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BALKAN JOURNAL OF STOMATOLOGYOfficial publication of the BALKAN STOMATOLOGICAL SOCIETY

ISSN 1107 - 1141

Volume 16 No 3 November 2012

BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141 STOMATOLOGIC

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ALBANIARuzhdie QAFMOLLA - Editor Address:Emil KUVARATI Dental University Clinic Besnik GAVAZI Tirana, Albania BOSNIA AND HERZEGOVINA Maida GANIBEGOVIĆ - Editor Address:Naida HADŽIABDIĆ Faculty of DentistryMihael STANOJEVIĆ Bolnička 4a 71000 Sarajevo, BIHBULGARIANikolai POPOV - Editor Address:Nikola ATANASSOV Faculty of DentistryNikolai SHARKOV G. Sofiiski str. 1 1431 Sofia, BulgariaFYROMJulijana GJORGOVA - Editor Address:Ana STAVREVSKA Faculty of DentistryLjuben GUGUČEVSKI Vodnjanska 17, Skopje Republika MakedonijaGREECEAnastasios MARKOPOULOS - Editor Address:Haralambos PETRIDIS Aristotle University Lambros ZOULOUMIS Dental School Thessaloniki, Greece

ROMANIAAlexandru-Andrei ILIESCU - Editor Address:Victor NAMIGEAN Faculty of Dentistry Cinel MALITA Calea Plevnei 19, sect. 1 70754 Bucuresti, Romania

SERBIADejan MARKOVIĆ - Editor Address:Slavoljub ŽIVKOVIĆ Faculty of Dentistry Zoran STAJČIĆ Dr Subotića 8 11000 Beograd, Serbia

TURKEYEnder KAZAZOGLU - Editor Address:Pinar KURSOGLU Yeditepe University Arzu CIVELEK Faculty of Dentistry Bagdat Cad. No 238 Göztepe 81006 Istanbul, TurkeyCYPRUSGeorge PANTELAS - Editor Address:Huseyn BIÇAK Gen. Hospital NicosiaAikaterine KOSTEA No 10 Pallados St. Nicosia, Cyprus

Editorial board

Editor-in-Chief Ljubomir TODOROVIĆ, DDS, MSc, PhD Faculty of Dentistry University of Belgrade Dr Subotića 8 11000 Belgrade Serbia

Council:President: Prof. H. BostanciPast President: Prof. P. KoidisPresident Elect: Prof. N. SharkovVice President: Prof. D. StamenkovićSecretary General: Prof. A.L. PissiotisTreasurer: Prof. S. DalampirasEditor-in-Chief: Prof. Lj.Todorović

Members: R. Qafmolla P. Kongo M. Ganibegović S. Kostadinović A. Filchev D. Stancheva Zaburkova M. Carčev A. Minovska T. Lambrianidis S. Dalambiras

A. Adžić M. Djuričković N. Forna A. Bucur M. Carević M. Barjaktarević E. Kazazoglu M. Akkaya G. Pantelas S. Solyali

BALKAN STOMATOLOGICAL SOCIETYSTOMATOLOGIC

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The whole issue is available on-line at the web address of the BaSS (www.e-bass.org)

International Editorial (Advisory) Board Christoph HÄMMERLE - Switzerland George SANDOR - Canada Barrie KENNEY - USA Ario SANTINI - Great Britain Predrag Charles LEKIC - Canada Riita SUURONEN - Finland Kyösti OIKARINEN - Finland Michael WEINLAENDER - Austria

BALKAN JOURNAL OF STOMATOLOGYOfficial publication of the BALKAN STOMATOLOGICAL SOCIETY

ISSN 1107 - 1141

Volume 16 No 3 November 2012

BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141 STOMATOLOGIC

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LR I. Markou Natal and Neonatal Teeth: A Review of the Literature 132 A. Kana A. Arhakis

LR E. Lioliou The Maxillary Labial Fraenum - 141 A. Kostas A Controversy of Oral Surgeons vs. Orthodontists L. Zouloumis

OP L. Kanurkova Association between Condylar Position and Tilt of 147

J. Gjorgova Frontal Occlusal Plane in Patients with

B. Dzipunova Transversal and Vertical Dentofacial Discrepancy

N. Toseska

A. Dorakovska

M. Popovska

M. Pandilova

OP E. Kongo Cephalometric Features of Class III Malocclusion among 154

Xh. Mulo Albanian Patients Seeking Orthodontic Treatment

OP E. Zabokova-Bilbilova Effect of Fluoride Varnish on Demineralization 157

A. Sotirovska-Ivkovska Adjacent to Orthodontic Brackets

B. Evrosimovska L. Kanurkova OP M. Carcev Sealing of Fissures and Pits of First Permanent 161

B. Getova Molar at Children with High Caries Risk

O. Sarakinova

H. Petanovski S. Carceva-Shalja OP S. Georgieva Use of Topical Bio-stimulative Laser Therapy among Individuals 165 M. Pandilova with Glossopyrosis and Hypochromic Anaemia L. Zendeli-Bedzeti

Contents

VOLUME 16 NUMBER 3 NOVEMBER 2012 PAGES 129-184

OP J. Nikolovska Oral Health-Related Quality of Life (OHRQoL) 169 D. Petrovski Before and After Prosthodontic Treatment with Full Removable Dentures OP A. Uludamar Bond Strength of Resin Cements to Zirconia Ceramics 173

F. Aykent with Different Surface Treatments

CR U.Cılasun An Unusual Laryngeal Complication 179

E.AlperSınanoglu Following Inferior Alveolar Nerve Block

S.Yılmaz

E.Guzeldemır G.Alnıacık

CR N. Güler Surgical Planning of Bilaterally Impacted 181 Maxillary Third Molars by Using Cone Beam Computed Tomography

Balk J Stom, Vol 16, 2012 131

SUMMARYNormal eruption of primary teeth into the oral cavity begins at about 6

months of child’s age. Teeth that erupt prematurely have occasionally been reported in the medical and dental literature and have been referred to as congenital teeth, foetal teeth, pre-deciduous teeth and dentitio praecox. The most affected teeth are lower central incisors and only 1-10% of them are supernumerary teeth. The incidence of natal and neonatal teeth ranges from 1:2000 to 1:3500. The exact etiology has not been proved yet, but there is a correlation between natal teeth and hereditary, environmental factors and some syndromes. The management of the case depends on clinical characteristics of the natal or neonatal teeth, as well as on complications they might cause.

The aim of this text is to present a literature review on important aspects of natal and neonatal teeth concerning prevalence, etiology, clinical and histological characteristics, differential diagnosis, complications and management.Keywords: Natal Teeth; Neonatal Teeth

I. Markou, A. Kana, A. Arhakis

Aristotle University of Thessaloniki School of Dentistry Thessaloniki, Greece

LITERATURE REVIEW (LR)Balk J Stom, 2012; 16:132-140

BALKAN JOURNAL OF STOMATOLOGY ISSN 1107 - 1141

Natal and Neonatal Teeth: A Review of the Literature

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Introduction

Typical eruption of primary teeth begins at about 6 months of age. Teeth observed at birth are considered as natal teeth, while teeth observed within the first 30 days as neonatal teeth, based on the classification given by Massler and Savara in 1950 according to the time of eruption78. In 1966, Spouge and Feasby categorized these teeth based on clinical features as mature and immature110. Mature are those which are fully developed in shape and comparable in morphology to the deciduous teeth; immature are the teeth whose structure and development are incomplete. Finally, Hebling in 1997 presented 4 clinical categories44: - Shell-shaped crown loosely attached to the alveolus by

gingival tissue and absence of a root; - Solid crown loosely attached to the alveolus by

gingival tissue and little or no root; - Eruption of the incisal margin of the crown through

gingival tissue; - Mucosal swelling with the tooth non-erupted but

palpable.

The rare occurrence of natal and neonatal teeth was associated in the past with superstition and folklore. Today this phenomenon creates great interest and concern, not only to parents but to clinicians as well. This is due to their clinical characteristics (small size, conical shape, and great mobility) which are the cause of certain complications (laceration of mother’s breasts, sublingual ulceration, and danger of aspiration of the teeth).

History

The rare occurrence of natal and neonatal teeth has led to association with superstition and folklore. Some cultures have believed that children born with teeth were favoured, particularly in Western Europe and Malaysia, whereas other considered natal teeth as an ill omen. In England it was believed that natal teeth showed that the children would grow into famous soldiers, in France and Italy that they ‘would get on in the world’ and in Sweden that they could cure an injured finger if it were placed in

whose teeth grow early, will early sink into the grave’14. Due to these superstitions it is suggested that a trans-cultural approach be adopted in managing cases in which the parents feel particularly anxious and uncomfortable about prematurely erupted teeth in order to cater for the social well-being of the child and family88.

Prevalence

Many authors have reviewed the incidence of natal and neonatal teeth (Table 1). The estimated prevalence ranges from 1:10 to 1:30.000. It is accepted by many authors that the ratio of natal and neonatal teeth is somewhere between 1:2000 and 1:350014,23,24,78,110,123.

their mouth. In many places like Poland India and Africa superstition still prevails considering these children to be monsters or evil children14. Among several native African tribes, such as in urban Bariba in Benin West Africa, one of the most dangerous signs suggesting a witch child is to be born with teeth and if that happened the child was either abandoned or killed. Precautions in the form of a purification ritual are still taken today in such cases, and sometimes the teeth will be extracted101. In China a child born with teeth suggests misfortune for the family: if the child is male then the father will die and if it is a female the mother. Many historic personalities, like Hannibal, Cardinal Richelieu, Broca, Zoroaster, Napoleon, English King Richard the III and King Louis XIV of France are said to be born with teeth. Also many proverbs and apothegms are made up for natal teeth, such as ‘The one

Table 1. Prevalence of natal and neonatal teeth

Author(s) Location of studyNatal andneonatal

teethTotal births Prevalence

Magicot (1883)71 Paris, France 3 17.578 1:6.000

Howkins (1932)48 Birmingham, England 1 10.000 1:10.000

Massler and Savara (1950)78 Chicago, USA 7 9.400 1:2.000

Allwright (1958)3 Hong Kong, China 2 6.817 1:3.400

Mayhall (1967)80 Juneau, Alaska (Tlinget Indians) 8 90 1:11.25

Gordon and Langley (1970)41 Oklahoma, USA (American Indian) 4 407 1:100

Jarvis and Gorlin(1972)50

Alaska, USA(Eskimo) 16 1.571 1:98

Anderson (1982)5 Columbia, USA 1:800

Kates et al (1984) 52 Boston, USA 13 18.155 1:3.667

Leung (1989)67 Alberta, Canada 15 50.892 1:3.392

King and Lee (1989)57 Hong Kong, China 17 22.500 1:1.324

Gladen et al (1990)39 Taiwan 13 128 1:10

Rusmah (1991)100 Kuala Lumpur, Malaysia 4 9.600 1:2.325

To (1991)117 Hong Kong, China 48 53.678 1:1.118

Diaz-Romero et al (1991)30 Mexico 31 1.200 1:38,7

De Almeida and Gomide (1995)27 Brazil 47* 1019** 1:22

Alaluusua et al (2002)2 Finland 34 34.457 1:1.013

Liu and Huang (2004)70 Taipei, Taiwan 2 420 1:140

Freudenberger et al (2008)36 Mexico 50 2182 2.3:100

* 14 with complete unilateral cleft lip and palate and 33 with bilateral cleft lip and palate**692 with complete unilateral cleft lip and palate and 327 with bilateral cleft lip and palate

Balk J Stom, Vol 16, 2012 Natal and Neonatal Teeth 133

134 I. Markou et al. Balk J Stom, Vol 16, 2012

pyelitis during pregnancy15. Another theory refers to hormonal stimulation, meaning the excessive secretion of pituitary, thyroid or gonads78. It is also significant to mention that congenital syphilis seems to have varying effect; in some cases premature eruption was noticed, while in others the eruption was retarded15. Moreover, febrile states can affect the normal eruption of teeth, for example fever and exanthemata during pregnancy can cause premature eruption78.

The hereditary factor is assumed a possible cause of natal teeth. Zhu and King (1995)123 have reported natal teeth as a familiar trait in 8-62% of cases. Bondenhoff and Gorlin (1963)14 reported family association in 14.5% of cases, while Kates et al (1984)52 found a positive family history in 7 out of 38 cases of natal and neonatal teeth. A hereditary transmission of an autosomal dominant gene has also been suggested24,49.

The prevalence of occurrence of natal and neonatal teeth in males and females is controversial, with some authors giving a higher ratio for females 3,5,23, 36, 52, 65,78, Kates et al54 reporting a 66% proportion for females against a 31% proportion for males, and others suggesting that there isn’t any correlation with gender14,25,106.

Natal teeth are more common than neonatal teeth14,23,33,57,78,110.

Etiology

The exact etiology of natal and neonatal teeth has not been elucidated yet. Many theories have been expressed regarding the cause of the occurrence of these teeth. One of them includes dietary deficiencies3 or hypovitaminosis due to poor maternal health, endocrine disturbances and

Table 2. Syndromes and developmental disturbances related to natal and neonatal teeth

Syndromes and developmental disturbances Author(s)Ellis-Van Creveld syndrome Himelhoch(1988)47; Kurian et al(2007)64

Hallerman-Streiff syndrome Fonseca and Mueller(1995)35; Oshihi et al (1986)87

Patent ductus arrteriosus and intestinal pseudo-obstruction Harris et al (1976)43

Opitz (G/BBB) syndrome Shaw et al (2006)103

Van der Woude syndrome Hersh and Verdi (1992)46

Pachyonychia congenital (Jadasshon- Lewandawsky syndrome) Feinstein et al (1988)34

Steatocystoma multiplex King and Lee (1987)56

Wiedermann-Rautenstrauch neonatal progeriaPivnick et al (2000), Arboleda (1997); Byung-Duk and Jung-Wook (2006); Castiñeyra et al (1992), Korniszewski et al (2001)91,7,18,22,62

Pfeiffer syndrome type 3 Alvarez et al (1993)4

Walker Warburg syndrome (Congenital hydrocephalus with congenital glaucoma) Mandal et al (2002)73

Hyper IgE syndrome Roshan et al (2009)98

Rubinstein-Taybi syndrome Hennekam and Van Doorne (1990)45

Bifid tongue and profound sensorineural hearing loss Darwish, Sastry and Ruprecht (1987)26

Cyclopia Boyd and Miles (1951)16

Transient Pseudohypoparathyroidism Koklu and Kurtoglu (2007)61

Pierre Robin syndrome Kharbanda et al (1985)54

Down syndrome Ndiokwelu et al (2004)[85]

Short rib-polydactyly syndrome type II(Saldino-Noonan syndrome ) Strømme Koppang, Boman and Hoel (1983)113

Soto’s syndrome Callanan, Anand and Sheehy (2009)20

Adrenogenital syndrome Leung (1989)67

Epidermolysis bullosa simplex Liu, Chen and Miles (1998)69

Cleft lip-palate Cabate et al (2000)19

Odonto-Tricho-Ungual-Digital-Palmar Syndrome Mendoza and Valiente (1997)81

Bloch-Sulzberger syndrome (incontinentia pigmenti) Wolf (2007)122

Goltz syndrome Dias et al (2010)28

Teebi hypertelorism syndrome Koenig (2003)59

Clouston syndrome Reynolds, Gold and Scriver (1971)96

Finlay-Marks Syndrome Taniai et al (2004)114

Beare-Stevenson Syndrome Tao et al (2010)115


they occur in pairs65,123. The eruption of more than 2 teeth is rare. Despite that, Masatomi et al77 in 1991 reported an 18-month-old Japanese boy with 14 natal teeth, Gonçalves et al40 in 1998 presented the case of a newborn with 12 natal teeth and Portela et al92 in 2004 reported a newborn with 11 natal teeth.

Natal teeth are described as conical or normal in size and shape, yellowish, with hypoplastic enamel and dentin, and poor or absent root development37,100,123. The hypoplastic enamel might be related to gingival covering52 and has a tendency to discolour. The incomplete root formation is the reason for the great mobility of the natal and neonatal teeth.

As far as histological characteristics are concerned, despite the normal basic structure of the natal teeth, early eruption is associated with hypo-mineralization of the enamel, which is usually described as dysplastic52, reduced in thickness and covering only the two thirds of the crown6,42, but has a normal ultrastructure111. Complete absence of enamel is noted rarely3,78. The enamel for the age of the child is normal but since the tooth erupts prematurely the matrix of the non-calcified enamel wears off in time and this is probably the reason why their crowns look small in size and appear yellow brown in colour52. The dentino-enamel junction seems irregular42.

Dentin and predentin appear normal coronally, but become irregular and with reduced number of dentinal tubules and large inter-globular spaces with abnormal cell inclusions14,16,42 cervically and bonelike apically resembling osteodentin, which is attributed to stimulation by movement of the teeth. It has been further suggested that the mobility may cause degeneration of Hertwig’s sheath, thus preventing root development and stabilization109. Increased mobility causes histological changes in the cervical dentin and cementum6,42,109. Cementum is either absent14 or, if present, shows variation in thickness covers the cervical third of the crown and is usually acellurar42. The pulp tissue has a normal appearance but the pulp cavity and the radicular canals are wider6,42,110.

In neonatal teeth the differences from normal primary dentition are less pronounced due to their more mature state at the time of eruption6. Root formation in natal and neonatal teeth is grossly deficient14.

Differential Diagnosis

Most of the teeth that occur in the oral cavity at birth or during the first days of life represent the early eruption of the normal primary deciduous dentition44,65. The prevalence of supernumerary teeth has been suggested to range from 1-10%17,37,123. At this point, it is important

Another theory explaining the premature eruption is considered to be the abnormal position of the germ during its development in the alveolar bone8,97. Furthermore, Clergueau-Guerithault proposed that the eruption of natal and neonatal teeth could be dependent on osteoblastic activity within the area of the tooth germ102.

As far as environmental factors are concerned, some environmental toxins are considered to be causative factors. Gladden et al (1990)39 reported that 13 of 128 newborns, whose mothers where exposed to polychlorinated binephyls and dibenzofurans during the Yusheng environmental accident in Taiwan, had natal teeth. Also, 2 out of 12 live-borns from parents poisoned by PCBs in Kyushu, Japan were reported to have natal teeth82. Another report by Alaluusua et al (2002)2 supports that there is no association between milk levels of polychlorinated binephyls, and dibenzofurans and the occurrence of natal teeth. They suggest that the prevailing levels of polychlorinated binephyls and dibenzofurans are likely below the threshold to cause prenatal eruptions of teeth.

Moreover, the presence of natal and neonatal teeth has been associated with many syndromes and developmental disturbances but there is no conclusive evidence of a correlation with these systemic conditions25. The conditions that are related with the appearance of natal teeth are shown in the table 2.

Natal and neonatal teeth have also been reported in cutis gyratum and acanthosis nigricans10, Turnpenny ectodermal dysplasia119, in association with primary congenital glaucoma72, in a case of an anencephalic infant with cleft palate74, in association with giant congenital nevocellular nevus53, in a case of restrictive dermopathy79, in a case of multiple joint dislocations with metaphyseal dysplasia90, in a case of multiple anomalies: natal teeth, palatal cyst, bilateral lymphangiomas of the alveolar ridge and median alveolar notch21, in a case of complex craniofacial anomalies112, in Mohr syndrome9 and in association with syringomas and oligodontia83. It is suggested that tooth abnormalities are dysmorphic markers of earlier developmental abnormalities, and could give warning signs in a syndrome diagnosis13.

Clinical and Histological Characteristics

Regarding clinical characteristics, the most affected teeth are the lower primary central incisors (85%), followed by the maxillary incisors (11%), mandibular canines and molars (3%) and maxillary canines and molars (1%)123. Another characteristic of natal teeth is that


breast106, inflammation of the surrounding tissues, pain associated with mobility, which all may lead to refusal to nurse52. Although no case is reported, there is usually a concern about aspiration or swallowing of the teeth due to excessive mobility or spontaneous exfoliation95. Furthermore there can be teething symptoms just as with eruption of the primary teeth52 or even infantile diarrhea, drooling and malaise106,110. The development of an abscess, probably due to the loss of attachment, has also been reported32,51.

A complication that is common with natal teeth is ulceration of the tip or the ventral surface of the tongue, known as Riga-Fede disease. The ulceration occurs after repetitive tongue thrusting not only in newborns but also to elder infants with the eruption of the primary mandibular central incisors and in children with familiar dysanatomia107. There has also been a report of prenatal ulceration of the tongue due to natal teeth58. The lesion begins as an ulcerated area and with repeated trauma it may progress to an enlarged fibrous mass with the appearance of a granuloma. The pain occurring from the ulceration often results on dehydration, feeding difficulties and discomfort. It also may lead to bleeding and in a child with other medical problems a potential of infection is added to the concerns107. Periapical abscess is possible because enamel breakdown may lead to carries52. Another complication in children with cleft lip-palate is the potential interference in naso-alveolar moulding124.

There have also been reported a case of reactive fibrous hyperplasia by a natal tooth106, hypoplasia of primary and permanent teeth following osteitis due to infection by neonatal tooth55 and also microdontic teeth succedaneous to natal teeth, suggesting that there might be some unknown developmental influence common to the occurrence of natal teeth and abnormally small (mesio-distal dimension) permanent successors75 and in neonatal orthopaedics31.

Management

The treatment plan for natal and neonatal teeth has many factors to consider. If the tooth is not interfering with the nutrient intake of the child and is otherwise asymptomatic no intervention should be made78. Although it is difficult to determine initially whether root formation will occur in natal or neonatal teeth104 those teeth that are stable beyond 4 months have a good prognosis52. The retention of a natal tooth, which is part of the normal primary dentition, is suggested because of possible space loss, although the opinions differ23,32,38. If the tooth is supernumerary or has an excessive mobility, if it is poorly developed or is associated with soft tissue growth106 or if

to mention the need of radiographic examination, in order to differentiate the premature eruption of a primary deciduous tooth from a supernumerary tooth15,25,65. Moreover, radiographic verification reveals the root development of the tooth, adjacent structures and the existence of a relative germ in the primary dentition.

