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In this Issue:
Scientific Editorial: Titanium Toxicity - A Review
References : 1.Renner AM. The versatile use of titanium in implant prosthodontics. Quintessence Dent Technol 2001;188–97. 3. L. Le Gu´ehennec, A. Soueidan, P. Layrolle ∗, Y. Amouriq , Surface treatment of titanium dental implants for rapid osseointegration. dental materials 2 3 ( 2 0 0 7 ) 844–854 http://bme.yonsei.ac.kr/community/data/01.pdf 4.Council on Dental Materials, Instruments and Equipment. Dental endosseous implants. JADA 1986;113:949–50.[Medline] 5.Nuevo-Ordóñez Y, Montes-Bayón M, Blanco-Gonzalez E, Paz J, Dianez Raimundez J, Tejerina Lobo J, Peña M, Sanz-Medel A (2011). Titanium release in serum of patients with different bone fixation implants and its interaction with serum biomolecules at physiological levels. Analytical and Bioanalytical Chemistry; DOI 10.1007/s00216-011-5232-8
Yours truly Dr. Syed Nabeel Editor -in-Chief Dental Follicle - The E Journal Of Dentistry Join us on FACEBOOK www.Facebook.Com/DentistryUnited1
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Endo surgical procedure for retrograde retrieval of broken root canal instrument 1.
Dr. Sanghmitra Dasgupta M.D.S., F. & Dip ICOI,
ABSTRACT:
KEY WORDS: Separated endodontic instrument, retrograde surgery
Fig 1: Orthopantomograph showing broken root canal instrument in 45
Fig 2: Intra oral periapical radiograph showing broken root canal instrument in 45 Procedure: The retrieval of the instrument was first planned through the root canal. Several attempts were unsuccessful since the instrument kept springing back to its embedded position in the canal. Hence surgical removal of the instrument was planned under local anaesthetic. Universal aseptic precautions associated with any surgical procedures were followed. Infiltration anaesthesia was administered on the buccal and lingual aspects of the right second premolar. A vestibular incision was made from the 46 to the n 44 region. The dissection was done in layers, the mental nerve was identified and retracted. The periosteum was reflected to expose the bone in the region of the apex of 45. A bony window was created, to expose the apex of 45. (Fig. 3 & Fig 4). The granulation tissue was curetted and then the root canal instrument was identified and grasped with a mosquito forceps and gently retrieved(Fig 5). Obturation was done in relation with 45(Fig 6). It was ensured that no root canal filling material protruded beyond the apex. Apical seal was performed. Closure was done in layers.
Fig 3: Showing bony window to access the apex of 45.
Fig 4: ShowingInferior labial branch of mental nerve exposed
Fig 5: IOPA radiograph after removal of the root canal instrument
Fig 6: IOPA radiograph after obturation of the root canal and apical seal Follow up: Follow up was done for five consecutive days. There was no paraesthesia of the lower lip and the pain in relation to 45 had subsided. Wound healing was satisfactory.
There is no standardized procedure, mentioned in the literature, for the successful removal of any broken instrument in the canal, although various techniques and devices have been described. 2 In root canals with a broken instrument the success of its removal depends on several factors. Among them are the length and location of the fragment, the diameter and the shape of the root canal, and the tightness of the fragment and its impaction in debris or sealer.3 The removal of a broken instrument from a root canal must be performed with a minimum of damage to the tooth and the surrounding tissues. Many techniques have been used to retrieve broken instruments, like ultrasonic tips and the Masserann kit. The ultrasonic tips are used as a trephine around the broken instrument, but this technique cannot be used in narrow and curved canals. The Masserann kit has been used for over 30 years for removing separated intracanal instruments, but its use is limited. This technique cannot be employed in posterior, narrow and curved canals.4 Another factor in determining the technique for retrieval is the position of the broken instrument, whether coronal, middle or apical. In this case the instrument was apical and protruding from the canal in the periapical region. The access through the canal though achieved, it was not possible to retrieve the springy lentulo spiral. It kept bouncing back to it’s original space because it was tightly locked in the apical foramen.. Hence the surgical method was adopted for retrieval. The instrument was protruding through the canal and hence could be grasped and removed. This also provided the added advantage of ensuring an apical seal after obturation.
