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             The        Monthly     E- Journal Of  Dentistry                  Vol -  V I   Number-    I I I    July  2011     ISSN   2230 – 9489 (e)

In this Issue:

  • Scientific Editorial - Titanium Toxicity - A Review - Dr.Syed Nabeel

  • Endo surgical procedure for retrograde retrieval of broken root canal instrument
      - Dr. Sanghmitra Dasgupta

  • Use of a Bioactive Alloplast, in the Treatment of Human Periodontal Osseous Defects - A Case Report .-1. Dr. Suvarna Patil MDS.

  • Dental Archieves  -  Pyorrhea The Disease Nearly Everybody Has   -Warsaw Daily Times - Jan 7, 1916


Scientific Editorial:

Titanium Toxicity - A Review

             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.1 In its metallic form at ambient temperature, titanium has a hexagonal, close-packed crystal lattice (α phase), which transforms into a body-centered cubic form (ß phase) at 883 C (with a melting point of 1,680 C).2 .The American Society for Testing and Materials recognizes 4 grades of pure titanium (Ti) and 3 grades of Titanium alloys . viz.Ti-6Al-4V, Ti-6Al-4V , Ti-Al-Nb. Most Dental implants are made of Grade 4 Titanium cpTi as it is stronger than other grades.3 The ADA council of scientific affairs in the  1996 update,  stated that ADA-Accepted endosseous implants, including those made of pure titanium or titanium alloys, can be used only to treat carefully selected patients with whom the relative merits of benefit and risk have been fully discussed. Before the 1996 update, the Council had not recommended endosseous implants for routine clinical practice.4 For a long time now various methods have been worked upon to quantify the levels of titanium in the blood of patients fitted with titanium orthopaedic implants. In a new method where isotope dilution analysis and mass spectrometry, or IDA-ICP-MS, was used to analyze the blood samples in patients with orthopedic implants, the researchers found titanium levels for different types of bone fixation devices. The more invasive implants shed more metallic debris into the blood than the external, superficial designs. The work also identified how the titanium from the implants is transported in the bloodstream and potentially distributed and accumulate.5Further studies in patients treated with dental implants need to be done to provide more evidence in the safety standards of Dental Implants.


References :

1.Renner AM. The versatile use of titanium in implant prosthodontics. Quintessence Dent Technol 2001;188–97.

2.Titanium applications in dentistry ,J Am Dent Assoc, Vol 134, No 3, 347-349.
© 2003 American Dental Association

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

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

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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,
CORE, The Dentofacial Centre

2. Dr. Ajit Shetty M.D.S., F. & Dip ICOI
Co Director,
CORE, The Dentofacial Centre,

3. Dr. Deepthi Mony M.D.S.,
Associate Oral & Maxillofacial Surgeon,
CORE, The Dentofacial Centre,

Dental Follicle -
The        Monthly     E- Journal Of  Dentistry                  Vol -  V I   Number-   I I I    July  2011     ISSN   2230 – 9489 (e)

Separation of endodontic instruments within the root canal is one of the complications encountered during root canal treatment procedures. There are various methods of retrieval that have been explained in literature. This paper presents the case of a 30 year old lady with a complaint of pain in a lower right tooth. She gave history of having undergone root canal therapy around 15 years ago. Orthopantamograph revealed a broken instrument in relation to mandibular right second premolar. The retrieval of the instrument was done surgically in a retrograde manner, the canal was obturated and apical seal was achieved.

KEY WORDS: Separated endodontic instrument, retrograde surgery

During cleaning and shaping of the root canal system, procedural accidents can occur, that might affect the prognosis of the tooth. Examples of such accidents include ledge formation, artificial canal creation, root perforation and extrusion of irrigating solution periapically, separation of endodontic instruments. Not all procedural problems lead to a reduced prognosis, but any error that compromises microbial control is likely to increase the risk of a poor outcome. Fracture of root canal instruments is one of the most troublesome accidents in endodontic therapy, especially if the fragment cannot be retrieved.
The overall prevalence of retained fractured instruments was 3.3% of treated teeth.1
A number of treatment protocols for removing obstructions have been described in the literature. Earlier authors have suggested that the object, regardless of the primary endodontic diagnosis, should be left in the canal, and that the canal coronal to the object should be treated according to standard endodontic procedures. Others have suggested that the object should be bypassed and incorporated into the root filling material. Surgical techniques for removal of either the object itself or the entire portion of the root encompassing the object have also been recommended.

