Knowledge . Service . Love
Journal of the Indian Dental Association
Tamil Nadu State Branch
ALA ST SN OE
C
D
IA
N
T
A
I
I
...
Guidelines for Authors
Submit all manuscripts to :
Prof. Dr. A. Thangavelu, MDS, DNB.,
Vel Dental Home,
No.10, Bharathi St...
Terms & Conditions:
Whilst every attempt will be made to ensure that all aspects of exhibition and sponsorship mentioned
w...
From the President's desk
"REMEMBER THAT THE GREATEST REWARD YOU GET FOR YOUR EFFORTS IS NOT WHAT YOU GET
FORTHEM,BUTWHATY...
From the Secretary's desk
Hello Members,
Wish youall a veryHappy NewYear.
First of all I congratulate the Editor Dr. Thang...
From the Editor's desk
Warm greeting to all members of the IDA state branch. The activities of our state branch and all lo...
Journal of the Indian Dental Association - Tamil Nadu
Contents
FORSUS FOR CORRECTION OF CLASS II MALOCCLUSION – A CASE REP...
Contents
Vol. 6 Issue. 20 January - March.-2014
MANDIBULAR CANINE INDEX – A KEY FOR SEXUAL DIMORPHISM 33
1 2 3
D. Thamarai...
JIDAT, Vol.6, Iss.20, January-March.-201401
INTRODUCTION:
Among all malocclusions, Class II malocclusion
constitutes appro...
2) by attaching a Gurin lock at the distal side of the lower
canine bracket, if necessary at some distance, 3) by
crimping...
JIDAT, Vol.6, Iss.20, January-March.-201403
Fig 5: Profile change, pre and post Forsus treatment
Fig 4: Extra oral and int...
REFERENCES:
1. William R. Proffit, Henry W. Fields, David M. Sarver.
4th ed. St Louis: Elsevier mosby; 2007.
2. Muralidhar...
JIDAT, Vol.6, Iss.20, January-March.-201405
INTRODUCTION:
Dental implants are prosthetic devices, made of
alloplastic mate...
placement. Such a delayed loading protocol was aimed at
allowing undisturbed healing and complete
osseointegration before ...
implants supporting a mandibular overdenture. Four
implants were placed per
patient, connected by a splinted bar attachmen...
JIDAT, Vol.6, Iss.20, January-March.-2014 08
Fig.1 Mandible at the time of implant placement
with moderate bone resorption...
CONCLUSION
In conclusion, within the limits of this interim report,
immediate loading of two
implants supporting a locator...
31. Gatti C, Chiapasco M: Immediate loading of
Branemark implants: a 24-month follow-up of a
comparative prospective pilot...
JIDAT, Vol.6, Iss.20, January-March.-201411
INTRODUCTION:
Stereotactic ( Greek word stereo means 3 dimensional ,
tactic to...
anatomical landmark or limitation of access. Major
limitation factor is whether there is unpredictable
movements of tissue...
but critical to understand .Now in knee replacement and
neurosurgery shows improved level of accuracy.
Complex and individ...
JIDAT, Vol.6, Iss.20, January-March.-2014 14
INTRODUCTION:
Ectodermal Dysplasia represents a group of inherited
condition ...
Phase I: Introductory phase
The child was brought regularly to the department of
Pedodontics for a week as recommended by ...
esthetic and psychological perspectives[2], [9].This case
report details the treatment phases for an ED patient
which take...
Fig 9: Intra oral view of inserted final prostheses
Fig 10: Pretreatment and post treatment photographs of
the patient in ...
JIDAT, Vol.6, Iss.20, January-March.-2014 18
INTRODUCTION:
A precise knowledge of the root canal system and its
variations...
FIGURESDISCUSSION
Clinically, with the numerous morphological and
anatomic variations of teeth detected and reported of la...
JIDAT, Vol.6, Iss.20, January-March.-2014 20
Figure 4 - Mastercone Figure 7 - Followup Radiograph
Figure 5 - Mastercone Ra...
JIDAT, Vol.6, Iss.20, January-March.-201421
INTRODUCTION:
Every human being likes to lead a healthy life in the
society. H...
history, dental history, and medical history and brushing
habits of patients. From this, percentage and prevalence
of root...
Table : 2 Age and sex wise analysis of different stages of
endodontic cases
Values with in the ( ) indicates the percentag...
increased with age 18-35 and 36-50 and no marked
gender differentials were observed. But gum disease was
high in all age g...
powder and ash on root canal infection was studied
(Figure 2). In the present analysis, male brush with tooth
powder showe...
JIDAT, Vol.6, Iss.20, January-March.-201426
INTRODUCTION:
Developmental anomalies of the dentition are not
infrequently ob...
with slightly higher rate seen in Asian populations.
Approximately 76-86% of cases represent single-tooth
hyperdontia (5)....
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW
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LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW

  1. 1. Knowledge . Service . Love Journal of the Indian Dental Association Tamil Nadu State Branch ALA ST SN OE C D IA N T A I I O D N NI Journal Office : Vel Dental Home, No.10, Bharathi Street, Pondicherry - 605 001. Volume 6 Issue 20 January-March. - 2014 Advisors Dr. S. Thillainayagam Dr. C.R. Ramachandran Dr. Gunaseelan Rajan Dr. George Paul Dr. Sivapathasundaram Dr. S.M .Balaji Dr. N.R. Krishnaswamy Editor in chief Associate Editors Assistant Editors Sectional Editors Reviewers Theme Editors Editorial Manager Dr. A. Thangavelu Dr. Jayantha Padmanaban Dr. G. Ulaganathan Dr. J. Selvakumar Dr. V. Arun Prasad Rao Dr. Thamarai Selvi Dr. R. Madhan Dr. A. Tamizhchelvan Dr. G. Mohan Dr. Vijay Vaikunth Dr. S. Rajasekar Dr. R. Sasirekha Dr. A.P. Maheswar Dr. S. Murugesan Dr. Subramanium Dr. S. Ramaswamy Dr. Vijayalakshimi Dr. Madhavan Nirmal Dr. Vidya Dr. S. Karthikeyani Dr. A.L. Meenakshisundaram Dr. T.R. Sudharson Dr. J. Johnson Raja Dr. C. Hari Prasath Dr. V. Balakumar Dr. Y.A. Bindhu Dr. A. Arvind Kumar Dr. Senthil Kumar Dr. J. Kannaperuman Dr. M. Ramaswamy Dr. N. Dhineksh Kumar Dr. Jagdeep Raju Dr. Srivatsa Kengasubbiah Dr. Yoganand Dr. K. Vasanthakumar Publisher IDA TN State Branch President Honorary State Secretary Honorary Treasurer President-Elect Imm. Past President Vice Presidents Hon. Asst. Secretary Convenor C.D.E. Convenor C.D.H Honorary Editor DR. S. THILLAINAYAGAM DR. C. SIVAKUMAR DR. T.S. RANJITH DR. T. GOKULRAJ DR. D. SENTHIL KUMAR DR. D. MANIVANNAN DR. K.K. UMASHANKAR DR. V. BASKAR DR. A.L. MEENAKSHISUNDARAM DR. KARTHIK KANDAPALANIVEL DR. A.P. MAHESWAR DR. ANNAMALAI THANGAVELU Convenor - Care & Concern DR. BALA. SIVA GOVINDAN Edited by Prof . Dr. A. Thangavelu MDS,DNB. Central Council Members Dr. Thillainayagam .S Dr. Sivakumar .C Dr. George Thomas Dr. (Capt) Bellie .R Dr. Arun .R Dr. Sudharson .T.R Dr. Maheswar .A.P Dr. Meenakshi Sundaram .A.L Dr. Murali Baskaran .K Dr. Aravind Kumar .A Designed & Printed by Kannan Offset, Pondicherry - 1. www.jidat.in Executive Committe Members Dr. Anand Yokesh .C.A Dr. Babu .R Dr. Balamurugan .L Dr. Dinakar .J Dr. Ganesh .S.R Dr. Gopalakrishnan .S Dr. Harihara Vel .V.P Dr. Kalaiselvan .N Dr. Kandasamy Ramesh .M Dr. Kanna Peruman .J Dr. Kingsly Selvakumar Dr. Murugan .R Dr. Mohamhed Mustafa .S.T Dr. Nanda Kumar .G Dr. Prassana Lakshmi Dr. Raja Ganesh Dr. Rajapandian Dr. Rajarajan Immanuvel Dr. Rajasekaran .K.G Dr. Ramakrishnan Dr. Ramasubramanian Dr. Samuel Sudhakar Dr. Saravanan .N Dr. Shaju .V.M Dr. Shankar Ram Dr. Sukumaran .DK Dr. Swamy .T.P Dr. Syed Rafiq .S Dr. Thiruneelakandan .S Dr. Umalakshmi Dr. Vinola Dr. Johnson Raja Dr. Vijayakumar .P Dr. Raby John .J Dr. Iyyappan Shankar .V Dr. Surendran .G.P. Dr. Annamalai Thangavelu Dr. Rajmohan .A Dr. Balakumar .V Dr. Pranav Balaji
  2. 2. Guidelines for Authors Submit all manuscripts to : Prof. Dr. A. Thangavelu, MDS, DNB., Vel Dental Home, No.10, Bharathi Street, Pondicherry - 605 001. 1. A Covering letter with the following words signed by all the authors should be submitted "The submitted material has not been published earlier and it is not under consideration for publication elsewhere. The copyright of the paper if published will stand transferred to the Journal of Indian Dental Association. We will indemnify and keep indemnified The IDA Tamilnadu State Branch and the Editorial Committee and the Editor of the Journal of the Indian Dental Association Tamilnadu against all claims and expenses including legal costs in case of breach of copyright or other laws arisingas a resultof publication of ourarticles" 2. Submit the final version of manuscript in MS Word format in a CD or send it by mail to the Editor newjidat@gmail.com 3. Senda Scanned photograph of theauthor/s 4. Editiorial decisions-all manuscriptssubmittedarepeerreviewedbyatleastone external peerreviewer. 5. Decisions of the Editorials committee will be final 6. The Editor has the right to alter and modify the articles as per needs and space restrictions Manuscripts, Length and number of references-guidelines Research Articles Case Reports Correspondence 1. Manuscript Text Parts 1. Title pages 2. Postal Address/ Labelsheet 3. Blind Title Page 4. Structured Abstract i. Objectives i. Materials and Methods i. Results ii. Conclusions 5. Introduction 6. Methods 7. Results 8. Discussion 9. Conclusions 10. Acknowledgments 11. Legends for figures 12. References 1. Title pages 2. Postal Address/ Labelsheet 3. Blind Title Page 4. Case Report/s 5. Comments 6. Acknowledgments 7. Legends for figures 8. References list 1. Title pages 2. Postal Address/ Labelsheet 3. Blind Title Page 4. Letter 5. Acknowledgments 6. References list 2. Tables and figures Total tables + figures = 5 no tables +2/3 figures no table 3. Manuscript length 2000 words maximum 6000 words maximum 600 words maximum 4. References Original 20 review 40 3 to 5 3 to 5
  3. 3. Terms & Conditions: Whilst every attempt will be made to ensure that all aspects of exhibition and sponsorship mentioned will take place as announced, the organizer reserves the right to make changes if required. Allotment on first-come-first-booked basis. The organizer reserves the right of final decision regarding allocation ofexhibition booths. The organizer is not responsible for personal accidents and damage to private property of exhibitors. Therefore exhibitors may wish to make their own arrangements with respect to personal insurance. Acceptance of Sponsorship applications will be at the sole discretion of the Organizer. The organizer reserves the right to decline applications based on any association, direction, indirect, that does not uphold the objectives of the Conference without assigning any reason whatsoever. Organizer will not be held responsible for bank handling fees. Hence please add bank charges as applicable. Payment can be made as Cash/DD. If paying through DD, the details should be as follows: Account Number : 1170135000003050 DD Name : 32nd Tamilnadu State Dental Conference Bank : Karur Vysya Bank IFSC Code: KVBL0001170 Please attach copy of remittance to Conference secretariat. The balance of sponsorship amount to be paid on or before 1st October, 2014. Any loss or damage claims or disputes relating to sponsorship package or theConference will be governed by the Indian Law and Courts ofNamakkal jurisdiction only. However in the event of a dispute, both parties agree to arbitration before approaching any court oflaw. Above said terms and conditions were subject to change without prior notice. Please visit our website www.32tnsdc.com for updated information. Cancellation Policy: Once confirmed, sponsorship/booth space cannot be cancelled or transferred. No refund on cancellation. No refund if postponement or cancellation of event due to reasons beyond organizer controlviz, natural calamities, riots, strike, etc. Dentophoria’ nd 32 Tamilnadu State Dental Conference 2014
  4. 4. From the President's desk "REMEMBER THAT THE GREATEST REWARD YOU GET FOR YOUR EFFORTS IS NOT WHAT YOU GET FORTHEM,BUTWHATYOUBECOME BYTHEM" Itakeitasa privilege topresentmymessagetoouresteemedjournal-JIDAT. Thank youall forallowingmetheopportunitytoserveyou forthisyear2014-asyourpresident. Itrulyappreciateyourtrustand confidencein meand ourassociation. As I begin my term as president and past EDITOR ,I always keep in mind that the success of our professional association is not possiblewithouttheactivesupportand involvementtopublish ourjournal withoutany interference. I congratulate our secretary and editor prof.Dr.A.Thangavelu that they proved their talents at national level and their award winning spreeforourassociation.Ialso appreciateeditor'sefficiencyand continuingefforttopublish all thefourissuesin time. One of ourobjectivesistofurtherenhanceourmembershipgrowth. Thefirstresponsibilityof a leaderistodefinereality,thelastistosaythank you,in between,theleaderisa servant. With thatin mind Iinviteyou tocallore.mail ustoshareyourthoughts,ideasand feedbacktosupportourjournal. Ilook forwardtohearingfromyou and seeingyou atone of ourmany upcoming events. Asalways,thank you forbeing a IDA member. Lastbutnot leastkindlysupportCARE AND CONCERN. With kind regardsand wishes Prof.Dr.S.Thillainayagam M.D.S. President IDA-TN drthillainayagam@gmail.com
