FROM THE EDITOR-IN-CHIEF

From the Editor's Desk

Dr. KMK Masthan

Professor and Head,
Department of Oral Pathology and Microbiology
Sree Balaji Dental College and Hospital, Chennai

In my editorial in the last issue, my outlook on foxhole syndrome also when they get to meet
private practice drew a variety of observations the caregivers of the other patients. There are no
and suggestions from various quarters. There atheists in the foxhole is the unwritten rule. I have
was enormous correspondence to include this also seen and sensed that the religious and pious
and that and I realised that the topic is too big to people put up with the unbearable stress much
be covered under one Editorial and hence a full better than the down to earth, happy go lucky
blown workshop is needed with speakers from types. Probably prayer does not lessen the burden
various disciplines like management, finance, law but definitely gives their shoulders more strength
and interior decoration etc. My final conclusion to bear the burden. Some caregivers tend to keep
is dental practice is as individualistic as a person's their mental agony and suffering invisible to the
face and dress. I also realised that each person's patient whereas loquacious to outsiders. There is
practice metamorphoses into a different kind with no fixed pattern as to which of their basic nature
passage of time and the quantity of success he/she will surface.
has gets. Best luck to all of them.
I think medical personnel must spend some
This editorial I dedicate to the discussion on time with the caregivers to help them develop
the plight of the care-giver of any terminally ill resilience, since most caregivers do not have the
cancer patient. On one side, after all the slash, energy or the mental stamina to withstand seeing
burn and poison treatments, some unfortunate their loved one's life melting away in front of their
patients realise that their suffering and pain are eyes. Physical impairment of the cancer patient
not going to go away and, at that moment, they due to the disease is another challenge the care-
wish that their end comes sooner than later. Most giver has to withstand. When pushed to care for
times, it is the caregiver, whether it is the spouse the daily life of the debilitated patient, care-givers
or the children, who entertains hopes of recovery develop depression, anxiety and sleep deprivation.
and return of the patient to his original busy and Feeding and washing the bedridden patient may
productive life. Most care givers develop the fall on their already overburdened shoulders.

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 843
 FROM THE EDITOR-IN-CHIEF

Lesser help from other relatives augment their The reality with the women and the children
problems. Some countries like Singapore insist when their financial support is their husband
on military service for one or two years after or the father who suffers and is likely to die are
higher secondary education. That concept can beyond words. When it is the young ones who are
be projected and such age group children in our the cancer patients, the agony of the parents can
country can be asked to do nursing care for six only be expressed by the Biblical quote, ''No one
months or one year. suffered more and nobody deserved less'.
Other problems they encounter when they look The sense of guilt that creeps in when the care
after the cancer patients are the care of cancerous givers realise that their efforts are fruitless and it
growths and their foul odour. The difficulty can really be taxing to the doctor when they ask
becomes more distressing when the patient the question ''Why my father and not somebody
resides in some faraway place from treatment else?''. It is also very difficult when some patients
facilities. Healthy person can easily share his ask ''How come you say no treatment is available
house with other family members however when things are so advanced in the world?''. The
much smaller the house may be and however reality is no doctor, excepting a few, is really
much bigged the family maybe. Not the same trained to handle these situations. Our medical
situation when the patient is very sick and may and dental education has a serious lacuna in these
require separate toilet, dedicated space etc. In the aspects.
terminal stages neurological deficits like delirium
and hallucination may augment the difficulties. The idea to write an editorial on this topic was
Frustration and hopelessness prevail over since seeded when I got the chance to visit Jeevodhaya
the end cannot be predicted. I vividly remember at Chennai, a hospice for Cancer patients in their
one comment of the son of a cancer patient who terminally ill stages. Once I saw the level of
had just passed away ''My house is now peaceful, dedication of the sisters who run the institution,
though we miss our mother dearly'' I was reminded of the famous saying of Mother
Teresa ''Please do not bring here patients who
Some care-givers, being unable to tolerate the can be treated by Doctors. Instead bring those
demands from the patient when the patient keeps who have been given up by Doctors''. May The
complaining persistently about pain, give more Almighty give them more strength and resources
pain killers. Some simply give up when forced to treat more such patients. Readers are welcome
to look after the patient day after day, week after to share their feelings at ijmdent@gmail.com.
week and literally look forward to the death of the
patient from sheer exhaustion. Best wishes

844 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
 Original Research

Assessment of Dentofacial structures in transverse

plane in individuals with long face

Ravi M S1, Rajendra Prasad B2, Srinivas Prasad V3, Vijayalakshmi B M4, Shine Benny5

Abstract
Background and Aim: Vertical growth pattern include increased total facial height, especially the lower facial height,
high mandibular plane angle, clockwise mandibular rotation, short mandibular ramus and high gonial angle. Vertical
facial patterns might play a strong role in the transverse growth of the maxilla and the mandible. Hence this study was
planned and designed for the assessment of dento-alveolar and skeletal asymmetries in long face individuals. Materials
and methods: Total of 60 individuals (30 males and 30 females) with vertical growth pattern (Y-axis more than 60° and
Jarabak’s ratio less than 56 %) were considered for the study. Lateral cephalogram, frontal cephalogram and study
casts were made. 16 cephalometric measurements and 6 dental cast measurements were made for evaluation. The
data obtained was statistically evaluated using Student’s t-test. Results: All the cephalometric values showed right
side dominance. In males, the values of Co-Me, Co-MSR and gonial angle showed statistically significant difference.
In females the value of Me-MSR and Lower dental arch midline showed statistically significant. All the values of
arch chords (dental cast measurements) suggested left side dominance both in males and females except Mandibular
1-3 chord which suggested right side dominance. Conclusion: Dento-alveolar and facial asymmetry with right side
dominance exist in individuals with long face. The mandible is found to be more asymmetric than maxilla.

Key words: Dental and Facial asymmetry; Frontal cephalometrics; Transverse dimension.

Introduction orthodontic diagnosis obtained from information

D entofacial structures need to be evaluated in
three planes of space (i.e., sagittal, transverse
and vertical) which helps to differentiate between
dentoalveolar and skeletal discrepancies and to
evaluate their relative contribution towards the
creation of malocclusion.¹ Most of the normative
data have been based on sagittal aspects of
dentofacial structures with the current emphasis on
Professor, 2Dean,
1
from the postero-anterior (P-A) cephalometric
radiograph films.²
Transverse problems are a great concern to
the orthodontist and have been mentioned as
having great potential for relapse.3,4 Analysis
of vertical components, although easily viewed
from sagittal cephalometric radiographs, cannot
be fully understood without the assistance of
a P-A cephalometric radiograph as bilateral
vertical asymmetries can only be evaluated

PG Student,
5 from a frontal view.² Facial growth studies that
Dept. of Orthodontics, include the transverse component have been even
A. B. Shetty Memorial Institute of Dental Sciences,
Nitte University, Mangalore fewer. In relation to diagnosis and treatment, the
Associate Professor,
3
specialty has been overwhelmingly preoccupied
Govt. Dental College, Bangalore
with vertical and sagittal relationships of the
4
Senior Lecturer,
Dept. of Orthodontics, dentofacial structures. Those available do not
PMN Memorial Dental College, Bagalkot, Karnataka include a detailed analysis of the P-A cephalo-
Corresponding Author:
metric radiographs.² The long faced individuals
Dr. M. S. Ravi
E mail id: drmsravi@gmail.com are characterized by growth variation in the vertical

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 845
 Original Research
plane. Vertical growth pattern include increased
total facial height, especially the lower facial
height, high mandibular plane angle, clockwise
mandibular rotation, short mandibular ramus and
high gonial angle.5 Vertical facial patterns might
play a strong role in the transverse growth of the
maxilla and the mandible.6 Hence this study is
planned and designed for the assessment of dento-
alveolar asymmetries in long face individuals
and to determine and also assess the skeletal
asymmetry in long face individuals.
Materials and Methods
60 subjects, (30 males and 30 females) in the age
group of 18 to 25 years, were selected as per the
following inclusion & exclusion criteria.
Inclusion Criteria
1. Clinically obvious long faced individuals.
2. Individuals in the age group of 18-25yrs.
3. Complete permanent dentition (with exception
of 3rd molars).
4. Subjects willing to participate in the study.
Exclusion Criteria
1. Individuals with Prior orthodontic / surgical
treatment.
2. Individuals with Craniofacial syndrome, cleft
lip and palate.
3. Individuals with no history of chronic nasal
or sinus infection
4. Individuals with clinically obvious
asymmetry.
5. Individuals having TMJ disorders or trauma.
6. Mutilated case, missing molar/ incisors.
7. Severe upper and lower anterior crowding.
Method of Collection of Data
The subjects fulfilling the above criteria were
requested to participate in the study. The
selected individuals were explained about the
846 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
procedures and with their written consent,
lateral cephalograms were made for evaluation.
The radiographs were made under standardized
conditions with the Frankfort horizontal plane kept
parallel to the floor and the midfacial plane kept
in a vertical position. The lateral cephalograms
and were traced on 0.003 inch acetate paper by
the same operator in order to avoid inter-operator
errors. Individuals with Jarabak’s ratio less than
56% and Y axis (N-S-Gn) value of more than 60°
were selected for the study. Frontal cephalograms
were then made under recommended conditions
for these individuals. The distance between the
transporionic axis and film was kept constant for
each subject to minimize the magnification error.
The central ray of the X- ray passed through
the center of the midsaggital plane so that the
magnification of right and left sides of the face
was the same.
The postero-anterior cephalogram was traced
and the landmarks and planes as required for
Grummon’s analysis were marked (Figure 1 & 2)
and analysis for facial asymmetry was carried out
as follows:
Figure 1: Land marks on postero-anterior (P-A)
cephalogram, Ag - Antegonial Notch, ANS -
Anterior Nasal Spine, Cg - Crista Gall,
Co – Condylion, J - Jagal process, Me – Menton,
A1 - Upper central incisal edge, B1 - Lower
central incisal edge, Ag - Constructed point
at MSR, J - Constructed point at MSR

Figure 2: Linear measurements on postero-
anterior (P-A) cephalogram, 1. MSR – Mid-sagittal
reference plane, 2. Co-MSR – Condylion -
Mid-sagittal reference plane, 3. J-MSR – Jugal
Process - Mid-sagittal reference plane,
4. Ag-MSR – Antegonial notch - Mid-sagittal
reference plane 5. Co-Ag – Condylion - Antego-
nial notch plane, 6. Buccal surface of 1st molar-
J – Buccal surface of 1st molar – Jugal Process,
7. Cg-J – Crista galli - Jugal Process plane,
8. Cg-Ag – Crista galli - Antegonial notch plane,
9. Co-Me – Condylion - Menton plane,
10. Ag- Me – Antegonial notch- Condylion
plane, 11. Gonial angle (Go ang)
Mandibular Morphology: Left – right triangles
are formed from the heads of the condylar
processes or condylion (Co), Antegonial notch
(Ag) and Menton (Me). These are split by ANS-
Me line and compared.
Volumetric Comparison: Two volumes are
calculated from the area defined by each Co-Ag-
Me and the intersection with a perpendicular from
Co-MSR.
Maxillo–Mandibular Comparison of
Asymmetry: Perpendiculars are drawn to MSR
from J and Ag and connecting lines from Cg-to J
and Ag. This produces 2 pairs of triangles, each
is bisected by MSR.
Linear Asymmetries: The vertical offset as well
as linear distance is measured from MSR to Co,
J, Ag and Me.
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
Original Research
Maxillo-Mandibular Relation: Distances are
measured from buccal cusp of upper first molars
along the J perpendiculars.
Dental arch midline in relation to MSR:
Deviation of upper and lower arch midlines to the
right side was given a positive sign and to the left
side was given a negative sign.
The upper and lower impressions were made
and study casts were prepared for analysis
of dental characteristics as mentioned below
(Figure 3 & 4)
1. Incisor overjet was measured separately
on the left and right central incisors.
2. Canine deviation was measured as the
horizontal distance from the cusp tip of the
maxillary canine to its normal position in the
embrasure between the mandibular canine and
first premolar.
3. Buccal segment relation (BSR) parallels
Angle’s molar classification, but on a
continuous scale, where the horizontal distance
of the buccal groove of the mandibular first
molar is measured relative to the mesio-buccal
cusp tip of the maxillary first molar. An
idealized Class I relationship has a BSR of 0
mm; Class II relationships have negative value
and class III relationship positive value.7
4. Upper molar width was measured as the
transverse distance from the central fosse of
the 1st molar to median raphae.
5. Upper canine width was measured as the
transverse distance from the cusp tip of the
canine to median raphae.
6. Arch chords are the straight-line distances
from the incisive inter-denal papilla measured
to (A) the distal-most aspect of the canine and
(B) the disto-buccal aspect of the first molar.
Chords were measured from the midline
to the canine (from central incisor through
canine) and to the first molar (from central
incisor through first molar) in each of the four
quadrants.
847
 Original Research
Figure 3: Dental cast Measurements,
1.Overjet, 2. Canine discrepancy,
3. Buccal Segment Relation
Figure 4: Dental cast Measurements,
4.Measurement of Molar width,
5.Canine width, 6.Arch chord
Results
The data collected were subjected to Student’s
‘t’ test for paired sample was used to test the
significance (p= 0.05 or less) in the difference
between the right and left sides and for any
differences between the gender. The following
results were obtained from the study:
848 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
Cephalometric Analysis:
All the parameters showed right side dominance.
All the parameters showed male dominance and
the differences were statistically significant.
Mandibular Morphology (Table 1)
The values of Co-Me and gonial angle showed
statistically significant difference in males but
in females, the difference was not statistically
significant.
Volumetric Comparison (Table 1)
In males, significant difference was observed
between right side and left side values in relation
to Co-MSR but in females, the value of Me-MSR
showed significant difference.
Maxillo–Mandibular Comparison of Asymmetry
(Table 2)
In this study no significant difference was
observed between right side and left side values
in relation to Cg-J, Cg-Ag, J-MSR, Ag-MSR,
Cg-MSR(J) and Cg-MSR(Ag) both in males
and females.
Linear Asymmetries (Table 2)
The value Me-MSR showed statistically
significant difference in females but in males,
there was no significant difference.
Maxillo- Mandibular Relation (Table 3)
1st molar to jugal process: In this study no
significant difference was observed between right
side and left side values in relation to 1st molar to
jugal process both in males and females.
Dental Arch Midline In Relation To MSR (Table 4)
Upper midline: No significant difference was
observed between right side and left side values
in relation to upper midline both in males and
females.
Lower midline: No statistically significant
difference was observed between right side and
left side values in males but the midline was
found to be significantly deviated towards right
side in females.
 Original Research

Dental Cast Measurements (Table 5)
In this study no significant difference was observed
between right side and left side values in relation to
incisor overjet, canine deviation, buccal segment
relation, maxillary canine width and maxillary
molar width both in males and females.
Arch Chord Measurements
All the values of arch chords suggested left side
dominance both in males and females except
Mandibular 1-3 chord which suggested right side
dominance. Significant difference was observed
in relation to Maxillary and Mandibular 1-6
chords both in males and females. However no
significant difference was observed between right
side and left side values in relation to Maxillary
1-3 chord and Mandibular 1-3 chords both in
males and females. (Table 5)

Table 1: Mandibular morphology and volumetric comparison

Variables Gender N Side Mean Deviation t p

(mm) Std.
Co-Ag M 30 Right 66.3000 6.64442 -1.076 .291
Left 65.5000 4.99482
F 30 Right 60.2000 4.99482 -.045 .964
Left 60.1667 5.73605
Ag-Me M 30 Right 53.1000 3.89828 .636 .529
Left 53.4333 3.82986
F 30 Right 49.3000 3.37486 1.073 .292
Left 50.3000 4.20304
Co-Me M 30 Right 105.2667 7.91303 -1.962 0.05
sig
Left 104.2667 7.42286
F 30 Right 99.5000 7.82459 -.466 .645
Left 99.2000 6.35935
Go ang M 30 Right 124.1333 12.14775 -2.495 0.019
Sig
Left 122.7667 12.13625
F 30 Right 128.8000 7.14577 -1.039 .307
Left 127.8000 6.10483
Co-MSR M 30 Right 54.2667 3.37264 -2.175 0.038
Sig
Left 53.0667 3.10654
F 30 Right 51.9333 3.64770 -1.194 .242
Left 50.8333 3.96609
Me-MSR M 30 Right 91.8333 8.04335 -.721 .477
Left 91.4667 7.18107
F 30 Right 85.3000 8.00496 -2.340 0.026
Sig
Left 84.4000 7.57764

*The mean difference is significant at the level .05 level

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 849
 Original Research

Table 2: Maxillo-mandibular comparison and linear measurements

Variables Gender N Side Mean Std. t p

(mm) Deviation
Cg-J M 30 Right 72.9000 4.48253 -1.297 .205
Left 69.8333 12.5919
F 30 Right 70.5667 6.53206 -.602 .552
Left 70.2000 6.75890
Cg-Ag M 30 Right 116.9333 6.94775 -.728 .473
Left 116.5667 7.07927
F 30 Right 109.3333 6.42373 .879 .387
Left 109.7667 5.80537
J-MSR M 30 Right 37.1333 3.94561 .073 .942
Left 37.1667 3.50451
F 30 Right 35.8500 3.36091 -1.670 .106
Left 35.1833 2.97253
Ag-MSR M 30 Right 43.3000 7.91398 1.564 .129
Left 45.6000 2.54070
F 30 Right 42.9500 2.67282 -.731 .471
Left 41.8333 7.64778
Cg-MSR(J) M 30 Right 66.8333 15.71971 1.383 .177
Left 67.3667 15.99026
F 30 Right 58.8500 8.34509 1.006 .323
Left 59.4833 9.13546
Cg-MSR(Ag) M 30 Right 105.8000 15.62580 1.135 .266
Left 106.4000 15.44423
F 30 Right 100.5333 7.48209 -.204 .840
Left 100.4000 6.38209
Me-MSR M 30 Right .9833 1.42927 -1.273 .213
Left .5167 .96921
F 30 Right 1.2833 1.57394 -2.478 0.019
Sig
Left .3667 .80872

*The mean difference is significant at the level .05 level

Table 3: Maxillo-Mandibular relation

Variables Gender N Side Mean Std. t p

(mm) Deviation
1st Molar M 30 Right 25.6667 4.19633 -.337 .738
to Jugal Left 25.5000 3.63650
process F 30 Right 22.9667 5.08197 -.867 .393
Left 22.5667 6.08380