CONCLUSION
Use of a
Bioactive Alloplast, in the Treatment of Human Periodontal
Osseous Defects - A Case Report
1. Dr. Suvarna Patil MDS 2. Dr.
Harsha M B MDS
Abstract Periodontal diseases are a group of inflammatory diseases mainly caused by bacteria and their products. The pathological hallmark of periodontitis is the destruction of the supporting structures of the teeth involved. One of the biggest challenges remaining in dentistry is to predictably regenerate the alveolar bone destroyed by periodontitis. The osseous regenerative procedure shown in this case using a bioactive glass alloplastic bone graft material, demonstrated structurally and functionally stable periodontium, both clinical and radiographically at the end of 6 months follow up.
Key Words Regenerative osseous surgery, bioactive glass, alloplastic bone grafts Introduction Periodontal diseases are a group of inflammatory diseases mainly caused by bacteria and their products. The host response to bacteria and their products is mediated by the production and release of local factors from inflammatory cells, especially lymphocytes and monocytes, as well as cells of mesenchymal origin, such as osteoblasts and fibroblasts.1 Plaque and its associated bacteria, which populate the periodontal pocket, release lipopolysaccharide and other bacterial products to the sulcus, affecting both the immune cells in the connective tissue, as well as the osteoblasts. In the immune cells, these products induce local factor production, including IL-1α, IL-1β, IL-6, prostaglandin E2 and tumor necrosis factor α. These factors increase osteoclast formation and activation as well as inhibit osteoblast function. The bacterial products also affect the osteoblasts directly, inhibiting their function and inducing factor production and release, eventually inducing pre-osteoclast differentiation and osteoblast activation.1 The processes of bone resorption and bone formation are regulated by systemic hormones as well as local factors. Changes in the normal balance of bone modeling and remodeling causes bone loss. In periodontal disease, the response of bone to local factors, produced by the inflammatory process, changes the bone remodeling balance, with a net effect of bone resorption and loss of attachment. Bone replacement grafts are the most widely used treatment options for the correction of periodontal osseous defects. Objectives of periodontal bone grafts2: 1) Probing depth reduction, 2) Clinical attachment gain, 3) Bone fill of the osseous defect 4) Regeneration of new bone, cementum and periodontal ligament. It has been proved that bone replacement grafts provide clinical improvements in periodontal osseous defects compared with surgical debridement alone. For the treatment of intrabony defects, bone grafts have been found to increase bone level, reduce crestal bone loss, increase clinical attachment level, and reduce probing pocket depths compared with open flap debridement procedures.3 Bone replacement grafts include autografts, allografts, xenografts, and alloplasts. Autogenous bone grafts: Due to their osteogenic potential, autogenous bone grafts of extra- and intraoral sources have been used in periodontal therapy. Iliac grafts have been used fresh or frozen. Successful bone fill has been demonstrated using iliac cancellous bone with marrow in furcations, dehiscences, and intraosseous defects of various morphologies. Iliac grafts have had only limited use because of the difficulty in obtaining the graft material, morbidity, and the possibility of root resorption.4 The maxillary tuberosity or a healing extraction site is typically the donor choice for intraoral cancellous bone with marrow grafts. Allogenic bone grafts: Allografts involve bone taken from one human for transplantation to another. Iliac cancellous bone and marrow, freeze-dried bone allograft (FDBA), and decalcified FDBA are the types of bone allografts widely available. Xenografts: A xenograft (heterograft) is a graft taken from a donor of another species and is referred to as anorganic bone. Recently, concern about the risk of transmission of diseases from bovine-derived products has arisen, hence the use of these grafts are restricted. Alloplasts: Alloplastic materials are synthetic, inorganic, biocompatible, or bioactive bone graft substitutes. Alloplast materials are believed to promote bone healing through osteoconduction. Currently, six types of alloplastic materials are commercially available: hydroxyapatite cement, nonporous hydroxyapatite, porous hydroxyapatite, beta tricalcium phosphate, polymethylmethacrylate/hydroxyethylmethacrylate (PMMA/ HEMA) calcium-layered polymer, and bioactive glass. Case Report: A male patient aged about 35 years reported to the department of Periodontics, KLE VK Institute of Dental Sciences, Belgaum, with a chief complaint of dull aching pain in the lower left front tooth region since 3 weeks. Patient gave a history of swelling in the gums in the same region 6 months back which subsided on its own in about a week’s time. On examination, a deep periodontal pocket measuring about 7 mm was detected on the mesial aspect of mandibular left canine tooth. The interdental papilla in that region was soft and edematous with exudation from the gingival crevice. An intraoral periapical radiograph showed severe bone loss in the interproximal region between mandibular left lateral incisor and canine teeth (Figure 1). Medical history of the patient was noncontributory. A regenerative osseous surgical procedure was planned. The patient was informed about the procedures and an informed consent obtained. Scaling and root planning procedures were performed following oral hygiene instructions. The patient review at 4 weeks follow up after phase I therapy, revealed improvement in the consistency of the gingival, however there was no reduction in the probing depth of the pocket. The planned regenerative procedure was undertaken.