  5. 5. From the Secretary's desk Hello Members, Wish youall a veryHappy NewYear. First of all I congratulate the Editor Dr. Thangavelu for the endless effort for IDA Tamilnadu State Journal and IDA activities. IDA Tamilnadu State got Best State Branch Journal Award from IDA Head –Office. I am very proud to serve with these typesof dedicativepersonalities. The journal is the new set of challenges, trends to deliver our ability. We need more peoples to write. The needy peoples are there to read the journal. I hope you are the one to inspire us to do more like this. All over the world 30% of peoples are readingjournals bypapers.Weareproviding E-Journal also.ReadMore.Getmoreknowledge. Wish you all thebest. Best Wishes. Dr.C. Sivakumar Hon. Sec IDA TN
  6. 6. From the Editor's desk Warm greeting to all members of the IDA state branch. The activities of our state branch and all local branches are going on actively from the beginning of this association year 2014-2015. The Journal was slightly delayed because we were waiting to receive the complete list of subscribers from the local branch. I am happy to bring out this first issue of this year. I request the entire dentalpractitionertosubscribethisjournal and bebenefitted. I understand that all the members are expecting many new programs of the IDA. Especially the forthcoming FDI in Greater Noida . The Head office has come out with attractive offers and excellent scientific and social program during the FDI. It should be a life time opportunity for the India Dentist to host and participate in the World Dental Congress. I wish and request all of you to grab this opportunity to be a part of the mammoth event .Each and every dental practitioner should register for this conference and be proud of our country to host this international congress. The next important issue which every member should be prepared is for the newly proposed “Clinical Establishment Act “by the central and state government. The IDA state branch has taken all the initiative to standardize the rule according to the proposed norm and circulate the rules among the members and conductan inspectionon requesttothisclinicand givean approval stickeras“IDA approvedClinic”. As we need to maintain the basic standards and cop up with the present needs of our patients these types of approvals as become mandatory. I request all the members to co operate and do the needful to update their infrastructures and knowledge to executethe“ParExcellencedentalservice”toourneedfulpatients. Warm Greeting Prof. Dr. A. Thangavelu, MDS, DNB., Editor-in-Chief, JIDAT Knowledge, Service, Love Nothing as Empowering as Knowledge, Nothing as Compassionate as Service, & Nothing as Gratifying as Love!!!
  7. 7. Journal of the Indian Dental Association - Tamil Nadu Contents FORSUS FOR CORRECTION OF CLASS II MALOCCLUSION – A CASE REPORT 01 1 2 3 Dr. P J Antony , Dr. Joby Paulose , Dr. Muhammed Shibin , LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW 05 1 2 3 ABDULGANI AZZ. , BAJALI M. , ABU-HUSSEIN M. STEREOTACTIC NAVIGATION IN ORAL AND MAXILLOFACIAL SURGERY - A REVIEW OF LITERATURE 11 1 2 3 Deepu . S , Dhineksh kumar , Mathew jose . DENTAL MANAGEMENT OF AN ECTODERMAL DYSPLASIA PATIENT – A STAGE BY STAGE APPROACH : A CASE REPORT. 14 1 2 3 Dr.Karthikeyani. S , 2. Dr.Bindhoo. Y.A, , 3. Dr.V.R.Thirumurthy . ENDODONTIC MANAGEMNT OF RADICULOUS MAXILLARY PREMOLARS -A case report 18 1 2 3 Dr. Velmurugan A , Dr. Bhavani S , Dr. Deepak . PREVALENCE OF ENDODONTIC INFECTIONS IN HOSPITAL REPORTED CASES AT KANYAKUMARI DISTRICT, TAMIL NADU 21 1 2 3 S.R.Sri Ramkumar *, Dr.Mano Christaine Angelo *, Dr.N.Sivakumar * “AN UNUSUAL OCCURRENCE OF HYPERDONTIA AND MICRODONTIA IN SINGLE CASE” 27 1 2 3 4 Dr. Anusha Rangare Lakshman , Dr. Sham Kishor Kanneppady , Dr. Preethi Balan , Dr. Chaithra Kalkur . "A SMALL CONE- BIG SCOOP”- A REVIEW ON SCOPE OF CBCT IN DENTISTRY'' 30 Dr.K.Janaki Vol. 6 Issue. 20 January - March.-2014
  8. 8. Contents Vol. 6 Issue. 20 January - March.-2014 MANDIBULAR CANINE INDEX – A KEY FOR SEXUAL DIMORPHISM 33 1 2 3 D. Thamarai Selvi , S.Ranjith , R. Madhavan Nirmal Juvenile Recurrent Parotitis – A rare case report 37 1 2 3 4 5 Dr. E.Pradeepa , Dr.J. Venkatesh , Dr. K. Ramya , Dr.L Vijayalakshmi , Prof. Dr. Ravi David Austin , 40 1 Dr Jaiganesh Ramamurthy RADIATION PROTECTION IN CBCT 44 1 2 P.PAVITHRA , DR. SRI ARATHY Probiotics and its application in dentistry – An overview
  9. 9. JIDAT, Vol.6, Iss.20, January-March.-201401 INTRODUCTION: Among all malocclusions, Class II malocclusion constitutes approximately 15%1. Class II malocclusion could be due to many reasons: (1) Mandibular deficiency with the teeth normally related to the jaw (2) Downward and backward rotation of the mandible produced by excessive vertical growth of the maxilla, or a number of other possibilities1. Various orthodontic appliances have been used to treat Class II malocclusions, including intra and inter-arch appliances, extra-oral appliances, and surgical repositioning of the jaws2. The intra-arch devices may be either removable (cetlin or sagittal appliances) or fixed (Pendulum, Distal Jet, Jones Jig). Inter-arch devices can be either removable (bionator, twin block) or fixed. They can be a pull (Class II elastics, SAIF springs) or push type (Frankel, Herbst, Jasper Jumper) 3.Class II malocclusions are difficult to treatand express greater tendency for relapse3. Intermaxillary elastics are a typical inter-arch method used for Class II correction. The effect of Class II elastics includes an increase in anterior lower facial height, increase in the mandibular plane angle, and clockwise rotation of the mandibular and the occlusal planes. Functional appliances have been shown to produce beneficial effects in growing patients with Class II malocclusions, but the mechanism and effectiveness of these appliances remain controversial4, 5. Some authors 1. Prof & HOD, Orthodontics department, Mar Baselious Dental College, Kothamangalam 2. Reader, Orthodontics department, Mar Baselious Dental College, Kothamangalam 3. Final Year PG student Orthodontics department, Mar Baselious Dental College, Kothamangalam FORSUS FOR CORRECTION OF CLASS II MALOCCLUSION – A CASE REPORT Forsus Fatigue Resistant Device Key words: Malocclusion, Forsus, Functional Appliances ABSTRACT: Among all the malocclusions, Angle’s class II malocclusion is the most prevailing which may be either skeletal or dental, presenting with different clinical manifestations. There are number of appliances to treat such a malocclusion in a growing child, which includes extra-oral appliances, functional appliances and fixed functional appliances. On the other hand, correction of Class II malocclusions in non-growing patients usually includes orthognathic surgery or selective removal of permanent teeth, with subsequent dental camouflage to mask the underlying skeletal discrepancy. Fixed functional appliances are indicated for class II corrections in patients who report late with minimal residual growth left. A case of class II skeletal and dental malocclusion treated with pre adjusted edgewise appliance (PEA) supplemented with Forsus Fatigue Resistant Device (FORSUS) is discussed. 1 2 3 Dr. P J Antony , Dr. Joby Paulose , Dr. Muhammed Shibin , contend that functional appliances have a mandibular skeletal effect6, while others do not believe7. Conventional functional appliances can be used when the patient reports during the active growth spurt period. But after the pubertal growth spurt or during the late stages of puberty, fixed functional appliances would be the better choice. The Forsus fatigue-resistant device spring is a 3-piece telescoping compression spring used for Class II correction8. It is an inter-arch push type spring that produces about 200g of force when fully compressed. The Forsus springs are rarely fully compressed and they are comparable to heavy Class II elastics in force magnitude. The unique coaxial spring design of the Forsus Fatigue Resistant Device addresses the issue of fatigue failure by repeated application of stresses in the coil spring. Unlike other push–spring appliances, such as the Herbst, the FRD can intrude the maxillary first molars and thus correct a Class II malocclusion without opening the bite. The Forsus flat spring made of Nitinol was being used as early as 19998. Later this was modified to a direct push rod type.The three-component Forsus corrector system has obvious advantages over one-piece systems. Forsus spring is directly attached to the lower full archwire without prior removal of brackets. This is quick and easy. Springs can be re-activated during regular checkups until the desired result is achieved. Reactivation can be attained in different ways: 1) by reducing the amount of pin play inside the headgear tube,
  10. 10. 2) by attaching a Gurin lock at the distal side of the lower canine bracket, if necessary at some distance, 3) by crimping a stop onto the push rod. The various options allow the orthodontist to have an individual treatment modality for each case. A combination of one or several of these options is possible. The springs though bulky, do not cause any visible bulging of the cheeks. Unlike one- piece Class II correctors, the Forsus appliance does not limit the patient’s ability to move the jaw. This means the real patient comfort during the course of the treatment. It is not devoid of disadvantages. Very rarely, the push of the spring against the cuspid bracket may cause a loose bracket. A Gurin lock screw, attached to the archwire behind the bracket will act as a stop and may prevent this. Alternatively, an elastic chain can be tied from the loop of the push rod to the hook of the lower molar band. This in short will limit the freedom of movement in mesial direction. The most relevant undesirable effect of using a Forsus spring is protrusion of the lower anteriors. However, this can be prevented by the useof full slot archwire with proper cinching. Another method is to incorporate a lingual crown torque on the anterior segment to counter effect the proclination of lower anteriors. CASE REPORT A female patient aged 15 years came to the orthodontic clinic with a chief complaint of irregularly placed upper and lower front teeth. On extra-oral examination, patient had a convex profile with high mandibular plane angle andincompetent lips. Intra-oral examination revealed an over bite of 7-8mm and bilateral Angles class II molarrelationship (Fig 1). Cephalometricevaluation (Table 1) revealed a class II skeletal pattern (mandibular deficiency with a tendency towards vertical growth pattern and Angles class II malocclusion. VTO was positive (Fig 2). Since the patient’s age was 15yrs, a hand wrist x-ray was obtained which revealed that the patient is in the late stages of puberty. Non extraction treatment with pre-adjusted edgewise appliance therapy was considered. Considering the age of the patient mandibular correction supplemented with Forsus fatigue resistant device was planned. Initial levelling and aligning was achieved in 3 months after the start of treatment with.016“ Niti. As soon as Upper and lower arch wire was stepped up to .019 x .025” SS, a lingual crown torque was incorporated to the arch wire in the lower anterior segment and forsus was placed (Fig 3). After 5 months, sufficient mandibular advancement was achieved and case was finished in class I molar and canine relationship (Fig 4). But the forsus appliance was removed only after 3 months as relapse tendency is more common in case of class II malocclusion. An aesthetic profile was attained (Fig 5) with minimal change in mandibular plane angle (Forsus would not produce a molar extrusion as in case of treatment using class II elastics). An increase in madibular plane would effect a clockwise rotation of mandible which would worsen the skeletal class II problem. Upper begg wrap around retainer and lower canine to canine fixed retainer was given. JIDAT, Vol.6, Iss.20, January-March.-2014 02 PHOTOGRAPHS Fig 1: Pretreatment extra oral and intra oral photographs of the patient
  11. 11. JIDAT, Vol.6, Iss.20, January-March.-201403 Fig 5: Profile change, pre and post Forsus treatment Fig 4: Extra oral and intra oral photographs of the patient after removal of Forsus Variable SNA SNB ANB N perp to Pog GoGn-SN U1-SN U1– NA L1 – NB IMPA Over jet L lip-S line Pre Rx 0 81 0 74 0 7 -8mm 0 34 0 92 0 3mm / 18 0 3mm / 24 0 93 8mm 8mm Post Rx 0 82 0 81 0 1 -2mm 0 34 0 103 0 5mm / 22 0 5mm / 26 0 97 2mm 1mm Table1: Pre & post treatment cephalometric evaluation Fig 2: photograph showing +ive VTO Fig 3:Forsus in place CONCLUSION: A case of skeletal class II malocclusion treated with PEA supplemented with FRD is reported. The Forsus (FRD) can be used in severe cases. Forsus springs work best in patients with convex profiles, but they are indicated in any Class II patients except those with normal mandibles and protrusive maxillae, or with protrusive or overly large mandibles relative to the other cranial structures.
