This document discusses force systems in orthodontics and provides an overview of traditional and recent concepts related to mechanotransduction, the process by which orthodontic forces are biologically transformed. Mechanotransduction is the field that examines how force is converted into biological reactions in teeth, with tooth movement occurring through the physiological process of bone resorption by osteoclastic cells in response to applied mechanical forces. A better understanding of force systems based on physics, mechanics and biology is important for effective orthodontic treatment.

4. EN
TAL ASSO Journal of the Indian Dental Association
D
C IA
INDIAN
Tamil Nadu State Branch
TI O N
Journal Office : Vel Dental Home, No.10, Bharathi Street,
Pondicherry - 605 001.
Volume 5 Issue 16 Knowledge . Service . Love
Jan. - Mar. 2013 www.jidat.in
Advisors President DR. D. SENTHIL KUMAR
Dr. S. Thillainayagam
Honorary State Secretary DR. C. SIVAKUMAR
Dr. C.R. Ramachandran
Dr. Gunaseelan Rajan Honorary Treasurer DR. T.S. RANJITH
Dr. George Paul
President-Elect DR. S. THILLAINAYAGAM
Dr. Sivapathasundaram
Dr. S.M .Balaji Imm. Past President DR. K. RAJASIGAMANI
Dr. N.R. Krishnaswamy
Vice Presidents DR. A.P. MAHESWAR
Editor in chief DR. RADHA KRISHNAN
Dr. A. Thangavelu DR. V. BASKAR
Associate Editors
Hony. Jt. Secretary DR. M. SETHU ANANDAN
Dr. Jayantha Padmanaban
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Dr. J. Selvakumar
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Dr. R. Madhan
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5. Guidelines for Authors
Submit all manuscripts to :
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of the Journal of the Indian Dental Association Tamilnadu against all claims and expenses including legal costs
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6. From the President's desk
At the outset I take this opportunity to thank all my IDA members and well wishers for honouring me on taking
over as the President of IDA-Tamilnadu for the year 2013. I wish everyone of you to have a very productive and fruitful
New year 2013.
A month has passed and I am happy to inform you that I have already touched the ground and visited a few
branches. It was a pleasure to meet and interact with several office bearers and members of Marthandam and Madurai.
I am happy to see the enthusiasm among several of our members and I hope this spirit continues to prevail all
across the state so that all of us together can make IDA truly a larger and stronger body.
I strongly believe that as dentists we have a strong commitment to the community in which we live.
The basic aim of IDA is to promote oral health and hygiene in the country and all the efforts of IDA are directed
at attaining this cherished goal.
At the same time enhancing the image of our members in the public and promoting their professional
advancements and their family security are matters very close to IDA.
Organising lectures and scientific symposia are means of keeping abreast with the changing world of dental
science and we are working on it.
We need your cooperation and support in taking dentistry to higher levels of excellence and without that IDA
would not be able to achieve the goals it has set for itself. Vazhga IDA.
Dr. D. Senthil Kumar BDS
President, IDA-Tamil nadu
C.Doraiswami Nalayini Dental Clinic,
8,Azad Street,Udumalpet.642126.
9842225506, sendhana@gmail.com.

7. From the Secretary's desk
Dear Friends,
Wish You All Very Happy Prosperous New Year.
Dentist are specialty oriented professional, each and every specialty in dentistry are interrelated and the specialist have
great relationship with each other The present day development in the Dental field especially the technological advances
in each specialty create a great challenge to update and to put it in our day to day practice for the benefits of our patients
.There is a wide range of technological changes in Dental Science- today. In these situations the journal published by
State Branch of IDA plays a major role in getting the update information to the clinic desk .
I am sure the Tamilnadu Journal (JIDAT) is severing the purpose for more than a year and continues to do so. Each and
every member reading the journal should promote the journal and motivate the other members to subscribe for the
journal. Similarly another field were we should improve is “Service and creation of Awareness among the rural patient.
We can improve this by improving our local branch CDH programs. CDE Credit Point is must to renew our council
registration. I sincerely request all the members to attend all IDA activities, and get the maximum benefit from our
association .
Do more CDH Activities.
Best Wishes.
Dr.C. Sivakumar
Hon. Sec IDA TN

8. From the Editor's desk
Knowledge, Service, Love
Nothing as Empowering as Knowledge,
Nothing as Compassionate as Service, &
Nothing as Gratifying as Love!!!
Dear Pals
Wishes for a happy and prosperous new year. Hope this New Year brings all the strength and prosperity to our
profession. After a long contemplation about 21st Dec 2012 – “The End Of The World “ , in spite of all prophesies ,
Mayans calendar, earth changing the axis, comets hitting the earth ,we now see the survival of the human continue to
exist towards 2013 and further .
Life is like that!...we pass through the difficulties we face , we cross all the hurdles we come across . Its sure that
nothing can stops us from living. The thing is how we live is the questions? We should think and take that path which
lead us to live with morality, ethic and humanity. Each and every individual should try to live for good. All of us should
take a task to improve our standards There are lots of things to ponder, to enjoy, to correct , to modify and to change Let
the new year give all that strength to all our members to take a resolution , take a chance ,join hands and fight for our
rights and to stabilize our profession “ Dentistry” .
Each one of us have a great role in it , let us not blame each others for the flaws Everyone has a responsibility, if
each one of us walk towards that good changes I am sure our profession will leap ahead and be an envy to our colleagues,
job opportunities, irregularities in dental education, Unethical practices, service to the needy and developing a clear
identity among the health professional are the areas of concern. So Let us arise, join hands to solve our problems,
Let us change for the CHANGE and create a history.
Prof. Dr. A. Thangavelu, MDS, DNB.,
Editor-in-Chief, JIDAT

9. Journal of the Indian Dental Association - Tamil Nadu
Vol. 5 Issue. 16 Jan. 2013
Contents
Force Systems in Orthodontics – An Overview of Traditional and Recent Concepts 01
Dr. Santhana Krishanan, Dr. K.Rajasigamani, Dr. N. Kurunji kumaran, Dr. V. Venkataramana
Cranial Bone Graft for Orbital Floor Reconstruction 04
Dr.C. Hari Prasath MDS, MOMS RCPS, Prof. Vinod Narayanan, MDS; FRDRCS; MOMS RCPS
Comparison of Radicular and Intra Radicular Stud Attachments: Case Reports 10
Dr. Bharanija Kalidasan Selvi, Dr. Eazhil Raj, Dr. Jaya KrishnaKumar S, Dr. Azhagarasan N.S
An Insight to Single Visit Endodontics 14
Dr. A. Shafie Ahamed, Dr. Deepa Vinoth Kumar
Common and Uncommon form of Oral Mucocele 18
Dr. Sudhaa Mani MDS , Dr. Eswaramurthy BDS
Interim and Esthetic Management of an Avulsed Tooth 22
Dr. S. Leena Sankari M.D.S
Periodontal Disease and Respiratory Infection - A Link 25
Dr. P.l. Ravishankar, Dr. S. Rajsekhar
Milestones in Periodontics 27
Dr. D. Ida Sibylla BDS, M.Sc., (Neuroscience)

10. Vol. 5 Issue. 16 Jan. 2013
Patient-Friendly Approach to the Management of Periodontal Disease 33
Dr. M. Vijayalakshmi, Dr. Gayathri. S, Dr. M. G. Krishna Baba, Dr. Sumathi. H. Rao, Dr. T. Geetha
Pathophysiology of Acute Necrotizing Ulcerative Gingivitis
(Anug) / Vincent's Infection - A Review 36
Dr. K. Sasireka M.D.S, Dr. M. Devi M.D.S
A New Concept of Dental Arch of Children in Normal Occlusion 39
Abu-Hussein Muhamad DDS, MScD, MSc, DPD, FICD, Sarafianou Aspasia DDS, PhD
Mobile Dental Clinic – An Outreach Government Programme - An Overview 45
Dr. Ramasubramanian .S, BDS
Non Pharmacological Management of Dental Anxiety in Adults 48
Dr. A.M.Devapriya MDS, Dr.D.Mythireyi MDS

