LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW

Knowledge . Service . Love
Journal of the Indian Dental Association
Tamil Nadu State Branch
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Volume 6 Issue 20
January-March. - 2014
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Warm greeting to all members of the IDA state branch. The activities of our state branch and all local branches are going
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Journal of the Indian Dental Association - Tamil Nadu
Contents
FORSUS FOR CORRECTION OF CLASS II MALOCCLUSION – A CASE REPORT 01
1 2 3
Dr. P J Antony , Dr. Joby Paulose , Dr. Muhammed Shibin ,
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION
WITH A LOCATOR;CASE REPORT,A REVIEW 05
1 2 3
ABDULGANI AZZ. , BAJALI M. , ABU-HUSSEIN M.
STEREOTACTIC NAVIGATION IN ORAL AND MAXILLOFACIAL SURGERY
- A REVIEW OF LITERATURE 11
1 2 3
Deepu . S , Dhineksh kumar , Mathew jose .
DENTAL MANAGEMENT OF AN ECTODERMAL DYSPLASIA PATIENT –
A STAGE BY STAGE APPROACH : A CASE REPORT. 14
1 2 3
Dr.Karthikeyani. S , 2. Dr.Bindhoo. Y.A, , 3. Dr.V.R.Thirumurthy .
ENDODONTIC MANAGEMNT OF RADICULOUS MAXILLARY PREMOLARS
-A case report 18
1 2 3
Dr. Velmurugan A , Dr. Bhavani S , Dr. Deepak .
PREVALENCE OF ENDODONTIC INFECTIONS IN HOSPITAL
REPORTED CASES AT KANYAKUMARI DISTRICT, TAMIL NADU 21
1 2 3
S.R.Sri Ramkumar *, Dr.Mano Christaine Angelo *, Dr.N.Sivakumar *
“AN UNUSUAL OCCURRENCE OF HYPERDONTIA AND MICRODONTIA IN
SINGLE CASE” 27
1 2 3 4
Dr. Anusha Rangare Lakshman , Dr. Sham Kishor Kanneppady , Dr. Preethi Balan , Dr. Chaithra Kalkur .
"A SMALL CONE- BIG SCOOP”- A REVIEW ON SCOPE OF CBCT IN
DENTISTRY'' 30
Dr.K.Janaki
Vol. 6 Issue. 20 January - March.-2014

Contents
Vol. 6 Issue. 20 January - March.-2014
MANDIBULAR CANINE INDEX – A KEY FOR SEXUAL DIMORPHISM 33
1 2 3
D. Thamarai Selvi , S.Ranjith , R. Madhavan Nirmal
Juvenile Recurrent Parotitis – A rare case report 37
1 2 3 4 5
Dr. E.Pradeepa , Dr.J. Venkatesh , Dr. K. Ramya , Dr.L Vijayalakshmi , Prof. Dr. Ravi David Austin ,
40
1
Dr Jaiganesh Ramamurthy
RADIATION PROTECTION IN CBCT 44
1 2
P.PAVITHRA , DR. SRI ARATHY
Probiotics and its application in dentistry – An overview

JIDAT, Vol.6, Iss.20, January-March.-201401
INTRODUCTION:
Among all malocclusions, Class II malocclusion
constitutes approximately 15%1. Class II malocclusion
could be due to many reasons: (1) Mandibular deficiency
with the teeth normally related to the jaw (2) Downward
and backward rotation of the mandible produced by
excessive vertical growth of the maxilla, or a number of
other possibilities1.
Various orthodontic appliances have been used to treat
Class II malocclusions, including intra and inter-arch
appliances, extra-oral appliances, and surgical
repositioning of the jaws2. The intra-arch devices may be
either removable (cetlin or sagittal appliances) or fixed
(Pendulum, Distal Jet, Jones Jig). Inter-arch devices can be
either removable (bionator, twin block) or fixed. They can
be a pull (Class II elastics, SAIF springs) or push type
(Frankel, Herbst, Jasper Jumper) 3.Class II malocclusions
are difficult to treatand express greater tendency for
relapse3.
Intermaxillary elastics are a typical inter-arch method
used for Class II correction. The effect of Class II elastics
includes an increase in anterior lower facial height,
increase in the mandibular plane angle, and clockwise
rotation of the mandibular and the occlusal planes.
Functional appliances have been shown to produce
beneficial effects in growing patients with Class II
malocclusions, but the mechanism and effectiveness of
these appliances remain controversial4, 5. Some authors
1. Prof & HOD, Orthodontics department, Mar Baselious Dental College, Kothamangalam
2. Reader, Orthodontics department, Mar Baselious Dental College, Kothamangalam
3. Final Year PG student Orthodontics department, Mar Baselious Dental College, Kothamangalam
FORSUS FOR CORRECTION OF CLASS II MALOCCLUSION – A CASE REPORT
Forsus Fatigue Resistant Device
Key words: Malocclusion, Forsus, Functional Appliances
ABSTRACT:
Among all the malocclusions, Angle’s class II malocclusion is the most prevailing which may be either skeletal or
dental, presenting with different clinical manifestations. There are number of appliances to treat such a
malocclusion in a growing child, which includes extra-oral appliances, functional appliances and fixed functional
appliances. On the other hand, correction of Class II malocclusions in non-growing patients usually includes
orthognathic surgery or selective removal of permanent teeth, with subsequent dental camouflage to mask the
underlying skeletal discrepancy. Fixed functional appliances are indicated for class II corrections in patients who
report late with minimal residual growth left. A case of class II skeletal and dental malocclusion treated with pre
adjusted edgewise appliance (PEA) supplemented with Forsus Fatigue Resistant Device (FORSUS) is discussed.
1 2 3
Dr. P J Antony , Dr. Joby Paulose , Dr. Muhammed Shibin ,
contend that functional appliances have a mandibular
skeletal effect6, while others do not believe7.
Conventional functional appliances can be used when
the patient reports during the active growth spurt period.
But after the pubertal growth spurt or during the late
stages of puberty, fixed functional appliances would be
the better choice.
The Forsus fatigue-resistant device spring is a 3-piece
telescoping compression spring used for Class II
correction8. It is an inter-arch push type spring that
produces about 200g of force when fully compressed.
The Forsus springs are rarely fully compressed and they
are comparable to heavy Class II elastics in force
magnitude. The unique coaxial spring design of the
Forsus Fatigue Resistant Device addresses the issue of
fatigue failure by repeated application of stresses in the
coil spring. Unlike other push–spring appliances, such as
the Herbst, the FRD can intrude the maxillary first molars
and thus correct a Class II malocclusion without opening
the bite. The Forsus flat spring made of Nitinol was being
used as early as 19998. Later this was modified to a direct
push rod type.The three-component Forsus corrector
system has obvious advantages over one-piece systems.
Forsus spring is directly attached to the lower full
archwire without prior removal of brackets. This is quick
and easy. Springs can be re-activated during regular
checkups until the desired result is achieved.
Reactivation can be attained in different ways: 1) by
reducing the amount of pin play inside the headgear tube,

2) by attaching a Gurin lock at the distal side of the lower
canine bracket, if necessary at some distance, 3) by
crimping a stop onto the push rod. The various options
allow the orthodontist to have an individual treatment
modality for each case. A combination of one or several
of these options is possible. The springs though bulky, do
not cause any visible bulging of the cheeks. Unlike one-
piece Class II correctors, the Forsus appliance does not
limit the patient’s ability to move the jaw. This means the
real patient comfort during the course of the treatment.
It is not devoid of disadvantages. Very rarely, the push of
the spring against the cuspid bracket may cause a loose
bracket. A Gurin lock screw, attached to the archwire
behind the bracket will act as a stop and may prevent this.
Alternatively, an elastic chain can be tied from the loop of
the push rod to the hook of the lower molar band. This in
short will limit the freedom of movement in mesial
direction. The most relevant undesirable effect of using a
Forsus spring is protrusion of the lower anteriors.
However, this can be prevented by the useof full slot
archwire with proper cinching. Another method is to
incorporate a lingual crown torque on the anterior
segment to counter effect the proclination of lower
anteriors.
CASE REPORT
A female patient aged 15 years came to the orthodontic
clinic with a chief complaint of irregularly placed upper
and lower front teeth. On extra-oral examination, patient
had a convex profile with high mandibular plane angle
andincompetent lips. Intra-oral examination revealed an
over bite of 7-8mm and bilateral Angles class II
molarrelationship (Fig 1). Cephalometricevaluation
(Table 1) revealed a class II skeletal pattern (mandibular
deficiency with a tendency towards vertical growth
pattern and Angles class II malocclusion. VTO was
positive (Fig 2). Since the patient’s age was 15yrs, a hand
wrist x-ray was obtained which revealed that the patient is
in the late stages of puberty. Non extraction treatment
with pre-adjusted edgewise appliance therapy was
considered. Considering the age of the patient
mandibular correction supplemented with Forsus fatigue
resistant device was planned.
Initial levelling and aligning was achieved in 3 months
after the start of treatment with.016“ Niti. As soon as
Upper and lower arch wire was stepped up to .019 x
.025” SS, a lingual crown torque was incorporated to the
arch wire in the lower anterior segment and forsus was
placed (Fig 3). After 5 months, sufficient mandibular
advancement was achieved and case was finished in class
I molar and canine relationship (Fig 4). But the forsus
appliance was removed only after 3 months as relapse
tendency is more common in case of class II
malocclusion. An aesthetic profile was attained (Fig 5)
with minimal change in mandibular plane angle (Forsus
would not produce a molar extrusion as in case of
treatment using class II elastics). An increase in madibular
plane would effect a clockwise rotation of mandible
which would worsen the skeletal class II problem. Upper
begg wrap around retainer and lower canine to canine
fixed retainer was given.
JIDAT, Vol.6, Iss.20, January-March.-2014 02
PHOTOGRAPHS
Fig 1: Pretreatment extra oral and intra oral
photographs of the patient

Fig 5: Profile change, pre and post Forsus treatment
Fig 4: Extra oral and intra oral photographs of the patient
after removal of Forsus
Variable
SNA
SNB
ANB
N perp to Pog
GoGn-SN
U1-SN
U1– NA
L1 – NB
IMPA
Over jet
L lip-S line
Pre Rx
0
81
0
74
0
7
-8mm
0
34
0
92
0
3mm / 18
0
3mm / 24
0
93
8mm
8mm
Post Rx
0
82
0
81
0
1
-2mm
0
34
0
103
0
5mm / 22
0
5mm / 26
0
97
2mm
1mm
Table1: Pre & post treatment cephalometric
evaluation
Fig 2: photograph showing +ive VTO
Fig 3:Forsus in place
CONCLUSION:
A case of skeletal class II malocclusion treated with PEA
supplemented with FRD is reported. The Forsus (FRD)
can be used in severe cases. Forsus springs work best in
patients with convex profiles, but they are indicated in
any Class II patients except those with normal mandibles
and protrusive maxillae, or with protrusive or overly
large mandibles relative to the other cranial structures.

