IDA Maharashtra State Branch Dental Dialogue April-Jun 2012

Dental Dialogue

Vol. XXXVIII No. 2 APRIL - JUNE 2012

Vol. XXXVIII No. 2

INDIAN DENTAL ASSOCIATION MAHARASHTRA STATE BRANCH Website : www.idamsb.org Office : 57, 38 Rutu Dent, Pradhan Park, M. G. Road, Nashik 422 001 Tel. No. (O) 0253-2313512 (R) 0253-2577389 Mob. : 90110 27610, 94222 46871 E-mail : n [email protected] n [email protected]

President : I st Vice President :

Dr. Sanjay Bhawsar Dr. Manoj Joshi

II nd Vice President :

Dr. Suhas Merchant

III rd Vice President :

Dr. Aruna Bhandari

President Elect :

Dr. Bajrang Shinde

Imm. Past President : Hon. Editor :

Dr. Arunkumar Chhajed Dr. Rajendra Bhasme

Dental Dialogue Official Journal of IDA MSB Editorial Office

Residence

1215 'A' Ground Floor, Opp. Daulatrao Bhosale School, Shivaji Peth, Kolhapur - 416 012. Tel. : 0231-2629331

249 / 79, JANAK, 1 / 101, Near Nagala Park Kaman, Nagala Park, Kolhapur - 416 003. Tel : 0231-2653473

Mobile : 9422419428

Telefax : P. P. 0231-2653906

E-mail : [email protected] / yahoo.com

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WHAT IS IN.... What is in . . . 53 ............................................................................................................................................ Editorial 55 ........................................................................................................................................... President’s Message 57 ............................................................................................................................................ Temporomandibular Joint Disorders : A Common Problem Yet

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Complex To Understand ............................................................................................................................................ A Rare Case Of Two Separate Mesial Roots In Mandibular

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First Molar : A Case Report ............................................................................................................................................ Reducing Sensitivity After Composite Restoration: A Study 64 ............................................................................................................................................ Comparing Amount Of Separation And Discomfort During Tooth

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Separation Between Two Types Of Separators ............................................................................................................................................ Feedback 68 ............................................................................................................................................ Class – II Correction, The Functional Therapy Approach 69 ............................................................................................................................................ Book Review 70 ............................................................................................................................................ Guiding Planes - Pathway For Success 71 ............................................................................................................................................ Nodular Fasciitis : A Rare Case Report 73 ............................................................................................................................................ Therapeutic Role Of Epsilon-Aminocaproic Acid In The Management Of

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Dentoalveolar Trauma In Hemophilia A- A Case Report ............................................................................................................................................ Periodontal Medicine In Clinical Practice 78 ............................................................................................................................................ Dental Dialogue News 79 ............................................................................................................................................

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Dental Dialogue

APRIL - JUNE 2012

Dental Dialogue

APRIL - JUNE 2012

Vol. XXXVIII No. 2

Don't miss the Scientific Extravaganza and Trade fair of International Standards

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EDITORIAL

JUnVr ~mßnm _moa`m Dear Collegues, At the outset, we apologise for delay in publishing this issue of Dental Dialogue. The editor was busy in covering XXX London Olympics in Daily Ekmat titled doY Am°{bqnH$Mo from 5th July to 15 Aug. 2012. We are very pleased to release this issue on the auspicious occasion of Ganesh Chaturthi eHo$ 1934. Itis good to know that the 51st MSDC will be held at Pune on 15th & 16th December 2012 at VITS Hotel & Orchid Convention Center, Balewadi, Pune. We would like to Congratulate our president Dr. Sanjay Bhavsar for arranging the Conference & conducting zonal conventions in Maharashtra without having much support from office of HSS IDA MSB. All are requested to attend in large numbers. The Golden Jubilee of IDA MSB did not take place due to reasons beyond our control. Similar event should not happen in future. The members of IDA are eager to meet each other in EC meetings & Zonal Conventions etc.

Dr. Rajendra Bhasme, BDS, MJC * Bachelor of Dental Surgery * Master of Journalism & Communication Science

It is very easy to critisize, but it is very difficult to work for the association. The book on Geriatric Dentistry by Dr. P. G. Diwan is excellent. We appeal DCI to include the subject of Geriatric Dentistry in the dental curriculum. Also, the members above age 60 yrs. should be excluded from collecting mandetory CDE points.

This Issue is released on 19th Sept. 2012 i.e. Ganesh Chaturthi Shake 1934, at Kolhapur

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Perseverance for Excellence..!

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PRESIDENT'S MESSAGE.. Dear Friends, It has been seven months in my journey as the President of IDA MSB. I am proud to inform you all that in these few months we have been successful in organizing various programmes in different zones of Maharashtra state. The 3 zonal programmes conducted in places like Mumbai, Aurangabad and Dr. Sanjay Bhavsar Panchagani were a grand scientific bonanza for IDA members. 6 other zonal programmes are meticulosely planned with the help of eminient speakers in next 5 months. IDA student members are the back bone of IDA future. This year 5 student Zonal conferences will be conducted at Maharashtra level so as to provide a platform to students to exhibit there hidden talent. Students from Dental colleges in the interiors of the state will have a opportunity to participate in scientific, sports, cultural competetions. The final state level round of the Students Conference will be held in Mumbai, this December. I am very much thankful to IDA Mumbai branch for hosting the student conference. For the first time a State level Table Tennis & Badminton Tournaments are arranged for IDA dentist & student members on 14 -16 th Aug. 2012 by IDA MSB in association with IDA Mumbai branch . IDA in association with Government of Maharashtra is planning to organize Dental Check up of near about 1 lakh Anganwadi Sevika & Children from all over the Maharashtra. I appeal to all the ida members & dental colleges to help us in making this Towering task successful. IDA Maharashtra state will be organizing the 51 st Maharashtra State Dental Conference at Pune in the month of December 2012. I appeal all the members to participate in large numbers to make it a grand memorable event. Recently Pepsodent has also joined hands with IDA to support of our scientific activities. With the magic of monsoon is in the air let us enjoy the spirit of the season; the season of warmth, joy and cheer. Best Wishes to all the IDA Members for the auspicious Shravan, Ganesh Chaturthi and upcoming Dassera and Diwali. “Ability is nothing without opportunity”. I thus take the opportunity to wish all our members good health and success in this wonderful year ahead. May IDA reach soaring heights which we all have dream of. Dr. Sanjay V. Bhawsar President, IDA MSB

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Dental Dialogue

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Vol. XXXVIII No. 2

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Dr. Laxmikant Kishanrao Bichile Elected Member, Maharashtra State Dental Council, Mumbai Mahatma Gandhi Mission's Medical College and Hospital, Aurangabad. Mob:-9422709054 (Off)- 0240-6601100 Indian Dental Association Maharashtra State Branch

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Vol. XXXVIII No. 2 Prosthodontics

Temporomandibular joint disorders : A common problem yet complex to understand Dr. Manish Agrawal, MDS, Prof., Dr. Anita Shipurkar, MDS, Prof. Dr. Dayanand Huddar, MDS, Reader Dr. Banashree Sankeshwari, MDS, Asst. Prof. Dept. of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Sangli

Abstract : Temporomandibular disorder is any disorder that affects or is affected by deformity, disease, misalignment or dysfunction of the temporomandibular joint and the associated responses in the musculature. The term temporomandibular disorder include displacement of one or both joints, misalignment of the disc, various diseases that affect bone or articular surfaces and other pathologic disorders, inflammation or injuries to specific intracapsular structures. This article highlights the causes, symptoms, diagnosis and treatment on temporomandibular joint disorder. Key words: tempormandibular joint, TMJ disorders, stabilization splints, night guard. Introduction: The temporomandibular joint is susceptible to all the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies and neoplasia. Although treatment is often similar to other joints in the body, some variations exist. This article will highlight various causes, symptoms, & treatment for temperomandibular joint disorder (TMJD). Temporomandibular joint:

The temporomandibular joint (TMJ)(fig 1,2) is the area directly in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet. Within the TMJ, there are moving parts that allow the upper jaw to close on the lower jaw. This joint is a typical sliding "ball and socket" that has a disc sandwiched between it. The TMJ is used throughout the day to move the jaw, especially in biting and chewing, talking, and yawning. It is one of the most frequently used joints of the body.1,2 The temporomandibular joints are complex and are composed of muscles, tendons, and bones. Each component contributes to the smooth operation of the TMJ. When the muscles are relaxed and balanced and both