*The mean difference is significant at the level .05 level

850 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
 Original Research

Table 4: Measurement of Dental arch midline

Variables Gender N Side Mean Std. t p
(mm) Deviation
Upper M 30 Right .50 .974 -.763 .452
midline Left .73 1.143
F 30 Right .40 .855 1.262 .217
Left .73 .980
Lower M 30 Right .63 1.033 1.229 .229
midline Left 1.10 1.447
F 30 Right .97 1.033 2.318 .028 Sig
Left .33 .884
*The mean difference is significant at the level .05 level
Table 5: Dental cast measurements (Chord measurements)
Variables Gender N Side Mean(mm) Std. t p
Deviation
Incisor M 30 Right 3.8833 2.16430 .047 .963
overjet Left 3.8667 1.90703
F 30 Right 3.5833 2.55317 1.306 .202
Left 3.3333 2.47864
Canine M 30 Right .0667 3.26352 1.758 .089
deviation Left -.3667 3.20811
F 30 Right -.3500 3.06299 -1.284 .209
Left .5667 3.94517
Buccal M 30 Right -.2667 2.34423 1.922 .064
segment Relation Left -.6000 1.88643
F 30 Right .5167 1.55632 .354 .726
Left .3333 2.02286
U Molar width M 30 Right 23.8833 2.16430 .582 .565
Left 23.7000 2.12376
F 30 Right 22.6000 1.85417 -.048 .962
Left 22.6167 2.52806
U Canine width M 30 Right 18.2833 2.18807 1.098 .281
Left 18.1000 2.29091
F 30 Right 16.7833 1.74536 .290 .774
Left 16.7000 1.83171
Maxillary-1-3 M 30 Right 23.750 2.2196 -.473 .640
chord Left 24.920 1.8760
F 30 Right 23.5667 2.23889 -.337 .738
Left 23.7000 1.82700
Mandibular 1-3 M 30 Right 18.6333 1.78564 1.005 .323
chord Left 18.4000 1.52225
F 30 Right 17.9833 1.39261 -.488 .629
Left 18.1167 1.55743
Maxillary-1-6 M 30 Right 46.1333 3.48873 - 2.262 .031 Sig
chord Left 47.1333 3.08202
F 30 Right 45.2500 2.56216 - 2.666 .012 Sig
Left 46.8000 2.29542
Mandiblar-1-6 M 30 Right 41.500 3.0115 - 2.449 .021 Sig
chord Left 42.37 2.428
F 30 Right 23.700 1.8270 - 2.714 .011 Sig
Left 23.57 2.239
*The mean difference is significant at the level .05 level

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 851
 Original Research
Discussion
Most of the normative data have been based on
sagittal aspects of dentofacial structures. With
the current emphasis on orthodontic diagnosis
obtained from information from the postero-
anterior (P-A) cephalometric radiograph films,
evaluation is needed in the transverse dimension
for a comprehensive dentofacial evaluation.2
The lower usage of PA cephalograms may be
attributed to the fact that orthodontic educational
centers do not emphasize the importance of
PA cephalometric evaluation or the difficulties
encountered in conducting such evaluation.
These problems include the errors associated
with reproducing head posture and identifying
landmarks of the structures that are superimposed
or not identifiable with poor radiographic
technique, as well as concern about additional
exposure to radiation.8 In the present study,
individuals of age group 18-25 yrs as per
the inclusion criteria and exclusion criteria
were selected. Lateral cephalogram, frontal
cephalogram and study casts were made. Total
of 60 individuals (30 males and 30 females) with
vertical growth pattern (Y-axis more than 600 and
Jarabak’s ratio less than 56%) were considered
for the study.
Postero-anterior cephalograms were used to
assess skeletal asymmetry. PA view is a valuable
tool in the study of right and left structures
since they are located at relatively equal distance
from the film and X-ray source, as a result the
effect of unequal enlargement by the diverging
rays is minimized and the distortion is reduced.
Comparison between sides is therefore more
accurate since the midlines of the face and dentition
can be recorded and evaluated.9 Several postero-
anterior analysis like Svanholt and Solow analysis
(Svanholt and Solow, 1977), Grayson analysis
(Grayaon et al 1983), Hewitt analysis (Hewitt,
1975) and Ricketts analysis are being used for
assessment of the facial asymmetry. Analysis
proposed by Grummons and Kappeyne Van De
Cappello (1987) contains quantitative assessment
852 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
of vertical dimensions and proportions. This is
a comparative and quantitative postero-anterior
analysis. This type of analysis provides a
practical, functional method of determining the
location and amount of facial asymmetry.10
In the present study, right side dominance has
been found in all cephalometric measurements
both in males and females. Similar findings were
reported by Haraguchi et al,11 Shah and Joshi,12
Peck et al13 and Oliver G14 in their asymmetry
analysis. This finding is in contradiction to a
study done by Giovanoli et al15 who had reported
left sided dominance. Right side dominance
may occur naturally because of neuroanatomic
development,16 might be caused by an imbalance
in the growth of the right and left sides of the
face,17 handedness and unilateral chewing have
been suggested to be additional causes of facial
asymmetry.18
The comparison between right and left side Co-
Me, Go angle, Co-MSR and Me-MSR showed
mandibular asymmetry and the difference
was statistically significant. This finding is
in agreement with studies by Rossi M et al,19
Haraguchi et al11 and Server TR and Profit20 but
is in contradiction to studies by Shore IL,21 Shah
and Joshi12 according to which there is a tendency
for the maxilla to be more asymmetric than
mandible. There is a tendency for the mandible
to be more asymmetric because (1) the mandible
grows longer than the maxilla and thus is likely
to show more deviation and (2) the mandible is a
mobile apparatus whereas the maxilla is connected
rigidly to its adjacent skeletal structures.19
In the present study, all the parameters showed
male dominance and the difference was
statistically significant. This finding is in
accordance with studies by Giovanoli P et al,15
Farkas LG22. This is thought to be because of
greater growth of the facial musculature and skull
of males compared with females.15 In the present
study, lower dental arch midline was found to be
shifted to right side in females. This finding is in

accordance with a study done by Debra.G et al.1
The measurements - Cg-J, Cg-Ag, J-MSR, Ag-
MSR, Cg-MSR (J) and Cg-MSR (Ag) showed no
significant difference both in males and females.
These findings were in contradiction to a study
done by Kelvin M Cassidy et al.8 On comparing
the maxillo-mandibular relation i.e., the linear
measurement between 1st molar to jugular
processes, no statistically significant difference
was observed between the right and left side
values both in males and females.
The present study showed that the asymmetries
decrease in magnitude, as we approach higher
in the craniofacial skeleton. The upper facial
region presents with asymmetries having the least
magnitude, whereas the mandibular region (lower
facial region) shows asymmetries of highest
magnitudes. This finding is in accordance with a
study done by Sumit et al23 but is contradictory to
a study done by Farkas LG7 according to which
the largest amount of asymmetry was observed in
upper third of face. In the present study upper and
lower study casts were analyzed for dentoalveolar
asymmetries by measuring 6 parameters, similar
to dental analysis done by Edward F Harris and
Katherine Badford.24 Both the Maxillary and
Mandibular 1-6 chords showed left side dominance
both in males and females. This finding is in
accordance with a study done by Edward F Harris
and Katherine Badford.24 Incisor overjet, showed
no statistically significant difference between
the right and left side values both in males and
females. This finding is in accordance with a
study done by Edward F Harris and Katherine
Badford.24 Canine deviation and buccal segment
relationship showed no statistically significant
difference between the right and left side values
both in males and females. However these
findings were in contradiction to a study done by
Edward F Harris and Katherine Badford.24 Upper
molar width and upper canine width showed
no statistically significant difference between
the right and left side values both in males and
females. This finding is in accordance with a
study done by Kelvin M. Cassidy et al.8
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
Original Research
In the present study, maxillary 1-3 chord and
mandibular 1-3 chord showed no statistically
significant difference between the right and left
side values both in males and females. This finding
is in accordance with a study done by Edward F
Harris and Katherine Badford.24
The clinical implication of the present study is:
Significant asymmetry in facial skeleton and
dental arches exists in the long face individuals
and this fact must be taken into account during
diagnosis and treatment planning.
Further studies with large sample size comprising
of different skeletal and dental malocclusions
in various racial groups may be required for
assessment of skeletal and dental asymmetries in
males and females of different age groups.
Conclusions
• Dento-alveolar and facial asymmetry exist in
individuals with long face.
• The mandible is found to be more asymmetric
than maxilla.
• Right side dominance has been found in all
the Cephalometric values in both males and
females. All the parameters showed male
dominance.
• Maxillary and Mandibular 1-6 chords
showed left side dominance both in males
and females.
References
1. Debra.G. Alavi, Ellen A. BeGole and Bernard
J.Schneider. Facial and dental asymmetry in Class II
subdivision malocclusion. Am J Orthod 1988; 93:38-
46.
2. Stephen F. Snodell, Ram Nanda and Frans Currier. A
Longitudinal Cephalometric study of transverse and
vertical craniofacial growth. Am J Orthod Dentofacial
Orthop 1993; 104:471-483.
3. Ferris HC. Discussion of Dr. G. V. I. Brown's paper.
Dent Cosmos 1914; 56:218.
4. Herold JS. Maxillary expansion: A retrospective study
of three methods of expansion and their long-term
sequelae. Br J Orthod 1989; 16:195-200.
853
 Original Research
5. Guilherme Janson, Roberto Bombonatti, Karina
Santana Cruz, Cristina Yuka Hassunuma, and Marinho
Del Santo. Buccolingual inclinations of posterior teeth
in subjects with different facial patterns. Am J Orthod
Dentofacial Orthop 2004; 125:316-22.
6. Dawn M.Wagner and Chun-Hsi Chung. Transverse
growth of the maxilla and mandible in untreated
girls with low, average, and high MP-SN angles: A
Longitudinal study. Am J Orthod Dentofacial Orthop
2005; 128:716-723.
7. Farkas LG, Cheung Gwynne. Facial asymmetry in
Healthy North American Caucasians.Angle Orthod
1981; 51:76-78.
8. Kelvin M Cassidy, Edward F Harris, Elizabeth A.Tolley,
Robert Keim. Genetic influence on dental archform in
orthodontic patients. Angle Orthod 1998;68(50):445-
454.
9. Samir E.Bishara, Pauls.Burkey, JohnG.Kharouf.
Dental and facial asymmetries: A review. Angle
Orthod 1994; 64(2):89-98.
10. Grummons DC, Kappeyne. A frontal asymmetry
analysis.J Clinical Orthod 1987; 21: 448 -65.
11. Seiji Haraguchi. Kenji Takada, Yoshitaka Yasuda.
Facial asymmetry in subjects with skeletal class III
deformity. Angle Orthod 2002; 72: 28-35.
12. Shah SM. Joshi MR. An assessment of asymmetry in
the normal craniofacial complex. Angle Orthod 1978;
48(2):141-48.
13. Peck, Leena Peck, MattiKataja. Skeletal asymmetry
in esthetically pleasing faces Sheldon. Angle Orthod
1991; No. 1: 43 – 48.
14. Oliver G, Sringfield,II Charles C Thomas. Practical
Anthropology. 196; pp 43-49.
854 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
15. Giovanoli P, Tzou CHJ, Ploner M. Three dimensional
video analyses of facial movements in health
volunteers. Br J PlastSurg 2003; 56:644.
16. Woo TL. On the asymmetry of the human skull.
Biometrika 1931; 22:324.
17. Melnik AK. A Cephalometric study of mandibular
asymmetry in a longitudinally followed sample of
growing children. Am J Orthod Dentofacial Orthop
1992; 101:3 5 5- 66 .
18. Wu-chulSong, Ki-Seok Koh, Sang-Hyun Kim, Kyung-
SeokHu, Hee-Jin Kim,Jung- Cheol Park and Byoung
–Young Choi. Horizontal angular asymmetry of the
face in Korean young adults with reference to the Eye
and Mouth. J oral maxillofac Surg 2007; 65:2164-
2168.
19. Rossi M, Ribeiro E, Smith R. Craniofacial asymmetry
in development: An Anatomical study. Angle orthod
2003; 73:381.
20. Severt TR, Proffit WR. The prevalence of facial
asymmetry in the dentoalveolar deformities
population at the University of North Carolina.Int J
Orthod Orhognath Surg 1997; 171:12.
21. Shore IL. A Cephalometric study of facial asymmetry
(Master’s Thesis) University of Pittsburg, 1959.
22. Farkas LG. Anthropometry of the head and face. New
York, NY: Raven Press; 1994:103-111.
23. Sumit Geol, Anand Ambekr, Milind Darda, Sourabh
Sonar. An assessment of facial asymmetry in Karnataka
population. J IndOrthodSoc 2003;36:30-38.
24. Edward F Harris; Katherine Bodford. Bilateral
Asymmetry in the Tooth Relationship of Orthodontic
Patients. Angle Orthod 2006; 77(5):779-786.
 REVIEW ARTICLE

The Presentation and Management of

Upper Airway Obstruction
Amit Prakash1, Rajendra Gupta2

Abstract
Sleep disordered breathing (SDB - snoring and obstructive sleep apnea (OSA) - affects tens of millions of people
worldwide. Sleep-disordered breathing is a worldwide epidemic with health and economic consequences that range
from annoying to deadly. Currently, treatment of snoring and OSA calls upon a mix of modalities and a coordinated team
of clinicians. Positive air way pressure, surgery, and therapy with oral appliances are frequently effective in managing
the sleep-induced unstable air way. Those who place their health in the hands of sleep and dental professionals are best
served if these clinicians can focuson the proper development of the upper airway immediately after birth and then work
as a team to recognize and manage anyabnormalities in breathing and facial morphology as early as possible.

Key words: OSA, Airway Obstruction, Orthodontics, Surgery

Introduction and behavior of Joe, which became the model

for many subsequent descriptions of these
O bstructive sleep disorders and sleep-
associated airway obstruction are being
recognized more frequently by all health care
patients. In 1889, Hill describes a child “who
breaths [sic] through his mouth instead of his
nose, snores, restless at night and suffers from
providers as significant problems in children
headache at school”. In 1918, Osler coined the
and adolescents. The significance of sleep-
term pickwickian to describe hypersomnolent and
related respiratory obstruction is not completely
morbidly obese patients. In 1965, Menashe and
understood and the proper diagnosis and
colleagues describes two non-obese children with
treatment remain controversial.1 Children and
adentotonsillar hypertrophy and cardiovascular
adolescents with adenotonsillar hypertrophy
changes who were treated successfully with
may present with a variety of conditions such
adenotonsillectomy.2,3
as nasal obstruction, mouth breathing, fatigue,
and obstructive sleep disorders. In 1837, dickens Pathophysiology
described an obese hypersomnolent boy named
“Joe” in the Posthumous Papers of the Pickwick In obstructive sleep apnea, there is decreased
Club. Dickens described the clinical features airway because of anatomic obstruction of the
upper airway. To maintain adequate airflow
through a diminished lumen, the patient must
increase respiratory effort. Because of the
Senior Lecturer, Bernoulli Effect, increased intraluminal negative
1

Dept. of Orthodontics and Dentofacial Orthopedics

Rishi Raj Dental College and Hospital, Bhopal pressure, and a compliant airway structure,
Associate Professor,
2
collapse of the airway and cessation of airflow
Dept.of Anatomy, Gaja Raja Medical College, Gwalior
result. Increasing negative airway pressure
Corresponding Author:
Dr. Amit Prakash
paradoxically causes further airway collapse and
Email id: amitprakash30@gmail.com increased resistance to airflow.1,4 Peripheral and

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 855
 review article
central neuromuscular regulation of respiratory
function also contributes to the development of
obstructive sleep disorders. There is a decrease
in the activity of the genioglossus and diaphragm
during a normal sleep cycle. It appears that
obstructive apneas occur more frequently
during these periods of decreased electromotor
activity. Anatomic obstruction and decreased
muscle tone causes cessation of airflow, which
leads to physiologic changes including acidosis,
hypercapnia, and hypoxemia. Once sufficient
changes in the partial pressure of oxygen, (PO2)
the partial pressure of carbon dioxide (PCO2),
and the pH occur, central and peripheral chemo-
receptors and baroreceptors are stimulated to
cause arousal and awakening from sleep, which
may occur many times in a night. Therefore,
the quality of seep, both physiologic and
psychological restful sleep, is markedly disturbed,
which may lead to behavioral changes such as
hypersomnolence, hyperactivity, depression, and
learning difficulties. Also, secondary cardio-
vascular changes including arrhythmias, right-
sided heart failure, and corpulmonale are of major
concern.4-6
Etiology
Adenotonsillar hypertrophy is the most common
cause of respiratory obstruction of the upper
airway. However, many other congenital,
anatomic, and neuromuscular causes have been
reported. Patients with craniofacial syndromes
such as Crouzon, Apert, Treacher Collins, and
Pierre Robin often have abnormalities of the
upper airway manifesting as snoring and
disorders, other causes such as nasal septal
deviation, choanal stenosis, maxillary hypoplasia,
micrognathia, retrognathia, and macroglossia
may also be contributing factors.2,4,6
Research in craniofacial growth has led to the
realization that the mechanisms controlling
the growth processes in the face are complex,
interrelated, and interdependent, growth of the
mandible alone is seen to be modulated by highly
856 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
complex system involving both local and peripheral
feedback mechanism and hormonal and central
nervous system influences. There are numerous
theories regarding facial growth, ranging from
intrinsic genetic factors controlling the mechanisms
of growth and development remain controversial.
However, children and adolescents who present
with mouth breathing and nasal obstruction
should have a compete evaluation to rule out
septal deviation, choanal atresia or stenosis, and
adenotonsillar hypertrophy regardless of their
age and the severity of malocclusion. The timing
of referral and evaluation should be coordinated
among the orthodontist, primary care physician,
and otolarynoglogist during the initial period of
evaluation and before any surgical or orthodontic
intervention.5,7
Symptoms of Upper Airway
Obstruction:1,7
• Snoring
• Restless sleep
• Mouth breathing
• Nocturnal sweating
• Frequent wakening
• Abnormal head posture
• Fatigue during the day
• Failure to thrive
Paradoxical chest-abdomen motionDiagnosis
The diagnosis of obstructive sleep disorder is
based on a through history, a physical examination,
and appropriate ancillary studies. Snoring is a
cardinal finding. However, severity of snoring
does not imply severity of the disorder. Loud
snorers may have little or no apnea, whereas
quiet snorers may have extended periods of
apneas. Nocturnal enuresis is also a common
complaint that occurs because of a decrease
in neuromuscular tope during sleep and may
be worsened by an obstructive sleep disorder.
Other nighttime complaints include night

