Lasers in Pediatric Dentistry

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JOURNAL OF DENTAL PEERS

July 2014 w Vol.2w Issue 2
Table of Contents
ORIGINAL RESEARCH
37 Evaluation of the Extent of Facial Asymmetry in Aesthetically Symmetric Faces of Bilaspur
Population
Abhay Prem Prakash Agarwal1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4
43 Assessment of Dental Aesthetic Index Among School Children of Bilaspur (CG), India
Hemlata Rajmani1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4
CASE REPORT
48 Resin Retained Prosthesis for anterior Tooth Replacement-Maryland Bridge- A Case Report
Manoj Upadhayay1, Sudhanshu Srivastava2, Sakshi Chopra3, Mansi Rajput4, Pratim Talukdar5, Rashi Singh6
52 Bar & Clip Retained Overdenture- A Case Report

Sahil Sekhri1, Shivali Goyal2, Sanjeev Mittal3
55 Management of Failed Implant using Platelet Rich Fibrin (PRF)- A Case Report
Amarnath1, Pratim Talukdar2, Nitika Sachan3, Mukut Seal4, Meghali Langthasa5
59 Management of Partial Edentulism with Flexible Dentures- A Case Series

Reeta Jain1, Gyan Chand2, Deepika3
LITERATURE REVIEW
62 Changing Perception and Attitude of Pediatric Dentistry
Neetika Singh1, Rohit Thakur2, Nagender Chauhan3, Marisha Kaul4
ORIGINAL RESEARCH
Evaluation of the Extent of Facial Asymmetry in Aesthetically Symmetric

Faces of Bilaspur Population
*
Abhay Prem Prakash Agarwal1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4
Abstract
Background: Although minor asymmetries are rarely evident, but the asymmetries which affects function, aesthetics or social
acceptance of an individual need complete evaluation.
Aims: To evaluate the extent of facial asymmetry in aesthetically symmetric faces of the Bilaspur population.
Materials and methods: Simple random sampling was executed to select 500 Adult subjects (250 males and 250 females) aged 12-25
years from the daily out patients of the Department of orthodontics and Dentofacial Orthopedics, New Horizon Dental College,
Bilaspur, Chhattisgarh. A Poster anterior (PA) cephalogram was obtained with each subject in centric occlusion. Skeletal asymmetry
was determined using Grummon's analysis.
Results: The results indicate less asymmetry and more dimensional stability as the cranium is approached and mandibular region
shows the asymmetries of higher magnitude. A tendency toward right side dominance was statistically significant.
Conclusion: Asymmetries are common finding in the present group of population, with males showing higher rate of asymmetry then
the females.
Keywords: Facial asymmetry, Symmetry, aesthetics.

Introduction
Minor asymmetries of the face are a common finding
Asymmetry is defined as being present when one or
in normal individuals [1,3] although they are rarely evident
more of the facial or cranial bilateral components (bone or soft
and generally pass unnoticed [2,4]. Asymmetry becomes
tissues) are not equidistant from the midline or that the center
important when it affects function, aesthetics or social
of each of the unpaired structures does not lie on that line[1].
acceptance of an individual. A more precise method to
Asymmetry of the face is one of the more difficult problems
measure asymmetry is to use radiographs of the subjects.
with which orthodontists have to contend and which often
Asymmetry of the craniofacial bones can be quantified only
present serious diagnostic difficulties [2]. The recognition of
through X-ray techniques. In the lateral cephalometric film,
the actual site of asymmetry is essential for correct treatment
vertical asymmetries are often recognized by the failure of
planning.
bilaterally symmetric objects to superimpose, as they normally

developmentally
will. An additional dimension can be added to the radiographic
acquired as well as in congenital abnormalities, usually
examination by panoramic films, which are useful when the
involve both soft and hard tissues.
sections of mandible are deformed. Sub-mental vertex view is
Gross
asymmetries
occur
in
*1
Post-Graduate Student, 2Professor & Head, 3Reader,

4
Reader, Dept. Orthodontics & Dentofacial Orthopedics, New
Horizon Dental College, Sakri, Bilaspur(CG), India.
E-mail:drabhayagarwal@yahoo.co.in
*
Corresponding Author
also useful when the mandibular ramus is severely deformed.

Computed tomography (CT) also allows the three
dimensional viewing but significantly more radiation is
required. Thus the most common view used is the PosteroAnterior on which researchers have used different reference
points for construction of the midline of the face, which is
essential in the study of asymmetries [5]. So for, Postero-
Journal of Dental Peers, Vol. 2. Issue 2, July 2014
37
ORIGINAL RESEARCH
Anterior (PA) view remains most widely used tool for the
in millimeters. The difference between each pair of
research on asymmetries. The present article aims to assess the
measurements was also recorded in millimeters as left side
nature of asymmetry in aesthetically pleasing faces in
minus right side; in this way sidedness in facial asymmetry
Bilaspur, Chhattisgarh population using Postero-Anterior (PA)
could be evaluated. The total width between the bilateral
films.
landmarks (sum of left and right side) was calculated.

The absolute value of the left and right difference was
Materials And Methods

A cross-sectional study was conducted on a sample of
used to compute the mean absolute asymmetry for each of the
500 adult subjects (250 male and 250 female). Simple random
dimensions studied. Separate computation was made to test for
sampling was executed for the sample selection. All the
left or right side dominance within the sample. Positive (+)
subjects were taken from the daily out patients of the
sign for the left side and negative (-) sign for the right side
Department of Oral Medicine and Radiology, and the
were used to indicate sidedness. The data collected from the
Department of Orthodontics and Dentofacial Orthopedics,
tracing was fed into the computer and the SPSS 17 was used to
New Horizon Dental College and Hospital, Bilaspur,
perform the statistical analysis. Mean absolute value, Standard
Chhattisgarh, India. All the subjects selected had clinically
Deviation (SD) and absolute value of the left and right
acceptable
full
difference (d) was calculated. To find the differences between
complement of teeth. They had no history of orthodontic
male and female for different measurements Independentt
treatment and mandibular displacement during opening and
test was applied.
closing.
Results
facial
harmony
and
symmetry
with
To minimize the subjective error in selection, a panel
All the subjects examined showed asymmetries in
of three orthodontists examined each person and the subjects
one or more of the measured dimensions. Table 1 shows the
were selected when all the three agreed. Ethical clearance was
vertical asymmetry in between male, female and in the whole
obtained from the ethical committee of New Horizon Dental
group (including male and female) for the four planes
College and Hospital, Bilaspur, Chhattisgarh. The purpose of
investigated. The comparison of the value depicted no
the study was explained to the subjects and the written consent
significant difference between the males and females. Mean
was obtained before exposing them to X-ray.
absolute value and sidedness (in degree and millimeter) for the
The single examiner on the acetate tracing paper
Mandibular morphology is depicted in Table 2A. In all the
traced all the P-A Cephalometric X-rays. The intra examiner
linear measurements of mandibular morphology males showed
variability was determined by randomly selecting a sample of
higher rate of asymmetry compare to females, and at Go-Me
10 PA cephalograms for retracing within period of two
length (5.10 mm) males have almost double the asymmetry in
months. The error was found to be 0.5 mm, which was within
comparison to females (2.65 mm), which is statistically
normal limits.
significant. In the sidedness, males showed left sidedness at
The analysis for assessment of transverse frontal
Co-Go, whereas at Go-Me and Co-Me they showed right
facial asymmetry was done by using parts of the frontal
sidedness, which is statistically significant. In females all the
asymmetry analysis suggested by Grummons [6]Fig.1. To
lengths showed right sidedness, but only Go-Me and Co-Me
check the linear transverse asymmetry, the distance between
are statistically significant (Table 2A). Table 3A gives the
each landmark, left and right, and the MSR line was recorded
description of skeleto-facial asymmetry in transverse direction.
38
ORIGINAL RESEARCH
Table 1: Mean absolute value for the vertical asymmetries (in degree).
Angle
Male (n=250)
SD
Mean
Female (n=250)
Mean
SD
Total(n=500)
Mean
SD
Z - plane
ZA - plane
Occlusion -plane
Ag - plane
= Mean
89.920
90.10
90.220
90.320
89.90
90.320
90.160
90.720
89.910
90.210
90.190
90.520
1.550
1.570
1.740
1.710
1.090
0.760
1.490
1.320
1.330
1.220
1.600
1.530
Table 2A: Gender wise mean absolute value and sidedness (in degree and millimeter) for the mandibular morphology
Absolute values ( |d|)
Male
Female
(N=250)
(N=250)
SD
|d| SD
|d|
Go 2.92 2.48
Angle
Co-Go
2.76 2.42
Length
Go-Me
5.10 3.25
Length
Co-Me
2.94
2.61
Length
* = Significant, p<0.05
P
value
Sidedness ( d )
Male (N=250)
0.22o
2.52o
P
value
0.66
1.98
1.53
0.11
-1.08
3.71
1.70
1.25
0.05
1.80
3.23
0.01*
-0.10
2.13
0.81
2.82
2.65
0.009*
-4.02
4.56
-2.06
3.30
0.005*
2.18
1.74
0.23
-1.82
3.51
0.000
*
0.01*
0.01
*
0.08
-1.58
2.32
0.002*
0.77
|d|
SD
P
value
P
value
0.15
|d|
SD
Female (N=250)
0.34
Table 3A : Gender wise skeletal asymmetry in transverse direction, mean absolute value and sidedness (in millimeter)
Male
Female
(N=250)
(N=250)
SD
SD
|d|
|d|
1.60
1.62
0.54
0.76
ZDistance
ZA 3.20
3.55
Distance
NC 1.38
1.26
Distance
Co 3.32
2.37
Distance
J1.74
1.44
Distance *
Ag 3.32
2.37
Distance
P
value
Sidedness ( d )
Female (N=250)
Male (N=250)
|d|
SD
0.005*
-0.04
2.30
P
value
0.932
P
value
SD
P value
0.34
0.87
0.064
0.44
-0.80
2.13
0.073
0.09
0.04
1.78
0.912
0.56
|d|
1.80
1.35
0.072
-2.40
4.15
1.44
1.01
0.85
-0.26
1.87
0.008
*
0.494
1.92
1.11
0.010*
-2.00
4.65
0.04*
-0.72
3.99
0.376
0.30
0.94
0.88
0.022
0.46
2.24
0.315
0.58
1.16
0.02*
0.81
1.92
1.11
0.010*
0.52
4.10
0.532
1.40
1.74
0.001*
0.32
39
ORIGINAL RESEARCH
Table 4A : Gender wise Mandibular deviation: mean absolute value and sidedness (in millimeters)
DIMENSIONS