11. FORCE SYSTEMS IN ORTHODONTICS –
AN OVERVIEW OF TRADITIONAL AND RECENT CONCEPTS
Dr. Santhana Krishanan1, Dr. K.Rajasigamani2, Dr. N. Kurunji kumaran3, Dr. V. Venkataramana 4
1. Assistant professor, 2. Vice principal, 3. Reader, 4. Reader,
Department of Orthodontics, Raja Muthiah Dental College and Hospital, Annamalai University, Chidambaram
ABSTRACT:
There is little doubt that the prevalence of patients with underlying medical conditions seeking orthodontic care has
increased over the past two decades. In this literature we are discussing some major medical problems and
precautions to be taken during orthodontic treatment.
INTRODUCTION: physiological reaction to the forces applied by
mechanical procedures. The physiological process of
Mechanotransduction is the field which discusses the resorption by the osteoclastic cells is the basic activity
mechanism of biotransformation of force into biological that allows the bone to change and tooth to move. Since
reaction. In orthodontics force is used to correct a given these osteoclastic cells are carried by the blood to the site
malocclusion, the tooth responds to the applied force and of their activity and resultant bone resorption, the key
move towards the proposed final ideal position. A better factor in the efficiency movement of teeth seems to be the
understanding of force systems on the basis of physics, blood supply carries cell and sustains their activity. When
mechanics and biology is a mandatory for proper a generous blood supply can be maintained by applying a
understanding of orthodontic mechanotherapy. light force, tooth movement is more efficient. When
blood supply to the area, the osteoclastic activity of bone
In this context, the present overview emphasizes on the
resorption is limited and the teeth do not move or they
traditional and recent concepts of force systems utilized
in orthodontics and their corresponding biological move slowly. Heavy forces that squeeze out the blood
response produced by teeth. cells can limit the physiologic response and markedly
affect the rate of tooth movement.
1. OPTIMUM ORTHODONTIC FORCE
3. STAGES IN TOOTH MOVEMENT
The magnitude of the optimum force will vary depending
on the way it is distributed in the periodontal ligament i.e. Figure 1, explains the stages of tooth movement after an
it is different for different types of tooth movement. application of a moderate orthodontic load of 20 to 50g.
Smith and Storey1 in their study on tooth movement in 8
patients concluded that optimal lower canine movement
occurs with 150 to 250 grams of force. At higher force
levels of 400 to 600 grams, the anchor unit of the second
premolar and first molar moved more than the canine.
Fortin2 recommends 147 gm as the optimum force for
premolar translation in dogs. Reitan3 advocates 250 gms stages of tooth movement
for retraction of human lower canines. Lee recommends
150 gms to 260 gms as optimum canine retraction force.
Tooth movement can be differentiated into three phases.
Rickctts and associates prescribe 75 gms as optimum
force for canine retraction.
3.1 Initial Phase
2. PHYSIOLOGY OF TOOTH MOVEMENT
This is characterized by rapid tooth movement. It lasts for
4 a few days normally. The rapid onset of displacement
Ruel W. Bench et al in 1978 put forth the physiology of
immediately after force application suggests that tooth
tooth movement. The orthodontic movement of teeth
movement in the initial phase largely represents
occurs as a result of the biological response and the
displacement of the tooth in the periodontal space.
01 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013

12. 3.2 Lag Phase tooth movement produced. This center of rotation (which
characterizes the type of tooth movement) is determined
Tooth does not move or show a relatively low rate of by the M/F parameter for a given tooth.
displacement compared to the initial phase. This lag in
tooth displacement is due to the hyalinization (non 6. WAYS OF INCREASING M/F RATIO
vitalization) of the periodontal ligament in maximal stress
areas. No tooth movement can occur until the area of non Poul Gjessing6 observed that M/F ratio could be raised by
vitalization has been removed by cellular process. I) Increasing the vertical dimension gingival to the bracket
2) Increasing the horizontal dimension in the apical part
3.3 Post Lag Phase of the loop 3) Decreasing the interbracket distance
4) Positioning of the loop close to the tooth to be retracted
Here, there is sudden increase in rate of tooth movement. 5) Angulating the mesial and distal legs of the spring
As the hyalinized zones disappear, force producing 6) Adding more wire gingival to the bracket.
frontal resorption on the alveolar bone increases the rate
of tooth movement. 7. FORCE DECAY
4. DESIGN FACTORS IN ORTHODONTIC The force magnitude of springs or loops gradually
APPLIANCES declines as the tooth moves. This decline is force decay.
Only in theory, it is possible to make a perfect spring, one
In order to achieve the desired tooth movements, the that would deliver the same force day after day, no matter
proper force system is a critical requirement. Few terms how much of how little the tooth moved in response to
must be borne in mind before determining the design that force. With many orthodontic device the force may
factors. even fall to zero.
A force is a load applied to an object that will tend to Based on force decay, force duration is classified as
move it to a different position in space. (figure 2)
The moment of a force is equal to the magnitude of the
force multiplied by the perpendicular distance from its
line of action to the centre of resistance.
The only force system that can produce pure rotation
(i.e. a moment with no net force) is a couple which is two
equal and opposite, non-collinear but parallel forces.
The point around which rotation actually occurs when an
object is being moved is center of rotation.
Center of resistance is that point at which a free object or
body can be perfectly balanced. At this point, resistance
to movement is concentrated for mathematical analysis.
5. FACTORS DETERMINING CENTRE OF RESISTANCE
Root lengths, Marginal bone level, characteristic of
periodontal ligament are some factors5 that has to be
considered while determining center of resistance. In
order to produce movement other than uncontrolled
tipping by applying a force system only at the bracket, a
single force alone is insufficient [movements such as Types of forces
bodily translation as required in space closure using
Continuous
edgewise and preadjusted edgewise appliances]. In these
Interrupted
cases, a rotational tendency (moment) must also be
Intermittent
applied to the bracket.
In order to attain a desirable tooth movement, an
The proportion of the rotational tendency (moment) to
optimum and a constant force is required. This is possible
the force applied at the bracket will determine the type of
only with a proper load deflection rate.
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 02