There are also 3 types of inclusion cysts that might be confused with natal teeth: Epstein’s pearls, Bohn’s nodules and dental lamina cysts. Epstein’s pearls are located along the mid-palatine raphe in the line of fusion of embryonic palatal processes. They are true cysts derived from residual ectodermal cells covering these processes. The cysts are lined by stratified squamous epithelium and the lumen contains keratin24. Bohn’s nodules are usually multiple and located along the buccal and lingual aspects of the mandibular and maxillary ridges68. They represent remnants of minor mucous salivary glands. They are true cysts comprised of stratified squamous epithelium lining a dense fibrous connective tissue wall that contains mucous acinar cells and well-formed ducts. The clinical appearance of Epstein’s pearls and Bohn’s nodules is similar. They are both small white-gray, raised nodules, 0.5-3 mm in diameter and no treatment is necessary24.

The third type of cyst is dental lamina cyst which appears as single or multiple swellings on the maxillary or mandibular ridges. These cysts, also known as gingival cysts of the newborn, are lined by thin epithelium and show a lumen usually filled with desquamated keratin, occasionally containing inflammatory cells. It is believed that they are created by fragments of dental lamina that remain within the alveolar ridge mucosa after tooth formation. Most of them degenerate and involute or rupture into the oral cavity within two weeks to five months of postnatal life63.

Furthermore, natal teeth should be discriminated from epulis and odontogenic hamartomas. Epulis are tumour-like growths of the gum that might be either sessile or pedunculated, and are reactive rather than neoplastic lesions68. Odontogenic hamartomas are tumour-like lesions, without the growth characteristics of a neoplasm, and develop during the time dental structures remain capable of further development and maturation38.

Complications

Problems that arise from the presence of natal and neonatal teeth include interruption in breastfeeding93 either by pain on suckling or by ulceration of the mother’s nipples, but the infant’s tongue usually overlies the lower incisors while nursing and any trauma will be to the infants tongue rather than mother’s


Paediatric dentists should educate parents and medical community about the preferred treatment and should conduct any necessary extraction in order to prevent trauma. The child should be re-evaluated periodically to ensure oral health. Management of natal and neonatal teeth should consist of concern to avoid any complication, to make early diagnosis and provide adequate treatment.

Conclusion

Natal and neonatal teeth are rare conditions in infancy. Most commonly involved teeth are the mandibular central incisors. Despite the fact that the exact etiology is still unknown, superficial position of the tooth germ with association of hereditary factors is the most accepted possibility. Many complications may occur with the nursing problem most commonly reviewed. Treatment and periodic follow-up should be conducted by a paediatric dentist.

References

1. Agostini M, León JE, Kellermann MG, Valiati R, Graner E, de Almeida OP. Myxoid calcified hamartoma and natal teeth: A case report. Int J Pediatr Otorhinolaryngol, 2008; 72(12):1879-1883.

2. Alaluusua S, Kiviranta H, Leppäniemi A, Hölttä P, Lukinmaa P-, Lope L, et al. Natal and neonatal teeth in relation to environmental toxicants. Pediatr Res, 2002; 52(5):652-655.

3. Allwright WC. Natal and neonatal teeth: a study among Chinese in Hong Kong. Br Dent J, 1958; 105:163-172.

4. Alvarez MP, Crespi PV, Shanske AL. Natal molars in Pfeiffer syndrome type 3: A case report. J Clin Pediatr Dent, 1993; 18(1):21-24.

5. Anderson RA. Natal and neonatal teeth: Histologic investigation of two black females. ASDC J Dent Child, 1982; 49(4):300-303.

6. Anneroth G, Isacsson G, Lindwall AM, Linge G. Clinical, histologic and microradiographic study of natal, neonatal and pre-erupted teeth. Scand J Dent Res, 1978; 86(1):58-66.

7. Arboleda H, Quintero L, Yunis E. Wiedemann-Rautenstrauch neonatal progeroid syndrome: report of three new patients. J Med Genet, 1997; 34:433-437.

8. Baghdadi ZD. Riga-fede disease: Report of a case and review. J Clin Pediatr Dent, 2001; 25(3):209-213.

9. Balci S, Güler G, Kale G, Söylemezoĝlu F, Besim A. Mohr syndrome in two sisters: Prenatal diagnosis in a 22-week-old fetus with post-mortem findings in both. Prenat Diagn, 1999; 19(9):827-831.

10. Beare JM, Dodge JA, Nevin NC. Cutis gyratum, acanthosis nigricans and other congenital anomalies. A new syndrome. Br J Dermatol, 1969; 81(4):241-247.

it interferes with naso-alveolar moulding124 or presents an abscess, the treatment of choice is extraction32,51,52. Before extraction, a dental radiograph should be obtained in order to inform the parents of possible complications and to get their consent. It is suggested to leave the tooth in the mouth as long as possible in order to decrease the possibility of removing permanent tooth buds with the natal tooth or risk defecting them76. The possibility of hypoprothrombinaemia should be taken into consideration as the commensal flora of the intestine might not have been established until the child is 10 days old. Since vitamin K is essential for the production of prothrombin in the liver it should be administered before extraction (0.5-1.0 mg, intramuscularly) if the routine postnatal injection is not given32. Also, haemophilia should be investigated38. The extraction is usually done under local anaesthesia but can also be done without anaesthesia depending on the gingival attachment, with the use of gauze as a pharyngeal guard32. After the extraction, it is advised to curette the socket to prevent the cells of the dental papillae from continuing to develop and erupting as odontogenic remnants11,25,108. If curettage is to become the routine treatment, then the injection of local anaesthetic to provide adequate anaesthesia would be required32. Residual natal teeth have been reported with a risk of formatting without curettage about 9.1%32, 86, myxoid calcified hamartoma1, pulp polyp as erupted remnants121, pyogenic granuloma due to trauma during extraction84 and peripheral ossifying fibroma60.

Riga- Fede disease is another complication of natal teeth and neonatal teeth but it’s not an indication for extraction78. The treatment options include smoothing off the incisal edges of lower incisors with an abrasive instrument3, modifying feeding behaviour or feeding devise, treatment of symptoms with oral triamcinolone acetonide in orabase applied on the lesion (Kenalog® in Orabase® Triamcinolone Acetonide Dental Paste USP, APOTHECON® A Bristol-Myers Squibb Company), or placement of composite over the edges of the insicors89,107. As many natal and neonatal teeth have hypo-mineralised enamel and are difficult to access and keep adequate moisture control, the bonding of the resin is questionable and presents the risk of swallowing or inhaling it. In cases of mild-to-moderate irritation to the tongue, such treatment may suffice. If the ulcerated area is large, however, even the reduced incisal edge may still contact and traumatize the tongue during suckling to such an extent that would delay healing86,118. The fact that the lesion could reoccur should also be taken into consideration89,107. If none of the more conservative measures is effective, the option is extraction of the tooth or even excision of the lesion107.


32. Dyment H, Anderson R, Humphrey J, Chase I. Residual neonatal teeth: A case report. J Can Dent Assoc, 2005; 71(6):394-397.

33. El Khatib K, Abouchadi A, Nassih M, Rzin A, Jidal B, Danino A, et al. Natal teeth: Apropos of five cases. Revue de stomatologie et de chirurgie maxillo-faciale, 2005; 106(6):325-327.

34. Feinstein A, Friedman J, Schewach-Millet M. Pachyonychia congenita. J Am Acad Dermatol, 1988; 19(4):705-711.

35. Fonseca MA, Mueller WA. Hallermann-streiff syndrome: Case report and recommendations for dental care. J Dent Child, 1995; 61:334-337.

36. Freudenberger S, Santos Díaz MÁ, Bravo JM, Sedano HO. Intraoral findings and other developmental conditions in mexican neonates. J Dent Child, 2008; 75(3):280-286.

37. Galassi MS, Santos-Pinto L, Ramalho LT. Natal maxillary primary molars: case report. J Clin Pediatr Dent, 2004; 29(1):41-44.

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SUMMARYThe maxillary labial fraenum is a normal anatomic structure in the

oral cavity, formed by mucous membrane and connective tissue. Although it is a normal structure, its presence has been associated with some unpleasant and even pathological situations. Specifically, a thick, hypertrophic or broad fibrous fraenum has been accused of causing a maxillary midline diastema, interfering with plaque removal, causing tension and gingival recession. A surgical removal of the fraenum is indicated in order to prevent these situations or facilitate orthodontic closure of the diastema. Frenectomy is the complete removal of the fraenum, including its attachment to the underlying bone. As shown in the literature there has been a controversy among researchers regarding the need of frenectomy and the time of the surgery.

The purpose of this study was to demonstrate the controversy of researchers regarding the removal of the maxillary labial fraenum, as a result of the study of the literature. Additionally, there has been an attempt to suggest the appropriate therapeutic strategy and indications for frenectomy, counting the medical experience and the patient’s needs. At the beginning of the study, it was important to cite the characteristics of normal and abnormal fraenum and consequences that presence of a pathological fraenum causes. Finally, there is a brief description of the most important surgical techniques for removal of the maxillary labial fraenum. Keywords: Maxillary Labial Fraenum; Frenectomy, controversy

Eva Lioliou, Apostolos Kostas, Lampros Zouloumis

Department of Oral and Maxillofacial Surgery, Aristotle University, School of Dentistry, Thessaloniki, Greece

LITERATURE REVIEW (LR)Balk J Stom, 2012; 16:141-146


The Maxillary Labial Fraenum - A Controversy of Oral Surgeons vs. Orthodontists

STOMATOLOGICA

L S

OC

IET

Y

Introduction

The maxillary labial fraenum is a normal anatomic structure in the oral cavity, usually triangular in shape, extending from the maxillary midline area of the gingiva into the vestibule and mid-portion of the upper lip16. It consists of epithelium, collagen fibres, blood vessels, nerves and sometimes few elements of minor salivary glands and isolated stratified muscle fibers19,42.

The fraenum is a dynamic and changeable structure, which tends to have variations in size, shape, and position of attachment during the different stages of growth and development12. It is found to be smaller in length, thicker and more inferiorly attached in children12,34. The eruption of primary incisors, the development of the maxillary sinus and vertical growth of the alveolar process make that insertion of the fraenum moves apically28. In

some of the cases a variation may lead to an “abnormal fraenum”; a fraenum which appears inordinately large or is attached especially close to the gingival margin16. Henry et al25, in their histological study, concluded that there are also elastic fibres which extend sometimes to the whole length of the fraenum, even perforating the periosteum. Those authors considered that the harmful effect of the fraenum is due to the presence of the elastic and collagen fibres, while no evidence of substantial differences in composition of normal and abnormal fraena were identified. Miller characterized as “pathological” a fraenum which is uncommonly wide, when there is insufficient attached gingival zone in the midline, and when the interdental papilla moves by stretch of the fraenum35.

An abnormal labial fraenum has been implicated in functional and aesthetic problems, such as a maxillary

142 Eva Lioliou et al. Balk J Stom, Vol 16, 2012

midline diastema. Regarding the maxillary midline diastema, two ways were suggested in which the fraenum may cause it. In the first way, the bulk of the fraenum fibres, retaining their embryological connection with the incisive papilla, will physically prevent approximation of central incisors2,15,22. Alternatively, these fibres will interrupt the fibres of the periodontal ligament between the central incisors and produce a weak link in the chain of fibres that join the teeth from one end of the arch to the other1,5,13.

High fraenum insertion can lead to gingival recession due to the tension which is applied on the tissues during normal functions, such as speaking, chewing, and laughing4,21,24,37,44. Moreover, a fraenum that encroaches on the gingival margin and prevents the closure of space between the maxillary central incisors creates an area for food impaction and difficulty in plaque removal24,37. The poor oral hygiene, due to difficulty in tooth brushing results in inflammatory periodontal destruction33. Aesthetics could be affected as well in cases of a high smile line4,44. Finally, a big and high attached fraenum could eliminate lip movement4.

Over the years, the relationship between the maxillary midline diastema and the labial fraenum has been the subject of much controversy and confusion. In the 1939, Hirschfield advocated frenectomy as a mucogingival procedure to eliminate the aforementioned pathologic situations caused by an abnormal fraenum attachment44. There is still a controversy among researchers concerning the need for it at all, as well as the right time for frenectomy.

Many orthodontists support the idea that even in cases of an abnormal fraenum we should wait the eruption of all 6 permanent anterior teeth first. If the eruption of all 6 permanent teeth has failed to close the diastema, frenectomy has a clinical validity only in conjunction with orthodontic treatment16,27. They also state that the relapse of orthodontically treated diastema caused by an abnormal fraenum, which had not been excised, is a rare phenomenon3,5,16. On the other hand, surgeons accuse a hyperplastic type of fraenum, usually with a fanlike attachment, of causing a diastema and enhancing the possibilities of a relapse. A frenectomy could also prevent the other unpleasant situations cited previously, such as gingival recession4,9,23,24,28,33,37.

There are some clinical situations in which a maxillary labial frenectomy is indicated4,24,37,49: 1. To avoid a relapse of an orthodontically treated

maxillary diastema;2. In cases with a too short labial fraenum, which creates

problems in upper lip movement, speech etc;3. To avoid gingival recession due to tension created

during the normal oral function;4. To facilitate lip lengthening procedure;5. To allow effective tooth brushing in the area of the

fraenum;

6. When a maxillary labial fraenum prevents the installation of a removable denture;

7. In rare occasions, for aesthetic reasons.

The Fraenum by Orthodontic Approach

The presence of the maxillary labial fraenum has a great significance for the orthodontic community, since it is considered to be the commonest causative factor for a maxillary midline diastema. An abnormal fraenum has also been accused of being a great danger for relapse after orthodontically treated diastema. Consequently, maxillary labial frenectomy was considered for many years as the indicated treatment for maxillary midline diastema9,14,34,37.

There has been a controversy even among orthodontists concerning the need at all, and the timing for a frenectomy. Some orthodontists support a viewpoint that there is a need for an early removal of the fraenum, so as to prevent any obstacles to complete diastema closure. Other orthodontists propose to close the diastema first, and then carry out frenectomy in the hope that the resultant scar tissue will hold together the teeth in close apposition. A third body of clinicians rarely, if ever, considers surgical removal of the fraenum. They prefer to combat the undeniably increased relapse potential when a diastema is closed, by using bonded retainers on the two central incisors6,31,37.

Literature offers a great variety of opinions during years and it is obvious that they differ a lot concerning the etiology of a persisting diastema, such as to the possibility of promoting closure of a diastema by means of frenectomy9.

At the beginning it was thought that the labial fraenum interfered with the closure of the midline diastema. This belief resulted in misdiagnosis and unnecessary surgical intervention of the fraenum13,14. Adams1 suggested that there is a specific type of fraenum which interrupts the continuity of interdental fibre, forms the factor that inducts the reaction for the development of the diastema. Although, he stated that there is a need of presence of other causative factors. Campbell et al11 stated the same. Shashua and Artun43 found that there is a relationship between abnormal fraenum and the width of the maxillary midline diastema. Edwards16 supported the presence of a strong but not absolute correlation between the fraenum and the upper midline diastema. Gardiner18 made a survey of 1000 children 5-15 years old. 80% of the cases with midline diastema were associated with a prominent fraenum. He took this finding as an evidence to support the opinion that the fraenum is often a contributory cause of midline diastema. Angle2 concluded that the presence of an abnormal fraenum is a cause for

Balk J Stom, Vol 16, 2012 The Maxillary Labial Fraenum 143

midline diastema. James29 used a sample of 10 girls 12-22 years old with medial diastema. A year after frenectomy, a reduction was noted in 8 cases. He assumed that frenectomy leads to a reduction of the diastema. By the time researchers rejected this statement and proved that there is no evidence to establish a relationship between the different types of fraenum and diastema.

Tait46 stated that the fraenum has no effect to the maxillary central incisors. Ceremelo12 concluded that the fraenum is not related to the presence or the width of the diastema. Bergstorm et al9 stated that the long term potential for spontaneous diastema closure, in patients with abnormal fraenum, has no difference even if there has been a frenectomy, or not. Popovich et al40,41 suggested that the presence of the diastema leads to the abnormal fraenum, and not the adverse.

Since there is no quite evidence concerning the fact that the maxillary labial fraenum is the main causative factor for a midline diastema, some orthodontists propose the following therapeutic methodology37,45: Initially, it is necessary for the dentist to make a diagnostic trial, in order to find out whether the fraenum is implicated in the pathogenecity of the diastema.

1. Positive “blanch test” of the incisal papilla, when pulling the lips forward. By pulling the upper lip and exerting pressure on the fraenum, if there is a blanching, (ischemia in the papilla) it is safe to predict that the fraenum will unfavourably influence the development of the anterior occlusion;

2. With the use of a periapical radiograph, in the area of central incisors we can discover: a presence of a mesiodens, an odontoma in the middle line; a presence of residual suture of alveolar bone. If we find out that the diastema in our case is related to the fraenum, a maxillary labial frenectomy is indicated.

It is important to emphasize on the fact that frenectomy has clinical validity only after the eruption of all 6 permanent teeth if it failed to close the diastema, and then only in conjunction with orthodontic treatment. So after the eruption of all 6 permanent teeth, orthodontic appliances are used to close the diastema. A frenectomy is carried out, so as the scar tissue will hold the teeth together16,20,27,33,37,39,48.

During the primary dentition phase, surgical intervention of the labial fraenum is not recommended7.

The Fraenum by Oral Surgery Approach

Oral surgeons accused an abnormal fraenum of causing unpleasant situations, such as maxillary midline diastema and consequently suggested the operation of maxillary labial frenectomy20,36.

In case of a diastema, a hyperplastic type of fraenum, with a fanlike attachment, can inhibit the closure of the diastema or even lead to a relapse of an orthodontically corrected diastema. Studies reveal that a midline diastema has closed earlier in operated cases. Thus, the result implies that frenectomy is indicated, if early closure of the diastema is considered desirable, especially if patient finds it very unsightly9.

The advantage of an early excision prior to orthodontic treatment is the ease of surgical access33,37. Access to the surgical procedure is more limited after orthodontic closure and it will not be possible to remove all the residual fibrous tissue thoroughly from the interdental suture area37.

In guides of paediatric, oral surgery treatment is suggested when attachment exerts a traumatic force on the gingiva, causing the papilla to blanch when the upper lip is pulled, or if it causes a diastema to remain after eruption of permanent canines23.

Interference with oral hygiene measures, aesthetics and psychological reasons are contributing factors that relate the treatment of the maxillary fraenum23.

Also, elimination of the maxillary labial fraenum is often indicated in edentulous or partial edentulous patients to allow denture flange extension in this area49.

The Fraenum by Periodontal Approach

The labial frenectomy must be examined by the aspect of periodontists as well. In 1950, Friedman was the first to introduce the term “mucogingival surgery”, in order to describe techniques that aim to preserve the attached gingiva, remove aberrant fraenum or muscle attachment and increase the depth of the vestibule36. For years, clinicians targeted in removing the fraenum or deepening the vestibule17; today, it is approved that the presence of an adequate zone of attached gingiva is the basic factor. When there is an adequate zone of attached gingiva, even a high fraenum attachment does not constitute dangerous factor for the beginning and the process of periodontal disease. On the other hand, in the case of inadequate zone of the attached gingiva, the draw of the fraenum and muscle attachment cannot be balanced, there is inability of good and atraumatic oral hygiene, and this is a fact that usually leads to gingival recession32,36. Consequently, there exist anatomic (not adequate zone of attached gingiva), biologic (inflammation, inability for good oral hygiene) and functional (inability for protection during chewing procedure) factors that lead to the decision of frenectomy32. The maxillary labial fraenum may present the aesthetic problem as well, compromise an orthodontic result or create traumatic problems in tissues


during oral hygiene actions. These situations also need surgical intervention32.

The initial approach was to remove the fraenum with simultaneous deepening of the vestibule. Later, this technique was replaced by plastic surgery, which aimed to cover the root of the tooth. Another technique was a frenectomy with a gingival augmentation procedure, using a pedicle graft36.

Edwards16 used a sample of 308 patients, who prior to orthodontic treatment demonstrated either diastema an abnormal fraenum or a combination of both. In his technique he noticed the aesthetic maintenance of the interdental papilla between the central incisors. Miller chose a surgical technique in which he avoided removal of the entire fraenum, but emphasized in orthodontic stability without aesthetic sacrifice. His technique seemed to be similar, but Edwards thought that the transeptal fibres of the fraenum should be destroyed, whereas Miller made no effort to destroy transeptal fibres35,36. Regarding the interdental papilla, it proved that it should be maintained, even though clinically it may appear to be a part of the labial fraenum36.

Periodontists do not tend to use the classical frenectomy, in which interdental tissue and palatine papilla are completely excised. Today, we use frenectomy in which we have a partial removal of the fraenum and relocate it to a more apically position. This technique leads to an acceptable solution of the problem and to the movement of the fraenum more apically16,44.

In case of a diastema, the ideal time for this technique is after the beginning of orthodontic treatment and about 6 weeks before the appliances are removed. That allows healing, tissue maturation and does not prolong orthodontic treatment36.

Surgical Techniques

Various surgical techniques have been described for the management of the abnormal upper labial fraenum8,20,30. It is important to refer that there is a distraction between the terms “frenectomy” and “frenotomy”. Frenectomy is the complete removal of the fraenum including its attachment to underlying bone; frenotomy is the partial removal of the fraenum and is used extensively for periodontal purposes to relocate the fraenum attachment, so as to create an increased zone of the attached gingiva between the gingival margin and the fraenum16,24,37.

2 main ways for the removal of the fraenum are the conventional technique with scalpels or periodontal knives and the technique with the use of soft tissue laser24,47. Archer described the classic frenectomy technique in which the fraenum, interdental tissues and palatine papilla are completely excised, leaving bone

and periosteum exposed3. After that, some modifications include the addition of horizontal relaxing incisions and the mucogingival junction, and the lateral underlying of the labial attached gingiva adjacent to the excision area. Disagreements have been expressed because of the increased possibility for creating hematoma and concerning the need for a dressing over the wound16.

Another procedure that was described called “the z-plasty technique”. In this technique, the fraenum is not removed but it is intended to relax the pull of the fraenum on the interdental soft tissue16,20. By the aspect of periodontists, there has been described a frenotomy with no excision of the marginal papilla, and “the curtain type” of gingivotomy of the palatal tissue behind 4 incisors (Frisch, Jones, Bhaskar)16. Other clinicians combined the classic frenectomy with a lateral pedicle graft, free papilla graft and free gingival graft taken from the papilla4,20. A lateral pedicle graft does not offer a complete coverage of the wound and has aesthetic problems creating an unsatisfactory colour match4. A technique known as “Archer incision” is a simple frenectomy that is made with a V-shaped incision3. The disadvantage of this technique is that it leaves a longitudinal surgical incision and scarring, which may lead to periodontal problems and an non-aesthetic appearance4.