  12. 12. REFERENCES: 1. William R. Proffit, Henry W. Fields, David M. Sarver. 4th ed. St Louis: Elsevier mosby; 2007. 2. MuralidharReddyY, Madhukar Reddy R. A case report of growing skeletal class ii treated with forsus fatigue resistance appliance. Annals and Essences of Dentistry Vol. - III Issue 1 Jan – Mar 2011. 3. WilliamVogt: The Forsus Fatigue Resistant Device, JCO 2006. 4. McNamara, J.A.; Bookstein, F.; and Shaughnessy, T.: Skeletal and dental changes following functional regulator therapy, Am. J. Orthod. 88:91-111, 1985. 5. Valant, J.R. and Sinclair, P.M.: Treatment effects of the Herbst appliance, Am. J. Orthod. 95:138-147, 1989. 6. Falck, F. and Frankel, R.: Clinical relevance of step-by- step mandibular advancement in the treatment of mandibular retrusion using the Frankel appliance, Am. J. Orthod. 96:333-341, 1989. 7. Creekmore, T.D. and Radney, L.J.: Frankel appliance therapy: Orthopedic or orthodontic? Am. J. Orthod. 83:89-108, 1983. 8. El-Sheikh MM, Godfrey K Manosudprasit M, Viwattanatipa N. Force deflection characteristics of the fatigue resistant device spring; an in vitro study. World J Orthod. 2007 Spring: 8(1): 30-6. JIDAT, Vol.6, Iss.20, January-March.-2014 04 Corresponding author : Dr. P J Antony Prof & HOD, Orthodontics department, Mar Baselious Dental College, Kothamangalam
  13. 13. JIDAT, Vol.6, Iss.20, January-March.-201405 INTRODUCTION: Dental implants are prosthetic devices, made of alloplastic materials that are inserted into the oral cavity to provide retention and support to removable and fixed dental prostheses [1, 2]. The concept of using implants to replace teeth is age old. In fact, in ancient history thousands of years ago, ivory teeth were used as implants in Egyptian mummies. However, the era of modern dental implantology began much later, in the 1940’s, with the discovery of screw type implants by Formiggini et al [3, 4]. The introduction of the concept and the biology of osseointegration, by Branemark et al (1952), added another milestone in the history of dental implantology [5]. Over the years, this field has significantly evolved and emerged as an extensively used treatment modality for oral rehabilitation The first clinical outcome of surgical procedure is the primary stability of the implant. Primary stability is rigid fixation and lack of micro motion of the implant into the bone cavity [1,6,7]. Absence of stability can lead to excessive mobility and cause fibrous tissue formation around the implants inhibiting osseointegration [7,9]. Primary stability depends on the surgical technique, implant design and the implant site [9,10]. 1. Assist.Prof.,AlQuds University,Jerusalem,Palestine 2. Assist.Prof.,AlQuds University,Jerusalem,Palestine 3. Visiting Prof.Napoli university,Italy-University of Athens,Greece LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW Key words: Locator,Freestanding Implants,Immediate Loading,Mandibular Overdenture ABSTRACT: Successful treatment with the two-implant overdenture has been documented with multiple implant designs (eg, hexagonal, Morse taper, internal connection) and many implant systems. Clinicians may select implants for retention of the two-implant overdenture according to personal experience and preference with confidence that treatment success will not be determined by the selection made. This is due primarily to the anatomy and density of the bone in the anterior mandible. The aim of this case report is to demonstrate the concept of immediate functional loading in the mandible using unsplinted implants to support a locator attachment supported overdenture. 1 2 3 ABDULGANI AZZ. , BAJALI M. , ABU-HUSSEIN M. -Bone tissue is arranged in two macro architectural forms, trabecular or cancellous and cortical or compact. Leckholm and Zarb (1985) have classified bone types in the oral cavity, depending on the relative proportions of cancellous and cortical bone: - Class I: predominantly cortical - Class II: thick layer of compact bone surrounding a dense cancellous core - Class III: thin layer of compact bone surrounding a cancellous core - Class IV: very thin compact layer around a low density trabecular bone Sennerby et al (1992) compared implants placed in rabbit cortical versus cancellous bone and established that cortical bone has a higher modulus of elasticity, is harder to deform and provides greater resistance to motion [11]. Hence, Class I and Class II bone would facilitate higher primary stability The original protocol for loading, as described by Branemark, involved waiting for three months (for mandible) to six months (for maxilla) after implant
  14. 14. placement. Such a delayed loading protocol was aimed at allowing undisturbed healing and complete osseointegration before implants could be loaded. For a long time it was assumed that premature loading would limit peri-implant osteogenesis and induce fibrous tissue formation [7,12]. Schnitman et al (1990) introduced the concept of immediate loading, which has been described as attachment of the prostheses within twenty-four hours to one week after implant placement [13,14]. Some of the advantages of immediate loading are shortened treatment time and early functional, physiological and psychological rehabilitation of the patient. In addition, there have been some claims made about a biologic advantage in the form of enhanced osteoblastogenesis with immediate loading. An in-vivo study by Qi et al (2009), evaluated the response of mesenchymal stem cells to mechanical strain and their consequent gene expression patterns [15]. Their results suggested that mechanical strain might act as a stimulator to induce differentiation of stem cells into osteoblasts [15]. Indeed, cyclic tensile strain has been shown to increase osteoprotegrin synthesis and decrease soluble receptor activator of nuclear factor kappa-B ligand (RANKL), thus favoring bone formation [16]. This theory was tested in an rabbit model by Duyck et al (2007), who concluded that mechanical loading stimulated bone formation and led to a higher bone fraction [17,18]. TREATMENT OF COMPLETE EDENTULISM: IMPLANT OVERDENTURES An overdenture is defined as any dental prosthesis that covers and rests on one or more remaining natural teeth, the roots of natural teeth, and / or dental implants [2]. The concept of overdentures is age old. Ledger as early as 1856, suggested utilizing natural teeth to stabilize removable prostheses and after a whole century Miller introduced the concept of tooth retained overdentures [19]. The downside of these prostheses was frequent failure of abutments caused by periodontaldisease, periapical lesions, caries and fracture of teeth [20]. The introduction of osseointegrated implants and implant-retained prostheses led to a paradigm shift for the management of edentulism. This is true especially for mandibular edentulism, where the problem of advanced alveolar resorption and difficulty in providing stable, retentive and functionally comfortable prostheses seemed to represent a major challenge [21]. JIDAT, Vol.6, Iss.20, January-March.-2014 06 A number of randomized controlled trials have demonstrated increased patient satisfaction and reduced negative impact on quality of life with implant retained overdentures as opposed to conventional dentures in the mandible [22]. Other studies have reported an improvement in chewing ability, bite force and in serum nutritional and anthropometric parameters (such as skin fold thickness, waist hip ratio and body mass index) [23,24]. The long-term efficacy of implant-supported overdentures has been established in many retrospective and longitudinal trials [25,26.27]. Implant overdentures are used in conjunction with attachments and there are many different attachments provided by a large number of manufacturers around the world. The attachments currently available can be broadly divided into twomajor categories: - Splinted / Bar Attachments- Dolder bar and hader bar are examples of splintedattachments - Non-splinted / Solitary / Stud Attachments - Ball attachments, magnets and locators exemplify solitary attachments. Loading of Implant Overdentures A fairly recent systematic review by Gallucci et al (2009), presented the strength of evidence available for different loading protocols (conventional, early and immediate loading) in completely edentulous patients. Their search led to a conclusion that the highest level of scientific and clinical validation was available for conventional loading with mandibular overdentures. However, immediate loading of mandibular dentures was clinically well documented but not scientifically validated [28]. Clinical documentation of immediate loading can be exemplified by various prospective trials that have been conducted using this protocol for mandibular dentures. For example, a longitudinal study with 3-8 years of follow up by Chiapasco et al (2003), looked at success and survival of immediately loaded
  15. 15. implants supporting a mandibular overdenture. Four implants were placed per patient, connected by a splinted bar attachment. A cumulative success rate of 88.2% and survival rate of 96.1% was seen after a mean follow up period of 62 months. The authors concluded that, for about 3 years after immediately loading the implants, the success and survival were the same as that documented for delayed loading. However, with a longer follow up it became evident that immediately loaded implants had a moderate decrease in success rate [29]. Similar results were reported by Kronstrom et al (2010), wherein he advised caution in using immediate loading due to a low survival rate of 81.8% at 1 year follow up [30]. Other investigators have, however, reported higher rates of success and survival using an immediate loading protocol. A cohort study by Gatti et al (2002) has shown a cumulative survival rate of 100% and minimal bone level changes (0.5 -0.9 mm) around immediately loaded implants [31]. Alfadda et al (2009) used historical controls with delayed loading in a prospective cohort study and compared it to immediate loading. At 5 years, they found identical success, survival, satisfaction and impact on quality of life between the two groups [32]. Randomized clinical controlled trials (RCT) are considered as the most reliable (Level I) form of validation in the hierarchy of scientific evidence, essentially because they reduce spurious causality and bias. In order to prove the efficacy and safety of an immediate loading protocol Chiapasco et al (2001)performed a RCT comparing an immediate and a delayed protocol for four splinted implants supporting a mandibular overdenture. They found no difference in cumulative survival rate, bone loss, clinical and radiographic parameters at 2 years between the two groups [33]. Review paper by Gallucci et al (2009) and a 10 years clinical trial by Meijer et al (2009), among many others, have shown that there is no difference in the clinical and radiographic performance of two or four implants supporting a mandibular overdenture [27,28]. Hence, having established that immediately loaded four implants supporting a mandibular overdentures are comparable to JIDAT, Vol.6, Iss.20, January-March.-201407 delayed loaded implants, it would be interesting to see if these results can be replicated when two implants were used in conjunction with unsplinted attachments such as locators. CASE REPORT A 58-year-old female patient without any medical contra- indication for implant therapy presented with an ill- fitting, lower complete denture that she had been wearing for four years. The clinical and radiographic findings revealed slight to moderate mandibular ridge resorption with an ill-fitting lowerdenture (Figs. 1 & 2). The patient was given the option of placing two implants to support her existing lowerdenture. The treatment plan was accepted and included an immediate functional loading by using a locator attachment-supported mandibular overdenture. At the surgical appointment, following the administration of local anaesthetic, a mid-crestal incision was performed and a full-thickness flap was reflected.In addition, osteotomies were prepared in type II bone. Bone taps were used to countersink the sites, after which two ITI Tapered implants (ITI 3,3X14-mm) were placed with the handpiece and hand ratchet. The implants were torqued to 35 N (Figs. 3 & 4).Immediately after implant surgery, the mandibular denture was seated in the patient’s mouth and adjusted to provide clearance in the area of the locator(s). two locators (4 mm in length) were torqued to 30 N (Figs. 7 & 8). Following the suture of the flap with4-0 vicryl, the processing rings were placed over the locators and were picked up directly in the mouth using hard self- curing acrylic (Rebase II, Tokuyama; Figs. 6). The patient was given post-operative instructions, including the use of 0.12 % chlorhexidine gluconate three times a day. She was furthermore prescribed 500 mg of amoxicillin(to be taken every six hours for seven days). The patient was then informed that the implant-supported overdenture was to be left in place for 48 hours. Two days later, she was seen for a follow-up visit and the healing process was uneventful. The black processing rings were switched to blue rings ten weeks after the placement (Figs. 5&6&7). After six months, the patient returned for another follow- up visit and all two locators were torqued to 30 N (Figs. 7&8). It was determined that all two implants had achieved full integration. Currently, the patient is on a six- month recall to ensure the proper maintenance of the implants and the prosthesis(9&10). The last maintenance visit was 24 months post-placementand all implants have maintained healthy soft tissue and a stable bone level.