13. 8. LOAD DEFLECTION RATE Light, intermittent forces during closing spaces allows the
resorbed cementum to heal and prevent further
Refers to the amount of force produced for every unit of resorption8. Mc Fadden et al9 found no difference in the
activation of an orthodontic wire or spring. If the rate is extent of root resorption in patients treated with or
lower, the force is more constant as the tooth moves. without extractions.
8.1. Wire Cross Section CONCLUSION
The load deflection rate in a round wire is directly Till date force is the only medicine available in the hand
dependent on the fourth, power of wire diameter. For by orthodontists to cure malocclusion. Various methods
example, if the cross-sectional diameter of a spring is of force generations have been attempted using elastics,
reduced from 0.016 inch to 0.014 inch (Only 0.002 coil springs, alloy materials, magnets, and screws.
inch), the load deflection rate is nearly halved. The load Irrespective of the utilized methods the applied force
deflection rate of a rectangular wire is directly dependent should be optional in Biological nature to overcome the
on the third power of the diameter. The rate is dependent iatrogenic root resorption and non vitality of tooth during
on the orientation of the rectangular dimensions. or after orthodontic treatment.
A sound knowledge for biological response for an
8.2. Wire Length applied force is the key to success in orthodontic
treatment.
The wire length changes the load deflection rate inversely
as the third power. For example, if the length of the spring REFERENCES
is tripled, the load-deflection rate is dramatically reduced 1. Story E and Smith R. Force in orthodontics and its
by one twenty seventh its initial rate. Therefore, small relation to tooth movement. Aust dent j. 1952:56;11-
increase in the length of the wire dramatically reduces the 18
load deflection rate.
2. Fortin JM: Translation of premolars in dogs by
8.3. Wire Material controlling the moment to force ratio on the crown.
American Journal of Orthodontics and Dentofacial
Altering the material affects the spring rate in direct Orthopedics; 1971; 59; 541- 551.
proportion to its modulus of elasticity. Stainless steel
3. Reitan K: Some factors determining the evaluation of
alloys have replaced the lower strength gold alloys many
forces in orthodontics. American Journal of
years ago. In order to improve the characteristics of
Orthodontics and Dentofacial Orthopedics;
stainless steel arch wire, multistrand wires with greater
1957;43:1;32-45.
flexibility (i.e.) reduced load deflection rates have been
introduced. 4. Ruel W. Bench, Carl F. Gugino, James J. Hilgers -
Bioprogressive therapy part - 6. Journal of Clinical
ROOT RESORPTION Orthodontics 1978:12;2;123-139
Reitan has shown that external root resorption is weakly 5. Kazuo Tanne, Koenig, Charles J. Burstone - Moment
related to force magnitude and closely related to the type to force ratios and center of rotation. American
of tooth movement, specifically intrusion and tipping. Journal of Orthodontics and Dentofacial
External root resorption (ERR) is initiated 14 to 20 days Orthopedics 1988; 94: 426 -431.
after force onset and the process of ERR continues even 6. Poul Gjessing - Biomechanical design and clinical
during retention periods of up to 1 year. It is a product of evaluation of new canine retraction spring. American
average force and the time during which it acts. Journal of orthodontics and dentofacial orthopedics
1985;87:5;353-362.
Dougherty made a clinical observation that in the cases,
in which maximum anchorage preparation was 7. Reitan. K. Biomechanical principles and reaction: In:
necessary and extreme tip back bends placed, there was a Graber TM. Swain BT. Orthodontics-current
greater resorption of mandibular 1st molars especially the principles and techniques: St. Louis CV Mosby.
distal roots. 8. Steadman Sr. Resume of the literature on root
resorption. Angle Orthodontist 1942:12;1;28-38
Root resorption is the same, irrespective of the treatment
modality. Be it Begg or edgewise, it is accepted that 9. Mcfadden et al. a study of the relationship between
extensive tooth displacement, torque movements and incisor intrusion and root shortening. American
jiggling forces are responsible for resorption7. Journal of orthodontics and dentofacial Orthopedics
1989; 96:5;390-396
03 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013
resorption8

14. CRANIAL BONE GRAFT FOR ORBITAL FLOOR RECONSTRUCTION
Dr.C. Hari Prasath MDS, MOMS RCPS1, Prof. VinodNarayanan, MDS; FRDRCS; MOMS RCPS2
1. Senior Lecturer, Division of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital,
Annamalai University, Chidambaram, Tamilnadu.
2. Division of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospital, Saveetha University, Chennai.
Purpose : The study was to evaluate use of cranial bone grafts in orbital floor reconstruction.
Patients and Methods : 12 patients with unilateral orbital floor fracture underwent cranial bone graft for correction
of enophthalmos, hypopthalmos and diplopia. The inclusion criteria were pure blowout fracture of the orbit or
impure blowout fracture of the orbit. Preoperative and postoperative CT scans, Radiographs and measurements
were recorded.
Results : Reconstruction of the orbital floor was done in twelve patients. The period of follow-up and evaluation
for the cranial bone graft was 1 week, 3 months and 6 months. These patients underwent CT scans at six months
period for evaluation of graft position, uptake. The pre operative enophthalmos in twelve orbital floor fractures
varied from 3-6 mm. In this series of twelve orbital floor fracture the post operative enophthalmos score was =2
mm. Five out of twelve patients in the series had preoperative diplopia and none had postoperative diplopia at the
time of follow-up and improvement of the eye position and gaze was also found during the checkups.
Conclusion : Cranial bone is an accessible autogenous tissue which should be considered when an autogenous
graft is needed for orbital floor fracture reconstructions.
INTRODUCTION: the deformity of the bony structures, and this predisposes
to entrapment of the soft tissues by the bony fragments.
Fractures in and around the orbit are common. The
important aspect of orbital injuries is their intimate Surgical correction mandates replacement of the bony
relationship with the globe, periorbital soft tissue, and soft tissues into anatomic position and if necessary,
eyelids, sinuses, brain and the lacrimal apparatus. correction of the deficit in volume 4,5,6
Blowout fractures of the orbit most commonly involve the
floor and/or medial wall. The displacement of the walls Despite the general good results of orbital reconstruction,
can have serious sequelae regarding function and there are cases in which the cosmetic outcomes may be
appearance of the eye 1. It can cause a number of different than those noted immediately after surgery. It is
problems, including diplopia, ocular muscle entrapment, suspected that the implant/graft and soft tissue undergoes
and enophthalmos. From the functional standpoint, resorption, which also affects the position and possibly
displacement of a bony wall disturbs the position of the function of the globe. However it is agreed that the
soft tissues, causing problems of eye movement and reconstruction of the orbital walls is essential to maintain
diplopia. Additionally, direct damage to the soft tissue shape and function of the orbit 7,8,9 . Autogenous cranial
can lead to scar contracture, globe dystopia, and bone grafts have been the preferred material for
dysmotility. If the globe is injured, there can be a loss of reconstruction of the orbital walls for many years10,11 . The
vision 2. purpose of the study was to evaluate use of cranial bone
grafts in orbital floor reconstruction.
Several theories have been proposed to explain the effect
of trauma to the orbit. In the hydraulic theory 2, a hard MATERIALS AND METHODS:
object strikes the soft tissues of the orbit and transfers
pressures from these tissues to one of the orbital walls. The study consists of twelve patients who had orbital
The inner wall then opens like a trap door in to the floor fracture during the period April 2006 to March
adjacent sinus, and the soft tissues are pushed through the 2007. The inclusion criteria were patient with pure
defect. In another theory, called buckling theory3, a force blowout fracture of the orbit, impure blowout fracture of
to the orbital rim causes the orbital walls to buckle, the orbit. The exclusion criteria were orbital fracture with
deforming them and the soft tissues. The deformity of the neurological complications, associated skull base
soft tissues of the orbit recovers much more slowly than fracture, direct trauma to the orbit.
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 04

