JURNAL

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September
JOURNAL OF DENTAL SCIENCES & ORAL REHABILITATION

An Official Publication of Institute of Dental Sciences, Bareilly (U.P.) India
Chief Patrons :
Dr. Keshav Kumar Agarwal
Dr. Ashok Agarwal
Dr. Lata Agarwal
Dr. Kiran Agarwal
Dr. S. R. Panat
Chairman
President
Vice Chairperson
Vice President
Principal
Editor in Chief :
Dr. Anuraag Gurtu
Assitant Editors :
Dr. Ashish Aggarwal
Dr. Sumit Mohan
Reviewer :
Dr. Abhiney Puri
Dr. Anil Dhingra
Dr. Anirban Chatterjee
Dr. Anupama Sahay
Dr. Chandramani More
Dr. G.M. Sogi

Dr. Nageshwar Iyer
Dr. Sanjay Labh
Dr. Tarun Kumar
Dr. Vineet Vinayak
Editorial Board Members :

Dr. S.S. Bharathi
Dr. Gokkulakrishnan
Dr. R. G. Shivamanjunath
Dr. Hari Choudhary
Dr. Anurag Singhal

Dr. Madhusudhan Astekar
Dr. Deepa Singhal
Dr. D. K. Agarwal
Advisors :
Dr. K. K. Dixit
Dr. P. K. Singh
Published Quarterly By Institute of Dental Sciences, Bareilly

Editorial & Office :
The Editor in Chief, Editorial Office, Institute of Dental Sciences, Pilibhit Bypass Road, Bareilly - 243006,
E-mail editorjids@gmail.com
The statement and opinions expressed in this journal are the responsibility of the concerned authors and do not
necessarily reflect the opinions of the editorial board. The editorial board will not be responsible for any in
accuracy or misleading data, opinion or statement published in the journal Permission of the editorial board is
mandatory for reproduction of the contents of the journal in full or in part in any form.
Principals Message
I congratulate the editorial team for bringing out a good

collection of articles in the form of the current issue I hope the
readers find the contents valuable to provide new insights in current
trends in Dentistry.
I wish the journal all the success and hope that it continues to
enrich all its readers.
Dr. S.R. PANAT

Principal
Institute of Dental Sciences
Bareilly
Editorial
Greetings to all the readers from editorial team we present our

current issue July Sept 2013 with great enthusiasm and
anticipation. Taking inputs from the feedback provided to the
readers and current trends in dentistry we provide a collection of
articles which are thought provoking and informative.
Many Stalwarts of our specialty have joined hands with us as
members of review board in our journal. I welcome them and
expect a long and fruitful working relationship with them.
I take this opportunity to thank all our contributors, college
management, principal sir and members of the editorial team for the
joint effort which has taken the form of this edition.
Good wishes to one and all for the approaching festive season.
Dr. ANURAAG GURTU

Editor in Chief
Journal of Dental Sciences
and Oral Rehabilitation
Contents
REVIEW ARTICLES
1. Role of GCF As Potential Biomarker in the Diagnosis of Periodontal Disease...........................01-04
R.G.Shivamanjunath
2. Cone Beam Computed Tomography................................................................................................05-08
Ashish Aggarwal, Nitin Upadhyay, Nupur Agarwal, Sowmya G. V., Md.Asad Iqubal
3. Nanotechnology- Its Implications in Conservative Dentistry and Endodontics..........................09-14
Sumit Mohan, Anuraag Gurtu, Anurag Singhal, Ankita Mehrotra
4. Flapless Implant Surgery- An Overview.........................................................................................15-18
Rashi Jolly, Himanshu Thukral, Mansi Thukral Chandra
5. Fluorides and Their Role in Demineralization and Remineralization.........................................19-21
Sonal Soi, Vineet Vinayak, Anurag Singhal, Sonali Roy

ORIGINAL RESEARCH
6. Bacterial Quantification in teeth with Apical Periodontitis Related to Different Intracanal
Irrigant : A Clinical Study................................................................................................................22-24
K.K. Dixit, Krishna Dixit, Anurag Gurtu, Nivedita Dixit, Rahul Pandey
7. Evaluation of the Root Canal Morphology of Mandibular First Premolars in the Western
Uttar Pradesh Population Using Computed Axial Tomography: An in Vitro Study...........25-27
Nishtha Chauhan, Anurag Singhal, Vineet Vinayak
CASE REPORTS
8. Sialolithiasis : A Case Series with Review of Literature................................................................28-31
Sunil R Panat, Ashish Aggarwal, Nitin Upadhyay, Mallika Kishore, Abhijeet Alok
9. Maxillary Canine With Two Root Canals : A Case Report...........................................................32-34
Anuraag Gurtu, Anurag Singhal, Ridhi Bansal, Kunal Agnihotri
10. Denuded Root - is Free Gingival Graft an Answer : A Case Report............................................35-37
Rika Singh, Sunil Kumar Mall
11. Complication of a Dental Extraction: Osteomyelitis : A Case Report..........................................38-40
Sowmya G. V., Nupur Agarwal, Nitin Upadhyay, Abhijeet Alok, Mallika Kishore
12. Eagles Syndrome : A Case Report...................................................................................................41-43
Nupur Agarwal, Sunil R Panat, Ashish Aggarwal, Anuja Joshi, Kratika Ajai
13. A Modified Sectional Custom Tray for Making Master Impression in Microstomia Patient:
A Case Report................................................................................................................................... 44-46
Pratik Gupta, Dilip Kumar Nath, Nadira Saba
14. Telescopic Denture : A Case Report.................................................................................................47-50
Mayank Shah
15. Bilateral Maxillary Second Molar With Two Palatal Roots : A Case Report..............................51-53
C. Ram Mohan, C. Krishna Chaitanya, Hari Deva Raya Choudary, Sainath Reddy
Information For Authors..................................................................................................................54-56
Role of GCF As Potential Biomarker in the Diagnosis of Periodontal Disease
R.G.Shivamanjunath
Professor & Head, Department of Periodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 08/Jun/2013
Date of Acceptance : 15/Jul/2013
Abstract: Diagnosis of periodontal disease is very critical in the phases of its treatment. At present diagnostic
methods for periodontal disease are not precisely accurate and only allow retrospective diagnosis of attachment
loss. We are handicapped in making precisive diagnosis and prognosis by two important limitations ie no
reliable markers for disease activity and no reliable criteria for identifying the risk individuals. Therefore its
necessary to have a knowledge on the present available information regarding the advanced diagnostic
Biomarkers in Gingival crevicular fluid (GCF) for the better understanding of the onset of disease
pathogenisis,course of disease progression so that the treatment will be successful.
Key words : Periodontitis, Dental Plaque, GCF, Biomarker.
INTRODUCTION
Periodontitis is a group of inflammatory diseases that affect
the connective tissue attachment and supporting bone around the teeth.
The initiation and the progression of periodontitis are dependent on the
presence of virulent microorganisms capable of causing disease.
Although the bacteria are initiating agents in periodontitis, the host
response to the pathogenic infection is critical to disease progression.1-3
After its initiation, the disease progresses with the loss of collagen
fibers and attachment to the cemental surface, apical migration of the
junctional epithelium, formation of deepened periodontal pockets, and
resorption of alveolar bone.4 If left untreated, the disease continues with
progressive bone destruction, leading to tooth mobility and subsequent
tooth loss5.
A goal of periodontal diagnostic procedures is to provide
useful information to the clinician regarding the present periodontal
disease type, location, and severity. These findings serve as a basis for
treatment planning and provide essential data during periodontal
maintenance and disease-monitoring phases of treatment. Traditional
periodontal diagnostic parameters used clinically include probing
depths, bleeding on probing, clinical attachment levels, plaque index,
6
and radiographs assessing alveolar bone level. Under diagnosis of
periodontal disease results in significant amounts of untreated disease
and low rates of appropriate therapeutic intervention. Researchers
created biomarkers that indicated the presence or absence of
periodontal pathogens, gingival and periodontal inflammation, the host
inflammatory-immune response to certain pathogenic species, and host
tissue destruction. The biological media of choice included saliva,
serum, sub gingival plaque, tissue biopsies, and gingival crevicular
fluid. As a result, and after many biomarkers and diagnostic tests were
developed.
BIOMARKER
A biomarker is a substance used as an indicator of a biologic
state. It may be measured and evaluated as an indicator of normal or
pathogenic biologic processes, or pharmacologic responses to a
therapeutic intervention7. Since periodontitis is a multifactorial disease
that includes initiation by bacteria and host interaction, it's unlikely that
a single biomarker will be able to predict periodontal disease activity. A
combination of biomarkers may emerge eventually, and in the
meantime, risk assessment is more meaningful than simple clinical
measures such as periodontal probing. Gingival crevicular fluid (GCF)
is a fluid occurring in minute amounts in the gingival crevice. Gingival
crevicular fluid is a complex mixture of substances derived from

serum, leukocytes, structural cells of the periodontium and oral
bacteria. These substances possess a great potential for serving as
indicators of periodontal disease8. In health GCF represents the
transudate of gingival tissue interstitial fluid but inthe course of
gingivitis and periodontitis GCF is transformed into true inflammatory
(9)
exudates. . The flow rate of GCF may increase about 30 fold in
periodontitis compared to the healthy sulcus. However, its resting
volume also increases at the same time with the formation of gingival
pocket10.
POTENTIAL MICROBIAL FACTORS
Bacterial plaque plays a primary role in the initiation and
progression of periodontal disease but the composition of the sub
gingival flora is a complex and vary from patient to patient and site to
site. Despite these differences and the complex interactions that exist
between bacteria and the host a number of possible pathogens have
been suggested on the basis of their association with disease
progression and heir possession of virulence factors which could
damage the tissue (11-13).
MAIN BACTERIA ASSOCIATED WITH PERIODONTAL
DISEASE
Phorphyromonas gingivalis
Prevotella intermedia
Bacteroides forsythus
Actinobacillus actinomycetemcomitans
Capnocytophaga ochracea
Eikenella corrodens
Campylobacter recta
Fusobacterium nucleatum
Treponema denticola
BACTERIAL PROTEASES IN GCF
Bacterial proteases are released into the pocket by the
subgingival flora and can be detected in GCF. (14-18). Selective
biochemical assays have been developed for two bacterial proteases ie
dipeptidylpeptidase (DPP) and trypsin like proteases. The trypsin like
protease detected by this assay is a cysteine proteinase and has the
characteristics of the enzyme now called arg-gingivain or arg-
01

gingipain.(14,15).
Polymorphonuclear
Main advantages of periodontal diagnostic test system using bacterial
neutrophil
markers19
leucocytes (PM Ns)
Some appears to be predictive of disease activity in longitudinal study
Simple to use
Ma crophages
Chair side test kits available eg:Evalusite, omnigene, perioccan.
Chair side test kits produce visual results which can shown to patient
POTENTIAL INFLAMMATORY AND IMMUNE MARKERS
The primary cause for the periodontitis is no doubt dental
plaque and sub gingival flora. But the bacteria triggers the local
inflammatory response and general and local specific immune response
which, along with the direct effects of bacteria, causes most of the tissue
20
destruction . Most of the substances which are released from
inflammatory and immune cells in the tissue pass into the GCF. GCF is
easy to sample and therefore these substances are easily available for
the analysis21, 22.
POTENTIAL IMMUNE AND INFLAMMATORY MEDIATORS
The substances released by the inflammatory and immune
cells during the disease process include antibodies (immunoglobulin,
Ig), complement proteins, inflammatory mediators such as
prostaglandins (PG) and the pro-inflammatory cytokines such as the
various interleukins (IL) and tumour necrosis factor(TNF)21,22. The
potential immune and inflammatory mediators relevant to periodontal
pathology are :
Immune response
Antibody: total immunoglobulin and IgG sub groups
Complement
Inflammatory response
Arachidonic acid derivatives, eg prostaglandinE2(PGE 2)
Cytokines, eg IL, IL-2, IL-4, IL-6, TNF-.
DIAGNOSTIC TEST
GCF PGE2 has considerable potential as a screening test for
periodontal activity strangely no commercial efforts are currently
underway to develop one. Therefore it is now possible to assay GCF
PGE2 with an ELISA assay using a monoclonal rabbit anti PGE2
23
antibody .
POTENTIAL PROTEOLYTIC AND HYDROLYTIC ENZYMES
OF INFLAMMATORY CELL ORIGIN
Inflammation leads to accumulation of polymorphonuclear
neutrophil leucocytes (PMNs), macrophages, lymphocytes and mast
cell which are very important in protecting the body against infection.
The inflammatory cell contains destructive enzymes within their
lysosomes which are normally used to degrade phagocytosed material.
These enzymes are, however , capable of degrading gingival tissue
components if released. Such enzymes may be released by the
inflammatory cells during their function or when they degenerate or
die. Cells and tissues in the vicinity of these cells will be damaged and
this process is known as bystander damage. The main tissue damage in
this process are the connective tissue components and the breakdown of
these tissues around the inflammatory cells helps the spread of these
cells through the tissues24.
Inflammatory and connective tissue cells and the proteolytic
enzymes and inhibitors which they contain within their
cytoplasmic bodies.25-30
Ma st cell
Fibroblast
collagena se, Gelatinase, Tissue

inhibiting
mettaloprotinase
(TIMP ), Plasminogen, Elastase,
Cathepsin G, Cathepsin B,
Cathepsin D
Cathepsin G, Cathepsin B,
Cathepsin D, TIM P,
1
antiprotinase
inhibitor,
2m acroglobu lin, plasminogen
activator, elastase, gelatinase
Heparin enzyme complexes,
tryptase, chymase,histamine
Cathepsin B, Cathepsin L,
DPP-II
,TIMP,
1
antiprotinase
inhibitor,
2m acroglobu lin, collagenase
Biomarkers of periodontal disease activity may be obtained

from potential proteolytic and hydrolytic enzymes of inflammatory
cells.
COLLAGENASE AND RELATED METALLOPROTEINASE
Collagenases are members of a family of metalloproteinase
which degrade collagen. They are synthesized by macrophages,
neutrophills, fibroblasts and kerationocytes and are secreted by these
cells as latent enzymes when stimulated by the appropriate cytokines
and some bacterial products. These cells also produce inhibitors known
31
as tissue inhibitors of metalloproteinase. . In periodontitis, GCF
collagenase activity has been shown to increase with increasing
severity of gingival inflammation and increasing pocket depth and
alveolar bone loss(32-36).
PROTEOLYTIC AND HYDROLYTIC ENZYMES IN
INFLAMMATORY CELLS
Proteolytic enzymes
Collagenase
Elastase
Cathepsin G
Cathepsin B
Cathepsin D
Dipeptidylpeptidase
Tryptase
Hydrolytic enzymes
Aryl sulphatase
glucoronidase
Alkaline phosphatise
Acid phosphatise
Myeloperoxidase
Lysozyme
Lactoferrin
There are some test kits based on some of the GCF factors are
currently available. For example, Periocheck to detect the presence of
neutral proteinases such as collagenase in GCF, Prognostik to detect
37
the presence of the serine proteinase, elastase, in GCF samples .
Advantages of diagnostic test systems based on proteolytic and
hydrolytic enzymes are;
Some are predictive of diseas activity in longitudinal studies eg;
cathepsin B, elastase, dipeptidylepeptidase II and 1V
Since it is a colour detective system, simple to use
Short chair side time
Can be shown to the patient related to the areas.
02

All enzymes released from inflammatory cells are likely to be Bone phosphoprotein (N-propeptide), Osteocalcin, Telopeptides of
associated with gingival inflammation. Since gingival inflammation is type I collagen have been considered for possible markers of bone
often present in the absence of disease activity this association with resorption and hence periodontal disease activity.
inflammation could produce a false association with disease activity. It
is therefore very important to show that a potential marker has a true OSTEONECTIN AND BONE PHOSPHOPROTEIN (Nassociation with periodontal disease activity which is independent of PEPTIDE)
and stronger than any association it may have with gingival
Osteonectin is a normal component of bone matrix which is
42
inflammation.
thought to play an important role in the initial phase of mineralisation .
Bone phosphoprotein, which is an amino propeptide part of type I
POTENTIAL MARKERS OF CELL DEATH AND TISSUE collagen, appears to be involved in the attachment of connective tissue
DEGRADATION
cells to the substratum. Both of these proteins have been detected in
Periodontal disease activity involves both damage to the GCF from patients with periodontitis. The total amount of both
epithelial cells of the pocket lining and to the connective tissue cells in component is increased in GCF at the site of increased probing depth.
the sites of connective tissue degradation. Active periodontal tissues are
densely infilterated with inflammatory cells most of these cells may be OSTEOCALCIN
damaged1. The damaged cells release their cytosolic enzymes (enzymes
Osteocalcin is a calcium-binding proteins of bone and is the
within the cytoplasm of the cells) and the concentration of these may most abundant non-collagenous protein of the mineralised tissues43. It
well reflect the amount of cellular death within the lesion. Two of these chemotactically attracts osteoclast progenitor cells and blood
enzymes are Asperate amino transferase (AST) and lactate monocytes.44-46 In addition , it is stimulated by vitamin D3, producing
dehydrogenase (LDH), have been widely used in medicine for several concentration that inhibit collagen synthesis in osteoblasts, promote
decades as diagnostic aids to assess cell death and tissue destruction. bone resorption.47 Further elevated levels of osteocalcin are found in the
These enzymes would be expected to pass from the periodontal tissues blood during periods of rapid bone turnover such as osteoporosis and
in the inflammatory exudates into the gingival crevicular fluid (GCF). fracture repair.48,49 Therefore osteocalcin has been suggested as a
Therefore, GCF levels of these enzymes, should provide evidence of possible marker for bone resorption and hence periodontal disease
cell death within the periodontal tissues and hence, possibly disease progression, it is present in GCF.
activity. For these reasons they have been studied as potential marker of
disease activity.38
CONCLUSION
Periodontal practice ranges from the detection, diagnosis and
CONNECTIVE TISSUE DEGRADATION MARKERS
treatment of attachment loss due to periodontitis. The new diagnostic
The degradation of connective tissue by inflammatory cells technologies may be capable of providing the clinician with effective
and possibly bacterial enzymes during active periodontitis can release tools that can assist in the early identification of periodontal disease that
components of these tissues. These components could be cleaved can result in expidated treatment. The newer diagnostic technique are
sections of the major molecules of the periodontal connective tissue and still at an adolescent stages of development and much work remains to
basement membrane such as collagens and proteoglycans39, 40. The performed to fully validate this utility such that they become important
components that could be degraded during periodontitis are listed in and cost effective for the successful periodontal management.
table -1
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Corresponding
Corresponding Address:
Address:
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C. Shivamanjunath
Ram Mohan
Dr.Dr.
R.G.
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Email:
Email:dr_rammohanc@yahoo.co.in
drmanju75@rediffmail.com
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04
Cone Beam Computed Tomography

Ashish Aggarwal, Nitin Upadhyay , Nupur Agarwal, Sowmya G. V. , Md.Asad Iqubal
Senior Lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Stutent, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 21/Mar/2013
Date of Acceptance : 08/Apr/2013
Abstract: CBCT is a compact, faster and safer version of the regular CT, through the use of a cone shaped x-ray
beam. The size of the scanner, radiation dosage and time needed for scanning are all dramatically reduced and
can be easily fitted into the dental chair.It involves the use of rotating x-ray equipment, combined with a digital
computer, to obtain images of the body. Using CT imaging, cross sectional images of body organs and tissues
can be produced. CT imaging can provide views of soft tissue, bone, muscle, and blood vessels. Computed
tomography (CT) imaging, is also referred as computed axial tomography (CAT) scan clarity.
Key words : Cone Beam, Radiology, Medicine, Implantology, Orthodontic.
INTRODUCTION
To understand the difference between CT imaging and other
techniques, x-ray of the head should be considered. Using basic x-ray
techniques, the bone structures of the skull can be viewed. With
magnetic resonance imaging (MRI), blood vessels and soft tissue can be
viewed, but clear, detailed images of bony structures cannot be obtained.
On the other hand, x-ray angiography can provide a look at the blood
vessels of the head, but not soft tissue. CT imaging of the head can
provide clear images not only of soft tissue, but also of bones and blood
vessels.
CT imaging is commonly used for diagnostic purposes. In
fact, it is a chief imaging method used in diagnosing a variety of cancers,
including those affecting the lungs, pancreas, and liver. Using CT
imaging, not only can physicians confirm that tumors exist, but they can
also pinpoint their locations, accurately measure the size of tumors, and
determine whether or not they've spread to neighbouring tissues.In
addition to the diagnosis of certain cancers, CT imaging is used for
planning and administering radiation cancer treatments, as well as for
planning certain types of surgeries. It is useful for guiding biopsies and a
range of other procedures categorized as minimally invasive. Thanks to
its ability to provide clear images of bone, muscle, and blood vessels, CT
imaging is a valuable tool for the diagnosis and treatment of
musculoskeletal disorders and injuries. It is often used to measure bone
mineral density and to detect injuries to internal organs. CT imaging is
even used for the diagnosis and treatment of certain vascular diseases
that, undetected and untreated, have the potential to cause renal failure,
stroke, or death.4
In layman's terms, CBCT is a compact, faster and safer version
of the regular CT. Through the use of a cone shaped X-Ray beam, the size
of the scanner, radiation dosage and time needed for scanning are all
dramatically reduced.
A typical CBCT scanner can fit easily into any dental ( or
otherwise ) practice and is easily accessible by patients. The time needed
for a full scan is typically under one minute and the radiation dosage is up
to a hundred times less than that of a regular CT scanner.4
CBCT IN ORTHODONTICS
There has been an escalating interest in three dimensional
imaging devices over the last decade. orthodontics are beginning to
appreciate the advantages that the third dimension gives to clinical

diagnosis, treatment planning and patient education with cbct
technology all possible radiographs can be taken in under 1 minute. The
orthodontics now has the diagnostics quality of periapicals,
panormic,cephalograms and occlusal radiographs and tmj series at their
disposal along with views that cannot be produced by regular
radiographic machines like axial views and separate cephalograms for
the right and left sides.6
UTILIZATION OF CBCT IN AN ORTHODONTIC PRACTICE
Prior to seeing the patient, the tri-planner view of the CBCT is
screened for any observable pathology. This is something we were only
able to do in a limited manner with two dimensional .The second task is
to review the tri-planner view examining the airways. This includes the
retro-glossal airway, retropalatal airway, nasal passageways and all
sinuses. Adequacy of airways can affect skeletal growth patterns in
growing individuals and can also affect dental stability in growing as
well as non growing individuals. The airways are also a reflection of
skeletal relationships and can give us a clue of those individuals that may
have or be at risk for sleep disorders including obstructive sleep apnea.
In addition, we will sometimes find sinus polyps, maxillary sinus
infections and even ethmoid sinus disease. Upon finding pathology, the
appropriate referrals are made accompanied by a video copy of the
CBCT on a CD radiographs looking through a great depth of anatomy
with inherent distortion due to the manner in which the image was
obtained within the alveolar trough, relative horizontal bone levels and
root proximity. Recognizing asymmetries and developing asymmetries
is an extremely important part of the orthodontic diagnostic process as
this has profound affects upon how we plan for the individual's
treatment. Following the tri-planner investigations, I will then build the
TMJ studies examining form, volume and position of the condyles
within the fossa as well as the anatomy of the fossa itself. Because our
patients have either completed their health history questionnaires online or in our office prior to my review of all of the above I am able to add
this information to the diagnostic information provided by the CBCT
and the information obtained by my treatment coordinator all before I
have even met my patient. To have this information at my initial exam
only enhances the diagnosis, treatment planning, an deducational
process. Prior to my viewing the CBCT volume in the proprietary
software another staff member takes a "step backwards in time" and
05