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jaw joints open and close comfortably, we are able to talk, chew, or yawn without pain. We can locate the TMJ by putting a finger on the triangular structure in front of the ear. The finger is moved just slightly forward and pressed firmly while opening the jaw. The motion felt is from the TMJ. We can also feel the joint motion if we put a little finger against the inside front part of the ear canal.1 These maneuvers can cause considerable discomfort to a person who is experiencing TMJ difficulty. Due to the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain. The pain may be referred in around half of all patients and experienced as otalgia (earache). Conversely, TMD is an important possible cause of secondary otalgia. Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus as well as atypical facial pain. The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc. The sounds produced by this dysfunction are usually described as a "click" or a "pop" when a single sound is heard and as "crepitation" or "crepitus" when there are multiple, rough sounds. Temporomandibular joint disorder (TMJD or TMD) TMJD is a term covering acute or chronic inflammation of the temporomandibular joint, which connects the mandible to the skull. The disorder and resultant dysfunction can result in significant pain and impairment. Because the disorder transcends the boundaries between several health-care disciplines—in particular, dentistry and neurology—there are a variety of treatment approaches. The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, and neoplasia. An older name for the condition is "Costen's syndrome", after James B. Costen, who partially characterized it in 1934.

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Dr. Manish Agrawal, et al Cause: There are many external factors that place undue strain on the TMJ. These include but are not limited to the following: Bruxism has been shown to be a contributory factor in the majority of TMD cases. Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways (laterally) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to: 1. Bruxism (repetitive unconscious clenching or grinding of teeth, often at night). 2. Trauma 3. Misalignment of the occlusal surfaces of the teeth due to defective crowns or other restorative procedures. 4. Jaw thrusting (causing unusual speech and chewing habits). 5. Excessive gum chewing or nail biting. 6. Size of food bites eaten. 7. Degenerative joint disease, such as osteoarthritis or organic degeneration of the articular surfaces, recurrent fibrous and/or bony ankylosis, developmental abnormality, or pathologic lesions within the TMJ 8. Myofascial pain dysfunction syndrome 9. Lack of overbite Patients with TMD often experience pain such as migraines or headaches, and consider this pain TMJrelated.. The dentist must ensure a correct diagnosis does not mistake trigeminal neuralgia as a temporomandibular disorder. The following are behaviors or conditions that can lead to TMJ disorders. 1. Teeth grinding and teeth clenching (bruxism) increase the wear on the cartilage lining of the TMJ. Those who grind or clench their teeth may be unaware of this behavior unless they are told by someone observing this pattern while sleeping or by a dental professional noticing telltale signs of wear and tear on the teeth. Many patients awaken in the morning with jaw or ear pain. 2. Habitual gum chewing or fingernail biting 3. Dental problems and misalignment of the teeth (malocclusion). Patients may complain that it is difficult to find a comfortable bite or that the way their teeth fit together has changed. Chewing on only one side of the jaw can lead to or be a result of TMJ problems. 4. Trauma to the jaws: Previous fractures in the jaw or facial bones can lead to TMJ disorders. Stress frequently leads to unreleased nervous energy. It is very common for people under stress to release this nervous energy by either consciously or unconsciously grinding or clenching their teeth. Occupational tasks such as holding the telephone between the head and shoulder may contribute to TMJ disorders.

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Symptoms: TMJ pain disorders usually occur because of unbalanced activity, spasm, or overuse of the jaw muscles. Symptoms tend to be chronic, and treatment is aimed at eliminating the precipitating factors. Many symptoms may not appear related to the TMJ itself. Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex, but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth. Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder. The following are common Symptoms associated with TMJ disorders: l Biting or chewing difficulty or discomfort l Clicking, popping, or grating sound when opening or closing the mouth l Dull, aching pain in the face l Earache (particularly in the morning) l Headache (particularly in the morning) l Hearing loss l Migraine (particularly in the morning) l Jaw pain or tenderness of the jaw l Reduced ability to open or close the mouth l Tinnitus l Neck and shoulder pain l Dizziness How are patients evaluated and diagnosed when TMJ problems are suspected? A complete dental and medical evaluation is often necessary and recommended to evaluate patients with suspected TMJ disorders. One or more of the following diagnostic clues or procedures may be used to establish the diagnosis. Damaged jaw joints are suspected when there are popping, clicking, and grating sounds associated with movement of the jaw. Chewing may become painful, and the jaw may lock or not open widely. The teeth may be worn smooth, as well as show a loss of the normal bumps and ridges on the tooth surface. Ear symptoms are very common. Infection of the ear, sinuses, and teeth can be discovered by medical and dental examination. Dental Xrays and computerized tomography (CT) scanning help to define the bony detail of the joint, while magnetic resonance imaging (MRI) is used to analyze soft tissues , Treatment for TMJ disorders:1 3 The mainstay of treatment for acute TMJ pain is heat and ice, soft diet, and anti-inflammatory medications. 1. Jaw rest: It can be beneficial to keep the teeth apart as much as possible. It is also important to recognize when tooth grinding is occurring and devise methods to cease this activity. Patients are advised to avoid chewing gum or eating hard, chewy, or crunchy foods such as raw vegetables, candy, or nuts. Foods that require opening the mouth widely, such as a big hamburger, are also not recommended.

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Vol. XXXVIII No. 2 Dr. Manish Agrawal, et al

2. Heat and ice therapy: These assist in reducing muscle tension and spasm. However, immediately after an injury to the TMJ, treatment with cold applications is best. Cold packs can be helpful for relieving pain. 3. Medications: Anti-inflammatory medications such as aspirin, ibuprofen, naproxen, or steroids can help control inflammation. Muscle relaxants, such as diazepam (Valium), aid in decreasing muscle spasms. In certain situations, local injection of cortisone preparations (methylprednisolone triamcinolone [, Celestone) into the TMJ may be helpful. 4. Physical therapy: Passively opening and closing the jaw, massage, and electrical stimulation help to decrease pain and increase the range of motion and strength of the joint. 5. Stress management: Stress support groups, psychological counseling, and medications can also assist in reducing muscle tension. Biofeedback helps people recognize times of increased muscle activity and spasm and provides methods to help control them. 6. Occlusal therapy: A custom-made acrylic appliance which fits over the teeth is commonly prescribed for night but may be required throughout the day. It acts to balance the bite and reduce or eliminate teeth grinding or clenching (bruxism). 7. Correction of bite abnormalities: Corrective dental therapy, such as orthodontics, may be required to correct an abnormal bite. Dental restorations assist in creating a more stable bite. Adjustments of bridges or crowns act to ensure proper alignment of the teeth. 8. Surgery: Surgery is indicated in those situations in which medical therapy has failed. It is done as a last resort. TMJ arthroscopy, ligament tightening, joint restructuring, and joint replacement are considered in the most severe cases of joint damage or deterioration. Reversible treatments In line with the recommendations treatments for TMJ should not permanently alter the jaw or teeth, but need to be reversible. To avoid permanent change, over-thecounter or prescription pain medications may be prescribed. Some sufferers may also benefit from gentle stretching or relaxation exercises for the jaw, which may be recommended by their healthcare providers. Other interventions include: l Stabilization splint1 (biteplate, night guard) is a common but unproven treatment for TMD. A splint should be properly fitted to avoid exacerbating the problem and utilized for brief periods of time. The use

of splint should be discontinued if it is painful or increases existing pain. l Mandibular Repositioning3 (MORA) Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night. l Regular exercise such as running for 20 minutes 3 times a week is extremely efficient in alleviating TMD brought about through stress-induced Bruxism. Exercise essentially burns away the chemicals like cortisol and norepinephrine that cause stress so the unconscious mind no longer feels the need to relieve its stress through jaw-clenching. Long-term approach Restoration of the occlusal surfaces of the teeth If the occlusal surfaces of the teeth or the supporting structures have been altered due to inappropriate dental treatment, periodontal disease, or trauma, the proper occlusion may need to be restored. Patients with bridges, crowns, or onlays should be checked for bite discrepancies. These discrepancies, if present, may cause a person to make contact with posterior teeth during sideways chewing motions. These inappropriate contacts are called interferences, and if present, they can cause a patient to subconsciously avoid those motions, as they will provoke a painful response. The result can be excessive strain or even spasms of the chewing muscles. Treatment could include adjusting the restorations or replacing them. Conclusion: Dentist should have detail knowledge of TMJ disorders its causes, symptoms & treatment options. Successful treatment of TMJ disorder can be attributed to doing a comprehensive examination, carefully and completely collecting all the needed information, & proper treatment planning. References:

51st Maharashtra State Dental Conference

66th Indian Dental Conference

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15th & 16th December 2012 61

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1. 2. 3.

