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VOL 3 NO. 2 DEC. 2015

JOURNAL OF DENTAL SCIENCES

DENTAL LAMINA

ISSN 2347-1859

Orthodontics Prosthodontics

Oral Medicine

Oral & Maxillofacial Surgery

PeriodontologyPublic Health Dentistry

Oral Pathology Conservative DentistryPaedodontics

Dr. N. GrewalDr. O.P Kharbanda Dr. Mahesh VermaDr. Anmol .S. Kalha Dr. Veena JainDr. Babu MathewDr. Vasundhara Bhad Dr. H. UmarjiDr. Gurkeerat Singh Dr. J. N KhannaDr. Sunali Khanna

Dr. Ghosala ReddyDr. C. Dwarkanath Dr. Girish Rao

Dr. N.C. RaoDr. A. Kumarswamy Dr. T. K Shah

Dr. C.M. MaryaDr. Naresh Thukral Dr. Sanjiv KumarDr. Manju Nath GDC RohtakDr. Sanjay Jain

Dr. B. SivapathsundharamDr. Sanjay TiwariDr. Samir Dutta Dr. D. Daftari

Dr. Vijay Mathur Dr. Sonali Taneja Dr. R.R PaulDr. Namita Kalra Dr. Sanjay Miglani Jamia Dr. Vinay HazareyDr. Amita Sharma Dr. Vivek Hegde

Publisher/ Printer

Mr Atul Kalra Published at : E/1-A, NIT, Faridabad, Haryana

Printed at : Vinayak Colour Offset C-114, Naraina Industrial Area, Phase-I, New Delhi-110028.

JOURNAL REVIEW BOARD

Sub: Change in Editorial BoardThe Following changes have been made in the Editorial Board

“DENTAL LAMINA” JOURNAL OF DENTAL SCIENCES

Dr. Amit Bhalla (Vice President, MRIU)

Dr. N.C Wadhwa (Vice-Chancellor, MRIU)

Dr. Sanjay Srivastava (Vice Chancellor, MRU)

Maj.Gen. (Retd) Dr. P.N Awasthi , M.D.S, VSM ( Advisor-MRDC)

Prof. Arundeep Singh, MDS (Principal, MRDC)

Prof. M.K Soni Exc. Dir., Dean, FET, MRIU Prof. Shivani Aggarwal, MDS, HOD - Oral PathologyDr. G.L Khanna Phd, Dean, FAS, MRIU Prof. Pankaj Dhawan, MDS, HOD ProsthodonticsProf. Sarita Sachdeva HOD, Dept. of Biotech, MRIU Prof. Ashim Aggarwal, FDSRCS, HOD - Oral SurgeryProf. Vishal Dang, MDS, HOD - Oral Medicine & Radiology Prof. Sridhar Kannan, MDS, HOD OrthodonticsProf. Hind P Bhatia, MDS, HOD - Paedodontics

Patron : Dr. Prashant Bhalla

(Chairman, MREI, Faridabad)

ADVISORS

Prof. Shveta Sood, MDS

EDITOR-IN-CHIEF

Prof. Vandana S. Chadha, MDS

Prof. Manish Bhargava, MDS

ASSOCIATE EDITORS

EDITORIAL BOARD

Prof. Ravindra Shah, University of British Columbia Vancouver, Canada

Dr. Bapanaiah Penugonda, Collage of Dentistry New York University, USA

INTERNATIONAL EDITORIAL CONSULTANTS

1

JOURNAL OF

DENTAL SCIENCES

“DENTAL LAMINA”

VOL 3 NO. 2 DEC. 2015

ISSN 2347-1859

2Dental Lamina - Journal of Dental Sciences Vol. 3 No. 2, Dec. 2015

Antibiotics have been considered one of the greatest discoveries of the 20th

Century . It's hard to imagine a world before the development of what many

consider to be miracle drugs. Unfortunately, antibiotic resistance, or the

increased ability of bacteria to survive in the presence of antibiotics, has

become a major public health threat. Ramanan Laxminarayan, Director,

Centre for Disease Dynamics, Economics & Policy aptly said "It has been a

long time since people died of untreatable bacterial infections and the

prospect of returning to that world is worrying." The challenges associated

with controlling antibiotic resistance are many and multifaceted. Exacerbating

this problem is the stagnation of the pharmaceutical industry in the

development of new antibiotics. The World Economic Forum has suggested

that Anti Microbial Resistance be added to the global risk register.

Antibiotic resistance is a global public health threat , but nowhere is it as stark

as in India .Antibiotic use is a major driver of resistance. In 2010, India was the

world's largest consumer of antibiotics for human health at 12.9 x 109 units

(10.7 units per person). The next largest consumers were China at 10.0 x109

units (7.5 units per person) and the US at 6.8 x109 units (22.0 units per person).

' Global Trends in Antibiotic Consumption, 2000-2010', a study by scientists

from Princeton University, has found that worldwide antibiotic use has risen

by 36% over those 10 years, with five countries — Brazil, Russia, India, China

and South Africa — responsible for more than three-quarters of that surge.

Poor public health indicators, rising incomes, and the availability of

inexpensive antibiotics over the counter without a prescription are converging

to create the ideal conditions for a large-scale selection and dissemination of

resistance genes in India.

Dr Hicks, Medical Director, Centre for Disease Control and Prevention, at the

American Dental Association 2015 presented that dentists prescribed 10% of

about 258 million courses of antibiotics prescribed by all healthcare providers

in 2010. General dental practitioners prescribe antibiotics therapeutically and

prophylactically to manage oral and dental infections. This is despite the fact

that the use of systemic antibiotics in dentistry is limited since most dental and

periodontal diseases are best managed by operative intervention and oral

hygiene measures. The type of antibiotic chosen and its dosing regime should

be based on the severity of the infection and the predominant type of

causative bacteria. It is most important that guidelines for prescribing

antibiotics are well promoted, understood and followed.

EDITORIAL


The inappropriate overuse of antibiotics has resulted in a crisis situation due

to bacterial mutations developing resistant strains. While addressing the

immediate concerns regarding antibiotic resistance should remain a priority,

long-term goals should also be kept in mind. These include formulating

strategies and incentives to kick-start new antimicrobial research by the

pharmaceutical industry. Public needs to be educated at mass level against self

medication with antibiotics.

WHO observed for the first time World Antibiotic Awareness Week from

November 16-22,2015 with the campaign titled “Antibiotics: Handle with

Care”. Kerela is all set to become the first state to adopt a comprehensive

policy to fight growing antibiotic resistance. The programme will be targeting

allopathic doctors and pharmacists to educate them on rational use of

antibiotics and will seek to change public behaviour through large scale

awareness programmes.

Antibiotics are life saving drugs but they will only remain effective if urgent

steps are taken to curb their overuse.

Dr. Shveta SoodEditor In Chief

INDEX

A) ORIGINAL ARTICLE

1. PREVALENCE AND SOCIO-DEMOGRAPHIC CORRELATION OF STRESS 6

AMONG INDIAN AND QATAR UNIVERSITY STUDENTS PURSUING

PROFESSIONAL COURSES

Dr Anjana Goyal, Taniya Malhotra

B) CLINICAL CASE REPORTS AND INNOVATIONS

2. PROSTHODONTIC MANAGEMENT OF SINGLE COMPLETE MAXILLARY 13

DENTURE ACCOMPANIED BY FLABBY RIDGE

Dr. Mukti Goel, Dr. Pankaj Dhawan, Dr. Pankaj Madhukar, Dr. Shivam Singh Tomar

3. PROSTHODONTIC MANAGEMENT OF A PATIENT SUFFERING 17

FROM PARKINSONISM

Dr. Sugandha Gupta, Dr. Pankaj Dhawan, Dr. Pankaj Madhukar, Dr. Piyush Tandan

4. FRENECTOMY- CONVENTIONAL AND LASER CASE SERIES 19

Dr. Renuka Gahlot, Dr. Pooja Palwakar, Dr. Ashish Verma,

Dr. Vandana Srikrishna Chadha, Dr. Nipun Dhalla

5. PROSTHETIC REHABILITATION WITH SECTIONAL COMPLETE 25

DENTURE OF A PATIENT WITH MICROSTOMIA

Dr. Susan Dax, Dr. Pankaj Dhawan, Dr. Pankaj Madhukar, Dr. Amrita Grover

6. MANAGEMENT OF ANKYLOGLOSSIA UTILIZING MONOPOLAR DIATHERMY 30

Dr. Kiranjot Kaur, Dr. Rajendra Kumar Gilhotra, Dr. Hind Pal Bhatia,

Dr. Shveta Sood, Dr. Naresh Sharma, Dr. Akshara Singh

7. INTRAORAL LIPOMA OF LOWER LIP : REPORT OF A RARE CASE 33

Dr. Meelu Lamba, Dr. Vishal Dang, Dr. Neelkamal Sharda Bharadwaj,

Dr. Natalia Desilva, Dr. Priyanka Kant

C) GUIDELINES TO CONTRIBUTORS 36


6

Abstract

Key words :

Key Message

1. BACKGROUND AND PURPOSE : Stress is usually a precursor to anxiety and anxiety is precursor to depression. This can reduce the efficiency of the individuals and induce various negative effects. Stress as experienced by students may adversely affect their academic achievements, personal well-being and long term professional capabilities.

This study is aimed to compare the perceptions and sources of stress among professional students from Manav Rachna University (India) and Qatar University (Qatar).

2. METHOD : A cross-sectional survey was administered. Data was collected using a questionnaire consisting of 8 attributes in Health indicators, 3 in Sleep indicators, 4 in Emotional indicators, 8 in Personal Habits indicators and 13 in Academic Indicators. Sample size selected was 73 in total from Manav Rachna University (India) and 42 from Qatar University (Qatar).

3. RESULT AND CONCLUSION : Stress is a response to any event which is perceived to alter or threaten our well-being and is a cognitive thought process. It is the body's reaction to a change that requires a physical, mental or emotional response (Dr.Balakishan et al)[5]. The high prevalence of depression, anxiety and stress symptoms among University students is alarming. The important result of our study on perceived stress shows that in Indian University, stress is mainly induced through academic sources during their study time, while in Qatar University, stress is induced mainly from emotional factors, sleep factors and personal habit factors. There is an agreement in the results so obtained with the review of studies done by Tamar Jacob etal.[18]

Stress, Likert scale, depression, anxiety

Dr Anjana Goyal, PhD* , Taniya Malhotra**

* Reader, Dept of Biochemistry, Manav Rachna Dental College, Faridabad

** Student, Manav Rachna Dental College, Faridabad

?Study has dwelt on the differences and comparisons in perceived stress among the students of professional courses.

