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


In this Issue:

  • Scientific Editorial - Psychological aspects of edentulous patients  - Dr.Syed Nabeel

  • Treatment of complicated crown fracture by partial pulpotomy– A case Report
    .-. Dr. Rohit kumar Khatri

  • Ultimate shade match in ceramics in a fluoride affected tooth- a case report                                                                                                                                    -Dr Sanjay Jamdade

  • Dental Archieves  -  Colgate Den Stops Tooth ; Afro American - Dec 23, 1950


Scientific Editorial:

               Psychological aspects of edentulous patients : The inability to wear a denture found in a large percentage of patients across the continents is usually connoted as "Dental Cripples" 1 or Oral invalids. It is one aspect of prosthetic rehabilitation that needs extensive research and study .Although with complete dentures patients usually are satisfied the esthetic demand of many patients ,unfortunately significant population still feels edentulism/ complete denture wearing affects their social life considerably. 2 In a study of interviews with the edentulous subjects the investigators Fiske found tooth loss was comparable to the death of a friend or loss of other important parts of a body in causing a reduction of self confidence ending in a feeling of shame or bereavement. 2 The Mandibular dentures have been more problematic as compared to the maxillary .The extent of the psychological impairment of the patients with loss of teeth and associated TMD has varied extensively between western and eastern hemispheres , specifically the Indian subcontinent. Contrary to the west, in India in a recent study the authors concluded that Loss of teeth did not have a marked emotional effect in the lives of the selected elderly community and found no significant difference between complete and partial edentulous subjects. 3 Therefore, the present findings emphasize the need to intensify the integration of psychosomatic aspects into dentistry and, in particular, to add psychological considerations to future.

References :

1.Carl E Mische , Contemporary Implant Dentistry 3rd Edition ; Page 17

2 Fiske J , Davis DM , Frances C et al . The emotional effects of the tooth loss in edentulosu people . Br Dent J 184:90-93 , 1998

3.Amit Vinayak Naik1 and Ranjana C. Pai2 ; Study of Emotional Effects of Tooth Loss in an Aging North Indian Community ISRN Dentistry Vol2011 Pages 1-4



Yours truly

Dr. Syed  Nabeel

Editor -in-Chief

Dental Follicle - The E Journal Of Dentistry

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Treatment of complicated crown fracture by partial pulpotomy– A case Report


1.Rohit Khatri; MDS

Senior Lecturer, M G Dental College & Hospital ,Jaipur

2.Setu Mathur MDS
Senior Lecturer, M G Dental College & Hospital ,Jaipur

3.Rahul Srivastava MDS
Senior Lecturer, Modern Dental College & Hospital ,Indore

4. Rashi Srivastava MDS
Post graduate student, Govt Dental College & Hospital ,Ahmedabad

Phone no.: 09414412840


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

Aim: To present the treatment and one year follow up of a permanent central incisor with complicated crown fracture, by partial pulpotomy.
Summary: A healthy permanent left central maxillary incisor with complicated crown fracture was treated by partial pulpotomy and reviewed clinically and radiographically for one year. At recall, there was no spontaneous pain; the pulp showed signs of vitality and no periapical radiolucency developed.

KEY WORDS: complicated crown fracture, partial pulpotomy, permanent teeth.


A tooth fracture involving enamel and dentine that exposes the pulp is defined as complicated crown fracture. If there is a concomitant luxation injury, the pulp appears ischaemic but otherwise may appear healthy and bleeding 1. Complicated crown fractures represent 18–20% of all traumatic injuries to permanent teeth 6. Treatment options include direct pulp capping, pulpotomy (partial or cervical) or pulpectomy, depending on factors such as the interval between the accident and examination, the degree of root development and the size of the exposure. The key determinants of success are the extent of pulp damage and the length of time after exposure of the pulp to the oral environment. The objective of treatment in complicated crown fracture is to maintain the pulp vitality. Pulp capping was traditionally recommended for small exposures that occurred not more than a few hours previously. When the exposure site was large or the time elapsed between the accident and examination was long, because of the penetration of microorganisms into the tissue, vital pulpotomy was considered the treatment of choice3. Cvek (1978) demonstrated clinically high success rates (96%) for complicated crown fractures in permanent incisors treated by partial pulpotomy. Favourable outcomes were seen regardless of the size of the pulp exposure or the time passed between the accident and treatment.
This case reports a successful treatment of a permanent incisor with complicated crown fracture, treated by partial pulpotomy and immediate esthetic composite restoration.