Okeson, Jeffrey P. (2003). Management of temporomandibular disorders and occlusion (5th ed.). St. Louis: Mosby. Gray`s Anatomy. 39th edition, Elsevier Peter E. Dawson Functional Occlusion: From TMJ to Smile Design (3rd ed.) Elsevier Health Sciences.

Attend in Large Numbers

KOLKATTA 21st to 24th February 2013

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Vol. XXXVIII No. 2

Endodondotics

A Rare Case Of Two Separate Mesial Roots In Mandibular First Molar : A Case Report Dr. Sunil Saler, MDS Prof. & Head Dr. Anita Shipurkar, Principal & Prof. Dr. Santosh Hugar, MDS, Asso. Prof. Dr. Jaykumar Patil, MDS, Prof. Dr. Hemanth Vagarali, MDS, Asso. Prof. Dr. Samruddhi Metha, BDS Asst. Prof. Department Of Conservative And Endodontics, Bharti Vidyapeeth Dental College, Sangli Abstract: This paper presents the presence of bifurcated mesial root of mandibular first permanent molar. A major anatomic variant of the first mandibular molar tooth the presence of an additional distolingual root, also known as Radix Entomolaris has been well documented. Very few studies have documented the presence of two separate mesial roots in mandibular first molar. Hence this paper presents the report of a case in which endodontic therapy was performed on mandibular first molar with rare occurrence of two separate mesial roots, each having a single canal. Key Words: Mandibular first molar, Bifurcated Mesial root, Anatomic variations. Introduction: The prime objective of endodontic therapy is thorough chemo-mechanical debridement of the entire pulp space & the three dimensional sealing of the root canal. For this, it is essential for an operator to be familiar with the tooth morphology & root canal anatomy. Failure to achieve the above may lead to persistence of infection & treatment failure. Pucci & Reig (1944) reported that first molar is the only multi-rooted molar that always presents with two perfectly differentiated roots–one mesial & one distal and rarely with an additional distolingual root.1,2 The major variant of this tooth type, i.e, the additional disto-lingual root has been mentioned in the literature by Carabelli (1844).3 This additional distolingual root was named as Radix Entomolaris by Bolk in the year 1915. However, there is little documentation about the two separate mesial roots (mesiobuccal & mesiolingual). This paper presents the unusual occurrence of two separate mesial roots in mandibular first molar. Case report: A female patient aged 18 years reported to the Department of Conservative Dentistry & Endodontics, with the chief complaint of dull pain in the left lower back region of the mandible since 6 months. Extraoral examination revealed palpable lower left submandibular lymph nodes & tender to percussion. Intraoral examination showed deep carious lesion in relation to left mandibular first molar. Vitality testing was performed

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using electric pulp tester and it was found to be non responsive. Radiographic examination revealed deep carious lesion (Fig 1) approximating pulp and increased

thickness of the periodontal ligament space suggestive of periapical periodontitis. On careful examination of the diagnostic radiograph, two separate mesial roots (Fig 2) were seen which was again checked with the help of radiovisiography. After achieving adequate local anesthesia, caries were excavated & access cavity was prepared. Complete care was taken during the location of all the root canal orifices as diagnostic radiograph showed aberrant root morphology. Working length was measured using electronic apex locator which was later confirmed by radiographic method. The presence of two separate mesial roots without extra canal was confirmed at this step. Biomechanical preparation was done & obturation was completed using lateral condensation method (Fig 4). Access cavity was restored immediately with silver amalgam and in the consecutive appointments the tooth was restored with complete cast metal restoration (Fig 5).

Discussion: The three rooted mandibular molar reported here had two mesial roots and one distal root with one canal in each root. Initial evaluation of preoperative radiograph revealed that distal root may contain two canals but on careful exploration only one oval distal canal was found which was connected with narrow isthmus in between. Presence of extra root or extra root canals has also been

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Vol. XXXVIII No. 2 Dr. Sunil Saler, et al

related to the aberrant morphology of the crown, i.e., presence of extra cusp or abnormally sized tooth. However in this case the occlusal portion of the crown was grossly decayed hence, it was difficult to associate root anatomy with crown morphology. Presence of extra canals is fairly common, but occurrence of extra mesial root is not. Several reports have discussed about the presence of additional distolingual root also known as Radix Entomolaris. The available literature does not document much about the occurrence of two mesial roots in mandibular first molar. Only few cases have been reported with such kind of anomaly. Previous studies document the presence of more than two root canals in the mesial root with an incidence of 2.07% up to 13.3% of the examined cases .5, 6 A third root has been reported in some cases either mesially or distally (5.3%).7 Ingle documents the 2.2% occurrence of three roots in mandibular first molar; however, he has not differentiated it in extra mesial or distal root.8 In this case no extra canal was found in spite of the presence of additional root. To locate all the canals deroofing of the pulp chamber becomes extremely important and immense care has to be taken to accomplish the above goal. Additional third root is commonly present on the lingual aspect of the distal root. Only Sperber & Moreau (1998) have reported an additional root on the buccal aspect.9 The nature of this additional root is also variable, ranging from a short conical extension to full length, with pulp extending into the root even if short. (Reichart & Metah, 1981).10 Very few cases report the presence of four roots with four canals but such rare variations of mandibular first molar are more common in Asians & Caucasians.11 The preoperative radiographs play an important role in the diagnosis and treatment plan of any case. During reimplantation knowledge of anatomy is the key to success. Partial removal of the tooth during extraction procedure, may lead to clinical failure. This anomaly is genetically oriented developmental defect during the maturation of the tooth as this was present bilaterally. Previous studies report the occurrence of extra root specific to the race & geographic location. This paper opens the door for further studies on the abnormalities in the mesial root anatomy of the mandibular first molars.

World Dental Show at BKC

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5th, 6th, 7th October 2012 www.wds.org.in

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References: 1.

Pucci FM, Reig R. Conductos Radiculares. Buenos Aires, Editorial Medico-Quirurgica 1944. 2. Philip AA, Shetty Harish, Varma Ravi. Madibular first molar with an unusual root morphology – A case report.Ker Stat Dent J 2006:33-34. 3. Moor RJG, Deroose AJG & Calberson FLG. Int Endod J 2004;37:789-799. 4. Burns R, Herbranson EJ. Tooth morphology and cavity preparation. In Cohen S, Burns RC, editors: Pathways of pulp, ed 8, St Louis, 2002, Mosby:211. 5. Goel NK, Gill KS, Taneja JR. Study of root canals configuration in mandibular first permanent molar. J Indian Soc Pedod Prev Dent. 1991 Mar;8(1):12-4. 6. Fabra-Campos H. Unusual root anatomy of mandibular first molars. J Endod. 1985 Dec;11(12):568-72. No abstract available. 7. Grossman LI. Endodontic practice, 10th edition, Philadelphia, 1981:170 8. Ingle JI, Bakland LK. Ontario, B.C. decker Co.Endodontics 5th edition:151 9. Sperber GH, Moreau JL. Study of the number of roots and the canals in Senegalese first permanent molars. Int Endod J 1998;31:112-116. 10. Reichart PA, Metah D. Three rooted permanent mandibular first molars in Thai. Commu Dent & Oral Bio 1981;9:191-192. 11. Weine FS. Endodontic therapy, St Louis, Mosby Co, 6th edition: 150.

