Ortho Case 4.1

A 12-year-old female presented with a class II division 1 malocclusion on a moderate skeletal class II pattern, with increased vertical dimensions complicated by an increased overjet (12mm), crowding of both dental arches and teasing in relation to her dento-facial appearance.

What is treatment plan?

TREATMENT PLAN

1) Functional appliance like Dynamax or Twin block (more preffered as overjet reduction is more effective) = maxillary retroclination, mandibular incisor proclination, guides the eruption of posterior dentition.

2) Need of Headgear with torqueing spurs = restricts maxillary forward growth and tipping of maxillary incisors.

3) Extraction of four second premolars followed by edge to edge appliances for stability of class II correction.

Picture based diagnosis case 1

Study the two radiographs which are of the same
patient at (a) 19 years and (b) 34 years of age.

1 . What is the most likely periodontal diagnosis at 34
years of age?

Generalised aggressive periodontitis. The severity
of bone resorption and the radiographic absence of
signs of resorption at 19 years preclude a diagnosis of
chronic periodontitis.

2 . What does the initial phase of treatment involve?

Initially conventional cause-related treatment
is instigated: instruction in toothbrushing and
use of adjunctive aids for interproximal and
subgingival cleaning, RSI, prophylaxis. Ultimately,
treatments such as surgery and the adjunctive use of
antimicrobials might be indicated, but conventional
treatment is first in line.

3 . The patient has a sister who is aged 29 years. What
advice might you offer?

Periodontal screening and radiographic examination.
There is evidence that certain subjects are at high risk
from developing aggressive periodontitis and this
risk may be under genetic control. Siblings should
be screened and affected individuals with children
warned that early signs may develop from around
puberty onwards

Case History 4 in Diseases of bone and the maxillary sinus

A 35-year-old man presents with gross loosening of both his lower left premolar teeth. The gingiva around them looks swollen and is purple–brown in colour. A radiograph shows irregular bone destruction to the apices. Incisional biopsy shows multinucleated osteoclast-like giant cells in a haemorrhagic fibrous stroma.

  1. Which investigations should now be performed?
    The serum calcium level should be measured and radiographs reviewed to exclude hyperparathyroidism.
  2. If these prove negative, what treatment should be undertaken?
    The lesion should be treated by local removal with curettage.
  3. Which other lesions in the jaws contain multinucleate giant cells of this type?
    Osteoclast-like giant cells are found in
    1. giant-cell granuloma
    2. brown tumour of hyperparathyroidism
    3. Pagetʼs disease of bone
    4. aneurysmal bone cyst
    5. some fibro-osseous lesions, particularly cherubism. 

INTRODUCTION Over the ages, oral health care has been delivered to the community in different ways. The horseback dentistry of olden days has evolved into the most modern painless dental procedures. In India, about 70% of the population live in rural areas whereas 70% of the dentists practice in urban areas. We seldom find certain dental offices and few government establishments in rural areas, which lack the required infrastructure.WHAT ARE MOBILE DENTALCLINICS? A mobile dental clinic is used primarily when oral health care is be delivered to small pockets of patients that are scattered over a specific geographic area. The mobile clinic generally is parked at a facility such as a school, residential facility or community center.SALIENT FEATURES:- •Useful life is shorter than a fixed facility. •Requirement of water and waste disposal methods. •Dental equipment can be a traditional or a portable one. •Requirement of a generator on board to provide electricity.TARGETED POPULATIONS FOR MOBILE DENTAL SERVICES:- •Low-income individuals or families. •Isolated or very rural rural populations. •Persons in residential care facilities. •People who are “ homebound”, bedridden, very frail or receiving hospital services at home. •Persons with a variety of special health care needs. •Migrant and seasonal workers. •People who are homeless or temporarily displaced.WHY MOBILE CLINICS ARE PREFERRED OVER USUAL ONES? •Moderate start up costs. •It addresses the problem of transportation to the clinics. •It decreases missed appointments when run in conjunction with schools. •Services can be made available at multiple sites. •Services are made available to the needy population.   Even though mobile clinics are preferred over the usual ones, but they do have certain disadvantages. Let’s have a look at certain “disadvantages” of it:- •High maintenance costs may occur. •Difficult to access and store patient record. •Provides limited services and follow up may be difficult. •Requires permission for site use. •Difficult to use during monsoon. ESSENTIALS OF MOBILE DENTAL CLINIC:- The mobile dental clinic should be equipped with 2 dental chairs with all attachments and seating space for 15-20 people. 1.PORTABLE DENTAL UNIT:-•Dental chair should be portable and easy to handle. It should be able to be folded for easy transportation.  All the parts  should be detachable type and well balanced and sturdy. •Mobile suitcase unit: Fitted with aerotar and micromotor hand piece. •Scaler with 3 scaling tips. •Control box with transparent, regulated water tank and foot control.2.OPERATING LIGHT:- Two, intensity fixed with hinge on the top of the van. 3.DENTAL X-RAY UNIT:-  X-ray unit with digital arm timer and day light manual developer. 4.AUTOCLAVE:-  High speed automatic instrument autoclave. 5.METAL CABINETS WITH WASH BASIN 6.WATER TANK: 400 litres capacity. 7.HEALTH EDUCATION MODELSPARTNERSHIPS IN PROVIDING MOBILE DENTAL SERVICES:-Some of the group or  Individuals who could potentially be partners are:- •GOVERNMENT:-State/ Local, Health Department, Department of Social Service. •COMMUNITY:- Local community, Business Leaders, Foundations. •PUBLIC:- Patient Care  Advocate, Organizations that promote health. •POLICY:- Local and Community Policy Makers. •HIGHER/ PROFESSIONAL EDUCATION:- Medical schools ,Dental schools and Allied Health Schools.CONCLUSION A fully-equipped mobile dental clinic is to provide effective dental care at the doorsteps of underprivileged, rural population is the need of the hour. The key to a successful dental practice is a cohesive dental team, which will create an atmosphere of co-operation resulting in the achievement of the goals of oral health in the coming up years.REFERENCE Essentials of public health dentistry-Soben Peter