Recently a new frenectomy technique has been proposed by Bagga et al4, which provides a good aesthetic result. In this technique, a V-shaped full-thickness incision was placed at the gingival base of the fraenum attachment. After the excision of a fraenum, a V-shaped defect on the gingiva side has remained. An oblique partial thickness incision is placed on adjacent attached gingiva extending beyond the mucogingival junction. A partial-thickness dissection of the attached gingiva is formed in an apico-coronal direction. Then we have a triangular pedicle of the attached gingiva with free apex and the base continuous with the alveolar mucosa. Finally, a bilateral triangular pedicle is sutured at the centre, covering the underlying defect4.

Discussion

The study of the literature reveals that the presence of the maxillary labial fraenum has been associated with many pathological situations in the oral cavity; the most common of them is the maxillary midline diastema. Consequently, for decades there has been a tendency from every part of the dental community, to remove the fraenum at an early age in order to achieve the diastema closure.13 Many researchers dealt with this issue and many research papers have been published. The therapeutic approach gradually changed into a more conservative management and a controversy among researchers started, existing until nowadays.

Balk J Stom, Vol 16, 2012 The Maxillary Labial Fraenum 145

In the orthodontic community there is unanimity on this issue37. Orthodontists support that the fraenum should be maintained until the age of the eruption of all 6 permanent anterior teeth. After that, and only if the diastema remains the same, a frenectomy is indicated, with subsequent orthodontic closure of the diastema9,16.

Periodontists concentrate on the issue of the adequate zone of the attached gingiva. In case of inadequate zone of the attached gingiva, the increased tension causes gingival recession and a frenectomy is recommended24,32,36.

Oral surgeons suggest that in case of a maxillary midline diastema, a small intervention of the fraenum is useful. In this way, the closure of the diastema is facilitated and the orthodontic treatment is not affected9,20. In cases that the fraenum causes problems in periodontal tissues, such as gingival recession, the removal of the fraenum should be direct24,44.

Moreover, it is quite clear that when the presence of the maxillary labial fraenum interrupts the installation of a removable denture, the removal of the fraenum is imperative49.

Today, the belief that the presence of a maxillary midline diastema does not prompt an early frenectomy predominates. We must wait for a short period, specifically until the eruption of all 6 permanent anterior teeth9,14,16,20,34,36,37. Yet, this is acceptable if the fraenum is not responsible for other pathological situations in the oral cavity.

On the other hand, it is important to remember that the final decision is taken by patients. The duration and the cost of the treatment are 2 basic factors. Patients rarely compromise with expensive and long-term procedures, especially if these include orthodontic treatment which affects aesthetics8,9.

References

8. Adams CP. The relation of spacing of the upper central incisors to abnormal labial fraenum and other features of the dento-facial complex. Dent Prac Dent Rec, 1954; 74:72-86.

9. Angle EH. Malocclusion of the teeth. 7th ed. Philadelphia: White dental manufacturing, 1907.

10. Archer WH. Oral surgery for dental prosthesis. In: Archer WH (Ed). Oral and maxillofacial surgery. Philadelphia: Saunders, 1975; pp 135-210.

11. Bagga S, Bhat KM, Bhat GS, Thomas BS. Esthetic management of the upper labial fraenum: a novel frenectomy technique. Quintessence, 2006; 37:819-823.

12. Baum AT. The midline diastema. J Oral Med, 1966; 21:30-39.

13. Beasley WK, Maskeroni AJ, Moon MG, Keating GV, Maxwell AW. The orthodontic and restorative treatment of a large diastema: a case report. Gen Dent, 2004; 52:37-41.

14. Bedell WR. Nonsurgical reduction of the labial fraenum with and without orthodontic treatment. J Am Dent Assoc, 1951; 42:510-515.

15. Bell WH. Surgical-orthodontic treatment of interincisal diastemas. Am J Orthod, 1970; 57:158-163.

16. Bergstrom K, Jensen R, Martensson B. The effect of superior labial frenectomy in cases with midline diastema. Am J Orthod, 1973; 63:633-638.

17. Campbell A, Kindelan J. Maxillary midline diastema: a case report involving a combined orthodontic/maxillofacial approach. J Orthod, 2006; 33; 22-27.

18. Campbell PM, Moore JW, Matthews JL. Orthodontically corrected midline diastemas. A histologic study and surgical procedure. Am J Orthod, 1975; 67:139-158.

19. Ceremello PJ. The superior labial fraenum and the midline diastema and their relation to growth and development of the oral structures. Am J Orthod, 1953; 39:120-139.

20. Dewel BF. The labial fraenum, midline diastema, and palatine papilla: a clinical analysis. Dent Clin North Am, 1966; pp 175-184.

21. Diaz-Pizan ME, Lagravere MO, Villena R. Midline diastema and fraenum morphology in the primary dentition. Journal of dentistry for children, 2006; 73:11-14.

22. Dickson GC. Orthodontics in general dental practice. London: Pitman, 1964.

23. Edwards JG. The diastema, the fraenum, the frenectomy: A clinical study. Am J Orthod, 1977; 71:489-508.

24. Friedman N. Mucogingival surgery. Texas Dent J, 1957; 75.25. Gardiner JH. Midline spaces. Dent Prac Dent Rec, 1967;

17:287-298.26. Gartner LP, Schein D. The superior labial fraenum: a

histologic observation. Quintessence Int, 1991; 22:443-445.27. Gkantidis N, Topouzelis N, Zouloumis L. Differential

diagnosis and combined treatment of maxillary midline diastema caused by the fraenum and/or intermaxillary suture. Balk J Stom, 2008; 12:81-88.

28. Gottsegen R. Fraenum position and vestibule depth in relation to gingival health. Oral Surg Oral Med Oral Pathol, 1954; 7:1069-1078.

29. Graber TM. Orthodontics: Principles and Practice. Philadelphia: Saunders, 1972.

30. Guideline on Pediatric Oral Surgery, American Academy of Pediatric Surgery (AAPD). 2010; p 8.

31. Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques. J Periodontol, 2006; 77:1815-1819.

32. Henry SW, Levin MP, Tsaknis PJ. Histologic features of the superior labial fraenum. J Periodontol, 1976; 47:25-28.

33. Herremans EL. Anterior diastema: frenectomy. Dent Surv, 1971; 47:33-37.

34. Huang SW, Creath CJ. The midline diastema: a review of its etiology and treatment. Pediatr Dent, 1995; 17:171-179.

35. Jacobs MH. The abnormal fraenum labii. Dent Cosmos, 1932; 74:436-439.

36. James GA. Clinical implication of a follow-up study after frenectomy. Dent Pract, 1967; 17:299-305.

37. Kahnberg KE. Fraenum surgery. A comparison of three surgical methods. Int J Oral Surg, 1977; 6:328-333.

38. Kinderknecht KE, Kupp LI. Aesthetic solution for large maxillary anterior diastemas and fraenum attachment. Prac Periodontics Aesthet Dent, 1996; 8:95-102.

39. Konstantinidis A. Periodontology. Vol 1.Thessaloniki: Konstantinidis A, 2003; p 77.


40. Koora K, Muthu MS, Rathna PV. Spontaneous closure of midline diastema following frenectomy. J Indian Soc Pedo Prev Dent, 2007; 25:23-26.

41. Lindsey D. The upper mid-line space and its relation to the labial fraenum in children and in adults. A statistical evaluation. Br Dent J, 1977; 143:327-332.

42. Miller PD Jr. The frenectomy combined with a laterally positioned pedicle graft. Functional and esthetic considerations. J Periodontol, 1985; 56:102-106.

43. Miller PD Jr. Regenerative and reconstructive periodontal plastic surgery. Dent Clin North Am, 1988; 32:287-305.

44. Mittal M. Maxillary labial fraenectomy: indications and technique. Dent Update, 2011; 38:159-162.

45. Munshi A, Munshi AK. Midline space closure in the mixed dentition: A case report. J Indian Soc Pedo Prev Dent, 2001; 19:57-60.

46. Oesterele LJ, Shellhart WC. Maxillary midline diastema: a look at the causes. J Am Dent Assoc, 1999; 130:85-94.

47. Popovich F, Thompson GW, Main PA. The maxillary interincisal diastema and its relationship to the superior labial fraenum and intermaxillary suture. Angle Orthod, 1977; 47:265-271.

48. Popovich F, Thompson GW, Main PA. Persisting maxillary diastema: differential diagnosis and treatment. Dent J, 1977; 43:330-333.

49. Ross RO, Brown FH, Houston GD. Histologic survey of the frena of the oral cavity. Quintessence Int, 1990; 21:233-237.

50. Shashua D, Artun J. Relapse after orthodontic correction of maxillary median diastema: a follow-up evaluation of consecutive cases. Angle Orthod, 1999; 69:257-263.

51. Sorrentino JM, Tarnow DP. The semilunar coronally repositioned flap combined with a frenectomy to obtain root coverage over the maxillary central incisors. J Periodontol, 2009; 80:1013-1017.

52. Spiropoulou MN. Basic Principles of Orthodontic. Vol 2. 2006; pp 250-251.

53. Tait CW. The median fraenum of the upper lip and its influence on the spacing of the upper central incisor teeth. Dent Cosmos, 1924; 76:991-992.

54. Takei HH, Azzi RA. Periodontal plastic and esthetic surgery. In: Newman MG, Takei HH, Carranza FA (Eds). Carranza’s clinical periodontology. London: WB Saunders, 2002; pp 870-871.

55. Taylor JE .Clinical observations relating to the normal and abnormal fraenum labii superiors. Am J Orthod, 1939; 25:646-660.

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Prof. Lampros Zouloumis Ippodromiou Sq 17 54621, Thessaloniki,Greece E-mail: [email protected]

SUMMARYAsymmetric malocclusion is a common problem in children with

transverse and vertical dental anomalies. These asymmetries can be skeletal, dental, functional or combination of these. The aim of this study was to determine condylar position and quantifying inclination of frontal occlusal plane in patients with transversal and vertical dentofacial discrepancy.

The study group consisted of 80 patients, 40 had unilateral posterior cross-bite, and 40 had normal occlusion. The age of the patients ranged between 13 and 18 years. In addition to transversal and vertical clinical observation, Ricketts facial PA cephalometric analysis was made. Radiographic analysis showed the relationship between the cant of the occlusal plane and mandibular position.

The obtained results showed that there was a very high statistical significance (p<0.001) for cephalometric measurements inclination of occlusal plane Zl-A6/Zr-A6 between the 18 patients with unilateral cross-bite and patients with normal occlusion. Mandibular displacement, facial asymmetry and strongest correlation with condyle path asymmetry were found in the experimental group. Unilateral cross-bites were very often associated with condylar deviations and, in some cases, signs and symptoms of temporomandibular joint disorders were present.Keywords: PA Cephalometric Analysis; Unilateral Cross-bite; Condylar Deviation; Occlusal Plane, inclination

L. Kanurkova1, J. Gjorgova1, B. Dzipunova1, N. Toseska1, A. Dorakovska2, M. Popovska3, M. Pandilova3

1Faculty of Dentistry, Department of Orthodontics, Dental Clinical Centre, Skopje, FYROM 2 Private Dental Practice, Skopje, FYROM 3Faculty of Dentistry, Department of Periodontology and Oral Pathology, Dental Clinical Centre, Skopje, FYROM

ORIGINAL PAPER (OP)Balk J Stom, 2012; 16:147-153


Association between Condylar Position and Tilt ofFrontal Occlusal Plane in Patients withTransversal and Vertical Dentofacial Discrepancy

STOMATOLOGICA

L S

OC

IET

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Introduction

The relationship between dentition and orofacial skeletal structures is not always harmonious and it depends on tooth number and position in dental arch. Identification of dental or skeletal factors, negative influence of growth and development, and tooth eruption is necessary to prevent orofacial malocclusion. Modelling of bone occurs as a result of different growth, of interrelated anatomic skeletal parts in orofacial region, influence of the function in orofacial region and forces applied on bone.

Asymmetric malocclusion is a common problem in children with transverse and vertical dental anomalies. These asymmetries can be skeletal, dental, functional or combination of these. Patients who have transversal

discrepancies usually have mandibular displacements and, if left untreated, they can lead to skeletal deformation4 with vertical asymmetry of the mandible, such as inclination of the frontal occlusal plane and inclination of the frontal mandibular plane.

Growth in the transverse dimension happens earlier than in the sagittal or vertical dimension and hence early treatment is necessary. Early treatment can prevent associated mandibular dysfunction and facial asymmetry caused by posterior cross-bites13. However, mandible displacement may not be all or even part of the cause of a craniomandibular dysfunction because orthodontic treatment may be responsible for the different degrees of symmetry.

Patients with asymmetric malocclusion have lateral displacement of the mandible because the maxillary

148 Lidija Kanurkova et al. Balk J Stom, Vol 16, 2012

arch is too narrow, the mandibular arch is too wide, or the maxillary arch is too wide and the mandibular arch is too narrow, and a combination of these situations. Some asymmetries are genetic in nature30. Of prime importance is the fact that uncorrected cross-bites can produce undesirable growth and dental compensations that may lead to asymmetric jaw growth. Mandible lateral displacement is clinically characterized by deviation of the chin, dental midline discrepancy and facial asymmetry; patients have cross-bites in the posterior region, and high prevalence of the internal temporomandibular joint derangement9.

Mandibular displacements are present in most unilateral posterior cross-bites. Patients have a deflective dental contact, resulting in a functional shift on closure. This functional shift can cause unbalanced muscular activity, with hyperactivity on the cross-bite side. This type of muscular hyperactivity has been shown to influence the size and shape of the developing temporomandibular joint. Deviation of the midline when the mouth is wide open suggests a mandible laterognathia8

.Diagnosis of temporomandibular joint disorders

is very difficult and confusing. In most cases, there is a

need of detailed medical history for complete evaluation of temporomandibular disorder, including patient’s description of symptoms and physical examination of the face and jaw movement. Complete medical history may be useful for making a correct diagnosis.

The aim of this study was to investigate the relationship between dental and skeletal morphologic changes in patients with transversal and vertical dentofacial discrepancy, and to determine condylar position and inclination of frontal occlusal plane.

Material and Method

The study group consisted of 80 patients, 40 had unilateral posterior cross-bite on the left side, and 40 patients had normal occlusion, and they were the control group. The age of the patients ranged between 13 and 18 years, with equal sex distribution. Ricketts facial PA cephalometric analysis27,28 was used as a method for transversal and vertical clinical observation. This analysis

was made on the cephalometric films by standard methods (Fig. 1).

Figure 1. PA cephalometric film Figure 2. Cephalometric transversal and vertical landmarks, reference lines, craniofacial angle, used in the PA analysis

The transversal and vertical landmarks, reference lines and measurements, used in the PA analysis (Fig. 2), are useful for determination of: - cranial width (Zr–Zl), distance between lateral left

and right zygomatico-frontal landmarks;

- facial width (ZA-AZ), distance of the left and right zygion point on the zygomatic arch;

- maxillary width (Jl-JR), distance between point jugale located on the maxillary corpus; and

- mandibular width (AGol-AGor), distance between bigonial point.

Balk J Stom, Vol 16, 2012 Patients with Vertical Dentofacial Discrepancy 149

- Other cephalometric measurements used in this analysis were done to measure:

- dental arch width, inter-canine maxillary cephalometric width (A3-3A);

- inter-canine mandibular cephalometric width (B3-3B); - inter-molar maxillary cephalometric width (A6-6A); - inter-molar mandibular width (B6-6B); - molar relation A6/B6, on the left side and molar

relation on the right side 6A/6B.Craniofacial angle showing the cross-bite type, is the

angle between points zygomatico-frontale-antegonion-jugale <Zr-Agor-Jr, <Zl-Agol-Jl, and this angle presents maxillo-mandibular relation. Facial symmetry is shown with the left and right angle of the face, between points zygion-antegonion-zygomatico-frontale, <ZA-Agor-Zr, <AZ-Agol-Zl (Fig. 2).

The vertical reference plane showing the facial midline is between point spina nasalis anterior-menton (SNA-Me). This measurement presents maxillo-mandibular midline and it is constructed as a straight line passing through crista galli and anterior nasal spine (Fig. 2), perpendicular to the straight line between intersection of the innominate line of the greater wing of the sphenoid bone and the lateral orbital margins22.

On the frontal cephalometric radiographs, occlusal plane tilt is defined as a difference between the height of the occlusal plane at the distal side on the left and right molars to the line that connects zygomatico-frontal sutures (Zl-A6/ Zr-A6). This variable represents inclination of the frontal occlusal plane relation27, which is usually warning of possible TMJ problem (Fig. 3).

condylar position (Fig. 4). Bilateral facial asymmetries and development of the orofacial area can be better assessed with a transverse analysis of PA cephalometric radiographs16,17. This analysis shows changes in vertical and transversal dimensions of the face.

Figure 3. Linear cephalometric measurements for inclination and evaluation of occlusal plane (Zl-A6/A6-Zr)

Symmetry in maxillo-mandibular region and type of the facial asymmetry is measured with linear cephalometrics27 - difference between point zigomatico-frontale and antegonion on the left and right side of the face (Zl-Agol), (Zr-Agor). This variable represents

Figure 4. Linear cephalometric measurements for facial symmetry condylar position, and evaluation of maxillo-mandibular relation

(Zl-Agol), (Zr-Agor)

Data were analyzed using a statistical programme with means and standard deviations. Student’s t-test was used to determine statistical significance between the groups.

Results

The results and comparison of the means of angular and linear skeletal dentofacial variables between patients with unilateral cross-bite and control group are presented in tables 1-3.

Results of facial, maxillary and mandibular skeletal cephalometric measurements are shown in table 1. Patients with unilateral posterior cross-bite had constriction of the maxillary corpus on the left side in the region of the point Jugale. Moreover, maxillary dental arch was smaller and maxillary first molar had palatal inclination (Tab. 1).

Results for angular cephalometric measurements obtained by Ricketts P-A analysis are shown in table 2. Angle which shows cross-bite type <Zl-Ago-Jl was increased in comparison with normal values. Patients with posterior cross-bite had high values for the angle, 19.80, which pointed to the skeletal lingual cross-bite.


Table 1. Linear facial and dental cephalometric measurements (mm) used in Ricketts PA analysis in patients with cross-bite on the left side

FacialCephalometric Measurements

Patients with unilateral cross-bite n=40

Patients with normal occlusion n=40

Mean SD Mean SD “t“ PZr - Zl 99.5 4.2 102.0 4.1 1.6 0.1ZA - AZ 127.0 5.4 132.2 3.5 2.5 0.01**Jr - Jl 65.7 3.5 70.9 4.5 4.3 0.001***Agor - Agol 86.3 3.3 88.9 3.1 1.8 0.72

Dental Cephalometric Measurements A3 - 3A 33.2 2.4 34.6 2.7 1.7 0.8B3 - 3B 29.2 1.8 29.8 2.6 0.8 0.42A6 - 6A 59.4 3.5 63.7 5.8 3.1 0.001***B6 - 6B 61.2 3.5 62.3 5.7 0.8 0.416A6 / B6 0.91 0.8 0.9 0.5 0.1 0.8826A / 6B -1.97 1.1 1.0 0.5 3.4 0.001***

* p< 0.05; ** p< 0.01; *** p< 0.001

Table 2. Angular cephalometric measurements used in Ricketts PA analysis

Cephalometricangular measurements

Patients with unilateral cross-bite

n = 40

Patients withnormal occlusion

n= 40Mean SD Mean SD “t“ p

<ZA-Agor-Zr 14.70 1.93 16.60 2.4 0.19 0.25<AZ-Agol-Zl 13.60 1.91 16.30 1.8 1.19 0.05*<Zr-Agor-Jr 15.50 1.5 14.30 2.3 2.5 0.01**< Zl-Agol-Jl 19.80 1.96 14.70 1.7 9.24 0.001***

* p< 0.05; ** p< 0.01; *** p< 0.001

Table 3. Cephalometric measurements (mm) for condylar position and

inclination of occlusal plane

Cephalometriclinear measurements

Patients with unilateral cross-bite

n = 18

Patients withnormal occlusion

n= 40

Mean SD Mean SD “t“ p

Zr -Agor 97.16 2.57 101.1 4.5 2.01 0.01*Zl - Agol 94.66 2.63 101.2 3.5 2.98 0.01**Zr - A6 73.55 3.36 76.6 2.3 1.96 0.5*Zl - 6A 73.47 3.35 76.6 3.5 1.96 0.05*

* p< 0.05; ** p< 0.01; *** p< 0.001


Results from PA cephalometric study provided useful information for condylar position Zl-Agol and inclination of occlusal plane Zl-6A. Results from these measurements in patients with unilateral posterior cross-bite are presented in table 3. Out of 40 patients, 18 had inclination of the occlusal plane and mandibular displacements.

Discussion

Orthodontic diagnosis is mostly based on the use of cephalometric radiographs as a diagnostic tool. Transversal and vertical components are easily viewed from lateral cephalograms, but cannot be fully understood without the assistance of PA cephalometric analysis. Roentgenograms, such as the postero-anterior view, submental vertex21, 3-dimensional image of the patients’ face22, and computerized tomography images are important methods for diagnosis and quantification of dentofacial transversal and vertical discrepancies and facial asymmetries.

Diagnosis of unilateral and bilateral vertical asymmetries and development of the orofacial area can be better assessed with frontal transverse analysis of PA cephalometric radiographs8,10,17. PA cephalogram, in fact, contains important diagnostic information, which shows level and type of facial asymmetries23,27,28. Patients with lateral occlusion and midline shift can be observed in occlusal position. In patients with laterognathy, the midline shift can be observed in both situations, in occlusal position and when the mouth is wide open. If cross-bite and lateral occlusion are not treated during growth, they can lead to asymmetric jaw growth. Degree of asymmetry in the vertical dimension significantly correlated with TMJ symptoms20.