REFERENCES:
1. William R. Proffit, Henry W. Fields, David M. Sarver.
4th ed. St Louis: Elsevier mosby; 2007.
2. MuralidharReddyY, Madhukar Reddy R. A case report
of growing skeletal class ii treated with forsus fatigue
resistance appliance. Annals and Essences of Dentistry
Vol. - III Issue 1 Jan – Mar 2011.
3. WilliamVogt: The Forsus Fatigue Resistant Device,
JCO 2006.
4. McNamara, J.A.; Bookstein, F.; and Shaughnessy, T.:
Skeletal and dental changes following functional
regulator therapy, Am. J. Orthod. 88:91-111, 1985.
5. Valant, J.R. and Sinclair, P.M.: Treatment effects of the
Herbst appliance, Am. J. Orthod. 95:138-147, 1989.
6. Falck, F. and Frankel, R.: Clinical relevance of step-by-
step mandibular advancement in the treatment of
mandibular retrusion using the Frankel appliance, Am. J.
Orthod. 96:333-341, 1989.
7. Creekmore, T.D. and Radney, L.J.: Frankel
appliance therapy: Orthopedic or orthodontic? Am. J.
Orthod. 83:89-108, 1983.
8. El-Sheikh MM, Godfrey K Manosudprasit M,
Viwattanatipa N. Force deflection characteristics of the
fatigue resistant device spring; an in vitro study. World J
Orthod. 2007 Spring: 8(1): 30-6.
Corresponding author :
Dr. P J Antony
Prof & HOD, Orthodontics department,
Mar Baselious Dental College,
Kothamangalam

INTRODUCTION:
Dental implants are prosthetic devices, made of
alloplastic materials that are
inserted into the oral cavity to provide retention and
support to removable and
fixed dental prostheses [1, 2]. The concept of using
implants to replace teeth is age old. In fact, in ancient
history thousands of years ago, ivory teeth were used as
implants in Egyptian mummies. However, the era of
modern dental implantology began much later, in the
1940’s, with the discovery of screw type implants by
Formiggini et al [3, 4]. The introduction of the concept
and the biology of osseointegration, by Branemark et al
(1952), added another milestone in the history of dental
implantology [5]. Over the years, this field has
significantly evolved and emerged as an extensively used
treatment modality for oral rehabilitation
The first clinical outcome of surgical procedure is the
primary stability of the
implant. Primary stability is rigid fixation and lack of
micro motion of the implant into the bone cavity [1,6,7].
Absence of stability can lead to excessive mobility and
cause fibrous tissue formation around the implants
inhibiting osseointegration [7,9]. Primary stability
depends on the surgical technique, implant design and
the implant site [9,10].
1. Assist.Prof.,AlQuds University,Jerusalem,Palestine
2. Assist.Prof.,AlQuds University,Jerusalem,Palestine
3. Visiting Prof.Napoli university,Italy-University of Athens,Greece
LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION
WITH A LOCATOR;CASE REPORT,A REVIEW
Key words: Locator,Freestanding Implants,Immediate Loading,Mandibular Overdenture
ABSTRACT:
Successful treatment with the two-implant overdenture has been documented with multiple implant designs (eg,
hexagonal, Morse taper, internal connection) and many implant systems. Clinicians may select implants for
retention of the two-implant overdenture according to personal experience and preference with confidence that
treatment success will not be determined by the selection made. This is due primarily to the anatomy and density of
the bone in the anterior mandible. The aim of this case report is to demonstrate the concept of immediate functional
loading in the mandible using unsplinted implants to support a locator attachment supported overdenture.
1 2 3
ABDULGANI AZZ. , BAJALI M. , ABU-HUSSEIN M.
-Bone tissue is arranged in two macro architectural forms,
trabecular or cancellous and cortical or compact.
Leckholm and Zarb (1985) have classified bone types in
the oral cavity, depending on the relative proportions of
cancellous and cortical bone:
- Class I: predominantly cortical
- Class II: thick layer of compact bone surrounding a
dense cancellous core
- Class III: thin layer of compact bone surrounding a
cancellous core
- Class IV: very thin compact layer around a low density
trabecular bone
Sennerby et al (1992) compared implants placed in rabbit
cortical versus
cancellous bone and established that cortical bone has a
higher modulus of
elasticity, is harder to deform and provides greater
resistance to motion [11].
Hence, Class I and Class II bone would facilitate higher
primary stability
The original protocol for loading, as described by
Branemark, involved waiting for three months (for
mandible) to six months (for maxilla) after implant

placement. Such a delayed loading protocol was aimed at
allowing undisturbed healing and complete
osseointegration before implants could be loaded. For a
long time it was assumed that premature loading would
limit peri-implant osteogenesis and induce fibrous tissue
formation [7,12].
Schnitman et al (1990) introduced the concept of
immediate loading, which has been described as
attachment of the prostheses within twenty-four hours to
one week after implant placement [13,14]. Some of the
advantages of immediate loading are shortened treatment
time and early functional, physiological and
psychological rehabilitation of the patient. In addition,
there have been some claims made about a biologic
advantage in the form of enhanced osteoblastogenesis
with immediate loading. An in-vivo study by Qi et al
(2009), evaluated the response of mesenchymal stem
cells to mechanical strain and their consequent gene
expression patterns [15]. Their results suggested that
mechanical strain might act as a stimulator to induce
differentiation of stem cells into osteoblasts [15]. Indeed,
cyclic tensile strain has been shown to increase
osteoprotegrin synthesis and decrease soluble receptor
activator of nuclear factor kappa-B ligand (RANKL), thus
favoring bone formation [16]. This theory was tested in an
rabbit model by Duyck et al (2007), who concluded that
mechanical loading stimulated bone formation and led to
a higher bone fraction [17,18].
TREATMENT OF COMPLETE EDENTULISM: IMPLANT
OVERDENTURES
An overdenture is defined as any dental prosthesis that
covers and rests on one or more remaining natural teeth,
the roots of natural teeth, and / or dental implants [2]. The
concept of overdentures is age old. Ledger as early as
1856, suggested utilizing natural teeth to stabilize
removable prostheses and after a whole century Miller
introduced the concept of tooth retained overdentures
[19]. The downside of these prostheses was frequent
failure of abutments caused by periodontaldisease,
periapical lesions, caries and fracture of teeth [20].
The introduction of osseointegrated implants and
implant-retained prostheses led to a paradigm shift for the
management of edentulism. This is true especially for
mandibular edentulism, where the problem of advanced
alveolar resorption and difficulty in providing stable,
retentive and functionally comfortable prostheses
seemed to represent a major challenge [21].
A number of randomized controlled trials have
demonstrated increased patient satisfaction and reduced
negative impact on quality of life with implant retained
overdentures as opposed to conventional dentures in the
mandible [22]. Other studies have reported an
improvement in chewing ability, bite force and in serum
nutritional and anthropometric parameters (such as skin
fold thickness, waist hip ratio and body mass index)
[23,24]. The long-term efficacy of implant-supported
overdentures has been established in many retrospective
and longitudinal trials [25,26.27].
Implant overdentures are used in conjunction with
attachments and there are
many different attachments provided by a large number
of manufacturers around the world. The attachments
currently available can be broadly divided into twomajor
categories:
- Splinted / Bar Attachments- Dolder bar and hader bar are
examples of splintedattachments
- Non-splinted / Solitary / Stud Attachments - Ball
attachments, magnets and
locators exemplify solitary attachments.
Loading of Implant Overdentures
A fairly recent systematic review by Gallucci et al (2009),
presented the strength of evidence available for different
loading protocols (conventional, early and immediate
loading) in completely edentulous patients. Their search
led to a conclusion that the highest level of scientific and
clinical validation was available for conventional loading
with mandibular overdentures. However, immediate
loading of mandibular dentures was clinically well
documented but not scientifically validated [28].
Clinical documentation of immediate loading can be
exemplified by various
prospective trials that have been conducted using this
protocol for mandibular
dentures. For example, a longitudinal study with 3-8
years of follow up by
Chiapasco et al (2003), looked at success and survival of
immediately loaded