  16. 16. JIDAT, Vol.6, Iss.20, January-March.-2014 08 Fig.1 Mandible at the time of implant placement with moderate bone resorption Fig. 2_Pre-op panoramic radiograph Fig. 3_Guiding pins at the time of implant placement Fig. 4_Two tapered implants at placement. Fig. 5_Panoramic radiograph immediately after implant placement. Fig. 8_Buccal view of the locators two weeks post- implant placement Fig. 9_Buccal view of the overdenture in place Fig. 10_final smile Fig. 6_The processing rings were picked up directly in the mouth. Fig. 7_Occlusal view of the locators two weeks post- implant placement
  17. 17. CONCLUSION In conclusion, within the limits of this interim report, immediate loading of two implants supporting a locator retained mandibular overdenture seems to be a suitable treatment option. The marginal bone level changes around immediately loaded implants are comparable to those seen around implants loaded with a torque do not effect peri-implant bone loss. Implant survival of immediately loaded implants maybe lower than those loaded with a delayed protocol, but this needs to be confirmed in future investigations with a larger sample size.elayed protocol, at 6 months post surgery. Implant length and peak insertion. Bibliography 1. Meyer U, Joos U, Mythili J, Stamm T, Hohoff A, Fillies T, Stratmann U, Wiesmann HP: Ultrastructural characterization of the implant/bone interface of immediately loaded dental implants. Biomaterials 2004, 25(10):1959-1967. 2. The glossary of prosthodontic terms. J Prosthet Dent 2005, 94(1):10-92. 3.15. Kibrick M, Munir ZA, Lash H, Fox SS: The development of a materials system for an endosteal tooth implant: I. Critical assessment of previous designs. Oral Implantol 1975, 6(2):172-192. 4. Kibrick M, Munir ZA, Lash H, Fox SS: The development of a materials system for an endosteal tooth implant. II. In vitro and in vivo evaluations of a new composite-material design. J Oral Implantol 1977, 7(1):106-123. 5. Branemark PI, Adell R, Breine U, Hansson BO, Lindstrom J, Ohlsson A:Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969, 3(2):81-100. 6. Adell R, Lekholm U, Rockler B, Branemark PI: A 15- year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981, 10(6):387-416. 7. Marco F, Milena F, Gianluca G, Vittoria O: Peri- implant osteogenesis in health and osteoporosis. Micron 2005, 36(7-8):630-644. 8. Soballe K, Hansen ES, H BR, Jorgensen PH, Bunger C: Tissue ingrowth into titanium and hydroxyapatite-coated implants during stable and unstable mechanical conditions. J Orthop Res 1992, 10(2):285-299. 9. Sevimay M, Turhan F, Kilicarslan MA, Eskitascioglu G: Threedimensional finite element analysis of the effect of different bone quality on stress distribution in an implant- supported crown. JProsthet Dent 2005, 93(3):227-234. 10. Buchter A, Kleinheinz J, Joos U, Meyer U: [Primary implant stability with different bone surgery techniques. An in vitro study of the mandible of the minipig]. Mund Kiefer Gesichtschir 2003, 7(6):351-355. 11. Sennerby L, Thomsen P, Ericson LE: A morphometric and biomechanic comparison of titanium implants inserted in rabbit cortical and cancellous bone. Int J Oral Maxillofac Implants 1992, 7(1):62-71. 12. Albrektsson T: Direct bone anchorage of dental implants. J Prosthet Dent 1983, 50(2):255-261. 13. Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV: The effectiveness of immediate, early, and conventional loading of dental implants: a Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants 2007, 22(6):893- 904. 14. Schnitman PA, Wohrle PS, Rubenstein JE: Immediate fixed interim prostheses supported by two-stage threaded implants: methodology and results. J Oral Implantol 1990, 16(2):96-105 15. Qi MC, Zou SJ, Han LC, Zhou HX, Hu J: Expression of bone-related genes in bone marrow MSCs after cyclic mechanica strain: implications for distraction osteogenesis. Int J Oral Sci 2009, 1(3):143-150. 16. Kusumi A, Sakaki H, Kusumi T, Oda M, Narita K, Nakagawa H, Kubota K, Satoh H, Kimura H: Regulation of synthesis of osteoprotegerin and soluble receptor activator of nuclear factor-kappaB ligand in normal human osteoblasts via the p38 mitogen-activated protein kinase pathway by the application of cyclic tensile strain. J Bone Miner Metab 2005, 23(5):373-381. 17. Duyck J, Slaets E, Sasaguri K, Vandamme K, Naert I: Effect of intermittent loading and surface roughness on peri-implant bone formation in a bone chamber model. J Clin Periodontol 2007, 34(11):998-1006. 18. Vandamme K, Naert I, Vander Sloten J, Puers R, Duyck J: Effect of implant surface roughness and loading on peri-implant bone formation. J Periodontol 2008, 79(1):150-157. 19. Miller PA: COMPLETE DENTURES SUPPORTED BY NATURAL TEETH. Tex Dent J 1965, 83:4-8. JIDAT, Vol.6, Iss.20, January-March.-201409
  18. 18. 31. Gatti C, Chiapasco M: Immediate loading of Branemark implants: a 24-month follow-up of a comparative prospective pilot study between mandibular overdentures supported by Conical transmucosal and standard MK II implants. Clin Implant Dent Relat Res 2002, 4(4):190-199. 32. Alfadda SA, Attard NJ, David LA: Five-year clinical results of immediately loaded dental implants using mandibular overdentures. Int J Prosthodont 2009, 22(4):368-373. 33. Chiapasco M, Abati S, Romeo E, Vogel G: Implant- retained mandibular overdentures with Branemark System MKII implants: a prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Implants 2001, 16(4):537-546. 20. Fenlon MR: Periodontal disease, periapical lesions and caries were, in that order, the causes of overdenture abutment loss. J Evid Based DentPract 2005, 5(2):94-95. 21. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, Head T, Lund JP, MacEntee M, Mericske-Stern R et al: The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 24-25, 2002. Int J Oral Maxillofac Implants 2002, 17(4):601-602. 22. Thomason JM, Lund JP, Chehade A, Feine JS: Patient satisfaction with mandibular implant overdentures and conventional dentures 6 months after delivery. Int J Prosthodont 2003, 16(5):467-473. 23. . Morais JA, Heydecke G, Pawliuk J, Lund JP, Feine JS: The effects of mandibular two-implant overdentures on nutrition in elderly edentulous individuals. J Dent Res 2003, 82(1):53-58. 24. . Bakke M, Holm B, Gotfredsen K: Masticatory function and patient satisfaction with implant-supported mandibular overdentures: a prospective 5-year study. Int J Prosthodont 2002, 15(6):575-581. 25. . Vercruyssen M, Marcelis K, Coucke W, Naert I, Quirynen M: Long-term, retrospective evaluation (implant and patient-centred outcome) of the two- implants-supported overdenture in the mandible. Part 1: survival rate. Clin Oral Implants Res 2010, 21(4):357- 365. 26, Attard NJ, Zarb GA: Long-term treatment outcomes in edentulous patients with implant overdentures: the Toronto study. Int J Prosthodont 2004, 17(4):425-433. 27. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vissink A: Mandibular overdentures supported by two or four endosseous implants: a 10-year clinical trial. Clin Oral Implants Res 2009, 20(7):722-728. 28. . Marzola R, Scotti R, Fazi G, Schincaglia GP: Immediate loading of two implants supporting a ball attachment-retained mandibular overdenture: a prospective clinical study. Clin Implant Dent Relat Res2007, 9(3):136-143. 29.Chiapasco M, Gatti C: Implant-retained mandibular overdentures with immediate loading: a 3- to 8-year prospective study on 328 implants. Clin Implant Dent Relat Res 2003, 5(1):29-38. 30. Kronstrom M, Davis B, Loney R, Gerrow J, Hollender L: A prospective randomized study on the immediate loading of mandibular overdentures supported by one or two implants: a 12-month follow-up report. Int J Oral Maxillofac Implants 2010, 25(1):181-188. JIDAT, Vol.6, Iss.20, January-March.-2014 10 Corresponding author : Abu-Hussein Muhamad DDS,MScD,MSc,DPD,FICD 123 ARGUS STREET, 10441 ATHENS GREECE abuhusseinmuhamad@gmail.com
  19. 19. JIDAT, Vol.6, Iss.20, January-March.-201411 INTRODUCTION: Stereotactic ( Greek word stereo means 3 dimensional , tactic to touch) surgery formerly was used in humans with thalamic lesions to treat parkinsonism. Current technique would be more appropriately termed as imageguided Stereotacticsurgery. At the end of 19thcentury, Sir Victor Horsley with the help of physicist Mr. Clarke,introduced anapparatus, which could be fixed to the head of the animals, enable him to introduce a 1 probe into a desired area of the brain . After a long time about fifty years later the technique was introduced to human neurosurgery by Spisel in 1947.Now surgical navigation has been described in a wide variety of maxillofacial procedures such as approaches to the skull base, Para nasal sinus and orbit to remove foreign bodies 2 and for orthognathic as well as implant surgeries Early the surgeons used bulky frames which attaches to patient head for guidance. Now the modern navigation surgery equipped with guidance system. Obviously the nomenclature also shifted from framedstereotactic surgery to frameless stereotactic surgery. There are four t y p e s o f g u i d a n c e s y s t e m a v a i l a b l e mechanical,acoustic,electromagnetic and optical based. Mechanical devices are bulky and infrequently used acoustic and electromagnetic devices have problems of interference with echoes and diathermy. Optical system uses infrared light which is not compromised with theatre light. The light source either attaches to the active 1. Postgraduate trainee, Sreemookambika institute of dental sciences , kulasekharam, kanyakumaridist 2. Reader, Sreemookambika institute of dental sciences , kulasekharam, kanyakumaridist 3. Professor and head of the department, Sreemookambika institute of dental sciences , kulasekharam, kanyakumaridist STEREOTACTIC NAVIGATION IN ORAL AND MAXILLOFACIAL SURGERY - A REVIEW OF LITERATURE ABSTRACT: Navigational surgery is applicable in any circumstances whether three dimensional surgical plan from computed tomography or magnetic resonance imaging possibly into surgical reality. But it is not easy because of absolute limitation of access or lack of anatomic land mark.For a successful navigation surgery it is very important to know digital recording, intraoperative tissue position and its changes. In maxillofacial surgery highly beneficial in terms of navigational stereotaxy is orbital reconstruction, hemi facial syndromes. Modern navigation system has multiple options for referring patient anatomy especially for movable structure like mandible and tongue 1 2 3 Deepu . S , Dhineksh kumar , Mathew jose . marker on the instrument or on the camera which got the passive marker that reflect into the instrument and the software that allow to manipulated and view the images in a way that is analogous to viewing the patient at operation . Fig 1 optical guidencesystem and passive markers a)passive marker on the leftside of the patient head b) passive marker on the instrument pointer NAVIGATION IN MAXILLOFACIAL SURGERY Computer aided oral and maxillofacial surgery is divided into three categories they are 1) computer aided preoperative planning 2) intra operative navigation 3) intraoperative CT / MRI imaging.3It is possible to make three dimensional plan for an operation, but is difficult to translate that plan during operation because of a lack of