builds 2Dlateral and posterior-anterior cephalograms in Dolphin 3D implant treatment, appropriate site or size can be chosen before
(orthodontic imaging software) to allow me to digitize the cephalograms placement, and osseointegration can be studied over a period of time.
and provide me with further diagnostic and treatment planning
This review discusses all the finer details of CBCT which has
information. This process is at this time a necessity for the orthodontist added a third dimension to the imaging in periodontics.
but 3D digitizing will soon be here and infact is being developed and
tested at this time. The quality of the cephalograms built from the CBCT USES OF CBCT IN HEAD & NECK REGION
is without a doubt a huge improvement over the conventional
CBCT is being increasingly used for point of service head &
2Dradiographs. The CBCT and extra-oral photographs are taken with an neck and dento-maxillofacial imaging. This technique provides
operator assisted first tooth contact centric relation wax bite registration. relatively high isotrophic spatial resolution of osseous structures with a
We can make more appropriate treatment decisions as opposed to images reduced radiation dose compared with conventional CT scans. In this
taken in habitual jaw positions that may not reflect the true relationship second installement in a 2-part review, the clinical application in the
of the mandible to the maxilla and thus may inaccurately reflect condylar dentomaxillofacial and head & neck regions will be explored, with
position and the relative dental relationships The superior diagnostic particular emphasis on diagnostics imaging of the sinuses, temporal
information provided by CBCT over conventional radiographic bone and craniofacial structures.3
technology dictates that we make the transition from 2D diagnosis and
Cone beam CT (CBCT) is an advancement in CT imaging that
treatment planning to 3D sooner rather than later. Most all of us have has begun to emerge as a potentially low-dose cross-sectional technique
inherent asymmetries and skeletal discrepancies but the greater the for visualizing bony structures in the head and neck. The physical
magnitude of these discrepancies the more important 3Dimaging, principles, image quality parameters, and technical limitations relevant
digitization and treatment planning becomes. For example, treatment to CBCT imaging were discussed in Part 1 of this 2-part series. The
planning of orthognathic surgical cases in 3D will provide us a more second part presented here will highlight the evidence related to CBCT
complete picture of treatment options and projected treatment outcomes, applications in head and neck as well as dentomaxillofacial imaging.
Controversial aspects of this technology will also be addressed,
which in the end is a huge benefit for the patient.7
including limitations in image quality and its often office-based
USES OF CBCT IN IMPLANTOLOGY
operational model.3
In the field of periodontology and implantology, assessment of
CBCT was first adapted for potential clinical use in 1982 at the
the condition of teeth and surrounding alveolar bone depends largely on Mayo Clinic Bio dynamics Research Laboratory. Initial interest focused
two-dimensional imaging modalities such as conventional and digital primarily on applications in angiography in which soft-tissue resolution
radiography though these modalities are very useful and have less could be sacrificed in favour of high temporal and spatial-resolving
radiation exposure, they still cannot determine a three dimensional capabilities. Since that time, several CBCT systems for use have been
architecture of osseous defects. Hence an imaging modality which developed both in the interventional suite and for general applications in
would gives an undistorted vision of a tooth and surrounding structures CT angiography. Exploration of CBCT technologies for use in radiation
is essential to improve the diagnostics potential. CBCT provides 3D therapy guidance began in 1992, followed by integration of the first
images that facilitate the transition of dental imaging from initial CBCT imaging system into the gantry of a linear accelerator in 1999.
diagnosis to image guidance throughout the treatment phase. This
The first CBCT system became commercially available for
technology offers increased precision, lower doses and lower costs when dentomaxillofacial imaging in 2001 (New Tom QR DVT 9000;
2
Quantitative Radiology, Verona, Italy). Comparatively low dosing
compared with medial fan-beam CT.
In the field of periodontology, assessment of the condition of requirements and a relatively compact design have also led to intense
teeth and surrounding alveolar bone depends largely on traditional two- interest in surgical planning and intra operative CBCT applications,
dimensional imaging modalities such as conventional radiography and particularly in the head and neck but also in spinal, thoracic, abdominal,
digital radiography. Though these modalities are very useful and have and orthopedic procedures. Diagnostic applications in CT
less radiation exposure, they still cannot determine a three-dimensional mammography and head and neck imaging are also under evaluation.
(3D) architecture of osseous defects. Hence, an imaging modality which The technical and clinical considerations pertaining to CBCT imaging in
would give an undistorted 3D vision of a tooth and surrounding many of these applications have been the subjects of several recent
structures is essential to improve the diagnostic potential. A well reviews.The recent review by Drfler et al of the neurointerventional
applications of CBCT is of particular interest to the field of
diagnosed periodontal lesion warrants an appropriate treatment.
In the medical field, the 3D imaging using computed tomography (CT) neuroradiology.5
has been available now for many years, but in the dental specialty, its
application is restricted to the use in cases of maxillofacial trauma and
USES OF CBCT IN PROSTHODONTICS
diagnosis of head and neck diseases. Routine use of CT in dentistry is not
Today's computer aided design & manufacture (CAD/CAM)
accepted due to its cost, excessive radiation, and general practicality. In
technologies contribute greatly to restorative dentistry & provide
recent years, a new technology of cone-beam CT (CBCT) for acquiring
clinicals with advanced treatment options for various
3D images of oral structures is now available to the dental clinics and
indications,including inlays,onlays,fixed dentures & full dentures,thin
hospitals. It is cheaper than CT, less bulky and generates low dosages of
veneers and crowns.These systems also allow use of many restorative
X-radiations. The innovative CBCT machine (fig 1] designed for head
materials,including metal,metal-ceramic,compositive & all ceramic, to
and neck imaging are comparable in size with an orthopantomograph.
best meet the needs of the care & patients. Further CAD/CAM systems
CBCT provides rapid volumetric image acquisition taken at
are available for both chairable & laboratory applications,so dentists
different points in time that are similar in geometry and contrast, making
now have the ability to create highly aesthetic & strong restoration in
it possible to evaluate differences occurring in the fourth dimension
4
office.
time. In its various dental applications, images of jaws and teeth can be
visualized accurately with excellent resolution can be restructured three
dimensionally, and can be viewed from any angle (Fig 2). Most ADVANTAGES OF CBCT
Being considerably smaller, CBCT equipment has a greatly
significantly, patient radiation dose is five times lower than normal CT.
Today, CBCT scanning has become a valuable imaging reduced physical footprint and is approximately 20-25% of the cost of
modality in periodontology as well as implantology. For the detection of conventional CT. CBCT provides images of high contrasting structures
smallest osseous defects, CBCT can display the image in all its three and is therefore particularly well- suited towards the imaging of osseous
dimensions by removing the disturbing anatomical structures and structures of the craniofacial area. The use of CBCT technology in
making it possible to evaluate each root and surrounding bone. In clinical dental practice provides14 a number of advantages form
axillofacial imaging. These include
06

RAPID SCAN TIME
patient. Surgical templates can then be laboratory fabricated on stone
Because CBCT acquires all projection images in a single casts, or directly CT-derived via stereo lithography, taking the scan data
rotation, scan time is comparable to panoramics of radiography. This is and turning it into solid resin models of the patient's mandible or maxilla.
desirable because artefact due to subject movement is reduced. However, as more companies invest in 3-D digital dentistry solutions,
Computer time for dataset reconstruction however is substantially linking the technologies together has become a reality. This presentation
longer and varies depending on FOV, the number of basis images will demonstrate how digital dentistry is evolving into a mainstream
acquired, resolution and reconstruction algorithm and may range from dentistry, allowing everyone to achieve successful "restorativelyapproximately 1 to 20 minutes.
driven" implant dentistry.
BEAM
Collimation of the CBCT primary x-ray beam enables
limitation of the x-radiation to the area of interest. Therefore an optimum
FOV can be selected for each patient based on suspected disease
presentation and region of interest. While not available on all CBCT
systems, this functionality is highly desirable as it provides dose savings
by limiting the irradiated field to fit the FOV.
IMAGE ACCURACY
CBCT imaging produces images with sub-millimeter
isotropic voxel resolution ranging from0.4 mm to as low as 0.09 mm.
Because of this characteristic, subsequent secondary(axial, coronal and
sagittal) and MPR images achieve a level of spatial resolution that is
accurate enough for measurement in maxillofacial applications where
precision in all dimensions is important such as implant site assessment
and orthodontic analysis
REDUCED PATIENT RADIATION DOSE COMPARED TO
CONVENTIONAL CT.
The effective dose (E) varies for various full field of view
CBCT devices from 29-477 Sv depending on the type and model of
CBCT equipment and FOV selected (Table 2) (Schulze et al.,2004; Mah
et al., 2003; Ludlow et al.,2003, 2006, 2007). Patient positioning
modifications (tilting the chin) and use of additional personal protection
(thyroid collar) can substantially reduce dose by upto 40% (Ludlow et
al., 2006). These doses can be compared more meaningfully to dose from
a single digital panoramic exposure(Ludlow et al., 2003), equivalent CT
dose (Ngan et al., 2002), or the average natural background radiation
exposure for Australia (1,500 Sv) (ARPANSA, 2007)in terms of
background equivalent radiation time (BERT) (MacDonald,
1997).CBCT provides an equivalent patient radiation dose of 5 to 80
times that of a single film-based panoramic radiograph, 1.3% to 22.7%
of a comparable conventional CT exposure or 7 to 116 days of
background radiation.
ORAL RADIOLOGY
A number of novel medical diagnostic imaging modalities
have emerged recently. Cone beam computed tomography (CBCT) is a
radiographic imaging method that allows accurate, three-dimensional
imaging of hard tissues. CBCT has been used for dental and
maxillofacial imaging for more than ten years now and its availability
and use are increasing continuously. However, at present, only best
practice guidelines are available for its use, and the need for evidencebased guidelines on the use of CBCT in dentistry is widely recognized.
CBCT is more reliable in evaluating the number of mandibular third
molar roots than panoramic radiography. CBCT scanners provide
adequate image quality for dentomaxillofacial examinations while
delivering considerably smaller effective doses.16
CONCLUSION
Even with CT imaging, clinicians have laboured to link the
information from the scan data to the surgical site, transferring angles
and positions manually. This is overcome with interactive software
applications that provide this information seamlessly.
As CBCT has become the state-of-the-art, the race is on to
identify opportunities which benefit from the digital information
embedded in each scan. Guided implant surgery has evolved as an
important modality and aid in transferring the virtual 3-D plan to the
REFERENCES
1. Kau CH, Richmond S. Current products and practice three
dimensional cone beam computerized tomography in orthodontics.
J Ortho 2005;32:282-93.
2. Mohan R, Singh A, Gundappa M. Three-dimensional imaging in
periodontal diagnosis Utilization of cone beam computed
tomgraphy. J Indian Soc Periodontol. 2011;15(1):7-11.
3. Miracle AC, Mukherji SK. Conebeam CT of the head and neck,
part 2: clinical applications. AJNR Am J Neuroradio
2009;30(7):1285-92.
4. Alamri HM, Sadrameli M, Alshalhoob MA, Sadrameli M, Alshehri
MA. Applications of CBCT in dental practice: a review of the
literature. Gen Dent. 2012; 60(5):390-400.
5. Danforth RA, Peck J, Hall P. Cone beam volume tomography: an
imaging option for diagnosis of complex mandibular third
molar anatomical relationships. J Calif Dent Assoc
2003;31(11):847-52.
6. Halazonetis DJ. From 2-dimensional cephalograms to 3dimensional computed tomography scans. Am J Orthod
Dentofacial Orthop 2005;127(5):627-37.
7. Mah J, Hate er D. Current status and future needs in craniofacial
imaging. Orthod Craniofac Res. 2003; 6(1):79-82.
8. Noar JH, Pabari S. Cone beam computed tomography current
understanding and evidence for its orthodontic applications? J
Orthod 2013;40(1):5-13.
9. Chaushu S, Chaushu G, Becker A. The role of digital volume
tomography in the imaging of impacted teeth. World J Orthod
2004;5(2):120-32.
10. Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption
of maxillary canines: a CT study. Angle Orthod. 2000;70(6):41523.
11. Mah J, Enciso R, Jorgensen M. Management of impacted
cuspids using 3-D volumetric imaging. J Calif Dent Assoc.
2003;31(11):835-41.
12. Aboudara CA, Hatcher D, Nielsen IL, Miller A. A threedimensional evaluation of the upper airway in adolescents.
Orthod Craniofac Res. 2003;6:173-5.
13. Robb RA. The Dynamic Spatial Reconstructor: An X-Ray VideoFluoroscopic CT Scanner for Dynamic Volume Imaging of Moving
Organs. IEEE Trans Med Imaging. 1982;1(1):22-33.
14. Fahrig R, Nikolov H,Fox AJ, Holdsworth DW. A threedimensional cerebrovascular flow phantom. Med Phys.
1999;26(8):1589-99.
15. Covalcanti MG. Cone beam computed tomegraplic imaging
perspective, challenges and the impact of near trend future
applications. J Craniofac Surg 2012;23(1):279-82
16. Suomalainen II., Kiljunen T, Kaser Y, Peltola J, Kortesniemi M.
Dosimetry and image quality of four dental cone beam computed
tomography scanners compared with rnultislice computed
tomography scanners, Dentomaxillofac Radiol. 2009;38(6):36778.
Corresponding
Address:
Dr.Ashish
C. Ram
Mohan
Dr.
Aggarwal
drashishagg@rediff mail.com
Email:dr_rammohanc@yahoo.co.in
Email:
07
LIST OF PHOTOGRAPHS
Fig 1 CBCT Machine
Fig 2 CBCT Image
08
Nanotechnology : Its Implications in Conservative Dentistry and Endodontics
Sumit Mohan , Anuraag Gurtu , Anurag Singhal , Ankita Mehrotra
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Reader, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor & Head, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 27/Feb/2013
Abstract: Feynman postulated concept of nanotechnology as an unavoidable development in the progress of

science. Since then, nanotechnology has been part of mainstream scientific theory with potential medical and
dental applications. Numerous theoretical predictions have been made based on the potential applications of
nanotechnology in dentistry. The most substantial contribution of nanotechnology to dentistry is the more
enhanced restoration of tooth structure with nanocomposites. The field of nanotechnology has tremendous
potential, which if harnessed efficiently, can bring out significant benefits to the human society such as
improved health, better use of natural resources. The future holds in store an era of dentistry in which every
procedure will be performed using equipments and devices based on nanotechnology. This article reviews the
potential clinical applications of nanotechnology in conservative dentistry and endodontics.
Key words : Nanotechnology, Nanodentistry, Nanocomposites; Dentifrobots, Nanosolution.
INTRODUCTION
Nanotechnology also known as molecular
nanotechnology or molecular engineering is production of
functional materials and structures in range of 0.1 to 100
nanometeres. Today the revolutionary development of
nanotechnology has become the most highly energized
disciplined in science and technology.1The term Nanotechnology
was coined by Prof. Kerie E Drexler.2 Nano is derived from vaos,
the Greek word for dwarf and usually is combined with noun to
form words such as nanometer, nanotechnology or nanorobot.3
First described in 1959 by physicist Richard P Feyman,
who said it as an avoidable development in progress of science,
nanotechnology has been a part of mainstream scientific theory
with potential medical and dental application since early 1990's.
Nanoparticle, nanosphere, nanorodes, nanotubes, nanofibres,
dendrimers and other nanostructures has been studied for various
applications to biologic tissue and systems. Growing interest in
future medical application of nanotechnology is leading to the
emergence of new field called Nanomedicine. Emerging
technologies and new nanoscale information have the potential to
transform dental practice by advancing all aspects of dental
diagnostics, therapeutics and cosmetic dentistry into a new
paradigm of state-of-the-art patient care beyond traditional oral
care methods and procedures.4
New potential treatment opportunities in dentistry may include
bottom up approach and bottom down approach.
The bottom up approaches are:
1. Local anaesthesia:- a colloidal suspension containing
millions of active analgesic micron size dental robot will be
instilled on patients gingivae. After contacting the surface of
crown or mucosa, ambulating nanorobots reach the pulp.
Once installed there, analgesic dental robots may be
commanded by dentist to shut down all sensitivity in any
2.
3.
4.
5.
6.
particular tooth that requires treatment. After oral procedure

is completed , dentist orders the nanorobots to restore all
sensations to relinquish control of nerve traffic and to egress
from tooth by similar pathways used to ingress.5
Hypersensivity cure:- Dentine hypersensitivity may be
caused by changes in pressure transmitted hydrodynamically
to pulp. Dental nanorobots could selectively and precisely
occlude selected tubule in minutes, using native biological
materials, thus offering patients a quick and permanent cure.2
Nanorobotic dentifrices (dentirobots):- Subocclusal
dwelling nanorobotic dentifrices delivered by mouthwash or
toothpaste could patrol all supragingival and subgingival
surfaces at least once a day, metabolising trapped organic
matter into harmless and odourless vapours and performing
continuous calculus debridement. Toothpaste containing
synthesized hydroxyapatite, calcium peroxide, patented
nano-technology aka Nanoxyd has proven useful to freshen
breathe as well as whiten teeth6.
Dental durability and cosmetics:- Tooth durability and
appearance may be improved by replacing upper enamel
layers with pure sapphire and diamond which can be made
more fracture resistance as nanostructure composites,
possibly including embedded carbon nanotubes.5
Orthodontic treatment:- Orthodontic nanorobots could
directly manipulate the periodontal tissues allowing rapid
and painless tooth straightening, rotating and vertical
repositioning within minutes to hours.7 Sliding a tooth along
a archwire involves a frictional type of force that resist this
movement. Use of excessive orthodontic force might cause
loss of anchorage and root resorption, but coating
orthodontic wire with inorganic fullerene like tungsten
disulfide nanoparticles, reduction in friction has been
reported.
Photosensitizers and carriers:- Quantum dots can be used as
09
7.
photosensitizers and carriers. They can bind to the antibody

present on surface of target cell and when stimulated by UV
light. They can give rise to reactive oxygen species and thus
will be lethal to target cell.5
Diagnosis and treatment of oral cancer:- Nano
electromechanical system (NEMS) which can convert
biochemical to electrical signal and cantilever array sensor
which is an ultrasensitive mass detection technology, can be
used for detection of 10-12 bacteria, viruses and DNA. These
are extremely useful for diagnosis of oral cancer and diabetes
mellitus. Nanomaterials for brachytherapy like
'BrachySilTM' delivers P32, are in clinical trial. Drug delivery
system that can cross the blood brain barrier is vision of the
future with this technology. Parkinson disease, Alzheimer
disease, brain tumour will be managed more efficiently by
the use of this technology. Nanovectors for gene therapy are
in a developing stage to correct disease at molecular aspect.5
Top-Down Approaches include:

1. Nanocomposites:- Nanocomposites has been successfully
manufactured by non-agglomerated discrete nanoparticles
that are homogenously distributed in resins or coatings to
produce them.4 The nanofiller used includes an alumino
silicate powder having a mean particle size of 80 nm2.
Commercially they are available as Filtek O Supreme
Universal Restorative Pure Nano O.
2. Nanosolutions:- It produces unique and dispersible
nanoparticles which can be used in bonding agents. This
insures homogeneity and adhesive is mixed every time.2
3. Impression materials:- Nanofillers are integrated in
vinylpolysiloxanes, producing a unique additions of
siloxane impression materials, having better flow, improved
hydrophilic properties and enhanced details.5 Commercially
available as Nanotech Elite H-D.
4. Nanoencapsulation:- Nanomaterials, including hollow
spheres, core-shell structure, nanotubes and nanocomposite,
have been widely explored for controlled drug release.
South-west research institute has developed targeted systems
that encompass nanocapsules include novel vaccines,
antibiotics and drug delivery with reduced side effects.5
Pinon-Segundo et al studied Triclosan loaded nanoparticles,
500 nm in size, used in an attempt to obtain a novel drug
delivery system adequate for the treatment of periodontal
disease. These particles were found to significantly reduce
inflammation at the experimental sites. An example of the
development of this technology is arestin in which
minocycline is incorporated into microsphere for drug
delivery by local means to a periodontal pocket.8
5. Nanoneedles:- Suture needles incorporating nano sized
stainless steel crystals have been developed. Nanoneedles
like Sandvik Bioline, RK 91 needles are available.5
6. Nanotweezers:- In 1999, Philip Kim and Charles Lieber at
Harward University created the first general purpose
nanotweezer. Its working end is a pair of electrically
controlled carbon nanotubes made from a bundle of
multiwalled carbon nanotubes. To operate the tweezers, a
voltage is applied across the electrode, causing one nanotube
arm to develop a positive electrostatic charge and the other to
develop a negative charge.9
7. Bone replacement materials:- Hydroxyapatite nanoparticles
are used to treat bone defects are Ostium, Vitosso and
8.
NanOSS .These can be used in maxillofacial injuries

requiring bone graft, cleft patients and osseous defects in
periodontal surgeries.7
Other products are:- Protective clothing and filtration masks,
using antipathogenic nanoemulsions and nanoparticles.
Medical appendages for instantaneous healing. Bone
targeting nanocarriers like calcium phosphate based
biomaterials are developed.6,3
ROLE OF NANOTECHNOLOGY IN CONSERVATIVE

DENTISTRY & ENDODONTICS
NANOCOMPOSITE
One of the most significant contributions to dentistry
has been the development of resin based composite technology.
Adhesively bonded composites have the advantage of conserving
sound tooth structure with the potential for tooth reinforcement,
while at same time providing cosmetically acceptable
restorations. However, no composite material has been able to
meet both functional needs of posterior class I or II restorations
and superior esthetics required for anterior restorations. There
was a need to develop a composite dental filling material that
could be used in all areas of mouth with high initial polish and
superior polish retention as well as excellent mechanical
properties suitable for high stress bearing restoration 1.
Composition: Nanocomposite has the basic composition of
conventional composite resin. Dental composites are composed
of synthetic polymers, inorganic fillers, initiators, and activators
that promote light-activated polymerization of the organic matrix
to form cross-linked polymer networks, and silane coupling
agents which bond the reinforcing fillers to the polymer matrix.
They have fillers that are 0.005 to 0.01m.6 Nanoproducts
Corporation has successfully manufactured nonagglomerated
discrete nanoparticles that are homogeneously distributed in
resins or coatings to produce nanocomposites. The nanofiller
used include an alumino silicate powder having a mean particle
size of 80 nm2.
Additionally, nanofillers are capable of increasing the
overall filler level due to their small particle sizes. More filler can
be accommodated if smaller particles are used for particle
packing. Theoretically, with the use of nanofillers, filler levels
could be as high as 90-95% by weight. However, the increase in
nanofillers also increases the surface area of the filler particles,
which limits the total amount of filler particles because of the
wettability of the fillers. Since polymerization shrinkage is
mainly due to the resin matrix, the increase in filler level results in
a lower amount of resin in nanocomposites and will also
significantly reduce polymerization shrinkage and dramatically
improve the physical properties of nanocomposites. The
nanocomposite is composed of three different types of filler
components: nonagglomerated discrete silica nanoparticles,
barium glass, and prepolymerized fillers.
Caries prevention fillers: To increase mineral content to
control dental caries, calcium and phosphate ion-releasing fillers
have been developed, such as nanoparticles of dicalcium
phosphate anhydrous (DCPA) 11,12 and tetracalcium phosphate
[TTCP: Ca4(PO4) 4O]-whiskers.13
LOCAL ANAESTHESIA
One of the most common procedures in dentistry is the
injection of local anesthetic, which can involve long waits and
varying degrees of efficacy, patient discomfort and
10
complications. Well-known alternatives, such as transcutaneous

electronic nervestimulation, cell demodulated electronic targeted
anesthesia and other transmucosal, intraosseous or topical
techniques are of limited clinical effectiveness.5,7 To induce oral
anesthesia in the era of nanodentistry, dental professionals will
instill a colloidal suspension containing millions of active
analgesic micrometer-sized dental nanorobot particles on the
patient's gingival (fig.6). After contactingthe surface of the crown
or mucosa, the ambulating nanorobots reach the dentin by
migrating into the gingival sulcus and passing painlessly through
the lamina propria14 or the 1 to 3m thick layer of loose tissue at
the cemento-dentinal junction.15 On reaching the dentin, the
nanorobots enter dentinal tubule holes that are 1 to 4 m in
diameter16,17and proceedtoward the pulp, guided by a combination
of chemical gradients, temperature differentials and even
positional navigation,7 all under the control of the onboard
nanocomputer, as directedby the dentist.
There are many pathways to choose from. Dentinal
tubule number density is typically 22,000 mm2 near the dentinoenamel junction, 37,000 mm2 midway between the junction and
the pulpal wall, and 48,000 mm2 close to the pulp in coronal
dentin, with the number density slightly lower in the root (for
example,13,000 mm2 near the cementum). Tubule diameter
increases nearer the pulp, which may facilitate nanorobot
movement, although circumpulpal tubule openings vary in
number and size.18
MAINTAINANCE OF ORAL HYGIENE
Nanorobotic dentifrice delivered by a mouthwash or
toothpaste could patrol all supragingival and subgingival
surfaces, at least once a day, metabolizing trapped organic matter
into harmless and odorless vapors and performing continuous
calculus debridement.19
These almost invisible (1 to 10 micrometre)
dentifrobots, perhaps numbering 1000 to 100000 per mouth and
crawling at 1 to 10 micrometre per second might have the
mobility of tooth amoebas but would be inexpensive purely
mechanical devices that safely deactivate themselves, if
swallowed. Moreover, they would be programmed with strict
protocol to avoid occlusal surfaces. Properly configured
dentifrobots could identify and destroy pathogenic bacteria
residing in the plaque and elsewhere, while allowing the 500 or so
species of harmless oral micro flora to flourish in a healthy
ecosystem. Dentifrobots also would provide a continuous barrier
to halitosis since bacterial putrefaction is the central metabolic
process involved in oral malodor. With this kind of daily dental
care available from an early age, conventional tooth decay and
gingival disease will disappear.
NANO TOOTHPASTE
Nano-Whitening Toothpaste is toothpaste that contains
synthesized hydroxyapatite, a key component of tooth enamel, as
nanosized crystals. It has been proven to freshen breathe as well as
whiten teeth. This toothpaste contains ingredents such as:
Patented nano technology aka Nanoxyd, Calcium peroxide,
Contains Enzymes such as (papain and bromelain), Fluoride
combination, Co-enzyme Q10 and Vitamin E.7
The risks of nanotechnology toothpaste: Nanotechnology
toothpaste has been shown to be harmful because some of the
nanotechnology toothpastes are made with silver hydroxyapatite:
1. If this accumulates in the tissues of people who use this
2.
3.
4.
toothpaste, it could cause potential health effects. If the silver

particles build up in our water systems, they may start
accumulating in other people and animals as well.
Risk of nanoparticles flowing through the body if the
toothpaste is actually swallowed.
Some people feel that this is not friendly for the environment.
They can even slip through the olfactory nerve into the
brain, evading the protective blood brain barrier. It's not clear
whether they penetrate the skin. Once they're inside the body,
it's not clear how long they remain or what they do'' says
Caroline Bass of Environmental 360. 6
NANOFILLED RESIN MODIFIED GLASS IONOMER