?Study identified the difference in stressors of Indian and Qatar University students

Introduction commitment to their professional education and achievement. Although some stress is expected in The term stress was firstly employed in the 1930's by the college and it can be a motivation to study and learn. endocrinologist Hans Selye [7]. Stress is a complex,

dynamic process of interaction between a person and Too much stress however, can deter learning (Le Blanc his or her life (Abhay B et 2011) [13]. It is the war one VR 2009)[10]. This type of stress which is experienced reacts physically, mentally and emotionally to the by students may adversely affect their academic various conditions (Gyan M 2004)[6]. achievement, personal well-being and long-term The stress in Undergraduate students have many professional capabilities. It can lead to mental distress sources which include academics, personal situations, and can have negative impact on their cognitive environment, time management and economic functioning and learning (Dahlin M etal 2005)[4]. When circumstances (Abhay et al 2015)[13]. stress is perceived negatively or becomes excessive,

students experience physical and psychological In a study by Janet, 1994 [9], a majority of students felt impairment (Murphy and Archer, 1996)[15]. that the stress they experienced strengthened their

PREVALENCE AND SOCIO-DEMOGRAPHIC CORRELATION OF STRESS AMONG INDIAN AND QATAR UNIVERSITY STUDENTS PURSUING PROFESSIONAL COURSES

Dental Lamina - Journal of Dental Sciences Vol. 3 No. 2, Dec. 2015

Methods to reduce stress by students often include A. Health- included sweating, chronic back pain, effective time management, social support, positive chronic headache, depression, migraine, stomach reappraisal and engagement in leisure pursuits (Blake upset, lack of physical energy,irregularity of and Vandier 1988[2], Mattlin, Wethington & Kessler, menstrual cycle (only females).1990[14]) B. Sleep-these included nightmares, tiredness due to Previous studies have also shown that high levels of insomnia etc.stress are observed in students studying professional C. Emotional factor- these included sensitivity, courses (Sajjan K et al 2005[16], Leisa L et al 2008[11], irritability, offensiveness, temper outburst etc.Beck et al 1997[1], Heins M et al 1984[8], Pau A et al

D. Personal habits- these included lack of feeling of 2007[19]). Several methods have been used to study the trust, reading habits, communication skills, stress in college students. Cohen and colleagues:1983[3] friendship etc.developed the original 14-item English version of the

E. Academic: - goal misplacing, dissatisfaction, lack perceived stress scale PSS -14 as a global measure of of confidence, distraction from work, difficulty stress.in making situations, language problem etc.Objective of this study is to summarize the systematic

To validate these attributes, students of various review of stressors in students pursuing professional disciplines were asked to fill the questionnaire consisting courses in an Indian University i.e Manav Rachna

University and Qatar University that included: of 8 attributes in health, 3 in sleep, 4 in emotional, 8 in

personal habits and 13 in academic indicators. Each item 1. The stress levels in students studying professional of the attribute is scaled on Likert scale of 1-5 scale. (1- courses in these countries;Being the lowest and 5 being the highest)2. Various academic, social, personal and emotional

factors responsible for inducing stress The ratings given by respondents were evaluated in

terms of the scores made by them and the score of 3 and 3. Implications of stress among these studentsabove was considered to the main contributing factor of

stress in that attribute. This data was normalized and The random sample consisted of 73 fulltime

then compared using bars and line charts among Undergraduate students of Manav Rachna University

students in various streams of MR University (India) doing professional courses of dental, nutrition and

and Qatar University, (Qatar). The data was analyzed physiotherapy and 42 undergraduate students of Qatar separately for male and female students.University studying Biotechnology, medicine, nursing

etc. Information was collected using a self administered, voluntary questionnaire. Each item of the attribute is The findings of this study demonstrated that there were scaled on Likert scale of 1-5 scale using the following differences in the way that students from various keys. professional courses perceived stress. The level of stress 5. Almost always varied between the students of different courses,

4. Most of the time universities and countries. The stress levels and reasons

have been mentioned against each of the categories 3. Sometimesseparately for males and females.2. Almost never

1. NeverStress EvaluationFollowing tools were used for study purpose :-Stress was evaluated and high level was determined by 1. Personal data :-students marking Likert Scale equal to or greater than 3.

This section includes general information and specific Percentage of students with high level of stress was

information concerning gender, age, dietary habits, identified.

biochemical indicators like B.Sugar, Pulse, blood group, Table -1 AHb, weight, family history etc.

Comparison of female students stream and country 2. Stress inducing factors :-wise having health issues in terms of percentage Questionnaire was used to determine the stress Comparison of females students stream-wise- inducing factors perceived as stress. These were divided health issues (all fig in %age)into 5 groups indicating various attributes:

Methodology and Tools used in the Study

Discussion

Observations and Results


of physical exercise, which affects their physical fitness. This could be due to the pressure of studies.

In case of Qatar female and male students, they are mostly stressed in all attributes of health mainly for the following reasons:

1. Demographic conditions- Qatar is largely desert and Graph :due to the fast growing economy, females and males do sit in air-conditioned environment ignoring health problems.

2. Obesity - Most of them are non-vegetarian (>60 %) and do very little work. According to the International Association for the Study of Obesity, Qatar has the 6th highest rate of obesity among boys in the Middle East and North Africa region. (Source-Wipipedia)

3. Diabetes - Due to their comfortable life style, it is Table -1 B observed that 27 % of our sample were diabetic,

having sugar level more than 128 mg %.Comparison of male students stream and country wise having health issues in terms of percentage 4. Consanguinity in marriages- .Practices that include

inter-marriage between close family members and Comparison of males students streamwise- health cousins, which leads to health problems in Qatar issues (all figs in %age)population.

Table -2 A

Comparison of female students stream and country wise having sleep issues in terms of percentage

Graph :Comparison of females students streamwise- Sleep issues

Graph :

From the above Table 1A and its graph, it is clear BDS and BPT students are far more stressed in terms of their health issues primarily due to lack of time for physical fitness, back pain and headache. It appears that back pain and headache persists due to long studying hours. Nutrition students are less stressed probably because they are more conscious towards health and fitness and give full attention to their dietary habits. In short, stress is a fact of life for students of BDS and BPT and needs to be addressed at large.

Table -2 BIt may be mentioned from Table 1B and its graph that

Comparison of male students stream and country wise there is no male student in 1st year of nutrition having sleep issues in terms of percentage discipline, hence in comparison they are not figuring. Comparison of males students streamwise- Sleep issuesBDS and BPT male students remain stressed due to lack

Findings

sweaty palm Backpain Headace Stomache energy_lack lack nutrition lack exercise Irregular mc

Comparison of females students streamwise - health issues100

90

80

70

60

50

40

30

20

10

0

BPT (India) N&D (India) BDS (India) Qatar (UAE)

8

sweaty palm

Back-pain

Head-ace

Stom-ache

Energy-lack

lack nutrition

lack exercise

Irregular mc

BPT (India) 29.2 37.5 62.5 33.3 20.8 45.8 50 33.3N&D (India) 15.8 15.8 26.3 21.1 31.6 47.4 31.6 10.5BDS (India) 40 80 80 20 26.7 66.7 86.7 6.7Qatar (UAE) 66.3 50 63.3 46.7 56.7 56.7 76.7 63.3

sweaty palm

Back-pain

Head-ace

Stom-ache

energy lack

lack nutrition

lack exercise

Irregular mc

BPT (India) 20 20 40 40 0 20 60 0

N&D (India) 0 0 0 0 0 0 0 0

BDS (India) 20 40 50 20 20 60 60 0

Qatar (UAE) 66.7 33.3 50 33.3 91.7 50 66.7 0

sweaty palm Backpain Headace Stomache energy_lack lack nutrition lack exercise Irregular mc

Comparison of males students streamwise - health issues100

90

80

70

60

50

40

30

20

10

0


(all figs in %age)

NightmaresDisturbed sleep

Tired postsleep

BPT (India) 25 37.5 29.2

N&D (India) 10.5 36.8 10.5

BDS (India) 20 40 86.7

Qatar (UAE) 56.7 76.7 76.7

Comparison of females students streamwise - Sleep issues

250

200

150

100

50

0Nightmares Disturbed sleep Tired postsleep



Table -3B

Comparison of male students stream and country wise having emotional issues in terms of percentage

Comparison of males students stream-wise- Graph :Emotional issues

Graph :

It may be mentioned that male and females BDS and BPT students feel tired even after sleep causing stress in them. This may be attributed due to stress prevailing in their mind for studies.

In case of Qatar students, it is seen that they are highly stressed due to repeated nightmares, bad dreams, disturbed sleep and feel tired even after having sleep.

Table -4 AMain reason may be due to lack of physical exercise, Comparison of female students stream and country food habits and comfortable life style. wise having personal habit issues in terms of percentage Table -3AComparison of females students stream wise- Comparison of female students stream and country personal habit issues (all figs in %age)wise having emotional issues in terms of percentage

Comparison of females students streamwise- Emotional issues

Graph :

Graph :

Table -4 B

Comparison of male students stream and country wise having personal habit issues in terms of percentage

Comparison of females students stream wise- personal habit issues (all figs in %age)

Findings

Findings

9

(all figs in %age)

NightmaresDisturbed sleep

Tired postsleep

BPT (India) 0 40 40

N&D (India) 0 0 0

BDS (India) 10 10 50

Qatar (UAE) 75 83.3 91.7

200180160140120100806040200


Nightmares Disturbed sleep Tired postsleep

Comparison of males students streamwise - Sleep issues

(all figs in %age)

Highly sensitive

Feel offended Outburst Frustration

BPT (India) 62.5 29.2 50 25N&D (India) 21.1 21.1 36.8 31.6

BDS (India) 86.7 33.3 66.7 20Qatar (UAE) 66.3 66.3 60 70

100

90

80

70

60

50

40

30

20

10

0Highly sensitive Feel offended Outburst Frustration


Comparison of females students streamwise - Emotional issues

(all figs in %age)

Highly sensitive

Feel offended Outburst Frustration

BPT (India) 20 20 40 20N&D (India) 0 0 0 0

BDS (India) 60 20 10 20Qatar (UAE) 75 75 91.7 66.7

100

90

80

70

60

50

40

30

20

10

0Highly sensitive Feel offended Outburst Frustration


Comparison of males students streamwise - Emotional issues

H1 H2 H3 H4 H5 H6 H7 H8

BPT (India) 50 33.3 33.3 62.5 62.5 58.3 62.5 33.3N&D (India) 31.6 15.8 31.6 31.6 36.8 42.1 31.6 21.1BDS (India) 40 60 86.7 53.3 93.3 53.3 93.3 40Qatar (UAE) 56.7 46.7 50 53.3 46.7 40 53.3 36.7

H1 H2 H3 H4 H5 H6 H7 H8

1009080706050403020100


Comparison of females students streamwise - personal habit issues


10

3B, 4A and 4B) and associated graphs, Qatar students

both males and females are quite sensitive and

irritable, sometimes feel offended and show

temperament outburst. These stressors may be due Graph :to their ignorance of health related problems like

obesity, diabetes, and comfortable life style and food

habits.

Table -5 A

Comparison of female students stream and country wise having academics issues in terms of percentage

Comparison of females students streamwise for stress- academic

Graph :

a) Emotional and personal habits for females in Indian

University- It is seen from above Tables (3A and 4A)

and associated graphs, that female BDS students are

more stressed in having smooth communication

with their peers and thus find difficulty in

understanding their friends. Their behavior is

somewhat sensitive and irritable. On the other hand, From the graph, it is seen that dental female students

female students of BPT have the major problem of have following areas of stress:

having developed a feel ing that others a) Dissatisfaction of workmisunderstand them and do not try to understand

them. b) Lack of confidence

b) Emotional and personal habits for males in Indian c) Decision taking problemUniversity-It is seen from above Tables (3B and 4B) d) Remembering/retention problemand associated graphs, that there are no male student

e) A lot of worryin nutrition discipline, hence in comparison they are

The reason for this stress in females may be due to not figuring. BDS and BPT male students remain exposure to basic medical subjects, which has vast area stressed due to lack of physical exercise, which to learn and understand in such a short period of time. affects their physical fitness. This could be due to the Dissatisfaction of work may be due to their exposure in pressure of academics and lack time for doing other pre-clinical work exposure.physical activities. Male BDS students are more

stressed in smoother communication with their BPT have the following areas of stress

peers and thus find difficulty in understanding their a) Decision taking problemfriends. They also devote less time in reading

b) Dissatisfaction from worknewspaper. BDS students are emotionally more

c) Less determination towards goalsensitive and irritable than students of other streams.