  20. 20. anatomical landmark or limitation of access. Major limitation factor is whether there is unpredictable movements of tissue in anaesthetized patient4. A change in the position of the tissue from pre-operative scan to the position on the table result in the CT or MRI being an inaccurate reflection of the actual position of the structure for example position of mandible before preoperative MRI and position on the surgical table . To overcome the inconvenience intraoperative scanners are introduced. Registration is the identification of at least three match points that are visible for the patient and for the scan used for navigation. It is very much essential that these points can be accurately identifiable and be relevant to surgical site .The ideal match point on bone is considered as a prefixed screw, but it is not applicable for primary surgery patient5. Other method is to fabricate a splint the fits accurately over the teeth and place screws by metal markers .they can locate easily and navigation probecan easily positioned over the screw head and transfer the position from patient to computer. Marker screws made in this way is known as fiducialsor registration match point. The center of registration match point is the most accurate andmovement with distance more than10 cm, declines the levelof accuracy. The accuracy of navigation systems used for maxillofacial surgery should not exceed 1 mm of deviation in total 6.Attention has to be paid that the screw markers are not inserted too close to adjacent metallic fillings. Instead of screws, oil or contrast medium containing capsules are attached to the plastic splint if the data acquisition and navigation is based on a MRI N A V I G A T I O N I N O R B I T A L T R A U M A /RECONSTRUCTION In case of orbital trauma or reconstruction the uninjured orbit is copied digitally and flipped around the sagittal plane to be superimposed over the injured region.This is done by matching the adjacent normal anatomy which can often to be found at the root of the zygomatic arch ,apex of the orbit , and the supraorbital rim . The flipping digital copies givesa good navigation target when applied to zygoma, it is less clear when applied to orbital floor because orbital floor is too thin may not clearly seen in CT. Surgical procedures are similar to surgery without using stereotactic surgery. For orbital reconstruction, after adequate exposure is made orbital bony segments are JIDAT, Vol.6, Iss.20, January-March.-2014 12 osteotemized and mobilized and zygomais reconstructed starting atzygomatic arch and frontozygomatic sutures. Navigation helps to position the fragments in ideal position from the preoperative three dimensional plan rather than relay on unpredictable clinical data Navigation provides a wonderful medium for teaching most sensible anatomic areas so that easy to identify and demonstrate the orbital plate of palatine bone and the orbital floor can be dissected correctly. The flipped digital orbital floor can be used as a navigation target to ensure that it is adequately reconstructed and corrected orbital volume. Intraoperative navigation was used to assess the accuracy of the restored internal and external orbital anatomy by assessing various points on the digitalized images NAVIGATION IN ORTHOGNATHIC SURGERY Intraoperative navigation surgery elaboratelyhelp toaccessvertical ,horizontal and sagittal jaw and tooth relation .It is potentially useful toaccess bony relationship and implement osteotomies especially in hemi mandibular hyperplasia also used as a research tool for 3 the accuracy of orthognathic surgery . NAVIGATION IN MANDIBULAR SURGERY Reported dynamic computer navigation system used for lower jaw4 FUTURE OF NAVIGATION SURGERY IN MAXILLOFACIAL SURGERY A major drawback of the navigation system is a high consumption of human financial resources and technical expertise7.Navigation Process is still complex to explain Investigator Shulltesetal Hoffman etal Watzingeretal Caspetal Caspetal Caspetal total Distraction osteogenesis Dental implantation Dental implantation Dental implantation procedure Screw removal from condyle using extraoral approach Removalofosteosynthesismaterial,implants Patient(n) 1 4 concept Positioning mandible using acrylic splint Positioning mandible using acrylic splintand mounting DRF to mobilesegment Mounding DRF to mandible Mounding DRF to mandible Mounding DRF to mandible Mounding DRF to mandible 2 1 2 1 11
  21. 21. but critical to understand .Now in knee replacement and neurosurgery shows improved level of accuracy. Complex and individual nature of the maxillofacial cases make hard to compare outcome with or without navigation surgery .In future robotic forms which execute specific steps completely autonomously. The techniques of virtual reality and computer assisted surgery are increasingly important in their medical applications. Many applications are still being developed or are still in the form of a prototype. It is already clear, however, that developments in this area will have a 9 considerable effect on a surgeon's routine work . REFERENCES 1. Horsley v, Clarke R H .structure and function examined by a new method. Brain 1908;31;45-124 2. J. Collier Stereotactic navigation in oral and maxillofacial surgery. Br J Oral Maxillofac Surg. 2010; 48: 79-83 3. R Bryan Bell computer planning and intraoperative navigation in orthognathic surgery Joms 2011-03-01 vol 69 page 592 -605 4. Heinz The o Lubbers , Jacchin A. Obwegeiser A simple and flexible concept for computer navigated surgery of the mandible JOMS 2011-03-01-vol 69 issue 3 page 924-930 5. Nyachhyon P, Kim PC Intraoperative stereotactic navigation for reconstruction in zygomatic-orbital trauma Nyachhyon P, Kim PC . J Nepal Med Assoc 2011;51(181):37-40 6. A. Martin, R.J. Bale, M. Vogele, W. Freysinger, A.R. Gunkel, W.F. Thumfart, The VBH mouthpiece: a registration device for frameless stereotactic surgery, Radiology 208 (1998) 261. 7. Max H, Christian HR, Rainer S. Indications and limitations of intraoperative navigation in maxillofacial surgery. J Oral Maxillofac Surg. 2004; 62: 1059-1063 8. kamatydaurakzai km. adhikariar Matthews d , kalairajah y ,field re ,Does computer navigation in total knee athroplasty improve patient out come at mid termfollowup?Intorthop 2008;26 JIDAT, Vol.6, Iss.20, January-March.-201413 9. Stefan Hassfeld, Joachim MuhlingComputer assisted oral and maxillofacial surgery – a review and an assessment of technology ijomsVolume 30, Issue 1, February 2001, Pages 2–13 Corresponding author : Deepu . S Postgraduate trainee, Sreemookambika institute of dental sciences , kulasekharam, kanyakumaridist
  22. 22. JIDAT, Vol.6, Iss.20, January-March.-2014 14 INTRODUCTION: Ectodermal Dysplasia represents a group of inherited condition in which two or more ectodermally derived anatomical structures exhibit aberrant development. The tissues primarily affected are skin, hair, nails, sweat glands and teeth [1], [2], [3], [4], [5]. The most common dental features are oligodontia or hypodontia which causes reduced alveolar bone growth [5], [6]. In addition teeth if present may show abnormal crown morphology. The ensuing functional and psychological impacts are overcome by early dental intervention which helps these children develop a positive self-image[7], [8], [9]. But insufficient awareness among parents and reluctance among the dentists in managing these patients, greatly affect the social integration and hence the psychological development of these children. This case report highlights the successful dental treatment of a 6 yr old male ED patient on a stage by stage basis. CASE REPORT: A 6 year old male patient residing in an orphanage was brought to the department of Pedodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore with the chief complaint of difficulty in chewing food. The child was thin built, short statured, apprehensive and very shy. The patient exhibited features of ED - hypotrichosis, hypohydrosis, hypodontia, frontal bossing and depressed nasal bridge (Fig 1). Intra oral examination 1. M.D.S, Professor, Department of Pedodontics, 2. M.D.S, Reader, Department of Pedodontics, 3. M.D.S, Professor, Department of Prosthodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore. DENTAL MANAGEMENT OF AN ECTODERMAL DYSPLASIA PATIENT – A STAGE BY STAGE APPROACH : A CASE REPORT. Key words: Ectodermal Dysplasia, Oligodontia, Hypodontia, Staged Treatment Plan, Training Denture Base. ABSTRACT: Ectodermal dysplasia is a hereditary condition associated with the defective development of two or more tissues of ectodermal origin. Skin, hair, nails, sweat glands and teeth are the ectodermal tissues primarily affected. The characteristic clinical features noted are hypotrichosis, hypohydrosis or anhydrosis and hypodontia or anodontia. The clinical features cause esthetic, functional, phonetic and psychological disturbances in the patient. Dental management of young ectodermal dysplasia patient is difficult as these children are psychologically immature. So in addition to extensive dental treatment, they also require proper understanding and handling of child psychology. This case report describes the dental management of a six year old male child with ectodermal dysplasia using a staged treatment plan. 1 2 3 Dr.Karthikeyani. S , 2. Dr.Bindhoo. Y.A, , 3. Dr.V.R.Thirumurthy . revealed intact permanent maxillary right first molar, missing mandibular deciduous central incisors and a severe loss of vertical dimension due to grossly decayed deciduous dentition (Fig 2 and Fig 3). Radiographic examination (OPG) revealed only few tooth buds - permanent maxillary (Left) and mandibular (Left and right) first molars and mandibular central and lateral incisors. Clinical and radiographic findings of the child confirmed Ectodermal Dysplasia. Elaborate dental treatment was required in the form of extractions, restorations and finally prostheses to replace the missing teeth. Proper treatment sequencing is important in these patients to achieve the desired functional and esthetic results. So a team comprising of psychologist, pediatrician, pedodontist and prosthodontist was formed and a treatment plan was formulated. The most important part of the treatment plan was to create awareness about the necessity of early and continued dental treatment for the child and to provide sufficient time for the child to get accustomed to the dental environment. The other important part was to preserve as many teeth as possible to maintain the alveolar bone height. The treatment was planned on a stage by stage basis. • Phase I – Introductory phase • Phase II – Pedodontic management • Phase III – Prosthodontic management • Phase IV – Recall & maintenance
  23. 23. Phase I: Introductory phase The child was brought regularly to the department of Pedodontics for a week as recommended by Nowak to build up his trust [3]. Counselling sessions, Communication, Tell-show-do approach, and modeling methods were followed to help the child get acquainted with the dental environment. This helped the child to become friendlier and less shy to the members of the dental team. At this point having won the patient’s trust, decision was made to start the dental treatment. Phase II: Pedodontic phase Symptomatic grossly decayed deciduous molars and mandibular lateral incisors were extracted. Maxillary deciduous central and lateral incisors and all the deciduous canines were retained after pulpectomy (Metapex, Korea) to maintain alveolar bone height. Phase III: Prosthodontic Phase The child was slowly introduced to the prosthetic phase of the treatment after satisfactory healing of extraction sites. Diagnostic impressions were made with irreversible hydrocolloid (Tulip- Cavex) in stock trays and models poured with dental stone (Fig 4). The child exhibited excess salivation and gag reflex on the introduction of the impression trays. This raised doubts regarding the denture acceptance by the patient. So the prosthodontic treatment was planned in two sub phases. • Sub phase I – Fabrication of training denture bases to train the child for denture wearing. • Sub phase II – Fabrication of RPD Training denture bases were fabricated with heat cure denture base resins (SR Triplex Hot- Ivoclar) after waxing up the training bases on the diagnostic cast (Fig 5). The patient was asked to wear the maxillary denture base alone for about a week followed by the use of both the denture bases. By the next appointment after 2 weeks, the child was able to retain both the training bases without difficulty. This proved to be an ideal time to introduce Removable Partial Denture to the patient to replace the missing teeth. Custom trays with wax spacers were fabricated on the study cast with autopolymerizing resin (Veracril, Brazil). Border molding and final impressions were made with elastomeric impression materials (3M Express XT (Soft Putty) and Express Soft (medium body)) (Fig 6). Temporary denture bases and occlusal rims were fabricated on the master cast. Vertical dimension at rest was determined and vertical dimension at occlusion was established providing 2mm of free way space. The child JIDAT, Vol.6, Iss.20, January-March.-201415 was trained to retrude the mandible and centric relation was recorded. The occlusal rims were articulated and teeth arrangement was done (Acrylux- Ruthinium). Trial dentures were inserted. Esthetics, phonetics, jaw relation and occlusion were assessed (Fig7). The child’s response was very positive and the trial dentures were processed in heat cure denture base resin (Fig 8). On the day of denture insertion, the denture extensions and occlusion were adjusted (Fig9). As the child was used to wearing trial denture bases, he easily understood the path of insertion and removal of the prosthesis and readily co-operated (Fig 10). Phase IV: Recall and Maintenance phase. The child was recalled the next day to assess the soft tissue response to denture wearing. The child was comfortable with the extensions of the dentures. On the next recall appointment after a week, the guardians reported an improvement in the diet and the social life of the patient. The recall appointments were planned for every 3 months to allow the eruption of the remaining permanent teeth. DISCUSSION: Treating ED patients at early ages using staged treatment plan, which emphasizes on the importance of psychological and behavioral management, creates a great rapport among the patient-parent-dental team.[2] This is very essential because ED patients require continuous dental treatment at different decades of life in accordance with their growth and development. The different prosthetic treatment options available for these patients range from simple removable prostheses (RPD, Complete dentures), overdentures and fixed partial dentures to the more extensive implant prostheses. The optimal prosthetic treatment option varies in relation to the patient’s age and the amount of bone present [6]. Removable prostheses are the most commonly employed interim treatment modality for ED patients. The success of this depends on the retention and stability for which preservation of alveolar bone is important. [3], [4], [5]. Further treatment in this patient will include modification of the dentures to allow eruption of remaining teeth, relining or replacement of the dentures according to the observed skeletal growth. CONCLUSION: Early management of ED patients is usually difficult because of the typical oral deficiencies and the young age. But oral rehabilitation is important from functional,