Case report

A 9-year-old boy was referred 16 hrs after falling at school. Clinical examination revealed a complicated crown fracture of maxillary permanent left lateral incisor (Fig. 1). The tooth was not mobile and gave a vital pulpal response on electronic pulp testing. Radiographic examination (Fig. 2) revealed that the root was incompletely formed with an open apex.

Figure 1: Pre-operative Photograph showing complicated crown fracture of left upper central incisor.

Figure 2: Initial Radiograph showing incompletely formed root apex.

Figure 3: After complete arrest of bleeding, calcium hydroxide powder was placed over the pulpal wound and cavity was sealed with glass ionomer cement.

Figure  4: Fractured tooth Restored with composite material to restore esthetics

There was no apparent periapical pathosis or alveolar bone fracture. It was decided to treat the tooth by partial pulpotomy. Briefly, after local anaesthesia, the tooth was isolated with cotton rolls and saliva ejector. The exposed area was cleaned with sterile saline solution. The pulp was amputated to a depth of 3 mm using a diamond bur on a high-speed turbine with water cooling. The wound surface was irrigated with a sterile saline solution and dried with cotton pellets to avoid clot formation. Calcium hydroxide powder mixed with distilled water was applied to the wound surface (Fig. 3). The cavity was sealed with glass–ionomer cement before restoring with composite material (Fig. 4). The tooth was examined clinically and radiographically at 3-month intervals during the first year. Healing was considered to have taken place when the following criteria were observed: (i) absence of clinical symptoms such as pain, tenderness to percussion, swelling etc; (ii) absence of any periapical pathology; (iii) continued root development and presence of dentine bridge; and (iv) positive response to electric pulp testing. In the follow-up examinations the tooth met all the criteria mentioned above. After one year, the tooth was clinically symptomless, and displayed normal colour and mobility. Radiographically, the apex of the tooth was closed without any sign of pathology, and a dentine bridge was apparent at the pulpotomy site (Fig. 5,6).

Figure 5: Formation of coronal  hard tissue barrier after 6 months.Tooth was asymptomatic

Figure 6: One year follow up showing complete formation of root apex

The treatment of complicated crown fractures may involve pulp capping, partial pulpotomy or cervical pulpotomy. Direct pulp capping can be performed in small exposure cases when the time between the accident and treatment is short. When the time between the accident and treatment is long, the exposed pulp shows proliferative changes 2. This is because of the continuous salivary rinsing, which does not permit accumulation of debris and microorganisms, eventually leading to regressive changes 8. Proliferative changes have been observed in a clinical study in humans2  and in histological studies in monkey teeth 5. Partial pulpotomy procedure is quick and easy to perform. It allows the tooth to maintain its vitality and continue its root development. When considering the disadvantages of cervical pulpotomy, where the entire coronal pulp is removed, physiological apposition of dentine is prevented and risk of cervical fracture is increased. Thus, partial pulpotomy seems to be the treatment of choice in cases of complicated crown fractures with large exposure areas. Partial pulpotomy causes only limited injury to the pulp and limited loss of tooth substances, which is important for pulpal healing and facilitates subsequent restoration of a fractured crown5.

For many years, a conventional root filling has been recommended when root formation is completed, in teeth treated by pulpotomy 9. Fuks et al.2 concluded that pulpotomy should not be considered an interim treatment that should be followed automatically by a complete root filling. They claimed that, regular periodic radiographic check-ups should be performed in order to disclose any pathosis that might eventually develop. Furthermore, clinical and histological findings confirm that partial pulpotomy is a permanent treatment both in immature and mature teeth 4,6.


Conclusion :  

One year follow-up of this case report has shown that partial pulpotomy may be a successful permanent treatment in teeth with complicated crown fractures.