PA cephalometric analysis is more conservative than 3-dimensional image of the patients’ face22 or computerized tomography images. This analysis gives opportunity to show the severity of the skeletal problem. Analysis of PA cephalograms in this study showed that patients with unilateral posterior cross-bite had a constriction on the maxillary corpus in the point jugale and smaller maxillary dental arch in inter-molar region. Mandibular arch was within normal parameters. PA roentgenograms showed that maxillary width had lower values in patients with unilateral cross-bite (65.7 mm). These values compared with the values of the patients with normal occlusion (70.9 mm) showed a very high statistical significance (p<0.001). Therefore, the patients with a cross-bite had a statistically significantly smaller palatal volume with skeletal constriction on the maxillary corpus.

Angle between point zigomatico-frontale and antegonion <Z-Ago-J, denoting the cross-bite type, in patients with unilateral posterior cross-bite had a value

of 19.8 degree, compared to that in the control group (p<0.001). The value of this angle showed that patients had skeletal lingual cross-bite.

PA cephalograms showed mandible asymmetry in 18 patients; they had inclination of the frontal occlusal plane for 3 mm (Zl-A6/ Zr-A6). The results suggest that the degree of asymmetry in the vertical dimension was statistically significant (p<0.01) and the inclination correlated with TMJ disorder symptoms. Irregular dental occlusion had also influence on the changes in cant of the occlusal plane3; differences in the heights of the right and left mandibular rami have been suggested as important skeletal problem associated with TMJ pathology32

. Our analysis was in agreement with the reports in similar studies2,27,32. Patients with facial asymmetry had shifted position of the mandible, which showed the strongest correlation with condyle path asymmetry9,12

. Unilateral cross-bites are very often associated with condylar deviations and in some cases are signs of TMJ disorders25.

Analysis of frontal PA radiographies in this study showed that patients with cross-bite had: lingual inclination of maxillary buccal teeth, constriction of the maxillary corpus on the level of the point jugale, skeletal, lingual cross-bite, and facial asymmetry. Our results coincide with the findings presented in the studies of Hewitt10 and Kusayama14.

Many studies have defined geometric and mathematical relationships between dental occlusion and rotations of the occlusal plane in the frontal view6,8,10. As a general clinical guide, each degree of rotation of the occlusal plane will result in a half-millimetre change in the dental occlusal relationship. This is important since changes in the cant of the occlusal plane are sometimes unintentional, as well as intentional, during occlusal therapy. The distance in millimetres between the facial midline and the midline of the mandible incisors has been described as the dental midline shift4. A dental midline shift on the left and right side was considered as the absolute value for diagnostic criteria for transverse asymmetry.

Asymmetrical patients have also been found to have a higher incidence of morphological changes and internal TMJ derangement on the shifted side when compared to the non-shifted side20,21 and it has been suggested that the incidence of disk displacement and TMJ disorder symptoms on the deviated side is higher than on the non-deviated side.

An insufficient maxillary arch width in our study is a typical finding in the unilateral posterior crossbite14. Functional shift results in lateral mandibular displacement, and thus, there is a mandibular midline discrepancy19. When the maxilla is severely constricted, a bilateral posterior cross-bite is present.

Causes of asymmetric malocclusion are multifactorial. O’Byrn21 suggested that congenital malformations, digital habits, interproximal caries and


extractions can influence the dental arch symmetry. Transversal and vertical discrepancy in orofacial region are malocclusions with a wide range of symptoms, leading to skeletal and dental arch deformities, tooth malposition, masticator disturbances, TMJ disorders, and facial asymmetry. Woodside and Linder-Aronson34

listed a number of factors that were contributory to malocclusions and altered skeletal relationships. Several studies confirmed the following contributory factors: genetic predisposition, enlarged adenoids, enlarged tonsils, allergic rhinitis, sleep apnea, deviated nasal septum, altered mandibular posture, altered tongue posture, extended head posture, incorrect orthodontic treatment, weakness in the muscles of mastication, and thumb sucking34. Most TMJ problems are multifactorial in origin, including a number of possible causes, such as condylar deviations and TMJ diseases, or irregular dental occlusion. Asymmetry of the mandible shows a high incidence of TMJ disorders14,32.

Functional shift of the mandible in children with unilateral posterior cross-bite results in an asymmetric position of condyle and suggests that this functional shift may transmit forces to the skeleton, resulting in asymmetry in the adult23,24. This asymmetrical function reflects different development of the elevator muscles on each side of the jaws, leading to a thinner masseter muscle on the cross-bite side32. Hesse9 described that uncorrected cross-bites may lead to restriction of maxillary growth and traumatic occlusion, producing undesirable growth and dental compensations that may lead to asymmetric jaw growth, and mandibular displacement resulting in facial asymmetry. Differences in the heights of the right and left ramus mandible have also been suggested as important skeletal problems associated with TMJ pathology32.

Occlusal instability, midline discrepancy, right and left differences in molar relationship, and inclination of the frontal occlusal plane2,3 have also been considered to be important occlusal characteristics in patients with unilateral posterior cross-bite12,15.

In patients with posterior cross-bite and midline deviation orthodontic treatment is necessary to rehabilitate the asymmetric muscular activity between the cross-bite and the other side and the changed position of the condyle caused by mandibular deviation. The success of the treatment rests on the presence of skeletal or dental changes. Skeletal asymmetries are preferably treated with a combination of orthodontics and orthognathic surgery. Dental and small skeletal asymmetries and functional mandibular asymmetries are most often treated with orthodontic therapy. A combination of orthodontic and orthopaedic treatment has been shown to correct the maxillary transverse deficiency, allow better mandibular growth and improve facial and dental aesthetics. When patients have problems in transversal maxillary development, maxillary expansion is the treatment of choice for posterior cross-bite; correction of maxillary

transverse deficiency allows better mandibular growth, proper bucco-lingual relations and good intercuspidation, resulting in normal function.

Early diagnosis and treatment will facilitate establishment of functional and aesthetic individual optimum to maintain the specific features of the concerned person, and will correct growth and development of the orofacial region.

References

1. Bishara S, Burkey P, Khartouf J. Dental and facial asymmetries: a review. Angle Orthod, 1994; 64(2):89-98.

2. Bonnie LP, Maureen OK, Leonard BK. Occlusal cant in the frontal plane as a reflection of facial asymmetry. J Oral Maxillofacial Surg, 1997; 55:811-816.

3. Braun S, Legan HL. Changes in Occlusion Related to the Cant of the Occlusal Plane. Am J Orthod Dentofacial Orthop, 1997; 111(2):184-188.

4 Buranastidporn B, Hisano M, Soma K. Temporomandibular joint internal derangement in mandibular asymmetry. What is the relationship? Eur J Orthod, 2006; 28(1):83-88.

5. Ciuffolo F, Manzoli L, D’Attilio M, Tecco S, Muratore F, Festa F. Prevalence and distribution by gender of occlusal characteristics in a sample of Italian secondary school students: a cross-sectional study. Eur J Orthod, 2005; 27:601-606.

6. Ferrario VF, Sforza C, Miani A, Tartaglia G. Craniofacial morphometry by photographic evaluations. Am J Orthod Dentofacial Orthop, 1993; 103:327-337.

7. Gandini P, Mancini M, Grampi B. Functional treatment of mild skeletal asymmetry. J Clinic Orthod, 2004; 38(11):607-612.

8. Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod, 1983; 84(3):217-224.

9. Hesse KL, Artun J, Joondeph DR, Kennedy DB. Changes in condylar position and occlusion associated with maxillary expansion for correction of functional unilateral posterior crossbite. Am J Orthod Dentofacial Orthop, 1997; 111:410-418.

10. Hewitt AB. A radiographic study of facial asymmetry. Br J Orthod, 1975; 2(1):37-40.

11. Higley LB. Crossbite - Mandibular malposition. ASDC J Dent Child, 1968; 35(3):221-223.

12. Keeling SD, McGorray S, Wheeler TT, King GJ. Risk factors associated with temporomandibular joint sounds in children 6 to 12 years of age. Am J Orthod Dentofacial Orthop, 1994; 105:279-287.

13. Kecik D, Kocadereli I, Saatci I. Evaluation of the treatment changes of functional posterior crossbite in the mixed dentition. Am J Orthod Dentofacial Orthop, 2007; 131:202-215.

14. Kusayama M, Motohashi N, Kuroda T. Relationship between transverse dental anomalies and skeletal asymmetry. Am J Orthod Dentofacial Orthop, 2003; 123(3):329-337.

15. Lam PH, Sadowsky C, Omerza F. Mandibular asymmetry and condylar position in children with unilateral posterior crossbite. Am J Orthod Dentofacial Orthop, 1999; 115:569-575.


16. Major PW, Johnson DE, Hesse KL, Glover KE. Landmark identification error in posterior anterior cephalometrics. Angle Orthod, 1994; 64:447-454.

17. Melnik KA. A cephalometric study of mandibular asymmetry in a longitudinally followed sample of growing children. Am J Orthod Dentofac Orthop, 1992; 101(4):355-366.

18. Mulick JF. An investigation of craniofacial asymmetry using the serial twin-study method. Am J Orthod Dentofacial Orthop, 1965; 94:163-168.

19. Nanda R, Margolis JM. Treatment strategies for midline discrepancies. Sem Orthodontics, 1996; 2(2):84-89.

20. Nerder PH, Bakke M, Solow B. The functional shift of the mandible in unilateral posterior crossbite and the adaptation of the temporomandibular joints: a pilot study. Eur J Orthod, 1999; 21:155-166.

21. O’Byrn LB, Sadowsky C, Schneider B, BeGole AE. An evaluation of mandibular asymmetry in adults with unilateral posterior crossbite. Am J Orthod Dentofac Orthop, 1995; 107(4):394-400.

22. Peck S, Peck L, Kataja M. Skeletal asymmetry in esthetically pleasing faces. Angle Orthod, 1991; 61:43-48.

23. Pirttiniemi P, Kantomaa T, Lahtela P. Relationship between craniofacial and condyle path asymmetry in unilateral cross-bite patients. Eur J Orthod, 1990; 12:408-413.

24. Pirttiniemi PM. Associations of mandibular and facial asymmetries - a review. Am J Orthod Dentofacial Orthop, 1994; 106:191-200.

25. Pinto AS, Buschang PH, Throckmorton GS, Chen P. Morphological and positional asymmetries of young children with functional unilateral posterior crossbite. Am J Orthod Dentofacial Orthop, 2001; 120:513-520.

26. Primožič J, Richmond S, Kau CH, Zhurov A, Ovsenik M. Three-dimensional evaluation of early crossbite correction: a longitudinal study. Eur J Orthod, 2011; 10:198.

27. Ricketts MR, Roth HR, Chaconas JS, Schulhof JR, Engel AG. Orthodontic diagnosis and planning. Volume 1. Denver: Rocky Mountain Data Systems. 1982; pp 42-143.

28. Ricketts RM. Clinical implications of the temporomandibular joint. Am J Orthod Dentofacial Orthop, 1966; 52 :416-439.

29. Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal derangements of the temporomandibular joint: effect on facial development. Am J Orthod Dentofacial Orthop, 1993; 104:51-59.

30. Schmid W, Mongini F. A computer-based assessment of structural and displacement asymmetries of the mandible. Am J Orthod Dentofac Orthop, 1991; 100(1):19-34.

31. Solberg WK, Bibb CA, Nordstrom BB, Hansson TL. Malocclusion associated with temporomandibular joint changes in young adults at autopsy. Am J Orthod Dentofacial Orthop, 1986; 89:326-330.

32. Trpkova B, Major P, Nebbe B, Prasad N. Craniofacial asymmetry and temporomandibular joint internal derangement in female adolescents: a posteroanterior cephalometric study. Angle Orthod, 2000; 70:81-88.

33. Van Eslande DC, Russett SJ, Major PW, Flores-Mi C. Mandibular asymmetry diagnosis with panoramic imaging. Am J Orthod Dentofacial Orthop, 2008; 134:183-192.


Lidija Kanurkova blvd, “Jane Sandanski“ No.118-3/11 Skopje, FYR Macedonia [email protected]

SUMMARYSkeletal class III malocclusion can have many contributors, including

mandibular protrusion, maxillary retrusion and deficiency or combination of both. The most reliable way to distinguish the nature of class malocclusion for every individual patient is cephalometric analysis. It is not only used to choose the appropriate treatment plan, but also to analyze the features of a group of patients. The aim of this paper was to describe features of Albanian patients with skeletal class III malocclusion by means of cephalometric analysis done in patients seeking orthodontic treatment.Keywords: Skeletal Class III; Cephalometric Analysis

E. Kongo1, Xh. Mulo2

1Albanian University, Department of Dentistry Tirana, Albania 2Faculty of Medicine, Department of Dentistry Tirana, Albania



Cephalometric Features of Class III Malocclusion amongAlbanian Patients Seeking Orthodontic Treatment

STOMATOLOGICA

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Introduction

Class III malocclusion seriously affects function and aesthetic. This malocclusion has long time been viewed as one of the most severe facial deformities. In 1178 John Hunter stated: “It is not uncommon to find the lower jaw projecting too far forwards, so that its fore teeth pass before those of the upper jaw, when the mouth is shut; which is attended with inconvenience, and disfigures the face”.

According to Angle, class III malocclusion occurs when the lower teeth occlude mesial to their normal relationship for the width of 1 premolar or even more in extreme cases. With the advent of cephalometric radiography in 1934 it was possible to discern the underlying skeletal pattern of the class III malocclusion. Using cephalometric analysis, orthodontists nowadays classify class III malocclusion as maxillary retrusion, mandibular protrusion or combination of both. Class III patients may have combination of skeletal and dentoalveolar components.

Thus identifying the causative factor, it is possible to choose the most appropriate treatment for every individual patient and also to perform differential diagnosis.

Related to the other types of malocclusions, the III class has the smallest prevalence. Although its prevalence is not too high compared with class I and class II, the complexity of facial deformation, the not

well established etiology, treatment difficulties and compromised outcomes being affected from growth, has taken lot of researches toward this type of malocclusion. This malocclusion has highest prevalence among Asian populations, reaching 12% in China. In Europe, the prevalence is 1.5-5.3%, in North American among Caucasian 1-4%1. Relatively high was found to be the prevalence among Mediterranean populations. Concerning Balkan population, in Northern Greece this prevalence is 1.21% 2. As we do not possess data regarding the prevalence of skeletal class III in our country we decided to perform this study to evaluate class III malocclusion among Albanian patients by means of cephalometric analysis.

Material and Method

50 cephalograms of patients aged 8-18 years were extracted from the files of orthodontic patients at the UFO Dental Clinic. Selected patients meet the following criteria:

Albanian ethnicity;Not undergone orthodontic treatment;Molar and canine relationship of class III;Negative overjet.

Results

Mean values, range, mean ± SC, and CI (confidence interval) for respectively linear and angular parameters are shown in tables 1 and 2. The results for analysis and discussion were divided with regard to anteroposterior relationship and vertical dimension.

Thus, regarding anteroposterior relationship, there was a wide range of the SNA (720-870) and SNB (730-860) angles and the linear distance of point A-Npog line [(-9) - (-5)]. The vertical dimension showed normal values of both indicators - the mandibular plane and lower third.

Table 1. Results of the measurements of linear parameters

Parameter Range (min-max) Mean ± SD SE CI = mean ± 1.96 SE

S: N 55 - 79 71.77 ± 4.44 0.79 69.01 - 74.53

Go-Me 54 - 90 74.70 ± 7.58 1.36 72.30 - 77.38

Point A (-9) - (-5) (-2.06) ± 3.56 0.64 3.57 - 1.06

E line (-11) - 5 (-2.87) ± 3.44 0.61 4.08 - 1.65

Table 2. Results of the measurements of angular parameters

Parameter Range min-max Mean ± SD SE CI= min ± 1.96 SE

SNA 72 - 87 78.54 ± 3.39 0.60 79.7 - 77.3

SNB 73 - 86 79.25 ± 3.31 0.59 78.09 - 80.42

ANB (-5) - 4 (-0.96) ± 2.49 0.44 1.84 - 0.088

Facial axis angle 84 - 97 90.61 ± 15.04 2.7 85.31 - 95.9

Mandibular plane 14 - 35 26.19 ± 5.81 1.04 24.14 - 28.23

Lower third 39 - 55 45.87 ± 3.73 0.67 44.55 - 47.18

Discussion

The statistically derived CI (confidence interval) indicates that skeletal class III among Albanian patients does not have significant difference with the values of referring authors: SNA angle is slightly reduced; maxilla is positioned posterior to the anterior cranial base; changes of the mandible to the sagittal plane are not registered.

Class III malocclusion was more often caused by maxillary retrusion rather than mandibular protrusion in patients of Albanian ethnicity. Our sample could be classified as mesofacial type.

Since the best choice for treatment of maxillary retrusion can be the forward movement of the maxilla

Lateral cephalograms were traced by hand and measured from the same person using Ricketts and Jaraback methods. Among all measurements, 6 angular (Fig. 1) and 4 linear (Fig. 2) were chosen as determinants of class III. Angular parameters included: (1) Facial axis angle; (2) Mandibular plane; (3) Lower face height; (4) SNA angle; (5) SNB angle; and (6) ANB angle. Linear parameters included: (1) Facial convexity A-N Pog (in mm); (2) Lower lip to E plane (in mm); (3) S-N; and (4) Go-Me.

Figure 1. Angular parameters done at the cephalograms

Figure 2. Linear parameters done at the cephalograms

Balk J Stom, Vol 16, 2012 Class III Malocclusion in Albanian Population 155

156 E. Kongo, Xh. Mulo Balk J Stom, Vol 16, 2012

2. Kavadia-Tsatala S. Skeletal Class III Malocclusion. A Cephalometric Study in adult Greeks. Balk J Stom, 2004; 8(1):58-66.

3. Proffit WR. Contemporary Orthodontics. St Louis: Mosby, 2000.


Dr. Elona Kongo Albanian University, Department of Dentistry Tirana, Albania E-mail: [email protected]

by means of Delaire facial mask, it seemed to be the best choice for our skeletal class III patients. However, the success was greatly affected by age, nature of the patient growth and patient’s collaboration.

References

1. Baccetti, Reyes, Mc Namara Jr. Gender differences in class III malocclusion. Angle Orthod, 2005; 75(4).

SUMMARYApplication of fluoride varnish is a preventive protocol that does

not require patient compliance and permits the orthodontist to benefit from the bond strength of composite resins. The aim of this study was to compare, in vitro, the effect of a fluoride varnish on inhibition of enamel demineralization adjacent to orthodontic brackets bonded with a resin-modified glass ionomer cement (RMGIC) and a composite resin. A total of 60 extracted human lower and upper premolars with no restorations, caries, and hypoplastic areas or pliers impressions were collected for this study. All teeth were cleaned and cut in half bucco-lingually with a diamond disc. The following adhesives for bonding brackets were used in this study: Con Tec LC (Dentaurum, Germany) and resin-modified glass ionomer cement Fuji Ortho LC (GC Corporation, Japan). Brackets in each group were bonded with a type of adhesive according to manufacturers’ bonding instructions. After brackets bonding, the premolars (test specimens) were kept dried carefully and the enamel received a single topical application of a fluoride varnish (Duraphat®; Germany) with the aid of a brush applicator. 3 minutes later, the teeth were wet with mild air/water spray and stored in artificial saliva until analysis, after 14 days and 1 month. Fluoride concentrations were measured by spectrophotometer.

The results obtained indicated a significant increase in the levels of fluoride uptake in enamel after the use of resin-modified glass ionomer cement for bonding brackets and topical application of a fluoride varnish. Use of a fluoride varnish, when bonding brackets with GICs, is more effective in preventing enamel demineralization than the conventional composite resin. Based on these findings, it may be concluded that the examined fluoride varnishes had impact on the inhibition of enamel demineralization adjacent to orthodontic brackets.Keywords: Enamel; Brackets; Decalcification; Fluoride Varnish

E. Zabokova-Bilbilova1, A. Sotirovska-Ivkovska1, B. Evrosimovska 2, L. Kanurkova 3

School of Dentistry, Skopje, FYROM 1Department of Pediatric and Preventive Dentistry 2Department of Oral Surgery 3Department of Orthodontics



Effect of Fluoride Varnish on DemineralizationAdjacent to Orthodontic Brackets

STOMATOLOGICA

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Introduction

It is well known that orthodontic treatment with fixed appliances predisposes patients to a larger accumulation of bacterial plaque and, hence, to enamel demineralization. This is due to the mechanical interference imposed by the orthodontic appliances, maintaining adequate oral hygiene more difficult. Consequently, enamel demineralization lesions, resulting from dissolution of the enamel, can appear within only

a few weeks after appliance placement1,2. These enamel scars can vary from microscopic alterations to visible “white spot lesions” that may reach cavitations3. The presence of these lesions is not usually observed until the removal of orthodontic appliances and has been reported to be a frequent event4,5. Although previously published reports have indicated that molars are more susceptible to white-spot formation because of difficulties in maintaining plaque control, the 6 maxillary anterior teeth are considered separately6.

158 Efka Zabokova-Bilbilova et al. Balk J Stom, Vol 16, 2012

cut in half bucco-lingually with a diamond disc. Thus, the control and test specimens were obtained from the same teeth.

Table 1. Sample preparation

Group number Bonding agent Condition12

DentaurumDentaurum

no Duraphatwith Duraphat

3 Fuji Ortho LC no Duraphat4 Fuji Ortho LC with Duraphat

After etching the enamel surface with a 37% phosphoric acid solution for 15 seconds and rinsing for 10 seconds, teeth were dried. Each bracket was positioned over the mid point of the clinical crown on buccal and lingual surfaces of the prepared premolar and pressed firmly onto the surface. Any excess adhesive was removed. The following adhesives for bonding brackets were used: Con Tec LC (Dentaurum, Germany) and RGIC Fuji Ortho LC (GC Corporation, Japan). Brackets in each group were bonded with the same adhesive according to manufacturers’ bonding instructions. After brackets bonding, the premolars (test specimens) were kept dried carefully and the enamel received a single topical application of a fluoride varnish (Duraphat®; Germany) with the aid of a brush applicator. 3 minutes later, the teeth were wet with mild air/water spray and stored in artificial saliva (20 mmol/l NaHCO3, 3 mmol/l NaH2PO4 and 1 mmol/l CaCl2, neutral pH) until analysis, which is done 14 days and 1 month thereafter. Fluoride concentrations were measured by spectrophotometer.

For statistical evaluation, a 1-way analysis of variance (ANOVA) followed by Tukey’s test was initially used to see if there was a significant difference between groups.