implants supporting a mandibular overdenture. Four
implants were placed per
patient, connected by a splinted bar attachment. A
cumulative success rate of 88.2% and survival rate of
96.1% was seen after a mean follow up period of 62
months.
The authors concluded that, for about 3 years after
immediately loading the
implants, the success and survival were the same as that
documented for delayed loading. However, with a longer
follow up it became evident that immediately loaded
implants had a moderate decrease in success rate [29].
Similar results were reported by Kronstrom et al (2010),
wherein he advised caution in using immediate loading
due to a low survival rate of 81.8% at 1 year follow up
[30].
Other investigators have, however, reported higher rates
of success and survival using an immediate loading
protocol. A cohort study by Gatti et al (2002) has shown a
cumulative survival rate of 100% and minimal bone level
changes (0.5 -0.9 mm) around immediately loaded
implants [31]. Alfadda et al (2009) used historical controls
with delayed loading in a prospective cohort study and
compared it to immediate loading. At 5 years, they found
identical success, survival, satisfaction and impact on
quality of life between the two groups [32].
Randomized clinical controlled trials (RCT) are
considered as the most reliable (Level I) form of validation
in the hierarchy of scientific evidence, essentially
because they reduce spurious causality and bias. In order
to prove the efficacy and safety of an immediate loading
protocol Chiapasco et al (2001)performed a RCT
comparing an immediate and a delayed protocol for four
splinted implants supporting a mandibular overdenture.
They found no difference in cumulative survival rate,
bone loss, clinical and radiographic parameters at 2 years
between the two groups [33].
Review paper by Gallucci et al (2009) and a 10 years
clinical trial by Meijer et al (2009), among many others,
have shown that there is no difference in the clinical and
radiographic performance of two or four implants
supporting a mandibular overdenture [27,28]. Hence,
having established that immediately loaded four implants
supporting a mandibular overdentures are comparable to
delayed loaded implants, it would be interesting to see if
these results can be replicated when two implants were
used in conjunction with unsplinted attachments such as
locators.
CASE REPORT
A 58-year-old female patient without any medical contra-
indication for implant therapy presented with an ill-
fitting, lower complete denture that she had been
wearing for four years. The clinical and radiographic
findings revealed slight to moderate mandibular ridge
resorption with an ill-fitting lowerdenture (Figs. 1 & 2).
The patient was given the option of placing two implants
to support her existing lowerdenture. The treatment plan
was accepted and included
an immediate functional loading by using a locator
attachment-supported mandibular overdenture.
At the surgical appointment, following the administration
of local anaesthetic, a mid-crestal incision was performed
and a full-thickness flap was reflected.In addition,
osteotomies were prepared in type II bone. Bone taps
were used to countersink the sites, after which two ITI
Tapered implants (ITI 3,3X14-mm) were placed with the
handpiece and hand ratchet. The implants were torqued
to 35 N (Figs. 3 & 4).Immediately after implant surgery,
the mandibular denture was seated in the patient’s mouth
and adjusted to provide clearance in the area of the
locator(s). two locators (4 mm in length) were torqued to
30 N (Figs. 7 & 8). Following the suture of the flap with4-0
vicryl, the processing rings were placed over the locators
and were picked up directly in the mouth using hard self-
curing acrylic (Rebase II, Tokuyama; Figs. 6). The patient
was given post-operative instructions, including the use
of 0.12 % chlorhexidine gluconate three times a day.
She was furthermore prescribed 500 mg of amoxicillin(to
be taken every six hours for seven days). The patient was
then informed that the implant-supported overdenture
was to be left in place for 48 hours. Two days later, she
was seen for a follow-up visit and the healing process was
uneventful. The black processing rings were switched to
blue rings ten weeks after the placement (Figs. 5&6&7).
After six months, the patient returned for another follow-
up visit and all two locators were torqued to 30 N (Figs.
7&8). It was determined that all two implants had
achieved full integration. Currently, the patient is on a six-
month recall to ensure the proper maintenance of the
implants and the prosthesis(9&10). The last maintenance
visit was 24 months post-placementand all implants have
maintained healthy soft tissue and a stable bone level.

Fig.1 Mandible at the time of implant placement
with moderate bone resorption
Fig. 2_Pre-op panoramic radiograph
Fig. 3_Guiding pins at the time of
implant placement
Fig. 4_Two tapered implants at placement.
Fig. 5_Panoramic radiograph immediately
after implant placement.
Fig. 8_Buccal view of the locators two weeks
post- implant placement
Fig. 9_Buccal view of the overdenture in place
Fig. 10_final smile
Fig. 6_The processing rings were picked up
directly in the mouth.
Fig. 7_Occlusal view of the locators
two weeks post- implant placement

CONCLUSION
In conclusion, within the limits of this interim report,
immediate loading of two
implants supporting a locator retained mandibular
overdenture seems to be a
suitable treatment option. The marginal bone level
changes around immediately loaded implants are
comparable to those seen around implants loaded with a
torque do not effect peri-implant bone loss. Implant
survival of immediately loaded implants maybe lower
than those loaded with a delayed protocol, but this needs
to be confirmed in future investigations with a larger
sample size.elayed protocol, at 6 months post surgery.
Implant length and peak insertion.
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T, Stratmann U, Wiesmann HP: Ultrastructural
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Surg 1969, 3(2):81-100.
6. Adell R, Lekholm U, Rockler B, Branemark PI: A 15-
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7. Marco F, Milena F, Gianluca G, Vittoria O: Peri-
implant osteogenesis in health and osteoporosis. Micron
2005, 36(7-8):630-644.
8. Soballe K, Hansen ES, H BR, Jorgensen PH, Bunger C:
Tissue ingrowth into titanium and hydroxyapatite-coated
implants during stable and unstable mechanical
conditions. J Orthop Res 1992, 10(2):285-299.
9. Sevimay M, Turhan F, Kilicarslan MA, Eskitascioglu G:
Threedimensional finite element analysis of the effect of
different bone quality on stress distribution in an implant-
supported crown. JProsthet Dent 2005, 93(3):227-234.
10. Buchter A, Kleinheinz J, Joos U, Meyer U: [Primary
implant stability with different bone surgery techniques.
An in vitro study of the mandible of the minipig]. Mund
Kiefer Gesichtschir 2003, 7(6):351-355.
11. Sennerby L, Thomsen P, Ericson LE: A morphometric
and biomechanic comparison of titanium implants
inserted in rabbit cortical and cancellous bone. Int J Oral
Maxillofac Implants 1992, 7(1):62-71.
12. Albrektsson T: Direct bone anchorage of dental
implants. J Prosthet Dent 1983, 50(2):255-261.
13. Esposito M, Grusovin MG, Willings M, Coulthard P,
Worthington HV: The effectiveness of immediate, early,
and conventional loading of dental implants: a Cochrane
systematic review of randomized controlled clinical
trials. Int J Oral Maxillofac Implants 2007, 22(6):893-
904.
14. Schnitman PA, Wohrle PS, Rubenstein JE: Immediate
fixed interim prostheses supported by two-stage threaded
implants: methodology and results. J Oral Implantol
1990, 16(2):96-105
15. Qi MC, Zou SJ, Han LC, Zhou HX, Hu J: Expression of
bone-related genes in bone marrow MSCs after cyclic
mechanica strain: implications for distraction
osteogenesis. Int J Oral Sci 2009, 1(3):143-150.
16. Kusumi A, Sakaki H, Kusumi T, Oda M, Narita K,
Nakagawa H, Kubota K, Satoh H, Kimura H: Regulation
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activator of nuclear factor-kappaB ligand in normal
human osteoblasts via the p38 mitogen-activated protein
kinase pathway by the application of cyclic tensile strain.
J Bone Miner Metab 2005, 23(5):373-381.
17. Duyck J, Slaets E, Sasaguri K, Vandamme K, Naert I:
Effect of intermittent loading and surface roughness on
peri-implant bone formation in a bone chamber model. J
Clin Periodontol 2007, 34(11):998-1006.
18. Vandamme K, Naert I, Vander Sloten J, Puers R,
Duyck J: Effect of implant surface roughness and loading
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79(1):150-157.
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31. Gatti C, Chiapasco M: Immediate loading of
Branemark implants: a 24-month follow-up of a
comparative prospective pilot study between mandibular
overdentures supported by Conical transmucosal and
standard MK II implants. Clin Implant Dent Relat Res
2002, 4(4):190-199.
32. Alfadda SA, Attard NJ, David LA: Five-year clinical
results of immediately loaded dental implants using
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22(4):368-373.
33. Chiapasco M, Abati S, Romeo E, Vogel G: Implant-
retained mandibular overdentures with Branemark
System MKII implants: a prospective comparative study
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20. Fenlon MR: Periodontal disease, periapical lesions
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21. Feine JS, Carlsson GE, Awad MA, Chehade A,
Duncan WJ, Gizani S, Head T, Lund JP, MacEntee M,
Mericske-Stern R et al: The McGill consensus statement
on overdentures. Mandibular two-implant overdentures
as first choice standard of care for edentulous patients.
Montreal, Quebec, May 24-25, 2002. Int J Oral
22. Thomason JM, Lund JP, Chehade A, Feine JS: Patient
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The effects of mandibular two-implant overdentures on
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25. . Vercruyssen M, Marcelis K, Coucke W, Naert I,
Quirynen M: Long-term, retrospective evaluation
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26, Attard NJ, Zarb GA: Long-term treatment outcomes in
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Toronto study. Int J Prosthodont 2004, 17(4):425-433.
27. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A,
Vissink A: Mandibular overdentures supported by two or
four endosseous implants: a 10-year clinical trial. Clin
Oral Implants Res 2009, 20(7):722-728.
28. . Marzola R, Scotti R, Fazi G, Schincaglia GP:
Immediate loading of two implants supporting a ball
attachment-retained mandibular overdenture: a
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Res2007, 9(3):136-143.
29.Chiapasco M, Gatti C: Implant-retained mandibular
overdentures with immediate loading: a 3- to 8-year
prospective study on 328 implants. Clin Implant Dent
Relat Res 2003, 5(1):29-38.
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L: A prospective randomized study on the immediate
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two implants: a 12-month follow-up report. Int J Oral
Abu-Hussein Muhamad
DDS,MScD,MSc,DPD,FICD
123 ARGUS STREET,
10441 ATHENS GREECE
abuhusseinmuhamad@gmail.com