15. These patients had a previous history of blunt trauma or fracture site. Donor defect is packed with surgical
road traffic accident to the facial skeleton or orbit. (oxidized cellulose). The harvested cranial graft is
Opthalmological and neurological evaluation 12 was prepared and ends are smoothened. Osteotomy cuts are
obtained for all the patients. Routine radiographs 13 and placed if needed to gain the shape of the floor. The cranial
computer tomography scans taken to identify the site and graft is inserted in the defect site and globe position and
size of the fracture. Patients underwent orbital floor level is compared clinically with the opposite normal
reconstruction with cranial bone graft for enophthalmos side.
and impairment in the range of ocular movements.
RESULTS
Pre operative and post operative enophthalmos were
measured by corneal projection using a Hertel Reconstruction of the orbital floor was done in twelve
Exopthalometer. More than 2mm difference was needed patients. The time from initial injury to surgery varied
to show clinically evident enophthalmos. The eye from one week to twelve weeks with a median of six
position on one side could also be used as a control for weeks. The period of follow-up and evaluation for the
the other in the absence of orbital rim displacement. cranial bone graft was 1 week, 3 months and 6 months.
Ocular motility was tested in the field of gaze for any
The most common preoperative clinical findings in this
muscle entrapment. The purpose of the surgery was to
series were limited ocular motility, paresthesia, diplopia
reduce the enophthalmos to as close to zero as possible
and enophthalmos. The indication for surgery in the
when comparing the pre operative values.
patients was orbital floor defect with herniation of orbital
Reconstruction with cranial bone graft was done in
tissue or orbital floor defects associated with other
twelve patients. In this series the cause of injury were
midface fractures with significant enophthalmos.
blunt trauma in 4 patients and road traffic accident in 8
patients. The age ranged from 24 yrs to 39 yrs with a mean
Out of twelve patients, one had developed post operative
of 30.25 years.
infection in the surgical site after one month and
ectropion of the lower eyelid was present. Plate removal
The post operative follow up was scheduled for One
was done for that patient after six months since the
week, Three months and Six months after surgery and
fixation was found to be loose on re-exploration. Scar
post operative CT scans and radiographs were taken to
revision was done for the ectropion of the lower eye lid.
evaluate the graft position, uptake. These post operative
In these twelve patients graft was left in situ with out
follow ups were used for determining resolution of
plating or other kind of fixation. In this series one patient
enophthalmos and diplopia.
had a breach of inner cortex of the calvarium with a dural
OPERATIVE TECHNIQUE: tear and venous bleed. The adjacent temporalis muscle
was taken, crushed, and used as a plug to close the defect
Lower mid lid- crease incision is placed on the skin or the and to stop bleeding. The patient was evaluated for signs
dissection is carried through the existing wound. of neurologic changes which were found to be
Unfortunately, there are limitation to dissect within the completely absent.
orbit and are described as “Safe distances”5. The
subcutaneous dissection is carried out in inferior These patients underwent computer tomography scans at
direction to the orbicularis muscle fibers and stopping six months period for evaluation of graft position, uptake.
when the orbital septum is encountered. Once the They were also evaluated as to whether the
septum is encountered, the preseptal approach is then enophthalmos became clinically insignificant or
carried out inferiorly to the orbital rim. The periosteum is reduced. The pre operative enophthalmos in twelve
incised just below it and subperiosteal dissection is orbital floor fractures varied from 3-6 mm. The post
carried out from orbital rim to the fracture site. operative enophthalmos was analyzed at three and six
months, a time when swelling was believed to have
Cranial bone graft is harvested by placing approximately subsided. The patients out come were recorded as either
6cm skin incision on the mid portion of the parietal bone successful (a post score of =2 mm) or unsuccessful (a post
and dissection is carried till the periosteum. Once the score of >2 mm). In this series of twelve orbital floor
periosteum is incised, bony marks are placed on the fracture the post operative enophthalmos score was =2
cranial bone. Cuts are deepened and limited to the outer mm. Five out of twelve patients had preoperative
dipole. The ends are beveled in 45° angulations and the diplopia and none had postoperative diplopia at the time
chisel and mallet is used for harvesting of the graft. The of follow-up and improvement of the eye position and
bony graft harvested is usually exceeding the size of the gaze was also found during the check ups.
05 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013

16. GRAFT PRE OP PRE OP POST OP POST OP DISCUSSION
NO ENAOPTAHM DIPLOPIA ENAOPTAHM DIPLOPIA
1 4 _ 0 _ The use of bone grafts has played an important role in oral
2 5 + 2 _ and maxillofacial surgery with relative disagreement
_ _ among surgeons on the different grafting methods
3 3 0
_ _ existing. The important criteria’s to be considered when
4 4 1
_ _ evaluating grafting materials include biocompatibility,
5 4 0 availability, osteogenesis, ability to act as a matrix, and
6 5 + 2 _
mechanical stability14,15
7 6 + 2 _
8 3 _ 0 _ The standard regenerative bone grafting material used is
9 4 _ 2 _ autogenous bone for its capability to support
10 3 _ 1 _ osteogenesis, osteoinductive and osteoconductive
11 5 + 2 _ properties. Three forms of free bone grafts include
_ cortical, cancellous, and corticocancellous 16. Cortical
12 6 + 2
grafts are able to withstand early mechanical forces;
< 2mm –Successful, > 2mm - unsuccessful however, they require more time to revascularize.
Common donor sites for bone grafting are cranial vault,
iliac crest, ribs, mandibular symphysis, and external
oblique ridge 7,16. Particularly the calvarial bone is more
permanent than bone from other donor sites 14. Variable
rates of resorption are seen, if iliac bone is used. But an
appropriate graft selection should be based upon the
goals of reconstruction.
Different materials are used for orbital floor fractures
reconstructions are autogenous and allogenous grafts 2,7
(cranial bone, iliac, rib, symphysis, septal and auricular
cartilage) or synthetic material (alloplastic materials-
Preoperative CT titanium mesh). When alloplastic materials are used
complications such as extrusion, foreign body reaction,
infection, displacements are possible sequelae 7 .
The ideal management of orbital floor fractures continues
to be debated.
Cranial bone grafts are widely used for numerous
maxillofacial reconstructive surgical procedures. We
sought to illustrate the usefulness of cranial bone grafts in
orbital floor fracture reconstruction mainly because of the
histomorphological similarities of the bone, curvature of
the bone to the recipient site and it is particular
integration with the facial bone structure. An ideal
Intra operative graft Harvest material should closely replicate the tissue it replaces 16.
Advantages with calvarial bone grafting are minimal
postoperative pain, scar is hidden in the hair line,
propensity to maintain original graft volume, local
availability, low infection rate and less donor site
morbidity 10,11. Disadvantages with calvarial bone grafting
can be difficulty to run two surgical teams
simultaneously, may not yield sufficient cancellous bone
(<30cc), neurologic sequelae may arise with other
potential complications10. Possible Complication rate
were 5.6-7.6%. Reported complications are,
hematoma/seroma, infection, dural tear with possible
Postoperative CT CSF leakage, leptomeningeal cyst, laceration of superior
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 06