terrors, restless sleep, diaphoreses, and frequent
awakening.These children may also present with
mouth breathing, hypersomnolence, excessive
daytime sleepiness, and behavior problems.
Mouth breathing and hyponasal speech quality
die to adenoid hypertrophy is also a frequent
finding. Articulation errors are common with
phonemes such as /m/, /n/, and /ng/. These
require nasal escape of air for proper formation
and can be assessed easily during the physical
examination.2,6,8
Physical Examination
The examination should include a complete head
and neck examination with particular attention to
the potential sites for airway obstruction from the
nares to the larynx, mouth breathing, dry lower
lip, and hyponasal speech are commonly found
in patients with adenotonsillar hypertrophy. A
complete nasal examination should be performed
to rule out deviated septum, allergic rhinitis, or
stenosis, and nasal masses such as dermoid,
glioma, and encephalocele. Adenoid hypertrophy
generally exists along with tonsillar hypertrophy
and does not need independent documentation.
However, if the tonsils are small or absent,
a flexible endoscopy is indicated to examine
the nasal cavity and nasopharynx for adenoid
hypertrophy. The oropharynx should be examined
for the condition of the teeth, occlusion, position
of the tongue, and tonsillar hypertrophy. The
mandible should be assessed with regard to
micrognathia are retrognathia.
There is some controversy with regard to the
accurate diagnosis of obstructive sleep disorder
based solely on history and physical examination,
Brouillette and colleagues have suggested that
the diagnosis of obstructive sleep disorder can
be based on a thorough history and examination.
Other investigators have concluded that parents
and physicians may overestimate the severity of
the sleep disturbances and have recommended
other ancillary testing to confirm the diagnosis.1,9
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
review article
Ancillary Studies
Radiography: Soft tissue lateral x-ray films
are most commonly used to assess adenoid
hypertrophy. However, it is important to realize
that these are two-dimensional studies and
their accuracy in assessing the degree of nasal
obstruction because of adenoid hypertrophy is
controversial.
Cephalometric Study: These studies are
used to assess the bony landmarks and have
limitations in assessing soft tissue abnormalities.
A cephalometric study is recommended in any
patient with craniofacial syndrome of facial
dysmorphism.
Polysomnography: Polysomnography or sleep
study is the gold standard for the diagnoses of
sleep apnea or any other associated sleep disorder.
The sleep study can determine frequency,
type, duration, and severity of apneic episodes.
It provides information on several variables,
which include 1) oxygen saturation monitoring,
2) electrocardiogram, 3) electroencephalogram,
4) thoracic respiratory movements, and 5) nasal
and oral airflow. By monitoring these variables,
one can differentiate between central and
obstructive apneas. With obstructive sleep apnea,
there is respiratory movement despite cessation of
airflow, which suggests upper airway obstruction.
Central apnea implies central nervous system
dysfunction demonstrating lack of respiratory
movement despite apneic episodes. The mixed
pattern is also seen in young children and it begins
as central and then progresses to obstructive
apnea.10,11
Treatment
Management of obstructive sleep disorders can
be surgical, medical, or airway position therapy.
Treatment must be individualized based on the
age, history, severity of obstructive episodes, and
physical examination. Medical treatment includes:
1) weight reduction and dietary measures,
2) nasal continuous positive airway pressure, and
857
 review article

Treatment Options For Upper Airway Obstruction1,10,12,13

1. Medical
2. Diet and weight reduction
3. Nasal positive airway pressure medications
(steroid, acetazolamide, protriptyline)
4. Intervention: bypass of obstruction
5. Nasopharyngeal airway
6. Tracheotomy
7. Surgery: removal of obstruction
8. Adenotonsellectomy
9. Uvulopalatopharyngoplasty
10. Septoplasty
11. Nasal polypectomy
12. Tongue reduction
13. Surgery: positional manipulation of airway
14. Hyoidoplasty
15. Orthognatihic surgery
16. Craniofaical surgery

3) medications such as acetazolamide, steroids, in serious neurocognitive, cardiovascular and

and theophyline.12
Surgical interventions are directed towards
relieving the site of airway obstruction.
Adenotonsillar hypertrophy is the most
common cases of obstructive sleep apnea,
and adenotosillectomy is the most frequently
performed procedure. Care should be used
remove all adenoid tissue at the level of the
choanae to relief the nasal obstruction and
prevent any future regrowth of the adenoid. Other
surgical interventions include orthognathic
surgery, uvulopalatopharyngoplasty, tongue
reduction, and tracheotomy. These procedures
may be considered in patients with a cransiofacial
abnormality after a careful evaluation by an
interdisciplinary team approach.1
Conclusion
Obstructive sleep apnea syndrome (OSAS) is
a common condition in children and can result
metabolic complications if left undetected
and untreated. The sequelae of OSAS include
excessive daytime sleepiness, poor school
performance, learning disability, attention deficit,
hyperactivity, behavior problems, cardiovascular
abnormalities and metabolic disorders. Therefore,
early diagnosis and treatment of pediatric OSAS
is beneficial in improving a child’s long-term
cognitive development, social interaction,
academic achievement, cardiovascular health and
overall wellbeing.
References
1. Brandley TD. Pathogenesis of obstructive sleep apnea
syndrome.Med Clin North Am. 1985; 69:1169-1185.
2. Burden D. Orthodontic treatment of patients with
medical disorders . Eur J Orthod; 2001; 23:363-372.
3. Proffit-WR. Orthodontic care for compromised
patients: possibilities and limitations. J Am Dent
Assoc; 1985; 111:262-266.

858 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

4. Katz ES, D’Ambrosio CM. Pediatric obstructive sleep
apnea syndrome. Clin Chest Med. 2010; 31: 221-34.
5. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower
AC, Jones J. Diagnosis and management of childhood
obstructive sleep apnea syndrome. Pediatrics. 2012;
130: 576-84.
6. Pirelli P, Saponara M, Guilleminault C. Rapid
maxillary expansion in children with obstructive sleep
apnea syndrome. Sleep. 2004; 27: 761-6.
7. Pirelli P, Saponara M, De Rosa C, Fanucci E.
Orthodontics and obstructive sleep apnea in children.
Med Clin North Am. 2010; 94: 517-29.
8. Principato JJ. Upper airway obstruction and craniofacial
morphology. Otolaryngol Head Neck Surg. 1991; 104:
881-90.
9. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower
AC, Jones J, et al. Diagnosis and management
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
review article
of childhood obstructive sleep apnea syndrome.
Pediatrics. 2012; 130: 576-84.
10. Robertson CJ. Dental and skeletal changes associated
with long term mandibular advancement. sleep
2001;24;531-537.
11. Marklund M. Predictors of long-term orthodontic
side effects from mandibular advancement devices in
patients with snoring and obstructive sleep apnea. Am
J Orthod Dentofac Orthop 2006; 129; 214-221.
12. Guilleminault C, Huang YS, Glamann C, Li K, Chan
A. Adenotonsillectomy and obstructive sleep apnea
in children: a prospective survey. Otolaryngol Head
Neck Surg. 2007; 136: 169-75.
13. Thawley, Stanley E. Surgical treatment of obstructive
sleep apnea. Med. Clin. Of N.Am 69; 1337-58.
859
 Review & Case Report

Supernumerary Teeth: An Epitome of Variability

and Unpredictability – A Comprehensive Review
And Five Case Reports
Vinodh Kumar P1, Shruthi B S2

Abstract
Supernumerary teeth may present in various forms and in any region of the mandible or maxilla, but have a predisposition
for the anterior maxilla. Each one may cause a variety of complications in the developing dentition. This article reviews
the prevalence, clinical features, complications, diagnosis and management of supernumerary teeth along with five
case reports to illustrate some possible presentations in the anterior maxilla. This paper is an attempt to emphasize the
importance of recognizing signs suggesting the presence of supernumerary teeth, particularly aberrations in the eruptive
pattern, and perform the relevant investigations. On diagnosis, each case should be managed appropriately in order to
minimize complications to the developing dentition.

Key words: Dentition, Dysmorphic, Eumorphic, Hyperdontia

Introduction Prevalence

D ental anomalies are associated with both the

primary and the permanent dentition andcan
have an influence on either the morphology or the
numberof teeth. Although these anomalies occur
infrequently, they can cause esthetic, spacing and
periodontal problems.1 Supernumerary teeth, or
hyperdontia, are defined as teeth that exceed the
normal dental formula, regardless of their location
and morphology and can be found in almost any
region of the dental arch both in the primary and
permanent dentition.2
Frequency : In a survey of 2,000 school children,
Brook found that supernumerary teeth were
present in 0.8% of primary dentitions and in
2.1% of permanent dentitions.3 In a review of
the literature, Scheiner & Sampson mentioned
the prevalence as 0•3–1•7%.4 Jarvinen&Lehtinen
found a prevalence of 0•4% among children in
Finland.5 It has been postulated that disturbances in
interactions between epitheliumand mesenchyme,
that affect tooth development, are less likely to
occur in primary teeth because of the more stable
environment prior to birth.6

1
Senior Lecturer
Site: Supernumerary teeth are estimated to occur
Department of Pedodontics, in the maxilla 8.2 to 10 times more frequently
Sree Balaji Dental College & Hospital, Bharath University,
Chennai, Tamilnadu
than the mandible, and most commonly affect the
2
Senior Lecturer, premaxilla. These findings may be explained by
Department of Oral and Maxillofacial the fact that the embryological development of
Pathology & Microbiology.
Vishnu Dental College, the premaxilla differs from that of the remaining
Vishnupur, Bhimavarm, Andhra Pradesh maxilla. Therefore, there can be deviations in
Corresponding Author:
the premaxillary region that do not occur in the
Dr. Shruthi B S
E mail id: shruthisahukar@gmail.com remaining maxilla. These deviations may lead to

860 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

the formation of supernumerary teeth and other
anomalies.7
Number: Occurrence may be single or multiple,
unilateral or bilateral, erupted or impacted, and in
one or both jaws. Multiple supernumerary teeth
are rare in individuals with no other associated
diseases or syndromes.4
Gender: Mitchell suggested no difference with
the sex distribution in cases with deciduous
supernumeraries, but a 2:1 ratio in favour of males
in cases exhibiting permanent supernumerary
teeth.4,9 Hogstrum and Andersson also reported a
2:1 ratio of sex distribution while Luten found a
sex distribution of 1.3:1. A study of supernumerary
teeth in Asian school children found a greater
male to female distribution of 5.5:1 for Japanese,
and 6.5:1 for Hong Kong children.4
Prevalence in Associated conditions: The
conditions commonly associated with an
increased prevalence of supernumerary teeth
include cleft lip and palate, cleidocranial
dysplasia and Gardner syndrome. Supernumerary
teeth associated with cleft lip and palate result
from fragmentation of the dental lamina during
cleft formation. The frequency of supernumerary
permanent teeth in the cleft area in children with
unilateral cleft lip or palate or both was found to
be 22.2%.10 The frequency of supernumeraries in
patients with cleidocranial dysplasia ranged from
22% in the maxillary incisor region to 5% in the
molar region.11 Additionally, there is a significant
association between supernumerary teeth and
invaginated teeth (teeth with an exaggerated
cingulum pit)7 and also with talon’s cusp.12
Aetiology
The aetiology of supernumerary teeth is not
completely understood. Both genetic and
environmental factors have been considered.13
Several theories have been suggested to explain
their occurrence:
 Atavism: It was originally suggested that
supernumerary teeth were the result of
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
Review & Case Report
phylogenetic reversion to extinct primates
with three pairs of incisors. This theory has
been largely discounted.14
 Dichotomy theory: This stated that the tooth
bud splits into two equal or different-sized
parts, resulting in the formation of two teeth of
equal size, or one normal and one dysmorphic
tooth, respectively. However, this theory has
been discounted.15
 Dental lamina hyperactivity theory: This
involves localized, independent, conditioned
hyperactivity of the dental lamina.15 According
to this theory, a supplemental form would
develop from the lingual extension of an
accessory tooth bud, whereas a rudimentary
form would develop from the proliferation
of epithelial remnants of the dental lamina.14
Although all theories are hypothetical
because of the inability to obtain sufficient
embryological material, most literature
supports the dental lamina hyperactivity
theory.14
 Genetic factors: These are considered
important in the occurrence of supernumerary
teeth. Many cases have been reported of
recurrence within the same family.15 A sex-
linked inheritance has been suggested by the
observation that males are affected more than
females.14,15
1. Environmental factors4
2. Dental lamina morphological disturbance
theory16
Classification
Supernumerary teeth are classified according
to anatomical resemblance to normal teeth,
morphology and location. In the primary dentition,
morphology is usually normal or conical. There
is a greater variety of forms presenting in the
permanent dentition.
I. Based on anatomical resemblance to teeth:8
1. Eumorphic: Supernumerary teeth which
display similar anatomy to their corresponding
tooth type.
861
 Review & Case Report
2. Heteromorphic/Dysmorphic: Supernumerary
teeth which display distinct forms such as
conical or pin, tuberculate, and molariform.
II. Based on Morphology:
 Conical: It is the most common type of
supernumerary tooth found in the permanent
dentition. It is usually smaller in size compared
to other teeth in the dentition and is conical or
peg-shaped. It develops with root formation
ahead of or at an equivalent stage to that of
permanent incisors and usually presents as a
mesiodens. It may occasionally be found high
and inverted into the palate or in a horizontal
position. In most cases, however, the long
axis of the tooth is normally inclined. The
conical supernumerary can result in rotation
or displacement of the permanent incisor, but
rarely delays eruption.17
 Tuberculate: The tuberculate type of
supernumerary possesses more than one
cusp or tubercle. It is frequently described
as barrel-shaped and may be invaginated.
Root formation is delayed compared to
that of the permanent incisors. Tuberculate
supernumeraries are often paired and are
commonly located on the palatal aspect
of the central incisors. Unlike conical
supernumerary teeth, which have complete
root formation, tuberculate types have either
incomplete or absent root formation. They
rarely erupt and are frequently associated
with delayed eruption of the incisors.14,15
 Supplemental: The supplemental
supernumerary refers to a duplication of
teeth in the normal series and is found
at the end of a tooth series. The most
commonsupplemental tooth is the permanent
maxillary lateral incisor, but supplemental
premolars and molars also occur. The
majority of supernumerary teeth found in the
primary dentition is of the supplemental type
and seldom remain impacted. 15, 16, 18
 Odontoma: Howard lists odontome as the
fourth category of supernumerary tooth.19
862 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
However, this category is not universally
accepted. The term “odontoma” refers to
any tumor of odontogenic origin. Most
authorities, however, accept the view that
the odontoma represents a hamartomatous
malformation rather than a neoplasm. The
lesion is composed of more than one type
of tissue and consequently has been called
a composite odontoma. Two separate types
have been described, the diffuse mass of
dental tissue which is totally disorganized is
known as a complex composite odontoma,
whereas the malformation which bears some
superficial anatomical similarity to a normal
tooth is referred to as a compound composite
odontoma.20
III. Classification based on location
1. Mesiodens: Typically, a mesiodens is a
conical supernumerary tooth located between
the maxillary central incisors.15 These
supernumerary teeth are usually located
palatal to the permanent incisors, with only
a few lying in the line of the arch or labially.
The mesiodens is usually small and short,
with a triangular or conical crown.21
2. Paramolar: A paramolar is a supernumerary
molar, usually rudimentary, situated buccally
or lingually/palatally to one of the molars
or in the interproximal space buccal to the
second and third molar.7
3. Distomolar: A distomolar is a supernumerary
tooth located distal to a third molar and is
usually rudimentary. It rarely delays the
eruption of associated teeth.7
4. Parapremolar:This is a supernumerary that
forms in the premolar region and resembles a
premolar.7
Medical conditions associated with Supernumer-
ary Teeth
Developmental disorders that show an association
with multiple supernumerary teeth include:15,22
• Cleft lip and palate;
• Cleidocranialdysostosis; and
• Gardner’s syndrome