  24. 24. esthetic and psychological perspectives[2], [9].This case report details the treatment phases for an ED patient which takes important factors like child psychology, preservation of alveolar bone and team approach into consideration. Difficulty in mastication was the main complaint of the patient at the start of treatment. The dental management helped not only to improve mastication, but also esthetics and self image of the child that will transform him into a socially acceptable individual Legends for figures Fig 1: Frontal view-& Lateral view of the patient showing ED; hypotricosis, frontal bossing, depressed nasal bridge. Fig 2: Intra oral view of grossly decayed deciduous dentition with missing mandibular central incisors Fig 3: Intra oral view showing loss of vertical dimension of occlusion JIDAT, Vol.6, Iss.20, January-March.-2014 16 Fig 4: Diagnostic casts Fig 5: Maxillary and mandibular acrylic Training denture bases Fig 6: Secondary impressions of maxillary and mandibular arches made with elastomeric impression materials Fig 7: Trial dentures Fig 8: Maxillary and mandibular removal partial dentures
  25. 25. Fig 9: Intra oral view of inserted final prostheses Fig 10: Pretreatment and post treatment photographs of the patient in frontal view. REFERENCES 1. Neville, Damm, Allan, Bouquot. Oral and maxillofacial pathology: W.B.Saunders Company. Dermatological diseases.2nd edition.Toranto. pp 644- 645. 2. Cenkhan Bal, Bilge Turhan Bal. Treatment Considerations for a Patient with Hypohidrotic Ectodermal Dysplasia: A Case Report. The Journal of Contemporary Dental Practice 2008;9:1-7. 3. Shigli A, Reddy R.P.V. Hypohidrotic ectodermal dysplasia: A Unique approach to esthetic and prosthetic management: A Case report. J Indian SocPedoPrev Dent 2005;23:31-34. JIDAT, Vol.6, Iss.20, January-March.-201417 4. KarllaAlmeidaVieira, Milena Schaaf Teixeira. Prosthodontic treatment of hypohidrotic ectodermal dysplasia with complete anodontia: case report. Quintessence Int 2007;38:75-80. 5. Rashmisingh, Gauri S lele. Hypohidrotic Ectodermal Dysplasia: A Case Report. International Dental and Medical disorders 2008;1:11-14. 6. PervinImirzalioglu, SinaUckan, SedaGürsoyHaydar. Surgical and prosthodontic treatment alternatives for children and adolescents with ectodermal dysplasia: A clinical report. J prosth dent 2002;88:569-572. 7. Jain, Prakash. Prosthodontic rehabilitation of ectodermal dysplasia patient. J Indian SocPedoPrev Dent 2000;18:2:54-58. 8. Vasan N. Management of ectodermal dysplasia in children--an overview. Ann R AustralasColl Dent Surg. 2000;15:218-22. 9. M.Pigno, R.Blackman, R.Cronin, E.Cavazos. Prosthodontic management of ectodermal dysplasia: A review of the literature. J prosth dent 1996; 76:541-545. 10. Bilal Ahmed and NaziaYazdanie. Hypodontia and Microdontia Associated with Hereditary Ectodermal Dysplasia. Journal of the College of Physicians and Surgeons Pakistan 2009;19:192-194. Corresponding author : Dr.Bindhoo.Y.A, M.D.S, Reader, Department of Pedodontics, 132, Ellango street, Mangalam road, Palladam, Tirupur, Tamil Nadu.- 641 664. Mobile:9842255347, Email ID: bindhoomds@yahoo.co.in
  26. 26. JIDAT, Vol.6, Iss.20, January-March.-2014 18 INTRODUCTION: A precise knowledge of the root canal system and its variations is very important for the success of the endodontic therapy. Anatomic variation such as extra roots is an additional challenge, which begins at case assessment level and involves all operative stages, including cavity design, canal access, localization, and cleaning and shaping of the root canal system. Maxillary premolars exhibit the greatest variations in root anatomy and root canal morphology. These diversities in number and type of root canals are probably the most discussed anomalies in the literature. Studies reported by Carns and Skid 1973(1), Green 1973(2) and Pineda and Kuttler 1972(3) dealing with the canal morphology of the maxillary premolars, have revealed that in most instances they have two canals from 73.3% to 92%, although teeth with three root canals do often exist from 0 to 6%, respectively. Mariusz et al. 2005 found 9.2% of first maxillary premolar with three canals (4). This case reports describes a permanent maxillary first and second premolars with 3 root canals (1MB, 1 DB, and 1 palatal), with unusual buccal canal morphology in that 2 canals with separate orifices and apex. CASE REPORT A 25 year old male patient reported to the Department of Conservative Dentistry and Endodontics with a chief 1. Senior Lecturer, Division of conservative Dentistry & Endodontics, Rajah Muthiah Dental college & hospital , Annamalai university ,Chidambaram 2. Senior Lecturer, Division of conservative Dentistry & Endodontics, Rajah Muthiah Dental College & hospital, Annamalai university, Chidambaram 3. Post graduate ,Division of conservative Dentistry & Endodontics, Rajah Muthiah Dental college &hospital, Annamalai university , Chidambaram ENDODONTIC MANAGEMNT OF RADICULOUS MAXILLARY PREMOLARS -A case report Key words: Maxillary Premolars, Anatomic Variations , Three Canals ABSTRACT: Diversities in the internal anatomy are found in all teeth. Knowledge of these variations, particularly concerning the location and treatment of all canals, is very important for the success of the endodontic therapy. Endodontic literature since ages suggested maxillary premolars to be bicuspid teeth with one or two canals .The possibility of three roots and three canals in maxillary premolars is still a rarity. This case report presents a clinical case of a maxillary premolar with one palatal canal, one mesio-buccal and one disto-buccal canal. This report serves to remind clinicians that such anatomical variations should be taken into account during endodontic treatment of the maxillary premolars. 1 2 3 Dr. Velmurugan A , Dr. Bhavani S , Dr. Deepak . complaint of pain in upper left back tooth since one week. On clinical examination a deep caries lesion involving the marginal ridge was observed in tooth. Radiographic examination revealed radiolucency involving the pulp cavity and three obvious independent canals in both first and second premolars (fig1). Cold pulp testing followed by electric pulp test elicited a lingering pain response. The condition was diagnosed as acute irreversible pulpitis and endodontic therapy was initiated. Local anaesthesia was administered and the operative field was isolated with a rubber dam. Pre-endodontic management was done with amalgam restoration. Access cavity preparation was modified in the mesio- distal direction to uncover the second buccal canal, such that the access cavity is triangular in shape (fig 2). Patency of the canals were checked with 10 size k-file and then a working length radiograph was taken (fig 3). Cleaning and shaping was carried out to a size of 25 in the buccal canals and 30 in the palatal canal respectively (fig 4) and a mastercone radiograph was taken (fig 5). This was followed by obturation with gutta-percha points and Zinc Oxide-Eugenol by lateral condensation technique. Post operative radiograph revealed well condensed gutta- percha in all the three different root canals (fig 6). Coronal seal was done followed by a metal ceramic crown restoration (fig 7).
  27. 27. FIGURESDISCUSSION Clinically, with the numerous morphological and anatomic variations of teeth detected and reported of late, 3-dimensional determination of the internal structure of teeth, the form and number of root canals has become a challenge encountered very often. Root canal treatment has shown that the pulp cavity is highly variable, making treatment of each tooth unique. Whenever there is an indication of unusual anatomy, additional periapical radiographs should be taken with mesial and/or distal shifts (5). If one eccentric orifice is found then one more canal should be searched on the opposite side (6). This case report emphasizes the importance of looking for canals and of ensuring adequate access to improve the likelihood of finding and treating additional canals. To investigate properly the possibility of additional canals, the dentist should understand the complexity of the morphology, take additional radiographs with shifted angles and ensure adequate “straight-line” access to improve visibility. And also proper examination of the pulpal floor has to be done to find for dentinal map which could lead to areas where additional canals may be located. A third canal should be suspected clinically when the pulp chamber does not appear to be aligned in its expected buccal-palatal relationship. In maxillary premolars with three roots, the crowns were broader mesio-distally necessitating the access cavity to be modified. The completed access cavity preparation was triangular in out line, resembling the access cavity for a maxillary first molar, but smaller in size. The root canal system of premolars with three roots is characterized by one large palatal canal and two smaller canals in the mesio-buccal and disto-buccal roots. Means of magnification like ocular loupes, microscopes and additional lighting are recommended. Various other methods such as dyes, CT scans can also be considered as valuable diagnostic aids in identifying morphological variations of root canals. JIDAT, Vol.6, Iss.20, January-March.-201419 Figure 1 - Preoprerative Radiograph Figure 2 - Access Cavity Figure 3 - Working length Radiograph
  28. 28. JIDAT, Vol.6, Iss.20, January-March.-2014 20 Figure 4 - Mastercone Figure 7 - Followup Radiograph Figure 5 - Mastercone Radiograph Figure 6 - Post-op Radiograph REFERENCES 1. Carn EJ ,Skidmore.Configuration And Deviations Of Root Canals Of Maxillary First Premolars. Oral Surg Oral Med Oral Pathol 36,880-6. 2. Pineda F, Kuttler Y. Mesiodistal buccolingual roentgenographs investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101-10. 3. Green D. Double canals in single roots. Oral Surg Oral Med Oral Pathol 1973;35:689-96. 4. Mariusz Lipski, Krzysztof Wo zniak, Ryta Lagocka, Ma ngorzata Tomasik. Root and canal morphology of the rst human maxillarypremolar, Durham Anthropology Journal. 2005;12:2-3. 5. Krasner P, Rankow HJ. Anatomy of the pulp-chamber floor.J Endod 2004; 30 : 5-16. 6. Vertucci FJ, Gegauff A. Root canal morphology of the maxillary first premolar. J Am Dent 1979; 99 : 194-8. Corresponding author : Dr. Velmurugan A Senior Lecturer, Division of conservative Dentistry & Endodontics Rajah Muthiah Dental college &hospital, Annamalai university ,Chidambaram Ph No: 9994022471, email: velsdentcare@yahoo.com CONCLUSION The treatment of the entire root canal system is essential to maximise the possibility of obtaining success in the endodontic therapy. It is necessary for the clinician to have a thorough knowledge of the dental anatomy, as well as of its variations.