INTRODUCTION:
Stereotactic ( Greek word stereo means 3 dimensional ,
tactic to touch) surgery formerly was used in humans
with thalamic lesions to treat parkinsonism. Current
technique would be more appropriately termed as
imageguided Stereotacticsurgery. At the end of
19thcentury, Sir Victor Horsley with the help of physicist
Mr. Clarke,introduced anapparatus, which could be fixed
to the head of the animals, enable him to introduce a
1
probe into a desired area of the brain . After a long time
about fifty years later the technique was introduced to
human neurosurgery by Spisel in 1947.Now surgical
navigation has been described in a wide variety of
maxillofacial procedures such as approaches to the skull
base, Para nasal sinus and orbit to remove foreign bodies
2
and for orthognathic as well as implant surgeries
Early the surgeons used bulky frames which attaches to
patient head for guidance. Now the modern navigation
surgery equipped with guidance system. Obviously the
nomenclature also shifted from framedstereotactic
surgery to frameless stereotactic surgery. There are four
t y p e s o f g u i d a n c e s y s t e m a v a i l a b l e
mechanical,acoustic,electromagnetic and optical based.
Mechanical devices are bulky and infrequently used
acoustic and electromagnetic devices have problems of
interference with echoes and diathermy. Optical system
uses infrared light which is not compromised with theatre
light. The light source either attaches to the active
1. Postgraduate trainee, Sreemookambika institute of dental sciences , kulasekharam, kanyakumaridist
2. Reader, Sreemookambika institute of dental sciences , kulasekharam, kanyakumaridist
3. Professor and head of the department, Sreemookambika institute of dental sciences , kulasekharam, kanyakumaridist
STEREOTACTIC NAVIGATION IN ORAL AND MAXILLOFACIAL SURGERY
- A REVIEW OF LITERATURE
ABSTRACT:
Navigational surgery is applicable in any circumstances whether three dimensional surgical plan from computed
tomography or magnetic resonance imaging possibly into surgical reality. But it is not easy because of absolute
limitation of access or lack of anatomic land mark.For a successful navigation surgery it is very important to know
digital recording, intraoperative tissue position and its changes. In maxillofacial surgery highly beneficial in terms of
navigational stereotaxy is orbital reconstruction, hemi facial syndromes. Modern navigation system has multiple
options for referring patient anatomy especially for movable structure like mandible and tongue
1 2 3
Deepu . S , Dhineksh kumar , Mathew jose .
marker on the instrument or on the camera which got the
passive marker that reflect into the instrument and the
software that allow to manipulated and view the images
in a way that is analogous to viewing the patient at
operation .
Fig 1 optical guidencesystem and passive markers
a)passive marker on the leftside of the patient head b)
passive marker on the instrument pointer
NAVIGATION IN MAXILLOFACIAL SURGERY
Computer aided oral and maxillofacial surgery is divided
into three categories they are 1) computer aided
preoperative planning 2) intra operative navigation 3)
intraoperative CT / MRI imaging.3It is possible to make
three dimensional plan for an operation, but is difficult to
translate that plan during operation because of a lack of

anatomical landmark or limitation of access. Major
limitation factor is whether there is unpredictable
movements of tissue in anaesthetized patient4. A change
in the position of the tissue from pre-operative scan to the
position on the table result in the CT or MRI being an
inaccurate reflection of the actual position of the structure
for example position of mandible before preoperative
MRI and position on the surgical table . To overcome the
inconvenience intraoperative scanners are introduced.
Registration is the identification of at least three match
points that are visible for the patient and for the scan used
for navigation. It is very much essential that these points
can be accurately identifiable and be relevant to surgical
site .The ideal match point on bone is considered as a
prefixed screw, but it is not applicable for primary surgery
patient5. Other method is to fabricate a splint the fits
accurately over the teeth and place screws by metal
markers .they can locate easily and navigation probecan
easily positioned over the screw head and transfer the
position from patient to computer. Marker screws made
in this way is known as fiducialsor registration match
point. The center of registration match point is the most
accurate andmovement with distance more than10 cm,
declines the levelof accuracy. The accuracy of navigation
systems used for maxillofacial surgery should not exceed
1 mm of deviation in total 6.Attention has to be paid that
the screw markers are not inserted too close to adjacent
metallic fillings. Instead of screws, oil or contrast medium
containing capsules are attached to the plastic splint if the
data acquisition and navigation is based on a MRI
N A V I G A T I O N I N O R B I T A L T R A U M A
/RECONSTRUCTION
In case of orbital trauma or reconstruction the uninjured
orbit is copied digitally and flipped around the sagittal
plane to be superimposed over the injured region.This is
done by matching the adjacent normal anatomy which
can often to be found at the root of the zygomatic arch
,apex of the orbit , and the supraorbital rim . The flipping
digital copies givesa good navigation target when applied
to zygoma, it is less clear when applied to orbital floor
because orbital floor is too thin may not clearly seen in
CT.
Surgical procedures are similar to surgery without using
stereotactic surgery. For orbital reconstruction, after
adequate exposure is made orbital bony segments are
osteotemized and mobilized and zygomais reconstructed
starting atzygomatic arch and frontozygomatic sutures.
Navigation helps to position the fragments in ideal
position from the preoperative three dimensional plan
rather than relay on unpredictable clinical data
Navigation provides a wonderful medium for teaching
most sensible anatomic areas so that easy to identify and
demonstrate the orbital plate of palatine bone and the
orbital floor can be dissected correctly. The flipped
digital orbital floor can be used as a navigation target to
ensure that it is adequately reconstructed and corrected
orbital volume. Intraoperative navigation was used to
assess the accuracy of the restored internal and external
orbital anatomy by assessing various points on the
digitalized images
NAVIGATION IN ORTHOGNATHIC SURGERY
Intraoperative navigation surgery elaboratelyhelp
toaccessvertical ,horizontal and sagittal jaw and tooth
relation .It is potentially useful toaccess bony relationship
and implement osteotomies especially in hemi
mandibular hyperplasia also used as a research tool for
3
the accuracy of orthognathic surgery .
NAVIGATION IN MANDIBULAR SURGERY
Reported dynamic computer navigation system used for
lower jaw4
FUTURE OF NAVIGATION SURGERY IN
MAXILLOFACIAL SURGERY
A major drawback of the navigation system is a high
consumption of human financial resources and technical
expertise7.Navigation Process is still complex to explain
Investigator
Shulltesetal
Hoffman etal
Watzingeretal
Caspetal
Caspetal
Caspetal
total
Distraction osteogenesis
Dental implantation
Dental implantation
Dental implantation
procedure
Screw removal from condyle using
extraoral approach
Removalofosteosynthesismaterial,implants
Patient(n)
1
4
concept
Positioning mandible
using acrylic splint
Positioning mandible
using acrylic
splintand mounting
DRF to
mobilesegment
Mounding DRF to
mandible
Mounding DRF to
mandible
Mounding DRF to
mandible
Mounding DRF to
mandible
2
1
2
1
11

but critical to understand .Now in knee replacement and
neurosurgery shows improved level of accuracy.
Complex and individual nature of the maxillofacial cases
make hard to compare outcome with or without
navigation surgery .In future robotic forms which
execute specific steps completely autonomously. The
techniques of virtual reality and computer assisted
surgery are increasingly important in their medical
applications. Many applications are still being developed
or are still in the form of a prototype. It is already clear,
however, that developments in this area will have a
9
considerable effect on a surgeon's routine work .
REFERENCES
1. Horsley v, Clarke R H .structure and function examined
by a new method. Brain 1908;31;45-124
2. J. Collier Stereotactic navigation in oral and
maxillofacial surgery. Br J Oral Maxillofac Surg. 2010;
48: 79-83
3. R Bryan Bell computer planning and intraoperative
navigation in orthognathic surgery Joms 2011-03-01
vol 69 page 592 -605
4. Heinz The o Lubbers , Jacchin A. Obwegeiser A
simple and flexible concept for computer navigated
surgery of the mandible JOMS 2011-03-01-vol 69 issue
3 page 924-930
5. Nyachhyon P, Kim PC Intraoperative stereotactic
navigation for reconstruction in zygomatic-orbital
trauma Nyachhyon P, Kim PC . J Nepal Med Assoc
2011;51(181):37-40
6. A. Martin, R.J. Bale, M. Vogele, W. Freysinger, A.R.
Gunkel, W.F. Thumfart, The VBH mouthpiece: a
registration device for frameless stereotactic surgery,
Radiology 208 (1998) 261.
7. Max H, Christian HR, Rainer S. Indications and
limitations of intraoperative navigation in maxillofacial
surgery. J Oral Maxillofac Surg. 2004; 62: 1059-1063
8. kamatydaurakzai km. adhikariar Matthews d ,
kalairajah y ,field re ,Does computer navigation in total
knee athroplasty improve patient out come at mid
termfollowup?Intorthop 2008;26
9. Stefan Hassfeld, Joachim MuhlingComputer assisted
oral and maxillofacial surgery – a review and an
assessment of technology ijomsVolume 30, Issue 1,
February 2001, Pages 2–13
Deepu . S
Postgraduate trainee,
Sreemookambika institute of dental sciences ,
kulasekharam, kanyakumaridist

INTRODUCTION:
Ectodermal Dysplasia represents a group of inherited
condition in which two or more ectodermally derived
anatomical structures exhibit aberrant development. The
tissues primarily affected are skin, hair, nails, sweat
glands and teeth [1], [2], [3], [4], [5]. The most common
dental features are oligodontia or hypodontia which
causes reduced alveolar bone growth [5], [6]. In addition
teeth if present may show abnormal crown morphology.
The ensuing functional and psychological impacts are
overcome by early dental intervention which helps these
children develop a positive self-image[7], [8], [9]. But
insufficient awareness among parents and reluctance
among the dentists in managing these patients, greatly
affect the social integration and hence the psychological
development of these children.
This case report highlights the successful dental treatment
of a 6 yr old male ED patient on a stage by stage basis.
CASE REPORT:
A 6 year old male patient residing in an orphanage was
brought to the department of Pedodontics, Sri
Ramakrishna Dental College and Hospital, Coimbatore
with the chief complaint of difficulty in chewing food.
The child was thin built, short statured, apprehensive and
very shy. The patient exhibited features of ED -
hypotrichosis, hypohydrosis, hypodontia, frontal bossing
and depressed nasal bridge (Fig 1). Intra oral examination
1. M.D.S, Professor, Department of Pedodontics,
2. M.D.S, Reader, Department of Pedodontics,
3. M.D.S, Professor, Department of Prosthodontics, Sri Ramakrishna Dental College and Hospital, Coimbatore.
DENTAL MANAGEMENT OF AN ECTODERMAL DYSPLASIA PATIENT –
A STAGE BY STAGE APPROACH : A CASE REPORT.
Key words: Ectodermal Dysplasia, Oligodontia, Hypodontia, Staged Treatment Plan, Training Denture Base.
ABSTRACT:
Ectodermal dysplasia is a hereditary condition associated with the defective development of two or more tissues of
ectodermal origin. Skin, hair, nails, sweat glands and teeth are the ectodermal tissues primarily affected. The
characteristic clinical features noted are hypotrichosis, hypohydrosis or anhydrosis and hypodontia or anodontia.
The clinical features cause esthetic, functional, phonetic and psychological disturbances in the patient. Dental
management of young ectodermal dysplasia patient is difficult as these children are psychologically immature. So
in addition to extensive dental treatment, they also require proper understanding and handling of child psychology.
This case report describes the dental management of a six year old male child with ectodermal dysplasia using a
staged treatment plan.
1 2 3
Dr.Karthikeyani. S , 2. Dr.Bindhoo. Y.A, , 3. Dr.V.R.Thirumurthy .
revealed intact permanent maxillary right first molar,
missing mandibular deciduous central incisors and a
severe loss of vertical dimension due to grossly decayed
deciduous dentition (Fig 2 and Fig 3).
Radiographic examination (OPG) revealed only few
tooth buds - permanent maxillary (Left) and mandibular
(Left and right) first molars and mandibular central and
lateral incisors. Clinical and radiographic findings of the
child confirmed Ectodermal Dysplasia. Elaborate dental
treatment was required in the form of extractions,
restorations and finally prostheses to replace the missing
teeth. Proper treatment sequencing is important in these
patients to achieve the desired functional and esthetic
results. So a team comprising of psychologist,
pediatrician, pedodontist and prosthodontist was formed
and a treatment plan was formulated. The most important
part of the treatment plan was to create awareness about
the necessity of early and continued dental treatment for
the child and to provide sufficient time for the child to get
accustomed to the dental environment. The other
important part was to preserve as many teeth as possible
to maintain the alveolar bone height. The treatment was
planned on a stage by stage basis.
• Phase I – Introductory phase
• Phase II – Pedodontic management
• Phase III – Prosthodontic management
• Phase IV – Recall & maintenance