Case Report:
A 30 yr old lady reported to the clinic complaining of pain in the lower right tooth. The patient gave history of root canal therapy with 45 around 15 yrs ago. On examination she had caries in relation with 27, 38, 48. An orthopantomograph was obtained as a diagnostic aid. Roentgenographic examination of the orthopantomograph revealed a broken root canal instrument --a lentulo spiral in 45 at the apical region and extending beyond the apex. 

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.


Many factors determine the method of retrieval of a broken root canal instrument namely the length and position of the instrument in the canal, the canal anatomy and the tooth involved. Based on these factors the most ideal technique, within the framework of tissue conservation, should be chosen.

1. Piyanee P. , Pimnalin P. ,Chankhrit S. and Harold H. M., May 2010. Impact of a Retained Instrument on Treatment Outcome: A Systematic Review and Meta-analysis Journal of Endodontics 36 ( 5) pp 775-780
2. Hulsmann M. 1990. The removal of silver cones and fractured instruments using the canal finder system. Journal of Endodontics ;16:pp. 596-600.
3. Camillo D. , Giuseppe V. and Pietro D, 2000. Broken Instrument Removal -Two Cases, Journal of Endodontics , 26 (6) pp.368-370
4. Nimet G., Dilek H. , 2009 . Comparison of the Different Techniques to Remove Fractured Endodontic Instruments from Root Canal Systems, European Journal of Dentistry 3, pp. 90 - 95
5. Ranganath, N. N., Somshekhar H., Shabana S. and Aarati R. N. 2011. Dysesthesia with pain due to a broken endodontic instrument lodged in the mandibular canal—a simple deroofing technique for its retrieval: case report, Oral Surgery Oral Medicine Oral Pathology Oral Radiology Endodontics, 111 pp.e48-e51



Use of a Bioactive Alloplast, in the Treatment of Human Periodontal Osseous Defects - A Case Report


1. Dr. Suvarna Patil MDS
Prof. and Head,
Department of Periodontics,
KLE VK Institute of Dental Sciences, Belgaum

2. Dr. Harsha M B MDS
Assistant Prof.,
Department of Periodontics,
Dayanandasagar college of Dental Sciences, Bangalore


Dental Follicle -
The        Monthly     E- Journal Of  Dentistry                  Vol -  V I    Number-   I I I    July  2011     ISSN   2230 – 9489 (e)


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


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                 


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


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.


  1. 1.Schwartz Z, Goultschin J,   Dean DD & Boyan BD. Mechanism of alveolar bone destruction in periodontitis. Periodontol 2000, Vol. 14, 1997, 158-172.
  2. 2.Schallhorn RG. Present status of osseous grafting procedures.J Periodontol 1977: 48: 570-576.
  3. 3.Reynolds M, Aichelmann-Reidy W, Branch-Mays G. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Ann Periodontol 2003;1:227–65.
  4. 4.Dragoo MR, Sullivan HC. A clinical and histological evaluation of autogenous iliac bone grafts in humans. I. Wound healing 2 to 8 months. J Periodontol 1973;44(10):599–613.
  5. 5.Sonis T, Williams L, Jeffcoat M. Healing of spontaneous periodontal defects in dogs treated with xenograft demineralized bone. J Periodontol 1985; 56: 470.
  6. 6.Ohtsuki C, Kamitakahara M, Miyazaki T. Bioactive ceramicbased materials with designed reactivity for bone tissue regeneration. J R Soc Interface. 2009;6 Suppl 3:S349-60.
  7. 7.Garrett S. Periodontal regeneration around natural teeth. Ann Periodontol 1996:1:638-639.


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Pyorrhea The Disease Nearly Everybody Has

Pyorrhea a common disease discovered


Warsaw Daily Times - Jan 7, 1916