  29. 29. JIDAT, Vol.6, Iss.20, January-March.-201421 INTRODUCTION: Every human being likes to lead a healthy life in the society. Health is the state in which the individual feels the sense of physical and mental well being, in such a way that the status of general health is closely associated with the maintenance of oral health. In this connection, numerous studies have been reported. The dental health of the general population is being very poor in all over the world1. In India, it is very sad to know that very few people believe in regular dental care2. Proper dental care is very much important as far as oral health is concerned3. Negligence of oral hygiene and failure of medication pose microbial abundance in teeth surface which causes periodontitis and root canal infections. The prevalence of these diseases has been continuously increasing 60% - 65% due to change in dietary habits of people with high sugar foods. Such food particles are deposited on the surface of tooth and facilitate the growth of microbes like Enterococcus faecalis, E. faecium, Candida albicans in oral cavity and thereby releasing acids4. The acid end products initially affect the enamel and then spread to dentine and pulp, which results in formation of cavity. School children are easily affected by such infection5. When the infections spreads to pulp, patient feels increasing pain with prolonged sensitivity and results in endodontic infection. Endodontic abscess can cause insignificant morbidity, insusceptible individuals they can pose life threatening problem6. 1. Research Scholar, Department of Microbiology, Bharathiar University, Coimbatore. 2. Reader, Department of Conservative Dentistry and Endodontic, Sri Mookambika Institute of Dental Science, Kulasekharam, Kanyakumari District. 3. Assistant Professor, School of Biotechnology, Madurai Kamaraj University, Madurai. PREVALENCE OF ENDODONTIC INFECTIONS IN HOSPITAL REPORTED CASES AT KANYAKUMARI DISTRICT, TAMIL NADU Key words: Endodontic Infections, Gum Disease, Root Canal Infection And Brushing Habits. ABSTRACT: Objectives: A study was conducted with an aim to analyse the dental attendance for root canal infection and assess their association with age, sex, stages of infection, patho physiological conditions (diabetic, hypertension cardiovascular problem, urinary tract infection (UTI)) and brushing habits. The study suggested that there is a need to conduct awareness programme highlighting importance of oral hygiene for the people with levities on oral health. 1 2 3 S.R.Sri Ramkumar *, Dr.Mano Christaine Angelo *, Dr.N.Sivakumar * Cardiovascular disease such as atherosclerosis and myocardial infarction are also associated with oral infections. Despite oral infections are being challenged. Endodontic therapy is an appropriate remedy to reduce the infections7. Root canal treatment (RCT) and coronal restoration (CR) in general dental practice is being required to promote oral and periapical health8. To prevent such infections, the study would feasibly helpful to insist the importance in maintaining oral health, create the awareness about dental infections and educate the public highlighting dental problems. Hence, the study is an attempt to analyse the root canal infected cases and their association with age, sex, patho-physiological (diabetic, hypertension cardiovascular problem, UTI) and brushing habits of hospital visited cases in Kanyakumari District, TamilNadu. 2. METHODOLOGY The data was collected from five different private dental hospitals of Kanyakumari District, TamilNadu. Duration of the study was from July 2012 to December 2012. Study was conducted on (n=1817) hospital attended cases with the complaints of gum disease, tooth decay or dental caries and anticipating root canal cases in dental visit. Every individual had equal chance of selection based on the registered record data. The hospital register was fulfilled by the objectives of the present survey which consists of personal history family
  30. 30. history, dental history, and medical history and brushing habits of patients. From this, percentage and prevalence of root canal infections analysed with the patient’s history which includes age, sex, other medical complications (diabetic, hypertension, cardiovascular problem and UTI) and their dental care. 3. RESULTS The present study clearly enunciates the total number of cases (n=1817) reported for dental visit with the complaints of gum disease, tooth decay and secluded root canal cases from tooth decay (shown in Table 1). Out of 1817 cases, males 49.5% (n=900), females 50.5% (n=917) were reported and analysed. In this total population, 13.65% males, 11.4% females had gum disease whereas, 36.87% males and 38.30 % female were recorded under tooth decay. The highest numbers of above cases (gum disease, tooth decay) were reported in the age 18-35 but the lowest numbers of these affected cases were reported under the age of 12-17, and the age above 50 respectively. However, no root canal cases were reported in patient with gum infection, but reported only in tooth decay, (n=1366) thus n=419 (males 216, females 203) root canal cases secluded from tooth decay. Hence patients with gum disease were not mentioned in further analysis. During analysis, prevalence of root canal cases would maximum at the age of 18-35 (male, n=142; female, n=125) whereas lowest numbers of such positive cases reported at the age of above 50 (male, n=13; female, n=8). The percentages of root canal infected cases were calculated distinctly out of total population of tooth decay in each age group, also tabulated. In such a way the age group 18-35 showed highest percentage of positive root canal infected cases, n= 584 (24.3% males and 21.4% female), percentage of positive root canal cases of tooth decay were tabulated in Table.1. Table 2 shows the root canal infected cases in different stages of infection. Among the 419 root canal infected cases, 57.52% (n=241) acute pulpitis, 35.32% (n=148) chronic pulpitis and 7.16% (n= 30) chronic with periapical inflammation were reported. Percentages of cases were calculated out of total number of each stage. The highest number of acute male (71.64 %), female (65.42%) and chronic male (60.52%), female (54.54%) was reported under age group 18-35. But lowest numbers of acute male (4.47%), female (3.7%) JIDAT, Vol.6, Iss.20, January-March.-2014 22 and chronic male (5.63%), female (3.89%) were recorded under the age above 50. Cases with chronic periapical inflammation male (36.36 %), female (26.31 %) were maximum at the age 36-50. But lowest number of such cases reported in the age 12-17 (male, 9.09%). Figure 1 shows the various patho-physiological conditions of root canal infected cases. Diagram has been given by means of percentage of affected cases out of total in each age group. As a result, patho physiology associated problems, such as diabetic, hypertension were not much influence on root canal affected cases in the age 12-17 and 18-35. But little difference was showed in the age group of 36-50 and above 50. In above 50 age group, 23.1% of male and 25% of the female cases showed cardio vascular problems. UTI and allergy were not influenced more in such infections. Brushing the tooth with various materials was reported in Figure 2. In the age group 12-17, the highest percentages of root canal infections reported in patients who had single time brushing habits with tooth paste. Whereas in 18-35, such cases had single time brushing habits with powder and ash. The age 36-50, above 50 the occurrence of such cases reported in patient by using finger with ash, but it is being discriminated in female. In female the age 36-50 above 50, 33.9% and 37.5% of root canal cases were reported respectively due to single time brushing with tooth powder. Moreover people who had the brushing habits using finger with ash for tooth cleaning were considering the major cause in this infection. Brushing habits like single time and two times were showed in Figure 3. Single time brushing habits always had showed highest percentage of root canal infections than two times brushing in both male and female at all age groups. Table : 1 Sex and age wise distribution of gum disease and tooth decay cases reported in dental visit Values with in the ( ) indicates the percentage. Age Gum Disease Tooth Decay Grant totalMale Female Total Male Female Total & (%) Root canal case Non root canal case Root canal case Non root canal case Root canal case Non root canal case Root canal case Non root canal case 12 – 17 Nil 26 Nil 23 49 (10.86) 19 114 17 148 298 (21.81) 347 (20.36) 18 – 35 Nil 81 Nil 92 173 (38.35) 142 158 125 159 584 (42.75) 757 (41.66) 36 – 50 Nil 79 Nil 57 136 (30.15) 42 143 53 147 385 (28.18) 521 (28.67) 50 above Nil 62 Nil 31 93 (20.62) 13 38 8 40 99 (7.25) 192 (10.57) Total Nil 248 Nil 203 451 (100) 199 453 220 494 1366 (100) 1817 (100)
  31. 31. Table : 2 Age and sex wise analysis of different stages of endodontic cases Values with in the ( ) indicates the percentage. Figure – 1: Root canal infected cases with different pathological conditions. a) Diabetics, b) hypertension, c) cardio vascular problems, d) urinary tract infection and e) allergy. Percentage of the positive cases were calculated on the basis of root canal infection in Male [12-17 (n= 19); 18-35 (n= 142); 36-50 (n= 42) and above 50 (n=13)] and female [12-17 (n= 17); 18-35 (n= 125); 36- 50 (n= 53) and above 50 (n=8)]. male, female. JIDAT, Vol.6, Iss.20, January-March.-201423 Figure -2: Brushing habits of dental care visited cases with root canal infections a) Brush with paste, b) Brush with tooth powder and c) Finger with ash. Male, Female. Percentage of the positive cases were calculated on the basis of root canal infection in Male [12-17 (n= 19); 18- 35 (n= 142); 36-50 (n= 42) and above 50 (n=13)] and female [12-17 (n= 17); 18-35 (n= 125); 36-50 (n= 53) and above 50 (n=8)]. Figure -3: Brushing habits of dental care visited cases with root canal infections. a) Single time brushing and b) two time brushing. male, female. Percentage of the positive cases were calculated on the basis of root canal infection in Male [12-17 (n= 19); 18-35 (n=142); 36-50 (n= 42) and above 50 (n=13)] and female [12-17 (n= 17); 18-35 (n= 125); 36-50 (n= 53) and above 50 (n=8). 4. DISCUSSION Oral health is an important and integral part of health care in every individual9. It should be needed to every one for bringing them rejoice and evolving healthy life. So the present study feasibly helps in intensify the needs of dental care as well as home care thus zealous on oral health of individual is being instigated to improve the status of general health10 successfully. Hence there is a need to conduct a survey on people who have gum disease and tooth decay followed by root canal infection in hospital reported cases. The study population was done purely on the basis of dental care attended cases, their by percentage of root canal infections were analysed in different strategies. Among 1817 cases, 23.05% (n=419) were recordically subjected into root canal treatment. This data is only obtained from tooth decay and not in gum disease. It is comparatively less than that of cases reported in Europe11 (42%). The prevalence of root canal infection AGE MALE FEMALE Grant totalAcute (n = 134) Chronic (n = 71) Chronic periapical inflammation (n = 11) Total (n = 216) Acute (n = 107) Chronic (n = 77) Chronic periapical inflammation (n = 19) Total (n = 203) 12-17 9 (6.71) 9 (12.68) 1 (9.09) 19 (8.8) 15 (14.01) 2 (2.59) 0 17 36 18-35 96 (71.64) 43 (60.56) 3 (27.27) 142 (65.7) 70 (65.42) 42 (54.54) 13 (68.42) 125 267 36-50 23 (17.16) 15 (21.12) 4 (36.36) 42 (19.44) 18 (16.82) 30 (38.96) 5 (26.31) 53 95 50-above 6 (4.47) 4 (5.63) 3 (27.27) 13 (6.02) 4 (3.738) 3 (3.89) 1 (5.2) 8 21 Total (%) 62.04 32.87 5.09 100 52.70 37.93 9.36 100 419 Mean 31.76 32.43 49.18 30.55 37.84 35.26
