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In this Issue:
History of dentistry - Dr.Rasha Seragelden Miswak beneficial for dental health, study finds - News Report
Now you can hear
Dental Caries - News Report Editorial : Dear Fellow Dentist, Its been a long journey and now we are 2 years old. This is the special anniversar edition where in I have selected some of the best articles published in the last 12 months. Your Dental Follicle now reaches more than 60k Dentists across the globe.Olny your cooperation and support will help us make Dental Follicle a better Journal.Please do write your comments/send us your cases/artiles which you feel are good to share with the global dental fraternity . I have recieved frequent mails that some subscribers are not getting Dental follicle in mail box. Please do the following in this case 1. Join DentistryUnited on yahoo groups. 2. Add Info@dentistryunited.com / dentistryunited@gmail.com to your friends list in mail box settings Yours truly Dr. Syed Nabeel Editor of Dental Follicle & WebMaster www.DentistryUnited.com Subscribe Dental Follicle here News :
Laughter - The Best Medicine :
Man: "Darling, your teeth remind me of the stars"
Usage of nanocrystalline Hydroxylapatite in paste form to preserve post–extractive sites. A one–case report.
DMD, DDS, private practice in Castelletto Ticino (NO) Italy Via G.Barberis 1 28053 Castelletto Ticino (NO) Italy Tel. +39–0331–973311 Fax +39–0331–971729
ABSTRACT This article proposes a technique to preserve post–extractive sites in order to simplify prosthetically-guided insertion of osseointegrated dental implants. KEY WORDS Nanocrystalline hydroxylapatite, dental implants, extraction sockets, bone regeneration. INTRODUCTION The healing process following tooth extraction often leads to a partial filling of the empty socket1,2, together with 3–4mm ridge resorption both in transversal and vertical direction1,3. The result of these processes is a narrow and reduced ridge, with inadequate bone volume to support soft tissue or to permit implant placement in an ideal position. Applying GBR principles to post–extractive sockets significantly reduces the amount of bone resorption3. To make GBR effective, it is mandatory to obtain and maintain soft tissue coverage over the augmented site4,5 by elevating and advancing a wide mucoperiosteal flap. This inevitably leads to a modification of normal mucoginigival anatomy of the augmented site, with a subsequent esthetic alteration. Full thickness flap elevation interrupts periosteal vascularization of buccal bony plate, thus inducing a partial resorption. Recently a technique to preserve post–extractive site was propose (Bio–Col technique, Sclar 20036). The tooth has to be extracted without causing trauma to the neighboring tissue, the empty socket has to be filled with bovine bone mineral — a slow–resorbing osteconductive material — and the site has to be sealed with resorbable collagen sponge and cyanoacrylate. This combination, according to the Author, leads to a good re generation of alveolar bone, without the problems caused by the need to obtain primary wound closure. One big problem with this technique is the long resorbtion time of bovine Hydroxylapatite. Nanocrystalline hydroxylapatite in paste form (Ostim®, Heraeus–Kulzer GmbH, Hanau, Germania) is a pure, unsintered hydroxylapatite material, made of crystals of hydroxylapatite (average dimension 18 μm) in 35% water suspension. The nanocrystalline structure of the biomaterial allows a quick vascularization of the graft, with a wide contact surface between the graft and the osteoblasts (106 m2/g, vs 50–90 m2/g of bovine bone mineral). This characteristic makes hydroxylapatite in paste form a very quick resorbing biomaterial. A recent animal study reports a 53,9% average percentage of mineralization of a defect filled with Ostim® at 12 weeks; this data is not statistically different from the percentage of mineralization of a similar defect filled with autogenous bone7. Another characteristic of nanocrystalline hydroxylapatite in paste form is its complete radiolucency, which allows for a radiographical evaluation of bone regeneration process.
CASE REPORT A 37 years old, Caucasian male man presented at my office requesting the substitution of the ill–fitting gold–acrylic veneer crown on tooth 2.4. Radiological examination (Fig. 1) revealed very deep caries on 2.5 and external root resorption on 2.4.