The less common disorders include Fabry
Anderson’s syndrome, Marfan’s syndrome,
Ehlers-Danlos syndrome, incontinentia pigmenti
and Tricho- Rhino-Phalangeal syndrome.16, 23
Cleft lip and palate: Clefts can form in the lip or
palate alone, or in both structures. The aetiology
is unknown, but there is a genetic component in
approximately 40% of cases. Cleft lip occurs in
about 1 per 1000 live births, while isolated cleft
palate occurs in about 1 per 2000 live births.24
Teeth in the region of the cleft are typically
missing,24 however, supernumerary teeth can also
occur.15,22
Cleidocranialdysostosis: Cleidocranial dysostosis
is a rare syndrome with autosomal dominant
inheritance.23 The affected gene has been located
on chromosome 6p21.25 The main features include
supernumerary teeth, aplasia or hypoplasia of one
or both clavicles and other skeletal deformities.23
The triad of multiple supernumerary teeth,
partial or total absence of the clavicles, and open
sagittal sutures and fontanelles is considered
pathognomonic for cleidocranial dysostosis.26
Dental features include multiple supernumerary
teeth, multiple crown and root abnormalities,
ectopic positions of teeth and failure of eruption.
The maxilla is poorly developed while the growth
of the mandible is usually normal, resulting in a
characteristic skeletal III relationship.23
Gardner’s syndrome: Gardner’s syndrome
typically comprises multiple adenomatous
polyposis of the large intestine, multiple osteomas
of the facial bones, cutaneous epidermoid cysts
and fibrous hyperplasia of the skin and mesentery.
Inheritance is autosomal dominant with complete
penetrance and variable expressivity. The
affected gene is located on the long arm of
chromosome 5. The syndrome represents part
of the spectrum of familial colorectal polyposis.
Oral manifestations include multiple odontomes
and other supernumerary teeth, impacted teeth
and osteomas of the jaws.23
Clinical features of Supernumerary Teeth
Supernumerary teeth may erupt normally, remain
impacted, appear inverted or assume an abnormal
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
Review & Case Report
path of eruption.27 Supernumerary teeth with a
normal orientation will usually erupt. However,
only 13-34% of all permanent supernumerary
teeth are erupted, compared with 73% of primary
supernumerary teeth.15
Problems Associated with Supernumerary Teeth
Supernumerary teeth can cause a variety of
complications in the developing dentition.
Occasionally, supernumerary teeth are not
associated with any adverse effects and may be
detected as a chance finding during radiographic
examination. Supernumerary teeth in the
premaxilla are usually known to cause various
complications than those in the posterior jaw.
Whenever a supernumerary anterior tooth is
identified, any one of the following consequences
to the permanent dentition is possible:3
1. A normal complement of permanent anterior
teeth will be present,
2. A corresponding supernumerary permanent
anterior tooth will be present, and/or
3. A succedaneous anterior tooth will (rarely) be
missing.
The complications caused by supernumerary
teeth are given below:
1. Failure of Eruption/Delayed eruption
The presence of a supernumerary tooth is the
most common cause for the failure of eruption
of a maxillary central incisor. It may also cause
retention of the primary incisor. Tuberculate
supernumeraries are the main cause for failure
of eruption of maxillary permanent incisors.The
problem is usually noticed with the eruption of
the maxillary lateral incisors together with the
failure of eruption of one or both central incisors.
Supernumerary teeth in other locations may
also cause failure of eruption of adjacent teeth.7
Delayed eruption of associated tooth has been
reported to occur in 28-60% of Caucasians with
supernumerary teeth.28
2. Displacement
The presence of a supernumerary tooth may cause
displacement of a permanent tooth. The degree
863
 Review & Case Report
of displacement may vary from a mild rotation
to complete displacement. Displacement of the
crowns of the incisor teeth is a common feature
in the majority of cases associated with delayed
eruption.19
3. Crowding
Erupted supplemental teeth most often cause
crowding. A supplemental lateral incisor may
cause crowding in the upper anterior region. The
problem may be resolved by extracting the most
displaced or deformed tooth.17
4. Resorption
Resorption of roots adjacent to a supernumerary
may occur but it is extremely rare.29 It can lead to
loss of tooth vitality.30
5. Pathology associated with supernumerary
teeth
These include cyst formation,14,15 and migration
into the nasal cavity, maxillary sinus or hard
palate.14 Primosch reported an enlarged follicular
sac in 30% of cases, but histological evidence
of cyst formation was found in only 4 to 9% of
cases.14
6. Dilacerations of the crown /root of
developing permanent teeth16
7. Rotation16
8. Diastema16
9. Eruption into nasal cavity16
Diagnosis and Management:
Supernumerary teeth are usually identified
clinically in case of erupted ones. In case of
suspicion of any unerupted supernumeraries
radiographs are used for the identification and
localization. The management of a supernumerary
tooth should form part of a comprehensive
treatment plan and should not be considered in
isolation. The first stage of management is the
localization and identification of complications
associated with supernumeraries.
864 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
Treatment depends on two factors:6
1. The type and position of the supernumerary
teeth
2. Its potential effects on adjacent teeth.
If teeth are causing no complications at the time
of presentation, the patient should be warned
of complications, such as cystic change and
migration with damage to nearby roots. If the
patient does not wish to risk such complications,
it is acceptable to remove supernumerary teeth.
If supernumerary teeth are associated with
complications, it is usual to extract such teeth,
which usually involves a surgical procedure.
Timing of surgical removal of supernumerary
teeth has also been contentious. Hogstrum and
Andersson suggested two alternatives exist. The
first option involves removal of the supernumerary
as soon as it has been diagnosed. This could
create dental phobia problems for a young
child and has been said to cause devitalization
or deformation of adjacent developing teeth.
Secondly, the supernumerary could be left
until root development of the adjacent teeth is
complete. The potential disadvantages associated
with this deferred surgical plan include; loss of
eruptive force of adjacent teeth, loss of space
and crowding of the affected arch, and possible
midline shifts.29
Case Reports
The following eight cases were referred to the
Pediatric Dental Clinic for the early intervention
of the cases in order to prevent the future
complications. These cases represent some of the
possible presentations of supernumerary teeth.
Case 1:Supernumerary with talon’s cusp (Figure 1, 2, 3)
An eight year old male patient presented with a
complaint of abnormal alignment and spacing
between his anterior teeth. On examination, patient
revealed mixed dentition with a supernumerary
tooth in between the maxillary central incisors.
This extra tooth did not resemble any of the other
teeth in the dentition and had an elongated cusp

on the lingual side appearing like a talon’s cusp.
Radiograph revealed the complete root formation
of the supernumerary tooth. It appeared to be
responsible for rotation and displacement of
incisors causing abnormal spacing. Extraction of
the culprit tooth was advised.
Figure 1: Mesiodens with the Talon’s
cusp in the maxilla
Figure 2: Mesiodens with the Talon’s
cusp in the maxilla
Figure 3: Radiograph showing the mesiodens
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
Review & Case Report
Case 2: Tuberculate type (Figure 4, 5)
A six year old female patient presented with the
complaint of spacing in between the upper central
incisors. On examination, a partially erupted
supernumerary tooth was found in the midline
region which was responsible for spacing.
Extraction was advised and revealed to be a
tuberculated type of supernumerary with multiple
tubercles or cusp like projections on the crown.
Figure 4: Partially erupted supernumerary tooth
Figure 5: Barrel shaped tooth with
multiple tubercles
Case 3: Supernumerary with Gemination
(Figure 6, 7)
An eighteen year male patient visited dental clinic
for routine oral prophylaxis. On examination a
cone shaped supernumerary tooth was found in
the palatal side of the maxillary central incisors.
Gemination with respect to maxillary left lateral
incisor was also noticed. Supernumerary tooth
was comparatively smaller in size and showed
865
 Review & Case Report

complete root formation on radiograph. As it was
absolutely asymptomatic patient was explained
regarding the complications like caries and food
lodgment and advised for extraction.
and review eruption of all the other permanent
successors, as the dentition was not crowded and
mixed dentition analysis was suggestive of space
excess in the mandibular arch. However, constant
monitoring of the occlusion development and
molar occlusion was considered and parents
were informed about the anticipated orthodontic
treatment requirement for space closure and (or)
to maintain arch symmetry.

Figure 6: Palatally erupted conical tooth and ger-

mination associated with left lateral incisor

Figure 8: Supplemental tooth in the region of

maxillary left lateral incisor
Case 5: Occult supernumerary tooth (Figure 9, 10)
An eighteen year old patient presented with the
complaint of food lodgment in the maxillary anterior
teeth region. On examination, a supernumerary
tooth placed palatally to central incisors was found.
The tooth resembled the maxillary lateral incisor,
and was rotated & carious in the cervical region.
Radiograph revealed the presence of an impacted
conical supernumerary tooth adjacent to it.
Extraction of both the supernumeraries is advised.
Figure 7: Radiograph depicting a
conical supernumerary
Case 4: Supplemental type (Figure 8)
A five year old female patient reported to dental
clinic with the complaint of brown discoloration
of the anterior teeth. Intraoral examination
revealed the presence of complete primary
dentition, together with a unilateral supplemental
maxillary primary incisor on the left side. The
supernumerary tooth resembled the maxillary
lateral incisor and was well aligned in the arch.
As it was asymptomatic and seen in the primary
dentition, conservative treatment was advised. Figure 9: Palatally erupted carious
It was decided to keep the supplementary teeth supernumerary tooth

866 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
 Review & Case Report

Conclusion
Supernumerary tooth is a kind of dental anomaly
which is relatively common and presents in diverse
forms in the oral cavity. However it is essential
to enumerate and identify the teeth present
clinically and radiographically before a definitive
diagnosis and treatment plan can be formulated
accordingly, in order to provide comprehensive
treatment, thereby preventing complications in
the developing dentition.
Table 1: Prevalence of Supernumerary teeth8
Figure 10: Radiograph showing an Number of Prevalence
impacted supernumerary tooth next to an Supernumerary
erupted supernumerary tooth
One 76 – 86%
Two 12 – 23%
Discussion Three or more 1%
The cases described above represent a small
sample of the possible presentations for cases Table 2: Prevalence7 and effects4,7 of different
types of supernumeraries on dentition
involving supernumerary teeth. The occurrence
of the talon cusp in a supernumerary tooth is Type of Relative Common Effects on
supernumerary occurrence location dentition
extremely rare with only four cases reported till Conical 75% Anterior maxilla Displacement/
now. Talon cusps of supernumerary teeth are Rotation of
adjacent teeth
extremely rare.12 Salama et al31 reported two Tuberculate 12% Anterior maxilla Delayed
cases of talon cusp on supernumerary teeth and eruption &
Displacement of
later, another case of talon cusp was reported by adjacent teeth
Nadkarni et al32, recently, a case of talon cusp on Supplemental 7% Any location Crowding
multi-lobed supernumerary teeth was reported by (commonly / mostly
maxillary lateral asymptomatic
Marwah et al.12 One of such is illustrated in the incisor)
above mentioned case reports (Case 1). Odontome 6% Anterior maxilla Displacement/
and posterior delayed eruption
mandible
Tuberculate type of supernumerary tooth is
reported to occur most commonly in the anterior References
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in the above presented second case. It has been and functional treatment of fused permanent teeth: A
suggested that tuberculate supernumeraries case report. Quintessence Int; 1997; 28: 677-80.
may represent a third dentition.14 Majority of 2. Bruning LJ, Dunlop L, Mergele ME; A report of
supernumerary teeth found in primary dentition supernumerary teeth in Houston, Texas school
is supplemental type, especially in the maxillary children. J Dent Child;1957; 24: 98–105.
lateral incisor region which was similar in the 3. Brook AH; Dental anomalies of number, form and size:
above presented case (Case 4).6,16 However their prevalence in British schoolchildren. J IntAssoc
the 5th case showed a supplemental tooth in Dent Child; 1974; 5:37-53.
the permanent dentition with an occult conical 4. Scheiner MA; Sampson WJ. Supernumerary teeth: a
shaped tooth adjacent to it in the alveolar bone review of the literature and four case reports. Australian
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5. Jarvinen S, Lehtinen L; Supernumerary and
congenitally missing primary teeth in Finnish children.
ActaOdontologicaScandinavica; 1981; 39:83–6.
6. Venkataraghavan K, Anantharaj A, Nihal
NK;Supplemental Primary Tooth: Review and report
of a rare case Occurrence;IJCDS 2011; 2(2): 48-52.
7. Ashish Shah, Daljit S Gill, Christopher Tredwin
and Farhad B Naini; Diagnosis and Management of
Supernumerary Teeth. Dent Update; 2008; 35: 510-
20.
8. Fernández-Montenegro P, Valmaseda-Castellón E,
Berini-Aytés L, Gay-Escoda C; Retrospective study
of 145 supernumerary teeth. Med Oral Patol Oral Cir
Bucal 2006; 11:E339-44.
9. Kinirons MJ;Uneruptedpremaxillary supernumerary
teeth. A study of their occurrence in males and females.
Br Dent J; 1982; 153:110.
10. Vichi M, Franchi L; Abnormalities of the maxillary
incisors in children with cleft lip and palate. ADSC J
Dent Child; 1995; 62:412-7.
11. Jensen BL, Kreiborg S; Development of the Dentition
in Cleidocranial Dysplasia. J Oral Pathol Med; 1990;
19:89-93.
12. Arora R, Marwah N, Goel M, Dutta S;Multilobed
Supernumerary Teeth with Talon: Pioneer Case Report.
J Oral Health Comm Dent; 2008; 2(1):13-5.
13. Hall A, Onn A; The development of supernumerary
teeth in the mandible in cases with a history of
supernumeraries in the pre-maxillary region. J Orthod
2006; 33: 250-5.
14. Primosh RE; Anterior supernumerary teeth - assessment
and surgical intervention in children. Pediatr Dent;
1981; 3: 204-15.
15. Rajab LD, Hamdan MAM; Supernumerary teeth:
Review of the Literature and a survey of 152 cases. Int
J Paediatr Dent; 2002; 12: 244-54.
16. CugatiN, DewiFD; A rare case of supplemental
mandibular central incissor in mixed dentition period.
e-Journal of Dentistry; 2012; 2(3): 216-22.
17. Garvey MT, Barry HJ, Blake M; Supernumerary
Teeth -An Overview of Classification, Diagnosis and
Management. J Can Dent Assoc; 1999; 65:612-6.
18. Liu JF; Characteristics of premaxillary supernumerary
teeth: a survey of 112 cases. ASDC J Dent Child 1995;
62: 262−5.
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19. Howard RD; The unerupted incisor. A study of the
postoperative eruptive history of incisors delayed in
their eruption by supernumerary teeth;Dent Pract Dent
Rec; 1967; 17:332-41.
20. Shafer WG, Hine MK, Levy BM;A Textbook of Oral
Pathology; 4th ed. Philadelphia: W.B. Saunders; 1983.
p. 308-11
21. Von AT. Anterior maxillary supernumerary teeth: A
Clinical and Radiographic Study. Aust Dent J; 1992;
37: 189−95.
22. Yusof WZ. Non-syndrome multiple supernumerary
teeth: literature review; J Can Dent Assoc; 1990; 56:
147-9.
23. Gorlin RJ, Cohen MM, Stefan Levin L. Syndromes of
the Head and Neck 3rd edn; Oxford: Oxford University
Press; 1990: pp.249-53.
24. Cawson RA, Odell EW; Essentials of Oral Pathology
and Oral Medicine 6th edn; China: Churchill
Livingstone; 2002: pp.28-31.
25. Mundlos S;CleidocranialDysplasia: Clinical and
Molecular Genetics; J Med Genet; 1999; 36: 177-82.
26. Tanaka JL, Ono E, Filho EM, Castilho JC, Moraes
LC, Moraes ME;Cleidocranial dysplasia: importance
of radiographic images in diagnosis of the condition; J
Oral Sci 2006; 48: 161-6.
27. Nazif MM, Ruffalo RC, Zullo T; Impacted
supernumerary teeth: a survey of 50 cases. J Am Dent
Assoc 1983; 106: 201-4.
28. Mitchell L, Bennett TG; Supernumerary teeth causing
delayed eruption − a retrospective study. Br J Orthod;
1992; 19: 41−6.
29. Hogstrom A, Andersson L; Complications related to
surgical removal of anterior supernumerary teeth in
children; ASDC J Dent Child; 1987; 54:341-3.
30. Zmener O; Root resorption associated with an impacted
mesiodens: a surgical and endodontic approach to
treatment; Dent Traumatol; 2006; 22: 279−282.
31. Salama FS, Hanes CM, Hanes PJ, Ready MA; Talon
cusp: a review and two case reports on supernumerary
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presentation of talon cusp: two case reports. Int J Ped
Dent;2002;12: 332-335.
 REVIEW ARTICLE

Management for Oral Submucous

Fibrosis – A Comprehensive Review
Vijayavel. T1, Ponni V2

Abstract
OSMF is characterized by inflammation and progressive fibrosis of the lamina propria. Further it has characterized
by juxtaepithelial fibrosis, along with atrophy or hyperplasia of overlying epithelium and accumulation of hyalinized
collagen beneath the basement membrane with a progressive loss of vascularity. Based on the clinical involvement,
management is proceeded. This premalignant condition is managed with Steroids, antioxidants, peripheral vasodilators,
placental extracts, INF-γ, turmeric, lycopene, hyalurunidase, collagenase, chymotrypsin, physiotherapies, surgical
treatments. But an ideal treatment is one which provides no morbidity, reduces the symptoms, reverses the changes in
oral mucosa and completely cures OSMF. This article highlights about various treatment modalities in OSMF.

Key words: Oral Submucous Fibrosis (OSMF), Medical Management

Introduction and phonation”.1,2 In India, the first mention of

O SMF was defined as an “insidious, chronic
disease affecting any part of the oral cavity
and sometimes the pharynx. Occasionally it
is preceded by and/or associated with vesicle
formation and is always associated with a
juxta-epithelial inflammatory reaction followed
by progressive hyalinization of the lamina
propria and later subepithelial and submucosal
myofibrosis leads to stiffness of the oral mucosa
and deeper tissues with progressive limitation in
opening of the mouth and protrusion of the tongue,
thus causing difficulty in eating, swallowing
Senior Lecturer,
1
Department of Oral Medicine and Radiology,
Madha Dental College and Hospital,
Chennai, Tamil Nadu.
Senior Lecturer,
2
Department of Oral Medicine and Radiology,
Thai Moogambigai Dental College and Hospital,
Maduravoyal, Chennai, Tamil Nadu.
Corresponding Author:
Dr. Vijayavel T
E mail id: vijayavelt@gmail.com
this disease in literature dates back to time of
‘Shushruta’ as ‘Vedari’. However in modern
literature ‘Shwartz’ in 1952 first described it as
“Atropicaidiopathica mucosa oris”. Later it was
termed Oral Submucous Fibrosis (OSMF).
The etiology of this crippling disease is complex
even though the actual mechanism is obscure.
The condition has a multifactorial origin such as
consumption of Areca nut chewing, ingestion of
chilies, Nutritional deficiency, Immunological,
Genetic, Infectious agents and Radiation leads to
pathogenesis of this disease.3
The disease is predominantly seen in Asian
countries, prevalence being more in India. Recent
epidemiological data indicates that the number of
cases of OSF has raised rapidly in India from an
estimated 250,000 cases in 1980 to 2 million cases
in 1993. Prevalence rate is 0.2% to 0.5 % and
prevalence by gender varying from 0.2-2.3% in
males and 1.2-4.57% in females.4 The age range
of patients with OSMF is wide ranging between
20 and 40 years of age.5 Malignant potential rate