Phase I: Introductory phase
The child was brought regularly to the department of
Pedodontics for a week as recommended by Nowak to
build up his trust [3]. Counselling sessions,
Communication, Tell-show-do approach, and modeling
methods were followed to help the child get acquainted
with the dental environment. This helped the child to
become friendlier and less shy to the members of the
dental team. At this point having won the patient’s trust,
decision was made to start the dental treatment.
Phase II: Pedodontic phase
Symptomatic grossly decayed deciduous molars and
mandibular lateral incisors were extracted. Maxillary
deciduous central and lateral incisors and all the
deciduous canines were retained after pulpectomy
(Metapex, Korea) to maintain alveolar bone height.
Phase III: Prosthodontic Phase
The child was slowly introduced to the prosthetic phase
of the treatment after satisfactory healing of extraction
sites. Diagnostic impressions were made with irreversible
hydrocolloid (Tulip- Cavex) in stock trays and models
poured with dental stone (Fig 4). The child exhibited
excess salivation and gag reflex on the introduction of the
impression trays. This raised doubts regarding the
denture acceptance by the patient. So the prosthodontic
treatment was planned in two sub phases.
• Sub phase I – Fabrication of training denture bases to
train the child for denture wearing.
• Sub phase II – Fabrication of RPD
Training denture bases were fabricated with heat cure
denture base resins (SR Triplex Hot- Ivoclar) after waxing
up the training bases on the diagnostic cast (Fig 5). The
patient was asked to wear the maxillary denture base
alone for about a week followed by the use of both the
denture bases. By the next appointment after 2 weeks, the
child was able to retain both the training bases without
difficulty. This proved to be an ideal time to introduce
Removable Partial Denture to the patient to replace the
missing teeth.
Custom trays with wax spacers were fabricated on the
study cast with autopolymerizing resin (Veracril, Brazil).
Border molding and final impressions were made with
elastomeric impression materials (3M Express XT (Soft
Putty) and Express Soft (medium body)) (Fig 6).
Temporary denture bases and occlusal rims were
fabricated on the master cast. Vertical dimension at rest
was determined and vertical dimension at occlusion was
established providing 2mm of free way space. The child
was trained to retrude the mandible and centric relation
was recorded.
The occlusal rims were articulated and teeth arrangement
was done (Acrylux- Ruthinium). Trial dentures were
inserted. Esthetics, phonetics, jaw relation and occlusion
were assessed (Fig7). The child’s response was very
positive and the trial dentures were processed in heat
cure denture base resin (Fig 8). On the day of denture
insertion, the denture extensions and occlusion were
adjusted (Fig9). As the child was used to wearing trial
denture bases, he easily understood the path of insertion
and removal of the prosthesis and readily co-operated
(Fig 10).
Phase IV: Recall and Maintenance phase.
The child was recalled the next day to assess the soft
tissue response to denture wearing. The child was
comfortable with the extensions of the dentures. On the
next recall appointment after a week, the guardians
reported an improvement in the diet and the social life of
the patient. The recall appointments were planned for
every 3 months to allow the eruption of the remaining
permanent teeth.
DISCUSSION:
Treating ED patients at early ages using staged treatment
plan, which emphasizes on the importance of
psychological and behavioral management, creates a
great rapport among the patient-parent-dental team.[2]
This is very essential because ED patients require
continuous dental treatment at different decades of life in
accordance with their growth and development. The
different prosthetic treatment options available for these
patients range from simple removable prostheses (RPD,
Complete dentures), overdentures and fixed partial
dentures to the more extensive implant prostheses. The
optimal prosthetic treatment option varies in relation to
the patient’s age and the amount of bone present [6].
Removable prostheses are the most commonly employed
interim treatment modality for ED patients. The success of
this depends on the retention and stability for which
preservation of alveolar bone is important. [3], [4], [5].
Further treatment in this patient will include modification
of the dentures to allow eruption of remaining teeth,
relining or replacement of the dentures according to the
observed skeletal growth.
CONCLUSION:
Early management of ED patients is usually difficult
because of the typical oral deficiencies and the young
age. But oral rehabilitation is important from functional,

esthetic and psychological perspectives[2], [9].This case
report details the treatment phases for an ED patient
which takes important factors like child psychology,
preservation of alveolar bone and team approach into
consideration. Difficulty in mastication was the main
complaint of the patient at the start of treatment. The
dental management helped not only to improve
mastication, but also esthetics and self image of the child
that will transform him into a socially acceptable
individual
Legends for figures
Fig 1: Frontal view-& Lateral view of the patient showing
ED; hypotricosis, frontal bossing, depressed nasal bridge.
Fig 2: Intra oral view of grossly decayed deciduous
dentition with missing mandibular central incisors
Fig 3: Intra oral view showing loss of vertical dimension
of occlusion
Fig 4: Diagnostic casts
Fig 5: Maxillary and mandibular acrylic Training denture
bases
Fig 6: Secondary impressions of maxillary and
mandibular arches made with elastomeric impression
materials
Fig 7: Trial dentures
Fig 8: Maxillary and mandibular removal partial dentures

Fig 9: Intra oral view of inserted final prostheses
Fig 10: Pretreatment and post treatment photographs of
the patient in frontal view.
REFERENCES
1. Neville, Damm, Allan, Bouquot. Oral and
maxillofacial pathology: W.B.Saunders Company.
Dermatological diseases.2nd edition.Toranto. pp 644-
645.
2. Cenkhan Bal, Bilge Turhan Bal. Treatment
Considerations for a Patient with Hypohidrotic
Ectodermal Dysplasia: A Case Report. The Journal of
Contemporary Dental Practice 2008;9:1-7.
3. Shigli A, Reddy R.P.V. Hypohidrotic ectodermal
dysplasia: A Unique approach to esthetic and prosthetic
management: A Case report. J Indian SocPedoPrev Dent
2005;23:31-34.
4. KarllaAlmeidaVieira, Milena Schaaf Teixeira.
Prosthodontic treatment of hypohidrotic ectodermal
dysplasia with complete anodontia: case report.
Quintessence Int 2007;38:75-80.
5. Rashmisingh, Gauri S lele. Hypohidrotic Ectodermal
Dysplasia: A Case Report. International Dental and
Medical disorders 2008;1:11-14.
6. PervinImirzalioglu, SinaUckan, SedaGürsoyHaydar.
Surgical and prosthodontic treatment alternatives for
children and adolescents with ectodermal dysplasia: A
clinical report. J prosth dent 2002;88:569-572.
7. Jain, Prakash. Prosthodontic rehabilitation of
ectodermal dysplasia patient. J Indian SocPedoPrev Dent
2000;18:2:54-58.
8. Vasan N. Management of ectodermal dysplasia in
children--an overview. Ann R AustralasColl Dent Surg.
2000;15:218-22.
9. M.Pigno, R.Blackman, R.Cronin, E.Cavazos.
Prosthodontic management of ectodermal dysplasia: A
review of the literature. J prosth dent 1996; 76:541-545.
10. Bilal Ahmed and NaziaYazdanie. Hypodontia and
Microdontia Associated with Hereditary Ectodermal
Dysplasia. Journal of the College of Physicians and
Surgeons Pakistan 2009;19:192-194.
Dr.Bindhoo.Y.A,
M.D.S, Reader, Department of Pedodontics,
132, Ellango street, Mangalam road, Palladam, Tirupur,
Tamil Nadu.- 641 664. Mobile:9842255347,
Email ID: bindhoomds@yahoo.co.in