APPEAL To, All branch Secretaries & Members Copys for the news matter should be - Typewritten or well written with the spacing without spelling mistakes. - On one side of page only (keep back page empty) - Reach before the 10th of Every Quarter i.e. March, June, September & December month. Photographs should be - Colour photograph shall be sharp, Well contrast with full light effect. - Caption should be written on the back of photograph Names of the persons from Right to Left. - Photographs with action are most preferable (As lighting the lamp, / opening ceremony etc.) - News matter if published in the local news paper please send the photo copy of the page. - Photographs & Newsmatter will not be returned back (it would not be possible) - News matter which will be sent should be signed by office bearer of the branch. - Any special extra-curricular activity of member should be sent for DD. which all our members should know. - Poems, Dental Unfortgetable experience, jokes subject which should be discussed all over the state & practical tips to the treatment of patients should be sent. - Editorial board's decision will be final. - Address - 249/79 JANAK - 1 / 101, NAGALA PARK, KOLHAPUR. Ph. : 0231-2653473, Mobile 9422419428 email - [email protected] / yahoo.com

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Vol. XXXVIII No. 2

Restorative Dentistry

Reducing Sensitivity after Composite Restoration: A Study Dr. Manjiri Vartak Govt. Dental College and Hospital, Mumbai

Abstract It is usual problem to face tooth-sensitivity after resin composite restoration. A Sensitivity analysis was carried out depending upon the cavities of different depths and use of various liners and base materials. Factors responsible for post-operative sensitivity in general dentistry and measures to avoid them same were listed. The results were obtained accordingly (Keywords: Resin composite restoration, postoperative sensitivity, pulpal protection, dentine bonding system, cavity depth, cavity class, survey in private dental clinics.) Introduction The use of tooth coloured restorative materials for posterior teeth began with earliest generation of bondable composite restorative material in early 1970s. For forty years industry continues to search for bulk full composite that can be used with ease and predictability of dental amalgam. Despite improvements in composite treatment over past decades, postoperative sensitivity still remains a problem. Caries profunda showed a fourteen times higher risk of failure in cavities with pulp exposure compared to restorations that were localized in dentin. Regard to type of sensitivity no patients reported sensitivity to sweet or sour, most of them described their sensitivity sharp or dull. Incidence of postoperative sensitivity was evaluated in resine based posterior restorations. Objective To analyze the relationship between cavity depth and liners with postoperative sensitivity of resin composite restorations. Methods A clinical follow up was conducted on 152 resin composite restorations made in two private dental clinics over 2 months period. A total 73 class I and 79 class II restorations (MO/DO and MOD) were placed in patients ranging in age from 20 to 50 years. After cavity preparations were completed, rubber dam was placed and preparations were restored using total etch system (prime and bond NT) and resin based restorative material. Patients were contacted after 24 hours and 7, 30 and 9 days postoperatively and questioned regarding the presence of sensitivity and stimuli that triggered that sensitivity.

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Results Group 1: 39% of restorations had no protective layer. As depth of prepared cavities increased restoration received one of three pulpal protection methods. Group 2: Calcium hydroxide base. Group 3: Glass inomer cement. Group 4: Protection with calcium hydroxide base in combination with glass inomer cement. Incidence of postoperative sensitivity showed significant difference among groups 1, 2 and 3 but was significantly lower in group 1 when cavity was limited to enamel than in group 4 with deep cavity. Restorations made in shallow and medium depth cavities demonstrated significantly less postoperative sensitivity than those made in deep cavities. In restorations with approximately same length, group 2 and group 3 restorations showed less or nil sensitivity compared to group 1 or 2. The newer generation dentin bonding agents showed significantly lower incidence of postoperative sensitivity than early generation group. Concluding Remarks Postoperative sensitivity in resin composite restorations was related to absence of protective layer at a same time it increased with depth of cavities restored with resin composite. Type of dentine bonding agent could also be responsible for postoperative sensitivity. Though postoperative sensitivity has been vexing issue for most dentists, fortunately there are simple solutions to this irritating problem. Listed below are causes and solutions. 1. Poor dentine penetration by bonding agent. Application of 2 or 3 layers of bonding agent with air thinning and curing separately for each one. Or Use of 1 bottle self-etch resin. 2. Bad C factor and boxy conventional preparations: Bad C factor in responsible for postoperative pain in tooth with simple conservative class 1 preparation on the same patient where deep restoration has no postoperative sensitivity. Tooth reduction for cavity preparation should be confined to elimination of carious tooth structure and cavity design to withstand intraoral environment. Bevel enamel margins to conceal the margins. Roughed margins of enamel also enhance bond strength. Internal line angles of cavity

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3.

4.

a.

b.

5.

6.

7.

8.

design should be rounded to improve stress distribution after placement of restorative material through Micro-mechanical adhesive approach. Isolation is key feature in the success of the composite restorations for proper moisture control, to prevent bacterial or salivary contamination and reduce airborne debris. Replacing old GV Black style: a. Dentine should be built by layering process in increments. Cusps should be built in increments followed by cross linking. Cavity should not be filled horizontally. b. Bulk filled cavity preparations result in photopolymerization induced stress resulting from volumetric shrinkage, reaction kinetics and viscoelastic properties of composite resins. c. Recommended techniques to fill the cavity by composite restoration are, * Oblique incremental technique. * Modified incremental technique * Centripetal incremental insertion technique. d. Use RMGIC as a liner to replace missing dentine. e. Use of 1 bottle self-etch resin. Flowable base: Glass inomer cement bonds directly with tooth structure, biocompatible and considering ease with which it can be used; it acts as an excellent base before placement of composite restoration. Glass inomer can be placed in small disposable syringe and introduced into floor of cavity. It can be very easily shaped using condenser to provide Leveled floor for composite restoration. An alternative technique is almost fill the cavity floor with glass inomer cement And then use high speed rotary instrument to reshpe cavity preparation. Acid etching or Rinse etching: Acid etching the dentine before use of self-etch bonding agent.This additional etching creates “over-etch” situation which has deep demineralization zone for subsequently placed primer to completely penetrate. Shaking of bottle containing bonding agent: As multiple components in bonding agent tend to settle or separate during storage, it is necessary to thoroughly shake the bottle prior to despensing. Air bubble entrapment at bonding interphase of composite and dentine. Sensitivity in this case occurred because bubble shrinks during biting and applies pressure. Solution-Remove restoration and replace it with correct one. Use air thinning technique along with curing of each layer separately while application of bonding agent. Type of polymerization protocol: Soft start polymerization protocol reduces final stress of restoration by producing modest decrease in conversio of composite as compared to pulse protocol or conventional full intensity care technique.

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9. Not following manufacturers' protocol. Agitate the bonding agent for time prescribed by manufacturer. Use of air thinning technique after application of bottle bonding agent. 10. No heavy chewing for 24 hours:Tooth coloured composite filling is 80% hard at a time of placement and continues to harden for additional 24 hours before reaching its full strength. Heavy chewing can cause microfractures in restoration reducing its life span. Select References Black, G. V. 1917. A Work on Operative Dentistry, 2 Volums. 3rd edition, Chicago: Medico- Dental Publishing. Hickel, R. and J. Manhart. 2001. Longevity of restorations in Posterior Teeth and Reasons for Failure. Journal of Adhesive Dentistry, 3(1): 45–64. Letzel, H. 1989. Survival Rates and Reasons for Failure of Posterior Composite Restorations in Multi-centre Clinical Trial. Journal of Dentistry, 17: S10–S17. U. S. Natinal Library of Medicine, National Institute of Health. PMID19192831. PuMed-indexed for MEDICINE. Wendt, S. L. and K. F. Leinfelder. 1992. Clinical Evaluation of Clearfill Photo Posterior: 3 Year Results. American Journal of Dentistry. 6: 121–125.