On the other hand, male students of BPT are TV Reasons could possibly be the same as that of BDS

savvy and thus communicate less with their peers. students.

c) Emotional and personal habits for males/females in Nutrition and Dietetics female students, however feel that subjects are not very interesting. Qatar University- It is seen from above Tables (3A,

Findings

Findings

H1 H2 H3 H4 H5 H6 H7 H8

BPT (India) 40 60 20 60 40 60 40 20N&D (India) 0 0 0 0 0 0 0 0BDS (India) 50 50 90 40 80 10 80 30Qatar (UAE) 58.3 58.3 66.7 58.3 33.3 75 75 50

H1 H2 H3 H4 H5 H6 H7 H8

1009080706050403020100


Comparison of males students streamwise - personal habit issues

H1 Spend less time for hobbiesH2 Spend less time for peersH3 Complex during communicationH4 TV savvyH5 Less inclination for reading newspaperH6 Trust problemH7 Issues of others’ Understanding H8 Issue of low Self esteem

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13

BPT (India) 54.2 33.3 29.2 54.2 58.3 70.8 41.7 12.5 29.2 37.5 29.2 50 70.8N&D (India) 42.1 31.6 21.1 36.8 31.6 68.4 63.2 15.8 21.1 31.6 31.6 52.6 57.9BDS (India) 60 40 86.7 86.7 86.7 100 46.7 26.7 66.7 40 93.3 60 93.3Qatar (UAE) 53.3 36.7 46.7 50 53.3 63.3 40 36.7 33.3 33.3 53.3 43.3 63.3

Comparison of females students streamwise for stress - academic


120

100

80

60

40

20

0A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13


Table -5B retention of subject, get nervous to face problems and worry a lot.Comparison of male students stream and country wise

having academics issues in terms of percentage Academic stress in male and female students of Qatar University - It is seen from the Tables (5A and 5 Comparison of males students streamwise for B) and associated graphs that students in general are less stress- academic stressed in academic issues, which may be due to following:

a) Less population,

b) Growing economy due to oil rich nation,

c) Demographic conditions and Graph : d) Non-competitive environment for studies.

The important result of our study shows that Academic

Stress in all professional courses in MR University, India

is higher in comparison to Qatar University. The

students in Qatar are less stressed of academic issues,

which may be due to their less population, growing

economy being oil rich nation, demographic conditions

and non-competitive environment for studies. In

January 2013, the Qatar Statistics Authority estimated

the country's population at 1,903,447, of which

1,405,164 were males and 498,283 females and had the

highest per capita income in the world (Information as

per Wikipedia, Qatar).

At the same time, when academic stress is seen in all the

streams of MR University of India, it is observed that it

is significantly higher among Dental students as

compared to other streams. The high prevalence of As seen from above, male BDS students have the stress among Dental students is obvious and alarming. following problems : There is an agreement in the results so obtained with the

review of studies done on medicine students. Llyod et a) Lack of confidenceal[12] and Sindhu Jagmohini[17] in their systematic b) Decision taking abilityreview which reported that medical students experience

c) Trouble remembering thingshigh level of anxiety and depression.

d) Worry a lotWhile comparing other stress factors, it is observed that

e) Escape from problems health, sleep and emotional factors are significantly

higher and alarming among Qatar university students as The reason for this stress in males may be due to compared to Indian professional students. This is exposure to basic medical subjects, which has vast area

to learn and understand in such a short period of time. mainly due to exceedingly high rates of obesity, diabetes

Dissatisfaction of work may be due to their exposure in and genetic disorders. pre-clinical work exposure. According to the International Association for the BPT have the following areas of stress Study of Obesity, Qatar has the 6th highest rate of

obesity among boys in the Middle East and North a) Less time to work on goalAfrica region. As of 2013, 16% of the adult population

b) Decision taking problemin Qatar have been diagnosed with diabetes and this is

c) Dissatisfaction from work pushing up rates of related illnesses and complications, d) Forget repeatedly their goals like hypertension, blindness, partial paralysis, heart

disease, and loss of productivity.Qatar ranked 16th Reasons could possibly be the same as that of BDS globally for the number of birth defects per 1,000 students. However they have moderate problems in

Conclusion

Findings

11

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13

BPT (India) 40 40 20 20 60 60 60 40 20 20 60 60 20N&D (India) 0 0 0 0 0 0 0 0 0 0 0 0 0BDS (India) 60 40 50 80 60 90 30 20 30 20 80 30 90Qatar (UAE) 33.3 41.7 50 50 58.3 41.7 58.3 58.3 58.3 41.7 66.7 66.7 33.3

Comparison of males students streamwise for stress - academic


100908070605040302010

0A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13

A1 Spend less time to achieve goal

A2 Habit of forgetting goalA3 Dissatisfaction from workA4 Lack of confidence

A5 Follow escape philosophy A6 Decision taking problem

A7 Subjects not in accordance to taste

A8 Command on language

A9 Very pessimist about his future

A10 Tired and disinterested from life

A11 Remembering problems

A12 Getting frightened on seeing the problems

A13 A lot of worry


12

births; this is due to the high degree of consanguinity in 9. Janet

marriages. (Wikipedia information of Qatar) The perceived stressors and the coping strategies among occupational therapy students: AJ OT 1994; It can be concluded from above that for Indian students 48(11) : 1022-27pursuing professional courses, there is a need for

intervention of primary and secondary prevention 10. Le Blanc VRmeasures for stress alleviation particularly in academics, The effect of acute stress on Performance: along with the development of adequate and implications on the health professionals education appropriate support services at all levels. In Qatar, Acad Med 2009: 84: 25-33students should primarily focus more on intervention

11. Leisa L, Amy Allison MLS, Diane N , Lanke S.such as physical fitness programs, food habits and health

American Journal of Pharmaceutical education services. 72(6):1 8:2008

12. Lloyd C, Musser LA1. Beck DL, Hacket MB, Srivastava R, Mckim E,

Psychiatric symptoms in dental students. J Rockwell B

NervMent Dis 1989;177(2):61-9The perceived stress levels and the sources of stress

13. Mane Abhay B. Krishna kumar MK, Niranjan in University professional schools. J.Nurs.

Paul C, Hiremath Shashidhar GEdu.1997;36: 180-186

Professional students, perceived stress scale, coping 2. Blake, R.L, &Vandiver, T.A. strategies, psychological support: J of clinical and

The association of health with stressful life changes, diagnostic research 2011 Nov (cited; 2015 Aug 14); social support and coping. Family practice research 5:1228-1233journal,7(4),205 -218:1988 14. Mattin,J.A,Wethington, E & Kessler,R.C

3. Cohen S, Kamark T, Memmeistein R : Situational determinants of coping effectiveness. J. of Health and social behavior, 31(1), 103-122:1990A global measure of perceived stress. Journal of

Health Soc Behav 1983; 24:385-96 15. Murphy, M.C. & Archer

4. Dahlin M, Joneborg N, Runeson B Stressors on the college campus; a comparison of 1985-1993. Journal of col lege student Stress and Depression among medical students; a development, 37(1), 20-28:1996.cross-sectional study. Med.Educ 2005;39;594-604

16. Sajjan K,Jejurkar K 5. Dr.Balkishan Sharma , Dr.Rajskekhar Wavare J

A study on the stress level in occupational therapy Academic stress due to depression among medical students during their academic curriculum. The and paramedical students in an Indian medical Indian JOURNAL of occupational therapy 2005; college; Journal of Health Sciences 2013:3(5)37(1):11-14

6. Gyan M. 17. Sindhu Jagmohini Kaur

A study on perceived stress, its impact and the Effect of stress on medical students; IeJSME coping strategies.2007;1(1);52-53

The International Journal of interdisciplinary social 18. Tamar Jacob, Christina Gummerson, Eva

sciences: 2(4);325-334Nordmark, Doa El-ansary, Louisa

7. Hans SelyeRemedies and Gillian Webb: Journal of physical

The stresses of life; MC Graw Hill, New York :523- therapy education; vol.26 no.3; 2012567,1956

19. Pau A, Rowland M,Sudeshni N, Abdul Kadir R.8. Heins M, Fahey SN, Leiden LI

Emotional intelligence and perceived stress in Perceived stress in medical, law and graduate dental undergraduate; a multinational survey: students: J Med Educ.1984; 59:169-179 Critical Issues Dent Educ.2007:71:197-204

References


13

Abstract :

Keywords :

The single complete denture is a complex prosthesis that requires a complete understanding of the basics of prosthetic rehabilitation of lost natural dentition. Several difficulties are encountered in providing a successful, single complete denture treatment. This case report deals with the successful rehabilitation of completely edentulous maxillary arch accompanied by flabby ridge opposing natural teeth by incorporating metal meshwork in denture base to combat the masticatory forces from natural dentition.

Single complete denture, Flabby ridge, Hobkirk's Technique, Yurkstas Technique.

Dr. Mukti Goel*; Dr. Pankaj Dhawan, MDS**; Dr. Pankaj Madhukar, MDS***; Dr. Shivam Singh Tomar, MDS****

*Post Graduate Student, Department of Prosthodontics, MRDC

**Prof & Head, Department of Prosthodontics, MRDC

***Professor, Department of Prosthodontics, MRDC

****Senior Lecturer, Department of Prosthodontics, MRDC

Introduction Preservation of That What Remains Rather Than 3

Meticulous Replacement Of What Has Been Lost." The situation in which a patient has become entirely This is especially true in terms of single complete edentulous in one jaw while retaining either all or some

1 dentures opposing natural dentition. The diagnostic and of his natural teeth in the other jaw is not uncommon. technical ingenuity of the dentist is challenged in The challenge to provide comfort, retention, function, providing an adequate diagnosis, prognosis, and a long-and esthetics for the patient with edentulous maxilla range treatment plan for patients. Success of complete opposing natural teeth is often difficult. Numerous denture depends on many variables, but three factors problems like lack of retention, tissue changes of the stand out in terms of functional success: retention, edentulous ridge accompanied by discomfort, fracture

4stability and support. Occlusal problems and denture-of the maxillary denture base, the need for readjustment base fracture seen in these dentures are the result of one of tongue movements for speech and mastication, or all of the following reasons: occlusal stress on reorientation of the lips and cheeks for functional maxillary denture and underlying edentulous tissue movements, and the inevitable appearance changes, from teeth and musculature accustomed to opposing results in frustration and disappointment for the patient

2 natural teeth, the position of the mandibular teeth and the dentist.which may not be properly aligned for the bilateral balance needed for stability and finally the flexure of denture base.

Fig. 1 : Pre-operative photograph

The main objective of any prosthetic treatment should Fig. 2 : Window preparation in the maxillary flabby be based on De Van's statement that "Perpetual ridge region (Hobkirk's Technique)

PROSTHODONTIC MANAGEMENT OF SINGLE COMPLETE MAXILLARY DENTURE ACCOMPANIED

BY FLABBY RIDGE - A CASE REPORT


14

Fig. 3 : Final Maxillary Impression made with Hobkirk's Technique

Fig. 6 : Teeth Arrangement

Class 2 - Patients for whom minor additions to the height of the teeth are needed to obtain balance.

Class 3 - Patients for whom both reductions and additions to teeth are required to obtain balance. The treatment of these patients usually involves a change in vertical dimension of occlusion.

Fig. 4 : Evaluation of occlusal plane using Yurkstas Class 4 - Patients who present with occlusal Technique discrepancies that require addition to the This case report describes step by step fabrication of width of the occlusing surface.maxillary single complete denture in a patient with Class 5 - Patients who present with combination

[7]flabby ridge (hypermobile tissue) anteriorly using syndrome 1 5

Yurkstas and Hobkirk's technique respectively for the successful outcome of the treatment.

Fig. 7 : Metal meshwork embedded in the maxillary denture

A 58 year old male patient reported to the Department Fig. 5 : Evaluation of occlusal plane after occlusal of Prosthodontics, Manav Rachna Dental College, correction Faridabad with the chief complaint of repeated fracture

6The Glossary of Prosthodontic Terms defines Single of maxillary denture and for replacing the missing lower Denture Consturuction as the making of a maxillary or anterior teeth. Past medical history revealed that patient mandibular denture as distinguished from a set of was diabetic since 1 year and was on medication for the complete dentures. same. Past dental history revealed that he had

4Classification of Single Complete Dentures: undergone extractions of his lower anterior teeth a year ago due to chronic periodontitis. Intraoral examination Class 1 - Patients for whom minor, or no, tooth revealed that his maxillary arch was edentulous and reduction is all that is needed to obtain mandibular arch was having posterior teeth and missing balance.