A new nano-filled RMGI restorative material has been
introduced for restoration of primary teeth and small cavities in
permanent teeth. It is based on a prior RMGI with a simplified
dispensing and mixing system (paste/paste) that requires the use
of a priming step, but no separate conditioning step. Its primary
curing mechanism is by light activation, and no redox or self
curing occurs during setting. Apart from the user-friendliness, the
major innovation of this material involves the incorporation of
nano-technology, which allows a highly packed filler
composition (69%), of which approximately two-thirds are nanofillers. 20
Composition: Chemistry of nanoionomer is based on the
methacrylate modified polyalkenoic acid, which is capable of
both crosslinking via pendate methacrylate groups as well as the
acid-base reaction between the fluoroaluminosilicate glass (FAS)
and the acrylic and itaconic acid copolymer groups. It contains
surface treated nanofillers (approx 5-25nm) and nanoclusters
(approx 1 to 1.6 microns). Filler loading is approx. 69% by weight
of which the relative proportion of two filler types (FAS and
combination of nanofillers ) are approx 2/5 and 3/5 respectively.
All nanofillers are further surface modified with methacrylate
silane coupling agents to provide covalent bond formation into
free radically polymerized matrix.21
DENTAL HYPERSENSITIVITY
Dentin hypersensitivity is defined as a sharp pain arising
from exposed dentin as a result of various stimuli such as heat,
cold, chemical or osmotic, and that cannot be ascribed to any
other pathology. It a may be caused by changes in pressure
transmitted hydrodynamically to the pulp. This is based on the
fact that hypersensitive teeth have 8 times higher surface density
of dentinal tubules and tubules with diameters twice as large as
nonsensitive teeth. Dental nanorobots could selectively and
precisely occlude selected tubules in minutes, using native
biological materials, offering patients a quick and permanent
cure.5 On reaching the dentin, the nanorobots enter dentinal
tubular holes that are 1 to 4 m in diameter and proceed toward
the pulp, guided by a combination of chemical gradients,
temperature differentials and even position of navigation, all
under the control of the onboard nanocomputer as directed by the
dentist.
Novamin containing dentrifice has the ability to
significantly reduce dentin sensitivity within one week compared
to placebo dentrifices. 2 2 Novamin (calcium sodium
phosphosilicate) is a bioactive glass in the class of highly
biocompatible material that were originally developed as bone
regenerated material. The Chinese researchers have
demonstrated that dentinal tubules can be blocked with the aid of
11
gold nanoparticles. One of the method of closing sub micron sized

dentinal tubules involved sintering of highly concentrated gold
nanoparticles that were brushed into exposed open ends of
tubules. Laser irradiation induced the photofusion of these
particles via photothermal conversion. This method seems to be
very promising for the purpose of occlusion of dentinal tubules.23
microbiology started with the detection of cultivable as well as

uncultivable bacteria by examining bacterial 16 sRNA and DNA.
The spatial distribution of different oral bacteria within
the plaque has been revealed by fluorescent in situ hybridization.
The metagenomic project for oral microbial flora will reveal the
metabolic genes and virulence factors of oral microbes.
Nanotechnology has been used to study the dynamics of
demineralization/remineralization process in dental caries by
BONE REPLACEMENT MATERIAL
Although tooth enamel, cementum, and bone are using tools such as atomic force microscopy (AFM) which detect
composed of organized assemblies of carbonated apatite crystals, bacteria induced demineralization at an ultrasensitive level.
enamel is unusual in that it does not contain collagen and does not Using AFM the correlation between genetically modified
remodel. Self-assembly of amelogenin protein into nanospheres Streptococcus mutans sp. scale morphology has been assessed.
has been recognized as a key factor in controlling the oriented and The nanoscale cellular ultrastructure is a direct representation of
elongated growth of carbonated apatite crystals during dental genetic modifications as most initiate changes in surface protein
and enzyme expression, where host- cell nutrient pathways and
enamel biomineralization.
immune response protection likely occur. The surface proteins
and enzymes, common to S. mutans strains are a key contributor
BIOCERAMICS
Nanosized hydroxyapatite (HA) is the main component of to the cariogenicity of these microbes.
Another nanotechnology application used so far is
mineral bone in the form of nanometer sized needle-like crystals
16
18
of approximately 5-20 nm width by 60 nm length. Synthetic HA O /O reverse proteolytic labelling to determine the effect of
possesses exceptional biocompatibility and bioactivity properties biofilm culture on the cell envelope proteome of oral pathogen,
with respect to bone cells and tissues, hence have been widely Porphyromonas gingivalis sp. which is linked to chronic
used clinically in the form of powders, granules, dense and porous periodontitis. A group of cell-surface located C-terminal domain
blocks and various composites. Nanophase HA properties such as family proteins including R gp A, Hag A, CPG 70 and PG99
surface grain size, pore size, wettability, etc, could control protein increased in abundance in the bio-film cells. The other proteins
interactions modulating subsequent enhanced osteoblast which increased were transport related proteins (Hmu Y and Iht
adhesion and long-term functionality. However, since nanophase B), metabolic enzymes (Frd AB) and immunogenic proteins.
materials can mimic the dimensions of constituent components of Nanotechnology can further enable us to detect both cultivable
natural tissues, implants developed from nanophase material can bacteria and non cultivable with the help of nanochip. Similarly
be a successful alternative. Several encouraging reports on plaque acidity which is a good index for monitoring tooth
nanophase materials encourage its use for tissue engineering demineralization can be monitored using a microscale planer pH
applications. This has been achieved by the combined effect of its sensor. Application of nanotechnology to this prototype will
ability to mimic the natural nano dimensions and also the cell further reduce the size of the sensors and make the device more
responses encouraging high reactivity and in turn helps in user friendly to both the patients and clinicians.
New silver nanotechnology chemistry has proven to be
regenerating tissues. 5,7,24
NanOssR bone void filler from Angstrom Medica is effective against biofilms. Silver works in a number of ways to
considered to be the first nanotechnology medical device to disrupt critical functions in a micro-organism. For example it has
receive clearance by the US Food and Drug Administration in a high affinity for negatively charged side groups on biological
2005. Utilizing nanotechnology, calcium and phosphate are molecules such as sulphydryl, carboxyl, phosphate and other
manipulated at the molecular level and assembled to produce charged groups distributed throughout microbial cells. Silver
materials with unique structural and functional properties. It is attacks multiple sites within the cell to inactivate critical
prepared by precipitating nanoparticles of calcium phosphate in physiological functions such as cell wall synthesis, membrane
aqueous phase and the resulting white powder is compressed and transport, nucleic acid (RNA and DNA) synthesis and translation,
heated to form a dense, transparent, and nano crystalline material. protein folding and function and electron transport. For certain
bacteria as little as one part per billion of silver may be effective in
It is strong and also osteoconductive. 24
OstimR is an injectable bone matrix in paste form which preventing cell growth. Recent studies show that ionic plasma
received CE marking in 2002. It is composed of synthetic disposition silver antimicrobial nanotechnology is effective
nanoparticulate hydroxyapatite which is indicated for against pathogens associated with biofilms including E.coli sp.,
metaphyseal fractures and cysts, acetabulum reconstruction and S.pneumoniae sp., S.pneumoniae, S.aureus and A.niger.
periprosthetic fractures during hip prosthesis exchange
operations, osteotomies, filling cages in spinal column surgery, CONCLUSION
Nanodentistry will give a new vision to comprehensive
combination with autogenous and allogenous spongiosa, filling
24
oral
health
care, as now trends of oral health have been changing
in defects in children etc.
to more preventive intervention than a curative and restorative
procedure. This science might sound like a fiction now, but
NANOTECHNOLOGY AND BIOFILM23
Nanodentistry
has a strong potential to revolutionize dentistry as
Nanotechnology is a promising field of science which
to
diagnosing
and
treating dental diseases in future. It opens up
offers better insight into the spatial relationship between different
new
avenues
for
vast,
abundant research. Nanotechnology will
species and how their diversity increases over time.
Nanotechnology can guide our understanding of the role of change dentistry, health care and human life more profoundly
interspecies interaction in the development of bio-film. The than other developments.
contribution of modern technology in the field of oral
12
REFERENCES
1. Mitra S, Holmes B. An application of nanotechnology in
advanced dental material. J Am Dent Assoc 2003; 134(10):
1382-1390.
2. Schleyer TL. Nanodentistry Fact or Fiction. J Am Dent Assoc
2000; 131:1567-1568.
3. Saunders SA. Current practicality of nanotechnology in
dentistry. Part 1: Focus on nanocomposite restoratives and
biometics. Clin, Cos Investi Dent 2009:47-56.
4. Freitas RA. Personal choice in the coming era of
nanomedicine.
Nanoethics: The Ethical and Social
Implications of Nanotechnology, John Wiley, NY, 2007, pp.
161-172.
5. Kumar S R, Vijayalakshmi R. Nanotechnology in dentistry.
Ind J Dent 2006;17 (2): 62-65.
6. Future of Nanotechnology Toothpaste: Nanodentistry
Archive for category Nanotechnology Toothpaste.
7. Freitas RA. Nanodentistry. J Am Dent Assoc 2000; 131(11):
1559-1565.
8. Verma SK et al. A critical review of the implication of
nanotechnology in modern dental practice. National J of oral
maxillofacial surgery. 2010 (1) : 1: 41-44.
9. Freitas RA. The future of nanofabrication and molecular
scale devices in nanomedicine. Studies in health technology
and molecular scale devices in nanomedicine. 2002;80:4559.
10. Chen MH. Update on Dental Nanocomposites. J Dent Res
2010;89(6): 549-560.
11. Xu HH. Nano DCPA-whisker composites with high strength
and Ca and PO4 release. J Dent Res 2006;85:722-727.
12. Xu HH. Effects of calcium phosphate nanoparticles on CaPO4 composite. J Dent Res 2007;86:378-383.
13. Xu HH, Weir MD, Sun L. Calcium and phosphate ion
releasing composite: effect of pH on release and mechanical
properties. Dent Mater 2009;25:535-542.
14. Paulsen F, Thale A. Epithelial-Connective tissue boundary in
the oral part of human soft palate. J Anat 1998;93:457-67.
15. YamamotoT. The structure and function of the cementodentinal junction in human teeth. J Perio Res 1999;34(5):
261-8.
16. Dourda AO. A morphometric analysis of the cross-sectional
area of dentine occupied by dentinal tubules in human third
molar teeth. Int End J 1994;27(4):184-89.
17. Arends J .The diameter of dentinal tubules in human coronal
dentine after demineralization and air drying: a combined
light microscopy and SEM study. Caries Res 1995;
29(2):118-21.
18. Marion D, Jean A, Hamel H. Scanning electron microscopic
study of odontoblasts and circumpulpal dentin in a human
tooth. J Endod 1991; 72(4) 473-8.
19. Ling Xue Kong. Nanotechnology and its role in the
management of periodontal diseases. Periodontol 2000;
40:184196.
20. Ketac Nano Light Curing Glass Ionomer Restorative. 3M
ESPE technical product profile.
21. Requicha AAG Nanorobots NEMS and Nanoassembly.
Proc. IEEE J Endod 2003;91(11):1922-1933.
22. Marini I, Checchi L, Greenspan D. Pilot clinical study
evaluating efficacy of NovaMin containing dentifrice for
relief for relief of dentin hypersensivity. NovaMin Research
Report 2002.
23. Bhardwaj SB, Mehta M, Gauba K. Nanotechnology: Role in

dental biofilms. Indian J Dent Res 2009;20(4 ):511-513.
24. Paul W, Sharma CP. Nanoceramic Matrices: Biomedical
Applications. Am J Biochem Biotech 2006;2(2):41-48.
Corresponding
Address:
Dr.
Sumit
Mohan
Dr.
C.
Ram
Mohan
KKAggarwal
Dixit
Dr.Dr.
Neha
Email:
samsharma770@gmail.com
Email:
dr_rammohanc@yahoo.co.in
Email:
dixit.kk@gmail.com
Email: dr.nehaaggarwal19@gmail.com
13
LIST OF PHOTOGRAPHS
Fig 1: Comparison of nanoparicle with water molecule and tennis ball
Fig. 2 Three different types of fillers components, non-agglomerated discrete silica nanoparticles,
prepolymerized fillers (PPF) and barium glass filler in nanocomposite.
Fig.3 Nanorobots in local anaesthetic solution
14
Flapless Implant Surgery : An Overview
Rashi Jolly , Himanshu Thukral , Mansi Thukral Chandra
Senior Lecturer, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).

Oral and Maxillofacial Surgeon, New Delhi.
Cosmetic Surgeon, New Delhi.
Date of Receiving : 28/Apr/2013
Date of Acceptance : 03/Jun/2013
Abstract: As osseointegration is now considered highly predictable, the current trendis to develop techniques
that can provide function, esthetics, and comfort with aminimally invasive surgical approach. To achieve those
goals, flapless implantsurgery using a tissue punch technique has been suggested. This paper presents
anoutline of the indications and advantages of flapless implant surgery for delayed placementand loading
protocols.
Key words : Flapless, Minimally Invasive, One-Stage, Tissue Punch.
INTRODUCTION
Dental implant therapy has been used frequently for the
rehabilitation of missing dentition, It is replacing conventional
treatment options like Fixed bridges and Removable partial
dentures in many clinical situations of one or more missing teeth.12
The surgical procedure for placement of implants to

replace posterior teeth normally begins with an incision to
uncover the osteotomy site. Conventionally, a two-stage surgical
approach using submerged implants was advocated with the
concept that a healing period of at least 3 to 4 months should be
allowed to provide a load-free environment and undisturbed
healing for successful osseointegration.3The concept that
implants should be covered by tissue to ensure primary
stabilization and reduce infection was standard of care in the
original concept of surgical protocol.4 This is now being
challenged as unnecessary with flapless surgery for implant
placement.
REVIEW OF LITERATURE
Studies have recommended the use of a one-step punch
technique for many clinical situations requiring implants.30 These
include a wide bony ridge, presence of a broad zone of keratinized
tissue, the absence of vital structures, and surgery requiring
difficult and complex flap manipulation. This technique has also
been used when primary anchorage and stabilization were
predictably obtained and to maintain the integrity and topography
of adjacent hard and soft tissues. For patients who cannot
discontinue use of anticoagulants and patients with meticulous
plaque control, one-punch surgery is useful.
Landsburg and Bichacho (1998)5recommended use of a
one step punch technique for many clinical situations requiring
implants.These include a wide bony ridge,presence of a broad
zone of keratinized tissue, the absence of vital structures, and
surgery requiring difficult and complex flap manipulation. This
technique was also used when primary anchorage and
stabilization were predictably obtained and to maintain the
integrity and topography of adjacent hard and soft tissues.For
patients who cannot discontinue use of anticoagulants and
patients with meticulous plaque control, one punch surgery is
useful.
Campelo and Camera (2002)6used flapless surgical
procedures and placed 770 implants in 359 patients over a 10 year
period.They reported a success rate of only 74% in 1990 but a
100% success in 359 patients over a 10 year period.They reported
a success rate of only 74% in 1990 but a 100% success rate in
2000.Each patient was examined after 3 months,6 months,1 year
and then once every year.Prosthesis was removed,if possible,and
implant mobility was assessed,periapical radiographs were
obtained, and periodontal probing was performed.
Implants were considered failed if they had mobility or
pai,had to be removed,or if they showed more than 0.5mm of
bone loss per year and signs of active periimplantitis.They called
flapless surgery a blind surgical technique but said advantages
include less time and minimal bleeding, with no suturing
necessary.They also stated that patient selection and proper
surgical technique were essential factors for success.
In a 2 year study by Becker et al (2005)7, 79 implants
were placed in 57 patients from 24 to 86 years old using a
minimally invasive one stage flapless technique.The parameters
evaluated were total surgical time, implant survival,bone quality
and quantity, implant position by tooth type, depth from mucosal
margin to bone crest, implant length, probing depth,
inflammation, and crestal bone changes.Thirty two implants were
placed in the maxillae and 42 were placed in mandibles.The
cumulative success rate was 98.7%. For remaining implants,
changes in crestal bone over time were clinically insignificant, as
were mean changes for probing depth and inflammation.The
results of this study demonstrate that by following specific
diagnostic and treatment planning criteria, flapless surgery using
a minimally invasive technique is successful and predictable.The
benefits of this procedure are reduced surgical time, minimal
changes in crestal bone height, probing depth, and inflammation,
minimal haemmorhage, and less postoperative discomfort.
Tae Ju Oh et al (2007) demonstrated successful use of
flapless implant surgery for both immediate and delayed loading
protocols in the esthetic region.Advantages of the flapless
implant surgery shown in the cases included less traumatic
surgeryand decreased operative time, which resulted in
accelerated postsurgical healing, fewer postoperativ
15
complications, and increased patient comfort and

satisfaction.Especially with the immediate loading protocol, the
advantages were more pronounced because of the absence of a
waiting period before prosthetic restoration.
Another advantage of the flapless implant surgery was in
preservation of soft tissue profiles, including the gingival margins
of the adjacent teeth and the interdental papillae.This is attributed
to the avoidance of flap reflection, which might cause
postsurgical bone resorption and soft tissue recession.
Nadine Brodala (2009) reviewd the current literature
with regard to the efficacy and effectiveness of flapless surgery
for endosseous dental implants. Only clinical(human) studies
with five or more subjects were included.The available data on
flapless technique indicate high implant survival overall.The
prospective cohort studies demonstrated approximately 98.6 %
survival,suggesting clinical efficacy,while the retrospective
studies or case series demonstrated 95.9% survival,suggesting
effective treatment. Six studies reported mean radiographic
alveolar bone loss ranging from 0.7 to 2.6mm after 1 year of
implant placement.Intraoperative complications were reported in
four studies,and these included perforation of the buccal or
lingual bony plate.Overall,the incidence of intraoperative
complications was 3.8% of reported surgical procedures.It was
concluded that flapless surgery appears to be a plausible treatment
modality for implant placement ,demonstrating both efficacy and
clinical effectiveness.
Presently, one piece Implants with implant therapy
utilizing the one-stage surgical protocol (nonsubmerged
implants) has also been available, and its successful use has been
proven comparable to the two-stage surgical approach.10-11
With the high predictability of osseointegration, the
current trend is geared toward developing methods to enhance
patient function, esthetics, and comfort.
Along with continuous improvements in implant materials,
designs (macrostructures and microstructures), surface treatment
and placement techniques, clinical usage of immediate implant
non functional loading has been adopted in implant therapeutics,
thus providing patients with enhanced function, esthetics, and
comfort.
Clinical Considerations
TABLE 1
Indications of the Flapless Implant surgical procedure
1.
2.
3.
4.
5.
6.
7.
8.
Wide Bony Ridge

Presence of a wide Zone of Keratinized tissue
Absence of Vital Structures in the anatomical region
Surgical procedures requiring Complex Flap
manipulation
Patients on Anticoagulant therapy who cannot stop
these medications
In cases where Predictably the surgeon can obtain a
Primary stability with the Implants.
Not suitable in ridges with concavities and parabolic
shaped ridges
Need for an experienced operator with sound clinical
judgment
TABLE 2
Limitations of Flapless Implant Procedures.
1.
2.
3.
Not suitable in ridges with concavities and parabolic

shaped ridges
Need for an experienced operator with sound clinical
judgment
Absolute necessity for using axial tomography or CT
for pre-operative evaluations.
TABLE 3
Advantages of the Flapless Implant surgical procedure
1.
2.
3.
4.
5.
6.
Reduced trauma
reduced operative time
Faster soft tissue healing
fewer complications
Improved Patient comfort
Patient resumes normal diet and Oral Hygiene habits
following the procedure
TABLE 4
Disadvantages of the Flapless Implant surgical procedure
1.
2.
Inability to visualize anatomic landmarks.