REQUEST & GUIDELINES TO AUTHORS 1. The article should be sent to the editor both by post in three copies and CD / by Email & copyright letter should be send with the artical. 2. The text should be in MS Office 2003 only & in A4 Size & Illustrations in JPEG Format & restrict the references 10 only. 3. Decision of the editorial committee would be final & binding. 4. The accepted manuscript would be liable to editorial modifications & alterations. 5. Please spell-check and check your articles for any grammatical & technical mistakes/errors prior of sending them for publishing. 6. Kindly give the proper references to the photographs included & attached with the article & Mark the said CD with proper references. 7. IDA ID No. should be given by author & co-authors & should give preferenses of authors. 8. Clinical articles are also invited from our Hon. Members. 9. Beautiful photographs for cover page are also invited. Send your articles to : EDITOR,

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Orthodondotics

Comparing Amount Of Separation And Discomfort During Tooth Separation Between Two Types Of Separators Dr. Bidarkar Mayur, PG Student Dr. Swaroop Savanur, Prof. & HOD Dr. Basavraj, Reader Dept. Of Orthodontics, PDU Dental College, Solapur Dr. Jayasudha K., Reader Dept. Of Pedodontia, PDU Dental College, Solapur

ABSTRACT: Introduction:- For treatment with a fixed orthodontic appliance, different types of separators have been used in orthodontics. Separation of the molars is necessary to create enough space for bands that anchor the appliance. Materials & Methods:-The separators tested were springtype and elastomeric separators. Fourteen patients are taken. Two spring-type and two elastomeric separators were placed alternately in the left or the right quadrant. After a separation period of 5days, the amount of separation was measured with a leaf gauge. A questionnaire will be used to register the patient discomfort. Results: The mean separation was 0.3 mm for the spring-type and 0.4 mm for the elastomeric separators. The springs were considered less painful than the elastomerics, For both separators, the pain was worst at day 2 and subsided almost completely by day 5. Discussion:- The difference in separation effect between springs and elastomerics are small. Although bands for a fixed appliance is approximately 0.25 mm, the amount of separation is 0.3mm & 0.4mm respectively. It was found that mild to moderate pain is associated with orthodontic separators. Conclusions: The separation effect of the two separators was considered clinically equivalent and since pain of moderate intensity occurs during the separation period. INTRODUCTION Treatment with a fixed orthodontic appliance, separation of molars are necessary to create space for bands that anchors the appliance. Ideal Requirements Of Separators includes rapid & Good separation, no patient discomfort or pain, it should be easily cleaned & radiopaque and not to be lost 1. Different types of separators are used in orthodontics. Angle discussed the need for separation in 1907, and his method is still popular today. Angle explained the use of a brass wire ligature passed under the contact, then carried on over the contact, after which the ends were tightly twisted together. In 1921 Calvin Case advocated the use of a separating tape, which was wax wrapped tape wrapped around the contact. He

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said that the tape should left on for only 24 hours. The changed in separation was not sufficient. Rubber separators were mentioned by Thurow and Dickson. Anderson and Begg describes about separating springs2.

(a) Brass wire separators \

(b) Latex elastic separators

(c) E lastomeric separators (d) Spring type steel separators l

Hoffman 2 - separation effect of four types of separators was examined, but subjective experience was not investigated.

l

Ngan et al3,4- perception of pain & discomfort in patients undergoing treatment for 7 days of separation. It was found that separators caused high levels of discomfort at 4 and 24 hours after placement. No systematic studies had been performed on separating effect and perception of pain and discomfort after placement of separators.

AIM AND OBJECTIVES AIM:-Comparing Amount Of Separation And Discomfort During Tooth Separation Between Two Types Of Separators OBJECTIVES:1) To measure Amount of separation 2) Pain and discomfort associated with separation

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MATERIAL AND METHODS l Fourteen patients, 7 girls and 7 boys with age range of 17 to 21 years. (mean age of 20 years ) participated in study. Informed consent was taken. Separators were placed mesial and distal point contact of maxillary 1st molar which had bilateral approximal contacts. The separators used were spring-type steel separators and elastomeric separators. The springs applied with light wire pliers and the elastomerics with separator placing forceps. Two springs and two elastomeric Separators were placed alternatively in the left and right quadrant of maxilla. The separators had been place for 4 days. Elastomeric and springs were removed with a curved probe and light wire plier respectively.

After air spray drying of the maxillary molars, amount of separation of each maxillary molar was measured mesially and distally with a thickness gauge.(01mm with difference gauge 0.05 gradings) The patients perception of pain/discomfort was recorded by questionnaires.

Occlusal View

Lateral View

STATISTICAL ANALYSIS To detect the difference between quantitative variables, paired t test was used. Whether there was any significant difference in the amount of pain reported due to separators ,wilcoxon's signed rank test is used. Difference of probabilities of less than 5% were considered statistically significant. RESULTS

Measurement of separation distance with thickness gauge of distance 0.4mm 2) Pain & discomfort:All 14 patients completed the study and the response rate was excellent. The patients noted that elastomeric are more painful than the springs, but the difference was not statically significant. Two patients complained of pain during chewing. The pain gradually increased with both separators and peaked at day 2.

1) Separation Effect:As the results obtained did not differ significantly between the genders or between separation mesial or distal to maxillary molars. The mean separating effect was 0.3mm for the springs and 0.4 mm for the elastomerics. Difference in effect was significant p

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DISCUSSION

CONCLUSION

The difference in separation effect between springs and elastomeric was small and statistically not significant. The space needed for fitting bands for a fixed appliance is approx.0.25 mm. So, the amount of separation 0.3 and 0.4 mm for springs and elastomerics. Which concludes twice the thickness of bands. It was found that mild to moderate pain was associated with orthodontic separators5. So, the springs are considered less painful than the elastomerics.

Ø The difference in separation effect between springs and elastomeric was small and statistically not significant.

The pain was perceived as worst during day 2 and subsides at day 4 and subsides almost on 5th day. So, we advice that to perform molar band fitting at least 5 days after inserting the separators. No significant difference found between boys and girls pain/discomfort experience during the separation. Although some studies report more patient discomfort for girls than boys. More girls than boys used analgesics in this study. It has been reported that orthodontic patients use analgesics often. Eating was most affected during the separation period. Most patients preferred soft foods. So, it should be in mind that pain may occur during eating. The influence on regular activities as well as day today work was considered negligible. Hence, in this study the patient had no problem in discriminating between pain & discomfort in right and left posterior teeth when two types of separators were placed on right and left side respectively. As there is high scope of this study, we advice to use recent elastomeric materials, and also requirement of good sample size.

Ø The separation effect of the two types of separators was considered clinically significant. Ø Both types of Separators caused pain of mild to moderate intensity with springs considered less painful than elastomeric. Ø The pain was worst at day 2 and had subsided completely at day 4. Therefore, molar banding should be done at least 4 days after inserting the separator. REFERENCES 1) Separation effect and Perception of Pain and Discomfort from two types of Orthodontic Separators World J Orthod 2004;5:172-176 2) Hoffman WE. A study of four types of orthodontic separators. Am J Orthod 1972; 62; 67-73. 3) Ngan P, Wilson S, Shanfeld J. The effect of ibuprofen on the level of discomfort in patients undergoing orthodontic treatment AJODO 1994; 106;88-95 4) Scheurer P, Firestone A. Perception of pain as a result of orthodontic treatment with fixed appliance. Eur J Orthod 1996,18:349-357 5) Ngan P, Kess B, Wilson S. Perception of discomfort by patients undergoing orthodontic treatment . AJODO 1989;96;47-53 6) Proffit WR. Contemporary Orthodontics(ed.4)

Very nice issue of Dental Dialogue of Jan. to Mar. 2012 this shows that MSB is functining. Dr. Nitin Barve, Pune (1st June 2012) Beautiful Photo of Koyna Lake Tapping on Dental Dialogue. Dr. Mansing Chavan, Pune (1st June 2012) Beautiful Photo of Koyna Lake Tapping on Dental Dialogue. Dr. R. S. Birngane, Principal, PDUDC, Solapur (2nd June 2012) It’s excellent issue thank you. Dr. Vikas Kamble, Solapur (19th May 2012) Read & informative Dental Dialogue. Dr. Tushar Vora, Akola (2012)

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Congratulations Dr. Bhasme for coming out with a timely issue inspite of all that is happening IDA MSB. It has really assured common members like me that we still have our beloved association in existence. In Greek Mythology the earth is supported on shoulders of ATLAS. I am happy you have become ATLAS for IDA MSB. Dr. Shivkumar Ranjalkar, Aurangabad (2nd June 2012)

By Sms

Respected Sir, Thanks again for adding a new era of knowledge in Dental Dialogue. I feel your work is totally justifiable inspite of all odds which is going in IDA MSB. Keep the same enthusiasm. Dr. Rahul Patil, Chopada-Jalgaon (5th June 2012) Once again congratulations for publishing very nice issue of Dental Dialogue. Dr. Sandeep Patil, Amravati (5th June 2012) Received Dental Dialogue Journal congratulations for receiving award. Very informative issue. Continue same good work in future. Dr. Sanjay Sakkarshetti, Solapur (23rd July 2012)

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Vol. XXXVIII No. 2 Orthodontics

Class – II Correction, The Functional Therapy Approach Dr Rishi A Joshi Sr Lect. Dept of Orthodontics. Hithkarini Dental College, Jabalpur, Madhya Pradesh.

Dr Parikshit Rao Sr Lect, Dept Of Orthodontics, K..M.Shah Dental College, Pipariya, Vadodara, Gujrat.