Case Report


anteriors i.e. 31, 32, 41, 42. (Fig. 1) All treatment selected and arranged in centric occlusion. The denture modalities were discussed with the patient and due to try-in was carried out and patient's consent was low socio-economic status, surgical management and obtained. The conventional procedures of flasking, implant prosthetic options were discarded. Keeping all dewaxing were performed. During the packing stage, a these concerns in mind, the treatment plan decided was metal meshwork was incorporated in the maxillary to provide him with single complete denture for denture base. (Fig 7) Then curing, finishing and maxillary edentulous arch with embedded meshwork polishing of the dentures were carried out.(Fig 8) and removable partial denture for the missing Dentures were inserted and delivered to the patient. (Fig mandibular anteriors. 9) Post insertion instructions were given to the patient.

According to the Classification of Single Complete Dentures, the patient was categorized as Class 1 patient in whom minor, or no, tooth reduction is all that is needed to obtain balance.

Thorough examination of the oral cavity was done. The patient was completely edentulous with an extensive area of flabby ridge on the maxillary anterior region. Radiographic evaluation showed good prognosis for mandibular teeth. Oral prophylactic procedure was Fig. 8 : Cured and Polished denturesperformed. Diagnostic casts were made and examined carefully to identify malposed or supraerupted teeth.

Prosthodontic management of a patient with a flabby

maxillary ridge can be challenging problem and taking The primary impression of maxillary denture bearing care to consider the influence of both the impression area was made with alginate (Zelgan, Dentsply, India) to surface and occlusal surface detail is paramount.

85ensure minimal distortion of the displaceable tissues. Hobkirk's technique was used to make final

Mandibular arch was also recorded with alginate. The impression of the maxillary flabby ridge as standard impressions were poured in dental stone (Kalstone, mucocompressive impression techniques are likely to India). A special tray was fabricated with auto- result in an unretentive and unstable denture as the polymerizing acrylic resin (DPI-RR Cold Cure). Border denture constructed on a model of the flabby tissue in a molding was done with green stick compound distorted state. The use of selective pressure or

(Pinnacle, DPI, India). An impression of maxillary minimally displacive impression techniques should help

to overcome some of these limitations. The use of edentulous arch was made with the Hobkirk's window 5 holes, windows and wax relieve reduces the hydraulic technique using a combination of medium and light

pressure and minimize the displacement of the bearing bodied silicone material.(Fig 2, Fig 3) Impressions were tissues. poured in dental stone (Kalstone, India). Master casts

were obtained and modified to a more acceptable One of the most common clinical situations involving a 1 single denture is that of a complete upper denture and occlusal relationship according to Yurkstas technique

lower natural teeth. When a complete denture is which uses a metallic U-shaped occlusal template on opposed by natural teeth, it will almost always require the occlusal surfaces of the mandibular cast to identify some degree of contouring to provide a harmonius the cusps to be adjusted.( Fig 4, Fig 5) The cast was then occlusion. used as a guide for modifying the natural teeth. Judicious

The reasons for such alteration is mainly due to: grinding of the natural teeth was done in mouth.

(1) Unfavourable inclination of the occlusal planeOcclusal rims on the maxillary and mandibular denture base were constructed and contoured for adequate lip (2) malpositioned individual teeth which have assumed support in the anterior region to simulate the vertical positions resulting excessively steep cuspal inclinations, and horizontal overlap of the anterior teeth. The vertical and dimension of occlusion was established. Face bow 9(3) too wide buccolingual width of the natural teeth. transfer was made followed by recording of jaw relation

Maxillary denture bases may encounter tissue changes which was secured in a semi-adjustable articulator for of the residual ridge followed by discomfort, occlusal teeth arrangement. (Fig 6) The artificial teeth were

Prerequisite Treatment

Discussion

Procedure


16

problems and fracture of denture bases. The improperly treatment. Achieving this desirable characteristic is

aligned mandibular teeth may also avoid achievement of usually much more difficult than arranging artificial

bilateral balance for stability and results in flexure of the teeth for opposing complete dentures. Due to 2 biomechanical differences in the supporting tissues for denture bases. The midline fracture in a denture is often

opposing arches the patient requiring single denture a result of flexural fatigue. Occlusal correction by [1] opposing a natural or restored dentition faces a Yurkstas technique provides stability and decreases

challenging job for the dentist. Thus the treatment the chances of fracture due to these stresses. Though planning and the prosthesis to be given should be Polymethyl Methacrylate (PMMA) denture bases have evaluated and corrected to provide a stable functional good mechanical, biological and esthetic properties, the relationship. Therefore, controlling the resorption and impact and fatigue strength of PMMA are not entirely discomfort to the patient. satisfactory, thus may fail when there is excessive

10,11parafunctional and/or functional forces. Metal

meshwork embedded in maxillary denture reduces 1. Sharry JJ. Complete Denture Prosthodontics. Vol functional deformation and thrust to the supporting 3rd Ed. New York: McGraw-Hill; 1974.tissues, thus making the dentures less prone to fractures. 2. Koper A. The maxillary complete denture opposing It improves the longevity of the prosthetic natural teeth?: Problems and some solutions. J rehabilitation, at the same time improving the strength Prosthet Dent. 1987;57(6):704-707.of the maxillary denture base and preventing the

3. Zarb GA, Bolender CL, Hickey JC CG. Boucher's resorption of the underlying residual maxillary ridge.

Prosthetic Treatment for Edentulous Patients. Vol

11th Ed. St. Louis: CV Mosby; 1990.

4. Driscoll CF, Masri RM. Single maxillary complete

denture. Dent Clin N Am. 2004;48:567-583.

5. Hobkirk JA. Complete Denturesda Dental

Practitioner Hand Book. Bristol: Wright; 1986.

6. The Glossary Of Prostodontic Terms. J Prosthet

Dent. 2005;94(1):10-92.

7. Kelly E. Changes caused by a mandibular

removable partial denture opposing a maxillary

complete denture. J Prosthet Dent. 1972;27(2):140-

150.

8. Sabarigirinathan C, Vinayagavel K, Rupkumar P, et al.

Making the Unstable Stable-A Case Series of Fig. 9 : Post-operative photograph Management of the Flabby Ridge. 2015;14(6):67-71.

Other techniques to modify the existing occlusal pattern 9. Ellinger CW, Henderson D. Single Complete prior to denture construction represented in literature dentures. J Prosthet Dent. 1971;26(1):4-10.are: 10. Ohkubo C, Kurtz KS SY. Comparative study of

31) Swenson's technique maxillary complete dentures constructed of metal

base and metal structure framework. J Oral Rehabil. 2) Bruce method2001;28:149-156.3) Boucher's method

12 11. Schneider RL, Stokes JL LD. Design and fabrication 4) L. Kirk Gardener's techniquetechnique for metal palates in maxillary complete

135) Han Kuang Tan's technique dentures. J Dent Technol. 2000;17(7):8-11.6) The use of Broadrick's flag 12. L. Kirk Gardener et al. Using a tooth reduction All the techniques for single denture construction are guide for modifying natural teeth. J Prosthet Dent. aimed to provide a harmonius occlusion. 1990;63(6):637-639.

13. Han Kuang Tan. Prepartion guide for modifying the

mandibular teeth before making a maxillary single The development of a harmonious occlusion is most complete denture. J Prosthet Dent. 1997;77:321-322. critical to the success of a single complete denture

References

Summary and Conclusion


17

Abstract

Keywords :

Parkinson's disease is an idiopathic, slowly progressive disorder of the central nervous system characterized by resting tremor, muscular rigidity, slow and decreased movement (bradykinesia), and postural instability. The Prosthodontist has a large role in geriatric health care and care of elder population with associated physical and neurological diseases. Parkinson's disease is usually seen in adults in their middle and late ages. Tremors caused by Parkinson's disease can make dental appointments a challenge. This clinical report presents a case of a Parkinson's patient who was completely rehabilitated in four appointments using snapfit buttons.

Parkinson's disease, Complete Denture Prosthesis, Snapfit buttons, Detachable handles and Monoplane teeth

Dr. Sugandha Gupta*, Dr. Pankaj Dhawan, MDS**, Dr. Pankaj Madhukar, MDS***, Dr. Piyush Tandan, MDS***

*Post graduate student, Department of Prosthodontics, MRDC

** Prof & Head, Department of Prosthodontics, MRDC

*** Professor, Department of Prosthodontics, MRDC

**** Associate Professor, Department of Prosthodontics, MRDC

Introduction Previous attempts have been done on the fabrication of complete denture for patients suffering from Parkinson's disease is seen in adults in their late middle

4-8Parkinson's disease. The prosthetic rehabilitation in or old age. The affected patients have uncontrolled these cases involved mandibular implant supported movements of the body along with stiffness of

1 overdenture. The main drawback of implants is its cost. muscles. This disease affecting day to day life was 1 The Parkinson's patient who belongs to a poor socio-described first by James Parkinson in 1817 as a

economic status refused to undergo expensive degenerative disorder caused by depletion of treatment procedure and hence it was decided to neurotransmitters, dopamine and nor-epinephrine in fabricate a denture which is simple and cost-effective. basal ganglion. Parkinson's disease is characterized by This clinical report describes the fabrication of degeneration of dopaminergic neurons of the complete denture for a patient suffering from substantia nigra, locus caeruleus, and other brain stem Parkinson's disease in an affordable manner with dopaminergic cell groups. The loss of substantia nigra minimal number of visits.neurons results in depletion of the neurotransmitter

dopamine in the caudate nucleus and putamen of the 2striatum. To provide competent care to these patients,

prosthodontist must understand the disease and its impact on the patient's ability to respond to dental care. Prosthodontic procedures become difficult to perform and require special care and attention. As Parkinson Disease progresses, the face becomes masklike, with the mouth always open, and the patient may have diminished blinking. Patients may experience difficulty swallowing and tend to drool. Speech becomes slurred, monotonous, stuttering, and soft (hypophonia). This secondary effect is due to rigidity and hypokinesia of the

3muscles involved in speech production. Moreover, the patient cannot visit the dentist several times due to

Fig. 1 : Mask like appearance of faceexisting medical condition.

PROSTHODONTIC MANAGEMENT OF A PATIENT SUFFERING FROM PARKINSONISM - A CASE REPORT


18

Fig. 2 : Stare gaze of the patient

A 65-year-old female patient reported to Department of Fig. 4 : Primary casts poured in type II dental stone

Prosthodontics, Manav Rachna Dental College,

Faridabad with complaint of difficulty in eating food due

to an ill-fitting partial denture. The patient was looking for

complete oral heath check followed by full mouth

rehabilitation. Medical history of the patient revealed that

she was suffering from Parkinson's disease since 10 years.

Patient was on Levodopa from last 10 years. Signs and

symptoms observed included difficulty to stand and walk

and stiffness of the joint and muscles with limited Fig. 5 : Custom tray with detachable handles. movements. Extraoral examination revealed a Mask-like 5. After setting, the handles were separated from the face (Fig 1), fixed gaze (Fig 2) and reduced blink rate. tray and occlusal rims were fabricated on it. Now the Examination of neuromuscular co-ordination elicited maxillary and mandibular custom trays were ready jerky movements of mandible and intraoral for making impressions with the detachable handles examination revealed completely edentulous arches and occlusal rims, depending on the procedure. (Fig 6)

with reduced salivary flow.

First appointment

1. On the first day, primary impressions were recorded using impression compound and the primary cast Fig. 6 : Wax occlusal rims incorporated with snap fit was obtained. ( Fig 3 and Fig 4) buttons

Second appointment

6. On the second appointment, with the handles attached, border molding was done using green stick compound.

7. Now the handles were removed and occlusal rims were attached and vertical and centric jaw relation records were established in a conventional manner. Facebow transfer and Gothic arch tracings cannot be recorded due to the medical condition of the patient.