INTRODUCTION:
A precise knowledge of the root canal system and its
variations is very important for the success of the
endodontic therapy. Anatomic variation such as extra
roots is an additional challenge, which begins at case
assessment level and involves all operative stages,
including cavity design, canal access, localization, and
cleaning and shaping of the root canal system.
Maxillary premolars exhibit the greatest variations in
root anatomy and root canal morphology. These
diversities in number and type of root canals are probably
the most discussed anomalies in the literature. Studies
reported by Carns and Skid 1973(1), Green 1973(2) and
Pineda and Kuttler 1972(3) dealing with the canal
morphology of the maxillary premolars, have revealed
that in most instances they have two canals from 73.3% to
92%, although teeth with three root canals do often exist
from 0 to 6%, respectively. Mariusz et al. 2005 found
9.2% of first maxillary premolar with three canals (4).
This case reports describes a permanent maxillary first
and second premolars with 3 root canals (1MB, 1 DB, and
1 palatal), with unusual buccal canal morphology in that
2 canals with separate orifices and apex.
CASE REPORT
A 25 year old male patient reported to the Department of
Conservative Dentistry and Endodontics with a chief
1. Senior Lecturer, Division of conservative Dentistry & Endodontics, Rajah Muthiah Dental college & hospital , Annamalai university ,Chidambaram
2. Senior Lecturer, Division of conservative Dentistry & Endodontics, Rajah Muthiah Dental College & hospital, Annamalai university, Chidambaram
3. Post graduate ,Division of conservative Dentistry & Endodontics, Rajah Muthiah Dental college &hospital, Annamalai university , Chidambaram
ENDODONTIC MANAGEMNT OF RADICULOUS MAXILLARY PREMOLARS
-A case report
Key words: Maxillary Premolars, Anatomic Variations , Three Canals
ABSTRACT:
Diversities in the internal anatomy are found in all teeth. Knowledge of these variations, particularly concerning the
location and treatment of all canals, is very important for the success of the endodontic therapy. Endodontic
literature since ages suggested maxillary premolars to be bicuspid teeth with one or two canals .The possibility of
three roots and three canals in maxillary premolars is still a rarity. This case report presents a clinical case of a
maxillary premolar with one palatal canal, one mesio-buccal and one disto-buccal canal. This report serves to
remind clinicians that such anatomical variations should be taken into account during endodontic treatment of the
maxillary premolars.
1 2 3
Dr. Velmurugan A , Dr. Bhavani S , Dr. Deepak .
complaint of pain in upper left back tooth since one
week. On clinical examination a deep caries lesion
involving the marginal ridge was observed in tooth.
Radiographic examination revealed radiolucency
involving the pulp cavity and three obvious independent
canals in both first and second premolars (fig1). Cold pulp
testing followed by electric pulp test elicited a lingering
pain response. The condition was diagnosed as acute
irreversible pulpitis and endodontic therapy was
initiated.
Local anaesthesia was administered and the operative
field was isolated with a rubber dam. Pre-endodontic
management was done with amalgam restoration.
Access cavity preparation was modified in the mesio-
distal direction to uncover the second buccal canal, such
that the access cavity is triangular in shape (fig 2). Patency
of the canals were checked with 10 size k-file and then a
working length radiograph was taken (fig 3). Cleaning
and shaping was carried out to a size of 25 in the buccal
canals and 30 in the palatal canal respectively (fig 4) and a
mastercone radiograph was taken (fig 5). This was
followed by obturation with gutta-percha points and Zinc
Oxide-Eugenol by lateral condensation technique. Post
operative radiograph revealed well condensed gutta-
percha in all the three different root canals (fig 6). Coronal
seal was done followed by a metal ceramic crown
restoration (fig 7).

FIGURESDISCUSSION
Clinically, with the numerous morphological and
anatomic variations of teeth detected and reported of late,
3-dimensional determination of the internal structure of
teeth, the form and number of root canals has become a
challenge encountered very often. Root canal treatment
has shown that the pulp cavity is highly variable, making
treatment of each tooth unique. Whenever there is an
indication of unusual anatomy, additional periapical
radiographs should be taken with mesial and/or distal
shifts (5). If one eccentric orifice is found then one more
canal should be searched on the opposite side (6).
This case report emphasizes the importance of looking for
canals and of ensuring adequate access to improve the
likelihood of finding and treating additional canals. To
investigate properly the possibility of additional canals,
the dentist should understand the complexity of the
morphology, take additional radiographs with shifted
angles and ensure adequate “straight-line” access to
improve visibility. And also proper examination of the
pulpal floor has to be done to find for dentinal map which
could lead to areas where additional canals may be
located. A third canal should be suspected clinically
when the pulp chamber does not appear to be aligned in
its expected buccal-palatal relationship.
In maxillary premolars with three roots, the crowns were
broader mesio-distally necessitating the access cavity to
be modified. The completed access cavity preparation
was triangular in out line, resembling the access cavity for
a maxillary first molar, but smaller in size. The root canal
system of premolars with three roots is characterized by
one large palatal canal and two smaller canals in the
mesio-buccal and disto-buccal roots.
Means of magnification like ocular loupes, microscopes
and additional lighting are recommended. Various other
methods such as dyes, CT scans can also be considered as
valuable diagnostic aids in identifying morphological
variations of root canals.
Figure 1 - Preoprerative Radiograph
Figure 2 - Access Cavity
Figure 3 - Working length Radiograph

Figure 4 - Mastercone Figure 7 - Followup Radiograph
Figure 5 - Mastercone Radiograph
Figure 6 - Post-op Radiograph
REFERENCES
1. Carn EJ ,Skidmore.Configuration And Deviations Of
Root Canals Of Maxillary First Premolars. Oral Surg Oral
Med Oral Pathol 36,880-6.
2. Pineda F, Kuttler Y. Mesiodistal buccolingual
roentgenographs investigation of 7,275 root canals. Oral
Surg Oral Med Oral Pathol 1972;33:101-10.
3. Green D. Double canals in single roots. Oral Surg Oral
Med Oral Pathol 1973;35:689-96.
4. Mariusz Lipski, Krzysztof Wo zniak, Ryta Lagocka, Ma
ngorzata Tomasik. Root and canal morphology of the rst
human maxillarypremolar, Durham Anthropology
Journal. 2005;12:2-3.
5. Krasner P, Rankow HJ. Anatomy of the pulp-chamber
floor.J Endod 2004; 30 : 5-16.
6. Vertucci FJ, Gegauff A. Root canal morphology of the
maxillary first premolar. J Am Dent 1979; 99 : 194-8.
Dr. Velmurugan A
Senior Lecturer, Division of conservative Dentistry & Endodontics
Rajah Muthiah Dental college &hospital,
Annamalai university ,Chidambaram
Ph No: 9994022471, email: velsdentcare@yahoo.com
CONCLUSION
The treatment of the entire root canal system is
essential to maximise the possibility of obtaining success
in the endodontic therapy. It is necessary for the clinician
to have a thorough knowledge of the dental anatomy, as
well as of its variations.

INTRODUCTION:
Every human being likes to lead a healthy life in the
society. Health is the state in which the individual feels
the sense of physical and mental well being, in such a
way that the status of general health is closely associated
with the maintenance of oral health. In this connection,
numerous studies have been reported. The dental health
of the general population is being very poor in all over the
world1. In India, it is very sad to know that very few
people believe in regular dental care2. Proper dental care
is very much important as far as oral health is concerned3.
Negligence of oral hygiene and failure of
medication pose microbial abundance in teeth surface
which causes periodontitis and root canal infections. The
prevalence of these diseases has been continuously
increasing 60% - 65% due to change in dietary habits of
people with high sugar foods. Such food particles are
deposited on the surface of tooth and facilitate the growth
of microbes like Enterococcus faecalis, E. faecium,
Candida albicans in oral cavity and thereby releasing
acids4. The acid end products initially affect the enamel
and then spread to dentine and pulp, which results in
formation of cavity. School children are easily affected by
such infection5. When the infections spreads to pulp,
patient feels increasing pain with prolonged sensitivity
and results in endodontic infection. Endodontic abscess
can cause insignificant morbidity, insusceptible
individuals they can pose life threatening problem6.
1. Research Scholar, Department of Microbiology, Bharathiar University, Coimbatore.
2. Reader, Department of Conservative Dentistry and Endodontic, Sri Mookambika Institute of Dental Science, Kulasekharam, Kanyakumari District.
3. Assistant Professor, School of Biotechnology, Madurai Kamaraj University, Madurai.
PREVALENCE OF ENDODONTIC INFECTIONS IN HOSPITAL
REPORTED CASES AT KANYAKUMARI DISTRICT, TAMIL NADU
Key words: Endodontic Infections, Gum Disease, Root Canal Infection And Brushing Habits.
ABSTRACT:
Objectives: A study was conducted with an aim to analyse the dental attendance for root canal infection and assess their association
with age, sex, stages of infection, patho physiological conditions (diabetic, hypertension cardiovascular problem, urinary tract
infection (UTI)) and brushing habits. The study suggested that there is a need to conduct awareness programme highlighting
importance of oral hygiene for the people with levities on oral health.
1 2 3
S.R.Sri Ramkumar *, Dr.Mano Christaine Angelo *, Dr.N.Sivakumar *
Cardiovascular disease such as atherosclerosis and
myocardial infarction are also associated with oral
infections.
Despite oral infections are being challenged. Endodontic
therapy is an appropriate remedy to reduce the
infections7. Root canal treatment (RCT) and coronal
restoration (CR) in general dental practice is being
required to promote oral and periapical health8. To
prevent such infections, the study would feasibly helpful
to insist the importance in maintaining oral health, create
the awareness about dental infections and educate the
public highlighting dental problems. Hence, the study is
an attempt to analyse the root canal infected cases and
their association with age, sex, patho-physiological
(diabetic, hypertension cardiovascular problem, UTI) and
brushing habits of hospital visited cases in Kanyakumari
District, TamilNadu.
2. METHODOLOGY
The data was collected from five different private
dental hospitals of Kanyakumari District, TamilNadu.
Duration of the study was from July 2012 to December
2012. Study was conducted on (n=1817) hospital
attended cases with the complaints of gum disease, tooth
decay or dental caries and anticipating root canal cases in
dental visit. Every individual had equal chance of
selection based on the registered record data. The
hospital register was fulfilled by the objectives of the
present survey which consists of personal history family