Results

Table 2. The mean concentrations of total fluoride (ppm) in enamel in the group of teeth brackets bonded with composite resin 14 days after topical application of a fluoride varnish

Group N Mean SD t - value p

test 15 1660.608 156.2963.074 0.01326*

control 15 150.800 47.726

Table 2 shows the mean concentrations of total fluoride in enamel in the first group of tooth brackets bonded with Con Tec Duo 14 days after topical

Fluoride is important in the prevention of enamel demineralization. There are several methods of delivering fluoride to teeth in patients during orthodontic treatment (in addition to fluoridated toothpaste). These include: - topical fluorides (e.g. mouthrinse, gel, varnish,

toothpaste); - fluoride-releasing materials (e.g. bonding materials,

elastics).Application of fluoride varnish is a preventive

protocol that does not require patient compliance and permits the orthodontist to benefit from the bond strength of composite resins. Prolonged contact time with fluoride varnish permits significantly more incorporation of fluoride than with other fluoride applications, e.g. acid phosphate fluoride gel, monofluoride phosphate dentifrices, home fluoride rinses7,8. For instance, Petersson et al9 observed that a 3-monthly application of fluoride varnish resulted in a dramatic reduction in caries incidence and the application of a fluoride varnish can be easily adapted to current orthodontic bonding techniques.

Fluoride varnishes have benefit of adhering to the enamel surface longer than other topical fluoride products. Thus, fluoride varnishes have been reported to be superior to sodium fluoride and monofluorophosphate dentifrices in their ability to increase fluoride uptake in enamel10. An increase was also found after 3 weeks when comparing fluoride varnish with 2% sodium fluoride gel applied weekly, 2% acidulated phosphate fluoride gel applied weekly, or 0.25% sodium fluoride rinse used daily. Teeth with fluoride varnish applied around composite resin-bonded brackets showed a 35% reduction in demineralised lesion depth11. Teeth with RMGIC (resin-modified glass-ionomer cement)-bonded brackets demonstrated a 50% reduction in lesion depth with or without fluoride varnish application. The RMGI adhesives have been demonstrated to sustain fluoride release long after initial application, but they only protect a limited area immediately adjacent to the orthodontic bracket. In addition, bond failures with RMGIC have been found to be similar or worse than composite resins12-14.

The aim of this study was to compare, in vitro, the effect of a fluoride varnish on inhibition of enamel demineralization adjacent to orthodontic brackets bonded with a RMGIC and a composite resin.

Material and Methods

A total of 60 extracted human lower and upper premolars with no restorations, caries, and hypoplastic areas or pliers impressions were collected for this study. All extractions were indicated for orthodontic purposes in patients of 11-18 years of age. After being extracted, teeth were stored in artificial saliva and were divided in 4 groups of 30 teeth (Tab. 1). All teeth were cleaned and

Balk J Stom, Vol 16, 2012 Effects of Fluorides on Demineralization 159

the bracket bonded with resin-modified glass ionomer cement Fuji Ortho LC and topical application of a fluoride varnish is shown in table 5. After 1 month, a statistically significant difference occurred in the values of fluoride in enamel between the experimental and control groups.

Discussion

During orthodontic treatment, bonded brackets promote more retention of dental plaque and make oral hygiene difficult. A preventive method could be the use of fluoride varnishes. Fluoride varnish applied around orthodontic appliances has been proven to diminish the incidence of white spot lesions. For instance, fluoride varnish, composed of a 5% sodium fluoride in a resin base, has shown a reduction in white spot incidence of about 50%18,19. Therefore, periodic fluoride application may provide a clinically effective solution, although it was observed that such material cannot completely prevent white spots20. Moreover, application of fluoride varnish on existing lesions does prevent their progression and may help remineralisation.

The aim of this study was to evaluate, in vitro, the effect of a fluoride varnish on the inhibition of enamel demineralisation adjacent to orthodontic brackets bonded with a RMGIC and a composite resin. Our investigation was done on 2 different bonding materials most commonly used in orthodontic practice. The results obtained have indicated a significant increase in the levels of fluoride uptake in enamel after the use of RMGIC Fuji Ortho LC for bonding brackets and topical application of a fluoride varnish. The analysis of the value of fluoride in enamel before and after bonding the brackets with Fuji Ortho LC as well as the application of a fluoride varnish clearly showed that after its application the fluoride level in enamel was significantly increased. Thus, the value of fluoride in enamel before bonding the brackets was 664,052 ppm. 14 days after bonding, the amount of fluoride in enamel was 924,240 ppm, which was significantly higher than the initially. After 1 month, the value of the quantity of fluoride in enamel in the examined (first) group was still high (534,788 ppm). The finding from this in vitro study indicates that application of fluoride varnish may inhibit enamel decalcification adjacent to orthodontic brackets.

In our study enamel demineralization in vitro was inhibited to a certain degree. Similar decalcification prevention has been reported by many authors for other fluoride-releasing materials21-23. Besides the positive impact on local fluoride-release, cement used for bonding the brackets provides continuous presence of low concentrations of fluoride in the oral medium, which also influences on inhibition of demineralised enamel around orthodontic brackets and bands.

application of a fluoride varnish. The mean value of fluoride in the examined group of teeth was 1660,608 ppm, and in the control group of teeth the value of F was 150,800 ppm. There was a statistically significant difference between values of fluoride in the enamel in both examined groups of teeth.

Table 3 shows the mean concentrations of total fluoride in enamel in the group of teeth brackets bonded with RMGIC Fuji Ortho LC 14 days after topical application of a fluoride varnish. The mean value of fluoride in the examined group of teeth was 924,240 ppm, and in the control group of teeth the mean value of fluoride was 664,052 ppm. There was a statistically significant difference between values of fluoride in the enamel in both examined groups of teeth.

Table 3. The mean concentrations of total fluoride (ppm) in enamel in the group of teeth brackets bonded with Fuji Ortho LC

14 days after topical application of a fluoride varnish


test 15 924.240 428.8652.152 0.01862*

control 15 664.052 350.612

Table 4 shows the mean concentrations of total fluoride in enamel in the group of examined teeth compared to the control group of teeth 1 month after brackets bonded with Con Tec Duo and topical application of a fluoride varnish. There was a statistically significant difference of the values (389,300 ppm against 143,200 ppm).

Table 4. The mean concentrations of total fluoride (ppm) in enamel in the group of teeth brackets bonded with composite resin 1 month after topical application of a fluoride varnish


test 15 389.300 326.2092.321 0.04539*

control 15 143.200 48.928

Table 5. The mean concentrations of total fluoride (ppm) in enamel in the group of teeth brackets bonded with Fuji Ortho LC

1 month after topical application of a fluoride varnish


test 15 534.788 178.3272.076 0.04238*

control 15 425.529 183.247

The mean concentrations of total fluoride in enamel of the examined and control group of teeth 1 month after

160 Efka Zabokova-Bilbilova et al. Balk J Stom, Vol 16, 2012

caries-susceptible teenagers: A 3-year clinical study. Caries Res, 2000; 34:140-144.

10. Arends J, Lodding A, Petersson LG. Fluoride uptake in enamel: in vitro comparison of topical agents. Caries Res, 1980; 14:403-413.

11. Todd MA, Staley RN, Kanellis MJ, Donly KJ, Wefel JS. Effect of a fluoride varnish on demineralization adjacent to orthodontic brackets. Am J Orthod Dentofacial Orthop, 1999; 116:159-167.

12. Schmit J, Staley R, Wefel J, Kanellis M, Jakobsen J, Keenan P. Effect of fluoride varnish on demineralization adjacent to brackets bonded with RMGI cement. Am J Orthod Dentofacial Orthop, 2002; 122:125-134.

13. Voss A, Hickel F, Holkner S. In vivo bonding of orthodontic brackets with glass ionomer cements. Angle Orthod, 1993; 63:149-153.

14. Gorton J, Featherstone JD. In vivo inhibition of demineralization around orthodontic brackets. Am J Orthod Dentofacial Orthop, 2003; 123:10-14.

15. Bowman SJ. Use of a fluoride varnish to reduce decalcification. J Clin Orthod, 2000; 34:377-379.

16. Derks A, Katsaros C, Frencken JE, Van’t Hof MA, Kuijpers-Jagtman AM. Caries-inhibiting effect of preventive measures during orthodontic treatment with fixed appliances. Caries Res, 2004; 38:413-420.

17. Geiger AM, Gorelick L, Gwinnett AJ, Griswold PG. The effect of a fluoride program on white spot formation during orthodontic treatment. Am J Orthod, 1998; 93:929-938.

18. Madlena M, Vitalyos G, Marton S, Nagy G. Effect of chlorhexidine varnish on bacterial levels in plaque and saliva during orthodontic treatment. J Clin Dent, 2000; 11:42-46.

19. Jenatschke F, Elsenberger E, Welte H, Schlagenhauf U. Influence of repeated chlorhexidine varnish applications on mutans streptococci counts and caries increment in patients treated with fixed orthodontic appliances. J Orofac Orthop, 2001; 62:36-45.

20. Gillgrass T, Creanor S, Foye R, Millett D. Varnish or polymeric coating for the prevention of demineralization? An ex vivo study. J Orthod, 2001; 28:291-295.

21. Valk J, Davidson C. The relevance of controlled fluoride release with bonded orthodontic appliances. J Dent, 1987; 15:257-260.

22. Ögaard B, Rezk-Lega F, Ruben J, Arends J. Cariostatic effect and fluoride release from a visible light-curing adhesive for bonding of orthodontic brackets. Am J Orthod Dentofacial Orthop, 1992; 101:303-307.

23. Trimpeneers L, Dermaut L. A clinical evaluation of the effectiveness of a fluoride-releasing visible light-activated bonding system to reduce demineralization around orthodontic brackets. Am J Orthod Dentofacial Orthop, 1996; 110:218-222.

Correspondence and requests for offprint to:

Dr Efka Zabokova-Bilbilova, PhD Department of Pediatric and Preventive Dentistry School of Dentistry Vodnjanska 17 1000 Skopje, FYR Macedonia E-mail: [email protected]

The positive effects of fluoride varnish presented in this study are in agreement with findings of other reports. 2 of these investigations used Duraflor varnish, which contains the same 5% concentration of sodium fluoride as Duraphat. Daily rinsing with a solution of 0.05% sodium fluoride also reduces the severity of white-spot lesions, although it cannot prevent them completely15-17. The efficacy of this method depends on patient compliance, which has generally been found to be lacking (13%). Patients who do not practice proper oral hygiene are particularly unlikely to cooperate in using mouthrinses.

Conclusions

Use of a fluoride varnish, when bonding brackets with GICs, is more effective in preventing enamel demineralization than the conventional composite resin. Fluoride varnishes examined in this study had impact on the inhibition of enamel demineralisation adjacent to orthodontic brackets. Orthodontists should consider its routine use in clinical practice, especially in patients exhibiting poor oral hygiene.

References

1. Ögaard B, Rolla G, Arends J. Orthodontic appliances and enamel demineralization: Part 1. Lesion development. Am J Orthod Dentofacial Orthop, 1988; 94:68-73.

2. O’Reilly M, Featherstone J. Demineralization and remineralization around orthodontic appliances: An in vivo study. Am J Orthod Dentofacial Orthop, 1987; 92:33-40.

3. Gorelick L, Geiger A, Gwinnett A. Incidence of white spot formation after bonding and banding. Am J Orthod, 1982; 81:93-98.

4. Årtun J, Brobakken B. Prevalence of carious white spots after orthodontic treatment with multibonded appliances. Eur J Orthod, 1986; 8:229-234.

5. Ögaard B, Larsson E, Henriksson T, Birkhed D, Bishara S. Effects of combined application of antimicrobial and fluoride varnishes in orthodontic patients. Am J Orthod Dentofacial Orthop, 2001; 120:28-35.

6. Mizrahi E. Enamel demineralization following orthodontic treatment. Am J Ortod, 1982 July; 82(1):62-67.

7. Demito CF, Vivaldi-Rodriguez G, Ramos AL, Bowman SJ. The efficacy of a fluoride varnish in reducing enamel demineralization adjacent to orthodontic brackets: An in vitro study. Orthod Craniofac Res, 2004; 7:205-210.

8. Vivaldi-Rodrigues G, Demito CF, Bowman SJ, Ramos AL. The effectiveness of a fluoride varnish in preventing the development of white spot lesions. World J Orthod, 2006; 7:138-144.

9. Petersson L, Magnusson K, Andersson H, Almquist B, Twetman S. Effect of quarterly treatments with a chlorhexidine and a fluoride varnish on approximal caries in

SUMMARYThe results of epidemiological study realized in 2007 by calibrated

paedodontists for estimation of oral health condition of children in the Skopje region showed unfavourable values (DMFT-8.10 at 12 years old children). Especially alarming is a condition of the first permanent molars at 8 years old children (DMFT-3.18). In general aim to prevent caries, we sealed fissures of first permanent molars right after their eruption at 6386 children in the Skopje region (98.01% of total number of children born 2002) and 17.242 teeth (68.76%) were sealed. Non-erupted teeth were sealed later, right after their eruption. The teeth with registered presence of initial caries were not sealed. The sealing was conducted by GC Fuji Triage.

The first evaluation of the effects of sealing was conducted after 2 years by the same calibrated paedodontists and the marked reduction of DMFT index 0.87 (reduction of caries of the first permanent molars from 72.65%) was noticed, and the second evaluation, 3 years after the beginning of the sealing, showed values of the DMFT index from 1.07 (reduction of 66.36%). These results show that sealing of fissures and pits is an effective primary preventive measure for caries control, especially in areas where there is a high caries risk in children population.Keywords: Pits; Fissures; Caries Risk, prevention; Sealing; Glass-ionomer

M. Carcev1, B. Getova2, O. Sarakinova1, H. Petanovski1, S. Carceva-Shalja3

1University St. Cyril and Methodius, Faculty of Dental Medicine, Department of Paediatric and Preventive Dentistry, Skopje, FYROM 2Healthy Centre Valandovo, FYROM 3University St. Cyril and Methodius, Faculty of Dental Medicine, Department of Orthodontics, Skopje FYROM



Sealing of Fissures and Pits of First Permanent Molar at Children with High Caries Risk

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Introduction

According to the opinion of the most of the experts in preventive dentistry, the control of dental caries can be successfully conducted by application of the following primary preventive measures2,6,7,9:

● Mechanical and chemical control of dental plaque; ● Application of fluoride (systemic and topical); ● Discipline of sugar intake regime; ● Sealing of fissures and pits; ● Education and motivation for keeping oral health.

The oral hygiene and sugar intake control have the primary role in the prevention of caries7,20. On the other hand, the same are mostly related to the tradition and mentality of people, so the measure of promoting oral health in these spheres give results in a longer time period. But, even in the conditions with good oral hygiene, with toothbrush, the dental plaque cannot be efficiently

eliminated when accumulated in the fissures and pits; that is why such places remain to be caries risk.

In the past years observation was made of the caries incident and conclusion was made that the caries of occlusal surfaces is 56-70% of all caries lesions in children from 5-17 years of age6. At the end of the sixties, putting plastic mass over occlusal surfaces of teeth, which penetrates into deep fissures and fulfils the parts that cannot be cleaned by toothbrush, was the suggested procedure. Plastic mass had the role of sealant and presented barrier between teeth and oral environment.

Many studies show that fissure sealants are an effective primary preventive procedure for caries prevention in occlusal surfaces1,5. Many years ago, several materials were used as fissure sealant. More of dental materials that were used for tooth filing were used also as sealants, for example, some kinds of composites and glass ionomer cements11,12,14,21.

162 M. Carcev et al. Balk J Stom, Vol 16, 2012

According to the fact that occlusal surfaces have the highest participation in DMFT index between children, in this project we set the aim to seal occlusal fissures and pits of first permanent molars right after their eruption at children in Skopje region.

Fluorides have strong influence on the process of demineralisation and remineralisation, which is the reason that numbers of authors recommend sealing to be done with dental materials that will provide enough fluorides after their application, which will help the process of remineralisation18. Having in mind the fact that glass-ionomer cements make chemical connection with enamel, humid environment does not compromise adherence, as well as that glass-ionomer cements from all dental materials release most fluorides, sealing of fissures and pits was conducted with Fuji Triage, a glass-ionomer cement that releases even 5-6 times more fluorine from Fuji IX that was the riches material with fluorine until recently.

Material and Method

Sealing the fissures and pits of the first permanent molar was conducted by 142 calibrated paedodontists according to the standards of WHO, who, after the privatization of the dental sector, continued to work in frame of public health. Except sealing, they have obligation to make other primary preventive measures according to the National strategy of prevention of oral diseases in children at age 0-14 in FYROM.

The sealing covered 6.386 children at age 6 in the Skopje region and 17.242 first permanent molars were sealed. The teeth which not erupted at the time of the activities were sealed later, right after their eruption. Before the beginning of the sealing activities, DMFT index was registered in children at age 8 and 12.

Coloured Fuji Triage was use as a sealant for better visualization if it eventually falls. The sealing was conducted in professional conditions, in school dental offices. Before setting the sealant, professional elimination of dental plaque was made and conditioning with 20% polyacrylic acid in the period of 20 sec.

The effects from sealing of DMFT index were followed-up twice; the first evaluation was done after 2 years and the second 3 years after sealing by the same calibrated paedodontist who were involved in the preparation of the study in registration of the DMFT index at the beginning.

Results

The results for values of DMFT index in the children at age 8 and 12 from the Skopje region, got from epidemiologic study conducted in 2007, as the results of evaluation effects of sealing after 2 and 3 years, are shown on the following figures and tables - figure 1 depicts the DMFT index of children at the beginning of the study, tables 1 and 2 show the DMFT indices at the first and second evaluation, and figure 2 compares the results of the procedures after 2 years.

Figure 1. DMFT index in children at age 8 and 12 in the Skopje region in 2007

Figure 2. DMFT at 8 year old children before sealing, after the first and the second evaluation

Table 1. DMFT index in children at age 8 in the Skopje region in 2010 - first evaluation

total number and percent of children

number of the examined

children

sealed first permanent

molars

unsealed first permanent

molars

decayed first permanent

molars

extracted first permanent

molars

filled first permanent

molars

non-erupted first permanent

molars

number of unexamined

children

6516 6386 17242 2265 3886 28 1654 469 130

100% 98,01% 68,76% 9,03% 15,49% 0,11% 6,59% 1,83% 1,98%

Balk J Stom, Vol 16, 2012 Efficacy of Sealing of Fissures in High Caries Risk Children 163

Table 2. DMFT index in children at age 8 in Skopje region in 2011 - second evaluation

total number of children

number of examined children

sealed first permanent

molars

unsealed first permanent

molars

decayed first permanent

molars

extracted first permanent

molars

filled first permanent

molars

non-erupted first permanent

molars

number of unexamined

children

6994 6374 16915 1638 4031 53 2763 96 620

100% 91,13% 66,34% 6,42% 15,81% 0,20% 10,83% 0,37% 0,88%

came 1 year or more later, and this would compromise the results after 2 and 3 years.

After the first evaluation (2 years after sealing), we confirmed that on 3.886 (15.49%) teeth there was caries, 1654 (6.59%) teeth were filled, and 28 (0.11) were extracted, that means that reduction of caries is achieve on the first permanent molar of 72.65%.The results of the researches in the second evaluation after 3 years of sealing showed caries reduction of 66.36%.

There is an insignificant increasing of the number of caries teeth registered after the second evaluation. After the first monitoring of the sealed teeth, we found certain inconsistency by same paedodontists who participated in the project (partial covering of fissures system with sealant); we considered that it could have some influence on the results of the achieved caries reduction. Such inconsistency in fissures and pits sealing pointed to the need for better education of next student generations of students.

Increasing the caries reduction in the participants in our study could also be due to participation in other primary preventive measures that are part of National strategy, but we consider that it is of minor influence because changing mentality (good oral hygiene, sugar intake control, fluorine intake, education and motivation for oral health) needs longer time.

Encouraged by the results in the first and second evaluation concerning the reduction of caries of the first permanent molar, Coordinative Body for implementation and monitoring of National Strategy, recommended sealing to be conducted on all permanent teeth with fissures system (first and second premolars and second molars) and the results of effect of the next clinical evaluation will be published soon.

Conclusion

The results of clinical evaluation of the sealing effect of fissures and pits in the first permanent molars showed that the fissure sealing is the primary preventive measure for tooth caries control, especially in environments with high tooth caries risk in children.

Discussion

The sealing of fissures and pits is a primary preventive measure providing maximum protection from caries on occlusal surfaces, but apart from this, the experts opinion is that it is not enough used by dentist in everyday practice.

Ripa et al16, made researches in children at age 8 and 9 during 2 years. The first group of children used 0.2 % fluoride solution for individual rinsing of mouth, and the second group used the same solution plus sealing of fissures and pits. From 51 participants in the first group, 24 got occlusal caries lesion and from 84 participants in the second group only 3 got caries lesion. Authors concluded that the implementation of these 2 preventive measures can almost fully eliminate caries. Sealing would be most economical if it is done on those teeth which are caries sensitive16.

Glass-ionomer cements are materials that contain high level of fluorine release during the application. That is why glass-ionomers are frequently used, especially at caries-risk patients, and they provide fluorine protection from their application until fall out.

The results of the presented epidemiological research by calibrated paedodontists, made in 2007, showed that only 2 years after eruption, in 3 from 4 permanent molars caries appeared on occlusal surfaces (DMFT at 8 years old children was 3.18), which shows a high caries risk.

Having in mind the attitude of ADA (American Dental Association) that the sealing of fissures and pits is absolutely indicated, with no exception, on all individuals with high caries risk, and it is best done with glass-ionomer cement15. According to this, we decided to seal with Fuji Triage - glass-ionomer cement that releases the biggest quantity of fluorine compared to other glass-ionomer cements available at the market. The program activities planned sealing of all first permanent molars of children in the Skopje region, right after their eruption. From total 6516 children at the age of 6, we examined 6.386 (98.06%), and 17.242 (68.76%) erupted teeth were sealed. The remaining teeth that were sealed later, successively, after their eruption, were not included in the results presented in this study because their eruption

164 M. Carcev et al. Balk J Stom, Vol 16, 2012

References

1. Ahovuo–Saloranta A, Hiiri A, Nordblad A, Worthington H, Mäkelä M. Fissure sealants for preventing dental decay in the permanent teeth of adolescents. Cochrane Syst Rev, 2004; n. 3

2. Featherstone JDB. Prevention and reversal of dental caries: role of fluoride. Community Dentistry and Oral Epidemiology, 1999; 27(1):31.

