D e n t a l    F o l l i c l e               

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

In this Issue:

  • Scientific Editorial - Physiologic Occlusion - Dr.Syed Nabeel

  • Extra Medullary Plasmacytoma: A Case Report  - Dr.Sowmya M. Rajagopal.

  • Distraction Osteogenesis - A Brief Review Of Literature
    -Dr.  Asma Syed , Kuwait

  • Dental Archieves  -  Dentists Experiment With Tooth Implants .  - The Day - Mar 18, 1974

Scientific Editorial:

                Be it attainment of desired results in Restorative dentistry , Orthodontics , Aesthetic dentistry or prognosis and life expectancy of a dental implant. or the treatment of TemperoMandibular Dysfunction - all results depend upon one common factor - Occlusion - or in more advanced terms , the attainment of Physiologic Occlusion , defined simply as occlusion in harmony with functions of the masticatory system or in a more detailed definition - as a closure of the teeth that produces no pathologic effects on the stomatognathic system, normally dissipating the stresses placed on the teeth and creating a balance between the stresses and the adaptive capacity of the supporting tissues. Gaining the physiologic occlusion by means of application of TransElectric Nerve Stimulation and followed by getting the "Optimal bite" by application of  Computerized Mandibular Scanning (CMS) or Jaw Motion Analysis (JMA) with Electromyography is gaining momentum in dental practices across the globe. The K7 Evaluation System ( from Myotronics ) is one of the most popular of the  computer-based system for three dimensional jaw tracking, surface electromyography and temporomandibular joint sound study.

               With More Cases of full mouth rehabilitations in the dental practices , CMS is the technology dentists need to equip with , to deliver Physiologic Occlusion  thereby getting the desired occlusion and aesthetics

      I hope you enjoy this issue of Dental Follicle.


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Dr. Syed  Nabeel

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1. Dr.Sowmya M. Rajagopal, B.D.S.
Asst. Dentist ,J.S. Dental Clinic ,Mysore

2. Dr.Jai Shankar H.P. M.D.S.
J.S.Dental Clinic,Mysore
Professor and HOD Dept of Oral Medicine & Radiology
Coorg Institute of Dental Sciences.

3.Dr.Shashidara M.D.S
Professor, Dept of Oral Pathology,

Coorg Institute of Dental
4. Dr. M.Fazeel Ahmmed M.D.S.
Senior Lecturer,Dept of Oral Medicine and Radiology
Royal Dental college, Palakkad


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

A case of extramedullary plasmacytoma manifesting as recurrent gingival swelling is presented. One of the most common reasons for which patients visit dentists are bleeding gums which is routinely treated by the dentists without giving much importance to the exact aetiology of the disease other than local factors. In the present case also, none of the dentists’ the patient visited previously, were able to diagnose the disease properly and was treated symptomatically. It is important to identify the exact cause underlying for the bleeding gums, to diagnose, investigate and treat the disease appropriately. In plasmacytoma, early diagnosis is very important because of its risk for developing into more serious multiple myeloma. A brief discussion of the disease process, Radiographic features and the histopathological evaluation needed for diagnosing such cases is also presented.

KEY WORDS: Extramedullary, plasmacytoma, gingival enlargement.


Extramedullary plasmacytoma (EMP) is a rare entity belonging to the category of non-Hodgkin’s lymphoma1. EMP, solitary plasmacytoma of bone (SPB) and multiple myeloma (MM) are plasma cell neoplasms. EMPs in the head and neck region are rare and comprise less than 1% of head and neck tumours. The mean age of the patients with EMP is 50 years2.
In the present case the patient had generalized swelling of the marginal, interdental and attached gingiva which had recurred several times after the preliminary treatment, during the last 2 years. The swelling was soft to firm in consistency and showed bleeding on probing. Biopsy showed plasma cell infiltration of the connective tissue.