Introduction Conventional orthodontic appliances use mechanical forces to alter the position of the teeth into a more favourable position. However the scope of these appliances is restricted by the aberrations in the developmental process or the neuromuscular capsule.1

was achieved and case was ready for debonding after 4 months. PHOTOGRAPHS : Pre Treatment

About 40% of the malocclusions treated belong to Class-II category. Abundant research has shown that most of the Class-II problem occurs because of retrognathic mandible which can be corrected by the use of functional appliances if the patient reports to the orthodontist when some percentage of growth is still left in the patient ( ie in and around puberty). 2 The following case report shows in detail how a case of Cl-II malocclusion was treated using Twin Block followed by finishing the case with fixed mechanotherapy.

Front Profile

Lateral Profile

Front Smile

Case Details CHIEF COMPLAIN : Patient by the name of Shantanu Goswami, aged 11 years reported with a chief complain of protruding upper front teeth. DIAGNOSIS : After clinical examination and cephalometric analysis the case was diagnosed to be of Class-II malocclusion with retrognathic mandible and normal maxilla. Molar relation and canine relation were Class- II with overjet of 7 mm and overbite of 4mm.

Front Occlusion

Right Buccal Occlusion

TREATMENT PLAN : As the patient had about 60 to 70 percentage of grwth left according to the CVMI status, the treatment was planned in two phases. In phase-1 Twin Block was planned to -treat the retrognathic mandible and in phase -2 fixed appliances were planned to finish of the case with minor dental corrections treated. TREATMENT PROGRESS : Phase 1 : Twin Block was fabricated with 5 mm sagittal advancement and 5mm vertical opening. Expansion screw was placed in the maxillary arch to correct maxillary constriction.The Twin Block was cemented to achieve 24hr wear. Patient wore the appliance for 6 months after which trimming was started to achieve proper vertical erruption of posterior dentition. At the end of 12th month after achieving Class-I molar relation Twin Block was discontinued. Phase 2 : Fixed mechanotherapy was started by bonding MBT 0.022 prescription. Finishing and detailing

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Left Buccal Occlusion Mid treatment with Twin Block

Frontal view

Right buccal view

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Book Review

Left buccal view End treatment

Front profile

Lateral Profile

Front Smile

Dr. P. G. Diwan needs to be complemented for his great contribution to Dentistry in India by authoring the book titled “Geriatric Dentistry in India”. This is a unique book of its kind on the very important topic of Geriatric Dentistry that has been written with 50 plus years of Clinical Experience. He has covered most of the topics pertaining to the practice of dentistry for elderly people (age 60 years of above) who contribute almost 8% of the Indian Population. i.e. about 100 million people.

Front occlusion

Left Buccal occlusion

Ironically, Geriatric Dentistry has not been included in the curriculum in the Dental Institutions in India that should have been. This book will be a great guide for the undergraduate students to learn the geriatric changes in the oral cavity. Also the changes occuring in the oral cavity as a result of systemic diseases that are prevalent in elderly population have been discussed in details. The knowledge about dental treatment for medically compromised people & also the emergencies in geriatric dental practice will be very useful for the practising Dental Surgeons in India. Price j: 450/Dr. Anil Kapadia

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Right Buccal Occclusion Conclusion : Skeletal Class-II malocclusion if treated by combination of functional appliance and fixed mechanotherapy can give good and stable results. Twin block is a very good appliance of choice as it has good patient compliance and is a full time wear appliance. References : 1 Woodside DG, Metaxas A, Altuna G. The influence offunctional appliance on glenoid fossa remodelling . Am J Orthod Dentofacial Orthop. 1987;92:181-98. 2 Bishara SE, Ziaja RR. Functional Appliances: A review, Am J Orthod Dentofac Orthop 1989;95:250-6

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Vol. XXXVIII No. 2 Prosthodontics

GUIDING PLANES - PATHWAY FOR SUCCESS Dr. Vaishali Bondekar, Prof. Dr. Pranab Kumar Sanyal, Prof., HOD, Dean Dr. Pravin Badwaik, Reader Dr. Guruprasad Handal, Lecturer Dept. of Prosthodontics:Y.C.M.M & R.D.F Dental Collage, Ahmednagar

Abstract : Guiding planes play as very vital role in removable prosthodontics but unfortunately it is least considered. Guiding planes provide easy path of placement and removal and also helps in designing other components of RPD Guiding planes not only essential in removable prosthesis but are equally important in fixed restorations, over denture and implant denture. Introduction: Although the term 'guide plane' is used more widely in partial denture design but the significance of planes and the concept of guide plane denture is perhaps not fully appreciated. A brief introduction to the concept of guiding planes and how to achieve then in various situations is discussed in this presentation. The glossary defines the guiding planes as "two or more vertically parallel surfaces of abutment teeth so oriented as to direct the path of placement and removal of removable partial denture" This definition makes the point that guide planes establish a single and direct path of insertion as a basis on which denture may be designed. Guiding planes presents in natural crown contour or formed by selective grinding of natural crown contour or contouring of surveyed crown. Guiding planes may be contacted by various components of removal partial denture. Functions of guiding planes surface:1)

7) To minimize food traps between abutment teeth and components and possibility for improved esthetics. Length of the guide plane:Guiding planes 2 to 3 mm in length is sufficient to achieve during insertion any plane prepared to a much greater length interfere with health of the gingival cervices. Locating the guiding planes:(1) Place the analyzing rod in the surveyor spindle. (2) Move the tilt-top table, with the cast in position slightly anteroposteriorly until the spindle contacts the occlusal one third of the proximal surfaces of the proposed abutment teeth. when anterior teeth are missing, guide planes on either side of the edentulous space must be given precedence. Preparing guiding planes for removable partial denture: Guiding planes should be prepared to be parallel to one another and to the path of insertion as determined by the surveying stylus. these surfaces very seldom occur naturally and need to be prepared directly on enamel or on cast or composite restorations. Procedure:Mount the diagnostic cast on a tilt table; Position the adjustable table so that occlusal surfaces of the teeth are parallel to the platform Select most desirable tilt to attain parallelism for future guiding planes. Record the surface which needs reduction and relation of the cast to the surveyor.

To provide one path of placement and removal.

2) The more vertical walls they are prepared parallel, fewer the possibilities for dislodgement of prosthesis 3) Guiding plane retention has less potential for causing supporting structure damage 4) Guiding planes have horizontal bracing capabilities. 5) To ensure the intended actions of reciprocal stabilizing and retentive components. 6)

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To minimize deep undercut zones.

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Dr. Vaishali Bondekar, et al Determine the relative parallelism of the tooth surface by contacting proximal tooth surfaces with surveyor blade. Alter the cast position anteroposteriorly until proximal surfaces are in a parallel relation to one another ( Fig A and B ) Selecting suitable anteroposterior tilt should to provide parallel proximal surfaces that may act as guiding planes. Differentiation between tooth borne and distal extension removable partial denture as they affect the choice of guiding plane location:Many competent dentists mistakenly believe that guiding planes are advantageous for every type of removal partial denture. Distal extension removable partial denture present different set of circumstances than a total tooth supported removable partial denture. Tooth born removable partial denture:Tooth borne removable partial dentures are supported on both ends of the edentulous area by rest located on prepared tooth surfaces. These rests direct the forces during mastication down the long axis of teeth deriving support from the tension on the periodontal ligaments. The guiding planes need to be considered in relation to the forces or actions cause during dislodgement. The larger the numbers of vertical walls that can be made parallel to each other, the more retentive the removable partial denture. All the forces of dislodgement will be non destructive in fact these guiding planes will provide horizontal bracing of teeth involved. A precision partial denture is prime example of retention and bracing that can be provided by guiding planes. Distal extension removable partial dentures:Distal extension removable partial denture should be considered different than tooth borne removable partial dentures to the design of prosthesis and associated preparation of abutment teeth one end of the denture base moves more than the other because resiliency of the soft tissues overlying the bone. This movement can cause rapid destruction of periodontal support of the abutment teeth and dictates a different design of both claps assembly and the guiding planes. Guiding planes must be considered with respect to center of rotation of the removable partial denture and consequent movement of denture during function, many of the tooth surfaces used for guiding planes on a tooth born removable partial denture should not be contacted with distal extension removable partial denture because of potential damage to the teeth. This damage can be caused by guiding plates which can in combination with clasp assembly act as levers to lift the teeth occlusally and distally.