3. Forss H, Halme E. Retention of a glass ionomer cement and a resin fissure sealant and effect on carious outcome after 7 years. Community Dentistry and Oral Epidemiology, 1998; 26(1):21-25.

4. Gladys S, Van-Meerbeek B, Braem M, Lambrechts P, Vanherle G. Comparative physico-mechanical characterization of new hybrid restorative materials with conventional glass-ionomer and resin composite restorative materials. J Dent Res, 1997; 76(4):883-894.

5. Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, CDC Dental Sealant Systematic Review Work Group, Bader J, Clarkson J, Fontana MR, Meyer DM, Rozier RG, Weintraub JA, Zero DT. The Effectiveness of Sealants in Managing Caries Lesions. J Dent Res, 2008, 87(2):169-174.

6. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res, 1996; 75(Spec Issue):631-641.

7. Konig KG, Navia JM. Nutritional role of sugars in oral health. Am J Clin Nutr, 2005; 62(Suppl); 275 S-283S.

8. Luca-Fraga LR, Freire Pimenta LA. Clinical evaluation of glass-ionomer/resin based hybrid materials used as pit and fissure sealants. Quintessence International, 2001; 32(6):463-468.

9. Mejäre I, Mjör IA. Glass-ionomer and resin-based fissure sealants: the clinical study. Scand J Dent Res, 1990; 98(4):345.

10. Mertz-Fairhurst EJ, Schuster GS, Fairhurst CW. Arresting caries by sealants: results of a clinical study. J Am Dent Assoc, 1986, 112:194-197.

11. Pardi V, Pereira AC, Mialhe FL, Meneghim MC, Ambrosano GM. Evaluation of two glass ionomer cements used as fissure sealants. Community Dentistry and Oral Epidemiology, 2003; 31(5):386-391.

12. Pereira AC, Basting RT, Pinelli C, Castro-Meneghim M, Werner CW. Caries prevention of Vitremer and Ketac-Bond used as occlusal sealants after 6 and 12 months. Am J Dent, 1999; 12(2):62.

13. Poulsen S, Beiruti N, Sadat N. A comparison of retention and the effect caries of fissure sealing with a glass–ionomer and a resin-based sealant. Community Dentistry and Oral Epidemiology, 2001; 29(4):298-301.

14. Raadal M, Utkilen AB, Nilsen OL. Fissure sealing with a light-cured resin reinforced glass–ionomer cement (Vitrebond) compared with a resin sealant. International Journal of Paediatric Dentistry, 1996; 6(4):235-239.

15. Report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc, 2008; 139(3):257-268.

16. Ripa LV, Leske GS, Forte F. The com bined use of pit and fissure sealants and fluoride mouth rinsing in second and third grade children: Final clini cal results after two years. Pediatr Dent, 2002; 9:118-120.

17. Silva KG, Pedrini D, Delbem ACB, Cannon M. Microhardness and fluoride release of restorative materials in different storage media. Brazilian Dental Journal, 2007; 18(4):309-313.

18. Silverstone LM, Wefel JS. The ef fect of remineralization on artificial caries-like lesions and their crystal content. J Crystal Growth, 1981; 53:148-159.

19. Songpaisan Y, Bratthall D, Phantumvanit P, Somridhivej Y. Effects of glass ionomer cement, resin-based pit and fissure sealant and HF applications on occlusal caries in a developing country field trial. Community Dentistry and Epidemiology, 1995; 23:25-29.

20. Tooth brushing for oral health (Co chrane Review) In: The Cochrane Li brary, Issue 1, 2003, Oxford: Update.

21. Williams JA, Billington RW, Pearson GJ. A long term study of fluoride from metal-containing conventional and resin-modified glass-ionomer. J Oral Rehabil, 2001; 28(1):41-47.

22. Winkler MM, Deschepper EJ, Dean JA, Moore BK, Cochran MA, Ewoldsen. Using a resin–modified glass ionomer as an occlusal sealant: a one year study. J Am Dent Assoc, 1996; 127(10):1508-1514.


M. Carcev University St. Cyril and Methodius Faculty of Dental Medicine Department of Paediatric and Preventive Dentistry Skopje, FYROM

SUMMARYAmong numerous etiological factors that could be related to the

onset of the complex symptom recognized as glossopyrosis and being most frequent as well, is hypochromic anaemia. Through cytological analysis of tongue epithelium, we tried to objectify the impact of laser light in the therapeutic treatment of patients with glossopyrosis and hypochromic anemia.

Clinical examinations revealed that among the representatives of the study group, beside subjective complain, alterations on the surface of the tongue could be seen (atrophic signs and metabolic furrowed tongue). Epithelial cytology investigation offered findings of tongue epithelial alterations. Beside disturbances in the keratinisation and presence of degenerated epithelial cells, reduced thickness of tongue epithelium and positive findings for acanthosis and mitotic activity was found as well. These findings denote to disturbances in oxygenation in the structure of oral mucosa as result of biochemical and metabolic changes caused by hypochromic anaemia.

Topical use of bio-stimulative laser therapy has proved to produce positive effects in regulation of disturbed tongue epithelium keratinisation; by stimulation of mitotic activity and enhanced oxygenation, regenerative and reparatory mechanisms are being stimulated.Keywords: Glossopyrosis; Tongue, epithelium; Laser Therapy

Silvana Georgieva, Maja Pandilova, Lindita Zendeli-Bedzeti

University Dental Clinical Centre „St. Panteleimon”, Department of Oral Pathology and Periodontology Skopje, FYROM



Use of Topical Bio-stimulative Laser Therapy among Individuals with Glossopyrosis andHypochromic Anaemia

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Introduction

Experimental, professional and scientific investigations within the field of oral pathology by many authors all over the world, as well as the continuing clinician’s experience, highlight the role of iron deficiency anaemia as a principal etiological factor in the clinical objectification of the oral burning symptom. Gallagher et al3, Grushka et al4, Hadjadj et al5, among others, disclose that glossopyrosis in most cases generally reflects some systemic disorder of the human body, pointing out hypochromic anaemia as the most important cause.

Knowing the grounds, the subjective symptoms and objective status seem not enough in support of clarifying the problem known as glossopyrosis. So the treatment of

these individuals is complicated and very often without the expected treatment outcome.

The light of the red spectrum is one of the most investigated rays. Clinical and experimental investigations in the last 25 years stressed the influence of the laser beam bio-stimulation and the mentioned spectrum. The most important function when treating with laser beam and the red spectrum is stimulation of the regenerative process in the cells.

Another important utility of the laser beam is its anti-inflammatory effect, which is one of its most important roles in clinical practice. The laser light in the inflammatory process increases the lysosomes and the interferon protective proteins; increases microcirculation and furthermore normalizes penetration of the blood cells. Factors of inflammation decrease under the influence of the laser light and phagocytic activity increases. The

166 Silvana Georgieva et al. Balk J Stom, Vol 16, 2012

role of the laser beam on oral mucous membranes is confirmed by many histo-morphological, biochemical, and cytological, as well as immunological and microbiological investigations. The aim of our study was to objectify the influence of the laser light in the treatment of individuals with hypochromic anaemia through cyto-morphological analysis of the tongue epithelium.

Material and Method

Cytological examinations included cyto-morphological analysis of the tongue epithelium with determination of acanthosis, level of keratinisation, intensity of parakeratosis, intensity of mitotic activity, and the presence of altered epithelial cells.

Cyto-morphological analysis was conducted among 10 patients with hypochromic anaemia and glossopyrosis before and after haematological therapy. Half of the individuals additionally received local bio-stimulative laser therapy with continuous mode of irradiation (Optica Laser- SCORPION 405.7A, λ= 630 nm), applied at the dorsum of the tongue, which was divided into 3 areas (the apical area and both lateral sides). Each area was exposed 1.5 minutes with non-contact mode of irradiation with a distance between the laser probe and the irradiated surfaces of 1 mm and following specifications: power of 10 mW/cm, exposition of 4-5 minutes, and interval of 10 days. In order to compare the obtained results, cyto-morphological analysis was conducted in a group of 10 individuals comprising the control group with glossopyrosis, but without hypochromic anaemia.

Cytological investigations were realized by taking specimens with a plastic instrument from the parts with most emphasized burning symptom. The samples were immediately fixed with 96% ethyl alcohol, and after 15 minutes they were stained by Papanicolaou technique. The staining of the slides was done with a suspension of 5 reagents; 3 of them differ from each other by the concentration of eosin, bismarck brown colour and light green colour. The prepared slides were cyto-morphologically analyzed with an optic microscope under immersion.

The results from the conducted cyto-morphological analysis for each parameter were noted as follows:

no changes+- weak positive++ mild positive+++ strong positiveResults of the cyto-morphologic analysis were

compared as follows: - the study group and control group - the study group after the haematological therapy with

and without local bio-stimulative laser treatment.The results of the conducted research are presented

graphically and photographically.

Results

From the presented results of the chart 1, it is evident that there are no obvious differences in the final results of hyperkeratosis, parakeratosis and altered epithelial cells between the both examined groups. Remarkable results between control and study group were noted for acanthosis and mitotic activity.

Chart 1. Cyto-morphological findings of the tongue epithelium among patients from study and control group

The chart 2 presents the results of cytological analysis for all the examined parameters among individuals from the study group after haematological therapy and those treated additionally with bio-stimulative laser treatment. Important differences between both study groups for the presence of hyperkeratosis, parakeratosis and mitotic activity are evident. Figures 1-3 document the results of the cytological investigations.

Chart 2. Cyto-morphological findings from the tongue epithelium among patients of the study group after the treatment with and without laser

therapy

Balk J Stom, Vol 16, 2012 Laser Therapy in Patients with Anaemia 167

Figure 1. Epithelial cells during mitotic activity

It can be noted from the figure 1 that the cells contain 2 nucleuses in their cytoplasm. These results can be accepted as predictive, revealing the increased mitotic activity of the cells in the deeper layers of the epithelium. Cells like these are noted in patients of the study group treated with laser. The figure 2 illustrates the epithelial cell with cytoplasm filled with keratin and the nucleus being partly destroyed. Cells like these are being noted among individuals of the study group after laser bio-stimulative treatment. Epithelial cell in the form of keratin husk showed in figure 3. This result illustrates total keratinisation of the epithelial cells (orto-parakeratosis) with disappearing of the cell structures. This finding was present in a large percent of the patients from the study group treated with laser light.

Discussion

Cytological examination after the use of local bio-stimulative laser treatment verifies its positive effects. Clinical outcome resulted in improving the subjective symptoms8 due to stimulation of regenerative processes of cellular, nerve and epithelium tissues, thus activating vascularity and metabolic processes into the irradiated areas.

Exfoliative cytological results revealed changes among individuals from the study group treated with laser light. It was markedly decreased presence of epithelial cells with hyperkeratosis and parakeratosis. The result demonstrates more epithelial cells in the form of keratinized husk disclosing that laser treatment influences the regulation of keratinisation of the tongue epithelium (hyper-orto-parakeratosis).

Results of many other investigators, like Biskin1, Frentzen and Koort2, Hansson6, and Kesic and Jovanovic7, provide evidence for the positive influence of the laser beam in the treatment of glossopyrosis, disclosing positive and good analgesic effect.

Patients treated with laser beam revealed increased mitotic activity of epithelial cells evidenced through cytological investigations. Our results as many other experimental investigations, support the influence of the laser beam on mitotic activity of epithelial cells that stimulates regeneration. In this case regenerative factor is providing the balance between the oxygen and the tongue epithelium, which is realized through activation of enzymes that supply cells with oxygen. So, the use of laser therapy regulates the altered keratinisation and improves oxygenation in the treated area, resulting in positive treatment outcome of patients with glossopyrosis and hypochromic anaemia.

Figure 2. Keratotic tongue epithelial cell with karyolitic nucleus Cell transforming into a keratin husk

Figure 3. Epithelial cell transformed into a keratin husk

168 Silvana Georgieva et al. Balk J Stom, Vol 16, 2012

Conclusion

Results of cytological analysis after the use of bio-stimulative laser treatment verify its positive effect. This allows us to conclude that the laser beam influences regulation of keratinisation and stimulates epithelial cells for increased mitotic activity; thus it stimulates and expands the regenerative processes, providing oxygen balance in the tongue epithelium.

Positive effect of the laser beam resulted in significant improvement of subjective symptoms among individuals with glossopyrosis.

References

1. Bishkin T. Biologic Influence of the Laser Beam. Apolonija, 2001; 3(6):45-56.

2. Frentzen M, Koort HJ. Lasers in dentistry: new possibilities with advancing laser technology? Int Dent J, 1990; 40:323-332

3. Gallagher FJ, Baxter DL, Denobile J, Taybos GM. Gllosodynia, iron deficiency anaemia, and gastrointestinal malignancy. Oral Surg Oral Med Oral Pathol, 1998; 65:130-133.

4. Grushka M, SessiLe BJ. Burning mouth syndrome: Review. Dent Clin North Am, 1991; 35(1):171-184.

5. Hadjadj ML, Martin F, Fichet D. Anemia caused by iron deficiency and pagophagia: A propos of a case. Rev Med Interne, 1990; 11(3):236-238.

6. Hansson TL. Infrared laser in the treatment of craniomandibular disorders, arthrogenous pain. J Prosth Dent, 1989; 61(5):614-617.

7. Kesic Lj, Jovanovic G. Low power lasers in treatment of glossopyrosis. III Congress of Macedonian Dentists, Ohrid. Abstract Book, 2002; p 120.

8. Kato IT, Pellegrini VD, Prates AR, Ribeiro MS, Wetter NU, Sugaya NN. Low Level Laser Therapy in Burning Mouth Syndrome Patients: A Pilot Study. Photomed Laser Surg, 2010; 28(6):835- 839.


Silvana Georgieva University Dental Clinical Centre „St. Panteleimon” Skopje, FYR Macedonia

SUMMARYThe aim was to present a possibility of the use of OHIP-MAC49

questionnaire, by determination of changes in relevant aspects of quality of life in patients with full removable dentures, before and after prosthodontic treatment. The OHIP-MAC49 questionnaire was administered to a total number of 35 participants (evaluated by sex, age, ethnics). Participants were edentulous patients attending the University Dental Clinic Centre “St. Pantelejmon” in Skopje. Authors selected a convenience sample of patients aged 45-83 years, who fulfilled the OHIP-MAC49 questionnaire twice, before the prosthodontic treatment and 1 month after the treatment with full removable dentures. The gathered values of total OHIP scores and all 7 subscales before and after treatment were compared using t-test.

The statistical analysis showed significant difference of OHIP scores before and after treatment with full dentures in relation to functional limitations (p<0.01), physical pain (p<0.01), psychological discomfort (p<0.01), and psychological disability (p<0.01). In other subscales - physical disability, social disability and handicap, there were no statistically significant differences of the OHIP score before and after prosthodontic treatment. Statistically significant difference was registered for the total OHIP score before and after prosthodontic treatment with full dentures (p<0.01).

The presented results indicate an impact of oral conditions associated with full denture wearing on the oral health-related quality of life. There is quality of life improvement in relation to oral health after prosthodontics treatment with full removable dentures, compared to the situation before treatment in certain wellbeing aspects defined by the OHIP model.Keywords: Oral Health; Quality of Life; OHIP-MAC49

Julijana Nikolovska, Dragan Petrovski

University “Ss. Cyril and Methodius” Faculty of Dental Medicine, Skopje, FYROM



Oral Health-Related Quality of Life (OHRQoL)Before and After Prosthodontic Treatment withFull Removable Dentures

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Introduction

Regarding the relationship of oral health and disease to quality of life, there appears to be an association between these domains, which is not clearly defined. Locker suggested that health problems may affect quality of life, but such a consequence is not inevitable10,11. Traditionally, dentists have been trained to recognise and treat disease, such as caries, periodontal disease and tumours, but they give no indication on the impact of the disease process to function or psychosocial well-being

of patients. Usually, patients’ assessment of their health-related quality of life is often markedly different to the opinion of health care professionals.

The combination of clinical and subjective indicators provides a more comprehensive and multidimensional assessment of a patient’s oral health condition, resulting into benefits for clinical decision making and oral health research19. The impact of oral disorders and interventions on patients’ perceived oral health state and oral health-related quality of life is an important component of health5. Oral healthcare researchers and policymakers

170 Julijana Nikolovska, Dragan Petrovski Balk J Stom, Vol 16, 2012

ethnics). Participants were edentulous patients attending the University Dental Clinic Centre “St. Pantelejmon” in Skopje. Authors selected a convenience sample of adult patients aged between 45 to 83 years. The participants fulfilled the OHIP-MAC49 questionnaire twice, once before the prosthodontic treatment and the second time 1 month after the treatment with full removable dentures.

According to the adequate epidemiological design, we used the questionnaire and interview method. This instrument consisted of 49 questions divided in 7 subscales: functional limitation (9), physical pain (9), psychological discomfort (5), physical handicap (9), psychological handicap (6), social handicap (5) and handicap (6). The subjects answered questions in which they evaluated how frequent an oral health problem occurred before and after prosthodontics treatment with removable dentures. Answers were evaluated by the Lickert scale (0 = never, 1 = very rare, 2 = sometimes, 3 = relatively often, 4 = very often). 0 presented absence of problems.

Besides the OHIP-MAC 49 questionnaire, the subjects answered questions about their personal oral and general health perception, using an analogue scale from 1 to 5 (1 = bad; 5 = excellent). These data were used to compare 2 examined variables.

The gathered values of consecutive measurements for the total OHIP score and all 7 subscales before and after treatment were compared using t-test.

Results

The statistical analysis showed significant difference of OHIP scores before and after treatment with full removable dentures in relation to functional limitations (p<0.01), physical pain (p<0.01), psychological discomfort (p<0.01), and psychological disability (p<0.01). In other subscales - physical disability (p>0.05), social disability (p>0.05) and handicap (p>0.05), there were no statistically significant differences of the OHIP score before and after prosthodontic treatment. Statistically significant difference was registered for the total OHIP score before and after prosthodontic treatment with full removable dentures (Tab. 1).

Arithmetic means along with the standard deviations of OHIP-MAC subscales before and after the prosthodontic treatment are presented in figure 1, and the arithmetic means of total OHIP score before and after the treatment with full removable dentures is presented on figure 2.

have recognised that assessment of oral health outcomes is vital to planning oral healthcare programmes1; so, according to modern aspects, oral health evaluation of a population must include social-dental indicators, beside clinical indicators (KEP, CPITIN). This means realizing the influence of an oral disease over physical, psychical and social wellbeing of humans, i.e. their subjective health. Being a physician, a dentist must estimate the influence of his therapy on the patient’s general health and life quality, besides just resolving the oral disease.

Oral health-related quality of life is a multi-dimensional concept, meaning patients personal estimation of his/her wellbeing in relation to: 1. Functional factors (mastication, swallowing, and speech); 2. Psychical factors (personal appearance, self-respect); 3. Social factors (social interaction, communication, socializing); and 4. Factors related to pain and discomfort (acute and chronic).

In order to determine the relation between oral health and life quality, several instruments are developed. The Oral Health Impact Profile (OHIP-49) is accepted as one of the most widely used and sophisticated methods of estimation7. It’s most important feature is the possibility to measure oral health improvement or decline given by the patient. Original version of the OHIP-49 has been developed in Australia and was adopted in many countries worldwide5,9,12-14,17. Now, it is available in many languages, which makes the instrument as an excellent tool for conducting cross-cultural research in the realm of oral health-related quality of life2. In the Balkan region, the translation and adaptation of the instrument are already completed in several countries: there is a Turkish, Romanian, Croatian, Greek and Serbian version3,15,16,18,20.

In order to use this instrument in the FYROM, i.e. to measure quality of life of population in relation to oral health, a Macedonian version of the OHIP was needed (OHIP-MAC 49). The elaboration of the Macedonian version means adequate translation of the original, cultural adaptation and review of the psychometrical characteristics8. The Faculty of Dental Medicine in Skopje (University Ss. Cyril and Methodius) developed the Macedonian version of OHIP (OHIP-MAC49) in collaboration with experts from the Faculty of Philosophy. In this paper, we used OHIP-MAC49 instrument to evaluate the quality of life in patients after prosthodontics treatment with full removable dentures. The aim of this paper was to present a possibility of the use of OHIP-MAC49, by determination of changes in relevant aspects of quality of life in patients with full removable dentures, before and after prosthodontics treatment.

Material and Methods

The OHIP-MAC49 questionnaire was administered to a total number of 35 participants (evaluated by sex, age,

Balk J Stom, Vol 16, 2012 Quality of Life with Full Removable Dentures 171

Tab1e. Differences before and after prosthodontic treatment with full removable dentures

Subscales OHIP М N SD t df p

Pair 1Functional limitation 1 13.71 35 4.50

3.329 34 0.002** Functional limitation 2 10.6 35 4.30

Pair 2 Physical pain 1 11.69 35 4.87

7.140 34 0.000** Physical pain 2 6.46 35 3.76

Pair 3 Psychological discomfort 1 7.57 35 3.78

2.772 34 0.009** Psychological discomfort 2 5.71 35 3.64

Pair 4 Physical disability 1 10.34 35 4.71

2.004 34 0.053 Physical disability 2 8.49 35 4.91

Pair 5 Psychological disability 1 6.23 35 4.21

2.241 34 0.032* Psychological disability 2 4.83 35 4.82

Pair 6 Social disability 1 3.74 35 3.49

.548 34 -0.607 Social disability 2 4.17 35 4.02

Pair 7 Handicap 1 5.49 35 3.38

1.835 34 0.75 Handicap 2 4.03 35 4.11

Pair 8 OHIP total score 1 58.77 35 20.96

3.428 34 0.002*OHIP total score 2 44.28 35 25.19

Figure 1. Arithmetic means of OHIP-MAC49 subscales before and after prosthodontic treatment

Figure 2. Arithmetic means of total OHIP-MAC49 scores before and after prosthodontic treatment

172 Julijana Nikolovska, Dragan Petrovski Balk J Stom, Vol 16, 2012

5. John MT, et al. Oral health-related quality of life in Germany The German version of the Oral Health Impact Profile: translation and psychometric properties. Eur J Oral Sci, 2002; 110:425-433.