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 869
 review article
of OSMF is 7.6%. The reasons for the rapid
increase of the disease are reported to be due
to an upsurge in the popularity of commercially
prepared areca nut preparations (pan masala) in
India (Ranganathan et al, 2004)6 and an increased
uptake of this habit by young people (Gupta et al,
1998)7 due to easy access, effective price changes
and marketing strategies.
The disease has a spectrum of presentations
ranging from, excessive salivation, burning
sensation, absent gustatory sensation and
limitation of mouth opening leading to difficulty
in chewing, swallowing, articulation and poor
oral hygiene and its complications. It has been
associated with an increased risk of malignancy
and hence is considered as a pre-malignant
condition.8 The treatment of patients with OSMF
depends on the degree of clinical involvement. If
it is at a very early stage, cessation of the habit
is sufficient. Medical treatment is essential for
moderate to severe cases. The main aim in the
treatment of oral submucous fibrosis is to relieve
the symptoms and improve the oral opening.
Management of OSMF can be divided into
• Habit counseling
• Basic regimen
• Medical management
• Physiotherapy
• Surgical management
I. HABIT COUNSELING:
The preventive measures should be in the form of
discontinuation of habit, which can be encouraged
through education & advocacy. Affected patients
should be explained about the disease and its
possible malignant potential. Thorough counseling
should be given for de-addiction.
II. BASIC REGIMEN:
Vitamins, iron and mineral rich diet should
be advised to patients with OSMF. Intake of
870 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
redtomatoes, fresh fruits and green leafy vegetables
should be included in the regular diet. Intake of
green tea should be included in the diet chart.
Various studies have implicated deficiency ofiron
both as a cause and effect in etiopathogenesis of
OSMF. Thus routine hemoglobin levels followed
by iron supplements should be included in
treatment plan.9
III. MEDICINAL MANAGEMENT:
1. Corticosteroids
• Hydrocortisone:
• Dexamethasone:
• Triamcinolone acetonide:
2. Vitamins and minerals
3. Placental extracts
4. Interferon gamma
5. Enzymes
• Chymotrypsin
• Hyaluronidase
• Collagenase
6. Alternative Medicine
• Immune milk
• Turmeric
• Lycopene
7. Combination Regimen
1. Coricosteroids: Steroids andespecially
glucocorticoids were first used in the treatment
of OSMF and were extensively used in past
decades because of their anti-inflammatory
properties. Cytokines and growth factors
produced by the inflammatory cells can promote
the fibrosis by inducing a proliferation of
fibroblast, subregulating collagen synthesis and
down regulation collagenase production. Several
glucocorticoids were used, such as short acting
drugs (hydrocortisone), intermediate acting drugs
(tramcinolone) and long acting (betamethasone
and dexamenthasone). Glucocorticoids exert
their anti-inflammatory action by inhibiting the

generation of inflammatory factors and increasing
the apoptosis of inflammatory cells.10
Usage: Submucosal injections twice a week
in multiple sites for 3 months/ Topical for 3
months.11
2. Vitamins and minerals: Usually vit A, vit E,
vit C, zinc copper, maganeses are given.Vitamin
“E” acting as antioxidant prevents the formation
of toxic substances and enhances the indigenous
concentration of Vitamin “A”. The functional
and structural ingredients of epithelial cells are
dependent on adequate concentration of Vitamin
“A”. It plays a major role in induction and control
of epithelial differentiation in mucous secretary
and keratinization tissues. The basal cells are
stimulated to produce mucous and inhibition
of keratinization. In presence of Vitamin
“A” in adequate concentration, the progress
of premalignant cells to cells with invasive
malignant potential is slowed, delayed, arrested
or even reversed. It improves themucosal colour,
reduction of fibrous bands and improvement in
mouth opening.
Usage: Vitamin A 50,000 IU orally daily (12
weeks)
3. Placental extracts: Placentrex is an aqueous
12
extract of human placenta that contains nucleotides,
enzymes, vitamins, amino acids, and steroids. Its
action is essentially "biogenic stimulation." It is
suggested that it stimulates the pituitary and the
adrenal cortex, and regulates the metabolism
of tissues. Its use is based on the tissue therapy
method. According to this theory when animal
and vegetable tissues are severed from the parent
body and exposed to unfavorable conditions,
but not mortal to their existence, undergo
biogenic readjustment leading to development of
substance in the state of their survival to ensure
their vitality biogenic stimulators. Such tissues
or their extract when implanted or injected into
the body after resistance of pathogenic factors
stimulates metabolic or regenerative process
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
review article
thereby favoring recovery. The intra-lesional
injection of human placental extract had been
shown to be effective, lasting, and safe. There
was significant improvement in mouth opening,
color of oral mucosa (increases the vascularity
of tissues, burning sensation, and reduction of
fibrous bands.
Usage: lnj. of Placenta extract (lnj. Placentrex) 2
ml was given locally in the predetermined areas,
once a week upto total duration of one month.
4. Interferon gamma:13 This plays a role in
the treatment of patients with OSMF because
of its immuno-regulatory effect. IFN-gamma is
a known anti-fibrotic cytokine.Patients treated
with an intra-lesional injection of IFN-gamma
experienced improvement of symptoms. IFN-
gamma, through its effect of altering collagen
synthesis, appears to be a key factor to the
treatment of patients with OSMF, and intra-
lesional injections of the cytokine may have a
significant therapeutic effect on OSMF.
Usage: Intralesional injection of interferon
gamma (0.01- 10.0 U/mL) 3 times a day for 6
months.
5. Enzymes
• Chymotrypsin: Chymotrypsin, an
endopeptidase, hydrolyses ester and peptide
bonds, thus acting as aproteolytic and anti-
inflammatory agent.
Usage: Chymotrypsin (5000 IU), twice weekly
submucosal injections for 10 weeks
• Hyaluronidase:14 The combination of steroids
and hyaluronidase shows better long-term
results than either agent used alone (Kakar,
1985). It reduces burning sensation &trismus.
It acts by breaking down hyaluronic acid,
lowers the viscosity of intracellular substances
and decreases collagen formation.
Usage: Hyaluronidase (1500 IU) twice weekly
submucosal injections for 10 weeks
871
 review article
6. Alternative Medicine
Immune milk: Immune milk is a kind of skim
15
milk produced from cows immunized with
multiple human intestinal bacteria. It has good
anti-inflammatory effect and contains moderate
amounts of Vit. A, C, B1, B2, B6, B12, nicotinic
acid pantothenic acid, folic acid, iron, copper
and zinc. Though chemically it is identical to
commercial milk but it contains 20-30% higher
concentration of IgG type I antibody. Few
studies have shown that the local andsystemic
upregulation of fibrogenic cytokines and down
regulation of ant fibrotic cytokine arecentral to
the pathogenesis of oral submucous fibrosis.
The immune milk contains an anti-inflammatory
component that may suppress the inflammatory
reaction and modulate cytokine production.
Symptomatic relief in patients may be partially
attributed to the micronutrients contained in the
immune milk powder.
Usage: 45 g milk powder twice a day for 3
months
Turmeric:16 Administration of turmeric powder
offers protection against benzopyrene induced
increase in micronuclei in circulating lymphocytes
and it is an excellent scavenger of free radical in
vitro. Turmeric oil & turmeric oleoresin both act
synergistically in vivo to offer protection against
DNA damage.
Usage: Alcoholic extracts of turmeric (3 g),
turmeric oil (600 mg), turmeric oleoresin (600
mg) daily for 3 months
Lycopene:A number of studies have proven
that the management of premalignant conditions
should include antioxidants along with the
cessation of the habit. Lycopene is a powerful
antioxidant obtained from tomatoes. It has been
shown to have several potent anti-carcinogenic
and antioxidant properties which inhibit fibroblast
activity.
Usage: 8 mg twice a day for 2 months
872 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
7. Combination Regimen
Combination regime has also been tried like:
 Steroid, vitamins, minerals and enzymes
 Hyaluronidase and steroids
 Chymotrypsin and steroids
 Enzymes, chymotrypsin and steroids
 Placental extracts and steroids
 Steroids, peripheral vasodilator, vitamins
and enzymes
 Levamisole and vitamin A
 Steroids and antihistaminics
IV. Physiotherapy
Muscle stretching exercises for the mouth may
be helpful to prevent further limitation of mouth
movements. This includes forceful mouth
opening with the help of sticks, ballooning of
mouth, hot water gargling. This is thought to
put pressure on fibrous bands. Forceful mouth
opening have been tried with mouth gag & acrylic
surgical screw.The use of microwave diathermy
is one of the physiotherapeutic modality in the
management of OSMF. Microwave diathermy
(Low current is used 20 watts × 2450 cycles)
is useful in some early or moderately advanced
stages. It acts by physiofibrinolysis of bands.
Microwave diathermyseems superior to short
wave, because selective heating of juxta epithelial
connective tissue ispossible, thereby limiting the
area treated.
V. Surgical Treatment
Surgical treatment remains the method of choice
at this late and irreversible stage. The fibrous
bands have been surgically excised followed by
placement of split thickness skin graft, nasolabial
flaps, fresh human placental grafts, pedicled
buccal fat pad, oral stent made of acrylic, palatal
island flap, or reconstruction using superficial
temporal fascia flap and split thickness skin graft.

The only effective surgical procedure is that of
split thickness skin grafting following bilateral
temporalis myotomy or coronoidectomy.17-24
LASER - CO2 laser surgery offers advantage in
alleviating the functional restriction.
Conclusion
OSMF is a crippling disease of oral cavity, having
multifactorial etiology with arecanut chewing the
most elicited one. Oral submucous fibrosis is one
of the most poorly understood and unsatisfactorily
treated oral diseases. All available treatments
give the patient only symptomatic relief which is
short lived. This is mainly due to the fact that the
etiology of the disease is not fully understood and
the disease is progressive in nature.
References
1. Pindborg J.J and DrOdont. Is submucous fibrosis
precancerous condition in the oral cavity. International
Dental Journal, 1972, Vol. 22; No. 4: 474-480.
2. Pindborg J.J. and Sirsat S.M. Oral submucous fibrosis
Oral Surg Oral Med Oral Pathol, 2001, 22(6): 764-79.
3. Pillai R, Balaram P, Reddiar KS. Pathogenesis of
oral submucous fibrosis. Relationship to risk factors
associated with oral cancer. Cancer, 1992;69:2011-
2020.
4. Phatak A. Fibrin producing factor in Oral Sub-Mucous
Fibrosis. Indian Journal of Otolaryngology and Head
& Neck Surgery, 1979; 31(4):103-4.
5. Rajendran R, Sugathan C, Remani P, Ankathil
R, Vijayakumar T. Cell mediated and humoral
immune responses in oral submucous fibrosis.
Cancer,1986;58(12):2628-31.
6. Ranganathan K, Uma Devi M, Joshua E, Kirankumar
K, Saraswathi TR.: Oral submucous fibrosis: a case
control study in Chennai South India. Journal Oral
Pathology& Medicine, 2004;33:274–277.
7. Gupta PC, Sinor PN, Bhonsle RB, Pawar VS, Mehta
HC. Oral submucous fibrosis in India: a new epidermic.
National Medical Journal of India, 1998;11:113–116.
8. Sirsat SM, Khanokar V R .Submucous fibrosis of the
palate in diet-preconditioned Wistarrats.The Saudi
Dental Journal, Volume 1, Number 2,1989 Arch Pathol
1960;70:171-179.
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
review article
9. Lavina T., Anjana B. and Vaishali K. Haemoglobin
levels in patients with oral submucous fibrosis,
JIAOMR 2007, 19:02,329- 333.
10. Bathi R.J. and Prabhat. P53 aberrations in oral
sub mucous fibrosis and oral cancerdetected by
immunohistochemistry. Indian J Dent Res, Oct-Dec;
14(4):214-9, 2003.
11. AjitAuluck, Miriam P. Rosin, LeweiZh a n g , Suma n t
h KN, Or a l Submucous Fibrosis, a Clinically Benign
but Potentially Malignant Disease: Report of 3 Cases
and Review of the Literature, JCDA, October 2008,
Vol. 74, No. 8,735-740
12. Chitko G.A., Oral submucous fibrosis: A Clinical,
Hitopathologicaland Therapeutical Study MDS Thesis,
University of Bombay, 1968; 84-88.
13. Haque M.F., Meghji S., Nazir R. and Harris M.,
Interferon gamma may reverse oralsubmucous fibrosis.
J Oral Pathol Med, Jan 2001, 30: 12-21.
14. Kakar P.K., Puri R.K. and Venkatachalam V.P.
Oral submucous fibrosis-treatment with hyalase J
LaryngolOtol, 1985, 99 :57-59.
15. Tai Y.S., Liu B.Y.,Wang J.T., Sun A., Kwan H. W. and
Chiang C.P. Oral administration of milk from cows
immunized with human intestinal bacteria leads to
significant improvements of symptoms and signs in
patients with oral submucous fibrosis. J Oral Pathol
Med, 2001, 30: 618-25.
16. Hastak K., Lubri N., Jakhi S.D. et al Effect of turmeric
oil and turmeric oleoresin on cytogenic damage in
patients suffering from oral submucous fibrosis.
Cancer Letters; 116: 265-9,1997.
17. Mostehy MRE, Al Jassem AA, El Mahmeed BE. Oral
Submucous Fibrosis: Review and Case Report. Saudi
Dental Journal 1989; 1: 60-4.
18. Murti PR, Bhonsle RB, Gupta PC, Daftary DK,
Pindborg JJ, Metha FS. Etiology of oral submucous
fibrosis with special reference to the role of areca nut
chewing. J Oral Pathol Med. 1995; 24: 145-52.
19. Bhaskar SN. OSMF – Synopsis of Oral Pathology.
Seventh Edition. St Louis, the CV Mosby Company
1986; 479.
20. Sinor PN, Gupta PC, Murti PR, Bhonsle RB, Daftary
DK, Mehta FS, Pindborg JJ. A case control study of
oral submucous fibrosis with special reference to the
etiologic role of areca nut. J Oral Pathol Med.1990;
19: 94-8.
873
 review article

21. Sirsat SM, Khanolkar VR. The effect of arecoline on
the palatal and buccal mucosa of the wistar rat- an
optical and electron microscope study. Ind J Medical
Sciences. 1962; 16: 198-2.
22. Canniff JP, Harvey W, Harris M. Oral submucous
fibrosis: Its pathogenesis and management. Brit Dent
J. 1986; 21: 429-34.
23. Le PV, Gornitsky M. Oral stent as treatment adjunct
for oral submucous fibrosis. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 1996; 81: 148-50.
24. Shah A, Raj S, Rasaniya V, Patel S, Vakade M. Surgical
management of oral submucous fibrosis with “Opus
5” diode laser. J Oral Laser Applications 2005; 5: 37.

874 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
 REVIEW ARTICLE

CBCT a Diagnostic Aid in Dentistry

Saravanan1, Ramachandra Prabakar2, Karthikeyan1, Raj Vikram3, Sathya Chandran4

Abstract
Cone Beam Computed Tomography (CBCT) is a revolutionary diagnostic aid indentistryusedatpresent. Aim of paper
is to emphasize the process and the significance of CBCT in various treatment modalities which overcomes the 2
dimensional conventional method of radiography used to 3 dimensional imaging in dentistry.

Key words: Cone beam computed tomography, TMJ disorder,Fractures, impacted teeth.

Introduction Materials & Methods

T he advancement in technology and

innovations of imaging systems for practice
require a continuous update of their applications
and assessments of their strength and weakness,
as well as guidelines for utilization. Dentists
are challenged by the increasing number and
complexity of these systems and softwares.
Accurate diagnostic imaging is an essential
requirement for the optimal diagnosis and
treatment planning of dental patients.1 In addition,
it is a critical tool that allows the clinician to
monitor and document the treatment progress
and outcome. The purpose of this article is to
updatedentists about the current options and
applications of the latest imaging techniques in
orthodontic practice and to review the existing
software advances.4
Professor, 2Professor & Head,
1 of 2D images are generated. The software then
Reader, 4PGStudent,
3 reconstructs the images into three-dimensional
Department of Orthodontics,
ThaiMoogambigai Dental College, Chennai.
Corresponding Author:
Dr. Saravanan
Email id: dentalsaravanan@yahoo.in
The authors reviewed thelimitations of 2
dimensional imaging over the 3 dimensional
computed tomography which is cone beamed.8
The Cone Beam Computed Tomography (CBCT)
has contributed in diagnosis and profound
understanding of diagnosis to developmentof more
efficient biomechanical treatment approaches and
biological considerations.
TheCone-Beam Computed Tomography (CBCT)
scanners were introduced in the late1990s. Shortly
after, the US Food and Drug Administration
(FDA) approved the first CBCT unit in 2001.4
Since then, there has been an enormous interest in
this new technology for its clinical and research
applications. The CBCT is an imaging acquisition
technique that utilizes a volumetric scanning
machine. (Figure 1)This technology uses a
cone-shaped X-ray beam directed towards a flat
two-dimensional (2D) detector. (Figure2) When
both rotate around the patient’s head, a series
(3D) data set using a specialized algorithm.3,4,9
Figure 1 shows all 360 slices at a single shot
and Figure 2A: shows the pre object apparatus

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 875
 review article
of x-ray source path of rotation and object, 2B
shows the image area detector with x-ray beams
in shape of cone.3
Figure 1: 360 slices at a single shot
Figure 2A: pre object apparatus of x-ray source
path of rotation and object
Figure 2B: the image area detector with x-ray
beams in shape of cone
Currently, there are more than 4 CBCT systems from
20 different companies available commercially.
The commonly used CBCT imaging acquisition
systems are the 3D Accuitomo (J. Morita,
Kyoto, Japan), CB MercuRay (Hitachi Medical
Corporation, Osaka, Japan), iCAT (Imaging
Sciences International, Hatfield, PA), Galileos
876 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
(SironaDental Systems LLC, Charlotte, NC),
New-Tom 3G (QRsrl, Verona, Italy), Scanora3D
(SOREDEX, Milwaukee, WI), and Kodak 9500
(Kodak Dental Systems, Rochester, NY).4,9
There are large variations in the quality and
characteristics of the images or the reconstructed
volumes and the radiation doses between most
of these CBCT systems. Machines with reduced
radiation doses and less powerful tubes are often
associated with poor image quality, low contrast
resolution and increased noise. The exposure
parameters, the source-detector distance, the field
of view (FOV), the data reconstruction algorithm,
and the software used are among the major factors
responsible for those variations.4 The currently
available CBCT unitsutilize radiation doses
ranging from 87 to 206 μSv for a full craniofacial
scan.10 These radiation doses are slightly higher
than the conventional radiographic techniques
such as the lateral cephalograms or the panoramic
radiographs and markedly lower than that of
multi-slice CT. The scan time varies between 10
to 75 seconds, depending on the FOV and the
CBCT unit used.12
Discussion
Craniofacial imaging is a crucial content of adental
patient’s record. The gold standard for patient’s
records is the efficiency to achieve an accurate
replication of the real anatomical structures or
the “anatomic truth”.9 Although at present the use
of the traditional imaging indentistry has been
adequate, the achievement of the ideal imaging
goal of replicating the anatomic truth has been
limited by the traditional technology such as the
2D frontal and lateral cephalograms, panoramic
radiographs, and intraoral/extraoral photographs.8
Recently, higher emphasis has been placed on the
CBCT technology, the 3D images, and virtual
models. The main advantage for the use of
CBCT is that the clinician can get more accurate
data from single scan than from the many 2D
radiographs traditionally used, with less radiation
exposure.8

The 3D CBCT data can greatly expand the dentist’s
diagnostic capabilities. It offers a comprehensive
evaluation of the dentition and is very useful for
identifying abnormalities such as missing teeth,
supernumerary teeth, eruption disturbances, teeth
malpositions, and/or root irregularities that could
delay or prevent tooth movement.3,5,6 CBCT
can be considered the technique of choice for
examining and identifying the impacted teeth.7
(Figure 3) The exact position of impacted tooth
and its relations to the adjacent roots or important
anatomical structures such as the maxillary
sinus or the mandibular canal when planning
surgical exposure and subsequently orthodontic
management can be precisely assessed by 3D
CBCT.2,6,7
Figure 3:Malposition of a 8yrs. old patient due to
odontoma in relation to 21 causing impaction of
permanent teeth diagnosed by 3D CBCT
Using CBCT scans, alveolar bone can be accessed
from all aspects not only on the mesial and distal
surfaces of the tooth. This allows for the assessment
of the width of available bone for buccolingual
movement of teeth during orthodontic
management especially in cases requiring arch
expansion or labial movement of incisors.5
Fenestrations, dehiscence, and/or external apical
root resorption can be precisely visualized on the
3D images.6 Evaluation of alveolar bone volume,
which is especially important in periodontally
compromised adult orthodontic patients, is one of
the beneficial uses of CBCT in orthodontics. The
width of alveolar ridges for placement of implants
is another variable that can be investigated
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
review article
using CBCT.2,5 The exact measurement of root
resorption either external or internal can be
measured at most accurate dimension.13 (Figure 4)
Figure 4: A 3-dimensional rendering of the
defect in yellow, after outlining the
defect on serial sections.
The image can be rotated in all 3 planes
of space to confirm the accuracy of
resorption defect’s outline.
CT is the modality of choice for the evaluation
of complex facial fractures, especially those
involving the frontal sinus, nasoethmoidal region
and the orbits, it is found 3-D CT as most useful
in imaging comminuted fracture of the middle
third of the face and zygomatico maxillary
complex (Figure 5).These 3-D CT scan altered
or cancelled surgical procedures, particularly in
naso-orbitoethmoid fractures. CBCT provides the
highest accuracy for not only for the identification
of fractures involving disruption of the orbital
rim, but in soft tissue assessment in orbital blow-
out and blow-in fractures.14 Axial and coronal
CT are adequate for diagnosis of medial orbital
wall fractures. The superiority of coronal CT
in the diagnosis of fractures of the orbital floor,
blow-out fractures was confirmed, especially in
patients who develop diplopia or enophtalmos.
Generally, the original coronal images may
be better for diagnosing orbital floor fracture
877
 review article

detection, for adequate assessment of the cribi

form plate, orbital roof, orbital floor and planum
sphenoidale.