17. sagittal sinus. Voska P et al used cranial bone grafts for ocular examination is necessary; in particular, special
treating posttraumatic defects, defects originated after attention is required to check vision and pupillary
tumor removal and cranial anomalies in 95 patients. No response for optic neuropathy and to assess extraocular
serious postoperative complications appeared in any of motility and forced ductions/generations for extraocular
the 95 patients. In 10% of the cases, when bone grafts muscle entrapment, ischemia, hemorrhage, or orbital
were used like onlays, he reported resorption was up to compartment syndrome22. Following the findings, a
20% of the volume. Author in conclusion added that rigid carefully planned surgical treatment of blow-out fractures
method of fixation of the graft will reduce the resorption is proposed in correlation with the clinical symptoms and
rate 11. Smolka et al states that calvarial split bone grafts radiological evidence and proper history.
shows low rate of bone resorption after extensive alveolar
ridge reconstruction 17. CT scans are the method for evaluation of orbital floor
fractures 4. Axial and coronal CT scans is the standard
Stanislaw B.Bartkowski et al evaluates 90 patients with diagnostic imaging technique for assessing orbital
blow-out fracture of the orbit and states that in cases with trauma, and careful analysis of CT slices can contribute
a defect of the orbital floor fracture reconstruction, the toward improved planning of treatment 23,24,25,26.
best material is autogenous bone graft18. V. Ilankovan et al Calculations of blow-out fractures of the orbital floor by
in 1992 states that orbital reconstruction can be 3D-CT and 2D-CT method are accurate for assessing the
performed using with cranial bone graft in 222 patients area of fracture and the volume of herniated tissue 23.
with 279 calvarial grafts. There were 13 (4.6%)
complications, most occurring during harvesting full- In our clinical study, twelve patients with orbital floor
thickness calvarial grafts. fracture were analyzed from 2006 to 2007 at the
department of Oral and Maxillo-Facial Surgery. Age
The main aim of surgical treatment is the anatomical ranged from 24 to 39 yrs. The reconstruction was made
correction of the bony defect by restoring the anatomy by calvarial bone grafts taken only from the outer table of
and volume of the orbit to avoid any complications.
the calvarium. The size of the graft was approximately
Orbital floor morphology differs with age and gender.
from 2cm to 2.5cm. In this study we analyze the pro and
The inclination of the orbital floor is steeper in children
vs of calvarial bone grafting. Today alloplastic materials
than in adults and in males than in females. Also the
merit certain circumstances only when bone autogenous
lowest point shifts lower and more posteriorly as patient
graft is contraindicated or when the surgeon don't want to
ages 19
use it and is also cost effective. At the end of six months
In case of orbital blowout fractures the most commonly we found that the graft position, uptake was excellent
fractured area is the orbital floor; where intrusion and with less resorption rate and no donor site morbidity.
entrapment of the orbital content, and more specifically,
Orbital surgery is not risk free. The decision to proceed
of the inferior rectus and the inferior oblique muscles or
with surgery must consider potential surgical
their facial attachments into the fracture lines and toward
complications, which can include blindness, subsequent
the maxillary sinus . They account to approximately 11%
infection of implanted material, orbital implant
of fractures involving the orbit 20. The indications and
migration, postoperative mydriasis, epiphora, and
timing for fracture repair are still controversial5,6. Lester M
worsening diplopia 27,28.
Cramer1 study shows that the earlier the surgery is
performed the easier it is to accomplish successful
We are in the conclusion that on the basis of our
anatomic reductions and to ensure uniform excellent
investigations early surgical treatment leads to
results. The “ideal” time to intervene after fracture
satisfactory long-term results. As a result of favorable
occurrence cannot be precisely defined. Ultimately, the
biological response in our study with no surgical
decision to proceed with surgery should be based on the
complications, cranial bone graft was considered to be a
patient’s symptoms, clinical findings, and thorough
promising autogenous material for orbital floor fracture
informed consent about the risks and benefits of surgical
reconstructions with advantages of minimal
intervention 8.
postoperative pain, scar hidden in the hair line,
Symptoms of orbital floor fractures include orbital pain, propensity to maintain original graft volume and less
enophthalmos, hypesthesia in the V2 distribution donor site morbidity. This, together with our favorable
(infraorbital: cheek and teeth), and diplopia. Eyelid experience, encourages us to continue to use cranial
ecchymosis, subcutaneous emphysema, ptosis, epistaxis, bone graft in the future. Thus we conclude by saying that
lacrimal system injuries, and pupillary dilation may be cranial bone graft is an ideal autogenous material for
associated with orbital floor fractures 6,21. Thorough orbital floor fracture reconstruction.
07 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013

18. REFERENCES: 13. Stephen H. Miller and William J. MorrisCurrent.
Current concepts in the diagnosis and management
1. Lester M. Cramer, Frank M. Tooze and Sidney of fractures of the orbital floor, The Am J Surg, 1972,
Lerman. Blowout fractures of the orbit, Br J of Plast 123(5); 560-563.
Surg, 1965, 18; 171-179.
14. Edward Ellis III, Elias Messo. Use of nonresorbable
2. Dongmei He, Preston H. Blomquist and Edward alloplastic implants for internal orbital
Ellis III. Association between Ocular Injuries and reconstruction, J Oral Maxillofac Surg, 2004, 62(3);
Internal Orbital Fractures, J Oral Maxillofac Surg, 873-81.
2007, 65(4); 713-720.
15. Mario F. Muoz Guerra, Jesus sastre Terez et al.
3. Shoab A. Siddique and Robert H. Mathog. Reconstruction of orbital fractures with dehydrated
Comparison of parietal and iliac crest bone grafts for human duramater, J oral maxillofac surg, 2000,
orbital reconstruction, J Oral Maxillofac Surg, 58(12): 1361-1366.
2002, 60(1); 44-50. 16. Risto Kontio. Treatment of orbital fractures: The case
for reconstruction with autogenous bone, J Oral
4. Oliver Ploder, Clemens Klug, Werner Backfrieder, Maxillofac Surg, 2004, 62(1); 863-68.
Martin Voracek, Christian Czerny and Manfred
Tschabitscher. 2D- and 3D-based measurements of 17. Smolka W, Eggensperger N , Carollo V, Ozdoba C,
orbital floor fractures from CT scans, J Cranio- Lizuka T. Changes in the volume and dentistry of
Maxillofac Surg, 2002, 30(2); 153-159 calvarial split bone grafts after alveolar ridge
augmentation. Clin Oral Impl Res. 2006, 17; 149-
5. B.T. Evans and A.A.C. Webb. Post-traumatic orbital 55.
reconstruction: Anatomical landmarks and the
concept of the deep orbit, Brit J Oral Maxillofac 18. Bartkowski SB, Krzystkowa KM: Blow-out fracture of
Surg, 2007, 45(3); 183-189. the orbit. Diagnostic and therapeutic
considerations, and results in 90 patients treated, J
6. Hartstein ME, Roper-Hall G. Update on orbital floor Oral Maxillofac Surg, 1982, 10; 155-164.
fractures: indications and timing for repair, Facial
Plast Surg. 2000, 16(2); 95-106. 19. Tomohisa Nagasao, Makoto Hikosaka, Tadaaki
Morotomi, Maki Nagasao, Kaoru Ogawa and Tatsuo
7. Mordechai Kraus, Albert Gatot and Dan M. Fliss. Nakajima. Analysis of the orbital floor morphology, J
Repair of traumatic inferior orbital wall defects with Cranio-Maxillofac Surg, 2007, 35(2); 112-119.
nasoseptal cartilage, J Oral Maxillofac Surg, 2001,
59(12); 1397-1400. 20. Chen JM, Zingg M, Laedrach K, Raveh J. Early
surgical intervention for orbital floor fractures, J Oral
8. Lena Folkestad and Gösta Granström. A Maxillofac Surg, 1992, 52; 935-41.
prospective study of orbital fracture sequelae after 21. Michael A. Burnstine, Clinical Recommendations
change of surgical routines, J Oral Maxillofac Surg, for Repair of Isolated Orbital Floor Fractures An
2003, 61(9); 1038-1044. Evidence-based Analysis, Ophthalmol 2002, 109;
1207–1213.
9. M. Marasco and F.S. De Ponte. Reconstruction of
orbital floor fractures. A current surgical 22. K. de Man, R. Wijngaarde, J. Hes and P.T. de Jong.
management, J Cranio-Maxillofac Surg, 2006, Influence of age on the management of blow-out
34(1);11. fractures of the orbital floor, Int J Oral Maxillofac
Surg, 1991, 20(6); 330-336.
10. V. Ilankovan and I.T. Jackson. Experince in the use
of calvarial bone grafts in orbital reconstruction, Brit 23. Harris GJ, Garcia GH, Logani SC, MurphyML, Sheth
J Oral Maxillofac Surg, 1992, 30(2); 92-96. BP, Seth AK: Orbital blow-out fractures: correlation
of preoperative computed tomography and
11. Koz~k J., Voska P. Long-term experiences with postoperative ocular motility. Trans Am
calvarial bone grafts in cranio- maxillo-facial Ophthalmol Soc 1998 96: 329–347.
surgery, J Cranio-Maxillofac Surg, 1996, 24(1); 65.
24. Edward Ellis and Yinghui Tan. Assessment of
12. Thomas H. O'Hare. Blow-out fractures: A review, J internal orbital reconstructions for pure blowout
Emerg Med, 1991, 9(4); 253-263. fractures: Cranial bone grafts versus titanium mesh, J
Oral Maxillofac Surg, 2003, 61(4); 442-453.
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 08