Case History:

A 45yr old female patient reported to our Dental clinic with a chief complaint of recurrent gingival swelling and bleeding gums, since 11/2 yrs. The Patient had consulted several dentists and was treated with oral prophylaxis and sub gingival scaling along with antibiotics. The symptoms used to resolve after treatment and recur 6-8 weeks after treatment.
The extra oral findings were non-contributory.
On intraoral hard tissue examination, dental caries were present in 16, 21, 27, 37, and 47. Grade II mobility in 16, 17, 26, 27, 37, 46 with generalized grade-I mobility and periodontal pockets. Soft tissue examination showed generalized diffuse swelling of the marginal & attached gingiva and interdental papillae which showed erythematous and shiny appearance (fig-1). The swelling covered almost 1/ 3 rd of the crown of the teeth. It was soft to firm in consistency and bled on application of pressure. Mild tenderness was present. Supragingival and sub gingival calculus was minimal. With all these findings a provisional diagnosis of combined gingival enlargement and differential diagnosis of idiopathic gingival enlargement, ligneous periodontitis, leukemic gingival enlargement, and gingival enlargement due to granulomatous diseases were given.

Figure 1 - Preoperative, on the day of presentation

As a part of investigation, a panoramic radiograph was taken (fig-5). The radiograph showed generalized infrabony and horizontal bone loss, especially in the posterior region in all the quadrants. Complete hemogram, biochemical investigations and urine analysis were done for the patient. ESR was raised to 45mm/hr and all the other findings [FBS, PPBS, cholesterol, triglycerides, urea, creatinine, and uric acid] were within the normal limits.

Incisional biopsy was performed from anterior and posterior areas and sent for histopathological examination. The histopathological diagnosis of a plasma cell lesion was arrived upon (fig-2). The appearance of plasma cells in gingival lesions is a very common appearance, and does not point to any particular diagnosis. Most of the lesions are polyclonal and inflammatory; on the contrary plasma cell tumors i.e. EMP/MM will show a monoclonal population of cells. Therefore for a definite diagnosis the lesion was subjected to staining for kappa and lambda light chains. The lesion showed lambda light chain restriction with only the kappa light chain being expressed (fig-3).
Considering the immunohistochemical findings a diagnosis of extra-medullary plasmacytoma was arrived upon.

Fig 2 : H&E section High power



Fig 3 : lambda light chain has not taken up the stain

The patient was further subjected to radiographic examination of the skull (PA) and PA chest radiographs (fig-4) to rule out multiple myeloma. The skull and chest radiographs were normal.

Radiotherapy is emerging as the treatment of choice in cases of EMP. However considering the behaviour of the lesion in our patient we decided to subject the patient to conservative surgical treatment. As a part of treatment scaling and root planning, extraction of mobile teeth and flap surgery with internal bevel gingivectomy and open debridement was performed in all quadrants. The lesion has showed complete regression after the treatment (fig-6) and has showed no recurrence in nine months time.

Fig 4: Chest X-ray .



Fig 5: Orthopantomogram .


Fig 6 :Post operative


Plasmacytoma is a unifocal, monoclonal, neoplastic proliferation of plasma cells that usually arises within the bone. Present as two types
1 Solitary osseous [solitary plasmacytoma of bone] (SPB)
2 Extramedullary plasma cytoma [if seen in soft tissues] (EMP)

Plasmacytoma is important because it may give rise to the more serious disease of multiple myeloma. Solitary osseous plasmacytoma are two times more common than extra osseous variants2.
Extramedullary plasma cytoma (EMP) is an uncommon plasma-cell tumor that may arise in many parts of the body including the skin, lymph nodes, thyroid, testes and viscera, but most frequently occurs in the soft tissues of the head and neck and upper respiratory passage 3,4,5,. EMP may originate in any tissue except bone marrow as a primary neoplasm of plasma cells. About 75% of soft tissue plasmacytomas arise in the upper respiratory tract and oropharynx. The first indication of a neoplasm in this area may be metastases to cervical lymph nodes
6. Less commonly involved in the head and neck region are the salivary glands, skin, cervical lymph nodes, orbit, thyroid gland, and larynx. Solitary extramedullary plasma cytoma of the skin is rare 7. A very few cases of EMP occurring in the parotid gland is also reported6.