Male (N=250) Female
P
(N=250)
value
SD
SD
|d|
|d|
Mandibular
2.56
1.59
offset at
mention
1.82
1.51
0.099
Male (N=250)
|d|
1.20
Sidedness ( d )
Female (N=250)
SD
P value
2.80
0.043*
|d|
1.18
SD
P value
2.07
0.009*
P
value
0.97
skeleton is made up of numerous constituent parts, each of

which is capable of having individual variations between the
right and the left side. In some instances, asymmetry of the
cranio-facial complex can be of concern to the orthodontist in
the diagnostic and treatment procedure. In others, asymmetry
is so slight that it cannot be detected by gross observation.
Mild asymmetries are invariably present even in the most
pleasing of faces. It becomes necessary to discover such mild
asymmetry so that the range of normal variation of asymmetry
can be established.
Parallelism of the facial structures in the cranial base
and the lower facial region was assessed and it was found that
Fig. 1. Grummons Analysis
the facial structures were more or less parallel to each other

and no gross canting was seen in the present study, which is in
Highest rate of asymmetry at Co was seen in both
agreement with the study done by Sumant Goel (2003)[8],
males and females. Lowest rate of asymmetry was seen at NC
who compared three planes that is Z, Occlusal and Go plane,
(1.38 mm) in males, whereas, in females Z (0.54 mm) shows
and found that all were almost parallel to each other.
lowest rate of asymmetry. Males show higher rate of
In mandibular morphology males show higher rate of
asymmetry compared to females in all the parameters but only
asymmetry at Go angle compared to females, which was
measurements Z, J and Ag are statistically significant. In the
measured directly in between the two lines that is Co-Go and
sidedness males show right side bias at Z, ZA, NC and Co, but
Go-Me. In the sidedness, at Go angle both the males and
only ZA and Co are statistically significant.
females show right sidedness, which is in accordance with the

earlier studies [3,8].
Table 4A shows mandibular deviation in males and
The right side of the face is dominant because the
females. Males show higher mandibular deviation (2.56 mm)
development of the right hemisphere of the brain is greater and
compared to female (1.59 mm). In the sidedness both the
therefore the type of cranium is responsible for asymmetry of
males and females show left side dominance, this is
other cranial bones [3].
statistically significant (Table 4A).
Discussion
It was true in the present study with the right side of

the face being larger than the left. In the linear measurements
Asymmetries are invariably present even in the most
of mandibular morphology, at Co-Go length males show left
pleasing of faces. Scott [7] suggested that the human facial
side bias but females show right side bias and the difference is
40
ORIGINAL RESEARCH
statistically significant. All the transverse parameters used for
Lear[10] described a method for graphic and metric appraisal
assessment of skeleto-facial asymmetry were measured from
of arch and palate form. He concluded that there was a marked
MSR line and recorded individually for left and right side. The
asymmetry in the arch form where the subject spent equal
asymmetry at Ag and Co distance is higher compare to Z, NC
positions at night with the right and the left cheeks pillowed.
and J distance. Peck et al., (1991)[9] found the asymmetry in
Mandibular deviations showed asymmetry of 2.19 mm, which
the upper facial region to be 0.87 mm.
is less compared to the study done by Sumant Goel (2003)[8].
In their study, Peck et al., (1991)[9] have used lateral
This is in agreement with Severt and Proffit (1997)[11] who
orbital (LO) point to check the asymmetry in upper facial
found an incidence of 74% of chin deviations. This high
region, whereas in the present study as well as in the study of
incidence of chin deviation may be due to the asymmetries of
Sumant Goel[8] zygomatico frontal suture (Z) point was used
mandibular length, which also showed high incidence.
for the same. The asymmetry observed for Z distance in our
Various parameters that showed right sidedness in the
study is 1.07 mm, which is higher in comparison to earlier
present study are: Go angle, Go-Me and Co-Me in mandibular
results[9].
morphology,
ZA
and
Co
in
transverse
skeletofacial
When we considered the asymmetries from hairline
asymmetry, in which except Go angle all parameters are
to chin, we found that the asymmetries decrease in magnitude
statistically significant. Which is similar to the study done by
as we approach higher in craniofacial region and mandibular
Shah and Joshi (1978)[3], Farkas and Cheuing (1981)[10],
region showed the asymmetries of higher magnitude. This
Peck et al., (1991)[9], Ferrario et al. (1994)[13] and Sumant
finding is in agreement with the results of earlier studies[8,9].
Goel (2003)[8].
Zygomatic (ZA) point showed right sidedness and is
Conclusion
statistically significant, which is in accordance with the results
Following conclusion can be drawn from the present study;
of the previous study [9]. Certain habits like sleeping only at
1.
one side with pillow, during growing period may make
Asymmetries are common finding in the present

group of population.
difference between left and right side at lateral zygomatic
2.
(ZA) point.
The asymmetries decrease in magnitude as we

approach
Less asymmetry was seen in mandibular region (at
higher
in
craniofacial
regions
and
mandibular region shows the asymmetries of higher
Ag) in comparison to the previous studies [8,9]. Mandibular
magnitude.
region shows left sidedness, which is opposite to the study
3.
done by Peck et al., (1991)[9] but in agreement with the results
Males show higher rates of asymmetries compare to

females.
of Sumant Goel (2003)[8]. In both the studies, authors have
4.
used gonial point (Go) to check the asymmetry in mandibular
There is a right side dominance of facial asymmetry.
Source of Interest/ Conflict: None Declared.
region, whereas in the present study antigonial notch (Ag) was

used as suggested by Grummons[6] for the same.
The asymmetry for condylar distance indicates that
the mandibulo-facial region exhibit the highest asymmetries in
patients with malocclusion. Similar findings were reported by
Farkas and Cheung (1987)[10] and Sumant Goel (2003)[8].
Sleeping habits and other environmental influences may play a
role in the difference between left and right of Co, but
References
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1968;38:82-93.
2.
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ORIGINAL RESEARCH
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Shah SM, Joshi MR. An assessment of asymmetry in the
10. Farkas LG, Cheung G. Facial asymmetry in Healthy
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North American Caucasians. - Angle Orthod 1981;51:76-
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Marmary Y, Zilberman Y, Mirsky Y. Use of foramina
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analysis. J ClinOrthod 1987; 21:448- 65.

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11. Lear CSC. Symmetry analysis of the palate and maxillary
13. Ferrario VF, Sforza C, Carlo EP, Tartaglia G. Distance
Scott JH. The analysis of facial growth in the anterior and
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asymmetry. American association of oral and maxillo-
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How to cite this Article;

Abhay Prem Prakash Agarwal, Thilagrani P.R., Ashok
Kumar Dhanyasi, Jaiprakash Mongia. Evaluation of the
Extent of Facial Asymmetry in Aesthetically Symmetric Faces
of Bilaspur Population. J. Dent. Peers 2014;2(2):37-42.
42
ORIGINAL RESEARCH
Assessment of Dental Aesthetic Index Among School Children of Bilaspur

(CG), India
*
Hemlata Rajmani1, Thilagrani P.R.2, Ashok Kumar Dhanyasi3, Jaiprakash Mongia4
Abstract
Introduction-Malocclusion is one of the most widespread oral health problems that the society is facing. There is increased concern
for dental appearance during adolescents to early adulthood. Most of the malocclusion can be corrected if detected early by
correctional methods.
Objectives-This study is to know the prevalence of malocclusion and orthodontic treatment needs among 12-15yr old school children
of Bilaspur.
Materials and Methods-A total of 351 study subjects were selected based on convenience sampling and examination was carried out
under natural light and data was recorded using WHO Proforma 1997. The collected data was subjected to statistical analysis using
SPSS16.
Results-Out of the 351 children examined, 46.2% were boys & 53.8% were girls and their mean age was 13.89yrs. One and two
segment crowding was seen in 24.5% & 11.4% respectively. Normal molar relation was seen in 80.3% of children. Definite, severe
and very severe or handicapping malocclusion was seen in 9.7%, 4.3% & 3.4% of children respectively. There is no statistically
significant difference in malocclusion status between boys and girls.
Conclusion-Only 4.3% and 3.4% of children required highly desirable and mandatory orthodontic treatment needs.
Keywords- Malocclusion, Dental Aesthetic Index, Orthodontic Treatment needs.

Introduction
Dento-facial appearance has a lot to do with the way
Orthodontics has traditionally focussed on children
the people are perceived in the society.[1] People equate good
and adolescents.[4] There is an increases concern for dental
dental appearance with success in many aspects.[2] Social
appearance during adolescents to early childhood has been
interactions that have a negative effect on self-image, career
observed.[2] Malocclusions are 3rd in the ranking of priorities
advancement and a peer group acceptance have been
among the problems of dental public health worldwide,
associated with an unacceptable dental appearance.[3] The
surpassed only by dental cavity and periodontal diseases.[5]
prevalence of malocclusion varies from country to country and
The benefits of taking orthodontic treatment are to prevention
among different races.[1] The reasons to develop malocclusion
of tissue damage and correction of aesthetic component,
could be genetic or environmental and/or combination of both
improve the physical function[2]. A variety of indices have
the factors along with various local factors such as adverse
been developed to assist professionals in categorizing
oral habits, tooth anomalies, form and developmental posit ion
malocclusion according to the treatment needs[6]. Dental
of teeth can cause malocclusion.
Aesthetic Index (DAI) introduced by Cons et al(1986), which
*1Post-Graduate Student, 2Professor & Head, 3Reader,

4
Reader, Dept. Orthodontics & Dentofacial Orthopedics, New
Horizon Dental College, Sakri, Bilaspur(CG), India.
E-mail: drhemnhdcri@gmail.com
* Corresponding Author
links clinical and aesthetic components. It was developed

originally based on North American Caucasian sample.[7] The
World Health Organization concerning to acknowledge the
real malocclusions conditions in different countries, adopted it
as a cross cultural index and advocated it in the 4th Edition of
43
ORIGINAL RESEARCH

the Manual of Basic Oral Health Survey, so there would be a
mandibular irregularity of 0, 1-3 and >3mm was seen among
suitable instrument to gather epidemiological data collection
72.1%, 27.6% and 0.3% of school children respectively.
and assessment of orthodontic treatment needs [5,7-9]. DAI is
Maxillary over-jet of 0-3mm is considered normal and was
proven to be reliable, valid, versatile, simple and easily
seen among 76.4% of school children and >3mm was seen
applied index[7,9]. Most of the malocclusion can be corrected
among 23.6%of school children. Mandibular overjet of 0-3mm
if detected early by correctional methods.[1] This study was
was among 99.4% of school children and 0.6% of them had
intended to evaluate the prevalence of malocclusion, its
>3mm of overjet. Open bite of >3mm was seen among 0.9%
severity and the orthodontic treatment needs using DAI,
of study subjects. Molar relation was normal among 80.3% of
among 12-15yr old school children of Bilaspur, Chattishgarh.
school children whereas half cusp and full cusp molar relation
was seen among 14.8% and 4.8% of school children. There
Materials and Methods

The present study was conducted among 12-15yr old
school children of Bilaspur, Chattishgarh. The schools were
selected based on convenience sampling. A total of 351 school
children of both sexes were selected for the study based on
convenience sampling. Approval was obtained from the
was no statistically significant difference between the DAI

scores and the gender. Table 3 shows the distribution of
according to DAI score, severity of malocclusion, treatment
indicated and gender. 4.3% and 3.4% of the study subjects had
severe and very severe malocclusion respectively and required
highly desirable and mandatory orthodontic treatment needs.
concerned authorities before the start of the study. All

examinations were performed at schools while children were
Discussion
seated on chair under normal illumination. The examiners
Many epidemiological studies have been conducted
were trained and intra-examiner calibration was done. Kappa
worldwide utilizing various indices for quantifying the extent
statistics showed a good agreement. Sufficient number of
of malocclusion.[1] Crowding of incisal segment affects half
autoclaved instruments was taken to the examination site. The
of all children in mixed dentitions and it worsens in adolescent
WHO Proforma (1997) was used to assess the malocclusion.
years as the permanent teeth erupt and continues to increases
Data collected was coded, processed and subjected to
as the age progresses.[2] In the current study, 35.9% of the
statistical analysis using SPSS version 16.
study population had incisal crowding. The results of the

current study are in correlation with the study conducted by
Results
The study population consisted of about 351 school
children aged 12-15years in Bilaspur city, out of which 46.2%
were males and 53.8% were females (Table 1). Table 2 shows
the distribution of DAI components. Out of 351 school
children, 24.5% had one segment crowding and 11.4% had
two segments crowding. One and two segment spacing was
seen in 8.5% and 1.7% school children respectively. Diastema
of 1-3mm was seen among 5.7% of the study subjects. Largest
maxillary irregularity of 0, 1-3 and >3mm was seen among
80.9%, 17.1% and 2% of school children respectively. Largest
Shivakumar et al[2] and in contrast with a study conducted by