Figure 6: 3D CBCT volume allows for better

visualization and provides more details about
the morphology and position of the TMJ and the
condyles from different views. In addition,
the TMJ cross-section view permits complete
and thorough examination of the joint
Figure 5: 3-D reconstruction of mid face showing through a group of cross section slices.
Rtzygomatic complex fracture

Temporomandibular joint (TMJ) disorders with

Orthodontic patients arecommon.10 During
period of development, the disorders may alter
the facial growth pattern and may also affect the
growth of the ipsilateral part of the mandible with
compromisation in the maxilla, tooth position,
occlusion, and cranial base. CBCT allows the
orthodontists to assess and quantify these changes
associated with TMJ disorders more accurately
than the 2D images as these changes occur in the
vertical, horizontal, and transverse directions.10,11 Figure 7: Axial and sagittal sections showing
CBCT is especially indicated when more the buccal and lingual bone thickness,
information about the morphology and internal as well asthe relationship between the
structure of the bony components of the TMJ is implant and the inferior alveolar nerve
(labeled in red color).The 3D view is
in need. Studies have shown that CBCT images important in the evaluation of space availability
provide higher reliability and accuracy than
CT and panoramic radiographs in the detection Preoperative implant site assessment is
of condylar cortical erosion.10-12 CBCT images probably one of the most useful applications
of CBCT in orthodontics. In the orthodontic
also allow for the visualization of the TMJs
field, osseointegrated implants are either used
from different views and efficient evaluation of
for anchorage or as a prosthetic replacement of
its relationship to the dentition and occlusion.
missing teeth. The accurate determination of root
(Figure 6)

878 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

angulations and the available space are essential
for successful placement of the implant.3,5
CBCT can be used to accurately assess the space
availability and root angulations as well as the 3D
quantification of the alveolar bone at the implant
site.(Figure 7)
Conclusion
In orthodontics, the application of CBCT
technique has made a remarkable breakthrough
in diagnosis and the treatment plan by giving the
orthodontists inspiration to do better of what they
do the best. However the hunt for further advanced
diagnostic aids is evidenced in recent years like of
how 2D imaging is replaced by 3D imaging due to
the advantages and disadvantages in detecting the
exact location of supernumerary and impacted
teeth and in appropriate treatment planning.11,12
Likewise, advantages and disadvantages of CBCT
must be considered together, and only when more
information is in need, the use of this technique
is suggested. It’s unnecessary prescription should
otherwise be avoided.
References
1. Dan Grauera; Lucia S.H. Cevidanes; Martin A.Styner
; InamHeulfed;Eric T.Harmon ; HongtuZhuf; William
R.Proffit :Accuracy and Landmark Error Calculation
Using Cone-Beam Computed Tomography–Generated
Cephalograms, Angle Orthod. 2010;80:286–294.
2. SnehlataOberoi, DDS, MDS, Associate Professor of
Clinical Orofacial Sciences, Center for Craniofacial
Anomalies, Department of Orofacial Sciences, School
of Dentistry, University of California at San Francisco,
San Francisco, California: CBCT Evaluation of
Impacted Canines and Root Resorption, P C S O B u l
l e t i n ;November 2011.
3. Xubair,Graber,Vanarsdall,Vig;Orthodontics - Current
Principles and Techniques - Graber 5th edition; 2011.
4. Ahmed Ghoneima1,2, Eman Allam1, Katherine Kula1
and L. Jack Windsor1: Chap 8-Three-Dimensional
Imaging and Software Advances in Orthodontics
, Orthodontics - Basic Aspects and Clinical
Considerations; March, 2012.
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
review article
5. Kee-Joon Lee, EukJoo, Kee-Deog Kim, Jong-
Suk Lee, Young-Chel Park, and Hyung-SeogYuf, :
Computed tomographic analysis of tooth-bearing
alveolar bone for orthodontic miniscrew placement,
Am J OrthodDentofacialOrthop 2009;135:486-94.
6. HongyuRen; Jun Chen; Feng Deng; LeileiZheng;
Xiong Liu; Yanling Dong: Comparison of cone-beam
computed tomography and periapical radiography
for detecting simulated apical root resorption, Angle
Orthod. 2013;83:189–195.
7. HosseinNematolahi,HamedAbadi,ZahraMohamm
adzade,MostafaSoofianiGhadim: The Use of Cone
Beam Computed Tomography (CBCT) to Determine
Supernumerary and Impacted Teeth Position in
Pediatric Patients: A Case Report :J Dent Res Dent
Clin Dent Prospect 2013;7(1):47-50 | doi: 10.5681/
joddd.2013.008.
8. Adams, G., Gansky, S., Miller, A., Harell, W. & Hatcher
D; Comparison between traditional 2-dimensional
cephalometry and a 3-dimensional approach on
human dry skull. Am J OrthodDentofacOrthop; 2004;
126:397-409.
9. Cevidanes, L., Oliveira, A., Grauer, D., Styner, M.
&Proffit, W., Clinical application of 3D imaging for
assessment of treatment outcomes. SeminOrthod;
2011, 17:72-80.
10. Hilgers, M., Scarfe, S. &Scheetz, J., Accuracy of linear
temporomandibular joint measurements with cone
beam computed tomography and digital cephalometric
radiography. Am J OrthodDentofacialOrthop; 2005;
128:803-811.
11. Kumar, V., Ludlow, J., Cevidanes, L. &Mol, A., In
vivo comparison of conventional and cone beam CT
synthesized cephalograms. Angle Orthodontist; 2008;
78: 873–879.
12. Swennen, G. &Schutyser, F., Three-dimensional
cephalometry: spiral multi-slice vs cone-beam
computed tomography. Am J OrthodDentofacOrthop;
2006, 130: 410–416.
13. Stacy N. Ponder, Erika Benavides, Sunil Kapila, and Nan
E. Hatch. Quantification of external root resorption
by low- vs high-resolution cone-beam computed
tomography and periapical radiography: A volumetric
and linear analysis, Am J OrthodDentofacialOrthop
2013;143:77-91
14. Iqbal Ali, Anup Gupta, Imaging in maxillofacial
trauma,Central India Journal of Dental Sciences, Vol.
3 (4), Oct - Dec 2012.
879
 CASE REPORT

Deceptive lesion in the palate: A Case Report

Nidhi Gupta1, Ahmed Mujib BR2, Kiran Jadhav1

Abstract
At times it is difficult to diagnose a case presenting as a chronic inflammatory lesion, especially which is not responding
to conventional treatment modalities. This case report describes one such case, where the patient presented with a
suppurative lesion, where making a diagnosis was challenging. Same time the patient was not responsive to prescribed
treatment. Looking back carefully into the history of the patient gave a big inkling, to advice for a biopsy from a nearby
viable tissue around the lesion. The lesion on microscopy was confirmed as Actinomycosis. This case report describes a
very interesting case with diverse microscopic presentations, attempting to unravel the mysteries often hidden in a case
of Actinomycosis.

Key words: Actinomycosis, Splendore-Hoeppli phenomenon, necrosis

Introduction Case report

T he first case of actinomycosis, in man, was

described by Von Langebeck, in 1845.Israel
and Ponfick, in 1891, defined its anaerobic nature
of Actinomyces.1 Actinomycosis is a suppurative,
granulomatous, chronic infectious disease.1 The
disease usually spreads into adjacent soft tissues.2
In man Actinomycesisraelii is the most frequent
causative agent. By nature these bacteria are
saprophytes and possess a low-grade virulence.1,3
Actinomycesdo not have nuclear membranes,
glycans, or mitochondria.4 The following
case report describes a rare intraoral case of
cervicofacial form of Actinomycosis.3
Senior Lecturer,
1 years.
Department of Oral & Maxillofacial Pathology,
Rural Dental College & Hospital,
Loni, Maharashtra, India.
Professor & Head,
2
A 39 year old male patient reported with
complains of pain and swelling on left side of
palate since last two months. The pain was rapid
in onset, continuous, throbbing and radiating to
forehead and submandibular region. Initially it
was a pin point swelling, which increased in size
gradually. He gave a history of burning sensation,
which was preceded by rupture of swelling.
There was salty discharge in oral cavity and foul
odor since last ten days. He gave a history of road
traffic accident two years back, when he suffered
a blunt trauma in the left upper posterior region
of jaw. He had the habit of chewing quid (tobacco
with lime), 9-10 times a day since ten years and
of drinking alcohol once a week since last fifteen
Intra-orally a well-defined, elevated brownish
patch was evident on left side of antero-lateral

Department of Oral and Maxillofacial Pathology, palate.The extensions were from the marginal
Bapuji Dental College, Davangere, Karnataka, India. gingiva in relation to teeth 22-25, till 1.5 cm
Corresponding Author:
posterior to rugae, and crossing the midline.5
Dr. Nidhi Gupta
Email id: dr.nidhi59@yahoo.com The lesion measured about 2 x 5 x 1.5 cm and

880 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
 CASE REPORT

had an oval shape. The surface of the lesion was U daily for first two weeks, followed by an oral
rough, granular and friable. Floor of lesion was dose of 500 mg four times a day oral for six
covered with thick cheesy material (Figure 1). months). First week follow up revealed mild
Tooth vitality tests exhibited that 22, 23, 25 were pain and a healing granulation tissue. The patient
vital with a single non-vital tooth that is 24. There made a complete recovery and moreover, a two
were deep pockets in relation to teeth 22-26, with year follow-up revealed no recurrence of the
pus discharge, and also first degree mobility of infection.
22, 23, 24.6 There was fracture in the root area of
11 and 24 (Figure 2).
All serum investigations done were found
to be normal. A provisional diagnosis put
forward was of chronic infection orperiapical
abscess in relation to tooth 24 with sloughing
of overlying epithelium. Entire lesional tissue
was excised, defect curetted, debrided and
irrigated. Metronidazole (400 mg three times a Figure 1. A: Exhibits brownish, rough,
day for five days) was prescribed. Tooth 24 was granular and scrappable lesion intra-orally.
extracted. Microscopy of tissue sent revealed B: Lesion when elevated exhibited cheesy
loose dispersed connective tissue with lost material and there was exposure of
underlying palatal bone
architecture. Connective tissue exhibited papillae
like projections over the surface. There were also
noted densely basophilic stained linear strands and
dense brown pigmented material. These brown
stained areas were confusing as to what they were.
A correlation with the history of tobacco chewing
and keeping of tobacco in the same area revealed
that it was lodged vegetable material (tobacco
leaves). Collagen fibers and blood capillaries
were not well architectured. Inflammatory cell
infiltration was not significant. Looking at this
presentation a diagnosis of necrosed tissue, with Figure 2. A: Radiograph exhibiting fractured
root of 24.
a recommendation for a repeat biopsy, from an B: Radiograph exhibiting fractured root of 11
adjacent viable tissue was put forward.
Microscopy of repeated biopsy tissue revealed
round to oval shaped colonies of micro-
organisms (Figure 3). These were surrounded
by pus and chronic inflammation. The colonies
were mats of radiating and branching filamentous
structures as of Actinomyces. The picture looked
of actinomycosis. Periodic acid Schiff stain was
done to exclude a possibility of fungal infection,
which was found to be negative. So the case was Figure 3. A: Hematoxylin and eosin stained
diagnosed as of actinomycosis. The patient was section exhibiting colonies of Actinomyces at 5x.
started on penicillin (intravenously 18 million B: A 40x view of the colonies shown in A.

Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014 881
 CASE REPORT
Discussion
The classic actinomycos is characterized by
abscesses, woody fibrosis, draining sinuses with
sulfur granules.7 It is the great degree of necrosis
and fibrosis that is unique to Actinomyces species.
Therefore, high doses of antibiotics are required to
penetrate this barrier.8 The patient described had
compromised oral hygiene with deep periodontal
pockets. This makes an easy residence site for
these microaerophilic organisms to grow and
multiply resulting in a lesion. The predisposition
in males is believed to be due to increased
sports, automobile and motorcycle accidents,
alcohol abuse, and aggressive behavior in men.4
Chronic intake of alcohol is a predisposing factor
like in our case.1 Actinomyces are bacteria that
cannot penetrate healthy tissue. As they have a
low pathogenicity, mucosal break-down is a
prerequisite for infection, wherein it becomes
invasive to gain access to the subcutaneous
tissue.1 Similar could be the etiopathogenesis in
our case, where the trauma that the patient had
two years back must have led to a breakdown and
breach in the normal mucosal barrier leading to
seeding of the Actinomyces. Gingiva and palate
is an uncommon location though found in this
case, and makes it unusual. The draining sinus
tracts give the presentation the term "lumpy jaw".
Even in our case, the prior swelling ruptured to
drain as a salty, foul smelling discharge.8
The macroscopic presence of the classic sulfur
granules in tissue specimens may be of some help
(55% cases) when observed histologically and only
rarely clinically.2 Nocardiosis may also present
with the same.2,6 On microscopy the granules
(average 290 um) are round to oval basophilic
structures consisting of intertwined filamentous
organisms, the ends of which are frequently
encased by eosinophilic material, giving them
a club-shaped appearance (Splendore-Hoeppli
phenomenon). Surrounding this arrangement is
the sea of neutrophils and granulation tissue.8
Under the spectrum of other investigations,
imaging techniques contribute to define lesional
882 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
limits.1 At times, fine-needle aspiration (FNA)
does allow in morphologic identification, through
microbiologic identification.2 Culturing the
microorganism is difficult and is time consuming
(2-3weeks).
In this case the papillary projections resembled
as in papillary squamous cell carcinoma. The
embedded tobacco leaves was something rare
to notice, unique and initially confusing as to
what they were.The disease requires a prolonged
medication because of high resistance against
therapy.9 Surgical debridement reduces the
numbers of organisms and also change the
anaerobic environment that is so important for
survival of these organisms.8 Surgical excision
remains the only really resolute approach,
particularly in cases presenting with abscess,
unresponsive to antimicrobial therapy or when
FNA is non-diagnostic. 2-4 weeks of high-dose
intravenous antibiotics (penicillin, 18–24 million
U daily) are a fundamental part of treatment,
followed by 3-6 months of oral antibiotics (500
mg four times a day).8
Conclusion
Cervicofacialactinomycosis has been referred to as
the ‘great masquerader of head and neck disease’
due to diagnostic difficulties. Actinomycosis
should always be kept in mind when one is
confronted with chronic inflammatory processes,
abscess formation or fistulas associated with oral
cavity. The opportunistic nature of the infection
demands quick diagnosis to prevent the spread of
the disease.
Acknowledgement: We, the authors would like
to sincerely thank Dr. Ashok Kumar, Professor
and Head, Department of Oral Medicine and
Radiology, Bapuji Dental College and Hospital,
Davangere, for providing the clinical photographs
of the patient.
References
1. A Lancella, G Abbate, AM Foscolo, R Dosdegani. Two
unusual presentations of cervicofacialactinomycosis

and review of the literature. ActaOtorhinolaryngol
Ital. 2008; 28(2):89-93.
2. M Volante, AM Contucci, M Fantoni, R Ricci, J
Galli. Cervicofaciala ctinomycosis: still a difficult
differential diagnosis. Acta Otorhinolaryngol Ital.
2005; 25(2):116–119.
3. Umur Sakallioglu, Gokhan Acikgoz, TugrulKirtiloglu,
FilizKaragoz. Rare lesions of the oral cavity: case
report of an actinomycotic lesion limited to the gingiva.
Journal of Oral Science 2003; 45(1): 39-42.
4. F Bononi, AV Iazzetti, N S da Silva. Pediatric
cervicofacialactinomycosis – case report and review
of the literature. Journal de Pediatria 2001; 77(1):52-
54.
5. M Ash, Stanley J Nelson. Introduction to Dental
Anatomy. In Wheeler’s Dental Anatomy, Physiology,
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
CASE REPORT
and Occlusion. Reed Elsevier India Private Limited,
New Delhi. 8thed 2005, pp 6.
6. Stephen Cohen, Richard C. Burns. Diagnostic
procedures. In Pathways of the pulp. Reed Elsevier
India Private Limited, New Delhi. 8thed 2004, pp. 11.
7. Selvin S. Sudhakar, John J. Ross. Short-Term Treatment
of Actinomycosis: Two Cases and a Review. Clinical
Infectious Diseases 2004; 38(3):444-447.
8. R E. Marx, D Stern. Bacterial diseases. In Oral and
maxillofacial pathology: a rationale for diagnosis and
treatment. Quintessence Publishing Co, Illinois. 1sted
2003, pp. 63-65.
9. M Guvercin, G Gurler, O Goktay, T Kadir, B Gursoy.
Cervicofacialactinomycosis: a case report. OHDMBSC
2005; IV (2):58-61.
883
 CASE REPORT

Improving Facial Esthetics with an Andrew’s

Bridge: A Clinical Report
Muthuvignesh J1, Bhuminathan Swamikkanu2, EgammaiS3, Narayana Reddy Donapati2

Abstract
Traumatic dental injuries due to road traffic accidents are common in developing countries like India. Replacement of
teeth with esthetics and function is a major challenge as the bone loss is also encountered in most of the cases. Selection
of treatment plan is very important as the prosthesis should replace both hard and soft tissues. This article describes a
method of Fixed –removable prosthesiswhich is a therapeutic treatment option in emergency cases.