history, dental history, and medical history and brushing
habits of patients. From this, percentage and prevalence
of root canal infections analysed with the patient’s history
which includes age, sex, other medical complications
(diabetic, hypertension, cardiovascular problem and UTI)
and their dental care.
3. RESULTS
The present study clearly enunciates the total number of
cases (n=1817) reported for dental visit with the
complaints of gum disease, tooth decay and secluded
root canal cases from tooth decay (shown in Table 1).
Out of 1817 cases, males 49.5% (n=900), females
50.5% (n=917) were reported and analysed. In this total
population, 13.65% males, 11.4% females had gum
disease whereas, 36.87% males and 38.30 % female
were recorded under tooth decay. The highest numbers
of above cases (gum disease, tooth decay) were reported
in the age 18-35 but the lowest numbers of these affected
cases were reported under the age of 12-17, and
the age above 50 respectively. However, no root canal
cases were reported in patient with gum infection, but
reported only in tooth decay, (n=1366) thus n=419
(males 216, females 203) root canal cases secluded from
tooth decay. Hence patients with gum disease were not
mentioned in further analysis. During analysis,
prevalence of root canal cases would maximum at the age
of 18-35 (male, n=142; female, n=125) whereas lowest
numbers of such positive cases reported at the age of
above 50 (male, n=13; female, n=8). The percentages of
root canal infected cases were calculated distinctly out of
total population of tooth decay in each age group, also
tabulated. In such a way the age group 18-35 showed
highest percentage of positive root canal infected cases,
n= 584 (24.3% males and 21.4% female), percentage of
positive root canal cases of tooth decay were tabulated in
Table.1.
Table 2 shows the root canal infected cases in
different stages of infection. Among the 419 root canal
infected cases, 57.52% (n=241) acute pulpitis, 35.32%
(n=148) chronic pulpitis and 7.16% (n= 30) chronic
with periapical inflammation were reported. Percentages
of cases were calculated out of total number of each
stage. The highest number of acute male (71.64 %),
female (65.42%) and chronic male (60.52%), female
(54.54%) was reported under age group 18-35. But
lowest numbers of acute male (4.47%), female (3.7%)
and chronic male (5.63%), female (3.89%) were
recorded under the age above 50. Cases with chronic
periapical inflammation male (36.36 %), female (26.31
%) were maximum at the age 36-50. But lowest number
of such cases reported in the age 12-17 (male, 9.09%).
Figure 1 shows the various patho-physiological
conditions of root canal infected cases. Diagram has been
given by means of percentage of affected cases out of total
in each age group. As a result, patho physiology
associated problems, such as diabetic, hypertension were
not much influence on root canal affected cases in the age
12-17 and 18-35. But little difference was showed in the
age group of 36-50 and above 50. In above 50 age group,
23.1% of male and 25% of the female cases showed
cardio vascular problems. UTI and allergy were not
influenced more in such infections.
Brushing the tooth with various materials was
reported in Figure 2. In the age group 12-17, the
highest percentages of root canal infections reported in
patients who had single time brushing habits with tooth
paste. Whereas in 18-35, such cases had single time
brushing habits with powder and ash. The age 36-50,
above 50 the occurrence of such cases reported in patient
by using finger with ash, but it is being discriminated in
female. In female the age 36-50 above 50, 33.9%
and 37.5% of root canal cases were reported respectively
due to single time brushing with tooth powder. Moreover
people who had the brushing habits using finger with ash
for tooth cleaning were considering the major cause in
this infection. Brushing habits like single time and two
times were showed in Figure 3. Single time brushing
habits always had showed highest percentage of root
canal infections than two times brushing in both male and
female at all age groups.
Table : 1 Sex and age wise distribution of gum disease and
tooth decay cases reported in dental visit
Values with in the ( ) indicates the percentage.
Age
Gum Disease Tooth Decay
Grant totalMale Female
Total
Male Female
Total &
(%)
Root
canal case
Non root
canal case
Root
canal case
Non root
canal case
Root canal
case
Non root
canal case
Root canal
case
Non root
canal case
12 – 17 Nil 26 Nil 23
49
(10.86)
19 114 17 148
298
(21.81)
347
(20.36)
18 – 35 Nil 81 Nil 92
173
(38.35)
142 158 125 159
584
(42.75)
757
(41.66)
36 – 50 Nil 79 Nil 57
136
(30.15)
42 143 53 147
385
(28.18)
521
(28.67)
50 above Nil 62 Nil 31
93
(20.62)
13 38 8 40
99
(7.25)
192
(10.57)
Total Nil 248 Nil 203
451
(100)
199 453 220 494
1366
(100)
1817
(100)

Table : 2 Age and sex wise analysis of different stages of
endodontic cases
Values with in the ( ) indicates the percentage.
Figure – 1: Root canal infected cases with different
pathological conditions. a) Diabetics, b) hypertension, c)
cardio vascular problems, d) urinary tract infection and e)
allergy. Percentage of the positive cases were calculated
on the basis of root canal infection in Male [12-17 (n=
19); 18-35 (n= 142); 36-50 (n= 42) and above 50
(n=13)] and female [12-17 (n= 17); 18-35 (n= 125); 36-
50 (n= 53) and above 50 (n=8)]. male, female.
Figure -2: Brushing habits of dental care visited cases with
root canal infections a) Brush with paste, b) Brush with
tooth powder and c) Finger with ash. Male, Female.
Percentage of the positive cases were calculated on the
basis of root canal infection in Male [12-17 (n= 19); 18-
35 (n= 142); 36-50 (n= 42) and above 50 (n=13)] and
female [12-17 (n= 17); 18-35 (n= 125); 36-50 (n= 53)
and above 50 (n=8)].
Figure -3: Brushing habits of dental care visited cases with
root canal infections. a) Single time brushing and b) two
time brushing. male, female. Percentage of the
positive cases were calculated on the basis of root canal
infection in Male [12-17 (n= 19); 18-35 (n=142); 36-50
(n= 42) and above 50 (n=13)] and female [12-17 (n=
17); 18-35 (n= 125); 36-50 (n= 53) and above
50 (n=8).
4. DISCUSSION
Oral health is an important and integral part of
health care in every individual9. It should be needed to
every one for bringing them rejoice and evolving healthy
life. So the present study feasibly helps in intensify the
needs of dental care as well as home care thus zealous on
oral health of individual is being instigated to improve the
status of general health10 successfully. Hence there is a
need to conduct a survey on people who have gum
disease and tooth decay followed by root canal infection
in hospital reported cases. The study population was
done purely on the basis of dental care attended cases,
their by percentage of root canal infections were analysed
in different strategies.
Among 1817 cases, 23.05% (n=419) were recordically
subjected into root canal treatment. This data is only
obtained from tooth decay and not in gum disease. It is
comparatively less than that of cases reported in
Europe11 (42%). The prevalence of root canal infection
AGE
MALE FEMALE
Grant
totalAcute
(n = 134)
Chronic
(n = 71)
Chronic
periapical
inflammation
(n = 11)
Total
(n = 216)
Acute
(n = 107)
Chronic
(n = 77)
Chronic
periapical
inflammation
(n = 19)
Total
(n = 203)
12-17
9
(6.71)
9
(12.68)
1
(9.09)
19
(8.8)
15
(14.01)
2
(2.59)
0 17 36
18-35
96
(71.64)
43
(60.56)
3
(27.27)
142
(65.7)
70
(65.42)
42
(54.54)
13
(68.42)
125 267
36-50
23
(17.16)
15
(21.12)
4
(36.36)
42
(19.44)
18
(16.82)
30
(38.96)
5
(26.31)
53 95
50-above
6
(4.47)
4
(5.63)
3
(27.27)
13
(6.02)
4
(3.738)
3
(3.89)
1
(5.2)
8 21
Total (%) 62.04 32.87 5.09 100 52.70 37.93 9.36 100 419
Mean 31.76 32.43 49.18 30.55 37.84 35.26

increased with age 18-35 and 36-50 and no marked
gender differentials were observed. But gum disease was
high in all age groups. Gum disease (Gingivitis) is the
mildest form of periodontal disease12.
In the age group (12 - 17), 133 (31%) males and 165
(39%) females were affected by tooth decay this may be
due to the appearance of early teeth eruption. The India
Dental Association (IDA) shows that 70% of children
under the age of 15 suffer from gum problems13. Forty-
two percent of children and adolescents aged 6-19 years
and approximately 90% of adults had dental caries in
their permanent teeth 14. Only 10.37% of this age group
was root canal infected cases. Previous study by Arifkhan
et al. reported that 5.48% male and 4.8% female were
assessed as root canal infected cases15.
In this age, occlusal pit and fissure caries would develop
by means of deposition of food particles on its surface and
utilization of such deposit by microorganism, 90% of the
children were affected by this caries16. Inspite of more
pit-and fissure caries under the age group, cases reported
for root canal infection is less in comparison to other
mentioned age group age group. It may be depending
upon the formation of caries, because caries process
might have begun meticulously during this age group.
But it is only at an incipient stage. So it would not have
developed to attain the stage of root canal infection. It
seems to understand that such cases might have visited
dental hospital for root canal treatment at the age of 18-
35.
The age 12-17, people have least interest in frequent
dental check up because they feel that such treatment is
costly 17 and dental fearness 18. This may be the other
vital reason of dental visit being lower in the age group.
The reason for this lower dental attendance may be due to
food habits, money and medication they are specially
depend upon their parents 19.
The age groups 18-35, was one of the utmost age group to
be high lightened among the study population, since root
canal cases was much higher than the other age groups. It
may be ascribed to the factors such as (a) tooth
morphology, (b) previous infections, (c) newly developed
caries, (d) high inquisitiveness in oral and personal
hygiene, (e) self earning and (f) beauty conscious. The
peoples have adequate knowledge in oral hygiene and
oral health also influence in increasing the case visit for
regular checkup, cleaning of teeth restoration of teeth3,
extraction of teeth and treatment for bleeding gum and
endodontic treatment20. This may be the reason of dental
attendance being higher in the age group. Moreover
these people are mostly beauty conscious they could
clearly understand that the oral health itself decides their
beauty. Next income and education may be an important
factors and in response to dental visit being more in this
age group.
Root canal infected cases with 3 different stages also
assessed and recorded in accordance with signs and
symptoms. They are acute pulpitis, chronic pulpitis and
chronic with periapical inflammation So far discussed the
results the highest case of acute pulpitis male (71.64) and
(65.42) female were reported under age of 18-35 it is
credibly supported by Benoit et al.3 to the present study.
In the age 36-50 smooth caries were very common21.
This statement looks quite plausible, that it is developed
by the disappearance of pit and fissure of teeth, due to
brushing habits, abrasive food, brushing with ash,
rubbing with finger and chewing of leaf and also it is
associated with poor oral hygiene22. As previously
reported, mostly the root canal treatment is being taken
under the age group 18-35, therefore report for the dental
visit is being comparatively less in the age 36-50. In this
age group endodontic failure cases were reported. People
may lazy and dental fearness in dental visit for attending
root canal treatment under the age of above 50. To
support this, similar findings have been reported by
Quteish Taan23. Also smooth surface caries and pit and
fissure caries were not found to be common though it is
present. It may not attain the stage of root canal infection
whereas root caries is common24.
Among the study population in all age groups various
patho physiological condition and habits interruption on
root canal cases were recorded and represented in Figure
1. People know that the diabetes mellitus is a major risk
factor, in that way present study analysed the root canal
case with diabetic. Diabetic mellitus25 is closely linked
with tooth decay it gives great significance in periodontal
disease. In this study male 8.3%, female 6.4% had
diabetic consequences out of total population. Based on
the results, the study concludes diabetic was not
significantly influence the root canal infection. In such a
way that hypertension, cardio vascular problem, and UTI
were also not significantly influence the root canal
infections. From this study we could know that hygienic
maintenance is the only plausible mechanism to protect
our teeth. The influence of brushing materials like paste,