Bhardwaj et al[1].
Both the upper and lower incisal segments were
examined for spacing. In the present study, 10.2% had incisal
segment spacing either in one or both the arches which school
children and this result was in correlation to the study
conducted
by
Artenio
Jose
IsperGarbin
et
al[5].
Diastema>1mm was seen among 5.7% of school children and

this result was in correlation to the study conducted by Artenio
Jose IsperGarbin et al5. Irregularity may occur with or without
crowding. In the current study, 19.1% of the children had
maxillary anterior irregularity of >1mm, and the results are in
44
ORIGINAL RESEARCH

TABLE 1. Age Wise Distribution of Study Population
AGE
12
13
14
15
TOTAL
FREQUENCY
13
95
133
110
351
PERCENTAGE
3.7
27.1
37.9
31.3
100
TABLE 2. Distribution of Dai Component

DAI COMPONENTS
CROWDING
SPACING
DIASTEMA
LARGEST MAXILLARY
IRREGULARITY(mm)
LARGEST MANDIBULAR
IRREGULARITY(mm)
MAXILLARY OVERJET (mm)
MANDIBULAR OVERJET(mm)
OPEN BITE(mm)
MOLAR RELATION
0
0NE SEGMENT
TWO SEGMENT
0
0NE SEGMENT
TWO SEGMENT
0
1-3
0
0-3
>3
0
0-3
>3
0-3
>3
0
>3
0
>3
NORMAL
HALF CUSP
FULL CUSP
PERCENTAGE (%)
64.1
24.5
11.4
89.7
8.5
1.7
94.3
5.7
80.9
17.1
2
72.1
27.6
0.3
76.4
23.6
99.4
0.6
99.1
0.9
80.3
14.8
4.8
TABLE 3. Distribution of the Subjects According to Dai Scores, Severity of Malocclusion, Treatment Needs and Gender (P=3.946).
DAI
Severity Of
Treatment MALE FEMALE
TOTAL
SCORE Malocclusion
Indicated
(%)
(%)
(%)
No/ minor
No/slight
<25
84
81.5
82.6
Malocclusion
Treatment
Definite
26-30
Elective
8
11.1
9.7
Malocclusion
Severe
Highly
31-35
3.1
5.3
4.3
Malocclusion
Desirable
Very severe or
handicapping
>35
Mandatory
4.9
2.1
3.4
malocclusion
TOTAL
100
100
100
45
ORIGINAL RESEARCH
References
correlation with the study conducted by Shivakumar et al[2]
1.
VK Bhardwaj, KL Veeresha and KR Sharma.
and Artenio Jose IsperGarbin et al[5]. 27.9% had mandibular
Prevalence of malocclusion and orthodontic needs
anterior irregularity >1mm and the result were in contrast with
among 16 and 17year old school going children in
the study conducted by Bhardwaj et al[1], DS Rwakatema et
Shimla city, Himachal Pradesh. Indian Journal of
al[8], B. Eduardo and F.M Carlos[9].
Dental Research 2011;22(4): 556-560.
In the present study, maxillary overjet of >3mm was
2.
Shivakumar KM, Chandu GN, Subba Reddy VV, et
seen in 23.6% and it was similar to the study conducted by B.
al. Prevalence of malocclusion and orthodontic
Eduardo and F.M Carlos9 and Bhardwaj et al1 and in contrast
treatment needs among middle and high school
to a study conducted by Matilda Mtaya et al10.
children of Davangere city, India by Dental Aesthetic
Mandibular overjet of >3mm was seen in 0.6% of

school children and it was in correlation with studies
Index. J India SocPedodPrev Dent 2009; 27:211-218.

3.
conducted by Shivakumar et al2, DS Rwakatema et al8 ,

1
Index scores and perception of personal dental
Bhardwaj et al and Artenio Jose IsperGarbin et al .
appearance among Turkish university students.
An anterior openbite of >3mm was seen in 0.9% of
European Journal of Orthodontics 2009; 31: 168-
school children which was similar to studies conducted by

1
H. Nihal, B. Guvenc and U. Ersin.Dental Aesthetic
Bhardwaj et al and B. Eduardo and F.M Carlos . Normal
173.
4.
B.A Carlos, M.C Jose-Maria, M.P David, et al.
molar relation was seen in 80.3% of the school children and
Orthodontic treatment need in Spanish young adult
which was similar to the study conducted by Bhardwaj et al1
population. Med Oral Patol Oral Cir Bucal 2012;
and was in contrast with the study conducted by Artenio Jose
17(4):638-643.
IsperGarbin et al . Definite malocclusion was seen in 9.7% of
5.
I.G Artenio Jose , P.P Paulo Cesar, S.G CleaAdas, et
the school children, severe malocclusion was seen in 4.3% of
al. Malocclusion prevalence and comparison between
school children and very severe or handicapping malocclusion
the Angle classification and the Dental Aesthetic
was seen in 3.4% of children. Similar results were found in the
Index in scholars in the interior of Sao Paulo state-
study conducted by Vijaya Hedge and RekhaShenoy11,
Brazil. Dental Press J Orthod 2010; 15(4):94-102.
Bhardwaj et al1 and Shivakumar et al2, whereas it was in
6.
Poonacha KS, Deshpande SD, Shigli AL. Dental
contrast with the study conducted by B. Eduardo and F.M
Aesthetic Index, applicability in Indian population: a
Carlos9 and D.S Rwakatema et al8.
retrospective study. J Indian Pedod Prev Debt 2010;

28: 13-17.
Conclusion
7.
B. Venkatesh, Gopu H. Assessment of Orthodontic
Thus the present study concluded that out of 351
treatment needs according to Dental Aesthetic Index.
study subjects, 4.3% and 3.4% of school children required
Journal of Dental Sciences and Research 2011;
highly desirable and mandatory type of orthodontic treatment
2(2):9-13.
needs respectively. The information from this study forms a
8.
D.S Rwakatema, P.M. Ng'ang'a and A.M. Kemoli.
part of the basis not only for further research, but also for
Orthodontic treatment needs among 12-15 year olds
planning orthodontic care.
in Moshi, Tanzania. East African Medical Journal
2007; 84(5): 226-232.
46
ORIGINAL RESEARCH

9.
B. Eduardo and F.M Carlos. Orthdontic treatment
11. H. Vijaya and S. Rekha.Dentition status, treatment
need in Peruvian young adults evaluated through
needs and malocclusion status among 15-year-old
Dental Aesthetic Index. Angle Orthodontist 2006;
school children of Mangalore- a pilot study. JIDA
76(3): 417- 421.
2010; 4 (12): 568-569.
10. M Matilda, B. Pongsri and A. Anne Nordrehaug.

Prevalence of malocclusion and its relationship with

Rajmani, Thilagrani P.R., Ashok
socio-demographic factors, dental caries and oral
Hemlata
hygiene in 12 to 14 year old Tanzanian school
Dhanyasi, Jaiprakash Mongia. Assessment of Dental
children. European Journal of Orthodontics 2009;
Aesthetic Index Among School Children of Bilaspur (CG),
31: 467-476.
India. J. Dent. Peers 2014;2(2):43-47.
Kumar
47
CASE REPORT
Resin Retained Prosthesis for anterior Tooth Replacement-Maryland Bridge- A

Case Report.
Manoj Upadhayay1, Sudhanshu Srivastava2, Sakshi Chopra3, Mansi Rajput4, *Pratim Talukdar5, Rashi Singh6
Abstract
Restoring a missing single central incisor is one of the most difficult esthetic procedures in dentistry. A space in the anterior region of
the dental arch either due to trauma, congenital missing tooth, tooth lost to decay, trauma, root fracture, failed root canal treatment, or
pathology can produce a huge amount of psychological impact on the patient. The various treatment option like implant, removable
partial denture and fixed partial denture are available. However these treatment options are not applicable in every case due to various
reasons like growth of the jaws, cost, amount of tooth reduction, and chair side time for the procedure. In some of such situation, a
resin- bonded fixed partial denture (RBFPD) such as Maryland Bridge fulfills all the requirements of an ideal interim solution.
Keywords- Missing single central incisor, Resin- bonded fixed partial denture, Maryland Bridge.
Introduction
Over the last several decades, dentistry has focused
To remove healthy tooth structure of adjacent teeth to
on more conservative treatment modalities and preventive
replace a congenitally missing tooth or a tooth lost to decay,
techniques. This has been possible not only because of
trauma, root fracture, failed root canal treatment, or pathology
improved techniques and materials, but also because of the
is a very aggressive treatment option for both patients and
understanding that tooth preparation, regardless of how
dentists. Infection in any of these situations creates an
conservative it may be, is an irreversible procedure.
environment in the hard and soft tissues that makes
It is said that restoring a missing single central incisor
regeneration procedures more difficult, thereby complicating
is one of the most difficult esthetic procedures in dentistry. A
the ability to create a natural appearance in the definitive
number of dental concerns need to be considered when
restoration
treating an anterior tooth such as shade, morphology, gingival
Today techniques and materials are available that
contours, bone levels, and occlusion. Additionally, a choice
provide the typical clinician a number of options which are
between a fixed prosthesis, removable prosthesis, and an
both professionally satisfying to the dentist and aesthetically
implant needs to be determined. Finally, in present era patient
and functionally appropriate to the patient.
is more demanding in terms of esthetics, they opt for more
1.
cost factor. A few of the disadvantages were the lack
conservative and less invasive procedures [1].
of mastication ability, and the possibility of problems
A missing tooth in the anterior region is not only a
during speaking.
physical loss, but also has a physcological impact on the

2.
patient.
1
Reader,
2,3,4
Private Dental Practitioner.
E-mail:pratyrocks18@gmail.com
* Corresponding Author
ImplantThe implant option had the advantage of

long-term stability. The disadvantages were the cost
PG Student, Department of Prosthodontics,
and the time factor before a final restoration could be
Babu Banarsi Das University, Lucknow, Uttar Pradesh, India.

*5,6
FlipperThe only advantage for the flipper was the
completed.
3.
Three-unit bridgeThe advantages for this option

included excellent stability and function. The major
CASE REPORT

disadvantage was the necessity of reducing viable
4.
After the metal try-in was successful (Fig.4) shade
tooth structure.
selection was done using a shade guide. The trial fitting of the
Maryland BridgeThe advantage for this type of
prosthesis was done. Esthetics, mastication and speech were
bridge was in the minimal reduction on the lingual of
evaluated. The laboratory technician was instructed to keep the
the abutment teeth. The given disadvantage for this
metal wings of the prosthesis off the incisal third to prevent
option was the possible debonding of the bridge.
darkening of the tooth because of the inhibition of light

transmission. In addition, care was taken to make sure metal
While a conventional three-unit fixed partial denture
would not be visible interproximally or at the embrasure areas.
is a predictable technique to replace a missing tooth, the
After isolation, the Maryland Bridge was cemented (Fig. 5,6,
invasive nature of the treatment can lead to other
7) using conventional composite resin cement. A 12-month
complications
follow-up was advised until the patient is ready to replace the
throughout
the
life
of
the
restoration.
Complications may include mechanical overload of the
bridge with a more permanent solution.
abutment teeth with weakening or fracture, risk of endodontic

treatment, periodontal problems, decay, and cement failure. If
any of these complications occurs on one of the abutment
teeth, the entire prosthesis will fail.
Discussion
For more than 50 years, dentistry has sought amore
conservative approach to replacing a single missing tooth with
This case report describes the use of resin bonded
a conventional fixed prosthesis, which involves the cutting of
fixed partial denture as a valuable treatment plan in restoring
sound tooth structure. Treatment possibilities have evolved
smile and oral functions with minimal biological cost.
from bonding a natural extracted tooth or composite resin
Case Report
restoration to the adjacent teeth, [2-4] to the Rochette bridge,
A male patient, aged 31 years presented with a
[5,6] to the maryland bridge,[79] and currently to the single-
missing upper left maxillary central incisor (21). Patient gave
implantsupported crown. It is debatable which technique is
a history of tooth lost due to trauma 2 years back. On
the most conservative, and in many instances the patients
examination it was revealed that the entire tooth was missing
preference tells the restoration of choice. The clinician must
with an edentulous area with no space loss (Fig.1). An intra
also evaluate the advantages and disadvantages of such
oral periapical radiograph was taken and the radiography
techniques in order to provide the patient with the best clinical
revealed complete root formation of the adjacent teeth (12 &
result since not all patients should be treated with the same
21).
restoration type or design.