6. John MT, et al. OHRQoL in patients treated with fixed, removable and complete dentures 1 month and 6 to 12 months after treatment. Int J Prosthodont, 2004; 17:503-511.

7. John MT, Hujoel P, Miglioretti DL, LeResche L,Koepsell TD, Micheelis W. Dimensions of oral-health-related quality of life. J Dent Res, 2004; 83:956-960.

8. Kenig N, Nikolovska J. Assessing the Psychometric Characteristics of the Macedonian Version of the Oral Health Impact Profile Questionnaire (OHIP-MAC49). OHDM, 2012; 11(1):29-38.

9. Larsson P, List T, Lundström I, Marcusson A, Ohrbach R. Reliability and validity of a Swedish version of the Oral Health Impact Profile (OHIP-S). Acta Odontol Scand, 2004; 62:147-152.

10. Locker D. Issues in measuring change in self-perceived oral health status. Community Dentistry and Oral Epidemiology, 1998, 26:41-47.

11. Locker D. Measuring oral health: a conceptual framework. Community Dental Health, 1988; 5:3-18.

12. Lopez R, Baelum V. Spanish version of the Oral Health Impact Profile (OHIP-Sp). BMC Oral Health, 2006; 6:11.

13. Meulen MJ, John MT, Naeije M, Lobbezoo F. The Dutch version of the Oral Health Impact Profile (OHIP-NL): Translation, reliability and construct validity. BMC Oral Health, 2008; 8: 11.

14. Montero-Martín J, Bravo-Pérez M, Albaladejo-Martínez A, Hernández-Martín LA, Rosel-Gallardo EM. Validation the Oral Health Impact Profile (OHIP-14sp) for adults in Spain. Medicina Oral Patologia y Cirugia Bucal, 2009; 14:E44-50.

15. Murariu A, Hanganu C. Oral health and quality of life among 45- to 64-year-old patients attending a clinic in Iasi, Romania. Oral Health and Dental Management in the Black Sea Countries, 2009; 8(2):7-11.

16. Petricevic N, Celebic A, Papic M, Rener-Sitar K. The Croatian version of the Oral Health Impact Profile questionnaire. Collegium Antropologicum, 2009; 3:315-321.

17. Pires CPAB, Ferraz MB, DeAbreu M. Translation into Brazilian portuguese, cultural adaptation and validation of the oral health impact profile (ohip-49). Braz Oral Res, 2006; 20(3):263-268.

18. Roumani T, Oulis CJ, Papagiannopoulou V, Yfantopoulos J. Validation of a Greek version of the oral health impact profile (OHIP-14) in adolescents. European Archive of Paediatric Dentistry, 2010; 11:247-252.

19. Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dental Health, 1994; 11:3-11.

20. Stancic I, Tihacek Šojic Lj, Jelenkovic A. Adaptation of Oral Health Impact Profile (OHIP-14) index for measuring impact of oral health on quality of life in elderly to Serbian language. Vojnosanitetski Pregled, 2009; 66:511-515. (in Serb)

21. Szentpetery A, John MT, Slade G, Setz J. Problems Reported by Patients before and after Prosthodontic Treatment. Int J Prosthodont, 2005; 18(2):124-131.


Julijana Nikolovska DDS, PhD University “Ss. Cyril and Methodius” Faculty of Dental Medicine Vodnjanska 17 1000 Skopje, FYR Macedonia E-mail: [email protected]

Discussion

Problems with chewing and eating dominated first month after prosthodontic treatment with full removable dentures. These problems were followed by the problems in pronunciation of some sounds.

The influence of oral diseases and interventions from the patient’s perspective, i.e. their personal estimation of oral health status and oral health-related quality of life (OHRQoL) presents a very important social-dental indicator. This aspect is especially relevant in elderly population, in which edentulism is at raise and needs a broad oral health concept6.

Location of tooth loss is very important for patients and influences the quality of patient’s life. Based on the systematic review and meta-analysis, Gerritsen et al4 concluded that there is a fairly strong evidence that tooth loss is associated with impairment of oral health-related quality of life (OHRQoL), and location and distribution of tooth loss affects the severity of the impairment.

The fact that most of the problems disappear after prosthodontic treatment with full dentures, especially after 6 to 12 months period of adaptation, is promising21.

Conclusion

The gathered data showed quality of life improvement in relation to oral health after prosthodontic treatment with full removable dentures, compared to the situation before treatment in certain wellbeing aspects defined by the OHIP model. Beside our better results after the treatment with full removable dentures, the challenge for permanent improvement in the prosthodontic treatment still persists. The OHIP-MAC49 can be a valuable instrument for evaluation of prosthodontics therapy.

The present results indicate an impact of oral conditions associated with full denture wearing on oral health-related quality of life.

OHIP-MAC49 can be use in future in cross-sectional studies on general population in order to determinate the impact of oral health to quality of life of population

References

1. Allen FP. Assessment of oral health related quality of life. Health Qual Life Outcomes, 2003, 1:40.

2. Allison P, Locker D, Jokovic A, Slade G. A cross-cultural study of oral health values. J Dent Res, 1999; 78:643-649.

3. Caglayan F, Altun O, Miloglu O, Kaya MD, Yilmaz AB. Correlation between oral health-related quality of life (OHQoL) and oral disorders in a Turkish patient population. Medicina Oral, Patologia y Cirugia Bucal, 2009; 14(11):e573-578.

4. Gerritsen A, Allen PF, Witter D, Bronkhorst E, Creugers

N. Tooth loss and oral health-related quality of life: a systematic review and meta-analysis. Health Qual Life Outcomes, 2010; 8:126. doi: 10.1186/1477-7525-8-126

SUMMARYPurpose: To evaluate the influence of different surface preparation

methods on the bond strength of 2 composite resins to zirconium oxide ceramic restorations.

Material and Methods: 80 specimens 2 mm thickness of IPS e.max ZirCAD blocks were prepared and divided into 4 groups. The first group was left as a control (C). In the second group, specimens were treated with sand blasting (SB). In the third group, specimens were treated with roughening the surfaces with diamond burs (DB). Laser irradiation was applied for the last group (LI). Specimens were divided into 2 subgroups (n: 10) for each surface treatment protocol followed by the application of 2 resin cements: Multilink Automix (MA) and Multilink Sprint (MS). The shear bond strength was measured using the universal testing machine with a crosshead speed of 0.5 mm/min. The retentions force required to remove the specimens was recorded. After debonding of specimens, the fractured surfaces were evaluated with an optical microscope to classify the failure modes and selected specimens for each group were examined in a scanning electron microscope for determining interfacial morphologies of surface treatment. Data were submitted to 2-way ANOVA, Kruskal-Wallis and Mann-Whitney U tests (P<.05).

Results: The bond strengths were significantly influenced by the resin cement and surface treatment (P<.05). Both cements showed the highest bond strength values when specimens were treated with sandblasting. The bond strength of the MA adhesive cement to the sandblasted zirconia resulted in the highest bond strength values (5.42 ± 1.28 MPa).

Conclusions: Applying sandblasting surface treatment improves the bond strength of self- adhesive resin cement to zirconia.Keywords: Zirconium Oxide; Resin Cements; Surface Treatment; Bond Strength

Altay Uludamar1, Filiz Aykent2

1Private Practice, Ankara, Turkey 2University of Selçuk, Faculty of Dentistry Department of Prosthodontics, Konya, Turkey



Bond Strength of Resin Cements to Zirconia Ceramics with Different Surface Treatments

STOMATOLOGICA

L S

OC

IET

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Introduction

All-ceramic restorations are metal free alternatives to widespread metal-ceramic composite structures1. The interest in using high-strength zirconium oxide ceramics for oral rehabilitation has been growing in recent years2-7. The evolution of tetragonal zirconia (Y-TZP) materials has introduced a new class of dental ceramics to the market.5 Clinical use of zirconium oxide as the core material brings about many advantages, such as satisfactory optical features, a high resistance to bending

exceeding 1000 MPa, and a biologic harmony7. The use of zirconium oxide ceramic restorations is increasing since they are stronger than aluminium oxide ceramics and allow construction of multi unit restorations2,6. CAD/CAM technologies have made working with this high crystalline material simpler, allowing the fabrication of full coverage crowns or bridge frameworks7-9.

The success of full ceramic restorations in serving for a long time in the mouth depends on the success of bonding between the ceramic, adhesive agent and tooth structures. Although improved mechanical properties are

174 Altay Uludamar, Filiz Aykent Balk J Stom, Vol 16, 2012

energy of 150 mJ at a 100 microseconds blasting time for a duration of 60 seconds. The wavelength of the device was 2940 nanometers and its focal spot size was 0.8 mm. During irradiation, the laser point was kept approximately 8 to 10 mm away from the surface and the whole surface was treated for 60 seconds.

Bonding Procedure After appropriate surface treatment, each adhesive

resin cement was applied according to the manufacturers’ instructions at room temperature (23.0 ± 1.00C) and relative humidity (50% ± 5%)10. Application mode and chemical composition of the investigated materials are reported in table 1. To standardize the cementing of resin cements on zirconium specimens, specially prepared ring-shaped plastic moulds with 5 mm inner diameter and 2 mm height were used. Resin cements were applied into the plastic ring from a syringe using an automatic mixing tip, which allows a homogeneous mixture. The ring was covered with a cellulose tape and a standard weight of 400 gm was applied on the specimen. Excess cement was removed with a dental explorer. It was left to rest for 10 minutes in the room temperature for the cement to cure by itself. Specimens were stored in distilled water at 370C for 24 hours before testing shear bond strength.

Shear Bond Strength Test Shear bond strength was determined according to

ISO/TS 11 405:2 003 using a Universal Testing Machine (TSTM 02500, Elista Ltd Şti, Istanbul, Türkiye) at acrosshead speed of 0.5 mm/min2. The force at separation (N) was divided by the cross-section area (100 mm2) to provide results in units of stress (MPa). After debonding, the fractured surfaces were evaluated with an optical microscope (100x magnification) to classify the failure modes into 1 of the following categories (A) adhesive failure at the interface between the ceramics and resin-luting agent (C) cohesive failure within the ceramics, within the resin-luting agent only and (M) adhesive and cohesive failure at the same site or a mixed failure2.

Representative interfacial morphologies of surface treatment and debonded specimens were examined in a Scanning electron microscopy (SEM) (JEOL JSM-6060LV Scanning Electron Microscope, Tokyo, Japan). Prior to analysis, specimens were dried and gold coating was applied with a sputter coater (Polaron SC 502 Sputter Coater, SPI supplies/ Structure Probe, Inc. West Chester, USA)10.

Statistical Analysis The values obtained as a result of the shear test

were assessed using 2-way ANOVA, Kruskal-Wallis test, which is a non-parametric statistical analysis, and Mann-Whitney U statistical tests with Bonferroni correction. The statistical analyses were carried out in Windows XP environment using SPSS 13.0 package programme.

important for the long-term performance of a ceramic material, the clinical success of fixed ceramic prostheses seems to be strongly dependent on the cementation procedure. There is a common thought that conventional methods of adhesive cementation, which include prior acid etching of the ceramic surface with hydrofluoric acid and further silanation, are not efficient for Y-TZP ceramics, because of their lack of silica and glass phase10-12. Even though some Y-TZP manufacturers suggest the use of air abrasion or tribochemical coating prior to adhesive cementation, the effect of those surface treatments on the mechanical properties of Y-TZP materials is controversial, and both positive and negative results have been described in the literature10. Therefore, the most appropriate surface treatment for Y-TZP ceramics still has to be determined. Moreover, there are some possibilities for improving bonding to Y-TZP ceramics that need to be tested, including modern techniques for surface treatments and adhesive primer materials.

Therefore, the aim of this study was to compare the effect of various surface treatment methods on the zirconium oxide all ceramic restorations while using common alternative products for adhesive cementation of such restorations. The null hypothesis was that there is no difference in zirconia-composite cement bonding effectiveness among 4 different surface preparations.

Material and Method

80 specimens 15x12x1.6 mm in diameter were obtained of ZrO2 (87-95%) stabilized by 5% Y2O3 ceramic (IPS e.max ZirCAD, Ivoclar Vivadent AG, Schaan, Liechtenstein). They were ground with 600 grit silicon carbide polishing paper (DCCS, Sankyo Fuji star, Japan) under water cooling and ultrasonically cleaned in acetone and distilled water for 15 minutes.2 A total of 80 specimens available were randomly divided into 4 groups (n: 20) according to the surface treatments. Group 1: No surface treatments (C); Group 2: Specimens were sandblasted (Easy Blast BEGO, Wilhelm-Herbest-Strabe, Bremen, Germany) for60secondswith110μparticlesizeAl2O3 sand (BEGO, Wilhelm-Herbest-Strabe, Bremen, Germany) from a distance of 1 cm under 2.8 atmospheres of air pressure (SB). Group 3: Specimens were roughened from various directions by the same investigator with a porcelain finishing diamond bur (Edenta AG, Dental Produkte St., St.Gallen, Switzerland), using a micro motor hand piece revolving at a speed of 15000 cycles (DB); Group 4: Er: YAG laser irradiation (LI). The specimens were roughened with a Fotona Fidelis Plus III Er: YAG laser device (Fotona Fidelis Plus 3 Lazer, Fotona dd, Ljubljana, Slovenia) The irradiation procedure was carried out using a pulsation frequency of 10 Hz and pulsation

Balk J Stom, Vol 16, 2012 Bond Strength of Resin Cements to Zirconia Ceramics 175

In all groups, the MA cement had higher bond strength than MS cement (P<.05). With the groups cemented with MA, SB and DB resulted in significantly higher bond strengths, while LI and C presented similar results. The same order was seen for the groups luted with the MS (Tab. 2). There were statistically significant differences between all groups for both cements except C and LI.

Table 3 describes the distribution of failure modes in the groups. Adhesive failures were most prevalent in all the experimental groups, with an average of 77% adhesive failure between the ceramics and resin luting agent. No cohesive failure was observed. SEM images showed morphologic differences among the groups after surface treatments (Fig. 1). SA (Fig. 1b) created rougher surface compared to DB, LI and C (Figs. 1a and 1c). Er: YAG laser irradiation originated a smooth surface (Fig. 1d).

Table 1. List of materials used in this study

Product/Code//Manufacturer Main Compositions Application

Resin cements

Multilink® Automix resin cement (MA)Ivoclar Vivadent AG, Bendererstr2Schaan, Liechtenstein

Dimethacrylates and HEMA, adhesive monomer, barium glass filler, SiO2 filler, Ytterbium triflorite, accelarator and stabilisator and pigments

Apply Zirconia primer on the surfaces of the specimens. Then apply into the plastic ring from a syringe using an automatic mixing tip which allows a homogeneous mixture. The ring was covered with a cellulose tape and a standard weight of 400 gm was applied on the specimen. It was left to rest for 10 minutes in room temperature for the cement to cure by itself.

Multilink® Sprint resin cement (MS)Ivoclar Vivadent AG, Bendererstr2Schaan, Liechtenstein

Dimethacrylates, adhesive monomer, inorganic filler, accelerator and stabilisator

Apply into the plastic ring from a syringe using an automatic mixing tip which allows a homogeneous mixture without any prior treatment to the surfaces of the specimens as recommended by the manufacturer. The ring was covered with a cellulose tape and a standard weight of 400 gm was applied on the specimen and again it was left to rest for 10 minutes in room temperature for the cement to cure by itself.

Primer Metal/Zirconia Primer (P) Ivoclar Vivadent AG, Bendererstr2Schaan, Liechtenstein

Diluter, phosphonic acid acrylate, ethoxile BIS-GMA, accelerator and stabilisator

Apply primer on the surfaces of the specimens and let to rest for 180 seconds

Results

The results showed that bond strengths were significantly influenced by the resin cement and surface treatment (P<.05). The shear bond strength values and the results of multiple comparisons are summarized in table 2 for all 2 resin cements and 4 surface treatments. The mean values were 1.84±0.27 to 2.47±0.31; Mean: 2.15±0.42 MPa for C, 4.35±0.72 to 5.42±1.28; Mean: 4.88±1.15 MPa for SB, 3.28±0.90 to 3.72±0.89; Mean: 3.50±0.90 MPa for DB and 1.74±0.30 to 2.37±0.39; Mean: 2.05±0.46 MPa for C. The bond strength of the MA adhesive cement to sandblasted zirconia resulted in the highest bond strength values (5.42±1.28 MPa). Both cements showed the highest bond strength values when specimens were treated with sandblasting (SB).

Table 2. Bond strength of self-adhesive resin cements to zirconia. Means, standard deviations (SD) MPa (n=10) and significancy (P<.05)

GROUPS

C SB DB LI

Mean±SD Mean±SD Mean±SD Mean±SD

MA 2,47±0,31 (A) * 5,42±1,28 (C) 3.72±0,89 (EC) 2.37±0,39 (AB)

MS 1,84±0,27 (B) 4.35±0.72 (DC) 3.28±0,90 (ADE) 1.74±0,30 (FB)

* The same letter denotes the results were not statistically significant.


in zirconia-composite cement bonding effectiveness among 4 different surface preparations. Moreover, SEM images demonstrated considerable qualitative differences in the surface topography of Y-TZP specimens after the surface treatments. Sandblasting appeared to be a more efficient method to modify zirconia surfaces compared to diamond burr and laser irradiation. This finding could be directly related to bond strength results, which showed that both resin cements yielded higher bond strengths after sandblasting10,17-22.

Untreated zirconium oxide ceramic is a relatively inert substrate, with low surface energy and wettability17. De Oyague et al18 reported that atomic force microscopy analysis reveals a significant increase in surface roughness aftersandblastingwith125μmaluminum-oxideparticles.Sand blasted surfaces might present an increased surface area, which favours wettability19-21. However, some authors have stated that the micro porosities created by surface treatments may act as crack initiators, weakening ceramic materials22,23. Thus, the effect of those alterations on the durability of Y-TZP restorations should be investigated in long-term clinical trials to determine whether the higher retention of sandblasted surfaces compensate for the changes in mechanical properties.

Some studies have suggested the use of Er:YAG (erbium-doped yttrium aluminum garnet) laser to enhance the bond strength of adhesive materials to resin composites used for indirect restorations and lithia based ceramics24,25. However, the capacity of the Er:YAG laser to increase the roughness of Y-TZP ceramics for adhesive luting procedures has not been investigated. In this study, irradiation of Y-TZP surfaces with Er: YAG laser was proposed as a surface treatment method. Our results indicated that laser irradiation was not as effective in improving bond strength as treatment with sandblasting and diamond bur for both resin cements. Laser treated and untreated surfaces presented similar results10,24. The Er: YAG laser has the ability to remove particles by micro explosions and by vaporization, a process called ablation. During laser treatment, local temperature changes due to heating and cooling phases create internal tensions that can damage the material10,24. The mechanical properties of Y-TZP ceramics can be negatively affected by changes in temperature, which can induce phase transformation10.

Discussion

Previous studies investigated the bond strength of adhesive restorative materials to Y-TZP ceramics13-16. Adhesion tests were applied in laboratory conditions in order to assess the effectiveness of the restoration systems being used, or to make a prior estimation of the status of a newly marketed adhesive system in the mouth. Clinical recommendations and selection of material related to resin adhesion to ceramics are based on mechanical laboratory tests which demonstrate significant differences in the choice of material and method. The widely preferred bond strength tests are 3-point bending test, tensile and micro-tensile tests, and shear and micro-shear tests. Shear bond test was used for measuring bond strength in a large number of studies in the literature to investigate adhesion of resin cements to porcelain surface13-16. In this study shear bond test was used to measure the bond strength of 2 different resins cements on the zirconium surfaces that were roughened in a number of ways.

The surface treatments investigated in the current study resulted in significantly different bond-strengths. So null hypothesis was rejected as there were differences

Table 3. Percentage of the failure modes in each experimental group

Resin cement Surface Treatment None SB DB LI

Adhesive Mixed Adhesive Mixed Adhesive Mixed Adhesive Mixed

MA 70 70 66 34 75 25 78 22

MS 80 20 78 12 85 15 86 13

Figure 1. SEM images (original magnifications 500X) of specimens’ surfaces: (a) Control (C); (b) Sandblasted (SB); (c) Diamond burr (DB);

(d) Er: YAG laser irradiated (LI)

a

c

b

d

Balk J Stom, Vol 16, 2012 Bond Strength of Resin Cements to Zirconia Ceramics 177

In this study, failure mode results indicated that, regardless of the experimental group, most failures of the resin cement-Y-TZP ceramic were adhesive, which left the zirconia specimens free of remnants of adhesive materials. Fractures being caused mostly by adhesive failure indicated that no real chemical bond could be established between the resin cement and the yttrium stabilized zirconium oxide specimens2.

Conclusions

Within the limitations of the present in vitro study, the following conclusions can be drawn:

1. Applying sandblasting surface treatment improves the bond strength of self-adhesive resin cement to zirconia;

2. In the surface treatment of sand blasted and diamond bur roughness, self-adhesive resin cement Multilink Automix shows the highest bond strengths to zirconia. The using of zirconium primer may have an effect on the mechanical strength of the cement;

3. Fractures were mostly adhesive failure, indicating that no real chemical bond could be established between the resin cement and the zirconium oxide specimens.

References

1. Anusavice KJ. Recent developments in restorative dental ceramics. J Am Dent Assoc, 1993; 124:72-74, 76-78, 80-84.

2. Lin J, Shinya A, Gomi H, Shinya A. Effect of self-adhesive resin cement and tribochemical treatment on bond strength to zirconia. Int J Oral Sci, 2010; 2:28-34.

3. Guazzato M, Albakry M, Ringer SP, Swain MV. Strength, fracture toughness and microstructure of a selection of all-ceramic materials. Part II. Zirconia-based dental ceramics. Dent Mater, 2004; 20:449-456.

4. Tsalouchou E, Cattell MJ, Knowles JC, Pittayachawan P, McDonald A. Fatigue and fracture properties of yttria partially stabilized zirconia crown systems. Dent Mater, 2008; 24:308-318.

5. Lüthy H, Loeffel O, Hammerle CHF. Effect of termocycling on bond strength of luting cements to zirconia ceramics. Dent Mater, 2006; 22:195-200.

6. Derand T, Molin M, Kvam K. Bond strength of composite luting cements to zirconium oxide ceramics. Dent Mater, 2005; 21:1158-1162.