8. The final impression was made with zinc oxide Fig. 3 : Primary impression of edentulous arch with eugenol with handles reattached. (Fig 7)impression compound

2. The autopolymerizing acrylic resin was mixed and adapted on the primary cast to make a custom tray.

3. Before the acrylic resin set, the sleeve of one snapfit button was inserted in the anterior region and two in the posterior region. (Fig 5)

4. Now the other part of the snap fit button was Fig :7 : Final impression of edentulous arches made in placed on the anterior region and handles were ZOE pastemade.

Case Report

Clinical Steps


19

9. After the final impression, both occlusal rims were Third appointment

reattached and sealed at the established vertical and 1. Try in was done and trial dentures were checked in centric relation. (Fig 8) the patient's mouth for border extensions, vertical

dimension, phonetics, esthetics, occlusion and midline.

2. Wax-up and carving was done followed by dewaxing, packing, curing and finishing in conventional manner.

Fourth appointment

3. Cured and polished dentures were delivered to the patient.(Fig 11, Fig 12)

The patient was thoroughly educated and instructed Fig. 8 : Final impression and Jaw relation done in a regarding the use of the prosthesis. Postinsertion and single appointment oral hygiene instructions were imparted and routine

follow up appointments were scheduled. 10. Custom tray and final impressions from occlusal

rims were separated and handles reattached and

impressions were poured in type III dental stone.

(Fig 9)

Fig. 11 : Finished polished denture Fig. 9 : Final casts poured in type III dental stone

11. Occlusal rims were reattached and measurements

of the proper position of buttons and height of the

rims noted to avoid any error in placing buttons on

denture bases.

12. Mounting was done.

13. Denture bases were fabricated in the conventional

manner but at the same time placing sleeves of

buttons on it before setting. Position of the buttons

can be verified by the rims as well as measurements

taken before. Fig. 12 : Relaxed and satisfied patient post denture

14. Now the rims were reattached on the new sleeves and insertionteeth arrangement was done using monoplane teeth because of poor neuromuscular control. (Fig 10)

Geriatric health care is a critical part of health care systems around the world due to the rapidly increasing elderly population. Prosthodontist plays an important role in geriatric health care and can contribute significantly in restoring the quality of life in elderly patients. Several diseases of the aged population are neurological disorders. Symptoms of Parkinson's disease (PD) are a result of insufficient formation and action of dopamine produced in dopaminergic neurons of mid brain. It is accompanied by various signs and Fig. 10 : Monoplane teeth arrangement to avoid symptoms, which affect the day-to-day activities of the deflective contacts

Discussion


20

patient. To provide competent and timely care to pharmacologic treatment on quality of life and patients with Parkinson's disease, clinicians must economic outcomes. Am J Health-System understand the disease, its treatment, and its impact on Pharmacy 2000;157:953-962.the patient's physical and cognitive ability to maintain 3. Betarbct R, Sherer TB, MacKen^ie G, Garcia-their oral health and undergo and respond to dental

Osuna M, Pancv AV, Greenamyre JT. Chronic 9 care. Diminished physical and cognitive function during systemic pesticide exposure reproduces features of

the course of disease underscores the patient's inability Parkinson's disease. Nat Neurosci 2000;3(12):1301-to care for oneself and, consequently, to perform 1306.

10routine oral hygiene procedures. When patients are

4. Heckmann SM, Heckmann JG, Weber HP. Clinical able to insert, remove and maintain their prosthesis, or outcomes of three Parkinson's disease patients when caregivers are available to provide these services, treated with mandibular implant overdentures. Clin removable prostheses are appropriate to restore Oral Implants Res. 2000;11:566-571. function. Dentists face many problems in fabrication of

complete denture in such patients because increased 5. Omprakash YV, Hallikerimath RB, Gangadhar SA. tremors, increased saliva, diminished adaptive skills and Prosthodontic management of a case of poor muscle control make impression making and jaw Parkinson's disease - A case report. J Indian relation recording difficult, causing compromised Prosthodont Soc. 2004;4:21-24.retention. To minimize problems with adaptation, ill-

6. Chu FC, Deng FL, Siu AS, Chow TW. Implant-fitting prostheses should be modified or improved when

tissue supported, magnet-retained mandibular 11-13possible. The use of tissue conditioners are overdenture for an edentulous patient with

recommended for functional relines where vertical Parkinson's disease: a clinical report. J Prosthet

dimension has to be changed. Patients and caregivers Dent. 2004;91:219-222.

must be informed that success with dentures depends to 7. Packer M, Nikitin V, Coward T, Davis DM, Fiske J. a large degree on appropriate muscle function, which

The potential benefits of dental implants on the oral controls and stabilizes the prosthesis during periods of health quality of life of people with Parkinson's rest and use. The tongue may dislodge the mandibular disease. Gerodontology. 2009;26:11-18.denture, and facial muscles that are rigid or

uncontrollable may prevent a maxillary denture from 8. Rajeswari CL. Prosthodontic considerations in maintaining a retentive seal. There are several ways Parkinson's disease. PJSR. 2010;3:45-47.patients and their caregivers can improve the value of

9. Friedlander AH, Mahler M, Norman KM, Ettinger their visits to their dentist, beginning with timing them 14 RL. Parkinson disease: systemic and orofacial strategically. It is wise to plan early morning visits. It is

manifestations, medical and dental management. J better to take levodopa 60-90 mins prior to appointment Am Dent Assoc. 2009;140:658-669.to take advantage of peak response period, which may

improve the patient's ability to meet the demand of 10. Dirks SJ, Paunovich ED, Terezhalmy GT, Chiodo 15 LK. The patient with Parkinson's disease. dental examination.

Quintessence Int. 2003;34:379-393.

11. Clifford TJ, Warsi MJ, Burnett CA, Lamey PJ. The significant number of Parkinson patients in society Burning mouth in Parkinson's disease sufferers. requires the complete denture for functional, aesthetic, Gerodontology 1998;15:73-8. and psychological rehabilitation. Tender Love Care with

diligently handling the patients during the treatment, 12. Steifier M, Hofman S. Disorders of verbal reducing the number of appointments is required by the expression in Parkinsonism. Adv Neurol 1984;40: prosthodontist. Proper diagnosis, combined with 385-93. 13.Scully C, Cawson R.Medical Problems in proper prosthodontics management may be of Dentistry,4th ed. Butterworth Heine London: inestimable help to these patients. Wright, 1998, 362-5.

14. Dougal A, Fiske J. Access to special care dentistry Part 9: special care dentistry services for older 1. Lilienfdd DE, Perl DP. Proiected neurogetierative people. Br Dent J 2008; 205:421-34. disease mortality in the United States, 1990-2040, N

euro epidemiology I993;12:219-228. 15. Clifford T, Finnerty J. The dental awareness and needs of a Parkinson's disease population. 2. Scheife RT. Schumock GT, Burstein A, Gottwald Gerodontology 1995; 12:99-103.MD, Luer MS, Impact of Parkinson's disease and its

Conclusion

References


21

Abstract

Objectives :

Conclusion :

Keywords :

Introduction: Abnormalities of frenulum can initiate periodontal disease and orthodontic problems.

This case report aims to performing and comparing the procedure of frenectomy using blade and

LASER.

Both the techniques show strength, patient safety, similar outcomes and patient comfort. Further

studies should be recommended by adding greater amount of sample.

Frenectomy, blade, LASER.

Dr. Renuka Gahlot*, Dr. Pooja Palwakar**, Dr. Ashish Verma***, Dr. Vandana Srikrishna Chadha****,

Dr. Nipun Dhalla*****

*Post-Graduate Student, Department of Periodontology, MRDC.

**Professor and Head, Department of Periodontology, MRDC.

***Associate Professor, Department of Periodontology, MRDC.

**** Professor, Department of Periodontology, MRDC.

*****Senior Lecturer, Department of Periodontology, MRDC.

Frenectomy- Conventional And Laser Case Report between the two central incisors and an abnormal

frenum attachment results. The mandibular frenum is The frenum is a mucous membrane fold that attaches considered as aberrant when it is associated with a the lip and the cheek to the alveolar mucosa, the gingiva, decreased vestibular depth and an inadequate width of and the underlying periosteum. Frenum can be defined

2,3the attached gingiva .as "a fibrous band of tissue attached to the bone of the

mandible and maxillae, and is frequently superficial to The abnormal frena are detected visually by applying 1muscle attachments." The frena may jeopardize the tension over the frenum to see the movement of the

gingival health when they are attached too closely to the papillary tip or the blanch which is produced due to

gingival margin, either due to interference in the plaque ischaemia in the region. When the insertion point of the

control or due to a muscle pull. In addition to this, the frena is at the gingival margin it may pose a problem.

maxillary frenum may present aesthetic problems or This kind of abnormal insertion of the frenum may

compromise the orthodontic result in the midline cause marginal recession of the gingiva. Abnormal

diastema cases, thus causing a recurrence after the frenal insertion can distend and retract the marginal

treatment. The management of such an aberrant gingiva or papilla away from the tooth when the lip is

frenum is accomplished by performing a frenectomy. stretched. A frenum that encroaches on the margin of

the gingiva may interfere with plaque removal, and The superior labial frenum begins to form in the fetus at tension on this frenum may tend to open the sulcus. This the tenth week of gestation. By the third month in utero condition may be more conducive to plaque the tectolabial frenum of the fetus - morphologically accumulation and inhibit proper oral hygiene. The similar to the abnormal frenum of post natal life - frenum is characterized as pathogenic when it is extends as a continuous band of tissue from the unusually wide or when there is no apparent zone of the tuberculum on the inner side of the lip, over and across attached gingiva along the midline or the interdental the alveolar ridge to be inserted in the palatine papilla. papilla shifts when the frenum is extended.The maxillary labial frenum develops as a post-eruptive

remnant of the ectolabial bands which connect the Frenectomy can be accomplished either by the routine

tubercle of the upper lip to the palatine papilla. When scalpel technique, electrosurgery or by using lasers. The conventional technique involves excision of the frenum the 2 central incisors erupt widely separated, no bone is by using a scalpel. However, it carries the routine risks deposited inferior to the frenum. A V-shaped bony cleft

FRENECTOMY- CONVENTIONAL AND LASER CASE SERIES


22

of surgery like bleeding and patient compliance. LASER is an emerging treatment option for various soft tissue surgeries including frenectomy.

Case-1

A male patient, aged 22yrs, reported to the Department of Periodontology, Manav Rachna Dental College with a chief complaint of gap in the upper front tooth region for the past 2-3yrs and wanted to get it corrected. Clinical examination revealed positive tension test in relation to maxillary labial frenum (Fig. 1). The frenectomy was planned using conventional scalpel technique. The procedure was carried out under local Figure 2 . Haemostat Holding The Frenumanaesthesia. The frenum was held with a haemostat upto the depth of the vestibule (Fig. 2). With the No. 15 blade mounted on a Bard-Parker handle, an incision was made along the upper surface of the haemostat till the entire depth of the frenum extending into the vestibule. A similar incision was repeated on the under-surface of the haemostat so that the haemostat gets detached along with the resected portion of frenal tissue within its beaks (Fig. 3). Once this was achieved, a rhomboid area Figure 3 . Excised Tissueexposing the fibrous attachment to the bone became visible (Fig. 4). A blunt dissection was done with a horizontal incision to detach the deeper fibres from the underlying periosteum. Periosteal scoring is done with the help of surgical blade so as to prevent the reattachment of fibers. The labial mucosa was undermined so as to permit the approximation of the edges. The bleeding was controlled by applying pressure packs. The approximated edges were sutured by using 4-0 black silk with interrupted sutures (Fig. 5). A periodontal dressing was placed over the surgical area. The periodontal dressing and the sutures were removed after a period of 10 days (Fig 6).