After considering the patients wish and the clinical
With improvements in the field of adhesive dentistry,
situation, other treatment options like removable partial
resin-bonded bridgework has become a viable option for the
denture, fixed partial denture and implant were eliminated and
long-term replacement of missing teeth. One study reported a
it was decided to replace it with a Maryland bridge as an
median survival time of 7 years 10 months [10]. Possible
interim solution. Tooth preparation for both 12 and 21 was
designs include: cantilever, fixed-fixed and hybrid where one
done following the standard technique. Lingual preparation
of the retainers is conventional. A major advantage of resin-
ended 1mm from the incisal edge and a light chamfer finish
bonded prostheses is that minimal tooth preparation is required
line was prepared 1 mm supra-gingivally (Fig.2, 3) an
and so they can usually be considered a reversible procedure.
impression was made in polyether impression material and
As dentine preparation is not involved, the integrity of a young
sent to the laboratory.
pulp is maintained. Other advantages include the fact that

anaesthesia is not normally required, soft tissues are not
49
CASE REPORT

disturbed which simplifies impression procedures, and
patients conservative requirements of replacing the missing
margins are supragingival, facilitating plaque removal.
tooth, even though it required the patients compliance not to

overload the prosthesis during masticatory function and
necessitated a modified flossing technique because of the
splinted prosthesis. Resin-bonded prosthesis continued to
improve, and their evolution led to the development of the
Maryland Bridge.
In this technique, the tooth required a conservative
Fig. 1. Intra oral view of missing tooth.
preparation in the enamel only with a gingival rest to create a

definite seat. The preparation design included an interproximal
wraparound to help prevent lingual displacement and to
increase stability on a bondable surface area (enamel) with a
Fig.2 & 3. Palatal view of prepared tooth surfaces.
solid, non-perforated, metal substructure that could be as thin

as 0.2 mm. Use of a non-noble metal alloy significantly
increases the mechanical retention of the etched framework
and more easily prevents degradation of the luting resin in the
oral cavity. Care must be exercised so the framework does not
Fig.4. Metal Try In.
involve the incisal third of the abutment teeth, since this could
block translucency and result in a graying effect. While use of
a resin-bonded retainer involves a very conservative technique
and preparation of the enamel is minimal care must be
exercised to prevent occlusal overload during function
Fig.5 & 6. Cemented Restoratin Frontal and Palatal View.
Conclusion
Resin bonded bridges can be highly effective in
replacing missing teeth, restoring oral function and aesthetics
and result in high levels of patient satisfaction. They represent
a minimally invasive, cost effective and long lasting treatment
modality.
Reference
Fig.7. Extra oral view of Cemented restoration.
1.
Restoring a Missing Central Incisor. Contemporary
The Rochette bridge replaces the missing tooth
Esthetics 2007: 30-34.
without any tooth preparation, it was, at best, considered a

temporary solution, and its framework was designed with a
gold substructure and hence resulted in a thick metal
framework. Such restorations were designed with macromechanical retentions to lock the composite into the gold and
through the bonded lingual surface. This technique met the
Parker RM. An Ultraconservative Technique for
2.
Ibsen
RL.
One-appointment
technic
using
an
adhesive composite. Dent Surv 1973;49:3032.

3.
Ibsen RL. Fixed prosthetics with a natural crown

pontic using an adhesive composite: Case history. J
South Cal Dent Assoc1973;41:100102.
50
CASE REPORT

4.
Jordan RE, Suzuki M, Sills PS, Gratton DR,
6.
resin-bonded retainers. Compend Cont Educ Dent
fabricated by means of the acid-etch resin technique:
1986;7:631632.
8.
10. Djemal S, Setchell D, King P, Wickens J. Long-term
Am Dent Assoc1978;96:9941001.
survival characteristics of 832 resin-retained bridges
Rochette AL. Attachment of a splint to enamel of
and splints provided in a post-graduate teaching
lower anterior teeth. J Prosthet Dent 1973;30:418
hospital between 1978 and 1993. J Oral Rehab
423.
1999;26: 302320.
Howe DF, Denehy GE. Anterior fixed partial

dentures utilizing the acid-etch technique and a cast
7.
Rubinstein S, Jekkals V. Preparation for anterior
Gwinnett JA. Temporary fixed partial dentures

A report of 86 cases followed for up to three years. J
5.
9.
metal framework. J Prosthet Dent 1977;37:2831.

Manoj Upadhayay, Sudhanshu Srivastava, Sakshi Chopra,
Livaditis GJ, Thompson VP. Etched castings: An
Mansi Rajput, Pratim Talukdar, Rashi Singh. Resin
improved retentive mechanism for resin-bonded
Retained Prosthesis for anterior Tooth Replacement-Maryland
retainers. J Prosthet Dent 1982;47:5258.
Bridge- A Case Report. J. Dent. Peers 2014;2(2):48-51.
Simonsen R, Thompson V, Barrack G. Etched Cast

Restorations: Clinical and Laboratory Techniques.
Chicago: Quintessence, 1983.
51
CASE REPORT
Bar & Clip Retained Overdenture- A Case Report

*
Sahil Sekhri1, Shivali Goyal2, Sanjeev Mittal3
Abstract
It is more important to preserve what already exists than to replace what is missing as stated by MM De Van has never
been questioned or disagreed. Considering this the preservation of one or more teeth/roots to facilitate an overdenture has many
advantages, including preservation of alveolar bone overtime. Overdentures provide better function than conventional complete
dentures through a variety of factors, such as improved biting force chewing efficiency, and increased speed of controlled mandibular
movement. In addition, they minimize the downward and forward setting of a denture, which otherwise occurs with alveolar bone
resorption. This article presents a case report in which bar and clip retained overdenture was constructed for the patient.
Keywords overdenture, bar, clip, ridge preservation.
Introduction
It is more important to preserve what already exists
than to replace what is missing as stated by MM De Van has
never been questioned or disagreed. Considering this the
preservation of one or more teeth/roots to facilitate an
overdenture has many advantages, including preservation of
alveolar bone overtime[1]. Retaining teeth for an overdenture
is an old concept and a viable treatment modality[2-5].
Through a reduction of crown to root ratio, it is
distinctly possible that retained roots could support retentive
elements that would be used to secure a dental prosthesis.
Overdenture can be defined as a complete or partial removable
denture supported by retained roots or teeth to provide
improved support, stability, and tactile and proprioceptive
sensation and to reduce bone resorption. The clinician must
face a number of decisions when planning for over denture.
Overdentures
provide
better
function
than
conventional complete dentures through a variety of factors,
such as improved biting force chewing efficiency, and
increased speed of controlled mandibular movement[5]. In
addition, they minimize the downward and forward setting of
a denture, which otherwise occurs with alveolar bone
resorption[6].
With increasing stress on preventive prosthodontics,
the use of over dentures has reached a point where it is now a
feasible alternative to most treatment plan outlines in the
construction of prosthesis for patients with remaining teeth.
*1
P.G. Student, 2P.G. Student, 3Professor, Department of

Prosthodontics, M.M. College of Dental Sciences & Research,
Mullana, Ambala, India.
E-mail: sekhrisahil@yahoo.co.in
*
House No.427, Sec-46-A,Chandigarh-160047
Journal of Dental Peers, Vol. 2 Issue 2, July 2014
The overdenture, a complete or partial denture

prosthesis constructed over existing teeth or root structure, is
not a new concept in a technical approach to a prosthodontic
problem. Indeed its use dates back to 100 years. Overdenture
is also known as Overlay dentures, Onlay dentures, Hybrid
dentures, Superimposed dentures, Telescoped dentures,
Biologic dentures, Coping prosthesis [5-7].
Advantages
Preservation of alveolar bone.
Preservation of proprioceptive response.
A simple approach to a problem patient.
Simplicity of construction ease of obtaining accurate
records and superior denture stability
Support
Periodontal maintenance
Retention
Open palate possible
Cost effective
Ideal occlusion
Superior patient acceptance
Less trauma to supporting tissues
Conversion to complete denture
Indications
Patients with poor prognosis for complete dentures
In maxilla in cases with excessive vertical overlap
of anterior teeth
Unilateral overdenture with bone loss is excessive on
one side of the arch
Contraindications
Lack of patient acceptance
Lack of proper oral hygiene and periodontal tissue
maintenance
When other treatment modalities promise superior
results.
Cost considerations
52
CASE REPORT

Denture stability is believed widely to be related to
resistance against other forces like oblique and anteriorposterior forces. The patient's satisfaction is directly
influenced by the amount of denture retention as it has been
shown through several studies. The need for correcting the
patients problems with faulty denture is an inevitable
consequence of retention failure and residual ridge resorption.
Various methods to connect overdentures have been described.
Industrial balls and cast round or oval (e.g. Dolder bar) bar
attachments are frequently used.
Following clinical case report describes the procedure
of fabricating bar retained mandibular overdenture with a
superior retention and stability as compared to conventional
complete denture.
Fig.2 Wax pattern prepared on to the cast
Case report
An 80 year old male patient reported to Department
of Prosthodontics, M. M. college of Dental Sciences &
Research, Mullana, Ambala for replacement of missing teeth.
The patient with lower partial edentulism with intact canines,
thorough intraoral examination presented periodontally
sound mandibular canines and patient wanted to preserve his
teeth. So keeping in consideration patients needs and oral
findings it was planned to fabricate a mandibular overdenture
for the patient. An OPG (Orthopantomogram) along with
IOPAR (intra oral periapical radiograph) i.e. 33 and 43 were
taken to rule out any underlying pathology. Thorough oral
prophylaxis was performed on both upper and lower arches
before impression procedures.
Diagnostic impressions were made and
tentative jaw relation record was made to carefully evaluate
the interarch space and for occlusal considerations to aid in
further treatment planning. Considering the close proximity of
abutments and clinical condition of abutments it was decided
to provide a bar splinted mandibular overdenture. Intentional
RCTs were performed on both the canines.
Clinical Steps
1. Tooth preparation was done on abutments (33,43).
Crowns were reduced to approx. 4mm length with
uniform axial taper.
Fig.3 Casting tried on to the patients mouth
Fig.4 Denture with metallic clip
Fig.5 Nylon rider in place
Fig.6 Post-operative
2.
3.
Fig. 1 Final Impression of lower ridge

For additional retention of copings radicular means of

retention was opted and post space was prepared upto
depth of 5mm.
Border moulding of the lower ridge was done.
Impression of both the space created and the lower
ridge was taken with light body impression material
(indirect technique)(Fig 1).
53
CASE REPORT

4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
The cast was poured in die stone.