7. Luthardt RG, Sandkuhl O, Reitz B. Zirconia-TZP and alumina - advanced technologies for the manufacturing of single crowns. Eur J Prosthodont Restor Dent, 1999; 7:113-119.

8. El Zohairy AA, De Gee AJ, Mohsen MM, Feilzer AJ. Microtensile bond strength testing of luting cements to prefabricated CAD/CAM ceramic and composite blocks. Dent Mater, 2003; 19:575-583.

Therefore, in this study, a lower power setting for the Er: YAG laser was selected (150mJ) and the surfaces were irradiated with constant water cooling. However, more studies need to be carried out in this area using different power and pulsation settings before and after the sintering process.

In this study of measuring bond strengths, the results of the shear test showed that the bond strength of MA (3.49±1.47) on zirconium surfaces was statistically significantly higher than that of MS (2.80±1.23). Multilink sprint (MS) is self etch, self adhesive resin based adhesive cement and designed for ease of use with no bonding application. Multilink Automix (MA), on the other hand, is a resin cement used with bonding applications on the teeth and metal/zirconia primer on the restoration in the aim of having higher bond strength. Metal/Zirconia Primer is only used with Multilink Automix. Metal/Zirconia Primer was used on the surfaces before applying MA as recommended by the manufacturer, but no zirconium primer was used before applying the new generation MS, which contains the etch and adhesive systems in its own composition. It was reported in previous studies that the use of resin cements containing phosphate-based monomer increased adhesion to zirconium surface12,26. The phosphate-containing methacrylate in MA’s zirconium primer, which was used in this study, increased bond strength on zirconium surfaces in a similar way. Therefore, higher bonding values achieved by Multilink Automix may well be due to the application of Metal/zirconia primer. The reason for such increase was because phosphate-containing methacrylate in the primer formed a salt-like bond with zirconium. Due to low bond strength of Multilink Sprint, it is not on the market anymore. However, the purpose of this in vitro study was to evaluate the influence of different surface preparation methods on the bond strength of 2 composite resins to yttrium stabilized zirconium oxide ceramics.

It is not the bonding strength of Multilink Sprint that is important, but the effect of surface treatment methods on the shear bond strength of resin cements authors have focused on. The principal aim of this study was to compare the effect of various surface treatment methods on the zirconium oxide all ceramic restorations while using common alternative products for adhesive cementation of such restorations.

It was interesting that the bond strength values of this study were quite lower than previous stated2,10,22,23. If the bond strength values were achieved in the region of 20-30 MPa (avarage bonding values of adhesive cements on tooth substances), there would be no problems as to adhesive bonding of resin cements on zirconium oxide restorations. Therefore, authors should question such high bonding values rather than suspect more realistic numbers found in this study.


19. Awliya W, Oden A, Yaman P, Dennison JB, Razzoog ME. Shear bond strength of a resin cement to densely sintered high-purity alumina with various surface conditions. Acta Odontol Scand, 1998; 56:9-13.

20. Derand P, Derand T. Bond strength of luting cements to zirconium oxide ceramics. Int J Prosthodont, 2000; 13:131-135.

21. Wolfart M, Lehmann F, Wolfart S, Kern M. Durability of the resin bond strength to zirconia ceramic after using different surface conditioning methods. Dental Mater, 2006; 23:45-50.

22. Zhang Y, Lawn BR, Rekow ED, Thompson VP. Effect of sandblasting on the long-term performance of dental ceramics. J Biomed Mater Res Part B: Appl Biomater, 2004; 71:381-386.

23. Kumbuloglu O, Lassila LV, User A, Vallittu PK. Bonding of resin composite luting cements to zirconium oxide by two air-particle abrasion methods. Oper Dent, 2006; 31:248-255.

24. Gokce B, Ozpinar B, Dundar M, Comlekoglu E, Sen BH, Gungor MA. Bond strengths of all-ceramics: Acid vs. laser etching. Oper Dent, 2007; 32:173-178.

25. Burnett LH Jr, Shinkai RS, Eduardo CP. Tensile bond strength of a one-bottle adhesive system to indirect composites treated with Er: YAG laser, air abrasion, or fluoridric acid. Photomed Laser Surg, 2004; 22:351-356.

26. Wegner SM, Gerdes W, Kern M. Effect of different artificial aging conditions on ceramic composite bond strength. Int J Prosthodont, 2002; 15:267-272.

Correspondence and requests for offprints to:

Dr. Altay Uludamar Filistin cad. Kader sok. No: 6 Kat: 1, D: 1, 06700 Gaziosmanpaşa,Ankara,Turkey E-mail: [email protected]

9. Luthardt RG, Holzhüter MS, Rudolph H, Herold V, Walter MH. CAD/CAM machining effects on Y-TZP zirconia. Dent Mater, 2004; 20:655-662

10. Cavalcanti AN, Foxton RM, Watson TF, Oliveira MT, Giannini M, Marchi GM. Bond Strength of Resin Cements to a Zirconia Ceramic with Different Surface Treatments. Oper Dent, 2009; 34:268-275

11. Blatz MB, Sadan A, Martin J, Lang B. In vitro evaluation of shear bond strengths of resin to densely sintered high-purity zirconium-oxide ceramic after long-term storage and thermal cycling. J Prosthet Dent, 2004; 91:356-362.

12. Kern M, Wegner SM. Bonding to zirconia ceramic: adhesion methods and their durability. Dent Mater, 1998; 14:64-71.

13. Kussano CM, Bonfante G, Batista JG, Pinto JHN. Evaluation of shear bond strength of composite to porcelain according to surface treatment. Braz Dent J, 2003; 14:132-135.

14. Madani M, Chu FCS, McDonald AV, Smales RJ. Effects of surface treatments on shear bond strength between resins cement an alumina core. J Prosthet Dent, 2000; 83:644-647.

15. Nakamura S, Yoshida K, Kamada K, Atsuta M. Bonding between resin luting cement and glass infiltrated alumina-reinforced ceramics with silane coupling agent. J Oral Rehabil, 2004; 31:785-789.

16. Øilo M, Gjerdet NR, Tvinnereim HM. The firing procedure influences properties of a zirconia core ceramic. Dent Mater, 2008; 24:471-475.

17. Ozcan M. Evaluation of alternative intra-oral repair techniques for fractured ceramic fused to metal restorations. J Oral Rehabil, 2003; 30:194-203.

18. De Oyague RC, Monticelli F, Toledano M, Osorio E, Ferrari M, Osorio R. Influence of surface treatments and resin cement selection on bonding to densely-sintered zirconium-oxide ceramic. Dent Mater, 2009; 25:172-179.

SUMMARY

Local anaesthetic administration is the most common procedure

that accompanies almost all procedures in dentistry. Some of immediate

post-injection local complications are fairly common, whereas some are

less frequent and rarely reported. Some complications can be bizarre

and difficult to explain. In this cases report, 2 cases of unusual laryngeal

complications following inferior alveolar nerve block are presented.

Keywords: IAN Block; Complication; Acute Hoarseness

Ulkem Cılasun1, E. Alper Sınanoglu2, Serdar Yılmaz1, Esra Guzeldemır3, Gamze Alnıacık4

1University of Kocaeli, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Kocaeli, Turkey 2University of Kocaeli, Faculty of Dentistry, Department of Oral Diagnosis and Radiology, Kocaeli, Turkey 3University of Kocaeli, Faculty of Dentistry, Department of Periodontology, Kocaeli, Turkey 4Private Practice, Ankara, Turkey

CASE REPORT (CR)Balk J Stom, 2012; 16:179-180


An Unusual Laryngeal ComplicationFollowing Inferior Alveolar Nerve Block

STOMATOLOGICA

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Introduction

Local anaesthetic (LA) administration is the most common procedure in dentistry. Although this procedure accompanies almost all dental procedures, it has many potential risks for the patient6. When LA is administered carefully and within recommended dosage limits, they have established an enviable record of safety7. Even though some life threatening systemic reactions may occur, most adverse effects or complications are local and temporary.

LA complications can be classified as local or systemic7. Local and immediate post-injection, in-the-chair complications, such as needle breakage, pain or burning sensation on injection, penetration of a blood vessel (venous or arterial), haematoma, oedema, tissue blanching, nerve damage, facial nerve paralysis, amaurosis, diplopia and adverse drug interactions (overdose, allergy or idiosyncrasy)7 to anaesthetic injections are fairly common6, some are less frequent and rarely reported. Such complications can be bizarre and difficult to explain. Especially neurological complications following the administration of a local anaesthetic can be alarming.

There is only 1 case of vagus nerve inhibition reported following dental anesthesia. Including the very

recent ones, some textbooks do not even mention this complication. In this cases report, 2 acute hoarseness and mild dysphagia immediately after local anesthesia administration are presented.

Report of Cases

Case 1A 33-year-old man had received an inferior alveolar

nerve (IAN) block for endodontic treatment of his right mandibular second molar. A few seconds after the injection, hoarseness occurred and he complained of dysphagia and claimed respiration difficulty. He was immediately referred to the Oral and Maxillofacial Surgery Clinic where he was evaluated for laryngeal oedema, bronchospasm and airway obstruction. None was present and the symptoms were diagnosed as complications of the local anesthesia.

The complication was explained to the patient and he was followed-up until the symptoms completely resolved, which lasted approximately 2 hours.

Case 2A 42-year-old man had had LA injection for the IAN

block for endodontic treatment of his right mandibular

180 Ulkem Cılasun et al. Balk J Stom, Vol 16, 2012

first molar. Immediately after the injection, hoarseness occurred but he did not have any other complaints. He was immediately referred to the Oral and Maxillofacial Surgery clinic for further evaluation. The symptom was again diagnosed as LA complication. He completely recovered after approximately 3 hours.

Both patients were clear of any systemic diseases and the injections were performed by using a LA solution of 4% articaine hydrochloride and 1:200.000 epinephrine hydrochloride (Ultracain D-S; Aventis, Istanbul, Turkey) with 50 mm, 27-gauge needles.

Discussion

Complications of IAN blocks have been reported in the literature and during the past decades, some studies have investigated the frequency of immediate complications during the administration of a LA3-5,6.

Neurological complications have been reported as rare complications of local anaesthesia and can be divided into: a) those that arise as a direct result of the procedure itself (IAN block and posterior superior alveolar nerve block); and b) those due to the toxicity of the agents used2.

Campbell et al1 reported the development of Horner’s Syndrome, which arose due to penetration of the LA through the lateral pharyngeal and prevertebral spaces, causing blockade of the stellate ganglion. The features of the syndrome include:

● flushing of the face on the same side; ● ptosis of the eyelid; ● vasodilatation of the conjunctiva; ● pupillary constriction; and (occasionally) ● a rash over the neck, face, shoulder and arm of the

ipsilateral side.The case described by Campbell et al1 also had

a hoarse voice and difficulty in breathing due to the involvement of the recurrent laryngeal nerve. All of these effects were transient1. In the presented cases, none of the above-mentioned symptoms of Horner’s Syndrome was observed but only the laryngeal complications occurred right after the administration of articaine HCl. Hoarseness, dysphagia, and claimed respiration difficulty resolved within 2-3 hours.

A possible cause of the hoarseness was reported as the involvement of the recurrent laryngeal nerve. It may

be caused by accidentally medially located injection but in the presented cases, as the doctors did not report an unusual technique during injection, an anatomic variation was taken into consideration as a possible cause.

Fortunately, permanent damage to nerves, facial and oral tissues are extremely rare. Being aware of the anatomy and the properties of LA solutions, the clinician should be cognizant of even these rare complications that can occur during regional nerve blocks, and should be prepared to manage them.

This cases report highlights an event where individual anatomic variation of the sympathetic nerve may allow anaesthetic solution to be delivered to an ectopic site, which will cause unusual signs and symptoms, such as hoarseness and laryngeal complications. Fortunately, these complications were temporary and resolved totally by the time local anaesthesia resolved.

References

1. Campbell RL, Mercuri LG, Van Sickels J. Cervical sympathetic block following intraoral local anaesthesia. Oral Surg Oral Med Oral Pathol, 1979; 47:223-226.

2. Crean SJ, Powis A. Neurological complications of local anaesthetics in dentistry. Dent Update, 1999; 26:344-339.

3. Daublander M, Muller R, Lipp MD. The incidence of complications associated with local anesthesia in dentistry. Anesth Prog, 1997; 44:132-141.

4. D’Eramo EM, Bookless SJ, Howard JB. Adverse events with outpatient anesthesia in Massachusetts. J Oral Maxillofac Surg, 2003; 61:793-800.

5. Keetley A, Moles DR. A clinical audit into the success rate of inferior alveolar nerve block analgesia in general dental practice. Prim Dent Care, 2001; 8:139-142.

6. Lustig JP, Zusman SP. Immediate complications of local anesthetic administered to 1,007 consecutive patients. J Am Dent Assoc, 1999; 130:496-499.

7. Malamed SF. Handbook of Local Anesthesia. 5th Ed. Philadelphia: Elsevier, Mosby, 2004.


Dr. U. Cilasun KocaeliUniversitesi, YuvacikYerleskesi DisHekimligiFakultesi, 41190 Yuvacik, Basiskele, Kocaeli Turkey E-mail: [email protected]

SUMMARYSurgical planning of a case with bilaterally impacted maxillary teeth

by using cone beam computed tomography is presented. The 3D model provide valuable information for improved diagnosis and treatment plan and ultimately results in more successful treatment, as in the present case. The surgeon, knowing the precise location of the tooth and shape of roots in all projections would reduce the invasiveness of surgery. Keywords: Impacted Third Molar; Maxillary Sinus; Headache; Cone Beam Computed Tomography

Nurhan Güler

Yeditepe University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Istanbul, Turkey

CASE REPORT (CR)Balk J Stom, 2012; 16:181-184


Surgical Planning of Bilaterally ImpactedMaxillary Third Molars by Using Cone Beam Computed Tomography

STOMATOLOGICA

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Introduction

Impaction of a tooth is a situation in which an unerupted tooth is wedged against another tooth (or teeth) or otherwise located so that it cannot erupt normally. Many theories have been suggested on the aetiology of ectopic eruption such as trauma, infection, pathologic conditions, crowding and developmental anomalies10. The maxillary sinus, palate, mandibular condyle, coronoid process, orbit, nasal cavity or through the skin are common maxillofacial areas for the ectopic eruption. Developmental disturbances such as cleft palate, displacement of teeth by trauma or cyst, infection, genetic factors, crowding and dense bone are the possible causes of the ectopic tooth into maxillary sinus2,5,6. Caldwell-Luc procedure and the endoscopic surgical approach are common techniques for removing ectopic teeth from the sinus although latter has less morbidity4.

Treatment decision on the impacted teeth has depended on several factors, including location of the impaction, prognosis of the intervention on the impacted tooth and adjacent teeth, surgical accessibility, impact of treatment on the final functional occlusion, and possible surgical morbidity. This decision has traditionally been based on planar 2-dimensional (2D) radiography. New imaging techniques are now available in dentistry, like

cone-beam computed tomography (CBCT), which has a lower-dose, lower-cost alternative to conventional CT and is being used for localization of tooth impaction. These machines use cone-shaped radiation to gather information in the maxillofacial region, with high spatial resolution and significantly decreased radiation doses3,8.

In this report, the surgical planning of a case with bilaterally impacted maxillary teeth by using CBCT is presented.

Case Report

A 37 years old woman was referred to our clinic with a complaint of facial pain and headache for 8 months. The past medical history was unremarkable. There was no obvious sign of disorder on both extra- and intraoral examinations. Her specialists (neurologist and ENT physician) told her that no signs of any disorders but, based on panoramic radiograph, the possible cause of pain might be the impacted maxillary teeth. There were no signs of temporomandibular joint disorders such as disc displacement with or without reduction and osteoarthritis.

On panoramic radiograph, both third molars were impacted with a connection to the root of second molar

182 Nurhan Güler Balk J Stom, Vol 16, 2012

and maxillary sinus (Fig. 1). CBCT scans were performed to evaluate the position and direction of the impacted teeth in the maxillary sinus and related tooth (NewTom Dental volumetric tomography). Both coronal and sagittal images showed the close proximity to the root of left second molar and right maxillary sinus. The root of left second molar without sign of resorption was placed in the middle of occlusal surface of the impacted tooth (Fig. 2). There was no dilacerations of roots of both impacted teeth. On the frontal view of 3D volumetric image, while the right tooth without bone coverage was in the maxillary sinus, the crown of the left impacted tooth was full covered with bone (Fig. 3). On sagittal views, there was no bony structure on the impacted teeth and close proximity to maxillary sinus (Fig. 4, a and b).

Figure 1. Panoramic view of bilaterally impacted maxillary third molar

Figure 2. 3D CBCT image shows the close proximity to the root of the left second molar and proximity to the right maxillary sinus; the root of the left second molar is placed in the middle of occlusal surface of the

impacted tooth

a b

Figure 3. On the frontal view of 3D volumetric image, while the right tooth, without bony coverage, was in the maxillary sinus, the crown of

the left impacted tooth was fully covered with bone

Figure 4. The sagittal view of the right (a) and the left (b) impacted maxillary teeth

Figure 5. The impacted tooth (white arrow) was seen under the sinus mucosa (black arrow)

Balk J Stom, Vol 16, 2012 Surgical Planning with CBCT 183

Discussion

Although most of impacted teeth in the maxillary sinus are asymptomatic and usually found during routine clinical and radiographic examinations, facial pain associated with intermittent purulent nasal discharge and headache can be the main complaints2. It has been reported a case with facial asymmetry because of bilateral ectopic third molars in the maxillary sinus causing osteomeatal complex obstruction5. Based on the present case complaints, the impacted maxillary teeth could be one of the factors of the facial pain and headache.

CBCT images are inherently more accurate than traditional x-rays, since beam projection is orthogonal; this means that the x-ray beams are approximately parallel to one another, and the object is near the sensor. This explains why there is little projection effect and no magnification. In addition, the computer software addresses the projection effect, resulting in undistorted 1:1 measurements. This contrasts with traditional imaging, which always has some projection error because the anatomic regions of interest are at varying distances from the film. In this situation, the dentist must account for these imaging artefacts when reading the images. Another advantage of the CBCT scan is that the data acquired include information for the entire craniofacial region. Additional views, such as lateral cephalograms, panoramic radiographs, airway evaluations and volumetric images, are available from the original acquisition data. These images can be manipulated with imaging software to aid the dentist in diagnosis and treatment planning. The costs, efficiency, and benefits of CBCT imaging are

Under sedation, Caldwell-Luc procedure was performed for the removal of the right upper wisdom tooth, while a standard third molar surgery was made for the other. The right wisdom tooth between sinus mucosa and alveolar bone was carefully removed without mucosal perforation of the sinus (Fig. 5). Postoperative period was uneventful and no complaints at 2 years follow-up (Fig. 6).

favourable, because one imaging session can provide many views9. In the present case, both impacted third molar with a connection to the root of second molar and maxillary sinus were not clearly demonstrated on panoramic radiography. The best images demonstrating the bone and/or mucosa of maxillary sinus were taken on frontal view of 3D CBCT.

A common application of CBCT is in evaluation and surgical planning of impacted teeth6,11. The additional third dimension provided by CBCT increases the information available for the surgeon while planning exposure or removal, and may notably alter the prevalence of root resorption1. To take full advantage of the information provided by CBCT, it is necessary to interpret volumetric images on a 3D scale. Such a technique would enable clinicians to describe and evaluate pathologies, deformities, and impactions with greater detail and accuracy7.

In conclusion, the case presented here describes the spatial relationship of the impacted third molar to the surrounding anatomic structures using CBCT. 3D computed tomographic model provide valuable information for improved diagnosis and treatment plan and ultimately results in more successful treatment, as in present case. The surgeon, knowing the precise location of the tooth and shape of the roots in all projections would reduce the invasiveness of surgery.

References

1. Alqerban A, Jacobs R, Lambrechts P, Loozen G, Willems G. Root resorption of the maxillary lateral incisor caused by impacted canine: a literature review. Clin Oral Invest, 2009; 13:247-255.

2. Baykul T, Doğru H, Yasan H, Cina Aksoy M. Clinical impact of ectopic teeth in the maxillary sinus. Auris Nasus Larynx, 2006; 33:277-281.

3. Chaushu S, Chaushu G, Becker A. The role of digital volume tomography in the imaging of impacted teeth. World J Orthod, 2004; 5:120-132.

4. Hasbini AS, Hadi U, Ghafari J. Endoscopic removal of an ectopic third molar obstructing the osteomeatal complex Ear Nose Throat J, 2001; 80:667-670.

5. Jude R, Horowitz J, Loree T. A case report: Ectopic molars that cause osteomeatal complex obstruction. J Am Dent Assoc, 1995; 126:1655-1657.

6. Kim SJ. Cone beam computed tomography findings of ectopic mandibular third molar in the mandibular condyle: report of a case. Imaging Sci Dent, 2011; 41:135-137.

7. Lou L, Lagravere MO, Compton S, Major PW, Flores-Mir C. Accuracy of measurements and reliability of landmark identification with computed tomography (CT) techniques in the maxillofacial area: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2007; 104:402-411.

Figure 6. Final panoramic view of patient

184 Nurhan Güler Balk J Stom, Vol 16, 2012

8. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB. Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB MercuRay, NewTom 3G and i-CAT. Dentomaxillofac Radiol, 2006; 35:219-226.

9. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two extraoral direct digital imaging devices: NewTom cone beam CT and Orthophos Plus DS panoramic unit. Dentomaxillofac Radiol, 2003; 32:229-234.

10. Raghoebar GM, Boering G, Vissink A, Stegenga B. Eruption disturbances of permanent molars: a review. J Oral Pathol Med, 1991; 20:159-166

11. Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone-beam computed tomography in dental practice. J Can Dent Assoc, 2006; 72:75-80.

Correspondence and request for offprints to:Assoc. Prof. Nurhan Güler Yeditepe Universitesi, Dis Hekimligi Fakultesi Bagdat cad. No: 238 Goztepe Istanbul, Turkey E-mail: [email protected]

The BALKAN JOURNAL OF STOMATOLOGY provides contributors with an opportunity to publish review and original papers, preliminary (short) communications and case reports.

Review papers (RP) should present an analytic evaluation of certain problems in stomatology based on a critical approach to personal experience and to the published results of other authors.

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