Possibly thermal bone damage secondary to
inadequate irrigation during osteotomy preparation (
In cases where Surgical templates are used)
3. Malposed angulations
4. Inadequate depth of implant placement (if soft tissue
width is not taken into consideration)
5. No access to contour the osseous ridge to facilitate
restorative procedures, if required.
Some factors considered detrimental to this treatment
modality include lack of direct visibility, difficulty in evaluation
of any existing facial osseous defects.
FLAPLESS IMPLANT PLACEMENT
In case of immediate implant placement, the clinical
procedure for the flapless placement technique starts with an
atraumatic extraction of the unsalvageable teeth. Drilling is then
performed through a surgical template with the use of a buccally
placed guiding finger, to avoid perforating the buccal bone.
Autogenous bone chips collected from the drill flutes may be
packed around the implant in case of any existing gaps. Finally
the round edges may be approximated and sutured. This not only
provides better primary closure but also avoids post-operative
soft tissue complications.
In the delayed implant placement protocol, gingival
tissue punching is done to remove a piece of soft tissue and
expose the bone for implant placement. This reduces postoperative soft tissue recession.
DISCUSSION
Advantages of the flapless implant surgery, include less
traumatic surgery and decreased operative time, which result in
accelerated postsurgical healing, fewer postoperative
complications, and increased patient comfort and satisfaction.
Another advantage of the flapless implant surgery is preservation
of soft tissue profiles, including the gingival margins of the
adjacent teeth and the interdental papillae. In our opinion, the
16
remaining buccal bone thickness after implant placement should

be at least 2.0 mm to minimize postsurgical resorption. This is in
agreement with the critical facial bone thickness of 1.8 mm
proposed by Spray et al. 12 The critical facial bone thickness must
be carefully analyzed when surgical stents are constructed.
The feasibility of flapless implant surgery with
immediate loading 13or with delayed loading 14has been
demonstrated. However, prerequisites for the flapless implant
surgery have also been reported; these include sufficient bone
width and height, adequate keratinized soft tissue, and an absence
of significant tissue undercuts.15
First, sufficient amounts of available bone and
keratinized tissue are necessary because direct visualization of
bone topography is limited and sacrifice of some keratinized
tissue, although minimal, is inevitable in this particular technique.
For example, required bone volume for the placement of a
standard endosseous root-form implant. 16Computer software's
like SimPlant and NobelGuide definitely aid in increasing the
precision of surgical templates in guiding the direction of implant
drilling.Although debatable, the presence of peri-implant
keratinized tissue is regarded beneficial, especially for the
longevity of rough surfaced implants.17An adequate amount (i.e.,
more than 2 mm) of keratinized tissue must remain on the facial
aspect of the implant site after tissue punch. If the soft tissue is
insufficient or not expected to be esthetically pleasing after the
flapless surgery, soft tissue grafting procedures or papilla
regeneration techniques should be considered. In addition to the
factors described previously for case selection, precautions
should be taken during surgical and prosthodontic procedures.
Because of the lack of visibility of hard tissue contours
in the flap, it is extremely crucial during implant site preparation
to place implant drills against surgical stents using the full length
of the apicocoronal drill orientation. Incorrect angulation of
implant drills can cause perforation of the cortical plates, usually
on the buccal aspect, resulting in dehiscence or fenestration.
Although not presented here, perforation of the buccal plate is
generally detected by palpation or by observation of implant
threads through the soft tissue. With regard to immediate loading,
primary stability should be confirmed with hand-torquing of the
provisional abutment. If any movement is noted during handtorquing, a delayed loading protocol should be considered.
CONCLUSION
Flapless implant surgery using a tissue punch technique
can be successfully employed when replacing posterior teeth.
Careful diagnosis and treatment planning are essential. The
protocol for this procedure includes proper evaluation of bone
type, height and width of the residual ridge, and amount of
available keratinized tissue. The surgical technique should
include use of a surgical stent, appropriate use of rotary punches
and implant burs, and an osteotomy that promotes a stable
implant.
REFERENCES
1. Adell R, Lekholm U, Rockler B, Brnemark P-I. A 15-year
study of osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981;10:387416.
2. Brnemark P-I, Hansson BO, Adell R, et al. Osseointegrated
implants in the treatment of the edentulous jaw. Experience
from a 10-year period. Scand J Plast Reconstr Surg Suppl
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Osseointegrated titanium implants. Requirements for
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Brnemark PI, Hansson BO, Adell R, et al. Osseo-integrated
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from a 10-year period. Scand J Plast Reconstr Surg Suppl.
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Pract Periodontics Aesthet Dent 1998;10:1033-1039
Compelo LD, camara JR. Flaplesh implant surgery: a 10 year
clinical reprospective analysis. Int J Oral Maxillofac
Implants 2002;17:271-276
Becker W, Goldstein M, Becker BE, et al. Minimally
invasive flapless implant surgery: a prospective multicenter
study. Clin Implant Dent Relat Res. 2005;7(suppl 1):S21S27.
Oh TJ, Shotwell, Byun HY, Wanq HL. Flapless Implant
Surgery in the esthetic region: advantag & Precautions. Int J
Perio Rest Dent 2007; 27: 27-33.
Brodala N. flapless surgery & its effect on dental implant
outcomes. Int J Oral Maxillofacial Implants 2009;24:118125.
Buser D, Mericske-Stern R, Bernard JP, et al. Long term
evaluation of non-submerged ITI implants. Part I: 8-year life
table analysis of a prospective multi-center study with 2359
implants. Clin Oral Implants Res 1997;8:161172.
Weber HP, Buser D, Fiorellini JP, Williams RC.
Radiographic evaluation of crestal bone levels adjacent to
nonsubmerged titanium implants. Clin Oral Implants Res
1992;3:181188.
Spray JR, Black CG, Morris HF, Ochi S. The influence of
bone thickness on facial marginal bone response: Stage 1
placement through stage 2 uncovering. Ann Periodontol
2000;5:119128.
Hahn J. Single-stage, immediate loading, and flapless
surgery. J Oral Implantol 2000;26:193198.
Campelo LD, Camara JR. Flapless implant surgery: A 10year clinical retrospective analysis. Int J Oral Maxillofac
Implants 2002;17:271276.
Hahn J. Single-stage, immediate loading, and flapless
surgery. J Oral Implantol 2000;26:193198.
Sclar AG. Guidelines and pitfalls of minimally invasive and
flapless dental implant surgery. J Oral Maxillofac Surg.
2007;65(suppl):9-10.
Block MS, Kent JN. Factors associated with soft- and hardtissue compromise of endosseous implants. Int J Oral
Maxillofac Surg 1990;48:11521160.
Corresponding
Address:
Dr.
C.
Ram
Mohan
Dr.
Rashi
KKAggarwal
Dixit
Jolly
Dr.Dr.
Neha
Email:
Email:
Email:
rashijolly5@yahoo.co.in
dixit.kk@gmail.com
Email:
dr.nehaaggarwal19@gmail.com
17
LIST OF PHOTOGRAPHS
Figure 1- Drill used for Flapless Implant Surgery
Fig: 2 Pre- Treatment Photograph
Fig: 3 Post- Treatment Photograph
18
Fluorides and Their Role in Demineralization and Remineralization
Sonal Soi , Vineet Vinayak , Anurag Singhal , Sonali Roy
Senior Lecturer, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor & Head, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
PG Student, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 28/Mar/2013
Date of Acceptance : 01/May/2013
Abstract: Demineralization and remineralization begins with historical prespective on caries. Caries were
identified as a major public health problem in 1940s . Demineralization is a process of removal of minerals from
dental enamel. Remineralization on the other side is the process of restoring minerals to hydroxyapatite lattice.
The battle to keep teeth strong and healthy is dependent upon ratio between demineralizaton and
remineralization. In this scientific era new advances have changed our idea from "cure" to "prevention".
Remineralization can mainly be achieved by mineral or ionic technology .Ionic technology mainly includes
fluorides. Fluorides works primarily via topical mechanism which includes ,inhibition of demineralization at
crystal surface, enhancement of remineralzation at crystal surface, and at high concentration inhibition of
bacterial enzymes. This article deals with various aspects of fluorides in management of De/ Remineralization.
Key words : Demineralzsation, Remineralization, Fluorides.
INTRODUCTION
In early 1960 Massler, Fusayama and Branstorm dealt
with the science of De / Remineralization. Earlier dental caries
was thought to consist of a one-way progressive demineralization
of enamel crystallite followed by degradation of dentin leading to
cavity formation. Later with increased knowledge dental caries
was found to be a dynamic process with demineralization of the
hard dental tissue by the acidic products of bacterial metabolism
that alternates with periods of remineralization.1 When the two
processes are in balance no net mineral loss occurs at the tooth
surface, but when the magnitude of one exceeds the other it leads
to net demineralization or alternatively to remineralization.2 The
notion that loss of tooth mineral can be compensated by mineral
deposition has considerable consequences in operative and
preventive dentistry. It implies that non-restorative clinical
strategies have become a realistic option.
DEMINERALIZATION
Demineralization is the process of removing minerals, in
the form of mineral ions, from dental enamel. In another words,
Demineralization is "dissolving the enamel." A substantial
number of mineral ions can be removed from hydroxyapatite
latticework without destroying its structural integrity. When too
many minerals are dissolved from an area of the hydroxyapatite's
latticework, results in a cavity that is the loss of the
hydroxyapatite's crystalline latticework structure. The
latticework can be strengthened and restored through the process
of remineralization.3
REMINERALIZATION
Remineralization is the process of restoring minerals in
the form of mineral ions to the hydroxyapatite latticework
structure. Remineralization should be three-dimensional and
must be replaced with same shape, size and the same electrical
charge as those lost from the lattice.
Rationale for De / Remineralization

The solubility of the hydroxyapatite depends on both the
presence of impurities and the pH of the environment. pH is the
driving force for dissolution and precipitation of hydroxyapatite.4
At low pH the saturation concentration of the calcium
and phosphate ions with respect to apatite is higher than at high
pH. At neutral pH saliva and plaque fluid are super-saturated with
respect to hydroxyapatite. Consequently mineral will precipitate
if a suitable precipitation nucleus is available. The consumption
of fermentable sugars leads to acid production in the plaque and
the resulting decrease in pH increases the calcium and phosphate
concentration needed for saturation. The decreasing pH also
slows down the fermentation (rate of acid formation) by oral
bacteria.4
The calcium and phosphate content and in particular the
pH of these liquids determine whether enamel and dentin will
dissolve or alternatively whether mineral will precipitate.The
acid ions react principally with the phosphates in saliva and
plaque, until the critical pH for the dissociation of hydroxypatite
is reached at approximately pH 5.5 - 5.2. Further decrease in pH
results in progressive interaction of acid ions with phosphate
groups of hydroxyapatite causing partial or full dissolution of the
surface crystallites.5
The stored fluoride released in this process reacts with
Ca2+ and HPO42- ion breakdown products, forming fluorapatite, or
fluoride enriched apatite. If the pH decreases further below 4.5
that is the critical pH for fluorapatite dissolution, even
fluorapatite will then dissolve. If acid ions are neutralized, and the
Ca2+ and HPO4 2- ions are retained, then the reverse process of
remineralization occurs. The composition of the apatite then
formed depends on the composition of the solution from which it
is precipitated, in this case the plaque fluid. This periodic cycling
of pH results in a step-by-step modification of the chemical
composition of the outer layers of enamel that becomes
somewhat less soluble with time. This process is known as the
post-eruptive maturation of the enamel.4,5
19
De Remineralization Cycle4-6
It is apparent that the pH cycle depends on the strength of
the acid that is present, the frequency and duration of its
production and the remineralization potential in each particular
situation, any one of the following sequelae can occur.
1. The enamel may continue to mature
2. Chronic caries may develop slow demineralization
with active remineralization
3. Rapid (rampant) caries may arise rapid
demineralization with inadequate remineralization
4. Erosion may occur very rapid demineralization with
no remineralization at all
The chemical basis of the demineralization
remineralization process is similar for enamel, dentin and root
cementum. However the different structures and relative quantity
of mineral and organic tissue content of each of these materials
causes significant differences in the nature and progress of the
carious lesion.7
Enamel lesion
The initial enamel lesion results when the pH level at the
tooth surface exceeds that which can be counter-balanced by
remineralization but is not low enough to inhibit surface
remineralization. The acid ions penetrate deeply into the prism
sheath porosities, leading to sub-surface demineralization. The
tooth surface may remain intact through remineralization, which
occurs preferentially at the surface due to increased levels of
calcium, phosphate, fluoride ions and buffering by salivary
products.7
The clinical characteristics of such lesions are
1. Loss of normal translucency of enamel with a chalky
white appearance on dehydration
2. A fragile surface layer susceptible to damage from
probing particularly in pits and fissures.
3. Increased porosity particularly of the sub-surface with
potential for uptake of stain.
4. Reduced density of the sub-surface detected
radiographically or with Transillumination
5. A potential for remineralization with an increased
resistance to further acid challenge
The advancing coronal lesion1,6
If the demineralization - remineralization imbalance
continues the surface of the incipient lesion collapse through the
dissolution of apatite or fracture of the weakened crystallite
resulting in cavitations. Plaque can now be retained within the
depths of the cavity and the remineralization phase is rendered
more difficult and less effective. The dentin-pulp complex will
become involved at this point but there can still be fluctuations in
the degree of activity.
Demineralization into dentin7,8
The process of demineralization continues to be driven by
dietary substrate after bacteria have invaded dentin. The acid
production by bacteria dissolves the hydroxyapatite of deeper
dentin so there is a front of demineralization in advance of the
bacterial invasion.
The texture and color of dentin changes as
demineralization advances. The color will darken because of
bacterial products and stains from foods and beverages. If the
lesion is left to extend through the dentin the enamel will become
progressively undermined and weakened resulting in a wide-open
cavity that is relatively self-cleansing. The caries process may
then slow down leading to the development of a hard leathery
floor on the cavity that is more or less inactive.
FACTORS INFLUENCING DE- REMINERALIZATION

A high level of acid concentration and a high frequency
of contact will lead to demineralization of the tooth surface,
however natural protective factors and repair mechanisms can be
enhanced and the problem controlled at least to a degree. There is
a delicate balance between health and disease, involving acid
arising from bacteria laden plaque competing with protective
factors that are provided through normal salivary flow and good
hygiene.9
ROLE OF FLUORIDES
There have been many schools of thought over the years
as to the relative importance of different ways in which fluoride
acts to reduce dental caries. It is now well accepted that the
primary mode of action is the inhibition of demineralization and
enhancement of remineralization. Fluoride acts by inhibiting
mineral loss at the crystal surfaces and by enhancing the
rebuilding or remineralization of calcium and phosphate in a form
more resistant to subsequent acid attack.
Mechanism of action of fluoride
The most probable mechanism through which fluoride
prevents dental caries is by stabilizing the enamel crystal i.e. by
preventing enamel demineralization from the acid produced by
the microflora or by favoring recrystallization of dissolved
enamel surfaces or both. Preferably the fluoride should be bound
permanently to the enamel crystal in the form of fluorapatite.10
Fluoride ion substitutes for the hydroxyl ion in the
apatite structure giving rise to a reduction of crystal volume and a
concomitant increase in the structural stability. Under the
influence of fluoride, large crystals with fewer imperfections are
formed thus stabilizing the lattice and presenting a smaller
surface area/ unit volume for dissolution. Also enamel, which
mineralizes under the fluoride influence, has lower carbonate
content, thus giving a reduced solubility.1,8,10
Fluoride can be firmly bound when it is incorporated in
the crystalline lattice of hydroxyapatite or loosely bound when it
is adsorbed to apatite forming calcum fluoride deposits. In the
research on the cariostatic effect of fluoride, considerable
emphasis is placed on the role of free fluoride ions in the oral
fluid. Calcium fluoride is formed during treatments with high
concentration fluoride solutions. It can act as a fluid reservoir on
the tooth surface and release fluoride ions at low pH. This fluoride
ion along with calcium and phosphate diffuses into the lesion and
precipititates as fluorhydroxyapatite. The acid cycle thus
contributes to the conversion of loosely to firmly bound
fluoride.11,12
The fluoride ion (F-) inhibits the bacterial enzyme
enolase, thereby interfering with production of
phosphoenolpyruvate (PEP). PEP is a key intermediate of the
glycolytic pathway and, in many bacteria, is the source of energy
and phosphate needed for sugar uptake. The presence of 10-100
ppm of F-, inhibits acid production by most plaque bacteria (Fig.
99-4). These levels are delivered easily by most prescription
fluoride preparations; of equal interest is the finding that at acidic
pH values (5.5 or below), low levels of F- (1-5 ppm) inhibit the
oral streptococci. These levels are found in plaque, especially in
individuals who drink fluoridated water or who use fluoridated
dentifrices. If this plaque fluoride is derived from the tooth, an
antibacterial mode of action, which involves a depot effect, can be
postulated for systemic (water) and topical fluoride
administration.
The depot effect comes about in this manner. Water
fluoridation promotes the formation of fluorapatite, whereas
topical fluorides cause a net retention by the enamel of fluoride as
fluorapatite or as more labile calcium salts. Microbial
20
acid production in the plaque may solubilize this enamel-bound

fluoride, which at the prevailing low pH in the plaque
microenvironment could become lethal for the acid-producing
microbes. Such a sequence would discriminate against S mutans
and lactobacilli because they, as a result of their aciduric nature,
are most likely the numerically dominant acid producers at the
plaque-enamel interface. The fluoridated tooth thus contains a
depot of a potent antimicrobial agent that is not only released at an
acid pH value but is most active at this pH value. This hypothesis,
then, attributes some of the success of water fluoridation and
topical fluorides to an antimicrobial effect. It further suggests that
judicious use of topical fluorides would be effective in patients
with highly active caries. The most effective dose schedule and
fluoride preparation have not been determined.13
SOURCES OF FLUORIDES
Fluoride containing dentifrices
The use of fluoride containing toothpaste has been
proven to reduce the incidence of caries in numerous clinical
studies. During a typical one minute brushing period fluoride
rapidly permeates the tooth and is taken up by the enamel as
fluorapatite, calcium fluoride or even free fluoride. Rinsing the
mouth after brushing rapidly drops the salivary fluoride
concentration to 1 ppm or less within 15 minutes. However the
treated tooth enamel and perhaps the oral mucosa acts as a sink for
fluoride and subsequently release it to the oral cavity.4
The FDA as safe and effective for use in dentifrices
approves three sources of fluoride. They are Sodium Fluoride,
Sodium Monofluorophosphate and Stannous fluoride. Sodium
fluoride directly provides free fluoride. It is generally not found in
toothpaste formulations containing calcium-based abrasives
because of its potential to irreversibly bind to the abrasive and
form insoluble calcium fluoride on storage. Sodium
Monofluorophosphate is the fluoride of choice when calciumcontaining abrasives are used. The Monofluorophosphate ions
releases free fluoride when it hydrolyses on exposure to
phosphatase enzymes naturally present in the mouth.
Stannous fluoride provides fluoride and stannous ions
which act as an antimicrobial agent. It can also produce stannous
phosphate fluoride precipitates which slows down the caries
process but has staining as a side effect.14
Fluoride mouth rinses
They raise the concentration of fluoride in saliva for
several hours after use. Even though the residual concentrations
of fluoride in plaque and saliva are small, the modest elevations in
fluoride concentration may be sufficient to boost the rate of
remineralization and help inhibit caries development. Use of 0.05
% sodium fluoride mouth rinses has been shown to be better than
brushing with conventional fluoride toothpaste.
Fluoride releasing dental materials15,16
Resin modified GIC, conventional GIC and fluoride
releasing composites have been postulated to protect against
secondary caries in enamel and dentin. They have a synergistic
effect with fluoride rinses or dentrifrices in inhibiting
demineralization.
Pit and fissure sealants
They are effective in preventing pit and fissure
caries.The currently available sealants are second and third
generation which are polymerized with chemical catalyst or
require visible light to initiate a auto-catalytic reaction. It has been
suggested that fluoride released from sealants may have its great
effect at the base of the sealed groove helping remineralization of
incipient enamel lesion.3-5
CONCLUSION
Florides have anticaries effect and it also prevents
demineralisation, promotes remineralisation of early caries.
Fluoride is most commonly used remineralising agent. As the pH
rises, new and larger crystals that contain more floride forms are
formed , therby reducing the enamel demineralisation by forming
fluorhydroxyapetite. crystals and enhancing remineralisation.
REFERENCES
1. Thylstrup A, Fejerskov O. Textbook of Clinical Cariology
Second Edition Munksgaard .
2. Bynum AM, Donly KJ. Enamel de/ remineralization on teeth
adjacent to fluoride releasing materials without dentifrice
exposure: Journal of Dentistry for Children 1999;2: 89-91.
3. Anusavice KJ. Caries risk assessment: Op Dent 2001; 6: 1926.
4. Chow LC, Vogel GL.Enhancing remineralization: Op Dent
2001; 6:27-38.
5. Chow.L, Takagi, Carey CM. Remineralization effects of a
Two-solution Fluoride Mouth rinse: An in situ study: J Dent
Res 2000; 79(4): 991-995.
6. Donly K J et al. Evaluating the effects of fluoride-releasing
dental materials on adjacent interproximal caries: J Am Dent
Assoc. 1999 Jun; 130(6): 817-825.
7. Donly K J. Enamel and dentin demineralization inhibition of
fluoride-releasing materials: Am J Dent. 1994 Oct; 7(5):
275-8.
8. Duggal. M. S, K J Toumba, B T Amaechi, M B Kowash, S M
Higham. Enamel demineralization in situ with various
frequencies of carbohydrate consumption with and without
fluoride toothpaste: J Dent Res 2001; 80(8): 1721-1724.
9. Featherstone. An in-situ model for simultaneous assessment
of inhibition of demineralization and enhancement of
remineralization : J Dent Res. 1992; 71: 804-810.
10. Fazzi R, Vieria D Fad Zucas SM. Fluoride release and
physical properties of a fluoride-containing amalgam: J
Prosthet Dent. 1977 Nov; 38(5): 526-31
11. FejerskovOT. Rationale use of fluorides in caries prevention:
a concept based on the possible cariostatic mechanisms: Acta
Odontalog Scada 1981; 39: 241-249
12. Francci C. Fluoride release from restorative materials and its
effects on dentin demineralization: J Dent Res; 78, 16471654.
13. Kitasako, Nakajima, Foxton, Aoki, Pereira , Tagami.
Physiological remineralization of artificially demineralised
dentin beneath glass ionomer cements with and without
bacterial contamination In Vivo: Op Dent 2003; 28(3): 274280.
14. Rolla et al: Critical evaluation of the composition and use of
fluorides with emphasis on the role of calcium fluoride in
caries inhibition: J Dent Res 1990; 69: 780-785.
15. Ten Cate: Remineralization of caries lesions extending into
dentin: J Dent Res 2001; 80(5): 1407-1411.
16. Ten Cate J M, Duinen V. Hypermineralization of dentinal
lesions adjacent to glass ionomer cement restorations: J Dent
Res 1995; 74(6): 1266-1271.
Dr. Sonali Roy
Email: sapney86@yahoo.com
21
Bacterial Quantification in teeth with Apical Periodontitis Related to

Different Intracanal Irrigant : A Clinical Study
K.K. Dixit , Krishna Dixit , Anurag Gurtu , Nivedita Dixit , Rahul Pandey
Professor, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor, Department of Pedodontics.
BDS Intern, Institute of Dental Sciences, Bareilly (U.P).
BDS Intern, Institute of Dental Sciences, Bareilly (U.P).
Abstract: The antibacterial efficacy of intracanal irrigants, metronidazole, normal saline, EDTA, 3%
Hydrogen peroxide, 3% sodium hypochlorite and 2% Chlorhexidine was assessed in teeth with asymptomatic
apical periodontitis. 25 canals were randomly divided into three groups, instrumented and irrigated with three
different combination of irrigants. Bacterological samples were collected from the root canals before and after
irrigation in the first visit of treatment. Later the bacterial growth was assessed. It was concluded that EDTA,
Sodium hypochlorite(3%),and Chlorhexidine(2%) reduced the bacteria significantly.
Key words : Apical Periodontitis, EDTA, Chlorhexidine, Hydrogen peroxide, Sodium Hypochlorite.
INTRODUCTION
The main aim of root canal treatment is elimination of
bacteria from root canal and prevention of recontamination after
(1)
treatment . It has been reported that success rate of root canal
treatment was higher when teeth were free of bacteria after
chemomechanical instrumentation (2) . While instruments are
important in removal of infected dentin from the main root canal.
Irrigants play an important role in areas, where instruments cannot
reach, viz lateral and accessory canals as well as fins and webs
throughout the canal(3).
A lot of root canal irrigants are available which are used singly or in
combinations. Despite advances in disinfection in root canal
treatment, the irrigants are still not effective against all
microorganisms found in the root canal system. The purpose of the
study was to evaluate the efficacy of different combination of
irrigating solution during the first visit of treatment.
MATERIAL AND METHOD
Following materials tested and evaluated for antimicrobial efficacy :
Group I
: Metronidazole and normal saline.
Group II
: EDTA, Hydrogen peroxide(3%) and sodium
Hypochlorite(3%)
Group III : EDTA, Sodium Hypochlorite(3%) and
Chlorhexidine(2%)
METHODOLOGY
Patient Selection
Twenty five systemically healthy patient aged between 23
49 years. The patients were selected at random and included both
males and females. None of them had received systemic antibiotic
therapy in the preceding 3 months. All selected teeth had single roots,
Infected pulp chambers and showed an asymptomatic apical
periodontitis without communication to the mouth through fistula or
otherwise.
Collection of clinical specimen
Microbial samples and endodontic treatment were
performed for 60 sec with a 0.2 % chlorhexidine solution. Teeth under
treatment were isolated by a rubber dam. The pulp cavity was opened
with sterile round bur of appropriate size under distilled water spray.
Briefly the first collection was made by means of size 15 or size 20
sterile absorbent paper points to an approximate level of 1 mm short of
the tooth apex as determined by preoperative radiography and
maintained in place for 30 sec. Paper points were immediately
transferred to transport to the autoclaved veil containing Nutrient
broth. After completing biomechanical preparation using step back
technique; Second sample was made by means of using appropriate
size paper point and were immediately transferred to the autoclaved
veil containing Nutrient broth.
Isolation and identification of microorganisms
The average time between sample collection and laboratory
processing was 6 hrs. It is important to emphasize that the samples
were processed in the laboratory within 6 hrs to preserve the
reproductive capacity of bacterial cells and to prevent the growth of
0
microorganisms in the sample. Transport veil were placed at 37 C for
30 min and then vigorously mixed for 20 30 sec using a vortex
mixture and were incubated for 24 hours. Each sample was then
serially diluted in peptone water and aliquots (25l) were plated onto
several media as follows: MacConkey and Blood Agar.
Semi Quantization of Bacteria
A platinum loop of 0.001 ml of diameter was taken for
streaking the specimen. And Semi Quotation of bacteria was done by
multiplying the colony count by 1000.
Heavy: If the colony count was uncountable and growth was present
in all three streaking it was taken as heavy.
Moderate: If the colony count were more then 50 and was present in
first and second streaking it was taken as moderate.
Scanty: If the colony count was less then 50 and was present only in
first streaking it was taken as scanty.
No growth: Was taken when there was no growth
RESULTS
In present study Enterococcus, Streptococcus,
Staphylococcus, Neisseria and Pseudomonas were the frequent
bacteria recovered from the first sample of canal. The second sample
of canal shows heavy, moderate, Scanty and no growth of bacteria.
22
DISCUSSION
Several studies on root canal infections have focussed on 4.
aerobic and anaerobic bacteria due to their predominance in
samples taken from untreated teeth with necrotic pulps.
Microorganisms were recovered from the first sample in 25 root 5.
canals in agreement with previous studies that showed the
relationship between the microorganisms and the development of
apical periodontitis. (4) In majority of in vivo studies root canal
6.
samples were acquired with paperpoint (5) as in the study.
It is important to emphasize that the samples were
processed in the laboratory within 6 hrs to preserve the
reproductive capacity of bacterial cells. In the study K files were 7.
used for the preparation of the root canal by step back technique.
As the result of various studies showed neither of instrument
techniques were more efficient in cleaning of root canals.(6) (7)
In the present study Enterococcus, Streptococcus,
Staphylococcus, Nesseria and Pseudomonas were the frequent 8.
bacteria recovered from the canals before treatment. Despite
mechanical instrumentation and disinfection of the root canal
system in the first sitting, microorganisms were recovered in 22 9.
canals (Sample 3), clearly showing that root canal preparation and
irrigation is unable to eliminate all bacteria from the root canal
system. However preparation did reduce the bacterial population.
In accordance of the study carried out by Shuping AB et al(8), by 10.
Storm A et al(9) and Siqueira J.F et al(10) .
Removal of smear layer from the surface of
instrumented root canals should allow the penetration of irrigant
into root canal irregularities and the dentinal tubules. Various 11.
chemicals have been used to remove smear layer. They include
different formulation of EDTA, Acetic acid, Citric acid,
Polyacrylic acid, Tannic acid. In the study EDTA used in
combination of other irrigants. The result of study shows the 12.
Group III irrigants shows significant reduction of bacterial
population may be attributed to EDTA and Chlorhexidine which
has a broader antibacterial spectrum(11)and even at a highest 13.
concentration of chlorhexidine has a very low toxicity.(12)
It has been suggested that the bacterial population may be further
by adding ultrasonic.(13) The techniques such as ultrasonic, sonic
and pressure system might demonstrate different results and
further exploration is needed on this subject.
necrotic porcine muscle tissue. J Endod 1988;14: 125 7.