Figure 4 . Frenum Removed

Figure 1. Pre-operative Figure 5 . Sutures Placed

Case Reports


23

Figure 8 . Frenectomy Using Diode LaserFigure 6 . Post Operative (10days)

Dressing was removed 10 days later. There was uneventful healing. Healing was obtained by secondary intention. No loss of interdental papilla was observed.

CASE 2

A 32 year old female patient reported to the Department of Periodontology, Manav Rachna Dental College with a chief complaint of spacing in the lower front tooth region. The patient reported no significant medical history. Presence of a high mandibular frenal attachment was identified as the cause of loss of interdental papilla in the mandibular central incisors

Figure 9 . Frenum Removed(Fig 1). Therefore frenectomy procedure with 940 nm diode laser to excise the aberrant frenum was planned. The problem was explained to the patient and a written consent was signed and the procedure was carried out under local anaesthesia. The frenum was excised with a diode laser(Fig 2). Periosteal scoring is done with the help of surgical blade so as to prevent the reattachment of fibers. The procedure was completed within 10 minutes and caused no discomfort to the patient. The surgical field was clear and dry without bleeding and caused no pain to the patient. No suturing was required for the patient. The postoperative area was left to heal by secondary intention. Healing was uneventful and no

Figure 10 . Post-Operative (2 Weeks)scarring was seen at 2 weeks(Fig 4).

The conventional frenectomy was performed using blade no.15, whereas second frenectomy used 940nm diode laser. The diode laser is a solid-state semiconductor laser that typically uses a combination of Gallium (Ga), Arsenide (Ar), and other elements such as Aluminum (Al) and Indium (In) to change electrical energy into light energy. The wavelength range is about 800-980 nm. The laser is emitted in continuous wave and gated pulsed modes, and is usually operated in a contact method using a flexible fiber optic delivery system. Bleeding in conventional frenectomy is greater

Figure 7 . Pre-operative than with LASER. This is because LASER has a

Discussion


24

coagulation effect to the area which makes less bleeding. is effectively worth. In conclusion, both the techniques Coagulation of protein that formed over the wound is show strength, patient safety, similar outcomes and also act as biological dressing and seals the end of sensory patient comfort.nerves.6 Moreover, it has an antibacterial influence so the possibility of infection is minimized. Operator

1. Zarb GA, Bolender CL. Prosthodontic treatment could easily handle the frena when it is visible and less of

for edentulous patients, complete dentures and blood. Besides bleeding aspect, to manipulate

implant-suppor ted prostheses, 12th ed. frenectomy with LASER, it is need an advance skill. Amsterdam: Elsevier; 2004.Using LASER is saving time than using blade.

2. Huang WJ, Creath CJ. The midline diastema: a Frenectomy using blade occasionally comes with review on its etiology and treatment. Pediatric massive bleeding during the procedure. This will makes Dentistry. 1995;17:171-179. the operation become more complicated to be

controlled. Lele et.al (2014) found that the conventional 3. Jhaveri H. Jhaveri Hiral., editor. The Aberrant method generally requires more than 15 minutes that Frenum. Dr. PD Miller the father of periodontal necessarily includes hemostasis and suturing. Whereas, plastic surgery. 2006:29-34.the LASER indigenously possesses the property of

4. Olivi G, Chaumanet G, Genovese MD, Beneduce C, cauterization that heals well by secondary intention.7

Andreana S. The Er,Cr:YSGG laser labial The outcome of both techniques is good. The healing frenectomy: a clinical retrospective evaluation of process of the mucosa using blade and LASER has 156 consecutive cases. Gen Dent 2010; 58:126-33.shown almost the same result. Even though, we knew

5. Cunha RF, Silva JZ, Faria MD. A clinical approach that less bleeding in LASER procedure but in fact the of ankyloglossia in babies: a report of two cases. J blood supply is good enough to vascularize.8Clin Pediatr Dent 2008; 32:277-82. 15.

Viewing from the cost of those two procedures, LASER 6. Epstein SR. The frenectomy: a comparison of are beneficial in reducing bleeding, give a good vision,

classic versus laser technique. Pract Periodontics no needs of suturing and also eliminates bacteremia. In Aesthet Dent 1991; 3: 27-30. contrast, LASER is cost abundantly than blade.

Devishree et.al (2014)9 reveals that the LASER 7. Gontijo I, Navarro RS, Naypek P, Ciamponi AL, procedure offered the advantage of minimal time Haddad AE. The application of diode and Er:YAG consumption and a bloodless field during the surgical lasers in labial frenectomies in infants. J Dent Child procedure, with no requirement of sutures. 2005; 72(1):10-15. 17.

Whereas, the conventional techniques like fail to 8. Pie-Sanchez J, Espana-Tost AJ, Arnabat-provide satisfactory aesthetic results.8 However, the use Dominguez J, Gay-Escoda C. Comparative study of of LASER gave the same result as blade but with a upper lip frenectomy with CO2 laser versus the greater cost. Er,Cr:YSGG laser. Med Oral Patol Oral Cir Bucal

2010; 17(2): e228-32. 18.

9. Devishree, Gujjari SK, Shubhashini PV. Considering the strengths of these two techniques, both Frenectomy: A Review with the Reports of Surgical the treatment modalities are equally effective. The ability

of coagulation and antibacterial influence by LASER, it Techniques. J Clin Diagn Res. 2014; 6(9):1587-1592.

References

Conclusion


25

Abstract

Keywords :

Prosthodontic treatment is quite a challenging task for dentist to treat patients with limited oral opening. Prosthetic rehabilitation of microstomia patients present difficulties from preliminary impressions to insertion of prostheses. For successful rehabilitation, the methods and designs incorporated in the fabrication of prosthesis have to be modified to achieve favorable esthetics, mastication and retention. This clinical report describes the method of fabrication of sectional denture for completely edentulous patient with microstomia with modified primary impression procedure without using tray and also method of fabricating a sectional complete denture.

Microstomia, Sectional denture, Snap fastners.

Dr. Susan Dax*, Dr. Pankaj Dhawan, MDS**; Dr. Pankaj Madhukar, MDS***; Dr. Amrita Grover****

*Post Graduate Student, Department of Prosthodontics, MRDC

**Prof & Head, Department of Prosthodontics, MRDC

***Professor, Department of Prosthodontics, MRDC

****Post Graduate Student, Department of Prosthodontics, MRDC

Introduction restricted mouth opening commonly leads to 6

1 compromised impression and prosthesis. A According to the Glossary of Prosthodontic Terms , modification of standard impression procedures is microstomia is defined as an abnormally small oral often necessary to accomplish this fundamental step in orifice. Microstomia is a definite prosthodontic the fabrication of such dentures. Sectional dentures hindrance to carry out the treatment successfully. These with modified denture construction techniques have patients may experience a significant limitation of

5,7usually been prescribed for these patients.mouth opening, and mandibular movements. It has

been reported that the limited oral opening may result from genetic disorders, temporomandibular dysfunction syndrome, surgical treatment of orofacial cancers, cleft lips, trauma, burns, head and neck

2, 3 radiation.

Fig. 1 : Patient with restricted mouth opening Fig. 2 : Maxillary and mandibular primary impression

In these situations where the mouth opening is limited, This clinical report presented describes a simple and the patient finds it very difficult to insert or remove a cost-effective method for fabrication of custom large conventional removable partial denture (RPD) or sectional trays and prosthesis for a patient with limited

4,5complete denture. Prosthodontic treatment of oral opening.

PROSTHETIC REHABILITATION WITH SECTIONAL COMPLETE DENTURE OF A PATIENT WITH MICROSTOMIA


26

Fig. 6 : Sectional teeth arrangement

A 65 year old edentulous female patient suffering from microstomia reported to the Department of Prosthodontics, Manav Rachna Dental College, Faridabad, Haryana for prosthetic rehabilitation. The patient had a small oral aperture since childhood. The etiology was unknown as there was no history of trauma or TMJ ankylosis. Past medical history revealed that the

Fig. 3 : Sectional custom tray patient was hypertensive and was on medication for the same. Hence short and late afternoon appointments were scheduled. On clinical examination the patient had completely edentulous maxillary and mandibular ridges. The maxillary and the mandibular ridges were favourable. An oral examination revealed limited mouth opening of about 22mm [Fig 1]. Patient refused to undergo any surgical treatment due to low socioeconomic status which demanded the simplest and least expensive dental treatment. It was therefore decided to make a sectional complete denture with modified preliminary impression techniques.

The fabrication of complete denture is often cumbersome in patients with microstomia. Hence it was decided to make modified preliminary impression without using tray to fabricate sectional denture.

Preliminary impression was made using polyvinyl Fig. 4 : Sectional final impressionsiloxane putty impression (Affinis Coltene Whaledent) material reinforced with heavy gauge stainless steel wire which was contoured on the residual ridge[Fig 2]. The wire was incorporated to provide rigidity to the flexible impression material and to prevent distortion. Primary cast was poured and a special tray with wax spacer was fabricated in acrylic (DPI-RR Cold Cure) on it. This special tray was then sectioned through the midline, after which die-pin slots were made. The die pins were placed in position, petroleum jelly was applied to parts

which will come in contact with other half [Fig 3]. Border molding of the maxillary and mandibular sectional trays was then completed in sections using low fusing compound (DPI Pinnacle), followed by the making of sectional final impressions using zinc oxide eugenol impression paste (DPI Impression Paste) [Fig Fig. 5 : Temporary record bases

Case Report

Procedure


27

4].The trays were assembled extraorally for pouring of the master casts. Temporary record bases were A non surgical prosthodontic treatment protocol was fabricated on the obtained master casts using followed for this particular case. Modifications in the autopolymerizing acrylic resin. The record base was impression procedure and technique were made to sectioned through the midline and then connected using overcome the potential clinical difficulties. In prosthetic size '0' stainless steel press buttons (snap fasteners, treatment, the loaded impression tray is often the largest Needle Ind.) [Fig 5]. On these sectional record bases, item requiring the intra-oral placement. During the wax rims were fabricated and jaw relation were impression procedures, wide vertical and horizontal oral recorded, after placing the individual sections intra- opening is required for proper tray insertion and orally. The transfer of jaw relation record to the alignment, but is not possible in patients with restricted articulator, arrangement of teeth, and the try-in were opening.8,9 The overall bulk and the height of typical carried out in the conventional manner. The master cast impression trays make the recording of impressions was duplicated using reversible hydrocolloid (agar) and

exceptionally difficult if not impossible because the kept aside for later use. One half of the waxed up

paths of insertion and removal of impressions are sectional prosthesis along with the male portion of the

compromised by lack of clearance. A modification of press button was placed on the original master cast and

the standard impression procedure is often necessary to acrylized conventionally after which it was recovered,

accomplish this fundamental step in the fabrication of a polished, and finished [Fig 6]. The other half of the

successful prosthesis. Various techniques to make sectional prosthesis was placed on the duplicated master

preliminary impressions for patient with constricted cast and duplicated again using agar [Fig 7]. The first

oral openings have included , sectional stock trays, half of the sectional prosthesis was placed on the

flexible tray with silicone putty and flexible tray used for duplicated cast, and the female portions of the press

fluoride application.2,10 In such conditions, a semi rigid buttons were fixed in their corresponding positions and

silicone putty impression material is commonly used as waxed up. Acrylisation of the above was carried out

impression tray impression tray for preliminary conventionally, followed by finishing, polishing of the impression. But in this case, preliminary impression sectional prosthesis. Both the sections are recovered made with silicone putty reinforced with stainless steel finished and polished and approximated for accurate fit heavy gauge wire was used because it served to ease [Fig 8].making impression by providing handle to carry the

After ensuring the fit and stability of the sectional impression material and prevent distortion by giving

prosthesis, it was placed in the patient's mouth [Fig 9]. additional support and rigidity to the impression

The patient was thoroughly educated and instructed 11material. Impressions can be made for patients with regarding the use of the prosthesis, to ensure proper

restricted mouth opening with a sectional impression assembly of the same. Post insertion and oral hygiene

tray that can be assembled and disassembled in the instructions were imparted, and routine follow-up

mouth and reassembled outside the mouth.appointments were scheduled.

