeusedasanalternative.Nevertheless,optimal esthetic appreance was achieved with goodocclusion.

ConclusionCaninesubstitutioninbilateralmaxillarylateralincisoragenesis requires a multidisciplinary approach andcareful case selection. The case report demonstratesthatcaninesubstitutioncanbeaviablealternativetoprosthetic replacement in selected cases. Specialconsiderations in the biomechanics and adjunctiverestorative treatment are essential to obtain idealesthetics.

References1. Kennedy DB. Orthodontic management of

m i s s i n g t e e t h . J C a n D e n t A s s o c . 1999;65(10):548-550.

2. Kokich VO Jr, Kinzer GA, Janakievski J .Congenitally missing maxillary lateral incisors:restorative replacement [Point/Counterpoint].AmJOrthodDentofacialOrthop2011;139:435-45.

3. WriedtS,WernerP,WehrbeinH.Toothshapeandcolorascriteriafororagainstorthodonticspaceclosureincaseofamissinglateralincisor.JOrofacOrthop.2007;68:47-55.

4. ZachrissonBU.Improvingorthodonticresultsincases with maxillary incisors missing. Am JOrthod1978;73:274–289.

5. ZachrissonBU,RosaM,ToreskogS.Congenitallymissing maxillary lateral incisors: caninesubstitution. Point. Am J Orthod DentofacialOrthop.2011;139(4):434-445.

6. Kokich VG. Managing orthodonticrestorativetreatment for the adolescent patient. In:McNamaraJA,BrudonWL,eds.Orthodonticsanddentofacial orthopedics. Ann Arbor, Michigan:NeedhamPressInc,2001.p.1–30

7. Kinzer GA, Kokich VO. Managing congenitallymissing lateral incisors . Part I : caninesubstitution.JEsthetRestorDent2005;17:5-10.

8. KravitzND,MillerS,PrakashA,EapenJC.Caninebracketguideforsubstitutioncases.JClinOrthod.2017;51(8):450-453.

9. SabriR.Managementofmissingmaxillarylateralincisors.JAmDentAssoc. 1999;130(1):80-84.


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Corresponding author:Dr.ShwetaNageshLecturerDepartmentofOrthodonticsanddentofacialorthopaedics,KLESociety'sInstituteofDentalSciences

nd#20,Tumkurroad,II stageYeshwantpursuburb,Bengaluru,Karnataka560022Ph:887012072Emailid:[email protected]


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