Case History 1 = Diseases of bone and the maxillary sinus

A 58-year-old woman noticed that her front teeth had become spaced and seeks advice from her dentist. On entering the surgery, the dentist notices that she has difficulty in walking and does not respond to his questions. She has become increasingly deaf and her vision has also deteriorated. On examination, the maxilla and zygoma are enlarged and there is enlargement of the forehead.

1. What diagnosis would you suspect?
Pagetʼs disease of bone results in enlargement of cranial bones and deformation of weight- bearing bones. The cranium is usually expanded in thickness and symptoms may arise from cranial nerve compression.

2. What information might be gained from oral radiographs and blood tests to support this diagnosis?
Radiographs of the jaws may show hypercementosis, cemental masses, abnormal trabeculation and a cotton-wool appearance in the jaws. The alkaline phosphatase level is markedly raised.


3. What are the principal histological features of this disorder?

Disordered bone remodelling is seen; larger osteoclasts are present and the trabeculae show a scalloped outline. Numerous resting and reversal lines, resulting in a mosaic pattern, are seen and the vasculature may be increased. Globular cementum-like masses are seen in the jaws. 

ACTIVATOR

DEFINITION = Functional appliances are defined as ‘loose fitting or passive appliances which harness the natural forces of the orofacial musculature that are transmitted to the teeth and alveolar bone through the medium of appliance’.

ACTIVATOR 4m**

  1. Given by anderson and haul
  2. Also called as norwegian appliance or loose fitting appliance
  3. It doesn’t have any clasp to hold onto dentition normally 
  4. Only one wire component = labial bow

Mechanism of action 2m

  1. Pt has to forcibly hold the appliance in its place aka maxilla as its loose appliance with no clasps
  2. This causes the pt to bring his mandible forward and keep mouth closed so the activator doesn’t fall down. 
  3. When pt swallows = muscles get stretched, continous remodeling at TMJ and mandible stays in forward direction
  4. Mandible is staying forward due to a REFLEX – myotatic reflex = due to continuous stretch of muscles, kinetic energy is generated and transferred to maxillary and mandibular dentition and skeletal base. Leading to: 
    1. Distal force on maxilla
    2. Mesial force in mandible 
    3. Hence, condylar adaptation occurs
  5.  ‘viscoelastic property’ = passive tension caused by stretching of muscles, soft tissue, tendinous tissue, etc. are responsible for the action


Indications 2m

  1. Class II division 1 malocclusion
  2. Class II division 2 malocclusion
  3. Class III malocclusion
  4. Class I open bite malocclusion
  5. Class I deep bite malocclusion
  6. As a preliminary treatment before major fixed appliance therapy to improve skeletal jaw relations
  7. For post­ treatment retention
  8. Children with lack of vertical development in lower facial height.

Contraindications

  1. Crowding 
  2. Adult pt 
  3. Too much proclination of lower anteriors 
  4. Increased lower anterior facial height

Advantage

  • pt can remove it
  • oral hygiene is maintained
  • no food restrictions
  • chair side time is less

Disadvantage = pt compliance

TYPES of activator 

  1. H activator 
    1. Horizontally growing pt
  2. V activator 
    1. Vertically growing pt 

FABRICATION STEPS

  1. Take impression
  2. Bite registration = gives us an idea how much mandible needs to be displaced. U shaped wax is placed on the oral cavity and asked to bring it forward and the bite is also opened posteriorly. 
  3. Articulation
  4. Wire elements  
  5. Acrylization of appliance
  6. Trimming = to bring about certain movements of the dentition