1. Andreasen JO, Andreasen FM, Bakland LK, Flores MT (1999) Traumatic Dental Injuries: A Manual. Copenhagen: Blackwell Munksgaard, pp. 22–3.
2. Cvek M (1978) A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. Journal of Endodontics 4, 232–7.
3. Cvek M (1981) Endodontic treatment of traumatized teeth. In: Andreasen JO, ed. Traumatic Injuries to the Teeth. 2nd edn. Copenhagen: Blackwell Munksgaard, pp. 321–83.
4. Cvek M (1993) Partial pulpotomy in crown-fracture incisors: results 3 to 15 years after treatment. Acta Stomatologica Croatica 27, 167–73.
5. Cvek M, Cleaton-Jones PE, Austin JC, Andreasen JO (1982) Pulp reactions to exposure after experimental crown fractures or grinding in adult monkeys. Journal of Endodontics 8, 391–7.
6. de Blanco LP (1996) Treatment of crown fractures with pulp exposure. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 82, 564–8.
7. Fuks AB, Bielak S, Chosak A (1982) Clinical and radiographic assessment of direct pulp capping and pulpotomy in young permanent teeth. Pediatric Dentistry 4, 240–4.
8. Fuks AB, Chosack SGA (1993) Long-term follow-up of traumatized incisors treated by partial pulpotomy. Pediatric Dentistry 15, 334–6.
9. Hallett GEM, Porteous JR (1963) Fractured incisors treated by vital pulpotomy- a report on 100 consecutive cases. British Dental Journal 115, 414–26.



Ultimate shade match in ceramics in a fluoride affected tooth- a case report
Dr Sanjay Jamdade B.D.S., P.G.Cert. NYU. (Implants and Oral Rehabilitation)

Dr Sanjay Jamdade is a speaker on dental implants and is a consultant with Smilecare Dental Clinic Pvt. Ltd. Mumbai which is known as India’s leading dental esthetics, implants and oral rehabilitation center. He is also the CEO of Dr Jamdade’s Dental clinic and Implant center since 23 years which is a practice devoted to aesthetic dentistry, microscope assisted endodontics, implants and oral rehabilitation situated at Boisar Tal Palghar Dist Thane near Mumbai, India, as well is a visiting implantologist to private dental clinics. email: -


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

Objective: - to test the efficacy of the custom made composite shade tab as an alternate but means of effective shade communication to the laboratory cases with severe discoloration of enamel like due to fluorosis or tetracycline stains
Materials and methods: - Anterior composites of enamel and opaque/dentin, composite shaping instruments, Composite tints, Vitapan shade tab card and a Canon Cybershot IS5 Camera with doctorseye ring light and picture were used to create a life like shade tab and was then layered with composite colors. After curing both were sent to the dental laboratory along with properly exposed digital pictures of the tooth before crown preparation and a very closely matched crown made in Porcelain fused to non-precious metal (PFM) was delivered to the patient.
Results: - A very closely matched PFM crown was obtained pleasing and exceeding the expectations of the operator, technician and patient.
Conclusion: - a custom made composite shade tab is an underutilized but very helpful means of shade communication with the laboratory along with properly exposed digital photographs under proper setting and light conditions.

Keywords: Discolored ceramic crown shade matching. Customized shade tab, Tetric tints, Shade mapping, shade matching of Fluorosis, Tetracycline stains on enamel.


The whole purpose of shade taking and understanding the whole art and science of light and colors is to be able to communicate to the laboratory what the patients natural teeth look like. So the clinician’s understanding should translate into effective communication to the laboratory and this communication should translate into indirect tooth colored restorations which look like the patient’s own natural teeth. So Collection of tooth color Data, Communication and Reproduction are the three important steps.
The first step is collection of appropriate shade under Ceramic shade selection protocol which have been generally accepted in the profession. These have been discussed at length in various scientific publications as wells as by various authorities from time to time. (1, 2, 4, 6) So by now most dentists have been exposed to terms related to shade selection and begun to comprehend the same to a great extent. The definitions of terms like hue, value, chroma, tints/stains, polychromy, and characterizations are well understood by most dentists.