Inlay wax copings were fabricated on cast which
were connected by pre-fabricated bar; as it is known
that the splinting of two or more teeth with a bar
produces stability similar to that obtained with rigid
stud-type attachment when the overdenture is in
place.The design was similar to that of a dolder bar.
The Dolder bar is the one most often mentioned in
discussions of the bar system. (Fig 2).
The sprues were attached over copings as well over
the bar and casting was done in Ni-Cr using
conventional technique, it was finished and polished.
The casting was tried on cast and then intraorally to
check for passive fit. (Fig 3).
Jaw relation recording was done in conventional way
and a tooth set up was done which was tried in
patients mouth.
The metal rider and the spacer were placed and the
cast was blocked with type IV die stone.
Rest of the acrylization procedure is similar to
conventional complete denture, after dewaxing stage,
the metal rider clip was snapped onto the bar and
packing is done.
After curing was complete, the denture was retrieved
with metal clip picked up in denture, the denture was
finished and polished. (Fig 4).
Seating tool was used to place the nylon rider in the
metal clip which will be attached to the bar. (Fig 5).
The copings with bar attachment are cemented in
patients mouth, and the denture was delivered to
patient after checking the fit in patient. The patient
was given placement and home care instructions.
Patient was recalled for examination after 24 hrs and
was advised to get check up done every 6 months.
(Fig 6).
prognosis than would a replacement fixed partial denture, and

are more retentive stable, and functional than complete
dentures, the mandibular bar retained overdenture provides a
sense of proprioception. It also reduces torquing of the
remaining root structures because crown-root ratio is
decreased. The bar affords adequate retention without unduly
torquing the bar and canine abutments. Further, the patient can
more easily perform plaque-control procedures because access
is unimpeded. Last, the abutments are less susceptible to caries
because the cast coping covers the exposed tooth structure[6].
Conclusion
The use of teeth as over denture abutments is
beneficial to the patients. The patients strict compliance with
oral hygiene procedures and maintenance instructions will
greatly increase the long-range prognosis of the denture tooth
complex.
Source of Interest/ Conflict: None Declared
References
1.
2.
3.
4.
5.
6.
Discussion
It is well known fact that the residual ridge resorption
is an inevitable pathophysiological phenomenon. The
mandibular residual ridge resorbs almost 4 times faster than
the maxillary ridge according to the literature. It is also proven
that the bone/supporting structures around the retained teeth or
implants are maintained for a longer duration of time. It is thus
essential and well required that a clinician endeavors to
preserve the last tooth/root.
For this type of patient, mandibular overdenture are
less expensive than implant prosthodontics, have a better
7.
Crum AJ, Rooney GE, Jr. Alveolar bone loss in

overdentures: a 5 year study. J Prosthet Dent 1978;
40:610-3.
Tallgren A. Changes in adult face height due to
aging, wear, loss of teeth and prosthetic
treatment. Acta Odontol Scand. 1957;15:24.
Brill N. Adaptation and the hybrid prosthesis. J
Prosthet Dent. 1955;5:811823.
Miller PA. Complete dentures supported by natural
teeth. J Prosthet Dent.1958;8:924928.
Prince JB. Conservation of the supportive
mechanism. J Prosthet Dent.1965;19:327338.
Williamson RT. Retentive bar overdenture
fabrication with preformed castable components: A
case report. Quintessence Int 1994;25:389-94.
Dole VR, Marathe SS, Singh GS, Dable RA. Cost
effective pre-fabricated semi-precision attached
overdenture- a case report. J Evo Med Dent Sci
2012;1(6):1263-6.

Sahil Sekhri, Shivali Goyal and Sanjeev Mittal. Bar & Clip
Retained Overdenture- A Case Report. J. Dent. Peers
2014;2(2):51-53.
54
CASE REPORT
Management of failed implant using platelet rich fibrin (PRF)- A case report
Amarnath1, *Pratim Talukdar2, Nitika Sachan3, Mukut Seal4, Meghali Langthasa5
Abstract
Implant-supported restoration offers a predictable treatment for tooth replacement. Reported success rates for dental
implants are high. Nevertheless, failures that mandate immediate implant removal do occur. The consequences of implant removal
jeopardize the clinicians efforts to accomplish satisfactory function and esthetics. Appropriate use of the contemporary techniques
like PRF will enable the successful treatment of almost any complicated case with bone deficient regions of the jaw. This case
reports the step-by-step procedures in a case of failed maxillary right central incisor implant which was removed and restored by
placement of implant simultaneous with the use of bone grafting and PRF for the re-establishing predictable bone volume to
support the new implant.
Key words: Implant failure, PRF, centrifuge, predictable bone volume.
Introduction
Platelet-rich fibrin (PRF), developed in France by

for
Choukroun et al (2001), is a second-generation platelet
maximizing the healing response of the patient during
concentrate widely used to accelerate soft and hard tissue
reconstructive procedures. The search for predictable
healing. PRF is a strictly autologous fibrin matrix containing
outcomes in terms of volume of bone and implant
a large quantity of platelet and leukocyte cytokines. Platelet-
osseointegration had lead to development of many bioactive
rich fibrin (PRF) represents a new step in the platelet gel
surgical additives [1]. In 1974, platelets regenerative
therapeutic concept with simplified processing minus
potentiality was introduced, and Ross et al., [2] were first to
artificial biochemical modification[5]. Unlike other platelet
describe a growth factor from platelets. After activation of
concentrates, this technique requires neither anticoagulants
the platelets which are trapped within fibrin matrix, growth
nor bovine thrombin (nor any other gellation agent), making
factors are released and stimulate the mitogenic response in
it no more than centrifuged natural blood without
the bone periosteum during normal wound healing for repair
additives.[6,7]
Dental
surgeons
are
constantly
looking
of the bone.[3] Better understanding of physiologic

properties of platelets in wound healing since last two
decades led to increase its therapeutic applications in the
various forms showing varying results.
Case report
A 21 year old male reported to the dental clinic
with chief complaint of loosening of implant and unesthetic
Platelet-rich plasma (PRP) was proposed as a
appearance. On clinical examination, implant placed in
method of introducing concentrated growth factors PDGF,
region of 11 was found to be mobile and showed signs of
TGF-, and IGF-1 to the surgical site, enriching the natural
peri-implantitis (Fig 1). Due to implant failure, the length of
blood clot in order to expedite wound healing and stimulate
the offending prosthesis was visibly longer compared to the
bone regeneration.[4]
contra-lateral tooth. Radiograph showed considerable bone
M.D.S. Orthodontics, *2M.D.S. Prosthodontics, 3M.D.S.

Prosthodontics, 4M.D.S. Endodontics, 5M.D.S. Pedodontics.
Email: drpratimtalukdar@gmail.com
loss around the implant (Fig 2). History revealed that

implant had been placed 3 years back which progressively
became loose over the period of last six months. After
examination and history, decision was taken to remove the
Dr. Pratim Talukdar, House No. 13, Bye Lane-2,

Swahid Dilip Huzuri Path, Sarumotoria, Dispur, Guwahati781016, Assam, India.
existing implant and restore the surgical site with bone graft
mixed with platelet rich fibrin and place a new implant at the
same visit.
55
CASE REPORT
Procedure
Discussion
Before starting the surgical procedure, patient was
Dentists are often faced with implant failure that
prepared to draw 3 vials of blood to prepare PRF. It required
may occur due to multiple reasons. It is important to manage
a 24 gauge butterfly needle and 9 ml blood collection tubes.
such cases with techniques that will give predictable
For PRF preparation, whole blood was drawn into the tubes
outcomes and which are considerably less technique
without anticoagulant and immediately centrifuged using
sensitive and economical. Removal of failed implants often
laboratory centrifuge(R-8C, SRL Diagnostics) (Fig 3).
leads to large bone defects due to use of trephines. This
Within a few minutes, the absence of anticoagulant
necessitates placement of larger dimension implant which
allows activation of the majority of platelets contained in the
might not be feasible due to limited available bone. Such
sample to trigger a coagulation cascade. Fibrinogen is at first
cases require use of bone graft to restore the defect. To
concentrated in the upper part of the tube, until the effect of
maximise the benefits of grafting and to ensure good bone
the circulating thrombin transforms it into a fibrin network.
volume, PRF membranes are used.
The result is a fibrin clot containing the platelets located in
PRF is easy to obtain, less costly, and a possibly
the middle of the tube, just between the red blood cell layer
very beneficial ingredient to add to the regenerative mix.
at the bottom and acellular plasma at the top (Fig 4).
The easily applied PRF membrane acts much like a fibrin
The platelet rich fibrin also called as the snot clot
bandage,[8] serving as a matrix to accelerate the healing of
was removed from the tubes and the RBC portion was
wound edges. [9] It also provides a significant postoperative
carefully seperated. (Fig 5) PRF from one tube was kept to
protection of the surgical site and seems to accelerate the
be mixed with bone graft (Nova bone, bioactive synthetic
integration and remodeling of the grafted biomaterial. [10-
bone graft) , while the other two were placed into a PRF box
12]
which flattens the PRF into a membrane with 1mm

thickness. (Fig 6)
Release of growth factors from PRF through in

vitro studies and good results from in vivo studies has led to
Patient was then prepared for surgery. The failed
increased clinical application of PRF. It was shown that
implant that had a diameter of 3mm was removed (Fig 7);
there are better results of PRF over PRP. Dohanet al.,[13]
use of trephine drill was not necessary due to extreme
proved a slower release of growth factors from PRF than
mobility of implant. Incisions were made to expose the
PRP and observed better healing properties with PRF. It was
surgical site (Fig 8). The socket left by the extracted implant
observed and shown that the cells are able to migrate from
was curetted and all granulation tissue and socket debris
fibrin scaffold; while some authors demonstrated the PRF as
were removed. A new implant was placed in the surgical site
a supportive matrix for bone morphogenetic protein as well.
(Nobel Active , 3.0*11.5mm). The defect around the implant
There are several advantages of PRF over PRP like
was filled with bone graft mixed with PRF. After
no biochemical handling of blood, simple and cost-effective
condensing the graft around implant the PRF membrane was
process, use of bovine thrombin and anticoagulants not
delicately placed over the implant (Fig 9) and the surgical
required, favorable healing due to slow polymerization,
site, followed by flap replacement and sutures (Fig 10).
more efficient cell migration and proliferation. PRF has
Patient was recalled after 24hrs and 1 week to
supportive effect on immune system and also helps in
assess healing and then after 3months for radiographic and
hemostasis.[14,15]
clinical examination. Adequate bone was found surrounding
Conclusion
the implant and signs of osseointegration could be
Although PRF belongs to a new generation of
appreciated on the radiograph. (Fig 11) A healing period of
platelet concentrates, the biologic activity of fibrin molecule
3 months was found to be sufficient to resist a torque of 25
is enough in itself to account for significant cicatricial
N.cm applied during abutment tightening.
capacity of the PRF. The slow polymerization mode confers
56
CASE REPORT

to PRF membrane as a particularly favorable physiologic
architecture to support the healing process. This case report
demonstrates the clinically predictable outcomes obtained in
management of failed implant using PRF.
Fig. 9 & 10: After condensing the graft around implant the
PRF membrane was delicately place over the implant and
closed surgical site with sutures.
Fig. 1 & 2: Pre-operative intra-oral photograph showing

failed implant which is considerably longer than its
counterpart and Radiographic view showing severe bone
loss around the failed implant in the region of 11.
Fig. 11: 3-months post-operative radiograph showing

osseointegrated implant with adequate surrounding bone.
References
1.
Dohan DM, Choukroun J, Diss A, Dohan SL,

Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin
(PRF): A second-generation platelet concentrate.
Fig. 3 & 4: Vials of blood collected from the patient are

centrifuged and Fibrinogen concentrated in the upper part
of the tube resulting in a fibrin clot.
Part I: Technological concepts and evolution. Oral

Surg
Oral
Med
Oral
Pathol
Oral
Radiol
Endod. 2006;101:e3744.
2.
Ross R, Glomset J, Kariya B, Harker L. A plateletdependent
serum
factor
that
stimulates
the
proliferation of arterial smooth muscle cells in

vitro. Proc Natl Acad Sci U S A. 1974;71:120710.
3.
Gassling V, Douglas T, Warnke PH, Ail Y,