Key words: Fixed-removable partial dentures, road traffic accidents (RTA), tooth loss, traumatic
dental injuries (TDI), esthetics, residual ridge resorption.

Introduction treatment options include 1) fixed partial denture,

A nterior Teeth loss during adolescence can be
contributed to many factors like accidental
falls, road traffic accidents, violence and sports.
Road traffic accident (RTA) is the second
common cause of traumatic dental injuries (TDI)
across the world.1 Tooth loss due to any of the
above reasons not only impairs function but also
affects the social welfare of the patients. The
necessity for replacing the missing tooth/teeth
also contributes to irreversible loss of edentulous
ridge due to disuse atrophy.2 In most of the
cases,the balance between function and esthetics
is a major challenge to a restorative dentist.The
treatment of anterior teeth loss and its associated
soft tissues requires knowledge of prosthetic
limitations and esthetic outcomes. The prosthetic
2) implant supported fixed partial dentures 3)
removable partial denture, or 4) fixed-removable
partial denture (hybrid denture).
Dr. James Andrews of Amite Louisiana
(Institute of Cosmetic Dentistry, Amite L.A)
first introduced a fixed removable prosthesis. It
is also called as Andrew’s bridge which consists
of a fixed retainer and removable pontics.3 The
retainers are joined with prefabricated bars, and
thencast. The retainers areeither porcelain fused
to metal (PFM) or full veneer metal, which are
permanently cemented to the abutments. The
removable pontics are attached to the bar by
means of Hader clips or rubber sleeves. This case
report explains the treatment of a patient with a
fixed removable prosthesis. The objectives of the
treatment were to give maximum esthetics and
function.

Senior Lecturer, Department of Prosthodontics,

1
Case Report
K.S.R Institute of Dental Science and Research,
Thiruchengode. A 26 year old female patient reported to the
2
Professor, Department of Prosthodontics, hospital to replace her existing denture. The
Sree Balaji Dental College and Hospital,
Bharath University, Pallikaranai,Chennai. patient’s main complaint was compromised
Consultant Prosthodontist, Chennai.
3 esthetics and function. Complete medical and
Corresponding Author: dental history was obtained. History revealed that
Dr. J.Muthuvignesh, she had undergone road traffic accident (RTA)
Email id: jayamvignesh@ymail.com

884 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

before 2 years and had fractured her middle third
of the face. She was treated for the same and
subsequently given an acrylic removable partial
denture (RPD) in her maxillary anterior region,
which she has been wearing since then. the denture flanges and bone resorption.10 Due
Extra oral examination revealed reduced upper
lip support and intraoral examination revealed
missing maxillary teeth from right lateral incisor
to left canine (Kennedy’s class IV) and there was
considerable reduction in the height and width
of the residual alveolar ridge (Siebert’s class
3 defect) leading to reduced upper lip support.
Intra oral periapical radiographs (IOPA) and
orthopantamographs (OPG) were made. The
radiographs showed good bone support in the
abutments (maxillary right canine and left first
premolar). The treatment options presented to the
patient included implant supported fixed partial
denture with autogenous bone graft, conventional
fixed partial denture and a fixed–removable partial
denture. Implants were better treatment modality
in the anterior maxillary region, but the increased
bone resorption will need bone augmentation and
bone grafting. With pre-prosthetic surgeries such
as onlay grafts or alloplastic grafts may require
4-5 months healing period, in which the patient
should not wear any prosthesisand the outcome
of the treatment will not be predictable.4 Fixed
partial dentures can restore function and esthetics
to a certain extent. The extent of the ridge defect
needed to be corrected by tissue engineering
techniques like the soft-tissue autogenous graft
for which adequate time is needed for the desired
result and also, the length of the edentulous span
was not satisfying the laws of biomechanical
principles and the increased bone loss leads
to increase in the length of the pontics (long
pontics)which can cause an esthetic failure.5
The conventional removable prosthesis was not
satisfying the patient’s needs however designed
with biomechanics, which basically aims at
patient comfort and function.6 If not maintained
properly, it also causes decalcification and dental
caries to the adjacent abutment teeth, periodontal
problems like inflammation of the gingival tissues,
progression of the disease to the underlying tissues
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
CASE REPORT
and there after tooth mobility in regular users.7-9
In prolonged denture wearers, it may cause
inflammation of the mucous membrane, denture
induced hyperplasia due to broad coverage of
to time andcost constraint on the patient’s side,
a fixed-removable prosthesis was planned. An
informed consent was taken from the patient
for her willingness and cooperation for the fixed
removable bridge treatment protocol. (Figures 1
& 2)
Procedure
The patient underwent oral prophylaxis and
diagnostic impressions were made with irreversible
hydrocolloid and study models were prepared. The
study models were mounted on a semi adjustable
articulator with facebow transfer and centric
relation records. Diagnostic wax-up was done and
treatment plan formulated.Conventional crown
preparation was made for full veneer porcelain
fused to metal (PFM) crowns in maxillary right
canine andleft first premolar. The abutments
were prepared with approximately 10-20 degrees
taper, and ensured that there was a common path
of insertion.11 The teeth were temporised put as
after making the impression by conventional
impression procedures using addition silicones.12
The models were poured with type IV gypsum and
were mounted in the semi adjustable articulator.
The interocclusal distance was checked and was
sufficient for a bar retained denture.
Wax up was done for porcelain fused to metal
(PFM) retainers with a metal bar 3mm height and
2mm width placed between the two abutments.
Metal trial was done with the bar in place and the
shade was matched using a shade guide. Ceramic
build up was done on the retainers in the bar frame
work. Due to inadequate mesio-distal width, the
lateral and central incisors of both the sides were
only replaced. A wax try-in was done.Proper
anterior guidance was established in the patient’s
mouth and wax up was done in the labial portion
for adequate lip support and esthetics. After the
patient’s approval for esthetics, a removable partial
885
 CASE REPORT

denture was fabricated using injection moulding

technique withmetal and rubber sleeves in the
intaglio surface of the denture.The PFM crowns
were luted with type I Glass Ionomer Cement
and the denture was inserted shortly after the final
set of GIC. The patient was taught to insert and
remove the prosthesis. The hygienic maintenance
of the denture was emphasised and the patient was
Figure 4(b): Prosthesis with rubber
advised a 3 months recall. (Figures 3 to 6)
sleeves in the tissue side

Figure 5(a): Ceramic crowns with bar attached to

their respective abutments

Figure 1: Pre-operative view

Figure 5 (b). Prosthesis in place

Figure 2: Intra-oral view after tooth preparations

Figure 6: Post-operative view

Figure 3: Ceramic crowns with bars inbetween
Figure 4 (a): Partial denture with
enhanced tissue support
Discussion
Residual Ridge Resorption after trauma arises due
to loss of teeth and reduced functional stimulus.
Bone loss occurs both in vertical and sagittal plane
as the time increases.2 The reduced bone volume
can result in altered facial features and reduced
lip support. It also poses a challenge in prosthesis
fabrication like implants and RPDs. The implant
prosthesis is one good option but does not have

886 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

a good predictable rate. The removable partial
denture for class IV cases though considered as
a simple treatment option, involves more lever
action equal to the Kennedy’s class I situations.13
The removable partial denture design also
involves placement of clasps in the esthetic zone
which is not desirable for a young female patient.14
Since the abutments are strong enough to receive
load, a fixed -removable partial denture in these
situations offers both function and esthetics. When
a proper diagnosis and treatment plan is made the
Andrew’s bridge provides a better therapeutic
and emergencytreatment.14 Replacement along
with an acrylic denture flange for tissue defects
is an added advantage as it does not require
separate prosthesis for the gingival as in fixed
dental prosthesis. This is a good advantage which
is not provided by the fixed dental prosthesis as
it becomes more difficult to maintain. Since the
prosthesis is retained by a bar retainer, the normal
perception of taste is maintained as the flanges
need not be extended palatally for support.The
acrylic prosthesis can be removed by the patient
when desired for hygienic access.15 The fixed
removable bridges offer good retention and
stability thereby increasing the patient comfort.
Summary
Loss of anterior teeth in young patients carries
with it a significant social stigma. The resorbed
ridge certainly will affect the implant placement
and is time consuming.When conditions like
good periodontal health of the abutments,
crown-to-root ratio, location of the abutment
teeth in the arch and adequate inter occlusal
distance are favourable the fixed-removable
bridge offers a better therapeutic and emergency
treatment choice. The Andrew’s bridge provides
both function and esthetics, and can be a better
cost effective treatment option though denture
hygiene has to be emphasized for the longevity of
the prosthesis and tissue health.
References
1. Hussaini HM, Rahman NA, Rahman RA, Nor GM,
Ai Idrus SM, Ramli R., Maxillofacial trauma with
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
CASE REPORT
emphasis on soft-tissue injuries in Malaysia. Int J
Oral Maxillofac Surg. 2007; 36(9):797-801.
2. Atwood, D.A. Some clinical factors related to rate of
resorption of residual ridges. J Prosthet Dent 2001;86:
119–125.
3. Everhart RJ, Cavazos E Jr.Evaluation of a fixed
removable partial denture: Andrew’s Bridge system. J
Prosthet Dent;1983; 50(2):180-184.
4. Frank RP, Milgrome P, Leroux BG, Hawkins N.
Treatment outcome with mandibular removable
partial dentures: A population based study of patient
satisfaction. J Prosthet Dent 1998;80:36–45.
5. Douglass CW, Watson AJ. Future needs for fixed and
removable partial dentures in the United States. J
Prosthet Dent, 2002; 87(1):9-14.
6. Wostmann B, Budtz-Jorgensen E, Jepson N,
Mushimoto E, Palmqvist S, Sofou A, Owall B.
Indications for removable partial dentures: a literature
review.Int J Prosthodont. 2005; 18(2): 139-45.
7. Carlsson GE, Hedegård B, Koivumaa KK. Studies in
partial dental prosthesis. IV. Final results of a 4-year
longitudinal investigation of dentogingivally supported
partial dentures. Acta Odontol Scand 1965;23:443–
472.
8. Bergman B, Hugoson A, Olsson C-O. Periodontal
and prosthetic conditions in patients treated with
removable partial dentures and artificial crowns. Acta
Odontol Scand 1971;29:621–638.
9. Bergman B, Hugoson A, Olsson C-O. Caries and
periodontal status in patients fitted with removable
partial dentures. J Clin Periodontol 1977;4:134–146.
10. Davenport JC, Basker RM, Heath JR, Ralph JP,
Glantz PO, The partial denture equation. British dental
journal, volume 189, no. 8, october 28 2000: 414-24.
11. Gilboe DB, Teteruck WR. Fundamentals of extracoronal
tooth preparation. Part I. Retention and resistance form.
J.Prosth.Dent, aug 2005 vol 94#2:105-107.
12. Abarno JC, Spatakis S. Impression techniques for
preparations with shoulder, J.Prosth.Dent: jan 1984:vol
51 #1 42-45.
13. Glen P. McGivney, Dwight J. Castleberry. Principles of
removable partial denture design. Robert W. Reinhardt,
editor: Text book of McCracken’s Removable Partial
Prosthodontics, 8th edn. Newdelhi: CBS publishers;
1989:157-82.
14. DeBoer J. Edentulous implants: overdenture versus
fixed. J Prosthet Dent; 1993;69:386-90.
15. Finley JM. Restoring the edentulous maxilla using an
implantsupported,matrix-assisted secondary casting. J
Prosthodont.1998;7(1):35-9.
887
 CASE REPORT

Tooth Hemisection and Restoration

an Alternative to Extraction
Hitesh U. Pawar1, Leena Padhye2, Narpatsingh Rajput3

Abstract
Hemisection denotes removal or separation of root with its accompanying crown portion of mandibular molars. This
procedure represents a form of conservative approach, aiming to retain as much of the original tooth structure as
possible. The results are predictable and success rates are high. In this paper a case is presented in which hemisection
was done because the tooth was grossly carious along with furcation involvement. Distal half of tooth was extracted and
the remaining tooth was restored as premolar which helped to reduce the masticatory load.

Key words: Hemisection, Root resection.

Introduction Indications for hemi-section

Hemisection refers to sectioning of a mandibular
molar into two halves followed by removal of the
diseased root and its coronal portion. Because
of two roots present in mandibular molars, one
half of the crown and associated root is removed.
Thus tooth resection procedures are used to
preserve as much tooth structure as possible
rather than sacrificing the whole tooth.1 It differs
from bicuspidization, in which a separation is
made between the two roots in the furcation area
without removal of any root. The separated roots
along with its crown part are then restored as
premolars.2
Lecturer, 2Professor
1
1. The teeth which are affected by caries,
vertical root fracture, periodontal disease
or iatrogenic root perforation where only one
root of a multirooted tooth is affected.
2. The surviving root is accessible and treatable
endodontically.
3. The surviving root is structurally capable of
supporting a dowel and core restoration.
4. The surviving root is aligned so as to provide
proper draw for the resulting fixed prosthetic
restoration.
5. The root morphology allows for surgical
access and proper periodontal maintenance
of the final restoration.5
Contra indicationsfor hemi-section
1. Poorly shaped roots or fused roots.
2. Poor endodontic candidates or inoperable
endodontic roots.5

Department of Conservative Dentistry &Endodontics,

Dr. D Y Patil Dental College & Hospital, Nerul, Navi Mumbai
3. Patient unwilling to undergo surgical and
Private practice at Khushi Dental Care,Mumbai,Maharashtra
3

Corresponding Author:
endodontic treatment.5
Dr. Hitesh U. Pawar The loss of posterior molar can result is several
Email id: dr.hitesh9999@gmail.com
undesirable sequelae including shifting of

888 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

teeth, collapse of the vertical dimension of
occlusion, super eruption of opposing teeth, loss
of supporting alveolar bone and a decrease in
chewing ability. The treatment options to replace
severely damaged and possibly unrestorable teeth
include removable partial denture, fixed partial
denture and dental implants. A guiding principle
should be to try and maintain what is present.5
The presented case report is about hemisection of
mandibular first molars.
Case Report
Case 1 : A 29 year old female patient came with
chief complaint of decayed tooth in the lower
right posterior region of the jaw, on examination
revealed a grossly carious 46, with the absence of
any mobility. The periodontium appeared normal.
Radiographic examination shows deep caries
involving enamel, dentin & pulp with distal half
of the tooth involving furcation area & presence
of periapicalinfection at both the roots.
Case 2 : A male patient reported with a chief
complaint of decayed tooth in the mandibular
left posterior region of the jaw. An intraoral
examination revealed a grossly carious 36. There
was no mobility and the periodontium appeared
normal. Radiographic examination shows deep
caries involving enamel, dentin & pulp with
distal half of the tooth involving furcation area &
presence of periapical infection at both the roots.
Treatment Plan
In both above cases following treatment protocol
was followed.
Endodontic phase involved the root canal
treatment, wherein the access opening was done
using a round bur and the orifice was enlarged
using g.g. drills no1-3.
Following this the working length was determined
and the canals were biomechanically prepared by
rotary system using the crown down technique.
The master cone radiograph was taken and the
canal was obturated using lateral condensation
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
CASE REPORT
technique. The chamber was filled with
composite resin to maintain a good seal and
allow interproximal area to be properly contoured
during surgical separation.
The vertical cut method was used to resect the
crowns in both the crowns. A long shank tapered
fissure carbide bur was used to make vertical cut
toward the bifurcation area. A fine probe was
passed through the cut to ensure separation. The
compromised roots were extracted and the socket
were irrigated adequately with sterile saline to
remove bony chips and debris. The retained roots
were trimmed to ensure that no spicules were
present to cause further periodontal irritation.The
extraction site were irrigated and debrided. After
healing of the tissues, crown preparation was
done and impression was taken for PFM crowns.
Discussion
Root amputation/hemisectionis a useful alter-
native procedure to save those multi-rooted teeth
which have been indicated for extraction. Before
selecting a tooth for hemisection, patient’s oral
hygiene status, caries index and medical status
should be considered.3 Success of root resection
procedures depend, to a large extent, on proper
case selection.
It is important to consider the following factors
before deciding to undertake any of the resection
procedures:1
• Advanced bone loss around one root with
acceptable level of bone around the remaining
roots.
• Angulation and position of the tooth in the
arch.
• A molar that is buccally, lingually, mesially
or distally titled, cannot be resected.
Divergence of the roots - teeth with divergent
roots are easier to resect. Closely approximated
or fused roots are poor candidates.1 Length and
curvature of roots - long and straight roots are
more favourable for resection than short, conical
889
 CASE REPORT

roots. For long term prognosis of the remaining

segment, post and core is required which would
fulfill the need for additional retention of the
weakened root.1 Hemisection may be a suitable
alternative to extraction and implant therapy
and should be discussed with patients during
consideration of treatment options.4

Figure 4: Case 2- Clinical picture

Figure 1: Case 1- 6 Month follow-up

Figure 5: Case 2-Distal root extracted

Figure 2: Case 1- Vertical cut radiograph

Figure 6: Case 2-One month follow up

Figure 3: Case 1-Preoperative Figure 7: Case 2-Pre-operative radiograph

890 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

Conclusion
The prognosis for hemisection is the same as
for routine endodontic procedures provided that
case selection has been correct, the endodontic
treatment has been performed adequately, and the
restoration is of an acceptable design relative to
the occlusal and periodontal needs of the patient.
Root amputation and hemisection should be
considered as another weapon in the arsenal of
the dental surgeon, determined to retain and not
remove the natural teeth. With recent refinements
in endodontics, periodontics and restorative
dentistry, hemisection has received acceptance as
a conservative and dependable dental treatment
and teeth so treated have endured the demands of
function.
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
CASE REPORT
References
1. Parmar G, Vashi P, Endodontology, Hemisection : A
Case Report and Review;2003Vol. 15,; 26-29.
2. M. NajeebSaad, BDS, Cert Prosth; Jorge Moreno,
DDS, Cert Endo; Cameron Crawford, B.Sc (Hons);
Hemisection as an Alternative Treatment for Decayed
Multirooted Terminal Abutment: A Case Report;
JCDA June 2009, Vol. 75, No. 5; 387-390.
3. SavithaAkki, Sudhindra Mahoorkar; Tooth
Hemisection and Restoration an Alternative to
Extraction - A Case Report; International Journal of
Dental Clinics 2011:3(3):67-68.
4. Sunandan Mittal, Tarun Kumar, RamtaBansal, Dilpreet
Kaur; Hemisectionas an Alternative Treatment for
Decayed Multirooted Tooth, Indian Journal of Dental
Sciences; 2010, Vol. 2, Issue 5, 8-9.
5. Bhutada G; Hemisection as a Treatment Option: A
Case Report;Indian Journal of Dental Research and
Review Oct 2011 - Mar 2012, 87-90.
891
 CASE REPORT

Innovative Denture- A Case Report

Laxman Singh Kaira1, Esha Dabral2

Abstract
Preventive Prosthodontics emphasizes the importance of any procedure that can delay or eliminate the future
Prosthodontic problems. The innovative denture is a logical method for the Dentist to use in preventive Prosthodontics.
The innovative denture not only preserves the residual alveolar ridge but also the propioceptive ability of the periodontium
is maintained. It serves as one of the treatment options for patient with very few remaining teeth, in compromised
condition. Aninnovative denture is a type of complete denture with holes relined with permanent soft liners, allowing
the remaining natural teeth to protrude through. This case report describes a technique for fabrication of innovative
denture for patient with commonly available soft liners.