MODIFICATIONS 

BOW ACTIVATOR 

  • WUNDERER MODIFICATION = Given in class 3 
  • CYBERNATOR = similar to bionator = activator with reduced palatal acrylic 
  • PROPULSOR
  • Cutout or palate free activator
  • Karwetzky modification 
  • Herren modification 
  • Elastic open activator
  • Kinetor by Stockfish 

EPIDEMIOLOGY OF DENTAL CARIES 9M*****

  • Dental caries is defined as a chronic infectious disease which results from the demineralization of the inorganic portion and destruction of the organic portion of the tooth. 
  • Epidemiology of dental caries can be studied under the following heading: Host, agent and environment All these factors should react over a period of time for dental caries to occur. 
  • CARIES FORMATION 
    • Substrate (sugar) + microorganism (s.mutans in plaque) = lactic acid = causing demineralization
    • Remineralization = fluoride, calcium, phosphate
      1. Fl = dentifrice
      2. Ca and PO4 = teeth and saliva
  • HOST FACTORS
    • TEETH 
      1. 80% of caries occur on occlusal surfaces
      2. Lower incisors are the least affected teeth 
      3. Malaligned rotated = bristles cannot reach and clean leading to increased caries 
      4. Dentinogenesis and amelogenesis imperfecta = hypoplastic teeth and pitts = more prone to caries
      5. Caries is considered to be bilateral 
    • SALIVA 
      1. COMPOSITION
        1. rich in calcium phosphate and fluoride = decrease in caries
        2. Rich in carbonate = increase in caries attack
      2. pH = 
        1. unstimulated pH is slightly acidic 
        2. High flow rate = pH increases
        3. pH of saliva = main is bicarbonate content 
        4. Sialin, phosphate and ammonia = also determines pH of saliva
      3. QUANTITY 
        1. Normal secretion = 700-800 ml/day 
        2. Aplasia of glands and xerostomia = increase in rampant caries
      4. VISCOSITY 
        1. Mucin responsible for viscous saliva  
        2. Viscosity does not influence caries 
      5. ANTIBACTERIAL PROPERTIES 
        1. Lactoperoxidase = this prevents early microbial colonization of tooth 
        2. Lysozyme = it is a positive enzyme that catalyzed the degradation of negatively charged peptidoglycans matrix of microbial cells 
        3. Lactoferrin = iron binding protein = needed for microbial growth
        4. IgA = inhibits adherence and thereby prevents colonization on mucosal surfaces and teeth by organisms, facilitating their removal of swallowing 
    • AGE = 3 peaks for caries development
      1. 4-8 years = manual dexterity is less
      2. 11 – 19 years = adolescents
      3. 55 – 65 years = root caries
    • Gender = Reasons 
      1. Early eruption of teeth 
      2. More fondness of sweets
      3. Hormonal variations
      4. Morphological differences
    • Familial hereditary 
      1. Good or bad teeth seen in the family 
      2. Morphology, occlusion, salivary flow
    • Emotional disturbances 
      1. Increase stress = decrease salivary flow = increased caries in oral hygiene is not followed 
    • Socio-economic status 
      1. Low SES = increases decayed and increased missing 
      2. High SES = increased filling 
      3. Overall low SES = increase dental caries
      4. Reason = affordability for prevention and treatment 
      5. Caries is considered as disease of poverty
    • TIME FACTOR FOR DEVELOPMENT OF CARIES
      1. Peak susceptibility = 2-4 years after eruption 
  • Agent factors
    • Diet 
    • Organisms = S.mutans = pioneer = acidogenic, aciouric, eat/consume sugar 
      1. Extracellular = dextrans and fructans. Responsible for adhesion on tooth
      2. intracellular polysaccharide = glycogen
    • Lactobacilli = secondary organisms, when caries have reached dentin. It kills all S.Mutans creates an environment of very low pH
    • Veillonella = anti caries organism = consumes acid as food = produced by S.Mutans for demineralization

DIET OF DENTAL CARIES

  1. Diet = it is defined as type and amount of food eaten daily by an individual
  2. Nutrition = defined as seen of the processes by which an individual takes in and utilizes food
  3. Carbohydrates
  1. Organic compound containing carbon, hydrogen and oxygen 
  2. Physical nature of diet = form, clearance, time, retention, oral hygiene
  3. Frequency of carbohydrate diet  
  4. Types 
    1. Monosaccharides = glucose, galactose, fructose
    2. Disaccharides = sucrose [ glucose+fructose]
    3. Polysaccharides = starch, glycogen 
    4. Polyols of alcohol = xylitol, mannitol and sorbitol

Classification of sugars 

Total sugars 

  1. Intrinsic sugar
    1. Sugar molecules inside the cell
  1. Fruit and vegetable
  2. Extrinsic sugar 
    1. Sugar molecules outsides the cell 
    2. Milk sugar = found in dairy products = lactose
    3. Non milk sugar = honey, fruit juices, table sugar = responsible for the caries