EMP most commonly occurs in the older age group, ranging from 50yrs to 70yrs1. The lesion predominantly occurs in the males in the ratio of 3:1, compared to females
1,7,8. The tumour may be confined to the soft tissues or may involve the underlying bone8. Lesions can be polyploid or sessile and have a smooth or nodular mucosa, but are rarely ulcerated. Mandibular lesions are usually asymptomatic and occur in advanced stages. EMPs in the nasal cavity and Para nasal sinuses present as submucosal lesions. Diffuse infiltration of the neighbouring structures such as the orbit, hard and soft palates, skin and skull base can also occur 3. Laryngeal plasmacytomas occur in approximately 6% to 18% of EMPs. The most common laryngeal sites are epiglottis, followed by vocal cords, false cords, ventricles and subglottis. Patients typically present with hoarseness, hemoptysis, dyspnoea or dysphagia1.
Diagnosis is not always easy and the lesion has often been mistaken for an inflammatory process. Biopsy is necessary and the histologic pattern is characterized by invasion of plasma cells displaying marked monomorphism, which replace the normal structure of the tissue5. The neoplastic cells, some of which are bi or multinucleated, are arranged in a delicate reticular stroma. Their degree of differentiation varies and mitotic figures are rare

Histological criteria for diagnosis of plasmacytoma include:

(1) Broad sheets of plasma cells arranged in a delicate stroma consisting chiefly of capillaries.
(2) Connective tissues are replaced by the plasma cell sheets.
(3) Large red-staining nucleoli are present.
(4) The nuclear : cytoplasmic ratio is altered.
(5) Nuclear characteristics display atypism and multinucleated cells are present6.
Diagnosis is purely histological but histology alone does not help in the identification of the type of plasmacytoma. A systemic investigation by means of bone marrow aspiration, hematologic and urine studies, chest x-rays, radiographic bone survey, serum protein analysis should be carried out to establish whether the lesion is solitary or multiple

Knowling et al reported a 48% conversion rate to MM for SPB, compared with 8% for EMP. Corwin and Lindberg reported a similar difference, 50% of the patients with SPB had conversion to MM, compared with only 17% of the patients with EMP 8.

Plasma cell neoplasms are highly radiosensitive. Radiation therapy is currently the standard treatment for SPB and EMP
4,5,6 . The dosage of radiation is not well defined because of small numbers of patients and the lack of prospective studies. Abemayor reports fewer local recurrences for doses greater than 4000cGy in EMP. Knowling et al suggest that radiation fields include cervical lymph nodes in order to prevent lymph node recurrences in EMP. Although complete surgical removal is potentially curative in EMP and SPB, surgery is usually reserved as second line therapy. Management of SPB or EMP by surgical excision alone is controversial. The lesion can be treated by the combination of radiation and surgery also 4.

Recurrence rate and conversion to MM is less compared to the SPB. Of all plasma cell tumours, EMP has the best prognosis2. Patients who are diagnosed with EMP remains under life-long medical observation because even if therapy is successful, relapses or generalized plasmacytoma still may appear years later 1


Plasma cell neoplasms are unusual tumours of the head and neck region. We present a case of EMP involving the gingivae. Plasma cell neoplasms are histologically indistinguishable and represent a disease continuum, as illustrated by progression of EMP and SPB to MM. The diagnosis is made on the basis of clinical, radiological, histopathological and histochemical findings and distinguishing one from the other is critical for treatment and survival.

1.Christoph A, Reinhardt J K, Hermann D et al. Extramedullary plasmacytoma.
Cancer 1999; 85: 2305-2314
2 Leandro N S, Lucyana C F, Luis ANS, Ricardo A M, Hercilio M J et al.
Asymptomatic expansile lesion of the posterior mandible. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2007; 103: 4-7.
3 Steven E B, Don R G and Malcolm A B. Extramedullary plasmacytoma of the head
and neck. Radiology 1981; 140: 801-805
4 Alexiou C, Kau RJ, Dietzfelbinger H, et al. Extramedullary plasmacytoma: tumor occurrence and therapeutic concepts. Cancer. Jun 1 1999;85(11):2305-14.[Medline]
5 Galieni P, Cavo M, Pulsoni A, et al. Clinical outcome of extramedullary plasmacytoma. Haematologica. Jan 2000;85(1):47-51[Medline]
6 Rajni A. Extramedullary plasmacytoma of the lung. Cancer 1985; 56: 152-156.
7 Yoon Choi N, Natasha M, Philip T R and Donald L. Head and neck manifestations
of plasma cell neoplasms. The laryngoscope 1997; 107:741-746.
8 Roger K W, John M W and James S M. Solitary plasmacytoma. Cancer 1979; 43:




Distraction Osteogenesis - A Brief Review Of Literature

Dr. Asma Syed , BDS

Private Practice,



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


Distraction Osteogenesis is a surgical procedure for the correction of skeletal deformities, parting (distraction) two bony segments in a manner such that new bone is allowed to fill in the gap created by separated bony segments. It can be applied to both maxilla and the mandible like micrognathia in craniofacial deformities . In this paper an attempt has been made to review the historical perspective to the applications and shortcomings of Distraction Osteogenesis in Dentistry.

Key Words

Callus distraction, Osteodistraction, Callotasis


History of the Procedure:

A crude method of distraction osteogenesis first appeared in the literature in 1905 and was described by Codivilla, who used the technique to elongate a femur.
Ilizarov is the father of modern distraction osteogenesis. In 1951, Ilizarov developed a technique for repairing complex fractures or nonunions of the long bones. While treating a patient with a short amputation stump, Ilizarov performed an osteotomy and applied an external fixator to lengthen the stump with the intention of placing a bone graft. However, by chance, he discovered that the bone grew in the distraction gap, eliminating the need for a bone graft. Later research by Ilizarov demonstrated that the tension-stress effect caused an increase in metabolic activity, an increase in cellular proliferation, and a neovascular in growth similar to normal endochondral ossification.

Advantages over traditional methods:
1. Compared to Bone Grafting:
Distraction osteogenesis decreases the need for bone grafting for large (>10 mm) mandibular advancements; one can achieve 20 mm or more of advancement without a bone graft and the associated donor site morbidity, scarring, and potential for infection.

2. Compared to Osteotomy:
This procedure results in less distortion and loading of the temporomandibular joint than sagittal split osteotomy.

3. Age factor:
The procedure can be performed in infants and children, who would otherwise not be candidates for mandibular osteotomy because of the interference with the developing tooth buds and/or insufficient bone to safely perform a traditional osteotomy.

4. Often has obviated the need for a tracheotomy in newborns and infants with micrognathia and airway obstruction.

5. Can be performed in 3 dimensions, i.e., advancing, widening, and increasing vertical height of the basal mandibular bone. Also the amount of movement can be tailored to each patient, especially in those with significant facial asymmetry.

6. Can be used to rotate the anterior portion of the mandible to correct open bites related with mandibular deficiencies.

7. Greater patient acceptance exists with this procedure, especially with the development of low-profile intraoral devices.


Fig 1:

Ilizarov's study proved that the success of the distraction depended on the rate and rhythm of the force applied on site. The optimal rate of distraction is 1 mm per day.

 Distraction of 0.5 mm or less per day may cause premature consolidation of the bone.
 Distraction of more than 1.5 mm per day may cause delayed ossification or pseudoarthrosis due to local ischemia in the interzone.

Soft tissue also has the ability to grow linearly along lines of tension. This is referred to as DISTRACTION HISTOGENESIS. Skin, muscle, nerves, and vascular tissue are generated, not stretched.
Advantage: In severe retrognathia, stretched soft tissue envelope can contribute to relapse when a traditional mandibular osteotomy is performed for a large (>10 mm) advancement.

Types of Distraction Osteogenesis:
1. Monofocal Distraction Osteogenesis
2. Transport Distraction Osteogenesis – Bifocal, Trifocal, Quadrifocal
Monofocal Distraction Osteogenesis: It involves the separation of two mandibular bone segments at a single osteotomy site and is widely used for bone lengthening to correct craniofacial deformities, such as
1. Mandibular widening to correct dental crowding
2. Sutural expansion at the maxilla and skull
3. Mandibular or midface advancement
4. Treatment of unilateral craniofacial microsomia.