The proposed treatment plan was, after full mouth scaling and root planing, to perform endodontic therapy of 2.5, to place a cast gold post and core restoration on 2.5; 2.4 had to be extracted and a technique of socket preservation was applied before placing an osseointegrated implant. The tooth 2.4 was extracted by means of periotomes and thin elevators, an envelope flap was raised, performing intrasulcular incisions on 2.3 and 2.5 and a limited exposition of buccal and palatal bony margins of the socket were exposed (Fig. 2).
The empty socket was carefully debrided and rinsed with sterile saline, then it was filled with Ostim® up to the level of the surrounding bone (Fig. 3). The material, extruded from the syringe, was adapted to the bone cavity, then stabilized with a PLA mesh (Vicryl VM302, Ethicon inc., Cornelia GA, USA) (Fig. 4). The mesh was covered with a resorbable collagen sponge (Hémocollagène, Septodont, Saint-Maur-des-Fossés Cedex, Francia).
The flap was sutured with a 4–0 resorbable PLA thread (FS–3 Vicryl JV394, Ethicon inc., Cornelia GA, USA), applying two single sutures on the papillae and a cross suture over the collagen sponge (Fig. 5–6).
To further protect the grafted site a fixed provisional restoration (crown on 2.5 and mesial cantilever ovate pontic on 2.4) was placed (Fig. 7); no occlusal contacts, neither in centric occlusion, nor in lateral excursions, were present on the pontic.
Three months after the extraction good bone regeneration is evident at the grafted site (Fig. 8); after flap elevation it is not possible to notice any difference between native and regenerated bone (Fig. 9). One single self–tapping, external hex, rough surface, 4mm in diameter and 15mm in length implant was placed (OSS415, 3i Implant Innovations, West Palm Beach FL, USA) (Fig. 10).
After 6 months of healing (Fig. 11), there’s still a deficiency in tissue volume below th mucogingival junction (Fig. 12), a roll technique was performed, at the same time the healing abutment was connected (Fig. 13–14). Overcorrection of the defect was necessary to compensate for the subsequent graft contraction.
After 3 months of soft tissue healing, the final impression was taken (Fig. 15) using a polyether material (Permadyne H/Permadyne L, 3M Espe AG, Seefeld, Germania) (Fig. 16). Prosthetic rehabilitation was carried out using a UCLA cast–on abutment on the implant (SGUCA1C, 3i Implant Innovations, West Palm Beach FL, USA) and two single ceramometal crowns (Fig. 17).
The position of 2.4 and 2.5 interproximal contact points, in a apico–coronal direction, was placed — according to Tarnow’s investigations8 — at less than 5mm from the crest of the ridge to predictably obtain a papilla both in the interproximal space in between the crowns and between each crown and neighboring natural teeth (Fig. 18–19).
DISCUSSION AND CONCLUSIONS The usage of the socket preservation technique allowed for an ideal implant placement, avoiding the use of more complex techniques such as sagittal osteotomies (“split crest”), guided bone regeneration or onlay block graft. The subsequent soft tissue augmentation and the placement of interproximal contact point following well–documented scientific criteria permitted, after only three months from final prostheses delivery, to obtain a natural looking esthetic result with a complete filling of the interproximal spaces by papillary tissue (Fig. 20).
ACKNOWLEDGEMENTS The Author would like to thank his office team: Dr. Mario Iorio MD, DMD, DDS (thank you dad!), Dr. Rossana Repossi RDH, Dr. Silvia Terazzi DMD, Mr. Luca Varalli and Mr. Marco Brignoli MDT, Ms. Patrizia Losi, Ms. Erica Bagaini, Ms. Alice Guerini dental assistants for the invaluable help in treating this patient and many others.