Wiltfang
Fig. 5 & 6: Plasma rich fibrin removed from the tubes with
RBC portion removed and PRF box, which flattens the PRF
into a membrane with 1mm thickness.
J,
Becker
ST.
Platelet-rich
fibrin
membranes as scaffolds for periosteal tissue

engineering. Clin Oral Implants Res. 2010;21:543
9.
4.
Soffer E, Ouhayoun JP, Anagnostou F. Fibrin

sealants and platelet preparations in bone and
periodontal healing. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2003; 95:521-528.
Fig. 7 & 8: Failed implant was removed and Incisions made

to expose the surgical site. A new implant was placed in the
surgical site.
5.
Dohan DM, Choukroun J, Diss A, Dohan SL,

Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin
(PRF): a second-generation platelet concentrate.
Part I: technological concepts and evolution. Oral
57
CASE REPORT

Surg Oral Med Oral Pathol Oral Radiol Endod
6.
2006; 101:e37-44.
Dohan AJJ, Mouhyi J, Gogly B. Platelet-rich fibrin
Marx RE, Carlson ER, Eichstaedt RM, Schimmele
(PRF): A second generation platelet concentrate.
SR, Strauss JE, Georgeff KR. Platelet-rich plasma:
III. Leukocyte activation: A new feature for platelet
Growth factor enhancement for bone grafts. Oral
concentrates? Oral Surg Oral Med Oral Pathol
Surg Oral Med Oral Pathol Oral Radiol Endod
Oral Radiol Endod 2006; 101:51- 55.
1998; 85(6):638-646.
7.
8.
9.
12. Dohan DM, Choukroun J, Diss A, Dohan SL,
Weibrich G, Kleis WK, Buch R, Hitzler WE,
Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin
Hafner G. The Harvest Smart PReP system versus
(PRF): A second-generation platelet concentrate.
the Friadent-Schutze platelet-rich plasma kit. Clin
Part II: Platelet-related biologic features. Oral Surg
Oral Implants Res 2003; 14:233-239.
Oral
Vence
BS,
Mandelaris
GA,
Forbes
DP.
Med
Oral
Pathol
Oral
Radiol
Endod. 2006;101:e4550.
Management of dentoalveolar ridge defects for
14. He L, Lin Y, Hu X, Zhang Y, Wu H. A
implant site development: An interdisciplinary
comparative study of platelet-rich fibrin (PRF) and
approach. Compend Cont Ed Dent 2009; 30(5):250-
platelet-rich plasma (PRP) on the effect of
262.
proliferation and differentiation of rat osteoblasts in
Gabling VLW, Ail,Y, Springer IN, Hubert N,
vitro. Oral Surg Oral Med Oral Pathol Oral Radiol
Wiltfang J. Platelet-rich Plasma and Platelet-rich
Endod. 2009;108:70713.
fibrin in human cell culture. Oral Surg Oral Med

Oral Pathol Oral Radiol Endod 2009; 108:48-55.
10. Choukroun J, Adda F, Schoeffler C, Vervelle A.
15. Vinazzer H. Fibrin sealing: Physiologic and

biochemical
background. Fac
Plast
Surg. 1985;2:2915.
Une opportunit en paro-implantologie: le PRF.

Implantodontie 2001; 42:55-62.
Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin
(PRF): a second-generation platelet concentrate.

Amarnath, Pratim Talukdar, Nitika Sachan, Mukut
Seal, Meghali Langthasa. Management of failed
implant using platelet rich fibrin (PRF)- A case report.
J. Dent. Peers 2014;2(2):54-58.
Part II: platelet-related biologic features. Oral Surg

Oral Med Oral Pathol Oral Radiol Endod 2006;
10145-50.
58
CASE REPORT
Management of Partial Edentulism with Flexible Dentures- A Case Series

*
Reeta Jain1, Gyan Chand2, Deepika3

Abstract
The fabrication of prosthesis for partially edentulous arches creates a challenge when soft tissue and bony undercuts, interferences,
multiple paths of placement, tilted teeth and deranged occlusion are present to complicate the treatment plan. Flexible dentures are the
best treatment options to treat partial edentulous conditions. These case reports describe the management of partially edentulous
conditions with flexible partial dentures rather than with cast partial dentures.
Key words: Thermoplastic Resin FRS Lucitone, Injection System, Flexible Denture, Acrylic clasps.
Introduction
This material generally replaces the metal, and the
Restoration of esthetics is an important factor to
pink acrylic denture material used to build the framework for
consider in the fabrication of a removable partial denture
standard removable partial dentures. Flexible partials blend in
(RPD). Several types of polymers and metal alloys have been
well with the natural appearance of your gums, making the
used in RPD construction. Frequently, RPD clasps made from
partial virtually invisible. The plastic has almost a chameleon
the same alloy as the metal framework. The most common
effect; it is so strong that the partial dentures can be made very
alloys used for clasps are cobalt-chromium (Co-Cr) alloy and
thin and also picks up the characteristics of the underlying
gold and titanium alloys; although these may be unaesthetic
tissue. This article presents cases of partially edentulous
[1]. Thermoplastic materials for dental prostheses were first
patients who are successfully treated with pressure injected
introduced to dentistry in the 1950s. These materials were
FRS Lucitone flexible removable partial dentures.
similar grades of Polyamides (nylon plastics). It is reported

that these materials have a sufficiently high resilience and
modulus of elasticity to allow its use in the manufacture of
Case Report- 1
A
healthy
58-year-old
man
was
reported
in
retentive clasps, connectors, and support elements for
department of prosthodontics, with chief complaints of
removable partial dentures [2, 3].
difficulty of eating food and poor appearance. Clinical
FRS Lucitone is a pressure injected, flexible denture
Examination of the patient revealed 5 missing maxillary teeth
base resin that is ideal for partial dentures and unilateral
11, 16, 17, 26, 27 and 4 missing mandibular teeth 34, 37, 46,
restorations.
47 (Fig.1, 2). As the maxillary and mandibular teeth were
*1Professor and Head, Department of Prosthodontics,

Crown and Bridge Including Implantology, 2Sr. lecturer,
Department of Oral and Maxillofacial surgery, 3Sr. lecturer,
Department of Prosthodontics, Crown and Bridge Including
Implantology, Genesis Institute of Dental Sciences and
Research, Ferozepur, (Punjab).
E-Mail:- rtjn132@gmail.com
*
55/6, Gandhi Nagar, Jind (Haryana)
periodontally sound and caries free, they were retained. The

planned treatment was placement of a maxillary and a
mandibular flexible removable partial denture (RPD).
With the aim of maximizing the border seal to ensure
retention, the decision was made to incorporate flexible
flanges in the undercut region using resilient FRS lucitone
material to allow optimal height (extension) and thickness
(width) of the denture flange. The denture flange was designed
to fill the entire available vestibular space. Preliminary
impressions were made in alginate, the model poured.
59
CASE REPORT

Secondary impressions were made with dual impression
technique. Bite registration and try-in was done. FRS Lucitone
Case Report- 2
A
healthy
53-year-old
man
was
referred
to
uses the Retento Grip tissue bearing technique for retention.
department of prosthodontics from oral medicine department.
No tooth or tissue preparation is needed. After designing the
Intraoral examination of the patient revealed 7 remaining
case on the master model, placing all necessary relief and
maxillary and 7 mandibular teeth (Fig. 6, 7). Missing teeth
blocking in wax, sprue was attached as straight as possible.
were 11, 14, 16, 17, 21, 22, 25, 26, 34, 35, 36, 37, 45, 46, 47.
After investing and washing out, the teeth were prepared for
As the maxillary and mandibular teeth were periodontally
mechanical retention. The FRS lucitone resin was injected into
sound and caries free, they were retained. The planned
a closed flask using success injection system (Dentsply).
treatment was placement of a maxillary and a mandibular
After the case is deflasked, it is finished and fit on the

master model, polished, and placed in water. The partials were
flexible removable partial denture (RPD). Similar procedure

was followed as in Case 1 (Fig. 8, 9, 10).
left in the hot water for about one minute. The hot water
treatment permits a very smooth initial insertion and a good
adaptation with the natural tissues in the mouth. If the patient
senses any discomfort because of tightness of a clasp, the clasp
may be loosened slightly by immersing that area of the partial
in hot water and bending the clasp outward. Like any
removable prosthesis, the patient was instructed to utilize good
Fig. 6 & 7. Front and Intraoral pre-operative
hygienic practices to maintain the appearance and cleanliness

of the FRS Lucitone restoration (Fig. 3, 4, 5).
Fig. 8: Flexible maxillary and mandibular prosthesis

Fig. 1 & 2. Front and Intraoral pre-operative view
Fig. 9 & 10. Front and Intraoral post-operative view

Fig. 3. Flexible maxillary and mandibular prosthesis
Discussion
Thermoplastic resins have been used in dentistry for
over 50 years. During that time the applications have
continued to grow, and the interest in these materials of both
the profession and the public has increased. The materials
Fig. 4 & 5. Front and Intraoral post-operative view
60
CASE REPORT

have superior properties and characteristics and provide
dentures in appropriate situations in order to obtain a
excellent esthetic and biocompatible treatment options. With
successful treatment outcome.
the development of new properties, elastomers and copolymer

alloys, there are certain to be additional new applications for
thermoplastic resins in the future, to help patients with

damaged or missing teeth [4].
Retentive clasp arms must be capable of flexing and
returning to their original form and should retain an RPD
References
1.
cobalt chromium, titanium, and gold alloy cast
satisfactorily. The tooth should not be unduly stressed or

permanently distorted during service and should provide
esthetic results [5]. The clinical experience of loss of retention
denture clasp. J Prosthet Dent 1995;74:412-21.

2.
insertion and removal of the denture fatigues the clasp. The
denture clasps. J Prosthodont 1999;8:188-95.

3.
denture.
Mater 1994;17:125-9.
4.
dentures. Indian Journal Of Dental Advancements
make the denture softer and tissue compatible. They do not

superior removable dentures with full functionality and
2009;1(1):60-2.
5.
the principle causes of allergic reactions in conventional
alloy cast clasps. Int J Prosthodont 1997;10:547-52.

6.
Due to their ability of excellent mould ability,
Prashanti E, Jain N, Shenoy VK. Flexible denture - A

flexible option to treat edentulous patient. J of Nepal
denture materials [7].
Conclusion
Kotake M, Wakabayashi N, Ai M, Yoneyama T,

Hamanaka H. Fatigue resistance of titanium-nickel
comfort [6]. Complete biocompatibility is also achieved

because the material is free of monomer and metal, these being
Chittaranjan B, Aswini Kumar Kar. Management of a

case of partial edentulism with esthetic flexible
Flexible dentures absorb small amounts of water to

warp or become brittle. These dentures stand aesthetically
Fitton JS, Davies EH, Howlett JA, Pearson GJ. The

physical properties of a polyacetal denture resin. Clin
rationale for using flexible flanges and clasp was to aid

retention by ensuring seal around the entire border of the
Turner JW, Radford DR, Sherriff M. Flexural

properties and surface finishing of acetal resin
of the RPD after the prosthesis is worn for some time raises
the question of whether constant deflection of the clasp during
Vallittu PK, Kekkonen M. Deflection fatigue of
Dental Association 2010;11(1): 85-7.