Key words: Innovative denture, permanent soft liners, residual alveolar ridge

Introduction in their studies that there is relatively far less

T
resorption of alveolar bone when some teeth are
he prime focus of present day dentistry is
present as compared to residual ridge resorption
on preservation of teeth, thereby preserving
found in completely edentulous patients. It also
alveolar ridge integrity and propioceptive
has positive psychological effect on patient. In
ability of Periodontium. Some of the consequences
1958, Miller reported that retention of a few teeth
of total loss of teeth followed by complete
under complete dentures allowed the weak teeth to
denture therapy include compromised reflex
regain healthy status.2 Kawamura and Watanabe
adaptability, possible increase inparafunctional
(1960) found that patients with natural dentition
habits, undermined aesthetics and compromised
could discriminate differences at the 2 mm
masticatory system.1,2,3 Therefore preservation of
range better than those with artificial dentures.3
even a single lone standing healthy tooth in the
These findings emphasized the importance of
oral cavity can help in preventing these problems.
conservative procedures and the importance of
Various researchers including Crum and Rooney4
the retention of natural teeth. However Tallgrens
seven years study of alveolar bone loss around
mandibular natural teeth in patients with partial
dentures showed vertical loss of 0.8mm as
compared to 6.6mm loss in those wearing
1
Assistant Professor, complete denture.4 Crum and rooney (1978)
Department of Dentistry,
Veer Chandra Singh Garhwali Government Medical claimed that the retention of mandibular canines
Science and Research Institute, for overdentures helped preserve the remaining
Srinagar Garhwal, Uttrakhand, India.
2Private Practionner
edentulous ridge.5
Srinagar Garhwal,Uttrakhand, India
Corresponding Author:
The treatment option for patients having very few
Dr.Laxman Singh Kaira teeth remaining are overdentures or transitional
Email id: luckysinghkaira111@gmail.com dentures or Immediate dentures or innovative

892 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

Dentures following complete extractions.3
Overdentures cannot serve a solution for all of
such cases because of contraindications, need
for prerequisite treatment, poor positioning of
remaining teeth, requirement of more patient
visits and economic reasons.1,2,6 Most of the
patients defer getting all their teeth extracted as it
has a mutilating effect on their psychology. Thus
transitional dentures serve as treatment option for
many of such patients. So an innovative denture
is a relatively new type of transitional denture for
such patients.
An innovative denture is essentially a new type
of complete denture with holes allowing the
remaining natural teeth to protrude through.
Normally the key to retain a complete denture is
the suction that is obtained by the intimate contact
of denture to mucosa and adequate peripheral
seal. A hole allowing a tooth to protrude through
disturbs the peripheral seal and breaks the suction.
In case of innovative denture it is unique because
the hole is relined with a rubber gasket form by
permanent soft liners so that it snugly holds the
remaining teeth while allowing a natural suction
to form under the denture in addition to the
mechanical stability provided by the immobile
natural teeth. Even a single remaining tooth
increases the stability of denture several times.
But the fabrication of an innovative dentures is
technique sensitive, costly and time taking. In
this case report the management of a case of a 55
year old male patient with mandibular kennedy
class II arch and maxillary edentulous arch is
described.
Case report
A 55 year old male patient reporting to the
Department of Prosthodontics, Darshan Dental
College and Hospital, Udaipur, for replacement
of missing teeth. On intraoral examination,we
found that the missing teeth were extracted due to
periodontal disease. The medical histories do not
reveal anysignificant finding which may hamper
the proposed treatment plan. A preliminary
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
CASE REPORT
examination revealed a Kennedy class II
mandibular arch and completely edentulous
maxillary arch (Figure 1). In mandibular arch
only 37 is present.Extraoral examination showed
no significant finding. Radiographic examination
revealed that teeth are free of caries. Because of
compromised state of 37 a definitive treatment
plan could not be worked outfor this patient.
Thus it was decided to fabricate a conventional
complete denture for maxillary arch and a
innovative denture for mandibular arch.
Figure 1: Pretreatment Photograph
Method
Preliminary impressions were made with
irreversible hydrocolloid impression material.
Custom trays were fabricated with self cure resins.
For mandibular arch, a special tray was made by
compagna technique7 used for immediate denture
impressions and final impression is made. Jaw
Relation recording and try in was done in routine
fashion. Wax up for maxillary and mandibular
denture was done.
Processing of mandibular denture: Mandibular
innovative denture can be fabricated by
Acrylicbased permanent soft liners.
Wax up against the remaining teeth in the
mandibular cast was made thick. Flasking and
dewaxing was done. After de-waxing the putty
elastomeric impression material is adapted
893
 CASE REPORT

around the remaining teeth i.e. 37 near cervical

region, in adequate thickness. Separating medium
was applied on both parts of mould, packed with
acrylic resin and trial closure was done with
putty placed around remaining teeth on the cast
(Figure 2). The placement of putty around the
teeth provides space for soft liner material. After
trial closure putty index was removed from the
teeth. freshly mixed acrylic based heat cured long
term soft liner (Permasoft soft liner, Dentsply)
was adapted around the remaining teeth on the
cast to occupy space created by removal of putty
Figure 4: Application of soft liner
index (Figure 3&4) was adapted around the
around remaining teeth
remaining teeth on the cast. Flasks were closed
and curing was done. The denture was removed
after deflasking. It was finished, polished and
inserted in the patient (Figure 5&6).

Figure 5: Finished Denture

Figure 2: Application of putty around
remaining tooth

Figure 6: Post Operative Photograph

Discussion
Figure 3: Armamentarium By innovative denturesthe remaining natural teeth
can be preserved and integrity of residual ridge

894 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

is maintained. They improved the retention and
stability of dentures. In addition to this it gives the
patient psychological satisfaction of retaining the
natural teeth as they were. Attachment devices
are avoided by this technique. This case report
describes an alternate technique which does not
require special tooth preparations and extra patient
visit. Further adds-ons and relines are possible.
If the tooth is lost in future, existing denture can
be modified to occupy its place. These dentures
serve as a solution for single standing teeth present
in dental arch; they should be avoided in patients
with bruxism. There are some disadvantages also.
The functional duration of elastic material used
is short. It requires frequent corrections. Entire
gingival margin of remaining teeth is covered
leading to plaque accumulation.
Conclusion
Innovative like dentures serves as a convenient
and alternative treatment for patients with very
few remaining teeth. They rest on soft tissue while
providing a snug fit over remaining, healthy tooth
structures. An elastic gasket seals itself around the
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
CASE REPORT
cervical part of remaining teeth, thereby providing
a stable and healthy fit. It promotes healthy
stimulation to maintain alveolar bone. Retention
and stability is improved,vertical dimensions and
tactile propioception are maintained. Factors to
be considered during treatment planning include
number of remaining teeth, their position across
the arch, undercuts and periodontal status.
References
1. Zarb –Bolender :Prosthetic Treatment for Edentulous
Patients,12th edition,mosby, 2003; 6-23,160-176.
2. Sheldon winkler: Essentials of Complete Denture
Prosthodontics, 2ndedition, 1988; 22-34,384-402.
3. Charles M. HeartwellJr, Arthur O.Rahn- Syllabus of
Complete Dentures, fourth edition,48-53.
4. Brewer AA, Morrow RM: Overdentures, ed 2. St
Louis, CV Mosby, 1980; 128-129.
5. Crum RJ, Rooney GE Jr: Alveolar bone loss in
overdentures: A 5-year study. J Prosthet Dent
1978;40:610-613.
6. Ettinger RL, Taylor TD, Scandrett FR: Treat¬ment
needs of overdenture patients in a longitu¬dinal study:
Five-year results. J Prosthet Dent 1984;52:532-537.
895
 SHORT COMMUNICATION

Treatment of Localised Aggressive

Periodontitis -Still an Enigma !
Deepti Gattani1, Narpatsingh Rajput2, Anurag Ashok Shen3

Abstract
Periodontal diseases range from the relatively benign gingivitis to chronic & aggressive forms of the disease. It is a
rapidly progressing disease associated with specific microflora namely, Actinobacillusactinomycetemcomitans&Porp
hyromonasgingivalis. LAP is not a very prevalent disease; it does have serious repercussions for those affected. The
clinical management of LAP has not received the same intensity of interest as its etiology & pathogenesis, but due to
significant impact of LAP, the need for treatment is evident. This article basically deals with the treatment modalities
for localized aggressive periodontitis.

Key words: Therapy, Localized Aggressive Periodontitis, Microflora, Surgical, Non-Surgical

Introduction hormones that could serve as growth factors for

P eriodontal diseases range from the relatively
benign gingivitis to chronic & aggressive
forms of the disease. A much severe form of
periodontitis termed as aggressive periodontitis
(formerly termed as early onset periodontitis,
localized juvenile periodontitis) affects 1% of the
population. Localized aggressive periodontitis
(LAP) is a well defined clinical entity which
makes its debut when children are between 11 and
13 years of age. The reasons for onset at puberty
are obscure, but may be related to elevation in
blood and gingival fluid concentrations of certain
1
Professor, 3PG Student
Department of Periodontics and Oral Implantology
Swargiya Dadasaheb Kalmegh Smruti Dental
College&Hospital, Nagpur
Private Practice at Khushi Dental Care, Mumbai, Maharashtra
2 thorough understanding of etiology, pathogenesis
Corresponding Author:
Dr.Deepti R Gattani
Email id:deepti.gattani@yahoo.com
infecting bacteria. It is a rapidly progressing
disease associated with specific micro flora
namely, Actinobacillusactinomy cetemcomitans
& Porphyromonasgingivalis, both of which
are Gram negative organisms with the ability
to invade host epithelial tissues which have
important implications for treatment.1
Aggressive periodontitis displays a strong
genetic influence and shows familial and racial
aggregation. Symptoms like tooth mobility,
pathologic migration of central incisors, increased
tooth sensitivity, pain during mastication,
periodontal abscesses are common. Thus the
impact on patient physically, psychologically,
esthetically & economically is great. Although
LAP is not a very prevalent disease, it does
have serious repercussion for those affected. A
& treatment would be valuable to educate & treat
the patient to obtain best outcome. The clinical
management of LAP has not received the same

896 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014

intensity of interest as its etiology & pathogenesis,
but due to significant impact of LAP, the need for
treatment is evident. Along with conventional
treatment modalities, adjunctive therapies may
be warranted to deal with the invasive nature
of microorganisms. Robinson2 stated that local
therapy is of little avail in aggressive periodontitis.
This tended to reinforce the opinion that extraction
of involved teeth was practical approach to
treatment. Baer and Everest3 however opposed
the early extraction of maxillary first molars.
They noted that the maxillary sinus enlarges by
pneumatization from third month of fetal life
until age 18, thereafter becoming stable. Likewise
he observed that accelerated pneumatization of
maxillary sinus into resultant edentulous therapy
may complicate future periodontal therapy. This
led to the opinion that these teeth should be retained
as long as possible. Tenenbaumetal4 evaluated that
local dental treatment with splint & stabilization
improved clinical parameters. Vitamins, Calcium
Phosphate therapy hormone therapy showed no
appreciable changes. Everets& Baer5 proposed
occlusal adjustment by selective grinding which
may lead to decrease in depth of the defect.
Nonsurgical Therapy: Although most current
studies & case reports on LAP involve surgical
therapy, several investigations found nonsurgical
therapy to be successful. Gold reported clinical
& radiographic improvement in a 14 yr old
LJP patient treated by a 6 week regimen of
biweekly scaling & root planning (SRP) under
local anesthesia combined with tetracycline
administration (250mg 4 times a day for I week,
then 250 mg once a day during 6 weeks of
subgingival therapy).6
Slots & Rosling7 studied effectiveness of
subgingival debridement, topical Betadine
Solution and systemic tetracycline in suppressing
subgingivalAa. Effectiveness of tetracycline
against Aa has been confirmed in many studied.
Aa is 2-4 times susceptible to combination
of Metronidazole + Amoxicillin.8 Other
antibiotics included amoxicillin,clavulanic acid,
Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
SHORT COMMUNICATION
Metronidazole, doxycyline. Haffazee et al (2003)
found statistically significant improvement in
clinical attachment level (CAL) for tetracycline
and Metronidazole & also for combination
of amoxicillin + Metronidazole. Antibiotics
may have adverse effects as Gastrointestinal
disturbances, future resistance to organisms.
Local drug delivery with tetracycline &
subantimicrobial doses of doxycyline (20mg) can
be given.
Surgical Therapy: Surgical treatment has been
proposed by Gjermo, Waerhaug.9,10 They stated
that it is often indicated to provide access to
subgingival plaque where total plaque removal
could not be possible by scaling alone. Surgical
techniques studied were both respective &
regenerative including GTR membranes, root
conditioners, DFDBA (decalcified freeze dried
bone allograft). Modified Widman flap with
curettage of bony defects 7 root surfaces was
reported by Lindhe & Liljenberg.11 Yuknaet al12
used (DFDBA) with local & systemic tetracycline
& it proved to be effective in gaining bone fill.
Tooth Transplantation: In cases where bone loss
was severe & first molar teeth were considered
hopeless &were tobe extracted, transplantation
of unerupted 3rd molars into site occupied by first
molar has been performed & reported by Baer &
Gamble.13 But with advances in alternative forms
of therapy it would seem prudent to reserve this
type of treatment for carefully selected cases.
Adjunctive Orthodontics & Endodontics:
Adjunctive orthodonticswas proposed by
Goldstein14 for replacement of first molars by
second & third molars. Adjunctive Endodontics
in extensive lesions should be bone prior to
periodontal therapy.
Photodynamic Therapy (PDT): PDT could be
useful adjunct to mechanical therapy & antibiotics
in eliminating periodontopathogenic bacteria.
PDT involves use of low power lasers with
appropriate wavelength to kill microorganisms
897
 SHORT COMMUNICATION
treated with a photosensitizer drug.15 The
treatment of LAP always presented a challenge
for clinicians, but there are no established
protocols & guidelines for efficient control of the
disease. The standard treatment for LAP remains
highly nonspecific. Studies using larger sample
sizes are warranted to confirm the results. The
purpose of this article was to present evidence
based & patient centered decision options & their
proper application. Currently, there is limited
evidence to provide specific recommendation for
use of any particular regimen
References
1. Newman MG, TakeiHH, CarranzaFA Carranza’s
Clinical periodontology 9th ed. Philadelphia W.B
Saunders Co. 2002 409-93
2. Robinson H: Periodontitis &Periodontosis in
childrenandyoung adolescents J Am Dent Assoc 43
:709,1951
3. Baer P.N and Everett F: The Maxillary Sinus As a
problem in the therapy of periodontosis. J Periodontal
41:476,1970.
4. Tenenbaumetal:- Result of several types of treatment
of periodontitis J Am Dent Asso 55:651,1957
898 Indian Journal of Multidisciplinary Dentistry, Vol. 4, Issue 1, November 2013 - January 2014
5. Everett F and Baer P : A preliminary report on treatment
of osseous defects in periodontosis J Periodontol
35:429,1964
6. Gold S. Combined therapy in treatment a periodontosis
Case Report Periodont Care rep 1:12,1979.
7. Slots J.Periodontal microflora in LJP by Systemic
tetracycline J ClinPeriodontal 10:465,1983.
8. XajigeorgiouC etal:Clinical & microbiological effect
of different antimicrobials on aggressive periodontis J
ClinPeriodontol 2006,33:254-264.
9. Gjermo The treatment of periodontal diseases in mixed
dentition : Int Dent J 31:45,1981
10. WaerhaugJ. Plaque control in treatment of juvenile
periodontitis. J ClinPeriodontol 4:29:1977
11. Lindhe J and Liljenberg B: Treatment of localized
juvenile periodontitis J ClinPeriodontol 11:399.1984
12. Yukna R Clinical Evaluation of localized periodontosis
defects treated with freeze dried bone allograft
combined with local & systemic teracyclinesInt J
Periodont Res. Dent 5:9.1982.
13. Baer P & Gamble J: Autogenous dental defects in
periodontosis Oral Surg 22:405,1966.
14. Goldsterm M. & Fritz M: Treatment of periodontosis
by combined orthodontic & periodontal approach :
Report of a case : J Am Dent Assoc 93:985,1976.
15. Takasaki etal: Application of antimicrobial photodynamic
therapy in periodontal and periimplantdieases:
Periodontol 2000,2009,51:109-140