19. 25. Stewart MG, Patrinely JR, Appling WD: Late
proptosis following orbital floor fracture repair. Arch
Otolaryngol Head Neck Surg, 1995, 121:649.
26. Sachs ME: Orbital floor fractures: The maxillary
approach. Adv Ophthalmic Plast Reconstr Surg
6:387, 1987
27. Lena Fol kestad and Thomas Westin: Long-term
sequelae after surgery for orbital floor fractures,
Otolaryngol Head Neck Surg 1999;120:914-21.
28. H. Popat and Liu D. Blindness after blow-out fracture
repair. Ophthal Plast Reconstr Surg
2007;10:206–10.
Corresponding author :
Dr C. Hariprasath, Senior Lecturer,
Division of Oral and Maxillofacial Surgery,
Rajah Muthiah Dental College and Hospital,
Annamalai University, Chidambaram,
Tamil Nadu – 608002, INDIA
hcprasath@yahoo.co.in
+ 91 9487474246
09 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013

20. COMPARISON OF RADICULAR AND INTRA RADICULAR
STUD ATTACHMENTS: CASE REPORTS
Dr. Bharaniraja Kalidasan Selvi1, Dr. Eazhil Raj2, Dr. Jaya KrishnaKumar S3, Dr. Azhagarasan N.S4
1. Senior lecturer, Department of Prosthodontics, SRM Dental College, Bharathi salai, Ramapuram, Chennai-89.
2. Reader, Department of Prosthodontics, Chettinad Dental college and Research Institute, OMR, Padur, Chennai- 603103.
3. Professor, Department of Prosthodontics, Ragas Dental College & Hospital, 2/102, East Coast Road, Uthandi, Chennai-119. .
4. Professor & H.O.D, Department of Prosthodontics, Ragas Dental College & Hospital, 2/102, East Coast Road, Uthandi, Chennai-119.
Key words: Tooth supported overdenture, stud attachments, radicular attachments, intra radicular attachments.
ABSTRACT:
Complete dentures present many problems that may be avoided by the retention of roots of selected key teeth.
Retention of these roots makes possible to fabricate a denture that provides support, retention, stability and comfort,
superior to that of a conventional complete denture. Alveolar bone is preserved, and the occlusal vertical
dimension and centric relation are maintained. Facial and lip changes are minimized, while the ability to masticate
is maximized. The patient experiences a sense of security and feels that he has his teeth and he looks his best.
Despite recent developments in dental implantology, the conservative approach to root preservation is still valid.
Placement of attachments in the abutments further increases retention of overdentures. Though many attachments
such as stud and bar attachments are available, proper selection to meet patient’s needs is essential.
Short running title: Clinical report on usage of stud retention of the denture, thereby helps in better
attachments. mastication9,10,11. The overdentures render maximum
support and improve compromised esthetic appearance
ARTICLE PROPER in patients with congenital anomalies such as cleft palate,
ectodermal dysplasia, hypodontia, those with sequelae of
INTRODUCTION: maxillofacial trauma and tumor1. Other patients who may
benefit from tooth-supported dentures are those with
Edentulousness was once considered to be a normal part malrelated ridges, those facing the loss of teeth in one
of aging and the conventional way of treating edentulous dental arch while the other arch is dentulous, those with
patients was by means of complete dentures. However, unfavourable tongue positions, muscle attachments, or
limitations such as residual ridge resorption, loss of residual ridges and those who encounter difficulty with
occlusal stability, undermined esthetic appearance & stability or retention of conventional complete denture2.
decrease in neuromuscular skills in manipulating the
dentures as age progresses has detracted the quality of life The tooth supported overdentures are of two types,
of such patients1. Considerable clinical experience and conventional and with attachments1,12. The notion of
documented research have underscored the merits of underscoring the use of attachments shifts the
retained natural teeth or substitution by dental implants to conventional overdenture design which provides
serve as abutments under complete dentures and partial stability and retardation of RRR, to major emphasis on
denture2-6. In this regards overdentures have found prosthesis retention. Overdenture attachments are
increased application in prosthodontics. available for chair side procedure or requiring a
laboratory casting. The attachments are of bar and stud
Periodontally compromised teeth are often too weak to types1,12. Stud type attachments may be positioned over
support a partial denture for long term. The larger crown the root/ implant (radicular) or in the root/ implant
root ratio created by periodontal disease results in forces abutment (intra radicular). In intra radicular stud type
that can gradually extract the remaining teeth. Reduction attachments, a prefabricated component is placed within
of the clinical crown creates a more favorable crown to the center of the teeth root and the male component is
root ratio to compensate for progressive bone loss, to incorporated in the impression surface of overdenture.
increase the longevity of remaining natural teeth and The radicular attachment is incorporated on or into a post
provides adequate place for the overlying artificial and coping type casting. The crown root ratio is also
denture tooth and denture base4,7,8. They also provide enhanced with the low profile of the stud type
psychological benefit to the patient, tactile attachments12.
discrimination, better load transmission of the prosthesis
to the underlying structures and improve stability &
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 10

21. CASE REPORTS:
Case 1: A 74 year old female patient presented with the
complaint of inability to retain partial denture in the
lower arch. Her dental history revealed that the patient
had been completely edentulous in upper arch and
partially edentulous in lower arch for past five years and
had been wearing dentures. Clinical examination
revealed ill fitting lower denture with the presence of
Intaglio surface of the denture with
33,35,41 and 43. Patient had been a known diabetic for
resilient female element.
past 10 years and has neuromuscular inco-ordination and
under medication the same. Radiographic investigations
revealed generalized bone loss.
Taking into consideration patient’s age, medical and
psychological status, overdentures with stud attachments
were planned with 33 and 43 as abutments. The height
and width of the abutments were evaluated
radiographically and clinically and intra radicular stud
type attachment was selected (zest standard, zest anchors
attachment system, CA). Sprue former attached to wax patterns with
castable male component.
Abutment teeth adequately prepared after elective
endodontic procedure.
Metal female element oriented over cemented
male components.
Metal female element luted in prepared root recess.
Orientation of male component analog in
reline impression.
Resilient male element placed in position.
Intaglio surface of denture with female components.
11 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013