7.
Shamnur SN, Jagdish KN, Kalavathi K. Flexible

Dentures - An alternate for rigid dentures? Journal of
Dental Sciences and Research 2010;1(1):74-9.
lightweight to density ratio and high thermal strength,

thermoplastic materials have occupied an envious place for
making complete and partial dentures. However careful case
selection and clinical judgment is required to use flexible

Reeta Jain, Gyan Chand and Deepika. Management of
Partial Edentulism with Flexible Dentures- A Case Series. J.
Dent. Peers 2014;2(2):59-61.
61
REVIEW
Lasers - Changing Perception and Attitude of Pediatric Dentistry

*
Neetika Singh1, Rohit Thakur2, Nagender Chauhan3, Marisha Kaul4
Abstract
Past several years have witnessed emergence of lasers entering the field of dentistry. Some of the first reports of their use
invitro date to late 1960s. With laser technology, clinical experience has become beneficial for treatment of children than with
conventional methods, as it eliminates need of high-speed drill along with its noise and vibration, prevents hemorrhage by sealing
blood vessels, providing excellent visibility and reducing operating time. Children and adolescents are best candidates as they are
bothered by pain, bleeding, incapacitation and need for office visits for extensive post-operative activities. Although presently the use
of lasers in dentistry is not as widespread, its use will continue to gain support as more knowledge is gained about its advantages over
the drill. It will only be a matter of time before it becomes the new standard of care in dentistry. There is no doubt that fear of the
infection and pain keeps most patients dreading the dentist. Therefore this is a valuable instrument to provide patients with a satisfying
experience, thus changing the perception and attitude many have of dentistry.
Key words: Lasers, Micro dentistry, Children, Pediatric Dentistry

Introduction
(1977)[4] suggested that pulp was more resistant to injury by
Over the years, the use of medical lasers have
Nd laser than by the ruby laser. Wigdor H et al (1993)[5]
become so wide spread that it has grown to be the standard of
concluded that Er:YAG laser has lesser thermal effect as
care for a vast variety of medical procedures that were once
compared to CO2 and Er:YAG lasers. Moshonov J et al
performed with scalpels. Similarly with the advent of new
(1995)[6] stated mean cleanliness in non-lased specimens was
technological advances in dentistry the drill can also now be
approximately 9% and in laser treated it reduced to 2%.Visuri
replaced by the laser, introducing a new philosophy in
SR et al (1996)[7] concluded that laser preparation leaves a
dentistry called microdentistry[1]. This development in
suitable surface for strong bond than the standard dental bur.
laser dentistry has led to an increasing acceptance of this
Baggett FJ et al (1999)[8] stated that Nd:YAG laser removes
technology by both practitioners and general public[2].
soft tissue by photoablative reaction with resultant coagulation
Review of Literature
and haemostasis. Medeiros F et al (2005)[9] evaluated
Taylor R (1965)[3] stated that with 55 joules beam,

pulp tissue of incisors were destroyed, cavitation was
produced in enamel and dentine, and enamel adjacent to
cavitation appeared to be fused so that rod structure was no
longer apparent as compared to 35 joules beam. Adrian JC
*1
Senior Lecturer, Institute of Dental Studies and

Technology, Meerut, Uttar Pradesh, India., 2Dental Officer,
Military Dental Centre (MDC), Meerut., 3M.D.S.,
Prosthodontics and Crown & Bridge., 4M.D.S., Orthodontics
and Dentofacial Orthopedics.
E-mail: neetika.jasrotia@gmail.com
*
H.No 634, Sector 37, Noida, Uttar Pradesh, India.
performance of DIAGNOdent for detection and quantification

of smooth surface caries in primary teeth. Radatti D et al
(2006)[10] stated that lased canals had significantly more
debris than rotary instrumentation. DeMoor R and Delme K
(2009)[11] concluded that erbium lasers (Er:YAG and Er,
Cr:YSGG) are most efficient and with right parameters as the
thermal side effects are small.
Components of A Typical Laser [12] (Fig 1)
1. Active medium
It may be solid, liquid or gas (argon and CO2). The
remainders are solid-state semiconductor wafers of metals
such as gallium, aluminum, indium, and arsenic[3]. Itis
62
REVIEW

positioned within laser cavity with mirrors co-axially
photons of identical wavelength. This was postulated by
positioned at each end and surrounded by pumping mechanism.
Einstein as stimulated emission[12]. Also as pumping from
2. Pumping mechanism
energy source continues, number of excited electron in
It is usually a light source, diode laser unit or
medium exceeds number in ground state. This is called
electromagnetic coil. Energy from this primary source is
population inversion.
absorbed by the active medium, resulting in the production of
Radiation
Light produced by the laser as a specific form of
laser light[12].
electromagnetic energy can be related to Radiation. This
3. Optical resonator
Laser light produced by the stimulated active
medium is bounced back and forth through the axis of the laser
electromagnetic spectrum is the bundle of wave energy with

different wavelengths[15].
cavity, using two mirrors placed at either end, thus amplifying

the power. The distal mirror is reflective and proximal mirror
Laser Delivery System
is partly transmissive[12].
Depending upon the wavelength, they may be quartz
4. Delivery system
fibre-optic or flexible hollow waveguide or an articulated arm
It can be quartz fibre-optic, a flexible hollow

waveguide, an articulated arm (incorporating mirrors), or
or a hand piece.
LASER EMISSION MODES
hand-piece containing laser unit (at present only for low
The primary one is continuous wave means beam is
powered lasers) (Fig 2)[13-14].
emitted at one power level. The second one is gated pulse
5. Cooling system
mode; means there are alterations in laser energy that
It represents bulkiest component. Co-axial coolant
resembles to blinking light. Gated pulse mode is used in
systems may be air- or water-assisted[12].
surgical devices[17]. The third mode is free running pulsed
6. Control panel
mode or true-pulsed mode. This mode emits large amount of
This allows variation in power output with time.
Properties of Laser
laser energy for short time and then followed by an application

of energy for a long time during which device is off[17].
Light
Laser light is one specific color, with a unique
property called monochromacity (single wavelength). In
CLASSIFICATION OF LASERS (Table 1)

Classification of laser:[18]
I. According to the wavelength
dental applications, this color may be visible or invisible. It

possesses
three
additional
characteristics:
collimation
(constant size and shape of beam emitted from laser cavity),

coherency (light waves produced are all equal i.e. peaks and
valleys are equivalent), and efficiency (clinically useful
1.
UV range 140 to 400 nm
2.
VS range 400 to 700 nm
3.
IR range more than 700 nm

II. According to strength
feature)[15].
Amplification
1.
Active medium amplifies the beam by process of
i. CO2 lasers
stimulated emission[16].
ii. YAG lasers
Stimulated emission
If an already energized atom is bombarded with a
second photon, this will result in the emission of two, coherent
Hard laser (for surgical work)
iii. Argon laser

2.
Soft laser (for biostimulation and analgesia)
63
REVIEW

2. Maintaining Pulpal Vitality after Trauma
i. He-Ne lasers
In young patients, placing 808-nm probe over the root
ii. Diode lasers

III.
may prevent the tooth from devitalizing[21]. Laser is placed
According to transmission system
for a period of 1 minute on facial root area and 1 minute on

1.
Glass fiber systems CO2 lasers
2.
Mirror system - Nd:YAG lasers, Argon lasers, He-Ne
lingual or palatal root area[20].

3. Healing of Soft Tissue Trauma
lasers, Diod, Q- switched Nd:YAG lasers
Patients benefit from placing laser/light-emitting
3.
Both glass fiber and mirror system
diode (LED) unit over area for approximately 3 minutes and
4.
Pulsed excimer laser
placing the 660- or 808-nm probe over the most injured area
for 1 to 2 minutes, helping to heal the lesions more quickly
I. APPLICATIONS OF LASERS IN PEDIATRIC

DENTISTRY
Commercially DIAGNO dent or DD (KaVo America,
Lake Zurich, III), a device, for detecting caries, using laser
fluorescence, has been growing in popularity. This device
emits a light ( = 655 nm) that is absorbed by dental substance
and is partially re-emitted as near-infrared fluorescent light.
The system collects this fluorescence and provides quantitative
measures of caries lesions on a scale from 0 to 99. Deeper
caries lesions present higher values[9]. The dental lasers
(DIAGNOdent) can also be used to detect caries at the
of
4. Controlling Gag Reflex

Using 3 J to 4 J of energy with 660-nm probe placed
1). Diagnosis
margins
and with less post trauma discomfort[21].
amalgam
and
resin-based
composite
restorations[19].
2). Soft-Tissue Procedures
A). Photobiostimulation laser treatments/Therapeutic laser
therapy
Lasers of shorter wavelengths are used to produce
biostimulation and analgesic effects.
1. Pulpal Analgesia
In selected patients, using 660-nm laser probe on
occlusal surface for 1-2 minutes can achieve adequate pulpal
analgesia[20]. Success in primary molars varies from 50% to
75%. Things such as pigmentation of the patients gingival
tissue may affect analgesia effect, because the diode may react
with the pigment in tissue rather than be absorbed by pulpal
tissue.
over the P-6 acupuncture point (1 inch above wrist crease) on

each wrist for 1-2 minutes may prevent the gag from
occurring[22,23].
5. Treatment of Herpetic Type Lesions
Placing the laser/LED unit in mode 3 for 3 minutes
and the 880-nm probe for 1 minute over large lesions reduces
the discomfort and disease outbreak period in many children.
More than one treatment over a 24- to 48-hour period may be
needed to treat the lesions.
6. Orthodontic and Temporomandibular Joint Discomfort
Laser/ LED unit over area for 3 minutes using mode
3 is used. More than one treatment over a 24- to 48-hour
period may be needed to reduce the discomfort[24,25].
7. Pretreatment of Surgical Sites
Pretreating a surgical site using 660-nm laser for 1
minute
may
reduce
postoperative
hemorrhage
and
discomfort[20].
B).
Photothermal
laser
treatments
(Erbium:YAG,
Erbium:Cr; YSGG, And Diode)

Treatment of soft tissue procedures are completed
using the Erbium:YAG laser (2940 nm) where complete
hemostatis is not required or Diodent (810 nm) diode laser.
Diodes in the 810- to 980-nm range are excellent lasers for
treatment where hemostasis is an absolute necessity.
64
REVIEW

Table 1. Classification of lasers according to hazards
CLASS
I
RISK
Fully enclosed system
EXAMPLE
Nd:YAG laser welding system in laboratory
II
Visible low power laser protected by blink

reflex
Visible red aiming beam of surgical laser
IIIa
Visible laser over 1 milliwatt
No dental example
IIIb
Higher power laser unit (0.5 watts) which

may or may not be visible. Direct viewing
hazardous to eye
Low power (50 milliwatt) diode laser used for biostimulation
Damage to eye and skin possible. Direct

and indirect viewing hazardous to eyes
All lasers used for oral surgery, whitening and cavity

preparation
IV
Table 2. Laser wavelength and its possible application in periodontics[26]

Er:YAG
2940 nm
Calculus removal
Periodontal
pocket
disinfection
Photoactivated
dye
disinfection of pockets
De epithelialisation to
assist regeneration
1.
2.
9.
Er,Cr:
YSSG
2780
nm
Argon
488,
515 nm
Diode
810980 nm
Nd:YAG
1064 nm
3.
4.
5.
6.
He-Ne
633 nm
Diode
635,670,
830 nm
7.
8.
10.
CO2
10600
nm
11.
Table 3. Laser wavelength and its possible application in endodontics[30]
Lasers
Procedures
Diode (810-980 nm)
Desensitization, pulp capping, root canal disinfection
Nd:YAG (1064nm)
Desensitization, pulp capping, pulpectomy, root canal cleaning and

disinfection
Er,Cr:YSGG
Access cavity preparation, root canal shaping, cleaning and disinfection
(2780nm)
Er:YAG (2940nm)
Access cavity preparation, pulpectomy, root canal shaping, cleaning and

disinfection
CO2 (10600nm)
Desensitization, pulp capping, pulpectomy
65
REVIEW

Table 4. Laser wave length and its application in surgical procedures[26]
Minor
soft
tissue surgery
Major
soft
tissue surgery
Surgical
treatment of
large vascular
treatment
Bone cutting
Implant
exposure
Er:YAG
2940 nm
Least
hemostatic
12.
Er,Cr:YSSG
2780 nm
CO2
10600
nm
KTP
532
nm
13.
14.
15.
Diode
810-980
nm
Argon
488, 515
nm
Nd:YAG
1064 nm
Most hemostatic
16.
17.
18.
19.
20.
22.
21.
23.
24.
Fig. 3. Gingival recontouring in orthodontic patients.

a. Preoperative b. One week postoperative.
Fig. 1. Various components of lasers
b
Fig. 4. Clinical steps of LANAP
Fig. 2. Examples of different laser delivery systems, showing

quartz fibre (a), articulated arm (b) and hollow waveguide (c,
d)
66
REVIEW

1. Pulp capping
An energy level of 1 W at 0.1-second exposure time
with 1-second pulse intervals was applied until exposed pulps
were completely sealed. They were then dressed with calcium
c
Fig. 5. Treatment of ankyloglossia.
hydroxide (Kerr Life; Kerr Corp., Orange, California). In

control group, pulps were capped with calcium hydroxide only.
Symptoms and vitality were examined after 1 week and
II. PERIODONTAL THERAPIES (Table 2)
monthly for 1 year: 89% of the experimental group had no
1. Photo activated dye disinfection using lasers
symptoms and responded normally to vitality tests versus only
The PAD technique uses low power (100 milliwatt)

visible red semiconductor diode lasers and tolonium chloride
68% of the control group[30].