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With clasp type removable partial denture the contact of distal surface of guiding plates against guiding planes will move the fulcrums or rotation centers to these points thus placing the retentive clasp on the opposite side of the fulcrum line and causing possible extrusion of abutment teeth during function. Any part of the distal surface of an abutment tooth must be free of contact by removable partial denture during functionally movement. This can be accomplished by placing a short vertical guiding plane on occlusal one third of the tooth and then constructing guiding plate of the removable partial denture so that its occlusal edge is at the same level as the gingival limit of the prepared guiding plate, because of the convexity of teeth mesiodistally guiding plate should not wrap around the distal surface. The only buccolingual surfaces of an abutment teeth supporting distal extension partial denture that should have guiding planes are those surfaces they are mesial to greatest mesiodistal convexity unless the guiding plates are constructed to immediately disengage the tooth during functional compression of the base. Summary:Guiding planes they are contacted by guiding plates are an important aspect of removable partial denture design principal complete vertical contact is beneficial for tooth born removable partial dentures. When distal extension ridges are present complete contact is detrimental. The design should be modified to take into account the different resiliencies of the supporting structures. References:1. Arthur M.L, Angelo L.F A simplified procedure for survey and design of diagnostic casts. J Prosthetic Dent 1977;37;681 2. MC, crackens: - Removable partial prosthodontics eighth edition, 1989 3. O.L Bezzon, M.G.C Mattos, R.F Ribero. Surveying removable partial dentures: the importance of guiding planes and path of insertion for stability J Prosthetic Dent 1997:78:413 4. Stewart, Rudd, kuebker Clinical removable partial prosthodontics 1983 .

66th Indian Dental Conference

KOLKATTA 21st to 24th February 2013 www.idc2013.org.in

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Vol. XXXVIII No. 2 Oral Pathology

NODULAR FASCIITIS : A RARE CASE REPORT Dr. Dr.Vaishali Anil Nandkhedkar, Dental Surgeon, Oral Pathology & Microbiology Dr. Jaishri Sanjay Pagare, Assit. Prof., Oral Medicine & Radiology Dept. of Oral Medicine & Radiology Govt.Dental College & Hospital, Aurangabad

ABSTRACT Nodular fasciitis (NF) a soft tissue lesion mainly composed of myofibroblastic cells, is well documented in various body locations however, in the oral cavity it is rare. Accurate diagnosis of such lesion is very important as some of these lesions resemble a sarcoma and this presents a diagnostic challange for the pathologists. Also, clinician should avoid unnecessary and often mutilating surgery for the same. Hence, the rare case of nodular fasciitis in the right cheek is reported together with a differential diagnosis. INTRODUCTION : Nodular fasciitis is a single, rapidly growing and firm subcutaneous nodule most commonly over the arm and trunk and may be characterized as benign reactive proliferation of fibroblasts. Initially nodular fasciitis is defined as pesudosarcomatous fibromatosis. It was first reported by “KONWALER. KEASBY” and “KAPLAN” in 1955. Nodular fasciitis is most common in third decade, but may occur at all age groups. Males and females are equally affected. It usually presents as a rapidly growing soft tissue mass, some what tender and fixed structure but with freely movable overlying skin. Although cause is unknown, trauma is believed to be important. Clinically the lesion present as a rapidly growing soft tissue mass, usually of short duration 2-4 weeks on average. The histopathological diagnosis is not so easy because it's histopathologic finding having bizarre appearance and show considerable variations. Because of this nature, nodular fasciitis was infrequently diagnosed as fibrosarcoma and other malignancies in the past. Therefore, in a view of this aggressive clinical behaviour of this lesion accurate histopathological investigation is essential to prevent unnecessary over radical and mutilating surgery. CASE HISTORY : A 25 years old young female reported to Dept. of Oral Diagnosis and Radiology, Government Dental College and Hospital Aurangabad, with a complaint of swelling on the right side of the cheek since 2 months. On clinical examination, medium built young patient having a swelling on the right side of the cheek. Extraoral

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examination revealed, a small, oval shape swelling about size (2x2 Cm) on the right cheek. The swelling was fixed to underlying skin; and consistency of the swelling was firm to hard. Skin over the swelling was normal. There was no sign of any inflammation or sinus tract. In past medical history, patient gave history of trauma to the right cheek 3 weeks back. After that lesion gradually increased in size to attempt present size. On intraoral examination, there was no relevant clinical finding. The associated teeth with swelling were vital and non tender. Radiological examination revealed the teeth and supporting tissue showed no abnormality.

Routine Haematological examination was normal. Ultrasonography of the lesion was advised to the patient. High frequency probe ultrasonography was done. USG reports suggestive of nodular hypoechoic lesion on the right cheek, just superior to right mandibular ramus. No obvious bony erosion. No definitive diagnosis was made until an incisional biopsy was performed under local anaesthesia. The histopathological examination revealed as a neurofibroma. But second opinion was taken from Bombay Hospital and Medical Research Center. Histopathological examination, suggests that fragments of a spindle cell lesion composed of short spindle cells arranged in intersecting fascicl and whorls with focal stori

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form pattern. The cells posses, oval, bland appearing, palestaining nudei fair number of mitoses are detected. The intervening stroma is loose textured and myoxid with microcysts containing extravasated RBCs and nucleated giant cells. There was no malignancy. Diagnosis was NODULAR FASCIITIS.

DISCUSSION : Nodular fasciitis, a soft tissue lesion mainly composed of myofibroblastic cells, is well documented in various body locations however in the oral cavity it is rare. Nodular fasciitis is relatively rare and recognized as occuring in the sub-cutaneous tissues of the expremities and trunk6. In Japan, IWASKI and Enjoji, reported that the percentage of orofacial lesion was 7% of all cases of nodular fasciitis. Thus, it was uncommon in the orofacial region. Trauma is often cited as a possible aetiology, but the true pathogenesis is still unknown2. If trauma is an important cause then one should expect to see the lesion more commonly in the oral cavity. Most authors, believe that the lesion represents a reactive or inflammatory process of fibrous connective tissue13. Nodular fasciitis in the oral cavity, occurs at all ages. A peak incidence occurs between 30 and 40 years1. The most common location of oral nodular fasciitis was the buccal mucosa3. The tumour is usually a discrete soft tissue mass, some what tender and fixed to the subjacent structure but with a freely movable overlying skin. Size varies from 4mm to 4 cm in size. On clinical presentation, the lesion clinically simulate anything from an abscess to a neurofibroma1. Histologically, the appearance of the lesion is characteristic and striking, it shows hapazard arrangement of irregular bundles or single fibroblastis in a mucoid matrix1. Prince et al, have divided nodular fasciitis into three

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histological subtypes. Type-I nodules are moderately cellular with an abundant interestitial ground substance giving the lesion a distinctly myoxid appearance. This ground substance is most abundant in the pari Cellular Center with increasing cellularity of periphery of the lesion. Vascularity is prominent, and multinucleated giant cells are commonely seen. Type II nodules manifests less ground substance and tendency toward greater cellularity with less haphazard arrangements of the cells. Type III nodules are biologically more mature. There is increased collagen production with small amount of ground substance1. Histologically features of nodular fasciitis may vary considerbly, but four features are commonly observed. I] Spindle shaped fibroblasts that tend to be arranged in long fascicles which are slightly curved, whorled or 's' shaped. II] Small clett or slit like space that often separate fibroblasts. III] Few extravasated erythrocytes. IV] Mucoid interstitial ground substance1. Nodular fasciitis should be differentiated from f i b ro s a r c o m a / s a rc o m a . B e c a u s e o f w i d e histopathological diversity in nodular fasciitis approxametly 50% cases were misdiagnosed as sarcoma or other malignant neoplasm. Another lesion considered for differential diagnosis is neurofibroma. As both lesions are unencapsulated lesions composed of spindle cells. However, neurofibroma lacks an inflammatory component and extravasated blood cells frequently encounter in nodular fasciitis. Fibrous Histiocytoma and Nodular fasciitis are some time impossible to distinguish, only differentiating point is histocyte like cells with abudant cytoplasm which may be prominent in many fibrous histiocytama but absent in nodular fasciitis. Presence of foam cells also another point which favour a diagnosis of fibrous histiocytoma. Fibromatosis is another group of lesion taking for consideration as a differential diagnosis. Fibromatosis usually clinically infiltrate into the surrounding tissue. Fibromatosis is lacking the myoxid tissue and granulation tissue like appearance frequently found in Nodular fasccitis3. Schawanoma, myofibroma should be distinguished from nodular fasciitis mainly n the basis of it's biphasic “zoing” phenomenon that refers to the presence of light staining collagenous hyalinized areas, schawanoma presents as a mixture of Antoni Type A & Type B structure which is not feature of nodular fasciitis. In addition, proliferating capillaries, extravasated red blood cells and inflammatory cells are not typically found is schawanoma. Immuno histochemical study of S-100 exclude neural tumor. In summary, nodular fasciitis is a soft tissue lesion mainly composed of myofibroblastic cells. In the oral cavity it is very rare. Because of it's histological variation's