22. Endodontic procedures for the abutment teeth were bone, the health of the individual, and the amount of
completed and adequately prepared for overdenture trauma to which the structures are subjected4.
procedures (fig 1). The complete denture was fabricated.
The abutment was clinically reduced to the height of The concept of overdentures developed as a simple and
about 1mm above the gingival tissue level and a pilot economic alternative to prolong the retention and
hole made in canal orifice with No 700 carbide bur of a function of the last few remaining teeth in a compromised
depth of 7mm. The drill was aligned parallel to path of dentition. The biological maintenance of a
insertion of the denture. The pilot hole was enlarged neuromuscular mechanism, the temporomandibular
using No 6 round carbide bur to a depth of 4mm. The articulation and a better medium for support and stability
diamond sizing bur was used to create a full 360 degree for a denture can be accomplished better by retained
recessed seat in the occlusal surface. The metal female natural teeth than by the mucoperiosteum4. The area that
element was tried in the prepared root recesses for proper is most critical for maintaining teeth to retain alveolar
fit and then cemented using glass ionomer cement (fig 2). bone is the anterior region of the mandible. Preservation
The resilient male element was attached to female of atleast two roots in the anterior mandible to avoid the
element (fig 3). The lower denture was tried in to check advanced resorption of the anterior edentulous mandible
for clearance to accept resilient males. A small vent hole has been the primary application of the overdenture7.
was made on the lingual surface of the denture. Self cure
acrylic resin of thin consistency was placed in the denture Natural roots may prevent or retard residual alveolar
recess and also painted around the male elements. bone loss. The threshold of minimal perceived pressure
Denture was seated in the patient’s mouth and was asked was significantly lower with overdentures supported by
to occlude. Excess material was expressed through the tooth roots than by implants due to presence of receptors
vent hole and sufficient time was allowed for the resin in periodontal ligament10,14,15.
material to set. The overdenture was removed, finished
and polished. (fig 4). Stud attachments are simple and versatile in connecting
complete denture to remaining natural teeth / implants. A
Case 2: A 63yr old patient presented with complaint of solid attachment as that used in case 2, allows no
inability to eat and speak properly due to missing teeth. movement between the male and female elements. This
He gave history of partial edentulousm for past two years. feature transfers stress towards the roots / implants and
Clinical and radiographic examination revealed presence away from the ridge. The intra radicular resilient stud type
of 33 and 44 with adequate bone support. Various attachments allow movement in any plane and transfers
treatment options were explained to patient and stress away from the root/ implants and towards the
removable prosthesis was considered. The inter ridge tissues. For this reason, resilient attachments are selected
distance was found to be adequate for placement of much more frequently than solid attachments. Retention
radicular attachments. The adequate tooth preparation achieved is satisfactory and they promote better oral
was performed and denture construction was done till the hygiene. The intra radicular attachment requires less
trial denture stage. Root preparation was done and the space than other attachments and doesn’t require
castable male component was attached to the post additional precious metal casting. Any significant
pattern and parallelism checked. After investing (fig 5), divergence between the roots or between roots and path
casting, finishing and polishing, the post was cemented. of insertion of the denture results in rapid wear of male
The metallic female was oriented over the male components and requires frequent replacement12.
component (fig 6) and a reline impression was made
using trial denture. The analog of male component was Disadvantages of overdenture include fracture of denture
oriented to the female component in the impression (fig base resin, fracture of teeth, need for changes of
7) and denture was processed. The retention rings were prosthetic design followed by fabrication of new
placed in the female component incorporated in the final prosthesis. Prosthesis related adjustments include sore
denture (fig 8). Denture was seated intraorally and spots, relining of overdenture, occlusal adjustments,
evaluated. changes of tooth arrangement for esthetic reasons,
excessive wear of teeth10.
DISCUSSION:
SUMMARY:
Extraction of entire dentitions with complete denture
replacements was used to be promoted as an inexpensive Now a days numerous attachments are available suitable
and permanent solution for oral health care in the past. for various clinical scenario. With proper case selection,
The structure of maxillae and mandible was designed to treatment plan considering biological and prosthodontic
hold the natural teeth roots, but not to act as a supporting aspects and post insertion maintainence, overdentures
factor for artificial dentures. So it is certain that resorption with attachments can be used with great success to
occurs if this structure is disturbed4,13. The rate of improve retention and esthetics.
resorption depends on three factors; the character of the
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 12

23. REFERENCES 14. Mericske-Stern R, Hofmann J, Wedig A, Geering AH.
In vivo measurements of maximal occlusal force and
1. Zarb GA, Bolender CL, Carlsson G,editors. minimal pressure threshold on overdentures
Boucher’s prosthodontic treatment for edentulous supported by implants or natural roots: A
patients. 11th ed. St Louis: Mosby-Year Book; 1997. comparative study, Part I. Int J Oral Maxillofac
2. Morrow RM, Feldmann EE, Rudd KD, Trovillin Implants 1994; 9: 63-70.
HM.Tooth-supported complete dentures:An 15. Crum J, Loiselle RJ. Oral perfection and
approach to preventive prosthodontics J Prosthet proprioceptions. A review of the literature and its
Dent. 1969;21(5):513-22. significance to Prosthodontics. J Prosthet Dent 1972;
3. Lord JL, Teel S. The overdenture. Dent Clin North Am 28: 215-30.
1969;13:871-81.
4. Miller PA,Complete dentures supported by natural
Corresponding author :
teeth J Prosthet Dent. 1958: 8(6):924-928. Dr.K.S.Bharaniraja, M.D.S. Senior lecturer,
Department of Prosthodontics, SRM Dental College,
5. Fenton AH, Hahn N. Tissue response to overdenture Bharathi salai, Ramapuram, Chennai-89.
therapy. J Prosthet Dent 1978; 40: 492-8. Tamil Nadu, India.
Email id: bharanija@gmail.com
6. Toolson LB, Taylor TD. A 10- year report of a Mobile number: 919841228066,
longitudinal recall of overdenture patients. J Prosthet Fax number: 044- 22492429.
Dent 1989; 62:179-81.
7. Fenton AH. The decade of overdenture: 1970-1980. J
Prosthet Dent 1998;79(1):31-6.
8. Crum RJ, Rooney GE. Alveolar bone loss in
overdentures; a 5year study. J Prosthet Dent 1978;
40:610-3.
9. Bassi F. Comparing overdenture therapies with teeth
and implant abutments. Int J Prosthodont 2009;
22(5): 527-28.
10. Hug S, Mantokondis D, Mericske-Stern R. Clinical
evaluation of 3 overdenture concepts with tooth
roots and implants: 2-year results. Int J Prosthodont
2006; 19(3): 236-243.
11. Rissin L, House JE, Manly RS, Kapur KK.Clinical
comparison of the masticatory performance and
electromyographic activity of patients with complete
dentures, overdentures, and natural teeth. J Prosthet
Dent 1978; 39:508-11.
12. Prieskel H. Overdentures may easy. Berlin:
Quintessence; 1996.
13. Atwood DA, Coy WA. Clinical, cephalometric, and
densitometric study of reduction of residual ridges. J
Prosthet Dent 1971; 26: 280-5.
13 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013

24. AN INSIGHT TO SINGLE VISIT ENDODONTICS
Dr. A. Shafie Ahamed1, Dr. Deepa Vinoth Kumar2
1. Professor, Dept of Conservative Dentistry and Endodontics,
Rajah Muthiah Dental College, Annamalai University, Chidambaram. Tamil nadu.
Key words: Periapical lesions, calcium hydroxide, nonsurgical endodontic therapy
INTRODUCTION: INDICATIONS FOR SVE :
• Uncomplicated vital teeth.
Single visit endodontics (SVE) is gaining popularity these
days as compared to multiple visits. SVE implies • Physically compromised patients who have to make
‘Conservative non-surgical treatment of an an effort to come to the dental clinic.
endodontically involved tooth consisting of complete
biomechanical preparation and obturation of the root • Medically compromised patients who require
canal system in one visit’.The concept of single visit antibiotic prophylaxis and sometimes alteration in
endodontics started at least 100 years old. In the recent the medication they take.
years single visit endodontics has gained increased • Fractured anterior where esthetics is a concern.
acceptance as the best treatment for many cases. Recent
studies have also shown that there is no difference in • Apprehensive but cooperative patient
quality of treatment and incidence of post treatment • Patients who require sedation or operation room.
complication or success rates between single visit and
multiple visit root canal treatment (Albashaireh and • Uncomplicated non vital teeth with sinus tract.
Alnegrish, 1998;Weiger et al.,2000;Sathorn et
al.,2005;Field et al.,2004). Many dentists nowadays CONTRA INDICATIONS FOR SVE :
prefer single visit endodontic treatment because of many
• Acute alveolar abscess cases with pus discharge.
advantages. Perhaps, the most important advantage is the
prevention of root canal contamination and bacterial re- • Patients who have acute apical periodontitis with
growth that can occur when the treatment is prolonged severe pain on percussion
over an extended period due to leakage of temporary seal
(Trope et al., 1999; Soltanoff and Montclair, 1978; • Painful non vital tooth with no sinus tract.
Pekruhn, 1981; Rudner and Oliet, 1981; Lin et al.,2007 ). • Asymptomatic teeth with apical lesion and no sinus
tract.
REASONS FOR NOT DOING SVE
• Cases with procedural difficulties like calcified
1) Fear of post-op pain. canals, curvatures, extra canals, etc....
2) Fear of failure. • Patients with TMJ disorders and inability to open the
3) Lack of time. mouth.
4) Lack of clinical experience. • Teeth with limited access.
5) Lack of equipment. • Non surgical retreatment cases.
6) Fear of being “unconventional”. OLIET’S CRITERIA FOR CASE SELECTION
7) Fear of patient not accepting SVE
• Positive patient’s acceptance.
8) Discomfort to the patient.
• Sufficient available time to complete the procedure
GUIDELINES FOR SVE properly.
1. Accurate diagnosis • Absence of any acute symptoms requiring drainage
via the canal and of persistent continuous flow of
2. Proper case selection
exudates or blood.
3. Skilled operator
• Absence of anatomical obstacles like calcification
4. Working time not more than 60 minutes in the canals and procedural difficulties (ledge
formation, blockage, perforation).
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 14