Transport Distraction Osteogenesis: It involves incremental movement of one (bifocal distraction), two (trifocal distraction) or three (quadrifocal distraction) bone segments, called “Transport Discs” across a defect. Used in Reconstruction of Segmental defects resulting from
1. Removal of cancer
2. Chronic bone infection
3. Blast injuries
4. Gunshot wounds

Trifocal transport distraction requires half the time of bifocal transport distraction for the same mandibular bone defect.


Fig 2

MBT Devices:  Mandibular Bone Transport devices are of two types

-          External Distraction devices

-          Internal Distraction devices

They comprise four parts (Fig 3):

1.      Frame

2.      Bone Transport unit

3.      Distraction activating mechanism

4.      Activation arm

Fig 3

Fig 4



·        Severe retrognathia associated with a syndrome (Eg, Pierre Robin syndrome, Treacher Collins syndrome,      Goldenhar syndrome), especially in infants and children who are not candidates for traditional osteotomies.

·        Patients who have unilateral hypoplasia of the mandible eg, hemifacial microsomia.

·        Mandibular hypoplasia due to trauma and/or ankylosis of the temporomandibular joint.

·        Mandibular continuity defects resulting from excision of tumors and/or aggressive developmental cysts.

·        Craniofacial anomalies, particularly for the treatment of potentially life-threathening, deformity-associated upper airway obstruction and respiratory dysfunction in neonates.

·        Children with severe midfacial deformities.


·        Patients who have inadequate bone structure are not ideal. Adequate bone stock must be available to accept the device and to provide adequate surface area of the osteotomy sites for regeneration.

·        Disadvantages include device failure, cutaneous scars with external pin-based devices, necessity of a secondary procedure for removal of internal devices.

·        In older patients, a decreased number of mesenchymal stem cells may impair bone healing at the distraction site.

·        Patients who have metal allergies are not ideal.

·        Patients who have received prior radiation treatment- this procedure must be performed with caution because these patients are more likely to develop complications and to experience delays in wound healing. Patients who have inadequate bone structure are not ideal. Adequate bone stock must be available to accept the device and to provide adequate surface area of the osteotomy sites for regeneration.

·        Disadvantages include device failure, cutaneous scars with external pin-based devices, necessity of a secondary procedure for removal of internal devices.

·        In older patients, a decreased number of mesenchymal stem cells may impair bone healing at the distraction site.

·        Patients who have metal allergies are not ideal.

·        Patients who have received prior radiation treatment- this procedure must be performed with caution because these patients are more likely to develop complications and to experience delays in wound healing.

faf   Conclusion:

                Distraction Osteogenesis is a new variation of more traditional orthognatic surgical procedures for the correction of dentofacial deformities and is a remarkable way to improve deficiencies in bone development. The procedure not only repairs
asymmetries and restores facial esthetics but also restores airway patency and occlusion to a functional condition.


1. John W. Werning, Oral cancer: Diagnosis, Management, and Rehabilitation
2. Dale A Baur, MD, DDS ; Distraction Osteogenensis of the Mandible [Medscape]
3. Uriel Zapata, M.Sc., Ph.D., Mohammed E. Elsalanty, M.D., Ph.D., Paul C. Dechow, Ph.D., and Lynne A. Opperman, Ph.D., Biomechanical Configurations of Mandibular Transport Distraction Osteogenesis Devices [PubMed]
4. Wang X. Lin Y. Yi B. Liang C. Li Z., Mandibular functional reconstruction using internal distraction osteogenesis. Chin Med J. 2002;115:1863. [PubMed]
5. Spagnoli D.B., Gollehon S.G., Distraction osteogenesis in reconstruction of the mandible and temporomandibular joint. Oral Maxillofac Surg Clin North Am. 2006;18:383. [PubMed]
6. Guerrero C.A. Bell W.H. Contasti G.I. Rodriguez A.M. Mandibular widening by intraoral distraction osteogenesis. Br J Oral Maxillofac Surg. 1997;35:383. [PubMed]



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The Day - Mar 18, 1974