BIBLIOGRAPHY 1. Lekovic V, Kenney EB, Weinlaender M, et al. A bone regeneration approach to alveolar ridge maintenance following tooth extraction: Report od 10 cases. J Periodontol 1997; 68:563–570 2. Lang N, Becker W, Karring T. Alveolar bone formation. In Lindhe J (ed). Textbook of clinical periodontology and implant dentistry, ed 3. Copenhagen: Munksgaard, 1998:906–932. 3. Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol 1998; 69:1044–1049. 4. Warrer K, Gotfredsen K, Hjorting–Hansen E, Karring T. Guided tissue regeneration ensures osseointegration of dental implants into extraction sockets. An experimental study in monkeys. Clin Oral Implants Res 1991;2:166–171. 5. Becker W, Becker B, Handelsman M, Ochsenbein C, Albrektsson T. Guided tissue regeneration for implants placed into extraction sockets: A study in dogs. J Periodontol 1991;62:703–709. 6. Sclar AG. The Bio–Col Method. In: Sclar AG (ed.). Soft Tissue and Esthetic Considerations in Implant Therapy. Carol Stream: Quintessence Publishing Co, Inc., 2003:75–112 7. Thornwarth WM, Schlegel KA, Srour S, Schultze–Mosgau S, Wiltfang J. Untersuchung zur knöchernen Regeneration ossärer Defekte unter Anwendung eines nanopartikulären Hydroxylapatitis (Ostim®). Implantologie 2004;12:21–32. 8. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol. 2001;72:1364-71.
Radiotherapy induced
osteosarcoma of the orbit in a 60-year old; a case report
following choroidal melanoma treatment without retinoblastoma
oncogenesis or Paget’s disease predisposition.
Osteogenic sarcoma (OS) is a rare malignant bone tumour occurring in 1:100,000 people per year, with around 6% to 13% of these tumours affecting the craniofacial bones 1-4. Approximately 25% of osteosarcoma involving the head and neck in one series occurred following previous head and neck radiotherapy 5. Review of the literature of post radiotherapy induced osteosarcoma reveals 12 cases following orbital radiotherapy for retinoblastoma, a tumour of childhood. We report the clinical presentation of a 60-year-old woman and the clinical course of this rare occurrence after choroidal melanoma treatment. Case ReportA 60-year-old lady presented with a numb, swollen left periorbital region ten years after radiation for a recurrence of choroidal melanoma. On examination she had a fungating mass visible within the left orbit invading through the socket and displacing her shell prosthesis. At the age of nineteen she was treated with enucleation of the left globe for choroidal malignant melanoma extending into the orbit. 30 years later she presented with an ill fitting ocular shell prosthesis. CT scan confirmed an orbital mass displacing the ocular shell prosthesis. Biopsy confirmed a recurrence of a malignant melanoma, which was treated with radiotherapy shrinkage and surgical resection. In total 4,800 centigray in 12 fractions was administered over four weeks using 4 MeV x-rays in a two field planned technique. Radiotherapy was well tolerated. Over the next ten years, she attended routine review periodically with the ophthalmology and radiotherapy teams without any signs of recurrence. Ten years following her radiotherapy course she presented to the ophthalmologist with an inflamed orbit with a six month history of left midfacial numbness. On examination she had a left orbital nodular mass involving the periorbital structures. CT and MRI scans revealed a large mass extending through the lateral orbital wall into temporal, infratemporal and pterygopalatine fossae (figures 1 and 2). Biopsy confirmed osteoblastic osteosarcoma.
The osteosarcoma grew rapidly over the next four weeks. Repeat CT scans revealed a very large mass in the left temporal fossa further extending into the left frontal lobe, the floor and roof of orbit and extending posteriorly to the zygomatic arch, greater wing of sphenoid, petrous bone and mastoid region. The patient was managed palliatively for two half years after presentation before dying of osteosarcoma related complications at 62 years of age.