25. ADVANTAGES Studies evaluating healing of single visit and multiple visit
• Intimate awareness of the canal anatomy root canal treatment
immediately following instrumentation. Trope et al (1999) 64 Vs 74 %
• No risk of losing important landmarks. Weiger et al (2000) 83 Vs 71 %
• Canal is never cleaner than immediately after Peters and Wesselink (2002) 81 Vs 71 %
proper instrumentation.
• No risk of flare-up induced by leakage of temporary The success of endodontic treatment is directly
seal. associated with infection control. The literature indicates
that rotary, hand or hybrid instrumentation, even when
• Teeth are ready for final restoration, diminishing the
risk of a fracture necessitating extraction. performed correctly, is inadequate to clear all organic
and inorganic debris from the root canal system. For this
• Patient’s pre appointment anxiety and post-
and other reasons, irrigating solutions play an important
operative discomfort are limited to one episode.
role making up for the shortcomings of instrumentation
• Time is saved for the patient and for practitioner and complementing endodontic disinfection procedures
since the treatment is completed in one visit. (Almeida et al., 2012; Bashetty and Hegde, 2010). Post
instrumentation sampling showed reductions of
DISADVANTAGES
cultivable microbiota. However bacteria still found in
• Inability to dry the canals completely. 62% of teeth in one visit group and 64% in two visit group
• Insufficient time to complete the procedure. (Kvist et al., 2004). Mechanical debridement with
antibacterial irrigation (0.5% NaOCl) can render 40-60%
• Possible stress of TMJ musculature or increased
of treated teeth bacteria negative (Bystrom and Sundqvist,
psychological stress on patients or clinicians
because of longer appointment time or both. 1983, Sjogren et al.,1997). Intraradicular microbes
surviving root canal treatment- entomed by obturation
• Flare-ups cannot be easily treated by opening the and die as a result of inadequate nutrients. Kronfeld’s
tooth for drainage.
theory, bacterial count decreases –suitable environment
IS THE PROGNOSIS? for healing.
Compromised by performing RCT in One appointment POST-OPERATIVE PAIN AND FLARE-UP IN SVE
----NO
There are numerous studies focusing on post operative
In Humans, over whelming evidence shows the healing is pain and flare up in SVE and MVE. Most of the studies
same for both single or multiple visits regardless of pulp result showed that there is not much significant difference
vitality (Trope et al., 1999; Weiger et al., 2000; Peters and
in the post operative pain between SVE and MVE.
Wesselink, 2002).
Post operative pain Flare up
• Pekruhn-1981,1986 • Eleazer and Eleazer-1998
• Almeida et al-2012 • Oginni and Udoye-2004
• Bashetty and Hegde -2010 • Trope-1991
• El Mubarak et al-2010 • Imura and Zuolo-1995
• Siqueira and Barnett-2004 • Walton and Fouad-1992
• Di Renzo et al-2002
• Albashaireh and Alnegrish -1998
• Fava-1995
• Oliet-1983
• Roane et al-1983
• Soltanoff and Montclair-1978
• Fox et al-1970
• Al-Jabreen and Tarik -2002
15 JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013

26. Morse defines “Flare-up” as either patient’s report of pain 2. Preparatory phase – contents of root canal removed
not controlled with over the counter medication or as and canal prepared for filling material
increased swelling.
3. Restorative phase – filling of the canal to obtain a
Walton defines “Flare-up” within a few hours to a few hermetic seal at the cementodentinal junction and
days after a root canal treatment procedure, a patient has post endodontic restoration
either pain or swelling or combination of both.
SVE is now within the reach of most practitioners, as new
The factors that can reduce the incidence of flare-up, pain technology provides better designs of instruments for
and swelling are prophylactic antibiotics (Penicillin V or canal shaping and efficient cleaning protocols for
erythromycin). Intentional over instrumentation of root meticulous canal cleaning and disinfection followed by
into the approximate center of the bony lesion reduces three dimensional filling of the canal.SVE is successful
the prevalence of flare-ups from about 20% to 1.5% (non- when there is careful case selection and strict adherence
vital) (Fox et al., 1970). to standard endodontic principles.
Pain in endodontic procedures is related to the presence REFRERENCE
or absence of inflammation. It is reasonable to assume
that if severe inflammation exists before treatment, there Albashaireh ZS, Alnegrish AS (1998). Postobturation pain
would be a tendency to expect a distinct increase in the after single and multiple-visit endodontic therapy.
postoperative pain after a single-visit procedure rather Aprospective study.J Dent 26(3):227-32.
than if two or more visits were used. If single-visit
procedure is performed on teeth that have a potential for a Al-Jabreen, Tarik M (2002) Single visit endodontics:
"flare-up," antibiotics are suggested beginning 48 hours Incidence of post-operative pain after instrumentation
preoperatively. This routine has greatly reduced the with three different techniques:An objective evaluation
number of flare-ups (Soltanoff and Montclair.,1978). study. Saudi Dental Journal: 14(3);136-139
SUCCESS RATE AND FAILURE OF SVE: Almeida G, Marques E, De Martin AS, da Silveira Bueno
CE, Nowakowski A, Cunha RS (2012). Influence of
Prognostic studies have shown that there is no substantial Irrigating Solution on Postoperative Pain Following
difference in the success rate of single and multiple Single-Visit Endodontic Treatment: Randomized Clinical
appointment cases ( Sathorn et al.,2005;Figini et Trial. J Can Dent Assoc78:c84
al.,2008;Field et al.,2004). Necrotic teeth with apical
periodontitis showed favorable periapical healing at 12 Bashetty K, Hegde J (2010). Comparison of 2%
months, with no statistically significant differences chlorhexidine and 5.25% sodium hypochlorite irrigating
between groups (Penesis et al., 2008). Failure of 5.2% in solutions on postoperative pain: a randomized clinical
single visit cases. The incidence of failure was higher in trial. Indian J Dent Res 21:523-7
teeth with periapical extension of pulpal disease which
had no prior access opening (Pekruhn, 1986). Byström A, Sundqvist G (1983). Bacteriologic evaluation
of the effect of 0.5 per cent sodium hypochlorite in
Healing following endodontic therapy will usually occur endodontic therapy. Oral Surgery, Oral Medicine and
following an accurate diagnosis, proper case selection, Oral Pathology 55, 307–12.
and the use of skilled techniques of treatment. These
procedures are based upon known biological principles DiRenzo A, Gresla T, Johnson BR, Rogers M, Tucker D,
incorporated into the technique triad, specifically: BeGole EA( 2002). Postoperative pain after 1 and 2 visit
biomechanical preparation of the canal system, root canal therapy. Oral Surg Oral Med Oral Pathol Oral
debridement and disinfection, and complete obturation Radiol Endod 93(5):605-10
of the prepared canals. Each of these objectives must be
achieved in order to ensure a successful result. El Mubarak AH, Abu-bakr NH, Ibrahim YE(2010 ).
Postoperative pain in multiple-visit and single-visit root
CONCLUSION canal treatment. J Endod 36:36-9.
As far as the endodontic treatment aspect is concerned, Eleazer PD, Eleazer KR (1998). Flare-up rate in pulpally
whether it is SVE/MVE three basic phases has to be met to necrotic molars in one-visit versus two-visit endodontic
obtain success. treatment. J Endod 24:614-6.
1. Diagnostic phase – disease determination and design Fava LR (1995).Single visit root canal treatment:
of treatment plan incidence of postoperative pain using three different
instrumentation techniques. Int Endod J 28:103-7.
JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 16