2. Pulpotomy
(toluidine blue) dye. It is effective for killing bacteria in
Treatment consists of placing erbium laser (30 HZ,
complex biofilms, such as Gram positive, Gram negative
55 mJ for 15 seconds) tip into coronal portion of tooth.
bacteria,
Pulpotomy is completed by placing ZOE cement into
fungi
and
viruses.
Its
applications
include
disinfection of root canals, periodontal pockets, deep carious
chamber[27,20].
lesions, and sites of peri-implantitis[26].
3. Pulpectomy
2. Gingival recontouring and gingivectomies in orthodontic
Er:YAG laser at 8 Hz and 2 W is used to prepare root
patients; Dilantin hyperplasia and crown lengthening in
canals. Tip slides from apical portion to coronal portion, while
caries preparations
pressing laser tip to root canal wall under water spray. When
The erbium settings are 20 to 30 Hz and 55 to 80 mJ,
laser fiber is unable to be inserted into root canals, it should be
with no water spray. Fig 3 a,b shows removal of hyperplastic
performed after carrying out usual root canal preparation using
tissue during orthodontic treatment and 1-week postoperative
reamers and files[31].
healing[20].
4. Sterilization of root canals
3. Lasers can be used to treatment of pericoronal problems in
CO2 and Nd:YAG lasers is used. The latter is more
erupting teeth[27].
popular because a thin fiber-optic delivery system for entering
4. Laser assisted new attachment procedure (LANAP)
into narrow root canals is available with it. All lasers have
It removes diseased and necrotic tissue selectively

-6
from periodontal sulcus. It utilizes free-running (10 seconds)

pulsed Nd:YAG laser (Fig 4)[28].
5. Laser assisted subgingival curettage
Fiber optic tip is inserted perpendicularly into pocket
bactericidal effect[32].
5. Apicectomy
Er:YAG laser gave excellent result with smooth,
cleaned resected root surfaces, devoid of charring. It resulted
in improved healing and less postoperative discomfort[30].
depth and moved around tooth, from depth of pocket toward

gingival margin at 3 6 W and a repetition rate of 15 30
IV. ORAL SURGICAL PROCEDURE
Hz[29].
The surgical procedures include (Table 4):

1. Exposure of teeth for orthodontic care
III. ENDODONTIC PROCEDURES
Er:YAG 30 Hz, 45 mJ; Er,Cr:YSGG 20 Hz, 70 mJ;
There are a number of endodontic procedures, which include
both in contact and non-contact mode can remove soft tissue
(Table 3):
and bone. Topical anesthetic, such as EMLA should be

applied33.
67
REVIEW

II). Environmental hazards
2. Removal of lesions and biopsies

Fibrotic lesions, gingival growths, mucoceles, and
The main environmental hazard is fire. The most
other non-hemangioma type lesions can be quickly and safely
recent review of laser hazards reported an overall 7.3%
removed using Erbium laser from 15 to 45 Hz and 55 mJ.
incidence of fire-related events. Of particular, is the risk of
Diode settings using the 400 um fiber are 1.0 to 1.5W
CO2 laser-induced fire in the presence of oxygen[36].
CW.HIV positive patients are at high risk of post-operative
III). Macrobiologic hazards
bleeding due to thrombocytopenia, liver involvement or
A. Eye: The primary human hazard is ocular injury. It
coagulation abnormalities, lasers cauterize and coagulate as it
accounts for almost 75% of laser accidents. Superficial corneal
cuts the tissue. Its anti-bacterial effect destroys bacteria at
epithelium damage is quickly repaired, but corneal scarring
surgical site and there are less chances of biopsy wound
from deeper laser exposure can result in loss vision[36].
becoming contaminated.
B. Skin: Rockwell (1977) reported an incidence rate of
3. Treatment of aphthous ulcers and herpetic lesions
13.9% for skin injuries and accidental exposures. Thermal
Er:YAG or Diode laser are used in low power
injury can result in various degrees of erythema, blistering or
settings (15 Hz and 35 mJ), and is directed at target tissue in a
ulceration[36].
noncontact fashion[34]. The advantage of lasers over systemic
IV). Microbiologic hazards
pharmacological
intervention
includes
avoidance
of
A. Pulmonary risks: There are high chances of viral
deleterious interaction with other medications and side effects
transmission to surgeon, dental assistant and others present in
of medication themselves[35].
operatory[35].
4. Treatment of ankyloglossia
B. Infections: Laser cutting with CO2 and erbium
A diode laser or Erbium family of lasers (30 Hz and
system has been found to transport yeasts and bacteria from
55 mJ) significantly reduces postoperative discomfort, and
surface to the depths of laser-formed craters. Er:YAG laser
sutures may not be required in some cases, especially in
vapors have shown to contain infectious viral genes, infectious
infants and toddlers[20]. It takes approximately 15 to 30
virus and viable cells[36].
seconds to complete and suture can be placed to prevent

reattachment (Fig 5)[20].
Safety Precautions While Using Lasers
5. Treatment of maxillary frenum in infants and in mixed
1.
dentition
depressor to confirm spot size, influence and pattern
Optimal results occur when it is completed between 8

and 18 months of age. In infants, no sedation is usually
aimed at intended location[36].

2.
required. The lasers settings are: Er:YAG 30 Hz, 50 mJ;

Er,Cr:YSGG 20 Hz, 50 mJ, both with no water. Laser energy
Before treating patient, test laser settings on tongue
Maintaining laser in standby mode when not in

use[36].
3.
Patient, surgeon and other personnels in the operatory
is directed at insertion of frenum and area between two front
should
teeth. Sutures are not required.
(Stefanovsky
Lasers Hazards
better[36].
Laser hazards can be divided into following categories:
4.
It is mainly electric shock. Issues of appropriate laser

safeguards should be addressed[36].
sundry
corneal
protector).
eye
Metallic
protectors.
shields
are
Moistened towels around patients head and neck and

gauze placed intraorally absorbs CO2 laser light and
I). Mechanical hazards

installation, grounding, automatic shutoff features and other
wear
significantly decrease chance of burn[36].

5.
Explosive or inflammable gases and liquids should

not be used near laser beam[37].
68
REVIEW

6.
7.
Smoke/plume evacuation and filtering system should
soft tissue surgery. This development of technology may
be used, which is 98.6% efficient when suction tip is
provide superior results over conventional methods and may
placed 1 cm from the treatment site[36].
help clinician to carry out procedures, which may not be
A sign Laser Surgery in Progress should be affixed
possible with routine therapy with good results.
to the door of operating room[37].
Laser Regulatory Agencies

In addition to various state governments, the United
States has four major organizations that are concerned with
regulations regarding the safety of laser systems:
1.
American National Standards Institute (ANSI)
2.
Food and Drug Administration (FDA) and its

regulatory bureau.
3.
Centre for Devices and Radiological Health (CDRH)
4.
Occupational Safety and Health Administration

(OSHA).
OSHA regulates workplaces for employee safety. The
Conclusion
From the vast literature on lasers, it is understood that
it is not only important to realize the various potential uses but
also the necessity to select proper wavelength, understand
laser tissue interactions and not over enthusiastically jump into
laser dentistry before science properly supports it.
However, with evidence based dentistry and ongoing
research work in the field of laser science, laser might replace
the conventional therapy over the coming years. This library
dissertation was an attempt to highlight the basic scientific and
clinical research on lasers in dentistry with special emphasis
on applications in field of Pediatric Dentistry.
office or surgical location must have written policies of the

standard operating procedures that take into account the laser
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p-ISSN No.

Journal of Dental Peers

A Dental Journal for All

Vol.2, Issue 2, April-June 2014

Journal of Dental Peers. All rights reserved.

pISSN NO. 2348-1870

Journal of Dental Peers 2013. All Rights Reserved.

JOURNAL OF DENTAL PEERS

52 Bar & Clip Retained Overdenture- A Case Report

59 Management of Partial Edentulism with Flexible Dentures- A Case Series

Evaluation of the Extent of Facial Asymmetry in Aesthetically Symmetric

Keywords: Facial asymmetry, Symmetry, aesthetics.

Minor asymmetries of the face are a common finding

Asymmetry is defined as being present when one or

in normal individuals [1,3] although they are rarely evident

more of the facial or cranial bilateral components (bone or soft

and generally pass unnoticed [2,4]. Asymmetry becomes

important when it affects function, aesthetics or social

of each of the unpaired structures does not lie on that line[1].

acceptance of an individual. A more precise method to

Asymmetry of the face is one of the more difficult problems

measure asymmetry is to use radiographs of the subjects.

with which orthodontists have to contend and which often

Asymmetry of the craniofacial bones can be quantified only

present serious diagnostic difficulties [2]. The recognition of

through X-ray techniques. In the lateral cephalometric film,

the actual site of asymmetry is essential for correct treatment

vertical asymmetries are often recognized by the failure of

bilaterally symmetric objects to superimpose, as they normally

will. An additional dimension can be added to the radiographic

acquired as well as in congenital abnormalities, usually

examination by panoramic films, which are useful when the

involve both soft and hard tissues.

sections of mandible are deformed. Sub-mental vertex view is

Post-Graduate Student, 2Professor & Head, 3Reader,

also useful when the mandibular ramus is severely deformed.

Journal of Dental Peers, Vol. 2. Issue 2, July 2014

in millimeters. The difference between each pair of

research on asymmetries. The present article aims to assess the

measurements was also recorded in millimeters as left side

nature of asymmetry in aesthetically pleasing faces in

minus right side; in this way sidedness in facial asymmetry

Bilaspur, Chhattisgarh population using Postero-Anterior (PA)

could be evaluated. The total width between the bilateral

landmarks (sum of left and right side) was calculated.

Materials And Methods

used to compute the mean absolute asymmetry for each of the

dimensions studied. Separate computation was made to test for

sampling was executed for the sample selection. All the

left or right side dominance within the sample. Positive (+)

subjects were taken from the daily out patients of the

Department of Oral Medicine and Radiology, and the

were used to indicate sidedness. The data collected from the

Department of Orthodontics and Dentofacial Orthopedics,

New Horizon Dental College and Hospital, Bilaspur,

perform the statistical analysis. Mean absolute value, Standard

Chhattisgarh, India. All the subjects selected had clinically

Deviation (SD) and absolute value of the left and right

difference (d) was calculated. To find the differences between

complement of teeth. They had no history of orthodontic