CommentOsteosarcoma of craniofacial bones is rare and represents 2% of all osteosarcomas 6. In one series of 66 patients, the presentation of radiotherapy induced osteoscarcoma is described with an age range of 3.5 to 33 years and a median latent period following radiotherapy of 10.5 years 7. However reported post radiotherapy craniofacial cases usually follow retinoblastoma or Paget’s disease. In one series, 2 orbital cases out of 27 post radiotherapy induced osteosarcomas of skull and maxilla, followed retinoblastoma 2 with another case predisposed by Paget’s disease 5. It is very unusual to follow choroidal melanoma radiotherapy treatment and predictably occuring at an older age than retinoblastoma radiotherapy treated patients. Interestingly, there is another case report in a similarly aged 59 year old lady following radiotherapy of an unknown orbital primary tumour in an enucleated socket. The patient having previously undergone enucleation after trauma and then subsequently developing an orbital tumour, without having histology prior to radiotherapy in Vietnam. Histology of the traumatised enucleated eye is not described in the case report and may have been unavailable to the authors but she is the age at which choroidal melanoma is feasible 8. Identified predisposing factors for osteosarcoma include retinoblastoma, Li-Fraumeni syndrome, Paget disease and radiation exposure 5. Mutation of the RB1 & TP53 genes are hypothesised to both be needed to predispose to osteosarcoma 9. Craniofacial osteosarcoma has a much worse prognosis than long bone osteosarcomas and retinoblastoma cases of post radiation induced osteosarcoma having a similar prognosis to other cases. Survival rates in craniofacial post radiation induce osteosarcomas overall being reported as 66% at two years and 55% at five years 5. Survival of this post choroidal melanoma case is similar to the published series of radiation induced tumours of other origins. Patients managed with radiotherapy for choroidal melanoma are at very small risk of developing osteosarcoma of the orbit as a rare complication ten years after radiotherapy exposure. Surgeons and physicians reviewing patients previously treated by radiotherapy for this condition should be aware of this occurrence as an unusual complication 10 years after radiotherapy. The time-to-presentation being similar to other craniofacial tumours treated with radiotherapy but in an older age group.
Vol - I I Number- II July 2007 Maziar
MIR, Abstract
Background: A 3.5 year old girl patient presented with 10 missing and 6 mobile primary teeth
in April 1998. Physical examinations revealed palmar and plantar hyperkeratosis. No other
physical, mental or laboratory disorder was found. Dental examinations showed severe
generalized gingival attachment loss in both dental arches. There was a root exposure around
all present teeth.
Methods: Clinical, radiographic, histopathological and microbiological examinations were
carried out. Blood was taken for mutation analysis of the cathepsin C gene. Based on the
outcome of the microbiological test the patient was treated with daily chlorhexidine mountrinse.
All primary teeth were extracted to prevent re-infection. A diode laser (970 nm, 2 W, 20 Hz)
was selected for de-epithelialization of free gingival margins additional to the sulcus
decontamination.
Results: The patient was treated successfully and no signs of relapse were present during
the last recall.. Mutation analysis of the cathepsin C gene confirmed that the patient described
in this paper is a Papillon-Lefevre syndrome patient. Mutation analysis revealed a novel
mutation(1212 A G;405 His Arg) in the cathepsin C gene. The laser treatment additional to
periodical scaling and root planning is successful to save the 12 erupted permanent teeth
till the age of 12 while the patient was last time visited on 27th July 2007.
Conclusions: Careful screening for the appropriate antibiotic and excellent oral hygiene
successfully lead to the preservation of the permanent dentition.