Stuart CH, Schwartz SA, Beeson TJ, Owatz CB;
Enterococcus faecalis. Its role in root canal treatment failure
and concepts in retreatment. J Endod 2002;32, 93 98.
Kvist T, Molander A, Dahln G, Reit C, Micro biological
evaluation of one and two visit endodontic treatment of teeth
with apical periodontitis ; a randomized clinical trial. J
Endod 2004; 30 : 572 6.
Valli KS, Lata DA, Jagdish S An in vitro SEM comparitive
Study of debridment ability of K files and canal Master. Ind J
Dent Res 1996;7:128 34.
Joao Vicente Baroni Barbizam, Luis Fernando Fariniuk,
Melissa Andre ia Marchesan, Jesus Djalma Pecora, Manoel
D. Sousa-Neto; Effectiveness of manual and rotary
instrumentation techniques for cleaning flattened root
canals. J Endod 2002;28(5):40-45.
Shuping GB, Dorstavik D, Sigurdsson A, Trope M;
Reduction of intracanal bacteria using nickel titanium
instrumentation and various medication 2000; 26:751 5.
By storm A, Sunvqvist G. Bacteriologic evaluation of the
efficacy of mechanical root canal instrumentation in
endodontic therapy Scand Journal of Dental Research 1981;
89: 321 - 8.
Siqueira JF Jr., Rocas IN, Santos SR, Lima KC, Magalhaes
FA, Deuzeda M, Efficacy of instrumentation technique and
irrigation regimens in reducing the bacterial population
within root canal. J Endod 2002; 28:181 4.
SiqueiraJF Jr., Batista MM, Fraga RC, De Uzeda M;The
Effects of endodontic irrigants on black pigmented gram
negative anaerobes and facultative bacteria. J Endod 1998;
24: 414 - 6.
Yesiloy C, Whitaker E, Cleveland D, Phillips E, Trope M;
Antimicrobial and toxic effects of established and potential
root canal irrigants. J Endod 1995; 21: 513 15.
Sjogren U, Sundquist G. Bacteriological evaluation of
ultrasonic root canal instrumentation on oral surgery
1987;63:366 - 70.
CONCLUSION
Among the three groups
Group 1: Normal saline and metronidazole reduced the microorganisms insignificantly.
Group 2: EDTA, Hydrogen peroxide and sodium hypochlorite
reduced micro-organisms more then group I.
Group 3: EDTA, sodium hypochlorite and chlorhexidine was the
one which reduced the root canal microflora significantly, and in
three cases there was no growth.
REFERENCES
1. Storm A. Sundquist G. Bacteriologic evaluation of the
efficacy of mechanical root canal instrumentation in
endodontic therapy. Scand J Dent Res 1981;89: 321 - 8
2. Sjogren U. Figdor, D. Persson S., Sundquist G. Influence of
infection at the time of root canal filling on the outcome of
endodontic treatment of teeth with apical periodontitis. Int
End J 1997;30: 297 306
3. Hasselgren G, Olsson B, Cvek M. Effect of calcium
hydroxide and sodium hypochlorite on the dissolution of
Corresponding
Address:
Dr.
C.
Ram
Mohan
Dr.
KKAggarwal
Dixit
Dixit
Dr.Dr.
Neha
Email:
Email:
Email:
dixit.kk@gmail.com
dixit.kk@gmail.com
Email:
23
LIST OF TABLES
Group I : Metronidazole and normal saline
No. Of Cases
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
SAMPLE 1: Growth and Predominant

bacteria
Heavy Growth
Staphylococcus, Bacillus, Enterococcus
Moderate Growth
E. Coli, Streptococcus
Heavy Growth
Streptococcus, Bacillus, Enterococcus
Heavy Growth
Pseudomonas, Streptococcus
Heavy Growth
Streptococcus
Heavy Growth
Moderate Growth
Neisseria, E.coli, Bacillus
Heavy Growth
Enterococcus, Pseudomonas

bacteria
Moderate Growth
Staphylococcus, Enterococcus
Moderate Growth
Streptococcus
Moderate Growth
Enterococcus, Bacillus
Heavy Growth
Streptococcus
Heavy Growth
Bacillus, Streptococcus
Heavy Growth
Enterococcus,
Moderate Growth
Bacillus
Heavy Growth
Group II EDTA, Hydrogen peroxide(3%) and sodium Hypochlorite(3%)

No. Of Cases
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8

bacteria
Moderate Growth
Streptococcus, Neisseria
Heavy Growth
Enterococcus
Heavy Growth
Enterococcus, Pseudomonas
Heavy Growth
Streptococcus, Enterococcus,
Heavy Growth
Enterococcus, Neisseria
Moderate Growth
Neisseria, Bacillis
Heavy Growth
Pseudomonas
Moderate Growth
Staphylococcus, Enterococcus

bacteria
Moderate Growth
Dipthroids
Moderate Growth
Heavy Growth
Moderate Growth
Dipthroids, Enterococcus
Heavy Growth
Enterococcus
Moderate Growth
Bacillus
Moderate Growth
Pseudomonas
Moderate Growth
Group III EDTA, Sodium Hypochlorite(3%) and Chlorhexidine(2%)

No. Of Cases
Case 1
Case 2
Case 3
Case 4
Case 5
Case6
Case 7
Case 8
Case 9

bacteria
Heavy Growth
Pseudomonas
Moderate Growth
Staphylococcus, Enterococcus, Neisseria
Heavy Growth
Enterococcus
Moderate Growth
Streptococcus
Heavy Growth
Heavy Growth
Neisseria, Bacillus
Moderate Growth
Streptococcus, Neisseria
Moderate Growth
Staphylococcus, Bacillus
Heavy Growth
Pseudomonas, Bacillus

ba cteria
Scanty Growth
Bacillus
No Growth
------------Scanty Growth
Bacillus
Scanty Growth
Streptococcus, Bacillus
Scanty Growth
Neisseria,Bacillus
Scanty Growth
Bacillus
No Growth
------------No Growth
------------Scanty Growth
Pseudomonas, Bacilli
24
Evaluation of the Root Canal Morphology of Mandibular First Premolars

in the Western Uttar Pradesh Population Using Computed Axial Tomography:
An in Vitro Study
Nishtha Chauhan , Anurag Singhal , Vineet Vinayak
PG Student, Department of Conservative Dentistry & Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Professor & Head, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 15/May/2013
AIM: To investigate the root and canal morphology of mandibular first premolar teeth in the Western UP
population.
METHODOLOGY: One hundred extracted mandibular pre molars were collected from local dentists in
western Uttar Pradesh and a CT scan was performed using Brightspeed Elite ,GE.
RESULTS: The most prevalent canal pattern in this study was Type I, occurring in 69 % of the mandibular first
premolars scanned followed by Type III occurring in 29 % of the teeth and Type II and Type V which were each
found in 1 % of all the teeth scanned.
Key words : Mandibular First Premolar, Root Canal , Morphology , CT Scan .
INTRODUCTION
A thorough knowledge of root canal anatomy and an
understanding of the potential for variations from the norm are
essential for successful endodontic therapy. Failure to recognize
and treat an additional root canal can result in treatment
failure1.According to Cleghorn variations can be attributed to sex
and ethinicity .
Mandibular first pre molars are known for the complex nature of
their canal configurations.
The textbookdescription of the mandibular first
premolar is typically of a single-rooted tooth2 .Two-rooted, threerooted and four-rooted varieties have also been reported, but are
rare. Slowey has suggested that the mandibular premolars may
present the greatest difficulty of all teeth to perform successful
endodontic treatment.
A study at the University ofWashington in 1955 assessed the
failure rate of non surgical root canal treatment in all teeth. The
mandibular first premolar had the highest failure rate in the study
at 11.45%3.
Various population groups have been studied including:
I. Chinese
II. Turkish
III. Mexican
IV. African american
V. Iranian
AIM
The aim of the study is to determine the root canal
morphology of the mandibular first premolar teeth in the Western
UP population using computed axial tomography.
III. Fractures
IV. Incompletely formed roots
V. Endodontically treated
RESULT
The most prevalent canal pattern in this study was Type
I, occurring in 69 % of the mandibular first premolars scanned
followed by Type III occurring in 29 % of the teeth and Type II
and Type V which were each found in 1 % of all the teeth scanned.
DISCUSSION
Many studies of root and canal morphology in
mandibular premolars have been conducted because these teeth
present complex morphology that often complicates treatment
(ENIGMA TO THE ENDODONTIST!)
In the current study CT scan has been used to analyse the
canal morphology of the mandibular first pre molars among the
western UP population.
Traditional radiography, hard tissue section, and root
canal staining in vitro are commonly used tools in identifying the
configuration of canals. However, most of these studies have
been performed ex vivo and involved complete destruction of the
tooth during examination (hard tissue sections) or have acquired
only two dimensional anatomic information (traditional
radiography)5
Robinson S, Czerny C, Gahleitner A, Bernhart T,
Kainberger FMfirst used CT scan to evaluate the root canal
configuration and variations in mandibular first premolar6
Later on in 2006 Eder A et al reported that CT scan was a
viable tool for the evaluation of unclear root canal configurations
7
MATERIAL AND METHODS

One hundred extracted mandibular pre molars were
collected from local dentists across Agra , Bareilly and Merrut .
Exclusion criteria:
I. Deep caries
II. Metallic restoration
The most prevalent canal pattern in this study was Type

I, occurring in 69 % of the mandibular first premolars scanned
followed by Type III occurring in 29 % of the teeth and Type II
and Type V which were each found in 1 % of all the teeth scanned.
Although most mandibular first premolars have a single
root, two-, three-, and even four-rooted forms have been reported
25
Number of canals and apices in the mandibular first premolar (incidence by number of teeth)3
Reference
No. of Teeth (n)
Ty pe of study
1 canal
Vertucci, 1984
400 (USA)
In vitro; clearin g
70% (280)
30% (120)
>2 canals 1 canal at apex >2 canals at apex

74% (2 96)
26% (104)
Lu et al. , 2006
82 (China)
In vitro; radiography
and sectioning
54% (44)
46% (38)
Sert and Bayirli, 2004 200 (Turkey; gender)
In vitro; clearin g
60.5% (121) 39.5% (79)
89.5% (1 79)
10.5% (21)
Yoshiok a et al., 2004
139 (Japan)
In vitro; clearin g
80.6% (112) 19.4% (27)
80.6% (1 12)
19.4% (27)
aliskan et al., 1995
100 (Turkey)
In vitro; clearin g
75% (75 )
25% (25)
Sabala et al., 1994
1002 (USA)
In vivo; review o f
patient records
64% (64)
36% (36)
81.8% (820) 18.2% (182)
CASE REPORTS OF MANDIBULAR FIRST PREMOLAR ANOMALIES3

Reference
MFP teeth in study (n)
Type of study
Anatomic variation
Milano et al.,
2002
1 (USA; 17-y.o. His panic

male)
Rad iographic
Study
All first and second mandibular premolars

exhibited 2 roots
M oayedi and Lata

2004
1 (India; 35-y.o. female)
Clinical RCT
3 canals (DB, DLi, and M) and an MB root

bifurcation
Nallapati, 2005
1 (USA; 49 -y.o. Caucasian

Jamaican male)
Clinical RCT
Single main canal split into 3 separate canals

and apical foramina
COMPARISON OF THE PRESENT POPULATION STUDY WITH THE STUDIES PERFORMED ON

OTHER POPULATIONS
POPULATION
STUDIED
SAMPLE
SIZE
(n)
TYPE
I
TYPE
II
TYPE
III
TYPE
IV
TYPE
V
TYPE
VI
TYPE
VII
TYPE
VIII
C SHAPED
CANAL
WESTERN
U.P
100
69
29
TURKISH8
(Sert S,2004)
200
60.5
18.5
10.5
2.5
Not reported
WESTERN9
CHINESE
(Xuan Yu,2012)
178
86.8
1.7
9.8
0.6
1.1
INDIAN10
(Sandhya R, Velmurugan
N, 2010)
100
80
as 2.1% incidence when grouped together. The majority

of mandibular first premolar teeth have a single canal but there is a
relatively high incidence, or one-quarter of mandibular
premolars, that have two or more canals (24.2%)3.
CONCLUSION
Among the Western U.P population , the Type I root canal
morphology occurred most frequently ( 69%) in the mandibular first
premolar teeth. This result is consistent with the results of the
previous studies done in India .
CT scan is a useful tool in assessing the root canal morphology .
REFERENCES
1. Martin Trope, Leslie Elfenbein Mandibular Premolars with
More Than One Root Canal in Different Race Groups
J.Endod1986 ;12:343-45
2. Ash M, Nelson S. Wheeler's dental anatomy, physiology and
occlusion. 8th ed. Philadelphia: Saunders, 2003.
3. Blaine M. Cleghorn William H. Christie et al The Root and Root
Canal Morphology of the Human Mandibular First Premolar: A
Literature Review (J Endod 2007;33:509 516)
4. Cohen S, Hargreaves KM: Pathways of the Pulp. 10th edition. St
Louis: Mosby-Elsevier 2011. p.144
5. XuanYu,BinGuo,Ke-Zeng Li et al.Cone-beam computed
tomography study of root and canal morphology of mandibular
premolars in a western Chinese population. BMC Medical
Imaging 2012, 12:18
6.
Robinson S, Czerny C, Gahleitner A, Bernhart T, Kainberger

FM. Dental CT evaluation of mandibular first premolar root
configurations and canal variations. Oral Surg Oral Med Oral Pathol
Oral RadiolEndod. 2002;93(3):328-32.
7. Eder A, Kantor M, Nell A,Moser T , Gahleitner A , Schedle A, et
al. Root canal system in the mesiobuccal root of the maxillary
first molar: an in vitro comparison study of computed
tomography and histology. DentomaxillofacRadiol 2006;
35:175-77
8. Sert S, Aslanalp V, Tanalp J: Investigation of the root canal
configurations of mandibular permanent teeth in the Turkish
population. IntEndod J 2004, 37:494499.
9. XuanYu,BinGuo,Ke-Zeng Li et al.Cone-beam computed
tomography study of root and canal morphology of mandibular
premolars in a western Chinese population. BMC Medical
Imaging 2012, 12:18
10. Sandhya R, Velmurugan N, Kandaswamy D. Assessment of root
canal morphology of mandibular first premolars in the Indian
population using spiral computed tomography: an in vitro study.
Indian J Dent Res. 2010;21 2:169173.
Dr. Nishtha Chauhan
Email: chauhannishtha@gmail.com
26
LIST OF PHOTOGRAPHS
Teeth were stuck on surgical plaster tape and 16 slice CT scan

(BRIGHTSPEED ELITE 16, GE) was used to scan the 100
premolars simultaneously.
Vertucci's classification was used to 4determine

the pattern of the root canal .
RESULT
Type I (1-1)
CORONAL -------------------------------------------------- APICAL
Type II (2-1)
CORONAL -------------------------------------------------- APICAL
Type III (1-2-1)
CORONAL -------------------------------------------------- APICAL
Type V (1-2)
CORONAL -------------------------------------------------- APICAL
27
Sialolithiasis: A Case Series
Sunil R Panat, Ashish Aggarwal, Nitin Upadhyay, Mallika Kishore, Abhijeet Alok
Professor and Head, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Abstract: Sialoliths are the calcified organic matter that forms within the secretory system of the major salivary
glands. Sialolithiasis accounts for 30% of salivary diseases. Stones may be encountered in any of the salivary
glands but most frequently in the submandibular gland and its duct(83-94%), less frequently the parotid (410%) and the sublingual glands (1-7%).Its occurrence in the adult population is approximately 12 per 1,000
patients, with a slight male predominance.While the majority of salivary stones are asymptomatic or cause
minimal discomfort, larger stones may interfere with the flow of saliva and cause pain and swelling. This case
report describes two patients presenting with submandibular gland sialolith and review of the literature
regarding the salivary sialothiasis.
Key words : Submandibular Salivary Gland, Sialolith, Warthon's Duct.
INTRODUCTION
Heterotopic calcification which results from deposition
of calcium in normal tissue despite normal serum calcium and
phosphate levels is known as idiopathic calcification. Sialoliths
belongs to the category of idiopathic calcification.1Salivary duct
lithiasis refers to the formation of calcareous concretions or
sialoliths in the salivary duct causing obstruction of salivary flow,
resulting in salivary ectasia, sometimes even dilatation of the
salivary gland.2More than 80% of salivary gland calculi can be
found in the submandibular gland and located in the glandular
parenchyma or the excretory duct.3
Males are affected twice as much as females, especially
in case of parotid gland lithiasis. Sialolithiasis usually occurs
between the age of 30-60 years, though it can also occur during
teen age. Children are rarely affected, but submandibular gland
calculi have been reported in children aged from 3 weeks to 15
years.4Within the submandibular gland, the vast majority of
sialoliths are found in the Wharton's duct. The ratio of sialoliths
found within the gland to those found in Wharton's duct is 3:7.2.5
The classic symptom are that of obstruction manifested
by pain and swelling of the involved during eating. Sialoliths are
usually unilateral and do not cause xerostomia. Submandibular
stones consist of 82% inorganic and 18% organic material while
the parotid stones are composed of 49% inorganic and 51%
organic material.6
Bimanual massage of the affected gland and the
excretory duct should be carried out, observing the flow and the
clearness of the saliva. Submandibular stones are typically
removed surgically via either an intraoral or an external
approach.7
CASE REPORT 1
A 35 year old male patient reported to the Department of
Oral Medicine and Radiology with a chief complaint of swelling
and pain on the right side of the jaw since 2 months. History of the
present illness revealed that there was history of increase in the
size of swelling during meals and subsides during the rest of the
day. It was not associated with any discharge. Pain was dull,
aggravated on eating food and relieved by itself. Extraoral
examination revealed a diffuse swelling won the right
submandibular region roughly measuring about 2x3 cm in
greatest dimension extending from base of mandible to 2 cm
below the inferior border of mandible. The skin overlying the
swelling was normal(Figure 1). On palpation,it was firm in
consistency and tender on palpation. In intraoral examination, a
firm mass was palpable on the floor of mouth extending from
mesial aspect of 46 to 47(Figure 2).On the basis of history and
clinical examination,a provisional diagnosis of sialolith was
given. In the investigations a mandibular occlusal radiograph was
taken which revealed a well defined radiopaque structure
measuring about 1x2 cm lingual to the body of mandible on the
right side(Figure 3). In the treatment surgical excision was done
which revealed the final diagnosis of sialolith.
CASE REPORT 2
A 45 year old female patient reported to the Department
of Oral Medicine and Radiology with a chief complaint of
swelling and pain on the left side of the jaw since 2 months.
History of the present illness revealed that there was history of
increase in the size of swelling during meals and subsides during
the rest of the day. It was not associated with any discharge. Pain
was dull, aggravated on eating food and relieved by itself.In
intraoral examination, a firm mass was palpable on the floor of
mouth extending from mesial aspect of 36 to 37(Figure 4). On the
basis of history and clinical examination,a provisional diagnosis
of sialolith was given. In the investigations a mandibular occlusal
radiograph was taken which revealed a well defined radiopaque
structure measuring about 1.5x1cm lingual to the body of
mandible on the left side(Figure 5). In the treatment surgical
28
excision was done which revealed the final diagnosis of sialolith.

DISCUSSION
Sialolithiasis accounts for more than 50% of diseases of
the large salivary glands. Submandibular sialolith formation is
more common because its saliva is more alkaline, has an
increased concentration of calcium and phosphate, and has a
higher mucous content than saliva from the parotid or sublingual
glands. Further, the submandibular duct is longer than that of the
other major glands, and the saliva flows against gravity.8 The
etiological factors that account for sialolith formation are
unknown, but saliva retention due to anatomical considerations,
and saliva composition, are believed to be important.9 Traditional
theories suggest that the formation of sialoliths occur in two
phases: 1. Formation of a central core and 2. A layered periphery.
The central core is formed by the precipitation of salts, which are
bound by certain organic substances. The second phase consists
of the layered deposition of organic and non-organic material.
Submandibular sialoliths are thought to be formed around a nidus
of mucus, whereas parotid sialoliths are thought to be formed
around a nidus of inflammatory cells or a foreign body.4
It is likely that for stone formation to occur, intermittent
stasis of calcium-rich saliva occurs, producing a change in the
mucoid element of saliva, and a gel forms. This gel produces the
framework for deposition of salts and organic substances thus
creating a stone.8 Salivary calculi are usually small and measure
from 1 mm to less than 1 cm. They rarely measure more than 1.5
cm .Mean size is reported as 6 to 9 mm .10
Sialoliths have been identified in the literature as
causing repeated swelling during meals. However, symptomless
sialoliths are common. If pain is present, the severity of the
symptoms depends on the degree of obstruction, which is related
to the size and location of the sialolith.11Sialolithiasis causes pain
and swelling of the involved area by obstructing the food-related
surge of salivary secretion. In some cases, the sialolith may cause
stasis of the saliva, leading to bacterial contamination of the
parenchyma of the gland, and clinical infection, with pain and
swelling of the gland. Long-term obstruction in the absence of
infection can lead to atrophy of the gland with resultant lack of
secretory function and eventual fibrosis.12
Correct diagnosis of a sialolith requires a proper history
and clinical examination. Sialoliths can occasionally be palpated
using a bidigital palpation approach at the floor of the mouth and
parotid regions. Bi-manual palpation of the gland itself can
identify a hypofunctional or nonfunctional gland associated with
a uniformly firm and hard mass.13 In the anterior floor of the
mouth, an occlusal radiograph may reveal the calculus. All
salivary stones cannot be visualized through conventional
radiograph because a few of them are hypominelarized and are
superimposed by other radiodense tissues. In these cases other
advanced imaging modalities should be considered. 14
Ultrasonography is widely reported as being very helpful in
detecting salivary stones. As many as 90% of all stones larger than
2mm can be detected as echodense spots on
ultrasonography.However, detection of small calculi may be
difficult with ultrasonography. Computed tomography (CT) is
also highly diagnostic.15Sialography is also useful to locate
obstructions that cannot be detected by means of bidimensional
radiography, especially whenever sialoliths are radiolucent or
whenever they are not present (as is the case with stenosis.2
Differential diagnosis of a sialolith could include a
calcified lymph node, an avulsed or impacted tooth or foreign
body, a phlebolith, or myositis ossificans.11Once a diagnosis of

sialolithiasis is determined, effective treatment of the sialolith
depends on the location of the stone, and is accomplished by
extraoral or intraoral surgical removal of the sialolith. Removal of
the affected salivary gland and its associated duct may also be
necessary.12 However, initial management consists of antibiotic
therapy to reduce or eliminate the acute infection. The drug of
choice is penicillin (250 mg- 500 mg orally, every 6 hr). The
patient is also instructed to suck on sour lemon or orange candy to
stimulate salivary flow.16Patients presenting with sialolithiasis
may benefit from a trial of conservative management, especially
if the stone is small. The patient must be well hydrated and the
clinician must apply moist warm heat and gland massage, while
sialogogues are used to promote saliva production and flush the
stone out of the duct.17 In the management of large sialoliths which
are located in the close proximal duct, extracorporeal shock wave
lithotripsy (ESWL) can be considered.18
Conclusion
The dental practitioner has an important role to play in
the management and possible treatment of sialolithiasis.
Establishing a diagnosis of sialolithiasis requires a thorough
history and physical examination along with routine radiographs.
Patients should be educated regarding the mechanism of their
underlying pathology and methods of maintaining control over
them by emphasizing the value of hydration and excellent oral
hygiene, which lessens the severity of the attacks and prevents
dental complications.The accepted treatment of sialolithiasis is
surgical intervention, either removal of the sialolith or complete
excision of the gland.
REFERENCES
1. White SC, Pharoah MJ. Oral radiology principles and
interpretation. Chapter 27. In: Soft Tissue Calcification and
Ossification. Mosby, Missouri 2004:p597-614.
2. Torres-Lagares D, Barranco-Piedra S, Serrera-Figallo MA,
Hita-Iglesias P, Mart inez-Sahuquillo-Mrquez A, GutirrezPrez JL. Parotid sialolithiasis in Stensen's duct , Med Oral
Patol Oral Cir Bucal 2006; 11: E80-84
3. Goncalves M, Hochuli-Vieira E, Lugao CE, et al. Sialolith of
unusual size and shape. Dentomaxillofac Radiol.
2002;31:209-210.
4. Ali Iqbal, Anup K Gupta, Subodh S Natu, Atul K Gupt a.
Unusually large sialolith of Wharton's duct. Ann Maxillofa
Surg 2012; 2: 70-73.
5. Grases F, Santiago C, Simonet BM, et al. Sialolithiasis:
mechanism of calculi formation and etiologic factors. Clin
Chim Acta. 2003;334:131-136.
6. Giacomo Oteri, Rosa Maria Procopio and Marco Ciccci.
Giant Salivary Gland Calculi (GSGC) : Report of Two Cases,
Open Dent J. 2011; 5: 90-95.
7. Zenk J, Constantinidis J, Al-Kadah B, Iro H. Transoral
removal of submandibular stones. Arch Otolaryngol Head
Neck Surg. 2001;127:432-6.
8. Markiewicz MR, Margarone JE 3rd, Tapia JL, et
al.Sialolithiasis in a residual Wharton's duct after excision of
a submandibular salivary gland. J Laryngol Otol.
2007;121:182-185.
9. Siddiqui SJ. Sialolithiasis: an unusually large submandibular
salivary stone. Br Dent J. 2002;193:89-91.
10. Yu CQ, Yang C, Zheng LY, et al. Selective management of
obstructive submandibular sialadenitis. Br J Oral Maxillofac
Surg. 2008;46:46-49.
11. Mandel L, Hatzis G. The role of computerized tomography
29
12.
13.
14.
15.
16.
17.
18.
in the diagnosis and therapy of parotid stones: a case report. J