  32. 32. increased with age 18-35 and 36-50 and no marked gender differentials were observed. But gum disease was high in all age groups. Gum disease (Gingivitis) is the mildest form of periodontal disease12. In the age group (12 - 17), 133 (31%) males and 165 (39%) females were affected by tooth decay this may be due to the appearance of early teeth eruption. The India Dental Association (IDA) shows that 70% of children under the age of 15 suffer from gum problems13. Forty- two percent of children and adolescents aged 6-19 years and approximately 90% of adults had dental caries in their permanent teeth 14. Only 10.37% of this age group was root canal infected cases. Previous study by Arifkhan et al. reported that 5.48% male and 4.8% female were assessed as root canal infected cases15. In this age, occlusal pit and fissure caries would develop by means of deposition of food particles on its surface and utilization of such deposit by microorganism, 90% of the children were affected by this caries16. Inspite of more pit-and fissure caries under the age group, cases reported for root canal infection is less in comparison to other mentioned age group age group. It may be depending upon the formation of caries, because caries process might have begun meticulously during this age group. But it is only at an incipient stage. So it would not have developed to attain the stage of root canal infection. It seems to understand that such cases might have visited dental hospital for root canal treatment at the age of 18- 35. The age 12-17, people have least interest in frequent dental check up because they feel that such treatment is costly 17 and dental fearness 18. This may be the other vital reason of dental visit being lower in the age group. The reason for this lower dental attendance may be due to food habits, money and medication they are specially depend upon their parents 19. The age groups 18-35, was one of the utmost age group to be high lightened among the study population, since root canal cases was much higher than the other age groups. It may be ascribed to the factors such as (a) tooth morphology, (b) previous infections, (c) newly developed caries, (d) high inquisitiveness in oral and personal hygiene, (e) self earning and (f) beauty conscious. The peoples have adequate knowledge in oral hygiene and oral health also influence in increasing the case visit for regular checkup, cleaning of teeth restoration of teeth3, JIDAT, Vol.6, Iss.20, January-March.-2014 24 extraction of teeth and treatment for bleeding gum and endodontic treatment20. This may be the reason of dental attendance being higher in the age group. Moreover these people are mostly beauty conscious they could clearly understand that the oral health itself decides their beauty. Next income and education may be an important factors and in response to dental visit being more in this age group. Root canal infected cases with 3 different stages also assessed and recorded in accordance with signs and symptoms. They are acute pulpitis, chronic pulpitis and chronic with periapical inflammation So far discussed the results the highest case of acute pulpitis male (71.64) and (65.42) female were reported under age of 18-35 it is credibly supported by Benoit et al.3 to the present study. In the age 36-50 smooth caries were very common21. This statement looks quite plausible, that it is developed by the disappearance of pit and fissure of teeth, due to brushing habits, abrasive food, brushing with ash, rubbing with finger and chewing of leaf and also it is associated with poor oral hygiene22. As previously reported, mostly the root canal treatment is being taken under the age group 18-35, therefore report for the dental visit is being comparatively less in the age 36-50. In this age group endodontic failure cases were reported. People may lazy and dental fearness in dental visit for attending root canal treatment under the age of above 50. To support this, similar findings have been reported by Quteish Taan23. Also smooth surface caries and pit and fissure caries were not found to be common though it is present. It may not attain the stage of root canal infection whereas root caries is common24. Among the study population in all age groups various patho physiological condition and habits interruption on root canal cases were recorded and represented in Figure 1. People know that the diabetes mellitus is a major risk factor, in that way present study analysed the root canal case with diabetic. Diabetic mellitus25 is closely linked with tooth decay it gives great significance in periodontal disease. In this study male 8.3%, female 6.4% had diabetic consequences out of total population. Based on the results, the study concludes diabetic was not significantly influence the root canal infection. In such a way that hypertension, cardio vascular problem, and UTI were also not significantly influence the root canal infections. From this study we could know that hygienic maintenance is the only plausible mechanism to protect our teeth. The influence of brushing materials like paste,
  33. 33. powder and ash on root canal infection was studied (Figure 2). In the present analysis, male brush with tooth powder showed higher percentage of root canal infections under the age group of 18-35, 36-50 and above 50. Using finger with ash showed highest percentage root canal infection at the age group 36-50 and above 50. In female used finger with ash for tooth cleaning has higher percentage of root canal infection at all age groups. It was also found that the brushing habits were of so much concern among the younger age group in maintaining oral health. 5. CONCLUSION The analysis was concluded that highest number of cases reported in the age group of 18 - 35. The reason for this could be attributed to person belongs to this age group showing more interest in oral and personal hygiene. Other health related issues are not directly influence the tooth decay and root canal infections. Maintenance of oral hygiene could be the only possible means of protecting our tooth. REFERENCES 1. Jyoti B, Muneeshwar PD, Srivastava R, Singh AR, Kiran M, Simlai J. Oral Health Status and Treatment Needs of Psychiatric Inpatients in Ranchi, India. J Indian Academy Oral Medi Radio. 2012; 24(3), 177-181. 2. Kakatkar G, Bhat N, Nagarajappa R, Prasad V, Sharda A,. Asawa K, Agrawal A. Barriers to the Utilization of Dental Services in Udaipur, India. J Dent (Tehran). 2011; 8(2): 81–89. 3. Varenne B, Msellati P, Zoungrana C, Fournet F, Salem G. Reasons for attending dental-care services in Ouagadougou, Burkina Faso. Bulletin the World Health Organization, 2005; 83(9), 650-655. 4. Aysin Dumani, Oguzyoldas, Sehnaz yilmaz, et al. PCR of Enterococcus faecealis and Candida albicans in apical periodontitis from Turkish patients. J Dent Clin Expe, 2012; 4(1): 34-39. 5. Adekoya-Sefowora CA, Nasir WO, Oginni AD, Taiwo M. Dental caries in 12-year old sub urban Nigeria school children. Afr health sci.2006; 6(3):145-150. 6. Walsh LJ. Serious complications of endodontic infection some cautionary tales. 1997; 42 (3) : 156-9. JIDAT, Vol.6, Iss.20, January-March.-2014 25 Corresponding author : S.R.Sriram Kumar, Research Scholar, S/o.S.Rajendran, Keezhamavilai, South Soorankudi (P.O), K.K.District – 629 501. Cell : 9442312911
  34. 34. JIDAT, Vol.6, Iss.20, January-March.-201426 INTRODUCTION: Developmental anomalies of the dentition are not infrequently observed in the dental clinic. Microdontia is a rare phenomenon. The term microdontia (microdentism, microdontism) is defined as the condition of having abnormally small teeth (1). It may involve all the teeth or be limited to a single tooth or a group of teeth. Often the lateral incisors and third molars may be small (2). According to Boyle, “In general microdontia, the teeth are small, the crowns short, and normal contact areas between the teeth are frequently missing”(3). Shafer, Hine, and Levy divide microdontia into three types: microdontia involving only a single tooth; relative generalized microdontia due to relatively small teeth in large jaws; and true generalized microdontia, in which all the teeth are smaller than normal (4). Hyperdontia is the development of an increased number of teeth, and the additional teeth are termed as supernumerary. Supernumerary teeth are considered as one of the most frequent dental anomalies which exceed the normal dental formula. Depending upon their location, several terms have been used to describe supernumerary teeth. A supernumerary tooth in the maxillary anterior region is termed as the mesiodens; an accessory fourth molar is often called a distomolar or distodens. A posterior supernumerary tooth situated lingually or buccally to a molar tooth is termed a paramolar (5,6). We are hereby reporting an unusual 1. M.D.S, Assistant Professor, Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre, Poinachi, Kasaragod. 2. M.D.S, Reader, Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre, Poinachi, Kasaragod. 3. M.D.S, Department of Oral Medicine and Radiology, A B Shetty memorial institute of dental sciences, Deralakatte, Mangalore. 4. M.D.S, Assistant Professor, Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre, Poinachi, Kasaragod “AN UNUSUAL OCCURRENCE OF HYPERDONTIA AND MICRODONTIA IN SINGLE CASE” Key words: Hyperdontia, Microdontia, Mesiodens, Supernumerary. ABSTRACT: Abnormalities in size of teeth and number of teeth are occasionally recorded in clinical cases. Hyperdontia is the development of an increased number of teeth, and the additional teeth are termed as supernumerary. Microdontia is a condition where the teeth are smaller than the normal size, which may involve all the teeth or be limited to a single tooth or a group of teeth. We are reporting a unique and unusual case of occurrence of supernumerary tooth with microdontia in the maxilla. 1 2 3 4 Dr. Anusha Rangare Lakshman , Dr. Sham Kishor Kanneppady , Dr. Preethi Balan , Dr. Chaithra Kalkur . occurrence of mesiodens and microdontia of third molars in the maxilla. CASE REPORT: A 50 year old male patient reported to the Department of Oral Medicine and Radiology, with the complaint of pain in the lower front tooth region since a year. Pain was dull aching, intermittent, non- radiating, throbbing type. Past medical, dental and family histories were non- contributory. On examination, a supernumerary tooth was noticed between the upper central incisors which was smaller in size when compared to the adjacent teeth and the both upper third molars were smaller in size compared to the other teeth (Figure 1A, B). Generalised periodontitis was also observed. The left upper third molar was mobile. Provisional diagnosis of chronic generalised periodontitis, hyperdontia and microdontia were given. He was referred to Department of Oral and Maxillofacial Surgery for extraction of the supernumerary tooth and the third molars, followed by periodontal therapy. DISCUSSION: The human dentition shows various developmental dental anomalies which generally manifest as a variation in tooth size, shape, number, or structure. Supernumerary teeth are considered as one of the most frequent dental anomalies. The prevalence of supernumerary teeth in Caucasians is between 1- 3%,
  35. 35. with slightly higher rate seen in Asian populations. Approximately 76-86% of cases represent single-tooth hyperdontia (5). The pathogenesis of hyperdontia has been postulated to be caused by the development of excess dental lamina, which presumably leads to the formation of additional tooth germs (5). Multiple supernumerary teeth are frequently associated with various craniofacial anomalies including cleft lip and palate, Gardner’s syndrome, and cleidocranial dysostosis (4-6). Subacute pericoronitis, gingivitis, periodontitis, and abscess formation are the most common complications of supernumerary teeth. In selected cases, clinical judgment may not dictate surgical removal, or patient resistance to therapy may be present. In these instances regular monitoring is appropriate (5). The complications of mesiodens clinically include delayed eruption of permanent incisors, midline diastema, axial rotation, or inclination of erupted permanent incisors, resorption of roots of adjacent teeth, root anomaly, cyst formation, and intra-oral infection (7-10). Periapical, maxillary occlusal and panoramic radiographs are essential in the diagnosis of impacted supernumerary teeth (7). Early diagnosis and treatment often are crucial in minimizing the aesthetic and functional problems of the adjacent teeth. Only 7-20% of supernumerary teeth are associated with clinical complications, the standard treatment management would be removal of the extra teeth. Microdontia is a condition where the teeth are smaller than the normal size, which may involve all the teeth or be limited to a single tooth or a group of teeth. Both genetic and environmental factors are involved in the complex etiology of microdontia. Genetic factors probably play a role in the formation of microdontia. The deciduous dentition appears to be affected more by maternal intrauterine influences; the Permanent teeth seem to be more affected by environment (5). The syndromes associated with microdontia are Gorlin- Chaudhry-Moss syndrome, Williams’s syndrome, Chromosome d/u, 45X [Ullrich-Turner syndrome], Chromosome 13 [trisomy 13], Rothmund-Thomson syndrome, Hallermann-Streiff, Orofaciodigital syndrome (type 3), Oculo-mandibulo-facial syndrome, Tricho- Rhino-Phalangeal, type1 Branchiooculo- facial syndrome (11). Peg laterals are the one of the commonest forms of localized microdontia which affects the maxillary lateral incisor. Instead of exhibiting parallel or diverging mesial and distal surfaces the sides converge or taper together incisally forming peg shaped or conical shaped crown. The next tooth which can be affected is the third molars (11, 12). In the present case, the mesiodens as well as maxillary third molars were smaller in size compared to the other teeth. A conservative management is advised for microdontia keeping in view the age and sex of the patient. In our case, we advised for the extraction of the supernumerary tooth. JIDAT, Vol.6, Iss.20, January-March.-2014 27 A) Shows the presence of mesiodens and microdontia of maxillary third molars bilaterally. B) Shows the microdontia of left maxillary third molar.

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