powder and ash on root canal infection was studied
(Figure 2). In the present analysis, male brush with tooth
powder showed higher percentage of root canal
infections under the age group of 18-35, 36-50 and above
50. Using finger with ash showed highest percentage root
canal infection at the age group 36-50 and above 50. In
female used finger with ash for tooth cleaning has higher
percentage of root canal infection at all age groups. It was
also found that the brushing habits were of so much
concern among the younger age group in maintaining
oral health.
5. CONCLUSION
The analysis was concluded that highest number of cases
reported in the age group of 18 - 35. The reason for this
could be attributed to person belongs to this age group
showing more interest in oral and personal hygiene.
Other health related issues are not directly influence the
tooth decay and root canal infections. Maintenance of
oral hygiene could be the only possible means of
protecting our tooth.
REFERENCES
1. Jyoti B, Muneeshwar PD, Srivastava R, Singh AR, Kiran
M, Simlai J. Oral Health Status and Treatment Needs of
Psychiatric Inpatients in Ranchi, India. J Indian Academy
Oral Medi Radio. 2012; 24(3), 177-181.
2. Kakatkar G, Bhat N, Nagarajappa R, Prasad V, Sharda
A,. Asawa K, Agrawal A. Barriers to the Utilization of
Dental Services in Udaipur, India. J Dent (Tehran). 2011;
8(2): 81–89.
3. Varenne B, Msellati P, Zoungrana C, Fournet F, Salem
G. Reasons for attending dental-care services in
Ouagadougou, Burkina Faso. Bulletin the World Health
Organization, 2005; 83(9), 650-655.
4. Aysin Dumani, Oguzyoldas, Sehnaz yilmaz, et al. PCR
of Enterococcus faecealis and Candida albicans in apical
periodontitis from Turkish patients. J Dent Clin Expe,
2012; 4(1): 34-39.
5. Adekoya-Sefowora CA, Nasir WO, Oginni AD, Taiwo
M. Dental caries in 12-year old sub urban Nigeria school
children. Afr health sci.2006; 6(3):145-150.
6. Walsh LJ. Serious complications of endodontic
infection some cautionary tales. 1997; 42 (3) : 156-9.
S.R.Sriram Kumar, Research Scholar,
S/o.S.Rajendran,
Keezhamavilai, South Soorankudi (P.O), K.K.District – 629 501.
Cell : 9442312911

INTRODUCTION:
Developmental anomalies of the dentition are not
infrequently observed in the dental clinic. Microdontia is
a rare phenomenon. The term microdontia
(microdentism, microdontism) is defined as the condition
of having abnormally small teeth (1). It may involve all the
teeth or be limited to a single tooth or a group of teeth.
Often the lateral incisors and third molars may be small
(2). According to Boyle, “In general microdontia, the
teeth are small, the crowns short, and normal contact
areas between the teeth are frequently missing”(3).
Shafer, Hine, and Levy divide microdontia into three
types: microdontia involving only a single tooth; relative
generalized microdontia due to relatively small teeth in
large jaws; and true generalized microdontia, in which all
the teeth are smaller than normal (4).
Hyperdontia is the development of an increased
number of teeth, and the additional teeth are termed as
supernumerary. Supernumerary teeth are considered as
one of the most frequent dental anomalies which exceed
the normal dental formula. Depending upon their
location, several terms have been used to describe
supernumerary teeth. A supernumerary tooth in the
maxillary anterior region is termed as the mesiodens; an
accessory fourth molar is often called a distomolar or
distodens. A posterior supernumerary tooth situated
lingually or buccally to a molar tooth is termed a
paramolar (5,6). We are hereby reporting an unusual
1. M.D.S, Assistant Professor, Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre,
Poinachi, Kasaragod.
2. M.D.S, Reader, Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre,
Poinachi, Kasaragod.
3. M.D.S, Department of Oral Medicine and Radiology, A B Shetty memorial institute of dental sciences, Deralakatte, Mangalore.
4. M.D.S, Assistant Professor, Department of Oral Medicine and Radiology, Century International Institute of Dental Science and Research Centre,
Poinachi, Kasaragod
“AN UNUSUAL OCCURRENCE OF HYPERDONTIA AND MICRODONTIA IN
SINGLE CASE”
Key words: Hyperdontia, Microdontia, Mesiodens, Supernumerary.
ABSTRACT:
Abnormalities in size of teeth and number of teeth are occasionally recorded in clinical cases. Hyperdontia is the
development of an increased number of teeth, and the additional teeth are termed as supernumerary. Microdontia
is a condition where the teeth are smaller than the normal size, which may involve all the teeth or be limited to a
single tooth or a group of teeth. We are reporting a unique and unusual case of occurrence of supernumerary tooth
with microdontia in the maxilla.
1 2 3 4
Dr. Anusha Rangare Lakshman , Dr. Sham Kishor Kanneppady , Dr. Preethi Balan , Dr. Chaithra Kalkur .
occurrence of mesiodens and microdontia of third molars
in the maxilla.
CASE REPORT:
A 50 year old male patient reported to the Department of
Oral Medicine and Radiology, with the complaint of pain
in the lower front tooth region since a year. Pain was dull
aching, intermittent, non- radiating, throbbing type. Past
medical, dental and family histories were non-
contributory. On examination, a supernumerary tooth
was noticed between the upper central incisors which
was smaller in size when compared to the adjacent teeth
and the both upper third molars were smaller in size
compared to the other teeth (Figure 1A, B). Generalised
periodontitis was also observed. The left upper third
molar was mobile. Provisional diagnosis of chronic
generalised periodontitis, hyperdontia and microdontia
were given. He was referred to Department of Oral and
Maxillofacial Surgery for extraction of the supernumerary
tooth and the third molars, followed by periodontal
therapy.
DISCUSSION:
The human dentition shows various developmental
dental anomalies which generally manifest as a variation
in tooth size, shape, number, or structure.
Supernumerary teeth are considered as one of the most
frequent dental anomalies. The prevalence of
supernumerary teeth in Caucasians is between 1- 3%,

with slightly higher rate seen in Asian populations.
Approximately 76-86% of cases represent single-tooth
hyperdontia (5).
The pathogenesis of hyperdontia has been postulated to
be caused by the development of excess dental lamina,
which presumably leads to the formation of additional
tooth germs (5).
Multiple supernumerary teeth are frequently associated
with various craniofacial anomalies including cleft lip
and palate, Gardner’s syndrome, and cleidocranial
dysostosis (4-6).
Subacute pericoronitis, gingivitis, periodontitis, and
abscess formation are the most common complications of
supernumerary teeth. In selected cases, clinical judgment
may not dictate surgical removal, or patient resistance to
therapy may be present. In these instances regular
monitoring is appropriate (5). The complications of
mesiodens clinically include delayed eruption of
permanent incisors, midline diastema, axial rotation, or
inclination of erupted permanent incisors, resorption of
roots of adjacent teeth, root anomaly, cyst formation, and
intra-oral infection (7-10).
Periapical, maxillary occlusal and panoramic
radiographs are essential in the diagnosis of impacted
supernumerary teeth (7). Early diagnosis and treatment
often are crucial in minimizing the aesthetic and
functional problems of the adjacent teeth. Only 7-20% of
supernumerary teeth are associated with clinical
complications, the standard treatment management
would be removal of the extra teeth.
Microdontia is a condition where the teeth are smaller
than the normal size, which may involve all the teeth or
be limited to a single tooth or a group of teeth. Both
genetic and environmental factors are involved in the
complex etiology of microdontia. Genetic factors
probably play a role in the formation of microdontia. The
deciduous dentition appears to be affected more by
maternal intrauterine influences; the Permanent teeth
seem to be more affected by environment (5).
The syndromes associated with microdontia are Gorlin-
Chaudhry-Moss syndrome, Williams’s syndrome,
Chromosome d/u, 45X [Ullrich-Turner syndrome],
Chromosome 13 [trisomy 13], Rothmund-Thomson
syndrome, Hallermann-Streiff, Orofaciodigital syndrome
(type 3), Oculo-mandibulo-facial syndrome, Tricho-
Rhino-Phalangeal, type1 Branchiooculo- facial syndrome
(11).
Peg laterals are the one of the commonest forms of
localized microdontia which affects the maxillary lateral
incisor. Instead of exhibiting parallel or diverging mesial
and distal surfaces the sides converge or taper together
incisally forming peg shaped or conical shaped crown.
The next tooth which can be affected is the third molars
(11, 12). In the present case, the mesiodens as well as
maxillary third molars were smaller in size compared to
the other teeth. A conservative management is advised for
microdontia keeping in view the age and sex of the
patient. In our case, we advised for the extraction of the
supernumerary tooth.
A) Shows the presence of mesiodens and
microdontia of maxillary third molars bilaterally.
B) Shows the microdontia of left maxillary third
molar.

LOADING OF TWO IMPLANTS IN THE MANDIBLE AND FINAL RESORATION WITH A LOCATOR;CASE REPORT,A REVIEW

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