The second step is the Laboratory communications done by drawing the distribution of the various hues on the tooth map which is a well established protocol so is the process of sending the laboratory a photograph of the zone where the tooth colored indirect restoration is to be made. The laboratory can be informed about where the color distribution, and what the value, intensity of color and characterizations desired should be.
The third and the final step after the first two steps is reproduction where it is the job of the technician to reproduce the restoration with all the knowledge, information and appropriate materials into a closely matched ceramic indirect restoration.
Challenges: - limitations of current systems of shade matching are known4 and understood by most practitioners. For e.g. it is known that Ceramic shade tabs and ceramic materials often do not match from batch to batch and the same applies for two separate batches of shade tabs. A dry shade tab will look different from a moist one and exactly the same applies for the natural teeth. Matching across various manufacturers is challenging. Even if the shade tabs and ceramic powders match, the thickness of the shade tab and the ceramic restoration are different. The shade tab tooth has no metal and has no opaque behind it whereas the ceramic crown has either opaque with metal, or a pressed ceramic coping or a zirconia coping behind it. Phenomenon of “Metamerism” is by now common knowledge (two objects match color in one light yet when the light source changes the colors do not match). The role of color corrected light sources as well as the importance of having light source intensity of 200 to 250 candles is known. So also importance of North day light is established. Even the knowledge of the color wheel is by now understood. Dentists have also noticed that the dental technician skills will vary from one technician to another so do the material brands they use vary. Nowadays automated and remote shade mapping selection is done7.

The application of all the knowledge mentioned above helps in getting a close shade match often and that too in uncomplicated teeth. But how would you get a good shade match for a single tooth with enamel discolorations due to fluorides, tetracycline stains or having unusual colors especially when only one of the patient’s teeth needs to be crowned, not all of them?
Practical experience of the author suggests that few points in the entire shade selection technique are critical.
The secret lies in communicating to the laboratory what the tooth really looks like! There are two critical steps needed to get a good match over and above the existing shade match protocol for tetracycline stained teeth.
1) Photographs
a. good close up photograph of the zone in question under the correct camera setting (white balance setting), and
b. some photos with the particular selected standard shade tab in place next to the tooth in question.
2) A custom made shade tab of the tooth in question for special cases.3

The photograph tells the technician what the polychromy is like i.e. the color distribution is actually like in its distribution in the various parts of the tooth. The picture with the shade tab in the photo allows the technician to see the tooth in question and the shade tab both at the same time in the same light condition. Even the photograph can be used as a back ground to draw a map on top of it showing the distribution of colors and other characters instead of using paper. Using the patient’s own photograph as a map is more reliable and more accurate than a map drawn on paper.
The custom made shade tab gives the ACTUAL color and color distribution to the technician the combination of the two assures better results than just the color map drawn on paper3. This is particularly true when there is a unilateral shade match to be done or a case of extreme enamel discoloration. Making customized shade tabs has been discussed in detail by Dr Douglas Terry3

Image 1: - Top left-regular Vita shade tab (Vita Zahnfabrik, Germany), Top right-Composite custom made stump shade tab to match shade of stumps. Below left and right - shade mapping done on top of the digital photos of the adjacent teeth.

Image 1 Sequential pictures of shade selection process and customized root stump shades and color map of tooth