Figure 1: Interdental Bone loss seen between lateral incisor and canine Surgical technique: The surgical area was prepared with adequate local anesthesia using 2% Lignocaine HCl containing 1:80,000 adrenaline. An envelope flap was raised using the crevicular incision extending from mesial aspect of mandibular right canine to distal aspect of mandibular left first premolar. Thorough debridement of granulation tissue revealed a 3-walled intra bony defect between mandibular left lateral incisor and canine teeth (Figure 2).
Figure 2: Surgical exposure showing 3-walled intra bony defect between mandibular left lateral incisor and canine teeth The root surfaces were planed adequately and rough bony margins were smoothened with bone files. An alloplastic bone graft material (bioactive glass) was placed in the defect (Figure 3). The mucoperiosteal flap was secured with 3-0 silk sutures. Postsurgical instructions were given along with a course of nonsteroidal anti-inflammatory drugs for three days. The sutures were removed one week following the procedure. The post-operative period was uneventful. The patient was reviewed six months post operatively. Stable periodontal tissue was noticed with a 2mm probing depth. Six months post operative intraoral periapical radiograph revealed appreciable bone fill in the interproximal area between mandibular left lateral incisor and canine (Figure 4).
Figure 3: Alloplastic bone graft material placed in the defect
Figure 4: Six months post operative radiograph showing bone fill seen till the middle third of the root Discussion Loss of alveolar bone is one of the characteristic signs of destructive periodontal disease and is generally considered to represent the anatomical sequel to the apical spread of periodontitis. One of the biggest challenges remaining in dentistry is to predictably regenerate the alveolar bone destroyed by periodontitis. Clinicians have long tried with varying degrees of success to induce osseous regeneration, cementum formation & fibrous attachment to achieve new attachment. With recent advances there has been a shift in the concepts of resective osseous surgeries to regenerative surgeries which has changed the aim for treatment of periodontal procedures from only repair to gaining new attachment of the defects. Disadvantages of autogenous grafts like requirement of additional surgical procedure, antigenic and disease transmission potential of allografts and xenografts,5 prompted the use of alloplastic graft material in the present study. Bioactive ceramics have been used clinically to repair bone defects owing to their biological affinity to living bone; i.e. the capability of direct bonding to living bone, their so-called Bioactivity.6 The radiographic evidence in the case presented here shows marked bone fill which is consistent with a review of the literature that has shown synthetic graft materials to date have functioned primarily as biocompatible defect fillers.7 Conclusion: Osseous regenerative procedure presented here, using bioactive glass showed improved healing outcomes when probing depth reduction, osseous defect fill, and gain in clinical attachment are used as clinical parameters. A six month post surgical follow up revealed a structurally and functionally stable periodontal architecture both clinically as well as radiographically. Case selection is particularly important to the use and success of bone replacement grafts. Higher success rates in regenerative osseous techniques have been seen in treatment of 3 walled bone defects. Also the patient must be highly motivated and demonstrate the ability to effectively remove bacterial plaque from every surface of every tooth on a daily basis. References:
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Pyorrhea a common disease discovered
Warsaw Daily Times
- Jan 7, 1916
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Titanium, in the form of the oxide rutile, is abundantly available
in the earth’s crust. Metallic titanium is obtained from the
ore by a method called Kroll process.
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