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Dr. Vaishali Nandkhedkar, et al in the past it is misdiagnosed as sarcoma or other malignancies. Accurate diagnosis is important to avoid unnecessary and often mutilating surgery. It is hoped that this publication will aid in identification of a reactive lesion, in an already diagnostically challening group, which can be mistaken for low grade malignancy. REFERENCES : 1] Tumour's of Head and Neck - John Batsakis, 2nd edition, William and Wilkins, Batimocel London Page 259-262. 2] Oral Nodular fasciitis - A Case Report - D.M.Badia, L.Rossi, A.R.Sorci and M.Riminucei - Oral Oncology Eur. J. Cancer, 1994. - Vol. 30 B, No.3, P.P. 221-222. 3] Clinico pathologic correalations of myofibroblastic tumours of the oral cavity. 1. Nodular fasciitis. - Dan Dayan, Varda Nasrallah, Marillena Vered - Journal of oral pathology and medicine vol.34 issue - 7 Page 426-435 Agusut - 2005. 4] Oral Nodular Fasciitis - H.T.Davies, N.Bradley and J.E. Bowerman. - British Journal of Oral and Maxillofacial Surgery (1989), Vol.27, Page No.147-151. 5] Nodular Fasciitis and Solitary Fibrous tumour of the oral region - Tumours of fibroblast heterogeneity. - Lewis R. Eversole, Russel Christene, Ginseeppe Ficarra, Lucina Pierleoni et al. - Oral surgery, oral medicine, oral pathology oral Radiology Endodontic 1999 6] Soft tissue tumours. - Enzinger - Weis SW - 3rd edition, St.Louis, Mosby, 1995. 7] Nodular fasciitis In : Fletcher CDM Unni KK Mertens, F, eds, Pathology and genetics, Tumours of Soft Tissue and bone (WHO Classification of Tumours). Evan's H., Bridge J.A. 8] Intravascular fasciites : a case report in an intraoral location - M.A.Kahn, D.R.Weathers and D.M.Johnson - Vol.16, No.6, July 1987. - Journal of Oral Pathogy - Page No.303 - 306. 9] Connective tissue lesions in oral pathology. Clinical pathologic corelations. - Regezi J.A., Sclubba J.J., Jordan RCK eds. - 4th edition, St.Louis : skounders 2003 Page No.164-166. 10] Burket's - Oral Medicine 'Benign Lesions of the oral cavity' A. ROSS KERR. - John A. Phelam, 11th edition, chapter No.6 Page No.134-

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135. 11] Nodular fasciitis of the upper labial fascia:cytometric and ultrastructural studies. - Authors :- Tomonori Kawana, Hijrotsugu yamato, Akira Deguli, Testuo Oikawa and Hirotusugu - Int.Journal Oral Maxillofacial Surgery 1986, Vol.15, 464468. 12] Shater's Text book of oral pathology, Rajendran and Shivpath Sundnaram, Elsevier, 6th edition 2009. 13] Lucas's Pathology of Tumour of the oral tissues - Roderik A. Cawson et al. - Edition - 5th - Churchill Livingstone London.

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Dental Dialogue

APRIL - JUNE 2012

Dental Dialogue

APRIL - JUNE 2012

Vol. XXXVIII No. 2 Oral Surgery

Therapeutic Role Of Epsilon-aminocaproic Acid In The Management Of Dentoalveolar Trauma In Hemophilia A- A Case Report Dr. Vivek Gurjar, Prof., Dept. of Oral and Maxillofacial Surgery Dr. Minal Gurjar, Reader, Dept. of Periodontics BVDU Dental College & Hospital, Sangli

ABSTRACT: The dental treatment of patients with inherited bleeding disorders has been widely discussed in the literature with the aim of developing guidelines for common procedures. A factor VIII level of 6% to 50% of normal factor activity (mild hemophilia) is associated with bleeding during surgery or trauma, 1% to 5% with bleeding after mild injury and < 1% (severe hemophilia) with spontaneous bleeding. In patients with hemophilia, transfusion of appropriate factor to 50-100% of normal levels is recommended when a single bolus infusion is used in an outpatient setting. Considering usage of an antifibrinolytic agent like epsilon aminocaproic acid (EACA) may be helpful. We are presenting a case of dentoalveolar trauma treated in a patient with hemophilia A. Key words: Hemophilia A, Epsilon-aminocaproic acid INTRODUCTION: Hemophilia A is the most common type of hemophilia. It is largely an inherited disorder in which one of the proteins needed to form blood clots is missing or reduced. The use of EACA has proved to be an efficient and practical method for treating hemophiliacs who require dental treatment. In the past, patients required prolonged hospitalisation and received replacement infusions every 12 hours during their stay. This resulted in a large expense because of the cost of the material and hospitalization, not to mention the trauma sustained by the patient both physically and psychologically. By decreasing the number of factor infusions, the risk of complications such as the transmission of hepatitis, allergic reaction and inhibitor formation decreases. CASE REPORT: A 48 year old male patient reported to our unit with complaining of mobile upper anterior teeth. He gave a history of assault with a blow on his face. He also gave a family history of hemophilia A . On examination, the upper central & lateral incisors were significantly mobile with continuous mild bleeding from that site. No other soft tissue injuries were noticed on the face. Since the involved teeth required immobilization if they were to be retained and as the patient also insisted on the same, it was planned to immobilize them with an arch

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bar. Based on the family history, routine laboratory investigations for hemophilia were carried out. The local hemophilia unit was contacted , who would be responsible for arranging the administration and monitoring of treatment products. The administration of clotting factor concentrates both before and after the procedure along with the use of an antifibrinolytic agent namely EACA (50 mg/kg four times a day) was considered. It was decided to continue the drug for a further period of 4 days post treatment. We had the patient rinse the mouth with chlorhexidine mouthwash two minutes before the administration of the local anesthetic. The teeth involved were immobilized with an arch bar as atraumatically as possible and occlusion checked. (fig.1) The patient was given detailed postoperative instructions like no mouth rinsing for 24 hours, no smoking for 24 hours, soft diet for 24 hours and prescribed medication to be taken as instructed. Antibiotics were used following the procedure considering that their use may prevent a late bleed due to infection. An antibacterial mouthwash was prescribed. Emergency contact details were given to the patient in case of a problem. The patient was followed up every 24 hours for the next 5 days and no bleeding episode was encountered. After a period of 4 weeks, at the time of arch bar removal, the same procedure of factor concentrates and EACA administration was followed and the procedure was completed uneventfully. (fig.2) The patient was followed up for a further period of 5 days. DISCUSSION: Dental surgeons must be aware of the impact of bleeding disorders on the management of patients. Patient evaluation and history should begin with standard medical questionnaires. For the purpose of history-taking, a clinically significant bleeding episode(1) is one that continues beyond 12 hours, causes the patient to call or return to the dental practitioner or to seek medical treatment or emergency care, results in the development of

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Dr. Vivek Gurjar, et al hematoma or ecchymosis within the soft tissues or requires blood product support. When a bleeding disorder is suspected, laboratory investigations, including blood counts and clotting studies should be carried out. Preoperative laboratory tests(2)include bleeding time to determine platelet function, activated partial thromboplastin time to evaluate the intrinsic coagulation pathway, international normalized ratio to measure the extrinsic pathway and platelet count to quantify platelet function. Hemophilia A is an X-linked hereditary disorder with a deficiency of factor VIII. In about 30% of cases, there is no family history of the disorder and the condition is the result of a spontaneous gene mutation. All races and economic groups are affected equally. Hemophilia is considered severe when plasma activity is