Am Dent Assoc. 2000;131:479-482.
Soares LP, Gaiao de Melo L, Pozza DH, et al. Submandibular
gland sialolith in a renal transplant recipient: a case report. J
Contemp Dent Pract. 2005;6:127-133.
Van den Akker HP. Diagnostic imaging in salivary gland
disease. Oral Surg Oral Med Oral Pathol. 1988;66:625-37.
Weissman JL. Imaging of the salivary glands. Semin
Ultrasound CT MR. 1995;16:546-68.
Yousem DM, Kraut MA, Chalian AA. Major salivary gland
imaging. Radiology. 2000; 216:19-29.
Blatt IM: Studies in sialolithiasis. III. Pathogenesis,
diagnosis and treatment. South Med J 57:723-29, 1962.
Williams MF Sialolithisis Otolaryn Clin North Am 1999; 32:
819834.
Bodner L. Giant salivary gland calculi: diagnostic imaging
and surgical management. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2002 ; 94:320-3.
Corresponding
Address:
Mallika
Kishore
Dr.
C.
Ram
Mohan
KKAggarwal
Dixit
Dr.Dr.
Neha
Email:
dr.mallika.kishore01@gmail.com
Email:
Email:
dixit.kk@gmail.com
Email:
30
LIST OF PHOTOGRAPHS
Fig: 1 Facial view of the patient
Fig: 2 Intraoral view
Fig: 4 Radiograph Showing

Sialolithiasis
Fig: 3 Mandibular occlusal

Radiograph
Fig: 5 Intra Oral Photograph

31
Maxillary Canine With Two Root Canals : A Case Report
Anuraag Gurtu , Anurag Singhal , Ridhi Bansal , Kunal Agnihotri
Profesor & Head, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly (U.P).
Abstract: Endodontic therapy is essentially a micro neurologic surgical procedure involving complete
debridement and three dimensional obturation of the root canal system to obtain a fluid impervious seal. The
foundation of the procedure is based on the intimate knowledge and thorough understanding of the anatomy of
both the pulp chamber and the root-canal system. Teeth exhibit variations in their root canal anatomy and pose
a challenge in diagnosis and treatment. Maxillary canine are statistically more commonly single rooted, single
canalled but rarely may have single root with two root canals.
Key words : Endodontic Treatment, Maxillary Canine, Root Canal Anatomy, Two Root Canals
INTRODUCTION
The pulp canal system in any tooth has the potential of
being very complex with branching and divisions throughout the
length of the root.1 Diagnosis and identification of variations in
number of roots and root canals are the key factors in endodontic
treatment. The anatomy of root canal systems dictates the
condition under which root canal therapy is carried out and can
directly affect its prognosis. Extra root canals if not detected are a
major reason for failure of endodontic therapy.2
Maxillary canines are statistically more common to be
single-rooted, single-canaled teeth. It has been reported that 39%
have straight canals, whereas 32% have root canals curved
distally. Lateral canal are present in 30% cases. Two root canals
in a permanent maxillary canine is a rare condition.3-6 Of those
having two canals, majority join in apical third and exit at single
apical foramen.7
CASE REPORT
A 34 year old male patient reported to the department of
conservative dentistry and endodontics with a chief complaint of
pain in upper front region past 4 months. Subjective symptoms
included dull, continuous, non radiating pain that aggravated on
mastication and relieved on medication. Past dental history and
Medical history were non contributory.
Oral examination revealed deep dental caries extending
subgingivaly with no direct pulpal exposure. Tooth was
asymptomatic on palpation and tested negative using electric pulp
tester. Periodontal status was within normal limits. Radiographic
examination spotted abnormal root canal anatomy, single root
with two root canals. Periapical radiolucency was seen with size
less than 1 cm in diameter. Provisional diagnosis made was
chronic periapical abscess.
Endodontic treatment was started under local
anaesthesia. Access cavity was made using #1014 round diamond
bur and endo Z carbide bur, pulp extirpation was done using
bared broach. Root canals were negotiated with #10 k- file and
working length was established. Crown down root canal
preparation was done, coronal preparation was done using

#4,#3,#2 gates glidden drills(Tulsa dental, dentsply) middle and
apical preparation by hand files (k-files) preparing the apical till
#30. The chemo-mechanical preparation was performed under
copious irrigation using 5.25% sodium hypochloride and 17%
EDTA after use of each file. Final irrigant used was 2%
chlorohexidine. The root canals were obturated with gutta percha
and zinc oxide eugenol sealer using lateral condensation
technique. Finally the tooth was restored with composite resin.
DISCUSSION
Knowledge to basic concepts is more important than the
tools of measurement.8 Therefore it is of utmost importance to
locate and treat all root canals in a tooth.
During the past years, there have been many studies of
pulp morphology. The anatomical studies of Vertucci3, Pineda
and Kuttler4 Black9, and Green10 all state that maxillary incisors
have a single root 100% of the time.. The percentage of
permanent maxillary canines with type V canal configuration
(one canal leaves the pulp chamber and divides short of the apex
into two type V canal configuration (one canal leaves the pulp
chamber and divides short of the apex into two separate and
distinct canals with separate apical foramina 2 was 2.17 and type
III canal configuration (one canal leaves the pulp chamber,
divides into two
within the root, and merges to exit as one canal 2 was 4.35. A
review of the literature revealed that Alapati et al.6 reported a
maxillary right canine with type II canal configuration and
Weisman reported a bi-rooted maxillary left canine.
In the present case two distinct root canal orifices were
located in a labial/palatal configuration. The palatal canal coursed
laterally and then curved back to join the buccal canal in the apical
third, forming a type II canal configuration. Although one of the
two canals, the one most continuous with the large main passage,
is usually amenable to adequate enlarging and filling procedures,
the preparation and filling of the other canal is often extremely
difficult.
32
CONCLUSION
Clinicians should be aware of anatomical variations in
the teeth they are managing, and should never assume that canal
systems are simple. Even though the most common anatomy of
maxillary canines comprises a single root and a single root canal,
clinicians should consider the possible variations and always
search for the second root canal in teeth with either one or two
roots.
REFERENCES
1. Nagesh bolla. Maxillary canine with two root canals. J
Conserv Dent 2011;14:80-2
2. Hulsmann M, Schafer E. Problems in gaining access to the
root canal system. In: Hulsmann Michael, Schafer Edgar,
editors. Problems in Endodontics: Etiology, Diagnosis and
Treatment. 1st ed. Germany:Quintessence Publishing Co
Ltd; 2009. p. 145-72
3. Vertucci FJ. Root canal anatomy of the human permanent
teeth. Oral Surg, Oral Med, Oral Pathol, Oral Radiol,
Endod1984;58: 589 -99.
4. Zeigler PE, Serene TP. Failures in therapy. In Cohen S, Burns
RC, eds. Pathways of the pulp. 4th ed. St. Louis: CV. 1994,
690-91.
5. Pineda F, Kuttler Y. Mesiodistal and buccolingual
roentgenographic investigation of 7,275 root canals. Oral
Surg, Oral Med, Oral Pathol, Oral Radiol, Endod
1972;33:101-10.
6. John. I. Ingle, James H. Simon, Pierre Machtou , and Patrick
Bogaerts.Outcome of endodontic treatment and retreatment. In.Ingle Ij, . Bakland Lk, Endodontics. 5th ed. BC
Decker Inc 2002;747-68.
7. Ravi SV.Maxillary canine with two root canals:a case report.
Ind J Dent Res 2012:69-71.
8. Krasner P, Rankow H J Anatomy of the Pulp-Chamber Floor.
J Endod 2004;30:5-16.
9. Alapati S, Zaatar EI, Shyama M, Al-Zuhair N. Maxillary
canine with two root canals. Med Principles Prac
2006;15:74-6.
10. Weisman MI. A rare occurrence: a bi-rooted upper
canine.Aus Endod J 2000;26:119-20.
Corresponding
Address:
Dr. C.
Ram Mohan
Dr.
Anuraag
gurtu
Email:
Email: anuraggurtu@yahoo.com
33
LIST OF PHOTOGRAPHS
Fig: 1 Pre - Operative IOPAR
Fig:3 Master Cone IOPAR
Fig:2 Working Length Estimation
Fig: 4 Post Obturation IOPAR
34
Denuded Root - is Free Gingival Graft an Answer : A Case Report
Rika Singh , Sunil Kumar Mall
Senior Lecturer, Department of Periodontology, Institute of Dental Sciences, Bareilly (U.P).

Oral and Maxillofacial Surgeon.
Abstract: Gingival recession is defined as the apical displacement ofthe gingival margin from the cementoenamel junction (CEJ). Gingival recessions require treatment for many reasons impaired aesthetic
appearance, root sensitivity, cervical caries or abrasion. Many surgical techniques have been advocated for
recession coverage. Since its introduction in 1963, the free gingival graft procedure has proven reliable in
increasing attached gingiva and stopping progressive gingival recession. In 1982, Miller proposed a
modification of the conventional technique for autogenous gingival graft surgery for root coverage. This paper
presents a case of denuded root coverage using free gingival graft technique.
Key words : Gingival Recession, Gingival Graft, Gingiva, Denuded Root, Cementoenamel Junction.
INTRODUCTION
Gingival recession is defined as the location of gingival
margin apical to cementoenamel junction.1When occurring in
anterior tooth regions of the oral cavity, gingival recession can be
aesthetically unpleasing for the patient and it can also further lead
to root sensitivity, cervical abrasion and root caries. Besides
periodontal disease, various other factors such as faulty tooth
brushing, orthodontic tooth movements, faulty restorations,
frenum pull, tooth malpositioning etc. are considered as a major
cause for gingival recession.
Miller classified gingival recession into four
categories.3The classification is used to assess the defect as well
as predict root coverage which may be possible using various
surgical procedures. Root coverage is more predictable and more
successful with Class I and II defects, whereas only partial
coverage can be expected with Class III defects. Root coverage in
Class IV defects should not be expected. Various periodontal
plastic surgical procedures are used alone or in combination for
predictable root coverage such as connective tissue grafts, pedicle
flaps, free gingival grafts, guided tissue regeneration etc.
Autogenous gingival grafting or epithelialized free gingival
grafting was introduced in 1963,4 and the procedure has proven
reliable in increasing attached gingiva and stopping progressive
gingival recession. Also, long-term stability (up to 4 years) of
these treatment outcomes has been demonstrated.5 Although root
coverage is not a primary goal of autogenous gingival grafting,
however it may occur in cases of narrow recession (< 3 mm), as a
result of bridging, whereby some of the grafted tissue remains
vital over the avascular zone of the root.6
In 1982, Miller7 proposed a modification of the
conventional technique for autogenous gingival graft surgery for
root coverage. This modification used a thicker graft (2 mm)
positioned over a carefully planed root surface that had been
previously conditioned with citric acid. With detailed suturing
marginally and apically, the graft could be adapted in intimate
contact with the recipient site. He showed 95.5% of root coverage
when recession was less than 3mm, 80.6% when recession was 3
to 5mm and 76.6% when it exceeded 5mm. Despite these results,
failure rates are also high for free gingival grafts when solely used
for root coverage procedure. Miller 19878 has proposed many
factors for incomplete or failure of root coverage. These include
improper classification of marginal tissue recession, inadequate
root planning, failure to treat the planed root with citric acid,
improper preparation of recipient site, inadequate size of
interdental papillae, improperly prepared donor tissue,
inadequate graft size, in adequate graft thickness, dehydration of
graft, inadequate adaptation of graft to root and remaining
periosteal bed, failure to stabilize the graft, excess or prolonged
pressure in captions of sutured graft, reduction of inflammation
prior to grafting, trauma to graft during initial healing.
CASE REPORT
A 22 years old female patient visited the department of
Periodontics, with a chief complaint of sensitivity of a tooth in
lower anterior region. The periodontal examination revealed
Miller's class II recession in relation to 31(Fig 1). There was
probing depth of 1.5mm and radiographic examination showed
no bone loss interdentally. The vestibular depth was also
insufficient in relation to 31 (Fig 1).Patient's medical and dental
histories were non-contributory.
Four weeks before surgery full-mouth scaling and
polishing were performed and oral hygiene instructions were
given to eliminate habits related to the etiology of the recession.
Re-evaluation of the tooth (31) at 4 weeks showed apicocoronary 5mm of recession, mesio-distally 3mm of recession.
Accordingly after the patient's consent, it was decided to treat the
site by Miller's technique for free autogenous gingival grafting to
achieve root coverage and simultaneously increase the attached
gingiva and the vestibular depth.
SURGICAL PROCEDURE
Preparation of Recipient Bed: the patient was asked to rinse
with 10ml of 0.12% chlorhexidine for 30 seconds, following
which local anesthesia was administered. After adequate local
anesthesia had been achieved, the exposed root was planed
thoroughly to reduce the convexity. Root conditioning was
35
achieved by burnishing the root using a cotton pellet saturated

with tetracycline solution for about 3 minutes. A horizontal
incision was made at the level of cementoenamel junction
extending from the line angle of adjacent teeth on either side of the
recession deep into the papilla, creating a well defined butt joint
At the distal terminal of the horizontal incision, vertical incision
was given extending well into the alveolar mucosa, so that it is
3mm beyond the apical extent of the recession. A partial thickness
flap was elevated and excised apically (Fig 2).
Preparation of Donor Tissue: A tin foil template was used to
accurately determine the amount of donor tissue. The template
was made by adapting it to the recipient site. The right side of
palate was chosen as the recipient site. The area between first and
second premolar which had greater thickness was selected to
harvest the donor tissue. The initial incision was outlined by the
placement of tinfoil template with a no 15 scalpel blade. All
palatal incisions were made in such a fashion as to create the butt
joint margin in the donor tissue. Tissue pliers was used to retract
the graft distally as it is being separated apically and dissected,
until the graft was totally freed (Fig 3). The graft obtained was
inspected for any glandular or fatty tissue remnants. The
thickness of the graft was also checked to ensure the smooth and
uniform thickness (Fig 4). The graft was placed on the recipient
bed and sutured by means of sling sutures (5-0 vicryl sutures) (Fig
5). A vertical stretching suture was given for close adaption of the
graft to the tooth surface. After suturing a periodontal dressing
was placed to protect the surgical site (Fig 6). The palatal wound
was protected by periodontal dressing stabilized by a passive
Hawley's retainer.
Post Operative Instructions: The patient was asked to refrain
from tooth brushing at the surgical site for two weeks. 0.12%
chlorhexidine mouth rinsing was advised twice daily for 3 weeks
and for post operative pain control, combiflam was prescribed,
twice daily for 3 days. The periodontal dressing was removed 2
weeks post operatively (Fig 7 & 8). Healing was uneventful and
was completed in about six weeks. There was significant
augmentation of attached gingiva and also reduction in the
recession size (Fig 9).
DISCUSSION
This case report presented Miller's class-II recession of
31, which was successfully treated by free autogenous soft tissue
graft. Also there was increase in vestibular depth led to
improvements in mucogingival relationships and also better
opportunity for plaque control by the patient.
Miller's criteria8 for successful root coverage include:
the soft tissue margin must be at the cemento-enamel junction,
clinical attachment to the root, with sulcus depth of 2mm, and no
bleeding on probing. All these criteria were achieved in the
present case. According to Sullivan and Atkins9 when free
gingival graft is placed over recession, some amount of
bridging can be expected because a portion of grafted tissue
which is covering the root will survive by receiving circulation
from the vascular portion of the recipient site. In addition to
bridging, creeping attachment can result in a post operative
coronal migration of free gingival margin. Free gingival grafting
is a procedure of high degree of predictability when used alone or
combined with other technique. However it is more technically
demanding, time consuming, and the color match of the tissue is
often less than ideal. Due to the predictability and versatility of
connective tissue graft, the use of the free gingival graft for root
coverage has drastically declined. However free gingival graft

appears to be the best treatment alternative to increase the amount
of keratinised tissue and for treatment of class I and class II
gingival recessions. With appropriate case selection, this
technique is predictable in achieving complete root coverage.
CONCLUSION
The free gingival graft for root coverage is still a feasible
and predictable procedure not only to increase the amount of
keratinised gingival tissue but also in achieving coverage of
denuded roots. Adequate vestibular depth can be achieved by the
procedure which helps in better oral hygiene maintenance by the
patient. The results obtained in this case suggests that with proper
case selection, the procedure of free gingival graft holds promise
for successful management of denuded root coverage.
REFERENCES
1. The American academy of periodontology. Glossary of
periodontic terms. 4th ed. 2001
2. Ashley F, Usiskin L, Wilson R, Wagaiyu E. The relationship
between irregularity of the incisor teeth, plaque, and
gingivitis: a study in a group of school children aged 11-14
years. Eur J Ortho1998;20(1):65.
3. Miller P D Jr. A classification of marginal tissue recession.
Int J Periodont Rest Dent 1985; 5: 813.
4. Bjrn H. Free transplantation of gingiva propia. Sver
Tandlak Tidskr 1963; 22:684.
5. Dorfman HS, Kennedy JE, Bird WC. Longitudinal
evaluation of free autogenous gingival grafts. A four year
report. J Periodontol 1982; 53(6):34952.
6. Sullivan HC, Atkins JH. The role of free gingival grafts in
periodontal therapy. Dent Clin North Am 1969;
13(1):13348.
7. Miller PD Jr. Root coverage using a free soft tissue autograft
following citric acid application. Part 1: Technique. Int J
Periodontics Restorative Dent 1982; 2(1):6570.
8. Miller Jr P. Root coverage with the free gingival graft.
Factors associated with incomplete coverage. J
Periodontol1987;58(10):674.
9. Sullivan H, Atkins J. Free autogenous gingival grafts. 3.
Utilization of grafts in the treatment of gingival recession.
Periodontics1968;6(4):152.
Corresponding
Address:
Dr.
RamSingh
Mohan
Dr.C.Rika
Email:
Email:
rikasingh22@gmail.com
36
LIST OF PHOTOGRAPHS
Fig 1- Gingival Recession
Fig 2- Preparation of
recipient bed
Fig 3-The donor site
Fig 4- Free gingival graft
Fig 5- Graft secure in position

using 5-0 vicryl sutures
Fig 6- Periodontal
dressing given
Fig 7- Donor site 2

weeks post operative
Fig- 8 Recipient site 2

weeks post operative
Fig 9-3 months after healing
37
Complication of a Dental Extraction: Osteomyelitis : A Case Report

Sowmya G.V., Nupur Agarwal, Nitin Upadhyay, Abhijeet Alok, Mallika Kishore
Senior lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Senior lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P.G Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
P.G Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P).
Date of Receiving : 14/Feb/2013
Abstract: Osteomyelitis, an inflammation of bone & its marrow contents is a sequela of periapical infection
results in diffuse spread through medullary spaces with subsequent necrosis of bone. It may be acute, subacute
& chronic. The pain, the pus, the new bone formation and all the trouble, this case showed it all. Here we are
reporting a case with complication of dental extractions with clinical & histopathological examination,
diagnosed as chronic osteomyelitis.
Key words : Osteomyelitis, Extraction, Mandible.
INTRODUCTION
The word Osteomyelitis originates from the ancient
Greek words osteon (bone) and muelinos (marrow) and means
infection of medullary portion of the bone.1 Osteomyelitis is an
inflammatory condition of bone that involves the medullary
cavity and has a tendency to progress along this space.2 It can be
classified as acute, subacute or chronic, depending on the clinical
presentation.The decline in prevalence can be attributed to the
increased availability of antibiotics and the progressively higher
standards of oral and dental health.3 The incidence of
osteomyelitis has dramatically decreased since the introduction
of antibiotics.4
Moreover, osteomyelitis of the head and neck skeleton is rare,
particularly in the jaws.5,6
CASE REPORT
A 60 year old male patient reported to the Department of
Oral Medicine and Radiology with a chief complaint of swelling
and pain in left lower back tooth region since 6 months (fig 1).
History of present illness revealed that pain was present. Pain was
sudden, intermittent and localised. Patient got his tooth extracted
in left lower back tooth region 6 months back after which there is
continuous pus discharge. History of paresthesia was there. On
extra oral examination, a diffused swelling, roughly oval in shape,
roughly 1x 2 cm in diameter extending from infra orbital margin
till base of mandible, antero-posteriorly it extends from .5 cm
from ala of nose to .5 cm from tragus of ear. Overlying mucosa
appears normal. No secondary changes was seen. On palpation it
was hard in consistency, non tender. On intra oral examination,
missing 37 and 38 was there. Pus discharge from that region was
present. On palpation Grade I mobility was present w.r.t. 36,35.
Based on the clinical appearance and history, a provisional
diagnosis of chronic suppurative osteomyelitis was given w.r.t 36
region.
In investigations, orthopantomogram was done which
revealed an ill defined radiolucency on the left mandibular region,
roughly oval in shape, roughly 1x2 cm in diameter extending
from distal of 35 to the coronoid area. Ill defined borders are
present suggestive of pathological fracture (fig 2).