Case report

 A 50 year old male patient has discolored teeth. The band of discolored tooth was fortunately in the cervical zone of the tooth hence wasn’t too noticeable even in a broad smile. The origin of the discoloration was never ascertained but assumed to be fluorosis. The discolored parts were hidden during smiling. In the past the author attempted whitening and even after 3 lengthy sittings there was no change whatsoever. Even scrubbing away discolored tooth structure with acid and pumice brought no results at all. The patient had already accepted his appearance as it is and he did not desire to further pursue any serious attempts to whiten to his teeth with any other as yet untried techniques or with ceramic laminates.
A lower right premolar tooth needed endodontic treatment which was done. The patient had previously done dental work done over a period of 20 years. He had old metal crowns with worn out acrylic facings. The metal crowns were in fact placed because it would have been impossible to match the natural tooth colors back then when ceramic technology was in its nascent state in our country. The crowns were functionally sound and the patient desired to leave them alone. While doing a PFM crown shade match would have been a challenge but the patient was explained that a crown with an acrylic facing would have been a worse choice in every possible way. So no matter how challenging a PFM crown shade match was it was the only way out. General Shade match was done to get a general idea of what the hue was like. No tab color was close. Crown preparation was done and an impression was made. The tooth was temporarizied with an acrylic crown prepared by the block technique.
Materials and methods - making of the customized shade tab
Making customized shade tabs has been discussed in detail by Dr Douglas Terry 3
A ball of B2 dentin (Tetric EvoCeram Ivoclar Vivadent) was taken and flattened into a very thin plaque of a hexagonal shape and was cured. Then it was layered in small increments with A3 composite (Tetric EvoCeram Ivoclar Vivadent) and was carved into a laminate like shape after placing it on a white mixing pad. It was then light cured. The cervical region of the composite was stained with Tetric composite tints (Ivoclar Vivadent) after making a mix of ochre and dark brown. The body was tinted yellow and the cuspal ridges were tinted white.
This tab was made in the same way a polychromatous composite laminate is created. This composite plaque matched the tooth very much. This piece was sent to the laboratory with notes of which shades had been used on the plaque, how much were they used and their distribution at each location.


When the finished crown arrived an overall close match was noted. The white tinting of cuspal tips was a bit overdone. The band of stain around the cervical zone was narrower than the neighboring premolar .Yet overall it merged very well into the overall color scheme of the patients’ teeth.


Image 2 Sequential before during and after pictures of reported case of discolored enamel matched with help of customized shade tabs

Discussion: - 

The patient had been told by many practitioners that a close match was impossible. The results far exceeded both the doctor’s and patient’s expectations. Those “crusty snowy flakes” were offered to be brushed away as well as the zone of discoloration was offered to be broadened coronally to match with the neighboring premolar, but the patient was so impressed with what he had received that in the already multicolored scheme he had in his mouth the excess snowy tint on cusp tips as well the narrower band of stain just merged into the background giving a true to life appearance. The patient was more than pleased and is now willing to take up the next challenge of replacing the old worn out molar crowns! A good shade match has in fact ensured more business to our practice!

Conclusion: -

  • Understanding of basics of shade matching like hue, value, chroma, light condition etc. is a fundamental requirement.

  • Chairside customized shade tabs and digital photographs are an underutilized but effective means of assessing and effective laboratory communication even in the most difficult cases
    • a photograph of the patient’s teeth (with white balance correction adjusted) with the closest shade tab in place,
    • a photograph without the readymade shade tabs and
    • Finally the customized shade tab made of composite will ensure you are pretty close to where you wanted with the patient’s ceramic shades.


    1) Stephen J. Chu, Recommended Shade-Matching Protocol - Dental XP
    2) Luke Kahng, Fine Tuned Key to Success for Custom Shade Matching - Spectrum dialogue Vol. 10 No. 1 – January 2011
    3) Douglas Terry - Color matching with composite resin: a synchronized shade comparison – Practical procedures Aesthetic Dentistry 2003; 15(7):5151-521
    4) James Fondriest, - Shade Matching in Restorative Dentistry: The Science & Strategies
    5) Rade Paravina, Dragutin Stankovi, Ljiljana Aleksov, Dragan Mladenovi, Kitka Risti - Problems in standard shade matching and reproduction procedure in dentistry: a review of the state of the art - The scientific journal Facta Universitatis Series: Medicine and Biology Vol.4, No 1, 1997 pp. 12 – 16 University of Niš Yugoslavia
    6) Bernhard Egger - Natural Color Concept: A Systematic Approach to Visual Shade Selection-, Quintessence of Dental Technology 2003
    7) Barry F. McArdle - Shade matching for indirect restorations using a remote laboratory-by, USA - Dental Tribune U.S. Edition, Vol. 6 No. 14, August/September 2011


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Dental Archieves

Colgate Den Stops Tooth

Afro American - Dec 23, 1950