KEY WORDS
INTRODUCTION
Papillon-Lefevre syndrome (PLS) is a rare autosomal recessive disorder. Its reported
incidence is 1-4 per million and both the sexes are equally affected by palmo-plantar hyperkeratosis, periodontopathy and premature loss of deciduous as well as
permanent dentition. It manifests between 1-5 year of life and the patient becomes edentulous
in the early teens. Another component of PLS is asymptomatic ectopic calcification in choroid
plexus and tentorium. About 20% of these patients also show an increased susceptibility to
infections probably due to dysfunction of lymphocytes and leukocytes clinical. PLS patients usually have very complex subgingival flora which includes the presence of
Actinobacillus actinomycetemcomitans, capnophilic and Capnocytophaga spp Bacteroides, in particular Bacteroides forsythus were associated with different types of
periodontitis cytokines may be responsible for modulating the process of rapidly progressive periodontitis in a
patient with PLS cathepsin C. This gene is located on chromosome 11. Up to now 43 different mutations have been
described in PLS patients. The conventional mechanical treatment of Papillon-Lefèvre syndrome
periodontitis has a poor prognosis. Up to now, nearly no successful treatment that saved the
permanent dentition in PLS patients has been described. The most optimistic papers described an
extraction of all the deciduous teeth followed by a period of edentulousness. The edentulous period
may explain the fact that there has been no recurrent attachment loss in the permanent teeth up to
age 17 dentures as the best solution of this problem. In this study a complete clinical, radiological, pathological and genetic diagnosis is performed on
a PLS patient. An excellent oral hygiene, professional periodontal treatment and selective antibiotic
therapy were used to treat the patient. The patient was successfully treated and the permanent dentition
of this patient could be preserved. Currently, Cobb concluded from the literature some clinical evidence
that shows some wave lengths of laser could be helpful for periodontal sockets decontamination. Ishikawa and Sculean published a review article on 2007 showing the successful results of diode laser
assisted de-epithelializing and sulcus decontamination therapies. MATERIALS AND METHODS
Clinical Findings A 3.5 year old girl patient presented with 10 missing and 6 mobile primary teeth in April 1998. Physical
examinations revealed palmar and plantar hyperkeratosis. No other physical, mental or laboratory disorder
was found. Dental examinations showed severe generalized gingival attachment loss in both dental arches.
There was a root exposure around all present teeth. Radiographic Findings Severe bone loss was evident in
panoramic and occlusal radiographs.
Microbiological Findings
The early antibiogram detection showed cephalexine as the antibiotic of choice for
the disease. The result of cultures revealed the predominant presence of Bacterioids. Histopathologhy:
Hypercementosis and inflamatory reactive (fibrosis) hyperplasia was observed in the slides of the
involved teeth and surronding tissues, respectively.
Genetic Analysis
By the use of PCR we amplified the 7 exons of cathepsin C by using the primers previously described by
other groups. After the PCR process we confirmed the presence of the PCR product by 2% agarose gel
electrophoresis. The PCR products were purified by using columns and the concentration of the DNA was
determined spectophotometrically. For the sequence reaction we used the same primers as for the PCR reaction
and the reaction was carried out using the BigDye Terminator mix. The data were automatically collected and
analysed by the software of the Sequencer.
The sequences were compared with the published cathepsin C sequence. A nucleotide 1212 A G mutation in the
cathepsin C gene was found, which was predicted to result in an amino acid 405His Arg mutation. The mutation was
confirmed by the use of restriction enzyme analysis performed on exon 7. The nucleotide mutation has not been
reported previously. The alteration of the Histidine at position 405 has been demonstrated in a Pakistani
family with PLS.
Treatments and Follow-Ups
The patient was treated with a daily chlorhexidine mouth rinse. To eliminate the source of infection all primary
teeth were extracted in June 1998. Early antibiogram to select the best antibiotic for recommending after
extraction of teeth prevents the furture infection and need to antibiotic therapy before the eruption
of permanent teeth.
Follow-up The infection was successfully controlled. The patient was reevaluated clinically and paraclinically
and no future antibiotic therapy was needed. The permanent incisors and first molars have erupted under good oral
hygiene care. During the last recall (November 2003) no significant finding were reported in the panoramic X-ray.
We conclude that the microbiological tests may be a powerful tool to select the proper antibiotic for a successful
treatment of a Papillon-Lefevre syndrome patient. Also, as the last laser assisted treatment on 27th
July 2007 showed successful acceptance of patient, this new method as assistant to routine scaling and
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