Patients's lesion was surgically excised and sent for
histopathological investigations which revealed that soft tissue
component that consists of chronically or subacutely in flamed
fibrous connective tissue filling the lntertrabecular areas of the
bone which was suggestive of chronic suppurative osteomyelitis.
So final diagnosis of chronic suppurative osteomyelitis was
given.
DISCUSSION
Chronic Suppurative Osteomyelitis (CSO) is an often
preferred term in Anglo-American texts and can mostly be used
interchangeably with the term secondary chronic
Osteomyelitis which is predominantly used in literature from
continental Europe. Suppurative Osteomyelitis can involve all
three components of bone: periosteum, cortex, and marrow.7
Marx (1991) and Mercuri (1991) were the first and only authors to
define the duration for an acute osteomyelitis until it should be
considered as chronic. They set an arbitrary time limit of 4 weeks
after onset of disease.1 It is by far the most common osteomyelitis
type. The primary cause of chronic osteomyelitis of the jaws is
infection caused by odontogenic microorganisms. It may also
arise as a complication of dental extractions and surgery,
maxillofacial trauma and the subsequent inadequate treatment of
a fracture, and/or irradiation to the mandible.3,8,9 The four primary
factors which are responsible for deep bacterial invasion into the
medullar cavity and cortical bone and hence establishment of the
infection are: 1. Number of pathogens, 2. Virulence of pathogens,
3. Local and systemic host immunity, 4. Local tissue perfusion.
Additionally, exposure of the head and neck region to
radiotherapy, uncontrolled diabetes,and immunosuppressive
therapies as well as heavy smoking and drinking increase risk for
mandible osteomyelitis development.10,11 Other predisposing
factors are those that are characterized by the formation of
avascular bone for example, therapeutically irradiated bone,
osteopetrosis, Paget's disease, and florid osseous dysplasia. A
study by Taher, of 88 cases of osteomyelitis of the mandible,
found trauma to be the most common predisposing cause for
38
osteomyelitis, attributing it to the geo-political

difficulties.12
In the healthy individual with sufficient host immunity
mechanisms these factors form a carefully balanced equilibrium.
If this equilibrium is disturbed by altering one or more of these
factors, deep bone infection establishes.1 Osteomyelitis is more
commonly observed in the mandible because of its poor blood
supply as compared to the maxilla, and also because the dense
mandibular cortical bone is more prone to damage and, therefore,
to infection at the time of tooth extraction.1 Although
osteomyelitis of the maxilla is rare, it is more frequently seen in
infants and children, as more bone is available in the maxilla
during infancy. Osteomyelitis of the maxilla is much less frequent
than that of the mandible because the maxillary blood supply is
more extensive.13 The typical age of presentation is in the fifties to
the sixties, with males more likely to be affected.14 Clinical
features documented are deep intense pain, high intermittent
fever, parasthesia or anesthesia of the lip due to involvement of
the mental nerve, pus and sequestra exudates through fistulae,
trismus, regional lymphadenopathy, induration of soft tissue, and
wooden character of bone with pain and tenderness on palpation.
The associated teeth may be mobile and sensitive to percussion.15
Teher12found that 37% of his patients had fistulas and
sequestrations and 3% had pathological fractures, fistulas, and
sequestrations. In the present series, discharging sinus with
sequestra was seen in 88% of patients and pathological fractures
in 6%.
Culture and sensitivity of the discharge usually reveals
staphylococci, streptococci, pneumococci, and anaerobes such as
bacteroides, as was the case in the present series. Before
application of any cross sectional imaging modality, the
orthopanoramic view is indispensable in recognizing direct
radiographic signs of osteomyelitis. The orthopanoramic view is
the procedure of choice in follow-up examinations in patients
who have osteomyelitis.16 This showed scattered areas of bone
destruction, sequestra/ involucrum, alteration in the contour of
the mandible, and occasionally pathological fractures. If surgical
treatment is planned, high-resolution CT is required to specify the
degree of cortical destruction, the presence of sequestra in
particular, and to define the extent of osseous removal required.16
To detect early osteomyelitis, a two-phase technetium bone scan
followed by a gallium citrate scan may help to confirm
diagnosis.15
Histopathological examination of the surgical specimen
or granulation tissues was carried out in most of our cases, which
helped in accurate diagnosis of the predisposing factors such as
malignancy, tuberculosis or other granulomatous conditions. The
treatment protocol consisted of a combination of surgery and
antimicrobial treatment amoxicillin, co-amoxiclav, cephalexin,
and metronidazole.17,18 Other options include Clindamycin due to
its excellent absorption and bioavailability in bone infections,
HBO therapy is also one treatment modality which can be used in
osteomyelitis.
REFERENCES
1. Marc Baltensperger and Gerold Eyrich. Osteomyelitis of the
Jaws: Springer Berlin Heidelberg. November 07, 2008.
2. Aitasalo K, Niinikoski J, Grnman R, Virolainen E: A
modified protocol for early treatment of osteomyelitis and
osteoradionecrosis of the mandible. Head Neck 1998; 20(5):
4117.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Yeoh SC, MacMahon S, Schifter M. Chronic suppurative

osteomyelitis of the mandible: A Case report. Aust Dent J
2005; 50(3): 200-03.
Kushner G M, Alpert B. Osteomyelitis and
osteoradionecrosis.In: Miloro M, Ghali GE, Larsen PE,
Waite PD, eds. Peterson's Principles of Oral and
Maxillofacial Surgery, 2nd ed. London:BC Decker ; 2003:
313-21.
Fonseca RJ, Turvey TA, Betts NJ. Oral and Maxillofacial
Surgery, 1st ed. Philadelphia: WB Saunders; 2000: 485-90.
Barry CP, Ryan CD, Stassen LF. Osteomyelitis of the maxilla
a secondary to osteopetrosis: a report of 2 cases in sisters.
Oral Maxillofac Surg 2007;65:144-7.
Mallikarjun K, Kohli A, Arvind K, Vatsala V, Bhayya DP
,Shyagali TR. Chronic suppurative osteomyelitis. of the
mandible- A Case Report. J. Int Oral Health 201;3:57-62.
Eyrich Gk, Baltensperger Mm, Bruder E, Graetz Kw:
Primary chronic osteomyelitis in childhood and
adolescence: a retrospective analysis of 11 cases and review
of the literature. J OralMaxillofac Surg 2003; 61 (5): 56173.
treatment of chronic osteomyelitis of the mandible: case
report. Br J Oral Maxillofac Surg 2008; 46 (5): 4002.
Jorge LS, Chueire AG, Rossit AR. Osteomyelitis: a current
challenge. Braz J Infect Dis 2010;14 (3):3105.
Slough Cm, Woo Bm, Ueeck Ba, Wax Mk: Fibular free flaps
in the management of osteomyelitis of the mandible. Head
Neck 2008; 30 (11):153134.
Taher AAY. Osteomyelitis of mandible in Tehran, Iran. Oral
Surg Oral Med Oral Pathol 1993;/76:/28-31.
Topazian RG. Osteomyelitis of jaws. In: Topazian RG,
Goldberg MH, editors. Oral and maxillofacial infections, 3rd
edn. Philadelphia, PA: Saunders; 1994. 251-86.
Jagdhari SB, Patni VM, Motwani M, Gangotri S. chronic
suppurative osteomyelitis of jaw - report of two cases. Int J
Dent Case Reports 2013; 3(1): 93-97.
Lee L. Inflammatory lesions of the jaws. In: White SC,
Pharoah MJ, editors. Oral radiology: principles and
interpretation, vol 3, 4th edn. Missouri: Mosby; 2000. p. 33854.
Schuknecht B, Valavanis A. Osteomyelitis of the mandible.
Neuroimaging Clin North Am 2003;/13:/605-18.
Gutierrez K.Bone and joint infections in children. Pediatr
Clin North Am 2005; 52(3): 779-794.
Mandracchia VJ, Sandres SM, Jaeger AJ, Nickles WA.
Management of osteomyelitis. Clin Pediatr Med Surg 2004,
21: 335-351.
Corresponding
Address:
Dr.C.
Abhijeet
Alok
Dr.
Ram
Mohan
Dr.
Neha
Aggarwal
Email:
drabhijeet786@gmail.com
Email:
Email:
39
LIST OF PHOTOGRAPHS
Fig:1 Intra Oral Photograph
Fig:2 Orthopantomogram
40
Eagles Syndrome : A Case Report
Nupur Agarwal , Sunil R Panat , Ashish Aggarwal , Anuja Joshi , Kratika Ajai
Principal, Professor and Head, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly.(U.P)
P.G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P)
P.G. Student, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly (U.P)
Abstract: Elongation of the styloid process or stylohyoid ligament calcification is a well recognized finding of
dental practice, and an incidence of 4 to 30 percent has been reported on radiographs. Eagle syndrome is an
aggregate of symptoms caused by an elongated ossified styloid process, the cause of which remains unclear.
Ossification of the stylohyoid and stylomandibular ligament causes prolongation of the styloid process and
clinical symptoms. Eagle's syndrome is defined as the symptomatic elongation of the styloid process or
mineralization of the stylohyoid ligament complex. The symptoms related to this condition can be confused with
those attributed to a wide variety of facial neuralgias. Here we report a case of eagle syndrome in which patient
exhibiting unilateral symptoms with bilateral elongation of styloid process is reported and the literature is
reviewed.
Key words : Styloid process, Stylohyoid Ligament, Facial Neuralgia, Ossification.
INTRODUCTION
Eagle's syndrome was first described by an American
Otorhino laryngologist Watt weems Eagle in1937.1 Styloid process is
normally a slender; cylindrical bone that arises from the temporal
bone in front of the stylomastoid foramen which is normally varies
from 2.0 to 2.5 cm in adults.2
Eagle further described it as atypical facial neuralgia and
reported that it has various symptoms like feeling of a foreign body
lodged in the throat, difficulty and pain during swallowing, throat
pain, pain on turning the head, pain in infraorbital, infratemporal, ear
and occipital areas, pain on wide opening of mouth, headache,
tinnitus and vertigo.3 Eagle's syndrome is characterised by the
following symptoms: pharyngeal pain localised in the tonsillar fossa,
radiating to the oesophagus, to the hyoid bone, painful head rotation
and lingual movements.4 Male : female ratio is 1:3. Bilateral is quite
common, but symptoms are mostly unilateral.1 There is high
variability in prevalence studies about elongated styloid process with
a slight gender prediction for females (KEUR, CAMPBELL,
McCARTHY et al., 1986; O'CARROLL, 1984).2 The length of the
styloid process is variable. Kaufman et al. reported that 30 mm is the
upper limit for normal styloid processes.5 The styloid process
normally measures 2.2-3 cm in length; when length exceeds 3 cm it is
said to be elongated.6 Here we present a case of 25 yr old female
patient suffering from eagles syndrome.
CASE REPORT
A 25 year old female patient reported to Department of Oral
Medicine and Radiology,Institute of Dental Sciences, Bareilly (U.P)
with a chief complaint of pain in left neck region since 4 mnths.
History of present illness reveals that there was pain in throat which
was radiating to the head and neck, the pain was continuous and
moderate and it is more on the left side especially on turning the head
towards left.General physical examination revealed that, bilaterally,
there is no clicking and popping sound was present on TMJ and there
is no deviation of mandible.In extraoral examination tenderness were
present on left and right post auricular region and neck region. On
intraoral examination no significant findings are observed. On the
basis of history and clinical findings provisional diagnosis of Eagles
syndrome was given with a differential diagnosis of
temporomandibular arthritis was made. On radiographic
examination, OPG of the oral cavity (Figure 1) revealed an elongated
styloid process on both sides measuring about 32.1 on left side. On
the basis of history, clinical features and radiographic features, final
diagnosis of Eagles syndrome were made.
DISCUSSION
Carotid artery syndrome or stylohyoid syndrome is caused
by the elongated styloid process.2 Specific orofacial pain secondary
to calcification of stylohyoid ligament or elongated styloid process
has been known as Eagle's syndrome.1Stylalgia (elongated styloid
process, long styloid process syndrome, Eagle's syndrome) is related
to abnormal length of the styloid process, to mineralisation of the
styloid ligament complex , or to calcification of digastric
muscles.4(3)7Embryologically, it has been derived from the Reichert's
cartilage of the second branchial arch. It is a slender, pointed
structure which projects anteroinferiorly from the inferior aspect of
temporal bone.3
The actual cause of the elongation is a poorly understood
process. Several theories have been proposed:
1) Congenital elongation of the styloid process due to persistence of a
cartilaginous analog of the stylohyal (one of the embryologic
precursors of the styloid),
2) Calcification of the stylohyoid ligament by an unknown process,
and
3) Growth of osseous tissue at the insertion of the stylohyoid
ligament.8
From Eagle's early descriptions, patients were categorized
into two groups: those who had classical symptoms of a foreign
body lodged in the throat with a palpable mass in the tonsillar region
following tonsillectomy; and those with pain in the neck following
41

syndrome: a case report. J. Morphol. Sci., 2012;29(1):58-59.
the carotid artery distribution (carotid artery syndrome).9 Although
these two types have a common etiology, their symptomatology 3. More CB, Asrani MK. Eagle's syndrome: report of three cases.
Indian J Otolaryngol Head Neck Surg. 2011;63(4):396-9.
differ.
The pain aggravates typically on rotation of the head.10The 4. Nemeth O, Csaki G, Csado K,Kivovics C.Case report of a 27
year old patient suffering from Eagle's
cause of onset of pain in patients previously free of symptoms is
syndrome.OHDMBSC.2010;9(3)
unknown, but several mechanisms have been proposed that include
rheumatic styloiditis caused by pharyngeal infections, trauma, 5. Savranlar A, Uzun L,Ugur M B,Ozer T. Three-dimensional CT
of Eagle's syndrome. Diagn Interv Radiol 2005; 11:206-209.
tonsillectomy, and involutional changes associated with aging (e.g.,
degenerative cervical discopathy,which may shorten the cervical 6. Raina D, Gothi R, Rajan S.Eagle's syndrome.Indian J
Radiol.2009;19(2) 107-108.
spine and alter the direction of the styloid process)11
Elongation of the styloid process or stylohyoid ligament 7. Mortellaro C, Biancuccci P, Picciolo G, Vercellino V. Eagle's
syndrome. Importance of a.corrected diagnosis and adequate
calcification is a well recognized finding of dental practice. Most
surgical treatment. J Craniofac Surg. 2002 Nov; 13(6):755-8.
cases are asymptomatic; however, a small number of such patient's
experience symptoms of Eagle's syndrome, related to the 8. Murtagh R D, Caracciola J T, Fernandez G. CT findings
associated with Eagle syndrome. Am J Neuroradiol.2001; 22;
compression of adjacent nerves and blood vessels.12 In about 4% of
1401-1402.
general population an elongated styloid process occurs, while only
about 4% of these patients are symptomatic; thus the true incidence is 9. Feldman V B.Eagle's syndrome: a case of symptomatic
calcification of the stylohyoid ligament. J Can Chiropr Assoc
0.16% with a female predominance of 3:1.13
14
2003; 47(1) 21-27.
Langlais et al. (1986) classified elongated styloid process
and mineralised styloid complexes based on the radiographic 10. Ryan MD. CT findings associated with Eagle's syndrome.
AJNR AMJ Neuroradiol 2001; 22:1401-2.
appearance and structures as follows:
11.
Khandelwal S, Hada Y S, Harsh A. Eagle's syndrome- a case
Type I: the elongated type pattern represents an uninterrupted
report and review of the literature. Saudi Dent J.2011;
process.
23:211215.
Type II: characterised by a single pseudoarticulation that seems an
12.
Shahoon H,Kianbaht C. Symptomatic Elongated Styloid
articulated elongated styloid process.
Process or Eagle's syndrome: A case report. JODDD, 2008; 2(3)
Type III: represents an interrupted process that gives the appearance
102-105.
of multiple pseudo- articulations within the ligament.
The diagnosis of ES must be based on a good medical 13. Casale M, Rinaldi V, Quattrocchi C, Bressi F, Vincenzi B,
Santini D, Tonini G, Salvinelli F. atypical chronic head and neck
history and physical examination. It should be possible to feel an
pain:
don't forget Eagle's syndrome.Eur Rev Med Pharmacol
elongated styloid process by careful intraoral palpation, placing the
Sci.2008 12:131-133.
index finger in the tonsillar fossa and applying gentle Pressure.15 The
diagnosis of ES can be ascertained with imaging which includes 14. Langlais RP, Miles DA, Van Dis ML. Elongated and
mineralized stylohyoid ligament complex: A proposed
lateral head and neck radiograph, Towne radiograph, panoramic
classification and report of a case of Eagle's syndrome. Oral
radiograph, lateral-oblique mandible plain film etc.16
Surg Oral Med Oral Pathol. 1986 May; 61(5):527-32.
In differential diagnosis, laryngopharyngeal dysesthesia
15.
Montalbetti, L., Ferrandi, D., Pergami, P., Savoldi, F., 1995.
has to be considered as well as dental malocclusion, neuralgia of
Elongated styloid process and Eagle's syndrome. Cephalalgia
sphenopalatine ganglia, temporomandibular arthritis,
15, 8093.
glossopharyngeal and trigeminal neuralgia, chronic tonsillo16.
Dayal, V., Morrison, M.D., Dickson, T.J.M., 1971. Elongated
pharyngitis, hyoid bursitis, Sluder's syndrome, histamine cephalgia,
styloid process. Arch. Otolaryngol. 94, 174175.
cluster type headache, esophageal diverticula, temporal arteritis,
cervical vertebral arthritis, benign or malign neoplasms, and 17. Harma, R., 1966. Stylalgia clinical experiences of 52 cases.
Acta Otolaryngol. 224, 149.
migraine type headache (Harma, 1966).17 Eagles syndrome can be
6
treated by surgical and non surgical means. Non surgical treatment
involve reassurance to the patient, analgesics, and steroid injections.
Surgical treatment can be performed using one of two approaches:
transpharyngeal or extraoral. The latter is thought to be superior
because it is likely to cause deep space infections.6Also, barium
swallow studies can show the indentation of the elongated styloid
process as a filling defect.16
CONCLUSION
The elongated styloid process syndrome can be diagnosed
by a detailed history, physical examination, and radiological
investigations. It can be confused or mistaken for many other
conditions that must be excluded. An awareness of pain syndromes
related to the styloid process isimportant to all health practitioners
involved in the diagnosis and treatment of neck and head pain. In a
non specific orofacial pain there should be a high index of suspicision
of stylalgia Eagle's syndrome.
REFERENCES
1. Karam C, Koussa S. "Eagle syndrome: the role of CT scan with
3D reconstructions". J Neuroradiol. 2007; 34 (5): 3445.
2. Veena k M, Ashwini S S, Jagdishchandra H. Carotid artery
Corresponding
Address:
Anuja
Joshi
Dr.
C.
Ram
Mohan
Dr.
KKAggarwal
Dixit
Dr.Dr.
Neha
Email:
dranujajoshi88@gmail.com
Email:
Email:
dixit.kk@gmail.com
42
LIST OF PHOTOGRAPHS
Fig : 1 Elongation of styloid process
43
A Modified Sectional Custom Tray for Making Master Impression in

Microstomia Patient : Case Report
Pratik Gupta , Dilip Kumar Nath , Nadira Saba
P. G. Student, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).

Professor, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
P. G. Student, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
1.
Abstract: Patients with limited mouth opening are often found during prosthodontic practice Micrstomia has
been defined as an abnormally small oral orifice associated with various etiopathologic factors. Management
of these patients poses extreme difficulties in every procedures during fabrication of prosthesis2. Restricted
mouth opening of the patient makes the insertion and removal of the tray extremely difficult. So sectioning of the
tray is necessary, so that the trays can be inserted and removed in sections. The main problem encountered
during this procedures reorientation of the tray back in position. This article present a simple technique for easy
handling of the sectioned tray.
Key words : Sectional , Microstomia , Press Buttons , Constricted, Reorientation.

INTRODUCTION
Micrstomia has been defined as an abnormally small
oral orifice 3. It can occur either due to trauma or burns of
electrical, thermal or chemical origin. The condition can be result
from genetic disorders, plummer-vinson syndrome, scleroderma,
surgical treatments of orofacial tumors and reconstruction of lip
defects4,5,6.
Prosthetic Rehabilitation micrstomia patients presents
difficulties from primary impression to insertion of dentures. This
is mainly due to the decreased oral opening and tongue rigidity. A
maximal possible mouth opening does not accommodate the
smallest impression trays7.
Insertion and removal of impression tray is extremely
difficult and various modification of the trays have been tried in
the past. Mirfazalian for example used orthodontic expansion
screws to fabricate sectional trays . Cura et al used metal pins and
an acrylic resin block to attach the sections of the impression
trays7. Bennetti et al used a flexible plastic tray intended for
fluride application to make the preliminary impression 6. On one
of sections, Benetti et al prepared a stepped butt joint to make a
definitive impression8.
The purpose of this article is to describe a sectional
custom tray system that is much helpful for making final
impression with a constricted oral opening without giving any
oral injury and tearing down of impression..
CASE REPORT
A 54 year old edentulous male patient with limited oral
opening appeared in the department of prosthodontics, IDS,
Bareilly, (U.P), India. for complete dentures prosthesis giving the
history of surgery followed radiotherapy on the right side of the
cheek three years back due to carcinoma. Oral opening was found
22mm (Fig1). Because of reduced oral opening, it was impossible
in making accurate impressions with usual custom tray. So in this
patient, sectional custom tray using press buttons was planned for
making final impression of maxilla and mandible with Zinc oxide
euginol paste.
Sectional impression tray was designed with right and
left sections that could be detached and rejoined together in
correct original position in and outside the oral cavity for final
impression and cast making procedure. For each tray a total of
five press buttons were used two on the each side of the section
and one on the handle. Press buttons were fitted symmetrically
and parallel to each other.
PROCEDURE
1) Conventional custom trays for maxilla and mandible was
first fabricated using autopolymerizing acrylic resin and then
with diamond disc each custom tray was divided into two
equal halves at the midline along with the handle. (fig
2,4,9,10)
2) Two male component of press buttons were attached with
autopolymerizing acrylic resin on both sides of sectional
trays.
3) Then two acrylic plates were fabricated with female
component of press buttons on each side(fig 3,10).
4) Female component on acrylic plate engages the male
component on the sectional trays when pressure is applied
with fingers.(fig 4,11)
5) On the handle of maxillary tray one male-female component
of press buttons attached for extra rigidity as it is large in size.
6) With each section of sectional tray, first border molding was
done.(fig 6,12)
7) After that sectional impression tray were inserted into the
patients mouth in two separate pieces left and right loaded
with zinc oxide eugenol impression material.
8) After placement the sections of sectional tray were stabilized
by means of preformed acrylic resin plate in patients mouth.
9) After impression material was set, the acrylic resin plates
were removed first and the right and left sections of
impression were removed separately from the oral cavity by
carefully fracturing the impression material.(fig 7)
44
10) Then extraorally female component on acrylic resin plate

reattached with the male components on sections of sectional
tray with help of press buttons and thus we get the final
impression.(fig 8,13)
11) Carefully determine that the fracture line was joined
smoothly and then dental stone was poured to get master
cast.
9.
Ohkub C, Ohkubo C, Hosoi T, Kurtz KS .A sectional stock

tray system for making impressions.J Prosthet Dent
2003;90(3):201-4.
10. Dhanasomboon S,Kiatsiriroj K.Impression procedure for a
progressive sclerosis patient;A clinical report. J Prosthet
Dent 2000;83(3):279-282.
DISCUSSION
It is always problematic to make an accurate impression
with a complete maxillary and mandibular arch for patients with a
constricted oral opening9. Various pins, bolt and lego pieces,
orthodontic devices have been used for locking mechanism of
sectional impression trays fabricated for patients with limited oral
openings7 and fixation of all these devices into trays requires
expert work. Here sectional trays were reoriented in and outside
the oral cavity accurately using autopolymerizing acrylic plate by
press buttons system and the technique was simple.
The main advantages for making sectional tray are
decreased patient trauma and no tear down of impression during
removal, moreover these trays has easy accessibility in patients
mouth and are less costly and easy to fabricate. The disadvantages
are additional time required for precise fabrication of sectional
tray. Extreme care should be taken during reorientation of
sections of sectional impressions in and outside the oral cavity.
CONCLUSION
It is often difficult to apply conventional clinical
procedures in fabricating complete denture prosthesis for
microstomia patients who demonstrate limited oral opening.
However with careful treatment planning, the use of sectional
impression procedure, many of the apparent clinical difficulties
can be overcome10.
REFERENCES
1. Baker PS, Brandt RL,Boyajian G.Impression procedure for
patients with severely limited mouth opening .J Prosthet
Dent 2000;84(2):241-244.
2. Kumar KA, Bhat V, K. Nair .Preliminary Impression in
Microstomia patient :An innovative technique . J Prosthet
Dent 2013; 13(1): 52-55.
3. The Academy of Prosthodontics. Glossary of Prosthodontic
terms- 8. J Prosthet Dent 2005; 94(1):52.
4. Geckili C, Altung C, Biling T . Impression procedures and
construction of sectional dentures for a patient with
microstomia : A clinical report. J Prosthet Dent
2006;91(3):387-90.
5. Wahle JJ, Gardner K, Fiebger . The mandibular swing lock
design for a patient with microstomia. J Prosthet Dent 1992;
68(3):523-7.
6. Benntti R, Zupi A, Toffanin A . Prosthetic Rehabilitation of a
patient with Microstomia: A clinical report. J Prosthet Dent
2004;92(4)322-7.
7. Cura C, Cotert HS, User A . Fabrication of sectional
impression tray and sectional complete dentures for a patient
with microstomia and trismus: A clinical report. J Prosthet
Dent2003; 89(6) : 540- 3
8. Geckili O,Cilinger A,Bilgin T. Impression procedure and
construction of a sectional denture for a patient with
microstomia:A clinical report.J Prosthet Dent
2006;91(3):387-90
Corresponding
Address:
Dr.
Kumar
Nath
Dr.
C.
Ram
Mohan
Dr.
KK
Dixit
Dr.Dilip
Neha
Aggarwal
Email:
dilip_nath2006@yahoo.co.in
Email:
Email:
dixit.kk@gmail.com
Email:
45
LIST OF PHOTOGRAPHS
Fig : 1- Mouth Opening = 22mm
Fig : 3
Fig : 2
Fig 5,6 - Border

Molding
Fig : 6
Fig : 5
Fig : 4
Fig- 2,3,4- Sectional Special

Tray With Press Buttons
Fig : 8
Fig : 7
Fig 7,8 - Final ZOE

Impression
MANDIBULAR SECTIONAL TRAY AND IMPRESSION
Fig : 9
Fig : 11
Fig : 10
Fig : 12
Fig : 13
Fig9,10,11-sectional special
tray with press buttons
Fig 12,13 final ZOE impression
Fig : 14
Fig : 15
Fig 14,15- complete denture in patient mouth

46
Telescopic Denture : A Case Report

Mayank Shah
Senior Lecturer, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).
Abstract: Preventive prosthodontics emphasizes the importance of any procedure that can delay or eliminate
future prosthodontic problems. In the past when patients presented themselves as candidates for a denture with
teeth that were badly broken down with periodontal involvement or without the ability to financially support an
extensive restorative treatment, those teeth were extracted that could have been retained under more favorable
conditions. A telescopic denture is a prosthesis which consists of a primary coping which is cemented to the
abutments in a patient's mouth and a secondary coping which is attached to the prosthesis and which fits on the
primary coping. It thereby increases the retention and stability of the prosthesis. Retention of the roots of one or
more teeth for overdenture offers the patient a lot of advantages like better stability, proprioception, and support
among a few. Telescopic crowns were initially introduced as retainers for the removable partial dentures at the
beginning of the 20th century. They were also known as a Double crown, a crown and sleeve coping or as
Konuskrone. The following case report is on telescopic over denture for mandibular arch.
Key words : Telescopic Denture, Double Crown System, Primary Coping, Secondary Coping, Preventive
Prosthodontics, Wedging Effect.
INTRODUCTION
A telescopic denture is a prosthesis which consists of a
primary coping which is cemented to the abutments in a patient's
mouth and a secondary coping which is attached to the prosthesis
and which fits on the primary coping. It thereby increases the
retention and stability of the prosthesis.1 According to GPT, a
telescopic denture is also called as an overdenture, which is
defined as any removable dental prosthesis that covers and rests
on one or more of the remaining natural teeth, on the roots of the
natural teeth, and/or on the dental implants. It is also called as
overlay denture, overlay prosthesis, and superimposed
prosthesis.2
Preventive prosthodontics emphasizes the importance
of any procedure that can delay or eliminate future prosthodontics
problems. The overdenture is a logical method for the dentist to
use in preventive prosthodontics.3 Overdenture therapy is
essentially a preventive prosthodontic concept since it attempts to
conserve the few remaining natural teeth. There are two
physiologic tenets related to this therapy: the first concerns the
continued preservation of alveolar bone around the retained teeth4
while the second relates to the continuing presence of periodontal
sensory mechanisms5 that guide and monitor gnathodynamic
functions.
Telescopic crowns were initially introduced as retainers
for the removable partial dentures at the beginning of the 20th
century. They were also known as a Double crown, a crown and
sleeve coping or as Konuskrone,1 a German term that described a
cone shaped design. These crowns are an effective means for
retaining the RPDs and dentures. They transfer forces along the
ling axis of the abutment teeth and provide guidance, support and
protection from the movements that dislodge the denture.