Fig.8 : Maxillary and mandibular sectional denturesFig. 7 : Sectional teeth arrangement of the other half

Discussion


28

requirement for correct fitting of the components to

produce an accurate cast.

Although patients with microstomia seeking prosthetic

rehabilitation pose a challenge to the clinician, they can

be conservatively managed by modifying clinical and lab

procedures. However care should be taken to avoid

compromising the basic principles of providing

optimum function and esthetics. However, to determine

the long term success, periodic recall, maintenance and

further improvements in design are needed.

1. The glossary of prosthodontic terms. J Prosthet

Dent 2005;94:10-92.

Fig. 9 : Pre operative and Post operative view 2. Luebke RJ. Sectional impression tray for patients

with contricted oral opening. J Prosthet Dent Microstomia patients pose a problem during each step 1984;52:135-7.of prosthetic reconstruction starting from selection of

primary impression to insertion of the dentures. 3. Conroy B, Reitzik M. Prosthetic restoration in Sectional dentures have been recommended, with the microstomia. J Prosthet Dent 1971;26:324-7.

3,4denture pieces connected by the clasps. Nair et al.12 4. Dhanasomboon S, Kiatsiriroj K. Impression describe a maxillary complete denture consisting of 2 procedure for a progressive sclerosis patient: a pieces joined by a stainless steel rod with a diameter of 1 clinical report. J Prosthet Dent 2000;83:279-82.

13mm fitted behind the central incisors. Bedard et al. and 5. McCord JF, Tyson KW, Blair IS. A sectional 5McCord et al. describe a sectional impression

complete denture for a patient with microstomia. J procedure for edentulous patient by using 2 plastic

Prosthet Dent 1989;61:645-7.sectional impression trays assembled with Lego building

6. Geckili O, Cilingir A, Bilgin T. Impression blocks and autopolymerising resin. The most important procedures and construction of a sectional denture requirement of sectional trays used is the mechanism to for a patient with microstomia: A clinical report. J accurately adapt and stabilize the two segments of the Prosthet Dent 2006;96:387-90. tray to each other both intra-orally and extra-orally. Also,

the technique should not be complicated and allow easy 7. Ohkubo C, Ohukubo C, Hosoi T, Kurtz KS. A manipulation to decrease patient trauma. Uses of both sectional tray system for making impressions. J anterior and posterior locks are important for better Prosthet Dent 2003;90:201-4. stability. The technique for sectional tray described in

8. Cura C, Cotert HS, User A. Fabrication of a 14,15this report fulfills all these criteria. Fabricating the sectional impression tray and sectional complete

denture in two pieces enables the patient to insert and denture for a patient with microstomia and trismus: remove the denture with ease. a clinical report. J Prosthet Dent 2003;89:540-3.The denture was fabricated using snap fastners. Snap 9. Baker PS, Brandt RL, Boyajian G. Impression fastners are readily available, easy to use and maintain. procedure for patients with severely limited mouth Sectional denture with snap fastner is easy to use for a opening. J Prosthet Dent 2000;84:241-4. patient as there is a simple mechanism for locking them

10. Whitsitt JA, Battle LW. Technique for making and most patients are aware of its use.flexible impression trays for the microstomia

The advantages of this technique are that it can be patient. J Prosthet Dent 1984;52:608-609.accomplished in any dental laboratory without using

11. Basavanna JM,Raikhy A. Sectionaldenture for complicated machinery, simplified tray manipulation microstomia patient. Int J Prosth Rest Dent and decreased patient trauma. The disadvantages being 2013;3(2):62-67.additional time, labor required for precise fabrication of

the sectional tray and secondary impression and the 12. Nair CK, Sivagami G, Kunnekel AT, Naidu ME.

Conclusion

References


Dynamic commissural splint. Indian J Dent Res patients with microstomia. J Oral Health Res

2008;19:165-8. 2012;3:22-5.

13. Bedard JF, Thongthammachat S, Toljanic JA. 15. Gauri M, Ramandeep D. Prosthodontic

Adjunctive commissure splint therapy: a revised management of a completely edentulous patient

approach. J Prosthet Dent 2003;89:408-11. with microstomia: a case report. J Indian

Prosthodont Soc 2013;13:263-9.14. Ravindran S, Shetty V, Saraf V, Naran S. An

improvised sectional custom tray technique for



Abstract

Key Words :

Tongue tie, also known as ankyloglossia or ankyloglossia inferior, is a commonly finding in pediatric surgical

outpatient clinics. It occurs because of a short, tight, lingual frenum causing tethering of the tongue tip.

Ankyloglossia limits the tongue movements upto varying degrees which leads to a range of problems, such as

difficulties in breastfeeding in infants, speech impediments, being embarrassed by peers during childhood and

adolescence, and poor oral hygiene. Treatment of ankyloglossia can range from frenotomy to frenectomy using

electrocautery or surgical method.. The treatment choice varies from case to case. The present article describes the

surgical management of a 11 yr. boy having ankyloglossia associated with restricted movement of tongue, who

underwent frenectomy using monopolar diathermy under local anesthesia.

Ankyloglossia, tongue-tie, Lingual frenum, monopolar diathermy

* Dr Kiranjot Kaur* Dr. Rajendra kumar Gilhotra* Dr. Hind Pal Bhatia** Dr. Shveta Sood*** Dr. Naresh

Sharma**** Dr. Akshara Singh*****

*Post Graduate, Department of Paedodontics and Preventive Dentistry, MRDC

*Post Graduate, Department of Paedodontics and Preventive Dentistry, MRDC

**Professor and Head , Department of Paedodontics and Preventive Dentistry, MRDC

*** Professor , Department of Paedodontics and Preventive Dentistry, MRDC

****Reader, Department of Paedodontics and Preventive Dentistry, MRDC

*****Sr. Lec. Department of Paedodontics and Preventive Dentistry, MRDC

Introduction 10.7%) than in studies investigating children, 2adolescents, or adults (0.1% to 2.08%). Ankyloglossia is derived from two Greek words skolios

(curved)and glossa (tongue). Ankyloglossia or tongue-tie, There is some evidence that ankyloglossia can be a which is a congenital condition occurs as a result of genetically transmissible pathology. It is not known fusion between the tongue and floor of the mouth. which genetic components regulate the phenotype and Wallace in 1960 defined tongue-tie as a condition in penetrance in the patients affected. To clarify the exact which tip of the tongue cannot be protruded beyond the etiopathogenesis of ankyloglossia, more of research is lower incisor teeth because of a short frenulum linguae. required. Ankyloglossia was also found associated with Tongue-tie can be of various types varying from a thin certain rare syndromes such as X-linked cleft palate elastic membrane to a thickened, white non elastic syndrome, Kindler syndrome, Van der Woude

1tissue. syndrome and Opitz syndrome. Mostly ankyloglossias In many individuals, it is asymptomatic, which may get are observed in persons without any other congenital resolved spontaneously or affected individuals may anomalies or diseases. learn to compensate adequately for their decreased Ankyloglossia can affect eating, speech, and oral hygiene lingual mobility. Some individuals get it corrected by as well as have mechanical/social effects. There is surgical intervention frenotomy, frenectomy and difficulty in pronouncing sounds like "s, z, t, d, l, j, zh, ch, frenuloplasty for their tongue-tie. Patients should be th, d. due to the limited mobility of tongue. aware about the possible long-term effects of tongue-tie Ankyloglossia can also prevent the tongue from so that they may make an informed choice regarding contacting the anterior palate. This can then promote an possible therapy. infantile swallow and hamper the progression to an

The prevalence of ankyloglossia reported in the adult-like swallow which can result in an open bite

literature varies from 0.1% to 10.7%. The prevalence is deformity. It can also result in mandibular prognathism;

also higher in studies investigating neonates (1.72% to this happens when the tongue contacts the anterior

MANAGEMENT OF ANKYLOGLOSSIA UTILIZING MONOPOLAR DIATHERMY: A CASE REPORT

portion of the mandible with exaggerated anterior 3

thrusts.

There are four surgical interventions available, i.e.,

snipping the frenum (sometimes referred to as

'frenotomy') of neonates, surgical revision of the

frenum (sometimes referred to as 'frenectomy',

'frenulectomy' or ‘frenuloplasty') under a general

anesthetic at or after 6 months of age, revision of the

frenum by laser without a general anesthetic and/or

revision by electrocautery or monopolar diathermy 4

using a local anesthetic.

Fig. 2 . Tongue is surgically corrected using monopolar Monopolar electrosurgery is the most commonly used diathermybecause of its versatility and effectiveness.

An eleven year old boy, accompanied by his parents

reported to the Department of Paedodontics &

Preventive Dentistry, Manav Rachna Dental College,

Faridabad with the chief complaint of restricted

movement of the tongue which lead to defect in speech.

Clinical examination revealed a thick fibrous lingual Fig. 3,4 : Operative photograph showing the placement frenulum attachment causing restriction in tongue of sutures after the release of tongue tie. movement.[Fig.1] Provocation test showed restriction

of protrusive and lateral movements of the tongue. Ankyloglossia is a congenital anomaly which is Patient showed inability to touch tip of the tongue over characterized by an abnormally short lingual frenulum. the palatal region. Heamatological investigations were The condition occurs as a result of a failure in cellular performed which showed normal findings. Treatment degeneration leading to a much longer anchor between plan was discussed with patient's parents and after

4 the floor of the mouth and the tongue. Newborns with taking consent of the parents, frenectomy was planned. tongue tie are generally diagnosed and treated by After obtaining informed consent, local anaesthesia was paediatricians. Congenital oral adhesions lead to esthetic administered followed by which monopolar diathermy and functional disturbing ailments to children. Mostly it was used to release the frenum. [Fig2] Bleeding is benign, easily cured and may be treated as soon as occurring during the procedure was controlled by ball possible in the dental office. The pathogenesis of electrode. After release of the lingual frenum, sutures ankyloglossia is unknown. Ankyloglossia can be were given. [Fig3,4] Appropiate antibiotics and associated with certain rare syndromes such as X-linked analgesics were prescribed. One week post-operative

1cleft palate and Van Der Woude syndrome. Maternal view showed presence of slough in the operated site use of cocaine has been reported to increase the risk of indicating healing process. ankyloglossia by three times. Association between frenal

involvement and gingival recession has been reported in

the literature. In most of the individuals, ankyloglossia is

asymptomatic; the condition may resolve spontaneously

or affected individuals may learn to compensate 5adequately for their decreased lingual mobility. The

ankyloglossia can be classified into 4 classes based on

Kotlow's assessment as follows; Class I: Mild

ankyloglossia: 12 to 16 mm, Class II: Moderate

ankyloglossia: 8 to 11 mm, Class III: Severe

ankyloglossia: 3 to 7 mm, Class IV: Complete

ankyloglossia: Less than 3 mm. 2 Class III and IV

tongue-tie category should be given special Fig. 1 : Preoperative photograph showing ankyloglossia

Case Report

Discussion



consideration because they severely restrict the tongue's return pad to complete the electric current circuit. 6 Monopolar electrosurgery is the most commonly used movement. A normal range of motion of the tongue is

3indicated by the following criteria: 1. The tip of the because of its versatility and effectiveness.

tongue should be able to protrude outside the mouth

without clefting . 2. The tip of the tongue should be able Following the surgery, the tongue could make wide

to sweep the upper and lower lips easily, without range of movements including tip elevation, grooving,

straining 3.When the tongue is retruded, it should not and protrusion. Functions like speech and mastication

blanch the tissue lingual to the anterior teeth . 4. The were also improved after frenectomy.

tongue should not place excessive forces on the Monopolar electrosurgery is useful in several modalities mandibular anterior teeth . 5~ The lingual frenum like cut, blend, desiccation, and fulguration. With this should allow a normal swallow-ing pattern . 6. The pencil instrument, the active electrode is placed in the lingual frenum should not create a diastema between the entry site and can be used to cut tissue and coagulate mandibular central incisors 7. In infants, the underside bleeding.. This provides better control over the area of the tongue should not exhibit abrasion . 8. The being targeted, and helps prevent damage to other frenum should not prevent an infant from attaching to sensitive tissues.the mother's nipple during nursing. 9. Children should

not exhibit speech difficulties associated with 7limitations of the movement of the tongue. 1) Chaturvedi R, Kumar A, Kumar V, Tuli A.