The double crown systems are usually distinguished
from each other by their differing retention mechanisms.6 There
are three different types of double crown systems. These are
telescopic crowns which-achieve retention by using friction, and
conical crowns or tapered telescope crowns which exhibit friction
only when they are completely seated by using a wedging
effect. The magnitude of the wedging effect is mainly
determined by the convergence angle of the inner crown: the
smaller the convergence angle, the greater is the retentive force.
The double crown with a clearance fit (also referred to as a hybrid
telescope or a hybrid double crown) exhibits no friction or
wedging during its insertion or removal. The retention is achieved
by using additional attachments or functional molded denture
borders.
The telescopic denture which was supported by the
natural teeth gained significant popularity as an alternative to the
conventional dentures during the 1970s and the 1980s. The
retained teeth that support the overdentures, preserve the bone
and they minimize the downward and forward settling of a
denture, which otherwise occurs with alveolar bone resorption.
The overdenture occlusion is maintained rather than shifting
forward to simulate the appearance of a prognathic mandible.4
The telescopic denture philosophy postulated a transfer
of occlusal forces to the alveolar bone through the periodontal
ligament of the retained roots. A proprioceptive feedback from
the periodontal ligament prevents the occlusal overload and it
consequently avoids the residual ridge resorption which is
adjacent to the roots and the rest of the ridge, due to excessive
forces. They also provide improved functions as compared to the
conventional dentures, such as an improved biting force, chewing
efficiency and even phonetics. The impairment of these
functional parameters which are created by edentulism reflects
47
the significant role of the periodontal receptors for a sensory

feedback and a discriminatory ability from the retained roots.
Tooth loss results in loss of the proprioception mechanism that
has been a part of the sensory programme throughout life.2
CASE REPORT
A 56-years old male reported to the department of
Prosthodontics with the chief complaint of difficulty in chewing
due to the missing lower teeth. On intraoral examination all teeth
were present in upper arch except 16, 21, 22 and the teeth present
in lower arch were 38, 48. The teeth present were firm with
generalized abrasion in relation to maxillary teeth. The
mandibular edentulous span had favorable ridge with firmly
attached keratinized mucosa. Further determination of the
vertical dimension of occlusion (VDO) was achieved using
Phonetics, Swallowing, patient preferences and facial
appearance. It was determined that there was loss of VDO and the
TMJ was normal (Fig1).
The treatment plan decided was to fabricate a
mandibular telescopic denture and a maxillary interim prosthesis.
After the intentional root canal treatment of the abutments 38 and
48, they were prepared with a tapered round end diamond rotary
bur with a chamfer finish line for the primary coping. The
abutments had to be prepared almost parallel with the minimum
taper for a better retention. After the preparation of the abutments,
the impression was made by using a polyvinyl siloxane
elastomeric impression material (putty and light body) by a
double step putty wash technique. The impression was poured
into a die material to obtain the cast, on which the primary copings
were fabricated. The fit of the primary coping was evaluated in the
patient's mouth, after which they were cemented on the abutments
with glass ionomer cement. Another impression was made by a
double step putty wash technique after the cementation of the
primary copings, by using a custom acrylic resin tray to obtain a
cast on which the secondary copings attached with the metal
framework were fabricated (Fig2,3) The fit of the metal
framework with secondary copings over the primary copings was
evaluated in the patient's mouth. The frictional contact between
the primary and secondary copings helped in the retention of the
prosthesis.
The metal framework had to be placed on the cast, it had
to be covered with wax and the special tray for border moulding
and final impression, had to be fabricated with chemically cured
acrylic resins after applying separating media over the cast. After
the final impression was made, the master cast was obtained and
occlusion rims were fabricated over the trial denture base.
Horizontal and vertical maxillomandibular records were obtained
with the record bases and the occlusion rims and these were
transferred to a semiadjustable articulator by using a face bow.
The artificial teeth were selected and arranged on the record bases
for a trial denture arrangement and they were evaluated
intraorally for phonetics, aesthetics, occlusal vertical dimension
and centric relation. After the wax up, the dentures were
processed, finished, polished and delivered to the patient
(Fig4,5). The patient was scheduled for follow-up visits every 3
months and he reported no complaints during the 2 years of
follow-up (Fig6,7).
DISCUSSION
Telescopic crowns have been used mainly in RPDs to
connect dentures to the remaining dentition7, but these can be
used effectively to retain complete dentures which receive their
support partly from the abutments and partly from the underlying
residual tissues. Telescopic crowns have also been used
successfully in RPDs and FPDs, supported by endosseous
implants, in combination with the natural teeth, which includes
the overdentures.8,9
Telescopic crows can also be used as effective direct
retainers for RPD. Their degree of retention can be planned to suit
different situations by modifying their designs. The amount of
intersurface friction depends on the configuration of the taper
angle and the area of the surface contact. One of the main
advantages of the telescopic retainers is that, being pericoronal
devices, they transmit the occlusal forces in the direction of the
long axes of the abutment teeth. This has proven to be the least
damaging application force. The lateral forces exert traumatic
pressure on the abutments.10
Careful assessment of the interarch space is very
important for the successful fabrication of the telescopic
dentures. Sufficient space must be present to accommodate the
primary and secondary copings, to have a sufficient denture base
thickness to avoid fracture, space for the arrangement of the teeth
to fulfill the aesthetic requirements and to have an interocclusal
gap. The space consideration usually requires the devitalization
of the abutments. The selected abutments should be periodontally
sound with adequate bone support and no/ minimal mobility.
There should be at least one healthy abutment in each quadrant.
An even distribution of the abutment in each quadrant of the arch
is preferable for better stress distribution and for increased
retention and stability of the prosthesis. The interocclusal gap/
interarch distance should be 10 mm, in order to have sufficient
space for the copings, denture base, teeth placement and adequate
closest speaking space.11
The telescopic dentures which are supported by the
roots of natural teeth have more predictable prosthodontic
outcomes because of increased support, stability and retention
and decrease in rate of the residual ridge resorption. Patients with
natural teeth can masticate more effectively than when they are
edentulous. This is due in part to their degree of accuracy in the
functional jaw movements, which are possible with a better
neuromuscular feedback mechanism from the periodontal
ligaments. The proprioceptive nerve endings in the periodontal
ligaments feed information into the neuromuscular mechanism.
In the absence of teeth, this information is missing. By retaining
the roots of some teeth, it may be possible to use this
proprioceptive apparatus with complete dentures.9 If this is so, a
higher degree of accuracy in the jaw movements and the
masticatory performance could result. By this means, teeth that
normally might have a very short life span can be retained for long
periods of time. This can thus benefit the patients in their denture
function.
It has been found that telescopic dentures have better
retention, stability, support and chewing efficiency as compared
to the conventional complete dentures and also, there is a
decrease in the rate of the residual ridge resorption because of
proprioception, better stress distribution and the transfer of
compressive forces into the tensile forces by the periodontal
ligament, which effects rate of bone remodeling. A clinical study
which was conducted by Bo Bergman et al on conical crown
48
retained dentures, concluded that most of the patients were very

satisfied with the restorations, both functionally and aesthetically
and it found their chewing comfort to be better after the treatment
with the conical crown-retained dentures.12
Complete denture fabrication for maladaptive elderly
patients becomes difficult. Therefore, they are the group of
patients who will benefit most with telescopic dentures.
Overdentures which are supported and/or retained with a few
remaining teeth or implants can be a predictable treatment that
will fulfill most of the demands of the elderly denture patients.
CONCLUSION
Tooth-supported, removable over dentures with
telescopic crowns may be considered as a good alternative to the
conventional removable dentures, because they provide better
retention, stability, support, stable occlusion, decrease in the
forward sliding of the prosthesis and better control of the
mandibular movements because of the proprioception feedback
which increases the chewing efficiency and even phonetics, as
compared to the conventional complete dentures. Also, the rate of
the residual ridge resorption was decreased because of the transfer
of compressive forces into the tensile forces by the periodontal
ligament and better stress distribution.
REFERENCES
1. Langer Y, Langer A. Tooth supported telescopic prostheses in
compromised dentitions: A clinical report. J. Prosthet Dent.
2000; 84: 129-32.
2. Glossary of Prosthodontic terms. J Prosthet Dent 2005; 94:
10-92
3. John J Sharry. Complete Denture Prosthodontics. Third
edition, New York, McGraw-Hill Book Co., 1974.
4. Prince IB. Conservation of the supporting mechanism. J
Prosthet Dent 1965; 15: 327.
5. Yalisove IL. Crown and sleeve coping retainers for
removable partial prosthesis. J Prosthet Dent 1966; 16: 106985.
6. Wenz HJ, Lehmann KM. A telescopic crown concept for the
restoration of the partially endentulous arch: the Marburg
double crown system. Int J Prosthodont 1998;11:54150.
7. Langer A. Telescope retainers for removable partial dentures.
J Prosthet Dent 1981;45:37-43.
8. Laufer BZ, Gross M. Splinting osseointegrated implants and
natural teeth in the rehabilitation of partially edentulous
patients. Part II: principles and applications. J Oral Rehabil
1998;25:69-80.
9. Besimo C, Graber G. A new concept of overdentures with
telescope crowns on osseointegrated implants. Int J
Periodontics Restorative Dent 1994;14:486-95.
10. Langer A. Telescope retainers and their clinical applications.
J Prosthet Dent 1980;44:516-22.
11. Preiskel H W. Overdenture made easy a guide to implant
and root supported prostheses 61: Quintessence Publishing
Co. Ltd. London.
12. Bergman B, Ericson , Molin M Long-term clinical results
after treatment with conical crown-retained dentures. Int J
Prosthodont 1996;9:53339.
Corresponding
Address:
Dr.Dr.
Mayank
Shah
Dr.
C.
Ram
Mohan
KKAggarwal
Dixit
Dr.
Neha
Email:
mashdreams33@gmail.com
Email:
Email:
dixit.kk@gmail.com
49
LIST OF PHOTOGRAPHS
Fig 1: Pre Operative Intra Oral View
Fig 2: Wax Pattern
Fig 3: Tooth Supported Metal Framework
Fig 4: Mandibular Telescopic Denture
Fig 5: Intra Oral View of Prosthesis Fig 6: Post Operative Intra Oral View
Fig 7: Post Operative Extra Oral View

50
Bilateral Maxillary Second Molar With Two Palatal Roots : A Case Report
C. Ram Mohan , C. Krishna Chaitanya , Hari Deva Raya Choudary , Sainath Reddy
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad.
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Sri Sai College of Dental Surgery, Vikarabad.
Senior Lecturer, Department of Conservative Dentistry and Endodontics, S.V.S. Institute of Dental sciences, Mahboobnagar.
Abstract: Variations in root number and canal morphology are challenges for successful endodontic therapy.
Unusual root and root canal morphologies associated with both buccal roots of upper molars have been
recorded in several studies in the literature. However, scientific information focusing on variations of the
palatal root is rare. This case report describes presence of two palatal roots in maxillary second molar of the
same patient bilaterally, a rare entity, diagnosed and confirmed with the help of spiral computed tomography.
Key words : Maxillary Second Molar, Number of Canals, Number of Roots, Computed Tomography, Buccal, Palatal.
INTRODUCTION
The majority of endodontic literature is replete with root
canal anatomy of maxillary first molar and there are relatively few
studies reporting the root canal anatomy of maxillary second
molar. Wong et al1 reinforced the importance of knowing the
anatomical variations of maxillary molars when he reported a
case of a maxillary first molar with the palatal canal trifurcating at
the apical level, with three independent foramina.
The commonest occurrence of two palatal canals in
double palatal roots (21/24 teeth) was found in maxillary second
molar(Christie et al2). Anamoly seemed to occur as:
1. Two palatal roots being long and divergent
2. Two palatal roots being shorter, nearly parallel and
comparable to 2 buccal roots
3. Variation of root fusion that included a two canal system on
the palatal aspect.
Benenati3, Barbizam et al4 reported a maxillary second
molar with two palatal roots. Fava et al5 reported the presence of
just one canal and one root in the second maxillary molars of the
same patient. while Alani6 encountered four roots in the second
maxillary molars of the same patient bilaterally. Baratto - Filho et
al7 carried out an in vitro study of two maxillary second molars
with four canals and two different palatal roots.
Libfield and Rostein8 1989 examined 1200 molar and
found 0.4% incidence of maxillary molar with four roots, while
Peikoff et al9 1996 observed that 1.4% of maxillary molars may
have second palatal roots.
The present case report confirms the presence of 2
separate palatal roots in maxillary second molar with the help of a
spiral Computed Tomography.
CASE REPORT
A 45 year old female presented with pain, both
spontaneous and temperature related, on the right side of the face
for several days.
The patients medical history was
noncontributory. Clinically the right maxillary second molar had
a deep carious lesion. Electric pulp testing (Vitality Scanner;
Analytic Technology, Glendora, CA) was indicative of

irreversible pulp damage.
After extensive clinical and
radiographic examination, the maxillary right second molar was
prepared for nonsurgical endodontic therapy. A preoperative
radiograph was obtained which revealed the presence of two
independant palatal roots (fig 1), which were relatively broad,
presenting two distinct foramina at the apical level. This
indicated a type I tooth, according to the classification of Christie
et al2. Spiral CT was used to determine morphology of root
canals. CT scan was done with a multi-detector CT scanner (16
slices/second). slices were obtained at different levels to
determine the canal morphology. CT confirmed the presence of
four totally separated roots, each with a distinct root canal. The
striking feature noted in CT was that maxillary left second molar
also had four roots (fig. 2).
The patient received local anesthesia of 2% lidocaine
with 1:100,000 epinephrine. A rubber dam was placed, and a
conventional endodontic access opening was made. The
conventional triangular access was modified to a trapezoidal
shape to improve access to additional canal. After removing the
coronal pulp and probing with a DG16 endodontic explorer, four
principal root canal orifices mesiobuccal, distobuccal,
mesiopalatal and distopalatal. The working length of each canal
was estimated by means of an apex locator (Root ZX : Morita,
Tokyo, Japan), and confirmed with intra oral periapical
radiograph (fig 3). The canals were initially instrumented with
#15 nickel titanium files (Dentsply Maillefer) under irrigation
with 3% sodium hypochlorite. Biomechanical preparation was
performed using the crown down technique with nickel
titanium rotary instruments (Protaper rotary files, Dentsply
Maillefer).
Palatal canals were enlarged upto F5 and
mesiobuccal and distobuccal canals were enlarged upto F3 file.
Master cone radiograph was taken (fig 4). Final irrigation with
17% EDTA followed by 3% sodium hypochlorite and sealing of
root canal space with gutta percha and AH plus resin sealer using
lateral condensation technique and tooth was restored with a
posterior composite filling (fig 5). The patient was followed up
51
for 6 months postoperatively and was found to be asymptomatic.

DISCUSSION
Unusual canal anatomy of maxillary molars has been
investigated in several studies. Most of the studies were based on
radiographic examination of the teeth which is 2-dimensional
view of a 3 dimensional object. Tachibana and Matsumoto10
studied the applicability of CT to endodontics. They concluded
that this method allowed the observation of the morphology of the
root canals, the roots, and the appearance of the tooth in every
direction. Moreover, the image could be analyzed, altered, and
reconstructed by the computer.
A major concern with use of CT scan is its high radiation dosage.
In the present study, CT was done with a multi detector CT
scanner (16 slices/second), as per Christoph et al11 guidelines to
reduce the radiation dosage.
Curzon12 suggests that additional rooted molar trait has high
degree of genetic penetrance. Supernumerary root formation
could be related to external factors during odontogenesis or
penetrance of atavistic gene.
Additional root may be suspected when indistinct images of
palatal roots are presented in preoperative X-ray images, the
clinician must consider the possibility of two palatal roots.
Dissociation of images must be performed and, if this anamoly is
confirmed, a broad coronal access will allow the correct
localization of root canals. Also clinically, cervical prominence
or an extra cusp associated with cervical prominence on a tooth
point towards presence of extra root.
second molar; Literature review and radiographic survey of

1200 teeth. J Endod 1989;15;129-31.
9. Peikoff MD, Christie WH, Fogel HM. The maxillary second
molar: Variations in the number of roots and canals. Int
Endod J. 1996;29:3659.
10. Tachibana H, Matsumoto K. Applicability of x-ray
computerized tomography in endodontics. Endod Dent
Traumatol 1990;6;16-20.
11. Christoph GD, Wilfried GH, Engel, Britta R, Hermann KP,
Oestmann JW< Must radiation dose for ct of the maxilla and
mandible be higher than that for conventional panoramic
radiography? Am Soc Neuroradiol 1996;96;1758-60.
12. Curzon ME. Miscegenation and the prevalence of three
rooted amndibular first molars in the Baffin Eskimo.
Community Dent Oral Epidemol 1974;2;130-1.
CONCLUSION
The four rooted anatomy in maxillary molars is very rare and is
more likely to occur in the second or third maxillary molar.
Careful examination of radiographs and internal anatomy is
essential. Although such cases occur infrequently, clinician
should be careful while considering endodontic treatment of a
maxillary molar, as these undetected extra roots or root canals are
a major reason for the failure. Hence the ability to locate all the
canals in the root canal system is an important factor in
determining the eventual success of a case.
REFRENCES
1. Wong M. Maxillary first molar with three palatal canals. J
Endod 1991;17;298-9.
2. Christie WH, Peikoff MD, Fugel HM. Maxillary molar with
two palatal root a retrospective clinical study. J Endod
1991;17;80-4.
3. Benenati Maxillary second molar with two palatal canals and
a palatogingival groove. J Endod 1994;11;308-10.
4. Fava LR, Weinfeld I, Fabri FP, Pais CR. Four secondmolars
with single roots and single canals in the samepatient. Int
Endod J. 2000;33:13842.
5. Barbizam JV, Ribeiro RG, Tanomaru Filho M.
Unusualanatomy of permanent maxillary molars. J Endod.
2004;30:668702.
6. Alani AH. Endodontic treatment of bilaterally occurring 4rooted maxillary second molars: Case report. J Can Dent
Assoc. 2003;69:7335.
7. Baratto-Filho F, Fariniuk LF, Ferreira EI, Pecora JD, CruzFilho AM, Sousa-Neto MD. Clinical and macroscopic study
of maxillary molars with two palatal roots. Int Endod J.
2002;35:796801.
8. Libfield H, Rostein I. Incidence of four rooted maxillary
Dr. C. Ram Mohan
Email: dr_rammohanc@yahoo.co.in
52
LIST OF PHOTOGRAPHS
Fig: 1 Pre- Operative Radiograph
Fig: 2 CBCT Image
Fig: 3 Working Length Radiograph
Fig: 4 Master Cone Radiograph
Fig: 5 Post Obturation Radiograph
53
Journal of Dental
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Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

JOURNAL OF DENTAL SCIENCES & ORAL REHABILITATION

Dr. Sumit Mohan

Dr. G.M. Sogi

Editorial Board Members :

Dr. Anurag Singhal

Published Quarterly By Institute of Dental Sciences, Bareilly

I congratulate the editorial team for bringing out a good

Dr. S.R. PANAT

Greetings to all the readers from editorial team we present our

Dr. ANURAAG GURTU

Sonal Soi, Vineet Vinayak, Anurag Singhal, Sonali Roy

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Role of GCF As Potential Biomarker in the Diagnosis of Periodontal Disease

crevicular fluid is a complex mixture of substances derived from

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

collagena se, Gelatinase, Tissue

Biomarkers of periodontal disease activity may be obtained

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Cone Beam Computed Tomography

appreciate the advantages that the third dimension gives to clinical

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Fig 1 CBCT Machine

Fig 2 CBCT Image

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Nanotechnology : Its Implications in Conservative Dentistry and Endodontics

Sumit Mohan , Anuraag Gurtu , Anurag Singhal , Ankita Mehrotra

Abstract: Feynman postulated concept of nanotechnology as an unavoidable development in the progress of

particular tooth that requires treatment. After oral procedure

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

photosensitizers and carriers. They can bind to the antibody

Top-Down Approaches include:

NanOSS .These can be used in maxillofacial injuries

ROLE OF NANOTECHNOLOGY IN CONSERVATIVE

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

complications. Well-known alternatives, such as transcutaneous

toothpaste, it could cause potential health effects. If the silver

NANOFILLED RESIN MODIFIED GLASS IONOMER

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

gold nanoparticles. One of the method of closing sub micron sized

microbiology started with the detection of cultivable as well as

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

23. Bhardwaj SB, Mehta M, Gauba K. Nanotechnology: Role in

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Fig 1: Comparison of nanoparicle with water molecule and tennis ball

Fig.3 Nanorobots in local anaesthetic solution

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

Flapless Implant Surgery : An Overview

Rashi Jolly , Himanshu Thukral , Mansi Thukral Chandra

Senior Lecturer, Department of Prosthodontics, Institute of Dental Sciences, Bareilly (U.P).

The surgical procedure for placement of implants to

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

complications, and increased patient comfort and

Wide Bony Ridge

Not suitable in ridges with concavities and parabolic

Inability to visualize anatomic landmarks.

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September

remaining buccal bone thickness after implant placement should

Albrektsson T, Brnemark P-I, Hansson HA, Lindstrom J.

Journal of Dental Sciences & Oral Rehabilitation 2013; July - September