Tongue-ties can be corrected through three surgical Ankyloglossia In Deciduous Dentition. Indian procedures. 1) Frenotomy is a simple cutting of the Journal of Dental Sciences. 2012 Oct 2;4.frenulum (of neonates). 2) Frenectomy is defined as 2) Moda A, Moda P, Jain N. Tongue Tie- A Treatment complete excision, i.e., removal of the whole frenulum

Dilemma- A Case Report & A Brief Review. Heal (at or after 6 months of age). 3) Frenuloplasty involves

talk. 2013;5(6): 28-30.various methods to release the tongue-tie and correct

3) Tuli A, Singh A. Monopolar diathermy used for the anatomic situation. Along with surgical correction of ankyloglossia. Journal of Indian intervention, electrocautery can be used along with Society of Pedodontics and Preventive Dentistry. local anesthetic to correct the tongue- tie which is also 2010 Apr 1;28(2):130.described in literature.1 The case presented in this paper

4) Kotlow A. Ankyloglossia (tongue-tie):A diagnostic was treated with monopolar diathermy and

postoperatively significant improvement was noticed and treatment quandary Quintessence Intl

during speech and mastication. The term diathermy 1999;30:259-262

means "electrically induced heat" the use of high- 5) Junqueira MA, Cunha NN. Surgical techniques for frequency electromagnetic currents as a form of the treatment of ankyloglossia in children: a case physical or occupational therapy and in surgical series. Journal of Applied Oral Science. 2014 procedures. The field was pioneered in 1907 by German Jun;22(3):241-8. physician Karl Franz Nagelschmidt, who coined the

6) Segal LM, Stephenson R, Dawes M, Feldman P. term diathermy. Diathermy is commonly used in

Prevalence, diagnosis, and treatment of physical therapy and occupational therapy to deliver

ankyloglossia Methodologic review. Canadian moderate heat directly to pathologic lesions in the

Family Physician. 2007 Jun 1;53(6):1027-33.deeper tissues of the body. In monopolar 7) Lalakea ML, Messner AH. Ankyloglossia: Does it electrosurgery, the current passes from the probe

matter? Pediatric Clin North Am 2003;50:381-97. electrode, to the tissue and through the patient to a

Conclusion

References


Introduction

Case report

Lipomas are benign mesenchymal neoplasm of the soft tissues composed of mature adipose tissues. They are

1relatively uncommon in oral cavity, especially on lips. The frequency of occurrence of lipoma in oral cavity reported in the literature is approximately 1 to 4%. These tumors can occur on the tongue, floor of the mouth, salivary glands, buccal mucosa followed by lips

2and gingiva.

Figure 2 : Specimen after excision

Here we report a rare case of intraoral lipoma occurring on the lower lip in a 55 year old female patient that was treated by surgical excision with no recurrence and complications.

A 55 year old female reported to the Department of Oral Medicine and Radiology, Manav Rachna Dental College, Faridabad with a chief complaint of a painless swelling on the inner surface of the left side of lower lip since 6 months. The history revealed that the growth was initially small and reached the present size in a

Figure 1 : Lipoma of lower lip on left side period of 6 months. The patient did not gave history of

INTRAORAL LIPOMA OF LOWER LIP :REPORT OF A RARE CASE

Abstract

Key words

Lipomas consist of benign tumors of mesenchymal origin that may be found in locations where adipose tissue is normally present. The most common locations for these tumors are the trunk and the end-points of the extremities. However, these tumors may occur in the oral cavity. Most patients with lipomas are above 40 years of age or older, lipomas are uncommon in children and with gender distribution appearing to be approximately equal. Lipomas are usually asymptomatic until they grow to large size and may interfere with speech and mastication. Other benign connective tissue lesions such as granular cell tumor, neurofibroma, traumatic fibroma and salivary gland lesions (mucocele and mixed tumor) might be included in differential diagnosis. Approximately 15-20% of cases occur in the head and neck region. However, its occurrence in oral cavity is rare accounting for only 1 to 4%. The most common site in the oral cavity has frequently been reported as buccal mucosa followed by floor of mouth, tongue and occassionaly on lower lip mucosa. The purpose of this report is to present a rare case of a 55 year old female patient with a histopathologically confirmed diagnosis of lipoma.

: Lipoma, Lower lip

Dr. Meelu Lamba*, Dr. Vishal Dang**, Dr. Neelkamal Sharda Bharadwaj***, Dr. Natalia Desilva***, Dr. Priyanka Kant***

*Postgraduate student 3rd year, Department of Oral Medicine and Radiology, MRDC, Faridabad

** Prof and Head, Department of Oral Medicine and Radiology, MRDC, Faridabad

***Reader, Department of Oral Medicine and Radiology, MRDC, Faridabad


pain, paresthesis, or ulceration associated with the women. They are uncommon in younger age group and swelling. No relevant medical and social history was affect patients mostly above 40 years of age with peak

3given by the patient. On intra oral examination of the occurrence in the 5th and 6th decade of life.soft tissue a well defined, solitary mass was seen on the inner left side of lower lip of size measuring 2.5 X 2 cm approximately. The overlying mucosa was pink in color with a yellowish tinge over the mass. On palpation the swelling was sessile, soft in consistency and was non tender. On bidigital palpation the swelling was mobile and was not fixed to the deeper tissues. The mucosa overlying the swelling was pinchable.

On the basis of the patient's history and clinical examination, a provisional diagnosis of lipoma was made. Patient was referred to the Department of Oral and Maxillofacial Surgery for further management.The excision of the lesion was done under local anaesthesia, through a linear incision over the swelling with a careful Figure 4 : 3 Months post operative photograph with no blunt dissection. The mass was completely excised and sighs of recurrencclosure of the wound was done with 3-0 silk interrupted sutures after attaining complete hemostasis. The surgical specimen was fixed in 10% buffered formalin and was sent for histopathological diagnosis. The gross specimen showed the tumour mass measuring 1.5x1 cm in size, yellowish-white in colour, soft in consistency with surface lobulations. The specimen was observed to be floating in the container with formalin thus indicating its lipomatous nature. On microscopic examination, the excised tissue mass showed well circumscribed, lobular proliferation of mature adipocytes with clear cytoplasm and flattened, eccentrically placed nuclei separated by connective tissue septae. The section showed lack of cellular atypia

Figure 5 : Histopathology (H and E stain) of the lesion or metaplasia with minimal vascularity . A final diagnosis showing mature adipocytes with inconspicuous of lipoma was made. Patient was kept on regular follow- vascularity(10x).up. No signs of recurrence were noted.

Intraoral lipomas are usually represents as painless, well defined, circumscribed, sessile or pedunclated

Lipomas are the most common mesenchymal tumors submucosal or superficial lesion, ranging from 1 cm, but

especially in the trunk and proximal portions of the can increase up to 5-6 cm over a period of years. Deeper 3

extremities but they are rare tumors of the oral cavity. lesions vary in contour and shape ranging from a well- The first description of an oral lesion was provided by defined, round contoured swelling to a large, ill defined, Roux in 1848. In his review of alveolar masses, Roux lobulated mass. The color, often yellow in tone, depends referred to the oral lesion as “yellow epulis”. Lipomas of on the thickness of the overlying mucosa. They are the mouth are benign tumors; grows slowly, do not usually asymptomatic until they grow to large size and

4infiltrate into other tissues and are painless. may interfere with speaking and mastication. Most oral The lipoma usually occurs as a solitary lesion that may be lipomas are composed of mature fat cells, presenting as

6sessile or pedunculated or submerged. The mean well-defined and covered by a thin, fibrous capsule.tumour size according to the literature is 2.2 centimetres No consensus exists regarding the pathogenesis of oral .2 Cheek is the commonest site of occurrence in the lipomas today. Heredity, fatty degeneration, hormonal intraoral cavity followed by tongue, floor of the mouth, basis, trauma, infection, infarction, metaplasia of buccal sulcus, vestibule, palate, lip and gingiva. This muscle cells, lipoblastic embryonic cell nest in origin and pattern corresponds closely to the quantity of fat chronic irritation are probable representative theories to

52deposit in the oral cavity. elucidate the pattern of a lipoma.

Lipomas of the oral and the maxillofacial region have The differential diagnosis of lipomas of lip should shown equal prediliction for involvement of men and include mucocele, minor salivary gland tumor and

Discussion


neurofibroma. The histopathology remains the gold odontol UNESP 2014; 43(2): 143-147.standard in the diagnosis of lipoma. Definitive 2. Tettamanti L, Azzi L, Croveri F, Cimetti I, Farronato diagnosis is usually by microscopic examination which D, Bombeccari GP, Tagliabue A, Spadari F. Oral shows lobules of mature adipocytes with uniform lipoms: Many features of a rare benign neoplasm.

7nuclei. Based on microscopic features they are classified Head and neck oncology 2014;6(3):1-7.into classic lipoma, fibro-lipoma, angio-lipoma, spindle

3. Juneja S, Juneja M, Babu NC. Intraoral lipoma in a cell lipoma, pleomorphic, myxoid, sialolipoma and 4 young male Patients: A case report. Internatonal intramuscular lipomas.

Journal of scientific study 2014; 1(5):44-47.Surgical excision is the main stay of treatment, with a

4. Venkateswarlu M, Geetha P, Srikanth M. A rare case recurrence rate of 5%. Recurrence is reduced by wide of intraoral lipoma in a six year old child: A case surgical excision with preservation of surrounding report. Int J oral sci 2011; 3: 43-46.7structures.

5. Chaudhary S, Prasad KD, Prakash A, Verma A. Intraoral lipoma: A case report and review of

Based on the cases reported in literature, oral lipomas literature. International Journal of dental and health are uncommon neoplasms in the oral cavity. The sciences 2014;1(3): 430-435.diagnosis is confirmed by clinical and microscopic

6. Agarwal P, Patil S, Chaudhary M. A rare case of examination and the treatment is surgical excision with

intraoral lipoma in a 33 months old child and a very rare incidences of recurrence.

review. Dentistry; 4(4): 1-4.

7. Omisakin O.O, Ajike S.O. Oral lipomas: A report of 1. Ferrereira CV, Gomes B, Mattos PH, Tavares I. two cases. International Journal of medicine and

Extensive lipoma in chin region. Case report. Rev biomedical research 2014; 3(1): 58-62.

Conclusion

References

36

The journal publishes original scientific papers, reviews, Articles: must present significant improvements in clinical case reports, and method presentation articles in the field practice (a novel technique, technological breakthrough or of dentistry. Manuscripts submitted for publication must practical approaches to clinical challenges). Up to 1000 be original articles and must not have appeared in any words excluding references and abstract and up to 10 other publication. The publisher reserves the right to edit references.manuscripts for length and to ensure conciseness, clarity Case reportsand stylistic consistency, subject to author's final approval.

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EDITOR IN CHIEFProf. (Dr.) Shveta Sood, M.D.S.Dental Lamina - Journal of Dental SciencesManav Rachna Dental Collage, Dept. of Paedodontics and Preventive DentistryDelhi - Surajkund Road, Aravalli Hills, Faridabad, Haryana, INDIAPhone : +91-9899000839email : [email protected]

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